Uworld review 7 Flashcards
Who is given the PCV23 given alone, as opposed to in combination with the PCV13?
Less than 65, with other chronic medical conditions that increase the risk of invasive pneumococcal disease
What is the first line treatment myasthenia gravis? Second line?
- Acetylcholinesterase inhibitor–pyridostigmine
2. Immunosuppressive therapy
What is the first line treatment for acute aortic dissection? Why?
Labetalol, since it decreases BP and HR. If HR is left unchecked, then the dissection may propagate.
What is the most significant risk factor for TB?
Emigration from an endemic area.
How sensitive/specific is anti transglutaminase for celiac? What is the main caveat to this?
Pretty sensitive, but if IgA deficiency is present, then will not show up
What is collagenous colitis, and what will bx show?
Idiopathic increase collagen deposition, causing a malabsorption with mucosal subepithelial collagen deposition.
Does lactose intolerance cause malabsorption of other stuff?
No
Recent h/l dysentery + hepatic abscess on CT = ?
Entamoeba histolytica
What is the treatment for a hepatic cyst caused by entamoeba?
Metronidazole
How can you differentiate between a hepatic cyst caused by echinococcus vs entamoeba histolytica?
Echinococcus does not have fever, and is usually asymptomatic. Also requires exposure to dogs. None of these with ent.
How sensitive is stool microscopy for entamoeba histolytica infection that has formed an amebic abscess?
Not very
Why is drainage of a hepatic cyst caused by entamoeba histolytica not recommended?
Metronidazole alone will usually resolve it.
What are the s/sx of CMV colitis?
- Intermittent dysentery
- Abdominal pain
- Frequent, small volume diarrhea
At what CD4 count do CMV infections occur?
Below 50
What is the diagnostic test for CMV colitis? What will this show?
- Colonoscopy with bx
- eosinophilic intranuclear and basophilic intracytoplasmic inclusions
What is usually in the h/o a pt with an infection of entamoeba histolytica?
Recent travel abroad to an endemic country
Who should get the PSV-13 + 23 vaccines? (5)
- over 65
- CSF leaks, cochlear implants
- Sickle cell or asplenia
- Immunocompromised
- CKD
Who should get the PSV23 alone? (4)
- Chronic heart, lung, or liver disease
- DM
- Smokers
- Alcoholics
Under what CD4 count does MAC cause illness?
50
What are the s/sx of digoxin toxicity?
- n/v/d
- Scotoma / halos around lights
- confusion and weakness
What causes the osteopenia/porosis with ankylosing spondylitis?
osteoclast activity in the setting of chronic inflammation
What are the alarm symptoms of a pt presenting with GERD?
- B symptoms
- Men over age 50 with symptoms for 5+ years
- anemia
- Obvious stuff
When are colloids indicated?
Hypovolemia s/p paracentesis
What is the effect of dopamine on the kidneys?
Increased renal perfusion from D1 receptor stimulation
What is brachytherapy, and what is its role in brain tumors?
- Implanting radioactive/ablative material.
- In combination with surgery
When is surgery for brain cancer a particularly good option? (4)
- Limited mets/masses
- Accessible area
- younger than 65
- Stable extracranial disease
True or false: erythema marginatum is pathognomonic for lyme disease and, if present, preclude the need for serology
True
Most pts that become ill from vibrio vulnificus have what underlying pathology?
Liver disease
What is the cause of bernard soulier syndrome, and what are the labs results like?
- AR loss of glycoprotein Ib, which is a receptor for wVF.
- Mild thrombocytopenia, “Giant” platelets, and bleeding
What is the prophylaxis for malaria in chloroquine resistant areas (drug, and duration of treatment)?
Mefloquine 2 weeks before travel and 4 weeks after
What occupations or exposures, besides obvious ones, are associated with Pb poisoning? (3)
- distilling alcohol with Pb parts
- Battery manufacturing
- Plumbing
How do thiazides work to decrease Ca stone formation?
Increased water loss stimulates Na reabsorption, along with Ca. Thiazides do not inhibit Ca reabsorption like Loops do
What is the effect of aldosterone antagonists on urine Ca?
Increases urine Ca
What are the US characteristics of Echinococcus cysts?
Large, smooth cyst with daughter cysts inside
What is the treatment for small and large hepatic cysts d/t echinococcus?
Small = albendazole Large = drainage with prophylactic antihistamine
Clonus is suspicious for a lesion where?
