Shelf Review

Question 1

Pituitary adenoma

Answer 1

• treat with: bromocriptine or cabergoline

Question 2

Tricuspid stenosis

Answer 2

• Opening snap with diastolic rumble at the left 4th interspace
• jugular venous A wave tall, due to atrial contraction (against increase resistance)
• increase intensity of murmur ( make it worse) with increase preload via inspiration, infusion, raise leg
• decrease intensity of murmur (make it better) via increase afterload

Question 3

Pyrphoria cutania tarda

Answer 3

• elevated ALT/AST, blisters in the dorsum of the hand, hirsutism
• deficiency in urooo…
• treated with phlebotomy (others are hematochromatosis)

Question 4

Whipple triad

Answer 4

• hypoglycemia + hypoglycemia symptoms + improve with glucose administration
• increase insulin & low C-peptide —> exogenous insulin
• increase insulin & C-peptide —> inslunoma
• increase insulin & C-peptide —> sulfanylurea
  —> use sulfalnylurea screen—> detect sulfanylurea in blood
  —> treat hypoglycemia with —> glycogen or glucose drip
  —> glucagonoma associated with necrotizing migratory erythema

Question 5

Diarrhea & organism

Answer 5

1. Pork consumption —> yersenia
2. Shelffesh —> vibrio
3. Severe rice-water stool in developing country —> vibro cholera
4. Bloody diarrhea with a super small inoculum —> shigella
5. Bloody diarrhea after consuming egg/poultry —> salmonella
6. Watery diarrhea 2 hours after consuming potato -> staph aureus
7. Bloody diarrhea with a low platelet + low unconjugated hyperbilirubinemia + elevated creatinine —> E.coli (EHEC) —> CAN lead to hemolytic uremic syndrome (HUS) (thrombocytopenia + hemolytic anemia + AKI) IF antibiotic is given

** most diarrhea treated with:
1. Fluoroquinolone
2. Macrolide (azithromycin)

Question 6

Continue diarrhea

Answer 6

1. Diarrhea upon return to the US from Mexico —> (ETEC)
2. Foul-smelling watery Diarrhea, after recent treatment for anaerobic bacteria pneumonia with antibiotics —> C.difficile (prevent with hand water, treat with: metronidazole, oral vancomycin, fedaxomycin, fecal transplant)
3. Crampy abdominal pain after consumption of home canned veggies —> botulism (+ flaccid paralysis)
4. Bloody diarrhea with ascending paralysis in a puppy owner —> campylobacter jenjuni ( the ascending paralysis is Gullain-Barre syndrome)
5. Watery diarrhea after eating fried rice at a Chinese restaurant —> B. Cerus ( rice-heated) —> toxin causes N/V

Question 7

Prussian blue staining of a bone marrow smear reveals basophillic inclusion around the nucleus in a 75 year old male that lives in a home built in the 1930s.
What are the associated iron lab value? How is this disease treated? ( + potential helpful vitamin supplement)

Answer 7

1. Sideroblastic anemia (caused by lead toxicity) —> heme synthesis pathway is damaged —-> microcytic anemia with ( low hemoglobin, low MCV, high iron, high ferritin, low TIBC)
2. Treated with: DMSA ..or succymere ..or EDTA
   Accompanied by vitamin B 6 (pyroxine) + thiamine + folic acid

Question 8

Chest x-ray showing diffused, bilateral, ground glass infiltrates in a febrile patient taking immunosuppressant.
What is the bug? Relevant stain ? Prophylaxis ? Treatment? Who should get concomitant steroid ? Diagnostic studies? Classically elevated marker from pulmonary fluid?

