UWORLD 3 Flashcards

Question

Severe seborrheic dermatitis and associated condtions

Answer 1

HIV infection, parkinson disease

Answer 2

inflammatory bowel disease

Answer 3

**Hypopigmented** spots, in combination with family hx of bilateral deafness NFI has **hyperpigmented** spots; can also present with acoustic neuroma (typically unilateral) but c**utaneous neurofibromas, axillary freckling and other symptoms are usually present.**

Answer 4

hypopigmented maculae (ash-leaf spots) glial proliferation several organ harmatomas/cysts **T**uberous - think **T**umors

Answer 5

facial port-wine stain and leptomeninngeal angiomatosis **S**turge = **S**tain

Answer 6

multiple telangiceastia and vascular lesions of the CNS

Answer 7

Asprin toxicity may manifest as tinnitus and vestibular symptoms, but unilateral hearing loss does not occur with this condition.

Answer 8

any strenous activity. They can participate in low-to-moderate intensity recreational noncompetitive sports (ex: bowling, golf, doubles tennis)

Answer 9

Pneumonia A number of psychiatric medications (ex: SSRI, carbamazepine, valproic acid)

Answer 10

low serum osmolaity (\<275), inappropriately high urine osmolality (\>100) high urine sodium concentration (\>40) in the setting of clinical euvolemia

Answer 11

pseudohyponatremia describes an **artifical lab result** that occurs in patients with **increased fraction of the nonaqueous component** of the serum (ex: paraproteinemia, hypertriglycermeida). The measured **serum osmolaity is normal** in patients with pseudohyponatremia

Answer 12

In Excessive water ingestion, **Urine osmolality is low (\<100)** as the kidneys attempt to excrete large amounts of free water.

Answer 13

Migraine headaches (increased risk of ischemic stroke due to estrogen in the contraceptives) Blood pressure \> or = 160/100 and women \> or = to 35 who smoke \> or = 15 cigarettes per day

Answer 14

nerve root irritation Positive straight leg test at 60 or less is usually present

Answer 15

specificity as specifity increases, PPV also increases and the number of FP decrease

Answer 16

Highly **sensitive** tests are useful for **screening**; highly **specific** tests are useful for confirmation. Given a test with high **s**ensitivity, a **n**egative result would help **rule** **_out_** a diagnosis (**SnNout**) High **s**pecificity, a **p**ositive results would help **_rule in_** a diagnosis **(SpPin)** **\***For example**, Anti-CCP antibodies** have some value in patients with a negative RF levels. They carry a **higher specificity.** **A technietium-99 nuclear scan is highly specific for meckel's diverticulum**

Answer 17

Sensitivity. Sensitivity = TP / (TP/FN) *Probablity of a disease person testing positive* This high sensitivy helps "RULE OUT" the disease by **decreasing the number of false-negative** results and by increasing the **n**egative predictive value (Sn**N**Out) NPV = TN/ TN +*FN*

Answer 18

ACL injuries are common in atheltic activities. Unlike patients with ACL, **PLC patients do not complain of a typical "popping" sound**

Answer 19

posteriorly directed force on the anterior aspect of the proximal tibia with the knee in a flexed position This results in distruption of the PCLda

Answer 20

Sample size is related to power, which is the ability to detect a diff between groups in a study. Larger sample size results in more power.

Answer 21

Persistent sadness, persvasive anhedonia and functional impairement can help differentiate normal grief from major depressive disorder. Grieving individuals tend to have intermittent periods of sadness that revolve around reminders of the deceased.

Answer 22

Dihphenhydramine IV aside from having anithistamine properties, it has anticholinergic properties as well.

Answer 23

motility disorder **esophageal manometry** - premature contractions of the distal esophagus with normal distal esophagel sphincter relaxation. Calcium channel blockers (ex: dilitiazem)

Answer 24

lower esophageal spincter cannot relax due to degeneration of the ganglia in the auerbach plexus infection with Trypansoma cruzi (Chagas disease) Dilated esophagus with bird's beak narrowing of the distal esophagus

Answer 25

cortical and brainstem function (pupillary, oculocephalic, oculovestibulor (calcoric), corneal, gag, sucking, swallowing and extensor pospturing) Patients with brain death can have reflexes and movement, but these orginiate from peripheral nerves or the spinal cord.

Answer 26

LMWH and should be started on admission even if the patient is scheduled for surgery. This can be stopped 12 hours before surgery.

Answer 27

statistically significant differences between the groups.

Answer 28

**scuba diving** (risk of fetal decompression sickness from air embolus formation) expercise associated with a **high risk of falling** (skiing, sky diving, horsback riding) and **contact sports**

Answer 29

HTN, diabetes, smoking and dyslipidemia. HTN \*some sttudies have shown modest benefit with smoking cessation and control of blood sugar and lipids

Answer 30

SSRI Another SSRI or OCP may be tried psychiatric disoders such as Depression \*80% lifetime risk. This includes primary mood and anxieity disorders

Answer 31

**central hyperthyroidism with elevated TSH and thyroid hormone levels.** biologically inactive alpha subunit and other pituitary hormones (ex: GH leading to acromegaly) and can cause mass effect symptoms (ex: headaches, visual field defects)

Answer 32

Prior hx of cardiac aarrest or sustained VT **Family hx of sudden death** **syncope** (recurrent or exertional) **nonsustaned VT** on holter monitering **hypotension with exercise** **Extreme LVH** (\>3 cm maximal septal wall thickeness)

Answer 33

betablockers

Answer 34

increased bone turnover obtain calcium and alkaline phoshatase levels (elevated ALP and normal calcium). Bisphosphonates (reduce bone turnover)

Answer 35

**Serum protein electrophoresis i**s useful **screening** test for patients with suspected monoclonal gammopathy, such as in **multiple myeloma** **MM** usually involves bones with **scattered lytic lesions** or occansionally diffuse osteopenia. The **thickened, sclerotic bone in patients with PDB** would not be seen in myeloma.

Answer 36

Hearing loss is a common complication Treatment with calcitonin or bisphosphonates can slow the progression of hearing loss but is unlikely to reverese hearing loss that has already occured

Answer 37

patients who have complications of anticoagulation, contraindications to anticoagulation or failure of anticoagulation

Answer 38

Streptococcus pneumoniae, **Nontypeable Haeomophilus influenzae** (may cause **otitis-conjuncitivitis syndrome**, which is purulent conjunctivitis that occurs the same time as acute otitis media) Moraxella catarhalis \*M. catarrhalis less common than S. pneumo and H. influenzae and does not cause otits-conjunctivitis syndrome

Answer 39

high dose oral amoxicillin recurrent AOM should raise concern for beta-lactamase resistant and warrants treatment with amoxicillin-clavulanci acid.

Answer 40

lipoatrophy, fat accumulation or both in different areas. A pattern with increased fat tissue deposition on the back of the neck and abdomen along with thin extremities and face Insulin resistance and dyslipedemia \*cause and effect is unclear

Answer 41

Icnreased fat deposition in the neck and abdomen could be confused with cushing's disease from adrenal hyperplasia. However, only adrenal insufficiency has a correlation with HIV infection.

Answer 42

a.k.a infected arterial aneurysm metastic infection from Infective endocarditis, with steptic embolization and localized vessel wall destruction in the cerebral (or systemic) circulation. expanding mass with focal neurologic findings or with aneurysm rupture and suarachnoid hemorrhage

Answer 43

delayed puberty retarded bone age postive family hx without any evidence of systemic disorder these patients develop puberty without any intervention

Answer 44

switching or adding an anti-cytokine drug (ex: infliximab, entanercept) Use of anti-cytokine therapy is associated with higher incidence of opportunisitc infections, particular reactivation of TB; therefore, all such patients hould be screened for latent TB by PPD testing.

Answer 45

septic arthritis especialy when accompanied by systemic signs of infeciton such as fever do joint aspirations

Answer 46

patients 55-80 who have \> or = 30 pack year smoking history and are current smokers or quit within the last 15 years.

