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1Current > USMLE STEP 3 > Flashcards

USMLE STEP 3 Flashcards

1
Q

Pertussis treatment

A

azithromycin or clarithomycin; start prophylactic treatment in everyone > 6 months

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2
Q

Erythromycin side effect in children

A

Risk of hypertrophic pyloric stenosis

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3
Q

Definitive treatment of hemochromatosis

A

deferoxamine

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4
Q

Causes of hemochromatosis

A

Primary (HFE gene) and secondary (requiring frequent blood transfusions)

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5
Q

Atraumatic hip pain in children

A

transient synovitis most common cause

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6
Q

Legg Calves Perthes

A

avascular necrosis of the femoral head

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7
Q

Hemodynamically unstable w/ no known source after EGD?

A

Angiography. If HDS, consider colonoscopy

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8
Q

If patient is having left lower quadrant pain and low grade fever, is colonoscopy indicated?

A

No, colonoscopy is contraindicated for risk of colonic perforation in diverticulitis

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9
Q

Risk of injured structures in lateral horizontal eyelid laceration?

A

orbital septum and levator palpebrae

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10
Q

Risk of injured structures in medial horizontal eyelid laceration?

A

Canaliculi, punctum and nasolacrimal duct injury

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11
Q

Proper timing of intercourse for conception?

A

Days 9 - 16

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12
Q

Infertility definition

A

> 12 months for < 35 yo; > 6 months for > 35 yo

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13
Q

When to get chromosomal analysis for infertility?

A

Patients with oligospermia or azoospermia on semen analysis or in women w/ > 3 spontaneous abortions

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14
Q

Chronic pain, immobile uterus, and pelvic nodularity are indicative of what?

A

Endometriosis; consider pelvic laparoscopy for improvement of fertility

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15
Q

Serum ascites albumin gradient

A

= serum albumin value - ascites albumin value

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16
Q

Portal hypertension is indicated by what?

A

SAAG > 1.1; but can also be seen with:

CHF

cirrhosis

alcoholic hepatitis

Budd-Chiari

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17
Q

Differential for SAAG < 1.1

A

malignancy of abdominal organs

tuberculosis

nephrotic syndrome

pancreatitis

serositis

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18
Q

Hypoparathyroidism treatment

A

Calciferol (25-OH-vitamin D); calcitriol (1,25-vitamin D); CalciFERol is preferred because it has been shown to be effective and is cheaper

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19
Q

Hypoparathyroidism pathology

A

Low PTH -> lack of conversion of 25-OH-vitamin D to 1,25-vitamin D -> high urinary exceretion of calcium and lack of phosphorous secretion

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20
Q

Organs important for vitamin D synthesis

A

Liver (25 position) is step 1 of hydroxylation and kidney is step 2 (1 position)

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21
Q

Next step in treatment of hypoPTH patient already receiving calcium and vitamin D

A

Consider addition of thiazide to

1) decrease urinary calcium
2) increase serum calcium

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22
Q

Risk of oxybutynin

A

anticholinergic effects -> delirium and falls; risks also present in patients with mysathenia gravis and glaucoma

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23
Q

Valproate pregnancy effects

A

neural tube defects, craniofacial abnormalities, microcephaly, growth retardation, cleft lip, limb defects, genital abnormalities

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24
Q

Bipolar patients contraindicated drugs

A

antidepressant monotherapy

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25
Q

Indications for electroconvulsive therapy

A

unipolar and bipolar depression; catatonia; bipolar mania

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26
Q

Onset of hungry bone syndrome

A

2-4 days after a parathyroidectomy

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27
Q

Causes of microcytic anemia

A

TAILS; thalassemia, anemia of chronic disease, iron deficiency anemia, lead poisoning,
sideroblastic anemia

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28
Q

Which sickle thalassemia has no HbA?

A

Sickle cell beta (0) thalassemia

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29
Q

Differential for high HbA and HbS

A

sickle cell beta + thalassemia and sickle cell trait

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30
Q

Sickle cell beta + thalassemia subtypes

A

type I: 3-5% HbA
type II: 8-14% HbA
type III: 18-25% HbA

If 60% HbA -> it is sickle cell trait

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31
Q

Physical exam finding for sideroblastic anemia

A

hepatosplenomegaly

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32
Q

Target glucose level for stress hyperglycemia

A

140-180

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33
Q

Diagnostic criteria for DM

A

1) > 200 serum andom glucose
2) fasting > 126
3) A1c > 6.5
4) OGTT > 200 @ 2h

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34
Q

Medicare Part A covers

A

hospital, skilled nursing, hospice

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35
Q

Medicare Part B covers

A

outpatient visits, preventive care, labs, outpatient surgery

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36
Q

Medicare Part C covers

A

Medicare benefits via private companies

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37
Q

Medicare Part D

A

Drug coverage

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38
Q

End stage conditions covered by Medicare

A

disability, ESRD, ALS, and other neurodegenerative diseases

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39
Q

Medigap

A

optional supplemental plans not covered by part A and B; no meds covered

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40
Q

Definition of a negatively skewed distribution

A

mean < median < mode

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41
Q

Definition of a positively skewed distribution

A

mean > median > mode

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42
Q

normal distribution

A

mean ~ median ~ mode

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43
Q

When is the median a better measure of central tendency than mean?

A

in positively and negatively skewed distributions

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44
Q

smear findings for thalassemia

A

target cells

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45
Q

Prophylactic regimens for neisseria meningitidis exposure

A

1) ciprofloxacin (1 dose)
2) rifampin (BID, 2 days)
3) ceftriaxone (1 dose)

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46
Q

Definition of close exposure to neisseria meningitidis

A

> 8 hours of exposure w/i < 3 feet of infected

OR

direct exposure to respiratory secretions w/i 7 days

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47
Q

TRUE OR FALSE: Women on OCPs should not take rifampin?

A

TRUE

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48
Q

Acute hepatitis B infection definition

A

elevated AST/ALT
+ HBsAg
+ HB IgM core
+ HBeAg
+ HB DNA

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49
Q

Outcome of acute HBV infection

A

70% asymptomatic; 30% with symptoms (anorexia, nausea, jaundice, RUQ pain)

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50
Q

Definition of chronic HBV

A

+ HBsAg after 6 months

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51
Q

Postexposure prophylaxis for Hep B

A

hepatitis B immunoglobulin and hep B vaccine; given within 12-24h

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52
Q

When is interferon therapy beneficial for hepatitis B

A

when genotype A is present

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53
Q

Risk of developing chronic hep B infection

A

5%

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54
Q

Difference in disease course for hepatitis B

A

Older are more likely to be symptomatic

Younger are likelier to have progression to chronic infection

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55
Q

Risk of progression to chronic disease for hepatitis C

A

75-85%; acutely often asymptomatic

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56
Q

Criteria for thrombolytics in stroke

A

onset < 3-4.5 hours

Excluded if hemorrhage, trauma, neoplasm, vascular malformation, recent surgery, BP > 185/110, Plt < 100,000, glucose < 50, INR > 1.7

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57
Q

Desmopressin effect on platelet function

A

agonist activity at V2 -> exocytosis of VWF from WP bodies causing platelet adhesion and protection of FVIII

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58
Q

Vasopressin effects

A

V1: uterotonic and vasoconstrictor properties

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59
Q

When is DVT risk highest in stroke patients?

A

Days 2-7; especially with hemiparesis (up to 75%); PE is most common cause of early death in acute stroke

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60
Q

Contraindications to VZV or MMR vaccine

A

1) anaphylaxis to neomycin
2) anaphylaxis to gelatin
3) pregnancy
4) immunodeficiency
- neoplasm
- suppression
- AIDS
- congenital)

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61
Q

VZV given at:

A

age 12-15 and age 4-6

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62
Q

VZV for transplant recipients

A

4-6 weeks prior to transplant

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63
Q

What to do if a VZV immunized patient develops a rash and sibling is immune compromised?

