Shelf Review Flashcards

Question

Hemoglobin less than 7

Answer 1

- need transfusion

Answer 2

- alcohol abuse

Answer 3

- next step: stool analysis (check for WBCs) 1. If WBC present: inflammatory diarrhea (campylobacter, EHEC, salmonella, shigella, yersenia) - management for gastroenteritis: 1. keep patient hydrated with oral/IV fluid 2. If patient is hypotensive, give them IV fluid 3. If patient is normotensive, give them oral rehydration therapy ( glucose + salt) 4. Only give antibiotic, if the patient is young, immunosuppressed or very elderly

Answer 4

1. Increase glucose dependent insulin secretion 2. Decrease glucagon secretion 3. Decrease gastric emptying 4. Decrease appetite

Answer 5

Similar effect as GLP-1

Answer 6

- causes hypoglycemia - activate epinephrine release - lead to: 1. Hypoglycemia awareness —> behavioral response —> risk for severe hypoglycemia 2. Hepatic glucose production —> risk for severe hypoglycemia

Answer 7

- antipsychotic medication (respiradone) : causes secondary hyperprolactinoma due to their dopamine blockade effect —> lead to elevated prolactin (25-100) - prolactinoma: lead to exaggerate elevation in prolactin ( above 200)

Answer 8

- sport injury: soccer -Knee pop, significant swelling, ± hemarthrosis -positive test: anterior drawer test & Lachman

Answer 9

- tibial forced posteriorly with fixed ankle ( dashboard injury) - positive test: posterior drawer test

Answer 10

- knee “clicking” - positive test: McMurray & thessaly test

Answer 11

- Often injured in combination with ACL & meniscus (unhappy triad) - positive test: laxity in Valgus stress

Answer 12

- Positive test: laxity on varus stress

Answer 13

- high-riding patella - positive test: inability to “extend knee” or “flex hip with knee straight”

Answer 14

- next best management: Semaglutide (induce weight loss)

Answer 15

1. Lifestyle modification - healthy diet, exercise 2. Oral metformin - 3. Additional non-insulin antidiabetic drugs - 4. Insulin therapy

Answer 16

1. Metformin - Mechanism: inhibits mGPD, activates AMP kinase —> decrease hepatic gluconeogenesis - side effect: GI upset, kidney injury - high yield: lead to lactic acidosis (AGMA) 2. GLP-1 agonist (-tide) - mechanism: Activates glucagon-like peptide-1 receptor —> decrease glucagon release + increase satiety - side effect: decrease appetite + weight loss + pancreatitis + gastroparesis - high yield: avoid in MEN syndrome (lead to thyroid or pancreatic cancer) + helpful with obesity 3. Sulfonylureas (-ride, -zide) - mechanism: inhibits beta-cell K+ channels —> endogenous insulin release (even when glucose in low) - side effect: hypoglycemia + weight gain + disulfiram-like reaction (first generation) (produce symptoms similar to alcohol hangover) - high yield: avoided these days 4. SGLT-2 antagonist (-gliflozin) - mechanism: inhibits SGLT-2 in the proximal tubules —> glucose excreted in urine - side effect: UTI (excess glucose in urine; candidiasis), dehydration —> orthostasis - high yield: reduce CVD mortality in diabetics & cardiovascular disease 5. Thiazolidinediones (TZD) (-zone) - mechanism: activates PPAP-gamma —> increased transcription of glucose/lipid gene metabolism - side effect: weight gain, heart failure, osteoporosis Note: - fibrates: activates PPAR- alpha

Answer 17

- management: initiation of CCB, ACE-I, & follow-up - additional test for primary HTN: fasting serum lipid

Answer 18

Reasons to suspect secondary HTN: (RRAS) 1. HTN refractory to 3 medications at maximum dose 2. Rapid onset of HTN (days to weeks) 3. Unusual age of onset ( < 30 years old) 4. Specific Symptoms ( abdominal bruits, electrolyte abnormality) ** if you don’t see these signs treat as uncontrolled primary HTN Initial evaluation of HTN: 1. ECG 2. Lipid panel (Metabolic syndrome) 3. Urinalysis (kidney damage from HTN) 4. Complete metabolic panel (Electrolyte abnormality)

Answer 19

Pre-HTN (120-129/<80) (SBP is 10 above normal) - management: lifestyle modification (weight loss (iF BMI >25) —> DASH diet —> exercise —> dietary sodium restriction) Stage 1 HTN (130-139/ 80-90) - management: lifestyle changes ± one antihypertensive - antihypertensive if: diabetes, CKD, ASCVD 10%+ Stage 2 HTN (> 140/>90) -management: Lifestyle changes + two antihypertensive

Answer 20

- suspect white-coat HTN - Initial management: ambulatory BP monitoring before initiation of anti-hypertensive medication

Answer 21

1. ACE-inhibitor (-pril) -Mechanism: inhibits angiotensin converting enzyme (ACE) -side effect: Dry cough, hyperkalemia, AKI, angioedema, avoid in pregnancy - high yield: Avoid in bilateral renal artery stenosis, useful in diabetic patients - prescribed in patient with: Diabetes, nephropathy, CHF, MI history - have synergistic effect when prescribed with thiazide 2. Angiotensin 2 receptor blocker (ARBs) (- satran) -Mechanism: blocks angiotensin 2 receptor -side effect: hyperkalmeia, AKI, contraindicated in pregnancy - high yield: avoid ACE cough 3. Thiazide diuretics (-thiazide) -Mechanism: inhibits Na/Cl cotransporter in distal convoluted tubules -side effect: hyponatremia, hypokalmeia, hyperglycemia, hypercalcemia, hyperurecemia (gout) - Used in caution in people with gout and diabetes - high yield: treats nephrogenic diabetic insipidus, increases lithium concentration, useful in osteoporosis 4. Dihydropyridine CCB (-dipine) -Mechanism: inhibits calcium channel in vascular smooth muscle (lead to vasodilation) -side effect: orthostasis, lower extremity edema - high yield: helpful in treating Raynaud syndrome Note: 1. non-dihydropyridine CCB: works on cardiac muscle —> verapamil & diltiazm —> can be used in HTN with atrial Fibrillation —> verapamil can cause constipation 2. With loop diuretics (furosemide)—> lead to hypocalcemia —> good to use in case of gout 3. Side effect of potassium sparing diuretics —> hyperkalemia & gynecomastia with spironolactone & contraindicated in renal failure 4. Alpha-1 blocker (-zosin) —> not first line for HTN, but can be used for BPH

