UWorld 4 Flashcards
1
Q
Tx for toxic megacolon
A
IV steroids, nasogastric decompression (put in NG tube and suck out air), abx
2
Q
CXR findings of asbestosis
(a) Latency period
A
Pleural plaques on imaging = hallmark of asbestosis
(a) become visible after a latency period of about 20 years
3
Q
What is carboxyhemoglobinemia?
A
Carboxyhemoglobin = Hg + CO
Presence of CO taking up Hg binding sites in the blood => decreases blood’s oxygen-carrying capacity
4
Q
Most important risk factor for stroke in a pt w/ DM2, HTN, EtOH, and smoking
A
All are risk factors, HTN has the strongest association w/ stroke
- HTN increases risk of all types of stroke
- smoking is not as strong an association for stroke
5
Q
51 yo F presents w/ fatigue and lower back pain radiating to buttocks x6 mo
- persistent muscle pain in arms and shoulders that worsens acutely after exercise
- joints not swollen, normal muscle strength
- palpation elicits tenderness
- normal ESR
A
Fibromyalgia
- widespread bilateral pain
- perception of pain and fatigue worsen acutely after exercise
6
Q
40 yo M s/p overdose presented in confused state
- drowsy and ataxic w/ blurry vision
- T 100F, tachy to 100
- dry mucous membranes and skin
- pupils 8 mm b/l
- foley catheter immediately connects 600 mL of urine
Dx
A
Cholinergic overdose:
Dry as a bone (dry mouth/dry skin)
Blurry vision/mydriasis (blind as a bat)
Hot as a hare (hyperthermia from impaired heat dissipation)
Full as a flask (urinary retention)
Decreased bowel sounds
Red as a beet (due to cutaneous vasodilation)
Mad as a hatter (delirium/hallucinations)
7
Q
Subconjunctival hemorrhage
(a) Etiology
(b) Appearance
(c) Tx
A
Subconjunctival hemorrhage
(a) Local trauma or Valsalva (coughing, sneezing, vom)
(b) Well-demarcated patch of extravasated blood beneath conjunctiva
(c) benign => no tx needed
8
Q
Anion gap
(a) Formula
(b) Normal value
A
(a) AG = Na - (HCO3 + Cl)
(b) 6-12
9
Q
Abx for pyelonpehritis
(a) Outpt
(b) Inpt
A
Pyelonephritis
(a) Outpt- fluoroquinolone (cipro, levofloxacin)
(b) Inpt- IV abx (fluoroquinolone, amiglycoside like gent +/- ampicillin)
Get UCx, then narrow abx when get results
10
Q
Post vs. precentral gyri
A
Precental gyrus = primary motor cortex
Postcentral gyrus = primary sensory somatic cortex
11
Q
Extreme eye redness in pt using extended-wear contact lenses
A
Bacterial conjunctivitis (corneal uninvolved) and pseudomonal keratitis (when cornea is involved)
12
Q
45 yo F presenting w/ fatigue, weakness, and diffuse bone pain
- dx w/ celiac sprue 6 yrs ago
- normal Ca, low phosphate, high PTH, high alkphos
(a) Dx
(b) Mechanism of disease
A
(a) Osteomalacia
(b) Due to malabsorption, which can be caused by celiac sprue (also by chronic liver or kidney disease)
- due to vitamin D deficiency => low Ca and phosphate => secondary hyperparathyroidism => normalizes serum Ca by reabsorption in bone and kidney => elevated alk phos
13
Q
What is renal tubular acidosis?
A
Kidneys don’t excrete enough acid in urine => develop normal anion gap (hyperchloremic) metabolic acidosis (too much acid in the blood)
Cause: failure to recover sufficient bicarbonate ion in proximal tubule vs. insufficient H+ secretion/loss in distal tubule
14
Q
2 mechanisms of diphenhydramine
A
Diphenhydramine = Benadryl
- antihistamine
- anticholinergic
15
Q
34 yo SE Asian M w/ lesion on left forearm w/o sensation
-hypopigmented plaque w/ no sensation to pinprick w/ upper arm muscle atrophy
(a) Dx
(b) Method of dx
A
(a) Leprosy can present as an insensate, hypopigmented plaque
(b) Skin biopsy- dx made by demonstration of acid-fast bacilli on skin biopsy (presence of acid-fast bacilli in the cutaneous nerve)
16
Q
Features of PTSD besides nightmares and flashbacks
A
Amnesia, sleep disturbance, hypervigilance, irritability, emotional detachment
“hyperaware of surroundings, prefers to sit in corner of the room”
“frequently distracted at work”
“always seems on edge, has less interest in spending time w/ his family”
17
Q
What is De Quervain tenosynovitis?
A
De Quervain tenosynovitis = ‘blackberry’ or ‘mommys’ thumb = tenosynovitis (inflammation of fluid filled sheath, synovium, that surrounds a tendon) of the sheath or tunnel surrounding the two tendons that control movement of the thumb
(extensor pollicus brevis and abductor pollicus longus)
18
Q
Major risk factors for squamous cell carcinoma vs. adenocarcinoma of the esophagus
A
Major risk factors:
Squamous cell carcinoma- smoking and EtOH
Adenocarcinoma- chronic GERD and Barrett’s esophagus
19
Q
What is moxifloxacin?
(a) Indication?
A
Moxifloxacin = 4th generation fluoroquinolone w/ coverage of GNR, atypicals, strep pneumo, and anerobs
(a) Indication: extended-spectrum fluoroquinolone can be used as empiric inpatient treatment of community-acquired pneumonia
20
Q
What is Bernard-Soulier syndrome?
(a) Symptoms and associated lab findings
A
Bernard-Soulier syndrome = deficiency in platelet glycoprotein Ib that is the receptor for von Willebrand factor
(a) Bleeding degree out of proportion to the mild thrombocytopenia
21
Q
Tests for Cushing
(a) initial test
(b) second step
(c) final step for Cushing’s diagnosis
A
Cushing syndrome
(a) First establish high cortisol levels w/ 24-hr urine free cortisol, late-night salivary cortisol measurement, or low-dose dexamethasone suppression test
(b) Once establish hypercortisolism- measure ACTH to see if ACTH dependent (Cushing or ectopic ACTH production) or ACTH independent (adrenal disease or exogenous glucocorticoid intake)
(c) Hypercortisol w/ high ACTH: high-dose dexamethasone suppression test to see if ACTH production is pituitary (high-dose dexameth suppresses cortisol production) or ectopic (dexmeth does not suppress cortisol production)
22
Q
Most frequent precipitant of Guillain-Barre syndrome
A
Campylobacter jejuni = most frequent precipitant of GBS
23
Q
Mechanism of action of loop diuretics
A
Inhibits NKCC (Na,K,2Cl) symporter to inhibit Na,Cl,K reabsorption -also indirectly inhibits Mg and Ca reabsorption since it is dependent on the positive lumen voltage gradient set up by K+ recycling thru renal outer medullary K+ channel
24
Q
41 yo F presents w/ elevated AST/ALT (75/97) after 1 month of izoniazid for newly diagnosed Tb
Next best step
A
Continue on same meds and monitor LFTs closely
10-20% of pts on isoniazid will develop mild aminotransferase elevation w/in the first few weeks of tx
-hepatic injury is typically self limited and will resolve w/o intervention
25
Typical presentation of digoxin toxicity
N/V/anorexia, confusion, weakness
- scotomata = blurry vision w/ changes in color
- blindness
Can be precipitated by viral illness or excessive diuretic use (due to hypokalemia)
26
68 yo M w/ right foot pain and swelling x2 days
- pain on any movement of ankle or weight bearing
- very active cyclist
- exam: warmth, swelling, and tender foot, LROM due to pain
- 2+ pulses, normal sensation
- Xray: chronic calcification of the articular cartilage
Dx
Pseudogout = acute calcium pyrophosphate arthritis
-highly associated w/ chondrocalcinosis (calcification of articular cartilage) and presents in ppl over 65 w/ monoarticular arthritis
27
75 yo M w/ 2 mo of intermittent right eye visual loss
- painless, lasts a few seconds, feels like curtain coming over the eye
- no neurological findings, normal blood work and CXR
(a) Dx?
