UWorld 5 Flashcards
1
Q
Association btwn adrenal activity and sodium status
A
Hypernatremia seen in Cushing’s
Hyponatremia seen in Addison’s (primary adrenal failure)
2
Q
Why are edema and significant hypernatremia not present in primary hyperaldosteronism?
A
Aldo escape
High aldo causes increased Na reabsorption => HTN and increased blood volume, which then increases renal blood flow and GFR which stimulates Na+ excretion
3
Q
Pneumococcal meningitis vs. meningococcal infection
A
Both have CSF findings of white cells w/ low glucose and high protein
Meningococcal typically has purpura and petechiae
-more intense myalgias
4
Q
What are the following
(a) heterophile antibody test
(b) purified protein derivative
A
(a) Heterophile antibody test- tests for EBV (mono)
(b) purified protein derivative tests for tuberculosis
5
Q
What is achalasia?
Clinical presentation
(a) Location
(b) Diagnostic test
(c) Clinical way to improve symptoms
A
Achalasia = impaired peristalsis of the esophagus and impaired relaxation of the LES
Dysphagia to both liquids and solids
(a) LES
(b) Barium swallow- ‘bird-beak’ narrowing
(c) Easier to swallow in upright position because increased pressure in the esophagus allows for more effective swallowing
6
Q
42 yo F w/ fatigue and weakness x1 mo
2 weeks of anorexia, nausea, abdominal pain
2 syncopal episodes
-hypotension
-hyperpigmentation noted on palmar creases
Dx
A
Addison’s disease = primary adrenal failure
- anorexia and fatigue in all, GI symptoms in 90%
- other signs: wt loss, hyperpigmentation, hypotension, vitiigio (autoimmune association)
7
Q
Possible pH and electrolyte changes after giving furosemide to a cirrhotic pt
A
So you give diuretics to a cirrhotic pt (ascites) which inhibits the NaK2Cl transporter => more Na+, K+, and H+ lost in urine => metabolic alkalosis (losing tons of H+, hypokalemia
8
Q
Expected primary cause of nephrotic syndrome in pts w/
(a) lymphoma
(b) Hep C
(c) breast cancer
A
Primary renal causes of nephrotic syndrome and clinical associations
(a)Lymphoma associated w/ minimal change disease
(b) Hep C associated w/ MPGN
(c) Breast/lung adenocarcinoma associated w/ membranous nephropathy
9
Q
Way to clinically distinguish vascular dementia and NPH
A
NPH (‘wacky, wobbly, wet’) does not present w/ focal neurological symptoms
Vascular dementia- can have the wacky/wobbly/wet, but also w/ focal neurologic findings and step-wise progression
10
Q
What is toxic megacolon?
A
Toxic megacolon = acute abdominal distention (radiographic diagnossi) + fever, tachy, neutrophilia, anemia
-volume depletion, AMS, electrolyte disturbance, hypotension
11
Q
Pill rolling tremor
A
Resting tremor of the hand associated w/ Parkinson disease
12
Q
34 yo M w/ severe substernal CP x 30 minutes
- no SOB cough or fever
- agitated, sweating profusely, tachycardic, RR 14
- dilated pupils
- ST elevations in leads V1-V3
Etiology of symptoms?
A
Cocaine induced vasospasm
-dilated pupils
13
Q
Fundoscopic exam revealing corneal vesicles and dendritic ulcers
A
Herpes simplex keratitis
14
Q
64 yo M w/ two falls
- loses balance when tries to turn or stop suddenly
- taking him a while to get himself out of bed
- hand tremor started in left hand last year, now in both hands
(a) Dx
(b) How to confirm dx?
A
(a) Parkinson Disease: rest tremor, bradykinesia (difficulty initiating movements)
- missing the third classic sign of rigidity => test for it on
(b) Physical exam Rigidity: lead pipe, cogwheel Gait Micrographia (small handwriting), hypomimia (decreased facial expression), hypophonia (soft speech Postural instability => falls
15
Q
Type of gastroenteritis caused by E. Coli
A
E. Coli = most common cause of bloody diarrhea in absence of fever
EHEC produces shiga toxin => inflammatory diarrhea w/ bloody stools and abdominal pain
Differentiate from shigella that presents w/ bloody diarrhea w/ fever
16
Q
55 yo M comes in w/ AFib RVR. Suddently becomes unresponsibve w/ no palpable pulses, cardiac monitoring still shows AFib w/ RVR
Next best step?
A
Start chest compressions
In this case pt is not in VT (don’t defibrillate), PEA (pulseless electrical activity) is when an organized rhythm is present on cardiac monitoring w/o palpable pulse
Dont need cardioversion or defib like would do if pulseless w/o electrical activity on monitor (either way would immediately start compressions first)
17
Q
Cushing reflex
(a) Indicates what?
