UWorld 1 Flashcards
1
Q
Physical exam findings of pulmonary embolism
A
Tachycardia, tachypnea
Hypoxemia (VQ mismatch)
Signs of DVT
2
Q
Elevated brain natriuretic peptide
(a) Where is BNP released from?
(b) What does it indicate
(c) Correlated physical exam finding
A
Elevated BNP
(a) BNP released from ventricular myocytes in response to high ventricular filling pressures and wall stress, seen in CHF pts
(b) Elevated levels of BNP correlate w/ the severity of LV systolic dysfunction
- normal BNP vales practically rule out CHF as a cause of dyspnea => prompts search for noncardiac cause of dyspnea
(c) Third heart sound = passive ventricular filling during diastole
- highly specific for CHF due to LV systolic dysfunction
3
Q
22 yo M w/ hematuria 5 days after a UTI
- no skin findings
- normal complement levels
Ddx and dx?
A
Hematuria following URI: IgA nephropathy vs. post-infectious glomerulonephritis
Dx = IgA neprhopathy- more common in young adult males, normal complement levels, seen sooner after URI (average of 5 days)
Post-infectious glomerulonephritis: more common in kids, seen 10-21 days after URI
-low complement
Lupus: more common in females, would have low complement levels
4
Q
Common cause of abrupt onset of mild eye pain and redness (redness of the white of the eye)
A
Episcleritis = inflammation of the episclera
- tx: symptom relief, lubricating eye drops
- rather benign condition
5
Q
What type of arrhythmias are most common in post-MI state?
A
Ventricular arrhythmias (PVVs, VT, VFib) more common post-Mi than atrial arrhythmias
-specifically reentrant ventricular arrythmia (V. fib)
6
Q
Describe why severe hypernatremia must be corrected very gradually
A
Must correct hypernatremia very slowly/gradually to prevent cerebral edema
Quickly making serum comparatively hypotonic will draw water into the CNS => cerebral edema
7
Q
Describe why severe hyponatremia must be corrected very gradually
A
Correct hyponatremia w/ 3% NS, but at very slow rate under .5 mEq/L/hr to prevent osmotic demyelination or central pontine myelinosis
Rapid correction of serum sodium draws water out of the intracellular (neuron and glia) into the extracellular compartment => cell damage
8
Q
19 yo w/ fever, myalgia, and rash that started on face and spread to rest of body
+lymphadenopathy
A
Rubella = German measles
9
Q
Large mediastinal mass w/ elevated AFP and beta-hCG
A
Nonseminomatous germ cell tumor
Primary germ cell tumor
See increased AFP and beta-hCG
-just elevated AFP could be HCC
-just elevated beta-hCG could be seminoma
10
Q
3 findings of severe uremia
A
Symptomatic uremia (ex: from acute kidney failure)
- encephalopathy: significant alteration in consciousness in uremic pts w/o any other notable cause
- pericarditis: results from inflammation of the visceral and parietal membranes of the pericardial sac
- bleeding
11
Q
What is pronator drift?
(a) What does it indicate
A
Pronator drift = weakness in supination that results in dominance of pronator muscles
-when pt closes eyes and stretched arms outward w/ hands up: affected side palm turns inward and downward (not just downward as seen in feigned upper-extremity weakness)
(a) Sensitive and specific for upper motor neuron disease
12
Q
What is albumino-cytogenic dissociation on LP?
(a) What does it suggest?
A
Albumino-cytogenic dissociation = high protein but normal cell count on spinal tap
(a) Suggestive of Guillain-Barre syndrome
13
Q
Subdural vs. epidural hematoma
(a) Which vessel is ruptured
(b) Location of the bleed
(c) Presenting symptoms
(d) CT appearance
A
Subdural hematoma
(a) Rupture of bridging veins (those that drain into dural sinuses)
(b) Bleed is btwn the dura and arachnoid layers- aka subdural space
(c) Present w/ gradually increasing HA and confusion
(d) Crosses suture lines on CT:semi-lenticular hematoma
Epidural hematoma
(a) Rupture of middle meningeal artery
(b) Bleed is btwn the skull and the dura mater
(c) Presents w/ lucid interval followed by unconsciousness
(d) Lens-shape, does not cross suture lines
14
Q
Name two medications that can trigger bronchoconstriction in an asthmatic/atopic pt
A
Aspirin and beta-blockers
15
Q
Most common cause of AR in young adults in
(a) developed countries
(b) undeveloped countries
A
Aortic regurgitation, most common etiology in
(a) Developed countries = bicuspid aortic valve
(b) Undeveloped countries = rheumatic heart disease
16
Q
First step tx for pts presenting in acute decompensated heart failure and dyspnea
A
IV diuretics (furosemide): tx the pulmonary edema and relieve SOB
+supplemental O2, possible vasodilator herapy (nitroglycerine, nitroprusside)
17
Q
Diagnostic test of choice for acute aortic dissection, explain why or why not for each
(a) CT
(b) MRI
(c) TEE
(d) TTE
A
Acute aortic dissection diagnosis
(a) CT- requires normal kidney fxn b/c requires contrast
- so not possible if elevated creatinine
(b) MRI- too slow, time consuming and requires pts to remain motionless for several minutes => not used to dx in acute setting
(c) TEE- bing bing bing, gold standard- gives great visualization of the abdominal aorta and doesn’t require contrast/kidney fxn
(d) Wouldn’t do transthroacic echo b/c doesnt give good visualization of the abdominal aorta
18
Q
Meniere’s disease
(a) Phsyiology
(b) Lifestyle modifications
(c) Medication tx
A
Meniere’s disease
(a) distention of the endolymphatic compartment of the inner ear
(b) Low salt diet, avoid cafffeine EtOH and nicotine- basically all things that increase endolymphatic retention
(c) Meds: diuretics, antihistamines and anticholinergics
19
Q
Tension pneumothorax
(a) Presenting symptoms
(b) Presenting signs
A
Tension pneumothorax-
(a) CP, SOB, hypotension.
