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UWorld Pt 1 Flashcards

1
Q

Dose of epi for ACLS algorithm

A

Epinephrine for asystole and PEA arrest: 1g q3-5 minutes to increase tissue perfusion

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2
Q

3 indications for sodium bicarb during ACLS

A

3 indications for sodium bicarb during ACLS

  1. metabolic acidosis (lactate…sepsis)
  2. hyperkalemia
  3. TCA overdose
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3
Q

Cough variant asthma

(a) symptoms
(b) physical exam

A

Cough variant asthma

(a) Cough usually worse w/ exercise, induced by forced exhalation, commonly occurs at night
- triggered by exercise, forced expiration, allergens (work exposure etc)

(b) No wheezing, no SOB, unremarkable physical exam

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4
Q

2 factors that determine severity of asthma for pts not on ICS

A
  1. frequency of SABA use
    daily = moderate persistent
  2. nighttime awakenings
    once a week but not nightly = moderate persistent
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5
Q

Escalation steps 1 through 6 of asthma treatment

A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LABA
    4-5. SABA + escalating dose of ICS + LABA
  4. SABA + high dose ICS + LABA + oral corticosteroid
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6
Q

Tracheomalacia

(a) Physiology
(b) Clinical finding

A

Tracheomalacia

(a) Weakness of tracheal wall causing collapse w/ expiration
(b) Expiratory stridor

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7
Q

5 Hs

A

5 H’s of reversible causes of cardiac arrest

  1. hypovolemia
  2. hypothermia
  3. hypo/hyper-kalemia
  4. H+ ions (acidosis)
  5. hypoxia
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8
Q

5 Ts

A

5 T’s of reversible causes of cardiac arrest

  1. Toxins (narcotics, benzos)
  2. Trauma
  3. Thrombosis (coronary or pulmonary)
  4. Tamponade (cardiac)
  5. Tension pneumothorax
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9
Q

Lung cancer associated w/ 2 different paraneoplastic syndromes

A
  1. Small cell carcinoma and SIADH due to ectopic ADH secretion
  2. Squamous cell carcinoma and hypercalcemia due to parathyroid-related hormone production
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10
Q

2 Drugs sometimes used in refractory chronic SIADH

A

Demeclocycline (tetracycline abx, first line b/c less nephrotoxic than lithium) and lithium both blunt the tubule’s response to ADH

(hence why lithium can cause nephrogenic diabetes insipidus)

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11
Q

G6PD deficiency

(a) Pathophysiology of disease
(b) Presentation
(c) Triggers

A

G6PD deficiency

(a) Enzyme used by RBCs to make NADPH and handle oxidative stress. When deficiency RBCs hemolyze under stress
(b) Either first few days of life w/ jaundice or later w/ acute hemolytic anemia
(c) Triggers = oxidative stress: infection, fava beans, sulfa drugs

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12
Q

Peripheral smear findings of G6PD deficiency

A

G6PD deficiency on peripheral smear

  • ‘bite’ cells where RBCs literally look like a bite has been taken out
  • Heinz bodies which is deposits/accumulation of denatured hemoglobin in the RBC
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13
Q

Tx for supraventricular tachycardia to 170s

A

SVT

Pt stable? If unstable => synchronized cardioversion

If stable- vagal maneuvers, adenosine

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14
Q

Buzzword: intracranial calcifications in a newborn

A

Congenital toxoplasmosis

From undercooked meat, cat poop, contaminated soil

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15
Q

Name 3 EKG findings of Wolff-Parkinson-White

A

WPW EKG findings:
recall accessory pathway

  1. prolonged PR (b/c not going through the pause gate of the AV note)
  2. delta wave- upsloping due to ventricular preexcitation
  3. Widened QRS b/c not going thru native conduction system
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16
Q

What are the following used for

(a) Dialectical behavioral therapy
(b) Exposure and response prevention therapy

A

(a) DBT for borderline personality disorder

(b) Exposure and response prevention therapy is a type of CBT used for OCD

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17
Q

What are you testing for w/ the following in the workup of HTN

(a) Plasma renin
(b) Urine metanephrines

A

(a) Plasma renin- testing for primary hyperaldosteronism, b/c in primary hyperaldo plasma renin is low to almost undetectable (since it’s suppressed by the volume expansion due to high aldo)
(b) Urine metanephrines testing for pheochromocytoma (catecholamine secreting tumor- MC presents w/ paroxysmal HTN)

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18
Q

Autosomal dominant Polycystic kidney disease

(a) Clinical features
(b) Key thing for treatment/management
(c) What to do for family members?

