UW Week 1 & 2

Question 1

What does succusion splash help dx?

Answer 1

Gastric outlet obstruction; retained gastric material >3 hrs after a meal will generate a splash indicating presence of viscus filled w/ fluid and gas -> definitive eval w/ endoscopy

Question 2

57yoM episodes of blood in urine, fatigue, and fever for 4 weeks, 50 pack year smoking, father died of blood disorder (meh) but pt unsure of name, left sided varicocele that fails to empty when pt is recumbent. Hgb = 18, WBCs 7400, PLTs = 580000, U/A > 10 RBCs/hpf, dx and imaging?

Answer 2

Renal cell carcinoma (classic triad of hematuria, back pain, and palpable mass not always present), note LEFT SIDED varicocele that does not empty while recumbent is pretty good indicator for mass - left gonadal vein drains into left renal vein; note ectopic production of EPO by tumor can produce polycythemia. Get CT abdomen

Question 3

Management of pulseless electrical activity or asystole?

Answer 3

Uninterrupted CPR along w/ vasopressor therapy to maintain adequate cerebral and coronary perfusion; potentially reversible causes of PEA = the 5H’s and 5T’s; there is no role for defib or cardioversion in PEA pts

Question 4

Polycythemia vera vs carbon monoxide poisoning question (47yoM, daytime HA, dizziness, nausea, works as a traffic controller in underground parking garage - cars in an enclosed space)

Answer 4

Polycythemia vera: clonal myeloproliferative disorder that causes inc in all 3 cell lines (PLTs, white count, hematocrit) pts often asymptomatic w/ occasional transient neuro symptoms or thrombosis
Carbon monoxide poisoning: can see secondary polycythemia d/t tissue hypoxia prompting kidneys to produce more EPO, pulse ox dose not differentiate btw carboxyhemoglobin and oxyhemoglobin so can not be used to dx CO poisoning; dx made on ABG w/ co-oximetry; tx w/ oxygen or hyperbaric/intubation if severe

Question 5

31yoF, nephrotic syndrome, renal bx performed, pt started on diuretics and salt and protein intake is restricted, edema improves but pts suddenly develops right sided abdominal pain, fever, and gross hematuria, dx and what will renal biopsy show?

Answer 5

Renal vein thrombosis! RVT is an important complication of nephrotic syndrome d/t loss of antithrombin III in the urine *inc risk of venous/arterial thrombosis. RVT can occur in any etiology of nephrotic syndrome but commonly seen w/ MEMBRANOUS!

Question 6

Gross or microscopic hematuria w/ MINIMAL proteinuria after upper respiratory

Answer 6

IgA nephropathy - rarely will develop into glomerulonephritis or nephrotic syndrome

Question 7

Fhx of colonic polyps and osteomas and alteration in tumor suppresor gene adenomatous polyposis coli, dx and mgmt?

Answer 7

Familial adenomatous polyposis (FAP), pts w/ classic FAP develop >1000 polyps and universally develop colorectal cancer -> inc screening and elective proctocolectomy are standard of care (start w/ annual sigmoidoscopies for children starting at 10-12 followed by annual colonoscopies - start screening 8 years after initial dx for adults). Also look out for upper GI tumors. CEA monitoring is used for pts w/ established colorectal cancer

Question 8

Hard unilateral non-tender lymph nodes are always suspicious for cancer; in pts w/ hx of smoking w/ lymph nodes in submandibular or cervical region, c/f what?

Answer 8

Head and neck cancer d/t squamous cell carcinoma

Question 9

Pts w/ severe bladder outlet obstruction d/t BPH will have inc in Cr and develop AKI, next steps

Answer 9

Get renal U/S to assess for hydronephrosis

Question 10

Ototoxic medications?

Answer 10

Aminoglycoside antibiotics, chemotherapeutic agents, aspirin, and LOOP DIURETICS. This pt had renal failure and was on aspirin (baby dose) and furosemide (normal dose but d/t renal failure = higher risk of ototoxicity leading to hearing loss)

Question 11

HIV screening in asymptomatic man preparing to “take the next step”

Answer 11

HIV screening recommended for all pts age 15-65 regardless of risk factors at least once

Question 12

Pts develops well-circumscribed and raised erythematous plaques w/ central pallor; pts have intense pruritus that can persist at night, individual lesions appear and enlarge over minutes to hours before disappearing within 24hrs, dx?

Answer 12

Acute urticaria (<6wks) can be d/t infections, NSAIDs, IgE mediated (abx, insects, latex, food), direct mast cell activation (narcotics, radiocontrast) or idiopathic (50% pts have this)

Question 13

Random Facts

Answer 13

1) Contact dermatitis - erythematous papules/vesicles and last several days
2) Atopic dermatitis - flexural areas lasting days/weeks
3) Erythema multiforme - target lesion w/ iris shaped macule +/- vesicle or bullae, extensor surfaces
4) Pts w/ malnutrition, pregnancy, or certain comorbid conditions (diabetes mellitus) should be started on pyridoxine supplementation (B6) when tx for latent or active TB w/ isoniazid to prevent INH induced peripheral neuropathy
5) Fluoroquinolone is a/w tedinopathy and tendon rupture (commonly Achilles); stop drug at onset and avoid exercise/use, change abx

Question 14

IVDU w/ fevers/chills for a week and holosystolic murmur at cardiac apex last used heroin yesterday, now w/ right arm weakness/lower facial droop/broad-based gait/difficult heel to shin (cerebellar lesion), dx?

Answer 14

Cerebral septic emboli; next steps include draw cultures, initiate broad spec abx, and obtain echo for vegetations

Question 15

Neck pain, syncope, hx of HTN, mediastinal widening on cxr, and pericardial effusion, but NO pulse differential blood pressure in UE, dx and next steps?

Answer 15

Aortic dissection (BP differential is present in only 20-30% pts); next steps get CT angio if kidneys working and HDS - TEE if hemodynamically unstable or renal insufficiency

Question 16

Painless, rapid, transient monocular vision loss, dx and imaging?

Answer 16

Amaurosis fugax - curtain descending over visual field - retinal ischemia d/t atherosclerotic emboli originating from ipsilateral INTERNAL carotid artery - get duplex US neck

Question 17

Dx and mgmt of esophageal rupture (pt had recent EGD)?

Answer 17

Contrast esophagram! Start w/ water soluble contrast since less inflammatory but if that is nondiagnostic get barium study; if perf confirmed = primary closure of esophagus and drainage of mediastinum

Question 18

Constipation, polyuria, and possibly abdl pain in the setting of Ca lvl of 11.4, and low phosphorus

Answer 18

Symptomatic hypercalcemia d/t primary hyperparathyroidism

Question 19

Hyperparathyroidism, recurrent PUD/ulcers/burning upper abdl pain, pituitary adenomas, dx?

Answer 19

MEN1 - the GI/pancreatic endocrine tumors including gastrinomas aka Zollinger Ellison

Question 20

Hypothyroid myopathy has myalgias, proximal muscle weakness, and elvated serum creatine kinase levels; pts often have features of hypothyroid (fatigue, delayed reflexes)

Answer 20

Vs polymyositis: SYMMETRIC proximal muscle weakness (lady just had LE), also myalgias is typically absent and DTR are normal (get bx to confirm polymyositis)

Question 21

Mechanism or etiology of Mallory-Weiss?

Answer 21

Sudden increase in abdl pressure (forceful retching or blunt abdl trauma) causes mucosal tear in esophagus (submucosal arterial or venous plexus bleeding); risk factors include hiatal hernia or alcohol, dx w/ endoscopy, most heal spontaneously

Question 22

Types of hearing loss:

Answer 22

Prescbycusis: old age hearing loss, high frequency first
Otosclerosis: chronic conducting hearing loss a/w bony overgrowth of the stapes, low frequency first (middle age pts)
Meniere’s: episodes of tinnitus, vertigo, and sensorineural hearing loss
Acoustic neuroma: most common tumor causing hearing loss - a/w unilateral hearing loss

Question 23

AIDS pts on HAART, 32yo, complains of 1 mo left sided difficulty hearing, no HA/fever/chills/weight loss/ or ear discharge, exam shows dull tympanic membrane that is hypomobile on pneumatic otoscopy, dx?

Answer 23

Serous otitis media (non infectious effusion)

Question 24

Mediterranean (this question was Greek), hemoglobin 10.2 w/ MCV 70, unresponsive to iron, dx?

Answer 24

Beta-thalassemia (minor)

Question 25

Note on oxygen management in COPD exacerbation pt:

Answer 25

Goal of SaO2 of 90-93% or PaO2 60-70 in chronic COPD pts since increase in oxyhemoglobin reduces the uptake of CO2 from tissues by the Haldane effect (CO2 remains in tissues). Uptake in CO2 leads to acidosis (this inc GABA and glutamine/decreases glutamate and aspartate causing changes in consciousness. Also hypercapnia causes reflex cerebral vasoDILATION and may induce seizures

Question 26

Celiac sprue and bone loss, mechanism?

Answer 26

Malabsorption -> severe Vit D deficiency -> osteomalacia (defective mineralization of organic bone matrix). Vit D def leads to dec intestinal calcium and phosphorus absorption resulting in hypocalcemia and hypophosphatemia -> which in turn leads to secondary hyperparathyroidism bringing Ca lvl to normal or near normal by inc Ca reabsorption in bone and kidney *this also leads to elevated alk phos. Osteomalacia - look for x-rays showing thinning of cortex w/ reduced bone density

Question 27

How bone formation and remodeling works?

Answer 27

Osteoclasts create cavity at bone surface that osteoblasts fill w/ organic matrix (osteoid). Calcium and phosphorus then deposit in the matrix to provide adequate mineralization

Question 28

Lights criteria?

Answer 28

At least one of the following:
Pleural fluid protein/serum protein ratio > .5
Pleural fluid LDH/serum LDH > .6
Pleural fluid LDH >2/3 ULN ( so greater than 60)
If pleural glu < 60 = d/t rheumatoid pleurisy, complicated parapneumonic effusion/empyema, malignant effusion, TB pleurisy, lupus pleurisy, esophageal rupture
If pleural glu < 30 = empyema d/t high metabolic activity of leukocytes or bacteria

Question 29

Pt w/ plantar puncture wound through footwear are at risk for what osteomyelitis infxn?

Answer 29

Pseudomonas; beta hemolytic streptococci and coag neg staph (staph epi) rarely cause osteomyelitis in the absence of predisposing factors like T2DM

Question 30

Small cell lung cancer paraneoplastic and associations

Answer 30

Lambert-Eaton (pre-synaptic NMJ dysfunction), ACTH/ADH

Question 31

Wide split fixed S2

Answer 31

ASD

Question 32

Fever and sore throat in pts just started on antithyroid drug, dx and mgmt?

Answer 32

Agranulocytosis - stop drug and check WBC

Question 33

Celiac sprue and bone loss, mechanism?

Answer 33

Malabsorption -> severe Vit D defiency -> osteomalacia (defective mineralization of organic bone matrix). Vit D def leads to dec intestinal calcium and phosphorus absorption resulting in hypoCa and hypophosphatemia -> which in turn leads to secondary hyperparathyroidism bringing Ca lvl to normal but STILL LOW by inc Ca reabsorption (not elevated like in primary PTH) in bone and kidney *this also leads to elevated alk phos. Osteomalacia - look for x-rays showing thinning of cortex w/ reduced bone density

Question 34

How does bone formation and remodeling works?

Answer 34

Osteoclasts create cavity at bone surface that osteoblasts fill w/ organic matrix (osteoid). Calcium and phosphorus then deposit in the matrix to provide adequate mineralization

Question 35

Management options for acute pain (including opioids) even in pts w/ prior substance abuse hx?

Answer 35

Pain management will be similar for all pts regardless of substance abuse (given documented need for analgesic); although those w/ hx of opioid addiction who are given opioids may need close f/u to avoid relapse

Question 36

22yoM recently returned from Honduras p/w 2 weeks fever, malaise, exudative pharyngitis, hepatosplenomegaly, generalized lymphadenopathy (he had posterior cervical), he also developed autoimmune hemolytic annemia and thrombocytopenia, dx?

Answer 36

Infectious mononucleosis; this is not malaria since that presents w/ cyclic fevers and dose not have leukopenia, lymphadenopathy, or exudative pharyngitis (although it does p/w fever, malaise, HSM, and anemia)

Question 37

Rare complication of infectious mononucleosis?

Answer 37

Splenic rupture, airway compromise, and autoimmune hemolytic anemia and thrombocytopenia (d/t cross reactivity of EBV induced antibodies against RBCs and platelets - antibodies are IgM cold agglutinin antibodies that cause complement mediated destruction)

Question 38

Old lady on chronic NSAID and aspirin, here for fatigue p/w conjunctival pallor, renal function normal, dx and concern for?

Answer 38

Iron deficiency anemia likely d/t gastritis and or gastric ulcers leading to chronic GI blood loss and depletion of iron

Question 39

Type 4 renal tubular acidosis (hyperkalemic renal tubular acidosis) is characterized by a non-anion gap metabolic acidosis, persistent hyperK, and mild to moderate renal insufficiency; commonly occurs in pts w/ poorly controlled diabetes

Answer 39

Primary hyperaldosteronism causes inc H+ and K+ excretion leading to hypoK and metabolic alkalosis! Renal artery stenosis causes secondary hyperaldo d/t low perfusion to kidney; look for similar hpoK, metabolic alkalosis, and HTN. Vomiting causes hypochloremic metabolic alkalosis d/t loss of gastric HCL. Loop diuretics are potassium wasting and cause metabolic alkalosis

Question 40

Causes of non-anion gap metabolic acidosis:

Answer 40

Good mneumonic but for the most part remember diarrhea (GI loss) or RTA; where is bicarb being loss (HARDUP)
Hyperalimentation (starting TPN)
Acetazolamide
Renal tubular acidosis (Type 1 = distal, 2 = proximal, 4 = hyporeninemic hypoaldosteronism)
Diarrhea
Uretosigmoid fistula
Pancreatic fistula

Question 41

PaO2 is influenced mainly by what vent settings? PaCO2 is therefore a measure of what?

