UWORLD Review Flashcards
1
Q
What key imaging feature helps distinguish between CNS lymphoma and Progressive Multifocal Leukoencephalopathy (PML)?
A
MRI in PML shows multiple, asymmetric NON-enhancing demyelinating lesions with NO mass effect.
2
Q
How can HIV Encephalopathy be distinguished from PLM?
A
HIV encephalopathy usually presents with Dementia as main symptom not focal neuro findings.
On MRI lesions in HIV encephalopathy are symmetric in their distribution.
3
Q
What is the leading cause of Hypophosphatemia in ICU pt?
A
Continuous Glucose Infusion
4
Q
What is are some complication of Hypophosphatemia in ICU pts?
A
Failure to be weaned off Ventilator d/t respiratory muscle weakness.
Decreased cardiac contractility
Decreased BPG–> less Oxygen delivery to tissues (dissociation curve shifts left)
5
Q
What is the proposed mechanism for Calcium Channel Blocker (CCB)-associated edema?
A
Preferential vasodilation of arteriole–>increased capillary hydrostatic pressure–>increased fluid movement into interstitium
6
Q
What are main side effects associated with dihydropyridine CCB’s?
A
Headache
Dizziness
Flushing
Edema
7
Q
At what anatomic site do ACEi’s work?
A
Post capillary (efferent) arteriole/venodilation
8
Q
What is the most common complication associated with Statin use?
A
Medication-induced Myopathy
9
Q
What is the treatment for late latent/unknown/gummatous/cardiovascular syphilis?
A
IM Benzathine Penicillin G weekly for 3 wks
10
Q
What is the treatment for Neurosyphilis/Congenital
A
IV Aqueous Penicillin G for 10-14 days
11
Q
What is the treatment for Primary/Secondary/Early latent (
A
IM Benzathine Penicillin G single dose
12
Q
What is the most common complication of Polycythemia Vera?
A
Myelofibrosis
13
Q
What type of leukemia are pts with Down Syndrome at increased risk of getting?
A
ALL
14
Q
At what platelet count id Prophylactic platelet transfusion indicated?
A
Plt
15
Q
What virus is associated with Adult T-cell Lymphoma?
A
HTLV-1
Endemic in Japan and Caribbean
16
Q
What is the most common type of Hodgkin Lymphoma?
A
Nodular Sclerosing
Mixed Cellularity is second most common type
17
Q
Which chemo drug is assoiciated with causing a reversible cardiotoxicity that affects left ventricular function?
A
Trastuzumab (Herceptin)
MOA: Causes decreased cardiac myocardial contractility.
18
Q
What is the most likely diagnosis in a pt with a loud 4/6 holosystolic murmur with thrill at 4th ICS at left sternal border?
A
Ventricular Septal Defect (VSD)
Note: loud murmur = small restrictive VSD
soft murmur = large nonrestricitve VSD with grater shunting
19
Q
Waht is the preferred method of imaging the esophagus and stomach?
A
Traditional Endoscopy
Note: wireless “pill” endoscopy is beneficial for areas of small bowel otherwise, views are limited in the esophagus, stomach, and cecum.
20
Q
What is the indication for treatment of Paget’s Disease of the Bone?
A
Wt bearing bone involvement Hypercalcemia/hypercalcuria Intolerable Pain Neuro Involvement CHF
21
Q
What are the features of Whipple”s Triad?
A
Low Blood Glucose
Sx of Hypoglycemia
Sx relief with glucose
Suggests true hypoglycemia
22
Q
What is the most likely dx in a pt who presents with bitemporal hemianopsia, hyperpigmentation, and h/o abdominal adrenalectomy prior.
A
Nelson Syndrome
23
Q
What is the best test to dx Nelson Syndrome?
A
Brain MRI Pituitary microadenoma (suprasellar pituitary enlargement d/t loss of negative feedback inhibition s/p bilateral adrenalectomy)
and
Elevated ACTH
24
Q
What is the most likely diagnosis in a pt with IBD who c/o several episodes of bloody diarrhea, abdominal pain, fever, weakness, and tympanitic, distended abdomen?
A
Toxic Megacolon
25
What is the next best step in management in a pt with the above presentation?
Abdominal Xray
26
What is the treatment for pt with Toxic Megacolon?
```
Steriods iff d/t IBD
IV Fluids
NPO (bowel rest and hold meds that can decrease peristalsis)
NG tube (decompression)
Electrolyte correction
```
Antibiotics if d/t infection
Surgery if signs of perforation detected on imaging
27
What are the treatment options for a pt with PD?
```
Mild and 60yo: Amantadine
Severe (cannot perfom ADL's):
Levodopa/Carbidopa or
Dopamine Agonist:
Pramipexole or Ropinerol or Carbergoline
```
28
What is the first Hemotologic parameter to change in response to Iron supplementation in a pt with Iron deficiency anemia?
Reticulocyte count will increase
29
What is the next step in treatment for a pt of Asian, Latin American, or Eastern European background who presents with dyspepsia without GERD sx or NSAID use and is
H. Pylori testing
30
What is the most likely diagnosis in a pt presenting with rapid ascites, hepatosplenomegaly, portal hypertension, jaundice, RUQ pain, and found to have hepatic vein and IVC thromboses and gastroesophageal varices?
Budd-Chiari Syndrome
31
What is the most likely dx in a pt presenting with Ataxia, confusion, and nystagmus-->ophthalmoplegia?
Wernicke's Encephalopathy
32
What is the next step in management for a pt on Metformin with normal renal fnc who will have a procedure with contrast via lg bore needle?
Discontiune Metformin on day of procedure and restart in 2 days (after renal func assessed)
Lactic acidosis risk increases when contrast is used in pt taking metformin.
33
What are two underlying metabolic abnormalities resulting in HIV lipodystrophy?
Insulin resistance
| Dyslipidemia
34
What conditions are patients who receive Diphtheria Antitoxin at increased risk of getting?
Serum Sickness
Anaphylaxis
(Antitoxin is made with horse serum so always have Epinephrine available when administering)
35
What metabolic tests are used to diagnose Pheochromocytoma?
Plasma free metanephrines OR
| 24-hr Urine metanephrines and catecholamines
36
What is the first line treatment for neuropathic pain associated with diabetic neuropathy?
Tight Gycemic control and if needed
SNRIs (Duloxetine)
Pregabalin
TCAs
37
What is the next step in management for a pt presenting with Whipple's triad for hypoglycemia and elevated Insulin, C-peptide, and Proinsulin?
Oral Hypoglycemic assay
38
What is whipple's triad for Hypoglycemia?
Symptoms of hypoglycemia
Low blood Sugar
Symptom resolution with the administration of glucose
39
What is the next step in management for a young pt who presents with dyspnea on exertion, no risk factors for coronary/atherosclerotic disease,physical exam findings of prominent S2 without murmurs/gallops, clear lungs, CXR showing prominent pulmonary arteries, and EKG showing right axis deviation?
Echocardiogram (to measure Rt pulm artery pressure, assess right ventricular and atrial function/size, and right heart valve mobility)
40
What tests should be done prior to diagnosing Idiopathic Pulmonary Artery Hypertension?
Pulmonary Function Tests (PFTs)
High resolution CT
Polysomnography
41
What is the next step in management for PAH once all other causes ruled out and pt diagnosed with idiopathic PAH?
Vasoreactivity Test (measure PA pressure following vasodilator administration)
42
If Vasoreactivity testing shows elevated PA pressure, what is next step in management?
Prostanoid (Epoprostenol)
Endothelin antagonist (Bosentan)
Phosphidiesterare-5 inhibitor (Sildenafil)
43
What is the drug of choice for Cluster Headache PREVENTION for greater than 2 months?
Verapamil (get baseline EKG for higher doses)
44
Which abortive therapy for cluster headache should be avoided in pts with Cornary Artery disease?
Sumatriptan
45
What is the next step in management for a pt diagnosed with Normal Pressure Hydroephalus?
LP to drain CSF (about 30-50ml) then assess cognition and gait
(Ventriculoperitoneal shunt is definitive treatment iff pt responds to removal of CSF with LP)
46
What is the next step in management for a pt suspected of active Tb?
Chest Xray
47
What is the next step in management of a pt suspected of active Tb with abnormal or normal CXR?
Sputm smears/microscopy (esp) and culture x3 for acid fast bacilli (cultures taken 8-24 hrs apart with at least one early morning sample)
48
What is one criteria to be considered non-infectious in a pt suspected of having Tb?
3 negative Sputum smear (marker for infectivity)
(note, this does not mean pt is not infected or does not need Tb treatmen. If they are symptomatic, treat empirically until cultures return)
49
What is the formula for SAAG?
Serum Albumin-Ascites Albumin
50
What conditions are associated with SAAG >/= 1.1?
```
CHF and
Portal Hypertensive Etiologies
Cirhosis
Alcohol hepatitis
Budd-Chiari Syndrome
```
51
What conditions are associated with a SAAG
```
Peritoneal Cancers
Peritoneal Tb
Serositis
Nephrotic Syndrome
Pancreatitis
```
52
What is the most likely diagnosis in a pt with rapidly progressing weakness of lower or upper extremities, decreased/absent DTR, sensory loss, and urinary retention following a URI?
Transverse Myelitis
53
What is the drug of choice for bite wounds?
Amoxicillin/clavulanate (PO) or Ampicillin/Sulbactam (IV)
54
What is the pathophysiology of scabies-related pruritis?
Delayed Type (IV) hypersensitivity rxn to the mite, its feces, and ova.
55
What are the features of Papilledema seen on Ophtho exam?
Blurred disc Margins
Serpintine engorgement of small veins
Obscured Vessels/Cotton Wool Spots
Splinter Hemorrhages
56
What are some red flag signs that indicate imaging should be the next step in management for a pt with headache?
```
Papilledema
Sudden onset, worse headache of life
Age >/= 50
Increased frequency or severity
Worse with Exercise/Sexual Intercourse
Neurologic Deficits
Personality Changes
Systemic Symptoms
```
57
What is one effective way to reduce Observer Bias?
Blinding
58
What is the formula for calculating Sensitivity?
a/a+c (Out of all the people with the disease, who had + test)
59
What is the formula for calculating Specificity?
d/d+b (Out of all people w/o the disease, who had a - test)
60
What is the formula for Positive Predicted Value?
PPV= a/a+b (out of all people w/ a positive test)
61
What is the formula for Negative Predicted Value?
NPV= d/c+d (out of all people w/ a negative test)
62
What are the three components of Leriche Syndrome?
Erectile Dysfunction
Lower Extremity Claudication
Diminished/Absent Femoral Pulses
63
What is the next step in management in a pt presenting with Erectile Dysfunction, chronic exertional buttock/thigh pain and a h/o DM2, hyperlipidemia, and active smoking?
Ankle-Brachial Index (to screen for PAD)
64
How is an ABI interpreted?
1.30 = Calcified, uncompressible vasculature--> Need further studies
65
What additional test should be done in a pt with Erectile Dysfunction and atherosclerotic disease risk factors (hyperlipidemia, smoking) prior to initiating therapy?
```
ABI
Stress Test (exercise or pharmacologic)
```
66
In a normal distribution curve, what are the values for the Median, Mode, and Mean?
Mean=Median=Mode
67
What value(s) of central tendency is/are affected by outliars in very skewed curves?
Mean
68
What is the relationship between Mean, Median, and Mode in a positively skewed distribution curve?
Mode
69
What is the relationship between Mean, Median, and Mode in a negatively skewed distribution curve?
Mean
70
What is the best choice to measure central tendency when the data (Ordinal or Continuous) is skewed?
Median
71
What is the best choice to measure central tendency when the data (nominal) is skewed?
Mode
72
What is the best prognostic Indicator for acute pancreatitis severity?
APACHE II score
73
What is the next step in management for a pt with an APACHE II score of 8 or more?
CT scan at 72 hrs to check for pancreatic necrosis
74
What is the best way to distinguish between IgA nephropathy and Thin Membrane Disease?
Renal Bx
Note: Hematuria in Thin Membrane Dx not usually related to URI, while with IgA Nephropathy, hematuria is Syn-pharyngitic (1-3 days post URI)
75
What are the limitations of HHA services?
Cannot give medications
| Cannot perform Health Evaluations
76
What is the most likely dx in a pt with Low TSH and Low FT4?
Central Hypothyroidism
77
What is the next step in management for a pt with low/borderline TSH, low FT4, and low/low normal Sodium?
ACTH levels
ACTH stimulation test (ck cortisol levels before and after)
Note, when central endocrine disorder suspected, also consider r/o other central endocrine disorders.
78
What is the most likely dx in a pt with back pain that is worse with extension and improved with flexion of lumbar spine and sitting, w/w/o pain radiating to buttocks (neurogenic claudication)?
Spinal Stenosis
79
What is the most likely dx when a pt presents with back pain that is worse with lumbar flexion of the spine and positive straight leg raise test?
Disc Herniation
80
What features are associated with severe C. diff colitis?
WBC > 15,000/uL
Temp > 38.3C (100.9F)
Albumin 1.5x Baseline
81
What is the treatment for mild-moderate C. diff colitis?
Oral Metronidazole
82
What is the treatment of choice for severe C.diff colitis?
Oral Vancomycin
83
When should IV metronidazole be added to therapy for C. diff colitis?
When severe AND Ileus is present
84
What are two alternative medications for the treatment of C.diff colitis when Vancomycin or metronidazole don't work or are not available?
Oral Rifampin
OR
Oral Rifaximin
85
What is the next step in dx for a pt presenting with localized tenderness, pain that is worse with use , and swelling of the legs/feet in a pt who runs a lot or is a military recruit, or athlete?
Plain Xrays- will be normal (until about 4 wks later)
Stress Fracture==> clinical dx,
86
What is the best imaging modality to use to dx Stress Fracture?
MRI
87
What is the management of choice for lower extremity Stress Fracture?
```
Pneumatic Splinting
Decreased Weight Bearing
Gradual Exercise (up to 12 wks for mild cases but can extend if recurrent pain develops)
```
88
What clinical tests can be used to dx Carpel Tunnel Syndrome?
1)Phalen's Sign (hyperFLEXION of wrists-->pain w/in 1 min)
2)Tinnel's Sign (tapping over medial nerve at Carpel
Tunnel)
3) Hand elevation over head-->reproduces sx after 1 min
89
What 2 tests can be used to confirm the dx of Carpel Tunnel Syndrome and determine severity of the condition?
Nerve Conduction Studies
EMG
(Note: the dx is clinical but these tests can be done for more thorough workup and to guide therapy)
90
When can steroids be used in the treatment of Carpel Tunnel Syndrome?
When Splinting fails to improve sx's (injected steroid preferred)
91
What is the next step in management for a pt in an MVA with multiple bruises/lacerations on/near his chest with normal cardiac and lung exam and normotensive?
12-lead ECG (most important test to r/o Blunt Cardiac Trauma)
92
What are the steps in management for a pt with blunt chest trauma?
1) ABC's
2) Physical Exam
3) CXR
4) EKG:
if Abnormal-FAST exam/ Transesophageal echo/ CT
if Normal- No further testing
93
What is the treatment of choice for Akathisia?
B-Blockers added to antipsychotic regimen (Propranolol)
94
What is the treatment of choice for Lead(Pb) poisoning in a pediatric pt?
Mild (venous level 5-44ug/dL): No treatment
Moderate (45-69ug/dL): Meso2,3-dimercaptosuccinic acid, Succimer
Severe(>/= 70ug/dL): IM BAL(dimercaprol) + IVCalcium disodium edetate (EDTA)
95
What are the clinical features/lab findings associated with Lead colic?
Abdominal Pain
Constipation
Anemia
Basophilic Stippling
96
What are the indications for Parathyroidectomy in pts with secondary/tertiary hyperparathyroidism?(7)
1) Calcium>10.5mg/dL and no response to therapy
2) PTH >1000pg/mL
3) Moderate-severe Hyperphosphatemia and no response to treatment
4) Intractable Bone Pain
5) Intractable Pruritis
6) Episode of Calciphylasix
7) Soft Tissue Calcification
97
What metabolic test should be done prior to parathyroidectomy?
ALK Phosphatase to assess bone turnover (if low, surgery may not be best)
98
In what condition associated with secondary hyperparathyroidism is Pamidronate contraindicated?
Chronic Renal Failure
99
What is the treatment of choice for Squamous Cell Carcinoma of the skin?
Surgical Excision
100
What are some alternative treatments for Squamous Cell Carcinoma of the Skin when surgery is not desired?
Cryotherapy
Electrosurgery
Radiation Therapy (risk of future malig-->used in elderly who refuse surgery)
101
What is the limitation of Cryotherapy and Electrotherapy for the treatment of Squamous Cell Skin Cancer?
No histology to confirm tumor margins
102
What is the next step in management for an HIV+ pt who presents with non-productive cough, SOB, Hypoxia, and increased LDH, with an induced sputum Negative for Pneumocystis?
Bronchoalveolar Lavage (Most Accurate/ definitive)
| Note: Sputum culture is the most common way to determine PCP
103
What is the indication for the addition of steroids to the treatment for PCP?
A-a gradient >35
and/or
PaO2 = 70mmHg
104
What dx should be suspected in a pt who presents with HYPOpigmented skin lesions (ash leaf spots), developmental/cognitive delay and seizure?
Tuberous Sclerosis Complex
105
What is the underlying cause of Tuberous Sclerosis Complex (TSC)?
Atusomal Dominant or Denovo Gene Mutation in TSC1 (hamartin) or TSC2 (tuberin) genes
These genes control cell differentiation--> benign tumors
106
What are the common sites of tumor development in TSC?
```
Skin: Ash Leaf Spots, Malar Angifibromas, Shagreen
Patches
CNS: Glioneuronal Hamartomas "Tubers"
Kidney: Angiolipoma
Cardiac: Rhabdomyomas (visible in utero)
```
107
What test should be included in the initial work up of a pt with possible TSC?
```
Skin evaluation
Fundoscopy
Brain MRI
Abdominal Ultrasound (renal)
EEG (if seizure suspected)
```
108
What is the predominant cause of death in pt with TSC?
Neurologic Impairment (esp uncontrollable seizures, obstructive hydrocephalus, and aspiration pneumonia)
109
What type of therapy is associated with prologned life span in pts with TSC?
Antiseizure medication (Optimal Seizure control)
110
What is the second most common cause of death in pts with TSC?
Renal impariment/Failure
111
What are two examples of anti-Pseudomonal Cehalosporins?
Cefepime
| Ceftazidime
112
What are other anti-pseudomonal antibiotics?
```
Amikacin (aminogylcoside)
Carbepenems
Piperacillin-Tazobactam
Certain Fluoroquinolones
Aztreonam
Cilostin
```
113
When should Vancomycin be added to antibiotic epmiric therapy in a pt with Cyctic Fibrosis being treated for acute pulmonary exacerbation/pneumonia?
If there is a h/o MRSA
114
What is a clue in the neonate that would suggest diaphragmatic paralysis rather than diaphragmatic hernia?
Presence of Erb's Palsy (phrenic nerve damage d/t shoulder traction/neuropraxia)
115
What are the 2 most common causes of phrenic nerve injury?
