Uworld Step 2 CK

Question 1

What is the difference between projection, displacement, and sublimation?

Answer 1

Immature:

• Displacement: Transferring feelings to a more acceptable object
• Projection: Attributing one’s own feelings to others

Mature:
Sublimation: Channeling impulses into socially acceptable behavior

Question 2

Contraindications for external cephalic version?

Answer 2

• C section already indicated for another reason
• Placental previa or abruption
• Oligohydramnios
• Ruptures membranes
• Multiple gestation
• Fetal/Uterine anomaly

Question 3

How to diagnose metabolic syndrome?

Answer 3

3 of 5 criteria met:

1 - Abdominal obesity (waist >40 in men, >35 in women)
2 - Fasting glucose > 100
3 - Blood pressure > 130/80
4 - Triglycerides > 150
5 - HDL cholesterol (men

Question 4

What is physiologic leukorrhea?

Answer 4

Normal vaginal discharge

Question 5

How do you diagnose bacterial vaginosis?

Answer 5

3 of 4 Amsel criteria must be met:
1 - Thin, gray-white vaginal discharge
2 - Vaginal pH > 4.5
3 - A positive whiff test with KOH
4 - Clue cells on wet mount

Question 6

What are the week cutoffs for when preterm labor should be managed?

Answer 6

• Under 37 weeks is considered preterm labor
• 34 to 37 weeks, risks are low so jsut go with it
• 23 to 34 weeks, should delay unless it’s emergent

Question 7

Pregnant female at 31 weeks gestation having regular contractions, cervical dilation. She has no fluid leakage, pregnancy complications, or recent trauma. Next step?

Answer 7

• Tocolytics
• Corticosteroids for lung maturity
• Magnesium sulfate for neuroprotection (under 32 wks)

Question 8

What are first-line tocolytics for delaying delivery for a couple days?

Answer 8

• Beta-adrenergic receptor agonists
• Calcium blockers
• NSAIDS

Question 9

Most common viruses in viral meningitis?

Answer 9

Echovirus

Coxsackie Virus

Question 10

Risks of combo oral contraceptives:

Answer 10

Bleeding
Breast tenderness, nausea, bloating
Amenorrhea
HTN
Venous thromboembolisms
Increased risk of cervical cancer
Decreased risk of ovarian and endometrial cancer
Liver disorders (Hepatic andenoma)
Increased triglycerides

Weight gain is NOT a side effect!

Question 11

Red flags that may distinguish preseptal peri-orbital infections from orbtial cellulitis?

Answer 11

• Pain with extraocular movement
• diplopia
• opthalmoplegia

Question 12

Premature infant with very low brith weight. He is getting enteral feeds and appears lethargic and has abdominal distention. What are you worried about?

Answer 12

Necrotizing Enterocolitis

• Looking for hallmark finding of pneumatosis intestinalis

Question 13

What is the classic image finding for infant with bilious vomiting shortly after feeds. Without abdominal distention.

Answer 13

Double-bubble sign of duodenal atresia

Question 14

36 hours after birth infant has abdominal distention, has failed to pass meconium, and mother is worried because infant is not feeding well…

Answer 14

Hirschsprung Disease

Question 15

Patient has had intermittent episodes of N/V, hyperactive bowel sounds. Now on imaging - dilated loops of bowel and pneumobilia is seen.

Answer 15

Gallstone ileus

Occurs due to gallstone entering GI tract and causing “timbling obstruction” before finally causing complete obstruction. Often occurs at ileocecal valve

Question 16

Describe potential manifestation of severe eclampsia:

Answer 16

HELLP syndrome:
1 - Hemolytic Anemia
2 - Elevated Liver enzymes
3 - Low Platelets

(Remember abdominal pain is due to liver swelling and distention of Glisson’s capsule)

Question 17

Lung problems in HELLP syndrome?

Factors that contribute to this problem?

Answer 17

Can cause severe pulmonary edema.

4 contributing factors

1 - HTN increases afterload, which increases pulmonary capillary pressures
2 - Decreased albumin
3 - Increased vascular permeability
4 - Decreased renal function

Question 18

Common manifestations of eclampsia:

Answer 18

New onset seizures
HTN
Proteinuria
headache
visual changes

(when seizures occur in pre-eclampsia patient, the patient now has eclampsia)

Question 19

Neonate delivered at 30 weeks has had decreased spontaneous movements, decreased tone, seizures, and rapidly increasing head circumference the last few days. (normal prenatal ultrasounds)
Currently neonate is intermittently bradycardic and apneic, he is lethargic with high pitched cry, tense fontanels, and hypotonia. Most likely diagnosis?

Answer 19

Intraventricular hemorrhage

If you said a malformation like Arnold Chiari or Dandy-Walker, it’s true these could cause noncommunicating hydrocephalus. However, this swifter neurological decline and acute hydropcephaly is more consistent with IVH.

IVH is a big complication in prematurity

Question 20

Most important interventions for septic arthritis?

Answer 20

Surgical drainage and IV abx to prevent permanent joint destruction

Question 21

50 year old man in the STAB room with altered mental status and gait instability.
He has had two falls in the last day. He drinks 1 pint of vodka and smokes 2 packs a day. He has horizontal nystagmus and conjugate gaze palsy in both eyes. Absent ankle relfexes in both legs. Lungs CTAB.
Diagnosis?

Answer 21

Triad of Wernicke’s Encephalopthy:
1 - Encephalopathy
2 - Oculomotor Dysfunction
3 - Gait Ataxia

Question 22

Atopic dermatitis presents as dry thickened skin often in antecubital/popliteal fossae or extensor surfaces and cheeks.
Excoriation can cause superimposed skin infections.
Name these two superimposed infections:

1 - Painful vesicular reash with punched out erosions and hemorrhagic crusting

2 - Painful non-pruritic pustules with honey-crusted adherent coating

Answer 22

1 - Eczema herpeticum - caused by HSV-1

2 - Impetigo - Caused by Staph Aureus or Strep Pyogenes

Question 23

treatment for varicocele

Answer 23

Gonadal vein ligation

Question 24

Episodic painless GI bleeding in a 65 year old patient. Stools have been maroon red. Recent colonoscopy did not see anything, although prep wasn’t great in ascending bowel. What do you think?

Answer 24

Angiodysplasia

Especially get suspicious if they have renal disease or a bleeding disorder or aortic stenosis

Question 25

Genital ulcers, which are painful? Chancroid, herpes genitalis, and primary syphillis

Answer 25

Genital ulcers in chancroid and herpes are painful

Question 26

Best test to diagnose primary syphillis?

Answer 26

Dark field microscopy! If you said RPR, this is a SCREENING serological test that actually has a very high false positive rate, so should be avoided in primary syphillis. FTA-ABS could be used for confirming RPR and would get you the diagnosis

Question 27

Woman presents with recurrent pregnancy loss and history of TIA. Likely diagnosis?

Answer 27

Antiphospholipid Syndrome Tx: Chronic anticoagulation is indicated

Question 28

Atypical antipsychotic most likely to cause tardive dyskinesia?

Answer 28

Risperidone Best thing to do is switch to clozapine.

Question 29

Mechanism by which maternal diabetes can cause RDS in infants?

Answer 29

Maternal hyperglycemia causes fetal hyperglycemia and in turn fetal hyperinsulinemia. High levels of fetal insluin antagonize cortisol and block the maturation of sphingomyelin - a vital component of surfactant

Question 30

Risk factors for RDS in infants?

Answer 30

``` PREMATURITY maternal diabetes male gender perinatal asphyxia C-section without labor ```

Question 31

Infant with bulbar palsies (ptosis, sluggish pupillary light response, poor suck) with descending flaccid paralysis, constipation, and drooling. NO history of eating honey, but recently moved to UT. Diagnosis?

Answer 31

Classic Infant botulism causes by Clostridium Botulinum. - Can get spores from soil even if no honey toxin is ingested. - Most common in soil of UT, PA, and CA Give human-derived botulism immune-globulin as treatment even before confirmation of toxin or spore

Question 32

Tx for viral menignitis?

Answer 32

IV acyclovir should be given empirically immediately for possible HSV encephalitis until confirmatory tests return

Question 33

What kind of fluid should be used for resuscitation of an infant with severe hypovlemic hypernatremia?

Answer 33

Normal saline Isotonic solutions should always be used for initial resuscitation when you want the sodium to correct more slowly

Question 34

3 year old boy with cystic fibrosis. Presents with respiratory distress and likely recurrent pneumonia. What empiric antibiotics should he get right away?

Answer 34

Vancomycin Why? Because Staph Aureus is the MOST common pathogenic organism in young children with CF. (he has CF so he's in the hospital all the time so you want to assume MRSA) Why not amikacin, caftadidime, cipro? These are great for Pseudomonas Aueruginosa, the most common pathogen in ADULTS with CF. Less common in young kids.

Question 35

1st line therapy for giardia?

Answer 35

Metronidazole

Question 36

Symptoms of giardia?

Answer 36

``` diarrhea from international travel abdominal cramps foul-smelling stools bloating benign abdomen ```

Question 37

Patient with COPD without smoking and family history of liver disease.

Answer 37

Alpha-1 antitrypsin definciency

Question 38

Patient presents to clinic with 2 months of low grade fever, abdominal pain, weight loss, and bloody diarrhea. Symptoms have worsened over the last 2 days. Patient with fever of 101.1, pulse of 128, WBC of 15,000 and hgb of 9.2. Abd XR shows extremely distended large bowel. Dx?

Answer 38

This is likely ulcerative colitis which has become toxic megacolon Emergency: prompt IC steroids, NG decompression, IV antibiotics

Question 39

43 year old man with history of SLE complains of frequent epigastric burning which he cannot relieve with antacids. Usually brought on by lifting heavy boxes at work. He is on prednisone for SLE. He has no shortness of breath, arm or neck pain. What should your first step in manging this patient?

Answer 39

Exercuse EKG Concerning story for ischemic heart disease (steroid use and SLE are risk factors for accelerated coronary atherosclerosis)

Question 40

What are the 4 centor criteria for strep throat?

Answer 40

- Tonsilar exudates - Fever by history - Tender anterior cervical adenopathy - Absence of cough Treatment if + for strep = oral penicillin or amoxicillin

Question 41

29-yr-old woman with 6 months of amenorrhea. Normal menarche at age 14. irregiular periods from 14-16, then oral contraception until getting married last year. She eat healthy with a normal BMI and does not smoke drink or use drugs. 1st and 2nd steps to evaluate amenorrhea?

Answer 41

1 - Check beta-hCG for pregnancy 2 - If not pregnant, check serum prolactin, TSH, and FSH These are to check for most common causes of secondary amenorrhea (hyperprolactinemia, thyroid dysfunction, and premature ovarian failure)

Question 42

Patient complains of fatigue and SOB for 2 weeks. No chest pain, no N/V, no weight loss. Recent URI. NO tobacco, EtOH, or drugs. BP 98/55, HR 105. Jugular veins distended sitting down. Lungs CTAB. CXR shows enlarged heart silhouette.

Answer 42

Pericardial effusion

Question 43

Signs of pericardial effusion:

Answer 43

- enlarged water-bottle shaped cardiac silhouette | - diminished heart sounds with difficult-to-palpate maximal apical impulse

Question 44

1 year old swinging from father's arms, but now she is in pain and will not move her right arm. Diagnosis? Treatment?

Answer 44

Nursemaid elbow: AKA subluxation of radial head 2 Techniques to treat: 1 - Hyperpronation of forearm while applying pressure to radial head 2 - Supination of forearm and then flexion of elbow while held in supination with pressure on radial head

Question 45

What is the pathophysiology for functional hypothalamic amenorrhea? AKA: When strenuous exercise, anorexia, weight loss, stress, or serious illness causes amenorrhea.

Answer 45

The HPO (hypothalamic-pituitary-ovarian) axis can be suppressed without an anatomic cause. Factors like low body fat and leptin, Ghrelin, NPY, GABA, beta-endorphin, and others are implicated in the actual suppresion at the hypothalamic level (GnRH). THis then goes on to suppress LH and FSH secretion from the pituitary and then estrogen from the ovaries. The low estrogen state creates amenorrhea and puts patient at risk for bone loss as well

Question 46

Neonatal heart anomaly presenting in first few hours of life with cyanosis and a single loud second heart sound?

Answer 46

Transposition of great vessels - Start prostaglandins to optimize intra-circulatory mixing

Question 47

What is the genetic make-up of Edwards syndrome?

Answer 47

Trisomy 18

Question 48

What are the characteristics of Edward's syndrome?

Answer 48

- Micrognathia - Microcephaly - Rocker-bottom feet - Overlapping fingers - Absent palmar creases - Holosystolic murmur @ LL sternal border

Question 49

Triad of Spherocytosis?

Answer 49

Coombs negative hemolytic anemia Jaundice Splenomegaly Eosin-5-maleimide Binding and Acidified Glycerol Lysis tests used to confirm

Question 50

On CT you see a well-circumscribed dural-based mass with partial calcifications. Management?

Answer 50

Likely a meningioma - Surgical resection is tx, if causing symptoms

Question 51

Patient presenting with incontinence, shuffling gait, and dementia. CT brain showed very widened ventricles. Management?

Answer 51

Normal pressure hydrocephalus Try large colume lumbar puncture, if this works then do a ventriculoperitoneal shunt

Question 52

When do you treat rhinosinusitis as if it is bacterial?

