UWorld 7 Flashcards
1
Q
What is Pellagra?
3 D’s
A
Pellagra = due to niacin deficiency
3 D’s = dermatitis, dirarrhea, dementia
Dermatitis in sun exposed areas- rough, hyperpigmented scaly skin
Diarrhea
Dementia
2
Q
What lab markers should be monitored in pts taking amiodarone
A
Amiodarine (dirty antiarrhythmic) is associated w/ hypo/hyper-thyroid and hepatotoxicity
=> Periodically monitor thyroid and hepatic function markers
3
Q
68 yo M w/ LLE pain: cold and pale below the knee
PMH: HTN, DM2, Afib, MDD
-Not palpable posterior tibial or dorsalis pedal pulses
Dx?
(a) What could have prevented this acute problem?
A
Arterial emboli causing acute limb ischemia
(a) Warfarin (or RIvaroxaban)- most effective (better than ASA+Plavix) to reduce risk of systemic embolization in pts w/ AFib
4
Q
IBS
(a) Subtypes
(b) Colonoscopy findings
A
IBS
(a) diarrhea or constipation predominant, or mixed
(b) Normal colonic mucosa on colonoscopy
5
Q
Surveillance screening for pts w/ cirrhosis
A
Surveillance for HCC w/ ultrasound every 6 mo
-regardless of the etiology of cirrhosis
6
Q
65 yo F presents w/ HF exacerbation, started on IV furosemide
- already on aspirin, digoxin, furosemide…
- day 3: tele reveals 6 beats of wide complex ventricular tachycardia
Next step in management?
A
Measure serum electrolytes- VT most likely from electrolyte imbalance (hypokalemia, hypomagnesemia) due to diuretics
Also check Dig levels- VT can be from dig toxicity
7
Q
Most common valve involved in IE in an IVDU
(a) What murmur does this cause?
A
Tricuspid valve involvement (right-sided) more common than aortic
(a) Systolic murmur that increases w/ inspiration
8
Q
Clinical features of hypocalcemia
A
Muscle cramps
Chvostek sign- facial twitch when tap on facial nerve
Trousseau sign- carpopedal spasm when inflate BP cuff for 3+ seconds
Paresthesias
Hyperreflexia/tetany
Seizures
9
Q
Mechanism of low Hb in beta-thalassemia major
(a) Tx
A
Normal adult Hb has 2 alpha and 2 beta chains (a2b2) w/ a heme.
Beta-thal major = impaired production of beta-globin chain => excess of alpha-globin chains which are unstable and cause chronic hemolysis
(a) Transfusion
- beta-thal major (not minor) is transfusion dependent anemia
10
Q
68 yo M p/w exertional fatigue
- mild mucosal pallor, no lymphadenopathy
- Hb: 9.4 (MCV 92)
- Na 136, K 4.4, Ca 10.7
- Tprot 9, Alb 3.7, Tbili .9, alk phos 100
Dx
A
Constitutional symptoms orbone pain + anemia + hypercalcemia + protein gap (total - albumin > 4) = multiple myeloma
Cloncal plasma cell proliferation
11
Q
Central retinal vein occlusion
(a) Clinical presentation
(b) Opthalmoscope findings
A
Central retinal vein occlusion
(a) Sudden, painless, unialteral loss of vision
(b) disk swelling, retinal hemorrhages, cotton wool spots, venous dilationa nd tortuosity
12
Q
Tx for acute MS exacerbation
A
First line = high dose IV glucocorticoids (methylprednisone)
Plasma exchange for pts who don’t respond to high-dose glucocorticoids
13
Q
65 yo M w/ sudden vision loss in left eye that resolved after 5 minutes
- similar episode 3 mo ago that lasted a few seconds
- no flashes or floaters
- funduscopy: whitened, edematous retina following destribution of retinal arterioles in the left eye
Dx and mechanism
A
Amaurosis fugax: hypertensive pt w/ temporarly vision loss
Mechanism: retinal emboli from the ipsilateral carotid artery, often due to atherosclerosis
-once the clot breaks up blood flow is restored and vision returns
14
Q
Name 2 ototoxic drugs
A
Aminoglycosides
Loop diuretics
15
Q
Most common vaccine-preventable disease among travelers
A
Hep A
-consider hepA vaccine for all ppl traveling to developing countries
16
Q
When do prolactinomas require tx?