(b) Absent breath sounds in one hemithorax and deviated trachea on physical exam
20
Q
What is cardiac tamponade?
A
Cardiac tamponade = pericardial tamponade- when a large pericardial effusion compresses/puts pressure on the heart
-when substance (pus, blood, clots, gas, fluid) accumulates in the pericardium at a rate faster than the pericardium can expand => pressure put on the heart
21
Q
WPW findings on EKG
A
WPW = ventricular preexcitation
- short PR intervals
- widened QRS (more time of ventricles depolarizing since one part starts early)
- delta waves = slurred upstroke of the QRS due to ventricular preexcitation
22
Q
Common bacteria responsible for
(a) sinusitis extension to brain abscess
(b) endocarditis extension to brain abscess
A
(a) Viridans streptococci = most common bug causing sinusitis that may spread to brain abscess
(b) Endocarditis- thinking gram negatives and staph aureus
23
Q
Physical exam findings of pleural effusion
A
Diminished breath sounds and dullness to percussion on exam
24
Q
Classic presentation of aortic dissection
A
Sudden onset tearing chest and back pain in pt w/ chronic HTN
25
2 presentations of anti-basement membrane antibodies
Can be renally limited => hematuria and elevated creatinine/BUN
Or renal + lungs (alveolar hemorrhage) = Goodpasture's
26
What conditions can give a false positive VDRL
False positive syphilis test
- pregnancy
- lymes disease
- lupus
- antiphospholipid antibody syndrome
- possibly some pneumonia, malaria, and Tb
27
What type of anemia is seen in ESRD?
(a) Tx
(b) Main side effect of the tx
Normochromic normocytic anemia = anemia commonly seen in end stage renal disease
(a) Tx = recombinant EPO (well this is after you r/o iron deficiency as a possible cause of the anemia and try iron supplementation)
- decrease risk of worsening HTN if give SC instead of IV
(b) 30% of pts will have worsening htn- mechanism not known
28
Indications fo urgent dialysis: AEIOU
Indications for urgent dialysis:
Acidemia: metabolic acidosis w/ pH under 7.1 not responsive to medical tx
Electrolyte abnormality: symptomatic hyperkalemia (EKG changes of ventricular arrhythmia) or severe hyperkalemia (K over 6.6)
Ingestion: toxic alcoholcs, salicylate, lithium, sodium valproate, carbamazepine
Overload- volume overload refractory to diuresis
Uremia- symptomatic: encephalopathy, pericarditis, bleeding (ex: pericarditis from ARF secondary to post-strep GN)
29
Hypokalemia
(a) Presenting features
(b) Late findings
(c) EKG findings
Hypokalemia
(a) Presents w/ fatigue, weakness, and muscle cramps
(b) Late/severe findings- paralysis and arrhythmia
(c) EKG findings: flat broad T waves, U waves, ST depression, premature ventricular beats
30
What kind of anemia (high normal low MCV, retic count in normal MCV) is caused by the following
(a) Lead intoxication
(b) Medication side effect
(c) Hereditary spherocytosis
(d) Autoimmune
(e) Leukemia
(f) Aplastic anemia
(g) Sideroblastic anemia
(h) Infection
(i) Thalassemia
(j) Folate deficiency
Etiology of anemia
(a) Lead intoxication => microcytic
(b) Medication side effect => normocytic w/ low reticulocyte count
(c) HS => normocytic w/ high retic count
(d) Autoimmune => normocytic w/ high retic count
- high liver enzymes and positive Coombs test
(e) Leukemia => normocytic w/ low retic count
(f) Aplastic anemia => normocytic w/ low retic count
(g) Sideroblastic anemia => microcytic
(h) Infection => normocytic w/ low retic count
(i) Thalassema => microcytic
(j) Folate deficiency => macrocytic
31
What is antiphospholipid antibody syndrome?
(a) Presentation
(b) Associated test findings
Antiphospholipid antibody syndrome = acquired hypercoagulable state
-many types of causative antibodies
(a) Presentation: recurrent fetal loss (lots of miscarriages), thrombocytopenia, prolonged PTT, arterial or venous thrombosis
(b) Can commonly cause false (+) VDLR (syphilis test)
32
G3P0 F w/ (+) VDRL, (-) FTA-ABS
-thrombocytopenia, prolonged PTT
(a) Dx
(b) Tx
Lots of pregnancies w/o babies => lots of miscarriages
- false positive VDRL
- hypercoagulable state w/ thrombocytopenia
(a) Acquired hypercoagulable state + recurrent fetal loss + thrombocytopenia + false positive VDRL = Antiphospholipid antibody syndrome
(b) Tx = LMWH (low molecular weight heparin) and aspirin to avoid pregnancy loss
33
What kind of syncope occurs w/ heavy activity?
