Step 2 Deck 2 Flashcards
1
Q
37 yo patient with weakness, dizziness and recent syncopal epsiodes. Has had vague chest discomfort the last week. He has thready pulses over both radial artieries that diappear with deep insipration. Likely dx?
A
Cardiac tamponade resulting from a viral pericarditis
pulsus paradoxus is what is the physical exam finding described
2
Q
Typical CSF findings for HSV encephalitis?
A
Elevated RBC and protein count, normal glucose.
3
Q
What does HSV encephalitis look like in a patient?
A
headache, seizures, confusion, stupor occurring over a few days.
4
Q
Explain lung spirometry findings in patients with restrictive lung disease vs COPD.
FEV1
FVC
FEV1/FVC
A
Restrictive:
FEV1: decrease
FVC: decrease
FEV1/FVC: normal
COPD:
FEV1: decreased
FVC: normal
FEV1/FVC: decreased
5
Q
Treatment for candida vaginalis?
A
Oral fluconazole
could also maybe use topical nystatin
6
Q
What does riboflavin (b2 deficiency look like?
A
- angular cheilitis
- glossitis
- stomatitis
- normocytic anemia
- seborrheic dermaitits
7
Q
What does b3 (niacin) deficiency look like?
A
Dermatitis
Diarrhea
Dementia
aka PELLAGRA
8
Q
51 yo man with renal failure. Has had nocturia and flank pain for the last several years. NO recent weight loss. BP is 164/100. Has hepatomegaly. Enlarged mass also felt on R flank deep palpation.
Dx?
A
ADPKD
Pts have HTN and palpable kidneys on exam. Liver may be enlarged due to cystic involvment. R kidney is lwoer, which makes it easier to palpate in general.
9
Q
You suspect aortic dissection in a patient. Explain your rationale for choosing TEE vs CT angio?
A
TEE: This is the preferred choice for a aptient with renal insufficiency or hemodynamic instability
CT angio: Preferred study in hemodynaically stable patients with good kidney fxn
10
Q
Let’s talk about after MI complications:
Hypotension, clear lung fields, and Kussmaul’s sign.
A
RV failure
11
Q
Patient has acute pulmonary edema and a new systolic murmur 4 days after MI.
A
Severe mitral regurgitation with flail leaflet from papillary muscle rupture
12
Q
5 days after MI patient has shock and return of chest pain. Patient also has holosystolic murmur and both R and L heart failure.
A
Interventricular septum rupture
13
Q
One week after MI patient has severe shock and chest pain. He then becomes unresponsive with PEA.
A
Free wall rupture
You don’t see any HF in this one
14
Q
How can you tell by exam if a person has hypercortisolism due to ACTH secretion or just cortisol?
A
If they have hyperpigmentation you know it must be ACTH overproduction. (The whole POM-C cleavage thing)
ALso keep in mind that ACTH is a polypeptide hormone, whereas cortisol is a steroid
Small cell lung cancer is a common cause of paraneoplastic ACTH production
15
Q
Man with sx of TIA in the etting of atrial fibrillation. What meds does he need to get on now?
A
Warfarin or a NOAC
Dabigatran, rivaroxaban, apixiban, edoxaban
16
Q
How could you tell between an empyema and a tuberculosis pleural effusion?
A
They are both going to be exudative and have a lot of protein, BUT the neutrophil count will be WAY higher in an empyema and they should have a lot more serious systemic sx.
17
Q
59 yo with small cell lung carcinoma. Complains of headaches that are diffuse and worse when leaning forward. He has facial and upper extremity swelling and has NO peripheral edema.
dx?
What should be done to relieve his symptoms?
A
Radiation therapy (palliative)
This is is superior vena cava sundrome. Cuased by tumor compresssion on the SVC
18
Q
MEthods to reduce the risk of aspiration pneumonia?
name 2
A
Diet modification
Elevation of head of bed to 30-45 degrees
19
Q
Most common intracranial tumors in adults?
A
Metastasis from other areas
melanoma, lung, breast, renal are most common
20
Q
Symmetric proximal muscle weakness. Painless with elevated creatitine kinase. NO skin findings are present.
Dx?
A
Polymyositis
Skin findings would make this dermatomyositis
21
Q
What is a good rule of thumb for picking out ALS in a patient?
A
The presence of UMN signs like hyperreflexia and babinski reflex
AND
LMN signs like fasciculations and atrophy
22
Q
What is Todd’s paralysis?
A
Common transient occurrence after a complex partial seizure. Could be leg-dragging or something like that
23
Q
26 yo African AMerican woman with left sided pleuritic chest pain and dyspnea for 7 days. ALso has 3 months of BLT knee pain and swelling without erythema. HEart sounds are muffled. ABdomen is nontender. No peripheral edema. HGB 9.6, PLT 90, WBC 3.8, Cr 1.9. CXR shows left-sided pleural effusion and enlarged cardiac silhoette.
Dx?
A
Lupus
24
Q
Stable patient found to have ventricular tachycardia on ECG.
Tx?
A
Load with amiodarone!
25
2 steps:
What do calcifications of the pancreas seen on CT probably mean?
Cause?
Means chronic pancreatitis
Most common cause is alcoholism
(gallstone and alcohol are the 2 biggest reasons for ACUTE pancreatitis)
26
On the test you see the wordsL shiny, hairless, this skin. What do you think?