A

AD PCKD

(a) B/l flank pain (stones, large cysts etc), HTN HTN HTN, then LVH on EKG from the HTN

(b) ACEi for tight BP control and to try to prevent progression of kidney disease
- don’t need to screen for RCC, they’re not at increased risk
- don’t need genetic testing, b/l renal ultrasound w/ enlarged kidneys w/ multiple cysts is diagnostic enough

(c) Screen family members w/ renal ultrasound

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19
Q

Window period where false negative on HIV test

A

Up to 4 weeks, b/c takes 1-4 weeks for antibody titers against the virus to develop

So wait 4 weeks then repeat testing

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20
Q

Proposed mechanism of gestational diabetes

(a) Risk to mother gDM
(b) Risk to baby of gDM

A

Human placental lactogen secreted by placenta promotes maternal insulin resistance

(a) To mother- preeclampsia
(b) To baby- hyperglycemia and hyperinsulinemia => macrosomia => shoulder dystocia

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21
Q

When are pregnant F screened for gestational diabetes?

(a) Screening test

A

At 24-28 weeks, give 50g glucose and check in one hour, if 140 or over then do glucose tolerance test

(b) Glucose tolerance test Give 100g of glucose and check q1hr for 3 hours

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22
Q

Treatment for gestational diabetes

A

Insulin, metformin, glyburide all safe

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23
Q

Besides the three mainstay drugs w/ mortality benefit in HF, what else improves mortality?

A

Beta-blocker, ACEi, and spironolactone have mortality benefit

But then in African Americans w/ EF < 40% and NYHA class III-IV HF (markedly limited activity 2/2 HF): combination of hydralazine and nitrates (isosorbide dinitrate) has a mortality and symptomatic benefit

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24
Q

Clinical presentation of cerebral palsy

(a) Risk factors

A

Spasticity. Child w/ delayed motor milestones, hyperreflexia, scissoring and clonus, associated w/ seizures

(a) Prematurity, low birth weight
CNS oxygen deficit => progressive damage

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25
Q

BMP abnormality expected in early compartment syndrome (before loss of pulses/sensation)

A

Acute renal failure 2/2 rhabdo- myoglobin is toxin to renal tubules from muscle breakdown

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26
Q

Papillary muscle vs. chordae tendinae

A

Papillary muscles = muscles that connect to the trebeculae carne of the LV

Then the chordae tendinae are the connective tissue (‘parachute’) that holds the valve to the muscle

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27
Q

Typical cause of

(a) Papillary muscle rupture
(b) Chordae tendinae rupture

A

(a) 3-5 days post-MI watch out for papillary muscle rupture

(b) Connective tissue disorders (Ehrlos-Danlos, Marfans) associated with chordae tendinae rupture

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28
Q

Marfans vs. Ehler-Danlos- major clinical difference

A

Both joint hypermobility, pectus excavatum, scoliosis

Ehler-Danlos: derm manifestations: velvety, transparent and hyperextensible skin
More prominent skin findings and atrophic scarring

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29
Q

1st line agent to manage HR and BP in acute aortic dissection

(b) Why not hydral

A

Beta-blockers: reduce HR and BP

(b) Hydral- prominently arterial vasodilator, but reflex sympathetic surge can cause tachycardia and hypotension

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30
Q

Define torsades de points

A

Gradual prolonging of QT causing form of polymorphic VT- cyclic alteration in QRS axis and morphology 2/2 acquired vs. congenital QT prolongation

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31
Q

Explain mechanism of Torsades

(a) PVC
(b) Bradycardia

A

(a) PVC w/ compensatory pause short-long RR phenomenon) can progress to VT
(b) Bradycardia (sinus brady or pause) can cause prolonged QTc

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32
Q

Immediate treatment of torsades

A

1st line- IV mag sulfate, regardless of serum mag levels

When inadequate response to IV mag- temporary transvenous pacing

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33
Q

When is CRT indicated in HFrEF in sinus rhythm?

A

LVEF under 35%
LBBB causing QRS over 150 msec
NYHA class II or above (essentially any heart failure symptoms)

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34
Q

Indications for ICD placement in heart failure

A
  1. Prior MI with LVEF under 30

2. NYHA class II-III (aka HF symptoms) w/ LVEF under 35

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35
Q

PAILS mneumonic

A

ST elevations in posterior leads, expect reciprocal depressions in anterior leads

Posterior (V7-V9)
Anterior (V1-V3)
Inferior (II, III, aVF)
Lateral (V5, V6)
Septal (V3,V4)
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36
Q

65 y/oM p/w substernal CP and SOB x2 hours, got ASA and SLN by EMS w/ big improvement in pain

EKG on arrival w/ ST depressions in II, aVF, V3-V6

Best next step in management?

A

NSTEMI- not straight to cath!! (no STE)

ASA/plavix load
Anticoagulation (heparin gtt)
Statin
Nitrate/beta-blocker

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37
Q

Pt p/w acute decompensated HF requiring BiPap

Still SOB despite IV lasix

Next step?

A

Add IV vasodilator (IV nitroglycerin = nitro gtt) = venous vasodilator- rapid decrease in cardiac preload = reduced intracardiac filling pressures to improve/reduce pulmonary edema

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38
Q

Why is nitroglycerin used over nitroprusside in flash pulmonary edema?

