UWorld - All Subjects Flashcards

Question

What are the symptoms of pertussis (including the 2 stages)? What is the treatment and prophylaxis protocol?

Answer 1

symptoms - first 1-2 weeks (catarrhal stage) - mild cough and rhinorrhea paroxysmal stage - characteristic whooping cough treatment - macrolide Abx (azithromycin, clarithromycin) prophylaxis - macrolide antibiotic is recommended for post exposure prophylaxis for close contacts

Answer 2

1. diminished and delayed carotid pulses (pulses parvus et tardus) 2. late-peaking, crescendo-decrescendo systolic murmur 3. soft and single S2 (can develop an S4 heart sound due to increased pressure load and concentric left ventricular hypertrophy)

Answer 3

1. chronic severe mitral regurgitation 2. chronic aortic regurgitation 3. heart failure 4. occasionally in those with high cardiac output states, such as pregnancy or thyrotoxicosis

Answer 4

mitral stenosis

Answer 5

antiviral therapy: acyclovir, valacyclovir, famciclovir postherpatic neuralgia: TCAs, pregabalin, gabapentin

Answer 6

Etiology: no underlying cause Clinical presentation: usually women < 30 yo, no tissue injury, negative ANA and ESR Management: avoid aggravating factors, calcium channel blocker for persistent symptoms

Answer 7

Etiology: connective tissue diseases, occlusive vascular conditions, sympathomimetic drugs, vibrating tools, hyperviscosity syndrome, nicotine Clinical presentation: usually men age >40yo, symptoms of underlying disease, tissue injury or digital ulcers, abnormal nail fold capillary examination Management: evaluate and treat underlying disorder, calcium channel blocker for persistent symptoms, aspirin for patients at risk of digital ulceration

Answer 8

``` mechanism: folate antimetabolite adverse effects: 1. hepatotoxicity 2. stomatitis 3. cytopenias ```

Answer 9

mechanism - pyrimidine synthesis inhibitor adverse effects - 1. hepatotoxicity 2. cytopenias

Answer 10

mechanism - TNF and IL-1 suppressor | adverse effect - retinopathy

Answer 11

``` mechanism - TNF and IL-1 suppressor adverse effects - 1. hepatotoxicity 2. stomatitis 3. hemolytic anemia ```

Answer 12

1. infection 2. demyelination 3. CHF 4. malignancy

Answer 13

adalimumab, certolizumab, etanercept, golimumab, infliximab

Answer 14

1. unilateral motor impairment 2. NO sensory or cortical deficits 3. NO visual field abnormalities

Answer 15

1. C/L somatosensory and motor deficits (face, arm, and leg) 2. conjugate eye deviation toward side of infarct 3. homonymous hemianopia 4. aphasia (dominant hemisphere) 5. hemineglect (non dominant hemisphere)

Answer 16

1. contralateral somatosensory and motor deficit, primarily in lower extremity 2. abulia (lack of will or initiative) 3. dyspraxia, emotional disturbances, urinary incontinence

Answer 17

1. alternate syndromes with contralateral hemiplegia and ipsilateral cranial nerve involvement 2. possible ataxia

Answer 18

1. diabetes mellitus 2. hypothyroidism 3. vitamin B12 deficiency

Answer 19

1. alcohol use 2. medications (phenytoin, disulfiram, platinum chemotherapy) 3. heavy metals

Answer 20

1. HIV | 2. Lyme disease

Answer 21

1. Charcot-Marie-Tooth | 2. Porphyria (acute intermittent porphyria)

Answer 22

Alzheimer disease

Answer 23

Vascular dementia

Answer 24

Frontotemporal demenita On imaging, you would see frontotemporal atrophy

Answer 25

dementia with Lewy bodies

Answer 26

normal pressure hydrocephalus

Answer 27

prion disease

Answer 28

Epidemiology - bimodal peak incidence: age 15-35 and >60; associated with EBV in the immunosuppressed

Answer 29

painless LAD, mediastinal mass, B symptoms (fever, sweating, weight loss), pruritus

Answer 30

lymph node biopsy that shows Reed-Sternberg cells on histology

Answer 31

eye involvement - unilateral OR bilateral eye "stuck shut" - yes discharge - water, scant, stringy discharge reappearing after wiping - no Sensation - burning, gritty Prodromal symptoms - sometimes Conjunctival appearance - diffuse injection; follicular or "bumpy"

Answer 32

Eye involvement - unilateral OR bilateral Eye "stuck shut" - yes Discharge - purulent, thick Discharge reappearing after wiping - yes Sensation - unremitting discharge Prodromal symptoms - no Conjunctival appearance - diffuse injection; nonfollicular

