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USMLE Step 3 > UWORLD Step 3 QBANK > Flashcards

UWORLD Step 3 QBANK Flashcards

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USMLE® Step 1 flashcards
1
Q

irritability, poor feeding, aversion to being held and a hip joint which is flexed, abducted, and externally rotated

A

pediatric septic arthritis

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2
Q

MC organisms in pediatric septic arthritis

[] <3 months old
[] >= 3 months old

A

[] < 3 months old:

  1. Staphylococcus aureus
  2. GBS
  3. GN bacilli

[] >=3 months old:

  1. Staphylococcus aureus
  2. GAS
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3
Q

end-of-life care is focused on minimizing discomfort, anxiety, and distress for the patient and family once efforts to cure or modify disease become futile

[] what is the stepwise approach toward family disagreements with palliative care

A
  1. Family meetings, where treatment and prognosis are discussed and joint-decision making is performed
  2. Palliative care consultation or referral to Ethics Committee
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4
Q

this research principle answers the question, “how generalizable are the results of the study to other populations?”

A

external validity

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5
Q

aka “fully crossed design”

a type of experimental study design that utilizes >=2 interventions and all combinations of these interventions

A

Factorial

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6
Q

a type of experimental study design in which subjects are exposed to different treatment or exposures sequentially

A

a crossover study

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7
Q

a form of retrospective observational study in which subsets of controls are matched to cases and analyzed for the variables of interest

A

nested study

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8
Q

this type of study seeks to determine whether an intervention works in real-life conditions

A

pragmatic study

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9
Q

how should patients with acute decompensated heart failure be initially managed and what is the physiologic idea?

A

diuretics (and/or IV vasodilators)

to reduce cardiac preload

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10
Q

the prevalence of clinically apparent DVT in acute stroke patients is 2-10% with the highest risk being 2-7 days following a stroke and is particularly high in those with hemiparesis (75%)

[] what should be given?

A

Low dose heparin or LMWH for prophylaxis in most patients with acute ischemic stroke

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11
Q

Most morbidity from silicone breast implants is associated with what?

[] should a pregnant woman worry about the fetus and/or breastfeeding?
[] how does mammography screening recommendations change for breast implants?

A

local complications such as capsular contracture, implant deflation, and rupture

silicone implants do not cause disease or defects in the developing fetus; additionally, breast milk is safe and the best source of nutrition for infants with no evidence of any harmful effects in babies who are breastfed by mothers with silicone implants

women with implants should continue to have screening mammography at regular intervals

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12
Q

older adults with new-onset cognitive impairment should be assessed for what disease?

[] this is a risk factor for development of what disease?

A

depression

late life depression frequently presents with reversible cognitive impairment (aka pseudodementia)

patients with late-life depression (MDD >=65) are at a high risk of developing Alzheimer’s dementia and vascular dementia

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13
Q

this is the MC fracture of the carpal bones caused by falling onto an outstretched hand with a dorsiflexed wrist, leading to decrease grip strength, decreased ROM in wrist, and tenderness to palpation of the wrist within the anatomic snuffbox

[] how would you confirm?
[] what if the test is negative?
[] how do you treat?
[] complication

A

Scaphoid fracture

confirm with XR of the wrist in full pronation and ulnar deviation to better expose the schapoid

n.b., initial XR can be negative if the fracture is compressed or minimally displaced, therefore, either MRI/CT of the wrist, repeat XR in 7-14 days or radioscintigraphy in 3-5 days should be performed

wrist splinting should be done

complicated by non-union or avascular necrosis; if not treated with casting for 12 weeks

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14
Q

this medication is a potent vasodilator that works on both arterial and venous circulation and is used for HTN emergency management because of its rapid onset and offset; however, it must be avoided in chronic renal failure

[] what are some clinical features of its toxicity

A

Cyanide toxicity from Nitroprusside

Nitroprusside > CN, which may accumulate and be toxic in patients with CKD or those on high dose or prolonged infusion

Always suspect toxicity in unexplained metabolic acidosis and AMS with patients who have “cherry red” flushing, tachypnea, arrhythmias, ABD pain, nausea/vomiting

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15
Q

new sexual behaviors with recent onset of irritability, argumentativeness, risky sexual behavior and impaired concentration in a child/teen should raise suspicion for what?

A

child abuse

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16
Q

results from a critical elevation in intra-cardiac filling pressures most often due to coronary ischemia, prolonged HTN, valvular disease, or excessive volume overload/resuscitation

[] early goals of therapy
[] what are important parts of therapy?
[] if initial therapy fails, what should be next?

A

acute decompensated heart failure

early goals: hemodynamic stabilization, improved oxygenation, and optimization of volume status

IV-diuretics (furosemide)

IV-vasodilators (e.g., Nitroglycerin) reduce intra-cardiac filling pressures and are recommended in patients with ADHF who have inadequate response to initial diuretics or as initial therapy in “flash” pulmonary edema

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17
Q

once a patient in ADHF of uncertain etiology is stabilized, what should be done?

