Step 2Ck Internal Medicine

Front 1

Best treatment for ventricular tachy in a pt with stable BP?

Back 1

amidarone is drug of choice. lidocaine can also be used.

Front 2

What type of arrhythmias can be treated by Digoxin?

Back 2

atrial arrhythmias

Front 3

Tx for sustained ventricular tachy with hemodynamic compromise?

Back 3

Cardioversion

Front 4

What role does carotid massage play in ventricular tachy?

Back 4

None - useful for SUPRAventricular tachy (narrow complex)

Front 5

What kind of pulse is found in aortic regurg?

Back 5

bounding aka "water hammer"

Front 6

What causes a bounding or water hammer pulse in aortic regurg?

Back 6

AR is associated with an increased SV which produces an abrupt rise in the systolic BP and rapid distension of the peripheral arteries. Then during diastole, there is a regurg of blood back into the left ventricle, resulting in a low diastolic pressure and collapse of the peripheral arteries.

Front 7

Fixed splitting of S2 plus a midsystolic pulmonary flow murmur?

Back 7

ASD

Front 8

Why is lidocaine not used prophylactically in patients with acute coronary sundromes to prevent ventricular fibrillation?

Back 8

it increases the risk of asystole

Front 9

3 most common causes of aortic stenosis?

Back 9

senile calcific aortic stenosis, bicuspid aortic valve, and rheumatic heart disease.

S4 in aortic stenosis is common - atrial kick against a stiff left ventricle.

Front 10

When is a pt at risk for ACUTE pericarditis after an MI?

Back 10

first several days - diffuse ST elevations, esp with PR depressions are typical ECG findings.

Dressler syndrome is an immune-mediated pericarditis that can occur WEEKS to months after infarction.

Front 11

Common complication 3-7 days after an MI?

Back 11

ventricular free wall rupture - presents with rapid deterioration of the pt 2dry to pericardial tamponade -- pulseless electrical activity on ECG is common

OR

interventricular free wall rupture and papillary muscle rupture - presents with new onset systolic murmor

Front 12

common LATE complication of anterior wall MI?

Back 12

ventricular aneurysm - can occur days to months after the initial infarction.

will see persistent ST elevations on ECG. S/sx of CHF, ventricuar arrhythmias, mitral regur, and/or thrombus formation can be seen.

Front 13

MILD hypovolemia can cause syncope in what population of pts?

Back 13

elderly - they very poorly tolerate even what seems to be an insignificant loss of fluid - especially orthostatic syncope upon getting up in the morning.

BUN/Cr ratio is a useful indicator of dehydration.

Front 14

Treatment of choice for DRessler's syndrome?

Back 14

NSAIDS. Corticosteroids can be used in refractory cases or if NSAIDs are CI.

Anticoagulation should be avoided to prevent development of hemorrhagic pericardial effusion.

Front 15

Most likely artery that is occluded in acute inferior wall MI?

Back 15

Right coronary artery, especially if it is complicated by right ventricular infarction (hypotension) and bradycardia.

Front 16

LAD occlusion causes?

Back 16

anterior wall MI

Front 17

What can confirm a diagnosis of malignant hypertension?

Back 17

Presence of papilledema - always suspect malig HTN if very high BPs (>/= 200/140).

Pathologic change responsible for end-organ dmg is fibrinoid necrosis of small arterioles.

Front 18

leading cause of mitral stenosis worldwide?

Back 18

Rheumatic heart disease

The mitral stenosis classically presents later during pregnancy bc of the physiologically increased total blood volume. Pulmonary edema and atrial fib may also occur due to left atrial overload/enlargement.

Front 19

Pharmacologic management of variant (or Prinzmetal's angina)?

Back 19

calcium ch blockers and/or nitrates to prevent coronary vasoconstriction.

Non-selective beta blockers and aspirin should be avoided bc they can promote vasoconstriction. Aspirin may cause vasospasm via prostacyclin inhibition.

Front 20

Greatest risk factor for variant angina?

Back 20

smoking

Front 21

When does variant angina classically occur?

Back 21

at night and can be associated with transient ST elevation on ECG.

Front 22

PITTING edema vs. non-pitting edema?

Back 22

PITTING - due to increased movement of fluid from vascular space into interstitial space. Can be due to increased intravascular hydrostatic pressure (CHF, portal HTN), decreased plasma oncotic pressure (low albumin 2ndry to malnutrition, nephrotic sydnrome, cirrhosis), or increased capillary leak (burns, trauma, or infection).

non-pitting - due to lymphatic obstruction (lymphedema) or decreased lymphatic flow(myxedema from hypothyroidism)

Front 23

First step in treating pt with a WITNESSED cardiac arrest?

Back 23

defibrillation

if arrest is unwitnessed or greater than 4-5 minute lapse btn arrest and arrival of defibrillator, a 2-min trial of CPR should precede defibrillaiton.

Front 24

tx for first degree heart block?

Back 24

nothing - completely benign condition

Front 25

A stenotic mitral valve causes increased left atrial pressure which in turn gets transmitted to the pulmonary vasculature. What symptoms can this increase in pulm vascular pressure cause?

Back 25

exertional dyspnea, nocturnal cough, and hemoptysis (hemoptysis in particular should raise suspicion for mitral stenosis)

Front 26

how do nitrates reduce chest pain in angina pectoris?

Back 26

venodilation --> blood pools in systemic venous circulation --> decreases preload --> reduces ventricular volume and wall stress (stretch) --> decreased myocardial oxygen demand.

They also cause some ARTERIAL vasodilation with modest decrease in afterload and myocardial oxygen consumption but this is not main mechanism.

Front 27

thiazide diuretic may cause electrolyte disturbances causing sudden syncope without warning signs. this is caused by?

Back 27

ventricular arrhythmia - drug predisposis to this

Front 28

s/sx of coarctation of the aorta?

Back 28

majority of pts are asymptomatic - but common s/sx (when present) include headache, epistaxis, cold extremities, delayed femoral pulse, or HTN in the upper extremity. In adults, enlarged pulsatile collateral vessels may be palpated in the intercostal spaces anteriorly, in the axilla or in the interscapular area. Also, upper extremity may be preferentially well developed.

Front 29

Almost pathognomonic for coarctation of aorta?

Back 29

"3" sign -indentations of the aorta at the site of the coarctation and pre and post stenotic dilation along the left paramedian border.

Front 30

Patent ductus arteriosus is associated with?

Back 30

birth at high altitudes and maternal rubella infection.

Front 31

aortic aneurysms present with what s/sx?

Back 31

hoarseness, chest pain, dysphagia or a dry cough.

Front 32

When is surgery indicated for an aortic aneurysm?

Back 32

aneurysm > 6 cm in diameter, persistent pain, continued elevated BP or wide expansion of the aneurysm.

Front 33

Why do pts with severe aortic stenosis have anginal chest pain?

Back 33

due to increased myocardial oxygen demand 2dry to large left ventricular mass.

Front 34

When is clopidogrel (plus aspirin) indicated for 2ndry prevention in a cardiac patient?

Back 34

1) All patients with a UA/NSTEMI for at least 12 months (aspirin indefinitely)
2) post- PCI pts x 30 days for bare metal stents and 1 year for drug eluting stents. Drug eluting stents need a longer duration bc epithelialization occurs slowly.

Front 35

How long is LMWH usually given post-MI?

Back 35

first 48 hours typically

Front 36

Classic physical exam findings for cardiac tamponade?

Back 36

pulsus paradoxus and Beck's triad (hypotension, jugular venous distention, and muffled heart sounds)

pathophys: fluid fills in pericardial sac --> pressure riss above diastolic pressure of the ventricles --> ventricles less able to expand and accept venous return to the heart --> decreased preload, SV, and CO --> decrease in CO made worse by inspiration due to lower intrathoracic pressure --> more systemic venous blood return to right ventriclue --> intraventricular septum bows into the left vetricle causing further reduction of left ventricular filling

Front 37

Why can a dual upstroke be present in HOCM?

Back 37

occurs from midsystolic obstruction that develops as the heart contracts

Front 38

What maneuver worsens the murmur of HOCM?

Back 38

anything that decreases preload - valsava, standin g

Front 39

Elevated BNP levels and an audible S3 are both signs of _____?

Back 39

increased cardiac filling pressures due to volume overload.

Front 40

Most useful test to assess coronary RE-occlusion after an MI?

Back 40

CK-MB bc it returns to normal levesl within 1-2 days, while troponin T (genrally a more sensitive marker of cardiac injury) takes up to 10 days to return to normal after an MI.

Front 41

Tx for hemodynamically stable SUPRAventricular tachy?

Back 41

vagal maneuvers followed by adenosine and AV nodal blockers. adenosine decreases conduction through the AV node.

SVT should be suspected on ECG with a regular, narrow QRS complex tachy withOUT definite P waves.

Front 42

What should be suspected in otherwise young healthy pts who develp s/sx of CHF including paroxysmal nocturnal dyspnea, dyspnea on exertion, peripheral edema, hepatomegaly, cardiomegaly, bilateral pleural effusions,a nd a third heart sound?

Back 42

Dilated cardiomyopathy 2ndry to myocarditis should be high on the DDx. Coxsackie B virus is the most common cause.

Diagnosis is via echocardiogram which typically shows dilated ventricles and diffuse hypokinesia resulting in systolic dsyfunction (low EF).

Front 43

Most effective lifestyle intervention for reducing blood pressure?

Back 43

decreased consumption of alcohol. smoking cessation decreases a pt's risk of cardiovascular dz but does NOT improve blood pressure itself.

Front 44

First line drugs for tx of cocaine-related cardiac ischemia?

Back 44

benzodiazepines, nitrates, and aspirin - allays the anxiety and reduces the HTN and tachycardia

beta-blockers (Metoprolol) would be CI bc they aggravate cocaine-medited vasoCONStriction.

Front 45

How long should a pt with an episode of rheumatic fever receive antibiotic prophylaxis with penicllin to prevent further attacks?

Back 45

Treat until pt reaches age 18 to prevent repeat episodes which can worsen valvular function.

Front 46

Most common cause of secondary HTN?

Back 46

chronic oral contraceptive use - simply discontinuing its use can correct the problem

Front 47

Tx for third degree heartblock?

Back 47

pacemaker insertion

3rd degree or complete heart block is marked by complete indepenence of the P waves and QRS complexes.

Front 48

Tx for subacute bacterial endocarditis?

Back 48

empiric ABX until causative bacterium is identivied. Native valve bacterial endocardities is most commonly due to Streptococcus viridans, which is highly susceptible to IV penicillin G or IV ceftriaxone.

Front 49

Intensive retrosternal pain that radiates to the back of the chest along with normal ECG strongly suggests?

Back 49

aortic dissection - check BP in both arms and auscultate for diasolic murmur of aortic regurg. TEE is the preferred diagnostic tool (bc MRI and CT are time consuming) but before performing procedure, HTN should be controlled.

Front 50

How does adenosine have diagnostic value in a suspected supraventricular tachycardia?

Back 50

an SVT is usually terminated by adenosine whereas other tachycardias are simply slowed.

Front 51

Review of renin-angiotensin-aldosterone axis...

Back 51

renin is produced by the juxtaglomerular cells of the kidney in response to hypOperfusion. Renin cleaves angiotensinogen to agiotensin I. In turn, angiotensin I is converted into angiotensin II by ACE in the lungs. Angiotensin II is a potent vasoconstrictor. It also promotes vasopressin (ADH) release from the pituitary and aldosterone prodxn from the adrenal cortex. Aldosterone acts on the distal convoluted tubules and collecting ducts to promote sodium and water resorption (at the expense of potassium).

Front 52

In a patient with an MI who develops a cold leg, one should get an ECHO to rule out?

Back 52

thrombus in the left ventricle that may have embolized to the leg. An MI results in blood stasis in the akinetic part of the heart with resultant thrombus formation.

Front 53

typical presentation for bacillary angiomatosis?

Back 53

immunocompromised indvidual (e.g. AIDS, malignancy, undergoing chemo, organ transplant recipients) with non specific constitutional symptoms PLUS characteristic lesions of the skin and viscera (angioma-like blood vessel growths). This condition is caused by Bartonella henselae and Bartonella quintana. Antibiotic treatment causes lesion regression.

Front 54

What should be suspected in a pt that has areflexic weakness in the upper extremities and dissociated anesthesia (loss of pain and temp with preserved position and vibration) in a "cape" distribution?

Back 54

Syringomyelia - presence of a cavitary expansion of the spinal cord (known as a syringe) with destruction of the gray and white matter adjacent to and often communicating with the central canal. Most frequent site of involvement is the lower cervical or upper thoracic region. When syringes occur in the upper cervical cord and extend proximally to involve the medulla oblongata, the condition is called syringobulbia. Causes include congenital, trauma, inflammatory conditions,tumors, and idiopathic.

Front 55

Strongest influence on long-term prognosis following an ST-elevation MI?

Back 55

duration of time that passes before coronary blood flow is restored (via PTCA or fingrinolysis). Reperfusion injury can occur but benefits of reperfusion far outweigh the consequences of reperfusion injury.

Front 56

Pt that presents with painLESS sub acute monocular vision loss?

Back 56

DDx includes central retinal vein occlusion (CRVO) or central retinal artery occlusion (CRAO).

CRVO will show optic disk swelling, retinal hemorrhage, dilated veins, and cotton wool spots. CRAO shows pallor of the optic disk, a cherry red fovea, and boxcar segmentation of blood in the retinal VEINS.

Front 57

Most common histologic lesion of diabetic nephropathy?

Back 57

diffuse glomerulosclerosis but NODULAR glomerulosclerosis (with Kimmelstiel-Wilson nodules) is pathognomonic.

Dz progression can be slowed with strict glycemic control, treatment of HTN, and angiotensin axis blockade.

Front 58

What can cause insoluble crystal precipitation in the tubular lumen leading to acute renal failure 2dry to renal tubular obstruction?

Back 58

hyperuricemia from tumor lysis syndrome, indinavir, acyclovir, and sulfonamide therapy.

Inadequate hydration is a predisposing factor. Look for oliguria with elevated creatinine and BUN.

Front 59

Best initial test in a patient with suspected hepatocellular carcinoma (typically caused by chronic viral hepatitis or cirrhosis)?

Back 59

AFP which is frequently elevated in hepatocellular carcinoma but is NOT EXCLUDED by a normal AFP level. If AFP is elevated, imaging (CT or MRI) will be needed to detect the lesion. Biopsy may ultimately be necessary in many patients if a concerning lesion is found on imaging.

Note that ascites fluid cytology has a low yield for confirming diagnosis of hepatocellular carcinoma and generally not recommended.

Front 60

Leukocytosis, anemia, and increased number of mature granulocytic forms (eg. segmented neutrophils and band forms on peripheral blood) with low leukocyte alkaline phosphatase score should raise suspicion for?

Back 60

CML - typically seen after age 50. Presence of Philadelphia chromosome confirms dx.

The only other dzs that may cause a low leukocyte alkaline phosphatase are hypophosphatemia and paroxysmal nocturnal hemoglobinuria (PNH).

Front 61

Elevated leukocyte alkaline phosphatase is characteristic of?

Back 61

Leukemoid reaction

Front 62

tartrate resistant acid phosphatase is present in ?

Back 62

hairy cell eukemia

Front 63

Adult treatment panel 3 recommendation for CHD or CHD risk equivalent (such as DM or PAD)?

Back 63

Goal LDL < 100
Lifestyle modification @ >/= 100
Drug therapy @ >/= 130

Front 64

Adult treatment panel 3 recommendation for 2+ risk factors for coronary heart disease?

Back 64

Goal LDL < 130
Lifestyle modification @ >/= 130
Drug therapy @ >/= 160

Front 65

Adult treatment panel 3 recommendation for 0-1 risk factors for coronary heart disease?

Back 65

Goal LDL < 160
Lifestyle modification @ >/= 160
Drug therapy @ >/= 190

Front 66

Risk factors for coronary heart disease?

Back 66

men >/= 45
women >/= 55
HTN
cigarette smoking
HDL < 40
fam hx of premature CHD (male < 55, female <65)

Front 67

CHD risk equivalents?

Back 67

DM
symptomatic carotid artery dz
abdominal aortic aneurysm
peripheral artery dz
10-yr risk of CHD of 20% or higher

Front 68

Decreases triglyceride levels and increases HDL concentrations?

Back 68

Niacin - NOT considered first line for reducing LDL levels

Front 69

Most common cause of fatal sporadic encephalitis in the U.S.?

Back 69

Herpes encephalitis 2dry to HSV-1. Affects the temporal lobe of the brain and presents acutely (< 1 week) with focal neuro findings such as AMA, cranial nerve deficits, hemiparesis, dysphasia, aphasia, ataxia, or focal seizures. Fever is present in approx 90% of pts.

CSF analysis shows lymphocytic pleocytosis, increased number of erythrocytes (due to hemorrhagic destruction of the temporal lobe), and elevated protein levels. MRI is the preferred method of imaging as CT may be normal in up to 50% of pts. Focal EEG findings (prominent intermittent high amplitude slow waves) occur in > 70-80%.

PCR analysis of HSV DNA in the spinal fluid is the gold std of diagnosis.

Front 70

India ink preparation is used to detect?

Back 70

cryptococcal meningitis in immunocompromised patients.

Front 71

What may simulate an iron deficiency anemia (microcytic/hypochromic) but with iron studies that reveal ELEVATED serum iron levels and decreased TIBC?

Back 71

Sideroblastic anemia resulting from defective heme synthesis, most commonly due to pyridoxine-dependent impairment in early steps of protoporphyrin synthesis. Often caused by alcoholism or drugs such as isoniazid.

Microscopy reveals two gropus of RBCs ("dimorphic" RBC population) - microcytic and hypochromic.

Front 72

Pt with signs of ischemia (parasthesia, change in temperature, and non-detectable radial arterial pulsations) BUT NORMAL neuro exam is suspicious for?

Back 72

embolus of the upper extremity arterial bed, specifically the radial artery. Immediate anticoagulation with heparin and surgical intervention (i.e. embolectomy) are crucial bc can lead to tissue death and amputation if not effectively treated in hours.

Front 73

Diagnostic study of choice in multiple sclerosis?

Back 73

MRI which shows white matter dz

Front 74

Reliable screening test for hemochromatosis?

Back 74

Percent transferrin saturation (greater than 45%) and serum ferritin level (greater than 1000 microg/L).

Front 75

Complications of hemachromatosis?

Back 75

chronic liver disease or cirrhosis, hepatocellular carcinoma, diabetes, pancreatic insufficiency, skin pigmentation

Front 76

First step in management of acute pyelonephritis?

Back 76

Blood and urine cultures FIRST, followed by IV antibiotics.

Acute pyelonephritis can lead to gram-negative sepsis so it is important to determine the causative agent, evaluate for bacteremia, and check for drug resistant organisms.

Fluoroquinolones or ceftriaxones can be used for treatment.

Front 77

When does acute pyelonephritis become complicated?

Back 77

progression to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis. Typically occurs in pts with DM, kidney stones, or other urologic abnormalities.

Front 78

When is CT or ultrasound indicated in the mgmt of acute pyelo?

Back 78

if fever or clinical symptoms persist after 48-72 hours of appropriate antimicrobial therapy to r/o obstruction, abscess, or other complications.

Front 79

what is allergic conjunctivitis?

Back 79

an acute hypersensitivity reaction caused by environmental exposure to allergens. Characterized by intense itching, hyperemia, tearing, conjunctival edema, and eyelid edema but NO vision disturbances. Usually a positive family or personal history of asthma, seasonal rhinitis, atopic dermatitis, food allergies, or urticaria. Condition usually subsides wi 24 hours even wo treatment. Topical antihistamines, artificial tears, and cool compresses can help.

Front 80

What is atopic keratoconjunctivitis?

Back 80

SEVERE form of ocular allergy with itching, tearing, THICK mucus d/c, photophobia, and blurred vision.

Front 81

What is blepharitis?

Back 81

chronic inflammatory condition involving lid margins bilaterally. Crusty d/c is seen clinging to lashes in ANTERIOR blepharitis whereas hyperemic lid margins with telangiectasias are seen in POSTERIOR blepharitis.

Front 82

What is dacrocystitis?

Back 82

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.

Front 83

Classic presentation of Guillain-Barre syndrome?

Back 83

ascending paralysis, areflexia and sensory changes 3-4 wks after a URI or gastroenteritis, PLUS albumino-cytologic dissociation (elevated protein despite normal cell count). Also can have cranial nerve paralysis and autonomic dysfunction.

Front 84

Tx for Guillan-Barre syndrome?

Back 84

IV immunoglobulin and plasmapheresis.

Front 85

Major signs/sx for Waldenstrom's macroglobulinemia:

Back 85

1) increased size of the spleen, liver, and some lymph nodes
2) Tiredness, usually due to anemia
3) Tendency to bleed/bruise easily
4) night sweats
5) headache and dizziness
6) various visual problems (opthalmoscopy may show dilated, segmented, and tortuous retinal veins)
7) pain and numbness in the extremities due to a predominantly demyelinating sensorimotor neuropathy.

Front 86

Diagnostic clues for Waldenstrom's macroglobulinemia?

Back 86

an IgM spike on electrophoresis which causes hyperviscosity of the blood (seen for example by retinal vein engorgement).

Hint 86

Pts with multiple myeloma may present with similar symptoms but the involved immunoglobulins are usually IgG or IgA. Further, they rarely have hyperviscosity sindromes such as retinal vein engorgement.

Front 87

Management of newly diagnosed iron deficiency anemia in an elderly pt?

Back 87

Secondary to chronic GI blood loss until proven otherwise. Colonoscopy should be next step in mgmt. A single negative occult blood test does not exclude the possiblity of GI bleeding.

Front 88

Clinical features of interstitial nephritis?

Back 88

fever, rash, and arthralgias. May be accompanied by peripheral eosinophilia, hematuria, sterile pyuria, eosinophiluria, and urine WBC casts.

70% of cases are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol. Discontinuing drug is the treatment.

Front 89

What drugs provide a survival benefit in CHF pts?

Back 89

ACE-I, ARBs, beta-blockers, and spironolactones.

Digoxin and loop diuretics (furosemide) provide symptomatic relief but no survival benefit.

Front 90

Warfarin inhibits?

Back 90

synthesis of Vit K dependent factors II, VII, IX, X, protein C and protein S.

Front 91

Antibiotic choice for prophylaxis/treatment of infections caused by human or dog bites?

Back 91

Amoxicillin-clavulanate (covers polymicrobial infections)

Front 92

Main mechanism of kidney damage in SLE?

Back 92

immune-complex mediated which activates complement leading to low serum C3.

Front 93

Mechanism of kidney damage in post-strep glomerulonephritis?

Back 93

immune-complex mediated which activates complement leading to low serum C3.

Front 94

Management of spontaneous subconjunctival hemorrhage?

Back 94

A benign finding that requires no treatment. Minor bruising that may be due to simple trauma from rubbing eyes, violent coughing spells, or hypertensive episodes. Usually disppears in 24-28 hours.

Front 95

Role of dihydropyridine calcium channel blockers (such as nifedipine) in ACS pts?

Back 95

contraindicated bc can worsen cardiac ischemia via peripheral vasodilation and reflex tachy.

NON-dihydropyridines (diltiazem and verapamil) can be used in STEMI pts with ongoing ischemia after beta-blockers have been administered but even then, they do not improve mortality.

Front 96

Classic findings of erysipelas?

Back 96

sharply demarcated, erythematous, edematous, tender skin lesion with raised borders. Legs are most frequently-involved site.

Most frequently implicated organism is group A beta-hemolytic streptococcus (S. pyogenes).

Front 97

Population most at risk of developing SLE?

Back 97

young, african-american women aged 20-40 years.

Front 98

common SLE s/sx?

Back 98

fatigue, painLESS oral ulcers, non-deforming arthritis (commonly affecting MCP/PIP hand joints) in 90%, low grade fever, weight loss, malar or discoid rash, hematologic abnormalities (thrombocytopenia and leukopenia), serositis, and proteinuria.

Front 99

What pathological mechanism underlies exophthalmos of Graves disease?

Back 99

1) sympathetic nervous system mediated lid retraction.
2) autoimmune attack on extraocular muscles wherein lymphocytes infiltrate the EOMs and orbital fat causing edema, proliferation of local interstitial fibroblasts, and deposition of glycosaminoglycans. End result is fibrosis and edema with EOM enlargement that pushes the lobe outward.

May be bilateral or unilateral!

Eye "grittiness" or "sandiness" and excessive tearing may occur due to corneal exposure and keratitis resulting from inability to completely close eyelids over protruding eyeball.

Front 100

First step in management of a diabetic ulcer?

Back 100

Proper wound care and debridement followed by antibiotics.

Front 101

Most common nephropathy associated with carcinoma?

Back 101

Membranous nephropathy; however, minimal change disease is a well-known complication of Hodgkin's lymphoma.

Front 102

Acanthosis nigricans is associated with?

Back 102

1) insulin resistant states such as DM, acromegaly, obesity, and others
2) GI (or GU) malignancies

Front 103

Reversible risk factors for premature atrial contractions?

Back 103

tobacco and alcohol. beta-blockers are often helpful in pts who are symptomatic

Front 104

Suspect what if there are signs of hypopituitarism plus headaches and bitemporal blindness?

Back 104

craniopharyngiomas (benign suprasellar tumors).

In chidlren, retarded growth is the most prominent feature 2dry to low growth hormone and thyroid hormone. Sexual dysfunction is more prominent in adults. Women can present with amenorrhea. Tumor compresses optic chiasm causing bitemporal blindess. Headaches are due to an increased intracranial pressure.

TX is surgery and/or radiotherapy.

Front 105

Tremor that is somewhat suppressed at rest and exacerbated toward the end of a goal-directed movement?

Back 105

essential tremor-first line tx is propranalol especially if the pt is hypertensive. Other possibilities include anticonvulsants such as primidone and topiramate.

Front 106

Tremor that is worst at rest and improves with intentional movement?

Back 106

Resting tremor associated with Parkinson's.

Front 107

Most common malignancy of the liver?

Back 107

Metastasis from another primary source

Front 108

Most common cause of hydatid cysts of the liver?

Back 108

Cystic echinococcosis is cuased by the tapeworm Echinococcus granulosus mostly in immigrants or pts that live in the SW region of the country and are exposed to SHEEP and DOGS. Microscopic exam reveals encapsulated and calcified cyst that contains fluid and budding cells.

Front 109

alpha feto protein is commonly elevated in which liver dz?

Back 109

hepatocellular carcinoma

Front 110

Suspect what if there is a solitary epithelial tumor of the liver (usually in the right hepatic lobe) in a middle-aged woman with a lengthy hx of oral contraceptive usage?

Back 110

hepatic adenoma (benign condition)

Front 111

Neoplasm of the liver characterized by vascular spaces that are lined with malignant cells?

Back 111

hepatic angiosarcoma - rare neoplasm more common in older men exposed to toxins such as vinal chloride gas, arsenic compounds, and thorium oxide.

Front 112

vomitus gastric contents are rich in?

Back 112

hydrogen, chloride, and potassium

Front 113

Remember what about heterophile antibodies used to dx infectious mono?

Back 113

very sensitive and specific but may be negative early in illness.

Front 114

Mechanism of hypercalcemia in pts with tumors that are metastatic to bone?

Back 114

local osteolysis by production of CYTOKINES such as IL-1 and tumor necrosis factor (TNF).

Front 115

Pathogenesis of chronic cough 2ndry to ACE-I?

Back 115

Related to an accumulation of the inflammatory or proinflammatory mediators bradykinin, substance P, thromboxanes, and prostaglandins.

Front 116

In mechanical ventilation, pO2 provides a measure of oxygenation and is influenced by _______ and ________ while pCO2 provides a measure of ventilation and is affected mainly by ________ and ________.

Back 116

pO2: FiO2 and PEEP levels

pCO2: Respiratory rate and tidal volume.

Hint 116

Mechanical ventilation improves oxygenation by providing an increased fraction of inspired oxygen (FiO2) and by providing PEEP to prevent alveolar collapse.