Answer 52

``` Persistent: > 10 days w/o improvement OR Severe: >102F, 3+ days of face pain OR Worsening: > 5 days after initial improvement of viral URI ```

Question 53

How do you treat uncomplicated, acute bacterial rhinosinusitis?

Answer 53

Amoxicillin - Clavulanate | augmentin

Question 54

Disorders that can present with vitiligo? | Try to name a couple at least/

Answer 54

pernicious anemia, autoimmune thyroid disease, type 1 diabetes, alopecia areata, hypopituitarism Autoimmune condition - these areas of depigmentation lack melanocytes. May have something to do with autoimmune response against melanocytes.

Question 55

30 year old patient has vaginal discharge with vulvar pruritis. pH is 6.0 and wet mount shows pear-shaped motile organisms. She gets treated with first-line medication along with her partner. Don't forget to tell her to avoid ______ during the treatment period.

Answer 55

Alcohol use Metronidazole combined with alcohol will have disulfiram-like reaction

Question 56

55 year old caucasian male who is having icnreasing falls the last few weeks. He has also noticed dry mouth, dry skin, and erectile dysfunction over the same period. PMH: recently developed resting tremor, diagnosed with DM II 6 months ago. Patient has orthostatic hypotension and physical exam shows rigidity and bradykinesia. Diagnsosis?

Answer 56

Multiple System Atrophy (Shy-Drager Syndrome) Degenerative Disease characterized by: 1 - Parkinsonism 2 - Autonomic Dysfunction (postural hypotnesion, impotence, abnromal salivation/lacrimation, gastroparesis, disturbance in bowel/bladder control) 3 - Widespread neurological sings (cerebellar, pyramidal, lower motor neuron) Always consider this diagnosis when patient with parkinsonism has orthostatic hypotension, impotence, incontinence, and other autonomic signs

Question 57

In HHS or DKA, K can get out of whack. Up or down? Why is that?

Answer 57

Can cause K deficit (even if labs look elevated or normal) Occurs because of urinary loss in glucosuria-induced osmotic diuresis. Aggressive insuln therapy can lower K even more, so be careful

Question 58

3 year old presents with 2 day hx of decreased appetite, neck swelling, and irritability. He keeps his head slightly rotated to the right and resists attempts to passively flex or rotate the neck to the left. What is this condition called? What do you do first?

Answer 58

- Acquired torticollis - First, get a cervical spine XR (to check for fracture or dislocation) Most commonly caused by URI, minor trauma, cervical lymphadenitis, retropharyngeal abscess

Question 59

Home-birthed 5-day old without prenatal care presents with easy-bruising and periumbilical bleeding. Platelets are 270. PT and aPTT are prolonged. What do you think is the most likely cause of bleeding?

Answer 59

Vitamin K deficient bleeding Often develops in the first week of life, which is why newborns are given Vit K shot. (many times are given by midwives) Kids are deficient in Vit K because of poor placental trasnfer, absent gut flora, immature liver fxn, and inadequate levels in breast milk.

Question 60

Obese 13 year old boy presents with R groin pain, R knee pain, and limping. Gotten worse over two weeks. Afebrile with normal vitals. Exam shows normal range of motion in knee. Hip movements are restricted. External rotation of thigh is seen with flexion of hip. Diagnosis? Tx?

Answer 60

Slipped Capital Femoral Epiphysis Treated with surgical pinning fo the slipped epiphysis where it lies in order to decrease risk of avascular necrosis of femoral head and chondrolysis

Question 61

40 year old woman with PMH of SLE on chronic glucocorticoids Pain in her hip for last 4 weeks which is worse weight-bearing. She has had no trauma and no pain like this before. She doesn't use EtOH/tobacco/drugs. Afebrile with normal vitals. Hip XR comes back clean. What's going on? Next step for management?

Answer 61

Avascular Necrosis (osteonecrosis) of femoral head MRI is next step She is at risk due to SLE and steroid use. XR often normal for first few months as well as exam. MRI is a much more sensitive test and can show the boundary between normal and ischemic bone.

Question 62

What are the symptoms of an individual who tests positive on the "Quantitative pilocarpine iontophoresis" test?

Answer 62

Cystic Fibrosis Patients have recurrent respiratory infections, steatorrhea, failure to thrive

Question 63

25 year old pregnant woman at 32 weeks gestation precents with acute onset abdominal pain and vaginal bleeding soaking her clothing. Blood presure is 160/95 and pulse is 100/min. Exam shows firm tender uterus. Speculum exam shows 100ml clot in vaginal vault. Bleeding is observed from cervix. No decelerations are seen in fetal heart beat and contraction are ever 2 minutes. Diagnosis?

Answer 63

Abruptio Placentae Premature separation of the placenta from the uterus caused by bleeding into the decidua-placenta interface are rupture of maternal decidual blood vessels. Abruption is a common cause of antepartum hemorrhage. Risk factors include: cocaine use, HTN, tobacco use, abdominal trauma

Question 64

Patient presents withseveral months of worsening severe watery diarrhea, muscle weakness, facial flushing, and N/V. Labs show hypokalemia. No recent travel. No fever, slightly tachycardic. CT scan shows 3 cm mass in pancreatic tail. Diagnosis?

Answer 64

VIPoma Confirm with VIP level greater than 75

Question 65

Apart from seeing those rhomboid-shaped crystals, what is another classic finding in pseudogout?

Answer 65

Chondrocalcinosis | calcified articular cartilage

Question 66

How do you treat pseudogout?

Answer 66

Intra-articualr gluticorticoids NSAIDs Colchicine

Question 67

What is erythromycin ophthalmic ointment used to treat in neonates?

Answer 67

Treatment of choice for gonococcal conjunctivitis. NOT for chlamydia, oral eythromycin would be key here

Question 68

When do you normally detect placenta previa? | How do you manage once it's detected?

Answer 68

Usually found on prenatal US at 18-20 weeks. Pelvic rest indicated: no intercourse, no digital vaginal exam, schedule C-section for 36-37 weeks gestation

Question 69

Describe the syndrome of Hemolytic Uremic Syndrome:

Answer 69

- Hemolytic anemia - Thrombocytopenia - Renal Failure

Question 70

Main cause of HUS? | Tx?

Answer 70

Shiga-toxin mediated endothelial damage after infection with E Coli O157:H7 or Shigella Tx is supportive - can require dialysis in about 50% of kids

Question 71

What is uterine tachsystole?

Answer 71

6+ contractions in 10 minute period

Question 72

What is a potential complication of oxytocin?

Answer 72

- tachsystole or tetanic contractions - hyponatremia - hypotension

Question 73

33 year old evaluated in office for bilateral intermittent leakage of pale gray fluid from breasts. Exam is benign, guiac is negative for blood. Pregnancy test negative. Next steps?

Answer 73

Check prolactin and TSH Can consider MRI of pituitary if prolactin is elevated and/or other signs of pituitary mass

Question 74

Boy under 5 with proximal weakness and bilateral calf enlargement. First thing you should think of?

Answer 74

Duchenne muscular dystrophy

Question 75

What 2 tests confirm the diagnosis of Duschenne muscular dystrophy?

Answer 75

absent dystrophin gene on genetic testing AND undetectable dystrophin protein on muscle biopsy

Question 76

What is the root cause of Duchenne muscular dystrophy?

Answer 76

X-linked recessive deletion of dystrophin gene on chromosome X p21

Question 77

What is the Gower's sign?

Answer 77

Classic finding indicating proximal muscle weakness. Patient has to use own arms to "walk up" their body to standing position (common in Duchenne muscular dystrophy)

Question 78

What is the risk of Benzos in the elderly?

Answer 78

increased risk of: - cognitive impairment - falls - paradoxical agitation

Question 79

risk factors for placental insufficiency?

Answer 79

- advanced maternal age - tobacco use - HTN - Diabetes

Question 80

A biophysical profile is performed to assess fetal oxygenation through ultrasound and a nonstress test. What are the scoring components of the BPP? What is normal?

Answer 80

1 - Nonstress test (want to see reactive HR) 2 - Amniotic Fluid volume (Single fluid pocket >2x1cm or amniotic fluid index >5) 3 - Fetal movements (3+ movements) 4 - Fetal tone (1+ episode of flex/ext of fetal limbs or spine) 5 - Fetal breathing movements (1+ breathing episode for 30+ seconds) Study is 30+ minutes. 2 points are given in each of these categories for a normal result, 0 for abnormal. Max score is 10. 8 or 10 is normal

Question 81

17 yo black male comes into office after en episode of gross hematuria which resolved spontaneously. He has no other complaints or medical problems. Normal physical exam and UA is only significant for blood. Micro examination of urine shows RBCs that are intact with no abnormalities. Most likely cause?

Answer 81

Sickle cell trait leading to Renal Papillary necrosis Hgb AS Renal complications can include painless hematuria, urinary tract infections, and renal medullary cancer

Question 82

What is a quick differential for main causes of gross hematuria?

Answer 82

- Bladder (cystitis, cancer) - Renal (glomerulonephritis) - Ureteral (nephrolithiasis) - Prostate (BPH)

Question 83

Apart from antipscyhotics, what is another good intervention for schizophrenia?

Answer 83

Family counseling and psychoeducation in order to reduce conflict adn stress at home will decrease the risk of relapse.

Question 84

What is HER2 and how can it be detected?

Answer 84

It is an oncogene and can be deteted with immunohistochemical staining or FISH Determining positivity in breast cancer will predict positive response to trastuzumab and anthracycline chemotherapy

Question 85

18 yo woman with primary amenorrhea, sexual infantilism, and clitoromegaly. Laparotomy at 2yo showed normal internal female genitalia. Estradiol and estrone are undetectable. FSH and LH are high. Testeosterone and androstenedione are high. Diagnosis?

Answer 85

Aromatase deficiency Enzyme that converts androgens to estrogens

Question 86

1 day old in nursery born uncomplicated at term. Physical exam shows breast hypertrophy and swollen labia with blood-tinged vaginal discharge. Next step in management?

Answer 86

Routine care without work-up These are normal effects from transplacental exposure to maternal estrogen

Question 87

What are early and late decelerations? Are either concerning?

Answer 87

Decelerations are decreases in fetal heart rate below its baseline. The gradually decrease and then increase back to baseline over a period greater than 30 seconds Early decelerations coincide directly with the increasing and decreasing strength of the uterine contractions. They are caused by vagal stimulation when the head is compressed in the contraction. Late decelerations are shifted so that the peak of contraction occurs at the beginning of the decrease in HR. THe delay occurs because they are caused by hypoxia which constricts blood vessels, leading to HTN and then vagal response of slowed HR. This two step process makes it take longer. Late decels are CONCERNING!!!!!

Question 88

Etiology of late decelerations:

Answer 88

- Excessive uterine contractions - maternal hypotension - maternal hypoxemia - reduced placental exchange (HTN, diabetes, IUGR, abruption)

Question 89

Patient with history of poor feeding in infancy, but now at 4yo currently has binge-eating and obesity problems. Has short stature, hypogonadism, and frequent problems with temper tantrums. What genetic abnormality is causing this diagnosis?

Answer 89

This is Prader-Willi Syndrome Sporadic disorder due to maternal uniparental disomy of chromosome 15q11-q13

Question 90

5 mo old in for well-child. Born uncomplicated at term. Has visited both the ED and clinic previously for inspiratory stridor with little improvement after racemic epinephrine. Feeding well on formula. His inspiratory stridor improves with neck extension, but not prone positioning. No cough or fever. Patient does have 3/4 holosystolic murmur heard best over left lower sternal border. What's going on?

Answer 90

Vascular ring or sling Why? Improves with neck extension is classic. Improvement with positioning would be more laryngomalacia Unlike croup or asthma, respiratory symptoms do not improve with nebulized racemic epi or brocnhodilators Surgery is only tx

Question 91

1st line antihypertensive for pregnancy?

Answer 91

- Methyldopa - Labetolol Also good: - Hydralazine - Nifedipine

Question 92

40 year old patient arrives with a Na of 156, intense thirst, lethargy, and confusion. Turns out she is on Lithium for bipolar. You determine she likely has nephrogenic diabetes insipidus. Her blood pressure is 80/60, HR 122, RR 15. On physical exam you also note that she has very dry skin and mucous membranes. What do you want to do for fluids?

Answer 92

IV NS until euvolemia is achieved, then you can decide to amke the switch to D5W. The reason is because in assessing fluid status we see that this patient is HYPOvolemic AND symptomatic (hemodynamically unstable). If they were euvolemic then we could just use free water. If they were hypovolemic and stable then we might just give D5W.

Question 93

Diabetic patient with severe ear pain radiating to TM joint. On further exam you see otorrhea and granulation tissue in lower external auditory canal... What organism is likely responsible?

Answer 93

Pseudomonas Aerginosa Malignant Otitis Externa

Question 94

Speaking of defense mechanisms: What is the difference between Sublimation and Reaction Formation? Sublimation: Channeling impulses in socially acceptable behavior Reaction Formation: Responding in a manner opposite of one's true feelings

Answer 94

