Step 2CK/Step 3

Question 1

In which demographic do cavernous hemangiomas present?

What is a possible complication of a visceral hemangioma?

Answer 1

Kids; cavernous=strawberry hemangioma (can be bluish if it is deeper; less likely to regress)

Visceral hemangioma: High output heart failure

Question 2

How do you differentiate osteoid osteoma from osteoblastoma?

Answer 2

Osteoid osteoma (OO) is in long bones and pain responds to aspirin

Osteoblastoma (OB) is larger than 2cm, happens in vertebrae and it’s pain doesn’t decrease with aspirin

Question 3

Presentation, macro and histological hallmarks of Osteoid Osteoma:

Answer 3

OhOh: little benign thing on the cortex that goes away with aspirin

Presentation: Benign, in younger than 25, less than 2cm and pain at night relieved by NSAIDs

Macro: on the cortex of the diaphysis (side), Rx radiolucent core of osteoid (dark) surrounded by sclerosis (white)

Micro: woven bone lined by a single layer of ~blasts

Question 4

Presentation, macro and histological hallmarks of OsteoChondroma:

Answer 4

OC tv show: young, mushroom

Presentation: most frequent benign, in younger than 25, mushroom shape, condro part can transform in chondrosarcoma

Macro: bony spike covered by a cartilage cap on the metaphysis (almost tip)

Micro: spike is continuous wit the marrow

Question 5

Presentation, macro and histological hallmarks of ChondroSarcoma:

Answer 5

CaSa: elder, pelvis

Presentation: in adults older than 50 around the pelvis!

Macro: moth eaten lytic appearance with popcorn-like spiculated calcifications in Rx

Micro: irregular cartilage and calcifications

Question 6

Presentation, macro and histological hallmarks of giant cell/osteoclatoma:

Answer 6

Presentation: benig but locally aggressive and may recur. Female=male

Macro: on the epiphysis!!! (tip) of the knee. Rx soap bubble. Nonsclerotic sharply defined border

Micro: tumor cells with RANK-L (~blasts) and multinucleated giant cells (~clasts)

Question 7

Presentation, macro and histological hallmarks of OsteoSarcoma/ osteogenic sarcoma:

Answer 7

OSsss: the most frequent malignant ‘sssss’

Presentation: Most common malignant. Painful enlarging mass or fracture. Bimodal distribution in teenagers (retinoblastoma) and elderly (Paget’s, radiation). Aggressive

Macro: on the metaphysis (almost tip) of the knee. Rx Codman triangle (periostial elevation, swelling) or sunburst (lytic, tiny fragments of bone)

Micro: plemomorphic cells making osteoid; malignant proliferation of osteoblasts (spindle shaped pink)
Malignant osteoblasts arise form mesenchymal stem cells in the PERIOSTEUM

Question 8

Presentation, macro and histological hallmarks of Ewing sarcoma:

Answer 8

Presentation: 2nd most common malignant. Painful and swelling, ±fever, boys, good px

Macro: on the diaphysis of femur, grows inside the narrow and pressures the periosteum that grows on onion skin reaction and moth eaten appearance (means extension to the soft tissue)

Micro: mesenchymal but small blue w Homer-Wright pseudorosettes and glycogen +CD99, +MIC2, t(11;22) EWS-FLI1 for DD with lymphoma and osteomyelitis

Tto: sx or Dactinomycin (drug for kid tumors)

Question 9

Clinic and how you differentiate α-thalassemia minor and β-thalassemia minor?

Answer 9

Both are normal but become anemic when they are under stress, have target cells

α has normal electrophoresis

β has aBnormal electrophoresis ↑HbA2(2α2δ) ↑HbF(2α2γ)

Question 10

What is the treatment for magnesium overdose?

Answer 10

IV calcium gluconate

Question 11

What do nodules with spiculated borders in chest Rx indicate? What is the management?

Answer 11

Lung ca, due to malignant cells extending within pulmonary interstitial tissue (stippled, irregular or eccentric calcifications also indicate malignancy but popcorn or bull’s eye calcifications indicate benign nodule).

1) Ask for previous Rx, if lesion has been stable 2-3 years you are done
2) Chest CT:
- Benign: less than 40 y.o, less than 0.8cm, never smoker or more than 15y since stopped, smooth → serial CTs

• Intermediate: 40-60//0.8-2//smoker or 15-5, scalloped → biopsy* or PET
  *Biopsy:
  Central: bronchoscopy
  Peripheral: CT-guided
• High risk: more than 60y.o, more than 2cm, smoker or less than 5y since stopped, corona radiata or spiculated → sx

Malignant pleural effusion makes lung ca. inoperable

Question 12

Which parameter increase when you lower the GUIDELINE’S cutoff for diagnosis? What about when you lower the cutoff of a NEW TEST to diagnose the disease?
What happens if you do the same test on a healthier (younger) population?

Answer 12

Lower GUIDELINE’S cutoff for diagnosis: ↑ prevalence. ‘A medical association changes the guidelines so more people are actually sick’

↑ sensitivity and NPV. ‘A new test positive cutoff changes but the gold standard and therefore the actual number of sick people remains the same’

↓ prevalence, ↓ PPV, ↑ NPV, =sensitivity and =specificity

Question 13

What do you think about if you see a middle easter male with abdominal mass in the gut, mesenteric lymph nodes and malabsorption?

Answer 13

IgA heavy chain disease= mediterranean lymphoma= Seligmann disease

Biopsy: jejunal mucosal infiltration with plasmacytoid cells

Question 14

What is important to do after diagnosing Raynauds?

Answer 14

Nailfold microscopy to look for enlarged distorted or scarce capillaries because if you see those, they indicate secondary Raynauds normally due to mixed connective tissue diseases as scleroderma

Question 15

Fetty syndrome signs and symptoms:

Answer 15

RA+ neutropenia+ splenomegally (anemia and thrombocytopenia are possible)

Question 16

What is the management of head and neck squamous cell ca?

And of a parotid tumor?

Answer 16

Squamous cell ca:

1) Ultrasound and fine needle aspiration
2) Panendoscopy (endoscopy of larynx, bronchus and esophagus) to find the ca.

Endoscope-guided biopsy for nasopharyngeal ca. → RT+QT

Parotid:

1) Fine needle aspiration
2) If non-dx fine needle aspiration of an enlarging parotid mass
3) Superficial parotidectomy (that is also curative for most benign parotid tumors)/deep parotidectomy*

If metastasis do a modified radical neck dissection + postsx RT

Question 17

What should you think about if you see a kid with RBC aplasia?

Answer 17

Transient erythroblastopenia of childhood, it is transient and normally due to a virus
Decreased reticulocytes
Normal MCV!!
Recovers in 1-2mo

NBSM; no need marrow aspirate; you just need to FOLLOW Hb for 2-3mo until resolution!!!

Question 18

Which malignancy can lead to sideroblastic anemia?

Answer 18

Myelodisplastic syndrome

Question 19

What is a different name for Wilms tumor?

Answer 19

Nephroblastoma

Question 20

What are the main symptoms and the possible treatments for essential thrombocythemia?

Answer 20

Vasomotor symptoms: headaches…

Treatments:
Low-dose aspirine
Hydroxyurea (avoid in pregnancy)
Anagrelide
Plateletpheresis

Question 21

QT regimes for ALL, CLL, Hodgkin and Non-Hodgkin lymphoma:

Answer 21

ALL:
Daunorubicin, Vincristine and Prednisone

AML:
Daunorubicin and cytosine arabinoside (AraC)

CLL:
Fludrabine and Chlorambucil (do not treat if asymptomatic and stage less than 3)

Hodgkin:
ABVD
Adriamycin (doxorubicin), Bleomycin, Vinblastine, Dacarbazine

Non-Hodgkin:
R-CHOP
Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin (Vincristine) and Prednisolone

Question 22

How do you prevent tumor lysis sd? How do you treat it? Which drug is contraindicated? Which are some of the SE of these drugs?

Answer 22

Prevention:
Allopurinol and febuxostat (febuxostat is better for the kidney than allopurinol); inhibit xanthine oxidase
* they do not decrease the amount uric acid that already exists (SE: Steven-Johnson and renal stones)

Treatment:
Rasburicase and pegloticase; recombinant urate oxidase that convert uric acid in allantoin (SE: G6PD hemolysis, anaphylaxis!, methemoglobinemia)

Add Ca supplementation to prevent hypocalcemia

Contraindicated:
Probenecib!!! uricosuric agent that blocks the reabsorption of uric acid at the PCT

Question 23

Urinary sample markers of pheochromocytoma and neuroblastoma vs carcinoid tumor:

Answer 23

Pheochromocytoma and Neuroblastoma: make epi, NE and DA so in urine you see homovanillic and vanillylmandelic acid. Also, if you don’t find the mass on CT scan you can check for ↑ uptake of iodine-131-metaiodobenzylguanidine = I-131 MIBG!!

Carcinoid: makes 5HT so in urine you see 5-hydroxyindoleacetic acid → CT scan → Octreotide scintigraphy if CT does not find the tumor

Question 24

Before electrophoresis, how can you differentiate between iron deficiency anemia and thalassemia?

Answer 24

Iron deficiency anemia:
↑ red cell distribution width (RDW)
MCV/RBC count (Mentzer ratio) more than 13
↓ reticulocytes
Suspect it on a kid having mostly cow’s milk before 1y, also all breast fed babies should be started on 400IU within 1mo

Thalassemia:
Nr RDW
Mentzer ratio less than 13
↑ reticulocytes

Question 25

What is the next step in management if you suspect bone metastases? What is the presentation buzzword?

Answer 25

1) IV glucocorticoids 2) MRI or radionucletide bone scan=bone scintigraphy! it is the most sensitive test to detect early bone metastasis → locate the primary tumor → biopsy if not primary tumor is identified Buzzword: point tenderness over the spinal processes

Question 26

Which drugs can cause drug-induced hemolytic anemia?

Answer 26

``` Penicillin, Cephalosporins NSAIDs Rifampin Phenytoin Methyldopa ``` They cause warm IgG mediated hemolysis

Question 27

What is the management of male or postmenopausal with iron deficiency anemia?

Answer 27

1) Occult blood test | 2) Colonoscopy

Question 28

What is the management of antiphospholipid syndrome?

Answer 28

Long term: lifelong warfarin INR target 2-3 (apixaban is inferior to warfarin) * Does not correct with mixing studies * Aspirin!! and LMW heparin if pregnant (miscarriages are due to thrombosis of the utero-placental A.)

Question 29

What do you do if you see a non-tender mass suspicious of malignancy?

Answer 29

Excisional biopsy

Question 30

What is the management of neutropenia?

Answer 30

Less than 1500 neutrophils Afebrile: observation Febrile: cefepime (or carbapenem or piperacillin-tazobactam) for pseudomonas ± vancomycin for MRSA*. If does not get better give voriconazole for aspergillus (halo sign on chest CT) * if pneumonia, septic shock, cellulitis, catheter infection

Question 31

What is the management of ITP?

Answer 31

No bleeding and more than 30k platelets*: observation Bleeding or less than 30k platelets*: 1) steroids 2) IVIG, anti-D immunoglobulins for Rh-positive patients only! Refractory: rituximab or splenectomy ± platelet transfusion * for kids the number of platelets doesn't matter, treat w IVIG/steroids if severe bleeding

Question 32

What is the initial treatment for venous insufficiency?

Answer 32

Compression wraps Leg elevation Encourage exercise

Question 33

Causes, pathophysiology, clinical signs and tto of hypercalcemia of malignancy:

Answer 33

Malignancy causes a ↑Ca more than 14mg/dL + symptoms; If primary hyperPTH no symptoms and just mild ↑Ca Causes: Renal cell, Breast, Squamous cell of the lung (strongest association with smoking), Bladder Multiple myeloma Immobilization and hyperthyroidism can also cause hyperCa but not that high Can be due to: Paraneoplastic PTHrP release (80%) *unlike PTH, PTHrP does not stimulate the hydroxylation of 25-dihydroxyvitamin D to 1,25-dihydroxyvitamin D Paraneoplastic 1,25-dihydroxyvitamin D release Osteolytic metastasis and L-1 release (MM) Signs and symptoms: Stones, bones, groans (constipation) and overtones Hyporeflexia Ca. gives you SHORT QT =) *PTH causes SHORT QT!! ↓ Ca and ↓ PTH gives you long QT =( Tto: IV fluids + calcitonin if need of immediate tto and bisphosphonates for long-term tto

Question 34

Treatment of hypercalcemia, hypernatremia and hyperkalemia:

Answer 34

↑ Ca: Immediate (if more than 14): IV fluids + calcitonin ± loop diuretics only in edema (just fixes it while you are giving the infusion) Long-term (if more than 12): bisphosphonates (± calcitonin 2-3 days until bisphosphonates kick in, but calcitonin leads to tachyphylaxis). Do not give bisphosphonates in AKI, do dialysis ↑ Na: Euvolemic/hypovolemic asymptomatic: 5% dextrose Hypovolemic w symptoms of dehydration: 1) ~1l normal saline (0.9% NaCl) until euvolemic 2) 5% dextrose + close neurologic monitoring ↑ K: 1) ECG If K is more than 6.3 or ECG changes, if NOT review the pt's meds and go to step 4) 2) IV Ca gluconate (stabilizes the heart) if ECG abnormalities/K more than 7/fast raising K due to tissue breakdown 3) Insulin+Glucose or dextrose*/Albuterol /Na bicarb: move K into the cell. * If concomitant hyperglycemia give insulin alone!! 4) Kayexalate, patiromer, lokelma (Na zierconium cyclossilicate), furosemide: ↓ body K 5) Dialysis if nothing works

Question 35

Where should you access the circulation in adults/kids fluid resuscitation?

Answer 35

``` Adults: Antecubital v. Spahenous v. Femoral v. Intraosseus cannulation (if you cannot get 2 access in an emergency pt put an intraosseus access) Central line: used for monitoring ``` ``` Kids: Intraosseus cannulation (preferably in the proximal tibia, if not the femur) ```

Question 36

Where do you have to place a chest tube in tension pneumothorax in adults? and in kids? Where can you do thoracentesis?

Answer 36

Pneumothorax: Adults: 5th left intercostal space along the midaxillary line Kids: 2nd left intercostal space along the midclavicular line ``` Thoracentesis: CAP 6-8th mid-Clavicular 8-10th mid-Axillary 10-12th Paravertebral Use the midaxillary line if the patient is supine and the posterior midscapular if the patient is sitting; remove 1L of fluid slowly ```

Question 37

How do you treat thyroid ca?

Answer 37

Most types: total thyroidectomy ± radioactive I** (if positive lymph nodes/capsular invasion...) + high dose levothyroxine to suppress TSH in papillary ** RT if not responsive to I For medullary monitor calcitonin!! and thyroglobulin for the rest Anaplastic: total thyroidectomy if resectable + palliative QT-RT

Question 38

How do you treat breast ca?

Answer 38

Localized: mastectomy/breast conserving sx + sentinel lymph node + RT → if + lymph nodes: node dissection + hormone modulators/trastuzumab or QT if triple negative larger than 0.5 cm → if positive margin: reexcision of the involved margin Locally advanced: neoadjuvant QT then, sx If pregnant or lactating no RT until 1 year after pregnancy and no QT on the 1st trimester so do: prompt mastectomy/breast-conserving tto + QT after the 1st trimester

Question 39

Indications and available procedures for bariatric sx:

Answer 39

``` Indications: Motivated patient Heavier than 40 kg, BMI more than 35 + serious comorbidities, 30 + resistant DM or resistant metabolic syndrome Reasonable sx risk Failure of previous weight loss regimes ``` Procedures: Sleeve gastrectomy, most frequently done because of good combination of effectivity and safety Laparoscopic gastric band (not shown to be effective in US population, bad for sweet eaters) Roux-en-Y Duodenal switch

Question 40

Indications for coronary bypass:

Answer 40

Left main coronary stenosis of more than 50%! Proximal!!! LAD + proximal!!! circumflex stenosis more than 70% 3 vessel disease Persisting ischemia after maximal medical therapy Diabetic with 2 or + vessel disease

Question 41

What is the BNSM if you suspect pneumothorax in an acute setting? What is the management of a pneumothorax?

Answer 41

BNSM: bedside ultrasonography Non-tension + stable patient + less or = 2 cm: Cover the wound with regular dressing and order a expiratory chest Rx ``` Tension: Stable 1) Immediate NEEDLE thoracostomy → 2) chest tube thoracostomy Unstable 1) Chest tube ``` * If persistent air leak in the chest tube and failure to re-expand → bronchial injury → bronchoscopy/esophagoscopy → intubation + sx repair

Question 42

What is the management of vascular injury?

Answer 42

+ hard sings: no pulses, expanding hematoma, hemorrhage, bruit, distal ischemia (pain, pallor, paresthesia, poikilothermia, paralysis, pulselessness) → exploratory sx + soft sings: unequal pulses, stable hematoma, resolved hemorrhage, unexplained hypotension, nerve deficit, injury close to major vessel → CT angiography (duplex US on renal insufficiency, then so exploratory sx if angiography indicates it)

Question 43

What is the effect of Metyrapone and what is it used for?

Answer 43

It inhibits 11ß hydroxylase, so prevents the conversion of 11-deoxycortisol to cortisol so cortisol ↓ and this causes ACTH ↑ (same happens if you eat licorice). If ACTH does not ↑ → pituitary insufficiency Used for pituitary insufficiency workup The opposite of dexamethasone that ↓ ACTH * The failure of both ACTH and 11-deoxycortisol levels to rise after the administration of metyrapone indicates secondary or tertiary adrenal insufficiency

Question 44

What is the effect of Cosyntropin and what is it used for?

Answer 44

1) You actually do plasma cortisol AM, if less than 3 you don't need to do the cosyntropin 2) Acthar = cosyntropin = ACTH stimulation test Acthar and cosyntropin act as ACTH!! they should ↑ cortisol Used for adrenal insufficiency: Addison's and pituitary insufficiency ACTH stimulation test is used to diagnose the cause of DECREASED cortisol If ACTH ↑ cortisol: pituitary insufficiency (is important to give steroids 1st before you treat the hypothyroidism and other hormonal deficiencies or before you go to sx) → only steroids If ACTH ↓ cortisol: adrenal insufficiency! → steroids + fludrocortisone

Question 45

What is the effect of the insulin tolerance test and what is it used for?

Answer 45

Insulin causes hypoglycemia which should ↑ cortisol by more than 20µg/dl. If cortisol does not ↑ → ACTH deficiency

Question 46

Main metabolic abnormality in Addison's, hypopituitarism and Conn sd:

Answer 46

Aldosterone deficit (Addison's): ↑ K; ↓ Na (because of sympathetic activation and ↑ ADH) Hypopituitarism: ↓ Na because CRH should inhibit ADH and here it cannot so there is ↑ ADH; K is normal!! because Aldo is normal. Pt also presents w. anorexia, hypoglycemia and pale skin Secondary adrenal insufficiency (form stopping steroids): ↓ Na, ↓ glucose, nr K and nr bicarb Aldosterone excess (Conn sd): Na is normal because of the aldo escape causing pressure natriuresis. You have HT and hypervolemia bc you pee a lot because of the aldo escape. ↓ K (not always) and metabolic alkalosis Cushing syndrome: HT, ↓ K (as cortisol has a mineralocorticoid effect at high doses, you might have T-wave flattening on ECG), Na is normal or ↑, metabolic alkalosis and ↓ Ca

Question 47

Which drugs can CAUSE nephrogenic diabetes insipidus? and SIADH?

Answer 47

``` Nephrogenic diabetes insipidus; they affect the collecting duct: Lithium Sickle cell patients with isosthenuria ↑Ca, ↓K. If you see ↑Na check Ca and K! Chronic kidney disease (ADPKD) Demeclocycline (tetracycline) Fluoride Amphotericin (among other SE) ``` Central diabetes insipidus: pituitary sx, neurosx, tx langerhan cell histiocytosis, sarcoidosis anorexia * Na can be normal in DI ``` SIADH; Can't Concentrate Serum Sodium: Carbamazepine and oxcarbazepine Cyclophosphamide!!! (1st generation sulfonylurea) SSRIs, TCAs, MAOIs Others: THIAZIDES Pulmonary ilness, CANCER... Surgery OXYTOCIN, Amphetamines, ecstasy and LEAD cause hyponatremia!! Hypothyroidism causes hyponatremia NSAIDs Chlorpropamide (sulfonylurea) Vincristine, vinblastine Clofibrate ```

Question 48

Which drugs can be used to TREAT diabetes insipidus? and SIADH?

Answer 48

Nephrogenic diabetes insipidus: Amiloride (± thiazides) if is due to Li Thiazides (± indomethacin) if other cause Central diabetes insipidus: Desmopressin SIADH: 1) Fluid restriction but not salt restriction 2) If seizures or coma give IV hypertonic 3% saline 200-300mL in 3-4h at 0.5-1mmol/L/h; emergency dialysis may also be considered Others: Demeclocycline and Vaptams

Question 49

How do acidosis, alkalosis, citrate and albumin affect Ca?

Answer 49

Acidosis ↑ FREE/ionized Ca and Alkalosis (conn's) and citrate ↓ FREE/ionized Ca * It is the ionized/free Ca the one that regulates PTH and causes the symptoms, so here you will have PTH changes and symptoms ↑ albumin ↑ TOTAL Ca: make sure you check the ionized/free Ca in MM ↓ albumin ↓ TOTAL Ca because without albumin it cannot be carried but here ionized Ca will be normal so PTH will be normal. Here calculate the corrected Ca= Ca+0.8 *(4-albumin). Malnutrition is a cause of hypocalcemia.

Question 50

Treatment and prevention of renal osteodystrophy in renal failure:

Answer 50

Give Ca and activated Vit D P restriction!!!* Cincalcet * P builds-up in renal failure which can lead to deleterious effects, such as metastatic calcification (which can increase risk of stroke, heart attack, etc.) and weak bones (because phosphorous pulls calcium out of bones); these complications are particularly important for kids because they progress chronically over time

Question 51

What is the presentation and management of femoral neck fracture?

Answer 51

Presentation: shortened and externally rotated extremity 2 types: Intracapsular: NO ecchymosis, high risk of avascular necrosis Extracapsular: ecchymosis, risk of displacement Management: Minimally displaced: open reduction with internal fixation!! Displaced: replacement of femoral head with metal prothesis All causes external rotation (femoral neck fracture and anterior dislocation of the hip) except for posterior dislocation of the hip!

Question 52

What is the management of urethral injury?

Answer 52

1) Retrograde urogram/cystography to rule out urethral rupture and intraperitoneal bladder dome rupture!! Then, Partial disruption: bridge ureteral catheter and repair sx in 2-3mo Significant disruption: suprapubic cystostomy and repair sx in 2-3mo * If repaired too early can lead to stricture and impotence

Question 53

What is the management of carpal tunnel sd?

Answer 53

Clinical dx → confirm with electromyography and nerve conduction studies 1) Wrist splint → steroid injection in the carpal tunnel → oral steroids → if fails, sx release (need nerve conduction studies before) Associated with hypothyroidism, pregnancy, typing

Question 54

Which injuries lead to external and internal rotation of the leg? and of the shoulder?

Answer 54

External: femoral head fracture and ANTERIOR femur dislocation * ABEr: anterior dislocation causes aBduction and External rotation Internal: POSTERIOR hip dislocation; can injure the Sciatic n. so no HIP extension Can injure the sciatic n. * PoDaIr: posterior dislocation causes aDduction and Internal rotation Tto: emergency closed reduction within 6h Same for the shoulder VS Femoral neck fracture: Shortened leg External rotation All causes external rotation except for posterior dislocation of the hip!

Question 55

What is the management of scaphoid fracture?

Answer 55

Thumb spica cast

Question 56

Unilateral bloody nipple discharge diagnostic suspicion and management:

Answer 56

Do not present with masses, just with bloody nipple discharge In young, benign (can hide atypic or ductal ca in situ): Intraductal papilloma (it's vascular stalk twists and bleeds) → rule out ca. with ultrasound, mx and subsequent fine NEEDLE ASPIRATION/ core needle biopsy → if - ultrasound and mx do breast MRI Micro: epithelial and myoepithelial cells lining a fibrovascular core forming papillae within a duct. Excision In old, malignant: Ductal carcinoma in situ. Micro: ducts distended by pleomorphic cells with central necrosis that do not penetrate the basement mb. the basal (myoepithelial) layer of the duct is uninvolved → ultrasound, mx and subsequent fine NEEDLE ASPIRATION/ core needle biopsy

Question 57

What is the management of a palpable nodule on rectal digital exam/ abnormal PSA?

Answer 57

Urinalysis and prophylactic antibiotic → transrectal ultrasound-guided fine needle biopsy taking multiple (12) biopsies

Question 58

What is the management of bowel perforation?

Answer 58

Rx: air under the diaphragm (pneumoperotoneum) Exploratory laparotomy! Even when is due to a stomach ulcer! The only time when you see air under the diaphragm and you don't do exploratory laparotomy is after sx, it is normal to have some free air after sx

Question 59

What is the management of GERD?

Answer 59

1) PPIs 1/day for 2mo → switch to different PPI or do 2/day → esophageal Ph monitoring/endoscopy Endoscopy if: men >50yo, symptoms >5y, melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia or odynophagia Barrett's esophagus/ low grade dysplasia: endoscopic radiofrequency ablation High grade dysplasia/ca: esophagectomy/ radiofrequency Symptomatic sliding hiatal hernias (Z line above the diaphragm): Nissen fundoplication SE of Nissen fundoplication: Dysphagia and gas bloat syndrome; decrease risk if pt adheres to diet that slowly progresses form liquids to solids

Question 60

What is the best way to transport a severed finger? What do you do with an avulsed tooth?

Answer 60

Finger: wrap it in a moist gauze, put it in a plastic bag and sumerge the bag into ice mixed with saline Tooth: store te tooth in cold milk or saliva, rinse it with saline, reimplant (even by the parents) and splint ideally within 15min to 1h

Question 61

What is the management of cardiac tamponade?

Answer 61

Transthoracic echocardiography Pericardiocentesis or pericardial window

Question 62

Causes and presentation of hyperosmolar hyperglycemic state in DM2:

Answer 62

Very high glucose → very high plasma osmolarity → polyuria → intravascular volume depletion No ketones! Confusion, high mortality Causes: infection!! (infections often lead to increased insulin requirement by causing a reactionary hyperglycemia), dehydration, non-adherence to DM2 tto, corticoids, thiazides, dobutamine, terbutaline, 2nd reneration antipsychotics Tto: 1) normal saline!

Question 63

What is the most common cause of congenital hypothyroidism?

Answer 63

Thyroid dysgenesis

Question 64

What is the management of amiodarone-induced hypothyroidism?

Answer 64

Add levothyroxine, no need to discontinue amiodarone as far as it controls the arrhythmia

Question 65

What is the management of cryptorchidism?

Answer 65

If the testicle does not descend at age 6mo it will not do it, so do laparoscopy and orchiopexy before 1 year, if atrophic testicle do orchiectomy Increased risk of germ cell malignancy, the contralateral testes is not as risk

Question 66

What is the management of infertility?

Answer 66

1) Semen analysis after 2-3 days of abstinence, if abnormal → repeat in 3mo (significant variability) → If azoospermia do ISCI 2) Female history: regular periods? 3) Midlutheal phase (day 21) progesterone level to see if she is ovulating 4) Ovarian reserve: day 3 FSH and estriol, clomiphene challenge, follicle count, Anti-Mullerian hormone 4) Hysterosalpingogram (painful) → if abnormal → IVF (check ovarian reserve before IVF)

Question 67

Presentation, macro, histological hallmarks and marker of embryonal ca:

Answer 67

Presentation: solitary painless testicular mass in 20-30 yo, rare and metastasizes fast * It can differentiate into another type of germ cell tumor as teratoma after QT Macro: hemorrhagic mass with necrosis, commonly mixed Micro: glandular/papillary normally mixed with other tumors, + citokeratin Marker: α fetoprotein, hCG

Question 68

Illnesses with high AFP (alpha-fetoprotein):

Answer 68

AFP is made by liver and yolk sac in fetus Yolk sac tumor Hepatocelular ca. (hep C is the MCC) Embryonal ca. when mixed (men) Ataxia-telangiectasia Pregnancy (high in neural tube defect low in trisomies) Different form placental alkaline phosphatase in seminoma

Question 69

Presentation, macro, histological hallmark and marker of yolk sac (endodermal sinus or INFANTILE embryonal ca.) tumor:

Answer 69

Presentation: most common in prepuberal children Macro: yellow mucinous mass Micro: endodermal sinus formation with Schiller-Duval bodies (glomeruloid structures lined by germ cells) and hyaline droplets Marker: α fetoprotein (± α1 antitrypsin)

Question 70

Presentation, macro, histological hallmark and marker of seminoma and dysgerminoma:

Answer 70

Presentation: most common in 15-35 yo Macro: painLESS, firm, HYPOechoic, homogeneous testicular enlargement, lobulated (dysgerminoma is a common cause of ovarian ca. in pregnant) Micro: large polygonal clear cells (with watery large cytoplasm) forming lobules + fried egg (membranes and central nucleus) Marker: placental alkaline phosphatase and β-HCG (seminoma) lactate dehydrogenase (dysgerminoma)

Question 71

Specific findings for Graves vs other hyperthyroidism causes:

Answer 71

Exophthalmos, ocular muscle restriction (NOT lid lag!) | Pretibial myxedema= infiltrative dermopathy

Question 72

Physiologic changes during pregnancy:

Answer 72

↓ MAP ↓ SVR ↓ systolic and ↓ diastolic but diastolic drops more so ↑ PP =CVP but ↓ femoral venous pressure so varicose veins and hemorrhoids ↑ CO by 30-50% between 20 and 24 w (systolic ejection murmur): good for the baby's nutrition ↑ Preload =LVEDP ↑ RBC mass but plasma vol ↑↑ so hemodilution ↑ WBC ↑ ERS, ↑ clothing factors, all but 13 and 2 so DVT (give heparin if no in labor) the first week postpartum is the most dangerous time for DVT, =platelets (between 100-150k is benign gestational thrombocytopenia) ↓ smooth muscle tone so constipation, cholelithiasis, GERD ↑ TV, ↑ min ventilation, RR =, all the rest of the vol ↓, CO2 ↓ and Ph becomes alkalotic in plasma and urine so UTIs ↑ kidney size specially on the right, ↑↑ GFR, ↓ Creatinin, ↓ renal threshold for glucose, progesterone relaxes pelvis muscles and ureters so hydroureters normally on the right so UTIs

Question 73

Which vessels do the umbilical cord contain?

Answer 73

2 arteries (deoxigentated blood) 1 vein (oxigeated blood) * The best indicator of how the baby is doing is the artery!

Question 74

Key effects of DES, phenytoin/dilantin, isotretinoin and valproic acid in the fetus:

Answer 74

DES: T shaped uterus, clear cell ca. Phenytoin/dilantin: nail hypoplasia Isotretinoin: hearing loss, migrognatia, heart abnormalities Valproic acid: neural tube and cardiac defects

Question 75

What does the P in GPAb stands for (pregnancy history)?

Answer 75

G: times where you were pregnant P: babies that lasted more than 20 w Ab: abortions

Question 76

Most common aneuploidies at conception and at birth:

Answer 76

Most common aneuploidy at conception: turner; most are aborted (hydrops...); it is the only one that has normal IQ, they lack adosdence growth spurt and cubitus valgus (Jesus), celiac disease Most common aneuploidy at birth: down Down has congenital hypothyroidism and Turner has immune-mediated hypothyroidism (Hashimoto)

Question 77

DD. of late pregnancy bleeding:

Answer 77

ABRUPTIO placentae: Premature separation of the placenta from the uterus. RF: PPROM, HT, PREECLAMPSIA, trauma (MVA), SMOKING, cocaine, uterine overdistention (twins, polyhydramnios)... Presentation: PAIN and firm uterus, can lead to DIC Baby can have hypoxia Tx: fluids, transition to blood products soon + lateral decubitus positioning, vaginal delivery if no fetal distress (you can even use oxytocin), if fetal distress emergency c-section Placenta PREVIA: Placenta extending over the cervix. RF: previous CESAREAN, >35, multiparty, smoker Presentation: NO PAIN, no fetal distress, transverse lie fetus, can resolve over time by migration, if it doesn't c-section Look for placenta accreta!! PP-PA VASA previa: Fetal blood, umbilical cord vessels extending over the cervix RF: placental accessory lobe, placenta previa, in-vitro Presentation: No pain + FETAL BRADYCARDIA (sinusoidal pattern) You are loosing fetal blood!! Emergency c-section! Uterine rupture: Rupture of the uterine myometrium and serosa RF: previous cesarean (vertical=classical incision) Presentation: Prepartum PAIN and fetal parts palpable on the abdomen, sudden loss of fetal station Emergency! laparotomy! Painful: abruptio and uterine rupture

Question 78

What are the causes of morning hyperglycemia?

Answer 78

You measure 3AM blood glucose: normal glucose → Dawn phenomenon: nocturnal release of GH and cortisol → increase evening insulin ↓ glucose → Somogyi phenomenon: rebound morning hyperglycemia due to nocturnal hypoglycemia → decrease evening insulin

Question 79

Main characteristics of Placenta ACCRETA, increta and precreta, RF, presentation and tto:

Answer 79

Accreta (80%): Abnormal trophoblastic invasion into the decidua basalis (endometrium). Increta (15%): invasion into the myometrium Precreta: invasion all the trough myometrium into the serosa RF: previous CESAREAN, anterior placenta previa PP-PA, multiparty... Presentation: POSTPARTUM vaginal bleeding (vs uterine atony that w respond to uterotonic agents) Tto: hysterectomy w the placenta in situ

Question 80

Most common cause of breech position:

Answer 80

Uterine septum

Question 81

Zig-zag lessions and micropthalmia indicate:

Answer 81

Congenital varicella

Question 82

Manifestations of congenital syphilis:

Answer 82

``` Maculopapular rash in the palms and soles → desquamating Rhinorrhea (snuffles) Congenital nephrotic sd Periostitis and osteochondritis Hydrops and macerated skin ```

Question 83

Cord compression causes:

Answer 83

Variable decelerations, treat with amnioinfusion

Question 84

How do you treat hyperemesis gravidum?

Answer 84

1) B6 pyridoxine | 2) Doxylamine (antihistaminic)

Question 85

How is breast development also called?

Answer 85

Thelarche, 1st sign pf puberty, as breast growth is often symmetrical the breast bud can be unilateral! but careful if there is blood coming out of it!

Question 86

Complications of asymptomatic bacteriuria in pregnancy?

Answer 86

Preterm labor Low birth weight Perinatal mortality Preeclampsia Pyelonephritis Cystitis

Question 87

Which are the only gestations that are at risk for twin-twin transfusion syndrome?

Answer 87

Monochorionic diamniotic

Question 88

DD. of preterm contractions:

Answer 88

Uterine irritability: many contractions, intensity low, very short duration Braxton-Hicks: few contractions, long duration, irregular, relieved with ambulation and NO cervical change Pre-term contractions: regular with NO cervical change Labor: regular painful contractions with cervical change

Question 89

Main characteristics of preterm prelabor rupture of membranes (PPROM):

Answer 89

Rupture of membranes before labor at less than 37 w (it is a third trimester gush of fluid from the vagina with closed cervix) Microscopic examination of dried amniotic fluid shows arborization (Ferning) and Nitrazine + blue fluid RF: ascending infection from the vagina, antepartum bleeding, previous PPROM, amniocentesis

Question 90

What can be used as a predictor of preterm delivery? What can be used to diagnose PPROM?

Answer 90

Prenatal delivery: Fetal Fibronectin Negative in 22-35 weeks, high close to delivery If it is negative it is very useful but if positive with cervix closed it is very likely a false positive RF: Bacterial vaginosis PPROM: Nitrazine test and ferning Gush of fluid before w 37. 1) Sterile speculum examination 2) Nitrazine test and ferning RF: previous PPROM, infection, smoking

Question 91

How do you differentiate between chronic, gestational hypertension, preeclampsia, eclampsia and HELLPsd?

Answer 91

Chronic HT: HT (>140/90) onset before 20 w → monitor and induce at 38 w → if more than 160/110 methyldopa/nifedipine/labetalol + deliver at 37 w * In HT less than 160 give low-dose aspirin to decrease the risk of superimposed preeclampsia! Gestational HT: HT (>140/90) onset after 20 w → antihypertensives, deliver at 38 w Preeclampsia: HT (>140/90) onset after 20 w + proteinuria (>300/day or >0.3) ± end-organ damage → antihypertensives, admit in-patient + deliver at 37 w Preeclampsia with severe features: HT (>140/90) onset after 20 w more 160/100 OR pulmonary edema/headaches/visual changes OR platelets less than 100.000/doubled liver enzymes/Cr more than 1.1 → * Eclampsia: HT (>140/90) onset after 20 w + proteinuria + seizures → * + protect airway HELLPsd: hemolysis + ↑LFTs + ↓platelets ± HT ± proteinuria ± seizures → * * 1) Admit as in-patient; 2) Stabilize, stop convulsions with Magnesium sulfate!!!! and leave it 1 day after delivery; 4) Manage HTN with IV Hydralazine (if bradycardia) /IV Labetalol /Oral Nifedipine*; 5) prompt delivery (induce w oxytocin) when mom is stable; 6) if baby monitoring is bad do c-section * NLH! Consequences: stroke (ischemic and hemorrhagic)

Question 92

DD. of cardiac problems in pregnancy:

Answer 92

Mitral stenosis; think mitral stenosis on immigrant with pharyngitis as a kid that gets heart symptoms during pregnancy. Excess preload of pregnancy passing trough a narrowed valve can lead to pulmonary hypertension, edema, arrhythmias and RHF → surgical repair before pregnancy if symptomatic and β-blockers if asymptomatic ASD or VSD: most common heart problem in pregnancy, patients do well (as patients do with any regurgitation lesion in pregnancy) → routine tto Tetralogy of Fallot: 😞 most common cyanotic defect in pregnancy Eisenmenger syndrome: 😞 right heart failure, there is intracardiac shunt and decreased oxygenation → avoid hypotension Marfan syndrome 😞 Peripartum cardiomyopathy: 😞 (75% mortality if not corrected in 6mo) no heart disease history, BOTH left and right heart failure in late pregnancy/postpartum, LVEF <45% → furosemide in ICU

Question 93

DD. True Gestational DM vs Overt Diabetes:

Answer 93

Gestational DM is a retrospective diagnosis: stop insulin and if post-partum glucose normalizes → True Gestational DM If persistently increased → Overt Diabetes (DM type 2) 35% of patients with gestational DM will likely develop overt DM in the next 5-10 years

Question 94

Consequences of maternal DM:

Answer 94

Overt: preeclampsia, sacral agenesis, caudal regression syndrome, anencephaly, spina bifida, transposition of the great vessels (most common cyanotic here ), ASD, VSD (number 1), coarctation Overt and gestational: macrosomia, HCOM, hypoglycemia* (↑insulin), PTH suppression (↓Ca, ↓Mg), polycythemia, ↑bilirubin, respiratory distress sd * Put an umbilical venous catheter to give IV glucose → start nasogastric feeding that is continuous so insulin and glucose do not fluctuate → if still hypoglycemic add an IV line

Question 95

How do you differentiate between HELLP sd. and acute fatty liver of pregnancy?

Answer 95

Both have HT, ↑ liver enzymes, thrombocytopenia... All is the same but in acute fatty liver of pregnancy you have ↓glucose!!!! (↑ bilirubin) and ↑amonia and NO proteinuria Symptoms of acute fatty liver of pregnancy include jaundice and encephalopaty (also vomiting, RUQ tenderness, slurred speech, hyperreflexia, and nystagmus) that do not necessarily appear on HELLP. They are due to fatty infiltration of the liver In HELLP sd there is distention of the hepatic Glisson capsule and overactivation of the coagulation pathway In both you have to stabilize the mom and deliver!

Question 96

Which heparins can and cannot be reversed?

Answer 96

Unfractionated heparin can be reversed with protamin sulfate LMWH cannot be reversed

Question 97

Fundal height at the umbilicus indicates ___ weeks:

Answer 97

20 weeks

Question 98

If the genders of two twins are different which type of twins are they?

Answer 98

Di Di Di (dizygous, dichorionic, diamniotic)

Question 99

If two twins have a thick intertwined septum between them which type of twins are they?

Answer 99

Di Di Di or Mono Di Di (dizygous/monozygous, dichorionic, diamniotic) Thick septum: Lambda sign

Question 100

If two twins are the same gender with a thin intertwined septum between them which type of twins are they?

Answer 100

Mono Mono Di (monozygous, monochorionic, diamniotic), possible twin-twin transfusion Thin septum: T sign

Question 101

If two twins are the same gender and are on a single sac which type of twins are they?

Answer 101

Mono Mono Mono (monozygous, monochorionic, monoamniotic), possible cord entanglement and or conjoint

Question 102

Pooling, nitrozine, ferning on speculum examination indicate:

Answer 102

Rupture of the membranes

Question 103

What do you think if you see a woman who presents with sings and symptoms of pregnancy with negative β-HCG?

Answer 103

Pseudocyesis, a somatoform disorder where a non-psychotic woman thinks she is pregnant

Question 104

Risks of hormone replacement therapy in post-menopausal pt:

Answer 104

Breast ca, MI, stroke, DVT... | * It is contraindicated in patients that have history of these diseases

Question 105

At which gestational age can you start using vacuum?

Answer 105

More than 34 weeks

Question 106

Management of a Rh - pregnant form Rh + dad:

Answer 106

1st prenatal visit: Antibody screen 28th weeks: Antibody screen Prophylactic 300mcg of RhoGAM Anytime when there is risk of fetomaternal hemorrhage: Prophylactic 300mcg of RhoGAM Delivery: No standard dose! calculate what you need! No concern of fetomaternal hemorrhage → 300mcg of RhoGAM within 27h of when a Rh + baby is born Concern of fetomaternal hemorrhage (abruption, procedures...) → Rosette test on mom's blood, if + → Kleihauer-Betke test to calculate the amount of RhoGAM (1st Rosette, the simplest name)

Question 107

Epidural contraindications and complications:

Answer 107

Epidural can be given in stages 1 and 2 Contraindicated if platelets are less than 70.000 or are rapidly dropping: do parenteral (general) anesthesia instead Complications: Hypotension (give IV fluids before, if happens give IV fluids + IV ephedrine) Spinal headache: IV fluids, caffeine or blood patch High spinal: accidental injection of the anesthesia on the subarachnoid space, causes ascending paralysis and sympathetic blockage can stop the diaphragm and cause cardiopulmonary arrest IV leaking: can cause seizures

Question 108

What is the management of DKA?

Answer 108

1) 3-6 liters of IV isotonic fluids=normal saline (0.9%) 2) IV insulin when K is more than 3.3* until closing the anion gap * If K is less than 3.3 give K first and then add insulin 3) Add dextrose when glucose is below 250 4) IV KCl if K is less then 5.3 5) Change them to subacute insulin but wait 2h of overlap with IV insulin Do not fix hyperglycemia too fast because it can affect the brain

Question 109

Differential diagnosis of vaginal discharge:

Answer 109

Gardnerella: gray thin and odorous Clue cells on Wet mount, +Whiff, ↑pH (nitrazine +), endogenous Tto: metronidazole (ok in pregnant) or clindamycin Trichomona: frothy green-yellow, ↑pH (nitrazine +) Gold standard: NAAT, trophozoite with corkscrew motility, STD Tto: metronidazole Candida: cottage cheese, itching!!! Pseudohyphae, germ tubes Tto: topical or oral azole

Question 110

What is the management of +GBS in pregnant woman?

Answer 110

Intrapartum IV penicillin G in labor at mom with: unknown status if less than 36w, if membranes broke more than 18h ago or if mom has fever * In allergic w. rash: cefazolin * In allergic w. severe penicillin reaction (anaphylaxis, respiratory distress, urticaria): vanco/clinda depending on sensitivity testing. Vanco if sensitivity unknown/unavailable!! * In allergic w. just rash: cefazolin

Question 111

What is the management of intussusception?

Answer 111

Air enema, if does not work do surgery!!!

Question 112

Which area does croup affect?

Answer 112

Subglotic larynx edema and proximal trachea narrowing (vs laryngomalacia affects the supraglotic; and epiglottitis that causes epiglottal and arypiglottic's folds edema) Parainfluenza, in kids from 1-4y Rx: Steeple sign due to subglotic narrowing (not part of the management) Presentation: barking cough, inspiratory stridor Mamagement: 1) symptomatic relief: cool mist and dexamethasone (maybe IM dexamethasone) 2) if biphasic stridor (inspiratory+expiratory)/ stridor at rest/ respiratory insufficiency: racemic epi ± hospitalize

Question 113

Most sensitive for dx of rotavirus:

Answer 113

Enzyme immunoassay of stool

Question 114

Where is the PDA?

Answer 114

On the descending aorta close to the ligamentum arteriosus

Question 115

What is the amniotic fluid index in oligo and polyhydramnios:

Answer 115

Oligohydramnios less than 5cm Normal 4-24cm Polyhydramnios more than 25cm: most cases are idiopathic

Question 116

What is the shape and significance of early, late and variable decelerations:

Answer 116

Variable: short! peaks down in less than 30s, indicate umbilical Cord compression, treat with 1) Maternal repositioning to left decubitus 2) aMnioinfusion Early: mirror the contractions, indicates head compression, not to worry! Early is good! Late: a little later than the contraction, indicates uteroPlacental insufficiency, you need to discontinue uterotonics or do an Emergency c-section. A common cause is maternal hypotension due to epidural, if due to hypotension 1st give pressors to mom, like phenylephrine

Question 117

Categories of fetal heart rate patterns:

Answer 117

1) Nr baseline of 110-160beats/min with moderate variability with NO late or variable decelerations, all good → continue labor 2) Is all tracing not categorized as 1 or 3, I don't know → re-evaluation 3) Absent baseline variability + bradycardia/ sinusoidal pattern/ recurrent late or variable decelerations → confirm that is not a physiologic reaction → intrauterine resuscitation* → if tracing does not normalize do c-section * Set mom in lateral decubitus ± stop oxytocin ± terbutaline if a lot of contractions ± IV fluids ± O2 mask ± amnioinfusion if variable decelerations ± vaginal exam to run out prolapsed cord ± scratch baby's head looking for accelerations

Question 118

Most common cause of operative obstetrics? and of C-section?

Answer 118

Operative obstetrics: prolonged second stage labor C-section: cephalopelvic disproportion* (also indicated if previous classical c-section, malpresentation, category 3 fetal HR and abdominal myomectomy!) * Cephalopelvic disproportion presents with molding of the fetal head and caput succedaneum

Question 119

Name 3 contraindications for DTaP vaccination:

Answer 119

Anaphylaxis Previous encephalopathy after a vaccine Unstable neurological disorder (complicated seizures): give DT

Question 120

Name 3 contraindications for rotavirus vaccination:

Answer 120

``` Previous intussusception Meckels diverticulum Anaphylaxis Congenital colon abnormalities SCIDs ``` IgA deficiency

Question 121

What is the low urine specific gravity and osmolarity (diluted)? What is high (concentrated)?

Answer 121

Low: Specific gravity less than 1.010 Osmolarity less than 200 High: Specific gravity more than 1.015 Osmolarity more than 500

Question 122

Possible treatments for hepatorrenal syndrome:

Answer 122

Vasocontrictors: Milrinone, octeotide, vasopressin+albunin Curative: trasplant

Question 123

How can you decrease the nephrotoxic potential of Ampho B?

