Step 2 Internal Med

Question 1

What kind of acid/base d/o does vomiting cause? What is the generation phase and maintenance phase? How do you correct it?

Answer 1

Hypochloremic Hypokalemic Metabolic Acidosis

Generation Phase - lose of gastric fluids (HCl, NaCl, and water) causes loss of acids (HCl) w/o compensatory loss of a base (HCO3-); thus a metabolic imbalance

Maintenance: B/c there’s a concomitant loss ECV, the RAAS system is turned on, via unperfused kidneys, and Aldosterone attempts to maintain intravascular volume w/ Adlosterone at the expense of K+ and H+.

Give IVF and potassium!!!

Question 2

Dx a woman who presents with weight gain, fatigue, constipation, hoarseness, and vision memory changes…
MCC?
Trmt?

Answer 2

Hypothyroidism 2/2 Hashimoto’s; give Levothyroxine

Question 3

A woman would most likely present with this d/o when pregnant w/ the S/S of: orthopnea, Afib, pulm edema, with previous infections and from Eastern Europe. What is this the leading cause of worldwide? S/S?

Answer 3

Dx: Rheumatic Heart Disease - declares itself in preg 2/2 increase in blood volume

Mitral Stenosis - hear diastolic rumble at apex, opening snap

Question 4

Best screening lab to order in NON-African American pt for hemoglobinopathy? VS if pt is AA?

Answer 4

CBC if non-AA; then if abnormal, get hemoglobin electrophoresis.

Whereas if pt is AA, start with hemoglobin electrophoresis

Question 5

Suspect this cardiac dz with a pt having HA’s, recurrent epistaxis, and signs of LV hypertrophy….
Xray Signs…
Defect commonly found at…
Congenital or Acquired or both?

Answer 5

Coarctation of the Aorta: “brachial femoral delay” can be felt on PE with notching of ribs 3-8 2/2 to erosion by intercostal arteries.

Xray would show “3” sign just distal to left subclavian artery by ligamentum arteriosum

Congenital or acquired via Takayasu vasculitis.

Question 6

What would a patients neuro exam look like with suspected MS? Esp. the ocular exam…

Answer 6

Changing neuro defects that couldn’t be explained by a single lesion. Symptx exacerbated by hot weather or exercise is a good clue!!!

Medial Longituidnal Fasiculus involvement is characteristic in MS with complete inter nucleate opthalmoplegia (when pt looks right, R eye abducts with horizontal nystagmus with stationary L eye; when pt looks left, L eye abducts with horizontal nystagmus and R eye is stationary)

Question 7

Explain categorization of Glomerulonephritis.

Types of each respective GN.

Explain how complement helps make a dx

Answer 7

When you see elevated Cr, proteinuria, and hematuria, suspect GN.

Nephrotic GN: proteinuria >3.5g, bland sedimentation, mild hematuria.
Nephrotic GN Types: FSGS, MCD, Membranous Nephropathy, DM, primary amyloidosis, and IgA

Nephritis GN: RBCs/WBCs, casts, mild proteinuria.
Nephritic GN Types: IgA, Lupus Nephritis, Postinfectious GN, MPGN, RPGN, and vasculitis (cryoglobulinemia with Hep C)

Low complement is associated with PostInfectious, Lupus, or Vasculitic…look for recent illness (10-21 days), positive ANA, or elevated liver enzymes/+RF respectively

Question 8

How might cryoglobulinemia associated with Hep C present? What is the pathophys? Trmt?

Answer 8

Skin findings: palpable purpura/Raynauds
Kidney: MPGN
Nervous: motor sensory axonopathy
MSK: arthralgias

IgM against IgG Anti-Hep C Ab’s, hep C virus RNA, and complement cause deposition of the antibody complexes in endothelium, small blood vessels, etc causing inflammation and damage

Tmt: of underlying Hep C, plasmapharesis for cryoglobulins and immunosuppressants (glucocorticoids and cyclophosphamide)

Question 9

How does Crohns Disease or other fat malabsorption d/o’s cause symptomatic hyperoxaluria?

Answer 9

Oxalate is normally bound to calcium in the gut and is therefore not absorbed. With fat malabsorption, the calcium binds with fat leaving oxalate to be absorbed.

Question 10

What should be ordered in all pts with suspected CAP? Why could is be a false negative in a pt?

Answer 10

CXray

Might not show anything with neutropenia, dehydration, or atypical infxn (PJP)

Question 11

A psoas abscess might result from hematogenous infection of skin, bone, or nearby bowel. What sign differentiates it from appendicitis?

Answer 11

Deep palpation and the ABSENCE of rigid abdomen, rebound tenderness or periumbilical pain.

Question 12

Pt who presents with nausea, vomiting, headache, stiff neck, and myalgias is concerning for what type of meningitis?

What additional signs would you expect to see in a patient with meningococcal meningitis with meningococcemia?

Answer 12

Bacterial Meningitis.

Signs of hypotension, tachycardia, myalgia, and petechial/purpuric skin lesions point more towards this specific type.

Question 13

Pt who presents with rhinitis, anosmia post nasal drip, and has a hx of allergy to NSAIDs most likely has what on PE?

Answer 13

Bilateral nasal polyps. This is highly associated with aspirin exacerbated respiratory disease.

Question 14

What do you want to do with a newly diagnosed pt with Lupus?

Answer 14

Get a renal biopsy to determine the extent (Class I - IV); then immunosuppressive meds can be initiated

Question 15

What is the post-exposure prophylaxis for the exposed healthcare workers to active Hep B?

Answer 15

Hep B vaccine series + Hep B Immunoglobulin

Question 16

What do you do first after a pt presents with splinter hemorrhages, AR, and hematuria s/p dentist work?

Answer 16

Get 3 blood cultures from different sites over time for suspected Infective Endocarditis

Question 17

What is the Modified Dukes Criteria for Infective Endocarditis?

Answer 17

Major:

1) Blood Culture + (Step Viridens, Stap Aur, or Enterococcus)
2) Echocardiographic evidence of valvular vegetation

Minor:

1) Fever
2) Predisposing Cardiac Lesion
3) IVDU
4) Emoblisms
5) Immunologic phenomena
6) Other + blood cultures

Definite Diagnosis:
2 major / 1 major + 3 minor

Possible Diagnosis:
1 major + 1 minor / 3 minor

Question 18

Differentiate the different types of optho probs:

1) Diabetic Retinopathy
2) Central Retinal Vein Occlusion
3) Macular Degeneration
4) Open Angle Glaucoma
5) Retinal Detachment

Answer 18

1) Hard exudates, micraneurysms, retinal edema w/ progressive loss of vision - use argon photocoagulation
2) Sudden unilateral loss of vision upon waking; bulging disc, venous dilation and tortuosity, retinal hemorrhages
3) Distorted central vision with scotomas; atrophic vs. exudative - can see drussen deposits; reading and driving likely to go first; age = RF but smoking increases risk too!
4) Progressive unilateral blurriness; hanging retina in vitreous
5) Gradual loss of peripheral vision; pathologic cupping of disc causing tunnel vision

Question 19

A pt with metabolic syndrome and elevated liver enzymes w/ mild to no EtOH hx make you think of?? This d/o is likely 2/2 to (patho)?

What is the histo findings?

Answer 19

Non-alcoholic fatty liver disease. Pts will have diabetes, be obese, hyperlipidemia, hypertension.

Patho: insulin resistance causing increased peripheral lipolysis, increased triglyceride synthesis, and hepatic uptake of FA’s leading to intrahepatic fatty acid oxidation > pro inflammatory cytokines&raquo_space; fibrosis and cirrhosis

Histo: macro vesicular fat deposition and peripheral displacement of the nucleus (looks like AFLD)

Question 20

A UTI with a pt having a urine pH > 7 makes you think of what pathogens? What hint would the question provide most likely?

Answer 20

Pt most likely having an indwelling catheter. A urease producing organism will cause an alkylotic pH; urease producing organisms = Proteus (struvite stones), Klebsiella, Morganella Morganii, Pseudo, Providencia, Staph, and Ureaplasma

Question 21

A false + Prot S Def could be caused by what anticoagulant?

Answer 21

Warfarin b/c it inhibits Vit-K dependent factors 2, 7, 9, 10 and C/S

Question 22

Which joints are affected early in RA? Which part of the axial spine is affected with RA with what possible side effects? What labs correlate with activity?

Answer 22

MTP, MCP, PIP and wrists are affected early with difficulty griping being a sensitive sign of early severe disease.

The cervical spine is the most likely affected area of the axial skeleton with the subsequent risk of subluxation and spinal cord compression.

CRP and ESR

Question 23

What type of medications are preferred for weight gaining in terminal cancer pts?

Answer 23

Progesterone Analogs: megestrol acetate and medroxyprogesterone acetate

Question 24

What pathogen causes a halo or crescent sign on pulmonary nodules in a immunocompromised pt?

Answer 24

Aspergillosis - it’s ubiquitous! Beware of this in patients with chronic high dosed corticosteroids, cytotoxic drug therapy, or neutropenia.

Question 25

Geographic infections cause ____ and found _____ for:

1) Histoplasmosis
2) Blastomycosis
3) Coccidiomycosis

Answer 25

1) Causes hilar adenopathy (disseminated form found in HIV pts) and found in SE and mid atlantic and central U.S.
2) Causes asymptomatic or flu-like illness but involves the skin, lungs, bones, joints, and prostate. Found in central/south and central/north U.S. Does NOT normally infect immunocompromised pts.
3) Causes cutaneous findings: erythema nodosum or erythema multiform with arthralgias. Found in SW U.S. and parts of Central and South America.

Question 26

What factors delineate the three common causes of esophagitis in an HIV patient?

Answer 26

1) Candida - white oral plaques that can be scraped off
2) HSV - visible vesicles, or large oval ulcers
3) CMV - long linear ulcerations in the distal esophagus

Question 27

What are you suspecting in a pt with rapidly progressive dementia, myoclonus, and spiked triphasic synchronous discharges on EEG?

Answer 27

Creutzfeldt-Jakobs disease, caused by prions, a spongiform encephalopathy VS. Pick’s which has a predominance of personality changes VS. Huntington’s which occurs earlier (35-50) and has a progressive choreiform movements in all limbs

Question 28

Gran negative rods causing nosocomial infections…which grows in mucoid colonies and predominates in the upper lung fields?

Answer 28

Pseudo, Proteus, E. Coli, Enterobacter, Klebsiella, Serratia Marc.

Klebsiella!!! Watch for in alcoholics

Question 29

What is a pt at risk for who is currently experiencing PAD?

Answer 29

Myocardial infarctions and stroke!

Question 30

What would you suspect on PE/imaging with a suspected esophageal rupture? What’s the diagnostic test of choice? What can cause this? What else would you do for them?

Answer 30

Hammans Sign - crunching of the mediastinum or air/effusion seen on CXray. Gastrograffin-contrast esophagography. Can occur from iatrogenic causes (surgery), pill esophagitis (watch out for K Chloride meds), or other conditions that cause damage to the esophagus. Give them parenteral nutrition, surgical repair, and immediate antibiotics.

Question 31

What would laboratory studies of Calcium, Phosphorus, and Alk Phos show in a pt with Paget’s Disease? What is the pathophys? What are the symptoms and PE signs?

Answer 31

Normal labs except for elevated Alk Phos! An idiopathic increase in bone resorption via osteoclasts thereby leading to an increase in osteoblastic activity to rebuild broken bone. It occurs to quickly so the “woven bone” yields to fractures and isolated bone pain. Pts are normally asymptomatic but could complain of ‘bone pain’, increased hat sizes, headaches, or hearing difficulties (2/2 to cochlear nerve impingement). Also, frontal bossing could be seen.

Question 32

How can late onset CAH be distinguished from PCOS?

Answer 32

Elevated 17-hydroxyprogesterone. It can be confirmed with a dramatic increase of 17-hydroxyprogesterone in response to an ACTH stimulus test. This is a disease with varying levels of severity so electrolytes could be normal in later in life, less severe presentations.

Question 33

How would you distinguish the three most common mechanical complications occurring in the Day 3- 7 post-MI range?

Answer 33

1) Ventricular Wall Defect - high mortality, likely to cause pericardial tamponade, hypotension, pulses paradoxes, pericardial rub, JVD
2) Ventricular Septal Rupture - holosystolic murmur heard best at the LSB, associated thrill
3) Papillary Muscle Rupture - leading to pansystolic murmur heard best at the apex, radiates to axilla, soft S1, pulmonary edema with SOB

Question 34

What about a pt’s history with Frontotemporal Dementia differentiates them from other disease processes?

Answer 34

Early behavioral/personality changes, early onset (35-50), strong family predominance, and compulsions (hyperorality), primitive reflexes, and only LATE memory probs

Question 35

In light of nephrotic GN, acute onset of fever, hematuria, and flank pain make you think of what? Which type of GN is this associated with most commonly?

Answer 35

Renal vein thrombosis!!! MC to occur in membranous GN although it can occur in any nephrotic type of GN. Occurs 2/2 to loss of ATIII.

Question 36

What differentiates osteomyelitis in regards to S/S? Predisposing RF’s? MCO? Most significant diagnostic study?

Answer 36

Osteomyelitis pain is elicited from light palpation of the vertebral body, does not improve with rest (vs. herniation/inciting event), not improved through the day or associated with progressive limitation of the back (vs. ankylosing spondylitis), no night pain (vs. pain from prostate cancer), and not associated w/ sig. changes in lumbar flexion/extension (vs. spinal stenosis - better/worse). WBC/fever = variable. Elevated platelets and ESR = inflammatory signs.

IVDU, SS, immunosuppression, or distal infections (ex: UTI)

Staph Aureas.

MRI

Question 37

What is the management of a pt presenting with Hepatic Hydrothorax?

Answer 37

This is a pt presenting with, MC, a right-sided pleural effusion in the ABSENCE of any cardiopulmonary etiologies for an effusion. Therapeutic thoracentesis with salt-restricted diet and diuretics = primary trmt. If refractory, can proceed to TIPS procedure. The BEST option for trmt is liver transplant.

Question 38

What are the three types of treatment options for someone with anogenital pappiliform, verucous skin-colored/pink lesions? What is this?

Answer 38

Condyloma Accuminata 2/2 HPV.

1) Chemical Trmt = podophylin, epinephrine gel, 5-FU or trichloroacetic acid
2) Immune Therapy = imiquimod / interferon a
3) Surgery

Question 39

What is suspected in a pt with thrombocytopenia, new onset easy bruising, purpura/petechiae, hx of bacterial infections, and skin findings of eczema? MCO’s w/ infections?

Answer 39

Triad of Thrombocytopenia, Recurrent Bacterial Infxns (Step Pna, H. Flu, Neisseria Men) and Eczema = X-linked Wiskott-Aldrich Syndrome.
“TREX WAS here”

Question 40

What do you worry about with a woman on OCP’s complaining of RUQ pain with palpable mass, or hepatomegaly, or jaundice with elevated GGT/Alk Phos and normal liver enzymes? Causes? Histo? Management?

Answer 40

Hepatic Adenoma’s present the risk of severe intra-adenoma hemorrhaging (which is why they are NEVER biopsied) and malignant transformation. Causes = OCP’s, anabolic androgen use, DM, pregnancy, and glycogen storage disease. Histo = sheets of enlarged adenomas w/ glycogen and lipid and loss of hepatic cell architecture. Follow if asymptomatic. Symptomatic = resection. Always f/u with AFP levels to assess for possible malignant transformation.

Question 41

MCC of hydatid cysts? RF’s? Histopath?

