Medicine/surgery Usmle/mccee

Front 1

What is the secretory product of chief cells and was is its action?

Back 1

- Pepsinogen
- Coverted to pepsin by gastric acid and cleaves proteins into peptides

Front 2

Name 3 hormones (factors) which stimulate gastric acid secretion

Back 2

1. Histamine
2. ACh
3. Gastrin

Front 3

What is 1st line eradication therapy for H. pylori?

Back 3

- PPI
- Clarithromycin (500mg)
- Amoxicillin (1000mg bid)
for 7 - 14 days
- Approx 90% eradication rate

Front 4

What regimen can be used for eradication therapy for H. pylori in a person with a penicillin allergy?

Back 4

- PPI
- Clarithromycin (500mg)
- Metronidazole (500mg)

Front 5

What is the triad in multiple endocrine neoplasia I (MEN I) ?

Back 5

"The 3 P's"
1. Pancreas (Zollinger-ellison, insulinoma, VIPoma)
2. Pituitary
3. Parathyroid

Front 6

What is Whipples disease?

Back 6

a systemic infectious disease caused by the bacteria Trpheryma whipplei.
- it mainly causes malabsorption but can affect other body parts including heart lungs brain joints and eyes
- significantly more common in men

Front 7

What are the consequences of Vit E deficiency?

Back 7

- retinopathy
- neurological problems

Front 8

Outline the Schilling's test

Back 8

1. Give radiolabeled B12 PO
2. Measure 24hr urine excretion of labeled B12
3. If decreased, give radiolabeled B12 w/ IF and measure 24hr urine
4. If normal = pernicious anemia
If still decreased could be:
- bacterial overgrowth (give antibiotics)
- pancreatic insufficiency
- ileal disease

Front 9

What genotype is found in 80-90% of people w/ Celiac disease?

Back 9

HLA-DR2

Front 10

What is the most specific and sensitive test for Celiac disease?

Back 10

anti-IgA tissue transglutaminase (TTG)
90-98% sen and 94-97% spec

Front 11

What is the NR for sodium (Na+) ?

Back 11

135-147 mEq/L (or mmol/L)

Front 12

What is the NR for potassium(K+) ?

Back 12

3.5 - 5.0 mEq/L (or mmol/L)

Front 13

What is the NR for bicarbonate (HCO3-) ?

Back 13

22-28 mEq/L (or mmol/L)

Front 14

Name 7 options in the treatment of Crohns

Back 14

1. 5-ASA (eg. sulfasalazine)
2. Steroids
3. 6-MP
4. Azathioprine
5. Cyclosporine or methotrexate
6. Infliximab
7. Surgical (fistulae/fissures)

Front 15

True/False

There is a greater risk of colon cancer in Crohns disease cf Ulcerative colitis

Back 15

FALSE!

Front 16

Where is the ligament of Treitz?

Back 16

suspensory ligament in the 3rd and 4th portions of the duodenum.
Proximal to this ligament is referred to as UPPER GI, distal to is LOWER GI

Front 17

What proportion of upper GI bleeds stop spontaneously or require only supportive therapy?

Back 17

80%

Front 18

What are the lobes of the liver?

Back 18

1. Left
2. Right
3. Caudate
4. Quadrate

Front 19

Which clotting factor is NOT synthesized in the liver?

Back 19

Factor VIII

Front 20

What are 3 lab tests of liver function and what is the order in which they become abnormal in liver deterioration?

Back 20

1. Increase in PT/INR
2. Increase in bilirubin
3. Decrease in albumin

Front 21

What is the risk of developing the following after needlestick injury?
1. HBV
2. HCV
3. HIV

Back 21

1. 30%
2. 3%
3. 0.3%

Front 22

What percentage of people infected w/ HCV will develop:
1. Chronic hepatitis?
2. Cirrhosis?

Back 22

1. 80%
2. 20%

Front 23

Which serum markers are abnormal in Wilsons disease?

Back 23

1. reduced total serum copper
2. low serum ceruloplasmin

Front 24

What is the difference b/w a retrospective (or a case control) study and a retrospective cohort study?

Back 24

In a case control study you begin with the outcome whereas in a retrospective cohort study starts at some point b/w exposure and outcome.

