UWorld Errata Flashcards
Dense deposits within GBM on EM in setting of proteinuria, hematuria, and IF positive for C3 is what glomerulopathy?
Activation of what pathway is responsible for the damage done by this disease?
Membranoproliferative glomerulonephritis, Type II
Causes by IgG antibodies (C3 nephritic factor) which causes persistent activation of the complement pathway by activating C3 convertase. Thus, most of this disease is complement mediated
What effect do oral contraceptive pills (OCPs; combined estrogen/progestin) have on risk for endometrial and ovarian cancer and how?
Name the three major risks of OCPs.
Reduce risk of endometrial and ovarian cancer. Endometrial risk reduced by progestin effect on stabilizing endometrium. Ovarian risk reduced by suppression of ovulation.
Hypertension, venous thromboembolism, hepatic adenoma
Patient presents with repeated history of edema (face, limbs, genitals, laryngeal, abdomen - causing colicky pain) without urticaria. What is the likely diagnosis and what is the pathogenic mechanism causing it?
What sorts of events do these episodes usually follow?
Hereditary angioedema due to C1 inhibitor deficiency which leads to elevation of bradykinin levels.
Infection, dental procedures, trauma
Young child presents with persistent ear drainage unresponsive to antibiotic therapy. Over the past week she is experiencing new unilateral hearing loss. On inspection of ear there is a retraction pocket of the TM with granulation tissue surrounding it and minor skin debris. What is the likely diagnosis?
Choleastoma
An IV drug user presents with fever, cough, and weakness. CXR shows scattered round lesions in the peripheral lung fields.
What does the patient have?
What valve is affected?
What type of murmur is appreciated?
What will happen to this murmur on inspiration and why?
- Infective endocarditis
- Tricuspid valve
- Tricuspid regurgitation
- Increases because inspiration causes a negative pressure which causes increased venous return that accentuates right-sided heart sounds
When a brain abscess results from sinusitis or some other head/neck infection what are the most common pathogens involved?
Viridans Streptococci (e.g. S. intermedius, S. mitis, S. oralis, S. mutans) Anaerobic bacteria
How does a disseminated gonococcal infection typically present?
Are blood cultures definitive?
What is the treatment?
Either purulent arthritis w/o skin lesions OR tenosynovitis, dermatitis, and a migratory asymmetric polyarthralgia w/o purulen arthritis
Blood cx are often negative
IV ceftriaxone followed by PO cefixime, joint drainage, empiric azithromycin or doxycycline for possible Chlamydial infection, treat sexual partners too.
What is the biggest risk factor for cerebral palsy?
How can the spasticity be managed?
Premature birth (
What is the INR goal for patients with idiopathic venous thromboembolism when treated with warfarin?
Goal INR is 2.5
Acceptable range is 2.0 - 3.0
Patient presents with itchy lesions over his trunk which are ring-shaped with central clearing and have scaly borders.
What is the diagnosis and what test/result is used to confirm?
Pathogen?
Tx?
Tinea corporis. Microscopic exam with KOH should reveal hyphae
Trichophyton rubrum
Topical terbinafine or systemic griseofulvin
Why is doxycycline not recommended for use in children and pregnant woman?
What is the treatment of choice for Lyme disease in pregnant woman?
Doxycycline can discolor teeth in children and retard skeletal development in children and fetuses
Amoxicillin
What classically presents with dyspareunia, dysmenorrhea, and dyschezia (pain with defecation)?
What is the recommended treatment and how does the treatment help to reduce symptoms?
Endometriosis
NSAIDs and OCPs. OCPs suppress ovulation which help reduce symptoms.
*If a patient has these classic symptoms then a definitive diagnosis does not have to be pursued unless the pain is severe, they need to exclude malignancy, or treat infertility
What are the best two measurement to follow when looking for resolution of diabetic ketoacidosis?
Serum anion gap and beta-hydroxybutyrate
A patient presents with mild gynecomastia, erectile dysfunction, decreased libido, but no headaches or visual changes. On work-up he has reduced testosterone. He has diabetes which is controlled. Do you continue your diagnostic work-up or treat and what is the next step?
Check prolactin levels first. If high then a brain MRI is warranted. If normal you may opt to treat with testosterone therapy.
An alcoholic patient who is also a vegetarian presents with lethargy and pallor. You treat with thiamine and folic acid. A few months later he returns with increasing forgetfulness and falls. What did he have and what happened after treating with folic acid?
He likely had a combination folic acid and B12 deficiency from being an alcoholic and vegetarian. By treating with folic acid you likely helped his folic acid deficiency anemia and reduced his megaloblastosis but no treating with any vitamin B12 likely caused rapid progression of B12-related neurologic symptoms
Are uric acid stones radiolucent or radioopaque?
What is the appropriate treatment?
Radiolucent
Hydration, alkalinization of urine with potassium citrate, and a low purine diet
A patient presents after being involved in an unrestrained MVA with chest pain, SOB, and tachycardia. He has a broken femur. Upon administration of 2 liters IV fluids his symptoms continue and worsen. What is the most likely diagnosis?
Pulmonary contusion secondary to blunt trauma
Fat embolism is less likely since it takes 12-72 hrs to manifest and often had petechiae present too
T/F
Patients with primary hyperaldosteronism often don’t have spontaneous hyperkalemia.
What can precipitate hyperkalemia in these patients?
True
Diuretic-use can lead to large hypokalemia
What disease is dermatitis herpetiformis associated with and what are treatment options?
Celiac disease
Follow a gluten-free diet. Dapsone.
What are typical treatments for Tourette’s disorder?
1) First gen antipsychotics (e.g. Haloperidol, Pimozide)
2) Second gen antipsychotics
3) Alpha adrenergic receptor agonists (e.g. clonidine, guanfacine)
An adult presents with recurrent bacterial infections. What test should you do first?