Answer 123

``` Salt loading (1L of isotonic saline per administration): reduces sensitivity of the macula densa Use lipid-based formulations ```

Question 124

Hallmark cell in acute interstitial nephritis? and other diagnostic criteria? Causes?

Answer 124

Eosinophils (maybe present in urine as WBC casts ± sterile pyuria) fever, RASH, proteinuria and hematuria → Hansel or Wright stains Rash Fever ↑ Cr Causes: 7Ps: NSAIDs (Pain), Penicillin (cephalosporins, sulfa drugs), Ppi's and cimetidine, diuretics (Pee), rifamPin, alloPurinol, Phenytoin Atheroembolic disease (+ livedo reticularis)

Question 125

Acute papillary necrosis presentation and causes:

Answer 125

Acute renal failure with painless gross HEMATURIA+PROTEINURIA +- renal colic PAIN Causes: Sickle, Acute pyelonephritis, NSAIDs (analgesics) and DM=SAAD Diagnosis: Rx/CT(more accurate) that shows papillary deformation as lobster claw, ball on tee, signet ring, clubbed calix

Question 126

Name a monoclonal antibody FDA approved for TTP:

Answer 126

Caplacizumab that binds vWF and inhibits platelet adhesion

Question 127

Which tests should you do after your dx essential HT?

Answer 127

ECG, urinalysis, fasting blood glucose, CBC, electrolytes, Cr, lipids, TSH To see if organ damaged has already happened

Question 128

HT initial monotherapy:

Answer 128

140/100 or more if no comorbidities: give 6 mo of lifestyle modification and if it fails start with 1 drug No comorbidities: chlorthalidone (most potent thiazide), hydrochlorothiazide, imdapamide. If they don't work add an ACEi DM or renal failure: ACEi/ARBs (do not work in black) CHF, LV systolic dysfunction: ACEi, spironolactone, β-blocker (do not use β-blockers alone, you can use labetalol because is a α and β blockers) Angina: Ca ch blocker (dihidropiridines as nifedipine) 160/100 or more: start with 2 drugs chlorthalidone + ACEi Oral antihypertensives take 2w to work

Question 129

At which ages should you suspect non-essential HT due to renal A. stenosis? What is the tto?

Answer 129

Age <25 or >55 (out of the blue having no HT at all before) Tto: 1) ACEi/ARBs; first line for renal A. stenosis but you need to monitor the GFR because they can be dangerous in bilateral disease 2) If ACEi don't work/ recurrent flash pulmonary injury/ HF: surgical tto/ percutaneous angioplasty w. stent

Question 130

Causes of Normal Anion Gap Acidosis:

Answer 130

HARDUPH H = hyperalimentation (e.g., starting TPN) A = acetazolamide R = renal tubular acidosis (Type I = distal; Type II = proximal; Type IV = hyporeninemic hypoaldosteronism) D = diarrhea U = uretosigmoid fistula (because the colon will waste bicarb) P = pancreatic fistula (because of alkali loss–the pancreas secretes bicarb)

Question 131

Name the 3 RTAs, their causes, key features and tto:

Answer 131

2/14: Valentine's day; indicates the order of the RTAs in the renal tubules All ↓ pl K but 4, all acid urine but 1 RTA type 2: proximal CD The body cannot reabsorb bicarb and then a lot of acid is excreted Causes: Fanconi, MM, amyloidosis, expired tetracyclins, acetazolamide, tenofovir, mitochondrial diseases, Wilsons Keys: osteomalacia (you loose P) Tto: K-phosphate, thiazides!!! (Two → Thiazides) RTA type 1: DCT, α-intercalated cells The body cannot excrete acid! Causes: Sjogren, SLE, liver disease, autoimmune hepatitis, Li, ampho B, topiramate, QT, severe in kids Keys: ↑ urine gap, basic urine, bicarb is VERY low, Ca stones ± nephrocalcinosis (H goes into the bone and kicks out Ca), low citrate Tto: K-citrate (replaces K and prevents stones) and bicarb ``` RTA type 4: CD, principal cells Aldo does not work Causes: DM Keys: ↑ plasma K Tto: furosemide (activates RAAS), bicarb and fludrocortisone ```

Question 132

How do you calculate urine anion GAP?

Answer 132

Na+K-Cl Negative: GI losses Positive: renal losses

Question 133

What should you do when you see a metabolic alkalosis?

Answer 133

Mesure urine Cl: ↑ Cl because of ANP: saline insensitive; due to anything that ↑ aldo (mostly CONGENITAL causes) as tumors, cushing, Liddle, HT ↓ Cl: saline sensitive; due to diuretics, vomiting

Question 134

How are bicarb and CO2 in mixed disorders?

Answer 134

Bicarb and CO2 go in different directions and Ph is really affected Bicarb and CO2 go in the same direction but Ph is normal. If you see metabolic acidosis do Winters 1.5*bicarb+8

Question 135

Hormone replacement in postmenopausal:

Answer 135

Normals: estradiol + progesterone *migraine is a contraindication for estrogen in cases of contraception but not in hormonal replacement in post-menopause because here the dose is much lower Hysterectomy: Only E!!! conjugate equine estrogens as transdermal estradiol! Breast ca, endometrial hyperplasia, stroke, thromboembolism: paroxetine Only genitourinary sd of menopause: vaginal conjugated estrogen Osteoporosis prevention: 1) bisphosphonates 2) teriparatide if bisphosphonates don't work (only drug that builds bone mass) 3) denosimab if renal failure

Question 136

What is the management of acromegaly?

Answer 136

Dx: 1) IGF-1 2) Glucose followed by GH levels Tto: 1) Transsphenoidal resection 2) Octreotide. Second lines are pegvisomant and DA agonists as cabergoline if sx does not work 3) RT if neither sx nor medications work

Question 137

How do you do breast ca. prevention? Who should receive it?

Answer 137

1) Raloxifene / tamoxife 2) Anastrozole if history of thromboembolism (SE: can decrease bone density) Women of more than 35 yo with significant risk of breast ca.

Question 138

DD of the different types of lichen:

Answer 138

All are itchy Lichen planus: Flat purple lesion with wickham striae. Kobner phenomenon + (from along lines of minor tx). Sawtooth infiltrate and thickening of the granulosum, hypergranulosis + lymphocytes at the dermoepidermal junction. Can be in the mouth or on the vagina. Associated to Hep C. ACEi, thiazides, βB and hydroxychloroquine. Risk of ca. Lichen sclerous: White!! plaque (leukoplakia) with purple border. THINing of the epidermis that leads to erosions. In prepuberal and postmenopausal. Normally in the vagina, is all over the perineum and can extend to the annus. Risk of ca. Lichen simplex: THICK skin patch with enhanced margins form scratching. Leather-like hyperplasia of the squamous epithelium. No risk of ca. Tto: Corticoids

Question 139

UTI treatment during pregnancy? and on a newborn? and on a kid?

Answer 139

Normal person: 1) Nitrofirantoin/TMP-SMX/Fosfomycin 2) Oral ciprofloxacin is reserved for uncomplicated pyelonephritis UTI and asymptomatic bacteriuria: First trimester: 7 days of cephalexin/ 1 day of fosfomycin Second trimester: 5 days of nitrofurantoin * avoid nitrofurantoin in the 1st and 3rd trimesters! also is not good for pyelonephritis and prostatitis Pyelonephritis (main cause of preterm labor): admit inpatient, IV fluids, IV ceftriaxone ± tocolysis Baby: IV ampicillin + gentamicin and hospitalice Infant: oral TMP-SMX/3rd generation cephalosporin (cefixime, cefotaxime)/amoxicillin, only IV cefixime if they have pyelonephritis or not eating

Question 140

What is the management of suspected urethral and bladder injury?

Answer 140

Retrograde urethrogram

Question 141

What is the management of bronchopulmonary dysplasia?

Answer 141

Bronchodilators and diuretics! Rx: Cystic figures

Question 142

What are the presentation, RF, dx and management of URGE, STRESS and OVERFLOW incontinence?

Answer 142

One of the 1st steps in management are a voiding diary! and test for UTIs URGE Presentation: urine leakage after big urge to urinate, due to DETRUSOR m. spasms or detrusor instability, hypertonia RF: ↓ Estrogen, STD, UTIs, MS, spinal chord injury, previous pelvic sx Dx: Thorough medical history. You will see small post-void residual vol. (10-50ml) Management: 1) Bladder training, Kegel or estrogen replacement 2) if they fail use antimuscarinics (oxybutynin, tolterodine, darifenacin, not in narrow-angle glaucoma) *If similar to urge incontinence but with lack of urge to urinate: detrusor sphincter dyssynergia STRESS Presentation: small urine leakage after increase in intra-abdominal pressure (laughing, standing up...) Dx: Urethral hypermotility/incompetence on the Q-tip test (>30° angle), associated with 'celes', MCC of incontinence in pregnant Sometimes there is retrograde voiding and you can see a small pool of urine on the vagina that does not come out after an increase in intra-abdominal pressure RF: multiple vaginal deliveries, pelvic floor weakness, ↓ Estrogen Management: 1) Kegel exercises, pessary placement, estrogen replacement 2) Sx: midurethral sling OVERFLOW Presentation: hesitance, driblling, enuresis, full bladder sensation, supra-pubic distension, detrusor underactivity RF: DM2, BPH, diphenhydramine, outlet obstruction form uterine fibroids, postpartum (epidural/pudendal injury) Dx: increased post-void residual volume (+150 for female + 100-50 for male) Management: treat underlying disease, intermittent catheterization, if due to BPH you can give α-blockers or muscarinic agonists as bethanechol, carbachol, neostigmine

Question 143

How do you treat Bartter sd?

Answer 143

NSAIDS and SPIRONOLACTONE (so you keep K in)

Question 144

What is the management of newborn's anuria?

Answer 144

If anuria in the first 24h of life suspect posterior urethral valves → place urethral catheter → then, do a voiding cystourethrogram!! after acute obstruction is resolved → then, remove the valves surgically in the firsts few days of life

Question 145

What is the empiric treatment for continuous peritoneal dialysis-associated peritonitis?

Answer 145

Intraperitoneal cefazolin + ceftazidime

Question 146

Do you need to do an Rx of the joints affected by RA?

Answer 146

Yes, because if you see EROSIONS!! you need to give a DMARDs ± TNF inhibitors (vaccinate for zoster, if one TNF inhibitor doesn't work change to another)

Question 147

What makes the prognosis of RA a lot worse?

Answer 147

Smoking

Question 148

What is Still's disease? How do you treat it?

Answer 148

Rare inflammatory arthritis with fevers, rash and joint pain. This inflammation can destroy affected joints, particularly the wrists. Very high ferritin Tto: anakinra

Question 149

When cannot you use TNF-inhibitors?

Answer 149

Demyelinating disease, use abatacept instead

Question 150

What is the triple drug therapy for RA?

Answer 150

Methotrexate Hydroxychloroquine Sulfasalazine Less expensive and very similar efficacy compared to TNF-inhibitors

Question 151

What indicates bad px in RA?

Answer 151

Both rheumatoid factor + citrullinated peptide

Question 152

Evan's syndrome is:

Answer 152

Autoimmune hemolytic anemia + ITP in lupus, HIV, HCV, CVID...

Question 153

Why you cannot use biologic agents to treat lupus?

Answer 153

Because TNF-inhibitors can cause drug-induced lupus, it can be anti-his negative, anti ANA and anti smith positive! The only biologic that can be used is Belimumab Never give TNF-inhibitors in lupus! SLE managements: NSAIDs for very mild disease Hydroxychloroquine to prevent flares If any systemic disease (ITP, serositis...) you need steroids Mycophenolate/cyclophosphamide for kidney disease, but cyclphosphamide predisposes to secondary cancers

Question 154

Which antibody is associated with renal crisis in scleroderma?

Answer 154

Anti-RNA pol 3 Renal crisis is a MAHA so you get schistocytes, it can be precipitated by steroids and you treat it with ACEi (IV), ARBs don't work. If a pt has scleroderma and HT give prophylactic ACEi Do not give steroids in scleroderma, they don't work very well and can precipitate renal crisis

Question 155

Which diseases (2) can give you a fixed splitting of P2? How do you differentiate them?

Answer 155

ASD: high DLCO | Pulmonary HT: low DLCO

Question 156

What does watermelon stomach corresponds to?

Answer 156

GAVE (Gastric antral vascular ectasia) in scleroderma

Question 157

Which antibody is associated with autoimmune pancreatitis in Sjogren's?

Answer 157

IgG4

Question 158

Which metabolic abnormality is not corrected with hemodialysis?

Answer 158

Hyperphosphatemia, you need dietary P restriction, P binders, Vit D or calcimimetic agents

Question 159

How do you differentiate between candida-diaper rash and contact dermatitis in baby?

Answer 159

Candida is beefy red and affects the skin folds while contact dermatitis consist of papules and raised confluent erythematous areas that spare the skin folds

Question 160

How do you remove a kidney stone depending on it's size?

Answer 160

In the ureter: Less than 5mm: discharge and give fluids + NSAIDs ± tamsulosin or Ca ch blocker (If more than 5mm: remove the stone by retrograde urethrogram) More than 10mm: urology consult In the kidney: Less than 2.5cm: percutaneous lithotripsy/ nephrostomy tube placement during acute pyelonephritis More than 2.5cm: open sx stone removal, pyelotomy If the pt develops pyelonephritis!! do emergency percutaneous nephrostomy!! and IV antibiotics

Question 161

Causes of fetal growth restriction:

Answer 161

Asymmetric: head and abdomen are equally affected → nutrient lack due to uteroplacental insufficiency (SLE, antiphospholipid sd) Symmetric: head is less affected than the abdomen → congenital, TORCH infection... bad px

Question 162

Can you do circumcision on hypospadias?

Answer 162

Yes but it needs to be delayed because you need the prepuce for the hypospadias repair which can be done after 6mo (when the baby can tolerate anesthesia better)

Question 163

Which A. aneurism can compress the ureter?

Answer 163

Large aneurysms of the common, external, or internal iliac artery may compress the ureter, causing an extrinsic urinary tract obstruction and resulting in unilateral hydronephrosis This is because the middle portion of the ureter runs anterior to the common iliac artery on its way from the kidney to the bladder

Question 164

Fundoscopy fidings in retinal vein vs artery occlusion:

Answer 164

Vein: looks like a planet; focal retinal hemorrhage instead of a white, pale retina Artery: cherry red

Question 165

Councilman bodies indicate:

Answer 165

Cell apoptosis; seen in yellow fever...

Question 166

How is I:E ratio in asthma?

Answer 166

I:E ratio is normally 1:2 | In asthma and COPD it is prolonged ~ 1:3

Question 167

What type of drugs are exemestane and letrozole?

Answer 167

Aromatase inhibitors (e.g., exemestane, anastrozole, letrozole) they are the first-line hormone-therapy for estrogen-positive and progesterone-positive breast cancers in POSTmenopausal women

Question 168

Tto of osteomyelitis in kids:

Answer 168

Uncomplicated: nafcillin/oxacillin or cefazolin Previous hospitalization: vancomycin/clindamycin Sickle: vancomycin/clindamycin + ceftriaxone/cefotaxime * Best dx test for osteomyelitis is bone MRI and to confirm the organism your do a bone culture

Question 169

Which cells take care of toxin degradation in the airway?

Answer 169

Club cells

Question 170

Which rheumatologic disease cannot be treated by steroids?

Answer 170

Seronegative spondyloarthropathies Normally you give a TNF-inhibitor if it gets bad

Question 171

What is biggest RF for osteoarthritis?

Answer 171

Age

Question 172

Tramadol use, mechanism of action and side effects:

Answer 172

Partial opioid agonist, given for pain, in between NSAIDs and opioids, when NSAIDs cannot be used SE: seizures, serotonin sd., opioid-induced constipation!

Question 173

Do glucosamine/ chondroitin work for osteoarthritis?

Answer 173

No

Question 174

Osteoarthritis management:

Answer 174

``` 1) Topical /oral acetaminophen or NSAIDs!! + quadriceps stretching exercises (Tramadol if they cannot be used) Opioids Duloxetine Corticosteroid injections Joint replacement surgery ```

Question 175

Which arthritis are associated with hyperuricemia?

Answer 175

``` Gout Psoriasis (cell breakdown) ```

Question 176

Gout management:

Answer 176

Flares: 1) NSAIDs: but not if HT, gastric ulcer, kidney disease, but NO PROBLEM if they had a recent surgery. No low dose aspirin!! because it ↓ uric acid excretion COX2-inhibitors if ulcer but cannot be given on kidney disease 2) Steroids: best in renal insufficiency!!! 3) Colchicine; if flare you normally do allopurinol + colchicine until uric ac. reaches the goal of 6. * Do not start allopurinol during the acute attack for a patient that has never been on allopurinol but also do not stop allopurinol if the patient is already taking it 4) If gout attack refractory to traditional tto: IL1 inhibitors: Anakinra/ Canakinumab NSAIDs → Steroids → Colchicine is also the too for pseudo gout Maintenance: 1) Xanthine oxidase inhibitors: Allopurinol/Febuxostat. Wait for 1mo after the acute attack 2) If you are on a XOi and have not reach uric ac. goal: Probenecib/Lesinurad Probenecib: you cannot give it in a patient with tumor lysis sd, history of stones or decreased GFR Lesinurad is ~ probenecib but less toxic 3) If chronic refractory tophaceous gout if all other drugs cannot be used our do not work: pegloticase Losartan increases uric acid release!

Question 177

Which HT drug can decrease uric ac?

Answer 177

Losartan. It makes you get rid of uric acid

Question 178

Tto for Behcet's sd, Giant cell arteritis, Takayasu, Polimialgia reumatica, Polyarteritis Nodosa and Granulomatosis with polyangiitis:

Answer 178

Behcet's sd: colchicin Giant cell arteritis: high dose steroids and tocolizumab Takayasu: sterois, bypass grafting Polimialgia reumatica and Polyarteritis Nodosa: steroids ± cyclophosphamide Chung-Strauss: steroids and mepolizumab IL5i Granulomatosis with polyangiitis: prednisone during flare and rituximab for maintenance

Question 179

Gold standard dx of Takayasu:

Answer 179

Angiography

Question 180

Polyarteritis Nodosa keys:

Answer 180

Does not affect the CAPILLARIES of lung (alveolar) and kidney (glomerular) because it is a medium vessel vasculitis, but it can affect the renal A. Pulmonary A are not involved and bronchial A are only rarely involved. There is not lung disease but the kidney can be affected by the HT Think this if you see a testicular infarction on young pt Gold standard: angiography, you see vessel beading Sural n. biopsy just if foot drop! P-ANCA negative Associated with Hep B, C and hairy cell leukemia Tto: steroids + cyclophosphamide, later change to a less toxic drug

Question 181

Polymyositis/ dermatomyositis vs inclusion body myositis and autoimmune necrotizing myositis:

Answer 181

Polymyositis/ dermatomyositis: only proximal m. progresses over months Dermatomyositis: more common in kids, CD4, perifascicular/perimysial. Look for ca. Polymyositis: more common in adults, CD8, endomysial Tto: steroids ± steroid sparing drugs, IVIG if myocarditis Inclusion body myositis: proximal + distal m. progresses over years. Hard to treat: does not respond to steroids, do supportive therapy Autoimmune necrotizing myositis: Associated with statins. Autoimmune disease caused by statins. Stop the statin and give immunosuppressants 1) Check CK in serum 2) Stop meds and look for endocrinological disease 3) EMG 4) Muscle biopsy

Question 182

Define how MAC and fast/ slow onset correlates with solubility of inhaled anesthetics:

Answer 182

↑ Blood/gas = ↑ blood solubility = ↑ AV gradient slow = Slower; as halothane ↑ Oil/gas = ↑ lipid solubility = ↑ potency = ↓ MAC*; as halothane * MAC ↓ with age, pregnancy and hypothyroidism * Do not use NO in pneumothorax * Halothane is Hepatotoxic, Methoxyflurane is Nephrotoxic and Enflurane is Epileptogenic

Question 183

Key features of IV anesthetics (Propofol, Etomidate and Ketamine):

Answer 183

Propofol (GABA agonist): DOC in STABLE patients! redistributed Fast! hypotension due to peripheral vasodilation (give phenylephrine, alpha 1 agonist) + slight ↑HR, increases TG Etomidate (GABA agonist): DOC in rapid sequence intubation + succinylcholine, hemodynamically neutral! good for hypotensive and unstable, inhibits corticoids synthesis so careful in septic shock and do not use for maintenance, emetic, causes m. jerks (add fentanyl) * Propofol and Etomidate are not analgesic so you need to give them with an opioid or another analgesic Ketamine (NMDA antagonist): activates the sympathetic, causes HT, bronchodilator, analgesic! dissociative, increases cerebral flow, hallucinations, vivid dreams (prevent with benzo), do not give after MI, HF, HT, pulmonary HT

Question 184

How do you reverse non-depolarizing neuromuscular blockers or phase 2 succinylcholine?

Answer 184

Neostigmine + glycopyrrolate/atropine You can also use sugammadex that is faster just for the 'roniums' (but monitor EKG)

Question 185

In which patients is succinylcholine contraindicated?

Answer 185

Stroke Burnt Hyperkalemia

Question 186

Which neuromuscular blockers is the DOC in renal and hepatic failure?

Answer 186

Cisatracurium

Question 187

Main side effects of atracurium:

Answer 187

Atracurium: histamine release; hypotension, tachycardia * Cisatracurium is more potent and doesn't cause histamine release

Question 188

Key differences between cauda equina, conus medularis and spinal shock:

Answer 188

Cauda equina: LMN lesion (radiculopathy), normal Babinski Lumbar lesion, both L4 and S1 lost Tends to be more unilateral Conus= clonus medularis: UMN lesion (spinal cord lesion), affected Babinski Sacral, just S1 lost Tends to be bilateral ± impotence Both have saddle anesthesia, low back pain and involve the sphincters causing incontinence Spinal sock: Acute loos of spinal cord reflexes that come back Post-traumatic

Question 189

Key differences between Mallory Weiss and Boerhaave syndrome:

Answer 189

Mallory Weiss= esophageal tear presents with hematemesis but not pneumomediastinum Boerhaave= esophageal perforation Pleural effusion with atypical fluid Pneumomediastinum: Hamman sign (crunching sound which each heartbeat), subcutaneous emphysema (neck/ precordial crepitus) → esophagography or CT scan w. water soluble contrast → sx debridement and repair

Question 190

When should you give a statin?

Answer 190

3 magic numbers: 190, 40, 7.5!!! If atherosclerotic cardiovascular disease (angina, MI, arterial revascularization, stroke, TIA...) LDL more than 190 LDL (mg/dL) = total cholesterol – HDL – (triglycerides/5) DM and older than 40 Estimated risk of atherosclerotic cardiovascular disease more than 7.5-10%

Question 191

What is the management of carcinoid sd?

Answer 191

1) 24h urine 5HIAA → if + CT scan to localize the mass → Octreotide scintigraphy if CT does not find the tumor

Question 192

What is the management of suspected appendicitis?

Answer 192

Adult → CT scan w. contrast (which is + accurate than MRI) → sx Pregnant or kid→ ultrasound ± MRI → sx Sx: Nonperforated: Ab and appendectomy within 12 h Perforated: Ab and bowel rest, then percutaneous drainage if contained abscess/ irrigation and drainage with appendectomy Acute abdomen (rebound tenderness, rigidity, involuntary guarding) and indeterminate CT * Appendicitis from onset of symptoms to perforation is 36-48 hrs

Question 193

Organisms and tto associated with bites:

Answer 193

1) Debridement and amoxi-clavulanic (clindamycin + cefuroxime if rash with penicillin). Covers Pasteurella multocida, also good coverage of gram + gram - and anaerobics that make beta-lactamases Let it heal by secondary intention because anaerobes are the cause If does not heal: Human: Eikenella corrodens (Cepha 3rd) Dog: Capnocytophaga canimorsus (Cepha 3rd) Cat scratch: Bartonella henselae (azithromycin) Osteolyelitis: pasteurella multocida

Question 194

Mini-Mental State Exam (MMSE) score interpretation:

Answer 194

25-30: ok!! normal aging 24-20: mild dementia!!* 20-13: moderate dementia Less than 12: severe dementia Montreal assessment (MoCA) scores range also between 0 and 30 and are very similar to mini-mental * Fronto-temporal dementia normally presents with mild dementia while Alzheimer presents with moderate or severe!

Question 195

DD of Biliary colic, Cholecystitis, Choledocholithiasis and Ascending cholangitis:

Answer 195

Asymptomatic gallstones: no tto Biliary colic: Stone on the gallbladder Pain for less than 6h Tto: 1) ursodiol/ ursodeoxycholic acid 2) elective cholecystostomy Acute cholecystitis: Stone on the cystic duct!! Pain for more than 6h + Murphy sign + pericholecystic fluid and ↑ wall thickness ± fever, leukocytosis NO jaundice no ↑ alkaline phosphatase Dx: 1) ultrasound if negative → HIDA scan (not filling of the gallbladder) Tto: 1) antibiotics (pipe+tazo), then within 72h cholecystectomy!!!/ if bad sx candidate do a percutaneous cholecystostomy (tube) Acalculus cholecystitis: ~ acute cholecystitis but on a patient with long ICU course pericholecystic fluid but no stone Tto: percutaneous cholecystostomy (placement of a cholecystostomy TUBE) No cholecystectomy right away, do it 6w after Emphysematous cholecystitis: gangrene + air in the biliary system Tto: 1) Antibiotics + emergent cholecystectomy Choledocholithiasis: PAINFUL JAUNCICE Stone on common bile duct, dilated on US Less severe pain + JAUNDICE + ↑ alkaline phosphatase Liver enzymes do not have to be ↑ NO fever (unless pancreatitis), no leukocytosis, no Murphy sign Can lead to acute pancreatitis!!!! gallstone pancreatitis is one of the MCC (with alcohol) of acute pancreatitis! The common bile duct will be dilated here too Tto: Endoscopic retrograde cholangiopancreatography w sphincterotomy followed by elective cholecystectomy within 72h Ascending cholangitis: PAINFUL JAUNDICE+ FEVER Obstruction at the common bile duct Infection of the biliary tree due to enteric organisms as E.Coli, Klebsiella, clonorchis sinensis Charcot triad: pain + jaundice + fever + leukocytosis + ↑ alkaline phosphatase Reynolds pentad if progresses to shock: + hypotension + metal status changes Dilation of the intrahepatic and common bile ducts!!!! Tto: Endoscopic retrograde cholangiopancreatography → antibiotics + IV fluids → cholecystectomy when stable

Question 196

Neonatal conjuntivitis causes, timing, tto and prevention:

Answer 196

Gonococcal conjuntivitis: In 2 days old Prevented with topical erythromycin Treat with IV/IM ceftriaxone x1!!! (you do not need to give cefotaxime here because one single dose w not cause bilirubin-albumin displacement) Chlamydia conjuntivitis: In 2 weeks old. Chlamydia is calm and goes slow! Beefy red palpebral fissure (~ trachoma) Dx: you need a conjunctival scraping for PCR Treat with oral macrolide (erythromycin) x 2w, causes a lot of GI problems Tto w prevent pneumonia

Question 197

What should you think about if you see someone on drugs with conjunctival injection?

Answer 197

Cannabis, associated with impaired reaction time

Question 198

Dandy walker malformation is associated with?

Answer 198

Cerebellar vernix hypoplasia associated with congenital failure of closure of the Mangendie's foramen

Question 199

CHA2DS2 VAS score for Atrial Fibrillation Stroke Risk and management of each result:

Answer 199

This is for chronic A. fib that lasts more than 2 days: ``` Congestive heart failure Hypertension (even if treated) Age ≥ 75 years (2 points) Diabetes mellitus Stroke or TIA or thromboembolism (2 points) Vascular disease (prior MI, peripheral artery disease, or aortic plaques) Age 65–74 years Sex category (female sex) ``` 0-1: no tto needed/aspirin 2 or more: direct 2 factor inhibitors (dabigatran, argatroban)/ factor X inhibitors (apixaban)/ warfarin (careful bc causes bleeding) Keep the anticoagulation even if you do an ablation Fall risk is not a reason for not to anticoagulate *If A. fib due to a valvular cause use warfarin; but if not for a valvular cause you should use the factor 10 or 2 inhibitors after calculating CHA2DS2VAS When you don't need CHA2DS2VAS? mitral stenosis, thyrocoxicaosis + A. fib, HCOM causing A. fib

Question 200

Main association with stress incontinence:

Answer 200

Urethral hypermotility

Question 201

What does not palpated fundus + mass at the introitus on a woman that just gave birth? What is the management?

Answer 201

Uterine inversion Management: 1) discontinue uterotonics (oxytocin) → manual replacement and placental detachment → then give uterotonics (oxytocin) again

Question 202

What is the treatment of endocarditis? What are the indications for valve surgery?

Answer 202

1) Blood cultures from 3 different venipuncture sites 2) Antibiotics: IV drug user: IV vancomycin ± ceftriaxone If sensitive after blood culture: nafcillin Subacute: penicillin/macrolide/wait for sensitivity HACEK*: IV 3rd generation cephalosporins (ceftriaxone)/ IV ciprofloxacin * Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella, Kingella Valve surgery indications: acute heart failure, hypotension, emboli on antibiotics, vegetation of >=10mm, positive culture after antibiotics

Question 203

Does broken heart syndrome present with high troponins?

Answer 203

Yes

Question 204

Answers that are normally distractors:

Answer 204

Biofeedback Magnetic Resonance Cholangiopancreatography Consulting ethics committee

Question 205

What do you give to a depressed patient that is going to die in 2w?

Answer 205

Methylphenidate

Question 206

What do you tell the wife of a guy that says I don't want her to know the dx?

Answer 206

Your husband is fully informed about his health issues, he can tell you anything he feels you need to know Because: It preserves confidentiality Involves the patient doing the telling

Question 207

Which bug is associated with hamsters?

Answer 207

Salmonella HR temperature dissociation: 'she has a fever to 103, heart rate 62/min'

Question 208

Can you have rheumatoid arthritis with negative anti-CCP?

Answer 208

Yes! IgM activates complement that destroys the joint and then there is synovial mb hyperplasia forming a pannus that erodes the join

Question 209

What is the most common comorbidity associated with Afib? What is the most common cause of Afib? What is the biggest RF for MS? What is the biggest RF for coronary A disease and AAA? What is the biggest RF for stroke and aortic dissection?

Answer 209

HT Mitral stenosis (Dx: echo, Tto: valve replacement!!!!/ balloon valvotomy JUST if sx not possible) Rheumatic fever Smoking (smoking is the most important modifiable RF for atherosclerotic heart disease) HT

Question 210

Name SNRIs and their SE:

Answer 210

Venlafaxine, Desvenlafaxine Duloxetine (DM) Milnacipran!! Levomilnacipran They work the fastest, 2-3w SE: HT Raised metanephrines and normetanephrines

Question 211

What is key when they give you multiple RF for an illness and you have to choose the most significant RF for that patient?

Answer 211

Pay attention to which RF has the patient been exposed to the longest!

Question 212

Cosalgia:

Answer 212

After stroke there are weirds symptoms on a extremity (warm...)

Question 213

Red hot painful ears with chronic stridor and a saddle nose deformity:

Answer 213

Relapsing polychondritis

Question 214

Fever, thigh is swollen and exquisitely painful. Physical exam is notable for red and purple splotches around the involved area, Dx?

Answer 214

Necrotizing fascitis or progression to myonecrosis Management: MRI Tto: debridement + clinda

Question 215

Where do primary CNS lymphomas go?

Answer 215

Optic radiations, cause contralateral homonymous hemianopsia

Question 216

Segmental aneurysmal dilation of the SMA and IMA means:

Answer 216

Polyarteritis nodosa. In adult look for Hep B, in kid look for stept pneumo

Question 217

Eustachian tube dysfunction is associated with:

Answer 217

Wegener's Granulomas in the lungs

Question 218

Late onset asthma + peripheral neuropathy:

Answer 218

Chung strauss Granulomas in the lungs

Question 219

Patient diagnosed with H.Pylori gastritis 3 mo. ago and completed triple therapy. But persistent gastric ulcers and a large posterior antral ulcer with raised edges:

Answer 219

MALToma Tto: triple therapy, if does not work rituximab

Question 220

Bechets disease dx, which HLA is associated?

Answer 220

Dx: pathergy test | HLA-B51

Question 221

Proximal shoulder/hip weakness with a normal CPK in a 22 yo F on chronic therapy for severe, persistent asthma. Dx?

Answer 221

Steroid induced myopathy EMG will show low amplitude, short duration, polyphasic motor unit potentials

Question 222

Septic arthritis management:

Answer 222

1) arthrocentesis: if more than 50.000 PMNs → septic arthritis → sx wash out the joint + Abs* *Antibiotics depend on gram stain: Staph: vancomycin+ clean joint by arthrocentesis Gonococcus: ceftriaxone+doxycycline/azithromycin Negative gram: vancomycin+ceftriaxone ``` DD: septic bursitis Normal range of motion Pt working on his knees Normally S. aureus Treat with vancomycin ```

Question 223

Treatment for Hyper IgM sd and common variable immunodeficiency:

Answer 223

IVIG

Question 224

6 mo boy with spontaneous nose bleeds and chronic bloody diarrhea, he has had recurrent bacterial infections, examination of his UEs shows a red, itchy rash on his extensor surfaces:

Answer 224

Wiskott Aldrich sd. | X-linked, just in boys

Question 225

Septic patient with PNH. Dx?

Answer 225

Eculizumab tto leading to Neisserial infection

Question 226

Kid with recurrent sinopulmonary infections, silvery hair and frequent sunburns. Bone marrow biopsy shows blast cells with intracellular “giant inclusion bodies”. Dx? What is the most common cause of infection?

Answer 226

Dx: Chediak-Higashi MCC of infection: Staph aureus; frequently causes a periodontitis

Question 227

Other names for integrin:

Answer 227

CD18 LAF-1 MAC1

Question 228

Proximal + distal neuropaty:

Answer 228

Inclusion body myositis

Question 229

Pseudogout is associated with:

Answer 229

``` Gitelman syndrome Thiazides Hemochromatosis Hyperparathyroidism Hypophosphatemia (low P) Hypomagnesemia (low Mg) Join trauma ``` 4Hs

Question 230

Tto of fibromyalgia:

Answer 230

SNRI: Duloxetine or Milnacipran TCA Pregabalin Gabapentin * remember that CK will be normal

Question 231

Most common cause of death in scleroderma:

Answer 231

Pulmonary HT! Findings: RV heave, loud P2 What is the pulmonary manifestation of CREST syndrome? Pulmonary vascular HT with hyperplasia of the intimal smooth m. layer. The parenchyma is ok. What is the pulmonary manifestation of diffuse scleroderma? Interstitial lung disease that causes secondary pulmonary HT. Only dx if you see a restrictive pattern and reticular opacities! because on diffuse scleroderma you can also just have pulmonary vascular HT ``` Remember that in CREST there are just: skin findings, GERD and pulmonary HT! Calcinosis Raynaud Esophageal hypomotility=GERD Sclerodactyly Telangiectasia Pulmonary HT ```

Question 232

Pt with history of end stage renal disease and wood like induration of the extremities that SPARES the digits:

Answer 232

Nephrogenic systemic fibrosis

Question 233

Antibody in lupus associated with kidney issues/disease activity:

Answer 233

Anti ds-DNA!! and complement

Question 234

Next best step in the management with rapidly rising Cr:

Answer 234

Renal biopsy (because there are a lot of different renal problems)

Question 235

Drug of choice for SLE:

Answer 235

Hydroxychloroquine for long term. You need to do an anual eye exam! Steroids for flares

Question 236

Management on heart acute rejection:

Answer 236

Echocardiography guided endomyocardial biopsy

Question 237

What do you do if you have a gram stain negative in septic arthritis?

Answer 237

Vancomycin+Ceftriaxone

Question 238

Selected causes of pneumonia and their ttos:

Answer 238

Recent stroke: anaerobes; fusobacterium, peptococcus, bacteroides. Tto: clindamycin Cavitation: staph aureus, anaerobe, (maybe klebsiella), squamous cell lung ca Abscess 'thin walled cavity with air-fluid levels' in alcoholic: anaerobes; tto: ampicillin-sulbactam Abscess with poor dental higine: anaerobe. Tto: clindamycin COPD: Haemophilus. But strep pneumo is still the MCC of COPD exacerbation! Tto: for both is ceftrixone Outbreak: legionella. (do urinary antigen) Most common cause in HIV: strep pneumo. Tto: ceftrixone Recent trip to New Mexico/Arizona: cocci, spherules. Tto: itraconazole Cleans chicken/bird coops: histo or crypto Works at a “bird” store: chlamydia pistachio Researcher that works with wild rabbits: francisella tularesnsis. Tto: doxycycline Takes care of goats, sheep, and cats: coxiella Exposure to rodent urine/poop: hantavirus

Question 239

Desquamation with silvery scales on the palms and soles and ulcers on the glans penis, dx? tto?

Answer 239

Desquamation with silvery scales on the palms and soles: keratoderma blenorragicum Ulcers on the glans penis: balanitis Dx: reactive arthritis Tto: NSAIDs

Question 240

Ankylosing spondylitis Rx findings, management, tto and possible complication:

Answer 240

Rx findings: calcification of the annulus fibrosus of the intervertebral discs and inflammatory changes in the sacroiliac joints 1) Rx → if negative MRI of sacroiliac joint Exercise → NSAIDs → TNF inhibitors → Surgery At risk for atlantoaxial instability

Question 241

Treatment for axial vs peripheral rheumatoid disease:

Answer 241

Axial → NDAIDs → TNF inhibitors (PPD test before) Peripheral → NDAIDs → methotrexate (you could give TNF inhibitors if methotrexate does not work)

Question 242

Inverted CD4 to CD8 ratio, Dx?

Answer 242

MHC2 deficiency!

Question 243

RA associations: Multiple lower lobe predominant nodules on CXR: Bilateral arm weakness and 4+ reflexes: Left upper quadrant fullness and WBC of 1k: Tto:

Answer 243

Multiple lower lobe predominant nodules on CXR: Capaln sd Bilateral arm weakness and 4+ DTRs: atlantoaxial instability LUQ fullness and WBC of 1k: Fetty sd Tto: 1) Methotrexate (do pulmonary fx tests) → TNF-inhibitor (screen for TB and hep B) *Hydroxycloroquine if pregnant

Question 244

Given the following clinical presentations, what is the most likely SSTI? Honey colored crusted papules and pustules. Dx, Bug, tto? Cellulitis and hemorrhagic bullae after going underwater diving in a 45 yo M with chronic Hep C. Bug tto? Chronic nodular infection of the distal extremities in a vegetable farmer. Bug? Necrotic skin ulcer in a 22 yo diabetic male with a WBC of 500. Dx, Bug? Chronic nodular infection of the distal extremities in a fish tank cleaner. Bug?

Answer 244

Honey colored crusted papules and pustules: impetigo, staph aureus, topical mupirocin (DD. with HSV infection that can also present as a honey-color crusted rash on the face, but it will be limited to the orolabial region and would not involve the cheek) Cellulitis and hemorrhagic bullae after going underwater diving in a 45 yo M with chronic Hep C: Vibrio vulnificus, doxycycline Chronic nodular infection of the distal extremities in a vegetable farmer: Sporothrix Necrotic skin ulcer in a 22 yo diabetic male with a WBC of 500: ecthyma gangrenosum, pseudomonas Chronic nodular infection of the distal extremities in a fish tank cleaner: Mycobacterium marinum

Question 245

``` 40 yo smoker with bilateral calf pain who is a postal worker. Dx: Initial test: Test reports a result of 1.6: First mgt step: 2nd mgt step: Before surgery: Biggest RF: ```

Answer 245

Peripheral A disease 1) Ankle-brakial index + if less than 0.9 If more than 1 it is probably a diabetic that has Mockeberg's First mgt step: supervised exercise program! ± smoking cessation ± statin ± aspirin 2nd mgt step: cilostazol Before surgery: angiography or arteriography Biggest RF: smoking Extra: put them on aspirin and high intensity statin

Question 246

Recent MI and sudden onset severe LLE pain and absent pulses.

Answer 246

Actue limb ischemia Management: 1) heparin (can do CT angiography to confirm) then emolectoy within 6h

Question 247

65 yo M with MI that underwent a successful cardiac cath 5 days ago. Cr has bumped up to 3.5, he has transient vision loss, and he has a netlike, purplish discoloration on his LEs bilaterally. UA is +ve for eosinophils. He also had an episode of transient vision loss and a “golden body” is seen on a fundoscopic exam. Dx?

Answer 247

Aortic atheroemolic disease, the golden body is a Hollenhorst plaque

Question 248

23 yo college student comes to the ED complaining of pain in his right arm. He went spelunking with a few friends and believes he may have been bitten by a bat. What is the next best step in the management?

Answer 248

Rabies immunoglobulin in one arm, vaccine in the opposite!

Question 249

``` 27 yo 4 ft tall female presents with severe, sudden onset chest pain. CXR is notable for a left sided pleural effusion. She has never had menses. Dx: Dx testing by patient: What are the 2 forms of this disease: Initial management step for all forms: Subtle management difference: Specific drug to avoid: Why would this person be hoarse: ```

Answer 249

Aortic dissection on a Turner sd patient Dx testing by patient: if stable CT angiogram but if untestable trasesophageal ECO What are the 2 forms of this disease: A: involves the ascending aorta B: does not involve the ascending, just the descending Initial management step for all forms: Beta bloquer (never hydralazine) Subtle management difference: A: sx after the beta blocker B: no need sx Why would this person be hoarse: affect the recurrent laryngeal n.

Question 250

Recent DVT and then stroke:

Answer 250

There is a patent foramen ovale so need to do echo with bubble study

Question 251

Holosystolic murmur at the LLSB with apical diastolic rumble. Dx?

Answer 251

VSD

Question 252

IVDU with 2 wk h/o malaise, fatigue, fevers, and a new LLSB murmur heard on auscultation. Next best step in the management: 3 groups needing antibiotic prophylaxis? Dx imaging? Bugs with blood cultures that need future colonoscopies (2)? Feared complication?

Answer 252

Infective endocarditis NBSIM: blood cultures, do not treat before you get those cultures 3 groups needing abx ppx? Prior endocarditis Prostetic valve Unrepaired cyanotic congenial heart defect Dx imaging? Transesophageal echo Bugs with blood cultures that need future colonoscopies (2)? S. bovis Clostridium septicum Feared complication: brain abscesses (1-7%)

Question 253

4 ft tall F with chronic LE claudication. CXR findings? Tto?

Answer 253

Coarctation of the aorta, 3 sign | Tto: sx

Question 254

Rolling thunder murmur heard throughout the cardiac cycle in a kid with mom having an upper respiratory illness during pregnancy and wide PP:

Answer 254

PDA

Question 255

Hematuria and flank pain with a blood transfusion: SOB and stridor with a blood transfusion: T 102 and chills 2 hrs after a blood transfusion. Dx? Tto?

Answer 255

Hematuria and flank pain with a blood transfusion: Acute hemolytic transfusion reaction (type 2). Management: fluids SOB and stridor with a blood transfusion. Anaphylactic transfusion reaction (type 1). Management: epi T 102 and chills 2 hrs after a blood transfusion: Afebrile nonhemolitic transfusion reaction. Management: Coombs (just in case is +), NSAIDs/acetaminophen

Question 256

Long term measure with recently placed prosthetic aortic valve. What is your therapeutic target? Why would this person potentially have an indirect hyperbilirubinemia?

Answer 256

Warfarin for life, INR goal 2.5-3.5 | Hemolysis can happen bc the valve can shear RBCs

Question 257

High pitched midsystolic click at the apex, how does this change with manuvers? RF? Histology?

Answer 257

Mitral valve prolapse If you put more blood in the LV you fix the murmurs of MVP and HCMO ↑ preload (as valsalva that increases intrathoracic pressures) ↓ murmur ↑ afterload ↓ murmur RF: marfan, ED, ADPKD, pregnant, woman with psychiatric problems Myxomatous degeneration

Question 258

MI Complications: Pt dies intra-intraoperative during percutaneous coronary intervention 2 hrs after the onset of chest pain with ST elevations on ECG: Sudden onset SOB with bilateral crackles on lung auscultation, you hear an holosystolic murmur at the apex: Same but you hear an holosystolic murmur heard at the left lower sternal border: Low voltage ECG and PEA:

Answer 258

Pt dies intra-intraoperative during percutaneous coronary intervention 2 hrs after the onset of chest pain with ST elevations on ECG: Arrhythmia Holosystolic murmur at the apex: Papillary m. rupture Murmur heard at the left lower sternal border: Intraventricular septal rupture Low voltage ECG and PEA: Tamponade, free wall rupture

Question 259

Opening snap at the apex. Dx? Most common arrhythmia present? Anticoagulant strategy?

Answer 259

Mitral stenosis Afib Warfarin!

Question 260

Syncopal episodes in a 41 yo 4ft tall woman with a systolic murmur heard at the right upper sternal border. Diagnostic test to avoid?

Answer 260

Aortic stenosis secondary to bicuspid aortic valve in Turner Do not do exercise stress test in AS!!!

Question 261

Migratory arthritis with painless nodules under the skin, elevated ESR/CRP in a 12 yo F. She had an URI 12 months prior. Dx: Tx strategies (2 drugs): Most likely future valvular anomaly: Choreiform movements with resolution over a 2 month period:

Answer 261

Rheumatic fever Tx strategies (2 drugs): NSAIDs+ penicillin!! Most likely future valvular anomaly: MS Valves affected form the most to the least: MAT; mitral → aortic → tricuspid → pulmonic Choreiform movements with resolution over a 2 month period: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus). Resolves spontaneously

Question 262

HIV and vaccine strategies:

Answer 262

S.Pneumo: PCV13 followed by PPSV23 8 weeks later and again in 5 years and at age 65 HPV: 9-26 yo Hepatitis B unless they have documented immunity Meningococcal vaccine with boosters every 5 years Tdap vaccine as an adult followed by Td boosters every 10 years and after injury Influenza every year (NOT the LIVE attenuated the inactivated) Zoster: if no signs of immunity, do a serology and if negative give the vaccine if CD4>200

Question 263

HIV associations: Watery, foul smelling diarrhea in a HIV patient. Bug, tto? Nuchal rigidity and high fevers in a HIV patient. Bug, tto? 3 days of SOB, non-productive cough, and interstitial infiltrates on a CXR. Bug, tto? 2 weeks of SOB, productive cough with a CXR revealing a right upper lobe cavitary lesion and a right sided pleural effusion. Bug, tto? 3 days of SOB, high fevers, and a lobar consolidation seen on CXR. Bug, tto? Odynophagia. Bug, tto? Blurry vision with a CD4 of 45. Bug, tto?

Answer 263

Watery, foul smelling diarrhea in a HIV patient. Cyptosporidium, paromonycin/nitazoxamine Nuchal rigidity and high fevers in a HIV patient. Cryptococcus. Ampho B + flucytosine, then fluconazole 3 days of SOB, non-productive cough, and interstitial infiltrates on a CXR: PCP, TMP-SMX 2 weeks of SOB, productive cough with a CXR revealing a RUL cavitary lesion and a right sided pleural effusion: TB, RIPE regime + vit B6 3 days of SOB, high fevers, and a lobar consolidation seen on CXR: Strep pneumo, ceftriaxone Odynophagia: Candida, nystatin or azoles (lozenge format) Blurry vision with a CD4 of 45: CMV, ganciclovir

Question 264

HIV key prophylaxis:

Answer 264

CD4 < 250: arizona, nevada, california: itraconazole for cocci CD4 < 200: TMP-SMX* for PCP CD4 < 150: Chicago, kentucky, Missouri: itraconazole for histo CD4 < 100: TMP-SMX* for toxo (TMP-SMX only for prophylaxis, tto is pyrimethamine+sulfadiazine) CD4 < 50 on HAART therapy: no need for prophylaxis CD4 < 50 not on HAART therapy: azithromycin for MAC *If sulfa allergy give atovaquone!

Question 265

JVD, BP goes from 120/80 to 101/70 with deep breaths, low voltage ECG. Dx? Other signs: Tto? Other ECG finding: CXR finding:

Answer 265

Tamponade (The vignette describes pulsus paradoxus) Other signs: blunted/ absent y descent on central venous pressure Tto? pericardiocentesis (pericardial window) If they are asking about Dx or pericardiocanetesis is not an option do echocardiography Other EKG finding: electrical alternants CXR finding: water bottle shaped heart

Question 266

Loud diastolic heart sound with more prominent JVP waves on inspiration. Auscultation findings? Imaging findings?

Answer 266

Kussmaul sign on constrictive pericarditis Auscultation: pericardial knock Imaging findings? calcifications in the pericardium Tto: surgery

Question 267

Acute onset stabbing chest pain alleviated with sitting forward. EKG findings (2)? Tto strategy? Tto strategy for post MI pericarditis?

Answer 267

Acute pericarditis EKG findings (2)? diffuse ST↑ and diffuse PR↓ Tx strategy? 1) NSAID+colchicine Tx strategy for post MI pericarditis? aspirin

Question 268

Key arrhythmias; dx and too: Fib rule: Tach rule: Above the ventricle rule: In the ventricle rule: The < 60 + Hemodynamically unstable rule: The > 100 + Hemodynamically unstable rule:

Answer 268

Fib rule: spaces between the QRSs are unequal Tach rule: spaces between the QRSs are equal Above the ventricle rule: QRS is narrow In the ventricle rule: QRS wide The HR < 60 + Hemodynamically unstable rule: pacing The HR > 100 + Hemodynamically unstable rule: synchronized cardioversion=direct current counter-shock

Question 269

Electrolyte abnormalities:

Answer 269

Low K, Low Ca, Low Mg: long QT High K: wide QRS, peaked T; 1) Ca gluconate High Ca: Short QT Hypothermia: J wave

Question 270

Biggest RF for multifocal tachycardia, which electrolyte abnormalities are associated with it? What is the tto?

Answer 270

Smoking leading to COPD Electrolyte abnormalities: ↓K ↓Mg Tto: treat the underlying cause and Ca ch blockers Never cardiovert or give a β-blocker

Question 271

Tto for Afib w/WPW:

Answer 271

Procainamide

Question 272

Hemodynamically unstable WPW:

Answer 272

Synchronized cardioversion

Question 273

Drugs that increase survival in heart failure, decrease remodeling:

Answer 273

``` ACE inhibitors (prils) ARAs (sartans) Beta-blockers (Bisoprolol, Carvendiol, Metoprolol -Beta blockers Curve Mortalily-) Sacubitril (increases ANP) + valsartan Cardiac resynchronization therapy ``` ``` Aldo antagonists (spironolactone, eplerenone) in EF less than 35% Hydralazine + isosorbide dinitrate in African-americans ```

Question 274

31 yo M is brought to the ED with a 24 hr history of worsening headaches and nuchal rigidity. He was admitted one week ago for cryptococcal meningitis that responded to liposomal Amphotericin B and 5-flucytosine therapy. He was discharged on HAART. His most recent CD4 count obtained 1 month ago was 25 (nl CD4 > 500). A cryptococcal latex particle agglutination assay of a CSF sample obtained by lumbar puncture is negative. Dx?

Answer 274

Inmune reconstitution inflammatory sd So combined antiretroviral therapy should first be initiated at least 2 weeks after initiating treatment for the opportunistic infection!!!

Question 275

46 yo M with a 25 yr history of HIV is brought to the physician by his daughter with a 4 mo h/o poor concentration and impaired cognition. His only medication is a multivitamin. CD4 count is 10. Neurological exam shows a diffuse impairment in UE/LE motor activity. Dx? Next best step in the management?

Answer 275

HIV dementia NBSM: Highly active antiretroviral therapy

Question 276

Coronary pathology: Dx and tto of stable angina When does acute coronary sd. start? 3 drugs THAT must be given acutely for acute coronary sd? And for chest pain? Whan do you do coronary artery bypass grafting?

Answer 276

Stable angina: Dx 1) exercise stress test; Tto: nitroglycerin + loose weight, stop smoking and drinking Acute coronary sd. starts at unstable angina! 1) Aspirin+clopidogrel → heparin → nitrate O2 For chest pain? nitrate (just morphine in RCA infarct because you cannot give nitrates) CABG? just if LMCA or 3 vessel disease Maintenance: beta blockers, statins

Question 277

``` 37 yo F smoker on OCPs with sudden onset chest pain and SOB. Dx? ABG findings: Ca: K: Next best step in the diagnosis: Next best step in the management: When do we give TPA? ```

Answer 277

PE ABG findings: respiratory alkalosis, and Ca ↓ K ↓ because of the alkalosis NBSID: CT angiography NBSIM: heparin When do we give TPA: in hemodynamically unstable patient or patient with right heart dysfunction

Question 278

Sensorineural hearing loss in a patient that received therapy for chorioamnionitis:

Answer 278

You give Ampicillin+gentamicin for chorioamnionitis so you can cause ototoxicity

Question 279

Aural fullness, spinning sensation, ringing in the ears. Dx?