Answer 22

Testicular torsion - torsion of the spermatic cord (due to sport…) - sudden onset, scrotal edema, testis in horizontal position, absent of cremasteric reflex, no relief with testicular elevation - ultrasound: absent doppler flow Torsion of appendix testis - remnant of the mullerian duct - insidious onset, focal testicular tenderness at upper pole, blue dot sign -ultrasound: enlarged testicular appendix, possible hydrocele, normal blood flow Epididymitis - STI or UTI causing inflammation of the epididymis - tenderness at posterior pole of testis, relief of pain with elevation (Prehn sign), dysuria (urinary discharge) - presence of cremasteric reflex - ultrasound: increase blood flow to epididymis

Answer 23

1. Upper airway cough syndrome (UACS) (POST-nasal drip) - worse at night (can be related to allergies) - relief with antihistamine 2. Asthma - young adult, worse with exercise/run - pulmonary function test —> methacholine challenge ( > 20% reduction in FEV1) 3. GERD - Worse after eating & at night - relief with proton pump inhibitor ( pantoprazole) 4. ACE-inhibitor: - recently started on new medication for HTN —> dry cough - relief after stopping ACE-inhibitor ( switch to ARBs) Note: —> if no improvement or suspicious symptoms (purulent sputum, immunocompromised) —> do chest X-ray

Answer 24

1. Acromioclavicular joint dislocation - trauma or injury - tenderness upon adduction of the arm across torso - palpable deformity at the superior aspect of the shoulder 2. Anterior shoulder dislocation - posterior trauma in vulnerable position ( throwing motion) - axillary nerve damage (loss of sensation at deltoid, deltoid weakness) - flattened deltoid prominence, prominent acromion, abducted, externally rotated shoulder 3. Posterior shoulder dislocation - fall on outstretch hand (FOOSH) - Anterior shoulder flattening - arm held in adduction & internal rotation 4. Rotator cuff tear - recent trauma or worsening of chronic symptoms (may not appear acute if torn chronically) - most common is supraspinatus tendon - arm drop positive (can’t left arm, can’t sleep on side) - decrease abduction with intact sensation Note: - with axillary nerve injury: sensation is lost

Answer 25

1. Allergic rhinitis - watery rhinorrhea + itchy eyes + sneezing - treat with: intranasal glucocorticoids —> oral antihistamine 2. Non-allergic rhinitis - seasonal variation, no obvious trigger, later onset ( 20 + years) - treat with: intranasal glucocorticoid or intranasal antihistamine (azelastine) 3. Viral sinusitis - rhinorrhea + nasal congestion + sore throat + cough ± fever - treat supportively (saline ….) 4. Bacterial sinusitis - 10+ days + fever > 39 + 3 or more days of purulent discharge + initially improved then worsened ( improvement of viral —> progressed to bacterial) - treat with: amoxicillin + clavulanic acid (Augmentin)

Answer 26

1. young patient with severe & sharp chest pain radiating to the back, unequal blood pressure in the right & left arm - aortic dissection 2. Patient with substernal chest pain, worsen after eating or at night - GERD 3. Recent viral illness, chest pain that improves when leaning forward, fever, “scratching” sound on cardiac auscultation - acute pericarditis - treat with: NSAID -Prevented recurrence with: colchicine 4. Young patient with sharp chest pain, reproducible with palpation of the chest wall - costochondritis 5. Recent viral illness, sharp chest pain, worsens with deep inspiration, scratching sound on auscultation that disappear while breath-holding - viral pleurisy

Answer 27

1. Severe, acute, epigastric abdominal pain radiating to the back - acute pancreatitis - similar to AAA 2. Long-standing history of GERD (or ulcer history), refractory symptoms, now with acute epigastric pain, rebound, abdominal rigidity - perforated peptic ulcer 3. Obese patient, history of coronary artery disease, present with abdominal pain, precipitated with eating, recent food avoidance (food eversion) & weight loss - chronic mesenteric ischemia (intestinal angina) 4. Middle-aged female, with epigastric pain (or RUQ) radiating to the right side & back, fever, leukocytosis - acute cholecystitis 5. Severe, unilateral flank pain, groin pain that periodically worsens & improves - nephrolithiasis

Answer 28

1. G1P0 patient at 32 weeks with gestational diabetes presents with uterine fundus measuring 36 cm - polyhydramnios ( GDM —> fetal glucosuria —> excess amniotic fluid) - fetus exposed to high level of glucose —> have increased growth & polyuria —> result in increased amniotic fluid - at week 32 we expect the fundus to be 32 2. G2P1 patient presents for prenatal appointment at 21 weeks with blood pressure 145/91 & 3+ pitting extremity edema - preeclampsia (diagnosed when BP 140/90 & 24-hrs Urine protein excretion of 300 mg or secondary organ dysfunction) 3. Patient at 7 weeks gestation with persistence N/V, now has orthostatsis & electrolyte abnormalities - hyperemesis gravidarum (uncontrollable pregnancy-related vomiting) - treat with: vitamin B6, or anti-histamine, or admit to hospital for IV fluid hydration if severe electrolyte imbalance 4. Pregnant patient with generalized pruritus, worse on the palms, elevated bile acid - intrahepatic cholestasis of pregnancy - treated with: urodeoxycholic acid ( to lower bile acid) 5. G3P2 with chronic HTN presents with decreased fetal movement & uterine fundus smaller than expected for gestational age: - oligohydromnios: intrauterine growth restriction + decrease amniotic fluid Note: 1. Diabetes —> lead to polyhydromnias (increase growth + increase amniotic fluid) 2. HTN —> lead to oligohydromnias ( intrauterine growth restriction + decrease amniotic fluid)