Measure serum IgG levels to check for selective immunodeficiency
What does thyrotoxicosis due to blood pressure and circulation and how?
Increases blood pressure and leads to increased cardiac output and atherosclerosis
What drugs most commonly cause a serum-sickness like reaction?
What are the symptoms?
B-lactams and sulfa drugs
Fever, urticaria, arthralgia, and lymphadenopathy
What is vasa previa?
Vasa previa: fetal blood vessels traverse lower segment of uterus between fetus and internal cervical os which are prone to rupture.
How is schizoaffective disorder distinguished from major depression with psychotic features?
Both may have concurrent depression and psychosis. However, schizoaffective disorder has a >2 week period of psychosis in absence of depressive symptoms
Rheumatic heart disease due to untreated S. pyogenes infection commonly leads to what valvular abnormality?
Why is it more common to become symptomatic during pregnancy?
Mitral stenosis
During pregnancy patients become more fluid overloaded making pulmonary edema development more likely.
How does lactation itself exert its anticontraceptive effect?
What are acceptable methods of contraception in the immediate postpartum period?
Lactation is from prolactin which has an anovulatory effect by suppressing GnRH release.
Sterilization, IUDs, barrier methods, and progestin-based contraceptives. Progestins won’t effect milk volume or infant the way estrogen may
In patients who present with elevated ALP and hyperbilirubinemia what imaging modality will you use to further refine your differential?
Ultrasound to distinguish intrahepatic from extrahepatic cholestasis
What is enthesitis and in what disease does it commonly occur?
How may this present?
Enthesitis: inflammation occurring where tendons and ligaments attach to bone
Common in ankylosing spondylitis
May present with pain at heel, tibial tuberosities, and iliac crests
What do loop diuretics do to potassium levels?
Hypokalemia
Also a contraction alkalosis
Match the following terms with their appropriate study:
Odds ratio
Relative risk
Case-control study
Cohort study
In what situation does OR approximate RR?
Case-control studies yield odds ratios
Cohort studies yield relative risks
OR approximates RR when the disease is rare
A patient with a history of pelvic fracture and accompanying urethral injury s/p realignment presents with erectile dysfunction. What is the likely cause of his erectile dysfunction?
Damage to parasympathetic nerves and likely altered arterial supply during injury and realignment
Hemolytic anemias, including those which are microangiopathic, have what types of disturbances to haptoglobin, LDH, and bilirubin?
Decreased haptoglobin
Elevated LDH
Elevated bilirubin
What is the normal vaccination schedule for DTaP and TdaP booster?
What is the treatment of pertussis?
Five doses of DTaP between 2 months and 6 years of age
One TdaP booster between age of 11 and 18
Macrolide antibiotics (e.g. azithromcyin, clarithromycin)
Describe ecthyma gangrenosum
What pathogen typically causes it?
Starts as erythematous macule progressing to nodule with necrosis
Pseudomonas aeruginosa
If a patient presents with cough and sore throat followed by signs of reduced cardiac output in coming days (e.g. dizziness, weakness, syncope) with pulsus paradoxus on exam what do they have?
Cardiac tamponade secondary to acute viral pericarditis
What is the FEV1/FVC ratio in restrictive disease?
Obstructive disease?
Restrictive disease it is normal or > 80%
Obstructive disease it is
Paraneoplastic Cushing Syndrome is caused by what hormone release?
Why is their hyperpigmentation as well in this situation?
ACTH
ACTH has melanocyte-stimulating hormone as a cleavage product which leads to the hyperpigmentation
Pleural effusion caused by tuberculosis often has what characteristic findings for:
Protein:
Glucose:
WBC:
Protein: High, often > 4g/dL
Glucose: Mildly low compared to serum values
WBC: Lymphocytic predominance
Greater than ____ neutrophils/uL is considered diagnostic of spontaneous bacterial peritonitis in a paracentesis.
250
Why are LDH and CPK often elevated in patients with polymyositis?
They are the products of muscle breakdown in these patients
Does postictal confusion occur in patients with typical absence seizures?
What is a common cause of complex partial seizures in adults?
No
Temporal lobe epilepsy
What indicates stable ventricular tachycardia?
What is the immediate treatment of a patient with stable ventricular tachycardia?
Hemodynamic instability, so the presence of a pulse and no hypotension
Amiodarone
The presence of a shiny, thin, hairless extremity with a nonhealing ulcer should raise suspicion of what disease?
Peripheral vascular disease
Do an ABI
Patients who have gastric bypass surgery are at greater risk for developing _________.
Since that is the case they are often offered elective _____ at the same time.
If the deny the elective procedure they should receive ______ in the period after bypass surgery.
Gall stones
Cholecystectomy
Ursodeoxycholic acid
Describe how secondary hyperparathyroidism manifests itself
ESRD leads to hypocalcemia from failed activation of vitamin D and phosphate retention.
This produces a stimulus for PTH release and subsequent PTH gland hyperplasia
Is peritonitis considered somatic or visceral pain?
Somatic
What is used as prophylaxis to prevent esophageal variceal hemorrhage in patients with cirrhosis or ascites?
B-blockers
Do neoplasms of the gallbladder typically cause jaundice?
What should lead a differential when painless jaundice is the major complaint? What findings would you expect with labs?
No
Pancreatic cancer; elevated ALP, Tbili, mild elevations of LFTs
The CXR of a smoker has a unilateral upper lobe infiltrate with cavitation and hilar lymphadenopathy. What is this classic for?
Tuberculosis
At what age range do patients with CLL usually present?
What cell type predominates?
How can you explain anemia and thrombocytopenia in these patients?
What is a monoclonal Ab treatment?
60s to 70s
Lymphocytes
CLL pts often have concomitant autoimmune hemolytic anemia and immune-mediated thrombocytopenia
Rituximab (anti-CD20)
What bacteria are sickle cell patients particularly susceptible to?