Answer 279

Meniere's disease=endolymphatic hydrops

Question 280

Spinning sensation on morning awakening. Worsened by head movements.

Answer 280

BPPV Dx: Dix-hallpike manuver Tto: Epley maneuver or Semont maneuver

Question 281

In brain metastasis, what is the immediate next best step in the management? Tx strategies?

Answer 281

Immediate NBSIM? corticoids | Tx strategies? whole brain radiation

Question 282

25 yo M with progressive R sided hearing loss and family history of hearing loss:

Answer 282

Otosclerosis

Question 283

Calcified mass with an enhancing linear projection connected to the dura refers to:

Answer 283

Dural tail of a meningioma

Question 284

Recurrent episodes of AOM. Evaluation reveals non-specific debris behind the tympanic membrane. He has chronic, foul smelling d/c from the affected ear. Dx: Dx testing? Tto?

Answer 284

Cholesteatoma Dx testing? head CT scan Tto? sx

Question 285

Patient with acute otitis media who develops pain, redness, and swelling behind the ear. Dx? Next best step in the management? Tto?

Answer 285

Acute mastoiditis, after a non-healed ear infection The ear also looks down and forward 1) drain the ear and send for culture + IV antibiotics 2) head CT!!! scan (in order to look for potential complications such periostitis/osteomyelitis) Tto: Myringotomy + IV vancomycin (S. aureus)

Question 286

Blunt kidney trauma algorithm:

Answer 286

1) urinalysis: No blood → home Blood → CT scan abdomen and pelvis

Question 287

7 week baby with projectile nonbilious vomiting 30 mins after feeds. Visible peristaltic waves. Dx? Dx test? Tto?

Answer 287

Pyloric stenosis Dx test? Ultrasound Tto? Myomectomy

Question 288

Baby with abdominal viscera to the right of the umbilicus vs through the umbilicus?

Answer 288

To the right of the umbilicus: gastroschisis Through the umbilicus: omphalocele

Question 289

Down’s syndrome with failure to pass meconium. Associated mutation? Dx? Dx testing?

Answer 289

Hirschsprung disease Associated mutation? RET Dx testing? Rectal suction biopsy

Question 290

Thyroid pathology keys: First step in working up nodules: Next best step in management with a hot nodule: Next best step in management with a cold nodule: If RAIU scan shows 1 hotspot. Dx? If RAIU scan shows multiple hot spots. Dx? If RAIU scan diffuse pattern. Dx? If RAIU scan shows no uptake + tender thyroid. Dx? Healthcare worker: MCC Cold thyroid nodule: Swallowing issues after lobectomy: MC thyroid cancer: Prolonged QT on EKG with thyroid cancer: Laminated calcifications: Method of spread: Old guy with widely disseminated lesions: Prophylactic surgery with MEN2 syndromes:

Answer 290

First step in working up nodules: TSH TSH ↓ → HOT nodule: RAIU scan TSH ↑/Nr → COLD nodule: 1) ultrasound → fine needle aspiration if meets criteria (cannot rule out follicular thyroid ca. but it can rule out the others) RAIU scan 1 hotspot: toxic adenoma RAIU scan multiple hot spots: toxic multi-nodular goiter RAIU scan diffuse pattern: graves RAIU scan No uptake + tender thyroid: de Keravin=granulomatorus=subacute thyroiditis Healthcare worker: factitious, also no uptake MCC Cold thyroid nodule: colloid cysts Swallowing issues after lobectomy: injury of the recurrent laryngeal n. MC thyroid cancer: papillary (papillary is popular) Prolonged QT on EKG with thyroid cancer: medullary because it makes calcitonin! Laminated calcifications: papillary All ca. spread trough lymph nodes, only follicular spreads hematogenously Old guy with widely disseminated lesions: aplastic Prophylactic surgery with MEN2 syndromes: thyroidectomy

Question 291

Where is the likely nerve lesion? 1) Midlateral thigh numbness in a basketball player who has required R thigh casting for a sports related injury: 2) Flattening of the thenar eminence, sensory loss on the ventral surface of the lateral hand: 3) Weakness in “finger spread”:

Answer 291

1) Lateral femoral cutaneous nerve leading to meralgia paresthetica 2) Carpal tunnel. Wrist splint → Inject steroids → nerve conduction studies before you cut the carpal tunnel in sx 3) Ulnar n.

Question 292

51 yo M with a 6 mo h/o numbness and paresthesias in his L foot radiating to his L great toe:

Answer 292

Tibial n. problem: tarsal tunnel sd.

Question 293

``` Male cyclist has been unable to train for the past 4 days. He had a sore throat and rhinorrhea that resolved 10 days ago without tx. Dx: Tx: Drug to avoid: Respiratory monitoring: ```

Answer 293

Gilliam-barre Tx: plasmapheresis Drug to avoid: corticoids Respiratory monitoring: if FEV1 goes down you intubate

Question 294

Tx for trouble smiling on one side of the face?

Answer 294

Steroids within 3 days of the onset

Question 295

Buffalo hump, DM, osteoporosis, amenorrhea. Dx: First dx test: 2nd dx test: 3rd dx test: Tx strategy:

Answer 295

Cushing's sd First dx test: late NIGHT salivary cortisol/ 24h urine cortisol (if pt works late at night)/ low dose dexamethasone suppression test (has a lot of false + so you cannot do it if the pt is taking OCPs, P450 activators, alcoholics, depressed...) Normally you do 2 test here because you end up doing the 24h urine cortisol to confirm that is the most accurate 2nd dx test: measure ACTH; ↓: adrenal cause so do a CT of the abdomen and pelvis; ↑: ectopic or Cushing's disease so go to the 3rd dx test 3rd dx test: if ↑ ACTH do a high dose dexamethasone suppression test: suppression: pituitary so do a brain MR; no suppression: ectopic due to cancer 4rd dx test if you still don't know if it is ectopic or pituitary: Inferior petrosal sinus sampling: check the sinuses and depending on where you see ↑ ACTH you can localize where the lesion is; if the inferior petrosal sinus has a lot of ACTH the tumor should be on the pituitary (pituitary gland is drains to this sinus) Tx strategy: 1) surgical resection 2) ketoconazole or metyrapone 3) mifepristone because it blocks cortisol receptors

Question 296

Pheochromocytoma dx:

Answer 296

1) Plasma (+ sensitive)/ urinary free metanephrines (ask pt to stop smoking 4h before testing) → CT abdomen and pelvis → if you don't find the mass on CT scan you can check for ↑ uptake of iodine-131-metaiodobenzylguanidine = I-131 MIBG!! * Suspect pheochromocytoma in pt with HT, paroxysmal headaches and unexplained hyperglycemia!!! (catecholamines inhibit insulin secretion)!

Question 297

Given the following vignettes, what is the most likely dx (bleeders)? 1) Painless, massive bloody bowel movement in a 65 yo F. Dx? Dx test? 2) 69 yo M with a history of PAD has a 3 mo h/o of severe LLQ pain worsened with meals: 3) 72 yo F with a Hb of 8. Fecal occult blood test is +. An ejection murmur radiating to the carotids is heard on auscultation: 4) Hb of 7, 3 months after a AAA repair: 5) Chronic bloody bowel movements with small vascular malformations visible on the buccal mucosa: 6) Sudden onset of painful hematemesis 30 minutes after weightlifting/eating disorder patient:

Answer 297

1) Diverticulosis. Dx test is barium enema or colonoscopy Diverticulitis Dx test is CT scan with contrast!!! do not do colonoscopy until episode resolves 2) Ischemic colitis; vascular disease of the mesenteric A 3) AS+GI bleed: Heidy sd=colonic angiodisplasia, the calcified aortic valve destroys the VW factor so you bleed! 4) Aorto-enteric fistula. Bleed into their GI tract! 5) Osler-Weber-Rendu disease=hemorrhagic hereditary tellangiectasia 6) Mallory Weiss tear (hemodynamically stable vs boerhaave that will be unstable). No need to treat Mallory Weiss

Question 298

To determine metastatic potential for a breast malignancy, what is the initial dx test that is performed? If this test is +, what is your NBSIM?

Answer 298

1) sentinel lymph node biopsy -: just mastectomy +: axillary lymph node dissection + RT + QT (tamoxifen or trastuzumab depending on positivity/QT IF triple negative)

Question 299

Can you withdraw fluid form a friboadenoma?

Answer 299

No! in that case is fibrocystic change!

Question 300

Weight loss, jaundice, steatorrhea, and dark urine in a 69 yo smoker. Palpable, nontender BUT distended GB. Dx testing?

Answer 300

Pancreatic ca. | Dx testing? CT scan of the abdomen and pelvis with contrast

Question 301

New onset DM + red blistering rash spreading across the skin:

Answer 301

Rash: necrolytic migratory erythema | Glucagonoma, bad px

Question 302

Epigastric pain radiating to the back. Dx? Physical examination findings: Management: Prognostic factors:

Answer 302

Pancreatitis ``` PE findings: Ecchymosis in Umbilicus: Collins sign Inguinal lig: Fox sign Flank: Grey-turner sign ``` ``` Mgt: PIN Pain control IV fluids Nothing per mouth * Do not do a cholecystectomy during acute pancreatitis! ``` Bad prognostic factors: ↓ Ca, high LFTs, ↓ Hb

Question 303

Hypodense hepatic mass with peripheral enhancement on arterial phase and centripetal filling on delayed phases:

Answer 303

Hepatic hemangioma

Question 304

Stellate scar on abdominal CT:

Answer 304

Focal nodular hyperplasia

Question 305

Heterogenous enhancement on CT:

Answer 305

Hepatic adenoma | Avoid contraceptives

Question 306

What is the most likely dx? How are these syndromes treated? 1) Elevated serum IgE/eosinophils with very difficult to control asthma and interstitial infiltrates on CXR: 2) Cough and hemoptysis in an IVDU currently on Rifampin/INH therapy. CBC is notable for marked serum eosinophilia: 3) Immunosuppressed with high fevers and leukopenia. His symptoms are not responding to vancomycin and cefepime. Chest CT shows a targetoid hyperdensity (halo sign) with surrounding ground glass attenuation:

Answer 306

1) Allergic bronchopulmonary aspergillosis, steroids 2) TB, then the pt developed aspergilloma, 1) biopsy to rule out ca. and then sx 3) Invasive aspergillosis (CT: nodules w surrounding ground-glass opacities 'halo sign'), 1) voricanazole 2) amp B

Question 307

Severe abdominal distension and bloody bowel movements in 39 yo M with h/o bloody diarrhea. Dx: Dx test and criteria?

Answer 307

Ulceritive colitis causing toxic megacolon Dx test: abdominal Rx (CT scan) Dx criteria? more than 6cm diameter Tto: IV glucocorticoids

Question 308

Sigmoid vs cecal volvulus via imaging and tto:

Answer 308

Facing right: cecal volvulus Facing left: sigmoid Tx: flexible sigmoidoscopy + rectal tube, if does not work colonoscopy if does not work sx

Question 309

Most common cause of death in refeeding syndrome:

Answer 309

Low P, food increases insulin and insulin puts P and other electrolytes into cells No P No ATP

Question 310

42 yo F with fever and RUQ pain. + distended hepatic duct. Dx?

Answer 310

Mirrizzi's syndrome Cystic duct bulges on the hepatic duct and distends it

Question 311

29 yo M with mild RUQ pain and scleral icterus. Dx?

Answer 311

No fever so Choledocholithiasis, stone in the common bile duct Dx: ultrasound Tto: ERCP

Question 312

32 yo M with fever, direct hyperbilirubinemia, and RUQ pain. Dx?

Answer 312

Charcot's triad | Ascending cholangitis, need to treat fast so 1) ERCP

Question 313

105 pack year smoking history with rapidly developing digital clubbing and diffuse joint pain:

Answer 313

Hypertrophic pulmonary osteoarthropathy | Chest CT to find the lung ca

Question 314

Most common cause of SVC syndrome vs Pancoast?

Answer 314

SVC sd: small cell lung ca. (tto: RT) | Pancoast: squamous cell lung ca. (measure FEV1 before you resect the lung)

Question 315

RR of 8 with a BMI of 45 and heavy snoring. Diagnostic hallmark? CBC?

Answer 315

Low RR makes obesity hypoventilation sd most likely OSA will NOT hypoventilate during the day Dx: polysonnograpy Diagnostic hallmark? day time hypercapnia CBC? high hematocrit Tto: CPAP, BiPAP

Question 316

Fired for napping at work with low hanging uvula and loud snoring. Dx? Tto?

Answer 316

OSA Dx: polysonnograpy Tto: CPAP, BiPAP

Question 317

27 yo M is brought to ER with SOB. He is found to have worsening hypoxemia and a rapid COVID-19 test is +. PaO2 is 100 on 100% FiO2. Dx: MCC of this dx? Tto? Pathophysiology?

Answer 317

ARDS MCC of this dx? Sepsis Tto? intubate Pathophysiology? Increased vascular permeability

Question 318

``` NBSIM in lung nodule seen on CXR? How do you biopsy a central lesions? How do you biopsy a peripheral lesion? Pleural effusions? Needle considerations? ```

Answer 318

NBSIM in lung nodule seen on CXR: Chest CT How do you biopsy a central lesions? mediastinoscopy/endobronchial ultrasound w biopsy (EBUS) How do you biopsy a peripheral lesion? CT guided percutaneous biopsy Pleural effusions? Thoracentesis!! if ca. cells in the fluid means stage 4 Needle considerations? above the rib

Question 319

What to consider before lung cancer resective surgery?

Answer 319

Just if FEV1 is more than 2L or more than 25% of prefixed FEV1 and DLCO are the best predictors of postoperative outcomes after surgery If + hoarseness means that the recurrent laryngeal n. is affected, so indicates extrapulmonary spread and in that case respective surgery is not indicated

Question 320

Tx differences in small cell vs non small cell lung ca?

Answer 320

Small cell: is already stage 4 at dx. Only QT Non small cell: QT, RX, Sx

Question 321

What is the major determinant of successful TB tx?

Answer 321

Medication adherence

Question 322

NBSIM with a + tuberculin skin test and a - CXR?

Answer 322

This is latent TB | 9 mo isoniazid + B6 (pyridoxine)

Question 323

25 yo M is brought to the ED after being found comatose on a military base. He just returned from deployment on a peacekeeping mission in Congo. His friends report that he had a bad cold for about 5 days but started having bloody bowel movements yesterday. PT, PTT, bleeding time, AST, and ALT are all markedly elevated. His Cr is 3.5. Dx? NBSIM?

Answer 323

Dx? Ebola | NBSIM? Supportive care

Question 324

A 26 yo F comes to the physician’s office complaining of severe bilateral elbow and knee pain. She just returned from a 6 month deployment. Her symptoms were preceded by 6 days of high fevers. PE is notable for LE petechiae. Dx? Most likely intervention to have prevented this illness? Close NBME exam cousin?

Answer 324

Dx? Chikungunya Most likely intervention to have prevented this illness? mosquito nets to avoid acedes mosquito Close NBME exam cousin? Dengue, also carried by the acedes mosquito

Question 325

SOB with: 1) Long bone fractures: 2) Central venous cath insertion but a nr CXR (+ NBSIM): 3) Recent labor and delivery: 4) Infective endocarditis:

Answer 325

1) Fat emboli (fx, petechia, respiratory distress, CNS problems) 2) Air embolism; NBSIM: roll to left lateral decubitus so the emboli does not go to the brain 3) Amniotic fluid embolus 4) Septic embolis

Question 326

Asymptomatic patient with INR of 9 on Warfarin. New reversal?

Answer 326

1) Four factor prothrombin complex concentrate!! PCC! | 2) Fresh frozen plasma

Question 327

``` 19 yo M presents with the sudden onset of severe RUQ pain and progressively worsening abdominal swelling. He has a history of chronic hematuria. Labs are notable for a Hb of 6, WBC 1100, and plts 20k. Dx? Gene mutation? Heritable? Dx testing? ```

Answer 327

Paroxismal nocturnal hemoglobinuria that has caused budd chiari syndrome Gene mutation? PIGA gene mutation so you cannot make GPI anchors for CD55 and CD59 Tto: eculizumab Heritable? no, the mutation is in somatic cells Dx testing? flow cytometry

Question 328

65 yo M with 6 mo hx of progressively worsening dyspnea, dry cough, and bibasilar fine crackles heard on lung auscultation. Dx? Buzzword: Dx test?

Answer 328

Idiopathic pulmonary fibrosis Buzzword: fine crackles!! Dx: Hight resolution CT scan showing honeycombing

Question 329

A female with 6 mo hx of dyspnea and dry cough. Dx? Tto? Testing problem? Confirmatory test? 1) same + tender, erythematous nodules on the shins 2) same + violet colored cheek, nose, ear, lesions What indicates good and bad prognosis?

Answer 329

Sarcoidosis Tto? No tto. If a lot of symptoms or does not resolve you can give steroids Testing problem? Frequent false negative PPD test so it is better to do quantiferon for screening on them Confirmatory test? Lymph node biopsy 1) erythema nodosum 2) lupus perino Good px: erythema nodosum, asymptomatic hilar adenopathy and acute arthritis Bad px: pulmonary fibrosis, African-american and extrapulmonary sarcoidosis

Question 330

31 yo F presents with a 2 day h/o of fevers and chills. She has a history of intermittent, severe pain on her forehead and maxilla that is well controlled with anti-epileptic therapy. Hb is 13, WBC is 400, Plt count is 140k. Dx? NBSIM? Other causes?

Answer 330

Trigemial neuralgia treated with Carbamazepine causing febrile neutropenia NBSIM? antipesudomonal Ab Other causes? clozapine, PTU, methimazole

Question 331

67 yo M presents with a 2 day h/o of recurrent epistaxis. Hb is 6.5, MCV is 110, leukocyte count is 1400, plts 45k. B12 and folate levels are nr. A blood smear sample shows nucleated erythrocytes and hypolobulated neutrophils. Dx? Most likely complication? Named PMN morphology?

Answer 331

Myelodysplastic sd Most likely complication? AML Named PMN morphology? Pelger huet

Question 332

What is the difference between ischemic colitis and chronic mesenteric ischemia? What is the management of acute mesenteric ischemia?

Answer 332

Both will cause pain after you eat Diffuse pain: ischemic colitis RLQ: chronic mesenteric ischemia Management: 1) IV fluids and broad spectrum antibiotics 2) Dx by CT angiography

Question 333

62 yo M presents with a 1 week h/o of blurry vision and severe headache. He has been taking daily Ibuprofen for severe pain in his hands and feet. PE is notable for splenomegaly and marked tenderness on palpation of the small joints of his hands and feet with overlying erythema. Hb is 6.5, plts 950k, leukocyte count 1200. Dx? NBSIM? Pathophysiology?

Answer 333

Essential thrombocythemia NBSIM? plasmapheresis + aspirin Pathophysiology? JAK 2 mutation

Question 334

MS complications, dx and management: 1) Pain with eye movement and visual acuity of 20/200 in the left eye (+ dx test, mgt): 2) Nystagmus when told to look to the right: 3) Chronic leakage of urine. Post void residual is 400 ml: Dx testing: Tx of acute exacerbations: Chronic mgt: Preventive medicine pearl:

Answer 334

1) Optic neuritis: do an MRI w contrast, IV steroids 2) INO (MLF lesion) 3) Overflow incontinence: give a muscarinic against like bethanechol Dx testing: MRI of brain and spine Tx of acute exacerbations: 1) IV steroids, plasmapheresis if does not respond Chronic mgt: 1) INF-β, glatiramer Preventive medicine pearl: vit D, improves morbidity

Question 335

HY psych contraindication of interferon-α:

Answer 335

We do not use it as tto of Hep C anymore because it causes suicidability and depression

Question 336

What is the association between superior cerebellar A. and Parinaud sd?

Answer 336

The superior cerebellar A. gives blood supply to the superior colliculus and if it gets infarcted you can get Parinaud sd

Question 337

A 32 yo F with a chronic h/o of diplopia and bulbar weakness is brought to the ED with significant SOB. She was recently started on oral gentamicin for a symptomatic pyelonephritis. PaO2 is 84. What is the NBSIM? Dx? Tto?

Answer 337

Myasthenia NBSIM: endotracheal intubation Does not affect the deep tendon reflexes vs in Lambert Eaton that decrease Dx: antibodies Tto: pyridostigmine Myasthenic crisis: intubation + plasmapheresis (or IVIG) + steroids Do not give an aminoglycoside in myasthenia

Question 338

Paraplegia after AAA repair, think about:

Answer 338

The A. of Adamkiewicz branches off form the abdominal aorta and supplied the anterior spinal A so you loss everything but touch

Question 339

7 mo boy losing motor milestones with fasciculations. Dx? Mode of inheritance: Mutation:

Answer 339

Werdnig-Hoffman sd MOI: AR Mutation: Ch 5 mutation of the survival motor neuron 1 gene

Question 340

P vera; O2 sats: Mutation: Tto:

Answer 340

O2 sats: normal Mutation: JAK2 Tto: hydroxyurea (± phlebotomy)

Question 341

22 yo M in a MVA 2 hrs ago. Now in the ER with 1) mild SOB, PaO2 of 60, and b/l pulmonary interstitial infiltrates 2) cardiac index of 1. Dx?

Answer 341

1) Pulmonary contusion | 2) Miocardial contusion

Question 342

Received continuous insulin therapy because it's glucose was 907. Then it becomes comatose and has blown pupils, what happened?

Answer 342

Cerebral edema Whenever you treat a HYPERglycemia/natremia too fast you can get cerebral edema

Question 343

The 3 key ingredients in DKA/HHNS management:

Answer 343

1) IV fluids 2) Insulin infusion with regular insulin 3) Pay attention to K! key numbers: 3.3-5.5! Less than 3.3: hold the insulin 3.3-5.5: give insulin and add K More than 5.5: give insulin If glucose is less than 200 halve insulin and add dextrose!

Question 344

Hypoglycemic agents contraindicated in: 1) 55 yo M with S3 and 3+ b/l LE pitting edema: 2) Obtaining some kind of contrast based imaging procedure: 3) Family h/o of MEN2A/2B: 4) Highest weight gain risk and hypoglycemia: 5) Cause diarrhea and flatulence:

Answer 344

1) Heart failure: glitazones 2) Contrast can affect the kidney so do not give metformin 3) GLP1 agonist (tides) and DPP-4 Inhibitors (gliptins) because they increase risk of medullary thyroid ca!!! But good for obese 4) Sulfonylurea 5) Acarbose and miglitol

Question 345

New onset DM in a 61 yo M with increased spacing between his teeth. NBSID? Tx?

Answer 345

1) Glucose suppression test 2) Brain MRI In endocrine disorders imaging is never the first thing to do, you first need to prove it biochemically Tx: transsphenoidal resection (pegvisomant)

Question 346

Profound hypotension in an SLE patient undergoing surgery that is not responsive to fluid repletion. What happened?

Answer 346

Adrenal crisis | Tx: stress dose of steroids

Question 347

↑ EF + thigh pain + ↑ alkaline phosphatase. Dx?

Answer 347

High output HF in paget's | Dx: bone scan

Question 348

6 yo M with a 6 wk h/o fevers, night sweats, and weight loss. Chest CT is notable for anterior and middle mediastinal lymphadenopathy. Dx?

Answer 348

ALL

Question 349

Recurrent DVTs with heparin failing to raise the PTT. Dx?

Answer 349

Antithrombin 3 deficiency; inherited or acquired in nephrotic sd.

Question 350

Patelet count of 10k 6 days after receiving medical tx for a pulmonary embolism. Dx? Screening: Confirmatory test: Tto:

Answer 350

HIT Screening: anti platelet factor 4 (PF4) antibodies Confirmatory test: serotonin release assay Tto: 1) stop the heparin, 2) argatroban, dabigatran, bivalirudin

Question 351

What is the most likely diagnosis given the following presentations of back pain? 1) Old man with leg pain that improves when he gets out of bed in the morning: 2) History of breast cancer treated with chemo 5 years ago (+ tx)? 3) Fever and a lower abdominal mass detected on PE: 4) Lower abdominal mass detected on PE. The patient was recently started on Apixaban as Afib stroke prophylaxis:

Answer 351

1) Lumbar spinal stenosis 2) Spinal metas, IV steroids 3) Spinal epidural abcess, do MRI, NEVER give steroids 4) Spinal epidural hematoma, NEVER give steroids

Question 352

Weight loss and 6 week history of severe leg pain with prior history of teriparatide therapy. Dx?

Answer 352

Teriparatide is a PTH analog that builds bone up, can lead to an osteosarcoma

Question 353

The NBME and myoclonus: 1) In a 39 yo neuropathologist with a 5 week h/o of profound memory loss: 2) In a 29 yo F who was recently started on phenelzine after treatment failure with sertraline for MDD: 3) In a 7 mo male with a midline abdominal mass:

Answer 353

1) Creutzfeldt-Jakob disease, check CSF high 1433protein 2) Serotonin sd. 3) Opsoclonus-myoclonus sd in neuroblastoma

Question 354

81 yo F with 3 episodes of pneumococcal meningitis over the last 14 mo. WBC is 108k with a lymphocytic pleocytosis. Dx?

Answer 354

CLL | Smudge cells

Question 355

Given the following presentations, what is the most likely dx? 1) Drug dealer was found down in his apartment and responded positively to naloxone therapy. He is found to be akinetic despite multiple attempts at encouraging movement: 2) Shoulder and neck hyperextension backward. Tto? 3) 39 yo computer scientist with progressive dementia, “an increasing number of angry outbursts”, and stereotypical arm movements. Dx? Tto?

Answer 355

1) MPTP toxicity can cause Parkinsonism 2) Dystonia, tto botox 3) Huntington's, Dx atrophy of the caudate, Tto: tetrabenazine

Question 356

NBME and Strokes; When do you give TPA? What is the correct dx test to select in a TIA? How are SAHs worked up? Dense paralysis on 1 side of the body. Dx? Medical mgt of carotid disease (1.2.3) Medical mgt of TIA with an irregularly irregular interval on EKG % cutoff for endarterectomy? 100% stenosis? What must be done before allowing food? BRF for intracerebral hemorrhage? 1) Pain and temp loss on the R face and LUE/LLE with R sided ptosis and hoarseness 2) Same presentation as above but with facial mm paralysis

Answer 356

When do you give TPA? within less than 2.5 h of symptoms What is the correct dx test to select in a TIA? carotid ultrasound How are SAHs worked up? 1) Non contrast head CT, if normal lumbar puncture Dense paralysis on 1 side of the body..Dx? Infarct of lenticulostriate A. that supplies the internal capsule Medical mgt of carotid disease: 1) aspirin 2) clopidogrel 3) dipiridamol Medical mgt of TIA with an Afib: Anticoagulant % cutoff for endarterectomy? more than 70% stenosis do endarterectomy 100% stenosis? no endarterectomy, they have already made collaterals What must be done before allowing food? swallow study Biggest RF for intracerebral hemorrhage? HT 1) lateral medullary stroke, Wallenberg sd. PICA infract 2) lateral pontine problem, AICA infract

Question 357

German teenager with a Hb of 8. Dx?

Answer 357

Hereditary spherocytosis MCHC is high Dx: Osmotic fragility or eosin 5 maleimide assay Tx: splenectomy

Question 358

71 yo M presents to his PCP with a h/o multiple falls. He has trouble holding down the pen as he fills out clinic forms. (dx, dermatologic association, tto, tto of psychosis)? 1) +Orthostatic hypotension and ataxia: 2) +Multiple “backward” falls, trouble looking upwards: 3) +Syncopal episodes, seeing rats in her hospital room: 4) +Tx for chemotherapy induced emesis:

Answer 358

Parkinson Association w seborrheic dermatitis Tto: carbidopa/levodopa Quetiapine for psychosis (no haloperidol) 1) Multiple system atrophy 2) Progressive supranuclear palsy (midbrain atrophy with intact pons=hummingbird sign) 3) Lewi-body dementia 4) Metoclopramide is a DA antagonist that can induce Parkinson

Question 359

Main antiepileptic drugs side effects: 1) Hyponatremia and hypertonic urine 2) Febrile neutropenia 3) Nephrolithiasis 4) Profound AST/ALT elevations with jaundice

Answer 359

1 and 2) Carbamazepine 3) Topiramete 4) Valproate. Never give this to a pregnant woman

Question 360

Car assembly plant/moonshiner and anemia. Dx? Manegement:

Answer 360

Lead poisoning (can be from houses before 1978, automobile batteries, pottery, pipes, toys, batteries, lipstick) 1) capillary fingerstick blood specimen as screening (a lot of false + results) 2) confirmatory venous lead 5-44: take them off the environment 45-69: DMSA=succimer More than 70: IV EDTA=versenate + BAL=dimercaprol Biggest fear: lead encephalopathy (starts at 70)

Question 361

Most common cause of readmission following hospital surgery?

Answer 361

Surgical site infection

Question 362

32 yo M with chronic heartburn that has not resolved with 2 trials of esomeprazole. NBSIM? 2nd NBSIM? Tx of Barrett’s Esophagus? Tx of Barrett’s Esophagus with dysplasia? Screening guidelines for cancer with a h/o GERD? Surveillance intervals?

Answer 362

NBSIM? EGD with biopsy, 2nd NBSIM? if normal do a 24h esophageal pH monitoring Tx of Barrett’s Esophagus? High dose PPIs Tx of Barrett’s Esophagus with dysplasia? Resection or ablation Screening guidelines for cancer with a history GERD? If male over 50 and is obese/smokes/long term GERD you screen 3-5years with EGD w biopsy for adenoca.

Question 363

Hep C screening guidelines:

Answer 363

Anyone between 18-70 yo; everyone once

Question 364

SOB, PaO2 of 80 6 hrs after a platelet transfusion for symptomatic ITP, CXR shows b/l interstitial infiltrates with diffuse crackles heard on lung auscultation. PCWP is 14 (nl < 18). BP is 75/40. Dx?

Answer 364

Transfusion-related acute lung injury, basically a ARDS after transfusion Tto same as ARDS

Question 365

Visiting a malaria prone country while getting an indirect hyperbilirubinemia. Dx?

Answer 365

G6PD def | X-linked recessive

Question 366

``` Broken bones and nerves; Humeral neck: Midshaft: Supracondyle: Medial Epicondyle: Hook of the hamate: Anatomical snuffbox tenderness: Head of the fibula: Can’t initiate shoulder abduction: Trouble reaching overhead: Failed thigh adduction: ```

Answer 366

Humeral neck: axillary Midshaft: radial Supracondyle: median Medial Epicondyle: ulnar Hook of the hamate: ulnar Anatomical snuffbox tenderness: scaphoid fracture (spica cast of the thumb) Head of the fibula: fibular Can’t initiate shoulder abduction: rotator cuff tear, supraspinatus Trouble reaching overhead: long thoracic Failed thigh adduction: obturator

Question 367

Over the past year a 71 yo M with a past medical history of DM has had his Cr increase progressively from 1.6 to 3.7. He received a matched renal transplant from his younger sister. What is the most likely finding on organ biopsy?

Answer 367

Chronic rejection Biopsy: fibrosis If it were acute: T cells and eosinophils

Question 368

Diarrheal outbreak in a military barrack. Dx?

Answer 368

Norwalk virus

Question 369

Diabetic with flank pain, T 103, and pyuria. Does not get better with antibiotics. Management?

Answer 369

CT scan, complication of the acute pyelonephritis Emphysematous pyelonephritis: gas bubbles in walls of the kidneys: nephrectomy Perinephric abcess: incision and drainage

Question 370

Fever and T10 pinpoint tenderness with b/l +ve Babinski signs.Dx:

Answer 370

Spinal abscess If it were fever+headache+neural deficits: brain access

Question 371

Blood test results with a prior history of T. Pallidum but recovered successfully:

Answer 371

RPR and VDRL will turn negative, the non-treponema tests go negative after tto The treponemal (FTA-ABS, MHA-TP) tests stay always positive

Question 372

Decreasing the risk of venous thromboembolic disease in a hospitalized patient?

Answer 372

Anticoagulation

Question 373

2 measures that have shown to reduce risk in orthopedic surgery patients?

Answer 373

Anticoagulation/ intermitten pneumatic compression device

Question 374

Most likely healthcare associated complication with TPN administration: Skin precaution: Type of access to be avoided:

Answer 374

Central line associated bloodstream infection. Clean the area w chlorhexidine Avoid always the femoral v. because infection is most common

Question 375

MCC of preventable hospital deaths:

Answer 375

PE

Question 376

Most important intervention in reducing the risk of wrong site, wrong patient, and wrong procedure errors?

Answer 376

Preprocedural timeout

Question 377

Pre-op antibiotic prophylaxis:

Answer 377

Cefazolin 30-60 min before sx Vancomycin/ clindamycin if allergic to penicillins If you delay the sx give it again

Question 378

Hemoptysis and a widened mediastinum in a textile factory worker. Dx? Tto?

Answer 378

Antrax | Tto: ciprofloxacin

Question 379

Chronic headache with muscle weakness and polyuria. This patient has HTN that has failed to respond to amlodipine, enalapril, and indapamide therapy. How do you sort out the 2 principal causes? Tto?

Answer 379

1) Plasma aldo/renin more than 20!!: Conn sd and the tto is spironolactone If less than 20!!: renal A. stenosis and the tto is an ACEi 2) Salt!!! suppression test=saline infusion test, if fails to suppress it confirms Conn's 3) CT of the abdomen and pelvis. It could be an incidental adrenal mass but it is not the cause of the ↑ Aldo 4) Adrenal vein sampling before the sx Unilateral disease: Aldo will be high on the side of the tumor and low on the other side → Unilateral adrenalectomy Bilateral disease: Aldo high everywhere → Aldo antagonist like spironolactone or eplerenone Other cause of secondary HT is sleep apnea

Question 380

Hypertensive emergency tto?

Answer 380

``` Labetalol Nitroprusside (not for too long on liver or renal fx) Nicardipine/ Clevidipine Phentolamine NO HYDRALAZINE ``` If you are worried about aortic dissection do not give a vasodilator (Nitroprusside/Nicardipine/Clevidipine) alone, you can use labetalol! If you use a vasodilator you need to add a β-blocker

Question 381

Urinalysis: ``` Dehydration: Nephrotic syndrome: Nephritic syndrome: ATN: AIN: Pyelonephritis: ```

Answer 381

``` Dehydration: hyline cats Nephrotic syndrome=lipoid nephrosis: fatty casts Nephritic syndrome: RBC casts ATN: muddy brown=pigmeted granular casts AIN: eos pyelonephritis: WBC casts ```

Question 382

Hematuria, HT and periorbital edema after 5 days after a URI. Dx? What if it were 4 weeks after? Which antibodies will be found on blood? How do you treat them?

Answer 382

5 days: IgA nephropathy=synpharyngitic nephropathy. Tto: steroids+ACEi 4 weeks: post-strep; Antibodies: ASO, ati-DNAse B* Tto: observation and loop diuretics!! * Antibiotics can reduce the incidence of rheumatic fever but not the incidence of post-strep glomerulonephritis!!!

Question 383

Mr. X presents to an ED with chest pain and SOB. He was accompanied by his girlfriend. He requests to see a physician but in triage becomes belligerent. Security escorts the patient out of the ED. An hour later, the patient presents again complaining of worsening chest pain. His girlfriend reports that he also had a seizure. She is requesting help in lifting her partner to a bed in the emergency room but the ED security refuses and asks them to leave. The patient’s girlfriend drives 20 mins to take Mr. X to another hospital. He is declared dead on arrival. What does the NBME expect you to know here?

Answer 383

You need to do a medical screening exam of someone comes in with a emergency medical condition (chest pain, stroke like, seizures) You need to evaluate and stabilize According to EMTALA law

Question 384

Cutoffs for live attenuated vaccines:

Answer 384

Less than 2yo Pregnant CD4 less 200

Question 385

Health benefits and contraindications of breastfeeding:

Answer 385

Benefits: Decreases risk of food allergies Decreases risk of acute otitis media Contraindications: HIV QT If baby has galactosemia (soy milk based formula) If baby is allergic to milk: soy based formula → if cannot tolerate it: protein hydrolyzed formula → if cannot tolerate it: elemental formula (single aa)

Question 386

MCCOD in galactosemia:

Answer 386

Sepsis form E.coli

Question 387

Formula for cow milk allergy:

Answer 387

Caseine hydrolyzing

Question 388

Circumcision contraindications:

Answer 388

Hypospadias and epispadias

Question 389

Mom took away his toy, child gets angry, loses consciousness:

Answer 389

Hold breath, reassurance

Question 390

Putting the baby to sleep with a feeding bottle. Why is it bad?

Answer 390

Causes caries

Question 391

Bedwetting; first line tto and second line tto?

Answer 391

1) emeuresis alarm | 2) desmopressin

Question 392

Erythematous papules and plaques on the UEs. Dx? Tx?

Answer 392

Ectopic dermatitis | Emollients or topical steroids (not steroids in the face)

Question 393

Round erythematous plaques with central clearing/scaly borders. Dx? Mos common causes in order of frequency: Dx? Tto?

Answer 393

Tinea MCC: Trichophyton → if not Microsporum → is not Epidermophyton (TIME) Dx: potassium hydroxide examination of skin scrapings Tto: Tinea corporis: TOPICAL azole Tinea unguium/ capitis: ORAL terbinafine/griseofulvin

Question 394

Nightmares vs night terrors?

Answer 394

Nightmares: remember the dream | Night terrors: do not remember

Question 395

Leading cause of death in maltreated children:

Answer 395

Abusive head tx

Question 396

Congenital heart disease mode of inheritance. Dx test?

Answer 396

Multifactorial Echo

Question 397

Rx findings in congenital heart disease:

Answer 397

Boot shaped heart: Tetralogy of Fallot Egg shaped heart/egg on a string: transposition Snowman heart: total anomalous VR

Question 398

Wide, fixed split of the S2 heart sound. MC overall? Down’s syndrome?

Answer 398

ASD | Secundum overall, primum in Down

Question 399

Holosystolic murmur at the LLSB + mid-diastolic rumble at apex. dX?

Answer 399

VSD

Question 400

Pulmonary vascular markings refers to:

Answer 400

Increase flow trough the pulmonary A: troncus arteriosus Decrease Pulmonary vascular markings indicate decreased flow: Tetralogy of Fallot

Question 401

Newborn gets cyanotic hrs-days after birth. | Immediate NBSIM:

Answer 401

Congenital heart disease masked by open ductus Immediate NBSIM: Alprostadil

Question 402

Brachial-femoral pulse delay indicates: | Tx?

Answer 402

Coarctation (you also hear an epigastric bruit corresponding to the site of the coarctation) Tx surgery

Question 403

Loud P2 and cyanosis while crying. Dx? Knee-chest physiology?

Answer 403

Tetralogy of Fallot Knee-chest compresses the femoral A so they increase the SVR and the shunt becomes L to R

Question 404

Cyanotic CHD with ASD and VSD needed to prevent cyanosis. Dx?

Answer 404

Tricuspid atresia

Question 405

URI 2 weeks ago with new S3 heart sound and b/l lung crackles. Dx?

Answer 405

Viral myocarditis by coxsackie B

Question 406

Child with language delay on NBMEs with a h/o of recurrent otitis media. Dx?

Answer 406

Hearing defect, to an audiometry

Question 407

Low birth weight, short palpebral fissures, flat philtrum, thin upper lip. Dx?

Answer 407

Fetal alcohol sd. Any philtrum abnormalities!!!

Question 408

D.D. of decreased growth:

Answer 408

Familial short stature: kid follows the growth curve but at a very low percentile. Management: get information of the height of different family members, they will be short in average, bone age is = to chronological age Constitutional growth delay: normal growth velocity until puberty, delayed adolescent growth spurt and puberty, but then steep growth spurt, + family history, they will catch up w normal heigh but we don't know when. Management: if you have + family history the dx is done, if you don't have family history you look for delayed bone age. No indication for GH, reassurance Deviation of normal growth: Nutritional: weight will flatten first, then height will flatten later, delayed bone age GH deficiency: flattening of the weight and height together, delayed puberty and delayed bone age. Very similar to constitutional growth delay but here the heigh goes down crossing 2 major percentiles!! (you you can be on a very low percentile for a long time and not go down and do not have GH deficiency) Dx: arginine stimulation test. Tto: GH Hypothyroidism: flattening of the height but weight goes up, delayed bone age, thelarche more affected than others

Question 409

Baby with macroglossia and umbilical hernia. Dx? | MCC:

Answer 409

Congenital hypothyroidism | MCC: Thyroid dysgenesis

Question 410

DD of neck cysts:

Answer 410

Lateral cervical cyst that doesn't move with swallowing: persistent cervical sinus; due to incomplete obliteration of the 2nd, 3rd and 4th CLEFT! (ECTOderm). Anterior to the sternocleidomastoid m!!! BRACHIAL CLEFT-CYST Medial cervical cyst that moves with swallowing: THYROGLOSSAL cyst; from ENDOderm. It shows up at the foramen cecum and migrates down. (It can be lined by squamous or respiratory epithelium). If it moves with swallowing it is a thyroglossal cyst!!

Question 411

MCC of ambiguous genitalia in baby: Metabolic panel: Dx blood test: Tx:

Answer 411

21 hydroxylase deficiency Metabolic panel: Aldo and cortisol are low so non anion GAP metabolic acidosis Dx: 17-hydroxypregesterone Tx: Fludrocortisone, ketokonazole and a steroid

Question 412

Definition of precocious puberty:

Answer 412

'Going into FM in 1989' Female less than 8 Male less than 9

Question 413

Cannot advance NG tube in child with excessive oral secretions and polyhydramnios in utero:

Answer 413

Esophageal atresia ``` Associated with other VACTREL defects: Vertebral defects Anal atresia Cardiac defects, VSD Tracheoesophageal-fistula Renal defects Esophageal atresia Limb, radial malformation ```

Question 414

The 3 causes of bilious emesis in a neonate!

Answer 414

1) Malrotation 90% Also: Duodenal atresia: double bubble, associated w Down Jejunal atresia: triple bubble

Question 415

Preemie with bilious emesis, bloody stools, and distended abdomen. Dx? Tto?

Answer 415

Necrotizing enterocolitis Rx: air in wall of the bowel and portal venous gas Tto? 1) bowel rest + fluids + blood cultures 2) empiric antibiotics!!! 3) If bowel perforation/ clinical deterioration: surgical reserction!!* * Surgical intervention for NEC is warranted when there is evidence of peritonitis (concerning for gangrenous bowel), perforation (pneumoperitoneum on x-ray), metabolic acidosis, elevated lactate, and/or portal venous gas on x-ray

Question 416

Diarrhea types; Lactose intolerance vs cholera vs celiac disease:

Answer 416

Lactose intolerance: osmotic (stool osmolar gap bigger than 100, acid pH and positive H+ breath test, stops at night) Cholera secretion of Cl, secretory (present all the time) Also secretory: VIPoma, Zollinger-Ellison sd, Medullary thyroid ca, unabsorbed bile acid (in post-cholecystectomy patients) Celiac: malabsorption UC, Chron, EHEC, Shigella, Campylobacter, Salmonella: inflammatory (bloody)

Question 417

13 yo boy with Ricketts, Fe deficiency anemia, and fat malabsorption. Dx?

