Uworld Mix 10/9-9

Question 1

35 IVDU has right sided wekaness that started 2 hours ago. Has had night sweats and malaise for the last 7 days. 102F, HTN., Tachy. Neuro exam shows 3/5 strength on right side. Theres small mobile vegetation of the aortic valve and mild aortic regurgitation. BCx done, IV antibiotics given. WHICH IS THE NEXT STEP?

• Aortic valve surgery
• Continue Current care with observation
• Antiplatelet therapy
• Start IV heparin
• Start Oral Warfarin

Answer 1

Continue care with observation

patient has a cerebral infarct from bacterial endocarditis with an acute stroke==TIA.

All you can do is give Antibiotics

ASA should have been used early and for atherosclerosis.
Heparin IS CONTRAINDICATED -would cause intracranial hemorrhage.
Would use warfarin b/c this is far cardiembolix stroke due to AFIB. Not in this patient.

Question 2

30 year old school teacher - 3 day hisotry of fever, chills, and sore throat. He denish cough, chest pain, or difficulty breathing. He has enlarged tender cervical lymph nodes on the left, and uvula is deviated to the right. What is the most appropriate tx?

Answer 2

Needle peritonsillar aspiration, THEN do antibiotics.

Because the abscess is obviously there, its more complicated than a throat swab and just abx is not enough.

Question 3

What two modalities of diagnosis are used to diagnose a stone in the urerters, and which is most appropriate to do first.

Answer 3

CT and Ultrasound. But US is done first.

Question 4

Patient has back pain that is releived with leaning forward, but hurts when leaning back. Pain radiates to the buttocks with no urinary issues. There is no pain when he lays down at night. His back pain is more related to posture. What is it

Answer 4

Lumbar Spinal stenosis, aka Osteoarthiritis of the spine. - Neurogenic Claudication

Lumnbar extension would narrow the spinal canal.

Question 5

Young person with back pain that worses with rest and improve with activity.

Answer 5

Ankylosing Sponyliitis (seronegative)

Question 6

Patient has back pain that is relieved with leaning forward, hurts with leaning back, depends on if he’s exerting himself. There is decreased pulses, cool extremties, and diagnosed with ankle brachial index

Answer 6

Vascular claudiaction - aorteliac atherosclerosis

Question 7

What are the wells criteria to deduce the clinical probability of PE

Answer 7

+3 - signs of DVT or alternate diagnosis less likely than PE

+1.5 - Previous PE or DVT, HR >100, Recent immobilization.

+1 - Hemoptysis, Cancer

Need >4.

Question 8

31 female has SOB and anxiety. She was on a recent plane ride. Non smoker. Uses condoms with sex. Has only a hx of anxiety and sleep probelms, and FH of colon cancer. No edema, no skin rashes.

Ph 7.43, CO2 35, PaO2 90.

D Dimer Normal as is Xray.

What is her likelyhood of PE, and what do you do next?

Answer 8

Not likely.

Reassurance

Question 9

What do you do when PE is unlikely

Answer 9

PE unlikely–> D-dimer.

If >500 Do Ct Angio.

Question 10

Patient has Giant Cell artirits that is treated. 6 months later, she has difficulter climbing up stairs and getting up from a chair. she has decreased strenght in the proximal lower extremities.
Normal ESR and CK

Answer 10

Drug induced myopathy due to steroids.

Question 11

Muslce pain and stiffness in the shoulder and pelvic girdle.
Tenderness with decerased range of motion at shoulder, neck and hp
RESPONDS to steroids
ESR increased

Answer 11

Polymyalgia Rheumatica

Question 12

1 hour old premature girl is born, had preterm premature rupture of membranes. Born via csection. Thers severe respiratory distress. CXR shows increased lung volumes and fluid in the interlobar fissures. What is the etiology?

Answer 12

Delayed resorption and clearance of alveolar fluid - This is Transient Tachypnea of the Newborn

Question 13

Findings of Transient Tachypnea of the newborn

Answer 13

Tachypnea, Increased work of breathing, CLEAR breath sounds, Chest X ray shows hyperinflation, fluid in fissures.

