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682 Cards in this Set
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Mobitz II second degree heart block is characterized by a a regularly dropped beat (e.g. a nonconducted P wave every second or third beat) without progressive prolongation of the PR interval and is usually associated with evidence of additional disease in the conduction system. What type of disease is it usually associated with?
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Bundle branch block or a bifascicular or trifascicular block. Mobitz Type II block suddenly and unpredictably progresses to a complete heart block and is usually treated with a pace maker.
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Electrocardiographically what type of bundle branch block is associated with absent Q waves in leads I, aVL and V6; and a large positive R wave in leads I, aVL and V6 ("tombstone" waves); and prolongation of the QRS complex to >0.12 sec?
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Left Bundle Branch block.
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This type of bundel branch block will, in lead I, show a small Q wave and tall R wave; lead V6 will show a small positive R wave followed by a small negative S wave followed by a large positive deflection ("rabbit ears"); there is ST depression and T-wave inversion in the right precordial leads; the QRS complex is >0.12. Diagnosis?
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Right Bundle Branch block.
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What is the ankle-brachial index? How is this test performed?
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This is a common initial test in the evaluation for peripheral vascular disease. With a Doppler probe, the ABI is measured as the ratio of the highest right/left dorsalis pedis/posterior tibial artery systolic press divided by the highest right/left brachial artery systolic pressure.
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What is a normal ankle-brachial index (ABI)? What does it indicate if a patients ABI is higher or lower than the normal range?
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A normal ABI is 1.0 to 1.3. Most patients with peripheral vascular disease have an ABI <0.9, and those with severe disease (rest ischemia) have an ABI <0.4. An ABI >1.3 suggests a calcified, noncompressible vessel, most commonly seen in patients with long-standing diabetes mellitus or hypertension.
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What underlying condition should be expected in any patient with a prosthetic heart valve and an unexplained fever?
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Bacterial prosthetic valve endocarditis.
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What is the recommended initial treatment for viral pericarditis?
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A high-dose nonsteroidal anti-inflammatory drug such as indomethacin or ibuprofen. Indomethacin is rapidly tapered after 5 to 7 days because of the potential for toxicity with long term use.
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Atrial tachycardia with variable block is the classic electrocardiographic finding for what drug induced toxicity?
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This is the classic finding for Digitalis toxicity.
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Hypokalemia, Hypogmagnesemia, hypercalcemia, renal insufficiency, hypothyroidism, advanced pulmonary disease, and pharmacologic interactions with other drugs, notably verapamil, quinidine, and amiodarone, are all risk factors for drug toxicity associated with what drug?
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Digoxin.
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Which arrhythmia is classically characterized by an ECG with a "sawtooth" pattern between QRS complexes?
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Atrial Flutter.
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Three-vessel coronary artery disease and left ventricular dysfunction with no contraindications to coronary revascularization warrant what type of intervention?
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This warrants an invasive treatment approach to intervention rather than medical management; one such invasive approach might be Coronary Artery Bypass Graft surgery (CABG) in combination with medical therapy.
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Patients with obstructive left main CAD and/or three-vessel CAD with a reduced left ventricular ejection fraction (<40%) or a moderate to large amount of myocardial ischemia have improved survival rates with what treatment?
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CABG (Coronary Artery Bypass Graft) in combination with medical therapy
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What are the next steps to be taken for an individual suspected of presenting with aortic dissection? (may be seen with differential right and left arm blood pressures)
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Chest radiograph for widened mediastinum, and one of the following: Contrast-enhanced CT of th e chest, TEE, Thoracic MRI.
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Diffuse ST-segment elevations that are concave upward and in no particular anatomic distribution and PR-segment depression, especially in leads II and III are characteristic of what cardiac process?
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Acute Pericarditis.
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What procedure improves survival in comparison to percutaneous intervention in patients with diabetes mellitus and multivessel coronary artery disease?
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Coronary Artery Bypass Grafting.
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This acute heart condition is often associated with signs of acute ischemia (coronary, cerebral or spinal), aortic regurgitation, and cardiac tamponade. Diagnosis?
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Aortic dissection, which can propagate both distally and proximally to the intimal tear.
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WIdening of the mediastinum on chest radiography and variation (>20mm Hg) in the right and left arm blood pressures are helpful diagnostic clues in the diagnosis of what condition?
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Aortic dissection.
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PR segment depression on ECG is virtually pathognomonic for what disease entity? What other condition can you see it in?
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Acute pericarditis; atrial myocardial ischemia.
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The pulmonary capillary wedge pressure is elevated and the cardiac output is low in patients with what type of shock condition?
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Primary cardiogenic shock.
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Exercise ECG with myocardial imaging and exercise echocardiography is reserved for patients with intermediate probability of coronary artery disease and what type of conditions?
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Conditions that reduce the specificity of the exercise treadmill test and reading of ECG for signs of ischemia (e.g. Pre-excitation syndrome a.k.a. Wolff-Parkinson-White, more than 1mm depression on baseline ECG, patients with history of revascularization procedures, those who take digoxin because digoxin often causes ST-segment depression, and in those who have left ventricular hypertrophy with a repolarization abnormality on baseline ECG).
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What is the best treatment for coronary artery vasospasm?
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Nitrates in the short term and calcium channel blockers in the long term.
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Infarction of which heart wall is indicated by ST elevation in leads V1-V4?
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Anteroseptal wall myocardial infarction.
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ST elevation in leads V4-V6 indicate infarction in which cardiac wall?
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Apical, or Lateral infarction.
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Dullness of a lung field and resting dyspnea in a patient suspected of having an aortic dissection indicates what possible complication?
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Hemothorax.
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Which post myocardial infarction therapy reduces infarct size, the frequency of recurrent myocardial ishcemia, and improves short-term and long-term survival?
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Beta-blockers.
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What defines an NSTEMI?
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A Non-ST elevation myocardial infarction is recognized by ST depressions and/or T wave inversions without Q waves.
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Which leads have most prominent PR depression seen in Acute Pericarditis?
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Leads aVL, aVF, V5, and V6.
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The physical exam findings of progressive hypotension, jugular venous pressure elevation, and clear lung fields are consistent with what type of myocardial infarction? (right ventricular lift is common and TRICUSPID VALVE regurgitation may be audible).
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Right ventricular myocardial infarction.
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Acute ischemia in the territory of the right coronary artery includes wat parts of the heart?
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The right ventricle and inferior and posterior portions of the left ventricle.
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In patients with nonvalvular artial fibrillation, warfarin with a target INR of 2.0 to 3.0 has been shown to decrease stroke risk by an average of what percentage compared with aspirin?
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Warfarin decreases stroke risk by an average of 62% compared to 19% with Aspirin.
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The CHADS2 score is a scale used for risk stratification in order to determine whether the risk of stroke is high enough to warrant the use of anticoagulation therapy in a patient. What are the components of the CHADS2 score?
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(C)ongestive heart failure, (H)ypertension, (A)ge >75 years, (D)iabetes, (S)troke or transient ischemic attack. Patients are given two points for a history of stroke or TIA (the strongest risk factor) and 1 point for all other risk factors. This risk is lowest in patients with a CHADS2 score of 0 (1.2%) and highest with a maximum score of 6 (18%). Patients with a CHADS2 score of >/= 3 and patients with a history of stroke are at high risk and should be considered for chronic anticoagulation therapy with warfarin. Patients with a score of 1 or 2 should be assessed on an individual basis for aspirin vs. warfarin therapy.
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Inferior wall infarction (ST elevation in the inferior leads II, III, aVF) is often seen in conjunction with Posterior wall infarction. Posterior wall infarction is often seen to have ST depression in which leads?
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V1 and V2; thus every time you see evidence of an inferior wall infarction (II, III, aVF) look for evidence of an accompanying posterior wall infarction with ST DEPRESSION in ANTERIOR leads V1 and V2.
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Anterior (anteroseptal) wall myocardial infarction is associated with ST elevation in what ECG leads?
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The ANTERIOR chest leads V1, V2, V3!!!
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Lateral wall and apical myocardial infarction is associated with ST elevation in what ECG leads?
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The LATERAL chest leads V4, V5, V6!!!
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Suppression of premature ventricular contractions is only indicated in patients with severe and disabling symptoms, which may include palpitations, fatigue, and light-headedness. In these patients what is the safest initial choice for medical management? What anti-arrhythmic agent is a second-line option for patients who continue to have debilitating symptoms despite the first line therapy?
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Beta-blockers; second-line drug is an antiarrhythmic such as Flecainide.
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Patients presenting less than 12 hours after the onset of a STEMI are best treated with what intervention?
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Less than 12 hours after a STEMI, patients are best treated with percutaneous intervention.
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What is the time period in which fibrinolytic therapy should be given in an ED if percutaneous intervention is not available in a patient presenting less than 12 hours after the onset of a STEMI?
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Fibrinolytic therapy should be given within 30min of arrival in the ED.
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What is the goal of all reperfusion strategies for patients with STEMI? That is how long should it take to establish reperfusion from the time of onset of symptoms?
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90 minutes.
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Is the asymptomatic patient with STEMI arriving more than 12 hours after the onset of symptoms still a candidate for fibrinolysis? What about patients with ST segment depression?
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No this patient is no longer a candidate for fibrinolytic therapy; studies have also shown that the risk of fibrinolysis outweighs the benefit in patients with ST-segment depression.
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This arrhythmia is recognized by its say tooth pattern of waves most noticeable in the inferior leads II, III, aVF; these waves are distinct from the small chaotic fibrillation waves of atrial fibrillation. Diagnosis?
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Atrial Flutter.
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Woman's vision had been blurry for the past few days and acutely worsened on hour ago with complete loss of vision in her right eye; describes right-sided headaches of two months duration for which she has taken ibuprofen without relief. Diagnosis? Tx?
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This patient's presentation is highly suggestive of temporal, or giant cell, arteritis. Temporal arteritis should be suspected in any patient over 50 years of age with a new headache, jaw claudication, scalp pain, visual loss, or symptoms of polymalgia rheumatica. Tx with HIGH DOSE STEROIDS IS PARAMOUNT. Prompt systemic steroid administration significantly lowers the rate of visual complications. The ESR will be elevated in this patient and TEMPORAL ARTERY BIOPSY will provide definitive diagnosis.
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What is the most appropriate next step in the management of a patient suspected of having isolated proteinuria?
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When isolated proteinuria occurs, the evaluation of the patient should begin by testing the urine on at least two other occasions. This is because proteinuria is a common cause of isolated proteinuria and can occur during stress or any febrile illness.
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what is the most common middle ear pathology in patients with AIDS?
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Serous otitis media; it is due to auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas. Serous otitis media is chareacterized by the presence of a middle ear effusion without evidence of an acute infection. Conductive hearing loss is the most common symptom experienced by patients with serous otitis media, and examination typically reveals a dull tympanic membrane that is hypomobile on pneumatic otoscopy.
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Individuals who received blood transfusions before 1992 should be screened for what viral infection? What about before 1986?
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<1992 = Hep C
<1986 =Hep B |
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What conditions of the musculoskeletal system and the GI system are both associated with HLA-B27, may occur in association with an inflammatory arthritis, and may also be associated with erythema nodosum and positive p-ANCA despite the absence of vasculitis in both conditions?
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IBD and Anklyosing spondylitis.
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Common extracolonic manifestations of this condition include skin findings, such as erythema nodosum, pyoderma gangrenosum, episcleritis, cholangitis, p-ANCA positive, with presentation of arthritis that is vary similar to ankylosing spondylitis. Diagnosis?
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ULCERATIVE COLITIS!!!
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Virtually 100% of patients with MEN-IIa have C-cell hyperplasia or MTC, 50% have pheochromocytoma, and 20-30% have hyperparathyroidism. In a patient with evidence of pheochromocytoma, hypercalcemia (suggesting hyperparathyroidism), and a positive family history, are very suggestive of MEN IIa. Thus is a patient presenting with the above findings, what is the next best step in evaluation of the patient?
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Serum Calcitonin levels, due to the likelihood of the presence of Medullary Thyroid Carcinoma.
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When a pleural effusion is suspected or diagnosed , the first step is to determine the cause of pleural effusion, and management starts with determining whether the fluid is transudate or exudate. What is the preliminary investigation of choice in order to determine this?
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Diagnostic Thoracentesis is the preliminary investigation of choice in the management of pleural effusion, except with classic signs and symptoms of congestive heart failure, where a trail of diuretic is warranted. Pleural fluid analysis provides decision making information in 90% of cases.
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What are the three tumors that cause 75% of all malignant pleural effusions?
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Lung carcinoma, breast carcinoma, and lymphoma.
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What is the most common cause of pleural effusion? When it is unilateral, which side is more commonly involved?
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CHF is the most common cause of pleural effusion; when it is occasionally unilateral, the right side is more commonly involved.
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1. Pleural fluid protein/serum protein ratio < 0.5
2.Pleural fluid LDH/serum LDH ratio < 0.6 3. Pleural fluid LDH less than two-thirds of the upper limit of normal serum LDH Transudate or Exudate? |
TRANSUDATE!!!
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What does pleural fluid pH < 7.3 indicate? pH 7.35?
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1) < 7.3 = indicates pleural inflammation
2) pH 7.35 is consistent with transudative pleural effusion. |
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In normal individuals, a blood glucose level below 60 mg/dl results in near-complete suppression of insulin secretion. Thus if a patient is hypoglycemic and has normal or elevated levels of insulin, this can be deemed an inappropriate response. What are two important causes of hypoglycemia in non-diabetic patients with elevated insulin levels?
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Insulinoma (BETA CELL TUMOR) or Surreptitious use of insulin or sulfonurea. Elevated C-peptide levels and proinsulin levels greater than 5 pmol/L are seen in patients with beta cell tumors.
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What pancreatic endocrine tumor produces a characteristic skin rash (necrotic migratory erythema) with elevated blood glucose levels?
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Glucagonoma.
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Symptoms of this condition include a sudden onset of photophobia, eye pain, headache, and nausea; on palpation the affected eye may appear very hard and fleshy. A non-reactive, mid-diated pupil can suggests an acute occurrence of this condition. The best diagnostic test for this is Tonometry. Diagnosis?
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Glaucoma.
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Most patients with proximal muscle weakness have a primary muscle disorder; if a patient is also having additional symptoms of fatiguability, action tremor, anxiety, and weight loss, what underlying diagnosis does this point to instead?
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Hyperthyroidism; which can be associated with proximal muscle myopathy. Some patients may have hyperreflexia with a shortened RELAXATION PHASE or they may have normal reflexes.
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The classic presentation is acute, severe chest or epigastric pain after an episode of retching; fever and dyspnea are common; physical exam can be non-specific, but often involves tachycardia, tachypnea, subcutaneous emphysema, and UNILATERALLY DECREASED BREATH SOUNDS (could make you think something else!!! be careful); unilateral pleural effusion, widened mediastinum , with pleural fluid having high amylase concentration, low pH, and may contain particles of food. Diagnosis?
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Spontaneous esophageal rupture, or Boerhaave's syndrome.
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What is a key difference to distinguish a complex partial seizure from an absence seizure in children?
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Unlike in absence seizures, hyper ventilation during the EEG cannot simulate a complex partial seizure. Hyperventilation during the EEG reveals a generalized 3Hz spike-and-wave pattern on a normal background in a patient with absence seizures. Also, although patients with absence seizures may have automatisms, there is also no post-ictal state seen, as is seen in complex partial seizures.
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This type of seizure in a child is characterized by brief (i.e. a few min) episodes of impaired consciousness, failure to respond to various stimuli during episodes, staring spells, automatsms (e.g. lip smaking, picking movements of the hand) and post-ictal confusion; the EEG pattern is usually normal or may show brief discharges. Diagnosis?
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Complex partial seizure.
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What is the difference between a typical absence seizure and an atypical absence seizure?
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Atypicals last longer an the characteristic EEG pattern is slow spike-and-wave activity with a frequency less than 2.5Hz as opposed to ~3Hz.
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The active phase of this disease is characterized by follicular conjunctivitis and pannus (neovascularization) formation in the cornea; concurrent infection occurs in the nasopharynx, leading to nasal discharge; the diagnosis can be made by Giemsa stain examination of conjunctival scrapings. Diagnosis? Tx?
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This is Trachoma, which is caused by Chlamydia trachomatis serotype A-C; it presents with FOLLICULAR CONJUNCTIVITS AND PANNUS (NEOVASCULARIZATION) formation in the cornea!!!
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What routine screening measure should take place in all sexually active women age 24 years and younger?
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Routine screening for Chlamydia trachomatis infection.
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What are the 12 treatable causes of PEA (pulseless electrical activity)? (6T's/6Hs).
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Hs: hypovolemia, hypoxia, hydrogen ions (acidosis), hypothermia, hypoglycemia, hyper/hypokalemia
Ts: Tamponade (cardiac), tension pneumothorax, thrombosis (MI, PE), trauma (hypovolemia), tablets (drugs) and toxins. |
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Any patient with a non-shockable rhythm (anything other than VF/VT) should immediately receive what management?
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CPR!!! including manual chest compressions, establishment of a definitive airway and ventilation with 100% O2.
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Is Afib without a pulse considered a shockable rhythm?
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NO!!! Unlike Vfib or Vtach, Afib without a pulse is NOT a shockable rhythm during cardiac arrest with not pulses! IV access should be established, in addition to chest compressions, so that ACLS medications such as epinephrine, vasopressin, and atropine can be administered.
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What type of management is appropriate for patients with perfusing tachyarrhythmia who are experiencing sigs and symptoms of serious hemodynamic compromise?
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Synchronized cardioversion is appropriate for these patients, but NOT for those in full cardiac arrest with no pulse or blood pressure.
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What management is used for patients in Vtach/Vfib?
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Defibrillation is utilized as early as possible in these patients.
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After CRP is initiated in a patient with PEA, what is the first-line pharmacologic intervention administered? When would you consider using Lidocane?
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Epinephrine 1mg IV, or Vasopressin 40U IV; Lidocane may be used for patients with VF or T who remain in cardiac arrest after three shocks
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If a patients Afib has been present for <48 hours what is the appropriate treatment? 48hrs< ?
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<48 hrs electric or pharmacologic cardioversion is appropriate; >48 hrs and the patient should be treated with rate control and 3-4 weeks of anticoagulation before cardioversion is attempted. Rate control is achieved with Ca2++ channel blockers or Beta-blockers.
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What type of arrhythmia are Carotid massage and adenosine appropriate for?
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Carotid massage and adenosine may be used to manage patients with SVT. Carotid massage is a vagal maneuver that slows the heart rate and may terminate SVT. Adenosine works in SVT by causing transient AV node blockade, which allows identification of the rhythm and terminates certain forms of SVT.
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Patients suffering from Ankylosing Spondylitis for two decades or longer are at an increased risk of what spinal pathology?
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Vertebral Fracture.
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A spinal pathology occurs that typically begins as insidious, unilateral, intermittent pain that may become bilateral and persistent with flares. Diagnosis?
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Ankylosing Spondylitis; vertebral fractures in these patients may occur with minimal trauma, therefore, the clinical suspicion for vertebral fracture in patients with longstanding AS must be high.
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The pain of this spinal pathology occurs in a dermatomal distribution with sensory loss, paresthesias and weakness of muscles innervated by the involved nerve root. Diagnosis?
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Sinal root compression.
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Anticardiolipin phospholipid antibody syndrome (APS) is a common cause of false positive VDRL in young-middle aged women. What is the key complication of this syndrome?
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Arterial and venous thromboses, and a resultant tendency toward spontaneous abortions; thrombocytopenia and prolonged PTT are common findings in affected patient (PARADOXICAL!!!); in pregnant patients low molecular weight heparin and low dose aspirin may be used to decrease the risk of spontaneous abortion.
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What is the most common cause of foot drop in patients? Which nerve roots are commonly involved when its not just peripheral neuropathy? What is a congenital cause of foot drop?
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The most common cause of foot drop is caused by Peripheral Neuropathy. Foot drop also classically results from trauma to the Common Peroneal nerve or radiculopathy to any of the spinal roots that contribute to the Common Peroneal nerve (L4-S2); finally foot drop may can congenital, such as in Charcot-Marie-Tooth disease.
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Lesions to this part of the brain cause a wide-based, erratic, staggering gait. Diagnosis?
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Patients with cerebellar lesions; they classically walk as if they were drunk.
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Because not all symptoms are always present, there should be a high suspicion for reactive arthritis in the case of any asymmetric oligoarthritis associated with urethritis, conjunctivitis or mouth ulcers. Synovial fluid analysis is usually sterile. What is the first-line therapy during the acute phase of this condition?
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NSAIDS.
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How can you distinguish gonococcal septic arthritis from reactive arthritis?
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This can be difficult because synovial fluid cultures can be negative in 50% of patients with gonococcal septic arthritis. If, however, the patient is afebrile, and has other symptoms suggestive of reactive arthritis such as mouth ulcers, enthesitis, and low back pain, reactive arthritis is more likely.
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In addition to the regular vaccine schedule what two extra vaccines should a child with Cystic Fibrosis receive?
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They should receive yearly influenza vaccinations and may require pneumococcal booster shots.
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Patients with high serum T4 and T3 levels with normal to mildly elevated TSH levels, in the setting of a hypothyroid presentation despite having the elevated free thyroid hormones. Diagnosis?
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Generalized resistance to thyroid hormones.
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Where are neurogenic tumors of the mediastinum located?
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In the posterior mediastinum.
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Bronchogenic cysts are usually benign and are found in what part of the mediastinum? Where are Thymomas found in the mediastinum?
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Bronchogenic cysts are found in the middle mediastinum; Thymomas are usually found in the anterior mediastinum.
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Why might a homeless alcoholic, with pancreatitis develop symptoms of hypocalcemia?
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Vitamin D malabsorption due to pancreatic insufficiency; Vitamin D malabsorption causes hypocalcemia accompanied with hypophosphatemia; the other cause of concordantly decreased serum calcium and phosphate levels is acute pancreatitis.
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The most common CNS lesion in AIDS patients is toxoplasmosis. What is the Abx for prophylaxis of Toxo? What is used for treatment purposes?
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Bactrim is used for prophylaxis; Sulfadiazine and pyrimethamine is used for treatment purposes.
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Which PFT is the most appropriate for monitoring a patients respiratory function in a progressing pathological state such as Guillan-Bare syndrome?
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Serial measurement of the Vital Capacity at the bedside can be very helpful; the risk for ventilatory failure increased significantly when the VC falls below 15 mL/kg, especially if there has been a clear downward trend.
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What is the drug of choice in treating Primary BIliary Cirrhosis?
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Ursodeoxycholic acid is the drug of choice in treating PBC, as it slows disease progression and relieves symptoms; methotrexate and colchicine have also been shown to be of moderate benefit. Advanced disease is an indication for liver transplantation, which offers a 1 year survival rate of 85-90%, and is the only definitive treatment. WIthout transplantation, survival averages 7-10 years after symptoms first arise.
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Where on the face are basal cell carcinomas rarely found?
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Basal cell cancer is rarely found on the lips. In sporadic instances, it has been reported on/around the upper, but hardly ever the lower lip.
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The majority of lip cancers are what type of cancer?
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Well-differentiated squamous cell carcinomas.
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These type of mouth ulcers are described as shallow, fibrin-coated ulcerations with underlying mononuclear infiltrates; they are recurrent , self-limiting ulcerations of indeterminate (possibly autoimmune) etiology. Diagnosis?
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Apthous ulcers.
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What should you suspect in a postpartum woman with pulmonary symptoms and multiple nodules on chest x-ray? What confirms the diagnosis?
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Suspect Choriocarcinoma; elevated hCG diagnosis it.
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Metoclopramide is a prokinetic agent used to treat nausea, vomiting, and gastroparesis. Patients taking this medication should be monitored closely for the development of what side-effects?
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Drug-induced extrapyramidal symptoms such as tardive dyskinesia, dystonic reactions, and Parkinsonism.
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In a patient with kidney transplant who is taking cyclosporin and develops the side effect of cyclosporin induced hypertension, what is the treatment of choice?
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Calcium channel blockers are the drugs of choice for treatment; this hypertension is due to renal vasoconstriction and sodium retention. It is is generally seen in the first few weeks of treatment.
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In transplant patients taking Cyclosporine immunosuppressive therapy, what malignancies are they at special risk for?
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Squamous cell carcinoma of the skin and lymphoproliferative malignancy
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GINGIVAL HYPERTROPHY and HIRSUTISM are two side effects associated with what immunosuppressive therapy used for transplant patients?
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Cyclosporin!!!