A

Quarantine immunized patient; give VZIG for seronegative patients

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64
Q

Cyanide toxicity symptoms

A

Think about this in patients post-MI

Symptoms:

1) skin flushing (early), cyanosis (late)
2) neuro: AMS, HA,
3) cardiac: arrhythmia,
4) pulm: tachypnea followed by bradypnea, pulmonary edema
5) Renal: metabolic acidosis

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65
Q

Nitrodilator physiologic effect

A

1) Venodilation
2) decreased preload
3) decreased oxygen demand

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66
Q

Treatment for cyanide toxicity from nitroprusside

A

sodium thiosulfate

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67
Q

palpable purpura, elevated rheumatoid, hypocomplementemia; presenting with fatigue and arthralgias or renal insufficiency (glomerulonephritis)

A

Mixed cryoglobulinemia syndrome; confirm with serum cryoglobulin

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68
Q

pathophysiology of mixed cryoglobulinemia

A

vasculitis from deposition of immune complexes (IgG and IgM RF); especially common with hepatitis C or lymphoproliferative, autoimmune disease

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69
Q

GPA distinction from cryoglobulinemia

A

Findings of respiratory symptoms (sinusitis, rhinorrhea) and normal/elevated complement

Other findings: palpable purpura, glomerulonephritis, fatigue

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70
Q

systemic lupus erythematous distinction from mixed cryoglobulinemia

A

shares arthralgias and renal disease but no palpable purpura; look for malar rash or discoid lesions

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71
Q

Goodpasture disease distinction from GPA

A

alveolar hemorrhage and hemoptysis without systemic symptoms; anti-GBM disease

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72
Q

Stages of treatment for mixed cryoglobulinemia

A

1) immune suppression with prednisone and rituximab
2) treatment of underlying disease

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73
Q

prophylactic treatment for pcp (pneumocystis pneumonia) and toxoplasma

A

trimethoprim-sulfamethoxazole; dapsone if TMP-SMX untolerated; dapsone + pyrimethamine + leucovorin

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74
Q

When to test for pheochromocytoma

A

headache, tachycardia, and diaphoresis

orthostatic hypotension, blurry vision, weight loss

early age onset hypertension

familial syndromes (MEN2, NF1, VHL)

Incidental adrenal mass

Dilated cardiomyopathy

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75
Q

diagnostic test for pheochromocytoma

A

24h urinary metanephrines and catecholamines

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76
Q

Drugs affecting pheochromocytoma testing

A

tricyclics and decongestants

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77
Q

Workup if urinary metanephrines + but MRI negative

A

MIBG scan (also obtain if tumor > 5 cm or with familial disorder)

Octreotide scan

Whole body MRI

PET

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78
Q

When to resect a pheochromocytoma

A

1) alpha blockade for 10-14 days
2) fluid repletion
3) beta blockade after alpha blockade (risk of hypertension)

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79
Q

Surgical complications from pheochromocytoma

A

1) hypertension -> nitroprusside, phentolamine, or nicardipine
2) hypotension -> NS, pressors
3) hypoglycemia -> IV dextrose
4) arrhythmia -> IV lidocaine or esmolol

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80
Q

Complications from brain death for organ transplantation

A

1) systemic infection
2) volume depletion (diabetes insipidus)
3) hypotension (ischemia)

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81
Q

PE with … is associated with poor prognosis

A

elevated cardiac troponin; hypotension; hemodynamic instability

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82
Q

common ABG finding in PE

A

respiratory alkalosis with elevated A-a gradient

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83
Q

Treatment options for PE

A

1) anticoagulation - all
2) IVC filter - contraindication to #1
3) thrombolysis - hypotension (SBP < 90) AND low bleeding risk
4) embolectomy - presence of shock or failed #3 w/ persistent hypotension

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84
Q

Antibiotic for mammalian bites

A

amoxicillin-clavulanic acid to cover pasturella and strep pyogenes

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85
Q

antibiotic for lymphadenitis

A

clindamycin

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86
Q

cat-scratch disease pathology

A

non-caseating granuloma

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87
Q

Pathology of otitis externa

A

infection of the external auditory canal -> pain with manipulation of pinna; contrast with postauricular pain seen in mastoiditis

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88
Q

labyrinthitis pathology

A

inflammation from mastoid air cells to bony labyrinth of inner ear (cochlea, vestibule, semicircular canals)

presents with vertigo, tinnitus, and nystagmus

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89
Q

Sitagliptin is contraindicated in pts with hx of…?

A

pancreatitis; dpp-4 inhibitors should not be used in those w/ hx of pancreatitis

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90
Q

Hemophilia inheritance pattern

A

X-linked recessive; usually occurring in males

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91
Q

Pseudohyphae indicate what on vaginal microscopy…

A

candidiasis

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92
Q

clue cells indicate what on smear…

A

bacterial vaginosis (gardnerella)

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93
Q

pear-shaped motile organisms indicate…

A

trichomoniasis

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94
Q

Name this personality disorder: emotional, attention-seeking, provocative, sexual, shallow, impressionistic and vague, suggestible

A

Histrionic

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95
Q

Name this personality disorder: avoids abandonment, intense relationships, self-injurious, impulsive, suicidal, intense anger, chronic emptiness, and unstable self-image

A

Borderline

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96
Q

Name this personality disorder: psychological dependence on others to meet needs

A

“Dependent; these patients lack ““clingy and emotional”” tendencies seen in histrionic”

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97
Q

marfan syndrome genetic mutation is in…

A

fibrillin 1

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98
Q

Skeletal findings in marfan syndrome

A

1) arachnodactyly
2) decreased upper to lower body ratio
3) increased arm to height ratio
4) pectus deformity, scoliosis, or kyphosis
5) joint hypermobility

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99
Q

ocular findings of marfan syndrome

A

ectopia lentis

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100
Q

cardiovascular findings of marfan syndrome

A

1) aortic dilatation, regurgitation or dissection (CAUSE OF MORBIDITY AND MORTALITY)
2) mitral valve prolapse

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101
Q

pulmonary findings for marfan syndrome

A

spontaneous pneumothorax

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102
Q

Standard screening for marfan syndrome

A

1) counseled on low-intensity exercise
2) TTE or CT chest

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103
Q

Patients with syphilis require a … if they have neurologic symptoms

A

lumbar puncture

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104
Q

Name the reaction from treatment of syphilis

A

Jarisch-Herxheimer reaction; no effective prevention is available

Symptoms are fever, malaise, chills, HA, and myalgias

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105
Q

Name the mechanism behind HIV lipodystrophy and ways to treat it

A

insulin resistance; metformin and TZDs (rosiglitazone and pioglitazone)

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106
Q

Side effects of nicotinic acid for hyperlipidemia

A

flushing, pruritus, and liver toxicity

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107
Q

Treatment for hypertriglyceridemia in setting of antiretroviral therapy

A

If triglycerides > 500 -> fibrates first.

If < 500, statins are first-line

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108
Q

Drugs which can cause macrocytosis

A

trimethoprim, methotrexate, and phenytoin can all cause macrocytic anemia via disruption of folic acid metabolism

MTX inhibits dihydrofolate reductase

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109
Q

Antidote for macrocytic anemia from chronic MTX treatment

A

Leucovorin aka FOLINIC acid, a more potent folic acid

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110
Q

Common nutritional deficiencies in Celiac disease

A

iron, calcium, vitamin D, and folic acid

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111
Q

Risk factors for celiac disease patients

A

osteopenia, osteoporosis

DXA at time of diagnosis and repeat 1 year later

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112
Q

Treatment of dermatitis herpetiformis

A

dapsone in addition to gluten free diet

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113
Q

Recommended vaccination for celiac disease

A

pneumococcal vaccination

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114
Q

Symptoms of whipple disease

A

arthralgia, diarrhea, weight loss

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115
Q

Etiology of infectious mono

A

EBV

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116
Q

Features of infectious mono

A

fever

tonsillar pharyngitis +/- exudates

lymphadenopathy

fatigue

Hepatosplenomegaly

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117
Q

What can happen after administering amoxicillin to those with infectious mono?

A

rash

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118
Q

False-negative rate of testing for infectious mono?

A

25% false negative rate with Monospot (heterophile antibody) test

transient hepatitis and lymphocytosis can be supportive

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119
Q

Treatment of infectious mono

A

counsel about avoiding contact sports > 4 weeks; NSAIDs if needed

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120
Q

Possible complications from infectious mono and its treatment

A

1) airway obstruction
2) aplastic anemia
3) thrombocytopenia

treat with STEROIDS for above

Peritonsillar abscess is usually UNIlateral and presents more often with dysphagia

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121
Q

Recommended treatment for Raynaud

A

nifedipine or amlodipine or diltiazem

DIHYDROPYRIDINE calcium channel blockers are best

Nitroglycerin is an adjunct agent

Praozosin and other alpha blockers can be used but patients become refractory

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122
Q

Workup for rheumatologic conditions:

A

ANA RF, CBC, chem panel, UA, complement level

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123
Q

Diagnostic workup for orthostatic proteinuria

A

split 24h urine collection; normal at night and elevated during daytime

all other workup should be negative

NO further invasive diagnostic workup or treatment needed

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124
Q

Recurrent C diff infection treatment

A

first recurrence: metronidazole or vancomycin depending on severity

second recurrence: pulsed vancomycin

third recurrence:
fidaxomicin or fecal matter transplant

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125
Q

Definition for severe c diff infection

A

fever, leukocytosis > 15k, or creatinine > 1.5x baseline

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126
Q

Aprepitant

A

new anti-emetic that works by blocking substance P and blocking effects of neurokinin

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127
Q

Metoclopramid side effects

A

extrapyramidal symptoms from blocking D2 centrally and peripherally -> akathisia, dystonia, and parkinson-like symptoms

risk: up to 30% in high-doses

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128
Q

hypomanic symptoms are described by:

