UWorld 3 Flashcards

1
Q

Clinical findings of cholecystitis and choledocholithiasis

A

Obstruction of bile duct causing inflammation of gall bladder (cholecystitis)
-biliary colic = intermittent RUQ pain

vs. obstruction of common bile duct (choledocho…)
- obstructive jaundice => severe icterus and high Alk phos

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2
Q

What drugs besides NSAIDs and triptans can be used as tx for acute migraine headaches

A

IV antiemetics such as chlorpromazine, prochlorperazine, or metoclopramide

D2 receptor antagonist

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3
Q

What is endophthalmitis?

(a) Biggest predisposing factor

A

Endophthalmitis = inflammation of the internal coats of the eye

(a) Most common after intraocular (cataracts) surgery

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4
Q

36 yo M from Wisconsin presents w/ warty, heaped up skin lesions w/ violaceous hue and sharply demarcated border

  • dry cough and mild malaise
  • wet prep shows yeast

(a) Dx
(b) Tx

A

(a) Blastomycosis- disseminated disease can even occur in immunocompromised
- S/S-central US states
- usually lung, but outside the lung most commonly goes to skin: wartlike lesions, violaceous, skin ulcers

(b) Tx = oral itraconazole in mild disease
- if disease is very severe: IV amphotericin B

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5
Q

Pt presents w/ spinal cord injury due to MVA
2 large-bored IV lines are in place
-CT scans of abdomen and spine are scheduled

Next steop?

A

Urinary catheter- assess for urinary retention, prevent acute bladder distention and damage

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6
Q

Abx of choice for

(a) sinusitis
(b) Moraxella and pneumococcus
(c) aspiration pneumonia
(d) nosocomial pneumonia

A

Abx of choice for

(a) Sinusitis = Augmentin (amox/clavulanate)
(b) Ceftriaxone
(c) Clindamycin is good for anaerobes => abx of choice in aspiration pneumonia
(d) Vanco for nosocomal pneumonia, where probability of MRSA is higher

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7
Q

67 yo F w/ acute onset of severe orthopnea and dyspnea
-3rd heart sound, bilateral crackles, SpO2 98% on 40% inspired O2 => intubated and given nitrates and diuretics

Afterwards, breath sounds on left side are markedly decreased

(a) How to restore breath sounds to left hemithorax?

A

Rather complication of intubation to go down the right mainstem bronchus, instead of sitting right above the carina =>

(a) Restore breath sounds to left hemithorax by repositioning the endotracheal tube to btwn the carina and vocal cords

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8
Q

68 yo 5 day post-op M presents w/ new-onset abdominal pain

  • spontaenous voiding of 200 ml of urine
  • new BUN and creatinine elevation

Next steps

A

Post-op urinary retention is a common complication of surgery and anesthesia => first assess bladder volume w/ portable scan

If portable scan is inconclusive, foley cath: important to restore normal urine output and resolve or prevent hydronephrosis, tubular atrophy, and renal injury

-if catheterization doesn’t relieve the oliguria, AKI may be pre-renal or intrinsic in etiology

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9
Q

Clinical significance of urinary 5-hydroxyindoleacetic acid excretion

A

5-HIAA = metabolic of serotonin

Elevated urinary excretion can indicate carcinoid tumor (neuroendocrine tumor usually in the small intestines)

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10
Q

What lab finding is crazy elevated in Zollinger-Ellison syndrome?

A

Markedly elevated serum gastrin (>1,000 pg/ml)

-well duh the syndrome is due to a gastrin-producing tumor

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11
Q

Describe the extrahepatic sequelae of Hep C

(a) Heme
(b) Renal
(c) Skin x2
(d) Endocrine

A

(a) Heme = essential mixed cryoglobulinemia
- immune deposition in BVs

(b) Renal = MPGN
(c) Skin: porphyria cutanea tarda (fragile skin, vesicles and erosions on dorsum of hands, photosensitivity), lichen planus (purple itchy flat-topped papules)
(d) Endocrine- increased risk of diabetes

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12
Q

Purpose of abdominal fat pad biopsy

A

To test for amyloidosis

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13
Q

Xanthochromia

A

Xanthochromia = yellow discoloration of the CSF due to the presence of bilirubin

-suggestive of SAH

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14
Q

44 yo G3P3 w/ intermenstrual bleeding and heavy menses.
BMI of 40
When would you use

(a) Low dose estrogen-progestin contraceptives
(b) Progestin therapy
(b) Hysterectomy

A

PTs w/ abnormal uterine bleeding should undergo endometrial biopsy to evaluate for hyperplasia vs. cancer

(a) Woudn’t use combined low-dose estrogen/progesterone therapy in obese pt- increased risk for venous thromboembolism

Next step = do endometrial biopsy

(b) If biopsy shows hyperplasia w/o atypia => tx is progestin therapy
(c) If biopsy shows hyperplasia w/ atypia => hysterectomy

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15
Q

First line medication tx for HOCM and how they help

A

HOCM first line = beta-blockers, and CCB if pt can’t tolerate beta-blockers

Beta-blockers help by slowing the HR => prolonging diastole => ventricles have more time to fill

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16
Q

Describe the following findings in aortic regurgitation

(a) BP finding
(b) Pounding sensation and uncomfortable awareness of heartbeat, espeically in left lateral decubitus position

A

Aortic regurgitation

(a) BP finding = widened pulse pressure (ex: 150/45)
(b) portion of the LV outleaks back into the LV => increase in LVEDV, myocardial hypertrophy, chamber enlargement
- LV enlargement brings the ventricular apex closer to the chest wall => pounding sensation and awareness of heart beat

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17
Q

35 yo M w/ nocturnal wheezing and chest tightness x3 mo

  • new hoarseness
  • non smoker
  • chest CTA
  • laryngoscope: red and inflamed posterior pharynx and larynx

(a) Dx
(b) Tx

A

Tx = omeprazole

GERD is present in 75% of pts w/ asthma, and is often the primary trigger for asthma
asthma in adulthood: worse after meals, exercise, or lying down (nocturnal asthma)

Adult w/ new onset asthma should always be questioned regarding reflux symptoms

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18
Q

First line tx for chemotherapy-induced nausea and vomiting

A

Ondansetron (Zofran) = Serotonin receptor antagonist: targets the 5HT3 receptor

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19
Q

3 choices for inpatient coverage of pseudomonas

A
  1. zosyn (piperacillin/tazobactam)
  2. meropenem
  3. cefepime
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20
Q

Endomysal and tissue transglutaminase IgA antibody are found in what disease?

A

Celiac disease

-pts typically present under 40 yoa w/ diarrhea, foul-smelling stools, flatulence

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21
Q

Hallmark triad of trichinellosis

A

Trichellosis = GI complaints followed by characteristic triad: periorbital edema, myositis, eosinophilia

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22
Q

Common comorbidity of carpel tunnel syndrome

A

Carpel tunnel and hypothyroidism often co-occur, carpel tunnel syndrome is present in about 30% of pts that have hypothyroidism

Carpel tunnel symptoms often improve if hypothyroidism is treated

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23
Q

Bence Jones protein

A

Paraproteins (abnormal antibodies) produced in multiple myeloma (plasma cell cancer) that deposits and causes renal insufficiency

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24
Q

Differentiate types of therapy:

Adjuvant
Neoadjuvant
Salvage

A

Types of therapy: (using example of radiation to treat re-elevated PSA after radical prostatectomy)

Adjuvant = additional therapy given at the same time as the standard therapy
-if the radiation was given at the same time as the surgery

Neoadjuvant = tx given before the standard tx
ex: radiation before doing the radical prostatectomy

Salvage = tx given when standard therapy fails

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25
Q

Differentiate lupus and RA type arthritis

A

Both Lupus arthritis and RA most commonly affect the metacarpophalangeal (MCP) and proximal interphalagneal (PIP) joints, but lupus arthritis is not deformign (while RA is)

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26
Q

63 yo M w/ fever and left-sided scrotal pain x2 radiating to the flank days

  • urinary frequency and urgency w/ dysuria
  • tender prostate
  • leukocytosis
  • UA: bacteriuria and pyuria
A

Acute epididymitis = fever, painful enlargement of testes, irritative voiding symptoms

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27
Q

Effect of the following drugs on kidney function

(a) IV acyclovir
(b) MTX
(c) Beta-lactam abx
(d) PPIs

A

(a,b) IV acyclovir, methotrexate- can cause crystal-induced acute kidney injury
-rapidly excreted into urine but the drug has low urine solubility => readily precipitates and obstructs the renal tubules

(c,d) Beta-lactams (penicillin, amox, cephalosporins) and PPIs can cause AIN (acute interstitial nephritis)

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28
Q

57 yo M returned from cruise to the Bahamas w/ fever, nonproductive cough, SOB x 2 days

  • HA, abd pain, diarrhea x1 day
  • 102.6 F
  • crackles bilaterally, bilateral interstitial infiltrates
  • confused
A

Legionella pneumonia
-typical to have history of travel
High fever, GI and neurologic symptoms differentiate from other community acquired pneumonia

=> tx w/ levofloxacin

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29
Q

Mechanism of ascites in

(a) Portal HTN
(b) Malignant ascites

A

Mechanism of ascites in

(a) Portal HTN = increased capillary hydrostatic pressure
(b) Malignant ascites (aka ascites caused by cancer)= increased capillary permeability

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30
Q

56 yo M w/ intermittent dizziness x2 weeks

  • brief spinning when turning over in bed
  • II/VI ejection murmur at LSB
  • precordial palpation and carotid upstroke are normal
  • normal EKG findings

Dx?