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Cyclosporin and Tacrolimus have the same mechanism of action (calcineurin-inhibitors). The major side effects of Cyclosporin include Nephrotoxicity, Hyperkalemia, Hypertension, Gum Hypertrophy, Hirsutism, and Tremor. Tacrolimus has a similar toxic profile except for two symptoms. Which are they?
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Hirsutism and Gum hypertrophy.
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What is the major toxicity associated with the immunosuppressant Azathioprine?
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Dose-related diarrhea, leukopenia, and hepatotoxicity.
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What it the major toxicity associated with the immunosuppressive drug (M)ycophenolate?
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(M)arrow suppression.
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What is the normal cervical cancer screening regimen for a woman without evidence or cervical intraepithelial neoplasia?
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A patient should get annual Pap smears until age 65-70. The screening interval may increase to every 2-3 years if they have three consecutive negative smears and maintain the same monogamous partner.
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Of all these risk factors, which is the most important risk factor for stroke: smoking, hypertension, elevated cholesterol, alcohol consumption, diabetes mellitus?
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Hypertension; this increases the risk of all types of stroke. Multiple observations studies have demonstrated that patients with hypertension have approximately four times the risk of stroke when compared to non-hypertensive subjects.
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What tests are helpful in differentiating between COPD and asthma in a patient with risk factors for both diseases?
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A bronchodilator response test is used to demonstrate reversibility of airway obstruction. It helps to differentiate between COPD and asthma, although a subset of patients with COPD may also demonstrate airway reactivity. Low diffusion capacity (DLCO) and characteristic CHEST CT findings can support the diagnosis of COPD.
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What should there be a high suspicion of in a patient who has a low BMI with efforts to lose weight, and history and lab evidence that point to hyperthyroidism?
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Factitious thyrotoxicosis; laboratory findings in factitious hyperthyroidism reveal a low TSH due to suppression of the body's native thyroid axis and an elevated T3 and free T4. A biopsy of such a patients thyroid would demonstrate follicular atrophy due to suppression of endogenous thyroid hormone production. 24-hour radioiodine uptake test showing diffusely decreasd uptake of iodine by the thyroid provides CONFIRMATION OF THE DIAGNOSIS.
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Orphan Annie nuclei are associated with what type of thyroid cancer?
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Orphan Annie nuclei are associated with papillary thyroid cancer, which commonly presents with a solitary thyroid nodule or neck mass due to lymph node metastasis. Papillary thyroid cancer is the most common form of thyroid cancer, and generally has good prognosis.
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Stroke is a common complication of sickle cell disease secondary to sludging and occlusion in the cerebral vasculature. What is the recommended treatment acutely for this condition?
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Exchange transfusion is the recommended treatment acutely since it helps to decrease the percentage of sickle cells and prevent a second infarct from occurring, even though it may not reverse the changes from the initial vascular event.
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What is the proper procedure for the removal of a newly found tick?
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The risk of developing a tick-borne disease is much less if the tick is attached for less than 24 hours. The recommended technique for tick removal is to grasp the ticks mouth parts with tweezers as close to the skin as possible. and remove the tick using slow, constant pressure
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Metabolic alkalosis is characterized by an alkaline pH and a primary increase in the serum bicarbonate level (>24 mEq/L). It can be classified in to two broad categories of Chloride-sensitive (hypochloremic, saline-responsive), and Chloride-resistant (normochloremic, saline-unresponsive) metabolic acidosis. What are the characteristics of urinary chloride levels for these and the underlying pathophysiology?
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Chloride-sensitive metabolic alkalosis is characterized by a urinary chloride level <20 mEq/day and signs of volume depletion. The common underlying pathophysiology in all causes of chloride-sensitive metabolic alkalosis involves volume contraction. Volume contraction increases mineralocorticoid action, which in turn causes bicarbonate retention, H+ loss, and K+ loss. The urinary chloride remains low due to avid renal retention of NaCl and water. Chloride-resistant metabolic acidosis (Bartter's syndrome, hyperaldosteronism, Gitelman's) is characterized by a urinary chloride level >20 mEq/day and ECF volume expansion.
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What type of metabolic acidosis does diarrhea cause? Anion gap or non-anion gap?
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Non-anion gap.
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What is Charcot's triad of acute ascending cholangitis? What is Reynold's pentad of suppurative cholangitis?
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Charcot's triad of fever, severe jaundice, and right upper quadrant abdominal pain is characteristic for acute, ascending cholangitis. Confusion and hypotension may also be observed in those with suppurative cholangitis, producing Reynold's pentad.
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The signs and symptoms of Reynold's pentad of suppurative cholangitis (fever, severe jaundice, RUQ pain, progressive confusion, and hypotension) are indications for what type of management?
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Urgent biliary decompression, preferably by Endoscopic Retrograde Cholangiopancreatography (ERCP). ERCP is minimally invasive, has a low rate of complications, and allows for diagnostic confirmation. Therapeutic intervention typically includes sphincterotomy with stone removal and/or stent insertion. Early drainage of the biliary tree in acute cholangitis can significantly decrease its morbidity and mortality. If non-surgical drainage procedures fail to relieve the biliary compression, choledochotomy with placement of a large-bore T tube is appropriate.
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What is the FEV1/FVC classic for COPD?
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<0.7; the hallmark of COPD is progressive airflow obstruction with a forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio of less than 0.7.
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What are the expected lab values (increased/decreased levels) for a patient experiencing Tumor Lysis syndrome in terms of Calcium, Phosphate, Potassium, Uric Acid?
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Hypocalcemia, Hyperphosphatemia, Hyperkalemia, and Hyperuricemia. Both K+ and PO4- are intracellular ions, and the breakdown of the cells release excess amounts of these. Released phosphate binds calcium and causes hypocalcemia. Hypocalcemia is also due to the release of intracellular products by cell lysis. Degradation of cellular proteins causes elevation of uric acid levels. Prompt ID and immediate treatment of such metabolic abnormalities is necessary since these may lead to fatal arrhythmias, acute renal failure, and even sudden death.
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Although the cause of rhinitis is usually suggested by careful history and physical examination (e.g.infectious, allergic), the diagnosis is not always clear, and laboratory evaluation may be necessary. What is the next best step in management in a patient suspected of having refractory allergic rhinitis to over the counter medications?
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Nasal cytology; demonstration of neutrophils in nasal secretions suggests infectious causes of the disease, while predominance of eosinophils will indicated that allergic rhinitis is the most likely diagnosis. Nasal eosinophilia is characteristic for allergic rhinitis, although it is not specific, however, nasal eosinophilia is absent in patients with infectious causes, and vasomotor rhinitis, so it can help to rule these entities out.
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What is the most common complication of peptic ulcer disease? What is the management of this most common complication?
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Hemorrhage is the most common and serious complication of peptic ulcer disease. The management of most bleeding ulcers include fluid and blood resuscitation, medical therapy, and endoscopic intervention, as deemed appropriate.
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HIV patients with a CD4 count < 50/mm3 should receive what antibiotic to prevent GI infection with what acid-fast bacili?
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Azithromycin should be given as prophylaxis against Mycobacterium Avium Complex (MAC).
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If an AIDS patient is allergic to sulfa-drugs, but needs to receive prophylaxis for PCP pneumonia, what is the alternative drug to use?
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Dapsone.
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At what mm induration on PPD screen is Isoniazide given to HIV patients?
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>5 mm
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What is the treatment for HIV patients suffering from MAC?
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Clarithromycin and Ethambutol.
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This medication is given when the CD4 count is less than 50/mm3 and the serum CMV IgG is positive, or when there is a positive biopsy for CMV?
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Ganciclovir.
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Cat bite wound are of significant concern because they often result in deep puncture wounds, which could inoculate Pasturella multocida. Localized cellulitis can develop subacutely and, can be associated with complications and systemic effects. What prophylactic treatment in such cases?
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Amoxicillin/Clavulanate; Cat bites should be prophylactically treated with a five day course.
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Why are fluoroquinolones not approved for use in children?
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Because of concerns about Tendon rupture.
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What disease is indicated by a SOAP BUBBLE APPEARANCE in the epiphyseal end of a long bone? What should your next step be if this is found?
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This is a GIANT CELL TUMOR of the bone; refer to an Orthopedic surgeon. The classical patient is 20-40yr old female with knee pain and some mass. The tumor cells are oval or spindle shaped intermingled with numerous multinuclear giant cell in fibrous stroma. It is benign, but locally aggressive. It frequently recurs even after local curetage.
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DVT management is divided into 1) acute anticoagulation and clot stabilization, 2) chronic anticoagulation, and 3) treatment of DVT-related complications.What drug is used to treat initial clot stabilization?
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Initial clot stabilization with a heparin product is mandatory. Heparin retards further retards thrombus formation by binding to antithrombin III and enhancing its activity; heparin stabilizes, but does not lyse existing clots.
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What drug is used for chronic anticoagulation?
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Warfarin; warfarin inhibits activation of the vitamin K-dependent coagulation factors II, VII, IX, X, but unfortunately it takes at least 4-5 days for warfarin to become therapeutic; thus, the need for concomitant "bridging heparin therapy.
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If a patient presents with a propagating clot in the setting of sub-therapeutic warfarin, how should this clot be managed?
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This must be treated like a new, unstable clot; thus heparin must be used while the INR becomes therapeutic.
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What is the number one risk factor for developing diabetic foot ulcers?
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Peripheral Neuropathy.
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A WBC count greater than what number helps to differentiate between crystal induced arthritis vs. septic arthritis?
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>50,000; counts that are high, but less than this may also be found in crystal induced arthritis.
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What bug is the most common cause of septic joint arthritis?
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Staph aureus.
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What is the treatment of choice for third degree heart block?
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Pacemaker insertion.
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Patients with ulcerative colitis are at an increased risk for the development of colorectal cancer. Most guidelines state that patients should begin colonoscopy surveillance 8 years after the diagnosis, possibly longer if only the left colon is involved. Once a surveillance program is started, colonoscopy should be repeated how often?
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Every 1-2 years to assess for development of colonic dysplasia.
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Which drugs are the drugs of first-choice for in-patient treatment of community-acquired pneumonia?
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Newer antipneumococcal quinolones, like Levofloxacin, or Moxifloxacin.
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For out-patient therapy, what are the drugs of first choice for treating community acquired pneumonia?
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Azithromycin, or Doxycyclin.
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What is the first step of choice if you suspect that a patient may have Multiple Myeloma? What is the best diagnostic test?
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Serum electrophoresis; Bone marrow biopsy.
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What are the two most common drugs that cause priapism?
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Prazosin, and Trazodone.
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What are the 4 common causes of Priapism?
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1. Sickle cell disease and leukemia- usually in children or adolescents
2. Perineal or genital trauma- results in laceration of the cavernous artery 3. Neurogenic lesions- such as spinal cord injury, cauda equina compression, etc. 4. Medications- such as trazodone and prazosin |
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Massive PE is defined as PE complicated by hypotension and/or acute right heart strain. What are the indications of of right heart strain that may be present on physical exam and ECG? What is the treatment indicated for massive PE?
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Jugular venous distension and RBBB on ECG; fibrinolysis is the treatment indicated for massive PE, however, surgery within the last ten days is a relative contraindication to fibrinolytic therapy.
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What is the mechanism responsible for the observation of polycythemia seen in patients with Obstructive Sleep Apnea?
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Hypoxia-induced increases in erythropoetin production.
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A short course (5 days) of what antibiotic has been found to be particularly effective in treating Cat Scratch Disease with B.henselae?
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Azithromycin, for Cat Scratch Disease.
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What infection should you consider as a late complication in post-Bone Marrow Transplant recipients who present with pneumonitis and colitis?
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CMV; consider when patient has both lung and intestinal involvement; median time to development is about 45 days (range 2 wks-4months) after transplantation.
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What is the most common organ involved in Graft-versus-host disease after a bone marrow biopsy?
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Skin; skin rash is almost always seen, but other organs commonly involved include the intestine, liver, and lung. Lung involvement is seen in chronic graft-versus-host disease and manifests as broncholitis obliterans.
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What are the 6 drug clases that are known to cause pancreatitis?
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1. Diuretics (furosimide, thiazides)
2. Drugs for Inflammatory Bowel Disease (Sulphasalazine, 5-ASA) 3. Immunosuppressive agents (Azathioprine, L-asparaginase) 4. Drugs used by patients with history of seizure or bipolar disorder (Valproic acid) 5. AIDS drugs (Didanosine, Pentamidine) 6. Antibiotics (Metronidazole, Tetracycline) |
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What acute bowel condition is one of the most common causes of lactic acidosis in patients with severe atherosclerotic disease or atrial fibrillation?
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Unrecognized bowel ischemia.
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In patients with ARDS, mechanical ventilation improves oxygenation by providing an increased fraction of inspired oxygen (FiO2) and providing PEEP to prevent alveolar collapse. In the hospital setting, the arterial pO2 provides an important measure of oxygenation. It is influenced by what two parameters? The arterial pCO2 is a measure of ventilation that is mainly effected by what two parameters?
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pO2 is influenced by FiO2 and PEEP level. pCO2 is affected by the respiratory rate and tidal volume.
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What are the major determinants of minute volume in a patients ventilator settings?
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Tidal volume (TV) and Respiratory Rate (RR); Rate + Volume = min/volume
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Octreotide, vasopressin, endoscopic ligation and sclerotherapy are all specific modalities to treat what condition?
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Esophageal variceal bleeding.
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Traveler's to where, get the Yellow fever vaccine?
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sub-Saharan Africa and South American countries.
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Which disease is the most common vaccine-preventable disease among travelers, and should be considered for people anticipating travel to developing countries?
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Hep A!!!
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Vancomycin + Ceftriaxone is ideal for treating community-acquired bacterial meningitis in adults and children since it covers the three most frequent etiological agents: Strep pneumo, H.flu, Neisseria. Why would it be good to add Amipicllin for empiric treatment in an elderly person?
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Amipicillin will cover Listeria monocytogenes, which is an important cause of meningitis in patients over 55; others who are at risk are immunocompromised, patients with malignancies (esp. lymphoma), and patients taking corticosteroids.
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What is the ideal antibiotic regimen for hospitalized patients who develop meningitis, esp. after neurosurgery?
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IV Ceftazidime + Vancomycin.
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What common medication potentiates the action of ADH and can cause a condition that presents essentially as SIADH?
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NSAIDs!!!
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The normal response to hypotonicity (low plasma osmolality) is the production of maximally dilute urine ( low urine osmolality = ,100mOsm/Kg). Low plasma osmolality (<280 mOsm/Kg) with high urine osmolality (>100-150) is diagnostic of what condition? Why would serum uric acid also be helpful?
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SIADH is diagnosed in the setting with suspected patients!!! Serum Uric acid is helpful because it is expected to be low due to increased urinary excretion of uric acid and hemodilution.
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What lab and clinical findings will be present to help differentiate Mineralocorticoid deficiency from SIADH?
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In mineralocorticoid deficiency, patients have hypotonic hyponatremia with HYPOVOLEMIA (rather than euvolemia), and potassium levels will be elevated as well.
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What lab and clinical findings will be present to help differentiate Advanced renal failure from SIADH?
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Advanced renal failure may produce hypotonic hyponatremia, however, patients are usually hypervolemic (rather than euvolemic as in SIADH), and BUN and serum uric acid levels, with be HIGH (rather than low as in SIADH).
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The indication for surgery in symptomatic patients with primary hyperparsthyroidism is present for all patients. Yet, the indication in asymptomatic patients with primary hyperparathyroidism rests on the presence of at least one of these 6 indications. What are they?
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1. Serum calcium level at lease 1mg/dL above the upper limit of normal
2. Urinary Calcium excretion greater than 400mg/24hr 3. Young age (<50 years old) 4. Bone mineral density (BMD) lower than T-2.5 at any site 5. Reduced renal function (eGFR < 60 ml/min) |
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In patients with esophageal varices, what prophylactic therapy is recommended to reduce the risk of hemorrhage?
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Beta-adrenergic receptor blockers; nitrates are sometimes added to the beta-blocker therapy
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When a farmer comes to you with Organophosphate poisoning, what step is just as important to take as administering Atropine?
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Removing all clothes and and washing the skin to prevent further transcutaneous absorption.
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The cause of Ventricular Tachycardia (regular, wide complex tachycardia) is due to coronary artery disease. What is the best treatment for a patient with ventricular tachycardia who has no hemodynamic compromise?
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Loading with either Lidocaine, or Amiodarone!!! EIther of these 2 agents will aid in the conversion to normal sinus rhythm, however, amiodarone has become the drug of choice.
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What is the best treatment for a patient with ventricular tachycardia who has not signs of hemodynamic compromise?
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Loading with either Lidocaine or Amiodarone. Either of these two agents with aid in conversion to a normal sinus rhythm. Between the two, Amiodarone has now become the drug of choice. With the presence of a stable blood pressure, cardioversion is not warranted.
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What is the treatment of choice for a sustained ventricular tachycardia with hemodynamic compromise?
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Cardioversion
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Are diltiazem and Cardizem used for atrial arrhythmias or ventricular arrhythmia?
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ATRIAL ARRHYTHMIA ONLY!!!
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What type of arrhythmia is carotid massage useful for?
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Narrow complex Super Ventricular Tachycardia.
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A patient presents with palpable pupura, proteinuria, and hematuria; there are also non-specific systemic symptoms, arthralgias, hepatosplenomegaly and hypocomplementemia; a majority of these patients have an underlying HCV infection. Diagnosis?
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Mixed essential cryoglobuilnemia
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It is important to be able to differentiate between the different types of dementia. This dementia causes alterations in alertness, VISUAL HALUCINATIONS, extrapyramidal symptoms, and relatively early compromise of executive functions. Diagnosis?
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Lewy Body dementia
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With this type of dementia, eosinophilic intracytoplasmic inclusions representing accumulations of alpha-synuclein protein, may be seen in neurons of the substantia nigra, locus ceruleus, dorsal raphe, and substantia innominata. Diagnosis? Treatment?
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Lewy body dementia; treatment of motor and psychiatric symptoms includes acetylcholinesterase inhibitors like Rivastigmine. For hallucinations refractory to acetylcholinesterase inhibitors, atypical antipsychotics may be of benefit.
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Compared with dementia in Lewy body disease, Alzheimer's disease has earlier and more pronounced anterograde memory loss, or hallucinations?
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Alzheimer's disease has earlier and more pronounced anterograde memory loss; Lewy body disease has earlier presence of hallucinations and changes in alertness.
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Dementia, abnormal gait, urinary incontinence. Diagnosis?
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Normal pressure hydrocephalus.
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Painless jaundice in a patient with conjugated hyperbilirubinemia and markedly elevated alkaline phosphatase should raise concern for what condition?
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An intraabdominal malignancy obstructing the biliary system, such as pancreatic adenocarcinoma.
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In a patient who has an MI, is treated with heparin, and a few days later suffers a cold leg, what is the etiology of this complication and how should it be diagnosed?
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This is a mechanical complication resulting from an embolus from the left ventricle. When the MI is large, a thrombus can form and embolize, generally to the legs. Echocardiogram is used to make a diagnosis of a thrombus. The MI results in blood stasis in the akinetic part of the heart with resultant thrombus formation. The thrombus in the left ventricle, if identified early, is treated with heparin and ECHO follow-up.
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If left untreated, patients with hyperthryroidism are at risk for what effects on their bone?
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Bone loss; direct effects of the thyroid hormones on the bone cels eventually lead to increased osteoclastic bone resorption. Consequently, increased calcium release from the bones leads to a mild increase in serum calcium levels, as well as hypercalciuria.
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In a patient with new onset atrial fibrillation, what endocrine disorder should you check for?
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Hyperthyroidism.
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Common cardiovascular effects associated with this endocrine abnormality include tachycardia, systolic hypertension, increased pulse pressure, and tachyarrhythmias, including atrial fibrillation (Afib can be sen with 10% of these patients); this disorder is not a risk factor per se, for CAD, but symptoms of coronary artery disease can be unmasked or worsened with this condition. Diagnosis?
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Hyperthyroidism; thyrotoxicosis.
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What do the JNC guidelines suggest that the best first-line antihypertensive agent in a patient with no comorbidities?
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Hydrochlorathiazide; thiazide diuretic.
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One of the branches of the Trigeminal nerves carries sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose and frontal sinuses. Damage to which branch of CN V results in corneal anesthesia?
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Opthalmic Nerve (V1).
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What is the treatment of choice for cellulits with systemic signs?
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IV Naficillin or Cefazolin.
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What antibiotic is used for the acute treatment of mild cellulitis (i.e. without systemic signs)?
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Oral Dicloxacillin.
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What psychiatric drugs can be used to treat posterherpetic neuralgia prophylactically or symptomatically?
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Amitriptyline or Nortriptyline, along with acute antiviral therapy.
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TCA overdose is characterized by CNS depression, hypotension, and other anticholinergic effects including dilated pupils, hyperthermia, and intestinal ileus. It can also cause QRS prolongation on EKG, leaving the patient susceptible to ventricular arrhythmias. Patients suspected of TCA overdose should first undergo the ABC's and the administered what medication? Why?
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Sodium Bicarbonate; improves blood pressure, shorten the QRS interval, and helps prevent arrhythmia.
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Immediate treatment of hyperkalemia is indicated if there is cardiac toxicity (as evidenced by EKG changes), muscular paralysis, or K+ >6.5. For these patients, what is the first step in management to stabilize the myocardial membrane? How do you lower the K+?
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10ml of 10% calcium gluconate should first be administered to stabilize the myocardial membrane. TO lower the K+ level, insulin an/or B2-agonists may be used since either of these drugs can shift K+ into the cells. Sodium bicarbonate can also be used to shift K+ into cells.
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Paroxysmal superventricular tachycardia (PSVT) most commonly results from accessory conduction pathways through they AV node. Vagal maneuvers and medications help resolve this condition through what means?
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Decreasing conduction through the AV node.
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Eggshell calcification cyst in the liver, lung, muscle, or bones; patient has intimate close contact with dogs. Diagnosis? Organism?
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HYDATID CYST!!!; Echinococcus granulosus; multiple lesions are associated with E. multilocaris.
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Infection with this organism generally results in cysts in the brain or in muscle (tapeworm). Diagnosis?
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Cysticercosis is secondary to infection with tenia solium.
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Of all regimens available, what is the most rapid-acting and effective treatment in aborting pain during an acute attack of a cluster headache (unilateral, sudden onset, severe, deep, excruciating, continuous or explosive in quality, starts as retro-orbital pain and later spreads to hemicranium).
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100% O2!!!
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What medication that is used for treating arrhythmia is also used for preventing cluster headaches?
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Verapamil; used for prophylaxis of cluster headaches and should be given as soon as possible after the onset of an acute attack. Other options are prednisone, ergotamine, methysergide, cyproheptadine, and indomethacin. Lithium is useful for prophylaxis of the CHRONIC form of cluster headaches.
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In cases where you are worried about a patient's renal function, but CT with contrast is necessary, certain precautions can be taken to minimize the risk of contrast induced nephropathy. What type of contrast should be used?
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Non-ionic contrast; these agents have been shown to have decreased incidence of contrast induced nephropathy compared to the older ionic hyperosmolar agents.
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Paget's disease may present with bone pain, headaches, and deafness depending upon the bones involved. As bones reshape they become soft and susceptible to fracture. Laboratory findings consistent with Paget's disease include an elevated alkaline phosphatase, but normal calcium, phosphorous, and other liver enzymes. X-rays will reveal dense, expanded bones. Treatment for Pagets disease of the bone consists of oral or intravenous *BISPHOSPHONATES. What is the main cause of all the pathophysiology associated with Paget's disease?
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Bone REMODELING!!!; BISPHOSPHONATES are known to decrease bone remodeling associated with multiple diseases.
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How do validity and reliability correlate with accuracy and precision?
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Validity = accuracy
Reliability = precision |
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Is Lidocane effective in atrial arrhythmias, ventricular arrhythmias, or both?
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ONLY VENTRICULAR ARRYTHMIAS!!!
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In patients with hyperthyroidism-related tachsystolic atrial fibrillation, what is the treatment of choice?
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Beta-blockers are the treatment of choice because atrial fibrillation in patients with hyperthyroidism is believed to be caused by increased sensitivity of beta- adrenoreceptors to sympathetic stimuli. Thus, beta-blockers help not only to control the rhythm in tachysystolic atrial fibrillation, but also diminishes other symptoms of hyperthyroidism.
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What physical exam feature indicates the presence of Bell's Palsy and excludes a diagnosis of Central Facial Paresis?
