UWorld 6 Flashcards
1
Q
How to confirm a diagnosis of CLL
A
Flow cytometry to demonstrate lymphocyte clonality
2
Q
Direct Coombs’ test findings of warm vs. cold agglutinin AIHA
A
Warm agglutinin AIHA: anti-IgG, anti-C3 or both
Cold agglutinin AIHA: anti-C3 or anti-IgM but not IgG
3
Q
When does sinus bradycardia require treatment?
(a) First line of tx
A
When pt is
- hypotensive or has signs of shock (cold extremities, slow cap refill)
- acute change in mental status
- chest discomfort concerning for cardiac ischemia
- acute heart failure
(a) IV atropine (anti-cholinergic)
4
Q
Name a cause of JVP w/o HF
A
Cardiac tamponade
5
Q
Most common organism causing infective endocarditis
A
Staph aureus
6
Q
65 yo M w/ dysuria and turbid, foul-smelling urine w/ air bubbles in it x2 weeks
- s/p abx course for diverticulitis 4 weeks ago
- no CVA tenderness, smooth nontender prostate
Dx?
A
Colovesical fistula = connection btwn colon and bladder
-possible complication of acute diverticulitis due to direct extension of ruptured diverticulum or erosion of a diverticular abscess into the bladder
7
Q
26 yo F w/ h/o severe asthma presenting w/ severe SOB, tachy and tachypnic -significant wheezing on exam -normal CXR -no cough/fever WBC 19k w/ N 82%
Most likely cause of lab findings?
A
Glucocorticoid-induced neutrophilia
Glucocorticoids tend to decrease eosinophils and increase lymphocyte number by increasing BM release and mobilizing the marginated neutrophil pool
-normal CXR w/o fever and cough make pneumonia less likely
So remember glucocorticoids cause neutrophilia by increasing BM release and mobilizing marginated neutrophil pool
-decreased eosinophils and lymphocytes
8
Q
When is trihexyphenidyl used in Parkinsons pts?
A
Trihexyphenidyl = anticholinergic agent, used in younger pts where tremor is the predominant symptom
9
Q
CMV retinitis vs. HSV keratitis
A
HSV keratitis- much more severe: central retinal necrosis
CMV retinitis: painless, usually not associated w/ keratitis or conjunctivitis
10
Q
Alternative non-surgical tx for primary hyperaldo
A
Aldo antagonists = Spironolactone and eplerenone
Eplerenone = more selevetive => fewer endocrine side effects than spironolactone
11
Q
Scleroderma renal crisis
(a) 2 presenting symptoms
(b) peripheral smear findings
A
Scleroderma renal crisis
(a) Presents w/ malignant HTN and acute renal failure
(b) Peripheral smear: microangiopathic hemolytic anemia w/ fragmented RBCS (schistocytes) and thrombocytopenia
12
Q
What is von-Hippel-Lindau syndrome?
A
Autosomal dominant inherited mutation in tsg manifesting with a variety of benign and malignant tumors
Most common lesion = hemangioblastoma = CNS tumors originating from the vascular system (cell of origin is endothelial cell)
13
Q
Mechanistic cause of heat stroke vs. heat exhaustion
(a) Clinical distinction
A
Inadequate/failure of thermoregulation: at humidity over 75% the body loses its ability to dissipate heat
Heat exhaustion is due to inadequate fluid and salt replacement
(a) CNS dysfunction (such as altered mental status) is present in heat stroke but NOT heat exhaustion
14
Q
Mechanism of ACEi effectiveness in diabetic nephropathy
A
Reduce intraglomerular hypertension and therefore, decrease glomerular damage
-b/c glomerular hyperfiltration is the earliest renal abnormality seen in diabetic nephropathy (can be detected as early as several days after diagnosis is made)
15
Q
How to histologically distinguish follicular cancers from follicular adneomas
A
Follicular cancers demonstrate invasion of the capsule and blood vessels
16
Q
Tx of Raynaud’s phenomenon
A
Phenomenon of increased vascular response to cold temp or emotional stress
Tx = avoid aggravating factors (cold, emotional stress)
If symptoms persist- tx w/ CCB (nifedipime, amlodipine)
17
Q
What is Chikungunya fever?
A
Mosquito-borne viral illness presenting w/ flulike illness, symmetric polyarthralgias, macular or maculopapular rash on limbs and trunk, peripheral edema, and cervical lymphadenopathy
18
Q
Multiple sclerosis
(a) Age of onset
(b) Typical presenting features
(c) Uhthoff’s phenomenon
(d) Lhermitte’s sign
A
MS
(a) Women of child bearing age (15-50)
(b) optic neuritis (painless vision loss), diplopia, sensory deficits, motor weakness, bowel/bladder dysfunction, neuropyschiatric disturbances
(c) Uhthoff’s phenomenon = worsening of symptoms in heat (heat sensitivity)
(d) Lhermitte’s sign = electric shock-like sensation down the spine or limbs upon flexion of the neck
19
Q
Normal postvoid residual volume
A
Normal postvoid residual volume is under 50 ml, when high = urinary retention
- Neurogenic bladder (ex: diabetes peripheral neuropathy)
- Bladder obstruction
20
Q
Differentiate the cauda equina and conus medullaris
(a) How does this differentiate signs of compression
A
Cauda equina = nerve ROOTS, the lumbosacral nerve roots under L1-L2
-since they’re nerve ROOTS, cauda equina syndrome presents w/ LMN signs (b/c nerve roots are peripheral)
Conus medullaris = end of the spinal cord at L1/L2
-it’s part of the spinal cord => compression causes both lower motor and upper motor neuron signs
21
Q
What is Factor V Leiden
A
Point mutation in gene coding for coagulation factor V => factor V becomes resistant to inactivation by protein C (important counterbalance in hemostatic cascade)
Factor V Leiden = inheritable hypercoagulable state w/ predisposition to thromboses, esp DVT of lower extremities
22
Q
What is Prinzmetal’s angina?