What are the common pathogens responsible for the following diseases in sickle cell patients:
Pneumonia
Osteomyelitis/Septic arthritis
Sepsis
Meningitis
Encapsulated organisms: Strep, Neisseria PNA: Strep pneumoniae Osteomyelitis/septic arthritis: Staph aureus, Salmonella Sepsis: Strep pneumoniae Meningitis: Strep pneumoniae
Dilation of small bowel greater than ___ cm on radiograph and absence of air in colon suggests small bowel obstruction
3 cm
What is the procedure or treatment of choice in relieving intrahepatic and extrahepatic cholestasis, respectively?
Extrahepatic cholestasis: place endoscopic stent in common bile duct
Intrahepatic cholestasis: Ursodeoxycholic acid
Multiple myeloma is likely to lead to renal failure. Does it generally do this by affecting renal tubular or glomerular function and how?
Renal tubules are usually damaged by light chains
Hemoglobin A is the main Hb in human blood. What chains make it up?
How many alpha globin genes and beta globin genes are there within the human genome?
What are the types of alpha thalassemia based on number of alpha globin genes?
4 alpha globin genes (two on each chromosome 16) and 2 beta globin genes (one on each chromosome 11)
If all 4 alphas are mutated: hydrops fetalis
If 3 alphas are mutated: hemoglobin H (four beta chains) forms
If 2 alphas are mutated: heterozygous alpha thalassemia minor
In the presence of pre-existing joint abnormality (e.g. RA), what is more likely as the cause of fever and a monoarticular arthritis: septic arthritis or RA?
Septic arthritis
Do an arthrocentesis promptly before considering the use of antibiotics
A neonate presents with bilious vomiting and on upper GI series there is a corkscre-shaped duodenum. What should this raise concern for?
Intestinal malrotation or volvulus
What are the most common causes of bacterial meningitis in adults up to 60 years of age? What is empiric therapy?
When older than 60 and also immunocompromised what other pathogen must be accounted for? What drug should be added on?
S. pneumoniae, N. meningitidis, H. influenzae. Ceftriaxone and Vancomycin
Listeria monocytogenes. Ampicillin
What and where is the murmur of aortic regurgitation heard?
Decrescendo diastolic murmur over the left sternal border
In the pediatric population what pharyngitis symptoms generally indicate a viral pharyngitis?
What symptoms are concerning for bacterial pharyngitis warranted a rapid strep test and possible culture?
Viral pharyngitis: Cough, rhinorhea, oral ulcers
Bacterial pharyngitis: Exudates, palatal petechiae, absence of viral symptoms
Poststreptococcal glomerulonephritis is often seen following certain group A Strep infections. Which ones are more likely to precede it?
Impetigo
Describe the mechanism of urge incontinence vs overflow incontinence.
What is the first line treatment for urge incontinence?
Urge incontinence: detrusor instability leads to uninhibited contractions which lead to a sensation of voiding and leakage, often en route to the bathroom.
Overflow incontinence: Often neurogenic, but inability to sense need to void leads to intrabladder pressures that surpass urethral pressures leading to leakage
Urge Incontinence: first line is timed voids and creating a void schedule
Henoch-Schonlein Purpura
Takayasu’s arteritis
Wegener’s
Churg-Strauss Syndrome
Which is a leukocytoclastic vasculitis and which are granulomatous?
HSP is leukocytoclastic
A 55 yo male with a history of atherosclerosis, smoking, and HTN presents with new low back pain. On exam you hear a right carotid bruit. What emergent condition on your differential should you rule out first?
Abdominal aortic aneurysm
A patient presents after blunt chest trauma with a widened mediastinum on CXR. What is the next appropriate imaging modality to use for diagnosis confirmation?
CT scan of chest
Trans-esophageal echocardiogram
Where are Bartholin glands located?
How do cysts or abscesses at this location present and what is the appropriate treatment?
4 and 8 o’clock positions of labia majora
Obstruction of the ducts can lead to cyst or abscess formation. Will present as a tender, fluctuant mass that is very painful, especially during intercourse, sitting, or even walking.
Incision and drainage is recommended
What is appropriate therapy or management for patients with long-term cocaine use and addiction?
Psychotherapy and 12-step groups
*Chronic cocaine addiction may cause a “cocaine crash” the following days presenting as depresssion
What is the mechanism of action of the following migraine abortive medications?
Triptans
Ergots (e.g. dihydroergotamine)
Both are 5HT agonists which cause vasoconstriction and decrease neurogenic inflammation
What are the diagnostic criteria for Kawasaki disease (5 items)?
What serious complication are they at risk for and what may be given to them to reduce the risk of this complication (2 items)?
Fever greater than 5 days and 4 of the following 5 items
(i) Cervical lymphadenopathy >1.5 cm
(ii) Bilateral conjunctivitis
(iii) Mucosal ulcers, cracked lips, “strawberry tongue”
(iv) Polymorphous rash
(v) Erythema of hands and feet
Coronary artery aneurysms; intravenous immune globulin and aspirin
(one of the few reasons to give aspirin to a child)
Your elderly patient presents with painless vision loss which is worse at night. She describes a “glare” in her visual field when looking at bright lights. What is the likely diagnosis?
Cataracts (opacification of lens)
What medications have been shown to increase long-term survival in patients with decompensated CHF (e.g. LV systolic dysfunction)?
ACE inhibitors, ARBs, Beta-blockers, Spironolactone, and a combination of hydralazine and nitrates in African-American patients
*Certain beta-blockers indicated: metoprolol succinate, carvedilol, bisoprolol
What is the mechanism by which pulmonary edema develops in patients with pre-eclampsia/eclampsia?