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The absence of forehead furrows indicates Bell's palsy (PERIPHERAL 7th nerve palsy) and rules out the diagnosis of a CENTRAL Facial Paresis; patients with central lesions still have forehead furrows because the contralateral motor innervation of the forehead remains intact.
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Nephrotoxicity is a well-known side effect of acyclovir therapy. What is the mechanism of action by which it induces kidney injury?
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Acyclovir is poorly soluble in urine and easily precipitates in renal tubules causing obstruction and acute renal failure. Crystalluria with renal tubular obstruction usually occurs during administration of large parenteral doses of acyclovir; inadequate hydration is a predisposing factor. A typical presentation described for acute renal failure is oliguria with elevated creatinine and BUN.
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Patient presents with right-sided hemiplegia and facial paresis; speech and praxis do not seem to be impaired; he correctly names his left and right arms; visual testing is normal (*this is motor impairment without any higher cortical dysfunction and visual field abnormalities). Where is the lesion?
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Posterior limb of the internal capsule (lacunar infarct).
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Patient presents with hemiplegia, conjugate eye deviation toward the side of infarct, hemianesthesia, homonymous hemianopia, *aphasia (dominant hemisphere), *hemineglect (non-dominant hemisphere). Where is the lesion?
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In on of the Middle Cerebral arteries.
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Patient presents with Contralateral weakness that predominantly affects the lower extremity, abulia, akinetic mutism, emotional disturbances, deviation of head and eyes toward lesion, sphincter incontinence. Where is the lesion?
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Anterior cerebral artery occlusion.
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Patient presents with 'Alternate' syndromes, with contralateral hemiplegia and ipsilateral cranial nerve involvement. Where is the lesion?
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Vertebrobasilar system lesion (*supplying the brain stem).
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Common signs of dysfunction of this area of the brain include intention tremor, nystagmus, ataxia, difficult with rapid alternating movements, dysmetria, and broad-based gait. Diagnosis?
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Cerebellar dysfunction.
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What eye exam finding should be present in a patient in order to make the diagnosis of malignant hypertension, even if the patients BP is >/= 200/140?
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Papilledema should be present in order to make a diagnosis of malignant hypertension.
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Osteoporosis refers to decreased bone mass and increased bone fragility. It is diagnosed by comparing the bone density T-score of a patient with that of a younger individual of the same gender and race. A T-score of -1.5 to -2.5 is called Osteopenia. Osteoporosis refers to a T-score of less than -2.5 or a higher T-score with fragility fracture. What is the recommendation for age and modality of screening for osteoporosis in females in te U.S.?
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It is recommended to have a one-time screening of all women who are 65 years and older with a DEXA scan (Dual energy X-ray absorptiometry) of the spine and pelvis.
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A "solitary pulmonary nodule" is defined as a 3cm or less coin-shaped lesion in the middle to lateral one third of the lung surrounded by normal parenchyma. Is this most likely malignant or benign, in a low risk patient (i.e. <40 years and non smoker)? What is the approach to workup? What do "popcorn" and "bulls eye" calcifications found on a CXR imply?
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This solitary nodule is most likely benign in a low risk patient. The best approach is to first ask for an old x-ray. If there is no change in it for the last 12 months it is considered benign. It is followed by a CXR every 3 months, for the next 12 months, and if there is no growth or symptoms it is left as such; popcorn calcification is a hamartoma, while bulls eye is a granuloma.
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Amikacin is what type of antibiotic with what type of toxicity that may be used in a multidrug resistant pyelonephritis, with a gram negative rod?
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This is an aminoglycoside that has the side effect of severe renal toxicity and ototoxicity.
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What part of the brain is the substantia nigra in? What is often the first presenting sign of Parkinson's disease?
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Substantia nigra is in the basal ganglia; the first presenting sign is often a resting tremor that starts in one hand and improves with intentional movement.
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What is the most common cause of fatal malignancy in young adults?
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Melanoma.
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What is the strongest risk factor for malignancy is a skin lesion?
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A recent change in the appearance (i.e. shape, color, size). A recently changed mole is associated with a relative risk of at least 10, but the RR can actually be as high as 200, according to several studies.
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Persistent nasal blockage with episodes of bronchoconstriction due to accumulation of leukotrienes and changed prostaglandin/leukotriene balance is a type of "Pseudo-allergic" reaction that can occur with the use of what type of medication?
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Aspirin and other NSAIDs that block COX 1 and 2; these are COX-1 and COX-2 inhibitors, and as a result of its pharmacologic action, arachidonate diverges from blocked COXs to a 5-lipoxygenase pathway. Accumulation of the leukotrienes and shifted prost/leuko balance triggers bronchoconstriction and polyp formation in susceptible individuals
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What type of testicular tumor is most likely to produce estrogen and testosterone?
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LEYDIG CELL TUMOR!!!; leydig cells are the principal source of testosterone and are capable of estrogen production, due to markedly increased aromatase expression. The estrogen production is markedly increased in tumorous growth of Leydig cells, with secondary inhibition of LH and FSH levels. Endocrine manifestations are found in only 20-30% of adults, the most common being gynecomastia, however in prepurbertal cases, precocious puberty is common.
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Primidone is an anticonvulsant agent, which can be used to treat benign essential tremors. Its becomes metabolized to phenobarbital, which causes an exacerbation of usually undiagnosed condition in a specific population of people. You will see colicky abdominal pain, confusion, headaches, hallucinations, and dizziness. What condition is this that is being uncovered? How do you diagnose this condition?
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Acute intermittent porphyria, which phenobarbital will exacerbate due to it induction of heme production through increasing cytochrome synthesis. AIP is diagnosed by checking for urine porphobilinogen.
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What is the formula for calculating the Attributable Risk Percent of a given risk factor from the Relative Risk?
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ARP = (RR-1)/RR
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What are the are the most common electrolyte abnormalities observed in Cushing's syndrome?
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Hypokalemia and Hypernatremia!!!; these both occur due to excessive mineralocorticoid receptor stimulation!
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If you suspect thymoma in a patient associated with myasthenia gravis, what test would be the most sensitive to pick up the abnormality?
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CT scan of the chest.
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Which centrally located lung cancer secretes PTHrP? Which one secretes ADH and ACTH?
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sCa++mous (squamous) cell carcinoma of the lung generally secretes PTHrP; Small cell carcinoma of the lung usually causes other paraneoplastic syndromes such as ACTH production and SIADH.
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A 70 y/o man presents with malaise, pain and stiffness of his neck, shoulders and hips for the last 3 months; his stiffness is worse in the morning and lasts one-two hours; he also complains of a recent weight loss of 7 lbs and mild fevers. Diagnosis? Treatment?
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Polymalgia rheumatica; low- dose prednisone is the initial therapy.
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The features required to make a diagnosis of Polymyalgia Rheumatica include age over 50 years, aching pain in the neck, shoulders and pelvic girdle lasting at lest one month, morning stiffness lasting over one hour and an elevated ESr (>40mm/hr) in the absence of other diseases that may account for these symptoms; tenderness with active or passive range of motion is often absent; signs of inflammation in the joints are absent; when asked to identify the location of their pain, patients typically indicate that it is in soft tissues and not the joints. What is the treatment for PMR?
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Low-dose prednisone.
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When a patient presents with signs of Giant Cell(Temporal) arteritis, whether alone or in conjunction with other disease, what treatment is used to prevent visual loss?
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Emergent High-dose prednisone therapy.
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Metastatic disease of the liver is many times more common than primary liver malignancy. Patients usually present with symptoms related to the primary malignancy, as liver metastases are generally asymptomatic. Where are common sites of primary lesions that metastasize to the liver?
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GI, Lung, Breast metastases are the most common to metastasize to the liver, and are also among the most common cancers overall.
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Will you ever see a hepatocellular carcinoma without the patient having a history of chronic liver disease?
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NO!!!; Hepatocellular carcinoma most commonly occurs in the setting of chronic liver disease!!!
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What type of dementia is characterized by personality changes (euphoria, disinhibition, apathy), compulsive behaviors (e.g. peculiar eating habits), hyperorality, and impaired memory?
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Pick's disease.
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Hemochromatosis produces one of the only restrictive cardiomyopathies that may be reversed with treatment. What is this treatment?
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PHLEBOTOMY for Hemochromatosis!!!
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A middle aged patient with nephrotic-range proteinuria and hematuria, and no other recent medical illness, most likely has membranoproliferative glomerulonephritis. Dense intramembranous deposits that stain for C3 is a characteristic microscopic finding for membranoproliferative glomerulonephritis, type 2 (also called dense deposit disease). This condition is unique among other glomerulopathies, because it is caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative compliment pathway. What is the pathophysiologic mechanism that causes the condition?
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The anti-C3 convertase antibodies reacting with C3 convertase lead to persistent complement activation and damage the kidneys.
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What is the mechanism of kidney injury associated with Idiopathic Crescentic Glomerulonephritis?
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Cell-mediated injury.
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This leukemia has a dramatic onset in adults, with most chief complaints being headaches, fever, weight loss, and bleeding from the gums or nose; signs include gingival hyperplasia and occasional skin lesions; peripheral smear reveals leukocytosis with a high proportion of blast forms; POSITIVE ALPHA-NAPHTHYL ESTERASE TEST is characteristic!!!. Diagnosis?
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Acute Monocytic (FAB M5) Leukemia.
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This adult leukemia is characterized by the predominance of MYELOBLASTS on the peripheral blood smear. Diagnosis
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Acute Myeloblastic Leukemia with Maturation (M2).
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This adult leukemia is characterized by many HYPERGRANULAR PROMYELOCYTES; each cell has many auer rods; there is a high incidence of DIC in these patietns. Diagnosis?
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Acute Promyelocytic Leukemia.
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This adult leukemia is characterized by erythroblasts, which have an irregular outline and a high nuclear-cytoplasmic ratio. Diagnosis?
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Acute Erythroblastic Leukemia.
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This leukemia is characterized by leukocytosis with many monoblasts, promonocytes and monocytes; monoblasts lack auer rods and will have PEROXIDASE NEGATIVE (PAS) AND NONSPECIFIC ESTERASE POSITIVE reactions. Diagnosis?
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Acute Monocytic (FAB M5) Leukemia.
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What is the first-line treatment for Enterobius vermicularis (pin worms)? Second-line?
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Albendazole or mebendazole are first-line treatments, but should not be used in pregnant women; Pyrantel pamoate is an alternative, but has more side effects and is less efficacious.
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What is the best method of treatment for Hypercalcemia in the acute setting?
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Intravenous Fluid Resuscitation with 0.9% (Normal) Saline IV; this increases renal excretion of calcium by decreasing calcium reabsorption in the proximal tubule. Loop diuretics are then used to inhibit calcium reabsorption in the Loop of Henle. Later, treatment of the specific cause of hypercalcemia is warranted.
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Which drugs are more effective at decreasing plasma calcium concentrations: Bisphosphonates or Calitonin?
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BISPHOSPHONATES; therefore, they are the second-line agents used for patients with moderate to severe hypercalcemia, after fluid resuscitation and a course of loop diuretics.
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What are the common findings in CSF fluid in a patient with Multiple Sclerosis, with reference to Total Protein/Immunoglobulin ratio, and type of Ig. Are CSF findings diagnostic of MS?
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Total protein concentration in such patients is usually normal, however, IG levels are high relative to other protein components. The predominant Ig type is IgG, although IgM and IgA are also increased. The IgG index is used to measure the increase in IgG levels relative to other proteins. Elevated Ig levels may be found in other diseases such as neuropathies, chronic central nervous system infections or viral syndromes, thus for these reasons, the presence of Oligoclonal bands is highly suggestive for MS, but not diagnostic.
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What is the CSF finding that is highly suggestive,but not diagnostic of Multiple Sclerosis?
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OLIGOCLONAL BANDS!!!; they are present in 85-90% of cases. CSF pressure, total protein, and cell count, are grossly normal, however.
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Viteligo involves a pathogenesis that is believed to involve an autoimmune process directed against melanocytes, and this theory is supported by the concomitant occurrence of other autoimmune diseases with vitiligo. What are some of these autoimmune diseases that are associated?
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Pernicious anemia, Autoimmune thyroid disease (usually Grave's, or Chronic autoimmune thyroiditis), Type 1 Diabetes, Primary Adrenal Insufficiency, Hypopituitarism, and Alopeica areata.
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When looking at an ECG strip of a patient with hypotension and recent viral illness beware of subtle alternating levels in QRS amplitude that indicate what condition? What is the best diagnostic test? What is the treatment?
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Cardiac tamponade; the ECG may reveal electrical alterans. A patient may develop pericarditis from an upper respiratory infection, causing pericardial effusion. The amplitude of the QRS alternates as the hear moves toward and away from the ECG leads in the fluid-filled pericardial sac. Pericardial effusions are well-visualized by Echocardiography. The treatment for cardiac tamponade includes volume resuscitation and emergent pericardiocentesis.
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What condition should you consider in a patient with hypotension, tachycardia, and JVD?
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CARDIAC TAMPONADE!!!
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What are the PaO2 and SaO2 parameters for considering a patient with COPD for home O2?
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Pa02 < 55mmHg
SaO2 <88% |
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Patients with signs of Pulmonary HTN or Hematocrit >55% should be started on home O2 when PaO2 reaches what level?
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PaO2 <60 mmHg
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How many hours out of the day must home O2 be used in order to confer a survival benefit?
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>/= 15 hours a day.
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Cipro and Erythromycin have dangerous interaction with what Asthma drug?
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Theophylline; they decrease its clearance from the body; the exact mechanism for theophylline toxicity is debated, but may include phosphodiesterase inhibition, adenosine antagonism, and stimulation of epinephrine release.
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This condition is a mucocutaneous blistering disease that is characteized by flaccid bullae and intercellular IgG deposits in the epidermis; autoantibodies are formed agains desmoglein. Diagnosis?
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Pemphigus Vulgaris.
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This condition is a benign pruritic disease; it is characterized by tense blisters (as opposed to flaccid blisters); oral lesions are VERY RARE in THIS disease; IgG and C3 deposits occur in the dermal-epidermal junction. Diagnosis?
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Bullous Pemphigoid
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This first-line treatment for Rheumatoid Arthritis has side-effects that include stomatitis, nausea, anemia, and hepatotoxicity; adverse effects can be reduced by using concomitant folic acid. What is the drug?
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Methotrexate.
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Patients with Hashimoto's thyroiditis are at risk for developing what type of thyroid malignancy?
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Thyroid Lymphoma.
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Rapidly developing hyperandrogenism with virilization is highly suggestive of an androgen-secreting neoplasm of the ovary or adrenal. What is the best screening test for a virilizing neoplasm? Why? Where is testosterone made vs. where DHEAS is made, vs. where DHEA is made?
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Measurement of the serum testosterone and DHEAS levels; this test is very helpful in delineating the site of excess androgen productions. Elevated testosterone levels with normal DHEAS levels indicate a gonadal source, while elevated DHEAS levels with relatively normal testosterone levels indicate an adrenal source. DHEA is secreted from both the gonads and adrenals, whereas DHEAS, a sulfated form of DHEA, is specifically secreted from the adrenals.
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Erysipelas is a specific type of cellulitis. It is characterized by inflammation of the superficial dermis, thereby producing prominent swelling. The classic finding is a sharply demarcated, erythematous, edematous, tender skin lesion with raised borders. The onset of illness is abrupt, and there are usually systemic signs, including fever and chills. What is the most likely causative organism?
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Group A beta-hemolytic streptococcus; S.aureus, S.pneumoniae, and Enterococci are very rare causes of erysipelas
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Why might you have an enlarged liver with someone who has Autosomal Dominant Polycystic Kidney Disease?
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Because the LIVER GETS CYSTS IN THIS DISEASE TOO!!!
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What is the heritable form of renal disease characterized by multiple renal cysts and intermittent flank pain, hematuria, urinary tract infections, and nephrolithiasis?
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Autosomal dominant polycystic kidney disease.
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Can renal cell carcinoma alone cause renal failure?
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NO!!!
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This is one of the most common hereditary diseases in the U.S. and accounts for 10% of dialysis patients; patients will often have hypertension and palpable kidneys on exam. Note: the enlarged right kidney is easier to palpate because it lies lower than the left kidney! The liver might be enlarged due to cystic involvement. Diagnosis?
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Autosomal Dominant Polycystic Kidney Disease.
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Combined interferon-alpha and ribavirin is used for the treatment of patients with chronic Hepatitis C and compensated liver disease. These drugs, however, are contraindicated in pregnancy. Why? What treatment should a pregnant woman diagnosed with chronic Hep C infection receive???
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Ribavirin is particularly highly teratogenic!!!; current recommendations state that all patients with chronic hepatitis C should receive vaccinations to Hep A and B if not already immune, and both vaccinations are safe for use during pregnancy.
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What is the most well-known complication of Giant Cell (Temporal) Arteritis?
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Aortic aneurysms are well-known complications because branches of the aorta can become involved in Giant Cell arteritis. This obligates close following of patients with serial chest X-rays.
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The increased incidence of colorectal carcinoma in patients with Ulcerative Colitis is increased such that UC requires annual surveillance colonoscopy beginning at what time period after diagnosis?
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8-10 years after diagnosis; this is important given the 1% annual incidence of colon cancer in patients with UC.
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If you receive a question about Allergic Bronchopulmonary Aspergillosis, what are the two most likely predisposing conditions that the patient in question will have to have?
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Asthma or Cystic Fibrosis.
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What is the treatment of choice for acute agitation in the elderly (*Benzos are NOT recommended)?
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Haloperidol; atypical antipsychotics like quetiapine and risperidone may also be used. It is important to know that prolonged use of both typical and atypical antipsychotics can increase mortality in the elderly, but they are safe in the acute setting.
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Why shouldn't atypical antipsychotics be used in a patient with agitation and Lewy Body dementia?
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Lewy body dementia patients are just extra sensitive to the effects of these medicines.
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What is Memantines role in attenuating Alzheimer's disease?
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Memantine works by blocking glutamate's actions on the NMDA receptor.
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What clinical feature of a patient with CLL would represent the prognosticating factor with the worst overall outcome?
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CLL with THROMBOCYTOPENIA is associated with the POOREST PROGNOSIS!!!
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Is CLL a T-cell or B-cell disease?
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B-CELL!!!
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What is the principal cause of death in patients with CLL?
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Infection!!
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What are common causes of Hypomagnesemia?
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Poor nutrition, malabsorption, diuretic use, and alcohol abuse.
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This disease is characterized by nonspecific symptoms and signs including anorexia, fatigue, GI complaints, weight loss, and HYPOTENSION and signs of VOLUME CONTRACTION; there may also be hyperpigmentation of the skin anywhere (e.g. in the palmar creases). What is this disease and what are the two most commonly found electrolyte disturbances?
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Addison's disease (adrenal insufficiency and adrenal failure); Hyponatremia is the most common associated electrolyte abnormality, and Hyperkalemia is also common.
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Paget's disease of the breast should be suspected in a patient with no prior history of skin disease who presents with an eczematous rash near the nipple that does not improve with topical treatments. What is the type of cancer that is most commonly associated with Paget's Disease of the Breast?!
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ADENOCARCINOMA!!!
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In the evaluation and management of Acute Renal Failure (ARF), what is the first critical step, which can resolve various post-renal obstructions in addition to facilitating monitoring of urine output in pre-renal and intrinsic renal failure?
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Foley Catheterization!!!
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Dapsone is the first-line therapy for what skin lesion?
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DERMATITIS HERPETIFORMIS!!!
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Hyposthenuria can present in a patient as nocturia due to an impairment in the kidney's ability to concentrate urine. Hyposthenuria is found in patients with sickle cells disease, but also commonly, though usually less severe, in patients with sickle cell trait. What is the pathophysiological mechanism of this symptom?
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Hyposthenuria is thought to result from red cell sickling in the vasa rectae of the inner medula, which impairs countercurrent exchange and free water reabsorption.
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This disease presents in an AIDS patient and usually shows up on an MRI as a solitary, weakly ring-enhancing lesion, with irregular borders, and is periventricular. Diagnosis?
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Primary CNS lymphoma; EBV DNA will most likely be found in the CSF.
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Which immunologic deficiency predisposes to anaphylactic reactions from blood transfusions?
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IgA DEFICIENCY!!!
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What is the one major exception to not giving live vaccines to AIDS patients?
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Many live vaccines are contraindicated in patients with HIV, including BCG, anthrax, oral typhoid, intranasal influenza, oral polio, and yellow fever vaccines. The MMR vaccine, however, is strongly recommended for patients with HIV as long as the CD4 count is greater than 200/micro-L and there is no history or evidence of any AIDS-defining illnesses. And although the MMR vaccine is routinely administered in childhood, HIV-infected individuals without AIDS should receive a booster due to their increased susceptibility.
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Fever and neutropenia warrant hospital admission for empiric antibiotic therapy and further evaluation and observation. Blood cultures should be initiated prior to starting atibiotics, and the empirical antibiotics of choice should cover the Gram-negative organisms, especially Pseudomonas. What two drugs in particular would be good?
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Third-generation (i.e. Ceftazidime) and Fourth-generation (i.e. Cefepime) Cephalosporins are active against Pseudomonas, the Enterobacteriaceae, and many Gram-positive organisms, thus making them first-choice drugs in a patient with fever and neutropenia.
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What is the definition of Neutropenia?
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Absolute Neutrophilic Count (ANC) of <500 cells/m3.
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An immunocompromised patient presents with an area of skin associated with constant burning pain and without any other physical examination abnormalities. What is the most likely diagnosis?
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Herpes Zoster; pain is the most common symptom of shingles. The pain can develop several days before the classic shingles rash appears, or the pain and rash may appear concurrently. The pain is typically intense, deep and burning in quality.
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What are the treatments for Shingles (Herpes Zoster)?
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Analgesics and antiviral medication like Acyclovir.
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In any patient, what are the lab values that provide the best picture of acid-base status on ABG?
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pH and PaCO2.
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Patient complains of a 'nagging' dry cough over the last 4 weeks; says that the cough is present during the day and also wakes her from sleep at night; there is no associated shortness of breath, pain or wheezing; PMHx significant for chronic rhinorrhea and occasional itching skin rash; one week of chlorpheniramine significantly improves her symptoms. Decrease what is mostly likely responsible for her symptom relief?
|
Nasal secretions!!! She has postnasal drip with allergic rhinitis. Postnasal drip of nasal secretions can cause irritation and initiation of the cough reflex. In general, allergic rhinitis is a diagnosis that can be made based on history and physical examination. There is generally a background of environmental allergies.
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What is the main factor associated with causing syncope in a young patient with Hypertrophic Cardiomyopathy?
|
It is multifactorial, but it is due in large part to outflow obstruction from the hypertrophied myocardium; it can also be due to arrhythmia, ischemia, and ventricular baroreceptor response that inappropriately causes vasodilation
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If you see a patient who was diagnosed with Rheumatic Fever one year ago and was never treated for the throat infection, and has signs of valvular disease today, what is the next best step in management when you see her in your office?
|
Penicillin; repeated episodes of rheumatic fever can worsen valvular function, thus it is recommended that patients with a prior episode of rheumatic fever be given antibiotic prophylaxis with penicillin to prevent a recurrence. The duration of treatment is not firmly established, but most physicians will treat until the patient reaches the age of 18.
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What is the main medical treatment for Mitral Stenosis?
|
Primarily preload reduction with diuretics or nitrates as opposed to afterload reduction (e.g. with ACE-inhibitors)
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What are the most common locations for the development of angiodysplasia in the GI tract?
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Colon and particularly the cecum, although they can occur anywhere throughout the GI tract.
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If an older patient has a systolic ejection murmur at the right second intercostal space (which could represent aortic stenosis) and has blood in the stool, what diagnosis (although somewhat controversial with this association) should you consider?
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ANGIODYSPLASIA!!!; there is a somewhat controversial association between aortic stenosis and bleeding from angiodysplasia.
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This infection may present on chest X-ray as a crescent radiolucency next to a rounded mass; cavitary lesions may form because of destruction of the underlying pulmonary parenchyma; prophylactic resection is controversial, although some recommended if isolated disease is present in good risk patients. Diagnosis?
|
Aspergilloma!!!; cavitary lesions may form because of destruction of underlying pulmonary parenchyma, and debris and hyphae may coalesce and form a fungus ball, which lies free in the cavity and moves around with position change.
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What are the ECG findings that may tip you off that a patients has had a Pulmonary Embolism? CXR?
|
ECG may demonstrate RVH. RBBB, Right Axis deviation, and T-wave inversion in the anterior leads. CXR may be normal or may show decreased pulmonary vascular markings or an enlarged right descending pulmonary artery.