(a) Most common population
(b) Most common presenting symptom
(c) EKG changes
A
Prinzmetal’s angina = variant angina due to temporary spasm of the coronary arteries- so ischemia, but not to atherosclerotic narrowing seen in MI
(a) Young female smokers
- biggest risk factor = smoking
(b) Typically chest pain, typically occurs in the middle of the night
(c) Transient (short) ST elevations
23
Q
Breath sounds and response to percussion seen in pleural effusion
A
Pleural effusion => decreased breath sounds (b/c sound wave muffled by fluid in pleural space) and dullness to percussion
24
Q
What findings would you expect on lung CT of tricuspid endocarditis in an IVDU
A
Expect fragments of the staph aureus (most common organism) vegetations to embolize to the lungs, causing characteristic nodular infiltrates w/ cavitation
25
# Define precision in scientific studies?
(a) What represents high precision
| (b) How to increase precision
Precision = measure of random error
(a) Tighter the confidence interval, the more precise the result
(b) Increase precision (decrease the probability of random error) by increasing the sample size)
26
Describe AFib's appearance on an EKG
Irregularly irregular rhythm, varying RR interval w/ no clearly discernable P waves
-narrow complex tachycardia
27
Bedside ice pack test- what is it used for?
Support a diagnosis of myasthenia gravis
Ice pack over eyelid for a few minutes => improvement in ptosis
-cold temp inhibits ACh breakdown => improving muscle strength
28
54 yo M w/ DM2 and HTN well controlled presenting for f/u
-got Td booster 12 years ago
Which vaccines should he receive at this visit?
1. Tdap- once in adult years, then Td every 10 years
2. Intramuscular influenza
- only healthy (no comorbidities such as diabetes) nonpregnant under 50 can get intranasal
3. PPSC23 vaccine- for pts w/ chronic heart/lung. or liver disease, diabetes, current smokers, and alcoholics
Give PCV13 then PPSV23 (sequential pnuemococcal coverage) only to very high risk pts: asplenia, HIV, CKD
29
Management of uncomplicated distal ureteral stone
Hydration, analgesics, and alpha blockers to facilitate stone passage
Alpha blocker = tamsulosin
30
25 yo w/ N/V x6 episodes 4 hrs after eating fried rice at a Chinese restaurant
Cause?
'Fried rice syndrome' = Bacillus cereus!!!
| -heat stable toxin in inadequately refrigerated cooked rice, preformed toxin => get sick w/in 6 hrs of eating
31
76 yo M w/ recurrent pneumonia
- dysphagia, regurgitates undigested food
- halitosis and fluctuant mass in the left neck
Dx
(a) Diagnostic study
(b) Tx
Zenker's diverticulum: most common in elderly men, presents w/ dysphagia, regurgitation, foul-smelling breath, high risk for aspiration pneumonia, and occasionally a palpable masss
(a) Diagnostic study = contrast esophagram (not upper GI endoscopy due to risk of cannulating diverticulum)
(b) Surgical tx
32
Describe why Crohn's pts have an increased risk of nephrolithiasis
Due to increased absorption of oxalate due to fat malabsorption
Ca2+ usually binds oxalate to prevent its absorption, when fat isn't absorbed Ca preferentially binds fat so oxalate is left unbound to be absorbed into the bloodstream
33
Risk factors for small-bowel bacterial overgrowth syndrome
Motility disorders: such as diabetes and scleroderma
-anatomic changes: strictures, fistulas
ESRD, AIDS (immunodeficient), cirrhosis, age
34
Differentiate glucocorticoid vs. statin-induced myopathy
(a) ESR and CK
(b) Main symptom
Glucocorticoid-induced myopathy
(a) Normal ESR and CK
(b) Weakness w/o pain
Statin-induced myopathy
(a) Normal ESR, elevated CK
(b) Pain w/o weakness
35
HIV pt w/ upper lobe cavitary lesion on CXR
```
Mycobacterial infection (MTb)
-MTb is one of the few organisms that prefer the lung apices due to high oxygen tension and slower lymphatic elimination (allowing for organism accumulation)
```
36
30 yo HIV+ M w/ left-sided paralysis of recent onset
- memory loss, expressive aphasia
- CT shows multiple, hypodense, non-enhancing lesions w/ no mass effect in the cerebral white matter
Dx?
