UWorld 2 Flashcards
1
Q
Common GI comorbidity of asthma
A
30-90% of pts w/ asthma have GERD (aka a lot of overlap)
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
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
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
5
Q
Most common extraskeletal complication of ankylosing spondylitis
A
Anterior uveitis
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
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)
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)
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
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
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
12
Q
Where is ADH made/secreted from?
A
ADH- made by hypothalamus, stored then released from posterior pituitary
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
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)
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
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)
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)
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
19
Q
Pyridostigmine
A
Pyridostigmine = anticholinesterase agent
-used in myasethenia gravis (autoimmune diseaes against post-synpatic ACh receptors)
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)
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
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)
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
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
25
67 yo M LOC after shoveling snow
- increasing DOE
- h/o DM and HLD
(a) Dx
(b) Most likely physical exam finding
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
26
What type of diuretics are most likely to cause sensorineural hearing loss?
Loop diuretics (ex: furosemide) are associated w/ hearing loss
27
Presentation of renal vein thrombosis
RVT presents w/ symptoms of renal infarction: flank pain (may present as abdominal pain), hematuria, can also have fever, elevated LDH
28
Most common cause of cor pulmonale
Cor pulmonale = right heart failure from pulmonary HTN
Most common cause = COPD
29
Coccidioidomycosis
(a) Type of infection
(b) Endemic to which areas
(c) Most common presentation
(d) Tx
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
30
What is EGPA (eosinophilic granulomatosis w/ polyangiitis)?
(a) Initial stage
(b) Common systems involved
(c) Lab test finding
(d) Serious complication
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
31
Presentation of Zenker diverticulum
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
32
What is SVC syndrome?
(a) How to make dx
SVC syndrome = obstruction of the SVC that impedes venous return from the head, neck, and arms
(a) Make dx by CXR
33
Autosomal dominant polycystic kidney disease
(a) Most common extrarenal manifestation
Complications
(b) CNS
(c) Cardiac
(d) GI x2
ADPKD
(a) Most common extrarenal manifestation = liver cysts
Complications
(b) Intracranial aneurysm
(c) Valvular heart disease- mostly MVP
(d) Colonic diverticula and hernias
34
34 yo w/ easy fatiguability, difficulty concentrating, insomnia, right hand weakness, memory loss
- microcytic anemia
- elevated creatinine
- HTN
Lead poisoning in adults (check occupational exposure)
Fatigue, insomnia
HTN
Neuropathy and nephropathy
Neuropsychiatric changes
Microcytic anemia b/c Pb overflow disrupts Hgb synthesis
35
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?
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
36
34 yo w/ isolated thrombocytopenia
(a) First dx
(b) What do you have to rule out
(a) Think ITP (idiopathic thrombocytopenia)
| (b) Have to rule out HIV and Hep C, both of which in chronic infection can cause thrombocytopenia
37
Mechanism of ADH effect on the
(a) kidneys
(b) CV system
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
38
Acoustic neuroma
(a) What is it
(b) Most common presentation
Acoustic neuroma
(a) Nonmalignant tumor of CN VIII
(b) Most commonly presents w/ hearing loss
39
Explain how hyperthryoidism increases risk of fracture
Excess thyroid hormone stimulates osteoclast activity => bone breakdown
40
What do the following indicate?
(a) elevated alkphos
(b) elevated GGT
(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
41
Differentiate Mobitz type 1 and type 2
(a) Location of block
(b) PR interval duration
(c) Probability of progressing to 3rd degree block
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
42
Physical exam findings characteristic of
(a) AR
(b) MS
Physical exam finding of
(a) Aortic regurgitation- capillary pulsations in fingers and lips
(b) Mitral stenosis- late diastolic murmur w/ characteristic opening snap
43
What is an ANCA-associated vasulitis?
(a) Name the 3
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
44
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) Spinal cord compression
| (b) Surgery consult- need to decompress spinal cord ASAP to prevent permanent neurologic dysfunction
45
Tamsulosin
(a) Mechanism
(b) Indication
(a) Tamsulosin = alpha-1-antagonist
| (b) Indication = BPH
46
Anatomic abnormality of HOCM
Asymmetrical hypertrophy of the interventricular septum. Thickened proximal septum narrows the RVOT => obstruction of the outflow tract
47
Aortic stenosis
(a) Murmur
(b) Other physical exam features
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
48
63 yo M presenting w/ anorexia and wt loss x2 mo
+ fecal occult blood
-Ultrasound reveals solitary liver nodule
(a) Dx
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
49
Rapid plasma reagin test
RPR = syphillis test
50
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?