A

Both are venous vasodilators to reduce cardiac preload => reduce amount of fluid poured into lungs

But nitroprusside can cause cyanide toxicity and severe hypotension => use nitro(glycerin) gtt

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39
Q

Escalation of treatment for claudication 2/2 PAD

A
  1. Start w/ modification of risk factors
    - smoking cessation
    - BP and dit control
    - ASA and statin
    - supervised exercise therapy

Only once that fails ^ do cilostazol (PDE3 inhibitor)

Then can consider revascularization

Point is to try statin and exercise before cilostazol and stent

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40
Q

12 y/o boy, very tall, increased arm span to height ratio

(a) Possible diagnosis
(b) Further eval required prior to starting strenuous sports at school

A

(a) Marfanoid habitus

(b) TTE to evaluate aortic root for aneurysmal dilation, Aortic regurg, aortic dissection

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41
Q

MC cause sudden cardiac death in 20 y/oM w/ normal EKG and normal TTE

A

Normal EKG => not Brugada or WPW

Normal TTE => not HOCM

Actually pretty common is anomalous aortic origin of the coronary artery
-artery takes a sharp curve (doesn’t tolerate high flow well) or sometimes goes btwn aorta and pulmonary atery (externally compressed)

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42
Q

57 y/oF p/w syncope 2/2 severe AS
Gets aortic bileaflet mechanical valve

Indicated ppx
ASA?
Warfarin with what INR goal?

A

Yes ASA, always ASA for mechanical valve (mitral or aortic)

Warfarin goal
2.0-3.0 given aortic valve w/o risk factors
If had AFib, HFrEF, prior VTE, or cancer: higher INR goal (2.5-3.5)

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43
Q

Indications for INR goal 2.5-3.5 (instead of typical 2-3)

A
  • mitral valve replacement

- aortic valve replacement WITH risk factors: AFIb, HFrEF, hypercoag state (cancer), prior VTE

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44
Q

27 y/oF p/w chest pain after cocaine ingestion, BP 208/102

First line management?

A

First line- benzos (IV lorazepam)! reduce sympathetic drive

Beta-blockade contraindicated- unopposed alpha can vasodilate peripherally and drop pressures

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45
Q

68 y/oF getting breast implants after mastectomy for CA coming for pre=op clearance
H/o CAD s/p stent, LVEF 40%
Trouble walking up stairs to appt

Preop mgmt?

A

Proceed to surgery w/o further testing

B/c such low risk procedure

Need to take into account risk of procedure, METS4 really for bigger procedures

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46
Q

WHO classes of pulmonary HTN

A

Pulmonary HTN

Class I- idiopathic
Class II- 2/2 left heart failure
Class III- 2/2 chronic lung disease: COPD, ILD
Class IV- 2/2 chronic thromboembolic disease
Class V- other (sarcoid)

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47
Q

29 y/oM used cocaine 2 hrs ago, p/w chest pain, STE
STE persist after ASA, diazepam, nitro gtt

Next step?

A

Cocaine- increases coronary vasospasm (so give CCB), increases platelet activity (so give ASA)

If STE persist => cath!

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48
Q

Initial mgmt of cardiac chest pain after cocaine ingestion

(b) For persistent CP
(c) For persistent HTN
(d) Anti-platelet?

A

Cocaine-induced cardiac chest pain- benzos to control HR and BP

(b) Persistent chest pain- CCB
(c) Persistent HTN- phentolamine = alpha-2 agonist
(d) Yes ASA! b/c cocaine increases platelet activity

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49
Q

67 yoM 2 days s/p cath p/w persistent R groin pain
Mild swelling and bruising, accentuated pulsation

Next step?

A

Ultrasound of groin

Could just be hematoma but need to r/o pseudoaneurysm or AV fistula

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50
Q

Local vascular complications of cath when done femorally

A
  • Hematoma
  • Pseudoaneurysm: systolic thrill
  • AV fistula from femoral artery to vein: continuous thrill
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51
Q

Calculate CHADS-VASC

A

1 point for each

CHF
HTN
Age: 2 pts for over 75
DM
Stroke, TIA, thromboembolism

Vascular disease: 2 pts for prior MI, PAD
Age: 1 pt 65-74
Sex: 1 pt for female

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52
Q

How many CHADS-VASc points indicate anticoagulation

A

CHF, HTN, Age, DM, Stroke, Vascular (MI, PAD), Age, Sex

0 = low risk 
1 = intermediate risk
2 = high risk for stroke in AFib, def anticoagulate
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53
Q

HOCM

(a) beta-blocker use
(b) ACEi use

A

HOCM

(a) Beta-blockers good- want to decrease HR decrease LVOT
(b) ACEi bad- decreasing preload increases the LVOT gradient

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54
Q

Indications for ICD in HOCM

A

ICD in HOCM

  • recurrent or exertional syncope
  • prior arrest
  • spontaneous VT
  • family history of sudden death
  • extreme LDH
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55
Q

62 y/o African American M w/ HFrEF 30%, on metop/lisinopril/lasix/spironolactone

What med is best to add?