Answer 47

should be initated on treatment prior to bacteriologic confirmation Treatment involves **2 months of 4 drug therapy** with isonaizd, rifampin, pyrazinamide ad eitehr fluoroquinolone or injectable aminoglycoside, **followed by 9-12 months of continued therapy** with isoniazide plus rifampin. Patients should also receive **adjuvant glucocorticoids** to reduce treatment-associaed CNS inflammation

Answer 48

episodic symptoms (headaches, diaphoresis and tachycardia), early onset or refactory hypertension and paraosymal hypertension. Measuring **plasma free metanephrine levels** or **24 hour urine collection for measurement of catecholamine and metanephrine.** **Abdominal imaging (CT or MRI)** to help localize pheochromocytomas, which are usually located in the adrenal glands. If negative, **metaiodbenzylguanine (MIBG) scan,** which is a functional scintigraphhy with iodine labled MIBG. MIBG resembles NE, is taken up by adrenergic tissue and can detect tumors not detected by MRI or CT.

Answer 49

adrequate prepoperative control of blood pressure for 10-4 days with an alpha blocker, and intravascular fluid volume repletion with liberal fluid and salt. BB are given only to patients with adequate and complete alpha blockade. \*BB started before alpha blockade can lead to paradooxical increase in BP.

Answer 50

**tabes dorsalis** (sensory ataxia and lacinating pains) and **Argyll Robertson pupils** (consriction with accommodation (reduce in size on a near object) but not with light) **Diminished pain and temp sensation, areflexia.** lancinating pains (**brielf shooting or burining back in the face, back or extremities**) **instability during the Rhomberg test** \*Tabes dorsalis is a neurogenative disorder that inolves the poserior spinal column and nerve roots.

Answer 51

Both HHS and DKA occur in patients with poorly controlled diabetes. Patients with Type 2 DM tend to develop HHS as opposed to DKA which is ruled out by patient **negative serum ketones.** **HHS** - has **serum bicarbonate near lower limits of normal** **DKA - have anion gap acidosis** (secondary to ketoacid production) \*Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis.

Answer 52

Chronic aclohol use and DM can result in symmetric sensory peripheral nuropahty that presents similarly to Tabes dorsalis. Lyme disease has high incidence in Mid-Atlantic region of the US and can also have variable neurolgic manifestations. **However, Argyll Robertson puppils are not associated with these conditions.**

Answer 53

used to determine if the **occurance of cancer** in a small population is high or low **relative to an expected value** derived from a larger comparison population. It is calculated by **dividing the observed cases by the expected cases.**

Answer 54

**Aggressive volume resuscitation** since they are generally severely volume depleted. IV insulin should be started after the patient has been partially resusciated. **Aggressive management of Hyperkalemia should be avoided** in these patients since these patients generally have a total body potassium deficit (that would become unmasked with fluids and insulin). \* Analysis of the physiopathology of the HHS syndrome points to **sodium and water deficits as the principal cause** of symptoms. A r**apid lowering of the blood glucose level may be detrimental,** since this leads to an osmotic gradient between the central nervous system and the intravascular space. Treatment should be directed at the **rapid replacement of sodium and water with minimal administration of insulin.**

Answer 55

1:1 observation and hospitalization under involuntary status.

Answer 56

**most common cause of knee pain in young adults, especially women** \*women have greater angle btw the main axis of the quadriceps and the vertical axis of the patellofemoral grove **Clinical diagnosis** Patients may have a reproduction of pain by extension of the knee with anteior pressure on the patella (**patellofemoral compression test**) Treatment is primarily **stretching and streghening exercises of the thigh**

Answer 57

affects the **second and third metacarpophalangeal joints, knees, ankles and shoulders.** Joint aspiration can identify **calcium pyrophosphate dihydrate crystals in approx. 50% of patients.** These crystals have a rhomboid shape and positive birefringence under polarized light. Treatment: **phlebtomy** usually **does not improve the arthropathy**

Answer 58

**Gout** typically cause episodic, acute inflammatory arthritis affecting the **1st MCP joint** (2nd and 3rd in HCC). Microscopy shows **needle-shaped, negatively birefringent** crystals. (rhomboid shape and positive birefringence in HCC)

Answer 59

OA synvoivd fluid is typically bland, with less than \<2,000 cells, \<50% neutrophils and **no crystals**

Answer 60

RA causes arthritis in inflammatory synovial effusion, however no crystals are present.

Answer 61

HCC due to associated chronic liver disease. Treatmetn with phelbotomy can lead to improved HCC function, with reduced progression to cirrhosis and an associated reduction in the risk of HCC.

Answer 62

**midline neck mass that moves with protrusion of the tongue** (thyroid is formed as an outpouching from the base of the tongue and then descends to the base of the anterior neck. The Thyroglossal duct connects the tongue and the thyroid gland and a cyst can develop from the epithelial remnants within the duct.) Ectopic thyroid tissue is present in a large nubmer of patients within the thyroglossal duct cysts, but sometimes this is the only functional tissue present. Therefore **imaging studies, like thyroid nuclear scan, ultrasound or CT** is mandatory before subjecting patient to surgery.

Answer 63

Most common adverse event not undergoing surgery - **adverse drug event**

Answer 64

oligomenorrhea/amenorrhea relative caloric deficiency decrease bone mineral density \*cayses decrease levels of GnRH resuling int decreased LH and FSH levels, supressed ovarian function and low estrogen levels.

Answer 65

rare, potentially life threatening disorder caused by **neurotoxins found in the tick salivia.** Manifestations typically arise **4-7 days of tick attachment** and include **rapaidly progressive gait ataxia and ascending paralysis.** Neurologic examination usually reveals **absent deep tendon reflexes and normal sensation.** **Fever is uncommon.** A **teticulous skin examination** is required.

Answer 66

Colstridium Botulinum toxin can be found by serum analysis. Botulism usually causes a afebrile, descending paralysis, starting with the cranial nerves. This patient with motor weakness of the legs and normal cranial nerves is unlikely to have botulism

Answer 67

Electrodiagnostic studies and CSF (elevated protein with normal leukocytes) are often obtained to support Guillian-barree syndrome. This syndrome casues ascending paralsysis with absent deep tendon relfexes, but usually follows a GI or respiratory ifection and typically progresses over sveral days or weeks (rather than hours). This child who recently camped in the woods should first be examined meticulousy for ticks to rule out ticks paralysis.

Answer 68

meticulous skin exam. Tick removal usually significally improves symptoms within a few hours. Most patietns recover completely without further intervention.

Answer 69

_Early neurosyphillis_ - symptomatic meningitis, ocular syphillis and otosyphillis. \*early neurosyphillis most commonly occur during the secondary stage of syphillis (as indicated by the generalized maculopapular rash and lymphadenopathy) _Late neurosyphilis (tertiary)_- General paresis & tabes dorsalis (uncommon)

Answer 70

Disseminated gonoccocemia presents as eitehr a combination of a rash with tenosynovitis and a non-purulent polyarthraiga or lone purulent polyarthritis.

Answer 71

Meningococcal infections may present with rash and miningitis, but would progress rapidly (usually over a period of hours rather than days) to severe and life-threaning meningitis.

Answer 72

urinalysis and urine culture pyuria and positive urine culture are consistent with prostatitis.

Answer 73

Insulin Metformin and other sulfonylureas (ex: glyburide) since they are metbolized by the kidney, in order to avoid toxicity and adverse events. Rosiglitazone, pioglitzone, acarbose or repaglinide are alternatives. \*Rosiglitazone, pioglitzone are metabolized by the liver.

Answer 74

airway injury and edema (ex: supragloggic damage stems from inhaling hot air, steam or smoke).

Answer 75

**Telescoping of the proximal portion of the intestine into a distal portion.** Children ages **6 months to 3 years** **severe, episodic, crampy abdominal pain, emesis and "current" jelly** **Air or water soluble enema** \*barium contrast enemas are traditionally used for reduction of intussusception, but are no longer preferred given the risk of peritionitis if perforation occurs

Answer 76

**Intestinal perforation** **Radiographs of the abdomen** to rule out intestional perforation. \*Air (pneumatic) enema is generally preferred for intial reduction as it tends to be fast, thereby minimizing radiation exposure. In addition, perforation from air enemas tend to be smaller than those occuring with water soluble (hydrostatic) or barium enmas. Air, unlike contrast mediums, is not harmful to the contents of the peritoneal cavity.