(b) Next step in management
(a) Amaurosis fugax = painless loss of vision from emboli (usually cholesterol)
- warning sign of an impending stroke, underlying disease is almost always present
(b) Most emboli occur from the carotid bifurcation => do duplex ultrasound of the neck to identify plauqes
28
65 yo M w/ ED and decreased libido x1 yr
-DM2
-decreased testicular size, minimal b/l gynceomastia
Labs: low T, lower limits of normal FSH and LH, normal TSH
Secondary hypogonadism = Hypogonadotropic hypogonadism => measure serum prolactin levels to look for prolactinoma
Not primary hypogonadism b/c LH/FSH would be high in attempt to compensate
29
Most common locations of osteoarthritis
Weight bearing joints- hips and knees
Small peripheral joints in the hands (PIP, DIP)
Cervical and lumbar spine
30
Clinical presentation of VIPoma
VIPoma = rare endocrine tumor of the tail of the pancreas that produces VIP (neuropeptide that increases gut motility)
VIP stimulates H2O and electrolyte secretion from gut => presents w/ chronic watery diarrhea and consequences of dehydration and hypokalemia
31
Advantages and disadvantages of Rivaroxaban over its alternative
Rivaroxaban advantages over warfarin
- no monitoring needed (warfarin does)
- can be used acutely for acute DVT/PE due to time of onset 2-4 hrs
- not an injection (heparin is)
- no dietary restrictions (warfarin has a bunch)
Disadvantages of Rivaroxaban compared to warfarin
-no antidote if hemorrhage => higher risk of irreversible bleeding
32
Histoplasmosis
(a) 3 presenting features
(b) Tx for severe infection
Histoplasmosis
(a) 3 systems involved when immunocompromised pt is infected (asymptomatic generally in immunocompetent)
1. reticuloendothelial system: pancytopenia, HSN, adenopathy
2. Pneumonia: diffuse reticulonodular or cavity (cavitation)
3. Mucocutaneous lesion (ex: oral ulcers)
(b) Tx severe infxn w/ amphoretericin B, then switch to oral itraconazole once initial response documented
33
What makes cystitis considered 'complicated'?
Considered complicated when person has risk factor for abx resistance or tx failure
Diabetes, CKD, pregnancy, immunocompromised, hospital-acquired, foreign body (catheter, stent)
34
Bacillary angiomatosis
(a) Tx
Bright red, firm, friable, exophytic nodule in an HIV infected (or otherwise immunocompromised) pt = bacillary angiomatosis
-infection w/ gram-negative bacillus (bartonella)
(a) Abx of choice = oral erythromycin
35
27 yo w/ DOE
-III/IV systolic ejection murmur along LLSB that decreases when pt squats
(a) Dx
(b) Etiology
(a) HOCM
Squatting from standing increases afterload which decreases HOCM murmur intesnity
(b) Autosomal dominant
36
Normal serum magnesium range
1.5 - 2.5
37
24 yo from Long Island, NY presents w/ fever, drenching sweats, and malaise x 1 week
- jaundice, dark colored urine
- tick bite 2 weeks ago
- PSH: splenectomy
Dx
Babesiosis = parasitic infection caused by Babesia parasite transmitted by tick species endemic to NE US
- paraside enters RBCs => hemolysis
- nlike other tick infections- rash is not a feature
Usually asymptomatic unless immunocompromised (ex: asplenia) `
38
Differentiate the concept of dead space ventilation vs. physiologic shunting
(pneumonia vs. PE)
Dead space ventilation = volume of air not available for gas exchange
ex: in PE
vs.
Physiologic shunting = poor ventilation of well-perfused alveoli (ex: consolidation from pneumonia) can => hypoxemia via physiologic shunting
39
Dx acute diverticulitis: CT vs. sigmoidoscopy
CT!!!
SIgmoidoscopy is contraindicated due to risk of perforation
40
Tx for shingles
Tx shingles w/ valayclovir (acyclvoir as alternative)
Postherpetic neuralgia (pain due to varicella virus) can be treated w/ TCAs along w/ the acute antiviral therapy
41
Formula for calculated serum osmolality
Calculated serum osmolality = 2Na + (glucose/18) + (BUN/2.8)
42
Are all live vaccines contraindicated in HIV pts?
All live vaccines are contraindicated if the pt has a CD4 count under 200
If CD4 count is over 200- live vaccines NOT contraindicated!!
43
What is cystocele?
(a) Diagnostic findings
(b) Signs/symptoms
Cystocele = bladder prolapse into anterior vaginal wall
(a) Can be detected on bimanual examination
(b) Urinary frequency and urgency, incontinence, painful/sexual intercourse (dyspareunia)
44
Screening test for macular degeneration
Macular degeneration = leading cause of blindness in industrialized nations
Early finding = distortion of straight lines such that they appear wavy (grid test often used to sec)
Pt asked to cover one eye and look at grid of vertical and horizontal lines, vertical lines seen as bent and wavy
-activities that require fine visual acuity are usually the first affected
45
Most common cause of infective endocarditis after dental procedure
Species = strep viridans
Organisms: strep sanguinis, S. mutans
46
Adolescent vs. steroid induced acne
Steroid acne- monomorphous pink papules and ABSENCE of comedones
Adolescent- open and closed comedones w/ inflammatory nodules in diff stages of evolution (not monorphic)
47
Presentation of primary hyperaldosteronism
(a) How may mild primary hyperaldo present
Primary hyperaldosteronism => hypertension and hypokalemia
-can also caused metabolic alkalosis and mild hypernatremia
Aldo upregulates NaK ATPase in tubules => increased Na reabsorption and K+ excretion
(a) Pts w/ mild primary hyperaldo may not have spontaenous hypokalemia, but are prone to developing diuretic-induced hypokalemia
48
Most common thyroid malignancy
(a) Risk factors
Most common thyroid malignancy = papillary carcinoma
(a) exposure to radiation during childhood and FHx
49
Common causes of secondary gout
Any condition that increases catabolism and turnover and purines can raise uric acid levels and trigger a gouty attack
- hemotologic malignancies
- tumor lysis syndrome
- psoriasis
- myeloproliferative d/o (ex: polycythemia vera)
50
What does this pathology report indicate:
Leukocytes that have undergone partial breakdown during preparation of a stained smear or tissue section, b/c of their greater fragility
Dx confirmed by LN biopsy
Smudge cells- characteristic of chronic lymphocytic leukemia (CLL)
51
Describe the prototypical sarcoidosis pt and presentation
Young to middle age African American female
Gradual onset SOB and cough w/o fever
-erythema nodosum
1/4 of sarcoidosis pts develop anterior uveitis
52
55 yo alcoholic presents w/ muscle cramps and perioral numbness
- macrocytic anemia
- calcium of 6.0 corrected for albumin
- Mg 0.8, Phosphorus 2.0
Cause of hypocalcemia?
Hypomagnesemia- common in hospitalized alcoholics due to many factors: urinary losses, malnutrition, acute pancreatitis, diarrhea
Hypomagnesia induces PTH resistance and decreases PTH secretion => causing hypocalcemia
53
Prophylaxis for malaria
When traveling to endemic places: mefloquine** or doxycycline
54
Dressler syndrome
Post-MI pericarditis occurring weeks to months after MI
-pts present w/ pleuritic CP and pericardial friction rub
Usually improve w/ NSAIDs
55
Tx for sarcoidosis
Pts w/ symptomatic disease generally receive systemic glucocorticoids
56
72 yo M w/ severe right knee pain s/p inguinal hernia repair
- redness and swelling of knee
- Arthrocentesis: no organisms, few rhomboid-shaped crystals
(a) Dx
(b) Most likely associated condition
Post-surgical acutek nee pain- most likely
(a) Pseudogout- acute calcium pyrophosphate crystal arthritis
- also has positive birefringent crystals w/ rhomboid shaped crystals on synovial joint fluid analysis
(b) Meniscal calcification- see chondrocalcinosis of affected joint (calcium deposition)
57
Typical ABG findings in COPD exacerbation
Respiratory acidosis w/ hypoxia
Resp acidosis due to CO2 retention
58
Myopathy with elevated serum creatine kinase
Consider hypothyroidism in myopathy w/ unexplained elevated CK
59
Most common presentation of coarctation of the aorta
(a) Physical exam findings
Asymptomatic hypertension
-CP, epistaxis, HF
(a) Brachial-femoral delay, UE HTN w/ LE hypotension
60
3 features of Lewy body dementia
LBD
1. visual hallucinations
2. fluctuating cognition w/ alterations in attention/alertness
3. spontaenous motor features of Parkinsonism (ex: bradykineisa, stiff limbs, rigid, resting tremor)
61
What 2 scenarios will bronchoalveolar lavage be most useful in getting a dx?