A

Isosorbide dinitrate and hydral have mortality benefit for HF in African Americans

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56
Q

72 y/oF p/w chest pain, STE in II, III, aVF
Shortly after becomes cold, hypotensive

First line management while waiting for cath lab?

(b) What to avoid

A

Inferior wall MI => cardiogenic shock
While waiting for cath, if lungs not crackly give IV fluids to increase preload
If not responding to fluids can give dobutamine

(b) Avoid nitrates or diuresis which would drop preload

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57
Q

Marfan syndrome

(a) Mode of inheritance
(b) Ocular symptom
(c) Cardiac involvement

A

(a) Autosomal dominant of connective tissue glycoprotein fibrillin-1
(b) Ectopic lentis = lens subluxation or dislocation- acute unilateral vision loss
(c) Aortic dissection, aortic regurg

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58
Q

50 y/oM p/w chest pain, cold extremities
BP 84/52, HR 34
Crackles at lung bases b/l
ECG: sinus brady w/ 3mm STE II, III, aVF

Mgmt prior to cath? (first line, second line)

A

Cardiogenic shock after inferior MI, fluid overload with sinus brady
-complication of ischemia to SA node

Give atropine to reverse sinus brady, if unresponsive start temporary transcutaneous pacing

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59
Q

Downs syndrome associations

(a) Neurologic
(b) Oncologic

A

(a) Alzheimer’s dementia

(b) Acute leukemia

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60
Q

2 Conduction abnormalities seen in inferior wall MI

A

SA node ischemia => sinus bradycardia

AV node ischemia => AV block

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61
Q

Patellar tendonitis vs. patellofemoral syndrome

A

Patellar tendonitis = jumpers knee, episodic inferior patellar pain

Patellofemoral syndrome- young F athelets w/ subacute to chronic pain
Patellofemoral compression test- pain on extension of knee w/ anterior patellar compression

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62
Q

Typical causes of reactive arthritis

A

Reactive arthritis = spondyloarthropaty p/w peripheral asymmetric oligoarthritis

Typically after GU (chlamydia) or GI (salmonella, shigella, yersinia, campylobacter) infection

ex: 35 y/oM p/w R knee and ankle pain x2 weeks, also eye pain/blurry vision, dysuria. Reports diarrhea after eating 1 month ago

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63
Q

Extra-articular symptoms of reactive arthritis

A

Reactive arthritis- typically asymmetric oligoarthritis w/ h/o GU or GI infection

Enthesitis (pain at ligament/tendon insertion)
Dactylitis
Extra-articular: uveitis, urethritis

64
Q

HLA-B27 pt w/ diarrhea, at risk for?

A

Reactive arthritis- sacroilitis, peripheral asymmetric oligoarthritis (knee and ankle pain), enthesitis, dactylitis, uveitis (b/l conjunctival erythema), uretheritis (dysuria)

65
Q

What would joint aspiration show for reactive arthritis?

A

Sterile- no growth but w/ elevated WBC count

66
Q

Diagnostic joint aspiration features for septic joint

A

Over 2000 WBCs

75% PMNs (polymorphonuclear leukocytes)

67
Q

Scoliosis vs. kyphosis

A

Scoliosis = S-shaped curvature of thoracic and lumbar spine

Kyphosis = exaggeration of posterior thoracic curvature (hunchback)

68
Q

3 month old girl p/w fussiness, decreased PO intake, L leg flexed and externally rotated
Afebrile
WBC 16k, CRP 8.5
Effusion on joint ultrasound

Dx?

A

Septic arthritis- despite afebrile, elevated inflammatory markers/WBC w/ hip pain and effusion = septic arthritis

Not hip dysplasia b/c wouldn’t have effusion
Not Legg-Calve-perthes b/c wouldn’t be

69
Q

MC cause of septic arthritis

A

Staph aureus

70
Q

Presentation of Legg-Calves-Perthes disease

A

= idiopathic avascular necrosis of the hip
Child age 3-12 who presents w/ insidious-onset hip pain and limp

Normal inflammatory markers
Deformity of femoral head on Xray

71
Q

Top risk factors for osteonecrosis (avascular necrosis)

A
  1. corticosteroid use
    - ex: lupus pt on chronic prednisone 20mg p/w hip pain
  2. excessive EtOH
72
Q

22 y/o F p/w knee pain
while running felt a popping sensation in R knee, then pain and rapid swelling
Aspiration yields gross bloody fluid

Dx?

