Uworld questions #2 Flashcards
What are symptoms of someone OD on diphenhydramine? What’s the treatment?
Diphenhydramine is an anti-histamine with anticholinergic properties. OD presents with drowsiness and confusion 2/2 to anti-histamine effects and dry mouth, dilated pupils, blurred vision, bowel and urinary retention 2/2 to anti-cholinergic effects.
Treatment is physostigmine which is an achase inhibitor increasing concentrations of acetylcholine
Describe salicylate intoxication. What’s the treatment?
Salicylate intox: tinnitus, N/V, fever, AMS, metabolic acidosis with resp alkalosis
treatment: sodium bicarb to alkalinize urine
5-HT syndrome symptoms.
tachycardia diaphoresis dilated pupils HTN hyperthermia
What should you suspect in a sickle cell patient with macrocytic anemia?
SCD is usu a chronic normocytic hemolytic anemia with approp reticulocytosis. If pt has macrocytic anemia, suspect a folate deficiency due to increased RBC turnover and increased consumption of folate in the bone marrow. Hence, daily folic acid supplementation is recommended in all SCD pts.
What are the recommendations for colorectal carcinoma screening in someone with ulcerative colitis?
Begin colonoscopy surveillance 8 years after diagnosis. Then repeat every 1-2 years.
Common tetrad describing Parkinson’s
resting tremor (usu starts one-sided)
rigidity
postural instability
bradykinesia
What is hypertensive nephrosclerosis?
pts with chronic HTN and is assoc with retinopathy, LVH, progressive renal failure and mild proteinuria
Paraneoplastic syndromes of SIADH, ACTH and lambert eaton are most commonly assoc with which lung cancer? What about hypercalcemia?
SIADH, ACTH, Lambert –> small cell
hypercalcemia –> squamous
If you suspect adrenal insufficiency (hyponatremia, hyperkalemia, eosinophilia, fatigue, hypotension, hyperpigmentation), what’s the initial step?
-simultaneous basal early morning cortisol, ACTH, and cosyntropin test
low cortisol, high ACTH and minimal response to cosyntropin (ACTH synthetic analogue –> no to little rise in cortisol) –> primary
low cortisol, low ACTH and minimal response to consyntropin (minimal b/c low ACTH has caused adrenal gland atropy–> secondary adrenal insufficiency
lymphocytosis + smudge cells on peripheral blood smear
CLL
presence of thrombocytopenia indicates a poor prognosis
esophageal rupture either via vomiting or from endoscopic procedure can cause pneumomediastinum. Describe.
retrosternal pain
crepitus in suprasternal notch
b/c of esophageal rupture, amylase from saliva will leak into pleural fluid (mostly exudative and low pH)
A painless hard testicular mass + US result showing high likelihood of a testicular tumor, what’s the next step?
no need for biopsy or FNA; go straight to radical orchiectomy
in fact FNA and transcrotal biospy are contraindicated b/c of risk of spillage of cancer cells which can spread thru lymphatics and blood vessels
De Quervain tenosynovitis classically affects? Which 2 tendons are affected?
What’s the finkelstein test?
new mothers who hold their infants with the thumb outstretched (abducted/extended). The abductor pollicis longus and extensor pollicis brevis tendons are affected.
any passive stretch of these tendons elicits pain.
Finkelstein test: passively stretching the affected tendons by grasping the flexed thumb into the palm with fingers elicits pain
What should one suspect in someone with a chronic scar that develops into a nonhealing, painless, bleeding ulcer?
squamous cell carcinoma
Therefore, a punch biospy is warranted
COPD, interstitial lung disease, pulmonary vascular disease and OSA are common etiologies of cor pulmonale. What are some symptoms of cor pulmonale? What do you see on exam and imaging?
symptoms: exertional dyspnea, fatigue, lethargy, exertional syncope (due to decreased CO), exertional angina (due to increased myocardial demand)
PE: peripheral edema, increased JVP w/ a wave, loud S2, right-side heave, pulsatile liver, tricuspid regurg murmur
Imaging:
EKG -right axis deviation, RBBB, RVH
ECHO: pulm HTN, dilated right ventricle, tricuspid regurg
Right heart cath: GOLD STD can show RV dysfunction, pulm HTN without heart disease
someone with metastatic squamous cell carcinoma of the mucosa of the head and neck with a palpable cervical LN. What’s the best initial test?
