UWorld Flashcards
An elderly pt presenting with progressive memory impairment along with impaired vibration sense, positive romberg sign, spastic paresis and hyperreflexia most likely suffers from ..
Vitamin B deficiency
dementia with subacute combined degeneration
A pt with vitamin B 12 deficiency presenting with elevated lactate dehydrogenase, low haptoglobin, and indirect hyperbilirubinemia most likely suffer from …
Hemolytic anemia secondary to ineffective erythropoesis
defective DNA synthesis in new RBCs results in hemolysis when pt has vitamin B deficiency
An elderly pt presenting with dementia, cognitive fluctuations, visual hallucinations, parkinsonism (bradykinesia, rigidity, gait abnormalities), vivid dreams, and/or neuroleptic hypersensitivity most likely suffers from …
Lewy Body Dementia
What treatment for Lewy Body Dementia can exacerbate the pt’s visual hallucination symptoms?
dopamine agonist
lewy body dementia treated with cholinesterase inhibitors and anti-parkinson medications
A pt presenting with a unilateral headache, ipsilateral miosis (small pupil), and ipsilateral ptosis (eyelid drooping) most likely suffers from …
Carotid Artery Dissection
(in setting of trauma/ connective tissue disease/ smoking/ neck manipulation/ hypertension/ 3-point restraint belts in car accidents)
What is the most appropriate next step in management of a pt presenting with unilateral headache, ipsilateral miosis (small pupil), and ipsilateral ptosis (eyelid drooping)?
Head and Neck CT angiography
detect carotid artery dissection
An alcoholic pt presenting with confusion, ataxia and nystagmus (leading to ophthalmoplegia) most likely suffers from …
Wernicke’s Encephalopathy
due to thiamine deficiency; tx with IV/ IM thiamine
An alcoholic pt presenting with amnesia (anterograde and retrograde) and confabulation most likely suffers from …
Korsakoff’s syndrome
due to thiamine deficiency
Administration of what substance prior to thiamine in an alcoholic with Wernicke’s encephalopathy can precipitate progression into Korsakoff’s syndrome?
Glucose
do not give glucose before thiamine
What part of the brain is affected in alcoholic patients with Wernicke-Korsakoff syndrome?
mammillary bodies
What are three major reversible causes of dementia that should be ruled out before diagnosing a pt with Alzheimer’s?
- hypothyroidism (perform thyroid function test)
- Vitamin B12 deficiency
- depression
(consider vitamin B1 in alcoholic and severely malnourished)
A pt presenting with rapidly progressive dementia, periodic sharp wave complexes on EEG, and presence of 14-3-3 protein in CSF most likely suffers from …
Creutzfeldt-Jakob disease
What is the best initial treatment for Alzheimer’s disease?
acetylcholinesterase inhibitors
donepezil better than tacrine b/c once daily and more improvement in behavioral and cognitive domains
What part of the brain has been associated with the decreased levels of acetylcholine in Alzheimer’s?
degeneration of basal nucleus of Meynert (along with diffuse deficiency of choline acetyltransferase)
A pt presenting with unilateral onset of symptoms consisting of bradykinesia, resting tremor, and rigidity with a persistant asymmetry in the symptoms, and develops postural instability most likely suffers from ..
Parkinson’s Disease
dx: clinical
Other than physical exam, what diagnostic test can be used to diagnosis Parkinson’s disease in a pt whose symptoms are suggestive but pt not responding to initial therapy?
Striatal Dopamine Transporter Scan
low uptake of ioflupane-123 in striatal region
What is the best initial treatment for Parkinson’s Disease?
if > 65 years and severe: levodopa
if less than 65 years and mild: dopamine agonist
(prevent use of levodopa as long as can)
What is the clinical criteria for brain death? (3)
- imaging evidence of devastating cause
- absence of confounding factors (endocrine, electrolyte abnormalities, drug intoxication)
- hemodynamically stable (temp > 36; sbp > 100)
An elderly pt presenting with dementia along with hyponatremia, macrocytosis (high MCV), and bradypsychia (slowed thought process)/ cognitive slowing most likely suffers from..
Hypothryoidism
obtain thryoid function testing
A pt presenting with progressive flaccid ascending paralysis (progressive lower extremity weakness), areflexia (absent deep tendon reflexes), and possibly difficulty breathing weeks after an upper respiratory or gastrointestinal infection most likely suffers from ..
Guillian Barre Syndrome
intubate if signs of respiratory compromise
What diagnostic test is most useful in determining the degree of respiratory impairment in a pt with Guillian Barre Syndrome?
bedside vital capacity measurements
What is the mainstay of therapy for Guillian Barre Syndrome (after triaging the severity and providing appropriate respiratory support)?
plasmapheresis and/or IVIG (IV immunoglobulin)
A pt presenting with a tremor (usually in distal upper extremities) that becomes more pronounced with outstretching of the arm/ end of an activity or movement in the setting of a family member having had similar symptom and alcohol improves symptoms most likely suffers from ..
Benign Essential Tremor (Familial Tremor)
normal life expectancy, no significant disabilities/ neurologic problems
What is the best initial treatment for benign essential tremor (familial tremor) that is significantly impacting a pt’s life?
beta blockers (propanolol)
What is the next best step in management of a pt who meets all clinical criteria of brain death (clinical/imaging evidence of devastating cause, absence of confounding factors, hemodynamic stability)?
Neurologic examination
(cerebral and brain stem reflexes including motor response to pain, pupillary, oculocephalic, oculovestibular/ caloric, cough reflex with tracheal suctioning, corneal, gag, suckling, swallowing, extensor posturing)
What is the next best step in management of a pt who meets all clinical criteria of brain death (clinical/imaging evidence of devastating cause, absence of confounding factors, hemodynamic stability) and has abnormal neurologic findings (coma, absent motor response to pain, absent pupillary light reflex, absent corneal and oculocephalic reflexes, absent cough reflex with tracheal suctioning)?
Apnea Testing
(pre-oxygenated and then disconnect ventilator)
(absence of respiratory response for 8-10 minutes with PaCO2 > 60 or > 20 from baseline, and final arterial pH of less than 7.28
What are the three conditions in which ancillary testing (EEG showing electrocerebral silence or absence of somatosensory/ brainstem-evoked potentials; absent intracranial blood flow on brain imaging) for suspected brain death should be performed?
- don’t meet all clinical criteria
- difficult to evaluate neuro exam or pt paralyzed
- difficult to interpret or inconclusive apnea test
A pt presenting with loss of pupillary reaction bilaterally, vertical gaze paralysis (impaired upward gaze), loss of optokinetic nystagmus and ataxia in the setting of progressively worsening headache most likely suffers from …
Parinaud’s syndrome
pineal tumor that can secrete HCG
A male pt presenting with headaches, pulsating rhythmic sound in ears when bent over, papilledema, and progressive optic atropy leading to vision problems (possibly blindness) while on retinoic acid derivative treatment for acne most likely suffers from …
Pseudotumor Cerebri
Idiopathic intracranial hypertension
What spinal cord level is responsible for the cremasteric reflex?
L1-L2
can be absent if pt suffering from diabetic neuropathy
An adolescent presenting with generalized tonic clonic seizure and an EEG showing bilateral polyspike and slow discharge in the setting of a history of myoclonic jerks of the upper extremity within the first hour of waking and history of anxiety most likely suffers from …
Juvenile Myoclonic Epilepsy
What is the best initial treatment for Juvenile Myoclonic Epilepsy?
Valproic Acid (Depakote)
A pt presents with a history of unsteady gait rapidly progressing to ascending paralysis within hours to days of spending time in a wooded area along with loss of deep tendon reflexes, normal CSF findings, and absence of fever/ pupillary abnormalities most likely suffers from …
Tick Paralysis
dx: skin examination to assess for tick attachment
What is the best initial treatment for pt presenting with Tick Paralysis?
remove tick carefully (improvement immediately, may worsen initially)
What is the best initial step in management for a pt with suspected epidural spinal cord compression (i.e. pt with cancer history presenting with thoracic radicular pain wrapping around abdomen with associated weakness and sensory changes in lower extremities)?
High Dose corticosteroids (reduce inflammation and swelling) followed by spinal MRI (to confirm diagnosis and assess extent)
What is the definitive treatment for epidural spinal cord compression secondary to tumor metastasis?
radiation: if stable spine, minimal neuro symptoms or highly radiosensitive tumor
surgical decompression: if radioresistant or unstable spine
What diagnostic tests are included in a routine dementia work-up before diagnosing a pt with Alzheimer’s? (6)
- CBC (rule out anemia)
- Serum glucose (rule out hypoglycemia)
- electrolytes (rule out electrolyte disturbance)
- calcium level (rule out hypo/ hypercalemia)
- creatinine (rule out renal failure)
- TSH (rule out hypothryoidism)
What Mini-Mental Status Exam score indicates dementia? What score indicates benign forgetfulness of senility?
dementia: less than 20
benign: greater than 25
What is the prognosis of Alzheimer’s disease?
irreversible, medication slows progression but there is no cure
A pt who presents to the ER unconscious, unresponsive to verbal and tactile stimuli, has symmetric decrease in muscular tone, normal deep tendon reflexes, and a normal response to the caloric stimulation (transient conjugate slow deviation of gaze to side of stimulus followed by saccadic correction to midline after irrigation of the external auditory canal with cold water) most likely suffers from …
Psychogenic Coma
What is the net clinical benefit of a medication? (in reference to studies)
measure of possible benefit minus its possible harm
… is when participants in trials are analyzed in the groups to which they were randomized, regardless of whether they received or adhered to the allocated intervention and regardless of whether they withdrew from treatment
Intention-to-treat analysis
purpose is to maintain randomization
…. is the practice of monitoring the safety of medication or devices after they have been released on the market due to the fact that clinical trials have ….
Postmarketing surveillance; inadequate power (short follow-up times, underrepresented populations, too few participants to detect rare and serious side effects)
A pt presenting with sticking sensation in the throat (dysphagia) accompanied by heartburn and esophageal manometry showing absence of peristaltic waves in the lower two-thirds of the esophagus and significant decrease in lower esophageal sphincter tone most likely suffers from …
Scleroderma
results in esophageal dysmotility
What are the esophageal manometric findings in Achalasia?
significant decrease/ absence of peristaltic waves and increased lower esophageal sphincter tone
A pt with history of treated cancer (especially Hodgkin lymphoma) presenting with myocardial ischemia, restrictive cardiomyopathy with diastolic dysfunction, sclerotic and calcified valves with associated stenosis/ regurgitation, and ostial narrowing of the coronary arteries most likely suffers from …
Radiation Induced Cardiotoxicity
What is the next best step in management of a pt with suspected active TB (travel to endemic area, cough for more than 2-3 weeks, fever, night sweats, weight loss) after chest x-ray is performed (showing infiltrate or cavitary lesion)?
3 sputum specimens for acid fast bacillus smears and culture (within 8-24 hours intervals, and at least 1 early morning)
A pt with active TB (travel to endemic area, cough for more than 2-3 weeks, fever, night sweats, weight loss, imaging showing infiltrate or cavitary lesion) with 3 negative sputum specimens is considered …
noninfectious
What is the formula for the NNT (number needed to treat; number of patients who need to be treated in order to prevent on additional bad outcome)?
NNT = 1/ (control group rate- experimental group rate)
NNT = 1/ (absolute risk reduction)
What are the two most common causes of diaphragmatic paralysis (decreased movement of rib cage and abdominal flattening)?
- birth injury (Erb’s palsy secondary to shoulder traction)
2. cardiothoracic injury
A pt presenting with easy fatigability, pallor of conjunctiva, pallor of oral mucosa, low hemoglobin, microcytosis (low MCV), anisocytosis on blood smear and serum ferritin level ( less than 30) most likely suffers from …
Iron Deficiency Anemia
likely due to GI bleed in males so perform fecal occult blood test
What is the typical prognosis for an infant suffering from hypertrophic cardiomyopathy (i.e. hypertrophic interventricular septum) as a result of being born to a diabetic mother with poor glycemic control during gestation?
does well with conservative medical therapy and the abnormality corrects itself (resolves spontaneously b/c no longer exposed to maternal hyperglycemia leading to excessive glycogen within myocardium)
What is the likely cause of isolated gastric varices in a pt with a history of chronic recurrent pancreatitis?
splenic vein thrombosis
(runs along posterior surface of pancreas and gets directly inflamed and thrombosed due to recurrent pancreatic inflammation)
What is the likely cause of gastric varices with esophageal varices in a pt with a history of chronic recurrent pancreatitis?
portal vein thrombosis
leads to prehepatic/ noncirrhotic portal hypertension
What is the benefit of smoking cessation in a pt who is age 60 or older?
mortality risk will fall below current smokers within 5 years
(can result in initial temporary increase in cough during first few weeks after cessation, followed by improvement)
(reduces risk of COPD exacerbation and developing lung cancer)
What is the most reliable physical exam finding for excluding severe aortic stenosis?
normal splitting of second heart sound (increased splitting of aortic and pulmonic components during inspiration)
What are three physical exam findings that indicate severe aortic stenosis?
- soft, single S2 (no normal splitting)
- delayed and diminshed carotid pulse (parvus and tardus)
- loud and late-peaking systolic murmur
What is the most immediate step in management for an infant presenting with bilateral flame shaped retinal hemorrhages suggestive of shaken baby syndrome?
CT scan of head
ultrasound can be used if fetus or infant with open fontanelles but not as accurate
What are the four indications for head CT after a head trauma in a kid?
- glascow coma score equal to/ less than 14
- signs of basilar skull fracture (battle sign- mastoid ecchymoses, raccoon eyes- orbital ecchymoses, CSF rhinorrhea or otorrhea, hemotympanum, cranial nerve deficits)
- altered mental status
- symptomatic pt with bleeding disorder
A type 1 diabetic who presents with recurrent hypoglycemic episodes evenly distributed throughout the day while on stable insulin dose (signs of decreasing insulin requirement) in setting of weight loss, weakness, eosinophilia, hyperkalemia, mild anion gap acidosis, prerenal azotemia, and low blood glucose most likely suffers from …
Adrenal Failure (secondary to autoimmune disease)
if pt has one autoimmune disease, predisposed to get another
What is the best initial screening test when a pt is suspected of having pheochromocytoma (episodic headaches, diaphoresis and tachycardia, early onset/ refractory hypertension, paroxysmal hypertension)?
24 hour fractionated urinary metanephrines and catecholamines or plasma free metanephrine levels
What is the next best step in management for a pt with symptoms and biochemical confirmation of pheochromocytoma?
Abdominal CT or MRI
What is the next best step in management for a pt who develops hypotension during surgical removal of adrenal tumor responsible for pheochromocytoma?
normal saline bolus followed by continous normal saline infusion
(pressors if needed)
What is the next best step in management for a pt who develops hypoglycemia during surgical removal of adrenal tumor responsible for pheochromocytoma?