Generalized arterial vasospasm increases afterload on heart which leads to elevated pulmonary capillary pressures and development of pulmonary edema
Also contributing are increased capillary permeability, decreased renal function, and reduced serum albumin
What are the expected values for protein and LDH in exudative pleural fluid?
What is a normal pH of pleural fluid? What pH is often found in transudate vs exudate?
Pleural protein/serum protein > 0.5
Pleural LDH/serum LDH > 0.6
Pleural LDH > 2/3 upper limit normal serum LDH
7.60
Transudate 7.40-7.55
Exudate 7.30-7.45
An HIV patient presents with a bright red, friable, firm, exophytic nodule. What is the likely diagnosis? Causative agent? Tx?
Bacillary angiomatosis
Bartonella
Erythromycin (macrolide)
Young male presents with mucopurulent urethritis but no organisms are isolated on gram stain or culture. What is the likely diagnosis?
Chlamydial urethritis
Need to do a nucleic acid amplification test
What are you more likely to see a pleural effusion in Strep pneumo or Pneumocystis pneumonia?
What is the most common cause of pneumonia in HIV infected patients?
Pleural effusion more likely in Strep pneumoniae
Strep pneumoniae
Ectopic foci located where generally cause afib?
Pulmonic veins
Are fever and leukocytosis reliable signs in vertebral osteomyelitis?
What is the most reliable sign?
No, fever and WBC count aren’t reliable
Tenderness to percussion over the vertebra
What is the treatment of immune thrombocytopenia?
How does treatment differ in children and adults?
IV Ig or glucocorticoids
In children, spontaneous recovery is likely so they should be OBSERVED if they only have cutaneous signs w/o evidence of bleeding.
Adults should be observed if platelets > 30K but should be treated if platelets are lower than that
What is the stepwise approach to treating ascites (4 steps)?
1) Sodium and water restriction
2) Spironolactone
3) Loop diuretic (i.e. furosemide)
4) Frequent abdominal paracentesis
A young patient presents with bilious vomiting and abdominal distension. On radiograph you see dilation of the stomach, duodenum, and jejunum (“triple bubble” sign) with little air in the colon or rectum. Dx?
Jejunal atresia
Cat bites place patients at increased risk for which infection?
What is the treatment of choice (prophylactic and therapeutic)?
Pasteurella multocida
Amoxicillin/calvulanate
Tamoxifen has various effects throughout the body. List the effects at:
Breast
Endometrium
Bone
Breast: antagonist and used in treatment of ER positive breast cancers
Endometrium: agonist and increases the risk of endometrial carcinoma
Bone: agonist and decreases risk of osteoporosis
Name as many antidepressants as you can in each of the following classes:
SSRI SNRI Tricyclic MAOI Atypicals
If a patient doesn’t improve on an antidepressant at first, then what should be your next drug of choice?
SSRI: sertraline, citalopram, paroxetine, fluoxetine
SNRI: duloxetine, venlafaxine, desvenlafaxine
TCAs: amitryptiline, clomipramine, doxepin, nortryptiline
MAOI: phenelzine, tranylcypromine
Atypicals: mirtazapine, bupropion, trazodone
The second chosen antidepressant should be within the same class (usually SSRI) but if that one fails too then consider another class
Describe how being hyperandrogenic in PCOS leads to increased risk of endometrial cancer in such patients.
Androgens will be converted to estrogens peripherally. Since PCOS patients are anovulatory they have reduce progesterone. The imbalance between estrogen and progesterone leads to endometrial hyperplasia and increased risk of endometrial cancer
A patient with small, radiolucent gallstones denies an elective cholecystectomy. What is the next treatment you should recommend given surgery is not in the patient’s wishes?
Ursodeoxycholic acid if the gallbladder is functioning normally, but this is expensive.
Most kidney stones are made of what?
Calcium oxalate
Hepatocytes staining positive for PAS and resisting digestion by diastase are often indicative of what genetic disorder?
Alpha-1 antitrypsin deficiency
How is schizoaffective disorder diagnosed and how is it different from schizophrenia?
Schizophrenia symptoms with prominent mood symptoms. There should be a 2 week period of psychotic symptoms in the absence of mood symptoms.
Schizophrenia generally does not have mood symptoms and if they are there they’re usually transient.
What are the signs and symptoms of strangulation in a SBO?
What management is indicated?
Fever, tachycardia, leukocytosis, metabolic acidosis
Surgical intervention to relieve the acute strangulation
How does intussusception usually present?
Before the age of two, what is the most common cause?
After two (or recurrent intussusception) what causes should be considered?
Excruciating abdominal pain (pts may draw knees up to relieve), currant jelly stools, “target sign” on ultrasound
Viral causes (e.g. rotavirus) may cause. No lead point is noticed.
After two (or recurrent) there is usually a pathologic lead point e.g. Meckel’s diverticulum, HSP, Celiac disease, tumors, polyps
Tx: enema or surgical removal of lead point
What are common causes of fetal growth restriction?
Separate based on symmetric and asymmetric FGR.
Symmetric (often first timester): chromosomal, congenital heart disease, intrauterine infections
Asymmetric: vascular (HTN, DM), autoimmune, substance abuse, APAS, cyanotic cardiac disease
A healthy, sexually active, 17 yo girl presents to your office. She has no complaints and is doing well overall. What screening test should you offer her?
Screen for Chlamydia and Neisseria. Recommended to screen all sexually active women 24 or younger.
Can also offer an HPV vaccine
What is the most common cause of congenital aplastic anemia?
How is it acquired?
Besides bone marrow abnormalities, what other features are seen (e.g. appearance, skin, eyes/ears)?
Fanconi Anemia
Autosomal recessive
Appearance: Hypogonadism, Abnormal thumbs, Microcephaly, Short
Skin: Hypopigmented cafe au lait, large freckles
Eyes/Ears: Strabismus, low set ears, middle ear abnormalities
What is the mode of transmission of Duchenne, Becker, and Myotonic muscular dystrophies?