panendoscopy (triple endoscopy: esophagoscopy, bronchoscopy, laryngoscopy) to detect primary tumor
Compare the coloring of someone who has CO, CN poisoning and methemoglobinia
CO -headache, N/V, vague abd discomfort, confusion, and pinkish-skin hue,
CN-same as CO + almond breath
methemoglobinemia -cyanosis and bluish discoloration
Define Cauda Equina Syndrome in terms of pain, anesthesia, motor weakness, and onset of bowel/bladder dysfunction and either hypo or hyperreflexia
cauda equina (lumbosacral nerves below L1-L2)
Requires emergent MRI, IV glucocorticoids and neurosurg consult
- compression of spinal nerve roots 2/2 to disc herniation or rupture, spinal stenosis, tumors, infection, hemorrhage, iatrogenic
- cauda equina provides sensory innervation to the saddle area
- provides motor to anal and urethral sphincters
- provides parasymp to bladder and lower bowel
sympoms: BILATERAL severe radicular pain, saddle hypo/anesthesia, asymmetric motor weakness, hyporeflexia/areflexia, late-onset bowel and bladder dysfunction
Define Conus Medullaris Syndrome in terms of pain, anesthesia, motor weakness, and onset of bowel/bladder dysfunction and either hypo or hyperreflexia
cauda equina (lumbosacral nerves below L1-L2)
Requires emergent MRI, IV glucocorticoids and neurosurg consult
Conus medullaris is part of the spinal cord so injury here will cause both UMN and LMN signs (vs cauda equina onlyLMN)
- sudden-onset of severe back pain
- perianal hypo/anesthesia
- symmetric motor weakness
- hyperreflexia
- early onset bowel and bladder dysfunction
When should you suspect proteus as the cause of someone’s UTI?
proteus secretes urease that hydrolyzes urea to ammonia and carbon dioxide. ammonia + H+ –> ammonium leading to urinary alkalinization (pH > 7) and promotes formation of struvite stones which will be the nidus for infection.
So suspect proteus in someone with UTI with alkaline urine +/- presence of struvite stones
Of all the therapies available to treat COPD, which has been proven to prolong survival the best?
long-term O2 therapy
use O2 therapy in pts with PaO2 - 55, SaO2 - 88%, and erythrocytosis (hct > 55%) or evid of cor pulmonale
What are some symptoms of acute angle closure glaucoma?
- u/l orbitofrontal headache
- N/V
- u/l severe eye pain with conjunctival injection
- dilated pupil w/ poor light response
w/o treatment can lead to permanent blindness w/in 2-5 hours
Recurrent pneumonia in the same anatomic location is a red flag for bronchial obstruction. If X-ray confirms consolidation, what is your next step in addition to giving abx for the pneumonia?
CT to rule out carcinoma
Bronchoscopy is more invasive and should be done after CT
The anserine bursa is located anteromedially over the tibial plateau just below the joint line of the knee. What are some symptoms of anserine bursitis? How to differentiate from medial collateral ligament damage?
sharply localized pain over the anteromedial part of the tibial plateau. Xrays are normal
not medial collateral ligament damage b/c when you apply valgus stress, it won’t create pain.
intensive axillary freckling + cafe au lait spots + optic glioma (h/o of slowly progressive u/l visual loss)
NF type 1
how to treat solitary vs multiple brain mets
solitary –> surgical resection
multiple –> whole brain radiation
What’s the initial treatment of choice for SIADH?
fluid restriction to less than 800 mL/day
if resistant hyponatremia –> hypertonic saline
demecyclocycline works at the renal collecting tubule and can be nephrotoxic so not DOC unless pt is not responding to fluid restriction
Pts taking antipsychotics like fluphenazine should be advised to avoid prolonged exposure to extreme temp. Why?
can occasionally cause hypothermia by disrupting thermoregulation and body’s shivering mech.