(a) Associated features
Valvular heart disease caused syncope can occur during activity
(a) SOB, CP, fatigue
34
56 yo M w/ fullness of the face, splenomegaly, and BP 160/94
| -elevated hematocrit and RBC count
Polycythemia vera = clonal myeloproliferative disease of the pluripotent hematopoietic stem cell
=> presents w/ high red count => increased viscosity causes reversible moderate HTN
-also have mild leukocytosis and high platelet count
35
Differentiate the liver biopsy findings of
primary biliary cirrhosis and primary sclerosing cholangitis
Liver biopsy findings of
Primary biliary cirrhosis = destruction of intrahepatic bile ducts
Primary sclerosing cholangitis = inflammation and fibrosis of intra and extra hepatic bile ducts
-segmental stenosis of intra andextra-hepatic bile ducts
36
Ankle-branchial index
Ankle BP: upper arm BP
Lower in ankle indicates blocked arteries due to peripheral artery disease
Under .8 = some arterial disease
Under .5 = severe arterial disease
37
What drugs treat the following types of esophagitis in an HIV pt
(a) Candida
(b) CMV
(c) HSV
Esophagitis in HIV pt- as presented by dysphagia and odynophagia
(a) Candida => treat w/ fluconazole
(b) CMV- tx w/ ganncyclovir
(c) HSV- tx w/ acyclovir
38
More likely to be acute or chronic bacterial prostatitis
(a) Young age
(b) E. coli
(c) dull, poorly localized pain
(d) fevers, chills
(e) extremely tender prostate
(f) dysuria, frequency
Acute vs. chronic bacterial prostatitis
(a) Young age- more likely to be acute
(b) E. coli and other GNR- cause both acute and chronic
(c) Dull, poorly localized pain = chronic
- acute presents w/ perineal and lower back pain
(d) Fevers and chills- acute
(e) Extremely tender prostate = acute
- enlarged and nontender prostate seen in chronic
(f) Dysuria and frequency (irritative voiding) seen in both
39
Beta-blocker use in acute and chronic heart failure
Cardioselective beta-blockers (carvedilol) are beneficial for long-term management of pts w/ stable HF due to LV dysfunction
- should be avoided in acute decompensated heart failure b/c they can acutely worsen HF symptoms
- can be initiated after adequate diuresis
40
Most reliable and predictable sign of opioid intoxication
Decreased respiratory rate (ex: RR of 6)
-would also expect pinpoint pupils but not always! pupils can be dilated or even normal, pupils not as reliable of a sign as RR
41
Pt w/ DM, HTN, HLD who presents w/ myalgia
On a statin for their HLD? Test their CPK- if elevated then stop the statin
-can progress to rhabdomyolysis w/ renal failure
42
Hallmark feature of cat scratch disease
Self-limited lymphadenopathy
-and usually hx of exposure to cats...
43
Describe signs/symptoms of hypercalcemia
Body systems effected by hypercalcemia
Kidneys- trying to filter more out => increased thirst and urination
GI tract => upset stomach, diarrhea, nausea, vom
Bone pain
Brain => altered mental status, confusion, fatigue
44
29 yo w/ paraplegia, urinary incontinence, and urgency
-h/o trigeminal neuralgia
+spasiticity, LE hyperreflexia
Multiple sclerosis
45
Physical exam findings indicating
(a) Cerebellar dysfunction
(b) Impaired proprioception
(a) Cerebellar dysfunction: ataxic gait, dysdiadokinesis (rapid alternating movements), dysmetria (impaired finger to nose)
- upward drift on pronator drift test
(b) Impaired proprioception: Romberg test: can't maintain balance w/ feet together when they close their eyes
46
Effect of aldosterone activity
Aldo promotes Na+ and water retention, lowers plasma K+
- Upregulates and activates Na/K pumps on DCT and collecting duct
- upregulates ENaC
Increases: Na reabsorption
Increases H+ secretion and K+ secretion
47
Presentation of Alport's disease
Alport's = X-linked collagen IV mutation, presents w/ hearing loss, ocular abnormalities, hematuria, and gradual kidney dysfunction
48
Mechanism of renin activity- final effect
Renin = released by JGA cells (kidney) when hypoperfusion sense, function is to increase BP by
- activating RAAS system => more angiotensin II to cause vasoconstriction
- increase ADH and aldo secretion
- stimulate hypothalamus to stimulate thirst reflex
49
Pt is acutely post-MI, had episode of syncope
Most common cause of the syncopal episode
Reentrant ventricular arrhythmia = common cause of sudden cardiac arrest (and therefore syncope) in immediate post-MI period
50
ADAMTS13
von Willebrand factor-cleaving protease whose activity is severely reduced in TTP (thrombotic thrombocytopenic purpura)
51
Differentiate the following:
(a) Biliary colic
(b) Cholecystitits
(c) Choledocholithiasis
(d) Cholangitis
Spectrum of gall bladder/stone d/o
-many gall stones are passed asymptomatically, when they do produce pain it is called biliary colic
(a) Biliary colic = due to pressure of gallstones against the walls of the cystic or common bile duct
-intermittent RUQ pain
(b) Cholecystitis- occurs in about 20% of pts that have biliary colic
= when prolonged cystic duct obstruction causes inflammation of the gall bladder wall (gall bladder inflammation)
(c) Choledocholithiasis = bile stone gets lodged in the common bile duct
(d) Cholangitis = infection of the biliary duct
-high morbidity/mortality
-can be life threatening
52
Most common location of hypertensive cranial hemorrhage
Putamen and thalamus
53
Lambert-Eaton syndrome
(a) Mechanism
(b) Etiology
(c) Presentation
(d) Tx
Lambert-Eaton syndrome
(a) Rareautoimmune disorder
(b) 60% due to lung cancer, most typically small cell lung cancer
(c) Presents w/ muscle weakness of the limbs
(d) Tx- to treat the underlying lung cancer
54
Polycythemia vera
(a) Common presentation
(b) Two associated features
(c) Tx
Polycythemia vera
(a) Itching/pruritis
(b) Associated w/ gouty arthritis and PUD
(c) Phlebotomy- remove some of the excess volume of blood
55
Describe a pericardial friction rub
Typically 3 sounds: 1 systolic and 2 diastolic that sounds like squeaky leather
- also described as grating, scratching, rasping
- often positional
ex: 2 component diastolic sound w/ squeaking quality that improves when lean forward
56
Tx for severe hypercalcemia
Sever hypercalcemia = Ca2+ > 14 mg/dl or symptomatic (increased thirst and urination, GI upset, nausea, confusion)
NS infusion + calcitonin
-adequate hydration promotes clearance and calcitonin also helps decrease serum calcium
Dialysis only if pt cannot adequately handle NS infusion (ex: has kidney failure)
57
What are schistocytes?