PERIPHERAL VASCULAR DISEASE
| also non-healing ulcers
27
46 yo woman with HTN. Has been steadily rising despite diet and exercise modification. 2 weeks after starting chlorthalidone, she presents to the ED with repeated falls adn leg cramps. She has no sensoary loss but has 4/5 muscle strngth BLT in LE. What is going on? How should she be managed after stabilization?
Weakness and leg cramps after thiazide diuretic suggest HYPOKALEMIA. In the setting of persistent HTN, this probably means hyperaldosteronism.
These patient need an adrenal gland CT. IF it's an adenoma, they need an eadreanlectomy. If its adrenal hyperplasia, then give Spironolactone (aldosterone antagonist)
28
70 yo man lethargic and barely responsive. PMH of COPD, HTN and PUD. He has had right shoudler pain for 3 wks according to wife. Ca foudn to be 14.1.
Dx?
Hypercalcemia liekly for underlying lung malignancy
29
Mechanism for hypercalcemia of malignancy?
PTHrP secretion
(parathyroid-hormon-related-protein)
This causes hypophosphatemia and hypercalcemia.
Ca of this magnitude does not occur in hyperparathyroidism
30
Recommended prophylaxis to avoid gallstone problems in patients with gastric bypass surgery?
Either cholcystectomy at surgery
OR
prophylactic ursodeoxycholic acid
31
50 yo male. Hematuria with proteinuria. had sore throat this last week. Where in the kidney is the problem?
Glomerulus
SOunds like either IgA nephropathy or post-strep glomerulonephritis
32
Treatment for overflow incontinence?
| Techniques and pharm!
- Suprapublic pressure, timed voids, double-voiding
- Cholinergic agonists (bethanechol)
- May later require self-cath
33
ALcoholic recently admitted for serious esophageal varice bleeding is recovering well. His ascites is well-controlled with spironolactone and alcohol abstinence. In order to avoid bleeding again in the future what is the next step?
Start on beta-blockers (these will reduce reisk of variceal bleed)
TIPS can later be used as a very last resort after trying nitrates, and banding too.
34
Myocarditis should be suspected in young patients with a recent viral illness who present with heart failure, chest pain, or arrhythmias. What can develop after myocarditis?
Dilated cardiomyopathy
35
Painless jaundice is considered pancreatic cancer until proven otherwise. What's likely going on with painless jaundice and elevated bilirubin/alk phos?
Cholestatic cause of jaundice, like pancreatic mass blocking the common bile duct
36
What are the typical findings in a severe toxic ingestion of iron pills?
N/V, diarrhea. If severe both vomit and diarrhea will be bloody. Can also lead to hypovolemic shock.
Later findings include metabolic acidosis, hepatotox, bowel obstruction, or death
37
What infectious etiology should be considered in patient with back pain, intermittent fevers, normocytic anemia, and XR evidence of pulmonary and spinal disease?
Disseminated tuberculosis
38
Lab tests to always consider in a patient with new-onset a fib and weight loss?
T4 and TSH
39
Knee twisting injury often causes what pathology?
What is classic of the exam?
Meniscal Tear
- Classic sx: Locking or catching of knee joint, impaired extension, exacerbation while squatting, painful click while felxing or extending
- Thessaly or McMurray Tests
40
What is the most important characteristic for prognosis in evaluating an astrocytoma (or glioblastoma)?
Tumor grade (determined by degree of anaplasia)
Age and functional status at diagnosis are also important factors
41
Often pts with CLL are asymptomatic at dx. Median survival is 10 years. Treatment is not necessary until advanced symptoms occur. What is first line treatment when they do occur?
Monocloncal antibodies against CD20 anitgen
Called: Rituximab
42
MOst common cause of bacteremia/sepsis in sickl cell patient?
Strep pneumo!
Get that vaccine!
43
What kind of antibiotic prophylaxis should patients with mitral valve prolapse get before dental procedures?
none - not necessary, risk still low
44
diastolic rumbling murmur with opening snap?
| tx?
- mitral stenosis
| - balloon valvuloplasty
45
3 possible etiologies of aortic insufficiency?
endocarditis
aortic dissection
infarction
46
diastolic rumbling murmmur heard at right sternal border?
Aortic insufficiency
47
Systolic crescendo-decrescendo murmur heard at right sternal border?
Pathogenesis?
Tx?
- Aortic Stenosis
- Atherosclerosis
- Valve replacement
48
holosystolic murmur heard best at apex
Mitral insufficiency
49
Let's say you hear a systolic crescendo-descrescendo murmur at the right sternal border, but the aptient is not an old man with atherosclerosis, he is an 18 year old guy. What exam should you do?
Have them to a leg lift orsquat and see if the murmur improves. If it does then this is actually hypertrophic cardiomyopathy!
50
What if on examination of a 25 year old woman you hear mitral regurgitation. Then you have her squat and you listen again and the murmur improves?
Mitral valve prolapse!
51
Patient with severe agitiation is given t doses of haloperidol to calm him down. The next morning he complains of muscle stiffness and difficulty turning his neck. What is the best treatment for his complaints?
So this is acute dystonia from the antipsychotic.
Treat with an anticholinergic like diphenhydramine
52
How do you calculate the anion gap?
Anion gap = Na - HCO3 - Cl
53
Likely underlying cause in amenorrhea of elite female athlete?
