Step 2

Question 1

The likelihood that a correlation identified by an observational study is representative of a causation increases with certain criteria called the Bradford hill critera
1. Biologic plausibility
2. Dose response relationship
3. Specificity
4. Strength of association
5. Temporal association

Define each

Answer 1

1. Association can be explained by a known biologic pathway or mechanism
2. Positive correlation between increased risk of dx and # or qty of an exposure
3. one to one relationship between exposure and outcome
4. As r approaches 1 the strength of association increases and correlation is more likely to be causative
5. If the exposure is known to precede the outcome.

Question 2

Qualitative study

Answer 2

Used to study social or other less quantifiable phenomena.
- How individuals think about their dx, barriers to pursuing treatment, or a social stigma experienced

Question 3

What can a focused assessment with sonography for trauma (FAST) look for?

Answer 3

• Cardiac tamponade
• Pneumothorax
• Hemothorax
• Hemoperitoneum

Question 4

USPSTF recommends screening for hyperlipidemia in men aged greater than (BLANK A) years and women aged greater than (BLANK B) years who are at an increased risk for coronary vascular disease.

Answer 4

1. 35
2. 45

Risk factors for coronary vascular disease include HTN, T2DM, a positive family history of coronary vascular disease, and smoking

Question 5

Midgut volvulus require what imaging to confirm?

Answer 5

1. Upper GI barium series - this outlines the patient’s small bowel anatomy and further assess for presence of obstructive volvulus
   —infants in whom volvulus is confirmed or infants with suspected volvulus and unstable vital signs should undergo emergent exploratory laparoscopy

Question 6

Infants who are hemodynamically stable may be evaluated with x-ray to confirm the diagnosis of volvulus (after getting upper GI series) and rule out (BLANK)

Answer 6

1. GI perforation

Question 7

What medications can be given to a patient who has MDD but is wanting to avoid medication induced sexual dysfunction

Answer 7

1. Mirtazapine (5HT modulator that antagonizes receptors)
2. Bupropion - increases synaptic dopamine and NE

• Medications that increase synaptic 5HT commonly impair sexual dysfunction (Fluoxetine and paroxetine - SSRIs)

Question 8

Ulcerative Colitis

1. Mild dx limited to rectum may be treated with (BLANK)
2. Mild dx that extends to sigmoid colon frequently require (BLANK) and (BLANK)
3. Pts who continue to have sx despite topical tx/enemas may experience improvement with oral versions of above
4. Pts with dx refractory to initial therapy or higher clinical severity and more extensive involvement of colon –> (BLANK)
5. (BLANK) or (BLANK) may be warranted to both induce and maintain remission

Answer 8

1. Mesalamine suppositories
2. Mesalamine and glucocorticoid enemas
3. -as stated-
4. Systemic steroids such as prednisone, budesonide, or hydrocortisone
5. Anti-TNFa or Janus Kinase enzyme inhibitor (tofacitinib)

Question 9

What precautions have to be made after Mono is diagnosed?

Answer 9

none

Question 10

If a nodule on the prostate is found what is the next step/

Answer 10

Prostatic biopsy and possibly more advanced imaging modalities

Question 11

1.symmetrically enlarged, globular, boggy uterus
2. 40-50 years old
3. Heavy, painful menstrual bleeding

Answer 11

This is adenomyosis - presence of endometrial glands within the myometrium

Question 12

(BLANK) - viral illness
- Febrile prodromal phase followed by characteristic vesicular rash with lesions in the same stage of development and healing
- Vaccination is vaccinia

Answer 12

1. Smallpox

Question 13

(BLANK) syndrome
- Mutation in WAS gene on X chromosome - encodes a protein essential for actin cytoskeleton rearrangement that occurs during interactions between T lymphocytes, antigen presenting cells, and B lymphocytes leading to an impaired innate and adaptive immune system

-Eczema
-Thrombocytopenia
- Infections with SHiN + opportunistic pathogens
-Increased risk for autoimmune disease and malignancy (leukemia)

Answer 13

Wiskott Aldrich syndrome

Question 14

(BLANK) disease

• Adenosine deaminase deficiency
• Autosomal recessive mutation in ADA gene
• Recurrent viral, bacterial, and fungal infections starting at birth
• Failure to thrive
• Severe lymphopenia w/impaired cellular (failure of T cell development) and humoral immunity (B cell dysfunction d/t absent T cells)

Answer 14

Severe combined immunodeficiency disease (SCID)

Question 15

1. How do kids usually present with nursemaid’s elbow
2. How do you fix a radial head subluxation (nursemaid’s elbow)

Answer 15

1. Hold the elbow in semi flexion and in slight pronation and hold the arm immobile at their side
2. Hyperpronating the forearm elicits a palpable click when the annular ligament is returned to its normal position

OR – supination of the forearm with the elbow in flexion

Question 16

When a patient has asplenia and needs to be protected against the SHiN diseases what can be given?

Answer 16

Broad spectrum IV antibiotic empirically
– For ex: ceftriaxone

Question 17

Acute dystonic reactions that occur in response to potent D2 antagonists such as high potency typical antipsychotics (e.g. haloperidol, fluphenazine) can be tx with (BLANK)

Answer 17

1. Diphenhydramine or benztropine (anticholinergic meds) - to restore balanced between dopaminergic and cholinergic pathways

Question 18

Acute stress disorder - intrusive thoughts or memories, changes in arousal and reactivity, avoidance of reminders of trauma, and negative changes in mood/thoughts that occur with (BLANK) of a traumatic event

Answer 18

1. 1 month

Question 19

USPSTF recommends screening for AAA in men aged (BLANK to BLANK) who have a history of tobacco use

Answer 19

65-75

Question 20

For acute Hep B infection - what may be the only positive serologic assay in initial window phase?

Answer 20

Anti-HBc IgM

Question 21

In refeeding syndrome - metabolic changes occur in resumption of nutritional intake and are mediated by rise in insulin
1. Phosphate levels
2. Potassium levels
3. Magnesium levels

• this occurs (BLANK) within resumption of feeding and can be prevented by slow, deliberate increase in caloric intake and monitoring of electrolytes

Answer 21

1. Hypophosphatemia
2. Hypokalemia
3. Hypomagnesemia
4. Within 1-2 weeks of the resumption of feeding

Question 22

Dx of vesicoureteral reflux, hydroureteronephrosis, and congenital urinary tract abnormalities is often completed with (BLANK) followed by (BLANK) if necessary

Answer 22

1. renal U/S
2. fluoroscopic voiding cystourethrography

Question 23

REM sleep behavior disorder features a lack of normal muscle atonia during REM sleep mostly occuring in older male patients
– can be idiopathic or associated with (BLANK)

Answer 23

1. conditions of alpha synuclein deposition such as parkinson disease

Question 24

Case control is retrospective/prospective

Cohort study is retrospective/prospective

Answer 24

1. retrospective
2. prospective

Question 25

Viral meningitis/aseptic meningitis CSF
1. Leukocytes
2. Protein
3. Glucose

Answer 25

1. <100 (predominant lymphocytes)
2. normal or increased protein (<40)
3. Normal glucose (40-70)

Question 26

In a person with rheumatoid arthritis who is undergoing surgery –> what joints should be assessed first?

Answer 26

1. Axial skeleton (joints of the cervical spine) - there can be instability and subluxation of the atlantoaxial joint with resulting spinal cord compression
2. This is important to know before general anesthesia and intubation - cervical spine instability + positioning for intubation can lead to paralysis or death

Question 27

The presence of multiple vascular tumors would be highly suggestive of what disease?

1. inheritance pattern?
2. gene?

Answer 27

Von Hippel Lindau disease - presents with multiple benign and malignant tumors. Many originate from the vasculature including hemangioblastomas of the retina and cerebellum and angiomatosis of the skin and mucosa

1. Autosomal dominant
2. VHL gene

Question 28

• bloody diarrhea
• thrombocytopenia
• hemolytic anemia due to diffuse endothelial dysfunction with a tendency toward microvascular thrombosis (predisposes shear forces)
• acute renal failure
• tx is supportive

Answer 28

Shigella toxin producing E. coli
- Shiga toxin causes endothelial dysfunction

• Also release LDH while haptoglobin is depleted by binding free Hgb

Question 29

First line oral antibiotics for those with community acquired pneumonia include – (3)
(for outpatients without severe disease and no significant medical comorbidities)

Answer 29

1. oral azithromycin
2. oral doxycycline
3. oral amoxicillin

Question 30

How to differentiate constitutional growth delay and growth hormone deficiency on growth charts?

Answer 30

1. Growth hormone deficiency is typically associated with rapid decline in curve, crossing percentiles while constitutional growth delay has slow but consistent growth

Question 31

1. common benign primary tumor of bone
2. Tumor that creates cartilage
3. small bony spur protruding from surface of the bone capped by cartilage which is palpable clinically
4. adolescents
5. X ray shows a sessile or pedunculated tumor with its cortex continuous with cortex of underlying bone and cartilaginous cap

Answer 31

1. Osteochondromas - stop growing when the growth plate closes - tx is not always necessary
   - If lesion is symptomatic or causing limb deformity or growth disturbance then surgical excision is curative

Question 32

1. Benign neoplasm of cartilage which appears near the epiphysis of long bones in adolescents
2. low grade joint pain and swelling
3. X-ray - small well defined epiphyseal lesion with sclerotic border

Answer 32

1. chondroblastoma

Question 33

1. primary bone malignancy
2. t(11;22)
3. adolescent boys
4. X-ray - elevated periosteum and layered neocortex formation (onion skin), can also have central lytic lesions w/moth eaten appearance
5. occurs in long bones (diaphysis)
6. Histology shows multiple small, round blue cells

Answer 33

Ewing sarcoma

Question 34

1. malignant transformation of specialized macrophages (dendritic cells) which reside in the skin and act as antigen presenting cells to T lymphocytes
2. Typically in childhood or neonatal period (from birth to 15 years old)
3. Affects skin, bones, or visceral organs - pulm involvement later in life
   –variable rash
   —polyuria/polydipsia

What is this?
What does it look like on imagingz?

Answer 34

1. Langerhans cell histiocytosis
2. Lytic, “punched out” lesions on x ray

Question 35

1. radiolucent (black) bone lesion - most commonly in proximal femur
2. pain associated with tumor
3. typically solitary lesion
4. relieved by NSAIDs

Answer 35

1. osteoid osteoma

Question 36

fluctuant swelling near the urethra caused by blockage of the outflow of skenes glands

Answer 36

Vestibular gland cysts

Question 37

Caused by incomplete regression of mesonephric ducts during embryonic development
- most commonly located lateral to the vaginal wall in the broad ligament and not apparent on vulvar exam

Answer 37

1. Mesonephric (wolffian) duct cysts /gartner cyst

Question 38

• painful, fluctuant swelling over the posterior aspect of the labium majus external to the hymenal ring
• located near the posterior introitus

Answer 38

bartholin gland cyst
- typically managed with incision and drainage

Question 39

Early diastolic decrescendo murmur best heard at right 2nd intercostal space–>

Answer 39

aortic valve regurgitation/insufficiency

Question 40

MDD is symptoms for (BLANK) or more weeks

Answer 40

1. 2 or more weeks of atleast 5 of the following
   a. depressed mood
   b. anhedonia
   c. guilt or worthlessness
   d. difficulty concentrating
   e. psychomotor retardation or agitation
   f. SI
   g. Neurovegetative symptoms (decreased energy, sleep disturbance, appetite disturbance)

Question 41

Decreased total lung capacity and residual volume on PFTs are suggestive of

Answer 41

Restrictive lung disease - decreased chest wall compliance, respiratory muscle weakness, or decreased lung parenchyma compliance

-ex: ILD, obesity hypoventilation syndrome, neuromuscular disorders (e.g. ALS)

Question 42

Preterm labor refers to onset of uterine contractions and cervical change between (BLANK -BLANK) weeks gestation

Answer 42

20-37 weeks gestation

Question 43

Gestation <34 weeks
1. Tocolytic therapy (BLANK)
2. (BLANK) to improve fetal lung maturity
3. (BLANK) for neuroprotection in gestation <32 weeks
4. antibiotics for (BLANK)

Answer 43

1. examples- nifedipine, terbutaline
2. corticosteroids
3. magnesium sulfate
4. GBS

Question 44

adjustment disorder refers to onset of emotional disturbance within (BLANK) of an identifiable stressor

–tx

Answer 44

3 months

• marked distress out of proportion to the stressor and a significant impairment in daily functioning (does not meet depression)
• Tx: brief supportive psychotherapy

Question 45

Acral lentiginous melanoma

Answer 45

Subtype of malignant melanoma that occurs on the fingers and toes
- often Asian and African descent, unrelated to sun exposure
-Pigmented lesion that demonstrates asymmetry, irregular appearing borders, variable coloration, diameter greater than 6 mm, rapid evolution in characteristics
- may begin as a longitudinal brown streak on the nail

Question 46

Ogilvie syndrome (AKA …)
1. pathophysiology
2. symptoms
3. Treated

Answer 46

Colonic pseudo-obstruction
1. signs and symptoms of colonic obstruction in absence of mechanical cause of obstruction - idiopathic or can be due to abnormal function of GI autonomic NS
2. Abdominal distention and diffuse tenderness. Abdomen tympanic to percussion. Bowel sounds are often decreased but usually present. Perforation or ischemia may lead to severe pain, peritoneal signs, and evidence of shock.
3. Tx: NPO, NG/rectal tube decompression
–> pro-cholinergic agent (neostigmine) if no improvement w/in 48 hrs
–> if perforation then emergent ex lap

Question 47

What is first line treatment of lupus pleuritis

Answer 47

NSAID (e.g. ibuprofen)
– then systemic glucocorticoids for refractory disease

Question 48

1. 1 - false negative rate = A
2. 1 - false positive rate = B

Answer 48

A. Sensitivity (ability of test to detect a dx if it is present)
B. Specificity (probability that a test will demonstrate negative result when dx is actually absent)

Question 49

Initial guideline recommended therapy for HFrEF is what 3 drugs (+2 other ones for HFrEF)

Answer 49

1. Diuretic - volume and BP management
2. RAAS inhibitor - volume and BP management
3. BB - first assess with 1&2, if repeat echo shows persistent HFrEF despite volume control then BB should be added
4. MRA (spironolactone) – if additional BP and volume control is needed or if hypokalemia with loop diuretic occurs
5. SGLTi

Question 50

Clinical manifestations
Infancy
- Lymphedema, cystic hygroma
- Renal and heart defects (coarctation of the aorta, bicuspid aortic valve, horseshoe kidney)

Childhood
- Short stature
- Dysmorphic features (webbed neck, broad swelling, high arched palate, cubitus valgus, short 4th metacarpals)

Adolescence
- Delayed thelarche
- Amenorrhea
- Infertility
- Decreased estrogen concentration –> fail to develop secondary sexual characteristics and demonstrate an underdeveloped uterus
- Increased LH and FSH due to lack of negative feedback from estrogen

1. what is this and management?

Answer 50

1. Turner syndrome (45, XO)
   –Growth hormone and Estrogen replacement to promote increased stature and development of secondary sexual characteristics

Question 51

Schizophrenia demonstrate 2/5 following symptoms
1.
2.
3.
4.
5

• for at least 6 months

Answer 51

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized behavior
5. Negative symptoms (flat affect, apathy, avolition, alogia)

Question 52

1. Primary prevention strategies
2. Secondary
3. Tertiary

Answer 52

1. Strategies to prevent the effects of the disease before the disease occurs
2. aims to identify disease early in its course through screening efforts
3. aims to slow or ameliorate the progression and complications of a disease through therapeutic intervention

Question 53

USPSTF recommends routine colorectal cancer screening for all patients beginning at age (BLANK) and continuing up until age (BLANK)

–Patients with low risk polyps (1-2), tubular adenomas should undergo screening q (BLANK) to (BLANK) years

–Patients with multiple polyps (3+), polyps with atypical features or large size, or atypical serrated polyps should undergo screening q (BLANK) years

Answer 53

1. 45-75 years
2. 5-10 years
3. 3 years

Question 54

Gilbert vs Crigler Najjar

Answer 54

1. absence or decreased activity of UDP-glucuronosyltransferase (UGT), an enzyme required for glucuronidation of unconjugated bilirubin in the liver.
2. More severe form of above

Question 55

Dubin-Johnson
1. Pathophysiology
2. Notable characteristics
3. Serum bilirubin levels

Answer 55

1. Mutation in the ABCC2 gene – mutation prevents conjugated bilirubin from leaving liver, collects in liver instead
2. Black liver
3. Serum bilirubin levels - moderately elevated

Question 56

Rotor
1. Pathophysiology

Answer 56

1. Similar to dubin-johnson just without liver pigmentation
   — Both conjugated and unconjugated hyperbilirubinemia due to defective hepatic uptake and storage

Question 57

• presents in 2nd to 4th decade of life
• Multiple, recurrent sinus or pulmonary infections, including pneumonia, bronchitis, and sinusitis
• Dx is made by quantitative measurement of serum immunoglobulins (decreased IgG, IgA, and/or IgM)
• Pathophysiology: impaired B lymphocyte differentiation into plasma cells so impaired production of immunoglobulins
• blunted or absent response to vaccinations

1. what is this?
2. tx?

Answer 57

1. Common variable immunodeficiency disease
2. IVIG

• These patients are at increased risk for the development of autoimmune disease such as RA, autoimmune hemolytic anemia, and non-hodgkin lymphoma

Question 58

FEV1, FVC, and TLC for asthma

Answer 58

1. FEV1 decreased
2. FVC normal
3. TLC increased

Question 59

Tx for infective endocarditis prophylaxis before procedures
1.
2. with allergy to #1

Answer 59

1. amoxicillin (ampicillin for those unable to take oral meds)
2. macrolides (e.g. clarithromycin)

Question 60

In patients with obvious arterial injury what should be done to manage?

Answer 60

emergent exploration and management in the operating room

Question 61

Patients with chronic renal failure are prone to
1. volume overload
2. (K)
3. (phosphate)
4. (acid base disturbance)
5. (PTH)
6. Osteodystrophy
7. Anemia

Answer 61

1. volume overload
2. Hyperkalemia
3. Hyperphosphatemia
4. Metabolic acidosis
5. Hyperparathyroidism
6. Osteodystrophy
7. Anemia

-Patients should minimize intake of fluids, potassium, and phosphate

Question 62

Deep ulcers at bottom of feet that have been exposed to bone or probe to bone may be complicated by osteomyelitis or gas gangrene –> what organism group(s) are usually cause of the infection?

Answer 62

1. Mixed aerobic and anaerobic bacteria

• Pseudomonas may cause osteomyelitis following a puncture wound to foot, particularly if exposure to water or moist environment

-Staph aureus is common cause of superficial cutaneous infections

Question 63

Primary amenorrhea is described as absence of menarche at (blank) years of age with (BLANK)

OR at (BLANK) years of age without (BLANK)

secondary amenorrhea is defined as absence of menses for (BLANK) months in women who have previously had regular menstrual cycle. Or for (BLANK) months in women who cycles were previously irregular

Answer 63

1. 15 yrs w/appropriate secondary sexual characteristics
2. 13 years w/out secondary sexual characteristics
3. 3 months
4. or 6 months in irregular cycle women

Question 64

1. Tx of uncomplicated UTI and cystitis
2. Tx of pyelonephritis (4)

Answer 64

1. Nitrofurantoin
2. 3rd gen cephalosporin (ceftriaxone), fluoroquinolone (ciprofloxacin), TMP-SMX, or an oral B lactam (e.g. amoxicillin/claulanate, cefuroxime, cefpodoxime)

Question 65

Ampicillin is typically used to treat infections caused primarily by gram (BLANK) bacteria

• 3 examples

Answer 65

1. Gram positive bacteria
2. Strep, staph, and listeria

Question 66

Valproic acid at therapeutic doses can cause
1. GI distress
2. sedation
3. tremor
4. weight gain
5. BLANK
6. BLANK

Answer 66

5. hematologic effects (e.g. leukopenia, thrombocytopenia) check platelet counts
6. Benign increases in transaminases or hepatotoxicity

Question 67

Achalasia
- dysphagia to what?
- tx?

Answer 67

1. solids and liquids
2. pneumatic dilation or injection of botulinum toxin to relax LES

Question 68

Shatzki ring
- dysphagia to what?

Answer 68

solid only

Question 69

Essential tremor - bilateral tremor of upper extremities.
- Head tremor w/out dystonia
- Tremor is exacerbated by activity and sustained antigravity postures and improved by rest.

1. tx:

Answer 69

1. Beta blocker (propranolol)
   –also small qty of alcohol
2. anticonvulsants: primidone

*sometimes patients self treat with alcohol
*worsens with stress, improves with alcohol

Question 70

CT angio of the chest is most often used to identify what?

Answer 70

pulmonary emboli

Question 71

ACOG: Screening mammogram is recommended q 1-2 years from the ages (BLANK) to (BLANK) for patients at average to moderate risk for breast cancer

• After (BLANK) screening can be continued if the patients life expectancy is more than 10 years

Answer 71

1. 40-74
2. 74

Question 72

What does urinalysis for acute tubular necrosis look like?
1. Protein levels
2. WBC/hpf
3. casts

Answer 72

1. proteinuria
2. increased WBC/hpf
3. muddy brown casts

–often following an ischemic or nephrotoxic insult (cardiac arrest following prolonged resuscitation, shock, heavy metals, myoglobin)

Question 73

What does urinalysis for acute interstitial nephritis look like?
1. Protein levels
2. WBC/hpf
3. casts
4. other

PLUS other
1. GFR
2. Cr

Answer 73

1. proteinuria
2. increased WBC/hpf
3. occasional WBC casts -
4. eosinophiluria

–Often secondary to meds (NSAIDs, antibiotics, sulfas)
1. decreased GFR
2. increased Cr

Question 74

After starting monoclonal Ab that targets TNFa what should be done in a month

Answer 74

1. Get CBC bc anemia is a potential adverse effect

Question 75

Soft tissue sarcomas (like fibroscarcoma) - are a heterogenous group of tumors derived from mesenchymal tissue such as skeletal or smooth muscle, adipose, or fibrous tissue.

1. Once someone is identified as having a fibrosarcoma what should be done?

Answer 75

CT scan of the chest and abdomen to locate metastasis (which occurs via blood) – pulmonary spread is common

Question 76

• Chronic nosebleeds and isolated increase in PTT is what disease?

Answer 76

1. Von willebrand disease - recurrent nosebleeds, easy bruising, petechiae, menorrhagia, GI and gingival bleeding
   –> Tx: supportive care w/bleeding control and transfusions, may involve administration of desmopressin

• von willebrand protein acts as a serum transport protein for coagulation factor VIII, factor VIII may be decreased leading to the increase in PTT without affecting PT

Question 77

What type of bleeding does hemophilia present with?

Answer 77

Visceral bleeding (e.g. splenic hemorrhage, rectus sheath hematoma, hamarthrosis)

Question 78

X ray of joints with osteoarthritis typically shows as…

Answer 78

Joint space narrowing, marginal osteophytes, and subchondral sclerosis or bone cysts

Question 79

What is first line agent that can be used in treatment of atrial fibrillation with rapid ventricular response?

Answer 79

1. metoprolol
   –rate control is preferable to rhythm control in afib as the risks for adverse outcomes has been shown to be lower

Question 80

Hx of intermittent epigastric pain relieved with antacid use raises suspicion for (BLANK)

(BLANK) can demonstrate intra-abdominal free air and leakage of enteric contents resulting in inflammation, irritation, and infection of the peritoneum.

What imaging is best to get done in this situation?

Answer 80

1. peptic ulcer
2. perforated peptic ulcer
3. Upright X rays of the chest and abdomen –> can show free air under the diaphragm to confirm diagnosis of the perforated viscus. Perforated peptic ulcer is sx emergency and patients are tx with broad spectrum antibiotics and surgery + lavage.

Question 81

Oral contraceptives are associated with increased risk for VTE, MI, and stroke

–> Risk of stroke is increased particularly in patients older than (BLANK) who (BLANK). This is a contraindication to continuation of oral contraceptive

Answer 81

1. 35 years old who smoke greater than 15 cigarettes daily

***OCP commonly cause a mild elevation in BP and can sometimes lead to overt HTN. Those who develop OCs should d/c medication.

Question 82

Impetigo is contagious, childhood bacterial skin infection on the face and extremities with lesions that progress from papules to vesicles and crusts that have yellow, gold, or honey color

1. most common responsible organisms are (2)
2. What is treatment?

Answer 82

1. Staph aureus and GAS
2. Topical mupirocin (preferred to neomycin or bacitracin which have high likelihood of inducing allergic contact dermatitis where applied)
   —> widespread impetigo or immunocompromised host –> may need systemic antibiotics

Question 83

Why does salt craving, fatigue, anorexia, psychiatric manifestations, and loss of libido occur in patients with Addison disease?

Answer 83

1. Addison dx/Primary adrenal insufficiency –> destruction of bilateral adrenal cortex (contains aldosterone, cortisol, androgens)

–> low aldosterone causes renal salt wasting which can cause salt craving
–> Glucocorticoid deficiency leads to fatigue, anorexia, and psychiatric manifestations (irritability, depressed mood)
–> Androgen loss leads to loss of libido and suppression of secondary sexual characteristics (e.g. reduced pubic hair)

Question 84

What is cosyntropin used for?

Answer 84

1. Cosyntropin is a synthetic form of ACTH
   –> it is given to stimulate cortisol production. Low production of cortisol following stimulation is diagnostic of primary adrenal insufficiency

Question 85

Patients with familial adenomatous polyposis (FAP)
1. management of late teens or early twenties patients
2. management of younger patients

Answer 85

1. elective total proctocolectomy
2. surgery is delayed in favor of close surveillance with frequent colonoscopy until patients have completed puberty and matured both physically and emotionally

–> Urgent total proctocolectomy is performed no matter the patient’s age in those with colorectal cancer or adenomas with high grade dysplasia, severe sx like hemorrhage, and a significant increase in polyp # during screening interval

Question 86

What parasite is this?

1. dog tapeworm (sheep intermediate host), rural/developing countries, humans are incidental hosts
2. initially asymptomatic for years, RUQ pain, N/V, hepatomegaly, fever, cough, chest pain, hemoptysis
3. Large, smooth hydatid cyst often with internal septations.
   —IgG serology

• What is treatment

Answer 86

Echinococcus granulosis
–Albendazole
–Percutaneous therapy (>5 cm or septations)
–surgery if cyst ruptures

Question 87

Presence of retrocardiac air-fluid level on chest imaging suggests what disorder?

• Pts also have N/V, postprandial fullness, dysphagia, epigastric and/or chest pain

–>what is it diagnosed with?

Answer 87

1. paraesophageal hiatal hernia (PEH)

Dx is confirmed with barium swallow or upper endoscopy

Question 87

-Patient visited caribbean region, central/south america, africa, and asia
- Vector is Aedes mosquitors
- Symptoms: high fever, severe polyarthralgia, headache, myalgia, conjunctivitis, maculopapular rash
-Labs: lymphopenia, thrombocytopenia, transaminitis

–> What infection is this?
–> Tx?

Answer 87

1. Chikungunya virus infection
2. supportive care (sx resolve within 7-10 days)
   –chronic arthralgia/arthritis frequently occurs and can last months or years

Question 88

1. Gout can occur in what joints?
2. common triggers include? (5)

Answer 88

1. 1st metatarsophalangeal joint, knee, and ankle
2. heavy alcohol use, intake of urate rich foods (meat, seafod), trauma/surgery, dehydration, and medications that raise uric acid levels (thiazide diuretics, cyclosporine), or lower uric acid levels (e.g. allopurinol)

Question 89

What is the first step to be done in suspected epidural spinal cord compression (ESCC) due to metastatic malignancy

–> then what next 2 steps
–> what are late findings of ESCC

Answer 89

1. IV glucocorticoids –> decrease vasogenic edema (caused by obstructed epidural venous plexus), help alleviate pain, and may restore neurologic function

–> then MRI to diagnose
–> Neurosurgery and/or radiation oncology consultation is typically required

–> bowel and bladder dysfunction, increased deep tendon reflexes, paralysis

Question 90

Physiologic tremors
1. what are they
2. what are they worsened by

Answer 90

1. Most common cause of action tremor and usually has a medical etiology

–> these are action tremors, which may be kinetic, intention, or postural (e.g. holding arms outstretched)

2. Worse with movement, worsened by emotional or physical stress, toxic/metabolic derangements, caffeine, or drug withdrawal [increased sympathetic activity]

Question 91

Resting tremor
1. what is this
2. pathophysiology
3. What worsens this?

Answer 91

1. Resting tremor, decrease with voluntary movement, pill rolling, asymmetric
2. Progressive loss of dopaminergic neurons in the substantia nigra of the basal ganglia
3. worsened when patients are distracted

Question 92

Etiologies for Acute colonic pseudoobstruction (Ogilvie syndrome) (4)

Answer 92

1. Major sx, traumatic injury, severe infection
2. Electrolyte derangement (decreased K, decreased Mg, decreased Ca)
3. Medications (e.g. opiates, anticholinergics)
4. Neurologic disorders (e.g. dementia, stroke)

Question 93

Euvolemic hyponatremia is primarily caused by SIADH or primary polydipsia

1. what lab can help distinguish these disorders?

Answer 93

1. Urine osmolality
   >100 mOsm/kg in SIADH
   <100 mOsm/kg in primary polydipsia

Question 94

Rheumatoid arthritis (RA) complicated by AA amyloidosis can lead to renal disease with proteinuria or nephrotic syndrome

1. Diagnosis is confirmed via (BLANK)
2. Renal biopsy shows

Answer 94

1. presence of amyloid on tissue biopsy (e.g. fat pad)
2. amorphous hyaline material that stains with congo red; green birefringence is noted under polarized light

Question 95

What is the treatment of choice for hypovolemic hyponatremia?

Answer 95

Normal saline - replenishes body’s depleted salt stores, restores euvolemia, and shuts off nonosmotic stimuli (low plasma osmolality) for ADH release

Question 96

Severe hypercalcemia is >14 mg/dL and can cause weakness, GI distress, neurospychiatric symptoms (confusion, stupor, coma)
–> tx with? (3)

• moderate calcium is 12-14 - no immediate tx required unless sympotmatic. Tx is similar as above

-asymptomatic or mild is <12 - no immediate treatment

Answer 96

1. aggressive saline hydration to retore intravascular volume and promote urinary calcium excretion
   –calcitonin can be administered with saline to reduce serum calcium
   –bisphosphonates can decrease calcium by inhibiting bone resorption but this takes 2-4 days

Question 97

• CD4 <100 and often with cat exposure or homelessness
• Manifestations
  –vascular cutaneous lesions
  –systemic symptoms (fever, night sweats, fatigue)
  –organ involvement rarely (liver, bone, CNS)

1. what causes this?
2. treatment?

Answer 97

1. Bartonella henselae/quintana
2. Doxycycline or erythromycin + restart HIV antiretroviral therapy

-vascular cutaneous lesions: often begin as small reddish/purple papules and evolve into friable pedunculated or nodular lesions

Question 98

Can TB be ruled out with one negative acid fast baciullus stain?

Answer 98

No bc this requires a high burden of organisms (>10,000) for a positive result. Sensitivity is low

—Sensitivity can be increased by taking 3 samples, 8-24 hours apart

Question 99

Wet, wacky, wobbly
-what is this for?

Answer 99

• urinary incontinence/urgency, cognitive dysfunction, wide based ataxia

-Normal pressure hydrocephalus

-can also have depressed affect and UMN in lower extremities

Question 100

Patients who develop occult GI hemorrhage days after being admitted to ICU for septic shock likely have …

Answer 100

stress induced ulcer

—risk factors include shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, and high dose corticosteroids

Question 101

What can cause constant, progressive back pain that is worse at night and when supine.