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This is the most common fungal infection in the U.S,; calcified noeds in the lung, mediastinum, spleen, and liver may occur; CXR may demonstrate central or target calcification; a solitary nodule may be seen and occasionally lymphogenous reaction to the infection will cause mediastinal lymph node enlargment. Diagnosis?
|
Histoplasmosis.
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A mobile cavitary mass in the lung, which presents with intermittent hemoptysis. Diagnosis?
|
Aspergilloma; fungus ball.
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Any adolescent who presents with nasal obstruction, visible nasal mass, and frequent nosebleeds is considered to have what diagnosis until proven otherwise?
|
Angiofibroma; this is typically found in the back of the nose or upper throat of adolescent boys. It is a benign growth, but is capable of eroding and locally invading.
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The diagnosis of PCP pneumonia must be considered in any HIV patient who presents with a dry cough, exertional dyspnea, fever and a normal white count; chest X-ray usually shows bilateral interstitial infiltrates, and HYPOXIA is usually out of proportion to radiographic findings; serum LDH levels are frequently elevated. How is the diagnosis of PCP confirmed?
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By demonstration of the organism in sputum or BAL aspirate.
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Bactrim is the initial DOC for the treatment of PCP irrespective of the severity of the pneumonia. Steroids have been shown to decrease mortality in cases of severe PCP. What are the indications of steroid use in PCP pneumonia?
|
PaO2 < 70 mmHg or A-a gradient >35 mmHg.
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When is Pentamidine used to treat PCP pneumonia?
|
Pentamidine is less effective than Bactrim, but can be used to treat PCP pneumonia for patients with severe cases of PCP and intolerance to TMP-SMX
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In patients with chronic hyponatremia, cells in the brain compensate by extruding osmolites (e.g. Na+, K+) and intracellular water, thus reducing cerebral edema and symptoms. The sodium deficit must be corrected slowly because increases in the serum sodium concentration by more than 0.5 mEq/L/h raises the risk of Central Pintine Myelinosis. In patients with acute symptomatic hyponatremia, however, the brain has not yet lost volume to accomodate the new serum concentration and cells are still edematous, thus correction can happen much mor rapidly. How should this correction be done?
|
3% Hypertonic Saline; patients with acute, symptomatic hyponatremia should receive hypertonic saline until their symptoms resolve.
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What is the physiologic cause of senile purpura?
|
Perivascular connective tissue atrophy.
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Why is lupus anticoagulant associated with clotting, but a prolonged PTT???
|
The lupus anticoagulant is an IgM or IgG immunoglobulin that prolongs the activated partial thromboplastin time (aPTT) by binding the phospholipids used in the assay. Thus, it is a laboratory artifact resulting in a prolonged aPTT. In fact, as stated above, it is not an anticoagulant at all and is associated with an increased risk of thrombosis and spontaneous abortion.
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Inflammatory symmetric arthritis that resolves within two months is most likely due to what cause? (*Positive rheumatoid factor may occur and weakly positive ANA would not be surprising findings here)
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VIRAL CAUSE!!!; including parvovirus, hepatitis, HIV, mumps, and rubella among others.
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When should corticosteroids and/or Interferon-beta be used in treating Multiple Sclerosis? Which should be used to treat the acute attacks and which decreases the frequency of relapses?
|
High-dose Corticosteroids should be administered during the acute attack of the disease; Interferon-beta has been proven to decrease the frequency of relapse.
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What is the test used to confirm the presence of DVT? What if the suspicion for DVT is low?
|
Compression Ultrasonography; if suspicion for DVT is low, the D-dimer level is first checked because this test has a high negative predictive value
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Why is Heparin used first in treating DVTs as opposed to Warfarin?
|
Because Warfarin has initial prothrombotic effects due to action on Vit. K dependent factors Proteins C and S, and it has delayed action. Heparin is continued in conjunction with Warfarin until the INR is within therapeutic range for two consecutive days. At that point Warfarin therapy alone is appropriate and should be continued for 3 months if the DVT was caused by a reversible risk factor, and 6-12 months if it was unprovoked.
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In a patient with both liver and renal disease who needs to undergo surgery, what neuromuscular blocking agent should be used for intubation? (*this agent is unique in the way it is degraded in the body)
|
Atracurium; it is unique in that it degrades spontaneously in the plasma and is also hydrolyzed by serum esterases; therefore, the half-life of this drug does not change significantly with liver or renal dysfunction.
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Why is succinylcholine dangerous to use in patient with renal dysfunction?
|
Succinycholine is a depolarizing age, with ultra-short duration of action, but in patients with renal dysfunction it succinylcholine may cause apnea and HYPERKALEMIA!!!
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What is the difference between Stevens-Johnson syndrome and Toxic epidermal necrolysis?
|
TEN is at the end of the spectrum for idiosyncratic skin reactions, which include Stevens Johnson syndrome and TEN/Stevens Johnsone syndrome overlap. In Stevens Johnson syndrome </= 10% of the body surface area is involved, whereas in TEN >30% of the body surface area is involved. Patients in between are labeled as TEN/Stevens Johnson syndrome overlap.
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"Target lesion" is a buzz word for what drug associated skin reaction?
|
Erythema Multiforme.
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What is the pathophysiologic mechanism believed to be associated with Isolated Systolic Hypertension (ISH)? What is the first-line DOC for this condition?
|
Decreased elasticity of the arterial wall, which leads to an increased systolic blood pressure, without concurrent increase (and even decrease) in diastolic blood pressure. The DOC for this condition is HTZ
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One rare but serious side effect of Isoretinoin use or Vitamin A toxicity is Pseudotumor Cerebri. What are some of the signs and symptoms associated with this condition?
|
Headache and blurry vision are the most prominent symptoms of this condition. Physical exam may reveal papilledema, vision loss, and cranial nerve palsies (CN VI is most common). Lumbar puncture will show an increased opening pressure with otherwise normal CSF.
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In a patient who has severe acne, you find that they complain of headache and blurry vision. Physical exam reveals papilledema, and vision loss (maybe even CN Vi palsy). Lumbar puncture shows an increased opening pressure with normal CSF analysis. Diagnosis?
|
Pseudotumor cerebri as a rare, but serious side effect of taking ISORETINOIN FOR THE PATIENT'S ACNE!!!; young obese women are most commonly affected.
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The finding of bloody diarrhea has a somewhat more limited differential than diarrhea in general. The presence of abdominal pain and lack of fever in a patient without travel makes the diagnosis of what bug most likely?
|
Enterohemorrhagic E.coli (EHEC) ; O157:H7 is the most common strain in the U.S. Shigella, Salmonella, and Campylobacter can also cause bloody diarrhea, but often result in fever and/or lack of abdominal pain. Potential complications of EHEC are HUS and TTP.
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After the diagnosis of a solid, painless testicular mass has been made (painless hard mass in testicle + suggestive ultrasound = cancer), what is the initial next best step in management?
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Radical Orchiectomy; removal of the testis and its associated cord. The testis and abnormal tissue present is then examined under the microscope to determine the type of cancer. Depening on the cell type of the cancer present, other therapies, i.e. additional surgery, radiation therapy, or possibly chemotherapy may be indicated. This is a tumor that we kill first and investigate later. So, observation, chemotherapy, and biopsies are not the next best step in these cases.
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A young afebrile female patient with no smoking history presents with an acute-onset cough productive of yellow, blood-tinged sputum. The most likely cause of hemoptysis in this case is acute bronchitis. Fever is uncommon in acute bronchitis, but wheezing is a common physical exam finding. The presence of fever would suggest a more severe diagnosis, such as pneumonia, while constitutional signs, weight loss or more significant hemoptysis may suggest malignancy or TB. What is the next best step in the management of this patient?
|
Acute bronchitis is most commonly viral in etiology, so antibiotics are not indicated. In these cases, observation and close follow-up is the most appropriate treatment strategy.
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In a patient with recurrent episodes of hemoptysis, in the assessment of mass lesions in the airways, and in cases where diagnosis is unclear with high-resolution CT scanning, what management is indicated?
|
BRONCHOSCOPY!!!
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What role do intravenous antiemetic agents such as chlorpromezine, prochlorperazine or metoclopramide, have in acute treatment of migraine attacks?
|
These medications can be used as monotherapy or as adjuvant therapy in combination with NSAIDs or triptans for the treatment of acute migraine headaches. Prochloperazine is an effective acute treatment for migraine and can be given IV, which is often necessary given these patients' tendency towards vomiting. Triptan medications are an effective migraine treatment, but must be started early on in the course of the migraine before symptoms become severe in order to be of benefit.
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Why would a patient being treated with Radioactive I-131 therapy for hyperthyroidism show signs of Afib and tremor shortly after starting treatment?
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This is because I-131 is taken up by the thyroid follicular cells and then destroys them by emitting beta radiation rays. While this effectively treats hyperthyroidism in the longterm, dying thyroid cells release excess thyroid hormone into the circulation, which can temporarily aggravate the hyperthyroid state. Thyroitoxicosis would likely explain the new-onset Afib.
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Why is it recommended that elderly hyperthyroid patients (vs. young hyperthyroid patients) be pretreated with medications like methimazole before receiving I-131 therapy?
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In general, young patients fre of cardiovascular disease tolerate radioactive iodine ablative treatment without major problems. In elderly patients and patients with significant cardiovascular disease, however, the temporary increase in thyroid hormone levels with I-131 treatment can lead to complications such as Afib and other signs of thyrotoxicosis.
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Where is D-xylose absorbed in the small bowel, and thus where can it help you diagnose malabsorption?
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D-xylose absorption occurs in the PROXIMAL SMALL BOWEL. Its absorption and subsequent excretion in the urine will give > 4.5 grams in 5 hours in cases of malabsorption due to both bacterial overgrowth and Celiac disease. With bacterial overgrowth, the test becomes normal after antibiotic treatment.
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Chalazion initially presents as a painful swelling that progresses to a nodular rubbery lesion on the eye lid margin. This is a chronic granulomatous condition that develops when a meibomian gland becomes obstructed. Recurrent chalazions require what next best step in management?
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They require histopathologic examination because there is a risk for an underlying malignancy of sebaceous (meibomian gland) carcinoma. Additionally, basal cell carcinoma is the most common malignancy of the lid margin, and may appear similarly to chalazion.
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Patients with DVT in whom anticoagulation is contraindicated (those with recent surgery, hemorrhagic stroke, bleeding diathesis, or active bleeding) require what type of treatment to prevent PE?
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Placement of an IVC filter.
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Esophagitis occurs with advanced HIV disease, usually when the CD4 count is <50/microL. What is the most common etiologic agent of esophagitis in HIV-infected patients and therefore what is your empirical treatment and next best step in management? What if the patient is refractory to therapy?
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Candida is the most common etiologic agent of esophagitis in HIV-infected patients, therefore such patients are first started on Fluconazole. Failure to respond to a 3-5 day course of oral fluconazole warrants further investigation and the next step after that would be to perform esophagoscopy with cytology, biopsy and culture to determine specific etiology.
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Beta-blockers are contraindicated in patients with Obstructive lung disease, but can they be used in Restrictive lung disease?
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YES!!! Amiodarone should be avoided in restrictive disease, and other forms of lung disease!!!
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Dizziness can be classified as vertigo if the patient describes a sensation of spinning that is accompanied by nausea. Meniere's disease is the likely cause of vertigo if the patient also has a sensation of ear fullness. What part of the ear anatomy does Meniere's disease effect?
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Meniere's disease is a disorder of unclear etiology in which there is an abnormal accumulation of endolymph within the INNER EAR!!!
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What is the most effective symptomatic therapy for Parkinson's disease and the one that should be used in initial treatment?
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L-dopa; is associated with a greater risk of dyskinesia than dopamine agonists, but dopamine agonists have slightly less efficacy than L-dopa.*Younger patients are usually initially treated with dopamine agonists, and older patients are given L-dopa.
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What is the MAO-B inhibitor that acts as a neuroprotective agent that may slow the progression of Parkinson's disease; it has mild symptomatic action, and may be used as an adjunctive treatment in patients receiving L-dopa. Medication?
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SELEGILINE!!!
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In many patients with a broad differential diagnosis for their dysphagia for solids and liquids (suggesting a motility disorder), a barium esophagram is performed before an upper endoscopy. Why?
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Because there are certain conditions of the esophagus (e.g. achalasia) that it evaluates better, and may be safer in patients with an upper esophageal lesion or tortuous stricture. Endoscopy can be performed next, if the barium esophagram is inconclusive or negative.
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Why might a child with cystic fibrosis have an elevated PT???
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Vitamin K deficiency (due to fat malabsorption) leading to decreased activation of Factors II, VII, IX, X!!!
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Which tuberculosis drug creates idiosyncratic liver injury with histological features similar to those seen in patients with viral hepatitis?
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Isoniazid.
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Once the diagnosis of Rheumatoid arthritis is certain, therapy with disease modifying anti-rheumatic drugs (DMARDs) is indicated. What is the first-line DMARD used in the treatment of RA because of its long history of efficacy and safety when used as a weekly pulse? What is used in patients who are refractory to this first-line agent?
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METHOTREXATE!!! Etanercept and Infliximab are used in those refractory to methotrexate.
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Time to what action is strongly correlated with survival in VF and pulseless VT?
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DEFIBRILLATION!!!!
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In the ACLS algorithm for VF and pulseless VT, defibrillation precedes the use of medications. Once defibrillation has been attempted, what medication should first be given? What medication should be given every 3 minutes while CPR is ongoing? After this medication defibrillation is attempted and the use of what drugs are administered?
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Epinephrine is given initially and then repeated every 3 min while CPR is ongoing; after a repeated attempt at deibrillation, use of antiarrhythmics (amiodarone, lidocane, and magnesium) is warranted.
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What arrhythmia is Digoxin used for?
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Atrial Tachycardias
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What is the first-line of treatment for an acute episode of glaucoma?
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Administering Mannitol IV, which is an osmotic diuretic and works immediately.
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How does acetazolamide work to treat glaucoma?
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It's a carbonic anhydrase inhibitor that rapidly reduces further production of aqueous humor, thus decreasing intraocular pressure.
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How does Pilocarpin work to treat Galucoma?
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Pilocarpine rapidly reduces intraocular pressure by opening the canals of Schlemm and allowing for drainage of the aqueous humor.
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How does Timolol work to treat Glaucoma?
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Timolol is a beta-blocker that decreases the intraocular pressure by decreasing production of the aqueous humor.
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Which Ig against HBcAg is present during the "window" period of HBV infection?
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IgM anti-HBcAg
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Rupture of an abdominal aortic aneurysm is a dramatic and often fatal process. Screening and surgical repair of large AAAs (>5.5cm) have been associated with decreased AAA mortality in men 65-75 who have a history of smoking. The USPSTF recommends screening male active or former smokers aged 65-75 years with a one-time screen to evaluate for adbominal aortic aneurysm. What modality is used?
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Ultrasound.
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Hypertension is the most important risk factor for this entity; focal neurological signs suddenly develop and gradually worsen over minutes or hours; symptoms usually start during normal activity or may be precipitated by sex or strenuous activity. As the lesion expands, headache, vomiting and altered mental status develop. Diagnosis?
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Intraparenchymal brain hemorrhage; the most common site of hypertensive hemorrhage is the putamen (35%), and the internal capsule that lies adjacent to the putamen is almost always involved, thereby leading to hemiparesis. The other neurological signs include hemi-sensory loss, homonymous hemianopsia, stupor and coma. The eyes are deviated away from the paralytic side.
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CML is characterized by leukocytosis, anemia and increased number of mature granulocytic forms, such as segmented neutrophils and band forms on peripheral blood film. Is leukocyte alk-phos increased or decreased in CML?
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DECREASED!!! Low leukocyte alkaline phosphatase with leukocytosis is classic for chronic myelogenous leukemia.
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What is the most common extra-articular manifestation of Ankylosing Spondylitis (which occurs in 25-40% of patients)?
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ANTERIOR UVEITIS!!!
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Here, the combination of arterial/venous thrombosis and thrombocytopenia in patients receiving heparin therapy is suggestive of the diagnosis. Antibodies against heparin-platelet factor-4 complex are responsible for activating platelets, thereby leading to premature removal of platelets from the circulation, and consequent thrombotic complication. Diagnosis?
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Heparin Induced Thrombocytopenia.
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Pronlonged placement of central lines can lead to subclavian vein thrombosis and result in are swelling and pale skin. What is the first step in the management of this condition?
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Catheters should be removed and duplex ordered to document the thrombus and for the need of anticoagulation.
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When patients have suspected diverticulitis, the best treatment includes IV antibiotics until the symptoms resolve. When patients fail to respond to antibiotic, a complication must be suspected, such as formation of an abscess, fistula, or frank perforation. What is the best diagnostic test to evaluate such complications?
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CT scan is a highly sensitive and specific for diverticulitis, especially when it is accompanied by a perforation or abscess.
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When is a patient with gallstones recommended to undergo surgery?
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Cholecystectomy is indicated in all patient with SYMPTOMATIC gallstones who are medically stable to undergo surgery.
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The presence of diffuse musculoskeletal pain in the absence of joint swelling, muscle weakness, or laboratory abnormalities is suggestive of what diagnosis?
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Fibromyalgia; the diagnosis is made based on the presence of widespread musculoskeletal pain and excessive tenderness on palpation of at least 11 of 18 predefined soft tissue locations during physical examination. These sites include the upper quadrants of the buttocks and medial aspect of the knees, as well as the sternocleidomastoid and trapezius muscles. The absence of joint swelling or muscle weakness is also characteristic of fibromyalgia, as is the worsening of symptoms with exercise.
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Analgesic nephropathy is the most common form of drug-induced chronic renal failure. Papillary necrosis and chronic tubulointerstitial nephritis are the most common pathologies seen. What are early and progressive manifestations of the disease?
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Polyuria and sterile pyuria (WBC casts may be seen) are early manifestations. Microscopic hematuria and renal colic may occur following sloughing of renal papilla. Hypertension, mild proteinuria, and impaired urinary concentration commonly occur as the disease advances.
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What are the most common medications used in the treatment of ance that induce phototoxicity?
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The tetracycline class of antibiotics!!! and of the tetracyclines used in the U.S., Doxycycline is the most photosensitizing.
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Low back pain in patients with history of malignancy should always raise suspicion of what diagnosis? What time of day would the back pain most likely be greatest?
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Low back pain in patients with history of malignancy should always raise suspicion for BONE METASTASIS. Tumors metastatic to bone typically cause constant progressive pain that is worsened at night or at rest.
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This type of cholecystitis is a form of acute cholecystitis that arises due to secondary infection of the gallbladder wall with gas-forming bacteria (eg, Clostridium, E.coli, Staph, Strep, Pseudomonas, Klebsiella); patients with this condition are typically male aged 50-70 years; predisposing factors include vascular compromise (by obstruction or stenosis of the cystic artery, which is the sole arterial supply to the gallbladder, immunosuppression (as seen with diabetes mellitus), gallstones, and infection with gas-forming bacteria. Diagnosis?
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Emphysematous cholecystitis.
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The clinical manifestations of this condition include RUQ pain, nausea, vomiting, and low-grade fever; CREPITUS in the abdominal wall adjacent to the gallbladder is occasionally detectable, but peritoneal signs are absent. Complications include gangrene and perforation. Diagnosis? Treatment?
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Emphysematous cholecystitis; treatment includes immediate fluid and electrolyte resuscitation, early cholecystectomy, and parenteral antibiotic therapy that is effective against the Gram positive anaerobic Clostridium species (ampicillin-sulbactam, peperacillin-tazobactam, or the combination of an aminoglycoside, or quinolone with clindamycin or metronidazole).
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This is a common form of acute cholecystitis in elderly diabetic males, which arises due to infection of the gallbladder wall with gas-forming bacteria. Diagnosis?
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Emphysematous cholecystitis.
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What vitamin deficiency is common after total or partial gastrectomy? Why?
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B12!!!; THIS IS DUE TO THE LOSS OF INTRINSIC FACTOR PRODUCTION!!!
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What are the recommendations for the screening of bladder cancer, especially for those who are at risk of developing the disease?
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THERE ARE NONE!!!; the USPSTF currently has recommends against bladder cancer screening due to its relatively low incidence and poor positive predictive value of the current screening tests (i.e. U/A and cytology, bladder tumor antigen, nuclear matrix protein). Thus, screening for bladder cancer is not recommended, even in patient who are at risk of developing the disease.
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What are the "4 Ts" that are included in the differential for an anterior mediastinal mass?
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Thymoma, teratoma, thyroid neoplas, terrible lymphoma.
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In what way are the serum levels of Beta-HCG and AFP useful for differentiating Seminomatous germ cell tumors from nonseminomatous variants( yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed germ cell tumor)?
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Beta-HCG can be elevated in 1/3 of patients with seminoma, although AFP is essentially always normal. Nonseminomatous germ cell tumors have an elevated AFP, with a considerable amount also having an elevated Beta-HCG.
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The diagnosis of Nocardia (Nocardiosis) infection in immunosuppressed patients is made via Gram stain, which shows the characteristic crooked, branching, beaded, Gram-positive and partially acid-fast filaments. What is the treatment of choice for Nocardiosis?
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Bactrim (TMP-SMX) is the first-line treatment for Nocardiosis; Minocycline is the best oral alternative. The risk of Nocardiosis in AIDS and transplant patients can be decreased by prophylaxis with trimethopirim-sulfamehtoxazole.
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An HIV patient with a positive PPD skin test, but normal CXR should be treated with what type of antibiotic prophylaxis?
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1) Isoniazide with pyridoxine (B6) for 9 months, or
2) Pyrazinamide with Rifampin or Rifabutin for 2 months, or 3) Rifampin alone for 4 months |
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Patients with suspected BPH and elevated serum Cr, should undergo what next step in management?
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Abdominal ultrasound, because patients with severe BPH can eventually progress to urinary obstruction and renal failure due to hydronephrosis. Thus, Renal U/S is necessary to check for signs of HYDRONEPHROSIS!!!
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What is the treatment of choice for Trigeminal Neuralgia? What is the second-line procedure employed if the DOC does not work?
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Carbamazepine!!! is the treatment of choice for Trigeminal Neuralgia as it is effective in up to 80% of patients. Aplastic anemia can occur with prolonged use, therefore routine CBC is included in the follow-up management of such patients. When medication fails to control the pain, surgical gangliolysis or suboccipital craniectomy for decompression of the Trigeminal Nerve are options.
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Hepatic hydrothorax is a cause of transudative pleural effusions in patients with cirrhosis who have no underlying cardiac or pulmonary disease to account for the development of such effusion. Hepatic hydrothorax usually results in a right sided pleural effusion. Initial treatment is usually with salt restriction and diuretic. What is done for patient with hepatic hydrothorax refractory to these treatments?
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Transjugular intrahepatic portosystemic shunt (TIPS).
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What is a common heart sound finding on physical exam, in a patient who is suspected to have an aortic dissection?
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Early diastolic murmur, as the dissection causes AORTIC REGURGITATION!!!
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What is Pulsus parvus et tardus and what valvular lesion does it imply?
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Pulsus parvus et. tardus refers to a carotid pulse that is slow (parvus) and late (tardus). it is classically observed in AORTIC STENOSIS.
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What medication common to congestive heart failure patients is most likely to cause ototoxicity and sensorineuronal hearing loss?
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LOOP DIURETICS!!!; loop diuretics are associated with reversible or permanent hearing impairment, reversible deafness, and /or tinnitus. The risk of ototoxicity is greater in patients taking high doses of furosemide, but patient who have coexistent renal failure may experience hearing loss or deafness at lower doses.
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What other STDs/test screens should a patient presenting with PID be screened for?
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HIV, Syphilis, Hepatitis B, Pap smear
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Proximal muscle weakness is the primary complaint in patients with Polymyositis, and there are no skin findings, which helps it be distinguished from Dermatomyositis. While muscle tenderness may be present in PM, severe tenderness in the absence of weakness should lead to a consideration of another diagnosis such as?
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Polymyalgia Rheumatica.
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A patient presents with uncontrolled hypertension, increase in ring size, doughy and sweaty hands, skin tags, and carpal tunnel syndrome. Diagnosis? (*new coarse facial features are also present)
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Acromegaly
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What is the most specific test for making the diagnosis of Acromegaly?
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Measuring Growth Hormone levels following an oral glucose load; following the administration of 75g of oral glucose, most normal individuals will suppress serum GH levels to below 1 mcg/dL, whereas patients with Acromegaly are unable to supress or sometimes paradoxically increase ther serum GH levels following an oral glucose load.