Secondary amenorrhea from lack of estrogen
| they have decreased gnrh and LH too
54
Hemolytic uremic syndrome results in which kind of anemia?
microangiopathic hemolytic anemia!
55
Classic presentation of HUS?
Child who recently recovered from diarrheal illness. Presents with acute renal failure, microangiopathic hemolytic anemia, thrombocytopenia, and schistocytes on peripheral smear.
56
What are the CHA2DS2 VASc criteria?
- CHF (1)
- HTN (1)
- Age >75 (2)
- DM (1)
- Stroke (2)
- Vascular dis (1)
- Age 65-74 (1)
- Sex female (1)
2+? Warfarin!
57
Patient has been in afib with RVR for the last couple weeks most likely. He is hemodynamically stable. Initial management?
Rate control first with beta-blcokers or Ca channel blockers
Diltiazem, Digoxin
Hemo unstable -> cardioversion
58
TCA overdose can present with CNS cardiac and anticholinergic findings. If a patient overdoses on notriptyline and his ECG shows wide QRS complexes, what is the best step to manage this?
Sodium bicarb
This is used to treat cardiac toxicity characterized by prolonged QRS as well as ventricular arrhythmias
59
30 yo woman with dizziness and unsteadiness for 2 weeks. Sob but no chest pain. Has chronic cough and had an episode of uveitis 6 months ago that was treated. ECG shows sinus rhythm with 2:1 atrioventricular block and left bundle branch block. CXR shows BLT midfield lung opacities.
Dx?
Sarcoidosis
Pt with recent uveitis, dyspnea, and presyncope liekly due to conduction abnormalities. Sarcoid w/ cardiac involvement. Can cause conduction defects, restricted and dilated cardiomyopathy.
60
Initial treatment for myasthenia gravis?
Pyridostigmine!!!!!!!
Acetylcholinesterase inhibitor
61
AWesome medication you should always remember will slow the progression of diabetic nephropathy!?!?!?!?!
ACE inhibitors
62
You can remember Duschenne and Becker muscular dystrophy as X-linked recessive disorders involving deletion of dystrophin on chromosome Xp21. What is the genetic component of myotonic muscular dystrophy?
Autosomal dominant expansion of CTG repeats on chromosome 19.
63
How does myotonic muscular dystrophy present?
Progressive muscle weakness, facial weakness, hand grip myotonia, and dysphagia.
ALSO: Arrhythmias, cataracts, balding, and testicular atrophy
64
There is a difference in risk factors that cause assymetric vs symmetric fetal growth restriction. What are the most common for both?
Symmetric FGR:
- maternal intrauterine infection
- Infant genetic disorder
- fetal anomaly
Asymmetric FGR:
- Diabetes
- HTN
- Smoking
- Antiphospholipid antibody syndrome
- Autoimmune (SLE)
- Cyanotic cardiac disease
65
Etiology of variable decelerations. Name 3.
- cord compression
- oligohydramnions
- cord prolapse
66
Patient in labor, fetal tracing shows variable decelerations which become persistent. What is the first line management?
2nd line?
- Start with left lateral positioning
| - if this fails, may need amniotransfusion
67
hcg responsible for what function in pregnancy?
preservation of corpus luteum
68
78 year old diabetic with wornseing ear pain and drainage. Pain is unrelenting, hear loss present. External audiotry canal is edematous with purulent discharge and granulation tissue. TM is clear.
Best tx?
Malignant External Otitis
Treatment is with Ciprofloxacin!
(Because you NEED something good for pseudomonas)
69
```
Hard question:
Tell me about what b cells and Ig's look like in each syndrome:
- CD40 ligand defic (Hyper IgM)
- Common variable immunodef
- Job syndrome
- Selective IgA def
- X linked agammaglob
```
- CD40 ligand def: Tons of IgM
- Common Variable: Normal B cells and ALL Ig's low
- Job syndrome: lots of IgE
- Selective IgA: Low IgA
- X linked Agamma: b cells and all Ig's low
70
Big cause of mortality in infant meningococcemia?
Adrenal Failure
| Waterhouse Friderichsen Syndrome
71
How to confirm dx of laryngomalacia?
Direct laryngoscopy
72
25 yr old with 2 past spontaneous miscarriages tests positive for VDRL. She also has WBC 7, PLT 88. NExt step in management?
This patient possibly has antiphosholipid antibody syndrome (often has false + VDRL).
Start her on LMWH to avoid arterial/venous thromboses than can cause spontaneous abortions
73
How can the Hep B vaccine decrease the incidence of cancer?
Decreases chance of hepatocellular carcinoma
74
What type of antibodies are present in hashimoto's thyroiditis?
Anti-TPO antibodies
| Anti-thyroid peroxidase antibodies
75
Which systolic murmur presents with a delayed and diminished carotid pulse?
aortic stenosis
76
Methotrexate is an antimetbolite drug. What are some its common side ffects?
- GI sx
- Oral ulcers or stomatitis
- rash
- alopecia
- hepatotix
- pulm tox
bone marrow suppression
Remember to give folate!
77
Murmur associated with "water hammer" pulses?
Aortic regurgitation
78
Patient with carcinoid syndrome is likely tp experience whcih vitamine deficiency?
WHY?
Niacin deficiency
It's because tons of serotonin is being converted from tryptophan in carcinoid cells.