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
51
Pt presents w/ cryptococcal meningitis and is found to have HIV, when do you start the antiretrovirals?
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
52
What type of thyroid nodules are more likely to be malignant?
Hyperfunctioning ('hot') thyroid nodules are rarely malignant, it's the large hypofunctioning ('cold') nodules that cary and increased malignancy risk
53
Associated w/ cerebellar dysfunction
(a) What type of muscle tone
(b) What type of tremor
(c) What type of ataxia
Cerebellar dysfunction
(a) Hypotonia
(b) Intention tremor
(c) Truncal ataxia
-also dysdiacokinesis
54
Indications for at home O2 therapy
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
55
What is sarcoidosis?
(a) Classic presentation
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
56
Give 2 general causes of hyponatremia and how to differentiate them
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
57
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
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
58
What is cardiac tamponade?
Cardiac tamponade = rapidly developing pericardial effusions that impairs cardiac filling
59
Is the risk of renal vein thrombosis higher in nephrotic or nephritic syndrome?
(a) Why?
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
60
Cauda equina syndrome vs. conus medullaris syndrome
(a) Type of pain
(b) Location of numbness
(c) Type of motor weakness
(d) Change in reflexes
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
61
Features of hepatorenal syndrome
(a) Main lab finding
(b) UA results
(c) Sodium excretion
(d) Urine volume
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
62
Describe the overall acid/base problem caused by
(a) Anaphylaxis
(b) Vomiting
(c) Asthma exacerbation
(d) Excessive diuresis
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
63
Name 4 agents that can be used to shift potassium intracellularly
- insulin
- glucose
- albuterol (beta-2 agonist)
- sodium bicarbonate
64
28 yo otherwise healthy pt develops CHF
Think myocarditis- most commonly caused by a viral infection
| -espeically coxsackie B
65
54 yo M w/ facial puffiness, bilateral leg swelling
- Hx: recurrent pulm infxns due to bronchiectasis
- PE: S4, hepatomegaly, palpable kidneys
- 4+ proteinuria
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)
66
Target values for at home O2 therapy
Target: titrate dose until keep SaO2 above 90% at all times (especially when sleeping)
67
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) 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
68
What is amyloidosis?
2 most common types
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
69
What color fever do we have a vaccine for?
What kind of illness is it?
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
70
Treating hyperthyroidism
(a) Acute
(b) Chronic
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
71
Tx for chlamydia
Azithromycin
| -or doxycyclin
72
Acute respiratory acidosis
(a) ABG changes
(b) Expected normal compensation
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
73
Ocular complication of RA and IBD
Episcleritis = inflammation of episclera- thin tissue layer btwn conjunctiva and sclera (CT that forms the white of the eye)
74
Which maneuvers
(a) Improve
(b) Make louder
the murmur of MVP
Mitral valve prolapse murmur
(a) Made softer by squatting
- increases venous return (preload)
(b) Made louder by valsalva and standing
- these decrease preload
75
Which maneuvers
(a) Improve
(b) Make louder
the murmur of VSD
VSD murmur
| a) Improved by valsalva and standing (decrease preload
(b) Made louder by squatting and handgrip (increase afterload)
76
Common cause of nosebleeds during pregnancy
Pyogenic granulomas = benign vascular tumors of the skin or mucous membranes (in this case the nose)
77
Would it take longer to become B12 or folate deficient?
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
78
Best tx for frost-bite injury
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)
79
MPA vs. GPA
(a) Renal features
(b) Pulmonary features
(c) Tx
(d) Association w/ ANCA
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 (+)
80
Fever, tinnitus, and tachypnea in the settings of a drug overdose
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
81
Would negative predictive value or sensitivity change due to prestest probability?
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
82
Spinal tap results differentiating viral and bacterial encephalitis
CSF findings
Vital: lymphocyte predominance, normal glucose
Bacterial: neutrophilic predominance, low glucose
83
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
Ankylosing Spondylitis = chronic spinal inflammatory disease associated w/ radiographic sacroiliitis
84
What medication adjustments will you have to make for a pregnant woman on levothyroxine
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
85
What is diabetes insipidus?