Answer 29

1. Child with 6 days history of fever, red eyes, oral & tongue redness, hand/foot swelling - kawasaki disease - treat with: Salicylates, IVIG - CRASH & BRUNS—> 1. Conjunctivitis (non-exudative, bilateral injection) 2. Rash (non vesicular, no bullae) 3. Adenopathy ( cervical, unilateral) 4. Strawberry tongue (redness of oral mucosa, or lips, or dry peeling lips) 5. Hand (swelling or erythema of hand or feet) 6. Burns ( >5 days of fever) 7. Coronary artery aneurysm 2. 1-year old male with urinary tract infection (secondary), stool 1-2 times per week, blood on toilet paper, anal fissure - constipation 3. Child with red, itchy eyes, runny nose, and rash spreading from head to rest of the body - measles - history of no vaccination or family don’t believe in vaccination 4. 5-week old previously healthy male with projectile vomiting, formula colored - pyloric stenosis 5. No childhood immunization, bilateral jaw swelling, presenting with nuchal rigidity, and brudzinski sign - Mumps (can cause: parotitis, meningitis, pancreatitis, bronchitis, or inflammation of the testis) 6. 5-year old child with RUQ pain, jaundice, palpable mass - biliary cyst - need to be removed because increase risk for malignancy

Answer 30

1. Thiazide diuretics 2. ACE-i/ARBs 3. CCB

Answer 31

1. Thiazide diuretics 2. Long-acting CCB

Answer 32

1. ACE-i/ARBs 2. Beta-blockers (not used as initial monotherapy)

Answer 33

1. ACE-I/ARBs: - heart failure - systolic dysfunction - diabetes - CKD - History of STEMI or NSTEMI 2. Thiazide diuretics: - good monotherapy in HTN & osteoporosis 3. CCB: - HTN & gout

Answer 34

HTN urgency: 1. Increased BP greater than 180/120 without any sign of end organ damage 2. Treatment: Clonidine (alpha-2 agonsit) HTN emergency: 1. Increase in BP greater than 180/120 with impending or progressing end organ damage 2. Treatment: Nitroprusside

Answer 35

Screening guideline: 1. In high risk people —> - begin around 20-25 years in males - begin around 30-35 years in females 2. In lower risk people—> - begin around age 35 in males - begin around age 45 for females 3. Reassess every 5 years in patients that do not have cardiovascular disease Target value: 1. Total cholesterol < 200 2. LDL (BAD) < 100 3. HDL (GOOD) > 60 4. Triglyceride < 150 Note: - hypercholesterolemia ( caused by high cholesterol or LDL) - hypertriglyceridemia ( high triglyceride) - hyperlipidemia is the umbrella term for all of these

Answer 36

Symptoms: 1. Asymptomatic 2. Develop xanthomas (lipid deposits on the skin tendons & subcutaneous tissue) 3. Significant hypertriglycerdemia lead to pancreatitis First line treatment: 1. Lifestyle modification (diet + exercise) 2. Statin Four rules to guide initiation of statin therapy: 1. Any patient with clinical atherosclerotic CVD 2. Any patient with LDL level > 190 (most likely familial) 3. Any patient aged 40-75 with an LDL > 70 & diabetes 4. Any patient aged 40-75 with LDL > 70 & estimated ASCVD risk of > 7.5% * gal of treatment is to lower LDL by 30% Drugs: 1. Statin - reduce production of cholesterol by inhibiting (rate-limiting step) thus decrease LDL - effective in reducing LDL - Not effective in reducing triglyceride - contraindicated in pregnancy & lactation & liver disease - side effect of statin: myalgias & cramps & elevated CK level 2. Ezetimibe: - used with statin to further reduce level of LDL 2. Fibrates (Gemfibrazil & phenofibrates) - Reduce level of triglyceride - increase in HDL - contraindicated in hepatobiliary disease and severe renal disease - Side effect: increase LFT & Myositits & myalgias & increase risk of gallstones 3. Bile acid sequestrants (cholesteramine) - useful in combination with statin or niacin - reduces LDL level - bind bile acid in intestine - only cholesterol medication that is safe in pregnancy - used for pruritus associated with biliary obstruction - side effect: increase triglyceride & should bot be used in hypertriglyceremia 4. Niacin - is vitamin B3 - Increase level of HDL & Second best drug to reduce triglyceride - side effect: flushing ( treated with aspirin prior to niacin), headache, pruritus, hyperglycemia, hyperuricemia - used in caution with diabetic & gout patient 5. Ezetimibe 6. Omega-3 fatty acid

Answer 37

- occurs when there is reduced in coronary blood supply but there is increase in demands - common cause is atherosclerosis (occludes coronary vessels), vasospasm, aortic stenosis, pulmonary HTN, Regurgitation, severe systemic HTN, hypertrophic cardiomyopathy - risk factor for CAD: HTN, smoking, diabetes, hyperlipidemia, male gender, increased age, family history, obesity - patient become symptomatic if there is occlusion (stenosis) of 70% or more symptoms: - asymptomatic - chest discomfort & SOB - Chest pain (angina) (stable or unstable) Stable angina: - predictable -presents with a consistent amount of exertion - relieve is achieved with rest or nitroglycerin Unstable angina: - unpredictable - presents during rest - often recurrent - indicative of ruptured plaque with clot formation in the vessel Diagnosis of CAD: - Cardiac catheterization (visualize any blockage in coronary artery)