Tryptophan is ALSO use to produce Niacin
79
The D-xylose test is used for what?
D-xylose is absorbed in the small intestine without enzyme degradation.
Patients who absorb it normally have intenstinal mucosal disease like Celiac. Patient who absorb it fine must have an enzyme deficiency malabsorption (like chronic pancreatitis)
80
Patient has combination of ataxia, scoliosis, and cardiomyopathy. What should you think of?
Friedrich ataxia!
The most common of the spinocerebellar ataxias
81
Midshaft humerus fracture fear of damaging what structure?
Radial nerve
82
best tx for C-diff?
metronidazole
83
Most common cause of septic arthritis?
| When do you see the two lesser common causes?
Staph Aureus
IV drug use/immunosuppressed: Pseudomonas or E.Coli
Sexually active young adult: Neisseria Gonorrhea
84
What kind of anemia is seen in patients with DIC?
Microangiopathic hemolytic anemia
85
How often are screening mammographies recommended?
In women over 50 - every two years
86
How often should lipid profiles be screened in adults?
Every 5 yrs
87
Cisplatin toxicity?
```
Nephrotox
Tinnitus
Hearing loss
N/V
Neurotox
```
88
64 yo patient on immunosuppressive medications for recent kidney transplant presents with headache, nausea, fever and neck rigidity. He is started on high dose ceftriaxone along ampicillin. What are each of these abx treating?
Strep Pneumo, Neisseria Meningitis, and Hemophilus Influenzae are the 3 most common and are covered by Ceftriaxone.
Over 60 and immunocompromised give patient special risk for Listeria Monocytogenes, which is covered by Ampicilln
89
3 yo boy presents with 2 days of fever cough and worsening SOB. He recently recovered from diarrheal infection due to Giardia. Hx significant for recnt lobar pneumonia and recurrent ear infections since 6 months old. Physical exam shows small tonsils and crackles in the RLL. Most likely cause of symptoms?
X-linked gammaglobinemia (or Bruton Agammaglobulinemia)
Caused by abnomral B-lymphocyte maturation
Treatment is monthly IVIG and prophylactic abx
90
How do you treat symptomatic sarcoidosis?
Glucocorticoids
91
After bladder training and pelvic floor exercises, what is a first line medication for urge incontinence?
Oxybutinin
92
Diet recommendation for renal calculi prevention?
- increased fluids
- decreased sodium
- normal calcium intake
93
How does the knee-chest position help patient with tetralogy of fallot during a tet spell?
Increases systemic vascular resistance
This increases pulmonary blood flow and improves cyanosis
94
Explain in detail why lactulose is used in hepatic encephalopathy
HE is a complication of cirrhosis due to liver's inability to convert ammonia to urea. Ammonia and other toxins stimulate GABA and inhibit glutamate pathways in the brain. Often precipitated by medications, hypovolemia, infection, or excessive nitrogen load. Nonabsorbable disaccharides like lactulose get metabolized to short chain fatty acids that acidify the colon. This acidification causes the ammonia to convert to ammonium and create catharsis as well.
95
Immediate drug of choice after diagnosing Primary Biliary Cholangitis
ursodeoxycholic acid
96
Characteristic finding lon peripheral blood smear in patient with CLL?
Smudge cells
| Smudge cells are mature, but fragile lymphocytes
97
Initial testing for venous thromboembolism in a pregnant patient?
Ventilation/Perfusion scan
98
Which HIV drug is knowto cause insomina with vivid/bizarre dreams, deprresion, anxiety, confused thinking, and aggression?
Efavirenz
VIRENZ VIVID
99
You need to know treatment for each type of incontinence.
Stress:
Urge:
Overflow:
Stress: Pelvic floor exercises, pessary, pelvic floor surgery
Urge: Bladder training, Oxybutinin
Overflow: Double-voiding/suprapubic pressure, Bethanechol, catheterization
100
What kind of pathology is the vasculitis of HSP?
Leukocytoclastic vasculitis
101
Patient presents with 3cm swelling in medial aspect of right labium majorus. Has pain in the area when sitting down and attempting sexual intercourse. Dx and Tx?
Bartholin gland cyst
Needs incision and drainage
102
Patient with unknown PMH has howell Jolly bodies on smear as well as thrombocytosis. Likely issue?
Patient likely has lack of spleen or spleen that does not function.
103
first line for tocolysis?
Nifedipine - a caclium channel blocker
104
Patient with genetic hypertriglyceridemia. Palmar xanthomas, etc.
Most appropriate initial tx?
Fibric acid deriv like FENOFIBRATE
105
Most effective way of limiting progression of diabetic nephropathy?
Tight blood pressure control
106
Treatment for Raynaud's phenomenon?
Nifedipine (calcium channel blockers)
107
Give me the run-down for oral combo contraceptives and cancer risk:
Increased risk of:
- Cervical and breast cancer
Decreased risk of:
- ovarian and endometrial cancer
108
60 yo patient with two epsidoes of syncope over a 12 hr period. 1 eating breakfast and 1 watching TV. THey were sudden blackouts lasting 1-2 minutes without confusion afterward. He has had some diarrhea recently. PMH of CAD, paroxysmal A-fib. Takes statin, aspirin, clopidogrel, lisinopril, and solatol. Vitals and chest exam normal.
Most likely explanation?