Answer 33

``` Eye involvement - bilateral Eye "stuck shut" - yes Discharge - watery, scant, stringy Discharge reappearing after wiping - no Sensation - itchy Prodromal symptoms - no Conjunctival appearance - diffuse injection, follicular or "bumpy," conjunctival edema (chemosis) ```

Answer 34

1. decreased visual acuity 2. photophobia 3. ciliary flush 4. foreign body sensation 5. corneal opacity/infiltrate 6. fixed/distorted pupil 7. trouble keeping eye open 8. severe headache with nausea

Answer 35

norepinephrine reuptake inhibitor; non stimulant option for ADHD

Answer 36

alpha-2 adrenergic agonists; non-stimulant options for ADHD (used when there is a poor response to or intolerable side effects from stimulants or coexisting conditions (tic disorders))

Answer 37

appropriate for patients with a history of illicit substance use or when there is a strong family preference against stimulant medication

Answer 38

MOA - inhibition of dihydrofolate reductase, which causes cellular folate depletion This leads to impaired DNA synthesis, which is most pronounced in rapidly dividing cells. Causes bone marrow suppression -> microcytic anemia

Answer 39

immune thrombocytopenia

Answer 40

most cases resolve within 3 months; however, some patients continue to have platelets < 100,000 for > 1 year, which is known as chronic ITP

Answer 41

1. examination and blood test for infection (H IV, Hep C, CMV) and autominne disorders (SLE, thyroid disease) Then treat as if acute ITP: 1. asymptomatic = observation 2. combo of glucocorticoids, anti-D immune globulin (if Rh-positive and Coombs-negative) and/or IVIg for bleeding episodes)

Answer 42

observation alone if asymptomatic. OR (if bleeding and/or platelets < 30,000) combo of glucocorticoids, anti-D immune globulin (if Rh-positive and Coombs-negative) and/or IVIg for bleeding episodes

Answer 43

second line therapies = rituximab, thrombopoeitin receptor agonists, or splenectomy You would consider using these if the patient has bleeding and thrombocytopenia requiring repeated pharmacologic interventions

Answer 44

Etiology: platelet autoantibodies AND preceding viral infection Clinical findings: petechia, ecchymosis, mucosal bleedings (epistaxis, hematuria) Lab findings: isolate thrombocytopenia < 100,000, few platelets (size normal to large) on peripheral smear

Answer 45

1. evaluate for presence of uterus. Present -> test FSH Absent -> Karyotype (46, XY (androgen insensitivity) or 46, XX (mullein agenesis)

Answer 46

Test TSH and prolactin If both are normal -> functional hypothalamic amenorrhea

Answer 47

Dx = imperforate hymen

Answer 48

Karyotype -> 46, XX = primary ovarian insufficiency | 45, XO -> Turner syndrome

Answer 49

hypothyroidism

Answer 50

prolactinoma

Answer 51

sinusitis, particularly of the ethmoid or maxillary sinuses; strep species and staph aureus

Answer 52

1. Overproduction (hemolysis) 2. Reduced uptake (drugs, portosystemic shunt) 3. Conjugation defect (Gilbert syndrome)

Answer 53

1. viral hepatitis 2. autoimmune hepatitis 3. toxin/drug-related hepatitis 4. hemochromatosis 5. ischemic hepatitis 6. alcoholic hepatitis

Answer 54

1. Dubin-Johnson syndrome | 2. Rotor syndrome

Answer 55

1. cholestasis of pregnancy 2. malignancy (pancreases, ampullary) 3. cholangiocarcinoma 4. primary biliary cirrhosis 5. primary sclerosing cholangitis 6. choledocholithiasis Next step in work-up: abdominal imaging (U/S or CT) and antimitochondrial Ab

Answer 56

1. pleural fluid protein/serum ration >0.5 2. Pleural fluid lactate dehydrogenase (LDH)/serum LDH ration >0.6 3. Pleural fluid >2/3 of the upper limit of normal (ULN) for serum LDH If positive, pleural effusion is exudative.

Answer 57

1. CXR can show reticular or nodular opacities 2. high-resolution chest CT usually shows fibrosis, honeycombing, or traction bronchiectasis 3. PFTs: normal or increased FEV1/FVC ratio, decreased total lung capacity, decreased reserve volume 4. exertion usually causes significant hypoxemia due to V/Q mismatch (Will have increased alveolar-arterial gradient)

Answer 58

IGF-1 level | If normal -> rules out acromegaly

Answer 59

oral glucose suppression est If adequate GH suppression -> rules out acromegaly

Answer 60

MRI of brain

Answer 61

evaluate surgical vs medical management

Answer 62

evaluate for extra pituitary cause of acromegaly (ectopic growth hormone and growth hormone-releasing factor secreting tumors)

Answer 63

Path: Sarcoptes scabiei mite infestation, spread by direct person-to-person contact Sx: extremely pruritic pathognomonic burrows and small, erythematous papules; rash located on interdigital web spaces, flexor wrists, extensor elbows, axillae, umbilicus and genitalia Tx: topical 5% permethrin OR oral ivermectin

Answer 64

Normal saline and regular insulin infusion

Answer 65

5% dextrose when serum glucose is = 200mg/dL

Answer 66

hold IV insulin if K+ < 3.3 mEq/L) Switch to SQ from IV insulin for the following: 1. able to eat 2. glucose < 200mg/DL, anion gap < 12 mEq/L and serum HCO3 >/= 15 mEq/L Overlap SQ and IV insulin by 1-2 hours.

Answer 67

add IV K+ if serum K+ <5.3 mEq/L; nearly all patients are K+ depleted

Answer 68

phosphate < 1.0 mg/dL, cardiac dysfunction, or respiratory depression Monitor serum calcium frequently

Answer 69

Path: inherited DNA repair defect, bone marrow failure Sx: short stature, hypo/hyperpigmented macule, abnormal thumbs, genitourinary malformations Lab findings: pancytopenia, positive chromosomal breakage testing Tx: hematopoietic stem cell transplant

Answer 70

MOA - inhibits voltage-gated sodium channels Acute toxicity - signs of cerebellar dysfunction - horizontal nystagmus, ataxia, dysmetria, slurred speech, N/V, and hyperreflexia Severe toxicity: AMS (lethargy, confusion), coma, paradoxical seizures, and death

Answer 71

immune system forms IgG autoAb that covers platelets and forms complexes (heparin-PF4-HIT Ab) resulting in thrombocytopenia and arterial and venous thrombus

Answer 72

HIT Abs activate platelets, resulting in platelet aggregation and the release of procoagulant factors. The risk of thrombus is as high as 50% in untreated HIT

Answer 73

binds antithrombin, which inactivates factor Xa; this prolongs activated partial thromboplastin time

Answer 74

dizziness, vertigo, ataxia, and visual disturbances

Answer 75

Epidemiology: usually autosomal dominant, Northern European descent Sx: hemolytic anemia, jaundice, splenomegaly Lab findings: increased MCHC, negative Coombs test, Spherocytes on peripheral smear, increased osmotic fragility on acidified glycerol lysis test, abnormal eosin-5-maleimide binding test Tx - folic acid supplementation, blood transfusion, splenectomy

Answer 76

sx: muscle weakness (proximal, symmetrical, UE = LE), skin findings (Gottron's papules, heliotrope rash), extra muscular findings (interstitial lung disease, dysphagia, myocarditis) Dx - increased CPK, aldolase, LDH, anti-RNP, anti-Jo-1, anti-Mi2, diagnostic uncertainty - EMG, skin/muscle biopsy Tx - high dose glucocorticoids PLUS glucocorticoid-sparing agent, screen for malignancy

Answer 77

immunocompromised patients; causes pulmonary disease (upper lobe cavitary disease) microscopy shows acid-fast negative hyphae

Answer 78

presence of filamentous, gram-positive, weakly acid-fast rods Tx = TMP/SMX

Answer 79

Path: IgA-mediated leukocyctocalstick vasculitis Sx - palpable purpura, arthritis/arthralgia, abdominal pain, intussusception, renal disease similar to IgA nephropathy Lab findings: normal platelet count and coagulation studies, normal to increased creatinine, hematuria +/- RBC casts +/- proteinuria Tx - supportive (hydration and NSAIDs) for most patients, hospitalization and systemic glucocorticoids in patients with severe symptoms

Answer 80

Constitutional: fever, fatigue, and weight loss Symmetric, migratory arthritis Skin: butterfly rash + photosensitivity Serositis: pleurisy, pericarditis, peritonitis Thromboembolic events (due to vasculitis + antiphospholipid antibodies) Neurologic: cognitive dysfunction + seizuress

Answer 81

hemolytic anemia, thrombocytopenia + leukopenia hypocomplementemia (C3+C4) Antibodies: ANA (sensitive), Anti-dsDNA + anti-Sm (specific) Renal involvement: proteinuria + elevated creatinine

Answer 82

multiple oral and genital ulcers that are recurrent and painful (hematologic and renal abnormalities are not typically seen)

Answer 83

Felty syndrome is a potentially serious complication of RA characterized by neutropenia and splenomegaly. Recurrent bacterial infection is common (due to neutropenia) and may lead to LAD.

Answer 84

path: patients with long-standing HIV disease and CD4+ count <200. Macrophage-mediated signaling pathways and associated toxicity leads to neuronal dysfunction Sx - increasing apathy and impaired attention, subcortical dysfunction with slowed movement and difficulty with smooth limb movement Tx - adherence to antiretroviral therapy may improve HAD symptoms

Answer 85

cutaneous blastomycosis manifests as well-circumscribed verrucous nodules and plaques that progress to micro abscesses Endemic to the central US

Answer 86

Shy-Drager syndrome Sx: 1. Parkinsonism 2. Autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis, etc) 3. Widespread neurological signs (cerebellar, pyramidal, or lower motor neuron)

Answer 87

Treatment is aimed at intravascular volume expansion with fludrocortisone, salt supplementation, alpha-adrenergic agonists, and application of constrictive garments to the lower body

Answer 88

Riley-Day syndrome Autosomal-recessive seen predominantly in children of Ashkenazi Jewish ancestry Presents at birth with feeding problems and low muscle tone; it is characterized by gross dysfunction of the autonomic nervous system (no tears) with severe orthostatic hypotension (swings from severe HTN to postural hypotension)

Answer 89

Epidemiology: mycobacterium leprae, primarily in developing world, spread by respiratory droplets or armadillos Sx: macular, anesthetic skin lesions with raised borders; nodular, painful nearby nerves with loss of sensory/motor function Dx: full thickness biopsy of skin lesion; not culturable Tx: dapsone + rifampin (add clofazimine if severe)

Answer 90

1. HIV-positive patients 2. Recent contacts of known TB case 3. Nodular or fibrotic changes on CXR consistent with previously healed TB 4. Organ transplant recipients and other immunosuppressed patients

Answer 91

1. Recent immigrants (< 5 years) from TB-endemic areas 2. Injection drug users 3. Residents and employees of high-risk settings (prisons, nursing homes, hospitals, homeless shelters) 4. Mycobacteriology lab personnel 5. Higher risk for TB reactivation (diabetes, leukemia, ESRD, chronic malabsorption syndromes) 6. Children age <4, or those exposed to adults in high-risk categories

Answer 92

- presents in the first few days of life Sx: high-pitched cry, sleeping and feeding difficulties, tremors, seizures, autonomic dysfunction (sweating, sneezing), tachypnea, vomiting, diarrhea (within 48 hours of birth for heroin withdrawal and 48-72 for methadone)

Answer 93

symptomatic care to calm the infant and help them sleep, providing small, frequent feeds, and keeping the infant in a low-stim environment (Pharmacologic treatment, including morphine, methadone, and buprenorphine, should only be used when supportive treatment alone does not control withdrawal symptoms)

Answer 94

Prenatal exposure can result in jitteriness, excessive sucking, and a hyperactive Moro reflex Long-term effects on behavior, attention level, and intelligence may be seen

Answer 95

miliary TB (autoimmune adrenalitis is the most common etiology of primary adrenal insufficiency/Addison disease but disseminated chronic infection can also cause the disorder)

Answer 96

Sx: blisters, bullae, scarring, hypopigmentation/hyperpigmentation on sun-exposed skin (back of hands, forearms, face); scarring and calcification similar to scleroderma Associated conditions: Hepatitis C, HIV, excessive alcohol consumption, estrogen use, smoking Dx: mildly elevated liver enzymes and iron overload; elevated plasma or urine porphyrin levels

Answer 97

Sx: palpable purpura, arthralgias, and glomerulonephritis Associated with hepatitis C due to immune complex deposition in small blood vessels, leading to endothelial injury and end-organ damage

Answer 98

Path: progressive tissue fibrosis, vascular dysfunction Sx: systemic: fatigue, weakness Skin: telangiectasia, sclerodactyly, digital ulcers, calcinosis cutis Extremeties: arthraglias, contractors, myalgias GI: esophageal dysmotility, dysphagia, dyspepsia Vascular: Raynaud phenomenon Lab findings: Antinuclear antibody, Anti-topoisomerase I (anti-Scl-70) antibody, Anticentromere antibody

Answer 99

Lung: interstitial lung disease, pulmonary arterial HTN Kidney: HTN, scleroderma renal crisis (oliguria, thrombocytopenia, microagniopathic hemolytic anemia) Heart: myocardial fibrosis, pericarditis, pericardial effusion

Answer 100

Neurologic - AMS, seizure, fasciculations, tremor | GI - vomiting, diarrhea

Answer 101

Lithium levels >2.5 (Patient with levels > 4 and creatinine >2.0 should generally be prescribed dialysis)

Answer 102

NSAIDs, ACE inhibitors, angiotensin receptor blockers, and dehydration by any cause. (lithium is really excreted)

Answer 103

1. Arthritis in >/= 1 joint for >/= 6 weeks (commonly affected joints = hips, knees, and hands) 2. Fever for >/= 2 weeks (quotidian pattern in which temp spikes once daily, often in the evening). A pink rash often accompanies the fever. Hepatosplenomegaly and LAD are also common.

Answer 104

1. leukocytosis 2. elevated inflammatory markers 3. thrombocytosis 4. hyperferritenemia 5. anemia of chronic inflammation and iron deficiency 6. Rheumatoid factor and antinuclear antibodies are typically negative

Answer 105

1. N-methyl-D-aspartate receptors, particularly in the hippocampus and limbic system (causing excitatory and psychotic effects) 2. sigma receptor complex (causing psychotic and anticholinergic effects) 3. Dopamine, norepinephrine and serotonin receptors (causing adrenergic and dopaminergic effects)

Answer 106

Path: chromosome 22q11.2 deletion -> defective development of pharyngeal pouches Sx: CATCH: C: conotruncal cardiac defects (ToF, truncus arteriosus, interrupted aortic arch) A: abnormal facies T: thyme hypoplasia/aplasia (T-cell deficiency) C: craniofacial deformities (cleft palate) H: hypocalcemia/hypoparathyroidism

Answer 107

1. Leads to respiratory alkalosis by stimulating the respiratory center in the medulla and causing tachypnea 2. Then causes an anion gap metabolic acidosis by uncoupling of oxidative phosphorylation in the mitochondria leading to anaerobic metabolism (with resultant low HCO3- from acid buildup)

Answer 108

1. Low PaCO2 - due to primary respiratory alkalosis (and respiratory compensation for metabolic acidosis) 2. Low HCO3- - due to primary metabolic acidosis (and metabolic compensation for respiratory alkalosis) 3. Near normal pH - as the 2 primary acid-base disturbances shift the pH in opposite directions

Answer 109

Sx/patient: age 3-8 with preceding viral illness, afebrile, hip pain, limp, able to bear weight Dx: normal to mildly elevated WBC count, ESR, CRP, small effusions on ultrasound Tx: conservative, NSAIDs Prognosis: full recovery in 1-4 weeks, recurrence uncommon

Answer 110

Organism: staph aureus Abx: low likelihood of MRSA -> Nafcillin/oxacillin OR cefazolin High likelihood of MRSA -> clindamycin OR vancomycin

Answer 111

Organisms: salmonella spp., staph aureus Abx: Low likelihood of MRSA -> nafcillin/oxacillin OR cefazolin High likelihood of MRSA -> clindamycin OR vancomycin (same as healthy children) PLUS third-generation cephalosporin (ceftriaxone, cefotaxime)

Answer 112

MOA - increase fetal hemoglobin Indicated - in patients with frequent pain crises, history of acute chest syndrome, and/or severe symptomatic anemia Side effect: myelosuppression (neutropenia, anemia, thrombocytopenia)

Answer 113

Lumbar flexion (walking uphill, leaning on cane, walking while leaning forward, leaning on shopping cart) relieves the pain from spinal stenosis; Extension of the lumbar spine further narrows the spinal canal and worsens the symptoms

Answer 114

Dx - MRI of spine | Tx - conservative with physical therapy and exercise but can require surgical intervention

Answer 115

typically causes acute back pain with unilateral radiation down the sciatic nerve to the foot (sciatica); usually follows an inciting event Lumbar flexion makes the pain worse

Answer 116

CNS stimulation (HA, insomnia, seizures), GI disturbances (N/V), and cardiac toxicity (arrhythmia)

Answer 117

cirrhosis, cholestasis, respiratory infections with fever, drugs - cimetidine, ciprofloxacin, erythromycin, calrithromycin, verapamil Theophylline is metabolized by the cytochrome oxidase system in the liver

Answer 118

Cardiac - sinus bradycardia, heart lock; risk of proarrhythmias: QT prolongation & risk of tornado de pointes Pulmonary - chronic interstitial pneumonitis (cough, fever, dyspnea, pulmonary infiltrates) Endocrine: hypothyroidism, hyperthyroidism

Answer 119

GI/hepatic: elevated transaminases, hepatitis Ocular: corneal microdeposits, optic neuropathy Derm: blue-gray skin discoloration Neurologic: peripheral neuropathy

Answer 120

Organism: strep pyogenes Sx: superficial dermis & lymphatics; raised, sharply demarcated edges; rapid spread and onset; fever early in course

Answer 121

Organisms: S pyogenes, MSSA Sx: deep dermis + subcutaneous fat; flat edges with poor demarcation; indolent (over days); localized (fever later in course)

Answer 122

Organisms: MSSA, MRSA Sx: purulent drainage; folliculitis: infected hair follicle; furuncles: folliculitis -> dermis -> abscess; carbuncle: multiple furuncles

Answer 123

Tumor type: squamous cell; renal + bladder; breast + ovarian Mechanism: PTH mimic Labs: decreased PTH, increased PTHrP

Answer 124

Tumor type: breast, multiple myeloma Mechanism: increased osteolysis Labs: decreased PTH and PTHrP, decreased Vitamin D

Answer 125

Tumor type: lymphoma Mechanism: increased calcium absorption Labs: decreased PTH, increased Vitamin D

Answer 126

acetaminophen, NSAIDs, mesalamine, sulfasalazine, opiates

Answer 127

isoniazid, tetracyclines, metronidazole, TMP/SMX

Answer 128

valproic acid, carbamazepine

Answer 129

thiazides, furosemide, enalapril, losartan

Answer 130

lamivudine, didanosine

Answer 131

azathioprine, mercaptopurine, corticosteroids

Answer 132

vertebral osteomyelitis; next get blood cultures, ESR/CRP, and plain spinal X-rays

Answer 133

elevated ESR/CRP but normal X-rays; MRI -> CT-guided needle aspiration/biopsy

Answer 134

Path: thiamine deficiency Associated conditions: chronic alcoholism, malnutrition, hyperemesis gravidarum Sx: encephalopathy, oculomotor dysfunction (horizontal nystagmus, bilateral abducens palsy), postural & gait ataxia Tx: IV thiamine followed by glucose infusion

Answer 135

Sx: 1. Asymptomatic -> identified by abnormal LFTs 2. Symptomatic -> fatigue, anorexia, nausea, jaundice, can progress to fulminant liver failure +/or cirrhosis Often associated with other autoimmune disorders

Answer 136

1. hepatocellular pattern (increased AST + ALT) 2. hypergammaglobulinemia 3. elevated autoantibodies (anti-smooth muscle, anti-liver/kidney microsomal type 1m antinuclear)

Answer 137

histology: portal + periportal lymphoplasmacytic infiltration Tx: prednisone +/- azathioprine

Answer 138

advanced cirrhosis with portal hypertension and edema

Answer 139

1. reduced renal perfusion 2. GI bleed, vomiting, sepsis, excessive diuretic use, spontaneous bacterial peritonitis 3. reduced glomerular pressure + GFR (NSAID use, which constricts afferent arterioles)

Answer 140

1. renal hypoperfusion 2. FeNa < 1% (or urine Na < 10 mEq/L) 3. Absence of tubular injury 4. No RBC, protein, or granular cast sin urine 5. No improvement in renal function with fluids

Answer 141

1. address precipitating factors (eg hypovolemia, anemia, infection) 2. Splanchnic vasoconstrictors (midodrine, octreotide, norepinephrine) 3. Liver transplantation

Answer 142

Sx: purulent mono arthritis OR triad of tenosynovitis, dermatitis, migratory polyarthralgia Dx: Detection of Neisseria gonorrhoeae in urine, cervical, or urethral sample; culture of blood, synovial fluid (less sensitive) Tx: 3rd gen cephalosporin IV AND oral azithromycin

Answer 143

annular macule (erythema migrans)

Answer 144

breath sounds: increased tactile remits: increased percussion: dullness mediastinal shift: none

Answer 145

breath sounds: decreased or absent tactile fremitus: decreased percussion: dullness mediastinal shift: away from effusion (if large)

Answer 146

breath sounds: decreased or absent tactile fremitus: decreased percussion: hyperresonance mediastinal shift: away from tension pneumothorax

Answer 147

breath sounds: decreased or absent tactile fremitus: decreased percussion: dullness mediastinal shift: toward atelectasis (if large)

Answer 148

cocaine; tachycardia, pupil dilation, diaphoresis, and tremors

Answer 149

anxiety, irritability, mood wings, panic attacks, grandiosity, impaired judgment, and psychotic symptoms (paranoia, hallucinations)

Answer 150