(a) Surgery vs. meds
A
If asymptomatic- can do no tx
If symptomatic or huge (> 10 mm): start w/ dopamine agonists (cabergoline, bromocriptine)
If very large (over 3 cm) or if increases in size while on tx => resection (transsphenoidal surgery)
17
Q
34 yo Brazillian male w/ h/o megacolon 2 yrs ago presents w/ new onset HF
A
Chagas disease = chronic disease from protozoa trypanosoma cruzi (endemic to Latin America) that can cause megaesophagus, megacolon, and/or cardiac dysfunction
18
Q
Lab value to differentiate beta-thalassemia from iron deficiency anemia
A
Both are microcytic anemias, but beta-thalassemia you have a disproportionately high RBC count
Iron deficiency anemia has low RBC count
19
Q
Major cause of mortality in TCA overdose
A
Hypotension
=> after ABCs administer sodium bicarb to help improve BP
20
Q
Malignant otitis externa
(a) Most common causative organism
(b) Tx
A
Malignant otitis externa = severe infection typically seen in elderly diabetic pts
(a) Pseudomonas
(b) Systemic (not topical) abx: ciprofloxacin
21
Q
What is the most common benign primary cardiac tumor?
(a) Most common location
(b) Clinical presentation
A
Cardiac myxoma
(a) 80% in the left atrium
(b) Constitutional (fever, wt loss), CV complications (mitral disease, arrhythmias), embolization
22
Q
Mechanism of osteomyelitis adjacent to a foot ucler
A
Contiguous spread of infection = along tissue planes
23
Q
Bronchoscopy sample culture: branching, filmentous bacteria that is partially acid fast
A
Nocardia
24
Q
68 yo F w/ recent right-sided facial droop.
What could help localize facial nerve palsy to lesion above or below the pons?
A
Bell’s palsy = rapid onset of unilateral upper and lower facial weakness = acute peripheral neuropathy of CN VII (lesion below the pons)
Peripheral vs. central facial palsy
Peripheral = Bell’s palsy = loss of forehead and brow movement, inability to close eyes and eyelid dropping
vs. central: preservation of forehead and brow movements
- contralateral lower facial weakness that spares the forehead
25
Syphilis tx in ppl w/ penicillin allergy
(a) Primary
(b) Secondary
(c) Tertiary
(d) During pregnancy
Treating syphilis in ppl w/ penicillin allergy
(a) Primary- doxy x14 days
(b) Secondary- doxy x14 days
(c) Tertiary- ceftriaxone x14 days
(d) Pregnancy- desensitize and administer penicilin
26
Name some causes of acute hypocalcemia
- neck surgery (parathyroidectomy)
- pancreatitis
- sepsis
- tumor lysis syndrome
- acute alkalosis
- chelation
27
How long after an MI would you expect the following complications
(a) papillary muscle rupture
(b) free wall rupture
(c) pericarditis
(d) left ventricular aneurysm
MI complications
(a) Papillary muscle rupture: 2-7 days after MI
(b) free wall rupture: hour to 2 weeks after MI
(c) pericarditis: 1 day to 3 mo after
(d) left ventricular aneurysm: 5 days to 3 mo after
28
24 yo F w/ daily crampy abdominal pain x2 years
- not always preceded by eating
- often accompanied by passage of small loose stools and mucus, which relieves the pain
- mother died of colon cancer at age 65
Dx
IBS = Irritable bowel syndrome
| -diagnose using Rome III criteria
29
When would you transfuse in a pt w Hb above 7?