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Riluzole is a glutamate inhibitor that cannot arrest the underlying pathological disease process that occurs in this disease, but it may prolong survival and the time to tracheostomy. Diagnosis?
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ALS; amyotrophic lateral sclerosis.
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CRX of a patient with Pulmonary Embolism may reveal dilatation of the pulmonary artery proximal to the clot and collapse of the vessels distal to the clot (1). Pleural infiltrates corresponding to areas of pulmonary infarction (2), pleural effusions, and atelectasis may be seen as well. The most common finding, however, is a normal CXR. What are the signs designated by (1), and (2) called respectively?
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Westermark's sign; Hampton's hump.
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An elderly patient presents with bilateral lower extremity abnormalities that are consistent with upper motor neuron disease, including weakness without fasciculations, hyperreflexia, and decreased sensation. What should you be worried about? What are the potential etiologies of this condition? Best diagnostic test?
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SPINAL CORD COMPRESSION!!!; other red flags to spinal cord compression include saddle anesthesia and compromised bladder or bowel control. Potential etiologies include disk herniation, abscess, trauma, or malignancy. Spinal cord compression is a medical emergency warranting immediate MRI or the spine.
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This syndrome referes to an association between brain tumors and FAP or HNPCC. FAP most likely associated with medulloblastomas and HNPCC, usually with high-grade gliomas. Diagnosis?
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Turcot's syndrome!!!; autosomal recessive
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This syndrome is autosomal dominant where colonic polyps are seen with prominent extraintestinal lesions. These include desmoid tumors, sebaceous or epidermoid cysts, lipoma, osteomas (especially of the mandible), supernumerary teeth, gastric polyps, and juvenile nasopharyngeal angiofibromas. Diagnosis?
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Gardner's syndrome.
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This syndrome is an association of GI-tract hamartomas with breast cancer, thyroid cancer, and nodular gingival hyperplasia. Diagnosis?
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Cowden, or multiple hamartoma syndrome.
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These are contraindications associated with what migraine-aborting medication?
1.Familial hemiplegic migraine 2. Uncontrolled hypertension 3.CAD 4.Prinzmetal angina 5. Pregnancy 6. Ischemic Stroke 7. Basilar Migraine |
Sumatriptan!!!
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pH below what number in a parapneumonic effusion is almost always indicative of an empyema and indicates removal of the fluid by thoracostomy (chest tube placement)? Glucose below what mg/dL is also an indication for thoacostomy?
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Low pH (<7.2); Low Glucose (<60mg/dL).
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There are two types of heparin-induced thrombocytopenia (HIT). HIT I has a non-immune mechanism, and is possibly due to the direct effect of heparin on platelet activation. HIT II is an autoimmune disorder characterized by the formation of antibodies against the heparin-platelet factor 4 complex. What is the period of time after the initiation of heparin therapy that each of these conditions will begin to appear?
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HIT I occurs within the first two days of heparin therapy!!! HIT II usually occurs within 4 to 10 days of heparin treatment!!!
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What are the therapies that are indicated if someone is started on heparin and shows signs of HIT?
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Lepirudin or Argatroban, and Danaproid.
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These episodes that produce syncope are preceded by nausea, diaphoresis, tachycardia, and pallor; pain, stress, and situations like medical needles and urination can all precipitate this event. Diagnosis? What is the test to help confirm diagnosis?
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Vasovagal syncope, or Neurocardiogenic syncope. This can be diagnosed with the tilt table test.
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Why should O2 and sedatives be used with caution in patients with COPD exacerbations? What event can they cause?
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These two agents should be avoided or used with caution because they can decrease respiratory drive and thus alveolar ventilation. Alveolar hypoventilation, as in a COPD exacerbation, can cause CO2 retention and resultant lethargy, somnolence, seizures, coma, and even death.
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What are the PCWP and PaO2/FiO2 diagnostic requirements for ARDS?
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PCWP <18 and PaO2/FiO2 ratio <200.
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What is the most common valvular abnormality observed in patients with infective endocarditis not related to IV drug abuse?
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Mitral regurgitation.
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A patient presents with a "sticking sensation in the throat" or dysphagia accompanied by heartburn, and manometric findings of absent peristaltic waves in the lower two-thirds of the esophagus and significant decrease in the LES tone. This clinical scenario is most consistent with esophageal dysmotility associated with what condition?
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SCLERODERMA!!!
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Unexplained hemolytic anemia ad thrombocytopenia in a patient with renal failure and neurologic symptoms should raise strong suspicions for what acute hematologic process?
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TTP-HUS; HIV increases the risk of this event.
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What is the initial screening test used in the evaluation of primary hyperaldosteronism? What test is used for diagnosis?
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Plasma aldosterone to plasma renin activity ratio (PA:PRA) is used as an initial screening test for primary hyperaldosteronism; a ratio over 30 is suggestive of the diagnosis. Non-supressibility of aldosterone levels after IV saline or oral salt loading is used to confirm autonomous production of aldosterone in primary hyperaldosteronism. Once primary hyperaldosteronism is confirmed, adrenal CT is performed to look for adrenal adenoma.
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Chloroquine-resistant Plasmodium falciparum is particularly common in Sub-Saharan Africa and the Indian subcontinent, therefore what is the DOC for chemoprophylaxis agains chloroquine-resistant malaria?
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MEFLOQUINE!!!
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In a patient with the combination of neurologic abnormalities, renal disease and anemia with a low-normal MCV, what type of poisoning should be on your differential?
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LEAD POISIONING!!!; hig-dose poisoning or chronic, moderate dose exposure can cause permanent neurologic dysfunction in the form of peripheral neuropathy, which typically manifests as extensor weakness; it can also cause lead nephropathy, a chronic form of interstitial nephritis.
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Squamous cell carcinoma of the mucosa of the head and neck is common in people with a significant history of alcohol and tobacco use. This first manifestation may be a palpable cervical lymph node. What is the best initial test?
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PANENDOSCOPY!!! = triple endoscopy = esophagoscopy, bronchoscopy, laryngoscopy to detect the primary tumor.
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Diphenhydramine overdose leads to anti-histamine effects including drowsiness, confusion and anticholinergic effects including dry mouth, dilated pupils, blurred vision, reduced bowel sounds, and urinary retention. What is the medication used to treat Diphenhydramine overdose?
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Physostigmine, a cholinesterase inhibitor, which can counteract these anti-cholinergic effects.
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Bronchiectasis is best confirmed in diagnosis through CT. What is one of the major complications that can develop with bronchiectasis?
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Hemoptysis!!!; sometimes massive to the point of requiring bronchial artery embolization, is a potential complication that can occur in some patients.
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What is the treatment advised for patients who have gallstones, but refuse gallbladder surgery?
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Ursodeoxyxcholic acid, which decreases the cholesterol content of the bile by reducing the hepatic secretion and intestinal reabsorption of cholesterol. This medication is expensive, however, and therapy may be necessary for several months before the gallstones dissolve. In addition, gallstones recur in 50% of patients once the treatment is stopped.
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What blood condition is the sugar water test done for?
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Paroxsymal Nocturnal Hemoglobinuria (PNH).
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When a patient presents with a STEMI it is generally appropriate to initiate MONA BASH therapy. Nitrates and beta-blockers are contraindicated in certain circumstances, however. What are these circumstances?
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Nitrates are not indicated in the setting of aortic stenosis, recent phosphodiesterase use (viagra), or Right Ventricular Infarction (which occurs in more than 30% of cases of inferior wall MI). In the setting of significant RV infarct, any medication that reduces preload (eg, nitrates or diuretics) will exacerbate, rather than improve symptoms. The first step in treatment of RV MI is generally IV fluid resuscitation to increase RV stroke volume and enhance left ventricular filling.
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Serum sickness-like reactions are a hypersensitivity reaction that occurs most classically in association with drugs such as penicillin, amoxicilin, TMP-SMX and ceflacor. It most commonly occurs in young children following the treatment of viral infections with antibiotic agents. The mechanism of serum sickness-like reactions is not fully understood but like true serum sickness, symptoms of fever, urticaria, and arthralgias begin at what time-point after administration of the offending agent?
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Serum-sickness-like reactions occur ONE to TWO WEEKS after administration. The condition derives its name from its similarities to true serum-sickness, an immune-complex mediated hypersensitivity reaction to non-human proteins. Serum-sickness like reaction is a clinical diagnosis, and should resolve with withdrawal of the offending agent; it DOES NOT REPRESENT A TRUE DRUG ALLERGY!!!
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Malignant Otitis Externa is a severe infection typically seen in elderly diabetic patients; presentation is typically with ear pain and ear drainage that is not responsive to topical medications. Granulation seen within the ear canal is a characteristic manifestation of MOE, and progression of the infection can lead to osteomylitis of the skull base and cranial nerve damage (CN VII). What bacteria is responsible?
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Psuedomonas aerugenosa
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Homeless man presents with anion gap metabolic acidosis, hypocalcemia, flank pain, AMS, oliguria, hematuria, and AKI. Diagnosis? Treatment?
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Ethylene Glycol Poisoning!!! Hypocalcemia occurs due to oxalic acid binding calcium, and forming calcium oxalate crystals. Treatment involves administration of Fomepizole or ethanol to achieve ADH inhibition, sodium bicarbonate to alleviate acidosis, and hemodialysis in the case of acidosis and/or end organ damage.
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What does immediate intervention of central retinal artery occlusion entail?
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Ocular massage, which dislodges the embolus to a point further down the arterial circulation, and improves retinal perfusion; and Carbogen therapy (5% CO2 and 95% O2) or hyperbaric oxygen (HBO) therapy have been shown to be beneficial if given early.
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Hyperlipidemia (or hypercholesterolemia, most frequently LDL), unexplained hyponatremia, or elevated serum muscle enzymes are indications for testing of what enzyme level?
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TSH for HYPOTHROIDISM!!!; high LDL due to decreased LDL receptors, Hyponatremia due to inappropriate ADH secretion, elevated muscle enzymes due to myopathy.
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What process creates the exopthalmos associated with Graves disease?
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Exopthalmos results from an autoimmune attack on the extraocular muscles, wherein lypmhocytes infiltrate the EOMs and orbital fat causing edema, proliferation of local interstitial fibroblasts, and deposition of glycosaminoglycans. The end result is fibrosis and increased edema.
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Anasarca typically results from organ failure or hypoalbuminemia. In patients with Nephritic Glomerulonephritis which mechanism is at work?
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End organ failure and glomerular damage with decreased GFR; nephrotic syndrome causes anasarca through hypoalbuminemia.
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What are the main differential diagnoses of normotensive patient with hypokalemia and metabolic alkalosis?
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1. Diuretic use
2. Surreptitious Vomiting 3. Bartter's syndrome 4. Gitelman's syndrome |
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The underlying pathology of this disease is defective Na+ and Cl- reabsorption in the thick ascending limb of the loop of Henle, thereby resulting in hypovolemia and consequent activation of the RAAS system. Activated RAAS then causes an increase in K+ and H+ secretion, which eventually leads to Hypokalemia and Metabolic Alkalosis. This syndrome usually present early in life as polyuria, polydipsia, and growth and mental retardation, however, such presentation can occur much later. Diagnosis?
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Bartter's syndrome.
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Patients with this syndrome have hypokalemia, urinary chloride levels above 20mEq/L (most often 40mEq/L), metabolic alkalosis, and normal blood pressure. Diagnosis?
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Bartter's syndrome.
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Anasarca typically results from organ failure or hypoalbuminemia. In patients with Nephritic Glomerulonephritis which mechanism is at work?
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End organ failure and glomerular damage with decreased GFR; nephrotic syndrome causes anasarca through hypoalbuminemia.
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What are the main differential diagnoses of normotensive patient with hypokalemia and metabolic alkalosis?
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1. Diuretic use
2. Surreptitious Vomiting 3. Bartter's syndrome 4. Gitelman's syndrome |
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The underlying pathology of this disease is defective Na+ and Cl- reabsorption in the thick ascending limb of the loop of Henle, thereby resulting in hypovolemia and consequent activation of the RAAS system. Activated RAAS then causes an increase in K+ and H+ secretion, which eventually leads to Hypokalemia and Metabolic Alkalosis. This syndrome usually present early in life as polyuria, polydipsia, and growth and mental retardation, however, such presentation can occur much later. Diagnosis?
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Bartter's syndrome.
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Patients with this syndrome have hypokalemia, urinary chloride levels above 20mEq/L (most often 40mEq/L), metabolic alkalosis, and normal blood pressure. Diagnosis?
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Bartter's syndrome.
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If you are using a 2 x 2 SQUARE to compare conditions and associations of data from research, what is the best statistical method to assess the associations?
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Chi-SQUARE test!!! That is because this type of test is used to compare proportions, which a 2 x 2 square gives you.
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Are the two-sample z-test and the two-sample t-test used to compare two proportions or two means?
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They are used to compare TWO MEANS!!!
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What is the best way to diagnose/visualize the acoustic neuromas that are associated with NFII?
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MRI with gadolinium enhancement.
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This type of Heart Block is seen on ECG to be characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped, and then the sequence is repeated; this type of heart block may be seen after digitalis toxicity, increased vagal tone, and inferior myocardial wall infarct because this implies occlusion of the RCA, which helps supply the SA and AV nodes. Diagnosis? Treatment?
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Mobitz Type I Heart Block!!!; treatment includes observation in asymptomatic patients, correction of reversible causes (eg. holding medications that affect AV node conduction) and uncommonly, cardiac pacing.
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What is the antibiotic of choice for prophylaxis and treatment of infections caused by a human bite? (*these infections are usually polymicrobial, and thus coverage for Gram positives, Gram negative, and anaerobes should be provided)
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Amoxicillin-clavulanate is the DOC. Clauvulanic acid is a beta-lactamase inhibitor and is helpful against beta-lactamase-producing anaerobes. This is also the drug of choice for dog bites.
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Clindamycin is efective for treating against Gram-positive bacteria and anaerobes. Thus, what type of infections is it most often used for?
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Lung abscesses and infections of the female genital tract.
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What bugs do Fluoroquinolones not have good coverage against?
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ANAEROBES!!!; remember that with all of the O's in fluoroquinolones that the drug needs bugs that use O2 in order to be affective!!!
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What is the DOC for Legionella infection?
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Erythromycin.
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When a patient has a metastatic mass that is bleeding inside the brain, what cancer should you think of?
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Malignant Melanoma.
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This cancer is called "the fascinating disease" because it spread to the most unimaginable places, lie dormant for 15-25 years, then recur in surprising ways, even if the primary tumor was resected. In many cases this cancer has spread to all sorts of places like the muscles of the heart and the bile duct. Diagnosis?
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Malignant Melanoma.
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What are four tumors in the body that never (or almost never) metastasize to the brain?
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1. Non-melanotic skin cancer
2. Oropharyngeal cancer 3. Esophageal carcinoma 4. Prostate cancer |
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A pituitary tumor less than 10mm in diameter is called a microadenoma. Microprolactinoma is a prolactin-secreting microadenoma, and is one of the most common pituitary tumors encountered. Microprolactinoma classically presents as amenorrhea and galactorrhea in females, and as hypogonadism in males. Due to its small size, the microadenoma usually does not cause problems with other pituitary hormones or a mass effect. What is the primary treatment for all prolactinomas (both micro- and macroprolactinoma)?
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Medical treatment with Dopaminergic agents (because dopamine is inhibitory to Prolactin secretion!!!) such as Bromocriptine and Cabergoline. Medical treatment not only results in normalization of prolactin levels, but leads to significant reduction in tumor size. Cabergoline is a new drug, which has fewer side effects and has been shown to be more effective than Bromocriptine.
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What condition should be expected in a young obese female with a headache that is suggestive of a brain tumor, but with normal neuroimaging and elevated CSF pressure; neurologic signs are usually absent except for papilledema, visual field defects and sometimes sixth nerve palsy; there may be a history of exposure to provoking agents such as glucocorticoids or vitamin A, and oral contraceptive pills have also been associated; the pathology involves impaired absorption of CSF by the arachnoid villi. Diagnosis? Treatment?
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PSEUDOTUMOR CEREBRI!!!; treatment includes weight reduction and acetazolamide (if weight reduction fails). When medical measures fail or visual field defects are progressive, shunting or optic nerve sheath fenestration is done to prevent blindness, which is the most significant complication of this otherwise benign disorder.
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What is the most common cause of death in the dialysis population?
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Cardiovascular disease; it accounts for 50% of deaths in this patient group. Of these deaths, 20% are attributed to acute MI and 60% are sudden cardiac deaths.
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What is the USPSTF recommendation for Mammography screening in women between the ages of 50-74? >74 y/o?
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Every two years between the ages of 50-74 years. Routine mammography is not necessary beyond age 75.
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When does the USPSTF recommend routine cholesterol screening in men and women at average risk for CAD?
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Begin at age 35 for men and 45 for women; many experts advocate checking lipids no more than every 5 years in patients with normal risk for coronary artery disease and normal lipids in the past.
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The USPSTF recommends starting colon cancer screening at 50 years of age. How often should screening occur?
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Every 10 years after the age of 50 colonoscopies should be done.
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What is the LDL goal for a patient with no risk factors? At what level do lifestyle modifications start? At what level does drug therapy start?
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<160 mg/dL; >160 mg/dL; >190 mg/dL
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What is the LDL goal for a patient with 2+ risk factors for Coronary Heart Disease?
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<130 mg/dL
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What is the LDL goal for a patient with Coronary Heart Disease or CHD risk equivalent?
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<100 mg/dL
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What are the risk factors for Coronary Heart Disease in men and women?
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1) Age: men >45, women >55
2) Hypertension 3) Smoking 4) HDL <40 mg/dL 5) Family history of premature CHD (men <55, women <65) ***Having HDL >60 negates one risk factor |
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What are Coronary Heart Disease equivalent diseases?
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Diabetes mellitus, symptomatic carotid artery disease, abdominal aortic aneurysm, peripheral artery disease, or a 10 year risk of CHD of 20% or greater.
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What are the three major lipid panel risk categories associated with Coronary Heart Disease?
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Elevated Total Cholesterol, Elevated LDL, and low HDL.
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This condition is a serious neurologic disorger characterized by saddle anesthesia, bowel and bladder dysfunction, low back pain, and a variety of lower extremity findings. This condition effects the spinal nerves before they exit the spinal canal. Diagnosis?
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Cauda equina syndrome (CES).
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What size induration is considered a positive TB test in the following patients?:
-HIV positive persons -Individuals with recent contact of TB-positive person -Individuals with signs of TB on chest x-ray -Organ transplant patients and patients on immunosuppressive therapy |
> 5 mm
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What size induration is considered a positive TB test in the following patients?:
-Individuals who have recently emigrated from TB endemic location -Injection drug users -Residents/employees of high-risk settings (e.g. prisons, homeless shelters) -Patients with diabetes, chronic kidney disease, hematologic malignancies, or fibrotic lung disease -Children less than 4 years old, teens exposed to high-risk adults |
> 10 mm
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What size induration is considered a positive TB test in the following patients?:
-Healthy individuals with no risk factors for TB infection |
> 15 mm
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Patients with advanced chronic kidney disease and end-stage renal disease develop a normocytic, normochromic, hypoproliferative anemia due to decreased erythropoietin production by the failing kidneys. Besides Epo replacement therapy, what other therapy must be considered when treating the anemia associated with Chronic Kidney disease?
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Iron replacement!!!; the mainstay of treatment for the anemia of chronic kidney disease is supplemental Epo along with Iron replacement therapy!!! Epo stimulates progenitor cells in the bone marrow to create more RBCs, and the production of new RBCs is associated with a surge in iron usage. This causes a rapid depletion in the body's iron stores, particularly in chronically ill patients whose iron stores may already be low.
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What is the treatment of choice for iron deficiency in dialysis patients?
|
IV iron preparation, such as iron dextran.
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Is Lidocaine useful for atrial or ventricular arrhythmias?
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VENTRICULAR!!!
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Lidocaine is a class IB anti-arrhythmic drug that is effective against a variety of ventricular arrhythmias and has a wide therapeutic/toxic ratio. It is widely used to control complex forms of ventricular arrhythmia (eg. ventricular tachycardia) in patients with acute coronary syndromes. At the same time, its use prophylactically to prevent the development of ventricular fibrillation in patients with acute MI is discouraged. Why???
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Because clinical trials demonstrated that prophylactic lidocaine decreases the frequency of VPBs and diminishes the risk of ventricular fibrillation, but the overall prognosis is unaffected because the RISK OF ASYSTOLE is so greatly increased in these patients.
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When symptoms of acute colitis are associated with radiologic evidence of colonic dilatation (say, in a patient with a history of Ulcerative Colitis), what is the likely diagnosis? Tx?
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TOXIC MEGACOLON!!!; this can progress rapidly and result in colonic perforation; hence it is a medical emergency. The treatment includes intravenous fluids, antibiotic, and bowel rest. IV-corticosteroids are the drugs of choice for IBD-induced toxic megacolon.
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This degenerative disease is characterized by Parkinsonism, autonomic dysfunction, and widespread neurological signs (cerebellar, pyramidal, or lower motor neuron). Diagnosis?
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Multiple System Atrophy (Shy-Drager syndrome)
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What syndrome should you always consider in a patient who presents with Parkinsonism, orthostatic hypotension, impotence, incontinence, or other autonomic symptoms? Tx?
|
Multiple system atrophy (Shy-Drager syndrome); treatment is focused on intravascular volume expansion with fludrocortisone, salt supplementation, alpha-adrenergic agonists, and application of constrictive garments to the lower body.
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When a patient complains of recent weight gain and headaches, and presents with Hypertension, Hyperglycemia, and Hypokalemia, what diagnosis should you think of?
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Cushing's syndrome; High levels of cortisol enhance vasoconstriction, insulin resistance, and mineralocorticoid activity. This results in blood pressure elevation, hyperglycemia, and hypokalemia.
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This infections produces and presents as a ring-shaped lesion with an advancing scaly border and central clearing, or as scaly patches over the trunk. Diagnosis?
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Tinea corporis; body ringworm
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This skin infection is characterized by pale, velvety pink or whitish, hypopigmented macules THAT DO NOT TAN and DO NOT APPEAR SCALY, BUT SCALE ON SCRAPING. Diagnosis? Tx?
|
Tinea versicolor (malassezia furfur); topical treatment with SELENIUM sulfide lotion and KETOCONAZOLE shampoo is recommended.
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This condition is a complication of neuropathy and repeated joint trauma; it affects weight bearing joints and manifests with functional limitation deformity, and degenerative joint disease and loose bodies on imaging. Diagnosis?
|
Neurogenic arthropathy, or Charcot's joint. This occurs because as normal neurologic input is lost (diabetic neuropathy, peripheral nerve damage, syringomyelia, spinal cord injury, B12, tabes dorsalis), patients unknowingly traumatize their weight bearing joints. This causes secondary degenerative joint disease, joint deformation, and functional limitation.
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Fine crackles hear at the end of inspiration on lung exam suggests what type of pathophysiological process?
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Interstitial lung disease.
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What are the 5 main risk factors associated with the development of Pancreatic cancer?
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1) Chronic pancreatitis
2) Smoking 3) Obesity 4) Diabetes mellitus 5) Diet high in fat |
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What separates Blastomycosis infection from Tuberculosis or Histoplasmosis?
|
Systemic Blastomycosis may cause characteristic ulcerated SKIN LESIONS and LYTIC BONE LESIONS.
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This is a pulmonary fungal infection endemic to the Great Lakes, and Mississippi and Ohio River basins; this infection may cause skin and bone lesions in addition to pulmonary manifestations. Itraconazole or Amphotericin B may be used to treat symptomatic disease. Diagnosis?
|
Blastomycosis!!!
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Obese woman with headaches, vision findings, HTN, and clean MRI or few other symptoms. Diagnosis?
|
Idiopathic increased intracranial pressure (Psuedotumor cerebri).
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How does megadoses of Vit. C affect the formation of renal stones?
|
Megadoses of Vit C lead to increased formation of oxalate stones, especially in patients with renal failure.
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What is the diagnostic procedure of choice for a patient with suspected renal stones?
|
CT scan of the abdomen without contrast because it can detect radio opaque and radio lucent stones.