BAL samples lung cells => is most useful in evaluating suspected malignancy and opportunistic infxn
ex: over 90% sensitive and specific for PCP
62
What other neoplasms is Zollinger-Ellison syndrome associated with?
ZE syndrome = gastrinoma, part of MEN1 triad (pancreatic tumor aka gastrinoma, pitutiary tumor, parathryoid tumor)
ZE associated w/ parathyroid adenoma
63
45 yo F w/ several months of numbness and occasional nocturnal pain in the right palm
- recently started L-thyroxine for hypothyroidism
- PE: flattening of the thenar eminence
(a) Dx
(b) Location of pathologic process?
(a) Carpel tunnel: paresthesias of the first 3.5 digits, occasional thenar eminence atrophy
- thyroid thing was a distractor (grrrr)
(b) Pathological process is at the wrist where the median nerve gets entrapped while passing thru the carpal tunnel
64
Presentation of cyanide poisoning
Altered mental status, lactic acidosis, seizures, coma
NOT SOB-ish
65
Nitroprusside- what is it?
(a) Indication
(b) Side effect
Nitroprusside = potent vasodilator w/ rapid onset
(a) used in hypertensive emergency and sometimes severe HF (b/c reduces preload and afterload)
(b) Too high a dose or pt w/ underlying renal insufficiency can suffer from cyanide toxicity
Nitroprusside metabolized into NO and CN-
66
Typical presentation of acute diverticulitis
(a) Best dx test
Abdominal pain (usually LLQ), fever, N/V, leukocytosis
(a) Dx w/ abdominal CT w/ contrast
67
PT presents w/ HA, sudden vision loss, abnormal funduscopic exam findings, elevated ESR, carotid bruit
(a) Suspected dx
(b) Tx
(a) Giant cell arteritis- chronic vasculitis
- most common ocular manifestation = anterior ischemic optic neuropathy
(b) Tx = IV steroids
68
Risk factor for hepatic adenoma
Hepatic adenoma = benign tumor most often seen in young and middle-aged women on COPs
69
When can the urine anion gap be helpful?
Urine anion gap is calculated when there is a normal anion gap metabolic acidosis to help determine if the acidosis is due to renal or intestinal bicarbonate loss
```
Renal losses (low anion gap): renal tubular acidosis, carbonic anhydrase inhibitor use
GI bicarbonate loss (high anion gap): diarrhea
```
70
Most likely causative organism of
(a) Endocarditis after dental procedure
(b) Bactermia associated w/ colon cancer
(c) Prosthetic valve endocarditis
(a) Streptococcus mutans (part of the strep viridans group) => endocarditis following dental procedure
(b) Steptococci bovus => bacteremia associated w/ colon cancer
(c) Staphylococcus epidermis => prosthetic valve endocarditis
71
Risks for diverticular disease
Chronic constipation, lower-fiber, high fat diet
72
What is acute diverticulitis?
Acute diverticulitis = inflammation due to microperforation of a diverticulum
73
Differentiate type 1 vs. type 2 heparin-induced thrombocytopenia
Differ by onset, clinical course, and severity of disease
Type 1: direct effect of heparin on platelet activation, presents w/in first 2 days of heparin exposure
-platelet count normalizes w/ continued heparin tx and no clinical consequences
Type 2- immune-mediated d/o due to antibodies to platelet factor 4 complexed w/ heparin => platelet aggregation, thrombocytopenia, thrombosis (both arterial and venous)
- plt count drops over 50% from baseline, typcially occurs about 5-10 days after initiation of tx
- may have life-threatening consequences: limb ischemia, stroke
74
Salivary gland enlargement in 43 yo M found wandering the street in the winter by EMS, mildly hypothermic at 95 F disheveled, lethargic, extensive dental carries
Alcoholism
Sialadenosis = nontender enlargement of the submandibular glands- commonly found in pts w/ advanced liver disease (ex: alcoholic and nonalcoholic cirrhosis)
75
74 yo M w/ urinary frequency and straining during urination x2 mo
- 2 episodes hematuria that self resolved
- 30 pack year history
- father died of colon cancer
- enlarged and smooth prostate w/o nodules
Next step?
Cytoscopy- (endoscopy of bladder via the urethra) considered complicated BPH b/c he has microscopic hematuria w/ increased risk of malignancy (smoking)
-smoking is biggest risk factor bladder cancer
Need cytoscopy to r/o bladder cancer, then if negative start BPH tx (tamsulosin, finasteride)
76
Erythema over nose, cheeks, forehead w/ telangiectasias, pustules, and papules
-worsens when drinking something hot or going out in the sunny weather
Dx
Rosacea- rosy hue w/ telangiectasias over cheeks, nose, and chin
-flushing typically precipitated by hot drinks, heat, emotion, and other causes of rapid body temperature change
77
42 yo w/ subjective fever, sre throat, malaise, skin rash
- nonpruritis maculopap rash involving entire body, including palms and soles
- generalized lymphadenopathy
Dx
Syphilis
Secondary syphilis = rash starting on trunk extending to periphery, including palms and soles
78
44 yo IVDU M presents w/ anorexia, fatigue, memory impairment x6 mo
- 20 lb weight loss
- Mini mental 24/30
Next best step
HIV- HIV is associated w/ dementia and depression
Any IVDU w/ wt loss should be immediately tested for HIV and Hep C
79
Presentation of ventricular free wall rupture
(a) Typical time line
Presentation: acute onset of CP and profound shock w/ rapid progression to pulseless electrical activity (no pulse) and death
- suspect LV free wall rupture in pts w/ pulselessness after recent first MI and no signs of heart failure
(a) peaks 5 days after acute MI (usually anterior- LAD), 5 days - 2 weeks after acute MI
80
32 yo M w/ fever, HA, malaise, myalgia x2 days + confusion
- tick bit 2 weeks ago in Arkansas
- T 102, neck supple, no rash
- neutropenic, thrombocytopenia, elevated aminotransferases
(a) Dx
(b) Tx
(a) Ehrlichiosis
- transmitted by tick vector, SE and S. central US
- flu like illness w/ neurologic symptoms
- rash is uncommon (sometimes called Rocky Mtn spotted fever w/o the spots)
- leukepnia and thrombocytopenia
(b) Empiric tx of ehrlichiosis w/ doxycycline
81
Medication used for diabetic gastroparesis
Metoclopramide (Reglan)
82
35 yo HIV+ (CD4 80) M presents w/ cough, fatigue, night sweats x3 weeks
- recent travel to Ohio, VT, Georgia
- two small ulcers on hard palate
- hepatomegaly
- CXR: b/l reticulonodular opacities
(a) Dx
(b) Diagnostic test
(a) Histoplasmosis- asymptomatic in immunocompetent, but can cause mucocutaneous lesions, pneumonia, and reticuloendothelial (HSN, adenopathy) in immunocompromised
(b) Histoplasmosis is best diagnosed w/ either serum or urine antigen
83
3 common causes of community-acquired pneumonia
1. strep pneumo
2. Haemophilus influenza
3. atypical organisms: mycoplasma, legionella
84
Nonallergic vs. allergic rhinitis
(a) symptoms
(b) Age of onset
(c) Triggers
(d) Tx
Nonallergic
(a) nasal congestion, sneezing, rhinorrhea, postnasal drainage (dry cough)
(b) Later onset common- after 20 yoa
(c) No obvious allergic trigger
(d) Intranasal antihistamine or intranasal glucocorticoids
Allergic rhinitis
(a) watery rhinorrhea, sneezing, eye symptoms
(b) Earlier age of inset
(c) Identifiable allergen or seasonal pattern
- associated w/ other d/o
(d) Intranasal glucocorticoids, oral antihistamines
85
Pleural effusion s/p upper GI endoscopy
(a) Dx
(b) Risk/danger?