IV dextrose infusion
due to decrease catecholamine supression of insulin secretion leading to hyperinsulinemia
What is the next best step in management for a pt who develops cardiac tachyarrhythmias during surgical removal pheochromocytoma?
IV lidocaine or esmolol
due to increase catecholamine release from adrenal gland handling
What is the next best step in management for pt who develops acute severe hypertension during surgical removal of pheochromocytoma?
IV phentolamine/ nitroprusside/ nicardipine
due to increase catecholamine release from intubation and adrenal gland manipulation
What is the best next step in management for a pt with an ECHO confirmed bicuspid valve?
ECHO screening in first degree relatives (autosomal dominant with incomplete penetrance or sporadic)
What is the next best step in management for a pt with suspected osteomyelitis (foot pain, swelling and erythema along with elevated WBC and ESR) but negative foot X-rays (lack periosteal reaction and osseous lucency)?
MRI of foot
non-invasive modality with highest accuracy for diagnosing osteomyelitis
A pt presenting with hyperthyroid symptoms, nontender thryoid goiter, elevated T3 and T4, low TSH, positive TPO antibody and diffusely decreased radioiodine uptake study in the setting of immunotherapy treatment (interferon for hep C) or lithium treatment most likely suffers from..
Painless Thyroiditis/ Silent Thyroiditis/ Subacute lymphocytic thyroiditis
(autoimmune induced proteolysis of thyroglobulin leading to thyroid hormone release until stores depleted)
What treatment can be used in painless/ silent/ subacute lymphocytic thyroiditis during the hyperthyroid state?
propanolol (beta blockers)
What is the best initial step in management prior to treating a sexually active female of reproductive age for a UTI?
urine beta-hCG (pregnancy test)
What is the best initial treatment for UTI’s in a pregnant patient?
nitrofurantoin (and first generation cephalosporin)
What is the influenza vaccination protocol in a pt with egg allergies in which the reaction is limited to hives?
administer inactivated influenza vaccine and observe for at least 30 minutes
…. is a measure of the likelihood that an outcome will occur in the presence of a particular exposure compared to the likelihood that the outcome will occur in the absence of that exposure
Odds Ratio
OR = ad/ bc
(if greater than 1: exposure associated with high odds of outcome)
(if less than 1: exposure associated with lower odds of outcome)
An asthmatic pt presenting with history of recurrent fever, malaise, cough with brownish mucoid expectoration, wheezing, symptoms of bronchial obstruction, eosinophilia and bilateral upper lobe parenchymal infiltrates on CXR most likely suffers from …
Allergic Bronchopulmonary Aspergillosis (ABPA)
What is the initial screening test for suspected allergic bronchopulmonary aspergillosis in an asthmatic pt?
skin prick test for aspergillus
(if negative, unlikely diagnosis)
(if postive, perform serum total IgE level and precipitating serum antibodies to Aspergillus fumigatus)
What is the best initial treatment for allergic bronchopulmonary aspergillosis (ABPA)?
oral prednisone (corticosteroids)
A pt presenting with fragmented sleep, hypnagogic hallucinations (seeing/hearing things as fall asleep), recurrent lapses into sleep or napping multiple times within the same day occuring at least 3 times weekly for 3 months along with at least one of the following symptoms (cataplexy-conscious brief episodes of sudden bilateral muscle tone loss precipitated by emotions or spontaneous abnormal facial movements without emotional triggers; hypocretin 1 deficiency by CSF analysis; rapid eye movement sleep latency less than 15 minutes) most likely suffers from ..
Narcolepsy
What is the diagnostic test of choice for suspected narcolepsy?
Polysomnography (Sleep Study)
shows multiple spontaneous awakenings, reduced sleep efficiency, reduced latency of rapid eye movement sleep
What is the best initial treatment for narcolepsy?
Modafinil (stimulant) along with behavioral intervention (good sleep hygiene, scheduled naps)
What is the best treatment for cataplexy (sudden onset of muscle weakness triggered by intense emotional episodes) associated with narcolepsy?
serotonin-norepinephrine reuptake inhibitor (venlafaxine)
can also use SSRI, TCAs, sodium oxybate- restricted due to abuse potential
A pt presents with respiratory difficulty, cough, sputum, fever, chills, and infiltrate on CXR 1-5 days after choking most likely suffers from …
Aspiration Pneumonia
What is the best initial treatment for aspiration pneumonia (gram positive cocci, gram negative rods, anaerobes)?
Clindamycin (or beta lactam and beta-lactamase inhibitor combination)
What is the best step in management in a hospitalize pt who develops acute renal failure to distinguish between prerenal azotemia and acute tubular necrosis?
fluid challenge
(if improved urine output, then prerenal azotemia)
(if no improvement in urine output, then acute tubular necrosis)
A pt who develops oliguria after hypotension with an elevated BUN and creatinine but a normal BUN to creatinine ratio (10-15), anion gap acidosis, and oliguria does not improve with fluid challenge most likely suffers from …
Acute Tubular Necrosis
muddy brown casts, high fractional excretion of sodium > 2%
What is an important diagnostic test that should be performed in all high-risk pts being treated for aspiration pneumonia?
speech and swallow evaluation by speech therapist (to assess for need for diet modification)
What is the best initial treatment for insomnia secondary to bereavement in the elderly patients?
behavioral therapy and relaxation techniques
(elderly at increased risk of falls and bone fractures at night and reduced daytime alertness if use medications for insomnia)
What are the indications for adding antibiotic therapy to incision and drainage for a skin abscess in kid? (6)
- diameter > 5 cm
- multiple abscesses
- extensive surrounding cellulitis
- systemic signs of infection
- immunocompromised
- age less than 6 months
What is the best step in management for a pt with a septate uterus (septum within the uterus) and non-obstructing fallopian tubes who experiences recurrent miscarriages?
metroplasty via hysteroscopy (surgery to decrease risk of future miscarriage)
A pt who develops hyperactive deep tendon reflexes, muscle cramps and possibly convulsions during or shortly after surgery (especially if extensive transfusions were required) most likely suffers from …
Hypocalcemia
due to volume expansion and hypoalbuminemia
A pt with sarcoidosis presenting with acute onset red eye, photophobia, blurring of vision, and mild to moderate pain most likely suffers from ..
Anterior Uveitis
most common ocular manifestation of sarcoidosis
A pt presents with a papular lesion that slowly grows in size and eventually ulcerates with non-purulent discharge along with similar lesions along the lymphatic channels proximal to the original lesions after an outdoor activity/ occupation most likely suffers from ..
Sporotrichosis
Sporothrix schenckii inoculated in skin or subcutaneous tissue
What is the treatment for lymphocutaneous sporotrichosis?
itraconazole for 3-6 months
A pt who develops intense pain which increases with passive stretch accompanied by paresthesia (ant crawling sensation, burning sensation), tightness of extremity, weakness, and rapidly increasing and tense swelling after extremity thromboectomy most likely suffers from …
postischemic Compartment Syndrome
due to interstitial edema and intracelluar swelling following tissue ischemia and subsequent reperfusion
What is a diagnostic test used to confirm compartment syndrome?
measuring tissue pressures
(compartment pressure more then 30 mmHg or delta pressure (diastolic bp - compartment pressure) less than 20-30 mmHg)
(time to surgical intervention is most important factor of prognosis; fasciotomy is tx)
What is the management step of choice to prevent deep venous thrombosis complication in a pt with a hip fracture?
low-molecular weight heparin (start at time of fracture, hold at time of surgery, then continue for at least 10 days post-op)
What is the initial and subsequent treatment options for mild- moderate functional constipation in children?
initial: dietary modification (increase fiber, decrease dairy)
subequent: mild laxative (magnesium hydroxide aka milk of magnesia)
What is the recurrence risk after having an infant with Turner’s syndrome (dorsal feet and hands edema, short webbed neck, cardiac murmur, wide spaced nipples)?
no increased recurrence risk (same as general population)
A pt presenting with a pervasive, lifelong pattern of suspiciousness and distrust in home and work relationships, hypervigilience, hostility, interpreting others’ motives as malevolent, controlling in personal relationship, and pathologically jealous most likely suffers from …
Paranoid Personality Disorder
A pt presenting with pattern of excessive emotionality, attention seeking behavior, inappropriate and sexually seductive/ provocative behavior, shallow/shifting/ dramatic emotions, easily influenced behavior, impressionistic/ vague speech and considers relationships more intimate than they really are most likely suffers from …
Histrionic Personality Disorder
often attempt to manipulate doctor-patient relationship through seduction and dramatic descriptions of new symptoms
What is the next best step in management of a pt who decides to take herbal medications against medical advice?
counsel pt on side effects, document discussion and refusal to discontinue, continue to follow-up pt’s health
A pt presenting with recurrent episodes of wheezing, dyspnea, cough and chest tightness that occurs especially at night and early morning hours and cough is induced when the pt is asked to do a forced expiration most likely suffers from ..
Asthma
What is the best test to diagnosis a pt with asthma who is currently asymptomatic?
Pulmonary function testing with methacholine challenge
obstructive pattern/ FEV1 decreased by more than 20% with methacholine challenge
What are the arthritic swellings of the distal interphalangeal joints in a pt with osteoarthritis called?
Heberden’s nodules
What are the arthritic swellings of the proximal interphalangeal joints in a pt with osteoarthritis called?
Bouchard’s nodules
What is the next best step in management for a pt diagnosed with diphtheria (pharyngitis, cervical lymphadenopathy, fever, pharyngeal erythema with exudate and membrane formation)?
Diphtheria Antitoxin
have epinephrine available in case of anaphylaxis or serum sickness because made with horse serum
What is the best initial test for diagnosing acute cholecystitis (gallbladder inflammation presents with ill appearance, right upper quadrant tenderness with guarding, positive murphy sign)?
Ultrasound
shows gallstones, gallbladder wall thickening/ edema, sonographic murphy’s sign
What is the next best step in management for suspected acute cholecystitis (gallbladder inflammation presents with ill appearance, right upper quadrant tenderness with guarding, positive murphy sign) when ultrasound findings are unclear (i.e. small stones without gallbladder edema/ ultrasonographic murphy’s sign)?
HIDA scan
positive if no visualization of gallbladder
What is the best initial treatment for a well-differentiated adenocarcinoma in the head of a pedunculated colonic polyp without involvement of the stalk or resection margins?
endoscopic removal
What is the next best step in management after endoscopic removal of a well-differentiated adenocarcinoma in the head of a pedunculated colonic polyp without involvement of the stalk or resection margins?
follow-up colonoscopy 2-3 months later (followed by 1 year, 4 years and 9 years later)
A pt with a history of an autoimmune disorder (type 1 diabetes, hypothyroidism) presenting with macrocytic anemia, loss of proprioception and vibration sense, ataxia, spasticity, weakness and loss of reflexes most likely suffers from …
Pernicious Anemia
(due to autoimmune destruction of parietal cell leading to decreased intrinsic factor leading to decreased vitamin B12 absorption)
What should be monitored during the first few days of treatment with vitamin B12 for vitamin B 12 deficiency associated megaloblastic anemia?
potassium level
formation of new RBCs can causes hypokalemia
What is the first line, second line and third line treatment for a patient with significant obesity (BMI greater than 35) with comorbid conditions?
- dietary changes, behavioral therapy, exercise
- Orilstat (medical therapy)
- Bariatric surgery
A pt presenting with fever, otalgia (ear pain), tympanic membrane erythema, bulging of tympanic membrane (TM inflammation) and limited tympanic membrane motility on insufflation (middle ear effusion) most likely suffers from …. and the likely causes are…. (3)
Acute Otitis Media
- Strep pneumoniae
- nontypeable H. influenzae
- Moraxella pneumoniae
What is the most likely cause of concurrent otitis media and purulent conjunctivitis?
Nontypeable H. influenzae
What is the first line treatment for acute otitis media? What is the best treatment for repeat infection within one month of initial treatment?
first: high dose amoxicillin
repeat: amoxicillin-clavulanic acid (due to beta-lactamase resistance)
What is the best step in management to maximize the viability of donor organs in a brain dead patient? (2)
- achieve hemodynamic stability
2. maintain normothermia with blankets (using warm air blankets and warm IV if body temp less than 35 C)
What is the inheritance status of a daughter born to an affected father and normal mother in the case of an X-linked recessive disorder (i.e. hemophila)?
carrier (received 1 affected X from dad and 1 normal X from mom)
What is the hemoglobin threshold level for red blood cell transfusion in a hemodynamically stable pt with an upper GI bleed and no comorbidities?
hemoglobin less than 7 g/dl
What is the hemoglobin threshold level for red blood cell transfusion in a hemodynamically stable pt with an upper GI bleed and a risk for morbidity in setting of severe anemia such as unstable coronary artery disease?
hemoglobin equal to or less than 9 g/dl
A pt presenting with chronic intense rash with excoriated lichenified plaques and a possible history of asthma/ allergic rhinitis most likely suffers from …
Atopic Dermatitis (Eczema)
What are treatments for atopic dermatitis (eczema)? (5)
- avoid excessively hot/ dry environments
- avoid harsh soaps and detergents
- oral antihistamines
- regular use of emollients (to maintain hydration)
- steroid cream if severe (short term)
What is the best treatment for atopic dermatitis involving the face, eyelids, flexural areas if symptoms persist after avoiding irritants and using emollients?
topical calcineurin inhibitors (tacrolimus)
A pt presenting with wrist pain radiating to palmar surface of thumb and first 2 fingers, associated with numbness and tingling sensation in same distribution, worse at night and can awaken from sleep, provoked by flexing/ extending wrist or raising arms (typing, driving), improved by flicking wrist (flick sign) or warm running water, symptoms reproduced with full flexion at wrist with elbow in full extension or by tapping on wrist most likely suffers from …
Carpal Tunnel Syndrome
(risk factors: diabetes, rheumatoid arthritis, hypothryoidism, wrist trauma, obesity, end stage renal disease, pregnancy)
(due to median nerve entrapment in the carpal tunnel)
What is the best initial treatment for carpal tunnel syndrome?
nocturnal wrist splinting
followed by steroid injection followed by surgery
(also surgery if motor weakness or atrophy of thenar eminence)
What medications should a pt with a recent myocardial infarction be taking? (5)
- antiplatelet (aspirin and clopidogrel/ prasugrel/ ticagrelor)
- beta blocker (metoprolol/ atenolol/ bisoprolol except if severe asthma/ COPD/ CHF/ hypotension/ bradycardia)
- statin (lipid lowering)
- ACE inhibitor/ ARBs
- aldosterone antagonist (eplerenone if LV ejection fraction less than 40%)
What is the next best step in management of an intoxicated pt who was brought in for threatening suicide attempt or suicidal ideation but is dismissing attempt as due to intoxication?
keep for observation in ER and perform suicide assessment when pt is completely sober
What is the strongest predictive risk factor for suicide?
prior history of attempted suicide
What are the four protective factors for suicide?