Answer 41

FiO2 and PEEP. PaCO2 is a measure of pulmonary minute ventilation = affected mainly by RR and TV. Think of it like this: look at PaO2 and PaCO2 to determine what settings you need to change: FiO2/PEEP for PaO2 while RR/TV for PaCO2

Question 42

Finasteride mechanism of action?

Answer 42

5-alpha reductase inhibitor: second line for BPH since not as fast as alpha 1, prevents conversion of testosterone to potent DHT (anti-androgen) so good for hair loss and transgender women

Question 43

Skin lesion that does not meet ABCDE characteristics for melanoma but has these features; ugly duckling sign (different from others, dark brown instead of light, or nodular) has sensitivity up to 90% for melanoma, any mole that itches or bleed since benign lesions are
generally asymptomatic, next steps is melanoma suspected?

Answer 43

Excional biopsy w/ initial margins of 1-3mm of normal tissue

Question 44

Pt w/ severe bladder outlet obstruction d/t BPH will have inc in Cr and develop AKI, next steps?

Answer 44

Get renal U/S to assess for hydronephrosis

Question 45

Painless, rapid, transient monocular vision loss, dx and imaging?

Answer 45

Amaurosis fugax - curtain descending over visual field - retinal ischemia d/t atherosclerotic emboli originating from ipsilateral INTERNAL carotid artery - get duplex US neck

Question 46

Proximal muscle weakness (inc difficulty up stairs,) pain is mild/absent, elevated muscle enzyme (CK, aldolase, AST), autoantibodies (ANA and anti-Jo-1), bx will show endomysial infiltrate, patchy necrosis, dx?

Answer 46

Polymyositis (anti-Jo-1 like dermatomyositis but w/o skin findings like Gottron papules or the butterfly rash)

Question 47

Progressive pain in pts w/ prostate cancer and bony metastases even after androgen ablation, radionuclide bone scan now showing inc uptake in these pain areas next step?

Answer 47

Radiation therapy

Question 48

Recent diverticulitis (or a Crohn disease, malignancy), p/w air in urine, stool in urine, recurrent UTI, dx and use what to dx?

Answer 48

Colovesical fistula - dx w/ abdl CT w/ (oral or rectal) contrast

Question 49

Pernicious anemia MOA?

Answer 49

VitB12 deficiency d/t presence of autoantibodies against gastric intrinsic factor (which is required for B12 absorption); confirm w/ anti-intrinsic factor antibodies

Question 50

Megaloblastic anemia in whites of Northern European ancestry shiny tongue (atrophic glossitis), vitiligo, thyroid disease, and neuro abnormalities (autoimmune and megaloblastic anemia), dx?

Answer 50

Pernicious anemia - antibodies against intrinsic factor = B12 def

Question 51

Elevated alk phos, normal hepatic transamniase, normal RUQ U/S, positive AMA antibody, dx?

Answer 51

Early primary biliary cholangitis (chronic progressive liver dz w/ cholestasis and autoimmune destruction of intrahepatic bile ducts); very common in middle-aged women look for pruritus and fatigue first symptom onset; tx ursodeoxycholic acid as soon as dx made regardless of symptoms (liver transplant if severe)

Question 52

Murmur? Delayed and diminished carotid pulse, soft second heart sound, mid to late peaking systolic murmur w/ maximal intensity at 2nd right intercostal, radiation to carotids

Answer 52

Aortic stenosis!

Question 53

Chronic epigastric pain suddenly worsens, acute abdomen w/ rebound tenderness and guarding, x-ray showing radiolucency under diaphragm, dx?

Answer 53

Perforated peptic ulcer - air under the diaphragm

Question 54

66yoF agitation, restlessness, and poor sleep; past 3 mo HA and weight gain, no meds, smokes 50 yrs. BP 160/110 and pulse 90; skin findings show facial plethora and scattered bruises on extremities. Lab findings NOT RAS but Cushing syndrome, why?

Answer 54

Likely paraneoplastic w/ ACTH. Cushing syndrome: HTN, hyperglycemia, weight gain, easy bruising (causes look for excess glucocorticoid intake, ACTH producing pituitary adenoma, and ectopic ACTH - eg small cell lung cancer)
NOT RAS because: RAS is severe HTN a/w flash pulmonary edema, resistant HF, chronic kidney disease (elevated Cr), abdl bruit, look for other features of atherosclerosis

Question 55

Work up of hypercortisol?

Answer 55

Start w/ low dose dexamethasone or 24 hr urine free cortisol or late night salivary cortisol measurement -> if these are positive get ACTH lvl next to determine whether ACTH dependent (Cushing disease or ectopic ACTH) or ACTH independent (adrenal disease or
exogenous glucocorticoid)

Question 56

20yoM w/ 4-6 watery bowel movements w/ intermittent bright red blood per rectum; sigmoidoscopy demonstrates mild erythema involving the rectum and distal sigmoid colon and rectal biopsy confirms mucosal inflammation and crypt abscesses, dx and future required screening?

Answer 56

CRYPT ABSCESSES = UC (Crohn has abscesses but not crypt). Ulcerative colitis; inc risk for colorectal carcinoma. Other complications of UC = toxic megacolon, PSC, erythema nodosum/pyoderma gangrenosum, spondyloarthritis

Question 57

Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts are the most common renal vascular lesions seen, dx? Vs increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis, dx?

Answer 57

HTN (arteriosclerotic) vs Diabetes (mesangial expansion)

Question 58

Lady w/ hx of migraines but develops new type of headache w/ signs of INC pressure (frequent nausea, vomiting, blurry vision), next steps?

Answer 58

MRI - need to r/o mass

Question 59

Toxic shock rash vs meningococcemia rash?

Answer 59

TSS: staph aureus exotoxin will cause erythroderma (macular rash similar to sunburn)
Meningococemia: petechial rash

Question 60

Skin infection caused by poxvirus presents as small pruritic skin colored papules w/ umbilicated centers, dx? And which pts have prolonged course as opposed to self-limiting 6months?

Answer 60

Molloscum contagiosum; pts w/ impaired cellular immunity ie HIV disease, have prolonged course w/ widely distributed papules, facial involvement, and lesion counts in the hundreds *test for HIV in aduts w/ large or numerous lesions

Question 61

Primary vs central AI

Answer 61

Primary: most common cause autoimmune, dec cortisol (same in central), elevated ACTH, DEC ALDO, look for hyperpigmentation/hyperK/hypoNa/hypotension
Central: most commonly d/t glucocorticoid therapy, dec cortisol, DEC ACTH, normal aldo, less severe symptoms/no hyperpigmentation/no hyperK

Question 62

Bones, stones, abdominal moans, psychic groans (muscle weakness, recurrent nephrolithiasis, neuropsychiatric symptoms, hyperCa), dx?

Answer 62

Primary hyperparathyroidism - majority of cases d/t parathyroid adenoma; HTN w/ primary hyperparathyroidism is suspicious for MEN2A (parathyroid hyerplasia) w/ pheochromocytoma requiring w/u

Question 63

MEN1; MEN2A and MEN2B

Answer 63

MEN1: primary hyperparathyroidism, enteropancreatic tumors (gastrinoma), pituitary tumor
MEN2A: medullary thyroid carcinoma, pheochromocytoma, parathyroid hyperplasia
MEN2B: MTC, pheo, other (mucosal/intestinal neuromas, marfanoid habitus)

Question 64

Low frequency tinnitus w/ feeling of fullness, episodic vertigo, sensorineural hearing loss, dx?

Answer 64

Meniere disease

Question 65

Common causes of vertigo: meniere, BPPV, vestibular neuritis, migraine, brainstem/cerebellar stroke

Answer 65

Meniere: recurrent eps lasting 20 mins to hrs, sensorineural hearing loss, tinnitus w/ feeling of fullness (mechanical humming causing distortion of speech) BPPV: brief eps triggered by head movement, dix-hallpike causes nystagmus
Vestibular neuritis: acute single ep last days, follows viral syndrome, abnormal head-thrust test
Migraine: vertigo a/w HA or other migrainous phenomenon (visual aura), symptoms resolve in btw eps
Brainstem cerebellar stroke: sudden onset persistent vertigo, w/ other neuro symptoms

Question 66

Lesion at spinal cord affecting bladder?

Answer 66

Thoracic or sacral

Question 67

Diabetes insipidous - central vs nephrogenic?

Answer 67

Cental = decreased ADH secretion from pituitary
Nephrogenic = normal ADH but kidneys resistant to ADH . Cutoff for dilute urine = 100mOsm/kg

Question 68

Polyuria in nonhospitalized pt can be d/t diabetes mellitus, primary polydypsia, and diabetes insipidus

Answer 68

Primary polydipsia (HypoNa) = inc water intake that surpasses kidney’s ability to excrete it; look for hyponatremia (Na <137), very dilute urine (osmolality <100mOsm) and urine osmo < serum osmo

Question 69

Polyuria in nonhospitalized pt can be d/t diabetes mellitus, primary polydypsia, and diabetes insipidus

Answer 69

DI = central vs nephrogenic (both HyperNa). Ddx the two w/ water deprivation test (also distinguishes if there was true polydipsia). The pt must abstain from water for 2-3hr; urine osmo >600 suggest primary polydipsia d/t INTACT ADH and ability to concentrate urine in the absence of water intake. Pts w/ continued dilute urine likely have DI. These pts then receive desmopressin to distinguish btw central and nephrogenic. Central DI = >50% inc in urine osmolality w/ demopressin (ADH analogue replacing the nonexistent ADH)

Question 70

Nephrogenic DI will not see inc in urine osmo since kidneys do not respond to ADH. Tx for central DI is desmopressin (ADH analogue)

Answer 70

Demeclocycline is for SIADH; where you see hyponatremia w/ concentrated urine

Question 71

Cystic hepatic lesion w/ egg shell classification, dx?

Answer 71

Will also see hydatid cysts d/t echinococcus, tx w/ surgical resection under the cover of albendazole (aspiration can be performed but there is risk of anaphylactic shock d/t cyst content spillage)

Question 72

High fever, chills, tenosynovitis, polyarthralgias, pustular/papular lesions on trunk and extremities, commercial sex worker, dx?

Answer 72

Disseminated gonococcal infection; blood cx may be negative so get NAAT. IV ceftriaxone (switch to oral cefixime when improving) and empiric azithro/doxy chlamydial co-infection coverage

Question 73

Classic TSS rash by Staph aureus?

Answer 73

Diffuse erythematous desquamating rash throughout the body including palms and soles; also look for hypotension and fever

Question 74

When to start colonoscopy screenings in pts w/ UC

Answer 74

8 years after initial diagnosis and repeat 1-2 years after for CRC

Question 75

4 indications when to start statin

Answer 75

1) any atherosclerotic disease (ACS, MI, stable angina, stroke, TIA, PAD)
2) LDL > 190
3) Age 40-75 w/ diabetes
4) 10 year ASCVD risk > 7.5

Question 76

Antiplatelet therapy vs anticoagulation therapy (recommended in A-fib pts w/ appropriate CHADS-VASC scoring)

Answer 76

Antiplatelet = aspirin and clopidogrel
Anticoagulation = Warfarin or non-Vit K antagonist orals like apixaban, dabigatran, rivaroxaban

Question 77

Contraindications to anticoagulation?

Answer 77

Active bleeding or failed therapy = consider IVC filter

Question 78

Ankylosing spondylitis buzz words?

Answer 78

Reduced forward flexion of lumbar spine and tenderness over lumbosacral area. Chronic progressive back pain and stiffness; pain relief w/ activity; lumbosacral tenderness *SI; and reduced spinal range of motion *bamboo sign d/t fusion of vertebral bodies w/ ossification of discs. Prevalent in young and males

Question 79

Best dx for ankylosing spondylitis?

Answer 79

X-ray of SI joints more specific than HLA-B27; not everyone w/ HLA-B27 has AS

Question 80

6mo intermittent upper abdl pain w/ nausea, dull epigastric pain worse after meals, relieved leaning forward, occasional diarrhea *steatorrhea, lost 15lbs over 12 months; five years ago w/ similar event. Alcohol daily. Dx and use what to test?

Answer 80

Chronic pancreatitis; best modality is CT to look for pancreatic calcifications *lipase in chronic panc may only be slightly elevated or even normal

Question 81

Presbyopia and poor near vision, d/t loss of what mechanic?

Answer 81

Loss of lens elasticity; cornea shape change = astigmatism

Question 82

Skin lesion presents as macules, vesicles, and bullae w/ honey colored crusts (common in children); dx and what bug?

Answer 82

Bullous impetigo caused by Staph aureus (coagulase negative staphylococci that threw you off on the poison ivy question - common skin contaminant in cultures)

Question 83

Armpit lesion w/ painful nodules and abscesses *chronic and relapsing, dx?

Answer 83

Hidraneitis suppurativa

Question 84

22yoM yellow eyes, otherwise feels well no symptoms, has noticed occassional darkening of urine in past; no other medical problems, immigrated from Turkey. Fasting for past 2 days for religious reasons, normal vitals, scleral icterus present. PE - heart lungs abdomen normal, no HSM or masses. Labs - elevated INDIRECT total bili and direct bili, normal alk phos, dx and mgmt?

