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
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
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
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
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
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
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
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
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)
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
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
12
Q
Purpose of abdominal fat pad biopsy
A
To test for amyloidosis
13
Q
Xanthochromia
A
Xanthochromia = yellow discoloration of the CSF due to the presence of bilirubin
-suggestive of SAH
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
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
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
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
18
Q
First line tx for chemotherapy-induced nausea and vomiting
A
Ondansetron (Zofran) = Serotonin receptor antagonist: targets the 5HT3 receptor
19
Q
3 choices for inpatient coverage of pseudomonas
A
- zosyn (piperacillin/tazobactam)
- meropenem
- cefepime
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
21
Q
Hallmark triad of trichinellosis
A
Trichellosis = GI complaints followed by characteristic triad: periorbital edema, myositis, eosinophilia
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
23
Q
Bence Jones protein
A
Paraproteins (abnormal antibodies) produced in multiple myeloma (plasma cell cancer) that deposits and causes renal insufficiency
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
25
Differentiate lupus and RA type arthritis
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)
26
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
Acute epididymitis = fever, painful enlargement of testes, irritative voiding symptoms
27
Effect of the following drugs on kidney function
(a) IV acyclovir
(b) MTX
(c) Beta-lactam abx
(d) PPIs
(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)
28
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
Legionella pneumonia
-typical to have history of travel
High fever, GI and neurologic symptoms differentiate from other community acquired pneumonia
=> tx w/ levofloxacin
29
Mechanism of ascites in
(a) Portal HTN
(b) Malignant ascites
Mechanism of ascites in
(a) Portal HTN = increased capillary hydrostatic pressure
(b) Malignant ascites (aka ascites caused by cancer)= increased capillary permeability
30
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?
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
31
Vaccines recommended for adults w/ HIV
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
32
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
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
33
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
Stevens-Johnson- from bactrum
SJS denotes less than 10% of body surface area involvement, vs over 30 = TEN (toxic epidermal necrolysis)
34
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
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
35
Describe how exogenous progestin would affect the endometrium
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
36
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
Viral arthritis due to parvovirus B19- presents w/ acute onset of polyarticular and symmetric arthritis
37
Describe the cause of the following in scleroderma pts
(a) Right heart failure
(b) GERD
(c) Renal dysfunction
(d) Skin findings
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
38
What is it called when there is herpes on the finger?
Herpetic whitlow- about 14% of adults w/ it are healthcare workers (ex: dentists) b/c can be caused by direct contact w/ infected secretions
39
Confounding vs. effect modification
ex: alcohol use --> bladder cancer, smoking
ex: OCP --> breast cancer, family hx of breast cancer
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
40
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) 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
41
Elderly pt w/ bone pain, renal failure, and hypercalcemia
Multiple myeloma until proven otherwise
42
Strongest predictor of abdominal aortic aneurysm explansion
Current smoking
| -NOT uncontrolled HTN
43
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
Angioedema = ACEi = Enalapril
-angiogedema from ACEi can occur at anytime, not just w/in weeks of starting the medication
44
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?
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
45
Clinical presentation of multiple myeloma: CRAB
```
CRAB:
Calcium (hyper)
Renal failure- 50% of multiple myeloma pts develop some degree of renal insufficiency
Anemia
Bone lesions
```
46
Drug given for acne that can cause photosensitivty reaction
Most common = tetracyclines
47
Development of digital clubbing and sudden-onset joint arthropathy in a chronic smoker
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
48
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) 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
49
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) 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
50
Noncontrast head CT showing hyperdense signal in a cistern
Cisterns = subarachnoid space that fill up w/ blood (hyperdense/bright signal on noncontrast CT) due to an SAH
51
Lab indication of pre-renal azotemia
BUN:creatinine > 20:1 indicates pre-renal azotemia
| -usually due to volume depletion causing hypoperfusion of the kidneys
52
Febrile pt w/ new soft systolic crescendo-decrescendo murmur at LSB
Fever induces a hyperdynamic state, during which an audible flow murmur may be heard
-hyperkinetic flow murmur due to fever
53
2 manifestations of alpha-1 antitrypsin deficiency
Liver and lung involvement due to deposition of abnormal A1AT protein
lung involvement: COPD or severe panacinar emphysema
54
Describe how a pulmonary embolism can alter calcium homeostasis
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
55
What dose tracheal deviation indicate?