DOC for hypertrophic obstructive cardiomyopathy
beta blockers or cardio selective CCB like verapamil or dilitazem
Associate with the renal pathology muddy brown granular casts --> RBC casts --> WBC casts --> Fatty casts --> Broad and waxy casts -->
muddy brown granular casts –> ATN
RBC casts –> glomerulonephritis
WBC casts –> interstitial nephritis and pyelonephritis
Fatty casts –>nephrotic syndrome
Broad and waxy casts –> chronic renal failure
classic xray finding of someone with flail chest
multiple rib fractures overlying a lung contusion
development of a palpable mass in the epigastrium 4 weeks after onset of acute pancreatitis –>
pseudocyst
preferred imaging modality is US
usu resolves spontaneously, but if persists for greater than 6 wks, or becomes infected or greater than 5 cm in diameter –> drainage
An induration of greater than what in a healthy individual actually warrants TB treatment
> /- 15 mm
any healthy individual with no risk factors with any thing less than 15 mm does not have to be treated
Guillain barre syndrome presents as symmetric ascending muscle weakness and absent DTRs after recent infection that can have some sensory symptoms and autonomic dysregulation. How to diagnose? Treat?
Diagnosis
- clinically
- LP: elevated CSF fluid protein with normal white blood cell count aka albuminocytologic dissociation
Treatment
- IV immunoglobulins
- plasmapheresis Wha
What is euthyroid sick syndrome?
aka low T3 syndrome when there’s a fall in total and free T3 levels with normal T4 and TSH levels usu found in people with acute, severe illness
How to treat temporal arteritis? what about polymyalgia rheumatica that is pelvic girdle, shoulder pain (elevated ESR, normal CK)?
iv high-dose corticosteroid tapered slowly over a period of time
low-dose glucocorticoids can treat polymyalgia rheumatica as well
what is glucocorticoid-induced myopathy?
complication of chronic corticosteroid use, characterized by painless proximal muscle weakness more prominent in LE. There is no muscle tenderness or inflammation. NORMAL ESR and CK. This will slowly improve once offending medication is d/c
Describe clinical features of statin-induced myopathy and whether ESR and CK are elevated
prominent muscle pain/tenderness with or without weakness
normal ESR
elevated CK
Cocaine OD presents with sympathetic hyperactivity (tachy, HTN, dilated pupils), chest pain due to coronary vasoconstriction, seizures. How to treat?
IV benzos will improve psychomotor agitation, reduce myocardial oxygen demand, and alleviate cardiovascular symptoms.
other helpful meds: aspirin, nitroglycerin, CCB
what’s the moa of rivaroxaban? How long does it take to get into effect?
direct factor Xa inhibitor with effects within 2-4 hours that can also be used as a single agent (w/o bridging) for acute DVT treatment.
How does respiratory alkalosis lead to hypocalcemia?
respiratory alkalosis (pH is high) will cause dissociation of hydrogen ions from albumin so more binding sites for Ca2+, decreasing free Ca2+ leading to clinical manifestations of hypocalcemia.
ppx vs treatment for toxoplasmosis
ppx -TMP/SMX
treatment -sulfadiazine and pyrimethamine
Suspect bartonella henselae infection/Cat scratch disease in someone with localized cutaneous and lymph node disorder near the site of scratch. Can self-resolve, but what’s the general abx course
5-days of azithromycin
Triad of wernicke encephalopathy due to vitamin b1/thiamine deficiency
seen in malnourished chronic alcoholics
- encephalopathy
- ocular dysfunction
- gait ataxia
treat with thiamine + glucose
How to treat benzo OD
flumazenil -GABA antagonist
Neurocardiogenic/vasovagal syncope is preceded by prodrome of pallor, dizziness, nausea diaphoresis and is assoc with triggers (mictuirtion, cough, defecation, emotional stress, prolonged standing). How to diagnose?
- clinical diagnosis based on history
- upright tilt table testing in uncertain cases which involves patient being strapped on an exam table with continuous EKG and BP monitoring. the table is passilve moved from a supine to a head up position that the pt is in for 20-45 min. If there are signs of unconsciousness –> positive test
Pt with episodic dizziness triggered by positional changes is called? Due to? What’s the name of the maneuver that can diagnose this condition?
Benign paroxysmal positional vertigo due to crystalline deposits (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system.