Duchenne: X-linked recessive
Becker: X-linked recessive
Myotonic: Autosomal dominant with a trinucleotide repeat expansion
Precocious puberty happens to girls
Adrenal androgens from the adrenal glands
What are Stanford type A and type B aortic dissection?
How does management differ for the two?
What is the anti-hypertensive med of choice?
Stanford type A: Ascending aortic dissection
Stanford type B: Descending aortic dissection
Type A require medication and surgery
Type B require medication only
Labetalol is the anti-hypertensive medication of choice
What is emphysematous cholecystitis?
What is seen on radiographs and ultrasounds, respectively?
Gall bladder wall infection due to gas-forming bacteria infection (e.g. Clostridium, Escherichia, Staph, Strep, Pseudomonas, Klebsiella).
Occurs more often in elderly male diabetics
Radiograph: air-fluid level in GB
Ultrasound: curvilinear gas shadowing in GB
What is vaginismus?
What is tx?
Involuntary contraction of perineal muscles
Kegel exercises and gradual dilation
How do you distinguish anovulation from premature ovarian failure by looking at the FSH and LH levels?
In anovulation (e.g. from morbid obesity) the FSH and LH levels will be low
In premature ovarian failure the LH and FSH levels will be elevated (negative feedback phenomenon)
What is the mode of inheritance in Wiskott-Aldrich syndrome?
What is the classic triad seen?
X-linked disorder
Thrombocytopenia, Eczema, Recurrent Infections (Mnemonic: WATER)
Thrombocytopenia is due to impaired platelet production and the platelets that are present are typically small
Bedwetting is normal until what age?
After that age what therapies are recommended for persistent bedwetting?
Normal until 5 yo
Enuresis alarms, desmopression (make sure to do a urinalysis to r/o conditions like DM)
Warts are caused by what infectious agent?
Human papillomavirus (HPV) infection
What is the treatment of Guillain-Barre Syndrome?
IV Ig or plasmapharesis
What type of adrenal insufficiency does chronic glucocorticoid use lead to, primary or central?
What findings would you expect for ACTH, cortisol, and aldosterone in primary and central, respectively?
Chronic glucocorticoid use leads to central adrenal insufficiency
Central: Low ACTH, Low cortisol, Normal aldosterone
Primary: High ACTH, Low cortisol, Low aldosterone
Necrotic migratory erythema is a characteristic of what disorder?
NME: erythematous papules/plaques which may enlarge and coalesce. Central clearing, blistering, crusting, and scaling
Glucagonoma
*The hyperglycemia is often mild. There’s also usually an anemia present (normocytic, normochromic). May also present with diarrhea, anorexia, and neuropsych symptoms.
Muffled voice or tonsillar deviation should make you concerned about what infection in patients with suspected pharyngitis or tonsilitis?
What is appropriate management?
Peritonsillar abscess
Needle aspiration with IV antibiotics
What are the most common side effects of EPO use?
Hint: there are 3
Hypertension
Headache
Flu-like symptoms
What is the APGAR score out of?
What are the five categories?
Scores less than what value are concerning and require evaluation?
What receives a “full score” in each category?
10 Appearance, Pulse, Grimaces, Activity, Respirations 100 Grimace: Cough/Sneeze/Cry Activity: Active/Spontaneous Respiratory effort: Regular, good cry
What is the time point women Rh (-) women should receive anti-D immune globulin during pregnancy if there is the possibility their child is Rh (+)?
At what gestational age should women be tested for Group B Streptococci during pregnancy?
Can you vaccinate a pregnant woman with the MMR vaccine?
Anti-D immune globulin: 28-32 weeks and then w/in 72 hrs of delivery
Testing for GBS: 35-37 weeks
MMR?: No. Nonimmunized patients should receive the vaccine postpartum
Where is osteoid osteoma typically found?
How does it appear on plain x-ray films?
What is the appropriate management?
Proximal long bones
Small radiolucency
NSAIDs relieve pain and most regress spontaneously. Surgical management for refractory lesions
What are common causes of primary adrenal insufficiency?
4; think generally
Autoimmune (e.g. Addison’s disease)
Infectious (e.g. TB, HIV, disseminated fungal disease)
Hemorrhagic infarction (e.g. meningococcemia, anticoagulants)
Metastatic cancer (e.g. lung)
Distinguish Dubin-Johnson syndrome from Rotor syndrome.
How are they similar (e.g. lab-wise) and different (e.g. histologically).
Both lead to elevations in conjugated bilirubin
Dubin-Johnson Syndrome: Normal histologic features but a dense pigment of epinephrine metabolites is present in lysosomes
Rotor Syndrome: Defect in conjugated bilirubin storage which leads to hyperbilirubinemia of both direct and indirect. Pigmented granules are NOT seen in hepatocytes.
Distinguish schizoid from schizotypal personality disorder
Schizoid: Odd, eccentric behavior in individuals. Prefer isolation.
Schizotypal: Odd, eccentric behavior often accompanied by magical thinking (e.g. paranoid ideations, bizarre fantasies)
During the acute phase of an MI what heart sound may be heard. Explain.
S4. The lack of oxygen to myocardium leads to dysfunction and stiffening of the LV causing an S4
S4 = atrial gallop
What is the drug of choice for treating poor appetite in a patient with cancer-related anorexia/cachexia?
Progesterone analogs (e.g. megestrol acetate and medroxyprogesterone acetate)
What antibiotics are the drugs of choice for cellulitis with systemic signs?
IV nafcillin or cefazolin
What should the physician do if parents are trying to refuse life-saving medical treatment for their child?
If it is a non-emergent condition the physician should obtain a court order mandating treatment
Most of estrogen produced during child-bearing years comes from the conversion of what precursor and by what enzyme?