Answer 8

1. pneumocystis Jirovecii pneumonia (PCP) = (fungus)
2. Silver stain positive organism
3. Prophylaxis with: TMX-SMZ, pentamidine, dapsone
4. Begin prophylaxis when CD4 is 200
5. Treat with: TMX-SMX
6. Who should get steroid: SaO2 is less than 92% & PO2 is 70% & A-a gradient > 35
7. Diagnose PC pneumonia via: bronchioalveolar lavage
8. Elevated LDH in pulmonary fluid

Question 9

Flank pain with gross hematuria. Envelop shaped? Coffin shaped ? Radiolucent? Shape like hexagon?
What is the best diagnosis testing modality? How is this presentation treated ?

Answer 9

—> causes urinary tract infection:

1. Kidney stone (nephrolithiasis)
2. Envelop shaped = calcium oxalate (seen with chron’s disease) (common type)
3. Coffin shaped= struvite stone (magnesium-ammonium-phosphate stone) ( Proteus bug is urease positive = make urine alkaline) (avoid acetazolamide becuase it enhances urine alkalinization) (huge stooone)
4. Radiolucent = uric acid stone
5. Shaped like hexagon = cysteine stone (transporter defect that don’t absorb cysteine at proximal tubule) ( they are acidic stone —> give them acetazolamide ) ( type 2 RTA at proximal tubule )
6. Helical CT scan for diagnosis of kidney stone ( ultrasound for pregnant women)
7. Treat with:
   - Iv fluid + pain control + tamsulosin (alpha 1 antagonist) + Nifedipine (CCB) + struvite stone (surgery)

Question 10

24 year old male present with painless, palpable bony mass on the left knee.
Knee x-ray shows a contiguous mushroom shaped mass. What is the diagnosis ?

Answer 10

1. Osteochondroma

Question 11

66 year old female found unconscious at home by her daughter in December (fire places). PE is notable for cherry red appearance of skin

Answer 11

1. Carbon-monoxide poisoning
2. Diagnose with: Carboxy-hemoglobin level
3. Treat with: Hyperbaric oxygen (decrease half life of CO bind to hemoglubin)
4. Left-shift ( tissue hypoxia)
5. Symptoms of CO poisoning: Headache + altered mental status + cherry red lips + winter space heater + garage suicide
6. Hyper-intense lesion in Glubus Palidus region in MRI of brain

Question 12

Elevated creatinine 24 hours after getting CT scan.

Answer 12

1. Contrast- induced nephropathy
2. Prevented with: fluid + oral N-acetylcysteine (Nac)
3. Skin fibrosis after getting MRI —> nephrogenic system fibrosis (NSF)—> caused by exposure to Gadolinium-based contrast agent
4. If person has diabetes —> hold metformin before getting CT scan—> can lead to lactic acidosis
5. Nac —> in addition to contrast-induced nephropathy, can be used for acetaminophen overdose or cystic fibrosis or hemorrhagic cystitis
6. Hemorrhagic cystitis (damage to bladder) caused by:
   - adenovirus
   - schistosomiasis ( +person from egypt)

Question 13

A common lower extremity side effect associated with hydralazine & CCB (causes vasodilation)

Answer 13

1. peripheral edema
2. Caused increase hydrostatic pressure in capillaries

Question 14

B 12 deficiency

Answer 14

1. Pernicious anemia is associated with autoimmune disease ( adrenal insufficiency, Addison disease, Hashimoto thyroiditis)
2. Cystic disease
3. Chronic
4. Extreme vegan

Question 15

CD4 cutoff & prophylaxis in HIV
(200, 100, 50)
(250, 150)

Answer 15

1. Pneumocystis Jirocercii (PCP) pneumonia
   - CD4 = 200
   - via TMP-SMX, dapsone, pentamidine
2. Toxoplasmosis: (ring enhance lesion in MRI)
   - CD4 = 100
   - TMP-SMX (bactrim)
3. MAC:
   - CD4 = 50
   - azithromycin (macrolide)
4. Coccidiodes Immitis
   - CD4 = 250
   - Arizona, Texas, California, los angles
   - Itraconazole
5. Histoplasmosis
   - CD4 = 150
   - Ohio, kentaki, Missouri
   - itraconazole