Progressive multifocal leukoencephalopathy (PML) = opportunistic infection of the JC virus in immunocompromised pts
Not toxo- toxo would show ring-enhancing lesions
37
Breath sounds and response to percussion seen in pneumothorax
Pneumothorax => hyper-resonant to percussion (b/c tons of air) and decreased breath sounds (b/c collapsed lung...)
38
pH of
(a) Normal pleural fluid
(b) Transudative pleural effusion fluid
(c) Exudative pleural effusion fluid
(a) Normal pleural fluid has a pH of 7.6
(b) Transudative: pH 7.4-7.55
(c) Exudative: 7.3-7.45
- so super low pH associated w/ inflammation
ex: bacteria in fluid decreasing H+ efflux from pleural space
39
Pt w/ elevated PTH and serum calcium, has a sister w/ HTN
(a) Dx
(b) Why would you expect plasma free metanephrines to be high?
Elevated PTH despite elevated serum Ca = primary hyperparathryoidism
Sister w/ HTN, potentially suggesting FHx of pheochromocytoma (NE secreting tumor)
(a) => MEN2: medullary thyroid carcinoma + pheochromocytoma + parathyroid tumor
(b) Metanephrine = metabolite of epinephrine => expected it to be elevated in MEN2A
40
What other disorders is Prinzmetal's angina associated with?
Prinzmetal's angina = coronary vasospasm
| Associated w/ other vasospastic disorders: such as Raynaud's phenomenon and migraine headaches
41
Folate vs. B12 deficiency anemia
(a) Clinical symptoms
(b) Duration of stores lasting
(a) B12 deficiency anemia can be accompanied by neurologic deficits, while folate deficiency causes anemia alone
(b) B12 stores last about 3-4 years, while folate stores last much shorter (like months)
42
Tx for carpel tunnel syndrome
First line tx is nocturnal wrist splinting
Those w/ significant weakness or refractory symptoms may require surgical decompression
43
RBC pathology seen in peripheral smear in pts w/ thalassemias
Target cells = RBCs w/ central density surrounded by pallor
44
What to give to a pt w/ sinus bradycardia who is not responsive to IV atropine?
Either IV dopamine or IV epinephrine
| or transcutaneous pacing
45
Optimal tx regimen for PCP in HIV pt
IV Bactrim +/- corticosteroids depending on PaO2 on room air (or Aa gradient)
Pts may experience initial worsening of pulmonary fxn when abx are initiated => give steroids + bactrim in pts w/ PaO2 under 70 mmHg on room air or Aa gradient over 35 to minimize pulmonary complications
46
Eplerenone
Indication
Eplerenone = selective mineralocorticoid antagonist w/ low affinity for progesterone or androgen receptors
Used for non-surgical tx of primary hyperaldo
-fewer side effects than spironolactone b/c more selective
47
When to get D-dimer vs. CT pulmonary angiography to workup PE
Get D-dimer when PE is unlikely (pre-test probability is low) b/c it's sensitive but not specific
-so negative value rules it out
When pre-test probability is high (PE is likely) go straight to CT pulm angiogram
48
85 yo M w/ rash over forehead, tip of nose, and left eye
- pain and decreased vision
- fever, malaise, burning sensation of left eye x5 days
- T 101F
- vesicular rash on periorbital region and lid margins
- chemosis of conjunctiva, dendriform ulcers on cornea
Dx
Herpes zoster opthalmicus = dendriform corneal ulcers and vasicular rash in the trigeminal distribution
49
Autoimmune hemolytic anemia
| a) type of anemia (micro, normo, macro
(b) 2 physical exam findings
(c) key lab finding
(d) Tx
Autoimmune hemolytic anemia
(a) Normocytic
(b) Splenomegaly, jaundice (indirect hyperbilirubinemia)
(c) Key lab finding: indirect hyperbilirubinemia, normocytic anemia
(d) Tx = high-dose glucocorticoids
50
Mutations in JAK2 cause what?
Polycythemia vera- pancytosis
51
72 yo w/ poorly controlled DM2 presents w/ pyelonephritis due to MDR organism
Which abx?
Amikacin (aminoglycoside) = abx for MDR GNR
52
Name 3 cancers seen in Von-Hippel-Lindau syndrome?
1. Most common lesion = hemangioblastoma = CNS tumors originating from vascular system (endothelial cell origin)
2. pheochromocytoma
3. renal cell carcinoma
53
68 yo M w/ deep aching HA x2 mon
- alk phos 656
- CT: no brain lesions, skull w/ thickened cortices and mixed lytic and osteoblastic lesions
- nuclear bone scan: increased uptake in skull and tibia
(a) Dx
(b) Tx
(a) Paget's disease- requires tx when becomes symptomatic
| (b) Tx = bisphosphonate, optimize vitD and Ca intake
54
Most common form of genetic hypercoagulability?