Answer 417

Celiac disease | If not tto enteric associated T cell lymphoma

Question 418

Non-calcified flank mass on a kid:

Answer 418

Wilms tumor, give dactinomycin Vs neuroblastoma that is calcified, crosses the midline and sends metas to the marrow

Question 419

``` Peds embryology pathophysiology of: Duodenal atresia: Jejunal atresia: Malrotation: Hirschsprung’s disease: Congenital diaphragmatic hernia: Meckel’s diverticulum: ```

Answer 419

Duodenal atresia: recanalization failure Jejunal atresia: vascular problem Malrotation: midgut 270deg rotation around SMA failure Hirschsprung’s disease: myenteric plexus does not develop Congenital diaphragmatic hernia: fail of development of the pleuroperitoneal mb Meckel’s diverticulum: failed obliteration of omphalomesenteric/vitelin duct

Question 420

Why are kids polycythemic at birth?

Answer 420

In utero they do not use their lungs so relative hypoxia so EPO increases and RBC increase

Question 421

When should you introduce cow milk in a child’s diet?

Answer 421

1 y.o.

Question 422

Goat milk problems:

Answer 422

Low folate so child can get megaloblastic anemia!

Question 423

Persistent, painless, firm cervical/supraclavicular lymphadenopathy in a 17 yo F. Mediastinum. Dx? Epi?

Answer 423

Hodgkin Bimodal sidtrinution Anterior mediastinum: Ts (thymus, thyroid, thoracic aorta, terrible lymphoma, teratoma and germ cell tumors - see mediastinal germ cell tumors) Posterior mediastinum: neuroendocrine tumors

Question 424

Syndromes associated with Wilms tumor:

Answer 424

WARG: WT1 is associated with anhiridia, genitourinary malformation, retardation. PAX6!!!! next to WT1 is important for iris formation, contiguous gene deletion Denys-Drash: WT1 is associated with Difusse mesangial sclerosis (nephrOtic) and Dysgenesis of gonads Beckwith-Wiedemann: WT2 is associated w macroglossia, hemihyperplasia, hypoglycemia, hyperinsulinemia, hypocalcemia because over expression of ILGF2!!!!*, omphalocele!, hepatoblastoma, is an example of imprinting (IGF-2 is normally metlylated on mom, here they get 2 copies from the dad) * pancreatic beta islets grow a lot so insulin increases and they become hypoglycemic, similar to gestational DM but here mom is not diabetic

Question 425

Irritable, ear tugging 9 mo, with mild fever and a red, bulging TM on otoscopy. Dx? Best test? Most important physical examination finding? Tto (1st/2nd line)? Multiple recurrences? Major D.D?

Answer 425

Acute otitis media: Organisms: Moraxella, Non Typeable H. influenzae and S. pneumo Presentation: acute onset after a cold! normally UNIlateral, middle ear effusion! tympanic membrane inflammation! Best test: pneumatic otoscopy Most important finding? bulging tympanic membrane, decreased movement!! Important: A red TM membrane by itself does not equal AOM! If both ears are equally red and the kid has a cold it might be just because of the cold Most accurate test: tympanocentesis and culture Tto: 1) 10 day course of high dose amoxicillin 2) amoxi-clavulanic, ceftriaxone, azithromycin if allergic to penicillin Multiple recurrences? tympanocentesis 2 w follow up Otitis media with effusion: maybe after the acute otitis media the effusion does not go away BNSM: motley checks for the effusion, if 3mo of persisten effusion in a row you call it otitis media with effusion BNSM: audiology test, we are worried about hearing loss If bilateral effusion + hearing loss or discomfort: PE tube Otitis externa: Presentation: child with pain/itching of the ear + pain upon manipulation of the tinna Tto: topical antibiotic (ciprofloxacin drops) Prevention: alcohol-based ear drops after swimming activities Necrotizing otitis externa Presentation: Pt with type 1 diabetes who has recent recreational water exposure who presents with a severe form of otitis externa (fever, ill-appearing) Tto: intravenous antipseudomonal antibiotics and surgical debridement if antibiotics are unsuccessful

Question 426

Vesicles in posterior oral cavity, vesicles and papules on the hands and feet. Dx?

Answer 426

Coxackie A

Question 427

1) Cough, runny nose, b/l conjunctival injection, rash below posterior hairline going downwards, mouth stuff: 2) Temp of 105 for 3 days then red rash on the face and trunk 2 days afterwards: 3) Rash on face, goes down trunk, posterior auricular lymphadenopathy:

Answer 427

1) Measles=rubeola 2) Roseola=exanthem subitum 3) Rubella=German measles

Question 428

How do we treat newborns from a mom with varicella?

Answer 428

Varicella Zoster Ig, no vaccine until 1 yo

Question 429

MCC of diarrhea in kids:

Answer 429

Rotavirus

Question 430

18 yo sexually active F with myalgias, exudative pharyngitis, and HSM. Dx test? Smear?

Answer 430

Mono Dx test: monospots test Smear: Downy cells No sports!

Question 431

Why would you have RUQ pain in Kawasaki?

Answer 431

Galbladder hydrops Presentation: Acute phase: Unresponsive fever for at least 5d + 4 of: bulbar conjunctivitis, erythema and swelling of palms and soles, intraoral erythema, rash w no vesicles!, huge unilateral anterior cervical node Leading cause of acquired heart disease in developed countries. But it contraries are ok after 4-6w the heart w be ok BNSM after the Dx: admit + ESR, platelets, ECG, echo for baseline and to discard pericarditis and myocarditis Best tto: IVIG (but they lines is not due to auto-antibodies) + oral high dose aspirin* (add a PPI) * Before you get the aspirin you need to give the influenza vaccine because Reye syndrome is not only associated with aspirin ingestion but with aspirin ingestion as a tto of influenza and varicella!! Subacute phase: Fever and primary presentation goes away and then ESR peaks, then the platelets peak (they can be more than 1million!) Desquamation Aneurysms (the aneurysm combined with the high platelets can lead to acute MI) Get a second echo Change to low dose aspirin Convalescent: Get a 3rd echo to make sure they are not aneurysms, also get an ESR and platelets, if those 3 are negative stop the aspirin!

Question 432

Septic arthritis vs osteomyelitis on NBMEs:

Answer 432

Tenderness over joint on septic arthritis Tenderness over bone on osteomyelitis

Question 433

Sneakers/Nail osteomyelitis?

Answer 433

Pseudomonas

Question 434

7 yo M w/recent episode of AOM. T 99.9, R hip and knee pain, full ROM but painful limp in involved extremity. Otherwise OK child.

Answer 434

Transient toxic synovitis, give an NSAID

Question 435

2x/daily fever spikes in a 10 yo F with “salmon colored” rash on the trunk, weeks of R knee pain. Dx? What are possible complications?

Answer 435

Still's disease= juvenile arthritis All are associated with anterior uveitis!! except the systemic and the seropositive, blindness, glaucoma and synechia. So you need to do slit-lamp examination screening! There are different types: Oligoarticular: females less than 6y with less than 5 joints involved that are on the lower body, most ANA+ (more frequent uveitis if ANA+), do slit lamp! Polyarticular RF negative: 5 or more joints on the hands (asymmetric) on female 6-7y, can lead to mandible and C-spine problems. Some ANA+ Polyarticular RF positive: Rare. Bad px. 5 or more joints affected causing aggressive symmetric!! polyarticular disease on a 9-12y female. antiCCP+ Systemic onset: Rare. Any number of joints can be involved, progresses to polyarticular disease affecting the hips, C-spine and mandible on a 2-5y female=male. You have a systemic presentation of: Arthritis + Quotidian fever for at least 3 days on a row Evanenscent rash, salmon colored (gets worse w fever) Lymph nodes Hepatosplenomegally Serosistis Tto: NSAIDs for mild cases, corticoids for flares, methotrexate

Question 436

Bilateral thigh/calf pain in a 5 year old M relieved by acetaminophen. Dx? NBME Distractor?

Answer 436

Growing pains Osteoid osteoma will be unilateral

Question 437

Baby is blue at rest (feeding), that gets worse when eats and gets better when cries. Dx? Associated sd? What is the best next step in management?

Answer 437

Atresia of the choanae (Dx; 1: nose catheter confirmatory: head CT w contrast) ``` CHARGE sd: Coloboma Heat Atresia of the choanae Retardation in groth Genial abnormalities Ear problems ``` BNSM: echocardiography is the most urgent

Question 438

CF pneumonia cause by age?

Answer 438

S. aureus younger than 20 | Pseudomonas more than 20

Question 439

4 yo boy with a 12 hr h/o drooling, dysphagia, can’t talk, T 103, and tripoding. Dx?

Answer 439

Epiglotitis Rx: thumb sign (not part of the management) Organisms: Strep./Staph./rare H. influenza B in unvaccinated Presentation: sore throat + fever → tripod pose → drooling Most accurate dx test: cherry red epiglottis on laryngoscopy Tto: Do not touch the kid until 1) Intubation! + aspirate for culture 2) Nafcillin + cefotaxime

Question 440

Hyperpigmented macules on the skin, prior eye enucleation procedure, multiple posterior mediastinal masses. Dx? Possible radiographic findings?

Answer 440

NF1 | Rx: cortical thinning of the long bone cortex and sphenoid dysplasia

Question 441

Dx, age is key: 1) 6 mo with developmental delay and daily generalized tonic-clonic seizures. Dx? EEG? Tto? 2) 4 yo boy with generalized tonic-clonic seizures, focal seizures, myoclonic seizures. Dx? Tto? 3) 13 yo F with generalized tonic-clonic seizures that are worse in the morning. Dx? Tto?

Answer 441

1) Infantile spasms=West sd, EEG: chaotic background=hypsarrhythmia!!! Tto: ACTH 2) Lenox-gastou, Tto: valproate, bad px 3) Juvenile myoclonic epilepsy, Tto: valproate, good px

Question 442

Seizure lifestyle modification for NBME exams:

Answer 442

Ketogenic diet

Question 443

Alport sd mutation

Answer 443

Alpha 5 chain of type 4 collagen COL4A3, COL4A4, and COL4A5 X-linked dominant

Question 444

The respiratory distress D.D: 1) Preemie with respiratory distress, hypoxia, CXR showing air bronchograms and decreased lung volumes: 2) Delivered by C-section, born at term, mom has DM, respiratory distress and tachypnea at birth with grunting/retractions, no hypoxia or evidence of cyanosis, perihilar infiltrate with fluid in the fissures: 3) Delivered at 42.5 weeks, respiratory distress at birth, CXR showing hyperinflation and patchy atelectasis:

Answer 444

1) Preemie + decreased lung vol: neonatal respiratory sd = diffuse reticulonodular pattern with air bronchograms 2) C-section: transient tachypnea of the newborn = interstitial infiltrates with prominent interlope fissures 3) Postterm + increased lung vol: meconium aspiration sd = patchy infiltrates and hyperinflation

Question 445

Barrel chest with scaphoid abdomen at birth, all heart sounds on the right. Dx?

Answer 445

Congenital diaphragmatic hernia GI content and bile on the thorax!

Question 446

2 causes of ALWAYS pathological pediatric jaundice:

Answer 446

If appears in the first day of life Conjugated hyperbilirubinemia (biliary athersia, tto is early surgery/ choledochal cysts)

Question 447

Kid with sneezing, rhinorrhea for 5 days then many weeks of post-tussive emesis. Wakes up with red eye. Sudden onset severe chest pain, hyperresonance to percussion, and unilaterally decreased breath sounds. Dx? Blood marker? Tto?

Answer 447

Pertussis, they cough so much that can present w a pneumothorax, subconjunctival hemorrhages or vomiting Blood marker: Reactive lymphocytosis Tto: macrolide for patients and close contracts

Question 448

Chlamydia/gonorrhea screening guidelines:

Answer 448

Risky sexual behavior

Question 449

Tto of a Tanner 5 boy at 7 yo. | What do you watch out for with this treatment?

Answer 449

Continuos leuprolide | Careful because can decrease the bone mineral density

Question 450

Postvoid residual of 40 cc. Dx? Pathophysiology? Tx?

Answer 450

Urge incontinence Detrussor hypertonia, hyper mobility, hyperreflexia Muscarinic antagonist as oxybutynin, alderamin, darifenacin, solifenacin or trospium. On The Darn Toilet

Question 451

IUD mechanisms and contraindications:

Answer 451

Cooper: is for 10 years, kills sperm, causes heavy periods, not in Wilsons or in distorted uterine anatomy (bicornuate and fibroids!) Progesterone (Mirena): thickens cervical mucus!! decreases sperm transport and decreases implantation, does not cause heavy periods! Do not put in PID! but they actually decrease the risk of PID and you should leave them in if they develop a PID, you can also put it if history of IUD

Question 452

PCOS infertility management:

Answer 452

1) Letrozol!!! 2) Clomiphene SE: Fullness/bloating/dark urine/decreased UOP/2 Ib/day wt gain= ovarian hyperstimulation syndrome

Question 453

Taiwanese woman at 11 weeks gestation with hyperemesis gravidarum, HT, heavy vaginal bleeding, size-dates discordance and theca lutein cysts. Dx?

Answer 453

Molar pregnancy *The NBME here may mention blue lesions on speculum examination indicating vaginal metastasis

Question 454

Over the past 2 days, a 32 yo F at 30 weeks gestation has had yellowing of her skin. She reports significant RUQ pain. AST and ALT are in the thousands. Dx?

Answer 454

Acute fatty liver of px Deliver immediately!!! If ALP high but not very high AST/ALT, not HT nor thrombocytopenia think intrahepatic cholestasis of pregnancy and give urodisol and deliver at 36-38 w

Question 455

Severe SOB, cough, hemoptysis 3 weeks after an abortion.

Answer 455

Chorioca. with metas to the lungs

Question 456

What is the most common kind of vaginal malignancy? Biggest RF for primary vaginal carcinoma? Tto? Complication?

Answer 456

MC kind: Squamous cell ca. BRF: HPV Tto: Sx and Qt Complication: vaginal stenosis

Question 457

Glandular cell vaginal malignancy indicates:

Answer 457

Clear cell ademoca.

Question 458

82 yo F w/pruritus and a thin labia. Dx? Dx test? Tto?

Answer 458

Lichen sclerosis Dx test? Biopsy of the vulva Tto: Clobetasol

Question 459

Most important prognostic predictor in vulva cancer.

Answer 459

Lymph node involvemet

Question 460

Increased susceptibility of young females to STIs. Why?

Answer 460

Cervical ectropium: endocervix has simple columnar epithelium that come a little down in puberty. They are not very resistant so there is risk of infection

Question 461

What do I do with atypical squamous cells of undetermined significance? and if you see atypical glandular cells? And if the squamocelular junction is not completely visualized?

Answer 461

ASCUS: colposcopy/ HPV co-testing, if HPV co-testing is + you need to do a colposcopy Atypical glandular cells in >35: endometrial biopsy + endocervical curettage Not visualized squamocelular junction: Endocervical curettage

Question 462

Worrisome colposcopy findings:

Answer 462

Weird shape blood vessel | Acetowhite changes

Question 463

Protective factors, MC histology and MC stage at diagnosis for ovarian cancer:

Answer 463

Late menarche Early menopause OCPs Multiparous MC histology: epithelial serous MC stage at diagnosis: 3, peritoneal metastasis

Question 464

Follicular cyst size cutoff for management:

Answer 464

Less than 6cm observation, if more cystectomy

Question 465

Calcified, smooth walled ovarian mass in a 12 y.o. female. Dx?

Answer 465

Teratoma Can also be in the mediastinum Tto: cystectomy

Question 466

Most likely presenting complain in endometrial cancer. Dx testing? Tto?

Answer 466

Abnormal vaginal bleeding Dx testing: endometrial biopsy Tto: hysterectomy with bilateral salpingo-oophorectomy

Question 467

The Celes:

Answer 467

Cysto: weak anterior vaginal wall, urinary incontinence Recto: weak posterior vaginal wall, stool incontinence Entero: mass high up in the vaginal wall, pouch of Douglass herniation, associated with hysterectomy Uretro: urinary incontinence right after peeing, there is a diverticulum that holds urine

Question 468

Most important health hazard associated with menopause:

Answer 468

Osteoporosis 1) Bisphosphonates (-ates, zolendronic acid...)

Question 469

MCCOD in a postmenopausal female?

Answer 469

Cardiovascular disease

Question 470

Tx of common postmenopausal maladies Hot flashes: Vaginal atrophy: Osteoporosis:

Answer 470

Hot flashes: hormone replacement therapy and venlafaxine (if hysterectomy you can do equine estrogens) Vaginal atrophy: estrogen cream Osteoporosis: bisphophonate

Question 471

Hormone replacement (OCP) contraindications and side effects:

Answer 471

``` Contraindications: MIGRAINE with aura ER/PR + breast ca Endometrial ca Over 35 and smokes SLE Vascular disease (stroke) History of hepatic adenoma and acute liver disease History of venous thromboembolism Prinzmetal Thrombophilia Acute pancreatitis HT: do not give to a patient with hypertension! ``` Side effects: Hypertension Thrombosis and ischemic stroke

Question 472

Normal order of sex maturity in female:

Answer 472

TAM: Thelarche: development of the breast Adrenarche: development of pubic hair, body odor, skin oiliness, and acne (premature adrenarche is most common on obese) Menarche: period

Question 473

Depressed and irritable starting on day 24 of a 28 day cycle. Dx? Do first? Tto?

Answer 473

PMS Do first? symptom diary Tto? SSRI

Question 474

β-HCG and ultrasounds:

Answer 474

If β-HCG is less than 1500 no sac can be seen on ultrasound

Question 475

Pap smear follow up post-hysterectomy for leiomyoma vs endometrial hyperplasia/cancer:

Answer 475

If hysterectomy is due to benign reasons you can stop Pap smear, if it is for malignancy you do Pap smear of the vaginal cough

Question 476

Amenorrhea with severe lower abdominal pain at the end of the month (2 NBME possibilities):

Answer 476

Inperforated hymen: cut the hymen Transverse vaginal septum

Question 477

Progestin/Estrogen-Progestin withdrawal test results in common disorders: PCOS: Turner’s: Kallmann: Asherman’s/Uterine Synechiae:

Answer 477

PCOS: they are always in the follicular phase so if you give progestin and then you withdrawal it, they will bleed Turner’s and Kallmann: streak ovaries so they fo not have E so if you give progestin and then you withdrawal it they w NOT bleed. But if you give E+P and then withdraw they w bleed Asherman’s/Uterine Synechiae: w never bleed

Question 478

Amenorrhea and chronic fatigue/bradycardia. Dx?

Answer 478

Hypothyroidism that causes increase in TRH and increases PRL

Question 479

Name the 3 leiomyoma types: IUD to avoid? What if the IUD above is already in place before discovering the leiomyoma? Most symptomatic? Contraindicated interventional radiology tx if desiring pregnancy? Tto if desiring pregnancy? No longer desiring pregnancy?

Answer 479

Submucosal: most symptoms Intramucosal Subserosal IUD to avoid? Cooper IUD, if they have it already there, leave it Contraindicated IR if desiring pregnancy? Uterine A. embolization Tto if desiring pregnancy? myomectomy No longer desiring pregnancy? hysterectomy

Question 480

Crampy abdominal pain during menses in a F that skips work. PE is nl. Dx? Tx?

Answer 480

Dysmenorrhea | NSAID

Question 481

Infertile F w/Painful menses, painful poop, painful sex. Dx? ``` BRF? Tto? Ligament? Definitive dx? Definitive tx? ```

Answer 481

Endometriosis ``` BRF? Family history Tto? OCP Ligament? modularity of uterosacral lig Definitive dx? laparoscopy Definitive tx? hysterectomy ```

Question 482

Heavy menstrual bleeding, symmetrically soft/tender uterus on bimanual exam. Dx? Tx? Definitive dx? Definitive tx?

Answer 482

Adenomiosis Tto? mirena IUD Definitive dx? laparoscopy Definitive tx? hysterectomy

Question 483

Woman on OCPs gets pregnant with TB tx. Why?

Answer 483

Rifampin rides up the cytochrome P450 system

Question 484

Most effective emergency contraception?

Answer 484

1) Cooper IUD, only the Cooper one | 2) Ulipristal

Question 485

Agreeable postpartum contraception:

Answer 485

Progesterone-based contraception Avoid E if lactating because E decreases the amount of protein in breast milk but ALSO avoid E less than 1mo postpartum because it increases the risk of thromboembolism Options: Sub-dermal progestin-releasing implant: high efficacy, lasts for 3 years, decreases menstrual bleeding in 50% and causes amenorrhea in 20% of pts Methylprogesterone (= Depo-provera): IM/subcutaneous injection given every 14w. Can be used in pt with previous DVT. Can cause weight gain, breakthrough bleeding, osteoporosis and delayed ability for pregnancy! Levonorgestre-DUI: can cause amenorrhea Progestin-only oral contraceptive: less effective because you need to take the pill at the same time every day Cooper IUD: not if heavy menstrual bleeding

Question 486

Contraception on a woman with the need for Vit D/Ca supplementation:

Answer 486

Progestin injection = Depo-provera

Question 487

I want to get pregnant 1 month after stopping contraception. Which contraception should I use?

Answer 487

You should not use Depo-provera because it can take up to 2 years to recover fertility after stopped

Question 488

+ β-HCG, vaginal bleeding, abdominal pain in a 23 yo F. Dx? MTX contraindications. Doubling rule: Rising β-HCG afterwards:

Answer 488

Ectopic pregnancy MTX contraindications: fetal cardiac activity and cutout β-HCG Doubling rule: if β-HCG is less than 1500 you cannot dx pregnancy, you need to wait until tomorrow, if it doubles she is pregnant Rising β-HCG afterwards: need to be on birth control so if β-HCG increases you look for mole or chorioca.

Question 489

PCOS criteria:

Answer 489

Polycystic ovaries on echo Anovulation Hyperandrogenism 2 out the 3

Question 490

5 yo F, WBC 16k, foul smelling vaginal discharge. Dx?

Answer 490

Vaginal foreign body

Question 491

Cervical petechiae means:

Answer 491

Strawberry cervix

Question 492

Unilateral swelling/fluctuant mass in inferior labia with T of 101. Dx? Tx?

Answer 492

Bartholin gland abscess Tx? Incision + drainage + wart catheter

Question 493

The 3 polymicrobial OBGYN infections:

Answer 493

Bartholin gland abscess Endometris Chorioamnionitis

Question 494

Increased UTI risk in pregnant women. Why? | Asymptomatic UTIs in the pregnant. Dx?

Answer 494

Progestin is a smooth m. relaxant! | If you see an asymptomatic UTI in a normal woman you do not treat but YES in pregnant (risk of pyelonephritis)

Question 495

N/V at 8 weeks. If admitted, what do you give? Bloody emesis?

Answer 495

Hyperemesis gravidarum, you loose more than 15% of their pre-pregnant weight Admit and give ondansetron, B6 and doxilamine when they go home

Question 496

The HY pregnancy dates in weeks:

Answer 496

8w (1st visit): check mom's HIV, hepB, syphilis, chlamydia, gonorrhea, urine culture, urine protein, rubella, varicella, Rh, hematocrit, pap if indicated, 24h urine collection if HR of preeclampsia, 50g oral glucose tolerance challenge if HR of DM (BMI>25 or family history) 9-13: P-APP, β-hCG, nuchal translucency 10: cell-free DNA 10-13: chorionic villous sapling (definitive diagnosis) 12: low-dose aspirin in HR for preeclampsia 16-18: AFP for screening of neural tube defects 15-22: quadruple screening: AFP, estradiol, β-hCG, inhibin A After w 15: amniocentesis (definitive diagnosis) 18-20: anatomical echo, check for placenta previa, fetal growth 16-24: screening for short cervix (transvaginal echo), after 24w can be shorter due to baby's weight 22-35: can use fetal fibronectine if contractions 24-28: 50g oral glucose tolerance challenge, anemia screening, Rh! 28-32: 1st RhoGAM dose 28 or after: HIV, hepB, syphilis, chlamydia, gonorrhea test if previous STI/ less than 25 27-36: Tdap 32: transVaginal US if placenta previa vas seen before to see if it is still there, also* 32-34: c-section for monochorionic-monoamniotic twins 36: if on LMWH change to unfractionated heparin (take out intrapartum and put back 6h after vaginal/ 12h after cesarean). Also start acyclovir prophylaxis if previous genital HSV infection 36-38: rectal/vaginal culture to detect S. agalactiae (group B strep) 36-37: * transVaginal US + c-section if placenta previa 37 or more!!!: external cephalic rotation (if breach or transverse) 37: scheduled c-sec if breech + vaginal delivery contraindications 41: induce Day 1 life: Hep B vaccine (or when preeme is more than 2kg), Vit K, 2nd RhoGAM dose, fasting blood glucose in mom if gestation diabetes 6-12 postpartum: 50g/2h oral glucose tolerance challenge if gestation diabetes

Question 497

NBSIM with +ve cell free DNA? | Higher rates of inconclusive cf DNA results?

Answer 497

1) Fetal ultrasound, 2) amniocentesis If fat mom it is very inconclusive

Question 498

1) Which is riskier CVS vs Amniocentesis? | 2) NBSIM of increased MSAFP?

Answer 498

1) CVS | 2) First fetal echo then amniocentesis

Question 499

The Rh algorithm:

Answer 499

1) Check woman Rh 2) If - do an indirect Coombs to see if she has Abs 3) Check dad's pstatus 4) If she does not have Abs and dad is Rh+/not known give the RhoGAM at 28th weeks and anytime when there is risk of fetomaternal hemorrhage 5) If she has Abs and dad is Rh+/not known do percutaneous umbilical blood sampling to dx fetal anemia, if fetal anemia do fetal transfusion

Question 500

NST with a nl FHR but no accels and the child is not moving. | What is your NBSIM?

Answer 500

Baby is sleeping, you can do a contraction stress test giving a little oxytocin or move the uterus to wake baby up

Question 501

1) Kleihauer Betke test: 2) Apt test: 3) Fibronectin: 4) Nitrazine test:

Answer 501

1) RhoGAM dose determining test 2) 3rd trimester vaginal bleeding to tell apart mom vs baby's blood 3) preterm delivery risk 4) is this amniotic fluid?

Question 502

BRF for preterm labor.

Answer 502

History

Question 503

Ultra HY obstetric complication associated with BV, Ureaplasma Urealyticum infection, and asymptomatic bacteriuria!

Answer 503

Preterm labor

Question 504

Recurrent 2nd trimester pregnancy losses. Emergent tx: Preventive measure in future pregnancies: Classic NBME risk factor:

Answer 504

Cervical insufficiency Tx: Cerclage Prevention: Progestin suppositories RF: Conization

Question 505

Preventive measure for eclampsia:

Answer 505

Aspirin

Question 506

.Preventive measure to reduce risk of neonatal/fetal infection in women with PROM? What do you do in PROM at > 37 weeks? NBSIM if PROM > 18 hrs?

Answer 506

Decrease the number of vaginal exams What do you do in PROM at > 37 weeks? nothing NBSIM if PROM > 18 hrs? ampicillin

Question 507

Criteria for prophylactic C/S in an IODM?

Answer 507

Weight less than 4500 grams

Question 508

NBME association with < 20 week eclampsia:

Answer 508

Mole

Question 509

Antihypertensives in pregnancy:

Answer 509

Hydralazine Methydopa Labetalol Nifedipine

Question 510

Hyponatremic seizures in a F receiving an infusion for labor induction:

Answer 510

SIADH | Oxytocin looks like ADH!

Question 511

Neonatal hypoglycemic seizures (2 causes):

Answer 511

Beckwith-Wiedemann sd | Baby of diabetic mom

Question 512

DOC in GDM: Polyhydramnios. Why? Increased incidence of respiratory distress syndrome. Why?

Answer 512

Baby has polyuria because pees glucose Insulin inactivates surfactant

Question 513

Hep BSAg +ve mom delivering a newborn: Nurse stick by a needle of a patient with hep B: Tto of chronic Hep B

Answer 513

Give hepB immunoglobulin and hep B vaccine, if nurse was vaccinated already you do not need to do anything Tto: emtricitabine, lamivudine, tenofovir

Question 514

Herpes with genital lesions:

Answer 514

C-section, don't let membranes rupture If baby passes will have vesicles on the body a few days after birth, careful because can progress to meningoencephalitis and disseminated herpes. If you see something IV acyclovir

Question 515

Congenital toxo. How can you reduce fetal morbidity in utero?

Answer 515

Spirolysin

Question 516

The 3 stages of labor:

Answer 516

1, Latent: 0-6cm dilation, less than 20h in nulliparous or less 14 if multi You should admit, start fetal monitoring, check GBS status on records ± epidural 1, Active: 6-10cm 2-3.5h (it has to progress at least 1cm/2h). There are 2 possible problems: Protraction: the cervix progresses less than 1cm/2h → 1) break the water 2) put a pressure catheter 3) give IV oxytocin Arrest: no cervical change for 4h!! with good contractions* or 6h with bad contractions → C-section * >=200 Montevideo units in 10 min and contractions every 2/3min 2: After 10 cm, the fetus is delivered, 3h if nulliparous 2h if multiparous. Arrest of the second stage if it lats longer. Epidural lengthens this stage. If prolonged you can give IV oxytocin or do operative vaginal delivery if possible 3: Placental expulsion. 30 min. If prolonged: IV oxytocin → D&C or manual extraction

Question 517

Biggest NBME RF for fetal tachycardia:

Answer 517

Maternal fever

Question 518

Shoulder's dystocia management:

Answer 518

Baby’s anterior shoulder is stuck behind the pubic symphysis 1) Suprapubic pressure and maternal thigh flexion (McRobert's maneuver). Do NOT do fundal pressure! it makes it worse Other: Wood's corkscrew maneuver, manual delivery of the posterior arm, Zavanelli maneuver (cephalic replacement) and c-section

Question 519

Fetal HR 190, Mom T 102, uterine tenderness, foul smelling vaginal d/c:

Answer 519

Chorioamnionitis, give ampi+genta

Question 520

BRF for postpartum hemorrhage:

Answer 520

Uterine atony RF: macrosimia

Question 521

Day 1-2 vs day 2-3 vs day 4-5 postpartum fever:

Answer 521

Day 1-2: UTI; IV antibiotics Day 2-3: Endometritis (uterine tenderness); give clindamycin (~ macrolide; covers gram + and anaerobes) + gentamicin (aminoglycoside; gram - bacilli) Day 4-5: Wound infection; IV antibiotics for cellulitis + wound drainage/packing + close by secondary intention

Question 522

BRF for postpartum depression:

Answer 522

Personal history of depression

Question 523

``` DD: Postpartum blues? Postpartum depression? Postpartum psychosis? Who do you admit? ```

Answer 523

Postpartum blues? less 2w Postpartum depression? more than 2w Postpartum psychosis? hears voices, admit Also admit if good reason to worry about suicide or kill baby

Question 524

Decanoates?

Answer 524

For medication non-adherence in schizophrenia Decanoate form of Halo IM 1 a month

Question 525

ECT indications and primary complication.

Answer 525

Catatonia Depression w every symptoms Complication: amnesia

Question 526

A 91 year old M has been hospitalized for hypertensive emergencies 5 times over the past 15 months. He lives alone and cooks his own meals but is unable to take his medications regularly. What is the NBSIM?

Answer 526

Legal guardian

Question 527

Acute mania tto:

Answer 527

Antipsychotic + Li Antipsychotics can be given IM and will start working fast on the acute setting

Question 528

Patient on a mood stabilizer that has acute onset RUQ pain with an AST and ALT of 1000+. Cause?

Answer 528

Valproic acid

Question 529

MDD treatment that can be stopped abruptly with no taper?

Answer 529

Fluxetine, has metabolites that are very long lasting

Question 530

SSRI uses:

Answer 530

``` 1st line for Depression Anxiety PTSD PMS OCD Premature ejaculation ```

Question 531

Fewest SSRI squibbles.

Answer 531

Citalopran | Escitalopram

Question 532

SSRI in pregnancy; Best: Contraindicated:

Answer 532

``` Best sertraline (also best for a pt with cardiovascular problems) Worst paroxetine: causes pulmonary TH in baby ```

Question 533

What TCA is used in treating OCD?

Answer 533

Chlomipramine

Question 534

DOC in MDD in a terminally ill patient with a life expectancy of 4 weeks?

Answer 534

Methiphenidate

Question 535

Given the following scenarios, what is the most likely diagnostic error? 1) I have seen a similar presentation in the past so the current diagnosis must be the same as the previous diagnosis: 20 A gastroenterologist at an outside hospital has made a diagnosis of IBD so that must be the diagnosis:

Answer 535

1) Availability 2) Anchoring CHECK

Question 536

Seizures with SSRIs:

Answer 536

SIADH

Question 537

Patient with flu-like symptoms 2 days after stopping paroxetine:

Answer 537

Discontinuation sd | Put them back on their original dose and taper them down

Question 538

Flooding vs systematic desensitization in phobias tto:

Answer 538

Flooding: I trough you on a room full of snakes, fast and high risk of relapse Systematic desensitization: little by little you increase the exposure, slower, low relapse

Question 539

Treating the ER slashed wrist. Dx? Tto?

Answer 539

C

Question 540

Reducing the risk of suicide in a patient that hears voices and does not want to leave his room: Reducing the risk of rehospitalization in the same patient?

Answer 540

Schizophrenia, clozapine reduces the risk of suicide, family interventions (family therapy) reduce the risk of rehospitalization

Question 541

The 4 dopaminergic pathways (and how they are affected by low dopamine after taking an antipsychotic).

Answer 541

Nigrostriatal pathway: Parkinsonism Tuberoinfundibular: high PRL Mesolimbic: controls + symptoms Mesocortical: worsens - symptoms

Question 542

``` Antipsychotic side effects: Amenorrhea: Avoid in DM/fall risk: Avoid in heart failure with reduced ejection fraction/neutropenic fever: Associated with TdP: ```

Answer 542

Amenorrhea: risperidone Avoid in DM/fall risk: olanzapine Avoid in heart failure with reduced ejection fraction/neutropenic fever: clozapine TdP: ziprasidone

Question 543

Altered mental status, T 105, BP 170/100 in a patient who was recently placed on a drug regimen for diabetic gastroparesis. Dx? Tx?

Answer 543

Metochlopramide | Tx. Dantrolene

Question 544

Extrapyramidal side effects and treatment strategies; Sustained abnl posture: Motor restlessness: Most dangerous complication of the “motor restlessness” Cogwheeling Stereotypical mouth movts 2 years after being placed on fluphenazine:

Answer 544

Sustained abnormal posture: dystonia benztropine or antimuscarinic Motor restlessness: akathisia, increases suicede, 1) propranolol 2) benzo Cogwheeling: parknsonism, benztropin or amantadine Stereotypical mouth movts 2 years after being placed on fluphenazine: tar dive diskinesia, change antipsychotic and valvenazine

Question 545

Anatomical association of conduct disorder and antisocial personality disorder:

Answer 545

CSF with low 5TH

Question 546

Anatomical association and tto of ADHD:

Answer 546

Decrease activity of frontal cortex Give tto starting at age 6, if 4-5 do parent-child behavioral therapy: 1) methylphenidate 2) atomoxetine 3) clonidine/guanfase

Question 547

Personality disorders: 1) Holds grudges, suspects spousal infidelity, are you an enemy or a friend? Fears exploitation: 2) Lacks close friends, believes in the occult, yellow pants with red shirt: 3) Emotionally cold, same rxn to praise/criticism, not interested in sex, loves solitude: 4) Impulsive, intense relationships, radial nerve damage: 5) Requires admiration, lacks empathy, sense of entitlement: 6) Remorseless, disobeys the law, deceitful: 7) Center of attention, seductive, theatrical: 8) Afraid of social criticism, does not take risks, feels inferior to others: 9) Stubborn, rule oriented, miserly, perfectionistic, devoted to the cause/no leisure: 10) Needs reassurance for every decision, problems initiating projects, needs urgent companionship:

Answer 547

1) paranoid 2) schizotypal 3) skizoid 4) borderline 5) narcissistic 6) antisocial 7) histrionic 8) avoidant 9) obsessive compulsive 10) dependent

Question 548

Primary NBME disadvantage associated with relative risk reduction?

Answer 548

RRR is deceitful, that is why you use the ARR so you don't get mislead

Question 549

Safe antiepileptics in pregnancy:

Answer 549

Lamotrigine!!! which works for bipolar and epilepsy Lurasidone for bipolar depression and schizophrenia Gabapentin, lamotrigine and levetiracetam Haloperidol for acute symptoms Topiramate Phenytoin if she was on that before

Question 550

Best CBT for anorexia on NBMEs: | Best antidepressant for anorexia:

Answer 550

``` Family therapy (or behaviorally-based therapy) Mirtazapine: alpha 2 blocker ```

Question 551

Antidepressant for bulimia:

Answer 551

SSRI

Question 552

Eating disorder with sudden onset, severe chest pain with pneumomediastinum:

Answer 552

Pneumothorax on someone that vomits

Question 553

Insomnia with frequent urge to move legs at night. Tto:

Answer 553

tto pramipexole or ropinerol. You can also give primidone that is a barbiturate

Question 554

Narcolepsy tto:

Answer 554

Stimulant: modafinil, dextroamphetamine Na oxidate for cataplexy

Question 555

Complex motor behaviors during sleep:

Answer 555

REM sleep behavior disorder

Question 556

Outside observer to one’s thoughts. No recollection of a traumatic event:

Answer 556

Depersonalization dosorder

Question 557

MDMA toxicity:

Answer 557

Hyperthermia, rhabdomyolysis, hyponatremic seizures, serotonin syndrome

Question 558

Miosis, bradycardia, RR of 4. Intoxication tto: Withdrawal tto:

Answer 558

Opioid overdose Intoxication tto: Naloxone Withdrawal tto: clonidine

Question 559

Nystagmus, violence towards others, myoclonus. Tto:

Answer 559

PCP intoxication, tto with an antipsychotic

Question 560

Cyclical recurrent N/V/colicky abdominal pain.

Answer 560

Marihuana cyclical vomiting sd

Question 561

Pressured speech, tachycardia, mydriasis, HTN. How do you differentiate from amphetamine?

Answer 561

Cocaine intoxication. Cocaine can lead to hypotension, bradycardia and respiratory depression later on! Amphetamine you have prominent hallucinations and tooth decay (if smoked), not in cocaine intoxication, both can have formication!! here it is called delusional parasitosis and is associated to skin picking

Question 562

``` Nystagmus, gait ataxia, confusion. Dx? + Neuroanatomy: + Enzyme association: Tx: Irreversible progression: ```

Answer 562

Wernicke's Neuroanatomy: Hemorrhagic infection of the maxillary bodies Enzyme association: Transketolase Tx: Vit B1 thiamine before glucose Irreversible progression: Korsakov psychosis (confabulation, amnesia)

Question 563

82 yo F pulling IVs, attempting to get OOB. Inducing agent: Acute tx: How to not treat this:

Answer 563

Delirium Acute tx: Haloperidol Bz makes it worse

Question 564

Progressively forgetful, Future planning: ALZ neuroanatomy:

Answer 564

Alzeimer Future planning: Get living will done ALZ neuroanatomy: dysfx of the BASAL nucleus of Meyert, =( posterior 1/3 of temporal lobe

Question 565

Poor language, lack of inhibition, sexually suggestive statements.

Answer 565

Frontotemporal dementia =( anterior 1/3 of temporal lobe + frontal lobe

Question 566

Abnormal gait and urinary incontinence. Pathophysiology:

Answer 566

Problem at arachnoid granulations, communicating hydrocephalus

Question 567

Recurrent nightmares 6 weeks after being fired from an ED nurse role in a COVID unit. Dx: Tx. Tx of REM sleep problems:

Answer 567

PTSD | SSRI, prazosine for the Nightmares

Question 568

In which part of the sleep cycle do sleep terrors and nightmares happen?

Answer 568

Terrors: N3 Nightmares: REM

Question 569

Intrusive thoughts about killing friend. Dx? Tto?

Answer 569

OCD | Tto: Pharm (SSRI) + psychotherapy (exposure and response prevention)

Question 570

Feels humiliated and is terrified at the prospect of giving speeches. Pharm: 1st line and 2nd line

Answer 570

1) propranolol 2) Bz if asthma or COPD

Question 571

MDD; Fastest/most effective tx:

Answer 571

Electroconvulsive therapy Indications: Severe suicidality, malnutrition due to food refusal, severe psychosis), or if medication is contraindicated (e.g., pregnancy)

Question 572

Schizophrenia timelines:

Answer 572

Brief phychotic disorder: less than 1mo Schizophreniform: 1-6mo Schizophrenia: more than 6 mo

Question 573

The ratio of individuals detected by the test to be disease free out of the total number of healthy people refers to:

Answer 573

Specificity

Question 574

The likelihood of a negative test result being true refers to:

Answer 574

NPV

Question 575

The ratio of individuals detected by the test to be with disease out of the total number of diseased people refers to:

Answer 575

Sensitivity

Question 576

The likelihood of a positive test result being true refers to:

Answer 576

PPV

Question 577

Major depression disorder; Monoamine hypothesis: Adrenal axis anomaly:

Answer 577

Monoamine hypothesis: NE, 5HT, DA in CSF | Adrenal axis anomaly: High cortisol in CSF

Question 578

Regime for testicular ca:

Answer 578

cisplatin, etoposide, and bleomycin (BEP regimen)

Question 579

Tto for migraine + vomiting:

Answer 579

Prochlorperazine or chlorpromazine can be used as monotherapy for acute migraine attacks, especially if the migraine is associated with vomiting.

Question 580

Riboflavin deficiency:

Answer 580

The increased activity coefficient of erythrocyte glutathione reductase confirms this diagnosis. Normocytic anemia Patients with riboflavin deficiency are at increased risk of developing seborrheic dermatitis

Question 581

What should you give after to all patients after reperfusion therapy

Answer 581

aspirin + clopidogrel DAPT reduces mortality and the risk of developing subsequent ischemic episodes and stent thrombosis. The duration of DAPT is an individual decision based on bleeding risk and the risk of stent thrombosis. After PCI with stent placement, DAPT is usually recommended for 12 months. In addition to DAPT, long-term pharmacotherapy for secondary prevention after acute coronary syndrome consists of an ACE-inhibitor, beta blocker, nitrate, and a high-dose statin therapy. Low-dose aspirin therapy is continued lifelong.

Question 582

Infective endocarditis in kid

Answer 582

This child fulfills all of the 5 minor criteria of the modified Duke criteria for the diagnosis of infective endocarditis. These include a predisposing heart condition (ventricular septal defect), fever ≥ 38°C (100.4°F), vascular phenomenon (splinter hemorrhages and Janeway lesions, i.e., purplish lesions on her palms and soles), immunologic phenomenon (glomerulonephritis and Roth spots, i.e, retinal hemorrhages), and a positive blood culture for atypical microorganisms consistent with IE. The fulfillment of these 5 criteria (even in the absence of vegetations on the transthoracic echocardiography) are adequate to make a diagnosis of IE.

Question 583

``` A 6 mo male is losing motor milestones. He has over the last 2 mo lost the ability to sit, turn over, or crawl. He has also had multiple seizures and does not respond when he is called by his mom. He lives in a small Amish community in Pennsylvania. Dx: Pathophysiology: Classic populations: Buildup: ```

Answer 583

Tay sachs Hexosaminidase deficiency that makes GM2 ganglioside accumulate French Canadians and Ashkenazi and Cajuns in Louisiana

Question 584

``` Progressive vision and hearing loss in a 2 yo F. She was profoundly hypotonic at birth. PE is notable for hepatosplenomegaly. Further testing reveals markedly elevated levels of very long chain fatty acids in her plasma. Dx: Pathophysiology: Buildup: Mode of inheritance (MOI): ```

Answer 584

Zellweger syndrome Pathophysiology: PEX gene mutation Buildup: VLCFA Mode of inheritance (MOI): AR

Question 585

A 5 yo M is brought to the ED with a 2 week history of daily morning fevers. He lives on a farm and consumes milk sourced from goats. His parents note that he sweats profusely at night and oftentimes his pajamas have a foul smelling odor by morning. He also complains of right knee and left hip pain. Labs are notable for a WBC of 2k and a Hct of 27%. Dx: Tx: Preventive medicine: Macrocytic anemia in this “goat milk” population:

Answer 585

Brucellosis Tx: Doxy + rifampin/aminoglycoside Preventive medicine: Milk pasteurization Macrocytic anemia in this “goat milk” population: folate deficiency

Question 586

2 day history of severe abdominal pain, myalgias, chills, fevers, and a frontal headache in a SEWAGE worker. Funduscopic exam is notable for bilateral conjunctival suffusion. Labs are notable for elevated LFTs and a Cr of 2. Dx? Method of transmission: Tto: Dx testing: Most important predictor of poor outcomes:

Answer 586

Leptospirosis Method of transmission: animal urine exposure Tto: doxy/macrolide Dx testing: ELISA screening for IgM antibodies, then microscopic agglutination or dark field microscopy to confirm Most important predictor of poor outcomes: spread to the lungs

Question 587

22 yo M with a non-painful, non-itchy circular rash on the UEs that has been increasing in size over the last 2 days. He also complains of fevers, chills, and a mild headache. He went hiking with a few friends in Minnesota. On PE, the rash is observed to have an especially erythematous center. Dx? ``` NBSM: Most common cranial nerve affected: Classic cardiac complication: Coinfection: Tick timeline: Tx strategies by age: Treatment for neurological/cardiac involvement: Precaution to be taken with standard treatment: Preventive measures: ```

Answer 587

Lyme by Borrelia burgdorferi NBSM: Screening by ELISA, confirmation by Western Blot Most common cranial nerve affected: CN7 Classic cardiac complication: 3rd degree AV block Coinfection: anaplasma and babesia (give atovaquone for babesia) Tick timeline: just treat if tick has been there for more than 36 h Tx strategies by age: If less than 8 give amoxicillin/cefuroxime, if more than 8 doxy Treatment for neurological/cardiac involvement: cerfriaxone Precaution to be taken with standard treatment: avoid the sun Preventive measures: DEET skin repellant or permethrin sprayed clothes

Question 588

A 32 yo army engineer with a PMH of T2DM is brought to the ED with a 2 day history of high fevers, SOB, and altered mental status. He just returned from a military relief mission to Thailand. He participated in teams that helped with rebuilding homes that were flooded during a severe hurricane. On further evaluation, his WBC is 2k with a BP of 70/40. Fluid collections are visualized by imaging in his brain and liver. Dx? Biggest risk factor: Tto?

Answer 588

Melioidosis by burgdorferi pseudomallei. Transmitted by Water soil!!! Biggest risk factor: history of DM Tto: IV Ceftacidime and then TMP-SMX for a few months

Question 589

45 yo TSA agent on chemotherapy for testicular lymphoma presents with a 2 wk history of high fevers, malaise, and a 7Ib weight loss. Labs are notable for a WBC of 17k (with 70% lymphocytes) and a Ca of 12.2. Dx? What is the Next best step in management? Why would this patient have a Na of 122, K of 6.7, and a bicarb of 14?

Answer 589

Miliary TB NBSIM: RIPE regime; rifampin, isoniazid, pyrazinamide, and ethambutol, vit B6 Metabolic acidosis secondary to adrenal insufficiency that is the MCC of adrenal insufficiency worldwide

Question 590

High fevers in a rabbit farmer. PE is notable for a painful ulcer on his right great toe with prominent superficial inguinal lymphadenopathy. Dx: Tx: Transmitting bug:

Answer 590

Tularemia by francisella tullarensis Tx: 1) aminoglycoside. Also ciprofloxacin or doxycycline Transmitting bug: dermacentor tick

Question 591

Causes (2) of toxic shock syndrome? Tto?

Answer 591

Strep pyogenes, more mortality! Staph aureus Tto: fluids + Abs + ICU

Question 592

A 23 yo F presents with a 2 day history of high fevers, SOB, malaise, and diffuse myalgias. She adopted a dog 3 weeks ago from an animal shelter. Labs are notable for elevated LFTs and a moderate leukocytosis. A new LLSB murmur is heard on cardiac auscultation. CXR is notable for bilateral interstitial infiltrates. Dx: Common cardiac complication: Dx test: Tto:

Answer 592

Q fever Common cardiac complication: culture negative endocarditis Dx: antibodies in the serum Tto: doxi

Question 593

Hematologic differentiation of anaplasmosis, babesiosis, and ehrlichiosis:

Answer 593

Anaplasmosis: pancytopenia Babesiosis: maltese cross, hemolytic anemia Ehrlichiosis: leukopenia, it decreases TNF that causes leukopenia and leads to opportunistic infections

Question 594

Fever and rash for 3 days in a 10 yo M followed by the onset of petechial bleeding on the wrists and ankles that is now spreading towards the abdomen. He recently returned from a field trip to New Mexico associated with his geography class where they explored a few mountains. Labs obtained are notable for a WBC of 2k, plts of 50k, Na of 123, and elevated LFTs. Dx: Transmission: Tx (for all ages); and what should be monitored?

Answer 594

Rocky mountain spots fever by riketsia rikesie Transmission: Dermacentor tick Tx: Doxycycline including kids. Chloramphenicol in pregnant; monitor WBC count!

Question 595

Mononucleosis like syndrome with a -ve monospot test. Dx: Tx strategies: Mechanism of resistance: Tx resistant: Pathology in: In newborn/HIV patient/Transplant recipient:

Answer 595

CMV Ganciclovir, resistance by UL 97 kinase, give foscarnet (pyrofosfate analog) Baby: periventricular calcification Retinitis in HIV Colitis in trasplant

Question 596

Treatment of blastomycosis

Answer 596

Itraconazole

Question 597

Odynophagia in a patient that was recently started on inhaled budesonide for asthma. Dx: Tx strategies: Vaginal presentation (+ tx strategies, classic risk factor): Preventing oral dz while patients are in the hospital: Tx strategies for invasive dz (+ drug MOA): Pediatric presentation: Oral hypoglycemic agent increasing risk: Dx testing: Uncircumcised male: Below the breast:

Answer 597

Candida Nystatin swiss and swallow or oral azole Vaginal presentation: white cottage cheese classic risk factor): Less 4.5 (+ tx strategies, classic risk factor): Prevent chlorexidine mouth wash Invasive tto: echinocandins (fungins, inhibit 1-3 betaglucan synthase) Peds: moisture areas leads to diaper rash SGLT2 inhibitors, flozins KOH prep pseudohifae Balinitis Intertrigo in obese and diabetic patients, treat with topical azole

Question 598

27 yo marine comes to the physician after noticing a lesion on his left hand that has gotten progressively larger. He just returned from a deployment in the Democratic republic of congo and together with his unit participated in a deforestation initiative. Dx: Vector: Preventive measure: Tto strategies: Bone marrow smear findings:

Answer 598

Leishmaniasis Vector: sandfly Preventive measure: nest, insect repelant Tto strategies: liposomal amphotericin B Bone marrow smear findings:---

Question 599

Chagas, Tx strategies:

Answer 599

Nifurtimox, benznidazole For achalasia: 1) endoscopy if need to rule out ca. 2) tto: botox, the Heller myotomy, ca ch blocker, balloon dilation (careful not to cause Boerhaave syndrome) Achalasia presents with low peristalsis and increased LES tone

Question 600

Marine who just returns from the DRC over time becomes somnolent and progresses to an eventual coma. Dx: Vector:

Answer 600

African trypanosomiasis, or sleeping sickness by trypanosoma brucei Tsetse fly

Question 601

A 59 yo M is brought to the ED after being found down in his hotel while on a business meeting. He is apneic and has to be placed on a ventilator. EKG is consistent with pulseless electrical arrest. After multiple attempts, return of spontaneous circulation is achieved. MRI of the brain is consistent with global anoxic injury. The patient’s primary care physician is called and he mentions that a document was signed 3 years ago where the patient stated that he was not interested in life sustaining measures and would like to “go peacefully”. What is the next best step in management? What is the document called? What is a classic alternative on NBMEs to this document? Assuming a patient does not have this document or the alternative (and no one knows his preferences for care), what is the NBSIM?

Answer 601

NBSIM: Take off life support What is the document called? Living will Alternative: Medical power of attorney that is more flexible than the Living will NBSIM 2: Spouse, adult children, parents, siblings, other relatives

Question 602

What are classic NBME scenarios where patient confidentiality should not be honored (4 key situations)?

Answer 602

Child/elder abuse Suicidal/ homicidal Infectious diseases: TB, hepatitis, trichomonas, HIV, unsafe driver (seizures, old...)

Question 603

Prior to declaring a patient brain dead, what must be true of the following? Brainstem reflexes: pCO2: Core body temp: Drug of abuse:

Answer 603

Absent brainstem reflexes: caloric test, pharyngeal reflex (gag), pupillary light reflex, corneal reflex pCO2: bigger than 60 Core body temp: bigger than 90 Fahrenheit (you can be hypothermic) Drug of abuse: no drug intoxication

Question 604

When is parental consent not necessary on NBMEs?