Answer 84

Gilbert syndrome , reassurance/supportive care. Intermittent jaundice d/t mild unconjugated hyperbilirubinemia w/o evidence of hemolysis; triggered by fasting or consumption of fat-free diet, physical exertion, illness, stress

Question 85

RANDOM FACTS

Answer 85

1) Elevated unconjugated bilirubin (aka INDIRECT) = think hemolysis or reduced conjugation process like Gilbert. Elevated conjugated bili (DIRECT) = think hepatobiliary disease obstructive nature (cirrhosis, hepatitis, Dubin-Johnson and Rotor)
2) Unconjugated bili disease = Gilbert -> Crigler Najjar (bad for babies) *GC
3) Conjugated bili disease = Dubin Johnson and Rotor *DR
4) Aortic coarctation vs dissection (the dissection is before the aortic split - pressure difference btw arms will be present) (the coarctation is after the split - difference in UE vs LE BPs *unless the coarctation occurs proximal to the left subclavian artery)
5) Plantar warts are d/t HPV infection and most commonly occur in young adults and immunocompromised individuals; lesions appear as hyperatotic papules on sole of foot that can be painful when walking or standing

Question 86

1st line tx for chemotherapy induced nausea

Answer 86

Serotonin (5HT) receptor antagonist, like ondansetron, that target 5HT3 receptors; second line if refractory is dopamine antagonist (metoclopramide, prochloperazine, promethazine)

Question 87

HyperK management: 3 goals in this order

Answer 87

Stabilize cardiac membrane w/ calcium gluconate -> shift K intracellularly (fastest is insulin/glucose) -> reduce total K ie Kaexelate (sodium polystyrene sulfonate)

Question 88

Cough, chest pain, hemoptysis, numerous round alveolar infiltrates on chest imaging, murmur best heard systolic murmur inc on inspiration, prior IVDU, dx?

Answer 88

Infective endocarditis affecting tricuspid valve leading to pulmonary septic emboli (most commonly staph aureus)

Question 89

Note on paradoxical aka reversed splitting of second heart sound: normally A2 closes then P2 (A before P - makes sense longer breath)

Answer 89

In paradoxical: A2 comes AFTER P2; best heard during expiration - commonly d/t fixed LVOT obstruction (aortic valve or subaortic stenosis, LBB)

Question 90

Most reliable indicator for opioid intoxication?

Answer 90

DEC respiratory rate! Dec bowel sounds and hypotension are good indicators too; absence of miosis does not exclude diagnosis

Question 91

Pt w/ organ transplant on high dose immunosuppressive suddenly stopped bactrim and valganciclovir, now p/w pneumonitis (diffuse bilateral interstitial infiltrates), gastroenteritis (bloody diarrhea), and hepatitis (elevated transaminases), dx?

Answer 91

CMV; dx w/ CMV PCR; tx w/ either IV ganciclovir if severe or oral valganciclovir (not acyclovir)! Legionella - hyponatremia, diarrhea, pulmonary symptoms (NO bloody diarrhea)

Question 92

Concern for what bone complication in pts w/ rheumatoid arthritis?

Answer 92

Osteoporosis (soft tissue swelling, joint space narrowing and bony erosions)! Osteitis deformans = aka Paget disease of bone

Question 93

BP 180/120 *high, they’ve mentioned it being this threshold on multiple questions, HA, upper abdominal systolic-diastolic bruit, dx?

Answer 93

Renal artery stenosis (look for resistant multi drug HTN, malignant HTN, pressures 180/120, abdl bruit, unexplained atrophic kidney, or unexplained rise in Cr after starting ACE). Vs AAA = abdl bruits typnically NOT present, most pts are asymptomatic, if anything look for pulsatile mass

Question 94

42yoM 4 weeks fatigue, weakness, fleeting joint pains/low grade fever/dark cloudy urine/pain in fingertips (Osler) and SOB; exam shows swelling and tenderness in several finger pads. Normocytic anemia, elevated leukocytosis, SUPER elevated ESR and elevated RF, UA 2+ blood and 1+ protein, dx?

Answer 94

Infective endocarditis! The giveaway was the Osler nodes and abnormal urine sediment

Question 95

Another bone pain w/ hx of Crohn’s and small bowel resection, what are the calcium phosphate and PTH levels

Answer 95

LOW Ca, LOW phos, HIGH PTH. Malabsorption causing Vit D def causing low calcium and phosphate absorption -> high PTH = concern for osteomalacia. Note high PTH also causes inc urinary phosphate excretion as serum calcium levels try to go up (Ca and Phos go in opposite direction unless this is a malabsorption problem)

Question 96

Polycythemia management

Answer 96

Myeloproliferative disorder characterized by erythrocytosis - HTN, transient vision disturbances, facial plethora, and splenomegaly are common! Tx w/ serial phlebotomy; bone marrow suppressive drugs like hydroxyurea may be added if there is high risk of thrombosis

Question 97

HACEK organisms account for 3% of organisms that can cause infective endocarditis

Answer 97

Eikenella a/w normal human oral flora - dental procedure or peridontal infection

Question 98

1st line mgmt of carpal tunnel syndrome

Answer 98

Start w/ nocturnal wrist splinting -> if significant weakness or refractory symptoms consider surgical decompression

Question 99

Nephrotic range proteinuria and hematuria w/ electron microscopy showing dense deposits within glomerualr basement membrane; immunofluorescence microscopy is positive for C3 not immunoglobulins, most likely pathophysiologic mechanism?

Answer 99

COMPLEMENT activation antibodies against C3 convertase - MPGN. Persistent activation of the alternative complement pathway = membranoproliferative glomerulonephritis (unique nephropathy because IgG antibodies against C3 convertase of the alternative complement cause persistent complement activation). VS immune complex mediated glomerulopathies is d/t circulating immune complexes (SLE, post strep glomerulonephritis)

Question 100

Raw oyster consumption or wound contamination during sailing/boating or raw seafood handling; usually causes mild cellulitis but those w/ liver disease or hemochromatosis are at risk of nec fascitis w/ hemorrhagic bullous lesions and septic shock, dx?

Answer 100

Vibrio vulnificus: dx w/ blood and wound cultures and tx w/ IV ceftriaxone + doxycycline

Question 101

Organ transplant prophylaxis?

Answer 101

Bactrim for PCP proph and ganciclovir or valganciclovir for CMV coverage

Question 102

Scabies? Bed Bugs?

Answer 102

Scabies = intense pruritus that is worse at night, pustules, finger web involvement, and excoriations (mites dig burrow into skin causing delayed type IV hypersensitivity); focus on flexor surface of wrist, lateral surface of fingers, and FINGER WEBS. Tx w/ permethrin topical or oral ivermectin
Bed bugs: breakfast/lunch/dinner bites sparing palms and soles, worse at night

Question 103

55yo white male, many falls for the past weeks, dizzy, dry mouth, dry skin, erectile dysfunction over this period, past hx of resting tremors, orthostatic hypotension, dx?

Answer 103

Multiple system atrophy (Shy-Drager syndrome): degenerative disease w/ 1) parkinsonoism, 2) autonomic dysfunction (postural hypotension, sweating, bladder/sexual problems), 3) widespread neurological signs (cerebellar, pyramidal, or LMN)

Question 104

Always consider what syndrome when a Parkinson pt experiences orthostatic hypotension, impotence, incontinence, and other autonomic symptoms?

Answer 104

Shy-Drager: concern for laryngeal stridor/bulbar dysfxn; tx is aimed at intravascular volume expansion w/ fludrocortisone, salt supplementation, alpha adrenergic agonists

Question 105

BIOSTATS:

Answer 105

Loss to f/u in prospective studies create potential for attrition bias a subtype of selection bias

Question 106

Timeline of renal changes in pts w/ diabetes?

Answer 106

Glomerular hyperfiltration (as early as several days after diabetes dx is made) -> this leads to intraglomerualr HTN leading to progressive glomerular dmg and renal fxn loss -> thickening of GBM -> mesangial expansion -> nodular sclerosis (specific to diabetic nephropathy)
*ACEi help diabetes by reducing intraglomerular HTN

Question 107

Schilling test

Answer 107

How well stomach can absorb B12 (intrinsic factor problem vs absorption vs dietary)

Question 108

34yoF diarrhea, weight loss and fatigue for a year; diarrhea 2-3x daily w/ abdl pain; no tenesmus or bloody diarrhea but stool is very foul smelling and floating; also complains of diffuse bone pain; lab shows Hgb 9.8 w/ MCV 72, dx? and expected calcium, phosphate, pth
levels

Answer 108

Steatorrhea and malabsorption (from some chronic GI disease) resulting in poor absorption of Vit D thereby causing poor absorption of calcium and phosphorus -> pts with low calcium and phosphorus d/t poor absorption will develop secondary hyperparathyroid (low Ca and low phos high PTH). Low Vit D can
lead to osteomalacia (bone pain

Question 109

Tylenol toxicity management; toxic ingestion = > 7.5g

Answer 109

Initial mgmt = focus on gastric decontamination w/ activated charcoal if pts presents within 4 hrs of ingestion; also obtain acetaminophen level at that time. Next use nomogram to determine change of hepatotoxic effects given acetaminophen level at hr since ingestion - tool will guide whether NAC is required

Question 110

Spontaneous bacterial peritonitis, dx criteria? Tx?

Answer 110

Paracentesis - PMNs > 250, positive culture (often gram neg like E. coli or Kleb), protein < 1 and SAAG > 1.1. Tx = 3rd gen cephalosporin; fluoroquinolones for SBP proph

Question 111

Corneal vesicles, opacification, dendritic ulcers, dx and tx?

Answer 111

Viral keratitis d/t herpes simplex or VZV tx w/ ganciclovir or trifluridine

Question 112

Localized swelling along margin of lower eyelid w/ erythema and tenderness, no conjunctival injection or ocular discharge, dx and tx?

Answer 112

External hordeolum (stye!) - acute inflammatory d/o of eyelash follicle or tear gland often d/t staph aureus but sterile in many cases; start w/ warm compresses first (pustule may form -> then rupture w/ pus/relief of pain -> chalazion may take its place and regress over months)

Question 113

Mgmt of pts w/ vasovagal syncope?

Answer 113

Reassurance and education about benign nature of condition, advised to avoid triggers and use physical counterpressure maneuvers during prodromal phase in order to abort episode; BB don’t help - no sig benefits in trial

Question 114

Autoimmune hepatitis vs hemochromatosis:

Answer 114

Hereditary hemochromatsis a/w calcium pyrophosphate dihydrate crystal deposition (pseudogout) in joints leading to chondrocalcinosis, pseudogout, and chronic arthropathy. Not autoimmune hepatitis since that affects symmetric small joints while the pt w/ hemochromatosis (both him and dad w/ diabetes and aminotransferases) had a single bad knee

Question 115

Cardiac (aortic dissection, MVP), skeletal (disproportionately long extremities and inc arm-span-to-height ratio), pulmonary (spontaneous pneumo), and ocular (ecoptia lentis), abnormalities, dx? All of these pts w/ acute chest pain require eval for what?

Answer 115

Marfan syndrome; aortic dissection! Pts w/ dissection and or progressive aortic root dilation can develop AR. Look for early descrendo diastolic murmur best heard along left sternal border at 3rd and 4th intercostal space w/ pt sitting up, leaning forward, and holding breath after full expiration

Question 116

All about Marfan: tall w/ long arms, flexible joints, pectus carinatum

Answer 116

Skeletal: arachnodactyly, upper to lower body segment ratio is dec while arm to height is inc, pectus deformity/scoliosis/lyphosis, and joint hypermobility Ocular: ectopia lentis CV: aortic dilation, regurgitation or dissection (the trifecta of aortic valve!), and MVP
Pulmonary: spontaneous pneumo from apical blebs

Question 117

Tachyarrhythmia (narrow or wide doesn’t matter), a/w clinical or hemodynamic instability (hypotension, cardiogenic shock, signs of ischemia, acute HF), first line tx?

Answer 117

Immediate synchronized cardioversion (amiodarone is for maintence of sinus rhythm - duh antiarrhythmic)

Question 118

Hypothyroidism can cause what additional metabolic abnormalities?

Answer 118

HYPERLIPIDEMIA, hyponatremia and asymptomatic elevations of creatinine kinase and serum transamniases

Question 119

Common side effect of CKD pts started on EPO (after ruling put iron def anemia)?

Answer 119

Hypertensive crisis (pts who receive large dose or exp rapid rise in HgB)

Question 120

40yo w/ SLE on prednisone has atraumatic hip pain w/ normal x-ray findings, dx and best imaging modality?

Answer 120

Osteonecrosis (aka avascular necrosis) of the femoral head (d/t disruption of circulation of bone through micro-occlusion); common complication of SLE/pts on glucocorticoids. X-ray normal in first few months; MRI more sensitive

Question 121

Absent of identifiable bacteria on culture or gram stain, mucopurulent discharge in a pt who is sexually active suggests what dx?

Answer 121

Chlamydial urethritis; get NAAT

Question 122

What to check before initiating these therapies: TNF-alpha inhibitor vs Trastuzumab

Answer 122

TNF-alpha inhib - tx of rheumatologic disease, can cause reactivation of latent TB prior to initiating agent get PPD
Trastuzumab - used for HER-2 positive breast carcinoma. Risk of cardiotoxicity get baseline echo and ctm

Question 123

MOA of nitrates?

Answer 123

Primary anti-ischemic effect = systemic vasodilation and dec in cardiac preload resulting in a dec in left ventricular end-diastolic and end-systolic volume -> this in turn leads to 1) reduction in left ventricular systolic wall stress (which reflects afterload and is proportional to pressure*radius/thickness) AND 2) dec in myocardial oxygen demand

Question 124

Antiischemic effect of nitrates?

Answer 124

Mediated by systemic vasodilation w/ a dec in left ventricular end diastolic volume and wall stress resulting in dec myocardial oxygen demand

Question 125

Multiple myeloma pts are at increased risk for recurrent infections d/t what abnormality?

