Step 2 UW 1 Flashcards
11 year old girl presenting w/ arthralgia and purpura in setting of recent URI that’s since resolved
Henoch-Schönlein purpura, aka IGA VASCULITIS
Best next step: UA to screen for renal involvement (can develop days to months later)
Tx: steroids if severe
Acute myeloid leukemia blood smear finding
Auer rods
Neutrophil predominant cancer
Patient presenting with anemia and bone pain found to have leukopenia and what finding on a peripheral smear? Diagnosis? 
Rouleaux formation; multiple myeloma
Chronic lymphocytic leukemia:
1. clinical features
2. peripheral smear
3. Complications.
4 Worst prognosis with…
5. Treatment targets cell marker:
- Old person, lymphadenopathy (cervical, supraclavicular, axilla) HSM; mild thrombocytopenia and anemia asymptomatic. 
- Severe lymphocytosis and smudge cells, diagnosed on flow cytometry. No biopsy.
- infection, auto immune, hemolytic, anemia, secondary malignancy (Richter syndrome).
- worsened by multiple chain lymphadenopathy, HSM, anemia and thrombocytopenia
- CD20 (on B lymphocytes) ie rituximab
Symptoms and timeline of alcohol withdrawal
Treatment & most feared complication
- epigastric pain.
– elevated liver enzymes.
– sympathetic overactivity[i.e. tachycardia, elevated BP, restlessness, tremulousness) within 12 hours of admission
Other symptoms of alcohol withdrawal may, including anxiety, insomnia, diaphysis, nausea, and vomiting.
Prompt treat benzodiazepines is required to prevent progression to severe alcohol withdrawal that may include seizures and life-threatening delirium tremens
Management to reduce the risk of systemic thromboembolism in patients with atrial fibrillation and a high risk of thromboembolic events (ie CHA2DS-VASc score >= 2 in men >= 3 in women 
Warfarin or a direct oral anticoagulant (eg rivaroxaban, apixaban, edoxaban, dabigatran )
The first stage of labor is divided into two phases: the latent phase (0- 6 cm) and the active phase (6- 10 cm). Active phase protraction occurs when cervical dilation proceeds slower than expected. (<______) and is managed by _______ 
<1cm every 2 hours contraction inadequacy is the most common etiology
Management: oxytocin augmentation
CSF findings for tuberculosis, meningitis: glucose (inc/dec), lymphocytes (inc/dec), protein (inc/dec) 
Glucose markedly decreased
Lymphocytes pleocytosis.
Protein, mildly elevated 
CSF findings in acute bacterial meningitis: glucose, lymphocytes, protein
decreased glucose.
Neutrophil pleocytosis .
Increase protein
CSF findings and herpes simplex virus encephalitis: glucose, lymphocytes, protein
-Glucose normal
-Lymphocytic pleocytosis and elevated erythrocytes
-Elevated protein
most likely diagnosis:
Chest pain, signs of decreased cardiac output, and pulses paradoxus, following a viral infection 
cardiac tamponade, resulting from acute pericarditis
Right atrial filling is impaired, which results in an increase in the systemic venous pressure. However, the lungs remain clear to auscultation because there is no back up of blood into the pulmonary circulation. 
Lesions of eczema, gangrenosum progress very rapidly from a small erythematous macule to _________ & ________ & is caused by ________
Treat with :
Larger non-tender nodules with necrosis. Erythema gangrenosum is caused by pseudomonas aeruginosa bacterial invasion through the media and adventitia of blood vessels
Treatment: penicillin, cephalosporin, or carbapenems
What electrolyte derangements are as associated with ethylene glycol (antifreeze) poisoning
Hypocalcemia
Precipitation of calcium oxalate crystals in urine
Ethylene glycol is metabolized, alcohol aldehyde dehydrogenase, which produces glycolic acid that is subsequently converted to oxalic acid. Oxalic acid combined to calcium.
What is the biggest risk of complications with parenteral feeding?