Associated w/ tension pneumothorax
56
Most common cause of primary adrenal insufficiency in
(a) developing countries
(b) developed countries
Primary adrenal insufficiency
(a) Developed countries- adrenal tuberculosis
(b) Developed countries- autoimmune adrenalitis
57
2 antibodies present in scleroderma
Antinuclear and anti-topoisomerase I antibodies
58
Specifically where are bile acids reabsorbed
In the ileum => get decreased bile acid reabsorption if have extensive ileal resection (ex: secondary to Crohn's)
59
Clinical presentation of craniopharyngioma
Craniopharyngioma = sellar mass (benign tumor arising from Rathke's pouch)
Compresses on optic nerve => bitemporal hemianopsia
- headache
- hormonal deficiency (b/c impacts pituitary)
60
Name some causes of acute nephritic syndrome
Glomerular damage due to
- post strep GN
- IgA nephropathy
- lupus nephritis
- MPGN
- RPGN
61
AIDS pts should be on what prophylactic meds once their CD4+ count drops below
(a) 200
(b) 150
(c) 100
(d) 50
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)
62
76 yo M w/ stiffness in pelvis and shoulders w/ elevated ESR
(a) Dx
(b) Associated disease
(a) Polymyalgia rheumatica = pain/stiffness in shoulders, neck, hips/pelvis
(b) Associated w/ temporal arteritis
- have to have elevated ESR
63
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) 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
64
How to prevent bone loss due to prolonged immobilization
Hydration and bisphosphonates- prevent bone loss (and therefore hypercalcemia) due to immobilization
65
32 yo F w/ h/o advanced Chrons diesease presents w/ LE paresthesias and difficulty balancing
- tingling in feet
- macrocytic anemia
Vitamin B12 deficiency due to chronic malabsorption from Crohn
66
Typical presentation of rabies
Motor weakness, paresthesias, encephalitis that can acutely progress to coma/death
67
Typical presentation of uveitis
Uveitis = inflammation of uvea (middle layer of the eye), presents w/ blurred vision + moderate pain, conjunctival injection, and constricted pupils
68
Describe how Risperidone can cause breast tenderness and milky-white discharge from both nipples
Risperidone = dopamine and serotonin antagonist
| -inhibiting dopamine => elevated serum prolactin => amenorrhea and galactorrhea
69
What is Addison's disease
(a) Tx
Addison's disease = autoimmune cause of primary adrenal insufficiency
(a) Hydrocortisone
70
Zolendronic acid indications
= 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
71
Most common cancer of the lip
Squamous cell carcinoma
| -sun exposure
72
3 symptoms to help distinguish atypical Legionella pneumonia from other causes of community-acquired pneumonia
- High-grade fever (>102.2)
- GI symptoms
- neurologic symptoms: confusion, ataxia
73
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
Tearing CP radiating to back = acute aortic dissection
Common complication of acute aortic dissection = cardiac tamponade = pericardial fluid accumulation
74
Most common cause of necrotizing fasciitis- mechanism wise
(a) Most common causative organism
Generally caused by trauma, can result from significant peripheral vascular disease
(a) Usually polymicrobial, most frequently recovered pathogen is GAS
75
Classic physical exam findings of cardiac tamponade
Classic triad of distant heart sounds, hypotension, and distended neck veins
76
Amantadine
(a) Indications
(b) Side effects
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
77
Tinea corporis vs. tinea versicolor
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
78
Describe the possible danger of supplemental O2 in pts w/ advanced COPD
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
79
Indications for surgical repair of aortic aneurysm
Aneurysm > 5.5cm, rapid rate of aneurysm expansion, presence of symptoms (abdominal, back, or flank pain; limb ischemia)
80
What rare diagnosis to suspect when newly diagnosed diabetic presents w/ erythematous papules on face, extremities, diarrhea, anemia, and wt loss
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
81
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
Alcohol hepatitis
- AST:ALT ratio over 2
- leukocytosis
82
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) 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
83
Describe the predominant mechanism of HF in HOCM
Primarily diastolic heart failure => impaired ventricular filling and outflow obstruction
(inability of myocardium to properly relax)
84
2 most common causes of acute pancreatitis
Chronic alcoholic use and gallstones
85
What is Whipple disease?
(a) Most common presenting symptoms
(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
86
Splenectomy
(a) What vaccines to be given
(b) Prophylactic abx protocol
(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
87
Clinical signs to distinguish lower leg DVT vs. cellulitis
Common in that they present w/ swelling, fever, erythema, and warmth
Cellulitis: higher fever, presence of regional lymphadenopathy
88
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
Tuberculosis- most common cause of primary adrenal insufficiency in developing countries
-adrenal calcification = typical feature of adrenal TB
89
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
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
90
25 yo HIV pt w/ HA and left sided weakness, febrile to 100.8
CT: multiple ring-enhancing lesions
Dx?