```
Birth Injury (associated with signs of brachial plexus injury)
Cardiothoracic Injury/Surgery
```
116
What are the dignostic criteria for Bacterial Vaginosis?
3 out of 4:
1) Clue Cells on wet mount
2) Amine odor on KOH prep of discharge (+ Whiff test)
3) Vaginal pH>4.5
4) Homogenous vaginal discharge
117
How is Bacterial Vaginosis treated (in pregnancy)?
ORAL Metronidazole (must let mothers know it crosses placenta but not teratogenic effects)
OR
ORAL Clindamycin
(Note: only need to treat symptomatic pts (ie abnormal discharge), no need to screen asymptomatic pts)
118
What complications can be associated with untreated BV in pregnancy?
Increased risk of Preterm Birth, PROM, SAB
| Increased risk of STD
119
When is a stress test indicated prior to the onset of sexual activity post MI?
Only if pt is of intermediate or indeterminate risk status--> do stress test to reclassify the pt prior to recommendation about sexual activity.
120
How are Somatic Symptom and Illness Anxiety Disorder (Hypochondriasis) distinguished?
Somatic Symptom Disorder : Actual Symptoms
| Illness Anxiety Disorder: Minimal/No Symptoms but preoccupied with having serious disease/condition
121
What type of disease process should be suspected in an African-American pt found to have bilateral Hilar fullness on CXR?
Granulomatous disease
122
What does an isolated elevated Alk Phosphatase with normal AST, ALT suggest?
Infiltrative Liver Disease
123
What is the benefit of the findings of mild hepatomegaly w/o focal lesions and ascites on abdominal ultrasound?
Nonspecific BUT
| Help r/o Underlying Mass as cause of infiltrative liver disease.
124
What are the most effective methods of contraception?
```
IUD (>99%)
Progesterone Implant (>99%)
```
125
What condition should be suspected in a female pt presenting with post-void dribbling, dysuria, and dyspareunia, anterior vaginal wall fullness, who has had multiple vaginal deliveries?
Urethral Diverticulum
126
How can Stress incontinence be distinguished from Urethral Diverticulum?
Stress incontinence is associated with loss of urine upon increased abdominal pressure.
127
How is Urethral Diverticulum dx?
Transvaginal Ultrasound
128
What condition should be considered in pts with low iron, low vitamin D, and Low calcium w/ or w/o GI symptoms, a healthy diet, and a personal and FHx of autoimmune disease?
Malabsorptive Disease Processes (ex: Celiac Disease)
129
What are the screening (best initial) tests for Celiac Disease?
Anti-Tissue Transglutaminase Ab
| Anti-endomysial Ab
130
What is the test of choice for definitive dx of Celiac Disease?
Small Intestinal Bx
131
What type of Bias is associated with a Funnel Plot that shows asymmetric data points?
Publication Bias
132
What is the drug of choice for immediate treatment of Metoclopramide-induced acute dystonia?
Diphenhydramine IV
133
What is an alternative medication for Metoclopramide-induced acute dystonia treatment id Diphenhydramine does not work?
Benztropine IV
134
What aspects of ADHD tend to resolve/diminish by adolescence?
Physical Hyperactivity
135
What features might be associated with ADHD that persists into adolescence and/or adulthood?
```
Inattention (often reported as boredom)
Impulsivity
Procrastination
Forgetfulness
Hyper-talkativeness
```
136
What is the treatment of choice for adolescents/adults with persistent ADHD?
Stimulants (even if pt has FHx of Drug abuse/addiction or personal drug use)
[Note: Stimulant medications are not associated with increased risk of substance use/abuse]
137
What test should be done prior to treating a UTI in a female of child-bearing age who is sexually active, regardless of contraception use?
Urine Pregnancy Test
138
Why should TMP-SMX be avoided in pregnancy?
Interferes with Folate metabolism.
139
Why should Fluoroquinolones be avoided in pregnancy?
Increased risk of fetal arthropathy
140
Which antibiotics are safe to treat uncomplicated UTI in pregnant pts?
Amoxicillin
Cephalexin
Ntrofurantoin (except at term, during labor/delivery, or if labor is imminent)
141
What are the concerns associated with use of St. Johns Wort?
St. Johns Wort:
- P450 inducer--> interfere with medications
- Increased risk of Serotonin Syndrome
142
What is the treatment of choice for a pt with optic neuritis and suspicious for Multiple Sclerosis acute exacerbation?
IV Steroids
[Note: Oral and IV steroids are equally efficacious for MS exacerbation, but IV preferred with optic neuritis bc increased risk of recurrence with oral steroids]
143
What is the treatment for acute MS exacerbation when steroid therapy is not effective?
Plasmapharesis
144
What is the first line treatment for severe spasticity (spasms/stiffness) associated with MS?
Muscle Relaxers:
Baclofen
Tizanidine
145
What is the treatment of choice for fatigue associated with MS?
Sleep hygeine Modifications
Exercise
Amantadine
Stimulants
146
What is the test of choice to dx HIV when screening test (ELISA) is negative or indeterminate and there is a high level of suspicion for primary infection?
HIV RNA PCR (detect viral load)
or
HIV p24 ag
147
Why shouldnt Western Blot be used to confirm HIV infection in a pt who presents with a negative ELISA and is suspected of having early/primary infection?
Increased False Negatives early in disease course (ie: b/f seroconversion)
148
What is the most likely dx in a pt who presents with altered mental status, extreme hyperglycemia (glc>1000), and absence of ketones and a normal anion gap with a h/o type 2 DM and recent illness or steroid/antipsychotic use?
Hyperglycemic Hyperosmolar Nonketotic State (HHS)
149
What is the management for a pt with HHS?
1) High Flow normal Saline (Add Dextrose 5% in water once glc=200)
2) IV continuous Insulin
3) Monitor K+, replace when Serum level = 5.2
4) Monitor Bicarb (for metabolic status)
150
Once a pt with HHS is stabilized, what should be changed regarding the Insulin during hospitalization?
Switch to Subcutaneous Basal-Bolus regimen with Sliding scale (short acting + long acting)
151
What signs when present in a baby or young child (not walking) would indicate increased intracranial pressure and should increase suspicion for Intentional Head Trauma/Shaken Baby Syndrome?
Lethargy
Apnea
Vomiting
H/o repeat ER visits for similar reasons
152
What is the next step in management for a baby presenting with signs of increased intracranial pressure and Intentional Head Trauma is suspected?
Heat CT (to r/o intracranial bleed)
153
How are Chronic Tic Disorder and Tourette Syndrome distinguished?
Chronic Tic Disorder: Motor OR Vocal tics for >/=1yr
| Tourette Syndrome: Motor AND Vocal tics present simultaneously
154
What is the treatment of choice for Tourette Syndrome?
Antipsychotic (dopamine antagonist) ex Risperidone
[Note: first generation antipsychotics can also be used but they have worse side effect profile so Second Gen are preferred]
155
What condition should be suspected in a pt who presents with a h/o fall on outstretched hand with pain, swelling, tenderness over the radial dorsal aspect of wrist (Anatomic Snuff Box), decreased grip strength, and relatively intact range of motion?
Scaphoid bone Injury
156
What is the next step in management for a pt with suspected Scaphoid bone injury?
Xray of Wrist in full pronation and ulnar deviation
157
What are some key differences between Colles Fracture and Scaphoid Bone Fracture?
Colles Fracture:
- Visible Upward displacement/Angulation (dinner fork
deformity) -->Comminuted
- Initial XR confirms dx
Scaphoid Bone Fracture:
- Normal Xray
- Most common injury associated with fall on outstretched hand with forced dorsiflexion of wrist
158
What is the next step in management for a pt suspected of having a scaphoid bone fracture with a negative Xray?
MRI or CT of wrist
159
What is the management for a pt dx with nondisplaced Scaphoid bone fracture that does not require surgery?
Spica Cast
| F/u xray in 7-10 days and every 2 weeks to check healing
160
What is the management for a pt with a Scaphoid Bone fracture with displacement?
Ortho consult for surgical repair
161
What are the most common complications of Scaphoid bone fractures?
Nonunion
| Avascular Necrosis
162
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule > 1.0 cm who has NO risk factors for cancer?
TSH or Ultrasound
163
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule >1cm, with risk factors of cancer and/or clinical suspicion?
FNA
164
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule>1cm, no risk factors for cancer, and no suspicious US findings?
TSH:
If normal or elevated-->FNA
If decreased
165
What is the next step in management when an asymptomatic pt presents with solitary thyroid nodule that has no suspicious US findings, decreased TSH?
```
Thyoid Scintigraphy:
If Hyperfunctioning (hot)--> treat hyperthyroidism
If Hypofunctioning (cold)--> FNA
```
166
What is the next step in management for a pt who is diagnosed with differentiated thyroid cancer(papillary or follicular)?
U/s of neck and cervical lymph nodes for staging to determine appropriate surgery?
167
What is the treatment for diagnosed differentiated thyroid cancers that are small solitary masses
Solitary, in situ malignancies Lobectomy
168
What are the indications for total Thyroidectomy as treatment for Papillary Thyroid Cancer?
1) Tumor >/= 1cm
2) Distant mets
3) Extension of tumor beyond Thyroid gland
4) Head/Neck Radiation exposure
169
What is the treatment of choice for a pt dx with Scleroderma renal Crisis?
ACE-inhibitors, Captopril (reverse angiotensin-induced vasoconstriction at Efferent (efflux) arteriole--> decrease GFR)
[NOTE: All other conditions of renal failure, avoid ACE inhib's]
170
What is the treatment of choice for a pt presenting with Acute Scleroderma Renal Crisis with CNS manifestations?
Oral Captopril and ADD one dose of IV Nitroprusside (monitor bp bc do not want sudden major decrease as this would worsen renal perfusion --> ATN)
171
What is the next step in management for a pt who presents with unilateral moderate knee pain/tenderness, swelling, and erythema but able to bear weight and does not appear ill of have any constitutional signs with a h/o travel to the wooded areas of the northeast or upper midwest United States?
Arthrocentesis
and
Lyme Serology (ELISA then confirm w/ Western Blot)
All pts with Artrhitic Lyme will hv +IgG
172
What are some typical features of Late Lyme disease?
Arthritis (monoarticular, mild inflammatory signs, can bear weight, and well appearing)
Encaephalitis
Peripheral Neuropathy
173
What is the treatment of choice for Late Lyme Disease?
Oral Doxycycline or Amoxicillin (28dys) with full recovery and no sequelae w/in 6-12mos
Note: Avoid Doxycycline in children can cause tooth discoloration/skeletal problems
174
What is the most common cause of gastroenteritis in adults and children, especially associated with epidemics?
Norovirus
175
What are some typical features associated with Norovirus gastroenteritis?
```
Vomiting(mainly)
Watery Diarrhea
Fever (low grade)
Headache
Systemic signs (if severe)
Culture Negative Stool
Sx generally last 48-72 hrs
```
176
How is the dx of Tinea Versicolor confirmed?
KOH prep of skin scraping-->shows hyphae and yeast
177
What is the causal organism associated with Tinea Versicolor?
Malassezia species
178
What is the treatment of choice for Tinea Versicolor?
Topical Anti-fungal agents
Note: Use oral antifungals if extensive disease or refractory to topical agents
179
What should be done prior to any decision -making for a pt with Mental Retatrdation?
Determine guardianship status and capacity
180
What is the physician's responsibility on reporting newly dx'd HIV?
Mandatory reporting to Department of Public Health
181
What is the best initial treatment for pts ages 3-5 newly diagnosed with ADHD?
Non-pharmacological interventions (Parent-Child Behavior Therapy)
182
What should be done prior to initiating ADHD therapy with stimulant medication?
Cardiac Hx and FHx of Cardiac problems (sudden death)
Physical Exam
Baseline Weight
Vitals (monitor throughout use)
183
When is an ECG indicated prior to starting stimulant therapy for ADHD?
ECG only if there are findings associated with possible Cardiac disease on H&P
184
What are 2 alternative non-stimulant medications that can be used to treat ADHD if stimulants are ineffective or side effects are intolerable?
Atomoxetine (Norepi reuptake inhibitor)
| Alpha-2 agonist (Clonidine)
185
What level of unconjugated bilirubin is considered high in general?
18mg/dL and up
186
At what bilirubin level is the risk of neurologic dysfunction increased?
Serum Bili >25mg/dL
187
What Ab is most sensitive for the detection of CREST variant of scleroderma?
anti-Centromere Ab
188
What Ab is most sensitive to detect Primary Biliary Cirrhosis (PBC)?
anti-Mitochondrial Ab
189
What Ab is highly specific for SLE but have a very poor sensitivity?
anti-Smith Ab
190
What Ab's are most likely seen in pt with Sjogren's Syndrome?
anti-Ro/SSA Ab
| anti-La/SSB Ab
191
What Ab has good sensitivity for SLE, can be used to as an indicator of disease activity, and is associated with the development of LUPUS Nephritis?
anti-dsDNA Ab
192
What is the treatment of choice for a pt dx with SLE who presents with mild cutaneous sx, serositis, and arthralgias w/o extensive solid organ involvement?
Low does , short term Prednisone + Hydroxychloroquine
193
What should be included in the initial workup of a pt with chronic diarrhea ( loose stools w/w/o increase in frequency for > 4wks)?
```
History (including travel, sexual hx, diet, associated sx)
Physical (including rectal exam)
Stool sample
Gram Stain
Cx
Microscopy for leukocytes/ova/parasites
Fecal Fat staining
Occult Blood
pH
Electrolytes (calculate osmotic gap)
```
194
What are the characteristic Bx findings associated with Celiac Disease?
Villus Blunting (mucosal flattening)
Loss of normal villus architecture
Lymphocyte and Plasma cell mucosal infiltration
195
What bx findings are associated with Crohn's Disease?
TRANSMURAL inflammation w/ Lymphocytic infiltration
196
What bx findings are associated with Ulcerative Colitis?
Superficial mucosal inflammation w/Plasma cell infiltration
197
What is the preoperative diabetes management in a pt with Type 1 DM who has a scheduled C-section?
Normal Insulin night before (even though NPO after 12)
| Insulin Drip w/ D5 1/2 Normal Saline w/ 40 mEq KCl to keep blood glucose
198
What is the most likely dx in a pt who presents w/ abdominal pain, diarrhea, N/V, dizziness, sweating, and dyspnea who has a h/o of recent gastrectomy?
Dumping Syndrome (food moves faster from stomach to jejunum --> causes symptoms)
199
What is the initial management for a pt with Dumping Syndrome?
Goal: decrease the speed of food passage into Small Gut
- High Protein
- Smaller, More frequent Meals
200
What types of wounds should not undergo primary closure?
Bites on hand (any place with decreased blood supply)
Puncture Wounds (Anywhere)
Pts presenting late after a bite
201
What are some risk factors associated with Intussusception?
```
Meckel's Diverticulum
Henoch-Schonlein Purpura
Celiac Disease
Polyps
Intestinal Tumor
```
202
How is Intussusception Dx'd when presentation is unclear?
Target Sign on Ultrasound
203
What is the most likely dx in a child netween age 6mos-3yrs with crampy, episodic, severe abdominal pain, sausage-like mass on right side of abdomen, and current jelly (very red) stools?
Intussusception (can also see vomiting and drawing up of legs during pain)
204
What is the most common lead point for Intussusception?
Hypertrophied Peyer's Patch
205
What is the primary risk associated with non-surgical (Enema) reduction og Intussusception?
Perforation (even with air/water-soluble substances)
206
What is the pathophysiology resulting in the sx's associated with intussusception?
Telescoping of Ileum into Cecum (rt-side)--> Edema/Obstruction/Pain-->Vascular Compression--> Bowel Ischemia--> Rectal Bleeding (current jelly stools)
207
What are the current Cervical Cancer screening guidelines for sexually active females?
If 65: No screening if prior negative screens and not high risk
Hysterectomy (no cervix): No screening if NO h/o:
-High grade precancerous lesion
-Cervical Cancer
-Diethylstilbestrol (DES) exposure
Immunecompromised: PAP at onset of sexual activity q 6mos 2 times, then annually if negative
208
What is the next step in management for an elderly pt with a hip fracture whose vitals are stable and was ambulatory prior to incident?
Ortho consult and surgical repair w/in 48 hrs (lower mortality and morbidity)
209
What are the criteria for non-operative management of hip fracture in the elderly population?
Those who are
- Non-ambulatory prior to injury
- Demented
- Have end-stage terminal illness
- Medically Unstable (can delay surgery up to 72 hrs)
210
What patterns are more commonly associated with benign solitary lung nodules on imaging?
Popcorn
Laminated (concentric)
Diffuse homogenous
Central
211
What structure is responsible for draining the testes?
Pampiniform Plexus
212
In addition to venous drainage, what does the pampiniform Plexus also maintain for the testes?
Appropriate temperature (2 degrees cooler than body-seminiferous tubules very sensitive to increase in temp)
213
What are pts with untreated varicocele at increased risk of developing?
Testicular Atrophy (dilation of pampiniform plexus--> increase in intrascrotal temp--> seminiferous tubular atrophy)
Note: Seminferous tubules make up majority of testicular mass
214
What is the location of the fluid location associated with a testicular hydrocele?
The potential space in the Tunica Vaginalis
215
What is the next step in management for a pt who presents with varicocele involving the right side and why?
CT abdomen and Pelvis (to determine cause of obstruction)
-Right venous drainage is at a larger angle directly into IVC therefore, facilitating continuous venous flow unless something is blocking flow.
Varicocele more likely on left side--> spermatic vein drains into renal vein at 90 degree angle.
216
What is the treatment of choice for pediatric sepsis?
Child = 28dys: Ampicillin + Gentamicin or Cefotaxime(esp for suspected meningitis)
Child>28 days: Cetriaxone or Cefotaxmine
+/-Vancomycin (meningitis)
217
Why should Ceftriaxone, Sulfonamides, and Sulfamethoxazole use be avoided in neonates (=28 days old)?
They cause:
| bilirubin displacement from albumin-->elevated serum bili-->increased bili crossing BBB-->increased risk of kernicterus
218
Why should TMP-SMX use be avoided in children
Can cause Methemoglobinemia
219
What are the most common causes of pediatric sepsis/meningitis?
Child=28days:
- GBS (esp w/in first 24 hrs of life)
- E. coli
Child>28days:
- S. pneumo
- E.coli
- S.aureus
220
What should be included in the workup for all febrile neonates?
```
CBC
Blood Culture
Urinalysis
Urine Culture
Lumbar Puncture: CSF cell count and Culture
```
221
What features distinguish Guillan Barre Syndrome from Transverse Myelitis?
GBS:
No sensory level
No bladder/bowel dysfunction
Autonomic Dysfunction (severe)
Transverse Myelitis:
Sensory level present
Bladder/Bowel dysfunction present
222
What is the next step in management for a pt presenting with onset of progressive lower extremity weakness and paresthesias with bladder/bowel dysfunction, sensory level, and recent URI?
MRI (immediate)
223
What is the most likely dx for a pt presenting with
Transverse Myelitis
224
What is the treatment for Transverse Myelitis?