Question 16

Hyperosmolar serum + hypoosmolar urine + hypernatremia + hypokalemia

Answer 16

Central DI:
- damage of supraoptic nucleus in hypothalamus (no ADH produced) in posterior pituitary

Nephrogenic DI:
- kidney not responding to ADH

—> water deprivation test then + desmopressin
1. Central DI: diluted urine then urine osmolarity go up
2. Nephrogenic DI: diluted urine than stays diluted

Treatment:
1. Nephrogenic DI:
- HCZT
- amiloride or triamterene: treat lithium-induced nephrogenic DI

2. Central DI:
   - desmopressin (ADH)
3. Normovolemic hypernatremia:
   - normal saline
4. Hypovolemic hypernatremia:
   - normal saline first (to become normovolemic) then 5% dextrose
5. Fix hypernatremia quickly lead to cerebral edema
6. Fix hyponatremia quickly lead to osmotic demyelination

Question 17

Osteoarthritis

Answer 17

1. Joint space narrowing + osteophyte + subchnodro sclerosis/cyst
2. In older people
3. Pain gets worse throughout the day
4. Less than 2000 WBC (during taping)
5. First line medication: acetaminophen (not NSAIDs), then proceed to NSAIDs
6. If medication don’t work send them to ortho to replace the whole joint
7. Obesity increases risk for OA
8. Obesity decreases risk for osteoporosis (constant weight bearing ) -> mostly seen with anorexic patients

Question 18

Business conference 1 week ago + fever+ abdominal pain + nonproductive cough + hyponatremia

Answer 18

1. Legionella —> test via: urinary antigen—> treat via: fluoroquinolone, macrolide (azithromycin)
2. Common cause of atypical pneumonia: mycoplasma —> chlamydia —> legionella ….typical chest x-ray finding: interstitial infiltrate
3. C. Psittaci —> associated with birds/turtles
   - also turtle associated with salmonella
4. C. Burnetii —> associated with cow, cattle, goat
5. Mycoplasma —> associated with walking pneumonia —> teenager or 20-40 year old (variety of age) + not super high fever + not productive cough + interstitial infiltrate

Question 19

Macrolide

Answer 19

1. Mycoplasma
2. chlamydia
3. legionella,

Question 20

Midsystolic click heard best at apex

Answer 20

1. Mitral valve prolapse (MVP) —> risk factor: marfan, ehler danlos, autosomal dominant polycystic kidney disease/ADPKD (bilateral kidney mass)
2. Female + history of psychiatric problem + pregnancy + connective tissue diseases (lupus..)
3. Myxomatous degeneration of the valve common for MVP
4. Diagnosis any murmur with: echocardiogram
5. Increase murmur (worse) with decrease preload ( valsalva/standing) & decrease afterload (amyl nitrate)
6. Decrease murmur (better) with increase preload (leg raise/ squatting) & increase afterload ( handgrip)

Question 21

Aortic dissection

Answer 21

Associated risk factors: HTN + cystic medial necrosis (Marfan)

Question 22

Maneuvers & murmurs

Answer 22

Increase venous return/ preload ( leg raise, inspiration, infusion, squat)

1. Increase murmur (worse) in: MS, AS, MR, AR, VSD (better with decrease preload: valsalva/standing)
2. Decrease murmur (better) in: HOCM, MVP (worse with decrease preload: valsalva/standing)

Increase afterload (handgrip)
1. Decrease murmur (better) in: AS, HCOM, MVP ( increase murmur with decrease after load: amyl nitrate)

2. Increase murmur (worse) in: MR, AR, VSD (decrease murmur with decrease afterload: amyl nitrate)

Question 23

Drugs with murmur

Answer 23

Diuretic:
1. Better
2. Replace AS + Balloon MS
3. Use in AR, MR, VSD
4. Don’t use for HOCM, MVP