Both might be socially acceptable, but in sublimation the behavior matches the original thought/impulse whereas it is the opposite in reaction formation. For example: A woman is angry and resentful for having to quit her job to take care of an ailing parent who never treated her well. Sublimation: Woman plays paintball in her free time in order to blow off steam Reaction Formation: Is very solicitous to all of parent's needs smiles a big fake smile and says, "Boy it sure is great to have dad back with me again!"

Question 95

Most common conditions in which you see sialadenosis? (swollen salivary glands)

Answer 95

- advanced liver disease | - nutritional disorder

Question 96

1st line tx for Magnesium toxicity?

Answer 96

IV calcium gluconate

Question 97

26 year old male is on anti-retroviral therapy and presents with hematuria. On further analysis urine contains needle-shaped crystals in sediment. Which category of anti-retroviral is causing this problem?

Answer 97

Protease inhibitor Indinavir, a protease inhibitor, has a well-known side effect of crystal induced nephropathy.

Question 98

Polycythemia in term neonates is defined as >65% hematocrit. What symptoms commonly occur?

Answer 98

Respiratory distress, hypoglycemia, and neurological manifestations Also: Ruddy skin, cyanosis, abdominal distention

Question 99

14 yr old boy with 3 week skin rash. Started as red spots on arms and legs which itched and burned. They then filled with clear fluid and some crusted over. Rash located on extensor surfaces of elbows and knees. Diagnosed with type 1 DM five years ago. He has been tired lately and has lost 10 lbs in 4 months. CBC is unremarkable except for some iron deficiency anemia. Fecal occult blood test is negative x2. Next step in management?

Answer 99

This rash is suspicious for Dermatitis Herpeteformis and the overall presentation is suspicious for Celiac Disease. Next step is screening with: Anti-tissue transglutaminase antibody assay Confirmation with: Duodenal biopsy showing increased intraepitheial lymphocytes and flattened villi

Question 100

Most common adverse effect associated with olanzapine?

Answer 100

Weight gain

Question 101

64 year old patient recovering from URI develops mailaise and productive cough. Presents to your ED 2 days later with confusion, severe dyspnea, and coughing copious amount of yellow sputum with blood streaks. Temp is 104, BP 150/90, HR 110. CXR shows infiltrates of lung midfields bilaterally and multiple thin-walled cavities. Most likely causal organism?

Answer 101

Staph Aureus Known to cause 2ndary pneumonia complicating a viral URI AND associated with necrotizing bronchopneumonia resulting in pneumatoceles (which is what we are seeing in this case)

Question 102

Child with fever, dysphagia, inability to extend neck, muffled voice. Lateral XR shows widended prevertebral space. Dx?

Answer 102

Retropharyngeal abscess

Question 103

Refeeding syndrome can occur in individuals with severe anorexia nervosa after initiating feeding. What are the main manifestations?

Answer 103

Arrhythmia and cardiopulmonic failure Insulin release causes cellular uptake of phosphorous, potassium, and magnesium

Question 104

Older patient with renal artery stenosis leading to HTN. How do you manage it?

Answer 104

ACEi's or ARBs Stenting or revscularization is not indicated unless resistant HTN, recurrent pulmonary edema and/or refractory HF from HTN

Question 105

Long term cyclophosphamide carried risk of what primarily?

Answer 105

Acute hemorrhagic cystitis and bladder carcinoma

Question 106

Pregnant patient has pap testing done which shows high grade squamous epithelial lesion. Colposcopy shows no abnormalities. Next step in management?

Answer 106

Repeat cytology and colposcopy are delivery

Question 107

Raloxifene contraindications?

Answer 107

Venous thromboembolism history All medicine with estrogen agonist activity will increase risk of VTE. Raloxifene is an agonist in the bone and an antagonist in the breast and uterus

Question 108

7 year old presents with bleeding in gums for 3 months. Easy fatigability, punding sensation in ears. 5th percentile for height, 25th percentile for weight. Thumbs bent with areas of hypopigmentation of the skin. Labs studies show WBC 3, Hgb 7.5, PLT 40, and MCV 115. What's the likely cause?

Answer 108

Fanconi anemia (caused by chromosomal breaks) Labs are showing aplastic anemia and in kids this is more likely going to be congenital. Macrocytic anemia is common in Fanconi. Hypopigmentation, short stature, and abnormal thumbs are all part of syndrome as well.

Question 109

44 yr old non-pregnant female with tubal ligation presents with abnormal uterine bleeding. She asks how things will go depending on the result. How do you manage results of: Hyperplasia without atypia AND Hyperplasia with atypia

Answer 109

Without Atypia: Progestin therapy to stop the effects of unopposed estrogen and reverse hyperplasia With Atypia: Hysterectomy if they are done having kids OR if they fail progestin therapy

Question 110

6 year old asian patient with high grade fever and brick-red maculopapular rash which started on his face and then spread to trunk and extremities. Parents say before reash patient had cough, tearing eyes, and runny nose. Labs show leukopenia and thrombocytopenia. What is the dx?

Answer 110

Measles

Question 111

32 year old F in labor, on arrival 6cm dilated, 60% effaced, head at 0 station. Fetal heart tracing normal. 2 Hours later patient suddenly appears restless, pelvic exam shows moderate vaginal bleeding, cervix is 6cm dilated, 60% effaced, -3 station. Fetal heart shows tachy w/ variable decelerations. Likely dx?

Answer 111

Uterine rupture Sudden abd pain, recession of presenting part during active labor, and fetal HR abnormalities are red flags for rupture. Risk factors: pre-existing uterine scar (like c-section)

Question 112

Woman in prolonged labor and rupture of membranes. She has a fever and the fetus tachycardic. Likely dx?

Answer 112

Chorioamnionitis

Question 113

Osteoarthritis is most common at which joints?

Answer 113

- large weight bearing joints of lower extremity - lumbar spine - proximal and distal interphalangeal joints (Remember RA is most frequently in MCP joints)

Question 114

More people in Pawnee Indiana seem to have obesity than in Camas Washington. What type of study design should be used to determine if there really is a difference in incidence of obesity between the two towns?

Answer 114

Cohort study

Question 115

50 yr old having diffciulty following solids but not liquids. GERD for 12 years, recently found to have barret's. Barium study shows circumferential narrowing of distal esophagus. Best explanation?

Answer 115

Esophageal stricture

Question 116

What diseases should all pregnant women be screened for regardless of risk factors?

Answer 116

Syphillus, HIV, Hep B

Question 117

How should medications be managed for a pregnant patient who has hypothyroid? She has been a on a stable dose of levothyroxine for many years.

Answer 117

Levothyroxine requirements will increase during pregnancy, so this patient will need to increase their dose when pregnancy is detected. Subsequent adjustments can be made accordingly based on TSH and T4 later.

Question 118

What is the prophylaxis used by HIV+ patients to prevent opportunistic infections by Pneumocystis Jiroveci and Toxoplasma Gondii?

Answer 118

Trimethoprim/Sulfamethoxazole | bactrim

Question 119

36yo nulliparous female presents with syncope at work. Patient on day 10 of menses. Periods have become longer and heavier, but continue at regular 28 day intervals. On oral contraceptives, sexually active with boyfriend only. UPT negative. Hgb is 5.5. Pelvic exam shows irregularly enlarged uterus. Likely cause of anemia?

Answer 119

Uterine fibroids Proliferation of smooth muscle cells within the myometrium Heavy menstrual bleeding is hallmark. Anemia and irregularly enlarged uterus also occur.

Question 120

Most important points in managing mastitis in breastfeeding women?

Answer 120

- Analgesics - Frequent breastfeeding - Antibiotics targeting staph aureus

Question 121

Greatest risk of completing homocide?

Answer 121

Access to firearms

Question 122

Classic presentation of Leukocyte Adhesion Deficiency?

Answer 122

Delated umbilical cord separation, recurrent skin and mucosal bacterial infections, and severe peridontal disease. Usually you also see lots of leukocytosis with TONS of neutrophils

Question 123

20 year old woman evaluated 8 hrs after nomral vaginal delivery. She has fatigue, perineal discomfort, and bloody vaginal discharge. Has voided twice since delivery, but finds it hard to initiate urination. 3rd degree laceration was quickly repaired. After spontaneous placental delivery patient experienced rigors and chills for 30 minutes which resolved. Temp is 100.2, BP 120/80 and pelvic exam shows intact perineal repair, but bloody discharge with small clots on perineal pad. Uterus is firm and fundus at umbilicus. What is the next step in management of this patient?

Answer 123

Normal post-partum care Normal puerperium changes include : - Shivering - Uterine contraction and involution - Lochia

Question 124

Most concerning complications stemming from RSV infection and bronchiolitis in neonates?

Answer 124

Apnea and respiratory failure

Question 125

Big risk factors for abruptio placentae?

Answer 125

cocaine use and HTN

Question 126

Elevated maternal serum alpha-fetoprotein is an indicator of what fetal abnormalities?

Answer 126

- open neural tube defects - gastroschisis - omphalocele - (also multiple gestation) - US should be performed if alpha fetoprotein is elevated

Question 127

Dipyridamole is used during myocardial perfusion scanning to reveal areas of restricted myocardial perfusion. How does this drug work?

Answer 127

Coronary blood blow is redistributed to the non-diseased segments by a phenomenon called "coronary steal." It works because the narrowed ischemic vessels are maximally dilated all of the time. Using a vasodilator like dypridamole causes blood to shunt into the non-ischemic vessels because now they are way bigger than the ischemic ones.

Question 128

Big pieces of diagnosis of congenital adrenal hyperplasia in female?

Answer 128

Hyperandrogenism in adolescence or adulthood Elevated 17-hydroxyprogesterone (usually caused by 21-hydroxylase deficiency)

Question 129

Term for normal age-related sensorineural hearing loss?

Answer 129

presbycusis

Question 130

Fetal demise is suspected and then confirmed in 28 week gestation. Coagulation abnormalities are found in lab results. Fibrinogen and platelet levels are just under normal. Next step?

Answer 130

Labor induction | induce without delay in these patients because these fibr/platelet abnormalities could indicate developing DIC

Question 131

Most common ear pathology in a patient with HIV?

Answer 131

Serous otitis media - caused by auditory tube dysfunction arising from lymphadenopathy or obstructing lymphomas - Characterized by presence of middle ear effusion without evidence of acute infection

Question 132

The vast majority of head and neck cancers are what type?

Answer 132

Squamous cell carcinoma

Question 133

What is the other name for Wilson's Disease?

Answer 133

Hepatolenticular degeneration

Question 134

How do you confirm case of hepatolenticular degeneration?

Answer 134

One of these three: - Low ceruloplasmin - Increased urinary copper excretion - Kayser Fleischer Rings Usually unexplaiend chronic hepatitis in patients under 30

Question 135

65 year old presenting with back pain in lumbar/throracic spine. Worse with activity. Takes OTC Vit D and Ca supplements. 1 year ago had normal physical and lab results. No lymphadenopathy. Cardio/Abd exams normal. NO fical tenderness in spine. Muscle strength 5/5 in all extremities. Labs: Hgb: 10.2, PLT: 220, WBC: 8.8 Na: 138, K: 4.2, Cl: 102, HCO3: 26 BUN: 30, Cr: 2.5, Ca: 10.9, Glu: 118 Urine Dip/Sediment: Negative and bland except a few granular casts. Whats the dx?

Answer 135

Multiple Myeloma Often presents with fatigue, weight loss, or bone pain. Proliferation of neoplastic cells in bone marrow and excessive production of single immunoglobulin. (see bone destruction, hypercalcemia, anemia, monoclonal protein) Monoclonal protein can accumulate at high levels in the serum and deposit in the renal tubules resulting in renal insufficiency. Often has bland UA with granular casts.

Question 136

38 year old male with PMH of DMII presents with nodular lesions under his arm. Have been there for 1 year, but much worse over last 6 months. THey have begun to smell and look like fluctuant tender nodules with subcutaneous fibrosis in the axillae. Dx?

Answer 136

Hydradenitis Suppurativa

Question 137

Treatment for croup in mild cases vs moderate/severe cases:

Answer 137

Mild (no stridor at rest): Corticosteroids (dexamethasone) Mod/Severe (stridor at rest): Corticosteroids AND nebulized epinephrine Corticosteroids reduced airway inflammation and nebbed epi constricts mucosal arterioles in upper airway and alteres capillary hydrostatic pressure to decrease airway edema and reduce secretions

Question 138

How do you treat children with ITP, who aren't actively bleeding?

Answer 138

Observation - usually will resolve in 6 months If they start bleeding then they should get IVIG or glucocorticoids This is different than adults who should be treated with with glucocorticoids or IVIG if they get a platelet count less than 30,000

Question 139

Woman has profound blood loss after MVC. She has emergent surgery and ends up receiving about 7L of blood products and crystalloid. Her Cr is 2.2. What microscopic findings do you expect to see on UA?

Answer 139

Muddy brown casts. Why? Profound hypotension often leads to ATN

Question 140