A

popping sensation, rapid swelling/hemathrosis (bloody fluid) = anterior cruciate ligament tear

hemathrosis not seen in PCL or meniscal injury

73
Q

Classic features of Scarlet Fever

A

Scarlet fever = kids after strep pharyngitis p/w sand-paper rash (little papules), strawberry tongue, circumoral pallor

74
Q

Feared complications of Kawasaki disease

A

Kawasaki disease = febrile vasculitis of unknown etiology

Coronary artery aneurysm
Myocardial ischemia/infarction

75
Q

Tx of Kawasaki disease

A

ASA and IVIG- by unclear mechanism reduces risk of cardiac sequelae

76
Q

Typical arthralgia seen in

(a) Parvovirus B12
(b) Acute rheumatic fever
(c) Lyme arthritis

A

(a) Parvovirus B19- acute symmetric joint pain, typically small joints (of the hand)
(b) RF- migratory polyarthritis of large joints (knee, elbow)
(c) Lyme- monoarticular

77
Q

16 y/o girl p/w hand and knee stiffness upon waking 1 week after URI

Dx?

A

Viral arthritis- typically symmetric and involves small joints of hands

Specifically MC parvovirus B19

78
Q

Buzzwords

(a) Sandpaper rash
(b) Slapped cheek rash

A

(a) Sandpaper rash = scarlet fever = post-strep pharyngitis

(b) Slapped cheek rash = parvovirus B19

79
Q

anti-cyclic citrullinated peptide antibodies

A

Over 90% specific for rheumatoid arthritis

So yes order RF, but anti-CCP also for RA

80
Q

52 y/oM p/w difficulty using L hand

Progressive stiffness at palm and 3rd/4th digis
Decreased extension of 3/4th MCP joints

Dx?
Risk factors?

A

Dupuytren’s contracture

RF: diabetesssssss, males over 50, tobacco and EtOH

81
Q

53 y/oF p/w 6 months pain/tightness in neck, posterior shoulders, buttocks
+fatigue, insomnia
Widespread symmetric tenderness to firm palpation over muscles and bony prominences
Normal CBC, normal ESR

Dx?

A

Polymyalgia rheumatica widespread MSK pain, associated cognitive/psychiatric disturbances (depression, impaired concentration, impaired sleep), disordered sleep, fatigue, impaired cognition
Over 3 months

82
Q

Typical features of fibromyalgia

A

Middle aged F w/ widespread MSK pain (ex: tightness/pain in neck/shoulders/buttocks), disordered sleep (ex: insomnia), impaired cognition, fatigue

Normal inflammatory markers (ESR, CRP)

83
Q

52 y/oF p/w left groin pain x1 week
Is on 20mg/day prednisone for SLE
+limp, limited ROM

(a) Dx?
(b) Scan most sensitive for diagnosis

A

(a) Osteonecrosis = avascular necrosis of hip
- high dose prednisone (over 15-20 daily for over 3 weeks, high risk AVN)

(b) MRI most specific

84
Q

Why do women w/ hemochromatosis typically present later than men

A

Menstrual iron loss

85
Q

Hereditary Hemochromatosis manifestations

(a) Dermatologic
(b) MSK
(c) Cardiac

A

HH

(a) Dermatologic- hyperpigmentation (‘bronze diabetes’)
(b) MSK- arthritis, pseudogout, chondrocalcinosis
(c) Restrcitve cardiomyopathy, conduction abnormality

86
Q

46 y/oF p/w knee pain x3 weeks after initial insult
Initial insult- no deformity/edema, able to walk normally
2 weeks later- intense pain, unable to weight bear, swollen, hot
L leg: mottled, bluish discoloration, sweating more tan R

Dx?

A

Chronic regional pain syndrome = pain, swelling, skin changes (mottled), vasomotor changes (sweating), not immediately after but following injury

87
Q

Features of complex regional pain syndrome

A

Complex regional pain syndrome = pain, excess sweating, mottled/blueish skin (vasomotor, skin changes) following an injury
due to over-active sympathetic activation after an injury

88
Q

27 y/oM w/ knee pain after hitting knee on dashboard during MVA
Mild swelling and stiffness

Which ligament is injured?

A

PCL injury- typical after dashboard (anterior) force application
Not huge effusion seen in ACL tear

89
Q

2 knee injuries that typically have large effusion

(b) How to distinguish

A

ACL tear
(b) Rapid onset hemathrosis

Meniscal tear
(b) Onset w/in 24 hrs, not bloody

90
Q

Risk factors that would indicate Xray in pt w/ back pain

A

Nighttime pain
Age over 50
Unexplained weight loss (?inflammatory condition)
H/o malignancy (?mets)

91
Q

Pt w/ Sjogrens p/w neck mass

Most likely diagnosis?