Pyramidal tracts
What are pendular reflexes, and what do they suggest?
Slow, repeated (over 4 times) reflexes that are pendular in motion (not quick like clonus), and suggest cerebellar dysfunction
What are the classic s/sx of a morton’s neuroma?
Burning in the distal forefoot between the third and fourth metatarsals. Produces a clicking sensation and pain reproduction with squeeze over this area.
What is the treatment for a Morton’s neuroma?
Bar or padded shoe to reduce pressure over the metatarsals
What is the composition of most kidney stones?
Ca oxalate
What are Ca PO3 renal stones seen in?
Primary hyperPTH or RTA
What is the most common nephrotic syndrome seen in pts with Hodgkin’s lymphoma? What about other malignancies?
HL = Minimal change disease
Others (usually solid CAs) = membranous glomerulonephropathy
What almost always accompanies crescentic glomerulonephropathies?
AKI
What are the associated diseases with focal segmental glomerulosclerosis?
HIV
Heroin use
Obesity
Hep B is associated with which nephrotic syndrome?
Membranoproliferative
What causes a continuous murmur with coarctation of the aorta?
if collateral vessels form
Where is the murmur of coarctation of the aorta usually best heard?
Left infraclavicular area anteriorly, and left interscapular area posteriorly.
What might a CXR show with Ebstein’s abnormality?
Prominent right atrial contours
Brain mass in an HIV pt + ENV + serology =
Primary CNS lymphoma
What are the characteristics of a primary CNS lymphoma on head MRI?
Solitary, irregular, weakly ring enhancing mass in the periventricular area
What will head MRI reveal with toxoplasmosis?
Several ring-enhancing, spherical lesions in the basal ganglia.
Are the lesions with progressive multifocal leukoencephalopathy ring enhancing?
No
What is the treatment for euvolemic hypernatremia?
Free water supplementation
What is the treatment for hypovolemic hypernatremia? (2)
Symptomatic = NS until euvolemic, then D5 Asymptomatic = D5
How fast should hypernatremia be corrected?
0.5 mEq/dL/hr without exceeding 12 mEq/dL/day
If a pt develops Li-induced DI, what is the long term treatment if they cannot stop Li?
Salt restriction and selected diuretics (e.g. amiloride)
What is the MOA of amiloride?
ENaC inhibitor
When is hemodialysis indicated for the treatment of Li toxicity?
Serum Li levels over 4, OR over 2.5 + s/sx of significant toxicity
What is the typical presentation of a stress fracture?
-Abrupt increase in activity without rest, causing sharp, localized pain over a bony surface (most commonly the 2nd, 3rd, or 4th, metatarsals) that worsens with palpation over the area.
What is the treatment for a stress fracture?
Rest
What is the typical presentation of a morton’s neuroma?
Pain between the 3rd and 4th metatarsals on the plantar surface, and with a clicking sensation (Mulder sign) that occurs when simultaneously palpating this place and squeezing the metatarsal joints. Numbness/tingling into toes
https://www.youtube.com/watch?v=SCXzm4tLDTs
What is the usual pain with metatarsalgia?
Pain on the plantar surface of the foot between the 2nd and 3rd metatarsals. “Stepping on a rock”. No numbness/tingling
What causes the lower extremity edema with CCBs?
Preferential dilation of the precapillary vessels, which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitium.
What medication can be added to reduce the swelling associated with CCBs? How does this work?
ACEIs/ARBs
These cause post capillary venodilation, and can normalize hydrostatic pressure
What is malignant HTN?
HTN that causes papilledema or retinal hemorrhages
What is the treatment for exertional heat stroke?
Immersion in ice water
Osteolytic lesions + infections + anemia in a old person = ?
Multiple myeloma
What is the “ugly duckling” sign of melanoma?
If skin lesion is substantially different from other skin lesions
What is the Breslow depth?
Depth of melanoma from the stratum granulosum
What is the general treatment of actinic keratoses?
Local cryotherapy of topical 5FU
What is the preventative treatment for Acyclovir nephrotoxicity?
Aggressive IFVs
What are the screening recommendations for annual low dose CT?
55-80 year old with a 30+ pack year, wh0 are currently smoking or quit within the last 15 years
What is the recommendations for Pap smears?
- q3 years for 21-65 OR
- q5 years age 30-65 if combined with HPV testing
What is the usual presentation of mixed (type II) cryoglobulinemia? (4)
- Palpable purpura
- Renal disease
- Arthralgias
- Peripheral neuropathies
Mixed (type II) cryoglobulinemia is usually associated with which infection and autoimmune disease(s)?
