UWORLD 10 Flashcards

Question

Patients with nongonococcal urethritis with continued symptoms after azithromycin therapy - Management

Answer 1

Patients with nongonoccocall urethritis frequently have continued symptoms after azithromycin therapy **due to reinfection or infection with an organism (ex: mycoplasma genitalium) not susceptible to azithromycin.** Patients should receive **repeat urethral gram stain and nucelic acid amplification testing** of the urine for common urethritis organisms.

Answer 2

Parvovirus B19 can cause **viral arthritis**, sometimes with a rash, following a nonspecific flu-like illness. **Acute onset pain, swelling and stiffness** of the **symmetric** small joints of the hand are typical.

Answer 3

_Acute rheumatic fever_- **erythema marginatum and suctuaneous nodules** _Lyme arthritis_ - **monoarticular** and associated with **erythema migrans.**

Answer 4

Ventilaiation perfusion scintigraphy may be considered as an alternative test if the patient is unable to recieve IV contrast agents (ex; renal insuffiency, contrast allergy)

Answer 5

**Troponin can be elevated** in the setting of large pulmonary emboli with resulting right heart strain and would not indicate acute cardiac ischemia. **Elevated troponin in the setting of PE is associated with a worse prognosis.** Patients with suspected PE should be **initated on anticoagulant therapy** and **undergo urgent CT pulmonary angiography.**

Answer 6

Anticoagulation is the mainstay of treatment for PE, with most patients initally receiving LMWH or Unfractionated heparin followed by initation of warfarin. Fibrinolytic therapy is used in patietns with persistent hypotension and IVC filters may be used in patietns with a CI to anticoagulation.

Answer 7

a small amount of hemopthysis is normal in patients with PE, particulary if pulmonary infraction has occured. The treatment regimen need not be latered if the patient is otherwise stable.

Answer 8

Breast cysts that are **simple** can be managed with observation (in asymptomatic patients) or with FNA (in symptomatic patients) Nonbloody benign cysts that resolve with aspiration are then followed with clinical breast examination and repeat US. *simple - thin walled and fluid filled without septations are beign*

Answer 9

**Heart failure with preserved ejection fraction due to left ventircular diastolic dysfunction** **comorbid systemic HTN and obesity** **Chest xray** can aid in the diagnosis and may show pleural effusion or pulmonary edema often manifested as **kerley b lines** (horzontal lines representing intersititual edema or linear densities at eh margins of the lung fields). **Echo** provides an estiaimate of LEVEF and can identify impaired filling. **B-type NAP\<100** is often usefully in ruling out clinically signficant heart failure, however obesity lwoers BNP levels, making htis test unreliable in such patients.

Answer 10

iron deficiency a serum ferritin level should be obtained as iron deficiency is frequently present in the absence of anemia.

Answer 11

dopamine agonists such as pramipexole or ropinirole

Answer 12

**Flail chest** is the result of **double rib fractures in more than one site**, resulting in **paradoxical movement of the flail segment** during inspiration. The diagnosis may be obvious on examination, but many are occult. Management includes **supplemental oxygen, pain control** (invasive or noninvasive), **Positve pressure ventilation and surgical** stabilization for **more severe cases.**

Answer 13

**cardiac contusion**, especially if massive, may lead to hemodynamic instability; however, **disordered breathing (rapid, shallow breathing) with stable vital signs** would not be typical.

Answer 14

mysthenia gravis as it may trigger a myasthenic crisis due to inhibition of acetylcholine release. Valproic acid should be used instead.

Answer 15

**prothrombin complex concentrate and IV Vitamin K.** **Prothrombin complex concentrate** contains Vit. K dependent clotting factors and normalizes INR \<10 mins after administration. **Best choice for rapid reversal.** IV Vitamin K, which results in sustained warfarin reveral but takes 12-24 hours for full effect. **Because of this delayed effect, vitamin K is alway used with a clotting factor replacement.** *\*FFP is considered second line therapy for prelacing vitamin K-dependent clotting factors due to the large volume (often \>2L0 required and the delay for blood compatibiliy tests. It is typically used when prothrombin complex concentrate is not avilable.*