A

BPPV = benign paroxysmal positional vertigo: brief episodes often predictably occurring w/ certain movements or position changes

AS suggesed by murmur, but no pulses parvus et tardus (as expected in AS)

Not Meniere’s b/c that comes w/ unilateral hearing loss and tinnitus

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31
Q

Vaccines recommended for adults w/ HIV

A

HepA, HepB, Pneumococcus (PCV13 once then PPSV23 8 weeks later then once every 5 yrs), Tdap, anual flu

  • HPV if btwn 9-26
  • meningococcus if large group in close proximity (college, jail, military)

Live vaccines contraindcated if CD4 count is under 200
-so now MMR, VZV

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32
Q

Guidelines for colonoscopy screening for pts w/

(a) Family history of adenomatous polyps
(b) Family history of CRC
(c) Ulcerative colitis
(d) Chron colitis
(e) FAP
(f) HNPCC/Lynch

A

Colonoscopy guidelines

(a,b) FHx of adenomatous polyps or CRC- begin at age 40 or 10 yrs before index case, repeat every 3-5 years
(c, d) IBD: begin 8 years post diagnosis (12-15 yrs if disease in only left colon), repeat every 1-2 years

(e) FAP: annually starting at age 10-12
(f) Lynch: every 1-2 yrs starting at age 20-25

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33
Q

45 yo M w/ sudden onset skin and oral lesions w/ fever after starting batrum 5 days ago

Erythema, blistering, ulceration of oral mucosa
Erythematous rash w/ scattered involvement on trunk, hands, arms, feet

A

Stevens-Johnson- from bactrum

SJS denotes less than 10% of body surface area involvement, vs over 30 = TEN (toxic epidermal necrolysis)

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34
Q

63 yo Asian F presents w/ severe right-sided HA x2 hrs
+ 1 episode vomit
-seeing “halos” around lights
-on Bactrum for UTI
-mother has hx of migranes
-Nonreactive, dilated r. pupil and erythematous r. eye w/ excessive lacrimation and decreased visual acuity
-elevated sed rate

A

Acute angle-closure glaucoma = sudden narrowing or closure of the anterior chamber angle

  • affected eye: severe pain, dilated pupil w/ poor response to light, vision loss
  • HA, N, V
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35
Q

Describe how exogenous progestin would affect the endometrium

A

Potent progestin given to treat abnormal uterine bleeding when endometrial biopsy shows hyperplasia w/o atypia b/c it will stop the effect of unopposed estrogen and reverse endometrial hyperlasia

-progestin activates progesterone receptors in the endometrium => decidualization of the stroma and thinning of endometrium

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36
Q

55 yo F presents w/ one week of pain in multiple joints

  • worse in morning and takes 10-15 minutes before she regains her dexterity
  • no swelling or tenderness on exam
  • normal ESR

(a) Dx
(b) Etiology

A

Viral arthritis due to parvovirus B19- presents w/ acute onset of polyarticular and symmetric arthritis

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37
Q

Describe the cause of the following in scleroderma pts

(a) Right heart failure
(b) GERD
(c) Renal dysfunction
(d) Skin findings

A

Scleroderma- CT thickening due to myofibroblast proliferation => increased collagen and ground substance production

(a) Pulmonary HTN => r. heart failure
(b) GERD due to esophageal and gastric dysmotility
(c) Thickening in tubular structures => hypertension
- before ACEi were invented, renal crisis was the most common cause of death in scleroderma pts
(d) Skin finding: “mask-like” face due to dermal thickening, thickening of skin of hands and feet => flexion contractures. Raynaud phenomenon and calcinosis

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38
Q

What is it called when there is herpes on the finger?

A

Herpetic whitlow- about 14% of adults w/ it are healthcare workers (ex: dentists) b/c can be caused by direct contact w/ infected secretions

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39
Q

Confounding vs. effect modification

ex: alcohol use –> bladder cancer, smoking
ex: OCP –> breast cancer, family hx of breast cancer

A

Confounder = extraneous factor that is associated w/ both the exposure and the disease

Effect modification = external variable directly impacts the effect of a risk factor on the disease of interest

ex: alcohol use and its association w/ bladder cancer is confounded by smoking (smoking associated w/ both, but alcohol use and bladder cancer when stratified btwn smokers and non-smokers are not associated)
ex: OCP use associated w/ breast cancer, effect modified by family history of breast cance

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40
Q

72 yo w/ sudden onset non-productive cough, fever, malaise, runny nose, severe body aches
-spO2 88% on room air
-diffuse crackles w/ occasional wheeze
CXR: diffuse interstitial infiltrates b/l

(a) Dx
(b) Tx

A

(a) Influenza pneumonia: abrupt onset fever, chills, malaise, myalgias, cough, coryza
- febrile w/ variety of pulmonary findings

(b) Start antivirals w/in 48 hrs to be effective
Oseltamivir and zanamivir = neuraminidase inhibitors

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41
Q

Elderly pt w/ bone pain, renal failure, and hypercalcemia

A

Multiple myeloma until proven otherwise

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42
Q

Strongest predictor of abdominal aortic aneurysm explansion

A

Current smoking

-NOT uncontrolled HTN

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43
Q

50 yo M presents w/ acute onset of respiratory difficulty
-periorbital, circumoral, facial edema
-2 weeks s/p stent in RCA
On aspirin, clopidogrel, metoprolol, enalapril, simvastatin, isosorbide mononitrate
^Which drug most likely caused his symptoms

A

Angioedema = ACEi = Enalapril

-angiogedema from ACEi can occur at anytime, not just w/in weeks of starting the medication

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44
Q

17 yo M in MVA in a coma. 4 weeks after initial injury he develops nausea, polyuria
serum Ca 12.1
serum albumin 3.0
TPH 9 (low)

What is the cause of his hypercalcemia?

A

Hypercalcemia due to immobilization- median onset about 4 weeks after immobilization due to balance btwn magnitude of bone turnover and renal calcium excretion

-pts w/ chronic renal insufficiency may develop hypercalcemia earlier

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45
Q

Clinical presentation of multiple myeloma: CRAB

A
CRAB: 
Calcium (hyper)
Renal failure- 50% of multiple myeloma pts develop some degree of renal insufficiency
Anemia
Bone lesions
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46
Q

Drug given for acne that can cause photosensitivty reaction

A

Most common = tetracyclines

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47
Q

Development of digital clubbing and sudden-onset joint arthropathy in a chronic smoker

A

Suggestive of hypertrophic osteoarthropathy- subset of which can be attributable to underlying lung disease (ex: lung cancer, COPD)

-presents w/ digital clubbing w/ sudden onset arthropathy most commonly affecting wrist and hand joints

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48
Q

33 yo presenting w/ TC seizure afetr IV cocaine/heroin use

  • no post-ictal state but complains of muscle pain
  • crazy high CPK, AST, ALT

(a) Dx
(b) Acute tx

A

(a) Rhabdomyolysis and seizure after simultaneous use of cocaine and heroin (= speedball)
- cocaine and opiates both predispose to seizures
- cocaine can lead to rhabdo

Muscle breakdown can => myoglobinuria => renal failure =>

(b) Initial tx w/ aggressive fluid resuscitation to treat rhabdo and prevent renal failure

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49
Q

38 yo w/ progressive SOB and productive cough x6 mo, worse w/ exertion

  • previous soker
  • breath sounds decreased at the bases, no crackles or wheezes
  • CXR: bilateral basilar lucency
  • normal CBC and BMP

(a) Next step for dx
(b) How to differentiate this from COPD

A

(a) Test for alpha-1 antitrypsin deficiency: chronic SOB, productive cough, and evidence of destruction of the lower lobes (key here is lower lobes)
(b) COPD presents w/ more disease in the upper lobes and at older age

Alpha-1 antitrypsin: smokers present in their 30s, a decade earlier than non-smokers
-can confirm dx w/ serum alpha-1 antitrypsin levels

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50
Q

Noncontrast head CT showing hyperdense signal in a cistern

A

Cisterns = subarachnoid space that fill up w/ blood (hyperdense/bright signal on noncontrast CT) due to an SAH

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51
Q

Lab indication of pre-renal azotemia

A

BUN:creatinine > 20:1 indicates pre-renal azotemia

-usually due to volume depletion causing hypoperfusion of the kidneys

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52
Q

Febrile pt w/ new soft systolic crescendo-decrescendo murmur at LSB

A

Fever induces a hyperdynamic state, during which an audible flow murmur may be heard
-hyperkinetic flow murmur due to fever

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53
Q

2 manifestations of alpha-1 antitrypsin deficiency

A

Liver and lung involvement due to deposition of abnormal A1AT protein

lung involvement: COPD or severe panacinar emphysema

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54
Q

Describe how a pulmonary embolism can alter calcium homeostasis

A

PE => tachypnea => blowing off tons of CO2 = respiratory alkalosis

Due to respiratory alkalosis H+ dissociates from albumin => increasing albumin affinity for Ca2+ => increase in Ca2+ bound to albumin and decrease in serum ionized (active) calcium

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55
Q

What dose tracheal deviation indicate?