(c) Diagnostic test?
(a) Esophageal rupture secondary to GI endoscopy
(b) Immediate esophageal closure and drainage to prevent mediastinitis
(c) Diagnostic test = water-soluble contrast esophagogram (like a barium swallow but w/ water-soluble contrast which is less inflammatory to tissues)
86
Person comes in w/ DVT and PE, gets tx and then plts drop from 246k to 78k
Heparin-induced thrombocytopenia
Type 1 (which is is b/c happened w/in first 2 days of tx initiation, not 5-10 days like type 2) is a nonimmune direct effect of heparin on platelet activation
-benign
-self-resolves and can continue w/ heparin tx
87
Tx for TTP
Tx for TTP = plasma exchange
-removes the antibodies that inhibit ADAMTS13 (protease needed to cleave vWF) to prevent the increased clotting
88
23 yo F complains of diplopia at the end of the day
- jaw cramps while eating steak
- funny change in voice after talking a while
(a) Dx
(b) Most likely abnormality to find on imaging
(a) Myasthenia gravis
| (b) CT scan of neck to find thymoma- present in 15% of MG pts
89
Cause of abnormal bleeding in pt on dialysis
Platelet dysfunction is the most common cause of abnormal hemostasis in a pt w/ CRF
-PT, PTT, plt count are normal, but bleeding time is prolonged b/c platelet function is abnormal
Mechanism: thought to be from uremic toxins causing platelet dysfunction, messing up platelet-vessl and platelet-platelet interaction needed for fxn
90
Effect of the following on lung compliance
(a) fibrosis
(b) pulmonary edema
(c) emphysema
Lung compliance- ease at which the lungs expand
(a) fibrosis: decreased compliance
(b) pulmonary edema: excess fluid reduces lung compliance by preventing some of the alveoli from fully expanding
(c) emphysema- increased compliance due to loss of alveoli and elastic tissue
91
Thyroid lymphoma
(a) Typical presentation
(b) Most common risk factor
(c) Physical exam findings
Thyroid lymphoma
(a) Rapidly enlarging neck mass presenting w/ respiratory difficulty (due to compressive symptoms)
(b) Hashimoto's thyroiditis
(c) Diffuse non-tender, rubbery enlarged thyroid gland w/ lymphadenopathy
92
Echo findings of free wall rupture vs. IV septum rupture
Echo findings
Free wall rupture = pericardial effusion with tamponade
IV septum rupture => left to right shunt at level of the ventricules
93
How to test for C. Dif
PCR detection of toxin genes in stool
94
pH abnormality seen after seizure
(a) How to treat
Postictal lactic acidosis (anion gap met acidosis) classically due to accelerated production of lactic acid in the muscle and reduced hepatic lactate intake
(a) Is typically transient and self limited w/in 60-90 mins => repeat labs in 2 hrs, no acute tx needed
95
Stepwise approach for tx of ascites
1. Sodium and water restriction
2. Spironolactone = first med added
3. Loop diuretic (furosemide)
- but NO MORE THAN 1 L/day of diuresis: aggressive diuresis (over 1 L/day) not recommended due to risk of hepato-renal syndrome
4. frequent abdominal paracentesis (2-4 L/day)
96
When would IV bicarbonate be given for an anion gap met acidosis?
Pretty controversial, but only in really severe cases when pH drops below 7.2.
And dont correct back to normal, only correct back to 7.2. In lactic acidosis, bicarb tx may paradoxically depress cardiac performance and therefore worsen acidosis by enhancing lactate production
97
Correction for serum calcium depends on what other molecule?
About 50% of circulating calcium is protein bound, mostly to albumin
Serum Ca falls by 0.8 mg/dl for every 1 gm/L decrease in albumin
ex: albumin of 3 causes .4 mg/dl decrease in serum calcium
98
Give the escalation in acne tx regimens from: comidonal to inflammatory to cystic
Acne tx regimens
Comidonal: topical retinoids
Inflammatory (comodones + erythema):
1. topical retinoids + benzoyl peroxide
2. topical abx (erythromycin/ azithro)
3. oral abx
Cystic (most severe)
-same 3 things as inflammatory, then for unresponsive severe can use oral isotretinoin (formerly sold as Accutane in US)
99
Tx for diphenhydramine overdose
Benadryl overdose (antihistmaine and anticholinergic) tx = physostigmine = cholinesterase inhibitor to counteract the cholinergic effect
100
First step workup for pt w/ hypercalcemia
Ddx at the two branchpoints
Measure PTH!!!
PTH high-normal or elevated (PTH dependent) ddx
- hyperparathyroid
- familial hypercalcemia hypocalciuria
- lithium induced
PTH suppressed (PTH independent hypercalcemia)
- hypercalcemia of malignacy
- vitamin D toxicity
- thyrotoxicosis
101
Mechanism of class IC antiarrhythmic agents against supraventricular arrhythmias
Phenomenon of use dependence- in pts w/ faster HR the drug (MOA: sodium channel blocker that inhibits the initial depolarization phase of the action potential) has less time to dissociate from the Na+ channels
=> more channels get blocked => progressive decrease in impulse conduction and widening of the QRS complex
= progressive decrease in impulse conduction w/ faster HR => increase in QRS complex duration
102
What is plasma exchange?
(a) Indication
Literally remove pt's plasma and discard it- replace it w/ donor plasma + albumin (or in some cases albumin + NS)
(a) Indications
- great at removal of pathogenic antibodies: TTP, Lupus
- Guillain Barre, Goodpasteurs
103
What are varicoceles?
(a) What cancer are unilateral vericoceles associated with?
Varicoceles = dilated scrotal veins
(a) Renal cell carcinoma can cause unilateral vericocele by tumor obstruction of the gonadal vein where it enters the renal vein
104
Abx for UTI
WHen is UCx needed?
(a) 2 first line options for uncomplicated cystitis
(b) First line for complicated cystitis
UTI Tx
(a) Uncomplicated cystitis- either Bactrum x3 (in places w/o high resistance) days or nitrofurantoin x5 days
- UA confirms dx, UCx only needed if initial tx fails
(b) Complicated cystitis- 5-14 days of fluoroquinolones
- get UCx before start abx, then narrow abx when get culture results
105
Type 1,2, and 4 renal tubular acidosis: hyper or hypo-kalemic?
Type 1 (failure of K+ reabsorption in CT) => hypokalemia
Type 2 = hypokalmia
Type 3 = hyperkalemia
106
What is flail chest?
(a) Clinical presentation
3 or more adjacent rib fractures that break in 2 places, usually due to crush injury
-unstable chest wall segment that moves in paradoxical motion w/ respiration (retracts inward w/ inspiration, bulges outward during expiration)
Present w/ respiratory distress and tachypnea w/ shallow breaths
107
What is haptoglobin? What does its level indicate?
Haptoglobin = serum protein that binds free Hgb released from RBCs
When RBCs are getting destroyed (both intra and extravascular hemolysis) more Hgb is released to bind to haptoglobin -> low haptoglobin indicates hemolytic anemia
108
Glomerular vs. non-glomerular hematuria
(a) Type of hematuria
(b) UA results
Glomerular hematuria
(a) Microscopic hematuria more common
(b) Blood AND protein on UA, see RBC casts and dysmorphic RBCs
Non-glomerular hematuria
(a) Gross hematuria
(b) UA has normal appearing RBCs and NO protein
109
What other neoplasms to expect in a pt w/ a VIPoma
VIPoma = rare tumor affecting pancreatic cells that produce VIP (neuropeptide increasing gut motility)
VIPoma is associated w/ MEN1 = endocrine neoplasm syndrome including neoplasms of the pancreas (VIPoma), pituitary gland, and parathryoid gland
Parathyroid gland neoplasm => hyperparathyroidism
110
43 F w/ medication-controlled bipolar d/o presents w/ confusion
- polyuria and polydipsia
- Na 154, Ch 116, glucose 95, urine osmolality 250, plasma osmolality 326
(a) Dx
(b) Etiology
(a) Diabetes insipidus- leading cause of euvolemic hypernatremia
Urine osmolality is btwn 300-600 => partial DI, nephrogenic due to renal ADH resistance can be drug-induced
(b) Commonly by lithium
111
Tx for beta blocker and CCB toxicity
Beta-blocker toxicity (blocking all beta-sympathetic tone) => get bradycardia, AV block, hypotension, and diffuse wheezing
-CCB similar presentation except no wheezing
Tx for both: IV fluids and atropine (tx hypotension and bradycardia)
IV glucagon = next step for refractory or profound hypotension
-b/c glucagon stimulates cAMP production in dependent from beta-adrenergic pathway
112
What is pneumoomediastinum?