``` Let's talk HIGH YIELD casts!!!!!!! Muddy brown granular: RBC: WBC Fatty: Broad/Waxy: ```

Answer 140

``` Muddy brown granular: ATN RBC: Glomerulonephritis WBC: Interstitial nephritis and Pyelo Fatty: Nephrotic syndome Broad/Waxy: Chronic renal failure ```

Question 141

What disease can lead to Sicca syndrome? Where everything is dry

Answer 141

Sjogrens

Question 142

1st line medication for enuresis, when behavior modifications and alarm therapy have already failed?

Answer 142

Desmopressin

Question 143

Test used to compare proportions of categorized outcome?

Answer 143

Chi square

Question 144

Risperidone is a second generation antipsychotic. What is it's mechanism of action?

Answer 144

- Serotonin 2A antagonist | - Dopamin D2 Antagonist

Question 145

12 week old child was born outside the US and appeared normal at birth, but is brought in by mother because of changes in the last 3 weeks. Apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and an umbilical hernia. What's going on?

Answer 145

Classic of congenital hypothyroid

Question 146

How do you manage eclampsia?

Answer 146

- Administer Mag Sulfate - Administer anti-hypertensive - Deliver fetus

Question 147

4 year old diagnosed with Pertussis. Her family members are all up to date on vaccinations and have no symptoms. How can risk to household contacts be limited?

Answer 147

Prescribe macrolide antibiotic for all household contacts

Question 148

53 year old has localized R-sided abdominal pain. Lightly touching the skin to the right of the umbilicus causes severe pain. Abdomen is soft, nondistended, without guarding. Patient had breast cancer a year ago followed by radical mastectomy and chemo which she finished 3 weeks ago.. Lung field are clear. What's going on?

Answer 148

Likely shingles from ractivated varicella zoster Triggered by stress of cancer treatment

Question 149

Give 5 features of turner syndrome:

Answer 149

- Loss of X chromosome - bicuspid aortic valve or coarctation - short webbed neck - broad sheft - widely spaced nipples

Question 150

Explain the kind of acid base disturbance that can be cause by Tuberculosis?

Answer 150

Can commonly cause adrenal insufficiency (addison's disease). This then goes on to cause a hyperkalemic hyponatemic metabolic acidosis

Question 151

Lead points for intussusception:

Answer 151

- Meckel's Diverticulum - Henoch Schonlein Purpura - Celiac disease - Intestinal tumor - Polyps

Question 152

Describe levels of AST, ALT, GGT, and ferritin in alcoholic hepatitis:

Answer 152

AST/ALT: elevated but not crazy, AST about 2x as much as ALT GGT: elevated Ferritin: elevated

Question 153

Effective treatment for bipolar depression?

Answer 153

2nd gen antipsychotics like Quetiapine and Lurasidone Also Lamotrigine, Lithium, valproate or a Olanzapine/Fluoxetine combo Remember NO antidepressant monotherapy

Question 154

HIV patient has a subacute cough and a cavitary lesion on CXR. Likely dx?

Answer 154

Tuberculosis reactivation

Question 155

Preeclampsia is defined by new onset HTN > 140/90 and proteinuria or end-organ damage after 20 weeks gestation. What are the manifestations that would identify a patient with severe disease?

Answer 155

- HTN >160/110 - Thrombocytopenia - High Cr - High transaminases - Pulm edema - Visual/Neuro sx

Question 156

Primigrad coman at 26 weeks gestation. Has had very uneventful course, but urine culture shows bactiuria. She is asymptomatic. What complication are you most worried about for this patient?

Answer 156

Progression to pyelo

Question 157

Patient presents with fatigue, exudative pharyngitis, and cervical lymphadenopathy. After taking her mom's leftover amoxicillin, she suddenly develops a full body maculopapular rash. What organism is likely responsible for this infection?

Answer 157

EBV

Question 158

Definitive dx of vesicoureteral reflux made by:

Answer 158

voiding cystourethrogram

Question 159

13 yo male presents with intermeittent knee pain for 3 months. Wrose after basketball, but does not remember any recent trauma. NSAIDs and rest offer relief. Has tenderness and swelling over proximal tibia at site of patellar tendon insertion. NO effusion or abnormality of joint. Pain reporduced with extension of knee against resistance. Likely cause of pain?

Answer 159

Traction apophysitis (AKA Osgood-Schlatter) Common is adolescents. Rapid growth makes quadriceps tendon put ttraction on the apophysis of the tibial tubercle where the patellar tendon inserts) Tx: Activity restriction, stretching, NSAIDs

Question 160

Contraindication of rotavirus vaccine for kids?

Answer 160

History of inussusception

Question 161

Most effective post-coital contraceptive?

Answer 161

Copper IUD insertion Remember though that contraindicated in PID

Question 162

13 day old infatn presents with mild swelling of both eyelids and conjunctival injection. Scant mucopurulent discharge is noted. Rest of exam normal. After sending sample to lab, what is the next step in management?

Answer 162

Administer oral erythromycin Probably neonatal chlamydial conjunctivitis - occurs at 5-14 days of life and presents with swelling, chemosis, and watery or mucopurulent discharge Remember that topical is best for prophylaxis of gonococcal conjunctivitis and would not be effective for chlamydial infection

Question 163

You remember that amiodarone can cause pulm toxicity. What are the other big side effects to this drug?

Answer 163

Thyroid dysfunction Hepatotoxicity Cornal deposits Skin changes (blue)

Question 164

Characteristic ECG findings in wolf-parkinson-white?

Answer 164

- Short PR interval - Delta wave (slurred upstroke of QRS) - Widened QRS

Question 165

60 yr old woman has fever, cough productive of foul-smelling sputum. 1 week ago had EGD for GERD sx. What are you worried about?

Answer 165

Anaerobic lung infection Think clinda, metronidazole+amoxicillin, or amoxicillin/clav.

Question 166

42 yearold olf with skin rash and hair loss. PMH of many years of Crohn's disease s/p resection leading to short bowel. Currently on TPN. Complains that food no longer tastes good. Stable vitals. Exam shows alopecia and bullous, pustular lesions around perioral and periorbital areas. Nutritional deficiency in what is leadign to this presentation?

Answer 166

Zinc Alopecia, abnormal taste, bullous/pustular lesion surrounding orifices, impaired wound healing

Question 167

Guillain Barre is an acute or subacute ascednign flaccid paralysis often occurring after URI or diarrheal illness. What does the CSF look like?

Answer 167

Elevated protein level with normal cell count and normal glucose.

Question 168

29 year old with severe HTN and signs of LV hypertrophy. What do you need to check for?

Answer 168

Coarctation of the Aorta

Question 169

How do antipsychotics cause infertility?

Answer 169

Block Dopamine D2 receptors not only in CNS, but ALSO in the tuberoinfundibular pathway. When DA is blocked here it increases the production of Prolactin. This can lead to galactorrhea, menstrual irregularity, and infertility.

Question 170

Which antipsychotics most likely to cause infertility?

Answer 170

high potency 1st gen (haloperidol, fluphenazine) and second gen risperidone

Question 171

Man with lymphoma shows evidence of nephrotic syndrome. Dx?

Answer 171

Minimal change disease

Question 172

African American heroine user shows signs of nephrotic syndrome. Dx?

Answer 172

Focal segmental glomerulosclerosis

Question 173

Treatment for incidentally found endometriosis. No sx. | ?

Answer 173

No treatment necessary without symptoms IF symptomatic - NSAIDS, oral contraceptives, or a progesterone IUD

Question 174

Best strategy to reduce transmission of HIV to infant with HIV+ mother?

Answer 174

Combination antiretrivral therapy for mom (HAART). | Then neonatal Zidovudine for the infant.

Question 175

15 year old male presents with epistaxis and is found to have a small right-sided mass at the back of the left nostril. His septum is intact. CT scan reveal erosion of adjacent bone. What should you think of?

Answer 175

Angiofibroma

Question 176

12 year old sickle cell patient with 2 hr right-sided arm weakness and slurred speech. He takes hydroxyurea, oxycodone PRN, and floic acid. Vital relatively stable. CT shows no intracranial bleed. Next best step in management?

Answer 176

Exchange transfusion This may not reverse changes from initial vascular event, but will help decrease % of sickle cells in the bloodstream and makes additional strokes less likely.

Question 177

Type of incontinence stemming from multiparity?

Answer 177

Stress urinary incontinency. Loss of urine with increased intraabdominal pressure High parity weakens urethral support and leads to urethral hypermobility

Question 178

32 year old woman is showing all the signs of CHF following a viral illness. What's the dx? What will you see on echocardiogram?

Answer 178

Sounds like dilated cardiomyopathy secondary to acute viral myocarditis. Echo is going to show dilated ventricles and diffuse hypokinesia resulting in low systolic ejection fraction. Management basically supportive.

Question 179

7 year old presents with malaise and headache after camping trip. Red ring rash is apparent on right thing. Treatment?

Answer 179

Lyme disease. Treat with amoxicillin. Normally tx is doxycycline, but that is contraindicated in children and pregnant women. Can cause enamel hypoplasia/teeth staining in kids and slow bone development in fetuses.

Question 180

MOst important first step for patient who appears to be symptomatic from severe hypercalcemia?

Answer 180

Aggressive normal saline infusion

Question 181

23 year old with infertility. Appears to be related to stress and overexercise. What would be your first line to improve her anovulation?

Answer 181

1st: cut down on stress/exercise. If that doesn't work: Pulsatile GnRH therapy

Question 182

Single episode of major despressive epsisode. Treat with SSRI for how long? Recurrent or severe MDD?

Answer 182

4-9 months Recurrent/severe: 1-3 years or indefinitely

Question 183

Patient with multiple liver masses. You are assuming this is cancer. Most likely primary? secondary? from where?

Answer 183

Most likely metastatic disease. Most commonly from GI tract, lung, and breast.

Question 184

16 year old female with history of very irregular periods. Currently having abnormal uterine bleeding. SHe is hemodynamically stable. Management?

Answer 184

Hormone treatment is 1st-line in this case, including estrogen, combo pills, or progesterone. Most common cause of abnormal uterine bleeds in adolescents is annovulation from immature hypothalamuc-pituitary-ovarian axis. Without ovulation, the endometrium builds up for way too long. Tranexamic acid can be used if hormonal therapy cannot be used.

Question 185

MS patient with internuclear opthalmoplegia bilaterally. This results to damage to what structure?

Answer 185

Medial longitudinal fasciculus

Question 186

Most important side effects to monitor in Olanzapine and Clozapine?

Answer 186

Metabolic syndrome Monitor fasting glucose and lipids

Question 187

Labs that should be tested when a patient has suspicious symptoms for normal menopause, but you want to make sure it isn't an overlapping disorder?

Answer 187

TSH and FSH levels should be tested as Hyperthyroidism can have overlapping symptoms

Question 188

Potential complications of uncontrolled maternal hyperglycemia?

Answer 188

- congenital malformations (heart, neural tube, small L colon) - macrosomia - neonatal hypoglycemia - Polycythemia

Question 189

Infant has low birth weight, tachycardia, flushed skin, and irritability. Mother has hx of Grave's disease. Diagnosis? Tx?

Answer 189

Thyrotoxicosis (Due to transplacental maternal TSH receptor antibodies) Tx: Short-term Methimazole and a beta-blocker

Question 190

17 year old male with left shoudler pain and swelling. X-ray shows sunburst periosteal reaction. Dx?

Answer 190

Osteosarcoma

Question 191

18 year old patient with left flank pain radiating to the groin. He says he has had these issues with stone passage many times before. It has happened since childhood and two of his uncles have the same issues. UA shows hexagonal crystals and is posistive on cyanide nitroprusside test. Likely pathogenesis of this issue?

Answer 191

Amino acid transport abnormality | defective transport of dibasic amino acids by the brush borders of renal tubular and intestinal epithelial cells

Question 192

Patient is showing all the classic signs of Vit B-12 deficiency (macrocytic anemia, glossitis, neuro changes) and you suspect pernicious anemia. What long term complications should this patient be monitored for?

Answer 192

Gastric cancer | Risk increases 2-3x in this population

Question 193

How does oral estrogen affect patients on oral thyroid replacement therapy?

Answer 193

Oral estrogen increase thyroxine-binding globulin (TBG). Patients on estrogen will thus need higher doses of thyroid replacement in order to saturate the increased number of TBG sites.

Question 194

Mechanism by which octreotide helps with bleeding esophageal varices?

Answer 194

Inhibit the release of vasodilator hormones which indirectly vasoconstricts splanchnics and decreases portal flow

Question 195

3 important peices of management in bleeding esophageal varices?

Answer 195

1 - Vol resuscitation 2 - Prophylactic abx (ceftriaxone) 3 - Somatostatin analogue (octreotide)

Question 196

2 days after starting citalopram and risperidone. Patient develops fever to 103, blood pressure of 16.80, pulse of 118, and mental confusion. On exam he has severe muscle stiffness without myoclonus or hyperreflexia. Dx?

Answer 196

Neuroleptic Malignant Syndrome A life-threatening condition associated with the use of antipsychotics. Generally see delirium, high fever, autonomic instability, severe rigidity, elevated Creatinine kinase, and leukocytosis

Question 197

How should vaccines be administed to pre-term infants?

Answer 197

According to chronological age. EXCEPTION: Must be over 2kg before the first HepB vaccine

Question 198

23 year old woamn presents with right foot pain starting 6 weeks ago. NO trauma or inciting event, but keeping her from doing normal exercise. Runs and hikes normally. Exam shows clicking sensation when 3rd and 4th metatarsal heads are squeezed together. This also produces pain in the plantar surface. Dx?

Answer 198

Morton's Neuroma Mechanically induced degenerative neuropathy. Causes numbness, aching, and burning of distal forefoot from metatarsal heads to third and fourth toes. Tx is conservative

Question 199

Patient with hyperparathyroid and chronic hypercalcemia. What is the cause of her acute painful monoarthritis? Findings on x-ray?

Answer 199

Pseudogout! See calcification of articular cartilage on XR (chrondrocalcinosis)

Question 200

Primidone is used to treat what condition most often? | Feared side effect?

Answer 200

Benign essential tremor | Acute intermittent porphyria so watch out for abdominal pain and neuro/psych abnormalities

Question 201

53 yo patient w/ no PMH of skin disease presents with strange itchy rash on left breast. Eczematous plaque on left nipple and areola. What condition is associated with this finding?

Answer 201

Mammary Paget Disease Likely underlying Adenocarcinoma

Question 202

Patient with a recent stroke is experiencing a central post-stroke pain syndrome. AKA: Contralateral sensory loss involving all sensory modalities then develops into a condition characterized by severe paroxysmal burning pain over the affect area. Classically allodynia (exacerbation by light touch. What kind fo stroke makes the most sense in this case?

Answer 202

Lacunar stroke to the thalamus often presents in this way

Question 203

30 yr old caucasian female with Rheum arthritis. Improved in her symptoms over past year. Lab studies, however show a macrocytic anemia. Likely medication?

Answer 203

Methotrexate. Methotrexate inhibits DHFR and macrocytic anemia is a common side effect

Question 204

1 year old with growth delays, recurrent respiratory infections, nose bleeds, and greasy, stinky stools. What is leading to the steatorrhea? The nosebleeds?

Answer 204

Kid probably has cystic fibrosis. Pancreatic enzyme deficiency is causing the steatorrhea as well as fat soluble vitamin malabsorption. Lack of Vit K leads to prolonged INR and easy bleeding.

Question 205

Post-partum patient with PMH of depression, off SSRI's presents with hypotension, inability to breastfeed, weigh t loss, and fatigue. Patient 5 mos ago gave birth to twins, complicated by uterine atony and hemorrhage. Primary cause of patient's symptoms?

Answer 205

Sheehan Syndrome Ischemic infarction and necrosis of anterior pituitary. Rare but severe complication of massive obstetric hemorrhage

Question 206

3 mo old jewish infant is lethargic with doll-like face with fat cheeks, thin extremities, protuberant abdomen, with palpable liver. Hypoglycemic, lactic acidosis, hyperuricemia, hyperlipidemia. What is the inherited problem?

Answer 206

Glucose-6-phosphatase deficiency

Question 207

Bed-wetting is normal until what age? | As in before then you should tell parents to just relax for a while.

Answer 207

5 yo | especially boys take longer

Question 208

2 prefered tx for absence seizures?

Answer 208

ethosuximide | valproate

Question 209

Multiple small groups ulcers on the genitals. Painful, with tender lymph nodes. Cause?

Answer 209

Herpes Simplex Virus

Question 210

Single, well circumscribed painless ulcer on the genitals. Non-tender lymph nodes. Cause?

Answer 210

Syphillis

Question 211

What is the mechanism by which acyclovir, sulfonamides, methotrexate, ethylene glycol, and protease inhibitors cause kidney injury?

Answer 211

crystal-induced kidney injury Drug is excreted by kidney into urine, but has low solubility, so it precipitates in the renal tubules. This causes obstruction of the tubules and direct renal tubular toxicity. Discontinue drug and replete volume to treat. OR give drug with more fluid to avoid this problem.

