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Amb Care > UWorld 2 > Flashcards

UWorld 2 Flashcards

1
Q

Common GI comorbidity of asthma

A

30-90% of pts w/ asthma have GERD (aka a lot of overlap)

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2
Q

How to differentiate toxic thyroid adenoma and multinodular goiter

A

Radioactive iodine uptake

  • single focal uptake = toxic adenoma
  • multifocal increased uptake = multinodular goiter
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3
Q

25 yo w/ right shoulder pain and swelling

  • heel pain while walking
  • tenderness over heels, iliac crest, and tibial tuberosities

(a) Name of findings
(b) Dx
(c) Limited spinal finding

A

(a) Enthesitis = inflammation and pain at sites where tendons and ligaments attach to bones
- often seen in HLA-B27 associated arthopathies such as

(b) ankylosing spondylitis, psoriatic arthritis, reactive arthritis
- heel pain due to tenderness at insertion of the Achilles tendon

(c) limited spine mobility

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4
Q

Hereditary hemochromatosis manifestations

(a) Skin
(b) MSK
(c) GI
(d) Endo
(e) Cardiac

A

Hereditary hemochromatosis clinical manifestations

(a) Hyperpigmentation of the skin
(b) Arthritis, arthralgia, chondrocalcinosis (calcium deposition in joints)
(c) GI: hepatomegaly that develops into cirrhosis
- increased risk of hepatocellular carcinoma
(d) Endo: diabetes, secondary hypogonadism and hypothyroidism
(e) Cardiomyopathy

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5
Q

Most common extraskeletal complication of ankylosing spondylitis

A

Anterior uveitis

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6
Q

Primary metabolic acidosis

(a) ABG changes
(b) Expected normal compensation

A

Primary metabolic acidosis: main problem is
ex: diabetic ketoacidosis

(a) Decreased bicarb on ABG
(b) Compensation for low bicarb on ABG is hyperventilation so the respiratory system can blow off more CO2

Formula: (Winter’s formula)
Arterial PaCO2 = 1.5 (serum HCO3) + 8 +/- 2

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7
Q

Clinical presentation of anterior unveitis

A

Anterior uveitis presents w/ pain and photophobia in one eye

-associated w/ ankylosing spondylitis (20-30 yo pt w/ lower back pain)

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8
Q

38 yo presents w/ worsening knee and shoulder pain x6 mo

  • tan skin even tho it’s winter
  • DM
  • mild hepatomegaly
  • Xrays reveal chondrocalcinosis

(a) Next step to diagnose
(b) Dx

A

(a) Iron studies- will have elevated ferritin, TIBG etc

(b) Hereditary hemochromatosis
- arthralgia, chondrocalcinosis (calcium deposition in joints)

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9
Q

Which murmurs are

(a) Improved
(b) Made louder

by Valsalva

A

Valsalva maneuver reduces preload (by decreasing venous return)

(a) Makes all other murmurs softer besides:
(b) Makes HCM (hypertrophic cardiomyopathy) and MVP louder

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10
Q

Acid/base d/o caused by aspirin toxicity

A

Aspirin toxicity causes 2 primary acid/base disorders

  • stimulates medullary respiratory center => hyperventilation => blow off tons of CO2 => primary respiratory alkalosis
  • aspirin also causes increased acid production and increased renal organic acid retention => primary metabolic acidosis
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11
Q

Which maneuvers

(a) Improve
(b) Make louder

the murmur of regurgitation

A

Both AR and MR murmurs are

(a) Improved by valsalva and standing (decrease venous return => decrease preload)

(B) Made louder by squatting and handgrip
-increase afterload and regurg fraction

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12
Q

Where is ADH made/secreted from?

A

ADH- made by hypothalamus, stored then released from posterior pituitary

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13
Q

Effect on the CV system of the following maneuvers

(a) Valsalva
(b) Standing
(c) Squatting
(d) Handgrip

A

Effect on CV system

(a) Valsalva decreases venous return => decreases preload
(b) Standing also decreases venous return => decreases preload

(c) Squatting increases venous return (increases preload)
- also increases afterload
- increases regurgitation fraction

(d) Handgrip similar to squatting: increases afterload
- increases BP
- increases regurgitation fraction

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14
Q

Tx for obesity hypoventilation syndrome

A

Tx: noninvasive positive pressure overnight (nocturnal positive pressure)
-wt loss (as always but dats probs not happening)

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15
Q

Lumbar puncture in a newly diagnosed AIDS pt:

Elevated LP opening pressure, low white count, low glucose and elevated protein

A

Cryptococcal meningitis = opportunistic fungal infection by cryptococcus neoformans

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16
Q

Tx of Lyme’s disease in pregnant F

A

Normally in an adult you’d use doxycycline- but contraindicated in kids under 8 and pregnant/lactating women due to teeth discoloration and skeletal developmental retardation => oral amoxicillin

Oral amox = tx of choice in pregnant/lactating women and children under 8

(amox better than azithromycin for lyme’s)

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17
Q

Give the normal values for an ABG

A 
Normal ABG:
pH: 7.4 (7.34-7.44)
PaCO2 40 mmHg (35-45)
PaO2 100 mmHg (75-100)
Bicarb 24 mEq/L (22-26)
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18
Q

What is a porcelain gallbladder?

(a) Complication of this dx

A

Radiologic term describing a calcium-laiden gallbladder wall
-often assocaited w/ chronic cholecystitis

(a) Porcelain gallbladder is associated w/ an increased risk for gallbladder adenocarcinoma => usually requires cholecystectomy

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19
Q

Pyridostigmine

A

Pyridostigmine = anticholinesterase agent

-used in myasethenia gravis (autoimmune diseaes against post-synpatic ACh receptors)

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20
Q

Differentiate next course of action for chemical vs. foreign body in the eye

What about scratch in the eye?

A

Chemical in the eye- immediately rinse w/ water for 15 minutes, then seek medical attention (go to ER)

Foreign body or cut/scratch of the eye- immediately go to ER (don’t wash out first)

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21
Q

Tx of erythema nodosum

A

Tx of erythema nodosum- usually self limited (symptomatic) or it’ll resolve when the underlying disorder (ex: streph pharyngitis or sarcoidosis) is treated

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22
Q

First way to distinguish Lyme’s disease from Guillain-Barre

A

Find the tick! Both present w/ ascending paralysis
-if you remove the tick, most paralysis will spontaneously improve

-GBS will also usually have autonomic involvement (tachycardiac etc)

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23
Q

45 yo obese F w/ HLD, HTN, DM2 w/ daytime somnolece, fatigue, and exertional dyspnea
-LE edema
-low voltage QRS complexes on EKG
ABG: 7.3, 69 (PaCO2), 60 (PaO2)

A

Obesity Hypoventilation Syndrome (OHS) = daytime hypercapnia and hypoxia in an obese pt
-frequently w/ comorbid OSA: tons of overnight apneic events and daytime hypersomlonence

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24
Q

Common locations for enthesitis

A

Enthesitis = inflammation and pain at sites where tendons and ligaments attach to bone

  • heels (insertion of Achilles tendon)
  • tibial tuberosities
  • iliac crest
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25
Q

67 yo M LOC after shoveling snow

  • increasing DOE
  • h/o DM and HLD

(a) Dx
(b) Most likely physical exam finding

A

67 yo M w/ loss of consciousness after shoveling snow

  • increasing DOE
  • h/o of DM and HLD

(a) Aortic stenosis
- dude doesn’t have heart failure for no reason, first start w/ AS causing DOE
(b) Holosystolic ejection murmur radiating to carotids

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26
Q

What type of diuretics are most likely to cause sensorineural hearing loss?

A

Loop diuretics (ex: furosemide) are associated w/ hearing loss

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27
Q

Presentation of renal vein thrombosis

A

RVT presents w/ symptoms of renal infarction: flank pain (may present as abdominal pain), hematuria, can also have fever, elevated LDH

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28
Q

Most common cause of cor pulmonale

A

Cor pulmonale = right heart failure from pulmonary HTN

Most common cause = COPD

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29
Q

Coccidioidomycosis

(a) Type of infection
(b) Endemic to which areas
(c) Most common presentation
(d) Tx

A

Coccidioidomycosis

(a) Dimorphic fungo
(b) Endemic to SW US, Mexico, central and S. America- specifically Arizona, Texas, New Mexico
(c) Most cases are asymptomatic (=> don’t present)
- those that do come to medical attention present as self-limited community acquired pneumonia

(d) As self limited entails, most cases will not require antifungal tx
-complicated cases (aka disseminated) including coccidiodal meningitis requires antifungals
^most complicated cases seen in immunosuppressed (those w/o cellular immunity) => HIV, post organ transplant

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30
Q

What is EGPA (eosinophilic granulomatosis w/ polyangiitis)?