Treshold of Hb under 9 is considered for unstable pts w/ ACS or active bleeding and hypovolemia
30
Mechanism of heparin
Activates antithrombin III that inactivates thrombin, factor IXa (intrinsic pathway) and Xa (common pathway)
31
Esophageal cancer associated with
(a) Heavy EtOH consumption
(b) smoking
(c) Barrets
Esophageal cancers
Adenocarcinoma from Barrett's/GERD
Squamous cell from heavy EtOH or smoking
32
Diagnostic test for acute onset of acute pancreatitis
Amylase/lipase- don't need imaging to confirm diagnosis
CT used if diagnosis is unclear or pts don't improve w/ conservative management
33
UA sediment findings indicative of ATN vs. AIN
Acute tubulonephritis = muddy brown granular casts
Acute interstitial nephritis = WBC casts
34
Organism that causes bacillary angiomatosis in immunocompromised pt
Bartonella
35
Hairy cell leukemia
(a) Type of cancer
(b) Clinical presentation
(c) Peripheral smear
(d) Bone marrow aspirate
Hairy cell leukemia
(a) B-lymphocyte derivative of chronic leukemia (CLL subtype)
(b) Pancytopenia (10% w/ leukocytosis tho) and splenomegaly
(c) Peripheral smear: lymphocytes have fine hair-like irregular projections
(b) Often a 'dry tap'- unsuccessful BM biopsy b/c BM is fibrotic
36
59 yo w/ h/o COPD presents w/ severe dyspnea and left-sided chest discomfort
- trace ankle edema, markedly decreased breath sounds over left chest
- EKG: snus tach
- PaO2 59 mmHg
Dx and mechanism
Spontaneous pneumothorax- suspect it in pts w/ COPD w/ catastrophic worsening of respiratory symptoms
Chronic destruction of alveolar sacs in COPD cause formation of large alveolar blebs (dilated apical alveoli) in the upper lobes. these blebs can then rupture and leak air in to the pleural space => spontaneous pneumothorax
37
50 yo F wandering the streets w/ abnormal gait BIB police
- incoherent mumbling, not oriented to time or place
- T 97.3, BP 160/100, HR 100, RR 18, BMI 17
- pupils 3mm b/l, react slowly to light
- symmetrical DTRs
Best initial tx
Thiamine (B1) then give glucose
Chronic malnutrition => Wernicke's encephlopathy: classic triad of encephalopathy, ocular dysfunction, and gait ataxia
When don't know the cause of AMS, often start empiric tx w/ thiamine
38
ROME III criteria
Diagnostic criteria for IBS
Recurrent abdominal pain/discomfort for 3+days/mo for the past 3 mo + 2:
- symptom improvement w/ BM
- change in frequency of stool
- change in form of stool
39
Associated BMP lab finding of upper GI bleed
Elevated BUN/creatinine ratio
Possibly due to increased urea production (from intestinal breakdown of Hb) and increased urea reabsorption (due to hypovolemia)
40
Which type of anemia can prednisone be effective in treating?
Prednisone = tx of choice for autoimmune hemolytic anemia
41
Tx of TCA overdose
1st- ABCs (duh always)
| Then sodium bicarb to improve BP, shorten QRS interval, and prevent arrhythmia
42
What drug should be avoided in acute glaucoma?
Atropine (muscarinic antagonist) = mydriatic agent (dilates the pupil) and worsen glaucoma
43
28 yo F in MVA
-liver laceration and extensive hemoperitoneum, fluid resuscitaiton abd blood transufion
post-op numbness, forceful flexion of wrist while measuring BP, diffusely hyperactive reflexes
Dx
Hypocalcemia
Due to citrate in transfused blood that binds to ionized (active) calcium
Positive Trousseau's sign: carpopedal spasm when BP cuff inflated for 3+ seconds
High risk when liver is injured (liver laceration) b/c citrate is rapidly metabolized by the liver
44
66 yo M w/ right elbow pain, back pain, headaches
- Xray of right arm exhibits a radiolucent lesion
- Labs: Normocytic Anemia
Next best step
Serum protein electrophoresis- looking for M-spike (monoclonal protein) of multiple myeloma
45
75 AA M w/ diabetes and HTN presents for annual physical
- fundus: cupping of the optic disk
- constricted peripheral vision
Dx
Primary open angle glaucoma- often asymptomatic early on
| gradual loss of peripheral vision (vs. macular degeneration which is loss of central vision)
46
Ddx for Restrictive lung disease- differentiate by DLCO
Restrictive lung disease:
Normal DLCO = chest wall weakness
Reduced DLCO = interstitial lung disease
47
Vitreous hemorrhage
(a) Clinical presentation
(b) Risk factor
(c) Diagnostic clue on opthalmoscopy
Vitreous hemorrhage
(a) sudden loss of vision and onset of floaters
(b) Most commonly caused by diabetic retinopathy
(c) Loss of fundus details (fundus hard to visualize), floating debris
48
Most common causative organism of infective endocarditis
Staph aureus
49
When oseltamivir is indicated
To tx confirmed or suspected influenza within 48 hrs of symptom onset
-can decrease illness severity and duration by 2-3 days
Key is w/in 48 hrs of symptom onset (or later if pt is at high risk for complications), just get symptomatic treatment
50
Ludwig angina- what is it?