Question 212

Sypillis treatment for severely allergic patient? | Pregnant allergic patient?

Answer 212

Allergic: Oral doxycycline Prego+allergic: Desensitize and then penicillin

Question 213

50 year old man with long hx of joint pain in small joints of hands. Symptoms are wrose in the morning and last several hours. Fingers are sausage-like with rough-looking and pitted. Red plaques with silvery scaling are also seen. Dx?

Answer 213

Psoriatic Arthritis

Question 214

32 year old man presents at 2am for severe pain behind the left eye waking him from sleep. Pain is stabbing and intense. No fever/chills, changes in vision, or N/V. Vitals stable. Exam remarkable only for left sided ptosis and miosis. Likely dx?

Answer 214

Cluster headache Apparently can have ipsilateral eye redness, tearing as well as runny nose and ipsilateral horner's syndrome Often occur every day in clusters for 6-8 weeks with up to 1 year remissions in between

Question 215

Management of cluster headaches

Answer 215

Prophylaxis with verapimil, lithium and ergotamine Acute attack tx is 100% Oxygen and SubQ Sumatriptan

Question 216

What UA and urine microscopy abnormalities would make you suspicious of rhabdomyolysis? (Other than acute renal failure)

Answer 216

Large amount of blood on UA with a relative absence of RBC's on urine microscopy (Myoglobinuria is the likely cause behind this)

Question 217

Squamous Cell carcinoma vs basal cel carcinoma?

Answer 217

SCC forms enlarging nodule in sun-exposed areas than becomes keratinized, and can ulcerate with crusting and bleeding BCC presents as a pearly, fleshy or pink-colored nodule with telangiectatic vessels.

Question 218

You suspect a patient has Parkinson's. What are the typical CT findings in these patients?

Answer 218

Atrophy of the caudate nucleus

Question 219

Patient with recurrent skin abscesses and recent pulmonary abscess. You suspect an immunodeficiency syndrome. What syndrome is likely present? What test can be done to confirm this suspicion?

Answer 219

Chronic Granulomatous Disease (impaired killing by phagocytes) Dx made with neutrophil function testing: Dihydrodamine 123 or nitroblue tetrazolium testing

Question 220

Transient synovitis is most most cause of hip pain in children. What signs and symptoms would actually make you suspicious for septic hip? How are the two managed differently?

Answer 220

Septic Arthritis: - Fever over 101 - Can't bear weight - WBC > 12 - ESR > 40 - CRP > 2 Transient synovitis Tx: Rest and ibuprofen Septic Arthritis: Arthrocentesis and IV antibiotics

Question 221

Neonate is born to mother with preeclampsia with webbed neck, horseshoe kidney, nail dysplasia and carpal/pedal edema. What is the likely cause of the edema?

Answer 221

This sounds like Turner's syndrome. Congenital lymphedema occurs due to abnormal development of lymphatic system

Question 222

27 year old woman is showing all the signs of excess testosterone for the last 2 months. Ultrasound shows left adrenal mass. Which hormone is MOST specific for her condition?

Answer 222

DHEA-S This hormone specifically is elevated in androgen-producing adrenal tumors. DHEA and testosterone are actually produced by the ovaries and adrenal glands, whereas DHEA-S is only produced in adrenals

Question 223

Interventions in warfarin-induced bleeding?

Answer 223

- Vit K - Prothrombin-complex concentrate - Fresh Frozen Plasma (If PCC not available)

Question 224

YOu are evaluating an 8-year-old with precocious puberty. What genetic syndrome should cross your mind? What other signs would point to this diagnosis?

Answer 224

McCune Albright Syndrome - Precocious Puberty - Cafe Au Lait spots - Multiple bone defects (Polyostotic Fibrous Dysplasia)

Question 225

Biggest causes of neonatal sepsis. Two.

Answer 225

Group B strep | E Coli

Question 226

46 yo patient undergoing elective hernia repair. PMH significant for frequent HA's, HTN, and anxiety disorder. AFter induction of anesthesia, patient becomes pale and tachycardic. Blood pressure rises from 144/90 to 250/140. ECG shows sinus tachy without ischemia. Likely dx?

Answer 226

Pheochromocytoma Paroxysms of severe HTN in Pheos can be precipitated by surgical procedures, anesthesia, and medications.

Question 227

Newborn with low-set ears, micrognathia, cleft palate, and absent thymus. Ehco shows truncus arteriosus. What is the dx? What electrolyte abnormality should you evaluate for?

Answer 227

DiGeorge Syndrome (22q11 deletion) Hypocalcemia can be life-threatening

Question 228

When to suspect DiGeorge disease?

Answer 228

(suspect DiGeorge in setting of craniofacial anomalies, thymic dysplasia, and congenital heart disease)

Question 229

Patient with recent diarrheal illness and leukocytosis >50 with marked neutrophilia. Leukocyte alkaline phosphatase score is high. What 2 diagnoses do you think of with neutrophilic leukocytosis. What does the LAP score point to?

Answer 229

CML vs Leukemoid Reaction High LAP points to Leukemoid reaction

Question 230

1st line antibiotics for asymptomatic bactiuria in pregnancy?

Answer 230

Amoxicillin Nitrofurantoin Cephalexin

Question 231

Which type of immunological response is responsible for contact dermatitis?

Answer 231

T-cell and macrophage mediated

Question 232

What type of immunological response mediates anaphylaxis and urticaria?

Answer 232

IgE-mediated

Question 233

4yo girl presents with seizures. You note a flat red lesion covering the area around her left eye and nearby facial skin. It does not blanch and parents say it's been there since birth. Other findings include hemiparesis, hemianopia, and hemisensory disturbance. Skulls XR shows tramline intracranial calcifications. Dx?

Answer 233

Sturge Weber Syndrome

Question 234

shoulder dislocation occurring after seizures?

Answer 234

posterior shoulder dislocation

Question 235

Cutoff in weeks between preeclampsia and primary HTN?

Answer 235

20 weeks.

Question 236

Risks of HTN in pregnancy?

Answer 236

- superimposed preeclampsia - abruptio placentae - fetal growth restriction - pre-term labor - stillbirth

Question 237

In addition to vaccines of normal population, what additional vaccines should HIV patients receive?

Answer 237

- PCV13 and PPSV23 ever 5 years | - Hep A and HepB unless documented immunity

Question 238

Most likely knee injury in a young athlete after quick directional change followed by pain, rapid swelling, and hemarthrosis?

Answer 238

ACL injury

Question 239

Remember that gross parasite infection Enterobius Vermicularis. The one where you use tape to identify perianal eggs... How do you treat it?

Answer 239

Albendazole! | or Pyrantel Pamoate

Question 240

What is the pathogenesis ofhemophilic arthropathy? AKA joint problems after having recurrent hemarthrosis from genetic problem or something like that?

Answer 240

Hemosiderin deposition leads to synovitis and fibrosis within the joint

Question 241

40 year old woman at 35 wks gestation and PMH of spontaneous preterm labor. Presents today with uterine contractions 6 hours ago. Vitals are stable, cervix is closed on exam. US confirms fetal weight at 35 weeks in vertex presentation. Fetal heart tracing is normal and tocometry shows irregualr uterine contractions. Next step in management?

Answer 241

Reassurance and discharge home, patient experiencing false labor despite hx of preterm labor in past. False labor has irregular, mild contractions. They will ultimately resolve and cause no cervical change

Question 242

Mix phenelzine, some heavy sauces, and red wine and you could end up with:

Answer 242

Hypertensive crisis Avoid mixing MAO inhibitors with tyramine-rich foods

Question 243

treatment of choice for fight-bites?

Answer 243

Amoxicillin-Clavulanate

Question 244

Explain FSH levels in a patient with Turner;s syndrome:

Answer 244

Likely they will be high. OFten they have ovarian dysgenesis and poor ovarian function. This leads to poor neagtive feedback and elevation of FSH

Question 245

Patient with ulcerative collitis hx complains of sunburn-type rash and watery diarrhea. No neurological signs, stable vitals. What vitamin deficiency is likely causing this presentation?

Answer 245

This is Pellagra, caused by Niacin (Vit B3) Diarrhea Dermatitis Dementia

Question 246

How is elevated Prolactin different when caused by antipsychotics vs prolactinomas?

Answer 246

Tend to be a lot higher in Prolactinomas. Like over 200.

Question 247

Management for restless leg?

Answer 247

- Iron supplementation for iron deficiency - Conservative measures - Dopamine agonists - Gabapentin

Question 248

Group home resident with PMH of Schizophrenia treated with antipsychotics becomes incresingly restless after dose increase. He spends all day wadnering around the neighborhood and gets aggressive if staff try to keep him inside. What would you call this symptom? How would you manage?

Answer 248

Akathisia Manage: lower antipsychotic dose and use propanolol or lorazepam

Question 249

Vasovagal syncope is usually a clinical diangosis, but if further testing is needed, what test can establish the dx?

Answer 249

Upright tilt table testing

Question 250

10 yr old boy with abdominal pain and bloody diarrhea. He appears pale and jaundiced. Abdominal tenderness and 2+ pedal edema present. Labs show anemia, thrombocytopenia, and renal insufficiency. Most likely organism causing presentation?

Answer 250

E coli O157:H7

Question 251

Tamoxifen is associated with increase risk of what cancer?

Answer 251

endometrial cancer Also hot flashes are the most common side effect

Question 252

Difference between schizotypal and schizoid?

Answer 252

Schizotypal: Odd thoughts, behaviors and perceptions. Eccentric Schizoid: Prefers to be loner. Detached and unemotional

Question 253

You are suspecting acute rejection in a patient that just underwent renal transplantation. Next most appropriate step in management?

Answer 253

IV steroids

Question 254

Treatment of choice for non-bullous impetigo of with relatively limited skin involvement:

Answer 254

Topical abx like Mupirocin

Question 255

YOu are treating a patient with active Tb using Isoniazid, Rifampin, Ethanmbutol, and Pyrazinamide. One month later her symptoms have improved a lot. Labs show mild aminotransferase elevation. What med is causing this? Management going forward?

Answer 255

Isoniazid: self-limited hepatic injury NO changes necessary with intervention. aminotrasnferase elevation will resolve on its own

Question 256

What drugs other than warfarin can be used to prevent thromboembolism risk in patients with A-fib?

Answer 256

Apixiban, Dabigatran, rivaroxaban

Question 257

Major depressive disorder in elderly patient presenting with memory loss:

Answer 257

Pseudodementia

Question 258

47 year old male presents with sudden onset chest pain and diaphoresis. While waiting for EMS to arrive he complains of dizziness and then becomes unresponsive. Coworkers begin resuscitation immediately and he regains consciousness 2 minutes later. In the ED ECG shows noral sinus rhythm with PVCs and ST elevation. in leads v1-v3. This patient has an MI, but what was the likely mechanism leading to the syncopal episode?

Answer 258

Reentrant ventricular arrythmia | - The most common cause of sudden cardiac arrest in the immediate post-infarction period in patients with acute MI

Question 259

What week of gestation is the cut-off for when intervention is indicated for a breech presentation?

Answer 259

37th week of gestation If a cephalic version fails, the plan a cesarean delivery

Question 260

When a man gets gynecomastia and sexual dysfunction from a drug like risperidone, what neurotransmitter is acting on which pathway?

Answer 260

Antipsychotics cause hyperprolactinemia by blocking dopamine activity in the tuberoinfundibular pathway. This can then cause amenorrhea, galactorrhea, gynecomastia, and sexual dysfunction

Question 261

Which dopamine pathway accounts for the efficacy of antipsychotics? Which dopamine pathway casues the extrapyramidal side effects like dystonia, akathisia, and parkinsonism?

Answer 261

Mesolimbic: Antipsychotic efficacy Nigrostriatal: Extrapyramidal side effects

Question 262

Best screening test for fetal aneuploidy?

Answer 262

Cell-free fetal DNA testing | (cffDNA) of maternal plasma

Question 263

55 yo patient has facial swelling, BLT LE edema, and massive proteinuria. You diagnosie this as nephrotic syndrome. Patient also has palpable kidneys, hepatomegaly, and a 4th heart sound. PMH of recurrent pulmonary infections from bronchiectasis. Most likely diagnosis of this patient?

Answer 263

Secondary amyloidosis as a complication of chronic inflammatory condition. This appears to be leading to multi-organ dysfunction

Question 264

35 yo male with BLT gynecomastia. Genital exam shows 1cm nodule in R testis. Otherwise, normal exam and no current drug, alcohol, or medication use. Labs show low LH and FSH, very high testosterone, and very high estradiol. Beta-HCG and AFP are undetectable. What type of tumor is this?

Answer 264

Leydig cell tumor! Leydig cells are principle source fo testosterone and capable of estrogen production too with seconary inhibition of LH and FSH.

Question 265

62 year old man with sidden onset eye pain and redness in left eye. Photophobia, nausea, and severe headache present. No trauma, first time it's happened. Recently had cold and used over the counter docongestant. Exam shows non-reactive mid-dilated left pupil. Dx? Next step in evaluation?

Answer 265

Acute angle-closure glaucoma Call the opthamologist. Gonioscopy is gold standard test, ocular tonometry can also be helpful

Question 266

Medication for herpes zoster?

Answer 266

Acyclovir And other antivirals can be used to decrease duration and incident of post-herpetic neuralgia

Question 267

Genetic disorder often associated with HIrschsprungs?

Answer 267

Down Syndrome

Question 268

PAtient with abrupt-onset retrosternal pain and severe odynophagia. EGD shows discrete ulcer in mid-esophagus with normal surrounding mucosa. Dx?

Answer 268

Pill esophagitis

Question 269

38 yo woman with +HIV test today presents with 7 days of fatigue and worsening headache. 1 episode of vomiting. Fever of 101 and supple neck. No focal neuro deficits. Brain MRI is normal. Exam shows bilateral papilledema. Most likely dx? Tx?

Answer 269

Cryptococcal meningitis Tx: Amphotericin B with flucytosine then Fluconazole maintenace

Question 270

What kind f physical exam maneuvers increase the preload? | Decrease the preload?

Answer 270

Increase: Squatting, leg raise, hand grip Decrease: Valsalva, abrupt standing, amyl nitrate

Question 271

Atrial fibrillation is most commonly caused by ectopic foci where? How about A-flutter?

Answer 271

A-fib: Within the pulmonary veins A-flutter: Reentrant circuit around tricuspid annulus

Question 272

What is the MOST accurate way to estimate gestational age?

Answer 272

Ultrasound dating in the 1st trimester EGA should not be changed based on discrepancies on a 2nd or 3rd trimester US

Question 273

12 year old patient with back pain and new urinary incontinence at night. On physical exam there is a "step-off" at the lumbosacral area. Dx?

Answer 273

Spondylolosthesis Developmental disorder characterized by forward slip of vertebrae in preadolescent children. (Usually L5 over S1)

Question 274

2 weeks after MI patient is worried about another heart attack. He has chest pain that is worse with deep inspiration that seems to improve with leaning forward. EKG shows diffuse ST elevation except in RVR which shows ST depression. What is the dx? How do you tx?

Answer 274

Dressler's Syndrome NSAIDs are tx of choice DO NOT anticoagulate - want to acoid hemorrhagic pericaridal effusion

Question 275

AFter positive bx for gastric adenocarcinoma what is the next step in management?

Answer 275

YOu want to do a CT ab/pelvis for staging

Question 276

Patient being treated with breast cancer is urged to not get pregnant. Best contraception for her?

Answer 276

ALL HORMONAL CONTRAINDICATED! No OCP, no progesterone IUD, etc. Best method is probably a copper IUD in this case

Question 277

33 yo woman iwth sudden dysnea and right-sided chest pain started 3 hours ago suddenly. She was just DC'd from hospital after c-section. BP 100/70, afebrile, pulse 128, RR 32. Pulse ox 88% on RA. Chest clear to auscultation, CXR shows no infiltrates and has normal heart size. ECG shows sinus tachy. Patient in moderate distress with accessory muscle use. ABG shows respiratory alkalosis. Next step in management?

Answer 277

IV heparin NOW You might think you want to do a CT angio first, but you're goign to want to give heparin first because this is so likely a PE

Question 278

Cyclical vomiting syndrome. What is the family hx that makes this dx more likely?

Answer 278

Fam hx of migraines

Question 279

Name the type of head swelling a a baby gets a few hours after birth. Scalp swelling that is limited to one cranial bone. Tx?

Answer 279

Cephalohematoma Most don't require tx, will resorb spontaneously within 2 to 3 months - depending on size

Question 280

Most common cause of urinary tract obstruction in newborn boys?

Answer 280

Posterior Urtethral Valves

Question 281

Characeristics of Neurofibromatosis type 1 INFANT?

Answer 281

cafe au lait spots, macrocephaly, feeding problems, short stature, learning disabilities

Question 282

Newborn infant with jaundice, light colored stool, hepatomegaly. Labs show conjugated hyperbilirubinemia. Should immediately evaluate for what dx?

Answer 282

Biliary Atresia

Question 283

What is the initial treatment for infant with biliary atresia?

Answer 283

Kasai procedure Almost all kids will require liver transplant eventually, but this procedure buys time and reduces morbidity and mortality