(a) Initial stage
(b) Common systems involved
(c) Lab test finding
(d) Serious complication

A

EGPA = Churg-Strauss

(a) Initial stage of asthma/allergic rhinitis precedes vasculitis by 8-10 years
- 90% of pts have a history of asthma
- also common is nasal polyps and chronic rhinosinusitis

(b) Hypereosinophilia causes tissue damage/inflammation commonly in the lungs and GI tract
- 2/3 have some kind of skin involvement

(c) Peripheral hypereosinophilia
- can also do biopsy of affected organ systems (skin, peripheral nerves) and see hypereosinophilia

(d) Serious complication = heart disease

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31
Q

Presentation of Zenker diverticulum

A

Zenker diverticulum = pharyngoesophageal diverticulum, posterior hernation right above the upper esophageal sphincter

Male over 60 yo w/ dysphagia and halitosis (change in breath odor)

  • regurgitation and aspiration
  • variable size neck mass
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32
Q

What is SVC syndrome?

(a) How to make dx

A

SVC syndrome = obstruction of the SVC that impedes venous return from the head, neck, and arms

(a) Make dx by CXR

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33
Q

Autosomal dominant polycystic kidney disease

(a) Most common extrarenal manifestation

Complications

(b) CNS
(c) Cardiac
(d) GI x2

A

ADPKD

(a) Most common extrarenal manifestation = liver cysts

Complications

(b) Intracranial aneurysm
(c) Valvular heart disease- mostly MVP
(d) Colonic diverticula and hernias

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34
Q

34 yo w/ easy fatiguability, difficulty concentrating, insomnia, right hand weakness, memory loss

  • microcytic anemia
  • elevated creatinine
  • HTN
A

Lead poisoning in adults (check occupational exposure)
Fatigue, insomnia
HTN
Neuropathy and nephropathy
Neuropsychiatric changes
Microcytic anemia b/c Pb overflow disrupts Hgb synthesis

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35
Q

35 yo healthcare worker got vaccinated for Hep B as a kid, last month tested (+) for HBs-Ag, what is her next move after a needle stick exposure?

A

Reassurance- she doesn’t need HBIG after needle stick exposure b/c she’s immune
-you know she’s immune b/c HBs-Ag titers were measured last month

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36
Q

34 yo w/ isolated thrombocytopenia

(a) First dx
(b) What do you have to rule out

A

(a) Think ITP (idiopathic thrombocytopenia)

(b) Have to rule out HIV and Hep C, both of which in chronic infection can cause thrombocytopenia

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37
Q

Mechanism of ADH effect on the

(a) kidneys
(b) CV system

A

ADH = anti-diuretic hormone = vasopressin

(a) Kidneys: increases transcription and insertion of aquaporin-2 on the cells of the distal convoluted tubule and the collecting duct => increase water reabsorption by nephron
- more ADH => more concentrated urine b/c you’re holding onto more water

(b) Cardiovascularly: ADH is a pressor (aka vasopressor) = peripheral vasoconstrictor to increase BP
- important compensation in hypovolmeic shock

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38
Q

Acoustic neuroma

(a) What is it
(b) Most common presentation

A

Acoustic neuroma

(a) Nonmalignant tumor of CN VIII
(b) Most commonly presents w/ hearing loss

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39
Q

Explain how hyperthryoidism increases risk of fracture

A

Excess thyroid hormone stimulates osteoclast activity => bone breakdown

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40
Q

What do the following indicate?

(a) elevated alkphos
(b) elevated GGT

A

(a) Alkphos = dephosphorylator that works in an alkaline setting, mostly liver biliary tract and pancreas. Also is a marker of bone production b/c it is a biproduct produced by osteoblasts
- elevated Alkphos can indicated liver/bile duct problems and bone disease

(b) GGT is a liver diagnostic marker, more specific than Alkphos
- not also elevated in bone disease as alkphos is

=> when both Alkphos and GGT are elevated it is pretty indicative of liver/bile duct pathology

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41
Q

Differentiate Mobitz type 1 and type 2

(a) Location of block
(b) PR interval duration
(c) Probability of progressing to 3rd degree block

A

2nd degree AV block is split into 2 types

Mobitz type 1 (Wenckeback)

(a) Block at the AV node
(b) Progressive prolonging of the PR interval until eventually there is a dropped QRS
(c) Usually benign and transient

Motbiz type 2

(a) Block in the His-Purkinje bundle below the AV node
(b) PR interval is constant (no progressive prolongation), QRS is just suddenly dropped
(c) Commonly progresses to 3rd degree block => usually requires pacemaker

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42
Q

Physical exam findings characteristic of

(a) AR
(b) MS

A

Physical exam finding of

(a) Aortic regurgitation- capillary pulsations in fingers and lips
(b) Mitral stenosis- late diastolic murmur w/ characteristic opening snap

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43
Q

What is an ANCA-associated vasulitis?

(a) Name the 3

A

ANCA-associated vasculitis = autoimmune attack by ANCA (antineutrophil cytoplasmic antibodies) that most commonly affects the lungs and kidneys

3 ANCA-associated vasculitides:

  1. Wegeners = GPA = granulomatous polyangitis
  2. MPA = microscopic polyangiitis
  3. Churg-Strauss = EGPA = eosinophilic granulomatosis w/ polyangiitis
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44
Q

64 yo w/ sudden onset of LE weakness

  • can’t pass urine
  • significant motor weakness from umbilicus to soles of feet
  • no sensation in perineal area
  • absent rectal tone

(a) Dx
(b) Tx

A

(a) Spinal cord compression

(b) Surgery consult- need to decompress spinal cord ASAP to prevent permanent neurologic dysfunction

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45
Q

Tamsulosin

(a) Mechanism
(b) Indication

A

(a) Tamsulosin = alpha-1-antagonist

(b) Indication = BPH

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46
Q

Anatomic abnormality of HOCM

A

Asymmetrical hypertrophy of the interventricular septum. Thickened proximal septum narrows the RVOT => obstruction of the outflow tract

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47
Q

Aortic stenosis

(a) Murmur
(b) Other physical exam features

A

Aortic stenosis

(a) Systolic ejection murmur classically radiating to the carotids
(b) Pulses parvus et tardes on palpation: rises gradually and has a delayed peak

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48
Q

63 yo M presenting w/ anorexia and wt loss x2 mo
+ fecal occult blood
-Ultrasound reveals solitary liver nodule

(a) Dx

A

63 yo M w/ anorexia and wt loss x 2 mo

  • some GI bleeding
  • most common cause of solitary liver nodule = metastatic liver cancer

(a) Dx = undiagnosed colorectal cancer (explains the GI bleeding) that metastasized to the liver

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49
Q

Rapid plasma reagin test

A

RPR = syphillis test

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50
Q

72 yo M presents after 3 episodes of bright red blood in stool, is hemodynamically unstable

After giving IV fluids what is the next step?

A

Hematochezia can be from lower GI bleed or very brisk upper GI bleed. If pt is hemodynamically unstable- do EGF (esophagogastroduodenoscopy) first to rule out brisk upper GI bleed.

If pt is hemodynamically stable, do colonoscopy

-wouldn’t do imaging (like CT scan or something) b/c would only be positive if currently bleeding and can’t also be curative

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51
Q

Pt presents w/ cryptococcal meningitis and is found to have HIV, when do you start the antiretrovirals?

A

Don’t start antiretrovirals for at least 2 weeks after starting an antifungal (tx for acute infection)

Don’t initiate antiretroviral tx in the setting of an acute infection b/c of the risk of immune reconstitution syndrome

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52
Q

What type of thyroid nodules are more likely to be malignant?