- social support/ family consciousness
- pregnancy
- parenthood
- religion and participation in religious activities
What is the best anticoagulation regimen for a pregnant patient requiring anticoagulation throughout pregnancy (i.e. for mechanical valve presence)?
replace warfarin with unfractionated heparin or low molecular weight heparin during the first trimester (warfarin teratogenic at 6-12 weeks gestation) and prior to delivery (heparin easily reversible in cases of bleeding; otherwise on warfarin (for 2nd and 3rd trimester)
What is the most important factor in perioperative adverse drug reaction in the elderly population?
multiple medication use
A child presenting with hypopigmented skin lesions, seizure like activity, developmental delay, and possible autistic like behavior most likely suffers from …
Tuberous Sclerosis
benign tumors throughout body: skin, CNS, heart, kidney
What diagnostic tests should be performed in a child with suspected tuberous sclerosis? (5)
- thorough skin exam (ash leaf spots, angiofibromas of malar region, shagreen patches)
- fundoscopy
- brain MRI (glioneuronal hamartomas)
- EEG (for baseline/ seizure activity)
- abdominal imaging
What is the predominant cause of death in patients with tuberous sclerosis?
Progressive neurologic impairment (uncontrollable seizures, aspiration pneumonia, obstructive hydrocephalus)
When can low-risk pts (few CVD risk factors, controlled HTN, asymptomatic LV dysfunction, successful revascularization of clinically significant lesions > 50-60%) initiate/ resume sexual activity after a myocardial infarction?
once they can perform light intensity exercise without symptoms (within weeks of MI)
A pt presenting with nightmares, flashback of an event, avoids distressing thoughts/ feelings/ external reminders of event, have persistent feeling of horror/ anger/ guilt, have negative belief about self or world, decreased interest in activities, emotional detachment, amnesia of event, sleep disturbance, hypervigilence, and impaired concentration lasting for more than 1 month after exposure to a life threatening trauma most likely suffers from ..
Post Traumatic Stress Disorder (PTSD)
What is the best medical treatment for nightmares associated with PTSD (post-traumatic stress disorder)?
prazosin
An infant presenting with constipation followed by lethargy, poor sucking, weak cry and impaired gag reflex after being fed honey most likely suffers from ..
Infant Botulism
An HIV pt who has a recent history of severe pain in mouth, throat and epigastric region and then develops ocular pain, photophobia, scotomas (large glistening off-white lesions with indistinct borders on funduscopy) and fever most likely suffers from ..
Candida endophthalmitis
(risk factors: central venous catheter, TPN, broad spectrum antibiotics, prior abdominal surgery, neutropenia, steroid therapy, IV drug abuse)
What is the best medical therapy for candida endophthalmitis?
systemic amphotericin B or fluconazole
also vitrectomy if vitreal involvement
In a normal distribution graph, 68% of all observations lie within … standard deviations of the mean, 95% of all observations lie within …. standard deviations of the mean, and 99.7% of all observations lie within …standard deviations of the mean..
1 (68%); 2 (95%); 3 (99.7%)
What type of study involves a group of subjects being selected and their exposure status is initially determined before being followed for a certain period and observed for development of the outcome?
Prospective Cohort Study
What type of preventative medicine strategy is defined as the prevention of risk factors for a disease?
Primordial prevention
What type of preventative medicine strategy is defined as an action that attempts to halt the progression of a disease at its initial stage before irreversible pathological changes take place, thus preventing complications?
Secondary prevention
What type of preventative medicine strategy takes place when the disease process has advanced beyond early stage and all actions available are taken to limit impairments and disabilities?
Tertiary Prevention
What type of preventative medicine strategy is an action taken before a patient develops the disease and acts to prevent the occurrence of the disease itself?
Primary Prevention
… is when a test is able to diagnose more patients that actually have the disease (more true positives and less false negatives) such that less “sick” pts will have negative test results
Sensitivity
(sensitivity = a/ (a+c))
(associated with high negative predictive value)
… is when a test is able to identify pts who are actually healthy (more true negatives and less false positives) such that less “healthy” patients will have a positive test result
Specificity
(specificity = d/ b+d)
(SpIn= specificity rules in disease)
When determining which test to use as a screening test, what is more important for the initial test used as a screening test: specificity or sensitivity?
sensitivity (use more sensitive test first then more specific test as confirmation)
What physical activity is strictly prohibited in pregnancy?
scuba diving (risk of decompression injury and gas emboli in fetus)
What is the next best step in management of a pt presenting with symptomatic normocytic, normochromic anemia?
reticulocyte count (to distinguish between hemolytic disorder and disease of decreased RBC production)
low retic count: disease of decreased RBC production
high retic count: hemolysis
What is the typical interval for breastfeeding a newborn?
every 2-3 hours (no more than 4 hours overnight)
feed early if signs of hunger: rooting, hand/ finger sucking, arm movement toward mouth
What type of drug test is the preferred screening test to identify recent drug use in the emergency setting?
Urine immunoassay
antibodies to opioids, cocaine, marijuana, phencyclidine, amphetamines and alcohol used in last 1-3 days
A girl presenting with cyclic pelvic/ abdominal pain with primary amenorrhea, appearance of bluish tissue bulging between labia and a small rounded palpable mass in the suprapubic area in the setting of secondary sexual characteristics adequately developed for age most likely suffers from ..
Imperforate Hymen (hematocolpos)
What is the best initial step in management of a pt with non-suicidal self-injury (cutting behavior)?
inform relatives that pt is not in danger, screen for suicidal ideation and perform comprehensive psychiatric evaluation
An HIV pt not on medication presenting with rapidly progressive focal neurologic deficits such as cognitive impairment, hemiparesis, aphasia, ataxia, visual field deficits, seizure activity and a brain biopsy reveling oligodendrocytes with intranuclear inclusions, demyelination and astrogliosis most likely suffers from ..
Progressive Multifocal Leukoencephalopathy (PML)
tx: HAART therapy prolongs life for 2 years but not cure
(prognosis: without treatment, most die within 3-6 months)
What is the best step in management of a battery ingestion in which the battery is lodged in the esophagus? What is the best step in management of a battery ingestion in which the battery has made it to the stomach?
esophagus: immediate endoscopic removal
stomach: outpatient management (pass on own)
A pt with syncopal episode and an EKG showing short PR interval with delta wave (initial slow upstroke of QRS) and prolonged QRS most likely suffers from ..
tachyarrhythmia secondary to Wolff- Parkinson-White syndrome
pre-excitation syndrome due to accessory pathway
What is the best treatment for symptomatic pts with Wolff-Parkinson White syndrome?
catheter ablation therapy
What is the most common complication of bacterial conjunctivitis (unilateral eye redness with mucopurulent discharge)?
Keratitis (inflammation of cornea)
(presents as foreign body sensation, photophobia, corneal opacity/ ulceration especially in contact wearers)
(tx: antibiotics and urgent optho consult/ referral)
What is the best initial treatment for bacterial conjunctivitis (due to Strep penumoniae, Moraxella catarrhalis, H. influenzae)? (3)
- erythromycin ointment
- sulfa drops
- polymixin/ trimethoprim drops
When can a pt with bacterial conjunctivitis return to work/ school?
after 24 hours of antibiotic therapy (but should wait until discharge has resolved if can)
When is it acceptable to disclose genetic information to relatives?
if disclosure serves to ameilorate/ prevent a highly likely and forseeable harm to relative
(Huntington’s does not do this bc get disease regardless)
What is the most appropriate next step in management if a pt with positive genetic testing results for a serious hereditary illness refuses to disclose the information?
discuss with pt the reason for decision and document counseling and pt’s refusal to disclose in chart
What is the next best step in management of a pt who is competent and refusing appropriate health care?
identify possible barriers to accepting appropriate health care by asking pt why he/she is refusing
What is the finding in an aspiration of an affected joint associated with a diagnosis of gout?
negatively birefringent needle-shaped crystals
A pt on cyclosporin who presents with acute swelling of the first metatarsophalangeal joint associated with erythema, warmth and tenderness most likely suffers from ..
Gout
cyclosporin causes hyperuricemia via decreasing urate excretion
What is the best initial treatment of gout in a pt with renal failure or post- renal transplant?
intra-articular glucocorticoids (avoids systemic effect of steroids) or increase dose of systemic steroids if on them
What is the best initial treatment for prolactinomas (erectile dysfunction, galactorrhea, sexual dysfunction, visual changes, amenorrhea, hot flashes, decreased bone density) regardless of size?
Dopaminergic receptor agonist (bromocriptine, cabergoline)
use trans-sphenoidal surgery if pt fails medical therapy especially if have significant neuro symptoms
What is the best initial step in management of a pt with symptomatic bradycardia?
IV atropine
What is the next best step in management of symptomatic bradycardia if there is no response to atropine?
transvenous cardiac pacing
A pt presenting with decreased hearing, history of aural irrigation for removal of cerumen, otalgia (ear pain), purulent drainage/ discharge from the ear (otorrhea), ear lobe tenderness, and visible granulation tissue on floor of external auditory canal at osseocartilaginous junction most likely suffers from ..
Malignant Otitis Externa
usually in elderly pt with diabetes, HIV pt, immunocompromised
(due to Pseudomonas aeruginosa)
What is the treatment for malignant otitis externa?
IV antibiotics initially then switched to oral to complete 6-8 weeks
- IV ciprofloxacin
- IV piperacillin/ ticarcillin with/ without aminoglycoside
- IV ceftazidime
A pt presents with fever, malaise, hydrophobia (water triggers pharyngeal spasms causing pt to fear drinking), aerophobia (fear of fresh air), agitation, ascending flaccid paralysis, aphasia, drooling and lethargy after an encounter with an animal most likely suffers from ..
Rabies
(bats especially is spelunking/ cave exploration, raccoons)
(once symptomatic, poor prognosis)
Why should selective estrogen receptor modulators (raloxifene, tamoxifen) be discontinued 4 weeks prior to surgery?
risk of venous thromboembolism
What other treatments should be given to a pt who is on chronic glucocorticoid therapy? (2)
- calcium
- vitamin D
(b/c longterm steroids increase risk of osteoporesis via decrease intestinal absorption of calcium, increase renal excretion of calcium and acclerated bone resorption)
A pt presenting with symmetric polyarthritis involving MCP and PIP joints, associated with morning stiffness lasting more than 30 minutes for several weeks most likely suffers from ..
Rheumatoid arthritis
dx: rheumatoid factor and anti-cyclic citrullinated peptide/ CCP, X-rays
What is the first line treatment for rheumatoid arthritis?
NSAIDs (ibuprofen)
(use disease modifying antirheumatic drugs if higher risk of disease progression: multiple inflamed joints, functional limitation, extraarticular disease, bone erosion on X-ray, markedly elevated RF, positive anti-CCP)
What is the first line disease modifying anti-rheumatic drugs (DMARDs) used for rheumatoid arthritis?
Methotrexate
What P-value signifies statistical significance in studies?
P- value less than 0.05
What is a major side effect of Ginko Biloba used for memory enhancement?
increased bleeding risk
bleeding and platelet dysfunction
What is a major side effect of Ginseng used for improved mental performance?
increased bleeding risk
What are major side effects of Saw Palmetto used for benign prostatic hyperplasia? (2)
- Hypertension
2. increased bleeding risk
What are major side effects of Black Cohosh used for post-menopausal symptoms (hot flashes, vaginal dryness)? (2)
- hepatic injury
2. increased bleeding risk
What are major side effects of St John’s Wort used for depression and insomnia? (2)
- drug interactions (with antidepressants causing serotonin syndrome, OCP, anticoagulants causing decreased INR, digoxin)
- hypertensive crisis
What is a major side effect of Kava kava used for anxiety and insomnia?
severe liver damage (hepatotoxicity)
What are major side effects of Licorice used for stomach ulcers and bronchitis/ viral infections? (2)
- hypertension (due to inhibition of 11-beta hydroxysteroid dehydrogenase leading to elevated cortisol)
- hypokalemia
What is a major side effect of Echinacea used for treatment and prevention of cold and flu?
anaphylaxis (more likely in asthmatics)
What are major side effects of ephedra used for treatment of cold and flu and for weight loss and improved athletic performance? (4)
- hypertension
- arrhythmia/ MI/ sudden death
- stroke
- seizure
What cell type is responsible for acoustic neuromas observed in patients with neurofibromatosis?
Schwann cells
What is the best initial screening test for Down’s syndrome detection during pregnancy?
integrated test
(ultrasound measurement of nuchal translucency thickness at 10 weeks, PAPP-A level in first trimester, and in second trimester alfa-fetaoprotein, HCG, unconjugated estriol, dimeric inhibin-A levels)
What is the most accurate test for detecting Down’s Syndrome in a fetus during pregnancy?
fetal karyotyping from CVS or amniocentesis
What mode of inheritance is associated with all children of an affected mother being affected; however no children of an affected father being affected?
Mitochondrial
What is the next best step in management for a pt with short duration syncopal episodes triggered by prolonged standing/ emotional distress/ painful stimuli and associated with prodrome with dizziness/ nausea/ pallor/ diaphoresis/ abdominal pain/ generalized sense of warmth if an EKG is normal and there is no orthostatic hypotension?
no further testing
Vasovagal Syncope is clinical diagnosis; can use tilt table test if uncertain
Is a retroverted uterus a possible etiologic cause of spontaneous abortions in a woman experiencing recurrent miscarriages?
No
What is the next best step of management for a female pt older than 45 years old who experiences periods of amenorrhea followed by irregular unpredictable bleeding (anovulatory bleeding) with associated hot flashes and sleeping difficulties?
Endometrial Biopsy
symptoms suggestive of menopausal transition/ perimenopause
(to assess for endometrial hyperplasia and cancer)
A pt presenting with shoulder pain associated with ipsilateral ptosis, miosis, enophthalmos and anhidrosis, as well as weight loss, supraclavicular lymph node enlargement, and weakness/ atrophy of intrinsic hand muscles along with pain and paresthesisa of 4th finger, 5th finger, medial arm, and forearm most likely suffers from …
Pancoast Tumor
(superior pulmonary sulcus tumor is subset of non-small cell lung cancer and affects paravertebral sympathetic chain and inferior cervical ganglion)
What is the most worrisome findings in the setting of a pt having a Pancoast Tumor?
low back pain and asymmetric lower-extremity deep tendon reflexes (hyper-reflexia on affected side)
(suggest spinal cord compression)
A pt with history of atherosclerotic disease (cartoids, coronary, HTN, diabetes)/ vasculitis/ hematologic disease presenting with painless acute vision loss in 1 eye, an afferent pupillary defect, retinal whitening/ cherry red spot in macula and diffuse ischemic retinal pallor on funduscopy most likely suffers from ..