Front 117

Typical goal FiO2?

Back 117

Initially, pts are usually given high FiO2 (~ 80% or 0.8), pending the results of the first blood gas analysis. Based on results, FiO2 should be decreased to prevent oxygen toxicity; typically below 50-60% is desirable. Goal is to maintain paO2 >/= 60!! PEEP can also be adjusted to increase/decrease the number of alveoli available for gas exchange and maintain adequate oxygenation.

Front 118

Criterion for initiating home oxygen in COPD patients?

Back 118

PaO2 < 55 mmHg or SaO2 < 88%.

Pts with signs of pulmonary htn or hematocrit > 55% should be started on home oxygen when the PaO2 < 60 mmHg.

The dose of oxygen should be titrated such that SaO2 is maintained at >90% during sleep, normal waking hours, and at rest. Survival benefits are significant when used for a minimum of 15 hours per day.

Front 119

Acidosis accompanied by hypercarbia (elevated pCO2) and a normal/elevated serum bicarb is diagnostic of a?

Back 119

respiratory acidosis (often caused by hypOventilation)

Note: post-ictal state can cause apnea/hypoapnea during prologned seizures or an aspiration event.

Front 120

Pathogenesis of aspirin sensitivity syndrome?

Back 120

a 'psuedo-allergic' reaction due to prostaglandin/leukotriene misbalance. Aspirin is a cyclooxygenase inhibitor --> arachidonate diverges from blocked COXs to a 5-lipoxygenase pathway --> accumulation of leukotrienes and changed prostaglandin/leukotriene balance triggers characteristic reactions (bronchoconstriction, polyp formation).

Tx includes avoidance of NSAIDs and the use of leukotriene receptor ANTagonists (drug of choice).

Hint 120

Very high yield!

Front 121

Common cause of upper lobe cavitary lung lesions in immigrant patients?

Back 121

TB

Front 122

Recommended therapy for an acute bacterial exacerbation of COPD?

Back 122

supplemental oxygen, inhaled bronchodilators (beta-2 agonests or anticholinergics such as ipratropium), broad-spectrum ABX, a 2-week corticosteroid taper, and smoking cessation.

Care must be taken with supplemental oxygen bc it can suprress the hypoxia-fueled respiratory drive in COPD pts.

Front 123

An important cause of pneumonia in HIV/AIDS patients?

Back 123

Pneumocystis jiroveci (carinii) pneumonia - hypoxia occurs 2ndry to alveolar and interstitial inflammation causing areas of V/Q mismatch. This manifests as an increase in the alveolar-arterial oxygen gradient.

Front 124

Symptoms that help distinguish Legionella from other causes of community acquired pneumonia?

Back 124

1) high-grade vever
2) GI symptoms
3) confusion

Front 125

What will be a common finding on sputum gram stain for Legionella pneumophila?

Back 125

Many neutrophils but no organisms bc it is a Gram-negative rod that stains poorly and is primarily intracellular.

Hint 125

Commonly spread by cooling towers and water supplies. Travel-associated infection is well-documented.

Front 126

Diagnosis and treatment of Legionella pneumophila CAP?

Back 126

Dx is confirmed by urine antigen testing or culture on charcoal agar. Tx with azithromycin or levofloxacin.

Front 127

NEW clubbin in a pt with COPD often indicates?

Back 127

lung cancer - interestingly finger clubbing is RARELY a feature of COPD.

Front 128

Alveolar hypoventilation (as in COPD exacerbation) can cause?

Back 128

confusion, somnolence, coma, and tonic-clonic seizures. Sedatives should be avoided in these pts as they can exacerbate alveolar hypoventilation.

Front 129

Only two modalities shown to decrease mortality in COPD?

Back 129

home oxygen therapy and smoking cessation

Front 130

Non-cardiogenic pulmonary edema aka ARDS can develop in what settings?

Back 130

sepsis, severe bleeding, pneumonia, toxic ingestion, or burns when release of inflammatory mediators cause increased alveolar capillary permeability and resultant pulmonary edema.

Front 131

How can cardiogenic pulmonary edema be distinguished from non-cardiogenic?

Back 131

Measurement of pulmonary capillary wedge pressure (PCWP).

PCWP > 18 mmHg -- pulmonary edema 2dry to impaired left ventricular fxn.

PCWP < 18 mmHg -- NON-cardiogenic etiology

Front 132

Non-invasive positive pressure ventilation (NIPPV) should be tried before intubation and mechanical ventilation in a pt with respiratory distress because?

Back 132

Better alveolar ventilation and less fiatigue of respiratory muscles.

Recommended in pts with a pH < 7.35 or PaCO2 > 45 mmHg or respiratory rate > 25/min.

Front 133

When is non-invasive positive pressure ventilation contraindicated?

Back 133

pts who are septic, hypotensive, or dysrhythmic.

Front 134

Characteristic change in FEV1/FVC in COPD patients versus restrictive lung dz?

Back 134

decreased in COPD due to reduction of mainly FEV1.

normal ratio in restrictive lung dz.

Front 135

DLCO (diffusion capacity) may help distinguish between what two COPD entities?

Back 135

it is decreased in emphysema and normal in chronic bronchitis

Front 136

Suspect what with presence of a mobile cavitary mass (crescent radiolucency next to a rounded mass) in the lung which presents with intermittent hemoptysis?

Back 136

Aspergilloma - cavitations are due to destruction of underlying pulmonary parenchyma. Mobile mass is due to debris and hyphae coalescing to form a fungus ball.

Front 137

Number one cause of chronic cough in nonsmokers?

Back 137

postnasal drip

Front 138

Most specific test available for GERD?

Back 138

24-hour pH recording - usually used in pts with chest pain or chronic cough when esophagoscopy is negative.

Front 139

Suspect what in COPD pts with catastrophic worsening of their respiratory symptoms?

Back 139

spontaneous secondary pneumothorax - destruction of alveolar sacs and formation of large airspaces (generally in the UPPER lobes) are predisposing factors.

Front 140

In addition to panlobular emphysema, pts with alpha-1 antitrypsin deficiency are also at risk for _________?

Back 140

liver disease

note: AAT is an enzyme that counteracts NEUTROPHIL ELASTASE. Uninhibited elastase causes bullous changes of the lungs.

Front 141

Goal INR in pts with prosthetic heart valves?

Back 141

2.5-3.5

Front 142

how long should a pt with a VTE be treated with oral anticoagulation?

Back 142

At least 3 months if there is a reversible risk factor and for 6-12 months in pts with idiopathic DVT.

Front 143

The proximal deep veins include?

Back 143

iliac, femoral and popliteal

Front 144

Potential therapies for patients with obesity hypoventilation syndrome?

Back 144

weight loss, ventilator support, oxygen therapy and progestins (a respiratory stimulant).

Front 145

cause of obesity hypoventilation sydrome aka Pickwickian sydrome?

Back 145

decreased lung compliance

Front 146

Suspect what if a loculated, abnormally contured effusion with adjacent pulmonary consolidation is seen on CXR?

Back 146

empyema, an intrapleural collection of pus - most commonly due to bacterial seeding from an untreated pneumonia.

Often unrepsonsive to antibiotics bc infection progresses to a mixed aerobic and anaerobic bacterial population.

Front 147

How can bronchiectasis be identified on CT?

Back 147

presence of dilated bronchi with thickened walls. Hemoptysis, sometimes massive to the point of requiring bronchial artery emoblization is a potential complication.

Front 148

Treat an ANaerobic lung infection (suspected due to foul-smelling sputum) with what ABX?

Back 148

Clindamycin

Front 149

Common responsible antigens in hypersensitivity pneumonitis?

Back 149

aerosolized bird droppings ("bird facier's lung") and molds associated with farming ("farmer's lung")

Front 150

Typical presentation of hypersensitivity pneumonitis?

Back 150

acute episodes of cough, breathlessness, fever, and malaise that occur within 4-6 hours of antigenic exposure. Chronic exposure may cause weight loss, clubbing, and "honeycombing" of the lung. Management is avoidance of the responsible antigen.

Front 151

In pneumonia pts, placing the consolidated lung segment in a dependent position can increase right-to-left shunt. Why?

Back 151

Alveoli of consolidated lung segments 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. These positions decrease the patient's oxygen saturation levels which is the same theory as an increased R-to-L shunt.

Front 152

Mainstay therapy for ARDS?

Back 152

Mechanical ventilation with LOW tidal volumes and PEEP. Levels up to 15 of PEEP may be necessary in ARDS pts.

Note: potential complications of PEEP include barotrauma and tension pneumothorax.

Front 153

What may help distinguish asthma from COPD?

Back 153

FEV1 measurement before and after bronchodilator treatment - demonstrates reversibility if greater than 15% improvement of FEV1 is seen. Reversibility is more consistent with asthma; however a certain subset of pts with COPD also show positive bronchodilator response indicating an overlap of pathophysiology may exist.

Front 154

Presentation of blastomycosis?

Back 154

pulmonary and CXR findings similar to TB and histoplasmosis however systemic blastomycosis may cause skin ulcerations and lytic bone lesions.

Note: found endemically in the Great Lakes, Mississippi and Ohio River basins. Wisconsin has the HIGHEST rate of infection.

Front 155

Coccidiodomycosis is endemic to what part of the US?

Back 155

Southwestern

Causes fungal infection of the lungs that can lead to fever, cough, and night sweats. X-pulmonary manifestations include skin, skeleton, and MENINGES.

Front 156

Definitive diagnostic test for bronchiectasis?

Back 156

high-resolution CT scan

Front 157

Suspect what in a pt with an asymptomatic pulmonary nodule that resides in Mississippi?

Back 157

Histoplasma capsulatum - endemic to Mississippi and Ohio River valleys and Central America. Found in soil with a high concentration of bird or bat guano droppings.

Note: chronic cavitary pulmonary histoplasmosis (which is a fatal form) usually develps in older COPD pts. Disseminated histoplasmosis is seen in immunocompromised pts.

Front 158

Bacteria commonly responsible for acute exacerbation of COPD?

Back 158

S. pneumoniae, H. influenza, and M. catarrhalis. All pts suspected with a bacterial pneumonia should have a CXR as the first step and then ABX wo waiting for sputum gram stain or cultures.

Front 159

How long before Warfarin becomes therapeutic in treatment of a VTE?

Back 159

4-5 days which is why concurrent heparin for 5 days should be used.

Front 160

Drugs of choice for in-patient treatment of community acquired pneumonia?

Back 160

newer antipneumoccocal quinolones like levofloxacin or moxifloxacin.

For outpatient therapy, either azithromycin or doxycyline can be used.

Front 161

What is an important interaction of ciprofloxacin and erythromycin with theophylline?

Back 161

decreases theophylline clearance and raises plasma concentration with possibility of theophylline toxicity. Toxicity manifests as CNS timulation (headache, insomnia), GI disturbance (N/V), and cardiac toxicity (arrhythmia). Mechanisms responsible for toxicity may include phosphodiesterase inhibition, adenosine antagonism, and stimulation of epinephrine.

Front 162

Typical FEV1/FVC ratio in COPD?

Back 162

less than 0.7

Front 163

Suspect what with asymmetric breath sounds immediately after intubation?

Back 163

Right mainstem bronchus intubation - a relatively common complication of endotracheal intubation. Ideally the tip of the endotracheal tube should be between the vocal cords and the carina. CXR confirms diagnosis and slight withdrawal of the tube resolves the complication.

Front 164

Left-sided endocarditis commonly sends septic emoli to where?

Back 164

regions rich in blood supply such as the brain, kidneys, liver, and spleen.

Front 165

Drug of choice in a pt who presents with stable angina AND hypertension?

Back 165

beta-blocker - increases the threshold for the development of an anginal episode and controls the hypertension. They are also believed to be cardioprotective bc they decrease the sympathetic output to the heart.

Front 166

What makes a test reliabile?

Back 166

similar results on repeat measurements. reliability is maximal when random error is minimal.

Front 167

What makes a test valid or accurate?

Back 167

The test's ability to measure what it is supposed to measure. To determine validity, results must be compared to those obtained from the gold standard test.

Front 168

When should a patient be screened for bladder cancer?

Back 168

never due to its relatively low incidence and poor positive predictive value.

Front 169

The two phases involved in the pathogenesis of metabolic alkalosis?

Back 169

generation phase - vomiting results in the loss of gastric fluids high in HCl, NaCl, and water. The loss of hydrogen ions as HCl results in unbalanced retention of HCO3- leading to a metabolic alkalosis.

maintenance phase - volume loss in the vomitus causes a decrease in the ECV volume leading to decreased renal perfusion pressure. The kidneys respond by increasing activation of the renin-angiotensin-aldosterone system. Aldosterone promotes retention of water at the expense of H+ and K+ loss in the urine. This action of aldosterone is what causes the hypokalemia and a contraction alkalosis.

First step in management - restoration of the ECF volume with IV normal saline and potassium.

Front 170

Possible mechanism of adverse effects such as myopathy of statins?

Back 170

decreased synthesis of products unrelated to cholesterol products such as reduced CoQ10 production.

Front 171

Mechanism of action of statin?

Back 171

inhibits HMG-CoA reductase which is the rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate.

Front 172

When is an AIDS pt at risk for CMV retinitis?

Back 172

When CD4 count falls below 50. Pts may be asymptomatic with characteristic fundoscopic findings of yellow-white patches of retinal opacification and hemorrhages. Tx is ganciclovir or foscarnet.

Front 173

Suspect what if there is necrosis involving the inner layers of the retina that appear as white, fluffy lesions surrounded by retinal edema and vitritis?

Back 173

ocular toxoplasmosis in an immunocompromised host. More than 50% will also have encephalitis.

Front 174

Suspect what in an older pt that presents with fever, malaise, and a burning/itching sensation of the periorbital region with examination revealing a vesicular rash in the distribution of the cutaneous branch of the first divison of the trigeminal nerve?

Back 174

Herpes zoster opthalmicus caused by varicella-zoster. Usually in the elderly but may also be a presenting sign in HIV pts that predict increased risk of progression to AIDS.

Front 175

A saw-tooth pattern of P waves that do not all conduct QRS complexes?

Back 175

atrial flutter due to a re-entrant rhythm within the atria. A 2:1, 3:1, or 4:1 heart block is often seen.

Front 176

A P-wave that is morphologically distinct from those originating in the sinus node; will also occur prematurely and may not conduct to the ventricles?

Back 176

atrial ectopy

Front 177

Suspect what in a pt with diffuse telangiectasias, recurrent severe epistaxis, and widespread AV malformations in the mucous membranes, skin, GI tract or even the liver, brain, and lung?

Back 177

Osler-Weber-Rendu sydrome aka hereditary telangiectasia.

Note: AVMs in the lungs can shunt blood from the right to the left side of the heart causing chronic hypoxemia and a reactive polycythemia. They can also present as massive hemoptysis.

Front 178

The use of anti-estrogen, tamoxifen, reduces the risk of recurrence of breast cancer from the original site or a new breast site, but increases the risk of ________, _______, and _______?

Back 178

endometrial cancer, uterine sarcoma and venous thrombosis.

Tamoxifen has a mixed agonist and antagonist activity.

Front 179

Diarrhea due to Vibrio parahaemolyticus is usually transmitted by the ingestion of ?

Back 179

seafood including shrimp, crab, and raw oysters

Front 180

Post-splenectomy pts are at increased risk for sepsis from encapsulated organisms due?

Back 180

impaired antibody-mediated opsonization in phagocytosis - antibodies produced by germinal center plasma cells enter the systemic circulation to bind specific antigens and facilitate phagocytosis via opsonization which is not possible in asplenic pts.

Front 181

Fever every 48 hours occurs with what type of malaria?

Back 181

P. vivax and P. ovale

Front 182

Fever every 72 hours occurs with what type of malaria?

Back 182

P. malariae

Front 183

Type of malaria with no periodicity?

Back 183

P. faciparum - most malaria deaths are due to faciparam malaria

Front 184

"Smudge cells" are characteristically seen in?

Back 184

CLL - a disease of mostly older patients. Pts are often asymptomatic and diagnosed due to incidental finding of lymphocytosis with a peripheral blood fil showing small, mature-appearing lymphocytes. Symptomatic pateints usually c/o lymphadenopathy.

Front 185

What indicates a poor prognosis in CLL?

Back 185

thrombocytopenia

Front 186

Chronology of disease progression in measles caused by Paramyxovirus?

Back 186

1) exposure to the virus transmitted via respiratory droplets.
2) Prodrome of cough, coryza, and conjunctivitis after 10 days
3) Koplik's spots appear ~48 hours BEFORE skin rash and slowly fade once the rash appears.
4) Rash is initially over the face and then spreads to cover trunk and extremeties.

Koplik's spots are red spots with bluish specks over the buccal mucosa opposite the premolar tooth.

Hint 186

Complications are pneumonia, Vit A deficiency, and bronchiectasis. Late complications include immunosuppression and subacute sclerosing panencephalitis.

Front 187

What type of thyroid cancer has the propensity for early hematogenous spread to the lung, brain, and bones?

Back 187

Follicular thyroid cancers - they can be differentiated from follicular adenomas by histopathological demonstration of invasion of the capsule and blood vessels.

Front 188

Most common thyroid malignancy?

Back 188

Papillary throid cancer characterized by psammoma bodies. Fine needle aspiration biopsy reveals large cells with ground glass cytoplasm, and pale nuclei with inclusion bodies and central grooving.

Front 189

Prognosis of papillary thyroid cancer?

Back 189

excellent even in the presence of metastasis

Front 190

sensory and reflex abnormalities on PE generally indicate?

Back 190

neuropathies due to peripheral nerve problems

Front 191

What should be suspected with absent/diminished reflexes at rest but improved muscular strength with repetitive tasks?

Back 191

PREsynaptic membrane damage, i.e. Lambert-Eaton syndrome

Front 192

paraplegia/quadriplegia with sensory abnormalities and urinary retention/incontinence on PE generally indicates?

Back 192

some type of myelopathy originating from damage to the spinal cord

Front 193

Even with therapeutic range INRs, there is significant risk of _______ with warfarin treatment?

Back 193

Retroperitoneal hematoma - should be suspected with back pain and hemodynamic compromise. Dx with an abdominal CT.

Front 194

DOC for trigeminal neuralgia?

Back 194

carbamazepine - effective in approx 80% of cases.

Note: Risk of aplastic anemia; therefore routine CBC should be included in follow up management.

Front 195

Tx for cluster headaches?

Back 195

Sumatriptan and high-flow oxygen

Front 196

Untreated hyperthyroid pts are at risk for?

Back 196

Rapid bone loss resulting from increased osteoclastic activity (from direct effects of the thyroid hormones) AND cardiac tachyarrhythmias including A-fib.

Front 197

Toxic adenomas causing hyperthyroidism do not cause proptosis as in Grave's disease bc?

Back 197

there is no autoimmune process underlying the disease

Front 198

Glucocorticoids cause what classic changes on blood cells?

Back 198

1) Leukocytosis due to neutrophilia
2) Diminished eosinophils
3) Lymphopenia

Front 199

DOC for treatment of myasthenia gravis?

Back 199

oral anticholinesterase such as pyridostigmine or neostigmine. Atropine (anticholinergic agent) can be used to prevent muscarinic side effects of anti-ACh therapy.

Note: edrophonium can be used to diagnose MG but is no longer used

Front 200

What is a complication that can arise in pts requiring multiple blood transusions or immediately after surgery that manifests as hyperactive deep tendon reflexes, muscle cramps, and sometimes convusions?

Back 200

hypOcalcemia resulting from volume expansion and hypOaluminemia PLUS decreased IONIZED calcium due to citrate binding.

Note: severe hypOmagnesemia may mimic hypocalcemia bc it causes decreased PTH secretion and decreased peripheral responsiveness to PTH.

Front 201

When is aspirin indicated as the ONLY antithrombotic therap in a pt with atrial fibrillation?

Back 201

IN an otherwishe healthy pt with "lone" atrial fibrillation in the absence of other risk factors for stroke (CHADS2).

Front 202

Indications for thyroid function tests?

Back 202

1) hyperlipidemia, esp high LDL
2) unexplained hypOnatremia
3) elevated serum muscle enzymes

Front 203

Drugs of choice for treating/preventing chemo-induced N/V?

Back 203

serotonin ANTagonists that block 5HT3 receptors such as ondansetron. Corticosteroids are sometimes added to the regimen for better prophylaxis.

Front 204

A rare malignancy that often arises in Hispanic and Southwestern Native American females with a hx of gallstones?

Back 204

Gallbladder carcinoma - typically diagnosed after cholecystectomy. If discovered while still confined to the lamina propria of the gallbladder, a simple cholecystectomy results in a cure rate of 73-100% and is considered sufficient treatment.

Front 205

Negative predictive value varies with?

Back 205

pretest probability of a dz - a pt with high probability of having a dz will have a low NPV whereas a pt with low probability of having a dz will have a high NPV.

Front 206

Known side effects of anti-tubercular therapy?

Back 206

peripheral neuropathy due to pyridoxine deficiency (Vit B6) and hepatitis

Front 207

Light's criteria to distinguish an exudative pleural effusion from one that is transudative:

Back 207

1) pleural fluid protein/serum protein ration > 0.5
2) pleural fluid LDH/serum LDH ratio > 0.6
3) pleural fluid LDH greater than 2/3 of the upper limit of normal for serum LDH

Front 208

How to determine if a pleural effusion is complicated?

Back 208

Complicated fluids have:
1) a positive gram stain or cultures
2) pH < 7.2
3) glucose level < 60 mg/dL

Complicated effusions require a chest tube drainage.

Front 209

Prophylaxis for a cluster headache?

Back 209

prophylaxis is key to mgmt and includes verapamil, lithium, and ergotamine. Tx of acute attacks is inhalation of 100% oxygen and subcutaneous sumatriptan.

Front 210

Tx for acute exacerbations of MS?

Back 210

corticosteroids; beta-interferon or glatiramer acetate is used to decrease the frequency of exacerbations.

Front 211

Evaluation for diarrhea in HIV-infected pts should include?

Back 211

stool culture, examination for ova and parasites, and test for C. difficile toxin.

Front 212

Suspect what in a pt over 50 years old with pain and stiffness in the neck, shoulders, and pelvic girdle with an elevated ESR and morning stiffness lasting OVER 1 hour?

Back 212

polymyalgia rheumatica - treatment when NOT associated with giant cell arteritis is low-dose prednisone.

Note: pts indicate that pain is in the soft tissues and not the joints.

Front 213

Characteristic findings in brain death?

Back 213

ABSENT cortical and brain stem functions such as pupillary light rxn, heart acceleration after atropine injection, or spontaneous respiration.

The spinal cord may still be functioning; terhefore, deep tendon reflexes may be present.

Front 214

Management of pts with probable benign prostatic hyperplasia based on hx and rectal exam?

Back 214

urinalysis and serum creatinine to assess for infection, obstruction, or hematuria. Abnormalities warrant furter investigation.

Front 215

Life threatening complication of succinylcholine used during rapid-sequence intubation?

Back 215

Hyperkalemia leading to life-threatening arrhythmias - should not be used in pts at high risk for hyperkalemia such as those with crush/burn injuries more than 8 hours old (due to high risk of rhabdomyolysis), demyelinating syndromes like Guillain-Barre, and tumor lysis syndrome.

Vecuronium or rocuronium are better choice in these pts.

Front 216

Most common cause of death in acromegaly?

Back 216

cardiovascular accounting for ~ 38-62%.

acromegaly results from: high GH-->excess prodxn of IGF-1 --> excessive/abnormal bone and soft tissue growth including the heart leading to cardiomyopathy

Front 217

What can help prevent contrast-induced nephropathy in pts with a hx of DM or chronic renal insufficiency (elevated baseline creatinine)?

Back 217

Adequate IV hydration with isotonic bicarbonate or normal saline AND administration of acetylcysteine.

Contast-induced nephropathy presents as a transient spike in creatinine within 24 hours of contrast administration with a return to normal renal function within 5-7 days.

Front 218

Suspect what in a pt older than 60 years with back pain that radiates to the buttocks/thighs and numbness/parasthesias that are worse during walking and lumbar extension and better with lumbar flexion?

Back 218

Lumbar spinal stenosis due to two factors:
1) enlarging osteophytes at facet joints
2) hypertrophy of the ligamentum flavum

Dx via MRI.

Front 219

Common extracolonic manifestations of inflammatory bowel dz?

Back 219

1) skin findings such as erythema nodosum and pyoderma gangrenosum.
2) episcleritis
3) arthritis
4) cholangitis

p-ANCA is positive in ulcerative colitis.

Front 220

What do inflammatory bowel dz and ankylosing spondylitis have in common?

Back 220

HLA-B27 and presentation of arthritis is similar (low back pain/stiffness worse in the morning and improved with activity; plain radiographs show sacroiliac joint inflammation).

Front 221

Suspect what with sharply localized pain over the anteromedial part of the tibial plateau just below the joint line of the knee (with possible complaints of exacerbation of pain while sleeping on one's side)?

Back 221

Anserine bursitis - the result of abnormal gait, overuse, or trauma. A valgus stress test does NOT reproduce pain, thereby ruling out damage to the medial collateral ligament and XR will be normal. Treatment is rest, ice, and maneuvers that reduce pressure on the bursa. Corticosteroid injections into the bursa are helpful.

Front 222

Most appropriate step in management of a pt with suspected recurrence of gouty arthritis?

Back 222

synovial fluid analysis bc gouty arthritis cannot be reliably distinguished from septic arthritis (which can rapidly dstro the involved joint) or pseudogout based upon history and exam alone.

Synovial fluid analysis will reveal a WBC count of 2,000-50,000/ml and needle-shaped, NEGatively birefringent crystals under polarized light. Gram stain and culture will be negative.

Front 223

Most appropriate step in managment of a young patient presenting with progressive low back pain and spinal stiffness of >3 month duration that typically improves with exercise?

Back 223

XR demonstrating fused sacroiliac joints and/or bamboo spine caused by ankylosing spondylitis. It is a seronegative (negative for rheumatoid factor and ANA)spondyloarthropathy with a strong association with HLA-B27 (>90%).

Front 224

Most likely diagnosis in a pt that is awakened by severe, acute pain in the great toe and describes occasional pruritus that can be "unbearable" after a hot bath?

Back 224

Polycythemia vera-related gout. Myeloproliferative disorders are common causes of uric acid overproduction that can precipitate attacks of gouty arthritis.

Note: Polycythemia vera commonly causes splenomegaly and characteristic pruritis (due to histamine release from an increased number of circulating basophils).

Front 225

Treatment of fibromyalgia?

Back 225

Improves with TCAs and exercise.

Seen in women 20-50 years and is associated with fatigue, poor sleep, and depression.

Front 226

A common complication of advanced osteoporosis?

Back 226

compression fracture of the vertebrae - usually manifests as acute back pain withOUT any obvious preceding trauma. PE will show local tenderness and a normal neuro and musculoskeletal exam.

Note: Glucocorticoids predispose a pt to osteoporosis.

Note: Absent ankle reflex can be seen in elderly pts as part of the normal aging process.

Front 227

Common complication of giant cell or temporal arteritis?

Back 227

aortic aneurysms due to the involvement of the branches of the aorta. Pts should be followed with serial chest X-rays.

Front 228

signs and symptoms of temporal arteritis?

Back 228

symptoms such as headache, jaw claudication, muscle fatigue, and visual disturbance. PE may show scalp tenderness and a decreased temporal artery pulse. ESR is greater than 50 typically.

Front 229

Prophylaxis for gout?

Back 229

Allopurinol and probenecid - there is some risk of inducing uric acid RENAL stones with probenicid, so allopurinol is the first line agent.

Front 230

Presentation of drug-induced serum sickness?

Back 230

Symptoms of fever, urticaria, and arthralgias begin 1-2 weeks after administration of a drug such as penicillin, amoxicillin, TMP-SMX or cefaclor. Most commonly occurs in young children when a VIRAL infection is treated with an antibiotic agent.

Front 231

How does degenerative joint disease (osteoartritis aka "wear and tear" arthritis) present?

