step 3 22

Question 1

factors of solitary pulmonary nodules suggesting further workup

Answer 1

Large size* (greater than 0.8 cm)
Advanced patient age
Female sex
Active or previous smoking
Family or personal history of lung cancer
Upper lobe location
Spiculated radiographic appearance

Question 2

biopsy approach for pulmonary nodules

Answer 2

• if central, fiberoptic bronchoscopy

- if peripheral, surgical excision percutaneoulsy

Question 3

first step in SLE patient presenting with potential kidney disease

Answer 3

renal biopsy (there are 6 subclasses of renal disease and therapy is based on subclass. This is why you need a biopsy).

Question 4

tinea capitis treatment

Answer 4

oral griseofulvin or oral terbinafine (need an oral to penetrate the hair follicles)

Question 5

first steps with lung cancer

Answer 5

1) identification and staging of the tumor, 2) preoperative physiologic assessment of lung function

Question 6

pericarditis presentation after MI + on EKG + on exam

Answer 6

pericarditis typically have pleuritic chest pain and a pericardial friction rub <4 days following an acute myocardial infarction. The characteristic ECG changes of diffuse PR depression and ST elevation may also be present, but can be masked by ECG changes of recent myocardial infarction.

• pleuritic chest pain that worsens with deep inspiration and improves with sitting up.
• pericardial friction rub

Question 7

ventricular aneurysm post MI treatment

Answer 7

late complication, typically weeks to months, after acute MI. It is characterized by ECG findings of persistent ST-segment elevation, along with deep Q waves in the same leads. The usual presentation is progressive left ventricular enlargement causing heart failure, refractory angina, ventricular arrhythmias, or systemic arterial embolization due to mural thrombus.

Question 8

most specific diagnostic finding for tamponade

Answer 8

Echocardiography showing early diastolic collapse of the right ventricle and right atrium

Question 9

most common type of brain cancer

Answer 9

mets

Question 10

cancers with mets to brain in order

Answer 10

lung, breast, unknown primary, melanoma, and colon cancer.

Question 11

tumor type with predilection for early metastasis to the brain.

Answer 11

small cell lung cancer

Question 12

osteoblastic bone mets

Answer 12

prostate
small cell lung
Hodgkin’s
breast (or lytic)

Question 13

workup of patient with possible prostate cancer presenting with bone pain

Answer 13

radioisotope bone scan

Question 14

pain features of bone mets

Answer 14

dull and aching or boring in character, and symptoms often occur at night.

Question 15

workup of osteolytic mets

Answer 15

PET, plain film

Question 16

factors most associated with request for euthanasia

Answer 16

A loss of sense of autonomy and dignity and the fear of future suffering

Question 17

first step in coma workup and interpretation

Answer 17

oculovestibular testing

• if normal (gaze deviation toward stimulus), prob psychogenic coma
• if abnormal than other cause

Question 18

stimulants for ADHD association with substance abuse?

Answer 18

none

Question 19

how to preserve organs in brain dead patients

Answer 19

intravenous fluids and desmopressin (central DI happens in brain death)

Question 20

ovarian torsion management

Answer 20

Laparoscopy with detorsion

Question 21

postop atelectasis management

Answer 21

IF NO respiratory secretions then continuous positive airway pressure,
IF secretions then aggressive pulmonary hygiene, including chest physiotherapy and suctioning.

Question 22

CXR with atelectasis

Answer 22

linear opacifications in the bilateral lung bases

Question 23

SVC syndrome presentation

Answer 23

• high risk of malignancy (e.g., family history or smokers) and presents with dyspnea, orthopnea, neck pain and swelling, and has cervical and upper extremities venous dilatation
• Pertinent physical findings are edema and erythema of the neck (which may sometimes compromise the face), and dilated veins of the arms and neck

Question 24

Nelson’s syndrome presentation

Answer 24

Bitemporal hemianopsia and hyperpigmentation following bilateral adrenalectomy for Cushing’s disease. Cause of pituitary enlargement is the loss of feedback by the adrenal glucocorticoids following bilateral adrenalectomy. The tumor in Nelson’s syndrome is aggressive and is treated by surgery and/or pituitary radiation. Following bilateral adrenalectomy, prophylactic pituitary radiation sometimes prevents the development of Nelson’s syndrome; however, this leads to an increased risk for hypopituitarism. Previously, bilateral adrenalectomy was the preferred treatment for Cushing’s disease; however, with the advent of better localization and improved techniques of transsphenoidal surgery, primary pituitary surgery is now the preferred treatment for Cushing’s disease.