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What are the 4 main dietary recommendations for patients prone to renal stone formation?
|
1) Decreased dietary protein and oxalate- increases in these make one prone to stone formation, es. calcium stones
2) Decreased Na+ intake- increased Na+ intake enhances Ca++ excretion and puts it in the urine, in addition to increasing Ca++ reabsorption through increasing reabsorption of water and due to increased filtration of solutes and blood 3) Increase fluid intake 4) Increase dietary Ca++, so the body does not try to retain it |
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Venous insufficiency results from incompetence of the valves within the lower extremity veins. Complications include chronic edema, stasis, dermatitis, and ulceration. What are the therapies to treat Venous insufficiency?
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Leg elevation, compression stockings, wound care.
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If you have a patient with renal stones that are visualized by CT, but not X-ray what type of stones are these likely to be and what treatment is most appropriate?
|
Radiolucent stones likely do not have Ca++ in them are are probably uric acid stones. Uric acid stons are most commonly seen with patients with unusually low urine pH levels (which may be due to a defect in renal ammonia secretion) and hyperuricosuria. Uric acid stones are highly soluble in alkaline urine; therefore, alkalinization of urine to pH > 6.5 with oral potassium bicarbonate or potassium citrate is the treatment of choice.
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In simple terms, what is positive predictive value?
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This is defined a the proportion of subjects with a positive test that actually have the disease.
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In simple terme what is negative predictive value?
|
This is the proportion of subjects with a negative test that are actually free of disease.
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What are the organs/tissues that are likely to be seeded or infarcted with septic emboli in a left-sided vegitative endocarditis?
|
Regions rich in blood supply such as brain, kidney, liver, and spleen.
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What is the next best step/test to order in the management of a patient who has newly diagnosed Myasthenia Gravis?
|
CT of the CHEST to look for THYMOMA!!!; if thymoma is present, thymectomy is useful, although the results are only typically seen 3-4 years after surgery.
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This patient has hepatic encephalopathy that develops within eight weeks of onset fo acute liver failure; the patient has HBV. Diagnose this class of liver failure.
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Fulminant hepatic failure; mortality exceeds 80%; liver transplant is the treatment of choice.
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What are the two DsOC for treating acute HBV infection?
|
Interferon and lamivudine.
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Whereas peptides get presented to T-cells by macrophages and B-cells, polysaccharides cannot be presented to T-cells. Thus, what type of immune response do non-conjugated pollysaccharide vaccines elicit?
|
B-cell only, T-cell independent response.
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Antithrombin III is lost in the urine and puts patients at an increased risk of venous and arterial thrombosis, when a patient has nephrotic syndrome. Which form of nephrotic syndrome is the most common in adults to give this complication?
|
Membranous Glomerulonephritis.
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What is the first best step in all patients suspected to have a stroke?
|
CT scan without contrast; this distinguishes between the three subtypes of stroke. CT scan without contrast can confirm the presence, size and location of a hemorrhage. Ischemic changes may not appear in the CT scan in the first 24 hrs; however, the absence of hemorrhage in such cases, still makes CT very valuable for the diagnosis.
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In a COPD patient presenting with catastrophic worsening of their respiratory symptoms, what diagnosis should be suspected?
|
PNEUMOTHORAX!!!; in contrast, the evolution of clinical symptoms is much slower in an acute exacerbation of COPD secondary to infection or another inflammatory cuase.
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Symptoms that would raise a red flag for this broad category of disease might include back pain not relieved by rest, pain at night, constant or dull pain, fevers, lack of exacerbation with movement, and presence of neurological changes. This type of pain is often not tender to palpation. Diagnosis?
|
Cancer metastatic to bone!!!; the most common cancers that metastasize to bone are lung, breast, prostate, renal, and thyroid.
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The three main actions of this pancreatic endocrine tumor include causing diarrhea, hypokalemia, and decreasing the amount of acid in the stomach (thus, increasing bicarbonate on labs). Diagnosis? Diagnostic test?
|
VIPomas!!!; the cause is not known; other symptoms include dehydration, abdominal pain and cramping, weight loss, facial flushing and redness. High level of VIP in the blood is diagnostic. Ct scan or MRI is ordered to determine the location of the tumor.
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This pancreatic endocrine tumor presents with necrotizing dermatitis, weight loss, anemia, and persistent hyperglycemia. Diagnosis?
|
Glucagonoma.
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|
What electrolyte abnormality is an important cause of Subarachnoid Hemorrhage?
|
HYPONATREMIA!!!; "Cerebral salt-wasting syndrome" may occur in patients with subarachnoid hemorrhage. The pathology involves: 1) and inappropriate secretion of vasopressin, which causes water retention, and 2) an increased secretion of of atrial/brain naturetic peptide, which causes cerebral salt-wasting. These changes result in hyponatremia, which usually resolves within 1-2 weeks.
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If you suspect that a patient has a collapsed lung due to reabsorption atelectasis, what is the next best step?
|
Bronchoscopy for diagnosis and identification of the obstructing process.
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In general, patients with atrial fibrillation and rapid ventricular rate are treated with AV nodal blockers like beta-blockers, calcium channel blockers, digoxin, and adenosine. In Wolf-Parkinson-White, however, drugs that increase refractoriness of the AV node only serve to increase conduction across the accessory pathway, which can lead to degeneration and Vfib. Thus, what is the best treatment for a patient with WPW and Afib?
|
Conversion back into sinus rhythm, either through electrical cardioversion or with an antiarrhythmic like Procainamide.
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|
What are the three treatments available to patients with Myasthenia Gravis?
|
Anticholinesterase therapy, immunosuppressive therapy, and thymectomy.
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|
What are the anticholinesterases used in therapy for Myasthenia Gravis?
|
Physostigmine, and Neostigmine.
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Native valve endocarditis due to Strep viridans highly susceptible to penicillin, should be treated with one of which two antibiotics, according to the American Heart Association?
|
IV Penicillin G or IV Ceftraxone (Once a day dosing for Ceftriaxtone)!!!; oral antibiotics are not appropriate for the treatment of endocarditis.
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The anemia of lymphoproliferative disorders, such as leukemia and lymphoma, is due to what mechanism?
|
The replacement of RBC progenitor cells with cancer cells in the bone marrow.
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Elevated liver enzymes and myopathy are well-known side effects of statins, the popular lipid-lowering drugs, HMG-CoA reductase is inhibited from making mevalonate not only for the synthesis of cholesterol, but also for the production of several other products that may be responsible for some of these adverse effects of statin therapy. What are these other products?
|
Reduced CoQ10 and dolichol have been implicated in the pathogenesis of statin-induce myopathy. Therefore, synthetic reaction inhibition may be responsible for some adverse side effects of statin therapy.
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|
What do sharp 'x' and 'y' descents on central venous tracing imply?
|
Sharp 'x' and 'y' descents on central venous tracing are characteristic of constrictive pericarditis as is the presence of a pericardial knock (early heart sound after S2).
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|
Constrictive pericarditis results in pericardial fibrosis and diastolic dysfunction. What is the most common cause of constrictive pericarditis in developing countries?
|
TUBERCULOSIS!!!
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|
|
What is the most common cause of constrictive pericarditis in the U.S.?
|
Idiopathic or viral (>40%), radiotherapy (~30%), cardiac surgery (~10%), and connective tissue disorders.
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|
What are signs of Pulmonary Hypertension on physical exam?
|
Narrow split S2 and/or increased intensity of the Pulmonic component of S2.
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Narrow split S2 and/or increased intensity of the Pulmonic component of S2 found on physical exam, signifies what condition?
|
Pulmonary Hypertension.
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Sudden onset of bilateral neurologic dysfunction in a patient signifies what type of CNS lesion? What type does it most likely rule out?
|
This represents acute symptoms of spinal cord compression. This finding is suggestive of NOT being A STROKE.
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In a patient who presents with what you suspect to be acute symptoms of spinal cord compression such as, absent rectal tone, urinary incontinence, and motor and sensory loss in the lower extremities, what 'syndrome' are you concerned about?
|
Cauda equina syndrome!!!
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|
Classic "stocking glove" sensory loss is typical of this disorder. The type of sensory involvement depends on the nerve fibers involved. Pure small fiber neuropathy has more pain, allodynia and paresthesias; sensory loss is not marked and ankle jerks may be preserved. Pure large fiber neuropathy causes less pain, but more numbness; pressure, proprioception and vibratory sensations are decreased, while ankle jerks are usually lost. Diagnosis as to what causes this?
|
Diabetic peripheral neuropathy.
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|
What are the main treatment options available to Diabetic neuropathy pain?
|
Current options include TCAs (such as amitryptiline, desipramine, nortryptyline), Gabapentin, or NSAIDs.
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|
What is the diagnostic method used for confirming the diagnosis of CLL in an elderly patient?
|
Flow cytometry!!!; this proves the clonality of the abnormal lymphocytes and is generally used to confirm the diagnosis.
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|
JAK2 mutations are associated with which type of hematological conditions?
|
Myeloproliferative diseases, Particularly Polycythemia Vera.
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Ewing's sarcoma is a highly malignant tumor that is found in the lower extremity more than the upper extremity of white males in their 1st or 2nd decades of life. The most common sites are the metaphysis and diaphysis of the femur, followed by the tibia and humerus. The tumor is very aggressive and metastasizes early to the lungs and lymph nodes. Ewing's sarcoma can be distinctly characterized radiologically by what features?
|
Its lamellated appearance or "onion skin" periosteal reaction. The lesion is usually lytic, central, and accompanied by endosteal scalloping. The "onion-skin" appearance is often followed with a "moth-eaten" or mottled appearance and extension into soft tissue.
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This is a malignant spindle cell neoplasm found mostly in patients 30-60 years of age; the clinical presentation is usually a painful mass; the radiologic picture is that of an osteolytic lesion whose margins can be well-defined or ragged and moth-eaten. Diagnosis?
|
Fibrosarcoma.
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|
This type of dementia is characterized by personality changes (euphoria, disinhibition, apthay), compulsive behaviors (peculiar eating habits, hyperorality) and impaired memory; visuospatial functions usually remain intact, and a positive family history may be present. Diagnosis?
|
Frontotemporal dementia.
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|
How Leprosy is a chronic granulomatous disease that primarily affects the peripheral nerves and skin. In the early part of the disorder, it may present as an insensate, hypopigmented plaque. Progressive peripheral nerve damage results in muscle atrophy, with consequent crippling deformities of the hands. The most common affected sites are the face, ears, wrists, buttocks, knees, and eyebrows. How is the diagnosis of leprosy made?
|
SKIN BIOPSY!!!; diagnosis is made by demonstration of acid-fast bacilli
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|
Hyponatremia and a normal anion gap, hyperkalemic, metabolic acidosis. Diagnosis?
|
Hypoaldosteronism.
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|
What is the FEV1/FVC ratio found in restrictive lung disease?
|
> 80%!!!
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|
Why do patients with Ankylosing spondylitis have a restrictive lung disease? Most restrictive lung diseases present with a decreased FRC, but AS presents with a normal or increased FRC. Why?
|
Inflammation leads to fusion of the costovertebral joint resulting in restriction of chest wall motion, thus causing a restrictive pathology. The FRC can actually be increased in this disease because although the costovertebral joints are fixed they can become fixed in a slightly more inspiratory position.
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|
This is a very common benign growth that has a warty or CEREBRIFORM, stuck-on appearance. It is typically pigmented, but may lack pigment in many cases. Diagnosis?
|
Seborrheic keratoses.
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|
What is the recommended increase in fluid intake when a patient presents with a renal stone measuring < 5 mm in diameter?
|
Fluid intake > 2L/day
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|
On chest X-ray, this condition may appear as an enlarged, globular-appearing cardiac shadow (the characteristic "water-bottle" heart shape); physical exam will reveal distant heart sounds and a non-palpable pulse at the cardiac apex (or PMI). Diagnosis?
|
Pericardial effusion, without evidence of Tamponade.
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|
This triad presents as hypotension, JVD, and tachycardia. Diagnosis? Tx?
|
Pericardial effusion, with evidence of tamponade; the treatment for cardiac tamponade is vigorous volume resuscitation and pericardiocentesis.
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|
What is the hypersensitivity reaction associated with Stevens-Johnson syndrome?
|
Immune complex-mediated hypersensitivity.
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|
This drug reaction is characterized by the sudden onset of target-shaped, MUCOCUTANEOUS lesions and systemic signs of toxicity; the pathology involves immune complex mediated hypersensitivity. Diagnosis?
|
Stevens-Johnson syndrome.
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|
This skin rash is characterized by target lesions, and usually occurs after a herpes simplex infection; mucosal involvement is rare and systemic symptoms are not so severe as in Stevens-Johnson. Diagnosis?
|
Erythema multiforme minor.
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|
What "ratio" may be elevated in a patient with prerenal failure, GI bleeding (secondary to bacterial breakdown of blood and reabsorption of blood from the GI tract), and steroid administration?
|
BUN/creatinine RATIO!!!
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|
This endocrine disease is associated with a wide spectrum of muscle involvement ranging from asymptomatic elevation of serum CK concentrations to myalgia, muscle hypertrophy, proximal myopathy and even rhabdomyolysis; this disease should always be considered in patients with an unexplained elevation of serum CK concentration and myopathy. Diagnosis?
|
HYPOTHYROIDISM!!!
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|
Female with myalgia associated with elevation of serum CK concentration and sluggish muscle tendon reflex. This is highly suggestive of what diagnosis?
|
HYPOTHYROIDISM!!!
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|
Do lateral spinothalamic tracts that provide information about pain and temperature cross in the spinal cord or in the brain?
|
SPINAL CORD!!!; therefore damage to the spinothalamic tracts cause contralateral loss of pain and temperature sensation beginning two levels below the level of the lesion.
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|
Enthesitis is a condition in which inflammation and pain occur at the site of tendon and ligament attachment to bone; typical sites of enthesitis include heels, tibial tuberosities, and iliac crests. Enthesitis is a common finding in what seronegative spondyloarthropathy?
|
Ankylosing Spondylitis!!!
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|
In general Membranous Glomerulonephritis is the most common nephropathy associated with carcinoma; nephrotic syndrome, however, is a well-known complication of Hodgkin's lymphoma, and is usually cause by what disease (even in adults)?
|
MINIMAL CHANGE DISEASE!!!
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|
What is the first step when you recognize Migratory Thrombophlebitis (Trousseau's sign, usually associated with adenocarcinoma)?
|
Look for other symptomatology in the patient and order the appropriate investigation to evaluate the most likely location of the occult malignancy.
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|
Initial treatment of a UTI includes empiric antibiotics. When there is no adequate response to 72-hr treatment, with appropriate antibiotics, what is the next best step and why?
|
Urological imaging (CT scan or ultrasound) is performed to search for any underlying pathologies (e.g. obstruction) or complications (e.g. renal, perirenal abscess).
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|
In a patient suspected of have esophageal cancer, what is the first initial investigation to be done?
|
Barium swallow; after would be endoscopy.
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|
This eye disease is characterized by corneal vesicles and dendritic ulcers; it is the most frequent cause of corneal blindness in the U.S.; usually the recurrences are precipitated by excessive sun exposure, outdoor occupation, fever, or immunodeficiency. Diagnosis? Tx?
|
Herpes simplex keratitis; antiviral therapy is effective.
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|
What disease should you suspect in any patient who presents with a malabsoprtion syndrome and the sequlae that coincide due to Vitamin malabsorption, along with Iron-deficiency anemia?
|
Celiac Sprue!!!
|
|
|
What is the treatment of choice for early localized Lyme disease in pregnant/lactating women?
|
Amoxicillin!!!
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|
|
When do you use third generation cephalosporins (e.g. ceftriaxone and cefotaxime) in the treatment of Lyme disease?
|
Early disseminated and Late Lyme disease.
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|
A prolonged QRS complex suggests what condition and what general rate/rhythm?
|
Bundle Branch Block, and a bradyarrhythmia.
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A prolonged QT suggests what type of rate/rhythm?
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Tachyarrhythmia.
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What is the most important cause of Torsades de pointes?
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Hypomagnesemia.
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In a patient who presents with typical exertional angina and hypertension, what medication is probably the best initial treatment due to its ability to increase the threshold for the development of an anginal episode and control the hypertension?
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Beta-blocker!!!; it is cardioprotective and can potentially reduce the risk of major cardiovascular evenets and arrhythmic episodes by decreasing the sympathetic output to the heart.
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What is the DOC for patients who present with stable angina and hypertension?
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BETA-BLOCKERS!!!
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Trastuzumab, also known as Herceptin, is a monoclonal antibody commonly used in the treatment of women with breast cancer that is positive for HER2/neu gene amplification. It can be used in patients with early stage disease for an adjuvant effect or in patients with later stage metastatic disease. The combination of Trastuzumab with chemotherapy can lead to toxicity of what organ, and thus what test do you need to perform before you start these two drugs in a patient?
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Cardiotoxicity!!!; perform an echocardiogram before beginning treatment, both to est. a baseline, and also to consider other treatments in patients with poor baseline function.
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What should be suspected in any patient with new ascites and pedal edema if accompanied by stigmata of chronic liver disease such as spider angiomata and gynecomastia, no matter what else they are presenting with?
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CIRRHOSIS!!!
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Mid-diastolic rumble, without an opening snap, hear best at the apex, and a mass in the left atrium on echocardiography?
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Atrial myxoma.
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What is the most common cause of hypercalcemia in ambulatory patients?
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Primary Hyperparathyroidism; if you see a patient with elevated PTH and Hypercalcemia, then this is the diagnosis by definition. There is nothing else you can call it.
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Injection drug users, patients with sickle cell, and immunosuppressed individuals are at higher risk for what type of infection?
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OSETOMYELITIS!!!
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What anatomical site is a frequent site of involvement for osteomyelitis in IV drug users?
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The SPINE!!!; in this group S.aureus is the most common pathogen, but infections with Gram-negative organisms also frequently occur.
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This type of Glaucoma is characterized by a sudden onset of symptoms such as blurred vision, severe eye pain, nausea, and vomiting; examination reveals a red eye with a hazy cornea and a fixed, dilated pupil. Diagnosis?
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Angle Closure Glaucoma.
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This type of Glaucoma is usually asymptomatic in the earlier stages, and is more common in the african american population, and in those with a family history of glaucoma and diabetes; there is a gradual loss peripheral vision over a period of years and eventually tunnel vision; there may be CUPPING OF THE OPTIC DISK. Diagnosis?
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Primary open angle glaucoma.
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Patients with this eye condition usually complain of blurred vision, problems with nighttime driving, and glare. This is due to oxidative damage to the lens. Diagnosis?
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Cataract.
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What type of psychiatric medication has been shown to be effective in the treatment of Fibromyalgia? How do they affect the patient's sleep patterns?
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Tricyclic Antidepressants such as amitryptiline; these drugs are given in low doses at nighttime and are able to provide an increased restorative stage 4 sleep. Cyclobenzaprine may be used in a similar manner. This is helpful because one possible etiology of fibromyalgia is fatigue due to lack of phase 4 sleep. In patients exhibiting depression in addition to fibromyalgia, treatment with SSRIs should be initiated as well.
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This type of leukemia may cause the bone marrow to become fibrotic leading to dry taps. Diagnosis? Treatment?
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Hairy Cell Leukemia; Cladribine is the drug of choice for patients with hairy cell leukemia.
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What is the DOC for treating Hairy Cell Leukemia?
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CLADRIBINE!!!
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What are the three studies done to confirm the diagnosis of Crohn's disease?
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Abdominal CT, a small bowel fluoroscopic study, or endoscopy.
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This heart mumur is a short systolic mumur heard at the apex; squating decreases the murmur; patients with the cause of this murmur have a hight-than-expected incidence of chest pain compared with the normal population, wich cannot be explained by the valvular abnormality; the pain is atypical for cardiac pain and is easily distinguishable from angina (e.g. pain lasting 5-10 seconds); anxiety, palpitations, and hyperventilation are also reportedly more common in patients with this valvular condition. Diagnosis?
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Mitral Valve Prolapse.
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Back pain accompanied by low-grade fever, and elevated ESR is the typical presentation for this condition; high grade fever and chills are uncommon; physical exam may demonstrate local tenderness on percussion over the affected area of the spine. Diagnosis? Treatment?
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VERTEBRAL OSTEOMYELITIS!!!; there may be tenderness to percussion over the vertebrae involved and paravertebral muscular spasm. Early diagnosis is important because epidural abscess and spinal cord compression may develop if the treatment is delayed. MRI of the spine is the most sensitive test for identification of vertebral osteomyelitis. Since MRI is excellent for evaluation of soft tissues, it will also reveal whether there is any abscess or cord compression.
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A right atrial pressure >10 and pulmonary artery systolic pressure of >40 are the criteria used to diagnose what acute lung event?
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Massive Pulmonary Embolism; such patients develop shock with hypotension, tachycardia and cool extremities.
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This diruetic is effective in treating patients with ascites from cirrhosis and those with New York Heart Association class III and IV heart failure?
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Spironolactone.
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Back pain due to this cause worsens with sitting; patients present with low back pain and sciatica; a positive straight leg test is sensitive for this diagnosis?
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Herniated disc.
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This diagnosis should be suspected in patients with low back pain in conjunction with history of malignancy, failure to improve with conservative therapy, and constant dull pain. Diagnosis?
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Vertebral metastasis.
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This back pain presents with pain paralysis, hyperreflexia, urinary and fecal incontinence, or urinary retention. Diagnosis?
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Spinal cord compression.
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What is the most common cause of Lumbar spinal stenosis?
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Degenerative disk disease, which presents with low back and leg pain
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The leg pain of spinal stenosis ("neurogenic claudication") can be confused with that of PVD-induced claudication. In both cases, leg pain worsens with walking. What is different about the leg pain associated with Neurogenic claudication?
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It is position-dependent and persists while standing still.; also on exam, normal ankle-brachial index and arterial pulses are seen in spinal stenosis.
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Acanthosis nigricans in a young person is due to what cause? Old person?
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Diabetes in a young person; GI malignancy in an old person
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What is the first step in evaluation of a patient with a thyroid nodule?
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TSH level.
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What is Winter's formula?
|
PaCO2 = 1.5 (HCO3-) + 8
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What is the cutoff value for the diamete of AAAs, in terms of when surgery is required?
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For abdominal aortic aneurysms (AAAs) greater than about 5 cm in diameter, surgery is typically recommended because the risk of rupture increases dramatically at this diameter. For patients with smaller AAAs, periodic imaging should be done to assess for aneurysm growth. Rapid growth itself can be an indication for surgical repair
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For patients being medically managed for their AAAs, what is the intervention with the greatest likelihood of slowing AAA progression?
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SMOKING CESSATION!!!; smoking is a major risk factor for aneurysm formation, enlargement, and rupture. Continued smoking increases the rate of aneurysm growth by about 25%. In most patients, atherosclerosis is the underlying precipitant for AAA formation, but altering other atherosclerotic risk factors has not been demonstrated to have as much impact as smoking cessation. Thus, smoking cessation is the medical intervention with the greatest potential impact.
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Cervicofacial actinomycosis classically presents as a slowly progressive, non-tender, indurated mass, which evolves into multiple abscess, fistulae, and draining sinus tracts with sulfur granules, which appear yellow. What is the treatment for Cervicofacial actinomycosis?
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High-dose penicillin for 6-12 weeks.
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What are the two most common causes of pancreatitis?
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Gallstones and alcohol.
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In severe pancreatitis, administration of several liters of IV fluid may be required to correct associated hypotension. Explain this phenomenon and why hypotension can occur.
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Hypovolemic shock causing hypotension can occur during acute pancreatitis due to inflammatory effects of locally released activated pancreatic enzymes and other inflammatory mediators into the circulation causing an increase in vascular permeability within and around the pancreas with accompanying exudation of a large volume of plasma into the retroperitoneum. This also causes systemic inflammation, with widespread vasodilation, capillary leak, and resultant hypotension.
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This dermatologic condition is characterized by a rosy hue with telangectasia over the cheeks, nose, and chin. Flushing of these areas is typically precipitated by hot drinks, heat, emotion, and other causes of rapid body temp changes. The episodes are intermittent, but can progressively lead to permanent flushing of the skin; sometimes, papules and pustules may be present; this is most commonly found in 30- to 60-year-old patients with fair skin, light hair and light eye color. The pathogenesis is not known, although hair follicle mites have been thought to play a role; medical treatmetnt is aimed at the inflammatory papules, pustules, and erythema. Diagnosis?
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ROSACEA!!!
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Renal insufficiency accompanied by hyperkalemia and a non-anion gap metabolic acidosis is consistent with type 4 RTA. Type 4 RTA is caused by what hormone deficiency?