Answer 41

Ecchinococcus Granulosus (cystic echinococcus). SW U.S. and people exposed to sheep and dogs. Looks like encapsulated and calcified cyst with fluid and budding cells.

Question 42

What is seen in S/S of Cushing Syn? What electrolyte abnormality is seen? Why does this happen? MCC?

Answer 42

Fatigue, weight gain, central adiposity, proximal muscle weakness, supraclavicular fullness, easy bruising, hyperglycemia, osteoporosis and osteopenia, hypertension, acne, cataracts, and predisposition to infxns.

Hypokalemia, hypernatremia, and hypervolemia 2/2 to elevated corticosteroids having some effect on aldosterone receptor.

MCC = iatrogenic cortisol injections

Question 43

Clinical associations with common GN's:
FSCS
Membranous
MPGN
MCD
IgA Neph
Crescentic

Answer 43

1) FSGS - blacks, hispanics, obesity, HIV, and heroin
2) Membranous GN - adenocarcinoma, NSAIDs, hep B, SLE
3) MPGN - Hep B/C and lipodystrophy, chronic bacterial infxns
4) MCD - NSAIDS and Lymphoma
5) IgA Neph - concurrent URI
6) Crescentic GN - hematuria, hypertension, autoimmune d/o

Question 44

Wt loss and post-prandial pain that causes abdominal angina is MC 2/2? Diagnostic imaging?

Answer 44

Atherosclerosis of mesenteric arteries. Use angiography or Doppler U/S. Pt may have abdominal bruit.

Question 45

Removal of K FROM THE BODY can be accomplished with what three methods?

Answer 45

Dialysis, Cation exchange resins, or diuretics. Kayexalate (sodium polystyrene sulfonate) is a cation-exchange resin which acts on GI to promote exchange of Na and K.

Question 46

Side Effx’s of Cyclosporine? MoA?

Answer 46

GI disturbances in the form of N/V/D, increased risk of SCC and lymphoproliferative d/o, infection, glucose intolerance, gingival hypertrophy, hirsutism, hypertension 2/2 renal vasoconstriction (use CCB for trmt), and nephrotox (hyperuricemia, hyperkalemia, hypophosphatemia, and hypomagnesemia), and tremor. Hemorrhagic cystitis, bladder carcinoma, sterility and myelosuppression

MoA = inhibits transcription of IL-2 and other T-helper lymphocytes

Question 47

SEffx of Tacrolimus? MoA?

Answer 47

Similar to cyclosporine but more commonly has neurotoxicity with diarrhea and glucose intolerance.
MoA = same as cyclosporine

Question 48

Seffx of Azathioprine? MoA?

Answer 48

Dose related diarrhea, leukopenia, and hepatotoxicity.

MoA = purine analog that’s converted to 6-MP

Question 49

Seffx of Mycophenolate? MoA?

Answer 49

Reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH) - enzymes in purine synthesis and major suppression of bone marrow!!!!

Question 50

Pale patches of skin with hyper pigmented borders around body orifices and in acral locations is most likely?

Answer 50

Vitiligo - 2/2 destruction of melanocytes

Question 51

What are some common causes of metabolic acidosis with an increased Anion Gap? When would you calculate osmolar gap?

Answer 51

MUDPILES:
M- methanol (formic acid accumulates)
U- (ESRD) can't excrete H+ and NH4+
D- Diabetic Ketoacidosis 
P- Phenformin (Metformin)
I- Iron, Isoniazid 
L- lactic acidosis 
E- ethylene glycol (glycolic and oxalic acid accumulation), ethanol 
S- salicylates (w/ resp. alk)

Calculate osmolar gap for suspected ethylene glycol, ethanol, or methanol

Question 52

Gastric cancer staging is very important since most are diagnosed at such a late stage - what’s the next best step in mgmt?

Answer 52

Order a CT to stage the cancer once there’s a histologic dx.

Question 53

New or worsening respiratory sympt. during/within 1 week of known clinical insult with bilateral lung opacities is consistent with what dx? How is it categorized?

Answer 53

ARDS: get objective assessment to r/o primary cardiopulmonary d/o. Severity is based on PF Ratio:
PaO2/FiO2 < 300mmHg with PEEP > 5cm H2O

ARDS can happen 2/2 pancreatitis from transfer of elevated pancreatic enzymes causing alveolar damage

Question 54

What else is associated with PPH besides Sheehan Syn?

Answer 54

Primary Adrenal Insufficiency 2/2 adrenal hemorrhage - the pt would have hypotension

Question 55

What electrolyte abnormality do you need to be wary of w/ a pt on Furosemide? What cardiac problem is associated with this + Digoxin?

Answer 55

Hypokalemia and Hypomagnesemia can lead to ventricular tachycardia. Digoxin + this electrolyte abnormality can exacerbated Vent. Tachy.

Question 56

What classifies the different types of MEN?

Answer 56

MEN I = Pituitary, Parathyroid, and Pancreatic tumors (“PPP”)

Men IIA = Medularry Thyroid Cancer, Pheochromocytoma, Parathyroid hyperplasia (“MPP”)

Men IIB = Marfinoid Habitus/Mucosal Tumors, Medullary Thyroid Cancer, Pheochromocytoma

Question 57

Thickened gastric folds, heartburn, and pain, diarrhea, multiple petic ulcers, and ulcers distal to duodenum and jejunum make you think of?

Answer 57

Gastrinoma - look for MEN syndromes!!!

Question 58

How does Histo present differently in immunocompetent vs. immunocompromised people? What’s the fastest and most sense. test? Trmt?

Answer 58

Mild cold or asymptomatic presentation in immunocompetent people. In immunocompromised people it presents as fever, fatigue, weight loss and involves cytopenias, lymphadenopathy, and hepatosplenomegaly with reticulonodular pulm infiltrates or cavitary lung lesions.

Urine antigen immunoassay!

Itraconazole or Amphotericin B for severe disease.

Question 59

Anti-phospholipid antibody syndrome should be suspected in people with SLE and clotting hx. It causes what type of lab abnormality? How would you confirm it’s presence?

Answer 59

An artificially prolonged PTT 2/2 to the IgG/IgM binding to the lipids in the assay - doesn’t actually increase bleeding. It does NOT correct when mixed with 1:1 plasma. The Russell viper venom test will be prolonged if this is presently happening.

Question 60

How do nitrates work primarily as an anti-ischemic and anti-anginal medication?

Answer 60

They cause systemic ventilation (decreasing the preload), arteriole dilation and coronary dilation. It’s the significant and systemic vasodilation that causes a decrease in the LVEDV and therefore decreased myocardial stress on the heart.

Question 61

What is the main risk factor of using Raloxifene for osteoporosis prevention? What else could it cause? Protective factors? How does it work?

Answer 61

Venous Thromboembolism!!!

Can cause hot flashes and leg cramps.

It decreases risk of Breast Cancer!!

It’s a selective estrogen receptor modulator (SERM) that increases bone mineral density and is used to prevent osteoporosis. It’s an antagonist in the vaginal and breast tissue but an agonist in bone.

Question 62

Describe how the following present and any respective path findings:

1) Giant Cell Tumor of Bone
2) Baker’s Cyst
3) Osgood-Schlatter
4) Osteitis Fibrosa Cystica (von Recklinghausen disease of bone)
5) Osteoarthritis
6) Osteoid Osteoma

Answer 62

1) Benign and locally aggressive bone tumor in young adults. Appears at epiphyseal region of long bones, MC distal femur and proximal tibia. Sheets of large osteoclast cells that are round or elongated mononuclear cells. See cystic and hemorrhagic cysts on MRI. “Soap Bubble” Surgery = trmt
2) Bakers Cyst appear on medial side of popliteal fossa 2/2 gastrocnemius-semimembranosus bursa 2/2 degenerative joint disease and/or injury.
3) Overuse injury accompanied with rapid growth spurt. Xray shows avulsion of the apophysis of the tibial tubercle.
4) 2/2 Hyperparathyroidism from parathyroid cancer. Bone resorption replaced with fibrous tissue (brown tumors). Imaging shows subperiosteal bone resorption on radial aspects of middle phalanges, distal clavicular tapering, salt and pepper appearance of skull, bone cysts and brown tumors on long bones
5) Joint space narrowing, subchondral sclerosis, osteophyte formation, and subchondral cysts.
6) Causes pain that’s worse at night and unaffected by movement, readily decreased pain with NSAID use. Corticol lesion with central nidus of lucency.

Question 63

A young pt presenting with progressive lower back pain and stiffness with decreased lumbar spinal mobility and tenderness over the sacroiliac joints = ??? What is the first initial best test for dx? What category of autoimmune d/o’s does it fall under?

Answer 63

Ankylosing spondylitis! Get an Xray to assess for fusion of sacroiliac joints and/or bamboo spine.
It’s a seronegative spondyloarthropathy so DO NOT ORDER ANA. Don’t get an HLA-B27 either because if +, only 5% have AS vs. 90% of people with already dx’d AS have + HLA-B27

Question 64

What drugs increase/decrease the action of Warfarin?

Answer 64

Increase: Acetominophen, NSAIDS, Omeprazole, Ginko Biloba, Vit E, Thyroid hormone, SSRI, Amiodarone, Antibiotics, Cranberry Juice and Antifungals

Decrease: Rifampin, Carbamazepine, OCP, Ginseng, St. John’s Wort, Green veggies

Question 65

Flushing in the cheeks, nose, forehead and chin with associated telangiectasias and papules/pustules in the setting of hot drinks, emotional states, heat or other rapid body changes is???? Initial Trmt?

Answer 65

Rosacea! Metronidazole

Question 66

Describe the histo of:

1) Herpetic Lesions
2) Apthous Ulcers
3) BCC
4) SCC

Answer 66

1) Giant cells on Tzanck prep
2) Shallow fibrin coated ulcerations with underlying mononuclear infiltrates
3) Invasive clusters of spindle cells surrounded by palisaded basal cells
4) Invasive cords of squamous cells with keratin pearls; look for sun exposure, vermillion border locale = epi clue

Question 67

What markers would be elevated in a nonseminomatous germ cell tumor? What else would you look for? Almost all mediastinal tumors are primary or metastatic?

Answer 67

AFP and B-hCG!

Do a testicular U/S to exclude primary tumor.

Primary mostly.

*Seminomas present with isolated elevation of B-hCG

**Thymoma are associated with myasthenia gravis and pemphigus

Question 68

What value does MRI have over Xray in suspected Osteomyelitis? When would you order a radionuclide scan?

Answer 68

Xray can be negative for 2-3 weeks and MRI can also detect complications like epidural abscess and cord compression. Bone scan for those that cannot undergo an MRI

Question 69

What is associated with the condition with painful subcutaneous pretibiall nodules?

Answer 69

(Erythema Nodosum) associated MC w/ recent strep infxn. Other causes = Histo, TB, Sarcoid, HIV, IBD

Question 70

What are these heart meds generally used for?

1) Atropine
2) Amiodarone
3) Adenosine
4) Epinephrine

Answer 70

1) Decrease vagal tone and increase HR in setting of sinus bradycardia
2) Antiarrhythmic used for supra ventricular and ventricular tacchyarrhythmias to slow SA and AV nodes.
3) Adenosine causes temporary AV block to help identify/terminate supra ventricular tachycardias
4) Use in hemodynamically unstable pts

Question 71

Do superficial thromboses need anticoagulation? Do DVT’s? What do you use?

Answer 71

No. Yes, begin Heparin as they begin to transfer to Warfarin for > 3 months in a pt with an identifiable/reversible cause. Can begin as soon as 2-3 days s/p surgery w/o increase risk of bleeding.

Question 72

Young (15-50) female with transient vision loss in one eye, headaches, carotid bruit, hypertension and family hx of stroke makes you think of??? This d/o causes??? Order???

Answer 72

Fibromuscular displasia causes vessel stenosis, aneurysm, or dissection MC w/ carotids, renal, and vertebral arteries. Get a CT angio or Duplex U/S.

*Aldosterone/Renin ratio < 20 signifies that adrenal patho is unlikely

Question 73

With a high suspicion of testicular tumor, what’s the next step in mgmt?

Answer 73

Kill first, investigate later…high inguinal orchiectomy. Then examine to determine if further surgery, radiation or chemo is appropriate.

*Testicular cancer has one of the highest cure rates of all types of cancers.

Question 74

Lidocaine is used widely to control complex forms of ventricular tachycardia in patients with ACS, but it should not be used prophylactically to prevent VFib b/c of an increased risk of….

Answer 74

asystole

Question 75

____ is the MCC of lower gI bleeding in an elderly pt. RF’s?

Answer 75

Diverticulosis. False diverticula that have chronic constipation from a low-fiber diet as the MCC RF! Diverticula can erode a penetrating piece of the bowel vasculature and cause profuse self-limited bleeding per rectum.

Question 76

Differentiate the presentations of ascending paralysis w/ tick paralysis, GBS, and spinal cord tumors.

Answer 76

Tick-borne paralysis occurs rapidly (hours) and can be asymmetrical, no hx of fever or sensory abnormalities and NORMAL CSF. GBS presents over days to weeks (not hours) and involves autonomic instability, mild sensory loss, with CSF of high protein with few cells (Trmt = immunoglobulins or plasmapharesis). Tumors take a days to weeks to present and sensation is either moderately to grossly abnormal; get an MRI to confirm and IV steroids!

*Botulism presents with descending paralysis

Question 77

Craniopharyngiomas present w/…? Age distribution?

Answer 77

These suprasellar tumors present with signs of hypopituitarism, HA’s and bitemporal blindness. Children and 55 - 65 yrs = bimodal distribution. Kids present with retarded growth MC’ly and adults with sexual dysfxn.

Question 78

Name that hemorrhage!

1) MC site of hypertensive hemorrhage is ______. The Internal capsule is adjacent thereby leading to hemiparesis, hemi-sensory loss, homonymous hemianopsia, stupor and coma. Eyes deviate away from lesion.
2) Present with ataxia, vomiting, occipital HA, gaze palsy, and facial weakness. NO hemiparesis.
3) P/w deep coma and paraplegia, pinpoint pupils reactive to light - rigid.
4) Hemiparesis, upgaze palsy, nonreactive pupils, eyes deviate towards the lesion

Answer 78

1) Putamen Hemorrhage
2) Cerebellar Hemorrhage
3) Pontine Hemorrhage
4) Thalamus
* Htn is MC and important RF for an intraparenchymal brain hemorrhage!!!

Question 79

What’s the CSF like for Herpes Encephalitis?

Answer 79

Elevated RBC and WBC with normal protein and glucose levels.

Question 80

Hepatorenal Syndrome is a deadly complication of ESLD. What would the pt’s clinical picture look like? MCC of death? Best trmt?

Answer 80

HRS has decreased GFR in the absence of shock, proteinuria, or other causes of renal dysfxn…it fails to respond to 1.5L of NS. 2/2 decreased total renal blood flow and vasodilatory substance synthesis. Infxn and hemorrhage = MCC of death in these patients. It is BEST treated with liver transplant!

Question 81

Any patient with recent hx of travel to developing country or camping trip who returns with foul smelling stools, fatty stools, bloating, flatulance, N, malaise and abdominal cramps…dx? Patho? Trmt?

Answer 81

Giardia lamblia has adhesive disks that cause malabsorption. Empiric trmt w/ Metronidazole!

Question 82

What 4 things make up the rotator cuff? MC’ly damaged? PE finding?

Answer 82

Tendons of the Supraspinatous, Infraspinatus, trees minor, and subscapularis. MC’ly damaged = Supraspinatus. Arm Drop test is + = can’t abduct arm or hold arm at the 90 degree angle.

Question 83

What causes a pt to have a “winged scapula”? What muscles does this involve? When is it commonly seen?