Answer 125

Impaired effective antibody production (bone marrow infiltration by neoplastic cells alters normal leukocyte population thereby causing hypogammaglobulinemia)

Question 126

New mom holding infant w/ thumb outstretched (abducted and extended); inflammation of abductor pollicis longus and extensor pollicis brevis tendons passing through fibrous sheath at radial styloid process; pain elicited w/ direct palpation of radial site of wrist at base of hand (also positive Finkelstein test = passive stretching of tendons) dx?

Answer 126

De Quervain tenosynovitis

Question 127

Pain over palmar aspect of first MCP joint and locking of the thumb in flexion?

Answer 127

Trigger thumb

Question 128

Wells score < or equal to 4 = PE unlikely -> get diagnostic study before starting IV heparin

Answer 128

Wells score > 4 = PE likely -> consider symptoms and contraindications then start IV heparin

Question 129

Wells score takes into account what factors?

Answer 129

3+ for signs of DVT or no alt diagnosis 1.5+ for previous PE/DVT, HR >100, or recent sx/immobilization 1+ for hemoptysis or cancer

Question 130

Mgmt of C diff? Suspect in what pts?

Answer 130

Any pt on abx and has diarrhea and or abdl pain; send stool studies for C diff TOXIN; tx initial ep w/ oral vancomycin or oral fidaxomicin; pts w/ fulminant dz (like hypotension, ileus, megacolon) should be tx w/ high dose oral vanc and IV metro

Question 131

The lupus anticoagulant, an anti-phospholipid antibody, is a prothrombotic immunoglobulin that causes artifact error w/ prolonged aPPT in vitro; with this prolongation and clinical findings = still anti-phospholipid syndrome

Answer 131

Specific tests like diluted Russel viper venom test exist

Question 132

Thickened white patch inside mouth after recently started chewing tobacco? Granular texture on buccal mucosa, not indurated, not removed by scraping w/ tongue depressor

Answer 132

Leukoplakia. Canker sore = aphthous stomatitis

You can scrape of thrust (oral candidiasis) but you can not scrape off leukoplakia

Question 133

Fever, leukocytosis, prostate tenderness, more pronounced than UTI symptoms w/ systemic symptoms like fever, chills, ill appearance, associated REGIONAL pain, dx and what to get next?

Answer 133

Acute bacterial prostatitis - get mid stream urine sample to direct abx therapy (start empiric w/ bactrim or fluoroquinolone while waiting cultures)

Question 134

Amiloride side effects?

Answer 134

Potassium sparing diuretic - hyperK. Other potassium diuretics = spironolactone, eplerenone (both aldosterone antagonist), triamterene (sodium channel blocker like amiloride)

Question 135

Tx categories for Parkinsonism?

Answer 135

Levidopa plus carbidopa (dopamine precursor), benztropine (anticholinergic), amantadine *unclear MOA, bromocriptine/pramipexole (dopamine agonist), selegiline (MAO B inhibitor)

Question 136

Most common initial side effect of levidopa plus carbidopa? long term side effects?

Answer 136

Hallucinations! Dyskinesia/dystonia appear after 5-10 years after therapy

Question 137

Cerebellar dysfunction causes what, vs pyramidal tract disease?

Answer 137

Ataxia, intention tremor, impaired rapid alternating movements; pyramidal signs = look for pronator drift, focal weakness, spasticity, hyperreflexia and Babinski sign. Basal ganglia dysfunction causes EPS signs (resting tremor, rigidity, choreiform)

Question 138

10-20 days after strep throat or skin infection, now w/ hematuria, HTN, red cell casts, and mild proteinuria, dx?

Answer 138

Acute post-streptococcal glomerulonephritis

Question 139

How to ddx ACL tear from MCL/meniscus?

Answer 139

ACL injuries usually present w/ rapid onset of pain/swelling w/ hemarthrosis

Question 140

Renal transplant dysfunction in the early post op period manifests as oliguria, hypertension, and inc Cr/BUN; what causes are there and what’s the immediate tx in acute rejection?

Answer 140

Ureteral obstruction (expect dilation of calyces on US), cyclosporine toxicity (supratherapeutic levels), vascular obstruction, ATN, acute rejection (heavy lymphocytic
infiltration and vascular invlvmt w/ swelling of intima = IV steroids!)

Question 141

Reversal for Heparin? Warfarin?

Answer 141

Heparin - protamine

Warfarin - FFP/Vit Kand prothrombin complex concentrate

Question 142

Most common cause of death in dialysis patients?

Answer 142

Cardiovascular disease - 20% MI, 60% sudden cardiac death

Question 143

This question you missed because most likely main contributor to GI bleed/COPD lady’s lethargy was hypoventilation (she had mixed respiratory acidosis and non-anion gap metabolic
acidsosi); but what is type 2 RTA (very common type of non-anion gap metabolic acidosis)

Answer 143

Defective tubular bicarb resabsorption in the proximal tubules = type 2 RTA (aka proximal RTA

Question 144

YOUNG LADY, transient monocular vision loss, family hx of stroke, HTN (160/110s) carotid bruit, dx?

Answer 144

Fibromuscular dysplasia: commonly women age 15-50; non inflammatory and nonatherosclerotic condition caused by abnormal cell dvlpt in arterial wall that leads to vessel stenosis, aneurysm, or dissection (most commonly affects renal, carotid, and vertebral
arteries); dx w/ CT angio abdomen or duplex US.

Question 145

How does fibromuscular dysplasia affect the kidneys?

Answer 145

FMD decreases perfusion to kidneys causing inc in both renin and aldosterone levels and resistant HTN (secondary hyperaldosteronism); note since both aldo/renin inc the aldo to renin ratio is <20. Cerebrovascular symptoms of brain ischemia = amaurosis fugax, Horner’s, TIA, HA, tinnitus, dizziness

Question 146

BRBPR in man <40, first steps?

Answer 146

Anoscopy first if likely hemorrhoids and no risk of cancer; if pt >50 or w/ clinical features suggesting malignancy get colonoscopy

Question 147

Clinical features of IBS:

Answer 147

Recurrent abdl pain/discomfort for >3 days per month for at least 3 months AND: symptoms improve w/ BMs, change in freq of stool, change in form of stool. S/s suggesting other etiologies = rectal bleeding, nocturnal abdl pain, weight loss, abnormal lab findings

Question 148

Recent UTI, now w/ 10 days of malaise, low back pain, and fever and focal spinal tenderness, dx and next steps?

Answer 148

Vertebral osteomyelitis; note white count and fever not always present but ESR and CRP are usually markedly elevated; get MRI if you suspect vertebral osteo followed by CT guided needle aspiration/biopsy (low back pain, focal spinal tenderness, recent infection)

Question 149

Patients w/ cardiac tamponade usually have Beck’s triad of hypotension, distended neck veins, and muffled heart beats

Answer 149

Symptoms are d/t exaggerated shift of the interventricular septum toward the left ventricular cavity which reduces left ventricular preload, stroke
volume, and CO

Question 150

Recurrent bacterial infections (pneumonia, sinusitis, oitits and GI bugs like salmonella/campy; also w/ chronic diarrea or IBD like conditions) in an adult raises suspicion for what?

Answer 150

Common variable immunodeficiency; get quantitative measurement of serum immunoglobulin levels

Question 151

Wheezing following ingestion of naproxen as well as rhinitis and post nasal drainage = what dx and what is it commonly a/w?

Answer 151

Aspirin exacerbated respiratory disease; commonly a/w nasal polyps

Question 152

Malignancies that commonly mets to spine = lung, renal, prostate and multiple myeloma (thoracic most frequent followed by lumbar)

Answer 152

Gradually worsening, severe local back pain, pain worse in recumbent position (pain from degenerative joint disease is better laying down). EARLY signs: symmetric LE weakness and hypoactive DTRs. LATE signs: Babinski, dec rectal sphincter, paraplegia w/ hyperactive DTRs and sensory loss, diagnosis?

Question 153

Malignancies that commonly mets to spine = lung, renal, prostate and multiple myeloma (thoracic most frequent followed by lumbar)

Answer 153

Spinal cord compression; look for spinal injury, malignancy, infection; get MRI, IV glucocorticoids, rad-onc/neurosx consult

Question 154

Pts w/ asplenia (gunshot pt that had abdl sx in the past now w/ strep pneumo) are at risk for fulminant infection w/ encapsulated bacteria like what? this is d/t deficits in what response?

Answer 154

Strep pneumo, H influenzae, Neisseria meningitidis; no spleen = no antibody response and antibody-mediated phagocytosis/complement activation

Question 155

Recurrent bacterial infections primarily of the skin and mucosa is d/t what impaired mechanism?

Answer 155

Chemotaxis is impaired in pts w/ leuykocyte adhesion deficiency (can’t move to the SKIN)

Question 156

Pts w/ recurrent bacterial or fungal infxns d/t catalase producing organisms like Aspergillus and Staph aureus is d/t what deficiency/disease?

Answer 156

Pts w/ chronic granulomatous disease have impaired oxidative burst (catalase - chronic granulomatous dz - oxidative burst)

Question 157

Cancer related anorexia/cachexia mgmt? Vs HIV cachexia

Answer 157

Progesterone analogues (megestrol acetate and medroxyprogesterone acetate) 
Synthetic cannaboids for HIV cachexia

Question 158

This pt has symptomatic hypotonic hyponatremia d/t SIADH (serum osmo <275 = hypotonic). Normally kidneys excrete free water at rate to prevent blood hypotonicity. However in SIADH, inappropriately HIGH levels of ADH prevent kidneys from excreting dilute urine (leading to urine osmo > 100), and hypotonicity and hyponatremia develop. Pts w/ SIADH are typically euvolemic; therefore, urine sodium concentration is typically elevated (>40 mEq/L), unlike in pts w/ hypovolemia. In addition, in SIADH, serum uric acid levels are characteristically low, serum K is normal, acid base status is normal

Answer 158

Etiologies: CNS disturbance, medications (CBZ, SSRIs, NSAIDs), lung disease (pneumonia), ectopic ADH (small cell), pain and nausea
Labs: hyponatremia, serum osmo <275 (hypotonic), urine osmo >100 (concentrated), urine Na >40
Mgmt: fluid restriction + salt tablets, hypertonic saline for severe s/s

Question 159

RANDOM FACTS

Answer 159

1) Lactose intolerance characterized by positive hydrogen breath test, positive stool test for reducing substances, low stool pH and inc stool osmotic gap; no steatorrhea
2) Noninvasive evaluation w/ compression US is recommended as an initial test in pts w/ moderate or high probability of DVT
3) P2y12 = clopidogrel
4) Ejection murmurs think AR or PR
5) Aspirin and beta blockers can trigger bronchoconstriction in pts w/ asthma. ACE too but by inc bradykinin (can occur at any time), not affected by asthma

Question 160

CPPD vs urate crystal gout

STONES: calcium vs uric acid

Answer 160

CPPD: smaller rhomboid shaped weakly positively birefringent
Urate cyrstal gout: needle shaped and negatively birefringent

Calcium oxalate - enveloped shaped *most common
Uric acid - low pH, RHOMBOID shaped, tx w/ potassium citrate
Cysteine - hexagonal *familial cystinuria impaired transport of cystine, urinary cyanide nitroprusside test +
Struvite - coffin lid shape

Question 161

HMG-CoA reductase MOA

Answer 161

Inhibition of INTRACELLULAR synthesis pathway

Question 162

A number of features are helpful in ddx Crohn from UC.

Answer 162

Crohn: multiple portions of GI, rectal sparring, noncaseating granulomas (noninfectious), fistula formation, transmural inflammation, crypts but NO abscesses
UC: CRYPT abscesses

Question 163

55yoF pain itching red streaks on left arm (similar in past that resolved), also w/ heart burn and milkd upper abdl pain for months. Lots of smoking. Epigastric tenderness to palpation; tender erythematous palpable cord like veins on left arm and upper chest, dx and next steps?

Answer 163

Migratory superficial thrombophlebitis - aka TROUSSEAU’“S syndrome. Typically a/w pancreatic (or lung, prostate, stomach, colon), cancer. Tumor releases mucins that react w/ platelets to form platelet rich microthrombi. Get CT to r/o cancer

Question 164

Three types of infections w/ Bartonella

Answer 164

Bartonella henslae - local cutaneous dermal infection
Bartonella angiomatosis - lymphatic penetration leading to vascular cutaneous lesions (red/purple papules that become friable/pedunculated nodular)
Endovascular infection - endocarditis
Tx doxy or erythromycin, start HAART in HIV (esp CD4 < 100)

Question 165

Use/rate dependent anti-arrhythmic

Answer 165

Flecainide. Class 1C and Class IV CCB antiarrhythmics

Question 166

No pain w/ palpation for osteoarthritis! Also no redness, warmth, tenderness. X-ray shows loss of joint space, ostephyte formation and subchondral sclerosis. Vs aortoiliac atherosclerosis

Answer 166

LE pain w/ activity; pain typically in entire leg (butt, thigh, calf) and pedal pulses diminished!

Question 167

Pulmonary emboli classically p/w sudden onset pleuritic CP, cough, and dyspnea; hemoptysis can occur as a result of pulmonary infarction. Chest CT shows?

Answer 167

Wedge shaped infarction is virtually pathognomonic for PE

Question 168

Asthma vs COPD PFT findings

Answer 168

Asthma will improve post bronchodilators; COPD will not. Also, remember that DLCO is normal in asthma while it is dec in COPD

Question 169

HoCM mechanism of inheritance?

Answer 169

Autosomal dominant

Question 170

Metals that can trigger allergic contact dermatitis:

Answer 170

Cobalt, chromium, beryllium, nickel, zinc; the good shit like gold/silver/platinum/titanium don’t do it

Question 171

Hypovolemia’s affect on kidney?