(a) 3 most common causes
Abnormal presence of air in the mediastinum
(a) Etiology
- Asthma causing alveolar rupture => air leaks out of lungs into mediastinum
- Bowel rupture
- Esophageal rupture (Boerhaave syndrome)
113
CBC values in polycythemia vera
(a) Physical exam finding
Polycythemia vera = hyperproliferative BM leads to overproduction of RBC, WBC and platelets usually elevated too
(a) Splenomegaly
- low EPO levels
114
Utility of bronchoalveolar lavage in:
(a) Sarcoidosis pt
(b) HIV pt w/ CD4 count of 150 and diffuse pulmonary infiltrates
(c) interstitial pulmonary fibrosis
Bronchoalveolar lavage utility
(a) No definitive test for sarcoidosis. BAL is not helpful- transbronchial biopsy can be used to demonstrate noncaseating granulomatous pathology
(b) Great!!! Main benefit of BAL = super sensitive and specific for PCP pneumonia
(c) Not helpful for interstitial pulmonary fibrosis, instead need lung biopsy
115
3 parts of treatment for a radiolucent kidney stone
Radiolucent kidney stone = uric acid or xanthine (more commonly uric acid)
vs. radiopaque which is the calcium stone
Tx for uric acid stones
1. hydration
2. low purine diet (purine broken down into uric acid
3. alkalinize urine w/ potassium citrate
- potassium citrate = readily absorbed in gut and excreted in urine as alkaline salt (=> good for any disease w/ mechanism of acidic urine)
116
What must happen for a metabolic acidosis to have a normal anion gap?
Hyperchloremia!!! So non-anion gap metabolic acidosis tells you pt is hyperchloremic
AG = Na - (HCO3 + Cl)
-plasma HCO3 is decreased (renal tubular wasting), so Cl is high
117
2 most common organisms responsible for epiglottitis in adult population
Epiglottitis in adult population
- staph pyogenes
- haemophilus influenza
118
Clinical features: free wall rupture vs. IV septum rupture
Clinical symptoms: both present w/ shock and CP
Free wall rupture: pulselessness, no signs of HF
-on average presents later: 5 days - 2 weeks
IV septum rupture: new holosystolic murmur
-acute or w/in 3-5 days of MI
119
Most popular tx for Graves' disease in nonpregnant women
(a) Main side effect
Radioactive iodine
-pts become euthyroid in 2-6 months
(a) Major complication = hypothryoidism
- develops in over 80% of ppl adequately treated for Graves' disease
- easily controlled w/ L-thyroxine
120
P2y12 receptor blocker
Anti-platelet mechanism
| aka Clopidogrel
121
47 yo G4P4 w/ lower abdominal pain relieved w/ urination x 2mo
- afebrile
- no rebound/guarding
- severe pain upon palpation of anterior vaginal wall
- bland UA
(a) Dx
(b) Associated conditions
(a) Interstitial cystitis = painful bladder syndrome = bladder pain for 6+ weeks w/ no other attributable cause
- pain exacerbated by bladder filling, relieved by voiding
(b) Associated w/ psychiatric d/o (anxiety) and pain syndromes (fibromyalgia)
122
Lung cancers you think of in smokers vs. nonsmokers
Adenocarcinoma of the lung is the most common lung cancer in both smokers and nonsmokers
Then in smokers, can also consider squamous cell carcinoma (next common), small cell carcinoma, and large cell carcinoma (least common)- but these 3 are pretty rare in nonsmokers
123
Cushing vs. pheochromocytoma- where is the problem?
Cushings = adrenal cortex's hormone (cortisol) getting over produced
Pheo = adrenal medulla hormones (NE and epi) getting overproduced
124
What is idiopathic intracranial hypertension?
(a) Most likely population
Idiopathic intracranial hypertension = pseudotumor cerebri = increased intracranial pressure in absence of brain tumor
(a) Obese/overweight = biggest risk factors
-much more common in females than males
=> 20-30 yo obese female
125
Which drug overdose presents with:
Bradycardia, AV block, hypotension, diffuse wheezing
Bradycardia, AV block, hypotension suggest beta-blocker or CCB overdose
Wheezing more specific for beta-blocker overdose
126
Best medical tx for
(a) Cancer-related anorexia/cachexia
(b) HIV cachexia
Medical tx for
(a) Cancer-related anorexia/cachexia = progesterone analogues (megestrol acetate) or corticosteroids: effective at increasing appetite, causing wt gain, and improve well-being
- longer life expenctancy progesterone analogues are preferred over corticosteroids due to decreased side effects
(b) For HIV cachexia- synthetic cannabinoid
127
What two pneumonia-causing bugs is erythromycin active against
Legionella and mycoplasma
128
What is a V/Q scan used for in an acute setting?
VX testing used in suspected PE
129
Describe dipyramidole and the coronary steal phenomenon
Dipyramidol is a vasodilator. Key here is that diseased (stenosed) coronary vessels are maximally vasodilated at rest => when given a vasodilator this shunts blood towards the smaller resistance vessels and AWAY from the diseased coronary arteries => creating more ischemia
Myocardial perfusion scanning revealed inhomogeneous distribution of perfusion after dipridamole indicates ischemic heart disease
130
Conditions associated w/ the following bone abnormalities
(a) Accelerated focal bone remodeling
(b) Defective formation of collagen
(c) Impaired osteoid matrix mineralization
(d) Low bone mass w/ normal mineralization
(a) Accelerated focal bone remodeling = Paget's disease
(b) Defective formation of collagen = osteogenesis imperfecta
(c) Impaired osteoid matrix mineralization = osteomalacia
- most commonly secondary to vitamin D deficiency
(d) low bone mass w/ normal mineralization = osteoporosis
131
Differentiate presentation of gout vs. pseudogout
Gout- acute onset, painful monoarthropathy
-most often affecting first metatarsophalangeal joint (connecting big toe to foot)
Pseudogout- monoarthropathy due to calcium pyrophosphate deposition
-acute onset painful monoarthropathy affecting the knee
Can differentiate diagnostically by tapping synovial fluid
132
27 yo obese F presents w/ HA x 2 weeks, +N/V
- papilledema
- normal MRI
(a) Dx
(b) Most likely complication
(a) Pseudotumor cerebri = idiopathic intracranial hypertension = increased intracranial pressure in absence of tumor
(b) Untreated most commonly develop papilledema => swelling of optic disc => vision loss
133
Effect of renal failure on
(a) serum calcium
(b) PTH levels
Renal failure => decreased production of active vitamin D =>
(a) Decreased serum calcium
- less Ca absorbed if less vitamin D is around
(b) crazy high PTH
- much higher than seen in primary hyperparathyroidism
134
Acute episodic hemolysis after bactrum
G6PD deficiency
135
Most common location of coarctation of the aorta
Coarctation of the aorta (narrowing of descending thoracic aorta) is usually just distal to the origin of the left subclavian artery at the site of the ligamentum arteriosum
136
Zinc deficiency
(a) 2 causes
(b) Symptoms
Zinc deficiency
(a) 2 causes = TPN or malabsoprtion
(b) Symptoms: alopecia, skin lesions, abnormal taste, impaired wound healing
- "skin rash and hair loss", "food does not taste good"
137
What is carboxyhemoglobinemia?
CO-Hgb: Carbon monoxide poisoning
-body compensates by developing secondary polycythemia
138
Key features of selenium deficiency
Cardiomyopathy
139
What is sialadenosis?
(a) Seen in which 2 types of pts?
Sialadenosis = nontender enlargement of the submandibular glands
(a) Found in
1. pts w/ advanced liver disease- alcoholic and nonalcoholic cirrhosis
2. malnutrition: diabetes, bulimia
140
What abnormality on the cardiac physical exam is likely to be seen in a pt w/ Marfan Syndrome?