(a) Presentation
(b) Differentiate the two types
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)
86
What is Plummer-Vinson syndrome?
Unknown cause (possibly genetic or nutritional deficiency) of
- Esophageal web => dysphagia, odynophagia
- Fe deficient anemia
- glossitis, chelitis (inflammation of the lipds)
87
Most common presentation of pancoast tumor
Shoulder pain
-often Horner's syndrome
88
What is acalculous cholecystitis?
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
89
Diagnostic tool for ankylosing spondylitis
(a) Characteristic finding
Anklyosing spondylitis- diagnosed by Xray of the sacro-iliac joints
(a) On Xray see fusion of the SI joints and/or bamboo spine
90
Most common adverse effect of inhaled beclomethasone tx
Inhaled beclomethasone = inhaled steroid (asthma tx)
```
Oropharyngeal thrush (oral candidiasis)
-not adrenal suppression or osteoporosis b/c the steroids are not systemically absorbed
```
91
Treatment for cryptococcal meningitis
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
Describe the gait seen in
(a) Basal ganglia lesions
(b) Cerebellar dysfunction
(c) Common peroneal neuropathy
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
How long does a diabetic pt need IV abx for a UTI?
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
Footdrop
(a) Type of gait it results in
(b) Associated signs
(c) Cause
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
Amylase levels
Increased serum amylase is associated w/ pancreatitis
96
2 EKG changes caused by hyperkalemia
Hyperkalemia => QRS prolongation and peaked T waves
97
Myasthenia gravis
(a) Hallmark feature
(b) Most common presenting symptom
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
Describe the gait seen in damage to frontal lobe cortico-cortical white matter tracts
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
Skin-colored, verrucous, papilliform lesion on genitals
HPV
| -most common STD in the US
100
Plummer-Vinson syndrome
(a) Most likely population
(b) Tx
(c) Complication risk
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
Acute respiratory alkalosis
(a) ABG changes
(b) Expected normal compensation
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
2 abx choices for oral tx of UTI
Good PO coverage for E. coli (most common cause of UTI) = fluoroquinolones (ex: ciprofloxacin) and bactrum (TMX-SMP)
103
Bronze diabetes
Buzzword for hereditary hemochromatosis (auto recessive iron overload)
104
Elevated serum alpha-fetoprotein
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
Sarcoidosis
(a) CXR findings
(b) Biopsy results
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
Is DI associated w/ hypo or hyper-natremia?
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
Pt from Arizona/California makes you think of which fungal infection
Coccidioidomycosis
108
54 yo M w/ facial puffiness, bilateral leg swelling
- Hx: recurrent pulm infxns due to bronchiectasis
- PE: S4, hepatomegaly, palpable kidneys
- 4+ proteinuria
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
Differentiate BPH from prostate cancer
(a) Affected part of the prostate
(b) Palpation findings
(c) PSA levels
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
Differentiate the types of paralysis seen in
(a) Lyme's disease
(b) Guillan-Barre Syndrome
(c) Botulism
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
21 yo F w/ fatigue and weakness x 9 mo
- alleviated by rest
- one episode of double vision, difficulty raising eyelids, and swallowing problems
Myasethenia gravis = autoimmune d/o of the nmj
-50% present w/ ocular symptoms: diplopia, ptosis
112
Cause of hepatorenal syndrome
(a) Chronic
(b) Acute
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
Normal value of urine specific gravity
(a) Possible cause of high urine SG
(b) Possible cause of low urine SG
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
F w/ hypothyroidism is going on estrogen pills for unretractable night sweats during menopause
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
Most common inherited kidney disease
Most common inherited kidney disease = ADPKD = autosomal dominant polycystic kidney disease
116
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?'
Negative predictive value
-NOT sensitivity: sensitivity and specificity don't vary w/ pretest probability
117
Describe a magnetic gait
(a) 2 associated syndromes
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
75 yo s/p advanced prostate cancer surgery presenting w/ worsening back pain x3 days
Initial management and dx
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
Describe the mechanism of outflow obstruction seen in HOCM
HOCM outflow obstruction due to
- interventricular septum hypertrophy
- systolic anterior motion of the mitral valve leaflets
120
Associated signs of Parkinsons disease besides shuffling gait
Parkinsonian features
- shuffing gait
- bradykinesia
- resting tremor
- postural instability
- decreased arm swing
121
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
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
IV crystalloids vs. colloid solution
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
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) Pancoast tumor = superior sulcus tumor
Most commonly presents w/ shoulder pain
(b) CXR
124
Acute symptoms of lead poisoning
Abdominal pain and constipaiton
125
Most common tumor seen in NF2
(a) Is it benign or malignant?