High-dose steroids for 3-5 days
225
What should be done to confirm eradication of H. Pylori infection and when should it be done?
Fecal Antigen Testing or Urea Breath Test after 4 weeks
[Note: Do not do serology bc may remain positive even a year or more post eradication ]
226
What is the purpose of an Intention-to-Treat (ITT) analysis?
```
Preserve Randomization
(ITT principle states that individuals should be analyzed in the groups of their original randomization, regardless of compliance, completion, or receipt of the allocated intervention)
```
227
What is used to monitor disease progression in pts dx'd with Ankylosing Spondylitis?
Xray q3mos or ESR levels
- AP and Lateral view of Lumbar Spine
- Lateral view of Cervical Spine
- Pelvic area including sacroiliac joints and hip
228
What conditions are the most significant extrearticular manifestations of Ankylosing Spondylitis?(5)
```
Anterior Uveitis
Restrictive Lung Disease (deceased CV joint mobility)
Apical Pulmonary Fibrosis
IgA Nephropathy
Aortic Regurgitation
```
229
What is the initial step in management far a pt presenting with palpitations but no chest pain or SOB, normal lung and cardiac exam, and an ECG showing no organized P-waves, narrow complex tachycardia, and irregularly-irregular rhythm w/ varying R-R intervals?
```
If Stable:
Rate/Ventricular response Control w/:
-B-blockers
-Ca-channel Blockers
-Digoxin
```
230
What is the next step in management for a pt presenting with ... and EKG does not show anything
```
Telemetry (if in pt)
Holter Monitor (if outpt)
```
231
What is the next step in management for a pt who presents with palpitations, tachycardia and no h/o ischemic heart disease?
EKG
232
What is the next step in management for a pt who presents with palpitations, tachycardia, and EKG shows regular sinus rhythm with a ventricular rate of 160-180 bpm?
Stable:
| -Rate Control w/ Vagal maneuvers--> if fails--> IV Adenosine
233
What is the best long term management for a pt with Supraventricular Tachycardia?
Radiofrequency Ablation (of the re-entrant pathway)
234
When should IVIG be administered for the treatment of ITP?
Platelet Count
235
By what mechanism does IVIG aid in the treatment of ITP?
IVIG consumes Fc receptors on Macrphages -->Ab's bound to platelets cannot bind to/stimulate macrophages-->inhibit further platelet destruction
236
What is the most likely dx in a pt presenting with a h/o asthma who subsequently develops recurrent fevers, cough productive of brown mucoid sputum, malaise, and wheezing/bronchial obstruction?
Allergic Bronchopulmonary Aspergillosis (ABPA)
237
What is the next step in management for a pt presenting with ?
Skin prick test for mold (Aspergillus)
238
What is the nest step in management for a pt suspected of having ABPA with a positive skin prick test?
Serum IgE and precipitating Serum Ab to Aspergillus
[Note: if skin prick is negative ABPA is highly unlikely]
239
What are the clinical/radiographic, and immunologic criteria that aid in the dx of ABPA?(7)
1) History of Asthma
2) Immediate skin test reactivity to Aspergillus antigen
3) Precipitating serum antibodies to Asergillus fumigatus
4) Serum total IgE >1000
5) Peripheral eosinophilia >500/cubic cm
6) Upper lobe lung infiltrates (bilateral)
7) Central Bronchiectasis (CT only if skim and serum studies are positive
240
What is the pathophysiology that results in ABPA?
Hypersensitivity Rxn to Aspergillus colonization in hyperactive airways:
Colonization of airways w/ Aspergillua-->intense
IgE/IgG mediated immune response-->recurrent
fever, cough w/ brown mucoid expectorant, malaise,
wheezing
241
What is the best treatment for ABPA?
Oral Steroids (Prednisone) - to prevent recurrent inflammation which can lead to bronchiectasis and fibrosis
242
How is the response to treatment monitored in a pt with ABPA?
Decreased total serum IgE
Resolution of lung findings on imaging
Symptomatic improvement
243
What is the single most important risk factor in devloping post partum endometritis?
Route of delivery (c-section has increased risk)
244
What is the nest step in management for an adult pt who presents with multiple recurrent bacterial sinopulmonary and/or GI infections?
Quantitative Serum Immunoglobulin levels
245
What dx should be suspected in a pt who has recently emigrated from Mexico and presents with chronic diarrhea, weight loss, abdominal distention, and found to have a positive FOBT, Eosinophilia, and microcytic anemia?
Helminth/Parasite infection (chronic inglammation of gut--> bleeding-->iron deficiency anemia)
246
What is the next step in management for a pt diagnosed with uncomplicated Bicuspid Aortic Valve?
Echocardiogram (TTE) to screen First degree relatives
247
What is the treatment for a pt dx'd with Bicuspid Aortic Valve?
F/u Echo every 1-2 yrs
| Balloon Valvuloplasty
248
When is valvuloplasty indicated in the management of Bicuspid Aortic Valve?
Severe Aortic Stenosis
Significant AV calcification /regurgitation
Peak Gradient >50
249
What are the characteristics of the murmur associated with Bicuspid Aortic Valve?
Mid-Systolic Ejection Murmur -best at left lower sternal border (may hear click)
250
What are the characteristic features of Alopecia Areata?
Well demarcated (round) patch of complete hair loss
Non-scarring
Any hair bearing area can be affected
+/-Exclamation Point Hairs
Personal/Family History of Autoimmune Disease
251
What is the most likely dx for a pt who presents with bilateral cataracts, basal ganglia calcifications in the context of chronic hyperphosphatemia and hypocalcemia?
Pseudohypoparathysoidism (targets are resistant to PTH)
252
What are the types of Pseudhypoparathyroidism?
Type 1A:
-Albright Hereditary Osteodystrophy features
(round face, short stature, short neck, short 4th and
5th metacarpals) AND
-Hypoparathyroidism
Type 1B: no Albright Hereditary Osteodystrophy features
253
What are the metabolic features assoiacted with Pseudohypoparathyroidism, Vitamin D deficiency, and Hypoparathyroidism?
PHP: High PTH, Nml Vit 25 D, Low Ca2+, High Phos
VDD: High PTH, Low Vit 25 D, Low Ca2+, Low Phos
HP: Low PTH, Nml Vit 25 D, Low Ca2+, High Phos
254
How are acute hyperphosphatemia and pseudohypoparathyroidism distinguished?
Pseudohypoparathyroidism is associated with evidence of chronic presentation:
- Intracranial Calcifications
- Cataracts
255
When should Sodium Bicarb be administered for pts with TCA intoxication?
If EKG shows wide QRS or Ventricular Arrhythmias
256
What is the treatment protocol for TCA intoxication?
Oxygen and Intubation
IV Fluids
Activated Charcoal (if no ileu and w/in 2hrs of ingestion)
Sodium bicarb (ventricular EKG abnormalities)
257
What should be given to a pt with TCA intoxication who presents with ventricular arrhythmia on EKG that is not improved with sodium bicarb?
Add Magnesium or Lidocaine
258
What are the 2 most common congenital heart defects in adults?
Bicuspid Aortic Valves (mid-systolic murmur, LLSB)
| Atrial Septal Defects (mid-systolic murmur, LUSB +/- mid diastolic rumble)
259
What are the features associated with Atrial Septal Defect?
Wide-Fixed Split S2
NOMRAL Pulmonary Artery Pressures
Dilated Rt atrium and Rt Ventricle (L-> R shunt-->volume overload)
260
What are some characteristic features of Pick's Dementia?
Irritable Mood/ Change in Behavior (Disinhibition)
Hyperorality
Impaired Executive Function(initiation, planning, goals)
Speech Abnormalities (echolalia, mutism, aphasia)
Symmetric Atrophy of Frontal and Temporal lobes
261
What are some typical features associated with Lewy Body Dementia?
Slow progressive Neurological decline
Persistent Visual Hallucinations
Varying cognitive function/ alertness
Parkinsonism motor deficits (rigidity, intention tremor)
262
Describe Pick bodies?
Sliver-staining cytoplasmic inclusions
263
What is the most common site of systemic Cryptocoocus infection?
CNS--> Encephalitis/Meningitis
264
What is the most common extraneural site for Cryptococcus infection to manifest?
Skin: Flesh to Red-colored papules w/ umbilicated center and hemorrhagic crust
Note: cutaneous lesions can be early sign of disseminated disease
265
What is the next step in management for a pt dx with cutaneous Cryptococcus?
```
CXR
Blood cultures
CSF cultures
India Ink on CSF
Serum and CSF Cryptococcoal Ag
```
266
How is the dx of Cutaneous Cryptococcosis confirmed?
Bx and histopathology of skin lesion (use PAS or Gomori methamine silver nitrate for histo)
267
What is the most likely dx in a neonate who presents with mild respiratory distress, pulmonary congestion w/o infiltrated on CXR, and born to a diabetic mother who had less than optimal glucose control during pregnancy?
CHF secondary to Hypertrophic Cardiomyopathy (d/t excess glycogen deposition in myocardium in response to increased insulin production in utero.)
Note: Interventricular Septum is most commonly affected
268
What are the characteristic features associated with Henoch-Schonlein Purpura?(10)
```
Palpable Purpura (legs buttocks)
Arthritis/Arthralgias (late)
Abdominal Pain/Intussusception
GI bleed (edema/hemorrhage-->lead point)
IgA Nephropathy (Hematuria +/- RBC casts/proteinuria)
Normal/increased Creatinine
NORMAL Platelets
Normal Coags
Elevated Inlammatory Markers (WBC, ESR)
Sx onset- 5-10 dayf following URI
```
269
What is the most common cause of sudden, instantneous death d/t steering wheel injuries in MVA?
Aortic Rupture
270
What is the management protocol for a pt with sickle cell disease presetning with acute Vaso-occlusive Event?
```
IV Analgesia (Opiates)
Hydration (1/4 or 1/2 Normal Saline)
```
Note: if outpt-give NSAIDS and Acetaminophen
271
When should Normal Saline be used to rehydrate a pt with Sickle cell disease with acute Vaso-occlusive Episode?
If pt. is Hypovolemic or Hypotensive
272
What should be included for long term management of a mp with sickle cell disease?
Vaccinations
Penicillin (until age 5)
Folic Acid Supplementation
Hydroxyurea (if multiple Vaso-occlusive episodes)
273
What are the diagnostic criteria for Acute Chest Syndrome?
Sickle Cell Disease pt w/
-New pulmonary infiltrate on CXR + 1 or more of
-Fever (>101.3F, 38.5C)
-Chest Pain
-Increased work of breathing, Wheezing, Cough,
Tachypnea
-Hypoxemia
274
What is the management for a pt with Acute Chest Syndrome in children?
Empiric Antibiotics:
-3rd Gen Ceph- Cefrtiaxone or Cefotaxime (S.pneumo)
-Macrolide-Azithromycin (Mycoplasma pneumoniae)
IV Hydration
Analgesics
275
What are the most common causes of Acute Chest Syndrome in children?
Infection
Asthma Exacerbation
Pulmonary Infarction
276
What are the most common causes of Acute Chest Syndrome in adults?
Bone Marrow or Fat Embolism
277
What clinical sign is pathognomonic for Rabies infection?
Hydrophobia
278
What dx should be suspected until proven otherwise in a presenting with unilateral headache, unilateral misosis and ptosis, but no anhidrosis (Partial Horner's syndrome)?
Carotid Artery Dissection (note, sympathetic chain travels along carotid artery)
Note: if no Anhidrosis--> Internal Carotid Artery Invovled bc, sympathetic sweat fibers travel along External Carotid Artery.
279
What is the next step in management for a pt suspected of having a Carotid Artery Dissection?
CT Angiography of Head and Neck
Note: If CTA is negative but suspicion high-->MRA or Catheter Angiography (gold Standard)
280
What is the most common arrhythmia associated with Inferior Wall MI (leads II, III, AVF)
Sinus Bradycardia (d/t Rt Coronary artery thrombosis--> SA node (and inferior wall) ischemia)
281
What is the next step in management for a pt with recent Inferior Wall MI who develops symptomatic (dizziness, hypotension, confusion, syncope) bradycardia?
IV Atropine (to block vagal tone)
Can give IV fluids if Hypotension persists
Note: if asymptomatic--> No treatment, usually resolves spontaneously
282
What is the criteria for Arrest of first stage of Labor?
Cervical Dilation >/= 6cm, ruptured membranes, and
-No cervical change for >/=4 hrs w/ adequate
contractions
OR
-No cervical change for >/=6hrs w/ inadequate
contractions
283
What is the next step in management when a pt in labor is suspected of having arrest of labor and only an external monitor is placed?
Placement of Intrauterine Pressure Monitor (to assess adequacy of contraction strength and calculate Montevideo units)
284
At what lead level is chelation therapy indicated?
Venous Pb level >44mcg/dL
- Moderate: 44-69-->2,3 Dimercaptosuccinic acid
- Severe:>/= 70->Dimercaprol (BAL) + Ca Disodium edetate
285
What are two alternative medications used to treat chemo-associated nausea in pts for whom EPS effects of Metoclopromide (D2 receptor blocker) is a major concern?
Ondansetron (5HT3 antagonist)
| Aprepitant (substance P antagonist; blocks NK1 Rec)
286
What are some risk factors associated with Carpel Tunnel Syndrome?(9)
Most Common:
- Diabetes
- Rheumatoid Arthritis
- Hypothyroidism
- Others:
- Wrist trauma
- Obesity
- Pregnancy
- Acromengaly
- Menopause
- End-Stage Renal Disease
287
What is the next step in management for a pt who has had unprotected sex within 5 days and has active STD but a negative urine/serum pregnancy test?
Offer Emergency Contraception:
-Ulipristal (anti-progestin - best oral emergency
contraceptive)
-Levonorgestrel
-Combined Oral Contraceptives
Note:
-Copper IUD cannot give to pt w/ active infection
288
Which type of emergency contraception is the most effective?
Copper IUD
- contraindicated in pts w/
- active gyn/pelvic infection
- undiagnosed vaginal bleeding
- Wilson's Disease
289
What should be included in post-exposure prophylaxis for a sexual assault victim?
HIV: 3 drug Regimen (2NRTI + Protease Inhib)
HepatitisB: HepB (Hep B vaccine (unless vaccinated) +/- Immunoglobulin)
Gonorrhea: Ceftriaxone
Chlamydia: Azithromycin
Trichomonas Vaginalis:Metronidazole
Note: HIV and HEPB prophylaxis depend on risk factors
290
How so Juvenile Myoclonic Epilepsy and Childhood Absence Seizures differ?
Juvenile Myoclonic Epilepsy:
- Late onset Absence seizures w/ myocloic activity
- Life long Seizures
Childhood Absence Epilepsy:
- Early onset Absence Seizures (4-8yrs old)
- No myoclonic activity
- Starring spells usually resolve by adolescent years
291
What is the treatment of choice for severe Otitis Externa?
TOPICAL Ab's (polymyxin B/Neomycin or Cipro) 7-10dys
292
What is the treatment for Mild and Moderate Otitis Externa?
Mild (minor pain, puritis, canal edema): Topical Acidifiers
Moderate/Severe
(pain pruritis, partial/complete canal occlusion d/t edema):
-Clean Ear w/ wire loop
-TOPICAL Ab's
-Wick placement if canal completely occluded
Can add topical steroids for severe itching/pain with either severity.
293
What dx should be suspected in a pt with Celiac Disease who adheres to strict Gluten-free diet but presents with abdominal discomfort, weight loss, and Diarrhea?
Intestinal T Cell Lymphoma (pt. w/ Celiac are at increased risk)
- Jejunum commonly affected
- Nodular or Ulcerative Tumors
294
Why is a neonatal TSH level not checked until at least 24 hrs post delivery?
Physiological surge in TSH immediately following delivery in baby
295
What is the next step in management for a neonate who has a low T4 and an elevated TSH from the heel pad sample?
Check Serum TSH and T4 from regular venous blood draw to confirm.
296
How long should a pt who develops a DVT d/t an associated cause but has no personal or family history or other risk factors for DVT be anticoagulated?
3-6 mos (surgery, pregnancy, trauma, OCP use)
Note: after 6 mos, risk significantly decreases
297
How long should a pt who develops idiopathic DVT be anticoagulated?
At least 6 mos w/ re-evaluation at end of 6mos course for further treatment according to risk factors
298
What is the next step in managament for a pt presenting with hyperpigmented skin, low LH, FSH, and Testosterone, elevated fasting and fingerstick glucose, liver dysfunction, and joint pain, stiffness involving the 2nd and 3rd metacarpophylangeal joints?
Serum Transferrin* and Ferritin (Fasting)
299
What are the classic features associated with Hemochromatosis?(5)
```
Central Hypogonadism
Diabetes
Skin Pigmentation
Liver Dysfunction
Arthropathy (Hook-like osteophytes on Xray)
```
300
What dx should be considered in an elderly pt who presents with recurring episodes of antibiotic sensitive pneumonia w/ a hx of smoking?
Bronchogenic Carcinoma resulting in Endobronchial Obstruction
301
What is the next step in management in a pt suspected of Endotrachial obstruction d/t mass?
CT Chest
302
What is best test to confirm a dx of Bronchogenic carcinoma in a pt with recurrent pneumonia and smoking history, raising suspicion for endotrachial obstructive mass?
Flexible Bronchoscopy
303
What should be included in the initial work up of a pt suspected of lead poisoning?
CBC
Reticulocyte Count
Serum Iron and Ferritin
Venous Lead level
304
Which antibiotics are commonly associated with adverse CNS events (ex, seizure)?(5)
```
Beta Lactams:
-Penicillins
-Cephalosporins
-Monobactams
-Carbapenems
Fluoroquinolones
```
305
Who should be treated with antibiotics for Salmonella gastroenteritis?
Children
306
What is the most likely dx for a pt presenting with "swinging fever", leukocytosis, abdominal discomfort/pain, and recent abdominal surgery?
Subphrenic Abscess (usually w/in 14-21 dys post op)
307
What is the best way to dx subphrenic (or any abdominal) abscess?
Abdominal Ultrasound
308
What are the medications of choice for treating a pt with Parkinson's disease who develops psychotic symptoms?
Quetiapine
| Clozapine (second choice d/t agranulocytosis and hematology f/u)
309
What is the likelihood of a pt who is High Risk for lung cancer (>/=30pack yrs and current smoker or smoker who quit /= 4mm) for screening actually having a malignant lesion?
With a positive Low-dose CT, the risk is
310
What acne treatments are acceptable to use in pregnancy and therefor do not require pregnancy test prior to prescribing?
```
Topical Erythromycin
Topical Clindamycin (Inflammatory Acne)
Azelaic Acid (Comedonal Acne)
```
311
What are the typical treatments for Comedonal Acne?
Salicylic Acid
Azelaic ACid
Glycolic Acid
Topical Retinoids
312
What is the treatment for Inflammatory Acne?
Mild: Topical Retinoids + Benzoyl Peroxide
Moderate: Mild Tx +Topical Antibiotics
Severe: Moderate Tx + Oral Antibiotics
313
What is the treatment for Nodular Cystic Acne?