Answer 83

Seen MC’ly by iatrogenic injury during axillary lymphadenopathy to the long thoracic nerve affecting the serratus anterior.

Question 84

Polyuria, polydipsia, N/V, and constipation make you think of what electrolyte abnormality?

Answer 84

Hypercalcemia - PTH is suppressed in most its when this is 2/2 to malignancy and the Ca levels are usually very high > 13 vs. those with primary hyperparathyroidism.

*Sarcoidosis causes increase conversion of 1,25-hydroxyvitamin D in granulomatous tissue

VS.

*low levels of “ “ in CKD

Question 85

Sickle Cell patients can have:

1) Acute Hg Drop + No Reticulocyte Response
2) Acute Hg Drop + Reticulocyte Response
3) Acute Hg Drop + Hypotension

Answer 85

1) Aplastic Crisis (Parvo B19)
2) Hyperhemolytic Crisis
3) Splenic Sequestration (get a splenectomy)

*Aplastic crisis in SS pt is different than aplastic anemia = pancytopenia

Question 86

Screening tests for microalbuminuria?

Answer 86

Timed and Spot Urine Test to assess micro albumin to creatinine ratio. 24 hr collection works too but is inconvenient

Question 87

Three D’s of Endometriosis? Trmt?

Answer 87

Dyschezia, Dysmenorrhea, Dyspareunia…unless urgent or contraindicated, try NSAIDS and OCPs first

Question 88

Parkinsonism + autonomic dysfunction (postural hypotension, abnl sweating, bowel/bladder control, etc) + widespread neuro signs = ???

Answer 88

Shy-Drager Syndrome - treat with IVF and fludricortisone, salt supplementation, alpha-adrenergic agonists, and constrictive garments for lower body.

Question 89

Riley-Day syndrome or familial dysautonomia = AR disease seen in Jews and p/w…

Answer 89

autonomic dysfxn and severe orthostatic hypotension

Question 90

What would you prescribe with your pt taking niacin for elevated levels of triglycerides? Preventing???

Answer 90

Low-dose aspirin to reduce possible affect of histamine and prostaglandins induced from the medication. Results in flushing and extreme itching.

Question 91

Constrictive Pericarditis is caused by scarring and thickening that results in signs of decreased CO and venous overload. MCC in developing vs. developed countries?

Answer 91

Developed = viral/idiopathic, heart surgery, chest radiation.

Developing = TB

Question 92

What causes Chagas Disease? It’s endemic to _____ and can cause?

Answer 92

Trypanosoma Cruzi

Megacolon, Megaesophagus, and cardiac disease

Question 93

What to give a patient to help decrease risk of potential rhabdo?

Answer 93

1) IVF
2) Mannitol
3) Alkalinize the Urine

Question 94

Name that lung tumor!
1) centrally located, necrotic w/ cavitation p/w hypercalcemia

2) peripherally located p/w clubbing and hypertrophic osteoarthropathy
3) peripherally located, p/w gynecomastia and galactorrhea
4) centrally located p/w Cushing syndrome, SIADH, and Lambert Eaton Syn

Answer 94

1) Squamous Cell Carcinoma
2) Adenocarcinoma
3) Large Cell Carcinoma
4) Small Cell Carcinoma

• Adenocarcinoma = MCC of lung cancer in both smokers/non-smokers; stage and respectability determine prognosis and survival respectively

Question 95

MCC of Vitreous Hemorrhage is? Clue on fundoscopy?

Answer 95

Diabetic Retinopathy - hard to visualize the optic disk, obscure details

Question 96

Central Retinal Artery Occlusion differs from Retinal Emboli by….

Answer 96

Pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood in arteries and veins.

The latter has white edematous retina tracing the arterioles

Question 97

Treat of dx with young pt having headaches, elevated BP, and renal bruit, female is….

Answer 97

Angioplasty w/ stent placement for renal artery stenosis 2/2 Fibromuscular Dysplasia

Question 98

Elderly patients presenting with sympt of depression and complaining of memory loss likely suffer from…

Answer 98

Pseudodementia

Question 99

Absent/weak peripheral pulses, BP difference > 20mmHg in R and L arm, diastolic decrescendo murmur heard better on the right sternal border suggests…

Answer 99

Aortic dissection….tearing chest pain radiating to back with Aortic Regurg

Question 100

Chondrocalcinosis (2/2 calcium pyrophosphate dihydrate crystals) is associated with what three things?

Answer 100

Hypomagnesemia, Hyperparathyroidism, and Hemochromatosis.

*Hemochromatosis pt = more at risk for Listeria, Vibrio, Yersinia

Question 101

Hallmark ECG findings of acute pericarditis?

Answer 101

Diffuse ST elevation with down-sloping PR segments

Question 102

Differentiate compression fracture, herniated disk, and lumbago (lumbosacral strain)…

Answer 102

Compression fractures are acute in nature with its predisposed to osteoporosis w/ no hx of trauma. (watch out for steroid users!!!)

Herniated disk would have positive straight leg test and sciatica like pain

Lumbar muscle strain normally has paravertebral tenderness rather than spinal tenderness; less dramatic onset and related to physical strain

Question 103

Premature Ventricular Complexes are described as……seen commonly after…..and you treat symptomatic vs. asymptomatic pts via…

Answer 103

Wide QRS, bizarre morphology, and compensatory pause. Seen after MI’s and despite their presence indicating a poor prognosis and cardiac pathology, preventative trmt has been shown to WORSEN survival. Just observe asymptomatic patients with B-Blockers being first line for symptomatic pts.

Question 104

Children presenting with bifrontal or unilateral head pain that is recurrent, accompanied with photophobia, phono phobia, N/V and visual, auditory or linguistic aura = dx?

Answer 104

Migraines - treat with conservative mgmt and acetaminophen. Triptans can be tried for refractory cases.

Question 105

Treatment of a limb with pulselessness, pallor, parenthesis, poikilothermia, and pain =?

Answer 105

Surgical embollectomy, intra arterial fibrinolysis/mechanical embolectomy via interventional radiology

Question 106

Light’s criteria for exudative effusion? Causes?

Answer 106

LDH ratio >0.6
Protein ratio >0.5
LDH > 2/3 of normal

Malignancy, PNA, TB, PE, connective tissue disease, and iatrogenic causes.

Question 107

ADPKD is characterized by what three findings? What common complication is considered dangerous but not warranting screening? What 4 extra-renal complications occur?

Answer 107

Hypertension, bilateral palpable abdominal masses, and microhematuria. Get an U/S!!!

Berry Anneurysm

Hepatic Cysts (MC), AR or MVP, Colonic Diverticula, and Abdominal Wall or Inguinal Hernia

Question 108

Traveling to an endemic area for this dx, + RUQ pain, diarrhea (possible dysentery), leukocytosis, elevated alk phos level, hepatic solitary lesion with anchovy paste = ??? Trmt??? What NOT to do???

Answer 108

Amebic Abscess (Entamoeba Histolytica) is treated with metronidazole (or tinidazole) b/c aspirating could cause complications or problems if it’s an undiagnosed echinococcus (seen with close contact with dogs!). Also give luminal treatment (paromomycin, iodoquinol, diloxanide furoate)

Question 109

Always suspect ???? in a young patient with chronic diarrhea, abdominal pain, weight loss, elevated platelets and white count, and anemia…

Answer 109

Crohns

Question 110

Dyspnea on exertion + exertional syncope + exertional angina w/ peripheral edema, clear lungs, elevated JVP, RVH, R-sided heave, pulsatile liver, tricuspid regurg w/ a hx of COPD = ???

Answer 110

Cor Pulmonale!

COPD = MCC, others = ILD, thromboembolic event, OSA

EKG would show RBBB, RVH, enlarged R atrium

Enlarged Pulm Art w/ decreased retrosternal space (2/2 RVH)

R Heart Cath = gold standard, showing elevated RVEDP, CVP, and mean pulm artery pressure (>25 mmHg)

Question 111

Intracranial pressure is determined by volume and compliance and depends on brain parenchyma, CSF and _____. What 3 things increase the cerebral blood flow? Ways to decrease ICP?

Answer 111

Blood

Hypercapnia, increased metabolic demand, and hypoxia cause vasodilation.

Hyperventilation, elevated head of bed, sedation to decrease metabolic deman, IV mannitol for diuresis

Question 112

COPD is diagnosed with FEV1/FVC of < ???? This is caused by what>

Answer 112

< 0.7 and is caused by air trapping on exhalation 2/2 damaged alveoli

Question 113

Arterial occlusions can occur in the lower extremity from these three main causes? How to differentiate b/w this and arterial thrombosis or DVT? Where do they most commonly originate from?

Answer 113

Trauma, Emboli, or Thrombosis

Thrombosis causes bilateral narrowing, so this is a gradual process. DVT has more dull and achey characteristics to the pain vs. sudden and acute in arterial emboli; also appears warm to the touch since a DVT causes retrograde congestion vs. pale from arterial occlusion.

MC’ly originate from heart via the ventricles following a MI or from atria in the setting of A-fib

Question 114

What women get screened for Gonorrhea/Chlamydia and Hep C in preg? What about Syph, HIV, and Hep B?

Answer 114

Women at risk get screened for Hep C, GN, and CL.

ALL women get screened for HIV, Syph, and Hep B

Question 115

What do you do in a laboring patient with active HSV vesicles found on PE?

Answer 115

C-section

Question 116

Osmotic diarrhea has an osmotic gap > ??? and is calculated by this formula…

Answer 116

> 50

290 - [2 x (Stool Na + Stool K) ]

Question 117

Lactose Intolerance occurs commonly in this group of patients…? It causes a high osmotic gap, no steatorrhea, with what stool pH (acidic/alkalotic)?
Test?

Answer 117

Asian Americans. Acidic pH 2/2 fermentation products.

Lactose Hydrogen breath test will be + because lactase (brush border enzyme that hydrolyzes lactose) is decreased and is fermented in GI tract.

Question 118

Allergic Contact Dermatitis is what kind of hypersensitivity reaction? Example?

Differentiate this with type I/II/III hypersensitivity =) You’re getting smarter

Answer 118

Type IV - cell mediated, therefore the pt had to have prior contact - Ex = poison ivy (wheepy and itchy)

Type I - IgE mediated; allergen crosslinks two IgE molecules that are attached to Mast cell (Ex = atopy, urticaria and anaphylaxis) = Immediate

Type II - Antibody Mediated; IgG and IgM attachment to antigens cause cytotoxic events w/ complement activation resulting in cellular damage (ex = immune hemolytic anemia, Rh hemolytic disease)

Type III - Immune complex-mediated; Ab-antigen complex activates complement and additional inflammatory processes (ex = serum sickness and Arthus reaction)

Question 119

When would a pt with suspected RF present? What could happen to the left main stem bronchus?

Answer 119

Anything that causes tachycardia (exercise, pregnancy, anemia)

L-atrial enlargement can occur 2/2 MS and impinge on recurrent laryngeal nerve or displace the left main stem bronchus.

*Afib = common complication

Question 120

Superficial skin lesion seen in hot, humid climates with pruritic, erythematous, scaly lesions with a red ring and central clearing = dx? Trmt?

Answer 120

Tinea Corporis = Ring Worm

Treat with Terbinafine

*Nafcillin is used to treat cellulitis, a painful, erythematous, and indurated skin lesion

Question 121

Increased water intake, serum Na < 137, antipsychotic use, polyuria and low urine osmolality (urine osmolality < 1/2 the serum osmolality) = ???

Answer 121

Primary Polydipsia - serum osmolality is maintained by diuresing fluid.

Question 122

Central DI = clinical path? Causes? Features?

Answer 122

Insufficient ADH release from pituitary 2/2 trauma, pituitary surgery, ischemic encephalopathy, or idiopathic cause. Serum Na > 150 b/c body doesn’t reabsorb water, thus leaving concentrated serum. Low urine osmolality. Dysfunctional thirst mech

Question 123

Nephrogenic DI = clinical path? Causes? Features?

Answer 123

Varying kidney response to ADH 2/2 chronic lithium use, hypercalcemia, or hereditary AVPR2 mutation. Serum Na is about normal 2/2 intact thirst mechanism.

Question 124

What would you use for suspected ectopic preg with a B-hCG of 2,000?

Answer 124

Trans-vaginal U/S b/c b/w 1,500 - 6,000 you can see gestational sac with trans-vag but not trans abd (> 6,000)

Question 125

A resp quotient (CO2/O2) production can tell us what with a person we’re trying to wean off a respirator?

Answer 125

Quotient of 0.8 = normal b/c 1.0 is for PURe glucose metabolism and since we don’t just use glucose, it’s a little less than 1.0 in normal physiology. But with a tube-fed pt, an elevated quotient above one tells us that the pt is being overfed and producing too much CO2 and subsequently make it harder to wean off the respirator

Question 126

How would you manage an empyema?

Answer 126

If it’s NOT complex and w/o a rim of fibrinous material, attempt antibiotics or a drain. If it’s complex, antibiotics alone will not work. If there’s a fibrinous ring, only surgery is the answer.

• Pt has low grade fever and it’s best diagnosed with CT
• *Hemothorax = excellent medium for bacterial growth

Question 127

A man complaining of sexual dysfunction, unintentional weight loss, fatigue, bilateral gynecomastia, small firm tests should make you think of? Labs?

Answer 127

Chronic liver disease. Normal TSH and low total T3 and T4 b/c liver is responsible for making serum binding proteins, therefore the concentration of free hormone isn’t changed but total (free + bound) accounts for loss.

*Alcohol and Hemochromotosis = common causes

Question 128

Differentiate clinical features of Babesiosis, Lyme, and Ehrlichiosis… =) Smarter every day!!!

Answer 128

Babesiosis = Babesia from Ixodes tick causes RBC to hemolyze. Labs will show hemolytic anemia, thrombocytopenia, leukopenia, atypical lymphocytosis, elevated ESR, abnormal LFT’s, and decreased complement levels, hemoglobinuria, renal failure and pt may have jaundice. Dx with Giemsa-stained thick and thin blood smear. Trmt = Quinine-clindamycine and atovaquone-azithromycin.

Lyme = look for erythema chronic migrans

Ehrlichiosis = “spotless RMSF” fever malaise, HA, N/V. Labs show leukopenia and thrombocytopenia NO HEMOLYSIS OR JAUNDICE!

Question 129

A pt who develops skin necrosis is different than a pt who has bruising and hemorrhage…what does this distinguish b/w in terms of bleeding/clotting problems?

Answer 129

The first characterizes a prothrombotic state vs. the latter being a bleeding diathesis

*Warfarin can cause a sudden drop in Prot C (half life of Prot C = 9 hrs) so it can cause paradoxical pro-coagulant state!

Question 130

Common HIV therapy reactions to know:

1) Didanosine
2) Abacavir
3) Lactic Acidosis
4) Stevens-Johnson Syndrome
5) Nevirapine
6) Protease Inhibitor

Answer 130

1) Induced Pancreatitis
2) Hypersensitivity Syn
3) NRTI’s
4) NNRTI’s
5) Liver Failure
6) Crystal-induced nephropathy

• -navi (protease)
• • -virines (NNRTI)

Question 131

What inherited thrombosis-promoting problem is MC?

Answer 131

Factor V Ledien - can’t be broken by protein C/S

Question 132

Three common causes of + hepatojugular reflex? What does this show?

Answer 132

Constrictive pericarditis, RV infarction, and restrictive cardiomyopathy = shows the R-hearts inability to compensate for increase venous return

*helps differentiate cardiac vs. portal hypertension

Question 133

Formula for serum osmolarity = ?? Normal range

Answer 133

2xNa + BUN/2.8 + Glucose/18

Normal = 280 - 295

Question 134

When you have hyponatremia, what do you want to calculate and know?