Answer 77

Smoking, obesity and hypertension hematuria, abdominal mass, and/or flank pain. Paraneoplastic syndrome (ex: erythropoietin secretion) are common CT of the abodmen to evaluate for renal mass

Answer 78

myeloproliferative disorder (ex: myelofribrossi) are diagnosed by Bone marrow biopsy and can cause erythrocytosis. However, hematuria is not a common typical feature of these disorders (unless patients have severe thrombocyopenia).

Answer 79

PCV is a chronic myeloproliferative neoplasm often associated with JAK2 mutations. Erythrocytosis is a defining feature, patietns also have aqugenic pruritis, HTN, and arterial or venous thrombosis. This patient with long-term cigarette use and hematuria is more likely to have erythrocytosis due to RCC

Answer 80

Anabolic steriods can stimulate erythropoiesis and stimulate erythrocytosis. THis patietn with hematuria and chronic cigarette use is more likely to ahve RCC

Answer 81

enhancing kidney mass with thickened, irregular walls or septa. If the tumor is localized within the kidney, nephectomy is usually curative.

Answer 82

Simple and complex cysts as well as cyts for PCKD do not enhance with contrast. RCC mass enhances with contrast.

Answer 83

**nonejection click** due to snapping of the mitral chordae as the valves cusps extend into the atrium during systole, followed by **systolic mumur** of mitral regurg **The timing of the click during systole varies depending on LVEDV.** In the setting of **increased venous return** (ex: squatting, supine leg raise), LVEDV is relatively high and the critical point at which prolpase occurs is reached **late in systole** or may not be reached at all (disappearance of the click). In contrast, maneuvers that **decrease venous return** (ex: standing, valsalva) result in relatively low LVEDV, earlier reaching of the critical prolapse during systole and an **earlier click and murmur.**

Answer 84

An ejection click followed by midsystolic murmur is heard in patients with aortic or pulmonic valve stenosis. The murmor is typically crescendo-decresendo and increases in intensity with increased venous return. MVP - nonejection click and systolic mumur of mitral regurg. murmur becomes less promiment in the setting of increased venous return Increased Venous return --\> increases LVEDV --\> proplase occurs late in systolic or may not be reached at all (disppearce of click)

Answer 85

MVP and HCM

Answer 86

accentuated S1 (mitral valve closure), an opening snap heard after S2 and a low pitched mid-diastic meumur best heard at cardiac apex

Answer 87

house dust mites

Answer 88

**delayed meconium passage and abdominal distension** due to lackof innervation in the rectosigmoid colon **distal bowel obstruction on xray and a transition zone** (normal versus narrow) **on contrast enema.** **rectal suction biopsy** - absence of ganglion cells

Answer 89

Upper GI series is the best test for diagnosing malrotaiton of midgut volvulus, which can cuase bilious emesis but is not associated with delayed meconium passage. In addition, abdominal xray may show a nasogastric tube in a displaced duodenum rather than dilated loops of large bowel.

Answer 90

free living, gram neg. bacteria found in coastal water and marine environments. infections are acquired primarily through consumption of raw oysters or through wound contamination during recreational activities or raw seafood handling. Patients with certain characteristics (ex: liver disease or DM) are at high risk for fatal infection, incuding rapidly progressive cellulitis, hemorrhagic bullae and septic shock. Dx: blood & Wound cultures Treatment with IV antibotics should not be delayed

Answer 91

Pseudomonas skin infections are associated with hot tub exposure and usually result in folliculitis (tender papules or nodules). Rapidly progressive celluluitis with hemorrhagic bullae after injury in a marine enviroment is more likely to have V. vulnificus.

Answer 92

Staph. Aureus is a common cause of skin abscess and cellulitis. However this infeciton usually arises over a few days (not hours) and is typically not associated with marine environments.

Answer 93

flu-like febrile illness with marked myalgias & joint pains (**break bone fever**) ## Footnote **retro-orbital pain** **rash (white islands in sea of red)**

Answer 94

**increased vascular permeability** **thrombocytopenia** (\<100,00 **Spontatenous bleeding --\> Shock** **Positive tourniquet test** (petechiae after cuff inflation for 5 mins)

Answer 95

supportive

Answer 96

Respiratory/Circulatory failure can develop with signficant plasma leakage due to increased capillary permeability.

Answer 97

Cerebral edema can occur in Plasmodium falciparum malaria, which sually presents with fever, anemia and splenomegaly. This patietns absence of anemia makes it less likely. In addition, patients that took advised prophylaic medications can rule out malaria.

Answer 98

68% lie within the 1st standard deviation of the mean 95% of observations lie within 2 S.D of the mean 99.7 lie within 3 standard deviations of hte mean.

Answer 99

**Primary** - before pt. develops disease; prevention **Secondary** -halt the progression of a disaease before irreversible change takes place (ex: statins use with hx of angina) **Tertiary** - disease has advanced, limit impairments and disabilities (ex: CABG) **Quatenary** - set of health activities that limit the conseq. of unncessary or excessive intervention by the health system (ex shared EMR to lmit unncessary repeated cardiac catherization procedures)

Answer 100

selective estrogen receptor modulator increses the risk for endometrial hyperplasia/cancer and uterine sarcoma in postmenopsual women. However, asymptomatic patients on tomixfien do not rrequire routine screening for these complications. Endometrial biopsy is indicated only for symptomatic patients

Answer 101

**monoclonal b-cell leukemia** has significant lymphocytosis that causes **lympahdenopahty**, **organomegaly** (liver, spleen) and **anemmia/thrombocytopenia**, all of which are associated with worse prognosis

Answer 102

**peripheral smear (smudge cells) and flow cytometry** \*LN and bone marrow biopsies are generally not needed!

Answer 103

medical mgmt to lessen the degree of colitis, with **glucocorticoids** used for patients with underlying inflammatory bowel disease and appropriate antibotics used for patients with infectious colitis. 5-ASA compounds and opiods should be avoided in patients with toxic megacolon as they can precipitate attacks. 5-ASA can be retarted at a later time after the patient's condition has improved with glucocorticoids.

Answer 104

Vancomycin with the addition of gram neg. coverage (cephalosporin cefepime) if the patient is neutropenic or septic Majority of catheeter associated infections are due to coagulaase negative staph and in the majority of cases, the isolates are methicillin resistant.

Answer 105

treated as an emergency with empiric high dose corticosteriods MRI should be ordererd to confirm the diagnosis and assess spine stablilty Patietns with highly radiosensitive tumors may be treated with radiation. Patients with radioresistant tumors and those with an unstable spine should undergo surgical evaluation.

Answer 106

naked patient should be spray with tepid water mist or covered with a wet sheet while large fans circulate air to maiximize evaporative heat loss. Other cooling methodds includie icepacks, ice water lavage or cold IV fluids are helpful adjuncts but not first line

Answer 107

bitemporal hemianopsia and hyperpigmentation following bilateral adrenalectomy for cushing disease The cause of pituitary enlargement is the loss of feedback by the adrenal glucocorticoids following bilateral adrenalectomy.

Answer 108

MRI - a pituitary microademia with suprasellar extension and extremly high plasma ACTH are diagnositic Usually these tumors are rapid growing and can be treated withs urgery and/or local radiation

Answer 109

after a strong contraction of the quadriceps (ex: pivot, landing), patients with severe pain, anterior knee swelling and an inability to actively extend the knee or maitain passive extension of the knee

Answer 110

direct impact to the lateral knee causing valgus stress to the joint laxity of the knee joint occurs when valgus stress is applied

Answer 111

early surgical repair optimizes recovery of normal knee moation to prevent long-term disability.

Answer 112

immediate cessation of all forms of heparin, lab testing to confirm the diagnosis and starting alternate anticoagulants (ex: direct thrombin inhibitors) even if thrombosis has not occured. Warfarin is suallys tarted after treatment of non-hepatrin anticoagulant and platelet count recovery to \> or = 150,000

Answer 113

**Asymptomatic pulmonary sarcoidosis generally do not require treatment.** **Hilar adenopahty assocaited with erythema nodosum** represents a **favorable** variant of sarciodosis that is associated with a high rate of spontaneous remission and **good prognosis** **Fever, hypercalemia means systematic manifestations, and extra pulmonary manifestations (including cutaneous) require corticosteroid therapy, except erythema nodosum is an exception**

Answer 114

common in atheletes and nonatheletes who suddenly increase their physical activity pain, localized tenderness and swelling Plain x-ray is \<50% sensitive for stress fractures, especially in the first 2-3 weeks after onset of symptoms - will often show no bone abnormalities in the first 2-3 weeks. (MRI is preferred if definitive diagnosis is needed)

Answer 115

splinting, reduced weight bearing and graudated exercise program. Most paients may resume full intensity exercise within 12 weeks, but the program may need to be delayed if the patient develops recurrent pain

Answer 116

Oral metronidazole is recommented first line for treatment of mild to moderate C. diff associated colitits. Oral vanco is recommened for severe C. Diff colittis (systemic toxicity such as high fever, WBC \>15,000 and creatinine \>1.5 baseline)

Answer 117

unscheduled bleeding occurs due to a thin atrophic unstable endometrium that sheds erratically (occurs when oral contraceptives do not contain enough estrogen) Oral contraceptives do not cause weight gain or impaired fertility.