ACE-i
1. Not used in AS/MS
2. Used in AR, MR, VSD
3. Don’t use for HOCM, MVP

Question 24

Scaly, itching skin, with yellow crust in the winter

Answer 24

• sehborriec dermatitis
• treat with: topical antifungal

Question 25

Pheochromocytoma (over-expression of catecholamine)

Answer 25

- catecholamine-secreting tumor - located in adrenal tumor & posterior mediastinum - episodic HTN + Headache + palpitation - associated with with MEN 2A & 2B - Associated with NF type 1 - associated with VHL ( hemangioma in the brain ) ** diagnosis with: elevated urine metanephrine + CT scan (if CT is negative, do MIBG scan) ** treat with: alpha-blocker (phenoxibenzamine or phentolamine) + then, beta-blocker (propranolol)

Question 26

Low GI bleed in elderly

Answer 26

1. common cause : diverticulosis —> diagnosed with barium enema or colonoscopy (note that diverticulitis is diagnosed with CT scan) 2. prevent diverticulosis with eating high-fiber diet

Question 27

Macrocytic or megaloblastic anemia ( MCV > 100)

Answer 27

1. Blood smear finding: hyper-segmented neutrophils + big RBC cell 2. Folate deficiency seen with: alcoholic, malnutrition (elderly women on tea & toast diet) 3. Folate synthesis inhibitors: - molar pregnancy (methotrexate) - ring enhance lesion + HIV (pyrimethamine + sulfadiazem) - HIV + CD < 200 ( TMP-SMX) 4. Methotrexate can lead to pulmonary fibrosis —> lead to toxicity in lung, liver, kidney 5. Leucovorin is used rescue bone marrow with methotrexate toxicity

Question 28

Classic CMV present with —> esophagitis, colitis, retinitis + periventricular calcification + owl-eye inclusion

Answer 28

- CMV esophagitis shows in endoscopy as linear ulcer with punched out lesion -post-transplant patient tend to get CMV colitis - HIV patient tend to get CMV retinitis ( Usually when CD4 count below 50) * if a kid gets congenital CMV —> Calcification in periventricular of the brain ** diffused calcification (everywhere in brain) + infection —> associated with congenital toxoplasmosis ( chorioretinitis + hydrocephalus + intracranial calcification) - histology of CMV shows —> owls eye inclusion - treat CMV via intiviral drugs: 1. ganciclovir —> foscarnet

Question 29

CD4 < 200 + severe peripheral edema + frothy urine

Answer 29

- focal segmental glumerulosclerosis (FSGS) - In HIV patient shows colapsin variant of FSGS - Treat FSGS with: ACE- inhibitor (protect kidney) (+ steroid + cyclophosphamide) - HIV drugs side effect on kidney: 1. Indinavir: causes nephrolithiasis - triad of: 1. fever + rash + eosinophil in urine/blood —> seen with acute interstitial nephritis (AIN) —> mainly caused by drugs—> Classic drug causing AIN is penicillin —> treat AIN with: 1. Stop drug, if severe AIN add steroid

Question 30

Vitamin D metabolism

Answer 30

- vitamin D in stomach —> go to liver & converts it into 25- hydroxyvitamin D (calcidial) —> go to kidney & converts it into 1-25-hydroxyvitamin D ( calcitriol) - osteomalacia: shows in adult - rickets: shows in kids Causes of vitamin D deficiency: 1. CKD —> 1-alpha-hydroxylase deficiency 2. Liver disease —> 25-hydroxyvitamin D deficiency 3. Cystic fibrosis/chron’s disease —> malabsorption (CF: no pancreatic enzyme/ADEK vitamins are not absorbed, CD: no terminal ileum) - treat vitamin D deficiency with: vitamin D & Ca supplement Laboratory: 1. Vitamin D deficiency: - low vitamin D + low Ca + low/high phosphate + high PTH (Secondary hyperparathyroidism) ( if vitamin D deficiency is caused by liver disease: low phosphate) ( if vitamin D deficiency is caused by CKD: high phosphate) 2.