Answer 171

Dec renal perfusion leads to activation of renin-angiotensin-aldosterone system -> aldosterone stimulates aggressive sodium reabsorption in collecting tubules of kidney in an effort to sustain blood volume *answer was dec urine sodium

Question 172

Lady who recently started weight loss supplement p/w clear signs of hyperthyroidism; work up showed elevated T4 and low TSH (primary hyperthyroidism), no signs of Graves (goiter or proptosis), and RAIU was low (so again not Graves or toxic adenoma or multinodular goiter), next steps to confirm that this is exogenous administration of thyroid

Answer 172

Measure serum thyroglobulin: 1) if it is high then the thyroid is endogenous coming from either thyroiditis condition or iodide exposure, 2) if the thyroglobulin is low = confirmed exogenous hormone

Question 173

Brief morning stiffness, normal ESR, exposure to small children, dx?

Answer 173

Viral arthritis d/t parvovirus B19 (anti-parvovirus IgM levels will be elevated; unnecessary for dx purposes); tx symptomatically w/ NSAIDs

Question 174

Fibromyalgia 1st line tx?

Answer 174

Amitryptyline is effective initial therapy; pregablin/duloxetine/milnacipran are alternate therapies

Question 175

Sinusitis/otitis, saddle nose deformity, lung nodules/cavitation, RAPIDLY PROGRESSIVE GN, livedo reticularis, nonhealing ulcers, ANCA+, dx? labs? mgmt?

Answer 175

GPA (Wegner), bx of skin = leukocytoclastic vasculitis, kidney = pauci immune GN, lung = granulomatous vasculitis, tx w/ steroids and immunomodulators (MTX, cyclophosphamide). C-ANCA = GPA. P-ANCA = microscopic polyangiitis, eosinophilic granulomatosis w/ polyangiitis

Question 176

Pt > 50, new onset HA localized to the temples and frequently a/w fever, weight loss, vision changes, jaw claudication (fatigue and pain when chewing), dx and complication?

Answer 176

Giant cell arteritis (aka temporal arteritis); biggest complication is aortic aneurysm/dissection

Question 177

Info on UC

Answer 177

Bloody diarrhea, weight loss, fever
Endoscopic findings show: erythema friable mucosa, pseudopolyps, invlmt of rectosigmoid, continuous colonic involvement (no skip)
Bx shows: submucosal inflammation, crypt abscesses
Complication: colorectal cancer, toxic megacolon, PSC, spondyloarthritis!, erythema nodosum

Question 178

Rib notching on cxr is a/w what?

Answer 178

Coarctation of the aorta

Question 179

19yoF recurrent HAs for years, hx of HTN, BP on exam 175/100 and 170/102 on left and right arm; pulses in all extremities full and symmetric (this obvs incluide LE). Systolic bruit heard under right ear; abdl exam w/o tenderness or mass, dx?

Answer 179

Fibromuscular dysplasia (typically affects internal carotid and renal arteries - leading to arterial stenosis, aneurysm or dissection, 90% women): subauricular systolic bruit and abdl bruit are common. Dx w/ duplex US, CTa, MRA, catheter based arteriograph based arteriography. Tx w/ anti-HTN, PTA (percutaneous transluminal angioplasty), sx

Question 180

Flank or abdl pain radiating to the perineum often w/ nausesa and vomiting, dx and imaging?

Answer 180

Ureterolithiasis; get US or NONCONTRAST spiral CT (contrast not needed)

Question 181

Flank or abdl pain radiating to the perineum often w/ nausesa and vomiting, dx and imaging?

Answer 181

Ureterolithiasis; get US or NONCONTRAST spiral CT (contrast not needed)

Question 182

Characteristic pattern of referred pain:

Answer 182

Cholecystitis - right shoulder 
Angina - substernal
Pancreatitis - radiates to the back
Appendicitis - periumbilical
Nephrolithiasis -flank/abdl pain down to groin

Question 183

45yoF months of watery diarrhea; cramps in leg muscles and feels dehydrated, abdl discomfort and stool is tea colored; episodic flushing in her face, no fever or weight loss, nontender abdomen w/ normoactive bowel sounds. Low K, low HCO3, elevated Cr, 3 cm mass in pancreatic tail, dx?

Answer 183

VIPoma - rare tumor affecting pancreatic cells that produce VIP (vasoactive intestinal peptide) - causes inc fluid and electrolyte secretion in intestinal lumen. Look for watery diarrhea, a/w flushing/lethargy/muscle cramp and weakness, hypoK, stool studies show secretory diarrhea w/ inc sodium and osmolal gap <50

Question 184

VIPoma dx and tx?

Answer 184

Dx = watery diarrhea w/ VIP lvl > 75; abdl CT or MRI to localized tumor in pancreas (tail usually, mets to liver possible). Tx = IV volume repletion, octreotide to dec diarrhea, hepatic resections if mets

Question 185

Most common cause of primary hyperparathyroidism (pt usually mild asymptomatic hypercalcemia) is d/t? Vs PTH independent hypercalcemia

Answer 185

Primary HPT: parathyroid adenomas or parathyroid hyperplasia - stones/bones/abdl moans/psychic groans but usually asymptomatic
PTH independent hyperparathyroidism: malignancy (that’s why need to measure PTH first to determine dependent/independent aka low or high PTH). These pts have crazy high Ca > 14 and are symptomatic

Question 186

Painless thyroiditis *silent thyroiditis

Answer 186

Acute thyrotoxicosis w/ mild thyroid enlargement and suppressed TSH; thyroid scintigraphy shows decreased RAIU (released of PREFORMED thyroid hormone - unlike Graves which is d/t inc synthesis of thyroid hormone - antibodies to receptor). Mild brief hyperthyroid phase w/ spontaneous recovery. Not struma ovarii = would present in women >40yo w/ pelvic mass, ascities or abdl pain

Question 187

Tetanus mgmt for adult pt who completed childhood series but has not had a booster in years, stepped on nail, mgmt?

Answer 187

Single dose of Tdap vaccine (if last dose > 5 years ago, NOT 10) is sufficient; give immune globulin if never had 3 shot series or vaccine status unknown

Question 188

Major side effect = nephrotoxicity, hyperK, HTN, gum hypertrophy, hirsutism, and tremor, drug?

Answer 188

Cyclosporine. Tacrolimus has similar effects since similar MOA but no hirsutism or hypertrophy (both calcineurin inhibitors)

Question 189

Major toxicity of azathioprine (inhibits purine synthesis) =

Answer 189

Dose related diarrhea, leukopenia, hepatotoxicity

Question 190

Major side effect of mycophenolate =

Answer 190

Bone marrow suppression (M for M)

Question 191

Recently started on Parkinson drug, develops acute angle glaucoma, drug?

Answer 191

Trihexyphenidyl an anticholinergic leading to eye dilation precipitating ACG

Question 192

Normal pupilary constriction w/ accomodation but not w/ light, sensory ataxia/lancinating pains/reduced or absent DTR, dx and tx?

Answer 192

Late neurosyphilis manifesting as tabes dorsalis and Argyl Robertson pupils; IV PCN

Question 193

Murmurs that get softer w/ squatting?

Answer 193

HCM and MVP (inc in preload causes inc in LV size and volume leading to delay in valve prolapse w/ a later click and shorter murmur)!

Question 194

Chronic glucocorticoid followed by abrupt termination causes what, what lab values (ACTH, cortisol, aldo)

Answer 194

Central adrenal insufficiency w/ suppression of hypothalamic-pituitary-axis; look for low morning cortisol and ACTH (if this was primary adrenal insufficiency you would see high ACTH, low cortisol, and low aldo) AND also normal aldosterone as that is regulated by the renin-angiotensin-aldo system

Question 195

Urease producing bacteria causing UTI w/ pH > 8

Answer 195

Proteus mirabilis: alkaline urine dec solubility of phosphate inc risk of urinary calculi w/ struvite stones

Question 196

What increases risk of stroke more than any other factor?

Answer 196

HTN!

Question 197

Coalescing erythematous macules, bullae, desquamation, MUCOSITIS, recently started on Bactrim (5 days ago)

Answer 197

Stevens-Johnson syndrome: <10% is SJS but >30% toxic epidermal necrolysis. Usually occurs 4-28 days after exposure to trigger (mycoplasma pneumoniae can do it too)

Question 198

What antiemetics can cause EPS and why?

Answer 198

Metoclopramide, prochloperazine, promethazine (phenergan); anti-psychotics that are dopamine antagonists

Question 199

GGT an enzyme present in liver and ferritin (acute phase reactant) would likely be seen in what dz?

Answer 199

Alcoholic liver disease - will also see 2:1 AST/ALT though that NBME exam had alcohol at just elevated GGT w/ normal AST/ALT

Question 200

Molar extraction, mass over angle of right mandible w/ erythematous skin, serosanguineous fluid w/ yellow granules, cx shows gram positive rods w/ rudimentary branching dx and tx?

Answer 200

Actinomyces tx penicillin

Question 201

Pt w/ hypertension and hypokalemia; w/ dec renin and inc aldosterone?

Answer 201

Primary hyperaldosteronism: d/t either aldosterone producing tumor or bilateral adrenal hyperplasia
*If RENIN and ALDO is elevated = secondary hyperaldosteronism d/t renovascular HTN, malignant HTN, renin secreting tumor, diuretic use (thiazide); if secondary hyperaldo then Aldo:Renin ratio <20 as in that fibromuscular dysplasia or RAS card

Question 202

Spiculated appearing RBCs w/ serrated edges seen in liver disease and ESRD?

Answer 202

Burr cells aka echinocytes (E for Edges)

Question 203

RBCs w/ irregularly sized and spaced projections most commonly seen in liver disease

Answer 203

Spurr cells (S for Spaced)

Question 204

Graves opthalmopathy is d/t what mechanism?

Answer 204

Activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes

Question 205

What complication occurs following radioactive iodine tx for Graves pt?

Answer 205

Worsening opthalmopathy if that was present before tx (TRAB titers inc following RAI therapy); administer steroisd prior to prevent complication

Question 206

Cardiovascular effects of thyrotoxicosis: rhythm? hemodynamic effects? HF? angina symptoms?

Answer 206

Rhythm: sinus tach, premature atrial/ventricular complexes, A-fib/flutter
Hemodynamic effects: systolic HTN and inc pulse pressure, inc contractility and CO, dec systemic vascular resistance, inc myocardial oxygen demand
HF: high output failure, exacerbation of pre existing low output failure
Angina symptoms: coronary vasospasm, pre-existing coronary atherosclerosis

Question 207

When is a vaginal pessary indicated in urinary incontinence?

Answer 207

Symptomatic pelvic organ prolapse and stress incontinence when surgical correction (midurethral sling surgery) fails (do not use in urge incontinence since that can exacerbate issue)

Question 208

Inflammation and pain at sites of tendon/ligament attachment to bone (tenderness over shoulder/AC junction, heels, iliac crests, tibial tuberosities), a/w what what condition?

Answer 208

Ankylosing spondylitis - limited spine mobility, low back pain that improves w/ activity, and peripheral arthritis

Question 209

Ice pack test is for what disease?

Answer 209

Myasthenia gravis - get antibodies against ACH receptors after (ice pack similar to Edrophonium - increases ACH in junction); again tx of myasthenia = acetylcholinesterase inhibitors
Pt in this question had surgery recently then developed lid lag post op (likely exposed to NMJ blocking agent like rocuronium - anticholinergic)

Question 210

Acute limb ischemia after MI suggests what and requires what?

Answer 210

Possible arterial embolus from left ventricular thrombus -> requires anti-coagulation, vascular sx consultation, and TTE to screen for the thrombus and evaluate LV function

Question 211

32yoM, 5 days high fever, chills, drenching sweats, malaise/fatigue/dark urine. Likes to explore the woods; recently camped in New England and found 2 ticks on legs, current temp 103 and mild sclera icterus, liver edge palpable 3 cm below margin, 4.3 total bili 10% retic, AST/ALT 60/70s, LDH 300, dx?

Answer 211

Babesiosis dx w/ blood smear. Protozoal illness endemic to NE US via Ixodes Scapularis (also transmits lyme and human granulocytic anaplasmosis); ticks multiply in RBCs so pts develop anemia w/ signs of intravascular hemolysis (jaundice, dark urine, indirect hyperbili, reticulocytosis, elevated aminotransferases and LDH) - MALTESE CROSS tx w/ atovaquone + azithro

Question 212

Early diastolic murmur, hyperdynamic pulse, bounding pulses aka water hammer pulses, dx?
Pulsus parvus (dec pulse amplitude) and pulsus tardus (delayed upstroke), dx?
Fixed split S2?

Answer 212

Aortic regurgitation
Aortic stenosis
Atrial septal defect

Question 213

1st line tx in pregnant or lactating pts w/ Lyme disease

Answer 213

Amoxicillin; avoid Doxycycline (though normally excellent since can treat coexisting human granulocytic anaplasmosis a conditions also caused by the same tixk I. scapularis) since it can cause permanent discoloration of teeth/retardation of skeletal dvlpt

Question 214

Southeast Asian pt w/ chronic anesthetic hypopigmented lesions w/ peripheral nerve involvement (nodular painful nerve deformations w/ diminished sensory/motor activity), dx?

Answer 214

Leprosy, dx w/ biopsy. Tx w/ Dapsone + rifampin

Question 215

Subarachnoid hemorrhage/embolic stroke vs intraparenchymal brain hemorrhage vs ischemic stroke, symptom severity?

Answer 215

SAH/embolic stroke = symptoms severity is maximal at onset
Ischemic stroke = symptoms progress in stuttering fashion
Intraparenchymal brain hemorrhage = symptoms get even worse over time (hemorrhage expands leading to ICP symptoms like HA/vomiting/seizures)

Question 216

Most common lesions for HTN hemorrhage leading to lacunar strokes (stand out features for each lesion)

Answer 216

Basal ganglia (putamen) - homonymous hemianopsia
Cerebellar nuclei - NO hemiparesis, ataxia/nystagmus
Thalamus - eyes deviate t for TOWARD hemiparesis
Pons - p for pinpoint reactive pupils, deep coma/total paralysis within minutes

Question 217

Pt w/ syphillis but severe penicillin allergy, next step?