Front 25

An HIV +ve pt presents w/ several purple skin masses on his lower abdomen. Abdo CT shows nodular contrast enhanced intrahepatic lesions of variable size. Liver biopsy is attempted but severe hemorrhage results. What is the cause of this pts condition?

Back 25

Bartonella infection
- aka causative agent in cat scratch disease
- causes bacillary angiomatosis in immunocompromised

Front 26

Pt presents w/ fever of 39C and S&S suggestive of acute pyelonephritis. What is the next step in management?

Back 26

- Blood cultures (must be BEFORE antibiotics given)
- After cultures sent off then antibiotics like ciprofloxacin or ceftriaxone can given

Front 27

True/False

Bipolar disorder is more common in people from higher socioeconomic classes?

Back 27

TRUE

Front 28

What is the risk of developing bipolar disorder in an individual w/ a 1st degree relative w/ bipolar disorder?

Back 28

5 - 10%

Front 29

Why do pts w/ Turners syndrome commonly present w/ swelling of the hands and feet at birth?

Back 29

Congenital lymphedema is common due to abnormal development of the lymphatic network
- lymphedema as in this case would typically be non-pitting

Front 30

What is ehrlichiosis?

Back 30

Tick borne illness similar to Rocky Mountain spotted fever (only without the spots)
Symptoms include:
- Fever
- Malaise
- Myalgia
- Headache
- N&V

Front 31

What is the most common cause of osteomyelitis in pts w/ sickle cell disease?

Back 31

Salmonella (up to 70% of cases)
Some debate over most common Salmonella vs S. aureus but evidence thus far is in favour of Salmonella

Front 32

How long after a toxic dose of acetaminophen ingestion can the antidote be administered and not adversely affects the pts outcome?

Back 32

- Within 8 hrs of ingestion
- Antidote is N-acetylcysteine
- Drug levels should be obtained at 4 hrs but not before
- Admin of activated charcoal w/in 4 hrs of ingestion is appropriate

Front 33

What screening must a women w/ hereditary non-polyposis colorectal cancer (HNPCC) have?

Back 33

Screening for endometrial cancer (up to 43% of females affected)

Front 34

What drug causes red to orange discoloration of bodily fluids including urine, sweat, tears, saliva?

Back 34

Rifampin (used in TB cocktail)

Front 35

What is the most common cause of liver disease?

Back 35

NASH
- associated w/:
- increased TG and cholesterol
- insulin resistance
- increased ALT

Front 36

What is the primary managment of a pt w/ portal hypertension?

Back 36

- Beta blockers (propanolol, nadolol)
- nitrates
Above help decrease portal venous pressure and decrease the risk of bleeding from varices
- Shunts (transjugular intrahepatic portosystemic shunt TIPS)

Front 37

Describe Gilbert's syndrome

Back 37

- mild disease of defective conjugation of bilirubin
- as a result of decreased activity of glucuronyltransferase

Front 38

Describe Crigler-Najjer syndrome

Back 38

- defective conjugation of bilirubin as a result of a deficiency in uridine diphosphate glycosyltransferase
- 2 Types - I is lethal

Front 39

Primary biliary cirrhosis (PBC) affects both intra and extra hepatic bile ducts

True/False?

Back 39

FALSE
Causes chronic inflammation and fibrous obliteration of intrahepatic bile ductules

Front 40

Primary sclerosing cholangitis affects the entire biliary tree (both intra and extra hepatic bile ducts) leading to scarring and obliteration

True/False?

Back 40

TRUE
-impt association w/ ulcerative colitis and men (cf PBC)

Front 41

What are the causes of acute pancreatitis?

Back 41

I GET SMASHED !!

I - Idiopathic (3rd most common)
G - Gallstones (most common)
E - Ethanol (2nd most common)
T - Tumours (pancreas, ampulla)
S - Scorpion stings
M - Microbiological (bacteria, viruses, parasites)
A - Autoimmune (SLE, crohns)
S - Surgery/trauma (ERCP)
H - Hyperlipidemia, Hypercalcemia, hypothemia
E - Emboli or ischemia
D - Drugs/toxins (AZT, furosemide, estrogens, ASA)

Front 42

Where does the majority of iron get absorbed in the gut ?

Back 42

Duodenum

Front 43

Where do the majority of carbohydrates get absorbed in the gut?