Answer 16

**IV desmopressin** is a **synthetic analaog of ADH** that **increases circulating factors VIII and von willebrand factor.**

Answer 17

**IV idarucizumab,** a monoclonal antibody

Answer 18

**Staph Aureus and Pseudomonas aeruginosa** *In contrast to most patients with suspected Gram-negative pneumonia, monotherapy is inappropriate in ththe treatment of P..aeurginosa in CF as **drug resistance** develops so rapidly in this population.* A **combination** of **tobramycin, ticarcillin-clavulnate and vancomycin** *(tobramycin = aminogycoside) to treat pseudomonas PLUS* anti-pseudomonal semisynethic pencillin ( ticarcillin-clavulnate)

Answer 19

**Urine sediment microscopy** (identifying parasite eggs) Schistosomasis is a parasitic fluke infection most comonly seen in sub-Saharan africa. Chronic schistosomais can cuase **dysuria, urinary frequency, terminal hematuria and peripheral eosinophia.**

Answer 20

thrush **toipcal antifungal** (ex: **nystatin suspension or clotrimazole troches**), with an oral antifungal such as fluconazole used for resistant cases. In patient where thrush is secondary to inhaled corticosteriods, proper technique should be assessed by watching the patient use the inhaler. **Oral fluconazole** is an antifungal agent and can be used in cases that are **resistant to intial treatment with topical nystatin.**

Answer 21

**typically good, with an 80% chance of full or near full recovery.** \*Erbs palsy invovles the upper roots **(C5,6 and sometimes 7**),resulting in an adducted and internally rotated arm with forearm pronation and flexed wrist. A serious complication is **diaphramatic paralaysis** due to **phrenic nerve involvement**

Answer 22

Decreased insulin dosage

Answer 23

**Schwann cells (schwannomas)** **neurofibromatosis**, as well as **sporodic**. Scwann cells are responsible for the **myelinazation of PNS axons**, including most axons of most cranial nerves. *\*In spite of the name neuroma, acoustic neuromas do not arise from neural cells*

Answer 24

_Oligodendrocytes_ - **myelinzation** of the **CNS axons**, including axons of the **optic nerves** _Astrocytes_ - **supportive** cells of the **CNS**. Give rise to the majority of **glial tumors** _Microglia_ - comproised of **phagocytic cells**

Answer 25

A SAAG gradient of **\> or = 1.1** indicates presence of **portal hypertension,** while a value of **\<1.1** indicates **absence of portal HTN** **SAAG = serum ablumin value minus ascitic fluid albumin value** (not the ratio of the two)

Answer 26

_high SAAG_ - **CHF, cirrhosis and alcoholic hepatitis** _Low SAAG_ - **peritoneal carcinomatosi**s (ex: ovarian cancer), **peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis**

Answer 27

active substance or alcohol abuse. relative contraindication - lack of psychosocial support

Answer 28

**\> 3 months of UTI , pain in the genitourinary region, and/or pain with ejaculation.** Exmaination of the prostate may be normal or show hypertrophy tenderness or edema Chronic bacterial prostatitis is a common condition of young and middle-aged men due to i**ntraprostatic reflux of urine with microbial seeding of the prostate.** Pathogens are similar to those that cause cysitits and inlcude **E.coli (75-80%).** Urine leuckocytes and bacteriuria are typically present, partciularly after prostatic massage. **Treatment requires 6 weeks of a fluroquinolone** (ex: ciprofloxacin) or trimethoprim sulfamethoxaole.

Answer 29

A physical examination of the penis should be performed to ascertain whether it is **fully erect** (as in ischaemic priapism) or **partially erect** (as in non-ischaemic priapism). **Penile blood gases** are vital for discriminating between the two types, with **ischaemic priapism** giving rise to **acidotic, hypoxic, hypercarbic cavernous blood gases** (pH≤ 7.25, pO2 \< 30 mmHg, pCO2\>60 mmHg) *These blood gases arise due to a build up of deoxygenated blood in the corpora cavernosa. This build up occurs as **persistent relaxation** of corporeal smooth muscle causes **compression of the subtunical veins,** which **prevents outflow of deoxygenated blood** via sinusoids. Consequently, **intracorporeal pressure is increased** to above the mean arterial pressure, **compressing the cavernosal arteries and preventing arterial blood flow.***