A

Hyperfunctioning (‘hot’) thyroid nodules are rarely malignant, it’s the large hypofunctioning (‘cold’) nodules that cary and increased malignancy risk

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53
Q

Associated w/ cerebellar dysfunction

(a) What type of muscle tone
(b) What type of tremor
(c) What type of ataxia

A

Cerebellar dysfunction

(a) Hypotonia
(b) Intention tremor
(c) Truncal ataxia

-also dysdiacokinesis

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54
Q

Indications for at home O2 therapy

A

PaO2 under 55 mmHg or SaO2 under 88%
-or in pts w/ pulmonary HTN 9aka increased risk of cor pulmonale) or HCt > 55%, start on home O2 when PaO2 falls below 60 mmHg

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55
Q

What is sarcoidosis?

(a) Classic presentation

A

Sarcoidosis = unknown etiology, noncaseating granulomatous disease affecting many organ systems

(a) Classic presentation = fever, erythema nodosum (painful red nodules on shins), arthralgia
+ bilateral hilar lymphoadenopathy

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56
Q

Give 2 general causes of hyponatremia and how to differentiate them

A
  1. Excess ADH secretion
    SIADH = syndrome of inappropriate ADH excretion
    -maybe from lung cancer or bone mets secreting ADH
    -would have high urine specific gravity
  2. Polydipsia- drinking too much water, water intake is higher than the ability of the kidney to excrete water => hyponatremia and urine w/ low SG (very unconcentrated urine)
    - associated w/ psychiatric disease, possibly central defect in thirst regulation
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57
Q

Which disorders carry the following kind of murmur

(a) Crescendo-decresendo at LLSB
(b) Midsystolic click
(c) Holosystolic murmur at apex w/ radiation to axilla

A

Cardiac d/o

(a) Crescendo-decresendo at LLSB in a young person- HOCM
(b) Midsystolic click- Mitral valve prolapse
(c) Holosystolic murmur at apex w/ radiation to axilla- dilated or ischemic cardiomyopathy

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58
Q

What is cardiac tamponade?

A

Cardiac tamponade = rapidly developing pericardial effusions that impairs cardiac filling

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59
Q

Is the risk of renal vein thrombosis higher in nephrotic or nephritic syndrome?

(a) Why?

A

Risk of RVT is higher in nephrotic syndrome

(a) Theory is that you’re losing important proteins such as antithrombin and plasminogen (needed to prevent clot formation) in the urine => increased risk for clots

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60
Q

Cauda equina syndrome vs. conus medullaris syndrome

(a) Type of pain
(b) Location of numbness
(c) Type of motor weakness
(d) Change in reflexes

A

Conus medullaris = end of spinal cord that then continues and branches out into the cauda eqina

Conus medullaris

(a) Sudden onset back pain
(b) Perianal anesthesia
(c) Symmetrical motor weakness
(d) Hyperreflexia

Cauda equina syndrome

(a) Severe radicular pain
(b) Saddle anesthesia
(c) Asymmetrical motor weakness
(d) Hyporeflexia

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61
Q

Features of hepatorenal syndrome

(a) Main lab finding
(b) UA results
(c) Sodium excretion
(d) Urine volume

A

Hepatorenal syndrome

(a) Gradual increase in serum creatinine
(b) UA: benign urine sediment (no RBC etc), no proteinuria (it’s not glomerular damage)
(c) FENa very low
(d) Oliguria = low urine volume

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62
Q

Describe the overall acid/base problem caused by

(a) Anaphylaxis
(b) Vomiting
(c) Asthma exacerbation
(d) Excessive diuresis

A

Acid/base disruption

(a) Anaphylaxis => obstruction of airway => can’t blow out CO2 => respiratory acidosis
(b) Vomiting- loss of tons of H+ from gastric contents=> metabolic alkalosis
(c) Asthma exacerbation => hyperventilation => blow off tons of CO2 (acid) => acute respiratory alkalosis
(d) Excessive diuresis => low volume so bicarb is concentrated => metabolic alkalosis

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63
Q

Name 4 agents that can be used to shift potassium intracellularly

A
  • insulin
  • glucose
  • albuterol (beta-2 agonist)
  • sodium bicarbonate
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64
Q

28 yo otherwise healthy pt develops CHF

A

Think myocarditis- most commonly caused by a viral infection

-espeically coxsackie B

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65
Q

54 yo M w/ facial puffiness, bilateral leg swelling

  • Hx: recurrent pulm infxns due to bronchiectasis
  • PE: S4, hepatomegaly, palpable kidneys
  • 4+ proteinuria
A

Secondary amyloidosis- misfolded protein deposition associated w/ chronic infections/inflammation

Amyloidosis most likely to affect kidneys (nephrotic syndrome) and heart (signs and symptoms of HF, hence the S4 and bilateral pitting edema)

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66
Q

Target values for at home O2 therapy

A

Target: titrate dose until keep SaO2 above 90% at all times (especially when sleeping)

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67
Q

22 yo M w/ annoying noise in right ear and decreased hearing on right side
-PE: numerous cafe-au-lait spots

(a) Dx
(b) Diagnostic test

A

(a) Think of neurofibromatosis, type 2, in any pt that presents w/ hearing/oto-difficulties (acoustic neuroma) and multiple cafe au lait spots
(b) Dx test for acoustic neuroma = MRI w/ gadolinium

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68
Q

What is amyloidosis?

2 most common types

A

Amyloidosis = general term for when amyloid (basically misfolded and therefore non-soluble proteins) deposit extracellularly in tissues

2 most common types as AL (primary) and AA (secondary)

AL- due to deposition of light chain (Ig light chain fragments) in dif organs

AA- associated w/ chronic infections
ex: TB, bronchiectasis, RA

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69
Q

What color fever do we have a vaccine for?

What kind of illness is it?

A

Vaccine for yellow fever (lol color) = mosquito- borne viral hemorrhagic fever
-pretty high fatality: 3rd phase can cause hepatic dysfunction, renal failure, coagulopathy, and shock

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70
Q

Treating hyperthyroidism

(a) Acute
(b) Chronic

A

Hyperthryoidism tx

(a) Acutely give beta-blockers to alleviate symptoms
(b) Give thionamide (methimazole) to decrease thyroid hormone secretion. Methimazole is a thyroid hormone synthesis inhibitor
- then surgery and radioablation

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71
Q

Tx for chlamydia

A

Azithromycin

-or doxycyclin

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72
Q

Acute respiratory acidosis

(a) ABG changes
(b) Expected normal compensation

A

Acute respiratory acidosis

(a) See increased PaCO2 on ABG (over 40)
(b) To compensate for respiratory acidosis the kidneys will hold on to base => see increased in serum bicarb

-Increase in serum HCO3 by 1 mEq/L for every 10 mmHg increase in PaCO2

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73
Q

Ocular complication of RA and IBD

A

Episcleritis = inflammation of episclera- thin tissue layer btwn conjunctiva and sclera (CT that forms the white of the eye)

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74
Q

Which maneuvers

(a) Improve
(b) Make louder

the murmur of MVP

A

Mitral valve prolapse murmur

(a) Made softer by squatting
- increases venous return (preload)

(b) Made louder by valsalva and standing
- these decrease preload

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75
Q

Which maneuvers

(a) Improve
(b) Make louder

the murmur of VSD

A

VSD murmur

a) Improved by valsalva and standing (decrease preload
(b) Made louder by squatting and handgrip (increase afterload)

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76
Q

Common cause of nosebleeds during pregnancy

A

Pyogenic granulomas = benign vascular tumors of the skin or mucous membranes (in this case the nose)

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77
Q

Would it take longer to become B12 or folate deficient?

A

Body has much larger B12 stores than folate stores => you’d become folate deficient much faster after lacking folate in diet

  • body stores of folate can last about 4-5 months
  • body stores of B12 can last about 4-5 years of a pure vegan (no animal product) diet
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78
Q

Best tx for frost-bite injury

A

Rapid rewarming with water- more effective than tx w/ slow rewarming (at room temp)

  • put feet in warm water which is continuously circulated
  • no attempt should be made to debride any tissue initially (first warm em up, then assess da situation)
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79
Q

MPA vs. GPA

(a) Renal features
(b) Pulmonary features
(c) Tx
(d) Association w/ ANCA

A

Microscopic polyangiitis vs. granulomatous polyangitis (Wegener’s) = 2 similar ANCA-vasculitides

(a) Identical renal involvement => RBC cases in urine and elevated creatinine
(b) Pulmonary features more seen in GPA
- granulomatous involvement of the upper and lower respiratory tract => oral ulcers, purulent nasal discharge, lung nodules
(c) Tx = glucocorticoids + immunsuppression
(d) 90% are ANCA (+)

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80
Q

Fever, tinnitus, and tachypnea in the settings of a drug overdose

A

Aspirin toxicity

  • fever
  • tinnitus: aspirin doesn’t cause hearing loss but causes ringing in the ears
  • tachypnea b/c stimulates medullary centers => blow off tons of CO2 => respiratory alkalosis
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81
Q

Would negative predictive value or sensitivity change due to prestest probability?