Moderate:Topical Retinoids+ Peroxide+Topical Ab
Severe:Moderate +Oral Antibiotics
Unresponsive: Oral Isotretinoin
314
What features are associated with acute Opioid intoxication?
```
Miosis
Decreased Mental Status
Decreased Respiratory Rate/Shallow Breathing(crackles)
Decreased Bowel Sounds
Bradycardia
Hypo/normothermia
Respiratory Acidosis
Hypoglycemia
```
315
Which pts are at increased risks of opiod intoxication with Morphine use?
Those with Liver disease or Renal Insufficiency/Failure
-Morphine metabolites M3glucuronide and
M6glucuronide are produced in liver and renal cleared.
M6glucuronide is more potent than Morphine so if not
cleared appropriately can lead to Opioid toxicity.
316
When should DVT prophylaxis begin in a pt with hip fracture?
On admission and stopped 12 hrs prior to surgery
317
What types of DVT prophylaxis should be used for pt with hip or any long bone fracture?
Low Molecular Weight Heparin
or
Low Dose Unfractionated Heparin
318
What is the underlying cause of the viral exanthem associated with infectious Mononucleosis?
Immune-complexes:
-circulating antibodies to penicillin derivatives (ex
ampicillin, amoxicillin)
319
What is the management for a pt dx with Thyroid cancer following surgical resection and Radioiodine ablation?
Levothyroxine hormone replacement
| -Dose to maintain adequate TH levels and keep TSH low
320
What are the guidelines for Levothyroxine dosing s/p Thyroidectomy and ablation?
Initial 6-12 mos post:
-Enough Levo to maintain TSH 0.1-0.5uU/mL
Maintenance: Depends on Risk of Recurrence (TSH level)
Small tumor, Low Risk- TSH kept in Low Normal Range
Intermediate Risk- TSH kept at 0.1-0.5uU/mL
Large, High Risk- TSH kept
321
What are the typical features of Opioid withdrawal?
```
Lacrimation
Yawning
Mydriasis
Abdominal Discomfort
Nausea/Vomiting
```
322
What medications are used to treat opiod withdrawal?
Methadone
Clonidine (alternative)
Buprenorphine (alternative)
323
What is the treatment for Opiod toxicity?
Naloxone (but be careful bc can induce w/drawal)
324
Overdose of what drugs/medications can be associated with Mydriasis?
Cocaine
Amphetamines
TCA
325
What are the classic features asociated with Adhesive Capsulitis (Frozen Shoulder)?
Decreased Actvie and Passice range of motion
| Stiffness> Pain
326
What are the typical features associated with Rotator Cuff Tear?
Pain w/ aBduction
Pain/Weakness w/ external rotation
Usually in a pt >40yr old
327
What are the typical features associated with Rotator Cuff impingement/tendinopathy?
Pain w/ aBduction/ external Rotation
Subacromial Tenderness
Normal ROM w/ + impingement Tests (Hawkins, Neer)
Decreased Range of Active Motion
328
What are the underlying causes that result in Frozen Shoulder?
Glenohuleral joint loses distensibility d/t chronic inlfammation-->fibrosis-->contracture of joint capsule
329
What is the treatment recommendations for a pt with Adhesive Capsulitis?
Initially--> Range of Motion Exercises
| If Exercise fails (after several months)--> Steroid Injections
330
What are the treatment options for Latent Tb (Positive PPD w/ negative CXR)
INH + Rifapentine weekly for 3 mos (observed)
INH for 6-9* months (9 mos preferred for adherent pts)
Rifampin for 4months
INH + Rifampin for 4months
(Add pyridoxime to prevent peripheral neuropathy w/ INH)
331
What is the next step in management for a child >/=5 yrs old who presents with isolated enuresis?
Urinalysis
332
When is urologic imaging indicated in a child with isolated enuresis?
Recurrent UTI
| Significant Daytime symptoms
333
What is the order of management for isolated enuresis?
Behavior Modifications
- Max fluids in day and minimize fluids in evening
- Avoid caffeine/sugary beverages
- Void regularly in day and immediately before bed
- Reward System (gold star)
Alarm (if behavior modifications fail)
Medications (short-term improvement/ high relapse risk)
First Line: DDAVP/ Desmopressin
Second Line: TCA
334
What is the recommendation for anticoagulation therapy in a pt with a mechanical heart valve and no other risk factors for hypercoagulability?
Aortic Valve Replacement:
-Aspirin (75-100mg) + Warfarin w/ goal INR 2.0-3.0
Mitral Valve Replacement (or Aortic valve w/ risk factors:
-Aspirin (75-100mg) + Warfarin w/goal INR 2.5-3.5
335
What is the next step in management for a pt who presents w/ hypercalcemia, a h/o gastric ulcer, and FHx of pituitary tumor?
Measure PTH-->24 hr Urine Ca2+-->Bone Mineral Density
336
What is the next step in management for a pt with confirmed hyperparathyroidism and h/o gastric ulcer in the context of likely MEN1 syndrome?
Surgical referral for Parathyroidectomy (either 3.5 or total w/ autotransplant)
337
When should Gastrin levels be checked in the workup for MEN 1 syndrome and why?
- Following correction of Serum Calcium and
- Discontinuation of PPI for at least 2 wks
Elevated Gastrin Associated with:
- Hypercalcemia (ca2+ -sensing receptors)
- PPI use (decreased feedback inhibition d/t low acid)
338
What malignant condition is associated with Sjogren's Syndrome and should be suspected in a pt w/ neck mass, xerostomia and keratoconjunctivitis sicca?
B-Cell non-Hodgkin's Lymphoma (5% lifetime risk w/ sjogren's)
Note: Sjogren's results in Polyclonal B cell Activation and infiltration of salivary glands secondary to chronic inflammation
339
What are the recommendations for precautions in hospitalized pts with disseminated herpes zoster (shingles)?
Contact and Airborne Isolation until ALL vesicles are dry/crusted
340
What are the features of CHarcot's Triad?
Fever
RUQ pain
Jaundice
341
What is the most likely dx in a pt with Charcot's Triad?
Acute Cholangitis
342
What is the next step in a pt with Charcot's Triad and labs representing extrahepatic obstruction (elevated Alk Phos and Bili w/ normal Aminotransferases)?
1)Hospitalization
2)Blood Cultures then Empiric Ab's:
-Ampicillin + Gentamicin or
-Imepenen or
-Levofloxacin
3)IV Fluids
4)Monitor Vitals
5)Schedule Elective ERCP (can also use for urgent
bilibary decompression if no improvement w/
antibiotics w/in 24 hrs)
343
What are the features of Reynold's Pentad associated with Acute Cholangitis?
```
Fever
Jaundice
RUQ pain
Hypotension
Altered Mental Status (Confusion)
```
Very high mortality rate= 50%
344
Intense glycemic control in a diabetic will benefit which aspect of dibetes related sequelae the most?
Microvascular complication (retinopathy peripheral neuropathy)
Note: Little to no effect on macrovascular complications (stroke, MI)
345
What are the features seen on funduscopic exam in a pt with non-proliferative diabetic retinopathy?
Hard Exudates (whitish-yellow)
Microaneurysma
Hemorrhages
346
What is the next step in management for a pregnant woman found to have a positive HBsAg and HBcAb?
Treat ALL pregnant woman w/ active Hep B w/:
-Hep B vaccine + Antivirals
Treat ALL neonates (w/in 12 hrs) w/ Hep B vaccine and HBIG
347
What are the recommendations for screening pregnant women for Hep B?
All pregnant women get screened at 1st prenatal visit
| All pregnant women w/ unknown immunization or ongoing high risk behavior need rescreen near time of delivery
348
What is the management for a pt with symptomatic Peripheral Artery Disease?
Statin (independent of LDL)
Aspirin or Clopidogrel for anticoagulation
BP control
Diabetes Screening/Treatment
Note: give high intensity statin if /= 190, Clinically significant Atherosclerotic disease (ACS, MI, stable/unstable angina, arterial revascularization, stroke/TIA, PAD), or 10yr cardiovascular disease risk >/=7.5%
349
What is the management for intermittent claudication in a pt with significant Peripheral Artery Disease?
Statin, Aspirin or Clopidogrel, BP control +
- Monitored Exercise Program--> if no impovement, ADD
- Cilostazol--> if no improvement--> consider percutatneous/surgical revascularization
350
What is the next step in management for a pt with sudden onset severe extremity pain, delayed/abset capillary refill, absent distal pulses, absent arterial Doppler signal, and sensory or motor deficits?
Immediate LMWHeparin Bolus then continuous infusion and Emergency surgical revascualrization (Acute limb ischemia w/ threatened limb)
351
What is the most common complication of Tick bites?
Local Inflammation or infection
Risk of Lyme after tick bite is low if
352
What is are common skin reaction assoiacated with Hydrochlorothiaziade (sulfonamide) use?
Photosensitivity and generalized rash
353
What epidemiologic tool is employed to increase the power of a study in order to detect true differences in the interested outcome between groups?
Meta-Analysis (pooling the data from several studies)
354
What are the criteria for dx'ing delayed puberty in a male?
Absence of testicular enlargement by age 14 or
Testicular diameter = 2.5cm or
Delay of 5 yrs or more of testicular enlargement following initial increase in size
355
What is the next step in management for a 15yo male who has concerns regarding delayed puberty, has minimal pubic hair and no facial or axillary hair and is found to have decreased testicular size indicative of delayed puberty?
Image long bone to determine bone age (if same as or > chronologic age-->further testing testing)
356
What type of malignancy is most commonly found in the proximal esophagus in a pt with no h/o reflux, but has a h/o tobacco smoking?
Squamous Cell Carcinoma
357
What type of malignancy is most commonly found in the mid-distal esophagus and can be associated with chronic, untreated reflux and Barret's Esophagus?
Adenocarcinoma
358
What are two main risk factors associated with Squamous cell CArcinoma of the esophagus?
Chronic Smoking and Alcohol use
359
What is the most common long term complication of a Trans Urethral Resection Procedure (TURP) used to manage refractory BPH?
```
Retrograde Ejaculation (leading to dry ejaculate)
-d/t failure of bladder neck to close
```
Note: Elevated PSA is also common but levels will decrease w/in 3-4 wks after procedure (or Bx)
360
What is the most likely dx in a pt who is >50 yrs old, presenting with pain of the neck, shoulders, proximal thighs, or hip, morning stiffness that lasts >1 hr, constitutional signs/sx (weight loss, fever, malaise), elevated ESR or CRP and no other explanation for sx's?
Polymyalgia Rheumatica
361
What is the next step in management for a pt just dx'd with Polymyalgia Rheumatica?
Low-Dose Steroids ( 10-20mg Prednisone)
-responsds extremely well, if no response in the
immediate course-->consider another dx)
362
What are the potential teratogenic effects of Methimazole use to treat Graves disease in pregnancy?
Use in First trimester:
- choanal atresia
- scalp defects
- tracheoesophageal fistula
363
What is the accepted treatment for pregnant pt with Graves' disesae?
PTU in first trimester
| Methimazole in 2nd and 3rd trimesters
364
What possible fetal side effects are associated with PTU use in later pregnancy trimesters?
Liver Failure
365
What changes in Thyroids labs are associated with pregnancy?
Normal TSH
| Increased Total T4 (d/t increased circulating Thyroid Binding Globulin)
366
What is the risk of a fetus developing Spina Bifida if the mother has first degree relatives with the same condition but has taken appropriate Folic Acid supplementation (at least 3 mos b/f pregnancy and during the first 4 wks of pregnancy)?
Increased (relative to general population) but low risk
367
What are two conditions that can commonly accompany a myelomeningocele?
Hydrocephalus and Chiari II malformation
368
What is the next step in management for a fetus born with a myelomeningocele?
Immediate Neurosurgical evaluation Referral-must perform corrective surgery w/in 24-48 hrs of birth to decrease risk of infection
369
What is the most likely dx in a child who presents with crampy abdominal pain, fever, low-volume, and bloody diarrhea (dysentery)?
Bacterial Gastroenteritis
370
What are the common causes of dysentery associated Bacterial Gastroenteritis in the US?
```
Salmonella (most common )
Shigella
E.Coli (enterohemorrhagic/enteroinvasive types)
Yersinia
Campylobacter
```
371
Which pts should receive Antibiotic therapy for bacterial gastroenteritis?
Under 3mos old
Cholera infection
Immunocompromised
Invasive disease (sepsis, osteomyelitis, meningitis)
372
What are the first and second line medications for treating status epilepticus in children and adults?
First Line: Children AND Adults
-Benzodiazepines (Lorazepam)
Second Line: Children
-Barbituates (Phenobarbital)
Second Line: Adults
-Phenytoin/ Fosphenitoin
373
What are two malignancies commonly associated with Familial Adenomatous Polyposis (FAP)?
Gastric and Duodenal adenomas/carcinomas
374
What is the nesxt step in managment for a pt found to have innumerable colonic and rectal polyps on colonoscopy?
Upper GI Endoscopy-to r/o presence of extracolonic polyps
375
What are the averages for normal cardiac pressures as measured by Pulmonary Artery Catheter?
```
Rt Atrial P: 4mmHg
Pulmonary Capillary Wedge P: 9mmHg
Cardiac Index: 2.8-4.2 L/min/m2
Systemic Vascular Resistance: 1150dynes*sec/cm5
Mixed Venous O2 Saturation: 60-80%
```
376
What changes are seen in Central Cardiac Pressure Catheter measurements with Hypovolemic Shock?
All parameters decrease except Systemic Vascular Resistance -->increases
377
What changes are seen in Central Cardiac Pressure Catheter measurements with Cardiogenic Shock?
```
Rt Atrial P: Increased
PCWP: Increased
Cardiac Index: Markedly Decreased
Systemic Vascular Resistance: Increased
Mixed Venous O2 Saturation: Decreased
```
378
What changes are seen in Central Cardiac Pressure Catheter measurements with Septic Shock?
Rt. Atrial P: Normal or slightly Deceased
PCWP: Normal or slightly Decreased
Cardiac Index: Increased
Systemic Vascular Resistance: Decreased
Mixed Venous O2 Saturation: Increased (Tissue damage)
379
How do alcohol and sedative-hypnotics contribute to snoring?
```
Decrease upper airway muscle activity
Inhibit Postapneic (in those w/ OSA) arousal response
```
380
What is the next step in management for a pt whose sleep partner complains of intolerable snoring w/out any other associated sx's?
According to whichever applies, advise pt to:
- Lose Weight
- Avoid Alcohol right before bed
- Stop Smoking
Note: no special tests needed for habitual smoking and no signs/sx's of OSA
381
What is the most likely dx in a middle age female who presents with Xanthelasmas and excoriations on her skin (from scratching) and found to have significantly elevated Alk Phos and mildly elevated Liver transaminases?
Primary Biliary Cirrhosis (PBC) (autoimmune destruction of intrahepatic bile ducts)
382
What is the nest step in management for a pt suspected of having PBC with abnormal liver enzymes?
Check Serum Antimitochondrial Ab's (high sensitivity and specificity)
383
What are some complications associated with PBC?
Hyperlipidemia
Steatorrhea
Osteoporosis/Osteomalacia (Vit D malabsorption)
Xanthoma formation (joints)
Other Autoimmune diseases:
- Keratoconjunctivitis Sicca
- CREST syndrome
- Antithyroid Ab's
- Rheumatoid Arthritis
- Diabete type 1
Note: PBC does NOT increase risk of atherosclerosis!!!
384
What are the treatment options for pts with PBC?
Ursodeoxycolic Acid (slows progression and improves survival)
Liver Transplant
385
What should be included in the long term management of pts with PBC in addition to standard medical therapy?
Bone Density screening for Osteoporosis
Calcium, Vit D A E K supplementation
Bisphosphonates
386
What body position seems to offer the greatest protection against aspiration in a hospitalized pt with impaired swallow function/gag reflex?
Upright Supine
387
What is the most likely dx in a neonate who presents with apnea, hypoglycemia, jaundice, hypotonia, irritability, lethargy, abdominal distension, poor feeding, and cyanosis of distal extremities, and found to have a capillary HCT of 70% and repeat venous HCT of 68% (or Hb>22)?
Neonatal Polycythemia
388
What is the next step in management for a neonate diagnosed with Polycythemia?
IV Hydration and
| Partial Exchange Transfusion
389
What are the criteria to dx Peripartum Cardiomyopathy?
1)LVEF
390
What parameter should be monitored to determine a pts risk of adverse cardiac outcomes in subsequent pregnancy?
Tranthoracic Echo (to assess Left Ventricular function, EF return to normal or persist in abnormal range)
Note: those w/ persistent LV dysfunction should be advised against pregnancy
391
What is the first line treatment for Prolactinomas (regardless of size)?
Dopaminergic Receptor Agonists (Bromocritpine, Cabergoline)
| Note: Visual sx's resolve within days as tumor size decreases quickly with medication
392
What is the management for a pt with a prolactinoma being treated with Dopaminergic Agonist?
Close Monitoring upon treatment initation:
- Clinical Sx resolution
- Prolactin Levels
- Pituitary MRI
- Visual Field Exam
393
What are the most common organism associated with Necrotizing Fasciitis?
Group A Strep (pyogenes)-most common in healthy pt
Staph aureus (usually polymicrobial)
Clostridum perfringens
Polumicrobial
-tends to be in Diabetics/Peripheral Vascular Disease.
-Related organisms include: Bacteroides and
Provetella species as well as Staph aureus, Strep
pyogenes, and E coli)
394
What are some clinical features that should raise suspicion for Necrotizing Fasciitis?
```
H/o Minor Trauma
Erythematous Skin (usually extremities or perineal area)
Swelling/Edema
Pain out of proportion to exam findings
Systemic Symptoms (fever, hypotension)
```
395
With which two Necrotizing Fasciitis-causing organisms is crepitus associated?
Clostridium perfringens
| Bacteroides fragilis
396
What is the immediate management for a pt who presents with clinical findings suggestive of Necrotizing Fasciitis?
Broad Spectrum IV Antibiotics
Surgical Debridement
Hemodynamic Support
397
What are the antibiotics typically used to treat Necrotizing Fasciitis empirically?
Piperacillin/Tazobactam (or Carbapenem)-GAS/Anaerobes
Vancomycin (staph/MRSA)
Clindamycin (stop toxin formation in staph /strep species)
398
What is the criteria for lung cancer screening ?
Annual Low Dose CT for:
High Risk pts between ages 55-80 who have >/= 30
pack-yr smoking hx AND currently smoking or quit
399
What dx should be suspected in a pt with resistant hypertension ( defined as uncontrolled BP despite three antihypertensives of different classes including diuretic at max dose) and abdominal bruit?
Underlying Renovascular Disease
400
What type of imaging study should be avoided or at least delayed for further assessment in pts suspected of Renovascular disease as cause for resistant hypertension?
Contrast -required imaging studies (d/t increased susceptibility to contrast nephropathy)
401
What condition should be suspected in a pt with diabetes presenting with multiple scaly, erythematous skin lesions with central clearing and slightly elevated crusted borders, diarrhea, angular chelosis, abdominal cramping, weight loss, lethargy, and +/-facial flushing?
Glucagonoma
402
How is the rash associated with Glucagonoma distinguished from that associated with Pellagra?