HCV
SLE
HIV
Which antibodies are found with mixed (type II) cryoglobulinemia 2/2 HCV?
-anti-HCV IgG, and IgM anti-IgG abs (RF)
What happens to complement levels with mixed (type II)cryoglobulinemia? Type I?
I = normal II = Low
What is the treatment for mixed (type II) cryoglobulinemia?
- Treat underlying condition
- plasmapheresis
- Immunosuppression
What are the presenting symptoms of type I cryoglobulinemia? (3)
- asymptomatic
- Hyperviscosity
- Livedo reticularis
What diseases are associated with type I cryoglobulinemia?
Lymphoproliferative or hematologic disorders (e.g. multiple myeloma)
What s/sx characterize amyloidosis?
- Hepatomegaly
- Renomegaly
- Nephrotic syndrome
What are the associated conditions and composition of the amyloid in AL amyloidosis?
- Multiple myeloma / waldenstrom’s macroglobulinemia
- Light chains
What are the associated conditions and composition of the amyloid in AA amyloidosis?
- Chronic inflammatory conditions (e.g. RA, IBD etc) or chronic infections (e.g. Osteomyelitis, TB etc)
- Beta-2- microglobulin
What will renal bx electron microscopy demonstrate with amyloidosis?
thin fibrils
Hyalinosis of afferent and efferent arterioles on renal bx = ?
DM nephropathy
What are the severe side effects of carbamazepine, that require close monitoring of?
Leukopenia and aplastic anemia
What sort of HA are TCAs used as prophylaxis for?
Tension
What s/sx can CMV cause in immunosuppressed pts?
- Pulmonary s/sx
- GI s/sx (diarrhea, dysentery)
- Hepatitis
- Esophagitis
Does PCP usually cause GI s/sx?
No
Does Mycoplasma pneumonia usually cause GI s/sx?
No
What are the renal findings associated with Goodpasture syndrome?
- Nephritic range proteinuria (less than 1.5g/day)
- Dysmorphic RBCs
- AKI
What is the pathophysiology of Goodpasture syndrome?
Antibodies against type IV collagen
For how long does central HPA suppression occur following discontinuation of long term corticosteroids?
6-12 months
Rapid onset hirsutism with a normal bmi = ?
Androgen secreting tumor
What is the effect of testosterone on erythropoiesis?
Decreases hepcidin levels, causing an increase in Hb
What are the components Beck’s triad?
- Hypotension
- JVD
- Decreased heart sounds
What happens to the filling pressure in the RA, RV, PCWP with cardiac tamponade vs PE??
Tamp = all increase PE = PCWP decreases
What are the antibodies that are found with primary biliary cirrhosis?
Anti-mitochondrial antibodies
What are the antibodies associated with autoimmune hepatitis??
Ant-smooth muscle
What are the classic s/sx of Zinc deficiency?
- Alopecia
- Lack of taste
- Perioral dermatitis
What are the classic s/sx of Cu deficiency?
- Fragile hair
- Skin depigmentation
- Neurologic dysfunction
What are the s/sx Selenium deficiency?
- Cardiomyopathy
- Thyroid dysfunction
Why is RV and FRC increased with pulmonary manifestations of ankylosing spondylitis?
Decrease rib excursion and ribs stuck in inhalation
What happens to FRC, TLC, and RV with pulmonary fibrosis?
Decreased
What is the only time that PEP for tetanus is needed?
If the wound is dirty, and the patient did not receive immunization or less than 3 toxoid doses
Occlusion of what artery can cause a AV block?
RCA
What are bath salts?
synthetic cathinones (amphetamine analogs)
What are the classic findings with bath salt use?
- HTN
- Tachycardia
- Agitation
- No nystagmus
- Prolonged duration of effect
What causes shock with pancreatitis?
Distributive shock from release of activated pancreatic enzymes in the serum, increasing vascular permeability
Which arrhythmia is most specific with digoxin toxicity? Why?
- Atrial tachycardia with AV block.
- increases atrial activation and vagal input to the AV node, causing block. Both occurring otherwise is rare
What is the MOA of chlorthalidone? What is the common side effect?
Thiazide diuretic
Hyperglycemia
How do thiazide diuretics cause hyperglycemia?
Impair insulin release from pancreas and glucose utilization in peripheral tissues.
What is the classic triad of Wernicke’s encephalopathy?