Infection (central line associated bloodstream infection CLASBI).
Factors that increase the risk of CLASBI in patient receiving PN poor patient hygiene, severity of patient illness and duration of. Common bacterial organisms that cause CLASI in patient receiving PN include coagulase negative staph, staph aureus, & gram negative (Klebsiella pneumoniae, Pseudomonas aeruginosa).
Fungal CLASBI is due to Candida 
What additional vaccinations are indicated for a person with HIV
Pneumococcal, inactivated influenza, hepatitis A and B if not immune 
Diagnosis: symmetric proximal muscle weakness, mild myalgia elevated muscle enzymes (creatine kinase, AST, LDH)
Polymyositis. Auto antibodies (ANA, anti-Jo-1)
Biopsy: endomysial, mononuclear infiltrate patchy necrosis
How can a tension pneumothorax cause hypotension
High intrathoracic pressure impedes venous return to the right atrium by compressing the vena cava . Treat with needle, decompression or direction emergency tube thoracostomy 
Focal seizures with impaired consciousness in otherwise healthy adult
Temporal lobe epilepsy.
Patients appear alert, but do not interrupt with environment. Automatism (lip, smacking, hand movements) and postictal confusion.
Common presentation of lupus
Serositis and asymmetric polyarthritis (knees and hands most commonly), May, rash and photosensitivity, thrombolic events.
He will anemia thermia and leukopenia common low complement anti-nuclear (sensitive)  anti-DS DNA anti smith ab (specific))
Clinical presentation for chronic pancreatitis 
What are the two most common causes of acute pancreatitis?
Frequent bulky foul, smelling bowel movements (steatorrhea) due to impaired secretion of pancreatic enzymes. Epigastric abdominal pain and diabetes due to pancreatic insufficiency occur with advanced disease.
Can have malabsorption of micro and macro nutrients leading to weight loss and fat soluble vitamin deficiency 
Alcohol and gallstone disease are most common causes of acute pancreatitis. Alcohol is the most common cause of chronic
Patients who experience, rapid weight loss after bariatric surgery parentheses especially malabsorption procedures like RYGB increased risk for _________. Predisposing factors are _______
-altered bile composition: cholesterol super saturation in the bio promoting gallstone precipitation
-Gallbladder stasis: CCK (normally secreted from duodenum and jejunum) stimulates gallbladder contraction. In RYGB duo is passed resulting in lower CCK—> less mobility —> sludge and stones
Diagnosis: Abdominal pain and vomiting after meals with diarrhea and vasomotor symptoms ( flushing, dizziness, palpitations.) in the setting of gastric bypass surgery. 
Dumping syndrome 
Diagnosis: Elevated phosphate and low calcium in the setting of chronic kidney disease
Secondary hyperparathyroidism, which can cause renal osteodystrophy with associated bone pain
Stress versus urge versus overflow incontinence
Stress: decreased sphincter tone, urethral hypermobility. Leak with increased abdominal pressure.
Urge: detrusor overactivity; sudden urge
Overflow: impaired contract activity, bladder outlet obstruction; incomplete emptying and persistent dribbling 
Affected nerve roots for neurogenic bladder
S2 – S4
Treatment for stress urinary incontinence
Pelvic floor exercises or mid urethral sling
Treatment for urge urinary incontinence
Beta agonist (mirabegron), muscarinic antagonists
Relax the bladder

Treatment of overflow incontinence
Super pubic pressure timed voids, double voiding, intermittent self catheterization
Neutrophil level for spontaneous bacterial peritonitis
≥ 250
Treat with their generation cephalosporin for gram negative rod (e coli, Klebsiella) and gram positive cocci
What do you use to compare the means of ≥ 3 independent groups 
ANOVA (analysis of variance)
Compares variability between groups to the variability within the groups 
Why does septic shock cause lactic acidosis? 