A

Sensitivity and specificity are fixed values, don’t change w/ pretest probability

While NPV and PPV will change w/ pretest probability

ex: Pt w/ high probability of the disease will have a low NPV, but sensitivity of that test will be the same

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82
Q

Spinal tap results differentiating viral and bacterial encephalitis

A

CSF findings

Vital: lymphocyte predominance, normal glucose

Bacterial: neutrophilic predominance, low glucose

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83
Q

23 yo F w/ progressive lower back pain x6 mo

  • morning stiffness
  • symptoms improve w/ physical activity
  • denies rash, eye pain, urinary problems, diarrhea
  • reduced forward flexion of lumbar spine, tenderness over sacroiliac joints
A

Ankylosing Spondylitis = chronic spinal inflammatory disease associated w/ radiographic sacroiliitis

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84
Q

What medication adjustments will you have to make for a pregnant woman on levothyroxine

A

Rise in estrogen is one of the mean reasons for higher L-thyroxine requirement during pregnancy
-estrogen decreases TBG (thyroid binding globulin) clearance => need more thyroxine to saturate binding sites

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85
Q

What is diabetes insipidus?

(a) Presentation
(b) Differentiate the two types

A

Diabetes insipidus = either underproduction or lack of sensitivity to ADH (vasopressing/anti-diuretic hormone)

(a) Presents w/ increased thirst and copious dilute urine
(b) Two types of DI

  1. Central DI = Neurologic
    - deficiency in vasopressin
  2. Nephrogenic DI = Kidney/nephron is insensitive to ADH secreted by posterior pituitary (ADH made in hypothalamus, stored in posterior pituitary)
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86
Q

What is Plummer-Vinson syndrome?

A

Unknown cause (possibly genetic or nutritional deficiency) of

  • Esophageal web => dysphagia, odynophagia
  • Fe deficient anemia
  • glossitis, chelitis (inflammation of the lipds)
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87
Q

Most common presentation of pancoast tumor

A

Shoulder pain

-often Horner’s syndrome

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88
Q

What is acalculous cholecystitis?

A

Acalculous cholecystitis = acute gall bladder inflammation in absence of gallstones

-seen in critically ill hospitalized pts, usually on prolonged fasting or TPN, often after surgery

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89
Q

Diagnostic tool for ankylosing spondylitis

(a) Characteristic finding

A

Anklyosing spondylitis- diagnosed by Xray of the sacro-iliac joints

(a) On Xray see fusion of the SI joints and/or bamboo spine

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90
Q

Most common adverse effect of inhaled beclomethasone tx

A

Inhaled beclomethasone = inhaled steroid (asthma tx)

Oropharyngeal thrush (oral candidiasis)
-not adrenal suppression or osteoporosis b/c the steroids are not systemically absorbed
91
Q

Treatment for cryptococcal meningitis

A

Cryptococcal meningitis (caused by cryptococcus neoformans) requires 3 steps of tx

  1. Induction therapy w/ 2 weeks of IV amphotericin B and flucytosine
    - can start ART (antiretroviral therapy) about 2 weeks after starting antifungal (if new diagnosis)
  2. Consolidation w/ 8 weeks of fluconazole
  3. 6-12 mo maintenance w/ lower dose fluconazole
92
Q

Describe the gait seen in

(a) Basal ganglia lesions
(b) Cerebellar dysfunction
(c) Common peroneal neuropathy

A

Gait seen in

(a) Basal ganglion lesions = Parkinsonian shuffling gait
(b) Cerebellar ataxia = wide based staggering gait
(c) Common peroneal neuropathy causes foot drop => see steppage gait

93
Q

How long does a diabetic pt need IV abx for a UTI?

A

Depends if they’re responding- if they respond you can switch to PO (off IV) after 48-72 hours

ex: IV Ceftriaxone for 48 hrs w/ good response –> switch to oral bactrum or fluoroquinolone (ex: Cipro)

94
Q

Footdrop

(a) Type of gait it results in
(b) Associated signs
(c) Cause

A

Footdrop

(a) Results in ‘steppage gait’- excessive hip and knee flexion while walking to lift up foot, slapping quality of foot, frequent falls
(b) Associated signs of motor neuropathy = distal sensory loss and weakness
(c) Motor neuropathy

95
Q

Amylase levels

A

Increased serum amylase is associated w/ pancreatitis

96
Q

2 EKG changes caused by hyperkalemia

A

Hyperkalemia => QRS prolongation and peaked T waves

97
Q

Myasthenia gravis

(a) Hallmark feature
(b) Most common presenting symptom

A

Myasthenia gravis = AI disease of the nmj

(a) Hallmark clinical feature = fluctuating muscle weakness
(b) 50% present w/ ocular symptoms: ptosis and/or diplopia

98
Q

Describe the gait seen in damage to frontal lobe cortico-cortical white matter tracts

A

Gait seen in damage to cortico-cortical white matter fibers of the frontal lobe (as seen in normal pressure hydrocephalus) => gait apraxia (Bruns ataxia): difficulty in initiating forward mov’t of feet when they’re in contact w/ the ground = magnetic gait

99
Q

Skin-colored, verrucous, papilliform lesion on genitals

A

HPV

-most common STD in the US

100
Q

Plummer-Vinson syndrome

(a) Most likely population
(b) Tx
(c) Complication risk

A

Plummer-Vinson syndrome = considered a premalignant process, characterized by esophageal web => dysphagia, odynophagia, cholangitis (lip inflammation), Fe deficiency anemia, glossitis

(a) Post-menopausal women
(b) Tx = iron supplementation + mechanical widening of the esophagus
(c) Increased risk of squamous cell carcinoma of the esophagus, pharynx, and oral cavity

101
Q

Acute respiratory alkalosis

(a) ABG changes
(b) Expected normal compensation

A

Acute respiratory alkalosis

(a) Decrease in PaCO2
(b) Kidneys compensate to respiratory alkalosis by getting rid of bicarb (base)

-Decrease in serum HCO3 by 2 mEq/L for every 10 mmHg decrease in PaCO2

102
Q

2 abx choices for oral tx of UTI

A

Good PO coverage for E. coli (most common cause of UTI) = fluoroquinolones (ex: ciprofloxacin) and bactrum (TMX-SMP)

103
Q

Bronze diabetes

A

Buzzword for hereditary hemochromatosis (auto recessive iron overload)

104
Q

Elevated serum alpha-fetoprotein

A

In pregnant women it’s a marker for neural tube defects etc

In nonpregnant: elevated AFP is associate dw/ hepatocellular carcinoma (most common primary liver cancer) and testicular cancer

105
Q

Sarcoidosis

(a) CXR findings
(b) Biopsy results

A

Sarcoidosis

(a) Characteristic CXR findings = bilateral hilar adenopathy
(b) Biopsy: noncaseating granulomas
- try to do biopsy on peripheral lesion like skin or palpable lymph node if possible

106
Q

Is DI associated w/ hypo or hyper-natremia?