Where is this enzyme located in females?
During menopause which location continues to be active with the enzyme?
Conversion of androgens by aromatase
Aromatase is in ovaries and adipose tissue
During menopause, ovary tissue regresses and adipose aromatase remains
The process of ectopic tissue being placed in the body which then responds to cyclical hormonal changes leading to bleeding, rebleeding, and eventual fibrotic adhesion development.
What disease does the above describe?
What are some risk factors?
What is needed for definitive diagnosis?
Endometriosis
Nulliparity, early menarche, short menstrual cycles, menstrual outflow obstruction
Direct visualization with laparoscopy and/or biopsy
What are two ways to change ventilation settings so that there is an increase in oxygenation?
Which is the preferred method in ARDS and why?
Increase the FiO2
Add/increase PEEP
In ARDS there is a risk of oxygen toxicity so it’s preferred to keep FiO2
Are sunscreens with SPF > 50 useful? Why?
Not really. There is a negligible amount of UV radiation which is blocked above SPF 50.
SPF 15: blocks 93%
SPF 30: blocks 97%
SPF 50: blocks 98%
What is the most likely pathogenic agent for infective endocarditis in each of the given situations?
IV drug user
Dental procedure/procedure involving respiratory tract
Nosocomial UTI
Prosthetic valve
Colon cancer
Immunocompromised/chronic indwelling catheter/prolonged antibx
IV: S. aureus Dental: Viridans UTI: Enterococci Colon cancer: S. bovis Prosthetic: Staph aureus or epidermidis Immunocompromised: fungal
What are the two types of breath-holding spells?
At what age do they generally occur?
What are they associated with which should be tested for?
Cyanotic: crying and breath-holding leading to forced expiration, apnea, limpness, and LOC
Pallid: minor trauma followed by breath-holding, LOC, pallor, and diaphoresis
6 months - 2 years
Iron deficiency anemia
Why don’t epidural hematomas cross suture lines?
There are dural attachments at the sites of the sutures
What are the presenting features of Beckwith-Wiedemann Syndrome?
What are two major complications?
What lab and imaging test should be checked regularly in these patients?
Macroglossia, Fetal macrosomia, Hemihyperplasia, Omphalocele/Umbilical hernia
Wilms tumor, Hepatoblastoma
Check serum AFP and do abdominal ultrasound
What are characteristic side effects and toxicities with tricyclic antidepressant overdose?
What is the best indicator for severity of intoxication?
What is used to treat the overdose?
Convulsions, Cardiotoxicity (arrhythmias, prolonged QRS), Hyperthermia, Hypotension, Anticholinergic effects
QRS prolongation
Bicarbonate
What is a complication of late-term pregnancy, oligohydraminios or polyhydramnios?
Explain.
Oligohydramnios.
An aging fetus has a risk of decreased fetal perfusion which leads to reduced urine output and oligohydramnios
Is there a role for antipyretic therapy in heat stroke? Why?
No, because there is no change to the set point of the hypothalamus
Why is Afib a particularly dangerous complication of Wolf-Parkinson-White Syndrome (thinking about the pathophysiology)?
If a patient is hemodynamically unstable how should they be managed?
What is they were stbale, what drugs are preferred?
WPW has an accessory pathway and Afib can bypass the AV node and enter that pathway causing a rapid ventricular rate.
Unstable: Cardioversion
Stable: IV ibutilide or procainamide for the RVR
Serum albumin to ascites albumin gradient (SAAG) >1.1 indicates ascites fluid due to what etiology?
Portal Hypertension
Gastric outlet obstruction can be elicited on exam with what unique physical exam test?
Ingestion of acid can cause gastric outlet obstruction over time. Where is a common location for a blockage to be?
Succusion splash: stethoscope over abdomen and patient rocked at the hips will elicit some fluid out into a hollow viscus
Pyloric stricture
What are the changes which occur to free T4, total T4, and TSH during the first trimester of pregnancy? Explain.
Free T4: Slight increase
Total T4: Large Increase
TSH: Decreases
B-hCG shares a subunit with TSH and stimulates slightly increased T4 and T3 production. However, estrogen increased thyroid hormone binding globulin concentration which binds more of it. So only a slight increase is seen despite a large increase in the total pool.
In patients with a penicillin allergy what is the primary treatment for syphilis?
What if they are pregnant with a penicillin allergy?
Penicillin allergy: Doxycycline
Pregnant with penicillin allergy: Desensitization and treatment
What is reaction formation?
Transformation of an unwanted thought or feeling into its opposite
In neonates, what generally presents earlier Gonorrhea or Chlamydial conjuncitvitis? What is the treatment for both?
Gonorrhea (2-5 days): IV/IM ceftriaxone
Chlamydia (5-14 days): Oral erythromycin
What other carcinoma should you check patients with Lynch syndrome with?
Endometrial carcinoma
What are common thephylline toxicities?
CNS disturbance
GI symptoms
Arrhythmia
Parasympathetic innervation of the bladder controls which muscles to contract and relax, respectively?
What is the mechanism by which diabetic autonomic neuropathy leads to incontinence?
Parasympathetics cause contraction of detrusor and relaxation of internal sphincter.
Diabetic neuropathy damages nerves (including parasympathetics) and reduced ability to sense a full bladder leading to bladder distention and incomplete emptying. Retention eventually leads to bladder pressure > urethra pressure and overflow incontinence. This process is known as a neurogenic bladder.
Which type of therapy aims at identifying maladaptive or negative thoughts and changing the emotions and behaviors coming from those thoughts?
Cognitive behavioral therapy
What type of therapy is centered around the belief that unconscious thoughts shape our experiences and focuses on exploring past experiences and potential transference as a cause of her behavior towards others?
Psychodynamic therapy
What is the cause of variable decelerations?