A

Sjogrens assocaited w/ proliferation of monoclonal B-cells that infiltrate salivary glands=> increased risk B-cell lymphoma

92
Q

Mechanism of methotrexate

A

Purine antimetabolite

93
Q

Main adverse effect of hydroxychloroquine

A

Retinopathy

94
Q

Mechanism of hydroxychloroquine

A

Hydroxychloroquine = DMART, TNF and IL-1 suppression (same as sulfasalazine)

95
Q

Main adverse effects of methotrexate

A
  1. hepatotoxicity
  2. stomatisis
  3. cytopenias

Inhibits division of rapidly-dividing cells

96
Q

36 y/o AA F p/w HA, acute onset blurry vision
PMH: Raynauds, GERD
BP 200/110, no abd bruit, +b/l papilledema
Cr 2.0

Dx?

A

Systemic sclerosis = scleroderma, specifically scleroderma renal crisis

Get narrowing of renal arterioles => RAAS activation => HTN

97
Q

Triad of HUS

A

HUS = hemolytic uremic syndrome

  • AIHA
  • uremia = acute renal failure
  • thrombocytopenia
98
Q

Tx of scleroderma renal crisis

A

Scleroderma renal crisis- ACEi, the one time in acute renal failure that ACEi would be indicated

B/c directly inactivates the RAAS system (which is the problem)

99
Q

Mechanism of disease in scleroderma

A

Scleroderma = systemic sclerosis = abnormal collagen deposition in organs

100
Q

Tx algorithm for acute gouty attack

(b) How this changes in ESRD

A

Acute gout attack: tx w/ indomethacin (NSAIDs) and colchicine
Not allopurinol, which reduces urate production, and can actually worsen symptoms in acute attack

(b) Both NSAIDs and colchicine contraindicated in renal failure, so
if monoarticular- do steroid injection
if polyarticular- consider PO systemic steroids

101
Q

45 y/oM p/w L shoulder pain/stiffness x3 months
Constant day/night
No focal tenderness but global restriction in both passive/active motion
Xray normal

Dx?

A

Frozen shoulder = adhesive capsulitis

  • both passive and active motion restricted
  • no bony stuff on Xray
  • features: stiffness more prominent than pain
102
Q

Tx of adhesive capsulitis

A

Adhesive capsulitis = frozen shoulder

Tx = rest and gentle ROM exercises

103
Q

12 y/oM p/w worsening hip pain x3 weeks
No recent URI symptoms
95th percentile weight, 50th for height
R hip externally rotated in pain

Dx?

A

Obese kid w/ gradually progressive hip pain = SCFE = slipped capital femoral epiphysis (ice cream slipping off cone)

= displacement of femoral head along the plane of the physis

104
Q

SCFE

(a) Xray findings
(b) Tx

A

SCFE

(a) Ice-cream slipping off cone due to displacement of femoral head along plane of the physis
(b) Tx = immediate surgical pinning to reduce risk of avascular necrosis and nerve impingement

105
Q

When to attempt manual reduction by flexion and supination

A

For nursemaid’s elbow = radial head subluxation = displacement of annular ligament btwn radius and humerus

From elbow subluxation (ex: swinging child by hands)

106
Q

Fracture expected after FOOSH in

(a) Adults
(b) Kids

A

FOOSH = fall on outstretched hand

(a) Adults- distal radius fracture (near wrist) = Colle’s fracture
(b) Kids- distal humerus fracture = supracondylar fracture of distal humerus

107
Q

After FOOSH in kids- how to check the following are intact

(a) Blood vessels
(b) Nerves

A

FOOSH => supracondylar fracture of distal humerus at elbow- dangerous b/c exposed arteries and nerves in the area

(a) Ensure brachial artery is ok- feel pulses, test cap refill
(b) Ensure median nerve ok- would cause weakness in hand/wrist flexion

108
Q

2 y/o girl p/w sudden refusal to move R arm after being grabbed by wrist by mother to prevent from falling

Dx?

A

Radial head subluxation = nursemaid’s elbow, annular ligament gets displaced btwn humerus and radius due to traction on forearm w/ elbow extended

109
Q

7 y/o boy p/w red round lesions that merged on legs and butt, abdominal pain, nausea, 1 week after URI
Pos stool guaiac

Dx?

A

Henoch-Schonlein purpura = IgA-deposition mediated vasculitis

rash = palpable purpura, abd pain due to small bowel intussusception, hemturia, joint and kidney involvement later

50% antecedent UTI

110
Q

Features of Henoch-Schonlein purpura

A

IgA-deposition mediated vasculitis
Starts w/ palpable purpura and abdominal pain (from intussusception)

Then later get joint pains and kidney involvement (nephritic syndrome)

111
Q

What common blood pressure drug has an association with drug-induced lupus?

(b) Expected antibody

A

Hydralazine

(b) ANA and anti-histone antibody

112
Q

Why is CKD associated w/ high PTH?

A

Reduction in phosphate filtration, Ca binds to phos so reduced circulating phos => elevated PTH

113
Q

74 y/oF p/w cough x4 weeks, DOE
Meds: ASA, metop, lasix, synthroid, amio, MVI
Afebrile, nonproductive cough, fine end inspiratory crackles at bases
Diffuse interstitial opacites at b/l LL fields

Dx?