``` CVP: decreased PCWP: decreased cardiac index: decreased SVR: increased SvO2: decreased ```

Answer 151

``` CVP: increased PCWP: increased cardiac index: decreased SVR: increased SvO2: decreased ```

Answer 152

``` CVP: increased PCWP: decreased cardiac index: decreased SVR: increased SvO2: decreased ```

Answer 153

``` CVP: decreased PCWP: decreased cardiac index: increased SVR: decreased SvO2: increased ```

Answer 154

Risk factors: prematurity, small for gestational age, low birth weight, genetic disorders Sx: empty, hypo plastic, poorly rugged scrotum or hemiscrotum, +/- inguinal fullness Tx: orchiopexy before age 1 year Complications: inguinal hernia, testicular torsion, sub fertility, testicular cancer

Answer 155

Path: bone marrow failure due to hematopoietic stem cell deficiency (CD34+) Causes: autoimmune, infections (parvo, EBV), drugs, radiation/toxins Sx: fatigue, weakness, bleeding and bruising, recurrent infections Labs: pancytopenia; biopsy: hypo cellular bone marrow with fat and stroll cells

Answer 156

carbamazepine, chloramphenicol, sulfonamides

Answer 157

bradycardia with sinus arrest

Answer 158

Path: mutation in GNAQ gene Sx: port-wine stain (trigeminal nerve distribution), leptomeningeal capillary-venous malformation, seizures +/- hemiparesis, intellectual disability, visual field defects, glaucoma Dx: MRI of the brain with contrast Tx: laser therapy, anti epileptic drugs, intraocular pressure reduction

Answer 159

seizures, intellectual disability, hypopigmented ash-leaf spots, angiofibromas (molar erythematous papule), and shagreen patches (flesh-colored plaque on the back)

Answer 160

They are a spectrum of the same disease: < 10% of body surface area = Stevens-Johnson syndrome 10-30% = SJS/TEN overlap >30% = TEN

Answer 161

1. 4-8 days after exposure to trigger (2 days after repeat exposure) 2. acute influenza-like prodrome 3. rapid-onset erythematous macule, vesicles, bullae 4. necrosis and sloughing of epidermis 5. mucosal involvement

Answer 162

``` Drugs 1. Allopurinol 2. Antibiotics (sulfonamides) 3. Anticonvulsants (carbamazepine, lamotrigine, phenytoin) 4. NSAIDs 5. Sulfasalazine Other 1. Mycoplasma pneumoniae 2. Vaccination 3. Graft-vs-host disease ```

Answer 163

Vaccine strain = <10 lesions, maculopapular and/or vesicular, mildly contagious Wild type = > 100 lesions, vesicular in successive crops, highly contagious Both have an incubation period of 1-3 weeks

Answer 164

single dose >/= 7.5g (pediatric >/= 150mg/kg) and = 4 hours since ingestion

Answer 165

check acetaminophen levels

Answer 166

If levels above treatment line in nomogram, >10 micrograms/mL if timing of ingestion is unclear, or any evidence of liver injury: administer N-acetylcysteine and monitor for liver injury

Answer 167

1. Klinefelter syndrome | 2. Varicocele

Answer 168

1. radiation 2. infection (mumps) 3. trauma 4. medications (alkylating agents, glucocorticoids) 5. chronic disease

Answer 169

decreased energy/libido, decreased body hair, gynecomastia, increased LH/FSH, decreased testosterone/sperm count

Answer 170

Kallman syndrome

Answer 171

1. hyperprolactinemia | 2. glucocorticoids/opiates

Answer 172

1. benign/malignant tumors 2. pituitary apoplexy 3. infiltration (hemochromatosis), 4. systemic disease

Answer 173

decreased energy/libido, decreased body hair, gynecomastia less likely than primary, decreased or normal LH/FSH, decreased testosterone/sperm count (but not as significantly decreased as primary)

Answer 174

prolactin, transferrin, +/- MRI

Answer 175

exudative effusions with very low (<50) glucose, and very high LDH ( >700), may also have low pH

Answer 176

RA, empyema, malignancy, TB

Answer 177

fever, HA, seizure, AMS, +/- focal neurologic findings (hemiparesis, cranial nerve palsies, ataxia)

Answer 178

CSF: increased WBCs, increased RBCs, increased protein, normal glucose, HSV DNA on PCR Brain MRI: temporal lobe hemorrhage/edema

Answer 179

IV acyclovir

Answer 180

low thyroxine levels feed back to the hypothalamus and increase the secretion of TRH, simulating the antihero pituitary and increasing TSH and prolactin levels -> hyperprolactinemia inhibits the hypothalamus and anterior pituitary, causing decreased FSH and LH levels -> an ovulation and abnormal uterine bleeding

Answer 181

elevated FSH, normal TSH and prolactin

Answer 182

congenital lymphedema (lymphatic network dysgenesis) -> accumulation of protein-rich interstitial fluid in the hands, feet, and neck Severe obstruction of lymphatic vessels can result in cystic hygorma of the neck and fetal hydrops

Answer 183

exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis, and ductal dilation of the glands; treatment is mostly artificial tears or other ocular lubricants

Answer 184

level of block: usually AV node ECG findings: progressive prolonged PR interval leads to a nonconductor P wave ("group beating") QRS: narrow Exercise or atropine: improves type 1 AV block Vagal maneuvers: worsens type 1 AV block Risk of complete heart block: low risk