Central Retinal Artery Occlusion
cherry red spot due to preserved circulation via posterior ciliary arteries
What is the treatment for central retinal artery occlusion? (4)
- urgent ophthalmology consult
- lower intraocular pressure (ocular massage, anterior chamber paracentesis, IV acetazolamide, mannitol)
- intra-arterial thrombolytics if needed
- long term atherosclerosis risk factor modification (statin, antiplatelet agent)
A pt presenting with acute painless vision loss in 1 eye and tortuous and dilated veins, diffuse hemorrhages, disk swelling and cotton wool spots on funduscopy most likely suffers from ..
Central Retinal Vein Occlusion
How should difficult patient encounters due to situations beyond the physician’s control (i.e. long waiting times) be managed?
apologize, acknowledge the delay and pt’s frustration, provide brief explanation
A young pt or pt with history of Paget’s disease who develops hypercalcemia in the setting of low PTH and normal vitamin D levels (1,25 Vitamin D may be low) while in the hospital most likely has hypercalcemia due to ..
Immobilization
excessive bone resorption leads to hypercalcemia
How do you correct the calcium level in the setting of hypoalbuminemia?
for every 1 g/dl decrease in serum albumin below 4 g/dl, add 0.8 mg to the total calcium level
(corrected calcium = measured total calcium + 0.8( 4- measured serum albumin))
What is the treatment for akathisia (subjective feeling of inner restlessness and the urge to move) due to antipsychotic medications?
Beta blocker (propanolol)
What is the best initial step in management to establish the cause of a syncopal episode?
through history and physical with an EKG
What is the next best step in management of a patient presenting with substernal chest discomfort that is relieved by nitroglycerin and has an EKG with findings of ST depression suggesting acute coronary syndrome (unstable angina/ non-ST elevation MI)? (6)
- dual antiplatelet therapy (aspirin and P2Y12 receptor blocker- clopidogrel/ prasugrel/ ticagrelor)
- nitrates
- beta blockers
- statins
- anticoagulant therapy (unfractionated/ LMW heparin, fondaparinux)
- oxygen
What is the best initial step in management for a female pt who has just become menopausal to prevent osteoporesis? (3)
- regular weight bearing and anti-gravity exercises
- 1200 mg of calcium (dietary and/or supplemented)
- 600-800 IU of vitamin D (dietary and/or supplemented)
When should postmenopausal women aged less than 65 years old undergo a bone density screening? (5)
- body weight less than 58 kg (127 lbs)
- chronic steroid use
- smoking
- malabsorptive disorders (cystic fibrosis)
- parental hx of hip fracture or personal hx of low-impact fracure
A pt presenting with expanding, painless lesions with central clearing, headache, fatigue, malaise, myalgias, and fever after spending time in woods most likely suffers from …
Early Limited Lyme Disease
(dx with initial ELISA followed by confirmatory western blot if history and physical not clear)
(transmitted by brown tick)
What is the treatment for Early Limited Lyme Disease?
oral doxycycline/ amoxicillin/ cerfuroxime
A pt presenting with history of cramping with volitional movements in early morning (i.e. stretching in bed), asymmetric weakness in distal extremity progressing to muscle wasting, atrophy, twitching and fasciculations that then spreads to multiple limbs with associated hyperactive deep tendon reflexes, spastic resistance to passive movement and difficulty chewing and swallowing most likely suffers from …
Amyotrophic lateral sclerosis (ALS)
What treatment has been shown to be beneficial in pts with amyotrophic lateral sclerosis (ALS)?
Riluzole
glutamate inhibitor prolongs survivial and delays tracheostomy
What is the risk of developing type 1 diabetes in an offspring of a parent with type 1 diabetes?
if mother has it: 3%
if father has it: 6%
What is the next best step in management for medication induced psychosis once the minimum effective dose of anti-parkinsonian medication has been established in a pt with parkinson’s disease (i.e. development of psychosis while on minimum effective dose of levodopa)?
add quetiapine (low dose antipsychotic)
second line is clozapine
A pt presenting with asymptomatic mild hypercalcemia, normal vitamin D level, PTH level within normal range but at upper limit of normal, urine calcium less than 100 mg/day and a family history of hypercalcemia most likely suffers from ..
Familial Hypocalciuric Hypercalcemia
mutation in calcium sensing receptor in parathyroid gland and kidneys
A pt presenting with asymptomatic mild hypercalcemia, normal vitamin D level, PTH level within normal range but at upper limit of normal, urine calcium more than 200 mg/day most likely suffers from ..
Primary Hyperparathyroidism
What are the procedures that warrant antibiotics prophylaxis in patients with high risk cardiac conditions? (4)
- dental procedures w/ manipulation of gingiva/ periapical region of tooth/ perforation of oral mucosa
- respiratory tract procedures with incision/ biopsy
- GI or GU procedure in pt with established infection
- procedures on infected skin/ musculoskeletal tissue
What is the next best step in management for a pt diagnosed with familial adenomatous polposis after finding more than 100 colonic adenomatous polps on colonoscopy (especially in setting of positive family history)?
proctocolectomy or total colectomy with ileoanal anastomosis
otherwise inevitably progresses to colorectal cancer by 50 years old
A pt presenting with asymmetric oligoarthritis that is inflammatory (elevated WBC on synovial aspiration) yet sterile (culture negative), circinate balanitis (painless, shallow penile ulcers)/ uveitis/ conjunctivitis/ oral ulcers/ keratoderma blennorrhagicum/ achilles enthesitis (pain at ligament/ tendon insertion site), dactylitis in the setting of a history of chlamydia infection 1-4 weeks ago most likely suffers from ….
Reactive Arthritis
(can also be associated with gastroenteritis from Shigella, Salmonella, Clostridium, Yersinia, Campylobacter)
(associated with positive HLA- B27)
(can’t see, can’t pee, can’t climb a tree)
What is the next best step in management in a pt with new onset reactive arthritis that have a history of chlamydia infection?
repeat chlamydia testing (urinary nucleic acid amplification for Chlamydia trachomatis)
What is the treatment for reactive arthritis from recurrent chlamydia infection?
antibiotics with naproxen (NSAID for symptomatic relief)
An african american pt presenting with dry cough, weight loss, fever, maculopapular rash, erythema nodosum (tender erythematous nodules on shin), bilateral hilar adenopathy and interstitial infiltrates on CXR, uveitis, lymphadenopathy, polyarthritis, hypercalcemia, suppressed PTH, increased urinary calcium, elevated alkaline phosphatase, hepatomegaly, and central diabetes insipidus most likely suffers from ..
Sarcoidosis
non-caseating granulomas
What is the cause of hypercalcemia in a pt with sarcoidosis?
calcitriol (1,25-OH Vitamin D) overproduction
(noncaseating granulomas produce 1-alpha hydroxylase which converts 25-OH Vitamin D to 1,25-OH Vitamin D to increased calcium absorption in GI tract)
What is the best treatment for hypercalcemia secondary to sarcoidosis?
glucocorticoids (steroids)
A pt presents with a persistent cough (lasting more than 5 days up to 3 weeks) after a respiratory illness with associated wheezing, rhonchi and chest wall tenderness but lacking fever and chills most likely suffers from ..
Acute Bronchitis
ts: symptomatic with NSAIDs and bronchodilators
What area of the heart is supplied by the left circumflex artery?
lateral and posterolateral wall of the left ventricle
affected if left main coronary artery occluded b/c branches off left main
What area of the heart is supplied by the left anterior descending artery?
anterior wall of the left ventricle
affected if left main coronary artery occluded b/c branches off left main
What area of the heart is supplied by the right coronary artery?
- inferoposterior wall of left ventricle
2. right ventricle
What is the next best step in management of a pt with signs of hepatic encephalopathy (hallucinations, wax and waning of consioucness) in the setting of spontaneous bacterial peritonitis (more than 250 neutrophils in ascitic fluid)?
lactulose (for hepatic encephalopathy) and antibiotics (for bacterial peritonitis)
What parameters are most useful in predicting a patient’s 90-day mortality from liver disease?
- bilirubin
- INR
- serum creatinine
(MELD score = 3.8 [Ln bilirubin] + 11.2 [Ln INR] + 9.6 [Ln creatinine])
What MELD score in a patient with liver disease correlates with a good outcome from placement of a transjugular intrahepatic portosystemic shunt (TIPS procedure)?
MELD score less than 14 (have high survival likelihood)
A pt presenting with diarrhea, fever, abdominal pain and leukocytosis in the setting of recent antibiotic use most likely suffers from ..
Clostridium difficile associated colitis
tx: metronidazole
What is the next best step if there is a high clinical suspicion for C. difficile colitis but laboratory testing is negative (negative PCR or enzyme immunoassay of stool)?
limited colonoscopy or sigmoidoscopy
detect pseudomembranous colitis- raised yellow plaques over the sigmoid mucosa
What are the most common antibiotics associated with causing C. difficile colitis? (4)
- fluoroquinolones (ciprofloxacin)
- enhanced spectrym penicillins
- cephalosporins
- clindamycin
What is the cervical cancer screening guidelines for patients age 21-29 years old?
Pap smear every 3 years
What is the cervical cancer screening guidelines for patients aged 30-65 years old?
- Pap smear every 3 years
or - Pap smear with HPV testing every 5 years
What is the cervical cancer screening guidelines for immunocompromised patients (HIV, lupus, organ transplant)?
start at onset of sexual intercourse performing every 6 months for 2 years and then annually
What is the next best step in management for a patient with clinical signs (gait disturbance- wide based and magnetic, dementia/ cognitive decline, urinary incontinence) and brain imaging (ventriculomegaly out or proportion to sulcal enlargment) suggestive of normal pressure hydrocephalus?
Miller Fisher test/ Lumbar tap test
(evaluate gait speed, stride length, verbal memory, visual attention before and after removal of 30-50 ml of CSF; if improvement after removal than will respond to VP shunt)
What is the best prognostic indicator for the severity of acute pancreatitis?
APACHE II score
(12 variables used at time of admission and daily)
(if score greater to or equal to 8, pt should have CT scan at 72 hours to evaluate for necrosis)
What is the next best step in management of a dog bite on the hand (not other places on body)?
cleaned, irrigated with normal saline, debrided and left open to drain with close observation
(high risk of infection, similar with any cat/ human bite and puncture wounds)
What intervention most significantly improves the quality of patient handoffs?
systemiatic sign out checklists and templates
(pt identifying info, DNR/ do not intubate status, hospital course and recent events, acuity/current conidtion, anticipatory info, plan and tasks by organ system)
A pt presenting with fatigue, paroxysmal nocturnal dyspnea, orthopnea, jugular venous distension, rales/ crackles, presence of S3, increased cardiac silhouette and pulmonary congestion on CXR, bilateral lower extremity edema, nocturnal cough, dyspnea on exertion and hepatomegaly most likely suffers from..
Congestive Heart Failure
dx: clinical- 2 major- goes up to CXR and 2 minor criteria
A pt presenting with pain and swelling behind an ear after a recent otitis media infection most likely suffers from
Acute mastoiditis
infection of mastoid air cells
A pt presenting with acute onset of upper abdominal pain radiating to the back, associated nausea and vomiting, blunting of left costophrenic angle on CXR most likely suffers from …
Acute Pancreatitis
dx: lipase and amylase levels
What is the treatment for acute pancreatitis?
aggressive IV fluids (prevent hypovolemia from third spacing), morphine (pain control), NPO
What is the next best step in management of a pt with acute pancreatitis after initiating treatment?
Obtain liver function tests (if not done already), abdominal ultrasound, lipid panel, assess alcohol use, calcium level
(assess cause of pancreatitis: gallstones, alcohol, hypertriglyceridemia)
What is the next best step in management of a pt with acute pancreatitis who was initially hemodynamically stable but deteriorates several days later?
contrast- enhanced CT scan of abdomen (assess for pancreatic necrosis or infection)
A pt with hyponatremia, low plasma osmolality, elevated urine osmolality and high urinary sodium (greater than 40 mEq/L) with normal renal, adrenal and thyroid function test most likely suffers from ..
Syndrome of Inappropriate ADH secretion (SIADH)
due to CNS disorders, HIV, tumors- small cell lung cancer, carbamazepine, cyclophosphamide, SSRIs, post-op pts
What antibiotics have an increased risk of seizure in the setting of renal insufficiency/ older age/ pre-existing CNS disease/ use of proconvulsant drugs?
beta-lactams and fluoroquinolones
penicillins, cephalosporins, monobactams, carbapenems- imipenem
An african american child presenting with painful swelling of the hands and feet (dactylitis or hand-foot syndrome), peripheral cyanosis, unlocalized pain, hemolytic anemia, howell-jolly bodies on smear and crying most likely suffers from ..
Vaso-Occlusive Painful Crisis of Sickle Cell Disease
dx: hemoglobin electrophoresis
What is the best screening test for suspected sarcoidosis (primarily in African American, Puerto Ricans, Irish, Scandinavians)?
Chest X-ray (bilateral hilar adenopathy/ mediastinal widening and interstitial infiltrates)
What is the best test to confirm sarcoidosis?
biopsy if easily accessible lesion
fiberoptic bronchoscopy with transbronchial lung biopsy if no accessible lesion
In a non-inferiority trial, if the test variable’s mean and confidence interval is to the right of the non-inferiority margin line, what does that mean?
the test drug is non-inferior to the control drug
new drug is not unacceptably worse than the control drug in reference to the variable
In a non-inferiority trial, if the test variable’s confidence interval crosses the zero line, what does that mean?
the test drug is not superior to the control drug
(if confidence interval is to right of zero line, test drug is superior to control)
(if confidence interval is to left of zero line, test drug is inferior to control)
A pt preseting with small, rough, erythematous and keratotic papules on sun-exposed areas that show signs of chronic photodamage (dyspigmentation, wrinkling, thinning, telangiectasia) in the setting of spending lots of one’s life in the sun most likely suffers from ..
Actinic Keratosis
(tx: liquid nitrogen cryotherpy, surgical excision, curettage)
(biopsy if diagnosis unclear/ lesion greater than 1 cm in diameter/ lesion indurated/ ulceration rpesent/ tenderness present/ rapidly growing lesion/ fails to respond to therapy)
What disease is there an increased risk for if a pt has actinic keratosis?
Squamous Cell carcinoma
A pt presenting with an enlarging fleshy nodule with ulceration on sun-exposed skin in the setting of spending lots of one’s life in the sun most likely suffers from..
Basal Cell Carcinoma
A young female athlete presenting with chronic anterior knee pain that worsens with squatting/ running/ prolonged sitting/ using the stairs (activities that require quadricep contraction) and has crepitation and pain on extension of the knee with anterior patellar compression most likely suffers from ..
Patellofemoral pain syndrome
tx: exercises to stretch and strengthen the thigh muscles and avoid activities that aggravate pain
An athlete who plays sports that involve alot of jumping (volleyball/ basketball) presenting with episodic anterior knee pain and tenderness at the inferior patella most likely suffers from ..