(a) Typical organisms
(b) Symptoms
Ludwig angina = cellulitis of the floor of the mouth (submandibular and subligual spaces b/l) from an infected tooth
(a) Strep species and anaerobes
(b) odynophagia, dysphagia, fever, difficulty breathing, pain, erythema
51
Clinical sign that can distinguish gastric vs. duodenal ulcer
Gastric ulcers often feel worse after eating due to increased acid secretion
Duodenal ulcers worse on an empty stomach and improves w/ food due to alkaline secretion into the duodenum
52
Workup for amaurosis fugax
Amaurosis fugax = transient monocular vision loss due to retinal emboli, most commonly from the ipsilateral carotid artery due to atherosclerosis
=> workup includes noninvasive evaluation of the carotids
53
Ddx for hypokalemia, metabolic alkalosis in a normotensive pt
- Bulimia
- Gitelmann's syndrome (thiazide-sensitive NCC loss of fxn mutation)
- Diabetic abuse
54
54 yo alcoholic M presents w/ dysphagia, drooling, and fever
- unable to eat, mouth is swollen and hot
- redness extending into floor of the mouth
- palpable crepitus of the mandibular area
- leukocytosis
(a) Dx?
(b) Source of infection
(a) Ludwig angina = rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces
(b) From infected 2nd or 3rd mandibular molar (from teeth!!)
55
Mechanism of MTX
(a) Causes what kind of anemia? How to avoid this
MTX = DMARD by inhibiting folate metabolism (needed for cell replication)
(a) Macrocytic anemia
=> often give w/ supplemental folic acid which doesn't decrease the efficacy of MTX
56
Describe how laryngeal edema would alter one's pulmonary flow-volume loop
Flatten both the top and bottom due to fixed upper airway obstruction: flattened b/c the obstruction limits airflow during inspiration and expiration
57
Describe how nephrotic syndrome increases risk for
(a) atherosclerotic disease
(b) renal venous thrombosis
Nephrotic syndrome (proteinuria, hypoalbuminemia, peripheral edema)
(a) low plasma oncotic pressure (due to hypoalbuminemia) causes increase of liver protein and lipid synthesis => increase in cholesterol and TG synthesis => increased atherosclerotic risk
(b) Loss of antithrombin II in urine => hypercoagulable which tends to affect venous system, particularly the renal veins
58
2 mo post MI- pt complains of CP
-EKG showing persistent ST seg elevation w/ deep Q waves in the same lead
Dx?
Ventricular aneurysm = late complication of MI
59
When to give fluids to prevent contrast-induced AKI
Start giving IV fluids before the procedure and continue a few hours after
60
Red urine is a side effect of which drug
Rifampin (Tb drug) causes red to orange discoloration of body fluids
61
Pt on chronic prednisone decides to abruptly stop: explain what happens and why
Chronic glucocorticoid therapy (only seen really w/ steroids for >3 weeks) suppresses the HPA axis => decreased CRH release from hypothalamus and therefore decreased ACTH from the pituitary => low cortisol levels
Adrenal insufficiency => nausea, weakness, fatigue
62
38 yo w/ 6 weeks of progressive r. hip pain
- present at rest, worse w/ weight bearing
- h/o sarcoidosis tx w/ extended courses of oral glucocorticoids
- forced abduction and internal rotation of the femur aggravates the pain
- normal reflexes and sensation
- Plain film of hip wnl
Dx?
Avascular necrosis 2/2 steroid use
Typical to see groin pain on weight bearing
- pain on hip abduction and internal rotation
- no erythema, swelling, or point tenderness
Normal WBC count, ESR, and CR
63
Knee joint aspiration:
calcium pyrophosphate dihydrate deposition vs. monosodium urate crystal deposition
Pseudogout (calcium pyrophosphate) vs. actual gout (monosodium urate crystals)
64
Most common secondary cause of hypertension
(a) Physical exam finding
Renovascular HTN is the most common and correctable cause of secondary HTN
ex: renal artery stenosis
(a) Abdominal bruit
65
43 yo M w/ periodic involuntary head turning and head fixation to the r. side
-hypertrophied left SCM
(a) Dx?