A

decreased sleep, increased energy, pressured speech, increased new ideas

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129
Q

Treatment for severe manic episode

A

lithium OR valproate

+

antipsychotic

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130
Q

Mania vs severe mania

A

decreased sleep, hypersexual, pressured speech, hyperactive, grandiose delusions

severe:
psychosis, aggression, high-risk behaviors

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131
Q

Chlamydial conjunctivitis time of symptom onset

A

5-14 days; transmitted transvaginally by secretions

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132
Q

Manifestations of chlamydial conjunctivitis

A

eyelid swelling, watery or mucopurulent discharge, thickened and injected conjunctiva (CHEMOSIS)

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133
Q

sequelae of untreated chlamydial conjunctivitis

A

chlamydial pneumonia at age 4-12 weeks; afebrile with staccato cough and rales

corneal scarring

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134
Q

Treatment for chlamydial conjunctivitis

A

oral erythromycin

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135
Q

diagnosis of chlamydial conjunctivitis

A

culture or PCR testing of drainage; requires conjunctival scrapings

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136
Q

chalmydia: intracellular or extracellular organism

A

INTRAcellular

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137
Q

Risks of living donor kidney transplant

A

fetal loss, pre-eclampsia

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138
Q

Which has better outcomes, living or deceased kidney transplant?

A

living

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139
Q

Best donor for living kidney transplant?

A

sibling with no HLA mismatch

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140
Q

OPTN guidelines on age for living donor transplantation?

A

if < 18; absolute contraindication to organ transplant

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141
Q

OPTN contraindications for living kidney transplant?

A

diabetes

hypertension with evidence of end-organ damage

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142
Q

Serotonin syndrome offending medications

A

SSRI/SNRI, TCA, tramadol, linezolid

MAOI + one of the above

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143
Q

Features of serotonin syndrome

A

1) mental status (anxiety, agitation, delirium)
2) autonomic dysregulation (diaphoresis, HTN, tachycardia, hyperthermia, vomiting, diarrhea)
3) neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)

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144
Q

Management of serotonin syndrome

A

1) discontinue causative meds
2) supportive care
3) prn benzodiazepines

4) CYPROHEPTADINE if above all fail

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145
Q

Common MAOI

A

phenelzine

tranylcypromine

rasagiline, selegiline

methylene blue

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146
Q

Washout period before starting MAOI

A

14 days

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147
Q

SSRI least likely to cause discontinuation syndrome

A

fluoxetine - long half-life

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148
Q

Neuroleptic malignant syndrome pathology

A

reaction to dopamine antagonism

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149
Q

NMS differences from serotonin syndrome

A

“lack of neuromuscular hyperactivity -> NO tremor, hyperreflexia, clonus

NMS characterized by ““lead pipe”” rigidity”

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150
Q

Mechanism of glipizide

A

secreatagogues -> requires pancreatic beta cell reserve

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151
Q

Which drug classes are incretin-based?

A

DPP-4 inhibitors (sitagliptin) and glucagon-like-peptide 1 agonists (liraglutide, exenatide)

BOTH classes to be avoided in pts with pancreatitis

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152
Q

Metformin contraindication

A

GFR < 30 ml/min

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153
Q

Pancreatogenic diabetes pathology…

A

exhaustion of both alpha and beta islet cells from chronic pancreatitis causing a lack of glucagon and insulin; treat with insulin

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154
Q

If a healthcare worker has sustained a fingerstick but the source patient has no HBsAg, what is given?

A

Hepatitis B vaccination and NO HB immunoglobulin

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155
Q

Name the risk associated with TZD when given to patients with CHF

A

Pioglitazone and rosiglitazone in the TZD class can cause PULMONARY EDEMA by acting on the PPAR-gamma receptor promoting sodium reabsorption at the collecting tubule; occurs at a rate of 4-6%

consider SPIRONOLACTONE to antagonize the effects of TZD on sodium reabsorption

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156
Q

Risk factors for cerebral palsy

A

prematurity, low birth weight

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157
Q

Features of cerebral palsy

A

delayed motor milestones

abnormal tone and hyperreflexia

seizures, intellectual disability

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158
Q

workup for cerebral palsy

A

MRI +/- EEG +/- genetic/metabolic testing

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159
Q

Most common cerebral palsy subtype

A

spastic

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160
Q

8 month motor milestones

A

rolling over

sitting without support

starting to crawl

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161
Q

9 month motor milestones

A

pull to a stand

cruise

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162
Q

potential MR findings in cerebral palsy

A

periventricular leukomalacia

ischemic insult

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163
Q

Are gifts permissible to physicians?

A

Yes, if they are not excessive and not likely to influence care

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164
Q

Treatment of herpes zoster

A

If presenting within 72h after rash onset, treat with 7 DAYS of oral valacyclovir +/- analgesics

If > 72 hours after rash onset, no antiviral treatment. Treat sympomatically with zinc oxide cream and analgesics

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165
Q

Postexposure prophylaxis for health care workers non-immune to VZV

A

varicella vaccine within 5 days

no treatment if prior documented immunity

if pregnant or immune compromised, VZIG or valacyclovir

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166
Q

Definition of post-herpetic neuralgia and treatment

A

> 4 months after rash onset

Treat with TCA, gabapentin, or pregabalin

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167
Q

Treatment of papillary thyroid cancer

A

1) stage w/ US of neck and cervical lymph nodes first
2) if simple disease w/ nodule < 1 cm -> thyroid lobectomy
3) if complicated or > 1 cm in diameter -> total thyroidectomy

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168
Q

phenytoin toxicity is marked by…

A

nystagmus on far lateral gaze

may present with blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased cognition –> can proceed to coma

therapeutic range 10-20

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169
Q

Is alcohol abuse an absolute contraindication to cardiac transplant?

A

yes

poor psychosocial support is a relative contra-indication

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170
Q

When does bone density screening start?

A

age 65 if no risk factors

risk factors:

1) body weight < 127 lbs
2) steroid use
3) smoker
4) malabsorptive disorder
5) hx of hip fracture

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171
Q

Risks of hormone replacement therapy for menopause

A

breast cancer, coronary artery disease, stroke, venous thromboembolism

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172
Q

RDA of calcium and vitamin D

A

1200 Ca2+, no greater than 2000

600-800 Vitamin D, no greater than 4000

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173
Q

Define flexible kyphosis

A

thoracic kyphosis of 20-40 degrees

should be correctable by voluntary hyper-extension

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174
Q

Define Scheuermann disease

A

kyphosis that is not easily correctable

Milwaukee brace if angulation is < 70-80 degrees of kyphosis

Severe cases: >70-80 degrees, intractable pain, neurologic abnormalities -> surgical correction

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175
Q

Labs suggestive of a non-functioning pituitary adenoma

A

suppressed LH and FSH

INCREASED alpha subunits

Usually asymptomatic until mass effect causes neurologic symptoms

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176
Q

Pathological origin of nonfunctioning pituitary adenoma

A

gonaotrophs

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177
Q

First-line treatment for non-functioning adenoma

A

trans-sphenoidal surgery

second line is radiation; risk of neurologic injury and hypopituitarism

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178
Q

First line treatment for prolactinomas

A

dopaminergic medications - eg cabergoline

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179
Q

levels usually associated with prolactinomas

A

> 200

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180
Q

Hormonal treatment for growth-hormone producing adenomas seen in acromegaly

A

Octreotide (somatostatin analog)

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181
Q

Symptoms of trichomonas vaginalis

A

pruritus

green, frothy, malodorous discharge

vaginal inflammation

vaginal pH > 4.5

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182
Q

Treatment for trichomonas vaginalis

A

metronidazole - single dose 2g

if breastfeeding, patient needs to stop for 24h

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183
Q

If pulmonary contusion is suspected… what is correct management?