Factor V Leiden = inheritable hypercoagulable state due to point mutation in coagulation factor V making it resistant to protein C inactivation
Predisposition to thromboses, especially DVT of the lower extremities
55
Define fulminant hepatic failure
Fulminant hepatic failure = hepatic encephalopathy that develops w/in 8 weeks of the onset of acute liver failure
56
Breath sounds and response to percussion seen in consolidation
Consolidation => dullness to percussion (b/c over a solid) and increased breath sounds (bronchial breath sounds which are louder)
57
2 risk factors for NASH
(a) AST: ALT seen in NASH
Obesity and diabetes increase risk of NASH
(a) AST/ALT under 1
58
Screening test for MEN2
MEN2A and MEN2B are due to mutation in RET proto-oncogene => test for it by PCR of peripheral blood for mutation in the RET proto-oncogene
59
Differentiate tx for echinococcosis and entameoba histolytica
Tx for solitary liver mass:
Echinococcosis (hydatid cyst): drain out (clear fluid) and albendazole
```
Entamoeba histolytica (amebiasis): empiric tx w/ metronidazole
-no drianiange
```
60
What is porphyria cutanea tarda?
(a) Most common manifestation
(b) Most common associated d/o
Porphyria cutanea tarda = congenital (autosomal dominant) condition from deficiency in enzyme in the heme synthesis pathway
(b) Painless blisters and increased skin fragility on the dorsal surfaces of the hands
- blisters/onycholisis (separation of nail from nailbed) at sun exposed area
(b) Hep C- can bring out symptoms, big risk factor
61
CML
(a) CBC findings
(b) Tx
CML
(a) CBC shows dramatic leukocytosis (like WBC of 42k) due to the constitutively active tyrosine kinase
(b) First line tx is tyrosine kinase inhibitors (ex: imatinib)
62
Clinical presentation of primary hyperaldo
HTN, metabolic alkalosis, hypokalemia, mild hypernatremia
No peripheral edema due to aldo escape
63
Multiple sclerosis
(a) MRI findings
(b) CSF findings
MS
(a) MRI: hypo/hyperintense lesions on MRI representing plaques of clustered demyleinated axons
(b) CSF shows oligoclonal IgG bands
64
Ventilator settings that determine
(a) pCO2
(b) pO2
(a) pCO2 if mainly affected by RR and tidal volume
| (a) pO2 is determined by FiO2 and PEEP to prevent alveolar collapse
65
Presentation of progressive multifocal leukoencephalopathy
Gradual (week to month) onset of neurologic changes- clumsiness, weakness, visual speech and personality changes
Caused by JC virus- opportunistic infection in HIV/immunocompromised pts
66
Typical location of aspiration pneumonia
Right side (b/c right bronchus is straighter) lower or middle lobe
67
Biopsy findings of UC vs. Crohn's
Both have neutrophilic cryptitis (inflammation of intestinal crypt)
Crohn's- disease transmural throughout entire bowel wall
UC: abnormalities tend to be superficially located at the mucosal surface
68
Age of onset for IBD
Bimodal peak
- most present in 20 or 30s
- second peak around age 60
69
What is small-bowel bacterial overgrowth?
(a) Clinical features
Small-bowel bacterial overgrowth syndrome = overgrowth of the native and non-native SI bacteria that alters the normal flora, causing excessive fermentation, inflammation, or malabsorption
-usually proximal SI bacterial load kept low by gastric acidity and peristalsis
(a) Abd pain, diarrhea, bloating, excessive flatulence, malabsorption
70
45 yo smoker F w/ occasional episodes of nocturnal substernal CP that wakes her up from sleep
EKG reveals transient ST elevations in V4-V6 during pain attack
Dx?
Prinzmetal's agina = variant angina due to coronary vasospasm
-causes ischemia not due to atherosclerosis, so ST seg elevations are transiently elevated, but return to normal when coronary arteries not vasospasming
71
Absence of CD55 and CD59 on flow cytometry
(a) Diagnosis
(b) 2 key clinical features
(a) CD55 and CD59 are RBC surface proteins used to inhibit complement activation- when absent = paroxysmal nocturnal hemoglobinuria
(b) Thromboses (increased risk of DVT etc), and hemolysis (complement destruction of RBC)
72
3 clinical findings of a Right ventricular MI
RV MI is due to occlusion of the proximal RCA-
| Hypotension, JVD, and clear lung fields
hint is JVD w/ clear lung fields, indicating RH dysfunction w/o LF dysfunction
73
Lower GI endoscopy reveals dark brown discoloration of the colon w/ lymph follicles shining through as pale patches
= characteristic finding of Melanosis coli = factitious diarrhea from chronic laxative use
- dark pigment gets deposited in the lamina propria of the large intestines
- get characteristic dark brown discoloration of the colon lining
74
Ddx for large single liver mass in 25 yo Mexican immigrant
Entamoeba histolytica (amebiasis)
Echinococcus (hytadid cysts)
pyogenic Bacterial sabscess
75
Colovesical fistula
(a) 2 causes
(b) Clinical presentation
Colovesical fistula = connection btwn colon and bladder
(a) Diverticulitis (often direct extension of ruptured diverticulum into bladder) and Crohn disease
(b) Air in urine (pneumaturia), stool in urine (fecaluria), recurrent mixed flora UTIs
76
Temporomandibular joint dysfunction- clinical presentation
(a) First line tx option
(b) Common physical exam signs
TMJ dysfunction- often pt's interpret as pain coming from the ear (due to anatomic proximity)
- worsened by chewing (b/c of strain on the TMJ)
- often seen in pts w/ h/o nocturnal teeth grinding
(a) Nighttime bite guard
(b) Clicks or crepitus in TMJ w/ jaw movement (but not always present)
77
Dysparenuria- what is it?