A

Diabetes insipidus is associated w/ hyPERnatremia b/c you’re just peeing out all the water
-either no ADH or kidneys aren’t sensitive to ADH => kidneys don’t reabsorb a lot of water => you’re just peeing out tons of water

107
Q

Pt from Arizona/California makes you think of which fungal infection

A

Coccidioidomycosis

108
Q

54 yo M w/ facial puffiness, bilateral leg swelling

  • Hx: recurrent pulm infxns due to bronchiectasis
  • PE: S4, hepatomegaly, palpable kidneys
  • 4+ proteinuria
A

Secondary amyloidosis- misfolded protein deposition associated w/ chronic infections/inflammation

Amyloidosis most likely to affect kidneys (nephrotic syndrome) and heart (signs and symptoms of HF, hence the S4 and bilateral pitting edema)

109
Q

Differentiate BPH from prostate cancer

(a) Affected part of the prostate
(b) Palpation findings
(c) PSA levels

A

BPH vs. prostate cancer

(a) BPH affects central prostate(transition zone). Prostate cancer more likely to affect sides (but can be anywhere).
(b) BPH- enlarged but smooth prostate on exam. Cancer- asymmetrically enlarged, firm, w/ nodules
(c) BPH can have elevated PSA, prostate cancer has markedly elevated PSA

110
Q

Differentiate the types of paralysis seen in

(a) Lyme’s disease
(b) Guillan-Barre Syndrome
(c) Botulism

A

Paralysis

(a) Lyme’s disease- asymmetrical ascending paralysis
(b) GBS- symmetrical ascending paralysis + autonomic dysfunction
(c) Botulism- descending paralysis + cranial nerve (and usually pupillary) involvement

111
Q

21 yo F w/ fatigue and weakness x 9 mo

  • alleviated by rest
  • one episode of double vision, difficulty raising eyelids, and swallowing problems
A

Myasethenia gravis = autoimmune d/o of the nmj

-50% present w/ ocular symptoms: diplopia, ptosis

112
Q

Cause of hepatorenal syndrome

(a) Chronic
(b) Acute

A

Hepatorenal syndrome etiology

(a) Insidious sequence of reductions in renal perfusion due to increasing severity of liver injury
(b) However can be acutely precipitated by an insult such as a bacterial infection

113
Q

Normal value of urine specific gravity

(a) Possible cause of high urine SG
(b) Possible cause of low urine SG

A

Urine SG normal: 1.002 - 1.030

(a) High urine SG: kidneys are concentrating urine
- dehydration (very severe dehydration indicated by SG > 1.035)

(b) Low urine SG: secreting very dilute urine
- excessive fluid intake, renal failure, diabetes insipidus, acute tubular necrosis

114
Q

F w/ hypothyroidism is going on estrogen pills for unretractable night sweats during menopause

A

Need to increase levo-thyroxine dose b/c exogenous estrogen (especially oral) decreases TBG clearance => need more levothyroxine to saturate the increased TBG binding sites

115
Q

Most common inherited kidney disease

A

Most common inherited kidney disease = ADPKD = autosomal dominant polycystic kidney disease

116
Q

35 yo gets negative FNA result of breast-mass. What value is she asking for when she asks: ‘what are the chances that I really do not have breast cancer?’

A

Negative predictive value

-NOT sensitivity: sensitivity and specificity don’t vary w/ pretest probability

117
Q

Describe a magnetic gait

(a) 2 associated syndromes

A

Magnetic gait = Frontal gait- as if feet are stuck to the floor by magnets: freezing- hesitation upon start and turns
-difficulty initiating forward mov’t of the feet when they’re in contact w/ the ground

(a) Magnetic/frontal gait associated w/ NPH (normal pressure hydrocephalus)
- also associated w/ frontal lobe degeneration

118
Q

75 yo s/p advanced prostate cancer surgery presenting w/ worsening back pain x3 days

Initial management and dx

A

Metastatic prostate cancer causing spinal cord compression => IV glucocorticoids + MRI

Not an Xray of the lumbar spine- won’t show cord compression (will just show fractures or lytic lesion)

119
Q

Describe the mechanism of outflow obstruction seen in HOCM

A

HOCM outflow obstruction due to

  • interventricular septum hypertrophy
  • systolic anterior motion of the mitral valve leaflets
120
Q

Associated signs of Parkinsons disease besides shuffling gait

A

Parkinsonian features

  • shuffing gait
  • bradykinesia
  • resting tremor
  • postural instability
  • decreased arm swing
121
Q

35 yo M w/ SOB, fever, malaise x 5 days

  • recurrent sinusitis x2 yrs
  • patchy rales on exam
  • CXR: multiple nodular densities
  • BMP: elevated creatinine
  • UA: RBC casts in urine

(a) Best diagnostic test

A

Pulmonary and kidney disease- can think ANCA vasculitides = autoimmune vasculitis affecting small and medium-size vessels => damage lung and kidneys

(a) Test for serum ANCA (antineutrophil cytoplasmic antibodies)

122
Q

IV crystalloids vs. colloid solution

A

IV crystalloids are for replacement fluids: NS, LR
-salt crystals

vs.

Colloid solutions are for oncotic pressure (things in solution that stay in the vascular space)

ex: albumin
- used in burns or conditions of hypoproteinemia

123
Q

5o yo F w/ long-standing RA presents w/ right shoulder pain radiating to her hand

  • swollen fingers, knee weakness => difficulty walking
  • cough for several months, more tired than usual
  • on MTX and NSAID
  • PE: bilateral hand joint deformities, constricted right pupil w/ doroping right eye lid
  • elevated ESR and CRP

(a) Dx
(b) Imaging required

A

(a) Pancoast tumor = superior sulcus tumor
Most commonly presents w/ shoulder pain

(b) CXR

124
Q

Acute symptoms of lead poisoning

A

Abdominal pain and constipaiton

125
Q

Most common tumor seen in NF2

(a) Is it benign or malignant?

A

Bilateral vestibular schwannoma

vestibular schwannoma = acoustic neuroma

(a) Acoustic neuromas are benign tumors of CN VIII

126
Q

MuSK antibodies

A

MuSK = muscle specific receptor tyrosine kinase

-one of the antibodies in myastenia gravis (other one being AChR)

127
Q

Why is HPV dangerous?

-2 reasons

A

Even tho the initial infection is usually self-limited…
-increased risk for squamous cell carcinoma of the anus, genitals, and mouth (and cervix in F)

-also increased risk of other STDs: always do HIV test in a newly diagnosed HPV pt

128
Q

Best diagnostic image for an acoustic neuroma

A

MRI w/ gadolinium (aka constrast)

-MRI w/ contrast preferred to CT scan for acoustic neuromas (aka vestibular schwannomas)

129
Q

Primary metabolic alkalosis

(a) ABG changes
(b) Expected normal compensation

A

Primary metabolic alkalosis

(a) Bicarb is high on ABG (over 24)
(b) Respiratory system compensates for too much base by holding onto CO2 => see increase in PaCO2 as compensation

-PaCO2 increases 0.7 mmHg for every 1 mEq/L increase in seurm HCO3

130
Q

Which type of nephropathy has the highest risk of renal vein thrombosis?

A

Membraneous glomerulopathy has the highest risk of RVT as a complication

131
Q

BUN:creatinine ratio > 20

-marginally high electrolytes and Hct

A

Indicates a state of dehydration

132
Q

24 yo w/ slowly progressive lower back and buttocks pain

  • most severe early in the morning
  • pain relieved w/ warm shower and OTC analgesics
  • limited range of motion in lumbar spine
A

Ankylosing spondylitis

133
Q

What is hepatorenal syndrome?

(a) Mechanism of kidney injury

A

Hepatorenal syndrome = acute kidney failure in a patient w/ acute or chronic liver disease
-aka AKI in a pt w/ portal HTN due to cirrhosis, severe alcoholic hepatitis, less commonly malignancy

(a) Sequence of reductions in renal perfusion induced by an increasing severity of hepatic injury
- arterial vasodilation in splanchnic circulation triggered by portal HTN (due to increased production of vasodilators, mainly NO)

134
Q

Name two diseases in which there is subcutaneous nodules

A

Rheumatoid arthritis and gout

135
Q

Effect of the following on both Mobitz type I and type II AV block

(a) Exercise
(b) Atropine
(c) Vagal maneuver

A

(a) Exercise improves Mobitz type I, worsens type II
(b) Atropine = muscarinic receptor antagonist (used as a tx for bradycardia, used to induce sympathetic tone)- similar to exericse will improve type I and worsen type II
(a) Vagal maneuvers (ex: carotid massage) worsens type I and paradoxically improves type II

136
Q

Bladder cancer

(a) Screening recommendations
(b) Most common presentation

A

Bladder cancer

(a) Even for ppl w/ high risk (ex: family Hx)- no screening is recommended
- no test that is good enough that would be worth it for screening
(b) 85% of the time presents w/ gross hematuria

137
Q

Exact criteria for positive bronchodilator response in PFTs

A

Improvement of FEV1 by 12% or 200 ccs

138
Q

What is the most common organ system involved in graft vs. host reaction?