Answer 118

Diphenhydraine has anticholinergic properties and some symptoms of anticholinergic toxicity (ex: mydraiasis, tachycardia) overlap with those of stimulatant intoxiciation. Anticholinergic toxicity is differentiated by presence of dry skin (as opposed to diaphoresis) and other classic anticholinergic manifestations, such as ileus and urinary retention.

Answer 119

represents teh value of a negative test result the smaller the LR, the less likely it is that the disease is actually present. NEgative result on a highly senstive test helps rule out the disease

Answer 120

confirmed initally with elevated levels of serum amylase or lipase in teh setting of acute characteristic epigastric pain. Advanced imaging (ex: MRI or CT) may be pursued if basic labs results and Ultrasound fail to provide a diagnosis

Answer 121

Abdominal CT scan with contrast to evaluate for potential complications or evidence of infection

Answer 122

osteoporosis and hip fracture. PPIS possibly decrease calcium abosprtion, inhibit osteoclastic activity and eventually reduce bone mineral density.

Answer 123

risk of the exposed divided by the risk of the unexposed group

Answer 124

**excess risk.** it estimates the proportion of the disease in exposed subjects that is attributed to exposure status. **ARP = (Risk in exposed-risk in unexposed)/Risk in exposed**

Answer 125

the proportion of disease in the population that is attributed to the exposure. PARP = (Risk in the total pop-risk in the unexposed)/Risk in the total population. Unlike attributable risk percent, PARP is the measure of excess risk in the total population, not only in exposed subjects.

Answer 126

rapidly acting sedative (etomidate, propofol, midazolam) and a paralytic agent (ex: succinylcholine, rocuronium) to facilitate emergent intubation while preventing aspiration).

Answer 127

PE causes pulmonary HTN, which can lead to acute RV dysfunction, Tricsupid annulus dilation and functional tricuspid valve regurg. Bedside echo can aid in teh diagnosis of acute, massive PE

Answer 128

**serious fluid otits media** generally resolves spontaneously within 3 months; therefore **watchful waiting** is the recommended mgmt, unless there are persistant symptoms of infection, the effusion is bilateral or \>3 months have lapsed since inital episode

Answer 129

patients with positive stress testing results should be started on appropriate **medical therapy and those with high-risk stress testing features should undergo coronary angiography to evaluate for revascularization** \*high risk eg, ST depression on minimal exertion

Answer 130

Lower GI source of hemorrhage After inital resuscitation with fluids and type and cross match for possible transfusion, a colonoscopy is generally the next step in mgmt for hemodynamically stable patietns, as it can be both diagnostic and theraupetic.

Answer 131

do EGD instead esophagelgastrodueodensoscopy

Answer 132

severe agitation and violent behavior should be treated immediately with benzodiazpines to improve sedation. A low stimulation environment (with or without benzodiazepines) is more appropriate for patients with milder symptoms of PCP intoxication.

Answer 133

1- hour 50-g glucose challenge test (greater than 140 is indication for 2nd step) confirmed with 3 hour 100-g glucose tolerance test \*Fasting gucose and Hb 1Ac are not effective. Hb1Ac are lower in pregnant women due to physiologic increases in RBC mass and cell turnover.

Answer 134

fetal macrosoma and should dystocia. If adequate glucose control cannot be achieved by diet and exercise, anti-hyperglycemic agents are initaated.

Answer 135

fasting \< or = 95 1 hour postprandial \< or = 140 or 2 hour postprandial \< or = 120

Answer 136

dietary modifications insulin, metformin, glyburide

Answer 137

fever, abdominal pain, and bloody diarrhea Salmonella, Shigella, E.coli (enterhemorrhagic or enteroinvasive), campylobacter and yersinia oral electrolyte solution antibotics for invasive (should be avoided until pathogen is identified)

Answer 138

UMN - contra, lower face only afected (as seen in strokes) LMN- Ips, cannot raise eyebrows (as seen in bell's palsy) \***b**e**Ll** -**b**row, **L**ower, **I**psi

Answer 139

nonmalignant lesion, but has a significant association with future development of invasive breast cancerr and at min close surveillance is required for the duration of the patient's life. If LCIS is detected on needle biopsy, **excisional biopsy** is recommened since a signficant percentage of cases are upstaged to eitehr invasive cancer or DCIS

Answer 140

**Patients can discountinue anti-hyperglycemic therapy after delivery.** However, paitents with GDM ar**e screened 6-12 weeks postpartum with a 2 hour oral glucose tolerance test** due to the association between GDM and type 2 DM. \*During 2nd and 3rd trimeser of pregnancy, placenta begins to secrete increasing amounts of diabetogenic hormones that increase maternal insulin resistance to promote fetal growth. However, women with pancreatic function that is inadequte to over come this insulin resistance are at risk for developing GDM. after delivery of the placenta, maternal insulin resistance decreases and glucose contentrations normalize to prepregnancy levels.

Answer 141

family hiostory of parental dyslipidemia or first or second degree relative with premature coronary artery disease. Screening is also indicated for a personal history of obesity, diabetes, hypertension or smoking.

Answer 142

**Dumping syndrome** Decreasing the speed of passage of fluids and food into the small gut A **high protein and low carb diet** is advised, as well as smaller but more frequent meals throughout the day.

Answer 143

uretral catehrization in order to decompress the bladder, alleivate the pain and avoid further renal compromise. Suprapublic catherization (because of bowel perforation) Suprapubic catherization should preferrablly be peformed by urologist if there is evidence of urethral or pelvic trauma or if Foley catherer placement is difficult.

Answer 144

screening for cervical cancer by cytology (pap test) **21 in most women regardless of age of onset of sexual activity.** **Routine testing for HPV is not indicated for women age \<30.** Most HPV infections (and therefore abnormal Pap test results) are transient and resolve without intervention. **Just do pap test every 3 years.** **Pap test with HPV cotesting every 5 years or Pap testing alone every 3 years** is recommended for women **age 30-65**

Answer 145

Repeat calcium with concurrent measurement of serum PTH hormone to disguistinguish PTH-dependent (ex: primary hyper PTH) from non PTH dependent causes. Even when malignancy is suspected, still do PTH first.

Answer 146

HHM is due to secretion of PTH related protein (similar to PTH and binds to PTH receptors). Hypercalcemia in primary hyperparathyroidism is usually mild (calcium \<12) and often asymptompatic, where as HHM is typically more acute and severe.

Answer 147

thiazide diuretics, lithium and excessvie doses of calcium carbonate or Vit. D

Answer 148

PTHrP increases, PTH decreases

Answer 149

Obstructing endobronchial malignancy A chest CT can help diagnose such maligancy as well as other casues of nonresolving pnemonia such as an abscess or empyema

Answer 150

Early immobilization and operative fixation of fractures There is no evidence that prophylactic heparin reduces the risk of fat embolism.

Answer 151

**Placement of chest tube** \*A large pneumothorax can quickly lead to tension phyiology, resulting in compression of mediastinal structures and marked hypotension; however, the normal blood pressure and absence of JVD and tracheal deviation suggests that tension pneumothorax has not deveoped. **Needle decompression** is appropriate emergency treatment of **tension pneumothorax** in a patient in whom **cardiac arrest is imminent.** However, needle decompression must always be followed by chest tube placemet for definitive management; threefore placement of a chest tube is more aporpriate in a patient who has not developed tension phyisology.