(b) Common etiology
(a) Dystonia, specifically torticollis = focal dystonia of the SCM
Dystonia = sustained muscle contraction resulting in twisting, repetitive mov'ts, or abnormal postures
(b) Drug induced by antipsychotics
66
Name the triad for nephrotic syndrome
1. proteinuria (technically more than 3.5 g/day in the urine)
2. hypoalbuminemia (under 4 g)
3. peripheral edema
67
Which anticoagulant is most likely to decreaselevels of protein S
Warfarin- inhibits vitamin-K dependent clotting factors and anticoagulating proteins (C and S)
68
Lab value to differentiate autoimmune adrenal insufficiency vs. secondary adrenal insufficiency 2/2 chronic glucocorticoid therapy
Difference is mineralocorticoid and ACTH
Both have low cortisol
Autoimmune (primary): ACTH is elevated and aldo is low
Secondary (2/2 chronic steroid use): ACTH is low and aldo is normal
69
Tx for normal pressure hydrocephalus
Tx w/ large volume LPs, and if successful- VP (ventriculoperitoneal) shunt
70
How to diagnose cancer in the head vs. tail of the pancreas
Cancers in the head of the pancreas (more common) will likely cause jaundice => if suspecting pancreatic adenocarcinoma in a pt w/ jaundice do abdominal ultrasound
Cancers in the tail of the pancreas: dx w/ CT w/ contrast
Wouldn't diagnose wither w/ ERCP- more invasive and more to clean out obstructed bile duct
71
Sensorineural or conductive hearing loss?
(a) Presbycusis
(b) Acoustic neuroma
(c) Colesteatoma
(d) Menieres disease
(e) Otitis media
Sensorineural hearing loss = disorder of the inner ear, cochlea, or auditory nerve
- presbycusis
- Menieres
- acoutsic neuroma
Conductive = something that limits sound from getting to the inner ear
- otitis media or externa
- cholestatoma (keratinizing expansion of middle ear)
- trauma
- cerumen impaction
- TM perforaction
72
Differentiate imaging findings of aspergillosis and histoplasmosis
Histo: calcified nodes, calcification of CXR or solitary nodule
Aspergilloma = cavitary lesions
73
P-ANCA (+) associations
Vasculitis, but p-ANCA can also be positive in IBD and ankylosing spondylitis (both of which are associated w/ HLA-B27) w/o vasculitis
74
Which Graves' tx is most likely to worsen eye disease initially?
Radioiodine ablation can cause worsening of opthlamopathy
75
Give example of when you don't need permission from pt's next of kin to remove pt from a vent
Brain death
Brain death is a legally acceptable definition of death
76
Myelofibrotic disorders findings on bone marrow biopsy
Myelofibrotic disorders = proliferation of abnormal hematopoeitic cells
BM biopsy hypocellular, fibrotic bone marrow => fatigue, anemia
77
Describe clinical presentation of presbycusis
Progressive b/l symmetric sensorineural hearing loss w/ subjective tinnitus (ringing in the ears), advanced age, and absence of other neurologic signs
ex: 75 yo M w/ prgoressive hearing loss and ringing in the ears, subjective continuous high-pitched ringing in both ears
78
Most common form of drug-induced chronic renal failure
Analgesic nephropathy
-causes a tubulointerstitial nephritis
79
Risk of Graves' treatments
(a) Methimazole
(b) Propylthiouracil
(c) Radioiodine ablation
(d) Surgery
Adverse effects of Graves' disease treatments
(a) Methimazole => agranulocytosis, cholestasis
(b) Propylthiouracil => hepatic failure, ANCA-associated vasculities
(c) Radioiodine ablation => permanent hypothyroidism, worsening of opthalmopathy
(d) Surgery => permanent hypothyroidism, recurrent laryngeal nerve damage
80
Clinical presentation of TCA overdose
TCA overdose => CNS depression, hypotension (major cause of mortality)
-anticholinergic effects => dilated pupils, hyperthermia, intestinal ileus, QRS prolongation
81
Differentiate epidemiology: alpha vs. beta thalassemia
Alpha- more common in pts from SE descent
Beta- Mediterranean descent
82
Gold standard diagnostic test for malaria
Blood smear
| showing Plasmodium falciparum parasites infecting RBCs
83
FIrst line tx for central diabetes insipidus
Intranasal desmopressin (basically synthetic ADH)
84
Central features of Cushing syndrome