A

Amiodarone induced pulmonary toxicity- chronic interstitial PNA

114
Q

Why even biopsy someone w/ lupus who comes in w/ LE edema, renal dysfunction, proteinura, UA w/ active sediment?

A

So you know they have lupus nephritis…butttt need biopsy to determine class which determines treatment

basically some classes warrant immunosuppressives while others dont

115
Q

Size cut-off for removal vs. medical management of ureteral stone

A

10mm

Under 10mm: hydration, pain control, alpha blockers

Over 10mm: urology consult

116
Q

2 other causes of hyponatremia aside from SIADH that cause low urine osms w/ low urine sodium

A

Adrenal insufficiency

Hypothyroidism

117
Q

Explain two mechanisms by which familial hypocalciuric hypercalcemia causes hypercalcemia

A

Autosomal dominant inheritance of inactivating mutation in calcium sensing receptor

  1. Need higher levels of serum Ca to suppress PTH
    so serum 11-12 suppresses PTH, instead of 8-9 (normal)
  2. Increased resorption of Ca by kidneys
118
Q

Classic clinical presentation of analgesic (NSAID)-induced neprhopathy

A

Rapid onset gross proteinuria- due to reversible decline in GFR from inhibition of vasodilatory prostaglandin production

119
Q

42 y/oM p/w nausea, weakness, oliguria, and purpura x4 days

  • also tingling in hands/feed and arthralgias
  • hepatomegaly, pitting edema, absent b/l ankle reflexes

Dx?
Lab test for diagnosis

A

Mixed cryoglobulinemia- dx w/ serum cryoglobulin levels
= vasculitis from immune complex (IgM and IgG RF) into small and medium vessel walls

Clinical triad: palpable purpura, weakness, arthralgias

120
Q

2 stages of treatment for mixed cryoglobulinemia syndrome

A
  1. initial immunosuppressives (prednisone, rituxan) to stabilize end-organ damage (glomerulonephritis)
  2. Treatment of underlying disease
    Some underlying inflammatory condition that generated the immune complexes that caused the vasculitis
    Ex: antivirals for tx of underlying hep C
121
Q

Typical murmur of VSD

A

VSD murmur = harsh holosystolic murmur with thrill
best heard at 3rd/4th L intercostal space

Smaller the VSD = harshes the murmur

122
Q

Explain why a soft, single second heart sound (S2) is heard during inspiration in severe aortic stenosis

A

During inspiration (increased RV volume) pulmonic valve typically closes just later than AV

W/ severe AS there is delayed closure of the aortic valve => simultaneous closure of aortic and pulmonic valves during inspiration

123
Q

42 y/oF presents w/ amitriptyline toxicity
EKG shows sinus tachy w/ wide QRS

How to prevent ventricular arrhythmia?

A

TCas inhibit fast Na channels => decreased conduction speed = prolonged QRS

Sodium bicarbonate!!! best agent to manage cardiotoxic effect of TCAs- goal is to increase serum pH to neutralize TCAs so TCA is less available to bind to rapid sodium channels

124
Q

Syndromes causes by fibrillin vs. myosin gene mutation

A

Fibrillin mutation = Marfan’s

Myosin mutation => HOCM

125
Q

Name 3 contraindications to OCPs

A

b/c of association w/ ischemic stroke and CV events, contraindicated if have additional risk factors:

  1. Migraine w/ aura
  2. BP > 160/100
  3. Over age 35, smoke > 15 cigs/day (not just any smokers)
126
Q

62 y/oF w/ HTN presents w/ LE edema

What med is she most likely taking?

A

Amlodipine or nifedipine- CCBs (not ACEi) are assocaited w/ peripheral edema due to preferential dilation of precapillary vessels => increased capillary hydrostatic pressure

127
Q

Describe the murmur of mitral valve prolapse

A

MVP murmur = non-ejection click and systolic murmur

Click is snapping of the mitral chordae as the valve cusps extend into the LA during systole

128
Q

What is the unique similarity between MVP and HOCM murmurs?

A

Both decrease w/ increased venous return/LVEDP (squatting, suping leg raise)

While other murmurs all increase w/ those maneuvers

129
Q

What is the unique similarity between MVP and HOCM murmurs?

A

Both decrease w/ increased venous return/LVEDP (squatting, suping leg raise)

While other murmurs all increase w/ those maneuvers

130
Q

Why would progestin-containing IUD be better than copper-IUD for PCOS?

A

PCOS = oligo or anovulation => unopposed estrogen which causes endometrial hyperplasia and potentially cancer

So need progestin (either in combined OCPs or in progestin-containing IUD) to help protect the endometrium

131
Q

Top most effective emergency contraception option

(b) Contraindication

A

Most effective is placement of a copper IUD (99%)

  • marginally more effective than ulipristal (98%)
  • more effective than Plan B = levonogesterol (50-90%)

(b) Acute cervicitis

132
Q

What STIs do the following treat

(a) Azithro
(b) CTX

A

(a) Azithro treats chlamydia

(b) CTX treats chlamydia

133
Q

Age for HPV screening

A

HPV screening q5 years once age 30

134
Q

46 y/oF G2P2 p/w increasingly heavy menses: heavy bleeding w/ clots and severe abd cramping
-uniformly enlarged, mobile uterus

Dx?