Back 231

Adults over 40 with indolent but progressive pain of the hands and weight bearing joints that is exacerbated by exercise and relieved by rest BUT sometimes with MILD morning stiffness (LESS than 30-60 minutes unlike rheumatoid arthritis). Unlike autoimmune processes, systemic symptoms are absent. Effusions may occur but joint will remain cool to touch. Bony crepitus, bony enlargement, and painful or decreased range of motion are common on exam. Synovial fluid analysis will reveal fewer than 2,000 WBC, no organisms, and no crystals.

Front 232

What will a plain film of an osteoarthritic joint show?

Back 232

narrowed joint space with osteophyte formation and subchondral sclerosis/cysts.

Front 233

How many WBCs can be seen on synovial fluid analysis with septic arthritis?

Back 233

> 50,000

Front 234

What should be suspected with proximal muscle weakness PLUS an elevated ESR AND CK?

Back 234

an inflammatory myopathy such as polymyositis or dermatomyositis - confirmed by muscle biopsy. Classic cutaneous findings include a rash over the face (with periorbital edema known as heliotrope sign), chst and lateran neck (called shawl sign), and on the knucles, elbows, and knees (Gottron's sign). Lichenoid papules overlying joints are known as Gottron's papules. Treated with high-dose corticosteroids.

Front 235

Auto-antibody associated with dermatomyositis?

Back 235

anti-Mi-2 (against helicase).

Front 236

What type of regular screening should a pt with dermatomyositis undergo?

Back 236

Cancer screening - over 10% will develop an internal malignancy, most commonly an ovarian cancer.

Front 237

Suspect what if a woman in the fifth or sixth decade complanes of keratoconjunctivitis sicca (xerophthalmia, dry eyes), xerostomia (dry mouth), and other associated problems such as dental caries and difficulty swallowing?

Back 237

Sjogren syndrome - diagnosed by the either the presence of lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and/or SSB (La).

PE may reveal enlargement and firmness to palpation of the salivary glands. Due to the antimicrobial and lubricating properties of normal amounts of saliva, there is an increased incidence of dental caries and difficulty swallowing with Sjogren's syndrome.

Front 238

Next step in management in a pt with rheumatoid arthritis?

Back 238

disease modifying anti--rheumatic drugs (DMARDs): methotrexate is the initial drug of choice.

Front 239

What is diagnostic of rheumatoid arthritis?

Back 239

Lab testing shows rheumatoid factor and anti-cyclic citrullinated peptide, while XR shows joint erosions, uxt-articular osteoporosis and narrowing of joint spaces (most commonly affecting the proximal interphalangeal and metacarpophalangeal joints).

Front 240

initial drug of choice for osteoarthritis?

Back 240

acetaminophen

Front 241

Most frequent cause of prosthetic joint septic arthritis?

Back 241

Staphylococcus aureus via hematogenous spread.

Front 242

Important adverse effect with use of methotrexate?

Back 242

Macrocytic anemia, sometimes even pancytopenia. Routine peripheral blood counts should be taken every 3 months.

Methotrexate works by inhibiting dihydrofolate reductase which can lead to folate depletion. The addition of folic acid supplements can alleviate or prevent this side effect.

Other side effects include, nausea, stomatitis, rash, hepatotoxicity, interstitial lung dz, alopecia, and fever.

Front 243

Who is at highest risk for osteomyelitis?

Back 243

injection drug uses, patients with sickle cell anemia, and immunosuppressed pts. The vertebrae is frequently involved site in IV drug abusers.

Platelet count is often high as a marker of inflammation/stress and the ESR is significantly elevated (>100) as well. MRI is the most sensitive diagnostic study. Treatment is long term IV ABX with or without surgery.

Front 244

Most common septic arthritis in young, sexually active pts?

Back 244

Neisseria gonorrhea which may present in one of two ways:
1) an asymetric polyarthrits (often with tenosynovitis and skin rash) OR
2) isolated purulent arthritis affecting one or a few joints.
**In some, an asymmetric polyarthritis will precede purulent monoarthritis.

Dx may be confirmed by gram stain of synovial fluid, blood cultures, urethral cultures or skin cultures.

Front 245

What is tennis elbow?

Back 245

Lateral epicondylitis that manifests as pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. Can be caused by a variety of activities that involve repeated forceful wrist extension and supination such as backhand in tennis or use of a screwdriver.

Underlying pathophysiology: degeneration of the extensor carpi radialis brevis tendon near the lateral epicondyle.

Front 246

What does "neuropathic claudication" in lumbar spinal stenosis mean?

Back 246

Exacerbation of leg symptoms with walking (similar to PVD). However, unlike PVD, the symptoms are positional. Extension (e.g. standing and DOWNhill walking) exacerbate symptos bc this narrows the spinal canal, whereas fexion (e.g. sitting and UPhill walking) improves symptoms bc it widens the spinal canal.

Front 247

Manifestations of sarcoidosis?

Back 247

cough, dyspnea, erythema nodosum, antrior uveitis, and acute polyarthrits.

CXR shows hilar adenopathy with or without reticulonodular infiltrates. Bioposy will reveal NONcaseating granulomas. Elevated serum ACE may be elevated.

Front 248

Treatment for symptomatic sarcoidosis?

Back 248

Systemic glucocorticoids. Asymptomatic sarcoidosis is often followed without treatment due to the high rate of spontaneous remission.

Front 249

Lab and radiographic evidence that supports the diagnosis of psuedogout?

Back 249

fever, leukocytosis with a left shift, and chondrocalcinosis (calcified articular cartilage). Synovial fluid analysis (needed for diagnosis) IDs rhomboid, positively birefringent crystals.

Front 250

Settings that may precipitate pseudogout?

Back 250

trauma, surgery, or medical illness.

Front 251

Characteristics of SLE induced arthralgia/arthritis?

Back 251

Affects greater than 90% of pts but is considered NON-deforming. Most commonly involves hands or knees. It is a migratory arthritis with pain that is often disproportionate to objective physical findings.

Front 252

First line therapy for reactive arthritis?

Back 252

NSAIDs

Front 253

Triad for reactive arthritis (Reiter syndrome)?

Back 253

conjunctivitis, Asymmetric oligoarthritis, and nongonococcal urethritis. Arthritis often involves knee and sacroiliac spine.

Note: mucocutaneous lesions (ulcers) and enthesitis (Achilles tendon pain) are common too!

Front 254

Red flags that warrant investigation rather than conservative treatment of back pain?

Back 254

1) Age over 50
2) Hx of previous cancer
3) Unexplained weight loss
4) Pain greater than 1 month duration
5) Nighttime pain causing difficulty with sleep
6) No response to previous therapy
7) Neurologic syndrome

**Initial test of choice is plain films to look for lytic lesions and compression fractures.

Front 255

Pain aggravated by pushing, pulling, lifting the arm above the head, and lying on the affected shoulder is most likely due to?

Back 255

Rotator cuff tear vs. rotator cuff tendonitis. Lidocaine injection can help distinguish btn the two - amelioration of pain with injection indicates tendonitis whereas no improvement indicates a tear. MRI is the study of choice for confirmation of diagnosis.

Front 256

Most likely cause of proximal muscle weakness with associated fatiguability, tremor, anxiety, and weight loss?

Back 256

Thyroid myopathy (in this case hypErthyroidism but can also be caused by hypothyroidism). Causes predominantly proximal muscle weakness. Search for additional symptoms of thyroid dysfunction to confirm diagnosis.

Front 257

How to distinguish btn thyroid myopathy and myasthenia gravis causing proximal muscle weakness?

Back 257

MG will more than likely involve eye and bulbar musculature whereas thyroid myopathy will not.

Front 258

How can a viral arthritis be distinguished from other symmetric inflammatory arthritides (namely RA and SLE)

Back 258

It tends to resolve within 2 months.

Positive rheumatoid factor may occur in RA, viral or bacterial infection, malignancy, and in normal individuals.

ANA is sensitive for SLE but can also be present in RA, hepatitis, and HIV. Weakly positive ANA can be found in approx 5% of normal individuals!

Treatment for viral arthritis is NSAIDs. Antiviral therapy is unnecessary as symptoms are self-limited.

Front 259

What should be suspected if a pt complains of pain with active range of motion of the shoulder, passive internal rottion, and forward flexion but with no signs of deltoid atrophy?

Back 259

Subacromial bursitis - typically occurs in the setting of chronic microtrauma to the supraspinatus tendon caused by overhead work and repeated overhead movements of the arm during work or sporting events. The tendon is traumatized by compression btn the acromian and the humeral head, and its vascular supply may be temporarily compromised during such episodes of compression. The subacromial bursa lies btn the acromian and the tendon of the supraspinatus muscle.

Front 260

A tear of the proximal end of the long head of the bicep tendon is associated with?

Back 260

rotator cuff injury and typically occurs during forceful flexion of the arm. Patients present with a prominent bulge in the midportion of the upper arm. Axillary nerve injury may occur as a result of anterior dislocation of the humerus out of the glenoid fossa.

Front 261

The axillary nerve supplies?

Back 261

the deltoid and the teres minor with motor innervation - palsy of this nerve would result in paralysis and ultimately denervation atrophy of these muscles.

Front 262

Precipitating factors for osteonecrosis? (aka aseptic necrosis, avascular necrosis, ischemic necrosis, and osteochondritis dessicans)

Back 262

Chronic corticosteroid use and chronic excessive ingestion of alcohol account for over 90% of cases. Other factors include trauma and antiphospholipid syndrome.

Pathogenesis: bone vasculature is disrupted --> bone and bone marrow infarction --> trabecular thinning --> ultimately causing collapse of the affected bone.

**process may take months to years and presents with ANTERIOR hip pain worsened by activity and relieved rest with progressive limitation of range of motion. Will ultimately cause joint instability and pain at rest.

MRI is the most sensitive test for this condition.

Front 263

Suspect what if a pt complains of painful joints with the formation of tumor-like protrusions with lesions draining chalky white material?

Back 263

Chronic tophaceous gout - begins with asymptomatic hyperuricemia and progresses to gouty arthritis, typically affecting the great toe first (called podagra). Uric acid crystals form in the renal tubules and collecting system resulting in nephrolithiasis. Urate crystals may deposit in the soft tissues forming tumors known as tophi which can ulcerate to drain chalky material.

Note: diuretics (especially HCT) have a hyperuricemic effect from hypovolemia-associated enhancement of uric acid reabsorption in the proximal tubule.

Front 264

Suspect what with normal serum calcium and phophate levels BUT INCR alk phos and urinary hydroxyproline levels?

Back 264

Paget disease of bone (osteitis deformans) - disorder of accelerated and disordered osteoclastic bone resorption of uncertain etiology. Incr bone resorption --> disorganized formation of lamellar or woven bone (inherently weaker than normally formed bone) --> pain and bowing of lower extremity weight bearing bones --> hypertrophy of skull compresses the vestibulocochlear nerve causing deafness.

Lab abnormalities include elevated alk phos plus urinary markers of bone degradation such as hydroxyproline, deoxypyridinoline, N-telopeptide and C-telopeptide.

Front 265

CREST syndrome refers to what constellation of findings?

Back 265

1) Calcinosis cutis - localized dystrophic deposition of calcium in the skin that appear as nodules typically on the upper extremities. May ulcerate and drain a chalky material like chronic tophaceous gout.
2) Raynaud phenomenon - acute bouts of digital ischemia in response to cold and may lead to digital necrosis.
3) Esophageal dysmotility - dysphagia and GERD
4) Sclerodactyly - fibrosis of skin on fingers distal to MCP joints resulting in "shiny appearance," flexion contractures, and joint pain.
5) Telangiectasias - "mat-like" patches most common on the face and palms.

Front 266

What are firm, flesh-colored, NON-tender nodules found over pressure points such as the elbow and extensor surface of the proximal ulna?

Back 266

rheumatoid nodules - almost all will have positive rheumatoid factor.

Front 267

What are Heberden and Bouchard nodes?

Back 267

hard, bony nodules over the DIP and PIP joints, respectively.

Front 268

Mechanism involved that leads to joint trauma in neurogenic arthropathy aka Charcot's joint?

Back 268

nerve damage - process starts with decreased pain, proprioception, and temperature perception. As normal neurologic input is lost, pts unknowingly traumatize their weight bearing joints. XR's will show loss of cartilage, osteophyte development, and loose bodies. Associated pain is typically mild. Management includes treating the underlying disease and providing mechanical devices (special shoes) to assist in weight bearing and decrease further trauma.

Front 269

Diseases that can lead to neurogenic arthropathy aka Charcot's joint?

Back 269

DM, peripheral nerve damage, syringomyelia, spinal cord injury, B12 deficiency, or tabes dorsalis.

Front 270

In chronic gout, what may an XR of the joints show?

Back 270

punched-out erosions with overhanging rim of cortical bone known as "rat bite" lesion.

Front 271

Typical population that is affected by ankylosing spondylitis?

Back 271

Young men (2-3:1 ratio compared to women) under 40 years of age (most frequently btn 20-30 years). Symptoms are typically worst in the morning and improve as the day progresses. Associated findings iclude arthritis of the peripheral joints and anterior uveitis.

Front 272

Side effects of methotrexate treatment (first line drug for RA)?

Back 272

stomatitis (ulcers), nausea, abdominal pain, fever, LFT elevation 2dry to hepatotoxicity and anemia 2dry to myelosuppression.

Front 273

triad of Felty syndrome?

Back 273

Rheumatoid arthritis, splenomegaly, and granulocytopenia with neutrophil < 2,000/mm3). Granulocytopenia generally does not occur until symptoms of arthrits have been present for over 10 years.

Front 274

Suspect what in a patient over 50 years with NEW-onset temporal headache, jaw claudication, vision loss, or symptoms of polymyalgia rheumatica?

Back 274

temporal arteritis - immediate empiric treatment with high dose steroids is necessary, especially to prevent visual loss.

Note: ESR will be elevated and temporal artery biopsy will provide definitive diagnosis.

Front 275

Important preventative measures to prevent gouty attacks?

Back 275

1) alcohol cessation: ethanol is metabolized to lactate, which competes with urate for renal excretion, leading to accumulation of urate in the body.
2) eating a low purine diet
3) avoiding drugs such as diuretics and pyrazinamide.

Tx of ACUTE attack: NSAIDs, colchicine, or steroids.

Front 276

What are Baker cysts?

Back 276

A result of excessive fluid production by an inflamed synovium that occurs in cases of RA, osteoarthritis, and cartilage tears. Excess fluid accumulation expands in the poplitieal bursa, creating a tender mass in the popliteal fossa. They can occasionally burst to release their contents into the calf, resulting in an appearance similar to a DVT.

Front 277

Most prominent extraarticular manifestation of ankylosing spondylitis?

Back 277

anterior uveitis

Front 278

Bone demineralization is present in _________ and _________.

Back 278

osteomalacia and osteoperosis.

osteomalacia is due to inadequate serum vitamin D, calcium or phosphorus resulting in demineralized osteoid. Osteoperosis is due to a decrease in bone mineral density.

Front 279

Suspect what in a pt that has traveled to or is from an endemic area and presents with RUQ pain, diarrhea, leukocytosis, elevated alk phos, and tender liver mass on abdominal CT?

Back 279

Amebiasis - most pts are asymptomatic but can develop liver abscess, dysentery, and other organ develpment. Those with liver abscess typically present with 1-2 weeks of fever, RUQ pain that starts wi 5 months of returning from an endemic aria, dysentery (1/3 of pts), and occasionally jaundice (<10% of pts).

Diagnosis is confirmed with ultrasound, CT, or MRI of SOLITARY liver lesion. Leukocytosis (>10,000) or an elevated alk phosphatase is also supportive. Serologic testing for antibodies should be performed to definitively r/o a pyogenic abscess. While awaiting serology results, treatment with oral metronidazole should be started which results in a cure for >90% within 7-10 days. If tests are negative or pt does not improve, alternative testing such as percutaneous drainage to rule out pyogenic abscess can be done.

Front 280

Treatment for pyogenic abscess of liver?

Back 280

Drainage and tx with oral metronidazole PLUS IV ceftriaxone.

Front 281

POST cholecystectomy pain is due to one of three reasons:

Back 281

1) common bile duct stone
2) sphincter of Oddi dysfunction
3) functional causes

Abnormal alkaline phosphatase or dilatation of biliary tree observed on ultrasound are indicators of either CBD stone or sphincter dysfunction. ERCP would be indicated to confirm and treat the condition, either through stone removal or sphincterotomy. No evidence of LFT abnormalities or dilation of biliary tree indicates functional pain with no obvious organic basis. Tx symptomatically with analgesics and reassurance.

Front 282

Three major types of gallstones?

Back 282

1) cholesterol
2) pigment
3) mixed

**cholesterol and mixed stones together comprise 80% of all gallstones in the Western population.

Front 283

Pathogenesis of gallstones?

Back 283

Water-INsoluble cholesterol is secreted in bile and converted into soluble micelles by bile acids and lecithin. Gallbladder hypomotility or excess cholesterol:bile salt ratio can cause cholesterol to precipitate into insoluble crystals which form gallstones.

Front 284

Risk factors for formation of pigment gallstones?

Back 284

chronic hemolysis (like in sickle cell anemia), chronic biliary tract infection or parasite infection; and advanced age.

Front 285

Protective factors against development of gallstones?

Back 285

low-carb diet, physical activity, consumption of caffeinated coffee, and aspirin or other NSAID usage.

Front 286

Dx of cholelithiasis?

Back 286

best confirmed with ultrasound. Tx for symptomatic cholelithiasis is laparoscopic cholecystectomy.

Front 287

Treatment options for pregnant pts who experience repeated attacks of biliary colic?

Back 287

cholecystectomy, preferably during the second trimester OR bile salt such as ursodeoxycholic acid to dissolve cholesterol stones. Gallstones frequently recur once treatment with bile salt is stopped, however.

Front 288

Gallstones are common in what population?

Back 288

fat, female, fertile woman of forty years.

Front 289

Consider what diagnosis if a pregnant woman c/o intense pruritus, especially significant on the palms and soles and worse at night?

Back 289

intrahepatic cholestasis - a fxnl disorder of bile formation that develops in the second and third trimesters of pregnancy and is characterized by intense, often intolerable generalized pruritus, especially significant on the palms and soles and worse at night.

Total bile acids are typically elevated and may be the only finding. If other liver studies indicating stasis are abnormal, it may include elevated alkaline phosphatase and total/direct bilirubin. Serum aminotransferases may be quite high, which requires ruling out viral hepatitis.

Front 290

Treatment for intrahepatic cholestasis of pregnancy?

Back 290

Relief and preventing complications! Relief is provided using ursodeoxycholic acid as it increases bile flow and can relieve pruritus. Maternal prognosis is good as condition resolves shortly after delivery with no hepatic sequelae. Condition may recur in subsequent pregnancy and affected women are at increased risk for developing gallstones.

Reducing complications is centered around the fetus bc known complications include fetal prematurity, meconium-stained amniotic fluid, and intrauterine demise. Preferred approach is early delivery once fetal lung maturity is established.

Front 291

What is Reye syndrome?

Back 291

fatty liver with encephalopathy seen exclusively in children younger than 15 years, and is preceded by a URI with influenza or varicella. Tx with aspirin (salicylates) significantly increases likelihood of developing Reye syndrome.

Characterized by headache, nausea/vomiting, excitability, delirium, combativeness, hypOglycemia, liver failure, and progressive CNS damage.

Front 292

Morphological changes seen in liver showing Reye syndrome?

Back 292

extensive fatty vacuolization of the liver withOUT inflammation due to diffuse mitochondrial injury.

Front 293

Lab abnormalities found in Reye syndrome?

Back 293

Elevated aminotransferases, ammonia levels, PT prolongation, hypOglycemia, and metabolic acidosis.

Front 294

Treatment of Reye syndrome?

Back 294

glucose with FFP and mannitol to cerebral edema.

Front 295

Balloon degeneration with polymorphic cellular infiltrates seen in the liver indicates?

Back 295

ACUTE alcoholic hepatitis

Front 296

Panlobular mononuclear infiltration with hepatic cell necrosis with confluent hepatic cell necrosis connecting adjacent lobules (described as "bridging necrosis") in the liver indicates?

Back 296

ACUTE viral hepatitis

Front 297

CHRONIC active hepatitis has what morphological appearance?

Back 297

mononuclear inflammatory cells that extend from portal areas to disrupt the limiting periportal plate of hepatocytes undergoing necrosis -- called "piecemeal" necrosis.

Front 298

First diagnostic step in a pt suspected to have pancreatic cancer?

Back 298

Abdominal ultrasound followed by abdominal CT if sono is nondiagnostic.

Front 299

Prognosis of pancreatic cancer?

Back 299

typically presents late and has a poor prognosis, even in those with potentially resectable mass. Five-year survival rate ranges from 10-30%, depending on nodal status.

Front 300

Major risk factors for pancreatic carcinoma?

Back 300

chronic pancreatitis, smoking, DM, and hereditary predisposition.

Front 301

Typical presentation of pancreatic carcinoma?

Back 301

Tumors of the pancreatic body or tail = pain and weight loss

Tumors of the pancreatic head = steatorrhea, weight loss, and jaundice.

**Pain is usually a dull upper abdominal (epigastric) pain that radiates to the back

Front 302

Classic PE signs of pancreatic carcinoma?

Back 302

Often PE is unremarkable aside from jaundice with an abdominal mass or ascites (present in only 20%). Metastatic disease may be indicated by a nontender but palpable gallbladder (Courvoisier's sign) OR left supraclavicular adenopathy (Virchow's node).

Front 303

Tumor markers which may be elevated in pancreatic carcinoma?

Back 303

CA 19-9 - but this can also be elevated in pts with jaundice and NO pancreatic cancer which reduces its utility as a screening tool. Postoperative monitoring of pancreatic cancer with CA 19-9 may be helpful in evaluating response to chemotherapy.

Front 304

Most common underlying causes of cirrhosis?

Back 304

chronic alcohol abuse and chronic viral hepatitis (mostly hep C but can also be caused by hep B).

Front 305

How is infection with Echinococcus granulosus diagnosed?

Back 305

Serology and CT showing "eggshell" calcification of a hepatic cyst.

Front 306

Treatment of hydatid cysts from Echinococcus granulosus?

Back 306

Aspiration is NOT indicated due to risk of anaphylactic shock secondary to spilling of cyst contents. Treatment is surgical resection under the cover of albendazole.

Front 307

Classic criteria for acute cholecystitis?

Back 307

1) usually develops after a large or fatty meal
2) sudden appearance of steady pain in the epigastrium or RUQ
3) Pain may radiate to right scapula
4) positive Murphy's sign - sharp arrest of inspiration with gallbladder palpation.
5) fever, vomiting, and leukocytosis.
6) Total bili may range from 1-4 mg/dL, and serum aminotransferases and alk phos are often mildly elevated.

Front 308

Most likely cause of acute cholecystitis?

Back 308

2ndry to gallstone formation in over 90% of cases, most commonly arising when a gallstone impacts in the cystic duct.

gallstone impacts cystic duct --> ingestion of fatty foods --> contraction of gallbladder against obstructed cystic duct causing severe colicky pain --> tissue behind duct obstruction becomes inflamed 2dry to bacterial overgrowth 2dry stasis --> subsequent ischemia can lead to gangree or perforation or abscess formation.

Front 309

What should all patients with cirrhosis be screened for?

Back 309

Esophageal varices by endoscopy. Primary prophylaxis to reduce the risk of bleeding is via beta blockers.

Front 310

Two most common causes of acute pancreatitis?

Back 310

alcohol and gallstones.

other major causes include medications and hypertriglyceridemia.

Front 311

Why is ultrasound more sensitive than CT for detecting gallstones?

Back 311

Many stones have bile and are isodense, therefore would not be seen on CT scan.

Front 312

Initial diagnostic test in all pts suspected of experiencing a first attack of acute pancreatitis?

Back 312

Ultrasound of the RUQ to search for the presence of gallstones. Abdominal CT scan is used to confirm the diagnosis of acute pancreatitis and identify complications.

Front 313

What is a HIDA scan and what is it used for?

Back 313

it helps track production and flow of bile from the liver to the intestine - an excellent tool to diagnose cystic duct OBSTRUCTION (cholecystitis). Not as useful in detecting nonobstructive gallstones (cholelithiasis).

Also known as cholescintigraphy, hepatobiliary scintigraphy, and hepatobiliary scan.

Front 314

What is charcot's triad and what does it indicate?

Back 314

Triad of fever, severe jaundice, and RUQ abdominal pain.

Indicates acute ascending cholangitis - an infection of the common bile duct.

Front 315

What is Reynold's pentad and what does it indicate?

Back 315

Charcot's triad of fever, severe jaundice, RUQ pain PLUS confusion and hypOtension.

Indicates suppurative cholangitis with need for urgent biliary decompression/drainage preferably by ERCP. Therapy typically includes sphincterotomy with stone removal and/or stent insertion.

Front 316

Initial diagnostic test employed in suspected acute ascending cholangitis?

Back 316

Ultrasound.

Front 317

Treatment of acute ascending cholangitis?

Back 317

after diagnosis with ultrasound, immediate supportive care and broad spectrum ABX. Sufficient in 80% of patients. Pts who do not respond to this treatment should undergo ERCP for biliary drainage. Early drainage can significantly decrease morbidity and mortality.

Front 318

Most likely cause of acute pancreatitis in a patient with NO hx of alcohol use or gallstones but with the presence of eruptive xanthomas?

Back 318

hypertriglyceridemia (over 1,000 mg/dL) - confirm with FASTING serum lipid profile

Front 319

Downsides to using ursodeoxycholic acid for treating symptomatic cholelithiasis over surgical correction?

Back 319

expensive, therapy is needed for several months before gallstones dissolve, 50% recurrence rate once the treatment is stopped.

Front 320

What type of hyperbilirubinemia is found in Dubin-Johnson syndrome?

Back 320

Conjugated!

Front 321

How may a patient with Dubin-Johnson syndrome clinically present?

Back 321

Icterus is evident but is typically otherwise normal. Icterus may be so mild that it only becomes evident in the context of a trigger such as illness, pregnancy, or oral contraceptive usage. ROUTINE labs are usually unremarkable including LFTs. Interestingly serum bilirubin can range from 2-5 mg/dL, but can ALSO be normal or extremely elevated! Diagnosis requires a direct bilirubin fraction of at least 50% and confirmation of high levels of urine coproporphyrin I (as opposed to coproporphyrin III in normal individuals). Total urine copropophyrin is in normal amounts.

Front 322

Gross and histological appearance of liver in Dubin Johnson syndrome?

Back 322

Grossly the liver is strikingly black. Histology shows dense pigment composed of epinephrine metabolites within the lysosomes.

Front 323

What does hyperestrogenism in cirrhosis lead to?

Back 323

gynecomastia, testicular atrophy, decreased body hair, spider angiomas, and palmar erythema

Front 324

What stages of liver disease from alcoholism can be reversed by cessation?

Back 324

fatty liver (steatosis), alcoholic hepatitis, and early fibrosis.

True cirrhosis with regenerative nodules is irreversible.

Front 325

Two main causes of CONjugated hyperbilirubinemia?

Back 325

1) intrahepatic causes from either intrahepatic obstruction (e.g. viral or autoimmune hepatitis, alcoholic hepatitis, drug reactions, 3rd trimester of pregnancy or postop states).

OR congenital defects in hepatic excretion (e.g. Dubin-Johnson, Rotor)

2) extrahepatic causes

Front 326

What helps distinguish between the different causes for conjugated hyperbilirubinemia?

Back 326

dominant aminotransferase elevation = hepatocellular disease

vs.
dominant alk phos elevation = intra- or extrahepatic biliary obstruction.

Those with predominant alk phos elevations should have an ultrasound or CT scan to rule out extrahepatic obstrcution. If nondiagnostic, next step is ERCP or PTC (percutaneous transhepatic cholangiogram).

Front 327

Blood transfusions before what year are at risk for hep C or hep B?

Back 327

screen for hep C if before 1992.

screen for hep B if before 1986.

Front 328

What should be suspected in a patient with a palpable mass in the epigastrium 4 weeks after the onset of acute pancreatitis?