What is the management for intermittent variable decelerations?
What is the management for recurrent variable declerations?
Umbilical cord compression
Intermittent: Observe
Recurrent: Change maternal positions and administer oxygen
A woman develops a fever on hospital day 2 after giving birth. She has a tender uterus and foul-smelling lochia. What is the dx?
What is the common pathogenic source?
What is tx?
Endometritis
Polymicrobial
Broad spectrum: clindamycin and gentamicin
Elastic pressure + PEEP = ?
Peak airway pressure = resistive pressure + ?
? = Plateau pressure
Plateau pressure is that measured during an inspiratory hold maneuver when the pulmonary airflow and resistive pressures are both 0
Most cases of contact lens-associated keratitis are caused by what pathogenic organism?
Pseudomonas or Serratia
Topical broad-spectrum antibiotics are those of choice
How quick is the onset of B. cereus nausea and vomiting?
Why?
What food is it commonly found from?
Rapid (1-6 hours) because spores are present
Rice
Older males who present with trouble swallowing, foul-smelling breath, and a variable neck mass should be evaluated with what diagnostic imaging technique for what condition?
Zenker diverticulum
Barium esophagram
What is the initial management of a patient presenting with severe, symptomatic hypercalcemia?
Normal saline infusion
Long-term management includes bisphosphonate use
What ionic disturbance may cause hypocalcemia and how does it do this?
It’s often seen in alcoholics.
Hypomagnesia
Low Mg causes resistance to PTH secretion and thus reduced Ca release
A lateral x-ray shows widening of the prevertebral space in a child presenting with fever, drooling, dysphagia, and a muffled voice. What is the likely dx?
Retropharyngeal abscess
What steps must you take before withdrawing life-support on someone who is declared brain dead?
No additional steps need to be taken. Brain death is a legally acceptable form of death and permission does not need to be attained from next of kin, power-of-attorney, or from advanced directive.
At CD4 counts
Mycobacterium avium complex (MAC)
Azithromcyin
Fever, diarrhea, splenomegaly, cough, abdominal pain, night sweats
What is the antibiotic of choice for a patient who had a human bite?
Amoxicillin-clavulanate
A patient with colon cancer comes into the ED with sudden severe SOB and left chest pain. She is tachycardic and hypotensive with a JVD of 13cm and low oxygen saturation. Lungs are clear on exam however. What is the likely diagnosis?
Massive pulmonary embolism
Cardiac tamponade is unlikely given sudden onset, it would more likely accumulate in the chronic setting
After falling on an outstretched hand a patient presents with pain lifting his right arm above his shoulder. There is also pain to external rotation. Pain does NOT improve with lidocaine injection (why is this important). What is the likely dx and what test would you use to confirm your suspicion?
Rotator cuff tear (rotator cuff tendonitis would improve with lidocaine injection)
Shoulder MRI
4 yo unvaccinated boy presents with SOB, drooling, and high fevers. He is sitting up and stooped forward. He appears toxic-looking. What is your initial step in managing this pt?
Take to OR for endotracheal intubation.
He has epiglottitis (likely Hib)
What treatment is helpful in managing the bone pain in prostate cancer patients who underwent orchiectomy?
Radiation therapy
How do uterine fibroids (leiomyoma) present?
How does the uterus feel on exam?
What imaging modality is best used on work-up?
What is tx?
Pelvic pressure/pain, constipation, urinary symptoms, heavy and prolonged menstrual bleeding, pregnancy difficulties
Enlarged, irregular, firm
Ultrasound (best for pathology of pelvis and ovaries)
Observation if no symptoms
Contraceptive therapy, embolization, or surgery
Why would you want to do a RUQ ultrasound in a patient with pancreatitis who already had a CT done to confirm the dx?
RUQ ultrasound is imaging modality of choice to detect gallstones. By understanding the etiology of the pancreatitis you can prevent recurrent bouts.
All patients requiring epidural anesthesia after labor require what afterwards?
Indwelling urinary catheter for bladder emptying. They often have damage to some nerves or slow return of function of these nerves leading to overflow incontinence
Can patients with anorexia nervosa present with parotid gland swelling and Russel spots on knuckles?
Yes, there is a purge type of anorexia nervosa
Of the following types of murmurs which necessitate further work-up with transthoracic echo?
Continuous murmur
Midsystolic soft murmur
Diastolic murmur
Harsh murmur
All except the soft, midsystolic murmurs should be further evaluated
What is the most sensitive test to confirm disseminated Histoplasmosis?
Urine or serum assay for Histoplasma antigen
What is the preferred antifungal agent for Histoplasmosis?
Itraconazole
What is a marjolin ulcer?
SCC within a burn wound
What are medications with a mortality benefit in tx of CHF?
ACEi/ARB
Beta-blocker
Spironolactone
The treatment of basal cell carcinoma differs based on location.
What methods and margins are employed for most BCCs?
What is used for BCC in cosmetically sensitive areas (e.g. face)?
Electrodessication or surgical excision with 3-5mm margins
Mohs surgery in cosmetically sensitive areas
Patients with obesity hypoventilation syndrome have what disturbances to oxygen and CO2 at baseline. Explain.
What effect does this have on bicarbonate and chloride levels?
Since they have global hypoventilation, hypoxia and hypercapnia
Hypercapnia leads to a respiratory acidosis which is compensated for by retaining HCO3- and eliminating Cl-
What is the most common predisposing risk factor to the development of aortic dissection?
Hypertension
Prolonged surgeries which are characterized by hypotension and multiple blood transfusions for extensive blood loss into tissues may present with what skin finding a few days postoperatively?
Jaundice secondary to postoperative cholestasis
The hypotension shocks liver and reduces bilirubin excretion by kidneys due to ATN. Transfusion offers increased pigment load.