Question 25

Nelson’s syndrome diagnosis

Answer 25

MRI (looking for pituitary microadenoma with suprasellar extension on MRI)
ACTH (extremely high plasma ACTH levels diagnostic)

Question 26

septic abortion presentation and setting

Answer 26

• fever, tachycardia, hypotension, lower abdominal pain, and mucopurulent cervical discharge
• usually after elective termination procedure (eg abortion), particularly one that was performed using unsterile technique. retained products of conception are retained.

Question 27

septic abortion management

Answer 27

• broad spectrum abx

- surgical evacuation of the uterine contents via suction curettage

Question 28

reference range ABG for O2

Answer 28

80 to 100 mm Hg.

Question 29

interpretation of VBG and ABG

Answer 29

***reference range is different

Question 30

laryngeal edema, stridor management post intubation

Answer 30

reintubate

Question 31

cause of torticolis (acute dystonic reactions)

Answer 31

dopamine blockade, thus metoclopramide can do it

Question 32

contraceptive for patient with contraindication to estrogen

Answer 32

progestin only IUD

Question 33

best contraceptive for patients on anticoagulation

Answer 33

decreases menstrual blood loss (which is often increased in patients on anticoagulation) by causing endometrial atrophy.

Question 34

treatment of trichomoniasis during pregnancy

Answer 34

Single dose metronidazole. To avoid infant exposure, breast milk should be expressed and discarded for 24 hours after dose administration.

Question 35

best antihypertensive to use on a patient on lithium

Answer 35

CCB’s (most others interact with lithium) (lithium has a narrow therapeutic index and is renally excreted. medications that suppress the glomerular filtration rate or affect potassium and sodium levels can increase lithium levels and lead to potential drug toxicity. CCBs don’t affect GFR)

Question 36

how you can also prevent skin damage from sun exposure

Answer 36

stay well hydrated

Question 37

most common pathogen isolated from cultures of corneal foreign bodies

Answer 37

coagulase negative Staphylococcus

Question 38

alopecia areata vs tinea capitis

Answer 38

Alopecia areata is characterized by smooth and discrete areas of complete hair loss. There is no associated scaling, scarring, or inflammation.

Question 39

alopecia areata prognosis

Answer 39

The hair loss usually develops over a few weeks and has a recurring pattern, even after treatment. Most of the patients will have regrowth of the hair in the involved areas over time.
- most patients have normal hair growth within the next one to two years even without treatment.

Question 40

first line treatment for alopecia areata

Answer 40

Topical or intralesional corticosteroids, which can cause regrowth of hair but not curative

Question 41

management of patient on chronic steroids

Answer 41

add vitamin D as well as calcium supplementation to the patient’s therapy. Based on the duration of therapy, bone densitometry is indicated for every year. (
Glucocorticoids decrease the intestinal absorption of calcium and increase the calcium excretion in the urine)

Question 42

TOF features

Answer 42

right ventricular outflow tract (RVOT) obstruction, overriding aorta, right ventricular hypertrophy, and VSD

Question 43

tricuspid valve stenosis murmur

Answer 43

mid-diastolic rumble that is best heard along the left sternal border

Question 44

MVP murmur

Answer 44

single or multiple non-ejection clicks and/or mid to late systolic murmur of mitral regurgitation that is best heard at or just medial to the cardiac apex.

Question 45

most common cause of death from steering wheel injury

Answer 45

aortic rupture

Question 46

night terrors management

Answer 46

Mostly self-limiting

Administer low-dose benzodiazepine at bedtime if episodes are frequent, persistent & distressing

Question 47

predictors of severity in pancreatitis

Answer 47

older age, obesity, hematocrit, C-reactive protein, and blood urea nitrogen (BUN). An elevated hematocrit (>44%) on admission is predictive of more severe disease, as it reflects greater hemoconcentration from third-space losses. Similarly, a BUN >20 mg/dL at the time of admission is associated with an increased risk of death.

Question 48

epididymitis workup and treatment

Answer 48

UA + culture
NAAT for chlamydia and gonorrhea
IF gonorrhea can’t be ruled out (acute urethritis or proctitis, high risk of sexually transmitted infections) → CTX + doxycycline
IF low risk for gonorrhea → fluoroquinolone

Question 49

why do you give diuretics in acute decompensated HF

Answer 49

reduce preload

Question 50

more important test characteristic for test with high PPV

Answer 50

specificity

Question 51

delayed puberty workup

Answer 51

bone age radiograph and measuring FSH, LH, and testosterone levels.