Cushing syndrome = cortisol excess
Progressive central obesity, skin atrophy and wide purplish striae, proximal muscle weakness**, HTN, glucose intolerance, skin hyperpigmentation
85
Mechanism of warfarin
Inhibiting synthesis of vitamin-K dependent clotting factors (IX, X, VII, and II) AND vitamin-K dependent anticoagulant protein C and S
86
How to distinguish bulimia from Gitelmann's syndrome
Both present w/ hypokalemia metabolic alkalosis
Recall: Gitelmann's = autosomal recessive mutation in thiazide-sensitive NCC symporter
Differentiate by the urine chloride concentration
- high urine chloride in Gitelmann's
- low urine Cl in bulimia (b/c losing Cl- by voming up gastric juices)
87
34 yo M presents w/ difficulty walking x3 days
- lower back pain last week while lifting
- URI 1 mo ago in Connecticut
- smoker, normotensive
- LE sensation decreased
- mild hyperreflexia, +Babinski
(a) Dx
(b) Diagnostic test
(a) Spinal cord compression (possibly from disk herniation)
- UMN signs (hyperreflexia, Babinski) indicates CNS involvement
- LE and b/l => localizes to the spinal cord
(b) Diagnose w/ spinal MRI
88
Tx for
(a) Hairy cell leukemia
(b) non-Hodgkin's lymphoma
(c) CLL
Tx
(a) Hairy cell = cladribine (purine analog)
(b) NHL = CHOP regimen
(c) CLL = chlorambucil, rituximab etc (basically chemotherapy) and prednisone
89
Differentiate leukmoid reaction from CML
Both present w/ neutrophilia and dramatic leukocytosis
Leukmoid rxn: rxn to severe infection- Leukocyte count 50-100k
- high leukocyte alkaline phos
- more mature neutrophil precusors (more metamyelocytes aka bands than myelocytes)
AML: caused by BCR-ABL fushion gene, Leukocyte over 100k
- low leukocyte alk phos
- more immature neutrophil precursors (more myelocytes than bands)
90
Ppd induration cuttoff points for treatment
Ppd over 5 mm- treat in HIV positive or otherwise immunosuppressed (organ transplant)
Ppd over 10mm: recent immigrants from Tb-endemic areas, IVDU, children under 4
Ppd over 15mm: treat healthy individuals
So in an otherwise completely healthy pt- would need induration over 15 mm to indicate tx
91
2 indications for placing a chest tube to drain a parapneumonic effusion
1. pleural fluid pH under 7.2 (low pH indicates empyema)
* *important one
2. Glucose less than 60
92
Differentiate NPH and Alzheimer's
NPH- gait is predominant and early finding
Alzheimer's- gait disturbance is a late finding, starts w/ memory loss
93
Syphilis tx
(a) primary syphilis
(b) tertiary syphilis
(c) During pregnancy
Syphilis tx
(a) Primary and secondary- 1 dose PenG IM
(b) Tertiary- 14 days of PenG IV
(c) Pregnancy- the same depending on stage
94
Aplastic anemia
(a) Bone marrow biopsy findings
(b) CBC findings
Aplastic anemia = damaged BM and habitating hematopoetic cells causing decrease in all 3 cell lines
(a) Hypoplastic fat-filled marrow
(b) Pancytopenia (not just anemia)
95
32 yo Italian-American M presents for routine checkup
- Found to have Hb 10.8, high RBC count, MCV 61, normal leukocytes and platetes
- peripheral smear shows target cells
(a) Dx
(b) Tx
(a) beta-thalassemia minor (trait)
- one normal and one abnormal beta-globin gene
- beta most common in Mediterranean, alpha more common in SE asian descent
(b) Tx = no specific tx needed for beta-thalassemia minor (pts are asymptomatic and Hb is above 10)
96
Presbycusis vs. otosclerosis
Presbycusis = sensorineural hearing loss of aging, 60s yoa
-high frequency sound loss
Otosclerosis = chronic conductive hearing loss due to bony overgrowth of the stapes
- middle-aged individuals
- starts w/ low frequency hearing loss
97
Contrast induced AKI
(a) Time line- how long after contrast?
(b) Duration
(a) Spike in creatinine w/in 24 hrs of contrast administration
(b) Return to normal renal fxn w/in 5 days
98
Hairy cell leukemia
(a) Cytochemical feature
(b) Drug of choice
Hairy cell leukemia = B-lymphocyte derived chronic leukemia
(a) TRAP: tartrate-resistant acid phosphatase stain
(b) Drug of choice = Cladribine = purine analog
- but very indolent course, don't always need to treat
99
When to add corticosteroids to PCP tx?