A

hospital observation for 24-48 hours

pain control to prevent hypoventilation

physiotherapy, suctioning, O2 as needed

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184
Q

Signs and symptoms of pulmonary contusion

A

hemoptysis

dyspnea

irregular but LOCAL opacification

delayed onset of respiratory symptoms

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185
Q

Triad of fat emboli syndrome

A

rash

altered mental status

respiratory distress

negative CXR

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186
Q

Presentation of hypothalamic amenorrhea

A

significant exercise

caloric deficit

stress fractures

amenorrhea and infertility

breast atrophy

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187
Q

Hormone findings in hypothalamic amenorrhea

A

global decrease of

1) GnRH
2) LH/FSH
3) estrogen

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188
Q

Abnormal lab findings in hypothalamic amenorrhea

A

1) decreased bone mineral density
2) hypercholesterolemia
3) hypertriglyceridemia

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189
Q

Treatment for hypothalamic amenorrhea

A

increased caloric intake

estrogen

calcium and vitamin D

DXA scan

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190
Q

Diseases associated with primary ovarian insufficiency

A

age < 40

autoimmune disease

Turner syndrome

prior chemoradiation

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191
Q

Lab findings in primary ovarian insufficiency

A

elevated FSH

low estradiol

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192
Q

Plaque psoriasis treatment options

A

< 10% body surface area:
1) topical steroids (eg fluocinonide or betamethasone) for 4 weeks

2) calcipotriene (vitamin D derivative)

> 10% body surface area:
1) narrowband UVB therapy

2) systemic therapy (MTX, biologics)

FACIAL or intertriginous psoriasis

1) tacrolimus
2) low potency steroids (hydrocortisone)

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193
Q

Treatment of psoriatic arthritis

A

methotrexate or other systemic immune suppression

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194
Q

Joint involvement of RA in the hands

A

MCP and PIP

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195
Q

Joint involvement of psoriatic arthritis in the hands

A

DIP

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196
Q

Clinical features of 11-hydroxylase deficiency

A

Hypertension

Hypernatremia

Hypokalemia

Due to elevated buildup of 11-deoxycortisol and 11-deoxycortisone

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197
Q

True or false, 11-hydroxylase deficiency causes ambiguous genitalia

A

TRUE

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198
Q

True or false, 17-hydroxylase deficiency causes ambigious genitalia

A

FALSE

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199
Q

5 alpha reductase deficiency results in what

A

AR inheritance

Causes 46, XY to appear externally female

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200
Q

Conditions associated with acute severe seborrheic dermatitis (dandruff)

A

Parkinson disease

HIV

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201
Q

In the pre-contemplation stage, do patients recognize negative consequences?

A

NO

encourage evaluation of possible consequences

consider explaining risk

Do NOT recommend action

202
Q

in the stage of contemplation, what do patients think about consequences?

A

they acknowledge them but are ambivalent

encourage pro and con evaluation of situation

203
Q

What follows the stage of contemplation?

A

Preparation; a decision to change has been made

Encourage small steps

204
Q

What can be done when a patient is in the action stage?

A

help identify strategies

help identify sources of support

promote self-efficacy

205
Q

What follows the action stage?

A

Maintenance

This step should focus on relapse prevention

AND

development of intrinsic rewards

206
Q

What characterizes sicca syndrome?

A

Xerostomia (dry mouth)

Keratoconjunctivitis sicca (dry eyes)

207
Q

Sicca syndrome is associated with what?

A

Sjogren syndrome

208
Q

Name possible sequelae from having xerostomia

A

dental caries

candidiasis

chronic esophagitis

209
Q

Pseudotumor cerebri is associated with obese women but can be associated with these endocrinopathies…

A

hypoPTH

hypothyroidism

adrenal insufficiency

Cushing disease

210
Q

Name medications that can cause pseudotumor cerebri

A

isotretinoin

all-trans-retinoic acid

minocycline, tetracycline

cimetidine

steroids

danazol

tamoxifen

levothyroxine

lithium

nitrofurantoin

211
Q

Name the symptoms associated with cluster headaches

A

localization to the temporal and periorbital region

lacrimation

nasal congestion

nausea

occurring 1-2 periods lasting for 2-3 months

212
Q

Migraine headaches can present with the following symptoms…

A

pulsatile/throbbing in nature

nausea/vomiting

photophobia/phonophobia

flashes, loss of vision, dizziness, or tinnitus

213
Q

What are the hemodynamic characteristics of hypovolemic shock?

A

Decreased pressures with increased SVR

preload measured by right atrial pressure and PCWP and cardiac index

decreased mixed venous oxygen saturation

214
Q

What are the hemodynamic characteristics of cardiogenic shock?

A

Increased preload (RA, PCWP)

Decreased cardiac index

Increased SVR

Decreased mixed venous oxygen

215
Q

Name the defining characteristic of septic shock

A

decreased systemic vascular resistance

216
Q

By what amount does aspirin administration reduce mortality in acute MI?

A

25% for acute MI

50% for unstable angina

217
Q

When is prasurgrel given in MI?

A

ONLY AFTER angioplasty

MOA: blocks ADP induced activation of P2Y12; similar to clopidogrel and ticagrelor

218
Q

Drugs with mortality benefit for acute MI

A

Mortality benefit:
Angioplasty/thrombolytics (time dependent)

Aspirin (ASAP)

Metoprolol (no time dependence)

clopidogrel OR ticagrelor (add to aspirin w/ acute MI or if post angioplasty/stenting)

Statins

Dependent mortality benefit:
ACE-I or ARBs (mortality benefit with L ventricular dysfunction or systolic dysfunction)

No mortality benefit:
Oxygen
Calcium channel blockers
Lidocaine
Amiodarone
Nitrates + morphine

219
Q

Indication for primary angioplasty?

A

Primary angioplasty; must be done within 90 minutes of ED arrival; no mortality benefit if stable angina is present

220
Q

indication for thrombolytics

A

CP < 12 hours

given within 30 minutes of arrival in ED

ST segment elevation in 2 or more contiguous leads

new LBBB

221
Q

When do you choose PCI over thrombolytics in acute MI?

A

If access is available to PCI

If the question asks about the single greatest mortality benefit

If there is a contraindication to thrombolysis

222
Q

Mechanism of thrombolytic therapy

A

Converts plasminogen to plasmin, thereby breaking down fibrin clots

223
Q

Mechanism of beta blockers on improving mortality in MI:

A

Anti-ischemic effect by reduction in HR -> increased ventricular filling time -> increased stroke volume -> increased cardiac output

Anti-arrhythmia due to ischemia

224
Q

When are verpamil or diltiazem preferred over beta blockers in acute MI?

A

if intolerant to beta blockers (eg asthma)

if cocaine-induced chest pain

in cases of Prinzmetal angina

225
Q

Diagnostic criteria for prinzmetal angina?

A

1) Angina responsive to nitrates w/ one of the following:
- rest angina
- inducible by hyperventilation
- diurnal variation
- CP suppressible with calcium channel blockers

2) transient ischemic EKG changes
3) angiographic evidence of coronary artery spasm in response to ergot, hyperventilation, or acetylcholine

226
Q

Indications for pacemaker following acute MI

A

3rd degree AV block

2nd degree, Mobitz II

New LBBB

Symptomatic bradycardia

227
Q

Indications for lidocaine or amiodarone in acute MI?

A

Ongoing VTACH or VFIB

Do NOT give prophylactically

228
Q

When is exertion (eg coitus) acceptable post MI?

A

2-6 weeks

229
Q

Name the 3 differences in management with NSTEMI?

A

1) no thrombolytics

2) Use LMWH
- superior efficacy over UFH. LMWH has mortality benefit

3) Use GPIIb/IIIa inhibitors, which has mortality benefit (EG abciximab, eptifibatide, tirofiban)
4) angioplasty if available as an option

230
Q

What is the one way to improve mortality benefit when giving GPIIb/IIIa inhibitors?

A

Combine with angioplasty or stenting

Remember that GPIIb/IIIa is only efficacious in NSTEMI

231
Q

Name the four indications for CABG

A

1) Left main coronary artery stenosis >50%
2) 3 vessels w/ >70% stenosis
3) 2 vessels in diabetic patients
4) 2 vessels with low EF

232
Q

Treatment that improves mortality for stable angina?

A

Aspirin

Metoprolol

Nitrates do not improve mortality; symptomatic relief only

233
Q

When are ACE-I or ARBs used in cases of stable angina?

A

CHF

234
Q

Is the internal mammary artery or saphenous vein graft better for long-term outcome after CABG?

A

IMA often patent at 10 years

Saphenous vein becomes occluded at 5 years

235
Q

Statins are given for coronary artery disease. Which other diseases are considered equivalent to CAD and require statin therapy?

A

1) Diabetes
2) Peripheral arterial disease
3) Carotid disease
4) aortic disease
5) stroke

236
Q

Most common statin effect

A

liver toxicity

Obtain baseline AST/ALT

237
Q

What is the indication for PCSK9 inhibitors?

A

familial hypercholesterolemia

hyperlipidemia refractory to statins

MOA: Blocking PCSK9 increases hepatic clearance of LDL

No mortality benefit

238
Q

In patients with ED and MI, be sure to stop this medication … before giving sildenafil

A

nitrates

239
Q

Name high intensity statins:

A

rosuvastatin 20-40

atorvastatin 40-80

Indicated when risk of 10 year ASCVD risk > 10%

240
Q

Most complicated statin effect:

A

rhabdomyolysis

spectrum of myalgia -> rhabdo -> renal failure

Do NOT measure baseline CPK

measure CPK if symptomatic: muscle pain, stiffness, cramping, or fatigue
- also measure Cr and obtain UA

If mild symptoms -> restart statin to establish causality

241
Q

Name the mechanism for ezetimibe:

A

decreases cholesterol absorption in the gut

Has been shown to be effective in combination with statins

242
Q

What is a group of patients that can benefit from bile acid sequestrants?