A

Skin!!! A skin rash is almost always seen in graft vs. host reaction

139
Q

Describe an ataxic gait

(a) Give a few causes
(b) Some associated signs

A

Ataxic gait = staggering, wide based

(a) Some causes of an ataxic gait
- cerebellar degeneration
- stroke
- drug/alcohol intoxication
- B12 deficiency

(b) Associated signs of cerebellar ataxia
- dysdiadochokinesia
- dysmetria (uncoordinated finger to nose)
- nystagmus
- Romberg sign

140
Q

In addition to hyponatremia, what else would you see in the following

(a) Marked hyperglycemia
(b) Primary polydipsia
(c) CHF

A

Hyponatremia is seen in the following

(a) Marked hyperglycemia- also see high serum osmolality (over 290)
(b) Primary polydipsia- also see very dilute urine (low urine osmolality)
(c) CHF- Urine sodium is low (body reabsorbs Na+ to keep the water)

141
Q

Differentiate the cause of polyuria seen in

(a) diabetes mellitus
(b) diabetes insipidus

A

Increased thirst in

(a) DM is due to the excessive loss of glucose in urine that therefore drags water out into urine
- osmotic diuresis, serum glucose so high that it exceeds the kidney’s abilities to reabsorb it => glucose leaks into the urine and water follows

142
Q

56 yo M post-op day 3 develops fever of 102 and RUQ pain

  • leukocytosis
  • normal bilirubin, alkphos, LFTs, and amylase
A

Acalculous cholecysitis = acute gallbladder inflammation in absence of gallstones that develops in critically ill pts often surgery or after prolonged NPO

143
Q

Neurologic deficits expected in vitamin B12 deficiency

A

Neurologic deficits due to vitamin B12 deficiency

-loss of proprioception and vibratory sense in the lower extremities => recurrent falls

144
Q

Most common primary liver cancer

(a) Associated conditions

A

Most common primary liver cancer = HCC (hepatocellular carcinoma)
-but still much less common cause of liver mass than metastatic liver cancer

(a) HCC is associated w/ chronic liver inflammation
- chronic hepatitis
- cirrhosis

145
Q

Hereditary hemochromatosis

(a) First diagnostic step
(b) To confirm diagnosis
(c) Tx

A

Hereditary hemochromatosis

(a) First do iron studies: will show increased serum iron, ferritin, and transferrin saturation
(b) Confirm diagnosis w/ genetic testing or liver biopsy
(c) Tx: phlebotomy

146
Q

60 yo F w/ previous MI presenting w/ sharp central CP

  • pain worsens w/ inspiration and movement
  • PE: tenderness to palpation over the sternum
A

Pain worse w/ inspiration and movement, and reproducable upon palpation, indicates musculoskeletal etiology

ex: Costochondritis

147
Q

Differentiate PCP vs. CMV infection post-bone marrow transplant

(a) Timeline
(b) Which causes abdominal pain and diarrhea
(c) Which has decreased a lot in the past 10 years

A

Pneumococcal pneumonia vs. viral CMV infection after a BM transplant

PCP

(a) Occurs more immediately (just a few days) after transplant
(c) Has decreased a lot now w/ use of bactrum prophylactically after BM transplant (or in pts on chemotherapy)

CMV

(a) Occurs later, on average of 48 days after BM transplant
(b) Pulm symptoms + abdominal pain and diarrhea

148
Q

Pansystolic murmur heard best at the apex w/ radiation to the axilla

A

MR, potentially due to papillary muscle rupture

149
Q

Positive fluorescent treponemal antibody absorption test

A

FTA-ABS is a confirmatory test for syphilis

150
Q

2 secondary findings that indicate chronic hypercapnia and hypoxemia

A

Ex: seen in obesity hypoventilation syndrome

Chronic high CO2 and low O2 (respiratory acidosis)

  • erythrocytosis: increase RBC mass in attempt to increase O2 circulation
  • decreased renal bicarb excretion: serum bicarb increases in attempt to balance the respiratory acidosis
151
Q

Which murmurs are

(a) Improved
(b) Made louder

by Handgrip

A

Handgrip increases afterload

  • increases BP
  • increases regurg fraction

(a) Makes softer: HCM, AS
(b) Makes louder: AR, MR, VSD

152
Q

Type of ataxia common among chronic alcohol abusers

A

Cerebellar ataxia

-cereballar dysunction

153
Q

Classic finding of cardiac tamponade

A

Pulses paradoxus = more than 10 mmHg drop in systolic BP w/ inspiration

154
Q

Way to decrease side effects of MTX

A

Decrease side effects of MTX (anti-metabolite) by supplementing w/ folic acid

  • well obv when MTX is being used as DMARD not anti-cancer
  • giving folic acid reduces side effects of MTX (mouth sores, alopecia, rash, pulm and hepatic toxicity, BM suppression) w/o reducing efficacy of the drug
155
Q

Fibromyalgia tx

(a) First line
(b) First line drug option

A

Fibromyalgia = pain syndrome characterized by fatigue, widespread pain, and cognitive/mood disturbances

(a) First line tx is aerobic exercise and good sleep hygiene
(b) First line drug option = TCAs (ex: amitriptyline)

156
Q

69 yo F w/ days of increasing SOB, cough, LE edema
+smokes, ++EtOH
-JVD 9 mm, faint heart sounds, O2 sat 90% RA
-decreased breath sounds, ascites 3+ LE edema to knees
-CXR: enlarged pulmonary arteries

(a) Dx
(b) Mechanism of idsease

A

Core pulmonale = right heart failure from pulmonary HTN

-pulmonary HTN can be idiopathic, or due to COPD, OSA

157
Q

Which murmurs are

(a) Improved
(b) Made louder

by standing

A

Standing maneuver reduces preload (by decreasing venous return)

(a) Makes all other murmurs softer besides:
(b) Makes HCM (hypertrophic cardiomyopathy) and MVP louder

158
Q

Normal value of urine specific gravity

(a) Possible cause of high urine SG
(b) Possible cause of low urine SG

A

Urine SG normal: 1.002 - 1.030

(a) High urine SG: kidneys are concentrating urine
- dehydration (very severe dehydration indicated by SG > 1.035)

(b) Low urine SG: secreting very dilute urine
- excessive fluid intake, renal failure, diabetes insipidus, acute tubular necrosis

159
Q

PTH, Ca2+, and phosphorus levels seen in

(a) Osteomalacia
(b) Primary hyperparathyroidism
(c) Primary hypoparathyroidism

A

(a) Osteomalacia- most commonly due to vitamin D deficiency
-Low vit D => decreased absorption of Ca and Phos => low Ca stimulates PTH
PTH is high
Ca2+ and phosphorus low
-PTH stimulates urine secretion of phosphorus, exacerbating the problem

(b) Primary hyper-PTH
High PTH
High Ca
Low PO4 (b/c lots excreted in urine)

(c) Primary hypo-PTH
Low PTH
Low Ca
High PO4

160
Q

45 yo F w/ RA on MTX presents w/ left leg swelling, warmth, and tenderness

(a) Dx
(b) Diagnostic test
(c) Tx

A

(a) DVT = deep vein thrombosis

(b) Confirm DVT w/ compression ultrasound
- can be done quickly
- dictates therapy (don’t want to anticoagulate if you don’t see a DVT)

(c) Tx = anticoagulation to prevent PE
- use heparin (over warfarin) b/c acts quickly

161
Q

Typical presentation of AERD (aspirin exacerbated respiratory disease)

A

Suspect aspirin exacerbated respiratory disease in pt w/ asthma, chronic rhinosinusitis (often w/ nasal polyposis) w/ a history of NSAID reaction

162
Q

Diabetic w/ BPH develops erectile dysfunction, what is your next step?

A

BPH pt is probably on an alpha-blocker (Doxazosin), which can’t be combined w/ Sildenafil (PDE5 inhibitor) due to risk of severe hypotension => need to use the lowest dose of both meds and monitor very carefully

163
Q

2 complications of untreated hyperthryoidism

A
  • Bone loss => osteoporosis => increased fracture risk

- Cardiac arrhythmias (ex: AFib)

164
Q

50 yo M w/ history of opioid drug abuse rescued from MVA w/ severe deformity in right thigh and excruciating pain-

Most appropriate choice of analgesic?