Patellar tendonitis (jumper's knee)
An adolescent athlete who recently underwent a growth spurt presenting with anterior knee pain that worsens while playing sport and is relieved by rest, and has tenderness and swelling at the tibial tubercle most likely suffers from …
Osgood-Schlatter syndrome
A pt presenting with periodic vertigo (room spinning), unilateral hearing loss and tinnitus most likely suffers from …
Meniere’s syndrome
An elderly pt who withdraws from social life, avoids leaving home to avoid conversation, listens to the radio/ TV at high volumes, and failing the whispered voice test most likely suffers from ..
Presbycusis
age-related hearing loss
A pt presenting with joint pain and restriction of joint movement, elevated alkaline phosphatase, normal calcium level, thickening of outer cortex of the bone on X-ray and increased uptake on technetium bone scan most likely suffers from …
Paget’s Disease of bone
tx: bisphosphonates
(dx: radionuclide bone scan)
What is the treatment for Paget’s Disease and when is it indicated? (5)
Bisphosphonates (alendronate, risedronate, pamidronate)
- intolerable pain
- involves weight bearing bones
- neuro involvement
- hypercalcemia/ hypercalciuria
- CHF
A pregnant pt presenting with pruritic erythematous papules within the striae gravidum most likely suffer from ..
Papular urticarial papules and plaques of pregnancy (PUPPP)
tx: topical steroids
A pregnant pt presenting abdominal pruritis that develops into papules and vesicles surrounding the umbilicus most likely suffers from …
Herpes gestationis (pemphigoid gestationis)
autoimmune disorder
What is the best treatment for herpes gestationis (pemphigoid gestationis)?
corticosteroids (use systemic if fail topical)
What is the next best step in management of an asymptomatic pt with an incidental findings of Actinomyces while using an intrauterine device (IUD)?
advise pt to call if she develops pelvic infection symptoms
Actinomyces is normal flora of vagina but is associatd with infection in IUD users
What is the first line treatment for primary dysmenorrhea (crampy lower abdominal pain with the onset of menstrual bleeding, may have associated nausea and vomiting)?
NSAIDs (naproxen)
What is the second line treatment for primary dysmenorrhea (crampy lower abdominal pain with the onset of menstrual bleeding, may have associated nausea and vomiting)?
combined hormonal contraceptive pills
if fail to improve, evaluate for secondary causes
A pt presenting with a severe and sudden onset headache different from previous headache patterns (or described as worst headache of life) associated with nausea, vomiting, brief loss of consciousness, focal neuro deficits or meningismus especially in the setting of having hypertension/ being a smoker or heavy alcohol drinker most likely suffers from …
Subarachnoid Hemorrhage
due to ruptured saccular aneursym
What is the preferred initial test for establishing a diagnosis of subarachnoid hemorrhage?
Head CT without contrast
if negative or equivocal, then do lumbar puncture- xanthochromia
If a head CT without contrast is negative but history and physical is suggestive of subarachnoid hemorrhage, what is the next best step in management of the pt?
Lumbar puncture (assess for elevated opening pressure, xanthrochromia- pink/yello tint of CSF due to hemoglobin degradation products), consistently elevated RBCs in all tubes)
A pt with the history of celiac sprue presenting with abdominal pain, weight loss, diarrhea, and anemia despite being adherent to gluten-free diet most likely suffers from …
Intestinal T cell Lymphoma
What treatment in a pregnant woman lowers the risk of having an infant with spina bifida?
folic acid
A newborn with muscular weakness of the lower extremities and the presence of a protrusion of tissue in the midline lumbar region consisting of a sac of fluid most likely suffers from …
Myelomeningocele
no imaging, immediate neurosurgical eval and surgical closure within 24-48 hours
A pt with skin that has a leathery appearance with coarse, deep wrinkles and furrows, variable pigmentation, clusters of dilated capillaries and venules, and scattered flesh-colored scaly patches with slightly irregular margins most likely suffers from …
Photoaging
tobacco smoking is associated
What is the best treatment for photoaging of skin?
tretinoin (all-trans retinoic acid)
What is the next best step in management for a pt diagnosed with rhabdomyolysis (muscle tenderness, increased muscle tone, renal failure, hyperkalemia, hypocalcemia, hyperphosphatemia, elevated creatine kinase in the setting of cocaine/ alcohol intoxication/ severe trauma/ neuroleptic malignant syndrome)?
aggressive IV isotonic saline (followed by alkalinication of urine)
What is the next best step in management of a pt with loud snoring without other alarming symptoms (daytime hypersomnolence, nocturnal choking/ gasping/ apnea with oxygen desaturations, hypertension)?
lose weight, stop smoking, avoid alcohol near bedtime
What is the first line treatment for Raynaud phenomenon (fingers get numb and turn blue when exposed to cold)?
Dihydropyridine calcium channel blockers (nifedipine and amlodipine) and diltiazem
What is the next best step in the treatment of a pt with Raynaud’s phenomenon who is resistant to treatment with calcium channel blockers and has arthralgias and myalgias?
obtain ANA and rheumatoid factor (along with chemistries U/A and complement levels)
What are favorable prognostic factors for schizophrenia? (10)
- female
- older age of onset (older than 40)
- acute onset of symptoms
- identifiable precipitant
- mostly positive symptoms (hallucinations, delusions)
- presence of mood symptoms
- goo pre-morbid functioning
- no family history of schizophrenia
- good family support
- shorter duration of active symptoms
A young to middle aged woman presents with painless hepatomegaly and incidentally found elevated AST and ALT with normal alkaline phosphatase and normal bilirubin and may have a history of arthritis/ thyroiditis/ pericarditis most likely suffers from ..
Autoimmune hepatitis
dx: ANA and anti-smooth muscle antibodies
What is the antithrombotic guideline for patients with mechanical heart valves and no risk factors for thromboembolism?
aspirin (75-100 mg/day) with warfarin with INR goal of 2-3
What is the antithrombotic guideline for patients with mechanical heart valves and risk factors for thromboembolism (a-fib, severe LV dysfunction with ejection fraction less than 30%, prior thromboembolism, hypercoagulable state)?
aspirin (75-100 mg/day) with warfarin with INR goal of 2.5-3.5
A pt presenting with progressively worsening back pain with morning stiffness which improves with exercise for more than 3 months, reduced range of forward flexion of lumbar spine on Schober testing, and reduced chest expansion most likely suffers from ..
Ankylosing Spondylitis
exercise improves overall functional status, no reduced life expectancy
What is the best initial step in a pt with suspected ankylosing spondylitis?
X-ray of sacroiliac joint (sacrolitis, erosion of ischial tuberosity and iliac crest, squaring of vertebral bodies)
What is used to monitor the disease progression in a pt with ankylosing spondylitis?
X-rays (AP and lateral views of lumbar spine, lateral view of cervical spine, pelvic X-ray) and acute phase reactants
What are extraarticular manifestations of ankylosing spondylitis? (4)
- Restrictive lung disease (due to limited costovertebral joint motion & development of apical pulmonary fibrosis)
- anterior uveitis
- aortic regurgitation
- IgA nephropathy
What screening test should be performed in a pt who is diagnosed with familial adenomatous polyposis (FAP)?
upper GI endoscopy (to assess for extracolonic neoplasms such as gastric and duodenal adenomas/ carcinomas)
What is the next best step of management for a female pt presenting with spontaneous, unilateral nipple discharge that is guaiac positive/ grossly bloody who may have the presence of paplable lump/ skin changes?
Mammography with ultrasound)
to assess for possible papillary tumor- most common cause of pathologic nipple discharge
What is the next best step of management for a female pt presenting with bilateral/ multiple duct involving nipple discharge that is milky and nonbloody and lacking palpable lump/ skin changes? (3)
- urine beta-HCG
- TSH
- prolactin
What is the first line therapy for acute gout attack?
NSAIDs (indomethacin or ibuprofen) or colchicine
What is the best anti-hypertensive medication for treatment of hypertension in a pt with gouty arthritis?
ARBs (angiotensin receptor block- “sartans”)
has uricosuric effect and antihypertensive
What is the best treatment for a pt presenting with mild symptoms of acute otitis externa (minor discomfort, pruritus and minimal canal edema)?
gently clean canal using wire loop followed by topical acidifiers (acetic acid, domeboro)
(can add topical steroids to relieve itching and pain)
What is the best treatment for a pt presenting with moderate to severe symptoms of acute otitis externa (moderate pain, pruritis, partial/ complete canal occlusion from edema)?
gently clean canal using wire loop followed by topical antibiotics, wick placement if canal is completely occluded
(can add topical steroids to relieve itching and pain)
A pt presenting with ear pain, ear pruritis, erythema and edema of ear canal, and discharge along with pain caused by tragal pressure or traction on the auricle most likely suffers from …
Otitis Externa
swimmer’s ear due to Pseudomonas or S. aureus
What is the best preoperative management of type 1 diabetic during labor and cesarean section?
normal insulin dose on the night before surgery followed by insulin drip and infusion of D5 1/2 NS with 40 mEq of KCl to keep the blood glucose below 160 mg/dl during procedure
(insulin requirement significantly decreases following delivery of pregnant diabetic)
What is the formula for relative risk (RR)?
relative risk = risk of exposed group/ risk of unexposed group
(risk ratio comparing risk of an outcome among the exposed to that among the unexposed)
What is the formula for attributable risk percent (ARP)?
ARP = (risk in exposed - risk in unexposed) / risk in exposed
ARP = (relative risk -1)/ relative risk
(measure of excess risk and estimates the proportion of disease among exposed subjects that is attributed to exposure status)
What is the formula for population attributable risk percent (PARP)?
(Q ID: 5206)
PARP = (risk in total population - risk in unexposed)/ risk in total population
risk in total population = (risk of exposed) (proportion of exposure in population) + (risk of unexposed) (proportion of exposure in population)
PARP = (prevalence) (relative risk - 1)/ [ (prevalence) (relative risk -1) + 1]
(measure of excess risk in the total population that is attributed to exposure status)
A pt with sudden onset confusion, lethargy, bradycardia, skin flushing, miosis, wheezing and garlic like odor of clothing most likely suffers from ..
Organophosphate poisoning
tx: atropine and pralidoxime- cholinesterase activator
What diagnostic test is used to confirm the diagnosis of organophosphate poisoning?
RBC cholinesterase activity level
used to diagnosis and assess severity
What medical condition is saw palmetto most commonly used to treat?
Benign Prostatic Hyperplasia (BPH)
improves urinary symptoms scores, nocturia, peak urine flow
What medical condition is garlic most commonly used to treat?
Hypercholesterolemia
What medical condition is glucosamine and/ or chondroitin used to treat?
Osteoarthritis
What is the most effective parameter for preventing central-line associated bloodstream infections?
fully draping the body during insertion
(also use maximal barrier precautions, avoid femoral site, skin cleansing with chlorhexidine, prompt catheter removal when no longer needed)
What is the next best step in management of a pt who is not competent to make decisions and whose family members can not agree on the approach to the pt’s medical care?
involve hospital’s ethics committee in decision-making and mediation process
What is the next best step in management for a pt with a lab finding of isolated elevation of anti-HBc (total core antibody including IgG and IgM)?
measure IgM anti-HBc and liver enzymes
after repeating hep B serologies to rule out false positive
What does a finding of elevated liver enzymes and positive IgM anti-HBc in a pt who was previously found to have isolated elevation of anti-HBc (total core antibody) mean?
window period of acute hepatitis B virus infection
HBsAg has fallen but anti-HBs has not risen yet
What does a finding of normal liver enzymes and negative IgM anti-HBc in a pt who was previously found to have isolated elevation of anti-HBc (total core antibody) mean?
years after recovery from acute Hep B virus infection
What is the next best step in management for pt with abnormal liver function tests or evidence of chronic liver disease with negative IgM anti-HBc after having been found to have isolated elevation of anti-HBc (total core antibody)?
HBV DNA level (if detectable, chronic disease)
What is the main long-term complication of IVC (inferior vena cava) filter placement?
recurrent deep venous thrombosis (DVTs)
What is the initial best step in management for a pt with suspected idiopathic intracranial hypertension/ pseudotumor cerebri (obese women, headache, visual problems, on OCPs)?
ophthalmoscopic exam
assess for papilledema before brain imaging
What is the best treatment for a large retrosternal goiter that is causing compressive symptoms (dysphagia)?
surgical removal via cervical approach
What diagnostic test consists of hyperflexion of both wrists to reproduce characteristic symptoms of Carpal Tunnel Syndrome?
Phalen’s test
more sensitive than tinel sign
What diagnostic test consists of tapping or percussing over the region of the median nerve at the carpal tunnel to reproduce characteristic symptoms of Carpal Tunnel Syndrome?
Tinel sign
What diagnostic test can be used to confirm the diagnosis of carpal tunnel syndrome?
nerve conduction study
(shows slowed conduction along median nerve at level of carpal tunnel with normal conduction velocity proximally; along with reduced amplitudes)
What is the first line treatment for nongonococcal urethritis (dysuria, watery urethral discharge, many neutrophils with absence of bacteria on urethral swab in sexually active pt)?
Azithromycin 1 gm single dose (or doxycycline 100 mg PO BID for 7 days)
(chlamydia is most common cause)
What is the first line treatment for gonococcal urethritis (dysuria, purulent urethral discharge, many neutrophils with gram negative diplococci on urethral swab of sexually active pt)?
Injection of ceftriaxone
What is the likely cause of nongonococcal urethritis (dysuria, watery urethral discharge, many neutrophils with absence of bacteria on urethral swab in sexually active pt) in a pt who does not respond to azithromycin despite being compliant and not having repeated sexual exposures?
Trichomonas vaginalis
tx: metronidazole
A pt presenting with erythematous, scaling plaques and patches with indistinct margins on the scalp, central face, ears, chest, upper back, axilla, and pubic area along with dandruff of the scalp most likely suffers from …
Seborrheic dermatitis
should suspect HIV infection if new onset and severe
A pt presenting with a well circumscribed erythematous patch on skin/ mucous membrane that rapidly worsens and evolves into nodular patches marked by hemorrhage, ulceration and necrosis in a pt with an indwelling catheter/ central venous catheter or following infection of traumatic/ surgical infection most likely suffers from …
Ecythma gangrenosum
usually due to Pseudomonas aeruginosa bacteremia
What is the treatment for ecythema gangrenosum?
IV antibiotics (aminoglycoside with extended spectrum antipseudomonal penicillin/ antipseudomonal cephalosporin) for 7-10 days after catheter has been removed
(for 14 days after neutrophil count returns to normal in neutropenia pt)
What is the best management step for providing nutrition to a pt with oropharyngeal dysphagia who has failed oral feeding modifications?
gastrostomy tube feeding
… is when pt views another individual as perfect and flawless and is unable to tolerate any evidence to the contrary; often occuring in pts with borderline personality disroder when interacting with a “savior” (person who cared for him/her in time of crisis)
Primitive Idealization
type of splitting
What is the best treatment for borderline personality disorder?
dialectical behavior therapy
According toe Light’s criteria, what type of pleural fluid has a pleural fluid protein/ serum protein ratio greater than 0.5, a pleural fluid lactact dehydrogenase/ serum LDH ratio greater than 0.6, and/ or pleural fluid LDH > 2/3 the upper limit of normal for serm LDH?