CV features of Marfans = aortic dilation, regurg, or dissection, and MVP
Aortic root dilation/regurg (AI) => early diastolic murmur
141
Adrenal medullary tumor
(a) Symptoms
Adrenal medullary tumor = pheochromocytoma => excess catecholamines (epi, NE)
(a) Severe, episode HTN
- wt loss, tachycardia, diaphoresis, anxiety
142
Bite cells on peripheral smear
Seen in glucose-6-phosphate dehydrogenase deficiency
143
Hepatolenticular degeneration
Another name for Wilson's disease = copper deposition in tissues
144
Reactive arthritis
(a) Type of arthropathy
(b) Etiology
Reactive arthritis
(a) Seronegative spondyloarthropathy- asymmetric oligoarthropathy often w/ nongonococcal urethritis and conjunctivitis
(b) Etiology: results from enteric or GU infection
145
Best tx for acute rejection s/p organ transplant
IV steroids
146
Primary adrenal insufficiency vs. secondary adrenal insufficiency
(a) most common cause
(b) cortisol level
(c) ACTH level
(d) Aldo level
(e) skin findings
(f) K+, Na+
(g) Change in which vital sign?
Primary adrenal insufficiency vs. secondary
(a) Primary- Autoimmune (AI adrenalitis)
Secondary most commonly from chronic glucocorticoid therapy
(b) Cortisol low in both
(c) ACTH high (as opposed to low in secondary adrenal insufficiency)
(d) Aldo low (as opposed to normal in secondary b/c controlled by RAAS not pituitary)
(e) Hyperpigmentation only in primary (much more severe symptoms in primary
(f) Hyperkalemia and hyponatremia (due to low aldo) only in primary
(g) Primary- hypotension => dizziness, orthostatic hypotension
147
Common side effect of abx, local anesthetics, nitrates, metoclopromide
Methemoglobinemia = higher Fe2+ than Fe3+ hemoglobin and Fe2+ has lower oxygen carrying capabilities => hypoxia
148
80 yo F w/ 3 days poor oral intake
- dry mm
- pneumonia
- creatinine of 2.1, BUN 64
Underlying mechanism of abnormal lab findings
Renal arteriolar vasoconstriction
Prerenal azotemia due to hypo-filtration to kidneys
- decreased renal blood flow activates RAAS => high ADH => renal tubules avidly resorb Na, water, and urea
- high urea reabsorption => BUN/creatinine ratio > 20:1 indicating dehydration
149
Clinical presentation of cluster headaches
Acute, severe retroorbital pain (pain behind the eye) that wakes the patient up from sleep. May be accompanied by
- ipsilateral eye redness
- tearing
- stuffed or runny nose
- ipsilateral Horner's syndrome (cause of Horner's syndrome w/o increased ICP)
150
Male w/ blood at beginning vs. end of urine stream
Blood at beginning of urine stream indicates urethral lesion (ex: urethritis)
While blood at end of stream (terminal hematuria) suggests prostatic or bladder cause
151
67 yo w/ CAP s/p influenza- etiology of pneumonia?
Staph aureus is a relatively uncommon cause of community acquired pneumonia, but is what causes post-influenza pneumonia
=> need to tx w/ anti-staph abx
152
Vaccines for asplenic pts: when should they be given post-surgically?
For asplenic pts (increased risk of sepsis from encapsulated organisms) give vaccines: Meningococcal, PVC13, H. influenzae in 2 weeks
-PCV13 first, then PPSV23 at least 8 weeks later
Either give it 14 or more days before or after the surgery (not immediately after surgery)
153
Etiologies of anion gap metabolic acidoses
Anion gap metabolic acidosis = MUD PILES
Methanol glycol ingestion
Uremia (ESRD): failure to excrete H+ as NH+
DKA: DM1, starvation, alcoholism
Paraldehyde
Isoniazide
Lactic acidosis: poor tissue perfusion, hypoxia, mitochondrial dysfunction
Ethylene glycol
Salicylates: metabolic acidosis and respiratory alkalosis
154
Appearance of infarct vs. hemorrhage on CT scan
Infarct appears hypodense (lilght gray)
Hemorrhages are hyperdense (white)
155
64 yo nondiabetic complians of cramping pain in right thigh after walking 2 blocks
- diminished popliteal and dorsalis pedis pulses on right
- ankle brachial reflex .72 on the right
(a) Dx
(b) First line tx
(c) Second line tx
(a) Claudication = Peripheral artery disease of the right extremity
(b) Low-dose aspirin + statin + supervised exercise regimen
(c) If symptoms persist after initial exercise and pharma therapy => percutaneous or surgical revascularization or Cilostazol (vasodilator for claudication)
156
Pt w/ acute asthma exacerbation w/ ABG:
7.32/65/50 (pCO2)
Next step?
Endotracheal intubation
Normal or even high CO2 in acute asthma exacerbation means they have decreased respiratory drive (they should be tachypnic...)
Decreased respiratory drive is likely due to respiratory muscle fatigue, indicates impending respiratory failure
157
Lab abnormalities attributable to hypothyroidism
Hypothyroidism can cause hyperlipidemia, hyponatreima, and asymptomatic elevations in CK and serum transaminases
158
Which UTIs require urine sample before initiating tx
Both complicated cystitis and pyelonephritis- get urine culture, then start abx (key to get UCx before give abx). Then once get culture, start empiric coverage, then can adjust coverage when get UCx results
For uncomplicated cystitis, UA can confirm dx and pts can be treated w/o UCx
159
Rib notching on CXR
```
Rib notching (well especially in young adult) suggests coarctation of the aorta
-erosion of the ribs by enlarged intercostal arteries due to collateral flow
```
160
Common complication of myeloproliferative d/o
Gout due to excessive turnover of purines and resulting increase in uric acid production
161
Typical presentation of pseudogout
Pseudogout = acute calcium pyrophosphate deposition- typically mono articular, most commonly the knee
- often after surgery or illness
- acute pain, swelling, redness of knee
162
Order of frequency of cancers that met to the brain
Lung (multiple brain mets) --> breast (more likely primary) --> melanoma --> colon
very rare brain mets: prostate, esophageal, HCC, non-melanoma skin cancers
163
Triad of MEN1
MEN1 = multiple endocrine neoplasm syndrome type 1 (the P's)
1. Parathryoidism
2. Pancreatic tumors- most commonly gastrinoma, also includes VIPoma
3. Pituitary tumor
164
2 gases implicated in poison from closed spaces
CO (carbon monoxide) and HCN (hydrogen cyanide)
165
Location of the lesion in Brown-Sequard syndrome
Lesion is one one side (either right or left) of spinal cord 2 levels above where symptoms start
ex: loss of pain and temperature to left side beginning at T12 is due to lesion of right spinothalamic tract at T10
166
What form of kidney disease is HIV-related nephropathy?
Collapsing focal and segmental glomerulosclerosis (FSGS)
| -heavy proteinuria
167
Pt w/ altered mental status and these labs:
BMP: 141/4.6/100/13/28/2.5/90
-plasma osmolality 350
ABG:
7.21/100 (pO2)/30
Anion gap metabolic acidosis- use calculated serum osmolality to see if there is an osmolal gap (indicating alcohol ingestion)
Osmolal gap = 350 (measured serum osmolality) - calculated serum osmolality
Calculated serum osmolality = 2Na + (glucose/18) + (BUN/2.8)
168
CLL
(a) B or T cell?
(b) Poor prognostic factor
(c) Most common cause of death
CLL
(a) B cell disease
(b) Poor prognostic factor = anemia and big time thrombocytopenia (very poor prognosis)
(c) Most common cause of death is infection
169
66 yo F presents w/ agitation, restlessness, and poor sleep
- HA and 14 lb wt gain over 3 mo
- smoker
- BP 160/110
- K+ of 3.2
- glucose 205
Dx
Cushing syndrome = hypercortisolism
- hyperglycemia, HTN, wt gain
- associated hypokalemia seen in ectopic ACTH-producing tumors
170
Differentiate Mallory-Weiss tear and esophageal rupture
Mallory-Weiss tear is an incomplete mucosal tear => doesn't cause pneumomediastinum b/c the tear is incomplete
While esophageal rupture is complete tear => air escapes esophagus into mediastinum => can present w/ palpable crepitus in the suprasternal notch
171
Healthy 33 yo M presents for pre-employment physical
- from Mississippi
- CXR: 1.5 cm nodule in right mid-lung field
Dx
Dx for asymptomatic single lung nodule in person from Mississippi (or Ohio/Central America) = Histoplasmosis
Key is asymptomatic- 95% of pts infected w/ histoplasmosis are asymptomatic
-disseminated histoplasmosis seen in immunocompromised adults and young children
172
Newly diagnosed HIV pt found to have PPD test w/ 6 mm induration- tx?