Answer 217

Doxycycline - be strict on getting pre and post tx titers to ensure clearance. Only do penicillin w/ desensitization if severe like neurosyphillis, multiple tx failures or contraindicated conditions to doxy like pregnancy. Desensitization is costly/time consuming

Question 218

IF UNSTABLE SHOCK - IF NOT consider adenosine or vagal maneuvers (bearing down, squatting, breath holding) in pts w/ persistent tachyarrhythmia (like regular narrow complex supraventricular tachycardia)

Answer 218

Defib shockable rhythms?

V-fib, PEA ventricular tachycardia

Question 219

Bright red firm friable exophytic nodules in HIV infected patient, dx?

Answer 219

Bacillary angiomatosis caused by Bartonella (gram negative bacillus) - erythromycin tx

Question 220

Pt w/ prostate cancer w/ subacute back pain (months) now w/ LE motor weakness, hyperreflexia, bladder dysfunction (late finding), dx and immediate tx?

Answer 220

Epidural spinal cord compression (common mets come from lung, breast, prostate, MM). Tx w/ glucocorticoids (dec vasogenic edema - reduce pain restore neuro fxn) then get MRI

Question 221

Yellow fever is for what countries only?

Answer 221

Sub-Saharan Africa (not Egypt question) and South America. HepA is the most COMMON vaccine preventable disease among travelers; vacc should be considered for travels to developing countries

Question 222

Ugh common bugs in IE

Answer 222

Staph - HEALTHCARE *indwelling catheters, prosthetic valves or devices and IVDU
Strep - community acquired
Viridans - includes sanguinis/mitis/oralis/mutans/sobrinus think dental
Enterococci - UTI
Strep gallolyticus (bovis) - IBD/colon cancer

Question 223

H. pylori is a/w what what cancers?

Answer 223

Mucosa associated lymphoid tissue (MALT lymphoma) - eradication of H. pylori will help reduce relapsing of this cancer. Eradication of H. pylori is not curative for adenocarcinoma - get staging

Question 224

PCP vs aspergillosis again?

Answer 224

Aspergillosis is worse - fever, CP, HEMOPTYSIS; CXR shows pulmonary nodules or segmental infiltrates
PCP - fever, DRY COUGH, no hemoptysis; bilateral diffuse interstitial infiltrates

Question 225

Anterior uveitis is seen in what inflammatory diseases?

Answer 225

Sarcoidosis, spondyloarthritis (ankylosing spondylitis, reactive arthritis), and IBD

Question 226

45yoM 2 month PAINLESS nonpruritic purple lesions on legs, progressive fatigue/weakness/fleeting joint pains. Exam shows multiple purpuric palpable lesions on both LE that do not blanch w/ pressure. Labs show elevated AST/ALT, Cr, thrombocytopenia, low C3/C4 complement, RF positive, UA 3+ blood and proptein, dysmorphic RBCs, dx?

Answer 226

Mixed cyroglobulinemia syndrome (MCS) - nonblanching palpable purpura (painless, while erythema nodosum is painful), athralgias, renal disease and peripheral neuropathies. Most commonly a/w hepatitis virus and SLE (must test for hepatitis)

Question 227

Erythema nodosum is a/w (painful nodules on LE)

Answer 227

Sarcoidosis, IBD

Question 228

Mixed cyroglobulinemia, dx, associations, mgmt?

Answer 228

Dx - confirm serologically w/ serum cyroglobulins and low complement or w/ skin/renal bx
A/w - viral hepatitis or SLE
Tx - address underlying dz (hepatitis/SLE), including plasmaphresis and immunosuppression

Question 229

Advanced RA associated w/ splenomegaly and neutropenia, dx?

Answer 229

Felty syndrome (SANTA is felty: splenomegaly, anemia, neutropenia, thrombocytopenia, ARTHRITIS)

Question 230

What study is this: selecting pts w/ particular disease and pts w/o disease then determining their previous exposure status

Answer 230

Case control (selecting the cases of disease and cases of controls comparing exposures)

Question 231

More biostats: different types of studies and their end goal -> clinical trial, prospective cohort, retrospective cohort, case control, cross sectional

Answer 231

Clinical - tx group control group, compare outcome of interest
Prospective - risk factor +/-, compare disease INCIDENCE
Retrospective - risk factor +/-, compare disease INCIDENCE in the past
Case control - disease cases vs non diseased cases, compare risk factor frequency
Cross sectional - risk factor +/- compare disease PREVALENCE

Question 232

Xa inhibitors are as effective as Warfarin in tx of DVT or PE and do not inc risk of bleeding complications; also have rapid onset and do not require lab monitoring or dietary restrictions. Restrictions?

Answer 232

Renally cleared so do not give to renal pts or those w/ DVT/PE 2/2 malignancy. Diet - pt should avoid too much greens in order to have consistent vitK.

Question 233

Thrombolytic therapy is reserved for hemodynamically unstable pts w/ PE. IVC placement?

Answer 233

Anticoagulation failure (sub-therapeutic INR despite Warfarin compliance; tried the direct inhibitors too) OR active bleeding = IVC filter

Question 234

Dihydropyridine Ca-channel antagonist vs non-dihydro

Answer 234

Dihydro = -dipines. Amlodipine a/w peripheral edema (vasodilation) 
Non-dihydro = diltiazem, verapamil. Acts on heart

Question 235

USPTF recommendations for osteoporosis screening (osteoporosis =

Answer 235

Women > 65 at least one DEXA (if normal unsure when to repeat)
Women <65 screen if equivalent risk of osteoporotic fracture (using FRAX tool)

Question 236

Top 3 nonmodifiable and modifiable risk factors for osteoporosis?

Answer 236

Nonmodifiable = age, postmenopausal, low body weight Modifiable = smoking, alcohol, sedentary lifestyle

Question 237

Oliguria definition (number)

Question 238

68yoM recent knee replacement, on post op day 5 new onset abdl discomfort. Over past 12 hrs voided 200mL urine; recorded infrequent fluid input/output over previous 4 days. Large body habitus; portable bladder scan inconclusive. Labs show BUN:Cr = 70/3.5. Dx and next steps

Answer 238

Post renal obstruction get bladder cath (inefficient detrusor muscle activity)

Question 239

DDX systemic scleroderma vs ankylosing spondylitis (pulmonary fibrosis and pulmonary arterial HTN = scleroderma)

Answer 239

AS is a chronic inflammatory disease of the axial skeleton characterized by stiffness of the spine, sacroiliitis on radiographs, and positive HLA-B27 serology. Extraarticular features = anterior uveitis, IBD, and aortic regurgitation. Chest wall motion restriction *diminished chest wall/spinal mobility - restrictive pattern

Question 240

Massive PE is defined as what?

Answer 240

PE complicated by hypotension and/or acute right heart strain (RBBB on EKG and JVD); confirm w/ CTa and fibrinolysis!

Question 241

Ugh you put vitiligo but that is complete depigmentation most commonly on face/hands; the actual dx was

Answer 241

Tinea versicolor = salmon colored hyper/hypo pigmented macules. Confirm w/ KOH prep of skin scrapings; tx w/ antifungals

Question 242

C. diff testing?

Answer 242

Get stool toxin testing *PCR toxin (not stool cultures)

Question 243

3 possibilities when pt has symptoms c/w typical renal colic but no stones on x-rays

Answer 243

1) Radiolucent stones (uric acid stones, xanthine stones)
2) Ca stones <1-3 mm in diamater
3) Non-stone ureteral obstruction (blood clot, tumor)

Question 244

Uric acid stone - pt has low urine pH d/t possible defect in renal ammonia excretion, and hyperuricosuria, imaging and tx?

Answer 244

Radiolucent on x-ray but can be seen on US or CT *hexagonal on UA - tx w/ hydration, alkalinization of urine w/ potassium citrate

Question 245

Diabetic pt w/ symptoms of anorexia, nausea, vomiting, early satiety, postprandial fullness and poor glycemic control, what drug w/ both prokinetic and anti-emetic properties?

Answer 245

Metoclopramide!

Question 246

Rapid onset of unilateral upper and lower facial weakness (dx = focus on just the face) =

Answer 246

Bell’s palsy *acute peripheral neuropathy of cranial nerve VII (lesion BELOW the pons); also would be unable to raise eyebrow or close eye, and drooping of mouth corner and disappearance of nasolabial fold. MUST ASSESS for preservation of forehead and brow
movements (if forehead/eyebrow spared = intracranial lesion warranting imaging)

Question 247

Carcinoid is a/w what nutritional deficiency?

Answer 247

Niacin (carcinoid tumor cells inc production of serotonin using up tryptophan which is required for niacin synthesis); look for pellagra w/ dermatitis/diarrhea/dementia

Question 248

Hereditary spherocytosis is inherited disorder that increases RBC fragility; look for hemolytic anemia, jaundice, splenomegaly in person of Northern European ancestry, common complications?

Answer 248

Acute cholecystitis from pigmented gallstones

Question 249

Pulmonary airway diseases responsible for hemoptysis (3)?

Answer 249

Chronic bronchitis, bronchogenic carcinoma, bronchiectasis
Chronic bronchitis - chronic productive cough for >3mo in 2 successive years *smoking, clear mucus
Bronchiectasis - irreversible dilation/destruction of bronchi *cystic fibrosis, recurrent respiratory infxns, chronic cough w/ mucopurulent sputum

Question 250

Prolactinoma mgmt?

Answer 250

If incidental and w/o symptoms = observe w/ serial MRIs
If MACRO or symptomatic - start w/ dopaminergic agents (negative feedback on prolactin) like carbegoline, bromocriptine
IF meds don’t work or tumor > 3cm = transsphenoidal resection

Question 251

Nongonococcal urethritis, asymmetric oligoarthritis and conjunctivitis, mucocutaneous lesions and enthesitis (tendon pain), dx and first line given that pt is afebrile (not gonococcal septic arthritis)

Answer 251

Reactive arthritis - NSAIDs

Question 252

Oxalate absorption is increased in Crohn and all other intestinal diseases causing malabsorption, inc risk of what?

Answer 252

Nephrolithiasis d/t inc absorption of oxalate leading to hyperoxaluria and oxalate stone formation

Question 253

Hyperextension injury (car accident will do), w/ weakness that is more pronounced in the upper extremities than the lower extremities, lesion where?

Answer 253

Central cord syndrome - generally seen in old folks w/ underlying cervical spondylotic myelopathy after fall/whiplash

Question 254

24yoF lump in neck, palpable 2 cm nodule in right thyroid lobe, serum TSH and calcium levels are normal, but calcitonin is elevated. Family hx of thyroid malignancy. US guided aspiration bx reveals malignant cells, what test should you get next?

Answer 254

Plasma fractionated metanephrine assay - this pt likely has medullary thyroid cancer (1/3 of MTC are part of MEN2A or 2B -> must r/o pheo prior to thyroidectomy or HTN crisis will occur during sx). MTC = calcitonin producing tumor of the thyroid parafollicular cells

Question 255

HIIT - heparin induced (meaning LMWH like enoxaparin/dalteparin subcutaneous OR unfractionated heparin)

Answer 255

NOAC = dabigatran, rivaroxaban, apixaban, argatroban, fondaparinux

Question 256

What GU tumors are a/w inc in AFP or beta-hCG

Answer 256

First off Leydig cell tumor = testosterone +/- estrogen, will see secondary inhibition of LH/FSH
Choriocarcinoma = beta-hCG
Yolk sac tumor (endodermal sinus tumor) = inc in serum AFP

Question 257

HIV pt, eye problem - acute retinal necrosis a/w PAIN, keratitis, uveitis, funduscopic findings of peripheral pale lesions and central retinal necrosis, dx? versus?

Answer 257

HSV or VZV keratitis! In contrast to CMV = which is PAINLESS and is not a/w keratitis or conjunctivitis, imaging shows hemorrhages and fluffy/granular lesions around retinal vessels

Question 258

Pulmonary toxicity = serious adverse effect of long term amiodarone use that can occur months to several years after initiation, what tests should be obtained prior to initiation?

Answer 258

Baseline CXR and PFTs

Question 259

TEN vs Stevens-Johnson

Answer 259

Toxic epidermal necrolysis = >30%. SJS = <10%

Question 260

17yoM intense left flank pain radiating to groin (duh u know this), refers to symptoms as stone passage, which he has experienced many times in childhood; uncle has same problem. UA shows HEXAGONAL crystals. Urinary cyanide nitroprusside test is positive, dx and
cause?

Answer 260

Cystinuria - amino acid transport abnormality -> impaired transport of cystine and the dibasic amino acids (orthine, lysine, arginine) -> dec reabsorption of cystine which is poorly soluble leading to stone formation (cyanide-nitrprusside test can detect cystine levels)

Question 261

You drive CaRS using your PALMS and SOLES

Answer 261

Coxackie A virus, rocky mountain spotted fever rickettsia, syphillis rash starts on extremities. Though note the other rickettsia starts trunk and moves outward (R. prowazekii). Syphilis and the two handed sailor shake checking for elbow lymphadenopathy *epitrochlear

Question 262

Erythema infectiosum - Fifth disease Parvo B19 slapped cheek

Answer 262

Erythema multiforme - target lesion a/w herpes simplex

Question 263

Painful flaccid bullae that usually ruptures leaving raw ulcers, Nikolsky sign (separation of epidermis w/ light traction), antibodies against DESMOGLEINS 1 and 3, dx?