A
Cushing reflex/triad = hypertension, bradycardia, respiratory depression
ex: 170/100, HR 48, RR 19
(a) Worrisome of brainstem compression
18
Q
Differentiate Graves disease from painless thyroiditis
A
Both will have increased T3/T4 with suppressed TSH, difference is in the RAI scan
Graves disease = autoimmune cause of hyperthyroidism
-diffuse increase in uptake of radioiodine uptake
Painless thyroiditis = variant of Hashimoto’s thyroiditis
-thyroid scintigraphy shows decreased radioiodine uptake
19
Q
Differentiate the mechanism of exudative vs. transudative pleural effusion
A
Exudative is due to increased capillary permeability (infection, autoimmune processes, neoplasm)
Transudative- due to increased hydrostatic or decreased oncotic pressure
20
Q
What is succinylcholine?
(a) Major life-threatening side effect
A
Succinylcholine = depolarizing neuromuscular blocker used for procedures such as intubation b/c rapid onst (45-60 seconds) and short duration (6-10 minutes)
(a) Can cause life-threatening hyperkalemia => contraindicated in pts w/ hyperkalemia or at risk for it (crash and burn injuries due to risk of rhabdo)
21
Q
Differentiate defibrillation vs. synchronized cardioversion
A
Defibrillaion delivers energy randomly during the cardiac cycle (w/o synchronization to the QRS complex)
Cardioversion delivers energy synchronized to the QRS complex
22
Q
Acute tx for SVT
A
Supraventricular tachycardia tx = adenosine- works to temporarily slow conduction thru the AV node
23
Q
Name 2 drugs that require dose adjustments in digoxin if added to a regimen
A
Both amiodarone (anti-arrhythmic) and verapamil (CCB) can increase serum digoxin => need to decrease Dig dose if adding either
24
Q
What kind of gifts can be taken from pharma companies?
A
Um none…but you can take nonmentary gifts that directly benefit the patient- like unbiased educational materials or drug samples
25
What does S3 indicate?
LV volume overload
26
Drug of choice for
(a) Rest tremor
(b) Chorea w/ dementia
(c) Intention tremor
Tx
(a) Rest tremor (Parkinsons)- use benztropine (anticholinergic)
(b) Chorea w/ dementia = Huntingtons, used Haloperidol to tx Huntington's chorea
(c) Propranolol = drug of choice for benign essential tremor
27
Tx for polymyositis
Systemic glucocorticoids (prednisone) or MTX (steroid-sparing agent)
-NSAIDs would help a bit w/ the pain but not do anything about the underlying inflammation
28
Joints involved in RA
(a) Hands
(b) Which hand joint is NOT involved
(c) Spine
Rheumatoid arthritis
(a) PIP, MCP most commonly involved
(b) DIP joints are spared
- good differentiating factor from OA
(c) Cervical spine joints in the axial skeletal are the most commonly affected
- can lead to cervical spine subluxation and spinal cord compression => neck pain and stiffness
29
Differentiate skin findings of first and second stage of syphilis
Syphilis skin findings
Primary stage = painless ulcers of genitalia
Secondary stage = maculopapular rash of palms and soles
30
32 yo M recently started on meds for schizophrenia admitted for confusion
- febrile, dry MM, profuse diaphoresis
- muscle rigidity, CK 50,000
(a) Dx
(b) Tx
(a) Neuroleptic malignant syndrome from typical antipyschotic (dopaminergic antagonist)
- recent onset confusion, fever, muscle rigidity, diaphoresis, CK elevated
- symptoms usually start w/in 2 weeks of starting precipitating agent
(b) Dantrolene (muscle relaxant) usually first line to reverse NMS
31
Most common cause of steatorrhea in a middle aged man
Chronic pancreatitis due to alcohol use
32
Indication for sodium bicarbonate in TCA overdose
(a) Mechanism of NaCO3 activity in TCA overdose
QRS interval > 100 msec, NaHCO3 increases serum pH (which decreases drug avidity for Na channels) and increases extracellular sodium (increases gradient across cardiac cell => inhibits TCA binding to fast Na+ channels
(a) NaHCO3 increases serum pH and extracellular soidum => alleviating the cardio-depressant action of sodium channels
33
Most common cause of MR in developed countries
(a) Mechanism
Mitral valve prolapse- much more common than rheumatic heart disease in developed countries
(a) Mechanism of MVP = myxomatous degeneration of the mitral valve leaflets and chordae
34
Tx of Lambert-Eaton syndrome
Lambert-Eaton = proximal muscle weakness due to autoantibodies against voltage gated Ca2+ channels (presynaptic, needed for proper ACh release)
-associated w/ small-cell lung cancer
Tx: plasmaphoresis (get rid of the autoantibodies) + immunosuppresants
35
Moderate anemia w/ low serum iron, low TIBC, elevated ferritin
Consistent w/ anemia of chronic disease
Possible pathogenesis = iron trapping w/in macrophages => poor iron availability (low serum iron yet high ferritin storage)