A

Associated w/ tension pneumothorax

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56
Q

Most common cause of primary adrenal insufficiency in

(a) developing countries
(b) developed countries

A

Primary adrenal insufficiency

(a) Developed countries- adrenal tuberculosis
(b) Developed countries- autoimmune adrenalitis

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57
Q

2 antibodies present in scleroderma

A

Antinuclear and anti-topoisomerase I antibodies

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58
Q

Specifically where are bile acids reabsorbed

A

In the ileum => get decreased bile acid reabsorption if have extensive ileal resection (ex: secondary to Crohn’s)

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59
Q

Clinical presentation of craniopharyngioma

A

Craniopharyngioma = sellar mass (benign tumor arising from Rathke’s pouch)

Compresses on optic nerve => bitemporal hemianopsia

  • headache
  • hormonal deficiency (b/c impacts pituitary)
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60
Q

Name some causes of acute nephritic syndrome

A

Glomerular damage due to

  • post strep GN
  • IgA nephropathy
  • lupus nephritis
  • MPGN
  • RPGN
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61
Q

AIDS pts should be on what prophylactic meds once their CD4+ count drops below

(a) 200
(b) 150
(c) 100
(d) 50

A

Once CD4+ count drops below

(a) 200: bactrum for pneumocystis jirovecii
(b) 150: Itraconazole (antifungal) for histoplasma capsulatum
(c) Under 100: batrum for toxoplasma gondii
(d) Under 50: Azithromycin (or clarithromycin) for MAC (mycobacterium avium complex)

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62
Q

76 yo M w/ stiffness in pelvis and shoulders w/ elevated ESR

(a) Dx
(b) Associated disease

A

(a) Polymyalgia rheumatica = pain/stiffness in shoulders, neck, hips/pelvis
(b) Associated w/ temporal arteritis
- have to have elevated ESR

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63
Q

52 yo F w/ gradualonset weakness in leg muscles

  • difficulty climbing stairs and rising from a chair
  • mild weakness of thigh muscles b/l w/o tenderness

(a) Dx
(b) Test for dx

A

(a) Polymyositis = idiopathic inflammatory muscle disease
Characteristically presents w/ progressive LE proximal weakness
-proximal arm weakness usually follows => difficulty combing hair or working w/ hands
-pts may develop dysphagia

(b) Muscle biopsy

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64
Q

How to prevent bone loss due to prolonged immobilization

A

Hydration and bisphosphonates- prevent bone loss (and therefore hypercalcemia) due to immobilization

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65
Q

32 yo F w/ h/o advanced Chrons diesease presents w/ LE paresthesias and difficulty balancing

  • tingling in feet
  • macrocytic anemia
A

Vitamin B12 deficiency due to chronic malabsorption from Crohn

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66
Q

Typical presentation of rabies

A

Motor weakness, paresthesias, encephalitis that can acutely progress to coma/death

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67
Q

Typical presentation of uveitis

A

Uveitis = inflammation of uvea (middle layer of the eye), presents w/ blurred vision + moderate pain, conjunctival injection, and constricted pupils

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68
Q

Describe how Risperidone can cause breast tenderness and milky-white discharge from both nipples

A

Risperidone = dopamine and serotonin antagonist

-inhibiting dopamine => elevated serum prolactin => amenorrhea and galactorrhea

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69
Q

What is Addison’s disease

(a) Tx

A

Addison’s disease = autoimmune cause of primary adrenal insufficiency

(a) Hydrocortisone

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70
Q

Zolendronic acid indications

A

= Zolendronate = IV bisphosphonate

  1. Annual injection for osteoporosis
  2. One time injection for tx of Paget’s disease
  3. Prevent fractures in cancers (multiple myeloma and prostate cancer), tx hypercalcemia or malignancy, can help w/ pain from bone mets
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71
Q

Most common cancer of the lip

A

Squamous cell carcinoma

-sun exposure

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72
Q

3 symptoms to help distinguish atypical Legionella pneumonia from other causes of community-acquired pneumonia

A
  • High-grade fever (>102.2)
  • GI symptoms
  • neurologic symptoms: confusion, ataxia
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73
Q

63 yo F w/ ho HTN that collapses in church after severe CP that radiated to her back

  • lungs clear
  • variation of SBP during respiratory cycle
  • CXR: widening of mediastinum
A

Tearing CP radiating to back = acute aortic dissection

Common complication of acute aortic dissection = cardiac tamponade = pericardial fluid accumulation

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74
Q

Most common cause of necrotizing fasciitis- mechanism wise

(a) Most common causative organism

A

Generally caused by trauma, can result from significant peripheral vascular disease

(a) Usually polymicrobial, most frequently recovered pathogen is GAS

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75
Q

Classic physical exam findings of cardiac tamponade

A

Classic triad of distant heart sounds, hypotension, and distended neck veins

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76
Q

Amantadine

(a) Indications
(b) Side effects

A

Amantadine: mechanism not fully understood, possibly NMDA inhibition and some dopamine activity

(a) Antiviral, anti-Parkinsonian agent and treat EPS of antipsychotics
(b) Livedo reticularis and ankle edema

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77
Q

Tinea corporis vs. tinea versicolor

A

Tinea corporis = body ringworm- ring-shaped lesion w/ advancing scaly border and central clearing

Tinea versicolor- hyper or hypo pigmented macules, skin flora that grows in exposure to hot and humid weather
-involved areas never tan

-both fungal

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78
Q

Describe the possible danger of supplemental O2 in pts w/ advanced COPD

A

Supplemental O2 can worsen hypercapnia in advanced COPD pts due to

  • increased dead space perfusion => V/Q mismatch
  • decreased affinity of oxyHgb for CO2
  • reduction in alveolar ventilation

This CO2 retention can cause stroke and neurologic symptoms

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79
Q

Indications for surgical repair of aortic aneurysm

A

Aneurysm > 5.5cm, rapid rate of aneurysm expansion, presence of symptoms (abdominal, back, or flank pain; limb ischemia)

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80
Q

What rare diagnosis to suspect when newly diagnosed diabetic presents w/ erythematous papules on face, extremities, diarrhea, anemia, and wt loss

A

Glucagonoma
-confirm dx w/ glucagon > 500

Typically mild and diet or oral-agent controlled diabetes (doesn’t require insulin)
GI symptoms:
General symptoms: wt loss, neuropsychiatric

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81
Q

50 yo w/ worsening jaundice, anorexia, RUQ pain x3 days
-scleral icterus and tender hepatomegaly

LFT: 
Alk phos 120
AST 212
ALT 99
Amylase 91

Dx

A

Alcohol hepatitis

  • AST:ALT ratio over 2
  • leukocytosis
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82
Q

44 yo w/ severe epigastric pain radiating to the back

  • Amylase 2610 (crazy high)
  • AST 133 ALT 172 Alkpho 271

(a) Dx?
(b) Next step?

A

(a) Dx = acute pancreatitis

(b) Next step = RUQ ultrasound
- ultrasound is better for detecting gallstones than CT scan
- 2 most common causes of acute pancreatitis = gallstones and EtOH, she doesn’t drink so think gallstones until proven otherwise

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83
Q

Describe the predominant mechanism of HF in HOCM

A

Primarily diastolic heart failure => impaired ventricular filling and outflow obstruction
(inability of myocardium to properly relax)

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84
Q

2 most common causes of acute pancreatitis

A

Chronic alcoholic use and gallstones

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85
Q

What is Whipple disease?