Answer 185

Level of block: below the level of AV node (bundle of His) ECG findings: PR interval remains constant with intermittent nonconductor P waves QRS: narrow or wide Exercise or atropine: worsens type 2 AV block Vagal maneuvers: paradoxically improves type 2 AV block Risk of complete heart block: higher risk, indication for pacemaker

Answer 186

spinal cord compression (myelopathy) in the cervical spine (most common in older adults who have cervical spondylosis with spinal canal narrowing due to formation of osteophytes in the lateral vertebral bodies and ossification of the posterior longitudinal ligament)

Answer 187

Lhermitte sign = electric shock-=like sensation down the spine; presents in spinal cord compression and spinal cord inflammation from MS

Answer 188

papilledema due to increased ICP

Answer 189

painless, transient monocular blindness that lasts a few seconds; vascular (embolus to ophthalmic artery) in origin

Answer 190

Path: tyrosine kinase defect that prevents development of mature B cells Pt: recurrent sinopulmonary and GI infections after age 6 months; absence of lymphoid tissue examination Dx: decreased Ig and B cells; normal T cell concentration; no response to vaccinations Tx: Ig replacement therapy, prophylactic Abx if severe

Answer 191

causes impaired T cell development -> severe combined immunodeficiency (SCID); Pt with severe, recurrent viral, fungal, and bacterial infections and failure to thrive

Answer 192

disseminated bacterial infections, particularly with encapsulated bacteria (Strep pneumo, neisseria)

Answer 193

chronic granulomatous disease; Its with recurrent skin and pulmonary infections with catalase-positive organisms (Staph aureus, serratia)

Answer 194

shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burn, and high-dose corticosteroids; commonly form in proximal stomach and duodenum

Answer 195

cause: anterior spinal artery injury Pt: 1. B/L hemiparesis (lateral corticospinal tracts; at the level of the cord injury and below) 2. Diminished B/L pain and temp (lateral spinothalamaic tract; 1-2 levels below the cord injury because LST decussates 1-2 levels before the corresponding level) 3. Intact B/L proprioception, vibratory sensation, and light touch (Dorsal columns; blood is supplied from the posterior spinal arteries)

Answer 196

Path: coxsackie A virus Pt: 1-7 yo, late summer/early fall; fever, pharyngitis, gray vesicles/ulcers on oropharynx; tx = supportive

Answer 197

Path: HSV-1 Pt: 6 months - 5 yo; no seasonality; fever, pharyngitis, erythematous gingiva, clusters of vesicles on anterior oral mucosa/lips Tx: oral acyclovir

Answer 198

Path: autosomal recessive mutation of ATP7B Pt: hepatic: acute liver failure, chronic hepatitis, cirrhosis neurologic: Parkinsonism, gait disturbance, dysarthria psychiatric: depression, personality changes, psychosis Dx: decreased ceruloplasmin, increased urinary copper excretion, kayser-fleischer rings on slit-lamp, increased copper content on liver biopsy Tx: chelators (D-penicillamine, Tridentine), Zinc (interferes with copper absorption)

Answer 199

intravenous alteplase (tPA)

Answer 200

aspirin + dipyridamole OR clopidogrel

Answer 201

long term anticoagulation (warfarin, dabigatran, rivaroxaban)

Answer 202

mechanical thrombectomy (regardless if patient received alteplase), then aspirin

Answer 203

aspirin + clopidogrel for 90 days, then aspirin

Answer 204

1. ischemic stroke with measurable neurodeficits | 2. symptom onset <3-4.5 hours before treatment initiation

Answer 205

1. hemorrhage or multi lobar in fact involving >33% of cerebral hemisphere on CT scan 2. stroke/head trauma in the past 3 months 3. history of intracranial hemorrhage, neoplasm, or vascular malformation 4. recent intracranial/spinal surgery 5. active bleeding or arterial puncture in the last 7 days at non compressible site 6. blood pressure >185/110 mmHg 7. platelets < 100,000 or glucose <50mg/dL 8. Anticoagulant use with INR >1.7, PT >15 sec, or increased active PTT

Answer 206

1. minor or rapidly improving neurodeficits 2. major surgery/trauma in past 14 days 3. MI in the past 3 months 4. GU or GI bleeding in the past 21 days 5. seizure at stroke onset 6. pregnancy

Answer 207

1. antecedent history of neck injury | 2. pain/stiffness with neck movement

Answer 208

1. older individuals 2. pain/stiffness worse with movement 3. relieved with rest

Answer 209

1. pain radiates to shoulder/arm 2. dermatomal sensory/motor/reflex findings 3. positive spurling test

Answer 210

1. LE weakness, gait/bowel/bladder dysfunction | 2. Lhermitte sign

Answer 211

1. young men 2. HLA-B27 3. Relieved with exercise 4. prolonged morning stiffness

Answer 212

1. constant pain 2. worse at night 3. not responsive to position changes

Answer 213

1. focal tenderness 2. fevers and night sweats 3. IVDU, immune compromise, or recent infection

Answer 214

1. neutropenia/agranulocytosis 2. seizures 3. myocarditis

Answer 215

preeclampsia, malnutrition, placental insufficiency, multiparty, drug use

Answer 216

genetic factors, chromosomal abnormalities, congenital infections, or inborn errors of metabolism

Answer 217

hypoxia, perinatal asphyxia, meconium aspiration, hypothermia, hypoglycemia, polycythemia

Answer 218

Path: plasmodium falciparum, P viva, P ovale, or P malariae parasites via bite of Anopheles mosquito Pt: periodic febrile paroxysms, nonspecific malaise, HA, N/V, abdominal pain, diarrhea, myalgia, pallor, jaundice, petechiae, hepatosplenomegaly Dx: thin and thick peripheral blood smears Tx: antimalarial drugs

Answer 219

1. Atovaquone-proguanil 2. doxycycline 3. mefloquine 4. chloroquine 5. hydroxychloroquine

Answer 220

children: seizure, coma, hypoglycemia, metabolic acidosis adults: jaundice, acute renal failure, acute pulmonary edema

Answer 221

1. rapid cooling: ice water immersion preferred; can consider: high-flow cool water dousing, ice/wet towel rotation, evaporative cooling 2. fluid resuscitation 3. electrolyte correction 4. management of end-organ complications 5. no role for antipyretic therapy

Answer 222

1. insulin resistance | 2. GI malignancy

Answer 223

1. insulin resistance 2. pregnancy 3. Crohn disease (perianal)

Answer 224

hepatitis C

Answer 225

celiac disease

Answer 226

1. HIV infection | 2. Parkinson disease

Answer 227

GI malignancy

Answer 228

inflammatory bowel disease

Answer 229

sodium bicarbonate; improves systolic BP, narrows the QRS complex, and decreases the incidence of ventricular arrhythmia

Answer 230

Path: smoke inhalation, defective heating systems, gas motors operating in poorly ventilated areas Pt: mild-mod: HA, confusion, malaise, dizziness, nausea severe: seizure, syncope, coma, MI, arrhythmias Dx: ABG: carboxyhemoglobin level, ECG +/- cardiac enzymes Tx: high-flow 100% O2, intubation/hyperbaric O2 if severe

Answer 231

loss of cortical tissue volume with ventricular enlargement + decreased volume of the hippocampus and amygdala

Answer 232

structural abnormalities in the orbitofrontal cortex and basal ganglia

Answer 233

Path: T cell-mediated injury to podocytes: most common cause of nephrotic syndrome in children, median age 2-3 yo Pt: edema, fatigue Dx: proteinuria, renal biopsy without microscopic changes Tx: corticosteroids

Answer 234

Path: pseudo allergic reaction to NSAIDs, occur in patients with comorbid asthma,a, chronic rhino sinusitis with nasal polyposis, or chronic urticaria Pt: asthmatic symptoms (cough, wheezing, chest tightness), nasal and ocular symptoms (nasal congestion, rhinorrhea, or periorbital edema), and facial flushing within 30 minute to 3 hours after NSAID ingestion)

Answer 235

1. inadequate dietary intake 2. disorder of fat malabsorption (cystic fibrosis, biliary atresia) 3. disorders of intestinal inflammation (celiac disease, inflammatory bowel disease 4. decreased production by bacterial flora (frequent Abx use)

Answer 236

factors II, VII, IX, and X (2, 7, 9, 10, Vitamin K will help you win) and protein C and S; PT will be prolonged (aPTT will only be prolonged in severe vitamin K deficiency

Answer 237

Pt: elderly patients, bradycardia (fatigue, dyspnea, dizziness, syncope), bradycardia-tachycardia syndrome (atrial arrhythmias (a fib), palpitations) ECG: sinus bradycardia, sinus pauses (delayed P waves), senatorial nodal exit block (dropped P waves) Tx: pacemaker, +/- rate-control medication (if tachyarrhythmias)

Answer 238

Dz associations: lymphoproliferative or hematologic (ex: multiple myeloma) Pt: asymptomatic, hyper viscosity (blurry vision), thrombosis (Raynaud phenomenon), skin (livedo reticularis, purpura) Complement levels: normal

Answer 239

Dz associations: chronic HCV, HIV, SLE Pt: systemic: fatigue, arthralgias; renal: glomerulonephritis, HTN; pulmonary: dyspnea, pleurisy; skin: palpable purpura, leukoclasitc vasculitis

Answer 240

antiphospholipid antibody syndrome

Answer 241

Path: peripheral neuropathy involving cranial nerve VII Pt: acute-onset unilateral facial drooping involving the upper and lower face; may be preceded by a prodrome of auricular pain or dysacusis (distortion of sound); may hav decreased tearing, hyperacusis, and a reduced sense of taste Tx: oral glucocorticoids You can tell the difference between Bell palsy and stroke bc Bell palsy involves the upper and lower face while stroke typically spares the upper face.