Impaired and insufficient oxygen delivery to peripheral tissues causes anaerobic metabolism 
Most likely diagnosis: older person w/ cachexia, subacute abd/back pain, jaundice, migratory superficial thrombophlebitis & elevated alk phos and bili on labs
Pancreatic adenocarcinoma (most commonly in head of pancreas, causing obstructive jaundice by blocking CBD)
Tricyclic antidepressant overdose symptoms
anticholinergic effects: hyperthermia, flushing, tachycardia, hypotension, and altered mental status. and Decreased gastric motility
Acute iron poisoning
Clinical features: (5)
Diagnostic findings: (3)
Treatment: (2)
Clinical features: Abdominal pain, hematemesis, diarrhea, Shock, Liver necrosis
Diagnosis: Anion gap metabolic acidosis; Elevated serum iron; Radiopaque pills on abdominal x-ray
Treatment: Deferoxamine; Whole bowel irrigation
Acetaminophen toxicity can cause ______, _______, ______
Treatment:
nausea, vomiting, and hepatotoxicity
Treatment: N acetylcysteine
Diagnostic testing for patient w/ new onset afib, widened pulse pressure, weight loss
TSH and T4 (concerns for hyperthyroidism)
The wide pulse pressure (eg, 170 − 90 = 80 mm Hg) in hyperthyroidism results from peripheral vasodilation that decreases diastolic blood pressure and elevated contractility and SV that increase pulse pressure.
Most common brain tumor in adults: __________
Presenting symptoms _______
Worst prognostic factor:
-Astrocytoma
-new onset seizures
-High grade anaplasia.
The prognosis of astrocytomas is most affected by tumor grade, with increased atypia, mitoses, neovascularity, or necrosis conveying a worse prognosis
Chronic Myeloid Leukemia (CML)
1. gene mutation association
2. predominant cell type
3. treatment
- BCR-ABL tyrosine kinase fusion gene
- leukocytosis predominantly neutrophil
- Imatinib (inhibits BCR-ABL)
Most common cause of infection in sickle cell disease:
1. Pneumonia
2. Osteomyelitis/Septic arthritis
3. Bacteremia/Sepsis
4. Meningitis
- Strep pneumo
- Staph aureus, salmonella
- strep pneumo, HiB
- Strep penumo
Changing a cutoff point to a higher value has what impact on sensitivity and specificity?
DECREASE sensitivity
INCREASE specificity
Increasing the cutoff point typically causes fewer patients with the disease to test positive, decreasing test sensitivity. Fewer patients without the disease will also test positive, resulting in a decreased number of false positives and increased specificity.
First line treatment for A-fib?
Is it rate or rhythm control?
AV Node blocking agents
-Beta Blockers (eg metoprolol)
-nondihydropyridine Ca channel blockers (verapamil, diltiazem)
Rate control
Patients with sepsis who do not achieve a mean arterial pressure (MAP) >60 mm Hg after adequate fluid repletion (eg, septic shock) require ________________
a vasopressor (norepinephrine) to improve MAP to goal range. NE causes significant peripheral vasoconstriction and moderate increase in cardiac output.
A patient w/ a combination of renal failure, hypercalcemia, and anemia should be evaluated for ____________
multiple myeloma (MM)
Renal insufficiency is a common complication of MM. Light chain cast nephropathy with resultant renal tubular injury is most often the cause. The UA will often be normal.
chest pain, shortness of breath, hypotension, tachycardia, and low arterial oxygen saturation, but w/ clear lungs on exam
pulmonary embolism
Diagnosis: thrombocytopenia, decreased fibrinogen, and increased INR
elevated LDH, reticulocytes, and bilirubin are consistent w/ _______
DIC
hemolysis resulting from MAHA, which iscommonly seen in association withDIC. MAHA describes nonimmune hemolysis from erythrocyte fragmentationandcan develop in the absence of DIC; schistocytes are seen on peripheral smear.
describe murmur of mitral stenosis
loud first heart sound, an early diastolic sound after second heart sound (opening snap), and a low-pitched diastolic murmur heard best at the cardiac apex
When mitral stenosis is mild, the murmur is mostly heard in late diastole.