Exudative Pleural Fluid
associated with autoimmue, esophageal rupture, infection, malinancy, pancreatitis, post CABG, pulmonary embolism
What is the primary treatment for hepatic hydrothorax (right sided transudative pleural effusion in pt with cirrhosis and ascites)?
Sodium restriction and Diuretics
second line is TIPS- transjugular intrhepatic portosystemic shunt
A pt with history of alcohol abuse presenting with flank dullness, positive fluid shift, hypoalbuminemia and transudative pleural effusion most likely suffers from …
Hepatic Hydrothorax
What is the first line, second line and third line treatment for nocturnal enuresis (urinary incontinence at night in a child 5 years old or older)?
- behavior modification (void immediately before bed, minimize fluid intake prior to bedtime, reward system) for 3- 6months
- enuresis alarm (best long term outcome)
- desmopressin (immediate improvement but high relapse)
A pt presenting with headache, nausea, malaise, and dizziness in the setting of other family members with similar symptoms most likely suffers from …
Carbon Monoxide Poisoning
dx: carboxyhemoglobin level
What is the next best step in management of a simple breast cyst if the mass completely disappears after fine needle aspiration and discharge is nonbloody?
ultrasound breast tissue in 4-6 weeks
if discharge bloody, perform mamogram and excision
A pt with Raynaud phenomenon and GERD who presents with severe hypertension and associated symptoms (headache, papilledema, blurred vision) most likely suffers from ..
Scleroderma renal crisis
due to renal arteriole wall thickening and narrowing leading to ischemia and renin-angiotensin activation
What is the first line treatment for scleroderma renal crisis?
captopril (ACE inhibitor)
add IV nitroprusside if malignant HTN with CNS manifestations
A pt presenting with right upper quadrant pain, fever and jaundice along with elevated levels of direct bilirubin and alkaline phosphatase without rise in aminotransferases most likely suffer from ..
Acute Cholangitis
tx: blood cultures, antibiotics, fluid hydration, vital sign monitoring
What is Reynold’s pentad?
- right upper quadrant pain
- jaundice
- fever
- confusion (due to sepsis)
- hypotension (due to sepsis)
(suggests suppurative cholangitis)
What is the pathophysiologic mechanism behind toxic shock syndrom?
bacterial exotoxin production leading to widespread T cell activiation (releasing cytokines)
What is the treatment for toxic shock syndrome?
remove foreign body, extensive IV fluids, antibiotics (clindamycin with antistaphylococcal antibiotic)
What are the two major risk factors for pediatric dental caries?
- nighttime bottle feeding (especially with juice)
- frequent exposure to sugary snacks
(use fluoride toothpast 2x a day, exam teeth as soon as erupt)
What is the treatment for diabetic ketoacidosis?
normal saline bolus given over an hour followed by insulin drip and potassium containing IV fluids (if pt has low to normal potassium level)
A pt presenting with glucose greater than 200 mg/dL, bicarbonate less than 15 mEq/L, venous pH less than 7.3 and an anion gap greater than 14 most likely suffers from ..
Diabetic Ketoacidosis
(polyuria, polydipsia, polyphagia, kussmaul respirations- deep rapid breathing, dehydration, vomiting, abdominal pain, fatigue, altered mental status)
What are pts with diabetic ketoacidosis at greatest risk of developing (which is why they should be admitted to ICU)?
cerebral edema
An immigrant presenting with weight loss, abdominal pain, and diarrhea who is found to have eosinophilia most likely suffers from ..
Helminthiasis
(infection with nematodes- round worm, hook worm, whipworm)
(tx: albendazole/ mebendazole)
What is the next best step in management of depression if the pt is intolerant of an SSRI?
Switch to another SSRI
different SSRIs can have different side effect profiles
A pt being treated for diabetic ketoacidosis who then develops fever, facial swelling, maxillary pain and tenderness, foul smelling nasal discharge, ophthalmoplegia and headache most likely suffers from ..
Mucomycosis (due to infection with Zygomycetes)
What is the treatment for mucomycosis?
debridement of necrotic tissue and amphotericin B
When is valvular surgery for mitral regurgitation advised?
if presence of symptoms (exertional dyspnea, fatigue, overt heart failure) and LV ejection fraction less than 60%
An HIV pt (or immunocompromised pt) who presents with multiple, discrete flesh to red colored papules with central umbilication on the face and/or trunk most likely suffers from ..
Cutaneous Cryptococcosis
(assess for systemic involvement via CXR, blood and CSF cultures, india ink stain of CSF, cryptococcal antigens of serum and CSF)
What is the diagnostic test of choice for cutaneous cryptococcosis?
biopsy of skin lesion using Periodic Acid Schiff and Gomori’s methenamine silver nitrate
(granulomatous inflammation with multinucleated giant cells, histiocytes, lymphocytes, neutrophils and plasma cells with numerous yeast like organisms)
What allergen is most frequently associated with asthma?
house dust mites
What disease/ disorder is suggested to be the cause of a young patient with diabetes, osteoporesis, hypertension, hypokalemia and metabolic alkalosis?
Cushing’s syndrome
(dx: 24 hour urinary free cortisol or overnight dexamethasone suppression test- cortisol level greater than 3 in the morning)
A child presenting with sudden acceleration of growth prior to puberty that is out of sequence (not testicular followed by penis followed by pubic hair followed by growth spurt) along with severe cystic acne most likely suffers from …
Severe androgen excess (likely secondary to late-onset congenital adrenal hyperplasia)
(precocious pseudo-puberty)
How long should a pt wait before starting an MAO inhibitor after discontinuing SSRI use?
at least 5 weeks
A pt presenting with mental status changes, autonomic dysregulation (diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity (hyperreflexia, tremor, myoclonus, ocular clonus) in setting of using an SSRI and MAO inhibitor most likely suffers from …
Serotonin syndrome
tx severe cases with cyproheptadine
What is the formula for standardized incidence ratio (SIR)?
SIR = observed cases/ expected cases
(determines if occurrence of disease in a small population is high or low relative to an expected value derived from larger comparison population)
A pt who develops facial asymmetry after a recent upper respiratory infection most likely suffers from …
Bell’s palsy
A pt who presents with perioral numbness, muscle cramps, carpopedal spasm, positive chvostek sign (ipsilateral contraction of facial muscles on tapping of angle of jaw) and positive Trousseau’s sign (rapid development of carpopedal spasm on occlusion of blood supply to upper extremity) most likely suffers from …
Hypocalcemia
What is Hungry Bone Syndrome?
sudden withdrawal of PTH in pts with severe hyperparathyroidism causes increased influx of calcium into bone 2-4 days after parathyroid surgery
A pt presenting with early diastolic murmur at the left sternal border (aortic regurgitation), long extremities (especially arms), long fingers, tall stature, flat feet and scoliosis/ pectus deformity/ kyphosis and family member with similar problems most likely suffers from ..
Marfan’s syndrome
autosomal dominant defect in fibrillin-1
(ectopia lentis, aortic root dilation/ regurgitation/ dissection)
What diagnostic test is essential to detect the major cause of death in a pt with Marfan’s syndrome?
transthoracic ECHO (at diagnosis and every 6 months to assess aortic root and ascending aorta)
(replace aortic root if diameter greater than 50 mm)
What size induration on a tuberculin skin test is considered positive in a normal healthy pt? What size induration on tuberculin skin test is considered positive in moderate risk pt (immigrant, IV drug user, employee at high risk setting, kids less than 4 years old, homeless, prisoner)?
healthy: greater than 15 mm
high risk: greater than 10 mm
What size induration on a tuberculin skin test is considered positive in a high risk pt (HIV, recent contact of known TB case, CXR with nodular/ fibrotic changes, transplant, immunocompromised)?
greater than 5 mm
What is the next best step in management of a pt who presents with gross hematuria without signs of glomerular disease (red cell casts, dysmorphic red cells), older than 40 years old, and has a smoking history?
Cystoscopy (to visualize lower urinary tract) and CT urogram (to visualize upper urinary tract)
(assess for suspected urinary tract malignancy)
A young healthy pt presenting with lymphadenopathy and white plaques on the buccal mucosa and palate that can be easily scraped off revelaing hyperemia most likely suffers from …
Candidiasis secondary to HIV test
dx: gram stain/ KOH prep of scrapings and HIV test
What is the best step in management of hyperthyroidism during pregnancy?
use PTU (propylthiouracil) during 1st trimester (b/c methimazole is teratogenic) then switch to methimazole for second and third trimester (b/c PTU is hepatotoxic)
A pt who develops platelet reduction by more than 50% from baseline, arterial/venous thrombosis, necrotic skin lesions at heparin injection sites or anphylactoid reaction after 5-10 days after heparin administration most likely suffers from …
Type 2 heparin induced thrombocytopenia (HIT)
dx: serotonin release assy
(tx: stop heparin and use direct thrombin inhibitor- argatroban or fondaparinux)
When should warfarin treatment be started after a patient has developed HIT (heparin induced thrombocytopenia) from heparin use?
after treatment with non-heparin anticoagulant and platelet recovery to more than 150,000
What is the treatment for Lyme arthritis (usually affecting knee)?
28 days of doxycycline (if not pregnant and older than 8 years old) or amoxicillin
(good prognosis; cured after 6-12 months)
What is the recommendation for pilots taking Viagra?
wait at least 6 hours after taking viagra before a flight
due to disturbance in blue-green differentiation
(six hours from viagra to throttle time)
What is the next best step for a child with a foreign body visualized to be in the stomach on imaging?
no intervention
A pt who develops new or worsening respiratory symptoms which include respiratry distress, diffuse crackles, hypoxemia, bilateral alveolar infiltrate on CXR, and a PaO2/ FiO2 ratio less than 300 mmHg without signs of fluid overload most likely suffers from …
Acute Respiratory Distress Syndrome (ARDS)
What is the treatment for acute respiratory distress syndrome (ARDS)?
(Q ID 5307, 5308)
low-tidal volume ventilation (goal of plateau pressure less than 30 cm H2O and arterial oxygen of 55-80 mmHg or oxygen saturation of 88-95%)
(increase FiO2/ PEEP to improve oxygenation and prevent overdistension by opening collapsed alveoli)
(lower FiO2/ PEEP once overshoot oxygenation goal while continuing mechanical ventilation)
What is the best way to form an initial therapeutic alliance with a psychotic patient?
permit pt to maintain privacy and interpersonal distance
What is the next best step in management of a pt with history sytemic lupus erythematous who develops renal involvement?
renal biopsy (to determine type of renal involvement to determine treatment)
What substances can be measured and used to monitor the activity level of lupus nephritis? (2)
- serum complement
2. anti- ds-DNA level
What substance can be measured and used to monitor the current level of immunosupression in an HIV pt?
CD4 count
(the immunologic damage that has already occured)
(viral load determines disease activity and is the damage that is about to occur)
What is the initial treatment for hyperkalemia with severe EKG changes (prolonged PR interval, prolonged QRS, disappearance of P wave; all more severe than peaked T waves)?
IV calcium gluconate (stabilizes myocardium membrane potential)
What is the next best step for a depressed pt with a partial response to monotherapy (after trial of 2 antidepressants)?
aument with second agent (second generation anti-psychotic or an antidepressant from different class)
A pt who develops pituitary enlargement, bitemporal hemianopsia and hyperigmentation following bilateral adrenalectomy for Cushing’s disease most likely suffers from ..
Nelson’s syndrome
(dx: brain MRI- pituitary microadenoma with suprasellar extension and ACTH level- high)
(tx: surgery and/or local radiation)
What is the best initial test for a women under 30 years old with a breast mass on clinical exam>
Ultrasound
(if solid mass with atypical features, core needle biopsy)
(if cystic mass, followup routine clinical exams or FNA if desired)
A pt presenting with severe anion gap metabolic acidosis, rapid and deep breathing (kussmaul’s respiration), nausea, vomiting, slurred speech and ataxia most likely suffers from …
Ethylene gylcol (anti-freeze) intoxication
What is the best treatmeent for ethylene gylcol (anti-freeze) intoxication?
fomepizole
What is the next best step in management of worsening thrombotic disease while on sub-therapeutic level of warfarin (INR less than 2-3)?
admit and start IV heparin (until can get warfarin at therapeutic level)
What is the best initial treatment for a pt with visible, palpable, tortuous superificial veins on the legs with leg cramping, heaviness, fatigue and leg swelling?
leg elevation, weight reduction and compression stockings
varicose veins
What other cardiac abnormality is highly associated with a bicuspid aortic valve?
aortic root and ascending aortic dilation
screen for with ECHO
A pt presenting with eye pain/ discomfort, decreased visual acuity and visualization of a floating, white layer in the anterior chamber (hypopyon), and conjunctival and lid edema and erythema most likely suffers from …
Endophthalmitis
ophthalmic emergency- immediate ophthalmology referral
An infant presenting with staccato cough (inspiration between every single cough), history of concurrent conjunctivitis, and auscultatory and radiologic findings out of proportion to healthy appearance of child (hyperinflation, peribronchial thickening, bilateral symmetrical infiltrates on CXR), elevated eosinophil count in the setting of no fever most likely suffers from …
Chlamydia pneumonia
(due to vaginal contact during delivery)
(tx: oral erythromycin for 14 days)
A pt presenting with fever, sudden onset sore throat with tonsillar erythema and exudates, tender anterior cervical nodes and palatal petechiae most likely suffers from ..
Streptococcal tonsillopharyngitis (strep throat)
dx: rapid strep antigen test, throat culture
(tx: penicillin or amoxicillin)
A pt presenting with sudden onset shortness of breath, pallor, diaphoresis, pulmonary edema, hypotension, hyperdynamic precordium/ apical impulse, and a soft low pitched decrescendo systolic murmur head best at the lower left sternal border most likely suffers from …
Acute Mitral Regurgitation
usualy due to ruptured mitral chordae tendineae
(can be due to papillary muscle rupture if 2-7 days after MI)
A pt with joint hypermobility, recurrent joint dislocations, velvety hyperextensible skin with easy bruisabilty, anddelayed healing of atrophic scars most likely suffers from ..
Ehler’s Danlos Syndrome
What cardiac abnormality is associated with Ehler’s Danlos syndrome?
mitral valve prolapse
that can lead to acute mitral regurgitation from rupture of chordae tendineae
An infant presenting with tomatoe red papulovesicular lesions in the diaper area including the crural folds with satellite papules (usually after treatment with an antibiotic) most likely suffers from …
Candidal diaper rash
tx: antimycotic cream - clotrimazole or nystatin
A pt presenting with excoriated, lichenified plaques that are itchy and located near the belt-line most likely suffers from …
Allergic Contact Dermatitis
probably secondary to nickel allergy from belt
What is the next best step in a pt presenting with difficulty initiating swallowing accompanied by coughing, drooling and/or aspiration in the dysphagia was initially for solids but progresses to include liquids?