-Back/neurologic exams and radiographic imaging are generally normal

Answer 101

Pancreatic cancer in the body or tail of the organ
–> this is referred pain
–> Abdominal CT is usually diagnostic (identifying pancreatic cancer)

Question 102

What changes to muscles occur with hyperthyroidism?

Answer 102

–Myopathy–
Chronic - slowly progressive proximal muscle weakness

Acute: severe proximal and distal weakness; rhabdomyolysis can occur

Question 103

What muscle changes occur in hypothyroidism?

Answer 103

Myopathy typically causes pronounced muscle tenderness and myalgias; muscle swelling and edema may also happen
–Increased creatinine kinase

Question 104

Polymyositis and dermatomyositis
1. weakness of muscles?
2. pain and tenderness?
3. abnormal lab markers?

Answer 104

1. Yes
2. less common
3. increased creatinine kinase

Question 105

common respiratory pathogen in patients with cystic fibrosis
1. children
2. adults

Answer 105

1. Staph aureus
2. Psuedomonas

Question 106

Bronchiectasis due to CF most often shows this exam finding to differentiate itself from other causes of bronchiectasis

Answer 106

Upper lobe involvement (upper lung field crackles and infiltrate) –> due to bronchiectasis caused by CF

Question 107

Annual screening with low dose CT scan of the chest is recommended for those who have smoked (BLANK) pack years

• screening begins at age (BLANK) to (BLANK) or until >=15 years of smoking cessation is achieved

Answer 107

1. > = 20 pack years
2. 50-80 years

Question 108

Sarcoidosis
1. pathogenesis
2. pulmonary changes
3. cutaneous
4. optho
5. neurologic
6. cardio
7. GI
8. Other (Hypercalcemia, peripheral LN, parotid gland swelling, polyarthritis, fever, malaise)

Answer 108

1. Inflammatory disease that includes formation of noncaseating granulomas
2. Hilar LN (upper lobe reticulonodular opacities, diffuse or nodular parenchymal infiltrates), interstitial infiltrates
3. papules, nodules, plaques, erythema nodosum (tender red bumps on shins)
4. anterior/posterior uveitis, keratoconjunctivitis sicca (dryness of conjunctiva and cornea)
5. facial nerve palsy, central DI, hypogonadotropic hypogonadism
6. AV block, dilated or restrictive cardiomyopathy
7. Hepatosplenomegaly, asymptomatic LFT abnormalities, splenomegaly

-hypercalcemia is due to vit D conversion/production by macrophages in granulomas

Question 109

In setting of hypotension - acute, massive increases in transaminases with milder increases in total bilirubin and alk phosphatase indicates (BLANK)

Answer 109

Ischemic hepatic injury
–patients who survive the inciting condition have liver enzymes return to normal within a few weeks

Question 110

• correlation with underlying Hept B/C + weeks or months of nonspecific symptoms like fever, myalgia, joint pains, fatigue

Pathogenesis:
- fibrinoid necrosis of arterial wall which causes luminal narrowing and thrombosis –> tissue ischemia
–internal/external elastic lamina damage of arteries causes microaneurysm formation and eventual rupture and bleeding

what is this?
How to dx?

Answer 110

1. Polyarteritis nodosa
2. Angiography shows microaneurysms and segmental/distal narrowing
   —tissue biopsy shows transmural inflammation

Question 111

Thromboangiitis obliterans
1. patient populations
2. symptoms

Answer 111

1. young smokers
2. symptoms in distal extremities (e.g. finger ulcers, gangrene, infarction) due to formation of inflammatory thrombi

Question 112

What is a potential complication of roux en Y gastric bypass that would involve the need for EGD?

+ sx?

Answer 112

Stomal stenosis - narrowing of gastrojejunal anastomosis

Sx: Nausea, postprandial vomiting, gastric reflux, dysphagia to the point pt cannot tolerate liquids

Question 113

Mechanical ventilation is often required to support patients lungs in ARDS. What is done for each of the following:
1. Lung protection
2. Ventilation
3. Oygenation

Answer 113

1. limit alveolar distending volume and pressure
2. tolerate permissive hypercapnia to avoid excessive tidal volume
3. Set lowest feasible FiO2 (goal SpO2 92-96%) to avoid O2 toxicity

• youre avoiding higher tidal volumes to prevent excessive stretching of damaged and delicate alveoli

Question 114

what are the types of COPD?

Answer 114

1. emphysema (two types: smoking induced centriacinar/centrilobar emphysema and AAT deficiency induced panacinar/panlobar emphysema)
   — inflammation/damage to alveoli. Panacinar is alveoli base and centriacinar is part right before getting end of alveoli.
2. bronchitis - inflammation of bronchial tubes that carry air to alveoli

Question 115

COPD - emphysema type
–smoking induced centriacinar/centrilobar emphysema.

–AAT deficiency induced panacinar/panlobar emphysema.

For each
1. What part of the lung is affected usually?
2. what age do they appear?

Answer 115

1. upper lobes of the lungs and age >50
2. lower lobes of the lungs and in their 30- 40s

Question 116

What is treatment of alpha 1 antitrypsin (AAT) deficiency?

Answer 116

IV supplementation with pooled human AAT

Question 117

• gram negative, free living organism in marine environment
• often after ingestion of oysters or wound infection
  sx: rapidly progressive <12 hours, septic shock, bullous lesions, cellulitis with hemorrhagic bullae or necrotizing fasciitis

What is this?
How is it dx?
How is it tx?

Answer 117

1. Vibrio vulnificus
2. blood and wound culture
3. empiric in those with likely illness. IV ceftriaxone and doxycycline

—those with liver diseases have increased risk

Question 118

theophylline
1. drug class
2. what is this typically used for?/effects?
3. side effects

Answer 118

1. phosphodiesterase (PDE) inhibitor (inhibits cyclic AMP or GMP to become AMP or GMP. cyclic AMP/GMP causes increases cellular response such as smooth muscle relaxation)
2. Causes bronchodilation and is occasionally used for COPD and asthma
3. Undergoes hepatic clearance which can be decreased in elderly patients and by CYP450 inhibitors. Has narrow therapeutic index which can cause the drug to be in high enough levels to cause tremor, seizure, tachyarrhythmias, vomiting, hypotension, neuro sx (anxiety and hallucinations)

Question 119

What is isolated systolic HTN commonly caused by and who is it seen in?

Answer 119

Common in elderly patients
– due to age related increased stiffness of the walls of the aorta and other large arteries

Question 120

What is the purpose of the d-xylose test?

Answer 120

D-xylose is a monosaccharide that is absorbed in the proximal small intestine without degradation by pancreatic or brush border enzymes.

Patients with small intestinal mucosal disease will have impaired absorption of D-xylose.(celiac disease)

Patients with malabsorption due to enzyme deficiencies will have normal absorption of D-xylose. (chronic pancreatitis

Question 121

What disorders can cause a false positive D-xylose test (low urinary D-xylose despite normal mucosal absorption)

Answer 121

1. delayed gastric emptying
2. impaired glomerular filtration
3. small intestinal bacterial overgrowth (alterations in small intestine flora due to abnormal intestinal anatomy or motility leading to bacterial fermentation of D-xylose before it can be absorbed)
   —- SIBO can be treated with rifaximin and afterwards D-xylose levels should return to normal

Question 122

• sudden onset odynophagia and retrosternal pain that can sometimes cause difficulty swallowing
• most often occurs in the mid-esophagus due to compression by the aortic arch or an enlarged left atrium
• dx is made clinically but if endoscopy is done can show discrete ulcers with relatively normal appearing surrounding mucosa

1.What is this?

Answer 122

1. pill esophagitis
   –ab: tetracyclines
   –anti-inflam drugs: aspirin and NSAIDs
   –bisphosphonates
   –KCl, iron

Question 123

Oropharyngeal dysphagia vs esophageal dyspagia?

Answer 123

1. difficulty initiating swallowing + cough, choking, nasal regurgitation
2. difficulty with food passing through esophagus and feeling that food gets “stuck” in chest

Question 124

Esophageal dysphagia
1. motility disorder
2. mechanical obstruction

what is the difference and what are next steps in dx for each?

Answer 124

1. motility disorder - dysphagia with solids and liquids at onset. Barium swallow followed by manometry with endoscopy
2. mechanical obstruction - dysphagia with solids progressing to liquids. Upper GI endoscopy (+/- barium swallow before)

Question 125

If someone has oropharyngeal dysphagia what is best next step to diagnose/manage?

Answer 125

Videofluoroscopic modified barium swallow to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration

Question 126

What occurs to splanchnic vasculature in cirrhosis?

–what about Na and K levels

Answer 126

1. vasodilation –> meant to decrease systemic vascular resistance
   —NO and other vasodilatory factors are formed during cirrhosis
   —- + RAAS system is activated and ADH hormone is released to maintain renal perfusion
2. Hyponatremia (due to ADH release for water uptake)
   –Hypokalemia may be due to vomiting, diarrhea, or use of diuretics

Question 127

What is the difference between mycoplasma pneumonia and mycoplasma tuberculosis - when presenting in lungs

Answer 127

1. mycoplasma pneumonia
   - subacute fever, reticulonodular pattern on chest x-ray
   - limited to 2-3 weeks
2. mycoplasma tuberculosis (miliary TB in lungs)
   - caused by hematogenous spread during primary or reactivated infection. Diffuse reticulonodular pattern on chest x-ray.
   - Has fever, night sweats, anorexia, weight loss, malaise, fatigue. Can spread to LN, liver, bones, and CNS
   - Lasts months

Question 128

Histoplasma capsulatum
1. Location/activity
2. symptoms
3. organism type and pathogenesis
4. dx
5. tx

Answer 128

1. cave exploring exposure to bat or bird droppings around Ohio and Mississippi River Valleys, Asia, Africa, and South/Central america
2. 2-4 weeks after exposure - subacute fever, chills, malaise, headache, myalgia, dry cough.
   –chest x-ray shows mediastinal or hilar LAD with infiltrates
3. dimorphic fungus - granulomas with narrow based budding yeasts
4. antigen testing of the urine or blood
5. W/out intervention can resolve over weeks. With tx they can get oral itraconazole or IV amphotericin B

Question 129

Coccidioidomycosis
1. Location/activity
2. Symptoms/imaging
3. organism type
4. dx

Answer 129

1. South west US (e.g. Arizona), Mexico, and Centra/South America
2. subacute pulmonary symptoms
   – unilateral infiltrate with ipsilateral hilar LAD
3. endospores
4. Tissue biopsy shows spherules with endospores

Question 130

1. How is metformin cleared?
2. When should it be held?

Answer 130

1. renal clearance
2. During AKI (unable to clear metformin)
   – CKD or GFR <30
   – Hepatic insufficiency (liver metabolizes lactic acid)
   – Decompensated HF (impairs renal perfusion)
   - Sepsis and dehydration (increase lactic acid in addition to what metformin creates)

Question 131

Splenic abscess usually presents with what classic triad?

Answer 131

1. Fever
2. Leukocytosis
3. LUQ abdominal pain or left sided pleuritic chest pain (can also have left pleural effusion, and splenomegaly)

Question 132

Primary mitral regurgitation (MR)
1. LVEF 30-60%
2. Asymptomatic and LVEF >60%
3. Symptomatic and LVEF <30%

• when is surgery done to repair mitral valve?

Answer 132

1. do surgery
2. Consider surgery only if successful repair is highly likely
3. Consider surgery only if successful repair is highly likely

Question 133

Papillary muscle displacement
1. time after MI
2. involved coronary artery
3. clinical findings
4. Echo findings

Answer 133

1. 3-5 days
2. RCA
3. Severe pulmonary edema, new soft systolic murmur, hypotension/cardiogenic shock
4. severe MR

Question 134

Interventricular septum rupture
1. time after MI
2. involved coronary artery
3. clinical findings
4. Echo findings

Answer 134

1. 3-5 days
2. LAD (apical septal) or RCA (basal septal)
3. Chest pain, new harsh holosystolic murmur with thrill, hypotension, cardiogenic shock
4. L to R ventricular shunt

Question 135

Free wall rupture
1. time after MI
2. involved coronary artery
3. clinical findings
4. Echo findings

Answer 135

1. Within 5 days or up to 2 weeks
2. LAD
3. chest pain, distant heart sounds, shock, rapid progression to cardiac arrest
4. pericardial effusion with tamponade

Question 136

Left ventricular aneurysm
1. time after MI
2. involved coronary artery
3. clinical findings
4. Echo findings

Answer 136

1. several months
2. LAD
3. heart failure, angina, ventricular arrhythmias
4. thin and dyskinetic myocardial wall

Question 137

Presentation:
- Adult: myotonia (delayed relaxation of muscles after voluntary contraction), weakness in face, hands, ankles
- Child: cognitive and behavioral difficulties
- Infant: hypotonia, respiratory failure, inverted V-shaped upper lip

–> Autosomal dominant CTG repeat

what is this?

Answer 137

Myotonic dystrophy
-CTG repeat in the DMPK gene

Other sx: cataracts, frontal balding, insulin resistance, sleep disturbance and testicular atrophy

Question 138

• Flank pain
• Poor urine output
• Intermittent episodes of high volume urination
• Excessive diuresis may lead to potassium wasting and dehydration, can cause weakness

–> what is this?

Answer 138

This is likely a urinary outflow obstruction
–intermittent episodes of high volume urination is when obstruction is overcome by a large amount of retained urine (obstruction often being renal calculi)
– Patients with single kidney are more likely to develop

Question 139

• Flu like febrile illness
• marked myalgia and/or arthralgia
• diffuse maculopapular rash
• Leukopenia, thrombocytopenia, hemoconcentration
• • tourniquet test (petechiae after cuff inflation for 5 min)
• increased vascular permeability

-what infection is this?

Answer 139

Dengue fever
–Prevalence high in Asia and south america
– Manifestations occur 4-7 days after transmission
–Dengue shock syndrome: severe capillary leakage leading to capillary collapse and end organ damage

Question 140

Asthma treatment in adults
1. Less than daily –> step 1 and 2
2. most days, waking with asthma –> step 3
3. daily sx, waking with asthma, decreased FEV1 –> step 4
4. still uncontrolled after step 4

treatment for each

Answer 140

1. inhaled corticosteroid (ICS) - formoterol (long acting short onset beta agonist) PRN
   —OR ICS+SABA PRN
2. low does ICS-formoterol daily
3. medium to high dose ICS-formoterol daily
4. high dose ICS-formoterol daily + LAMA (tiotropium)
   –> PLUS consider biologic therapy

Question 141

a. Decreased ceruloplasmin, increased urinary copper excretion
b. hepatic pathology
–parkinsonism
–gait disturbance
–choreoathetosis (involuntary/irregular/purposeless movement)
–dysarthria (difficulty speaking)
–psychiatric issues like tremors, depression, personality changes, psychosis

what is this? + mutation
tx?

Answer 141

1. Wilson disease, autosomal recessive mutation of ATP7B causes hepatic copper accumulation and then leak from damaged hepatocytes causes deposits elsewhere
2. Chelators (D-penicillamine, trientine)
   –> Zinc (interferes with copper absorption)
   2.

Question 142

How does quetiapine cause orthostatic syncope?

Answer 142

1. has alpha 1 receptor blocking properties which leads to smooth muscle on veins and arterioles to dilate and unable to vasoconstrict –> syncope

Question 143

• Ring enhancing lesions, can be at grey-white junction
• Due to an intracellular protozoan due to severe deficits in cell mediated immunity
• Often when CD4 <100

What is this?
How is it treated?

Answer 143

1. Toxoplasmosis (toxoplasma gondii)
2. Sulfadiazine and pyrimethamine + leucovorin
   –>TMP-SMX used as ppx when CD4 < 100

Question 144

Cholesterol crystal emboli

1. Clinical features
   —Dermatologic
   —Renal
   —CNS
   —Ocular involvement
   —GI
2. Labs
   —complement levels
   —cell lines

Answer 144

1. Clinical features
   —Dermatologic: livedo reticularis, ulcers, gangrene, blue toe syndrome
   —Renal: AKI
   —CNS: stroke, amaurosis fugax
   —Ocular involvement: hollenhorst plaques
   —GI: intestinal ischemia, pancreatitis
2. Labs
   —LOW complement levels
   —cell lines: eonsinophiluria on UA

Question 145

For patients with cough following upper respiratory infection, initial empiric treatment includes … (2 options)

Answer 145

1. Oral first generation antihistamine (e.g. chlorpheniramine)
2. Combine antihistamine-decongestant (e.g. brompheniramine and pseudoephedrine)

–Pts who do not respond after 2-3 weeks may require further investigations or empiric sequential therapy for GERD, cough variant asthma, chronic sinusitis, etc

Question 146

• 2ndary cause of HTN that causes paroxysmal HTN (variable BP readings)
  –Can occur with headache, sweating, tachycardia, anxiety

What is this?
How to dx?
Tx?

Answer 146

1. Pheochromocytoma
2. Urine or plasma metanephrines (breakdown products of Epi and NE)
3. Preoperative alpha blockade prior to beta blockade
   —lap or sx resection

Question 147

Ascites from cirrhosis
1. color
2. amylase levels
3. total protein levels
4. SAAG level

Answer 147

1. Straw yellow
2. Normal amylase
3. Low total protein (<2.5 g/dL is consistent with cirrhosis or nephrotic syndrome)
4. High SAAG (indicates portal HTN)

Question 148

Pancreatic ascites
1. what does it result from
2. color
3. amylase levels
4. total protein
5. SAAG level (serum ascites albumin gradient)

Answer 148

1. damage to the pancreatic duct with leakage of pancreatic juice into the peritoneal space
2. serosanguinous or yellow fluid
3. high amylase
4. high total protein
5. low SAAG (indicates no portal HTN)

Question 149

6 Ps of acute limb ischemia

Answer 149

1. pain
2. pallor
3. paresthesia
4. pulselessness
5. Poikilothermia (cool extremity)
6. paralysis (late sx)

Question 150

Common causes of acute limb ischemia (3)

Answer 150

1. embolism of a cardiac or intraarterial thrombus. Seen with sudden onset and likely recent MI.
2. local thrombosis from disruption of a preexisting atherosclerotic plaque (e.g. PAD, hx of claudication or diminished pulses)
3. Traumatic vessel disruption or dissection (due blunt trauma or iatrogenic injury)

Question 151

Vitamin B12 deficiency can lead to risk of gastric cancer - how?

Answer 151

Antibody-mediated destruction of intrinsic factor (what allows for B12 absorption in distal ileum) and gastric parietal cells. Damage to the stomach results in gastric atrophy and increases the risk of gastric cancer.

Question 152

Cardiomyopathy due to viral myocarditis
1. What type of cardiomyopathy?
2. patient population
3. echo findings

Answer 152

1. dilated
2. <55
3. biventricular enlargement with diffuse ventricular wall hypokinesis

*in children this is most commonly due to coxsackievirus B or adenovirus

Question 153

• Persistent fever and LUQ pain (sometimes radiating to the back)
• w/ or w/out splenomegaly
• Lab shows leukocytosis with left shift
• Chest x ray shows elevated left hemidiaphragm (and/or left pleural effusion)

Answer 153

Splenic abscess

–complication of bacteremia from a distant infection (e.g. infective endocarditis, cholecystitis)

Question 154

1. What is considered low urine osmolality?
2. What is considered low urine specific gravity
3. What is considered high serum osmolality?

Answer 154

1. <300 mOsm/kg H2O
2. <1.006
3. > 250 mOsm/kg H2O

Question 155

what are the 4 common organisms to cause infectious bloody diarrhea?
– plus their source

Answer 155

1. Shiga toxin producing E coli (E coli O157:H7) – undercooked beef. (absence of high fever)
2. Shigella –contaminated food/water or outbreaks
3. Campylobacter – raw or undercooked meat
4. Salmonella – undercooked chicken

Question 156

Lemiere syndrome
1. organism that causes this
2. pathophysiology
3. symptoms

Answer 156

1. fusobacterium necrophorum (part of normal oral flora)
2. begins as an oropharyngeal infection (tonsilitis) - bacterium invades the lateral pharyngeal space through lymphatic system and affects the neurovascular structures causing internal jugular vein thrombosis and infection
3. prolonged sore throat, high fever, rigors, dysphagia, neck pain, swelling along SCM muscle
   —septic thromboemboli to lungs mostly

Question 157

Rapidly progressive hirsutism with virilization suggests very high androgen levels due to androgen producing neoplasm
1. DHEAS
2. Testosterone
3. LH

• describe what happens to each and why

Answer 157

1. Increased (most androgen producing adrenal tumors overproduce DHEAS but have negligible androgenic activity. Clinical features are due to conversion of DHEA/DHEAS into more potent androgens like androstenedione and testosterone.
2. Increased after DHEA/DHEAS is converted to testosterone
3. Testosterone has negative feedback on LH (LH is decreased)

Question 158

Intraparenchymal hemorrhages typically present with sudden FND that gradually worsen over minutes to hours
- common locations of hemorrhage include and what are the causes?

vs

subarachnoid hemorrhage - what are the main causes (3)

Answer 158

1. Lobar –> due to cerebral amyloid angiopathy, AVM, tumor
2. basal ganglia, pons, thalamus –> due to HTN

vs
1. aneurysm (80%)
2. Trauma
3. AVM

Question 159

When getting a blood transfusion - if patient gets reaction from cytokines in blood transfusion [febrile nonhemolytic transfusion reaction] - how long with this take?

vs anaphylactic shock

vs acute hemolysis

vs transfusion related acute lung injury

Answer 159

1. 1-6 hours within transfusion start (leukocytes are in the blood transfusion package)
2. seconds to minutes (due to recipient having anti-IgA Ab against donation)
3. minutes to hours (ABO incompatibility)
4. minutes to hours (donor antileukocyte antibodies - against recipient)

Question 160

Symptoms from someone having ABO incompatibility

Answer 160

Hypotension
fever, flank pain, hemoglobinuria
–within minutes to hours

Question 161

What cancer leads to increased PTHrP

Answer 161

Squamous cell carcinoma of the lung (the one associated with smoking)

Histology: polygonal cells with intercellular bridges, eosinophilic cytoplasm, keratin pearls, and extensive necrosis

–> single, large cavitary lesions on chest x-ray, most commonly center of lung

Question 162

What clinical associations occur with small cell carcinoma of the lung?

Answer 162

1. cushing syndrome
2. SIADH
3. Lambert-eaton syndrome

this is a central location lung cancer

Question 163

Indications for urgent dialysis (AEIOU)

Answer 163

1. A: acidosis (metabolic acidosis): pH<7.1 and refractory to meds
2. E: electrolyte imbalances (hyperkalemia, esp >6.5)
3. I: Ingestion (toxic alcohols, salicylate, lithium sodium valproate, carbamazepine)
   4: O: fluid overload refractory to diuretics
4. U: uremia (symptomatic, encephalopathy, pericarditis, bleeding)

Question 164

-Flank pain
-Hematuria
-Increased kidney size on imaging
-Increased LDH
-D/t hypercoagulability or trauma

what is this?

Answer 164

Renal vein thrombosis
dx: CT scan or MR angiography, renal venography
tx: anticoagulation, local thrombolysis/thrombectomy

Question 165

Depression with psychotic features or severely depressed patients who refuse to eat and drink or are acutely suicidal

-tx?

Answer 165

electroconvulsive therapy

Question 166

1. cell free fetal DNA testing is indicated in what patients
2. What does it screen for?

Answer 166

1. moms >= 35, abnormal maternal serum screening, abnormal sonographic findings, prior pregnancy with aneuploidy
2. Trisomy 21, 18, 13, and sex chromosome aneuploidies, fetal sex determination

Question 167

Secondary bacterial pneumonia as a complication of influenza most often occurs with… (2)

Answer 167

1. Strep pneumo
2. Staph aureus

Question 168

1. recurrent, painful oral aphthous ulcers
2. genital ulcers
3. eye lesions (uveitis)
4. skin lesions (erythema nodosum, acneiform lesions)
5. thrombosis
   –usually in young adults from turkish, middle east, or asian descent

Answer 168

1. Behcet syndrome

• exaggerated skin ulceration with minor trauma (e.g. needlestick)

Question 169

Can SCD pregnant patients recieve morphine during vasoocclusive pain episodes?

Answer 169

yes - they get IV hydration and aggressive pain control

Question 170

conus medullaris syndrome
1. vertebral level
2. UMN vs LMN?
3. presentation

Answer 170

1. L1-L2
2. UMN
3. severe low back pain, mild or absent radicular pain, bowel/bladder dysfunction
   –motor weakness usually symmetric
   –Hyperreflexia
   - Symmetic perianal numbness

Question 171

Cauda equina syndrome
1. vertebral level
2. UMN vs LMN?
3. presentation

Answer 171

1. L2-sacrum
2. LMN
3. 1. due to disc herniation or tumor that causes severe radicular pain.
      
      2. Saddle anesthesia, absent knee/ankle reflex
      3. Muscle weakness on one side
      4. Loss of anal sphincter control/urination urinary symptoms

Question 172

• pancytopenia (fatigue, bruising, recurrent infections)
• testicular enlargement , hepatosplenomegaly
• common in young children
• Adolescents and young adults often show mass of thymic origin (anterior mediastinal mass) causes compressive symptoms
  –bone pain (affects long bones)
  – Blasts >20 % in bone marrow aspirate

what is this?
how is it dx?
tx and prognosis

Answer 172

acute lymphoblastic leukemia

dx w/bone marrow biopsy

w/multidrug chemo prognosis is favorable in children

*bone pain (affects long bones) - due to rampant growth of leukemic cells in bone marrow
*Leukocyte count is initially low due to concurrent disease in normal white blood cell production but as dx progresses and lymphoblasts overcrowd then leukocytosis occurs as lymphoblasts spill into periphery

Question 173

Persistent pulmonary hypertension of the newborn (PPHN) can be caused by conditions that injure the lungs (eg, meconium aspiration syndrome). Treatment of PPHN includes ….

Answer 173

oxygenation
ventilation
administration of pulmonary vasodilators (eg, inhaled nitric oxide).

Question 174

Diclofenac is what type of drug?

Answer 174

NSAID

Question 175

Hypervolemic hyponatremia
1. how to fix volume
2. How to fix Na

Answer 175

1. diuretics
2. No specific one

Question 176

Central vs peripheral precocious puberty
1. pathophysiology
2. hormone changes
3. GnRH stimulation test
4. tx

Answer 176

Central
1. early activation of hypothalamic pituitary gonadal axis leading to premature development of secondary sexual characteristics.
2. elevated gonadotropins (LH, FSH)
3. Elevated LH and FSH after GnRH stimulation
4. GnRH analog to delay further progression

Peripheral
1. hormone production outside the HPG axis
2. Low or suppressed gonadotropins due to external source of sex steroids
3. GnRH stimulation test: no significant rise in LH or FSG after GnRH agonist
4. tx underlying cause

Question 177

• premature baby with low birth weight
• enteral feeding
• abdominal distention
• feeding intolerance, billious emesis
• bloody stools (often not seen early on)

likely it is ?

Answer 177

1. Necrotizing enterocolitis
   –> get x ray : shows pneumatosis intestinalis, pneumoperitoneum

Question 178

Hidradenitis suppurativa is very closely associated with what lifestyle choice?

Answer 178

Smoking

Question 179

First line analgesics for neuropathy pain (e.g. diabetic peripheral neuropathy)
1.
2.
3.

Answer 179

1. SNRI (duloxetine, venlafaxine)
2. TCAs
3. Gabapentin, pregabilin

Question 180

What are side effects of mirtazapine

Answer 180

sedation and weight gain

Question 181

Rine test
1. conductive hearing loss
—affected ear
—unaffected ear

2. sensorineural hearing loss
   –affected ear
   —unaffected ear

Answer 181

1. conductive hearing loss
   —affected ear (bone conduction>air conduction)
   —unaffected ear (air conduction >bone conduction)
2. sensorineural hearing loss
   –air conduction >bone conduction in both affected and unaffected ear

Question 182

Weber result
1. conductive hearing loss
2. sensorineural hearing loss

Answer 182

1. lateralizes to affected ear
2. lateralizes to unaffected ear, away from affected ear

-wine: place tuning fork on the middle of forehead and determine where sound lateralizes

Question 183

• BTK gene mutation
• impaired B cell maturation and immunoglobulin production
• recurrent sinopulmonary and GI infections at age >3-6 months
• chronic enteroviral infection
• small or absent lymphoid tissue

what is this?
Tx?

Answer 183

X-linked agammaglobulinemia
–flow cytometry shows decreases CD19 cells

tx: IVIG, ppx Ab

Question 184

risperidone, aripiprazole, quetiapine, olanzapine, ziprasidone

• what are these drugs?

Answer 184

second generation antipsychotics

Question 185

When do you use clozapine?

Answer 185

1. gold standard for schizophrenia but due to high risk of agranulocytosis it is reserved for patients who have failed to respond to at least 2 antipsychotic trials

Question 186

Pronator drift is a physical exam finding that is pathognomonic for UMN or (BLANK) dx - especially in the absence of proprioception deficits

Answer 186

1. Pyramidal/corticospinal tract
   – (starts at cortex, goes through internal capsule (posterior limb), down to body)

Question 187

What is the corticospinal tract?
–where does it cross over?

Answer 187

1. white matter pathway in the brain that controls voluntary motore function.
2. It decussates in the medulla

Question 188

What are extrapyramidal signs?

Answer 188

Group of side effects that affect the motor system
- involuntary movements (lip smacking or puckering)
- muscle stiffness (rigidity)
- tremors
- shuffling gait
- abrupt spasms
- physical restlessness (pacing, shaking legs, rocking)
- slowness of movements (bradykinesia)
- irregular, jerky movements (dyskinesia)

Question 189

What does an abdominal succussion splash mean?

Answer 189

1. heard with a stethoscope and done while patient rocks back and forth at the hips
2. Retained gastric material for >3 hrs after meal will generate a splash – can happen with gastric outlet obstruction like pyloric stricture, malignancy, peptic ulcer dx

Question 190

Hepatic adenomas
1. patient populations
2. What is it?

Answer 190

1. In young women who have been on prolonged estrogen based oral contraception
2. solitary solid lesion in right lobe of liver

Question 191

Intrahepatic cholestasis of pregnancy
1. at what point does it happen
2. what is the management?
3. Pathophysiology

Answer 191

1. 3rd trimester
2. Ursodeoxycholic acid
   - antihistamines for generalized pruritus
   - Delivery at 37 weeks as normal
3. Increased estrogen and progesterone cause hepatobiliary tract stasis and decreased bile excretion –> causes pruritus on palms and soles

Question 192

Neuropathic (Charcot) arthropathy
1. most commonly occurs in what patient group?
2. What does it start with?
3. What is the acute or chronic form?

Answer 192

1. diabetics
2. impaired sensation and joint proprioception
3. Acute: inflammatory erythema, warmth, and edema of the foot 1-2 days after minor trauma. No bone involvement on xray
   —-chronic: osseous fragmentation, new bone formation, and subluxation/dislocation predominantly in the mid and hind foot. Can get ulcers, rocker bottom feet (arch collapse), and callus formation

Question 193

Patients with COPD are classified into groups A, B, or E –> this determines their tx by their symptoms

–> Group A (low symptom severity and low exacerbation risk)
–> Group B (more severe symptoms but no hospitalizations required)
–> Group E (hospitalization and more frequent/severe exacerbation)

what is treatment for each?

Answer 193

Group A: inhaled SABA or SAMA (short acting muscarinic antagonist)

Group B and Group E: Initial therapy is daily inhaled LABA (e.g. fomoterol) plus a LAMA (e.g. tiotropium)

Group E: can also have inhaled corticosteroid

Question 194

Evaluation of polyuria
1. Urine output > (BLANK) = polyuria present
2. Dilute urine –> likely causes?
3. Concentrated urine –> likely causes?