(a) What do they indicate?
(b) What diseases are they seen in?
Schistocytes = fragmented RBC, 'helmet cells' b/c jagged w/ two pointed ends and no central pallor
-indciate destruction of vascular spaces: fibrin strands sever RBCs as they try to move past a thrombus, creating schistocytes
Schistocytes are seen in several microangiopathic diseases
- DIC
- thrombotic microangiopathies: TTP, HUS, mechanical artificial heart valve
58
Formula for
(a) Sensitivity
(b) Specificity
Formula for
| a) Sensitivity (true positive rate) = (TP) / (TP + FN
(b) Specificity (true negative rate) = (TN) / (TN + FP)
59
Common comorbidity of Primary sclerosing cholangitis
75% of pts w/ primary sclerosing cholangitis also suffer from IB D
60
2 serious complications of polycythemia vera
Polycythemia vera complications
1. Increased clots- b/c high platelet count and high blood viscosity/BP
2. Erythromelalgia = rare but classic finding: sudden severe burning and blue/red discoloration in hands and feet
- due to high platelet count of stickness (more likely to aggregate) => clot small BVs in the extremities
- tx w/ aspirin
61
Most common cause of glomerulonephritis in adults
IgA nephropathy- mesangial IgA deposits
- commonly seen 5 days post infection
- rather common in young men
62
Risk factors for angiodysplasia
Angiodysplasia = dilated submucosal veins and AV malformations in the gut
-usually asymptomatic but can cause melena (black tarry stools) and anemia
Frequent in pts w/ advanced renal disease and von Willebrand disease due to increased bleeding risk
More common in pts w/ aortic stenosis- possibly due to acquired vW factor deficiency (from disruption of vW multimers as they transverse the turbulent valve space induced by AS)
63
Name 2 diseases in which you'll find erythromelalgia
(a) Tx
1. polycythemia vera
2. essential thrombocytopenia
- high platelet count => sudden severe burning and blue/red discoloration in hands/feet due to clotting of the small BVs in the extremities
(a) Tx = aspirin
64
What is PCP?
(a) Seen in which pts
(b) Etiology
PCP = pneumocystis pneumonia = severe interstitial type of pneumonia
(a) Opportunistic infxn => seen in pts w/ immunosupression: HIV, chemo, on immunosuppressants
(b) Caused by pneumocystis jiroveci (previously called pneumocystis carni)
65
Name the 2 categories of lung cancer
-name which types are in each category
(a) Which is more common?
Lung cancer split into:
25% SCLC = small cell lung cancer
75% NSCLC = non-small cell lung cancer
- 35% adenocarcinoma (weakest association w/ cig smoke)
- 30% squamous cell carcinoma (most associated w/ local symptoms like cough, hemoptysis
- 5-10% large cell carcinoma
66
Todd's palsy
Post-ictal transient focal (unilateral) weakness, usually of hand arm or leg after partial seizures activity in that limb (focal motor seizure)
67
Conn's syndrome
(a) plasma renin activity
(b) serum aldosterone
(c) serum bicarbonate
Conn's syndrome = primary hyperaldosterone
(a,b) Serum aldo is increased which inhibits renin secretion
(c) High aldo causes metabolic alkalosis b/c hypokalemia (aldo stimulates K+ secretion) increases renal bicarb resorption
- increased bicarb + increased renal H+ secretion = metabolic alkalosis
- b/c H2CO3 --> HCO3- (gets reabsorbed into blood) so that H+ can be excreted => high bicarb 2/2 hyperaldo
68
Pt presents w/ tearing CP radiating to the back
Tearing CP radiating to the back is the classic presentation of acute aortic dissection
69
Name 3 causes of acute urinary retention in an elderly male
1. Obstruction
- BPH
- prostate carcinoma
2. Neurogenic bladder = syndromes due to a brain, spinal cord, or nerve problem
3. Detrusor underactivity
70
Acute presentation of
(a) aortic dissection
(b) acute pericarditis
(c) pulmonary embolism
Acute presentation of
(a) aortic dissection = stabbing substernal pain radiating to the back, difference in BP btwn arms, pericardial effusion
(b) acute pericarditis- sharp, pleuritic CP (positional)
(c) pulmonary embolism- pleuritic CP, SOB, tachycardia
71
Differentiate the triggers of neurally mediated vs. situational syncope
Neurally mediated syncope = vasovagal response
-medical needles, emotionally stressful situations, prolonged standing, painful stimuli
Features = warmth (diaphoresis), nausea, pallor, bradycardia
Situational syncope: associated w/ cough, micturition (urination) or defecation
72
Fibromyalgia
(a) Most common pt
(b) Presenting symptoms
(c) Physical exam findings
(d) Lab findings
(e) Initial tx
Fibromyalgia
(a) Typically middle aged woman (ex: 30-50 yo F) presenting w/
(b) Widespread pain, fatigue, and cognitive/mood disturbance
(c) Normal physical exam besides some point tenderness most commonly at neck, back, and shoulders
(d) Normal labs- normal ESR
(e) Initial tx- aerobic exercise regularly and good sleep hygiene
73
What is dacryocystitis?