Dix-Hallpike maneuver which is when you trigger verigo and nystagmus when pt quickly lies back into a supine position with the head rotated 45 degrees
Relieve symptom with Epley maneuver
suspect which condition when presented with someone with elevated JVP, hepatojugularreflux, kussmauls sign (increase of JVP on inspiration), pericardial knock (middiastolic sound), and pericardial calcifications on CXR
constrictive pericarditis
What’s the gold std in diagnosing someone with acute angle closure glaucoma (sudden severe u/l pain with dilated midline pupil)? What could be helpful if urgent opthalmological consultation is unavailable?
- Gonioscopy is the gold std
- ocular tonometry can be helpful
What’s the treatment of choice for mild cellulitis vs cellulitis with systemic symptoms?
mild cellulitis: oral dicloxacillin
severe: IV nafcillin or cefazolin
What is ludwig angina?
rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces classically arising from the teeth 2/2 to strep and anaerobic infection.
presents with fever, dysphagia, odynophagia, drooling
may have crepitus in submandibular area 2/2 to anaerobes
asphyxiation is the most common cause of death
VIPoma is a rare tumor affecting the pancreas causing excess production of VIP. VIP binds to intestinal epithelial cells to increase fluid and electrolyte secretion. Clinical symptoms? lab findings? dx?
Clinical symptoms: watery diarrhea, hypo- or achlorhydria due to decreased gastric acid secretion, flushing, lethargy, N/V, muscle weakness/cramps
Lab: hypokalemia, hypercalcemia, hyperglycemia, stool studies will show secretory diarrhea
Dx: watery diarrhea with VIP level > 75 pg/mL; abd CT or MRI to localize tumor, usu in pancreatic tail
What is systemic mastocytosis?
involves GI tract –> steatorrhea, hepatomegaly, peptic ulcer disease. Usually with skin symptoms like pruritus, facial flushing and urticaria.
Doxy is the DOC for lyme disease in non-pregnant, older than 8 patients. What’s the treatment of choice for pregnant and lactating pts and pts
amoxicillin
Chalazion presents as swelling on the eyelid as a nodular, painless, rubbery lesion is a chronic granulomatous condition that develops when a meibomian gland becomes obstructed. What kind of work up should you do if there’s recurrent chalazion?
histopathologic examination b/c there is a risk for an underlying sebaceous (meibomian gland) carcinoma. Also, be wary of basal cell carcinoma which can manifest in lid margin and look similar to chalazion
How can immobilization result in hypercalcemia?
unclear underlying mech but is likely due to increased osteoclastic bone resorption. Therefore, prolonged immobilization can result in significant bone loss which can be prevented by administering bisphosphonates
Sudden onset dyspnea, chest pain, and tachy with a hemorrhagic, exudative pleural effusion and absence of consolidation on CXR –> ?
Pulmonary embolism-hypoxemia, resp alkalosis, A-a o2 gradient
CHF vs COPD
Hypoxia, hypocapnia, resp alkalosis –>
hypoxia, resp acidosis –>
Hypoxia, hypocapnia, resp alkalosis –> CHF
hypoxia, resp acidosis –> COPD
dermatitis herpetiformis that can occur b/l, symmetrically and in a grouped herpetiform arrangement on extensor surfaces, elbows, knees, upper back and buttocks, commonly assoc with celiac disease. how to treat?
a gluten free diet
Dapsone -can see improvement within hours
Always suspect lacunar stroke if a patient presents with a limited neurologic deficit. Principal cause is HTN which induces lipohyalinotic thickening of the small vessels. List and describe the 4 classical lacunar strokes
1) pure motor hemiparesis due to lacunar infarction in posterior limb of internal capsule –> u/l motor deficit
2) pure sensory hemiparesis due to stroke in VPL nucleus of thalamus –> u/l sensory deficit involving face, arm, trunk and leg
3) ataxic-hemiparesis due to infarct in anterior limb of internal capsule –> weakness that is more prominent in LE, along with ipsilateral arm and leg incoordination
4) dysarthria-clumsy hand syndrome due to stroke at basis pontis –> hand weakness, mild motor aphasia, NO sensory abnorm
Small intestinal bacterial overgrowth can be caused by anatomical abnormalities (strictures, surgery), motility disorders (diabetes, scleroderma), advanced age, AIDS, ESRD, cirrhosis, etc. What are some clinical symptoms? Dx? treatment?