(a) How can it be connected to Sjogren's?
Dysparenuria = painful sexual intercourse
(a) Vaginal dryness
78
Name 3 drugs that can cause idiopathic intracranial hypertension
Growth hormone
Tetracyclines (minocycline, doxycycline)
Excessive vitamin A and its derivatives (ex: isotretinoin for acne)
79
Name the Duke Criteria
Duke criteria for infective endocarditis: either need 2 major, all 5 minor, or 1 major and 3 minor
Major
1. Positive BCx w/ typical organisms
2. Echocardiography evidence
Minor
1. Vascular (splinter hemorrhages, Janyway lesions, Roth spots)
2. Fever
3. BCx growing atypical organism
4. Immunologic (Osler nodes)
5. Presence of risk factors: IVDU, prosthetic heart valve
80
Would the following cause hypo,eu,or hyper-volemic hyponatremia?
(a) SIADH
(b) Cirrhosis
(c) CHF
(d) Primary adrenal insufficiency
(e) Diuretics
(f) Primary polydipsia
(g) Major GI bleed
(a) SIADH = euvolemic
(b) Cirrhosis = hypervolemic
(c) CHF = hypervolemic
(d) Primary adrenal insufficiency = no aldo = hypovolemic
(e) Diuretics = Hypovolemic
(f) Primary polydipsia = euvolemic
(g) Major GI bleed = hypovolemic
81
43 yo F w/ abdominal pain and dark urine
RUQ tenderness w/o guarding or rebound
Hb 8.9, Plt 134k, TBili 6.3, LDH 740, haptoglobin low
-MRI shows hepatic vein thrombosis
Dx?
Paroxysmal noctural hemoglobinuria = acquired deficiency in CD55 and CD59 RBC surface molecules that prevent complement cascade destruction of RBC
=> get hemolysis (dark urine) and increased thromboses
82
Tx for restless leg syndrome
1. iron supplementation if ferritin under 75 (iron deficiency is a cause of secondary RLS)
First line = dopamine agonist (ex: pramipexole)
Second line = Gabapentin (alpha-2 delta calcium channel ligand
83
Why is aspirin often given in addition to high-dose niacin tx
High-dose niacin (tx of lipid abnormalities) frequqnetly produces cutaneous flushing and pruritis due to prostaglandin-induced peripheral vasodilation
-side effect can be reduced by low-dose aspirin
84
What preventative measure should be taken in a pt w/ MEN2A?
Thyroidectomy b/c almost 100% lifetime chance of developing medullary thyroid cancer
85
Which ventilator setting should be the first to get reduced when pt is oxygenating well?
FiO2- want to slowly get the FiO2 below 50-60% to prevent oxygen toxicity to the lungs
-can often start w/ FiO2 of .8 (80%) but then after first ABG if pt is properly oxygenating, want to decrease FiO2 to non-toxic values
86
Cutoff for uremic pericarditis
Typically in pts w/ BUN over 60
| -UP occurs in 6-10% of renal failure pts
87
63 yo F w/ leg swelling especially bothersome in the evening + chronic cough
- JVP 1.5 cm above sternal angle
- b/l scattered wheezes
- 2+ pitting edema in b/l LE w/ dilated and tortuous superficial veins
- small ulcer on left medial ankle
(a) Diagnosis
(b) First line tx
(a) Chronic venous stasis
- All that is edema is not HF!!! Normal JVP (below 3 cm above sternal angle) and no crackles on exam
(b) Tx = frequent leg elevation, exercise, compression stockings
88
Drug of choice for PBC
Ursodeoxycholic acid (UDCA) = hydrophilic bile acid that decreases biliary injury by the more hydrophobc endogenous bile acids
89
Warm or cold agglutinin AIHA:
(a) Viral infections
(b) Mycoplasma pneumonia
(c) CLL
(d) SLE
(e) Amoxicillin
Warm vs. cold agglutinin AIHA
(a) Viral => warm
(b) Mycoplasma and infectious mono => cold
(c) CLL => warm
(d) SLE => warm
(e) Amox/drugs => warm
90
Cause of systolic HTN and wide pulse pressure in thyrotoxicity
Thyrotoxicosis causes positive inotropic and chronotropic effects => increased cardiac output and increased systemic oxygen consumption = increased oxygen demand
HTN due to increased myocardial contractility
91
What is the earliest renal abnormality seen in diabetes?
(a) What is the first renal abnormality that can be quantitated in diabetes?