Answer 30

**urination, cold compresses** **invasive treatment.** Management includes aspriation of the corpora cavenosa and intracavernosal **injection of an alpha agonist** (ex: phenylephrine) *As an α1-adrenergic receptor agonist, phenylephrine causes α-mediated vasoconstriction within the corpora cavernosa*

Answer 31

due to DM typically results in progessive visual loss in its late stages. has evidence of neovascularization or hemorrhage on funduscopy

Answer 32

causes **subacute (hours to days) monocular vision loss** associated with **eye pain that worsens with eye movement.** Patients can have afferent pupillary defect, but funduscopy characteriscally shows **optic disc edema.**

Answer 33

most commonly caused by carotid artery atherosclerosis and presents with acute painless monocular vision loss patients typically have affferent pupillary defect on examination and funduscopy may show a pale, ischemic fundus with a "cherry" red spot.

Answer 34

Fundus with retinal hemorrhages & opic disc edema (blood & thunder)

Answer 35

retinal detachment fundus with vitreous hemorrhages and marked elevation of retina surgical repair necessary

Answer 36

pelvic pain with exacerbation by bowel movement (**dyschezia**) and **rectovaginal nodularity** on pelvic examination Extrauterine implantation of endometrial tissue that causes inflammation and fibrosis as it immplants cyclically shed in the ectopic location. Endometrosis casues **pelvic adhesions and inlfmmation**, which can cuase **infertility** and chronic pelvic pain.

Answer 37

genetic syndrome that leads to benign tumors throughout the body.

Answer 38

through **skin** examination, **CNS** and **abdominal imaging** and **electroencephalogy** if **seizures** are suspected ## Footnote *\*Seizures are predominant symptoms that generally worsens over time.*

Answer 39

**Neurologic impairment** Uncontrollable seizures, aspiration pneumonia and obstructive hydrocephalus can result from progressive CNS involvement

Answer 40

**Chronic functional constipation can prevent full bladder emptying -\> urinary stasis -\> UTI** Evaluation and treatment of constipation is ncecessary to prevent dysfunctional voiding and recurrent UTI.

Answer 41

common **protozol** cause of **traveler's diarrhea** that can manifest with **watery diarrhea, malaise and abdominal cramps.** However, stools are typically **foul smelling or fatty** and symptoms almost always **arise \>1 week after exposure.**

Answer 42

is the **most common cause of traveler's diarrhea** and typically manifests **1-3 days after exposure** with **watery diarrhea** and **crampy abdominal pain**. Symptoms are usually **self-limited** and resove spontaenously **within 3-4 days.**

Answer 43

**Fecal impactation.** Managed with **manual rectal disimpaction** followed by **enemas** to clear the bowels. Once complete emptying has been achieved, the patient should **increase fiber and fluid intake** as well as start an aggressive bowel regiment to prevent recurrence.

Answer 44

Upt o 90% of foreign bodies that have made it to the stomach will be passed without difficult; therefore **no intervention is necessary**.

Answer 45

Diagnosis is confirmed with **HCV ribonucelic acid detection by polymerase chain reaction** as anti-HCV antibodies can take up to 122 wweks or longer to become positive in acute HCV.

Answer 46

**twin-twin transfusion syndrome**, a potentially fata complication that results from unbalanced arteriovenous anastomoses between the vessels supplying the umblical cords of the twins. \*Because of unblanced AV anastomoses, blood from the placental arteries (high resistance/pressure) of one twin (**donor**) is shunted into the placental veins (low resistance/pressure) of the other twin (receipient). The shutning of blood away from the donor twin causes **anemia** that leads to renal failure, **oligohydramnios**, low output heart failure and fetal growth restriction. In contrast, the receipient twin caues **polycythemia**, which leads to **polyhydramnios**, cardiomegaly, high output heart failure, and hydrops fetalis.