36
Interpretation of this PFT:
Vital Capacity 75%
FEV1/FVC 95%
FRC (functional residual capacity) 110%
Restrictive disease- suggested by reduced vital capacity w/ normal ratio
37
2 major complications of SAH and how to differentiate them
(a) Medication used to prevent one of them
Major cause of death in the first 24 hrs of presentation = Rebleeding
Then vasospasm can occur in up to 30% of SAH pts from days 3-10
(a) Give nimodipine (CCB) to prevent vasospasm as complication of SAH
38
pH change caused by acute kidney injury
Anion gap metabolic acidosis and hyperkalemia- decreased GFR => tons of aldo => hold on to H+ and K+
39
Effect of malignant HTN on
(a) Renin level
(b) Aldo level
(c) K+ levels
Malignant HTN => high renin and high aldo => hypokalemia (aldo decreases K+ reabsorption)
40
Clinical signs of amyloid
Cardiac, renal, GI, neuro, other
- asymptomatic proteinuria
- restrictive cardiomyopathy
- hepatomegaly
- peripheral neuropathy +/- autonomic neuropathy
- visible organ enlargement (ex: microglossia)
- tendency to bleed => easy bruising
- waxy skin thickening
41
Most common cause of megaloblastic anemia in chronic alcoholics
Folate (not B12) deficiency
42
First line tx for agitation in the elderly
Haloperidol
Don't want to use benzosssss (contraindicated in elderly)
43
Prussian blue stain positive
Indicates presence of iron (or hemosiderin)
ex: found in urine during hemolytic episodes
44
40 yo F w/ SLE (on low-dose prednisone, hydroxychloroquine, lansoprazole) p/w right hip pain x4 weeks that increases w/ weight bearing
- no morning stiffness, warmth, or erythema
- normal ROM, plain film normal
(a) Most likely diagnosis
(b) Diagnostic test
(a) Avascular necrosis of the hip
- relatively high risk of vascular necrosis in SLE, even higher by use of steroids
(b) MRI of the hip
45
Most common cause of MR in developed countries?
(a) Murmur you hear
Mitral valve prolapse = most common cause of MR in developed countries (much more common than rheumatic)
(a) Usually causes mild MR => mid-systolic click followed by mid-to-late systolic murmur
46
Most common causes of drug-induced acute pancreatitis
Diuretics
Abx (Metronidazole)
Anti-seizure drugs (valproate)
47
Clinical associations w/ causes of nephrotic syndrome
(a) FSGS
(b) Membranous nephropathy
(c) IgA nephropathy
(a) Focal segmental glomerulosclerosis = most common cause of nephrotic syndrome in adults
- AA and Hispanics especially
- assocaited w/ obesity, HIV, and heroin use
(b) Membranous- 2nd most common cause of nephrotic syndrome, associated w/ adenocarcinoma (not AA and obesity)
(c) IgA nephropathy- most usually causes hematuria following a URI
- only causes nephrotic syndrome in 10%
48
What is PSC?
(a) Associated condition
Progressive d/o of inflammation, fibrosis, and stricturing of both the intra and extrahepatic bile ducts
(a) Ulcerative colitis present in 90% of patients
49
44 yo hospitalized for episode of Afib w/ RVR
-echo reveals mildly dilated left atrium
Tx?
No therapy needed- CHADSVASc score (for stroke risk assessment in pts w/ nonvalvular Afib) for "lone AF" = paroxysmal AFib w/o evidence of cardiopulmonary of structural heart disease
Lone AFib in pts under the age of 60 have CHADSVASc of 0 = very low risk of systemic embolization => anticoagulation therapy not indicated
50
After a stroke pt only shaves right side of face, only raises right arm, only draws right side of clock
(a) Dx
(b) Location of the lesion
(a) Hemi-neglect syndrome: neglects left side of space and repsonds to stimuli only from the right side
(b) Due to lesion in right parietal cortex
51
2 main side effects of isoniazid
Side effects of isoniazid
1. heptatitis
2. peripheral neuropathy: can present as tingling in extremities, numbness, and ataxia
52
SIADH
(a) plasma osmolality
(b) urine osmolality
SIADH => hypotonic hyponatremia
(a) Low plasma osmolality (under 280)
- b/c reabsorbing tons of water, so dilute plasma
(b) High urine osmolality (over 100-150) b/c excreting little water out in urine
53
Compare and contrast ethylene glycol and methonol poisoning
Both cause an anion-gap metabolic acidosis
Ethylene glycol damages kidneys whereas methanol damages the eyes
54
EHEC
(a) Presentation
(b) How to make diagnosis
(c) Tx
EHEC = enterohemorrhagic E. coli = food borne pathogen causing acute watery to bloody diarrhea (w/ no fever)
(a) Acute watery and bloody diarrhea w/ abdominal pain, no fever
(b) Confirm diagnosis w/ stool assay for Shiga toxin
(c) Tx = supportive tx, NOT abx- increases risk of HUS
55
Consequence of hypomagnesemia in chronic alcoholics
Refractory hypokalemia since Mg is a cofactor needed for K+ uptake
56
What is metoclopramide?