Answer 38

Angina pectoris (stable angina) - substernal chest pain - brought on by exertion ( due to decreased coronary blood flow & increased demand) - radiates to arm, teeth, jaw, back, epigastrium, or shoulder - chest pain relieved by rest or nitroglycerin - associated symptoms: dyspnea, nausea, diaphoresis - women or diabetics don’t have the classical chest pain presentation —> complain of dyspnea, epigastric pain or shoulder pain Work-up: 1. ECG: - usually normal (50% of the times) - abnormal shows: ST depression, T-wave inversion, poor r-wave progression, Left ventricular hypertrophy 2. Stress testing: - Stress ECG: Performed on treadmill or pharmacologically ( adenosine or dipyridamol are coronary vasodilator) —> positive stress test shows ( ST depression, hypo or hypertension, arrhythmia or clinical symptoms) - Stress echo: can be done with exercise or pharmacologically —> locate ischemia, assess wall motion abnormalities, assess LV function, assess vulvular disease —> usually paired with stress ECG for further information - Stress nuclear myocardial perfusion scan: done on patient with baseline ECG abnormalities, can be done with exercise or pharmacologically —> to localize regions of ischemia in the heart - cardiac MRI: alternative to stress test —> imaging is performed with dobutamine infusion & assess cardiac perfusion & wall motion abnormalities 3. coronary angiography (cardiac catherization) - indicated for patient with CAD with negative stress test - indicated in patient need revascularization of coronary arteries - revascularization of coronary artery is done by either: percutaneous transluminal coronary angioplasty (PCI) or coronary artery bypass graft (CABG) Note: - adenosine & dipyridamol are constraindicated in asthma due to bronchspasm —> asthma patient receives dobutamine ( positive ionotropin & chronotrope ) - CABG (Open-heart surgery) is indicated when 3 or more vessels are blocked, or left main coronary artery, or have decreased LVEF - patient prescribed aspirin & clopidogrel after stenting to prevent stent thrombosis

Answer 39

1. Daily aspirin 2. Beta blocker or alternative CCB 3. Statin 4. Nitroglycerin as needed for chest pain NOTE: - Side effect of nitroglycerin—> headache + hypotension + contraindicated in patient with SBP below 90 + patient with right-ventricular MI + contraindicated in patient taken Phosphodiesterase 5 Inhibitors (viagra) in the past 48 hours

Answer 40

1. ACE-inhibitor 2. Beta- blocker 3. Ibuprophine 4. Adenosine 5. Dipyridamol Only paracetamol is allowed in asthma

Answer 41

1. Upper airway cough syndrome (UACS) -chronic cough that is worse at nigh & improve with antihistamine 2. GERD - chronic cough that is worse at nigh and after eating & improve with PPI 3. Asthma - chronic cough that is worse at nigh & did not improve with antihistamine - can be treated empirically with 2-4 weeks of inhaled glucocorticoid, if the cough improves, a diagnosis of asthma can be made - assess with PFT (spirometry)—> if negative, do methacholine 4. ACE-I - dry cough 5. Airway disease ( nonasthmatic eosinophilic bronchitis, chronic bronchitis, bronchiectasis, malignancy) 6. Pulmonary parenchymal disease (lung abscess, interstitial lung disease) Note: 1. Bronchoscopy —> assess foreign body 2. Chest CT —> suspect parenchyma lung disease or malignancy 3. Echo or direct laryngoscopy (cardiac & laryngeal testing) —> evaluate less common cause of chronic cough

Answer 42

- is a mild viral illness - vaccine at age of 12 months & 4 years with live MMR vaccine Symptoms: (develops 2-3 weeks after inhalation of respiratory droplet) 1. fever (low-grade) 2. rash (begins on face & spread to the rest of the body) (lasts < 3 days) 3. lymphadenopathy (suboccipital, posterior auricular, posterior cervical) 4. Erythematous soft palate (forchheimer spots) Treatment: - supportive Note: - prenatal infection leads to spontaneous abortion, fetal demise, or congenital rubella syndrome (hearing loss, cataract, patent ductus arteriosus)

Answer 43

Symptoms: 1. Fever (high-grade) 2. Conjunctivitis 3. Cough 4. Coryza ( copious clear mucus) 5. Koplik spot (white exudate on inner side of cheek) 6. Rash (Erythematous morbilliform ) - maculopapular rash that spread cephalocuadally & after few days, coalesces & darkens ( red/brown)

Answer 44

- diagnosis > 3 years - streptococcal infection Symptoms: 1. Fever 2. Palatal petechiae 3. Sand-paper texture rash - starts at skinfold ( axilla, groin), then spread to trunk & extremity

Answer 45

- caused by parvovirus B19 - occurs in school-aged children Symptoms: 1. Prodromal symptoms ( fever + rhinorrhea) 2. Slapped-cheek rash (occurs after resolved prodromal symptoms)

Answer 46

Maternal disease lead to utero infection 1. CMV 2. Rubella 3. Parvovirus B19 Viruses infect children as grow older: 1. Rhinovirus 2. Influenza virus Vaccine-preventable infection 1. Mumps 2. Measles 3. Rubella Antiviral drug treated infection: 1. HSV 2. Influenza virus 3. Varicella zoster virus 4. CMV

Answer 47

Symptoms: 1. Fever + fatigue in the setting of pharyngitis 2. Absent of cough 3. enlarged cervical nodes 4. Erythematous/enlarged tonsils 5. Enlarged spleen 6. Rash development after amoxicillin ** Can lead to acute airway obstruction + AIHA/thrombocytopenia + splenic rupture ** only virus with all 4 centor criteria Patient present with: 1. Dysphagia (difficulty swallowing) 2. Respiratory distress ( mouth breathing, tachypnea) Treatment: 1. Corticosteroid to decrease airway edema 2. Supportive = self-resolved

Answer 48

1. Lead to acquired subglottic stenosis (narrow of larynx below the vocal cord)

Answer 49

1. Common in young children after upper respiratory viral infection

Answer 50

1. Fetal cellulitis of the submandibular space 2. Caused by bacterial spread from adjacent infection —> most commonly bacterial abscess

Answer 51

1. Potential sequela of group A streptococcal (GAS) pharyngitis 2. Lead to: - fever - sore throat - tender anterior cervical node - resolve within a week

Answer 52

1. rash in the dermatomes —> small papule—> evolve into vesicles or bullae with ulceration & crusting 2. Caused by activation of varicella zoster virus 3. Increased risk seen with decreased cell-mediated immunity ( older age or HIV) 3. TREATMENT: antiviral agent ( acyclovir, famciclovir, valacyclovir) Note: - Post-herpatic neuralgia: persistence neuritic pain > 4 months after rash onset ( treated with TCA, pregabalin, Gabapentin)

Answer 53

- for treatment of drug-resistance CMV - for treatment of severe VZV after failing first line treatment (not for uncomplicated shingles)