Back 328

pseudocyst - not a true cyst as they lack an epithelial lining. Inflammatory fluid comprised of enzymes (amylase, lipase, enterokinase), tissue, and debris enclosed by a thick fibrous capsule. If amylase leaks out, serum amylase becomes markedly elevated.

Often resolves spontaneously so drain only if it persists for > 6 weeks, is greater than 5 cm in diameter, or becomes secondarily infected.

Note: ultrasound is the preferred means of imaging.

Front 329

Treatment for hepatic encephalopathy?

Back 329

1) correct precipitating factors such as hypOvolemia, GI bleeding, hypokalemia, metabolic alkolosis, hypoxia, sedative usage, hypoglycemia, and infection.

2) Lower blood ammonia level - typically with lactulose (a disachharide) that acidifies colonic contents thereby converting absorbable ammonia into nonabsorbable ammonium ION (an ammonia trap). Non-responders can be placed on ornithine-aspartate infusion or oral sodium benzoate.
3) Reduced-protein diet is recommended but not drastic limitation bc can lead to negative nitrogen balance.

Front 330

Single most important test to assess the FUNCTION of the liver?

Back 330

PT bc all clotting factors (except VIII) are made in the liver.

Front 331

What would a progressive decrease in liver transaminase levels indicate?

Back 331

either recovery from liver injury or that few hepatocytes are functional.

Front 332

Marked increase in transaminases is indicative of?

Back 332

ongoing tissue destruction in the liver.

Front 333

Two drugs approved for treatment of CHRONIC hepatits B and what is an important predictor of response to these drugs?

Back 333

interferon and lamivudine in patients with persistently elevated ALT levels, detectable serum HBsAg, HBeAg, and HBV DNA.

Degree of elevation of serum ALT is most important predictor of response to interferon and lamivudine - serum ALT should be more than 2 times the upper limit for a favorable response.

Note: in general, lamuvidine is more convenient (oral) with fewer side effects than interferon.

Front 334

Vanishing bile duct syndrome (aka ductopenia) indicates?

Back 334

primary biliary cirrhosis usually - rare!

Front 335

Why does cirrhosis sometimes lead to decreased TSH, T4, and T3?

Back 335

Primary pituitary failure -- hypothalamic-pituatary dysfunction can occur in pts with cirrhosis!

Front 336

What is hepatic hydrothorax?

Back 336

Transudative pleural effusions in patients with cirrhosis which are NOT 2dry to any underlying cardiac or pulmonary disease. Generally much more common on the right side and is thought to occur 2dry to small defects in the diaphragm which permit abdominal ascites fluid to pass into the pleural space.

Primary treatment is therapeutic thoracentesis followed by a salt restricted diet and diuretics. If that fails, the next best treatment is a transjugular intrahepatic portosystemic shunt (TIPS).

Front 337

ALL chronic hepatitis C with elevated ALT, detectable HCV RNA, and histological evidence of chronic hepatitis of at least moderate grade are candidates for antiviral therapy with?

Back 337

interferon and ribavirin - combination therapy has shown to be more beneficial than monotherapy.

Front 338

Most common diseases causing liver metastasis?

Back 338

primary tumors of the GI, lung and breast

Front 339

Most important reversible risk factor for pancreatic cancer?

Back 339

smoking

Note: alcohol consumption, gallstones, and coffee intake are not risk factors for pancreatic cancer.

Front 340

What confirms diagnosis of Wilson's disease?

Back 340

Gold standard for diagnosis is liver biopsy that demonstrates quantitative hepatic copper levels. More commonly, diagonsis is confirmed by the presence of low serum ceruloplasmin (particularly < 20 mg/dL) PLUS increased urinary copper excretion or Kayser-Fleischer rings.

Front 341

Treatment for Wilson's dz?

Back 341

First line meds include copper chelators like d-penicillamine or trientine. Oral zinc also helps as it prevents copper absorption. Liver transplantation may be the only option if there is fulminant hepatic failure or dz that does not respond to pharmacotherapy.

Front 342

Pathogenesis of Wilson's dz?

Back 342

genetic mutations causing poor copper metabolism by reducing the formation and secretion of ceruloplasmin and by decreasing the secretion of copper into the biliary system. Copper accumulates within the liver causing free radical damage and eventually leaks out and deposits in other tissues including the basal ganglia (hepatolenticular degeneration) and cornea.

Front 343

The most serious form of acute pancreatitis that can lead to systemic hypotension and eventual shock?

Back 343

Pancreatic necrosis - locally released and activated pancreatic enzymes can increase vascular permeability within and around the pancreas, leading to the loss of a large volume of plasma into the retroperitoneum. Release of pancreatic enzymes and other inflammatory mediators into the circulation can also cause SYSTEMIC inflammation, widespread vasodilation, capillary leak, and resultant hypotension.

Requires aggressive fluid resuscitation and ABX.

Front 344

What serological marker helps diagnose acute hepatitis B during the "window" period when HBsAg has disappeared but anti-HBs has not appeared?

Back 344

IgM anti-HBc. The IgG fraction of anti-HBc signals recovery from disease.

Front 345

What signals active viral replication and infectivity of hepatitis B?

Back 345

HBeAg - detectable shortly after appearance of HBsAg. Tends to disappear shortly after aminotransferase levels peak and before HBsAg is eliminated, and is followed by the appearance of anti-HBe. Should it persist for more than 3 months, there is increased likelihood of chronic hepatitis B.

Front 346

What marker suggests the cessation of active viral replication and low infectivity in hepatitis B virus?

Back 346

Anti-HBe

Front 347

Risk factors for the development of pancreatic cancer?

Back 347

family hx, chronic pancreatitis, smoking, DM, obesity, and a diet high in fat.

Alcoholism and gallstones are NOT risk factors.

Front 348

What are choledochal cysts?

Back 348

congenital abnormalities of the biliary tree characterized by dilation of the intra and/or extra hepatic biliary ducts or both. Most cases are related to an anomalous pancreaticobiliary junction, which leads to weakness and dilatation of the biliary wall due to the reflux of alkaline pancreatic secretions into the biliary tree.

Initial investigation of choice is an ultrasonogram followed by CT or MRI as needed.

Front 349

Treatment for benign hepatic adenomas?

Back 349

General consensus for all symptomatic hepatic adenomas is surgical resection. Complete regression of the tumor can happen with discontinuation of oral contraceptives but growth, rupture (risk approaches 40%), and malignant transformation (risk approaches 8-13%) can also take place.

Note: biopsy is contraindicated bc of risk of hemorrhage.

Front 350

Where is the primary infection in a pt who has an amebic liver abscess?

Back 350

in the colon leading to bloody diarrhea; the ameba is transported to the liver by portal circulation leading to liver abscesses.

Front 351

First step in management of acute variceal bleeding?

Back 351

Establish vascular access with two large bore IV needles or a central line. Fluid resuscitation should begin until necessary blood products can be transfused.

Next minimize risk of aspiration by securing airway and initiating gastric decompression with nasogastric aspiration.

Finally, control bleeding. Medical control of bleeding can start with vasoconstrictors like terlipressing (synthetic analogue of vasopressin), ocreotide, or somatostatin. Control of bleeding is established in 80% though rebleeding is very common especially during the 6 weeks following the initial hemorrhage.

Front 352

What does fresh frozen plasma contain?

Back 352

All clotting factors and plasma proteins and provides volume in hypotensive states.

Front 353

What does cryoprecipitate contain?

Back 353

factor VIII, Factor XIII, fibrinogen, and von Willebrand factor.

Front 354

Suspect what in a pt with evidence of atherosclerotic vascular dz that presents with abdominap pain followed by bloody diarrhea but have MINimal abdominal exam findings?

Back 354

ischemic colitis - most commonly in the splenic flexure bc it is supplied by end arteries.

Front 355

Patients with ulcerative colitis should undergo routine surveillance for what?

Back 355

colon cancer with yearly colonoscopies beginning 8-10 years after diagnosis.

Front 356

An elevated _______ in a pt with ulcerative colitis should raise suspicion for?

Back 356

an elevated alkaline phosphatase level raises suspicion for primary sclerosing cholangitis.

Front 357

Suspect what in a pt with a 5-month hx of episodic retrosternal pain lasting about 15 minutes and precipitated by emotional stress and hot or cold food?

Back 357

Diffuse esophageal spasm - diagnosed via manometry (motility study) that should repetitive, non-peristaltic, high amplitude contractions that are either spontaneous or after ergonovine stimulation.

Front 358

Suspect what in a pt with cirrhosis and ascites that presents with fever and lethargy?

Back 358

spontaneous bacterial peritonitis (SBP) - can be a subtle presentation. Fever and subtle changes in mental status are the most common signs with abdominal pain often LESS prominent than in peritonitis of other etiologies.

Diagnose with paracentesis - requires positive ascites fluid culture and PMN level greater than 250/mm3. Paracentesis should be done before ABX therapy. E. coli and Klebiella are the most common organisms - treat with third generation cephalosporin.

Front 359

Suspect what in a pt with multiple episodes of thrombosis withOUT a clear precipitating factor?

Back 359

hypercoagulability (clue can be elevated PT/PTT and fibrin split products).

In a younger patient the cause may be genetic whereas in an older patient the cause may be a primary malignancy.

Front 360

triad of carcinoid syndrome:

Back 360

flushing, valvular heart disease, and diarrhea

Note: elevated serotonin and its metabolites 5-hyroxyindole acetic acid (5-HIAA) are present in the blood and urine.

Front 361

Pts with carcinoid syndrome are at risk of developing what vitamin deficiency?

Back 361

niacin - due to the increased formation of serotonin from tryptophan. Tryptophan is needed to make niacin.

3 D's of niacin deficiency: diarrhea, dermatitis, and dementia

Front 362

Suspect what in a pt with an enlarged NON-tender gallbladder and evidency of biliary obstruction?

Back 362

carcinoma of the head of the pancreas - CT scan is the best initial test.

Front 363

first step in management of uncomplicated diverticulosis?

Back 363

high fiber intake

Front 364

Suspect what in a pt with a hx of GERD that hs difficulty swallowing solids by not liquids withOUT anorexia or weight loss?

Back 364

peptic esophageal stricture - caused by body's reparative response to chronic exposure to gastric acid. Strictures tend to appear as symmetric and circumferential narrowings on endoscopy.

Note: Adenocarcinoma generally occurs in pts who have had GERD for >20 years and presents with weight loss and Asymmetric narrowing of the esophageal lumen.

Front 365

What type of peptic ulcer gets better after meals and what type gets worse after meals?

Back 365

dudoenal ulcers = better after meals

gastric ulcer = worse after meals.

Front 366

Treatment for duodenal ulcer disease?

Back 366

90% are infected with H. pylori so ABX (amoxicillin plus clarithromycin) for eradicate causal organism and a proton-pump inhibitor for acid suppression.

Front 367

Why does total parenteral nutrition increase the risk of gallstones?

Back 367

TPN bypasses the gut therefore normal stimuli (fatty acids and protein in the duodenum) for the release of cholecystokinin (CCK) is impaired. CCK typically stimulates contraction of the gall bladder and bile release into the gut lumen. Without CCK, gall bladder stasis results in bile sludge which can lead to gall stone formation.

Front 368

Suspect what in the absence of perstaltic waves in the lower 2/3 of the esophagus and significant decrease in lower esophageal sphincter tone?

Back 368

esophageal dysmotility associated with scleroderma.

characteristic clues: "sticking sensation" in the throat or dysphagia accompanied by heartburn.

Front 369

How to diagnose lactose intolerance?

Back 369

Many ways:
1) Positive hydrogen breath test (after ingestion of lactose)
2) positive stool test for reducing substances
3) low stool pH and increased stool osmotic gap.

Note: there is NO steatorrhea

Front 370

Most common cause of intermittent and occult lower GI bleeding in pts over the age of 65?

Back 370

Angiodysplasia - a controversial clue may be a systolic ejection murmur at the right second intercostal space, most likely representing aortic stenosis. Can be seen on colonoscopy but often missed. Angiography is the gold standard test but rarely performed.

Front 371

How can C. difficile-induced colitis be diagnosed?

Back 371

cytotoxin assay in stool. Treat with oral/IV metronidazole. Oral (but NOT IV) vancomycin can also be used.

Front 372

Lab tests that can help confirm hepatorenal syndrome?

Back 372

Elevated creatinine and VERY low URINE sodium (< 10 mEq/L). Also, the absence of protein and blood in the urine is helpful bc it makes intrinsic renal disease less likely.

Front 373

Pathogenesis of hepatorenal syndrome?

Back 373

Pts with severe liver dz can develop generalized systemic vsodilation thought to be 2dry to generation of nitric oxide in the splanchnic circulation due to portal hypertension. This reduced peripheral vascular resistance causing renal hypoperfusion and pre-renal renal failure.

Front 374

Anti-endomysial or anti-gliadin antibodies indicate?

Back 374

celiac dz

Front 375

anti-scl-70 antibodies indicate?

Back 375

scleroderma

Front 376

anti-centromeric antibodies indicate?

Back 376

CREST syndrome

Front 377

anti-mitochondrial antibodies indicate?

Back 377

primary biliary cirrhosis

Front 378

signs and symptoms of malabsorpton due to celiac dz?

Back 378

1) bulky, foul-smelling floating stool
2) loss of muscle mass or subQ fat
3) pallor 2dry to iron deficiency anemia
4) bone pain due to osteomalacia
5) easy brusing due to vit K deficiency
6) hyperkeratosis due to Vit A deficiency.

Fatigue and weight loss are also common complaints.

Front 379

Suspect what with steatorrhea and with a hx of severe intermittent epigastric pain?

Back 379

chronic pancreatitis - look for alcohol consumption.

Front 380

Differential for a pt with dysphagia for BOTH solids and liquids, as well as regurgitation?

Back 380

Achalasia and pseudoachalasia (2dry to a neoplasm at the gastroesophageal junction).

Achalasia can be diagnosed with imaging studies showing a markedly dilated esophagus with decreased peristaltic contractions and smooth, "bird beak" tapering of the DISTAL esophagus. Achalasia results from degeneration of the neurons within the esophageal wall that control peristalsis. It is usualy idiopathic but can be 2dry to systemic disease (e.g. Chagas' disease, amyloidosis, and sarcoidosis).

An older pt (over 60) that also has weight loss should be evaluated for an underlying neoplasm via endoscopy.

Front 381

What is toxic megacolon?

Back 381

Symptoms of acute colitis with radiologic evidence of colonic dilation. Can rapidly progress to colonic perforation; therefore it is a medical emergency.

Front 382

MCC of toxic megacolon?

Back 382

ulcerative colitis.

Front 383

Treatment for toxic megacolon?

Back 383

it is a medical emergency - IV steroids are the drug of choice. Also, nasogastric decompression, IV fluids, antibiotics and bowel rest is needed.

Front 384

Indication for esophagoscopy in management of GERD?

Back 384

1) Empiric therapy with acid-suppressing drugs fails
2) pt has features of "complicated" disease (e.g. dysphagia, odynophagia, weight loss, overt or occult bleeding, and iron deficiency anemia) in addition to the typical symptoms of GERD (e.g. heartburn, regurgitation, or sour/bitter taste).

Front 385

When is esophageal pH monitoring used for the management of GERD?

Back 385

when empiric therapy fails AND endoscopy (aka esophagoscopy) is negative.

Front 386

Diagnostic clues to chronic inflammatory diarrhea (such as IBD)?

Back 386

weight loss and inflammatory changes in the blood such as anemia, elevated ESR, acute phase reactants, and reactive thrombocytosis. Positive occult blood or positive stool leukocytes are also important clues bc they are usually absent in other types of diarrhea (such as secretory and osmotic).

Front 387

Suspect what in a pt with back pain, anemia, renal dysfunction, and elevated ESR?

Back 387

multiple myeloma. another characterisitc finding in MM is hypErcalcemia from bone lysis caused by plasmocyte-released humoral factors.

Front 388

Manifestations of hypERcalcemia?

Back 388

severe constipation, anorexia, weakness, increased urination, or neurologic abnormalities (e.g. confusion or lethargy).

Front 389

Always consider ________ as a cause of constipation.

Back 389

hypERcalcemia

Front 390

What explains the "shifting" phenomenon of abdominal pain from the peri-umbilical to the right lower quadrant that is classic for acute appendicitis?

Back 390

In the initial stages, only the viscera are inflamed. Afferent visceral pain fibers from the appendix accompany sympathetic nerves and enter the spinal cord at the T10 segment which explains the peri-umbilical pain. Subsequent inflammation of the parietal peritoneum and skeletal muscles cause somatic pain which is well localized (RLQ) and more severe in intensity.

Front 391

Stepwise approach to treatment for ascites:

Back 391

1) sodium and water restriction
2) spironolactone
3) loop diuretic (not more than 1 L/day of diuresis bc can cause hepato-renal syndrome)
4) frequent abdominal paracentesis with/without albumin infusion (2-4 L/day, less aggressive if renal function is borderline).

Front 392

Important risk factors for adenocarcinoma of the esophagus versus squamous cell carcinoma of the esophagus?

Back 392

adenocarcinoma - Barrett's esophagus and GERD

squamous cell CA - smoking and alcohol are important ones among many others

Front 393

What should be suspected in an adult immigrant patient who presents with high-grade fever, a severe sore throat with odynophagia and drooling, stridor upon respiration and tenderness to palpation over the larynx?

Back 393

Epiglottitis - can still occur by Hib (especially in those from other countries) or Streptococcus pyogenes.

Front 394

What part of the GI does Crohn's disease involve?

Back 394

any component from the mouth to the anus, characteristically with skip areas of involvement. Even apthous mouth ulcers can be a component of the disease.

Note: Granulomas are identified pathologically in up to 30% of patients with Crohn's disease.

Front 395

Suspect what in an elderly patient with poorly controlled diabetes that presents with ear pain and drainage?

Back 395

Malignant otitis externa - most commonly caused by Pseudomonas aeruginosa. Ear pain and drainage is not responsive to topical medications. Granulation tissue may be seen within the ear canal. Progression of infection can lead to osteomyelitis of the skull base and destruction of the facial nerve. CT or MRI can be used to confirm the diagnosis.

Front 396

Treat malignant otitis externa with what type of antibiotics?

Back 396

SYSTEMIC abx that cover for Pseudomonas. TOPICAL abx are ineffective!

Front 397

It is important to distinguish between what two differentials when a patient presents with a swollen and painful eye accompanied by fever but has a normal fundoscopy?

Back 397

Orbital cellulitis (infection of the fat and muscles within the orbit) VS. preseptal cellulitis (infection that involves only the superficial tissues).

Protrusion of the eyeball (proptosis) and decreased visual acuity are usually only seen with orbital cellulitis. CT can be helpful if the clinical presentation is indeterminate or if there is concern for abscess. Treat requires IV broad spectrum ABX.

Note: Cavernous sinus thrombosis sometimes presents similarly to orbital cellulitis but is more often BIlateral with inolvement of cranial nerve III (resulting in ptosis) and V as well as early visual loss. Fudoscopy is usually NOT normal and reveals papilledema and dilated tortuous retinal veins.

Front 398

Suspect what in a patient with hard to remove white patches in the oral mucosa?

Back 398

leukoplakia that may lead to squamous cell carcinoma - caused by chronic irritation to the oral mucosa due to smoking, alcohol, or ill-fitting dentures.

Front 399

Suspect what in a child patient who presents with continued ear drainage for several weeks despite appropriate abx therapy?

Back 399

cholesteatomas - can be congenital or acquired. Congenital lesions are in pts around the age of 5 or younger. Acquired lesions are due to chronic middle ear disease that leads to formation of a retraction pocket in the tympanic membrane, which can fill with granulation tissue and skin debris. Complications of cholesteatomas include hearing loss, cranial nerve palsies, vertigo, brain abscesses or even meningits. Refer to an otolaryngologist!!

Front 400

What disease consists of the following features: asthma, chronic rhinosinusitis, nasal polyposis, and bronchospasm or nasal congestion following the ingestion of aspirin or NSAIDs?

Back 400

Aspirin exacerbated respiratory disease (AERD) - examination will reveal bilat, grey, glistening mucoid masses in the nasal cavities.

Note: food tastes bland secondary to anosmia from nasal congestion.

Front 401

Suspect what in a patient who presents with severe, sharp headaches, low-grade fever, periorbital edema, and cranial nerve palsies?

Back 401

cavernous sinus thrombosis (CST) - most are 2dry to a skin infection located in the medial aspect of the face (around eyes and nose) but ethmoid or sphenoid sinusitis can also cause this condition. Headache is usually the most common EARLY symptom, partly due to neuropathic pain from the irritation of V1 and V2 branches of the trigeminal nerve (which explains sharpness and location in the upper face). Cranial nerves III, IV, V1, V2 and VI all pass through the cavernous sinus and can be affected by CST. Low-grade fever and periorbital edema occur several days later due to impaired venous flow in the orbital veins.

Dx with MRI or CT with contrast of the orbits. Tx with IV broad spectrum abx. Sometimes anticoagulation, glucocorticoid therapy or surgery may be needed as well.

Front 402

Suspect what in a patient who presents with a combination of vertigo, ear fullness, tinnitus, and hearing loss?

Back 402

Meniere's disease - resulting from distention of the endolymphatic compartment of the inner ear. Episodes of vertigo last 20 min to 24 hours in addition to low frequency, sensorineural hearing loss and tinnitus. Acute symptoms may include vomiting, postural instability, and nystagmus. Triggers that increase endolymphatic retention should be avoided including alcohol, caffeine, nicotine, and high salt foods. A strict, salt restricted diet of 2-3 grams/day is recommended as initial therapy.

Front 403

What s/sx should lead to suspicion for a diagnosis OTHER than UNcomplicated pharyngitis or tonsillitis?

Back 403

1) a muffled voice or "hot potato voice"
2) deviation of the uvula
3) prominent UNIlateral lymphadenopathy

This condition is likely peritonsillar abscess and can be fatal! Treatment includes needle aspiration of the peritonsillar abscess and initiation of IV abx.

Front 404

Dense intramembranous deposits that stain for C3 from a renal biopsy is a characteristic microscopic finding for?

Back 404

membranoproliferative glomerulonephritis, type 2 - pts present with nephrotic range proteinuria and hematuria. It is caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative complement pathway.

Front 405

What are most kidney stones composed of?

Back 405

75-90% are composed of calcium oxalate (envelope-shaped on microscopy). Small bowel disease, surgical resection or chronic diarrhea can lead to malabsorption of fatty acids. unabsorbed fatty acids chelate calcium --> more oxalic acid free for absorption --> more likely calcium oxalate stones!

Front 406

Calcium phosphate stones are common in?

Back 406

primary hyperparathyroidism and renal tubular acidosis.

Front 407

Uric acid stones (10-15% of renal stones) are common when?

Back 407

urine is acidic or there is increased cell turnover (hyperuricemia). Dehydration is an important risk factor. Persistent stones due to hyperuricosuria can be treated with purine-restricted diet and allopurinol.

Front 408

Cysteine stones (< 1% of renal stones) are seen in?

Back 408

inborn error of metabolism leading to increased excretion of cysteine.

Front 409

Struvite stones (10-15% of renal stones) are common when?

Back 409

urine is alkaline bc of infection with urease producing bacteria (e.g. Proteus).

Front 410

Most common causes of calcium stones?

Back 410

1) idiopathic hypercalciuria: hypercalciuria, normal SERUM calcium, and absent metabolic dz. *most common form of hypercalciuria.
2) hypercalciuria due to systemic disorders (primary hyperparathyroidism, sarcoidosis)
3) hyperuricosuria
4) hyperoxaluria (due to large amounts of Vit C or green leafy vegetables or 2dry to IBD/short bowel syndrome).
5) Decreased urinary citrate
6) Renal tubular acidosis
7) chronic dz in urine output -- leads to precipitation of calcium salts.

Front 411

Treatment for calcium oxalate urolithiasis (in order of importance)?

Back 411

1) increased fluid intake (> 3L per day)
2)normal or increased calcium diet (1000 mg/dL is RDA)
3) dietary sodium restriction (<100 mEq/dL)
4) oxalate restriction (i.e. dark roughage, chocolate, and vitamin C)
5) decreased dietary proteins (i.e. beef, fish, eggs, and poultry.)

Front 412

Medical treatment for urolithiasis?

Back 412

Thiazides/amiloride diuretics - decreases urinary calcium excretion (primarily by inducing mild volume depletion which leads to a compensatory rise in proximal reabsorption of sodium and calcium) and prevents the precipitation of calcium in the urine.

Front 413

What DM drug should be discontinued in patients with acute renal failure, hepatic failure, or sepsis?

Back 413

Metformin - all increase the chance of developing lactic acidosis

Note: Pioglitazone is contraindicated in liver failure.

Front 414

Hyperkalemia with significant changes should be rapdily treated with?

Back 414

calcium gluconate to stabilize the heart cell membranes but effects are short-lived; therefore, agents to reduce the serum concentration of potassium such as insulin and/or sodium polystyrene sulfonate will also be necessary too!

Front 415

Suspect what in a pt that presents with recurrent episodes of hematuria beginning several days after an upper respiratory infection (serum complement levels are normal)?

Back 415

IgA nephropathy and post-streptococcal glomerulonephritis are major causes of hematuria after an URI. IgA nephropathy is the MOST common cause in adults and usually occurs less than 5 days after the URI. Post-strep glomerulonephritis averages 10 days after pharyngitis and 21 days for impetigo.

Front 416

Treatment for overflow incontinence due to diabetic autonomic neuropathy?

Back 416

Aside from strict glycemic control, intermittent catheterization and cholinergic medications such as bethanechol are options. Heavy alcohol intake may contribute so cessation is important.

Note: pts will have high post-void residual volumes in the bladder.

Front 417

Suspect what in a patient who presents with palpable purpura, proteinuria, hematuria, and other nonspecific findings such as arthralgias, hepatosplenomegaly, peripheral neuropathy and hypocomplementemia?

Back 417

Mixed essential cryogloulinemia. Most patients also have hepatitis C.

Front 418

Two treatment options for end stage renal disease?

Back 418

dialysis or renal transplantation. Renal transplant is always preferred due to better survival rates and quality of life. A living RELATED donor is best, followed by a living non-related donor and lastly a cadaveric donor.

Front 419

What qualifies a cystitis infection as complicated?

Back 419

infections in women who are pregnant, the very young or the very old, diabetics, immunocompromised, or those who have abnormal anatomy of the GU tract.

Front 420

Management of uncomplicated cystitis?

Back 420

Urine cultures are not indicated. Oral TMP/SMX and nitrafurantoin are the preferred empiric abx.

Front 421

Drug that is used to treat serious gram-negative infections but are potentially nephrotoxic?

Back 421

Aminoglycosides - drug levels and renal function must be monitored closely during therapy.

Front 422

Suspect what in a young patient that presents with recurrent episodes of hematuria and proteinuria, sensorineural deafness, and a family hx of renal failure?

Back 422

Alport's syndrome - microscopy shows alternating areas of thinned and thickened capillary loops with splitting of the glomerular basement membrane.

Front 423

Most common causes of nephrotic syndrome not secondary to a systemic disease are?

Back 423

minimal change disease, membranous nephropathy, and focal segmental glomerulosclerosis. Minimal change dz is most common in children. The other two are most common in adults, with more than 1/2 of cases in African American patients. FSGS also has an association with obesity, heroin use, and HIV.

Front 424

Definition of nephrotic syndrome?

Back 424

heavy proteinuris (> 3g/24 hours), hypoalbuminemia, and peripheral edema.

Front 425

Pathogenesis of analgesic-induced papillary necrosis?

Back 425

chronic tubulointerstitial damage - results from papillary ischemia induced by analgesic-mediated vasoconstriction of medullary blood vessels (vasa recta). Sometimes hematuria is prominent, and clots may form causing renal colic.

Front 426

Peculiar side effect of rifampin?

Back 426

red to orange discoloration of body fluids including urine, saliva, sweat, and tears.