A

IV morphine- he’s got acute, severe pain => treated w/ the same standard of pain management regardless of addiction history

165
Q

What is Romberg sign

A

(+) Romberg = when pt stands up and is told to close his/her eyes, they lose balance

-you need 2 of 3 senses (proprioception, vision, vestibular function) to stand up still, so by closing eyes you’re narrowing the etiology to proprioceptive (cerebellar) or vestibular loss (ex: Meniere’s etc)

166
Q

HLA-B27

A

Antigen associated w/ ankylosing spondylitis

167
Q

Neutrophilic vs lymphocytic predominance

A

Neutrophilic predominance- think bacterial

Lymphocytic predominance- think viral

168
Q

Late diastolic murmur w/ opening snap

A

Mitral stenosis

169
Q

64 yo F on tx for AFib develops red blistering lesions on her breast and thigh

(a) Dx
(b) Short term tx
(c) Long term tx

A

(a) Warfarin-induced necrosis
- typically a few weeks after starting warfarin therapy

(b) Short term- administer vitamin K to reduce the effect of warfarin
(c) Long term- use Heparin to maintain anticoagulation while the necrotic lesions heal

170
Q

34 yo F smoker w/ elevated BUN/creatinine and HTN

  • bilateral flank masses
  • UA: 10-12 RBC/HPF

Dx

A

ADPKD = autosomal dominant polycystic kidney disease

-HTN, palpable bilateral masses, microhematuria

171
Q

What does it mean to be a seronegative spondylarthropathy?

A

Seronegative spondyloarthropathy (ex: ankylosing spondylitis) = tests negative for rheumatoid factor

172
Q

Type of gait disturbance caused by Meniere’s disease

A

Meniere’s disease and acute labyrinthitis cause a vestibular unsteady gait, often falling to one side

173
Q

Myasthenia gravis treatment

(a) Symptomatic tx
(b) Next line
(c) Surgery

A

Myasthenia gravis tx

(a) Start w/ acetylcholinesterase inhibitor
(b) Next line: immunosuppression drugs
ex: glucocorticoids
- sometimes plasma exchange, IVIG

(c) Thymectomy in those w/ thymoma

174
Q

Normal PSA value

(a) Abnormal PSA value

A

PSA value considered normal if under 4.0 ng/ml

(a) For most docs anything about 4 they’d suggest a prostate biopsy to determine if cancer is present

175
Q

Myasthenia gravis is associated w/ what cancer?

A

Thymoma- 10-15% of MG pts have thymoma

176
Q

PFT value to differentiate obstructive and restrictive lung disease

A

FEV1/FVC ratio

Obstructive disease: FEV1/FVC under 70%
Restrictive disease: FEV1/FVC over 70%

177
Q

Which murmurs are

(a) Improved
(b) Made louder

by Squatting

A

Squatting increases venous return

  • increases afterload
  • increases regurg fraction

(a) Makes softer: HCM, MVP
(b) Makes louder: AR, MR, VSD

178
Q

How to differentiate hepatorenal syndrome from

(a) Hypovolemia
(b) Intrinsic AKI

A

Hepatorenal syndrome vs.

(a) vs. hypovolumea- hepatorenal syndrome doesn’t respond to fluid resuscitation
(b) Intrinsic AKI- hepatorenal syndrome will have very low Na+ excretion (b/c sensed hypotension activates RAAS system) while intrinsic AKI has > 2-3% FENa

179
Q

What is osteomalacia?

(a) Most common cause
(b) Symptoms

A

Osteomalacia = thinning of bones due to inadequate mineralization, can be due to either calcium or phosphorus nutritional deficiency, or increased bone breakdown

(a) Vitamin D deficiency
(b) Symptoms- bone pain and muscle weakness

180
Q

2 most common organs involved in amyloidosis

A

Kidney and heart
Renal: proteinuria or nephrotic syndrome
Cardiac: signs and symptoms of heart failure

181
Q

65 yo M w/ dysphagia and frequent coughing during meals

  • right sided neck mass that increases in size while drinking fluids
  • change in breath odor

(a) Dx
(b) Pathogenesis (mechanism of disease)

A

(a) Zenker (pharyngoesophageal) diverticulum
Posterior herniation of the fibers of the cricopharyngeal muscle due to

(b) upper esophageal sphincter dysfunction and esophageal dysmotility

182
Q

2 most common organs involved in amyloidosis

A

Kidney and heart
Renal: proteinuria or nephrotic syndrome
Cardiac: signs and symptoms of heart failure

183
Q

PTH

(a) Secreted from where
(b) Activity
(c) Opposing hormone

A

PTH

(a) Secreted by parathyroid glands
(b) Works on bone and kidneys to increase serum calcium
(c) Calcitonin does the opposite

184
Q

What is immune reconstitution syndrome?

A

Paradoxical worsening of a preexisting infectious process following HAART (highly active antiretroviral therapy) initiation

-aka inflammatory process that starts after starting antiretrovirals in an HIV pt

This is why if you diagnose HIV in the setting of an acute infxn, you first start tx for acute infection- wait two weeks then can start antiretrovirals

185
Q

Differentiate Broca’s vs. Wernicke’s aphasia

(a) Main deficit
(b) Location of lesion
(c) Associated finding

A

Broca’s aphasia

(a) Speech is the most affected, comprehension is preserved
(b) Frontal lobe
(c) Associated w/ ipsilateral hemiparesis

Wernicke’s aphasia

(a) Comprehension is diminished, speech is fluent and voluminous but lacks meaning
(b) Lesion in the temporal lobe
(c) Associated w/ ipsilateral superior visual field defect

186
Q

Horner’s syndrome

A

Ipsilateral ptosis (lid droop), miosis (pupil contraction), enopthalmos (inward displacement of eye, opposite of exopthlamus) and anhidrosis (no sweating)

187
Q

Which adrenergic receptor can be manipulated to treat hyperkalemia in a patient w/ EKG changes?

A

Stimulating/activating beta-2 adrenoreceptors

-giving albuterol helps push K+ into cells

188
Q

Name drugs that can cause folate deficiency

A

Anti-epileptics (phenytoin), MTX, trimethoprim- all can cause folate deficiency

189
Q

Long standing complication of RA:

Fetty syndrome

A

AFter 10+ years of RA: Fetty syndrome can arise

-neutropenia and splenomegaly

190
Q

34 yo F presenting w/ dyspnea and severe CP localized to the left side that worsens w/ inspiration

  • 1 episode hemoptysis
  • returned from Central Asia 2 days ago
  • 1 sexual partner, on OCPs
  • PE: tachycardic and tachypnic
A

Pulmonary embolism

  • immobilization, on OCPs
  • occlusion of peripheral pulmonary artery can cause pulmonary infarction => CP and hemoptysis
191
Q

What disease is optic neuritis a common initial feature of?

A

Optic neuritis is often the initial presentation of MS (multiple sclerosis)

192
Q

3 body systems affected in NF2

A

Neurofibromatosis 2 = genetic disorder due to mutation in tsg

  1. neurologic lesions: most commonly bilateral vestibular schwannomas
  2. eye lesions: cataracts etc
  3. skin lesions: cafe au lait spots, cutaneous tumors
193
Q

Mechanism of aspirin-exacerbated respiratory disease

A

Psuedoallergic drug rxn (NOT IgE): arachidonic acid diverted to leukotriene synthesis => exacerbation due to leukotrienes

-seen in pts w/ h/o asthma or chronic rhinosinusitis (often w/ nasal polyps)

194
Q

Erythema nodosum

(a) Two most common causes
(b) EN + hilar lymphadenopathy

A

Erythema nodosum

(a) Many: idiopathic, associated w/ strep pharyngitis
(b) Erythema nodosum + hilar lymphadenopathy = characteristic finding of sarcoidosis

195
Q

Urethritis in male: how to differentiate chlamydia trachomatis vs. neisseria gonorrhea

A

Urethritis in men (aka male w/ UTI)
-most common in neisseria gonorrhea: purulent discharge and gram stain showing gram negative cocci

-chlamydia trachomatis: suspect when gram stain is negative, also mucopurulent discharge