PPD is considered + in HIV pts w/ > 5 mm induration. All PPD + HIV pts should be given prophylactic tx given high risk of progression to active disease
(Not RIPE- RIPE is for active infection)
Instead: Isoniazid (first line drug for chemoprophylaxis) + pyridoxine (added to prevent possible neuropathy caused by isoniazid)
173
Difference btwn chemotherapy-induced and diabetic peripheral neuropathy
Chemotherapy induced peripheral neuropathy indicated by loss of ankle jerks and reflexes
-can involve motor neuropathy => weakness and bilateral foot drop
Diabetic peripheral neuropathy presents w/ sensory deficits and paresthesias in stocking-glove distribution
- can have loss of ankle reflexes
- however: motor weakness is typically a late finding that doesnt arrive until years after disease
174
Name 5 causes of pancreatitis in order of prevalence
Top 2 (each 40%): chronic alcohol use, gallstones
3. Hypertriglyceridemia
- TG over 1,000, associated xanthomas
4. Drugs- azathioprine, valproate, thiazide diuretics
5. infections: CMV, legionella, aspergillus
175
32 yo M found w/ right popliteal thrombus extending into femoral vein on venous doppler ultrasound
Next best step
Start oral rivaroxaban (direct factor Xa inhibitor)- can be used as single agent in tx for acute DVT or PE
Thrombolytic therapy is typically reserved for hemodynamically unstable PE pts. Would only give it for DVT if there was limb ischemia or something crazy
176
Two major serious complications of long term cyclophosphamid therapy
Cyclophosphamide = alkylating agnet frequently used as an immunosuppressant in SLE (when pts have renal problems and can't be on hydroxychloroquine), vasculitis, and certain cancers
Risk: transitional cell (bladder) carcinoma and acute hemorhagic cystitis
177
Digoxin mechanism of action
Digoxin inhibits the ATPase-dependent Na-K pump => increases intracellular Na which reduces Na-Ca exchanger activity => increase in intracellular calcium
Inhibits vagal tone => slows conduction thru AV node
178
What PFT pattern is seen in asbestosis?
Asbestosis gives a restrictive lung disease pattern
- decreased lung volumes
- decreased DLCO (diffusion capacity)
- normal FEV1/FVC ratio
179
What type of renal tubular acidosis causes urinary stone formation? Why?
Urinary stone formation occurs in type 1 (distal) RTA b/c calcium phosphate stones deposit at higher pHs
Stones develop due to
- alkaline urine (can't excrete H+)
- hypercalciuria
- low urinary citrate
180
Describe how COPD leads to increased WOB
COPD => air trapping (increased residual volumes) => hyperinflation and diaphragmatic flattening
Flattening of the diaphragm increases the WOB b/c makes it more difficult to decrease intrathoracic pressure to inhale
181
How may poorly controlled diabetes cause persistent hyperkalemia?
Poorly controlled diabetes => damage to the juxtaglomerular apparatus => hyporeninemic hypoaldosteronism (RAAS system not stimulating aldo release)
Low aldo release => low K+ reabsorption, can cause type 4 renal tubular acidosis
182
Skin condition associated w/ celiac disease
(a) Tx
Dermatitis herpetiformis (nothing to do w/ herpes, just can be vesicular so sometimes look likes herpes)
(a) Tx- dapsone
183
Mechanism of renal failure seen in
(a) BPH
(b) diabetes
Renal failure seen in
(a) BPH = obstructive uropathy
- postrenal acute injury requires obstruction of both ureters or obstruction distal to the bladder (prostate)
(b) Diabetes = nodular glomerulosclerosis
184
27 yo M w/ unremitting nose bleeding
- similar bleeding episode 1 yr ago
- ruby-colored papules on lips that blanch partially w/ pressure
- digital clubbing
- Hct 60%, WBC 8k, Plts 180;
(a) Dx
(b) Mechanism
(c) Etiology
(a) Epistaxis + hypoxia (evidenced by digital clubbing and reactive polycythemia) + lip/mucous membrane telangectasias = Heriditary hemorrhagic telangiectasias (osler weber rendu syndrome)
(b) Widespread AVM (arteriovenous malformations) in the skin, mucous membranes, and vital organs (lungs, liver, brain)
Hypoxia due to AVM creating right to left shunt in teh heart
(c) Autosomal dominant inheritance
185
AIDS pt presents w/ diminished vision in both eyes and CD count of 50
Yellow-white patches of retinal opacification and retinal hemorrhage
CMV retinitis
Tx = ganciclovir
186
70 yo M w/ pain and stiffness of neck, shoulders, and hips x3 mo
- stiffness worse in morning, lasts 1-2 hrs
- wt loss
- no HA, scalp tenderness, visual symptoms, or jaw claudication
- no overt synovitis, normal passive ROM
- anemic
(a) Dx
(b) Tx
(a) Polymyalgia rheumatica: joint pain at the girdles (shoulder and hips)
- r/o temporal arteritis, RA
(b) Tx = responds to glucocorticoids
187
Describe dual antiplatelet therapy for a pt post-NSTEMI
Dual antiplatelet = aspirin + P2y12 receptor blocker (clopidogrel)
188
31 yo M presenting w/ joint pain in r. knee, r. heel, and lower back
- recent tx for urethral discharge
- mouth ulcers on exam
- synovial fluid of right knee WBC 10k and PMNs w/ negative gram stain
(a) Dx
(b) Tx
(a) Reactive arthritis = seronegative (aka no auto-antibodies) spondyloarthropathy) commonly w/ nongonococcal urethritis (hence urethral discharge), asymmetric oligoarthritis, and conjunctivitis
- also commonly mucocutaneous lesions (oral ulcers) and enthesitis (Achilles tendon pain)
- no bacteria on gram stain and afebrile leads away from gonococcal septic arthritis
(b) First line for acute reactive arthritis = NSAIDs
189
GIve away physical exam finding for spinal osteomyelitis
(a) Typical pt population
Tenderness to gentle percussion over the spinous process of the involved vertebrae = most reliable sign for spinal osteomyelitis
(a) High risk of IVDU
190
Tx for acute diverticulitis
Acute diverticulitis tx: bowel rest, abx (cipro, metronidazole)
191
Risk factor for warfarin-induced necrosis
Protein C deficiency
Within first day of tx warfarin decreases anticoag protein C and S levels to 50%, then levels of procoag factors (II, IX, X) decline more slowly => transient hypercoagulable state => increased risk of venous thromboembolism and skin necrosis
-particularly dangerous in pts w/ underlying hereditaory protein C deficiency
192
Common drug causes of diabetes insipidus
Most commonly implicated meds causing DI (specifically nephrogenic DI) are lithium, demeclocycline (abx), foscarnet, cidofovir, amphotericin (antivirals/antiparasitics)
193
Differentiate thalamic stroke of VPL vs. stroke of post-central cortex
VPL (ventral postero-lateral) nucleus of the thalamus transmits sensory info from the contralateral side of the body
-accompanies by transient hemiparesis, athetosis (involuntary writhing) or ballistic movements
Post-central cortex interprets sensory info from contralateral side of body (post-central cortex = primary sensory cortex)
-no movement abnormalities
194
67 yo F 6-days s/p Cipro for UTI develops watery BM w/ lower abdominal pain, low grade fever, and altered mental status
-WBC 14,200 compared to 8,700 two days ago
Next step?