Answer 194

1. > 3 liters
2. Primary polydipsia or diabetes insipidus
3. Osmotic diuresis due to increased solute excretion like glucose, urea, saline

Question 195

What is asherman syndrome?

Answer 195

1. intrauterine adhesions that can follow intrauterine surgery
   –> most often after suction and sharp curettage for delivery complications
   –> can cause amenorrhea that does not respond to progesterone challenge (progesterone stops endometrial growth and promotes differentiation, once progesterone is stopped this withdrawal mimics the natural pattern of progesterone that signals for uterus to menstruate)

Question 196

Internal vs external hemorrhoids
1. which one is more painful

Answer 196

1. Internal is usually not painful and above the dentate line
2. painful and hemorrhoidectomy is done for severely painful thrombosis

Question 197

–> most common lung cancer in adolescents/young adults
–> neuroendocrine tumor
–> proximal airway obstruction causes dyspnea, wheezing, cough
–> recurrent pneumonia past tumor, hemoptysis

what is this?

Answer 197

bronchial carcinoid tumor

Question 198

• X linked recessive mutation of NADPH oxidase
• impaired respiratory burst and decreased reactive oxygen species leading to inhibition of phagocytic intracellular killing
  –will see recurrent infections with catalase positive bacteria and fungi, diffuse granulomas
  – Dx with tests to measure neutrophil superoxide production like DHR flow cytometry and nitroblue tetrazolium testing

what is this?
tx?

Answer 198

1. chronic granulomatous disease
2. Prophylaxis is w/TMP-SMX, itraconazole, interferon gamma

–> active infection is Ab based on culture results
–> Hematopoietic cell transplant is curative

Question 199

• arthritis of varied patterns
• enthesitis (inflammation at tendon insertion site)
• dactylitis of toe or finger
• nail pitting and onchyolysis
• pitting edema of hands or feet
• Skin lesions typically precede onset of arthritis

what is this?

Answer 199

psoriatic arthritis (nail pitting is highly specific for this)

Question 200

Time line for these?
1. postpartum blues
2. postpartum depression
3. postpartum psychosis

Answer 200

1. w/in 2-3 days and resolves within 2 weeks
2. within 4-6 weeks (can be up to a year)
3. days to weeks

Question 201

The first step in evaluation of suspected hydrocephalus is getting (BLANK)

Answer 201

1. ultra fast MRI
2. U/S of head (if fontanelle is still open)

–hydrocephalus should be considered when head circumference is moving up several growth lines

Question 202

Gradually enlarging, glandular breast tissue (small <4cm) in adolescent boys (12-14 during mid puberty) is often due to (BLANK)

Answer 202

1. transiently increased testicular production of estrogen compared to testosterone and peripheral conversion of prohormones to estrogen

*can be firm, unilateral or bilateral, subareolar mass that may be tender to touch –> managed with reassurance and observation

• resolves within a year

Question 203

• biconvex lens looking hyperdensity on CT scan (does not cross suture lines)
• Due to trauma to middle meningeal artery
• brief lucid interval
• can lead to herniation (subfalcine, uncal, etc)

what is this?

Answer 203

1. epidural hematoma
2. Tx with urgent surgical evacuation

Question 204

• When androstenedione and testosterone levels are very high
• undetectable estrone and estradiol levels
• This is likely what?

Answer 204

Aromatase deficiency
–for women you will see normal internal genitalia and external virilization because of excess androstenedione

Question 205

Congenital adrenal hyperplasia
1. pathophysiology
2. what lab abnormalities are there?

Answer 205

1. deficiency in 21 hydroxylase leading to decreased cortisol and aldosterone.
2. Hyponatremia because aldosterone is not there for reuptake.

–in infancy will have salt wasting and virilization
–in childhood you get premature pubarche/adrenarche (without virilization)
–advanced bone age expected

Question 206

What are the thyroid effects of amiodarone?
why?

Answer 206

1. Impairs synthesis of thyroid hormone and decreases peripheral conversion of T4 to T3.
   – AIT type 1: It can also increase synthesis of thyroid hormone in patients with nodular thyroid disease or latent Grave disease
   –AIT type 2: cause destructive thyroiditis with transient hyperthyroidism.

–amiodarone has iodine content

Question 207

What should be done when variceal hemorrhage bleeds are suspected?
1.
2.

Answer 207

1. place 2 large bore IV to volume resuscitate, IV ocreotide (vasoconstrict), and antibiotics
2. Urgent endoscopic therapy of esophageal varices
   -further management based on what is found

Question 208

Inspiratory “velcro” (e.g. fine, dry) crackles are sensitive for (BLANK)

• what imaging should patients undergo to visualize disease? (early on in disease)

Answer 208

interstitial fibrosis - get high resolution CT scan of the chest
- and full pulmonary function test

Question 209

Patients with chronic ITP have platelets <100,000 for >1 year

–what can be done for those with persistent bleeding and thrombocytopenia despite repeated pharm interventions

Answer 209

1. splenectomy to remove source of platelet destruction and is often curative in patients with ITP
2. pharm interventions: glucocorticoids, anti-D, IVIG

Question 210

Gestational DM
–when is it screened?
–How is it screened and what are the levels?

Answer 210

1. 24-28 weeks
2. 50 g glucose load and check serum glucose 1 hour later — if blood glucose <140 mg/dL then likely no GDM
   –> if >= 140 mg/dL
3. Check fasting serum glucose + give 100 g oral glucose load and then check blood glucose 3 hrs later. Need >=2 abnormal values to dx GDM

–> fasting >= 95 mg/dL or >= 105 (diff sources)
–> 3 hr >= 140 mg/dL or >= 145 mg/dL

Question 211

1. What is amblyopia?
2. Causes?
3. management?

Answer 211

1. Lazy eye- functional reduction in visual acuity. Usually unilateral and occurs when binocular vision is disturbed while the visual system is developing (age <5)
2. strabismus (ocular malalignment), uncorrected refracted error (eyes optical system fails to properly focus light onto the retina), vision deprivation due to cataracts/ptosis/corneal opacities
3. corrective lenses, encourage use of amblyopic eye, surgery (to remove opacities)

Question 212

How does prolactin cause hypogonadism?

Answer 212

Prolactin suppresses production of GnRH in hypothalamus
-this prevents FSH and LH release from anterior pituitary
-this diminishes estrogen release from ovary leading to anovulation, amenorrhea, menopausal symptoms (osteoporosis)

Question 213

What is acute dystonia?
How is it treated?

Answer 213

1. sudden sustained contraction of the neck, mouth, tongue, eye muscles
2. reducing dose or switching meds
   -benzos
   -diphenhydramine

Question 214

What is akathisia?
what causes it?
How is it treated?

Answer 214

1. Subjective restlessness, inability to sit still
2. dopamine antagonist meds (antipsychotics) and antiemetics (prochlorperazine, promethazine, metoclopramide)
3. . Reducing dose or switching meds
   - Beta blocker (propranolol)
   - Benzo (lorazepam)
   - Benztropine

Question 215

How is parkinsonism treated when caused by antipsychotic meds?

Answer 215

Reducing dose or switching meds
– Benzotropine
–Amantadine

Question 216

What is tardive dyskinesia?
How is it treated?

Answer 216

1. gradual onset after prolonged therapy (>6 months) –> dyskinesia of the mouth, face, trunk, and extremities
2. Reducing dose or switching meds
   - Valbenazine
   - Deutetrabenazine
   *switch to antipsychotic with lower tendency to cause TD such as quetiapine or clozapine

Question 217

Quadruple marker test - done in 2nd trimester

MSAFP, beta hCG, estriol, Inhibin A levels for
1. Trisomy 18
2. Trisomy 21
3. Neural tube or abdominal wall defect

Answer 217

1. decreased MSAFP, beta hCG, estriol
   -normal inhibin A
2. decreased MSAFP, Estriol
   -increased beta hCG, inhibin A
3. increased MSAFP (alpha fetoprotein)
   - everything else normal

Question 218

1. what is a subgaleal hemorrhage
2. presentation

Answer 218

1. rupture of emissary veins upon scalp traction during delivery. These veins connect the dural sinuses and the scalp and can cause massive bleeding between periosteum and galea aponeurotica.
   - can happen with vacuum assisted deliveries but also spontaneous vaginal or c-sections
2. diffuse, fluctuant scalp swelling that extends the suture lines and can go into the neck. Expands over 2-3 days

Question 219

Cephalohematoma is bleeding between skull and (BLANK)

–presentation?

Answer 219

1. periosteum
2. firm, nonfluctuant swelling that DOES NOT cross suture lines or lead to significant blood loss

Question 220

GI: N/V, cramping, diarrhea, increased bowel sounds
Cardiac: increased pulse, BP, diaphoresis
Pysch: insomnia, yawning, dysphoric mood
Other: myalgia, arthralgia, mydriasis, lacrimation, rhinorrhea, piloerection

–what is ths?
–management options?

Answer 220

1. opioid withdrawal (4-48 hours after last use)
2. opioid agonist –> methadone or buprenorphine
   –> non-opioid: clonidine or adjunctive meds (antiemetics, antidiarrheals, benzos)

Question 221

What is the treatment for specific phobias?

Answer 221

1. CBT with exposure
2. short acting benzos may be needed acutely

Question 222

What are the common drugs that can cause ototoxicity? (4)

Answer 222

1. aminoglycoside antibiotics (can also cause nephrotoxicity - can measure trough concentrations to help predict and prevent nephrotoxicity)
   *can act synergistically with penicillins
2. chemo agents (cisplatin)
3. high dose salicylates
4. high dose loop diuretics

Question 223

Acute onset dyspnea and cough
-Decreased breath sounds on affected side and wheezing
- Cheset xray : hyperinflation and mediastinal shift away from affected side
- usually right main bronchus

what is this?
management?

Answer 223

1. foreign body aspiration
2. bronchoscopic removal

Question 224

1. macrocytic anemia, reticulopenia, normal platelets and WBC
2. craniofacial anomalies
3. triphalagneal thumbs

–> what is this?
–> management?

Answer 224

1. Diamond blackfan anemia - congenital defect in erythroid progenitor cells which can lead to increased apoptosis
   –typically presents in infancy w/progressive pallor and poor feeding due to anemia
2. corticosteroids and RBC transfusions

Question 225

• thumb hypoplasia
• pancytopenia and hypocellular bone marrow
• defects in DNA repair genes lead to chromosomal instability and increased risk of malignancies (leukemia)

1. what is this?

Answer 225

Fanconi anemia

Question 226

Female and male pattern hair loss
1. treatment for men vs women

Answer 226

1. Men: finasteride, minoxidil
2. women: minoxidil

Question 227

Evaluation of red urine
1. red/brown urine, heme-positive dipstick
2. get urinalysis
a. >=3 RBC —> cause (BLANK)
b. 0-2 RBC –> cause (BLANK)

Answer 227

2a. hematuria
2b. caused by hemoglobinuria (intravascular hemolysis, decreased Hgb and haptoglobin) –> get CBC to evaluate hemolytic anemia

or myoglobinuria (rhabdo causing increased CK)

Question 228

Follicular lymphoma
1. form of hodgkin or nonhodgkin?
2. patient population
3. pathophysiology and mutation
4. presentation

Answer 228

1. Non-hodgkin
2. elderly patients
3. nodular growth of follicular lymphocytes.
   –> translocation between chromosome 14 and 18 that leads to overexpression of BCL-2
4. Indolent fashion with months or years of painless peripheral LAD in cervical, axillary, or inguinal region
   - LAD waxes and wanes

Question 229

1. What is abruptio placentae?
2. Painful or painless?
3. complications?

Answer 229

1. placental detachment from the uterus before delivery – accumulation of blood causes increased intrauterine pressure (lower abdominal or back pain), a firm, tender uterus, and high frequency contractions
2. painful
3. maternal hemorrhage, DIC, fetal hypoxia, preterm birth, mortality

Question 230

1. What clinical signs does uncal herniation cause?
2. What about tonsillar herniation
3. What about subfalcine hernation

Answer 230

1. ipsilateral fixed and dilated pupil due to compression of oculomotor nerve and parasympathetic fibers
   –contralateral hemiparesis with respiratory compromise (compression of ipsilateral cerebral peduncle/corticospinal tracts)
   –homonymous hemianopsia (visual field loss in the same halves of the visual field of each eye)
   –contralateral decerebrate posturing due to dysfunction of tract below red nucleus
2. fixed, midposition pupils due to disruption of sympathetic and parasympathetic innervation
3. No pupil change but as it progresses can cause ipsilateral anterior cerebral artery compression leading to contralateral leg weakness

Question 231

Atelectasis is a common post op complication that results from shallow breathing and weak cough due to pain
- common at day (BLANK)
- ways to decrease the incidence of this?

Answer 231

1. 2-3 days
2. adequate pain control, deep breathing exercises, incentive spirometry
   - early mobilization
   -directed coughing

Question 232

Acute otitis media
1. common pathogenes
2. 1st, 2nd line tx + tx for allergies to 1st line

Answer 232

1. strep pneumo, H influenzae, moraxella catarrhalis
   2.1st - amoxicillin
   2nd - amoxicillin -clavulante (if pt has already done amoxicillin within past 30 days)
   –penicillin allergy: azithromycin or clindamycin

Question 233

Fundoscopic findings: retinal vessel attenuation, optic disc pallor, abnormal retinal pigmentation

other features: night blindness, sx onset from age 10 to adulthood

what is this?

Answer 233

retinitis pigmentosa

Question 234

Chronic vomiting leads to volume depletion and metabolic alkalosis which is initiated by loss of H ions and Cl depletion

–> tx?

Answer 234

Normal saline restores intravascular volume and replenishes chloride thereby restoring kidneys ability to excrete bicarbonate (and resolve alkalosis)

Question 235

Women on phenytoin for seizures but are planning on becoming a parent should…

Answer 235

taper off medication slowly even though they are not pregnant yet but actively trying

Question 236

• Heavy, regular menses
• Dysmenorrhea, pelvic pain
• Uniformly enlarged (globular), tender uterus

what is it?

Answer 236

adenomyosis

Question 237

-Uncommon cause of heavy menses
-Dysmenorrhea, chronic pelvic pain, dyspareunia
-Fixed uterus, adnexal mass (endometrioma), rectovaginal nodularity, cervical motion tenderness
- infertility

what is it?

Answer 237

endometriosis
- ectopic implantation of endometrial glands

dx with direct visualization and surgical bx

1. tx: first medically (OCPs, NSAIDs)
   –> then surgical resection

Question 238

-Heavy, regular menses
-Bulk symptoms (eg, pelvic pressure/pain, constipation)
-Irregularly enlarged uterus with uneven contour

what is it?
tx?

Answer 238

Uterine leiomyomas (fibroids)
- proliferation of smooth muscle within the myometrium

–> tx: NSAIDs, combined oral contraceptive (estrogen makes them grow), GnRH agonist, and surgical option for severe cases

Question 239

Acute bacterial prostatitis
- fever, dysuria, and swollen tender prostate
- caused by what organisms?
- tx?

Answer 239

1. coliform organisms like E coli
2. 6 weeks of TMP-SMX or fluoroquinolone

Question 240

What are the common stimulant vs nonstimulant treatments for ADHD?

Answer 240

1. stim: methylphenidate
2. nonstim: atomoxetine

Question 241

How is tourettes syndrome tx?
(3)

Answer 241

1. Behavioral therapy
2. Antidopaminergic therapy (tetrabenazine/dopamine depletor or antipsychotic/dopamine receptor blocker)
   —2nd generation antipsychotics (risperidone, aripiprazole) bc have better adverse effect profile
3. Alpha 2 adrenergic receptor agonists

Question 242

1. How is microcephaly identified?
2. If pt has serial HC measurements across >=2 declining major percentiles
   —Neuro sx or dysmorphic syndromes
   –what is done next?

Answer 242

1. HC below 3rd percentile
2. MRI of brain (then eval for congenital infection or genetic testing)

Question 243

What breast pathology has unilateral, blood nipple discharge and no associated breast mass or LAD?

Answer 243

1. Intraductal papilloma - intraductal papillomas are papillary projections composed of epithelial and myoepithelial cells –> these cells line a fibrovascular stalk that protrudes into the breast duct lumen

Question 244

Multicolored, blue, or green-brown rather than sanguineous unilateral nipple discharge
–isolated, subareolar breast mass

what breast pathology is this?

Answer 244

1. mammary duct ectasia – distension of the subareolar ducts with fibrosis and inflammation

Question 245

When is syphillis screened for during pregnancy?

Answer 245

1. 1st prenatal visit
2. 3rd trimester and delivery if high risk

Question 246

what is screened at 24-28 weeks of pregnancy?

Answer 246

1. Hgb/hct
2. antibody screen if Rh negative
3. 1 hr 50 g GCT

Question 247

Rh(D) type & antibody screen
Hemoglobin/hematocrit, MCV, ferritin
HIV, VDRL/RPR, HBsAg, anti-HCV Ab
Rubella & varicella immunity
Urine culture
Urine dipstick for protein
Chlamydia PCR (if risk factors are present)
Pap test (if screening indicated)

Answer 247

1. screened at initial visit

Question 248

How does lithium affect thyroid?

How does lithium affect glucose levels?

How does lithium affect kidney?

other side effects:

Answer 248

1. Pts can develop hypthyroidism so pts need regular TSH labs a 6-12 months
   –tx with T4 supplements, dont stop lithium
2. Affects glucose metabolism leading to increased glucose
3. Increase in creatinine (chronic kidney dx after years of use) —can also cause nephrogenic diabetes insipidus leading to polyuira and state of dehydration and hypernatremia

Question 249

Patients receiving solid organ transplantations require high-dose immunosuppressive medication to prevent organ rejection. This results in systemic immunosuppression, which puts them at risk for opportunistic infections, most notably (BLANK) or (BLANK)

Answer 249

1. Pneumocystis pneumonia (PCP) and cytomegalovirus (CMV).

• PCP: pulmonary sx
• CMV: pulmonary sx, GI symptoms, pancytopenia, hepatitis

Question 250

Serum sickness–like reaction is most common in children and is typically triggered by (BLANK) and (BLANK) drugs.

Symptoms begin 5-14 days after exposure and include urticarial rash, arthralgia, lymphadenopathy, and low-grade fever. Manifestations resolve with withdrawal of the offending agent.

Answer 250

beta-lactam (eg, cefaclor) and sulfa drugs.

Question 251

Patients with cystic fibrosis are at risk for what vitamin deficiencies?

Answer 251

ADEK - due to fat malabsorption from a pancreatic insufficiency
– Vit K is necessary for coagulation factor activation

Question 252

Vit K is necessary for what coagulation factors?

Answer 252

2, 7, 9, 10

Question 253

enterobius vermicularis (pinworm)
- tx?

Strongyloidiasis - urticaria, abdominal pain, and respiratory problems
- tx?

Answer 253

1. pyrantel pamoate
2. ivermectin

Question 254

• Patient has prolonged fever (can have acute or subacute)
• murmur (new onset)
• Labs: leukocytosis, anemia (chronic dx effect), reactive thrombocytosis
• Glomerulonephritis (immune complex deposition and subsequent inflammation in glomeruli)

what is this most likely?
w/positive blood cultures –> what else needs to be done? (heart)

Answer 254

1. infective endocarditis
2. Echo to detect intracardiac vegetation or abscess

Question 255

acute limb ischemia
1. viable limb characteristics
2. threatened limb characteristics
3. nonviable limb characteristics

(pain, sensory/motor deficit, cap refill, doppler pulses)

tx for each

Answer 255

–> all initial tx should be anticoagulation (hep infusion)

1. mild pain, intact cap refil, audible doppler pulses – get CT angio and then tx with catheter based or surgical revascularization
2. severe pain, mild/partial sensory/motor deficit, delayed cap refill, inaudible arterial doppler, audible venous doppler – tx with emergency surgical revascularization
3. variable pain, severe/complete sensory/motor deficit, absent cap refil, inaudible doppler pulses - manage with amputation

Question 256

oral aspirin, clopidogrel, and high intensity statin –> what is this regimen for?

Answer 256

appropriate for post stent placement

Question 257

What are some risk factors when indomethacin is used for tocolysis in preterm labor <32 weeks gestation
–> explain why

Answer 257

1. oligohydramnios (cox inhibitor decreases prostaglandin production) –> leads to fetal vasoconstriction and subsequent decreased renal perfusion and fetal oliguria causing oligohydramnios
2. premature closure of the fetal ductus arteriosus

*typically only receive indomethacin for <= 48 hrs

Question 258

• most common renal malignancy in children (peak age 2-5)
• usually asymptomatic
• unilateral abdominal mass
• +/- abdominal pain, HTN, hematuria
  –what is this?

Answer 258

Wilms tumor (nephroblastoma)

• WAGR, may be associated with wilms tumor, aniridia, GU abnormalities, mental Retardation

Question 259

How is neuroblastoma different from wilms tumor?

Answer 259

1. Neuroblastoma is a tumor that can arise anywhere in the sympathetic nervous system but typically involves the adrenal glands and presents as an abdominal mass.

—Usually affects children age <2 and does not cause hematuria which wilms tumor can

—periorbital ecchymosis (orbital mets)
—spinal compression
—opsoclonus-myoclonus syndrome

Question 260

Hemolytic uremic syndrome
1. what is it caused by
2. what is pathogenesis
3. clinical features
4. lab findings

• tx with fluids, electrolytes, blood transfusion, dialysis

Answer 260

1. E coli O157:H7, shigella dysenteriae
2. toxin invades and destroys colonic epithelial lining causing abd pain, bloody diarrhea.
   –There is also vascular damage and microthrombi formation creating space for shearing forces.
   –Intrinsic renal injury is renal vascular occlusion by the capillary microthrombi
3. Bloody diarrhea
   – Week after diarrhea pt has signs of anemia (fatigue, pallor), thrombocytopenia (bruising, petechiae), AKI (oliguria, edema).
4. Hemolytic anemia (schistocytes, increased bilirubin)
   –thrombocytopenia
   - AKI (increased BUN, increased Cr)

Question 261

Primary prevention for statin therapy
1. LDL (BLANK)
2. age (BLANK) with DM
3. estimated 10 year risk of ASCVD (BLANK)

Secondary prevention (those with establised ASCVD)
–ACS
–Stable angina
–arterial vascularization
–stroke, TIA, PAD

Answer 261

1. LDL >= 190 mg/dL
2. Age>= 40 with DM
3. Estimated 10 year risk of ASCVD >7.5-10

Question 262

palpable breast mass
1. age <30 –>
2. age 30-39 –>
3. age >= 30 –>

Answer 262

1. age <30 –> U/S +/- mammogram
   —-if simple cyst is apparent then get need aspiration if symptomatic
   —if complex cyst/mass then get image guided core biopsy
2. age 30-39 –> can use either
3. age >= 30 –> mammogram +/- U/S
   —- if suspicious for malignancy then get core biopsy

Question 263

CHA2DS2VASc score
Male (0, 1, >=2)
Female (0, 2, >=3)

Answer 263

1. CHF
2. HTN
3. Age >= 75 (2 pts)
4. DM
5. stroke or TIA (2 pts)
6. Vasc dx (PAD or past MI)
7. Age 65-74
8. Sex category female

Male (0, 1, >=2)
- 1 = none or oral anticoagulant
- >=2 = oral anticoagulant

Female (0, 2, >=3)
- 2 = none or oral anticoagulant
- >=3= oral anticoagulant

Question 264

Neuroleptic malignant syndrome

1. causative agent?
2. slow onset/offset (days to weeks). Not dose dependent and can occur at anytime
3. symptoms? (symptoms that make it different from serotonin syndrome?)

Answer 264

1. Dopamine antagonist (antipsychotics, neuroleptics)
2. –
3. hyperthermia, AMS, autonomic dysregulation
   –diff from serotonin syndrome: NMS shows severe diffuse muscle rigidity

Question 265

Serotonin syndrome

1. causative agent?
2. rapid onset/offset (<24 hours)
   - often associated with dose increase
3. symptoms? (symptoms that make it different from NMS?)

Answer 265

1. serotonergic agent (lithium, illicit drugs like ectasy, antiemetic medication (ondansetron), migraine medication (e.g. triptans), opioid medications (meperidine, dextromethorphan, oxycodone, fentanyl))
2. –
3. autonomic dysregulation (diaphoresis, tachy, HTN, hyperthermia), AMS, neuromuscular hyperactivity (hyperreflexia, tremor, rigidity, myoclonus, ocular clonus, bilateral babinski sings)

–diff from NMS: has hyperreflexia, clonus, and N/V
*NMS has diffuse muscle rigidity and bradyreflexia

Question 266

• epilepsy presents in adolescents
• myoclonic jerks immediately on wakening

Answer 266

Juvenile myoclonic epilepsy

Question 267

TCA overdose can cause
- anticholinergic sx
- CNS toxicity (seizures)
- Cardiac toxicity (e.g hypotension, QRS prolongation)

what is given to counteract this toxicity?

Answer 267

sodium bicarbonate

Question 268

anterior uveitis - inflammation of the anterior uveal tract and is sometimes called iritis (if ciliary body is involved)
-ciliary flush
-pupillary constriction
- hazy “flare” in aqueous humor

what other dx can this often be associated with?

Answer 268

systemic inflammatory diseases such as infections, sarcoidosis, spondyloarthritis, and IBD

Question 269

treatment of minimal change disease?

Answer 269

corticosteroids

Question 270

how to differentiate partial vs complete small bowel obstruction on imaging?

Answer 270

1. both will have dilated loops of bowel with air fluid levels on plain film or CT scan
   a. Partial: will show air in colon
   b. Complete: shows no air in colon and transition point. This is life threatening and will not resolve with conservative management –> needs emergency lap

Question 271

• colicky abd pain, vomiting
• Hyperactive bowel sounds at first then absent
• Distended and tympanitic abdomen
  –what is this and what is the management?

Answer 271

1. SBO
   – bowel rest, NG tube suction, IV fluids
   –surgical exlap if signs of complications or complete obstruction

Question 272

What are the four things that make up tetralogy of fallot

Answer 272

1. VSD
2. Right ventricular hypertrophy
3. narrow RVOT (right ventricular outflow tract)
4. Overriding aorta

Question 273

How does knee chest position in a baby with tetralogy of fallot change systemic vascular resistance?

Answer 273

• this kinks femoral arteries which increases SVR –> leading to less right to left shunting and improving tet spells

Question 274

why do patients with chronic granulomatous disease need biopsy cultures when they are ill?

Answer 274

–defect in NADPH oxidase causes this person to have recurrent bacterial and fungal infections
–chronic activation of inflammatory cytokines frequently leads to granulomas in GI or GU tract
—When breakthrough infections occur biopsy of area of infection is necessary to identify what resistant bacterial or fungal organisms are at play and then best decide on antibioitc

Question 275

What is parinaud syndrome?
-age of onset?

Answer 275

• limited upward gaze
• upper eyelid retraction (collier sign)
• pupillary abnormalities like reactive to accommodation but not light
  –> can also block CSF flow in the aqueduct of sylvius causing hydrocephalus (papilledema, headache, and vomiting)

This is all due to pinealoma
- children 1-12 are most commonly affected

Question 276

prostaglandin functions (3 main ones)
- what medication stops its production?

Answer 276

1. blood vessel narrowing
2. fluid leak into tissues –> swelling
3. pain exacerbation

—NSAIDs

Question 277

What is first line treatment of GDM
–send line?

Answer 277

1. diet
2. insulin, glyburide, metformin

Question 278

When someone is dx with GDM what is goals of blood glucose
1. fasting
2. 1 hour postprandial
2. 2 hour postprandial

Answer 278

1. <=95 mg/dL
2. <= 140 mg/dL
3. <=120 mg/dL

Question 279

Bilious emesis in the neonate
1. Unstable vs stable
–unstable –> emergency exlap
–stable –> abdominal x-ray

=findings on abd x-ray=
a. free air: next step?
b. dilated loops of bowel: next step?
c. normal: next step?
d: double bubble sign: next step?

Answer 279

a. free air: emergency exlap

b. dilated loops of bowel:
—> first ask is there increased rectal tone and/or delayed passage of meconium
——-if yes: get contrast enema: This will show microcolon (meconium ileus) OR rectosigmoid transition zone (hirschsprung disease)
——–if no: get upper GI series (follow c)

c. normal: get upper GI series
—if shows right sided ligament of treitz then likely malrotation (complication is volvulus)

d: double bubble sign: this is likely duodenal atresia

Question 280

What are vaccines for adults with HIV infection (6)

Answer 280

1. HAV
2. HBV
3. HPV (pts age 11-26, can consider up to 45)
4. influenza annually
5. meningococcus all patients >=2 months and then booster q 5 years
6. Tdap once and then Td q 10 years
7. pneumococcal conjugate vaccine (PCV13) first then 23-valent pneumococcal vx (PPSV23)

Question 281

what complication of urterolithiasis requires urgent urology consultation and why?

Answer 281

complicated by infection
– can rapidly progress to pyelonephritis to severe sepsis and shock

—other indications: AKI, refractory pain or vomiting, and anuria

Question 282

What size stones can be passed spontaneously with conservative management?

Answer 282

<=5 mm
–outpatient urology referral may be needed for stones >10 mm that do not pass within 4-6 weeks

Question 283

What is MOA of amiloride?

Answer 283

This is a sodium channel blocker in collecting duct
— stops the reabsorption of Na through ENaC. Usually Na is taken in via ENaC and then further reabsorbed into body via Na/K pump (which releases K into urine)
—with this medication this no longer does this and thus spares potassium, keeping K in the body

Question 284

Differentiate between category I and category III fetal heart rate tracing patterns

Answer 284

Category I:
— baseline 110-160/min
— Moderate variability (6-25/min)
— No late/variable decelerations
—-+/- early decels, +/- accels

Category III:
>=1 of the following
— absent variability + recurrent late decels
— absent variability + recurrent variable decels
— absent variability + brady
— sinusoidal pattern

-category 2 is indeterminate pattern

Question 285

What does sinusoidal tracings in fetus indicate?

Answer 285

severe fetal anemia
– rapid fetal exsanguination and deterioration, mom requires urgent c section

Question 286

Baby born to mom that is positive for Hep B virus –what should baby get?

Answer 286

vaccine and immune globulin

Question 287

Peripartum cardiomyopathy (PPCM)
1. what is this?
2. When does this happen?

Answer 287

1. rapid onset systolic heart failure (fatigue, dyspnea, cough, pedal edema) – enlarged left ventricle and atrium
2. > 36 weeks gestation or early puerperium

Question 288

• episodic vertigo (20 min to 24 hrs) - can have N/V
• sensorineural hearing loss that fluctuates and varies but usually worsens over time
• low frequency tinnitus in the affected ear

–what is this likely?

Answer 288

Meniere disease - disorder of inner ear characterized by increased volume and/or pressure of endolymph thought to be due to defective resorption of endolymph. Resulting distension causes damage to both the vestibular and auditory components of the inner ear.

Question 289

How do topical glucocorticoid eye drops and systemic glucocorticoids affect eyes?

Answer 289

Can raise intraocular pressure (IOP) – can lead to corneal edema and possibly open angle glaucoma

–all patients on prolonged therapy should undergo assessment with tonometry

Question 290

• asymmetric muscle weakness
• Both UMN and LMN signs

Answer 290

amyotrophic lateral sclerosis (ALS)

Question 291

• muscle weakness
• UMN signs below a lesion
• radicular symptoms at level of lesion
• Occurs with aging, as degenerative changes of the spine occur

Answer 291

Cervical spondylotic myelopathy

Question 292

TTP - thrombotic thrombocytopenic purpura
1. pathogenesis
2. lab changes (LDH, haptoglobin, platelet count, PT/PTT, indirect bilirubin, AST/ALT, peripheral blood smear)
3. management

Answer 292

1. decreased ADAMTS13 leads to uncleaved vWF multimers –> lead to platelet trapping and activation. Shearing forces can damage RBC
2. Hemolytic anemia causes increased LDH
   - Decreased haptoglobin
   –Schistocytes on peripheral blood smear
   –thrombocytopenia <30,000 (increased bleeding time, normal PT/PTT)
   —increased indirect bilirubin, increases AST and ALT
3. plasma exchange
   -glucocorticoids
   -rituximab
   -caplacizumab

Question 293

What is acute rheumatic fever?
what causes it?
- major signs? (5)
- murmur outcomes?