196
Q

Most common features of a pt w/ Churg-Strauss syndrome

(a) How to make the dx of Churg-Strauss

A

Churg-Strauss syndrome = EGPA = eosinophilic granulomatosis w/ polyangitis
-ANCA-associated vasculitis

  • suspect in a pt w/ asthma, recurrent rhinosinusitis, eosinophilia
    (a) Confirm dx by biopsy of lung of affected tissue (skin, peripheral nerve)
197
Q

Cryptococcal meningitis

(a) Bug responsible
(b) How to track response to therapy

A

Cryptococcal meningitis = opportunistic infxn typically in untreated advanced AIDS pts

(a) Caused by meningeal infection by cryptococcus neoformans)
(b) Do serial lumbar puctures- key to keep an eye on ICP
- if ICP gets > 25 cm and stays high for 2+ days w/ symptoms: will need to drain ICF

198
Q

What is osteitis deformans/Paget’s disease of the bone

(a) Lab finding
(b) Ragiographic finding

A

Paget’s disease of the bone = aging bone (seen in pts over 55) due to osteoclast abnormality that causes disorganized bone remodeling

(a) Elevated alkaline phosphatase = marker of bone turnover
(b) Radiographically: see lytic lesions of the bone

199
Q

Describe the disease process of hereditary hemochromatosis

A

Autosomal recessive mutation in HFE gene that basically causes an increase in intestinal iron reabsorption => Fe deposits in tissues- mainly the liver (=> cirrhosis)

200
Q

Classic presentation of ankylosing spondylitis

(a) Physical exam findings

A

Ankylosing spondylitis: 20-40 yo w/ progressive lower back pain and spinal stiffness for more than 3 mo
-pain improves w/ exercise and not w/ rest

(a) On physical exam typically see decreased lumbar spine mobility and tenderness over the SI joints

201
Q

Differentiate condylomata acuminata and condyloma lata

A

Condylomata acuminata = anogenital warts from HPV infection
-verrucous, papilliform, skin-colored

Condyloma lata = genital warts from secondary syphilis
-flattened pink/grey papules on the mucous membrane (not the fleshy part) of the penis)

202
Q

46 yo chronic alcoholic admitted for right hand cellulitis and put on vanco
-arm swelling decreases but he complains of ‘bugs crawling on his skin’, mild hand tremors and diaphoresis

Next step?

A

Dude is in alcohol withdrawal => give him a benzo
-Chlordiazepoxide = Librium = common benzo used to tx alcohol withdrawal

Wouldn’t stop the Vanco- this isn’t red man’s
Wouldn’t start methadone: used for long-acting opioid withdrawal (not acute EtOH)

203
Q

What is myasthenia gravis?

A

Autoimmune d/o of the nmj: antibodies that attack post-synaptic proteins of the nmj, such as acetylocholine receptor

204
Q

Differentiate Parkinsonism from Normal pressure hydrocephalus

A

Parkinsons and NPH can both present w/ progressive memory problems and gait disturbance

  • NPH has traid that also includes urinary incontinence (NPH traid is dementia, urinary incontinence, gait disturbance)
  • also on MRI NPH shows enlarged ventricles
205
Q

Most common cause of foot drop

A

Foot drop = due to weakness in foot dorsiflexion due to L5 radiculopathy of the common peroneal nerve

206
Q

Side effects of thiazide diuretics

A

Orthostatic hypotension, photosensitivity, hypercalcemia

  • orthostatic hypotension due to volume loss
  • hypercalcemia b/c inhibiting reabsorption of Na-K increases Na-Ca symporter => more Ca reabsorbed
207
Q

What is micturition?

(a) Most common in what population
(b) Mechanism

A

Micturition = situational syncope shortly after or during urination

(a) Often middle age or older men- LOC immediately after urinating
(b) Vasovagal response, autonomic dysregulation

208
Q

Symptoms of chronic lead poisoning

A

Fatigue, insomnia, HTN, neuropathy, neuropsychiatric changes, nephropathy

  • muscle pain/weakness
  • easy fatiguability
  • difficulty concentrating
  • elevated creatinine
209
Q

Normal pressure hydrocephalus triad

A

NPH

  1. gait disturbance
  2. dementia
  3. urinary incontinence
210
Q

31 yo F presents w/ periorbital edema and ascites x6 weeks

  • proteinuria and hypoalbuminemia, does well on tx of diuretics and salt restriction
  • shortly after suddenly develops severe right-sided abdominal pain, fever, and gross hematuria
A

Renal vein thrombosis secondary to membraneous glomerulopathy

211
Q

SVC syndrome

(a) Most common cause
(b) Most common symptom
(b) Other symptoms

A

SVC syndrome = SVC obstruction that prevents venous return from face, neck, and arms

(a) 90% of cases caused by malignancy (tumor) that compresses the SVC from outside
(b) Most common symptom = SOB
(b) Edema of the face and arms. Collateral veins develop on the chest wall

212
Q

Most common cause of liver mass, explain why

A

Most common cause of liver mass = liver mets

-liver has dual blood supply => gets mets from colon, pancreas etc

213
Q

Which maneuvers

(a) Improve
(b) Make louder

the murmur of HCM

A

Hypertrophic cardiomyopathy murmur

(a) Improved (decreased murmur intensity) by
Squatting and leg raise- due to increased preload
Hand grip due to increased afterload
(b) Made louder by decreased afterload/preload
-valsava increases murmur intensity
-standing

214
Q

Size of lymph node where biopsy would be indicated

A

LN > 2 cm in diameter

215
Q

75 yo healthy male w/ elevated Alk Phos

A

Paget’s disease of the bone = most common cause of asymptomatic isolated elevation of alkaline phosphatase in elderly pt

Paget’s disease of the bone = osteitis deformans

216
Q

Melanoma vs. melanocystic nevus

A

Melanocystic nevus are noncancerous moles, just a pigmented mole- obey ABCDE

Melanoma = when a mole changes in size, color etc- disobeys ABCDE

217
Q

Side effects of

a) Anti-cytokine DMARDs (ex: TNF-alpha
(b) MTX

A

Side effects of

(a) Anti-TNF = neutropenia, immunosuppression => infections
(b) MTX (anti-metabolite) => mouth sores, alopecia, rash
- pulmonary and hepatic toxicity
- bone marrow suppression

218
Q

Most common cause of folic acid deficiency

A

Nutritional deficiency due to poor diet and/or alcoholism

219
Q

Calcitonin

(a) Secreted from where
(b) Activity

A

Calcitonin

(a) Secreted from C cells (follicular cells) of the thyroid gland
(b) Acts to decrease serum calcium

220
Q

What does a positive Babinski sign indicate

A

Babinski sign = upgoing toe, evidence of hyperreflexia => suggests upper motor neuron lesion (not cerebellar disease)

221
Q

Differentiate 1st, 2nd, and 3rd degree AV block

A

1st degree: delayed transmission from atria to ventricles => PR interval remains prollonged at > 20 sec, but no dropped QRS
-QRS wave is present for every P wave

2nd degree: P:QRS > 1, aka there are dropped QRS but not complete uncoupling
-split into Mobitz type I and II

3rd degree: complete uncoupling of P and QRS waves

222
Q

Blastomycosis vs. coccidioidomycosis

(a) Endemic region
(b) Characteristic presentation

A

Blastomycosis vs. coccidioidomycosis = fungal infections that most commonly present w/ pulmonary manifestations

Blastomycosis

(a) Endemic to Northern US (Wisconsin, Tennessee, great lakes region)
(b) Flu like symptoms (fevers, chills, arthralgia) + characteristic ulcerative skin lesions (verrucous ulcerated skin lesion)

Coccidioidomycosis

(a) SW US- like Texas Arizona Mexico
(b) Self limited acute pneumonia (valley fever) and disseminated disease (coccidiodal meningitis) in immunocompromised

223
Q

54 yo F w/ fatigue, dizziness, and palpitations
-pale conjunctiva, shiny tongue, macrocytic anemia

(a) Dx
(b) Associated cancer

A

(a) Pernicious anemia = autoimmune destruction of intrinsic factor producing cells => B12 deficiency and macrocytic anemia

(b) Associated w/ gastric cancer
- due to chronic atrophic gastritis (inflammation)

Amb Care (13 decks)

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