(a) Side effects
Metoclopramide (Reglan) = dopamine receptor antagonist used to treat N/V/gastroparesis
(a) Common side effects = agitation and loose stools
Less common side effects = EPS (dystonia, Parkinsonism)
57
Next step in management for HIV pt diagnosed w/ active CMV infection
Ocular exam to r/o concurrent retinitis
58
Which diuretic should be used to lower urinary calcium excretion?
Thiazide diuretic- cause mild volume depletion causing a compensatory rise in reabsorption of sodium and water w/ resulting increased passive reabsorption of calcium
59
# Define exertional heat stroke
(a) first line tx
Exertional heat stroke = temp over 40 C (104 F) + CNS dysfunction
(a) rapid cooling, preferably w/ ice water immersion
60
Most serious side effect of anti-thyroid drugs
Graves pt on methimazole who develops sore throat and fever? Immediately check white count b/c of risk of agranulocytosis
61
Mechanism of Parkinson disease
Neurodegenerative d/o caused by accumulation of alpha-synuclein within the neurons of the substantia nigra, ultimately leading to death of these neurons
62
Octreotide
(a) Mechanism
(b) Indication
Octreotide
(a) somatostatin analog that reduces glucagon release => causing splanchnic vasoconstriction and reduced portal blood flow
(b) Used to tx active variceal bleeding
63
Requirement for hospice
Prognosis under 6 mo
64
Most common vavular abnormality detected in pts w/ infective endocarditis
Mitral regurg from mitral valve prolapse
65
What does presence of urobilinogen in the urine indicate?
Indicates hemolysis
66
32 yo M w/ intense mildline CP and diaphoresis x4 hrs
- s/p recurrent vomiting
- injected conjunctivae, b/l dilated pupils
- CXR: widened mediastinum, moderate left pleural effusion
- EKG: sinus tachy
- pleural fluid: yellow exudate w/ high amylase content
Dx?
Esophageal perforation (Boerhaave syndrome = transmural esophageal tear)
- caused by forceful retching
- causes esophageal air/fluid leakage into nearby areas (pleura)
CXR shows pseudomediastinum and pleural effusions
-mediastinal widening b/c air and fluid accumulate in mediastinum causing inflammation
Pleural fluid analysis: exudative, very high amylase (due to saliva in esophageal contents)
67
Cancer syndrome due to mutations in RET proto-oncogene
MEN2A and MEN2B
68
Most common cause of bite cells in peripheral blood smear
G6PD deficiency
X-linked recessive common in African American men
69
Differentiate etiology of primary vs. secondary amyloidosis
```
Primary amyloid (AL type) is its own entity, while secondary (AA) is due to chronic conditions such as
-inflammatory arthritis (RA)
-chronic infections (Tb, osteomyelitis)
-IBD (crohn's)
-Malignancy (lymphoma)
vasculitis
```
70
Define pulses paradoxus
Exaggerate fall in systemic blood pressure > 10 mmHg during inspiration (normal is for systemic arterial pressure to fall less than 10 mmHg during inspiration)
71
15 yo w/ fever, non-productive cough, sore throat, HA x1 week
- skin rash: target shaped lesions over extremities
- CXR: interstitial infiltrates in left lower lobe
- no organisms on sputum stain
(a) Dx
(b) Most likely organism
(a) Atypical pneumonia
(b) Mycoplasma = most common cause of atypical pneumonia in ambulatory setting
- rash = erythema multiforme, is typical of mycoplasma
72
Dermatomyositis vs. Lambert-Eaton syndrome
Dermatomyositis- symmetrical muscle weakness, SKIN FINDINGS!!!
- Gottron's papules: violaceous papules on dorsum of fingers
- heliotrope rash
Lambert-Eaton: proximal muscle weakness, can have cranial nerve involvement, diminished or absent DTRs**
73
How to evaluate for internal hemorrhoids?