A

Diabetes patients

concomitant 0.5% decrease in A1c

243
Q

Standard of care for CHF exacerbation:

A

1) oxygen
2) furosemide
3) nitrates
4) morphine

244
Q

Key clinical features of CHF exacerbation:

A

S3

Rales

Dyspnea

Orthopnea

Others: edema, ascites, JVD, fatigue

245
Q

When does screening for HTN start?

A

Age > 18

Ambulatory BP monitors gold standard

246
Q

Common causes of secondary HTN from age 0-12?

A

renal parenchymal disease

coarctation of the aorta

247
Q

Common causes of secondary HTN from 19-39 years?

A

1) thyroid dysfunction
2) fibromuscular dysplasia
3) renal parenchymal disease

248
Q

Key workup for CHF exacerbation…

A

CXR

EKG

Oximeter/ABG

Echocardiogram

249
Q

Key feature of hyperaldosteronism?

A

Hypokalemia

250
Q

Key features of renal artery stenosis?

A

increase in serum creatinine > 0.5 to 1 mg/dL AFTER starting an ACE or ARB

251
Q

Most effective lifestyle interventions for decreasing blood pressure?

A

Intervention: SBP/DBP

DASH + <1500 mg Na: 11.5/6
<1500 mg Na: 7/3
DASH: 5-6/3
Weight loss (9lbs): 4.5/3.2
Exercise: 4/3
Alcohol: 3/2

THEREFORE: weight loss has the greatest potential impact given added benefit with each pound lost

Smoking: unclear

252
Q

BP goal for those age > 60 per JNC 8?

A

150/90

253
Q

BP goal for age < 60 per JNC 8?

A

< 140/90

254
Q

BP goal for those with CKD or diabetes

A

< 140/90

255
Q

Firstline treatment for hypertension in non-black population

A

thiazide

CCB

ACE/ARB

256
Q

First-line treatment for hypertension in black population?

A

thiazide

CCB

257
Q

If hypertensive and with CKD, regardless of race, the antihypertensive regimen should include:

A

ARB or ACE

258
Q

In patients with CHF with continued dyspnea after preload reduction, consider these 3 drugs

A

1) dobutamine (first-choice)
2) inamrinone
3) milrinone

259
Q

What does wedge pressure measure?

A

LEFT atrial pressure

Therefore, LV failure = increased LA pressure = increased wedge pressure

260
Q

Age of colon cancer screening in average risk patients?

A

Age 50

  • -q10 years for colonoscopy
  • -FOBT or FIT q1 year
  • -FIT-DNA q1-3
  • -colonography q5 years
  • -flex sig q5 years or 10 if combined with q1 year FIT
261
Q

What qualifies a patient as a high risk colon cancer patient?

A

First degree relative < 60 y of age with diagnosed cancer or adenomatous polyps

> 2 first degree relatives with colon cancer at ANY age

262
Q

Screening for increased risk colon cancer patients?

A

At age 40 q3-5 years

OR

10 years prior to age of cancer diagnosis in relative

263
Q

What defines adenomatous polyps?

A

> 1 cm

villous features

high grade dysplasia

264
Q

Etiologies of SIADH

A

1) brain trauma
2) carbamazepine, NSAIDs, or SSRIs
3) pneumonia
4) small cell lung cancer

265
Q

Diagnosis of hyponatremia in the setting of urine osmolality < 100 mOsm/kg?

A

psychogenic polydipsia

266
Q

What is considered inappropriately concentrated urine in the setting of hyponatremia?

A

> 100 mOsm/kg

267
Q

What is the key difference in cerebral salt wasting and SIADH?

A

CSW: Decreased extracellular fluid volume due to renal loss of salt - replete fluid and salt

In SIADH, restrict fluid intake

268
Q

How do you distinguish between renal or extrarenal loss of sodium in the setting of hyponatremia?

A

Urinary sodium

< 10 -> think loss from GI or skin

> 20 -> think cerebral salt wasting, diuretics, or addison’s disease

269
Q

What are the treatments for hyponatremia due to SIADH?

A

fluid restriction first

salt tablets next

If seizing or in coma, consider 3% saline

270
Q

What diagnosis is associated with the following symptoms: 1) dysuria 2) postvoid dribbling 3) dyspareunia 4) anterior vaginal mass

A

Urethral diverticulum

Risk factors: repeated infection, trauma of urethra (vaginal delivery or surgery), stress urinary incontinence

271
Q

What exam finding is associated with urethral diverticulum?

A

tender anterior vaginal wall mass

expresses bloody or purulent fluid on manipulation of urethra

272
Q

Diagnostic testing for urethral diverticulum?

A

MRI or transvaginal ultrasound

UA/UCx

273
Q

What are the treatment options for urethral diverticulum?

A

manual decompression

needle aspiration

surgical repair

274
Q

Diagnostic method for vesicovaginal fistula?

A

infusion of methylene blue into bladder

assess vagina with tampon to see if it turns blue

275
Q

What is the Q-tip test?

A

used to diagnose urethral hypermobility; a cause of stress urinary incontinence

Positive when > 30 degrees of movement with valsalva

276
Q

What is the test of choice for diagnosing pneumothorax acutely?

A

bedside ultrasound

+ when there is no evidence of lung sliding

CT chest is more sensitive but inappropriate if concern for acute decompensation

277
Q

What syndrome is associated with bicuspid aortic valve?

A

Turner syndrome

278
Q

What population is associated with congenital bicuspid aortic valve?

A

Male

Turner

279
Q

What is the typical auscultation finding for bicuspid aortic valve?

A

ejection murmur with a click heard at LLSB

280
Q

What xray findings can reveal a bicuspid aortic valve?

A

AV calcification

aortic enlargement (from aneurysmal dilatation)

rib notching

281
Q

What are the risks from having a bicuspid aortic valve?

A

infection

valve regurgitation or stenosis

aortic root dilatation

dissection

282
Q

Indications for balloon valvuloplasty

A

symptomatic patients

OR

asymptomatic patients anticipating pregnancy or sports

+

aortic stenosis
+
no significant regurgitation or calcification
+
peak gradient > 50 mmHg

283
Q

Name a common antihypertensive that can result in photosensitivity

A

hydrochlorothiazide

284
Q

What are risk factors for neural tube defects?

A

low folic acid

methotrexate

Antiepileptics

diabetes

prior pregnancy with a neural tube defect

285
Q

What dosages are given for folic acid?

A

0.4 mg in normal risk gravid patients

4 mg folic acid IF:

1) On an antiepileptic drug
2) prior pregnancy with a neural tube defect

286
Q

Most common pathogen for corneal foreign bodies?

A

Most common: Coagulase negative staphylococcus

Others: streptococcus, haemophilus, pseudomonas

Therefore treat with: erythromycin, sulfacetamide, ciprofloxacin, ofloxacin

287
Q

What is the indication for AV replacement in bicuspid aortic valve?

A

severe stenosis or regurgitation + symptoms of left ventricular dysfunction

288
Q

Define publication bias

A

where trials with positive results are published but

negative results are not

289
Q

Name the risk factors for pulmonary aspergillosis:

A

stem cell or organ transplantation

prolonged neutropenia

chronic steroids

AIDS

290
Q

What is the classic triad for aspergillosis?

A

cough

pleuritic pain

hemoptysis

291
Q

Nodules with ground glass opacity OR cavitations with air-fluid levels indicate what infection?

A

aspergillus

292
Q

Which drug increases the risk of euglycemic diabetic ketoacidosis?

A

SGLT2 inhibitors

Mechanism:
decreased insulin:glucagon ratio -> stimulating ketogenesis

293
Q

Respirations associated with DKA?

A

Kussmaul respirations

294
Q

Name the metabolic abnormalities that can occur with SGLT2 inhibitors

A

Hyperkalemia

Hyperlipidemia

Euglycemic diabetic ketoacidosis

295
Q

Where can ectopic thyroxine production take place?

A

ovaries

296
Q

Name a single etiology to explain the following clinical features in a newborn: 1) macrosomia 2) hypocalcemia 3) hypoglycemia 4) hyperviscosity 5) cardiomyopathy 6) cardiac heart failure

A

Gestational diabetes

297
Q

What is the expected blood sugar in a neonate born to a mother with gestational diabetes?

A

HYPOGLYCEMIA - because the baby is generating insulin but has no intrinsic hyperglycemia

298
Q

What is the mechanism for hyperviscosity in neonates when a mother has gestational diabetes?

A

polycythemia vera

299
Q

What is the expected echocardiographic finding in a neonate born to a mother with gestational diabetes?

A

hypertrophic myocardium

300
Q

What is the mechanism of hypertrophic myocardium in babies born to mothers with gestational diabetes?