Back 43

Duodenum

Front 44

Where do the majority of bile acids get absorbed in the gut?

Back 44

Ileum

Front 45

Where does VitB12 get absorbed in the gut?

Back 45

Ileum

Front 46

Where do the majority of proteins and lipids get absorbed in the gut?

Back 46

Duodenum
- but also in jejunum and ileum

Front 47

True/False

A pt w/ regular menstral cycles can be diagnosed w/ anorexia nervosa

Back 47

FALSE
- amenorhea is one of the diagnostic criterias for AN

Front 48

What is the appropriate sequence in management of a pt w/ a septic abortion?

Back 48

1. Cervical and blood cultures
2. Empirical antibiotics
3. Gentle suction and curettage

Front 49

How much Na+ does a 1L bag of normal saline (0.9%) contain?

Back 49

154mmol/L (and chloride)

Front 50

APPROXIMATELY how much Na+ is lost each day ?

Back 50

~150mmol/day

Front 51

How much Na+ does a 1L bag of Hartmann's solution contain?

Back 51

131mmol/L

Front 52

What are some advantages to Hartmann's solution?

Back 52

- has a lower level of chloride than normal saline (111mmol/L)

Front 53

What are some disadvantages to Hartmann's solution?

Back 53

- Contains excessive amounts of Na+ to be used exclusively
- Contains insufficient potassium (5mmol/L) and calcium (2mmol/L)

Front 54

Pt w/ diabetes presents w/ severe ear pain, otorrhea, and granulation tissue in the ear canal. What is the most likely causative agent?

Back 54

Pseudomonas aeruginosa

Front 55

What is the treatment of choice in a pt presenting w/ active rheumatic fever?

Back 55

Benzathine penicillin G

Front 56

What test can be used to differentiate b/w heart disease and liver disease related causes of lower extremity edema?

Back 56

Hepato-jugular reflex
- +ve when JVP elevates on abdo pressure
- suggests a cardiac cause (RHF)

Front 57

Pt presents post-stroke w/ hemi-sensory loss w/ severe dysesthesia (bad sensation).
Where was the stroke?

Back 57

Thalamus
(Dejerine-Roussy syndrome)
-specifically the VPL nucleus of thalamus

Front 58

What are some common complications of heat stroke?

Back 58

1. Rhabdomyolysis
2. Renal failure
3. ARDS
4. Coagulopathic bleeding

Front 59

What is a normal range for JVP?

Back 59

When reported as JVP: <8cm is considered normal

When reported as height above sternal angle: <3cm is considered normal

Front 60

What 3 forms does calcium exist in the plasma?

Back 60

1. ionized calcium (45%)
2. albumin bound calcium (40%)
3. calcium bound to inorganic and organic anions (15%)

Front 61

A RISE in pH increases/decreases/doesn't affect serum calcium levels?

Back 61

Decreases
- at increased pH more calcium becomes bound to albumin thereby decreasing ionized calcium levels in the serum

Front 62

Hypernatremia is a bad prognostic factor in pts w/ heart failure.
True/False?

Back 62

FALSE

HypOnatremia is a bad prognostic factor.
It reflects the degree of neurohormonal activation, with resulting increases in renin, aldosterone, ADH, and NE w/ corresponding water retension by the kidney causing a dilution effect on Na+.

Front 63

True/False

Fibromuscular dysplasia often presents as new onset hypertension in children

Back 63

TRUE
Causes narrowing of arteries particularly the renal, and carotids

Front 64

What are the layers of the abdomen from superficial to deep?

Back 64

1. skin
2. Campers fascia (fatty)
3. Scarpas fascia (membranous)
4. external oblique
5. internal oblique
6. transversus abdominus
7. transversalis fascia
8. preperitoneal fat
9. peritoneum

Front 65

What is Boerhaave's syndrome?

Back 65

- transmural esophageal perforation (cf Mallory-Weiss not transmural)
- associated w/ repeated forceful emesis

Front 66

What is carcinoid syndrome and what are 3 key features?

Back 66

Triad of:
1. Flushing
2. Diarrhea
3. Right-sided heart failure
- as a result of carcinoid tumor normally w/ liver involvement: lesion secretes 5-HT, kinins and vasoactive peptides directly into circulation (which are normally inactivated by the liver)

Front 67

What is the rule of 2 for Meckels diverticulum?