Tx w/ bactrim + steroids if PaO2 is under 70 mmHg (on ABG)
If PaO2 over 70- can treat w/ just bactrim
100
63 yo F w/ recent onset left-sided weakness
- fatigue, low fever, occasional palpitations over last 3 mo
- mid-diastolic rumble at the apex
- TTE shows mass in the LA
Dx
Intracardiac tumor = cardiac myxoma = most common benign primary cardiac tumor
-over 80% are in the left atrium
Often presents w/ chronic systemic symptoms and embolic phenomenon (left sided weakness)
Mass = not a vegetation! aka not infective endocarditis
101
1 day after being treated for a severe acute-asthma attak w/ albuterol nebs and IV methylprednisone- 25 yo F compalins of muscle weakness: difficulty lifting arms and mild hand tremors
Next step
Check serum electrolyte panel: beta-2 agonists (albuterol) pushes K+ into cells (hence why albuterol can sometimes be used during hyperkalemia)
Resulting hypokalemia => muscle weakness, EKG changes, tremor, HA
102
Mechanism by which splenectomized pts are at increased risk of encapsulated organisms
Due to impaired phagocytosis
Antigens enter thru splenic artery- get phagocytosed by dendritic cells which present antigens to helper-T cells that go to the primary follicles to find and activate B cells
103
How to confirm dx of multiple myeloma
Bone marrow biopsy w/ >10% clonal plasma cells
104
52 yo F w/ pounding sensation in neck and LE edema
- wt loss
- migraine, chronic diarrhea, severe post-menopausal flushes
- poor oral hygiene
- 2/6 systolic murmur that increases w/ inspiration
- severe tricuspid insufficiency
Dx
Carcinoid syndrome
- Skin: flushing
- GI: diarrhea
- Cardiac: right valvular lesions
Episodic flushing present in 85% of pts
Confirm w/ elevated urinary 5HIA
105
Riluzole
(a) Indication
(b) Mechanism
Riluzole = glutamate inhibitor approved for ALS (amyotrophic lateral sclerosis)
Doesn't stop or reverse the underlying neurodegenerative disease, but may prolong survival and time to tracheostomy
106
Complications of acute pancreatitis
Pleural effusion, ileus (failure of peristalsis), pancreatic pseudocyst/abscess/necrosis, ARDS
107
Define resistant hypertension
HTN that persists despite using at least 3 antihypertensive agents of different classes w/ one being a diuretic
Next step is to evaluate for secondary causes
108
First line tx for acute episode of glaucoma
IV mannitol = osmotic diuretic w/ immediate onset of action
109
In a pt w/ GI distress, what signs suggest etiology besides IBS
- rectal bleeding
- nocturnal awakening from abdominal pain
- wt loss
- anemia or electrolyte d/o (lab abnormalities)
110
Dressler syndrome
Dressler syndrome = post MI injury syndrome
Immune-mediated pericarditis weeks to months after an acute MI
Pleuritic CP, fever, leukocytosis, pericardial friction rub, diffuse ST seg elevation
111
How to make a diagnosis of asperilloma
Aspergillus IgG serology + radiographic findings (cavitary lesions on chest CT)
112
Most common cause of death from Ludwig angina
Asphyxiation
Ludwig angina = progressive b/l cellulitis of submandibular and sublingual spaces from an infected tooth
-swelling can obstruct the airway => asphyxiation
113
Preferred tx for Graves' disease and its contraindications
Radioactive iodine therapy is preferred
-less expensive and fewer complications than surgery (subtotal thyroidectomy)
Contraindications = pregnancy and very severe opthalmopathy
114
Describe microbiology of nocardioia
(a) Tx
Gram-positive rod
PARTIALLY ACID-FAST
(a) Bactrim
115
What does it mean when a murmur's intensity increases w/ inspiration
100% sensitive and 88% specific for a right sided murmur (tricuspid or aortic)
116
Which cause of hyperthyroidism is most likely to develop hypothyroidism following radioactive therapy?