A

Transthoracic ECHO (TTE)

look for LV dysfunction and valvular abnormalities

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18
Q

this ubiquitous organism is a common cause of pulmonary disease in patients who are immunocompromised, particularly those with prolonged neutropenia or on chronic corticosteroids

[] CT findings
[] how to confirm diagnosis
[] treatment
[] mortality rate

A

Invasive pulmonary Aspergillosis

CT shows nodules with surrounding ground-glass opacities (“Halo sign”) or cavitation with air-fluid levels (“air crescent sign”)

confirm diagnosis with serum fungal biomarkers (galactomannan and beta-d-glucan assay) with sputum sample for fungal staining and culture

IV-voriconazole and a reduction of immunosuppressive meds

MR >80%

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19
Q

the MC cause of a palpable breast mass in adolescents or women <30 YO, it is often a single, rubbery, mobile, well-circumscribed mass in the UOQ

[] how does the pain change
[] management

A

Fibroadenoma

due to hormonal fluctuations, many patients have tenderness a few days prior to menstruation, with tenderness and size often improving after menses

after observing for 1-2 menstrual cycles, reassurance can be given for spontaneous regression

persistent lesions should have an US, which would likely reveal a solid, well-circumscribed, avascular mass

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20
Q

(4) Broad Causes of prolonged QT

A

BOMM the QT

Bradyarrhythmias
Other (4)
Metabolic disorders
Medications (8)

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21
Q

these 8 types of medications can cause QT prolongation

A

BOMM
Brady, other, meds, metabolic

Meds: 
Antibiotics
Cardiac (angina, arrhythmia)
Depression (TCA, antipsych, SSRIs)
Electrolytes
Emetics

diuretics (electrolytes)
antiemetics (zofran)
antipsychotics (Haldol, Seroquel, Risperdal)
TCAs
SSRIs
Anti-arrythmics (amiodarone, sotalol, flecainide)
Anti-Anginas drugs (ranolazine)
Anti-infectives (e.g., macrolides, fluroquinolones, antifungals)

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22
Q

what are the (4) other causes of QT prolongation?

A

BOMM
Brady, other, metabolic, meds

Other:

  1. Hypothermia
  2. MI
  3. Intracranial disease
  4. HIV
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23
Q

a brief arrhythmia that terminates spontaneously, but can evolve into recurrent episodes in rapid succession, with a risk of degenerating into VFIB and death

[] if the patient is conscious and hemodynamically stable, what treatment should be given?
[] if the patient does not respond to this treatment, what is next?

A

Mag sulfate (even in patients with normal serum Mag)

temporary transvenous pacing should be used in patients who do not respond to IV-Mag sulfate

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24
Q

what are the (3) parameters of the GCS?

A 
(E) = eye        4
(V) = verbal   5
(M) = motor   6
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25
Q

the MC cause of ascites in the USA

A

hepatic cirrhosis

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26
Q

this gradient is useful in identifying the presence or absence of portal HTN and has replaced the old transudative-exudative model of classification

[] how do you calculate
[] how do you interpret
[] what clinical conditions have a high or low SAAG?

A

Serum Ascites Albumin Gradient (SAAG)

serum albumin minus the ascitic fluid albumin

SAAG >=1.1 g/dl indicates a high gradient and likely portal HTN

High: CHF, cirrhosis, ETOH hepatitis

Low: peritoneal carcinomatosis, peritoneal TB, nephrotic syndrome, pancreatitis, and serositis

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27
Q

these injuries commonly occur when a force is applied to the knee from the lateral to medial direction during skiing or contact sports with PE showing values laxity

[] treatment

A

Medical collateral ligament tear

uncomplicated MCL tears can be managed non-operatively with rest, ice, compression, and elevated (RICE), as well as analgesics

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28
Q

may parents consent for sterilization of intellectually disabled children?

A

forced sterilization is considered unethical and involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her body integrity

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29
Q

these two findings are strongly suggestive of NF-2

[] inheritance pattern

A

bilateral acoustic neuroma
hypo-pigmented skin lesions

Autosomal Dominant

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30
Q

recent onset of asymmetric oligoarthritis that is inflammatory, yet sterile (culture negative) in a patient with a recent history of chlamydia

[] MC preceding infection
[] classic triad of symptoms
[] an extraarticular manifestation that is painless, resolves in several months, and not a/w LAD
[] what is the treatment

A

Reactive Arthritis

GI:

  1. Campylobacter
  2. Shigella
  3. Salmonella
  4. Yersinia
  5. C diff

GU: Chlamydia

“Cant see, can’t pee, can’t climb a tree”

Uveitis, conjunctivitis
Urethritis, cervicitis, prostatitis
Arthritis

Circinate balanitis is extra-articular manifestation

active infections should be treated (i.e., chlamydia) with antibiotics, and symptoms treated with NSAIDs

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31
Q

a life-threatening disorder of thiamine deficiency seen MC in patients with heavy ETOH use and/or severe malnutrition

[] classic triad
[] treatment
[] complication
[] what are the signs of the complications and MRI finds?

A

Wernicke’s Encephalopathy

  1. Encephalopathy
    - ams, disoriented
  2. oculomotor dysfunction
    - lateral rectus palsy
  3. gait ataxia
    - wide based or complete impairment

tx: IV-thiamine

cx: Korsakoff Syndrome
up to 80% show retrograde or anterograde amnesia, often with confabulation; usually not reversible

n.b., cognition, attention, social behavior, and long-term memory are preserved

MRI shows mammillary body atrophy

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32
Q

a generalized maculopapular rash in a patient with recent amoxicillin use probably actually had what infection?