Answer 54

- Caused by: adenotonsillar hypertrophy ( lead to significant nasal airway obstruction by adenoid hypertrophy—> open mouth breathing) 1. Child with nighttime loud snoring (noisy breathing at night) 2. Gasping for air during sleeping 3. Enuresis + parasomnias 4. Failure to thrive ( low percentile for weight) 4. Daytime sleepiness may not present (in contrast to adults) 5. Daytime symptoms: inattention, learning difficulties, behavioral problems Management of Adults OSA: - weight loss + continuous positive airway pressure Management of children OSA: - tonsillectomy & adenoidectomy (T & A)

Answer 55

- open mouth breathing - runny nose - itchy eyes - sneezing

Answer 56

1. Pneumonia (consolidation) - increased breath sound + increased tactile fremitus + dullness on percussion + normal tracheal position 2. Pleural effusion - decreased breath sound + decreased tactile fremitus + dullness on percussion + tracheal deviates away from affected lung 3. Pneumothorax - decreased breath sound + decrease tactile fremitus + hyperresonance with percussion + tracheal deviates away from affected lung 4. Atelectasis - decreased breath sound + decreased tactile fremitus + dullness with percussion + trachea deviates towards collapsed lung

Answer 57

- A pulmonary bleb is a small collection of air between the lung and the outer surface of the lung (visceral pleura) usually found in the upper lobe of the lung. - When a bleb ruptures the air escapes into the chest cavity causing a pneumothorax (air between the lung and chest cavity) which can result in a collapsed lung.

Answer 58

- suspected in patient with history of lung disease (COPD, Cystic fibrosis) - smoking increase the risk of spontaneous pneumothorax Etiology: - chronic destruction of alveolar sacs leads to the formation of large alveolar blebs —> which can eventually rupture & leak air into the pleural space Symptoms: - SOB + chest pain + hypoxia + unilateral decreased breath sound + hyper-resonance on percussion Diagnosis: - chest x-ray Management: 1. observation with supplemental oxygen Or 2. emergency tube thoracotomy

Answer 59

Decrease FEV1/FVC (obstructive lung disease= asthma, COPD/ chronic bronchitis + emphysema, bronchiectasis) 1. Decrease DLCO —> COPD 2. Normal/Increase DLCO —> asthma Normal/Increased FEV1/FVC: 1. Decreased DLCO —> interstitial lung disease ( restrictive lung disease; progressive fibrosis, asbestos, beryllium, silicon dioxide, amiodarone, nitrofurantoin, RA, scleroderma) + granulomatous disease (sarcoidosis) 2. Normal DLCO —> chest wall weakness

Answer 60

* Obstructive pattern ( FEV1/FVC < 70% of predicted) 1. Decreased DLCO —> emphysema 2. Normal DLCO —> chronic bronchitis, asthma 3. Increased DLCO —> Asthma * Restrictive pattern (FEV1/FVC > 70%, with FVC < 80% predicted) 1. Decreased DLCO —> Interstitial lung disease + sarcoidosis + asbestosis + heart failure 2. Normal DLCO —> MSK deformity + neuromuscular disease 3. Increased DLCO —> morbid obesity * Normal spirometry 1. Decreased DLCO—> anemia + PE + Pulmonary HTN 2. Normal DLCO —> 3. Increased DLCO —> pulmonary hemorrhage + polycythemia

Answer 61

Panacinar emphysema: - typical of alpha-1 antitrypsin - usually lower lobe of lung Centriacinar emphysema: - typical smoking-induced COPD - upper lobe of lung

Answer 62

- can be similar in presentation 1. Bronchiectasis —> due to abnormal bronchial widening in the setting of recurrent infection/inflammation + more sputum production + chest x-ray shows dilated (rather than thickened) conducting airway + bacterial superinfection

Answer 63

1. Benign skin infection & not painful 2. Common in children 3. Flesh-colored papule with central umbilication 4. Lesion resolves in 6-12 months 5. Management typically reassurance & observation in children 6. Management can be cryotherapy, curettage , topical cantharidin in adults ( can be painful & lead to scarring)

Answer 64

1. Myocardial infarction (stable angina, unstable angina, STEMI, NSTEMI) - stable angina - unstable angina - NSTEMI - STEMI 2. Prinzmetal variant (vasospastic angina) - transient ST elevation (due to coronary artery vasospasm) + non exertional chest pain, often at rest - risk factor: smoking + cocaine abuse - diagnosis: coronary angiography in the CATH lab & injecting provocative agent (ergonovine), which induces vasospasm - treatment: CCB 3. Pericarditis: - chest pain relieved when leaning forward + worse when laying supine or during inspiration - on exam: hearing of friction rub + fever - ECG: shows diffused ST-elevation in the pericordial lead (v1 through v6) + with associated PR-depression - echo: to rule out complication such as, pericardial effusion - treatment: 1. NSAID or aspirin & 2. use of colchicine to prevent recurrence 4. Aortic dissection: - severe & sharp central chest pain that radiates to the back (between scapula) - risk factor: HTN - Diagnosis: MRI angiography - if the tear at the ascending aorta (Type A) —> the dissection is surgical emergency - if the tear at the descending aorta ( Type B) —> initially managed with beta-blocker 5. Pulmonary embolism: - SOB + pleuritic chest pain -risk factor: DVT from lower extremity - diagnosis: helical CT scan, adjunctive venous doppler Ultrasound, V/Q scan (pregnant women), pulmonary angiography ( hemodynamically stable), chest x-ray, D-dimer - treatment: anticoagulation ( heparin…) 6. Pulmonary HTN - exertional dyspnea + right-sided Heart failure (chest pain + edema + syncope) - causes: left-heart disease, chronic lung disease, mitral stenosis - diagnosis: right-heart catheterization (directly measures the pressure) - treatment of underlying cause 7. Carditis: - causes chest pain or discomfort - most common result of rheumatic fever - associated symptoms: joint pain + subcutaneous nodules + erythema marginatium +seinheim chorea - rheumatic fever occurs 2-4 weeks after GAS infection (strep throat) - diagnosis: based on John’s criteria - treatment: aspirin & corticosteroid …& penicillin G for all patients 8. Costochondritis: - pleuritic chest pain that gets worse with inspiration & palpation or movement of arms or torso - common after: MSK trauma or strain or viral illness where you cough a lot - treatment: rest & NSAIDS