A

glycogen deposition in myocardium

ESPECIALLY in the interventricular septum

leading to VENTRICULAR OUTFLOW obstruction

301
Q

Name the malformation syndrome that results in four chamber cardiac dilatation in neonates

A

cri du chat syndrome

302
Q

If a baby is hemodynamically stable at birth but decompensates with acute heart failure and shock several days after birth, what has pathologically occurred?

A

Closure of the ductus arteriosus

Treat with prostaglandin E1

303
Q

Causes of delayed (several days) cardiac failure in the newborn from closure of ductus arteriosus?

A

Aortic stenosis

Hypoplastic LV

Coarctation of the aorta

304
Q

What is seen on echocardiogram in Ebstein’s anomaly?

A

atrialized RIGHT ventricle

tricuspid regurgitation

305
Q

What is the treatment for hypertrophic cardiomyopathy in babies due to glycogen deposition due to hyperglycemia?

A

Conservative therapy

Glycogen will be depleted during fasting

306
Q

To answer the question: if patient has a condition X, how likely is the patient to have a + test result compared to patients with a - test result?

A

positive likelihood ratio

307
Q

How can you individualize sensitivity and specificity data?

A

Calculate likelihood ratios -> obtain the pre-test odds

LR * pre-test odds = post-test odds

308
Q

What is verification bias?

A

When researchers conduct the gold standard ONLY to confirm a positive or negative result in SELECT group of patients

309
Q

What is contamination bias?

A

control group unintentionally receives the intervention

310
Q

What is selection bias?

A

When study participants are selected in a non-random fashion or if they are LOST to follow up

311
Q

What are the four criteria for capacity?

A

1) communicates a choice
2) has understanding of situation
3) understands the risks of not proceeding
4) able to offer rationale

312
Q

What are the contraindications for bupropion?

A

seizure hx or TBI

Eating disorders

313
Q

What is the contraindication for varenicline?

A

risk of cardiovascular events

renal insufficiency - cleared by KIDNEYS

note the former black box warning for risk of NEUROPSYCHIATRIC problems (especially if unstable or hx of suicidal attempt)

314
Q

Which is more effective: varenicline or bupropion?

A

varenicline

315
Q

What is the simplest distinction between palliative care and hospice care?

A

palliative care can be offered concurrently with disease-modifying therapies

hospice care is provided when there is no continuation of life-prolonging therapy

316
Q

What is the cause and treatment of plantar warts?

A

HPV

salicyclic acid with tape to keep acid in place (for 2 - 3 WEEKS)

alternative: liquid nitrogen

317
Q

Which occupations are associated with increased risk of warts?

A

meat, poultry and fish handlers

318
Q

What is the risk of liquid nitrogen therapy in dark-skinned individuals?

A

hypopigmentation

319
Q

What are the JONES criteria for rheumatic fever?

A

Joints (migratory)
Carditis
Nodules
Erythema marginatum (target rash)
Syndenham chorea

requires 2 of the above

OR

requires 1 + minor criteria
(fever, arthralgia, esr, crp, prolonged PR)

320
Q

Which sex is more at risk for rheumatic fever?

A

GIRLS

ages 5-15

321
Q

What is the sequelae from untreated rheumatic fever?

A

mitral regurgitation/stenosis

322
Q

What EKG finding is a minor criteria in the diagnosis of rheumatic fever?

A

prolonged PR interval

323
Q

Describe the findings of syndenham chorea

A

emotional lability

distal hand movements

decreased strength
pronator drift

324
Q

When does syndenham chorea develop?

A

1-8 months after initial infection

325
Q

What is the treatment of syndenham chorea?

A

penicillin until ADULTHOOD for secondary prevention

to prevent recurrent rheumatic fever

326
Q

Which patients require further evaluation for resumption of sexual activity after a MI?

A

NYHA class IV heart failure

severe valvular disease

significant arrhythmias

refractory angina after PCI

327
Q

Name the rapidly progressive, ulcerative skin disorder that is seen in neutropenic patients and the etiology

A

ecthyma gangrenosum

pseudomonas bacteremia

treat with antibiotics; no indication for surgery

328
Q

Mechanism of ecthyma gangrenosum?

A

invasion of vascular structures -> inducing secondary necrosis

329
Q

What is the dermatological progression of ecthyma gangrenosum?

A

macules -> bullae -> gangrenous ulcers

violaceous margins

especially in anogenital, axilla, and extremities

330
Q

Fever, muscle pain, and purple-colored bullae are suggestive of…

A

clostridial myonecrosis

331
Q

What is mycosis fungoides?

A

Cutaneous T-cell lymphoma

332
Q

Invasive candida can affect which organ system?

A

Eyes -> endophthalmitis

especially in setting of neutropenia

333
Q

Agents used against pseudomonas

A

gentamicin/tobramycin

imipenem/meropenem

ceftazidime/cefepime

ciproflox/levofloxacin

piperacillin-tazobactam

aztreonam

334
Q

If diagnosis of perforated peptic ulcer is suspected, what are the next steps in management?

A

IV antibiotics

PPI

surgery

335
Q

Define failure to thrive

A

when children are < 5th percentile in weight

or

down-trending weight across 2 or more major percentiles (50th, 25th, 10th)

336
Q

What is the most common cause of failure to thrive?

A

Inadequate intake

337
Q

What does a positive serum anti-citrullinated peptide antibody indicate?

A

polyarticular juvenile idiopathic arthritis

338
Q

What are features suggestive of lyme arthritis?

A

able to bear weight

afebrile

well-appearing

339
Q

What is the alternative to doxycycline for treatment of borrelia?

A

amoxicillin

especially in children < 8 OR

for pregnant or lactating women

340
Q

What adverse effects can doxycycline cause?

A

tooth discoloration

skeletal problems

341
Q

What is osteochondritis dissecans?

A

avascular necrosis of the femoral head

342
Q

What are associated diseases with avascular necrosis of the femoral head?

A

1) SLE
2) sickle cell
3) antiphospholipid syndrome
4) hemodialysis
5) HIV
6) s/p renal transplant
7) Caisson’s disease

343
Q

What is Caisson’s disease?

A

decompression sickness

344
Q

What are the most common causes of avascular necrosis?

A

1) steroid use
2) excessive alcohol intake

345
Q

Treatment options for avascular necrosis of the femoral head?

A

1) Core decompression (stage 1 or 2 - radiographs without head collapse)
2) osteotomy
3) total replacement

346
Q

Risk factors for ovarian cancer

A

1) early menarche
2) later menopause
3) genetic mutation

347
Q

Protective factors for ovarian cancer

A

1) OCP
2) breastfeeding

348
Q

What is the most common allergen associated with asthma?

A

house dust mites

349
Q

What is ABO hemolytic disease?

A

Baby is A+ or B+

Mom is O+

350
Q

What is the treatment of ABO hemolytic disease?

A

Depends on the degree of unconjugated hyperbilirubinemia

mild: breastfeed
moderate: phototherapy

severe (> 25): exchange transfusion

351
Q

Make this diagnosis: 1) pelvic pain 2) dysmenorrhea 3) deep dyspareunia 4) dyschezia

A

endometriosis

352
Q

Physical exam findings for endometriosis

A

1) immobile uterus
2) cervical motion tenderness
3) adnexal mass

353
Q

Medical management of endometriosis

A

NSAIDS

OCPs

GnRH agonists

354
Q

Treatment of infertility due to endometriosis

A

surgical resection

IVF

355
Q

What are classical physical exam findings for subacute combined degeneration?

A

Specific: hyperreflexia, spastic paresis

Loss of vibratory sense

Romberg

356
Q

Age of presentation for Wilson disease?

A

Age 5-35

357
Q

Most common neurologic symptom of Wilson disease?

A

dysarthria

358
Q

Mechanism of anemia in B12 deficiency

A

intramedullary hemolysis

359
Q

Labs to check for hemolysis

A

LDH

haptoglobin

Indirect bilirubin

360
Q

What is the mechanism of serum sickness?

A

immune complex formation (TYPE III HYPERSENSITIVITY) - ie antigen and antibody (IgG) combination

361
Q

Features of serum sickness like reaction?

A

1-2 weeks after antigen exposure

fever, rash, polyarthralgia

362
Q

Offending agents associated with serum sickness like reaction?

A

antibiotics, especially beta lactams or sulfa drugs

acute hepatitis B

363
Q

Treatment for serum sickness reaction?

A

Stop offending agent

Supportive care

Steroids/plasmapheresis if severe

364
Q

Extrahepatic manifestations of hepatitis B infection?

A

polyarteritis nodosa

more likely membrane nephropathy

less likely membranoproliferative glomerulonephritis

365
Q

What defines anaphylaxis?

A

IgE mediated immediate hypersensitivity

TYPE 1 - reaction against a soluble antigen

366
Q

What is the mechanism of a type II hypersensitivity reaction?