Question 14

Management f Transient Tachypnea of the Newborn

Answer 14

Supportive care, resolves in 1-3 days.

Question 15

What are risk factors of TTN

Answer 15

C-section, preamture

Question 16

Patient has a 20 pack smoking history, and a plamber for the past 30. CXR shows atelectasis, bilateral pleural plaques over diaphragm. Theres a round 6 cm cavitary mass in the right lower lung field. What is most likely found on biopsy?

Bronchogenic cancer or Mesothelioma?

Answer 16

Bronchogenic Cancer

Remember that cancer is MORE common result of asbestos in smokers than mesothelioma.

Question 17

What are three PULMONARY and 2 systemic causes of hemopthysis

Answer 17

Bronchitis, Bronchiectasis, and Lung Cancer, Granulomatosis with Polyangiitis, Goodpasture syndrome

Question 18

Describe Bronchiectasis

Answer 18

IRREVERSIBLE dilation and destruction of bronchi, resulting in chronic cough and inadequate mucus clearance. Have a hx of recurrent respiratory tract infections

Question 19

72 year old man passes out while getting out of bed. He had recent watery diarrhea for the past 2-3 days. BP studies show orthostatic hypotension. Asucultation shows clear lung fields. ECG normal. What is the MOST SENSITIVE indicator of the condition

Answer 19

Decreased Urine NA.

Hypovolumia from diarrhea –> increased aldosterone production –>causing Na resorption and K wasting.

Question 20

PFts of Interstitial lung disease

Answer 20

normal to inc Fev1/FvC ratio, DECREASED DLCO, dec TLC, dec RV

Question 21

Etiologies of exudative thoracentesis

Answer 21

Empyema - see neutrophils in fluid. This is bacterial infection.

Chylothorax - Milky white fluid, increased triglycerides. from DISRUPTION OF THORACIC DUCT

Malignancy

TB

Question 22

What is are the PFTs for COPD or chronic bronchitis

Answer 22

FEV1/FVc <70% predicted, and a NORMAL DLCO.

Question 23

What would have an obstructive pattern and LOW DLCo

Answer 23

Emphysema.