Answer 65

hepatocellular pattern of liver disease - elevated AST & ALT - seen with: 1. Autoimmune hepatitis 2. Alcoholic hepatitis 3. Hepatitis A Cholestatic pattern: - elevated alkaline phosphatase & bilirubin - seen with: 1. Amlodipine (CCB) 2. Primary biliary cholangitis (PBC)

Answer 66

- Hepatocellular pattern of liver injury - asymptomatic patient present with abnormal LFT - symptomatic patient present with fatigue, anorexia, nausea, jaundice, can progress to fulminant liver or cirrhosis - can be associated with: vitiligo, autoimmune thyroiditis, celiac disease - findings: 1. Elevated AST & ALT (> 300-900) 2. Hypergammaglobinemia (high IgG) & large gamma gap ( total protein - albumin = > 4 g/dl) 3. Elevated autoantibodies: - Anti-smooth - anti- liver/kidney microsomal type 1 - anti-nuclear 4. Histology: portal & periportal lymphoplasmacytic infiltration - treatment: prednisolone + azathioprine

Answer 67

- hepatocellular pattern of liver injury - symptomatic patient present with fever, jaundice, heavy alcohol use ( 5-6 drinks/day) - findings: 1. Elevated AST> ALT (2:1), rarely exceeds 300 U/L

Answer 68

- hepatocellular pattern of liver injury - symptomatic patient present with vomiting, fever, abdominal pain - findings: 1. Elevated AST & ALT > 1000 2. AST & ALT normalize within 3 months

Answer 69

- Autosomal codominant mutation - lead to: emphysema (cough + dyspnea + in the 40’s ) + liver disease ( chronic hepatitis + cirrhosis + family history of liver disease + abnormal LFT)

Answer 70

- cholestatic pattern - symptomatic patient present with hepatotoxicity after weeks to months of amlodipine use (adverse effect)

Answer 71

- cholestatic pattern - symptomatic patients present with: fatigue + pruritus + females - findings: 1. Elevated Alkaline phosphatase (> 1.5 of the upper limit) 2. Elevated bilirubin 3. Elevated anti-mitochondrial antibodies

Answer 72

- present in patient with metabolic syndrome (diabetes, & obesity, hyperdislipedemia) - findings: 1. Elevated AST & ALT (ratio < 1) 2. Hyperechoic - appearing liver on ultrasound ( due to hepatic steatosis = fat deposition on the live) 3. Liver fibrosis & cirrhosis, if excessive fat deposition 4. Mild hepatomegaly or minimal RUQ pain - treatment: 1. Weight loss 2. Bariatric surgery (BMI > 35) Note: 1. Insulin resistance promotes fat deposition on the liver

Answer 73

- cause severe feature of elevated AST & ALT - Develop acute RUQ pain & associated thrombocytopenia in 3rd trimester

Answer 74

- associated with high progesterone level, which inhibits gallbladder contraction & promote gallstone formation - gallstone increase risk for cholecystitis & ascending cholangitis - patient present with: fever, leukocytosis, abdominal pain, gallbladder-wall thickening, elevated AST & ALT

Answer 75

- Symptomatic patient present with pruritus in the palm & soles, elevated total bilirubin , elevated AST & ALT

Answer 76

Patient at average risk: 1. Start at age of 45 - colonoscopy every 10 years - FIT every year - CT colonography every 5 years - flexible sigmoidoscopy every 5 years (or every 10 years with annual FIT) Patient with first-degree relative or colorectal cancer or adenomatous polyp: - colonoscopy at age of 40 (or 10 years prior to diagnosis of first-degree relative, whichever comes first) - repeat every 5 years (or every 10 years if diagnosis of first-degree relative at age > 60) Patient with ulcerative colitis: - start screening 8-10 years after diagnosis - colonoscopy every 1-3 years

Answer 77

1. Liver disease: acute fatty liver of pregnancy, preeclempsia 2. Viral hepatitis: - diagnosis with viral hepatitis serology - should be considered in pregnant women with hepatocellular pattern of liver injury (elevated AST &ALT), even in those with negative screening tests at initial prenatal visits 3. Autoimmune hepatitis:

Answer 78

Normal: 1. Intermittent, consolable, < 3 hrs/day Colic (crying for no reason) 1. > 3 hrs/day (usually evening), > 3 days/week 2. Healthy infant, age < 3 months 3. Crying usually occur on the same time of the day —> solved with reassurance of parents & review of soothing techniques for baby (pacifier, holding, rocking, swaddling the baby, minimize environmental stimulus/ dark room), upright feeding position/reduce air swallowing GERD 1. Frequent spit-up 2. Back-arch after feeding 3. Irritability 4. Severe form: poor feeding + poor weight gain —> require treatment with H2 receptor blocker Infection: 1. Acute otitis media: bulging tympanic membrane ± fever —> require oral antibiotics 2. Meningitis: fever, lethargy, bulging frontanel, 3. Septic arthritis: fever + limited extremity movement 4. UTI: fever + vomiting + poor feeding Insussusception: 1. Episodic irritability with legs drawn to abdomen 2. ± bilious emesis, bloody stool 3. Present at 6- 36 months 4. Diagnosed with US Torsion: 1. Testicular swelling or abdominal distention (ovarian) Trauma: 1. Hair tourniquet: hair accidentally wrapped around digit 2. Corneal abrasion: tearing + photophobia + fluorescein test 3. Abuse/fracture: bruising + laceration + asymmetric movement