[] pathophys
[] management

A

Infectious mononucleosis

(amoxicillin or ampicillin)

pathophys: unknown, but likely antibodies against PCN derivatives

not a true allergy to ABX, it will resolve spontaneously over time with observation and supportive care

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33
Q

patients with mononucleosis generally have rash, fever, fatigue, and throat pain

[] what patients have increased risk for prolonged fatigue

A

supportive care is the mainstay of treatment for individuals with IM, and most symptoms (including a rash) will resolved spontaneously within 1-2 weeks. Fatigue may persist for months, and women or individuals with pre-existing mood disorders may be at increased risk for prolonged fatigue

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34
Q

pooling the data from several studies to increase statistical power

A

Meta-analysis

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35
Q

rapidly progressive weakness of the LE after an URI, accompanied by sensory loss and urinary retention

A

Transverse Myelitis

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36
Q

recurrent, unexpected attacks consistent with chest pain, palpitations, SOB, sweating, nausea, dizziness, derealization/depersonalization, and fear of losing control or dying

[] treatment

A

Panic disorder

1st line/maintenance:
SSRI/SNRI +/- CBT

acute: benzodiazepines

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37
Q

EKG findings in WPW?

A

short PR
delta wave
wide QRS

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38
Q

the overall incidence of sudden cardiac death in patients with WPW is very low (<1%), but the risk is increased if patient’s have what?

[] recommended therapy

A

tachyarrhythmias due to Afib, as impulses can conduct from the atria > ventricles at a very fast rate, potentially causing rhythmic degeneration to VFIB

catheter ablation

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39
Q

commonly seen in patients >50 YO with sub-acute/chronic pain in the shoulder and hip girdle with morning stiffness >1h, constitutional symptoms, elevated ESR, and no other apparent explanation

[] treatment

A

Polymyalgia rheumatica (PMR)

Low-dose prednisone

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40
Q

a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick, silverly scales

[] what are the (3) classifications
[] treatment by class

A

Psoriasis

Mild-moderate psoriasis
Severe plaque psoriasis

Facial/intertriginous psoriasis

guttate psoriasis

Mild-Moderate:

  • topical high potency CS
  • topical Vitamin D

Severe:

  • Phototherapy
  • MTX, biologics

Facial/Intertriginous

  • Topical tacrolimus
  • Low potency CS

Guttate
-Observation or phototherapy

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41
Q

Moms with O type blood who give birth to A or B infants are at risk of this disease

[] when is bilirubin considered severe?
[] treatment by type

A

Neonatal hyperbilirubinemia

Bilirubin >20-25 mg/dl is severe

Mild (physiologic)
-breast feed q2-3 hours

Moderate

  • phototherapy
  • formula, IV hydration

Severe
-exchange transfusion

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42
Q

a procedure in which bilirubin and circulating antibodies are removed and the infant’s RBCs are replaced with donor RBCs

[] in which bilirubin level is this indicated
[] feared cx

A

Exchange transfusion

Bili >20-25 mg/dl
Failed phototherapy
Worsening hyperbilirubinemia

prevent Kernicterus (bilirubin crossing BBB)

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43
Q

(5) Causes of Recurrent Pneumonia

A
  1. Aspiration
  2. COPD/asthma
  3. Immunodeficiency
  4. Post-obstructive
  5. TB
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44
Q

a common cause of recurrent pneumonia in Parkinson’s disease duet o mental status and dysphagia/dysarthria

[] MC organisms
[] MC location in lung
[] best way to diagnose
[] treatment

A

Aspiration PNA

Anaerobes
Polymicrobial

MC in RML/RLL

dx: videofluoroscopic swallow study

Tx: Clindamycin

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45
Q

a common cause of recurrent pneumonia in smokers or those with prolonged SOB/cough

[] MC organisms

A

COPD/asthma/bronchiectasis

S pneumo
HiB
Moraxella
Pseudomonas (esp in bronchiectasis)
Viral
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46
Q

MC cause of recurrent pneumonia in recent immigrants, institutionalized patients, or homeless/low SES

A

Mycobacterium TB

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47
Q

(3) phase/classifications of acne

A
  1. Comedonal
  2. Inflammatory
  3. Nodular (cystic)
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48
Q

closed or open comedones on the forehead, nose, and chin which may progress to inflammatory pustules or nodules

[] treatment

A

Comedonal acne

  1. topical retinoids
  2. salicylic acid
  3. glycolic acid
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49
Q

inflamed papules (<5 mm)and pustules with erythema on the face

[] treatment

A

inflammatory acne

  1. topical retinoids + benzoyl peroxide
    • topical abx (e.g., erythromycin, clindamycin)
    • oral abx
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50
Q

large (>5 mm) nodules that can appear cystic on the face, forehead, chin, and may merge to form sinus tracts with scarring

[] treatment
[] special considerations

A

Nodular (cystic) acne

  1. topical retinoids + benzoyl peroxide + topical abx
    • po abx
  3. oral isotretinoin

tazarotene and oral retinoid isotretinoin are designated Category X in pregnancy and never used