(a) Most common presenting symptoms

A

(a) Whipple disease = multisystem d/o caused by gram-positive bacillus Tropheryma whippeli
(b) Most common presenting symptoms: chronic malabsorptive diarrhea, wt loss, migratory non-deforming arthritis, lymphadenopathy, low grade fever

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86
Q

Splenectomy

(a) What vaccines to be given
(b) Prophylactic abx protocol

A

(a) Several weeks before splenectomy pt should get anti-pneumococcal, Haemophilius, and meningococcal vaccines
(b) daily oral penicilin prophylaxis for 3-5 years following splenectomy

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87
Q

Clinical signs to distinguish lower leg DVT vs. cellulitis

A

Common in that they present w/ swelling, fever, erythema, and warmth

Cellulitis: higher fever, presence of regional lymphadenopathy

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88
Q

38 yo Mexican M presents w/ wt loss, fever, productive cough x 3 mo
CT scab revealed calcification of both adrenal glands

(a) Dx
(b) Cause of adrenocortical insufficiency

A

Tuberculosis- most common cause of primary adrenal insufficiency in developing countries

-adrenal calcification = typical feature of adrenal TB

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89
Q

34 yo F w/ fatigue for several months

  • difficulty combing hair
  • afebrile, HR 115
  • anxiety, irritability, unintentional 8 lb wt loss over 2 mo
  • fine finger tremor
  • decreased shoulder muscle mass
  • normal DTRs

Cause of pt’s symptoms

A

Symptoms suggest proximal muscle weakness like myopathy, then w/ fatigue anxiety tremor wt loss and tachycardia = hyperthyroidism

Would be an inflammatory muscle disease (myositis) but that wouldn’t account for the other symptoms => acute thyrotoxic myopathy

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90
Q

25 yo HIV pt w/ HA and left sided weakness, febrile to 100.8
CT: multiple ring-enhancing lesions

Dx?

A

Cerebral toxoplasmosis => tx w/ sulfadiazine and pyrimethamine

91
Q

Symptoms of chronic Hep C

A

Can be asymptomatic or have some nonspecific symptoms (arthralgias, myalgias, fatigue), pts usually have waxing and waning elevations in transaminases

92
Q

Bradycardia w/ sine wave pattern on EKG

A

Hyperkalemia: wide-complex rhythm at 32 bpm w/o P waves

93
Q

Reed Sternberg cells

A

= type of giant cells seen in lymph node biopsy of Hodgkin’s lymphoma

Pathognomonic for Hodgkin’s disease

94
Q

45 yo M w/ several months of easy fatiguability and DOE

  • 5 yrs s/p subtotal gastrectomy for nonhealing gastric ulcer
  • shiny tongue and pale palmar creases

Mechanism of fatigue

A

Macrocytic anemia due to B12 deficiency (probably due to the gastric resection in this case)
-glossitis

B12 deficiency causes anemia by defective DNA synthesis (B12 is a necessary cofactor for purine synthesis)

95
Q

65 yo 90-pack-year smoking history w/ blood in urine

-otherwise asymptomatic

A

Bladder cancer = most common neoplastic cause of painless hematuria

96
Q

34 yo M recently returned from S. America presenting w/ 4 weeks of diarrhea, foul-smelling stools, abdominal cramps, and bloating

(a) Dx
(b) Tx

A

Giardiasis: foul-smelling stools, bloating, >2 weeks of diarrhea

(b) Tx = metronidazole (flagil)

97
Q

44 yo M w/ new dx of gastric mucosa-associated lymphoid tissue (MALT) lymphoma of the pylorus
-no LN involvement

(a) Tx
(b) When do you turn to chemo

A

MALT is associated w/ H. pylori infection

(a) Initial tx = combo of omeprazole, clarithromycin, and amoxicillin
(b) Chemo indicated if eradication of H. pylori fails to produce regression of the lymphoma
typically CHOP: cyclophosphamide, adriamycin, vincristine, and prednisone

98
Q

55 yo M w/ h/o CHF, VT presenting for PFTs, what drug is most likely due to pulmonary dysfunction

A

Amiodarone = dirty antiarrhythmic

-serious adverse effect = pulmonary toxicity

99
Q

Hemoptysis associated w/ which valvular disease

A

Hemoptysis- raises suspicion for mitral stenosis

100
Q

Classic triad of Granulomatosis w/ polyangiitis

(a) 2 external manifestations

A

Granulomatosis w/ polyangiitis (Wegener’s) triad: systemic vasculitis, upper and lower airway granulomatous inflammation, glomerulonephritis

(a) Nasal cartilage destruction and vasculitic cutaneous lesions (ulcerations, palpable purpura)

101
Q

Peripheral smear findings that indicate

(a) Chronic lymphocytic leukemia
(b) Hodgkin’s disease
(c) Chronic myeloid leukemia

A

Peripheral smear findings of

(a) CLL = lymphocytes and smudge cells
- lymphocytosis
(b) Hodgkin’s disease = normal peripheral smear
- then see Reed-Sternberg cells on lymph node biopsy
(c) CML = leukocytosis, basophilia
- leukocytosis (not lymphocytosis)

102
Q

Classic presentation of myasthenia gravis

A

Muscle weakness, fatiguability, typically presents w/ CN and proximal limb weakness
-worsens w/ activity and resolves w/ rest

103
Q

Workup for new-onset iron deficiency anemia in a 65 yo W

A

New-onset iron deficiency anemia in an elderly pt is GI bleed until proven otherwise => do fecal occult blood test (FOBT) but even if negative still do a colonoscopy/endoscopy

104
Q

Neutropenic pt presents w/ fever

3 accepted therapies

A

Neutropenic adult w/ fever- start broad spectrum abx ASAP

Empiric monotherapy w/ an anti-pseudomonal agent (common cause)

  1. cefepime (4th gen cephalosporin)
  2. meropenem (big guns)
  3. Piperacillin-tazobactam = Zosyn
105
Q

Disopyramide

(a) Mechanism
(b) Indication

A

Disopyramide = class I antiarrhythmic

(a) Na+ channel blocker
(b) Used for V tach

106
Q

Water hammer or Corrigan pulse

A

Bounding and forceful pulse- rapidly increasing and subsequently collapsing
-associated w/ increase SV of the LV and decreased peripheral resistance => widened pulse pressure of AI

Rapid, abrupt upstroke followed by rapid collapse of peripheral pressure

  • due to wide pulse pressure
  • characteristic of AI (aortic insufficiency)
107
Q

73 yo w/ 3 mo of progressive urinary urgency, hesitancy, nocturia

  • enlarged prostate w/o induration or asymmetry
  • elevated creatinine compared to baseline

Next step

A

Renal ultrasound to r/o hydronephrosis or other cause of obstruction

Urine cytology wouldn’t be helpful for acute kidney injury workup.

108
Q

What is SAAG in the evaluation of ascites?

Cut off for portal HTN

A

SAAG = serum to ascites albumin gradient
(serum albumin - ascites albumin)

SAAG > 1.1 indicates portal HTN etiology (cardiac ascites, cirrhossi)

SAAG under 1.1 suggests nono-portal hypertensive etiologies (malignancy, pancreatitis, nephrotic syndrome, TB)

109
Q

Most common electrolyte abnormalities seen in Cushing’s

A

Hypokalemia and hypernatremia: cortisol has some mineralocorticoid activity to bind to aldo receptors in kidney => stimulating renal K+ wasting

110
Q

How does bronchoconstriction appear on CXR

A

Bronchoconstriction (ex: asthma, emphysema) commonly presents as hyperinflation on CXR

111
Q

Methylmalonic acid

A

Methylmalonic acid serum levels are elevated in pts w/ vitamin B12 deficiency

112
Q

27 yo F presents w/ bilateral joint pain x10 days

  • MCP, PIP, wrists, knees, ankles
  • fatigue, mild skin itchiness and patchy redness
  • joint stiffness lasts 10-15 mins in the morning
  • tenderness w/o swelling or redness of joints
A

Viral arthritis secondary to parvovirus B19- polyarticular symmetric

Why this isn’t RA: no joint swelling, morning stiffness > 1 hour, symptoms for at least 6 weeks

113
Q

72 yo M h/o diabetes presents w/ intense right ear pain and discharge

  • pain aggravated by chewing and radiates to TMJ
  • granulation tissue in ear canal

(a) Dx
(b) Causative organism

A

(a) Malignant otitis externa: ear discharge, severe pain radiating to TMJ in a diabetic pt
(b) >95% of cases of malignant otitis externa (worsen w/ topical abx shows its malignant nature) are caused b pseudomonas

114
Q

Nephritic syndrome(s) that can present w/ low complement levels

A

Post-strep GN: low serum complement C3 after a strep throat or skin infection

Membranoproliferative GN = uncommon disease, causes hematuria and low complement levels

115
Q

Two sample t vs. z test

A

T test compares two means using sample variances to obtain p-value

vs.