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ALDOSTERONE!!!; the lack of aldo in these patients leads to a failure to secrete acid as NH4+ and retention of K+. Type 4RTA may occur in the setting of diabetic nephropathy due to Type I or Type II DM, and the condition can be worsened by drugs that inhibit the Renin-ANG-ALDO system such as ACEi-s and ARBs.
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Patients who have consumed acid or alkali should be hospitalized and given intravenous hydration, and receive serial x-rays. What procedure should be done and is the next best step in management?
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Endoscopy should be performed expeditiously to assess the extent of esophageal injury and to determine if any further management is need. If perforation is suspected, a Gastrografin study should be performed.
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What parasitic infection should you suspect in a patient that presents with GI complaints followed by the characteristic triad of Periorbital edema, Myositis, and Eosinophilia; other clues include subungual splinter hemorrhages and conjunctival or retinal hemorrhages. Diagnosis?
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Trichinosis.
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1) Insulin and glucose 2) Sodium Bicarbonate 3) Beta-2-AGONISTS. All three of these agents share what use?
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They are used to shift K+ intracellularly in cases of Hyperkalemia!!!
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In any patient with a high likelihood of Pulmonary Embolism and respiratory distress, what is the first step in management?
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Heparin weight-based protocol!!!; this should be done before diagnostic tests are done to confirm the diagnosis.
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This condition can present acutely as unilateral eye pain, redness, and dilated pupil with poor light response. Nausea and vomiting may develop and patients may complain of seeing halos around lights. Diagnosis?
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Acute angle closure glaucoma.
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This condition is characterized by an immune-mediated inflammation of one eye (the sympathetic eye) after a penetrating injury to the other eye; typical manifestation is anterior uveitis, but panuveitis, papillary edema and blindness may develop. The pathophysiological mechanism is believed to be the uncovering of 'hidden' antigens; some antigens contained within the eye are protected from immunologic recognition by natural barriers, and breaking of these barriers results in the uncovering of 'hidden' antigens. An immune repsonse against these antigens can involve autoantibodies as well as a cell-mediated reaction. Diagnosis?
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Sympathetic opthalmia, also known as "spared eye injury"
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Whenever a healthcare worker is exposed to HIV, what is the first step, and how many anti-retrovirals should be used?
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HIV baseline testing should be performed immediately; post exposure prophylaxis with two or three antiretroviral drugs should be started without delay.
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Lynch syndrome II is distinctly associated with a high risk of extracolonic tumors, the most common of which is what?
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ENDOMETRIAL CARCINOMA!!!, which develops in up to 43% of women in affected families.
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What is the standard of practice in management of solitary brain metastasis with stable extracranial disease? Multiple metastases?
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Surgical resection followed by whole brain radiation is the preferred management of a solitary brain metastasis. The role of surgery is ro provide immediate control of the tumor; whole brain radiotherapy is given after surgical resection to destroy microscopic residual disease and to provide the patient with a better quality of life. Multiple brain metastases are best treated with palliative whole brain radiation.
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Latex allergy is particularly common in patients with what congenital spinal defect?
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Spina bifida.
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The drug of choice for treating a patient with SLE depends on the degree of organ involvement. What is the DOC for SLE with isolated skin and joint involvement? What is a side effect of this medication?
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Hydroxychloroquine is an excellent choice; a side effect of this medication is damage to the eye (retinopathy; corneal damage may also occur), therefore eye examinations at 6 month intervals are indicated in all patients taking hydroxychloroquine.
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This murmur typically causes a pansystolic murmur that radiates to the axilla. Diagnosis?
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Mitral valve regurgitation; Mitral valve prolapse leading to regurgitation is the most common cause.
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What condition should you expect in a patient with suspected mitral valve regurgitation and palpitations?
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Mitral regurgitation leading to increased atrial size and Atrial fibrillation.
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This drug is used in patients with chronic Afib and has side effects such as nausea, vomiting, diarrhea, scooped ST segments, prolonged PR intervals, shortened QT intervals, and T-wave inversion; renal failure and hypokalemia exacerbate the toxicity. Diagnosis?
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Digoxin toxicity.
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In patients with aortic dissection with hypertension what should be the first step in management?
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ANTIHYPERTENSIVE MANAGEMENT!!!; if hypertension is present, it should be aggressively treated before any diagnostic studies are done.
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If there are ECG changes seen in a patient with aortic dissection, the coronary ostia of which coronary artery are usually involved?
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Right coronary artery.
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What is the most common cause of death in patients with acute MI?
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Complex ventricular arrhythmia (reentrant ventricular arrhythmia such as ventricular fibrillation); acute ischemia creates heterogeneity of conduction in the myocardium. Areas of partial block of conduction are frequently formed that predispose the patient to reentrant arrhythmia. Ventricular fibrillation is a typical example of reentrant arrhythmia. Decline in mortality of patients hospitalized with acute coronary syndromes is largely attributable to the effective detection and treatment of ventricular arrhythmia.
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How do you correct the development of acute pericarditis in a patient with renal failure?
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The development of pericarditis in a patient with renal failure is most likely due to the development of uremic pericarditis. Hemodialysis is the procedure of choice in such cases.
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Metastatic breast cancer has a poor prognosis, with little chance of cure despite the major recent advances in the treatment of metastatic disease (even with localized metastases). It is important to choose local vs. systemic treatment in patients with metastatic breast cancer. Generally which approaches (local or systemic) are more successful?
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Local approaches (surgery, external beam irradiation) have a higher response rate than systemic approaches, if possible.
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Therapeutic radioisotopes are helpful in palliating what type of pain due to metastatic disease?
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Bone pain.
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What are three predisposing factors of elderly patients to dehydration?
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1) Decreased thirst response
2) Impaired renal sodium conservation 3) Impaired renal concentration ability |
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What is meant by administration of intravenous crystalloid solution?
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Usually sodium-containing crystalloid solution e.g. 0.9% NaCl = Normal saline
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When are intravenous colloid solutions used for fluid resuscitation?
|
Colloid solutions (e.g. albumin) are usually used in burns or conditions accompanied by hypoproteinemia.
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What vitamin deficiency screening is important to do in patients with Paget's disease?
|
Vitamin D deficiency because concurrent vitamin D deficiency with Paget's disease can increase bone turnover, which can lead to additional increase in the serum alkaline phosphatase level.
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What is the significance of Paget's disease patients that present with bone pain, hypercalcemia of immobilization, neurological deficit, high output cardiac failure, involvement of weight bearing bones, or preparation for orthopedic surgery?
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These patients are symptomatic and thus warrant treatment with oral or intravenous bisphosphonates. Asymptomatic patients with Paget's disease generally do not require any treatment unless they have an extremely elevated AlkPhos level.
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In a patient with evidence of portal hypertension such as caput medusa and splenomegaly, what is an important preventative screening measure that should take place? Tx?
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Esophageal endoscopy to look for esophageal varices; varices may be asymptomatic until they abruptly rupture and cause severe hematemesis. As a preventative measure, then, all patients with cirrhosis and evidence of increased portal hypertension should be screen for esophageal varices. Primary prophylaxis should include beta-blockers, which will significantly reduce the risk of bleeding.
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What primary medical prophylactic measure will significantly reduce the risk of bleeding in a patient with esophageal varices?
|
Beta-blocker therapy.
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What medical therapy is consider to be first line in treating cancer patients who become anorexic due to their chronic disease?
|
Progestin agents such as megestrol acetate and medroxyprogesterone acetate are usually considered first-line. Progestin medications are as efficacious as corticosteroid for cancer-induced cachexia, but have a better side effect profile. A slightly increased risk of venous thrombosis is the main potential adverse side effect.
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What is the treatment of choice for "lone atrial fibrillation" in the absence of risk factors for stroke, such as previous stroke or TIA, diabetes mellitus, HTN, heart failure, age >/= 75 years, or valvular heart disease? What if any of these risk factors are present?
|
ASA 81 therapy is sufficient for treating Afib in the absence of other risk factors. If risk factors are present long-term anticoagulation is generally necessary.
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What is the treatment of choice for moderate-to-severe acne that is predominantly nodulocystic form, and in those who have developed scars?
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Isoretinoin.
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Glucocorticoids have a complex effect on the blood cells. They tend to diminish the number of circulating eosinophils and have distinct lymphopenic effect. What is their effect on neutrophils?
|
Increase the neutrophil count by increasing the bone marrow release and MOBILIZING THE MARGINATED NEUTROPHIL POOL. It is not uncommon to see neutrophilia during treatment with glucocorticoids.
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Meniere's disease is a disorder resulting from distension of the endolymphatic compartment of the inner ear. The classic presentation consists of episodes of vertigo that last up to 20 min to 24 hours in addition to low-frequency, sensorineural hearing loss and tinnitus (may be described as a buzzing sound). Symptoms usually wax and wane, but the course of disease varies between individuals. Nystagmus may be seen during an acute attack. What are triggers that could increase endolymphatic retention that should be avoided? Tx?
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Avoid alcohol, caffeine, nicotine, and high salt foods. A strict salt-restricted diet of two to three grams of sodium per day is recommended as initial therapy. Medical therapy with diuretics, antihistamines, or anticholinergics is usually considered if lifestyle modifications are unsuccessful.
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Pronator drift is a relatively sensitive and specific finding for what type of neurological lesion?
|
Upper motor neuron disease. The upper extremity supinator muscles are naturally weaker than the pronators, a difference that is exaggerated in patients with an upper motor neuron lesion. As a result, when these patients close their eyes and extend their arms with the palms up, the affected arm will tend to pronate. In particular, many patients with strokes will demonstrate pronator drift.
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with normal or slightly prolonged PTT, with Von Willebrand's factor, bleeding time, and platelet count as normal, with D-dimer normal or high, and a history of miscarriages. Diagnosis?
|
Lupus anticoagulant.
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In patients who are within 4 hours of ingesting overdose levels of acetaminophen, what is the appropriate action? At what time point should you check the blood for toxic levels of acetaminophen? How long after ingestion can N-acetylcysteine be used as an antidote, without adversely affecting the outcome?
|
Administering activated charcoal in order to decrease absorption; at 4 hours you check blood levels to assess whether using N-acetylcysteine is warranted or not, because several studies have shown that there is no correlation between the amount of acetaminophen taken and the measured serum drug level!!!!!!!!!!; N-acetylcysteine is the antidote for overdose as long as it is administered within 8 hours of ingestion.
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What is the most common cause of thyroid nodule? What is the second most common cause?
|
Benign colloid nodule is the most common cause; Follicular adenoma is the second most common cause
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Hyponatremia with central nervous system symptoms requires what treatment?
|
Hypertonic saline.
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Chronic pancreatitis is an inflammatory condition characterized by chronic abdominal pain and pancreatic insufficiency. What is the most sensitive and specific test to diagnose pancreatic exocrine failure?
|
Stool elastase.
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Aztreonam, ciprofloxacin, imipenem/cliastatin, tobramycin, gentamicin, amikacin, cefepime and Zosyn all treat what hearty bacteria?
|
Pseudomonas.
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Which germ cell tumor in young men typically produces both alpha-fetoprotein and B-HCG? What if it was just B-HCG?
|
Nonseminomatous germ cell tumors; if it is just B-HCG it would be just a Pure Seminomatous Tumor.
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Firm, flesh colored, dome shaped, umbilicated papules are typical of molluscum contagiosum. The presence of a large number of these lesions on the trunk, limbs, or in anogenital areas should make you suspicious for what condition?
|
Cellular immunodeficiency such as in those with HIV, corticosteroid use and chemotherapy.
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What are 4 criteria to make sure to review to make a diagnosis of a simple renal cyst? Tx?
|
1. NOT a multilocular mass
2. NO thickened, irregular walls 3. NO thickened septae within the mass 4. NO contrast enhancement ***Simple renal cysts are almost always benign and do not require further evaluation. |
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What is the danger in initially treating the overactive adrenergic symptoms of pheochromocytoma with a beta-blocker?
|
Blocking-beta receptors leads to unopposed stimulation of vascular alpha-receptors by circulating catecholamines, which may result in a rapid, catastrophic increase in blood pressure. For these reasons, beta-blockers are never started unless reasonable alpha-blockade is achieved.
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New clubbing in patients with COPD often indicates what development?
|
Lung cancer.
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These are small red cutaneous papules common in aging adults. They do not regress spontaneously and typically increase in number with age. Light microscopy of these lesions reveals proliferation of capillaries, and post capillary venules in the papillary dermis. Diagnosis?
|
Cherry Hemangioma.
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This lesion consists of dilated vascular spaces with thin-walled endothelial cells; they present as soft blue compressible masses up to a few centimeters in size; they may appear on the skin, mucosa, deep tissues and viscera; when they appear on the skin they are most frequently based in the dermis. They are less likely to regress spontaneously than capillary hemangiomas. Diagnosis? Associated disease?
|
Cavernous hemangioma of the brain and viscera, which is associated with Von Hippel Lindau disease.
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Foods rich in Vitamin K, like leafy green vegetable (kale, spinach, mustard greens, Swiss chard), can decrease the INR in patients trying to achieve a therapeutic INR who are taking warfarin. Substances the can INCREASE warfarin's activity include alcohol, garlic, ginko biloba, ginseng, St. John's wort and several antibiotics. What is the Vitamin supplement that would most likely be responsible for INCREASING the action of warfarin if someone were to take it?
|
Vitamin E interaction with warfarin will INCREASE WARFARIN ACTIVITY!!!
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A patient presents with slurred speech, unsteady gait, and drowsiness. Pupils are normal in size and there is mild respiratory depression, if any. What is the most likely drug toxicity?
|
Benzodiazepines.
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Slurred speech, unsteady gait, and drowsiness can be seen in the overdose of multiple drugs. Overdose with this type of drug can be distinguished from opioid overdose by the lack of severe respiratory depression and the lack of pupillary constriction. Furthermore, while alcohol and phenytoin intoxication also share similarities with this drug, those drug toxicities can be distinguished by the presence of nystagmus, because this drug dose not share that feature. Diagnosis?
|
Benzodiazepine toxicity!!!
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This drug toxicity presents with horizontal nystagmus, cerebellar ataxia and confusion. Patient will likely have a history of seizures. Diagnosis?
|
Phenytoin toxicity!!!
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This drug toxicity presents with tremor and hyperreflexia, ataxia and seizures. The patient wil likely have a history of bipolar disorder. Diagnosis?
|
Lithium toxicity.
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A patients EKG show tachycardia with a heart rate of approximately 150 beats per minute. The QRS complex is narrow and the heart rate is regular. No P wave is identified. These findings are most consistent with Superventricular Tachycardia. Most cases of SVT are caused by either atrioventricular nodal re-entrant tachycardia (AVNRT) or atrioventricular re-entrant tachycardia (AVRT). What is the first line treatment to abort an SVT? What if drugs are not available?
|
Adenosine is the first-line treatment; Carotid massage is also an option if adenosine is not readily available.
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What diagnostic value can Adenosine have when treating a suspected SVT?
|
Adenosine usually terminates an SVT, whereas, other tachycardias are usually simply slowed. If adenosine is not successful then a calcium channel blocker, beta blocker or ultimately cardioversion may be necessary.
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A patient presents with paroxysmal nocturnal dyspnea in the setting of long-standing hypertension and a pulmonary exam concerning for cardiogenic pulmonary edema. He has likely developed diastolic dysfunction from his long-standing hypertension and is now in left ventricular failure. What drug will relieve the dyspnea and tachycardia associated with cardiogenic pulmonary edema by rapidly reducing preload. Several studies have suggested that this drug workers quicker than morphine or loop diuretics. It is not a part of the long-term management of patients with heart failure, but can be beneficial in acutely alleviating symptoms. Drug?
|
Nitroglycerin!!
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What is the most likely culprit for a lesion in an acute inferior wall MI, especially if it is complicated by right ventricular infarction (hypotension) or bradycardia?
|
Right Coronary Artery!!!
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These type of infarcts can occur in patients with hypertension, and can have severe focal symptoms depending on where they are located. By definition these are small infarcts and would not be be expected to cause rapidly progressing global CNS symptoms. Diagnosis?
|
Lacunar Infarcts.
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These type of strokes most commonly occur in the basal ganglia, thalamus, pons, and cerebellum. Patients tend to present initially with focal symptoms, but can rapidly progress to signs of elevated intracranial pressure. Diagnosis?
|
Hypertensive intraparenchymal hemorrhagic stroke.
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Potential causes of chronic inflammation associated with this secondary condition include chronic infection, psoriasis, inflammatory bowel disease and autoimmune diseases such as rheumatoid arthritis. This secondary condition is a systemic disease, and the kidneys and GI system are prominently affected. Nephrotic syndrome is common in these patients and may manifest with hypertension, proteinuria and edema of the face and legs; kidneys may be enlarged; hepatomegaly is also a common finding. Diagnosis?
|
AMYLOIDOSIS!!!; secondary amyloidosis results from the deposition of acute phase reactants, particularly serum amyloid A, in the setting of chonic inflammation, such as chronic infection, autoimmune disorders, IV drug users and various other diseases. Amyloidosis is a systemic disease, affecting the kidneys (nephrotic syndrome), GI tract (hepatomegaly), heart (cardiomyopathy), musculoskeletal system (pseudohypertrophy), and nervous system (peripheral neuropathy).
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This is a systemic disease affecting the kidneys (nephrotic syndrome), GI tract (hepatomegaly), heart (cardiomyopathy), musculoskeletal system (psuedohypertrophy) and nervous system (peripheral neuropathy); often found in the setting of chronic infection, autoimmune disease, IV drug use, and other causes of chronic inflammation. Diagnosis?
|
AMYLOIDOSIS!!!
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Hepatitis B, Hepatitis C, malaria, and syphilis are all associated with what type of Nephrotic syndrome? (*this is the most common cause of nephrotic syndrome in adults)
|
Membranous nephropathy.
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|
This syndrome is characterized by acute renal failure as a result of portal hypertension. It presents as decreased urine production. Diagnosis?
|
Hepatorenal syndrome.
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Monoclonal gammopathy of undetermined significance can be differentiated from multiple myeloma by an absence of what four findings?
|
Renal insufficiency, hypercalcemia, anemia, and lytic bone lesions. While MGUS is asymptomatic there can be progression to full-blown multiple myeloma and for patients with some of the findings mentioned above, a bone marrow biopsy could be considered to differentiate between multiple myeloma and MGUS. There must be a plasma cell level within the bone marrow of less than 10% for a diagnosis of MGUS.
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While the exact mechanism of this drug-induced myopathy is unknown, it is thought to relate to decreased protein synthesis, mitochondrial alteration, increased protein degradation, and electrolyte and carbohydrate metabolism disturbances. There are two forms of this myopathy, acute and chronic. Acute form is relatively uncommon and is cahracterized by diffuse muscle weakness and rabdomyolysis during high-dose treatment. The more common chronic form has an insidious onset with prolonged use and is characterized by proximal muscle weakness without significant pain; patients may complain of difficulty rising from a chair or brushing their hair. For both diseases, muscle strength improves after discontinuation of the drug, but it may take weeks to months to see improvement. Drug?
|
Corticosteroids-induced myopathy; pain is not a prominent finding, ESR will not be elevated.
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Most cases of this condition are secondary to an infection located in the medial aspect of the face around the eyes and nose, but ethmoid or sphenoid sinus infections can be the culprit as well; headache is the most common early symptom seen in patients with this condition, and a low-grade fever and periorbital edema usually occur several days later secondary to impaired venous flow in the orbital veins; there can also be double vision noted. Diagnosis? What test can confirm this diagnosis?
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Cavernous sinus thrombosis; a lateral gaze palsy or double vision is most likely due to an abducens nerve palsy (CN VI). Cranial nerves III, IV, V1, V2 and VI all pass through the cavernous sinus and can be affected in patient with CST. The headache that occurs in these patients is partly due to neuropathic pain as a result of irritation of the V1 and V2 branches of the trigeminal nerve, which explains why the apin is usually sharp and located in the upper face. Diagnosis can be confirmed with either MRI or CT scan of the orbits with contrast. Intravenous broad-spectrum antibiotic treatment is required, but anticoagulation, glucocorticoid therapy, or surgery may be used in some cases.
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If you see a patient that you suspect of having lupus, presenting with kidney involvement, what would be the next step in the management of the patient?
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Kidney biopsy; SLE's effects on the kidneys can range from minimal mesangial lupus nephritis to advanced sclerosing lupus nephritis and are graded classes I-VI. The treatments and outcomes are diffrent depending on the class of lupus nephritis, thus renal biopsy is required in all patients with new onset lupus nephritits. Immunosuppressive therapy may be given once the lupus nephritis is classified.
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In patients with malignancy, hypercalcemia is due to increased bone resorption and the release of calcium from the bone. What drugs are first line in women who have metastatic breast cancer and radiographic lytic bone disease for treating hypercalcemia?
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Bisphosphonates such as IV Zoledronic acid!!!; these drugs are relatively non-toxic, are more potent than normal saline, and are the drugs of choice for mild to moderate hypercalcemia. In addition, there is increasing evidence that bisphosphonates may prevent skeletal complications (reduce bone pain, fracture risk), and perhaps improve survival in patients with multiple myeloma or breast cancer.
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Expressive aphasia results from lesions in what lobe of the brain?
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The Dominant Frontal lobe; frontal lobe also contains motor cortex whose damage results in contralateral paresis.
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When giving pain medication to a patient who will need chronic pain management, should you start with long-acting or short-acting medication?
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The patient should be initially treated with a dose of short-acting morphine, and then subsequent doses titrated as needed to achieve complete pain control. Once the dose is established, the patient can be switched to long-acting narcotics, and the short-acting morphine is then used for break through pain.
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A patient with a tumor in this area of the brain typically presents with ipsilateral ataxia; the patient tends to fall towards the side of the lesion; when asked to stand with his feet together, the patient also tends to sway to the affected side, and may exhibit titubation, which is a forward and backward movement of the trunk. Other characteristic features of this type of tumor include nystagmus, intention tremor, ipsilateral muscular hypotonia, and marked difficulty in coordination and performing rapid alternating movement. Obstruction of CSF flow by the tumor can result in increased intracranial pressure, which may present as headaches, nausea, vomiting and papilledema. Diagnosis?
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Cerebellar tumor.
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In 25% of cases, brain abscesses arise from distant infections, usually lung infections (bronchiectasis, empyema, lung abscess), but teeth, heart (endocarditis), GI tract (e.g. diverticulitis) and bone infections are also potential causes. In another 25% of cases, brain abscesses arise due to contiguous spread of infection from the middle ear, mastoids, or paranasal sinuses. What are the most common causative organisms responsible for brain abscesses?
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Aerobic and anaerobic streptococci (60-70%) and Bacteroides species (anaerobes) (20-40%) are the organisms most commonly responsible.
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This type of diarrhea is characterized by very frequent, watery, nocturnal diarrea; diarrhea due to this cause can be confirmed with the characteristic biopsy finding of dark brown discoloration of the colon with lymph follicles shining through as pale patches (melanosis coli). Diagnosis?
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Laxative abuse (factitious) Diarrhea; in addition, an alternative means of diagnosis is histological evidence of pigment in the macrophages of the lamina propria.
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In the classical scenario of hemi-neglect the patient neglects the left side of a space and responds to the stimuli coming only from the right side. Patients may only shave the right side of their face, comb the right side of their hair, and ignore the subject located in the left side of a space. What lesion of the brain causes this syndrome?
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A lesion to the Right (non-dominant) PARIETAL LOBE, which is responsible for spatial organization.
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What three treatments are the mainstay of treating septic shock in a patient?
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Correction of the underlying cause and restoration of tissue perfusion; thus, antibiotic, IV normal saline, and vasopressor use for the treatment of hypotension only after intravenous fluids have failed to restore normotension.
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When are vasopressors used for patients in shock states?
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Vasopressors are indicated for the treatment of hypotension in states of shock only after IV fluids have failed to restore normotension.
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IN some forms of cardiac disease (tamponade, pericardial effusion) and pulmonarydisease (tension pneumothorax, and severe asthma) what phenomenon can be seen to affect the systolic blood pressure? What is the mechanism for asthma?
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Pulsus paradoxus; In asthma, significantly elevated intrathoracic pressures during inhalation are thought to exacerbate compression of the left ventricle, causing pulsus paradoxus.
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Because the GI tract is bypassed in patients on TPN, the stimulus for the release of GI hormones such as CCK is impaired. The normal stimulus for the release of CCK include the presence of proteins and fatty acids in the duodenum; this stimulus is absent in the patients being nourished with TPN. Why does all this lead to a propensity for patients receiving long-term TPN to develop gallstones?