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51
Q

used in survival analysis, it is similar to relative risk

A

Hazard ratio

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52
Q

significantly increased urinary cortisol levels, non suppressible high-dose dexamethasone, and undetectable ACTH levels are highly suggestive of this disease

[] diagnosis

A

Cushing Syndrome secondary to adrenal etiology

[] CT/MRI abdomen

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53
Q

transient neurologic disturbance (e.g., dizziness, disorientation, amnesia) after a mild traumatic brain injury

[] management

A

Concussion

after a concussion, average-risk adults should rest for >=24 hours before gradually increasing their activity level each 24-hour period they remain asymptomatic, potentially returning to full contact sports within 1-week; if you develop symptoms, you should return to the last activity level in which you were asymptomatic for 24 hours prior to progression

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54
Q

a screening test should have this high characteristic to prevent as many of these

A

high sensitivity to prevent as many false negatives and help “rule out” disease

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55
Q

what is the MC location of an abdominal aortic aneurysm

A

infrarenal

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56
Q

what are some RF associated with the development of an AAA?

A

male sex, smoking, age >60, family history, white ethnicity, and atherosclerotic disease

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57
Q

who do we screen for AAA?

A

men 65-75 YO who have ever smoked

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58
Q

what is the management for AAA?

A

it is by size

<4 cm, US q 2-3 years
4.0-5.4 cm, US q 6-12 months

Surgery is indicated for:

  1. Large (>=5.5 cm)
  2. Growth >=0.5 cm in 6 months
  3. associated with PAD or aneurysm
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59
Q

these two antibodies are associated with SLE, although one is more sensitive at 66-95%

A

anti-smith
anti-DS DNA

anti-DS DNA is more sensitive

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60
Q

which antibodies can be used to follow disease activity in SLE and are associated with lupus nephritis?

A

anti-DS DNA

61
Q

antibodies in scleroderma

A

anti-centromere

62
Q

antibodies in primary biliary cirrhosis (PBC)

A

anti-mitochondrial

63
Q

antibodies associated with Sjogren’s syndrome

A

anti-Ro

anti-La

64
Q

how do you treat SLE associated with arthralgia, serositis and cutaneous symptoms?

A

Hydroxychloroquine (anti-malarial)

65
Q

how do you treat serious manifestations of SLE (e.g., nephritis, cerebritis, vasculitis)

A

Prednisone with Cyclophosphamide

66
Q

in SLE, if patients with significant organ involvement have an incomplete response to prednisone alone, this can be added

A

Methotrexate

67
Q

this drug is not used often in SLE as there are reports of progressive multifocal leukoencephalopathy (PML)

A

Rituximab (CD20)

68
Q

ocular symptoms consistent with keratoconjunctivitis sicca and oral symptoms consistent with xerostomia should lead to the diagnosis of this syndrome

[] antibodies
[] test for ocular symptoms
[] complication

A

Sjogren’s Syndrome

chronic, auto-immune inflammatory condition that primarily affects the lacrimal and salivary glands

anti-Ro
anti-La

Schirmer test is used to confirm keratoconjunctivitis sicca; filter paper is placed along the lower eyelid and wetting of the paper is measured after a defined period of time

B-cell NHL is a complication of chronic B-cell activation in Sjogren’s

69
Q

an acute confusional state that is very common in elderly patients and those in SNF, it manifests as a change in awareness, easy distractibility, cognitive and perceptual disturbances which include memory loss, disorientation, hallucinations, and even agitation

[] management

A

Delirium

physical and chemical restraints should be judiciously used in a combative and disruptive patient

always give Haldol before restraints

Do not give BDZ, as they can worsen delirium

70
Q

the result of an abnormal fertilization of an empty ovum by either 2 sperm or 1 whose genome duplicates, the result is a gestation which is pre-malignant

[] can develop into
[] labs to order
[] treatment
[] further management

A

Hydatidiform mole

can develop into gestational trophoblastic neoplasia (GTN)

order b-hCG

management is by suction curettage, after which serial b-hcg are followed until undetectable for 6 months. Because pregnancy can confound this follow-up, contraception is required during the surveillance period

71
Q

progressive, painless, proximal muscle weakness with elevated muscle enzymes and inflammatory markers, it is an inflammatory myopathy triggered by unknown, possibly viral, antigens

[] clinical signs
[] what is a similar disorder which has one distinction
[] these disorders can often be seen as sequelae of what bigger entities
[] testing / definitive diagnosis

A

Polymyositis

peak incidence 40-50 YO

muscle weakness can manifest as difficulty climbing stairs, getting into or out of a chair/car, or working with the arms overhead

dermatomyositis is similar, but has skin manifestations (Gottron’s papules)

may occur as a paraneoplastic syndrome

anti-Jo may be elevated
definitive: muscle biopsy

72
Q

antibodies elevated in polymyositis

[] what complication can be seen if elevated

A

anti-Jo

interstitial lung disease, infections, drug-induced pneumonitis (e.g., MTX), and respiratory ms weakness

73
Q

young to middle aged women with chronic, widespread pain associated with fatigue and impaired concentration

[] physical exam findings
[] how do you diagnose

A

Fibromyalgia

tenderness at trigger points (e.g., mid-trapezius, costochondral junction)