Answer 604

``` Emergency Contraception Pregnancy and prenatal care Addiction STDs ```

Question 605

A nurse mistakenly gives a patient 1000U of aspart instead of the ordered 75U. 55 mins after the dose was given she notices her mistake and immediately begins an infusion of D5W. What is the NBSIM? What kind of error was committed by the nurse in this circumstance? The pyxis machine at a hospital has an antibiotic rack that includes cefotetan, cefazolin, and cefuroxime placed side by side. What is 1 potential issue associated with this setup? How can errors of this nature be reduced in the EMR? As an aside, when is it appropriate for a physician to have a sexual relationship with a patient?

Answer 605

Admit that an error was made Active error, Ade by the patient's bed Latent error Tallman lettering (emphasize the things that are different) Never (more than 6mo after the therapeutic relationship has been broken)

Question 606

A rural ER with only 1 physician and nurse are confronted with 3 patients who all present at the same time. Patient A is a 37 yo F who has over the past 12 hrs had worsening shortness of breath and chest pain. Her BP is 115/75 and EKG shows sinus tachycardia. Patient B is a 22 yo varsity athlete who has had chest pain for the past 3 days and has bilaterally auscultable breath sounds. His BP is 110/73, HR is 65 bpm, and RR is 17. Patient C is a 55 yo M with chest pain radiating to his jaw with territorial ST elevations visualized on an EKG. What is the most appropriate physician action in these circumstances? In taking care of 1 patient first over the other, is an ethical principle being violated? NBME implications for healthcare systems with COVID-19?

Answer 606

A) PE, treat second B) This patient is probably ok, should be the last one to be treated C) acute MI, treat first No, you are triaging the patients On a pandemic, which of the following temporary interventions should be employed? stop elective surgeries

Question 607

What is the most likely quality improvement concept being emphasized with the following case scenarios? A) A hospital is about to establish a new ICU. They design a project to examine dosing of opioids in the ICU and set up a taskforce to determine all the steps in this process along with a detailed analysis of potential pitfalls along the way. B) A 49 yo M dies in a hospital ICU from intracranial hemorrhage. He had initially been getting a heparin infusion for a submissive pulmonary embolism. The hospital sets up a taskforce to thoroughly analyze his hospital course and identify factors along the way that may have led to his death. Plotting?

Answer 607

A) Failure modes and effects analysis. How can this fail and which effects will those failures have? B) Root cause analysis, you can plot the data on a fishbone or ischikawa. Retrospective

Question 608

What kind of quality measure is being emphasized in the following measured situations in an ICU? A) Are readmission rates among heart failure patients increasing after measures are implemented to reduce their hospital length of stay? B) # of adverse drug events after a tallman lettering system is implemented in an ICU. C) # of patients having follow up appointments scheduled by the discharging nurse after admission for a CHF exacerbation.

Answer 608

A) Balanced measure B) Outcome measure C) Process measure

Question 609

1) What is the PDSA cycle? | 2) What is a forced function?

Answer 609

1) PDSA: Plan, do, study, act 2) Forced function: measure that you put in place so people don't make mistakes. You cannot turn the car off if you have parked

Question 610

NBME “buzzwords” for quality/safety practices that improve standardization in healthcare systems?

Answer 610

Checklist (used in newborns for example) Protocol (DKA plan, Sepsis plan...) Algorithm Timeout

Question 611

A procedure kit for placing central lines in a major university hospital is found to have 3 extra lidocaine vials, 4 extra syringes, and a thermometer. The hospital notices that most of these “extra” items get thrown away and decides to have the manufacturer create a custom central line kit that contains exactly what is needed. What quality/safety principle is being employed by the hospital in this circumstance?

Answer 611

Simplification, they are trying to reduce unnecessary steps on a process

Question 612

What is the most likely cause of erectile dysfunction given the following patient scenarios? A) 49 yo M recently started on therapy for angina: B) 32 yo M recently started on therapy for major depressive disorder: C) 29 yo M with hypomagnesemia, megaloblastic anemia, and an elevated GGT: D) 25 yo M with no relevant PMH who has nocturnal emissions: E) A 47 yo M with trace proteinuria and decreased sensation in his legs:

Answer 612

A) Beta blocker B) SSRI C) Alcoholism D) Psychogenic E) DM

Question 613

What are the 2 measures associated with reducing progression of nonalcoholic steatohepatitis to end stage liver disease?

Answer 613

Loose weight Healthy diet/statins

Question 614

Management of an RCA infarct (what should be given)?

Answer 614

DO NOT GIVE NITRATES | Give normal saline

Question 615

Dx test to be employed in an afebrile F presenting with flank pain radiating to the groin and UA showing 30-50 rbcs/hpf. Dx test?

Answer 615

Nephrolithiasis | Non contrast helical CT scan!!!

Question 616

4 yo M presenting with acute onset testicular pain. PE is notable for a “bluish nodularity” and tenderness at the upper pole of the R testicle.

Answer 616

Torsion of the appendage testis, just observe and conservative tto

Question 617

Given the following case scenarios, what is the most likely preventive medicine strategy being employed? A) An 11 yo boy is required to have meningococcal vaccination prior to beginning high school: B) A 65 yo M with a h/o of PAD is placed on daily aspirin therapy: C) Woman getting her yearly mammogram: D) Advising a 35 yo F with no relevant past medical history against getting a mammogram:

Answer 617

A) Primary prevention B) Tertiary prevention C) Secondary prevention D) Quaternary prevention

Question 618

Given the following case scenarios, how would these patients be best able to pay for healthcare? A) 68 yo M who spent 2 weeks in the ICU for the treatment of a severe lobar pneumonia. B) Same male as above being discharged and needing to pay for outpatient ciprofloxacin therapy. C) Same male as above visiting his PCP for outpatient follow up. D) Who typically qualifies for medicare? E) What are some other patient populations that would qualify for the kind of insurance in the case scenario described above?

Answer 618

A) Medicare part A (hospitAl) B) Medicare part D C) Medicare part B (outpatient visits and dx tests) E) Over 65, ALS, end stage renal disease, on social security disability for more tan 2years

Question 619

Potential curative measure for maple syrup urine disease:

Answer 619

Potential curative measure: liver transplant , because the enzyme is expressed in the liver

Question 620

33 yo F presents with a 2 day h/o severe, colicky, generalized abdominal pain. During the interview, her speech is predominated by loose associations. Her mom noticed that she has been passing dark red urine in the intervening time period. Dx? Pathophysiology: Mode of inheritance: Why they also have hyponatremia: Tto: Differentiating from close cousin (+ pathophysiology): Bug to be tested for with skin disorder: Long term prophylaxis: Tto strategies for close cousin:

Answer 620

Acute intermittent porphyria Pathophysiology: Deficiency of porphobilinogen deaminase or hydroxymethylbilane synthase MOI: AD Hyponatremia: Can lead to SIAHD and hyponatremic seizures Tto: Hemin or glucose because they inhibit ALA synthase. Also avoid triggers Close cousin: porphyria cutanea tarda, uroporphyrinogen decarboxylase deficiency that have skin and nail (onicholisis) findings and hypahydrosis (sweat a lot). 20% AD 80% de novo Bug to be tested for: Hep C Prophylaxis: cimetidine Tto: plebotomy

Question 621

Alpha 1 antitripsin deficiency; ``` MOI: Worsens morbidity/mortality: Skin association: Associated vasculitis: Genotype that tends to be symptomatic: ```

Answer 621

MOI: Autosomal codominant Worsens morbidity/mortality: smoking; smoke inhibits Alpha 1 antitripsin Skin association: paniculitis, subcutaneous fat inflammation Associated vasculitis: Wegener Genotype that tends to be symptomatic: PiZZ

Question 622

Classic eye finding in Prader Willi syndrome:

Answer 622

Strabismus

Question 623

MCC of esophageal perforation on NBME exams?

Answer 623

EGD

Question 624

NBSIM in a patient who is diagnosed with a mallory weiss tear?

Answer 624

Supportive care

Question 625

Reducing the risk of future bleeds in patients with esophageal varices?

Answer 625

Prevention: βb (propranolol) because they cause splanchnic vasoconstriction + spironolactone

Question 626

What should always be done after placing a central line on an NBME exam?

Answer 626

Chest Rx!! to confirm appropriate placement!! | You need to see the catheter tip near the angle between the trachea and the right mainstream bronchus

Question 627

What is the relationship between pericardial and ventricular filling pressures in a patient with pericardial tamponade?

Answer 627

Cardiogenic shock. Pericaldiac pressures are higher than the ventricular filling pressures

Question 628

Loss of radial and ulnar artery pulses with a shoulder dislocation?

Answer 628

Axillary A impingement

Question 629

Loss of dorsalis pedis and posterior tibial pulses with posterior knee dislocation?

Answer 629

Popliteal A. disloged

Question 630

``` A 12 yo M is brought to the ER with severe headache and high fevers over the last 24 hrs. PE is notable for nuchal rigidity and star shaped petechial lesions on the upper and lower extremities. These lesions do not fade away under glass pressure. The patient is somnolent and unable to participate in the interview. Dx: Mechanism behind petechiae: Classic outbreak: Major virulence factor: Prevention: Tx strategies: Close contacts: Inciting drug: Sickle cell: ```

Answer 630

Meningitis by N. meningitides Mechanism behind petechiae: toxin breaks blood vessels Classic outbreak: military/dorm Major virulence factor: endotoxin Prevention: conjugated vaccine around 12 y.o. Tx strategies: ceftriaxone Close contacts: rifampin/cipro/ceftriaxone -for pregnant- to contacts (the person that intubates, airway contracts) Inciting drug: eculizumab Sickle cell: asplenia

Question 631

``` Septic Shock SIRS criteria: Sepsis: Severe sepsis: Septic shock: Acid-base balance: MCC: SVR: CO: PCWP: Kind of shock: Pressor of choice: MC kind of infection causing dx: Bad sequelae of septic shock: ```

Answer 631

SIRS: 2 out of 4+infection=sepsis Ta less than 36 or greater than 38 HR more than 90 Resp rate more than 20 less 4k or more than 12k Severe sepsis: +end-organ dysfx Septic shock: +fluids are not working Acid-base balance: depend on anaerobic glycolysis so high anion gap metabolic acidosis due to lactic acid MCC: gram + infection SVR: decrease CO: increase * CO and SVR are opposite except in neurogenic PCWP: decrease Kind of shock: distributive Pressor of choice: NE + if doesn't work vasopressin + if doesn't work DA. Also give intravenous vancomycin and ceftriaxone MC kind of infection causing disease: UTI Bad sequelae of septic shock: multi organ failure

Question 632

A 37 yo M with a h/o familial hypercholesterolemia presents with a 2 hr h/o severe chest pain radiating to his left jaw. His BP is 60/40. ``` Dx: CO: SVR: PCWP: CVP: CI: Tx strategies: ```

Answer 632

MI, cariogenic shock CO: low SVR: high; * CO and SVR are opposite except in neurogenic PCWP: hight CVP: surrogate for RA pressure!!!! increase CI: low Tx strategies: dobutamine

Question 633

A 44 yo M is brought to the ED by ambulance after being involved in a severe MVA. His BP is 60/40 with a HR of 34 bpm. The patient’s skin is warm and flushed. ``` CO: SVR: PCWP: CVP: Tx strategies: ``` Assuming the patient goes into respiratory arrest, where is the likely lesion? What would be true of the A-a gradient in this patient? Mechanism behind the bradycardia:

Answer 633

Neurogenic shock; sympathetic knockout CO: low SVR: low * CO and SVR are opposite except in neurogenic PCWP: low CVP: low Tx strategies: presors Profound respiratory depression by high spinal injury A-a will be nr Parasympathetic is unopposed

Question 634

A 43 yo M is brought to the ED by ambulance after being involved in a severe MVA. His BP is 60/40. A large fluid collection is palpated in the lower abdomen and pelvis. ``` CO: SVR: PCWP: CVP: Tx strategies: ```

Answer 634

Hypovolemic shock CO: low SVR: high PCWP: low CVP: low Tx strategies: nr saline

Question 635

What kind of question should be used to initiate a discussion on NBMEs in relation to intimate partner abuse? In what setting should this be done? What if the partner refuses your suggestions, what are you supposed to do? Should you call CPS/APS?

Answer 635

Do you feel safe at home? Private setting, not with the partner in front Provide resources

Question 636

A 4 yo F is brought to the physician by her mother with a 2 week h/o of severe diarrhea. The mother has presented to the same clinic multiple times for the same complain. No therapeutic interventions appear to have worked. The physician decides to perform a colonoscopy which reveals extensive brownish discoloration of the colon. Dx: Next best stem in management:

Answer 636

Melanosis coli due to factitious disorder by proxy NBSIM: call child protective services

Question 637

Classic signs of child abuse on NBME exams: | Most common cause of death in this population:

Answer 637

``` Signs of child abuse: Sundural hematoma Sternal fractures Spiral fracture Retinal hemorrhages ``` MCCOD: Abusive head trauma

Question 638

A 12 yo F is brought to the ER by her dad after she started having “strange movements” of her UEs/LEs. She has also had severe pain in her knees and high fever. On auscultation of the chest, a diastolic murmur is heard at the apex. She had an URI 3 weeks ago. PE is notable for pink whorl like structures on the legs and inner surfaces of the thighs bilaterally. Dx: ``` Dermatology association: Most likely valvular anomaly: Decreasing incidence: Most likely arrhythmia: Hypersensitivity: Tx strategies: ```

Answer 638

Acute rheumatic fever Derm: erythema marginatum Most likely valvular anomaly in acute rheumatic fever: mitral stenosis??? shouldn't be mitral regurgitation in acute? Decreasing incidence: treat with antibiotics, especially penicillin Most likely arrhythmia: Afib Hypersensitivity: type 2 Tx strategies: penicillin and aspirin

Question 639

COVID-19 Risk factors associated with an increased risk for death: Dx testing: Tx strategies and it's mechanism of action:

Answer 639

RF: Pre-existing lung disease, immunocompromised Dx testing: antibodies test/ PCR Tx strategies: remdesavir (RNAse polymerase inhibitor), convalescent serum

Question 640

32 yo F with a family history of breast and ovarian cancers presents with a 2 month history of R arm pain and swelling. She underwent radiation therapy for breast cancer 3 months ago. Dx: Biggest RF? Biggest RF developing countries? Tx? Malignant complication?

Answer 640

Lymphedema Biggest RF? lymph node dissection (also radiation) Biggest RF developing countries? Filariasis by burferia bancrofti Tx? compression bandage Malignant complication? lymphangiosarcoma, bad px

Question 641

67 yo F presents with a 3 mo hx of moderate LLE pain. She describes the pain as a tight, full, achy sensation that is worse at the end of the day. PE is notable for ankle/calf edema which subsides with elevation of the involved extremity. Dx? ``` Dermatology association? Pathophysiology? Ulcer? Dx testing? Tx strategies? Veins affected? ```

Answer 641

Varicous veins Dermatology association? stasis dermatitis because of hemosiderin deposition Pathophysiology? valvular incompetence Ulcer? painless shallow ulcer above the medial malleolus Dx testing? DUPLEX ULTRASOUND of lower extremities Tx strategies? compression socks, una boots if ulcer Also RF ablation or sclerotherapy Veins? Saphenous v.

Question 642

HY Compression Syndromes: 1) Lower leg thrombosis in an individual with no associated hypercoagulable risk factors: 2) 2 month history of severe left hand, left clavicle, and left neck pain in a 23 yo M. He also reports tingling in all 5 digits of the involved extremity. PE is notable for purplish discoloration of the left hand: 3) Sudden onset severe pain, erythema, and swelling of the right arm in a 23 yo M guitarist who has recently had to increase practice time for an upcoming reality TV show: 4) 2 week history of hematuria and left testicular pain in a 23 yo M who recently lost 45 Lbs on a reality TV show. PE is notable for a bag of worms sensation in his left testicle: 5) Sudden onset severe RUQ pain and jaundice in a 22 yo M with a h/o chronic hematuria. Abdominal exam is notable for a fluid wave. Obtained labs reveal a pancytopenia with a bicarb of 13: 6) Sudden onset flank and lower back pain in a 33 yo M with a history of chronic proteinuria and generalized edema: 7) Sudden onset severe abdominal pain in a patient that was recently discharged from the hospital after a bout of acute pancreatitis. PE is notable for fullness in the LUQ. His plt count is 55k:

Answer 642

1) May-thurner syndrome, the right common iliac A compresses the left common iliac V so blood does not return form the lower leg 2) Thoracic outlet sd due to cervical rib and pancoast tumor 3) Paget-Schroter disease, overuse thrombosis, thrombosis of the axillary or the subclavian v. on someone that uses the arms a lot (jackhammer operator, weight lifter, musician) 4) Nutcracker syndrome 5) Budd chiari in paroxysmal nocturnal hemoglobinuria; hepatic v. thrombosis 6) Loss of antithrombin 3 in nephrotic sd (membranous neuropathy is the forest thrombogenic) 7) Splenic V. thrombosis which is associated w acute pancreatitis, platelet sequestration

Question 643

Odynophagia/GERD like sxs that have not improved with three, 6 week courses of esomeprazole. Esophageal pH monitoring is unremarkable. Dx: Tto strategies:

Answer 643

Eosinophilic esophagitis Tto strategies: steroids (can be potentially inhaled)

Question 644

BP of 190/120 and severe chest pain radiating to the scapula in a 55 yo M. Dx: ``` Next best step in Dx? Biggest RF? Tto strategies? New diastolic murmur? Other RFs? Most common extracardiac complication? Buzzword pathophysiology? ```

Answer 644

Aortic dissection NBSID? TEE if unstable; Ct angiogram of the chest if stable RF? HT Tto strategies? Beta blokers New diastolic murmur? aortic regurgitation Other RFs? Marfan, ED, turner, takayasu, syphilis... Most common extracardiac complication? renal failure Buzzword pathophysiology? cystic medial necrosis

Question 645

Sudden onset severe back/left flank pain in a 69 yo M with a barely perceptible supraumbilical mass. Dx? ``` Next best step in diagnosis? Next best step in management? Biggest risk factor? Tto strategies? Paraplegia? Post treatment positive fecal occult blood test and Hb of 8 with MCV of 70? Screening guidelines? Most common tto complication with endovascular repair? Most common location? Imaging finding in acute circumstances? ```

Answer 645

Rupture AAA NBSID? unstable ultrasound, stable CT scan NBSIM? 2 big IVs and fluids BRF? smoking; also biggest modifiable RF for progression (because smoking disrupts the arterial wall elastin matrix) Tto strategies? surgery Paraplegia? injury of A. of Adamkiewicz causing anterior spinal A sd Post treatment + FOBT and Hb of 8 with MCV of 70? fistula between aorta and GI trac Screening guidelines? more than 65 and smoke 1 time aldominal ultrasound, more than 5.5 cm sx Most common tto complication with endovascular repair? endo leak, contrast going beyond the confines of the stent Most common location? below renal A Imaging finding in acute circumstances? draped aortic sign (aorta drapes into vertebral bodies and causes calcifications anterior to them).

Question 646

What defines an unstable patient?

Answer 646

BP less than 90 systolic/60 diastolic! ``` Chest pain Shortness of breath Hypotension (pale) Confusion (altered mental status) Diaphoretic Severe abdominal plain ```

Question 647

Why does aspirin help with RF?

Answer 647

Avoid thrombosis Anti-inflammatory This is one of the cases where you can give aspirin to a kid

Question 648

Rising Cr 2 days after a patient with a history of A.fib presented with acute onset severe leg pain that was treated with a catheter embolectomy. Initial dx? Pathophysiology of the rise in Cr:

Answer 648

The patient had acute limb ischemia 6Ps: pallor, pain, paralysis, paresthesias, pulselessness and poikilothermia Tto: Amputate if no audible pulses in Doppler and complete paralysis Thrombectomy: in the vignette you caused a thrombosis of the renal A. by inserting the catheter or by dislodging a cloth that ends up in the renal A!

Question 649

Treatment of bleeding associated with end stage renal disease? and en stage liver disease?

Answer 649

ESRD=Uremia? Desmopressin, because urea prevents degranulation of platelets ESLD=Cirrhosis? FFP to supply missing clothing factors

Question 650

2 year history of recurrent intermittent fevers and pleuritic chest pain in a Libyan/Turkish/Greek immigrant. His only home medication is as needed ibuprofen for knee pain. These episodes last for about a week and resolve without treatment. Similar episodes have also been known to occur in other family members. PE/imaging are all wnl. Genetics? Classic lab findings? Cr of 3 and proteinuria after many years? Tx strategies?

Answer 650

Familial Mediterranean fever MEFV gene high ESR/CRP AA can build up and cause amyloidosis, MCC of death on amyloidosis us nephrotic sd Colchicin

Question 651

Red, hot painful ears with chronic stridor. This patient often has episodes of bilateral, parasternal chest pain. He is noted to have a saddle nose deformity. Dx? Dx testing? Tx?

Answer 651

Relapsing polychondritis Dx testing? cartilage biopsy Tx? 1) NSAIDs colchicine dapsone 2) steroid if they don't work

Question 652

What is the dx for the following patient permutations? 1) HR 170, BP 210/120, bilateral pupillary mydriasis: 2) HR 120, BP 170/100, bilateral pupillary mydriasis, hearing voices and seeing snakes in the room: 3) HR 45, profuse diarrhea and rhinorrhea, bilateral pupillary miosis in a farmer: 4) T 103F, HR 130, RR 26, bilateral pupillary mydriasis: 5) T 103F, HR 130, RR 26, bilateral pupillary mydriasis, WBC of 17k, diffuse muscle rigidity: 6) HR 32, RR 4, T 90, bilateral pupillary miosis: 7) HR 19, BP 60/40 in a 33 yo F on chronic therapy for variant angina. A suicide note is found by her side:

Answer 652

1) Cocaine intoxication, give a benzo or phentolamine 2) Amphetamine intoxication 3) Organophosphate poisoning, give atropin and then pralidoxine 4) Anticholinergic toxidrome (TCA, diphenhydramine) give physostigmine 5) Neuroleptic malignant syndrome, give dantrolene 6) Opioid intoxication, give naloxone 7) You treat variant angina with verapamil/diltiazem. Overdose treated w glucagon, if does not work pacemaker

Question 653

22 yo M was found unconscious by his family in January. His neighbor saw him grilling indoors yesterday as temperatures were sub-zero at the time. Dx testing? Brain imaging? Tx strategies? Most likely NBME presenting sxs?

Answer 653

CO poisoning Dx testing? Check CO levels Brain imaging? Bilateral hyperintensities on the globus pallidus Tx strategies? 100% O2 ot hyperbaric O2 Most likely NBME presenting sxs? headache

Question 654

Nausea, vomiting and diarrhea with a Cr of 3 4 days after starting chemotherapy for Burkitt’s lymphoma. Dx: Preventive measures/tx? Most likely electrolyte anomaly?

Answer 654

Tumor lysis sd Preventive measures/tx? hydration and allopurinol/febuxostat for prevention. Rasburicase/pegloticase if established. Most likely electrolyte anomaly? kyperkalemia

Question 655

A 19 yo with a history of Diffuse Large Cell Lymphoma on chemotherapy is brought to the ED with a 3 day history of high fevers and flu like sxs. His T is 102. A chest, abdominal, and pelvic CT series is unremarkable. His ANC is 300. ``` Next best step in management? If not febrile: Next best step in diagnosis? Prophylaxis? Despite a 6 day course of tx, the patient remains febrile, what is the NBSIM? Imaging findings? RLQ pain? ```

Answer 655

Febrile neutropenia NBSIM? antipseudomonal antibiotic (pime, dime, carbapenem) ± G-CSF If it is not febrile just observation! NBSID? blood culture Prophylaxis? GCSF GMCSF analog filgrastim sagramustin Despite a 6 day course of tx, the patient remains febrile, what is the NBSIM? this is invasive aspergillosis, voriconazole Imaging findings? halo sign (dense circular infiltrate) RLQ pain? necrotizing enterocolitis!! typhlitis do an abdominal CT scan for dx

Question 656

A 55 yo F with a history of breast cancer in remission presents with a 2 week history of left sided facial droop and left sided LE weakness. Brain imaging is consistent with multiple ring enhancing lesions. Dx? Next best step in management? Preferred brain imaging? Long term management?

Answer 656

Brain metastasis NBSIM? IV steroids Preferred brain imaging? MRI Long term management? whole brain radiation

Question 657

The CKD Patient: Tx of HTN in an AA CKD patient with proteinuria: BP target for HTN in CKD: 3 day history of SOB with JVD. An AV fistula was placed a week prior given the patient’s declining renal status: Hirsutism and dental anomalies after a renal transplant: Most likely malignant complication of renal transplantation:

Answer 657

Tto: ACEi/ ARAs BP target: 130/80 SOB with JVD on a patient with AV fistula: high output HF secondary to the AV fistula (it can also happen in Osler weber Rendu sd) Hirsutism and dental anomalies: Cylosporin toxicity Malignant complication: squamous cell ca of the skin because of the immunosuppression

Question 658

Subarachnoid hemorrhage in Alzheimer. Why?

Answer 658

Amyloid angioplasty, amyloid deposits in blood vessels

Question 659

A 39 yo F with a h/o of rheumatoid arthritis: 1 ) has had a progressive increase in her Cr over the past year. She is noted to have tongue enlargement on PE. Dx? 2) has fever, respiratory difficulty, negative sputum cultures and bilateral micronodular consolidations in chest Rx. Dx?

Answer 659

1) Amyloidosis | 2) Bronchiolitis obliterates organizing pneumonia. Tto with steroids

Question 660

Why do these patients bleed? MEN2A/2B: 55 yo M with a 12 year h/o T2DM:

Answer 660

MEN2A/2B: Medullary thyroid ca. makes calcitonin that makes amyloid; in amiloidodis amyloid binds factor 10 and causes a factor 10 deficiency 55 yo M with a 12 year h/o T2DM: DM leads to amyloidosis that again causes bleeding because amyloid binds factor 10

Question 661

Amyloidosis cases: 1) 54 yo M who has been on dialysis for 2 years and develops thenar atrophy. Why? What builds up? 2) Old person w/restrictive heart disease. What builds up? 3) Chronic osteomyelitis. What builds up? Structural view of amyloid on EM: Mechanism behind renal failure: Most common cause of death:

Answer 661

1) Beta 2 microglobulin → dialysis cannot filter beta 2 microglobulin that ends up making amyloid and can lead carpal tunnel 2) Transthyretin → transthyretin builds up in the heart Dx: echocardiogram ± cardiac MRI → end-myocardial biopsy to confirm 3) AA → chronic osteomyelitis is a chronic infection, so the body makes AA EM: beta pleaded sheds Mechanism behind renal failure: nephrotic syndrome MCCOD: renal failure

Question 662

A 25 yo Japanese M immigrant comes to the physician with a 6 mo h/o abdominal pain. He has also had chronic diarrhea over this time period. PE is notable for skin hyperpigmentation and nail atrophy. Further diagnostic testing reveals multiple flesh like growths in his stomach and large intestine. Pathological analysis of one of these lesions reveals non-malignant cells. Dx? Stool studies: Heritable: How can this be differentiated from FAP?

Answer 662

Cronkhite-Canada syndrome Stool studies: protein Heritable: no Differentiated from FAP: they both have polyps but in Cronkhite-Canada sd. there are in the stomach and in the large intestine, in FAP they are in both the small and large intestine

Question 663

FAP: Mode of inheritance: Screening guidelines: Eye findings: Syndrome associated if: Osteomas, fibromas: Gliomas, medulloblastomas: Further gene mutations: What if both parents never had these lesions?

Answer 663

MOI: AD Screening guidelines: every 1/2 years a screening colonoscopy since 10 y.o. Eye findings: pigmented lesions on retina Osteomas, fibromas: Gadner sd Gliomas, medulloblastomas: Turcot sd Further gene mutations: APC → K-ras → TP53 There is a FAP related syndrome that is AR called MUTYH associated polyposis

Question 664

Hyperpigmented macules on the lips w/multiple colonic polyps. Dx? Mode of inheritance: Unusual NBME pediatric manifestation:

Answer 664

Peutz yeger syndrome MOI: AD Manifestation: intussusception

Question 665

Social Science/Healthcare System scenarios; 1) Most common emergency requiring BLS: 2) Most likely healthcare outcome associated with receiving CPR: 3) Most important locational predictor of positive outcomes with CPR: 4) Organ donation w/DNR orders: 5) DNR orders with impending surgery: 6) Is physician assisted suicide legal in the US: 8) Hospice: greatest barrier to care: 9) 2 cardinal NBME signs that a patient should be placed in hospice:

Answer 665

1) Cerebral hypoxia 2) Death 3) In hospital CPR 4) If you have a DNR you are not considered as organ donor 5) If you are getting sx you need to suspend the DNR during sx 6) No 8) Fear that you are not doing any diagnosis or treatment and that you will not prolong life 9) Totally dependent on other people for the daily living and feeding difficulty

Question 666

A 49 yo M with a h/o Afib on metoprolol and apixaban is scheduled to undergo a partial colectomy for Crohn’s disease. To reduce the risk of bleeding associated with this procedure, what is the NBSIM?

Answer 666

Stop the apixaban 3 days before the sx

Question 667

What do you do in a situation where a patient’s spouse refuses to honor a DNR order associated with the patient’s living will?

Answer 667

Overide the wife

Question 668

For a patient with urinary incontinence, what should be done in a healthcare setting to decrease the risk of Catheter Associated Urinary Tract Infections (CAUTIs)?

Answer 668

Intermittent catheterization | Use aseptic theinhcque

Question 669

What is the microbial mechanism behind indwelling catheters being a source of UTIs?

Answer 669

Biofilm

Question 670

A 19 yo freshman college athlete comes to the medical geneticist for a follow up exam after collapsing during a basketball game. He is accompanied by his girlfriend and his coach. He has been highly recruited for the last 4 years and expects to be a top 10 NBA draft pick. A transesophageal echocardiogram obtained 2 hrs after his collapse reveals asymmetric septal hypertrophy associated with the left ventricle. Further genetic testing confirms the diagnosis. The physician plans to discuss these test results and implications for his long term future at this visit. Arrange the following physician responses in order of what should be done first to what should be done last? S1-What is your current understanding of all that is going on? S2-Before I get to the test results, I would like to summarize our journey to this point. S3-Unfortunately, your test results are worse than what we initially hoped for. S4-Even though we cannot cure your HCM, we can provide medications to reduce your symptoms and allow you to enjoy your life in a meaningful way. S5-Before we review your test results, would you prefer that we discuss things privately or would you rather have your girlfriend/coach here? S6-Would it be ok if we discuss the results of the tests we conducted? S7-Can you tell me more about what your current concerns are? Which murmur will this patient have

Answer 670

SPI-S-KES Set the stage: 5 Before we review your test results, would you prefer that we discuss things privately or would you rather have your girlfriend/coach here? Perception, what do you understand: 1 What is your current understanding of all that is going on? Invitation: are you ready to discuss: 6 Would it be ok if we discuss the results of the tests we conducted? Summarize: 2 Before I get to the test results, I would like to summarize our journey to this point Knowledge, bad news are coming: 3 Unfortunately, your test results are worse than what we initially hoped for Empathy: 7 Can you tell me more about what your current concerns are? Strategy and summary: 4 Even though we cannot cure your HCM, we can provide medications to reduce your symptoms and allow you to enjoy your life in a meaningful way Murmur: systolic crescendo-decrescendo murmur best heard at the LEFT upper sternal border (vs AS that is on the right)

Question 671

Nosocomial infections and the NBMEs: Most common mode of transmission: Most important measure associated with decreasing the risk of nosocomial infections: 3 HY NBME organisms associated with airborne transmission: Reducing risk of rotavirus/C. Diff infection in hospitals: Most important measure for decreasing the transmission of blood borne pathogens: MC kind of nosocomial infection (+ #2): MC nosocomial infection COD: MC bug cause of hospital-acquired pneumonia: Contraindications to ETOH based handwashing:

Answer 671

Most common mode of transmission: direct contact, touch Most important measure associated with decreasing the risk of nosocomial infections: hand-washing/ alcohol based solutions 3 HY NBME organisms associated with airborne transmission: TB, legionella, varicella Reducing risk of rotavirus/C. Diff infection in hospitals: hand-washing Most important measure for decreasing the transmission of blood-borne pathogens: gloves MC kind of nosocomial infection (+ #2): 1) Catheter associated UTI 2) Healt care associated pneumonia MC nosocomial infection COD: gram - rod infection MC bug cause of hospital-acquired pneumonia: staph aureus Contraindications to ETOH based handwashing: C. difficile, any organism that makes spores in general

Question 672

A medical student is tasked with caring for a 25 yo M who presented with nuchal rigidity, headache, and high fevers. Gram stain of an LP specimen revealed gram- diplococci. What kind of precaution should be taken in caring for this patient?

Answer 672

Dropplet precautions Other organisms that also requiere dropplet precautions: Peruses influenza Neisseria

Question 673

COVID 19 precautions:

Answer 673

It is airborne so: Negative pressure room N95 mask or respirator

Question 674

C-Difficile, Precautions: Management: Complication:

Answer 674

Precautions: had washing Management: 1st episode: oral fidaxomicin/oral vancomycin 2nd episode: change drug oral vancomycin/oral fidaxomicin Resistant: oral vancomycin + rifaximin Fulminant colitis: IV metronidazole + oral vancomycin Complication: toxic megacolon

Question 675

3 NBME interventions for reducing the risk of ventilator associated pneumonia? Reducing the risk of pneumothorax with central line insertions?

Answer 675

Supraglotic secretion drainage Lift the head 30 deg on the bed Chlorexidine mouth wash Avoid subclavian central IV Guided ultrasound

Question 676

For NBME purposes, how should a pressure ulcer be cultured for infection? For NBME purposes, what kinds of cultures are obtained when a CLABSI is suspected? How is a CLABSI treated?

Answer 676

Deep tissue specimen 2 samples for culture: 1 form the catheter central line and 1 form somewhere else in the body. * If in catheter has a lot more bugs it means the infection is from the catheter Remove catheter and IV antibiotic

Question 677

29 yo M with a h/o Hodgkin’s lymphoma reports severe pain in his R arm. His sxs began 2 hrs ago. Examination is notable for swelling in the involved extremity with palpable tenderness. His brachial pulse is palpable. He has a R jugular central venous catheter in place. Dx? Pathophysiology?

Answer 677

Catheter associated thrombosis When you put a catheter you are puncturing a blood vessel and expose sub-endothelial collagen so you activate the coagulation cascade which increases the risk of thrombosis

Question 678

Cancer patients and pain management: Ladder: Add-on therapy with opioids:

Answer 678

You should give them all the opioids they need Ladder: try to start with non-opioid pain control and if it does not work you switch to an opioid Add-on: stool softener

Question 679

NBME contraindications to getting a transplant?

Answer 679

Incurable malignancy Long cardiac arrest Creutz jakob disease * HIV is NOT a contraindication

Question 680

Immediate diagnostic test in a neonate presenting with bilious emesis:

Answer 680

Upper GI series

Question 681

Most important predictor of mortality in a newborn with congenital diaphragmatic hernia?

Answer 681

The degree of pulmonary hypoplasia

Question 682

Most dangerous complication of pericardiocentesis?

Answer 682

Cardiac puncture

Question 683

Mechanism behind the hypotension in a patient with a tension pneumothorax?

Answer 683

Obstructive shock that ↓ CO. Air compresses the SVC and the IVC so VR ↓↓↓

Question 684

3 populations that are not screened for AAA:

Answer 684

Women Less 65 Patient that never smoked

Question 685

Unique differentiating feature on NBMEs when comparing cluster headaches to migraine headaches

Answer 685

Cluster headache will present with rhinorrhea, eye symptoms like ptosis, and being in a dark room will not improve the headache

Question 686

Microangiopathic hemolytic anemia, skin ecchymosis, and renal failure in a 45 yo Male. Dx? Tx strategies:

Answer 686

TTP Tx strategies: plasmapheresis

Question 687

Mechanism behind infertility in a patient with decreased day 25 progesterone?

Answer 687

Day 25 is in the luteal phase, ↓ progesterone in the luteal phase indicates anovulation; classic in PCOS

Question 688

Complete hair loss in discrete circular patches on the hair in a 35 yo M with a h/o Addison’s. Dx? Tx strategies:

Answer 688

Alopecia areata Tx strategies: steroid injection in the lesions

Question 689

Breast cancer screening guidelines with BRCA1 and 2 mutations:

Answer 689

Mammogram and MRI every year from 30 y.o. on *Do the Mammogram and MRI spaced by 6 mo

Question 690

4 major NBME criteria for pursuing high-intensity statin therapy, also which drugs are high-intensity statins?

Answer 690

Atherosclerotic cardiovascular disease: MI, stroke, TIA LDL over 190 DM aged between 45-70 y.o. or with LDL more than 70 More than 7.5 points in the ASCVD High-intensity statins: Atorvastatin or Rosuvastatin

Question 691

Next best step in the management of a patient older than 50 who presents with a new, chronic headache:

Answer 691

MRI

Question 692

2 mechanisms behind HF in chronic, severe anemia:

Answer 692

1) High output heart failure because the oxygen carrying capacity of the blood ↓ and HR needs to ↑ 2) Blood gets less viscous which ↓ TPR

Question 693

Fe deficiency anemia in a 6 yo M with intermittent RLQ pain. Dx?

Answer 693

Meckel's diverticulum

Question 694

A 23 yo M presents to the physician with a 2 week h/o of mild pain in his R thigh. PE is notable for a hard, palpable mass in the involved extremity. The patient was mistakenly hit in the R thigh with a baseball bat 6 weeks ago during a game. Dx?

Answer 694

Myositis ossificans

Question 695

Increased INR in a newly diagnosed HIV patient with a h/o Afib that is currently well controlled with Metoprolol. His CD4 count measured 3 weeks ago was 45. He was started on HAART therapy and appropriate prophylactic measures. Dx? Electrolyte anomaly secondary to his medication:

Answer 695

INR ↑ because of the use of Warfarin + Ritonavir He is also in TMP-SMX that acts like a K sparing diuretic causing hyperkalemia

Question 696

Increased Cr and red urine in a 47 yo M with a h/o of DM who was recently started on appropriate therapy after he was found to have an LDL-C of 175 mg/dL. Dx? Classic “home product” that increases toxicity:

Answer 696

This is statin-induced rhadomyolisis due to a P450 inhibitor like grapefruit juice

Question 697

Treatment failures in individuals ingesting antacids:

Answer 697

Cations bind: Thyroid h Fluoroquinolones Tetracyclines

Question 698

Pharmacologic agents on NBMEs with the following side effects; Crystalline nephropathy (AIT): Pancreatitis (2):

Answer 698

Crystalline nephropathy (AIT): Acyclovir Indinavir Topiramate Pancreatitis (2): Stavudine, didanosine Gliptins (DPP-4 inhibitors) and Tides (GLP 1 agonists)

Question 699

Hyperkalemia on a normal patient. Why? What should you do?

Answer 699

Pseudohyperkalemia: RBC lysis or high platelets or WBCs on the sample, re-check K and put citrate (plasma K) on the tube True hyperkalemia causes: acidosis, DM (1 because there is no insulin 2 because there is no renin), beta-blockers, digoxin, rhabdo, hemolysis, burns, tumor lysis, RTA type 4, Addisons, K sparing diuretics, NSAIDs (you need PGs to get rid of K) Digoxin toxicity causes hyperkalemia but hypokalemia worsens digoxin toxicity

Question 700

D-dimer statistical characteristics:

Answer 700

High seNsitivity Low sPecificity High NPV Low PPV

Question 701

The NBME and Diarrhea; match the following scenarios to the most likely offending organism: Watery Diarrhea after returning from a trip Watery Diarrhea in a hiker/camper Watery Diarrhea on a cruise ship Watery Diarrhea in an infant Watery Diarrhea in an AIDS patient Bloody Diarrhea after consuming beef Bloody diarrhea after consuming poultry/eggs Bloody diarrhea in the setting of a Lactose Fermenter Most common cause of bloody diarrhea in the US Diarrhea and Ascending Paralysis Diarrhea after treatment for an anaerobic infection Diarrhea after Pork Consumption Protozoal cause of bloody diarrhea Bloody Diarrhea requiring a small inoculum Diarrhea after consuming Oysters/Seafood Diarrhea after consuming Oysters + Elevated Liver Function Tests Diarrhea after swimming in freshwater Diarrhea with massive amounts of fluid/electrolyte loss Diarrhea after consuming reheated rice Diarrhea 2 hours after consuming potato salad Diarrhea with a very low inoculum Bloody diarrhea + seizures in kid Most accurate test for diarrheas

Answer 701

Watery Diarrhea after returning from a trip: ETEC Watery Diarrhea in a hiker/camper: Giardia Watery Diarrhea on a cruise ship: Norovirus Watery Diarrhea in an infant: Rotavirus Watery Diarrhea in an AIDS patient: Cryptosporidium Parvum (acid fast) Tto: Nitazoxanide Bloody Diarrhea after consuming beef: EHEC/ Shigella. Tto: levofloxacin/TMP-SMX/amoxicillin Bloody diarrhea after consuming poultry/eggs: Salmonella Bloody diarrhea in the setting of a Lactose Fermenter: EHEC Most common cause of bloody diarrhea in the US: Campylobacter Jejuni (mucoid + bloody + pseudoappendicitis) Diarrhea and Ascending Paralysis: Guillain Barre due to Campylobacter Diarrhea after treatment for an anaerobic infection: C. Difficile Diarrhea that feels like Appendicitis (after PORK Consumption): Yersinia enterocolitica Protozoal cause of bloody diarrhea: Entamoeba histolytica Bloody Diarrhea requiring a small inoculum: Sigella! (seizures) Diarrhea after consuming Oysters/Seafood: Vibrio parahemolyticus Diarrhea after consuming Oysters/Seafood + Elevated Liver Function Tests: Vibrio vulnificus (bad prognosis if the patient has preexisting liver disease) Diarrhea after swimming in freshwater: Aeromonas Diarrhea with massive amounts of fluid/electrolyte loss: V. Cholerae (tetracyclines cover vibrio + oral rehydration therapy that upregulates the Na/glucose transporter) Diarrhea after consuming reheated rice: Bacillus Cereus, toxin: cerulite Diarrhea 2 hours after consuming potato salad: Staph Aureus Diarrhea with a very low inoculum: Shigella Bloody diarrhea + seizures in kid: Shigella Stoll culture

Question 702

Acute cervicitis presentation and treatment:

Answer 702

Postcoital bleeding, mucopurulent discharge and friable cervix, cervical motion tenderness if becomes PID* * not in pregnant because the infection does not ascend due to the sealed graves uterus Tto: ceftriaxone for gonorrhea, doxycycline for chlamydia * In pregnant ceftriaxone + azithromycin

Question 703

Rupture of the tympanic membrane:

Answer 703

The Eustachian tube cannot open normally (cold...) so there is a difference in pressures between the atmosphere and the middle ear. If there are big barometric pressure changes (as in a plane...) they can stretch the tympanic membrane and even break it causing minor bleeding. The tympanic membrane fractures heal spontaneously within a few weeks

Question 704

Which anticonvulsants can you give in pregnancy?

Answer 704

Gabapentin Lamotrigine Levetiracetam GA LA para LEVEs problemas *If an epileptic woman that is well controlled on a medication gets pregnant, keep her on the same drug unless it is valproate

Question 705

Most common post-influenza infection:

Answer 705

1) Strep pneumo: lobar consolidation | 2) Staph aureus: cavitary lesions

Question 706

Meningitis treatment depending on age range:

Answer 706

Children, elderly and immunocompromised: vancomycin +3rd cefalosporin+ampicillin Adult/children older than 1yo: vancomycin + 3rd cefalosporin (if it is pneumococcus you can take off vanco when you confirm sensitivity to penicillin)

Question 707

Transfusion RBC:platelets:plasma proportion:

Answer 707

Massive transfusion protocol: 1:1:1 ratio, whole blood transfusions are given in massive hemorrhage and shock, start the protocol if you predict that your pt is going to need 4+ units of RBCs over 1h RBCs alone should be give if Hb is less than 6, also if pt has low Hb and has an active bleed, or if Hb is less than 9 on pt with acute coronary sd

Question 708

Nonhealing ulcer for years in the setting of chronic venous insufficiency should raise suspicion for? Management?

Answer 708

Marjolin ulcer, a type of cutaneous squamous cell carcinoma Management: biopsy

Question 709

Features of a manic episode:

Answer 709

``` 'DIG FAST' D = Distractibility I = Irresponsibility G = Grandiosity F = Flight of ideas A = Activity increase S = Sleep deficit T = Talkativeness ``` You need > 3 symptoms (>4 if mood is only irritable) There is a genetic predisposition for bipolar disorder

Question 710

Which bone marrow biopsy findings are characteristic of Waldenstrom macroglobulinemia?

Answer 710

Dutcher bodies

Question 711

Hyperintense line in the meniscus on MRI is diagnostic of:

Answer 711

Meniscal tear

Question 712

Post-tranplant prophylaxis:

Answer 712

CMV: valganciclovir PCP: TMP-SMX

Question 713

Management of hernias:

Answer 713

Femoral hernia: elective surgery, they have a higher risk or incarceration Inguinal hernia: if asymptomatic just watch, if symptomatic do elective surgery* * elective sx must be done at least 6 mo after an MI!

Question 714

Management for high BP:

Answer 714

1) Weight loss 2) DASH diet (fruit, vegetables, low saturated fat) 3) Exercise 3) Decrease Na intake 4) Alcohol, decrease W-DE-DA

Question 715

Singed nasal hair and soot in the mouth indicate:

Answer 715

Airway involvement in burn patient

Question 716

Which neuromuscular blocker needs to be avoided in organophosphate poisoning?

Answer 716

Succinylcholine

Question 717

Cytochrome P450 inducers:

Answer 717

Barb’s funny smoker mom refuses greasy carb shakes: Phenobarbital (barbiturates), phenytoin, hydrocarbons, modafinil, rifampin, griseofulvin, carbamazepine, St. John’s wort ``` Think seizures Alcohol (chronic) Oral contraceptives (estrogens) Nevirapine Smoking (hydrocarbons) ``` You would need to increase the dose of a drug for it to work, contraceptives and warfarin might not work. Prodrugs will become more effective

Question 718

Cytochrome P450 inhibitors:

Answer 718

Gee queen GRACE IS inhibit when eats PI: Gemfibrozil, QUINolones, grapefruit juice, ritoNAVIR (protease inhibitors), AZOLes (and metronidAZOle), cimetidine and omeprazole, eryTHROmycin (macrolides except azithromycin ACE), isoniazid, sulfanilamides, PPis COKE (cimetidine, omeprazole, ketoconazole, eryTHROmycin) + Grapefruit juice + PI (PPis, isoniazid) ``` Alcohol (acute) Amiodarone!!! Chloramphenicol Diltiazem SSRIs (fluvoxamine+!!, fluoxetine-) Cyclosporine Metronidazole ``` Drugs (statins) will become toxic but prodrugs will become less effective P450 inhibitors that affect methadone: AZOLes, clarithromycin, ciprofloxacin and fluvoxamine

Question 719

Which patients with PCP pneumonia should get steroids and IV treatment? Which patients with HIV and toxoplasmosis should get steroids?

Answer 719

``` PCP: O2 partial pressure less than 70%!!! SaO2 less 92% A-a greater than 35 Dx: lavage with ↑ LDH ``` Toxo: ↑ ICP

Question 720

What are coffin, envelope, rhombi and hexagon-shaped stones? What is the first step in Dx? How to prevent the most common stones? How to prevent uric acid stones?

Answer 720

Coffin: struvite Envelope: ca oxalate (tto: give B6 to metabolize then oxalate) Radiolucent rhombi: uric acid Hexagon: cystein (tto: with acetazolamide) First step in Dx: Ultrasound!!! or NON-contrast spiral CT scan of the abdomen and pelvis! How to prevent Ca stones? Increase fluid intake, decrease Na intake, thiazides, potassium citrate!, decrease protein intake How to prevent uric acid (rhomboid) stones? Potassium citrate! decrease red meat, fish, alcohol (no statins!)

Question 721

What happen if someone gets ↑Cr after a CFT scan? And if someone gets skin fibrosis after a brain MRI?

Answer 721

Contrast-induced nephropathy; can be prevented by N-acetylcysteine and fluids Nephrogenic systemic fibrosis due to gadolinium

Question 722

What valvular problems do you get on carcinoid syndrome?

Answer 722

TIPS: Tricuspid insufficiency/regurgitation Pulmonic stenosis

Question 723

Which thyroid tumor can present with diarrhea?

Answer 723

Medullary because it makes calcitonin

Question 724

When should you transfuse a patient?

Answer 724

When Hb is less than 7

Question 725

How can you pharmacologically treat an AV block? What should you avoid?

Answer 725

Tto: atropine Avoid: βb, Ca ch blokers and DIGOXIN

Question 726

Treatment for the most common arrhythmias: Vfib: VTach: SVT: Afib (2 easy piles)/Aflutter: Multifocal atrial tachycardia: Heart blocks: TdP: WPW: TCA toxicity:

Answer 726

Vfib: wide and unequal QRS: defibrillation=UNsynchronized cardioversion + Epi + Amiodarone * Most common cause of death in the period after an MI VTach: wide complex, irregular tachyarrhythmia No pulse: defibrillation=UNsynchronized cardioversion Unstable with pulse: synchronized cardioversion Stable with pulse: amiodarone!! SVT: narrow complex, regular tachyarrhythmia First: Vagal maneuver (carotid massage, blow into a straw, submerge head into cold water) Second: Adenosine 6 → 12 → 12 If it works to maintain the rate low: βb, verapamil, diltiazem Unstable: synchronized cardioversion Afib/Aflutter: 1) Less 2 days or hemodynamically instable: synchronized cardioversion 2) Everyone else: rate control (Beta blocker, verapamil, diltiazem) rhythm control (amiodarone) + anticoagulation Multifocal atrial tachycardia: 3 or more p wave shape in COPD: verapamil/diltiazem. Never Bb ``` Heart blocks First degree: long PR Mobitz 1: PR getting longer then drop beat No too Mobitz 2: PR long by same amount 3rd degree: total dissociation Pacemaker ``` TdP: Mg WPW: short PR and wide QRS, procainamide TCA toxicity: wide QRS, Na bicarb

Question 727

When should you do synchronized, unsynchronized cardioversion or just vasopressors?

Answer 727

Epinephrin/vasopressin every 5 min → asystole or pulseless electrical activity Unsinchornized = defibrillation → just for Vfib and pulseless!!! Vtach!!! unstable TdP Synchronized → Vtach with pulse and unstable, unstable supraventricular tachycardias IV amiodarone → Vtach with pulse and stable Vagal manœuvres or adenosine → stable supraventricular tachycardias

Question 728

Most common ECG finding in PE:

Answer 728

Sinus tachycardia | S1Q3T3 is not as common; suggests RV strain

Question 729

What do you have to give to someone that is on steroids 3 mo or more?

Answer 729

Bisphosphonates, because steroids cause bone loss

Question 730

When should you start screening for osteoporosis? What is the T score cutoff for osteoporosis?

Answer 730

Screening: Normal woman: DXA scan at 65 Younger woman with multiple RF: FRAX fracture risk assessment tool and if + you can do DXA scan T score: less than -2.5!! big negative numbers mean osteoporosis!!!

Question 731

Helicobacter pylori eradication treatment:

Answer 731

Triple therapy: Amoxicillin (Metronidazole if allergy) Clarithromycin PPI ``` Quadruple therapy: Metronidazole Tetracycline Bismuth subsalicylate PPI ```

Question 732

DD of Uncomplicated parapneumonic effusion, Complicated parapneumonic effusion and Empyema: vs Transudative vs exudative effusion:

Answer 732

Uncomplicated parapneumonic effusion*: MORE than ph 7.2, MORE than glucose 60, LESS than LDH 2/3 upper limit of normal, NO bugs → antibiotics Complicated parapneumonic effusion*: LESS than ph 7.2, LESS than glucose 60, MORE than LDH 2/3 upper limit of normal, NO bugs → Chet tube** + antibiotics * Effusion during a pneumonia Empyema: LESS than ph 7.2, LESS than glucose 60, MORE than LDH 2/3 upper limit of normal, BUGS → Chet tube + antibiotics ** If chest tube does not work thoracic surgery/ tpa These effusions can be transudative or exudative effusion: Transudative effusion; if you meet the 3 criteria: LDH less than 2/3 of normal, less than 0.5 ration of fluid/serum protein, less than 0.6 ration of fluid/serum LDH Exudative effusion: criteria not met Very low glucose on effusion: RA, TB, ca or empyema

Question 733

On which (2) pathologies do you see arteriovenous nicking?

Answer 733

Hypertensive retinopathy Renal A. stenosis (+ resistant HT) *Arterioles crossing a venules, which results in the compression of the venules with bulging on either side of the crossin

Question 734

Irritable bowel syndrome buzzword, how are the labs?

Answer 734

Abdominal pain relief with defecation No lab anomalies IBS: Constipation: induce diarrhea, senna Diarrhea: induce constipation, loperamide

Question 735

What is the most common arrhythmia in mitral stenosis? and in Graves (any hyperthyroidism)?

Answer 735

Afib

Question 736

Tto of bullous pemphigoid vs pemphigus vulgaris:

Answer 736

Bullous pemphigoid: Oral steroids | Pemphigus vulgaris: topical steroid

Question 737

What does 'thick endometrial stripe' means?

Answer 737

Endometrial thickening, can be due to: Proliferative phase of the cycle Pregnancy, ectopic pregnancy Endometrial hyperplasia or ca.

Question 738

Bilateral high frequency sensorineural hearing loss in young. Dx?

Answer 738

Noise-induced hearing loss due to cochlear hair cell damage (irreversible death of hair cells) RF: exposure to loud noises, military, manufacturing, mining

Question 739

Which antidepressant is less likely to cause weight gain?

Answer 739

Bupropion It is a mild stimulant associated with insomnia so give on depressed + sleepy + low energy and concentration Does not cause impotence Not fist line on pediatric depression Helps you stop smoking, patients should stop smoking completely one week after stating bupropion

Question 740

What is the treatment of radial head subluxation?