Nasopharyngeal Laryngoscopy or Barium Esophagram
assess for mechanical obstruction leading to dysphagi
What is the next best step in a pt presenting with dysphagia initially involving both solids and liquids accompanied by coughing, drooling, and/ or aspiration?
Videofluoroscopic barium swallow
assess for neuromuscular disorder
What is the most likely histopathologic type of tumor to be found in the upper esophagus?
Squamous Cell Carcinoma
associated with chronic smoking and alcohol use
What is the most likely histopathologic type of tumor to be found in the lower esophagus?
Adenocarcinoma
associated with chronic GERD and Barrett’s esophagus
What are the common causes of hepatic encephalopathy? (8)
- GI bleeding
- hypokalemia
- hypovolemia
- hypoxia
- sedatives and tranquilzers
- hypoglycemia
- metabolic alkalosis
- infection (spontaneous bacterial peritonitis)
What are the three conditions in which potassium must be replaced immediately if hypokalemia is present? (3)
- hepatic encephalopathy (associated with loop diuretic)
- ventilatory failure
- cardiac arrhythmia
An HIV pt who presents with sensory ataxia (falling b/c feel off balance), lancinating pain (shooting/ burning), urinary incontinence, normal pupillary constriction with accommodation but not with light, aflexia, and impaired sensations most likely suffers from ..
Late Neurosyphillis
dx: test for treponema pallidum infection
… is a measure of risk that describes the chance of events occurring in one study arm compared to another and can be calculated at multiple time intervals throughout a study period
Hazard Ratios
(HR less than 1 means decreased risk)
(HR greater than 1 means increased risk)
(HR equal to 0 means no change in risk)
(only statistically significant if 95% confidence interval does not include null value of 1)
What are the measures of central tendency and their definitions? (3)
mode: value that occurs most frequently
Mean: sum divided by the total number of values
median: value separating the top half from lower half of data (50th percentile)
What are the contraindications to using dabigatran (or other target specific oral anticoagulants like rivaroxaban, apixaban, edoxaban)? (2)
- valvular a-fib (presence of moderate to severe valvular regurgitation/stenosis, prosthetic vallves)
- end stage renal disease
What is the best treatment for asymptomatic pulmonary sarcoidosis (i.e. hilar adenopathy with erythema nodosum)?
no treatment (spontaneous remission)
What are the three main disorders that make up Schmidt’s syndrome (polyglandular autoimmune failure type II)?
- Addison’s disease (no cortisol)
- Type 1 diabetes
- autoimmune thyroid disease
A pt with an EKG showing fast rate, narrow and regular QRS complexes with absent P waves most likely suffers from ..
Supraventricular tachycardia
A pt with an EKG showing regular rate and rhythm, presence of p waves, PR interval less than 0.12 sec, a slurred initial part of activation of the QRS complex and a QRS durationof about 0.12 sec most likely suffers from ..
Wolff Parkinson White syndrome
delta wave- slurried initial part of QRS complex
A pt who develops hypoxemia and increased work of breathing 2-5 days after thoracoabdominal surgery with a CXR showing small lung volumes most likely suffers from …
Atelectasis
due to splinting, reduced cough from abdominal pain, retained secretions and diminished lung compliance
What is the colon cancer screening guideline for a pt who has a first degree relative diagnosed before age 60 with colorectal cancer or advanced adenomatous polyps?
colonscopy at age 40 years old or 10 years before age of onset in relative (whichever comes first); repeat every 3-5 years
What is the best initial diagnostic test for renovascular disease/ hypertension in a pt with renal insufficiency?
renal duplex doppler ultrasonography
avoid contrast induced nephropathy with CTA and nephrogenic systemic fibrosis with MRA
What is the time interval between giving a phosphodiesterase inhibitor (sildenafil) and an alpha blocker (doxazosin)?
4 hours
What is the next best step in management of a symptomatic pt with a EKG documented STEMI?
percutaneous coronary intervention (if within 12 hours of symptom onset and 90 minutes of initial contact)
(fibrinolysis (tpa) if cant undergo PCI)
A pt who develops hypotension, diaphoresis, jugular venous distension, and cold extremities with clear lungs shortly after being diagnosed with an inferior wall MI (leads II, III, avf) most likely suffers from …
Right Ventricular MI
What is the best treatment for right ventricular MI?
bolus of IV fluids (increased preload)
avoid nitrates, diuretics, opiods that lower preload
What does asymmetry in a funnel plot suggest?
publication bias (studies showing opposite effect are absent as they are less likely to be published)
What is the best initial treatment for symptomatic (CNS symptoms) or severe hyponatremia (Na below 115)?
3% NaCl (hypertonic saline)
goal correction rate of 1.5-2 mEq/L/hour for first 3-4 hours; no more than 12 mEq/L in first 24 hours
What is the first line treatment used for torsade de pointes as well as to prevent recurrence?
IV Magnesium sulfate
depsite normal serum Mg levels
What is the next best step in management for torsade de pointes if pt does not respond to IV magnesium sulfate?
temporary transvenous pacing
What is the next best step in management of a pt with a palpable renal mass?
ultrasound: if low risk of cancer
CT abdomen: if high risk (older pt, smoking, elevated Hct and Hb, night sweats, weight loss)
A pt presenting with long standing smoking history, flank pain, flank mass, increased hematocrit and hemoglobin levels and night sweats most likely suffers from ..
Renal Cell Carcinoma
What conditions are associated with the presence of multiple skin tags (pedunculated, skin colored papules mostly on areas of friction)?
- insulin resistance/ metabolic syndrome
- pregnancy
- crohns disease (if located in perianal region)
What medical condition is associated with dermatitis herpetiformis (pruritc, erythematous, grouped papuloesicular lesions that usually occur on elbows)?
Celiac disease
What medical condition is associated with pyoderma gangrenosum (purulent ulcer)?
Crohn’s disease
A pt presenting with scaly patches with slight erythema in their hair with associated hair loss and cervical lymphadenopathy most likely suffers from ..
Tinea Capitis
What is the first line treatment for tinea capitis?
oral griseofulvin (alternative is oral terbinafine)
What is the most appropriate next step in management of a pt who is found to have multifocal atrial tachycardia (tachycardia with narrow QRS, 3 or more different P wave morphologies, variable PR and RR intervals)?
obtain arterial blood gas
(to assess for hypoxemia as cause of MAT which if corrected can fix MAT)
(followed by chemistries for electrlyte imbalance)
What are common causes of multifocal atrial tachycardia? (6)
- hypoxia
- COPD
- hypokalemia
- hypomagnesemia
- heart disease
- meds (theophyilline, aminophylline, isoproterenol)
A child presenting with emotional lability, decreased school performance, distal hand movements, facial grimacing, feet jerking, decreased strength, delayed relaxation phase of patellar reflex, and positive pronator drift sign in the setting of a history of self-resolving prior infection most likely suffers from ..
Sydenham chorea
complication of untreated strep pharyngitis; acute rheumatic fever
What is the JONES criteria and what disease is it used to diagnosed?
acute rheumati fever if have 2 major or 1 major with 2 minor criteria
major: Joints (migratory arthritis), carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham chorea
minor: fever, arthalgias, elevated ESR/ CRP, prolonged PR interval
What is the best initial step in management of a pt diagnosed with sydenham chorea secondary to untreated strep pharyngitis?
long acting IM penicillin (until adulthood to erradicate grap A strep)
A pt presenting with sudden onset vertigo, nystagmus, loss of pain and temperature in ipsilateral face and contralateral body, hoarseness, ipsilateral horner’s syndrome, decreased gag reflex and aspiration most likely suffers from..
Lateral Medullary Infarction
wallenberg syndrome
(loss of pain and temp make it lateral)
(cranial nerves 9 and 10 make it medullary)
What is the best initial step in management for a pt presenting with chronic diarrhea?
microscopic exam of stool
for leukocytes, ova, parasites, occult blood, fat staining, pH, osmotic gap
What are the findings on small intestinal biopsy that are suggestive of Celiac disease?
villus blunting, loss of normal villus architecture, increased lymphocytic infiltration of mucosa
What is the next best step in management of an HIV pt with CNS symptoms who is found to have positive syphillis test results?
Lumbar puncture
to assess whether pt has neurosyphilis
What is the treatment for late latent syphillis (more than 12 months of infection), syphilis of unknown duration or gummatous/ cardiovascular syphilis?
benzathine penicillin G IM each week for 3 weeks
What is the treatment for primary, secondary or early latent (less than 12 months of infection) syphilis?
single dose of benzathine penicillin G IM
What is the treatment for neurosyphilis?
aqueous penicillin G IV every 4 hours for 10-14 days
What is the treatment for congenital syphilis?
aqueous penicillin G IV every 8-12 hours for 10 days
A pt being treated for syphilis who develops fever, malaise, chills, headache, and myalgias within 24 hours of initiation the treatment most likely suffers from …
Jarisch-Herxheimer reaction
no effective prevention
… is the ability of a test to correctly identify patients with the disease and therefore is best to rule out a diagnosis
Sensitivity
SnOut= sensitivity rules out disease
What is the formula for positive likelihood ratio?
positive LR = sensitivity / (1- specificity)
independent of prevalence
What is the formula for negative likelihood ratio?
negative LR = (1- sensitivity)/ specificity
independent of prevalence
… occurs when a study uses gold standard testing selectively in order to confirm a positive/ negative result of preliminary testing; therefore performing the test in a random sample of participants reduces it occurence
Verification bias
What is the next best step in management of a pt presenting with substernal chest pain and dyspnea relieved with sublingual nitroglycerine?
admit, EKG and serial cardiac enzymes
takes up to 6 hours for cardiac enzymes to be positive
What is the best initial intervention of an unknown dry/ powdered chemical?
brush off remaining chemical
followed by irrigation with copious amounts of low pressure water for 15-30 minutes
What is the next best step in management of an acute exacerbation that is nor responding to nebulized albuterol therapy (shortness of breath and wheezing persist)?
IV corticosteroids (systemic steroids)
same in pregnant pt; PaCO2 greater than 35 suggests respiratory compromise in pregnant pt
what is the next best step in management of a depressed pt with passive suicidal ideation (wish to go to sleep and not awake, better off dead) without a plan?
outpatient treatment with antidepressant and close follow-up
A pt presenting with progressive fatigue, shortness of breath, fever, systolic murmur that increases with inspiration heard at LLSB, CXR showing circumscribed round pulmonary infiltrates and tricuspid vegetation on ECHO most likely suffers from ..
IV drug use induced infective endocarditis
right heart endocarditis: tricuspid valve abnormalities and septic pulmonary emboli
What is the formula for standardized mortality ratio?
SMR = observed number of deaths/ expected number of deaths
adjusted measure of overall mortality used in occupational epidemiology
What is the latent period?
time elapsed from initial exposure to clinically apparent disease
…. occurs when a study fails to reject a null hypothesis that is false; in other wrose the failure to detect a difference between groups when a difference exists and it is related to the … of a study
type II error; power (sample size)
A pt with history of anatomical change of GI tract/ motility disorder (scleroderma, diabetes)/ immunocompromised/ acid suppresion presenting with abdominal pain, diarrhea, bloating, excess flatulence, malabsorption, weight loss, anemia and nutritional deficiencies most likely suffers from ..
Small Intestine Bacterial Overgrowth
(lack of protective mechanisms such as bacterial degradation by proteolytic digestive enzymes, bacteria trapping in intestinal mucus layer, intact ileocecal valve preventing retrograde bacterial movement from colon, gastric acidity, peristalsis)
What is the most accurate test for diagnosing small intestine bacterial overgrowth?
endoscopy with jejunal aspirate showing more than 10,000 organisms/ ml
(less accurate is hydrogen breath test)
What is the next best step in management of a pt with rheumatoid arthritis that is resistant to methotrexate and steroid after 6 months of treatment?
switch to or add anti-cytokine (infliximab or etanercept)
screen for TB first
What is the next best step in management of a pt with rheumatoid arthritis who presents with new onset monoarticular arthritis with associated fever?
Joint Aspiration
to assess for septic arthritis
A pt presenting with recurrent and unexpected epsiodes of palpitations, sweating, shaking, and shortness of breath and have concern about having additional epsiodes/ about implications or consequences of episodes/ significant change in behavior because of episodes most likely suffers from ..
Panic Disorder
(associated with agoraphobia- fear of being in public should a panic attack occur and subsequently avoid public situations)
An infant who lives near farm/ construction site in California/ Pennsylvania/ Utah presenting with constipation and cranial nerve palsies (ptosis, pupillary paralysis, weak suck) followed by progressive hypotonia and loss of deep tendon reflexes most likely suffers from ..
Infant Botulism
(due to ingestion of C. botulinum spore in environmental dust; or ingestion of honey)
(good prognosis; 1-3 month hospitalization with full recovery)
what is the best treatment for infant botulism?
IV human derived botulism immunoglobulin
along with ICU, NG tube feedings, laxatives, PT/OT
What is the best treatment for foodborne botulism (due to ingestion of preformed C botulinum toxin)?
equine-derived botulism toxin
What is the best initial step in management of a man presenting with testicular swelling 9especially if painless nad negative transillumination)?
scrotal ultrasound
assess whether intra or extra tesicular lesions and whether it is solid or cystic mass
What is the next best step in management of a pt with lobular carcinoma in situ (nonmalignant lesion) on needle biopsy?
excisional biopsy
b/c has significant associated with future development of invasive breast cancer
What is the best treatment for symptomatic aortic stenosis (dysnea ofheart failure, anginal pain, syncope)?
aortic valve replacement
marked reduction in mortality and symptoms
What does non-overlapping confidence intervals suggest when comparing one group to another in a study and the P-value is significant?
significant differences between groups
A pt presenting with sandy sensation in eyes, dry eyes, prominent bulbar blood vessels and stringy discharge from eyes, oral candidiasis, dental caries, chronic esophagitis and dry mouth most likely suffers from …
Sjogren syndrome
sicca syndrome is keratoconjunctivitis- dry eyes and xerostomia- dry mouth
A pt presenting with wrist swelling, decreased grip strength, pain and tenderness on the radial aspect of the wrist after falling on outstretched hand with dosifleced wrist most likely suffers from …
Scaphoid fracture
pain located in the anatomical snuffbox
What is the next best step in management of a pt with suspected scaphoid fracture in which initial X-rays are negative? (3)
- MRI/ CT of wrist
- repeat X-ray in 7-10 days
- radioscintigraphy bone scane in 3-5 days
What is the treatment for nondisplaced scaphoid fractures?
short arm thumb spica cast
inadequate treatment results in nonunion and avascular necrosis
An athlete presents with excruciating pain and swelling of the knee, difficulty bearing weight, tenderness at the anterior aspect of the knee, inability to actively extend the leg, and inability to maintain passive extension of knee against gravity after a traumatic injury most likely suffers from ..