Front 427

How to distinguish between the following:
1) chronic bacterial prostatitis
2) inflammatory chronic prostatitis
3) non-inflammatory chronic prostatitis
4) acute bacterial prostatitis

Back 427

All may present with irritative voiding symptoms.
1) Afebrile pts, normal urinalysis, prostatic secretions show leukocyte count > 10 WBCs/HPF and culture of secretions is POSITIVE.
2) Afebrile pts, normal urinalysis, prostatic secreatons show leukocyte count > 10 WBCs/HPF and culture of secretions is NEGATIVE.
3) Afebrile pts, normal urinalysis, prostatic secretions show a NML number of leukocytes and culture of secretions is NEGATIVE.
4) FEBRILE pt, suprapubic/perineal pain, exquisitely tender prostate is noted on rectal exam, urinalysis shows bacteruria and pyuria.

Front 428

Tx for dehydration?

Back 428

IV sodium-containing crystalloid solutions (usually 0.9% NaCl)

Classic signs of dehydration: dry mucosa, marginally high hematocrit and serum electrolytes, BUN/Cr ratio > 20.

Front 429

Suspect what if a pt with typical renal colic does not show a stone on plain film?

Back 429

1) radiolucent stone (uric acid stone)
2) calcium stones less than 1-3 mm in diameter
3) non-stone causes (obstruction by a blood clot or tumor)

All will likely show on an ultrasound or CT scan.

Front 430

Cause and treatment of uric acid stones?

Back 430

Commonly caused by unusually low urine pH levels (which may be due to a defect in renal ammonia secretion) and hyperuricosuria.

Hydration plus alkalinization of urine to pH > 6.5 with oral potassium bicarbonate or potassium citrate since uric acid stones are highly soluble in alkaline urine.

Also a low-purine diet with/wo allopurinol can be helpful depending on the presence of hyperuricosuria.

Front 431

First step in management of acute renal failure/kidney injury due to possible urinary retention?

Back 431

Foley catheterization - it can resolve various post renal obstructions and monitor urine output in prerenal and intrinsic renal failure.

Note: Urine sediment analysis is helpful in differentiating between prerenal and intrinsic renal failure. Muddy brown casts indicate acute tubular nephritis while eosinophilic casts indcate AIN.

IV fluids are critical in prerenal acute kidney injury caused by hypovolemia. In ADEquately hydrated patients with recent-onset oliguria due to prerenal or certain intrinsic renal causes, a loop diuretic to avoid volume overload can be helpful.

Front 432

Meds commonly known to cause hyperkalemia?

Back 432

ACE-I, NSAIDs, and potassium-sparing diuretics (such as amiloride and spironolactone).

Front 433

EKG changes due to hyperkalemia?

Back 433

early: peaked T waves

followed by prolonged PR interval and QRS duration, and eventual loss of P waves. Progressive widening of the QRS complex and merging with the T wave produces a sine-wave pattern. This can progress to V-fib or asystole.

Front 434

Management of hyperkalemia?

Back 434

10 mL of 10% calcium gluconate to stabilize the myocardial membrane WHEN signs of cardiac toxicity are present or potassium level > 6.5. Follow with insulin and/or beta-2 agonists to shift potassium into cells. Sodium bicarbonate can also be used for this purpose.

Slower acting treatments to increase potassium excretion include loop and thiazide diuretics IF renal function of pt is intact.

Dialysis is reserved for those with renal failure and severe life-threatening hyperkalemia unresponsive to conservative measures.

Front 435

A simple renal cyst should NOT have the following findings:

Back 435

1) multilocular mass
2) thickened, irregular walls
3) thickened septae within the mass
4) contrast enhancement

simple renal cysts are most common in patients over age 50. They do not require further evaluation.

Front 436

Suspect what in a male patient with fever, painful enlargement of the testes, and irritative voiding?

Back 436

acute epididymitis - In younger patients, it is usually caused by sexualy transmitted organisms such as C. trachomatis or N. gonorrhea and is assocated with urethritis (pain at the tip of the penis and urethral discharge). In older men, it is usually non-sexually transmitted and caused by gram negative rods such as E. coli and is associated with a UTI.

Front 437

Varicoceles that FAIL to empty when a patient is recumbent should always raise suspicion for?

Back 437

renal cell carcinoma - scrotal varicoceles are usually on the left side and due to obstruction of the gonadal vein where it enters the renal vein.

Most pts with RCC are Asymptomatic until the dz is advanced. Classic triad of flank pain,hematuria, and a palpable abdominal renal mass is uncommon (10% of patients). CT scan of the abdomen is the most sensitive and specific for diagnosing renal cell carcinoma.

Front 438

Diagnostic procedure of choice for detecting renal stones?

Back 438

CT withOUT contrast bc it can detect radioopaque (calcium) as well as radiolucent (uric acid) stones.

Front 439

Dietary recommendations for patients with renal calculi are:

Back 439

1) DECR dietary protein and oxalate
2) DECR sodium intake
3) INCR fluid intake
4) INCR dietary calcium

Front 440

Why are patients with nephrotic syndrome at an increased risk for stroke or MI?

Back 440

because of abnormal lipid metabolism (including elevated LDL and/or a low HDL) as well as intrinsic hypercoagulability (tends to affect the venous more than the arterial system, particularly the renal veins). Both factors lead to accelerated atherosclerosis! Aggressive management including statins or other meds to lower cholesterol is indicated.

Front 441

It is important to consider what diagnosis in a male patient who presents with symptoms of a UTI?

Back 441

acute prostatitis because acute CYSTitis is uncommon in men! Pts with prostatitis may also complain of pain in the perineal region and a tender, boggy prostate is often found on PE. Most appropriate next step in order to help direct antibiotic therapy is a mid-stream urine sample. Prostatic massage should be avoided as it can result in bacteremia. Urethral catheterization should be avoided due to inflammation involving the urethra. If urinary retention develops, suprapubic catheterization may be necessary.

Front 442

When should a diagnosis for membranous glomerulonephritis in a CHILD with nephrotic syndrome be suspected considering minimal change disease is overall the most common cause?

Back 442

In a pt with active Hepatitis B infection, particularly if the HBeAg is positive (possibly due to deposition of HBeAg itself in the glomeruli).

Front 443

What should be suspected in a pt that presents with a hx of rheumatoid arthritis, enlarged kidneys, hepatomegaly, generalized edema, and 4+ proteinuria?

Back 443

Amyloidosis causing nephrotic syndrome. Note that rheumatoid arthritis predisposis to amyloidosis. Renal biopsy will show amyloid deposits that exhibit apple-green birefringence under POLARIZED light after staining with Congo red.

Front 444

What should be suspected in a patient with a hx of CRF that presents with abnormal hemostasis but normal PT, PTT, and platelet counts?

Back 444

uremic coagulopathy - BT is reflective of platelet function and is usually prolonged. The platelet count is normal but there is platelet dysfunction that causes bleeding.

Front 445

Treatment of choice for a uremic coagulopathy?

Back 445

DDAVP - increases the release of factor VIII:von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is not indicated bc the transfused platelets quickly become inactive.

Note: Major defect in uremic coagulopathies involves platelet-vessel wall and platelet-platelet interactions. Several uremic toxins have been implicated, the chief among which is guanidinosuccinic acid.

Front 446

Which antidiabetic drug causes some weight loss?

Back 446

Meformin - assess pt's renal status before starting on metformin

Front 447

Algorithm for Cushing's disease:

Back 447

1) 24-hr urinary free cortisol as a screening test - 90% of patients will have values greater than 90 microgram/24 hr.

2) Low dose dexamethasone test can also be used as a screening test - in patients wo any pathology, ACTH levels should decrease whereas in Cushing's, ACTH levels remain high.

3) Once a screening test is positive, plasma ACTH levels determine the etiology of the syndrome. Plasma ACTH levels > 20 pg/mL can occur in Cushing's and ectopic ACTH production.

4) High-dose dexamethasone suppression test can distinguish btn Cushing's and ectopic ACTH production. In Cushing's, the 24-hr urinary cortisol or serum cortisol levels will decrease by 50% of basal cortisol levels. NO suppression indicates ectopic ACTH prodxn.

This is explained by the fact that excess ACTH secretion from pituitary adenomas are only relatively resistant to negative feedback whereas most ectopic tumors are completely resistant to feedback inhibition.

Also, RAPD develoment of symptoms (hypokalemic alkalosis, pigmentation, and hypertension) is more indicative of ectopic secretion.

Front 448

Management of diabetic gastroparesis includes:

Back 448

1) improved glycemic control (delayed gastric emptying makes this difficult to achieve, often leading to post-meal hypOglycemia after insulin injection.
2) Small, frequent meals
3) Dopamine antagonists (e.g. metoclopramide, domperidone) before meals.
4) Bethanechol
5) Erythromycin - this drug interacts with motilin receptors and can promote gastric emptying
6) Cisapride - available only through manufacturer after documentation of need for drug and thorough assessment of the individual's risk factors for cardiac arrhythmia.

Front 449

How does diabetic autonomic neuropathy of the GI tract manifest?

Back 449

1) stomach involvment leads to gastroparesis with anorexia, n/v, abdominal bloating, and early satiety
2) small intestine involvement causes diarrhea due to bacterial overgrowth
3) large intestine involvement presents with constipation.

Front 450

What is megestrol acetate used for?

Back 450

anorexia associated with cancer

Front 451

How to detect factitious thyrotoxicosis?

Back 451

Signs/symptoms of hyperthyroidism but NO goiter or exophthalmos. Low TSH and elevated T3/T4. 24-hr radioiodine uptake test shows diffusely decreased iodine uptake by the thyroid. Biopsy shows follicular atrophy.

Front 452

What causes hypertension in hyperthyroid states?

Back 452

caused by hyperdynamic circulation - predominantly systolic hypertension and an increase in pulse pressure

Front 453

What causes hypertension in hypOthyroid states?

Back 453

increased systemic vascular resistance - predeominantly diastolic htn

Front 454

Indications for parathyroidectomy?

Back 454

Needed for all SYMPTOMATIC patients with primary hyperparathyroidism.

Criterion for ASYMPtomatic patients with primary hyperparathyroidism are:
1) serum calcium at least 1 mg/dL above the upper limit of normal
2) young age (< 50 years old)
3) bone mineral density less than T-2.5 at any site.
4) Reduced renal function.

Front 455

What two differentials should be considered when lab results show hypercalcemia, hypophosphatemia, and inappropriately elevated PTH levels?

Back 455

primary hyperparathyroidism and familial hypocalciuric hypercalcemia.

24-hr urinary calcium test helps distinguish the two. Levels > 200 mg indicate primary hyperparathyroidism while levels < 100 mg indicate the latter.

Front 456

What is a sestambi scan?

Back 456

Surgeons use it to assess and localize parathyroid adenomas for guidance to surgical approach.

Front 457

Why is corrected calcium important?

Back 457

It takes hypoalbuminemia into account. Albumin plays an important role in homeostasis of the 3 forms of calcium: ionized (active) form 45%, albumin-bound 40%, and bound to inorganic/organic anions 15%. Pts with low albumin may have low TOTAL plasma calcium but normal levels of ionized calcium therefore remain healthy.

For every 1 g/dL change in serum albumin from 4 g/dL, total calcium should be expected to decrease by 0.8 mg/dL.

Front 458

Most prominent cause of primary adrenal insufficiency in developING countries?

Back 458

adrenal tuberculosis - also, CT scan often shows calcification of both adrenal glands. tx is lifelong replacement with glucocorticoids and mineralocorticoids.

Front 459

Most prominent cause of primary adrenal insufficiency in developED countries?

Back 459

autoimmune adrenalitis (more than 80% of patients with primary adrenal insufficiency)

Front 460

What is cosyntropin?

Back 460

synthetic ACTH - should cause a rise in serum cortisol

Front 461

Two etiologies of early morning hypERglycemia?

Back 461

1) inadequate insulin dosage
2) Somogyi effect

Measurement of 3AM blood glucose is helpful in distinguishing the two. 3AM hypOglycemia will cause an incease in levels of counterregulatory hormones (i.e. epinephrine, norepinephrine, glucagon), which consequently increase the rate of glycogenolysis and gluconeogenesis. This eventually cuases elevation of the morning blood glucose level.

Front 462

Lab values that confirm a diagnosis of SIADH?

Back 462

low PLASMA osmolality (<280 mOsm/kg) with high URINE osmolality (>100-150 mOsm/Kg).

These patients are characterized by hypOtonic (i.e. low PLASMA osmolarity) hopOnatremia with euvolemia due to persistently elevated ADH levels in the absence of appropriate stimuli for vasopressin release.

Note: one cause for SIADH is NSAID therapy

Front 463

First line treatment for micro- versus macroprolactinomas?

Back 463

Medical treatment for both bc it not only results in normalization of prolactin levels but also significant reduction in tumor size! Use dopaminergic agents such as bromocriptine and cabergoline. Cabergoline is a new drug with fewer side effects.

Front 464

Definition of a microprolactinoma?

Back 464

less than 10 mm in diameter - manifests as amenorrhea and galactorrhea in women and hypogonadism in males. Usually does not cause problems with other pituitary hormones or a mass effect.

Front 465

TSH-secreting pituitary adenomas lead to...

Back 465

excess TSH levels which stimulate thyroid gland. Elevated circulating thyroid hormone levels with inappropriately normal/elevated TSH levls is characteristic.

Note: pathophysiology generally involves the overproduction of the ALPHA-subunit of TSH.

Front 466

Most appropriate initial management of DKA?

Back 466

rapid IV administration of normal saline and REGular insulin.

Note: bicarb administration is usually NOT indicated due to adverse effects.

Front 467

Criteria to make diagnosis of DKA?

Back 467

1) blood glucose > 250
2) pH < 7.3 or low serum bicarb < 15-20 mmol/L
3) detection of plasma ketones

Front 468

Most common risk factor for foot ulcerations?

Back 468

Diabetic neuropathy (seen in 80% of diabetics with foot ulcers) - even more than peripheral vascular disease and smoking.

Front 469

Suspect what in a patient with decreased hearing, increased hat size, and increased alk phos levels?

Back 469

Paget's disease - pt is usually over 40 years. Often asymptomatic but when symptomatic, first symptom is crainial enlargement, associated hearing loss, and occasional headaches.

Front 470

Basic pathophysiologic mechanism in Paget dz?

Back 470

abnormal bone remodeling -excess osteoclastic bone resorption with increased numbers of larger than normal osteoclasts at the involved sites --> compensatory activation of the osteoblasts --> immature bone deposition with transformation of normal lamellar and woven bone into a chaotic "mosaic" pattern

Front 471

What labs can accurately reflect the extent and activity of Paget's dz?

Back 471

1) alkaline phosphatase - marker of bone formation - used to assess the activity of disease as well as response to treatment
2) urinary n telopeptide - most commonly used as a marker of bone resorption
2)

Front 472

Pathogenesis of osteomalacia?

Back 472

Vitamin D deficiency --> decreased intestinal calcium and phosphorus absorption --> hypocalcemia stimulates parathyroid glands --> 2dry hyperparathyroidism brings the serum calcium levels to normal or near normal BUT increases urinary phosphate excretion

Note: Look for greater hypophosphatemia than hypocalcemia, especially in the early stages of osteomalacia

Front 473

Differential diagnosis of NORMOtensive patients with hypokalemia and metabolic alkalosis includes?

Back 473

1) diuretic use
2) surreptitious vomiting
3) Bartter syndrome
4) Gitelman syndrome

Clue: Urine chloride level is MARKEDLY elevated (> 20 mEq/L and most often >40 mEq/L) in Bartter and Gitelman syndromes.

Front 474

Classic presentation of Bartter syndrome?

Back 474

polyuria, polydipsia, and growht and mental retardation that presents early in life but can occur later in life too.

Defect is in sodium and chloride reabsorption in the thick ASCENDing limb of the LOH, resulting in hypovolemia and consequent activation of the renin-angiotensin aldosterone system (RAAS). Activated RAAS causes an incr in potassium and hydrogen ion secretion, leading to hypokalemia and metabolic alkalosis. Sodium tends to be normal!

Note: Gitelman syndrome is a subset of Bartter syndrome with a defect in the distal convoluted tubule causing the same sequence of events.

Front 475

Most common cause of hypokalemia?

Back 475

diuretic use - can be diffeicult to identify

Front 476

How to distinguish between primary hyperaldosteronism and renin-secreting tumors, both of which are characterized by HTN?

Back 476

Plasma renin activity - HIGH in renin-secreting tumors and low in primary hyperaldosteronism. Plasma aldosterone will be high in BOTH conditions. Serum sodium tends to be high in both conditions too.

Front 477

Preferred treatment for Graves disease and the contraindications of treatment?

Back 477

Radioactive iodine ablative therapy - most patients achieve euthyroidism with a single dose of radioactive iodine. Approx 10-30% will become hypOthyroid during first 2 years and 5% per year therafter. Usual time for initial improvement is 6-8 weeks after administration of radioactive iodine

Contraindications: pregnancy and very severe ophthalmopathy.

Front 478

Suspect what in a patient that presents with hypertension, muscle weakness, and numbness?

Back 478

Primary hyperaldosteronism - usually (85% of pts) caused by an aldosterone-secreting adrenal tumor. The rest have adrenal hyperplasia. Excess aldosterone in the body causes increased renal sodium reabsorption with resultant hypertension. Aldosterone also increases renal potassium loss with resultant MUSCLE weakness/numbness.

Front 479

Most specific lab value that indicates primary hyperaldosteronism?

Back 479

increased early morning aldosterone/renin ratio (>30) bc increased aldosterone suppresses renin.

Front 480

American Diabetes Association guidelines for the diagnosis of diabetes mellitus?

Back 480

Any 1 of the following:
1) HbA1C - over 6.5%
2) fasting plasma glucose over 125 mg/dl
3) plasma glucose > 200 mg/dl after 2 hours into a 75 g glucose tolerance test
4) random plasma glucose > 200 mg/dL

Note: all tests should be repeated bc false positives are high. Recommended that repeat testing be performed using the SAME screening test that was initially abnormal.

Front 481

Management of non-ketotic hyperglycemia?

Back 481

First and most important step is fluid replacement with NORMAL saline. Because of large volumes of glucose induced osmotic diuresis, pateints may require up to 8-10 L of normal saline to reach a euvolemic state. Normal saline can then be changed to half-normal saline.

Regular insulin should be administered.

Potassium should be administered in ALL cases once potassium reaches to the normal level. This is due to potential for hypOkalemia as K+ moves into the cells with administered insulin.

5% dextrse is given once blood glucose level has been lowered to 250 mg/dl by insulin therapy to prevent the development of cerebral edema.

Front 482

Manifestations of hypercalcemia of malignancy due to prodxn of PTH related peptide?

Back 482

Same effects that are seen with PTH secretion - including increased bone resorption, increased renal tubular calcium reabsorption, and phosphate secretion.

Front 483

Suspect what in a patient that presents with symptoms of hypothyroidism despite elevated T3/T4 levels and a normal to elevated TSH level?

Back 483

generalized resistance to thyroid hormones from receptor defects on the peripheral tissue. Patients usually present at an early age with growth and mental retardation; however pts with milder defects can present later in life.

Front 484

What is sick euthyroid syndrome?

Back 484

'Low T3 sydnrome' - any pt with an acute, severe, systemic illness may have abnormal thyroid function tests during the illness and while recovering from the illness. This is why TFTs are generally not performed unless there is a strong indication.

This condition is thought to be due to caloric deprivation and an increase in cytokine levels. Most common pattern is a fall in TOTAL and free T3 levels due to decreased peipheral conversion from T4 to T3. There is a rough correlation btn the severity of the underlying dz and fall in T3 levels. If illness continues for an extended period of time, serum T4 and TSH levels also decrease.

On recovery from non-thyroidal illness, pts often experience a modest, transient increase in serum TSH level, which is often misinterpreted as subclinical hypothyroidism.

Front 485

Indications for treatment of Paget's disease:

Back 485

1) bone pain
2) hypercalcemia of immobilization
3) neuro deficit
4) high output cardiac failure
5) preparation for orthopedic surgery
6) involvement of weight-bearing bones (to prevent deformities)

The initial goal is to establish which bones have been affected. Can be ascertained by full body bone scan, followed by radiologic confirmation in the documented areas of increased tracer uptake.

Symptomatic patients are best treated with oral or IV bisphosphonates. Calcium and vitamin D has NO effect on Paget's disease.

Front 486

MEN II consists of?

Back 486

1) virtually 100% will have C-cell hyperplasia or medullary thyroid carcinoma
2) 50% will have pheochrmocytoma
3) 20-30% have hyperparathyroidism

Front 487

Best next step in a pt with suspected pheochromocytoma plus elevated serum calcium?

Back 487

check serum calcitonin levels for possible medullary thyroid cancer (MEN II)

Front 488

When is ACE-I therapy indicated in a diabetic?

Back 488

when the patient has microalbuminuria, even if the blood pressure is normal. Microalbuminuria is a sensitive marker of renal microvascular damage.

Front 489

Most helpful diagnostic test in a pt with suspected erectile dysfunction?

Back 489

nocturnal penile tumescence - helps differentiate a psychogenic causes (these patients are eugonadal and still experience spontaneous erections during REM sleep and on waking up) VS. organic causes.

Front 490

In patients with suspected MEN II syndrome, what is the recommended screening test?

Back 490

genetic testing has replaced biochemical measurement of serum calcitonin. If genetic analysis is positive for a RET proto-oncogene (more than 95% of pts with MEN II have this mutation), total thyroidectomy is indicated.

Front 491

What lab values can be expected in X-linked hypophosphatemic rickets?

Back 491

Low serum phosphate due to RENAL phosphate wasting. There may also be a defect in 1-hydroxylase and as a result 1,25- dihydroxy vitamin D (calcitriol) may be low.

Serum calcium, PTH, alk phos, and 25-hydroxy vitamin D are all normal.

Front 492

What lab values can be expected in psuedohypoparathyroidism?

Back 492

low serum calcium, high serum phosphate, and high serum PTH. Alk phos and Vit D levels are WNL.

Front 493

What effects on calcium metabolism, phophate, PTH, and vitamin D does renal failure have?

Back 493

low serum calcium, high serum phophate, high PTH, and low 1,25 dihydroxy vitamin D.

Front 494

Osteomalacia due to Vitamin D deficiency shows what lab values?

Back 494

LOW 25-OH Vitamin D, low calcium, low phosphate, high PTH (secondary hyperparathyrodisim). 2dry increase in PTH brings calcium closer to normal values but makes hypophosphatemia worse.

Front 495

What lab value indicates that microalbuminuria has progressed to macroproteinuria?

Back 495

urine protein excretion of more than 300 mg/d - this is accompanied by progressive decline in GFR. Intensive blood pressure control is the most beneficial therapy to slow progression of diabetic nephropathy.

Front 496

Immediate cessation of antithyroid drugs (propilthiouracil or methimazole) is indicated when?

Back 496

any pt taking antithyroid drugs develops fever and sore throat suspicious of agranulocytosis caused by immune destruction of granulocytes (most cases occur wi 90 days of treatment). After stopping drug, measure WBC count. WBC < 1,000/cubic mm warrants permanent discontinuation whereas WBC count > 1,500/cubic mm makes antithyroid drug toxicity the unlikely source of fever/sore throat.

Front 497

How does PARTIAL deficiency of 21-hydroxylase present?

Back 497

in ADULThood as hyperandrogenism but NO salt wasting (therefore normal blood pressure).

Front 498

What is the next best step in a male pt with suscpected secondary (central) hypogonadism indicated by low testosterone and low or INNAPPOPriately normal levels of gonadatropin levels?

Back 498

prolactin levels - high serum prolactin inhibits release of GnRH thereby resulting in hypogonadism.

Front 499

glycosylated hemoglobin is an excellent way to monitor CHRONIC glycemic control bc?

Back 499

it is reflective of the pt's average glucose levels over the preceding 100-120 days (which correlates with RBC survival time). Generally a 1% increase in HbA1c corresponds with a 35 mg/dL increase in the mean plasma glucose level.

Front 500

The most reliable indicator of metabolic recovery in a pt with diabetic ketoacidosis?

Back 500

serum anion gap or arterial pH

Front 501

Drugs of choice in diabetic neuropathy?

Back 501

tricyclic antidepressants BUT TCAs can worsen urinary symptoms (due to cystopathy) and orthostatic hypotension (due to cardiovascular autonomic neuropathy). Gabapentin is an alternative for these patients.

Front 502

Pathophysiologic mechanism of Addison's disease?

Back 502

autoimmune! aka autoimmune adrenalitis. Pts with autoimmune adrenalitis also have autoimmune damage of other endocrine glands such as thyroid, parathyroid, and ovaries. Other non-endocrine autoimmune conditions such as pernicious anemia and vitiligo are also common.

Front 503

How should patients with PID be managed?

Back 503

1) Appropriate abx (ceftriaxone for gonorrhea and azithromycin for chlamydia)
2) Counseled on safe sex practices
3) encouraged to inform sexual partners in the past 60 days of their condition
4) Screened for HIV, syphillis, hepatitis B, cervical cancer (pap smear), and (if they have a hx of IV drug abuse) hepatitis C.

Front 504

A PPD test is positive when?

Back 504

1) induration > 5 mm in:
HIV-positive pts, with recent TB contact, signs of TB on CXR, or immunosuppressed.

2) Induration > 10 mm in:
Recent immigrants, IV drug abusers, exposure to high-risk settings (prisons, homeless shelters), or hx of DM or chronic kidney disease or malignancy or fibrotic lung disease.

Also children less than 4 years or teens exposed to high risk adults.

3) induration > 15 in:
healthy individuals with no risk factors

Front 505

Treatment for a positive PPD test?

Back 505

Isoniazid for chemoprophylaxis for 9 months PLUS pyridoxine to prevent isoniazid-induced neuropathy.

Isoniazid-induced hepatitis is still possible, so check LFTs periodically.

Front 506

What is the gardener's disease?

Back 506

Sporotrichosis from Sporothrix schenckii - initial lesion is a reddish nodule that later ulcerates, at the site of the thorn pick or skin injury. From this site of inoculation, the fungus spreads along lymphatics forming subQ nodules and ulcers.

Front 507

Esophagitis in HIV usually occurs when the CD4 count is?

Back 507

< 50/microL. Pts complain of swalloing and substernal burning. The most common agent is Candida. Start treating with oral fuconazole for 3-5 days. Failure to respond warrants further investigation with endoscopy, biopsy, and culture.

Front 508

How to distinguish between a primary HIV infection and infectious mononucleosis?

Back 508

1) Rash (unless antibiotics have been administered) and diarrhea are less likely in infectious mono.

2) Tonsillar exudates are uncommon in HIV.

Front 509

What is Kaposi sarcoma?

Back 509

Cutaneous lesions caused by human hersvirus 8 - lesions begin as papules and later develop into plaques or nodules. The color typically changes from light brown to violet. No associated necrosis of the skin or underlying structures.

Front 510

Management of a healthcare worker that is exposed to HIV?

Back 510

HIV serology and immediate initiation of aniretroviral therapy with 2-3 drugs.

Front 511

Management of mucormycosis most often caused by the fungus, Rhizopus?

Back 511

aggressive surgical debridement plus early systemic chemotherapy with amphotericin B.

Front 512

Management of disseminated histoplasmosis in HIV pts?

Back 512

Initial treatment with IV amphotericin B decreases the fungal load, and lifelong treatment with itraconazole prevents relapse.

Front 513

Classic signs of secondary syphillis?

Back 513

Bilateral symmetrical maculopapular rash involving the entire trunk and extremities (including palms and soles)! Also condylomata lata - broad exophythic formations which develop on the anogenital region or upper thighs and ulcerate subsequently. sSecond stage lesions may resolve spontaeously or even, never appear.

Front 514

What is indicated in a pt suspected to have infectious mononucleosis with a negative heterophile test?

Back 514

EBV-specific antibody test

Front 515

Treatment for primary syphillis in a penicillin allergic patient?

Back 515

single dose of oral azithromycin or a 2-week course of doxycycline

Front 516

Treatment of Pneumocystis pneumonia (an AIDS defining illness when CD4 counts are < 200)?