Glucagonoma:
- asymmetric distribution
- scaly w/ central clearing
Pellagra:
- symmetric distribution over Sun-Exposed areas
- vesicles and blisters present
403
What are two common complications associated with Inferior wall MI?
Sinus Bradycardia
High Degree AV Block
These are due to increased Vagal Tone and are usually transient
404
What is the first-line of treatment for a pt with Symptomatic Sinus Bradycardia and or AV block?
IV Atropine
405
What is the next step in management for a pt who does not respond to IV atropine in attempts to resolve symptomatic sinus bradycardia following recent MI involving Inferior wall?
Temporary Transvenous Cardiac Pacing
406
What symptoms are typically associated with sinus bradycardia?
Syncope
Heart Failure
Hypotension
Dizziness
407
What is the most likely dx in a child presenting with fever, multiple vesicles seen on posterior soft palate, pharyngeal erythema, odynophagia, but no cervical lymphadenopathy?
Herpangina
408
How is Herpangina distinguished from Herpes Gingivostomatitis?
Herpangina: vesicles/ulcers on posterior palate
Herpes Gingivostomatitis: vesicles/ulcers on anterior oral mucosa and around mouth
409
What virus is commonly responsible for Herpangina in children?
Coxsackie group A virus
410
What is the most common cause of primary Hypothyroidism?
Hashimoto's Thyroiditis
411
What is the next step in management for a pt presenting with increased fatigue, dry skin, amenorrhea, cold intolerance, and constipation, symmetric thyromegaly, delayed relaxation phase of ankle and knee jerks with occasional periorbital fullness, headaches, and muscle aches?
Serum Antimicrosomial (anti TPO) Ab level (high titers =dx)
412
What is a common associated finding in pts with Hashimoto's Thyroiditis?
Hypercholesterolemia (esp elevated LDL)
413
What is the next step in management for a pt presenting with steady upper abdominal pain that radiates to the back w/ associated Nausea and Vomiting?
Biochemical Test:
- Lipase (dx test of choice)
- Amylase (optional)
- Liver Enzymes (AST/ALT/ Alk Phos)
414
What parameter should be monitored closely in pt with Acute Pancreatitis?
Monitor Urine I/O-
-Must give IV fluidsEarly and Aggressively d/t significant
third spacing intravascular volume--> acute renal
injury, hypotension, and worsen pancreatitis
415
What is the next step in management for a pt with elevated Lipase, AST and ALT who is responding to IV pain meds and IV fluids?
Stable Pt--> No find cause of Pancreatitis:
-Abdominal U/s -to check for gallstones (elevated liver
fnc)
Lipid Panel
Check Calcium
416
When should an abdominal CT(w/contrast) be done in a pt with acute pancreatitis?
Clinical signs of deterioration (do CT w/ contrast) or infection w/in 72 hrs
If initial presentation is atypical
417
When should ERCP be used in pts with Acute Pancreatitis?
Only when there is imaging evidence of biliary obstruction from a gallstone
418
What are the firstline Ab's used in a pt with acute pancreatitis who develops SIRS?
Imipenem
Quinolones
Metronidazole
419
What is the name of arthritic swellings affecting the DIP joints in pts with OA and are usually seen in women and have a strong genetic predisporition?
Heverden's Nodules
420
What is the name of the arthritis swellings that affect the PIP joints in pts with OA and RA?
Bouchard Nodules
421
When should treatment be initiated in a pt with asymptomatic subclinical (TSH 5-10; normal fT4) hypothyroidism?
1) Antithyroid (antiTPO) Ab
2) Abnormal Lipid Profile
3) Abnormal Menstruation/Ovulation
4) Symptoms of Hypothyroidism
422
What are the cardiovascular effects of Hyperthyroidism?(8)
```
Increase:
HR
CO
EF
Pulse P
Pulmonary Artery P
Myocardial O2 consumption
```
Decrease:
Systemic Vascular Resistance
Diastolic BP
423
What is the most common supravetnricular arrhythmia associated with hyperthyroidism?
Atrial Fibrillation
424
What is the underlying mechanism resulting inmost of the symptoms associated with hyperthyroidism?
Increased B-adrenergic gene expression-->increased sympathetic tone
425
What is the next step in management for a pt presenting with signs and symptoms of hyperthyroidism as well as irregularly irregular cardiac rhythm on EKG?
Sympathetic control w/ Beta-Blockers
| Also start Thionamides or Radioiodine treatment then stop B-blockers once pt becomes Euthyroid
426
What are pts with repeated Fasting glucose levels between 100-126 at increased reisk of developing?
Coronary Artery Disease (even w/o hyperlipidemia) and progression to DM
427
What are the criteria associated with Rheumatic Fever?
Major: Minor:
Joints Fever
(o) Cardiac (do Echo to eval) Arthralgias
Nodules Elevated ESR/CRP
Erythema Migrinatum Prolonged PR interval
Sydenham Chorea (1-8mos post strep pharyngitis)
NOTE:
For DX- 2 major, 1 major+2 minor, or Sydenham Chorea or Carditis(1-3 wks post strep)
428
What is the next step in managment for a pt presetning with Sydenham Chorea?
IM Penicillin until adulthood (Secondary prevention-irradicate GAS and decrease risk of worsening rheumatic heart disease)
Note: the treatment for Sydenham Chorea is supportive but give penicillin as well to address underlying strep
429
What is the indication for Tetrabenzaine administration?
Huntington's Dx: It is a dopamine antagonist
430
What is the first step in management for an elderly pt presenting with sudden onset of change in mental status either in the hospital or out pt (nursing home/office) setting?
Check Vitals and Pulse Ox
431
When should fibrinolytics be used in pt with Acute PE?
If Hemodynamic Instability is present
432
What is the formula for calculating Likelihood Ratios?
+LR= (Sensitivity)/(1-Specificity)
-LR= (1-Sensitivity)/ (Specificity)
433
What is the most reliable cardiac exam finding that can ruole OUT Severe Aortic Stenosis?
Normal Splitting of S2 (increased split during inspiration)
Note: in severe AS- soft Single S2 d/t decreased leaflet mobility and delayed closure --> synchronized A2 with P2
434
What is the next step in management for an intoxicated pt who may have incurred life-threatening injuries (head wounds/trauma) but refuses to be treated?
Physical restraints and proceed with explanation and treatment (consent is implied in this case)
435
Which live vaccines can be given to HIV+ pts and when?
CD4>200/uL and no sx's or signs of AIDS-defining illness
-MMR and Varicella Zoster
All other live vaccines are contraindicated
436
What is the most common complication associated with Scuba Diving?
Ear Barotruma
437
What should a pt with a h/o allergic rhinitis be advised to do prior to scuba diving activites?
Suggest the use of non-sedating decongestants (pseudoephedrine) before diving (decrease incidence of ear/sinus barotrauma d/t decreasing ear secretions
Advise not to fly w/in 24 hrs of diving
438
What key features can be seen on Echo and indicate early cardiac tamponade and need for immediate percutaneous intervention?
RV or RA collapse during diastole
Exaggerated respiratory variation in cardiac and venous
flows
IVC Plethora (dilation and
439
What are the contraindications to a pt starting Hospice care?
6 month or less to live
Not receiving life-prolonging treatment for their illness
Note: Pt can choose to get life-prolonging treatment at any time and return to hospice as they choose once the treatments have ended.
440
What is the first line treatment for Keloid therapy?
Intralesion Glucocorticoids
Note: Keloids can present as painful, itchy lesions
(pts should be informed of the possibility of recurrence)
441
What is the next step in management for a pt with tonsilar and posterior pharyngeal exudates, anterior cervical lymphadenopathy, and fever who has a + Rapid Strep test?
Start Amoxicillin or Penicillin to treat GAS
Note: Rapid Strep has high specificity but low sensitivity
442
What is the next step in management for a pt with tonsilar and pharyngeal exudates, fever, cervical lymphadenopathy and a _Rapid Strep Test?
Throat Culture
| Rapid strep has low sensitivity so cannot be used to R/o Strep
443
What is the first-line treatment for Strawberry (superficial) Hemangiomas that involve the periorbital region, airway, or viscera and are disfiguring?
Propranolol
444
What is the most common pediatric vascular lesion?
Infantile hemangioma
445
What should be avoided in male pts who present with urinary retention/bladder distension/fullness, dysuria, and enlarged prostate?
```
Prostatic massage(can lead to bacteremia)
Foley catheters (can lead to bacteremia)
```
Such pts probably have prostatitis and not cystitis. Use suprapubic catheter to empty bladder before further workup (urinalysis/ culture from catheter)
446
Which antibiotics are typically used for empiric treatment of acute Prostatitis?
Fluorquinolones
| TMP-SMX
447
What is the first-line treatmetn for a pt with a h/o gout and uncontrolled Hypertension who has not yet received pharmacotherapy for the BP?
Losartan (increases urinary excretion of Uric Acid
448
Which antihypertensive medications should be especially avoided in pt w/ a h/o gout?
Loop diuretucs and Thiazide Diuretics
449
WHich anticoagulant/antiplatelet medication should be avoided in pts with h/o gout?
Aspirin (causes decreased renal urate excretion)
450
What is the next step in management for a pt who is found to have a small ocular pigmented lesion
Observation w/ close follow-up
451
What is the next step in management for a pt with an ocular lesion that is causing symptoms (eye pain/vision problems) and/or has a diameter >/= 10mm and thickness >/=3mm?
Radiation Therapy
452
Whenis Enucleation indicated for the treatment of ocular melanoma?
With Very Large lesions
Severe pain associated
Extrascleral Extension
453
What should be done in a pt who presents with substernal chest pressure that is relieved by sublingual Nitrate and lasts for 30 min and started 1 hr ago, dizziness, shortness of breath, EKG showing sinus tachycardia and normal initial troponin levels?
Admit or hold in ED and repeat troponins x2 for a total of 3
| Cardiac enzymes can take up to 6 hrs to become elevated
454
Whaen should stress test be done in pt who presents with signs of Acute Coronary Syndrome but has non-specific EKG and 1 reading of normal cardiac enzymes?
Only do aStress test once MI is ruled out (3 negative cardiac enzymes)
455
What is the first-line treatment for Alopecia Areata?
Topical or Intra-lesional Steroids
456
What is the preferred treatment for a pt dx'd with Hemochromatosis?
Therapeutic Phlebotomy (remove 1 unit of bld each week until iron stores normalize)
457
What are the major cardiac abnormalities associated with Turner Syndrome?
Coarctation of the Aorta
Bicuspid Aortic Valve
MVP
Hypoplastic Heart
458
Besides cardiac defects, what other abnormalities should be screened for at the time of dx of pts with Turner's Syndrome?
```
Hypothyroidism
Vision defects
Hearing Defects
Renal Anatomic Defects (horeshoe kidney)
Insulin resistance (older age)
```
459
What screening test should be done at the time of dx for pts w/ Turner Syndrome?
```
Echocardiogram
Renal Ultrasound
TSH
Eye Exam/Vision Assessment
Ear Exam/Hearing Assessment
```
460
When does the presence of streaked ovaries carry an increased risk of malignancy in pts with Turner Syndrome?
If Y chromosome Mosaicism is present
461
What is the typical age at which Hormone Replacement Therapy is initiaiated in pts with Turner Syndrome?
Age 14 (to avoid premature epiphysis fusion)
462
When can a pt presenting with signs/sx of preeclampsia be managed as an outpt?
1) No severe preeclampsia features (no end organ issues)
2) No severe range BP (Sys>160, Dias >110
3) No comorbidities
4) Pt is reliable/compliant
5) GA >32wks
6) Appropriate fetal growth, Reassuring monitoring
463
What is the next step in management for a pt newly dx'd with preeclampsia and she is
Admit to hospital for further workup (labs, fetal monitoring)
If no severe features devlop w/in 24 hrs-->expectant management
464
What is the next step in management for a pt found to have a small pituitary mass/sella abnormality but has no symptomatic or laboratory evidence of abnormality?
Observation w/ periodic pituitary MRI's
465
What is a common symptom associated with Antifreeze (Ethylene glycol) intoxication?
Kussmal Breathing (deep, rapid):d/t high anion gap metabolic Acidosis
466
What is a major complication of ehtylene glycol intoxication besides death?
Oxalic Acid Renal Stones
467
What is the most likely underlying cause of a pt who had a recent renal transplant pt receiving cyclosporin, azathioprine, and prednisone as his anti-rejection regimen who develops gout?
Cyclosporin-induced hyperuricemia (d/t decreased renal excretion of urate)
468
How is acute gouty treated in pt with recent renal transplant and on cyclosporin, azathioprine, and prednisone?
Intraarticular Steroid Injection or
| Increase dose of current systemic steroids being given for immunosuppression
469
Why should NSAID's be avoided in pts with new renal transplant and/or on Cyclosporin?
NSAIDs and Cyclosporin decrease renal Prostaglandin production-->decreased vasodilation of renal afferent arteriole-->compromise renal blood flow--> potential damage to transplanted kidney
470
What must be done for a pt taking azathioprine who will be started on Allopurinol for gout prophylaxis?
Decrease dose of Azathioprine
| -Allopurinol inhibits Xanthine Oxidase-->inhibits metabolism of Azathioprine-->Increased serum drug levels
471
What is a complication associated with simultaneous use of Azathioprine and Colchicine?
Leukopenia
472
What is the hallmark finding of thyrotoxicosis due to Priamry Thyroid Disease?
Suppressed TSH
473
What should be on the differential for a pt with elevated TSH, T3 and T4?
TSH-secreting Pituitary Adenoma
| Thyroid Hormone Resisitance Syndrome
474
How can a TSH-secreting pituitary adenoma be distinguished from Thyroid Hormone Resisitance Syndrome?
TSH-secreting Pituitary Adenoma:
- elevated Alpha-subunit
- pt has hyperthyroid symptoms
Thyroid Hormone Resistance Syndrome:
-pts usually present w/ hypothyroid symptoms
475
What are 2 clinical findings that are highly suggestive of IV drug use related Endocarditis?
Evidence of Rt-sided CArdiac Involvement:
- systolic murmur that increases w/ inspiration @ LLSB
- tricuspid vegetations seen on echo
CXR:Septic Emboli
-bilateral circumscribed pulmonary infiltrates
476
How should Area Under the Curve(AUC) on Receiver-operating Characteristic(ROC) curves be interpreted?
Larger the AUC--> better discrimination and Higher Diagnostic Accuracy
477
What are typical features associated with acute decompensated heart failure?
Dyspnea
Jugular Venous Distention
Bilateral Crackles
Lower-extremity Edema
478
What are the goals of managment for a pt presenting in Acute Decompensated Heart failure?
Ensure Hemodynamic Stability
Maintain Adequate Ventilation/Oxygenation
Provide Rapid Symptomatic relief
On-going evaluation to Identify cause
479
What are the steps in management for a pt in acute decompensated heart failure?
Urgent Pulse Ox, CXR, EKG
Symptom Relief: Decrease Preload
- IV Loop Diuretic and
- Vasodilators (if stable/perfusing well)
480
What are the initial goals of management for aortic Dissection?
Pain COntrol
Lower Systolic BP (100-120mmHg)
Decrease LV contractility-->decrease aortic wall stress
481
What medications are given as initial management for Aortic Dissection?
Morphine (Pain COntrol)
| IV Beta Blockers (Lower BP, decease contractility)
482
Which beta-blocker medication is preferred for initial treatment of Aortic dissection and why?
Esmolol
-short half-life (9 min) -->easier to titrate and less complications for those who might be intolerant to beta blockers (asthmatics/COPD)
483
When should Nitrated be used in pts with Aortic Dissection?
Sodium Nitroprusside can be added if B-blockers do not lower BP sufficiently (
484
What is the formula to calculate NNT?
1/ARR--> ARR = Rate in CONTROL - Rate in EXPOSED
485
Why are long acting (basal) insulins preferred over pre-mixed intermediate/short acting insulin regimens?
Basal (Long Acting) insulins-decreased risk of Hypoglycemia
Note: Premixed insulins are =/> Basal insulins in terms of glycemic control
486
What is the best initial method to diagnosing Congestive Heart Failure?
H&P-CLinical Dx(mainly): 2 major or 1 major+2minor (w/ no other cause)
- Major Criteria:
- Paroxysmal Nocturnal Dyspnea
- Orthopnea
- Raised JVP
- S3 Heart sound
- Rales
- Increased Cardiac Silhouette
- Pulmonary Vascular Congestion
- Minor Criteria:
- bilateral Lower extremity edema
- nocturnal cough
- dyspnea on exertion
- tachycardia
- Pleural Effusion
- Hepatomegaly
487
What are the typicalcomplaints/ findings on physical and funduscopic exam associated with Central Retinal Artery Occlusion?
```
Cherry Red Spot
Pale Fundus (pale vasculature)
Painless, sudden Monocular vision loss
-Cant mk fine distinctions (ct fingers)
-Can identify objects (hand motion)
Afferent Pupillary Defect
```
488
What is the most common cause of Central Retinal Artery Occlusion?
Carotid Atherosclerosis
489
What are the typical complaints and findings associaated with Central Retinal Vein Occlusion
Subacute Time Course
Asymptomatic-Severe vision loss
Fundus w/Retinal Hemorrhages and Optic Disc Edema --
("Blood and Thunder" appearance)
490
What is the confirmatory test for acute HCV infection?
HCV-RNA PCR (anti-HCV Ab can take up to 12 wks)
491
How are sickle cell beta (0)thalassemia, sickle cell trait, and sickle cell beta (+)thalassemia distinguished?
According to HbA content:
SCBeta(0)Thal: NO HbA
SCBeta(+)Thal:HbA and HbS (max of 25% HbA)
SCTrait: HbA and HbS ratio=60:40
492
WHat is the management for pediatric pts with Tb meningitis?
Early intitial therapy with :
INH, Rifampin, and Pyrazinamide for 12 months
(Note: these drugs have excellent CNS penetration
ALL pts with Tb meningitis should receive Tb
specific medications immediately )
493
When is a pt with Tb considered non-infectious?
IFF 3 consecutive NEGATIVE Sputum Acid-Fast smears on 3 separate occasions while receiveing effective anti-TB medication
494
What is the best prognostic indicator for Primary CNS lymphoma in an HIV +pt receiving Radiation therapy, steroids and HAART?
Increase in CD4 ct
| the lower the CD4 and persistently so, the worst the prognosis
495
What virus is associated with Primary CNS Lymphoma in HIV+ pts?
EBV
496
What is the most likely dx for a pt presenting with abdominal pain, distension, nausea and vomiting, found to have dry mucous membranes, electrolyte abnormalities, increased bowe sounds w/ tympanic features, multiple air fluid levels with some air seen in the colon and a h/o abdominal surgery?
Partial Small Bowel Obstruction
(Note: the key to partial vs complete obstruction is based on presence of air within the colon even though there are air/fluid levels within the small bowel)
497
What is the management for a pt with Partial Small Bowel Obstruction?
Stabilize pt and Observe: Conservative Management
- IV Hydration
- NG Suction (decompression)
- Correct Electrolyte abnormalities
498
When is surgery indicated for partial small bowel obstruction?