Answer 293

1. immune mediated consequence of untreated strep pharyngitis. Abnormal immune response to GAS infections.
2. GAS
3. JONES
   - joints (migratory arthritis)
   - carditis
   - nodules (subcutaneous)
   - erythema marginatum
   - sydenham chorea

–> Minor (fever, arthralgias, elevated ESR/CRP, prolonged PR interval)

4. can cause mitral regurgitation/stenosis –> if regurge is severe enough then atria can enlarge and cause afib/aflutter

Question 294

(BLANK) is contraindicated in patients with myasthenia gravis but experiencing preeclampsia with severe features (HTN, headache, visual changes)

what other 2 drugs are contraindicated?

Answer 294

1. Magnesium sulfate –> it can lead to myasthenic crisis
2. Fluoroquinolones
3. Aminoglycosides

Question 295

Candida endophthalmitis
1. patient population
2. presentation
3. pathophysiology

Answer 295

1. hospital patients with central venous catheter
2. progressive vision loss with floaters
3. Fundoscopy shows fluffy, yellow white chorioretinal lesions. Candida replicates in the choroid and attacks the retina

Question 296

Hidradenitis suppurative
1. mild tx
2. moderate tx
3. severe tx

Answer 296

1. topical clindamycin
2. oral tetracycline
3. TNFa inhibitors, surgical excision

Question 297

Lactational mastitis
- can it have LAD?
- can it have induration?

Answer 297

Yes to both - Rx antibiotic therapy and continue breastfeeding

Question 298

Mineral deficiency (BLANK)
- brittle hair
- skin depigmentation
- neuro dysfunction (ataxia, peripheral neuropathy)
- anemia
- osteoporosis

Answer 298

copper

Question 299

Mineral deficiency (BLANK)
- thyroid dysfunction
- cardiomyopathy
- immune dysfunction

Answer 299

selenium

Question 300

Mineral dysfunction (BLANK)
- alopecia
- pustular skin rash (perioral and extremities)
- Hypogonadism
- Impaired wound healing
- Impaired taste
- Immune dysfunction

Answer 300

Zinc

Question 301

Oral hairy leukoplakia is a condition caused by EBV and is highly associated with…

Answer 301

HIV infection

Question 302

• malignancy of the bile duct epithelium
• associated with elevated CEA, CA 19-9, AFP
• increased risk in those with ulcerative colitis

what is this?
-sx?
- dx?

Answer 302

Cholangiocarcinoma
– jaundice, pruritus, alcoholic stool, dark urine, weight loss, RUQ pain,
–Dx with abdominal imaging like U/S or CT scan

Question 303

Which causes more bleeding copper or progesterin based IUD?

Answer 303

copper

Question 304

What is the biggest risk factor for intraventricular hemorrhage in newborns? and why?

Answer 304

1. prematurity
2. involuation of the germinal matrix (fetal structure that eventually gives rise to neurons, has fragile vessels) begins at age 32 weeks so prematurity increases risk that this ruptures
   –if born <32 then cranial U/S is automatically done

– sx: anemia, tachycardia, and a bulging fontanelle

Question 305

What are the most common drugs to cause drug induced lupus erythematosus (arthralgias, serositis, rash, fever, malaise)

(6)

Answer 305

1. procainamide
2. hydralazine
3. penicillamine
4. minocycline
5. TNFa inhibitors
6. Isoniazid

Question 306

Positive pressure ventilation is a mainstay lifesaving treatment for acute cardiogenic pulmonary edema

1. what does it do to right ventricular preload
2. left ventricular preload
3. left ventricular afterload

and why

Answer 306

1. PPV raises the intrathoracic pressure causing a drop in venous return to the right of the hear which decreases R ventricular preload
2. With less blood to RV then less blood to LV
3. PPV decreases MAP (mean arterial pressure) via baroreceptor effects and lowers adrenergic tone. This makes the afterload less

overall enhances stroke volume in systole and improves filling in diastole

Question 307

Head and neck squamous cell carcinoma
1. risk factors
2. sx

Answer 307

1. older age, tobacco, alcohol, poor dentition. Young patients with HPV 16.
2. neck mass, ulcerated tonsillar lesion, pharyngitis, dysphagia, and halitosis

Question 308

1. Femoral hernia - how is this different from direct and indirect hernias?

Answer 308

1. usually in women
2. bulge located below the inguinal ligament
   - through a widened or laxed femoral ring (medial to femoral artery and inferior to inguinal ligament)

Question 309

What is considered active phase arrest?

Answer 309

Active phase 6-10 cm dilation

No cervical change for >=4 hours despite adequate contractions (>= 200 montevideo units)

OR

no cervical change for >=6 hrs with inadequate contractions

=next step is c section

Question 310

What is considered protraction of active phase of labor?

-tx?

Answer 310

1. cervical change slower than expected +/- inadequate contractions

<1cm/2hr

–tx with oxytocin

Question 311

organophosphate poisoning
1. management?

Answer 311

1. remove pts clothes and irrigate skin
2. atropine reverses muscarinic symptoms
   –pralidoxime after atropine (reverses nicotinic and muscarinic sx)

Question 312

• abnormal eosin 5 maleimide binding test
• increased osmotic fragility on acidified glycerol lysis test

what do these indicate?

Answer 312

hereditary spherocytosis

Question 313

In children what is the most common type of CNS tumor?

Answer 313

low grade astrocytomas
–slow growing and benign, causing symptoms to develop over many months
–originate in cerebral cortex (supratentorial)
–headache, seizures,etc

Question 314

what is another name for high grade astrocytomas?

Answer 314

glioblastoma - causes sx over days to weeks (not months)
- much more rare

Question 315

Craniopharyngiomas
– where do these arise?
– what do they look like?
– sx?

Answer 315

1. sella turcica (contains pituitary gland)
2. cystic structures with calcifications
3. compression of optic chiasm or pituitary stalk may lead to visual field defects and hormonal deficiencies (DECREASE in hormones coming out of pituitary gland like TSH, GH, LH, FSH, ADH –bc mass gets in the way)

Question 316

What does thyrotoxicosis cause on cardiovascular system?
1. SVR
2. Contractility and stroke volume
3. HR

Answer 316

1. reduced SVR - direct vasodilatory effects on endothelium, thus decreasing diastolic blood pressure
2. increased contractility and stroke volume - direct effect on myocardium and reflexive response to peripheral vasodilation.
3. increased HR

-complications can be high output heart failure, angina, tachyarrhythmias (afib)

Question 317

What is schizoaffective disorder vs schizophreniform disorder?

Answer 317

1. delusions or hallucinations for >= 2 weeks in the absence of major depressive or manic episode. Mood episodes are prominent and recur throughout illness. Sx of schizophrenia have to be for >= 6 months.
2. psychotic symptoms related to schizophrenia but >1 month and <6 months

Question 318

Ehlers danlos vs osteogensis imperfecta

Answer 318

1. connective tissue disorder caused by type V collagen. These patients have joint hypermobility but no fractures
2. defective collagen type I which is common in bone, sclerae, skin, and teeth. Pts often have frequent fractures with type I. Joints are also hypermobile. Blue sclerae. Hearing loss. Short stature. Pts can have easy bruising.
   (Don’t confuse this with toddler’s fractures which is seen in children during first few years of walking - will see issues focused on legs)

Question 319

What kind of toxicity can sodium nitroprusside cause?
- sx

Answer 319

cyanide poisoning
- inhibits oxidative phosphorylation and forces anaerobic metabolism
–cherry red skin, headache, confusion, anxiety, seizures, coma, HTN, tachycarida, tachypnea
—> elevated anion gap met acidosis with increased lactic acid

Question 320

Total bilirubin elevated for age
—unconjugated bilirubin >25 mg/dL means what next steps?

–if below <25 mg/dL and unconjugated bilirubin above phototherapy threshold for age then (BLANK)

–if not above for age then (BLANK)

Answer 320

1. initiate exchange transfusion, eval for pathologic causes
2. initiate phototherapy and if unresponsive (rapid rate of rise) then go to exchange transfusion

Phototherapy should be instituted when the total serum bilirubin level is at or above 15 mg per dL (257 micromol per L) in infants 25 to 48 hours old, 18 mg per dL (308 micromol per L) in infants 49 to 72 hours old, and 20 mg per dL (342 micromol per L) in infants older than 72 hours.

3. increase feed volume/frequency and monitor

Question 321

pediatric depression can be tx with SSRI or SNRI?

Answer 321

SSRI (fluoxetine)

– SNRI (venlafaxine) lacks evidence as good tx for pediatric age group for depression

Question 322

• cafe au lait (hyperpigmented macules)
• axillary/inguinal freckles
• lisch nodules (iris hamartomas)
• benign peripheral nerve sheath tumors
• Optic gliomas (can cause headaches and visual disturbance)
• what is this?
• how to dx?

Answer 322

Neurofibromatosis type 1

Question 323

• middle aged women
• arise from the meningothelial cells of arachnoid matter
• headaches, seizures, FND, but sometimes asymptomatic
• dural based, calcified, homogeneously contrast enhancing lesion

Answer 323

meningioma

Question 324

Until what age can you wait to see if testicle descends?

Answer 324

<6 months - at 6 months then have to refer for orchiopexy

Question 325

postmenopausal bleeding
1. first (BLANK)
2. then based on findings (BLANK) then endometrial biopsy

Answer 325

1. TVUS
2. <= 4 mm nothing else req
   —> >4 mm need bx

Question 326

Incidental short cervix at <24 weeks is (BLANK) cm
-tx with (BLANK)

Answer 326

1. <= 2.5 cm, tx with vaginal progesterone (this is for those who have never had prior preterm delivery and after 2nd trimester TVUS)

If pt did have preterm delivery before and it was NOT associated with painful contractions –> refer to cerclage

if pt did have preterm delivery before and it DID have painful contractions then give IM or vaginal progesterone

Question 327

What is a nonprogressive neurologic injury that occurs most often in premature infants?

Answer 327

1. cerebral palsy - motor delay, early hand preference, spasticity, and hyperreflexia

• happens because of ischemia and necrosis in poorly perfused area adjacent to the lateral ventricles –> causes white matter injury

Question 328

What medications can cause increased intracranial pressure (3)

Answer 328

1. growth hormone
2. tetracyclines
3. excessive vitamin A and its derivatives like isoretinoin

Question 329

What is a struvite stone (magnesium ammonium phosphate) made up of?
- what hx will patient usually have
- tx

Answer 329

1. made of from increased urine ammonia production - from urease producing organisms (proteus, klebsiella)
   —> hydrolysis of urea yields ammonia which alkalinizes urine and precipitates stone
2. Sx associated with recurrent UTI (rather than renal colic)
3. antibiotic tx, complete stone removal, urease inhibitor in some patients to prevent recurrence

Question 330

CN I
CN II
CN III
CN IV
CN V
CN VI
CN VII
CN VIII
CN IX
CN X
CN XI
CN XII

Answer 330

CN I - olfactory
CN II - optic
CN III - oculomotor (coordinates eye position during movement)
CN IV - Trochlear (SO4 - superior oblique allows eye to look down and move your eye toward your nose)
CN V - Trigeminal - sensation in the face (pain, touch, and temp)
CN VI - Abducens ( LR6 - lateral rectus)
CN VII - facial (facial movement, taste at anterior 2/3 of the tongue)
CN VIII - Vestibulocochlear
CN IX - Glossopharyngeal
CN X - Vagus
CN XI - acessory
CN XII - hypoglossal

Question 331

• unilateral head and neck pain, transient vision loss
• ipsilateral partial horner syndrome (decreased pupil size, drooping eyelid)
• signs of cerebral ischemia
• common after trauma or due to other contributors like HTN, smoking, connective tissue dx

what is it?
dx?
tx?

Answer 331

Carotid artery disease
- CT angio
- similar to stroke tx:
—> Thrombolysis if <= 4.5 hrs
—> Antiplatelet therapy (e.g. aspirin) +/- anticoagulation

Question 332

Reactive attachment disorder
1. when does this happen?
2. what does it look like?

Answer 332

1. when the normal developmental process of emotional bonding to primary caregiver is interrupted by inconsistent or inadequate care
2. Do not seek or respond to comfort, poor social responsiveness, limited positive affect, unexplained irritability, fear, sadness even during safe encounters

Question 333

Congenital infections - what is this?
1. hydrocephalus
2. diffuse intracranial calcifications
3. chorioretinitis

Answer 333

1. congenital toxoplasmosis - exposure to undercooked meat or cat feces

tx wtih pyrimethamine, sulfadiazine, folinic acid

Question 334

Congenital infections - what is this?
1. chorioretinitis
2. periventricular intracranial calcifications
3. microcephaly
4. sensorineural hearing loss

Answer 334

CMV
- exposure to infected bodily fluids
tx with ganciclovir or valganciclovir

Question 335

Congenital infections - what is this?
1. hepatomegaly and jaundice
2. cataracts
3. sensorineural hearing loss
4. congenital heart disease

Answer 335

1. rubella

Question 336

Management of acute exacerbation of COPD
1. maximize expiratory flow (BLANK)
2. reduce airway inflammation (BLANK)
3. tx underlying triggers (BLANK)
4. maintain adequate oxygenation SpO2 target 88-92)
5. maintain adequate ventilation: NIPPV or invasive mechanical ventilation

Answer 336

1. maximize expiratory flow – inhaled bronchodilators (e.g. albuterol)
2. reduce airway inflammation – systemic glucocorticoids (IV prednisone or methylprednisolone)
3. tx underlying triggers - antibiotics and/or antivirals

Question 337

Choroid plexus papilloma
1. pathophysiology
2. sx

Answer 337

1. slow growing benign overgrowth of the choroid plexus (what makes CSF) that results in increased CSF production
2. hydrocephalus, poor feeding, bulging fontanelle, developmental delay, etc

Question 338

Otitis media with effusion
1. How is this different than otitis media
2. management?

Answer 338

1. Non purulent, TM is not bulging or erythematous. Does not cause fever or severe ear pain
2. observe and follow up

Question 339

Posterior urethral valves in newborn boys are associated with reduced urine output and distended bladder
– how is this related to lungs and in utero development?

Answer 339

In utero, impaired fetal urinary excretion causes oligohydramnios and subsequent lung hypoplasia which can lead to respiratory distress

Question 340

Preeclampsia
1. BP at (BLANK) weeks
AND
2. (BLANK)

Answer 340

1. New onset HTN (SBP >= 140 or DBP >= 90) at >= 20 weeks gestation
   AND
2. proteinuria (urine protein/cr ratio >= 0.3) or signs/sx of end organ damage

Question 341

What are severe features in preeclampsia
1. severe range HTN (BLANK)
2. platelets (BLANK)
3. Creatinine (BLANK) or 2X normal
4. Elevated transaminases >2x upper limit of normal
5. pulmonary edema
6. vision or cerebral symptoms

Answer 341

1. severe range HTN (SBP >=160 or DMP >=110)
2. platelets (<100,000)
3. Creatinine (>1.1) or 2X normal

Question 342

Management of preeclampsia
1. <37 weeks and no severe features
2. >= 37 weeks
3. severe range BP
4. seizure prophylaxis

Answer 342

1. expectant
2. delivery
3. IV labetalol, IV hydral, PO nifedipine
4. mg sulfate

Question 343

Von Hippel Lindau Disease (vHL)
1. multiple hemangioblastomas
2. cancer –?
3. pancreatic neuroendocrine tumors
4. (BLANK - ears)
5. catecholamine production (BLANK)

Answer 343

2. clear cell renal cell carcinoma
3. endolymphatic sac tumors of the middle ear - hearing loss
4. pheochromocytomas

Question 344

Parkinson plus syndromes
1. multiple system atrophy

Answer 344

1. early autonomic failure (severe orthostasis, urinary incontinence)
2. early postural instability
3. cerebellar findings (gait ataxia)

Question 345

Parkinson plus syndromes
1. progressive supranuclear palsy

Answer 345

1. vertical gaze palsy
2. early postural instability
3. akinesia (early gait freezing)
4. progressive aphasia

Question 346

Parkinson plus syndromes
1. Dementia with lewy bodies

Answer 346

1. early dementia (executive dysfunction)
2. visual hallucinations
3. cognitive fluctuations
4. REM sleep behavior disorder
   –> Dementia first then parkinsonism

Question 347

Parkinson plus syndromes
1. corticobasal degeneration

Answer 347

1. rare
2. myoclonus, dystonia
3. alien limb phenomenon
4. cortical sensory loss

Question 348

small intestinal bacterial overgrowth
1. sx
2. differentiate between this and IBS
3. When does this often occur after?
4. dx?

Answer 348

1. bloating, flatulence, chronic watery diarrhea,
   –malabsorption, low vit B12 and folate
2. IBS has chronic abdominal PAIN and sx relief after bowel movement, nocturnal sx are not generally present
3. after ileocecal resection d/t to colonic bacteria entering small intestine.
4. carbohydrate breath test

Question 349

Condylomata lata –> caused by
Condylomata accuminata –> caused by

Answer 349

1. secondary syphilis
2. anogenital warts –> (low risk HPV 6,11)`

Question 350

Transfusion-related acute lung injury (TRALI)
1. pathophysiology
2. Tx

Answer 350

1. neutrophils in pulm vasculature activated by antibodies in the transfused blood, lead to release of inflammatory mediators –> pulm edema
   -risk factors include smoking, alcohol use disorder, critical illness
2. Respiratory supportive care

Question 351

First, second, third line treatment options for hyperkalemia

Answer 351

1. IV calcium gluconate
2. Insulin plus glucose
3. Inhaled beta 2 agonists (avoided in patients with active coronary disease due to tachycardia induced angina)

Question 352

What is the difference between immediate vs acute/subacute/delayed postoperative fever

Answer 352

1. immediate: most cases are caused by tissue damage incurred during a major procedure. Fever and leukocytosis last <3 days and are managed symptomatically.
2. acute (1-7 days)/subacute(7-28 days)/delayed: most often due to bacterial infection

Question 353

Neuroblastoma
1. diagnostic findings
2. sx when tumor is found on cervical region
3. what cells does this arise from?

Answer 353

1. elevated catecholamines metabolites
   – small, round blue cells on histology
   – N-myc gene amplication
2. Tumor involvement of the cervical paravertebral sympathetic chain can lead to horner syndrome
3. neural crest cells (precursors to sympathetic ganglia and adrenal medulla) which is why tumors commonly appear in sympathetic system and adrenal glands

Question 354

• CGG repeat in FMR1 gene ( X linked dominant)
• Developmental delay, Intellectual delay
• ADHD
• Autism spectrum
• Self injurious behavior
• Anxiety
• Long face w/prominent forehead and chin, large ears, deep set eyes
• Macroorchidism
• Macrocephaly
• Joint hypermobility

what is this?

Answer 354

Fragile X syndrome

Question 355

Benign neonatal rashes
1. pustules with erythematous base on trunk and proximal extremities. Observe.
–what is it
–age

Answer 355

1. Etox (erythema toxicum neonatorum)
   –birth to 3 days

Question 356

Benign neonatal rashes
1. firm, white papules on face at birth

Answer 356

milia

Question 357

Benign neonatal rashes
1. Erythematous papular rash on occluded and intertriginous areas. Avoid overheating and use thin/cotton clothing. If severe can use topical corticosteroid

• what is it?
  -age?

Answer 357

1. miliaria rubra
   - any age but not at birth

Question 358

Benign neonatal rashes
1. Neonatal pustular melanosis
2. Neonatal cephalic pustulosis

• describe each
• what age?
• tx

Answer 358

1. nonerythematous pustules –> evolve into hyperpigmented macules with collarette of scale. Diffuse, may involve palms and soles.
   – at birth
   –observe and pustules should go away in days but hyperpigmentation may last months.
2. Erythematous papules and pustules on face and scalp only
   —around 3 weeks of age
   –observe and should resolve. If severe, topical corticosteroid and ketoconazole.

Question 359

What are causes of anemia with decreased MCV (4)

Answer 359

1. iron deficiency
2. thalassemia
3. lead intoxication
4. sideroblastic anemia

Question 360

What are causes of anemia with normal MCV and decreased reticulocyte count? (3)

Answer 360

1. leukemia
2. aplastic anemia
3. anemia of chronic disease

Question 361

What are causes of anemia with normal MCV and increased reticulocyte count? (2 main)

Answer 361

1. hemorrhage
2. hemolysis due to …
   –> spherocytosis
   –> G6PD deficiency
   –> autoimmune
   –> microangiopathic

Question 362

Management of migraines in pregnancy
1. nonpharm: rest, hydration, heat
2. first line
3. 2nd line
4. 3rd line
5. 4th line

Answer 362

1. acetaminophen
2. antiemetics, codeine, caffeine (can be given in conjunction to #1)
3. NSAIDs (e.g. naproxen) –> BUT ONLY 2ND TRIMESTER
4. Opioids (oxycodone)

Question 363

Huntington disease
1. what part of brain is affected?
2. onset?

Answer 363

1. basal ganglia atrophy - caused by changes in a single gene
   –mutation in huntington gene with CAG
2. Onset is gradual and in adulthood

Question 364

• decreased passive and active range of motion of shoulder
• initial painful phase followed by stiffness > pain

Answer 364

adhesive capsulitis (frozen shoulder)

Question 365

Necrotizing (malignant) otitis externa
1. what is it?
2. what bug causes this?
3. tx?

Answer 365

1. life threatening infectious complication of acute otitis externa. Aggressive spread beyond external ear canal into skull base and adjacent tissue. Can show with elevated ESR and cranial nerve palsy.
2. pseudomonas
3. IV antibiotic for pseudomonas like cipro

Question 366

What drug intoxication shows up with agitation, violence, and prominent horizontal nystagmus?

Answer 366

PCP (phencyclidine)

Question 367

CATCH 22 for 22q11.2 deletion - DiGeorge syndrome
–loss of genes that control embryonic tissue template transformation (abnormal pharyngeal pouch system) and migration of neural crest cells

1. What does CATCH mean in terms of clinical features

Answer 367

1. Cardiac outflow tract anomalies (Tet of fallot, persistent truncus arteriosus)
2. Anomalous face (prominent nasal bridge, low set ears, micrognathia)
3. Thymic hypoplasia/aplasia –> decreased T cell immunity
4. Cleft palate
5. Hypoparathyroidism –> leading to hypocalcemia

Question 368

Closed spinal dysraphism (spina bifida occulta)
1. what is this?
2. sx?

Answer 368

1. Commonly due to failure of vertebral arch fusion (L5-S1). Skin is intact but underneath skin there is no vertebral piece covering spine.
2. asymptomatic or can have tethered cord syndrome (Neuro: LMN sings, urology: incontinence/retention, Ortho: back pain, scoliosis, foot deformity)
   — cutaneous, lumbosacral anomalies like hair tuft, hemangioma, nevus, pit.

Question 369

• Fever 102F
• hypotension
• Diffuse macular rash involving palms and soles
• Desquamation 1-3 weeks after dx onset
• Vomiting, diarrhea
• Altered mentation

what is this likely?

Answer 369

Staph toxic shock syndrome –> supportive therapy, removal of foreign body, and antibiotic therapy

Question 370

What is considered uterine tachysystole?

Answer 370

> 5 contractions/10 min

Question 371

VEAL CHOP MINE

VEAL (variable decels, early decels, accels, late decels)

what does CHOP mean

what does MINE mean

Answer 371

1. cord compression
2. head compression
3. okay
4. placental insufficiency
5. maternal repositioning (reccurent variable decels can be managed with amnioinfusion to reduce cord compression)
6. identify labor progress
7. no intervention
8. execute interventions

Question 372

Positive Hydrogen breath test
Positive stool test for reducing substances
Low stool pH
Increased stool osmotic gap

what is this

Answer 372

lactose intolerance

Question 373

A popliteal (baker) cyst is due to extrusion of synovial fluid from the knee joint into the gastrocnemius or semimembranous bursa
–most common in pts with underlying arthritis

what is a common physical exam finding? + sx?

Answer 373

1. Crescent sign - arc of ecchymosis is often visible distal to medial malleolus
2. painless bulge behind the knee (more noticeable with knee extension)
3. When cyst ruptures can cause pain in the calf and crescent sign

Question 373

Selective IgA deficiency
1. pathophysiology
2. clinical features
3. dx
4. blood transfusions

Answer 373

1. serum IgA levels are low/undetectable due to failure of B cells to differentiate into IgA secreting plasma cells.
2. Recurrent sinopulmonary and GI infections due to lack of secretory IgA on mucosal barrier.
   –atopic and autoimmune disorders (SLE, celiac) are common
3. low or absent IgA, normal IgG/IgM/B cells
4. In blood transfusion - host can form IgE ab against IgA so when getting blood that contains IgA the host can have anaphylaxis shock

Question 374

Cutis aplasia
Microcephaly, microphthalmia, cleft lip/palate
cardiac defects
kidney defects
Umbilical hernia/omphalocele
Rocker bottom feet
Polydactyly

what syndrome is this?

Answer 374

Trisomy 13 (patau syndrome)

Question 375

• thunderclap headache with rapid onset
• N/V, abnormal mental status
• Hypotension
• B/l visual field defects and ophthalmoplegia

what is this likely?
What is important initial management?

Answer 375

This is likely pituitary apoplexy due to hemorrhage or acute ischemia
– Bc of compression or ischemia of the pituitary, deficits of anterior pituitary often occur and loss of ACTH can cause central adrenal insufficiency (cause of hypotension)

Tx: parenteral glucocorticoids

**not subarachnoid hemorrhage bc no neck stiffness or HTN

Question 376

CSF findings
WBC Glucose Protein
(0-5) (40-70) (<40)

1. bacterial meningitis
2. TB
3. Viral
4. Guillain barre

Answer 376

1. bacterial meningitis
   (>1,000) (<40) (<250)
2. TB
   (100-500) (<45) (100-500)
3. Viral
   (10-500) (norm) (<150)
4. Guillain barre
   (norm) (norm) (45-1,000)

Question 377

Fetal hydantoin syndrome
1. what causes this
2. sx?

Answer 377

1. antiepileptics like phenytoin, valproate, carbamazepine
2. cleft lip/palate, wide ant fontanelle, distal phalange hypoplasia, cardiac anomalies, microcephaly

Question 378

1. what is loperamide?
2. What is metoclopramide

Answer 378

1. antidiarrheal medicatioin
2. D2 receptor antagonist that increases gastric contractility and motility

Question 379

• sunburst periosteal reaction (concentric layers of reactive bone)/ periosteal elevation
• Ill defined osteolytic/osteoblastic lesion
• May have hx of retinoblastoma
• Most cases arise in children or adolescents at long bone metaphysis (lytic lesion)
• Codman triangle

Answer 379

Osteosarcoma
– risk is greatest in those with RB1 and TP53

Question 380

Short interpregnancy intervals (<6-18 months) are associated with an increased risk of pregnancy complications including
1. preterm labor
2. (BLANK)
3. low birth weigth

Answer 380

Preterm prelabor rupture of membranes (PPROM)

Question 381

Sturge weber syndrome (mutation in GNAQ gene)
1. port wine stain along trigeminal nerve distribution
2. seizures
3. leptomeningeal capillary venous malformation
4. intellectual disability
5. visual field defects
6. glaucoma

what is the dx and management?

Answer 381

1. MRI of brain with contrast to visualize intracranial vascular malformation
2. laser therapy can improve port wine stain. Antiepileptic drugs, intraocular pressure reduction

Question 382

In patients with immature hypothalamic pituitary ovarian axis (usually early teens)
–> there is anovulation due to inadequate gonadotropin secretion (LH, FSH). without ovulation then body does not get corpus luteum that produces progesterone. Eventual decline in progesterone leads to menstruation.

–what determines just reassurance in teens vs intervention (progesterone tx)?

Answer 382

1. If patient is bothered by irregularity
2. If there is significant anemia even between menses

Question 383

most common risk factor for breast cancer?

Answer 383

1. increasing age
2. increased estrogen exposure via nulliparity, early menarche (<13), and late menopause (>51)
3. family history - first degree relative

Question 384

What is the preferred screening test to evaluate for cervical spine injury?

Answer 384

CT scan without contrast

–more sensitive than plain radiography

Question 385

How is lithium excreted?

What is used instead of lithium in cases that it cannot be excreted well?

Answer 385

1. kidneys –may increase to toxic levels when patients have renal dysfunction.
2. Valproate - not nephrotoxic but periodic monitoring of liver function tests and platelets is necessary due to medications rare association with hepatotoxicity and thrombocytopenia

Question 386

(BLANK) have been associated with improvements in cardiovascular risk in patients with very high triglycerides (>400) and low HDL (<= 40) but are typically given with a statin

Answer 386

Fibrates (fenofibrate)

• reduce synthesis of triglycerides and increase their catabolism

Question 387

What are other drug options to lower cholesterol other than statins?

Answer 387

1. ezetimibe - selectively inhibit intestinal absorption of cholesterol
2. PCSK9 inhibitors - block PCSK9 protein from breaking down LDL receptors in liver. This way LDL receptors stay open to uptake bad cholesterol and decreases LDL.

**statin reduce the amount of cholesterol the liver produces (by inhibiting enzyme used for production) and helps liver remove cholesterol from blood.

**1 and 2 can be considered if statins are not tolerated but not as effective in preventing cardiovascular events

Question 388

Transverse myelitis
1. Loss of pain, temp on opposite side (BLANK - part of CNS)
2. Loss of motor function on same side (BLANK - part of CNS)
3. Loss of vibration and proprioception on same side (BLANK - part of CNS)
4. Usually a defined sensory level
5. autonomic dysfunction

Answer 388

1. spinothalamic tract
2. corticospinal
3. dorsal column

*immune mediated disorder characterized by infiltration of inflammatory cells into a segment of the spinal cord

Question 389

Pain over AC joint and passive shoulder adduction provokes pain
* determined with cross body adduction test

Answer 389

• AC joint sprain –> when significant force is applied to lateral or superior shoulder causing a sprain on the ligament that connects the acromion and the clavicle

Question 390

Which ones of the second generation antipsychotics cause weight gain, dyslipidemia, and hyperglycemia? (2)

Answer 390

Olanzapine and clozapine

Question 391

A prominent v wave in jugular venous pulsation is highly specific for?

Answer 391

tricuspid regurgitation

Question 392

what is hemobilia?

Answer 392

Rare cause of upper GI bleeding - usually occurs as complication of hepatic or biliopancreatic interventions (e.g. liver bx, cholecystectomy, ECRP)
– massive hemobilia results in hemodynamic instability that occurs after procedure.

sx: RUQ pain, jaundice, UGIB,
-direct hyperbilirubinemia, anemia, leukocytosis

Question 393

What causes symmetric vs asymmetric fetal growth restriction?

Answer 393

1. symmetric
   - chromosomal abnormalities
   - congenital infection
2. asymmetric
   - uteroplacental insufficiency
   - maternal malnutrition

Question 394

Preterm labor management
-mom and baby stable
1. <32 weeks
2. 32-34 weeks
3. 34-37 weeks

Answer 394

1. antenatal corticosteroids (IM betamethasone) to decrease risk of ARDS and promote fetal lung maturity
   –> Penicillin if GBS+ or unknown
   –> Tocolysis: indomethacin
   –> Mg sulfate to decrease risk of cerebral palsy
2. Antenatal corticosteroids
   –> Penicillin if GBS+ or unknown
   –> Tocolysis: indomethacin
3. antenatal corticosteroids
   –> Penicillin if GBS+ or unknown

Question 395

• Rupture of inferior epigastric artery (supplies blood to lower aspect of rectus abdominis muscle)
• Often seen with blunt trauma and forceful abdominal contractions, particularly in patients with anticoagulation
• Sx: acute abdominal pain, rebound or guarding, palpable abdominal wall mass - mass does not cross midline and does not change w/movement of lower extremities
• anemia, leukocytosis

what is it?
what dx it?