- Confusion
- Ataxia
- Oculomotor dysfunction
What are the relative EPO levels in polycythemia vera?
Low
What is the treatment for polycythemia vera?
Serial phlebotomy
What is mucormycosis?
Infection of the rhino-orbital area with Rhizopus species, commonly seen in DM pts.
How do you diagnose mucormycosis?
Sinus endoscopy
What are the classic s/sx of interstitial cystitis?
- Painful bladder that is relieved with urination
- Dyspareunia
- Urgency, frequency, chronic pelvic pain
What is the treatment for interstitial cystitis?
Low dose amitriptyline
Is alk phos usually elevated with autoimmune hepatitis?
No
What is hepatorenal syndrome?
Kidneys not getting enough blood d/t vasodilatory chemicals that are not broken down 2/2 cirrhosis, leading to preferential splanchnic dilation
What sort of labs are seen with hepatorenal syndrome?
Like prerenal azotemia (which is pretty much is). Bland urine findings, and Urine Na excretion low.
What is the tick that carries Ehrlichiosis? Where in the US is this usually found?
Lone star tick
Southeastern and southcentral US
What are the usual s/sx of Ehrlichiosis?
Acute febrile illness with malaise, AMS, with NO rash.
What are the labs like with Ehrlichiosis? (3)
Thrombocytopenia
Leukopenia
Elevated LFTs
What DM meds cause weight loss?
- GLP-1 peptides (e.g. exenatide)
- SGLT-2 inhibitors
What type of medications are the -gliptins?
-DPP-IV inhibitors
What are the effects of sulfonylureas on weight?
Can cause weight gain
What are the major adverse effects of Glitazones? (3)
CHF
Bone fractures
Bladder CA
What type of medications are the -glutides or atides?
GLP-1 agonists
Greasy-looking scaly skin rash = ? Treatment?
Seborrheic dermatitis
Ketoconazole
When does free wall rupture of a ventricle occur with an MI?
5 days - 2 weeks
What is the treatment for post MI pericarditis (not dressler syndrome)?
Supportive (self limiting)
What are the 5 prophylaxis criteria for lyme disease? (type of tick, time attached, when PEP is started, Local rate of infx, drug issue)
- Attached tick is an adult ixodes tick
- Tick attached for more than 36 hours
- PEP started within 72 hours of tick removal
- Local borrelia burgdorferi infx rate over 20%
- No contraindications to doxycycline
What sort of kidney disease is seen with granulomatosis with polyangiitis? What antibodies are seen?
- glomerulonephritis
- Proteinase 3-ANCA (aka cANCA)
What are the two classic visual symptoms of retinal detachment? Signs?
- Photopsia and “curtain/veil coming down over my eyes”
- Sluggish pupil and a grayish appearing retina
What is “salvage” therapy?
failure of initial treatment, and new treatment to kill residual cells
What is “adjuvant” therapy?
Treatment given in addition to the standard therapy
What is “consolidation” therapy?
Multidrug therapy after induction
What is “induction” therapy?
Initial dose of treatment to rapidly kill tumors cells and send the patient into remission
What is “maintenance” therapy?
Therapy given after induction and consolidation therapies to kill any residual tumor cells , and keep the pt in remission.
What are the three common causes of pseudogout (3 H’s)
- HyperPTH
- Hypothyroidism
- Hemochromatosis
What is the biggest risk factor for aortic aneurysm expansion?
Smoking
Why is there an increase in the risk for atherosclerosis with nephrotic syndrome?
Loss of protein causes liver to secrete more cholesterol to maintain oncotic pressure
What kidney disease can infective endocarditis cause?
Immune complex mediated (RF+) glomerulonephritis
What is Still’s disease? What is the classic triad of symptoms?
Rare systemic autoinflammatory disease
- High fevers
- Arthralgias
- Salmon colored papular rash
What is the most common benign middle mediastinal mass? Anterior?
Middle = Bronchogenic cyst Anterior = thymoma
What is the effect of oral estrogen on thyroid binding globulin? Transdermal?
oral = Decreases clearance Transdermal = no effect
What is the other name for strep bovis?
Strep gallolyticus
Which part of the spine is most commonly affected with RA?
Cervical spine
What route of drug administration should be used to give abx for infective endocarditis?
IV
What is the alternative to PCN for endocarditis if the pt has an allergy?
Ceftriaxone
What is the confirmatory test for leukemia?
Bone marrow bx
What sort of anemia can phenytoin cause? How?