As the stenosis progresses, the diastolic murmur is heard earlier in the cardiac cycle (eg, mid-diastolic murmur) and eventually can be heard immediately after the opening snap.
aortic stenosis description
early diastolic murmur at the left lower sternal border
Type II error
What affects a type II error? (4)
failure to detect an effect (eg, difference between groups) when one truly exists.
The probability of a type II error is affected by
1. sample size (larger sample size = ↑ power, ↓ β.)
- outcome variability (smaller variability = ↑ power, ↓ β)
- effect size (larger effect size = ↑ power, ↓ β. A type II error could have occurred if the effect size (ie, real difference between groups) is smaller (ie, less) than expected.)
- significance level (higher significance levels = ↑ power, ↓ β; or in other words, a significance level that is too low (not too high) could cause a type II error)
_________ is a potential complication of a thoracentesis, and it should be suspected in patients who develop a rapid reaccumulation of pleural effusion, difficulty breathing, and hemodynamic instability shortly after the thoracentesis is performed.
Hemothorax
which causes dec in LV preload
how do nitrates reduce ischemic chest pain
Nitrates (eg, sublingual nitroglycerin) rapidly reduce ischemic chest pain via systemic venous dilation and a resulting decrease in cardiac preload, which reduces myocardial wall tension to lessen myocardial oxygen demand.
__________ is a common cause of bacterial meningitis in patients age >50 or who are immunocompromised (eg, chronic glucocorticoids).
These patients require empiric ampicillin in addition to the normal empiric treatment for bacterial meningitis of ______, ______, _____
Listeria monocytogenes
third-generation cephalosporin, vancomycin, dexamethasone
Bacterial meningitis is most commonly caused by Streptococcus pneumoniae (~70%), Neisseria meningitidis (~12%), Group B Streptococcus, and Haemophilus influenzae. Third-generation cephalosporins (eg, ceftriaxone) have excellent bacteriocidal efficacy against these organisms; vancomycin is added to cover the small amount of S pneumoniae resistant to beta-lactams.
Superior pulmonary sulcus tumors are usually primary lung malignancies and can present with referred arm, neck, or shoulder pain and paresthesia and weakness in the ulnar nerve distribution. What is strongest risk factor?
Smoking
decrescendo diastolic murmur that begins immediately after S2
Aortic regurgitation
In valvular AR, the murmur is usually best heard at the left third intercostal space. In AR due to aortic root dilation, the murmur is typically best heard at the right upper sternal border (aortic area).
Most likely diagnosis: middle aged older white person w/ nonhealing leg ulcer, recent-onset hearing loss, and evidence of kidney damage (eg, elevated creatinine, proteinuria, hematuria)
granulomatosis with polyangiitis (GPA) (formerly Wegener granulomatosis)
GPA is a necrotizing vasculitis affecting small- to medium-sized blood vessels.
What antibody is associated w/ granulomatosis w/ polyangiitis?
What are the manifestations in upper respiratory tract, lower respiratory tract, and kidney?
-Antineutrophil cytoplasmic antibodies (ANCA)
-Upper respiratory tract [ENT]: otalgia, hearing loss
-Lower respiratory tract: interstitial lung disease, cavitary lung lesions
-Kidney involvement: glomerulonephritis (eg, hematuria, proteinuria)
Next best step in diagnosis of old person w/ history of cancer presenting w/ macrocytic anemia, leukopenia, and thrombocytopenia
Blood smear shows oval macrocytes, hypersegmented/hypogranulated neutrophils
Diagnosis: myelodysplastic syndrome
Peripheral blood smear shows signs of dysplasia, including oval macrocytes and hyposegmented/hypogranulated neutrophils. Bone marrow biopsy is required for diagnosis.
NBS: bone marrow biopsy
potential sequelae of GAS impetigo?