Answer 740

Forced hyper-pronation of the forearm

Question 741

What are the most likely causes of adrenal insufficiency on an HIV patient with low CD4?

Answer 741

``` CMV MAC TB Cryptococcus Metastasic Kaposi sarcoma ```

Question 742

What is an important ECG finding in Wenckebach?

Answer 742

group beating

Question 743

Which drugs can precipitate hyperosmolar hyperglycemic state?

Answer 743

Corticoids High-dose thiazides Sympathomimetics (dobutamine, terbutaline) 2nd generation antiphychotics

Question 744

When do you teat a fracture with open reduction and internal fixation?

Answer 744

Open reduction and internal fixation is done in: Displaced fx (minimally displaced femoral neck fx) Neuromuscular injury (humerus mineshaft fx with radial n. injury) → if you see soft signs of arterial injury do CT angio 1st! Open fx Distal clavicle fx Closed reduction and internal fixation/spica cast: other fx

Question 745

How do you treat deep vein thrombosis in pregnancy? How do you treat HIT in pregnancy?

Answer 745

DVT: Low molecular weight heparin (dalteparin, subcutaneous) because they do not cross the placenta HIT: fondaparinux

Question 746

Management of caustic ingestion?

Answer 746

Remove clothes Intubate if he cannot breath Upper Endoscopy on the first 24h Do not let him/her vomit

Question 747

Signs of glucagonoma:

Answer 747

D's: diarrhea, dermatosis, diabetes, deep vein thrombosis, and depression

Question 748

What is the treatment for QT-induced cachexia? What is the treatment for QT-induced vomiting? What is the treatment for HIV-induced cachexia?

Answer 748

QT-induced cachexia: progesterone analogs (megestrol acetate) and corticoids QT-induced vomiting: 1) Setrons HIV-induced cachexia: cannabinoids

Question 749

What CN deficits can you have after parotidectomy?

Answer 749

CN7 causing ipsilateral palsy of upper and lower face Will not cause hyperacusis because the stapedius nerve leaves the CN7 as soon as it exits the skull!

Question 750

Marginal bone (punched out) erosions and opaque periarticular soft tissue indicate: Periarticular erosions indicate:

Answer 750

``` Marginal bone (punched out) erosions and opaque periarticular soft tissue*: Gouty arthritis * Also overhanging edges ``` Periarticular erosions: RA

Question 751

Management of peripheral artery disease:

Answer 751

1) exercise 2) cilostazol 3) bypass sx

Question 752

WBC in joint fluid differential:

Answer 752

Less than 20: normal 200-2k: osteoarthritis 2k-10k: inflammatory (RA, crystals) >50k: septic arthritis, maybe gout

Question 753

What is the tto for most GI infections?

Answer 753

Amoxicillin + metronidazole + gentamicin | Ciprofloxacin + metronidazol

Question 754

What is the therapeutic range for lithium? Which drugs increase lithium levels?

Answer 754

0.6-1.2 mEq/L NAT: Thiazides, NSAIDs and ACE inhibitors and ARBs (lithium blood levels will be high) because they decrease GFR. Also tetracyclines and metronidazole. If a patient on Li has HT give him a Ca ch blocker (-ipines) except nifedipine (nifedipine can affect Li clearance especially in the context of renal insufficiency, if Cr is ↑ better use another medication)

Question 755

Serum sickness: | Dress sd:

Answer 755

Serum sickness: Fever, urticaria, artralgias, proteinuria 1-2w!! type 3hs Dress sd: Eosinophilia, rash, fever, facial, edema, high ALT 2-8w!!!

Question 756

Acne management:

Answer 756

1) topical retinoids: tazarotene: uncomplicated 2) topical benzoyl peroxide: uncomplicated 3) oral antibiotic (minocycline)/topical clindamycin 4) oral isotretinoin: severe (careful because is teratogenic and causes hepatotoxicity) OCPs in PCOS

Question 757

Timing of psychiatric diseases:

Answer 757

Acute stress: up to 1 mo. Tto: tx-focused CBT PTST: more than 1 mo * life threatening to you or others STRESS-PTST Adjustment: less than 6mo and stressor happened within 3mo Generalized anxiety: more than 6mo * psychosocial non life threatening stressor ADJUSTMENT-ANXIETY Tto: psychotherapy (CBT) +/- adjunctive pharmacotherapy for anxiety, insomnia, etc. Biref psychotic: up to 1 mo Schizophreniform: 1-6mo Schizophrenia: more than 6mo

Question 758

Where do you have urine Na less than 20 but concentrated urine? Why?

Answer 758

Prerenal azotemia | RAAs activation reabsorbs Na even if because low BP the is little RPF so little urine output and concentrated urine

Question 759

Subchondral sclerosis and cysts indicate: | What is the first line tto?

Answer 759

Osteoarthritis | 1) NSAIDs

Question 760

What is the treatment for seborrheic dermatitis?

Answer 760

Topical anti-fungal

Question 761

Which variant of FSGN is most frequent in HIV?

Answer 761

Collapsing variant, most aggressive variant

Question 762

CURB-65 criteria, what for? what are the criteria? what is their indication?

Answer 762

Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment ``` Confusion BUN > 19 mg/dL (> 7 mmol/L) Respiratory Rate ≥ 30 Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg Age above 65 ``` 0-1: outpatient 2: inpatient 3 or more: ICU

Question 763

Treatment of Methicillin-resistant Staphylococcus aureus and of pseudomonas?

Answer 763

``` MRSA: Vancomycin Clindamycin Linezolid Cefazolin Tetracyclines (doxycyclin) ``` Pseudomonas: Think about a MAN dressed as BATMAN on a CAR smoking a PIPE that is driving to his PIME where his coworker is asking what? DIME? but he ends up hitting a TREE that has a FLOWER on it that needs OXIGEN!!! to live carbaPENEms (imipemen, meropenem) PIPEracillin, CARbenicillin, tiCARcillin +BAcTam azTREEonan (monobactam) cefePIME (4th generation), ceftaziDIME (3rd generation) floxacins (fluorquinolones: ciprofloxacin, levofloxacin) mycins!! (aminoglycosides)

Question 764

Which drugs can cause myocarditis?

Answer 764

Trastuzumab, clozapine, doxo/donorubicine

Question 765

Where are the lymph nodes in mononucleosis and strep pharyngitis?

Answer 765

MONO: Posterior cervical Involves the spleen Rash with amoxicillin ``` STREP: Anterior cervical Acute CENTOR criteria (in adults): C: no cough, E: exudates, N: nodes (anterior cervical), T: temperature=fever 0-1: nothing 2-3: best initial test: rapid step test, if positive: amoxicillin*, if negative: culture 4: amoxicillin* * macrolide if allergic ```

Question 766

Most common cause of death on treated lupus patients? and untreated?

Answer 766

Treated: infections Untreated: kidney failure

Question 767

What should you avoid on Bernard-Soulier?

Answer 767

Transfusion of platelets because they do not have GP1b on their blood so they can make antibodies against the GP1b on the donor platelets and have anaphylaxis! Same can happen in hemophilia, they can make foe example antibodies again factor 8, this can cause anaphylaxis or make them need larger and larger amounts of factor 8 to correct their PTT over time

Question 768

What can cause both transudative and exudative effusions?

Answer 768

Pulmonary emboli

Question 769

Why do you get a wide S2 with mitral regurgitation? How do preload and afterload affect the murmur?

Answer 769

Because the aortic closes fast ↑ preload ↑ intensity ↑ afterload ↑intensity

Question 770

What are the different stages of decubitus ulcers and their treatment?

Answer 770

1, non-blanching redness: reposition every 2h 2, superficial ulcer: occlusive dressing 3, involvement of dermis and subcutaneous fat: debridement 4, muscle, bone tendons involved: debridement Give nutritional support

Question 771

Dx criteria and checkups for DM1:

Answer 771

Hemoglobin A1c of 6.5% or more Random glucose 200 + symptoms Fasting blood glucose of 126 or more on 2 occasions Every 3 mo: Hb A1c Every year: eye exam w. fundoscopy, foot exam, Albumin/Cr

Question 772

Management of GI bleed:

Answer 772

1) ABCs 2) IV fluids 3) Nasogastric lavage/intubation: if blood upper GI bleed → upper endoscopy and treat; if bile no upper GI so: 4) Colonoscopy, if -: 5) CT angiogram/tagged RBC exam

Question 773

RBCs in the CSF indicate:

Answer 773

Herpes encephalitis

Question 774

How do you treat septic and anaphylactic shock?

Answer 774

septic: NE + vanco + piperacillin-tazobactam/ceftriaxone for MRSA and pseudomonas anaphylactic: epi

Question 775

Vaccines given in adults:

Answer 775

Shingles: Older than 60 contraindicated in immunosuppressed, kids and pregnancy Pneumococcal: Older than 65 or pt younger but with heart, kidney liver disease or smoker Meningococcal: 12y 16y booster older than 18 if complement deficiency, asplenia, Meca dorm or military Influenza virus: 1/y HPV: in 11-12 yo w 2 doses separated by 6mo, but if the pt receives the vaccine after 15yo you need to give 3 doses

Question 776

Most common cause of end-stage renal disease? and the second? BP reduction threshold in a hypertensive crisis?

Answer 776

1) DM 2) HT 25% reduction in the 1st hour (with clevidipine, labetalol, nitroprusside...)

Question 777

How do you treat osteopetrosis?

Answer 777

INF-gamma, inactivates macrophages

Question 778

How do you treat COPD exacerbation?

Answer 778

How do you dx? increased dyspnea, cough and sputum change ``` Tto: SOS+Abs Steroids O2 SABA (bronchodilators) + Antibiotics (macrolides, fluoroquinolones or amoxi-clavulanate for 3-7days) ``` If pt is still using accessory muscles and remains dyspneic start noninvasive positive pressure ventilation If confused, hemodynamically unstable or very acidotic intubate

Question 779

Management and indications for synchronized cardioversion in A. fib/flutter:

Answer 779

Management: Unstable: synchronized cardioversion Stable: rate control by 1) IV metoprolol/ IV diltiazem/ 2) digoxin if decompensated HF (digoxin takes a long time to work)/ 3) IV amiodarone** or dofetilide 4) catheter ablation Rhythm control: Elective by cardioversion/amiodarone**: we do it on young patients that are very symptomatic Less than 48 h A.fib A.fib for longer but anti-coagulated for 3w and TEE does nor show emboli A. fib refractory to medical tto Emergent by cardioversion: A. fib and unstable

Question 780

What is Blumer shelf sign:

Answer 780

Gastric ca. that metastasizes to the anus

Question 781

What is the first line too for infantile spasms?

Answer 781

1) ACTH, because sometimes they are due to CRH overproduction and ACTH w. suppress CRH 2) corticoids 3) vigabatrin

Question 782

Which drugs do commonly cause type 1 HS reactions?

Answer 782

Penicillins, Quinolones, Vancomycin, Aspirin, NSAIDs!!! OPIATES, contrast, platinum-containing QT, muscle relaxants Tto: antiHistaminics/ steroids/ Epi

Question 783

Management of systolic vs diastolic heart failure:

Answer 783

Systolic: digoxin, dobutamine (dilated cardiomyopathy can be treated with βb, ACEi and diuretics) Diastolic: βb, Ca ch blockers (if βb contraindicated as in COPD)

Question 784

How do you know if a non-anion gap metabolic acidosis is due to renal losses or not?

Answer 784

1) Measuring the urine anion gap: Na+K-Cl Positive, also if Na in urine is equal or more than 20 → renal losses as in RTA Negative, also if Na in urine is LESS than 20 → diarrhea Little Na in urine means you are loosing Na somewhere else 2) Low K will discard type 4 RTA, all type 1,2 RTA and diarrhea will have low K! 3) Normal urine pH (around 5) will discard type 1 RTA

Question 785

What is the most common malignant tumor of the lacrimal gland? and benign?

Answer 785

Malignant: Adenoid cystic ca: irregular margins and bony erosions + painful Benign: pleomorphic adenoma: well-defined margins + No pain

Question 786

When should you give O2 supplementation? When should you give PPV? When should you intubate? What is the best indicator for extubation?

Answer 786

O2 supplementation indications: Burns w. carboxyhemoglobin more than 5-10% O2 sat less than or = 88% (PaO2 less than or = 55) O2 sat less than or = 89% (PaO2 less than or = 59) if cor pulmonale, RHF or low hematocrit *O2 improves survival in chronic severe hypoxemia at rest in COPD but smoking cessation improves mortality and decreases disease progression in all COPD ``` Positive pressure ventilation: COPD exacerbation Cariogenic pulmonary edema Acute respiratory failure (hypoxemia after sx, immunosuppressed) Facilitate early extubation ``` Intubation indications: Hypoxemia (PO2 less 60) PaCO2 more than 45 Ph less than 7.1 ARDS Upper airway obstruction (H. influenzae acute epiglotitis) Glasgow less or = 8 Burnt w. stridor, hoarseness Guillain-Barre with ↓ FVC of more than 20mL/kg/ severe dysautonomia/ wide pulse pressure Maxilofacial tx Combative or uncooperative High aspiration risk Cardiopulmonary failure, encephalopathy, big GI bleed You do intubation even when there is evidence of unstable cervical spine injury (you can do manual stabilization of the cervical spine) Extubation indications: pH > 7.25 (not retaining CO2) FiO2 40% or less and PEEP 5 mm Hg or less; PaO2 more than 60 Intact inspiratory effort and sufficient mental alertness If all good: Spontaneous breathing trial: best indicator for extubation is RR/TV less than 105 which means rapid shadow breathing index

Question 787

Malaria prophylaxis:

Answer 787

Chloroquine if Central America, Argentina, Paraguay or the Caribbean Mefloquine in chloroquine-resistant areas Doxycycline in cardiac conduction abnormalities, neuropsychiatric disorders and seizure disorders

Question 788

How do you treat bacterial vaginosis in pregnancy?

Answer 788

If asymptomatic do not treat | If symptomatic vaginal and oral clindamycin mor metronidazole

Question 789

How do you confirm the dx of measles?

Answer 789

IgG and IgM titters

Question 790

Candida treatment:

Answer 790

``` Thrush: topical nystatin/ clotrimazole troche + AIDS/pharyngeal involvement: azoles Esophagitis: azole Diaper rash: topical nystatin Vulvovaginal: topical azole Systemic: ampho B ```

Question 791

Management of a penetrating abdominal wound:

Answer 791

Exploratory laparotomy

Question 792

Lyme disease treatment:

Answer 792

Doxycycline (causes teeth discoloration, bone problems, photosensitivity so do not give it in kids) Amoxicillin!!! first line in younger than 8, pregnant and nursing (cefuroxime can be given because is oral) IV!!! Ceftriaxone/ cefotaxime/ Penicillin G: if severe or disseminated (if AV block, carditis, arthritis or neuroborreliosis)

Question 793

Which treatment can you give in patients with DVT and chronic kidney disease?

Answer 793

Unfractionated heparin Warfarin Apixaban None of the other!

Question 794

How do you differentiate an ulnar injury on the guyon canal vs on the cubital tunnel?

Answer 794

At the wrist: at the Guyon canal, due to hook of Hamate fracture; frequent in cyclists. Affects the palmar medial sensation and the intrinsic muscles of that region (fingers 4th and 5th) but the dorsal surface of the hand is spared! At the elbow: cubital tunnel!!! (paresthesias elicited by compressing the cubital tunnel) injured by hitting the funny bone, sleeping with the elbow very flexed or hemodialysis position. All the previous problems + the dorsal surface of the hand is also affected + decreased grip + medial deviation + forearm pain

Question 795

What is the management of A.fib?

Answer 795

Stable: HR more than 100 (rapid ventricular response) or A.fib that has not come back to sinus rhythm in 24h: rate control (β-blocker, verapamil, diltiazem)/rhythm control (amiodarone) + anticoagulation Chronic A.fib with HR less than 100: only anticoagulation if meets the criteria Unstable: A.fib lasting less than 2 days: synchronized cardioversion

Question 796

1st line for post-herpetic neuralgia:

Answer 796

Gabapentin

Question 797

Zinc deficiency sings:

Answer 797

Anosmia Alopecia Hypogonadism Dermatitis acroenteropathica

Question 798

Clinical picture of hidradenitis suppurativa:

Answer 798

Recurrent accesses in the axila and perineal region, inflammation of apocrine cell glands Frequent in diabetics Tto: clindamycin for staph. aureus

Question 799

DD between celulitis and erysipelas:

Answer 799

Celulitis: dermis+ subcutaneous fat. Caused by Staph aureus and strep pyogenes. Blend into the skin. Tto clindamycin Erysipelas: upper dermis+ superficial lymphatics. Caused by strep pyogenes. Acute and systemic involvement. Elevated

Question 800

What are the worse px factors in aortic stenosis form the least bad to the worst?

Answer 800

ASH: Angina → Syncope → Heart failure

Question 801

Heyde syndrome presentation:

Answer 801

AS+ GI bleed/angiodysplasia | You shear the VW when blood goes trough the aortic valve

Question 802

Treatment of CHF exacerbation? and of MI or unstable angina?

Answer 802

``` CHF exacerbation: 1) O2 Furosemide (lasix)!! ACEi Morphine Nitrates!! Positioning: sit up ``` ``` MI or unstable angina: BAPSONA Beta-blockers (verapamil if wheezing) Antiplatelet (aspirin+clopidogrel/tiaglecor/pasteugrel!!!) Percutaneous coronary intervention Statins O2 (if sat is less than 90 or in respiratory distress) Nitrates Anticoagulation (LMWH/bivalirudin) ``` After MI you go home with: BASAA: Beta-blockers, Antiplatelet (aspirin+clopidogrel!!!), Statins, ACEi, Aldo antagonists * In inferior MI you give IV fluids!!!! Do not give Beta-blockers, Nitrates or Diuretics. If IV fluids don't work give dopamine (better than dobutamine)

Question 803

Antibiotic cocktail for GI infections:

Answer 803

Cipro + Metronidazole or MAG: Metronidazole + Amoxicilin + Gentamicin Fluoroquinolones/macrolides are a good tto for diarrhea

Question 804

What is the fist best next step in management of PE? What is the treatment?

Answer 804

Low risk: D-dimer High risk: CT angiogram Pregnant: V/Q scan Stable: heparin Unstable: tap Unstable + recent sx/bleeding problem: embolectomy

Question 805

Treatment of hypocalcemia, hyponatremia and hypokalemia:

Answer 805

↓ Ca: IV Ca gluconate in extreme cases (not if renal failure)/ vit D ↓ Na: Initial tto: restrict fluids ± salt tablets/ normal saline! ± furosemide If seizures, coma (=acute) OR Na of less than 120: hypertonic 3% saline (max 8mEq/L/day)/ demeclocycline/ vapstams ↓ K: Low risk patient: 1) ECG 2) IV KCL until ~2.8 and ECG is normal (slow if IV) and them Oral until 3.5 High risk patient (digoxin, AF, dialysis): 1) ECG 2) IV KCL until ~3 and ECG is normal (slow if IV) and them Oral until 4.5 We do not give dextrose with K!!!

Question 806

Large number of small, red, macular lesions on the back arranged on a Christmas tree distribution:

Answer 806

Pityriasis rosea

Question 807

How do you protect the kidney when you do a high volume paracentesis?

Answer 807

Albumin

Question 808

Does smoking increase the risk of mesothelioma?

Answer 808

No

Question 809

Spontaneous peritonitis; ``` Most common cause: WBC limit: Management: Tto: Prophylaxis: ``` Peritonitis in peritoneal dialysis; MCC: Management: Tto:

Answer 809

Spontaneous bacterial peritonitis; MCC: E. coli!! klebsiella pneumoniae, step pneumoniae WBC limit: WBC more than 250 Management: 1) paracentesis + gram stain of the abdominal fluid. >250 neutrophils is Dx Tto: ceftriaxone/ ciprofloxacin Prophylaxis: ciprofloxacin+ albumin Peritonitis in peritoneal dialysis; MCC: gram + cocci and gram - bacilli Management: 1) gram stain of the abdominal fluid Tto: intraperitoneal cefazolin/vancomycin + 3rd generation cephalosporin

Question 810

How do you treat pseudohypoparathyroidism?

Answer 810

Supplement vit D and Ca

Question 811

What is the only positive marker during window period?

Answer 811

Hep B core antibody (IgM) You cannot find surface antigen or antibody!! Tto: supportive therapy

Question 812

DD between spinal pathology; strain, lumbar spinal stenosis, degenerative disk disease, cauda equina, conus medularis and spinal sock:

Answer 812

Strain: paraspinal tenderness. Tto: NSAIDs, physical therapy Lumbar spinal stenosis: old man with leg pain that improves when he gets out of bed in the morning Degenerative disk disease=sciatica: shooting pain, + straight leg test Cauda equina: LMN lesion (radiculopathy), normal Babinski Lumbar lesion, both L4 and S1 lost Tends to be more unilateral Conus=clonus medularis: UMN lesion (spinal cord lesion), affected Babinski Sacral, just S1 lost Tends to be bilateral ± impotence Both have saddle anesthesia, low back pain and involve the sphincters causing incontinence Spinal sock: Acute loos of spinal cord reflexes that come back Post-traumatic

Question 813

Palpable purpura, ↓complement, ↑monoclonal IgM. Dx? Association: Tto of the association:

Answer 813

Mixed cryoglobulinemia Association: Hep C Tto: sofosbuvir, ledipasvir/ pegylated interferon* + ribavirin * Screen for depression before you give interferon

Question 814

Ca. that tend to cause lytic bone lesions? and blastic lesions?

Answer 814

Lytic: MM, Lung ca, Renal cell, Thyroid Blastic (sclerotic): prostate

Question 815

What is the cause of hypersensitivity pneumonitis in a patient that works in a barn?

Answer 815

Thermophilic actinomyces

Question 816

Do you have to screen family members of MEN2 patients? and of MEN1 patients?

Answer 816

Screen for MEN2 but not for MEN1 (for MEN1 screening does not improve survival)

Question 817

Which electrolyte abnormalities exacerbate digoxin toxicity? Which drugs decrease digoxin clearance?

Answer 817

Electrolyte abnormalities: ↓K ↓Mg!!! Loops and thiazides increase digoxin toxicity because they cause ↓K ↓Mg! (digoxin blood levels will be normal!) Drugs that ↓ clearance are VAQ: Verapamil, Amiodarone and Quinidine (digoxin blood levels will ↑)

Question 818

What do you do if your patient has A.fib and needs sx?

Answer 818

Admit to the ICU to optimize the cardiac variables and then do the surgery

Question 819

Management of a PDA:

Answer 819

Small: indomethacin Big: surgical ligation by thoracotomy (if cardiac compromise, CHF...)

Question 820

What is a possible tto for acute severe CHF or in post-MI papillary m. rupture?

Answer 820

Intra-aortic balloon pump | Give IV nitroprusside in acute conditions until the balloon can be placed

Question 821

Name main cerebral herniations and symptoms:

Answer 821

Transtentorial=uncal; Temporal/uncal herniation beneath the tentorium cerebelli; there is blood accumulating anywhere in the supratentorial area. Associated with epidural hematoma Presentation: Early: ipsi blown pupil (CN3 affected)+contralateral hemiparesis Late: contralateral blown pupil+ipsilateral hemiparesis SUbfalcine; cingUlate gyrus herniation beneath the falx cerebri: awake + contralateral hemiparesis because compresses the anterior cerebral A. =) Tonsilar: tonsils in foramen magnum; compression medulla and death

Question 822

What are the demographics for Slipped capital femoral epiphysis and Legg Clave Perthes?

Answer 822

Both: Kid/adolescent with hip/knee pain and a limp Slipped capital femoral epiphysis: obese adolescents, older than 12. ±Tendrelemburg sign (if the adolescent is not fat you might see atrophy of the quadriceps and gluteus muscles) Dx: bilateral Rx showing displacement of the epiphysis from the metaphysis Legg Clave Perthes (= avascular necrosis of the femur): normal weight kids, less than 12. Initial Rx can be nr, later you see femoral head sclerosis and fragmentation. ±Tendrelemburg sign

Question 823

Autopsy finding in sudden infant death syndrome:

Answer 823

Intrathoracic petechiae or pulmonary edema

Question 824

What is the best next step in management in a patient with hairy leukoplakia?

Answer 824

HIV test

Question 825

What is the first line tto of allergic conjuntivitis? and of bacterial conjuntivitis?

Answer 825

Allergic: Topical ketotifen (combination of H1 blocker + mast cell stabilizer) Bacterial: Sulfa ophthalmic drops (erythromycin ointment in children)

Question 826

Indications for the meningococcal vaccine:

Answer 826

Adolescents 11-18 y.o. Individuals at high risk of exposure (military, college students in residential housing, traveller to an endemic area, exposure to community outbreaks) Immunodeficiency (asplenia, complement deficiency, HIV)

Question 827

How do you calculate MAP?

Answer 827

1/3 systolic + 2/3 diastolic

Question 828

When is streptokinase contraindicated?

Answer 828

If you have given it on the past because it can cause sensitization/allergic reaction in re-exposure, just use a different fibrinolytic agent

Question 829

ECG pattern on right axis deviation:

Answer 829

A + R in lead 3, the QRS is inverted and low RSR’ pattern in V1-3

Question 830

What are the (2) possible SE of indomethacin tocolysis?

Answer 830

``` Transient oligohidramnios (due to decrease renal perfusion) Premature closure of the ductus arteriosus ``` Give it for less than 48h

Question 831

DD between atelectasis, PE and ARDS:

Answer 831

Atelectasis: within less 24h, diffused or localized, collapsed, tto: deep breathing, give analgesics to decrease the pain and allow breathing Tto: deep breathing, sitting upright or incentive spirometry to expand the lungs PE: later than 24h, tachycardia, big hypoxemia, a lot ARDS: within a week, PaO2/FiO2 ratio of less than 300 (the lower the worse), big hypoxemia, bilateral opacifications

Question 832

Management of postpartum hemorrhage:

Answer 832

1) fundal massage 2) oxytocin (3) ergots) 4) tranexamic acid!! 5) prostaglandins (carboprost): not in asthma 6) balloon tamponade 7) embolization 8) hysterectomy

Question 833

Which bug causes acute pericarditis?

Answer 833

Coxsackie B

Question 834

What should you do if you see bradycardia?

Answer 834

ECG to confirm sinus bradycardia, then if it is sinus bradycardia and is asymptomatic you do nothing

Question 835

ECG patter of Lown-Ganong-Levine (LGL) syndrome:

Answer 835

Accessory pathway that connects the atria to the bundle of His causing a re-entrant tachycardia with short PR and NO delta waves and normal QRS

Question 836

ECG patter of Brugada syndrome:

Answer 836

Young asian patient with a pseudo-RBBB and ST elevation in V1 and V2

Question 837

Management of tdp?

Answer 837

1) Mg | 2) Metoprolol

Question 838

ECG patter of hypothermia:

Answer 838

Osborn wave (convex hump at the J-point)

Question 839

Differential diagnosis of genital lesions and treatment:

Answer 839

Treponema pallidum, syphilis: painless chancre w rolled hard edge (usually single but can be multiple especially if HIV+) and painless bilateral lymphadenopathy. Micro: corkscrew. Tto: Penicillin 0 Klebsiella granulomatis: granuloma inguinale or donovanosis: painless nodule that ulcerates (beefy red) and can bleed (PSEUDObubon) WITHOUT lymphadenopathy. In Africa. Giemsa, intraCYTOPLASMATIC bipolar ~🧷 staining. Tto: doxy/macrolide 0 Clamydia trachomatis (L): painless ulcers→ tender painful lymphadenopathies that ulcerate (buboes) lymphogranuloma venereum. In Latin America and Africa. Micro: Giemsa, intraCYTOPLASMATIC. Tto: Doxy 1 Haemophilus ducreyi: chancrOID, deep purulent painful ulcers (papule→ pustule→ ulcer→ BLEEDING) with ragged borders, GRAY base and SUPPURATIVE inguinal lymphadenitis. Micro: clumping, school of fish. Tto: ceftriaxone/macrolide 2 HSV2: superficial ITCHY painful vesicles or ulcers w erythematous base (but do not bleed) and tender lymphadenopathy (but not suppurative) ± discharge ± constitutional symptoms (FEVER, malaise). Heal in 10 days. Easier to get AIDS. Micro: intraNUCELAR and multinucleated cells. Tto: acyclovir 2

Question 840

Pronator drift indicates which lesions?

Answer 840

Down: pyramidal lesion, UPN lesion Up: cerebellar lesion

Question 841

Which fetal abnormalities are associated with DM in pregnant?

Answer 841

Non-gestational DM (first trimester): caudal regression sd (sacra agenesis), small left colon (meconium plugging), CNS and cardiac abnormalities Gestational DM (2nd-3rd trimester): fetal macrosomia (cesarean if more than 5000g), transient hypoglycemia, ↓Ca, ↓Mg, polycythemia, jaundice, asymmetric septal hypertrophy*, respiratory distress syndrome * perihilar vessels, fluid in the lung fissures and expanded lungs

Question 842

MC complication of parenteral nutrition:

Answer 842

1) Infection | 2) Cholestasis and galstones

Question 843

What is the treatment for botulism?

Answer 843

Baby: IG Adult: equine anti-toxin

Question 844

Management of anal ca:

Answer 844

RT + QT

Question 845

Management of MS:

Answer 845

1) INF-β Natalizumab Glatiramer Exacerbation: 1) Corticoids, plasmapheresis if pt doesn't respond

Question 846

How do you treat candidiasis in pregnant?

Answer 846

Intravaginal ketokonazole, because fluconazole is contraindicated in pregnancy

Question 847

Which immunodeficiency presents with high α-FP?

Answer 847

Ataxia telangiectasia

Question 848

Tto of acute chest syndrome in sickle cell?

Answer 848

Plasma exchange

Question 849

Which is the most common type of ovarian mass in young women of reproductive age? And in pregnant? And in complete mole?

Answer 849

Non-pregnant ± PCOS: Follicular cyst (cause irregular bleeding). No vascular Normal in pregnant: Corpeus luteum cyst. Vascular Complete mole or twins: Theca lutein cyst (bilateral)

Question 850

Watery diarrea after 12-48h?

Answer 850

Norovirus, delayed! B. cereus and S. aureus start 6h after eating Norovirus is now is the number 1 cause of diarrhea in kids because of the rotavirus vaccine! Norovirus is not killed by hand-sanitizer

Question 851

What is the most common type of thyroid adenoma? and of thyroid carcinoma?

Answer 851

Adenoma: follicular adenoma Ca: papillary ca.

Question 852

What happens right after you inject insulin on a healthy patient?

Answer 852

Hypoglycemia. The body will try to compensate! by increasing glucagon (even if in normal physiology insulin suppresses glucagon), GH and epi

Question 853

What ate the causes (2) of blunted response to hypoglycemia?

Answer 853

β-blockes use | Long lasting DM1 causing autonomic failure

Question 854

Features of MMD:

Answer 854

``` 'SIG E CAPS' S = Sleep I = Interest G = Guilt E = Energy C = Concentration A = Appetite P = Psychomotor S= Suicidal ideation ``` Al leasts 5 symptoms for 2w or more than 2w is MMD

Question 855

Tto for genito-pelvic pain/penetration disorder:

Answer 855

It is the involuntary contraction of the outer 3rd of the vagina interfering w. intercourse Kegel exercises Vaginal dilators Relaxation techniques

Question 856

What is the key way to differentiate Berger's disease and hemolytic-uremic syndrome? And what is the key way to differentiate ITP and hemolytic-uremic syndrome

Answer 856

All can present with red urine after a GI infection on a kid DD with Berger's: Look at the platelets! in Berger's they will be normal and in HUS will be low! DD with ITP: platelets will be low in both but ITP will not have schistocytes on the smear

Question 857

Patient presents with arm adduction and internal rotation with the hand resting in the anterior chest wall after tx. Dx?

Answer 857

Posterior shoulder dislocation

Question 858

What is the 1st best step in management after clinical evaluation consistent with posterior urethral valves? and the best dx test?

Answer 858

NBSM: place urethral catheter | Best dx test: voiding cystourethrogram!!

Question 859

How can you clinically differentiate Conn sd. from adrenal hyperplasia?

Answer 859

In Conn syndrome changes in posture do not affect Aldo secretion while in adrenal hyperplasia changes in posture can affect Aldo secretion

Question 860

Best initial dx. test for 21-hydroxylase deficiency?

Answer 860

17-ketosteroids in urine!!

Question 861

Ergotamine possible SE:

Answer 861

Can worsen prinzmetal angina HT Retroperitoneal fibrosis (especially if associated w. smoking)

Question 862

How can you differentiate Phencyclidine from Bath salts intoxication?

Answer 862

Both cause aggressive behavior Phencyclidine wears off after 2 days and causes nystagmus Bath salts lasts longer, no nystagmus, you cannot found anything in the urine

Question 863

Main SE of Cannabis and Extacy:

Answer 863

Cannabis can last in the urine for 1mo and causes imponetnce Ecstasy causes hyponatremia

Question 864

Difference between Cooper and Progestin based DUI:

Answer 864

Cooper: Lasts 10 years Contraindicated in Wilson's, dysmenorrhea, menorrhagia, recent history of STD and active pelvic inflammation, distorted uterine cavity (submucosal leiomyoma) but do not remove if small Progestin based= Mirena: Lasts 3 years If they want to be pregnant soon after taking it off Also contraindicated in recent history of STD

Question 865

DD of myopathies based on ESR and CK:

Answer 865

Polymyositis and dermatomyositis: ↑ ESR and CK (Anti-Jo bad px and pulmonary fibrosis; Anti-Mi good px) Polimialgia reumatica: ↑ ESR nr CK!!!! Cushing: nr ESR and CK Statin used and hypothyroidism: nr ESR ↑CK

Question 866

What is the MCC of liver abscess?

Answer 866

Cholangitis (pol microbial: E. Coli, Klebsiella, strep)

Question 867

What is another name for mom's thumb? What is the associated test? What is the tto?

Answer 867

De Quervain tenosynovitis=radial styloid tenosynovitis, it is a tenosynovitis to the abductor or dorsal EXTENSOR tendons of the thumb: Extensor pollicis brevis! Pain with adduction (ulnar deviation) of the wrist due to stretching of the tendons over the radial styloid + Finkelstein test (pain if you put thumb inside closed fist and force the wrist into ulnar deviation) Tto: steroid injection

Question 868

Genital complication of DM:

Answer 868

Fournier gangrene: polymicrobial flora form the genital track infects the external genitals

Question 869

Management of neuroleptic malignant syndrome and serotonin syndrome?

Answer 869

Neuroleptic malignant syndrome: 1) Stop the drug + supportive tto 2) Bromocriptine (or amantadine) 3) Benzodiazepine 4) Dantrolene (more for malignant hyperthermia in the OR) Serotonin syndrome: 1) Stop the drug + supportive tto 2) Benzodiazepine 3) Cyproheptadine

Question 870

Treatment and MCC for bacterial conjuntivitis in adults:

Answer 870

Topical erythromycin | MCC: Staph aureus → Strep pneumo → Haemophilus

Question 871

How can you prevent the thickening of the skin in scleroderma?

Answer 871

D-penicillamine

Question 872

How do you threat abdominal and joint pain in Henoch-Schonlein purpura?

Answer 872

Corticosteroids

Question 873

Name 2 weird loop diuretics and 3 weird thiazides:

Answer 873

Loop: bumetanide, ethacrynic acid (-mides) Thiazide: metolazone, chlorthalidone (+ potent), indapamide (-thiazide)

Question 874

Schilling test possible results:

Answer 874

Give B12 and you see B12 in the urine: dietary deficiency Give B12+IF and you see B12 in the urine: pernicious anemia Give B12±IF and you do not see B12 in the urine: malabsorption/ diphyllobothrium latum

Question 875

What is the most common presentation of HCOM?

Answer 875

Dyspnea

Question 876

Which dose of acetaminophen can already be toxic in kids?

Answer 876

90 mg/kg

Question 877

What is the management of an ankle fracture?

Answer 877

Bimaleollar ~ displaced: 1) closed reduction and splinting → open reduction and internal fixation when soft tide edema has resolved Non-displaced: close reduction and casting

Question 878

How many abnormal semen analyses do you need before male infertility is diagnosed?

Answer 878

2

Question 879

DD of esophageal atresia ± TEF:

Answer 879

No blind pouch: esophageal atresia with NO distal TEF Blind pouch with distended stomach and: esophageal atresia + distal TEF Insidious presentation ~ GERD and nasogastric tube can reach the stomach: TEF with NO esophageal atresia

Question 880

Management of caustic ingestion:

Answer 880

1) Secure the airway 2) Chest and abdominal Rx 3) Copious IV fluids

Question 881

How long after ingestion should plasma acetaminophen be measured?

Answer 881

More or = to 4h, before that time the levels are nor interpretable because acetaminophen absorption may be delayed in overdose

Question 882

Management of CO poisoning:

Answer 882

Below 40% + no CV or neurological impairment: 100% O2 for 4h, if it doesn't work go to hyperbaric Above 40% or with CV and neurological impairment: hyperbaric O2 at 3 atmospheres

Question 883

BNSM in bright-red blood per rectum?

Answer 883

Nasogastric tube to aspirate gastric contents: If red or white fluid is returned it means is an upper GI bleeding → endoscopy If green fluid is returned is not an upper GI bleeding → anoscopy

Question 884

What is it placed after cricothyroidotomy in adults and kids?

Answer 884

Adults: cricothyroidotomy + tube Kids: cricothyroidotomy + cannula

Question 885

Baby with noisy breathing that improves when lying prone. Dx? Main physical exam finding? Management?

Answer 885

Laryngomalacia Main PE finding: inspiratory stridor!* all stridors are inspiratory except the vascular ring one and the one in complicated croup Dx test: flexible fiberoptic laryngoscopy that shows a collapsed supraglottic structures during inspiration and an Ω-shaped epiglottis Management: observation because it resolves by 2y.o.

Question 886

Best test to dx Becker and Duchenne:

Answer 886

Genetic analysis

Question 887

What is the treatment for diabetic neuropathy in DM?

Answer 887

SNRIs: not if the patient is on another serotoninergic agent Tricyclic antidepressants: do not use in heart conduction abnormalities or if the patient is on another serotoninergic agent Pregabalin

Question 888

DD. between hordeolum and chalazion:

Answer 888

Hordeolum: Painful! purulent inflammation of the eyelid. 2 forms: External hordeolum or stye, arises from the glands of Moll/Zeis Internal hordeolum (less common) is an inflammation of a meibomian gland, most typically at the palpebral conjunctiva Chalazion: Non-painful! firm, rubbery, and nonpurulent nodule on the eyelid

Question 889

Edema, pruritus, vesicles, and ulcers localized to the buccal mucosa directly in contact with recently installed orthodontic brace. Dx?

Answer 889

Allergic contact dermatitis

Question 890

What is the cause of a Zenker diverticulum? What is the confirmatory test and the tto?

Answer 890

Abnormal esophageal motor function; because esophageal spastic motility can result in inadequate relaxation of the upper esophageal sphincter and increased intraluminal pressure which causes outpouching of the pharyngeal wall Confirmatory test: barium swallow fluoroscopy ± endoscopy to rule out malignancy Tto: cricopharyngeal myotomy and diverticulectomy

Question 891

How do you treat lumbar spine prostate ca. metastasis?

Answer 891

Castration-sensitive: leuprolide Castration-resistant: external beam radiotherapy to the lumbar vertebrae ± zoledronic acid (bisphosphonate)

Question 892

1) Young boy with persistent nasal congestion with purulent discharge as well as facial pain over the maxillary sinuses with opacification upon transillumination. Dx? 2) Adult with gradually developing bilateral nasal obstruction, postnasal drip and impaired olfactory function. Dx? 3) Young boy with unilateral and foul-smelling nasal discharge, nasal congestion, and facial pain. Dx?

Answer 892

1) Acute bacterial rhinosinusitis 2) Nasal polyps. Associated with chronic rhinosinusitis. 3) Foreign body

Question 893

Young man presenting with scrotal pain and fever, swelling, crepitus, and skin necrosis of the scrotum. Dx? Management?

Answer 893

Fournier gangrene. If hypotension and tachycardia this k about septic shock Management: aggressive debridement of the affected tissue

Question 894

Which technique is associated to less catheter-associated urinary tract infections?

Answer 894

Intermittent catheterization

Question 895

Radiologic finding of pseudomembranous colitis:

Answer 895

Dilation of the colon with loss of haustration (toxic megacolon)

Question 896

Kid with abdominal pain, arthritis, and raised rash. Dx?

Answer 896

IgA vasculitis (Henoch-Schonlein purpura)

Question 897

What is another name for small vessel vasculitides?

Answer 897

Leukocytoclastic vasculitis

Question 898

When should you test for N. gonorrhoeae and C. trachomatis?

Answer 898

In sexually active women < 24 years of age and older women with specific risk factors (e.g., women with new or multiple sex partners)

Question 899

What is the management of slipped capital femoral epiphysis?

Answer 899

Surgical pinning of femoral head placement of 1–2 pins through the femoral neck into the epiphysis Conservative management alone is not ok because the lesion can become unstable, which is associated with a high risk of avascular necrosis of the femoral head

Question 900

When do you transfuse platelets?

Answer 900

Severe active bleeding: if platelet count < 50,000/mm3 (< 100,000/mm3 in the case of intracranial bleeding) Non-life-threatening bleeding: if platelet count of < 30,000/mm3 Rapid blood loss (usually due to surgery or trauma) Bleeding prophylaxis: if platelet count < 10,000/mm3 (< 50,000 mm3 if the patient is about to undergo a procedure)

Question 901

How do you treat dermatitis herpetiformis?

Answer 901

Oral dapsone and strict adherence to a gluten-free diet

Question 902

Sepsis + string of pearls in the centrum semiovale on MRI. Dx?

Answer 902

Watershed infarction | RF: internal carotid stenosis

Question 903

Dx test for urolithiasis:

Answer 903

CT without contrast, Ultrasound (if emergency, kid or pregnant) No Rx!

Question 904

Prophylaxis for premature babies:

Answer 904

Less than 32 w: β-methasone (↑risk of diabetic ketoacidosis, needs a few hours to work) Penicillin* Indomethacin for tocolysis IV MgSO4 (4 h before delivery) Screening with head ultrasound at 1-2w of age 32-34 w: β-methasone Penicillin* Ca ch blockers for tocolysis!! 34-37 w: β-methasone Penicillin* * if + or unknown

Question 905

Causes of papillary necrosis

Answer 905

``` SAADO: Sickle Acute pyelonephritis Analgesics DM Obstructive uropathy ```

Question 906

What is the most common complication of varicella in immunocompromised?

Answer 906

Varicella pneumonia

Question 907

Management of foreign-object airway obstruction in kids:

Answer 907

If breaths and coughs: observation If cannot cough: airway positioning → ventilation → back blows → chest thrusts if less than 1yo/abdominal thrusts if more than 1yo Complete obstruction/respiratory failure: intubation ± tracheostomy

Question 908

How do you decide if a sore throat is strep?

Answer 908

With the Center criteria: ``` Fever Tonsillar exudate Absent cough Anterior cervical lymphadenopathy Age 3-14 ``` 2-3: rapid strep test and treat if positive 4: treat (penicillin V for 10 days, you can give 1 dose of pen G if possible loss in follow up)

Question 909

Young patient presents with thumb tenderness, warmth, swelling after thumb sx. Dx? What are the best initial test and the gold standard?

Answer 909

Osteomyelitis Best initial test: nuclear bone scan Gold standard: biopsy and culture

Question 910

Cause, location, muscles and nerve that may be affected by tennis and golf elbow:

Answer 910

``` Tennis: Lateral epicondylitis Repetitive wrist extension (supination) Radial n. impingement Muscles that can be affected: EXTENSORS; mostly the extensor carpi radials brevis, extensor digitorum, extensor digitized minimi and extensor carpi ulnaris (not the extensor carpi radials longus) ``` ``` Golf: Medial epicondylitis Repetitive wrist flexion (pronator) Median n. impingement Muscles that can be affected: FLEXORS ```

Question 911

Which type of fluid should be given to a burn patient? What should we do to prevent wound infections?

Answer 911

Ringer's lactate; normally we use the Parkland formula to estimate the amount of fluid needed After fluids are given give early nutritional support with enteral nutrition (30kcal/kg/day and 1g/kg/day of protein), enteral nutrition is also the answer for critically ill patients (ICU)! TPN is only for pt with contraindications to enteral nutrition as intestinal discontinuity or prolonged ileus Intubate if shout around the mouth bc the airway could be burn, get also a carboxyhemoglobin IV PPIs Cut circumferential scars If genital burns or burns of a large surface area place a catheter Irrigation and gentle gauze debridement but if full-thickness burns do early wound excision and grafting to prevent wound infections Silver Sulfadiazine (antibiotic and occlusive) and non-stick dressing

Question 912

Plantar fasciitis dx keys:

Answer 912

Pain in the anteromedial aspect of the heel Calcaneus compression does not cause pain Pain with dorsiflexion!!

Question 913

What is the treatment for infection in a burn patient?

Answer 913

Cefepime or other antipseudomonal antibiotics | Vancomycin to cover MRSA

Question 914

What should you do if you see absence of distal deep tendon reflexes in the elderly?

Answer 914

Nothing, peripheral nerve dysfunction is very common among elderly individuals.

Question 915

What is the most common cause of back pain on the 3rd trimester?

Answer 915

Relaxation of the pelvic girdle ligaments

Question 916

What type of amnesia is associated to electroconvulsive therapy?

Answer 916

Retrograde amnesia

Question 917

CHA2DS2-VASc score:

Answer 917

``` Congestive heart failure Hypertension Age ≥ 75 years (2 points) Diabetes mellitus Stroke or TIA or thromboembolism (2 points) Vascular disease (prior MI, peripheral artery disease, or aortic plaque) Age 65–74 years Sex category (female sex) ``` 0-1: low risk, observation 1-2: intermediate risk, consider aspirin or anticoagulation ≥ 2-3: high risk, anticoagulate

Question 918

What is the main electrolyte abnormality secondary to adrenal insufficiency related to corticosteroid withdrawal?

Answer 918

Hyponatremia, here there is nor hyperkalemia or metabolic acidosis as normal aldosterone secretion is still preserved Here there is mainly loss of cortisol which leads to an increase in circulating ADH, which results in free water retention and hyponatremia

Question 919

What is the most effective pharmacotherapy for reducing the frequency of anginal episodes in stable angina?

Answer 919

β-blockers

Question 920

What is the treatment of C. difficile?

Answer 920

1st test is toxin on stools Best test: PCR 1st episode: oral vancomycin/oral fidaxomicin for 14-21 days (oral vanco is cheaper) 2nd episode: change drug oral fidaxomicin/oral vancomycin Resistant: oral vancomycin followed by rifaximin/ fecal transplant Fulminant colitis: IV metronidazole + oral vancomycin

Question 921

What should you do on a patient with severe burns and soot within the nose and mouth?

Answer 921

Intubation and mechanical ventilation

Question 922

Kid with abdominal distention, nausea, vomiting and large gastric bubble seen on abdominal CT after a tx. Dx? Tto?

Answer 922

Upper intestinal obstruction due to a duodenal hematoma Tto: nasogastric decompression and total parenteral nutrition if hemodynamically stable. They resolve in 3-4w

Question 923

What does a positive apnea test indicate? What is it?

Answer 923

Brain death After preoxygenation with 100% oxygen, the patient is disconnected from the ventilator and observed for evidence of respiratory drive (such as gasps or chest movement). After 8–10 minutes, an arterial blood gas reading is obtained. If the PCO2 is elevated above normal levels, this signifies an absence of respiratory drive, and the apnea test is considered positive

Question 924

What should you suspect if you see menorrhagia and dysmenorrhea in a multiparous woman with a diffusely enlarged and tender uterus?

Answer 924

fosis

Question 925

Respiratory distress immediately after birth in a neonate born through meconium-stained amniotic fluid. Dx? Main complication? Prevention? Tx?

Answer 925

Meconium aspiration syndrome (MAS) Main complication: persistent pulmonary hypertension of the newborn Prevention: amnioinfusion Tx: O2 to avoid pulmonary vasoconstriction

Question 926

Tachypnea and crepitus after a gun shot indicates?

Answer 926

Pneumothorax

Question 927

What is the target PTT on DVT prophylaxis? and in DVT?

Answer 927

DVT prophylaxis, surgery, CHF, MI: less than 1.5 DVT or PE: 1.5-2.5

Question 928

Name a complication of B12 or folate replacement:

Answer 928

Hypokalemia Causes of hypokalemia: beta-agonists, insulin, carbohydrate loading, alkalosis, diarrhea, loops, thiazides, Aldo, hypomagnesemia, RTA 1 and 2, ampho B, cisplatin

Question 929

Main characteristics of Achilles tendon rupture:

Answer 929

Pop, swelling and tenderness on the posterior leg | Positive Thompson test: absence of plantar flexion when the gastrocnemius is squeezed

Question 930

What is the first EKG abnormality in TCA intoxication?

Answer 930

Widen QRS

Question 931

Quick way to differentiate RTA types:

Answer 931

Check plasma K; if high is type 4 | If it is low check the urinary pH; if low (less than 5.5) is type 2 if high (more than 7) is type 1

Question 932

What is first use syndrome?

Answer 932

Chest pain + back pain + anaphylaxis in dialysis; it is an allergic reaction to the membrane used in dialysis

Question 933

How is the Y descent in tamponade and in constrictive pericarditis:

Answer 933

Blunted/ absent y descent: tamponade Exaggerated y descent: constrictive pericarditis

Question 934

Treatment of whipple's disease:

Answer 934

Ceftriaxone for 2w + TMP-SMX for 2 years

Question 935

Severe abdominal pain and distention in a 60 yo male septic patient. There is no obstructing lesion on CT scan. Dx? Tto?

Answer 935

Ogilvie syndrome, colonic pseudoobstruction Classical findings: constipation, obstipation, abdominal distention and dilated LARGE bowel (COLON) Tto: urgent colonoscopic decompression followed by IV neostigmine. If it does not resolve or it perforates → laparotomy

Question 936

Desaturate when stand or start walking and normal saturation when sitting. Dx?