If conservative management fails to improve pt symptoms/signs within 12-24 hrs-->early surgical intervention
499
What are two key features of Candidal Diaper Infection in infants that can be used to distinguish it from Diaper Dermatitis (Rash)?
Candidal Diaper Infection:
- Tomato-red Plaques
- Satellite Papules
- Crural Folds involved
500
What is the best initial therapy for Candidal Diaper Rash
Topical Antifungal Agent (ex: Clotrimazole)
501
What is used to manage pts with Venous Sinus Thrombosis w/w/o areas of hemorrhage seen on CT?
Heparin
Note: hemorrhagis areas seen on imaging are d/t venous hypertension
502
What are two major risk factors for Contrast-induced Acute Kidney Injury?
Impaired Renal Function (GFR 1.5)
| Dehydration
503
What is the underlying mechanism of contrast-induced AKI?
Contrast- induced Renal vasocontriction
504
What should be done to decrease the risk of contrast nephropathy in high risk pts?
IV Volume expansion before and after contrast exposure w/ Isotonic solution:
-Normal Saline
Or
-Sodium Bicarbonate
505
What medications should be held just before contrast use in pts at high risk for contrast nephropathy?
Diuretics and Metformin (risk of Lactic Acidosis)
506
What is the management for a female age 21-24 who has a PAP result of ASC-US or LGSIL?
Repeat PAP (cytology) in 1 yr
507
What is the next step in mangement for a female age 21-24 who has a repeat PAP at 1 yr d/t prior AsCUS, whose new result is ASC-H, AGC, or HGSIL?
Colposcopy
508
When is COlposcopy recommended in females 21-24 with ASCUS or LSIL PAP results?
After 3 consecutive (annual) PAP smear that show ASCUS or LSIL (Original and two repeats-->Colposcopy)
509
What is the recommendation for females >25 who are found to have a PA result of ASCUS or LSIL?
Reflex HPV DNA testing:
Sample for initial Cytology (only if liquid technique) is
used for HPV DNA if ASCUS
- If HPV DNA + --> Colpo
- If HPV DNA is negative-->No further work-up-->next
PAP 3yrs (Return to routine testing)
510
What should be done in all stroke pts, especially those with dysarthria prior to administration of any oral medications or food?
Bedside Swallow Screening w/ Formal Evaluation early on during hospital stay.
511
What is the next step in managment for a pt with an acute stroke who has residual neurologic deficits and remains hospitalized with a bp of 182/100 and a FSBG of 138?
Low-dose Heparin or LMWH for DVT prophylaxis (All acute stroke pts should receive dvt prophylaxis with heparin)
512
What type of Heparin is used to treat DVT?
Treat: Full Dose Heparin
Note: For DVT Prophylaxis Low Dose Heparin is used
513
What are the goal BP readings for pts with acute stroke who have and have not received fibrinolytics only given within 3-4.5 hrs of sx onset)?
Fibrinolytics: BP
514
What is the treatment for Herpes Zoster infection?
Acyclovir or Valacyclovir w/in 72 hrs (will hasten resolution of lesions and pain)
515
What adult cohort should receive the Varicella Zoster Vaccine, regardless of immune status?
Adults 60 and older
516
What are the effects of Varicella Zoster Vaccine in regards to SHingles?
Reduces risk of zoster (which increases w/ age d/t
decreased cellular immunity)
Reduces risk of Post Herpetic Neuralgia
517
What type of precautions should hospitalized pts with primary varicella infection as well as those with disseminsted zoster or local zoster in immunecompromised ?
Strict Isolation (contact and respiratory precautions) until ALL lesions are completely crusted over
518
What are the first line treatments for Post Herpetic Neuralgia?
TCA, Capsaicin Cream, Gabapentin, Long-acting oxycodone (as single agents or in combination)
519
What is the diagnosis for a pt presenting with episodic rash described as well curcumscribed raised erythematous plaques (with central pallor) and intense pruritis that recurrs for more than 6 wks?
Chronic Urticaria
520
How is Chronic Urticaria Dx'd?
Clinical presentation and History
521
What condition is associated with C1 esterase deficiency? (w/ sx detail)
Herediatry Angioedema
- swelling of throat, tongue, lips, gut mucosa-->pain
- Urticaria usually not seen
522
What are the areas of mas cell activation resulting in Urticaria and Angioedema?
Urticaria: Superficial Dermal Layer (papillary layer)
Angioedema: Deeper Dermis (Reticular Layer) and Subcutaneous Tissue
523
What is the prognosis for Chronic Urticaria?
Most pts have spontaneous resolution w/in 2-5 yrs
524
What are the next steps in manamgement for a pt with a h/o alcoholism who presents unresponsive/altered mental status with large volume hematemesis?
Intubation to protect the airway
Assess Breathing and Circulation
Endoscopy (to dx and possibly treat varices)
525
What is the next step in management for a pt who was dx'd with and treated for bleeding esophageal varices secondary to long standing alcoholism who presents with repeat hematemesis?
Repeat Endoscopy (Dx/Tx with sclerotherapy or banding)
526
What is the next step in management for pt who fails to maintain adequate variceal ligation with banding or sclerosing therapy?
Portal Shunting with:
-TIPS (transjugular intrahepatic portosystemic shunt)
or
-Surgical Shunt
527
What treament should be given as primary/secondary prevention to prevent bleed in a pt with esophageal varices?
Non-specific Beta-blocker (Propranolol, Nadolol) with
| Repeat Surveillance Endoscopy
528
What is the first-line therapy for Raynaud's?
1) Dihydropyridine Calcium-channel Blockers (Nifedipine, Amlodipine)
2) DIltiazem
529
What labs should be done in pts with Raynaud's who present with signs of systemic involvement?(6)
```
ANA
RF
CBC
Chemistry
Complement
Urinalysis
```
530
What characteristic skin finding(s) and autoab's are associated with Dermatomyositis?
1)Heliotrope Rash (Violaceous rash on face)
2)Grotton's Papules (violaceous papules/plaques on
dorsal surface pf hands)
3)Anti-Mi2, Anti-Jo-1, Anti-RNP
531
What are three medications that increase risk of Lithium toxicity d/t drug-drug interaction?
Thiazides: Distal Tubule
-increased Na excretion->increased Lithium reabsorption
Ace Inhibitors: Efferent Arteriole Vasodilation
- Decrease Glomerular Capillary Pressure--> Increased
Lithium Reabsorption
NSAIDs: Afferent Arteriole Vasocontriction (blocked PGs)
-Decrease Glomerular flow-->Increased Lithium reab at proximal tubule
532
What signs/sx are associated with chronic lithium toxicity?
Ataxia
Confusion
Neuromuscular Excitability (Tremors)
Slurred Speech
533
What serum levels of Lithium are considered therapeutic, toxic, and require emergency management?
Therapeutic: 0.8-1.2mEq/L
Toxic: > 1.5mEq/L
Emergency Management: >/= 2.5mEq/L
534
What are risk factors for Lithium Toxicity?
Volume Depletion
Drug Interaction
Renal Impairment (Renal Clearance)
535
What are the 2 main causes of precocious pubarche?
```
Precocious Puberty (Hypothalamic Dysfunction)
Precocious Pseudo-puberty (Gonadotropin-Independent Process)
```
536
How are Precocious Puberty and Precocious Pseudo-Pueberty distinguished?
Precocious Puberty-HPA premature activation:
-Sequential development:
(First) Testicular Enlargement-->Penis Enlargement-->
Pubic Hair growth-->Growth Spurt (last)
Precocious Pseudo-Puberty: Androgen Excess
Sudden and Dramatic onset of
-Severe cystic Acne
-Pubicl/Axillary Hair Growth/Texture
-Penis Enlargement
-Significant Growth Acceleration
-Small Testes
537
What condition can result in precocious pesudo-puberty that can also be associated with salt wasting, hyperkalemia, and decreased cortisol levels?
21-hydroxylase deficiency
538
What adrenal enzyme deficiency will result in elevated Deoxycorticosterone and Aldosterone and associated Hypertension but no virilization?
17 alpha-hydoxylase deficiency
539
Which adrenal enxzyme deficiency will result in hypertension and virilization?
11 b Hydroxylase deficiency
- Decreased Cortisol/Aldosteron
- Increased Deoxycorticosterone and Androgens
540
Which antiseizure medications are known to decrease OCP efficacy and how?
```
P450Inducers:
Phenytoin
Carbamazepine
Ethosuximide
Phenobarbital
Topiramate
```
541
What antiseizure medications are not associated with decreased OCP efficacy?
Valproate
| Gabapentin
542
What is the earliest sign of hypovolemia?
Tachycardia (immediate response to volume depletion)
543
What are two signs of interstitial fluid depletion?
Decreased Skin Turgor
| Dry Mucous Membranes
544
What are the most common causes in vision loss in elderly pts > 75yo?
Cataracts w/ associated Macular Degeneration
545
When an elderly pt presents with progressive, painless, decrease in vision, what dx should be suspected?
Macular Degeneration
546
What should be done prior to Cataeact surgery in a pt with cataracts and macular degeneration?
Thorough evaluation of severity of Macular Degeneration to determine if surgery will be necessary (may not restore vision with severe macular degeneration)
547
What are two common causes of hypoxemia seen immediately during the postoperative course?
Airway Obstruction/Edema:
-Stridor and Dyspnea
Residual Anesthetic Effects:(esp inhaled)
-Decreased Respiratory Drive (w/w/o low RR)-->High PCO2
548
Which pts are at increased risk of post op Hypoxemia d/t residual anesthetic effects?
COPD'ers
| Chronic Obstructive Sleep Apnea
549
How does secondhand smoke increase risk of recurrent sinusitis?
Cigarette Smoke and Air pollution damage nasal cilia--> decreased mucus clearing-->Mucus accumulation-->sinus obstruction-->secondary bacterial growth
550
What are common causes of recurrent sinusitis in healthy people?
```
Cigarette Smoke
Air Pollution
Allergic Rhinitis
Structural Abnormality (deviated septum/palatal issues)
Inadequately treated Acute Sinusitis
```
551
What is the most likely dx for an elderly pt who exhibits progressive social w/drawal, frequently asks for things to be repeated even if just stated, and sits very clode to television?
Presbycusis (Symmetric gradual sensorineural hearing loss)
552
WHat is the most notorious side effect of Gingko Biloba supplement?
Bleeding and Platelet Dysfunction (inhibition of platelet-activating Factor)
Note: It can potetitate effects of antiplatelet medications
553
What are other less common side effects of Ginko Biloba use?
```
Diarrhea
N/V
Headache
Seizure
Irritability
Restlessness
```
554
What herbal supplements are associated with liver toxicity?
```
Pyrrolizidine Alkaloids:
-Comfrey
-Borage Leaf
-Coltsfoot
Ephedra
Chaparral
Germanger
Jin bu huan (Chinese Medicine)
```
555
What Chinese herbal supplement is associated with potentially fatal cardiac arrhythmias?
Aconite (used to treat pain/heart failure in some Chinese meds)
556
What should be done for a pt newly dx with a terminal illness who expresses distress or concern about the burden of disease and quality of life for him/herself and family members?
Offer/Initiate Palliative Care (which can be in addition to disease-modifying treatments)
Note: Goals of Palliative Care are to ease the burden of the disease and its treatment course on the pt and family members. It involves mulitdisciplinary approach with physician, nurses, social worker, clergy, nutritionists, and therapists
557
What is the general stepwise approach to returning to sports activity following clavicular fracture?
Lower Body exercise can continue (if no other injuries)
Once Pain resolves:
-Gentle Pendulum for Shoulder w/ Active ROM for
Elbow and Hand
For non-contact Sports -Gradual return to activities:
-Painless, Full Active ROM
-Normal Strength
-Evidence of Bridging Callus
All of the above must be present and this usually takes 4-6 wks
558
What are the recommendations for Insulin administration in a pt who has Type1 DM with good glycemic control?
*Slight decrease in Basal Insulin (20-30%) bc not eating as much
AND
Short-acting Insulin q4 (if analogue) or 6hrs (regular) based on FSBG
559
What are the glycemic goals for Diabetic hospitalized pts?
Premeal: 100-140mg/dL
| Post Prandial:
560
What are the indications for Intrapartum GBS Antibiotics?
```
GBS+ rectovaginal culture (35-37wks)
GBS bacteruria during Pregnancy
Previous infant w/ GBS infection
Unknown GBS status AND:
-/=38, 100.4)
or
-Membrane Rupture >/= 18 hrs
```
561
When should workup be conducted in an infant born to a mother with +GBS status?
No Ab given at least 4hrs before delivery
AND
Infant is18hrs
562
What tests should be done to work up an infant for GBS infection born to a mother that is GBS positive but did not receive Ab therapy >4hrs prior to delivery?
CBC w/ Diff
Blood Cultures
Observation for at least 48hrs
563
What is the rcommendation for adequate GBS intrapartum antibiotic prophylaxis?
Ampicillin, Penicillin, or Cefazolin >/=4hrs b/f delivery
564
What is the next step in management for all infants born to mothers colonized with GBS?
Observation for 48hrs (unless ill-appearing then need to also run tests) EVERYONE is observed
565
What is the management for brain dead organ donors?
Maintain pt in ICU with adequate hemodynamic support:
-IV Volume Resuscitation and Pressors if needed
Continue Mechanical Ventilation (prevent acidosis)
Give Hormone Replacement (TH, Methylpred, ADH)
566
What are some complications that contribute to volume depletion in the brain dead pt?
Hypotention (decreased sympathetic tone)
Central Diabetes Insioidus (decreased ADH)
Systemic Infection
567
WHat is the most commonly used imaging study to dx Pyloric Stenosis in an infant?
Abdominal Ultrasound
568
What should be done orior to surgery in children with pyloric Stenosis?
Correct Hydration and Electrolytes
| (Hypokalemic, Hypochloremic Metabolic Alkalosis)
569
What antibiotic is associated with development of infantile hypertrophic pyloric stenosis?
Erythromycin (usually used as pertussis post-exposure prohylaxis)
570
What is the associated physical finding that indicates possiblity of retained gastric material?
Succession Splash (stethoscope over LUQ -->hear splash)
571
What is the next step in evaluating a pt who is suspected of having gastric obstruction secondary to delayed gastric emptying?
Upper GI Endoscopy (to r/o mechanical obstruction)
Note: Radiocontrast study (Barium Swallow) is also an option but less specific
572
What is the next step in managementn for a pt with signs of delayed gastric emptying who has a negative Upper GI endoscopy?
Scintigraphic Gastric Emptying Scan
573
What is the first step in managmenet for a pt dx w/ Diabetic Gastroparesis?
Dietary Mosifications:
- Frequent Small meals
- Avoiding High Fat/ High-FIber foods (slow emptying)
574
What medications can be used to treat a pt with diabetic gastroparesis who has not had sx improvement with dietary modifications or has acute worsening of sx's?
Erythromycin
| Metoclopramide
575
What are the typical features, history and Physical findings associated with Dengue Fever?
1) Travel to Endemic Area (S/SE Asia, Caribbean, Pacific Is, Americas)
2) Joint/muscle pain
3) Pharyngeal Erythema
4) Fever
5) Headache
6) Retro-orbital Pain
7) Macular Rash
8) Cervical Lymphadenopathy
9) Hemorrhagic Tendencies (petechiae w/ Tourniquet)
10) Elevated Liver Enzymes
11) Leukopenia
12) Thrombocytopenia
576
What is the most serious manifestation of Dengue infections?
Dengue Hemorrhagic Fever
-Increased Capillary Permeability->Pleural Effusion and
Ascites--> Circulatory Collapse (d/t third spacing of
fluid)
-Marked Thrombocytopenia (plt
577
What are the common side effects of Tetracyclins?
```
Photosensitivity
Blood Dyscrasias
Vertigo
Pseudotumor Cerebri
Lupus-like Syndrome
Tooth Discoloration (avoid in pregnant and young kids)
```
578
WHich acne medications are associated with Photsentitivity?
Benzoyl Peroxide
Tetracyclins
Retinoic Acid Derivatives
Minocycline (less common)
579
How is phototoxic reaction managed?
Fluid Replenishment
NSAIDs-pain and erythema minimize damage to epidermis if taken immediatelyafter sun exposure
If severe-hospitalization with IV hydration/Pain control and wound care
580
What are the adverse effects of Isotretinoin?
```
Hyperglycemia
Hypertriglyceridemia
Hepatotoxicity
Mucocutaneous Rxn
Blood Dyscrasias
Ocular Toxicity
Teratogen (preg test b/f start, 2 forms of contraception 1 mos before/after and during)
```
581
In addition to discussing the adverse effects of Isotretinoin, what else should pts be told?
Avoid alcohol consumption d/t increased risk of acute pancreatitis (d/t hypertriglyceride effects)
582
What labs should be done prior to starting Isotretinoin in females?
```
BHCG
Triglycerides(all pts)-continue to monitor throughout treatment
```
583
What should be done if pt on Isotrtinoin has rise in triglycerides to level >800?
Stop medication use
584
What is the most likely dx in a pt presenting with a sticking sensation in throat with heartburn and manometry showing absent peristaltic waves of lower 2/3 of esophagus w/ decreased LES tone?
Scleroderma
585
What is the most common lung parenchymal injury seen in pts with blunt chest trauma of any cause?
Pulmonary Contusion
586
What are the typical CXR finding associated with Pulmonary Contusion?
Homogenous Opacification of lungs -don't conform to any specific lung segment
587
What is the managmeent of pulmonary contusion in a stable pt?
Hospital Admission with observation for 24-48 hrs (full manifestations tend to develop later)
- Aggressive Pulmonary Toilet
- Supplemental O2
- Pain Control
- Cautious Fluid Mngmnt (prevent worsening edema)
Note: if severe, Intubation and Mechanical Ventilation may be needed
588
What is the management for a pt who is pregnant and has a persistent adnexal cyst that is >5cm in size found in the eirst trimester?
Surgical removal during 2nd trimester (Note: pt should not reach 3rd trimester/term w/out surgical removal)
589
What are the potential complications that necessitate prophylactic surgical removal of adnexal cyst during pregnancy?
```
High risk of:
-Torsion
-Rupture
-Hemorrhage
which can leaf to preterm/abnormal labor
```
590
What is the next step in management for a pt who presents with unilateral nipple discharge that is spontaneous, and bloody?
Mammogram and/or ultrasound
591
What is the most common cause of pathologic nipple discharge?
Papillary Tumor (Papilloma-benign but may have areas of atypia or ductal carcinoma)
592
Which test should NEVER be done for a pt with suspicious nipple discharge?
Cytology
593
What is the next step in managmement for a pt on SSRI who devlops sexual side effects?
Switch to non-SSRI:
-Bupropion (remember, lowers seizure threshold)
-Mirtazioine
Can use Sildenafil as adjunct
594
WHat are the negative symptoms associated with Schizophrenia?
Flat Affect
Anhedonia
Loss of motivation
595
WHat factors support a more favorable prognosis in pts with Schizophrenia?