(a) Etiology
(b) Tx
Dacryocystitis = infection of the lacrimal sac
- pain and redness on inner aspect, can be purulent
- edema and redness over medial canthus
(a) Staph and strep
(b) Tx = systemic abx
74
Name 3 complications of gallstones
(a) Management of complicated gallstones
Gallstone complications: acute cholecystitis, choledocholithiasis, gallstone pancreatitis
(a) Complicated gallstones tx w/ cholecystectomy within 12 hrs
75
Hereditary spherocytosis
(a) Mutation
(b) Typical presentation
(c) Common gall bladder complication
Hereditary spherocytosis
(a) Inherited deficiency of ankyrin and spectrum- proteins that provide scaffolding for RBCs => abnormally shaped RBCs (spherocytes) that have decreased life span and increased hemolysis => increased bilirubin load overwhelms the liver
(b) Pts present w/ hemolytic anemia w/ increased MCHC, jaundice (due to hyperbilirubinemia), splenomegaly (splenic sequestration of spherocytes)
(c) Pigment gallstones due to calcium bilirubinate gallstones
76
Side effects of
(a) Statins
(b) ACEi
(c) ARBs
Side effects of
(a) Statins- myalgia (elevated CPK)
(b) ACEi- dry cough and angioedema
(c) ARBs- hyperkalemia, hypotension, renal failure
77
Tx for pericardial effusion
Pericardial effusion = blood, fluid, pus in the pericardium (sac surrounding the heart)
Tx = Pericardiocentesis- drain the fluid
78
2 major presenting features of TTP
Thrombotic thrombocytopenic purpura presents w/ thrombocytopenia and hemolytic anemia
Other features:
CNS findings
Renal involvement
79
Losartan
(a) Most common SEs
Losartan = ARB = angiotensin receptor blocker
(a) Side effects of ARBs = hyperkalemia, hypotension, renal failure
80
What do the following findings on endoscopy suggest
(a) white plaques on the esophagus
(b) Large linear ulcers w/ intranuclear inclusions
(c) vesicles and round/ovoid ulcers
(d) small shallow sores
Endoscopy findings in an HIV (+) pt w/ dysphagia
(a) White plaques = candida => tx w/ fluconazole
(b) Large linear ulcers w/ intranuclear inclusions = CMV => tx w/ gancyclovir
(c) Vesicles and round/ovoid ulcers = HSV => tx w/ acyclovir
(d) Small shallow sores = aphtous ulcers (canker sore)- symptomatic tx
81
Sjogren's triad
Dry eyes
Dry mouth
Parotid gland enlargement
82
2 drugs used for PCP prophylaxis
Common first line = Bactrum
| If pt can't tolerate Bactrum = pentamidine
83
Hypovolemic shock
(a) Right atrial pressure
(b) PCWP
(c) Cardiac index
(d) SVR
- explain mechanism
(e) Venous O2 sat
Hypovolemic shock
ex: hemorrhage
(a) RAP (preload) reduced
(b) PCWP (also preload) => also reduced
(c) Cardiac index (measure of pump function, aka cardiac output) reduced
(d) SVR increased
- reduced preload and SBC activates the SNS => increases HR and causes vasoconstriction (increased SVR) to maintain flow to vital organs
(e) Venous O2 sat reduced (hence why tissues get hypoxic)
84
Name 4 sequelae of aortic dissections
Sequelae of aortic dissection
1. cardiac tamponade (compression of heart due to pericardial effusion)
2. acute aortic regurgitation: due to increased afterload
3. stroke: embolism up to carotids
4. renal failure
85
70 yo w/ severe constant chest and neck pain radiating to the interscapular area
-early decrescendo diastolic murmur at RSB
(a) Dx
(b) Next step
(a) Suspected aortic dissection
- diastolic murmur indicating primary aortic valvular disease (aortic regurg)
(b) Next step = Dx w/ TEE
86
What is acalculous cholecystitis?
(a) Seen in what kind of pts
(b) Lab values
Acalculous cholecystitis = gallbladder inflammation w/o gallstones or cystic duct obstruction
-very high morality
(a) Seen in pts w/ very severe illness: like those on TPN or mechanical ventilation (ex: sepsis, trauma, burns)
(b) High total bilirubin and alk phos
87
What is the meaning of a pulmonary capillary wedge pressure?