Answer 936

Orthodeoxia platypnea syndrome in hepatopulmonary syndrome

Question 937

What are the antibodies in autoimmune hepatitis:

Answer 937

Type 1: anti-smooth muscle (cal also be elevated in sclerosing cholangitis) Type 2: anti-LKM (liver, kidney microsomal antibodies) Tto: corticoids

Question 938

What do you do after a needle stick of an HIV patient?

Answer 938

Raltegravir + tenofovir + emtricitabine for 4 mo

Question 939

What do epithelial casts indicate?

Answer 939

ATN, toxic ingestion, CMV infection

Question 940

Macular rash that develops centrally on the trunk and spreads outward to the extremities sparing the face, palms, and soles. Dx?

Answer 940

Rickettsia prowazekii, epidemic typhus

Question 941

Infections associated with Bell's palsy:

Answer 941

HSV EBV Influenza B Lyme

Question 942

Fever, drooling, hot potato voice, ipsilateral otalgia, contralateral uvular deviation and trismus (lockjaw). Dx? Tto?

Answer 942

Peritonsillar abscess Tto: drainage + oral antibiotics D.D: Retropharyngeal abcess is similar but without uvular deviation, you get neck stiffness, torticolis. You need an Rx of the neck w head extension! showing widened prevertebral space. CT w contrast. Tto: drainage + oral antibiotics

Question 943

How do you treat gonorrhea? and if the patient is allergic to penicillin? and in pregnant?

Answer 943

Ceftriaxone + azithromycin Allergic to penicillin: azithromycin + gemifloxacin Pregnant: IV cefotetan + IV azithromycin (for chlamydia)

Question 944

Congenital inspiratory stridor that starts at 1 or 2 mo that increases in supine position and when the baby is agitated. Dx?

Answer 944

Laryngomalacia; is the MCC of congenital stridor Tto: H2 blockers, will resolve at ~ 1 yo

Question 945

Metabolic panel in vomiting and diarrhea:

Answer 945

↓Cl in vomiting ↑Cl in diarrhea! Vomiting: Metabolic alkalosis with low urinary Cl ↓ Na, K, H, Cl ↑ Bicarb (contraction alkalosis because of ↑AT2 that ↑ Na/H exchange int he PCT and ↑aldo that ↑ H secretion by α-intercalated cells) Diarrhea: No anion gap metabolic acidosis ↓ K, Na and bicarb. Worry about hypoNatremia if just drinking water especially if baby → seizures. But worry about hypoKalemia with laxative abuse ↑Cl (compensation for ↓ bicarb) Give glucose and salt because glucose is co-transported into enterocytes via Na

Question 946

What is the management of Colles fracture?

Answer 946

Closed reduction with volar splint, even if the radial pulse is absent as close reduction of teen resolves most neurovascular deficits

Question 947

How do you treat community acquired pneumonia? and in an alcoholic?

Answer 947

Monotherapy with macrolide, fluoroquinolone or doxycycline | Alcoholic: fluoroquinolone/ beta-lactam + macrolide

Question 948

Management of a pelvic fracture in a hemodynamically unstable patient?

Answer 948

External fixation, can be with a pelvic binder that is wrapping bedsheet around the pelvis

Question 949

Frail chest dx criteria:

Answer 949

Fx of 3 or more adjacent ribs in 2 places so there is a floating chest segment If criteria are not met consider pulmonary contusion

Question 950

Management of post-operative ileus:

Answer 950

Bowel decompression with nasogastric tube

Question 951

Management of corneal abrasion:

Answer 951

1) Meticulous eye inspection with topical anesthetic and removal of foreign body if present 2) Fundoscopy + fluorescein slit-lamp examination 3) Topical antibiotic + monitoring

Question 952

What do you hear in laryngospasm and bronchospasm:

Answer 952

Laryngospasm: high pitch sound during inspiration, stridor Bronchospasm: musical sound during expiration, wheezing

Question 953

Kid with palpitations, fatigue, condition defects and tricuspid regurgitation murmur. Dx?

Answer 953

Epstein abnormality

Question 954

EKG findings in hyperkalemia, form early to late findings:

Answer 954

Tall peaked T waves (6) → P wave becomes flat and broad (7) → PR prolongation → QRS widening (Sine wave pattern) (8)→ QT interval shortening → Asystole

Question 955

Which type of uveitis do you see in Crohn's?

Answer 955

Anterior nongranulomatous uveitis (in all systemic inflammatory diseases)

Question 956

Which drugs should you avoid in aortic stenosis?

Answer 956

Diuretics, because they decrease preload

Question 957

What is the most specific finding for right-sided MI? and of inferior wall MI?

Answer 957

Right-sided: V4R; ST segment elevation in V4 | Inferior wall: ST segment elevation in leads II, III and aVF

Question 958

Management of orbital cellulitis:

Answer 958

1) CT/ MRI of the orbit | IV ampicillin

Question 959

Characteristics of the 4 types of decubitus ulcers:

Answer 959

1: intact skin 2: superficial epidermis ± dermis 3: full thickness skin loss 4: bone and muscle are visible

Question 960

What are the characteristic radiologic findings in CHF?

Answer 960

Cephalization Kerley B lines Cardiomegaly Pleural effusion

Question 961

Microaneurysms, hard exudates, macular edema, cotton wool spots and dot and blot hemorrhages in fundoscopy indicate:

Answer 961

Non-proliferative diabetic retinopathy

Question 962

Which ribs will hurt the kidneys? and the spleen and liver?

Answer 962

Right kidney: 12 (L1-L4 level) Left kidney: 11, 12 (T12-L3 level, the splenic flexure is situated anteriorly) Right liver: 8, 9, 10, 11 Left spleen: 9, 10, 11

Question 963

what is the most common cause of intraoperative laparotomy?

Answer 963

Body temperature of less than 35 degrees

Question 964

What is a possible complication of displaced supracondylar fractures of the humerus?

Answer 964

Volkmann contracture, that is the injury of deep tissues and muscles of the volar compartment of the arm due to increased compartmental pressures; presents as a stiff arm

Question 965

How do you treat anaerobic infections in the CNS?

Answer 965

IV metronidazole

Question 966

What are the first teeth to erupt?

Answer 966

The mandibular (lower) central incisors at 6-8mo followed by the maxillary (upper) central incisors at 8-12mo

Question 967

Drainage of pink-salmon colored fluid after abdominal surgery. Dx? Tto:

Answer 967

Fascial dehiscence Tto: If fascia is intact is superficial: regular dressing changes Fascial involvement: bind/ tape the abdomen before transport to the OR for surgical correction Laparotomy is necessary to prevent evisceration!

Question 968

Hor do you trat B. pertussis on allergic to macrolides?

Answer 968

TMP-SMX

Question 969

How can you treat intestinal dysmotility in scleroderma?

Answer 969

Antibiotics (rifaximin) because small bowel estates leads to bacterial overgrowth which results in malabsorption and diarrhea

Question 970

What is the most common type of melanoma?

Answer 970

Superficial spreading melanoma

Question 971

High urinary coproporphyrins indicate:

Answer 971

Rotor sd

Question 972

Fragmented and nucleated RBCs on peripheral smear in cancer patient indicate:

Answer 972

Myelophthisic anemia / leukoerythroblastic picture Because the marrow gets overcrowded with other cells

Question 973

How do you treat community acquired pneumonia?

Answer 973

β-lactam + macrolide/doxycycline or Fluoroquinolone alone

Question 974

How are skin tags (verruguillas) also called?

Answer 974

Acrochondos

Question 975

What is the most accurate test to determine the EF in a patient with CHF?

Answer 975

MUGA scan

Question 976

Gastric varices without esophageal varices indicates:

Answer 976

Splenic vein thrombosis Gastric varices bleed quickly causing hematemesis

Question 977

What is a positive Freiberg's maneuver and what indicates?

Answer 977

Is the forceful internal rotation of the extended thigh that elicits buttock pain by stretching the piriformis muscle Indicates piriformis syndrome

Question 978

Which cells mediate exercise-induced asthma?

Answer 978

Mast cells

Question 979

Rapidly growing breast mass that is firm, contender, mobile and multinodular indicate:

Answer 979

Phyllodes tumor

Question 980

What is the management of HCOM?

Answer 980

Asymptomatic: nothing, avoid sports Symptomatic: β-blockers or Ca ch blockers If syncope/refractory to medical tto: pacemaker and then ventriculoplasty Sudden cardiac arrest or sustained ventricular tachycardia: implantable defibrillator (only one that reduces the risk of premature death) Mavacamten: modulates cardiac myosin and reduces contractility * for a baby of DM mom: there is no need for tto because it is self resolving, you can give a β-blocker for the symptoms

Question 981

What is the treatment of a 7yo kid with an umbilical hernia? What is the most likely outcome if not repaired then?

Answer 981

Surgical repair if it hasn't closed after 5yo Progressive enlargement of the umbilical ring * Congenital communicating hydrocele is also treated if it does not resolve after the 1st year

Question 982

What is the limit of permissive hypertension for ischemic stroke?

Answer 982

220/120

Question 983

What is the tto of a tubo-ovarian abscess?

Answer 983

IV cefotetan/cefoxitin + oral doxycycline

Question 984

What is the first step in management of diabetic ketoacidosis? and of hypoglycemia?

Answer 984

DKA: IV fluids Hypoglycemia: 50% dextrose or glucagon

Question 985

When is the fist time when you can palpate the uterus on a pregnant woman?

Answer 985

12w because it is above the pubic symphysis

Question 986

When is a baby considered macrocosmic?

Answer 986

When it weights more than 4Kg

Question 987

Wat is the systolic BP limit when you start treating with drugs right away?

Answer 987

140-150 w no comorbidities: 1) ambulatory/home BP readings/3 office readings 2) you try exercise and weight loss for 1 mo! More than 150: start treatment with 1 drug (hydrochlorothiazide) More than 160: start treatment with 2 drugs

Question 988

What is the treatment for cavernous sinus thrombosis?

Answer 988

IV amplicillin-sulbactam + vancomycin

Question 989

How is the uterus in endometriosis and adenomyosis?

Answer 989

Endometriosis: Younger woman Tender, inmobile*!! ± retroverted with rectovaginal nodularity (uterosacral ligament nodularity), *because of cul-de-sac adhesions CA-125 maybe high Tto: oral contraceptives, NSAIDs, maybe laparoscopy Adenomyosis: Older woman, multipara, secondary dysmenorrhea Mobile!! which is normal, firm, globular! and uniformly enlarged Tto: levonorgestrel=mirena IUD to make periods lighter

Question 990

What is the best treatment for pyelonephritis? And in pregnant?

Answer 990

Normal: IV ciprofloxacin Pregnant: IV cephalosporin (also penicillin and fosfomycin) When improvement (no fever for 48h) switch to oral! In pregnant continue daily prophylaxis during all the pregnancy

Question 991

Intrahepatic ductal dilation and a contracted gallbladder indicate:

Answer 991

Klatskin tumor; which is the most common type of cholangiocarcinoma and that occurs at the confluence of the right and left hepatic bile ducts

Question 992

When should you do external cephalic version?

Answer 992

When you have a baby on breech or transverse presentation at week 37 or more! If the patient is Rh- and you do the external cephalic version you need to give RhoGAM

Question 993

What is the best prognostic indicator in COPD? What is the best prognostic indicator of future coronary event?

Answer 993

COPD px: FEV1; determines the degree of obstruction and progression of the disease Coronary events: LDL cholesterol levels (goals: less than 100 in high risk of coronary disease patients; less 130 in moderate risk and less than 160 in normal patients)

Question 994

Well circumscribed hypotenuse hepatic mass with central scaring and radiating fibrous bands. Dx?

Answer 994

Focal nodular hyperplasia

Question 995

Management of long QT syndromes:

Answer 995

Non-selective beta-blockers: propranolol, nadolol Implantable defibrillator or denervation in high risk patients QT should be less than 2 big boxes

Question 996

Which bug causes an infection after you injure your foot sole?

Answer 996

Pseudomonas, can even cause osteomyelitis

Question 997

Characteristics of lactose intolerance:

Answer 997

``` Osmotic diarrhea Positive hydrogen breath test LOW pH ACID stools Increased osmotic gap (also in celiac) Positive reducing substances test in stool ```

Question 998

Indications of cervical CT after high energy injury:

Answer 998

``` Neurologic deficit Spinal tenderness Altered mental status Intoxication Distracting injury (other injury that hurts and makes the patient not realize a deficit ~) ``` If you find a single vertebral facture you should image the whole spine!

Question 999

Kid with protruded auricle + tenderness and swelling behind the ear indicates:

Answer 999

Acute mastoiditis

Question 1000

Patient with touch + pain and temperature loss on one side of the body:

Answer 1000

Pure sensory stroke normally due to thalamic infract | Can be followed by burning pain and allodynia weeks to months after the stroke (Dejerine–Roussy syndrome)

Question 1001

Which substance is the main player on abnormal hemostasis in uremia?

Answer 1001

Guanidinosuccinic acid

Question 1002

Positive carbohydrate breath test indicates:

Answer 1002

Small intestinal bacterial overgrowth Tto: rifaximin, neomycin

Question 1003

Patient with drooling, fever, elevated flood of the mouth and displaced tongue. Dx?

Answer 1003

Ludwig angina Mandibular celulitis normally coming form dental infections Tto: IV antibiotics and removal of the affected tooth

Question 1004

Treatment of a perianal abscess:

Answer 1004

Incission drainage + systemic antibiotics

Question 1005

When do you do surgery in valvulopaties?

Answer 1005

Mitral regurgitation: mitral valve repair If primary, when the LVEF is 30-60% (also you can do surgery depending on the pt if it is less than 30% and symptomatic and if it is more than 60% and asymptomatic) Mitral stenosis: Balloon valvuloplasty when the diameter is less than 1.5cm2 If the diameter is bigger treat only if symptomatic with diuretics and β-blockers Aortic regurgitation: If symptoms, EF less than 50% ``` Aortic stenosis: valve replacement If severe (diameter less than 1, velocity more than 4, pressure more than 40) + symptoms/ LEVF less than 50%/ patient undergoing other heart sx ```

Question 1006

3 mo. kid with asymptomatic normocytic anemia. Dx?

Answer 1006

Pysiologic anemia of infancy. Due to a transient decline in hemoglobin due to down-regulation of EPO triggered by a sudden increase in O2 at birth

Question 1007

LEOPARD syndrome characteristics:

Answer 1007

``` Autosomal dominant Sensorineural deafness Lentiginess ECG abnormalities Ocular hyperthelorism Pulmonary stenosis Genital abnormalities Groth retardation ```

Question 1008

Young patient with diarrhea, arthralgia, oral ulcers and oval pink macular lesions. Dx?

Answer 1008

Acute HIV infection

Question 1009

Old patient with retro-orbital headache and nonreactive dilated pupil. Dx?

Answer 1009

Acute angle closure glaucoma

Question 1010

Which 2 types pf kidney stones form on basic urine?

Answer 1010

``` Magnesium ammonium phosphate (struvite) Calcium phosphate (on tumor lysis syndrome and hyperPTH) ``` All the rest form on acid pH

Question 1011

Nephrotic syndrome predisposes to:

Answer 1011

Hyperlipidemia and atherosclerosis Hypothyroidism (due to thyroxine-binding globulin loss) Iron deficiency anemia (due to transferrin loss) Vitamin D deficiency and high PTH (due to cholecalciferol-binding protein loss)

Question 1012

Which type of fluid should be given to a kid?

Answer 1012

Isotonic crystalloid (20 mg/kg of normal saline IV bolus)

Question 1013

What is the leading cause of sentinel events? How can you prevent it?

Answer 1013

According to the Joint Commission failures at communication and team work are the leading cause of sentinel events that can be prevented by using uniform templates when conducting sing-outs

Question 1014

Why a postmenopausal woman on hormone replacement therapy will have low libido?

Answer 1014

Because of decreased androgens, ovaries not only produce estrogens, also produce androgens that play a central role in libido

Question 1015

A to-and-fro murmur indicates:

Answer 1015

PDA A to-and-fro murmur is a continuous murmur; actually a to-and-fro murmur involves two components: a systolic one, in which the blood flows in one direction, and a diastolic one in which the blood flows in the opposite direction, while in a true continuous murmur the blood flows in the same direction in both systole and diastole PDAs may also predispose to an increased risk of respiratory/lung infections PDAs present with hyperdynamic circulation and therefore accentuated pulses

Question 1016

Air in the liver indicates:

Answer 1016

Gallstone ileus; you can also have air in the biliary tree

Question 1017

Poison ivy rash characteristics:

Answer 1017

Vesicles/bullae Sharp line between rash and unaffected skin Linear pattern

Question 1018

What is the NBSM after finding abnormal total cholesterol levels?

Answer 1018

Serum lipid studies while fasting

Question 1019

What does withdrawal bleed after progesterone administration indicate?

Answer 1019

Used for the differential of secondary amenorrhea; confirms that the uterus is undergoing a normal proliferative phase and therefore eliminates: Estrogen deficiency: primary ovarian failure, menopause, hyperprolactinemia, hypothyroidism, functional hypothalamic amenorrhea Endometrial abnormalities: Asherman’s Outlet tract abnormalities: imperforate hymen

Question 1020

CSF findings on CNS infections and management:

Answer 1020

Viral: lymphocytic predominance, elevated protein and normal glucose → empiric IV acyclovir while awaiting PCR results and/or before brain MRI Fungal: lymphocytic predominance with decreased glucose Bacterial: WBC count (>1000) with neutrophilic predominance with decreased glucose

Question 1021

What is the difference between pericardiocentesis, thoracentesis and paracentesis?

Answer 1021

Pericardiocentesis: Drainage of pericardium (tto. of tamponade) Thoracentesis: Drainage of pleural space Paracentesis: Drainage of peritoneal cavity

Question 1022

What is the day after pill active (plan B) principle?

Answer 1022

Is oral levonorgestrel (now and again in 12 hours), not contraindicating in lactating We have four options for emergency contraception, they work up to 5 days from intercourse: Copper IUD (most effective) Ulipristal (second most effective, not in active infection or uterine anatomic abnormality) Levonorgestrel (“Plan B”) Oral contraceptives

Question 1023

What is the treatment of an anal fissure?

Answer 1023

1) anesthetic ointment and stool softeners

Question 1024

When should you stop one antidepressant before starting another?

Answer 1024

Your should stop SSRIs 2 w before starting a MAOi except fluoxetine that needs to be stopped 5 w!!! before

Question 1025

Histologic hallmark of diabetic nephropathy:

Answer 1025

Glomerular basement membrane changes (fibrosis and thickening) 1) Hyperfiltration 2) GBM fibrosis and thickening 3) Interstitial fibrosis, mesangial thickening and kimmelstiel wilson nodules

Question 1026

Pathophysiology of Bell's palsy vs trigeminal neuralgia:

Answer 1026

Bell's palsy: Inflammation and edema of the n. | Trigeminal neuralgia: Vascular loop/multiple sclerosis plaque/ neoplastic compression of the n. root

Question 1027

Increased renal medullary echogenicity on ultrasound indicates:

Answer 1027

Ischemic injury and renal papillary necrosis

Question 1028

What is the main cardiac abnormality associated with Noonan sd? Hurler sd? Ellis-Van Creveld sd?

Answer 1028

Noonan: pulmonary stenosis Hurler: mitral/aortic regurgitation Ellis-Van Creveld (short limb dwarfism, polydactyly, abnormal development of fingernails and normal intelligence): single atrium

Question 1029

What are the 2 main therapies to help an alcoholic that wants to quit but it might relapse?

Answer 1029

NalTREXone (do not use un liver problems or patients taking opioids) Acamprosate (preferred in liver disease or opioid abuse, but requires adjustment in renal failure)

Question 1030

How do you differentiate amphetamine form anticholinergic overdose?

Answer 1030

Amphetamines cause sweating Anticholinergics cause dry skin * Careful bc the decongestant pseudoephedrine and the antidepressant bupropion and selegiline can cause false + on toxicology testing

Question 1031

Specific non-pharmacologic therapies for psychiatric illnesses:

Answer 1031

ADHD: behavioral therapy as parent management training especially if 4-5yo Autism: behavioral modification Borderline personality disorder: dialectal behavior therapy Eating disorders: cognitive-behavioral therapy PTSD: cognitive-behavioral therapy Performance-only social anxiety disorder: cognitive-behavioral therapy Obsessive-compulsive disorder: exposure and response prevention or cognitive-behavioral therapy + SSRIs! You need to give SSRIs!!!! Specific phobia: CBT with exposure therapy! by systematic desensitization

Question 1032

What should you do if during colposcopy the squamocelular junction is not completely visualized?

Answer 1032

Endocervical curettage (this just looks at the endocervix that is still cervix so if it is + you do conization)

Question 1033

How does Pityriasis rosea present?

Answer 1033

1) erythematous annular lesion on the trunk (herald patch) → 2) outbreak of macules and papules on the trunk, neck and proximal limbs Sometimes preceded by flu-like symptoms

Question 1034

DD. between Right heat failure, Budd-Chiari and Portal vein thrombosis:

Answer 1034

RHF=cor pulmonale: liver =( cirrhosis nugmet liver; post-hepatic JVD+ If you have JVD + ascites it is because of the Right heart! Budd-Chiari is Hepatic vein thrombosis: liver =( cirrhosis nugmet liver; post-hepatic JVD- Portal vein thrombosis: liver =) pre-hepatic JVD- In all you have splenomegaly (thrombocytopenia), portal HT, varices, ascitis, edema

Question 1035

Pt with pain and redness ± purulent discharge in the medial eye. Dx? Pt with itching, discharge, foreign body sensation + redness and swelling of the lip margin. Dx?

Answer 1035

Dacryocystitis Blepharitis (associated with seborrheic dermatitis)

Question 1036

What do you do if you have to take out an ovary on early pregnancy?

Answer 1036

Give progesterone, bc the corpus lithium maintains pregnancy until weeks 8-10, progesterone can be discontinued after week 10

Question 1037

Which valve abnormality is associated with ankylosing spondylitis?

Answer 1037

Aortic regurgitation

Question 1038

What is the cause of Subclavian steal syndrome?

Answer 1038

Subclavian A. occlusion

Question 1039

Why ACEi help the kidney on DM?

Answer 1039

Because they reduce glomerular hydrostatic pressure decelerating glomerular capillary sclerosis

Question 1040

Which bug causes central retinal necrosis?

Answer 1040

HSV

Question 1041

What is the most common heart defect in Down syndrome? How does it present?

Answer 1041

Complete AV septal defect ``` Presents with: Diaphoresis and dyspnea when feeding around 6w of life ASD: fixed splitting of S2 + VSD: holosystolic murmur ```

Question 1042

Which abnormal heart sounds are heard in ToF?

Answer 1042

Single S2 | Harsh crescendo-decrescendo murmur due to RV outflow tract obstruction

Question 1043

When can you stop antidepressants on a patient with depression?

Answer 1043

Stop after 6mo of response to the antidepressant if this is the first episode Maintain 1-3 years if: + than 2 episodes (counting current episode!) Onset before 18 Persistent depressive symptoms during episodes Ongoing stressors Severe Maintain indefinitely: + than 3 episodes (counting current episode!) Chronic episodes (+ than 2 years) Suicide attempts * For a pt with schizophrenia and bipolar disorder antipsychotics/lithium need to be continued indefinitely

Question 1044

Effects of positive ventilation in cariogenic pulmonary edema:

Answer 1044

↑ intrathoracic pressure, so: ↓ LV and RV preload ↑ RV afterload also it ↓ LV because it ↓ MAP by decreasing sympathetic activation and ↓ LV transmural pressure because ↑ the pressure on the pleura This improves SV, filling in diastole and mortality

Question 1045

Pt presents with fever, abdominal pain, tachypnea and tachycardia a few days after Roux-en-Y sx. Dx?

Answer 1045

Anastomotic leak Management? CT scan with oral contrast and sx repair

Question 1046

How do you substitute penicillin on pt with syphilis that is allergic?

Answer 1046

Primary or secondary: doxy (14 days for primary and 28 days for secondary) Neurosyphilis: ceftriaxone IV

Question 1047

NBSM for a postmenopausal with endometrial cells on pap smear?

Answer 1047

Endometrial biopsy

Question 1048

What is the pathophysiology of acute renal failure in AML?

Answer 1048

Tumor lysis syndrome causing tubular obstruction

Question 1049

Which antidepressant causes hypertension?

Answer 1049

Venlafaxine, dose-dependent HT

Question 1050

Pt with knee pain, pop, rapid swelling, inability to extend the knee and low-riding patella. Dx? And if he had high-riding patella?

Answer 1050

Low-riding: quadriceps tendon rupture High-riding: patellar tendon tear

Question 1051

1) Pt presents with fever, leukocytosis, purulent discharge and widened mediastinum one week after a heart sx. Dx? Tx? 2) Pt presents with fever and leukocytosis 3 weeks after a heart sx. Dx? Tx?

Answer 1051

1) Acute mediastinitis, tto: surgical debridement + antibiotics 2) Postcardiectomy sd, tto: NSAIDs ± pericardial puncture if tamponade occurs

Question 1052

A COPD pt suddenly presents with altered mental status. Dx?

Answer 1052

Symptomatic hypercapnia Maybe due to ventilatory support removal and it can also be triggered or worsened by supplemental O2

Question 1053

Which type of fluid should be given to a septic shock patient? and to a patient in renal failure?

Answer 1053

Septic shock: crystalloids as normal saline or Ringer's lactate. If the pt does not respond and develops fluid overload give NE Renal failure: D5W bc they cannot get electrolytes

Question 1054

Which 2 psychiatric disorders are associated with Tourette syndrome? How do you treat Tourette's?

Answer 1054

ADHD OCD Tto: VMAT2 inhibitors Antipsychotics Alpha-2 agonists for comorbidities (ADHD)

Question 1055

D.D. of 'a curtain coming down' over the eye:

Answer 1055

Central retinal A. occlusion: optic disk pallor, cherry red fovea and boxcar segmentation of blood in the retinal vessels on ophthalmoscopy Retinal detachment: flashes and floaters with grey elevated retina on ophthalmoscopy

Question 1056

Pt develops severe bradycardia right after starting laparoscopic surgery. Cause?

Answer 1056

CO2 insulation on the peritoneum activates the stretch receptors which increases the vagal tone causing bradycardia and sometimes asystole The increased intraabdominal pressure can also cause an increase in SVR leading to BP elevation

Question 1057

Kid with bilious vomiting 2 days after a blunt abdominal tx. Dx?

Answer 1057

Duodenal hematoma, do a CT scan Rx: gastric dilation with scant distal gas Tx: bowel rest, nasogastric decompression and parenteral nutrition, sx if still present 2 w after

Question 1058

What is per-protocol analysis? What is intention-to-treat analysis?

Answer 1058

Per-Protocol: only analyzes patients that complete the protocol, does not take in consideration dropouts, it overestimates the effect of the intervention PP is bad! Intention to treat analysis that analyzes everyone that was located on a group, so it takes in consideration dropouts, it's more conservative. It preserves randomization!

Question 1059

How much is a kid supposed to grow on the 1st year?

Answer 1059

``` 4 mo: weight x2 (the fist 6mo babies gain 1oz/day) ``` 12mo: weight x3 height increases by 50%

Question 1060

Why do Beta-blockers, nondihydropyridine Ca ch blockers and Nitrates help on an MI?

Answer 1060

β-blockers and nondihydropyridine Ca ch blockers: ↓ O2 demand by ↓ contractility Nitrates ↓ preload

Question 1061

What is the gestational diabetes screening and management?

Answer 1061

At 24-28w: 1h/50g test, non fasting, if more than 140 do: 3h/100g test, fasting, diagnose gestational DM if 2 or more values are = or higher than: 95/fasting (if more than 125 diagnose, do not give the 100g) 180/1h (if more than 200 diagnose) 155/2h 140/3h ``` If gestational DM: check glucose at home and maintain at less than 95 fasting and less than 140/1h and 120/2h, if not: subcutaneous insulin/glyburide (insulin body weight x 0.8 -1st trimester- x 1.0 -2nd trimester- x 1.2 -3rd trimester-) + start antenatal testing at 32w Target goals!!!! 95 fasting 140/1h 120/2h + Postpartum: Measure fasting glucose at 1 day 3 days 2h/72g test at 6 and 12w postpartum, and at 3 year intervals if all good ```

Question 1062

Good drugs for treating DM2 and cause weight loss and protect the heart:

Answer 1062

--Tides (GLP1 agonists)! Best. They decrease glucagon release! They decrease gastric motility causing nausea. Not if history of pancreatitis. Semaglutide just came out as an oral form --Glifozins (SGLT-2 inhibitors). Less effective than the tides at decreasing HbA1c. Decrease hospitalization in HF. Decrease BP so do not give if BP is low or if pt is on a thiazide. Can cause euglycemic DKA Both decrease renal fx progression and have a cardiovascular benefit! Gliptins are not cardioprotective and weight neutral. Not bad for renal insufficiency

Question 1063

Management of open angle glaucoma:

Answer 1063

Open angle: 1) topical prostaglandins 2) topical β-blockers 3) laser trabeculoplasty

Question 1064

What are other names for neural tube defects?

Answer 1064

Spinal dysraphism | Tethered cord

Question 1065

When is c-section indicated in macrosomia?

Answer 1065

More than 4500g in diabetes | More than 5000g in non-diabetic

Question 1066

What do you do if a mom comes because the baby is not moving?

Answer 1066

* You also do fetal testing in DM, post-dates, HT, IUGR even if the baby is moving 1) Nonstress test, if 2 or more accelerations (+ than 15 beats/min at >32w) in 20 min 😃; you can do vibroacoustic stimulation in case the baby is sleeping ``` If nonreactive 😞: 2) Biophysical profile: NST Amniotic fluid index that should be 5-25cm Body movement Extremity tone (flex and extension) Breathing 8-10: 😃 4-6: contraction stress test (induce 3 contractions in 10 min), if the baby is more than 37w deliver 0-2: delivery! ``` 3) Umbilical doppler ultrasound

Question 1067

Different presentations and management:

Answer 1067

Cephalic: Occiput anterior vertex: back of the head is close to the pubis and flexed 😃 Face: c-section Breech: Frank: but is down and legs up; only breach that might be able to be delivered vaginally Complete: but is down and legs are crossed; c-section Footing; c-section Transverse: c-section

Question 1068

Causes of SECOND stage arrest:

Answer 1068

No fetal descend on 3h for nulliparous and 2h for multiparous (relative to amount of vaginal deliveries) Causes: Inadequate contractions Small pelvis Abnormal fetal size or orientation

Question 1069

Episiotomy indications:

Answer 1069

Not indicated in a regular basis, let it tear naturally ``` Shoulder dystocia Bad monitor tracing Forceps/ vacuum Vaginal breech Narrow birth canal ```

Question 1070

What are the indications of operative obstetrics:

Answer 1070

Prolonged 2nd stage (primigravida pushing + than 3h without epidural or + than 4h with epidural; multigravida pushing + than 2h without epidural or + than 3h with epidural) Category 3 when mom is fully dilated Mom's heart condition (hypertrophic cardiomyopathy) Maternal exhaustion They require dilated and effaced cervix, ruptured membranes and engaged occiput Forceps: could be used on a breech Vacuum: does not need so much experience and baby only needs to be vertex, do not put it for >10 min (risk of subgaleal hematoma and intracranial hemorrhage) and do not do it at >34w

Question 1071

Normal postpartum findings:

Answer 1071

Lochia rubra: 1w, blood (hemorrhage is pathological if + 500ml in vaginal or + 1000ml in cesarean) Lochia serosa: 2w, yellow Lochia rubra: 3w, white Hypotonic bladder and urinary retention: put a Foley catheter Hemorrhoids Postpartum blues, resolves in 2w

Question 1072

How do you treat catatonia?

Answer 1072

Benzodiazepines

Question 1073

DD. of differential BP on the upper extremities:

Answer 1073

``` Aortic dissection Blunt thoracic aortic injury Takayasu Supravalvular aortic stenosis (systolic murmur on the 1st right intercostal space) Widespread atherosclerotic disease ```

Question 1074

Position and management of Bartholin cyst/abscess:

Answer 1074

Bartholin: posterior, on the base of the labia majora. Only that if symptomatic (if abscess) → incision and drainage and place a catheter, marsupialization if recurrent

Question 1075

HPV screening and management algorithm:

Answer 1075

Vaccinate at 11-12 y.o. w 2 doses, if the pt receives the vaccine after 15yo you need to give 3 doses Screening: Older than 21: HPV cytology every 3 years *If less than 25 also test for gonorrhea and chlamydia Older than 30: you can keep doing cytology/3 years or better cytology + HPV co-testing/5 years If immunosuppressed or history of HPV screen every year, if HIV screen every 6mo Older than 65: if all good for 10 years (3 pap and 2 co-testing negative) and never HSIL stop testing, no smoke, immunosuppressed or DES If hysterectomy for benign reasons: stop Management of results: ASCUS: unknown significance (if HPV co-testing + → colposcopy) LSIL=CIN1: low risk** ASCH: cannot rule out HSIL* HSIL=CIN2,3: high risk → if less than 25*, if 25-64 do LEEP right away Squamous cell ca: if invasive ca. in pregnancy before 24w you do radical hysterectomy/RT if after 24w you wait up to 32w and then do it * * In younger than 25 repeat pap in a yer, in older * * 1) colposcopy ± biopsies (CIN 2/3 and already had kids and is more than 25 you can skip the biopsy) 2) if squamocelular junction is not visualized → curettage 3) if atypical glandular cells → endometrial biopsy 3) if CIN1: ablation/LEEP + pap in 6mo, if CIN2/3: LEEP; then, pap + HPV co-testing 1 and 2 y post-procedure (hysterectomy only for recurrent CIN2/3: sill do pap annually) The only thing you don't do during pregnancy is la LEEP or conization

Question 1076

What is the embryological cause of uterus Unicornuate, Didelphys, Bicornuate, Septate and Arcuate:

Answer 1076

Unicornuate: one müllerian duct did not form Didelphys: müllerian ducts do not connect at all, so there are 2 uterus and maybe 2 cervices and 2 vaginas Bicornuate: MC, müllerian ducts do not connect at the top Septate: the median septum does not degenerate Arcuate: all good, small midline indentation because the upper median septum does not degenerate

Question 1077

How do you manage a postmenopausal bleeding patient?

Answer 1077

1) transvaginal sonogram → if stripe more than 4mm: biopsy All good: OCPs/ progestin Simple and complex without atypia: progestin Complex with atypia: hysterectomy/progestin Endometrial ca: hysterectomy and bilateral salpingo-oophorectomy + lymph node dissection

Question 1078

DD of short kid with delayed and advanced bone age:

Answer 1078

Delayed: Constitutional growth delay: nr growth velocity, delayed growth spurt GH deficiency: ↓growth velocity=kid that stops growing, absolutely proportional kid, no GH increase after IV arginine Advanced: Peripheral precocious puberty: ↓LH Central precocious puberty: ↑LH

Question 1079

Benefits of combined oral contraceptives:

Answer 1079

Decrease risk of ovarian ca. Decrease risk of endometrial ca. (good for PCOS) Decrease risk of PID because the close of the cervix Make the periods lighter (good for dysmenorrhea)

Question 1080

Which class of antihypertensives gives you peripheral edema?

Answer 1080

Ca ch blockers (dihydropyridines cause more edema than non-dihydropyridines) If you combine them with ACEi the probability of getting peripheral edema decreases!!

Question 1081

What is the major RF for treat ca?

Answer 1081

Age

Question 1082

Which O2 parameter remains constant on CO poisoning, methemoglobinemia, anemia and polycythemia? Which one changes?

Answer 1082

Remains constant: PaO2, PARTIAL PRESSURE! of O2 or dissolved O2 (P50 will be nr in anemia and polycytemia and ↓ in CO and methemoglobinemia) Changes: O2 content or total O2! Normal partial pressure and low content!! In methemoglobinemia the pulse-oximeter is ↓ and does not improve with O2 but the arterial blood gas is falsely ↑ (~85). Skin turns blue In CO poisoning the pulse-oximeter is falsely ↑ but the arterial blood gas is ↓. Skin is red

Question 1083

DD between Hematoma, Pseudoaneuryms and AV fistula:

Answer 1083

Hematoma: ±mass, no bruit Pseudoaneuryms: pulsatile mass, systolic bruit AV fistula: no mass, continuous bruit

Question 1084

What is the key question and answer for facial CN lesion?

Answer 1084

Is the forehead affected? Yes: LMN→ ipsi: Bell's palsy (HSV reactivation), give steroids and valancyclovir No: UMN→ contra: stroke on internal capsule (pure motor) or cortex (+ cortical signs)

Question 1085

Adenosine deaminase in pleural fluid indicates? and amylase?

Answer 1085

Adenosine deaminase: TB Amylase: pancreatitis, esophageal rupture

Question 1086

Best tto of allergic rhinitis + asthma:

Answer 1086

LT modifiers

Question 1087

What are the criteria for acute liver failure?

Answer 1087

ALT, AST more than 1000 Hepatic encephalopathy INR more than 1.5

Question 1088

How do you hear S3 and S4?

Answer 1088

S4: A' s'tiff heart': ta-ta--ta S3: I'm re'la'xed: ta---ta-ta

Question 1089

HIV patient with renal failure, heavy proteinuria and edema. Dx?

Answer 1089

HIV associated nephropathy (biopsy: collapsing focal segmental glomerulosclerosis), HIV virus invades the renal epithelial cells DD. BK virus that causes interstitial nephritis with hematuria, pyuria and WBC casts

Question 1090

HIV patient with burning pain, loss of pain, touch and reflexes on the lower extremities. Dx?

Answer 1090

Distal systemic polyneuropathy

Question 1091

Clicking and separation of bonny edges of sternum after cardiothoracic surgery. Dx? Tto:

Answer 1091

Sternal dehiscence | Tto: urgent surgical exploration and repair (to prevent cardiac damage from loose wire or bone fragments)

Question 1092

Urethritis with negative culture. Causal organism?

Answer 1092

Chlamydial urethritis Gram stain will be + in gonorrhea (gram negative diplococci)

Question 1093

DD of abdominal mass in kids:

Answer 1093

Wilms=nephroblastoma: doesn't cross Presents later (2-5yo) From nephroblast (embryonic kidney) WT1 mutation Ch 11 Micro: triphasic with tubules, sheets and stroma ± hypertension (renin secretion), hematuria ±: WARG: WT1 is associated with anhiridia, genitourinary malformation, retardation. PAX6 next to WT1 is important for iris formation, contiguous gene deletion Denys-Drash: WT1 is associated with Difusse mesangial sclerosis (nephrOtic) and Dysgenesis of gonads Beckwith-Wiedemann: WT2 is associated w macroglossia, hemihyperplasia, low sugar and high insulin because over expression of ILGF2, omphalocele, hepatoblastoma Neuroblastoma: crosses and calcifies Presents earlier (birth-2) MC solid tumor in children Fever, pain and weight loss! Metas on the bone, marrow (anemia, thrombocytopenia...), skin (can cause blueberry-muffin baby!, raccoon eyes) SVC sd Associated w. opsoclonus-myoclonus-ataxia and VIPoma From neural crest (adrenal medulla ± hypertension) Micro: Homer pseudorosettes M-YCN! mutation (poor px) High homovanillic acid

Question 1094

D.D. of jaundice on the baby:

Answer 1094

``` Hemolysis: Immune-mediated: ABO (MCC), Rh or Kell (think if mom and baby are the same blood type) isoimmunization Non-immune: spherocytosis, elliptocytosis, G-6PD, pyruvate kinase deficiency. Early jaundice (day 1), ↑reticulocytes. Not responding to phototherapy and bilirubin of 25-30 (at 30 you get to kernicterus). Tto: double vol. exchange transfusion ``` Physiologic jaundice: peaks at day 2-3 and resolves in 1w, not rising more than 5mg/dl/24h, total bilirubin get to around 13, mostly unconjugated. Tto: maybe phototherapy Polycitemia: clamping the cord too late, twin twin transfusion, IURG, maternal DM. Tto: if symptomatic partial exchange transfusion to bring the Htc to 50 Breastfeeding jaundice (mala madre, early): more common. Baby is not feeding enough (not in every 2h) so in day 3 baby is dehydrated and jaundice. Bowel is not moving so a lot unconjugated bilirubin goes back to the liver trough enterohepatic circulation. Tto: hydrate + phototherapy + teach mom Breast-milk jaundice (mala leche, late): Feeding is great but baby gets jaundice in w2 because mom's milk has too much beta-glucuronidase so a lot unconjugated bilirubin goes back to the liver trough enterohepatic circulation. Tto: phototherapy, the beta-glucuronidase activity in mom's milk goes down by mo3 Biliary atresia=progressive obliterative polyneuropathy: progressive greenish-gold jaundice in the first 3w, hepatosplenomegaly, direct hyperbilirubinemia (direct!!! is more than 2mg/dl), ends up in cirrhosis. Best initial test: US; triangular chord, no gallbladder Most accurate test: liver biopsy Best initial tto: Kasai, hepatic portojejunostomy Best long-term management: liver transplant Galactosemia: jaundice, lethargic, big liver, + reducing substances in the urine that is not glucose and bilateral leukokoria. Avoid great feeding. Associated with E.coli sepsis Physiologic anemia of infancy: ↓Epo therefore ↓Htc around 2 mo of age because the baby is now on a very oxygenated state Only indirect bilirubin causes kernicterus!!

Question 1095

D.D. of respiratory distress on the baby:

Answer 1095

RDS: Premature baby w intercostal retraction, flaring, grunting and tachypneia Pathophysiology: increased alveolar surface tension → atelectasis → R to L shunting Most specific test: lecithin(phosphatidylcholine)/sphingomyelin on amniotic fluid >2:1 Best prevention tto: betamethasone Best first measure: O2/Continuous positive airway pressure ventilation, if fails give surfactant Best initial test: Rx; white everywhere=ground glass=reticulogranular=atelectasis, air bronchogram Best long term management: surfactant (trough intubation) Transient tachypnea: C-section baby that is only tachypneic Best Dx test: Rx; all dark=air trapping, white lines on the lung fissures (Kerley B lines)=fluid 1) IV fluids 2) Monitor O2... =) Neonatal polycythemia: RF: delayed cord-clamping, twin-twin transfusion, intrauterine hypoxia, genetic abnormalities Tachypnea, irritability, plethoric baby, hypoglycemia, hypocalcemia Hematocrit >65 Rx is normal Meconium aspiration: Post-term or baby with fetal distress during birth very sick, grasping Best Dx test: patchy 1) intubate and suction meconium before the 1st breath 2) ventilate (different form resuscitation on baby w no meconium where you will put an O2 mask) Diaphragmatic hernia: Very sick baby with scaphoid abdomen 1) intubate

Question 1096

Neonatal sepsis prophylaxis and MC organism:

Answer 1096

Ampi + aminoglycoside If meningitis suspected: ampi + cephotaxine (crosses BBB) Early onset bugs, 1week: Group B strep (agalactiae), E.coli, listeria Late onset bugs, 2-4weeks: Staph epidermis

Question 1097

Causes of osteoporosis in children:

Answer 1097

Osteogenesis imperfecta (MC genetic cause of osteoporosis) Ehlers-Danlos Marfan Homocysteinuria McCune-Albright syndrome= polyostotic fibrous dysplasia

Question 1098

Vaccines in peeds:

Answer 1098

Cannot use with immunocompromised: MMR, varicella, rotavirus, intranasal influenza Catch-up: you pick up when you left of, give the first batch of vaccines that were not given and then refer to the catch-up schedule to keep on going Unknown status: start form the beginning Preterm infants: start at the same time as a normal kid except the 1st dose of hep B Do not repeat if severe anaphylactic reaction Hep B: day 1 (or when baby is 2kg)→ 2mo → 6mo DTaP: 2mo → 4mo → 6mo → 15mo → 4y → 12y (Tdap) If they get a severe reaction under 7: keep calendar w DT If any dose left in older than 7give: Tdap Pregnant at 27-36: Tdap Every 10 years and after injury: Td Rotavirus: 2mo → 4mo → (6mo) If the kid has not gotten after 2y he does not need it Contraindicated if intussusception If kid has gotten immunoglobulins in within ~year wait a few months to give the vaccine Polio (Salk): 2mo → 4mo → 6mo → 4y Hib: 2mo → 4mo → (6mo) → 12mo After 5y if child does not have the vaccine he does not need it ``` Pneumococcus 13 (conjugated): 2mo → 4mo → 6mo → 12mo If sickle/asplenia/immunocompromised add 23 (unconjugated): 2y → 7y ``` MMR + varicella: 12mo → 4y If HIV but not HIV-related infection and CD4/lymphocytes>15%: give the vaccine, if not you wait until those conditions are met and give it If kid has gotten immunoglobulins in within ~year wait a few months to give the vaccine You can get varicella-associated disease after the vaccine If kid lives w a non-immunized you still give the vaccine to the kid HepA: 12mo → 18mo Meningococcal: 12y → 16y!!! Influenza: start at 6mo every year HPV: 11-12 yo w 2 doses separated by 6mo, if the pt receives the vaccine after 15yo you need to give 3 doses Egg allergy does not prevent you to get any vaccine

Question 1099

Post-exposure prophylaxis in under-immunized:

Answer 1099

Measles: 0-6mo: if mom is not immune give IM Ig Immune deficiency/pregnant: IM Ig All others: vaccine (if it is a kid, give the 2 doses of the normal vaccination calendar as this never happened) Varicella: Healthy babies up to 12mo: nothing if mom is vaccinated (if mom is unvaccinated IVIG) Immune deficiency/pregnant: VZIG Baby delivered form mom with a rash (also if shows up 5d before to 2d after delivery): VZIG, if not within that time you do nothing All others: vaccine Mumps, rubella: nothing Hep B: Ig + vaccine in different arms, repeat vaccine at 1 and 6mo Hep A: Vaccine within 2w of exposure If less than 1 year/immunocompromised/chronic liver fx: Ig Tetanus: Clean: Td Dirty, saliva, puncture, avulsion, crush, burns, frostbite, gunshot, IVDU: Td + Ig Rabies: Ig + vaccine after potential exposure if animal not available to observe for 10 days Ig on the day of exposure and vaccine on days 0, 3, 7, and 14 after exposure Meningococcus: rifampin, ceftriaxone or ciprofloxacin (in adults) even if vaccinated Pertussis: macrolides (azithromycin if less than 1mo) even if vaccinated. But only if: a) household contact b) third trimester pregnant, infants < 12 months, immunodeficiency c) exposed who have close contacts with high-risk persons

Question 1100

What are the vaccines given at 4-6y? (4) | What are the vaccines given at 12y? (3)

Answer 1100

4-6y: DTaP, Polio, MMR, Varicella | 12y: HPV, Meningococcal, Tdap

Question 1101

Key clinical findings in bronchiolitis (RSV):

Answer 1101

Wheezing + tachypnea D.D. with 1st asthma episode: brother that got a cold right before, very little kid (less than 2 years)... Definitive dx: nasopharyngeal swab Management: not Rx, only careful follow up. If severe put them on PICU and give ribavirin Prevention: palivizumab to preemies, pulmonary disease... younger than 1y Nov-March 1/mo

Question 1102

Staccato cough on a 1-3mo kid indicates:

Answer 1102

Short runs of a short cough (ta-ta-ta-ta-ta) Chlamydia trachomatis, form the birth canal, peripheral eosinophilia Tto: macrolides

Question 1103

D.D. of neonate with no meconium after 36h and abdominal distention:

Answer 1103

1) Rx: Asymmetrically distended loops + ground-glass/speckled on the RLQ: microcolon in meconium ileus (doughy appearance of the belly) → gastrografin enema → sx of fails → sweat test (Dx by ↑x2 sweat tests/2 copies of CFTR)

Question 1104

If you see rectal prolapse think:

Answer 1104

CF, do a sweat test Trichuriasis * Also if you see nasal polyps do a sweat test

Question 1105

The most common presentation of CF is: The MCC of infection before 25yo in CF: The MCC of infection after 25yo in CF: The most deathly infection in CF:

Answer 1105

Presentation: steatorrhea with vitamin loss, tto: pancreatic enzymes + vitamines + airway clearance Give antibiotics as soon as you see ↑sputum, fatigue... anti-inflammatories are also helpful Triple combination Ivacaftor/Elexacaftor/Tezacaftor for pts w ΔF508 older than 12yo Infection before 25yo: S. aureus Infection after 25yo: P.aeruginosa Most deathly: B. cepacia (incidence increases after 18yo), do not even intubate, they are going to die

Question 1106

Bronchiectasis vs Atelectasis:

Answer 1106

Bronchiectasis: dilated → inflamed → necrosis, CF, aspergillus Atelectasis: collapsed, Abnormal Alveoli, loss of surfactant

Question 1107

Sudden infant death sd prevention:

Answer 1107

Put the baby on their back, no soft surfaces or materials (pillows, blankets), no overheating, no bed starting, no cigarette smoke

Question 1108

Management, most accurate dx test and best long term management of allergic rhinitis and atopic dermatitis:

Answer 1108

Allergic rhinitis: Presentation: allergic salute, crease on the nose, allergic shiners, pale blue turbinates, pharyngeal cobblestoning Most accurate dx test: skin test (if wide spread dermatosis or previous anaphylactic reaction you cannot do skin test so do blood test) Tto: (2nd generation antihistamine → +) nasal steroids (most effective) → refer to the allergist Best long term management: desensitization, most reason for it nor working is non-compliance Atopic dermatitis: Presentation: erythema, pruritic, excoriations, lichenification Tto: emollients (bc transepidermal water loss), do an allergic workup, steroids if flare up!! triamcinolone (start with class 7 that does not have Fluor and keep going stronger 6,5,4... you cannot put fluorinated on face and intertriginous areas) Atopic march: Atopic dermatitis → food allergy → allergic rhinitis → asthma

Question 1109

Best test for allergies:

Answer 1109

Food elimination and challenge test in a controlled environment

Question 1110

Best test to evaluate asthma:

Answer 1110

Office: spirometry, best to evaluate flare ups and to follow medication, you can do it after 5yo Home: peak expiratory flow meter

Question 1111

What do you do with an asthma kid on the ICU?

Answer 1111

1) ABCs 2) Pulse oximetry and give O2 if less than 92% 3) Steroids PO/IV asap 4) Inhaled SABA 5) Inhaled SABA + ipatropium 6) Inhaled SABA (no more ipatropium because HR will increase too much) 7) 4h of observation, if does not deteriorate and SaO2> 92% 8) do PEF, if >70% of personal best 9) Discharge: 3-7 days oral steroids + SABA every 3h + continue daily controller No Rx, antibiotics or ABGs* * No ABGs unless respiratory distress and no breath sounds, if ABGs shows that the CO2 is normalizing you need to intubate! We don't like to intubate people with chronic pulmonary disease because when you use ventilator settings you can cause a pneumothorax, do permissive hypercapnia and low PEEP to avoid barotrauma

Question 1112

Strabismus management:

Answer 1112

Best initial test (in kids): corneal light reflex, to make sure is not pseudostrabismus (asymmetric epicentral folds) Best next step in management: patch the good eye Best long term tto: surgery

Question 1113

Causal organisms and new best step in management on conjuntivitis:

Answer 1113

Bacterial: bilateral Organisms: Strep pneumo, Nontypeable H. influenza, Staph aureus BNSM: topical antibiotics, if does not improve go to systemic Viral: starts on one eye and spreads to another Best prevention: hand washing Tto: cold compresses

Question 1114

Periorbital vs orbital cellulitis:

Answer 1114

Organisms: Strep pneumo, Nontypeable H. influenza, Staph aureus Periorbital: Presentation: Gradual swelling, no fever, no ophthalmoplegia or proptosis, normal vision BNSM: oral antibiotics, follow up in a few days if not improves admit! Orbital: Progresses form sinusitis Presentation: Acute, fever, vomiting, ophthalmoplegia and proptosis BNSM: admit + IV nafcillin + ceftriaxone + CT scan w contrast, if does not improve w need surgical drainage

Question 1115

Innocent murmur on a kid:

Answer 1115

``` No symptoms, no cyanosis Grade I, II, no thrill No diastolic (unless is a venous hum) S3 Normal pulses (you cannot hear the foot pulses which is normal) ``` Still's murmur: 3-6y, soft systolic ejection murmur, ejection of blood trough the infundibulum, decreases when sitting or standing Aortic outflow murmur: very similar, upper right sternal border, in young athlete, decreases when sitting or standing Venous hum: continuous murmur on the top of the left clavicle, sounds like the ocean, goes away in supine or with next flexion Peripheral pulmonic stenosis: up tp 1y, radiates to the axillae

Question 1116

VSD presentation:

Answer 1116

Large: Holosystolic murmur on the left sternal border, bc of the blood going trough the VSD + Low pitch diastolic rumble on the apex, because high volume is retuning to the heart * Sometimes the murmur is found after 1 mo of age because the drop of pulmonary vascular resistance over time which makes the LV pressure higher than the RV pressure and facilitates the shunt Small: Systolic ejection murmur + Widely split second S2 (this is how you differentiate it form Still's murmur) Presentation: tachypnea is the 1st sign because the blood accumulates on the pulmonary vessels and makes breeding harder, then you get RVHF bc of RV hypertrophy so you get JVD, hepatomegaly and edema. Finally you get LVHF because of LV fluid overload Wide splitting of S2: splitting continues to change w respiration, bc the pulmonary valve closes later bc of more blood on the RH

Question 1117

ASD presentation:

Answer 1117

Systolic ejection murmur (crescendo-decrescendo) on the mid sternum that radiates to the pulmonary area because more blood has to leave the RV to go into the pulmonary infundibulum, on all ASDs + Low pitch diastolic rumble over the tricuspid area, because high volume is coming to the RA and has to go to the RV, on significant ASD Wide fixed splitting of S2: does not change during respiration, bc the RA is distended at the maximum due to the extra blood input on inspiration the RA cannot be more distended of what already is

Question 1118

Endocardial cushion defect presentation:

Answer 1118

Is like a mix between ASD and VSD! Loud thrill systolic ejection murmur because all the blood on the LV goes into the narrow infundibulum on the upper sternum + Wide fixed splitting of S2 Can present early with mild intermittent cyanosis (as in troncus), when the kid is crying or sick ECG: biventricular hypertrophy

Question 1119

PDA presentation:

Answer 1119

Continuous machine-like murmur radiates to the scapula, carotids and axilla (everywhere) In systole some of the high flow coming from the aorta passes trough the ductus, and in diastole a lot more blood can pass trough the ductus because it is slower and sitting right there, also diastole makes more time of the cardiac cycle than systole ↑ PP systolic is a little decreased but diastolic pressure is very decreased causing BOUNDING pulses! (you can feel the feet pulses) and hyperdynamic precordium Pulmonary edema!