Answer 134

Calculate serum osmolarity, ECV, and any urine findings.

Question 135

Work through hyponatremia w/u….

Answer 135

Hyponatremia = Na < 130

Is the patient’s serum osmolarity:

1) Normal
2) High (>295)
3) Low ( 20 = renal salt loss (diuretics, ACEi, mineralocorticoid def)

If low osmolarity AND Euvolemic, what does the urine tell us? (1) Urine Na >20 AND Urine Osm > 300 = SIADH (**HINT urine osm > serum osm)
(2) Urine Na > 20 and Urine Osm < 300 = psychogenic polydipsia, beer potomania

if low osmolarity and Hypervolemic = CHF, hepatic failure, or nephrotic syndrome.

YOU DID IT!!! =)

Question 136

Cut off for a D-Dimer?

Answer 136

< 500 = excludes PE, more than 500, get a CT pulmonary angiography

Question 137

With cramping leg pain while walking, relief with rest and elevated Brachail index…what’s your management plan?

Answer 137

RF stratification: stop smoking, lipid-lowering therapy, evaluate for hypertension and DM.

Start low dose aspiring, statin and exercise for 30 min 3x weekly for 3 months!

Question 138

What abx commonly put people at risk for C. Diff?

Answer 138

Fluoroquinolones, penicillins, cephalosporins, and clindamycin.

• unexplained leukocytosis in hospitalized patients should raise concern for c. diff even if not diarrhea
• • switch from oral metro to oral vanco if severely elevated WBC’s >15k

Question 139

Tumors will high cell turnovers are frequently associated with Tumor Lysis Syndrome, these 2 tumors are? Electrolyte changes seen?

Answer 139

Lymphomas (like Burkitt’s) and Leukemias (ALL and AML)

Elevated: uric acid, potassium, and phosphate.
Decreased: calcium 2/2 to phosphate binding

Question 140

What to give a child presenting with Lyme disease, specifically someone < 8?

Answer 140

Amoxacillin b/c Doxy can cause slow bone growth in pregnant women and enamel hypoplasia with permanent teeth stains during tooth development in young children

Question 141

Suprachondylar fracture of the humerus is common in young children and adolescents who have fallen on an outstretched arm. A complication of fractures like this is compartment syndrome characterized by these 5 P’s and the final feared sequela with respect to the muscle is…

Answer 141

5 P’s = pallor, pulselessness, pain, paresthesia, poikilothermia

Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which dead muscle has been replaced w/ fibrous tissue

Question 142

Three MCC of AS? Presents w/?

Answer 142

Congenital Bicuspid Aortic Valve (MC in patients under 70), calcified senile aortic stenosis, and RHD.

Systolic murmur heard best at upper L-sternal border radiating to carotids. Associated S4

Question 143

Caustic ingestion w/ Sodium or K OH causes immediate injury to the esophagus and should get _______ in addition to supportive care and X-ray.

Answer 143

upper endoscopy to assess severity of damage and guide further therapy

Question 144

Why does serum screening for down syndrome not help in the setting of an identified marker for down syndrome on U/S?

Answer 144

These serum tests do not provide any further diagnostic value than the already identified U/S marker for down syndrome…thus a more diagnostic approach should be taken, get a CVS (b/w 10-12 weeks) for fetal karyotyping.

Question 145

What is the most significant risk factor for distal limb reduction defects associated with CVS?

Answer 145

The gestational age of the fetus; before 10 wks = associated great risk

Question 146

How do you correct Ca levels for low albumin pt?

Answer 146

Ca= measured Ca + [0.8( 4 - measured albumin)]

Question 147

Sustained prolonged PR interval > 0.2 sec (5 boxes) = ??? Mgmt differences b/w a normal and abnormal QRS?

Answer 147

First degree AV-block. QRS that is widened (>120 msec) is associated with conduction delay below the AV node and can have spontaneous progression to advanced 2nd degree or complete heart block thus get a electrophys test for this pt vs. someone with normal QRS, just observe =)

Question 148

What are the meds suggested for angina pectoris?

Answer 148

B-blockers = first line b/c they improve exercise tolerance and decrease O2 demand via decreased HR. CCB’s and long-acting nitrates are second line therapy options if pt is bradycardic or cannot tolerate B-blockers or if not responding adequately.

Question 149

IgA and Postinfectious GN timeline differences and finding differences?

Answer 149

IgA occurs within 5 days vs. > 10 for post-infect. Normal serum complement levels with mesangial IgA in kidney with IgA GN VS. low C3, ASO titers, anti-DNAse B titers, kidney bx w. humps of C3 complement

Question 150

When can you not give Fondaparinux (injection Xa inhibitor) and Rivaroxaban (oral Xa inhibitor)?

Answer 150

When a pt has GFR < 30

Question 151

First line trmt for PE?

Answer 151

Unfractionated heparin with subsequent warfarin initiation s/p therapeutic INR (1.5-2)

Question 152

What should you order for a pt before starting her on Trastuzumab (Herceptin) for HER2 + breast cancer?

Answer 152

Echo b/c trastuzumab + chemo can cause cardiotoxicity

Question 153

A pt that develops acute joint, often knee pain s/p surgery or illness is likely to have what findings on synovial analysis?

Answer 153

Rhomboid shaped, positively birefringent needles = Pseudogout = CPPD crystals and is associated with Chondrocalcinosis

Question 154

Femoral bowing of the town, recent hearing loss, old age, elevated alk phos, mosaic lamellar bone, and bone pain =???

Answer 154

Paget’s disease = hyper functioning osteoclasts …MC’ly affect the skull, long bones, spine and pelvis

Question 155

Which anatomic site is most likely the cause of a fib?

Answer 155

Pulmonary veins

Question 156

What should everyone get with central precocious puberty?

Answer 156

Brain CT or MRI (central = elevated FSH and LH 2/2 increased GnRH) vs. peripheral = adrenal or gonadal excess of sex hormones, low LH FSH

Question 157

Parathyridectomy is recommended for asymptommatic hypercalcemia patients who have one of these four things:

Answer 157

1) serum Ca >1 above normal
2) young age
3) bone mineral density < T -2.5
4) reduced renal fxn

Get a neck scan w/ sestamibi scintigraphy and U/S to locate pathology before sx

Question 158

How to distinguish b/w primary hyperparathyroidism and familial hypocalciuric hypercalcemia?

Answer 158

Both can have elevated PTH, high serum calcium, but the latter will have 24hr urinary Ca <100

Question 159

Pt with a hx of viral infection with subsequent weight loss, polydipsia, and rapid deep breathing….

Answer 159

DKA

Question 160

How to statistically compare:

1) means
2) > 3 means
3) proportions

Answer 160

1) double sided z-test/t-test
2) ANOVA
3) Chi-Square

Question 161

Screening for breast mammography…

Answer 161

Starting at 50 every two years and can stop at age 75

Question 162

Which class of meds is most likely to benefit an asymptomatic woman with multiple first degree relatives with breast cancer?

Answer 162

Raloxifene or Tamoxifen - SERMS

*Aromatase inhibitors (anastrozole, letrazole) are good for preventing mets of current dx of breast cancer

Question 163

Recd’s for pap smears….age range…combination screening

Answer 163

21 - 65 every three years

Between ages 30 - 65 a combined Pap + HPV screening stretches interval to 5 years

HPV vaccine from women 11- 26

Question 164

Chlamydia screening?

Answer 164

Age 15 - 25

Question 165

Regarding PSA, if the pt requests the test you should _____; if it inquires about mortality, then ______

Answer 165

Do the PSA if they request

Does not lower mortality

Question 166

Cholesterol and Lipid screening should begin at what ages in men and women? Or it should start if a pt has?

Answer 166

Men 35 Women 45

If they have metabolic problems: aortic disease, PVD, CAD

Question 167

BP screening begins at age ____ and is “screened” every ____ yrs

Answer 167

Begin at age 18 and is used for screening every 2 years

Question 168

What dx’s trigger DM screening? How do you screen?

Answer 168

If they have hypertension or hyperlipidemia. Test fasting glucose for >125 or HgA1C > 6.5

Question 169

Do not give live vaccines for which pts?

Answer 169

Pts > 50 yrs old or if they have chronic heart/lung/kidney disease (asthma), HIV/AIDS, Steroid users, immunocompromised, cancer pts, functional or anatomical asplenia, DM

Question 170

Who gets influenza vaccine and who gets pneumococcal vaccine?

Answer 170

Flu - everyone, healthcare workers, pregnant pts

Pneumococcal - over the age of 65, cochlear implant, CSF leaks, Alcoholics. Everyone gets one vaccination over the age of 65 or a single revaccination IF they are immunocompromised or they had their first shot right before age 65

Question 171

High dose varicella vaccine for pts over the age of? Preventing?

Answer 171

Over 60. It prevents post-herpetic neuralgia.

Question 172

What are the general Hep A/B indications in adults and what are their respective differences?

Answer 172

All adults with: chronic liver disease, MSM or multiple sex partners, household contact with hepatitis A/B, IVDU

Hep A: traveling to endemic areas

Hep B: End-stage renal disease, DM, Healthcare worker

Question 173

Tetanus vaccination schedule:

Answer 173

Toxoid (Td) booster every ten years. One Tdap for one of the boosters. If never vaccinated, give Tetanus Immunoglobulin.

If you get a dirty wound, revaccinate in 5 years. Clean wound = 10 years

Question 174

Meningococcal is routine for kids at age ____ and for adults with the following indications:

Answer 174

Age 11

College student, military, pilgrimage, terminal complement deficiency, asplenia

Question 175

Every woman should be screened at the age of 65 for osteoporosis with ….

Answer 175

DEXA scan

Question 176

All men above 65 yrs w/ a hx of smoking should receive what screening?

Answer 176

Abdominal U/S for AAA. If > 5cm, get surgical repair.

*Also screen age 65-75 for those with a fam hx of AAA

Question 177

Common characteristics of OA: findings, lab tests, most accurate test, imaging findings, trmt

Answer 177

Occurs in DIP, have crepitations, (PIP nodules = Bouchard, DIP = Heberden) stiffness is <15 min, does not improve through the day, lab tests are NL. Xray = most accurate test.

Joint space narrowing, subchondral sclerosis/cysts, osteophytes

Trmt: weight loss - Acetominophen - NSAIDS - Capsaicin cream - Intra-articular steroids - Hyaluronan Injection - Joint Replacement

Question 178

Two etiologies of gout…

Answer 178

Overpoduction: Cell turnover (hemolysis, cancer, psoriasis, chemo), Idiopathic, Enzyme Def (Lysch Nyhan, glycogen storage disease)

Underexcreter: renal insufficiency, thiazides and aspirin, ketoacidosis/lactic acidosis

Question 179

Deposits of uric acid crystals in parts of the body cause?

Answer 179

Tophi…uric acid crystal could also be seen

Question 180

Most accurate test for Gout? How to treat acutely and chronically?

Answer 180

Synovial fluid tap - showing needle shaped negatively birefringent needles, pred neturophils w/ WBC 200 - 50,000. Labs will shows leukocytosis and elevated ESR.

Acute Attack: NSAIDS, corticosteroids if refractory/contraindication (renal), then Colchicine

Chronic Mgmt: diet mod, stop thiazides/aspirin/niacin (can use Losartan for Htn), Colchinine can help prevent 2nd attack, Allopurinol decreases uric acid prod, Pegloticase dissolves uric acid, Probenecid and Sulfinpyrazone are uricosurics

Question 181

Gout drugs contraindicated in renal insufficiency:

Answer 181

NSAIDS, Probenecid, Uricosurics (the ones that affect the kidney excretion). Allopurinol = safe

Question 182

Can you start a pt on Allopurinol or Uricosuric agent during acute attack?

Answer 182

No, but can continue allopurinol if they were on it previously

Question 183

Adverse effects of Uricosurics, Allopurinol, and Colchicine

Answer 183

Uricosurics/Allopurinol = hypersen. (AIN, rash, hemolysis) 
Allopurinol = TEN, SJS
Colchicine = diarrhea and bone marrow suppression

Question 184

The most common RF’s for pseudo gout: ? Findings? Tap? Trmt?

Answer 184

Hemochromatosis, Hyperparathyroidism. Less commonly = hypothyroidism, DM, Wilsons.

MC’ly in wrist and knee. Positively birefringent rhomboid shaped crystals, elevated wbc 200 - 50,000
Trmt: NSAIDS first, then steroids if refractory. Colchicine can help prevent recurrence.

Question 185

Differentiate Cord Compression, Epidural Abscess, and Disk Herniation…

Answer 185

Cord Compr - hx of cancer, onset of neurological defects, sensory level loss below lesion, hyperreflexia, point tenderness. Xray = initial, MRI = most accurate. Steroids, chemo, surg.

Epidural Abscess - same as cord comp presentation but the ESR and fever make this more likely. MCC = staph aureas. Xray = initial, MRI = most accurate BUT steroids given first to decrease pressure

Disk Herniation - positive straight leg test, loss of lower extremity reflexes, pain radiating to below buttock and knee. Unless severe, no imagine. NSAIDS w/ continuation of normal activity, NOT bed rest

Question 186

Trmt of epidural abscess…

Answer 186

Steroids first. Then vanco or linezolid for empiric trmt. If staph sensitivity is found, switch to beta lactam Oxacillin, Nafcillin, Cefazolin. Add gentamicin for synergy (like endocarditis)

Question 187

Lumbar spinal stenosis presents like…what are the hallmark points in the hx? Trmt? Imaging?

Answer 187

Presents like PAD. Pt NL’y over age of 60 with pain that is worse with walking, worsened by going downhill, relieved by leaning forward. ABI and pulses being NL help!

Trmt = NSAIDS

Imaging = MRI

Question 188

Chronic MSK pain and tenderness with trigger points in the trapezius, medial fat pad of the knee, and lateral epicondyle. This young woman also has HA, sleep d/o, and fatigue. All labs are NL

Answer 188

Dx: Fibromyalgia
Trmt: Amitriptyline or Milnacipran (SNRI) and Pregablin
NO STEROIDS

Question 189

Associated diseases w/ Carpal Tunnel Syndrome?

Answer 189

“Pradah”

Pregnancy, RA, Acromegaly, DM, Amyloidosis, Hypothyroidism

Question 190

Carpal Tunnel findings:? Most ACCURATE test? Trmt?

Answer 190

Atrophy of thenar muscles, worse at night, + Tinel “tap” and + Phalen “flex”. Sensory symptoms happens before motor sympt.

Most accurate = electromyography and nerve conduction study

Trmt = splint

Question 191

Dupuytren Contracture is…? Trmt? Associationa?

Answer 191

Hyperplasia of the palmar fascia with nodule formation causing contracture of 4th/5th digits. Give it some “TLC” = Triamcinolone/Lidocaine/Collagenase Inj (last one helps early on in the disease process)

Question 192

Anterior knee pain secondary to trauma, uneven quadricept strength, or meniscal tear. Pain is worse walking up AND down stairs - particularly bad after getting up having been seated for a long period of time. Gets better walking. NL X-rays. Treated with PT

Answer 192

Patellofemoral Syndrome

Question 193

Very severe pain at the bottom of the foot, especially near the calcaneous. Worse in the morning but improves with walking. Point tenderness at the calcaneous. NL Xray. Trt with stretching, arch support, and NSAIDS

Answer 193

Plantar Fasciitis - differentiated from Tarsal Tunnel Syndrome with the hx of worsened symptoms with walking in TTS

Question 194

RA features? Dx test? Radio findings?