Answer 395

1. Rectus sheath hematoma
2. Abd CT confirms th edx

Question 396

For children with HIV, what are the CD4 counts that we should aim for to prevent dx of PJP?

1. Age 1-11 months
2. 12 months and above

Answer 396

1. > 1,500/mm3
2. > = 200/mm3

Question 397

Cobb angle 10-30 management
angle >= 30
angle >=40-50

Answer 397

1. monitored clinically q 6 months
2. brace in a child with growth potential to reduce curve progression
3. surgical fixation

Question 398

Functional hypothalamic amenorrhea
1. pathophysiology

Answer 398

Suppression of hypothalamic-pituitary-ovarian axis by strenuous exercise, calorie restriction, increased stress, or chronic illness
—Decreased GnRH leads to low FSH/LH and thus low estrogen level. Which means proliferation of endometrium does not happen. With progesterone challenge test you don’t get bleeding.

-Have increased risk of decreased bone mineral density due to low estrogen. Don’t have vasomotor sx bc normal yet unstimulated ovaries still make basal estrogen levels

Question 399

Patients with amenorrhea, vasomotor sx, and vaginal atrophy at ages less than normal menopause age likely have (BLANK)

Answer 399

primary ovarian insufficiency

Question 400

1. Hemorrhage symptom presentation pattern?
   sx of intracerebral hemorrhage due to AVM - recurrent headache, seizure, or focal neural deficits

Answer 400

1. sx tend to progress over minutes to hours as hemorrhage expands

Question 401

occiput posterior vs occiput anterior which is the preferred position for baby?

Answer 401

1. occiput anterior (back of head facing anterior of mom)

when occiput posterior this increases risk of cephalopelvic disproportion in which the fetal head is too large to fit through maternal pelvis

Question 402

CT scan of chest reveals nodules with surrounding ground glass opacities (halo sign)
–bronchoalveolar lavage (BAL) and bx are required if noninvasive testing (sputum stain/culture) is inconconclusive
- Classic triad: fever, pleuritic chest pain, hemoptysis
- In patients with severe immunocompromised situation

what is it?
how to tx?

Answer 402

1. invasive pulmonary aspergillosis
2. voriconazole +/- caspofungin

*chronic pulmonary aspergillosis is a fungus ball in preexisting lung cavity. usually quiescent with occasional hemoptysis, weight loss, cough/fatigue over 3 months

Question 403

1. Magnesium is excreted by (BLANK)
2. what is used as first line tx for magnesium toxicity
3. clinical features of toxicity

Answer 403

1. kidneys - common risk factor for toxicity is renal insufficiency
2. calcium gluconate
3. Mild: nausea, flushing, headache, hyporeflexia
   –mod: areflexia, hypocalcemia, somnolence
   –severe: respiratory paralysis and cardiac arrest

Question 404

PPI therapy can lead to false negative result on H pylor (BLANK) and (BLANK) and (Blank) tests. Wait 2 weeks until PPI is stopped

-

Answer 404

1. Stool antigen confirms new infection or eradication
2. Urea breath tests confirms new infection or eradication
3. • Endoscopic bx confirms new infection or eradication

*serologic test has limited use, cannot distinguish between past and current infection
* Endoscopic bx confirms new infection or eradication.

Question 405

Impetigo
1. nonbullous
-what does it look like
-what causes it?

2. bullous
   - what does it look like
   - what causes it

tx for both

Answer 405

1. Nonbullous
   - papules and pustules with honey crusted lesions
   - staph aureus and strep pyogenes (GAS)
   - tx with topical Ab (mupirocin) or oral Ab if extensive (cephalexin)
2. Bullous
   -enlarging, flaccid bullae with yellow fluid
   -ruptured lesions with a collarette of scale at periphery
   - caused by Staph aureus - producing exfoliative toxin A
   - tx: oral Ab cephalexin

Question 406

Myositis ossificans
1. what is it?

Answer 406

1. formation of lamellar bone in extraskeletal tissue (hetertropic ossification).
   - it is triggered by severe or recurrent trauma
   – presents as painful, firm, mobile mass with local swelling
   –Alk phose and inflammatory markers may be elevated

Question 407

Functional tremor

Answer 407

Most common functional movement disorders
–involuntary movements that are not consistent w/a neurologic cause AND IMPROVE WITH DISTRACTION

Question 408

If lead is screened by capillary sample and levels are high then what are next steps?

what is first line treatment?

Answer 408

1. obtain venous sample levels.
2. chelation therapy if lead level is >=45 ug/dL
   –> Dimercaptosuccinic acid (succimer) used at 45-69
   –> EDTA and dimercaprol should be administered on emergency levels >= 70

Question 409

Membranous nephropathy (nephrotic syndrome type)
-pathophysiology?
-what conditions are associated?
-symptoms

Answer 409

1. accumulation of subepithelial immune complex deposits and podocyte damage
2. malignancy, infection (hep B), autoimmune, Drugs
3. edema, proteinura, hyperlipidemia and hypoalbuminemia. BP and GFR usually normal

Question 410

Cardiac myxoma
1. clinical features
2. what is it?
3. dx and tx?

Answer 410

1. mitral valve obstruction (middiastolic murmur) - dyspnea, lightheaded, syncope.
   –embolization of tumor fragments (stroke)
   –consititutional sx like fever and weight loss
2. benign neoplasm often found in left atrium
3. Echo and then prompt surgery

Question 411

when a person gets a venous air embolism (such as with removal of central venous catheter) what position should they placed in and why?

Answer 411

Left lateral decubitus position because this traps the air bubble in the wall of the right ventricle preventing it from obstructing the RVOT or going anywhere else

Question 412

Isolated breast development with normal bone age is (BLANK)

Isolated pubic hair development with normal bone age is (BLANK)

Answer 412

1. premature thelarche
2. premature adrenarche

Question 413

early secondary sexual development with advanced bone age
1. first check LH
a. High basal LH indicates (BLANK A)
b. Low basal LH –> get GnRH stimulation test

2. W/GnRH stimulation, continued low LH means (BLANK B)
   –w/GnRH stimulation, now high LH means (BLANK C)

Answer 413

1. Central precocious puberty (idiopathic, CNS tumor)
2. Peripheral precocious puberty (nonclassic congenital adrenal hyperplasia, gonada/adrenal tumor)
3. Central precocious puberty

Question 414

What enzymes are elevated in biliary atresia?

Answer 414

1. alk phosphatase
2. gamma-glutamyl transpeptidase (GGT)

Question 415

Transfusion associated cardiac overload (TACO)
1. pathophysiology
2. symptoms
3. Tx

Answer 415

1. Due to large volume blood transfusion in patients with underlying cardiac disease.
   –occurs w/in hrs of transfusion
2. Sx of respiratory distress from hypervolemia, dyspnea from pulmonary edema, JVD, widened pulse pressure, HTN
3. Halt further blood transfusions and minimizing other IV fluids followed by diuresis w/a loop diuretic.

**does not cause ARDS

Question 416

Acute stroke management
1. Patient who were at their baseline < 4.5 hrs before presentation and do not demonstrate a brain hemorrhage on neuroimaging are candidates for (BLANK)

2. Patients who were at their baseline > 4.5 hrs before presentation should be treated with (BLANK)
3. after a transient ischemic attack - management should be enacted to prevent a future thromboembolic event. Patients without an identifiable embolic source should initiate (BLANK)

Answer 416

1. thrombolytic therapy (e.g. alteplase)
2. aspirin (antiplatelet med)
3. aspirin (antiplatelet med)

Question 417

If stroke is caused by afib what medications are used to prevent recurrent stroke?

Answer 417

Heparin, warfarin, dabigatran

Question 418

1. lack of movement in only lower face
2. lack of movement in lower face and forehead

• what is likely the pathology causing this?

Answer 418

1. Stroke - affects only lower face (broken upper motor neurons that synapse on the facial nerve nucleus but other side of brain recuperates the function of forehead)
2. Bells palsy - affects both lower face and forehead (LMN is broken and affects both forehead and lower face)

Question 419

Vertebral osteomyelitis
- occurs via hematogenous spread from another site of infection
- sx include back pain, fever, and malaise, point tenderness over affected area

–dx?

Answer 419

—MRI to confirm and exclude epidural abscess or discitis

Question 420

Osteosarcoma
1. Dx
2. Tx

Answer 420

–> Plain x rays may have you suspecting
–> then get MRI to evaluate extent of local invasion and allow for local staging
–> then get bone biopsy
–> then surgical resection + chemo

Question 421

electrolyte loss
1. perioral paresthesia, laryngospasm, prolonged QT interval
2. muscle weakness, cramps, ileus, paresthesia, hyporeflexia, cardiac arrhythmias
3. nausea, malaise, lethargy, obtundation or coma, and seizures secondary to cerebral edema

Answer 421

1. hypocalcemia
2. hypokalemia
3. Hyponatremia

Question 422

What medications are contraindicated in right ventricular MI (ST changes in inferior leads II, III, aVF) and why

Answer 422

1. nitates and opioids
   - These medications lower preload
   - W/right side of heart not working then heart becomes pre-load dependent so maintaining volume on right side is important. Nitrates and opioids lower preload.

Question 423

Healthy person >= (BLANK) mm is positive

Incarcerated or health care worker or foreigner >= (BLANK) mm

HIV or close contact with someone with TB >= (BLANK) mm

Answer 423

Healthy person >=15 mm is positive
Incarcerated or health care worker or foreigner >=10 mm
HIV or close contact with someone with TB >= 5 mm

Question 424

Multiple endocrine neoplasia type 1
(3)

Multiple endocrine neoplasia type 2A
(3)

Multiple endocrine neoplasia type 2B
(4)

Answer 424

Multiple endocrine neoplasia type 1
Parathyroid adenomas
Pituitary adenomas
Pancreatic adenomas

Multiple endocrine neoplasia type 2A
Medullary thyroid cancer
Pheochromocytoma
Parathyroid hyperplasia

Multiple endocrine neoplasia type 2B
Medullary thyroid carcinoma
Pheochromocytoma
Multiple mucosal neuromas
Often a marfanoid habitus

Question 425

Medullary thyroid carcinoma
-pathophysiology

Answer 425

1. arises from parafollicular C cells and produces calcitonin
   sx of hypocalcemia may be present if severe
   -typically asymptomatic until a nodule is of palpable size

Question 426

Due to a virus infection (what is it?)
-colitis
- retinitis
- esophagitis
- encephalitis
- pneumonia

Histology: mononuclear cell infiltrates with infected giant cells showing prominent intracellular inclusion bodies

-what is it?
-what is tx?

Answer 426

1. CMV (or HHV-5)
2. Ganciclovir - inhibit viral DNA polymerase

Question 427

attributable risk equation

Answer 427

AR = (a/(a+b)) - (c/(c+d))

Question 428

Statistical test to assess difference in numerical, quantitative, categorical, and qualitative datasets
–assess for statistically significant differences between 2 or more categorical values
–commonly used for larger samples and is also able to compare multiple values (e.g. three diff experimental groups)

Answer 428

chi-square test

Question 429

Statistical test that compares means between three or more groups

Answer 429

analysis of variance

Question 430

• Transmural inflammation of the GI tract (often terminal ileum)
• Chronic abdominal cramping, bloody diarrhea, and weight loss
• complications include enterocutaneous fistulas, stricture, bowel perforation, intra abdominal abscess, and uveitis

what is it?
dx?
tx?

Answer 430

1. Crohn disease
2. imaging and biopsy
   –lab shows increased ESR, C reactive protein
3. aminosalicylates (mesalamine, sulfasalazine)
   –corticosteroids (prednisone)
   –immunomodulators (azathioprine, 6-MP, methotrexate
   –biologic therapies (infliximab, adalimumab, certolizumab)

Question 431

Acute tubular necrosis (ATN)
1. blood
2. protein
3. RBC
4. WBC
5. Casts
6. Other microscopic findings

Answer 431

1. 1+
2. 1+
3. 0-5 RBC
4. 0-5 WBC
5. pigmented granular (muddy brown casts)
6. renal tubular epithelial cells –> what makes up the muddy brown casts in a Tamm-Horsfall (uromodulin) mucoprotein matrix

Question 432

• abrupt onset of fever, anemia, thrombocytopenia, renal failure, and neurologic symptoms
• Normal coagulation studies
• Can have scattered petechiae

–> what is is this?

Answer 432

Thrombotic thrombocytopenic purpura

Question 433

Spinal muscular atrophy (SMA)
1. Type I - infantile onset SMA (werdnig hoffman disease)
2. Type II - Intermediate SMA (Dubowitz disease)
3. Type III - Juvenile SMA (Kugelberg-Welander syndrome)

• describe each

Answer 433

Overall Autosomal recessive disorders –> caused by mutations in SMN genes at crhom 5q13 that lead to degeneration of motor neurons, resulting in progressive hypotonia and areflexia

1. Type I - infantile onset SMA (werdnig hoffman disease)
   –> difficulty with mobility, respiratory distress and difficulty feeding –> leading to death from respiratory failure during infancy
2. Type II - Intermediate SMA (Dubowitz disease)
   –> never gain ability to stand or walk without assistance.
3. Type III - Juvenile SMA (Kugelberg-Welander syndrome)
   –> Previous independent ambulation followed by increasing difficulty with ambulation. Proximal muscle weakness affecting both arms and legs. Some may develop scoliosis or lumbar hyperlordosis.

Question 434

• mutation in dystrophin gene
• X linked recessive fashion
• Proximal muscle weakness and hyperlordosis
• Typically in toddlers with calf pseudohypertrophy
• Gower sign

what is this?

Answer 434

• Duchenne muscular dystrophy

–> - Gower sign (child assumes the hands-and-knees position and then climbs to a stand by “walking” his hands progressively up his shins, knees, and thighs)

Question 435

lyme disease tx
1. regular patients
2. pregnant patients

Answer 435

1. doxycycline
2. ceftriaxone (doxycycline is contraindicated in pregnant women)

Question 436

What is first line drug for osteoarthritis?
-2nd
- 3rd
- 4th

Answer 436

1. acetaminophen
2. NSAIDs if not contraindications
3. intra articular injections (cortisone)
4. joint replacement for severe cases

Question 437

What is an effective intervention for obese or overweight patients with essential HTN

Answer 437

1. weight loss
   –for q lb lost - BP can decrease by 1 mmHg

Question 438

Imaging differences between idiopathic pulmonary fibrosis vs asbestosis

Answer 438

1. Chest x-ray: peripheral and basilar honeycombing (clustered cystic air spaces)
2. CT: peribronchial fibrosis, reticular opacities (meshlike/lace pattern), subpleural thickening

Question 439

What does sigmoid volvulus show on x ray
sx: acute abdominal pain, distension, constipation, vomiting

Answer 439

Dilated, air filled sigmoid colon – looks like a coffee bean

–cecal volvulus shows small bowel dilation

Question 440

Fetal scalp electrodes are recommended against in (BLANK) moms

Answer 440

HIV positive moms - this increases risk of exposing fetus to maternal blood

• intrauterine pressure catheter placement can be cautiously used if necessary and clearly indicated -

Question 441

Klinefelter syndrome
1. genotype?
2. pathophysiology?
3. presentation?
4. Labs (LH/FSH/testosterone)
5. Dx and tx

Answer 441

1. XXY
2. decreased testosterone production and absent sperm production in the setting of fibrotic seminiferous tubules and leydig cells
3. cryptorchidism or small testes, learning disabilities, behavioral issues, delayed pubertal development, signs of androgen deficiency (gynecomastia), and infertility
   –person can often be tall with disproportionate leg to arm length
4. Increases FSH and LH
   –Low testosterone
5. dx w/karyotype
   Tx with testosterone supplementation and counseling

Question 442

1. Presentation of males with incomplete androgen insensitivity syndrome
2. Presentation of females with incomplete androgen insensitivity syndrome

Answer 442

1. micropenis, hypospadias, gynecomastia, minimal body hair
2. female phenotype with virilization to a male phenotype

Question 443

Schirmer test

Answer 443

used to evaluate excessive dryness or watering of the eyes with test strip

—> Used in Sjorgren syndrome

Question 444

Blighted ovum

Answer 444

when a fertilized egg implants into the endometrial lining but an embryo fails to develop often bc of severe chromosomal abnormalities

–empty gestational sac w/out fetal cardiac activity
–tissue is often passed without intervention, supportive care

Question 445

• Lagging of bone age behind chronological age
• delayed puberty, lack of pubic hair and genital development in male patients or delayed thelarche and primary amenorrhea in female patients

what is this?

Answer 445

Constitutional growth delay

Question 446

At what sodium levels is it more likely to show acute and severe CNS symptoms due to hyponatremia (headache, N/V, confusion, delirium, weakness, seizures, and coma)

Answer 446

<120

Question 447

Begins with an erythematous, slightly edematous papule at the site of (BLANK) bite and then increases in size and may ulcerate and become wart like.
–characteristic hyperkeratotic eschar may form

Answer 447

Leishmaniasis (infection with Leishmania tropical - caused by sand fly bite)

• Middle east, asia, north africa (old world leishmaniasis/leishmania tropica)

-Central and south america (new world leishmaniasis/leishmania braziliensis)

Question 448

Pseudogout
- main treatment?

Answer 448

1. NSAIDs
2. colchicine

Question 449

Rotator cuff
-action of each muscle
1. subscapularis
2. teres minor
3. infraspinatus
4. supraspinatus

Answer 449

1. internal rotation
2. external rotation when in an adducted position
3. external rotation
4. abduction

Question 450

Rotator cuff tear typically occurs at the insertion of the tendons of the rotator cuff on the (BLANK).

–> weakness with (BLANK) and (BLANK) rotation

-commonly occurs to (BLANK) tendon
- risk factors: heavy labor, repetitive overhead lifting, DM, vascular disease
- presentation: pain and weakness in one of the axes of motion and late manifestations include (BLANK)

Answer 450

Rotator cuff tear typically occurs at the insertion of the tendons of the rotator cuff on the humeral head.

–> abduction and external rotation

-commonly occurs to supraspinatus tendon
- risk factors: heavy labor, repetitive overhead lifting, DM, vascular disease
- presentation: pain and weakness in one of the axes of motion and late manifestations include atrophy of corresponding muscle

Question 451

Patients that shows symptoms concerning for hemodynamically significant pericardial effusion should be evaluated urgently with…

Answer 451

echo

Question 452

Whipple disease
1. pathogen
2. clinical manifestations
3. dx
4. tx

Answer 452

1. Tropheryma whipplei
2. cardiac sx, arthralgias, and neuro sx
   –chronic infection shows weight loss, vitamin deficiencies, and foul smelling oily diarrhea occur as a result of the presence of foamy macrophages and inflammation in the intestinal wall causing malabsorption
3. Intestinal bx via upper endoscopy (acid-Schiff positive macrophages in lamina propria)
4. IV ceftriaxone 2 weeks then TMP-SMX for a year

Question 453

Diffuse esophageal spasm
- sx?

Answer 453

When muscular layer of esophagus is overactive. Spasms cause dysphagia and chest pain, often acutely in the setting of swallowing.

Question 454

Achalasia
1. pathophysiology
2. sx
3. dx
4. tx

Answer 454

1. deficient peristalsis as a result of impaired neuromuscular transmission and impaired relaxation of the lower esophageal sphincter (LES)
2. dysphagia, odynophagia, weight loss, reflux, halitosis, and regurgitation of undigested food.
3. barium swallow and esophageal manometry. Bird peak sign on barium swallow
4. pneumatic dilation and injection of botulinum toxin to relax LES

Question 455

Primary biliary cirrhosis - autoimmune dx of biliary tree resulting in destruction of intraheptic bile ducts
- affects middle aged women mostly
1. what autoantibody?
2. dx?
3. first line treatment?
4. complications from this?

Answer 455

1. antimitochondrial
2. biopsy is needed for definitive dx
3. Ursodeoxycholic acid to improve biliary excretion
4. ADEK vit malabsorption, metabolic bone dx (osteoporosis, osteomalacia), hepatocellular carcinoma

Question 456

1. What is lithogenic bile
2. How does this affect pancreas?

Answer 456

1. bile that has a high concentration of cholesterol and is obtained from patients with cholesterol gallstones.
2. Most common nontraumatic cause of acute pancreatitis include gallstones and heavy alcohol use
   –gallstones form in the setting of lithogenic bile and may subsequently pass out of the gallbladder through the cystic duct and eventually reach the common bile duct (CBD) - main pancreatic duct also connects to distal CBD and if it is occluded then pancreatic enzymes are released into the pancreas and causes acute pancreatitis

Question 457

Patients with symptomatic hyperthyroidism due to pospartum thyroiditis or inflammatory thyroiditis can get what medication for sx control?

Answer 457

beta blocker such as metoprolol or propranolol

Question 458

In patient with cardiogenic shock (acute decompensated heart failure) what is best medication to start?

Answer 458

1. first line: Dobutamine (beta 1 adrenergic agonist - increased cardiac contractility, stroke volume, heart rate, and CO) or dopamine
   –> (ionotropic support )
2. Norepinephrine
   –> can be used in conjunction to dobutamine

Question 459

Both PPV and NPV vary with (BLANK) so this information must be know to calculate PPV and NPV

Answer 459

disease prevalence

Question 460

What is a post hoc analysis?

Answer 460

statistical analysis are conducted after the data has been collected and seen by investigators.
- Since these are not originally included in the statistical methodology of the study then they are subject to bias and have a threat to validity

Question 461

Multiple sclerosis
1. tx for acute crisis
2. tx for prevention of crisis?

Answer 461

1. glucocorticoid (dexamethasone)
2. Long term disease modifying treatments (interferon beta therapy or monoclonal Ab)

Question 462

Stroke
1. strongest modifiable risk factor
2. strongest nonmodifiable risk factor

Answer 462

1. HTN (then cigarette smoking)
2. age (then family hx, gender, race/ethnicity)

Question 463

Kawasaki disease
1. CRASH and burn (conjunctivitis, polymorphous rash, adenopathy, strawberry tongue, hand and feet swelling, fever)

–> what does tx involve
–> what evaluations should these patients have?

Answer 463

1. high dose aspirin, IV immunoglobulin
2. echo and electrocardiography

dx:
Fever ≥5 days plus ≥4 of the following:
-Conjunctivitis: bilateral, nonexudative
-Mucositis: injected/fissured lips or pharynx, strawberry tongue
-Cervical lymphadenopathy: ≥1 nodes >1.5 cm
-Rash: perineal erythema & desquamation; polymorphous, generalized
-Erythema & edema of the hands/feet, periungual desquamation

Question 464

How to differentiate between hemophilia A and von willebrand disease

1.sx differences
2. bleeding time
3. PTT

Answer 464

1. Hemophilia A: recurrent hemarthrosis and cutaneous bleeding early in childhood.
   –> vonWB dx: mucocutaneous bleeding, epistaxis, gingival bleeding, petechiae, easy bruising, and menorrhagia
2. Increased bleeding time in vWB dx
3. very prolonged in hemophilia

Question 465

• recurrent infections (viral, bacterial, fungal starting at birth, failure to thrive, severe lymphopenia)
• low CD4+ T cells
• Low concn of immunoglobulins
• Deficiency in adenosine deaminase (ADA)
• Low in T and B cell lineages

what is this?
–curative therapy?

Answer 465

1. SCID (severe combined immunodeficiency)
2. stem cell transplantation

Question 466

• Mutations in the lysosomal trafficking regulator gene (LYST) –> needed for transportation of lysosomes within the cell
  -Bacterial infections, oculocutaneous albinism, peripheral neuropathy, and progressive neuro dysfunction

Answer 466

1. chediak higashi syndrome

Question 467

Hyphema

Answer 467

Accumulation of blood within the anterior chamber of the eye - most commonly d/t to blunt ocular trauma and damage to the vasculature of the iris

Question 468

Felty syndrome
1. pathophysiology
2. sx
3. tx

Answer 468

1. More likely to happen in patients with poorly controlled RA who have longstanding disease and positive Rheumatoid factor or anti-citrullinated peptide antibodies
   —Neutropenia occurs due to production of antibodies against granulocyte colony stimulating factor or the production of lymphocytes that target neutrophil precursors in the bone marrow
2. New onset fevers, pleurisy, neutropenia, splenomegaly
   —underlying infections (particularly lower respiratory tract)
3. Rituximab (Ab against CD20 on B cells) drug of choice for patients already on methotrexate
   **TNFa antagonists are not efficacious for this!

Question 469

AVNRT (a type of SVT) occurs in structurally normal hearts and is often provoked by (BLANK x5)
–characterized by regular rhythm w/abrupt onset and termination

Answer 469

1. alcohol
2. caffeine
3. exertion
4. stress
5. sympathomimetic medications

Question 470

Neck rotation commonly alters blood flow in (BLANK) artery and may lead to transient ischemia especially in pts with existing pathology in artery

—> This artery supplies brainstem, cerebellum, and occipital lobes causing
–>vestibulocerebellar sx (ataxia, dysmetria, dizziness, imbalance, vertigo, vomiting, nystagmus)
–> contralateral hemiparesis (damage to corticospinal tract)
–> potential contralateral homonymous hemianopsia with macular sparing

Answer 470

Vertebral artery

–> to prevent future TIAs/Stroke recommend smoking cessation, BP reduction, blood glucose control, healthy diet, regular exercise, use of statin and aspirin

Question 471

Internal carotid artery supplies (BLANK and BLANK) cerebral arteries

Answer 471

Anterior and middle cerebral arteries which supply the anterior and middle cerebral lobe

Question 472

Differentiate between pulmonary angiography vs spiral CT scan

Answer 472

1. Invasive catheter angiographic eval of the pulmonary arteries (going to lungs)
2. images of pulmonary arteries (make up of lungs)

Question 473

• Resistant HTN from renal artery involvement
• Sx of brain ischemia (amaurosis fugax, Horner’s syndrome, TIA, stroke)
• Nonspecific sx (e.g. headache, pulsatile tinnitus, dizziness) from carotid or vertebral artery involvement
  -PE findings: Subauricular systolic bruit and/or Abdominal bruit
• Can also involve iliac, subclavian, visceral arteries
  –often in women 15-50

1. what is this?
2. dx

Answer 473

1. Fibromuscular dysplasia - abnormal cell development in the arterial wall that can lead to vessel stenosis, aneurysm, or dissection. Most commonly involves the renal, carotid, and vertebral arteries
2. Dx is made via noninvasive imaging (CT angio of the abdomen or duplex U/S)

Question 474

Autoimmune metaplastic atrophic gastritis (AMAG)
1. pathophysiology
2. clinical findings
3. increased risk for what

Answer 474

1. presence of antibodies toward parietal cells, resulting in atrophy and metaplasia of the gastric corpus, hypochlorhydria, and unchecked gastrin production, and toward intrinsic factor
2. More often in women.
   –macrocytic anemia
   - dyspepsia, postprandial abd pain, bloating, nausea, heartburn, or regurgitation,
3. gastric adenocarcinoma and neuroendocrine tumors, routine surveillance with endoscopy is indicated

Question 475

What blood disorder causes hydrops fetalis?

Answer 475

alpha thalassemia MAJOR (4 gene loss)

Question 476

Signs of congenital hypothyroidism
1. when does it happen
2. what are the signs

Answer 476

1. weeks to months after birth as maternal T4 wanes
2. Hypometabolism causes low HR and temp, lethargy, poor feeding, hypotonia, constipation, jaundice
   –Mucopolysaccharide accumulation: macroglossia, umbilical hernia
   –delayed bone maturation, enlarged fontanelles

Question 477

1. abdominal/flank/groin pain
2. pulsatile mass
3. flank ecchymosis
4. limb ischemia

what is this?

–> if hemodynamically stable (BLANK)
–> If not hemodynamically stable and pathology is not know get (BLANK)

Answer 477

1. Unstable abdominal aortic aneurysm
2. Obtain CT of abdomen and identify AAA
3. Focused abd U/S

Question 478

What murmur is heard when patient has tetrology of fallot?

Answer 478

1. harsh crescendo-decrescendo systolic murmur over LUSB reflects stenotic pulmonary artery

Question 479

Central vs peripheral cyanosis

Answer 479

1. central: oral cavity lips, tongue, hands, feet, and mucous membranes
2. peripheral: hands, fingertips, or toes, sometimes circumoral and periorbital

Question 480

When there is concern for fetal growth restriction (FGR) (<10th percentile for gestational age)
—> what assessment should be done?

Answer 480

1. Umbilical artery Doppler U/S to assess placental perfusion
   -measures intravascular flow and resistance in the umbilical artery. More resistance = worse hypoxia.
   –measurement identifies patients who require urgent delivery to minimize the risk of fetal demise

– can be caused by maternal vascular disease (e.g. T1DM, chronic HTN). w/less being provided to baby then fluid is moved away from kidney and moved toward brain which causes oligohydramnios

Question 481

Eosinophilic esophagitis
1. patient population
2. pathophysiology
3. dx
4. tx

Answer 481

1. Toddlers (feeding difficulties with solid food, weight loss), school aged (abd pain, vomiting), adolescent (dysphagia, heartburn, food impaction)
   –> issue with swallowing solids (food sticking in the chest feeling)
   –> also common in young men 20-30
2. Th2 mediated inflammatory response trigged by food antigen exposure. Comorbid autoimmune diseases common.
3. endoscopy (furrowing, small, whitish exudates and multiple stacked, ringlike esophageal indentations) and esophageal biopsy (eosinophils >15)
4. elimination diety, pharm therapy (PPI, glucocorticoid), feeding therapy
   –> if not tx can progress to fibrosis leading to strictures that result in progressive dysphagia and food impaction

Question 482

Rupture of membranes for >= (BLANK) hours, intrapartum fever, and fetal prematurity (<37 wks) + unknown GBS status

–> require what?

Answer 482

1. 18 horus
2. penicillin - intrapartum Ab prophylaxis

Question 483

Symptomatic cholelithiasis in pregnancy
1. pathophysiology
2. clinical features
3. management

Answer 483

1. increased biliary cholesterol excretion (due to estrogen)
   — decreased gallbladder motility due to progesterone
2. recurrent postprandial epigastric/RUQ pain
   -RUQ U/S with echogenic foci
3. Conservative (pain control), cholecystectomy for complicated, recurrent cases

Question 484

What are the 2 most common causes for neonatal cholestasis or impaired biliary excretion?

Answer 484

1. biliary atresia
2. biliary cyst

Question 485

• presents during early childhood with abdominal pain, jaundice, and/or RUQ mass (classic triad)

what is it and what is management?

Answer 485

1. biliary cyst
2. cyst removal to decrease risk of cholangiocarcinoma

Question 486

What is the most common cause(s) of jitteriness in infants of diabetic mothers

Answer 486

1. hypoglycemia
2. If glucose is normal then check calcium bc hypocalcemia is next cause (osmotic diuresis caused by poorly controlled gestational diabetes causes hypomagnesium which leads to hypocalcemia)

–hypocalcemia can present with jitteriness, respiratory symptoms, and if severe seizures too

correction involves correcting magnesium first then calcium

Question 487

Angiodysplasia is an AV malformation that usually occurs in elderly patients as well as those with (BLANK) and (BLANK) disease

Answer 487

1. Severe aortic stenosis (gastrointestinal bleeding from angiodysplasia is a deficiency of high-molecular-weight multimers of von Willebrand factor which is sheared with aortic stenosis)
2. Chronic kidney disease

Question 488

Right ventricular myocardial infarction
1. changes to right ventricle preload
2. With reduced cardiac output and hypotension what does the RV rely on to maintain blood flow through pulmonary circulation
3. How to treat this?
4. What should be avoided?