A

Adenomyosis = abnormal endometrial tissue in the uterine myometrium

dysmenorrhea, heavy bleeding, diffuse uterine enlargement

135
Q

22 y/oF w/ RLQ pain x3 weeks exacerbated w/ BMs
small, nontender uterus
R adnexa enlarged and tender
nodularity and tenderness on rectovaginal exam

Dx?

A

Dyschezia = pelvic pain exacerbated by BMs
-nodularity

dx = endometriosis
chronic pelvic pain, dysmenorrhea

136
Q

Why does endometriosis carry increased risk of infertility?

A

causes pelvic adhesions and inflammation => infertility and chronic pelvic pain

137
Q

Adenomyosis vs. endometriosis

(a) Physiology
(b) Exam

A

Adenomyosis

(a) abnormal endometrial tissue in uterine myometrium
(b) diffuse uterine enlargement

Endometriosis
(a) fixed, immobile uterus, rectovaginal nodularity, tender adnexa

138
Q

Adenomyosis vs. endometriosis

(a) Physiology
(b) Exam

A

Adenomyosis

(a) abnormal endometrial tissue in uterine myometrium
(b) diffuse uterine enlargement

Endometriosis
(a) fixed, immobile uterus, rectovaginal nodularity, tender adnexa

139
Q

Coast of Maine cafe-au-lait spots

A

Buzzword for Mccune-Albright Syndrome

Coast of Maine cafe-au-lait
Precocious puberty
Bone dysplasia

140
Q

Management of familial hypocalciuric hypercalcemia

A

Benign- no treatment needed

141
Q

Contraindication to metformin

A

GFR under 30

142
Q

T3 vs. T4

A

T4 = hormone made by they thyroid gland, then it’s deiodinated peripherally to make T3

143
Q

78 y/oM p/w hyperthyroidism, 2.8cm thyroid nodule with RAI of 55% (ULN 30%) with rest of gland showing reduced uptake

Mgmt?

A

Mgmt = methimazole and that’s it

Hot nodule (high uptake on RAI w/ rest of gland suppressed) low suspicion for cancer => doesn’t need to be resected

144
Q

3 types of cancer that can cause hypercalcemia

A
  1. Squamous cell carcinoma (lung, renal, breast, bladder, ovarian) b/c PTHrP
  2. Bony mets
  3. Lymphoma- secretes 1-25OHD that increases Ca resorption from bone
145
Q

Clinical features of 21-hydroxylase deficiency in infancy?

A

MC form of congenital adrenal hyperplasia

No cortisol => hypoglycemia
No aldo => hyperkalemia, hyponatremia (salt wasting) => nausea/vomiting

146
Q

Classic congenital adrenal hyperplasia

(a) Mode of inheritance
(b) Enzyme deficiency
(c) Confirmed by elevation in what hormone

A

CAH

(a) autosomal recessive
(b) 21-hydroxylase
(c) Elevation of 17-OH progesterone

147
Q

Medication helpful in glyburide overdose

A

Glyburdie = sulfonylurea (like metformin) that increases insulin release
So overdose => recurrent hypoglycemia episodes refractory to D50

Tx w/ octreotide = somatostatin analog that inhibits insulin secretion

148
Q

27 y/oF on synthroid, wants to start OCPs

How to adjust synthroid dose?

A

Increase dose b/c estrogens stimulate production of thyroid-binding globulin that binds serum thyroid hormone

149
Q

Management of familial hypocalciuric hypercalcemia

A

Benign- no treatment needed

150
Q

Contraindication to metformin

A

GFR under 30

151
Q

Treatment for hyperthyroidism during pregnancy

A

PTU in first trimester

Then back to methimazole in 2nd/3rd trimester given high risk of hepatotoxicity w/ PTU

152
Q

Explain how pregnancy can induce diabetes

A

Placenta releases human placental lactogen that promotes insulin resistant (to ensure baby gets enough glucose)

hence gestational diabetes

153
Q

Calcitonin

(a) Action
(b) Site of production
(c) Elevated in what cancer

A

Calcitonin

(a) Works to oppose PTH, reduces serum Ca
(b) Produces in C-cells (parafollicular cells) of the thyroid
(c) Medullary thyroid cancer

154
Q

Antithyroid peroxidase antibody

A

Elevated in Hashimoto’s thyroiditis

155
Q

How does Hashimoto’s thyroiditis increase risk of future cancer?

A

Hashmoto’s thyroiditis = autoimmune chronic leukocytic infiltration of thyroid gland => increases risk of lymphoma

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