Anoscopy = small scope to visualize anal canal pathology/anatomy
74
Increased risk of which 2 pathologies due to Strep bovus biotype 1
Colorectal cancer and endocarditis
75
Differentiate oropharyngral and esophageal dysphagia
(a) What is it
(b) Symptoms
(c) Diagnostic test
Oropharyngeal dysphagia
(a) difficulty initiating swallowing due to inability to properly transfer food from mouth to pharynx
(b) coughing and choking upon swallowing, nasal regurgitation
(c) Barium swallow
While esophageal dysphagia
(a/b) food gets stuck in the esophagus (now the throat) after swallowing
(c) Esophageal motility study and upper GI endoscopy
76
Oral leukoplakia vs. squamous cell carcinoma
Difference in appearance, same risk factors (tobacco, alcohol)
Leukoplakia = precancerous lesion of hyperplasia of the squamous epithelium
-white patches/granular lesion
SCC: nodular, erosive, or ulcerative lesion w/ surrounding erythema or induration
77
Etiologies of toxic megacolon
Toxic megacolon = acute abdominal distention (radiograph showing dilated colon > 6 cm) + systemic symptoms (fever, hypotension, neutrophilia, tachy)
Most commonly a complication of IBD (more UC than Crohns)
Genetic- Hirschsprung
78
Lambert-Eaton syndrome
(a) Association
(b) Mechanism
(c) Clinical presentation
Lambert-Eaton syndrome
(a) associated w/ small cell carcinoma of the lung
(b) caused by autoantibodies directed against the presynaptic voltage-gated calcium channels => defective ACh release =>
(c) proximal muscle weakness, loss of deep tendon reflexes
79
Which skin cancer is the classic pearly, rolled border w/ overlying telangiectasia
Basal cell carcinoma
80
Pulses paradoxus
(a) Most common cause
(b) Other causes
Pulses paradoxus = abnormally large (>10mmHg) decrease in systolic BP w/ inspiration
(a) frequent finding in cardiac tamponade (pericardial effusion)
(b) can also occur w/o pericardial effusion in severe asthma or COPD
81
66 yo M w/ increasing back pain and severe constipation, urinating excessively
-Hgb 9.5, WBC 7k, Cr 1.9, ESR 80
(a) Dx
(b) Mechanism of constipation
(a) Multiple myeloma (CRAB)
| b) Association w/ hypercalcemia (electrolyte disturbance
82
Most common cause of sideroblastic anemia
(a) Drugs that can cause it
Sideroblastic anemia = bone marrow makes ringed sideroblasts b/c it can't incorporate available iron into Hgb
Most common cause = EtOH
(a) Can be caused by isoniazid, a known pyridoxine (b6) inhibitor
83
What is hepatic hydrothorax?
Transudative pleural effusion (usually right sided) in cirrhotic pt w/ no underlying pulmonary disease that would account for it
84
32 yo F presents w/ pain on EOM and visual impairment
- sluggish afferent pupillary response to light
- changes in color perception
- swollen disk of fundoscopy
Dx
Optic neuritis = most commonly females aged 20-45
- changes in color perception, central scomata
- APD and field loss
- more common in pts w/ MS
85
Dietary recommendations for pts w/ renal calculi
Increased fluid intake, decreased sodium intake, normal dietary Ca2+ intake
86
Diagnostic test for amyloidosis
Fat pad biopsy is the easiest (most accessible)
Could also do BM, kidney, endomyocardial biopsy (ouch)
87
Distinction btwn primary HIV infection and mononucleosis presentation
Both can present as febrile illness w/ lymphoadenopathy
Primary HIV- uncommon to find tonsillar exudate
Rash and diarrhea are less common in infectious mono
88
Features of primary hyperaldosteronism
(a) Etiology
(b) Features
(a) Either aldosterone-producing tumor or bilateral adrenal hyperplasia => tons of aldo
(b) Tons of aldo => decrease in K+ reabsorption (hypokalemia), decrease in H+ reabsorption (met alkalosis), increase in Na+ reabsorption (HTN/increased blood volume)
89
42 yo chronic alcoholic 4 weeks s/p acute pancreatitis p/w palpable mass in epigastrium w/ pain radiating to the back
-marked increased in amylase
(a) Diagnosis
(b) Diagnostic test
(c) Tx
(a) Pancreatic pseudocyst = inflammatory fluid lined by fibrous capsule (not epithelium or else would be true cysts)
- complication of both acute and chronic pancreatitis
(b) Ultrasound
(c) Often self-resolve
90
Normal activity of the G6PD enzyme
G6PD = enzyme that catalyzes NADP --> NADPH, NADPH needed to form reduced glutathione to protect RBCs from oxidative injury
91
27 yo F w/ 3 mo GERD
- constipation, excessive urination
- FHX: father w/ ulcers and multiple kidney stones
- +FOBT w/ epigastric abdominal pain
- ECG: prolonged PR, shortened QT
- high calcium, low phosphorus
Symptomatic hypercalcemia (constipation, polyuria) and peptic ulcers (epigagastric abdominal pain and occult bleeding) + FHx peptic ulcers and kidney stones = MEN1 w/ hyperparathyroid and gastrin-producing tumors
MEN1 = auto dom
- parathyroid adenomas/hyperplasia
- pituitary adenomas
- pancreatic endocrine tumors (gastrin producing tumors => Zollinger-Ellison)
92
Differentiate the characteristics of diarrheal illness seen in HIV pts infected with
(a) Cryptosporidium
(b) CMV
(c) MAC
(d) Giardia
Diarrheal illness in HIV pts
(a) Cryptosporidium- severey watery diarrhea w/ low grade fever
(b) CMV- freqent, small volume diarrhea. Hematochezia (bloody), abdominal pain w/ low-grade fever
(c) MAC- yes can cause diarrhea, watery diarrhea (not bloody
(d) Giardia- malabsorptive watery diarrhea, no colitis symptoms (no fever/abdominal pain)
93
What is malignant HTN?