Cerebral toxoplasmosis => tx w/ sulfadiazine and pyrimethamine
91
Symptoms of chronic Hep C
Can be asymptomatic or have some nonspecific symptoms (arthralgias, myalgias, fatigue), pts usually have waxing and waning elevations in transaminases
92
Bradycardia w/ sine wave pattern on EKG
Hyperkalemia: wide-complex rhythm at 32 bpm w/o P waves
93
Reed Sternberg cells
= type of giant cells seen in lymph node biopsy of Hodgkin's lymphoma
Pathognomonic for Hodgkin's disease
94
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
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
65 yo 90-pack-year smoking history w/ blood in urine
| -otherwise asymptomatic
Bladder cancer = most common neoplastic cause of painless hematuria
96
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
Giardiasis: foul-smelling stools, bloating, >2 weeks of diarrhea
(b) Tx = metronidazole (flagil)
97
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
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
55 yo M w/ h/o CHF, VT presenting for PFTs, what drug is most likely due to pulmonary dysfunction
Amiodarone = dirty antiarrhythmic
| -serious adverse effect = pulmonary toxicity
99
Hemoptysis associated w/ which valvular disease
Hemoptysis- raises suspicion for mitral stenosis
100
Classic triad of Granulomatosis w/ polyangiitis
(a) 2 external manifestations
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
Peripheral smear findings that indicate
(a) Chronic lymphocytic leukemia
(b) Hodgkin's disease
(c) Chronic myeloid leukemia
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
Classic presentation of myasthenia gravis
Muscle weakness, fatiguability, typically presents w/ CN and proximal limb weakness
-worsens w/ activity and resolves w/ rest
103
Workup for new-onset iron deficiency anemia in a 65 yo W
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
Neutropenic pt presents w/ fever
3 accepted therapies
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
Disopyramide
(a) Mechanism
(b) Indication
Disopyramide = class I antiarrhythmic
(a) Na+ channel blocker
(b) Used for V tach
106
Water hammer or Corrigan pulse
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
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
Renal ultrasound to r/o hydronephrosis or other cause of obstruction
Urine cytology wouldn't be helpful for acute kidney injury workup.
108
What is SAAG in the evaluation of ascites?
Cut off for portal HTN
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
Most common electrolyte abnormalities seen in Cushing's
Hypokalemia and hypernatremia: cortisol has some mineralocorticoid activity to bind to aldo receptors in kidney => stimulating renal K+ wasting
110
How does bronchoconstriction appear on CXR
Bronchoconstriction (ex: asthma, emphysema) commonly presents as hyperinflation on CXR
111
Methylmalonic acid
Methylmalonic acid serum levels are elevated in pts w/ vitamin B12 deficiency
112
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
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
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) 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
Nephritic syndrome(s) that can present w/ low complement levels
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
Two sample t vs. z test
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
Prognosis for cutaneous squamous cell carcinoma
Very good prognosis- curative resection seen in over 90% of pts
-if left untreated can metastasize
117
Physical exam findings of consolidation vs. pleural effusion
(a) Percussion
(b) Tactile fremitus
(c) Egophany
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
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
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
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) 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
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) Kidney stone!
| (b) Majority of kidney stones are made of calcium oxalate
121
3 forms of plasma calcium
45% ionized calcium (active)
40% albumin-bound calcium
15% Ca2+ bound to inorganic and organic anions
122
Most common cause of aortic regurg in
(a) developing countries
(b) developed countries
AR
(a) Developing countries = rheumatic heart disease
(b) Developed countries: aortic root dilation or congenital bicuspid valve
123
BUN:creatinine ratio > 20
BUN/creatinine ratio > 20 is consistent with a prerenal cause of azotemia
124
What type of arthropathies are associated w/ anemia of chronic disease
Inflammatory arthropathies (ex: RA, lupus) are associated w/ anemia of chronic disease/inflammation
-not osteoarthritis
125
Side effects of levodopa/carbidopa
(a) Early
(b) After several years of therapy
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
Tzanck preparation used for dx of what
Tzanck preparation = characteristic giant cells of HSV infection
127
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
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
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
Achilles tendinopathy secondary to fluoroquinolone
129
Criteria for diagnoses of diabetic ketoacidosis
1. Blood glucose > 240
2. pH under 7.3 or low serum bicarb (until 15-20)
3. detection of plasma ketones
130
3 things that can cause asterixis
Hepatic encephalopathy
Uremic encephalopathy
CO2 retention
131
Tx for legionella pneumonia
Macrolides (azithromycin) or respiratory floroquinolones (levofloxacin)
132
Valsartan
ARB
133
Classic presentation of primary adrenal insufficiency
Hyperpigmentation (dark brown pigmentation on skin creases and oral mucous membranes)
- fatigue, low BP, eosinophilia, hyponatremia w/ hyperkalemia
- wt loss, anorexia, depression
134
Lymphocyte vs. leukocyte
Leukocyte = general term for WBCs
Then lymphocytes are a type of WBC (Type of leukocyte)
135
Clinical differences btwn candida esophagitis and viral esophagitis in HIV pt
(a) How to treat these 2
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
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) 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
What is Zollinger-Ellison syndrome?