Back 67

- 2% of population
- symptomatic in 2% of cases
- found w/in 2 feet of IC valve
- 2 inches in length
- often present by 2 years of age

Front 68

What are the top 3 causes of small bowel obstruction?

Back 68

ABC
1. Adhesions
2. Bulge (hernias)
3. Cancer (neoplasms)

Front 69

What are the top 3 causes of large bowel obstruction?

Back 69

1. Cancer
2. diverticulitis
3. volvulus

Front 70

What is the order in which liver functions (Albumin, bili, coag) are affected in liver failure?

Back 70

CBA
C- Coagulation
B - Bilirubin conjugation
A - Albumin/protein synthesis

Front 71

दूरम्
dūram

Back 71

distance; dūre tiṣṭhati - is far away na dūre tiṣṭhati - is near

Front 72

What must HIV +ve pts w/ very low CD4 counts be given as prophylaxis?

Back 72

Azithromycin or clarithromycin
- for Mycobacterium avium

Front 73

Pt presents w/ bilateral hip, thigh, and buttock claudication and impotence.
What is the diagnosis?

Back 73

Aortoiliac occlusion or Leriche syndrome

Front 74

What is a common cause of early fetal heart rate decelerations in a women in active labor?

Back 74

fetal head compression

Front 75

What is a common cause of late fetal heart rate decelerations in a women in active labor?

Back 75

Uteroplacental insufficiency which causes fetal hypoxia which causes fetal acidosis

Front 76

What is a common cause of variable fetal heart rate decelerations in a women in active labor?

Back 76

Umbilical cord compression

Front 77

Pt presents w/ anogenital discomfort w/ pruritus, dysparenunia, dysuria, and painful defecation. PE reveals porcelain-white polygonal macules and patches with an atrophic "cigarette paper" quality

What is the diagnosis?

Back 77

Lichen sclerosus

Probably an autoimmune pathogenesis

Front 78

True/False

Lichen Sclerosus of the vulva is considered a premalignant lesion?

Back 78

TRUE

Can progress to vulvular SCC

Front 79

What is Gaucher's disease and what enzyme is deficient?

Back 79

a lysosomal storage disease in which glucocerebrosidase is deficient
- result is an accumulation of fatty glucocerebroside

Front 80

What is the most common cause of mitral regurgitation in pts from developed countries?

Back 80

Mitral valve prolapse

Front 81

What is the empirical treatment of choice in a pt w/ febrile neutropenia?

Back 81

3rd gen cephalosporin (like ceftazidime) OR
Cefepime (4th gen)
MUST cover P. aeruginosa

Front 82

Which is a potential complication of bronchiectasis:
Hemoptysis or Pneumothorax ?

Back 82

Hemoptysis

Front 83

3 day old newborn ready for D/C is found to have a rash on abdo and chest he is otherwise healthy. No fever. Rash appears erythematous papules and vesicles surrounded by patches of erythema. Microscopic evaluation reveals numerous eosinophils.

What is the likely diagnosis?

Back 83

Erythema toxicum
- benign self-limiting condition found in newborns after the first 2 days of life. Treatment is not necessary.

Front 84

Pt presents w/ sudden loss of vision in one eye. Described as "a curtain falling down in my eye". PHx significant for HTN. Fundoscopy reveals zones of whitened edematous retina following the distribution of the renal arterioles.
What is the diagnosis?

Back 84

Amaurosis fugax
- caused by retinal emboli from the ipsilateral carotid artery.

Front 85

30y M pt pale patches in a mottled distribution over his trunk. Just returned from a 2 week vacation to Fiji. Skin is normally well-tanned. Lesions appear velvety pink, pale macules which scale upon scraping. What is the diagnosis? What is the causative agent?

Back 85

Tinea versicolor
- Caused by Malassezia furfur
-KOH prep yeilds "spagetti and meatballs appearance.
- Treat w/ selenium sulfide lotion and ketoconazole

Front 86

What is treament for PCOS?

How does it work?

Back 86

Clomiphene citrate
- an estrogen analogue that improves GnRH release and FSH production and insulin resistance

Front 87

32 F pt presents w/ intermittent blood staining of her bra from her left breast. Palpation and U/S reveal no abnormality. What is the likely diagnosis?