Answer 242

Pt: leg discomfort, leg pain, leg swelling that is worse in the evening or following prolonged standing; improves with walking or leg elevation; pitting edema, medial malleolus ulcer Risk factors: advancing age, obesity, family history, pregnancy, sedentary lifestyle, previous LE trauma, and previous LE venous thrombosis

Answer 243

Path: mutation in TSC1 or TSC2; autosomal dominant Pt: derm: ash-leaf spots, angiofibromas of the malar region, shagreen patches neuro: CNS lesions (subependymal tumors), epilepsy (infantile spasms), intellectual disability, autism & behavior disorders CV: rhabdomyomas Renal: angiomyolipomas Screening: Tumor screening: regular skin and eye examinations, serial MRI of the brain and kidney, baseline echo + serial ECG Baseline EEG neuropsychology screening

Answer 244

Path: autosomal dominant neurocutaneous disorder Pt: seizures, intellectual disability, hyper pigmented cafe au lait macules, axillary freckling, and neurofibromas f/u: optic nerve glioma

Answer 245

Path: autosomal dominant disorder PT: hearing loss and tinnitus in young adults; vestibular schwannomas f/u: intracranial meningiomas and cutaneous plaques can occur

Answer 246

MVP is caused by myoxmatous degeneration of the mitral valve leaflets and chordae; presents with amid-systolic click followed by a mid-to-late systolic murmur MVP is the most common cause of mitral regurgitation. MR presents with displaced apical impulse, holosystolic murmur, and third heart sound

Answer 247

1. bronchitis 2. lung cancer 3. bronchiectasis

Answer 248

1. mitral stenosis | 2. acute pulmonary edema

Answer 249

Path: 1. exacerbation of pulmonary disease (COPD) 2. Electrolyte disturbance (hypokalemia) 3. catecholamine surge (sepsis) Pt: typically asymptomatic; rapid, irregular pulse; ECG> >/=3 p-wave forms + atrial rate >100/min Tx: correct underlying disturbance; AV nodal blockade (verapamil) if persistent

Answer 250

1. PaCO2 elevated or normal (suggests inability to meet increased respiratory demands and impending respiratory failure) 2. markedly decreased breath sounds 3. absent wheezing 4. decreased mental status 5. marked hypoxia with cyanosis

Answer 251

``` Path: majority X-linked recessive Pt: recurrent pulmonary + cutaneous infections with catalase-positive pathogens (S aureus, Serratia, Burkholderia, Aspergillus) Dx: neutrophil function testing: 1. dihydrorhodamine 123 test 2. nitro blue tetrazolium test ```

Answer 252

Pt: asymptomatic; scattered, erythematous papule and pustules Tx: none

Answer 253

3 Types: 1. vesicular clusters on the skin, eyes, + mucous membranes 2. CNS infection 3. Fulminant, disseminated, multiorgan disease Tx: acyclovir

Answer 254

Pt: fever, irritability; diffuse erythema -> flaccid, flexural blistering; positive Nikolsky sign Tx: oxacillin, nafcillin, or vancomycin

Answer 255

Pt: Upper resp: sinusitis/otitis, saddle-nose deformity Lower resp: lung nodules/cavitation Renal: rapidly progressive glomerulonephritis Skin: livedo reticularis, non healing ulcers Dx: ANCA: PR3 (~70%), MPO (~20%) Biopsy: Skin (leukocytoclastic vasculitis), kidney (pauci-immune glomerulonephritis), lung (granulomatous vasculitis) Management: corticosteroids + immunomodulators (MTX, cyclophosphamide)

Answer 256

decreased REM sleep latency, decreased slow-wave sleep, and increased REM sleep duration and density

Answer 257

Pt: young adults (<55 yo), viral prodrome (fever, malaise, myalgias), heart failure (dyspnea, orthopnea, edema), chest pain, sudden cardiac death ``` Dx: ECG: nonspecific Echo: 4-chamber dilation cardiac MRI: late enhancement of the epicardium biopsy: lymphocytic infiltration, viral DNA or RNA ``` Tx: medication (diuretics, ACE inhibitor, beta blocker), temporary ventricular assist device if needed, heart transplant if no recovery

Answer 258

Fever for >/= 5 days, cervical lymph node > 1.5 cm, rash, bilateral nonexudative conjunctivitis, mucositis, swelling and/or erythema of palms/soles

Answer 259

Epidemiology: 90% age <5; increased incidence in East Asian ethnicity Dx criteria: Fever >/= 5 days plus >/= 4 of the following findings: 1. Conjunctivitis: bilateral, nonexudative 2. Mucositis: injected/fissured lips or pharynx, "strawberry tongue" 3. Cervical LAD: >/= 1 lymph node > 1/5cm in diameter 4. Rash: erythematous, polymorphous, generalized; perineal erythema and desquamation; morbilliform (trunk, extremities) 5. Erythema + edema of hands/feet Tx: aspirin + IVIg Complications: coronary artery aneurysms, myocardial infarction and ischemia

Answer 260

Historical clues: - prothrombotic disorder (ATIII deficiency) - cardiac disease (PFO) - vasculopathy (SCD) Key findings: - focal infarct on brain imaging

Answer 261

Historical clues: - recent trauma - bleeding disorder (hemophilia) - signs of increased ICP (vomiting, bradycardia) Key findings: - hemorrhage on brain imaging

Answer 262

Historical clues: - symptoms preceded by limb jerking or loss of consciousness - presence of poetical confusion Key findings: - symptoms self-resolve

Answer 263

Historical clues: - onset in adolescence - positive family history - history of headache with aura Key findings: - symptoms self-resolve

Answer 264

Clinical features: 1. RA: - severe erosive joint disease and deformity - rheumatoid nodules - vasculitis (mononeuritis multiplex, necrotizing skin lesions) 2. Neutropenia (ANC < 2000) 3. Splenomegaly Dx: 1. Anti-CCP + RF are positive in >90% of patients 2. Markedly elevated ESR, often >85 3. Peripheral smear + bone marrow biopsy to rule out other causes of neutropenia

Answer 265

Bugs: staph aureus and Bacillus cereus Symptoms: quick onset (1-6 hours), vomiting predominant

Answer 266

Bugs: Clostridium perfringens, ETEC/STEC, Vibrio cholerae Symptoms: delayed onset (>1 day), watery/bloody diarrhea

Answer 267

Bugs: Campylobacter jejuni, nontyphoidal salmonella, Listeria monocytogenes Symptoms: variable onset, watery/bloody diarrhea, fever, systemic illness (listeria)

Answer 268

coronary artery disease

Answer 269

pulmonary/pleuritis (pleurisy, pneumonia, pericarditis, PE) pericarditis - worse when lying flat PE, pneumo - respiratory distress, hypoxia

Answer 270

aortic (dissection, intramural hematoma)

Answer 271

GI/esophageal

Answer 272

chest wall/MSK

Answer 273

1. transvalvualr regurgitation (cusp degeneration) 2. Paravalvular leak (annular degeneration, infective endocarditis) 3. valvular obstruction/stenosis (valve thrombus)

Answer 274

1. new murmur (regurgitant or stenotic) 2. Macroangiopathic hemolytic anemia 3. Heart failure symptoms, thromboembolism

Answer 275

more commonly occurs with mechanical valves results from dehiscence of the valve from the aortic or mitral annulus, often due to annular degeneration or underlying infective endocarditits

Answer 276

more commonly affects bioprosthetic valves can result from cusp degeneration or occasionally valvular thrombus that impairs valve closure

Answer 277

brain abscess

Answer 278

Pt - HTN, metabolic alkalosis, hypokalemia, mild hypernatremia; no significant peripheral edema due to aldosterone escape Dx - 1. elevated plasma aldosterone, low plasma renin 2. Plasma aldosterone to plasma renin activity ratio > 20 suggests diagnosis 3. Adrenal suppression testing after oral saline load confirms diagnosis 4. Abdominal imaging (CT) and adrenal venous sampling to distinguish between unilateral adrenal adenoma and bilateral adrenal hyperplasia Tx - 1. Unilateral adrenal adenoma - surgery (preferred); aldosterone antagonists (spironolactone, eplerenone) for poor surgical candidates or patients refusing surgery 2. Bilateral adrenal hyperplasia - aldosterone antagonists

Answer 279

serum BUN > 60 mg/dL; tx = dialysis

Answer 280

E. coli and Strep agalactiae

Answer 281

osteomyelitis of the foot after a puncture wound of the plantar surface; IV drug abuses are also at risk of pseudomonas osteomyelitis

Answer 282

salmonella (encapsulated)

Answer 283

patients who have indwelling vascular (hemodialysis) catheters

Answer 284

cohort studies focus on a group of people whereas case control studies focus on outcomes to start. cohort studies can be prospective or retrospective whereas case control is retrospective (positive for disease, negative for disease -> look back at risk factor exposure)

Answer 285

group of inherited disorders characterized by epithelial fragility (bullae, erosions, ulcers) triggered by minor trauma. These conditions are caused by mutations of proteins involved in intrapeidermal and dermoepidermal adhesion complexes int he basement membrane zone look for friction-induced blisters at the palms and soles, thickening of the skin of the feet, and oral blisters with bottle-feeding as an infant Dx - biopsy of a fresh blister for immunofluorescence microscopy

Answer 286

``` Renal: 1. serum electrolytes (Na, K, Ca) 2. serum Cr 3. Urinalysis 4. Urine albumin/creatinine ratio (optional) Endocrine: 1. Fasting glucose or HgA1c 2. Lipid profile 3. TSH Cardiac: 1. ECG 2. Echo (optional) Other: 1. CBC 2. Uric acid (optional) ```

Answer 287

Diagnostic criteria for irritable bowel syndrome. Recurrent abdominal pain/discomfort >/= 1 day/week for the past 3 months + >/= 2 of the following: 1. related to defecation (improves or worsens) 2. change in stool frequency 3. change in stool form

Answer 288

1. Older age of onset (>/= 50) 2. GI bleeding 3. Nocturnal diarrhea 4. Worsening pain 5. Unintended weight loss 6. Iron deficiency anemia 7. Elevated C-reactive protein 8. Positive fecal lactoferrin or calprotectin 9. Family history of early colon cancer or IBD

Answer 289

Diagnostic criteria: 1. Obesity with BMI >/= 30 kg/m 2. Awake daytime hypercapnia (PaCO2 > 45 Hg) 3. No alternate cause of hypoventilation Workup: 1. ABG on room air (hypercapnia, normal A-a gradient) 2. No intrinsic pulmonary disease on CXR 3. Restrictive pattern on PFTs 4. Normal TSH 5. Polysomnography Treatment: 1. Nocturnal positive-pressure ventilation as first line therapy 2. Weight loss (bariatric surgery in select cases) 3. Avoidance of sedative medications 4. Respiratory stimulants (acetazolamide) as last resort

Answer 290

status epilepticus = seizure lasting > 5 minutes or a cluster of seizures with the patient not recovering a normal mental status in between cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures (MRI of brain will show cortical hyperintensity)

Answer 291

Etiology - extrusion of fluid from knee joint space into semimembranosus/gastrocnemius bursa Risk factors: trauma (meniscal tear), underlying joint disease (OA, RA) Presentation: asymptomatic bulge behind knee that diminishes with flexion; OR posterior knee pain, swelling, stiffness Complications: 1. venous compression (leg/ankle swelling) 2. Dissection into calf (erythema, edema, positive Homan sing) 3. Cyst rupture (acute calf pain, warmth, erythema, ecchymosis)

Answer 292

autosomal dominant diffuse telangiectasia (ruby-colored papule that blanch with pressure), recurrent epistaxis, and widespread arteriovenous malformations (AVMs)