Sudden onset syncope without prodrome is consistent with arrhythmia. This kind of syncope is actually very rare in A-fib so we would actually assume this is a ventricular arrythmia like torsades de pointes.
His use of solatol, CAD, or hypo-mg or hypo-k from diarrhea could all predispose him to torsades.
109
Patient with recent epsiodes of syncope has prolonged PR and QT intervals without St evlevations. His K is low. Best initial tx?
Magnesium sufate!
Patient in danger of developing torsades. Initial tx of torsades in a stable patient is Mg sulfate, even if Mag level is normal
110
After 60 yo has an MI he is treated with cardiac catheterization and drug-eluting stent. In addition to aspirin, a beta blcoker, statin and ACEi, what should be included in his tx regimen?
What is the mechanism of action?
Clopidogrel (ticagrelor, prasugrel)
P2y12 receptor blocker
These are antiplatelet drugs, improve morbidity/mortality in this context
111
ACute post-partum urinary retention reulting from prolonged labor, perineal trauma, and regional analgesia. What is this condition actually stemming from?
Bladder atony
| temporary and reversible
112
Maternal complications that may extend from a placental abruption?
- DIC
| - Hypovolemic shock
113
Drug tx for Tourette's syndrome?
- Antipsychotics
114
2 yo w/ firm nodular mass in right flank. ALso has abdominal pain, fever, and irritabilty. Abd XR shows mutliple calcifications in the renal area.
Dx?
Serum elevation in what?
Embryonic origin?
- Neuroblastoma
- HVA and MVA will be elevated
- Neural crest cell embryonic origin of tumor
115
How soon should methotrexate be started in progression of rheumatoid arthritis?
Immediately
Joint damage occurs early in the course, so get that MTX going right away!
116
64 yo male presents with 13 hrs of chest pain and found to have anterior STEMI. Medical therapy initiated without other intervention. The next day he reports left leg pain. On exam his leg is mottled and coldwith absence of distal pulses. Vascular surgery is consulted and anticoagulation is initiated. What else should be done right away?
Should do an echo to check for left ventricular thrombus
| this is relatively common in anterior STEMIs
117
34 yo patient for infertility appt. She has had irregular cycles for 12 months and no periods for 3 months. She has hot flashes, dyspareunia,, and mood disturbance. She has 1 3yo daughter. Pelvic exam shows atrophic vaginal mucosa. FSH very elevated, Prolactin is normal, pregnancy test negative, TSH normal.
Best treatment for her infertility?
Premature Ovarian Failure
(decreased estrogen with increased FSH/LH)
The only option available is in vitro fertilization with donor oocytes
118
Most common mucopurulent cervicitis?
Chlamydia trachomatis
tx w/ azithromycin
119
Difference between Stevens Johnson and Toxic Epidermal Necriolysis?
SJS : 30%
| 10-30% = overlap
120
65 yo patient with decreased appetite, nausea, abdominal bloating adn early satiety. Hx of GERD, DM with retinopathy. Home glucose are 40-400. MOst helpful treatement for this patient?
Patient has diabetic gastroparesis!
Metoclopramide or another prokinetic would be very helpful (erythromycin, cisapride, etc)
121
How to treat actinomyces?
| Nocardia?
- Long course of penicillin
| - Trimethoprim-sulfamexazole
122
13 yo patient with hx of rheumatic fever 1 year ago immigrates to the U.S. She has a diastolic murmur on auscultation but is asymptomatic. Does she need any treatment now?
She needs penicillin prophylaxis for many years!
123
How do you test for C-diff?
C-diff TOXIN testing by PCR or immunoassay
124
Patient found to have renal stones - they are 100% uric acid stones. Good therapy for future prevention?
Alkalinize the urine with oral potassium citrate
125
Patient has seizures and he has a creatinine of 2.1. YOu also notice he is on Nitroprusside for hypertensive crisis. What are you thinking?
Cyanide toxicity
presents with altered mental status, lactic acidosis, seizures, and coma
OFten in setting of prolonged nitroprusside infusions with renal insufficiency
126
Criteria for arrest of labor?
2 options:
1 - dilated over 6cm without cervical change over 4 hrs despit contractions
2 - No cervical change for over 6 hrs without good contractions
127
Patient presents in 13th week of gestation with vaginal bleeding and is found to have threatened abortion. Management from here?
Reassurances and outpatient follow-up (US 1 week later)
128
Diabetic patient suffering from severe sinus problems and you dx it as mucormycosis. The question is, what is the causative organism?
Rhizopus
Mucormycosis will lead to death in days to weeks without tx
129
Typical level of obstruction in cystic fibrosis vs hirschsprung disease?
HD: Rectosigmoid
CF: Ileum
Also rememebr that HD has the "squirt sign" yuck!
130
Telangiectasias, recurrent nose bleeds and oral lesions. Also has very high hemoatocrit...
Dx?
Osler-Weber-Rendu syndrome
131
15 yo pt with 1 week non-productive cough, fever, sore throat and headaches. Has target-shaped lesions on all 4 extremities. LLL shows interstitial infiltrates on CXR. Sputum gram stain shows polymorphonuclear cells but no organisms.
dx?
Atypical pneumonia
Most commn is mycoplasma pneumonia
132
Where are hormones being produced in a child with precocious sexual development. They have pubic and axillary hair, acne, and body odor even though they are under 9!