Measure the PCWP (w/ Swan-Ganz catheter) to estimate the left atrial pressure
- diagnose severity of LV failure
- quantify degree of MS
- titrate diuretic dosage to reduce pulmonary edema
- evaluate pulmonary HTN
88
Cardiogenic shock
(a) Right atrial pressure
(b) PCWP
(c) Cardiac index
(d) SVR
(e) Venous O2 sat
Cardiogenic shock
(a) RAP increased
(b) PCWP increased
(c) Cardiac index massively decreased
(d) SVR increased
(e) Venous O2 sat decreased
89
What is pneumoperitoneum?
(a) Etiology
Pneumoperitoneum = air in the peritoneal cavity, seen on CXR as air under diaphragm and best seen on CT
(a) Can be caused by perforation of any visceral organ
- most commonly perforated peptic ulcer
- can be from perforated bowel after trauma
90
What is varicocele?
Varicocele = enlargement of the veins in the scrotum
| Caused by defective valves or compression of vein by nearby structure
91
What is thrombotic thrombocytopenia purpura?
Severely reduced activity of protease needed to cleave von Willebrand factor => small-vessel platelet-rich thrombi that cause thrombocytopenia, microangiopathic hemolytic anemia, and sometimes organ damage
92
54 yo w/ difficulty walking x 1 week
- h/o HTN on HCTZ and metoprolol
- severe muscle weakness, hyporeflexia, decreased strength throughout
- EKG: flattened T-waves
Dx?
Hypokalemia
-pt is on a K+ wasting diuretic (HCTZ)
Hypokalemia presents w/ weakness, fatigue, and muscle cramps
Characteristic EKG findings include flat broad T waves
93
75 yo M in hypovolemic shock w/ massively elevated transaminases and normal Tbili
Mechanism of liver injury?
Shock liver = ischemic hepatic injury
| -seen in the setting of hypotension: acute massive rise in AST/ALT w/ milder increase in Tbili and alk phos
94
45 yo M w/ several episodes of vomiting, last one containing blood
- nasogastric lavage revealed gastric contents + bright red blood
- had endoscopy 3 days ago for dyspepsia
Vomiting after lots of vomiting: Mallory-Weiss tear = tear of arteries at gastroesophageal jxn due to increase in intragastric pressure during vomiting
-wouldn't be a complication of endoscopy b/c wouldn't present 3 days later (would be immediate)
95
Differentiate the findings of the types of prostatitis
(a) Acute bacterial
(b) Chronic bacterial
(c) Inflammatory chronic prostatitis
(d) Noninflammatory chronic prostatitis
Prostatitis = prostate inflammation
(a) Acute bacterial = acute UTI
- bacteria in urine
(b) Chronic bacterial = recurrent UTI w/ same organism
- bacteria in urine
(c) Inflammatory chronic prostatitis = white cells in prostatic fluid
- do prostatic massage to get expressed prostatic secretions
(d) Noninflammatory chronic prostatitis = no white cells in the prostatic fluid
96
Tx of hypercalcemia
(a) Ca over 14 mg/dl
(b) Calcium 12-14 mg/dl
(c) Calcium under 12 mg/dl
(a) Severe: NS hydration + calcitonin
Avoid loop diuretics unless pt has coexistant HF
-volume replacement b/c hypercalcemia induces urinary salt wasting (therefore volume depletion)
(b) Immediate tx (see above) only needed if symptomatic
(c) No immediate tx
97
Upper or motor neuron process
(a) positive Babinski sign
(b) Diabetic neuropathy
(a) Positive Babinski sign indicates upper motor neuron process
(b) Diabetic neuropathy strictly affects the lower motor neurons
98
What type of urinary problems are indicative of diabetic neuropathy
Overflow incontinence- bladder overflows until pt just can't get to the bathroom in time
99
Chalazion vs. hordeolum
(a) appearance
(b) physiology
(c) timeline
(d) Tx
Chalazion
(a) hard painless lid nodule
(b) granulomatous, usually inside the lid
(c) Subacute (longer than stye)
(d) Often doesn't go away w/o intervention => steroid injection or surgical removal
Hordeolum = stye
(a) localized red tender swelling over eyelid (abscess)
- smaller and more painful than chalazion
(b) physiology- staph aureus infxn => water and pus
(c) acute, appear more suddenly than chalazion
(d) Self-resolve w/in 7-10 days (last shorter than chalazion)
- warm compress
- if doesn't resolve you can I&D
100
Mechanism by which breast cancer mets to spine may cause hypercalcemia
(a) Most common- involving PTHrP
(b) Most common mechanism in multiple myeloma/lymphoma/leukemia
Malignancy-associated hypercalcemia
(a) 80% of the time hypercalcemia due to malignancy is due to PTHrP production by tumor cells
PTHrP = PTH related peptide => activates PTH receptor which causes excessive bone resportion
(b) Another way is that tumor cells can secrete local factors (ex: cytokines) that activate osteoclasts and stimulate bone resorption
101
Which lung cancers are most likely to cause the following paraneoplastic syndromes
(a) Ectopic ACTH secretion
(b) SIADH
(c) PTHrP
(d) Hypertrophic osteoarthropathy
Lung cancers associated w/ paraneoplastic syndromes
(a) Ectopic ACTH syndrome associated w/ small cell
(b) SIADH associated w/ small cell
(c) PTHrP (=> hypercalcemia) associated w/ squamous cell
(d) Hypertrophic osteoarthropathy associated w/ NSCLC
102
Amiodarone
Amiodarone = antiarrhythmic for tx Afib and ventricular arrhythmias in pts w/ acute decompensated heart failure
-used in management of heart failure in presence of specific arrhythmias
103
Cause of asymptomatic melena in pt w/ aortic stenosis and negative colonoscopy
Angiodysplasia = dilated submucosal veins and AV malformations in the gut
-higher risk in pts w/ AS due to acquired von Willebrand deficiency
Diagnosis is made on colonoscopy, but it is frequently missed
104
What is MPGN?