Glomerular hyperfiltration is the earliest renal abnormality seen in diabetic nephropathy
(a) While thickening of the glomerular basement membrane is the first change that can be quantitated
92
Which lupus drugs require the following types of monitoring:
(a) AUdiometry
(b) Echo
(c) Eye exam
(d) LFTs
(e) PFTs
(f) TSH
Drugs that require monitoring
(a) Audiometry- aminoglycosides (Gentamicin) can cause ototoxicity- but routine following not recommended
(b) Echo- assess cardiotoxicity of RA pts taking TNF inhibitors
(c) Eye exam- retinal toxicity is a rare but real side effect of hydroxychloroquine
(d) LFTs frequently monitored in SLE pts taking MTX
(f) Amiodarone (antiarrhythmic) can cause a bunch of endocrinopathies including hypo-and hyper thyroid
93
70 yo w/ 4-6 mo of almost continuous urinary dribbling
- DM2: diabetic retinopathy, gastric study last month due to early satiety
- 50 pack year smoker
- normal-size prostate
- decreased sensation b/l below the knees
- postvoid residual volume of 550 ml
Dx
Neurogenic bladder dysfunction 2/2 diabetic autonomic neuropathy
- gastroparesis (delayed gastric emptying), retinopathy, peripheral neuropathy: indicating poorly controlled DM
- urinary retention since postvoid residual volume is over 50
Diabetes autonomic neuropathy => decreased ability to sense a full bladder, incomplete emptying
94
SCD pt w/ progressive DOE, fatigue, generalized weakness
Hct 20%
MCV 110
Retic 1.5%
Dx?
Mechanism?
Folate deficiency- common for sickle cell pts to require higher dose of folate b/c of the high turnover of RBCs =>
recommended for SCD pts to get daily folic acid supplementation
Just b/c they're sickle cell doesn't mean anemia is due to splenic sequestration...
Most SCD pts have chronic normocytic anemia w/ appropriate reticulocyte response
95
Which arrhythmia is most specific for digitalis toxicity?
Digitalis = Digoxin- enhances contractility and slows conduction thru the AV node
Causes cardiac toxicity by (1) increasing ectopy and (2) enhancing vagal tone and therefore decreasing conduction thru the AV node
Rare for both ectopy and AV block to occur at the same time, when they do the combo is fairly specific for digitalis toxicity
96
Test to confirm diagnosis of lactose intolerance
Positive hydrogen breath test
-rise in measured breath hydrogen after ingestion of lactose, indicating bacterial carbohydrate metabolism
97
18 yo M w/ 3 days of fatigue and DOE
- s/p URi tx w/ amoxicillin
- splenomegaly, mild scleral icterus
- Hb 7.8, MCV 90, retic 10%
Dx
Warm agglutinin autoimmune hemolytic anemia
-in this case 2/2 abx
Normocytic anemia, splenomegaly, reticulocytosis, jaundice w/ elevated indirect bilirubin (due to hemolysis), increased LDH, decreased haptoglobin
98
What drugs should be stopped prior to cardiac stress testing?
Beta-blockers, CCB, nitrates
Don't need to stop diuretics or statins
99
66 yo F presents w/ increasing productive cough and fever x2 days
- CAP 4 mo ago, sinusitis 2 mo ago
- right-sided CP, point tenderness w/ Xray showing osteolytic lesions w/ fractures at 7th and 8th rib
- bronchial breath sounds in left lower lung field
- Hb 9.4, MCV 88, Plt 235k, WBC 13.5
Dx
Multiple myelomaaaaaaa
CRAB
-bony lytic lesions => bone pain and fractures
Mechanism = impaired effective antibody production => hypogammaglobulinemia => recurrent infection and constitutional symptoms
100
28 yo commercial sex worker presents w/ fever, chills, tenosynovitis, polyarthralgia, and pustular lesions on trunk and extremities
Dx
Disseminated gonorrhea
Triad of tenosynovitis, dermatitis, migratory asymmetric polyarthralgia
101
33 yo F w/ repeat fever, malaise, chills, dry cough x 6 mo
- brreds small Australian parrots as a hobby
- PFTS: reduced lung volumes
Dx
Tx
Hypersensitivity Pneumonitis
Tx = avoid exposure
102
43 yo w/ intermittent upper abdominal pain w/ nausea x6 mo
- worse after meals, improved by leaning forward
- wt loss
- Pack per day and EtOH daily
Dx
(a) Diagnostic test
Chronic Pancreatitis; chronic epigastric pain w/ intermittent pain free intervals
-malabsorption => wt loss
(a) Presence of pancreatic calcifications on CT scan or plain film
Risk factors = smoking and EtOH
-pain improved by sitting up or leaning forward
103
What does FeNA tell you about AKI?