Answer 79

Risk factors: 1. Smoking 2. Hereditary pancreatitis 3. Nonhereditary pancreatitis 4. Obesity & lack of physical activity Clinical presentation: 1. Weight loss + anorexia 2. Epigastric Abdominal or back pain 3. Jaundice 4. Recent onset of atypical diabetes 5. Migratory thrombophlebitis ( trousseau syndrome) - (inflammation of a vein due to a blood clot) Laboratory: 1. Cholestatic pattern: elevated alkaline phosphatase & direct bilirubin 2. Elevated CA 19-9 3. Ultrasound for head pancreatic cancer (jaundice) 4. CT scan for tail pancreatic cancer (no jaundice) Note: 1. Cancer in the head of pancreas: jaundice + steatorrhea

Answer 80

- episodic epigastric pain + relieved by meal

Answer 81

1. Megaloblastic anemia - causes: impaired DNA synthesis due to B12 or folate deficiency - high (MCV > 110) + high MCH+ normal MCHC + low reticulocyte + low RBC + hypersegmented neutrophils (> 5 lobes) + anisocytosis + poikilocytosis - diagnosis: peripheral smear + reticulocytes count + B12 & Folate levels 2. Nonmegaloblastic anemia - caused by: alcohol use, liver disease, hypothyroidism, drugs - low/normal/high reticulocyte count (depend on etiology)

Answer 82

Seen with: 1. Lead poisoning 2. Thalassemia 3. Alcohol use

Answer 83

- in diagnosis of myelodesplasia - present with > 1 cell line cytopenia

Answer 84

Present with: 1. Low hemoglobin (7-10) + low heptoglubin + high reticulocyte count + high LDH + high bilirubin 2. Peripheral smear: Spherocyte

Answer 85

- perform iron-studies to confirm diagnosis Seen in: 1. Iron deficiency: - decrease intake or increase blood loss - low iron + low ferritin + high TIBG + high RDW + low transferrin 2. Anemia of chronic disease: - defect in use of stored iron (& increase inflammation) - low iron + high ferritin + low TIBG 3. Thalassemia: - reduced globin production - high iron + high ferritin - increase reticulocyte & bilirubin ( due to hemolysis) 4. Lead poisoning or sideroblastic anemia: - reduced heme synthesis - high iron + high ferritin - NORMAL TIBG Note: - transferrin = iron/TIBG ratio

Answer 86

- require treatment of underlying cause to improve anemia - examples: 1. Rheumatoid arthritis: - treat with: methotrexate, hydroxychloroquine, tumor necrosis agent ( infliximab, etanercept) - erythropoietin may be effective if patient is unresponsive to initial treatment - packed red blood cell, if all other medication fail

Answer 87

- treated with splenectomy

Answer 88

- caused by avascular necrosis (osteonecrosis of the femoral head) - findings: - groin/thigh/buttock pain on weight bearing - pain on hip abduction & internal rotation - no erythema, swelling, or point tenderness - no leukocytosis - normal inflammatory markers (CRP & ESR) - MRI: shows crescent sign OTHER causes: 1. SLE 2. Antiphospholipid syndrome 3. Infection (osteomyelitis, HIV) 4. Decompensation sickness 5. Steroid 6. Alcohol

Answer 89

1. Septic arthritis - due to splenic dysfunction predispose to infection with encapsulated organisms ( Strep pneumonia, H.influenza, N.meningitidis) 2. Avascular necrosis

Answer 90

- lead to assymetric arthritis typically in lower extremity after GI infection or genitourinary infection - can lead to: problem with vision, problem with urinating, problem with walking

Answer 91

- common cause of community acquired pneumonia - occurs in young, school trips, winter - symptomatic patient present with: fever + fatigue + nonproductive cough + dyspnea - some patient can have hemolysis due to cold agglutinin - x-ray shows: bilateral diffuse infiltrates - treatment: macrolide (azithromycin) or respiratory fluoroquinolone

Answer 92

- common organism: viridan streptococci - common cause: 1. dental procedure —> lead to transient bacteremia 2. Prosthetic valves - patient present with: 1. Fatigue, anorexia, malaise 2. Fever 3. Heart murmur 4. Splinter hemorrhage 5. Petechiae 6. Janeway lesions or osler nodes 7. Complications related to local cardiac infection (heart failure) or embolism (brain) Findings: 1. Elevated ESR 2. Hematuria (due to glomerulonephritis from septic emboli) Evaluation: 1. Blood culture from 3 different venipuncture sites (before initiating antibiotic treatment) 2. Prescribe empiric treatment (in patient with high DUKE criteria) after blood culture are drawn 3. Delay antibiotic treatment until after result of blood culture ( in low risk patient with low duke criteria)

Answer 93

- diagnose GAS infection in patient with rheumatic fever - patient present with: systemic symptoms + carditis + arthritis + CNS involvement ( sydenham chorea) + subcutaneous nodules - develops weeks after infection with GAS pharyngitis

Answer 94

Presebtal cellulitis: - eyelid erythema - eyelid swelling - chemosis - treat with: oral antibiotics —> caused by insect bite, wound Orbital cellulitis: - signs of preseptal cellulitis - pain with extraocular movement - proptosis - opthalmoplegia with diplopia - treat with: IV antibiotics ± surgery (if abscess, than drainage) —> caused by extension from bacteria from sinusitis, dental abscess, preseptal cellulitis

Answer 95

Focal (Lobar) pneumonia -caused by: strep pneumonia - clinical: 1. abrupt onset of fever, cough, chest pain 2. increased work of breathing 3. focal crackles - treatment: 1. Outpatient: Oral amoxicillin (outpatient) 2. Inpatient: IV ampicillin or ceftriaxone Bilateral (infiltrative) pneumonia - caused by: mycoplasma pneumonia, chlamydia pneumonia, viruses (rare) - clinical: 1. Fever, malaise, headache, sore throat 2. Prolonged & gradual worsening cough 3. Patient continue normal activities (walking pneumonia) 4. Bilateral crackles, wheezing, rhonchi - treatment: 1. Macrolide ( azithromycin)

Answer 96

- should be avoided in immunocompromised ( severe combined immunodeficiency) - should be avoided in immunosuppressed ( taken azathioprine or adalimumab)