Severe HTN (>180, >120) w/ retinal hemorrhages, exudates, or papilledema
94
What are esophageal webs
(a) Clinical manifestation
(b) Location
(c) Associated syndrome
Esophageal webs = mild focal narrowing in upper esophagus
(a) Dysphagia to solids but not liquids- it's only a mild narrowing (so liquids can still pass)
(b) Upper esophagus
(c) Plummer-Vinson syndrome: iron deficiency => esophageal web, glossitis, anemia, cheilitis (fissures on sides of lipds
95
What kind of EKG findings would you expect from bradyarrthymia-induced syncope?
Prolonged PR, prolonged QRS
| not prolonged QT as seen in Torsades
96
What is more likely to help prevent gouty attack: quitting smoking or cutting back on EtOH.
Cutting back of EtOH: heavy alcohol intake (esp beer and distilled spirits): ethanol increases uric acid production and may decrease renal elimination of uric acid
97
Finding on peripheral smear of RBC inclusions after crystal violent staining
(a) Name of finding
(b) Indication
(c) Possible etiology
(a) Heinz bodies
(b) = Inclusions w/in RBC of denatured Hgb
(b) Chronic liver disease, G6P deficiency, alpha thalassemia
98
17 yo M w/ intensive flank pain radiating to the groin
- "stone passage" many times since childhood, uncle has same problem
- UA: hexagonal crystals
(a) Dx
(b) Mechanism
(a) Dx = cyrstinuria = group of hereditary disorders due to
| (b) impaired amino acid transport by the brush borders of renal tubular and intestinal epithelial cells
99
Tx of wide-complex tachycardia
Depends if the pt is stable or unstable
Stable- IV amiodarone (if have fusion/capture beats) or carotid massage + rate control if no fusion beats
Unstable- cardiovert
100
How to differentiate folic acid and cobalmin deficiency by other serum levels of precursors?
Both folate and B12 deficiency cause increase in homocystine b/c homocystine is a precursor for both
While only B12 (not folate) deficiency will cause increase in MMA (methylmalonic acid) concentration
101
What other conditions is vitiligo associated with?
Vitiligo thought to be autoimmune against melanocytes => associated w/ other autoimmune processes
- Pernicious anemia: AI against parietal cells producing intrinsic factor
- DMI
- hypopituitary
- alopecia
- primary adrenal insufficiency (autoimmune adrenalitis)
102
Location of lesion in Parkinsons
(a) Neurotransmitters implicated
Parkinsonism: due to overactivity of cholinergic neurons and underactivity of dopaminergic neurons int he substantia nigra
103
24 yo F w/ skin rash and pain in her wrists, ankles, elbows x4 days
- fevers, sweats
- recent vacation and unprotected sex w/ new bf
- no thrush or lymphadenopathy
- 3 furuncles on anterior left shin
Dx?
Gonococcemia
Triad of disseminated gonococcal infeciton = polyarthralgia, tenosynovitis, vesiculopustural skin lesion
104
Levels of the following in tumor lysis syndrome: calcium, phosphate, potassium, uric acid
Tumor lysis syndrome: hypocalcemia, hyperphosphatemia, hyperkalemia, high uric acid
K+ and phosphate are intracellular anions => increased in serum. Then increased phosphate binds the serum calcium causing hypocalemia
Degradation of cellular proteins causes elevation in uric acid levels
105
Initial tx of pt w/ new finding of lung cancer presenting w/ hyponatremia
Fluid restriction!
Hyponatremia most likely due to SIADH (syndrome of inappropriate antidiuretic hormone secretion), common particularly in small cell lung cancer
-pt has low plasma osmolality w/ inappropriately elevated urine osmolality b/c just peeing out all the Na+/water
106
22 yo F w/ pulsatile HA x6 weeks + nausea, awaken her from sleep
- no photophobia, weakness, sensory abnormalities
- (+) papilledema
- CT of brain wnl, LP shows elevated opening pressure w/ normal CSF
(a) Dx
(b) First line tx
(a) Idiopathic intracranial hypertension = pseudotumor cerebri
(b) First line tx = acetazolamide = inhibits choroid plexus carbonic anhydrase to decreased CSF production and intracranial HTN
107
Most sensitive screen for nephropathy in diabetic pt
Random urine microalbumin/creatinine ratio
| -screening for microalbuminuria which is the initial stage of nephropathy
108
Abx of choice for pneumonia after GI endoscopy
Suspecting anaerobic pneumonia => clindamycin
109
Name 3 causes of pulmonary cavitation in an HIV (+) pt
1. Nocardia (partially acid fast staining)
2. MTb
3. atypical mycobacteria
110
Next step for pt in 1st degree heart block
Nothing- just observation
No acute tx needed, considered benign
Vagal maneuver wouldn't do anything for 1st degree block, only helpful to distinguish type 1 and 2 second degree
111
Parkinsonism vs. multiple system atrophy
Both can present similarly w/ rigidity, bradykinesia, resting tremor
MSA also has autonomic dysfunciton => ED, dry mouth, dry skin, incontinence, constipation
Also MSA has widespread neurological signs (cerebellar, ataxia)
-MSA doesn't have response to typical anti-Parkinsonian drugs
So Parkinsonism + urinary incontinence + ED + ataxia etc = MSA
112
Creutzfeldt-Jakob disease
(a) Clinical presentation
(b) EEG findings
(c) 2 definitively diagnostic tests
(a) Rapidly progressing dementia and myoclonus
- insomnia, apathy, behavioral changes, impaired vision
(b) EEG findings of sharp wave complexes
(c) Definitive diagnostic tests:
- genetic testing for prion protein (PRNP) gene
- brain biopsy findings of spongiform changes
113
Major risk factors for esophageal cancer
Tobacco and alcohol use
114
52 yo M w/ chronic alcoholism presents w/ small nonbleeding esophageal varices
Tx?