Answer 488

1. Increases RV preload
2. hydrostatic pressure to force blood through the pulmonary circulation
3. IV normal saline
4. nitrates, diuretics, and opioids

Question 489

• cachexia
• elevated alk phosphatase
• tenderness over spinous process indicated mets to spine
• elevated AFP
• abnormal liver function tests
• Risk factors include chronic Hep B infection or environmental toxin exposures

what is this likely?

Answer 489

hepatocellular carcinoma (HCC)

–AFP is a glycoprotein produced by the fetal liver and yolk sac
—Often occurs in setting of chronic liver disease and presents as solitary mass

Question 490

What is post cardiac injury syndrome?

Answer 490

Acute pericarditis is a form of this –> results from immune complex deposition in the pericardium. It can occur following any event or intervention (e.g. MI, CABG, perc coronary intervention) that exposes the immune system to cardiac antigens and typically has a latency period of several weeks to months

Question 491

Chronic radiation proctitis
1. pathophysiology
2. presentation

Answer 491

> 3 months to years
1. obliterative endarteritis and chronic mucosal ischemia
—submucosal fibrosis

2. severe bleeding +/- strictures with constipation and rectal pain.
   –on endoscopy you will see telangiectasias, mucosal pallor and friability

Question 492

Placenta accreta
Placenta increta
Placenta percreta

Answer 492

1. when the placenta attaches to deeply into the uterine wall (attachment of placental villi directly onto the myometrium rather than the decidua basalis - found usually in 2nd trimester U/S showing low lying placenta, myometrial thinning, and numerous placental lacunae)
2. Placenta attaches into the uterine muscle
3. Placenta goes through uterine wall and attaches to nearby organs

Question 493

Breast milk jaundice
1. pathophysiology
2. unconjugated bilirubin levels
3. when does this appear

Answer 493

1. High beta glucuronidase in breast milk deconjugates intestinal bilirubin and increases enterohepatic circulaiton.
2. increased
3. onset is after first week of life and no signs of dehydration

Question 494

How often should infants be feed?

Answer 494

every 2-3 hrs in the first few weeks of life (8-12 feeds a day)

Question 495

• Weight loss, fatigue, anorexia
• Painless jaundice with dilation of the common bile duct on U/S
• what is this and what is pathophysiology to these features?
• What imaging is done to dx?

Answer 495

1. Pancreatic adenocarcinoma
   —tumors in pancreatic head often cause compression of the pancreatic duct and common bile duct resulting in painless obstructive jaundice with elevations in bilirubin and alk phosphatase
   ***tumors in pancreatic body or tail often present with progressive abd pain W/OUT jaundice
2. Abdominal CT scan - can be used for staging purposes and preop plans

Question 496

Extraintestinal manifestations of celiac dx outside of abdominal pain, distension, bloating, diarrhea

Answer 496

General: failure to thrive/weight loss, short stature, delayed puberty/menarche

Oral: enamel hypoplasia, atrophic glossitis

Dermatologic: dermatitis herpetiformis

Hematologic: iron deficiency anemia (due to malabsorption)

Neuropsychiatric: peripheral neuropathy (stocking glove distribution/distal/symmetric - length dependent axonal polyneuropathy), mood disorders (eg, anxiety, depression)

Musculoskeletal: arthritis, osteomalacia/rickets* (due to vitamin D malabsorption)

Question 497

HIV management in pregnancy
Intrapartum

Viral load ≤50 copies/mL: (BLANK)
Viral load >50 copies/mL to ≤1,000 copies/mL: (BLANK)
Viral load >1,000 copies/mL: (BLANK)

Answer 497

Avoidance of artificial ROM, fetal scalp electrode, operative vaginal delivery

Viral load ≤50 copies/mL: ART + vaginal delivery
Viral load >50 copies/mL to ≤1,000 copies/mL: ART ± zidovudine + vaginal delivery
Viral load >1,000 copies/mL: ART + zidovudine + cesarean delivery

Question 498

HIV management in pregnancy
antepartum

Testing of HIV-1 viral load every (BLANK) until undetectable, then every 3 months
CD4 cell count every (BLANK) months

Resistance testing if not previously performed
Initiation or continuation of HAART
Avoidance of amniocentesis if viral load is detectable

Answer 498

1. monthly
2. 3 months

Question 499

1. HELLP syndrome stands for
2. Etiology is likely
3. tx?

Answer 499

1. Hemolysis, Elevated Liver enzymes, Low Platelets
2. LIfe threatening disorder related to preeclampsia w/severe features –etiology is likely abnormal placental development during early pregnancy
   - placental release of antiangiogenic factors which cause widespread maternal endothelial dysfunction and dysregulation of vascular tone (HTN)
3. Prompt delivery bc removal of placenta is only definitive cure

Question 500

Solid liver masses

1. associated with anomalous arteries. Arterial flow and central scar seen on imaging
2. Women on long term OCP, possible hemorrhage or malignant transformation
3. systemic sx, chronic hepatitis or cirrhosis, elevated AFP
4. single/multiple lesions, known extrahepatic malignancy

Answer 500

1. focal nodular hyperplasia
2. Hepatic adenoma
3. HCC
4. Liver mets

Question 501

what drug keeps pda open and what closes it

Answer 501

1. prostaglandin E1 (PGE1)
2. Indomethacin

Question 502

malignant hyperthermia
1. What triggers this
2. sx and tx
3. diff from NMS

Answer 502

1. anesthetic
2. sudden onset fever, tachycardia, tachypnea, and muscle rigidity
   – tx by stopping anesthetic and giving dantrolene
3. NMS is caused by neuroleptic agents (haloperidol, promethazine)

Question 503

Typical sx of gastroparesis

Answer 503

early satiety and postprandial emesis

Question 504

1. hematochezia
2. abdominal pain
3. tenesmus (fecal urgency followed by straining and inability to defecate)
   **pregnancy is a high risk period for patients with this. What does this do to baby?

what is this most likely?

Answer 504

1. Ulcerative colitis
   *high risk bc placental cytokines worsen colonic inflammation. This can lead to preterm delivery and small for gestational age.

Question 505

What does this have?
1. colloids
2. prothrombin complex concentrate
3. Desmopressin

Answer 505

1. FFP (fresh frozen plasma), albumin
2. Concentrate of vit K dependent cofactors (factors 2, 7, 9, 10 and small amounts of protein C and S) - normalizes INR in patients with warfarin in <=10 min but effects are transient
3. given preoperatively to patients with mild hemophilia A. Indirectly increases factor 8 by causing vWF release from endothelial cells which supports factor 8

Question 506

Risk factors for hyperemesis gravidarum
Clinical features

Answer 506

1. hydatidiform mole
2. Multifetal gestation
3. hx of this

–Sx: severe, persistent vomiting
>5% loss of prepregnancy weight
-dehydration
-orthostatic hypotension
- Hypoglycemia w/ketonuria

Question 507

Abortion types
1. missed
2. threatened
3. inevitable
4. incomplete
5. complete

Answer 507

1. No vaginal bleeding, closed cervical os, no fetal activity or emtpy sac
2. vaginal bleeding, closed cervical os, fetal cardiac activity
3. vaginal bleeding, dilated cervical os, products of conception may be seen or felt at or above cervical os
4. Vaginal bleeding, dilated cervical os, some products expelled and some remain in uterus
5. Vaginal bleeding, closed cervical os, products of conception completely expelled

Question 508

Toxic megacolon
–> systemic toxicity (fever, tachycardia, hypotension, leukocytosis), abdominal pain, distension following diarrhea illness

Dx is done with CT scan of the abdomen with what 3 typical features?

tx?

Answer 508

1. colonic dilation >6 cm
2. loss of normal haustra pattern
3. Irregular mucosal pattern, with areas of ulceration alternating with areas of edema

tx: in severe cases exploratory laparotomy and total colectomy can be done

Question 509

1. Nonoperative management of toxic megacolon include
2. TM due to IBD is treated with

Answer 509

1. supportive care, bowel rest, and decompression, broad spectrum Ab and tx of underlying etiology
2. IV glucocorticoids are 1st line therapy

Question 510

1. Polymicrobial infection characterized by fever >24 hours postpartum, purulent lochia, and uterine tenderness

• what is this
• how is this treated?

Answer 510

1. postpartum endometritis
2. clindamycin + gentamicin (broad spectrum coverage)

Question 511

why does indirect hyperbilirubinemia occur in babies 2-4 days of life (physiologic jaundice)

Answer 511

1. At brith RBC have shorted life span and thus have high turnover
2. This leads to increased unconjugated/indirect bilirubin
   –> UGT (uridine diphosphogluconurate glucuronosyltransferase) activity does not reach adult levels until 2 weeks so you get build up of indirect bilirubin and inability to excrete
3. Enterohepatic recycling is increased bc low bacterial population in newborn gut results in slower conversion of bilirubin to urobilinogen for fecal excretion

Question 512

Food protein induced allergic proctocolitis is a (BLANK) mediated reaction to a protein (typically cow’s milk or soy) that presents with bloody stools in well appearing young infants

when does this occur?

Answer 512

Non-IgE mediated allergic reaction

1-4 weeks but up to 6 months

*blood and/or mucus streaked stools
*Can happen in breastfed and formula fed

Question 513

Acalculous cholecystitis
1. risk factors
2. clinical presentation
3. Dx tests
4. tx

Answer 513

1. severe trauma or recent sx, prolonged fasting or TPN, critical illness

• These conditions likely cause gallbladder stasis and ischemia leading to distension, necrosis, and 2ndary bacterial infection. These conditions can cause adynamic ileus, and gaseous small and large bowel distension on imaging

2. Fever, RUQ pain, leukocytosis +/- increased LFTs
3. Abd U/S (HIDA or CT if needed)
4. Enteric Ab coverage, cholecystostomy for initial drainage, consider cholecystectomy once stable

Question 514

2nd stage of labor is period from complete cervical dilation (10 cm) to fetal delivery

2nd stage arrest =
1. (BLANK) - primigravida
OR
2. (BLANK) - multigravida

Answer 514

1. > = 3 hrs of pushing in primigravida w/out an epidural (>= 4 w/ epidural)
   OR
2. > =2 hrs of pushing in multigravida w/out an epidural (>= 3 w/epidural)

Question 515

What is the most common source of liver mets?

Answer 515

colorectal cancer
- if multiple liver lesions are seen on CT scan consider colonoscopy to rule out colorectal cancer as cause of mets

Question 516

• cyanosis w/in first 24 hours of life
• tachypnea
• single S2 on auscultation
• egg on a string appearance on chest x-ray

what is this likely?

Answer 516

1. Transposition of the great vessels

Question 517

Treatment for C diff infection in most patients, including those with nonsevere or severe disease

Answer 517

1. oral fidaxomicin or vancomycin
2. Metronidazole is now only considered if #1 is not available and only for non-severe dx

Question 518

A (BLANK) is required for dx of triglyceride induced pancreatitis
tx includes:

Answer 518

1. lipid panel showing TG >1,000
2. IV fluid, pain control, insulin infusion (limits fatty acid release from adipocytes) or apheresis (removes TG rich plasma)

Question 519

Cardiorenal syndrome
- acute heart failure exacerbation leads to increased central venous and renal venous pressure to the point that (BLANK) substantially drops. The reduced forward flow from failing left ventricle also decreases renal arterial perfusion.

Tx with IV diuretics reduces central venous and renal venous pressure and improves cardiac output and increases (BLANK)

Answer 519

GFR

Question 520

Acute tubular necrosis
1. caused by what
2. When does recovery phase usually start
3. BUN/Cr ratio
4. casts?

Answer 520

1. ischemic or toxic injury to renal tubular epithelium
2. 7-10 days after initial insult
3. BUN/Cr typically 10-15 (intrinsic renal injury)
4. muddy brown casts

Question 521

ACE inhibitors and ARBS are teratogens – what do they do to a fetus?

Answer 521

1. fetal renal hypoplasia (bilateral, underdeveloped fetal kidneys) and oligohydramnios

Question 522

How do you identify if there is long QT on ekg?
how do you tx it?

Answer 522

Look at R-R interval (between peaks of QRS) and then look at QT interval. If QT is more than half of the RR interval then it is long QT

• prolonged QT is >460 ms

Tx: beta blockers, specifically nonselective BB like propranolol and nadolol

Question 523

Listeria monocytogenes is a common foodborne infection due to consumption of contaminated food and typically causes (BLANK)

–during pregnancy can cause fetal infection and possible fetal demise

Answer 523

1. self limited gastroenteritis

Question 524

Etiology of acute liver failure?

Answer 524

• Viral Hep
• drug toxicity (acetaminophen overdose, idiosyncratic)
  —–> toxicity results from overproduction of toxic metabolite NAPQI which leads to hepatic necrosis. NAPQI is normally safely detoxified through glucuronidation in the liver but if this pathway becomes overwhelmed this can lead to overdose. Chronic alcohol use is thought to potentiate acetaminophen hepatotoxicity.
• ischemia
• autoimmune hep
• wilson disease
• malignant infiltration

Question 525

How elevated are aminotransferases in nonalcoholic steatohepatitis, alcoholic hepatitis, and cirrhosis

Answer 525

normal to moderately elevated (<500)

Question 526

Bilateral choanal atresia
1. noise?
2. when does it present?

Answer 526

1. stertor (ie. snorting)
2. immediate neonatal period with cyanosis during feeds and crying alleviates respiratory distress by allowing air exchange via mouth

Question 527

Vascular ring in babies
1. pathophysiology
2. sx

Answer 527

1. great vessels encircle and compress trachea
2. biphasic stridor improved with neck extesnion. Feeding difficulties from esophageal compression

Question 528

What is the difference between central venous pressure and cardiac preload

Answer 528

1. CVP is the pressure in the vena cava near the right atrium. This is not inside the heart.
2. This is the volume that is in the right atrium.

*If there is increased pressure in CVP then this decreased volume in the right atrium (cardiac preload)

Question 529

Anal fissures present with pain and rectal bleeding on defecation
1. tx includes increased fiber and fluid intake
–stool softeners
–sitz baths
– (blank) and (blank)

Answer 529

1. topical anesthetics and vasodilators (e.g. nifedipine and NO)

Question 530

T or F: impaired diastolic filling and let atrial enlargement is seen in athletes heart

Answer 530

False - this is not typical of athletes heart. This is seen in HOCM.

–Strength training: concentric LVH (increased LV wall thickness); unchanged diastolic filling and EF

–Endurance training: eccentric LHV (increased LV cavity size); increased diastolic filling and stroke volume, unchanged EF

Question 531

1. Transmural inflammation with noncaseating granulomas. Linear mucosal ulcerations. Cobblestoning, creeping fat.
2. Mucosal and submucosal inflammation with no granulomas. Pseudopolyps.

what dx is each?
-plus complication of each

Answer 531

1. Crohn dx
   –> fistulae, abscesses, strictures
2. Ulcerative colitis
   –> toxic megacolon

Question 532

Does pregnancy pathophysiology cause increase or decrease in BP?

Answer 532

1. Decrease - there is increased release of peripheral vasodilators (NO, prostacyclin) and decreased sensitivity to vasoconstrictors resulting in overall decrease in BP by 5-10 mmHg from baseline.
   *effect is more pronounced between 12-20 weeks gestation w/return to prepregnancy BP levels in 3rd trimester

Question 533

1. Chronic HTN
2. Gestational HTN

Answer 533

1. systolic pressure >=140 and/or diastolic pressure >=90 mmHg prior to conception or at <20 weeks gestation
2. New onset elevated BP at >=20 weeks getation. NO proteinuria

Question 534

Risk factors of sigmoid volvulus?

Answer 534

1. chronic constipation
2. colonic dysmotility

Question 535

Predictors for severe acute pancreatitis include
1. patient factors
- age (BLANK)

2. Clinical findings
   - AMS
   - SIRS criteria (BLANK, BLANK)
3. Lab findings
   - (blank)
   - (blank)
4. Radiologic findings
   - CXR: (blank)
   - Abdominal CT scan (blank)

Answer 535

Patient factors:
Older age (eg, age >55)
Comorbidities, including obesity (BMI >30 kg/m2)

Clinical findings:
Altered mental status
SIRS (eg, leukocytes >12,000/mm3, temperature >38 C [100.4 F])

Laboratory findings of intravascular volume depletion:
↑ BUN (>20 mg/dL) and/or ↑ creatinine (>1.8 mg/dL)
↑ HCT (>44%)

Radiologic findings:
CXR: pulmonary infiltrates, pleural effusions
Abdominal CT scan: severe pancreatic necrosis

Question 536

Fetal growth restriction is estimated fetal weight <10th percentile or a birth weight <3rd percentile.
–Fetal adaptation to uteroplacental insufficiency places infants at risk for (5 things)

Answer 536

1. Polycythemia - chronic hypoxia induces increased EPO
2. Hypoglycemia - chronic nutrient deprivation = lower plasma glucose and insulin concn leading to decreased liver and muscle glycogen stores
3. Hypothermia - shunting blood to vital organs causes decrease in subcutaneous fat and increased heat loss
4. Hypocalcemia - placenta dysfunction decreases calcium transfer to fetus
5. Perinatal asphyxia and meconium aspiraiton: small infants have a difficult respiratory transition

Question 537

Gaucher disease (autosomal recessive)
1. (BLANK) deficiency causes (BLANK) accumulation in macrophages
2. Clinical features
–> age
–> visceral organ involvement
–> bone
–> growth

Answer 537

1. glucocerebrosidase deficiency
2. at any age
   –> splenomegaly (severe), hepatomegaly
   –> bone marrow infiltration: anemia, thrombocytopenia, bone pain
   –> failure to thrive, delayed puberty

Question 538

What are risk factors for adult hip osteonecrosis (avascular necrosis) (5)

Answer 538

1. femoral head fracture
2. glucocorticoids
3. excessive alcohol use
4. sickle cell disease
5. systemic lupus erythematosus

Question 539

NON-pupil sparing CN III palsies –> caused by (BLANK)
–dx:

Pupil sparing CN III palsies –> caused by (BLANK)
–dx:

Answer 539

1. This is when ptosis (due to paralysis of levator palpebrae superioris) and paralysis of inferior oblique, superior, inferior, and medial recti (all of which are innervated by CN III) can result in a down and out position of eye. –> Pupillary dilation occurs in non-pupil sparing form.
   –> this is caused by external compression. The somatic (motor) components of CN III run w/in the nerve while parasympathetic nerves run outside of the CN III Fascicle. External compression can affect both.
   –> dx: MR or CT angiography to evaluate for aneurysm (mass effect)
2. This is caused by microvascular ischemia and often associated with diabetes, HTN, hyperlipidemia, and advanced age. This is ischemia of the inner motor portion so it spares the pupil.
   –> dx: no other test, just supportive care and tx of underlying condition

Question 540

SNRI is associated with dose dependent (BLANK)

Answer 540

HTN due to increased NE reuptake inhibiton at higher dose ranges - BP should be assessed before starting venlafaxine and regularly monitored

Question 541

Comorbidities in turner syndrome
1. cardiovascular
2. renal
3. MSK
4. vision and hearing
5. autoimmune

Answer 541

1. Aortic coarctation, bicuspid aortic valve
   –high risk of aortic dilation/dissection in pregnancy
   –Metabolic syndrome
2. horseshoe kidney
3. Osteoporosis due to lack of ovarian produced estrogen
4. strabismus, myopia
   –recurrent otitis media, hearing loss
5. Celiac disease
   –Hypothyroidism

Question 542

When someone has overdosed on both alcohol and benzos how do you differentiate what symptoms come from what drug

Answer 542

1. alcohol - can cause peripheral vasodilation and volume depletion via diuresis that can lead to hypotension –> this is not commonly seen in benzos
2. Benzos cause slurred speech, ataxia, hyporeflexia, and sedation. Does not cause extreme CNS depression and pts solely on this are still arousable

Question 543

What is morphine active metabolite excreted by?

Answer 543

active metabolites such as morphine 6 glucuronide is renally excreted –> someone with impaired kidney function should avoid this and favor instead opioids that don’t go through kidney (methadone) or dont have active metabolites (fentanyl)

Question 544

Patient with diffuse atherosclerosis (coronary intervention, carotid intervention) has recurrent flash pulmonary edema despite normal ejection fraction + severe HTN

-what is this likely and what test to dx

Answer 544

1. Renal artery stenosis
   –can result in chronic kidney disease. Urinalysis is typically bland.
2. Renal U/S with doppler

Question 545

Leriche syndrome
1. pathophysiology
2. classic triad

Answer 545

1. atherosclerotic occlusion at the bifurcation of the aorta into the common iliac arteries restricting blood flow through
   - External iliac artery - claudication of the hip, thigh, and distal lower extremity
   - Internal iliac artery - creating gluteal claudication
   - internal pudendal artery - restricting blood flow to the penis and causing ED
2. bilateral hip, thigh, and gluteal claudicaiton
   -absent or diminished femoral pulses
   - erectile dysfunction

Question 546

What is best treatment for mild carpal tunnel syndrome

Answer 546

nocturnal wrist splinting, holds the wrist in neutral position and prevents excessive flexion during sleep

Question 547

Distinguishing features that differentiate marfan syndrome and homocystinuria
— both have marfanoid body habitus

Answer 547

1. Marfan - autosomal dominant
   -normal intellect
   -aortic root dilation
   -upward lens dislocation
2. Homocystinuria -autosomal recessive
   - Intellectual disability
   - Thrombosis
   - Downward lens dislocaiton
   - Megaloblastic anemia
   - Fair complexion

Question 548

Kartagener syndrome
1. pathophysiology
2. sx

Answer 548

1. primary ciliary dyskinesia. Dysmotile cilia that results from aberrant production or attachment of ciliary dynein arms. Poor clearance of secretions and chronic infecitons.
2. situs inversus, recurrent sinusitis, bronchiectasis

Question 549

Patients at high risk for preeclampsia (e.g. multiple gestations) are prescribed (BLANK) at 12-28 weeks for prophylaxis

Answer 549

1. low dose aspirin (optimally before 16 weeks)
   -high risk of preeclampsia include
   Prior preeclampsia
   Chronic kidney disease
   Chronic hypertension
   Diabetes mellitus
   Multiple gestation
   Autoimmune disease

Question 550

What is salvage therapy in cancer tx?

Answer 550

Tx for a dx when standard therapy fails

-This is different from adjuvant therapy bc adjuvant therapy is given in addition to standard therapy (afterwards)

Question 551

Heel pain differential - what is each?
1. maximal plain on first stepping out of bed. Pain and tenderness at medial plantar heel, worse w/toe dorsiflexion

2. Posterior heel pain. Swelling and tenderness 2-6 cm proximal to tendon insertion.
3. Pain that is worse with activity. Pain reproduced by medial-lateral squeezing of the calcaneus.
4. Pain, paresthesia, and numbness on the sole of the foot. Percussion tenderness over the posterior tibial nerve in the tarsal tunnel

what is each?

Answer 551

1. Plantar fasciitis
2. Achilles tendinopathy
3. Calcaneal stress fracture (confirmed by x-ray or MRI)
4. Tarsal tunnel syndrome

Question 552

Takayasu arteritis
1. risk factors
2. sx
3. exam findings
4. dx and tx

Answer 552

1. Female, asian, age 10-40
2. constitutional, arteriocclusive (claudication, ulcers) in upper extremities, arthralgias/myalgias
3. BP discrepencies, pulse deficits, bruits
4. elevated ESR, chest x-ray (aortic dilation, widened mediastinum), CT/MR angio: wall thickening, narrowing of lumen
   –tx: systemic glucocorticoids

Question 553

Acute fatty liver of pregnancy
1. when does this usually present
2. platelet count levels?
3. pain location?

Answer 553

1. 3rd trimester
2. thrombocytopenia
3. acute right upper quadrant pain (diff from nonalcoholic fatty liver dx which is usually asymptomatic)

Question 554

Bupropion -
1. what are contraindications for this drug and why?

Answer 554

1. Bupropion can lower seizure threshold so it is contraindicated in patients with bulimia nervosa, anorexia nervosa, or epilepsy

• on lab work if you see hypokalemia and hypochloremia then these are classic signs of self induced vomiting

Question 555

Minimal change disease - more commonly nephrotic syndrome in childrne
1. pathophysiology
2. clinical features
3. dx

Answer 555

1. T cell mediated injury to podocytes (cytokine induced) –leading to increased molecular permeability to albumin
2. edema, fatigue, abdominal pain
3. Urine: nephrotic-range proteinuria
   -serum: hypoalbuminemia +/- hyperlipidemia
   -kidney bx: diffuse effacement of foot processes on EM

Question 556

What does VACTERL stand for

Answer 556

V: Vertebrae (spine)
A: Anorectal (anus and rectum)
C: Cardiac (heart) - VSD
T: Tracheal (windpipe) - tracheoesophageal fistula (TEF) w/esophageal atresia
E: Esophagus (food pipe)
R: Renal (kidneys and urinary tract)
L: Limb (arms, hands, legs, and feet)

*commonly seen with duodenal atresia (causing complete bowel obstruction and polyhydramnios)

Question 557

Tertiary hyperparathyroidism
1. pathophysiology
2. calcium levels
3. phosphate levels
4. PTH levels

Answer 557

1. Patients with long-standing chronic kidney disease often have hypocalcemia and hyperphosphatemia, which can lead to chronic parathyroid stimulation. Over time, this can cause parathyroid hyperplasia and autonomous parathyroid hormone (PTH) secretion.
2. hypercalcemia
3. Hyperphosphatemia
4. EXTREMELY HIGH PTH levels

Question 558

What age does meckels diverticulum typically manifest?

Answer 558

older children >6 months and its associated with complications like obstruction, perforation, intussusception

Question 559

What do androgenic steroids do to HPG axis?

what about opioids?

Answer 559

1. inhibit GnRH
2. leads to low LH, FSH, testosterone, and sperm counts
3. opioids also suppress GnRH and LH secretion leading to reduced Leydig cell testosterone synthesis, decreased spermatogenesis, and testicular atrophy

Question 560

Absent sperm concentration with normal hormone levels (FSH, LH, testosterone) are consistent with …

Answer 560

obstructive azoospermia -sperm cannot be ejaculated due to impaired transport. Disorders primarily include abnormalities of the epididymis and vas deferens.

Question 561

What is typical treatment of lung abscess caused by oropharyngeal anaerobic bacteria ?

Answer 561

1. ampicillin-sulbactam, imipenem, meropenem
2. alternate: clindamycin

Question 562

(BLANK) is a chronic inflammatory condition that can present with vulvar pruritus, white vulvar plaques, and loss of normal architecture (loss of labia minora).

–> (BLANK) is recommended to confirm dx and rule out vulvar cancer

Answer 562

1. Vulvar lichen sclerosus
2. punch biopsy

Question 563

Does chronic liver disease cause poor wound healing and gingival changes?

What else can?

Answer 563

1. NO it does not.
2. Scurvy (vit c deficiency) - occurs in setting of severe malnutrition due to alcohol use disorder, substance, psych dx.
   –> prominent cutaneous findings (follicular hyperkeratosis, perifollciular hemorrhage, ecchymosis, petechiae)
   –> gingivitis
   –> impaired wound healing

Question 564

• Diaphragmatic hernia
• rocker bottom feet
• clenched hands with overlapping fingers

Answer 564

Trisomy 18 (Edward syndrome)

Question 565

Breast discharge eval

-pathologic-
1. age <30
2. age 30-39
3. age >= 40

Answer 565

1. Ultrasound +/- mammogram
2. mammogram +/- ultrasound
3. mammogram + ultrasound

if both are negative, can get MRI of breast

Question 566

What are the top 3 causes for acute bacterial rhinosinusitis

Answer 566

1. Nontypeable H influenzae
2. Strep pneumo
3. Moraxellla catarrhalis

Question 567

Subclavian steal syndrome
1. what part is occluded?

Answer 567

Severe stenosis or occlusion in the left subclavian artery before/proximal to the origin of the vertebral artery occurs

-when person uses their arm it takes away from the brain and reverses blood flow away from brain and into subclavian artery which leads to dizziness and CNS sx

Question 568

Antiphospholipid syndrome

Clinical manifestations:

Dx:
Positive serology for 1 of 3

Tx:

Answer 568

Clinical manifestations:
Fatigue
Thrombocytopenia
Probable mitral regurgitation (holosystolic murmur heard at cardiac apex)
Thrombotic event - DVT or arterial thrombus or pulmonary embolism or ischemic stroke
Pregnancy morbidity → fetal loss, severe preeclampsia, placental insufficiency

Dx:
Positive serology for 1 of 3
Anticardiolipin antibody
Anti-beta2-glycoprotein-1 antibody
Lupus anticoagulant
Lupus anticoagulant effect: PTT prolongation not reversed on plasma mixing studies
False positive RPR test is not uncommon (syphilis antigen used in RPR testing contains cardiolipin)

Tx:
Anticoagulation for life (heparin product or warfarin)
With concomitant SLE → hydroxychloroquine is also added

Question 569

Vaccines during pregnancy
1. recommended (3)
2. indicated in high risk patients (6)
3. contraindicated (4)

Answer 569

1. Tdap, inactivated influenza, Rho(D) immunoglobulin (around 28 weeks)
2. Hep B, Hep A, pneumococcus, H influnzae, meningococcus, varicella-zoster immunoglobulin
3. HPV, MMR, Live attenuated influenza, varicella

Question 570

Emergency contraception
1. first line (0-120 hrs after intercourse)
2. 2nd line (0-120 hrs after intercourse)
3. 3rd line (o-120 hrs after intercourse)
4. 4th line (0-72 hrs after intercourse)
5. 5th line (0-72 hrs after intercourse)

Answer 570

1. copper IUD
2. progesterone IUD
3. Ulipristal
4. Oral levonorgestrel (plan B - high dose of progestin which inhibits LH surge, thereby delaying ovulation + cervical mucus thickening and thinning of endometrial lining)
5. Oral contraceptives

Question 571

What fluids should be used for initial fluid resuscitation vs maintenance fluid

Answer 571

1. normal saline
2. D5 normal saline

Question 572

Optic neuritis (inflammation of the optic nerve, which can lead to blurred or dim vision, pain, and swelling in one or both eyes)

Internuclear ophthalmoplegia (an eye movement disorder that impacts the ability to look to the side with both eyes at the same time)

Brainstem or cerebellar disorder

Transverse myelitis ( when a section of the spinal cord is inflamed, causing pain, weakness, sensory problems and dysfunction in the body at the point of the spine and below)

what are these suspicious symptoms of?

Answer 572

Multiple sclerosis
* 2 separate neuro deficit that cannot be explained by a single lesion
* constitutional sx
*worsened by heat exposure

dx via MRI of brain and spine to find lesions.

Question 573

1. what does finkelstein test determine (what does it look like)
2. what does tinel and phalen test determine (what do they look like)

Answer 573

1. De quervain tenosynovitis (fist with fingers covering thumb and then move fist down - toward ulnar side - if pain by thumb then positive test)
2. Tinel - tap on anterior wrist; phalen - bring back of hands together to collapse wrist area. Both determine carpal tunnel syndrome

Question 574

• benign estrogen sensitive fibroepithelial tumor
• usually in adolescent and women <30
• unilaterall, firm, mobile, well circumscribed mass in upper outer quadrant
• cyclic changes with menses

what is this?
management

Answer 574

1. fibroadenoma
2. Observe and repeat exam in adolescents
   - U/S in adults or patients with persistent mass

Question 575

• what is a mono like initial illness with several weeks of fever, malaise, fatigue, absolute lymphocytosis with >10 % atypical lymphocytes (large basophilic/blue cells with extra/a lot of cytoplasm surrounding nucleus)
  -Mild elevations in LFTs
• Mild pharyngitis, LAD, and splenomegaly

Answer 575

1. CMV
   - will have negative heterophile monospot test
   - Positive CMV IgM serology

Question 576

• X linked recessive
• Deficiency in hypoxanthine-guanine phosphoribosyltransferase (causing hypoxanthine and uric acid accumulation)
• delayed milestones and hypotonia
• Early childhood shows intellectual disability, extrapyramidal symptoms (dystonia, chorea), pyramidal sx (spasticity, hyperreflexia), self mutilation
• Gouty arthritis in late untreated dx

what is this?