(a) Distinguish type I vs. type II
MPGN = membranoproliferative glomerulonephritis- deposition of specific IgG antibodies against C3 convertase in the mesangium and basement membrane thickening => persistent complement activation
(a) Type I = most common
- persistent activation of classical complement pathway
Type II = persistent activation of alternate complement pathway
-on spectrum w/ C3 glomerulonephritis
105
66 yo M presenting w/ progressive lower back pain
- Bilateral leg pain worse when walking, better when leaning on cane
- moderate relief w/ ibuprophen
- negative straight leg test
- Lumbosacral spine Xray show degenerative changes
- ankle brachial index 1.1 on right, 1.2 on left
Cause of his condition
Neurogenic claudication = spinal stenosis
Posture-dependent pain
LE numbness, tingling, weakness + lower back pain
Normal pulses and normal ankle-brachial index = not peripheral vascular disease
106
First line initial tx for acute viral or idiopathic pericarditis
NSAIDs + colchicine to attenuate inflammation
-NSAIDs first line (often is enough), but can add colchicine in severe cases to reduce inflammation
-but NSAIDs and colchicine wouldn't be useful in uremic pericarditis b/c need to get rid of the urea (aka dialysis)
107
Describe the key findings/presentation of the following ocular d/o
(a) Retinal detachment
(b) central retinal artery occlusion
(c) diabetic retinopathy
(d) exudative macular degeneration
Eye stuff
(a) Retinal detachment = "curtain coming down over my eyes"
- flashes of light (photopsia) and floaters
- grey, elevated retina on exam
(b) CRAO: pallor of the optic disc, cherry red macula
(c) Diabetic retinopathy- key feature of neovascularization
(d) Exudative macular degeneration- progressive loss of central vision
108
23 yo M w/ severe abdominal pain and fatigue
RUQ tenderness worse on deep inspiration
Hepatosplenomegaly and jaundice
Hgb 10, MCV 88, MCHC 46 g/dL (hight)
Reticulocytes 12%
(a) Cause of anemia
(b) Cause of RUQ pain
(a) Hereditary spherocytosis- normocytic anemia w/ high MCHC (mean corpuscular hemoglobin concentration) and high reticulocyte count
Shoft sphenocyte lifespan and chronic hemolysis => high Hgb turnover => excess bilirubin that overwhelms the conjugation and elimination from the liver => jaundice, dark urine, pigment (calcium bilirubinate) gallstones
(b) Acute cholecystitis due to pigment (bilirubin) gallstones- manifestation of hyperbilirubinemia secondary to high RBC turnover due to hereditary defect in RBC membrane
109
What is Torsades de points?
Torsades de points = polymorphic ventricular tachycardia associated w/ QT prolongation
-disorder of myocardial repolarization
= acquired (bc there is a congenital type) long QT syndrome
110
45 yo HIV (+)male presenting w/ pain and difficulty swallowing
(a) First tx
(b) If first line of tx fails, what is the next step
45 yo HIV positive M w/ dysphagia (difficulty swallowing) and odynophagia (pain while swallowing)
(a) If symptoms are mild, it's likely oral thrush => tx w/ fluconazole
(b) If symptoms don't improve on fluconazole, do endoscopy to see if other cause of esophagitis (ex: CMV, HSV)
111
Management for biliary colic
Biliary colic = symptomatic gallstones typically presenting as intermittent RUQ pain
Tx = elective laparoscopic cholecystectomy (remove gall bladder)
Alternative to surgery = ursodeoxycholic acid = secondary bile acid that can be used to dissolve cholesterol gallstones
112
Management of the average gallstone
Average gallstone is asymptomatic => no tx needed
113
Electrolyte imbalance and pH disturbance seen in primary hyperaldosteronism (Conn's syndrome)
Conn's syndrome = primary hyperaldo
Aldo increases Na+ reabsorption => water retention, H+ K+ secretion
Mild hypernatremia
HTN due to the increase in volume
Hypokalemia
Metabolic acidosis: hypokalemia directly increases renal bicarb resorption
114
Amyotropic lateral sclerosis
(a) Hyper or hypo reflexia?
(b) Affect on cognition
(c) Affect on sensation
ALS = amyotropic lateral sclerosis
(a) Hyperreflexia, along w/ spasticity and fasciculations
Usually spares sensation and cognition => they're preserved
115
IgG and C3 deposits linearly among the basement membrane of the skin
Direct immunofluorescence finding of bullous pemphigoid = autoimmune blistering disease of pruritis, tense bullae, and uticarial plaques
-often medication induced
116
What is angioedema?
(a) Can be caused by what drug?