Causes a macrocytic anemia 2/2 folate absorption impairment
How does bactrim cause anemia?
Inhibits folate metabolism, causing a megaloblastic anemia
How does methotrexate cause anemia?
Inhibits folate metabolism, causing a megaloblastic anemia
What happens to the following labs with Kawasaki’s disease:
- CRP/ESR
- WBCs
- Platelets
- UA
- Elevated ESR and CRP
- Neutrophilia
- Thrombocytosis
- Sterile pyuria
What is the diagnostic test for hereditary spherocytosis?
Eosin-5-maleimide test positivity
What causes the mild gynecomastia in male puberty?
Transient increase in estrogen as testicle mature. Reassurance and observation,
What is the triad of milk-alkali syndrome?
- Hypercalcemia
- Alkalosis
- AKI
What happens to the Mean Corpuscular hb concentration with hereditary spherocytosis? Why?
Increase d/t a relative loss of membrane compared to Hgb
What is the diagnostic procedure of choice for suspected intussusception?
US guided air contrast enema (will relieve intussusception as well)
What is the major CD marker for B and T cells respectively?
B = CD19 T = CD3
What is the short and long term therapy for SCID?
Short = IVIG and abx
Long term = stem cell transplant
Should premature infants be given immunizations according to their chronologic or gestation age?
Chronologic, but must be over 2 kg before firs Hep B
What skin fold findings are concerning for developmental dysplasia of the hip?
If thigh skin folds go more posterior than the anus.
What is the classic heart murmur with a small VSD?
holosystolic murmur over the apex with a late diastolic rumble from mitral stenosis as flow is increased across this valve.
Which antibiotics should be given for aspiration pneumonia to cover for anaerobic pathogens? (5)
- Clindamycin
- Metronidazole
- Amoxicillin
- Augmentin
- Carbapenem
What is the acute management for a tet spell?
Flex the hips and oxygenate
Why is there a single S2 with tetralogy of fallot?
Normal aortic closure, but minimal pulmonic from reduce flow
Chronic otitis media in a child can lead to what inner ear pathology? How does this present?
- Cholesteatoma
- Continued ear drainage for several weeks, despite abx therapy
What are cholesteatomas? Complications?
- Destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process.
- Hearing loss, CN palsy, vertigo, brain abscess/meningitis
What are the five classic s/sx of riboflavin deficiency?
- Angular cheilosis
- Stomatitis
- Glossitis
- Seborrheic dermatitis
- Normocytic anemia
What are the two key symptoms of Beri Beri?
Peripheral neuropathy
Heart failure
What is the treatment for HUS?
Dialysis, transfusions
What are the s/sx of MAC infection in HIV pts?
Nonspecific systemic s/sx, diarrhea, abdominal pain
- splenomegaly
- Elevated alk phos
What is the prophylaxis for MAC?
Azithromycin
Under what CD4 count are HIV pts at risk of MAC attack?
50
What is the confirmatory test for chronic granulomatous disease?
Dihydrorhodamine test or nitroblue tetrazolium test
What is the lifelong treatment of chronic granulomatous disease?
Prophylactic abx and IFN for severe infxs
What is the CH50 test used for?
Determine complement levels in pts suspected of having complement deficiencies
What is the most serious complication (besides splenic rupture) from EBV infection?
Acute airway obstruction 2/2 tonsillar enlargement
Nephrotic syndrome in HIV pts is most likely what?
Focal, segmental glomerulosclerosis
Hep B infx predisposes to what nephrotic syndrome?
membranous
What is the treatment for enterobius vermicularis?
Albendazole or pyrantel pamoate if prego
What is the first line treatment for chagas disease?
Benznidazole
What is the first line treatment for strongyloides?
Ivermectin
What is the preferred medication for treating HTN 2/2 ADPKD?
ACEIs
What is postpericardiotomy syndrome?
Pleuropericardial disease that occurs days or months after cardiac surgery or injury. Inflammation for surgical intervention can lead to reactive pericarditis, pericardial effusion, or tamponade
What complement levels will be depressed with hereditary angioedema, vs acquired?
Hereditary angioedema = low C4 levels
Acquired = low C4 and C1q
Posterior urethral valves only affects what gender?
Males
What causes the congenital, bilateral absence of the vas deferens in male CF patients?
Accumulation of inspussated mucous in the fetal tract obstructs development
True or false: there testicles produce no sperm in male pts with infertility 2/2 CF
False