Question 284

Prego patient w/ hx of recurrent sore throats at a young age where she grew up in India. Now has new onset afib with RVR. Has cough, dyspnea, and orthopnea. Most likely diagnosis leading to these new heart symptoms?

Answer 284

Rheumatic mitral stenosis

Question 285

Warfarin inhibits synthesis of what factors?

Answer 285

2, 7, 9, 10, Prot C, Prot S

Question 286

Preferred initial treatment for tinea capitis?

Answer 286

Oral Griseofulvin

Question 287

37 yo F patient is worked up and found to have symptomactic prolactinoma. What should she be treated with initially?

Answer 287

Dopamine agonist (Cabergoline, bromocriptine) These can lower prolactin levels and decrease tumor size

Question 288

57 yar old woman on chemo for Hodgkin Lymphoma. She develops severe N/V and malaise with stable vitals. Best management for her chemo-induced N/V?

Answer 288

Serotonin antagonist | ondansetron

Question 289

Patient has hematuria. Describes stream as starting transparent, but then ending red by the end of the stream. Has also noticed small clots in urine. Dx?

Answer 289

Bladder or prostatic damage Initial hematuria would suggest urethral damage. Total hematuria represents kidney/ureter damage.

Question 290

Patient with asymptomatic hypercalcemia found on employer health serum screening. Patient has high normal parathyroid hormone and a low urinary calcium excretion. Dx?

Answer 290

Familial hypocalciuric hypercalcemia In this disorder higher Ca concentrations are required to suppress PTH. Also there is increased reabsorption of Ca in renal tubules. Both are caused by a mutation in the Ca sensing receptor

Question 291

Risk factors for placetna accreta?

Answer 291

- prior c section - hx of dilation/curetage - advanced maternal age

Question 292

Name of the plan B pill?

Answer 292

Oral levonorgestrel Remember that the copper IUD is most effective emergency contraception

Question 293

Different medications are used in Cancer-related anorexia/cachexia syndrome VS HIV-related cachexia. What drugs should you use in either case?

Answer 293

HIV Cachexia: Synthetic cannabinoids are useful here CACS: Progesterone analogues like Megestrol acetate and medroxyprogesterone acetate

Question 294

Most common organisms responsible for epiglottitis?

Answer 294

H Flu and Strep Pyogenes

Question 295

What kind of drug is Mirtazapine?

Answer 295

Brand name is Remeron Atypical antidepressant Noadrenergic and specific serotonergic activity Can cause drowsiness and increased appetite which could be good depending on the activity

Question 296

7 year old girl presents with breast development, increased growth, pubic hair, odorless vaginal discharge, and a pelvic mass. US confirms right ovarian mass. Likely type of tumor? How would it present in a post-menopausal woman?

Answer 296

Granulosa cell tumor This is a malignant estrogen-secreting tumor In a post-menopausal woman this is going to present with bleeding and endometrial hyperplasia

Question 297

How would you differentiate gonococcal conjuncitivits vs chlamydial conjunctivitis in a newborn?

Answer 297

Gonocccal: 2-5 days after birth, copious ocular drainage Chlamydia Trachomatis: 5-14 days after birth, milder

Question 298

Pregnant woman presenting with intesne pruritus, esp of palms and soles. Labs show elevated aminotasnferases and elevated bile acids. Dx?

Answer 298

Intrhepatic cholestasis of pregnancy

Question 299

74 year old immigrant with 2 very important diagnostic clues: 1) IgM spike on electrophoresis 2) Blood is hyperviscous Dx?

Answer 299

Waldenstrom's Macroglobulinemia

Question 300

Pulsus Paradoxus is an exaggerated fall in systemic blood pressure during inspiration. It can be caused in tamponade. What other conditions can cause it?

Answer 300

Severe astham or COPD

Question 301

Explain the patho-phys for uterine atony:

Answer 301

Most common cause of post-partum hemorrhage. Results from failure of the uterus to contract and compress the placental site blood vessels. Presents with profuse vaginal bleeding and a soft, enlarged uterus

Question 302

Risk factors for uterine atony?

Answer 302

- prolonged labor - induction of labor - operative vaginal delivery - Fetal weight > 8.8 lbs

Question 303

Treatment for uterine atony?

Answer 303

- bimanual uterine massage | - uterotonic agents like oxytocin

Question 304

Patient on multiple medications just developed angioedema. What common drug is a very likely culprit?

Answer 304

ACE inhibitors

Question 305

Treatment for woman with breast tenderness/engorgement after rapid cessation of breastfeeding?

Answer 305

- NSAIDs and ice packs for pain - supportive (not tight) bra - avoid nipple stimulation

Question 306

Long-term side effects of lithium?

Answer 306

- Nephrogenic diabetes insipidus - Hyperparathyroid with hypercalcemia - Thyroid Dysfunction

Question 307

Normal kidney physiology changes in pregnancy?

Answer 307

GFR and renal blood flow both increase AS a result, serum BUN and creatinine will both decrease. Renal protein excretion increases.

Question 308

Toxoplasmosis is a common infection in AIDS pateints. | Prophylaxis vs normal treatment regimen?

Answer 308

PPX: Trimethoprim + Sulfamethoxazole TX: Sulfadiazine + Pyrimethamine

Question 309

Most important risk factor in cerebral palsy?

Answer 309

PREMATURITY

Question 310

Infant with failure to thrive and ABG shows metabolic acidosis. NO symptoms of diarrhea. Akalotic urine. Dx?

Answer 310

Likely this is RTA (Renal Tubular Acidosis)

Question 311

23 year old woman presnts with leg edema, fatigue, chest pain and joint pain for 3 months. 10 lbs weight loss. Both wrists are tender. 2+ pretibial edema. Vitals are all stable. 2+ protein in urine. Dx? Tests to confirm?

Answer 311

Looks like SLE. Use Antinuclear antibody for screen. Confirm with Anti-DS-DNA or Anti-Smith

Question 312

Patient presents with fevers/chills, left upper quadrant abdominal pain (US shows splenic fluid collection), and left-sided pleuritic pain. Also has decreased breath sounds on LLL field and splenomegaly. Cardiac exam shows 2/6 systolic murmur at the apex. WBC of 27,000, HGB 13, PLT 250. Dx?

Answer 312

Infective endocarditis and splenic abscess (they are often associated with each other) Splenic abscess (triad of fever, WBC, LUQ abdominal pain)

Question 313

13 year old girl discovered to have karyotype 46 XY. What is the most important future treatment she will need?

Answer 313

Bilateral gonadectomy is recommended after completion of puberty to decrease risk of gonadal malignancy

Question 314

74 year old african american man with icnreased urinary frequency the last 2 months. Complains of nocturia, mild straining and 2 episodes of bloody urine that spontaneosuly cleared. Has had RKA and 30 pack year smoking hx. Prostate is enalrged, but smooth. PSA is 3.8 (nml

Answer 314

Cystoscopy Indications for cystoscopy: - gross hematuria - micro hematuria with increased risk of malignancy - recurrent UTI's - Obstructive symptoms with suspicion of stricture vs stone - Irritative symptoms without UTI - Abnormal bladder imaging or urine cytology (this patient is a smoker so he is at increased risk for cancer)

Question 315

Strongest influence on long-term prgnosis following a STEMI?

Answer 315

Duration of time theat passes before coronary blood flow is restored (via PTCA or fibrinolysis)

Question 316

2nd trimester quardurple screen shows: - low maternal alpha-fetoprotein - low estriol - increase beta-hcg - increased inhibin A Dx? Next step?

Answer 316

These results are consistent with Trisomy 21 US should be performed to evaluate fetal anatomy and growth

Question 317

Patient presents with fever of 101.3 three days post-partum. Delivery was at 37 weeks and was significant for prolonged labor and prolonged rupture of membranes. Bimanual exam shows tender uterus and foul-smelling lochia. Dx?

Answer 317

Endometritis

Question 318

Tx for endometritis?

Answer 318

IV Clindamycin and gentamicin

Question 319

What kind of infection is usually behind endometritis?

Answer 319

Polymicrobial | gram negs and positives

Question 320

14 yr old african american boy presents with right hip pain and difficulty walking for the last several weeks. HAs had two simialr episodes in the past and one episode of severe abdominal pain requiring hospitalization. Hematocrit is 25%. Difficulty walking is likely 2ndary to what?

Answer 320

Osteonecrosis secondary to sickle cell anemia (Up to 50% of people with homozygous SS anemia will get osteonecrosis by adulthood. Humeral and femoral heads are most common sites

Question 321

23 year old woman with low back pain and stiffness. Stiffness is in the morning and lasts an hour. NO rashes, no eyes sx, no urinary/GI sx. Stable vitals. REduced forward flexion on lumbar spin and tenderness in lubosacral area. Dx? Test to confirm dx?

Answer 321

Ankylosing spondylitis Plain XR of pelvis showing sacroiliitis will confirm the dx

Question 322

Most common causes of secondary digital clubbing?

Answer 322

- Lung malignancy - Cystic Fibrosis - Right-to-left cardiac shunts

Question 323

Opaescent teeth associated with what condition?

Answer 323

osteogenesis imperfecta

Question 324

Triad of gait disturbance, dementia, and urinary incontinence?

Answer 324

Normal pressure hydrocephalus

Question 325

Treatment for familial adenomatous polyposis?

Answer 325

Patients have a 100% risk of cancer and need a procto-colectomy

Question 326

6 year old child with single lytic lesion of right humeral head. Right shoudler pain for 2 weeks. Labs show mild hyercalcemia. Likely dx?

Answer 326

Langerhans Histocytosis

Question 327

53 year old woman with Rheum Arthritis presents to ED with seizures. Has had cough, fever, and nights sweats for 2 weeks. She is on immunosupressants for her RA. Temp 102, other vitals stable. CT chest shows multiple nodules, CT head shows left temporal lobe abscess. Bronchoalveolar lavage cx grows partially acid-fast, gram positive, branching rods. Organism? Tx?

Answer 327

Nocardia - classically affects immune-compromised pts and sounds like tb - Can disseminate from lungs to affect brain or skin - fillamentous, aerobic, g+, acid fast Treatment: Trimethoprim-Sulfamethoxazole (aka bactrim)

Question 328

Palpable breast mass found by woman who comes into clinic. How are the next steps different depending on age?

Answer 328

Age under 30: US and possible mammogram Over 30: Mammogram and possible US Adolescents: Okay to watch for a couple menstrual cycles to see if it regresses before imaging

Question 329

Risk factors for osteoporosis: | Modifibale vs non-modifiable

Answer 329

Modifiable: low estrogen, malnutrition, low calcium, low vit D, meds (glucocorticoids/anitconvulsants), immobility, smoking, alcohol Non-modifiable: female, advanced age, small body size, late menarchy/early menopause, caucasian/asian, fam hx Pts at risk should increase weight-bearing exercise, stop smoking, decrease alcohol

Question 330

1st line bipolar pt not adequately controlled with monotherapy

Answer 330

Continue lithium or valproate, then add a second generation antipsychotic

Question 331

In cystic fibrosis, what is the most common pneumonia-causing organism in kids vs adults?

Answer 331

kids: staph aureus adults: pseudomonas Both organisms can cause pneumonia in both age groups

Question 332

Patient with anemia has a tea and toast diet. What nutritional deficiency does he probably have?

Answer 332

Folic acid deficiency | apparently folic acid is heat sensitive

Question 333

46 yo patient presents to ED with severe sudden onset headache and is foudn to have subarachnoid hemorrhage. He undergoes endovascular coiling. Now let's say his condition worsens 12 hours later, what's the cause? 4 days later?

Answer 333

Rebleeding is the major cause of death in the first 24 hours Vasospasm occurs in 30% of patients in days 3-10

Question 334

How can you prevent vasospasm in the days following a subarachnoid hemorrhage?

Answer 334

Initiate nimodipine

Question 335

What is the mechanism by which Niacin causes pruritis and flushing?

Answer 335

Prostaglandin-induced peripheral vasodilation Just use some low dose aspirin

Question 336

65 year old male with HTN, smoker, alcohol user, high cholesterol, DMII. Which risk factor is most strongly assoicatied with strokes?

Answer 336

HTN HTN HTN HTN

Question 337

How do you tell the difference between oral coxsackie and HSV?

Answer 337

Coxsackie: posterior oropharyngeal vesicles/ulcerations (also occurs seasonally in summer/early fall) HSV: anterior oropharyngeal and lips

Question 338

Physical exam testing for developmental hip dysplasia?

Answer 338

Ortolani and Barlow maneuvers

Question 339

Cat bit antibiotics?

Answer 339

Amoxicillin with clavulanate | worried about pasturella multocida

Question 340

Underlying mechanism for heat stroke? | Heat exhaustion?

Answer 340

Heat stroke: thermoregulation failure Heat exhaustion: Inadequate fluid and salt replacement

Question 341

50 yo woman presents with adenocarcinoma of the anterior vagina. What is the biggest risk factor for this?

Answer 341

Daughters of women who received diethylstilbestrol during pregnancy

Question 342

Child presents with bilious vomiting, abdominal distention. Abd XR does NOT show double bubble or dilated loops of bowel. Next step in identifying dx?

Answer 342

Upper Gi series (barium swallow) should be performed to diagnose possible malrotation with midgut volvulus

Question 343

Barium swallow XR findings in midgut volvulus?

Answer 343

Corkscrew pattern

Question 344

Barium swallow findings in a malrotation?

Answer 344

Ligament of treitz is on the right-side of the abdomen

Question 345

66 yo man with low back pain and difficulty walking for several months. Pain is worse with standing and relieved by sitting. LEss severe uphill than downhill walking. NO spinal tenderness to palpation, no straight leg raise pain, reflexes normal, distal pulses strong. What is the likely dx?

Answer 345

Lumbar spinal stenosis Get an MRI to check it out Flexion of the spine in sitting or walking uphill widens the canal and causes relief of sx. Usually caused by degenerative joint disease. Similar to PVD presentation, but differnt because it hurts while standing still too

Question 346

How would you differentiate social anxiety disorder from panic attacks?

Answer 346

One of the best ways is to remember that in panic disorder you must have UNEXPECTED attacks. If the patient is only panicking about social situations then this is more likely social anxiety disorder.

Question 347

55 yo woman presents with one week of pain in multiple joints. MCP, PIP, and wrist joints hurt without any swelling, redness, or tenderness. Sx are worse in the morning and dexterity returns in about 20 minutes. She has no rashes or fevers, vital signs normal. ESR is not elevated. Likely dx?

Answer 347

Viral arthritis 2ndary to Parvo b19 Can be symmetric. Distinguished from other causes by ACUTE onset, lack of inflammatory markers, and resolution in 2 months or less.

Question 348

How is schizoaffective disorder differentiated from major depressive disorder with psychotic features?

Answer 348

In Schizoaffective disorder there is a significant mood disorder, either depressive or manic, with concurrent psychtoic symptoms. Psychosis without mood sx must last at least 2 weeks.

Question 349

Pregnant woman presents with painless vaginal bleeding at 30 weeks gestation. Soft, nontender abdomen. Dx?

Answer 349

Placenta previa

Question 350

Typical tx for solitary brain met in patient with good performance status?

Answer 350

Surgical resection followed by stereotactic or whole brain radiation.

Question 351

Genetic syndrome characterized by microthrombocytopenia, eczema, and recurrent infections?

Answer 351

Wiskott-Aldrich syndrome X linked recessive

Question 352

Pregnant patient w/ severe abdominal pain and vaginal bleeding after MVC. Soft BP, tachycardic, Hgb of 7.6. Likely dx? First step?

Answer 352

Likely placetnal abruption First trasnfuse w/ crystalloid! Dont' waste time with BPP for now, baby is probs fine.

Question 353

Side effects of Cyclosporine:

Answer 353

- Nephrotox - HTN - Neurotox - Hypergycemia - Infxn - Malignancy - Gingival hypertrophy - Hirsutism - GI stuff

Question 354

Azathioprine toxicity?

Answer 354

- diarrhea - leukopenia - hepatotoxicity

Question 355

Toxicity of mycophenolate?

Answer 355

marrow suppression

Question 356

Toxicity of tacrolimus?

Answer 356

- Nephrotox - Hyperkalemia - Neurotox - Diarrhea - Hyperglycemia

Question 357

Best tx for severely depresssed elderly patient who is not eating or drinking? PS also has psychotic features...

Answer 357

Electroconvulsive tx

Question 358

HIV patients with odynophagia and visible thrsh should be treated with oral fluconazole. If sx persist, or there is no thrush is visualized what is the differential and indivisual tx?

Answer 358

Herpes Simplex Esophagitis: Round/ovoid ulcers - Tx: Acyclovir Cytomegalovirus Esophagitis: large linear ulcers Tx: Ganciclovir

Question 359

Treatment for Neisseria Gonorrhea cervicitis?

Answer 359

Ceftriaxone and Azithromycin

Question 360

5 month old presents with areflexia, hepatosplenomegaly, cherry-red macula, and regression of milestones. Dx? Underlying pathology?

Answer 360

Niemann-Pick Disease Sphingomyelinase deficiency

Question 361

What disease results from glucocerebrosidase deficiency?

Answer 361

Gaucher disease

Question 362

Tay Sachs results from a deficiency in what?

Answer 362

Beta-hexosaminidase A deficiency

Question 363

What are professional ethical guidelines in reference to a drug company giving out gifts?

Answer 363

Accept non-monetary gifts from interested parties ONLY if the gifts directly benefit patient care and are of small monetary value

Question 364

Potential reversible causes of PEA? | 5H's and T's

Answer 364