Answer 194

Morning stiffness in mutiple, bilateral small joints of hands and feet, notably the PIP, MCP. Morning stiffness lasting > 30 min. Rheumatoid nodules. Other: Episcleritis, pleural effusion and lung nodules, cervical joint subluxation around C1/C2, Baker cyst rupture, pericarditis and pleural disease. Chronic synovitis leads to pannus formation.

Dx w/ Anti-CCP = anti-cyclic citrulinated peptide

Radiographs: joint erosion, panus, osteopenia,

Question 195

Sicca syndrome = constellation of these findings…

Answer 195

Dry eyes, dry mouth

Question 196

MCC of death in RA?

Answer 196

CAD

Question 197

1) RA + Splenomegaly + Neutropenia

2) Lung Nodule + Pneumoconiosis + RA

Answer 197

1) Felty Syndrome

2) Caplan syndrome

Question 198

Trmt consideration in RA: best initial drug for symptomatic pain relief? best drug to inhibit disease progression? no response to methotrexate? no response to TNFa-inhibs? Mild disease, want to avoid methotrexate? Another combo with methotrex?

Answer 198

Pain = NSAID
Disease Modifier = Methrotrexate
Refractory to Methotrexate = TNFa-inhibitors (etanercept, infliximab, adalimumab)
Refractory still = Rituximab (takes out CD20)
Mild disease = Hydroxychloroquine
Last one, I promise = Sulfasalazine

• Note - TNFa, Ritux, and Sulfa are added to methotrexate despite the poor response, only Hydroxychloroquine can be mono therapy

Question 199

RA drug toxicities/considerations:

1) Methrotrexate
2) TNFa Inhibitors
3) Hydroxychloroquine
4) Sulfasalazine
5) Gold Salts

Answer 199

1) Methrotrexate - pulmonary tox, bone marrow suppression, and liver tox
2) TNFa Inhibitors - reactivation of TB, screen with PPD before initiating; infection
3) Hydroxychloroquine - retinal toxicity (like ethambutol)
4) Sulfasalazine - bone marrow tox, G6PD hemolysis, and rash
5) Nephrotoxicity

Question 200

High spiking fever in a young person with fever-consistent salmon rash on chest and abdomen, with splenomegaly, pericardial effusion, and joint symptoms…Lab to check?

Answer 200

Juvenile Rheumatoid Arthritis/Adult Still Disease

Ferritin is markedly high!

Trt w/ aspirin, NSAIDS, steroids, TNFa-inhib

Question 201

No joint deformation or erosion is characteristic of…MC GN association? Other false +’s seen?

Answer 201

SLE. Membranous. Positive RPR and Leukocyte Esterase cell prep

Question 202

Treat an asymptomatic positive ANA?

Answer 202

NO!

Question 203

What two labs would you expect to see change in an acute flare of lupus?

Answer 203

Decreased complement and increased Anti-DS DNA. Treat with high dose bolus of steroids

Question 204

How do you determine trmt of Lupus Nephritis?

Answer 204

Biopsy! If glomeruloscerosis has occurred, trmt will have no effect.

Question 205

MCC death in young vs. old pts w/ SLE?

Answer 205

Young = infection
Old = advanced atherosclerosis

Question 206

Antiphospholipid Syndrome has two main types: ? What would you expect to see in each? Best initial vs. specific test?

Answer 206

Either IgG or IgM to negatively charged phosphlipids causing clotting in both arteries, veins, and recurrent abortions. False + RPR or VDRL

1) Lupus Anticoagulant - elevated aPTT, NL INR and PT
2) Anticardiolipin Antibodies - spont abortions

Best initial = mixing study which would show refractory elevation of aPTT

Most accurate = Russel Viper Venom Test which would be prolonged

Question 207

Treat asymptomatic APL?

Answer 207

No

Question 208

What will help prevent recurrent spont. abortions in pt with APL?

Answer 208

Heparin and aspirin

Question 209

A bucket handle tear of the medial meniscus leads to locking of the knee during terminal extension. What does the pt complain of with this tear?

Answer 209

Occurs during forceful torsion of the knee when foot is planted, loud pain, extreme pain w/ little to no swelling. + McMurray sign

*vs. immediate effusion seen with ACL tear

Question 210

Muscle compartment pressure more than ____ mm Hg indicates need for fasciotomy

Answer 210

30

Question 211

Toxic causes of peripheral neuropathy…

Answer 211

Chronic alcoholism, Vincristine, Phenytoin, Isoniazid, heavy metals

Question 212

Raynauds can be caused by what two meds?

Answer 212

Ergotamine and B-Blockers

Question 213

Cochlear dysfunction is a side effect of what two meds?

Answer 213

Aminoglycosides and cisplatin/carboplatin

Question 214

Bulimia Nervosa’s timeline…

Answer 214

Twice/week for at least 3 months

Question 215

RF’s for acute ottitis media in children? MCO’s? Trmt? Complications?

Answer 215

Being formula fed, second hand smoke, allergic rhinitis, viral URI, chronic middle ear effusion. Strep. Pna, H. Flu, Moraxella Catarrhalis. Comp = chronic infection, mastoiditis, labrynthitis, choleastoma, tympnaosclerosis, eardrum perforation, and conductive hearing loss. Trmt = 10 days of Amox. If recurrent give Augmentin (amox + clavulinic acid). Only do tympanostomy tube placement and myringotomy with > three episodes in 6 months or > 4 in a year

Question 216

Differences between CMV mono and EBV mono?

Answer 216

CMV is likely to NOT have pharyngitis and cervical lymphadenopathy, and negative heterophile antibody test, + atypical lymphocytes (large basophilic cells with vacuolated appearance)

Question 217

What cell line will clue you into glucocorticoid def in conjunction with weakness, fatigue, loss of appetite?

Answer 217

Eosinophilia.

*Secondary adrenal insuff does
NOT have salt wasting, hyperkalemia, or hyper pigmentation

Question 218

Sharply demarcated, acute, arythematous, edematous, tender skin lesion with raised borders = ??? MC found? MCO?

Answer 218

Erysipelas. Legs = MC site but face is common too. Group A Betal-hemolytic strep (strep pyogenes)

Question 219

This viral exanthem is caused by human herpes virus 6, the fever peaks with rash onset, and the rash appears as the fever resolves.

Answer 219

Roseola

Question 220

How does the viral exanthem Measles spread?

Answer 220

Fever, cough, coryza, non-purulent conjunctivities, and Koplik spots…spreads cephalocaudally and centrifugally (center to distal extrem)

Question 221

Steroids tend to do what to lymphocytes, neutrophils, and eosinophils?

Answer 221

Increase neutrophils, and decrease lymphocytes and eosinophils

Question 222

Main causes of orthostatic hypotension in elderly?

Answer 222

Progressive decrease in baroreceptor sens. and defect in myocardial response to this reflex

Question 223

Fluphenazine, a high potency typical antipsychotic med is occasionally responsible for?

Answer 223

Hypothermia

Question 224

Post-MI acute pericarditis typically occurs when? What is it called if it occurs weeks later? Trmt?

Answer 224

First couple of days. Dressler Syndrome. Give NSAIDS

Question 225

Sickle Cell disease/trait can cause patient to have nocturia 2/2 ???

Answer 225

Red blood cell sickling in the vasa rectae of the inner medulla, which impairs countercurrent exchange and free water reabsorption = hyposthenuria

Question 226

30-50 yr old presenting with mood disturbances (depression), dementia mildly, and facial grimacing, ataxia, dystonia, tongue protrusion or writhing movements of the extremities…dx?

Answer 226

Huntington’s disease

Question 227

MCC of superior vena cava syndrome? What’s the best initial test?

Answer 227

Cancer (lung cancer, or non-Hodgkin lymphoma). Cxray. See this with dyspnea, venous congestion, and swelling of the head/neck/arms

Question 228

Fever and lethargy presenting on top of a picture of cirrhosis, dx? Next step in dx? Trmt? MCO?

Answer 228

Spontaneous Bacterial Peritonitis and hepatic encephalopathy. Fever and mental changes are the most common signs. Get a diagnostic paracentesis to culture and assess for a PMN level > 250…if so start Ceftriaxone. Enteric organisms like E. Coli and Klebsiella = MCO.

Question 229

T/F: Alcohol causes a dose-dependent increase in the risk of osteoporotic fractures (>2 drinks/day)?

Answer 229

True

Question 230

Inflammation of the abductor pollicis longs and the extensor pollicis brevis tendons = ? PE test?

Answer 230

De Quervain Tenosynovitis. Finkelstein Test. Classic association with new moms and how they hold their kid. This contrasts flexor carpi radials tenosynovitis b/c pain occurs with radial flexion of the wrist and point tenderness over the trapezium.

Question 231

Common causes of priapism?

Answer 231

1) Sickle cell disease and leukemia
2) Perineal or genital laceration - cuts the cavernous artery
3) Neurogenic lesions - spinal cord injury, cauda equina compression
4) Meds - trazodone and prazosin

Question 232

What meds put you at risk for cholesterol gallstones?

Answer 232

Clofibrate, Octreotide, and Ceftriaxone = “coc block the gallbladder”

Question 233

Types of tremors:

1) bilateral action tremor of the hands or isolated head tremor, relieved with EtOH
2) resting tremor and decreases w/ movement and increases when distracted by mental activity
3) tremor associated with ataxia, dysmetria, or gait disorder - tremor gets worse at hand approaches target
4) low amplitude, not visible normally, acute onset with sympathetic activity (caffeine, stress, etc) and worse with movement - can involve face and extrem

Answer 233

1) Essential
2) Parkinson’s
3) Cerebellar
4) Physiologic

Question 234

When you have fat malabsorption, this can lead to insufficient absorption of what? This can lead to deficient levels of what? Can be exacerbated by???

Answer 234

Vit K. Factors II, VII, IX, and X, Protein C/S. Antibiotic usage

Question 235

Bicuspid Aortic valve causes ____ which is a high pitched, blowing, decrescendo diastolic murmur heard best at left sternal border.

Answer 235

Aortic Regurg

Question 236

Low IgG, IgM, IgA with recurrent sinopulmonary infxns around the age 15 - 35, B and T cell numbers are normal, dx?

Answer 236

Common Variable Immunodeficiency

Question 237

If the immunoglobulin levels normalize by age 6 mo - 11 mo, dx?

Answer 237

Transient hypogammaglobulinemia of infancy

Question 238

Formula to see how well lungs adapt to alkalemia? Acidosis?

Answer 238

PaCO2 = (0.9 x HCO3) + 16 +/- 2

Winter’s = PaCO2 = (1.5 x HCO3) + 8 +/- 2

Question 239

Rash extending from trunk out and involves palms/soles, generalized lymphadenoptahy and constitutional symptoms…

Answer 239

Secondary Syphilis - treat with IM benzathine penicillin

Question 240

Possible rxn to trmt for Syph?

Answer 240

Jarisch-Herxheimer rxn = acute febrile reaction with headaches, myalgias all occurring within 24 hrs of therapy.

*Doxy or azithromycin can be used for PCN allergic pts

Question 241

A rash that begins on the wrists and ankles, is maculopapular and spreads to trunk, extremities and palms/soles?

Answer 241

RMSF or Ehrlichiosis

Question 242

DDx for pulmonary cavitation in HIV pt?

Answer 242

Tuberculosis, atypical mycobacteria, nocardia, coccidiomycosis, and gram neg rods, and anaerobes

Question 243

HIV pt or Organ transplant w/ gram positive, weakly acid-fast FILAMENTOUS branching rod found in soil and water…=?

Answer 243

Nocardia - treat with Bactrim…

If there was acid fast bacilli = TB, check for PPD > 5mm

Question 244

Use BAL for what types of lung pathology?

Answer 244

Malignancy and opportunistic infections

Question 245

Chronic Granulomatous disease is a problem with phagocytic cells 2/2 dysfunctional NADPH oxidase enzyme complex….this leads to infections of _____ and MC infections are located where? Test?

Answer 245

Catalase positive organismsm.

MC infections = lymphadenitis, abscesses of the skin and viscera.

Dx = blue tetrazolium

Question 246

Severe combined immune def =

Answer 246

recurrent bacterial, viral, fungal infections w/ ABSENT lymph nodes, tonsils, and lymphopenia, absent thymic shadow, abnormal T/B/NK cells

Question 247

What agents shift K intracellular?

Answer 247

Insulin and glucose, sodium bicarb, and beta 2 agonists (albuterol)

Question 248

Irregular vaginal bleeding post-partum for > 8 weeks is abnormal. What are the two forms of gestational trophoblastic disease you’re worried about?

Answer 248

1) Choriocarcinoma - likes to met to the lung

2) Invasive gestational trophoblastic neoplasia - likes to remain local

Question 249

Get ____ w/ a pt who has sudden onset of photophobia, eye pain, headache, and nausea with a mid-dilated pupil. This suggests…

Answer 249

Tonometry. Glaucoma

Get CT if there were other neuro findings

Redness around the eye can be seen

Question 250

Common causes of gastric outlet obstruction?

Answer 250

Malignancy, PUD, Crohns, strictures (w/ pyloric stenosis) 2/2 caustic ingestion, and gastric bezoars

Question 251

RF’s for osteonecrosis?

Answer 251

Chronic corticosteroid use, alcohol use, trauma, and antiphospholipid syndrome

Question 252

Low back pain, hip, buttock and thigh claudication w/ impotence and atrophy of the lower extreme = ? Femoral pulses might also be weak and a bruit heard over the iliac and femoral arteries.

Answer 252

Leriche Syndrome

Question 253

What BP are you worried about for hypertension encephalopathy? 1st line anti-hypertensives?

Answer 253

> 180/120 - nitroprusside and labetalol

Question 254

Common first treatments for pt’s w/ disoriented presentation = Dextrose, Oxygen, Naloxone, and Thiamine . What would you give someone with confusion + ataxia + ophthalmoplegia?

Answer 254

Thiamine then glucose for suspected Wernicke’s encephalopathy

Question 255

What two things predispose someone’s angiodysplasia to bleed?

Answer 255

AS (disruption of vWf) and End Stage Renal Disease (platelet dysfunction 2/2 uremia)

Question 256

Reasons for prophylactic anti-D immune globulin with an UNSENSITIZED mom?

Answer 256

Give at 28-32 weeks b/c 6 week half life…and again at 72 hrs before labor

-ectopic preg, molar preg, CVS, amniocentesis, abd trauma, 2nd/3rd trim bleeding, and external cephalic version

Question 257

Digoxin toxicity looks like? WHAT CAN PRECIPITATE IT?

Answer 257

N/V and decreased appetite, confusion, and weakness, blurry vision, changes in color, blindness, arrhythmia.

Illness and diuretic use can cause pre renal azotemia and concentrate this drug with a narrow therapeutic index.

Question 258

Suspect renovascular hypertension in all its with….

Answer 258

Resistent hypertension and diffuse atherosclerosis, asymmetric kidney size, recurrent flash pulmonary edema and elevation of serum creatinine > 30% from baseline after starting ACEi or ARB!!!

Question 259

Melanosis coli is a dark discoloration of the colon with lymph follicles shining through as pale patches…what drugs can cause this? What to watch out for?

Answer 259

Anthraquinone-contraining laxatives and other laxatives. Beware of factitious diarrhea…very watery, 10-20 x / day

Question 260

Newborn/premie with feeding intolerance, abdominal distention, and bloody stools…look out for? Trmt?

Answer 260

NEC. Poor vascular supply to the GI with feeding substance that acts as good bacteria substrate can cause NEC.

Start broad spectrum antibiotics

Question 261

Hypokalemia, hypophosphatemia, and hypomagnesemia with a pt receiving TPN quickly is caused by what syndrome?