Back 516

TMP-SMX is the DOC.

Add oral prednisolone when PaO2 < 70 mmHg.

Front 517

Clinical features of Pneumocystis pneumonia?

Back 517

fever, DRY cough, exertional dyspnea, imaging that shows diffuse bilat intersititial infiltrates.

Front 518

Most likely organism in osteomyelitis from a nail puncture wound?

Back 518

Pseudomonas aeruginosa - treat with oral or parenteral quinolones and aggressive surgical debridement

Front 519

What should be considered in the differential when a pt with mononucleosis-like symptoms and atypical lymphocytes have a negative monospot test?

Back 519

CMV - usually presents withOUT pharyngitis and lymphadenopathy unlike EBV.

Front 520

Suspect what organism with nausea and vomiting 1-6 hours after eating rice?

Back 520

Bacillus cereus - from a PREformed, heat stable toxin.

Front 521

Most common cause of pneumonia in HIV pts?

Back 521

encapsulated bacteriadue to impaired humoral immunity, especially Pneumococcus

Front 522

Streptococcus bovis endocarditis whould prompt investigation for?

Back 522

colorectal or upper GI cancer

Front 523

A tick bite infection that is indemic to the northeastern United States and causes hemolyis?

Back 523

Babesiosis caused by Babesia. Unlike other tick-borne illnesses, rash is NOT a feature except in severe infection with thrombocytopenia which may cause a secondary petechial or purpuric rash.

Dx is made from Giemsa-stained blood smear. Tx is with either quinine-clindamycin OR atovaquone-azithromycin.

Front 524

The characteristic rash of rubella starts where?

Back 524

On the FACE and progresses to trunk and extremities. Prodromal symptoms include fever and occipital/posterior cervical lymphadenopathy. Adult women usually have associated arthritis!

Note: these patients usually have an unknown or not up to date vaccination status.

Also, measles (rubeola) can present with a similar rash that starts on the face but will have Koplik's spots and NO arthritis.

Front 525

Most appropriate management for a pt suspected to have HSV encephalitis?

Back 525

PCR for herpes simplex virus DNA from a CSF sample (not viral culture!). Start IV acyclovir without delay!

Front 526

When can influenza virus be treated with more than bed rest and simple analgesics such as acetaminophen?

Back 526

Antivirals are only effective within 48 hours of onset of illness.

Influenza A - amantadine and rimantadine

Influenza A & B - neuraminidase inhibitors zanamivir or oseltamivir are effective.

Note: treatment with antivirals shortens duration of symptoms by 2-3 days. Typical duration is usually 1-7 days. Most common in the fall and winter months.

Front 527

Treatment of choice for CNS cryptococcal infection in AIDS pt?

Back 527

IV amphotericin plus flucytosine.

Note: Cryptococcus grows as an "encapsulated" yeast on CSF cultures.

Front 528

What can cause pulmonary cavitation in an HIV-infected patient?

Back 528

many organisms: Mycobacterium tuberculosis, atypical mycobacteria, Nocardia, gram-negative rods, and anaerobes.

Front 529

How to diagnose Nocardia related pulmonary cavitation if suspected?

Back 529

A presumptive diagnosis can be made if sputum exam shows partially acid-fast, filamentous, branching rods.

DOC is TMP-SMX.

The lung is the most frequently involved organ and infection can manifest as nodules, reticulonodular pattern, diffuse pulmonary infiltrate, abscess, or cavity formation.

Front 530

When should Doxycycline be avoided as first-line treatment for early Lyme disease and possible simultaneous ehrlichiosis (spread by the same vector)?

Back 530

Children and pregnant/lactating mothers bc of possible skeletal and dental problems.

Amoxicillin is the preferred tx in these cases.

Front 531

What other organ beside the liver (hydatid cysts) is commonly affected by echinococcosis?

Back 531

lungs in 25% - transmitted in areas with sheep and dogs.

Front 532

Poorly controlled diabetes predisposes patients to _______ which causes a bloody, necrotic infection of the nasal cavities and often involves chemosis, proptosis, and diplopia of the eyes?

Back 532

mucormycosis caused by Rhizopus.

Front 533

HIV pts should be on MAC prophylaxis at what point?

Back 533

CD4 < 50/microL

Front 534

How is disseminated histoplasmosis (occurs in immunocompromised pts) characterized?

Back 534

Non-specific symptoms plus pancytopenia, hepatosplenomegaly, and PALATAL ulcers.

Front 535

Suspect what in an AIDS pt with multiple ring-enhancing lesions on CT of the CNS?

Back 535

toxoplasmosis - TMP-SMX for prophylaxis and empirical sulfadiazine and pyrimethamine is BOTH diagnostic and therapeutic.

Front 536

Suspect what with a bright red, firm, friable, exophytic nodule in an HIV pt?

Back 536

Bacillary angiomatosis caused by Bartonella - oral erythromycin is the ABX of choice.

Front 537

Definition of febrile neutropenia?

Back 537

absolute neutrophil count < 1500/microL PLUS a single temp reading of 100.9 OR a sustained temp of 100.4 for over an hour.

This is a medical emergency! Cover for Pseudomonas aeruginosa and treat with monotherapy or combination therapy!

monotherapy: cefepime, ceftazidime, imipenem, or meropenem.

Combo therapy: aminoglycoside plus an anti-pseudomonal beta-lactam.

Front 538

What form of MS is characterized by well-defined acute episodes with NO significant disease progression btn episodes.

Back 538

relapsing-remitting form of MS - several well defined clinical trials have proven that INTERFERON-BETA decreases the frequency of relapse and reduces disability in pts with relapsing-remitting form of MS.

Front 539

An important complication of subarachnoid hemorrhage?

Back 539

hyponatremia from "cerebral salt-wasting syndrome" - pathology involves (1) inappropriate secretion of vasopressin, which causes wter retention and (2) an increased secretion of atrial/brain natriuretic peptide, which causes cerebral salt wasting. Resolves wi 1-2 weeks.

Any intracranial hemorrhage can also cause SIADH leading to hyponatremia. Tx is water restriction.

Front 540

Classic triad of normal pressure hydrocephalus?

Back 540

abnormal gait, incontinence, and dementia - due to increased VENTRICULAR size withOUT persistent elevations in intracranial pressure.

Front 541

Pathophysiology of normal pressure hydrocephalus?

Back 541

TRANSIENT increase in intracranial pressure that causes ventricular enlargement. After ventricles enlarge, the pressure returns to normal. Initial increase in pressure is due to DIMINished CSF absorption at the arachnoid villi OR obstructive hydrocephalus.

Front 542

Features of NML age-related cognitive changes?

Back 542

tiredness, occasional forgetfulness, occasional word finding difficulty, and trouble falling asleep. Dementia canNOT be diagnosed unless there are functional impairments!

Front 543

Best way to determine if a Guillain-Barry patient is at high-risk for developing respiratory failure?

Back 543

SERIAL measurements of bedside vital capacity. VC below 15 mL/kg, especially with a clear downward trend indicates a significantly INCR risk for ventilatory failure.

Note: 20-30% will develop respiratory failure.

Front 544

Antecedent to Guillain-Barre?

Back 544

respiratory tract or GI (especially with Campylobacter infection) infection.

Front 545

What is internuclear ophthalmoplegia?

Back 545

A disorder of conjugate lateral gaze - eye shows impairment of ADDuction during gaze to the CONTRAlateral side. The opposite (contralateral) eye ABducts but with nystagumus. Same thing happens when gaze is changed to the other direction.

Convergence remains intact. Due to dysfunction in the MEDIAL LONGITUDINAL FASCICULUS, a characteristic finding in multiple sclerosis.

Front 546

Exacerbationof neuro deficits by hot weather or exercise are a useful clue to what dx?

Back 546

MS

Front 547

Suspect what in a pt with rapid onset of severe pain and vision impairment with an effected that appears injected with a NON-reactive DILated pupil?

Back 547

acute angle closure glaucoma - when a preexisting narrow anterior chamber angle is closed in response to pupillary dilation from medications (anticholinergics or sympathomimetics) or other stimuli (such as dime light). If untreated, can lead to severe and permanent vision loss in 2-5 hours after onset.

Front 548

Typical presenting features of Huntington's?

Back 548

mood disturbances (depression, apathy), dementia, anc chorea (facial grimacing, ataxia, dystonia, tongue protrusion, writhing movements of the extremities), and a family hx of similar symptoms.

Note: affects BOTH sexes equally. Age of presentation typically btn 30-50 years.

Front 549

Approved treatment for amyotrophic lateral sclerosis that prolongs survival and time to tracheostomy?

Back 549

riluzole - a glutamate inhibitor. Does not arrest underlying pathological process.

note: this is a neurodegenerative disorder NOT immunologically-mediated so corticosteroids and IVIG have no role in mgmt.

Front 550

Most appropriate management for pt suspected to have an acute ISCHEMIC stroke?

Back 550

1) First a NON-contrast head CT to confirm that stroke is ischemic and not hemorrhagic.
2) Confirmed ischemic stroke should be treated with fibrinolytics such as intravenous alteplase (tPA) within 3-4.5 hours of symptom onset.

Note: Anticoagulation with heparin is not recommended for acute ischemic stroke even if etiology is CARDIOembolic bc of increased risk for intracranial hemorrhage. However, warfarin anticoagulation should be started 2 wks after an acute CARDIOembolic stroke to prevent recurrence.

Front 551

Pronator drift is a relatively sensitive and specific physical exam finding for?

Back 551

upper motor neuron damage affecting the upper extremities. The supinator muscles are naturally weaker than the pronators so when pts close their eyes with arm extension and palms facing upward, an AFFECTED arm will tend to pronate. However, a pt that is faking will "drop" the affected arm withOUT pronating. Pt with strokes my demonstrate pronator drift.

Front 552

Hemi-neglect syndrome affects what part of the brain?

Back 552

the NON-dominant (usually right side) PARIETAL lobe, which is responsible for spatial organization.

Front 553

Manifestation of a lesion to the POSTERIOR limb of internal capsule (typically from a lacunar infarct)?

Back 553

UNIlateral motor hemiparesis of the face, arm, and leg withOUT loss of higher cortical function and NO visual field abnormalities.

Front 554

Manifestation of middle cerebral artery occlusion?

Back 554

CONTRAlateral hemiplegia, conjugate eye deviation TOWARD side of injury, and homonoymous hemianopia. Aphasia if the DOMinant hemisphere is involved OR hemi-neglect if the NON-dominant side is involved.

Front 555

Manifestation of anterior cerebral artery occlusion?

Back 555

CONTRAlateral weakness that affects predominantly lower extremities.

Front 556

Manifestation of a lesion to the vertebrobasilar system (supplying the brain stem)?

Back 556

"alternate" syndrome - CONTRAlateral hemiplegia BUT IPSIlateral cranial nerve involvement.

Front 557

Suspect what in a pt that presents with Parkinsonism symptoms, plus orthostatic hypotension, impotence, incontinence, or other autonomic symptoms?

Back 557

Shy-Drager syndrome aka multiple system atrophy, a degenerative dz characterized by:
1) Parkinsonism
2) Autonomic dysfunction (postural hypotension, abnormal sweating, bowl or bladder dysfunction, abnormal salivation/lacrimation, impotence, gastroparesis, etc.)
3) Widespread neuro deficits (cerebellar, pyramidal or lower motor neuron).

Note: Anti-Parkinson drugs are INeffective. Tx is aimed at intravascular volume expansion with fudrocortisone, salt supplements, alpha-adrenergic agonists, and application of contrictive garments to the lower body.

Front 558

How is Riley-Day syndrome aka familial dysautonomia characterized?

Back 558

seen predominantly in Ashkenazi Jewish children - gross dysfunction of the autonomic nervous system with severe orthostatic hypotension.

Front 559

How doesa thalamic stroke present?

Back 559

aka Dejerine-Roussy syndrome - caused by a stroke involving the ventral postero-lateral (VPL) nucleus of the thalamus, which ransmits sensory information from the contralateral side of the body.

Classic presentatin involves CONTRAlateral hemiANESthesia with accompanied TRANSient hemiparesis, athetosis, or ballistic movements. Severe DYSESTHesia (hypersensitivity to all kinds of stimuli inducing severe pain) of the affected area is also typical.

Front 560

Most common causative organisms of brain abscesses?

Back 560

aerobic and ANaerobic streptococci and Bacteroides species (ANaerobe).

Front 561

An ISOLATED, round, smooth-bordered, ring-enhancing intracranial lesion on contrast CT scan of the brain in an immunoCOMPETENT pt is suspicious for?

Back 561

brain abscess especially if there is a known extracranial infection. Streptococcus and Bacteroides (anaerobe) are the most common causes.

Front 562

Suspect what in a pt with cafe-au-lait spots, axillary freckles, Lisch nodules of the iris, neurofibromas, and bony lesions?

Back 562

Type 1 neurofibroma.

Note: Neurofibromatosis is a neurocutaneous syndrome with a tendency to form tumors in the CNS, PNS, skin and viscera.

Front 563

Suspect what in a pt with brain tumors, especially bilateral acoustic neuromas?

Back 563

Type 2 neurofibramatosis.

Note: Neurofibromatosis is a neurocutaneous syndrome with a tendency to form tumors in the CNS, PNS, skin and viscera.

Front 564

Suspect what in a pt with ash leaf hypOpigmentation, cardiac rhabdomyomas, kidney angioleimyomas, mental retardation, and seizures?

Back 564

Tuberous sclerosis: a neurocutaneous syndrome

Front 565

Suspect what in a pt with port wine stains in the V1 cranial nerve distribution, angomatous malformations of the brain, seizures, and hemiparesis?

Back 565

Sturge-Weber syndrome: a neurocutaneous syndrome

Front 566

CSF analysis reveals what findings in Guillain-Barre?

Back 566

INCR protein with remaining factors being NML (including glucose levels, WBC, and RBC counts).

Front 567

How does anticholinergic excess present?

Back 567

Red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hater, and full as a flask which describes:
flushing, anhidrosis/dry mouth, hyperthermia, mydriasis/vision changes, delirium/confusion, and urinary retention/constipation.

Headache, dizziness and tachycardia can also be present: headache and retro-orbital pain is attributed to precipitation of acute glaucoma by anticholinergics!!!!!!

ex of anticholinergics: trihexyphenidyl, benztropine

Front 568

Suspect what in a pt with hx of INTERmittent, painLESS vision loss (lasting a few seconds) with no other complaints and no hx of trauma to the eye BUT a medical hx significant for cardiac risk factors?

Back 568

Amaurosis fugax - painLESS loss of vision from emboli, which is a warning sign for impending stroke. Most emobli occur from the carotid bifurcation. Hence a duplex ultrasound of the neck is often done to identify plaques that may be present.

Front 569

Suspect what in a pt that presents with inability to move one-half of the face for 24 hours and absence of forehead furrows?

Back 569

Bell's palsy (peripheral 7th nerve palsy). A central facial paresis can be ruled out bc patients with central lesions STILL HAVE forehead furrows due to intact contralateral MOTOR innervation.

So forehead muscles SHOULD be paralyzed in Bell's palsy whereas the forehead muscles are not paralyzed in a central lesion.

Front 570

Suspect what type of lesion with a patient that has Broca's aphasia with right-sided weakness?

Back 570

a left MCA infarct of the FRONTAL lobe, likely from a CARDIAC embolic source!

Note: Broca's area is in the left frontal lobe.

Front 571

Hallmarks of Parkinson dz?

Back 571

mask-like immobile facial expression, bradykinesia, resting tremor, rigidity and a festinating gait. Thee is general slowing of all motor activity (hypokinetic gait) so pt will take short, NARROW-based, shuffling steps.

Front 572

Waddling gait indicates?

Back 572

muscular dystrophy (owing to weakness of gluteal muscles).

Front 573

spastic gait indicates?

Back 573

lesions of the upper motor neuron (e.g. spinal cord injury or cerebral palsy).

Front 574

gait disequilibirim indicates?

Back 574

disorders of the frontal lobe and multiple sensory systems

Front 575

WIDE-based, high-stepping gait?

Back 575

loss of proprioception

clue: Romberg's sign may be positive (i.e. the pt sways on standing with his feet together and eyes closed)

Front 576

en-bloc gait indicates?

Back 576

vestibular ataxia - a staggering gait with minimal head movements during walking plus vertigo and nystagmus.

Front 577

Difference between dizziness and vertigo?

Back 577

dizziness - sensation of imbalance and unsteadiness

vertigo - illusionary feeling of head movement frequently described as "head spinning"

Front 578

common cause of vertigo?

Back 578

acute labyrinnthine dysfunction aka "acute labyrinthitis" or "vestibular neuritis." The etiology is not found in most instances.

another important cuase is benign paroxysmal positional vertigo (BPPV), where the symptoms are precipitated by recumbent head position. About 30% of cases after head trauma, but typically no cause is found.

Front 579

Difference btn subural and epidural hematoma?

Back 579

subdural - ruptue of bridging veins that is semi-LETNICULAR in shape on CT - usually due to severe trauma or MINOR trauma in pts on anticoagulation therapy. More common in the elderly and alcoholics.

epidural hematoma - results from rupture of the middle meningeal artery with a bioCONVEX shape on CT - results from trauma

Front 580

Four cardinal symptoms of RLS:

Back 580

1) An uncomfortable sensation or urge to move the legs
2) discomfort that worsens in the evening or during sleep
3) discomfort which worsens at rest, and
4) discomfort alleviated by movement of the affected limb

Also tends to improve after massage or warming. More common in middle-age to older pts and in those with chronic kidney dz and/or iron deficiency anemia. Mechanism may involve abnormalities of dopaminergic transmission therefore dopamine agonists (pramiprexole, ropinerole, or levadopa) can help reduce symptoms and improve sleep quality.

Front 581

Some broad generalizations for CNS lesions:

Back 581

brainSTEM lesions - involve cranial nerves and sensory loss of 1/2 of the face and the CONTRAlateral half of the body.

thalamic and cortical lesions - sensory loss of 1/2 of the face and the SAME half of the body.

Front 582

Medial medullary syndrome is typically associated with?

Back 582

CONTRAlateral SPASTIC hemiplegia, CONTRAlateral vibratory/proprioception loss, and tongue deviation TOWARD the injured side.

Front 583

Wallenberg syndrome?

Back 583

lesion to the lateral medulla - IPSIlateral Horner syndrome, loss of pain and temperature to the face; weakness of the palate, pharynx, and vocal cords, cerebellar ataxia, and loss of pain and temp to the CONTRAlateral body.

Front 584

Most common sites for spontaneous intracranial hemorrhage (usually caused by HTN)?

Back 584

BASAL GANGLIA, cerebellum, thalamus, and pons.

Front 585

What should be screened for in all patients diagnosed with myasthenia gravis?

Back 585

coexisting thymoma (present in ~15%) via CT of the chest.

Front 586

Sometimes difficult to distingush between myasthenia gravis and amyotrophic lateral sclerosis, what physical exam finding can be helpful?

Back 586

normal reflexes are more suggestive of MG.

Front 587

One of the most specific symptoms indicating dementia?

Back 587

impaired activities of daily functioning

Front 588

Typical CT/MRI findings in the high-grade astrocytoma of glioblastoma mulitforme?

Back 588

HETEROgenous and serpiginous (slowly creeping/spreading with wavy border) contrast enhancement.

Classic "butterfly" appearance with central necrosis for GBM.

Front 589

Suspect what when a pt presents with s/sx of ONLY upper motor neuron dysfunction (including weakness, hyperreflexia, and extensor plantar response) especially if limited to the lower extremities?

Back 589

indicates a CNS lesion - since bilat and limited to lower extremities, lesion can be localized to the spinal cord. (Dysfunction is always distal to the site of spinal cord involvement). Possible etiologies include disk herniation, abscess, trauma, and malignacy leading to spinal cord compression. Epidural abscesses of the spinal cord are of particular concern in IV drug abuser (even in the absence of fever).

Front 590

Suspect what in an HIV-infected pt with altered mental status and a solitary, weakly ring-enhancing periventricular mass on MRI?

Back 590

primary CNS lymphoma - EBV DNA in the CSF is specific for this condition.

Note: Toxoplasmosis is a good differential dx. However MRI should reveal MULTIPLE ring-enhancing lesions in the basal ganglia. Also, a positive Toxoplasma serology is quite common in normal subjects in the U.S. therefore not specific for toxoplasmosis!!!

Front 591

Best diagnostic test in a pt suscpected to have acute glaucoma?

Back 591

ocular tonometry

Front 592

Common causes of acute delirium in the elderly?

Back 592

UTI, pneumonia and metabolic disturbances. For this reason, always include urinalysis and measurement of serum electrolytes in the intial work-up.

Front 593

DOC for initial therapy of absence seizures?

Back 593

ETHOSUXIMIDE (used almost exclusively) and valproic acid - ethosuximide affects the thalamic neurons by working against calcium currents

Front 594

Best initial symptomatic therapy for Parkinsonism?

Back 594

elderly - L-dopa

younger pts - dopamine agonists

Note: does not stop progression of dz

Front 595

When is selegiline used in Parkinsonism?

Back 595

as an adjunctive treatment in pts receiving L-dopa - it is a selective MAO-B inhibitor that may slow progression of dz

Front 596

When is amantadine used for Parkinsonism?

Back 596

pts with mild disease who have NO disability - advantage of having low toxicity and improves all features of Parkinsonism.

Front 597

When are anticholinergics used in Parkinsonism?

Back 597

for pts whose predominant problem is resting tremor. Not encouraged in pts who are elderly, have dementia, or NO tremor.

Front 598

What should be suspected when an older pt presents with FLUCTUATING cognitive impairment (pronounced variations in attention and alertness), recurrent and bizarre visual hallucinations, and motor features of Parkinsonism?

Back 598

Lewy body dementia

Front 599

Suspect what when an older pt presents with personality change (disinhibition, euphora, apathy), compulsive behaviors (peculiar eating habits, hyperorality), and impaired memory?

Back 599

Pick's disease - a fronto-temporal dementia

Front 600

Most likely location of the lesion in a pure motor stroke?

Back 600

lacunar infarct of the posterior internal capsule (which carries corticospinal and corticobulbar motor fibers). Underlying pathology is thought to be a combination of microatheroma and lipohyalinosis and very rarely embolic in origin. Hypertension and DM are the most important risk factors. Comprise up to 25% of ischemic strokes and have much better prognosis than embolic strokes due to their small size. Often NOT appreciable on non-contrast CT scans.

Front 601

Best way to confirm diagnosis of CLL?

Back 601

flow cytometry to demonstrate lymphocyte clonality - CLL may present with lymphadenopathy but a significant number of pts are ASYMptomatic. Clues may be abnormally high WBC count on CBC with lymphocyte predominance. Peripheral smear may show atypical lymphocytes with "smudge" appearance.

Front 602

What are diagnostic clues to G6PD deficiency?

Back 602

bite cells and Heinz bodies (red blood cell inclusions) - G6PD is needed to create NADPH, which is in turn required to create glutathione and prevent the oxidation of hemoglobin into Heinz bodies. The denatured hemoglobin disrupts RBC membranes and causes hemolysis. This oxidation reaction typically occurs in response to drugs, fava beans, and infection.

Front 603

PTT values will be _______ in the presence of lupus coagulant.

Back 603

prolonged! this is strictly a laboratory artifact bc IgM/IgG immunoglobulin binds phopholipds used in the assay resulting in prolonged PTT. In actuality, these patients do not have bleeding problems BUT are HYPERcoagulable.

Front 604

Suspect what in any pt with a hx of cancer that presents with acute back pain and neurological symptoms, particularly loss of bowel/bladder function?

Back 604

Compression of the thecal sac aka epidural spinal cord compression due to a neoplastic cause - rapid recognition is necessary bc symptoms can rapidly progress to paralysis.

Other neruo symptoms aside from loss of bowel/bladder function may include imbalance, weakness, and weak rectal sphincter tone.

Confirm with MRI of the spine but do not delay initiation of glucorticoid treatment to reduce swelling and preserve neuro fxn while awaiting imaging results.

Front 605

TTP-HUS should be suspected if what 4 characteristic features are present?

Back 605

1) Hemolytic anemia
2) thrombocytopenia
3) renal failure
4) neuro symptoms (headache, confusion, etc)

Front 606

Mechanism of TTP-HUS?

Back 606

due to a deficiency of OR autoantibody against a specific von Willebrand factor-cleaving protease (ADAMTS-13). Causes accumulation of LARGE von Willebrand factor multimers and platelet aggregation. TTP-HUS is fatal in 80% if appropriate therapy is not promptly initiated so a high degree of clinical suspicion is necessary.

Tx of choice - plasmapheresis to remove the offending autoantibodies and replete the deficient enzyme.

Front 607

Suspect what in a younger pt with anemia that is non-responsive to iron supplementation?

Back 607

Thalassemia, especially if pt is of Mediterranean origin. Normally, there are two functional copies of the beta-hemoglobin gene but in thalassemia, there is a point mutation in one or both of these genes. This leads to reduced hemoglobin synthesis and eventually produces hypochromic microcytic anemia. Thalassemia comes in two severities:

beta-thalassemia minor - defect in 1 gene - modest anemia with MCV btn 55-75.

beta-thalassemia major - defect in both genes leading to severe anemia.

Front 608

Age distribution for IBD?

Back 608

bimodal - 20s-30s and 60s

Front 609

what is transferrin saturation?

Back 609

serum iron/TIBC

typically low in iron deficiency anemia but often normal in anemia of chronic dz.

Front 610

most common causes of microcytic anemia?

Back 610

iron deficiency, anemia of chronic disease, and thalassemia

Front 611

Complications of multiple myeloma include?

Back 611

renal failure, hypercalcemia, and hyperviscosity syndrome

Note: lytic bone lesions, marrow plasmacytosis, and urine/serum monoclonal proteins are classic findings!

Front 612

Common causes of B12 deficiency:

Back 612

total/partial gastrectomy, pernicious anemia, gastritis, disorders of the ileum preventing absorption, and old age.

Gastric DERIVED intrinsic factor must bind B12 for it to be absorbed by the ileum. B12 is necessary for purine synthesis.

Front 613

Various manifestations of polycythemia vera?

Back 613

increased RBC mass, mild granulocytosis, elevated platelet count, and LOW erythropoietin levels (ABSENCE of measurable URINE erythropoetin), INCR leukocyte alkaline phosphatase.

REVERSIBLE moderate hypertension 2dry to expanded blood volume.

BOTH bleeding and thrombosis can occur 2dry to elevated plt count and impaired plt function.
INCR incidence of peptic ulceration 2dry to histamine release from basophils).

INCR incidence of gouty arthritis 2dry to increased cell turnover.

PE may show plethoric face and splenomegaly. May complain of pruritus after bathing.

Phlebotomy to keep HCT < 45% is treatment of choice.

Front 614

DOC for mild to moderate hypercalcemia due to malignancy?

Back 614

bisphosphonates

Note: intravenous Zoledronic acid is recommended in ALL women with metastatic breast cancer and radiographic lytic bone dz and are receiving either hormone therapy or chemotherapy.

Front 615

Mechanism of hypercalcemia of malignancy?

Back 615

osteolytic metasases with local release of cytokines and tumor secretion of parathyroid hormone related peptide.

Front 616

Suspect what in a pt with hundreds of ADENOMATOUS colonic polyps?

Back 616

Familial colonic polyposis - 100% risk of cancer if not treated with a proctocolectomy!

Front 617

difference btn HIT type 1 and type 2?

Back 617

type 1 is fairly benign that resolves spontaneously whereas type 2 is caused by antibody formation to heparin-platelet 4 complex and can result in ARTERIAL thromboses.

Front 618

Pts with pernicious anemia should be periodically screened for?

Back 618

gastric cancer and castric carcinoid tumors bc increases risk by 2-3 times!

anit-intrinsic factor antibodies decrease the amount of functional intrinsic factor available to facilitate B12 absorption. Second, pts develop chronic atrophic gastritis due to the decreased prodxn of intrinsic factor by gastric parietal cells. Atrophic gastritis leads to incr risk of gastric cancer.

Front 619

what is hyposthenuria?