Early activation of adrenal androgen release
So adrenals!
133
2nd trimester quadruple screen.
| How do you diagnose Trisomy 21, trisomy 18, and neural tube/abd defects?
Tri 18: Low MSAFP, low b-hCG, low estriol, normal inhibin A
Tri 21: Low MSAFP, high b-hCG, low estriol, high inhibin A
Neural/Abd: high MSAFP, normal b-hCG/estriol/inhibin A
134
triple bubble sign with gasless colon?
jejunal atresia
135
Treatment for SIADH causing hyponatremia?
| Asymptomatic vs symptomatic
Asymptomatic: fluid restriction and possible satl tabs
Symptomatic: Boluses of hypertonic saline
136
Cocaine-associated chest pain in 32 yo male.
Initial treatment?
Contraindicated medication?
Initial: Benzos!
Contraindicated: beta-blockers
137
Talk to me about SAAG?
SAAG is serum albumin minus peritoneal albumin
if over 1.1 = portal HTN
if under 1.1 = NOT portal HTN
138
What kind of murmur is present in an IV drug user with bacterial endocarditis?
Tricuspid regurgitation
- holosystolic murmur that increases with inspiration
139
What is kleihauer-Betke test used for?
determine dose of Rhogam (anti-D immuen globin) that needs to be given within 72 hrs of delivery
At 28 weeks everyone gets standard 300micro-g
140
What are the recommended vaccines for adults 19-64?
- Tdap once, then Td booster every ten years
- Flu annually
- PPSV23 alone: CHF, lung or liver disease, DM, smokers, alcoholics
- PCV13 nd PPSV23: CSF leaks, cochlear implants, sickle cell, asplenia, immunocompromised, CKD
141
Recommended vaccines over 65 yo?
- Tdap once, Td booster every 10 yrs
- flu annually
- 1 dose PCV13 followed by PPSV23 in 6-12 mos
142
What primary immune deficiency can actually cause anaphylaxis during blood transfusions?
Selective IgA deficiency
143
What is the underlying cause of congenital hypothyroid?
Thyroid dysgenesis
tend to see decreased activity, hoarse cry, and jaundice
144
3 ways to treat grave's disease:
- radioactice iodide, antithyroid drugs (propylthiouracil, methimazole), and thyroidectomy
Which of these 3 causes worsening of Grave's opthalmopathy?
Radioactive iodide
its because the destroyed thyroid cells release excess thyroid hormone
145
After giving birth, mother found to be positive for Hep B. Next step?
ADminister hep B IG followed by Hep B vaccine
146
Patient with less than 3 asthma attacks per week or less than 2 astham awakenings a month can just stay on albuterol rescue. If this number increases, what is the next step in therapy?
Inhaled corticosteroid for control
147
Well-appearing 1 mo old infant with painless bloody stools. ALso has had some vomiting and diffuse eczema on the body.
Cause?
Milk protein-induced enterocolitis
148
Patient with recent suspected flu infection presents with pneumonia. Causitive organism?
Staph Aureus
149
Guy with hx of ulcerative colitis presents with fatigue, elevated aminotrasnferases and alk phos. Positive pANCA. ESR 102.
Dx?
Primary Sclerosing Cholangitis
150
Important side effect to consider in Ca channel blockers like amlodipine?
peripheral edema
151
What electrolyte abnormality is a good predictor of congestive heart failure severity and adverse outcomes?
Hyponatremia!
152
Treatment of Raynaud phenomenon:
Ca channel blockers like amlodipine and nifedipine
153
Progression of acne treatment?
topical retinoids, acids -> topical abx -> oral abx
| -> oral isotretinoin
154
Nerve responsible for sensation of the anterior thigh and medial leg as well as for knee extension and hip flexion
Femoral nerve
155
Nerve responsible for muscles of anterior and lateral leg and sensation to anterolateral leg and dorsum of foot
peroneal nerve (superficial and deep)
| aka Fibular nerve
156
Describe the different situations when you use:
- Ca gluconate
- Mag sulfate
- Na Bicarb
Ca gluc: Cardioprotective in cases of hyperkalemia
Mag sulfate: Patient suffering from prolonged QT induced Torsades
Na bicarb: TCA overdose leading to hypotension, QRS prolongation, and ventricular arrhythmia
157
3 firs-line abx during pregnancy?
- amoxicillin
- nitrofurantoin
- cephalexin
158
7 week old slightly-pale but well appearing infant born premature and being fed formula. Hgb 7.8, WBC 7, PLT 230, retic 0.8%.
Dx?
Anemia of prematurity
159
3 keys to treating HHS?
| hyperosmolar hyperglycemic state
- Aggressive hydration with NS
- IV insulin
- Careful monitoring and supplementation of potassium
160
HIV patient with 4 day history of low grade fever, profuse watery diarrhea, and abdominal cramps. Most importnat next step in management?
Stool exam studies
161
35 yo with 5 day history of low back pain. Positive straight leg sign. Best next step in management?
trial of NSAIDs
162
What kind of infectin causes endometritis?
| How do you treat it?
Polymicrobial
Clindamycin and Gentamicin
163
Recipient of pRBC transfusion experiences febrile NON-hemolytic reaction 2 hours after transfusion. What could have bene done to prevent this?