Helps distinguish pre-renal from renal
FeNa under 1% = pre-renal: kidneys holding on to as much as possible
FeNa over 2% = intra-renal
104
68 yo M w/ myasthenia gravis has progressive weakness and inability to cough out sputum
-89% on 4L O2, inability to cough out sputum
(a) Dx
(b) Tx
(a) Myasthenic crisis- infection or surgery, pregnancy or childbirth, certain meds (aminoglycosides like azithromycin)
(b) Intubation and therapeutic plasma exchange or IVIG + corticosteroids
- typically hold pyridostigmine temporarily to reduce excess airway secretions
105
Tx option for pt w/ DVT who have contraindications to anticoagulation
IVC filters- placed via transvenous approach and inhibit progression of LE clots thru the IV toward the lungs => prevent PE in pts w/ DVT
106
Tx for Prinzmetal's angina
Prinzmetal's = variant angina = coronary vasospasm causing temporary ST elevations
Tx = CCB or nitrates
107
35 yo M in MVA: doesn't follow commands and makes inappropriate sounds
CT: punctuate hemorrhages w/ blurring of gray-white matter interface
Dx
Diffuse axonal injury: most significant cause of morbidity in pts w/ TBI
- frequently due to traumatic deceleration
- results in vegetative state
108
Most common source of acute PE
Proximal deep veins (iliac, femoral, and popliteal) are the source for over 90% of acute PE's
-large caliber and proximity to the lung
While calf vein clots are much less common in acute PE
109
Test to diagnose pheochromocytoma
Dx pheochromocytoma by 24hr urine for metapnephrines and free catecholamines or plasma free metanephrines
Metanephrine = metabolite of epinephrine
Recall: pheochromocytoma = adrenal medulla tumor secreting catecholamines
110
55 yo F presents w/ thrombosis of r. popliteal vein, placed on oral warfarin and subQ enoxaparin
-returns one week later w/ plts 70k (down from 210k) and INR up 1.7 (from 0.9)
Dx?
(a) Next step?
Type 2 heparin-induced thrombocytopenia = unexplained thrombocytopenia (decrease of plts by over 50%) a few days after starting heparin (regular or LMWH)
-immune mediated process causing simultaneous thrombocytopenia and arterial and/or venous thrombosis
(a) Next step- monitor closely for arterial and venous clots
111
Amikacin indications
(a) Side effect
Amikacin = aminoglycoside for multi-drug resistant GN bacteria: pseudomonas, acintobacter, enterobacter
(a) acute renal failure
112
29 yo F w/ N/V, abdominal pain, hypotension
- hyperpigmentation
- hyperkalemia, hyponatremia
- eosinophilia
Primary adrenal insufficiency- most commonly autoimmune
On labs will see low cortisol despite stress (hypotension)
113
What is pheochromocytoma?
Neuroendocrine tumor of the medulla of the adrenal glands => secreting tons of catecholamines (mostly NE, a bit of Epi)
114
What is presbyopia?
(a) Mechanism
(b) Peak age
(c) Tx
Presbyopia = age-related disease in lens elasticity causing difficulty w/ near vision
(a) Mechanism = loss of elasticity in the lens prohibits proper lens accommodation
(b) Onset in 40s w/ symptoms peaking in 60s
(c) Reading glasses!
115
MEN2A vs. MEN2B
MEN2A: almost all have MTC (medullary thyroid cancer)
- parathryroid tumor => hyperparathryoidism
- pheochromocytoma (neuroendcrine tumor of adrenal medulla secreting NE)
MEN2B: also MTC and pheochromocytoma
3rd is other
-mucosal and intestinal neuromas
-marfanoid habitus
116
Wells criteria
- 2 major
- 3 minor
- 2 minor minor
Modified Well's criteria for probability of PE:
If >4 pts- PE is likely
3 points each for:
- clinical signs of DVT
- alternate diagnosis less likely than PE
1. 5 points for
- previous PE or DVT
- HR over 100
- recent surgery or immobilization
1 pt for
- hemoptysis
- cancer
117
45 yo M w/ wasting of extremity muscles
+fasciculations and hyperreflexia
difficulty swallowing, chewing, and speaking
(a) Dx?
(b) Mechanism of disease
(a) ALS = amyotrophic lateral sclerosis
(b) Neurodegenerative d/o of both UMN and LMN signs
UMN signs: spasticity, bulbar symptoms, hyperreflexia
LMN sign = fasciculations
118
Sigmoidoscopy or colonoscopy findings of IBD
Erythematous mucosa w/ possible ulcers
ex: erythematous friable mucosa extending from rectum to sigmoid colon (large span)
119
Hydroxychloroquine- what is it?