Answer 261

Refeeding Syndrome

Question 262

Distinguish ethylene glycol vs. methanol ingestion via…

Answer 262

Hematuria and flank pain coincide with ethylene glycol poisoning as a result of renal tubular damage and the formation of calcium oxalate crystals. Elevated osmolar gap helps too b/c both have increased anion gap.

Methanol typically causes visual disturbances.

Question 263

An erythematous lesion that quickly develops into bulla surrounded by erythema that subsequently ruptures leaving a painless ulcer with black necrotic center is??? Associated with what bug? Trmt?

Answer 263

Ecthyma Gangrenosum - associated with P. Aeruginosa - treat with anti-pseudomonal PCN

Question 264

What distinguishes orthostatic and vasovagal symptoms?

Answer 264

Vasovagal has pallor, sweating, and nausea with an activity vs. blurry vision and dizziness after getting up

Question 265

The MCC of infectious myocarditis and pericarditis is? What complication could cause pulses paradoxus?

Answer 265

Coxsackievirus - cardiac tamponade. This could lead to CHF in a young pt with no other RF’s

Question 266

A pt presenting with Herpes Encephalitis would present with what S/S? What would you expect to find on CSF analysis?

Answer 266

Fever, HA, seizures, with abnormalities in the frontotemporal region of the brain. Other temporal lobe path is suggested by anosmia, gustatory hallucination and bizarre or psychotic behavior.

CSF findings = increased WBCs, RBCs, protein with a NORMAL glucose.

Question 267

Pulmonary fibrosis causes decreases compliance of the lungs and spirometry shows what for TLC, FVC, FEV1, and FVC/FEV1?

Answer 267

Decreased TLC, FVC, FEV1

And normal/elevated FVC/FEV1

Question 268

Why does the hx of increased back pain while walking down hill in an elderly pt still point to osteoarthritis vs. seronegative spondyloarthopathy?

Answer 268

The seronegative spondyloarthropathy is more common in pts in their 20’s-30’s

Pseudoclaudication refers to lower extremity pain with both walking and prolonged standing that is particularly evident when walking downhill

Question 269

Hormones derived from amino acids?

Answer 269

Dopamine, Serotonin, Epinephrine

Question 270

ACTH is a _____ hormone.

Answer 270

polypeptide

Question 271

Exudative effusions can be 2/2???

Answer 271

Empyema - frank pus with very low glucose and predominance of PMN’s

Malignancy

RA

Esophageal Rupture

Pancreatitis - high amylase in the effusion

Pulmonary Infarction - bloody pleural effusion

TB - high total protein concentrations > 4 g/dL, lymphocytic leukocytosis, no purulence, glucose that is just mildly low

Question 272

What should a pt who is just diagnosed with HIV get? When do you begin giving prophylactic antibiotics? At what level And for what?

Answer 272

Pneumococcal vaccine. (conjugate first, then polysaccharide)

CD4 < 200

Give Bactrim for CD4 < 200 for PJP prevention

Azithromycin for CD4 < 50 for MAC proph

Question 273

The primary treatment for SVC syndrome?

Answer 273

Radiation therapy

Question 274

What type of PNA is associated with posterior segment of the basal segment involvement? RF’s?

Answer 274

Aspiration PNA 2/2 impaired consciousness, tracheal or NG tubes, and impaired gag reflex.

Question 275

Suspect _____ in a patient with cirrhosis with confusion, fever, leukocytosis, and a non-acute abdomen.

Answer 275

SBP

Question 276

Bullous pemphigoid most commonly affects older people >60 yrs and can have oral lesions; bullae present in flexural areas (groin, axilla) - bx shows the blister being where? Vs. Pemphigous?

Answer 276

Subepidermal for Bullous with Ig deposition in a liner pattern along the basement membrane. Intraepidermal for pemphigous. Intact blisters for pemphigous is rare.

Question 277

The leading causes of brain mets = ?

Answer 277

Lung cancer, breast cancer, melanoma and RCC.

Question 278

Where are the characteristic ovoid plaques in MS?

Answer 278

periventricular region, corpus collosum, and deep white matter

Question 279

Difference b/w polymyalgia rheumatica and polymyositis?

Answer 279

Polymyositis = symmetric weakness of pros muscles with + CPK, LDH, and LFT’s vs. pros muscle weakness in rheumatic and not the above lab abnormalities

Question 280

Pt staring blankly for several minutes and having lip smacking/chewing with subsequent leg dragging = ?

Answer 280

Complex partial seizure of the temporal lobe (common) - Todd’s paralysis follows

Question 281

How does joint pain related to SLE differ?

Answer 281

Usually polyarticular, migratory, and symmetric with the knees and hands most commonly involved

Question 282

Trmt for wide-complex tacky with monomorphic ventricular tacky is treated with?

Answer 282

Amiodarone!

Question 283

Left-sided pleural effusion, N/V, retching with anterior chest pain and SOB and hematemesis 2/2 esophageal dilation?

Answer 283

Mediastinitis - also have pneumomediastinum

Question 284

Two MCC of acute pancreatitis?

Answer 284

Alcohol and gallstone disease

Question 285

PVD should be suspected in a pt at risk for atherosclerosis w/ an extremity that is shiny, thin, hairless skin and particularly if a non healing ulcer is present. What would help dx this?

Answer 285

ABI = 1.0 - 1.3
Abnormal = 0.4 - 0.9 with severe being less than 0.4

Question 286

The presence of hypertension with hypokalemia (muscle weakness) =?

Answer 286

Conn’s Syndrome = primary hyperaldosteronism

1st - get PAC/PRA (>20)
2nd - salt loading test (suppression?)
3rd - imaging
4th - if no discrete mass, venous sampling to differ b/w bil hyperplasia (med mgmt) or adenoma (sx)

Treat with mineralocorticoid receptor antagonist like spironolactone

Question 287

Two MCC of hypercalcemia =

Answer 287

hyperparathyroidism and malignancy - most pts develop severe symptoms 2/2 the latter

Question 288

Pts who receive gastric bypass are offered what prophylactically for 6 months post op?

Answer 288

Ursodeoxycholic acid

Question 289

Passing blood clots in urine is more suggestive of glomerular or extraglomerular disease?

Answer 289

Extraglomerular

Question 290

How to distinguish b/w primary hyperparathyroidism vs. renal osteodystrophy?

Answer 290

Primary hyperparathyroidism (2/2 single parathyroid adenoma) has low phosphorus and elevated calcium VS. Renal Osteodystrophy (2/2 CKD and parathyroid gland hyperplasia) with elevated levels of phosphorus (2/2 decreased GFR), bone pain, and poor renal function w/ abnormal processing of Vit D creating hypocalcemia; therefore, elevated phosphorus and low calcium stimulate parathyroid. The renal dysfunction also distinguishes this from parathyroid atrophy,

Question 291

Associated with:

1) Anti-Centromere Ab’s
2) Anti-neutrophilic cytoplasmic Ab’s
3) Anti-smooth muscle Ab’s
4) Anti-mitochondrial Ab’s

Answer 291

1) Limited Scleroderma, CREST
2) Granulomatosis with Polyangiitis (Wegeners)
3) Autoimmune Hepatitis
4) Primary Biliary Cirrhosis

Question 292

Visceral pain = ? Somatic pain = ?

Answer 292

Visceral pain is harder to localize 2/2 decreased number of nerve fibers.

Somatic is very easily localized from innervation of the peritoneum.

Question 293

Pt with overflow incontinence is treated with:

Answer 293

Augmented voiding (double voiding, suprapubic pressure, timed voids, and catheters) and pharm agents like cholinergic agents (Bethanechol)

Question 294

SBP can be caused by either ___ or ____ ?

Answer 294

Gram negative rods or gram positive cocci

Question 295

Serum-to-ascites gradient > ?? increases risk of ascites?

Answer 295

> 1.1

Question 296

How does spironolactone help cirrhotic patients with ascites?

Answer 296

It’s an aldosterone receptor antagonist so it prevents holding onto fluid and is also a potassium-sparing diuretic

Question 297

Two types of conjugated hyperbilirubinemia vs unconjugated hyperbilirubinemia?

Answer 297

Increased Conjugated Hyperbilirubinemia = Rotor and Dubin-Johnson; Rotor is a problem with storage so it leaks into the plasma and there is elevated unconjugated and conjugated forms (no pigment granules) vs. Dubin-Johnson MC seen in Jews with pigmented hepatocytes 2/2 epinephrine granules. Can test for it by seeing elevated Coproporphyrin I in the urine vs normal people having Coproporphyrin III; normal LFT’s - benign, no trmt

Increased Unconjugated Hyperbilirubinemia = Crigler-Najjar Syndrome and Gilberts. Gilberts is thought to be provoked by illness, stress or fasting. The former is an autosomal recessive disease w/ phototherapy and plasmapheresis being the mainstay for treatment.

Liver steatosis 2/2 OCP’s would have abnormal LFTs

Question 298

Metformin + Signs of Renal Failure = ?

Answer 298

Lactic Acidosis

Question 299

3 MCC of chronic cough are upper-airway cough syndrome (post-nasal drip), asthma, and GERD. What type of medications would cause relief 2/2 to the first cause?

Answer 299

H1 blockers - Anti-histamines. The hx of being awoken at night from her cough is also characteristic of post-nasal drip.

Question 300

What two signs are specific for pericardial effusion?

Answer 300

Electrical alternans (varying amplitude of QRS axis) w/ sinus tachy

Question 301

PBC histology?

Answer 301

Portal tracts are infiltrated by lymphocytes, macrophages, plasma cells, and eosinophills. Noncaseating granulomatous inflammation and progressive destruction are seen in the terminal and conducting bile ducts.

Question 302

Causes of hypoparathyroidism:

Answer 302

1) Post-surgical (MCC)
2) Autoimmune (MC non-surgical cause, low calcium and elevated phosphorus)
3) Congenital absence (DiGeorge)
4) Defective Ca-sensing receptor on PT glands
5) Non-autoimmune destruction of the parathyroid tissue 2/2 infiltrative diseases like hemachromotosis, Wilson, neck radiation

Question 303

Serum phosphorus is ____ in Vit D Deficiency? Insufficient Ca intake results in _____ phosphorus levels?

Answer 303

Low. Low 2/2 activation of PTH system

Question 304

Isolated Systolic Hypertension is an important cause of hypertension in the elderly - most likely 2/2 ?

Answer 304

Decreased elasticity of arterial wall - should always be treated b/c its associated with an increased risk of CV disease. Start with mono therapy of low dose thiazide, an ACE inhibitor, or long acting CCB

Question 305

What are the levels are varying medications used with asthma:

Answer 305

Intermittent: < 2 per week, < 2 per month, < 2 night time probs, no PFT changes = albuterol

Mild Persistent: > 2 per week but NOT daily, < 4 night time wakings/month, normal PFT = albuterol, inhaled corticosteroid

Moderate Persistent: daily, weekly night time wakings, PFT 60-80% = albuterol, inhaled corticosteroid, long-acting beta-agonist (salmeterol)

Severe Persistent: throughout the day exacerbations, frequent nighttime awakenings, FEV< 60% = albuterol, long acting beta agonist and either high dose inhaled corticosteroid OR oral corticosteroid

Question 306

Increased spleen, liver and lymph nodes with fatigue, night sweats, HA dizziness, various visual problems, and pain and numbness in peripheral extreme WITH IgM spike on electrophoresis and signs of hyper viscosity = ?

Answer 306

Waldenstrom’s Macroglobulinemia vs. IgG or IgA in multiple myeloma

Question 307

Drug induced esophagitis causes:

Answer 307

Potassium, Aspirin, Iron, NSAIDS, Alendronate, Quinidine, Tetracyclines - sudden onset of odynophagia, retrosternal chest pain

Question 308

Bloody diarrhea with no travel history = 3 MCC?

Answer 308

E Coli (don’t try and treat, HUS risk), Shigella, and Campylobacter

Question 309

Damage to CN V1 would affect what?

Answer 309

The trigeminal nerve has three branches, V1 carries sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose and frontal sinuses

Question 310

MC seen in young adult males, this disease has nephritic range proteinuria, urinary sediment with dysmorphic RBC’s and RBC casts + pulmonary findings of SOB, hemoptysis, cough. What’s the dx? What would be seen on renal bx?

Answer 310

Goodpasture’s Disease . IgG lining the basement membrane in immunofluroescence = against type IV collagen

• Systemic symptoms of fever, chills, dyspnea, sweats and weakness are rare

Question 311

Restrict what in a pts diest having kidney stones?

Answer 311

Protein and oxalate; NOT Ca!

Question 312

What to give a pt undergoing splenectomy weeks before the surgery and then after?

Answer 312

Weeks before give Meningococcal, Pneumococcal, Haemophilus Influenza

After surgery, daily PCN for up to 3 yrs

Question 313

What complication should you watch out for in a pt presenting with IBD who seems really sick?

Answer 313

Toxic Megacolon: dx requires
1) radiographic evidence of colonic distention

+ 3/4: fever , tachycardia, anemia, neutrophilic leukocytosis

+ 1/4: volume depletion, altered sensorium, electrolyte disturbances, and hypotension

Question 314

Fluctuating cognition with variations in attention + recurrent visual hallucinations that are well formed and detailed + spontaneous Parkinsonism that doesn’t respond well to dopaminergic agents = ?

Answer 314

Dementia with Lewy Bodies

Question 315

Worrisome signs that would make you think a cyst is malignant?

Answer 315

irregular border, multilocular, multiple septations, heterogeneous content and contrast enhancement on MRI - benign cysts can be left alone unless causing the pt a significant amount of pain

Question 316

If someone is stuck with known Hep B needle and their vaccination hx is unknown, what do they receive?

Answer 316

HepB Immunoglobulin and the Vaccine series…this is the same for someone never vaccinated. If immunity is confirmed, reassurance.

Question 317

What test help differentiates Leukemoid reaction vs. leukemia?

Answer 317

Alkaline Phosphatase elevation

Question 318

Leukemia markers:
AML
ALL
CLL
CML

Answer 318

AML - auer rods (eosinophilic needle-like inclusions), immature leukocytes
ALL - lymphphocytic marker = Tdt; kid predominant
CLL -
CML - leukocytosis > 500,000, Philadelphia chromosome, 9q 22q balanced translocation for bcr/abl fusion gene with tyrosine kinase activity

Question 319

Cerebellar ataxia, telangiectasias and immunodef = ?

Answer 319

Ataxia Telangiectasia

Question 320

Normal iron studies with basophilic stippling?

Answer 320

Lead poisoning

Question 321

Chloramphenicol side effect?

Answer 321

Aplastic anemia

Question 322

Pna pathogen descriptors:

Gram negative rods =
Gram positive rods =
Gram negative diplococci =
Gram positive diplococci in chains =

Answer 322

Gram negative rods = Klebsiella, Enterobacter, Serratia, Proteus (debilitated pts)

Gram positive rods = Corynebacterium Diptheriae

Gram negative diplococci = Strep. Pna (MCC CAP)

Gram positive diplococci in chains = Moraxella Catarrhalis
(chronic bronchitis, COPD)

Question 323

Differentiate silent lymphocytic thyroiditis and subacute thyroiditis in hx and PE

Answer 323

silent lymphocytic thyroiditis = seen in postpartum pts

subacute thyroiditis = tender and painful

Question 324

Gingivostomatitis and pharyngitis with adjacent vesicles is the MC presentation of?

Answer 324

HSV 1

Question 325

Precipitating factors for Porphyria Cutanea Tarda:

Answer 325

Smoking/Sun-Hep C-Alcohol-Iron-Estrogen use

Question 326

Speckling seen in a joint via arthroscope = indicates what pathology? Vs. what would be seen in bleeding, like hemophilia?