```
Female
Older Age of Onset(40yrs and up)
Sudden onset/No Prodrome
Identifiable Precipitant
Mainly Positive Sx(respond better to meds than neg sx)
Presence of Mood sx's
Good Premorbid Functioning
No FHx
Good Family Support
Shorter Duration of active sx
```
596
What is the next step in management for a pregnant pt who presents with no sx but has positive leukocyte esterase, WBCs, nitrites on urinlaysis and culture grows GBS?
Immediate Ab therapy:
-10-day course penicillin G or Cephalexin
(ALL pregnant pt get treated for asymptomatic bacteruria independent of bacteria species)
597
Once ab treatment is complete, what is the next step in managemnt for a pt who had asymptomatic bacteruria?
Repeat Urinalysis to ensure sterile
598
What medical conditions are at increased risk in pts witd are themselves risk factors for depression?
Cardiovascular Disease: CAD and MI
599
What is the underlying mechanism of Methotrexate related macrocytic anemia?
MTX inhibits Dihydrofolate Reductase-->Inhibit reduction of Folic Acid->Folonic Acid(FH4), which is the bioavailable form-->decreased DNA synthesis-->compromised RBC production
600
What medications are associated with Folate Metabolism?
TMP
MTX
Phenytoin
601
What is the drug of choice to treat pts receiving MTX who developed Folic Acid deficiency Anemia?
Folonic Acid (Leucovorin) bypasses DHFR so pt can remain on MTX and still correct anemia
602
What is the most likely dx in a pt who presetns with nonproductive (or productive) cough lasting grater than 5 days, associated chest discomfort from coughing, no hemoptysis, fever/chills, or wt loss, who currently smokes, takes lisinopril for Hypertension and had a recent URIa week ago?
Acute Bronchitis
603
WHat is the next step in managmenet for a pt suspected of having acute bronchitis?
Clinical Dx-->SUpportive CAre (No antibiotics b/c usually viral cause)
604
What is the next step in mnagement for a pt who presents with dysuria and urinary frequency and a positive urinalysis showing leukocyte esterase and nitrites and has had 2 previous UTI's within the last 6 months or more than 3 UTIs in 1 yr?
Antibiotic Prophylaxis (continuous or postcoitally)
No need for further workup unless signs of obstruction or stone (urine culture grows proteus)
605
What are the hallmark CT findings associated with chronic pancreatitis?
Pancreatic Calcifications
Other findings:
Pancreatic Enlargement
Ductal Dilation
Pseudocyts
606
What is the next step in managmeent for a pt who presents with abdominal pain (recurrent or persistent) associated with loose, bulky, foul smelling stools that are difficult to flush, and reports drinking 4-5 bottles of beer daily?
CT scan of the abdomen (chronic pancreatitis)
Note: Amylase and Lipase are not useful for chronic pancreatitis since much of the pancreatic enzyme production is decreased d/t fibrosis of the organ.
607
What is the first line treatment for a pt with chronic pancreatitis?
Dietary/Lifestyle modifications:
Alcohol Intake Cessation
Smaller, Low-Fat meals
If the above changes fail-->Pancreatic Enzyme replacement or minimally invasive procedures
608
What does the relative risk (RR) represent?
Ratio comparing the risk of an outcome in the exposed to the unexposed.
609
What is the formula for calculating RR?
(Risk in the exposed)/(Risk in the unexposed)
610
What is used to measure excess risk and what does it do?
Attributable Risk Percent (ARP)
| Estimates the proportion of disease in exposed that is due to being exposed.
611
What is the formula to calculate ARP?
ARP= (Risk in Exposed - Risk in Unexposed)/(Risk in Exposed)
or
ARP= (RR-1)/RR
612
How is vasovagal syncope dx'd?
Clinical dx according to H&P
613
What test should be done in the workup of vasovagal syncope?
EKG (all syncope pts)
| Upright Tilt table Test (only if dx is NOT clear)
614
What factor can account fora lack of statistically significant differences in the outcome of interest between two groups, provided one exists?
Limited Power (ie: inadequate sample size)
615
What is the most common type of headache syndrome?
Tension Headache
616
What are the typical features of Tension Headache?
Bilateral
Non-throbbing
No neurological findings
Occurs on weekdays
617
What are the typical features of Migraine Headache?
Throbbing
Usually Unilateral
Associated w/ Aura, N/V, photophobia, vision changes
Possible FHx
618
What are the typical features of Cluster Headache?
Unilateral
Periorbital region
Recurring around same time
Associated with tearing, rhinorrhea
619
What are the guidelines for use of electronic communication (email) between physician and patient?
```
For non-urgent , non-emergency matters
SHould not substitute for routine office visits
Clarify pt instructions
Improve rapport
Increase pt. satisfaction
```
Dr. must explicitly state/clarify the above with each pt.
620
What are the typical features of Hemochromatosis-related arthropathy and associated findings suggesting this dx?
Age of Onset: b/w 50-60
2nd/3rd MCP joints, knees and ankles
Morning Stiffness lasting
621
What tests should be done in a pt presenting with joint and assoicated sx's that are suggestive of Hemochromatosis?
Screen: Iron Studies: Transferrin Sat, Ferritin, Serum Iron
Confirm Dx w/ Liver Bx
622
What joints are typically involved/spared in Osteoarthritis,
```
DIP joint affected
Spares MCP joints
Heberden's Nodes (DIP osteophytes)
Bouchard Nodes (PIP osteophytes)
```
623
What are the typical features of Reactive Arthritis?
Urethritis (typically chlamydia)
Conjunctivitis
Arthritis (DIP joints affected; MCP joints spared)
624
What joints are typical features associated with Rheumatoid Arthritis?
PIP, MCP, and wrists involved
Morning Stiffness>1hr
No crystals in synovial fluid
Erosions but NO subchonral cysts/sclerosis)
625
What joints are typically involved/spared in Pseudogout (CCPD deposition)?
Knee and wrist
626
What joints are involved/spared in Gout?
DIP, spares MCP
627
What is the most likely dx in a pt presenting with joint pain(mainly) as well as diarrhea, stools that are bulky, foul smelling, and float, w/ weight loss and PAS + organisms?
Whipple Diseaes
628
What is the next step in managment for a pt whose presentation suggests Whipple disease?
Bowel Bx and PAS stain
629
What is the treatment for Whipple Diseae?
TMP/SMX
630
What should be done in a pt whose labs show Hypocalcemia?
Check Albumin
Note: Serum Ca decreases by 0.8mg/dL for every 1/dL decrease in Serum Albumin (Lab values do not correlate well with ionized Ca+)
631
What is the next step in management for a pt with hypocalemia and low albumin on labs?
Calculate corrected Calcium
| (Measured Total Ca)+[0.8(4g/dL-Serum Albumin (g/dL))]
632
What is the next step in management for a pt who has no symptoms but has low calcium and low albumin according to labs but corrected Ca2+ is WNL?
No further work up/intervention
633
Which pts have an increased risk of hypocalcemia secondary to receiving blood products?
Hypothermic
Renal Failure
Liver Failure
Shock
634
What is the next step in managment for a pt who is hypothermic, (or has liver/renal failure/shock), and receives blood products then develpos muscle spasms, muscle contractures, and seizures shortly thereafter but has normal Ca2+ on labs?
Start IV Calcium replacement (Blood Products contain CITRATE-->if it cannot be metabolized to lactate-->Excess Citrate-->bind Ca2+ and decrease availability to tissues)
Recall, lab values do not accurately reflect the ionized Ca2+ levels so even though citrate causes decrease in Ionized Ca2+, the total calcium may still appear normal on labs
635
WHat metabolic conditions favor increased Ca2+ vs decreased Ca2+?
Acidosis=>Decrease Albumin binding Ca2+-->increased Ca2+ to tissues
Alkalosis=>Increase Albumin binding Ca2+--> decreased Ca2+ to tissues
636
WHat are the recommendations for administering blood products to prevent sx's of hypocalcemia?
10cc of 10% Ca-gluconate for every 500mL of Packed RBC
637
What are the components of a Glascow Coma Scale Score?
Eye REsponse
Verbal Response
Motor response
```
Range= 3-15
Coma 3-8
Head Injury:
-=8-->Severe
-9-12-->Moderate
-13-15-->Mild
```
638
According to the Glascow Coma Scale scoring system, what value is an indication for intubation?
GCS=8
639
WHen should a Transurethral resection of prostate (TURP) be considered in men with prostatic enlargement?
When chronically obstructive sx's persist despite adequate first-line treatment with Medication
640
When is Transrectal Prostate Bx indicated?
Signs of malignancy present
-Prostate Nodules
-Asymmetric Prostate enlargement
Persistently elevated PSA
641
What is the most likely dx for a pt who had recent intraabdominal surgery, and now presents with abdominal pain, some tenderness, mild tympany over CVA region, and reports that no flatus or urine has passed during the entire post op course?
Urinary retension
642
What is a potential cause of urinary retention, especially in the early post-op period?
Bladder distention secondary to aggressive intravascular volume replacement (FLuids or Blood trransfusions)
643
What are the absolute contraindications to OCP use?(9)
```
Migraine w/ Aura
Smoking>/= 15 Cigarettes/day & >/=35yo
Stage 2 Hypertension (>/160/100mmHg)
H/o venous thrombophlebitis
H/o stroke/ischemic heart disease
Breast Cancer
Cirrhosis/Liver cancer
```
644
What is the next step in management for a pt dx'd with pulmonary Tb and receiving anti-tb meds who presents with shortness of breath, no fever, cough, or sputum, but CXR shows a new unilateral pleural effusion?
Thoracocentesis
(presence of new pleural effusion is rare when being treated for Tb but it does not indicate treatment failure so continue therapy unless other signs of new infectionare present)
645
What is the next step in management for a pt with a positive PPD (induration >/+ 10) who is from an endemic area and completed 9 mosof daily treatment for Latent Tb but has no symptoms and a CXR shows a small calcified granuloma?
Reassure the pt
| Note: skin test will always be positive in pt with h/o Tb infection so do not do skin test
646
What are some findings on CXR that indicate active Tb infection?(4)
Cavitary Lesions
Upper lobe infiltrates
Hilar Adneopathy
Pleural Effusions
647
WHat is the treatment for latent Tb?
Isoniazid daily for 6-12 mos
648
What is the absolute cut off fo reading a PPD test as positive for ALL individuals?
Induration >/= 15mm
649
What are the essentials of pt hand-off procedure?
```
Pt Demographics
Clinical Status
Care Plan
Anticipated Problems/Course of action
Pending actions/Follow-up
```
650
What are the early manifestations of infant botulism?
Constipation (first)
Lethargy
Poor Suck
Weak Cry
651
What is the next step in management in a child whose H&P suggest botulinum exposure?
Check Gag Reflex
652
What are the typical signs/symptoms associated with radiation proctitis?
Tenesmus (ineffectual/straining on defecation)
Bloody Diarrhea
Mucus discharge per rectum
Sx usually present w/in 6 wks post radiation
653
What are typical features associated with radiation proctitis seen on Colonoscopy or sigmoidoscopy?
Friability
Pallor
Telangectasias
Mucosal Hemorrhages
654
WHat is the treatment for Acute/Chronic Radiation Proctitis?
Acute: Supportive care (fluids, antidiarrheals)
Chronic: Sucralfate or Glucocorticoid Enemas
655
What are 3 conditions associated with painless bleeding per rectum?
Angiodysplasia
Diverticulosis
Meckel's Diverticulum
656
What is the most likely dx in a pt who presetns with periodic painless involuntary eye closure upon exposure to light or cigarette smoke?
Blepharospasm (acute dystonia)
| thought to be triggered by dry eyes associated with menopause=> more common in older women
657
Wht is the first-line treatment for Blepharospasm?
Botulinum Toxin Injection (can use for years)
658
What is the best screening test for Down Syndrome?
Integrated Test:
- U/S for nuchal translucency (@10 wks)
- Serum Markers:
- PAPP-A (first trimester)
- Ms-AFP, HCG, inhibin-A, Unconjugated Estriol
659
What does the Pemberton's Test comprise of and what does it indicate if positive?
Raise arms over head for 60 sec--> observe for Facial Plethora, engorged neck veins-->Suggests Thyroid as source for obstruction.
660
Wht is the primary risk factor for Thyroid lymphoma?
H/o Hoshimoto Thyroiditis
661
What antibodies are assoicated with Hoshimoto thyroiditis
Anti-thryoid peroxidase Ab's
662
What dx should be suspected in a pt with a h/o or signs and sx's that suggest previous Hoshimoto's Thyroiditis, dysphagia and other obstructive symptoms, and rapid enlargement of thyroid gland?
Thyroid Lymphoma
663
What serum marker is typically elevated in pts with Medullary Thyroid Cancer?
Calcitonin (cancer of Thyroid C cells)
664
What type of thyroid goiter is typically seen in adolescent girls with normal thyroid function tests, negative thryoid antibodies, but thyroid enargement?
Colloid Goiter
665
What is the most common viral sexually transmitted disease in US?
Condylomata Acuminata (HPV anogenital warts)
666
What is the firstline treatment for Condylomata Acimunata?
Topical Trichloracetic Acid (requires multiple applications; workd by protein coagulation destruction method)
667
What anti-wart medication should not be used in pregnancy and should not be applied to mucosal surfaces,
Podophyllin
668
What are the complications of untreated acute appendicitis?
Peritonitis-->Fetal death (if pregnancy)
Abscess
Pylephebitis (infectious portal vein thrombosis) (especially in third trimester pregnancy)
669
What are the contraindications to using NSAIDs for treatment of acute gout?
```
Congestive Heart Failure
Acute/Chronic Renal Disease
Peptic Ulcer Disease
NSAID sensitivity
Currently taking Anticoagulants
```
670
What is the first step in management for a person who presetnts with needle stick exposure to infectious bodily fluids?
Wash site thoroughly
671
What s the treatment for post exposure prophylaxis in a pt eposed to an HIV positive pt's serum who has low viral load or asymptomatic?
2 drug Regimen w/ NRTI's for 4 wks (started within 2 hrs of exposure)
672
What is the treatment for post-exposure prophylaxis in a health-care worker who was exposed to the body fluids of a pt who is HIV positive and has a high viral load and/or symptoms?
3 drug Regimen: 2NRTI's and 1 PI for 4 weeks
673
When is surgical removal indicated for ureteral stone?
Signs of infection
Size >10mm
Complete obstruction (hydronephrosis)
Failure to pass w/ at least 4 wks of medical therapy
674
What is the standard therapy for pts with ureteral stones that are
IV hydration (only admit if symptoms are not controlled)
Analgesics
Alphs Blockers
Strain Urine
675
What is the most likely dx in a pregnant pt who presents with pruritic urticarial plaques, papules, and vesicles surrounding the umbilicus?
Herpes Gestationis (aka Pemphigoid Gestationis)
[Note: No relation to Herpes Virus. Rather, It is autoimmune]
676
What is the firstline therapy to treat Herpes Gestationis?
Corticosteroids (topical triamcinolone)
Note: if severe of no change with topical, systemic steroids can be used
677
What is the typical treatment for most forms of pergnancy-related pruritic dermatoses?
Topical Steroids with Antihistamines
678
What is the management of choice for most head and neck malignancies?
Chemo and radiation (chemoratiation therapy)
Note: Combination is superior to either alone
679
What is the next step in management for a pt with prolapse uterus who is post-menopausal and having symptoms?
Surgical correction (no need for endometrial bx prior)
680
What is the most important MODIFIABLE risk factor for stroke?
Hypertension
681
What instruction should pts being treated for erectile dysfunction be told regarding medication interactions?
Phosphodiesterase inhibitors and alpha blockers should be taken 4 hrs a part (Ex: Sildenafil and Doxazosin)
682
What is the most likely dx for a pt presnting with lethargy, confusion, signs of dehydration, serum glucose >800, absent ketones, hyperkalemia,and abnormal sodium with a h/o type 2 diabetes?
Hyperosmolar Hyperglycemic State
683
WHat is the first step in managmeent for a pt dx with HHS (even with cardiac and significant electrolyte abnormalities)?
Aggressive Fluid resuscitation
684
What is the next step to address pt claims/suggests sexually inappropriate behavior by another physician?
Report the calim/physician to the State regulatory body (division of medical board)
Note: Never attempt to investigate the pts claims on your own.
685
Wht type of bias should be expected when a screening test being analyzed shows an earlier detection time c.w. the standard screening modality but there is no statistical difference in the prognosis between the two tests?
Lead-time Bias
686
What is the most likely dx for a pt with a recent transmural MI who presensts 1-4 days later with positional chest pain, friction rub heard on exam, EKG showing sinus tachycardia, Q waves, possible diffuse ST elevations or PR depression?
Infarction (Acute) Pericarditis
687
What is the treatment for Infarction Pericarditis?
High-dose Aspirin (pain control only, the condition is transient)
688
What is the most likley dx in a pt who had anaMI or Cardiac surgery several months/years ago and now presents with leukocytosis, fever, pleuritic chest pain, and pericardial friction rub on exam?
Dressler (Post-cardiac Injury) Syndrome)
689
What is the most likely dx in a pt presenting with fatigue,, Lower-Extremity Edema, Elevated JVP, mid-diastolic murmur/knock, ascites, EKG showing sinus tachycardia, (possibly low voltage QRS),mild regurgitation on echo, normal EF, and spotty Calcifications along heart border on CXR, and having a h/o heart surgery several months ago
Constrictive Pericarditis
690
What are the typical features associated with Constrictive Pericarditis?(7)
```
Friction rub/Pericardial knock
Lower-Extremity Edema
Ascities
Hepatojugular reflex
elevated JVP
Kussmal Sign
Pericardial calcifications on CXR
```
691
What is the initial treatment for a pt with recent cocaine use who presents with chest pain and EKG showing ST elevation (signs of transmural cardiac ischemia)
Nitrates (or Ca-ch blockers)
Aspirin
Benzodiazepines
692
What is the next step in management for a pt with ST segment elevation, chest pain following recent cocaine use but no prompt relief of symptoms after administration of nitrates, aspirin, and benzos?
Immediate Coronary Angiography (to check for coronary thrombus bc this will not respond to initial medications)
693
What is the gold standard for dx'ing cystic fibrosis?
Sweat Chloride Test (>60mEq/L is diagnostic)
694
What conditions increase the risk of adverse reaction associated with Varenicline use for smoking cessation?
Should avoid use if:
Unstable psychiatric disorders
Previous Suididal ideation
Only second-line use if
H/o Major Depression
Note: Varenicline is a partial agonist for a subunit of the Ach nicotinic receptor
695
What type of psychotherapy is used to treat Borderline Personality disorder?
Dialectical Behavior Therapy (behavior modification and skills building)
696
What are 2 defense mechanisms employed by individuals with Borderline Personality Disorder?
Splitting
-Primitive Idealization (view someone as perfect, flawless
and cannot tolerate any idea of the contrary-usually
associated with someone who helped them during a
time of crisis, a savior)
697
What is the next step in management for a pt who is pregnant with twins and has delivere the first infant, however baby#2 is at 1+station, in cephalic position, sac intact and reassuring fetal heart rate according to ultrasound?
Expectant management with Oxytocin
Note: always perform ultrasound to assess fetal position and heart rate once first baby delivered and there is a dleay in the second baby.