Impetigo presents as erythematous papules and pustules covered with a honey-colored crust, typically on the face or upper extremities. A potential sequelae of group A streptococcal impetigo is acute poststreptococcal glomerulonephritis.
potential sequelae of GAS pharyngitis?
Acute rheumatic fever may present with myocarditis and is a postinfectious complication of group A Streptococcus pharyngitis
Most likely diagnosis:
patient w/ leukopenia and neutropenia [ANC<1500] in setting of recent chemotherapy (10 days ago) presenting w/ fever.
MCC?
Neutropenic fever, MCC bacterial source
Neutropenia with fever (eg, 38.9 C [102 F]) is consistent with neutropenic fever.
Infections are the leading cause of fever in neutropenic patients and the primary cause of morbidity and mortality. In patients with neutropenia following chemotherapy, overwhelming infections can rapidly develop not only because of a blunted immune response but also because of the mucosal barrier disruption that occurs as an adverse effect of chemotherapy. With mucosal disruption, endogenous flora can translocate into the bloodstream, causing infection that the impaired immune system is unable to control.
Common pathogens include both gram-positive (eg, Staphylococcus epidermidis) and gram-negative (eg, Pseudomonas aeruginosa) organisms; therefore, broad-spectrum antibiotic coverage is required.
Provide patient description for borderline personality disorder
Can they have psychosis or paranoia?
Borderline personality disorder involves a pervasive pattern of unstable, chaotic relationships; mood instability; abandonment fears; excessive anger; and impulsivity.
Yes- Transient paranoia and psychosis may occur and last from minutes to hours.
If a patient is withdrawing from opiates and alcohol at the same time, which should be clinically prioritized?
Alcohol. Treat w/ benzos to prevent DTs. Opiate withdrawal is not fun but will not kill you, so opioid agonists like buprenorphine are prioritized after
Diagnosis:
nonblanching, palpable purpura and arthralgia/arthritis
Pathogenesis?
Next best step in management?
Henoch-Schönlein purpura, or IgA vasculitis
Pathogenesis: Perivenular leukocytoclastic (neutrophils & monocytes) vasculitis & Deposition of IgA, C3 & fibrin in small vessels
Management involves urinalysis to screen for renal involvement, which can occur days to months after symptom onset
Initial management of knee osteoarthritis includes exercise, weight loss, and nonsteroidal anti-inflammatory drugs.
When treatment fails conservative measures, what is next best step?
Joint aspiration with synovial fluid analysis should be considered especially when significant warmth, joint tenderness, or effusion is present
What test do you use to compare the mean of 2 related groups?
The paired t-test compares the mean of 2 related groups. The test requires that a quantitative dependent variable (ie, outcome) be evaluated in 2 related (ie, matched, paired) groups
Measles presentation
conjunctivitis, cough, corhyzia and cephalocaudal rash spreading; treat w/ Vitamin A
Diagnostic criteria for Kawasaki’s disease?
Treatment?
Fever ≥5 days plus ≥4 of the following:
-Conjunctivitis: bilateral, nonexudative
-Mucositis: injected/fissured lips or pharynx, strawberry tongue
-Cervical lymphadenopathy: ≥1 nodes >1.5 cm
-Rash: perineal erythema & desquamation; polymorphous, generalized
-Erythema & edema of the hands/feet, periungual desquamation
Kawasaki’s disease; treat w/ IVIG & aspirin to prevent coronary artery aneurysm
Pathophys and epidemiology of Kawasaki’s disease
-Medium-vessel vasculitis
-Usually affects children age <5
-↑ Incidence in East Asian ethnicity
Laboratory findings
-↑ Platelets & white blood cells; ↓ hemoglobin
-↑ Acute-phase reactants (eg, C-reactive protein)
-↑ AST & ALT
-Sterile pyuria
Complications:
Coronary artery aneurysm
Ventricular dysfunction
Diagnosis: loss of visual acuity, excessive glare, halos around bright light
ophthalmologic assessment additional findings:
Cataracts
Ophthalmologic assessment shows a visible opacity of the lens and reduced clarity of retinal detail. Advanced cases may also show loss of the red reflex.