Graves' disease b/c the entire thyroid gland is hyperfunction => radioiodine (radioactive that causes thyroid ablation via beta-emissions) is taken up by the entire gland
While toxic adenoma and multinodular goiter pts usually remain euthyroid b/c spotty extra uptake
117
Epigastric pain + intermittent melenia that improves after meals
(a) Dx
(b) Tx
(a) Duodenal ulcer
- improves after food due to alkaline secretion into duodenum (opposite of gastric ulcers which are worse after eating)
(b) Tx = PPI + abx eradication of H. Pylori
118
Signs/symptoms of neuroleptic malignant syndrome
Fever
muscle rigidity
autonomic instability: tachycardia, labile BP, tachypnea, diaphoresis
119
Main mechanism of nitroglycerin in MI pain relief
Dilation of capacitance vessels (veins)
| => decrease in ventricular preload and decreases heart size => decreasing oxygen requirement of the heart
120
Most common causes of duodenal uclers
(a) Tx of duodenal ulcers
Majority of duodenal ulcers are caused by H. pylori or NSAID use
(a) Tx = PPI + abx eradication of H. pylori (amoxicillin + clarithryomycin)
121
Primary vs. central adrenal insufficiency
(a) Cause
(b) Salt wasting
(c) Symptoms
(a) Primary (autoimmune) vs. Central (HPA axis inhibition ex: 2/2 chronic steroid therapy)
(b) Mineralocorticoid deficiency much more pronounced in primary
(c) Primary has much more severe symptoms w/ hyperkalemia, hyponatremia, and hypotension
- less severe symptoms in central
122
When can live vaccines be given to HIV+ patients
Most live vaccines are containdicated, EXCEPT MMR and varicella zoster vaccines- and only in pts w/ CD4 over 200 and no h/o AIDS-defining illness
123
What is Larmbert Eaton syndrome?
(a) Clinical presentation
(b) Etiology
Rare autoimmune syndrome where autoantibodies are produced against presynaptic voltage-gated Ca2+ channels at the nmj
(a) Muscle weakness (similar to MG)
(b) Etiology- 60% have underlying malignancy, most commonly small cell lung cancer
124
Differentiate obstructive vs. restrictive disease on spirometry
Obstructive disease (asthma, COPD) = low FEV1/FVC
Normal or high FEV1/FVC (low VC)
125
43 yo M w/ h/o Hodgkin lymphoma tx 20 years ago w/ chemo and radiation tx presents w/ left-sided CP
-CXR reveals mass in left chest
Dx
Secondary malignancy
Hodgkin lymphoma have very good response to treatment, recurrence after 20 yrs is very uncommon- but due to the chemo and radiation there's a 20x increase in developing a second cancer in HL pts
126
Which type of anemia is an indication for splenectomy?
Moderate, symptomatic, hereditary spherocytosis
127
32 yo F w/ fatigue, SOB, and swelling of feet x3 days
- recent cold 2 weeks ago
- JVP, b/l basilar crackles, 2+ b/l pitting edema to ankles
Dx
(a) Echo findings
Dilated cardiomyopathy 2/2 acute viral myocarditis (most commonly coxsackievirus B)
(a) Dilated ventricles w/ diffuse hypokinesia
128
Bullous pemphigoid vs. pemphigus vulgaris
Bullous pemphigoid = benign pruritic disease of tense blisters
-IgG and C3 deposits in dermal epidermal jxn
Pemphigus vulgaris = flaccid (not tense) blisters
-IgG intracellular deposits in the epidermis
129
67 yo M w/ HTN and HA
- BP 190/120 on lisinopril-HCTZ, amlodipine, metoprolol, ASA
- periumbilical systolic-diastolic bruit
Dx
Renal artery stenosis- think of secondary causes of HTN when still so high on multiple meds
Systolic-diastolic bruits seen in about 40% of pts w/ renal artery stenosis, but less than 1% of pts w/o renal artery stenosis.
130
Differentiate Trousseau's and Chvostek's sign
Both signs of hypocalcemia
Trousseaus = carpopedal spasm (spasm of wrist/thumb) when BP cuff inflated for 3+ seconds
Chvostek's = twitching of facial muscles when tap on the facial nerve
131
Name some common associated etiologies of avascular necrosis
```
Steroid use
EtOH use
SLE
Antiphospholipid syndrome
SCD
Osteomyelitis
HIV
```
132
Epidermal cyst vs. lipoma
Both free-moving benign lesions
Epidermal cysts recur and have central punctum (pore-like opening), while lipomas don't recur and don't have opening
133
34 yo M presents w/ HA, fever, fatigue who returned from Kenya 2 weeks ago
- intense chills w/ shivering
- few hrs later: high grade fever w/ profuse sweating
- similar symptoms a few days ago
Malaria- cyclical fevers (periodic febrile paroxysms)
| Nonspecific malaise, HA, nausea, vom, abdominal pain