Back 619

nocturia 2dry to kidney's impaired ability to concentrate urine - found in pts with sickle cell disease or less sever in those with sickle cell trait. Red blood sickling in the vasa recta of the inner medulla impairs countercurrent exchange and free water reabsorption.

Front 620

Suspect what in a pt with a chronic scar that develops into a non-healing, painLESS, bleeding ulcer?

Back 620

Squamous cell carcinoma until proven otherwise - ulcers may become painFUL if ulcers do not heal. Tar derivatives (tobacco smoke) and other carcinogens and chronic radiation exposure are predisposing factors.

Dx is confirmed via punch biopsy!

Front 621

typical age of pts with pernicious anemia?

Back 621

most commonly occurs in the elderly but may affect younger pts as well, especially in the setting of other autoimmune conditions (e.g. vitiligo, autoimmune thyroid disease).

Note: dietary deficiency does NOT usually cause B12 deficiency as it does folate deficiency

Front 622

Most common malignant bone tumor of youth?

Back 622

osteosarcoma - classic radiologic findings of Codman's triangle and sunburst appearance. Average age at presentation is 15 years. Most commonly found in larger bones in the area of fastest bone growth rate (metaphyseal portions). Initial symptom is usually pain.

Tx is surgery

Front 623

common cause of autoimmune platelet destruction?

Back 623

Immune thrombocytopenic purpura - acute and self limited in children typically but insidious and chronic in adults.

tx is with systemic immunosuppression via steroids.

Front 624

serum immunoelectrophoresis shows what in multiple myeloma?

Back 624

characteristically an abnormal M-spike due to IgG antibody production by abnormal plasma cells.

this test is the best initial test when MM is suspected. BM biopsy can help confirm an abnormal result.

Front 625

Management for pt with "soap bubble appearance" in the epiphyseal end of a long bone?

Back 625

this is a giant cell tumor - refer to an orthopedic surgeon immediately

Front 626

Firm, unilateral, NON-tender lymph nodes in an older pt with a smoking hx is suspicious for?

Back 626

lymph node metastases where as similar findings in the HEAD/NECK are concerning for squamous cell carcinoma. Prompt biopsy is needed.

Front 627

Turcot's syndrome?

Back 627

brain tumors (primarily medulloblastomas and gliomas) PLUS colonic polyps (FAP or HNPCC).

Front 628

Peutz-Jeghers syndrome?

Back 628

intestinal hamartomatous polyps plus mucocutaneous melanocytic macules.

Front 629

Multiple hamartoma syndrome (Cowden syndrome)?

Back 629

GI-tract hamartomas plus Br CA, thyroid CA, and nodular gingival hyperplasia.

Front 630

Medications that cause oxidative stress?

Back 630

sulfa drugs (TMP-SMX), antimalarials, and nitrofurantoin

Front 631

What are Heinz bodies?

Back 631

When hemoglobin becomes oxidized to form methemoglobin, denatured globin, and sulfhemoglobin - conbines as insoluble masses (Heinz bodies) that attach to RBC membrane --> decr membrane pliability --> promotes RBC removal in spleen's reticuloendothelial system.

Front 632

How can a leukemoid reaction (marked incr in leukocytes due to a severe infection/inflammation) be distinguished from CML?

Back 632

they are INdistinguishable on peripheral blood smear. An INCR leukocyte alkaline phosphatase score is typical of a LEUKEMOID rxn.

Note: incr LAP score is also seen in polycythemia vera BUT these pts will have an ELEV RBC mass while ALL other cell lines are usually nml.

Front 633

Erythropoietin levels and bone marrow response in anemia of chronic dz?

Back 633

generally decreased and poor marrow response.

Front 634

Step wise approach to breaking bad news to pts?

Back 634

1) ensure quiet, private, and comfortable environment
2) "How much do you know about your symptoms?" to give an idea of the patient's expectations
3) "How much would you like to know about your condition?"
4) Give him a warning shot, "Unfortunately the situation is more serious than hoped."
5) Give results if pt wants to know....
6) Give prognosis and ALL options....
7) Be clear and simple as possible.

Front 635

what should be considered in a pt that presents with ASYMptomatic thrombocytopenia but typical bone marrow and non-bone marrow causes have been ruled out?

Back 635

initial presentation of HIV - in up to 10% of pts.

Front 636

what is pagophagia?

Back 636

pica (appetite for non-nutritive substances) for ice in particular.

Front 637

What abnormalities in calcium, phosphate, potassium, and uric acid can be seen in tumor lysis syndrome?

Back 637

both potassium and phosphate are intracellular ions so the breakdown of the cells releases excess amounts of these.

Released phosphage binds calcium --> hypocalcemia

degradation of cellular proteins ---> elevation of uric acid levels

Front 638

Migratory thrombophlebitis (aka Trousseau's syndrome) along with symptoms of upper GI discomfort is suspicious for?

Back 638

Pancreatic ADENOcarcinoma - abdominal CT should be initial diagonstic test of choice.

Front 639

Lung cancer with the LEAST association to smoking?

Back 639

Adenocarcinoma of the lung - usually peripherally located

Front 640

Look for what cytochemical features when hairy cell leukemia is suspected?

Back 640

tartrate-RESISTant acid phosphatase and CD11c marker.

It is a B-lymphocyte derived leukemia - bone marrow may become fibrotic leading to a dry tap.

Front 641

Most common manifestation of hemophilia?

Back 641

Hemarthroses withOUT significant trauma (even more common than spontaneous bruising). An x-linked disorder to a deficiency in either factor VIII (hemophilia A) or factor IX (hemophilia B).

Front 642

Anticipated lab abnormalities and prophylactic treatment for loss of pregnancy in antiphospholipid antibody syndrome?

Back 642

false positive VDRL, prolonged PTT, and thrombocytopenia.

Prophylaxis is with low dose aspirin and LMWH to avoid pregnancy loss

Front 643

What can prevent a febrile transfusion reaction?

Back 643

Leukocyte depletion techniques such as cell washing. Rxn is believed to be due to antibodies in the patient's plasma that react with the donor's leukocytes.

Front 644

Tx for dermatitis herpetiformis (associated with celiac sprue)?

Back 644

Dapsone

Front 645

Areas commonly affected by seborrheic dermatitis?

Back 645

eyebrows, nasolabial folds, bases of eyelashes, paranasal skin, and scalp (called cradle cap when scalp is involved).

It is a found in all age groups but relatively common in infancy. Transparent to yellow papules and scaling plaques are characteristic. Treatment is moisurizers, topical antifungals, anti-dandruff shampoo, and topical steroids.

Front 646

Where is the latent infection of varicella zoster virus established?

Back 646

sensory dorsal root ganglia

Front 647

Rubella is caused by what organism?

Back 647

RNA togavirus.

Tx with acetaminophen for symptomatic relief.

Front 648

Why does recurrent chalazion (develops when a meibomian gland becomes obstructed) require histopathologic examination?

Back 648

There is a risk for an underlying sebaceous (meibomian gland) carcinoma.

Note: This can be clinically difficult to distinguish fom basal cell carcinoma (most common malignancy of the lid margin).

**chalazion present as painful swellings of the lid margin that progresses to a nodular rubbery lesion.

Front 649

What is a hordeolum?

Back 649

A stye aka an acute infection of one of the glands of the eyelid. Usually due to Staph so treat with anti-staph abx and frequent hot compresses (to promote drainage).

Front 650

Most commonly involved sites of warfarin-induced skin necrosis?

Back 650

breasts, buttocks, thighs, and abdomen - initial complaint is pain, followed by bullae formation and skin necrosis. Occurs within weeks after starting therapy and is sometimes associated with Protein C deficiency.

Administer Vitamin K early, discontinue warfarin if lesion progresses, and use heparin to maintain anticoagulation until necrotic lesions heal.

Front 651

What is pyoderma gangrenosum?

Back 651

an ulcerative skin lesion - initially starts as a bite-like reaction iwth a small papule or pustule with pain as the main complaint.

Front 652

A superficial skin lesion that is pruritic, erythematous, scaly, and has a red ring with a central clearing on a pre-adolescent is suspicious for?

Back 652

Tinea corporis (ring worm) - typical in hot, humate weather. Dx with scraping and potassium hydroxide examination. treat with topical antifungals.

Front 653

Molluscum contagiosum caused by poxvirus can be generalized if?

Back 653

pt is immunodeficient such as AIDS, especially when CD4 is < 100/uL. Conjunctivitis may occur if the lid margins have been infected.

Front 654

Sudden onset of pain and swelling at a site of trauma or recent surgery that progresses to purplish discoloration with gangrenous changes and signs of SYStemic toxicity is suspicious for?

Back 654

Necrotizing fascitis - A gloved finger can easily be passed btn the 2 layers, revealing yellow green necrotic fascia which helps in the Dx. CT scan reveals necrosis, asymmetrical fascial thickening and gas!

Aggressively debride necrotic tissues and use high-flow oxygen, fluid resuscitation, plus broad-spectrum antibiotics to cover for aerobic and anaerobic organisms.

Front 655

How does toxic epidermal necrolysis (TEN) manifest?

Back 655

an erythematous morbilliform eruption that rapidly evolves into exfoliation of the skin (looks like the world's worst 3rd degree sunburn)! Patches of skin slide off with slight pressure (postitive Nikolsky's sign). Oral mucosa shows painful blisters which limits oral intake.

Often due to a drug reaction. Commonly involved drugs include sulfonamides, barbiturates, phenytoin, and NSAIDs.

Note: TEN is at the END of the spectrum for idiosyncratic skin rxns which includes Stevens Johnson syndrome and TEN/Stevens Johnson syndrome overlap. In Steven Johnson syndrome, up to 10% of the body surface area is involved whereas in TEN greater than 30% is involved. In between pts are labeled as TEN/Steven Johnson syndrome overlap.

Front 656

What is seborrheic keratoses and is it worrisome?

Back 656

Very common BENIGN growths that have a warty, stuck-on or cerebriform appearance. They are typically pigmented but may lack pigment and be pink/white to pale in color too.

Note: sometimes pruritic and tender!

Front 657

Most common cause of acquired angioedema?

Back 657

ACE-I - due to increased levels of pro-inflammatory action of bradykinin, which promotes edema, inflammation and pain. Typically presents within days to weeks after starting therapy but can occur at ANYTIME after starting meds.

Check for airway compromise and vasomotor instability, which requires epinephrine. Stop ACE-I therapy immediately.

Front 658

What should be suspected in an infant boy that presents with fever, adenopathy, and numerous umbilicated vesicles over an area of healing atopic dermatitis?

Back 658

Eczema herpeticum - a form of primary herpes simplex virus infection associated with atopic dermatitis. Infection in infants may be life-threatening, and acyclovir treatment should be initiated as soon as possible.

Front 659

Common cutaneous associations of primary biliary cirrhosis?

Back 659

xanthomas and xanthelasmas (soft, yellow plaques on medial aspect of the eyelids) due to reduced ability to absorb and store fat-soluble vitamins.

Front 660

Diagnostic study of choice for a suspected melanoma?

Back 660

Excisional biopsy - if the depth of the lesion is < 1 mm, excision with a 1 cm tumor free margin gives a 99% 5-year survival. Tumors greater than 1 mm in DEPTH should have a sentinel lymph node study.

Note: Excision with wide margins is not recommended until dx is confirmed. Incisional biopsy may miss the malignant focus within an otherwise normal nevus.

Front 661

tx for mild acne (non-inflammatory comedonal acne)?

Back 661

topical retinoids

Front 662

tx for mild-to-moderate inflammatory acne?

Back 662

topical retinoids plus topical abx

Front 663

tx for papular and inflammatory acne (moderate-to-severe)?

Back 663

oral abx

Front 664

tx for nodulocystic and scarring acne?

Back 664

oral isotretinoin

Front 665

Best method of photo-protection from the sun?

Back 665

Sun avoidance especially in the middle of the day (btn 10 AM and 4PM) remains the best method.

Inform pts that sunscreens should be applied 15-60 minutes PRIOR to sun exposure to allow enough time for protective film development.

Front 666

What are strawberry hemangiomas (capillary hemangiomas) composed of?

Back 666

thin walled blood vessels separated by connective tissue.

Front 667

Suspect what in a pt that presents with diffusely blistered skin with flaccid bullae that appeared spontaneously, first starting in the mouth? Immunofluorescence shows IgG deposits INTRAcellularly in the EPIdermis.

Back 667

Pemphigus vulgaris - the flaccid bullae are tender and painful when they rupture and have a positive Nikolsky's sign. It is due to autoantibodies against desmoglein.

Common tx is steroids. Immunosuppressives (azathioprine) may be used with prednisone and methotrexate.

Note: Bullous pemphigoid is a PRURitic dz with TENSE (not flaccid) blisters and oral lesions are RARE. Immunofluroescence shows IgG AND C3 in the dermal epidermal JUNCTION.

Front 668

Pale, velvety pink or whitish, hypopigmented skin macules that do NOT tan and do not appear scaly, but scale on scraping is most likely due to?

Back 668

tinea versicolor due to Malassezia furfur - skin scrapings after KOH will show large, blunt hyphae and thick-walled budding spores (classic spaghetti and meatballs appearance).

Tx topically with selenium sulfide lotion and ketaconazole shampoo. Change in pigmentation requires MONTHS to return to normal.

Front 669

What causes toxic shock syndrome?

Back 669

an EXOtoxin producing strain of S. aureus - exotoxin acts as a superantigen leading to massive cytokine release. Pts present with fevers, hypOtension, and generalized erythema that 1-2 weeks later can lead to desquamation of the palms and soles.

Front 670

Stellate purpura with a central gunmetal gray color is a classic skin finding for?

Back 670

acute meningococcemia - skin finding may affect up to 50% of affected pts and therefore can be KEY to a quick diagnosis.

Front 671

Dry and rough skin with horny plates over the extensor surfaces of the limbs is a hallmark for ?

Back 671

ichthyosis - condition worsens in the winter bc of incr dryness. can be hereditary or acquired.

Front 672

What distinguishes a benzodiazepine overdose from an opioid overdose?

Back 672

Benzodiazepine overdose lacks severe respiratory depression and lacks pupillary constriction.

Front 673

What distinguishes alcohol and phenytoin inoxication from benzodiazepine overdose?

Back 673

The presence of nystagmus in alcohol/phenytoin intoxication.

Front 674

What should be first priority when there is any chemical contact with the eye?

Back 674

immediate flushing of the affected eye with copius amounts of running water for at least 15 minutes. Obtaining medical care AFTERWARD is appropriate.

Note: With exposure of the eye to acid, there is a good chance of full recovery whereas with alkaline exposure, permanent corneal damage is more likely.

Front 675

What should be first priority when there is a foreign body or cuts/scratches of the eye?

Back 675

Obtaining medical care.

Front 676

What is organophosphate poisoning?

Back 676

Acetylcholinesterase is rendered non-functional leading to symptoms of cholinergic excess (bradycardia, miosis, bronchorrhea, muscle fasciculations, salivations, lacrimation, diarrhea, and urination).

Atropine should be given to compete with acetylcholine at muscarinic receptors to counteract the cholinergic excess. Immediate removal of the pt's clothing to prevent continuedaborption through the skin is also necessary.

Note:physostigmine (acetylcholinesterase inhibitor) would WORSEN this condition.

Front 677

Best next step in mgmt for TCA overdose?

Back 677

an emergent ECG to analyze the QRS complex.

Front 678

What can confirm a suggested opioid intoxication?

Back 678

Improvement of the pt's respiratory rate with NALOXONE administration (an opioid antagonist).

Front 679

What drug is known to occasionally cause hypothermia by disrupting thermoregulation and the body's shivering mechanism?

Back 679

fluphenazine - a high potency "typical" antipsychotic - pts should be advised to avoid prolonged exposure to extreme temperatures.

Front 680

The most serious effect of alcohol withdrawal?

Back 680

delirium tremens - occurs after 48-96 hours and consistsofhypertension, agitation, tachycardia,hallucinations, and fever. Mortality rate of up to 5%. Pt should be placedin aprotective environment and treated with benzodiazpeines - chlordiazepoxide is a common choice.

Front 681

Hallucinations and withdrawal seizures from alcohol withdrawal can be seen when?

Back 681

24-48 hours.

Front 682

Early symptoms of reflex hyperactivity (anxiety, insomnia,tremors,and diaphoresis) in alcohol withdrawal can be seen when?

Back 682

first 24 hours.

Front 683

The most severe consequences of methanol intoxication are?

Back 683

vision loss and coma - PE in methanol intoxication may reveal optic disc hyperemia while lab studies reveal ANION GAP metabolic acidosis. An increased OSMOLAR GAP is often seen as well.

Front 684

Next best step in treatment for a pt who has ingested lye (sodium hydroxide)?

Back 684

Upper GI endoscopy to evaluate the extent of damage. Damage from alkaline solutions cause almost instantaneous liquefactive necrosis of the esophageal wall which can lead to perforation and mediastinitis. Efforts to neutralize the alkali, induce vomiting, or administer charcoal does not improve outcomes and in fact complicates management. Gastric decontamination with ipecac to induce vomiting will only RE-expose the esophagus to lye causing more injury. Activated charcoal will obstruct the view during endoscopy. And, neutralization will not reverse the INSTANTaneous damage caused by lye and will make things worse by generating heat.

Front 685

When is administration of activated charcoal helpful?

Back 685

Within one hour of non-alkaline poison.

Front 686

Most common associated electrolye abnormality in Addison's (primary adrenal failure) disease?

Back 686

hypOnatremia. hyperkalemia is also common.

Front 687

Signs of septic shock?

Back 687

acidosis(due to accumulation of lactate 2dry to tissue hypoxia and anaerobic respiration resulting from hypotension related to septic shock), low urine output, hypOtension, tachypnea, fever.

Front 688

What does sodium plystyrene sulfonate (kayexalate) do?

Back 688

A potassium-binding resin that decr total body potassium through the gut. Sodium is exchanged for potassium. It takes at least 1-2 hours to work.

Insulin and glucose is much more rapid-acting taking only 15-30 minutes to drive potassium intracellularly.

Front 689

How to tell if metabolic alkalosis is "chloride-sensitive?"

Back 689

LOW URINary chloride excretion (<20 mEq/day) and saline-RESPONSIVE volume depletion.

Front 690

How to tell if metabolic alkalosis is "chloride resistant?"

Back 690

normal serum chlorine --> normal urine chloride

saline UNresponsive

Front 691

Electrolyte abnormality in Cushing's syndrome?

Back 691

hypOkalemia and hypERnatremia - excessive cortisol which also means excess mineralocorticoid activity causing renal potassium wasting. Severe Cushing's can be treated with an aldosterone antagonist like spironolactone.

Front 692

Most common organisms involved in subacute (already present valvular abnormality) bacterial endocarditis?

Back 692

1) Viridans group (usually from upper respiratory)
2) enterococci - usually if genitourinary infections or GU procedures (ie.cystoscopy) have taken place
3) coagulase-negative staph (such as S. epidermidis) - usually from skin

Note: S. aureus is common in acute, severe illness with NORMAL heart valves

Front 693

Potential side effects of amiodorone (an antiarrhythmic):

Back 693

1) thyroid dysfunction
2) pulmonary fibrosis
3) hepatotoxicity

Front 694

Diagnostic criteria for ARDS:

Back 694

1) acute onset
2) PaO2/FIO2 < 200
3) the presence of bilateral infiltrates on CXR
4) Swan Ganz pressure (measures PCWP) <18

Note: LOW PCWP and absence of JVD aids in distinguishing ARDS from CHF. ARDS is a form of NON-cardiogenic pulmonary edema

Front 695

First step in management of SYMPTOMATIC sinus bradycardia?

Back 695

treat with IV atropine bc it decreases vagal input

Note: use epinephrine in hemodynamically UNstable patients with sinus brady.

Front 696

Causes of sinus brady:

Back 696

excellent physical conditioning, exaggerated vagal activity, sick sinus syndrome, hypOglycemia and certain meds (digitalis, b-blockers, Ca Ch blockers).

Front 697

How does prolonged, tachysystolic atrial fibrillation effect the left ventricle?

Back 697

causes LV DILATION and a DEPRESSED ejection fraction.

Front 698

Most important priority when managing prolonged, tachysystolic atrial fibrillation?

Back 698

controlling the rhythm or rate - improves LV function significantly and sometimes dramatically

Front 699

Classic symptoms that indicate need for surgery in patients with aortic stenosis?

Back 699

ASD
angina
syncope
dyspnea

onset of any of these 3 symptoms (especially dyspnea) indicates poor prognosis withOUT surgery (50% 3-year mortality rate).

Front 700

Indications for aortic valve replacement (3):

Back 700

1) ALL SYMptomatic patients with AS
2) patients with severe AS already undergoing CABG or other valvular surgery
3) ASYMptomatic patients with severe AS and EITHER poor LV systolic function, LVH > 15 mm, valve area < 0.6 cm2, OR abnormal response to exercise

Front 701

Definition of PEA pulseless electrical activity?

Back 701

DISCERNIBLE rhythm on cardiac monitoring BUT clinical cardiac arrest, i.e. NO palpable pulses or BP

Best management: manual chest compressions and CPR

Note: UNLIKE VF/VT, this is NOT a shockable rhythm

Front 702

When is synchronized electrical cardioversion used?

Back 702

To convert a patient with a PERFUSING tachyarrhythmia (i.e. positive pulses and BP) BUT with SERIOUS hemodynamic compromise nonetheless.

Front 703

Management for a pt showing evidence of a STEMI plus flash pulmonary edema (acute heart failure causing pulmonary edema)?

Back 703

Furosemide - diuresis to reduce preload thereby decreasing pulmonary capillary pressure. Also causes VENOdilation, also decreasing preload.

Morphine is also beneficial for both anxiolytic AND PRELOAD reducing effects.

Nitrates, oxygen, and heparin should be given as in all MI's.

B-blockers, although standard therapy in MI, should be AVOIDED as it can worsen acute heart failure.

Front 704

Chronic hypoxemia in COPD causes?

Back 704

constriction of the pulmonary ARTERIAL system leading to pulmonary HTN --> RVH --> right heart failure

Note: pulmonary CAPILLARY wedge pressure reflects the LEFT ATRIAL pressure

Front 705

Blood pressure control and salt restriction can help alleviate edema 2dry to:

Back 705

LEFT heart failure - a clue may be crackles on lung auscultation

Front 706

Smoking cessation and oxygen therapy will improve edema 2dry to:

Back 706

RIGHT heart failure from increased pulmonary ARTERY pressure

Clues may be evidence of cor pulmonale such as elevated JVP or ascites

Front 707

Best intervention to reduce AAA PROGRESSION when surgery is not indicated?

Back 707

smoking cessation!

antihypertensives, reducing cholesterol, improving DM, and alcohol cessation are all good but not as effective in reducing AAA progression.

Front 708

Common causes of amyloidosis?

Back 708

Chronic inflammatory disease such as rheumatoid arthritis and multiple myeloma.

Can result in involvement of heart, liver and kidney.

Front 709

How does amyloidosis involve the heart, liver, and kidney?

Back 709

deposition of amyloid fibrils:
in kidney - results in proteinuria
in heart - results in RESTRICTIVE cardiomyopathy with thick ventricular walls and diastolic dysfunction BUT PRESERVED ventricular dimensions--> CHF

liver - inhibits the synthesis of coagulation factors resultin in increased bruisability

Front 710

Electrical alternans (amplitude of the QRS alternates) signifies?

Back 710

cardiac tamponade

Remember that an URI can lead to pericarditis causing a pericardial EFFUSION and resulting in tamponade. Decreased preload and CO can lead to syncope from decreased cranial blood flow.

Treatment is massive volume resusciation and emergent pericardiocentesis.

Front 711

Isolated systolic HTN (as indicated by widened pulse pressure) is an important cause of HTN in ELDERLY patients is caused by?

Back 711

decreased ELASTIC properties of the arterial wall - ALWAYS treat despite fact that diastolic pressure is not elevated. Hydrochlorthiazide is DOC.

Front 712

The cause of generalized edema in patients with end stage renal disease as well as glomerulonephritis?

Back 712

decreased GFR (can present with TRACE proteinuria)

Front 713

Outflow obstruction in hypertrophic cardiomyopathy results from?

Back 713

both septal hypertrophy AND systolic anterior motion (SAM) of the mitral valve

Front 714

The most common cause of Afib is?

Back 714

HTN causing DIASTOLIC dysfunction (aka heart failure with preserved left venricular ejection fraction). Diastolic dysfunction refers to impaired filling of the left or right ventricle EITHER bc of impaired myocardial relaxation or a stiff, non compliant ventricle. Contractility may remain normal (i.e. normal EF) but increased diastolic pressures reduces cardiac output.

Chronically elevated LV DIASTOLIC pressures cause left atrial pressures to rise which in turn can lead to Afib.

Treatment is with antihypertensives and DIURETICS when decompensated heart failure signs begin.

Front 715

What occurs in more than 30% of cases of INFERIOR wall MI?

Best management?

Back 715

Right ventricular infarction - clues may be clear lung fields (although if LV infarction is severe enough to cause pulmonary edema, this may not be the case), JVD, and hypOtension.

IV fluid resuscitation to increase RV stroke volume and enhance left ventricular filling. Avoid any medication that reduces preload (NITRATES or diuretics) bc this will exacerbate symptoms.

Front 716

In what settings are nitrates NOT indicated?

Back 716

aortic stenosis

recent phosphodiesterase inhibitor use

R ventricular infarction (30% of cases with inferior wall MIs)

Front 717

3 causes of pulsus paradoxus (difference in SBP of > 12 mm Hg during inspiration)?

Back 717

1) cardiac tamponade
2) tension pneumothorax
3) severe asthma

Front 718

Why does systolic pressure drop during inspiration? Why does it drop more in scenarios that cause pulsus paradoxus such as tamponade, tension pneumothorax and severe asthma?

Back 718

increased venous return to the right heart causes impaired LVH filling due to COMPRESSION of the left ventricle.

elevated intraTHORACIC pressures during inhalation are thought to FURTHER exacerbate compression of the left ventricle.

Front 719

Common side effect of dihydropyridine Ca-Ch antagonists such as amlodipine?

Back 719

peripheral edema due to dilation of peripheral vessels

Front 720

Drugs other than ACE-inhibitors that have shown to have a mortality benefit in CHF?

Back 720

B-blockers, angiotensin II receptor blockers, and spironolactone.

Front 721

Initial investigation of choice in suspected aortic dissection?

Back 721

TEE but ONLY AFTER hypertension treatment is initiated.

Front 722

leading cause of constrictive pericarditis WORLDwide?

Back 722

TB

Front 723

Most common cause of 2dry hypertension, especially in those with RESISTANT htn and evidence of atherosclerotic disease?

Back 723

renal artery stenosis

clue may be a systolic and diastolic periumbilical murmur with the diastolic component more specific for renal artery stenosis.

Front 724

Subclavian artery atherosclerosis has a preference for _____ artery?

Back 724

the left artery - manifests as higher blood pressure in left arm versus the right arm

note: higher blood pressure in the right arm or arms pressure > leg pressure is more indicative of coarctation of the aorta.

Front 725

Increased risk for maternal cervical insufficiency?

Back 725

past GYN procedures (LEEP, cone biopsy), DES exposure, multiple gestation, preterm birth, or second trimester pregnancy loss.

Front 726

gold standard for evaluating the cervix for cervical incompetence?

Back 726

TRANSvaginal ultrasound - cervical length should be > 25 mm at 24 weeks gestation

Front 727

what is more sensitive to outliers - the mean, median or mode?

Back 727

the mean is very sensitive to outliers and easily shifts toward them

Front 728

Limiting side effects of nicotinic acid for increasing HDL?

Back 728

flushing (80%), pruritus (2-%), nausea, or paresthesias - limited by using a controlled-release form of the medication

Front 729

What is a common hip disorder seen in overweight adolescents?

Back 729

slipped capital femoral epiphysis - children with endocrine issues are more likely to have bilat dz and to present at an earlier age. On examination, pts hold the hip in passive external rotation and exhibit decreased internal rotation, abduction and flexion.