Answer 263

Pemphigus vulgaris (this is worse). As opposed to bullous pemphigoid (bullae are not as weak they are tense and less mucosal lesions) w/ antibodies against the hemidesmosomes (bullous is better than pemphigus - tense bullae and affects just the hemidesmosomes)

Question 264

Epigastric pain and intermittent melena that improves w/ eating, vs pain that worsens w/ eating, dx?

Answer 264

Duodenal ulcer vs gastric ulcer. Most duodenal ulcers are d/t H. pylori or NSAIDs

Question 265

Triple therapy H. pylori

Answer 265

Clarithromycin, amoxicillin, metronidazole, and PPI

Question 266

Brown-Sequard syndrome? *side note dorsal columns (proprioception, vibration, light touch), lateral corticospinal tract (motor), spinothalamic tract (pain and temp)

Answer 266

Ipsilateral hemiparesis and diminished proprioception/vibratory sensation/light touch at the level of the spinal cord injury and below
Diminished pain and temp (spinothalamic) CONTRALATERALLY, usually 1-2 levels BELOW the cord injury *so if stabbing occured causing right hemisection at T8 then 1) loss of motor/sensation right side at T8 and below, and 2) loss of pain/temp left side at T10 (belly button)

Question 267

More organisms to be worried about in HIV pt CD4 < 100

Answer 267

Toxo 
Cryptococcal meningoencephalitis (this question pt has oral thrush w/ meningeal signs indicates likely immunocompromised)

Question 268

Clinical manifestations of long term alcohol use (x3)

Answer 268

Alcoholic cerebellar degeneration - damage to Purkinje cells of cerebellar vermis leading to ambulation difficulty (wide based gait, truncal ataxia, postural instability). Limb coordination intact and everything else is too
Wernicke (COAT) - ataxia present but also confusion/opthalmoplegia - nystagmus/thiamine
Vit B12 def - spinal cord degeneration resulting in ataxia/paresthesia/loss of vibration and proprioception sensation

Question 269

Fever, rash, AKI, eosinophiluria w/ WBC casts

Answer 269

Acute interstitial nephritis most commonly d/t drug reaction

Question 270

One kidney pt w/ flank pain, low volume voids w/ occasional high volume voids, dx?

Answer 270

Urinary outflow obstruction; excessive diuresis can lead to potassium wasting, dehydration, weakness

Question 271

Hematuria, RBC casts, AKI, HTN, edema, dx?

Answer 271

Glomerulonephritis

Question 272

Hypocalcemia dx w/u?

Answer 272

HypoCa -> check PTH -> if elevated think Vit D def or CKD (oh yeah, secondary hyperparathyroidism card said despite elevated PTH, Ca still playing catch up)
If low PTH think parathyroid surgery previously, or polyglandular autoimmune

Question 273

Elevated conjugated (direct) hyperbilirubinemia along w/ elevated alk phos = cholestasis pattern in the setting of either extrahepatic or intrahepatic biliary obstruction, next step?

Answer 273

Get US to assess hepatic parenchyma (intrahepatic cholestasis) vs biliary ducts (extrahepatic) or both

Question 274

51yoM admitted for renal failure; pmhx recurrent eps of bilateral flank pain over the past several years as well as nocturia 2-3 times per night for the past 10 years. BP 164/100, mass felt at right flank, dx?

Answer 274

Polycystic kidney disease (autosomal dominant); multiple renal cysts causing intermittent flank pain, hematuria, UTI, nephrolithiasis

Question 275

Anterior cord (again) - anterior spinal artery from trauma resulting in?

Answer 275

Bilateral motor function loss at and below level of injury w/ diminished pain/temperature that begins 1-2 levels below cord injury. Proprioception, vibratory sensation, light touch (aka dorsal column aka posterior cord) are unaffected. Versus central cord = dec sensation AND motor in just the arms; seen in old folks w/ underlying cervical spondylotic myelopathy after fall/whiplash

Question 276

56yoF weight loss over 6mo, recent dx of diabetes controlled w/ sitagliptin, watery stools (no palpitations, abdl pain, vomting, or flushing), skin exam shows erythematous plaques w/ CENTRAL clearing and eroded borders on right thigh and mouth, next steps and dx?

Answer 276

Skin findings = necrolytic migratory erythema aka NME. Get glucagon levels for glucagonoma (rare pancreatic neuroendocrine tumor that usually p/w diabetes, weight loss, diarrhea, anemia and skin findings)

Question 277

HTN, elevated sodium, hypoK, and metabolic alkalosis (seen in the hepatic encephalopathy pt on K wasting diuretic)

Answer 277

Conn’s syndrome - primary hyperaldosteronism (mass on CT) you missed this because metabolic alkalosis w/ elevated bicarb goes along with hypokalemia (think vomit = hypoK aka hypochloremic hypokalemic metabolic alkalosis)

Question 278

Zollinger Ellison syndrome should be suspected in pts w/ multiple duodenal ulcers (or jejunal) that is refractory to tx OR a/w chronic diarrhea. Lots of fatty stools why?

Answer 278

Excess gastric acid inactivates pancreatic enzymes leading to malabsorption - intermittent abdl pain, weight loss, chronic diarrhea, possible other MEN1 manifestations, think Zollinger

Question 279

ALS is characterized by upper and lower motor symptoms, what are they?

Answer 279

Upper = spasticity, bulbar symptoms, hyperreflexia Lower = fasciculations

Question 280

Urine sample stain positive for Prussian blue, African American man recently tx for UTI now has dark urine, dx?

Answer 280

G6PD deficiency - oxidative stress precipitated this event

Question 281

35yoF, office for oral ulcers started a few days ago, similar lesions 3 months ago, in addition was recently diagnosed w/ anterior uveitis. Recurrent genital lesions over the last YEAR. Exam shows oral ulcerations and hyperpigmentation skin lesions and tender indurated areas on her legs, dx?

Answer 281

Bechet syndrome: recurrent painful oral apthous ulcers (canker sores), genital ulcers, eye lesions, skin lesions (erythema nodosum), high risk for THROMBOSIS, clinical dx but can get bx for nonspecific vasculitis. *This was not reactive arthritis despite so many similar
symptoms but no evidence of acute GI or GU infection; also multiple episodes of ulcers in the past

Question 282

36yoM weeks of lower abdl pain, bloody diarrhea, fecal urgency. Exam shows fever, DISTENTION, leukocytosis, hypotension, tachycardia, dx and next steps?

Answer 282

IBD likely UC complicated by toxic megacolon (d/t severe colitis w/ massive colonic distention = >6 cm dilation of right colon). Get abdl x-ray! This pt is acute do not get barium enema or CT - risk perforation

Question 283

Calcium, phosphorus, alk phos, urine hydroxyproline (collagen breakdown) findings in: 1) primary hyperparathyroidism, 2) Paget dz, 3) osteoarthritis, 4) hypoparathyroidism (following neck sx usually)

Answer 283

1) elevated Ca, dec PO4, elevated alk phos, elevated urine hydroxyproline (hyperparathyroidism)
2) normal Ca, normal PO4, elevated alk phos, elevated urine hydroxyproline (Paget)
3) normal EVERYTHING, just MSK pain and x-ray findings confined to joints and periarticular bone (not skull, or ears affected) (osteo)
4) low Ca, low PO4, normal alk phos, suggest hypoparathyroidism

Question 284

Painless hard mass in testicle + US suggesting testicular tumor, initial mgmt?

Answer 284

This is the kill first look at later type of cancer - prevent risk of seeding by avoiding fine needle or bx. High cure rate!

Question 285

Joint w/ chronic calcification (chondrocalcinosis), warmth/erythema/swelling/tenderness, dx?

Answer 285

CPPD arthritis - rhomboid shape, positive birefringence

Question 286

Hyperestrinism in cirrhosis can lead to what?

Answer 286

Gynecomastia, testicular atrophy, dec body hair, spider angiomas, palmar erythema. Caput medusae arises from dilation of superficial veins on abdl wall d/t portal HTN (also esophageal varices)

Question 287

Alteplase vs heparin for acute ischemic stroke = heparin sucks in the early acute phase and risk bleeding. Pathway for suspected acute ischemic attack

Answer 287

Get CT non con to r/o bleed -> if stroke and <4.5 hrs since symptom onset -> tPA w/ altepase

Question 288

Hodgkin lymphoma

Answer 288

Common cause of mediastinal mass w/ weight loss in young pts, involves cervical, supraclavicular and axillary nodes. Remember from this question: teratoma have all 3 germ layers but do not produce AFP or b-HCG

Question 289

Mechanisms involved in ARDS?

Answer 289

Gas exchange impaired d/t V/Q mismatch 
Lung compliance (ability to expand) is decreased (stiff lungs) d/t loss of surfactant and inc elastic recoil of edematous lungs 
Pulmonary arterial pressure is increased d/t destruction of lung parenchyma and compression of vascular structures 
PaO2/FiO2 is dec as you need more FiO2 to maintain that PaO2

Question 290

What to give and what to avoid in right ventricular MI?

Answer 290

Pt is pre-load dependent (will have hypotension, JVD, clear lung fields) - so give IV fluids and avoid preload reducing meds like nitrates/diuretics

Question 291

DIP joints affected, morning stiffness, deformity, swollen fingers (dactylitis - sausage digit), nail involvement, AND well demarcated red plaques w/ silvery scaling, dx?

Answer 291

Psoriatic arthritis - tx NSAIDs, methotrexate, TNF-alpha

Question 292

Only requirement for hospica care?

Answer 292

Pt has prognosis < 6 months

Question 293

Aspiration pneumonia vs aspiration pneumonitis

Answer 293

Pneumonia: symptoms of fever/cough/sputum presents days after event, CXR shows infiltrate classically in RLL. Need abx - clindamycin or beta-lactam w/ inhibitor

Pneumonitis: just aspiration of gastric acid *pt was being intubated, presents HOURS after event, CXR infiltrates can be unilateral but mostly bilateral, supportive care
*ddx w/ time of symptom onset

Question 294

Initial tx for pts w/ cocaine toxicity?

Answer 294

Benzodiazepine for symptomatic control of BP and anxiety, aspirin, nitro/CCB for pain, NO beta blockers d/t unopposed alpha adrenergic stimulation worsening vasoconstriction induced by cocaine

Question 295

1st line tx regimen for BPH (central symmetric prostate enlargement - where as peripheral and asymmetric think prostate cancer) -> 3 treatments

Answer 295

1) Alpha adrenergic anatagonists (tamsulosin, terazosin): relax smooth muscle in bladder neck. prostate. 1st line therapy since faster onset! Side effects - orthostatic
2) 5 alpha reductase inhibitors (finasteride): inhibit conversion of testosterone to dihydrotestosterone, reduces prostate gland size but takes 6-12mo to take effect. Side effects = dec libido, ED
3) Antimuscarinics (tolterodine, oxybutynin): used to tx overactive bladder, side effects of retention/dry mouth

Question 296

Erectile dysfunction 1st line after ruling out psych and lifestyle modification for (CAD, diabetes, etc) is what and MOA?

Answer 296

SILDENAFIL. PDE-5 inhibitors prevent degradation of cGMP by PDE-5 thereby increasing blood flow to corpus cavernosum

Question 297

Rapidly progressive ascending paralysis (can be asymmetrical, w/o fever or sensory abnormalities - so not GBS), CSF is NORMAL, dx?

Answer 297

Tick borne paralysis! Note ascending paralysis w/o CSF findings or autonomic dysfunction like seen in GBS. Tick releases neurotoxin - if you remove tick = cure

Question 298

1) Loss of pain temp in ipsilateral face and contralateral trunk and limbs, 2) ipsilateral Horner’s syndrome, 3) dysphagia, dysarthria, HOARSENESS (ipsilateral vocal cord paralysis), lesion where?

Answer 298

This is Wallenberg syndrome - lateral medullary infarction (occluded intracranial vertebral artery). L for waLLenberg

Question 299

Contralateral paralysis of arm/leg and tongue deviation toward lesion; contralateral loss of tactile position sense can also occur

Answer 299

Medial medullary syndrome (alternating hypoglossal hemiplegia)

Question 300

DDX cobalamin (b12) vs folate deficiency? Both cause inc homocysteine

Answer 300

Measure methylmalonic acid concentrations (if elevated = B12 deficiency)

Question 301

Smoker, seizures, MRI showing well-circumscribed lesions with edema at GREY and WHITE MATTER JUNCTION, dx?

Answer 301

Lung cancer METS to brain!

Question 302

Polyathralgia, tenosynovitis, painless vesiculopustular skin lesions (no signs of meningeal affects - stiff neck, petechial rash), dx?

Answer 302

Disseminated gonococcal infection

Question 303

Fever, athralgias, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea, weight loss, dx?

Answer 303

Acute HIV infection

Question 304

Squamous cell carcinoma - sCamous = calcium

Answer 304

Small cell - paraneoplastic w/ ACTH and SIADH. Other paraneoplastic syndromes - dont forget myasthenia gravis and lambert eaton

Question 305

Pt w/ WPW develops a-fib w/ RVR, he is HDS, next steps? And what to avoid

Answer 305

Anti-arrhythmic like procainamide. WPW = accessory pathway bypassing AV node leading to very rapid ventricular response rates that if untreated can lead to v-fib. Since this is an avoiding the AV node problem - do not give AV nodal blocking agents (adding to the
problem). Avoid adenosine, BB, CBB, digoxin

Question 306

Herpes simplex keratiits vs herpes zoster opthalmicus

Answer 306

HSK - adults, corneal vesicles/dendritic ulcers
HZO - caused by varicella ZOSTER, mostly elderly, vesicular rash in division of trigeminal nerve, conjunctivitis and dendriform corneal ulcer!