Clinical symp: abd pain, diarrhea, bloating, excess flatulence, malabsorption, weight loss, anemia, nutritional deficiencies
dx: endoscopy with jejunal asprate showing > 10^5 organisms/mL = GOLD STD; glucose breath hydrogen testing
treatment: abx, dietary changes, trial of promotililty agents
suspect what if a patient is presenting with ipsilateral ataxia, falling towards the side of the lesion, nystagmus, intention tremor, ipsilateral muscular hypotonia, dysdiadokinesia
cerebellar tumor
Tabes dorsalis/neurosyphilus affects
posterior columns –> loss of proprioception
pt walks with legs wide apart
In Brown sequard syndrome, damage to the lateral spinothalamic tracts causes contralateral loss of pain and temp sensation beginning where in comparison to lesion
two levels above lesion therefore if someone has left-sided loss of pain and temp at T12 then the lesion is right-sided at T10
What are some clinical symptoms of retinal detachment? What will opthalmoscopic exam reveal?
- loss of vision in affected eye, painless
- photopsia (flashes of light)
- floaters (spots in the visual field)
- classic description: “a curtain coming down over eyes”
- eye exam: grey, elevated retina
Giant cell tumor of the bone is a benign locally aggressive skeletal neoplasm that presents with pain, swelling, and decreased ROM. What is its typical xray appearance?
osteolytic lesions with a “soap-bubble” aka expansile and eccentrically placed lytic area in the epiphysis of long bones most commonly affecting distal femur and proximal tibia
Osgood schlatter disease affects young children and adolescents who have recently undergone a rapid growth spurt. Xray typically shows?
avulsion of the apophysis of the tibial tubercle
Osteitis fibrosa cystica aka von Recklinghausen disease of bone is a rare condition commonly due to?
hyperparathyroidism leading to osteoclastic resoprtion of bone –> replacement with fibrous tissue –> brown tumors that are painful
imaging: subperiosteal bone resorption, “salt and pepper appearance” of skull, bone cysts and brown tumors
Cardiac tamponade (beck’s triad: hypotension, muffled heart sounds, and jvp elevation): what happens to preload, SV and CO, HR, and cardiac contractility?
fluid accumulates in pericardial cavity that restricts venous return to the heart and lowers right and left ventricular filling. Therefore, preload, SV and CO decrease.
There will be compensatory symp stimulation in response to hypotension, decreased CO, SV via increasing HR and contractility
Pt treated for Hodgkins lymphoma years ago with chemo and radiation presents with pleuritic chest pain, nonproductive cough and xray of a solitary lesion, suspect?
malignancy recurrence b/c there’s an 18.5x increase risk of developing a second cancer in HL pts
Someone with unclear vaccination history with fever, occipital or posterior cervical LAD followed by a maculopapular rash that spreads from top to bottom sparring the palms and soles + arthritis –>
Rubella
vaccination: live rubella vaccine
Lateral epicondylitis (tennis elbow) presents as pain while
supination or extension of the wrist with point tenderness just distal to lateral epicondyle
External hordeolum aka stye is? How to treat?
a common staph abscess of the eyelid treated with warm compresses. Incision and drainage only when resolution does not begin in the next 48 hrs.
How to treat acute rejection of kidney as demonstrated by biospy of transplant showing heavy lymphocyte infiltration and vascular involvement with swelling of the intima within 3-5 days of transplant?
iv steroids!
Precipitating factors of avascular necrosiis/osteonecrosis/aseptic necrosis/ischemic necrosis/osteochondritis dissicans include long term corticosteroid use, excessive ingestion of alcohol, sickle cell anemia, trauma, antiphospholipid syndrome.
What are symptoms? What’s the best modality to diagnose?
symptoms: slowly progressive anterior hip pain with limitation of motion
MRI is best modality to use
When should you start looking at lipid panel in average women and men? What’s the interval of screening?
women - start at age 45
men -start at age 35
then every 5 years if normal
High fever with bradycardia, headache and confusion. Watery diarrhea. Hyponatremia. What is it? How to diagnose and treat?
Diagnose using legionella urine antigen test
Treat with respiratory fluoroquinolones or newer macrolides
How to manage someone with pulseless electrical activity when there’s no palpable pulse over arteries but EKG still shows activity?
uninterrupted CPR + vasopressor therapy to maintain adequate cerebral and coronary perfusion.