Findings in age-related macular degeneration? Clinical presentation?
Drusen (lipoproteinaceous deposits that appear as white or yellow spots, typically clustered around the central retina).
Increasing difficulty with reading during both the day and the night
Gradual peripheral loss and increased optic cup/disc ratio (ie, cupping) suggests?
atrophy of the optic nerve due to open-angle glaucoma
Findings in diabetic retinopathy? is vision loss typically acute or chronic?
Microaneurysms are a characteristic feature of diabetic retinopathy. Most patients are asymptomatic until late in the course of the disease, when vitreous hemorrhage or retinal detachment causes acute vision loss.
Which of the following drug(s) are associated w/ reduced mortality in HFrEF? Reduced hospitalization? Improved symptoms?
-ARNIs, ACE inhibitors, OR Angiotensin II receptor blockers
-Beta Blockers
-Mineralocorticoid receptor antagonist
-SGLT2 inhibitors
-Diuretics
-Digoxin
Mortality benefit:
-Angiotensin receptor-neprilysin inhibitor (eg, sacubitril-valsartan)
-ACE inhibitor (eg, lisinopril)
-Angiotensin II receptor blocker (eg, losartan)
-Beta blocker (eg, metoprolol, carvedilol)
-Mineralocorticoid receptor antagonist (eg, spironolactone, eplerenone)
-Sodium-glucose cotransporter-2 inhibitor (eg, dapagliflozin, empagliflozin)
Improves symptoms and reduces hospitalization:
Diuretic (eg, furosemide, metolazone)
Reduces hospitalization:
Digoxin
First line tocolytic for <32 wks? Mechanism? Side effects?
Indomethacin(<32 wk)
-Cyclooxygenase inhibitor
-Maternal Gastritis, Platelet dysfunction,
- Fetal Oligohydramnios, Closure of ductus arteriosus if given after 32 wks
First line tocolytic in 32-34 wks? Mechanism? Side effects?
-Nifedipine(32-34 wk)
-Calcium channel blocker
-Maternal Tachycardia/ palpitations, Nausea, Flushing, Headache
What short-term tocolytic is used to achieve acute myometrial relaxation (eg, uterine tachysystole during term labor? Mechanism? Adverse reactions?
Terbutaline, which stimulates beta-adrenergic receptors
-maternal arrhythmia, palpitations, and pulmonary edema.
-In addition, beta-agonists can worsen maternal hyperglycemia and are contraindicated in patients with poorly controlled diabetes mellitus.
What are typical symptoms of ulnar nerve compression? Where does compression typically take place?
-ulnar nerve can be compressed at the elbow in the epicondylar groove and/or the cubital tunnel.
-paresthesia and sensory loss in the fourth and fifth fingers and the medial hand (palmar and dorsal cutaneous branches).
- Weakness of the intrinsic hand muscles and ulnar-innervated flexor muscles of the forearm may also be present.
First line treatment for torsade de pointes
Intravenous magnesium sulfate in a patient who is hemodynamically stable, even if the patient’s magnesium level is normal.
Defibrillation (ie, unsynchronized electrical cardioversion) is indicated for unconscious or hemodynamically unstable patients with TdP
treatment of Raynaud phenomenon?
Calcium channel blockers, ie nifedipine
Raynaud phenomenon is a cold-induced vasospasm typically seen in the fingers, and is more common in patients with connective tissue disorders such as scleroderma.
__________ is a painless, sudden, and transient (<10 min) monocular vision loss that most commonly results from retinal artery emboli originating from an atherosclerotic plaque of the ipsilateral carotid artery
Amaurosis fugax
Vision returns after the embolus is broken up or displaced and retinal circulation is restored.
Funduscopic examination is often normal but may show embolic plaques and retinal whitening (due to ischemia).