698
WHat is the test of choice to dx renal stone during pregnancy?
Ultrasound of kidneys and pelvis (if negative--> transvaginal ultrasound-->if negative--> MRU or treat empirically, or low dose CT in 2/3 trimesters only)
699
What are the recommendations for management of a pt whor presents with signs, symptoms of Anaphylaxis following bee/wasp sting?
IM Epinephrine and refer to allergist for Venom Immunotherapy
700
What is the next step in management for apt with chronic hypoparathyroidism who is being treated with high-dose Vit D and Calcium but continues to have elevated renal calcium excretion and borderline low serum calcium?
Thiazide Diuretic (increase serum calcium and decrease urine calcium)
701
What should always be administered to pts who are using pessaries?
Vaginal Estrogen Cream
702
What is the most likely dx for a pt with altered mental status, generalized abdominal pain, and thirst, with a plasma glc less than 200 and ketonuria/ketonemia, anion gap acidosis, and osmolar gap?
Alcoholic Ketoacidosis
| Note: DKA usually has plasma glc>250
703
What is the next step in management for a pt with Alcoholic Ketoacidosis?
IV fluids (D5water) and Thiamine
704
Prior to considering peritoneal dialysis for a pt with polycystic kidney disease, what test should be done and why?
COlonoscopy (to r/o diverticulosis which can complicate peritoneal dialysis)
705
What other complications are associated with adult PCKD?
```
Liver, Pancreas, Splenic, Pulmonary Cysts
Cerebral Aneurysm (Berry)
Aortic Aneurysm
Diverticula
MVP
Inguinal Hernias
```
706
WHat tests should be done before dx a pt with Fever of unknown origin?
```
H&P
CBC
blood bultures
Urinalysis/Culture
Blood chemistries
CXR
Hepatitis Serology
```
707
What are the most common underlying causes of fever of unknown origin?
```
Most common
Vasculitis/Connective Tissue Disease
Infection
Malignancy
Miscellaneous
Least Common
```
708
What minearal deficiency is associated with restless leg syndrome?
Iron Deficiency
709
What test should be done in a pt suspected of having Restless leg sydrome?
Ferritin (most accurate measure of iron stores!! Also, anemia may not be present but iron stores are still low)
710
What are the treatment recommendations for Restless leg syndrome?
Mild/Intermittent/Daily- Iron Supplementation with mentally stimulating activities and avoid triggers (caffeine, nicotine, alcohol)
Severe/refractory-
Firstline: Dopamine agonists (Pramipexole, Ropinirole)
2nd Line: Benzos, Gabapentin
711
What is the management recommendations for a young woman
Expectant management with repeat PAP every 6 -12 mos with colposcopy for 1 yr
712
What is the best initial test to assess thyroid function during pregnancy?
TSH
713
How should Thyroid function tests be interpreted during pregnancy?
Use trimester specific reference ranges for TSH and Free T3 and FreeT4
or
Normal range for Total T3 and Total T4 become 1.5 times normal range for nonpregnant adult
714
What does the kappa test measure in statistical analysis?
Inter-rater reliability (concordance)
715
When should rhythm control be done rather than rate control for paroxysmal A-fib management?
Unable to achieve adequate heart rate control
Recurring Symptomatic Episodes
Heart Failure Sx with LV systolic dysfunction
716
What is the antiarrhythmic medication of choice for rhythm control in a pt with recurring Afib sx's but has no structural heart disease?
Flecainide
717
What is the antiarrhythmic of choice for a pt with Afib who also has LV hypertrophy and/or heart failure?
Amiodarone (or Dronedarone, but only w/o Heart Failure or LV dysfunction EF
718
What is the antiarrhythmic of choice for a pt with afib and coronary artery disease without heart failure?
Sotalol (or Dronedarone)
719
What is the treatment method of choice when a pt has recurrent symptomatic afib that is refractory to medical therapy?
Radiofrequency catherter Ablation
720
What is the initial management of pts with symptomatic narrow complex supraventricular tachycardia?
Vagal Maneuvers and/or Adenosine
721
Which cancers commonly metastasize to spinal cord?
Breast, Prostate, Lung, non-Hodgkin's Lymphoma, Renal Cell Carcinoma
722
What is the most likely dx in a pt presenting with discrete, small, violaceous, pruritic papules/plaques mainly involving flexural surfaces of extremities (esp wrists)as well as mucosal surfaces with a white, lacey pattern (Whickham's striae) present on buccal mucosa or external genetalia?
Lichen Planus
723
What is the next step in dx for a pt suspected of Lichen Planus?
```
Skin Bx (Punch)
Note, Lichen Planus is usually clinically diagnosed
```
724
What screening test should be done in all pts, especially those with related risk factors, dx'd with Lichen Planus?
anti-Hepatitis C Ab screen
725
What are some of the most common complications associated with Silicone Breast Implants?
Capsular Conntracture-->Pain
Rupture of implant
Shape Distortion
Deflation of Implant
726
What should Type 1 diabetics be advised to do prior to engaging in increased physical activity (ie sports)?
Decreased insulin dosage before/during increased physical activity to prevent hypoglycemia
If hypoglycemic--> eat candy or glucose tablet (granola bars are complex carbs so can eat immediately following activity to prevent hypoglycemia)
727
What are the steps involved in working up a pt who presents with gi symptoms and labs showing hypercalcemia?
1) Check albumin--> if low adjust Ca
2) Repeat Serum Ca
3) If retpeat CA high-->Contine work up
4) Check PTH:
- if High--> Check Urine Ca
- if low-->ck PTHrP, VitD25 and 1,25
728
What is the most common mechanism of Lymphoma-related hypercalcemia?
Increased VItD1,25 production--> increased gut Ca absorption
729
What clinical features are typically assoicatated with neonatal CHlamydial infection?
Conjunctivitis (w/in 5-14 days of delivery)
-Chemosis
Pneumonia (w/in 4-12 wks)
- Staccato Cough
- Rales
- Hyperinflation on CXR
730
What is the first-line treatment for neonatal Chlamydial Infection (conjunctivitis and pneumonia)?
Oral Erythromycin-14 days
731
How are RSV and CHlamydial Pneumonia distinguished in an infant?
Chlamydia Pneumonia:
- Afebrile
- No Wheezing
RSV:
- Wheezing present
- Fever
732
WHat is the main cause of morbidity and mortality in pts with Marfan Syndrome?
Aortic Root Disease
733
WHat test should be done to screen for and as part of routine management for any pt dx'd with Marfan's Sydrome?
TTE or( CT Chest) to monitor aortic root disesase presence/progression
734
What are the toxic side effects of Amiodarone use?
```
Liver Toxicity
Thyroid Dysfunction (hypo/hyperthyroid issues)
Skin Discoloration (Blue)
Pulmonary Fibrosis (Lipoid Pneumonitis))
Corneal Deposits
```
735
WHat is a possible major contributor to the adverse effects of Amiodarone on Thyroid Function?
High Iodine COntent
736
What is the most common side effect of Indinavir (protease inhibitor)?
Renal Stones
737
What is the most common life-threatening side effect associated with Didanosine HIV medication use?
Acute Pancreatitis
738
What is the most common life-threatening side effect associated with Abacavir muse in HIV treatment?
Hypersensitivity Reactions
739
WHat is the most common life threatening side effect associated with NNRTI use?
Steven-Johnson Syndrome
740
What is the most common life-threatening side effect associated with NRTI use?
Lactic Acidosis
741
What range of values os considered normal for PCO2 in pregnancy?
27 - 32 mmHg
742
What fetal risks/pregnancy outcomes are associated with poorly controlled Asthma during pregnancy?
Preterm Birth
Low Birth Weight
Preeclampsia
Spontaneous Abortion
743
How should Biposy proven Squamous Cel Carcinoma of the skin be treated?
Mohs micrographic surgery or excision w/ 4mm margins
744
What is the most common therapy for Actinic Keratosis that is a singular lesion
Cryodestruction
745
What is the most likely dx and the next step in management for a pt who complains of chronic constipation and presens with discolored thick mass protruding through anus with concentric rings of rectal mucosa appearing friable ?
Rectal Prolapse; Surgical Consultation (for complete prolapse or is prolaspe associated with fecal incontinence or constipation)
746
What is the treatment for Hidradenitis Suppurativa?
MIld: Toipcal Ab (Clindamycin)
Moderate: Oral Ab
Severe: TNF-alpha inhibitors (Infliximab)
747
What is the stadnard treatment rgeimen for children in DKA?
IV isotonic saline bolus (10ml/kg) given over 1 hr
Insulin Drip w/ potassium replacement for those with low/low normal K+
Monitor eletrolytes/acidosis/anion gap (can switch to subQ insulin once acidosis/anion gap resolved)
748
What is the most likely dx in a pregnant pt found to have a crescent -shaped hypoechoic area located adjacent to the gestational sac?
Subchorionic Hematoma
749
WHat si the next sep in managment for a pt suspected of having a subchorionic hematoma during pregnancy?
Repeat ultrasound to re-evaluate in 1 wk from time of dx.
750
What are some complications associated with subchorionic hematoma?
Spontaneous Abortion (most troubling)
Preterm birth
PROM
Growth Restriction
751
What is the most likely dx in a pt presenting with palpitations, dyspnea on exertion, and fatigue with an EKG showing 3 or more Pwave morphologies, narrow QRS complexes, variable PR segments and R-R intervals?
Multifocal Atrial Tachycardia (MAT)
752
What conditions are associated with precipitating MAT?(6)
```
Hypoxia
COPD
Hypokalemia
Hypomagnesemia
Coronary/HTN/Valvular Heart Disease
Medications (Theophylline, Aminophylline, Isopreterenol)
```
Note: Treatment should be directed at identifying and correcting underlying causes first
753
What is the next step in managment for a pt with MAT who is not responiding to initial therapy?
Beta Blocker (Verapamil for asthmatjcs /COPD'ers)
754
WHat does a cough induced by forced expiration indicate?
Airway Hypersensitivity (Asthma)
755
What are the contraindications to live-attenuated influenza nasal mist vaccine?
Egg Allergy ( any reaction)
Pregnancy
Immunocompromised
Asthma
756
What are the typical CSF findings associated with Cryptococcal meningitis?
Very High Opening Pressure (>200-300)
Low Glucose
Low WBC (
757
What is the best initial therapy for cryptococcal meningitis?
Amphotericin B and Flucytosine
758
What is the next step in managment for a pt dx with crytpococcal meningitis who has persistent headache, vomiting and/or other signs of increased intracranial pressure after initiation of medical treatment?
Repeat (Serial) LP's to decease CSF
759
What is the next step in management for a pt with Cryptococcal meningitis who has received induction therapy for 10-14 days AND shows clinical improvement during that time?
Stop Amphotercin B and Flucytosine & switch to Fluconazole
760
When should HAART be intiaiated in an HIV + pt being reated for Cryptococcal meningitis?
4-10 wks following initiation of antifungal therapy (to avoid Immune Reconstruction Inflammatory Syndrome -IRIS worseing seen in pt as their immune system strengthen and begin to fight off pathogen)
761
What is the treatment of choice for a female of reproductive age presenting with dysfunctional uterine bleeding who is stable, non-pregnant, and can tolerate oral medications?
OCP with High dose estrogen (cycle regulation and hemostasis)
NOTE: for those with severe bleeding/unstable or cannot tolerate oral--> IV Conjugated Estrogen
762
What is the treatment of choice for pts with metastatic prostate cancer that involves the spine despite hormone/chemo therapy and back pain not relieved by narcotics?
External Beam Radiation
763
What skin conditions are associated with Insulin Resistance?
Acanthosis Nigricans
| Acrochordons (Skin Tags)
764
Are atypical antipsychotic medications safe for use in elderly?
Atypical Antipsychotics carry increase risk of mortality inelderly so muct be used with caution.
765
What is the treatment of choice for organophosphate intoxication?
Atropine with Pralidoxime
766
What are the typical features associated with a Lateral medullary stroke (Wallenberg Syndrome)?
```
Vestibulocerebellar Findings:
-Vertigo
-Nystagmus (vertical and horizontal)
-Horner's (ptosis, miosis, anhydrosis)
-Loss of pain/teperature/vibration in ipsilateral face and
contralteral trunk
-Ipsilateral Bulbar Weakness/Hoarseness/Diminished Gag
reflex
-Hiccups
-Difficulty feeding oneself
```
767
What is the general pattern of sensory loss associated with brainstem lesions?
Ipsilateral Face and Contralateral Body
768
Which vascular structure is typically involved in a lateral Medullary Stroke?
Intracranial Vertebreal Artery Occlusion
OR
Posterior Inferior Cerebellar Artery (PICA)
769
What features are typical of a lateral mid-pontine lesion?
Ipsilateral Trigeminal Deficits
- muscles of mastication weakness
- diminshed Jaw reflex
- impaired tactile/position sense
770
What are tehe features of Medial Medullary Stroke?
Contralateral hemiparesis (pyramids)
Contralateral loss of positiontactile, vibratory sensation
(Medial Lemsincus)
Ipsilateal tongue paralysis w/ deviation toward lesion
(Hypoglossal nucleus/fibers)
771
WHat are the features of a Medial Mid-Pontine Lesion?
COntralateal Ataxia/hemiparesis of Face, Trunk, Limbs
| Variable loss of tactile/position sense
772
What is the most likely dx for a pt who presents with palpitations, tremors/shakiness, fatigue, and weight loss and had a coronary angiography several weeks prior to symptom onset?
Angiography induced Thyrotoxicosis (d/t Iodine used)
773
What type of goiter is associated with iodine -induced thyrotoxicosis?
Nodular Goiter (excess iodine -->substrate for hormone production)
Note: RAIU-->Low
774
What is the treatment for iodine-induced thyrotoxicosis?
Mild: B-Blockers
Moderate-Severe: Antithyroid drugs
Refractory: Potassium Perchlorate
775
How does Hypomania differ from mania?
Hypomania has less severeity/functional impairment and No psychosis!!
776
What si sthe most likely dx in a pt presenting with flatulence, bloating, diarrhea, weight loss, megaloblastic anemia, who also has a h/o antacid use, decreased motility disease (systemic scerosis, diabetes), and/or surgically created blind loops affecting small bowel?
Small Intestine Bacterial Overgrowth
777
How is Small Intestine Bacterial Overgrowth dx'd?
Jejunal ASpirate (Endoscopy) if >100000 bacteria ==>+
or
Hydrogen Breath Test (Carbohydrates, ie: lactulose)
Note: Jejunal Aspirate is Gold Standard
778
What physical exam finding can be used as a screening test to r/o Testicular Torsion?
Cremaster Reflex (intact--> Not likely torsion)
779
What conditioons should be on the differential for sudden onset testicular/scrotal pain more so than swelling?
Testicular Torsion
Epididymitis
Torsion of Appendix Testis
780
What conditions should for scrotal swelling more so than pain?
Varicocele
Hydrocele
Spermatocele
Testicular Cancer
781
What is the Prehn Sign and what does it indicate?
Pain relief w/ scrotal elevation
| -May be seen with Epididymitis but absent with Torsion (not very specific though)
782
What features are typically associated with a lesion in the Non-dominant Parietal Lobe?
Contruction Apraxia (cannot copy simple line drawings; difficulty putting on coat/pants)
Dressing Apraxia
Confusion
783
WHat is required prior to surgical resection of a thyroglossal duct cyst?
Imaging to check for ectopic thyroid tissue and Thyroid Function Assessment
784
What spinal cord level is associated with the Cremasteric Reflex as well as hip flexion and adduction?
L1-L2
Note: Cremasteric Reflex can be affected in diabetic neuropathy as well as injury to L1-L2 spinal level
785
What should be done for pts with supratherapeutic INR (>/= 5) but no serious bleed?
Hold Warfarin and give oral Vitamin K
786
What should be done for a pt presenting with abdominal pain, palpable full bladder and no sign of urethral or pelvic injury?
Urethral catheterization with Foley
Note: Only do Suprapubic Catheterization iff urethral/pelvic damage or if urethral catheter fails to empty bladder
787
What is considered first line treament for delirium in elderly patients?
Low dose Antipsychotics (Haldol or Respireridone)
788
WHat autoantibodies are typically assocaited with autoimmune hepatitis (lupoid hepatitis)?
ANA (hence lupid hepatitis) and Anti-Smith Ab
789
WHat is the next step in management for a pt who presents with mild eye pain/discomfort for 12-24 hrs associated with decreased visual acuity, and found to have a hypopyon in anterior chamber, swollen lids, erythema and edema of conjunctiva?
Immediate Ophtho consultation/referral to confirm dx of Endophthalmitis via vitreal aspirate and intravitreal Ab administration
790
What EEG finding is typically associated with a dx of Juvenile myoclonic epilepsy?
Bilateral polyspike and slow discharge (during interictal period)
791
What contraceptive methods are first line for women with SCD?
Progestin-only releasing IUD/Implant (decreased bleeding, no risk of thrombosis)
Note: Copper IUD is associated with heavy menses for the first yr of use--> could cause severe anemia in SCD pt>
792
Wha is the next step in managment for a pt dx'd with adenomatous pedunculated polyp that has adenocarcinoma in the head of the polyp, some invasion of muscularis mucosa but without any stalk involvement and clean margins?
Endoscopic Surveillance at 1, 4 and 9 yrs
793
What is a correctable risk factor for Acute Otitis Media that all parents should be informed about?
Smoking
794
What is the dx'ic test of choice for EBV?
Monospot test (ck for Heterophile Ab)
795
When should EBV serology be done for a pt suspected of EBV?
If Monospot test is negative
(Pos EBV serology : + IgM and IgG EBV viral capsid antigen and -IgG EBV nuclear Antigen (EBVNA)
(Note: EBVNA is only present 6-12 wks after onset of sx, and is absent during acute infection)
796
WHat are the risk factors associated with Colon Cancer?
```
African American race
polyopsis Syndromes
Family Hx
IBD
Alcohol
Cigarette Smoking
Obesity
```
797
What is the next step in managemnet for a young woman who presents with chronic diarrhea, weight loss, no signs of malabsorption, amenorrhea/irregular periods, generalized muscle weakness, tachycardia and tremors?
Check TSH (r/o hyperthyroidism)
798
What is the most likely dx in a pt who develops flank pain, hematuria (dark urine), fever, signs of renal failure within 1 hr of receiving a blood transfusion with a h/o multiple transfusions in the past?
Acute Hemolytic transfusion reaction (d/t blood-type mismatch [usually ABO] or pre-formed Ab's in recipients blood)
799
What is the treatment for Acute hemolytic transfusion reaction?
Immediately stop transfusion and give IV Fluids (Normal Saline)
800
Which antihypertensive medications are acceptable for use in pts on Lithium?
Dihydropyridine Calcium-channel Blockers (Amlodipine)
801
What is the most common adverse transfusion reaction?
Febrile NON -hemolytic (fever, chills w/in 1-6 hrs of initiating a transfusion)
802
What aspect of a study is affected by Confounding factors?
Internal Validity
803
What test must be done prior to considering a pt for Percutaneous Dialysis?
Total Colonocopy (to r/o diverticulosis)