Answer 293

AVMs in the lungs can shunt blood from the high tot the left side of the heart, causing chronic hypoxemia, digital clubbing, and a reactive polycythemia. Pulmonary AVMs can also present as massive, sometimes fatal, hemoptysis

Answer 294

1. hematologic malignancy (leukemia, lymphoma) 2. Infection (CMV, EBV, malaria) 3. Inflammatory disease (SLE, pancreatitis) 4. Splenic congestion (cirrhosis, pregnancy) 5. Medications (anticoagulation, G-CSF)

Answer 295

Pt - diffuse or LUQ abdominal pain, peritonitis; referred left shoulder pain (Kehr sign); hemodynamic instability Dx - acute anemia; intraperitoneal free fluid on imaging Tx - catheter-based angioembolization (stable patients); emergency splenectomy (unstable patients)

Answer 296

community-associated methicillin-resistant staph aureus (CA-MRSA) Pt - severe, necrotizing pneumonia that is rapidly progressive and often fatal; high fever, productive cough with hemoptysis, leukopenia, and multilobar cavitary infiltrates Tx - ICU admission, broad-spectrum empiric Abx, including either vancomycin or linezolid

Answer 297

1. Acamprosate - glutamate modulator at metabotropic glutamate receptor 5; first line treatment that can be used safely in patients with liver disease 2. Naltrexone - mu-opioid receptor antagonist; has been associated with hepatotoxicity so C/I with liver disease or those taking opioid medication 3. Disulfiram - second line therapy in highly motivated patients

Answer 298

1. pectus deformity 2. tall stature (increased arm:height ratio, decreased upper:lower segment ratio) 3. Arachnodactyly 4. Joint hyperlaxity 5. Skin hyperelasticity 6. Scoliosis

Answer 299

1. autosomal dominant 2. normal intellect 3. aortic root dilation 4. upward lens dislocation

Answer 300

1. autosomal recessive 2. intellectual disability 3. thrombosis 4. downward lens dislocation 5. megaloblastic anemia 6. fair complexion

Answer 301

Epidemiology: benign, slow growing; derived from remnants of Rathke pouch; bimodal age distribution (5-14 and 50-75) Pt: 1. optic chiasm compression -> bitemporal hemianopsia 2. pituitary stalk compression -> endocrinopathies: a. growth failure in children (decreased TSH or decreased GH) b. pubertal delay in children or sexual dysfunction in adults (decreased LH + FSH) c. diabetes insipidus (decreased ADH) Dx: MRI/CT scan: calcified and/or cystic suprasellar mas Tx: surgical resection +/- radiation therapy

Answer 302

time: acute involved artery: RCA pt: hypotension, clear lungs, Kussmaul sign echo: hypokinetic RV

Answer 303

time: acute or within 3-5 days artery: RCA pt: severe pulmonary edema; new holosystolic murmur echo: severe mitral regurgitation with flail leaflet

Answer 304

time: acute or within 3-5 days artery: LAD (apical septal) or RCA (basal septal) pt: chest pain, new holosystolic murmur, biventricular failure, shock echo: left-to-right ventricular shunt; increased O2 level from RA to RV

Answer 305

time: within 5 days (50%) to 2 weeks artery: LAD pt: chest pain, shock, distant heart sounds echo: pericardial effusion with tamponade

Answer 306

time: up to several months artery: LAD pt: subacute heart failure, stable angina echo: thin and dyskinetic myocardial wall

Answer 307

pathology is mediated by the release of exotoxins (toxin A and toxin B)

Answer 308

loud noises may induce sensorineural hearing loss (SNHL) via both mechanical damage and metabolic overload of cochlear hair cells; affected individuals experience bilateral, high-frequency SNHL

Answer 309

1. infection (infective endocarditis) with hematogenous spread 2. Hemoglobinopathy (sickle cell disease) 3. Immunosuppression (HIV) 4. IV drug use 5. Trauma

Answer 310

pt: 1. classic triad of fever, leukocytosis, and LUQ pain 2. Left-sided pleuritic chest pain with left pleural effusion commonly seen 3. possible splenomegaly dx: abdominal CT tx: combo of broad-spectrum Abx and splenectomy; possible percutaneous drainage in poor surgical candidates bugs: staph, strep, and salmonella

Answer 311

endocarditis

Answer 312

pt: 1. Systemic: fatigue, weakness 2. Skin: telangiectasia, sclerodactylyl, digital ulcers, alcinosis cutis 3. Extremities: arthralgias, contractures, myalgias 4. GI: esophageal dysmotility, dysphagia, dyspepsia 5. Vascular: Raynaud phenomenon serology: 1. antinuclear Ab 2. Anti-topoisomerase I (atni-Scl-70) Ab 3. Anticentromere Ab

Answer 313

Lung: interstitial lung disease, pulmonary arterial HTN Kidney: HTN, scleroderma renal crisis (oliguria, thrombocytopenia, MAHA) Heart: myocardial fibrosis, pericarditis, pericardial effusion

Answer 314

systemic sclerosis

Answer 315

1. long-standing HIV disease 2. Age >/= 5-0 3. CD4 count < 200

Answer 316

diffuse brain atrophy, ventricular enlargement and diffuse white matter changes

Answer 317

HAND has diffuse white matter lesions whereas PML has well-delineated, asymmetric white matter lesions. PML will also show focal cortical involvement, including motor deficits (focal arm/leg weakness or hemiparesis), ataxia, and vision abnormalities

Answer 318

Unrepaired, large VSDs can result in permanent pulmonary HTN and Eisenmenger syndrome (cyanosis from right-to-left shunting).

Answer 319

path: Malassezia globosa pt: hypo pigmented, hyper pigmented, or mildly erythematous lesions (face in children, turn and UE in adolescents + adults), +/- fine scale, +/- pruritus dx: KOH prep shows hyphae and yeast cells in a "spaghetti + meatballs" pattern tx: topical ketoconzaole, terbinafine, or selenium sulfide

Answer 320

1. substance abuse 2. chronic opioid use 3. hospitalized patients (esp post-op) 4. hepatic or renal insufficiency

Answer 321

1. somnolence, AMS 2. pinpoint pupils (mitosis) 3. shallow breathing + decreased RR 4. bradycardia, hypothermia, decreased bowel sounds 5. respiratory acidosis on ABG

Answer 322

mild: nonopioids (acetaminophen, NSAIDs) moderate: weak opioids +/- nonopioids (codeine, hydrocodone, tramadol) severe: strong short-acting opioids (morphine, hydromorphone) -> calculate total daily dose and convert to long-acting formulation (fentanyl patch, oxycodone) PLUS short-acting opioids for breakthrough pain

Answer 323

organisms: Streptococcus pneumonia, Neisseria meningitidis Abx: vancomycin + 3rd-gen cephalosporin

Answer 324

S. pneumoniae, N. meningitidis, Listeria Abx: vancomycin + ampicillin + 3rd-gen cephalosporin

Answer 325

S. pneumoniae, N. meningitidis, Listeria, gram negative rods Abx: vancomycin + ampicillin + cefepime

Answer 326

gram negative rods, MRSA, coagulase-negative staph Abx: vancomycin + cefepime

Answer 327

1. depressed serum iron level 2. increased TIBC 3. decreased serum ferritin level

Answer 328

normal to high serum iron and ferritin levels

Answer 329

1. below normal TIBC | 2. normal or increased serum ferritin level

Answer 330

normal to high serum iron and ferritin levels

Answer 331

laryngomalacia; presents with inspiratory stridor that worsens in supine position in an infant who is otherwise feeding and growing well ƒ

Answer 332

Micro: Hib Pt: distressed (tripod position, sniffing position, stridor), dysphagia, dysphonia, drooling, high fever Dx: X-ray: "thumb sign" (enlarged epiglottis) Management: intubation + Abx (ceftriaxone and vancomycin)

Answer 333

1. thin, smooth, regular wall 2. unilocular 3. no septae 4. homogenous content 5. absence of contrast enhancement on CT/MRI 6. usually asymptomatic 7. no follow-up needed

Answer 334

1. thick, irregular wall 2. multilocular 3. multiple septal, occasionally thick and calcified 4. heterogenous content (both solid + cystic) 5. presence of contrast enhancement on CT/MRI 6. May cause pain, hematuria, or HTN 7. Requires follow-up imaging + urological evaluation for malignancy

Answer 335

1. trigger (eg. emotional stress, prolonged standing) | 2. prodrome (eg. nausea, sweating, warmth)

Answer 336

tactile stimulus of carotid sinus while standing

Answer 337

1. orthostasis | 2. history of predisposing disease (eg. DM, Parkinson)

Answer 338

1. orthostasis | 2. history consistent with volume loss

Answer 339

1. syncope with exertion | 2. systolic murmur

Answer 340

1. no warning symptoms | 2. history of cardiomyopathy or ischemic HD

Answer 341

1. preceding fatigue or lightheadedness | 2. ECG abnormalities (eg. sinus pauses, dropped QRS)

Answer 342

Signs: oral thrush usually present; white plaques throughout esophagus Biopsy: pseudohyphae

Answer 343

Signs: orolabial lesions usually present; vesicular or ulcerative round/ovoid lesions ("volcano like") Biopsy: multinucleate giant cells

Answer 344

Signs: large, linear ulcers in distal esophagus Biopsy: intranuclear/intracytoplasmic inclusions

Answer 345

1. CNS disturbance (stroke, hemorrhage, trauma) 2. Medications (carbamazepine, SSRIs, NSAIDs) 3. Lung disease (pneumonia) 4. Ectopic ADH secretion (small cell lung cancer) 5. Pain and or nausea

Answer 346

1. mild/moderate hyponatremia: nausea, forgetfulness 2. severe hyponatremia: seizures, coma 3. Euvolemia (eg. moist mucous membranes, no edema, no JVD) Tx: fluid restriction +/- salt tablets; hypertonic (3%) saline for severe hyponatremia

Answer 347

1. hyponatremia 2. serum osmolality <275 (hypotonic) 3. urine osmolality > 100 4. urine sodium > 40

Answer 348

Genetics: autosomal recessive; loss of function, trinucleotide repeat (GAA) in frataxin gene Sx: neurologic deficits (cerebellar ataxia, dysarthria, loss of vibration and/or position sense, absent DTRs), hypertrophic cardiomyopathy, skeletal deformities (scoliosis), diabetes mellitus Prognosis: mean survival age 30-40; mortality due to cardiac dysfunction (arrhythmia, CHF)

Answer 349

Etiology: alcohol use, CF, ductal obstruction (malignancy, stones), autoimmune Pt: chronic epigastric pain with intermittent pain-free intervals; malabsorption: steatorrhea and weight loss; diabetes mellitus Labs: amylase/lipase can be normal + nondiagnostic; CT scan or MRCP can show calcifications, dilated ducts, and enlarged pancreas Tx: pain management, alcohol + smoking cessation, frequent, small meals, pancreatic enzyme supplements