Angioedema = rapid swelling of skin tissue below the upper dermis (dermis, subcutaneous tissue etc)
-similar to uticaria (can be an allergic response) but uricaria is swelling int he upper dermis
ex: swelling of eyes so aggressive that pt can't open eyes
ex: swelling can cause airway obstruction = medical emergency
(a) Can be caused by ACEi b/c angioedema is due to bradykinin (and ACE breaks down bradykinin)
- bradykinin causes vasodilation and increases vascular permeability => rapid accumulation of fluid in the interstitium
117
LP findings diagnostic for multiple sclerosis
Oligoclonal bands: present in large majority of MS pts
118
Presentation of Meniere's disease
Episodes of vertigo, sensorineural hearing loss, ear fullness, and tinnitus
- can acutely present w/ nystagmus
- can involve postural instability and vomiting
119
Lung cancer complications
(a) SVC syndrome
(b) pancoast tumor
(c) Malignant PE
Lung cancer complications
(a) SVC syndrome- SVC obstruction by mediastinal tumor
- presents w/ JVD, facial and arm edema
(b) Pancoast tumor = upper lung tumor presenting w/ brachial plexus sequelae (C8,T1,T2 root) => shoulder pain radiating down the arm
(c) Malignant PE seen in 10-15% of lung malignancies
120
Differentiate the types of syphilis tests:
| RPR vs. VDRL vs. FTA-ABS
2 classes of syphilis tests
1. Nontreponemal: test antibodies produced when body has been exposed to syphilis but can be from other conditions as well (doesnt test antibodies directly against T. palidum)
=> highly sensitivity, but tons of false positives
-RPR and VDRL
2. Treponemal tests: testing for antibodies directly produced against T. palidum => lower false positive
- FTA-ABS or immunoassays
So if you get a (+) RPR/VDRL, you do an FTA-ABS to confirm
121
Describe exact mechanism of how statins lower cholesterol
HMG CoA reductase inhibitor- inhibits rate limiting step of endogenous cholesterol production => decreases hepatocyte cholesterol production which causes the hepatocytes to increase LDLR expression on their cell membrane
=> more LDL removed from blood and digested in the hepatocyte
122
Shopping cart sign
Leaning forward (lumbar flexion) relieves the pain of spinal stenosis
123
Direct extension vs. hematogenous spread causing brain abscess
Give examples of each
(a) Which is more common?
Brain abscess
75% caused by direct extension:
- sinusitis (most common)
- mastoiditis
- otitis media
25% caused by hematogeous spread
- endocarditis
- osteomyelitis
124
The following pathophysiologic mechanisms cause which type of kidney damage
(a) circulating immune complex deposition
(b) non-immunologic damage
(c) persistent activation of complement pathway
(d) anti-GBM antibodies
Glomerular kidney damage
(a) Circulating immune complexes- seen in SLE and post-strep GN
(b) Non-immunologic damage, ex: diabetic nephropathy
(c) Persistent activation of complement pathway = MPGN (membranoproliferative glomerulonephritis)
(d) Anti-GBM antibodies = Goodpasteur's
125
Acute tx for left ventricular failure
IV diuretics
| -more effective than beta-blockers in short term tx
126
"Curtain coming down over my eyes"
hallmark of retinal detachment = separation of the layers of the retina
127
Rhizopus- what is it and what kind of pts does it infect
Rhizopus = fungus (usually grows on bread and fruits)
| -fungal infection in immunocomporised and poorly control diabetics
128
Septic shock
(a) Right atrial pressure
(b) PCWP
(c) Cardiac index
(d) SVR
(e) Venous O2 sat
Septic shock
(a) RAP (preload) normal to slightly decreased
(b) PCWP (preload) normal to slightly decreased
(c) Cardiac index increased
(d) SVR decreased
- venodilation
(e) Venous O2 sat increased
129
Describe the ratio used to calculate: 5 year risk of getting Acute coronary syndrome in subjects w/ elevated CRPs
5 year risk = (# ppl w/ ACS and elevated CRP) / (total # ppl w/ elevated CRP)
130
What is primary biliary cirrhosis/colangitis?
Autoimmune disease that causes slow progressive destruction of intrahepatic bile ducts
Most common cause of ductopenia (loss of intrahepatic bile ducts) in adults is primary biliary cirrhosis
131
Why does uremic pericarditis lack the typical EKG features of acute pericarditis
EKG features of acute pericarditis (concave up ST segment elevation) and PR segment depression are due to the involvement of the epicardium
Uremic pericarditis only involves the pericardium (not epicardium) => lacks the typical EKG findings of acute pericarditis
132
Describe the pathology of an aortic dissection
Aortic dissection: tear in tunica intima of the aorta allowing blood to flow btwn the layers of the walls of the aorta, forcing the walls apart
-common risk factor: chronic HTN
133
2 lab abnormalities seen in statins
- elevated CPK (associated w/ muscle injury)
| - slight elevation in transaminases
134
37 yo IVDU presenting w/ right weakness and right facial asymmetry after a week of fever/chills
- III/VI systolic murmur
- headaches and fatigue
- 2+ proteinuria
Cerebral emboli: stroke due to septic emboli from an infected heart valve (valvular vegetation)
- endocarditis suggested by IVDU w/ fever/chills and murmur
- proteinuria: immune complex disease or septic emboli
IVDU + fever + murmur + acute neurologic deficit = septic cardioembolic phenomenon
135
Long term management of hypercalcemia of malignancy
Bisphosphonates
136
Which diabetes meds should you use very sparingly in the elderly
Sulfonylureas and insulin- be careful using these in the elderly b/c they run the highest risk of hypoglycemia