Answer 97

Hep B: (hepatitis B) - months: birth, 1-2, 6-18 RV: (rotavirus) - months: 2, 4, 6 Dtap: ( diaphtheria, tetanus, pertussis) - months: 2, 4, 6, 15-18, 4-6 years HiB: (hemophilus influenza type B) - months: 2, 4, 6, 12-15 PCP: (pneumococcal conjugate vaccine) - months: 2, 4, 6, 12-15 IPV: (inactivated poliovirus) - months: 2, 4, 6-18, 4-6 years HepA: - months: 12-23 ( first & second dose) MMR: - months: 12, 4-6 years VZV: - months: 12, 4-6 years Tdap: - years: 11-12 HPV: - Years: 11-12 ( first & second doses) MCV (meningococcal conjugate vaccine) - years: 11-12, 16 MenB (meningococcal serogroup B) - year: 16 ( first & second dose) Inactivated influenza (annually) - start age: 6 months

Answer 98

- primary vaccine at age 11-12 years - booster shot at age 16 years Other uses: - complement deficiency - asplenia - college students - traveler to endemic area (central africa, alhaj)

Answer 99

1. ETEC - traveller diarrhea - watery diarrhea + abdominal pain - starts within 1-3 days - resolves in 5 days - severe diarrhea: dehydration (dry mucous membrane, reduced capillary refill, tachycardia) + prerenal azotemia ( BUN/CR> 20) + hypernatremia 2. Giardia - watery diarrhea - starts within > 1 week 3. Rotavirus - severe, watery diarrhea in unimmunized children age < 2 years 4. Salmonella S Typhi - high fever for a week + followed by abdominal pain with or without diarrhea 5. Shiga toxin-producing E.coli - bloody diarrhea - cause hemolytic uremic syndrome (HUS) after 1-2 weeks (typically intrinsic AKI, BUN/Cr < 20) - associated with anemia + thrombocytopenia

Answer 100

Age < 35: - sexually transmitted ( chlamydia or gonorrhea) Age > 35: - bladder outlet obstruction ( E.coli) Findings: - unilateral posterior testicular pain - epididymal swelling - pain improves with testicular elevation - dysuria + frequency (with coliform infection, > 35 age) Diagnosis: - NAAT ( chalamydia or gonorrhea) - urinalysis + culture

Answer 101

Viral: 1. Unilateral & bilateral eye involvement 2. Eye stuck and shut 3. Watery, scant, stringy discharge 4. No discharge appearing after wiping 5. Burning sensation 6. Sometime prodromal symptoms 7. Diffuse injection; follicular or bumpy appearance of conjunctival —> associated with URI (rhinorrhea, sore throat, cough) Bacterial: 1. unilateral or bilateral eye involvement 2. Eye stuck & shut 3. Purulent, thick discharge 4. Discharge appear after wiping 5. Sensation of unremitting discharge 6. No prodromal symptoms 7. Diffuse injection; non-follicular appearing conjunctival —> adult: caused by staph aureus —> children: caused by H.influenza, Maroxella, strep pneumonia Allergic: 1. Bilateral eye involvement 2. Eye stuck and shut 3. Water, scant, stringy discharge 4. No discharge appear after wiping 5. Itchy sensation 6. No prodromal symptoms 7. Diffuse injection; follicular or bumpy + conjunctival edema (chemosis)

Answer 102

- bacterial infection of the bone - presents with fever + focal bony pain - most common cause is staph aureus - treatment: vancomycin

Answer 103

- causes severe coughing paroxysms that lasts for weeks - associated with syncope & signs of elevated capillary pressure ( subconjunctival hemorrhage) - diagnosis: pertussis PCR & culture - treatment: azithromycin

Answer 104

Listeria monocytogenes: - less than 1 month - unlikely to cause meningitis in immunocompetent 18-month old Menongococcal meningitis: (Neisseria Meningitidis) - less than 1 month to adolescence - lead to: 1. Initial: nonspecific fever + headache + vomiting + myalgia + sore throat 2. Within 12-24 hours: petechiae/purpura + meningeal signs + AMS 1. Young children: fever + neck rigidity+ vomiting + petechial rash on the extremity 2. Older children: headache + severe myalgias ( leg pain) - symptoms progress rapidly (over 12-24 hours) to include purpuric rash & altered mental status - brudzinki sign is common, but absent in patient age < 1 year - diagnosis: lumbar puncture - treatment: ceftriaxone - chemoprophylaxis for close contact (rifampin, ciprofloxacin, or ceftriaxone) - can be fetal & causing: shock, multi-organ failure, DIC, death Group B strep.: - less than 3 months - unlikely to cause meningitis in immunocompetent 18-month old H. Influenza: - not associated with rash - unlikely meningitis in fully immunized child Enteroviruses ( coxsackievirus) - lead to: meningitis ( fever, headache, neck rigidity) + posterior pharyngeal sores + maculopapular rash on palms/soles. - symptoms develop over days

Answer 105

In clinic exam: 1. Digital rectal examination & anoscopy Laboratory: 1. CBC (ferritin) , LFT, renal function FIT test: 1. Blood in stool (microscopic amount of blood in stool) Colonoscopy: 1. Diagnosis (not screening ) within 24 hours

Answer 106

Bisphosphonate take drug once a week and starts to work (effectiveness) in 6 months

Answer 107

Can be caused by: 1. Viral —> more common 2. Bacteria —> group A strep. centor criteria: 1. In adult is often used to evaluate acute pharyngitis 2. In children is less predictive - GAS or viral infection can shows: tonsillar erythema & exudate, tender anterior cervical node & palatal petechiae - viral additional symp.: cough, rhinorrhea, congestion &/or oral ulcer Evaluation: 1. Initial rapid antigen detection testing (RADT) - the risk for acute rheumatic fever is higher in children with untreated streptococcal pharyngitis - a negative RADT in children should be confirmed with throat culture ( but confirmation is not required in adults)

Answer 108

- peaks a month after streptococcal infection - is not diagnostic for acute pharyngitis

Answer 109

- diagnostic for infectious mononucleosis (IM) - caused by EBV - symptoms: fever + exudative tonsillitis + posterior cervical lymphadenopathy + splenomegaly

Answer 110

- to guide for antiviral treatment of influenza - symptoms: fever+ pharyngitis + viral symptoms (cough + rhinorrhea)