``` HYpovolemia Hypoxia Hydrogen (acidosis) Hypo/hyper- kalemia Hypothermia ``` ``` Tension Pneumo Tamponade Toxins Thrombosis Trauma ```

Question 365

55yo man with sudden onset palpitations and chest pain. Cariac monitoring shows afib with a pulse of 120-140, Os sat at 92%. Patient suddenly becomes unresponsive. No palpable pulses can be found and patient in agonal breathing. Monitor continues to show a-fib. Next step in management?

Answer 365

CPR Patient is in PEA and should be resuscited with CPR and possible vasopressor tx while reversible causes of PEA are identified and treated. Remember: There is no role for cardioversion or defibrillation in these patients

Question 366

14 year old patient with facial puffiness, pretibial edema, fatigue, and decreased appetite. UA shows 4+ proteinuria. Patient also positive for Hep B. Dx?

Answer 366

Membranous Nephropathy Hep B is a VERY significant risk factor!

Question 367

Newborn infant delivered without prenatal care presents with low birth weight, jaundice, clear rhinorrhea, and maculopapualr rash on feet and buttocks in the first 48 hours. The rash later desquamates. Which congenital infection is the most likely?

Answer 367

Syphilis - Rhinorrhea - Desquamating or bullous rash - Abnromal long-bone radiographs

Question 368

Malaria chemprophylaxis in traveling to Sub-saharan africa, Amazon, and S/SE Asia? Other malaria-filled areas?

Answer 368

Subsaharan Africa, Amazon and S/SE asia: Mefloquine, atovaquone proguanil, or doxycycline (because of cloroquine resistance) Other malaria endemic areas: Cloroquine or hydroxycloroquine

Question 369

Most common predisposing facor to orbital cellulitis?

Answer 369

bacterial sinusitis

Question 370

Typical antipsychotic that can cause hypothermia?

Answer 370

Fluphenazine

Question 371

2 first-line treatments for obsessive compulseive disorder?

Answer 371

response prevention psychotherapy & SSRIs

Question 372

24 yo showing signs of hyperthyroid.Labs show increased t3/t4 and decreased TSH. Now how do you tell at this point whether this patient has silent (aka painless) thyroiditis VS Grave's disease?

Answer 372

Patients with hyperthyroid and suppressed TSH should undergo thyroid radioiodine scitigraphy. Silent thyroiditis: Radioiodine uptake is decreased Grave's: Radioiodine uptake is increased

Question 373

Recommended prophylaxis for HIV patients?

Question 374

Preferred hormonal contraception in lactating mothers?

Answer 374

Progestin-only oral contraceptive

Question 375

Metabolic side effects of thiazide diuretics:

Answer 375

- hyperglycemia - increased LDL adn triglycerides - hyperuricemia

Question 376

Best lab marker to follow to indicate resolution of DKA?

Answer 376

serum anion gap | also beta-hydroxybutyrate

Question 377

HIV+ patient presents with altered mental status, EBV DNA in the CSF, and a solitary weakly-ring-enhancing periventricular mass on MRI. Dx?

Answer 377

CNS lymphoma

Question 378

HIV+ patient with multiple ring-enhacing spherical lesions in the basal ganglia. Dx?

Answer 378

Toxoplasmosis

Question 379

Neuroimaging finding most commonly found in Schizophrenia?

Answer 379

Widening of the lateral ventricles

Question 380

5 year old presents with fever of 101 and left-sided neck swelling. NO trauma, ill contacts, or recent illness. Exam shows red, tender, fluctuant anterior cervical mass in the left anterior cervial lymph node chain. Dentition is normal. Dx? Infectious organism?

Answer 380

Acute Lymphadenitis Likely etiologies: Staph Aureus or Strep Pyogenes

Question 381

22 year old woman just delivered child at 40 weeks. Infant has jaundice, hepatosplenomegaly, and lymphadenopthy. CT shows hydrocephalus and intracranial calcifications. Likely dx?

Answer 381

Congenital toxoplasmosis

Question 382

How does Neonatal Abstinence syndrome (mother took opiates in pregnancy) present?

Answer 382

First few days of life. Infant develops high-pitched cry, poor sleeping, tremors, seizures, sweating, seizures, sneezing, tachypnea, poor feeding, vomiting, and diarrhea

Question 383

Most common and 2nd most common brain tumors in children?

Answer 383

1st: Astrocytoma 2nd: Medulloblastoma

Question 384

Classic traid of congenital rubella?

Answer 384

- Sensorineural deafness - cardiac defects - cataracts

Question 385

Etiology of painless hematochezia in young toddler? How to confirm diagnosis?

Answer 385

Meckel's div. Dx w/ Technetium-99m pertechnetate scan

Question 386

Patient with recurent epsidoes of hematuria, sensorineural hearing loss, and fam hx of renal failure. Dx?

Answer 386

Alport syndrome

Question 387

Asian patient developed insensate, hypopigmented patch of skin. Dx?

Answer 387

Suspect leprosy | Diagnose with acid fast bacilli on skin bx

Question 388

40yo multiparous female presents with pelvic pain that started a couple years ago and very heavy periods (soaking tampons every 2 hours). Pelvic pain used to stop with end of menses, but is now constant. Exam shows soft, tender uterus. Likely dx?

Answer 388

Adenomyosis condition where endometrial galnds are trapped withint he myometrium and cyclically shed in this location

Question 389

8 yo brought in with multiple starign episodes over last 3 weeks. During episodes he tilts his head and is unresponsive to his name or touch. He also look slike is is chewing on something. Episodes are 2-3 mintues and have a 20-30 minute period of confusion afterward. Neuro exam is normal. Likley dx?

Answer 389

FOCAL SEIZURE Not an absence seizure because they do NOT have a post-ictal period

Question 390

Febrile patient with sharply demarcated, erythematous, edematous, tender skin lesion with raised borders. Dx? Organism?

Answer 390

Eysipelas | Group A Strep

Question 391

34 year old woman with 2 day hx of progressive dyspnea and drowsiness. Husband says she had trouble swallowing food and almost choked at dinner. One week ago she was treated with Cipro for a URI. Patient is having trouble lifting books. Vitals stable, but respirations are shallow. Pulse ox 93% on RA. Speech sounds are nasally. Lungs sounds are clear and pateint is using accessory muscles to breathe. Muscle strength is decreased bilaterally. Most likely dx?

Answer 391

Myasthenic crisis! Fluctuating weakness that worsens over the course of the day and often involves extraocular, bulbar, proximal limb, and respiratory muscles.

Question 392

Indications for endoemtrial bx for eval of abnormal uterine bleeding?

Answer 392

- Women over 45 or post-menopausal - Women under 45 w/ persistent sx or risk factors for endometrial cancer - Unopposed estrogen exposure - Prolonged amenorrhea w/ anovulation

Question 393

Most important immediate management of uterine inversion?

Answer 393

Manual replacement of uterus (if you wait it can become edematous and the cervix can contract around the inverted uterus) Do not remove the placenta or use uterotonics until uterus is replaced

Question 394

Unvaccinated child with erythematous maculopapular xanthem. Started on the face and spead to to rest of body. Patient has tender lympadenopthy, non-exudative conjunctivitis, and patchy erythema on the soft palate. Dx?

Answer 394

Rubella

Question 395

What kind of osteoporosis screening is indicated for patients?

Answer 395

Women over 65 should get one time screening for osteoporosis with a DEXA scan Those at risk may need earlier screening.

Question 396

Some osteoporosis risk factors?

Answer 396

- advanced age - fam hx of minimal trauma fractures, hipfractures - smoker, excessive alcohol use - low body weight - medications - preamture menopause - hypogonadism - Malascorptive or inflammatory disorders - hyperthyroid or hyperparathyroid - Cushing's - Vit D deficiency - Chronic liver/renal disease

Question 397

Which genetic mutation results in Marfan syndrome?

Answer 397

Fibrillin-1

Question 398

Back pain radiating to thighs in patient over 60. Pain is worse with lumbar extension and persists even while standing still. Dx?

Answer 398

Lumbar spinal stenosis | remember: vascular claudication is exertion dependent and resolves with standing still

Question 399

Meconium ileus pathognomonic for?

Answer 399

Cystic fibrosis

Question 400

Explain genetics of fragile x syndrome:

Answer 400

Full mutation in FMR1 gene caused by increased CGG repeats

Question 401

1 day old boy born by forceps-assisted vaginal delivery at 40 weeks to mother w/ gestational diabetes and obesity. Exam shows supination of left forearm with extension of wrist, hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. There is also ptosis of left eyelid and anisocoria w/ left pupil smaller than right. What nerves have been injured here? Dx?

Answer 401

Klumpke Palsy due to shoulder dystocia C8 and T1 injured Sympathetic fibers running along them also injured causing Horner Syndrome (miosis and ptosis)

Question 402

first-line tx for CO poisoning?

Answer 402

100% oxygen by non-rebreather mask

Question 403

32 yo male w/ palpitations. Late diastolic murmur is heard along left sternal border with patient is sitting up, leaning forward, and holding breath in full expiration. Dx?

Answer 403

Aortic Regurgitation probably from congenital bicuspid aortic valve (or rheumatic fever in developing countries)

Question 404

Patient found to be in Afib w/ RVR. Also shows signs of hyperthyroidism (lid lag, fine tremor, recent weight loss). What treatment to you suggest initially?

Answer 404

Propanolol Beta-blockers are recommended as initial tx for Afib due to hyperthyroid.

Question 405

How to differentiate follicular adenoma from follicular cancer?

Answer 405

invasion of capsule and blood vessels is required to be a follicular thyroid cancer

Question 406

Helpful ways to distinguish Legionella from other CAP's?

Answer 406

high grade fever, GI sx, neuro sx, interstitial infiltrates, hyponatremia, hepatic dysfxn. Often sputum gram stain shows many neutrophils but no organisms.

Question 407

How do you treat legionella atypical pneumonia?

Answer 407

Macrolides (azithro) or fluoroquinolones (levofloxacin)

Question 408

Most common congenital heart defect in Down's?

Answer 408

complete atrioventricular septal defect | failure of endocardial cushions to merge results in both ventricular septal defect and atrial septal defect

Question 409

22 yo AFrican AMerican man presents to ED with fever, jaundice, abdominal pain and dark urine. Peripheral blood smear shows bite cells and RBC inclusions after crystal violet stain. What condition does this patient have?

Answer 409

Glucose-6-phosphate deficiency

Question 410

Treatment for 55yo male discovered to have hairy cell leukemia?

Answer 410

Cladribine

Question 411

List 3 lifestyle choices that can reduce risk of breast cancer:

Answer 411

1 - reduce alcohol intake to less than 2 drinks/day and less than 7 drinks/week 2 - Breastfeed 3 - Exercise

Question 412

10 yo boy with headache vomiting and visual disturbance. He ahs bilateral upper eyelid retraction and limitation of upper gaze. Pupils are sluggish to light reaction. Most likely lesion?

Answer 412

Pinealoma

Question 413

16 yo patient w/ 2 mo hx of left thigh pain. Occurs at night, not associated with activity, improves with ibuprofen. No trauma, no fever, no pain in other joints. No redness, deformity or local tenderness at thigh. XR shows small, roundm hypodense lesion on femur. Dx?

Answer 413

Osteoid osteoma

Question 414

Underlying mutation of osteogenesis imperfecta?

Answer 414

Type 1 collagen

Question 415

What's the deal with adipose tissue and estrogen and menopause?

Answer 415

Premenopause estrogens come from conversion of androgens to estrogen in the ovaries Postmenopause estrogens comes from aromtase conversion in peripheral fat This conversion outside of the ovaries can actually alleviate typical menopausal sx like vaginal dryness and dyspareunia

Question 416

Most common extraskeletal complication of ankylosing spondylitis?

Answer 416

Uveitus

Question 417

9 yo with fever hives and joint pain. Pruritic rash began two days ago and has spread to cover trunk and arms. Today he has wrist and ankle pain. Has been taking oral penicillin for 9 days to treat diagnosed strep pharyngitis. Palpable lymph nodes in cervical axillary and inguinal regions. Likely dx?

Answer 417

Serum sickness-like reaction Stemming from antibiotics (usually beta-lactams or bactrim is the etiology Serum sickness-like reaction usually occurs 1-2 wks after inital exposure and include fever, urticaria, arthralgia, and lymphadenopathy

Question 418

Symptoms of cardiac tamponade (distended neck veins, low BP, and muffled heart sounds) result from what exactly?

Answer 418

Intrapericardial pressure is icnreased above the diastolic ventricular pressure. This restricts venous return to the heart via LV filling. Net result: decreased preload, stroke volume, and cardiac output

Question 419

19 yo with back stab wound results in loss of pain and temp sensation below T12 on the left. At what side and level is the wound?

Answer 419

RIGHT T12 | Lateral Spinothalamic tracts

Question 420

Mother with no prenatal care. 14 day old infant with poor suckling develops whole-body spasms. Delivered by untrained birth attendant, infected looking umbilical stump. Dx?

Answer 420

Tetanus

Question 421

Treatment for foodborne butulism?

Answer 421

Equine antitoxin

Question 422

How do you a treat a pt with Neuroleptic malignant syndrome? Presenting with fever, muscle rigidity, autonomic instabilty, and mental status changes.