> =3 months of widespread pain or symptom severity score with normal labs

74
Q

a flu-like febrile illness with marked myalgia and joint pain

[] transmission
[] dangerous progression
[] management

A

Dengue fever

Aedes mosquito from endemic areas (SE Asia, Pacific Islands, Caribbean, Americas)

dengue hemorrhagic fever:

  1. increased vascular permeability
  2. thrombocytopenia (<100)
  3. spontaneous bleed > shock
  4. positive tourniquet test (petechiae after cuff inflation for 5 mins)

supportive care

75
Q

abrupt onset of fever, myalgia, and HA with slow reddening of the eyes without inflammation; it can also involve GI symptoms such as nausea/vomiting

A

Leptospirosis

conjunctival suffusion is key

76
Q

a severe form of this bacterial infection, it is characterized by dysfunction of the kidneys and liver, abnormal enlargement o the liver, jaundice, and/or alterations in consciousness

A

Weil Syndrome

severe Leptospirosis

77
Q

which is the best test to diagnose osteomyelitis?

how long does this test take to show infection

A

MRI

changes are present within 5 days of onset, therefore, patients with symptoms >1 week are considered “ruled out” for O.M.

78
Q

after O.M. is confirmed, what test should be done next?

A

since DM foot infections are likely polymicrobial, bone biopsies are needed to determine the pathogenic organism

79
Q

fatigue, exertion dyspnea, a systolic murmur which accentuates with Valsalva, asymmetric septal hypertrophy, systolic anterior motion of mitral leaflets, and increased LVOT gradient

[] genetics
[] symptomatic patients require what treatment

A

hypertrophic cardiomyopathy

Autosomal dominant genetic disorder of the cardiac sarcomere; it has heterogenous and variable clinical presentation

patients with symptoms of heart failure and LVOT gradient should be given negative inotropic agents (Beta blockers then verapamil, or disopyramide)

80
Q

these (3) maneuvers decrease preload

A

Valsalva
Abrupt standing
Nitroglycerin

81
Q

this maneuver increases afterload

A

hand grip

82
Q

this maneuver increases preload

A

leg raise

83
Q

this maneuver increases both preload and afterload

A

squatting

84
Q

these two scenarios are indications for ICD placement for primary prevention

A
  1. Prior MI & LVEF <=30%

2. NYHA II or III with symptoms and LVEF <=35%

85
Q

these two scenarios are indications for ICD placement for secondary prevention

A
  1. Prior VF or unstable VT without a reversible cause

2. Prior sustained VT with underlying cardiomyopathy

86
Q

should we screen for cervical cancer in women who have sex with women?

A

WSW have an increased risk of cervical cancer from HPV infection compared with heterosexual women, likely due to the lower rates of vaccination, lower rates of screening, and higher rates of smoking and obesity

there is also a higher risk of ovarian and breast cancer due to the above, as well as low parity and less OCP use

Bacterial vaginosis (while not an STI) is transmitted through vaginal fluids and is therefore more commonly seen in WSW; screening is not recommended, but symptomatic infection should be treated

87
Q

an invasive infection of the external ear canal

[] MC organism
[] MC risk factors
[] treatment and for how long
[] complication

A

External otitis externa

MC: Pseudomonas

Advanced age, DM, HIV

IV-fluroquinolones (Cipro), but anti-pseudomonas PCN (Piperacillin) with/without amionglycosides and 3rd gen cephalosporins (Ceftaz); treat with IV, if inflammatory markers are normal, then switch to po for 6-8 weeks

cx: untreated MOE can progress rapidly to involve the skull base, TMJ, and cranial nerves, leading to O.M. and CN palsy

88
Q

first line treatment for prolactinomas, including large prolactinomas

A

DA receptor agonists

usually see a decrease in tumor size within a few days and visual symptoms usually improve before the tumor’s decrease in size is seen on MRI

89
Q

pregnant women should not receive live vaccines, what are they?

A

Rotavirus
MMR
Varicella

90
Q

if a parent refuses medically necessary care for a child in an emergency situation, what are the options for the provider?

A

In emergency situations, the inability to obtain consent or parental refusal of consent should not delay care. Parental refusal to an intervention that may prevent severe injury or death may be considered an act that is not in the best interest of the child, and medical providers should proceed with treatment. A court order should also be sought to legally overrule a parental decision; however, treatment should not be withheld while awaiting a decision

91
Q

this infection may occur in patients with advanced HIV (CD4<100) and is typically a marker of disseminated disease; it most commonly includes the rapid onset of multiple papular lesions with central umbilication and central hemorrhage/necrosis

[] what other infection does this resemble?
[] how do you diagnose?
[] treatment

A

cutaneous cryptococcosis

it resembles molloscum contangiosum, but the central necrosis is key

diagnosed by lesion biopsy with histopathological exam

usually treated with >=2 weeks of IV Amphotericin B and po Flucytosine, followed by 1 year of po Fluconazole (higher dose for 8 weeks, then maintenance)

92
Q

meningoencephalitis following the bite from a mosquito, it typically occurs in the summer and presents with fever, HA, vomiting, nuchal rigidity, and AMS

[] diagnosis
[] treatment

A

West Nile Virus

CSF aseptic pleocytosis
viral serologies

supportive care
acyclovir for HSV

93
Q

patients with primary hypothyroidism are predisposed to get other AID. If a patient with this disorder starts to present with loss of proprioception, brisk reflexes, and loss of ankle jerks, what should be considered?