Back 87

Intraductal papilloma
- form of benign breast disease most common in perimenopausal women

Front 88

25y F pt G3P0 in her 6th week of gestation presents to the antenatal clinic. She has had 2 previous misscarriages in her 1st trimester. Lab results reveal:
VDRL: positive
FTA-ABS: negative
Hemocrit: 33%, WBC 7, Plat 88, PT 10s, APTT 46s
Urinalysis is normal.

What is the diagnosis?

Back 88

Antiphospholipid antibody syndrome (APS)
- a common cause of false positive VDRL
- APS can promote arterial and venous thromboses.

Front 89

Which of following is a side effect of thiazides?
- Decreased LDL
- Decreased triglycerides
- Hyperglycemia
- Hypocalcemia
- Hyperkalemia

Back 89

Hyperglycemia
- Increases insulin resistance

Front 90

What is Chadwick's sign?

Back 90

Bluish or purple discoloration of the vagina and cervix as a result of increased vascularity during pregnancy

Front 91

True/False

Arterial BP is normally elevated in pregnancy?

Back 91

FALSE!
- never normally elevated in pregnancy
- declines early in 1st trimester and slowly rises but never reaches pre-pregnancy BP

Front 92

What is the increase in plasma volume during pregnancy? (approx)

Back 92

Increases by 50%

Front 93

Cardiac output increases during pregnancy
True/False?

Back 93

True
- increases up to 50%
- both HR and SV increase

Front 94

Which maternal position results in the lowest CO in pregnancy.
Supine or L. lateral?

Back 94

Supine
- IVC compression results in decreased cardiac return

Front 95

Hematocrit decreases in pregnancy.
True/False?

Back 95

True
- both RBC mass and plasma volume increase during pregnancy however RBC mass increased by 30% and plasma volume by approx 50% thus resulting in a decrease in hematocrit.

Front 96

What is the only lung function volume that increases in pregnancy?

Back 96

Tidal volume
- increases to 40%

Front 97

What is Sheehan syndrome?

Back 97

Pituitary ischemic injury postpartum. Due to blood loss and hypovolemic shock after childbirth. The pituitary increases in size 100% during pregnancy which makes it susceptible to ischemic injury

Front 98

What is the name of the first secretion from the mammary gland of the breast in lactation?

Back 98

Colostrum
- contains more protein and less fat than subsequent milk
- also contains IgA

Front 99

Estrogen stimulates the production of milk from the breast.

True/False?

Back 99

False
- estrogen antagonizes the positive effect of prolactin on milk production
- the placenta when delivered stimulates milk production as it produces estrogens

Front 100

What are some causes of pulseless electrical activity (PEA)?

Back 100

6H's and 6T's

H's: hypovolemia, hypoxia, hydrogen ions, hypothermia, hypoglycemia

T's: tamponade (cardiac), tension pneumothorax, thrombosis, trauma (hypovolemia), tablets, toxins

Front 101

What is the typical cause of a epidural bleed?

Back 101

rupture of middle meningeal artery

Front 102

What is the typical cause of a subdural bleed?

Back 102

tearing of bridging veins

Front 103

3 y male pt presents w/ hyperphagia, obesity, dysmorphic facies (almond shaped eyes, small downturned mouth, small hands and feet). Hypotonia was noted at birth. PE reveals hypotonia, microphallus, cryptorchidism and developmental delay.

What is the diagnosis?

Back 103

Prader-Willi syndrome
- 50-70% of cases there is a deletion in chromosome 15q
- genetic transmission is via imprinting

Front 104

Pt presents w/ absent reflexes in her upper limbs along w/ absent pain and temperature sensation on the nape of neck, shoulder and upper arms in a "cape" distribution. Vibration and position sense is preserved.
No lower limb symptoms are present nor any other significant history.

What is the diagnosis?

Back 104

Syringomyelia
- cavitary expansion of the spinal cord normally associated w/ the central canal

Front 105

Child presents w/ nocturnal enuresis for 2 years. Parents have tried bladder training and alarms and are desperate for help. What is the next step in managment?

Back 105

Desmopressin (or imipramine)

Front 106

What are the features of Charles Bonnet syndrome?

Back 106

- presents with complex visual hallucinations and is associated w/ visual loss (often due to macular degeneration)

Front 107

What are the features of Laurence-Moon syndrome?