Z-test: compares two means using POPULATION variances (not often known) => limited applicability

116
Q

Prognosis for cutaneous squamous cell carcinoma

A

Very good prognosis- curative resection seen in over 90% of pts

-if left untreated can metastasize

117
Q

Physical exam findings of consolidation vs. pleural effusion

(a) Percussion
(b) Tactile fremitus
(c) Egophany

A

Consolidation (ex: pneumonia)

  • dullness to percussion
  • increased fremitus
  • presence of egophony and whispered pectoriloquy

Pleural effusion (fluid in pleural space- fluid blocks transmission from the air filled lungs)

  • dullness to percussion
  • decreased tactile fremitus
  • decreased breath sounds
118
Q

35 yo M w/ severe persistent bronchial asthma requiring multiple meds presenting w/ weight gain, moderate supraclavicular fullness

  • thinning of skin, areas of bruising and acne
  • decreased proximal muscle strength

Dx

A

Cushing’s- most likely due to iatrogenic steroid administration for his asthma
fatigue, wt gain, easy bruising, proximal muscle weakness, acne, susceptibility to infxn

119
Q

60 yo M presents w/ r. sided neck pain and numbness over the posterior surface of the forearm x2 yrs

  • episodes are remittent and respond to NSAIDs/PT
  • limited neck rotation and lateral bending
  • decreased pinprick sensation
  • no muscle weakness
  • normal reflexes

(a) Dx
(b) Finding on neck radiography

A

(a) Cervical spondylosis = history of chronic neck pain, limited neck rotation and lateral bending due to OA. Sensory deficit due to osteophyte-induced radiculopathy (osteophytes cause narrowing of space => compression of nerve roots)
- due to aging and chronic wear and tear on the cervical spine

(b) Xray finding = bony spurs

120
Q

26 yo M w/ sudden onset severe, colicky left-sided flank pain that radiates to the scrotum

  • N,V, and dark-colored urine
  • 5 mm radiopaque stone in left upper ureter

(a) Dx
(b) Composition of deposit

A

(a) Kidney stone!

(b) Majority of kidney stones are made of calcium oxalate

121
Q

3 forms of plasma calcium

A

45% ionized calcium (active)
40% albumin-bound calcium
15% Ca2+ bound to inorganic and organic anions

122
Q

Most common cause of aortic regurg in

(a) developing countries
(b) developed countries

A

AR

(a) Developing countries = rheumatic heart disease
(b) Developed countries: aortic root dilation or congenital bicuspid valve

123
Q

BUN:creatinine ratio > 20

A

BUN/creatinine ratio > 20 is consistent with a prerenal cause of azotemia

124
Q

What type of arthropathies are associated w/ anemia of chronic disease

A

Inflammatory arthropathies (ex: RA, lupus) are associated w/ anemia of chronic disease/inflammation

-not osteoarthritis

125
Q

Side effects of levodopa/carbidopa

(a) Early
(b) After several years of therapy

A

Levodopa/carbidopa (Parkinsonism tx)

(a) Most common early side effects = hallucinations, dizziness, HA, agitation
(b) After years of therapy involuntary mov’ts can occur ( choreiform dyskinesia)

126
Q

Tzanck preparation used for dx of what

A

Tzanck preparation = characteristic giant cells of HSV infection

127
Q

68 yo F w/ advanced COPD comes in w/ increased SOB and cough
-spO2 84% on 2L

(a) First step of tx
(b) Second line
(c) Third line

A

acute COPD exacerbation

(a) 1st: supplemental O2, IV abx (ex: levofloxacin), steroids (methylprednisone), 2 nebulized ipratropium w/ albuterol (SABA)
(b) Remains dyspneic after ^: noninvasive positive-pressure ventilation
- facemask to decrease work of breathing: improves alveolar ventilation

(c) Turn to mechanical ventilation is pt remains hypercapnic and develops decrease in mental status
- if pt fails a 2-hr trial of noninvasive positive-pressure ventilation, mechanical ventilation would be considered

**basically PAP before intubation

128
Q

62 yo F w/ pain behind right heel x 1 day

  • UTI 4 days ago being tx w/ cipro
  • tenderness 3 cm above posterior calcaneous
A

Achilles tendinopathy secondary to fluoroquinolone

129
Q

Criteria for diagnoses of diabetic ketoacidosis

A
  1. Blood glucose > 240
  2. pH under 7.3 or low serum bicarb (until 15-20)
  3. detection of plasma ketones
130
Q

3 things that can cause asterixis

A

Hepatic encephalopathy
Uremic encephalopathy
CO2 retention

131
Q

Tx for legionella pneumonia

A

Macrolides (azithromycin) or respiratory floroquinolones (levofloxacin)

132
Q

Valsartan

A

ARB

133
Q

Classic presentation of primary adrenal insufficiency

A

Hyperpigmentation (dark brown pigmentation on skin creases and oral mucous membranes)

  • fatigue, low BP, eosinophilia, hyponatremia w/ hyperkalemia
  • wt loss, anorexia, depression
134
Q

Lymphocyte vs. leukocyte

A

Leukocyte = general term for WBCs

Then lymphocytes are a type of WBC (Type of leukocyte)

135
Q

Clinical differences btwn candida esophagitis and viral esophagitis in HIV pt

(a) How to treat these 2

A

Candidal is the most common (60% of cases) and presents w/ mild-moderate odynophagia and will have oral thrush
(a) Empirically treat w/ fluconazole, do endoscopy if that fails

Viral esophagitis- less common but presents w/ severe odynophagia (pain w/ swallowing) w/o dysphagia (difficulty swallowing)
(a) Usually HSV => acyclovir, or CMV => gancyclovir. Differentiate on endoscopy (vesicular vs. large linear ulcers)

136
Q

Diseases associated w/ the following skin biopsy findings

(a) Giant cells in Tzanck prep
(b) Granulomatous inflammation
(c) Invasive cords of squamous cells w/ keratin pearls
(d) Invasive clusters of spindle cells surrounded by palisaded basal cells
(e) Shallow fibrin-coated ulceration w/ underlying mononuclear infiltrate

A

(a) Giant cells in Tzanck prep = HSV
(b) Granulomatous inflammation = tertiary syphilis, Tb, disseminated fungal disease
(c) Invasive cords of squamous cells w/ keratin pearls = squamous cell carcinoma
(d) Invasive spindle cell clusters surrounded by palisaded basal cells = basal cell carcinoma
(e) Shallow, fibrin-coated ulcerations w/ underlying mononuclear infiltreate = aphthous ulcers (canker sores)- benign

137
Q

What is Zollinger-Ellison syndrome?

(a) 2 clinical features

A

ZES = gastric-producing tumor (usually in the pancreas or duodenum)

Uncontrolled gastrin secretion => parietal cell hyperplasia => excessive production of gastric acid (hence the ulcers)

Extra gastric acid in the small intestines can cause diarrhea and steatorrhea due to inactivation of pancreatic enjoyes and injury to the ucosal brush border

(a) Presents w/ multiple peptic ulcers and diarrhea

138
Q

5 yo w/ decreased visual acuity + exophlamos of r. eye

  • cafe au lait spots
  • intensive axillary freckling
A

Intensive axillary (not a sun exposed area) freckling + cafe au lait spots = NF1

Optic glimoa occurs in 15% of pts w/ NF1

139
Q

24 yo F BIB mother for altered mental status

  • viral gastroenteritis 4 days ago
  • excessive thirst, water intake, and wt loss over the past 2 mo
  • respirations are rapid and deep
A

DKA = diabetic ketoacidosis, most likely precipitated by the GI infection

Deep rapid breathing (Kussmaul)- most likely due to acidosis

140
Q

BP medication w/ side effect of lower-extremity edema

(a) How to decrease this risk

A

Peripheral edema = common side effect of CCB therapy

ex: Amlodipine, Nifedipine
- edema related to preferential dilation of precapillary vessels

(a) Risk of edema w/ CCBs is decreased if use combo of CCB and ACEi

141
Q

Occupational exposure protocol for exposure from urine, feces, saliva, blood, semen, CSF

A

High-risk contact = non-intact skin, blood, semen, CSF
Prophylaxis recommended: start immediately w/ triple drug therapy for 4 weeks

Low risk contact = urine, feces, saliva, sweat (no visible blood) = no prophylaxis recommended

142
Q

2 causes of Kaposi sarcoma

A

KS = vascular tumor due to co-infection with HIV and HHV-8 (human herpesvirus-8)

143
Q

35 yo M w/ weakness, fatigue, wt loss x1 yr

  • lost interest in activities
  • BP 96/66
  • dark brown pigmentation on skin creases and oral mucous membranes
  • anemia
  • low white count w/ eosinophilia
  • hyponatremia, hyperkalemia

(a) Dx
(b) Diagnostic Test

A

(a) Fatigue, hyperpigmentation, low BP, eosinophilia, low Na, hyperkalemia = primary adrenal insufficiency (Addison’s)
- most characteristic finding is the hyperpigmentation

(b) Basal early-morning cortisol and ACTH, and cosyntropin test
- cosyntropin test (ACTH analog) done to speed up diagnosis since ACTH test can take days

144
Q

28 yo teacher w/ discharge from right eye x3 days

  • rhinorrhea, mild sore throat, 100.3 F
  • profuse watery discharge

(a) Dx
(b) Tx

A

(a) Viral conjunctivitis- watery (not purulent) discharge in setting of URI favors viral over bacterial conjunctivitis
(b) Tx for viral conjunctivitis = warm/cold compress, +/- antihistamine/decongestant drops

145
Q

Immediate management of DKA

A

NS (restoration of intravascular volume) + regular insulin (correction of hyperglycemia)

NOT NPH insulin b/c it has delayed onset and prolonged action, you want to use regular insulin

146
Q

Serum marker for serum B12 levels

A

Methylmalonic acid- elevations in MMA are more sensitive in detecting B12 deficiency than serum vitamin levels alone

147
Q

Enalapril

A

ACEi

148
Q

What is pulses paradoxus?