Bilateral vestibular schwannoma
vestibular schwannoma = acoustic neuroma
(a) Acoustic neuromas are benign tumors of CN VIII
126
MuSK antibodies
MuSK = muscle specific receptor tyrosine kinase
| -one of the antibodies in myastenia gravis (other one being AChR)
127
Why is HPV dangerous?
-2 reasons
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
Best diagnostic image for an acoustic neuroma
MRI w/ gadolinium (aka constrast)
| -MRI w/ contrast preferred to CT scan for acoustic neuromas (aka vestibular schwannomas)
129
Primary metabolic alkalosis
(a) ABG changes
(b) Expected normal compensation
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
Which type of nephropathy has the highest risk of renal vein thrombosis?
Membraneous glomerulopathy has the highest risk of RVT as a complication
131
BUN:creatinine ratio > 20
| -marginally high electrolytes and Hct
Indicates a state of dehydration
132
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
Ankylosing spondylitis
133
What is hepatorenal syndrome?
(a) Mechanism of kidney injury
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
Name two diseases in which there is subcutaneous nodules
Rheumatoid arthritis and gout
135
Effect of the following on both Mobitz type I and type II AV block
(a) Exercise
(b) Atropine
(c) Vagal maneuver
(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
Bladder cancer
(a) Screening recommendations
(b) Most common presentation
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
Exact criteria for positive bronchodilator response in PFTs
Improvement of FEV1 by 12% or 200 ccs
138
What is the most common organ system involved in graft vs. host reaction?
Skin!!! A skin rash is almost always seen in graft vs. host reaction
139
Describe an ataxic gait
(a) Give a few causes
(b) Some associated signs
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
In addition to hyponatremia, what else would you see in the following
(a) Marked hyperglycemia
(b) Primary polydipsia
(c) CHF
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
Differentiate the cause of polyuria seen in
(a) diabetes mellitus
(b) diabetes insipidus
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
56 yo M post-op day 3 develops fever of 102 and RUQ pain
- leukocytosis
- normal bilirubin, alkphos, LFTs, and amylase
Acalculous cholecysitis = acute gallbladder inflammation in absence of gallstones that develops in critically ill pts often surgery or after prolonged NPO
143
Neurologic deficits expected in vitamin B12 deficiency
Neurologic deficits due to vitamin B12 deficiency
| -loss of proprioception and vibratory sense in the lower extremities => recurrent falls
144
Most common primary liver cancer
(a) Associated conditions
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
Hereditary hemochromatosis
(a) First diagnostic step
(b) To confirm diagnosis
(c) Tx
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
60 yo F w/ previous MI presenting w/ sharp central CP
- pain worsens w/ inspiration and movement
- PE: tenderness to palpation over the sternum
Pain worse w/ inspiration and movement, and reproducable upon palpation, indicates musculoskeletal etiology
ex: Costochondritis
147
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
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
Pansystolic murmur heard best at the apex w/ radiation to the axilla
MR, potentially due to papillary muscle rupture
149
Positive fluorescent treponemal antibody absorption test
FTA-ABS is a confirmatory test for syphilis
150
2 secondary findings that indicate chronic hypercapnia and hypoxemia
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
Which murmurs are
(a) Improved
(b) Made louder
by Handgrip
Handgrip increases afterload
- increases BP
- increases regurg fraction
(a) Makes softer: HCM, AS
(b) Makes louder: AR, MR, VSD
152
Type of ataxia common among chronic alcohol abusers
Cerebellar ataxia
| -cereballar dysunction
153
Classic finding of cardiac tamponade
Pulses paradoxus = more than 10 mmHg drop in systolic BP w/ inspiration
154
Way to decrease side effects of MTX
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
Fibromyalgia tx
(a) First line
(b) First line drug option
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
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
Core pulmonale = right heart failure from pulmonary HTN
| -pulmonary HTN can be idiopathic, or due to COPD, OSA
157
Which murmurs are
(a) Improved
(b) Made louder
by standing
Standing maneuver reduces preload (by decreasing venous return)
(a) Makes all other murmurs softer besides:
(b) Makes HCM (hypertrophic cardiomyopathy) and MVP louder
158
Normal value of urine specific gravity
(a) Possible cause of high urine SG
(b) Possible cause of low urine SG
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
PTH, Ca2+, and phosphorus levels seen in
(a) Osteomalacia
(b) Primary hyperparathyroidism
(c) Primary hypoparathyroidism
(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
45 yo F w/ RA on MTX presents w/ left leg swelling, warmth, and tenderness
(a) Dx
(b) Diagnostic test
(c) Tx
(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
Typical presentation of AERD (aspirin exacerbated respiratory disease)
Suspect aspirin exacerbated respiratory disease in pt w/ asthma, chronic rhinosinusitis (often w/ nasal polyposis) w/ a history of NSAID reaction
162
Diabetic w/ BPH develops erectile dysfunction, what is your next step?