Answer 326

Calcium from pseudo gout = 2/2 costochondritis associated w/ hyperparathyroidism, hypothyroidism, acromegaly, Wilsons disease, hypomagnesemia, hemachromatosis

Question 327

Budd-Chiari normally manifests in association with?

Answer 327

Coagulopathic diseases because it’s obstruction of hepatic venous outflow = cancer, sickle cell, PNH, polycythemia vera

Question 328

Angiographic procedures in a pt with atherosclerosis predisposes them to?

Answer 328

Mesenteric Ischemia = sudden severe abdominal pain out of proportion to PE

Question 329

Greenish, foul smelling diarrhea with endoscopic yellow-green plaques adherent to GI mucosa = ?

Answer 329

Pseudomembranous Collitis 2/2 Clostridium Difficile

Question 330

RA is one of the MCC of ______. It can deposit where? Common PE findings? Dx step?

Answer 330

Amyloidosis. Can deposit in the kidneys, skin, tongue, GI, or peripheral nerves. Carpal tunnel, skin plaques around axilla, nephrotic syndrome, HSM, and macroglossia. Biopsy rectal mucoa, abdominal fat, or gingiva to confirm dx.

Question 331

Acute Intermittent Porphyria presents like? Defect?

Answer 331

Sudden abdominal pain manifested by anxiety, insomnia, depression, hallucinations, and paranoia. Hydroxymethylbilane Synthase = defect.

Question 332

Post-gastrectomy pts vs post-ileal resection pts and B12?

Answer 332

Post gastrectomy = intrinsic factor def causes anemia

Post-Ileal resection = Vitamen def 2/2 malabsorption of B12-Intrinsic Factor complex

Question 333

Metatarsal Stress Fracture hx?

Answer 333

Runner who has pain on bottom of foot that has decreased time to onset with each subsequent run and eases with relaxation

Question 334

DIC can be precipitated by?

Answer 334

Trauma, Obstetric complications, Malignancy, Sepsis = low platelets, elevated PT/PTT, shistocytes

Question 335

Pauci Immune D/Os = ?

Answer 335

PAN, Churg-Straus, Wegeners (Granulomatosis with polyangiitis = IgG + complement + granulomatous vasculitis) - first two have p-ANCA vs. latter having c-ANCA. Asthma and blood eosinophelia demarcate Churg-Straus with palpable purpura indicating PAN

Question 336

Dull epigastric pain + glucose intolerance + hypercoagulable =

Answer 336

Pancreatic Cancer

Question 337

Virchow’s node (supraclavicular) and Sister Mary Joseph’s Node = look for?

Answer 337

Gastric cancer

Question 338

Young male smokers with pain at rest in distal extremities (toes/fingers) with acute neuromuscular bundle inflammation?

Answer 338

Buerger’s = Thromboangiitis Obliterans

Question 339

Benign liver fibroma or ovarian tumors + ascites and large effusion – p/w right pleural effusion possibly with no liver abnormality or stigmata = dx ? Imaging? Trmt?

Answer 339

Meig’s Syndrome - get a CT. Remove tumor to remove fluid.

Question 340

T/F - classic OA symptoms can dx the d/o w/o imaging?

Answer 340

True

Question 341

Name the associated d/o with each marking:
CEA -
Alpha-fetaprotein -
5HIAA -

Answer 341

CEA - metastatic colon cancer
Alpha-fetaprotein - Hepatocellular carcinoma
5HIAA - Carcinoid syndrome (diarrhea, facial flushing, bronchoconstriction - requires liver involvement…damage to RHV might be seen)

Question 342

What infection predisposes woman to PTL and still birth (or miscarriage)?

Answer 342

Listeria Monocytogenes - unpasteurized milk, cheese, deli meat and raw veggies

Question 343

Pruritic papule that transforms into vesicle then black eschar with edema, erythema, and a few surrounding vesicles - dx? smear shows? Trmt? Who’s at risk epi wise?

Answer 343

Anthrax - Gram positive Encapsulated Rods - Pencillin G

Look out for farmers, vets, and workers in the wool mill!

Question 344

Osteomalacia = def of what? Lab values?

Answer 344

Vit D deficiency 2/2 malabsoprtion, intestinal bypass surgery, celiac spruce, or chronic liver/kidney disease. Very low phosphorus, elevated PTH, low/normal Ca.

*Can see thinning of bone cortex and eventual codfish vertebral bodies and pseudo fractures (Looser zones)

Question 345

A post-bone marrow transplant pt presenting 2wks-4month post-op with lung and GI probs = ?

Answer 345

CMV!!! Upper and lower GI ulcers, pneumonitis, arthralgias, myalgias, esophagitis

Question 346

Symmetrical proximal muscle weakness, smoking hx, and erythematous rash on the dorsum of the fingers or on upper eyes ?dx?

Answer 346

Dermatomyositis - get a muscle bx

Question 347

Prolactinoma treatment?

Answer 347

Dopamine-agonists like Bromocriptine or Cabergoline

Question 348

Antibiotic prophylaxis (IM Benzthine Pen G Q 4wks) for Rheumatic Fever:

1) RF w/o carditis
2) RF w/ carditis but no residual heart/valvular disease
3) RF w/ carditis and persistent or valvular heart disease

Answer 348

1) 5 yrs of until 21 yrs old (whichever is longer)
2) 10 years or until 21 (“ “)
3) 10 yrs or until 40 (“ “)

*RF = 2/2 Group A beta hemolytic streptococcus

Question 349

5 common Seffx of amiodarone:

Answer 349

1) Pulm tox
2) Thyroid dysfxn = hypothyroidism - get TSH checked before starting bc so common
3) Hepatotoxicity - stop if LFTs increase MORE than 2x
4) Corneal deposits
5) Blue-gray skin discoloration

Question 350

MMSE < 24 = ?? Findings on CT for Alzheimers (besides the MC, which is NL) ?

Answer 350

Diffuse cortical and subcortical atrophy which is disproportionately greater in the parietal and temporal area (around hippocampus)

Question 351

Idiopathic Intracranial Hypertension = symptoms? Trmt?

Answer 351

Usually seen in overweight woman of child bearing age with headaches, no focal neurological defects except 6th CN palsy, papilledema, negative CT but increased opening pressure on lumbar puncture. Can be associated with tetracycline or isotretinoin use!

Acetazolamide = 1st line, decreases CSF production from choroidal plexus – furosemide if refractory – shunting/repeated lumbar taps if still not responding

Question 352

FiO2 should be kept below _____ in ARDS to avoid _____

Answer 352

< 40% to avoid Oxygen toxicity

Question 353

In pt’s with Hypertrophic Obstructive Cardiomyopathy, what’s the deformation with the mitral valve?

Answer 353

Abnormal mitral leaflet motion = “systolic anterior motion”…basically the valve can be sucked into and further obstruct the outflow track

Question 354

Lewy bodies are described as what and seen in what?

Answer 354

They are eosinophilic intracytoplasmic inclusions that represent alpha-synuclein protein and can be seen in the substantial nigra, locus ceruleus, dorsal rap he, and substantial innominata.

Lewy Body Dementia = early dementia + signs of parkinsonism

Neurofibrilary tangles = Alzheimers

Question 355

Signs of anticholinergic toxicity?

Answer 355

Dry skin, dry mouth, constipation, urinary retention, flushing, vision changes (mydriases), and confusion. Trihexphenidyl can cause headache and retro-orbital pain too!

Question 356

Best test for suspected Chlamydia vs. Gonorrhea infxn?

Answer 356

Nucleic Acid Amplification Test.

Question 357

Atypical PNA is different from CAP how? Common Types? What does Erythema Mutiforme point you towards?

Answer 357

More indolent PNA and causes extra pulmonary findings.

Mycoplasma, Coxiela, Chlamydia, Influenza, Legionelle

Mycoplasma = MC and c/w EM

Question 358

Causes of proximal muscle weakness?

Answer 358

Connective tissue (polymyositis), endocrine (hypo/hyper thyroid, Cushing), and neuromuscular (LE or MG), or steroids.

Question 359

Parotid inflammation w/ what MCO? Prevent this how?

Answer 359

Commonly seen in dehydrated post-op pts. MCO = staph. Adequate fluids and good oral hygiene = preventative measures

Question 360

What drug administration distinguishes Crigler-Nijjar Syndrome 1 and 2?

Answer 360

One is more severe with signs of kernicterus and admin of phenobarbital does NOT lower levels; phototherapy and plasmapharesis are needed.

Type 2 is more mild and phenobarbital lowers serum bili.

Question 361

Don’t discontinue isoniazid in its with asymptomatic rise in their LFT’s unless…

Answer 361

it’s > 2x

Question 362

Nipple rash with ulcerating eczematous appearance consider…? Bx with large cells surrounded by halos = ?

Answer 362

Paget’s Disease. 85% of pt have underlying breast cancer. This biopsy shows adenocarcinoma and the halos are 2/2 keratin retraction from cancer cells

Question 363

Trmt options for people with hx of liver problems, ascites and elevated BUN/Cr?

Answer 363

Most likely hepatorenalsyndrome - can use midodrine and octreotide

Question 364

Drugs associated with pancreatitis?

Answer 364

1) Diuretics (furosemide and thiazides)
2) Immune drugs (sulfasalazine, 5-ASA, azathioprine)
3) HIV meds (didanosine)
4) Antibiotics (metronidazole, tetracycline)

Question 365

MCC of endocarditis in native valves following dental procedures?

Answer 365

Strep Viridins (S. mitis, S. Sanguis, S. Mutans, S. Salivarius)

Question 366

Find S. Bovis…get what next test?

Answer 366

Colonoscopy

Question 367

S. epidermidis is an important cause of what kind of endocarditis?

Answer 367

Prosthetic valve endocarditis

Question 368

What is required for the dx of AS?

Answer 368

Echo - symptomatic AS warrants valv replacement. DONT GET A STRESS TEST, COULD CAUSE ARRHYTHMIA

Question 369

Medical therapy is recommended for carotid artery stenosis with what % blockade?

Answer 369

< 50%

Question 370

Pulmonary dyspnea with bone and prostate spreading + skin findings like heaped up verrucous or nodular lesions with violacious hue that may evolve into micoabscess = ?

Answer 370

Blastomycosis - oral itraconazole or amphotericin B depending on severity

Question 371

Infectious causes of adrenal insufficiency?

Answer 371

Tuberculosis ( calcified), fungal infections and CMV

Question 372

Pig farmers associated with? vs. Sheep?

Answer 372

Neurocysticercosis vs. Echinococcosis

Question 373

With Cushingoid presentations, what else is no longer suppressed in this pt that might lead to hyponatremia>?

Answer 373

ADH is normally inhibited by cortisol so if the levels are low, then ADH would cause hyponatremia in a Cushing pt.

Question 374

What things to assess to consider hospitalizing a PNA pt?

Answer 374

CURB-65 = Confusion/Urea > 20/RR >30/BP 65

Question 375

Trmt for CAP?

Answer 375

New generation fluoroquinolones like Levofloxacin or Moxifloxacin for inpatient vs. Azithromycin or Doxy for outpt

*Clindamycin for suspected aspiration pna

Question 376

Tenosynovitis + migratory polyarthralgias + purpuric/pustular skin lesions = ?

Answer 376

Dissimenated Gonococcal Infxn

Question 377

ECG findings with PE?

Answer 377

S1Q3T3

Question 378

RCC findings? Lab findings? Test?

Answer 378

Flank pain, palpable abdominal renal mass, hematuria, scrotal varicoceles, and paraneoplastic syndromes (anemia, thrombocytosis, fever, hypercalcemia, and cachexia)

Elevated EPO

Get an abdominal CT!

*varicocele does not go down in recumbent position b/c of blockade

Question 379

Pna with GI manifestation, elevated LFTs, and hyponatremia?

Answer 379

Legionella! Get urine antigen test! Treat with quinolone or macrolide.

Question 380

Oxybutinin is for what? Vs Bethanechol and alpha blockers?

Answer 380

Oxybutynin = urge incontinence

Bethanechol and Alpha Blockers = overflow incontinence

Question 381

GERD predisposes to what two lower esophageal abnormalities?

Answer 381

Benign peptic esophageal strictures (which would be circumferential narrowings leading to decreased GERD symptoms) and Barrett’s esophagus (needing biopsy to r/o adenocarcinoma)

Radiation, scleroderma, and caustic ingestions can also causes peptic strictures

Question 382

Causes of high output cardiac failure?

Answer 382

Thyroxtoxicosis, Paget Disease, Anemia, And Thiamine Def, and AVMs. Present’s with flushed features, LVH, tachycardia, systolic murmur 2/2 more blood flow.

Question 383

Swelling + angioedema after given what med would make you suspect C1 inhibitor def?

Answer 383

ACEi

Question 384

Hyperkalemia causing drugs>?

Answer 384

ACEi, ARB, Digitalis, Cyclosporine, Heparin, NSAIDS, Succinylcholine, and BACTRIM

Question 385

Old person with isolated elevated alk phos?

Answer 385

PAGETS!

Question 386

Hep C can present with intermittent risings in LFTs and pt can be basically asymptomatic…waxing and waning labs! What extra hepatic association can be seen?

Answer 386

Porpheria Cutanea Tara, Mixed cryoglobulinemia, and membranoproliferative GN, lichen planus.

*low compliment levels 2/2 circulating immune complexes; palpable purpura and arthralgias.

Question 387

How to treat active vs. prophylaxis w/ + PPD?

Answer 387

Active = RIPE + pyridoxine (2 months) then RI (4 months)

+ PPD = Isoniazid and Pyridoxine for 9 months prophylactically

Question 388

Postherpetic neuralgia can be prevented and or treated with what two meds?

Answer 388

TCA and Antiviral therapy

Question 389

Episcleritis is associated with? Vs. Anterior Uveitis?

Answer 389

Episcleritis = RA and IBD

Anterior Uveitis = HAL-B27 stuff

Question 390

What helps distinguish Homocystinuria from Marfans?

Answer 390

Intelectual delay, thromboembolis events, FAIR HAIR AND EYES. See elevated homocysteine and methane levels 2/2 cystathionine synthase def. Give Vit B6, folate, B12 to lower levels. Give anti platelets and anticoagulation too!

Question 391

Glomus tumor MC found where?

Answer 391

Under the tongue = severe intermittent pain, tenderness and sensitivity to touch and is a common vascular benign tumor - can also be seen on palms and wrists

Question 392

Elevated lab value in PCP infxn? What are the indications for steroid use in conjunction with Bactrim again>?

Answer 392

LDH.

PaO2 < 70 mmHg or A-a gradient > 35

Question 393

What things are associated with secondary causes of Restless Leg Syndrome?

Trmt?

Answer 393

Fe def anemia, pregnancy, Parkinsons, MS, antidepressants/metoclopromide, DM, uremia.

Fe supplementation, conservative massaging, dopamine agonists (pramipexole) or alpha-2-delta CC ligands (Gabapentin)

Question 394

What is the causative agent of large, pedunculated, exophytic papule with scales? Dx?

Answer 394

Bartonella Henselae/quintana causes Bacillary Angiomatosis (on skin and viscera)

Dx with biopsy and look for angiomatous histology

RISK OF HEMORRHAGE!!!

Question 395

Cellulitis associated with Tinea Pedis with signs of toxicity, trmt =?

Answer 395

IV Nafcillin or Cefazolin (vanco in MRSA areas)…treat the tinea later, the cellulitis is the main prob

Question 396

A person with unremitting nose bleeds, blanching red papules on oral mucosa, and digital clubbing, and elevated hamtocrit = ?