(a) 2 clinical features
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
5 yo w/ decreased visual acuity + exophlamos of r. eye
- cafe au lait spots
- intensive axillary freckling
Intensive axillary (not a sun exposed area) freckling + cafe au lait spots = NF1
Optic glimoa occurs in 15% of pts w/ NF1
139
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
DKA = diabetic ketoacidosis, most likely precipitated by the GI infection
Deep rapid breathing (Kussmaul)- most likely due to acidosis
140
BP medication w/ side effect of lower-extremity edema
(a) How to decrease this risk
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
Occupational exposure protocol for exposure from urine, feces, saliva, blood, semen, CSF
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
2 causes of Kaposi sarcoma
KS = vascular tumor due to co-infection with HIV and HHV-8 (human herpesvirus-8)
143
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) 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
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) 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
Immediate management of DKA
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
Serum marker for serum B12 levels
Methylmalonic acid- elevations in MMA are more sensitive in detecting B12 deficiency than serum vitamin levels alone
147
Enalapril
ACEi
148
What is pulses paradoxus?
(a) Consistent w/ what diagnosis
(a) Pulses paradoxus = fall in systemic arterial pressure by > 10 mmHg during inspiration
(b) Associated w/ cardiac tamponade
149
Interpret these test results:
| Large blood found on urinalysis, urine microscopcy reveals 0-1 RBC
Large amount of blood on urinalysis but absence of relative RBCs on urine microscopy indicates myoglobinuria, usually caused by rhabdomyolysis
150
Stress fracture vs. motor neuroma
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
Atypical community-acquired pneumonia that develops after travel
+ CNS and GI features
Legionella- spread by infected water
152
Steven Johnson's vs. staph scalded skin syndrome
SSSS really not seen in adults, think more SJ in adults
153
Sudden-onset SOB, CP, tachycardia w/ hemorrhagic, exudative pleural effusion
-no consolidation on CXR
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
Tx for legionella
Macrolide (azithromycin) or respiratory fluoroquinolone (levofloxacin)
155
Most common etiology of nontraumatic SAH
Nontraumatic subarachnoid hemorrhage is most commonly due to ruptured saccular or berry aneurysm
Berry/sacular aneurysm = most common kind of cerebral aneurysm
156
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
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
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) 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
Who get rabies post-exposure prophylaxis after an animal bite?
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
Organ systems impacted by cysticercosis
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
Test of choice to rule out SAH
CT scan w/o contrast
-negative head CT and still suspect SAH? Still do LP
161
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) 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
```
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
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
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
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
EBV DNA in the CSF of an HIV pt
EBV DNA in the CSF is specific for a primary CNS lymphoma
-also MRI showed a weakly ring-enhancing periventricular mass
165
Tx for acute and chronic prostatitis
Both are most commonly caused by E. coli
Acute: Bactrum or fluoroquinolones
Chornic: Fluoroquinolones
166
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
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
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) Trigeminal neuralgia
| b) Drug of choice for trigeminal neuralgia = carbamazepine (anticonvulsant, mood stabilizer
168
Acute epididymitis in younger vs. older pts
(a) Causative organism
(b) Symptoms
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
Ulcerated, pearly nodule w/ a rolled border on sun-exposed skin
Basal cell carcinoma = most common form of skin cancer in the US
BCC = slow-growing papule w/ pearly rolled borders
170
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
Granulomatosis w/ polyangiitis (Wegener's): systemic vasculitis, upper and lower respiratory granulomatous inflammation, GN
-common manifestations: nasal cartilage destruction and skin lesions
171
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) Mucormycosis = fungal infection
| (b) Tx = surgical debridement + IV amphotericin
172
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
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
Best tx for chronic Hep B
Tenofovir = new drug and it's awesome, used w/ entecavir
174
Polymyositis
(a) Most typical presentation
(b) Differentiating factor from dermatomyositis
(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
What class of medication is associated w/ risk of hypothermia?