Non-selective beta-blocker- shown to reduce likelihood of progression to large varices and risk of variceal hemorrhage
If have contraindications to beta-blocker therapy, can do endoscopic variceal ligation
-octreotide only used to treat active variceal bleeding, not in primary prophylaxis of variceal hemorrhage
115
Mechanism of proptosis in Graves' disease
Same anti-TSH receptor autoantibodies stimulate orbitral fibroblasts => expansion of orbital tissue (connective, adipose, and muscular)
116
Differentiate presentation of macular degeneration and open angle glaucoma
Type of vision loss
Open angle glaucoma = gradual loss of peripheral vision causing tunnel vision, central vision usually spared
Macular degeneration = gradual loss of central vision, peripheral vision spared
117
Differentiate hypertensive urgency vs. hypertensive emergency
Differ by present of end-organ complications
Hypertensive urgency = (>180,>120) w/ no symptosm or acute end organ damage
Hypertensive emergency = severe HTN (>180, >120) w/ life-threatening, end organ complications
-Malignant HTN or hypertensive encephalopathy
118
Common symptoms of polycythemia vera
PV = myeloproliferative d/o causing increase in all 3 cell lines
Symptoms of hyperviscosity (dizziness, HA, visual disturbance), pruritis after shower (due to histamine release), splenomegaly `
119
Lab value used to differentiate primary hyperparathryoidism and familial hypocalciuric hypercalcemia
Both have high serum calcium and high parathyroid hormone level
-PTH will be higher in PHP
Difference is in the urine excretion of calcium
- high urine Ca excretion in primary hyperparathyroid
- low urine Ca excretion in familial hypocalciuric hypercalcemia (it's in the name- hypocalciuric)
120
Finding of corkscrew pattern of esophagram indicates what?
(a) First line tx
(b) Clinical presentation
Corkscrew pattern of esophagram = diffuse esophageal spasm
-uncoordinated contractions of esophageus
(b) Presents w/ CP and dysphagia intermittently
(a) First line tx = calcium channel blocker
121
2 triggers for hemolysis in a pt w/ G6PD deficiency
Infections and medications (ex: bactrum (sulfa abx), antimalarians, nitrofurantoin) that increase oxidative stress can trigger hemolysis in pt who can't handle the extra oxidative stress
122
What is indomethacin?
NSAID
123
Differentiate febrile nonhemolytic vs. acute hemolytic transfusion reaction
- symptoms
- cause
- time line
Febrile nonhemolytic = fever and chills w/in 1-6 hours of transfusion
-caused by cytokine accumulation during blood storage
Hemolytic transfusion reaction = fever, flank pain, renal failure, DIC, hemoglobinuria
- w/in one hr of transfusion
- caused by ABO incompatibility
124
Physical exam finding that can distinguish cardiac and liver disease related causes of LE edema
Hepatojugular reflex
When peripheral edema is due to heart failure, JVP will be elevated => positive HJR
Peripheral edema from primary hepatic disease and cirrhosis will have reduced or normal JVP => negative HJR
125
What does 'bird-beak' narrowing on barium swallow indicate
Achalasia = impaired peristalsis of the distal esophagus and impaired relaxation of the LES => chronic dysphagia w/ both liquid and solids
126
Jarish-Herxheimer reaction
Reaction to syphilis treatment with penicillin- spirochetes die rapidly and release antigen-antibody complexes in the body causing an immunologic reaction that looks like an acute flare-up of syphilis
127
How to determine necessity of warfarin in pts w/ AFIB
CHADSVASc of 2 or more points
128
Most common cause of lower GI bleeding in adults
Diverticulosis
129
What electrolyte abnormalities are seen in Addison's disease?