Answer 576

Lesch-Nyhan syndrome

Question 577

Mallory weiss tear vs Boerhaave syndrome
1. etiology and pathology
2. Clinical presentation

Answer 577

Mallory-Weiss Tear
1. sudden increase in abd pressure causes mucosal tear in esophagus or stomach (submucosal arterial or venous plexus bleeding)
2. vomiting, retching, hematemesis, epigastric pain. Most heal spontaneously.

Boerhaave syndrome
1. severe retching, penetrating trauma, or complication of endoscopy causes esophageal rupture
2. Acute chest pain, subcutaneous emphysema, left sided pleural effusion. Often shortly after procedure if caused by endoscopy

Question 578

Infections
Pain with hip flexion most likely –>
Pain with hip extension most likely –>

Answer 578

1. Hip septic arthritis
2. Psoas abscess

Question 579

a potentially fatal cellulitis of the submandibular space, is caused by bacterial spread from adjacent infection, most commonly dental abscesses

Answer 579

Ludwig angina

Question 580

CA-125
1. What causes elevation in this
2. How does this help categorize simple appearing masses on bimanual exams
3. What should be done if it is elevated?

Answer 580

1. Only should be checked in women with adnexal masses and who are postmenopausal. (in premenopausal women these benign appearing masses can be managed with reassurance)
2. if post menopausal then CA-125 is checked to risk stratify and be able to decide next steps
3. Elevated CA-125 indicates further imaging has to be done to assess extent of disease and guide management

*CA-125 is released by cells from the peritoneum and mullerian structures like uterus and fallopian tubes

Question 581

What medications can cause acute angle glaucoma (sudden onset of severe eye pain, N/V, unilateral conjunctival injection, and a dilated pupil with poor light response)

Answer 581

1. anticholinergics - such as trihexyphenidyl which is used for parkinson disease
   –anticholinergic meds cause mydriasis which can precipitate ACG

Question 582

Hx of swallowing difficulty
1. oropharyngeal dysphagia vs esophageal dysphagia = (explain)
–> if oropharyngeal dysphagia get (BLANK)
–> if esophageal dysphagia determine if motility disorder or mechanical obstruction (how do you differentiate each)

–> for esophageal dysphagia get (BLANK)
–> for mechanical obstruction get (BLANK)

Answer 582

1. oropharyngeal dysphagia - difficulty initiating swallow, cough, choking, nasal regurgitation

esophageal dysphagia-difficulty w/food passing through esophagus. Food gets “stuck” feeling

2. videofluoroscopic modified barium swallow
3. Motility disorder = dysphagia with solids and liquids at onset
   –mechanical obstruction - dysphagia to solids with progression to liquids
4. –> for esophageal dysphagia get barium swallow followed by manometry w/endoscopy
   –> for mechanical obstruction get upper GI endoscopy (+/- barium swallow before hand)

Question 583

Ovarian masses
1. heterogeneous composition and variable density. On U/S is seen as partially calcified mass (e.g. teeth) with multiple thin, echogenic bands (e.g. hair)

2. encapsulated collections of old blood - appear as homogenous cystic masses
3. simple, small, thin walled cysts +/- free fluid. Usually asymptomatic. Ovulation may cause unilateral pelvic pain mid-cycle
4. complex mass with solid components but typically not calcified or hyperechoic
5. large, bilateral cystic masses. Arise from markedly elevated beta hcg

Answer 583

1. cystic teratoma
2. endometrioma
3. follicular cysts
4. serous ovarian cancers
5. theca lutein cysts

Question 584

Patients with neutropenic fever are at risk for an overwhelming bacterial infection

• monotherapy with a broad spectrum gram negative agent that provides antipseudomal coverage (BLANK) should be started as soon as possible. Gram positive coverage is added as needed

Answer 584

Pip-tazo, cefepime

Question 585

(pathophysiology) located behind the eyes and beneath the brain
–usually blocks blood flow from the brain, which can damage the brain, eyes, and nerves, and increase pressure in the sinuses.
-Can be caused by a bacterial infection that spreads from the sinuses, teeth, ears, eyes, nose, or skin of the face, or by traumatic injury or surgery.

Answer 585

Cavernous sinus thrombosis (CST)

Question 586

CLASSIC TRIAD - dx seen in newborns
1. chorioretinitis - inflammation and scarring of the retina and choroid
2. diffuse intracranial calcifications
3. Hydrocephalus

+seizures, jaundice, hepatosplenomegaly, rash, growth restriction

what is this?
dx?
tx?

Answer 586

Congenital toxoplasmosis
1. toxoplasma serology or PCR
2. Pyrimethamine, sulfadiazine, folinic acid

Question 587

• Hyperkinetic movements (chorea, dystonia)
• sensorineural hearing loss
• gaze abnormalities (e.g. eyes are crossed)
  –> This is (BLANK) which is due to extreme unconjugated bilirubinemia

Answer 587

Bilirubin induced neurologic dysfunction/Kernicterus
–> Unbound bilirubin crosses the BBB

Other sx
Acute encephalopathy ( ± Reversible (treatment: phototherapy, exchange transfusion)):
Lethargy or inconsolability
Hypotonia (early) or hypertonia (late)
Apnea/respiratory failure, feeding difficulties, seizures

Chronic encephalopathy (Irreversible)
Developmental delay
Sensorineural hearing loss
Choreoathetoid movements
Upward gaze palsy

Question 588

Rett syndrome is caused by (BLANK) gene mutation
-affects girls and begins after 6 months-
sx?

Answer 588

MECP2 gene

1. speech regression
2. abnormal gait
3. loss of purposeful hand movements (e.g. repetitive hand wringing)

• Microcephaly, seizures, breathing abnormalities, sleep disturbance, autistic features

Question 589

• benign sex cord-stromal tumors that typically occur in postmenopausal women
• secrete estrogen and cause abnormal uterine/postmenopausal bleeding
• do not cause virilization

Answer 589

Ovarian thecoma

Question 590

Occurs after an unsterile and/or incomplete procedure for elective abortion.
–fever, heavy vaginal bleeding, purulent discharge and uterine tenderness

what is this and what is tx?

Answer 590

Septic abortion
- medical emergency that requires prompt tx with broad spectrum antibiotics and surgical evacuation of the uterus (e.g. suction curettage)

Question 591

Migraines
1. abortive therapies (5)
2. preventatives (4)

Answer 591

1. simple analgesics (e.g. NSAIDs, acetaminophen)
   - antiemetics (metoclopramide, prochlorperazine)
   - Triptans
   - Ergotamine, dihydroergotamien
   - CGRP receptor antagonists (rimegepant)
2. Antiepiileptics (e.g. topiramate, divalproex sodium)
   - TCAs
   - BB (propranolol)
   - CGRP monoclonal Ab (e.g. erenumab)

• During pregnancy first line preventative is BB (propranolol, metoprolol), after first line then can consider CCB too (verapamil)

Question 592

Hypothyroidism and hyperprolactinemia can cause central hypogonadism
–> what tx should be started to return to normal function?

Answer 592

levothyroxine therapy normalizes reproductive function.

*Hypothyroidism causes menstrual irregularities bc low TH causes decreased responsiveness of the pituitary to GnRH –> causing decreased FSH, LH –> no estrogen for ovulation

— >Thyrotropin releasing hormone is upregulated in hypothyroidism which stimulates TSH and prolactin production (hyperprolactinemia) from anterior pituitary

Question 593

Early vs late neurosyphilis manifestations

Answer 593

1. Early
   - meningitis
   - ocular: uveitis and optic neuritis
   - Otologic: hearing loss and tinnitus
   - Meningovascular: meningitis + ischemic stroke
2. Late
   - General paresis: progressive dementia
   - Tabes dorsalis: sensory ataxia and lacinating pains

Question 594

• Not neural axon length dependent. Can cause both proximal and distal muscle weakness
• Sx develop >8 weeks
• Motor&raquo_space; sensory sx
• Involves peripheral nerves so will show LMN signs

pathophysiology: immune mediated demyelination of peripheral nerves and nerve roots

what is this?

Answer 594

Chronic inflammatory demyelinating polyneuropathy
- tx: glucocorticoids, IV immunoglobulin, plasmapheresis

Question 595

Patients with preeclampsia typically have generalized arterial vasospasm leading to increases systemic vascular resistance and high afterload.

–> in response the heart becomes hyperdynamic and this increases pulmonary (BLANK) which causes (BLANK)

Answer 595

1. capillary pressure - which drives fluid from the capillaries into interstitium causing pulmonary edema

–> increased permeability promotes decreased serum albumin levels and decreased capillary oncotic pressure –> causing third spacing
–> normal diuresis is impeded due to decreased renal function

Question 596

Benign appearing endometrial cells on pap testing are normal in (BLANK)

Benign appearing endometrial cells on pap testing are abnormal and require additional evaluation (endometrial bx) in (BLANK)

Answer 596

1. premenopausal women particularly within the first 10 days of the menstrual cycle
2. post menopausal women

**all polyps in postmenopausal pts require histologic evaluation

Question 596

1. enlarged uterus and abnormal uterine bleeding after pregnancy. Affects women of childbearing age. Secretes high levels of hCG. Metastasis can occur often to lungs and vagina.
2. rare but aggressive malignancy. Presents as a uterine mass that causes bulk symtpoms (pelvic pressure, constipation) and abnormal postmenopausal bleeding.
   –> often indistinguishable from benign leiomyomata (ie, uterine fibroids); however, it should be suspected in postmenopausal women who have taken tamoxifen or have other risk factors (eg, pelvic radiation).

Answer 596

1. choriocarcinoma (ie. gestational trophoblastic neoplasia) -
   –> vaginal mets include bloody or purulent vaginal discharge.
2. uterine sarcoma

Question 597

IgA vasculitis (Henoch-Schonlein Purpura)
1. pathogenesis
2. clinical manifestations
3. tx

Answer 597

1. perivenular leukocytoclastic (neutrophils and monocytes) vascultitis. Deposition of IgA, C3, and fibrin in small vessels
2. palpable purpura/petechiae on lower extremities (often butt)
   - arthritis/arthrlagia
   -abd pain/intussusception
   -renal disease (similar to IgA nephropathy)
3. supportive care, systemic glucocorticoids for severe symptoms

Question 598

Why does hyperthyroidism appear with hydatidiform mole?

Answer 598

1. hCG and TSH have similar structure so elevated in hCG can mimic TSH and cause increase in thyroid hormones

Question 599

Medulloblastoma
1. population
2. location
3. sx
4. tx

Answer 599

1. most common MALIGNANT pediatric brain tumor
2. posterior fossa tumor - originates in cerebellum and often compresses 4th ventricle
3. Cerebellar dysfunction, Obstructive hydrocephalus which increases ICP (headache, vomiting, papilledema, abducens nerve palsy) - CN VI nerve has long intracranial course which makes it particularly vulnerable to compression
4. resection, craniospinal radiation, chemo

Question 600

Granulosa cell tumors

Brennor tumor

Embryonal carcinoma

Yolk sac tumors

Answer 600

Granulosa cell tumors
Malignant sex cord-stromal tumors of the ovary that secrete estradiol
Large ovarian mass and postmenopausal bleeding due to unopposed estrogen

Brennor tumor
Epithelial ovarian tumor that is typically found incidentally in asymptomatic patients

Embryonal carcinoma
Type of ovarian germ cell tumor that occurs in young women
Secrete alpha fetoprotein and hCG

Yolk sac tumors
Germ cell tumor that are more common in young women
Secrete alpha fetoprotein
Grow rapidly so patients have acute onset of pelvic pain

Question 601

present with right upper quadrant pain
elevated aminotransferases, and IUFD

fulminant liver failure (eg, scleral icterus, encephalopathy), leukocytosis, and platelet count ≤100,000/mm3.

Answer 601

Acute fatty liver of pregnancy

Question 602

Galactosemia (autosomal recessive)
Pathophysiology:
Sx:
Labs:
Tx: galactose free diet

Answer 602

Pathophysiology: GALT deficiency causes galactose accumulation after lactose or galactose ingestion

Sx: Jaundice and hepatomegaly. Vomiting, poor feeding/failure to thrive, cataracts, increased risk for E. coli sepsis. Possibly seizures due to low glucose

Labs: increased bilirubin, AST, ALT. Decreased glucose. + urine reducing substances.

Question 603

TMP-SMX is avoided in the third trimester because of

Answer 603

risk for neonatal kernicterus

Question 604

Bronchiolitis obliterans

Major manifestation of chronic lung transplant rejection and is common in transplant recipients (BLANK) years post transplant

Pathophysiology:

Answer 604

> 5 years post transplant

Chronic lymphocytic inflammation of the small airway submucosa which eventually leads to ingrowth of fibromyxoid tissue into the airway lumen. Some small airways become obstructed trapping air distally causing obstructive pattern.

Question 605

Chiari I malformation

Chiari II malformation

• describe each and their associations

Answer 605

Chiari I malformation
Inferior displacement of cerebellar tonsils
Syringomyelia is commonly associated with this

Chiari II malformation
Herniation of the cerebellar tonsils and vermis as well as inferior displacement of medulla
Associated with myelomeningocele

Question 606

How do you differentiate between brachial plexus injury (shoulder injury) from C5-6 nerve root radiculopathy (such as cervical radiculopathy from cervical spondylosis)

Answer 606

Brachial plexus injury
Significant pain with passive or active motion of the arm
Most occur during high impact trauma
Pain and muscles weakness

C5-6/cervical radiculopathy nerve root radiculopathy
Weakness in myotome
Sensory loss in a dermatome

Question 607

First line pharmacotherapies for alcohol use disorder (2)

First line therapies for smoking cessation (2)

Answer 607

First line pharmacotherapy for alcohol use disorder

• Naltrexone (long acting opioid receptor antagonist) - it can be initiated in opioid free patients w/out significant liver dx
• Acamprosate is option for those using opioids
• Disulfiram and gabapentin

First line therapies for smoking cessation
- Bupropion
- Varenicline

Question 608

Suspected appendicitis - what diagnostic imaging should be done?

Answer 608

If pregnant → U/S +/- MRI
Not pregnant → Abdominopelvic CT scan

Question 609

Acute stress disorder vs PTSD

Answer 609

Acute stress disorder: sx must last >= 3 days and <= 1 month following trauma exposure
PTSD: sx persist for >1 month

Question 610

Clozapine side effects

Answer 610

Greatest risk of causing seizures in 2nd generation antipsychotics
Neutropenia/agranulocytosis
Seizures
Myocarditis

Question 611

contraindications to breastfeeding that include

Answer 611

active untreated tuberculosis
varicella infection
herpetic breast lesions
current chemotherapy
active substance use (eg, cocaine, phencyclidine).

Question 612

Otitis externa
Pathophysiology:
Pathogens:
Clinical sx: otalgia, pruritus, discharge, hearing loss, pain with auricle manipulation, ear canal erythema, edema, debris. TM spared.
Tx:

Answer 612

1. Caused by water exposure, trauma, foreign material, dermatologic conditions
2. Pseudomonas or staph aureus
3. Topic antibiotic (e.g. floroquinolone) +/- topical glucocorticoid

Question 613

Severe pain with swallowing
No dysphagia (difficulty swallowing)
No thrush

Answer 613

Viral esophagitis - common in patients with HIV (especially CD4 <100)

Viruses involved include HSV (circular or ovoid vesicular and ulcerated lesions) and CMV (large, linear distal esophageal ulcers)

Question 614

Tourette syndrome
Tx includes: (2)

Answer 614

Tx includes:
1. Antidopaminergic drugs (VMAT 2 inhibitors work as dopamine depleters)
2. Alpha 2 adrenergic receptor agonists (guanfacine, clonidine - can be considered in patients with comorbid ADHD or behavioral sx)

Question 615

Rotator cuff impingement or tendinopathy
1. pain with (BLANK) and (BLANK) rotation
2. subacromial tenderness
4. Normal range of motion with positive (BLANK) tests

Answer 615

1. abduction and external rotation (like rotator cuff tear)
2. -
3. impingement tests like Neer (point thumb down and move arm in flexion) and Hawkins (have forearm in front of chest w/palm facing down. Then move hand downward while stabilizing elbow)
   - both are positive if there is pain with these movements. Indicate impingement

Question 616

What is prophylaxis for Neisseria meningitidis?

Answer 616

1. rifampin
2. ceftriaxone
3. ciprofloxacin (adults only)

*ppx should be given to asymptomatic close contacts regardless of vax status

Question 617

SHiN organisms are encapsulated organisms that can cause sepsis in patients with SCD but which one is more common and why?

Answer 617

1. strep pneumoniae - the other two are rare in vaccinated patients

Question 618

What is each of these?

1. Grey/milky/off white discharge. Fishy odor. Positive amine test (whiff test) - Clue cells and elevated pH (>4.5)
2. Yellow/green frothy discharge. Foul smell. Flagellated protozoa and elevated pH (>4.5)
3. Thick white curd like discharge, normal pH, pseudohyphae

Answer 618

1. Bacterial vaginosis (gardnerella vaginalis, coccobacilli)
   –> if asymptomatic then do not require tx. Tx is avoided bc it may resolve spontaneously and tx can lead to sx vaginal candidiasis.
2. Trichomonas vaginalis
3. Candida albicans

Question 619

• purulent monoarthritis
  OR
• Triad of tenosynovitis, dermatitis (pustular lesions), migratory polyarthralgia

what is this?

Answer 619

disseminated gonococcal infection

Question 620

(BLANK) and (BLANK) are most common causes of acute, unilateral cervical lymphadenitis in children

Answer 620

1. staph aureus
2. strep pyogenes

Question 621

Primary amenorrhea eval
1. Uterus is present
2. check FSH levels
a. if FSH is low what is next step? (BLANK A)
b. if FSH is normal what is likely dx (BLANK B)
c. if FSH is high what is next step? (BLANK C)

Answer 621

A. TSH and prolactin. Cause of amenorrhea can be hypothyroidism, prolactinoma. Or if levels are normal then functional hypothalamic amenorrhea.

B. imperforate hymen

C. Karyotype to determine if Turner syndrome (45, XO) and if not then likely primary ovarian insufficiency (common in women with FMR1 gene mutation)

Question 622

In addition to the presence of dementia, a diagnosis of dementia with Lewy bodies requires the presence of ≥2 of the following clinical features: (4)

Answer 622

1. parkinsonism
2. Fluctuating cognition
3. visual hallucinations
4. rapid eye movement sleep behavior disorder.

Question 623

Clinical features of Alzheimer disease

Early findings
1. (BLANK) memory loss
2. Visuospatial deficits
3. (BLANK) difficulties
4. Cognitive impairment with progressive decline

Late findings
1. (BLANK)
2. (BLANK) (eg, difficulty performing learned motor tasks)
3. Lack of insight regarding deficits
4. Noncognitive neurologic deficits (eg, pyramidal & extrapyramidal motor, myoclonus, seizures)
5. Urinary incontinence

Answer 623

Clinical features of Alzheimer disease

Early findings
1.Anterograde memory loss (ie, immediate recall affected, distant memories preserved)
2.Visuospatial deficits (eg, lost in own neighborhood)
3.Language difficulties (eg, difficulty finding words)
4.Cognitive impairment with progressive decline

Late findings
1. Neuropsychiatric (eg, hallucinations, wandering)
2. Dyspraxia (eg, difficulty performing learned motor tasks)
3. Lack of insight regarding deficits
4. Noncognitive neurologic deficits (eg, pyramidal & extrapyramidal motor, myoclonus, seizures)
5. Urinary incontinence

Question 624

Spinal epidural hematoma - potential complication of neuraxial anesthesia (epidural block), lumbar puncture, or spinal surgery

1. more common in patients taking…
2. Sx:
3. management:

Answer 624

1. antithrombotic meds
2. Bleeding within the spinal canal results in progressive motor and sensory dysfunction in the distribution of the affected nerve root.
   –bowel and bladder dysfunction
   - localized back pain and point tenderness
   - bleeding source is typically venous which is why sx are usually slowly progressive
3. urgent MRI of spine
   –surgical emergency and requires urgent decompression (e.g. laminectomy)

Question 625

Is uterine cavity distortion a contraindication to IUD?

Answer 625

yes

Question 626

amyotrophic lateral sclerosis
1. pathophysiology, what part of CNS is affected
2. sx

Answer 626

1. neurodegenerative disease. UMN and LMN are affected. Degeneration of cells in the anterior horn of the spinal cord.
2. ## Asymmetric weakness with upper and lower motor neuron signs.

Question 627

Initial management of ischemic stroke
1. If <4.5 hr give thrombolysis –> (BLANK)

2. If >= 4.5-24 hours not eligible for thrombolysis –> (BLANK)
3. If >= 24 hr not eligible for thrombolysis –> (BLANK)

–>For 1-3, the ones that go on to get CTA of head and neck
a. if large vessel occlusion is noted –> (BLANK)
b. if large vessel occlusion is absent –> (BLANK)

Answer 627

Initial management of ischemic stroke
1. If <4.5 hr give thrombolysis –> CTA of head and neck

2. If >= 4.5-24 hours not eligible for thrombolysis –> CTA of head and neck
3. If >= 24 hr not eligible for thrombolysis –> standard postischemic stroke management (e.g. antiplatelet therapy, investigate for embolic source)

–>For 1-3, the ones that go on to get CTA of head and neck
a. if large vessel occlusion is noted –> mechanical thrombectomy
b. if large vessel occlusion is absent –> standard postischemic stroke management (e.g. antiplatelet therapy, investigate for embolic source)

Question 628

What is typically the first sign of puberty in most girls?
-at what age?

Answer 628

1. thelarche (breast development)
2. around 10 but as early as 8 years old
   –breast buds - enlargement of areola, elevation of the papilla, and growth of a small mound of breast tissue. Firm, retroareolar mass that may be slightly tender. It is normal for breast bud to be unilateral in early stages.

Question 629

Breast masses

1. Results from trauma and presents as firm, irregular, nontender mass
2. subcutaneous, painless, soft tissue mass that occurs in women

Answer 629

1. fat necrosis
2. lipoma

Question 630

MRI showing bilateral hyperintensity of the globus pallidus is highly sensitive to (BLANK)

Answer 630

Hypoxic conditions like CO poisoning

Question 631

What is the DUMBBELLS mnenomic for?
1. what medication is often used to counteract this pathology?

Answer 631

CHOLINERGIC toxicity
1. atropine (reverses muscarinic sx)
–> pralidoxime reverses nicotinic and muscuarinic sx (administer after atropine)

Question 632

Explain how these changes happen w/thiazide diuretics
1. Hyponatremia
2. Hypokalemia
3. Hypercalcemia
4. Hyperglycemia
5. Hypercholesterolemia
6. Hyperuricemia

Answer 632

1. Inhibition of Na/Cl cotransporter in distal convoluted tubule
2. compensatory rise in renin & aldosterone leads to K release
3. Increased Ca reabsorption in distal tubule
4. Decreased insulin secretion and increased insulin resistance
5. same as above
6. Increased uremia reabsorption in proximal tubule

Question 633

Treatment resistant schizophrenia and/or schizophrenia associated with suicidality

—> what is best tx for this?

Answer 633

–> clozapine

Question 634

Acute hemolytic transfusion reaction is a rare but potentially fatal condition due to transfusion of mismatched blood (eg, ABO incompatibility).
- sx:
- dx:

Answer 634

1. Patients can develop fever, hypotension, flank pain, hemoglobinuria, and disseminated intravascular coagulation within minutes to hours of transfusion.
2. Diagnosis is with a positive direct Coombs test.

Question 635

Neonatal respiratory distress syndrome
1. when does this present
2. pathogenesis?
3. Xray findings

Answer 635

1. immediately after birth, in premature babies
2. surfactant deficiency causing increases alveolar surface tension and diffuse atelectasis
3. ground glass opacities, air bronchograms, decreased lung volumes

Question 636

Meconium aspiration syndrome
1. pathogenesis
2. xray findings

Answer 636

1. bronchiolar obstruction and inflammation due to particulate matter (ie. meconium)
2. hyperinflated lungs and streaky, linear densities

Question 637

Impaired clearance of alveolar fluid causes respiratory distress within hours of birth and causes transient tachypnea of newborn

–Chest x ray shows

Answer 637

• fluid in interlobar fissures
• severe hypoxia requiring invasive respiratory suppor

Question 638

Acute stress disorder vs adjustment disorder

Answer 638

1. Acute stress disorder – exposure to life threatening traumatic event. Reexperiencing events (intrusive memories, flashbacks), avoidance, negative mood, dissociation, and hyperarousal lasting 3 days - 1 month
2. mood and behavioral symptom onset within 3 months of identifiable stressor. Marked distress and/or functional impairment.

Question 639

Skin conditions and associated dx
1. multiple skin tags

Answer 639

1. insulin resistance
2. pregnancy
3. crohn disease

Question 640

Skin conditions and associated dx
1. porphyria cutanea tarda
2. cutaneous leukocytoclastic vasculitis (palpable pupura) secondary to cyroglobulinemia
3. lichen planus

Answer 640

1. hep c

Question 641

Skin conditions and associated dx
1. dermatitis herpetiformis

Answer 641

celiac disease

Question 642

Skin conditions and associated dx
1. sudden onset severe psoriasis
2. recurrent herpes zoster
3. disseminated molluscum contagiosum

Answer 642

1. HIV infection

Question 643

Skin conditions and associated dx
1. severe seborrheic dermatitis

Answer 643

1. HIV infection
2. Parkinson disease

Question 644

Skin conditions and associated dx
1. explosive onset multiple, itchy seborrheic keratoses

Answer 644

GI malignancy

Question 645

Skin conditions and associated dx
1. Pyoderma gangrenosum

Answer 645

1. inflammatory bowel disease

Question 646

Lymphaganitis
1. pathophysiology
2. pathogen that causes this
3. manifestations
4. tx

Answer 646

1. pathogen invasion of lymphatics in deep dermis
2. strep pyogenes & MSSA
3. tender, erythematous streaks proximal to wound, regional tender LAD, systemic sx
4. cephalexin

Question 647

Pathophysiology of cardiac dysfunction in kawasaki disease?

Answer 647

1. systemic inflammation leading to infiltration of lymphocytes and macrophages into cardiac tissue and vasculature leading complications like
   a. coronary artery aneurysm
   b. ventricular dysfunction
   c. pericardial effusion

Question 648

Antibiotics for surgical site infection prevention
1. Clean (uninfected, uninflammed, the viscus is not entered)
a. 1st line
b. alternatives

2. Clean contaminated (Viscus is entered under controlled conditions)
   a. typical contaminants
   b. antibiotics based on surgical site, broader coverage often indicated

Answer 648

1a. cefazolin
1b: vancomycin, clindamycin
–> skin flora are typical contaminants

2a. skin flora (strep, staph, coagulase neg staph), gram neg bacilli, enterococci, endogenous flora of the viscus

Question 649

Posttransplantation lymphoproliferative disorder
1. pathogenesis
2. sx
3 labs

Answer 649

1. Immunosuppression following solid-organ or stem cell transplantation → suppressed cytotoxic T-cell immunosurveillance → unchecked viral replication → immortalized lymphocytes or plasma cells (EBV is an oncogenic virus bc it makes proteins that lead to B cell proliferation and B cell immortalization)

Epstein-Barr virus causes >95% of cases, but other human herpesviruses (eg, HHV8) can also trigger the disease

2. fever, LAD, hepatosplenomegaly, leukopenia, masses in nonlymphatic tissue
3. high viral titers, bx evidence of lymphoid or plasma cell proliferation

Question 650

Gram stain and shape
1. clostridium perfringens
2. corynebacterium
3. Enterococcus faecalis
4. Listeria
5. staph aureus
6. GBS

Answer 650

1. gram positive rods
2. gram positive rods
3. gram positive coccus that organizes into pairs and chains
4. gram positive rod
5. gram positive cocci in clusters
6. gram positive coccus that organizes into pairs and chains

Question 651

Miliary TB is caused by (BLANK) spread of mycobacterium tuberculosis

– rare but serious complication of primary TB infection in hosts with poor T cell function such as infants and immunocompromised persons

–can disseminate through the body including (BLANK)

–The ineffective T cell response in these patients means that (BLANK) is often falsely negative

Answer 651

1. lymphohematogenous
2. LN, liver, spleen, bones and marrow, and CNS
3. interferon based testing

Question 652

Acute splenic sequestration
–> abdominal pain, palpable splenomegaly, hypotensive shock and signs of anemia
–> acute drop in Hgb, reticulocytosis, thrombocytopenia

1. what are the steps in treatment?

Answer 652

1. IV fluids
2. Packed RBC transfusion to help restore circulatory volume and correct the anemia (administer cautiously, half of normal volume)
3. If recurrence rate of splenic sequestration is high then this may warrant splenectomy but this is not done in acute setting

Question 653

acute acetaminophen overdose
1. <4 hr –>
2. 4-24 hours –>

-when do you consider empiric NAC (N-acetylcysteine)

*once acetaminophen level available…(BLANK)

Answer 653

1. administer activated charcoal then do #2
2. check acetaminophen level >=4 hr post ingesttion

–consider empiric NAC for
a. any evidence of liver injury
b. >= 8 hrs since ingestion or level not avail
c. >=8 hrs post ingestion

*once acetaminophen level available the nplot on Rumack-Matthew nomogram and administer NAC if level is above tx line

Question 654

a form of allergic conjunctivitis in which redness, pruritus, and tearing are common, but patients have chronic (not acute) symptoms, often with photophobia and a foreign body sensation.

Moreover, signs of chronic eyelid inflammation (eg, thickened, lichenified skin) are typical.

Answer 654

Atopic keratoconjunctivitis

Question 655

Acute conjunctivitis
- what is each?
1. unilateral/bilateral watery/mucoid discharge. Diffuse injection/follicular (bumpy/granular feeling) conjunctival appearance. 1-2 weeks
tx?

2. unilateral/bilateral purulent discharge. Diffuse injection/non follicular conjunctivitis. Unremitting discharge/reaccumulates in minutes. 1-2 weeks.
   tx?
3. bilateral watery discharge. Diffuse injection/follicular (bumpy/granular feeling) conjunctival appearance. Ocular pruritus. Lasts <30 minutes
   tx?

Answer 655

1. viral - also with viral prodrome, can have itchiness, can have mild crusting
   –> none
2. bacterial
   –> gentamicin
3. allergic
   –> olopatadine (mast cell stabilizer), hydrocortisone

Question 656

1. Huntington is associated with degeneration of (BLANK) producing neurons in caudate nucleus and putamen
2. Parkinson is associated with loss of (BLANK) producing neurons in substantia nigra

Answer 656

1. GABA producing neurons (inhibitory)
2. Dopamine producing

Question 657

1. inherited, commonly x linked. Mutation type IV collagen.
2. nephropathy (hematuria, progressive renal insufficiency, proteinuria, HTN)
   —b/l sensorineural hearing loss
   —anterior lenticonus (lens protrusion)

what is this ?
dx?

Answer 657

Alport syndrome
1. genetic testing
–renal biopsy: longitudinal splitting of GBM

Question 658

-Mesangial IgA deposition in mesangium usually within days of URI
-URI can trigger production of pathogenic IgA
-Complement is normal bc of weak complement fixing activity of IgA
-Often benign disease with no chronic kidney injury
-Hematuria with RBC casts
-Nephritic syndrome
-Flank pain, low grade fever, and HTN may be present

what is this?
dx?