How many manic episodes must one have before they are considered for life-time maintenance therapy with lithium?
Two manic episodes
*If they have three then they are definitely getting it for life
What is the immediate management of a patient with pulseless electrical activity or asystole?
CPR and vasopressor therapy
*There is no role for defibrillation or cardioversion in these patients
A 27 yo female presents with symmetric arthritis involving small hand joints. She has a positive rheumatoid factor and weakly positive ANA. She gets better in 1 month and stops taking prescribed meds. What is her dx?
Viral arthritis.
May present with self-resolving symmetric arthritis and may be Rh + and even weakly ANA positive
What STIs should be screened for in all pregnant woman as agreed by all recommendation-providing groups?
Syphilis, HIV, HBV
Iron deficiency anemia can be separated from thalassemia based on what CBC finding?
Red cell distribution width
RDW > 20% is indicative of IDA (Think: there will be variation in red cell width because nutrient levels will vary each day)
What warrants investigation of an asymptomatic cervical lymph node in a young adult or child?
> 2.0 cm and/or stigmata of malignancy (fixed, immobile, hard)
Erysipelas is most commonly caused by?
Strep pyogenes
A young boy presents with signs and symptoms of flu and urine dipstick shows 2+ proteinuria and no other symptoms. What should you do next for your evaluation?
Repeat urine dipstick on multiple occasions
Transient proteinuria is a common finding in children and young adults and can be related a number of things, including orthostasis.
Non-tender, solitary lymph node in the head/neck of a smoker is concerning for _____.
Squamous cell carcinoma
What are common side effects of OCPs?
HTN
VTE
Hepatic adenomas
Should dextrose be added to the initial fluid resuscitation?
No.
It can be in the maintenance fluids.
After diagnosing lupus nephritis what is the next step in your management and why?
Do a renal biopsy because the severity of lupus nephritis may range from stage I to stage IV and treatment depends on severity.
A patient presents with a lesion on their arm which is hyposensate. On closer examination of that arm you notice diffuse muscle atrophy and deformities of the hand. What is the likely dx and how is that dx made?
Leprosy (Mycobacterium leprae)
Skin biopsy for acid-fast bacilli
What are two acceptable methods for the rapid diagnosis of aortic dissection?
Which is better if the patient has kidney failure?
CT scan with contrast or TEE
TEE better in patients with renal failure
Can acute bronchitis present with blood-tinged sputum?
Yes. It is not uncommon for persistent cough to lead to sloughing and damage of blood vessels leading to minor bleeding. In the absence of red flag symptoms this doesn’t need to be immediately addressed.
What is trismus?
Trismus and limited cervical extension may be seen from what infection?
Trismus: inability to open mouth normally
May both be seen in retropharyngeal abscess
*Meningitis often has limited neck flexion
What is the most common middle ear pathology in patients with AIDS/HIV?
Serous otitis media from HIV lymphadenopathy or obstructing lymphomas
Seborrheic dermatitis (dandruff) is commonly seen where in infants?
Eyebrows, nasolabial folds, bases of eyeids, and paranasal skin
If a patient presents in preterm labor before 34 weeks gestation then what three agents should be given and why?
Tocolytics (reduce contractions)
Steroids (fetal lung maturity)
Magnesium sulfate (neuroprotection)
How should you obtain a urinalysis and culture in a patient wearing diapers?
Straight cath.
What are the signs and symptoms of Rheumatic fever?
Jones criteria
Major: joints (migratory arthritis), carditis, nodules (SC), erythema marginatum, Sydenham chorea
Minor: Fever, arthralgia, elevated ESR/CRP, prolonged PR interval
What is a late sequela of rheumatic fever?
How is it prevented?
Mitral regurgitation and eventual stenosis
Penicillin for Group A strep pharyngitis
Describe second degree heart block.
Which is benign?
Mobitz I (Wenckebach): progressive prolongation of PR before being dropped; benign
Mobitz II: Constant PR and then dropped. Needs treatment
What is crampy lower abdominal pain during menses with a normal PE?
Primary dysmenorrhea
NSAIDs and hormonal contraception are treatment
What is the major gluconeogenic amino acid and what is it produced into in the liver?
Alanine
Turned into lactate by alanine aminotransferase (ALT)
Hydroxychloroquine can be used for SLE of isolated skin and joint involvement. What is a the most serious side effect?
Retinopathy
How can Scarlet fever and Kawasaki disease be distinguished based on their rash?
Scarlet fever rash has a “sandpaper” like texture and SPARES the palms and soles
What 4 drugs are part of the standard secondary prevention protocol after an MI?
What drug should be added in unstable angina, NSTEMI, or post-PCI?
1) Aspirin
2) Beta-blocker
3) ACEi/ARB
4) Statin
Clopidogrel
What hormonal profile confirms a diagnosis of premature ovarian failure?
For women who want to become pregnant, what can be done?
Increased serum FSH and LH; Low estrogen
In vitro fertilization
What is the MOA of clomiphene and what is it used for?
A selective estrogen receptor modulator (SERM) which inhibits estrogen receptors in the hypothalamus to upregulate the HPG axis and promote ovulation; used in PCOS patients desiring fertility
What is the classic triad of renal cell carcinoma?
What unique unilateral presentation may also occur?
Flank pain, hematuria, and palpable abdominal mass
Left-sided varicocele
Wide pulse pressure, brisk/strong pulses, a systolic flow murmur, tachycardia, LVH, and flushed extremities in the setting of trauma may indicate ________
Symptomatic arteriovenous fistula
These may form after trauma, bypass the capillary bed, and lead to increased cardiac preload
What is first-line treatment of PCOS?
How does the pharmacologic approach work?
Weight loss and OCPs
OCPs reduce adrenal androgen secretion and LH secretion. Also increases expression of sex hormone binding globulin which binds and decreases free testosterone