Answer 350

Creutzfeldt-Jakob disease

Answer 351

Causes: primary (or tertiary) hyperparathyroidism, familial hypocalciuric hypercalcemia, lithium Labs: hypercalcemia + high-normal or elevated PTH

Answer 352

Causes: malignancy, Vit D toxicity, granulomatous diseases, drug-induced (thiazides), milk-alkali syndrome, thyrotoxicosis, Vit A toxicity, immobilization Labs: suppressed PTH W/u: measure PTHrP, 25-hydroxyvitamin D + 1,25-dihydroxyvitamin D

Answer 353

Path: infection of the mastoid air cells, complications of acute otitis media, most commonly due to Strep pneumoniae Pt: fever + otalgia; inflammation of mastoid; protrusion of the auricle; opacification of mastoid air cell son CT scan or MRI Mangament: IV Abe, drainage of purulent material (tympanovstomy, mastoidectomy) Complications: extra cranial extension ( subperiosteal abscess, facial nerve palsy, hearing loss, labyrinthitis); intracranial extension (brain abscess, meningitis)

Answer 354

fetal alcohol syndrome

Answer 355

a decrease in the volume of the frontal lobe

Answer 356

Sx: sudden, sustained contraction of the neck, mouth, tongue, + eye muscles Tx: benztropine, diphenhydramine

Answer 357

Sx: subjective restlessness, inability to sit still Tx: beta blocker (propranolol), benzodiazepine (lorazepam), benztropine

Answer 358

Sx: gradual onset after prolonged therapy (> 6 months): dyskinesia of the mouth, face, trunk + extremities Tx: valbenazine, deutrabenazine

Answer 359

Sx: difficult feeding, truisms; spasms + hypertonicity: clenched hands, dorsiflexed feet, opisthotonus Tx: supportive care; Abx + tetanus immune globulin Prevention: immunization; hygienic delivery + cord care

Answer 360

Hx: exposure to oxidizing substances (dapsone, nitrites, local/topical anesthetic) Pt: cyanosis; pulse ox sat ~85%; dark chocolate-colored blood Labs: saturation gap (>5% difference between oxygen saturation on pulse ox and ABG), normal PaO2

Answer 361

methylene blue; acts as an electron acceptor for NADPH and is reduced to leucomethylene blue, which in turn reduces methemoglobin to hemoglobin Alt: high-dose vitamin C can be used with methylene blue is unavailable or contraindicated (G6PD def)

Answer 362

dimercaprol

Answer 363

Resp tract features: chronic sinopulmonary infections, nasal polyps, bronchiectasis, digital clubbing Extra pulmonary features: situs inversus (50% cases), infertility due to immotile spermatozoa, normal growth

Answer 364

Resp tract features: chronic sinopulmonary infections, nasal polyps, bronchiectasis, digital clubbing Extra pulmonary features: pancreatic insufficiency, infertility due to absent vas deferens (azoospermia), failure to thrive

Answer 365

systemic disorder characterized by chronic rhinosinusitis, including nasal polyps, asthma, and prominent eosinophilia.

Answer 366

girls <8 and boys <9; evaluate bone age

Answer 367

Check basal LH -> low basal LH -> do GnRH stimulation test High basal LH -> central precocious puberty

Answer 368

Low LH -> peripheral precocious puberty High LH -> central precocious puberty

Answer 369

isolated breast development -> premature thelarche isolated pubic hair development -> premature adrenarche

Answer 370

beta blockers -> decrease myocardial contractility and HR

Answer 371

nondihydropyridine CCBs -> decrease myocardial contractility and HR

Answer 372

dihydropyridine CCBs -> coronary artery vasodilation -> decrease afterload by systemic vasodilation

Answer 373

long-acting, added for persistent angina; decrease preload by dilation of capacitance veins

Answer 374

ranolazine -> decrease myocardial calcium influx

Answer 375

Manifestations: 1. recurrent respiratory (pneumonia, sinusitis, otitis) + GI (Salmonella, Campylobacter) infections 2. Autoimmune disease (RA, thyroid disease) 3. Chronic lung disease (bronchiectasis) 4. GI disorders (chronic diarrhea, IBD-like conditions) Dx: significantly decreased IgG, decreased IgA/IgM; no response to vaccination Tx: immunoglobulin replacement therapy

Answer 376

early phase acute HBV

Answer 377

window phase of acute HBV

Answer 378

recovery phase of acute HBV

Answer 379

chronic HBV carrier

Answer 380

acute flare of chronic HBV

Answer 381

vaccinated against HBV

Answer 382

immune due to natural HBV infection

Answer 383

primarily in young women; associated with MS; immune-mediated demyelination

Answer 384

Pt: 1. acute, peaks at 2 weeks 2. monocular vision loss 3. eye pain with movement 4. "washed-out" color vision 5. afferent pupillary defect Dx: MRI of the orbits + brain Tx: IV corticosteroids

Answer 385

``` CVP (right-sided preload)- decreased PCWP (left-sided preload) - decreased cardiac index (LV output) - decreased SVR (after load) - increased SvO2 - decreased ```

Answer 386

``` CVP (right-sided preload) - increased PCWP (left-sided preload) - increased cardiac index (LV output) - decreased SVR - increased SvO2 - decreased ```

Answer 387

``` CVP (right-sided preload) - increased PCWP (left-sided preload) - decreased Cardiac index (LV output) - decreased SVR - increased SvO2 - decreased ```

Answer 388

``` CVP (right-sided preload) - decreased PCWP (left-sided preload) - decreased cardiac index (LV output) - increased SVR - decreased SvO2 - increased ```

Answer 389

trachoma path: caused by chlamydia trachomatis serotypes A, B, and C (leading cause of blindness worldwide) pt: often concomitant nasopharyngeal infection (rhinorrhea, pharyngitis) dx: clinical via examination of the tarsal conjunctivae; bug visible by Giemsa stain tx: azithromycin; eye surgery to preserve vision in case of trichiasis comp: repeated or chronic infection leads to scarring of the eyelids and inversion of the eyelashes (trichiasis); over time, the lashes rub on the eye and cause ulcerations and blindness

Answer 390

(ex: paroxysmal nocturnal hemoglobinuria, DIC); Hgb released binds to haptoglobin, and the hemoglobin-haptoglobin complex is cleared by the liver. Thus, decreased serum haptoglobin, elevated indirect bilirubin levels (from heme breakdown), and raised serum LDH (released from RBCs)

Answer 391

RBCs predominantly destroyed by phagocytes in the RES system (LNs, spleen); slightly low to normal haptoglobin, slightly elevated LDH, and elevated indirect bilirubin (ex: Ab-mediated RBC destruction (autoimmune hemolytic anemia) or intrinsic RBC enzyme (G6Pd) or membrane (hereditary spherocytosis) defects

Answer 392

AIHA - peripheral smear shows spherocytes without central pallor; NEGATIVE family history; POSITIVE Coombs test hereditary spherocytosis - same peripheral smear; STRONG family history; NEGATIVE Coombs test

Answer 393

Risk factors: occupational exposure (lead paint, batteries, ammunition, construction) Pt: GI (abdominal pain, constipation, anorexia), neurologic (cognitive deficits, peripheral neuropathy), hematologic (anemia) Labs: anemia, elevated venous lead level, elevated serum zinc protoporphyrin level, basophilic stippling on peripheral smear, hyperuricemia (due to impaired purine metabolism)

Answer 394

Etiology: autoimmune adrenalitis (most common), infection (TB), metastatic infiltration Pt: fatigue, weakness, anorexia/weight loss; nausea, vomiting, abdominal pain; salt craving, postural hypotension; hyperpigmentation; acute adrenal crisis: confusion, hypotension/shock Labs: hyponatremia, hyperkalemia, eosinophilia; low morning cortisol, high ACTH Tx: glucocorticoids, mineralocorticoids

Answer 395

Most common: pseudomonas aeruginosa Second most common: Staph aureus Treatment: topical antibiotic (fluoroquinolone) +/- topical glucocorticoid

Answer 396

1. folate deficiency 2. Vit B12 deficiency 3. Myelodysplastic syndromes 4. Acute myeloid leukemias 5. Drug-induced (hydroxyurea, zidovudine, chemotherapy agents) 6. liver disease 7. alcohol abuse 8. hypothyroidism

Answer 397

CS imaging is necessary if any of the following is present: 1. neurologic deficit 2. spinal tenderness 3. altered mental status 4. intoxication 5. distracting injury CT scan is the preferred screening test to evaluate for CS injury

Answer 398

hypokalemia (stimulate the Na-K-ATPase pump and the Na-K-2 Cl cotransporter); also stimulate the release of insulin, which further promotes intracellular K shift

Answer 399

Etiology: sterile exudate in pleural space Pleural fluid analysis: pH >/= 7.2, glucose >/= 60, WBC = 50,000 Pleural fluid gram stain + culture = negative Tx = Abx

Answer 400

Etiology: bacterial invasion of pleural space Pleural fluid analysis: pH <7.2, glucose <60, WBC > 50,000 Pleural fluid gram stain + culture: negative (usually false neg due to low bacterial count) treatment: Abx + drainage

Answer 401

causes: impaired CSF circulation, impaired CSF absorption, excessive CSF production pt: 1. macrocephaly +/or rapidly enlarging head circumference 2. prominent scalp veins 3. full anterior fontanelle 4. behavioral changes +/or developmental delay 5. signs of increased ICP (HA, vomiting, papilledema, HTN, bradycardia) evaluation: neuroimaging (U/S if open fontanelles, MRI if not)

Answer 402

Pt: depigmented macules on sacral areas + extensor surfaces; face commonly affected; lesions may be symmetrical, dermatomal, or unilateral course: 1. most cases progress gradually 2. regimentation is spontaneous in 10-20% of cases 3. increased incidence of other autoimmune disorders (lupus, thyroid, pernicious anemia, Addison dz) treatment: limited disease: topical corticosteroids extensive/unresponsive disease: oral corticosteroids, topical calcineurin inhibitors, PUVA (psoralen + UVA light)

Answer 403

laparotomy

Answer 404

laparotomy

Answer 405

consider CTAP (CT scan of abdomen + pelvis) or DPL (diagnostic peritoneal lavage); evaluate for other sources of hemorrhage

Answer 406

laparotomy

Answer 407

consider CTAP or serial abdominal examinations based on suspicion for intraabdominal injury

Answer 408

patients with mild disease probably only need PTU/methimazole; not recommended with opthalmopathy because it can worsen it (can give glucocorticoids to help prevent this though)