Addisons = primary adrenal failure
Hyponatremia most common (seen in 90%) due to volume contraction (mineralocorticoid deficiency) and increased vasopressin (ADH) secretion due to lack of cortisol suppression
Hyperkalemia also common (65%) due to decreased aldo activity
130
64 presenting w/ CP 2 weeks s/p acute MI
- deep breaths make the pain worse
- learning forward makes the pain somewhat better
- EKG: ST seg elevations in all leads except ST depressions in aVR
(a) Dx
(b) Tx
(a) Pericarditis- typical pattern of worse w/ deep inspiration and improved by leaning forward
-diffuse ST elevations w/ reciprocal depressions in aVR also classic for pericarditis
Dressler's syndrome = pericarditis after MI
(b) Tx = NSAIDs
131
25 yo AA obese female w/ abdominal distention, h/o heroin abuse
- negative HIV profiles
- 24 hr protein excretion of 7.5
Most likely to be present on kidney biopy?
FSGS (focal segmental glomeruloscerosis)
-associated w/ AA and Hispanic, obesity, HIV, heroin use
Also is the most common cause of nephrotic syndrome in adults, especially AA
132
Is Paget's disease of the osteoblast or osteoclast?
Paget's disease is caused by osteoCLAST dysfunction => mosaic pattern of lamellar bone
133
Which tumors are most frequently associated with tumor lysis syndrome?
Ones w/ high cell turnover: leukemia and lymphomas
134
30 yo obese F, "always had" irregular menses
- hair loss, male pattern baldness
- mother has endometrial cancer, grandma has met ovarian carcinoma
(a) Screening test most indicate in this pt
Obese F w/ irregular menses and signs of androgen excess (male pattern baldness)- think PCOS
(a) OGTT- screen for DM2
Don't be sucked into the distractor (family history)
135
25 yo F w/ pale patches on skin around mouth and areola for a few months
-white well-circumscribed macules
(a) Dx
(b) Mechanism
(a) Vitiligo
- predilection for acral areas and around body orifices
(b) Autoimmune destruction of melanocytes
136
Evaluation of a solitary pulmonary nodule detected on Xray
First- compare to old imaging
Second- get CT
Then decide to observe, biopsy, or surgically resect based on size, stability, pt's age, smoking history
137
Initial medical tx of a stroke based on
(a) Prior therapy
(b) Evidence of afib
Antiplatelet/antithrombotic therapy for ischemic stroke (basically to prevent another)
(a) Stroke w/ no prior antiplatelet therapy: tx = aspirin
Stroke on aspirin therapy: aspirin + dipyridamole (PDE inhibitor) OR clopidogrel (Plavix, inhibits ADP receptor on platelet membranes)
(b) Evidence of afib: long-term anticoagulation (warfarin, rivaroxaban)
138
Dressler's syndrome
(a) Tx
Immunologic phenomena post-MI causing pericarditis, malaise, sometimes fever, after MI
(a) NSAIDs
139
Prophylactic measure in pt w/ diagnosed MEN2A
Prophylactic total thyroidectomy in early childhood- risk of acquiring invasive medullary thyroid cancer is nearly 100%
MEN2: medullary thyroid cancer, pheochromocytoma
140
Color vision alterations is an adverse event of which drug?
Digoxin
141
Why are pts on Tb treatment also played on pyridoxine?
Peripheral neuropathy is a known side effect of isoniazid => pts started on pyridoxine 10 mg (vit B6)
142
Most common clinical features of scleroderma by system
(a) Pulmonary
(b) Vascular
(c) GI
Scleroderma
(a) Interstitial fibrosis
(b) Vascular- Raynaud's phenomenon
(c) GI- dysphagia, dyspepsia, angiodysplasia of the stomach (watermelon stomach)
143
# Define atrial premature beats/contractions
(a) Appearance on EKG
PAC/APB- premature atrial activation originating from site other than the SA note
(a) ECG shows early P-wave w/ a morphology different from the SA node generated P-waves
144
What is cystinuria?
Inherited disease of impaired amino acid transport causing recurrent urinary stone formation
-hx of recurrent kidney stones, often FHx
-UA: hexagonal cyrstals
Screening procedure = ruinary cyanid nitroprusside test
145
Consequence of citrate in blood transfusions
(a) Why is citrate added
(b) Consequenc
(a) Citrate added to blood transfusions to store the blood
| (b) CItrates chelates Ca and Mg => may reduce their plasma levels, causing paresthesias
146
Acetazolamide- what is it?
(a) Mechanism
(b) Indication
Acetazolamide = basically a CSF diuretic (kinda)
(a) mechanism = inhibits choroid plexus carbonic anhydrase to decrease CSF production
(b) Used in idiopathic intracranial HTN, glaucoma, epilepsy
147
Triad of disseminated gonococcal infection
Disseminated gonococcal infection (STI) = polyarthralgias, tenosynovitis, vesiculopustular skin lesions (2-10)