A

cytotoxic autoantibodies (IgG) directed against patient’s own blood cells

367
Q

What mediates a type IV hypersensitivity reaction?

A

Macrophages

368
Q

What time of hypersensitivity reaction is the allergy to penicillin?

A

type II

369
Q

What type of hypersensitivity reaction are the following diseases? transfusion reaction autoimmune hemolytic anemia erythroblastosis fetalis Goodpasture’s syndrome

A

type II, complement dependent

370
Q

Cell type which mediates type IV delayed hypersensitivity reactions

A

CD4+ T lymphocytes

371
Q

What cell line is chronic lymphocytic leukemia?

A

B cell

372
Q

What are the possible treatments for seborrheic dermatitis?

A

antifungals (selenium sulfide, ketoconazole)

topical steroids

calcineurin inhibitors (pimecrolimus)

373
Q

Treatment for tinea capitis?

A

oral Griseofulvin or terbinafine

374
Q

Treatment for tinea corporis?

A

Griseofulvin

375
Q

Treatment for scabies?

A

permethrin

alternatively, ivermectin is a possibility

376
Q

When does screening for group B streptococcus in pregnant women occur?

A

35-37 weeks

377
Q

What is the treatment for group B streptococcus in pregnant women?

A

Penicillin

378
Q

If a pregnant woman has a history of prior pregnancy complicated by Group B strep, are antibiotics indicated?

A

YES

379
Q

How long must membranes be ruptured for prophylactic administration of antibiotics?

A

> 18 hours

&

unknown GBS status

380
Q

Should penicillin be given for GBS if the mom has a fever?

A

YES, if GBS status is unknown

381
Q

Should penicillin be given for GBS if the mom is less than 37 weeks gestation?

A

YES, if GBS status is unknown

382
Q

What common condition can these organisms cause? Chlamydia Salmonella Shigella Yersinia Campylobacter

A

Reactive arthritis

383
Q

Which category of rheumatic disease does reactive arthritis fall under?

A

spondyloarthropathy

384
Q

Does B27 positivity increase risk of reactive arthritis?

A

YES, especially in the setting of acute infection.

Doubles the risk

385
Q

What side effects are associated with anabolic steroids in females?

A

changes in mood

acne

hirsutism

+/- eating disorders

clitormegaly

hair loss

386
Q

Is voice deepening reversible in women who use anabolic steroids?

A

NO

387
Q

Name the etiology for the following symptoms in men: decreased sperm count decreased testicle size gynecomastia

A

endogenous steroids

388
Q

True or false, acute infection with HCV requires vaccination against Hep A or B?

A

TRUE

389
Q

Diagnosis of spontaneous bacterial peritonitis requires what white cell count?

A

250

390
Q

In splanchnic vasodilation, what happens to peripheral vascular resistance?

A

DECREASE in PVR ->

decreased renal perfusion

391
Q

If there is bilateral nipple discharge, the first test should be…

A

pregnancy test

galactorrhea workup

392
Q

What are the criteria for pathologic breast discharge?

A

spontaneous

unilateral

persistent

393
Q

What is the most common cause of nipple discharge?

A

papilloma

394
Q

Do women under 30 receive mammograms if there is abnormal breast discharge?

A

NO, breast is too dense

395
Q

Can hypothyroidism cause hyperprolactinemia?

A

yes

396
Q

What are the three P’s of MEN 1?

A

pituitary

pancreatic

parathyroid

397
Q

What are the indications for parathyroidectomy?

A

symptomatic hyperCa++

End-organ damage (osteoporosis, CKD, nephrolithiasis)

Complications (urinary excretion of Ca++ > 400)

serum calcium > 1 mg/dL above ULN

398
Q

Risk factors that indicate need for higher INR goal in aortic valve replacement…

A

1) a fib
2) EF < 30%
3) prior VTE
4) hypercoagulable state

399
Q

Does mitral valve replacement require a higher INR than uncomplicated aortic valve replacement?

A

YES, 2.5 - 3.5

400
Q

What TSH level warrants treatment for hyperthyroidism?

A

TSH < 0.1

401
Q

If TSH is 0.1 - 0.5, what risk factors are needed to warrant treatment?

A

1- age > 65
2- heart disease
3- osteoporosis
4- nodular thyroid disease

402
Q

Best medication to raise HDL?

A

Niacin

403
Q

Mechanism of orlistat?

A

intestinal lipase inhibitor

404
Q

Normal carbamazepine levels?

A

4-12

405
Q

What is preferred? Greater QALY or DALY?

A

QALY should be higher

Time trade off better if higher

DALY better if lower

406
Q

Treatment for paget disease of bone?

A

Bisphosphonates

Alendronate (6 months)

risedronate (2 months)

407
Q

When is treatment of paget disease of bone indicated?

A

intolerable pain

involvement of weight-bearing bones

neuological disease

hypercalcemia, hypercalciuria

CHF

408
Q

Mechanism of bisphosphonates?

A

inhibits osteoclastic resorption

409
Q

Diagnostic criteria for STEMI

A

> 2 contiguous leads

> 1mm in all leads except V2 and V3

> 1.5 mm in women, > 2 mm in men in leads V2 and V3 if < 40

> 2.5 mm for men < 40 in V2 and V3

410
Q

What do anti-centromere antibodies indicate?

A

CREST

411
Q

Anti-mitochondrial antibodies indicate what?

A

Primary biliary cirrhosis

412
Q

Anti-smith antibodies indicate…?

A

SLE, low sensitivity of 25%

413
Q

Anti-Ro/SSA suggest…?

A

Sjogren’s

414
Q

What antibody can be followed to correlate with disease activity?

A

Anti ds-DNA

May anticipate occurrence of lupus nephritis

415
Q

SLE symptoms treated by hydroxychloroquine

A

arthralgia

serositis

cutaneous symptoms

416
Q

When is methotrexate indicated for SLE?

A

After lack of response to prednisone

Organ involvement

417
Q

Risk of what neurologic disease is associated with rituximab?

A

progressive multifocal leukoencephalopathy

418
Q

Indications for treating immune thrombocytopenia with IVIG/steroids?

A

Only if the patient is:

BLEEDING (indication in both pediatrics and adults)

In adults: patients should be treated if they have platelets < 30k OR are experiencing bleeding

419
Q

Where does bleeding associated with ITP occur?

A

mucocutaneous -

1) epistaxis
2) hematuria
3) GI bleed

420
Q

Laboratory findings of ITP

A

megakaryocytes on smear

< 100k platelets

421
Q

What is the treatment for TTP-HUS?

A

plasma exchange

422
Q

If a patient is Rh + and has a spleen, what is the treatment for ITP?

A

Anti-Rh(D)

423
Q

Under which category of neurologic disease is blepharospasm?

A

dystonia

424
Q

What are possible triggers of blepharospasm?

A

light

irritants

425
Q

First line treatment for blepharospasm?

A

botulinum toxin

426
Q

What defines unhealthy alcohol use?

A

F: > 3 drinks/day
>7 drinks/week

M: > 4 drinks/day
>14 drinks/week

427
Q

Drugs indicated for agitation in acute delirium in elderly?

A

antipsychotics

NO BENZODIAZEPINES - unless due to alcohol withdrawal

428
Q

Symptoms of hypertrophic cardiomyopathy?

A

fatigue

dyspnea

429
Q

The following echo findings suggest: 1) asymmetric septal hypertrophy 2) systolic anterior motion 3) left ventricular outflow obstruction

A

hypertrophic cardiomyopathy

430
Q

Inheritance pattern for hypertrophic cardiomyopathy?

A

autosomal dominant

431
Q

Initial monotherapy for hypertrophic cardiomyopathy?

A

beta blockers

can add verapamil OR disopyramide for persistent symptoms

432
Q

What is the indication for alcohol septal ablation?

A

Cases of hypertrophic cardiomyopathy unresponsive to medical therapy

OR

LVOT gradient > 50 mmHg

433
Q

What drugs should not be used in hypertrophic cardiomyopathy?

A

vasodilators

ACE-I/ARBs

nitrates

434
Q

Why should vasodilators NOT be used in hypertrophic cardiomyopathy?

A

Because decreased peripheral resistance can cause increase in the left ventricular outflow tract obstruction

435
Q

When is a ICD indicated for hypertrophic cardiomyopathy?

A

NYHA Class II/III HF

LVEF < 30-35%

Prior MI

Ventricular fibrillation or tachycardia

436
Q

What is an early finding of compartment syndrome?

A

paresthesia

437
Q

Atypical features of ITP such as bone pain, fevers, weight loss, lymphadenopathy, splenomegaly, neutropenia, or anemia warrants what treatment?

A

bone marrow biopsy

438
Q

Recurrent bleeding, no response to IVIG or steroids, and chronic immune thrombocytopenia warrants what treatment?