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CCK normally stimulates contraction of the gall bladder and expulsion of bile into the gut lumen. Without CCK, gall bladder stasis results Which predisposes to both gall stone formation and blie sludging, both of which may lead to cholecystitis.
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Up to 3.2% of patients (especially those treated before the age of 30) treated with chemotherapy and radiation for Hodgkin's disease will develop what condition within 20 years?
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A secondary malignancy; the risk of secondary malignancy is highest when chemo therapy is combined with radiation, reaching up to 3.2% within 30 years of treatment. Lung and breast cancers are among the most common secondary malignancies affecting patients previously treated for Hodgkin's disease.
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Epigastric pain, bloating and nausea not secondary to biliary or pancreatic disease are often referred to as 'dyspepsia'. Many patients with dyspepsia have nothing organically wrong while others have peptic ulcer disease or gastritis. How can these two groups of patients be distinguished?
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A recommended screen is testing for H.pylori serology; concerning factors that would warrant a more thorough evaluation via endoscopy include age over 55, weight loss, dysphagia, or persistent vomiting.
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The initial symptom of Pseudotumor cerebri is usually a headache that is pulsatile in nature and awakens the patient from sleep. The symptoms gradually evolve and become suggestive of increased intracranial pressure. In addition to persistent headache, nausea, vomiting, neck pain, double vision, visual loss and tinnitus may occur. Pertinent physical findings may include visual loss, papilledema on fundoscopy and abducent nerve palsy. Most patients with pseudotumor cerebri have an empty sella seen on neuroimaging, probably due to downward herniation of arachnocele due to high CSF pressure. Once neuroimaging excludes space-occupying lesions what is the next step?
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LUMBAR PUNCTURE, which should reveal normal CSF findings except for an increased opening pressure; sufficient CSF should be removed during the LP to decrease the intracranial pressure to 15 mm H2O
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In any dog bite, an attempt is made to capture the dog. If the dog is not captured, it is assumed rabid, and post-exposure prophylaxis is indicated, and post-exposure prophylaxis should be started immediately for exposures involving the head and neck. What is the next step if the dog is able to be held and does not show signs of rabies?
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If the dog is captured and does not show features of rabies, it is kept for observation for the development of rabies for 10 days. If the dog develops any features of rabies, post-exposure prophylaxis should be started immediately. The dog's diagnosis is confirmed by fluorescent antibody examination of the brain.
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In patients with acute onset of back pain linked to a specific event and positive straight-leg raise test, disk herniation may be the cause of the problem. If there is no neurological findings the patient may be managed conservatively with what treatments?
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Early mobilization, muscle relaxants, and NSAIDs; in randomized clinical trials, patients did better without bed rest than with it, so bedrest is no longer advised for this type of low back pain. Patients should be advised to return to daily activities as soon as possible. Pain and stiffness is better managed with NSAIDs and muscle relaxants. An exercise program has also not been shown to be beneficial for this type of pain. If the pain persists after 4-6 weeks of conservative treatment or progressive neurological deficit evolves, high-resolution diagnostic modalities are usually employed; MRI and CT with or without contrast myelography.
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This skin condition presents in infancy typically affecting the face, scalp, and extensor surfaces, with the diaper region typically being spared (a distribution that differs significantly from that seen in adults). Lesions usually begin with pruritus alone and evolve to erythematous excoriated papules and plaques that may weep. Diagnosis? Pathophysiology? Treatment?
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Atopic dermatitis; this is the result of decreased skin barrier function due to improper synthesis of components of the epidermal cornified cell envelope. This allows allergens ready access to the deeper levels of the epidermis where they may generate the immune response. Treatment is with improvement of skin barrier function through the use of mild cleansers and thick, bland emolients in addition to mild topical anti-inflammatory ointments.
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The typical clinical scenario described for someone with a vasovagal episode, or neurally mediated neurocardiogenic syncope, normally includes a prodrome (lightheadedness, weakness, and blurred vision), provocation by an emotional situation, and rapid recovery of conciousness. Vasovagal syncope is frequently recurrent. What is the diagnostic test indicated to confirm this if it is recurrent?
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Upright tilt table testing may be indicated to confirm the diagnosis if the syncope is recurrent.
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Should a woman less than 35 years of age have a mammogram?
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NO!; mammograms in women less than 35 years of age are not useful since the dense breast tissue at this age does not allow adequate visualization of any masses, if present.
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Placing a consolidated lung segment in the dependent position in a patient with pneumonia will decrease that patient's oxygen saturation due to what mechanism?
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Increased right to left shunting; in consolidated lung segments the alveoli are filled with exudate and do not participate in pulmonary gas exchange, so their ventilation is essentially zero, i.e. blood perfusing consolidated areas is not oxygenated. Positions that increase the proportion of pulmonary blood flow passing through such segment decreases the patient's O2 sat (right to left shunt).
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What is the treatment of choice for a female patient with fibromuscular dysplasia?
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Percutaneous angioplasty with stent placement.
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GERD is present in up to 75% of asthma patients, and may be the primary trigger in many. Patients with adult onset asthma and symptoms that are worse after meals, exercise or laying down are likely to have GERD-induced disease. What is the next best step in the management of these patients?
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Omeprazole; where GERD is suspected, a trial of proton pump inhibitors can be both diagnostic and therapeutic.
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Patients with Hemochromatosis and cirrhosis are at increased risk of infection with what bacteria? Why?
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Listeria monocytogenes; possible explanations include increased bacterial virulence in the presence of high serum iron and impaired phagocytosis due to iron overload in reticuloendothelial cells. Iron overload is also a risk factor for infection with Yersinia enterocolitica and septicemia from Vibrio vulnificus, both of which are iron-loving bacteria.
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Loss to follow-up in prospective studies creates a potential for what type of bias?
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SELECTION BIAS; this is because such loss may create a selection that either overestimates or underestimates the association between the exposure and the disease, because it is always possible that the lost people differ in their risk of developing the outcome from the remaining subjects.
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Infection with this virus is typically asymptomatic, and characterized by waxing and waning transaminase levels; lab values and hepatic function often worsen in the setting of physiological stress; sequelae can include chronic arthralgias (often with false-positive rheumatoid factor or antinuclear antibody), porphyria cutanea tarda, glomerulonephritis, and cryoglobulinemia. Diagnosis?
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Hepatitis C infection!!!
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Patients experiencing postcholecystectomy pain is usually due to one of three reasons: 1) Sphincter of Oddi dysfunction 2) Common bile duct stone 3) ???; normal liver function tests and lack of evidence of dilatation of the biliary tree help rule out both Oddi dysfunction and common bile duct stone. What is the third cause of pain in this setting?
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FUNCTIONAL PAIN WITHOUT OBVIOUS ORGANIC BASIS!!!; this should be treated symptomatically with analgesics and reassurance.
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Compression of the thecal sac should be suspected in any patient with a history of cancer or fever who presents with back pain and neurologic symptoms, particularly loss of bowel or bladder function. An MRI is the test of choice to confirm the diagnosis, but what treatment should be started while awaiting test results?
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GLUCOCORTICOID treatment!!!; this should be started while awaiting test results in order to decrease the risk of permanent neurologic damage.
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When someone who is suspected for infection with PCP pneumonia due to some risky activity or outright HIV is presented with a history of allergy to sulfonamides, what is the question stem trying to make you get at?
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Treating this PCP pneumonia with the alternative to TMP-SMX; it wants you to treat with Pentamidine and azithromycin (Pentamidine side effects include hypoglycemia, hyperglycemia, hypocalcemia, azotemia, and liver dysfunction).
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While almost all patients with RA develop a symmetric arthritis of their peripheral joints, involvement of the axial skeleton is less universal. However, when the axial skeleton is involved, what is the most frequent site of involvement?
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The Cervical Spine is the most frequently affected, resulting in neck pain, stiffness, hyperreflexia, and C1-C2 instability subaxial subluxation.
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Mohs surgery is a special type of laser surgery that has the highest cure rate for basal cell cancer. It can excise the cancer from the skin with very small margins. How smal can they be?
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1-2 mm of clear margins.
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A patient presents with signs and symptoms of a multi-organ system disease process, including hypogonadism (testicular atrophy, decreased sexual drive), arthropathy, new onset pancreatic endocrine dysfunction (diabetes), and hepatomegaly. What is this diagnosis and what involvment might you find in the heart?
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HEMOCHROMATOSIS!!!; this is a condition that can cause the listed findings, in addition to cardiac abnormalities. Cardiac involvement may include dilated or restrictive cardiomyopathy leading to heart failure or various conduction abnormalities. Hemosiderin deposition in the pituitary can lead to hypogonadotropic hypogonadism and deposition may cause arthropathy.
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What is the most appropriate course of action for a patient with known immunity to Hepatitis B, who is exposed to the disease? What if the patient has unknown immunity?
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Reassurance is all that is needed for a patient who is exposed to HBV and has a documented response to previous HBV vaccination; The HBIG and the Hepatitis B vaccination series should be given to patients with unknown immunity after exposure.
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A patient has recurrent episodes of a "pounding and racing" heart over the last several months; the symptoms are worst while lying supine and while lying on the left side. Physical exam shows a BP of 150/55 mmHg and HR of 73/min. Diagnosis?
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Aortic regurgitation!!! wide pulse pressure, and lying flat and turning to the left brings the heart closer to the chest wall and can make the patient mor aware of the forceful heartbeat are what explain his signs and symptoms.
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This virus is amongst the most common causes of viral arthritis. Other causes include hepatitis, HIV, and rubella. Adults who have frequent contact with children, such as schoolteachers and daycare workers, are at increased risk of this infection. Diagnosis?
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Parvovirus B-19.
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Achalasia generally present with complaints of dysphagia for both solids and liquids, as well as regurgitation. However, there is another condition you should be worried about in a patient presenting with signs and symptoms of achalasia who is over the age of 60 and/or who has an associated weight loss. Possible diagnosis? Next best step in management?
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Possible Pseudoachalasia secondary to a neoplastic mass at the gastroesophageal junction. Endoscopic evaluation is the next best step in management to determine between achalasia and pseudoachalasia.
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Unexplained hemolytic anemia and thrombocytopenia in a patient with renal failure and neurologic symptoms should raise strong suspicions for TTP-HUS. Idiopathic TTP-HUS is thought to be due to a deficiency of autoantibody against a specific von Willebrand factor-cleaving protease called ADAMTS-13. This causes the large accumulation of large von Willebrand factor multimers and platelet aggregation. TTP-HUS is fatal in 80% of cases if appropriate therapy is not promptly instituted, so a high degree of clinical suspicion is necessary. What is the treatment of choice for TTP-HUS?
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PLASMAPHERESIS (Plasma exchange); is the treatment of choice and should be stated ASAP, because it removes the offending autoantibodies and repletes the deficient enzyme.
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This is a severe form of ocular allergy; the most common symptom is itching, tearing, thick mucus discharge, photophobia, and blurred vision. Diagnosis?
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Atopic keratoconjunctivitis.
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This is a chronic inflammatory condition involving the eye lid margins bilaterally; crusty discharge is seen clinging to the lashes in the anterior version of this condition, whereas hyperemic lid margins with telangectasias are seen in the posterior version of this condition. Diagnosis?
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Blepharitis.
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This is an infection of the lacrimal sac due to obstruction of the nasolacrimal duct; it is characterized by pain, swelling, tenderness, and redness in the tear sac area; mucous or pus can be expressed. Diagnosis?
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Dacrocystitis.
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This is an acute hypersensitivity reaction that is caused by environmental exposure to allergens; intense itching, hyperemia, tearing, and conjunctival edema and eyelid edema are characteristic; some patients complain of photophobia and a burning sensation. There is usually a family or personal history of asthma, seasonal rhinitis, atopic dermatitis, food allergies, and urticaria. The condition subsides in 24 hours, even without treatment. Diagnosis?
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Allergic conjunctivitis; patients should be advised to never rub their eyes and to use topical antihistamines, artificial tears, and cool compresses.
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What is the initial diagnostic test of choice when a patient presents with unprovoked new-onset seizures, in order to rapidly rule out life-threatening processes such as an intracranial hemorrhage?
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CT without contrast; if the non-contrast CT excludes the hemorrhage then MRI or CT with contrast of the brain is the next step.
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Hematologic abnormalities are common in patients with SLE. What is the pathophysiologic mechanism by which they occur? What causes the anemia that is seen? What causes the thrombocytopenia?
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They occur due to formation of antibodies against blood cells and represent a form of Type II Hypersensitivity reaction. Anemia in SLE is caused by autoimmune hemolysis, and develops due to formation of warm IgG antibodies to RBCs. It is characterized by spherocytosis, a positive direct Coombs test, and extravascular hemolysis. The pathogenesis of SLE-associated thrombocytopenia is identical to that of ITP; antibodies against platelets are formed causing destruction of platelets. Neutropenia due to antibody-mediated destruction of WBCs also occurs, but this is less common.
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This infection occurs in immunocompromised patients, who may present with fever, cough, dyspnea, or hemoptysis. Chest X-ray may show a cavitary lesion and CT scan shows pulmonary nodules with a "halo sign" or lesions with an air "crescent". Diagnosis?
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Invasive aspergillosis.
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A child presents with symptoms (fatigue, pounding in the ears) and laboratory values consistent with aplastic anemia; anemia is macrocytic. The patient has bleeding that is secondary, presumably to thrombocytopenia. The patient's has hypopigmented spots, which suggest a systemic disorder, and poor growth that suggests a chronic process. Diagnosis?
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Taken together, these findings in a child suggest Fanconi's anemia, which is an autosomal recessive disorder marked by progressive bone marrow failure, areas of hypopigmentation, congenital abnormalities and predisposition to cancer.
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Fanconi's anemia is an autosomal recessive disorder marked by progressive bone marrow failure, areas of skin hypopigmentation, congenital abnormalities (microcephaly, abnormal thumbs and hypogonadism) and predisposition to cancer. Most patients with FA are diagnosed by age 16. What is the cause and what is the treatment?
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Numerous genes have been implicated in Fanconi's anemia and all are believed to involve DNA repair. The definitive treatment for aplastic anemia is hematopoietic stem cell transplantation.
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For what female age group can the HPV vaccine be used in?
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9-26 years
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A pansystolic heart murmur heard loudest at the apex with radiation to the axilla is the classic characterization of what cause of the murmur?
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MItral Regurgitation.
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Loss of consciousness helps to differentiate a simple partial seizure from a complex partial seizure or simple seizure with secondary generalization. Experiencing a particular aura before loss of consciousness is most consistent with which type of seizure?
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Simple partial seizure that secondarily generalizes (complex partial seizures do have LOC and usually some repetitive behavior, but patients do not have aura); partial seizures can often generalize to the entire brain, which then can cause loss of consciousness. In secondarily generalized seizures, a symptom such as an olfactory hallucination is sometimes referred to as an aura. It is important to elucidated symptoms of a partial seizure, as this can help to steer the differential diagnosis towards etiologies affecting a particular part of the brain.
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Molluscum contagiosum is characterized by multiple dome-shaped lesions with central umbilication. What virus is this caused by? What if there are a collection of many on a place such as the abdomen?
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Poxvirus; the patient may be immnocompromised, such as an HIV patient.
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After 48-72 hours of parenteral therapy for uncomplicated pyelonephritis, what action is generally taken with regard to the patients antibiotic regimen?
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The patient can usually be switched to an oral agent. Oral therapy is more convenient and less expensive; if the results of antibiotic susceptibility testing are known, the appropriate antibiotic can be easily chosen.
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Various studies have suggested an important role for Helicobacter pylori infection in the pathogenesis of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma. What is the most accepted and recommended management of gastric MALT lymphoma without any metastasis?
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Normal triple therapy to eradicate H.pylori, e.g. omeprazole, clarithromycin, and amoxicillin; if this fails to produce regression of the lymphoma therapetic regimens may include CHOP or CHOP + Bleomycin.
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In a patient with probable BPH based on history and rectal exam, what is the one required test that you must do next?
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URINALYSIS!!!; this is done to assess for urinary infection or hematuria. A positive leukocyte esterase would sugest a urinary tract infection like cystitis or prostatitis, while hematuria would raise suspicion for bladder neoplasm or calculus. Measurement of PSA can be considered to help evaluate the likelihood of prostate cancer, though the results are less specific in the setting of concomitant BPH.
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If a patient has mild acne (non-inflammatory comedones) what is the medication that is used first?
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Topical retinoids.
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If a patient has mild-moderate INFLAMMATORY acne topical retinoids are used, plus what other treatment?
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Topical antibiotics are added.
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What treatment is used if papular and inflammatory acne (moderate-to-severe inflammation) is present?
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ORAL ANTIBIOTICS.
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What medication is reserved for patients with nodulocystic and scarring acne?
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ORAL ISORETINOIN is reserved for patients with nodulocystic and scarring acne.
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Patients with rheumatoid arthritis and those who have joint damage are at increased risk of developing septic arthritis, particularly with Staph aureus. Inflammatory monoarthritis presents acutely with a red swollen joint and motion limited by pain; the differential diagnosis includes septic arthritis, crystal-induced arthritis, or trauma. If a patient in this category presents like this what is you next best step in management?
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Given its potential for joint destruction, septic arthritis should be considered the cause of inflammatory monoarthritis until proven otherwise. The next best step is treatment of septic arthritis, which requires prompt administration of IV antibiotics and adequate joint drainage to lessen the likelihood of joint destruction.
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For frostbite injuries, what is the best treatment?
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Rapid-rewarming with warm water; whenever frostbite of cold injuries are diagnosed, no attempt should be made to debride tissue initially. Rapid re-warming with dry heat (like a fan) is not effective for frostbite.
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Patients with severe aortic stenosis often have large left ventricular mass. In this situation what is the most likely pathophysiologic cause of anginal symptoms?
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The large left ventricular mass requires increased myocardial oxygen demand and can cause anginal pain. Accompanying prolonged myocardial contraction and impaired diastole, both of which reduce blood flow through the coronary arteries, exacerbate the situation.
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This condition may be congenital, but usually it occurs after trauma. Clinical signs include widened pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), and tachycardia. The extremities are typically flushed. The left ventricle hypertrophies, and the PMI is displaced to the left. EKG will show LVH. Patient has a history of a history of a knife injury. Diagnosis?
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Symptomatic AV fistula; shunting of a large amount of blood through the fistula increases cardiac preload and cardiac output. In patients with significant shunting, the oxygen requirements of the peripheral tissues are met by increasing the cardiac output; cardiac functions can occasionally decompensate over a period of time, and result in cardiac failure. Such patients are considered to have heart failure despite their higher cardiac output because the circulation is unable to meet the oxygen supply of the demand of the peripheral tissues.
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This condition typically presents in people (usually women) 20-45 years old. Patients experience rapid impairment of vision in one eye (or rarely both) and pain on eye movement. There are marked changes in color perception. Afferent pupillary defect and field loss occur, usually with central scotoma, with fundoscopy revealing a swollen disc. (*more common in MS) Diagnosis?
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OPTIC NEURITIS!!!
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Can hypoalbuminemia secondary to malnutrition cause bilateral lower extremity pitting edema???
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YES!!!
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Complicated GERD may manifest as dysphagia, odynophagia, weight loss, overt or occult bleeding, iron deficiency anemia, in addition to the typical symptoms of GERD (e.g. heartburn, regurgitation or sour/bitter taste). What is the next best step in management of a patient with evidence of complicated GERD or with GERD that fails to respond to empiric treatment? When is esophageal pH monitoring done?
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Esophagoscop, with the objective being to identify the underlying pathology (e.g. peptic strictures, gastritis), and biopsy is performed if indicated. Esophageal pH monitoring is done when the endoscopy is negative, or atypical symptoms are present.
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The history of normal skin at birth, with gradual progression to dry scaly skin, is typical of this condition; it can be hereditary or acquired. The skin is usually dry and rough with horny plates over the extensor surfaces of the limbs. In children, there may be relative sparing of the face and diaper area. The condition worsens in the winter because of increased dryness and sometimes is referred to as "lizard skin". Diagnosis?
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Icthyosis vulgaris.
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Thrombocytopenia without any other findings is the initial presentation of what infection, in up to 10% of patients? What screening test should be done?
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HIV!!!; an HIV antibody test is the first step in diagnosing the disease.
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A patient presents with history of recurrent oral ulcers, recurrent genital ulcers, anterior uveitis and a skin lesion that is probable for erythema nodosum (painful and nodular with areas of hyperpigmentation suggested by old healed nodules). Diagnosis?
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Behcet's syndrome; a multi-systemic inflammatory disease. This syndrome is more common in the Turkish, Asian, and MIddle Eastern population.
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This vaccine should be given every 10 years after the age of 18. A single booster is recommended between the ages of 19 and 64 years. Vaccine?
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Td; and a booster of Tdap.
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This vaccine should be given yearly to anyone over the age of 50. It should also be given to adults with chronic vasrdiovascular, pulmonary, hepatic, renal, or metabolic (e.g. diabetes) disease, immunosuppression, and pregnancy. Vaccine?
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Influenza.
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This vaccine should be given to all adults 65 years and older. Its should also be given to all adults with chronic cardiovascular, pulmonary, hepatic, renal, or metabolic (e.g. diabetes) disease, or immunosuppression. Persons vaccinated before age 65 need a booster in 5 years. Vaccine?
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Pneumococcal.
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What is the rare disease assumption in when talking about odds ratios and relative risks?
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Direct calculation of the relative risk is not possible in case-control studies, because the study design does not include following people over time. Nevertheless, the relative risk can sometimes be approximately equal to the odds ratio. If the prevalence of the disease is low, the exposure odds ratio approximates the relative risk. This statement is calle 'the rare disease assumption' and represents one of the fundamental epidemiologic concepts.
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What is the most common cause of secondary hypertension in children?
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Fibromuscular dysplasia; it is responsible for approximately 20% of all cases of renal hypertension. Physical exam reveals a hum or bruit in the costovertebral angle due to well developed collaterals.
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AAAs are usually asymptomatic and discovered incidentally. AAA rupture is a potentially life-threatening complication; therefore incidentally discovered aneurysms require close follow-up. What is the imaging modality of choice for AAAs?
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Abdominal Ultrasound, as it has nearly 100% sensitivity and specificity, facilitates measurements of aneurysm size, and can show the presence of any associated thrombus. Ultrasound is relatively inexpensive compared to CT or MRI and has the benefit of not requiring contrast administration.
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5% of chronic oral contraceptive users develop this complication, which is believed to be cause by an estrogen-mediated increase in the synthesis of angiotensinogen in the liver. It is important to recognize that oral contraceptives can be a potential cause of this condition in patients and simply discontinuing its use can correct the problem. Diagnosis?
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HYPERTENSION!!!
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pCO2 = 1.5[HCO3] + 8
What formula is this? |
WInter's Formula.
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What is Winter's Formula?
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pCO2 = 1.5[HCO3] + 8
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What is the next best step in management for a patient who is suspected of having acute prostatitis? Should urethral catheterization be used?
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Obtaining a mid-stream urine sample would be the most appropriate next step in order to help direct antibiotic therapy. Patents with prostatitis may complain of pain in the perineal region and tender, boggy prostate is often appreciated on physical examination. Urethral catheterization should be avoided in patients with acute prostatitis as there may be inflammation involving the urethra. In patients with acute prostatitis where urinary retention develops suprapubic catheterization of the bladder may be necessary.
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What are the three main medications used as first-line agents during cardiac complications of cocaine use such as ischemia and infarction?
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Benzodiazepines are the first-line therapy, along with aspirin, and nitrates in the treatment of cocaine-related cardiac ischemia. It allays the anxiety and reduces the hypertension and tachycardia that are associated. Aspirin retards thrombus formation, and nitrates being vasodilator, are beneficial for the cocaine-induced coronary artery vasoconstriction.
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High PaCO2 and low PaO2 levels are suggestive of this pathophysiological mechanism to acidosis, though an elevated PaCO2 alone, in the range of 50 to 80 mmHg, is sufficient to make the diagnosis. Diagnosis?
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Alveolar hypoventilation
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This is an eye infection of the episcleral tissue between the conjunctiva and sclera. Patients complain of an acute onset of mild to moderate discomfort, photophobia, and watery discharge. Examination reveals diffuse or localized bulbar conjunctival injection. Diagnosis?
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Episcleritis.
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This infection is an abscess located over the upper or lower eyelid. It is usually caused by Staph aureus. It appears as a localized red, tender swelling over the eyelid. Diagnosis?
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Hordeolum.
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This presents as lid discomfort. It is a chronic, granulomatous inflammation of the meibomian gland. It appears as a hard, painless lid nodule. Diagnosis?
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Chalazion.
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