Answer 658

IgA nephropathy

Dx
-Typically clinical but can be confirmed with kidney biopsy
-Urinalysis: positive protein, RBCs, RBC casts
Serum
-Normal C3 and C4
-Increased creatinine

Question 659

– Mesangial and glomerular capillary deposition of C3 and IgG.
–Patients typically have edema, hematuria, and hypertension.
–symptoms usually develop 1-3 weeks after sickness

what is it?

Answer 659

poststreptococcal glomerulonephritis

*symptoms usually develop 1-3 weeks after streptococcal pharyngitis or impetigo, and the C3 level is decreased (not seen in this patient).

Question 660

–a progressive glomerulonephritis accompanied by pulmonary disease (ie, alveolar hemorrhage)
– biopsy reveals linear IgG deposition in the GBM.

Answer 660

Goodpasture syndrome.

Question 661

pediatric traumatic brain injury
1. high risk features for age <2
–AMS, LOC, severe mechanism of injury (fall > (BLANK) ft, high impact, MVC)
- Nonfrontal scalp hematoma
- palpable skull fracture

2. high risk features for age >=2-18
   –AMS, LOC, severe mechanism of injury (fall > (BLANK) ft, high impact, MVC)
   -vomiting, severe headache
   - basilar skull fracture signs (ex BLANK)

manage with?

Answer 661

1. 3 ft
2. 5 ft
3. CSF rhinorrhea

• manage with head CT w/out contrast

Question 662

Measurement of (BLANK) concentration can confirm appropriate dosing of levothyroxine

Answer 662

serum free thyroxine (FT4)

Question 663

What does prednisone do to
1. wound healing
2. lipid metabolism
3. other changes

Answer 663

1. delayed wound healing
2. impaired lipid metabolism
3. insulin resistance
4. osteoporosis
5. weight gain
6. HTN
7. adrenal suppression

–exerts anti-inflammatory properties by inhibiting the production and function of T lymphocytes

Question 664

Sulfasalazine used for crohn diseae
adverse effects?

Answer 664

1. drug induced neutropenia
   other drugs that do this: TMP-SMX, antithyroid drugs (methimazole), clozapine

Question 665

Initial pharmacotherapy for heart failure with reduced EF (3)

Answer 665

1. BB
2. RAAS inhibitor (ACEi/ARB)
3. Diuretic

Question 666

Wolf-parkinson white
-ekg findings

Answer 666

1. shortened PR interval with delta wave (slurred upstroke of the QRS complex)

Question 667

What is likelihood ratio equation

Answer 667

LR = true positive/false positive

Question 668

1. How do ACEi affect kidney function in unilateral vs bilateral renal stenosis?

Answer 668

ACEi - inhibit function of angiotensin II which is constricting the efferent arterioles to increase GFR and filtration pressure, especially when renal perfusion is low

1. Unilateral + ACEi: one kidney is getting underperfused so will activate RAAS system but ACEi will prevent this. This decreases GFR in singular stenosed kidney but other healthy kidney will compensate and increase its filtration.
2. Bilateral + ACEi: both kidneys are underperfused so RAAS system activates. ACEi prevents this and so both kidneys experience decreased GFR and thus acute kidney injury

Question 669

Polycythemia vera
- gene mutation
- pathophysiology
- lab/cell line changes
- sx
- tx

Answer 669

1. JAK2 mutation
2. increased production of erythrocytes (but also eosinophils and platelets)
3. leukocytosis, thrombocytosis, increased erythrocyte mass and hematocrit (which causes hyperviscosity syndrome)
4. Pruritus, burning pain in digits w/red-blue discoloration, splenomegaly, congestion of vessels seen as plethora
5. tx with therapeutic phlebotomy

Question 670

Tx for patients presenting with severe hyponatremia + sx like confusion, stroke like sx, or seizures

–> first line tx?

Answer 670

IV administration of 3% saline

Safe rate of correction rate < 12 mEq/L in 24 hrs or < 19 mEq/L in 48 hrs

–when serum Na is <120 then correction should not exceed 8 mEq/L in 24 hrs

Question 671

-acute onset of pruritic rash followed by development of innumerous smaller macules and patches
- patches are ovoid and scaly with a rim of scale around the leading edge
-May occur following a viral illness and has been associated with HHV 6 or 7

what is this?
tx?

Answer 671

1. pityriasis rosea
2. observation, resolve in 6-8 weeks without treatment

*lesions are longitudinal axis and lined up with the relaxed skin tension lines on the trunk

Question 672

The most frequent underlying histopathology of vulvar carcinoma is (BLANK)

Answer 672

1. squamous cell carcinoma
   –incidence is greatest between 55-85
   –presents with a vulvar nodule, papule, or plaque. Rare occasions can be seen as verrucous carcinoma with a large cauliflower like growth

Question 673

What is first line tx of epiglottitis?

Answer 673

• emergent endotracheal intubation. Should be done in operating room under direct visualization with a laryngoscope

Question 674

duration of action of hydromorphone?

Answer 674

2-3 hrs

Question 675

• X linked recessive defect in CD40 ligand on T helper cells, a ligand that interacts with B lymphocytes to induce class switching of immunoglobulins
• present with severe pyogenic infections as well as infections with opportunistic organisms
• B and T cell populations normal

what is this?

Answer 675

Hyper-IgM syndrome

Question 676

what is agranulocytosis?
tx?

Answer 676

1. Neutrophil counts of less than 100/mm3 (neutropenia is absolute neutrophil count of less than 1500/mm3)

tx: withdrawal of implicated medication, tx of any underlying infection and administration of granulocyte colony stimulating factor

Question 677

What is the most common causative pathogen of bacterial meningitis outside of the newborn period (first 4 weeks)?

Answer 677

strep pneumoniae (gram positive lancet shaped coccus)

–> In infants –> bulging of anterior fontanelle, petechiae may be present, leukocytosis, etc

Question 678

What tests should be done in a pregnant female who has had or was exposed to parvovirus B19 infection in 2nd and 3rd trimester?

Answer 678

1. Determine whether she has been infected through measurement of serum specific IgG and IgM concentrations

Question 679

• sudden onset jaw pain, headache, neurologic deficits that begin while exercising or manipulation or trauma
• Pts in 4th-5th decade of life, underlying connective tissue
• Ipsilateral head, neck, or face pain
• Horner syndrome, cranial neuropathies, sx consistent with ischemia to anterior or middle cerebral artery distribution

what is this?
dx?
tx?

Answer 679

1. carotid artery dissection
2. CT or MR angiography
3. antiplatelet agents, alteplase, mechanical thrombectomy, and/or endovascular stenting

Question 680

Decrescendo diastolic murmur at the 3rd intercostal space on the right –>

Soft and single S2 with inspiration w/ late peaking crescendo-decrescendo systolic murmur at RUSB. radiates to carotids; S4 may be present (concentric LVH)
Diminished and delayed pulses (pulsus parvus et tardus)

Opening snap with mid diastolic rumble at cardiac apex

Holosystolic murmur best heard at cardiac apex, radiates to axilla

midsystolic click that varies in timing w/changes in left ventricular blood volume

midsystolic with wide and fixed splitting of S2

Answer 680

aortic insufficiency (aortic valve regurgitation) –> on left side indicates valve dx, on right indicates root disease

Aortic Stenosis

Mitral stenosis

Mitral regurgitation

Mitral valve prolapse

Atrial septal defect

Question 681

Zenker (pharyngoesophageal) diverticulum

1. occurs bc of an…
2. sx
3. dx

Answer 681

1. uncoordinated swallowing mechanism which results in muscle spasms of the cricopharyngeus
2. asymptomatic or initially dysphagia. Halitosis, regurgitation of UNDIGESTED food or pills. Appearance of neck mass
3. barium swallow

Question 682

1. CMV prophylaxis for patients with HIV and CD4 count < (BLANK)
2. Mycobacterium avium complex prophylaxis with azithromycin is indicated when CD4 count < (BLANK)
3. PCP prophylaxis with TMP-SMX when CD4 count < (BLANK)
4. Toxoplasma gondii prophylaxis with TMP-SMX when CD4 count < (BLANK)

Answer 682

1. 50
2. 50
3. 200
4. 100

Question 683

what are these parts of the bone
1. epiphysis
2. physis
3. metaphysis
4. diaphysis

Answer 683

1. ends of bone
2. line indicated growth plate and in between 1 and 3
3. neck portion
4. middle of bone

Question 684

Major structures adjacent to distal humerus include
1. (BLANK) nerve posteriorly near the medial epicondyle
2. (BLANK) artery and (BLANK) nerve in the midline atneriorly
3. (BLANK) nerve anterior to the lateral epicondyle

Answer 684

1. ulnar
2. brachial artery, median nerve
3. radial

*brachial artery bifurcates into the radial and ulnar arteries just distal to elbow joint

Question 685

Difference between thoracentesis vs chest thoracostomy tube in setting of hemothorax

Answer 685

1. thoracentesis works as more of a diagnostic and small volume
2. able to get rid of large volume and can be left in place to trend and monitor ongoing bleeding

Question 686

• recurrent UTI, pelvic or lower abdominal pain, dysuria or painful ejaculation
  -urinary frequency, urgency, or difficulty voiding
• Bloody or discolored ejaculate
• decreased libido or erectile dysfunction
• Risk factors: multiple sexual partners, unprotected anal sex, concomitant STI

what is this?
dx?

Answer 686

1. bacterial prostatitis (chronic does not show fever)
2. two glass test - urine sample is collected before and after prostatic massage to localize the infection to the prostate

Question 687

• infection of the trachea commonly by strep pneumo, H influenzae, staph aureus
• difficulty breathing, cough, hoarseness
• severe cough, intercostal retractions, inspiratory stridor + clear lung sounds, fever
• Chest x ray - peribronchial cuffing and tracheal air column with irregular borders (shaggy)

what is this?

Answer 687

Bacterial tracheitis

Question 688

What would indicate placing a percutaneous nephrostomy tube?

Answer 688

a temporary measure to prevent progression of kidney failure prior to definitive management of the vesicuoureteral reflux or ureteral obstruction

Question 689

When is d-dimer vs spiral CT scan of chest used when considering PE

Answer 689

1. d-dimer is when there is low suspicion for DVT or PE
2. when there is high risk (according to wells score) that PE has occured

Question 690

right ventricular infarction (V4-V6) –> often present with cardiogenic shock and are (BLANK) dependent so should be tx with (BLANK) as part of initial stabilization

Answer 690

1. preload dependent
2. IV crystalloids (e.g. saline)
   –also get antiplatelet agents (aspirin, clopidogrel), anticoagulants (e.g. heparin), pain meds, coronary revascularization

Question 691

the most common cause of low back pain is (BLANK)

-pain that worsens with flexion, on valsalva maneuver, coughing, or sneezing. + more
- what is first step in imaging/diagnosis?

Answer 691

Degenerative disc disease
–the nutrient gradient from the cartilaginous endplates decreases with aging along wit ha declining water content of nucleus pulposus resulting in loss of disc height

x-ray series of lumbar spine to evaluate degenerative changes

–often tx with NSAIDs, hot or cold compress, weight loss, activity modification, PT

Question 692

Osteomyelitis
1. most common bacteria implicated in pediatric pts
2. antibiotic?

Answer 692

1. Staph aureus, GAS, strep pneumo, H influenzae
2. Vancomycin (effective against MRSA and MSSA)

Question 693

Patients that lack a functional spleen such as in SCD patients are at risk for severe infection or sepsis with encapsulated bacteria

–what is done to protect these patients?

Answer 693

1. vaccination against the SHiN organisms
2. prophylaxis with penicillin or amoxicillin daily

Question 694

• Family hx
• chronic H pylori infection
• chronic gastritis
• pernicious anemia
• chronic ingestion of salt and salt preserved foods
• obesity
• smoking
• exposure to N-nitroso compounds through diet

what are these risk factors for?

Answer 694

Gastric carcinoma

Question 695

urinalysis will show proteinuria and presence of oval fat bodies
–pt has edema, foamy, or dark colored urine, hypoalbuminemia, and protein
- primary amyloidosis due to overproduction and deposition of immunoglobulin chains in brain, heart, kidneys, and other organs

Answer 695

• Multiple myeloma

Question 696

effectiveness vs efficacy in clinical trials?

Answer 696

1. Efficacy - ability of tx to produce a desired effect in an ideal patient under ideal circumstances (phase 2 trials)
2. Effectiveness - ability of the tx to produce a desired effect in a general pt population and in real world settings - taking into consideration conditions/challenges of actual clinical practice (phase 3)

Question 697

How does hypothyroidism affect HMG-CoA

Answer 697

HMG-CoA is enzyme responsible for cholesterol synthesis
–LOW thyroid hormone causes decrease in activity of this enzyme. The body compensates for decreased cholesterol synthesis by increasing absorption from the GI tract.

-Hypothyroidism also decreases production of LDL receptors in the liver further increasing serum cholesterol concn.

Question 698

• thickening of the bronchi that results from recurrent necrotiznig infections and chronic inflammation
• Frequent cough, excessive sputum that can be blood tinged, frequent respiratory exacerbations
  –wheezing on pulm exam
  -Hx of recurrent episodes of pneumonia in childhood and adolescence

what is this?
dx/

Answer 698

1. bronchiectasis
2. CT scan of the chest

Conditions associated: chronic bronchial obstruction, tobacco use, cystic fibrosis, primary immunodeficiency disorders, Kartagener syndrome, and allergic bronchopulmonary aspergillosis

Question 699

Treatment of temporal arteritis?

Answer 699

high dose corticosteroid such as prednisone should occur immediately after dx to preserve vision

sx: headaches, hx of preceding transient vision loss, jaw claudication, tenderness of the scalp, and pale optic disc

this is autoimmune inflammatory vasculitis of medium and large vessels

*tx does not compromise biopsy results needed for dx as long as bx is done within 1-2 weeks

Question 700

ABI = SBP in ankle/SBP in brachial artery
<= 0.9 :
0.91 - 1.13:
> 1.3 :

Tx:
Step 1A:
Step 1B:
Step 2:
Step 3: Percutaneous or surgical revascularization

Answer 700

ABI = SBP in ankle/SBP in brachial artery
<= 0.9 : diagnostic of PAD
0.91 - 1.13: Normal
> 1.3 : suggests calcified and incompressible vessels

Tx:
Step 1A: risk factor management → smoking cessation, BP and DM control, Antiplatelet (aspirin) and statin therapy
Patients diagnosed with PAD should undergo aggressive management of cardiovascular risk factors to reduce risk of MI and stroke
Step 1B: Initial treatment is supervised exercise program

Step 2: Pharmacological → cilostazol
Step 3: Percutaneous or surgical revascularization

Question 701

Acute limb ischemia (arterial occlusion or acute vascular injury)

-severe pain out of proportion to exam
-paresthesia
-pulselessness
-pallor
-poikilothermia

what is dx imaging/test?

Answer 701

Arteriography of extremity with contrast
MR angio of extremity

Question 702

Fibrocystic breast disease

Answer 702

diffuse, BILATERAL changes (lumps, cysts, dense, irregular, and bumpy consistency)

–may change with hormone chnages

Question 703

Galactocele
1. when does it happen
2. sx?
3. dx?

Answer 703

1. weeks to months after cessation of breastfeeding and is due to blockage with resulting milk accumulation
2. soft, mobile, non tender mass in the subareolar region
3. U/S and needle aspiration

Question 704

(BLANK) should be suspected in patients with persistent abd pain, fever, RUQ pain 2-10 days after lap chole

Answer 704

Biliary leakage

• lab studies show elevated LFTs, bilirubin, normal appearing bile ducts

Question 705

first line tx for bulimia nervosa

Answer 705

SSRI _ CBT

Question 706

(BLANK) will appear as pseudohyphae with budding yeast forms

(BLANK) appears as septate hyphae

Answer 706

Candida (budding yeast forms is blastoconidia)
*this is on KOH prep or fungal culture of skin

Dermatophytes (ex: tinea cruris)

Question 707

erythematous, pustular rash affecting the central face, consistent with (BLANK)

• what are the 4 primary manifestations?

Answer 707

ROSACEA

1. erythematotelangiectasisa: erythema and facial flushing, telangiectasias, roughness or scaling, and burning
2. Papulopustular : papules and pustules resembling acne
3. phymatous: chronic, irregular thickening of the skin, usually involving the nose
4. Ocular rosacea: involvement of the cornea, conjunctiva, and lids w/burning or foreign body sensations

Question 708

Acute liver failure is characterized by the triad of ..

Answer 708

1. elevated aminotransferases
2. hepatic encephalopathy
3. prolonged prothrombin time

in pt w/out underlying liver disease

Question 709

Where is the lesion for decerebrate vs decorticate posture

Answer 709

1. Decerebrate (contains multiple E’s - for extension): lesion in brain is in red nucleus where neurons are that allow for flexion. Since these are not working then extension occurs.
2. Decorticate (includes word core-involves arm movement toward body, less severe) - lesion in cerebral cortex where neurons that inhibit red nucleus are located. When these are not working well then flexors predomiante.

Question 710

Rule of 4s for stroke symptoms
1. 4 cranial nerves originate (BLANK), 4 in (BLANK), and 4 in (BLANK)

2. 4 midline CN divide equally into 12 except 1
3. Midline structures that start with M have 4 roles …
4. Side structures that start with S have 4 roles…

Answer 710

1. above pons (2 in midbrain), pons, and in medulla
2. –
3. Motor pathways/corticospinal tract (opposite motor weakness)
   -medial lemniscus (posterior column - opposite deficits)
   -medial longitudinal fasciculus (unable to coordinate lateral eye movements - same side of lesion look left, right stays straight)
   -medial CN
4. Spinocerebellar pathway (same ataxia in arm, leg)
   -spinothalamic (opposite pain/temp deficit)
   -sensory portion of CN 5 (same face sensation)
   -sympathetic pathway (same Horner)

Question 711

Tramadol

Answer 711

analgesic medication with serotonergic activity

Question 712

Chronic obstructive pulmonary disease, obstructive sleep apnea, active smoking, obesity, and advanced age are risk factors for postoperative pulmonary complications such as pneumonia.

(BLANK) helps reduce the postoperative risk of pneumonia and shortens postoperative hospital stay.

Answer 712

Preoperative physical therapy

Question 713

• prolonged bloody diarrhea and abd pain after travel to a resource limited country
• dx modality is stool PCR or antigen testing
  -what is this?

Answer 713

Entamoeba histolytica
- Liver abscess cause RUQ pain, fever

tx: metronidazole + intraluminal antibiotic

Question 714

Allergic bronchopulmonary aspergillosis (ABPA)

what does ABPA mnemonic mean

Answer 714

1. Asthma
2. Bronchiectasis
3. Positive Aspergillus skin test and/or IgE (elevated serum IgE, Eosinophilia)

*ABPA is a hypersensitivity to inhaled aspergillus fumigatus and typically presents in pts with underlying asthma or CF.
–> can have recurrent infiltrates, fever, cough productive of brown sputum, and hemoptysis

tx: oral corticosteroids for several months + itraconazole

Question 715

Hereditary hemochromatosis causes abnormal iron deposition and commonly presents with (BLANK), (BLANK), (BLANK)

• classic triad of cirrhosis, DM, and skin pigmentation is rare

Answer 715

1. fatigue, arthropathy, and hypogonadism (can cause ED, loss of libido)
2. dx can be confirmed by genetic analysis of HFE mutations

Question 716

Failure modes and effects analysis (FMEA) - is a prospective, systematic analysis that seeks to identify and reduce potential errors in a process

what are the steps in analysis

Answer 716

Form multidisciplinary team
Define process to be studied
Construct flowchart of process
Analyze error risks at each step
Identify potential corrective actions
Implement plan

Question 717

• proximal leg weakness (legs>arms)
• decreased or absent reflexes
• improvement in strength and reflexes following isometric contraction
• autonomic dysfunction (e.g. dry mouth)

What is this?
what is associated neoplasm?
what testing should be done?

Answer 717

1. Lambert-eaton syndrome
2. small cell lung cancer
3. CT of the chest to evaluate for lung mass

Question 718

Individuals age >50 with malaise, fever, proximal muscle pain and weakness
-elevated ESR
- Tx with low dose prednisone improves sx

what is this?

Answer 718

Polymyalgia rheumatica

Question 719

• several months of anal pain and bleeding with evidence of an anal ulcer and painless LAD (firm, nontender)
• develops from squamous epithelial cells due to HPV infection
• Greatest in men who have receptive anal intercourse and those with advanced HIV
• sx: rectal bleeding, anal pain, and/or sensation of anal pressure

what is this?

Answer 719

Anal cancer
- dx requires bx of the lesion
- may be falsely attributed to hemorrhoids if the tumor is located above the anal sphincter, hiding it from view

Question 720

What is each of these?

1. pain with BM, small amount of rectal bleeding. Lesions typically heal in <6 weeks
2. Large, painful genital ulcers with gray-yellow exudate and severe LAD that may suppurate.
3. Arise after anorectal abscess and manifest with chronic purulent perianal drainage and intermittent rectal pain.
4. Usually asymptomatic but may cause tenesmus, anorectal pain, and mucopurulent discharge
5. anogenital ulcer (primary), lymphadenitis (secondary), and fibrosis/strictures of the anogenital tract (tertiary).

Answer 720

1. Anal fissures
2. chancroid (H. ducreyi)
3. Anal fistulas
4. Gonococcal proctitis
5. Lymphogranuloma venereum (caused by chlamydia trachomatis)

Question 721

Mastoiditis
1. infection of mastoid air cells. Complication of acute otitis media most commonly due to (BLANK) pathogen

2. fever and otalgia, inflammation of mastoid, protrusion of auricle
3. management?

Answer 721

1. Strep pneumo
3. IV antibiotics, drainage of purulent material.
   —Imaging is not required for dx but is indicated if meningitis, FND are suspected, if no response to tx. Imaging is CT scan of temporal bones or MRI w/contrast

Question 722

Livedo Reticularis (LR) is a transient latticelike rash caused by impaired blood flow in the superficial venules

• often a benign finding but can be a sign of vasculitic or vasooclusive disorder.
• Most common dermal manifestation of (BLANK)

Answer 722

anitphospholipid syndrome (associated w/ prolonged PTT but NOT PT

Question 723

(BLANK) Cancer clinical manifestations

1. asymptomatic
2. postcoital bleeding
3. intermenstrual bleeding
4. increased vaginal discharge
5. pelvic/low back pain

This is an (BLANK) defining illness

Answer 723

Cervical cancer
(lower uterine segment mass can cause obstruction on ureters, blood vessels, lymphatics )

dx: cervical bx on colposcopy

AIDS defining illness

Question 724

Treatment of hypocalcemia due to inadvertently removed parathyroid glands during thyroid surgery require treatment with supplements (oral calcium and calcitriol/active form of Vit D)

A calcium phosphorus product >55 increases risk of (BLANK)

Answer 724

Soft tissue calcification in the basal ganglia - which can lead to extrapyramidal manifestations (e.g. movement disorders)

calcium phosphorus product (calcium level X phosphorus levels = ??)

Question 725

What are favorable prognostic factors in schizophrenia

Answer 725

1. acute onset (lack of prodrome)
2. identifiable precipitant
3. older age at onset
4. Presence of predominantly positive (as opposed to negative) psychotic symptoms
5. No family history
6. short duration of active symptoms
7. female sex

Question 726

1. anthracyclines (e.g. doxorubicin, daunorubicin, epirubicin, idarubicin) are chemo agents that are commonly implicated in (BLANK)

what is it and pathophysiology?

2. Tastuzumab related cardiotoxicity is due to (BLANK) and usually manifests as an asymptomatic decline in left ventricular EF
3. Radiation therapy to the chest for patients for hodgkin lymphoma can lead to (BLANK- cardio)

Answer 726

1. Chemotherapy induced cardiotoxicity
   –> cardiomyocyte replacement by fibrous tissue. Myocyte necrosis and destruction. This is type I
2. Myocardial stunning/hibernation without myocyte destruction. Loss of myocardial contractility/stunning. Type II.
3. thickening and fibrosis of the pericardium

Question 727

Longitudinal, pigmented bands in the nail plate
- involves multiple nails, is stable over years
- lesions are larger, have indistinct borders, change appearance over time, extend into the nail folds

what is this?

Answer 727

Nail melanomas that first were longitudinal melanonchia

Question 728

Borderline personality disorder tx?

Answer 728

Dialectical behavior therapy - psychotherapy

Question 729

1. Granulomatous reaction to a blocked meibomian tear gland.
   –occur more often in upper lid
   - Usually painless, eyelid swelling and erythema, rubbery, nodular lesion
   - resolve spontaneously but larger lesions can benefit from warm compresses
2. Acute inflammatory nodule arising from an eyelash follicle (external/stye) or from a meibomian gland under eye lid (internal). Typically d/t infection with staph aureus.
   - painful
   - develops closer to the lid margin

what is each?

Answer 729

1. Chalazion
   - Occur more commonly in patients with rosacea or eyelid margin blepharitis.
2. Hordeolum

Question 730

Benign but locally aggressive tumor in long bone epiphysis
- imaging reveals soap bubble appearance

what is this?

Answer 730

Osteoclastoma (giant cell tumor of bone)

Question 731

Postop dark red, sanguineous drainage and increasing incisional pain are consistent with (BLANK)

Risk factors are obesity and hypocoagulability

Answer 731

1. incisional hematoma - collection of blood at incision site often due to inadequate surgical hemostasis

–> tx by opening incision, evacuating clot, obtaining hemostasis, and reclosing incision

Question 732

Maternal hyperglycemia in first semester increases risk of baby having (4)

Maternal hyperglycemia in 2nd and 3rd semester increases risk of baby having (2)

Answer 732

1. congenital heart disease
2. neural tube defects
3. small left colon syndrome
4. spontaneous abortion
5. fetal hyperglycemia
6. Hyperinsulinemia

Question 733

Maternal hyperglycemia in 2nd and 3rd semester increases risk of baby having fetal hyperglycemia and hyperinsulinemia

– what can this lead to at birth? 5 scenarios

Answer 733

1. Increased metabolic demand causes hypoxia so baby can develop polycythemia
2. organomegaly
3. neonatal hypoglycemia
4. macrosomia can lead to shoulder dystocia (brachial plexopathy, clavicle fracture, perinatal asphyxia)
5. increased glycogen synthesis, glycogen deposition in interventricular septum can lead to hypertrophic cardiomyopathy

Question 734

What does DRESS syndrome stand for?

*has long latency (2-8 weeks)

Answer 734

1. drug - most commonly allopurinol and antiepileptics (e.g. phenytoin, carbamazepine)
2. reaction (rash) - morbiliform eruption that starts on the face or upper trunk and becomes diffuse and confluent, facial edema
3. eosinophilia
4. systemic symptoms: fever, malaise, diffuse LAD

*tx is stopping drug

Question 735

What is translocational hyponatremia?

Answer 735

Severe hyperglycemia and a hyperosmolar hyperglycemic state. Excess of osmotically active substance (e.g. glucose) in the bloodstream draws intracellular water out and dilutes extracellular fluid.

• serum osmolality is elevated bc of elevated serum glucose

Question 736

(BLANK) of the oral cavity often manifests as nonhealing ulcer with indurated edges.
Tobacco is an important risk factor.
Bx is required for diagnosis

Answer 736

Squamous cell carcinoma

• Leukoplakia or erythroplakia are precancerous plaques that progress to ulceration and deeper tissue invasion

Question 737

pediatric patient who has fever, refusal to bear weight, leukocytosis, and elevated ESR is consistent with (BLANK)

• most common organisms are staph aureus and GAS
• Can follow URI or skin infection where there may be intermittent bacteremia allowing for (BLANK)

Answer 737

1. septic arthritis
2. hematogenous spread of bacteria into joint space

• will want to maintain hip externally rotated.

dx and tx: blood cultures, arthrocentesis (purulent synovial fluid >50,000 leukocytes), prompt surgical drainage, IV antibiotics

Question 738

• watery and nocturnal diarrhea
• fecal urgency and incontinence
• risk factors: >50 years old, female, smoking, possibly NSAID use
• colonoscopy shows inflammatory infiltrates with a monocytic predominance

Answer 738

1. Microscopic colitis

stool studies should be done to exclude other common causes of diarrhea

Question 739

Macrocytic anemia with hyposegmented neutrophils
- likely cause? + explain lab findings?

Answer 739

1. Myelodysplastic syndrome - clonal neoplasm of hematopoietic progenitor cell that results in cytopenias and blood cell line dysplasias

–CBC shows normocytic or macrocytic anemia w/insufficient reticulocytes
- Leukopenia with immature neutrophil cells
- thrombocytopenia

Question 740

• D/t contaminated water in hospital, travel
• fever, relative bradycardia, GI (diarrhea, vomiting, cramps), pulmonary
• Hyponatremia
• Chest x ray - lobar infiltrate, multiple lobe and segment involvement

what is this?
dx?
tx?

Answer 740

1. legionella pneumonia
2. sputum gram stain: PMNs, few/no organisms
   – urine legionella antigen
3. respiratory fluoroquinolone or newer macrolide

Question 741

Isoretinoin
- tx severe inflammatory acne (e.g. nodular)
- decreases sebum production, inhibits cutibacterium acnes proliferation and inflammation, normalizes follicular epithelial proliferation and desquamation

Lab monitoring includes (3)

Answer 741

1. pregnancy test (2 negative pregnancy tests are required before starting + monthly pregnancy testing during tx)
2. liver function test
3. lipid panel

adverse effects are
1. teratogen
2. pseudomotor cerebri
3. hypertriglycerides
4. dry skin or mucous membranes
5. acne fulminans (initial worsening of acne)
6. elevated LFTs

Question 742

• elevated IgM
• hyperviscosity syndrome, neuropathy, bleeding, hepatosplenomegaly, LAD
• peripheral smear shows rouleaux
• bone marrow biopsy shows >10 % clonal B cells

what is this?
pathogenesis?
dx?
tx?

Answer 742

1. waldenstrom macroglobulinemia
2. rare B cell malignancy characterized by excessive production of IgM.
3. dx with serum protein electrophoresis (M-spike) and bone marrow biopsy
4. tx: plasma exchange

Question 743

What antibodies are increased in multiple myeloma?

Answer 743

1. IgG, IgA, light chains
   - also has rouleaux formation and >10% clonal plasma cells

Question 744

How does PE cause syncope?

Answer 744

Massive PE can lead to a sudden occlusion of >50% of the pulmonary arterial circulation, causing a rapid increase in pulmonary vascular resistance and right ventricular (RV) pressure load. This can result in acute RV dysfunction and sudden loss of cardiac output.

—Depending on the degree of compensation for these cardiovascular changes, patients can present with sudden cardiac death, syncope, or presyncope.
—Acute PE can also cause syncope due to cardiac arrhythmia induced by RV strain and ischemia, or due to a vasovagal response to PE.

Question 745

Acute cerebelar ataxia

Answer 745

1. acute post infectious cerebellar ataxia which often follows viral illness
   -1-3 weeks after infection and generally resolves spontaneously
   - ataxia, symmetric involvement of the extremities, staggering gait, intention tremor, and nystagmus.
   - Sensation and deep tendon reflexes are preserved

Question 746

What is first line treatment for condylomata accuminata (anogenital warts) during pregnancy?

Answer 746

1. trichloroacetic acid
   -warts tend to increase in size and number during pregnancy due to physiologic, pregnancy associated immunosuppresion

• Other first line tx include imiquimoid, pdophyllotoxin but this IS NOT FOR PREGNANT PTS bc of teratogenicity
  —> excisional bx is typically avoided due to increased anesthetic and surgical risks in pregnant pts but can be done in nonpregnant

**c section does not reduce risk of vertical transmission of HPV so it is only done if there is large condylomata blocking introitus

Question 747

inpatient pneumonia is treated with (2 drugs together)
outpatient pneumonia treatment? (2 options)

Answer 747

azithromycin and ceftriaxone
amoxicillin or doxycylcine