Answer 152

acute ischemic event involving the retinal artery sudden and usually reversible marker of carotid artery atheroscloertic disease A carotid bruit Carotid doppler evaulation

Answer 153

Anti-nuclear antibodies (in a homogenous staining pattern) and anti-smooth muscle antibodies (against actin) Elevated AST, ALT levels, normal or near normal ALP and normal bilirubin

Answer 154

Trimethoprim, methotrexate and phenytoin Methotrexate inhibits enzyme dihydrofolate reductase (DHFR) which is essential for the conversion of folic acid to its redued form (FH4-folinic acid), which can be utilized by cells.

Answer 155

Folinic acid (Leucovorin) is more potent than folic acid in 'rescuing' red blood cells from the deficiency by bypassing the block on DHFR. It is therefore the drug of choice for folate deficiency anemia induced by choric, high dose methrotrexate therapy.

Answer 156

**Xlinked recessive deletion of dystrophin gene on chromosome Xp21** **difficulty walking, gower sign, bilateral calf enlargement in toddler boys.** **Serum Creatine phosphokinse** is **markedly elevated,** reflecting significant muscle damage. \*The first step in the evaulation of muscle weakness involves measuring CPK. This enzyme is involved in muscle storage and transfer and is released into the blood with any muscle inflammation or damage. Serum CPK levels are markedly elevated 10-20 times normal by age 2 and then decrease with advancing disease as the muscle is replaced by fat and fibrosis.

Answer 157

**Genetic testing** showing deletion of one more exons of DMD gene confirms the diagnosis Muscle biopsy: Significant fibrosis, fat, muscle degeneration and absent immunochemistry staining of dystrophin.

Answer 158

Duchenne-wheelchair dependent by adolescence, death by age 20-30 from respiratory or heart failure Becker - Death by age 40-50 from heart failure

Answer 159

thrombosis of the hepatic (not portal vein) or intra/suprahepatic inferior vena cava. Acute - RUQ pain, hepatomegaly, jaundice, and rapidly developing ascities Chronic - ascities, cirrhosis, and signs of portal HTN (ex: gastroesophageal varies, splenomegaly)

Answer 160

due to occusion of the terminal hepatic venules (not veins) and causess posinusoidal portal HTN. It commonly occurs in patietns with bone marrow transplant and presents with tender heaptomegaly, jaundice and ascities. *\*The causes of veno-occlusive disease are still unclear, but a combination of pretransplant risk factors and transplant-related conditions are believed to trigger a primarily hepatic sinusoidal injury. \**

Answer 161

**Hypocalecemia** **Hyperactive deep tendon reflexes** *Usually hypocalcemia occurs due to volume expansion and hypoalbuminemia and is therefore asymptomatic, but sometimes it may mainfest as hyperactive DTR, msucle cramps or rarely convulsions.*

Answer 162

Hypomagnesemia may mimic hypocalcemia but it is associated with alcoholism, prolonged NG suction or diuretic use.

Answer 163

GI disturbances (Nausea, vomiting), ECG changes and asystole, if severe. severe burns, crush injuries and renal insufficiency.

Answer 164

metastic disease CT scan of the neck and chest to look for metastic disease. Medullary thyroid cancers do not take up idoine, therefore total boy iodine scan is not useful.

Answer 165

He does not have testicular enlargement by 14 years of age, or if his testicles are 2.5cm or less in diameter. Another criterion is a delay in the development for 5 years or more from the onset of genitalia enlargement.

Answer 166

Use of an imaging test to determine bone age. BOne age that is older or equal to the chronological age warrants further testing to rule out chromosomal abnormality and endocrine causes.

Answer 167

Acute retroviral syndrome may resemble infectious mono and commonly include fever, nontender lympadenopathy, sore throat, fatigue and myalagia. Two **distinctive** features are a **painful mucocutaneous ulcer** (shallow, discrete, white base) and a **generalized maculopapular rash** that may include the palms and soles. Laboratory testing often shows **leukopenia** and **thrombocytopenia**.

Answer 168

secondary syphillis can cause fever, headache, nontender lympadenphathy, fatigue and a maculopapular rash that includes palms and soles. A single painful mucocutaneous lesion would be atypical (sypilitic chancres are often nontender and a marker of primary syphilis).

Answer 169

Cremasteric reflex test (absent reflex is highly suggestive of torsion). ## Footnote *\*Pain relief with scrotum elevation (Prehn sign) can be seen in epididymtis and absent in torsion, but it is not a reliable diagnostic test to differentiate the two.*

Answer 170

Hypophosphatemia

Answer 171

Chronic alcoholic patients are frequently **phosphate depleted** **even though serum phosphate levels may initally be normal (due to decrease Vit D and P intake --\> increased PTH --\> increased Urinary Phosphate)** Refeeding in these patients, particularly if a respiratory alkalosis is also present, may lead to shifts in phosphate intracellularly and decreased serum phosphate. This may lead to the development of rabdomyylosis as many of these patients have an underlying myopathy

Answer 172

voiding cystourethrogram obtained by catheteriizing the patient, injecting radiopaque dye and obtaining images during voiding.

Answer 173

N/V, anorexia, fatigue, visual disturbances, confusion and cardiac abnormalities. Verapamil, quinidine, and amiodarone \*Verapamil inhibits renal tubular secretion of digoxin, resulting in almost 70-100% increase in serum digoxin levels.

Answer 174

headache, confusion, amnesia, difficulty in concentrating or with multitasking, vertigo, mood alteration, sleep disturbance and anxiety. symptoms typically resolve in symptomatic treatment within a few weeks to months following traumatic brain injury; however some patients may have persisitent symptoms lasting \> or = 6 months.

Answer 175

Calcium antagonists, typically nifedipine or amlodipine \*Use dihydropyridine CCBs. Verapamil has not been shown to be effective or least equally effective.

Answer 176

Neutropenia and bone marrow suppression

Answer 177

Meningitis and brain abscess Brain or spinal cord tumors Multiple sclerosis Guillain-Barré syndrome Syphilis \*only a small amount is normally present in CSF because proteins are large molecules and do not cross the blood/brain barrier easily. Decreases in CSF protein are not generally considered significant.

Answer 178

Pressure of the CSF can be measured when opening (starting) and closing (finishing) the collection. ## Footnote **Increased CSF pressure** may be seen with a variety of conditions that **increase pressure within the brain or skull and/or obstruct the flow of CSF**, such as tumors, infection, abnormal accumulation of CSF within the brain (hydrocephalus), or bleeding. **Decreased pressur**e may be due to **dehydration, shock, or leakage of CSF through an opening** (another lumbar puncture site or sinus fracture).

Answer 179

Cryptococcus neoformans is a Yeast that commonly causes opportunistic CNS infections in patients with AIDS (CD4 counts \<100) Skin findings of papular lesions with centeral umbilication that resumble molluscum contagiosum are common Inital therapy includes amphotericin B and flucytosine

Answer 180

Marked elevated opening pressure Low leukocyte count (compared to other mingitides) with a lymphocytic predominance Elevated protein and low glucose Positive ink preparation or cryptococcal antigen test

Answer 181

Early neurosyphillius can cause meningigits and is typically treated with aqueous crystalline Penicillin G. CSF lymphocyte count is usually 200-400 (unlike low count \<50 in Cryptococcus)

Answer 182

In adults,the most common causes of bacterial meningitis are Strep Pneumo and Neisseria. Empiric therapy includes a third generation cephalosporin such as ceftriaxone in addition to vanco (to cover some penicillin-resistant S. pneumo strains). Adults \>50 should also receive ampicillin as they have an increased risk of Listeria monocytogenes in menigningits. In this patient, the suacute course and low CSF leukocyte count with lymphocytic predominance makes bacterial mengingitis less likely.

Answer 183

CMV can cause encephaitis in patients with advanced HIV and can e treated with ganciclovir plus foscarnet. CMV is typically associated iwth AMS, focal neuro deficits and polymorphonuclear (not lymphocytic pleocytosis)

Answer 184

may have increased intracranial pressure. Paitents may require **repeated lumbar punctures t**o reduce elevated pressure. * \*Patients with AIDS who have cryptococcal meningoencephalitis often have dramatic CSF fungal burdens (\>1,000,000).* * The yeast and capsular polysaccharides can colg the arachnoid villi, which prevents CSF outflow and inreases ICP.*

Answer 185

Dexamethasone reduces inflammation, morbidity and risk of death. Dexamethasone is not recommended for treatment of cryptococcal meiningitis.