[] pathophys
[] what is the neuro-syndrome referred to as?

A

Vitamin B12 deficiency secondary to pernicious anemia

AI destruction of the parietal cells, leading to achlorhydria and decreased production of intrinsic factor

involvement of the posterior and lateral columns in the spinal cord is known as “subacute combined degeneration” and leads to ataxia, loss of proprioception, and vibratory sensation

94
Q

treatment of moderate to severe megaloblastic anemia with vitamin B12 can lead to this

[] mechanism

A

hypokalemia

results following the uptake of potassium by newly forming RBCs; monitor for 48 hours, replete as needed

95
Q

mutations of filaggrin and other epidermal barrier proteins lead to this disrupted skin barrier which has increased antigen exposure and hypersensitivity causing pruritus

[] associations
[] differences between infants and children/adults
[] lab findings
[] treatment

A

Atopic dermatitis (eczema)

infants - extensors
child/adult - flexural

associated with:
Asthma
Allergic Rhinitis
Atopic dermatitis

high serum IgE
eosinophilia

po antihistamines and regular use of emollients to maintain skin hydration

most patients will benefit from topical glucocorticoids:
hydrocortisone > TAC, betamethasone

if face or eyes > tacrolimus

if severe > UV therapy or systemic immunosuppresants

96
Q

acute onset symmetric joint pain, swelling, and stiffness in the PIP and MCPs a week after a flu-like illness

[] diagnosis
[] treatment
[] prognosis

A

viral arthritis with ParvoB19

serum serology with IgM

supportive and NSAIDs

no long term sequelae

97
Q

presents 2-4 weeks after GAS pharyngitis, causing a migratory polyarthritis in the larger joints (e.g., knee, elbow); skin findings often include erythema marginatum and SQ nodules

A

acute rheumatic fever

98
Q

often monoarticular (e.g., knee) associated with erythema migrans following exposure

A

lyme arthritis

99
Q

a chronic, inflammatory arthritis which often presents with morning stiffness in bilateral MCP and PIP joints, is insidious in onset and requires symptoms for at least >6 months

A

rheumatoid arthritis

100
Q

polyarticular arthritis, often gradual in onset, but with constitutional symptoms, malar or discoid rash

A

SLE

101
Q

what 3 things should you assess in a patient with high suspicion of self harm?

[] who needs admission

A

Ideation
Intent
Plan

ideation - passive vs active

intent - strength of compulsion, how close are they to completion

plan - method, time/place, lethality, likelihood of rescue

patients who have attempted or who have active SI with a specific plan and intent require hospitalization

102
Q

this drug has evidence of reducing the risk of suicide in mood disorder patients

A

Lithium

103
Q

what cardiac valvular disorder can cause dyspnea, orthopnea, PND, and hemoptysis with possible Afib and systemic thromboembolism and voice hoarseness

A

mitral stenosis

104
Q

What are the murmur findings in mitral stenosis?

A

Loud S1 (loud P2 if PHTN)

Opening snap (high freq, early diastole)

Mid-diastolic rumble (apex)

105
Q

what are the CXR, EKG, and TTE findings in mitral stenosis?

A

CXR: pulmonary blood flow redistribution to upper lobes, dilated p vessels, LAE, flat heart border

EKG: “p mitrale” (broad, notched p waves), atrial tachyarrhythmias, RVH (tall R waves in V1 and V2)

TTE: MV thickening/calcification, decreased mobility, coexisting MR

106
Q

the MC cause of hemoptysis in COPD

[] if patients have increased SOB, sputum volume, or purulence in sputum, what should be given?

A

while ABX are generally not recommended for acute bronchitis in otherwise healthy individuals 2/2 viral etiology, patients with COPD who have any 2 of these features should receive ABX:

  1. increased sputum purulence
  2. increased sputum volume
  3. increased SOB
107
Q

nearly 25% of C diff infection (CDI) recur after successful treatment, usually within 1-3 weeks (but up to 3 months)

[] mechanism of recurrence
[] how to confirm
[] how to treat

A

CDI

recur - persistent spores or reinfection with same/different strain

confirm with stool studies for C diff

First Recur:
-po vanc in prolonged/tapered course OR fidaxomicin if Vanc used in first episode

Multiple recur:

  • po vanc followed by Rifaximin (or above)
  • fecal transplant

fulminant (hypotension/shock/ileus, megacolon):
-flagyl IV plus high dose po vanc (or per rectum if ileus), surgical eval

108
Q

how do you treat an initial episode of C diff

A

po Vancomycin or Fidaxomicin

109
Q

what risk assessment tool is used for unstable angina/NSTEMI?

[] what are the 7 clinical variables
[] how do you interpret?