Question 24

What would have an Obstructive pattern and INCEASED DLCO

Answer 24

Asthma

Question 25

What would have restrictive pattern and LOW DLCO

Answer 25

Interstitial lung disease, sarcoidosis, asbestosis, heart failure

Question 26

what are the features of COMPLICATED effusion from pneumonia

Answer 26

Bacterial invasion - ph<7.2, Glucose <60, WBC >50k

Question 27

``` What would you change on a ventilator in a patient who has respiratory failure, bilateral opacities, and ABG of pH 7.45 PaO2 54 PaCO2 30 HCO3 - 21 ```

Answer 27

INcrease in PEEP. This both oxygenates AND stops respiratory collapse in ARDS

Question 28

What would the Arterial O2/FiO2 ratio in a patient with ARDS and an xray showing diffuse interstitial infiltrates. ?

Answer 28

Decreased. the PaO2 decreases, leading to a BIGGER FIO2 requirement. <300. More decreased, more severe.

Question 29

Decribe the effect of ARDS on lung compliance

Answer 29

leakage of fluid inot the alveoli, alveolar collapse due to loss of surfactant and increased elastic recoild of edematous lungs.

Question 30

What is consistent with "alveolar spaces filled with fibroblasts"

Answer 30

interstitial lung disease. NOT systemic sclerosis.

Question 31

When do you use diuretics instead of thoracentesis when you see fluid on chest x ray

Answer 31

when you know the patient has heart failure. Thoracentesis is done first to see etiology otherwise.

Question 32

What is the ONLY condition wher you heard increased breth sounds.

Answer 32

Lung consolidation - lobar pneumonia.

Question 33

What kind of back pain is when the patient is young, has pain thats worse with rest, better when leaning forward

Answer 33

Ankylosing spondylitis

Question 34

5 year old girl has malodorous vaginal discharge and a small amount of bleeding for about a week. She takes frequent baths. She has no fever, abdominal pain, or dysuria, The discharge is white, inside the vaginal introits. What is the next step?

Answer 34

Irrigate with warmed fluid after local anesthetic application.

Question 35

difference between Anti-topoisomerase I antibodies and Anti-Smooth Muscle

Answer 35

Anti smooth muscle - auto-immune hepatitis Anti-toposimerase I - Systemic Sclerosis

Question 36

Anti-centromere antibodies

Answer 36

Systemic Sclerosis

Question 37

Difference in presentation between CJD and FTD

Answer 37

FTD has teh onset around 50, personality changes are more prominent than cognitive. No change on EEG CJD - shapr triphasic synchronous discharges on eeg.

Question 38

What kind of abortion - Vaginal bleeding, Dilated cervical os, products of conception seen or felt at or above the os.

Answer 38

Inevitable

Question 39

So, 7 week pregnant lady had really bad bleeding and abdominal pain. There are blood clots in the vaginal vault and active bleeding from a dilated cervix. Bimanoua exam shows a 6 week size uterus. What kind of abortion is it.

Answer 39

Inevitable

Question 40

Abortion - No Vaginal Bleeding, Closed Os, No fetal cardiace activity or empty sac

Answer 40

Missed abortion.

Question 41

Abortino - Vaginal bleeding, closed os, fetal cardiac activity

Answer 41

Threatened

Question 42

Woman has right hip pain for the past 4 weeks, increased with weight bearing. Theres no warmth, erythemia, or other joint pain. She dx with SLE 7 years ago. She is afebrile, and vital signs are normal. There is no tenderness over ANY joints. ROM is normal.X ray is normal. What is the next step

Answer 42

MRI of the hip they have avascular necrosis

Question 43

Woman has right hip pain for the past 4 weeks, increased with weight bearing. Theres no warmth, erythemia, or other joint pain. She dx with SLE 7 years ago. She is afebrile, and vital signs are normal. There is no tenderness over ANY joints. ROM is normal.X ray is normal. Why do you NOT aspirate the joint?

Answer 43

You would do Arthrocentesis if they have warmth, or inflammatory symptoms, or decreased range of motion.

Question 44

What would be the lab findings in avascular necrosis

Answer 44

Normal white blood cell count, normal ESR and CRP.

Question 45

What steps do you take if a 5 year old patient has a varicella infection, and had received 1 varicella immunization shot, and otherwise UTD with vacs.

Answer 45

Give the Varicella vaccine.

Question 46

What when do you give the Varicella Zoster Immunoglobulin?

Answer 46

When the kid DOESNT have 2 doses of the vaccine, and is IMMUNOCOMPROMISED

Question 47

What is the most common heart defect in Edwards sydrome (trisomy 18) when the murmur at the left lower sternal border

Answer 47

VSD

Question 48

What are other heart defects are associated with edwards, and should consider if the mumur correlates

Answer 48

ASD and PDA

Question 49

36 man with 6 month history of headache, decreased libido. He has a hx of t2dm and bipoalr disorder, treated with metformin and risperidone. He has decreased testicular volume. Labs: ``` Lh 0.5 (low) Test 100 (below normal) Tsh 0.05 (low) T4 - 0.45 (low) Prolactin 35 HIGH ``` Which of the following is the most likely diagnosis