Answer 396

Osler-Weber-Rendu syndrome (auto dom) = diffuse telangiectasias, recurrent epistaxis, and widespread AV malformations (skin, GI, liver, brain, lung). They can even cause fatal hemoptysis. Can even develop R-L shunting,

Question 397

Elevated Cr in the setting of suspected BPH, what imaging would you get? What med mgmt can help with symptoms of obstructive uropathy?

Answer 397

Renal U/S to look for bilateral hydronephrosis (evidenced by elevated Cr and BPH).

Tamsulosin (alpha blocker) and Finasteride (5-alpha reductase inhibitors) can improve BPH symptoms

Question 398

3 P’s of McCune Albright Syndrome = ?

Answer 398

precocious puberty, polyostotic fibrous dysplasia, and pigmentations (cafe au lait)

Question 399

When to treat sarcoid? S/S?

Answer 399

When they are symptomatic! Hilar adenopathy, w/ or w/o reticulonodular infiltrates, biopsy of non-caseating granulomas, serum levels of ACE may be elevated. Give systemic glucocorticoids

Question 400

Three types of partial seizures?

Answer 400

Simple Partial - no LOC, aura, deja vu

Complex Partial - LOC with automatisms, aura

Partial with Secondary Generalization - have tonic clonic manifestations, muscle aches, elevated CPK,

Question 401

Drugs causing crystal-induced acute kidney injury?

Answer 401

Protease inhibitors, Ethylene Glycol, Methotrexate, Sulfonamides, Acyclovir

Question 402

Acanthosis Nigricans can be a sign of what in older people?

Answer 402

GI Malignancy

Question 403

What can be given to slow the progression of MS?

Answer 403

Interferon Beta

Question 404

Polymyalgia rheumatica is different than fibromyalgia how?

Answer 404

Highly elevated ESR, NO muscle pain, just stiffness in the shoulders and pelvic girdle. Associated with Temporal Arteritis!

Question 405

Immediate acting drug for migraines other than triptans?

Answer 405

Chlorpromazine, prochlorperazine, metoclopramide = IV antiemetics as mono therapy of as adjuvent therapy + NSAIDS or triptans

Question 406

What minors don’t need parental consent?

Answer 406

Homeless, Lives Alone, Financially Independent, Married, Military OR for med emergency, contraception, STI’s, prenatal care, and substance abuse

Question 407

SCC in situ of the skin with thin erythematous plaque with well defined irregular borders with overlying scale or crust?

Answer 407

Bowen’s Disease

Question 408

Systemic and topical corticosteroids can induce this eruption characterized by monomorphous erythematous follicular papules distributed in the face trunk and extremities - NO COMEDONES

Answer 408

“Steroid Acne”

Question 409

What meds should be considered for post-transplant pts for prophylaxis?

Answer 409

Bactrim for PCP, Toxo, Nocardiosis, and other infxns. Can also give Ganciclovir or Valganciclovir to prevent CMV infxns.

Vaccinate against Influenza, Pneumococcus, and Hep B

Question 410

Worsening signs of prognosis for CLL?

Answer 410

Splenomegaly —Anemia —- Thrombocytopenia

Question 411

Preseptal cellulitis is differentiated from orbital cellulitis how?

Answer 411

orbital cellulitis has opthalmoplegia, pain with EOM movement, proptosis, vision impairment

Staph and Strep = common pathogens

Question 412

Trmt pf prostatitis?

Answer 412

Bactrim/Fluoroquinolones = acute (4-6 wks)

Fluoroquinolones = chronic

Question 413

Don’t use these for the treatment of Essential Tremor if the pt has COPD or bradycardia….What else could you use? Seffx?

Answer 413

B-Blockers. Could use Primidone which is an anticonvulsant that converts into phenobarbital and can cause acute intermittent porphyria = abdominal pain, neurologic and psychiatric abnormalities.

Question 414

Mild hypovolemia hypernatremia can be treated with 5% dextrose in .45% saline. What if it’s severe?

Answer 414

0.9% saline

Question 415

Medicines causing ototoxicity?

Answer 415

Aminoglycosides, Chemo, Aspirin (high high doses) and loop diuretics like Furosemide!

Question 416

Pts with generalized resistance to thyroid hormones have…

Answer 416

High serum T4 and T3 levels with normal TSH. They typically have features of HYPOthyroidism despite having “HYPERthroid”-like labs

Question 417

Pellgra presents…

Answer 417

Dementia/Dermatitis/Diarrhea and MC’ly 2/2 corn-based diet. Niacin deficiency and the rash gets worse in the sun!

Question 418

Pt with Chronic Renal Failur with bleeding, normal PT, PTT and elevated BT = ? Trmt?

Answer 418

Platete Dysfunction 2/2 uremia - give Desmopressin to releave vWF and Factor VIII

Question 419

Trachoma is characterized by?

Answer 419

Chlamydia Trachomatis Serotype A-C and is a major cause of blindness worldwide. IT has follicular conjunctivitis, pannus (neovascularization).

Start topical erythromycin or oral azithromycin immediately

Question 420

Low leukocyte alkaline phosphatase WITH leukpocytosis = ?

Answer 420

CML

Question 421

3 Causes of spherocytes>?

Answer 421

G6PD def, Hereditary spherocytosis and Autoimmune Hemolytic Anemias

Question 422

Three therapies proven to prolong survival in COPD pts?

Answer 422

Smoking cessation, 02, and Lung reduction therapy in some

Other symptomatic relief can include SABA + anti-muscarinic agents

Question 423

Vasovagal is what kind of diagnosis?

Answer 423

Clinical - but can get a tilt table if unsure

Question 424

PNH = def in what? Test/.

Answer 424

GP1 RBC membrane anchor protein - since this is abnormal it CANT prohibit CH55 and CD59 from binding to it and being subsequently attacked by complement.

Patients with PNH have a tendency towards venous thrombosis, especially in the hepatic veins!!!!!

Question 425

Trmt of Torsades?

Answer 425

Mag Sulfate!

Question 426

Interstital Cystits = ?

Answer 426

Painful bladder syndrome with pelvic pain worsened by bladder filling, intercourse, exercise, spicy foods with urinary frequency, urgency, and nocturne

Cystoscopy shows submucosal petechiae and ulcerations

Question 427

Trmt of acute RF? for the pericarditis/arthritis? for the chorea?

Answer 427

Penicillin G until adulthood. Corticosteroids for the chorea. and NSAIDS for the arthralgia and pericarditis

Question 428

Common causes of viral meningitis>

Answer 428

Echovirus, coxsackievirus

Question 429

Recurrent damage to lungs via infections or chronic thromboembolic disease can cause (esp with COPD) chronic hypoxia leading to?

Answer 429

Constriction of the pulmonary artery system leading to pulmonary hypertension with RVH, and subsequent RVH – elevated JVP, congestive hepatosplenomegaly, hepatojugular reflux and lower extreme edema

Question 430

Cystinuria cause what kind of stones? Test?

Answer 430

Hexagonal, radioopaque crystals with + urinary cyanide nitroprusside

Question 431

Laying flat and turning to left side can make a patient become more aware of what murmur in particular?

Answer 431

AR - aortic root dilation and bicuspid AV are the MCC in US. RF = MC in other countries with poor access to ABx.

See water hammer pulse and increased pulse pressure

Question 432

Pressure definition of the pulmonary artery for Pulm Htn?

Answer 432

> 25 mmHg at rest or > 30 mmHg

Question 433

Best way to monitor respiratory function in pt with Guillain-Barre Syndrome?

Answer 433

Vital Capacity

Question 434

Differentiate AS from HOCM

Answer 434

They can both have a crescendo-decrescendo murmur BUT the location will differ….AS on the RSB and HOCM on the LSB…AS also tends to have radiating sounds to carotids

Question 435

What nerve is compromised:

1) Anterior shoulder dislocation, forceful abduction and external rotation ?
2) Fracture of the humeral midshaft, fitted crutches, wrist drop, sensory loss of posterior arm and lateral dorsal hand
3) Fracture of the medial epicondyle of the humerus with claw hand
4) Scapular winging, surgery around the axilla

Answer 435

1) Axillary n.
2) Radial n.
3) Ulnar n.
4) Long Thoracic n.

Question 436

Alkalotic pH causes what to happen with Calcium?

Answer 436

Increase in the affinity os serum albumin to calcium, thus decreasing levels of the only active form of calcium, ionized calcium

Question 437

What CD4 count can you give live vaccines?

Answer 437

> 200 = MMR, Varicella, Zoster (age >60)

• this also assumes no hx of AIDS defining illness

Question 438

Name the toxicity:
CNS stimulation (HA, insomnia, seizures) and GI distrubances (nausea, vomitting) and cardiac probs (arrhythmias).

Answer 438

Theophylline Tox

Question 439

Hepatic encephalopathy is 2/2 decreased ability to rid the body of? What can precipitate this? Trmt?

Answer 439

Excess ammonia 2/2 liver unable to convert it to urea.

Caused by medications, hypovolemia, infection, or excessive nitrogen load (GI bleed, high calorie diet).

Give lactulose/lacitol - it’s a non-absorbable disaccharide; it’s converted by colonic bacteria into short chain FA’s like lactic acid whereby it can convert ammonia to ammonium (a non-absorbable form that will be excreted). Rifaximin can also decrease the number of ammonia-producing bacteria in the colon. Laxatives can help too

Question 440

4 Centor criteria for adults with pharyngitis for trmt?

Answer 440

Fever, Adenopathy (anterior), Tonsilar exudates, and ABSENT cough

Question 441

Give cryoprecipitate for?

Answer 441

loss of fibrinogen, vWF, and Factor VIII def

Question 442

Type II DM = prone to develop what osmolar problem?

Answer 442

Non-ketotic Hyperglycemia = Nonketotic hyperosmolar syndrome …elevated glucose causes increase in cortisol and catecholamine and inhibit insulin (glucose > 600 normally) Causes AMS - can also cause acute change in vision

Question 443

Syphillis trmt in adults who have PCN allergy?

Answer 443

Doxycycline

Question 444

Brushfield spots (white spots on iris), sandal gap toes have what neurocognitive risks, hematolic risks, endocrine, MSK risk?

Answer 444

Down Syndrome

Duodenal atresia, Hirshsprung, Intelectual disability, Alzheimer, Acute Leukemia, Hypothyroidism, T1 DMAtlantoaxial instability, complete AV canal/VSD/ASD

Question 445

Amlodipine can cause?

Answer 445

Peripheral edema (Dihydropyridine Ca-inhibitors)

Question 446

Tinea Versicolor>

Answer 446

Pale, velvety pink or whitish hypo pigmented macules that do not tan and do not APPEAR scaly, but scale when scraped.

Trmt = Selenium Sulfide and ketoconazole shampoo

**VS. Tinea Corporis that has a VISIBLE scaly border

Question 447

Dilated cardiomyopathy caused by acute viral myocarditis = ?

Answer 447

Systolic dysfunction caused by Coxsackie B (MC), Parvovirus B19, human herpesvirus 6, adenovirus, and enterovirus

Question 448

Trmt for diabetic neuropathy?

Answer 448

TCA and Gabapentin

Question 449

Mixed Essential Cryoglobulinemia?

Answer 449

Palpable purpura, proteinuria, hematuria….arthralgias, HSM, low complement - look for underlying Hep C

Question 450

Transudative fluide has a pH of? Exudative?

Answer 450

7. 4 - 7.55

7. 3 - 7.45

Question 451

CMV retinitis looks like?>

Answer 451

CD4 less than 50, yellow-white patches of retinal opacification and hemorrhages

Question 452

Gritty sensation, eye discharge, with rhinorrhea, and mild sore throat ?

Answer 452

Viral conjunctivitis! Adenovirus commonly, cool/warm compress

Question 453

Thiazide diuretics metabolic side effects:

Answer 453

Hyperglycemia, elevated LDL, elevated triglycerides, hyponatremia, hypokalemia, and hypercalcemia

Question 454

People whom pneumococcal vaccine is recommended for < 65yrs?

Answer 454

Asthma, COPD, emphysema, chronic heart disease, DM, chronic liver disease, cigarette smoker, alcoholism, cochlear implants, CSF leaks, immunocompromised, function or asplenics, sickle cell, or hemoglobinopathy

• subsequent booster 5 years later

Question 455

Cerebral septic emboli are treated with ?

Answer 455

Antibiotics

Question 456

Sausage fingers, nail pitting, red plaques with silver scaling ?

Answer 456

Psoriatic Arthritis - systemic corticosteroids are relatively contraindicated - use NSAIDS, anti-TNF and methotrexate

Question 457

Meds conferring decrease mortality = >

Answer 457

Acei, arb, bblockers, and spironolactone/eplerenone

Digoxin and furosemie = symptomatic relief

Question 458

Addisons acid status?

Answer 458

Non-anion gap metabolic acidosis

Question 459

Alopecia, abnormal taste, impaired wound healing, bullous pustules surrounding mouth or body orifices ?

Answer 459

Zinc deficiency

*selenium = cardio tox

Question 460

Microcytic hypochromic anemia simulating iron deficiency with two groups of RBCS (normochromic and hypo chromic)…but lab studies show ELEVATED iron and decreased TIBC?

Answer 460

Sideroblastic anemia - B6 deficiency? “Ringed sideroblasts”

Question 461

Acute COPD exacerbation trmt?

Answer 461

O2 (88-92), inhaled bronchodilators and anticholinergics (albuterol and ipratropium) and antibiotics and glucocorticoids

Question 462

What on urine would distinguish diuretic abuse/barter/gitelman syndrome from vomitting/chronic diarrhea?

Answer 462

The first group has increased urinary chloride.

Question 463

Confirm lead levels with?

Answer 463

venous sample

Question 464

Ascite trmt:

Answer 464

Sodium and water restriction - Spironolactone - loo diuretic (furosemide) - recent abdominal paracentesis

Question 465

TTP trmt =>

Answer 465

Plasmapharesis

Question 466

Hypoxemia PaO2/FiO2 < 300, bilateral alveolar infiltrates, decreased lung compliance 2/2 collapsed alveoli, and increased pulm arterial pressure =?

Answer 466

ARDS

Question 467

Bilateral cellulitis of the submandibular and sublingual space = ? MCC?

Answer 467

Ludwig Angina - Strep and Anaerobs infect teeth - MCC of death = asphyxiation

Question 468

Painless blisters, increased skin fragility on dorsum of hands, facial hypertrichosis and hyper pigmentation =?

Answer 468

Porphyria Cutanea Tarda - can be triggered by ethanol or estrogens. Phlebotomy or Hydroxychloroquine and interferon alpha can provide relief

Associated with Hep C

Question 469

Diagnosis of achalasia?

Answer 469

Barium swallow and ENDOSCOPY - malignancy can mimic the findings.

Question 470

HIT management>

Answer 470

STOP HEPARIN - give thrombin inhibitor like Argatroban.

Serotonin release assay = confirmatory test

Question 471

Tumor presenting with shoulder pain, weakness and atrophy of hand muscles, pain or paresthesia too, enlarged supraclavicular lymph nodes = ?

Answer 471

Pancoast tumor (superior sulcus tumor) causing Horner’s syndrome

Also see contralateral sympathetic response with flushing and sweating

Question 472

Clear lung fields, hypotension and JVD in the setting of an MI in leads II, II, aVF =>

Answer 472

RV infarct - fluid resuscitation and avoidance of nitrates

Question 473

HOCM would benefit from what meds>

Answer 473

BBlocks or CCB’s if they can’t have those because these allow heart have more time to fill with blood