Antipsychotics, typically typicals (like fluphenazine)
=>pts on antipsychotics should avoid prolonged exposure to cold temps
176
What serum testosterone and DHEAS levels can help you distinguish in a F w/ rapidly developing hyperandrogenism w/ virilization
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
Diagnostic test of choice for ureteral calculi
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
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) Huntington's chorea
| (b) CT scan: atrophy of the caudate nucleus
179
2 causes of recurrent pneumonia
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
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) 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
What are the majority of kidney stones composed of?
Calcium oxalate make up 75-90% of kidney stones
182
21 yo M w/ h/o seizures BIB ambulance during tonic-clonic seizures. Nonresponsive
(a) Dx
(b) Highest risk for the following
(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
Tx for toxoplasmosis
First line: Sulfadiazine and pyrimethamine
Or: Azithromycin
184
LP findings suggestive of LAH
Elevated opening pressure and unexplained xanthochromia (yellowish tint from bilirubin) strongly suggest SAH
185
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
```
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
What is eletrical alternans?
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
Differentiate clinical symptoms of Meniere's vs. BPPV
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
```
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) 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
Black box warning of cipro
Increased risk of tendinopathy and tendon rupture associated w/ fluoroquinolones
190
Most common meds that can cause Stevens-Johnsons
Abx
Anticonvulsants
Allopurinol
191
Key clinical distinguishing factor btwn photosensitivity rash and Steven-Johnsons
Key feature of Steven-Johnsons = involvement of mucous membranes
-mucocutaneous rxn
192
CT reveals segmental pulmonary embolus, explain why this pt also has carpopedal spasm, crampy pain, and paresthesias in extremities
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
Differentiate clinical signs of pancreatic tumors of the head vs. body/tail
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
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) 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
How to evaluate results from thoracentesis
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
Periodic acid-Schiff (PAS) reaction
hepatocytes of individuals w/ alpha-1 antitrypsin
197
Relationship btwn COPD and clubbing
(a) Most common causes of secondary digital clubbing
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
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) 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
Laboratory findings of multiple myeloma
CBC: anemia, pancytopenia (low in all 3 cell lines), hypercalcemia
Bony lytic lesions
Renal disease
200
60 yo farmer presents w/ enlarging sore on his lip
-partially encrusted ulcer surrounded by area of induration
(a) Dx
(b) Biopsy findings
(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
What drug increases survival in HF
Biggest mortality benefit = ACEi
Other CHF drugs w/ motality benefit: beta-blockers, ARB, spironolactone
-not CCB, loopdiuretics, dig, dobutamine
202
Serum complement levels in
(a) Post-strep GN
(b) MPGN
(c) IgA nephropathy
(a,b) Serum complement reduced in post-strep GN and MPGN
| (c) Complement levels are normal in IgA nephropathy
203
Most common cause of non-purulent cellulitis
Group A Strep
204
Legionnella
(a) Mechanism of spread
(b) Clinical features
(c) Associated lab findings
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
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) 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
Prolactinoma tx
Prolactinoma tx = dopamine agonist (carbegoline)
207
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?
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
Nerve most commonly involved in diabetic mononeuropathy
(a) Mechanism of injury
(b) Which fibers of the nerve lose function
(c) Clinical findings
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
Describe how cirrhosis can result in
(a) erectile dysfunction
(b) decreased measured T3/T4
(c) testicular atrophy
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
Differentiate Steven Johnson syndrome from toxic epidermal necrolysis
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
AIDS pt w/ CD4 count of 30- what prophylactic meds should she be on?
Bactrum
Azithromycin
Itraconazole
212
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
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
33 yo F presents w/ occasional diplopia and ptosis
-fatigue in hands and legs after exercising
Dx
Myasthenia gravis = lesion at the nmj (auto-antibodies against ACh receptor)
214
Mechanism of carpel tunnel
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
Post exposure prophylaxis regimen for high-risk contact to HIV
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
What is ANOVA test?
ANOVA = analysis of variance- used to compare three or more mean (average, not like sassy lol) values
217
High pitched diastolic murmur
Clasically 'high pitched' diastolic = AR
While MS is usually dull (thrill)
218
Why is metformin usually held in the hospital?
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
IV cefazolin
First generation cephalosporin commonly used as prophylaxis before surgery to prevent wound infections
220
Tumor in the head of the pancreas
(a) Clinical findings
(b) Finding on imaging
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
The following side effects are due to what HIV drug?
(a) Needle-shaped crystals in urine
(b) lactic acidosis
(c) Stevens Johnson
(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
Kussmal breathing
Deep rapid breathing
ex: RR of 28 but trying to take deep breaths
ex of etiology: metabolic acidosis
223
Which CCB would you use in HOCM- amlodipine or diltiazem
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
Necrolytic migratory erythema
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