(a) Name 2 indications
Hydroxychloroquine = immunosuppressant and anti-malarial
(a) Malaria and SLE
120
Adenosine vs. amiodarone
Both are antiarrhythmics
Adenosine = transiently blocks impulse conduction thru AV node, useful for supraventricular tachycardia
Amiodarone = slows impulse generation and/or conduction in SA and AV node
-used for SVT and VTs
121
46 yo obese M w/ RUQ fullness
-DM2 and HTN, acanthosis nigricans
LFTs: 122/131, 100, 1.0/0.8
(a) Mechanism for increased liver enzymes
(b) Dx
(a) Insulin resistance
(b) Dx = NAFLD- typically middle-aged, obese, features of metabolic syndrome (DM, HTN)
- Mechanism: peripheral insulin resistance => increased peripheral lipolysis, TG synthesis, and hepatic FA uptake
Hepatic FFA increases oxidative stress and production of pro-inflammatory cytokines
122
Pt w/ alcoholic hepatitis: explain GGT and ferritin levels
Alcoholic hepatitis: >2:1 AST:ALT and
- elevated GGT: makrer of liver pathology (not just gallbladder)
- elevated ferritin b/c it's an acute phase reactant
123
Measurement of normal JVP
Under 3 cm above the sternal angle
124
Intestinal biopsy findings in C. Dif
Fibrinous pseudomembranes
-pancolitis on colonoscopy
125
Clinical findings of cardiac tamponade
Triad: hypotension, elevated JVP, muffled heart sounds
| -nonpalpable PMI
126
WPW-syndrome pt presents in AFib w/ RVR
WPW: recall presence of accessory pathway conducting depolarization directly from atria to ventricles w/o going thru AV node
=> DON'T want to use amiodarone or beta-blockers which work at the AV node- this may promote conduction thru accessory pathway and convert AF into VF :-(
Tx = procainamide or cardioversion (if HD unstable)
127
Diffuse axonal injury
(a) CT findings
(b) Clinical findings
Diffuse axonal injury
(a) numerous tiny punctuate hemorrhages w/ blurring of grey-white interface
(b) Clinically => vegetative state
128
32 yo F w/
- vision loss in right eye 4 mo ago that resolved over several weeks
- intermittent numbness in right arm
- intermittent urinary incontinence
- chronic lower back pain
- 5/5 muscle strength and 2+ DTRs throughout
Dx?
Relapsing-remitting neurologic deficits, disseminated in space and time, suggest multiple sclerosis
MS = autoimmune inflammatory demyelinating disease of the CNS
129
35 yo F w/ 3 days of fever and malaise after returning from vacation in Caribeean islands
- pain and swelling of b/l hand, wrist
- macular skin rash on body
- mild cervical lymphadenopathy
Dx
Chikungunya fever: mosquito-borne illness w/ flulike symptoms and symmetric polyarthritis, rash, cervical lymphadenopathy
130
75 yo M w/ DM2 presents w/ weakness and blurred vision
-serum glucose = 1070
(a) Diagnosis
(b) Which electrolyte abnormality will also be present
(a) Hyperosmolar hyperglycemic nonketotic syndrome
(b) Total body K+ depletion (despite normal serum levels) due to excessive urinary loss due to osmotic diuresis by the hyperglycemia
131
Tx of PE in pt w/ GFR under 20
Can't use enoxaparin (LMWH, lovenox) or any of the factor Xa inhibitors (ex: rivaroxaban)
Only anticoags you can use w/ poor kidney fxn (GFR under 30) is unfractionated heparin and warfarin (takes 5-7 days to reach therapeutic levels)
=> Heparin to acutely treat PE in pt w/ CKD
132
Describe the 2 features of digitalis cardiac toxicity
1. increased ectopy
2. increased vagal tone and decreased conduction thru AV node => AV block
=> typically see ectopic beats (Atrial tachy or VT) or some kind of heart block at the AV node (first degree)
-wouldn't see Mobitz type II b/c focus is below the AV Node
133
Best test for suspected stroke
Non-contrast head CT- very fast and sensitive for hemorrhagic strokes
MRI is more sensitive for ischemic strokes, but less sensitive for acute hemorrhages
134
Fundoscope exam of diabetic retinopathy
Microaneurysms, hemorrhages, exudates, and retinal edema
| -can have cotton wool spots or newly formed vessels
135
Toxicities: how to differentiate
(a) isopropyl alchohol ingestion
(b) Ethylene glycol
(c) Methanol ingestion
Toxicities
(a) Isopropyl alcohol => high osmolar gap but no anion gap and no metabolic acidosis
(b) Ethylene glycol ingestion => high osmolar gap and anion gap met acidosis
- characteristic calcium oxalate crystals in urine
(c) Methanol: high osmolar gap w/ high anion gap met acidosis: APD, central scotomata (vision loss)
136
Clinical feature of serum glucose > 1000
(a) Diagnosis
(a) >600 = hyperosmolar hyperglycemic nonketotic coma/syndrome
Neurological symptoms: focal neurologic findings- focal sensory or motor impairment
137
33 yo F w/ recurrent episodes of dizziness x6 mo that last 1-2 hrs
- severe spinning, nausea, unsteadiness
- no precipitating factor
- fullness in right ear, no ear pain or discharge
(a) Dx
(b) Mechanism of condition
(a) Meniere's disease- ear fullness and short duration of episodes suggests peripheral cause
- often dizzines, hearing loss, tinnitus
- can also present w/ ear fullness
(b) Accumulation of endolymph in the INNER ear
138
Name a way of using labs to track the severity of heart failure
Hyponatremia in CHF parallels the severity of HF and is an independent predictor of adverse clinical outcomes
139
Which of the two main types of skin cancer have a higher malignant potential?
Squamous cell carcinoma (from sun exposure, develop from actinic keratoses) have a much higher malignant potential than basal cell carcinoma (white pearly telangiectasias)
140
CHF: transudative or exudative pleural effusion?
Transudative- due to increased hydrostatic and decreased colloid pressure (not due to inflammation causing increased capillary permeability)