A

Thrombolysis in Myocardial Infarct Score (TIMI)

  1. Age >=65 YO
  2. > =3 risk factors for CAD
  3. Known CAD with >50% stenosis
  4. Use of ASA within 7 days
  5. > =2 anginal episodes in the past 24 hr
  6. elevated biomarkers (e.g., troponin)
  7. ST deviation >0.5 mm on EKG

0-2 pts: Low Risk
-Stress Test

3-4: Intermediate or 5-7: High risk
-early coronary angiography within 24h

Hemodynamic instability, heart failure or new MR, recurrent CP, ventricular arrhythmia
-immediate coronary angiography

110
Q

symptoms which suggest ACS, but without elevated troponin

A

unstable angina

111
Q

symptoms which suggest ACS, but without EKG changes

A

NSTEMI

112
Q

prevents employers from requiring or requesting genetic testing results of their employees, and if they already have the information, they cannot use it to discriminate against the employee

A

the genetic information nondiscrimination act of 2008 prevents this employer discrimination based on genetic testing information

113
Q

if a patient with SLE presents with proteinuria, active urinary sediment, or declining renal function, what should be done?

A

a kidney biopsy is needed prior to initiation of treatment to guide therapy, as treatment varies by class

Class I and II are mild and do not require treatment

Classes III and IV require immunosuppression with glucocorticoids (e.g., Methylprednisolone, Prednisone) and Cyclophosphamide or Mycophenolate

Class V requires immunosuppression if proliferative lesions or nephrotic syndrome is present

Class VI is advanced and immunosuppression is not recommended

114
Q

use this to monitor renal disease activity in SLE nephritis

A

complement and anti-ds-DNA antibody

immune complexes are deposited in the mesangial, subendothelial, or subepithelial space, with resultant influx of PMNs and mononuclear cells.

immune complex deposition within the glomerulus induces complement fixation, leading to low circulating completement levels; therefore, higher disease activity is associated with lower complement levels

115
Q

brief and shooting back pain provoked by bending forward and straining is typical for this nerve root irritation

[] diagnostic sign

A

Sciatica

straight leg raise at 60 degree angle or less should provoke the pain

116
Q

flaky, itchy skin with erythematous plaques and loose, greasy-looking scales commonly on scalp, central face, ears, and chest

[] risk factors
[] pathophys
[] treatment
[] prognosis

A

Seborrheic dermatitis

on the scalp – its dandruff
on central face – eyebrows and nasolabial

RF: CNS disease (parkinson) and HIV

Malassezia spp

Treatment:

  • topical antifungals (e.g., selenium sulfide, ketoconazole)
  • topical glucocorticoids
  • topical calcineurin inhibitors (e.g., pimecrolimus)

chronic, relapsing condition and initial treatment may provide improvement in symptoms, but patients often require intermittent re-treatment

117
Q

most commonly seen as a rash in children, it causes annular plaques with peripheral scaling and central clearing

treatment

A

Tinea capitis

Griseofulvin

118
Q

what is hospice care and what are the rules of entry/exit?

A

an interdisciplinary palliative care service for patients with life-limiting illnesses (prognosis <=6 months) who have chose to stop pursuit of disease-modifying, curative therapies

Patients are free to leave hospice at any time to pursue curative treatments and can return later

119
Q

which of these is a contraindication to hospice care?

A: ischemic brain damage
B: lack of advanced directive regarding return to hospice
C: lack of patient’s consent
D: ventriculoperitoneal shunt

A

E: None of these

the only requirements for hospice care are a prognosis <=6 months and the patient’s or surrogate’s decision to forego life-sustaining treatment.

Physicians should educate patients and family that comorbid medical conditions and inability to give full informed consent are not contraindications

120
Q

patient with RUE hypertension, LE claudication, weak delayed pulses, and heart murmur

[] MC location of defect
[] notoriously associated with this syndrome
[] CXR findings
[] how to confirm the diagnosis

A

Aortic coarctation

the defect is usually congenital and located distal to the L-subclavian

notoriously associated with Turner syndrome, but it can sporadically develop in males

CXR shows rib notching from collateral vessels and “figure 3 sign” at the site of aortic narrowing

EcHO confirms

121
Q

define delayed puberty

A

puberty is considered delayed if there are no secondary sexual characteristics (testicular enlargement >4mL or breast development by age 14 in boys or 12 in girls)

122
Q

delayed development of secondary sexual characteristics in conjunction with delayed bone age, short stature but normal growth velocity, and a family history of “late bloomers”

[] contrast to this other disease
[] management
[] prognosis

A

constitutional delay of growth and puberty

contrast to familial short stature, in which short stature and normal growth velocity are accompanied by normal bone age

management consists of watchful waiting, reassurance +/- hormonal therapy

prognosis is good with normal expected adult height and correlates with family members

123
Q

ureteral stones which cause proximal ureteral obstruction resulting in hydronephrosis, superimposed infection, and hemodynamic instability

management

A

requires decompression of upper urinary tract with percutaneous nephrostomy or ureteral stent placement

124
Q

MC manifestation of sickle cell disease

A

vaso-occlusive crisis

125
Q

acute episode of minor to severe pain that typically affect the back, chest, abd, or extremities in patients with SCD

[] common triggers
[] management
[] complication

A

vaso-occlusive pain crisis

triggers include dehydration, infection, stress, weather change, menstruation

often requires hospitalization and prompt administration of po or IV pain medications with gentle rehydration

acute chest syndrome is defined by the presence of a new pulmonary infiltrate on CXR and fever, hypoxemia, chest pain, tachypnea, or increased WOB; treat them with Ceftriaxone and Azithromycin with pain meds and IVF

126
Q

recurrent pneumonia in an elderly smoker should raise concern for what?