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
2 complications of untreated hyperthryoidism
- Bone loss => osteoporosis => increased fracture risk
| - Cardiac arrhythmias (ex: AFib)
164
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?
IV morphine- he's got acute, severe pain => treated w/ the same standard of pain management regardless of addiction history
165
What is Romberg sign
(+) 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
HLA-B27
Antigen associated w/ ankylosing spondylitis
167
Neutrophilic vs lymphocytic predominance
Neutrophilic predominance- think bacterial
Lymphocytic predominance- think viral
168
Late diastolic murmur w/ opening snap
Mitral stenosis
169
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) 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
34 yo F smoker w/ elevated BUN/creatinine and HTN
- bilateral flank masses
- UA: 10-12 RBC/HPF
Dx
ADPKD = autosomal dominant polycystic kidney disease
| -HTN, palpable bilateral masses, microhematuria
171
What does it mean to be a seronegative spondylarthropathy?
Seronegative spondyloarthropathy (ex: ankylosing spondylitis) = tests negative for rheumatoid factor
172
Type of gait disturbance caused by Meniere's disease
Meniere's disease and acute labyrinthitis cause a vestibular unsteady gait, often falling to one side
173
Myasthenia gravis treatment
(a) Symptomatic tx
(b) Next line
(c) Surgery
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
Normal PSA value
(a) Abnormal PSA value
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
Myasthenia gravis is associated w/ what cancer?
Thymoma- 10-15% of MG pts have thymoma
176
PFT value to differentiate obstructive and restrictive lung disease
FEV1/FVC ratio
Obstructive disease: FEV1/FVC under 70%
Restrictive disease: FEV1/FVC over 70%
177
Which murmurs are
(a) Improved
(b) Made louder
by Squatting
Squatting increases venous return
- increases afterload
- increases regurg fraction
(a) Makes softer: HCM, MVP
(b) Makes louder: AR, MR, VSD
178
How to differentiate hepatorenal syndrome from
(a) Hypovolemia
(b) Intrinsic AKI
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
What is osteomalacia?
(a) Most common cause
(b) Symptoms
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
2 most common organs involved in amyloidosis
Kidney and heart
Renal: proteinuria or nephrotic syndrome
Cardiac: signs and symptoms of heart failure
181
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) Zenker (pharyngoesophageal) diverticulum
Posterior herniation of the fibers of the cricopharyngeal muscle due to
(b) upper esophageal sphincter dysfunction and esophageal dysmotility
182
2 most common organs involved in amyloidosis
Kidney and heart
Renal: proteinuria or nephrotic syndrome
Cardiac: signs and symptoms of heart failure
183
PTH
(a) Secreted from where
(b) Activity
(c) Opposing hormone
PTH
(a) Secreted by parathyroid glands
(b) Works on bone and kidneys to increase serum calcium
(c) Calcitonin does the opposite
184
What is immune reconstitution syndrome?
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
Differentiate Broca's vs. Wernicke's aphasia
(a) Main deficit
(b) Location of lesion
(c) Associated finding
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
Horner's syndrome
Ipsilateral ptosis (lid droop), miosis (pupil contraction), enopthalmos (inward displacement of eye, opposite of exopthlamus) and anhidrosis (no sweating)
187
Which adrenergic receptor can be manipulated to treat hyperkalemia in a patient w/ EKG changes?