Leukoreduction of donor blood
164
65 yo pt with rapidly progressive dementia, myoclonus, sharp waves complexes on EEG. Likely dx?
Creutzfeldt-Jakob
165
Common manifestations of bulbar dysfunction?
- chewing fatigue
- dysphagia
- nasopharyngeal regurgitation
- dysphonia
166
What causes myasthenia gravis?
Autoantibodies originating in the thymus are directed against nicotinic acetylcholine receptors at the NMJ.
167
2 common locations for rash of dermatomyositis?
- dorsum of fingers (gottron's sign)
| - upper eyelids (heliotrope)
168
Patient with undetectable plasma renin activity and HTN:
Hyperaldosteronism
| probably from pituitary adenoma or BLT adrenal hyperplasia
169
Treatment for narcolepsy?
Stimulants:
- Modafinil
- Amphetamines
- Sodium Oxybate
170
Most common site of ulnar nerve compression?
elbow
171
Riluzole used to treat what?
ALS
172
Mainstay of symtpom management in COPD?
Ipratropium
| - inhaled anti-muscarinic
173
Most common causes of digital clubbing?
| hint, COPD is NOT one fo them
Lung malignancy, cystic fibrosis, R-L cardiac shunts
174
Best way to treat post-ictal lactic acidosis?
Transient anion gap metabolic acidosis resolves without treatment within 60-90 minutes
175
Most common early vs late side effects of levodopa/carbadopa tx for parkinsons?
Early: hallucinations, dizziness, headache, agitation
Late:
involuntary movements
176
drug of choice for hairy cell leukemia?
Cladribine
177
HIV and CD4 count under 50. Patient also has bloody diarhea...
What should you look for?
CMV colitis - do colonoscpy with biopsies
178
Likely lung amss and hypercalcemia:
squamous cell carcinoma
179
Lung cancer causing SIADH?
Small cell carcinoma
180
Transient vision loss in one eye described as a curtain falling down?
Amourosis Fugax
181
Most common heart sound in an acute MI?
4th heart sound from ventricular stiffening and dysfunction due to ischemia.
182
59 yo male post gastrecetomy 3 weeks ago after a perforated ulcer. For 10 days has had intermitten abdominal cramps and diarrhea always aoccurring 30 minutes after eating. ALso has nausea, weakness, palpitations, light-headedness, and diaphoresis.
Dx?
Tx?
Dx: Dumping syndrome
Tx: Small frequent meals, replace simple sugars with complex carbs, more high-fiber and protein-rich foods
183
RDW over 20% in?
Iron deficiency anemia. One of the first lab signs that is seen
184
Cauda equina syndrome vs conus medullaris syndrome. One really good way to differentiate their clinical presentation?
Cauda equina: assymmetric motor weakness
Conus medullaris: symmetric motor weakness
185
Most common sepsis in sickle cell disease?
strep pneumo
186
What is the immune mechanism in graft vs host?
Donor T-ce;;s recognize host's major/minor HLA antigens and creates a cell-mediated immune response
187
Bone marrow transplatn pt with pneumonia-like picture. CT shows halo sign in upper right lung:
Apergillosis
188
antidepressant contraindicated in eating disorders due to risk of seizures?
bupropion
189
How do patients present with ADPKD?
HTN, hematuria, proteinuria, palpable renal masses, progressive renal insufficiency
190
How to manage patient with persistent narrow-complex tachyarrythmia causing hemodynamic instability?
Immediate synchronized cardioversion
191
Most common area in the spine affected by rheum arthritis?
cervical spine
192
Common complications from acute pancreatitis?
- pleural effusion
- ARDS
- ileus
- renal failure
193
Patient has sx of pericarditis, but also has renal failure.
Your thoughts?
Tx plan?
Probably uremic pericarditis
Tx with dialysis
194
Tx for acute viral or idiopathic pericarditis?
NSAIDs and colchicine
195
Mechanism of 2nd gen. antipscyhotics?
Serotonin 2A and dopamine D2 receptor antagonists
196
Pregnant woman @ 37 weeks gestation found to have chorioamnionitis. Next step after administration of broad spectrum antibiotics?
Oxytocin to induce or accelerate labor.
197
2 similar disorder are Tay Sachs and Niemann Pick disease. What is the deficiency in each?
Tay Sachs: B-hexosaminidase A deficiency
Niemann-Pick: Sphingomyelinase Deficiency
198
Patient from Mississippi who is initially thought to have sarcoidosis due to cough hilar adenopathy, erythema nodosum, and non-caseating granulomas. HOWEVER, he rapidly decompensates after being started on steroids. Dx?
Likely untreated infection -> sounds like Histoplasmosis!
| always think of this in endemic area with pulmonary sx and mediastinal/hilar lymph nodes.
199
Ig spike is found in Multiple Myeloma, MGUS, and Waldenstrom Macroglobulinemia. How can you differentiate them?
Multiple Myeloma is easy because it's never an IgM spike, always IgG or IgA.
MGUS: Smaller IgM spike and no end-organ effects are seen clinically
Waldenstrom:Big IgM spike, and end-organ damage. (can get hyperviscosity, neuropathy, and cryoglobulinemia as a result)
200
Episodic flushing, diarrhea, cutaneous telangiectasias, bronchospasm, and tricuspid regurgitation. Dx?
Carcinoid syndrome
201
What kind of kidney failure is caused by rhabdomyolysis?