Answer 49

Pituitary adenoma - Patient has both central hypothyroidism (low TSH and low T4) and central hypogonadism (low LH and low testosterone) This means a NONfunctioning pituitary adenoma. causes a mass effect on local tissues, so most of the other pituitary hormones wil be DECREASED by compression.

Question 50

Man has had ascending paralysis tht began 18 hours earlier. The parasthesis is more common in the left leg. No fever. He recently came back from a hiking trip to Colorado. He has absent DTR, no motor activity. Theres no abnormalities are noted on CSF examination. WHat is the next step?

Answer 50

Meticulous search for a tick. In tick borne paralysis: No Fever Sensation is intact CSF normal

Question 51

If a patient has signs of spinal compression, what do you do

Answer 51

Steroids and then MRI to confirm.

Question 52

61 male has nocturnal urinary frequency, occasional dribbling, and a weak urinary stream for the past 3 months. Hes had T2DM for the past 16 years. BP is 160/100, and pulse is 70. He has a left carotid bruit and trace bilateral ankle edema. UA shows 3+ protein, and no blood. Cr is 2.1 What is the cause of the CKD?

Answer 52

Microangiopathy - he most likely has diabetic glomerulosclerosis - causing diabetic nephropathy. Damage glomerulos lead to nephropathy-- may lead to albuminuria

Question 53

What are the steps of kidny damage with diabetes

Answer 53

Glomerular hypertrophy 0-5 years, Mesangial expansion, membran thicking, arteriolar hyalinosis, then mesangial nodules.

Question 54

45 year old man has dyspnea, poor appetitis, and weight gain over 2 weeks, He has worsening shortness of breath with exertion. He cant even open his eyes due to the facial edema. BP is 200/120, and puls is 100. He has anasarca with distended JVP while sitting upright. Theres crackles in the lungs. UA shows 1+ protein, no nitrite, trace leukocyte esterase, >50 rbcs, rbc casts, and occasional neutrophils. Why does he have edema?

Answer 54

Primary GLomerular damage. He has acute nephritic syndrome due to fluid overload. The extreme proteinurie lead to hypoalbumiuria, leading to the edema.

Question 55

What are causes of acute peripheral edema

Answer 55

Increased Capillary Hydrostatic Pressure Decreased oncotic pressure Increased capullary permeability Lymphatic obstruction.

Question 56

What is a "Small Vessel Lipohyalinosis"

Answer 56

Lacunar Infarct

Question 57

What are the features of a lacunar stroke?

Answer 57

Abscence of cortical signs - aphasia, agnosia, neglect, apraxia, hemianopia - and no seizures or mental status changes. ``` Syndromes: Pure Motor Hemipareisis Pure Sensory Stroke Ataxis Hemipareisis Dysarthria Slumsy hand. ```

Question 58

57 m has right arm and leg weaknes 2 hours ago, couldnt grip a pen. He cant shake hands and walks with a limp. Hes had a mild constant headach for the past several days. He has HTN and hyperlipidemia. BP is 180/100. Theres asymmetry of the lower face, decreased muscle strength on right side. Ct scan of the head reveals no abnormalities. What is the cause?

Answer 58

Small vessel lipohyalinosis, aka lacunar infarct

Question 59

What differentiates a lacunar infarct with Carotid Artery Thrombosis?

Answer 59

Carotid Artery THrombosis would have cortical signs and altered mental status.

Question 60

Why does a lacunar infarct only have motor symptoms?

Answer 60

The lesion is only in the internal capsule and result in pure motor hemiparesis.

Question 61

A woman has easy bruisability, weight gain, acne, irregular periods, facial plethora, with dark terminal hair on the upper lip and chin. THeres tinea versicolor of the trunk. Is the PCOS or Cushing, and why

Answer 61

Cushing - due to the increased bruisability

Question 62

Why would a 24 year old male have 2 ays of fever, sore throat, hoarsness, pain when swalloing, drooling and muffled voice with stridor? There is anterior neck tenderness on palpation.

Answer 62

Lack of vaccination. this adult has H. Flu leading to Infectious Epiglottitis.

Question 63

What are the three symptoms of Felty Syndrome

Answer 63

Rheumatoid Arthritis, Neutropenia <1500, and Splenomegaly. This is an autoimmune disorder

Question 64

What is the treatment for Felty Syndrome

Answer 64

treat the underlying Rheumatoid Arthritis.

Question 65

What disease is associated with a tremor due to Basal Ganglia Dysfunction

Answer 65

Parkinsons

Question 66

Describe Essential Tremor

Answer 66

Bilateral action tremor of the hands. , or isolated hand tremor without dystonia. NO neurological signs. Relieved with alcohol.

Question 67

Describe Physiological Tremor

Answer 67

Usually not visible under normal conditions. Theres acute onset with increased sympathetic activity. Worse with movement. Could involve the face and extremities.

Question 68

What would cause Detrusor Hypocontractility in a elderly patient, who has been taking OTC treatment for a cough.

Answer 68

Diphenhydramine