Question 1120

D.D. of undetected PDA vs aortic coarctation:

Answer 1120

Undetected PDA: BLUE PDA stays open: Continuous machine-like murmur at the left infraclavicular area Bounding pulses (as in AR) because of the L→R shunt there is increased LV preload so ↑systolic; and because the flow gets lost into the R circulation ↓diastolic L→R shunt at the beginning but the R❤️ and lungs get a lot of pressure so ↑pulmonary flux can develop R❤️failure. Then R→L shunt so lower body CYANOSIS No coarctation: no weird pulses, just BLUE! Coarctation; POSTductal=JUXTAductal: NO LOWER PULSES Coarctation: bounding PULSES (↑TPR) JUST in upper body and NO PULSES (↓BP) in lower body Systolic ejection murmur or even continuous murmur ON THE BACK ±S4 Because of the upper body ↑TPR can lead to L❤️ failure, aortic dissection, stroke, endocarditis, endarteritis... No shunt: same flow through all circuit PDA closes: no machine-like murmur and not blue, just ABSEBT PULSES No cyanosis because tissues autoregulate their blood flow Q=P/R NBSM: Echo Both present very similarly: teenager with leg cramps Coarctation; PREductal=TUBULAR HYPOPLASIA: mixture Very different for the other 2: half blue baby associated with turner Coarctation: bounding PULSES in upper body and NO PULSES in lower body + PDA stays open: Continuous machine-like murmur Also contributing to the bounding pulses in the upper body, if closes baby goes into shock R→L shunt because of the low aortic pressure: lower body CYANOSIS Coarctations are associated with bicuspid aortic valve and intracranial aneurisms and Rx 3 sign

Question 1121

Click heard during mid-systole. Dx?

Answer 1121

MVP, best heard on left decubitus Valsalva and standing up moves the click closer to S1 and the murmur gets louder Happens at mid-systole because is when the valve comes down

Question 1122

ToF presentation:

Answer 1122

MC cyanotic anomaly Harsh crescendo-decrescendo systolic murmur O2 challenge test to differentiate form pulmonary disease: will not correct with O2, will only minimally increase Do not intubate, no need ECG: RV hypertrophy Rx: black lungs and boot shaped heart (the RV is displaced up) Echo: will give you the pulmonary gradient to see how bad it is 1) Balloon atrial septoscopy 2) Blalock-Taussig=systemic pulmonary shunt: left subclavian A to the left pulmonary A → 3) surgery

Question 1123

Tricuspid atresia presentation:

Answer 1123

Cyanosis in a newborn ECG: Huge left axis deviation! due to RV hypoplasia Rx: black lungs

Question 1124

Ebstein anomaly presentation:

Answer 1124

Early presentation: baby Rx: black lungs and a box-shaped heart, huge heart! ECG: large P waves on the right precordial leads Echo: huge RA very small RV Late presentation: adolescent Present with an SVT 1) break with ice water, adenosine or cardioversion 2) ECG: WPW

Question 1125

Transposition of the great arteries presentation:

Answer 1125

MC cyanotic anomaly at birth | Rx: egg-on-a-string sign, white lungs, increased markings

Question 1126

Truncus arteriosus presentation:

Answer 1126

Loud thrill systolic ejection murmur because all the blood on the LV goes into the narrow infundibulum on the upper sternum (as in endocardial cuishon defect) + Single loud S2 Respiratory distress and mild intermittent cyanosis (as in endocardial cuishon defect) Happens on the 1st week ECG: biventricular hypertrophy Rx: white lungs, increased markings on a neonate Tto: 1) pulmonary band on the pulmonary truncus to allow more blood into the aorta 2) surgery

Question 1127

Hypoplastic LH presentation:

Answer 1127

Mild intermittent cyanosis and will get cariogenic shock Systolic ejection murmur + S2 wide fixed splitting Rx: big heart, white lungs, increased markings ECG: tiny V5 V6 R waves Echo: big RA and RV Look for other dismorpholopgic findings: look at the karyotype (trisomy 18!!), head CT scan, renal ultrasound

Question 1128

Total anomalous pulmonary venous return presentation:

Answer 1128

Normally the pulmonary veins come back to the RA ``` Systolic ejection murmur + Mid-diastolic low pitched rumble (because of the ASD) + S3 + S2 wide fixed splitting ``` Rx: snowman heart, two heart shadows one on top of the other (the top one is the SVR coming back to the RA, the bottom one is the heart) ECG: Right axis deviation (RA and RV are huge)

Question 1129

JONES criteria:

Answer 1129

You need 2 major+ 2 minor or only Sherman's chorea ``` Major: Joints ❤️ carditis Nodes Erythema marginatum Sherman's chorea ``` Minor:

Question 1130

D.D. of villous vomiting on an infant:

Answer 1130

``` Duodenal atresia: Recanalization failure Villous vomiting Double bubble No abdominal distention bc the distended area is under the ribs ``` Jejuno-ileal atresia: Intrauterine vascular accident leading to segmental infection and resorption of fecal intestine More than 2 bubbles Abdominal distention Malrotation: Clockwise 270deg rotation does not happen well Occasional cramps w intermittent malabsorption Then, twists and presents as a volvulus, not immediately after birth, within ~1y

Question 1131

Where can we get toxic megacolon?

Answer 1131

Hisprung C. difficile Ulcerative colitis

Question 1132

When do you have to do imaging after UTI on a child?

Answer 1132

First 2y of life: Renal and bladder US after 1st UTI w fever, if abnormal get voiding cystourethrogram (maybe renal US before) Older than 2y: Voiding cystourethrogram!! after the 2nd UTI w fever Same for boys and girls

Question 1133

Henoch-Schonlein purpura presentation:

Answer 1133

After a common cold you get a rash on the lower part of the body + 1 of: IgA deposition, abdominal pain (intussusception), arthritis on the legs or back of the arms, renal vasculitis (leading cause of morbidity) Symptoms can show up up to 6mo! after the beginning of the disease

Question 1134

When and how do you screen for DM2 on kids?

Answer 1134

Screen kids with >85% BMI + 2 RF (between 10-19y, non-white, family history, metabolic sd) Screening: fasting blood glucose/2 y starting at 10 or onset of puberty BNSM: diet and exercise, if not metformin

Question 1135

When do you start giving Fe to a kid?

Answer 1135

Fe fortified cereal starting at 4-6mo + Do dot introduce cows milk up to 1 year because it has too little Fe and bad Fe bioavailability

Question 1136

Sickle cell trait and disease presentation:

Answer 1136

Trait: isosthenuria, UTIs, splenic infraction at high altitude Most common complication: hematuria from sickling in the renal medulla Disease: Howell-jolly bodies after 5y of age (before that splenic sequestration also causing pancytopenia; long term tto: splenectomy) Dactilitis after 6y Parvovirus aplastic anemia: emergency tto: transfusions; final tto: IVIG MCC of acute chest sd: mycoplasma pneumonia (bc of s. pneumo vaccination) Acute hemolytic crisis due to gallstones MCC of CVA: Middle cerebral A stroke (screen with transcranial doppler, if abnormal trascranial blood flow velocity transfuse) Renal papillary necrosis (solve w kidney transplant) Genreal tto: hydroxyurea (avoid in pregnancy)

Question 1137

Hair on end skull appearance indicates:

Answer 1137

β-thalassemia

Question 1138

Which kind of GI bleed presents with high BUN?

Answer 1138

Upper GI bleed, actually can be used to differentiate upper form lower GI bleed

Question 1139

Why do you give PPI drip to a GI bleeding patient?

Answer 1139

Because when the stomach pH is higher patients coagulate better

Question 1140

How can you decrease TG fast on a hypertriglyceridemic pancreatitis:

Answer 1140

Insulin (or heparin) turn on LPL; we don't give heparin on pancreatitis because it will increase the bleeding

Question 1141

How do you hydrate a cirrhotic patient?

Answer 1141

Albumin=colloids (also make sure you put then in a low Na diet even if they are hyponatremic) To diagnose hepatorenal syndrome you need to hydrate with albumin for 2 days to rule out pre-renal azotemia Spontaneous peritonitis can lead to hepatorenal syndrome, to prevent spontaneous peritonitis do not drain too much fluid from the Spontaneous peritonitis, give antibiotics and albumin!

Question 1142

Best treatment for focal seizures:

Answer 1142

Carbamazepine

Question 1143

When can you remove antiepileptics on a patient?

Answer 1143

If they have no seizures for 5 years you can taper down the antiepileptic slowly

Question 1144

What is neuromyelitis optica?

Answer 1144

Presents with optic neuritis and myelitis; attacks the optic n. and the spinal cord but nothing in the brain Due to an antibody that attacks an aquaporin channel MRI: no plaques in the brain, but you will see plaques on the spinal cord Tto: steroids, rituximab

Question 1145

Sudden flare of psoriasis. Associations?

Answer 1145

``` HIV Strep pharyngitis Skin tx (Koebner phenomenon) Systemic steroids withdrawal Antimalarials Indomethacin Propranolol ```

Question 1146

Tto of lupus nephritis:

Answer 1146

Mycophenilate (not in pregnancy)

Question 1147

What is the direction of the ductus arteriosus shunt in utero? and on a normal infant with a PDA? and on aortic coarctation tubular hypoplasia type?

Answer 1147

In utero and in persistent pulmonary HT of the newborn: R → L; Deoxygenated blood from the pulmonary A. to the descending Aorta PDA: L → R; Aorta → Pulmonary; Oxygenated blood from the Aorta. to the pulmonary A. Aortic coarctation PREductal=TUBULAR HYPOPLASIA: R → L; Deoxygenated blood from the pulmonary A. to the descending Aorta * Preductal=new baby. Here keeping the doctors open will allow blood flow to the lower extremities even if it is deoxygenated blood! When the ductus arteriosus closes in the first week of life, the left side of the heart then sees a massive increase in afterload, leading to heart failure

Question 1148

Hyponatremia DD:

Answer 1148

-CHRONIC: --Hypo-osmolar: ---- Hypovolemic: Dehydration: RAAS activated and thirsty, low urine Na and high urine osmolarity; tto: saline Addison's: RAAS activated and thirsty but high urine Na and low urine osmolarity because there is no Aldo; tto: Dexamethasone --- Euvolemic: SIADH (thiazides!, SSRI, carbamazepine, head tx, brain tumor, pneumonia): low plasma osmolarity and high urine osmolarity, BUT NORMAL/HIGH Urine Na >20 because RAAS is suppressed, low BUN and uric acid in blood; tto: fluid restriction ± stop meds/furosemide/demeclocycline/-vaptams You need to rule out Addisons and HYPOTHYROIDISM to diagnose SIADH Hypothyroidism: T4 is needed -permissive- to get rid of water. Tto: levothyroxine Potomania: low urine Na and urine osmolarity; it is a lot easier to get hyponatremic if you don't eat food, which is what happens in beer potomania (other alcohols have more Na) or in tea and toast diet --- Hypervolemic: Edema but low effective circulating vol: CHF, nephrotic, cirrhosis (anyone with edema has high total body Na) RAAS activated and thirsty, low urine Na!! and high urine osmolarity; tto: fluid restriction + treat the underlying disease -- Isotonic: lab error in MM, pseudohyponatremia: check protein or lipids -ACUTE: Ecstasy and marathon runners. Tto: hypertonic saline --Hyper-osmolar: due to mannitol or hyperglycemia. Here there is low serum sodium and high plasma osmolarity

Question 1149

How many Na mEqv can you give to correct hyponatremia?

Answer 1149

6/8 mEqv in 24h in chronic hyponatremia | 2 mEqv in one hour until the seizures stop in acute hyponatremia

Question 1150

Hypernatremia DD:

Answer 1150

Diarrhea on a pt that is not drinking and severe sweating (sweat is hypotonic): RAAS is activated and there is high urine Na and high urine osmolarity. Tto: nr saline, then hypotonic solution DI: low urine Na and low urine osmolarity. Tto: vasopressin if central/thiazides or NSAIDs if peripheral (thiazides cause decrease Na delivery to the macula densa and the proximal tubule reabsorbs a lot Na and therefore water)

Question 1151

How many Na mEqv can you decrease on a day to correct hypernatremia?

Answer 1151

10 mEqv in 24h

Question 1152

Hypomagnesemia causes:

Answer 1152

Hypokalemia: you need Mg to hold on to K Hypocalcemia: you need Mg for PTH to work, also ↓Mg will lead to ↓ PTH Both hypokalemia and hypocalcemia prolong QT =(

Question 1153

How many K mEqv can you give to correct hypokalemia?

Answer 1153

10 mEqv/h (you have to go even slower because it is very irritating)

Question 1154

Why do you get acidosis in RTA type 4 and other causes of hyperkalemia?

Answer 1154

Hyperkalemia decreases ammonia production on the PCD so hydrogen cannot be excreted and you get acidotic

Question 1155

How do you treat a hyperchloremic metabolic acidosis?

Answer 1155

Non-anion gap metabolic acidosis = hyperchloremic metabolic acidosis Tto: 1) Check the K 2) if pH is less than 7.2 give Na bicarb if the K is not low! To treat anion gap metabolic acidosis you can also give bicarb unless is a DKA or lactic acidosis

Question 1156

↑PT ↑PTT ↓Hb ↑D-dimer ↓fibrinogen. Dx?

Answer 1156

DIC or liver failure! Platelets ↓ in liver failure The liver makes fibrinogen On liver failure factor 8 and VW will be normal

Question 1157

How do you treat itching in primary biliary cirrhosis?

Answer 1157

Cholestyramine

Question 1158

DD of Diverticulosis and Angiodysplasia:

Answer 1158

Diverticulosis: not missed in colonoscopy, arterial bleeding! bright red blood Angiodysplasia: can be anywhere in the colon and can be missed in colonoscopy, venous bleeding so brown blood. Associated with aortic stenosis, VW factor deficiency and advanced renal disease

Question 1159

What should you check on a parting with statin myopathy?

Answer 1159

TSH, subclinical hypothyroidism is associated with increased risk of statin myopathy

Question 1160

What is the timing of the acid-base disturbances after aspirin intoxication?

Answer 1160

Minutes: respiratory alkalosis Hours: + high anion gap metabolic acidosis

Question 1161

Screening in kids:

Answer 1161

``` Autism: 18mo-2y Depression: 12y Visual acuity: 4y HIV once less than 18y Dyslipidemia: once 17-12y ```

Question 1162

RF of atonic uterus:

Answer 1162

Atonic: soft, above the umbilicus RF: twins, operative delivery, rapid delivery, meds

Question 1163

Particularities on kidney dysfunction:

Answer 1163

``` Careful if Cr is high: Metformin (if GFR>45 you can give full dose, if 30-45: half dose) Contrast (spiral CT angio for PE) High intensity statin Colchicine Bisphosphonates ``` Thiazides will not work, change to a loop BNP will be overestimated Mantoux will give you false negatives HbA1C is not reliable, it can be underestimated (also not reliable in iron def, it can be overestimated)

Question 1164

PR depressions on ECG suggest:

Answer 1164

Pericarditis

Question 1165

MCC of Cryptogenic stroke:

Answer 1165

Stroke that you do not know the cause Dx: loop recordings Not holter because is only for 2 days MCC: pt is going in and out of A. fib Aspirin x2w and then anticoagulation

Question 1166

Which drugs can increase PRL?

Answer 1166

``` SSRIs, TCAs Narcotics Cocaine Risperidone Pregnancy (monitor by eye exams bc PRL will be high anyways) Hypothyroidsm ``` They will not give you PRL above 100-200

Question 1167

INF-α SE:

Answer 1167

Thyrotoxicosis or hypothyroidism

Question 1168

How do you monitor Hyper/Hypothyroidism tto? What are the effects of Hyper/Hypothyroidism in BP?

Answer 1168

Hyperthyroidism: T3 and T4 Hypothyroidism: TSH Hyperthyroidism: increase systolic pressure, wide PP Hypothyroidism: decrease HR, increase diastolic pressure, narrow PP

Question 1169

What is important to check on Graves disease?

Answer 1169

K, because of hypokalemic periodic paralysis Normally patients present paralyzed after they eat a high carbohydrate meal or after they do exercise. It is associated with Graves but can happen outside it, if in Graves it will go away after you treat Graves

Question 1170

Löfgren sd. treatment:

Answer 1170

Erythema nodosum + arthritis + bilateral pulmonary infiltrates NSAIDs If they have hypercalcemia you give steroids

Question 1171

DD of ↑Ca:

Answer 1171

↓ PTH: 1) Hypercalcemia of malignancy: Ca higher than 14 2) Vitamin D toxicity ↑ or normal PTH: 3) Primary hyperPTH: urinary Ca is high. It is associated with pseudogout, you can have a flare of pseudogout after the parathyroidectomy. Vit D deficiency could mask primary hyperPTH. Indications of parathyroidectomy if: symptoms, ca more than 11.5, if GFR less than 60, age less than 50, kidney stones, osteoporosis and if urinary ca is more than 400mg/day. Make sure you check vit D before then parathyroidectomy because you can get extreme hypocalcemia after the sx 4) Hypercalcemic hypocalciuria: urinary Ca is low

Question 1172

DD of secondary hyperparathyroidism:

Answer 1172

Vit. D deficiency: Ca can be normal, 25-hydroxy vitamin D will be ↓, P will be ↓ Real failure: P will be ↑

Question 1173

How do you calculate PAO2?

Answer 1173

At sea level= 150-(aCO2/0.8) Not at sea level=(713-mmHg)*0.21-(aCO2/0.8) * subtract 1mmHg per every 10m ascend

Question 1174

Epitroclear lymphadenopathy + grey lesions on the mouth indicate:

Answer 1174

Secondary syphilis Herpangina also has grey lesions on the back of the mouth

Question 1175

Screening guidelines:

Answer 1175

Colon ca: 50-75yo colonoscopy every 10 years/ fecal blood annually/ fecal immunochemistry annually If you find: 1/2 polyps less than 1cm: repeat in 5y 3-10 polyps or any polyp >1cm or if villous: repeat in 3y + 10 polyps or any polyp >2cm or stage I-III ca: repeat in 1y (if + 10 polyps do genetic studies + endoscopy looking for stomach polyps) FAP: 10-12yo colonoscopy every 1/2y + 30 yo EGD Lynch: 20-25yo colonoscopy every 1/2y + 30-35yo endometrial biopsy + 30yo EGD and H.pylori biopsy for gastric ca. First degree relative before 60: 40yo/10y before dx of relative colonoscopy every 5y IBD pancolitis: 8y after onset colonoscopy every 2/3y Breast ca: 40-75yo mammogram every 2y BRCA 30-35 breast MRI annually, if more than 35 Mx + breast MRI annually Lung ca: 50-80yo with more than 20p/y and that did not quit on the last 15y low dose chest CT every year Cervical ca: 21-65**yo cytology every 3y/ of older than 30yo better cytology + HPV co-testing/5y * If less than 25 also gonorrhea and chlamydia, if immunosuppressed screen every year * * Stop at 65 yo if all good for 10 years and never HSIL stop testing, also stop if hysterectomy for benign reasons Bone densitometry: women over 65yo/ at risk of osteoporosis due to alcohol, tobacco or skinny AAA: Men 65-75yo who ever smoked Prostate: 55-69 consider PSA (confers reduced ca. mortality but tto has SE and most men die from other causes) Hep C: Anyone between 18-70yo once HIV: Anyone 15-65yo once by antibodies Lipid profile (measure HDL and total cholesterol to calculate ASCVD): asymptomatic females starting at 40-45yo and asymptomatic males starting at 35yo every 3-5y, only measure before if pt has family history of familial hyperlipidemia, MI or stroke at very young age. Children 1 time at age 9-11 and 17-21yo DM2: 40-70yo and BMI>25/ any age w HT, screen with fasting blood glucose/HbA1c Retinopathy and Alb/Cr screening after dx of DM2 and 5y after dx of DM1 every year; then every year. Monofilament testing every year. Serum lipid studies every year. ECG: once at 65yo Vision: first at 4yo Audition: in hospital BP: >18 yearly, if systolic 120-129 every 6mo Chihosis: upper endoscopy/year + liver US and α-fetoprotein/6mo

Question 1176

If it looks like DKA but your ketones are negative, what should you check?

Answer 1176

β-hydroxybutarate Same in alcoholics

Question 1177

DM2 for several years that comes in chronic diarrhea (>8w). Dx?

Answer 1177

Small intestinal bacterial overgrowth. Confirm by a carbohydrate/H+ breath test. Tto: rifaximin Same after gastric bypass and in scleroderma

Question 1178

DM2 for several years that comes in with orthostatic hypotension. What should you do?

Answer 1178

Stress test to look for silent ischemia. They cannot feel the pain of an angina!

Question 1179

Treatment for gastroparesis if pt has extrapyramidal side effects with metoclopramide:

Answer 1179

Promethazine

Question 1180

Adrenal mass workup:

Answer 1180

Irregular, heterogeneous, large: ca → adrenalectomy Regular, small: No symptoms: incidentaloma → check plasma free metanephrines and low dose dexamethasone bc both a pheochromocytoma (vascular mass) and Cushing can be asymptomatic HT: Aldo/renin ratio + check also free metanephrines and low dose dexamethasone

Question 1181

SE of testosterone replacement:

Answer 1181

Hyperviscosity, blood cloths Prostate ca. HT

Question 1182

Pt with hypertension presents with polycythemia and angina at night. Dx?

Answer 1182

OSA, order pulmonary function test

Question 1183

How can you treat MRSA pneumonia?

Answer 1183

Ceftaroline+ azithromycin | Azithromycin, ceftriaxone and vancomycin

Question 1184

When cannot you use Daptomycin to treat MRSA?

Answer 1184

In MRSA pneumonia because is inhibited by surfactant

Question 1185

How do you work up ascitic?

Answer 1185

SAAG: serum albumin-ascitis albumin More than 1.1: look at the total protein on the ascitic fluid → less than 2.5: portal HT=cirrhosis → more than 2.5: CHF or hepatic vein thrombosis Less than 1.1: look at the total protein on the ascitic fluid → less than 2.5: nephrotic sd → more than 2.5: TB (high lymphocytes on ascitic fluid; do a peritoneal biopsy and culture for TB), ca, pancreatitis

Question 1186

Thickened sub-epithelial collagen band on postmenopausal woman. Dx?

Answer 1186

``` Microscopic colitis (MC) Presentation: nocturnal diarrhea with macroscopically intact mucosa Pathology: intraepithelial lymphocytic infiltrates in lymphocytic MC or thick, subepithelial collagen bands in collagenous MC Causes: NSAIDs, PPIs, SSRIs ``` Management: 1) Stop drugs that can cause it 2) loperamide and bismuth 3) budesonide

Question 1187

Early onset dementia, arthritis and malabsorption on an old man. Dx:

Answer 1187

Whipple disease

Question 1188

Duodenal ulcer on bleeding pt with negative H.pylori. NBSM?

Answer 1188

Stool antigen/urea breath test because blood can give you a false negative for H. pillory

Question 1189

Meningitis after neurosurgery. Tto?

Answer 1189

Cefepime for pseudomonas and vancomycin for MRSA Pipe-tazo doesn't cross the BBB

Question 1190

How do you cover listeria in penicillin allergy?

Answer 1190

TMP-SMX

Question 1191

Hearing loss with reddish hue behind the tympanic membrane indicates:

Answer 1191

Otosclerosis | Paradoxical improvement on noisy environments (paracusis of willis)

Question 1192

Main DD of DVT:

Answer 1192

Ruptured baker cyst

Question 1193

When should you endoscopically biopsy a pancreatic cyst? When should you drain a pancreatic pseudocyst?

Answer 1193

``` Biopsy a cyst: More than 3mm Solid components or calcifications Ductal dilation (main pancreatic duct involvement) Thickened or irregular cyst wall ``` Drain a pseudocyst (CT guided percutaneous biopsy): Larger than 5cm Symptomatic Aspirate by ERCP!! (transpapillary approach), also by cystogastrostomy or cystoduodenoscopy

Question 1194

Which nerva can be compressed by a Colles fracture?

Answer 1194

Median n.

Question 1195

Heat exposure DD:

Answer 1195

Heat cramps: sweating, craps, Ta is normal, no systemic findings. Tto: hydrate Heat exhaustion: exercising into the heat, fever but less than 40 deg, nausea! cramps, no CNS dysfunction!. Tto: hydrate and cool patient (AC, shower) Heat stroke: Exertional: physical activity on hot and humid weather, >40 deg + CNS dysfunction (confusion) and organ damage as rhabdomyolysis, shock liver, DIC, AKI... Tto: ice water immersion, IV with cool fluids, cool rectal fluids or NG tube, spray and fans Classic: people with problems thermoregulating (anticholinergic medications, Parkinson, DM, alcoholism, cirrhosis) they stop sweating. Tto: evaporative cooling

Question 1196

Causes of hypoxemia:

Answer 1196

V/Q mismatch with ↓ Q=Increase in death space: thrombus, pulmonary embolism (ends up diverting Q to other areas and therefore ↓V/Q) V/Q mismatch with ↓ V: severe asthma, pneumonia, CF (partial). It's extreme is shunt R-L shunt: peanut (complete), atelectasis (ARDS, pneumothorax), congenital heart defects Diffusion impairment: sarcoidosis, fibrosis, emphysema, pulmonary edema (left heart failure) Hypoventilation: obesity, chest restriction (scoliosis), COPD, myasthenia gravis, opioids, altitude

Question 1197

Hermaphroditism DD:

Answer 1197

5-α-reductase deficiency: XY, female external genitalia with NO BREAST, male internal genitalia (cryptorchid testes)! female at birth and virilization at puberty, ↓ or nr testosterone ↑DHEA Androgen insensitivity: XY, female with normal breast, NO PUBIC HAIR, primary amenorrhea and cryptorchid testes Classic congenital adrenal hyperplasia: XX, baby girl with ambiguous genitalia and normal internal genitalia, after 1-2 w develop hypotension Aromatase deficiency: XX, baby girl with ambiguous genitalia and normal internal genitalia, in puberty they get even more virilized, do not develop breasts and do not menstruate. ↑testosterone ↑androstenedione and ↓ undetectable estrogen Nonclassic congenital adrenal hyperplasia: XX, female at birth and virilization at puberty (does not reach clitoromegally), can have irregular menses, no male internal genitalia, no problems with BP XY, boy with precocious puberty, advanced bone age and low LH. Is one of the causes of peripheral precocious puberty Sertoli-Leidig tumor: rapid onset hirsutism w clitoromegally, male-pattern balding and increased muscle mass, high testosterone

Question 1198

How do you treat Mg toxicity?

Answer 1198

Ca gluconate

Question 1199

Infections that affects palms and soles:

Answer 1199

CaRS: Coxsackie A: hand-foot-mouth disease in herpangina Rickettsia Rickettsii: Rocky Mountain Spotted Fever (maculopapular) Secondary syphilis (maculopapular, hyperpigmentation) Keratoderma blennorrhagica in reactive arthritis (hyperkeratosis, most in feet) Toxic shock sd (desquamating) Kawasaki (desquamating) Scarlet fever Disseminated gonococcal infection (pustular lesions)

Question 1200

Pulsus bispheriens or biphasic pulse indicates:

Answer 1200

Aortic regurgitation

Question 1201

What are the main exceptions in manouvers that modify murmurs:

Answer 1201

Valsalva and standing decrease preload but increase HCOM and MVP murmurs Squatting increases preload and afterload but decreases HCOM and MVP murmurs Handgrip increases afterload but decreases AS and MS murmurs!! as they are forward murmurs

Question 1202

Inability to palpate the point of maximal apical impulse indicates:

Answer 1202

Pericardial effusion

Question 1203

Which type of muscle is affect in scleroderma?

Answer 1203

Smooth muscle, affects the lower esophagus

Question 1204

Post-partum woman with decreased sensation on the anteromedial thigh and absent patellar reflex:

Answer 1204

Femoral n. neuropathy, due to hip hyperflexion during second stage of labor

Question 1205

First line tto. of bipolar major depression: | Tto for pts with severe bipolar disorder and frequent mood episodes:

Answer 1205

Bipolar major depression: lurasidone, quetiapine Severe bipolar: lithium/valproate + 2nd generation antipsychotic (quetiapine)

Question 1206

How do you differentiate a stroke on the pons form a stroke on the internal capsule?

Answer 1206

Internal capsule (above the pons): contralateral face w normal forehead, contralateral arm and leg Pons or below: ipsilateral face w affected forehead, contralateral arm and leg. The pons makes the change

Question 1207

DD of air in GI or biliary tract:

Answer 1207

Gallstone ileus: air on the biliary tract + RUQ pain and NO fever but + symptoms of GI obstruction. Do enterolithotomy Emphysematous cholecystitis: air on the gallbladder wall + RUQ pain and fever on DM pt. Do emergency cholecystectomy Necrotizing enterocolitis: intramural air on the wall of the bowel ± portal venous gas on a preemie Emphysematous pyelonephritis: air on the kidney's wall on DM pt

Question 1208

Which patients need spontaneous bacterial peritonitis prophylaxis?

Answer 1208

Portal HT | Pt who had SBP before

Question 1209

How do you treat acute bacterial prostatitis?

Answer 1209

6w of fluoroquinolone/ TMP-SMX

Question 1210

How do you differentiate between ischemic and hemorrhagic stroke on CT?

Answer 1210

Negative CT indicates ischemic stroke (dark) It can also be described as a mismatch between core and penumbra (penumbra is the area that can be saved while core is probably irreversibly infarcted) Hyperintense area and bright opacification (white) indicate hemorrhage

Question 1211

hat is the most common location of a rotator cuff injury?

Answer 1211

Supraspinatus

Question 1212

In which occasions you can take cultures after you give an antibiotic?

Answer 1212

Bacterial meningitis in adult with alarm signs

Question 1213

How do you treat tyramine-induced hypertensive crisis?

Answer 1213

Phentolamine

Question 1214

Bad prognostic factor of septic shock:

Answer 1214

Serum lactate

Question 1215

Pt with paroxysmal chest m. spasms and pleuritic chest pain after a URI. Dx?

Answer 1215

Pleurodynia or Bornholm disease, normally due to coxakie B

Question 1216

Most important RF for cerebral infraction? | Most important RF for cardiovascular disease?

Answer 1216

Cerebral infraction: HT (control HT also helps decrease hospitalization in HF) Cardiovascular disease: Smoking

Question 1217

What is the BP goal in DM?

Answer 1217

130/80, if more you have to adjust the medication until reaching it

Question 1218

Decreased residual vol. + pool of urine on the vagina. Dx?

Answer 1218

Vesicovaginal fistula | RF: pelvic radiation, pelvic sx

Question 1219

What does opacification mean on a chest Rx?

Answer 1219

``` Opacification = liquid: edema, pneumonia, hemothorax Hyperlucency = air: pneumothorax Haziness = atelectasis ```

Question 1220

Immunodeficiency not treated with IVIG:

Answer 1220

IgA deficiency: supportive and bracelet to avoid transfusions Transient hypogammaglobulinemia of infancy: no tto SCID: IVIG only waiting for transplant, stem cell transplant LAD Wiskott-Aldrich Chediak-Higashi CGD: INF gamma infections, TMP-SMX and itroconazole prophylaxis IVIG for: Bruton's agammaglobulinemia Common variable inmminodificncy

Question 1221

How do you differentiate between Transient tachypnea and Respiratory distress syndrome of the newborn?

Answer 1221

Both can have cyanosis, nasal flaring, intercostal retractions Transient tachypnea of the newborn: RF: prematurity, C-section Tachypnea a few hours after birth Due to delayed reabsorption of amniotic fluid in the alveoli leading to air trapping Best Dx test: Rx that shows flattened diaphragm and pulmonary congestion w fluid in the interlobular fissures! (you see all dark=air trapping, white lines on the lung fissures (Kerley B lines)=fluid) Tto: conservatory: 1) IV fluids 2) Monitor O2... =) Respiratory distress syndrome of the newborn: RF: prematurity Shows up at birth!! with intercostal retraction, flaring, grunting and tachypnea Pathophysiology: surfactant deficiency, alveolar collapse, increased alveolar surface tension Lecithin(phosphatidylcholine)/sphingomyelin on amniotic fluid >2:1 Best prevention tto: betamethasone Best first measure: O2 Best initial test: Rx showing bilateral ground glass opacities (white everywhere=ground glass=reticulogranular=atelectasis) and air bronchogram (air-filled bronchi surrounded by atelectasis) Best long term management: surfactant (trough intubation)

Question 1222

What happens when you put the intubation tube too far so you intubate only on the right bronchus?

Answer 1222

Air trapping immediately after the obstruction of the bronchus, then the air is reabsorbed and you get alveolar collapse also called atelectasis!

Question 1223

Cushing triad:

Answer 1223

HT Bradycardia Irregular respirations or respiratory depression * vs if you see hypotension and bradycardia and hypothermia where you should think neurogenic shock * vs if you see HT, tachycardia a and tachypnea where you should think of paroxysmal sympathetic hyperactivity

Question 1224

What is the MCC of necrotizing fasciitis?

Answer 1224

Strep pyogenes (group A)

Question 1225

Pt with gait instability that keeps falling backwards and cannot look up. Dx?

Answer 1225

Progressive supranuclear palsy

Question 1226

Formication happens on:

Answer 1226

Cocaine and amphetamine intoxication | Opioid withdrawal

Question 1227

Intermittent urine leakage and tender anterior vaginal wall mass. Dx?

Answer 1227

Urethral diverticulum Low post void residual

Question 1228

If you see ascites in a postmenopausal woman think of:

Answer 1228

Ovarian ca. Do exploratory laparotomy! as advanced ovarian cancer often spreads to the abdominal cavity, so the exploratory laparotomy with cancer resection and inspection is needed for surgical staging Image-guided biopsy is contraindicated, as it can predispose to abdominal cavity seeding

Question 1229

Enlarged supraclavicular lymph in young patient:

Answer 1229

Hodgkin lymphoma Hodgkin lymphoma also commonly associated with pruritis! Associated with increased LDH

Question 1230

Key locations of PAD based on symptoms:

Answer 1230

Femoropopliteal artery plaque → Calf claudication External iliac artery plaque → Thigh and calf claudication Aortoiliac plaque → Gluteal, thigh, calf claudication and impotence

Question 1231

What is the best action to improve long term px after an MI?

Answer 1231

Restoration of coronary blood flow by percutaneous intervention or fibrinolysis

Question 1232

When does a patient need psychotherapy vs SSRIs?

Answer 1232

If meets the criteria for MDD the pt needs SSRIs If it does not maybe it is adjustment disorder (reaction to an stressor that happened within 3mo) that is treated with psychotherapy

Question 1233

Risks of PPROM:

Answer 1233

Placental abruption Cord prolapse Preterm labor Intraamniotic infection

Question 1234

Upslanting palpebral fissures + hypotonia indicate:

Answer 1234

Down syndrome

Question 1235

What should you think of if you see an old pt with concentric LV hypertrophy in absence of HT?

Answer 1235

Restrictive cardiomyopathy Signs and symptoms: concentric LV hypertrophy and non-dilated LV cavity, RHF symptoms, bi-atrial enlargement, conduction abnormalities and high BNP

Question 1236

Management of ruptured ovarian cyst:

Answer 1236

Hemodynamically stable: reassurance | Hemodynamically unstable: laparoscopic cystectomy

Question 1237

What is the pathophysiology of vasovagal syncope?

Answer 1237

Sinus bradycardia and sinus arrest

Question 1238

Parkinson's characteristic gait:

Answer 1238

``` Hypokinetic gait Shuffling gait Festinating gait Narrow base Small-stride ``` Reduced amplitude on foot tapping or any other repetitive movement= bradykinesia

Question 1239

What can inverted T waves mean on to of MI?

Answer 1239

Hypertrophic cardiomyopathy, here you can see left axes deviation, or problems in depolarization (prominent Q waves) and repolarization (T-wave inversion)

Question 1240

How do you treat pulmonary fibrosis?

Answer 1240

Antifibrotic therapy as pirfenidone and nintedanib

Question 1241

DD. between tetanus and rabies:

Answer 1241

Rabies: hydrophobia, numbness around the wound, slower progression (months), animal bite Tetanus: spastic paralysis, faster progression (1w), inflammation around the wound, unvaccinated, dirty wound

Question 1242

How can you prevent Ca stones?

Answer 1242

Decrease Na intake

Question 1243

Dx requirements for acute liver failure:

Answer 1243

High ALT and AST (normally more than 1000) Signs of hepatic encephalopathy (confusion, asterixis) INR more or = 1.5

Question 1244

What reduces the risk of wound infection on burns?

Answer 1244

Early excision and grafting

Question 1245

How do you treat stroke in sickle cell disease?

Answer 1245

Exchange transfusion

Question 1246

If you see bilateral trigeminal neuralgia think of:

Answer 1246

MS

Question 1247

Murmur on a kid that had ToF corrected as an infant. Dx?

Answer 1247

Pulmonic regurgitation

Question 1248

Pt that goes on asystole right after he is put on mechanical ventilation. What is the pathophysiologic mechanism?

Answer 1248

Positive pressure ventilation causes an increase in intrathoracic pressure which on the setting of hypovolemia after tx can cause acute loss on RV preload and therefore decrease the CO and lead to cardiac arrest!

Question 1249

Episodes of vertigo induced by Valsalva or loud noises. Dx?

Answer 1249

Perilymphatic fistula

Question 1250

DD of infection after transplant:

Answer 1250

Less than 1 mo: bacterial infection 1-6 mo: opportunistic pathogens as CMV, aspergillus and TB More than 6mo: same pathogens as the normal population

Question 1251

Short inter-pregnancy interval leads to:

Answer 1251

PPROM Preemie Small baby Anemia in mom

Question 1252

Treatment of frostbite:

Answer 1252

Rapid rewarming on water bath at 37-39deg

Question 1253

Athlete collapses right after stopping exercise. Dx?

Answer 1253

Exercise-associated postural hypotension When the athlete stops exercising venous return suddenly drops because the muscle pump stops Management: place in trendelenburg and hydrate

Question 1254

Empiric antibiotic therapy for an empyema:

Answer 1254

Ceftriaxone + vancomycin/clindamycin + drainage

Question 1255

66 yo woman with dull LLQ pain, nausea/vomiting, alteration in bowel habits, sterile pyuria, dysuria and tender LLQ mass. Dx?

Answer 1255

Diverticulitis Management: bowel rest and antibiotics (ciprofloxacin + metronidazole) followed up with colonoscopy 4-8 weeks later (colonic malignancy can mimic the presentation and CT findings seen in diverticulitis) Indications for surgery in setting of acute diverticulitis (1) Emergency operation (peritonitis, abscess, etc.) (2) Any patient who has survived 2 episodes of acute diverticulitis should have elective removal of affected area to prevent recurrence

Question 1256

Kid with ulcerations in the lips, mouth and pharynx after drinking something under the sink. What did he ingest?

Answer 1256

Drain cleaner Ingestion of household bleach is often considered benign, whereas ingestion of industrial-grade bleach is very severe/morbid

Question 1257

Patient with recent liver transplant presents weeks later with fever, eosinophilia, elevated LFTs and a biopsy showing a mononuclear infiltrate with eosinophils in the hepatic triads. Dx?

Answer 1257

Allograft rejection Graft eosinophilia is a sensitive and specific marker of acute rejection in liver allografts

Question 1258

When can you start using sunscreen on a baby?

Answer 1258

After 6mo of age, before use protective clothing

Question 1259

How do you prevent neuropathic pain post herpes zoster?

Answer 1259

ORAL acyclovir Oral and IV acyclovir are equally effective in treating herpes zoster, so in pts who are going to be treated as an outpatient we would use oral acyclovir IV acyclovir is given to immunocompromised!! For kids with primary varicella infection (chickenpox) the treatment id only symptomatic

Question 1260

How can you prevent iron overload in its that need multiple transfusions (sickle, thalassemia)?

Answer 1260

Exchange rather than simple transfusion

Question 1261

1st line tto for symptomatic mitral stenosis:

Answer 1261

Percutaneous mitral balloon commissurotomy

Question 1262

Subepithelial deposits on renal biopsy indicates:

Answer 1262

Membranous nephropathy or Poststreptococcal glomerulonephritis Membranous has thickened capillary loops

Question 1263

Best next step in Dx when suspecting pancreatic adenocarcinoma:

Answer 1263

CT WITH contrast!

Question 1264

What do we use to estimate fluid requirements during the first 24 hours of care in burn patients? What do we use to verify adequate fluid infusion in burns?

Answer 1264

Parkland formula Urine output

Question 1265

Ataxia, ophthalmoplegia, and areflexia 2w after upper respiratory infection suggests:

Answer 1265

Miller-Fisher syndrome

Question 1266

D.D. between fistula, pseudoaneurism and hematoma:

Answer 1266

Fistula: continuous bruit (systolic + diastolic) Pseudoaneurism: pulsatile mass + systolic bruit Hematoma: no bruit Aneurism: pulsatile mass + continuous bruit + thrill. Choose if spontaneous!

Question 1267

What can be used as prophylactic treatment for chronic tension headache?

Answer 1267

Amitriptyline

Question 1268

What is thew tto. of an auricular hematoma?

Answer 1268

Incision and drainage

Question 1269

What is the tto. of carotid artery dissection?

Answer 1269

Heparin, aspirin or clopidogrel for 3-6 mo Tto is indicated for extracranial carotid artery dissection once a thrombus has been identified and intracranial hemorrhage has been ruled out by CT scan

Question 1270

Dermatofibroma vs Epidermoid cyst:

Answer 1270

Epidermoid cyst: firm, mobile, slow-growing nodule that arises from the epidermis Dermatofibroma: slow-growing, skin-colored or brownish nodules with positive dimple sign (squeezing leads to an inward retraction of the surface)

Question 1271

Confounding vs Effect modification:

Answer 1271

Confounding: no category is significant after stratification | Effect modification: one is significant after stratification

Question 1272

First line tto for rosacea:

Answer 1272

Topical metronidazole, azelaic acid or ivermectin

Question 1273

How is urine Na in SIADH?

Answer 1273

Normal or high, more than 20 as RAAS is suppressed and the pt is euvolemic

Question 1274

Pt with recent infection followed by features of a spinal cord lesion (urinary incontinence, hyperreflexia, a positive Babinski sign, bilateral weakness. sensory loss) with an identifiable level (loss up to a certain point on the spine). Dx? Characteristic feature?

Answer 1274

Transverse myelitis Pleocytosis on cerebrospinal fluid analysis

Question 1275

Best method to reduce childhood/adolesc obesity?

Answer 1275

Involve the parents

Question 1276

Metric of overall disease burden that takes into account the years lost due to death and disability: Metric of disease burden that takes into account the years lost due to death:

Answer 1276

Disability- adjusted life years Years of potential life lost

Question 1277

What is the BNSM when you suspect renal cell carcinoma?

Answer 1277

Nephrectomy when CT scan is concerning for a malignant mass

Question 1278

1st line tto in neonatal abstinence syndrome:

Answer 1278

Oral morphine

Question 1279

When looking at an Amsler grid, she says that the lines in the center appear wavy and bent. Dx?

Answer 1279

Age-related macular degeneration

Question 1280

Possible pericarditis complication:

Answer 1280

Cardiac tamponade

Question 1281

The net clinical benefit on a study is:

Answer 1281

Net clinical benefit=Clinical usefulness=Possible benefit - Possible harm

Question 1282

Sounds of severe aortic stenosis:

Answer 1282

Single S2 on inspiration (physiological splitting disappears because because aortic closure is delayed) Loud late-peaking systolic murmur Diminished carotid pulse

Question 1283

When is the patient obligated to disclose genetic information to its relatives?

Answer 1283

Only when the disclosure will help ameliorate or prevent a highly likely harm to an individual Huntington does not need to be disclosed because it cannot be treated

Question 1284

Buzzwords for rashes: Morbilliform Sandpaper Pustular

Answer 1284

Morbilliform: measles Sandpaper: scarlet fever Pustular: gonorrhea

Question 1285

What is used to calculate the MELD score (Model for End-stage Liver Disease mortality)?

Answer 1285

Bilirubin INR Creatinine Na

Question 1286

What is the biggest RF for osteoporosis?

Answer 1286

Age

Question 1287

Bilateral hemianopsia and hyperpigmentation following bilateral adrenalectomy for Cushing's disease:

Answer 1287

Nelson's syndrome; a pituitary microadenoma (pituitary enlargement) with supreasellar extension on MRI and very high plasma ACTH

Question 1288

Which factor is the most associated with euthanasia requests?

Answer 1288

Loss of autonomy and control of the dying process, also requests of euthanasia are more closely associated with fears of future suffering than acute pain at the moment

Question 1289

MCC of adverse events in hospitalized patients? and in hospitalized patients NOT undergoing surgery?

Answer 1289

Hospitalized patients: surgery complications as wound infections, bleeding, DVT Hospitalized patients NOT undergoing surgery: adverse drug events from hypoglycemic agents, anticoagulants, antibiotics or analgesics

Question 1290

Classic dashboard injury (anterior impact to a flexed knee) affect the:

Answer 1290

Posterior cruciate ligament

Question 1291

Treatment algorithm for HFrEF:

Answer 1291

ABDAS ``` Angiotensin-neprilysin inhibitor Beta-blocker Diuretic Aldosterone antagonist SGLT-2 inhibitor (glifozin) Isosorbid dinitrate/ Digoxin ```

Question 1292

Do RBCs express HLA antigens?

Answer 1292

No

Question 1293

How do you calculate the reduction in risk secondary to an intervention?

Answer 1293

1-RR

Question 1294

Management of pelvic fracture:

Answer 1294

1) Pelvic binder | 2) If the pelvic binder does not work you do an Angiographic embolization of the Hypogastric A. = Internal iliac A.