Answer 47

two twins share 1 placenta and 1 amniotic sac. Because the twins grow and evelop in 1 sac, monochorionic monoaminotic gestations can be complicated by **cord enlargement.**

Answer 48

occurs when the **results** of a clinical study are **distorted by knowledge** of which **intervention** the participants are assigned to. The best way to maximize unbiased ascertainment of outcome is to keep the individuals involved in the clinical study **blind** (unaware) to the particpants' **intervention assignment** for as long as possible.

Answer 49

**Randomization prevents selection bias** in allocating interventionsto participants at the beginning of a study (**before** the outcome is ascertained), whereas **blinding prevents ascertainment of outcomes bias** at the end of the study (**after randomization**). Blinding does not maximize randominzation because it does not consider which participants where randomized into each treatment; rather it focuses on how particpants will be evaluated because of the assigned treatment

Answer 50

**\< or = 2%** **mid-parental height and determining bone age** *\*Bone age study is a radiograph of th epatient's hand and wrist used to assess the rate of skeletal maturation*

Answer 51

height \< or =2%, normal growth velocity, normal bone age and a parental hx of short stature

Answer 52

**Constitutional delay of puberty** - patients with this condition have **delayed bone age** (ex: bone age younger than chroniological age) and **delayed evelopment of secondary sexual characteristis** (ex: breast development, testicular enlargement). **Familial** - This patients **bone age corresponds with her chronological age** and she has **appropriate secondary sexual characteristics** for her age.

Answer 53

statistical power through an increased sample size. The larger the sample size, the more likely a hypothesis will detect a small difference. This is known as type I error of false positive in hypothesis testing. Therefore, it is particularly important to consider clinical significance when the sample size is large.

Answer 54

Patients with PPROM at **\<34 weeks** are managed conservatively witih **prophylactic antibitoics** (ampicillin plus erthyromycin) to prolong hte interval between membrane rupture and delivery, thereby improving neonatal outcomes. \*antibotics are to prevent overt intrauterine infection (ex: chorioamnionitis), which can result from progression of the sublinical infection that caused PPROM or from the ascent of vaginal bacteria through the ruptured membranes. Ampicillin covers Group B strep, aerobic gram neg bacilli and anerobes; erythromycin covers ureaplasma

Answer 55

\<32 weeks. decreases risk of fetal neurologic omplications (cerebral palsy)

Answer 56

**ultrasound estimated fetal weight \<10%** for gestational age, are followed with weekly umbilical artery doppler sonography. **Absent or reveresed umbilcal artery end-diastolic flow** is a sign of impeding fetal hypoxia and an **indication for delivery.**

Answer 57

or **fifth disease** common benign childhood illness caused by **parvovirus B19.** Presentation begins with **fever and nonspecific prodrome (**ex: cough, malais, followed by a **bright red facial rash (**slapped cheek" and **reticulated rash on the trunks and extremities** *\*slapped cheek can also present as face appeared flushed* caues **arthritis in adults** and a **transient aplastic crisis** in those with **Sickle cell disease.**

Answer 58

presents with **\> or =5 days of fever** in **addtional to conjunctivitis, rash, lymadenopathy and extremity changes.** The patients brief illness presented with upper respiratory symptoms only and is now resolved. In addition, although this patient's classmate likely had kawaski disease (treated with aspirin), ti sis an inflammatory disease that is not contagious.

Answer 59

**Measles** can also present with upper respiratory symptoms followed by a diffuse maculopapular rash; However, patietns are typically **ill-appearing and have conjunctiviits.** Althought this patient is notimmunized against meales, he is well appearing and wihtout conjunctivitis and he has a classic presentaiton of erythema infectiosum.

Answer 60

Scarlet fever, caused by group A streptococcus, presents with fever, pharyngitis, and a diffuse, finde snandpaper-textured rash. This patient's fever is resolved and has a rash consistent with erythema infectiosum.

Answer 61

disorder of the MLF, problem in multiple sclerosis The syndrome of **internuclear ophthalmoplegia (INO)** is a well recognized disorder of **horizontal** eye movement often seen in **multiple sclerosis** patients [5]. It is manifested by i**mpairment of adduction of the eye on the side of the MLF lesion** and **abduction overshoot eventually followed by a nystagmus** of the abducting eye [6].