Acute tubular necrosis (ATN)
202
Class of medications beneficial for patients with Alzheimer's?
Name 2 drugs in this class:
Cholinesterase inhibitors
| - Donepezil, rivastigmine
203
2 Lab tests for hereditary spherocytosis?
- increased osmotic fragility on acidifed glycerol lysis test
- Abnormal eosin-5 maleimide binding test
204
Woman being treated for parkinsons is experiencing signs of anticholinergic toxcity. 2 drugs in this class that are used for Parkinson's?
Benztropine
Trihexyphenidyl
205
Man with progressive visual loss in R eye. Whn shown straight grid lines, patient perceives them as curved.
Dx?
Macular Degeneration
206
How do statins work?
- Inhibit intracellular HMG-CoA reductase
- prevent conversion of HMG CoA to mevalonic acid
- Increase number of cell membrane LDL receptors
207
How long to wait to play contact sports after dx of mono?
At least 3 weeks
208
Inheritance pattern f hypertrophic cardiomyopathy?
Autosomal dominant
209
Genetic disease that causes tons of cutaneous abcesses?
Test to diagnose?
Chronic granulomatous disease
Test with neutrophil fxn testing: (dihydrorhodamine 123 or nitroblue tetrazolium)
210
First renal change seen in diabetic nephropathy?
Glomerular hyperfiltration
211
Good diagnostic test for lactose intolerance?
- positive hydrogen breath test
- postitive stool test for reducing substances
- low stool pH
- increased stool osmotic gap
212
What arrhythmia is relatively specific for digitalis toxicity?
Atrial tachycardia with AV block
213
Elderly patient with spondylosis has weakness in the upper extremities while strength is normal in the lower extremities.
Dx?
Central cord syndrome
214
How many month/years should a bipolar patient stay on lithium?
Forever
215
What is the most important cause of bleeding in patients with chronic renal failure?
Platelet dysfunction.
| This actually involves platelet-platelet as well as platelet vessel interactions
216
Mammary paget's disease is indicative of whta underlying disorder?
Breast adenocarcinoma
217
Treatment for pseudomonal malignant necrotizing otitis externa?
IV ciprofloxacin
218
Breath and sounds and tactile fremitus in pleural effusions vs lung consolidation?
Pleural effusion: Decreased breath sounds, decreased fremitus
Consolidate: Increased breath sounds and increased tactile fremitus
219
Squamous cell carcinoma is often found in UV exposed areas, but another common presentation is:
Chronically wounded, scarred, or inflamed skin
220
Make the connection between obstructive sleep apnea and decreased Cl-
OSA causes hypercapnia and respiratory acidosis. In response the kidney increases bicarb retention and decreases CL reabsorption in order to create a compensatory metabolic alkalosis
221
60 yo F patient with acute back pain and point tenderness after lifting?
Vertebral compresssion fracture
222
Which diuretic can help prevent urinary calcium stone formation?
thiazide diuretics
223
Masses that are found in the MIDDLE mediastinum?
- Bronchogenic cyst
- tracheal tumors
- pericardial cysts
- lymphoma
- lymph node enlargement
- aortic aneurysms of arch
224
55 yo patient with BLT morning stiffness for 3 months in the neck, shoulders and hips. NO overt synovitis is seen at the joints and passive range of motion is normal.
Likely dx?
Polymyalgia rheumatica
225
Difference between pulmonary contusion and ARDS?
ARDS manifests 24-48 hrs after trauma and is always bilateral.
Contusion is more immediate and s only on the affected side
226
Let's talk about acute eye presentations:
- Retinal detachment:
- Diabetic retinopathy:
- Central veinous occlusion:
- Macular degeneration:
- Vitreous Hemorrhage:
Retinal detachment: See elevated retina with folds or tearing. Vision loss with showers of floaters
Diabetic Retinopathy: Patients asymptomatic
Central retinal vein occlusion: Sudden, painless loss of vision. There is disk swelling, venous dilation, retinal hemorrhages
Macular degeneration: Painless progressive vision blurring. BLT
Vitreous hemorrhage: Sudden loss of vision and floater onset.
227
Best way to evaluate patient with undiagnosed pleural effusion?
(No evidence for CHF)
Thoracentesis
228
Patient in MVA with blunt trauma has an elevated PCWP. AFter IV infusion of NS, the PCWP actually increases.
Dx?
Myocradial contusion
229
How do vagal maneuvers improve PSVT?
| What are these maneuvers?
Maneuvers include carotid massage, valsalva, immersion in cold water.
They increase vagal tone and decrease conduction through the AV node
230
What disorders have pulsus paradoxus?
- asthma
- COPD
- pericardial effusion
231
Cause of aortic stenosis by age group?
under 70 - bicuspid aortic valve
| over 70 - senile calcific
232
Mobitz type 1
vs
mobitz type 2
1 - progressive prolongation until drop QRS
2 - constant PR interval with drops of QRS
233
Patient with ACUTE decompensated heart failure. First things first:
Furosemide
Get that fluid off!
Worry about b-blockers and all that jazz later
234
Arrythmia caused by digitalis?
Atrial tachy with AV block
235
Patients with new-onset A-fib and no signs of ischemia shoudl be checked for what?
Underlying thyroid dysfxn
236
Persistent tachycardia causing hemodynamic instability should be managed how?
Synchronized cardioversion