(a) Consistent w/ what diagnosis

A

(a) Pulses paradoxus = fall in systemic arterial pressure by > 10 mmHg during inspiration
(b) Associated w/ cardiac tamponade

149
Q

Interpret these test results:

Large blood found on urinalysis, urine microscopcy reveals 0-1 RBC

A

Large amount of blood on urinalysis but absence of relative RBCs on urine microscopy indicates myoglobinuria, usually caused by rhabdomyolysis

150
Q

Stress fracture vs. motor neuroma

A

Running injuries of the foot/ankle

Stress fracture: sharp, focal pain over bony surface

Motor neuroma- numbness/pain btwn 3rd and 4th toes
mechanically induced neuropathic degeneration of the interdigital nerves => numbness, aching, burning

151
Q

Atypical community-acquired pneumonia that develops after travel
+ CNS and GI features

A

Legionella- spread by infected water

152
Q

Steven Johnson’s vs. staph scalded skin syndrome

A

SSSS really not seen in adults, think more SJ in adults

153
Q

Sudden-onset SOB, CP, tachycardia w/ hemorrhagic, exudative pleural effusion
-no consolidation on CXR

A

Suggestive of pulmonary embolism
PE can cause exudative effusions (according to Light’s criteria of exudative vs. transudative fluid
-hemorrhagic effusion suggests pulmonary tissue infarction

154
Q

Tx for legionella

A

Macrolide (azithromycin) or respiratory fluoroquinolone (levofloxacin)

155
Q

Most common etiology of nontraumatic SAH

A

Nontraumatic subarachnoid hemorrhage is most commonly due to ruptured saccular or berry aneurysm

Berry/sacular aneurysm = most common kind of cerebral aneurysm

156
Q

44 yo M presents w/ long history of joint pain in several joints

  • fever, diarrhea, wt loss
  • lymphadenopathy and non-deforming arthritis
  • small intestine biopsy: periodic anti-Schiff (PAS)-positive macrophages

Dx

A

Whipple’s disease = infection w/ gram positive bacillus that can manifest in many ways

  • chronic malabsorbtive diarrhea, migratory non-deforming arthritis
  • lymphadenopathy
  • low grade fever

Dx made by small intestinal biopsy and PCR

157
Q

What diseases are the following CT findings associated with?

(a) Diffuse atrophy of cerebral cortex
(b) Atrophy of lenticular nucleus
(c) Atrophy of frontal and/or temporal lobes
(d) Atrophy of caudate nucleus

A

(a) Diffuse atrophy of cerebral cortex = Alzheimer’s
(b) Atrophy of lenticular nucleus = Wilson’s disease
(c) Atrophy of frontal and/or temporal lobes = Pick’s disease = frontotemporal dementia (personality changes)
(d) Atrophy of caudate nucleus = Huntington’s

158
Q

Who get rabies post-exposure prophylaxis after an animal bite?

A

High risk wild animal (bat, raccoon)- test the animal and start PEP if test is positive
-if can’t test animal, start PEP

Low risk animal (squirrel, chipmunk, rabbit, rat) => no PEP

Dog, cat, or ferret bite- next step is to quarantine the animal and observe it for 10 days. Animals w/ rabies usually become sick and can die w/in 10 days of the rabies virus spreading from the salivary gland to the brain => 10 day quarantine decides if PEP is needed

159
Q

Organ systems impacted by cysticercosis

A

Cysticercosis generally presents as cysts in the brain or muscle

Cysticercosis = tissue infection from pork tapeworm
Neurocysticercosis => tons of cysts in the brain

Get eosinophilia

160
Q

Test of choice to rule out SAH

A

CT scan w/o contrast

-negative head CT and still suspect SAH? Still do LP

161
Q

45 yo M w/ URI prodrome presents after an episode of syncope

  • neck veins distended, heart sounds are distant, lungs CTA
  • CXR: small bilateral pleural effusions and enlarged cardiac silhouette

(a) Dx
(b) EKG findings

A

(a) Pericardial effusion- often secondary to viral pericarditis
(b) Electrical alternans (QRS complexes w/ variable amplitudes) = pericardial effusion
- JVD, muffled heart sounds indicate developing cardiac tamponade

162
Q
80 yo BIB son for fatigue
-bilateral knee osteoarthritis
Meds: low-dose aspirin, lisinopril, chlorthalidone, naproxen 
-conjunctival pallor
-normal kidney function 

Cause of pt’s pallor

A

Iron deficiency anemia

Simultaneous NSAID and aspirin increases risk of gsatritis and/or gastric ulcers => chronic GI blood loss and depletion of iron stores

Wouldn’t be anemia of chronic disease (OA doesn’t cause that), anemia of chronic disease/inflammation is seen in RA/lupus

163
Q

Gluconeogenesis

(a) major gluconeogenic amino acid in the liver
(b) ^where does it enter the gluconeogenic cycle
(c) Where does G3P come from
(d) How is lactate involved

A

Gluconeogenesis

(a) Alanine = major gluconeogenic AA in the liver
(b) Converted to into pyruvate (which then enters mitochondria to combine w/ OAA in the citric acid cycle)
(c) Glucose-3-phosphate comes from breakdown of adipose stores
(d) Lactate comes from anaerobic glycosis, enters as pyruvate

164
Q

EBV DNA in the CSF of an HIV pt

A

EBV DNA in the CSF is specific for a primary CNS lymphoma

-also MRI showed a weakly ring-enhancing periventricular mass

165
Q

Tx for acute and chronic prostatitis

A

Both are most commonly caused by E. coli

Acute: Bactrum or fluoroquinolones
Chornic: Fluoroquinolones

166
Q

54 yo M c/c fatigue

  • upper abdominal pain: gnawing and constant and interferes w/ sleep
  • poor appetite, 7 lb wt loss in past month
  • takes ranitidine
  • 30 pack year smoker
  • PE: tenderness and fullness in epigastrum
A

Think GI malignancy- abdominal pain worse at night , systemic symptoms: wt loss and fatigue

Peptic duodenal ulcer could cause periodic epigastric pain as well but it would be relieved by meals and you wouldn’t expect the systemic symptoms

167
Q

32 yo w/ severe, unbearable pain in her face x5 days

  • resistant to pain meds
  • paroxysms 10-20 times a day for a few seconds

(a) Dx
(b) First line tx

A

(a) Trigeminal neuralgia

b) Drug of choice for trigeminal neuralgia = carbamazepine (anticonvulsant, mood stabilizer

168
Q

Acute epididymitis in younger vs. older pts

(a) Causative organism
(b) Symptoms

A

Acute epididymitis

Younger pts- usually caused by sexual transmission => C. tachomatis or N. gonorrhea
-pain at tip of penis and urethral discharge

Older pts- usually non-sexually transmitted and caused by GNR (E. coli most commonly, next pseudomonas)
-UTI symptoms

169
Q

Ulcerated, pearly nodule w/ a rolled border on sun-exposed skin

A

Basal cell carcinoma = most common form of skin cancer in the US

BCC = slow-growing papule w/ pearly rolled borders

170
Q

40 yo M presents w/ SOB, cough, hemoptysis x2 days

  • chronic purulent nasal discharge
  • patchy rales b/l
  • 2x3 cm ulcer on right leg

Dx and mechanism of diease

A

Granulomatosis w/ polyangiitis (Wegener’s): systemic vasculitis, upper and lower respiratory granulomatous inflammation, GN
-common manifestations: nasal cartilage destruction and skin lesions

171
Q

46 yo M 3 days after presenting in DKA develops low-grade fever, dull facial pain, and bloody nasal discharge

  • diplopia + HA
  • necrosis of right nasal turbinates
  • KOH staining shows hyphae

(a) Dx
(b) Tx

A

(a) Mucormycosis = fungal infection

(b) Tx = surgical debridement + IV amphotericin

172
Q

82 yo F presents w/ sudden-onset epigastric pain

  • nauseated, vom x2
  • Hx: HLD, HTN, PUD, cholelithiasis
  • soft abdomen w/o tenderness, (-) Murphy’s sign

Next step

A

EKG- r/o cardiac symptomatology before doing other stuff (abdominal US, amylase/lipase, endoscopy etc)

She has all 3 risk factors (diabetes, female, elderly) to have atypical (no over CP) presentation of acute coronary syndrome
-abdominal pain and nausea/vom are atypical presentations of ACS

173
Q

Best tx for chronic Hep B

A

Tenofovir = new drug and it’s awesome, used w/ entecavir

174
Q

Polymyositis

(a) Most typical presentation
(b) Differentiating factor from dermatomyositis

A

(a) Progressive LE proximal weakness (ex: gradual onset thigh weakness) => difficult w/ stairs or rising from seated position
(b) Polymyositis has no skin findings

175
Q

What class of medication is associated w/ risk of hypothermia?