Answer 186

_Induction_ - **ampotericin B and flucytosine** **for \> or = 2 weeks** (until symptoms abate and CSF is sterilized) _Consolidation_ - **high dose fluconazole for 8 weeks** _Maintenance_ - l**ower dose oral fluconazole for \> or = 1 year** to prevent recurrence Antiviral threatment should generally be initated 2-10 weeks after beginning treatment for meningitis.

Answer 187

strong anticholinergic effectds (which increases colonic transit time). Other theraperies for depression (ex: SSRI) can be used.

Answer 188

Autoimmune condition that causes thrombocytopenia with no other lab. abnormalities. Patients with **mild (pecechaie, purpura) or no bleeding** do not require pharmacotherapy and can be managed with observation and monitoring of th plateletcounts. Those with **increase bleeding risk (mucosal bleeding, platelet count \<30,000)** are treated with **IV immune globulin.** Approx. 50% of children with ITP have spontaneus remission within a few years after diagnosis.

Answer 189

bacterial vaginosis and cervical cancer. This increased risk ikely arises from lower rates of HPV vaccination and cervical screening. The risk of bacterial vaginosis is increased due to the exchange of vaginal secretions.

Answer 190

BV is associated with an increased risk for pregnancy complications (ex: preterm labor). However, treatment has no impact on the incidence of these complicatons and pregnant women with BV are treated only for symptomatic management.

Answer 191

**MRI** shows ovoid-shaped periventricular white matter lesions. **Lumbar puncture** can confirm the diagnossi in equivoocal cases and may demostirate oligoclonal bands and an elevated IgG index. *\*MRI is superior to CT in evaluating posterior fossa/cerebellar abnormalities and is more sensitive/specific for detecting MS lesions.*

Answer 192

corticosteriods optic neuritis - should receive IV corticosteriods as oral agents may be associated with an increased risk of recurrence. Plasmapheresis can be used in refractory cases.

Answer 193

**Diesease modifying drugs (**ex: beta-interferon, glatiramer acetate) They can decrease the frequency of relapses and reduce the development of brain lesions.

Answer 194

Same as nonpregnant people, the treatment for acute MS exacerbation is short-term IV glucocorticoids as they are generally well tolderated and are not associated with teratogenicity.

Answer 195

cesarean section and assisted delivery (ex: vacuum, forcepts)

Answer 196

oral muscle relaxants such as baclofen or tizanidine Physical therapy and stretching exercises may be helpful

Answer 197

gabapentin or duloxetin

Answer 198

Sleep hygiene, regular exercise **Amantadine** *(antiviral also used for prevent/treat influenza. effective in relieving fatigue in MS)* Stimulants (ex: methylphendiate, monafinil)

Answer 199

_Maternal_ Active untreated TB Maternal HIV infection Herpetic breast lesions Active varicella infection Chemotherapy or radiation therapy Active substance abuse _Infant_ Galactosemia

Answer 200

**Hepatotoxicty** and range from mild hepatotoxicity to hepatitis. Patients should have **baseline and monthly monitoring** of aminotransferases. INH should be discontinued in patients who have **aminotransferases \> or = five times the upper limit of normal** OR develop **symptoms** *(ex: jaundice, AMS)* **with aminotransferases \> or = 3 times the ULN.**

Answer 201

ethambutol

Answer 202

aka skin tags are benign outgrowth of normal skin that appear as pedunculated, skin-colored papules in areas of friction. Associateed with obesity, insulin resistance, overt diabetes and metabolic syndrome.

Answer 203

Dermatitis herpetiformis which appears as pruritic, erythematous, group papulovesicular lesions.

Answer 204

**Perianal skin tags** (unlike acrochordon which is axillary skin tags) and **pyoderma gangrenosum** (which presents as a purlent ulcer.

Answer 205

lichen planus, porphyria cutanea tarda and cryoglobulinemia causing leukocytoclastic vasculitis.

Answer 206

Acute - gneeralized rash appearing as small and well-circumscribed red macules or papules. Chronic - molluscum, kaposi sarcoma and herpes zoster

Answer 207

transient hyperthyroidism due to follicular release of preformed hormone. Low TSH, elevated T4, elevated thyroglobulin and low RAIU tender thyroid and hx of recent viral infection

Answer 208

Graves has a high RAIU, wherease PT and silent have a low RAIU

Answer 209

Thyroglobulin is co-secreted with thyroid hormone by thyroid follicles and is **low in patients with exogenous thyrotoxicosis** *(due to suppression of follicular activity by exogenous thyroid hormone)*, but is **elevated in PT** (*due to destruction of thyroid follicles)* **and graves disease** *(due to increased activity of follicles)*

Answer 210

Body fluids such as **urine, feces, tears and vomitus** are considered noninfectious if no visible blood is present. DO NOT REQUIRE POSTEXPOSURE PROPHYLAXIS Blood, Fluids contaminated with visble blood, semen and vaginal secretions are high risk.

Answer 211

**Estrogen** **Tamoxifen** **Traloxifene** **Methadone, heroin** \*increases TBG & decrease free T4 The estrogen component of the combination pill increases TBG levels, resulting in an increase in total T4 levels and decrease in free T4 levels. *A person with a normal thyroid gland can compensate for these changes by increasing thyroid hormone production. A patient with thyroid replacement however, cannot compensate for these possible physiologic changes as the patient is dependent on exogenous levothyroxine therepy. The dosage of levothyroxoine may therefore need to be increased in hypothyroid patients taking OCPs. After starting this TSH levels should be checked in 12 weeks and the dose of levothyroxine should be adjusted accrordingly.*

Answer 212

Androgens Danazol Anabolic steroids Glucocorticoids These drugs decrease TBG & icnrease free T4 and may requrie lower dose of thyroxine replacement.

Answer 213

Individuals with borderline personality disroder can also exhibit attention seeking, manipulative behavior and rapidly shifting emotions. However, this patietn does not exhibit self-injurious and suicidial behavior, intense anger, chronic feelings of emptiness, and identity distrubance, which would be expected in borderline personality disorder.

Answer 214

Sample Size: **Smaller sample sizes generate wider intervals.** There is an inverse square root relationship between confidence intervals and sample sizes.

Answer 215

**As the confidence level increase, the width of the confidence interval increase as well. Which then increase the accuracy. However, the precision goes down.** ## Footnote Therefore, as the confidence level increase, so does the width of the confidence interval. Another way of thinking about this is the width of the area that captures the middle 95% or 99% of the distribution. The middle 99% will inevitably span a larger area, and hence the 99% confidence interval is going to be wider. Therefore, as we increase the confidence level, the width of the interval increases as well. More accurate means a higher confidence level. So if we are saying that we want to increase accuracy, we also need to increase the confidence level, but this might come at a cost. What is the drawback when using a wider interval As the confidence level increase, the width of the confidence interval increase as well. Which then increase the accuracy. However, the precision goes down.

Answer 216

Haloperiodal (antipsychotics) Benzos have a more rapid onset of action, but can worsen confusion and sedation. They can be used as an adjunct to antipsych to reduce extrapyridmal effect.

Answer 217

**comprehensive history** (ex. clear description of stool characteristics, duration and timing of symptoms), **basic serum analysis** and importantly, **stool analysis.** *(to look for leukocytes and parasite,s blood, pH, staining for fat and electroylye analysis calculating the osmotic gap)*

Answer 218

villous atrophy, loss of normal villus archtiecture, intrapeithelial lymphocytic infiltrates and crypt hyperplasia.

Answer 219

Normal mucosal architecture with no inflammation

Answer 220

transmural inflammation with lypmphocytic inflammation

Answer 221

- diarrhea after lactose-containing meals - increased stool osmotic gap - decrease stool pH - Positive Lactouse hydrogen breath test

Answer 222

- increase stool osmotic gap - Microcytic anemia is normally present - iron deficiency - histologic findings - villous atrophy

Answer 223

Macrocytic anemia, B12 deficiency Postive lactulose breath test

Answer 224

combination oral contraceptives containing high-dose estrogen, which stabllizes and endometrium and stops the bleeding

Answer 225

syndrome of marked psychomotor disturbance seen in a range of severe psychiatric illness (immobility or excessive purposeless activity, decrease alertness, resistance to instructions, lims remain fixed posture for long periods) benzodiazepines and/or electroconvulsive therapy. A lorazepam challenge test can be used to verify the diagnosis. A lorazepam test (IV bolus of 1-2 mg) results in parital, temp relief within 5-10 mins confirms the diagnosis of catatonia.