Answer 422

Dantrolene also consider Bromocriptine and amantadine (don't forget to stop offending agent too!)

Question 423

What auscultation finding is associated with LV hypertrophy?

Answer 423

S4 usually LV hypertrophy stems from prolonged HTN

Question 424

43 yo man with HTN. He has DMII, sedentary, 20 pack-yr smoker, 1-2 drink/wk, BMI 32. What lifestyle change would lead to biggest improvement in his HTN?

Answer 424

10% weight loss DASH deit, low Na, moderation of EtoH, regular exercise, and smoking cessation would also help

Question 425

56 yo man postop day 3 after CABG. Temp 102, other vitals stable. Exam reveals normal heart and lungs sounds. RUQ tenderness and decreased bowel sounds. No jaundice. Labs: HGB and PLT wnl, WBC 17. Total bili 1.0, alk phos 100, AST 32, ALT 34, amylase 110. Dx?

Answer 425

Acalculous Cholecystitis Acute inflammation of the GB in absence of gallstones, often occurring in critically ill patients who recently had surgery, severe trauma, burns, sepsis, or shock.

Question 426

2 wk old neonate has had vomiting and poor feeding. Episode of jerking movements this morning. Lethargic, irritable and jaundiced. BLT cataracts seen. Delivered at term without complications. Dx?

Answer 426

Galactosemia Consider this dx in newborn with FTT, BLT cataracts, jaundice, and hypoglycemia.

Question 427

6yo w/ abdominal pain for 4 days. No fever, vomiting, or bowel changes. Erythematous macular rash has now become confluent. Rash is non-blanching. R knee is swollen and painful with passive ROM. HGB, PLT, WBC all wnl. Elevated Cr with 1+ proteinuria. Dx? Mechanism?

Answer 427

Henoch-Schonlein Purpura An IgA medicated vasculitis of small vessels. Classic signs: Palpable purpura, arthralgias, abdominal pain, and renal disease

Question 428

64 yo patient with increasing pain in R groin for several months. Pain is worse w/ activity and relieved with rest. Sometimes radiates to upper thigh. No trauma, fever, weight loss. No current back pain. BMI 34. Normal vitals. Pain on passive internal rotation of right hip. Direct pressure over groin does not increase pain. Reflexes, muscle tone, strength, and LE pulses are all normal. Likely dx?

Answer 428

Degenerative joint disease from osteoarthritis

Question 429

Young child with nephrotic syndrome. Next step in management?

Answer 429

You are going to assume this is minimal change disease then you are going to give PREDNISONE. (Don't have to have the dx nailed down to start it)

Question 430

Treatment for suggested C-diff?

Answer 430

Metronidazole

Question 431

5yo boy presenting with bitemporal heminanopsia and diabetes insipidus is found to have calcified intracranial tumor in the suprasellar region. Dx?

Answer 431

Craniopharyngioma This is a low grade malignancy derived form remains of Rathke's pouch

Question 432

1st step in evaluating the risk fo pre-term delivery in patient with prior cervical cone biopsy?

Answer 432

Transvaginal US to measure cervical length | Short = greater risk

Question 433

How do you manage a patient found to have a short cervix on transvaginal US at 18weeks? What if she also has a history of of preterm labor?

Answer 433

Vaginal progesterone If hx of preterm, cerclage is performed with serial TransV US until 24 weeks

Question 434

What amniotic fluid index is considered oligohydramnios?

Answer 434

5-6

Question 435

5yo girl recieved aspirin to treat a recent fever. IF she gets Reye Syndrome. What is the pathology of the liver damage that will cause elevated transaminases, ammonia, INR, and PTT?

Answer 435

Microvesicular fatty infiltration

Question 436

Pelvic floor exercises are the first-lien treatment for stress incontinence. Pessary can be tried as well. Long term fix?

Answer 436

Pelvic sling surgery

Question 437

Important tx for patient presenting with preterm premature rupture of membranes PPROM whose PMH is unknown?

Answer 437

Penicillin prophylaxis for possible group B strep is very important in this situation

Question 438

Despite having a high lab K+ value, a patient with Type 1 Diabetes in DKA actually has low K+ in the body. Why is that?

Answer 438

Osmotic diuresis Happens in this case when tons of glucose is in the renal tubules and causes a fluid shift into the tubules and high volume diuresis

Question 439

Typical features of polymyositis?

Answer 439

- Symmetric proximal muscle weakness - No other neuro sx - Elevated Creatinine Kinase - Dx w/ muscle bx - ANA and Anti-jo-1 Antibodies

Question 440

How do I decrease risk of SIDS?

Answer 440

avoid smoke, pacifier use, sleep supine, firm bedding, room sharing without bed sharing

Question 441

Chronic alcoholic being treated for alcohol withdrawal. Also given agressive IV and oral K+ supplementation. Despite this, his K barely rises. Why is this?

Answer 441

Magnesium also needs to be corrected. This is likely low in the alcoholic too and Mg is actually an important cofactor for K uptake and intracellular K levels.

Question 442

What are the electrolyte abnormalities in tumor lysis syndrome?

Answer 442

Hyperphosphatemia Hypocalcemia Hyperkalemia Hyperuricemia (K and phos released from broken cells, Ca gets bound by phos, Uric acid comes from increased protein degradation)

Question 443

37 yo F pt with 4 mo hx of muscle weakness. Reports occasions where she had to rest after climbing just a few stairs. Has had difficulty raiding arms to blow-dry hair. Has also had problems w/ diplopia at the end of the day. Takes levothyroxine for hypothyroid and atovastatin for hyperlipidemia. Muscle strength is 5+ BLT and DTR 2+ BLT. No muscle tenderness. Likely dx?

Answer 443

Myasthenia gravis (fluctuating, fatiguable msucle weakness that worsens with repetitive motions and improves with rest. Ocular or bulbar dysfunction is often the presenting sx.)

Question 444

Screening test for a aptient presenting with new-onset Atrial fibrillation with RVR?

Answer 444

Chech TSh and T4 levels for underlying hyperthyroid

Question 445

43 yo patient presents to ED after inability to get out of bed due to leg weakness. Constant back pain for 5 days. HX of uncontrolled DMII and HTN. Recent leg cellulitis that resolved with oral abx. Temp is 101, BP 150/100, pulse 105. Patient's spine is tender to palpation over the lumbar area and he smells of urine. Motor strength is 3/5 in BLT LE, hyperactive DTR, extensor plantar reflexes BLT. Decreased sesnation in LE and he has weak rectal tone. Dx?

Answer 445

Spinal Epidural Abscess Evaluate further with spinal MRI Classic triad is: - Fever - severe focal spinal pain - neuro deficits Tx: Immediate surgical decompression!

Question 446

Patient with SLE is on hydroxycloroquine. | What precautions should be taken with this medication?

Answer 446

Basline opthalmogic eval w/ annual reassessments beginning after 5 yrs Can rarely cause Retinal Toxicity

Question 447

Italian-American patient with beta thalassemia trait comes in for routine check-up without any sx. He has a normal hemoglobin, but low MCV. What tx does he need?

Answer 447

No tx necessary

Question 448

15yo with sickle cell presnts with HGB of 4.5 with a .5% retic count. No hepatosplenomegaly is present. He has had SOB, weakness, and fatigue for the last 3 days. Dx?

Answer 448

Aplastic crisis! Parvo B19 is most common trigger

Question 449

Homeless pt with muscle and joint aches, nausea, diarrhea, abdominal crmaping, rhinorrhea, and pupillary dilation. He has been in for drug abuse before. Withdrawal Dx?

Answer 449

Probably heroine withdrawal

Question 450

Well-appearing infant with cyanosis and distress. Worsens with attempts to feed, but seems to improve with crying. R and L sided BP is normal. No murmurs. What should you think about?

Answer 450

Choanal atresia

Question 451

Non-caseating granulomas. Crohns or UC?

Answer 451

Crohns

Question 452

58 yo caucasian feamle is about to start trastuzumab tx for left breast adenocarcinoma which is ER/PR negative and HER2 positive. Which baseline test is important before starting this therapy?

Answer 452

Echocardiogram Herceptin carries risk of cardiotoxicity, particularly in pts with low baseline EF

Question 453

Initial management of newborn found to have a hydrocele?

Answer 453

Reassurance and observation. Most spontaneously resolve by 1 yo

Question 454

Why do patients get pyridoxine for tx in tuberculosis?

Answer 454

It is a vitamin supplement that will decrease the peripheral neuropathy that develops due to Isoniazid Hepatitis is another one to remember for Isoniazid

Question 455

What is cor pulmonale?

Answer 455

Imparied fxn of right ventricle due to pulmonary HTN that occurs due to chronic lung disease.

Question 456

Signs of cor pulmonale?

Answer 456

- Elevated jugular venous pressure - Right ventricular 3rd heart sound - Tricuspid regurgitation - Heptomegaly w/ pulsatile liver - LE edema, ascites, pleural effusions

Question 457

Post-menoapausal woman with adenxal mass, determined to be 5cm ovarian cyst on US without solid components septations, or loculations. Next step in management?

Answer 457

Measure CA-125 In post-menopausal women you use CA-125 in conjunction with the US to determine whether further imaging or exploratory surgery is necessary Even if there are no ugly features and the CA-125 is normal you are going to need to do serial ultrasounds

Question 458

Describe the symptoms of croup:

Answer 458

- Caused by parainfluenza - dry, barky cough - hoareness - inspiratory stridor - 3mos to 3yrs - steeple sign on CXR

Question 459

What do brick-red crystals in the diaper of a neonate in the first week of life mean?

Answer 459

Sign of dehydration

Question 460

Explain the mechanism behind breastfeeding failure jaundice.

Answer 460

Often occurs in the first week of life and is caused by lactation failure. Could stem form maternal or infant factors. Lack of proper feeding leads to inadequate stooling, and inadequate stooling leads to decreased bilirubin elimination.

Question 461

Mechanism of breast milk jaundice?

Answer 461

Patients with adequate feeding and normal exam. Basically there are high levels of beta-glucuronidase in breast milk, which deconjugate bilirubin in the intestine leading to jaundice. Tends to start in days 3-5 then peaks at 2 weeks of life.

Question 462

How often should neonates breastfeed?

Answer 462

Every 2-3 hours for 15 minutes per breast

Question 463

Down syndrome patient presents with behavioral changes. HAs begun refusing normal activities, is dizzy, and developed urinary incontinence. Exam shows hypotonia with hyperreflexia and positive babinki. ALso has ataxic gait. Dx?

Answer 463

Atlantoaxial instability

Question 464

Good 1st tx for bullous pemphigoid?

Answer 464

clobetasol - high potency topical glucocorticoid

Question 465

Tx for clubfoot?

Answer 465

Stretching, manipulation, followed by serial casting. Tx should be immediate! Surgery in first year if these measures don't work

Question 466

64 yo patient is found to have "knifelike" chest pain and nausea. No ST changes on ECG. CT angio confirms aortic dissection. Before srugery, patient develops SOB and refuses to lay flat. Auscultations reveals bibasilar crackles that were not present on initial exam. What is causing the SOB?

Answer 466

Aortic valve insufficiency Retrograde extension of intimal tear involves aortic valve and causes regurge

Question 467

65 yo COPD patient experiencing an exacerbation. Why might supplemental O2 not be a good idea if he his O2 sat is 90% currently?

Answer 467

Supplmental O2 in pts with advanced COPD can worsen hypercapnia and cause neurological side effects. This is due to combo of: - Loss of compensatory vasoconstriction in areas of ineffective gas exchange - Increase in oxyhemoglobin reduces CO2 uptake from tissues - Decreased respiratory drive and slowing resp rate causes reduction in minute volume

Question 468

Management of mother at 29 weeks gestation with fetus in transverse lie position?

Answer 468

Fetus will likely convert to cephalic presentation spontaneously

Question 469

Initial tx for patient with symptomatic sinus bradycardia?

Answer 469

IV Atropine

Question 470

65 yo patient with high fevers and confusion. Has had multiple bouts of bronchitis in the last 6 mos. Enlarged anterior cervical lymph nodes. Hepatosplenomegaly. WBC count is 43,000 with 85% lymphocytes. Abx are initiated. Next step in management?

Answer 470

FLow cytometry is used for diagnosis of CLL. Bone marrow bx and lymph node bx are NOT needed for dx!

Question 471

most frequent precipitant of guillain barre syndrome?

Answer 471

Campylobacter Jejuni

Question 472

First line therapy for vulvar lichen sclerosus?

Answer 472

High potency topical steroids Very good for relief of itching and dyspareunia

Question 473

Big fetal complication for preeclampsia?

Answer 473

Fetal growth restriction/small for gestational age | due to chronic uteroplacental insufficiency

Question 474

Patient in recovery from anorexia nervosa wants to get pregnant. What complications is she prone to?

Answer 474

- miscarriage - small for gestational age - hyperemesis gravidarum - preamture birth - C section - postpartum depresssion

Question 475

Common findings in anorexic patients?

Answer 475

- Osteoporosis ***** - Elevated cholesterol/carotene - Cardiac Arrhythmia - Euthyroid Sick syndrome - Hypothalamic-pituitary axis dysfxn - Hyponatremia (excess H2O)

Question 476

19 yo patient screens positive for chlamydia and negative for gonorrhea. Tx?

Answer 476

Single dose of azithromycin or doxycycline 7days (if gonorrhea were positive you'd add ceftriaxone too)

Question 477

Maternal factors leading to fetal growth restriction?

Answer 477

- HTN, preeclampsia, diabetes - Antiphospholipid syndrome - Autoimmune (SLE) - Cyantoic cardiac disease - Substance abuse (tobacco, EtOH, cocaine)

Question 478

Gastrinomas are assoicated with MEN1 tumors. What are MEN1 tumors?

Answer 478

parathyroid, pituitary, pancreatic

Question 479

Cause of irregular menses in time period following menarche?

Answer 479

Immature hypothalamic-pituitary-gonadal axis. FSH/LH aren't prodcued in high enough amounts which leads to anovulation and irregularity

Question 480

Patient experiences painless, sudden, permanent vision loss upon waking int he morning. You see optic disk swelling, retinal hemorrhages, and cotton wool spots on fundus exam. PMH of HTN. Dx?

Answer 480

Central retinal vein occlusion

Question 481

Virilized female infant with salt-wasting, and increased 17-hydroxyprogesterone levels. Dx?

Answer 481

21 hydroxylase deficiency | Most common cause of congenital adrenal hyperplasia

Question 482

Most common causes of osteomyelitis in chidlren with sickle cell?

Answer 482

Slmonella and Staph aureus

Question 483

Female patient presenting with absent puberty at 16yo and anosmia. FSH and LH are low. Dx?

Answer 483

Kallman syndrome normal XX karyotype, with deficiency of GnRH

Question 484

Treating acute iron poisoning?

Answer 484

Deferoxamine