Stimulating/activating beta-2 adrenoreceptors
| -giving albuterol helps push K+ into cells
188
Name drugs that can cause folate deficiency
Anti-epileptics (phenytoin), MTX, trimethoprim- all can cause folate deficiency
189
Long standing complication of RA:
Fetty syndrome
AFter 10+ years of RA: Fetty syndrome can arise
| -neutropenia and splenomegaly
190
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
Pulmonary embolism
- immobilization, on OCPs
- occlusion of peripheral pulmonary artery can cause pulmonary infarction => CP and hemoptysis
191
What disease is optic neuritis a common initial feature of?
Optic neuritis is often the initial presentation of MS (multiple sclerosis)
192
3 body systems affected in NF2
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
Mechanism of aspirin-exacerbated respiratory disease
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
Erythema nodosum
(a) Two most common causes
(b) EN + hilar lymphadenopathy
Erythema nodosum
(a) Many: idiopathic, associated w/ strep pharyngitis
(b) Erythema nodosum + hilar lymphadenopathy = characteristic finding of sarcoidosis
195
Urethritis in male: how to differentiate chlamydia trachomatis vs. neisseria gonorrhea
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
Most common features of a pt w/ Churg-Strauss syndrome
(a) How to make the dx of Churg-Strauss
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
Cryptococcal meningitis
(a) Bug responsible
(b) How to track response to therapy
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
What is osteitis deformans/Paget's disease of the bone
(a) Lab finding
(b) Ragiographic finding
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
Describe the disease process of hereditary hemochromatosis
Autosomal recessive mutation in HFE gene that basically causes an increase in intestinal iron reabsorption => Fe deposits in tissues- mainly the liver (=> cirrhosis)
200
Classic presentation of ankylosing spondylitis
(a) Physical exam findings
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
Differentiate condylomata acuminata and condyloma lata
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
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?
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
What is myasthenia gravis?
Autoimmune d/o of the nmj: antibodies that attack post-synaptic proteins of the nmj, such as acetylocholine receptor
204
Differentiate Parkinsonism from Normal pressure hydrocephalus
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
Most common cause of foot drop
Foot drop = due to weakness in foot dorsiflexion due to L5 radiculopathy of the common peroneal nerve
206
Side effects of thiazide diuretics
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
What is micturition?
(a) Most common in what population
(b) Mechanism
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
Symptoms of chronic lead poisoning
Fatigue, insomnia, HTN, neuropathy, neuropsychiatric changes, nephropathy
- muscle pain/weakness
- easy fatiguability
- difficulty concentrating
- elevated creatinine
209
Normal pressure hydrocephalus triad
NPH
1. gait disturbance
2. dementia
3. urinary incontinence
210
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
Renal vein thrombosis secondary to membraneous glomerulopathy
211
SVC syndrome
(a) Most common cause
(b) Most common symptom
(b) Other symptoms
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
Most common cause of liver mass, explain why
Most common cause of liver mass = liver mets
| -liver has dual blood supply => gets mets from colon, pancreas etc
213
Which maneuvers
(a) Improve
(b) Make louder
the murmur of HCM
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
Size of lymph node where biopsy would be indicated
LN > 2 cm in diameter
215
75 yo healthy male w/ elevated Alk Phos
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
Melanoma vs. melanocystic nevus
Melanocystic nevus are noncancerous moles, just a pigmented mole- obey ABCDE
Melanoma = when a mole changes in size, color etc- disobeys ABCDE
217
Side effects of
| a) Anti-cytokine DMARDs (ex: TNF-alpha
(b) MTX
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
Most common cause of folic acid deficiency
Nutritional deficiency due to poor diet and/or alcoholism
219
Calcitonin
(a) Secreted from where
(b) Activity
Calcitonin
(a) Secreted from C cells (follicular cells) of the thyroid gland
(b) Acts to decrease serum calcium
220
What does a positive Babinski sign indicate
Babinski sign = upgoing toe, evidence of hyperreflexia => suggests upper motor neuron lesion (not cerebellar disease)
221
Differentiate 1st, 2nd, and 3rd degree AV block
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
Blastomycosis vs. coccidioidomycosis
(a) Endemic region
(b) Characteristic presentation
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
54 yo F w/ fatigue, dizziness, and palpitations
-pale conjunctiva, shiny tongue, macrocytic anemia
(a) Dx
(b) Associated cancer
(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)