Answer 226

**Breast milk jaundice** is a common cause of unconjugated hyperbilirubinemia that **peaks at 2 weeks** in **well-appearing** and **healthy** neonates. In contrast, **neonates with lactation failure** typically present hte first week of life with **jaundice, inadequate feeding and dehydration.**

Answer 227

Treatment of breast milk jaundice includes frquent follow-up and monitoring of the infants hyperbilirubinemia. Exclusive breastfeeding should be continued and encouraged as the jaundice should resolve spontaenously by 3 months.

Answer 228

bisphosphonates

Answer 229

Xray - thickening of the outer cortex, sclerotic leasions, mild bowing Technetium bone scan - increase uptake Routine lab - creatinine and calcium levels are normal

Answer 230

Most children achieve complete urinary continence by ate 5, although boys generally achieve this milestone later than girls. A urinarlysis is recommended for **children \> or = 5** with persistent bedwetting to rule out an underlying medical problem.

Answer 231

1. behavior modification 2. Enuresis alarm (used when behavior fails; best long term outcome) 3. Pharmacotherapy: first line desmopressin, second line TCA

Answer 232

most common vascular tumors of childhood, affecting ~5% of all infants. Most superfiical infantile hemangiomas are small or clincially insignificant and **can be observed.** Evident at birth, goes through a **period of proliferation and then spontenaous involution by 7-10 years.** **Propanolol therapy** should be considered for lesions that are **disfiguring or located at sites of potential function impairement** (ex: eyelid or airway)

Answer 233

The use of glucocorticoids for less than 3 weeks, even in relatively high doses, does not cause significant suppression of the hypthalamic-pituitary-adrenal axis. When given for a short period, glucocorticoids can be stopped rapidly without signficant risk fo adrenal insufficiency.

Answer 234

rare pancreatic tumor associated with mild diabetes and a classic skin rash (necrolytic migratory eryhtemia) Erythemaous, scaly rash which appears to be clearing from the center. Borders appear slightly elevated and crusty. Angular chielosis is also noted.

Answer 235

hyperaldosteronism (conn's syndrome) measurement of plama aldosterone to plama renin activity (not renin levels) ratio. Should have suppressed renin activity and elevatd levels of plasma aldosterone.

Answer 236

in patietns with hypokalemia and HTN who have suppressed levels of both renin and aldosterone. Deoxycorticosterone has mineralocrticoid acitivty. Primary hyperaldosterinsm (has suppressved renin activity and elevated plasma aldosterone(

Answer 237

sodium restriction and diuretics. Transjuglar intrahepatic portosytemic shunt placment may be prursed in refractory cases. \*TIPS placment creates a fistula between the portal vein and the hepatic veins, which decreaes the hdyrostatic pressure in the portal venous system.

Answer 238

anti-endomysial antibody and anti-tissue transglutaminase antibody levels. Small intestional biopsy

Answer 239

**the combination of pharmacotherapy and psychotherapy is more effective than eitehr alone.** Although SSRI are typically used ast first line therapy, there is no evidence that one class of antidepressant is more effective; other classes can be considered depending on side effect profile and patient perference.

Answer 240

**_pertussis_ - Upper respiratory,** typically have **significant lymphocyte pedominant eukocytosis** (\>20,000 with \> or = 50% lympthocytes) and sick contacts with **coughing paroxysms** **_Coup_** = Upper respiratory syndrome consisting of hoarness, a **barky cough** and **inspiratory stridor** due to upper airway inflammation. **parainfluenza** is the most common cause. **_bronchiolotilis_** - most common cause is **RSV**, outbreaks peak during winder; **infants \<2** are at high risk of apnea.

Answer 241

cyclic pelvic pain, bulk symptoms (ex: constipation), primary amenorrhea, and hematocolpos (accomulation of blood and fluid bethind the intact hymen). Hymenectomy

Answer 242

Addison disease with type 1 DM. Other autoimmune disorders can occur. Type I diabetes shows high blood sugar levels, increased anion gap and positive plasma ketones.

Answer 243

The clinical features of glucorticoid-induced DM resemble type 2 DM. furthermore patietns who are receiving pysiological doses of glucocorticoids genrally do not manifest with clinical features of glucocorticods excess.

Answer 244

_Contact dermatits_ - spares creases/skinfolds; use barrier oitment or paste (petrolatum, zinc oxide) _Candida_ -beefy red rash involving skinfolds with satellite lesions erythematous papules seperate from the main rash) ; use topical antifungal therapy (ex: nystatin or clotrimazole)

Answer 245

choleliths within the glalbladder wall thickening or sonographic Murphy sign. If ultrasound is negative or inconclusive, a hepatatobillary iminodiacetic acid (HIDA) scan is the next diagnostic test of choice and is usually confirmatory. \*Patients with acute cholecystitis usually require an emergency laproscopic cholecystectomy (ideally within 72 houyrs of symptom onset); however diagnosis should be confrmed with US or HIDA scan before going through such an invasive procedure.

Answer 246

HIDA - used for diagnosis of acute cholescytisitis ERCP - used for choledocholitlhaisis

Answer 247

many antiihypertensive medications can interact with lithium due to their effects on renal function and electrolyte levels. Thiazides, ACE, ARB can icnrease serium lithium levels. CCB are gnerally considered safe.

Answer 248

bacterial infections These patients should be treated prophylactically with antibiotics. The preferred regimen involves the use of fluoroquinolone (ofloxacin, norfloxacin or ciprofloxacin) agent for 7-10 days.

Answer 249

CBC, serum iron and ferrtin levels, and reticulocyte count. These tests will help detect the presence of anemia and iron deficiency.

Answer 250

persistent, has complex features and/or is \> 10 cm in diameter. Surgical removal is recommneded during early second trimester to avoid acute comlications (ex: torsion, preterm delivery) and to prevent progression of potentially malignant disease.

Answer 251

**enteropathy-associated T-cell lymphoma (EATL)** an aggressive malignancy the primiarly affects the proximal jejunum. Manifestations typically **begin with abdominal pain and B symptoms (ex: weight loss, fatigue, fever).** Most patients with EATL present late in the disease process when curative options are limited. As such, prognosis tends to be poor with meidan survival of only 10 months.

Answer 252

aka frozen shoulder syndrome **due to chronic inflammation, fibrosis and contracture of the joint capsule.** It can be idiotpathic or secondary to rotator cuff tendinopathy, subacrominal bursitis, paralytic stroke, diabetes or humeral head fracture. Patients have **shoulder sitiffness with reduction of both passive and active range of motion.**

Answer 253

Subacromial bursitits typically occurs in patients with hx of heavy lifting or repetivie movements, especially with arm raised above shoulder level. Patietns can develop pain on abduction of the shoulder and restricted active ROM. However passive ROM should still be intact (adhesive capsulitis)

Answer 254

mild - rest and gental range of motion exercises severe and those who do not improve with conservative mesasures - glucocorticoid injection

Answer 255

Rotator cuff tendionpathy with partial or complete tear may cause pain with mild (partial) or severe (complete) decreased active ROM. However, unless tehre is concurrent adhesive capsulitis, pssive ROM is not affected. \*Rotator cuff has pain with abduction, external rotation Bicepts thenndionpathy/rupture - anterior shoulder pain

Answer 256

1. Metformin is **excreted by the kidneys** 2. Use of metformin is **not a contraindication to intravenous contrast administration** 3. For most patients, metformin **should be stopped at the time of contrast administration** *(held on the day contrast is given and retstarted 48 hours later after documenting stable renal function)* 4. Restarting metformin **depends on renal function and the volume of contrast used.** 5. For **small volumes** of contrast, patients with **normal renal function** taking metformin **may not require any changes** in care

Answer 257

loosely packed iwth saline-moistened gauze to preserve the moist wound environment \*these ulcers heal best when all pressure is removed from the involved area and a moist wound enviromment is maintained. Viable surrounding skin should be kept dry.