Workup and empiric coverage for C. Dif: send stoll studies and start empiric metronidazole (can be switched to PO vanco)
195
Why is pyridoxine added to isoniazid regimen for chemoprophylaxis of HIV pt w/ + PPD
Pyridoxine added to prevent possible neuropathy caused by isoniazide
Pyridoxine does not prevent isoniazid-induced hepatitis => periodic LFTs should be monitored
196
Normal serum albumin range
3.5 - 5.5
197
How to differentiate complete vs. partial diabetes insipidus
Differentiate based on the urine osmolality
Complete DI: urine osmolality is less than 300
-literally just peeing out ALL the water
Partial DI: urine osmolality ranges from 300-600
198
36 yo M w/ diarrhea, abdominal distention, flatulence x 1mo
- wt loss, night sweats, occasional arthralgias
- nontender cervical and inguinal LN
- ulcer on buccal mucosa
- no skin rashes or joint effusions
Next step
HIV testing- acute HIV infection can present w/ mononucleosis-like syndrome (fever, lymphadenopathy, sore throat, arthralgias, night sweats)
HIV vs. mono- painful mucocutaneous ulcerations, skin rash, prolonged diarrhea
199
Non-caseating granulomas seen in UC or Crohn's?
Non-caseating granulomas are not sensitive but very specific, are pathognomonic of Crohn's over UC
200
Manifestations of vitamin A deficiency
Ocular manifestations such as impaired night vision, dry eyes, keratinization of the conjunctiva and corneas
201
What cancer does Hashimoto's thyroiditis increase risk for?
RIsk of thyroid lymphoma is about 60 times higher in pts w/ Hashimoto's thyroiditis compared to pts w/o thyroiditis
202
26 yo previously health F presents after an episode of seizure
- T 102, hyperreflexia
- CSF: WBC 150 w/ 90% lymphocytes, 200 RBC, high opening pressure and high protein
Dx
HSV encephalitis
- lymphocytic predominance indicates viral etiology
- RBC in CSF associated w/ HSV specifically
203
CSF finding of Guillain-Barre syndrome
Albuminocytologic dissociation = elevated protein count w/ normal cell count
elevated protein
normal WBC, RBC, glucose
204
What is amaurosis fugax?
(a) What does it indicate?
(b) Next step on workup
Amaurosis fugax = painless loss of vision from emboli
(a) Warning sign for impending stroke
(b) The emboli will have a source, most commonly from the carotid bifurcation => do duplex ultrasound of the neck for workup
205
Polymyaglia rheumatica
(a) Age
(b) Location
(c) Associated lab abnormalities
(d) Timeline of symptoms
(e) Tx
(f) Associated symptoms
Polymyglaia rheumatica
(a) Age over 50
(b) neck, shoulders, hip, proximal thigh
- girdles: shoulder and hip girdles
(c) Elevated ESR and CRP, possible normocytic anemia
(d) B/l pain and morning stiffness > 1 mo
(e) Tx = glucocorticoids (NOT NSAIDs)
(f) Can have constitutional symptoms: fever, malaise, wt loss
206
Name one way that multiple myeloma and thyrotoxicosis may present in a similar manner
This is a stretch...but thyrotoxicosis: thyroid hormone stimulates osteoclast activity => high serum calcium w/ suppressed PTH
Then in metastatic multiple myeloma (and other osteolytic metastasis) can be associated w/ PTHrP secreiton => get hypercalcemia w/ suppressed PTH
Both of these are opposed to hypercalcemia w/ elevated or normal PTH which indicates primary hyperparathyroidism
207
Hiatal herniation increases risk for which cancer?
Adenocarcinoma of the esophagus
-increased stomach acid (ex: Chronic GERD and Barrett's esophagus) increase risk for adenocarcinoma of the esophagus
208
Acetazolamide
(a) Indication
Acetazolamide = diuretic
(a) Used to tx open-angle glaucoma and benign intracranial hypertension
209
Differentiate the etiologies of Type 1,2, and 4 Renal tubular acidosis
Type 1 (distal) = failure of alpha interacalated cells to secrete H+ and reclaim K+ in the collecting tubules
Type 2 (proximal)= failure of proximal tubular cells to reabsorb HCO3-
Type 4 = aldo deficiency or resistance to its effects
210
What are fibrocystic breast changes?
(a) Clinical exam findings
Common cause of cyclic breast pain in F of reproductive age
(a) Diffuse nodular breasts, cordlike thickening of breasts, diffusely nodular breasts w/ nonfocal tenderness
- no nipple d/c or lymphadenopathy
211
Joint tap shows
(a) needle shaped crystals w/ negative birefringence
(b) Rhomboid shaped, positive birefringent crystals
Joint tap showing
(a) needle shaped crystals w/ negative birefringence = diagnostic of gout
(b) Rhomboid shaped, positive birefringent crystals = diagnostic of pseudogout (calcium pyrophsophate deposition)
212
35 yo F w/ 5 mo episodic retrosternal pain precipitated by emotional stress and hot or cold food
- intermittently regurgitates food
- pain allevaited by sublingual nitroglycerin
(a) Dx
(b) Dx test
(a) Diffuse esophageal spasm
- nitrates relax myocytes in both coronary vessels and esophagus => alleviating the pain
- suggestive when precipitated by temperature of food and emotional stress
(b) Do esophageal motility study: show repetitive, non-peristaltic, high-amplitude contractions
213
Synovial fluid:
Rhomoid-shaped positive birefringent crystals
vs.
needle-shaped negative birefringent crystals
Psuedogout = rhomboid shaped, +
gout = needle-shaped, -
214
What do the following UA results indicate
(a) Muddy brown granular casts
(b) RBC casts
(c) WBC casts
(d) Fatty casts
(e) Broad and waxy casts
UA results
(a) Muddy brown granular casts = nonspecific, but very sensitive finding for ATN (acute tubular necrosis)
(b) RBC casts = glomerulonephritis
(c) WBC casts = interstitial nephritis and pyelonephritis
- know WBCs are coming from the kidney
(d) Fatty casts = nephrotic syndrome
(e) Broad and waxy casts = chronic renal failure
215
Empiric tx for immunocompromised pt w/ suspected bacterial meningitis
Vanc + Ampicillin + Cefepime
Covering for: pneumococcus, N. meningitides, listeria, gram-negative rods
216
How can acute hyperglycemia lead to blurred vision?
Myopic increase in lens thickness and intraocular hypotension secondary to hyperosmolarity
-result osmotic diuresis can => dehydration and serum hyperosmolarity
Called nonketotic hyperosmolar syndrome- DM2 associated w/ stressors like infection
217
22 yo M presents w/ resting tremor, muscle rigidity, clumsy gait x 6 months
- T bili 2.3
- Alk phos 130
- AST 325, ALT 258
- negative Hepatitis panels, normal CBC
(a) Dx
(b) Test
(a) Wilson's disease = rare autosomal recessive copper deposition d/o
- in young adults often presents w/ neuropsychiatric symptoms
(b) Serum ceruloplasmin (will be low) and slit lamp exam on the eye (for Kayser-Fleischer rings)
218
Wobbly wacky and wet
Wide based ataxic gait, dementia, urinary incontinence = NPH
-due to decreased CSF resorption
219
Rivaroxaban
Indications and mechanism of action
Rivaroxaban
Direct factor Xa inhibitor- anticoagulation agent, used for similar indications as warfarin but acts much faster (w/in 2-4 hrs) so can be used as single agent tx for acute DVT or PE
220
What is a plasma omolar gap? When should it be calculated
Osmolar gap = difference btwn measured and calculated serum osmolality.
Measured when ethanol, methanol, or ethlene glycol toxicity is suspected
221
Workup for ischemic stroke
First do head CT w/o contrast to r/o hemorrhage
If no hemorrhage- give fibrinolytic therpay (if within 4.5 hrs of symptom onset)
Def don't use urgent anticoagulation (heparin) due to risk of intracerebral hemorrhage, but anticoag warfarin started 2 weeks after CVA to prevent recurrence
222
63 yo F w/ cognitive impairment x 3 mo
- unsteady gait, mildly forgetful
- H/o HTN, CAD, DM
- pronator drift of left arm
- positive Romberg sign
Cause of cognitive impairment?
Sudden/acute (or stepwise) decline in executive function and mild memory problems after a stroke = Vascular dementia
Ischemic stroke => vascular dementia
-objective neurologic deficits (pronator drift, Romberg sign) wouldn't be caused by the other kinds of dementia