[] how do you diagnose?

A

bronchogenic carcinoma due to endobronchial obstruction

flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving PNA or pulmonary infiltrates

127
Q

are patients with active TB infectious?

A

patients with active TB are at risk of transmitting MTB to close contacts via aerosolized droplets for up to 3 months prior to the onset of their symptoms

128
Q

to evaluate potential exposure to TB via healthcare personnel, what should be done?

A

ppd or IFN y assay

if initial screening is negative, repeat the test in 8-10 weeks

129
Q

this ppd is positive in HCP

A

> =10 mm induration

130
Q

is latent TB infectious?

A

those with no CXR abnormalities and no symptoms (e.g., wt loss, NS, chronic cough), but positive screening are considered to have latent TB

LTBI is noninfectious, and individuals may continue to work and live normal lives. However, treatment should be offered if there is a high suspicion of conversion to active TB (only 5-10% do), such as immunocompromised individuals, inmates, or those who work in high risk congregate settings (health care)

131
Q

how do you treat LTBI?

3 options

A
  1. INH and rifapentine weekly for 3 months (not recommended for HIV)
  2. INH for 6-9 months
  3. Rifampin for 4 months
132
Q

when are patients treated for active TB considered non-infectious?

A

when 3 consecutive AFB sputum smears are negative (8-24 hour intervals, and >=1 early morning)

133
Q

these two herbs are used for memory enhancement and improved mental performance, but carry risk of bleeding

A

ginkgo biloba and ginseng

134
Q

this herb is used for BPH, but carries risk of mild ABD discomfort and bleed risk

A

saw palmetto

135
Q

this herb is used for postmenopausal symptoms (hot flashes and vaginal dryness), but can lead to hepatic injury

A

black cohosh

136
Q

this herb is used for depression and insomnia, but can lead to serotonin syndrome if used with antidepressants, or react with OCPs, Warfarin (low INR), dignoxin, and cause HTN crises

A

St John’s Wort

137
Q

used for anxiety and insomnia, it can lead to severe liver damage

A

kava kava

138
Q

used for stomach ulcers and bronchitis/viral infections, it can lead to HTN and hypokalemia

A

licorice

139
Q

used to prevent colds/flu, it can cause anaphylaxis (esp in asthmatics)

A

echinacea

140
Q

used to treat cold/flu or as a weight loss supplement, it can lead to HTN, arrhythmias/MI, CVA, seizures

A

ephedra

141
Q

an important natural phenomenon of disease epidemiology, it refers to both disease pathogenesis and exposure to risk modifiers to describe how an inciting event sometimes takes time before a clinical manifestation is evident

A

latency period

142
Q

an inherited disorder marked by multiple, bilateral renal cysts; patient are often asymptomatic, but can develop HTN, hematuria, proteinuria, AKI or flank pain

[] genetics
[] diagnosis
[] what % require renal replacement therapy by age 60?
[] extra-renal manifestations
[] management
A

autosomal dominant polycystic kidney disease

inherited with prevalence of 1 in 500

diagnosis requires renal US

50% require RRT by age 60 YO

Extra-Renal:

  1. cerebral aneurysms
  2. hepatic/pancreatic cysts
  3. MVP, AR
  4. colonic diverticulosis
  5. ventral/inguinal hernia

Management:

  1. aggressive HTN management
  2. control risk factors for CVD and CKD, including statins
  3. ACE-in for HTN
  4. H.D., renal transplant
143
Q

vaginal bleeding with a friable, exophytic cervical lesion

[] diagnosis
[] if patient has HIV+, what does this tell you
[] what are other risk factors for this condition?

A

cervical cancer

biopsy of the lesion (cervical punch)

in patients who are HIV+, cervical cancer is an AIDS-defining illness as immunocompromised patients do not clear HPV infections and have persistent infection that can progress to cervical dysplasia and cancer

Risk Factors:

  1. HPV 16, 18
  2. Hx of STD
  3. Early onset of sexual maturity
  4. Multiple or high-risk partners
  5. Immunosuppression
  6. OCPs
  7. low SES
  8. Tobacco use
144
Q

this reduces the statistical power to detect an association

A

sample size (low)

145
Q

pooling data from several studies to increase statistical power

A

Meta-analysis

146
Q

these (3) cause increased maternal serum AFP

A
  1. open neural tube defects (e.g., anencephaly, open spina bifida)
147
Q

acute retrosternal chest pain following episodes of repeated vomiting

[] where are the lesions
[] diagnostic studies
[] management

A

Boerhaave syndrome

full-thickness tear of the esophagus due to sudden elevation in esophageal pressure (e.g., vomiting) allowing gastric contents to enter sterile sites (e.g., mediastinum)

Most are in the distal 1/3

esophagography or CT with water soluble contrast

acid suppression, NPO, abx
emergency surgical consult

148
Q

this physical exam finding in a patient with recurrent, forceful retching should be concerning for Boerhaave syndrome

A

crepitus, crunching sound

Hamman sign

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