A

splenectomy

warranted in cases of CHRONIC ITP

439
Q

Name SIG E CAPS

A

sleep changes
loss of interest
guilt

decreased energy

cognitive changes
appetite changes
psychomotor retardation
suicidal ideation

440
Q

Schizoaffective is distinguished from schizophrenia in what way?

A

Mood symptoms are present throughout illness w/ and w/o psychosis

441
Q

Major depression/bipolar with psychotic features differs from schizoaffective and schizophrenia in what way?

A

psychosis occurs exclusively during periods of mood symptoms

442
Q

Hallmark of schizophrenia?

A

Mood symptoms are brief and generally not a defining feature

443
Q

What worsens visual hallucinations in cases of lewy body dementia?

A

dopamine agonists

444
Q

When does erythema migrans from borrelia develop?

A

3-7 days after infection

445
Q

What is the length of tick attachment that is required to transmit lyme disease?

A

> 36 hours

borrelia needs to travel from the tick’s gut to the tick’s salivary glands

tick ENGORGEMENT is a surrogate marker

446
Q

Tenderness of the medial knee along joint line indicates what?

A

medial collateral ligament injury

NO significant hemarthrosis

447
Q

Clinical features of locking, catching of the knee indicate what injury

A

meniscal tear

effusions can develop SLOWLY

448
Q

A patient has chronic overuse and has pain over the ANTERIOR KNEE reproduced by knee extension w/ compression of the patella

A

likely patellofemoral pain syndrome

449
Q

What is the preferred treatment of hyperthyroidism during the first trimester?

A

propylthiouracil

450
Q

What is the preferred treatment of hyperthyroidism during the second and third trimester?

A

methimazole

451
Q

What are the mechanisms by which pregnancy affects thyroid hormone?

A

1) stimulation of thyroid binding globulin leading to increased bound thyroid -> stimulates production of additional thyroid hormone
2) inhibition of TSH from pituitary but stimulation of thyroid hormone production

452
Q

What are the findings of typical T4 and TSH in pregnancy?

A

decreased TSH

elevated total T4 and free T4

453
Q

What is tilt table testing used for?

A

to differentiate between neurocardiogenic syncope (vasovagal) and orthostatic hypotension syncope

ultimately a poor test - low SN and SP

454
Q

What are the 3 features of vasovagal syncope?

A

1) inciting event (standing, stress, pain)
2) prodrome (nausea, pallor, sweating, warmth)
3) recovers quickly

455
Q

Treatment for actinic keratosis?

A

topical 5-fluorouracil cream (3-6 weeks)

imiquimod

diclofenac

photodynamic therapy

liquid nitrogen

surgical excision

curettage

456
Q

What is a important examination feature of actinic keratosis?

A

felt better than seen

457
Q

What is the risk of progression from actinic keratosis to squamous cell carcinoma?

A

20%

458
Q

Candida vaginitis has what type of discharge?

A

cottage cheese, white

Treat with fluconazole

459
Q

True or false, partner needs to be treated if there is a positive diagnosis of trichomoniasis.

A

True

460
Q

What is the risk of flagyl in babies?

A

loose stools

candidiasis

461
Q

Treatment of chlamydia trachomatis cervicitis is…

A

azithromycin single dose

doxycycline bid for 7 days

462
Q

Treatment for gonorrhea is…

A

ceftriaxone, single IM 250 mg

but DUAL therapy with azithromycin is recommended for treatment of concurrent chlamydia irrespective of chlamydia results

463
Q

If a woman is diagnosed with chlamydia vaginitis and is breastfeeding, what should she do?

A

continue to breast feed, no known effects despite excretion in milk

464
Q

Screening regimen for HIV?

A

HIV antigen (p24)

HIV1/2 antibodies

465
Q

What is the window period for HIV screening?

A

1-4 weeks of infection

466
Q

When does post-exposure prophylaxis of HIV need to start?

A

< 72 hours after exposure

preferably starting within 1-2 hours

467
Q

True or false, hepatitis B testing should occur before starting HAARTs?

A

true

468
Q

Diseases to screen for prior to starting HAARTs?

A

TB

hepatitis C

Treponema

Gonorrhea

469
Q

CV disease screening before HAART initiation

A

hypertension

hyperlipidemia

DM

tobacco abuse

470
Q

What first changes after addressing iron deficiency anemia in children?

A

increase in reticulocyte count

471
Q

What are the best diagnostic tests for paget disease of bone?

A

radiographs

alkaline phosphatase

serum calcium

bone scan

472
Q

Wallenberg syndrome localizes where?

A

lateral medulla

473
Q

What are the typical symptoms associated with infarct of the lateral medulla

A

vestibulocerebellar symptoms

sensory loss (ipsilateral face and contralateral trunk/limbs)

ipsilateral bulbar muscle weakness

autonomic dysfunction

474
Q

If a patient presents with Horner’s syndrome, hiccups, and lack of automatic respiration, you should consider which diagnosis…

A

Lateral medullary syndrome

475
Q

A type 2 error refers to:

A

FALSE NEGATIVE: not detecting an effect when there is one

BETA LEVEL

476
Q

A type 1 error refers to:

A

FALSE POSITIVE: detecting an effect when there is not one

ALPHA LEVEL

477
Q

Fever, unilateral eye pain, and fungating retinal lesions w/ vitreal extension (MOUND-LIKE lesions) suggest what?

A

Candida endophthalmitis in the setting of immune suppression

especially if central venous access is present

478
Q

What is the treatment for candida endopthalmitis?

A

vitrectomy and systemic amphotericin B (for 4-6 weeks)

Can consider fluconazole or voriconazole but NOT ketoconazole

479
Q

Treatment for mycobacterium avium?

A

clarithomycin and rifabutin

480
Q

What is the empiric treatment for community acquired pneumonia in the outpatient setting?

A

macrolide or doxycycline if healthy

481
Q

What is the empiric treatment for CAP in the outpatient setting if patients have comorbidities?

A

fluoroquinolone or beta lactam + macrolide

482
Q

What are the regimens for CAP in a non-ICU setting?

A

fluoroquinolone

or

beta-lactam + macrolide

483
Q

What are the regimens for CAP in an ICU setting?

A

beta-lactam + macrolide

OR

beta-lactam + fluoroquinolone

484
Q

CURB 65 stands for?

A

CONFUSION
UREMIA (> 19)
RESPIRATORY RATE (>30)
BP (<90 SBP OR < 60 DBP)
AGE > 65

grading scale for assessment of pnemonia treatment - outpatient vs inpatient

485
Q

What are risk factors for MRSA in pnemonia?

A

recent flu or antibiotic use

cavitary infiltrates

septic shock

respiratory failure

486
Q

Why are systemic corticosteroids contraindicated in psoriasis?

A

risk of induced pustular psoriasis

487
Q

What are risk factors for intussusception?

A

MOST COMMON: recent viral illness -> lymphoid hyperplasia of Peyer patches

OTHER:

  • malformation (Meckels)
  • HSP
  • Celiac disease
  • tumor
  • polyps
488
Q

What is the classic triad of intussusception?

A

vomiting, abdominal pain, passage of blood

other findings

  • sausage shaped mass
  • currant jelly stools
489
Q

Social circumstances in which a minor can provide their own consent… (EMANCIPATED MINOR)

A

1) homeless
2) is now a parent
3) married
4) military service
5) financially independent
6) high school graduate

490
Q

What is the pathophysiology of currant jelly stools in intussusception?

A

telescoped bowel -> vessel compression -> bowel ischemia -> rectal bleeding

491
Q

What is the primary risk of air enema?

A

intestinal perforation < 1% of cases

increased risk with

1) small bowel obstruction
2) age < 6 months

492
Q

What is scombroid poisoning?

A

ingestion of improperly stored seafood ( ie > 15 degrees C)

493
Q

What is the pathophysiology of scombroid poisoning?

A

histidine undergoes decarboxylation -> forms histamine

494
Q

What are the symptoms of scombroid poisoning?

A

flushing, throbbing headache, palpitations, abdominal cramps, diarrhea, and oral burning

begins within 10-30 minutes after ingestion

+/- erythema, wheezing, tachycardia, and hypotension

495
Q

What are the symptoms of pufferfish poisoning?

A

perioral tingling, incoordination, weakness

496
Q

Symptoms of vertebrobasilar insufficiency?

A

vertigo, dizziness, dysarthria, diplopia, and numbness

497
Q

Risk factors for vertebrobasilar insufficiency?

A

DM, hypertension, hypercholesterolemia, arrhythmia, CAD, and smoking

498
Q

Vertigo, tinnitus, nausea, and imbalance suggest….

A

labyrinthitis

499
Q

Kawasaki disease CRASH stands for…

A

conjunctival injection
rash
adenopathy
strawberry tongue
hands and soles

+ 5 days of fever

500
Q

Difference between rubella and measles…

A

measles: typically ill-appearing with higher fevers

measles rash is darker

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