A

Antipsychotics, typically typicals (like fluphenazine)

=>pts on antipsychotics should avoid prolonged exposure to cold temps

176
Q

What serum testosterone and DHEAS levels can help you distinguish in a F w/ rapidly developing hyperandrogenism w/ virilization

A

Rapidly developing hyperandrogenism w/ virilization in a F is highly suggestive of an androgen-secreting neoplasm of the ovary or adrenal

Ovarian source- elevated testosterone w/ normal DHEAS
-T and DHEA are produced by both ovaries and adrenals

Adrenal source- elevated DHEAS w/ relatively normal T
-DHEA-S (sulfate) is ONLY produced in the adrenals

177
Q

Diagnostic test of choice for ureteral calculi

A

Ureteral calculi = obstruction of ureter at the ureterovesical jxn => severe flank pain that radiates

Diagnostic test = ultasound

  • can also use nonconstrast CT (but more radiation risk)
  • can’t use UA b/c hematuria is nonspecific
178
Q

45 yo M w/ mov’t d/o and behavioral disturbance

  • frequent, sudden, jerky, irregular movements
  • irritability
  • father had similar problems and died in nursing home

(a) Dx
(b) CT findings

A

(a) Huntington’s chorea

(b) CT scan: atrophy of the caudate nucleus

179
Q

2 causes of recurrent pneumonia

A

Etiology of recurrent pneumonia

Same region of the lung

  • local anatomic obstruction (neoplasm), intrinsic bronchial obstruction (foreign body, bronchiectasis)
  • recurrent aspiration: seizures, EtOH/drugs, GERD

Involving dif region of lung

  • Sinopulmonary disease (CF, immotile cilia)
  • Noninfectious (vasculitis)
  • Immunodeficiency)
180
Q

45 yo M w/ 6 mo of recurrent, burning epigastric pain and diarrhea
-foul smelling, floating stools
-wt loss
-midepigastric tenderness to deep palpation
-Stool occult blood +, stool fat +
Endoscopy: 2 duodenal ulcers and jejunal ulcer

(a) Dx
(b) mechanism of pt’s impaired fat absorption

A

(a) Zollinger-Ellison syndrome: multiple and refractory peptil ulcers, ulcers distal to duodenum, chronic diarrhea

(b) Impaired fat absorption due to pancreatic enzyme inactivation
- excess gastrin (from gastrin-secreting tumor) causes parietal cells to pump out tons of acid => inactivates pancreatic enzymes (need basic environment to function)

181
Q

What are the majority of kidney stones composed of?

A

Calcium oxalate make up 75-90% of kidney stones

182
Q

21 yo M w/ h/o seizures BIB ambulance during tonic-clonic seizures. Nonresponsive

(a) Dx
(b) Highest risk for the following

A

(a) Status epilepticus = seizures >. 5 minutes or a cluster of seizures w/ pt not recovering a normal mental status between
(b) Cortical laminar necrosis = hallmark or prolonged seizures

183
Q

Tx for toxoplasmosis

A

First line: Sulfadiazine and pyrimethamine

Or: Azithromycin

184
Q

LP findings suggestive of LAH

A

Elevated opening pressure and unexplained xanthochromia (yellowish tint from bilirubin) strongly suggest SAH

185
Q

37 yo Cambodian F presents to ER w/ acute onset left-sided weakness

  • progressive DOE, occasional hemoptysis
  • frequent episodes of palpitations and irregular heart beats

Dx, mechanism of symptoms

A
This is a doozy...
Rheumatic fever (Cambodia) => stenotic mitral valve which increased left atrial pressure => pulmonary congestion causing DOE, nocturnal cough and hemoptysis

MS = high risk of AFib due to LA dilation => thrombus embolized to cerebral circulation => stroke and left sided weakness

186
Q

What is eletrical alternans?

A

Electrical alternans = finding of pericardial effusion on EKG when amplitudes of the QRS complexes vary from beat to beat b/c the heart is swinging back and forth in high volume pericardial fluid

187
Q

Differentiate clinical symptoms of Meniere’s vs. BPPV

A

Both have recurrent episodes of vertigo, BPPV brought on by predictable head movements or positional change

Meniere’s- preceded by ear fullness/pain, unilateral hearing loss and tinnitus

BPPV- no neurologic or auditory symptoms
-nystagmus and vertigo triggered as pt lies back quickly into a supine position w/ head rotated 45 degrees

188
Q
72 yo M s/p surgery found to be lethargic and drowsy
Meds: HCTZ, lisinopril, naproxen
-BUN 78, CK 3200 AST 112 ALT 42
-albumin 3.8 total bili 0.4
-Asterixis seen on exam

(a) Dx
(b) Next step in management

A

(a) Dx = Uremia secondary to acute kidney injury- probably secondary to rhabdomyolysis (CK is crazy high) and naproxen usage

(b) Next step = hemodilaysis
Indications for urgent dialysis = AEIOU: acidemia, electrolyte abnormalities, ingestion, overflow of volume, uremia

Don’t get confused into assuming liver etiology b/c of the asterixis: can be hepatic encephalopathy, uremia or CO2 retention

189
Q

Black box warning of cipro

A

Increased risk of tendinopathy and tendon rupture associated w/ fluoroquinolones

190
Q

Most common meds that can cause Stevens-Johnsons

A

Abx
Anticonvulsants
Allopurinol

191
Q

Key clinical distinguishing factor btwn photosensitivity rash and Steven-Johnsons

A

Key feature of Steven-Johnsons = involvement of mucous membranes
-mucocutaneous rxn

192
Q

CT reveals segmental pulmonary embolus, explain why this pt also has carpopedal spasm, crampy pain, and paresthesias in extremities

A

PE => tachypnea => respiratory alkalosis => H+ leaves albumin, albumin has increased affinity for Ca2+ => decrease in serum ionized (active) calcium => symptoms of hypocalcemia
-cramping, spasms, paresthesias

193
Q

Differentiate clinical signs of pancreatic tumors of the head vs. body/tail

A

Tumors of the head of the pancreas enlarge and compress the common bile duct => painless jaundice and distended nontender gallbladder

Tumors in body/tail of the pancreas usually present w/ abdominal pain and NO jaundice

194
Q

Poorly controlled diabetic w/ 102.2F, facial pain over right maxilla, bloody nasal discharge x3 days
-chemosis and proptosis of right eye

(a) Diagnosis
(b) Causative organism

A

(a) Mucormycosis of the nose and maxillary sinus
(b) Most common cause of mucormycosis agent = Rhizopus

Predisposed to mucormycosis = HIV/AIDS, diabetics

Mucormycosis = fungal infection that most frequently affects the sinuses, brain, and lungs

195
Q

How to evaluate results from thoracentesis

A

Thoracentesis = drainage of pleural effusion, need to differentiate exudative from transudative

Light’s criteria defines exudate as having:

  • pleural fluid protein/serum protein ratio > 0.5
  • pleural fluid LDH/serum LDH > 0.6
  • pleural fluid LDH > 2/3 ULN for serum LDH
196
Q

Periodic acid-Schiff (PAS) reaction

A

hepatocytes of individuals w/ alpha-1 antitrypsin

197
Q

Relationship btwn COPD and clubbing

(a) Most common causes of secondary digital clubbing

A

Clubbing is NOT due to COPD alone (hypoxemia does not cause clubbing), presence of clubbing should prompt a search for occult malignancy

(a) Most common causes secondary digital clubbing = lung malignancies, CF, right-to-left cardiac shunts

198
Q

62 yo M w/ incidental finding of elevated serum protein w/ normal albumin
-monoclonal paraprotein band on serum protein electrophoresis at 2.6 g/dL

(a) What is a gamma gap? What does it indicate?
(b) Next step in workup
(c) DDx MGUS vs. MM

A

(a) Gamma gap = elevated serum protein w/ normal albumin
- indicates d/o such as multiple myeloma (MM), amyloidosis, macroglobulinemia, MGUS (monoclonal gammopathy of undetermined significance)

(b) Next step is to rule out MM => do metastatic skeletal bone x-rays
(c) MGUS = absence of anemia, hypercalcemia, lytic lesions, and renal insufficiency. Serum monoclonal protein under 3 g/dl, less than 10% plasma cells in the bone marrow

MM: presence of anemia, hypercalcemia, lytic lesions, and renal insufficiency. Serum monoclonal protein > 3 g/dl. More than 10% plasma cells in bone marrow. Elevated beta-2 microglobulin.