Back 107

- rare autosomal recessive disorder
- retinitis pigmentosa
- spastic paraplegia
- hypogonadism
- mental retardation

Front 108

What is considered a normal LV ejection fraction?

Back 108

55-70%

Front 109

Which of the following is the most important risk factor for stroke?
- Smoking
- HTN
- Hypercholesterolemia
- DM
- EtOH

Back 109

Hypertension

Front 110

On clinical examination of a pt you suspect acromegaly. What test do you order to confirm the diagnosis?

Back 110

Measure GH after oral glucose load
- in normal people oral glucose will suppress serum GH levels

Front 111

A 55 yo pig farmer brought to ED after having a seizure for 2 hours. On arrival, unconscious, pulseless and not breathing. He eventually dies. Wife reports that he was well previously except for a headache for the past 2 weeks. Autopsy shows multiple fluid filled cyts.
What is the diagnosis?

Back 111

Neurocysticercosis
- parasitic disease caused by Taenia solium or pork tapeworm.
- Only causes cystercosis if the eggs are ingested which are excreted in human feces

Front 112

Which one of the following is NOT a feature of Lithium toxicity?
tremor, hyporeflexia, ataxia, and seizures

Back 112

Hyporeflexia
- pts w/ Li toxicity are HYPEReflexic

Front 113

A term male baby weighs 2.6kg has closed fists, overlapping index finger and 3rd digit as well as his 5th digit overlapping the 4th. He also has microcephaly, prominent occiput, micrognathia, and rocker-bottom feet.

What is the most likely diagnsos?

Back 113

Edwards syndrome (trisomy 18)
- other features include limited hip abduction, short sternum, cardiac and renal malformations, and mental retardation.

Front 114

Female pt admitted to ER for hypotension. Intra-arterial BP is 72/46, HR is 120/min, PCWP is 6mmHg and mixed venous oxygen concentration (MVO2) is 16% (normal is 15.5%). What is the cause of the pts condition?
- Hemorrhage shock
- Volume depletion
- Cardiogenic shock
- Septic shock
- Neurogenic shock

Back 114

Septic shock
- key is the depressed PWCP and normal MVO2
- the hyperdynamic state of septic shock is characterized by: elevated CO, low systemic vas. resistance, low rht atrial and PCWP, and normal MVO2

Front 115

What is the normal PWCP?

Back 115

8-10 mmHg

Front 116

What is a common serious complication of ADPKD?

Back 116

intracranial bleeding from berry aneurysms

Front 117

Pt presents w/ 2 months of occasional severe headache and blurring of vision. BP is found to be 200/140 and HR 75/min. Presence of which sign confirms the diagnosis?

Back 117

Papilloedema on fundoscopy.

Front 118

What vitamin is deficient in pellagra?

Back 118

Niacin (Vit B3)

Front 119

What are the 3 D's of pellagra?

Back 119

Diarrhea
Dermatitis
Dementia

Front 120

What is Beck's Triad?

Back 120

For Cardiac tamponade
- hypotension
- JVP elevation
- muffled heart sounds

Front 121

What is the most serious side effect of hydroxychloroquine?

Back 121

Retinopathy

Front 122

What type of cast is found on urinalysis with each pathology?
1. Acute tubular necrosis
2. Glomerulonephritis
3. Intersitial nephritis and pyleonephritis
4. Nephrotic syndrome
5. Chronic renal failure

Back 122

1. Acute tubular necrosis - muddy brown granular cast
2. Glomerulonephritis - RBC cast
3. Intersitial nephritis and pyleonephritis - WBC cast
4. Nephrotic syndrome - Fatty cast
5. Chronic renal failure - Broad and waxy cast

Front 123

True/False

Non-caseating granulomas are pathognmonic of Ulcerative colitis

Back 123

False

They are pathognomic of Crohns disease

Front 124

TRUE/FALSE

Pregnancy is a contraindication in the use of triptans for common migraine prophylaxis?

Back 124

TRUE

Front 125

Diethylstilbestrol (DES) is a risk factor for the development of which type of cancer?

Back 125

Adenocarcinoma of the vagina
(clear cell adenocarcinoma)

Front 126

What is the investigation of choice in the diagnosis of MS?

Back 126

MRI brain