Question 307

The worse acute complication from myocardial infarction - acute onset CP and profound shock no murmur, rapid progression to PEA and death

Answer 307

Ventricular free wall rupture (LAD) - no murmurs so not VSD

*if it was interventricular septum rupture aka VSD - look for paradoxical change in O2 from atria to ventricle

Question 308

43yoM, confusion and left sided weakness, shelter for month, 10 year history HIV, normal vitals, + oral thrush, expressive aphasia, CD4 = 30 and toxo positive, upper motor neuron signs, CT shows several asymmetric, hypodense/nonenhancing white matter lesions w/ no
edema, dx?

Answer 308

Progressive multifocal leukoencephalopathy (JC virus) - tx the HIV w/ HAART. So AIDS pts - progressive neuro symptoms and imaging of nonenhancing white matter lesions = PML

Question 309

Approximately 40% of pneumonias are a/w what?

Answer 309

Pleural effusions! Most are free flowing, sterile, resolve w/ abx (ie uncomplicated parapneumonic effusion). However if bacteria cross from infected pulmonary parenchyma into pleural space = complicated parapneumonic effusion w/ large loculated effusions and typical thoracentesis abnormalities. Unlike complicated parapneumonic effusions, empyemas = frank pus or bacteria! This was not an abscess since that = cavity w/ air fluid level (think aspiration, dvlpt takes days)

Question 310

Calcified rim in gallbladder wall w/ central bile-filled dark area, dx and a/w?

Answer 310

Porcelain gallbladder a/w GB adenocarcinoma

Question 311

Berry aneurysms vs HTN vasculopathy

Answer 311

Berry - subarachnoid hemorrhage (thunderclap headache - hyperattenuation of sulci/basal cisterns)

HTN - DEEP intracerebral hemorrhage commonly basal ganglia/cerebellar nuclei/thalamus/pons

Question 312

Prolonged infusion of sodium nitroprusside in the setting of renal failure can lead to AMS, arrhythmias, respiratory issues, GI complaints, and diffuse hyperreflexia, dx?

Answer 312

Cyanide poisoning tx sodium thiosulfate

Question 313

> 35yoM, unilateral testicular pain, epididymal edema, dysuria/frequency, dx?

Answer 313

Acute epididymitis - likely E. coli in older men; STD like neisseria chlamydia in younger men. Tx either levofloxacin or ceftriaxone/doxycycline

Question 314

CXR w/ ring of calcification around heart, JVP tracings show prominent x and y descents, signs of HF, dx in developed country vs developing?

Answer 314

Constrictive pericarditis - pericardial fibrosis and obliteration of pericardial space leading to impaired ventricular filling during diastole
Developing - TB!
Developed - idiopathic or viral pericarditis, radiation therapy, cardiac sx, connective tissue disorders

Question 315

Facial swelling, bilateral LE edema, massive proteinuria = nephrotic syndrome, pt has palpable kidneys, hepatomegaly, ventricular hypertrophy (4th heard sound) in the setting of chronic inflammatory disease (recurrent pulmonary infxns, bronchiectasis), dx?

Answer 315

Secondary amyloidosis - tx and proph w/ colchicine

Question 316

What is a complication of chronic inflammatory conditions (chronic infections, IBD, RA) resulting in extracellular tissue deposition of fibrils into tissues/organs?

Answer 316

Secondary amyloidosis - multi-organ dysfunction (heart, kidneys, liver, GI tract) = tx underlying inflammatory disease +/- colchicine

Question 317

1st line tx CML (splenomegaly, neutrophil predominance - low leuk alkaline phosphatase score d/t poorly functional leukocytes)

Answer 317

BCR-ABL translocation btw chr 9 and 22 causing constitutively active tyrosine kinase = imatinib is a tyrosine kinase inhibitor

Question 318

Pts w/ dementia w/ Lewy bodies are extremely sensitive to antipsychotics (problem was low dopamine so giving anti-psychotic can worsen symptom - caution when treating psychosis *use SGA but not Risperidone)

Answer 318

Dementia w/ Lewy bodies vs Parkinson Disease dementia

DLB = dementia before parkinson (or at the same time)
PDD = Parkinson symptoms for a year first, then cognitive impairment

Question 319

Mydriasis, piloerection (hair standing up), yawning, abdl cramps/diarrhea, dx?

Answer 319

Opioid withdrawal - occurs within a day.

VS alcohol = tremulousness, significant BP elevations, diaphoresis and possible seizures - NO EYES involved

Question 320

Adjustment disorder, finally

Answer 320

Onset within 3 months of identifiable stressor w/ marked distress and/or functional impairment (does not meet criteria elsewhere); tx w/ psychotherapy

Question 321

Severe back pain, syncope, hypotension, hematuria, dx?

Answer 321

AAA rupture - hematuria can occur if AAA ruptures into retroperitoneum and create aortocaval fistula w/ IVC leading to venous congestion in retroperitoneal structures like bladder

Question 322

Blunt abdominal, blunt thoracic, blunt genitourinary trauma. This pt was able to urinate normally w/ clear urine but UA showed 50-100 erythrocytes/hpf, dx

Answer 322

Concern for renal contusion/lac/renovascular injuries. Did not get retrograde cystourethrograms (unless had gross hematuria, difficulty urinating and blood at meatus
*urethral injury or suprapubic pain *bladder rupture)

Question 323

How does PaCO2 affect cerebral blood flow?

Answer 323

As cerebral PaCO2 rise so does blood flow (to compensate for inc CO2?). Lowering cerebral arterial PaCO2 through hyperventilation results in rapid vasoconstriction thereby decreasing ICP

Question 324

Severe burn, extensive scar formation, chronic non healing wound, enlarging nodule at lesion site a/w persistent pain and inc drainage, dx?

Answer 324

Squamous cell carcinoma (SCC arising within burn = Marjolin ulcer)

Question 325

Cutaneous T cell lymphoma aka? findings?

Answer 325

Mycosis fungoides - scaly, pruritic patches or plaques

Question 326

Repleting blood/platelets info

Answer 326

Platelets > 50,000 provides adequate hemostasis for most invasive procedures
VitK is good in the long run for warfarin reversal but not emergently
Transfuse packed red blood cells if hemoglobin <7
FFP for Wafarin
Protamine for Heparin

Question 327

Initial hematuria vs terminal hematuria vs total hematuria indicates what?

Answer 327

Initial (blood at initiation but then normal) - urethral damage (urethritis or urethral injury)
Terminal (normal pee followed by bloody pee) - bladder or prostate damage
Total hematuria - damage to kidneys or ureters

Question 328

Abdl or flank pain w/ microscopic or gross TOTAL hematuria (blood throughout entire pee stream), and occasionally bulky mass on abdl exam, dx?

Answer 328

Polycystic kidney disease

Question 329

Pt stands on 1 leg w/ knee flexed 20 deg, pt then internally and externally rotates on flexed knee - this will elicit locking sensation/sharp pain, dx?

Answer 329

Meniscal injury! For MCL - do valgus test - if laxity = MCL injury

Question 330

Acute cardiac tamponade occurs d/t sudden rise intrapericardial pressure and should be suspected in all adults pts w/ blunt chest trauma who p/w persistent JVD, tachycardia, hypotension despite aggressive fluids

Answer 330

CXR findings typically reveal normal cardiac silhouette (small amount of fluid can cause tamponade in the acute setting) w/o tension pneumothorax

Question 331

Complication of rapid sequence intubation w/ succinycholine?

Answer 331

Cardiac arrhythmia d/t severe hyperkalemia (especially in pts w/ muscle crush injury - cellular release of K through rhabdo); stick to nondepolarizing neuromuscular blocking agents (vecuronium, rocuronium)

Question 332

59yo office for postop f/u 3 weeks ago, now w/ intermittent abdl cramps and diarrhea occuring 25-30 minutes after eating a/w palpitations/light lightheadedness/diaphoresis, what surgery did he have and this diagnosis?

Answer 332

Gastrectomy - dumping syndrome (rapid emptying of hypertonic gastric contents leading to GI and vasomotor symptoms - rec dietary modification (small meals, replace simple sugars, high fiber)

Question 333

Small bowel obstruction clinical presentation

Answer 333

Clinical presentation: colicky abdl pain, vomiting, inability to pass flatus or stool if complete (partial = stome stool), hyperactive progresses to absent bowel sounds depends on peristalsis, distended and tympanic abdomen

Question 334

Small bowel obstruction dx, complications, mgmt?

Answer 334

Dx: dilated loops w/ air fluid levels on plain film or CT, partial = air in colon, complete = transition pt *abrupt cut off w/ no air in colon
Complications: ischemia necrosis, strangulation, bowel perforation
Mgmt: bowel rest, NG tube suction, IV fluids; surgery if hemodynamically unstable/signs of complication

Question 335

SBO is categorized by anatomic location (proximal versus mid/distal) or simple vs strangulated

Answer 335

Complete proximal: early vomiting, abdl discomfort, abnrml contrast filling
Mid/distal: colicky abdl pain, delayed vomiting, prominent abdl distention, constipation/obstipation, hyperactive bowel sounds
Simple obstruction: luminal occlusion

Question 336

Soft scrotal mass bag of worms, dec in supine position inc w/ standing/valsalva, US shows?

Answer 336

Dilation of papmpiniform plexus - most often on left side d/t “nutcracker effect” where left gonadal vein drains into left renal which can be compressed by SMA. Tx w/ gonadal vein ligation for young males to prevent testicular atrophy

Question 337

Penile fracture mgmt (blood at meatus, hematuria, dysuria, urinary retention)?

Answer 337

Retrograde urethrogram and surgical mgmt

Question 338

Spinal cord injury from car accident in the past, now w/ dec strength and diminished pain and temperature sensation affecting arms/hands (OR having cape like distribution) w/ preservation of dorsal column fxn (light touch, vibration, position sense), dx?

Answer 338

Syringomyelia

Question 339

Complete small bowel obstruction vs paralytic ileus question

Answer 339

SBO - no distended bowel after point of obstruction, also hyperactive TINKLING bowel sound typically present Paralytic ileus - hypoactive bowel sounds, distended small and large bowel dilated gas filled loops w/ no transition point (r/o volvulus); ileus common after abdl surgery/abdl hemorrhage inflammation, intestinal ischemia, eletrolyte abnormalities (bowel rest and tx cause)

Question 340

37yoM hospitalized evaluated for acute onset of INTENSE periumbilical abdl pain, currently tx for infective endocarditis w/ vegetations on MV, abdl shows mild diffuse tenderness, no rigidity/rebound, abdl x-rays no free air or obstruction, dx?

Answer 340

Acute mesenteric ischemia

Presentation - rapid onset preiumbilical pain, POOP to exam, hematochezia, bowel sounds decreased Risk - atherosclerosis, embolic source (thrombus/vegetations)

Labs - leukocytosis, elevated amylase, metabolic acidosis (lactate)
Dx - CT or MR angiography
*not opioid withdrawal - bowel sounds typically increased

Question 341

Femoral nerve innervation and function?

Answer 341

Femoral nerve innervates muscle of anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion; femoral nerve provides sensation to anterior thigh and medial leg via saphenous branch

Question 342

Tibial nerve innervation and fxn?

Answer 342

Tibial nerve: supplies muscles of posterior compartment of the thigh, posterior compartment of the leg, and planatar muscles of the foot (so femoral is front while tibial is back).
Tibial controls flexion of knee and digits and plantar flexion of the foot; sensation to leg except medial side and plantar foot (common peroneal provide sensation to anterolateral lag and dorsum)

Question 343

Acute diverticulitis vs ischemic colitis vs mesenteric ischemia

Answer 343

Acute diverticulitis: L sided appendicitis (d/t abscess, perforation, inflammation)
Ischemic colitis: painful BRBPR - vatershed areas recent sx
Mesenteric ischemia: POOP, not MI but gut attack

Question 344

Prosthetic joint infection timeline w/ what bugs?

Answer 344

Early onset (<3mo): staph aureus, gram negative, anaerobes *the bad stuff 
Delayed (3-12mo): coagulase negative staphylococci (staph epi), enterococci THE E's
Late onset (>12mo): similar to early onset + beta-hemolytic strep

Question 345

Hemothorax is indistinguishable from pleural effusion on cxr; blunting of costophrenic angle or even partial to complete opacification of one hemithorax might be expected from a significant hemothorax

Answer 345

Pulmonary contusion = most common finding after blunt chest injury; cxr reveals opacities caused by hemorrhage

Question 346

Acute onset severe abdl pain followed by peritoneal signs and abdominal distension; abdl x-ray demonstrates free air under the diaphragm

Answer 346

Peptic ulcer perforation

Question 347

Fever and RUQ pain w/ ileus (dec or absent bowel sounds), infection d/t gas producing organism, dx?

Answer 347

Emphysematous cholecystitis

Question 348

82yoF severe abdl pain and vomiting, intermittent nausesa and vomiting and abdl cramps/bloating. Hx of gallstones. Abdl is distended w/ HYPERACTIVE bowel sounds, mild elevation of liver transaminases, abdl x-ray shows dilated loops of small bowel and air in the
intrahepatic bile ducts, dx?

Answer 348

Mechanical bowel obstruction: intermittent N/V, pneumobilia (air in biliary tree), hyperactive bowel sounds, dilated loops bowel = gallstone ileus (gall stone passes through biliary enteric fistula in small bowel and lodging in ileum). Tx is sx removal +/- cholecystectomy

Question 349

Subclavian central venous catheter placement, rapid onset severe SOB, tachycardia, tachypnea, hypotension, and distention of the neck veins d/t superior vena cava compression, dx?

Answer 349

Tension pneumothorax

Question 350

Recent cardiac surgery (CABG) p/w fever, CP, leukocytosis, mediastinal widening on CXR (a touch of pericardial fluid), dx and mgmt?

Answer 350

Acute mediastinitis - drainage, surgical debridement and prolonged abx therapy