199
Q

Laboratory findings of multiple myeloma

A

CBC: anemia, pancytopenia (low in all 3 cell lines), hypercalcemia

Bony lytic lesions

Renal disease

200
Q

60 yo farmer presents w/ enlarging sore on his lip
-partially encrusted ulcer surrounded by area of induration

(a) Dx
(b) Biopsy findings

A

(a) Squamous cell carcinoma = sun exposure (farming) w/ persistent, indurated, ulcerating lower lip lesion
- SCC is the most common malignancy of the lip

(b) Biopsy of SCC: invasive cords of squamous cells w/ keratin pearls

201
Q

What drug increases survival in HF

A

Biggest mortality benefit = ACEi
Other CHF drugs w/ motality benefit: beta-blockers, ARB, spironolactone
-not CCB, loopdiuretics, dig, dobutamine

202
Q

Serum complement levels in

(a) Post-strep GN
(b) MPGN
(c) IgA nephropathy

A

(a,b) Serum complement reduced in post-strep GN and MPGN

(c) Complement levels are normal in IgA nephropathy

203
Q

Most common cause of non-purulent cellulitis

A

Group A Strep

204
Q

Legionnella

(a) Mechanism of spread
(b) Clinical features
(c) Associated lab findings

A

Legionella = cause of atypical community acquired pneumonia

(a) Contaminated water
- risk factor = recent travel (esp cruise or hotel stay)
(b) Clinically: fever w/ paradoxical bradycardia, neurological symptoms (esp confusion), GI symptoms (esp diarrhea)
(c) Lab values
- hyponatremia
- mild hepatitis
- hematuria and proteinuria

205
Q

67 yo M 24-hrs post op from stent placement presenting w/ acute-onset upper abdominal pain w/ N/V

  • epigastric tenderness
  • LE and toes are mottled, reddish-blue, reticulated, blanch on pressure
  • normal ALT/AST, elevated alkphos and lipase

(a) Dx
(b) Tx

A

(a) Dx = acute pancreatitis
- cardiac embolism, at high risk after vascular procedure
(b) Initially can help pain w/ IV morphine, then give IV fluids and supportive care only

Skin findings = livedo reticularis (manifestation of cholestrol emobli to small venules in extremities)

206
Q

Prolactinoma tx

A

Prolactinoma tx = dopamine agonist (carbegoline)

207
Q

55 yo M w/ fever, productive cough, and foul-smelling sputum

  • SOB
  • H/o RLL pneumonia 6 mo ago
  • smoker and +++EtOH
  • T 102, pulse ox 90% RA
  • CXR: right lower-lobe infiltrate

(a) Cause of symptoms?

A

Recurrent pneumonia- can be due to local anatomic obstruction or recurrent aspiration

(a) Excessive alcohol intake- chronic drinkers can aspirate during episode of altered consciousness

208
Q

Nerve most commonly involved in diabetic mononeuropathy

(a) Mechanism of injury
(b) Which fibers of the nerve lose function
(c) Clinical findings

A

Diabetic mononeuropathy most commonly involves CN III

(a) Nerve damage is ischemic and only somatic nerve fibers are affected
(b) Only somatic fibers are affected, parasympathetic fibers retian fxn =>
(c) Pupils have ‘down and out’ graze w/ normal light and accommodation reflexes

209
Q

Describe how cirrhosis can result in

(a) erectile dysfunction
(b) decreased measured T3/T4
(c) testicular atrophy

A

Cirrhosis =>

(a) ED by hypogonadism due to primary gonadal injury or HPA dysfunction
(b) Decreased production of TBG => decreased bound (total) T3/T4
- but doesn’t usually change free T3/T4 since most is usually bound anyway
(c) Testicular atrophy due to high estrogen

210
Q

Differentiate Steven Johnson syndrome from toxic epidermal necrolysis

A

They’re a spectrum. Steven Johnson = severe form of erythema multiform and minor form of toxic epidermal necrolysis

Both are immune-complex-mediated hypersensitivity causing separation of the dermis and epidermis

If less than 10% of the body surface area is involved = SJS
10-30% involved: SJS/TEN overlap
More than 30%: TEN

211
Q

AIDS pt w/ CD4 count of 30- what prophylactic meds should she be on?

A

Bactrum
Azithromycin
Itraconazole

212
Q

Associated disease(s)

(a) Anti-topoisomerase-I antibodies
(b) Rheumatoid factor
(c) Antimitochondrial antibodies
(d) Anti-neutrophil cytoplasmic antibodies
(e) Anti-smooth muscle antibodies
(f) Antinuclear antibodies

A

Autoimmune diseases

(a) Anti-topoisomerase I: sceroderma
(b) RF- RA, SLE, Sjogrens, dermatomyositis
(c) Antimitochondrial antibodies- primary biliary cirrhosis/cholangitis (PBC)
(d) ANCA- vasculitides: granulomatosis w/ polyangiitis (Wegener’s = GPA), MPA, and EGPA
(e) Anti-smooth muscle antibodies- autoimmune hepatitis
(f) Antinuclear antibodies- SLE, scleroderma, Sjogrens

213
Q

33 yo F presents w/ occasional diplopia and ptosis
-fatigue in hands and legs after exercising

Dx

A

Myasthenia gravis = lesion at the nmj (auto-antibodies against ACh receptor)

214
Q

Mechanism of carpel tunnel

A

Accumulation of matrix substances
-not fluid or tendon inflammation

Carpel tunnel = deposition of mucopolysacchardie protein complexes w/in the perineurium and endoneurium of the median nerve

215
Q

Post exposure prophylaxis regimen for high-risk contact to HIV

A

HIV post-exposure prophylaxis (ex: needle stick to healthcare worker) = 3+ drugs:

2 nucleotide/nucleoside reverse transcriptase inhibitors (tenofovir + emtricitabine)
+
integrase stand transfer inhibitor (raltegravir), protease inhibitor

216
Q

What is ANOVA test?

A

ANOVA = analysis of variance- used to compare three or more mean (average, not like sassy lol) values

217
Q

High pitched diastolic murmur

A

Clasically ‘high pitched’ diastolic = AR

While MS is usually dull (thrill)

218
Q

Why is metformin usually held in the hospital?

A

Metformin can cause lactic acidosis in AKI and sepsis, should be withheld until kidney injury is perfect
-hold metformin in acutely ill pts w/ acute renal failure, liver failure, or sepsis: conditions that increase risk of lactic acidosis

219
Q

IV cefazolin

A

First generation cephalosporin commonly used as prophylaxis before surgery to prevent wound infections

220
Q

Tumor in the head of the pancreas

(a) Clinical findings
(b) Finding on imaging

A

Most (about 65%) of pancreatic tumors occur at the head of the pancreas => compress the pancreatic and common bile duct =>

(a) Painless jaundice
(b) Subsequent back up of bile => intra and extra hepatic duct dilation and nontender, distended gallbladde

221
Q

The following side effects are due to what HIV drug?

(a) Needle-shaped crystals in urine
(b) lactic acidosis
(c) Stevens Johnson

A

(a) Crystal-induced nephropathy = well-known side effect of indinavir therapy (protease inhibitor)
(b) Lactic acidosis from any of the NRTIs = nucleoside reverse transcriptase inhibitor
(c) Stevens-Johnson from any of the NNRTIs = non-nucleoside reverse transcriptase inhibitor

222
Q

Kussmal breathing

A

Deep rapid breathing

ex: RR of 28 but trying to take deep breaths
ex of etiology: metabolic acidosis

223
Q

Which CCB would you use in HOCM- amlodipine or diltiazem

A

Amlodipine = peripherally acting CCB so works as arterial vasodilator

Diltiazem = centrally acting CCB so works to prolong diastole (so ventricles have more time to fill and therefore less outflow obstruction)

224
Q

Necrolytic migratory erythema

A

Presenting rash of glucagonoma, also can be from liver disease or intestinal malabsorption

red blistering rash that starts on mouth and distal extremities then spreads