Patellar Tendon Rupture
tx: surgery
What is the best initial treatment for bipolar maniaduring pregnancy?
haloperidol
A bone marrow transplant pt presenting with fever, cough, chest pain, localized headache, nasal bleeding and has patchy infiltrate on CXR most likely suffers from ..
Invasive Aspergilliosis
A pt presenting with eyelid erythema, swelling and tenderness along with proptosis, ophthalmoplegia and pain with eye movements most likely suffers from ..
Orbital Cellulitis
tx: inpatient Iv antibiotics
A pt presenting with eyelid erythem, swelling and tenderness along with fever, and leukocytosis most likely suffers from …
Preseptal Cellulitis
tx: oral antibiotics
What are complications of orbital cellulitis?
- orbital abscess
- intracranial infection
- cavernous sinus venous thrombosis
What is the next best step in the management of an elevated capillary lead level in a child?
obtain venous lead level
(mild: 5-44; no meds, repeat level in 1 month)
(moderate: 45-69, treat with DMSA)
(severe: more than 70; treat with dimercaprol with EDTA)
What is the next best step in management for a pt on amiodarone who develops abnormal thryoid biomarkers in which there is nomal to high TSH, low T3 and high T4?
repeat thryoid function testing in few weeks
effect of decreased peripheral conversion of T4 to T3 from amiodarone usually improves after 3-4 months
What is the next best step for a pt with epigastric/ abdominal discomfort and nausea worse after eating that does not respond to trial with PPI and has no alarming symptoms (age greater than 55, weight loss, anemia, gross bleeding)?
H. pylori testing (stool antigen testing or breath test)
What is the best initial treatment for oral candidiasis (cottony taste in mouth, white plaques on buccal mucosa that can be scraped off leaving hyperemic spots)?
nystatin suspension or clotrimazole troches
(topical antifungal)
(if associated with use of inhaler in asthma, rinse mouth out after using inhaler and proper technique)
What is the best initial treatment for moderate lead toxicity (lead 45-69)?
oral meso-2-3-dimercaptosuccinic acid (DMSA, succimer)
What is the best initial treatment for severe lead toxicity (lead 70 or greater)?
dimercaprol with EDTA (calcium disodium edetate)
What is the best initial diagnostic test for suspected acute diverticulitis?
abdominal CT (showing colonic wall thickening and stranding of mesenteric fat, diverticulae, as well as complications such as abscess, perforation, fistula)
What is the next best step in management of individuals exposed to pt with active TB whose PPD test result is negative?
repeat PPD in 3 months
if PPD positive, monotherapy with INH for 9 months
What is the best next step in management of acute aortic dissection after pain management?
IV beta blocker (esmolol- short acting)
to slow HR, lower sBP to 100-120 mm/Hg, reduced LV contractility
What is the next best step in management of acute aortic dissection if systolic blood pressure remains above 100-120 mmHg after IV beta blocker?
nitroprusside
A pt presenting with episode of syncope while standing that was proceeded by nausea, lightheadness, pallor and diarphoresis and recovered while supine without jerky movements, tongue biting, and incontinence most likely suffers from …
Vasovagal Syncope (Neurocardiogenic)
An obese boy presenting with hip pain that may spread to the thigh and knee without recent history of trauma, and the hip is externally rotated most likely suffers from …
Slipped Capital Femoral Epiphysis (SCFE)
acute less than 3 weeks; chronic more than 3 weeks
(stable can bare weight; unstable cant bare weight)
What is the treatment for slipped capital femoral epiphysis (SCFE)?
immediate internal fixation with pins
What antibiotics can be used as first line treatment for UTI in a pregnant patient? (4)
- nitrofurantoin
- amoxicillin
- cephalexin
- amoxicillin- clavulanate
What is the best initial treatment of pyelonephritis (fever, chills, dysuria, nausea, vomiting, CVA tenderness) in a pregnant pt?
hospitalization and IV antibiotics until afebrile for 24-48 hours and symptom improvement, then outpatient antibiotics for total of 10-14 days
(ceftriaxone, aztreonam, ampicillin with gentamicin)
A pt with a lumbar puncture showing elevated RBC, elevated WBC at a ratio of 1 WBC to 750-1000 RBCs, elevated protein and glucose level in the absence of xanthochromia most likely suffers from …
Traumatic Lumbar Tap
An elderly pt presenting with signs of osteoporesis such as multiple fractures that is not responding to bisphosphonate therapy along with constitutional symptoms, weight loss and pallor most likely suffers from …
Multiple Myeloma
What is the diagnostic test for multiple myeloma?
serum and urine protein electrophoresis
An IV drug abuser who presents with malaise, nausea, jaundice and right upper quadrant pain along with have elevated transaminases (10-20 times upper limit) most likley suffers from ..
Acute Hepatitis
(if anti HAV antibodies, HBsAg, anti HBsAg antibodies and anti HCV antibodies are negative, likely hep C infection prior to formation of antibodies)
What are the absolute contraindications to combined hormonal contraceptives? (9)
- migraine with aura
- smoking more than 15 cigs/ day and older than 35
- stage 2 HTN (greater than 160/100)
- hx of venous thromboembolic disease
- hx of stroke/ ischemic heart disease
- breast cancer
- cirrhosis and liver cancer
- major surgery with prolonged immoblization
- less than 3 weeks postpartum
What type of cancer is at increased risk in a pt with Klinefelter’s syndrome (hypogonadism, low testosterone, gynecomastia, karyotype of 47 XXY)?
Breast Cancer
50x more likely compared to pt with normal karyotype
What is the formula for positive predictive value (PPV)?
PPV = true positive/ (true positive + false positive)
PPV = a/ (a+b)
(probability that an individual truly has disease given a positive test result; dependent on prevalence of disease)
(increasing specificity results in increasing positive predictive value)
What is the formula for negative predictive value (NPV)?
NPV = true negative/ (true negative + false negative)
PPV = d / (d +c)
(probability that an individual truly does not have disease given a negative test result; dependent on prevalence of disease)
A pt who develops swinging fever, leukocytosis, cough and shoulder tip pain 14-21 days after abdominal surgery most likely suffers from …
Subphrenic Abscess
dx: abdominal ultrasound
What is the best diagnostic test for monitoring cardiotoxicity from anthrocycline chemotherapy agents (doxorubicin, daunorubicin)?
Radionuclide Ventriculography (MUGA) to assess LV ejection fraction
(chemotherapy contraindicated if ejection fraction less than 30%; discontinue therapy if ejection fraction decreases by 10% or more)
What is the best initial test used to determine the cause of a couple’s infertility issues (unable to conceive after 1 year of unprotected sex)?
semen analysis
easy and detects male cause which is 20-30% of time
What is the first line treatment of hypertension in a pt with bipolar depression who is being treated with lithium?
Calcium channel blockers
avoid ACE inhibitors, ARBs, diuretics as affect renal exretion of lithium
What is the best initial step in management of an adult pt with mental retardation or dementia?
ask about guardianship status
What is the serum-ascites albumin gradient (SAAG) formula and what is it used for?
SAAG = serum albumin - ascitic fluid albumin
used to identify presence or absence of portal HTN
(SAAG greater or equal to 1.1 is portal HTN)
(SAAG less than 1.1 is non-portal HTN - peritoneal TB or carcinomatosis, nephrotic syndrome, pancreatitis, serositis)
A pt who develops anorexia, weight loss, insomnia, palpitations, tachycardia, elevated BP, irritability and agitation after starting treatment for ADHD most likely suffers from …
Methylphenidate/ stimulant toxicity
long term: decreased height and weight
What is the best initial treatment for keloids (benign fibrous growths in scar tissue secondary to overproduction of extracellular matrix and dermal fibroblasts)?
intralesional glucocorticoids
high recurrence rate; use excisional removal if fail steroids
When should a C-section be performed for an HIV positive pregnant pt?
if vial load greater than 1000 copies/ ml
(if pregnant pt on HAART therapy prior to conceiving maintain same HAART therapy during pregnancy to minimize drug resistance and loss or viral suppression)
What is the best management of a newborn of an HIV positive mother?
Zidovudine for 6 or more weeks with serial HIV PCR testing
avoid breastfeeding; use formula
What are maternal contraindications to breastfeeding? (6)
- active untreated TB (can after 2 weeks of therapy)
- maternal HIV infection
- herptic breast lesions
- varicella infection less than 5 days before or 3 days after delivery
- chemotherapy/ radiation therapy
- alcohol or drug use
What is the next best step in management of a pt with a pituitary lesion that was incidentally found and who lacks clinical or laboratory evidence of pituitary abnormality/ dsfunction?
repeat MRI of pituitary in 6-12 months
incidentaloma
A pt presenting with dyspnea, tachypnea, hypoxemia and hemoptysis after a blunt chest traumain which CXR shows homogenous opacification of the lung fields without a specific anatomic segment involved most likely suffers from ….
Pulmonary Contusion
What is the next best step in management of a pt with pulmonary contusion?
admit to hospital and monitor for 24-48 hours (for signs of clinical deterioration)
What is the effect of magnitude of the expected effect size (size of expected difference between the groups) on the power of a study?
the smaller the magnitude of expected effect size, the higher the power of the study needs to be to see effect
(therefore more subjects are required to see the effect)
An HIV pt presenting with fat tissue deposition on the back of the neck and abdomen along with thin extremities and face most likely suffers from …
HIV lipodystrophy due to insulin resistance
tx: metformin and “zones”
What is the next best step in management of an HIV pt with dyslipidemia particularly marked triglyceridemia (TGs greater than 500)?
Fibrates (gemfibrozil)
What is the next best step in management of an HIV pt with dyslipidemia with moderate elevation if triglycerides (TGs less than 500)?
statin
What are the common associated disorders of having Turner’s syndrome (XO karyotype)? (4)
- coarctation of aorta
- bicuspid aortic valve
- horseshoe kidney
- streaked ovaries/ amenorrhea/ infertility
What is the best next step in preventing further retinal damage or peripheral neuropathy damage in a diabetic patient?
strict glycemic control (goal of HbA1c below 7%)
improves microvascular complications of diabetes such as retinopathy, peripheral neuropathy and nephropathy
What is the best next step in management of a pt who develops lithium-induced hypothyroidism (elevated TSH, fatigue, constipation) while being treated for bipolar disorder?
continue lithium and add levothyroxine
especially if hx of severe mood episodes that respond to lithium
What is the best initial diagnostic test for a pt who presents with hemoptysis?
Chest X-ray
What is the best next step in management of a pregnant pt at high risk of cervical insufficiency (in ability of cervix to hold pregnancy in the absence of labor resulting in increased risk of preterm birth)?
serial ultrasound cervical lengths and evaluations for cerclage placement during second trimester (16-24 weeks)
What are risk factors for cervical insufficiency? (5)
- collagen abnormalities (Ehlers- Danlos)
- uterine abnormalities (septate/ bicornuate uterus)
- prior mechanical cervical dilation (D&C, pregnancy termination)
- prior OB cervical laceration
- prior cone or LEEP procedure for CIN
What is the most common extraneural complication of myelomeningoceles (bulging sac covered with membranes in lower back)?
Genitourinary system involvement (bladder dysfunction, urinary tract and renal dysfunction)
What is considered hypoglycemia?
blood sugar level less than 60 mg/dL
normal is 70-100 mg/dL
What is the target pre- meal blood sugar level in diabetic patients?
80-120 mg/dL
if blood sugar level outside this range, adjust insulin
What is Whipple’s triad?
- low blood glucose level
- symptoms of hypoglycemia (headache, palpitations, sweating, irritability)
- symptomatic relief with glucose administration/ eating
(suggests true hypoglycemia)
What is the next best step in management of exercise induced hypoglycemic episodes in diabetic patient? (2)
- eat source of glucose before exercising
2. decrease level of basal insulin (in morning if exercise in afternoon)
What is a common gram negative anaerobe found in human bites?
Eikenella corrodens
What is the best antibiotic treatment for human bite wounds (polymicrobial with mixture of anaerobic and aerobic organisms)?
Amoxicillin- clavulanate
A pt presenting with episodes of well-circumscribed and raised plaques with central pallor and intensely itchy in which lesions appear and enlarge over minutes to hours before disappearing within 24 hours and episodes occur for more than 6 weeks most likely suffers from …
Chronic Urticaria (Hives)
dx: clinical
(prognosis: spontaneous resolution within 2-5 years)
What is the best initial treatment for chronic urticaria?
second generation antihistamine (loratadine, certirizine) and avoid aggravating factors
(if fail: increase dose or add additional first generation H1 blocker like hydroxyzine/ leukotriene receptor antagonist like montelukast/ H2 blocker like ranitidine, or short course of steroids)
A pt presenting with knee pain, swelling and stiffness after hitting the knee on the dashboard during a motor vehicle accident most likely suffers from …
Posterior cruciate ligament injury
(posteriorly directed force on anterior aspect of proximal tibia with knee flexed such as with athlete falling on flexed knee with foot plantar flexed)
A pt presenting with multiple psychotic episodes with concurrent major depressive or maniac symptoms along with at least 2 weeks of delusions or hallucinations in absence of mood symptoms most likely suffers from …
Schizoaffective Disorder
What is the most common cause of hereditary/ inhertied thrombophilia?
Factor V Leiden
increased risk of venous thromboembolism
A pt who develops nightmares and flashbacks of a traumatic event, negative mood, avoids thoughts/ feelings/ external reminders of the event, sleep disturbances, irritability/ outbursts, hypervigilence, impaired concetration and exaggerated startle reflex 3 days to 1 month after a life- threatening trauma most likely suffers from …
Acute Stress Disorder
tx: trauma focused cognitive behavioral therapy and short term benzos for agitation/ insomnia
What is the best next step in management of an infant 6 months or older with hypoplastic, hypopigmented, poorly rugated and empty scrotum with bilateral inguinal fullness without signs of torsion (tenderness, swelling, discoloration)?
elective ochiplexy
cryptorchidism may resolve during first 6 months of life but if not surgery to bring testes down
What is the most common adverse event in a hospitalized patient who is not undergoing surgery?
adverse drug events
in surgery pts it is wound infections, bleeding and DVTs
What are the 4 criteria that are used to determine whether a patient has SIRS (systemic inflammatory response syndrome- only need 2 of them)?
- temp greater than 38.5
- HR greater than 90
- respiratory rate greater than 20
- WBC greater than 12,000
What is the best initial step in management of a pt with SIRS (systemic inflammatory response syndrome)?
aggressive fluid resuscitation until central venous pressure is 8-12 mmHg
(use pressors if not responsive to fluids)
What is the mechanism responsible for exacerbated hypotension in patients on long term corticosteroids who develop septic shock?
suppression of pituitary-adrenal axis
long term use of steroids negatively feedbacks to decrease ACTH causing decrease cortisol response to septic shock