Answer 409

path - degeneration of the brainstem nuclei responsible for inhibiting spinal motor neurons during normal REM sleep -> incomplete or absent muscle atonia; can be a sign of subsequent Parkinson disease or dementia with Lewy bodies pt - dream enactment, can be awoken easily, often do not recall movement during sleep but recall dreams; more common in older adult men

Answer 410

1. idiopathic or viral pericarditis 2. cardiac surgery or radiation therapy 3. TB pericarditis (in endemic areas)

Answer 411

Pt: 1. fatigue + DOE 2. Peripheral edema + ascites 3. increased JVP 4. Pericardial knock may be heard 5. Pulsus paradoxus 6. Kussmaul's sign Dx findings: 1. ECG may be nonspecific or show atrial fibrillation or low-voltage QRS 2. Imaging shows pericardial thickening and calcification 3. JVP tracing shows prominent x + y descents

Answer 412

lack of the typical inspiratory decline in central venous pressure; constrictive pericarditis

Answer 413

``` Frequency: 10% age of onset: age < 18 Clinical features: 1. arthritis in >/= 1 joint for >/= 6 weeks 2. quotidian fever for >/= 2 weeks 3. evanescent rash 4. hepatosplenomegaly 5. LAD Sex ratio: F=M ```

Answer 414

``` Frequency: 40% age of onset: age 2-5 OR 10-14 clinical features: 1. arthritis in >/5 joints 2. may be complicated by uveitis sex ration: F >M ```

Answer 415

``` frequency: 50% age of onset: 2-4 clinical features: 1. arthritis in <5 joints 2. may be complicated by uveitis sex ratio: F > M ```

Answer 416

``` Pt: 1. LAD (cervical, supraclavicular, axillary) 2. HSM 3. mild thrombocytopenia + anemia 4. often asymptomatic Dx: 1. severe lymphocytosis + smudge cells 2. flow cytometry 4. LN + bone marrow biopsy not generally needed ```

Answer 417

Prognostic: 1. median survival 10 years 2. worse prognosis with: - multiple chain LAD - HSM - anemia + thrombocytopenia Complications: 1. infection 2. autoimmune hemolytic anemia 3. secondary malignancies (Richter transformation)

Answer 418

splenomegaly and pancytopenia

Answer 419

massive leukocytosis with a variety of neutrophil precursor cells (eg promyelocytes, myelocytes)

Answer 420

1. smoking 2. hereditary pancreatitis 3. nonhereditary chronic pancreatitis 4. obesity + lack of physical activity

Answer 421

Pt: 1. systemic symptoms (eg weight loss, anorexia), 2. abdominal/back pain 3. jaundice 4. recent-onset atypical diabetes mellitus 5. unexplained migratory superficial thrombophlebitis 6. hepatomegaly + ascites with metastasis Lab findings: 1. cholestasis (increased all phos + direct bilirubin) 2. increased CAA 19-9 3. abdominal ultrasound (if jaundiced) or CT scan (if no jaundice)

Answer 422

1. AMS (fussy behavior) 2. LOC 3. severe mechanism of injury (fall > 3 feet, high impact, MVC) 4. confrontal scalp hematoma 5. palpable skull fracture

Answer 423

1. AMS (somnolence, agitation) 2. LOC 3. severe mechanism of injury (fall > 5 feet, high impact, MVC) 4. vomiting, severe headache 5. basilar skull fracture signs (CSF, rhinorrhea)

Answer 424

rifampin, ciprofloxacin, or ceftriaxone

Answer 425

1. prosthetic valves 2. intravascular catheters 3. implanted devices 4. IV drug users

Answer 426

1. gingival manipulation | 2. respiratory tract incision or biopsy

Answer 427

1. prosthetic valves 2. intravascular catheters 3. implanted devices

Answer 428

nosocomial urinary tract infections

Answer 429

1. colon carcinoma | 2. inflammatory bowel disease

Answer 430

1. immunocompromised host 2. intravascular catheters 3. prolonged Abx therapy

Answer 431

neurofibromatosis 1

Answer 432

viral myocarditis

Answer 433

atrial septal defect

Answer 434

mitral stenosis

Answer 435

Etiology: 1. Neisseria gonorrhoeae 2. Chlamydia trachomatis 3. Mycoplasma genitalium 4. Trichomonas (rare) Pt: dysuria, discharge, urgency, increased voiding frequency Dx: urinalysis, gram stain + culture, NAAT Tx: azithromycin OR doxycycline PLUS ceftriaxone if gonococcus suspected or not ruled out

Answer 436

Decreased renal perfusion: 1. true volume depletion 2. decreased EABV (effective arterial blood volume) (eg heart failure, cirrhosis) 3. displacement of intravascular fluid (sepsis, pancreatitis) 4. renal artery stenosis 5. afferent arteriole vasoconstriction (NSAIDs)

Answer 437

1. increase in serum Cr (50% from baseline) 2. decreased urine output 3. BUN/Cr ratio > 20:1 4. fractional excretion of sodium < 1% 5. unremarkable ("bland") urine sediment Tx: restoration of renal perfusion

Answer 438

1. obesity 2. macromastia (large breasts) 3. sequelae of COPD (barrel chest deformity, chronic cough) 4. smoking 5. diabetes Tx - surgical emergency involving surgical exploration, debridement, and sternal fixation to prevent cardiac damage

Answer 439

porcelain gallbladder = calcium-laden gallbladder wall with bluish color and brittle consistency associated with chronic cholecystitis at increased risk of gallbladder adenocarcinoma cholecystectomy is considered for patients with porcelain gallbladder

Answer 440

Epidemiology: age > 50, increased risk with smoking, obesity, and chemical exposure Pt: 1. hematuria (microscopic or gross +/- clots) 2. abdominal/flank mass 3. flank pain 4. left-sided varicocele that does not decompress 5. paraneoplastic syndrome (EPO production or increased calcium) Dx: abdominal CT, partial/complete nephrectomy for histology

Answer 441

etiology: male > female, urethral trauma (catheterization) urethritis, radiotherapy Pt: weak or spraying strep, incomplete emptying, irritative voiding (dysuria, frequency)

Answer 442

dx: postvoid residual, uroflowmetry, urethrography, cystourethroscopy tx: dilation, urethroplasty Complications: acute urine retention, recurrent urinary tract infection, bladder stones

Answer 443

path: autosomal recessive, 21-hydroxylase deficiency Pt: 1. ambiguous genitalia in girls 2. salt-wasting syndrome (affects most girls and boys -> hypotension, dehydration + vomiting) Labs: decreased sodium, increased potassium, decreased glucose, increased 17-hydroxyprogesterone Tx: 1. glucocorticoids + mineralocorticoids 2. high salt diet 3. genital reconstructive surgery for girls 4. psychosocial support

Answer 444

excess androgen leads to virilization in female (46, XX) infants; male (46, XY) infants are phenotypically normal or hypervirilized (enlarged phallus)

Answer 445

acute glaucoma

Answer 446

Pt: fever, confusion, muscle rigidity (generalized), autonomic instability (abnormal vital signs, sweating) Tx: 1. stop antipsychotics or restart dopamine agents 2. supportive care (hydration, cooling), ICU 3. dantrolene or bromocriptine if refractory

Answer 447

``` Symptoms: bloody diarrhea, WL, fever Endoscopic findings: 1. erythema, friable mucosa 2. pseudopolyps 3. involvement of rectosigmoid 4. continuous colonic involvement (no skip lesions) Biopsy: mucosal + submucosal inflammation, crypt abscesses Complications: 1. toxic megacolon 2. primary sclerosing cholangitis 3. colorectal cancer 4. erythemanodosum, pyoderma gangrenosum 5. spondyloarthritis ```

Answer 448

``` description: staggering, wide-based associated signs: dysdiadochokinesia, dysmetria, nystagmus, Romberg sign causes: 1. cerebellar degeneration 2. stroke 3. drug/alcohol intoxication 4. vitamin B12 deficiency ```

Answer 449

description: magnetic (freezing): start and turn hesitation associated signs: dementia, incontinence, frontal lobe signs causes: 1. frontal lobe degeneration 2. normal pressure hydrocephalus

Answer 450

description: short steps, shuffling associated signs: bradykinesia, resting tremor, postural instability, decreased arm swing causes: Parkinson disease

Answer 451

description: foot drop - excessive hip and knee flexion hile walking, slapping quality, falls associated signs: distal sensory loss + weakness cause: motor neuropathy

Answer 452

description: unsteady, falling to one side associated signs: normal sensation, reflexes + motor strength; nausea, vertigo causes: acute labyrinthitis, Meniere disease

Answer 453

paget disease of bone; osteoclast dysfunction leads to bone breakdown and a compensatory increase in bone formation

Answer 454

Epidemiology: JC virus reactivation, severe immunosuppression (untreated AIDS) Pt: slowly progressive, confusion, paresis, ataxia, seizure Dx: 1. MRI of the brain: asymmetric white matter lesions; no enhancement/edema 2. Lumbar puncture: CSF PCR positive for JC virus 3. brain biopsy (rarely needed) Tx: often fatal; if HIV positive -> retroviral therapy

Answer 455

Definition: 1. hepatic steatosis on imaging or biopsy 2. exclusion of significant alcohol use 3. exclusion of other causes of fatty liver Pt: mostly asymptomatic, metabolic syndrome, +/- steatoheaptitis (AST/ALT ration <1), hyper echoic texture on u/s Tx: diet + exercise, consider bariatric surgery if BMI >/= 35

Answer 456

hilar LAD + interstitial infiltrates

Answer 457

papules, nodules + plaques; ereythema nodosum

Answer 458

anterior + posterior uveitis; keratoconjunctivitis sicca

Answer 459

facial nerve palsy, central diabetes insipidus, hypogonadotropic hypogonadism

Answer 460

AV block, dilated or restrictive cardiomyopathy

Answer 461

HSM, asymptomatic LFT abnormalities

Answer 462

Etiology: congenital or squired (rarely, carcinoid) Pt: severe: right-sided heart failure in childhood mild: symptoms (dyspnea) in early adulthood crescendo-decrescendo murmur (increased on inspiration) systolic ejection click + widened split of S2 Dx: echo Tx: percutaneous balloon valvulotomy (preferred), surgical repair in some cases

Answer 463

Acute toxicity: intentional overdose chronic toxicity: decreased renal perfusion (decreased lithium clearance): 1. dehydration 2. thiazide diuretics, NSAIDs, ACE inhibitors)

Answer 464

Acute toxicity: 1. GI: N/V/D 2. late neurologic sequelae Chronic toxicity (neurologic): 1. lethargy, confusion, agitation 2. ataxia, tremor/fasciculations, seizure Tx: IV hydration, hemodialysis (severe cases)

Answer 465

1. >/= 2 weeks 2. >/= 5 of 9 symptoms: depressed mood + SIGECAPS 3. significant functional impairment 4. no lifetime history of mania