Answer 258

**hypocaclemia** because of their impaired ability to metabolize citrate into lactate. In these patients (renal failure, hepatic failure, shock, lactic acidosis) **prophylatic administeration of at least 10cc of 10% calcium gluconate** is recommended for every 500 ml of packed red blood cells transfused. \*Citrate is concomitantly transfused with every blood transfustion. The conversion of citrate into lactate is impaired, which leads to an excess amoutn of citrate in the blood. These excess citrate then binds calcium, and this lead sto hypocalemia. The measured serum calcium levels may be normal despite this occurence, because the deficit of ionized calium is not reflected in total calcium levels.

Answer 259

indicate**s how many patients need to be exposed to a particular risk factor over a specific period before a harmful event occurs in 1 patient.** NNH is the **inverse of the absolute risk increase** (or attributable risk), which is the difference in incidence rate between exposed and non exposed.

Answer 260

association between an exposure and an outcome. IT can be calciulated on a 2 x 2 contingency table, using the formula OR = ad/bc

Answer 261

Topical salicylic acid (takes 2-3 weeks to beecome apparent) other option: liquid nitrogen cyrotherapy Dx: single or multiple hyperatotic papules on the sole of the foot. Scrapings of hyperkeratoci debris can confirm the diagnosis by showing thrombosed capillaries (also called seeds).

Answer 262

Synovial fluid aspriation excludes ovther destructive forms of bacterial arthritis, and lyme serology is diagnostic. Bacterail culture of synovial fluid is ually negative in Lyme disease, as B burgdoferin is difficult to isolate and require a special medium.

Answer 263

can be treated successfully with a 28 day course of oral doxycycline or amoxicllin. Prognosis is favorable and most patients recover completely.

Answer 264

Anti-Ro-SSA and anti0la/SSB. no true diagnostic test is available.

Answer 265

B lymphocyte activation and infiltration of the salivary glands. lincreased risk for B-cell lymphoma

Answer 266

bibasilar atlelectasis

Answer 267

PE can lead to acute hypoxic respiratory failure, but like respiratory failure due to pulmonary edema, **respiratory alkalosis** is expected initally. (unlike respiratory acidosis in OBA) Acute hyperacapnic resp. failure is not typical of PE in the abscent of significant underlying COPD. *\*PE most commonly shows hypoxemia and hypocapnea (respiratory alkalosis) due to hyperventilation,*

Answer 268

type of selction bias that usually occurs in occupational cohort studies when the general population is used as the reference group. The general population consists of healthy and unhealthy individuals; those who are unhealthy are less likely to be employed, whereas the employed workforce ends to have fewer sick individuals. Consequently, the comparisons of mortality rates between the employed population and the general population are usually biased.

Answer 269

**Neurocardiogenic** (vasovagal syncope) is usually preceded by an autonomic prodrome of **nausea, pallor, diaphroesis or generalized warmth.** These **symptoms often temporarily persist following the episode.** Both the prodome and hte persistence of symptoms following the episode help **differentiate the neurocardiogenic syncope from more serious causes (ex: cardiogenic syncope)**

Answer 270

autoimmune disorders such as Addison disease, hypothyroidism, pernious anemia, etc

Answer 271

Cranial III palsy (ptosis and anisocoria) ataxia and bulbar dysfunction

Answer 272

Arthrocentesis confirms acute gout by showing monosodium urate crystals that are negatively birefringent and needle-shaped under polarizing light. Serum uric acid does not accurately diagnose acute gout as many patients have normal or even low uric acid during an acute gouty attack

Answer 273

NSAIDs (indomethacin, ibuprofen) and are effective in \>90% of patients with acute gout. Oral colchicine is an alternative therapy in patients with contraindication to NSAIDS. Intraarticular steriods can be used in acute gout for patients with one or two inflamed joints and contraindications to NSAIDS or colchine. \*Aspirin is generally not used for acute gout due to its renal handling of uric acid. Low dose apriin (1-2 g/day) causes uric acid retention; high dose aspirin (\<3 g/day)

Answer 274

allopurinol

Answer 275

Candida infections. Those with central venous access, particularly if the patient is on TPN. endophthalmitis and manifestifestations include fever, eye pain, decreased viscual acuity and funuscopic evidene of focal, glisteining, white, mount-like lesions that may extend into the vitrious and cause vitreous haze.

Answer 276

Invasive aspergillus typically manifests in the lungs (fever, dsypnea, pleuritic pain, hemoptysis ) or sinuses. Endopthalmitis may occur rarely, but leasions are typically hemorrhagic and encrotic, not white and mount like

Answer 277

Cryptococcal infections typically causes meningoencephalitis (headache, memory loss, personality change) or less commonly pneumonia. Cryptococcal endopthalmitis is exceedly rare and is almost always associated with concomitant meningoencephalitis; this patient with Central venous access on TPN is far likely to have candidiasis

Answer 278

Infective endocarditis may cause microthrombi in the retina with a resultant immune-mediated vasculitis. This maifests as roth spots, which are excudative, edematous **retinal** **hemorrhages** **with pale centers.** (not white and mount like fungatig retinal lesions with vitreous extension)

Answer 279

systemic antifungal medication (ex: amphotericin B), intravitreal antifungal injection and vitrectomy. \*Although fluconazle and voriconazole may be used for treating candida endophthalmitis, ketoconzole does not achieve high enough vitreous concentrations to be recommended.

Answer 280

Marked hyperglycemia, Advanced renal failure

Answer 281

Primary polydipsia malnutrion (beer drinker)

Answer 282

Volume depletion CHF Cirrhosis

Answer 283

SIADH Adrenal insuffiency Hypothyroidism

Answer 284

Can be associated with mild euvolemic hyponatremia. treatment of underlying hypothyoridism with levothyroxine can correct the hyponatremia

Answer 285

Dual-energy xray absorptiometry - used to measure bone density (osteoporosis/osteopenia screening) radioistope bone scan - detect areas of increased bone turnover and are very sensitive for osteoblastic bone metastases of prostate and other cancers.

Answer 286

Akathisia, characterized by a feeling of inner restlessness, urge to move, inability to sit still, is a common side effect of antipsychotic drugs. Use Beta blocker

Answer 287

asbestos. characterized by dyspnea and chest pain, and CXR shows nodular thickening of the pleura and/or obscuring of the diaphragm

Answer 288

hypercalemia due ot parathyroid like hormone production

Answer 289

SIADH is associated with normovoemic hyponatremia

Answer 290

water restriction

Answer 291

Typically occurs within a month after tick attachment and is characterized by erythema migrans and viral like symptoms. Diagnosis is made cliically; Lyme disease serology is often falsey negative is not recommended. Treatment with oral antibotics (x: 14 days of doxy) is required.

Answer 292

Unlike early localized lyme disease, patients with manifestations of early disseminated (ex: multiple eryhtema migrans, carditis, neuritis) or late (ex: arthritis, peripheral neuropahthy) lyme disease have fully developed humoral antibody response and SHOULD receive testing prior to treatment. Screening with b budorferi enzyme linked immunosorbent assay and confirmaiton with western blot are usually peformed.

Answer 293

suggest prior MI.

Answer 294

chronic inflammatory disorder characterized by occlusion of skin follicles commonily involving interitrignous area (ex: axillae, groin, etc) Mild cases - topical antibotics (ex: clinidamin) Moderate cases with sinus tracts and scar formation require oral antibotics (tetracycline perferred) More severe cases with diffuse involment and extensive sinus tracts formation may require biological TNF-alpha inhibitors (ex: infliximab) and wide surgical excision

Answer 295

Hypophosphatemia Contnous glucose infusions are the leading cause of hypophosphtemia in hospitalized patients. THe patients are usually alcholic or otherwise debiliated and the nadir in serum phosphate appears in the first few days after admission. Hypo-P can impair ATP generation (which is needed by skeletal muscles to perform work) and muscle weakness can result.

Answer 296

**Sulfonylrureias** (glyburide, glipizide, glimeprine) and **meglitenides** (nateglinide, repaglinide). These drugs increase insulin secretion by pancreatic beta cells even when blood glucose is normal

Answer 297

interferon-gamma release assay. As they may have a false positve TB skin test.

Answer 298

Localized infection - standard precaution and lesion covering Disseminated infection (other areas)- standard precaution PLUS contact and airborne precaution Patietns with Herpes Zoster may transmit VZV through direct contact (primiarly) or aerosolized particles (rarely) to health care personnel and other individuals)