DX is made via plain XR of the hip (AP and frog leg lateral views). Tx is surgical fixation at the current degree of slippage to avoid risk of avascular necrosis.

Front 730

Why do Turner's patients have a higher risk of osteoperosis?

Back 730

lower estrogen levels and bc they have only one copy of the X chromosome genes involved in bone metabolism.

Front 731

best means of evaluating liver damage in patients with acute hepatitis vs. chronic hepatitis (hepatitis >6 months)?

Back 731

acute - LFTs and viral serology

chronic - liver biopsy

Front 732

gastric outlet obstruction is characterized by what symptoms? Major causes of gastric outlet obstruction?

Back 732

early satiety, nausea, non-bilous vomiting, and weight loss (diabetic gastroparesis presents in a similar way)

causes: PUD, strictures 2dry to ingestion of caustic agents, pyloric stenosis, and pancreatic cancer

Front 733

Most commonly injured rotator cuff muscle?

Back 733

SUPRAspinatus

Front 734

What is the drop arm sign?

Back 734

Arm is abducted passively to greater than 90 degrees and asked to lower arm slowly. With complete rotator cuff tear, the pt will be unable to lower the arm smoothly and will appear to drop rapidly from near the 90 degree position.

Front 735

What will a biopsy show in laxative abuse?

Back 735

dark brown discoloration of the colon with lymph follicles shining through as pale patches (melanosis coli).

Front 736

A deadly complication of cirrhosis characterized by renal failure that does not respond to volume resuscitation?

Back 736

hepatorenal syndrome - best treated with liver transplantation. ACE-I and low-dose dopamine proves to be of no benefit

Front 737

The typical cause of erectile dysfunction from a pelvic fracture and urethral injury?

Back 737

NERVE injury and altered ARTERIAL supply - not veins

Front 738

The typical cause of erectile dysfunction from a penile injury?

Back 738

venogenic

Front 739

Endocrinologic causes of erectile dysfunction?

Back 739

hyperprolactinemia, testosterone deficiency, and DM

Front 740

5 phases of iron intoxication:

Back 740

1) GI phase with direct mucosal damage (30 min - 6 hours) - N/V, hematemesis (coffee ground emesis), melena, abdominal pain
2) latent phase (6-24 hours) - mostly asymptomatic
3) Shock and metabolic acidosis (12-96 hours)
4) hepatotoxicity (12-96 hours)
5) Bowel obstruction 2dry to mucosal scarring - several weeks post-ingestion

Front 741

Main substrates of gluconeogenesis?

Back 741

alanine, lactate, and glycerol-3-phosphate

pyruvate is an intermediate during gluconeogenesis

Front 742

Give tetanus-diptheria TOXOID in what scenarios?

Back 742

in almost all scenarios EXCEPT if pt received the booster <10 years and the wound is MINOR and clean

Note: in more severe or dirty wounds with unknown immune status or booster given >10 years, give toxoid AND tetanus immune globulin

Front 743

3 major treatment options of Grave's dz?

Back 743

1) Radioactive iodine ablation: preferred in the US
2) antithyroid drug therapy - propylthiouracil OR methimazole
3) thyroidectomy

Serious side effect of antithyroid drug: agranulocytosis. Pts advised to stop if sore throat and fever arise and the WBC count is checked. Routine monitoring is NOT helpful.

Front 744

True or false: A pregnant woman has the right to refuse treatment, even if it places her unborn child at risk.

Back 744

True

Front 745

Suspect what in an HIV pt with pleuritic pain and CAVITATING lung nodules on CXR?

Back 745

tricuspid endocarditis caused by S. aureus from IV drug use - fragments of vegetation from the tricuspid valve can embolize to the lungs as nodules that cavitate

Front 746

top three risk factors for NASH?

Back 746

obesity, DM, hypertricglyceridemia

other risk factors include TPN, endocrinopathies, and use of certain meds (corticosteroids, amodorone, diltiazem, tamoxifen, HAART).

Front 747

Most common cause of 2dry HTN in children?

Back 747

Fibromuscular dysplasia - can present as new onset HTN in children. Bruit or venous hum can be heard at costovertebral angle. Angiogram reveals the "string of beads" sign.

Front 748

Recommended chemoprophylaxis for people traveling to Sub-saharan Africa or the Indian subcontinent?

Back 748

Mefloquine for chloroquine-resistant Plasmodium falciparum - start one week before travel and continue 4 weeks after departure from endemic area

Front 749

What is caused by autoimmune destruction of melanocytes and peaks in persons aged 20-30 years?

Back 749

vitiligo - macular depigmentation that involves the peri-orificial and acral areas

Front 750

An anticonvulsant agent which can be used to treat benign essential tremors but may precipitate acute intermittent porphyria which manifests as abdominal pain, neurologic and psychiatric abnormalities?

Back 750

Primidone - check for urine porphobilinogen if this side effect is suspected

Front 751

Chronic hepatitis C is associated with a number of EXTRA-hepatic complications like:

Back 751

1) cryoglobulinemia
2) Bcell lymphomas
3) Plasmacytomas
4) Autoimmune dz like Sjogren's syndrome and thyroiditis
5) Lichen planus
6) Porphyria cutanea tarda
7) Idiopathic thrombocytopenic purpura
8) membranoproliferative glomerlunephritis (2dry to cryoglobulinemia)

Front 752

Three complications that can lead to hypOtension btn day 3-7 after an MI:

Back 752

1) Mitral regurg due to papillary muscle rupture - pansystolic murmur loudest at the apex with radiation to the axila (classic of MR)

2) Left ventricle free wall rupture - JVD, distant heart sounds, pericardial rub, and pulsus paradoxus (all 2dry to tamponade)

3) Interventricular septum rupture - pansystolic murmur heard best at left sternal border.

Front 753

Why does CF often present as failure to thrive?

Back 753

Due to fat and protein malabsorption from pancreatic insufficiency.

Pts may also have dry skin (Vit A deficiency), epistaxis (Vit K deficiency), meconium ileus at birth, and infertility.

Front 754

Suspect what in any patient with a hx of tick bite, systemic symptoms, leukopenia, and/or thrombocytopenia, and elev aminotransferases?

Back 754

Ehrlichiosis - incubation period varies from 1-3 weeks. Also known as the spotLESS Rocky Mountain fever bc there is usually NO rash. Peripheral blood smear may show intracellular WBC inclusions called morulae but such diagnosis is NOT necessary for starting treatment.

DOC=doxycyline (same as for Lyme dz and RMSF).

Front 755

Treatment for pregnant women with RMSF?

Back 755

Chloramphenicol

Front 756

What acid-base status is seen in COPD patients?

Back 756

respiratory acidosis due to chronic CO2 retention.

Front 757

Treatment that is often used in COPD patients who have developed signs of cor pulmonale (elev JVP, hepatomegaly, and peripheral edema, all present with CLEAR lungs) but must be used cautiously so that cardiac output is not reduced to the point of subsequent renal failure?

Back 757

loop diuretics - may also see hypOkalemia as result.

Front 758

depressed cardiac output plus an elevated PCWP is indicative of?

Back 758

left ventricular failure. As a result, systemic vascular resistance is increased (mediated by sympathetic neurohumoral activation, renin-angiotensin system activation) in attempt to preserve cardiac output and maintain tissue perfusion.

Remember: PCWP is an indicator of left ATRIAL pressure, and most of the times left ventricular END-DIASTOLIC pressure too).

Front 759

What does an anion gap represent?

Back 759

concentration of UNmeasured serum ANIONS - it is increased by the abnormal presence of NON-CHLORINATED acids in the serum such as MUDPILES.

Front 760

The two most common explanations for inflammatory monoarthrits?

Back 760

septic arthritis and crystal-induced arthritis: given the potential for joint destruction from septic arthritis, it should be considered the cause of inflammatory monoarthritis until proven otherwise.

Synovial fluid analysis, gram stain and culture are critical for distinguishing septic from crystal-induced arthritis.

Front 761

Patients with rheumatoid arthritishave an increased risk of what other type of arthritis?

Back 761

septic arthritis from S. aureus.

Front 762

Most common indication for hysterectomy?

Back 762

uterine fibroids

Front 763

uterine fibroids grow in response to what hormone?

Back 763

estrogen - so become larger with OCPs and during pregnancy; often regress after menopause

Front 764

Features of an innocent murmur in children?

Back 764

asymptomatic
systolic ejection quality
less than grade 2 of 4 intensity
VARIES with position
normal S2 sound
no other extra sounds
normal pulses

Front 765

What is sample distortion bias?

Back 765

when the study sample is not representative of the target population with respect to distribution of exposure and outcome

Front 766

What is information bias?

Back 766

imperfect assessment of association between exposure and outcome as a result of errors in measurement. Can be minimized by using standardized techniques as well as trained observers.

Front 767

What is confounding bias?

Back 767

presence of one or more variables associated INDEPENDENTLY with both exposure and outcome.

Front 768

Recurrent pneumonia in the same anatomic location is a red flag for?

Back 768

lung cancer, especially in a smoker. Initial investigation of choice is a CT scan of the chest to look for a mass. A bronchoscopy guided biopsy should be done for PERIbronchial mass, whereas a CT-guided biopsy should be used for a PERIPHERAL mass.

Front 769

True or false? A physician is authorized to provide emergent life-saving treatment to an unconscious patient who does not have a living will despite a spouse requesting treatment be witheld for religious reasons?

Back 769

true

Front 770

How does an infant with C. botulinum in the intestinal tract present?

Back 770

often with CONSTIPATION and poor feeding. This is followed by progressive hypotonia, weakness, loss of DTRs, cranial nerve abnormalities (impaired gag reflex, ptosis, mydriasis), and respiratory difficulties. Signs of autonomic dysfunction such as hypotension and neurogenic bladder can occur early too.

Note: Do not confuse with C. botulinum TOXIN intake which causes pseudomembranous colitis with diarrhea. This is ingestion of food with actual C. botulinum organism which grows in the gut and produces toxin responsible for blocking acetylcholine release.

Front 771

Management of a septic abortion?

Back 771

1) cervical and blood culture
2) antibiotics
3) GENTLE suction curettage to remove infectious nidus

Note: vigorous suction curettage may cause perforation of the uterus and should be avoided.

Front 772

The most common cause of death in patients with an MI?

Back 772

Vfib-a RENTRANT arrhythmia

Front 773

Patients with an epidural hematoma may present with what focal neuro signs?

Back 773

ipsilateral dilation of the pupil (caused by oculomotor nerve compression) along with ipsilateral hemiparesis.

Front 774

Borrelia burgdorferi causes?

Back 774

Lyme disease - intermittent inflammatory arthritis is a typical PRESENTation

Front 775

Reliability or reproducibility is a measure of?

Back 775

random error

Front 776

INternal validity is the same thing as?

Back 776

bias

Front 777

External validity or generalizability means?

Back 777

the extent to which results of a study are applicable to other populations. For example, a study conducted in middle-aged women would not be applicable to elderly men.

Front 778

How to distinguish gonococcal vs. chlamydial conjunctivitis in an infant?

Back 778

gonococcal - btn 2-5 days and very purulent

chlamydial - greater than 5 days and LESS purulent

Note: chemical conjunctivitis from prophylactic drops occurs in the 1st 24 hours and is mild

Front 779

Priorities in managing a rib fracture?

Back 779

analgesia to allow proper ventilation and prevent atelecatasis/pneumonia. NSAIDs and opiates are commonly used but an intercostal nerve block can also be used if oral meds are not sufficient.

Note: opiates may depress respiratory function but a nerve block carries some risk of pneumothorax

Front 780

What is an inflammatory change in the medial CANTHAL region of the eye usually due to S. aureus or beta-hemolytic Streptococcus?

Back 780

Dacrocystitis

Front 781

What is bronchoalveolar lavage and when is it useful?

Back 781

A method of sampling lung cells during bronchoscopy - it has the greatest diagnostic utility in the evaluation of suspected malignancy or an opportunistic infection.

Note: It has a well-established role in dx of PCP AFTER sputum induction (which is less invasive) does not yield a diagnosis.

Front 782

Age for colonoscopy screening?

Back 782

50 for average risk patients.

For patients with an affected first-degree relative, screening should begin 10 years before the age the relative was DIAGNOSED.

Front 783

If dantrolene is not available for the treatment of neuroleptic malignant syndrome, what can be used as an alternative?

Back 783

bromocriptine (a dopamine agonist) and amantadine (an antiviral drug with dopaminergic properties).

Front 784

How to distinguish the vascular claudication of PVD from the "neurogenic claudication" of spinal stenosis?

Back 784

PVD-induced claudication is EXERTION dependent and resolves while standing STILL. Neurogenic claudication is POSITION-dependent and resolves with sitting or laying but PERSISTS while standing still.

Front 785

Dementia that has a fluctuating cognitive impairment and often bizarre, visual hallucinations?

Back 785

Lewy body dementia

Front 786

What can cause painLESS blisters, increased fragility on the dorsal hand surface, facial hypertrichosis, and hyperpigmentation that is often associated with Hepatitis C infection?

Back 786

Porphyria cutanea tarda - from a deficiency of uroporphyrinogen decarboxylase (an enzyme in the heme synthesis pathway). It can be triggered by ingestion of certain substances like ethanol or estrogens and should be discontinued.

Front 787

Tx for porphyria cutanea tarda?

Back 787

phlebotomy or hydroxychoroquine may provide reliev

interferon-alpha if pt is simultaneously infected with Hep C.

Front 788

What is Ramsay Hunt syndrome?

Back 788

a form of herpes zoster that causes Bell's palsy - vesicles are seen on the outer ear.

Front 789

When should a pt with asthma be prescribed an inhaled LOW-dose corticosteroid (in addition to the preexisting PRN albuterol inhaler)?

Back 789

When symptoms are > 2 days/wk with nighttime awakenings 3-4x/month, minor limitation of activities, and normal FEV1.

Front 790

when should an asthma pt on PRN albuterol inhaler and corticosteroid inhaler be prescribed a long-acting beta-2 inhaler?

Back 790

Daily asthma symptoms, frequent nighttime awakenings, extremely limited activity, and FEV1<60% predicted. Corticosteroid inhaler should also be upgraded to a HIGH-dose.

Front 791

How should palpation of the vertex at the fundus before 37 weeks gestation be managed?

Back 791

Routine follow up as most will self-correct by week 37. External cephalic version is inicated if breech presentation persists after 37 weeks.

Front 792

When is serologic testing with ELISA, followed by western blot for Lyme disease performed?

Back 792

in patients with intermediate pretest possibility such as those with no clear hx of tick bite but probable exposure and positive s/sx.

Front 793

Dissection of aorta can extend into the pericardium, coronary arteries or carotid arteries, leading to...?

Back 793

cardiac tamponade, MI, or stroke, respectively.

Front 794

positive McMurray sign is specific for?

Back 794

meniscal injury

Front 795

Standard management of solitary lesion brain metastasis?

Back 795

surgical resection followed by whole brain radiation.

Front 796

Standard management of MULTIPLE brain metastases?

Back 796

palliative whole brain radiation

Front 797

What should be suspected in a pt with GI symptoms including abdominal pain, diarrhea, and malabsorption with distention, flatulence and steatorrhea PLUS fever, weight loss, arthralgias, skin hyperpigmentation, chronic cough, and heart murmur?

Back 797

Whipple's dz - a MULTI-system illness caused by bacillus Tropheryma whippelii - most common in white men during the 4th-6th decades.

EXTRA-intestinal manifestions include migratory polyarthropathy, chronic cough, and myocardial/valvular involvement leading to CHF or regurg. Later stages of dz may include dementia and other CNS findings such as supranuclear ophthalmoplegia and myoclonus.

Biopsy will show PAS-positive material in lamina propria of the small intestine.

Front 798

When is D-xylose absorption abnormal?

Back 798

Both in bacterial overgrowth and celiac dz. However, with bacterial overgrowth, absorption becomes normal after antibiotic treatment.

Note: Absorption of D-xylose ONLY requires INTACT mucosa in the PROXIMAL small bowel so is unaffected by the other fat malabsorptive diseases such as pancreatic insufficiency and Crohn's.

Front 799

When should screening for colon cancer begin in a pt with ulcerative colitis?

Back 799

8 years after diagnosis with repeat colonoscopy once every 1-2 years.

Front 800

What should be suspected in a fairly young AA pt who presents with progressive dyspnea and dry cough PLUS erythema nodosum and a hx of uveitis?

Back 800

Sarcoidosis - 25% will develop anterior uveitis which is usually self-limited but can sometimes progress to blindness.

CXR shows bilateral hilar lymphadenopathy and/or diffiuse interstitial infiltrates.

Front 801

What does VIPoma=pancreatic cholera mean?

Back 801

a rare pancreatic cancerous tumor that causes severe watery diarrhea PLUS hypokalemia (may manifest as leg cramps). Other symptoms include dehydration, abdominal pain/cramping, weight loss, facial flushing and redness.

Tx: First correct dehydration. Second slow diarrhea with meds like ocreotide. Third, surgically remove if no metastasis will often cure dz.

Front 802

What is tamoxifen's effects on breast tissue, endometrium, and bone?

Back 802

antagonist to breast tissue DECR CA

agonist to endometrium INCR CA

agonist to bone osteoclasts DECR osteoperosis

Front 803

What pregnant women should be screened for syphillis?

Back 803

ALL of them regardless of risk factors (at first prenatal visit)

Front 804

What pregnant women should be screened for chlamydia?

Back 804

Under the age of 24 or at high-risk (hx of STDs, new/multiple partners)

Front 805

Frequent comorbid conditions in Tourette syndrome?

Back 805

ADHD (60%) or obsessive-compulsive disorder (27%).

Front 806

Treatment of choice in schizophrenia patient that is noncompliant with medication?

Back 806

Depot antipsychotics such as fluphenazine and haloperidol.

Front 807

Treatment for hepatic encephalopathy?

Back 807

1) Treat underlying precipitant
2) Lactulose - a nonabsorbable disaccharide syrup that is converted into ACIDS by colonic bacteria. This acidification causes catharsis and a decrease in circulating ammonia levels.
3) Antibiotics may help in decreasing the number of ammonia-producing bacteria
4) Laxatives also promote catharsis and may be of some benefit.

Front 808

When should children develop separation anxiety?

Back 808

Btn 9-18 months

Front 809

What may be the only indication of a diaphragmatic hernia in a patient with blunt abdominal trauma?

Back 809

An elevated LEFT diaphragm on CXR. Patients usually have respiratory distress and deviation of mediastinal contents to the opposite side.

Early diagnosis is important bc therre is a high rate of mortality and bowel strangulation may be up to 30%.

Front 810

Antidote for TCA or aspirin overdose?

Back 810

sodium bicarbonate

Front 811

Tx for torsades de points?

Back 811

Magnesium sulfate

Front 812

Tx for severe lithium toxicity?

Back 812

hemodialysis

Front 813

antidote for moderate to severe lead poisoning?

Back 813

Calcium EDTA

oral succimer can be used in mild to mod lead poisoning.

Front 814

What is cardioprotective in cases of hyperkalemia?

Back 814

Calcium gluconate

Front 815

antidote for acetaminophen?

Back 815

N-acetylcysteine

Front 816

Management of pt who presents with lab findings indicative for lupus nephritis?

Back 816

renal biopsy to determine the class of nephritis. Different types of nephritis require different therapies.

Front 817

Why may a patient with BPH present with an inability to void when in severe pain?

Back 817

inability to Valsava due to pain

Front 818

Most frequent cause of NON-traumatic subarachnoid hemorrhage?

Back 818

rupture of saccular aneurysm, especially when larger than 7 mm or present in the anterior circulation of the circle of Willis.

Front 819

Side effects of niacin can be reduced with what drug?

Back 819

low dose aspirin to negate the prostaglandin-induced peripheral vasodilation

Front 820

Smudge cells are characteristically seen in what type of leukemia?

Back 820

CLL

Front 821

Reid Sternberg cells are pathognomonic for?

Back 821

Hodgkin's dz

Front 822

nasopharyngeal carcinoma is strongly associated with?

Back 822

EBV infection - common in pts of Mediterranean and Far Eastern descent

Often presents with recurrent otitis media, recurrent epistaxis, or nasal obstruction

Front 823

Management of an arterial embolus?

Back 823

1) heparin therapy immediately without delay for confirmatory testing
2) percutaneous thrombolysis (i.e. intra-arterial fibrinolysis AT SITE of embolus)/mechanical embolectomy or surgical embolectomy.

Front 824

What is a malabsorption syndrome which can be associated with a hx of abdominal surgery?

Back 824

bacterial overgrowth - pts in severe and advanced cases may present with tetany (hypocalcemia due to Vit D deficiency), night blindness due to Vit A deficiency, neuropathy due to vit B-12 deficiency, dermatitis, arthritis, and hepatic injury.

Front 825

Comorbidities associated with vitiligo?

Back 825

autoimmune conditions such as pernicious anemia, DMT1, primary adrenal insufficiency, hypopituitarism, autoimmune thyroid dz, and alopecia areata.

Front 826

autosomal dominant polycystic kidney dz may involve enlargement of which organ(s)?

Back 826

bilateral kidneys (note that the right one is often palpable since it lies lower than the left one)

liver due to cystic involvement

Front 827

first step in tx of pseudotumor cerebri?

Back 827

acetazolamide bc it inhibits choroid plexus carboinc anhydrase and thus reduces CSF.

Note: Do not do a lumbar puncture unless you have radiographic conformation that there is NO space occupying lesion causing increased intracranial pressure.

Also note that the goal of treatment is to prevent visual loss and to reduce intracranial pressure for symptomatic relief.

Front 828

What is suspected in a pt that presents with non-purulent vesicles on the fingers or hand and multinucleated giant cells on the Tzanck smear of the vesicles?

Back 828

Herpetic whitlow - caused by either type 1 or type 2 herpes simplex virus and is SELF-limiting. Health care workers who come in contact with infected orotracheal secretions are at increased risk of developing whitlow.

Front 829

formula for calculating serum osmolality?

Back 829

2(serum Na) + blood glucose/18 + BUN/2.8

Front 830

what characterizes hyperglycemic, hyper osmolar non-ketotic coma?

Back 830

EXTREMELY high blood glucose, plasma hyperosmolality, NORMAL anion gap, and NEG serum ketones

Front 831

Treatment for hepatitis A?

Back 831

a self-limiting condition so mainly supportive with complete recovery in 3-6 weeks.

Close contacts of individuals with Hep A should be given immune globulin.

Front 832

What lab abnormalities are common in sarcoidosis?

Back 832

Elevated Ca and ACE levels

Front 833

Tx of choice in sarcoidosis

Back 833

steroids

Front 834

Pathophysiology seen on biopsy of sarcoidosis?

Back 834

non-caseating GRANULOMAS

Front 835

Suspect what in a pt that presents with slowly progressive proximal muslce weakness of the lower extremities characterized by difficulty with stair climbing or rising from a seated position? Muscle tenderness may be present. No SKIN findings and the muscles of mastication and facial expression are spared.

Back 835

Polymyositis - an inflammatory muscle dz of unknown etiology. Muscle biopsy is diagnostic study of choice.

Front 836

Most sensitive and specific tests for diagnosis of acute pancreatitis?

Back 836

serum lipase > serum amylase

Patients who FAIL to IMPROVE with conservative treatment of acute pancreatitis, should undergo an abdominal CT to search for areas of infection and necrosis.

Front 837

3 key principles to the use of pain meds in patients with terminal stages of cancer?

Back 837

1) use non-narcotics first unless you are SURE that the patient is in severe pain from your clinical judgement
2) Do not be afraid to give narcotics
3) Prescribe adequate amounts - START with SHORT ACTING morphine and titrate doses until adequate pain control is established.

Then switch to LONG-acting narcotics and use short-acting morphine for break through pain.

Front 838

Discovery of iron-deficiency anemia in an adult male or a post-menopausal woman should prompt investigation for?

Back 838

occult GI blood loss, often due to a right sided colon cancer. Other GI causes may be PUD, angiodysplasia, colonic diverticula.

Note: testing for occult blood should be done even if iron studies indicate depressed serum iron and ferritin levels.

Front 839

ototoxic medications?

Back 839

loop diuretics!
aminoglycosides!
also aspirin and chemotherapeutic agents.

Note: higer doses of furosemide, coexistant renal failure, or other concurrent ototoxic meds increase the risk of this side effect.

Front 840

Suspect ________ in a pneumonia with prominent GI symptoms such as diarrhea, hypOnatremia, and LFT abnormalities?

Back 840

Legionella - diagnose with urinary antigen. Tx with quinolone or a macrolide.

Front 841

Suspect what when a 40-year school teacher presents with acute onset polyarticular and symmetric arthritis of teh MCP, PIP, wrist, and ankle joints but NO fever, weight loss or rash.

Back 841

Parvovirus - amongst the most common causes of viral arthritis especially in those in close contact with children. "Slapped cheek" appearance is often absent in adults and the most common finding is arthritis.

Self limiting - resolves within 2 months. Confirm with detection of ANTI-B19 IgM ANTIBODIES.

Front 842

What happens to the following in a restrictive lung disease such as idiopathic pulmonary fibrosis...
A-a gradient
diffusing capacity
V/Q
TLC
residual volume
FEV1/FVC

Back 842

A-a gradient=INCR
diffusing capacity=reduced
V/Q=mismatched, reduced
TLC=reduced
residual volume=reduced
FEV1/FVC=normal to increased

Front 843

What does PEEP do?

Back 843

Maintains airway pressure above atmospheric pressure at the end of EXPiration.

Front 844

Known complications of ventilation with a high PEEP?

Back 844

alveolar damage, pneumothorax, and hypotension, especially pts with fragile lung parenchyma such as those with ARDS.

Can result in tension pneumothorax --> compression of mediastinum and impaired ventricular filling --> hypotension, tachycardia, tracheal deviation, and unilateral absence of breath sounds.

Front 845

Suspect what in a patient presenting with s/sx of systolic heart failure plus thrombocytopenia, macrocytosis, and elevated transaminases suggestive of alcoholism?

Back 845

dilated cardiomyopathy 2dry to alcoholism. Measure most likely to REVERSE heart failure is abstinence from alcohol.

Note: ACE-I should be given and will slow the progression of heart failure but will NOT reverse the dz process.

Front 846

What is the major source of estrogen in menopausal women?

Back 846

peripheral conversion of ADRENAL androgens by the aromatase enzyme present in ADIPOSE tissue.

Front 847

What is a medication that is helpful in a pt with depression as well as difficulty with smoking cessation?

Back 847

Bupropion

Front 848

Disorder characterized by emotional/behavioral symptoms that develop wi 3 months of exposure to an identifiable stressor and rarely last more than 6 months after the stressor has ended?

Back 848

Adjustment disorder - marked distress in EXCESS of what is expected from exposure to the triggering stressor.

Front 849

How does hyrdoxyurea benefit sickle cell patients?

Back 849

increases fetal hemoglobin.

adverse SE's include bone marrow suppression, leukopenia, anemia, and thrombocytopenia.

Front 850

Diagnosis of a child who presents with lab values consistent with aplastic anemia, areas of skin hypopigmentation, and poor growth?

Back 850

Fanconi's anemia - an autosomal recessive disorder believed to involve impaired DNA REPAIR. This dz is marked by progressive bone marrow failure, skin hypopigmentation, morphological abnormalities (such as microcephaly, abnormal thumbs, and hypogonadism), and a predisposition to cancer. The anemia is often MACROcytic and definitive tx for aplastic anemia is a hematopoietic stem cell transplantation.

Front 851

When does tenosynovial inflammation cause carpal tunnel syndrome?

Back 851

in the setting of rheumatoid arthritis

Front 852

When does synovial tendon HYPERPLASIA cause carpal tunnel syndrome?

Back 852

acromegaly

Front 853

when does accumulation of FLUID in the carpal tunnel cause carpal tunnel syndrome?

Back 853

pregnancy especially 3rd trimester.

Front 854

When does accumulation of matrix substances in the median nerve and tendons cause carpal tunnel syndrome?

Back 854

hypothyroidism

Front 855

What can be used to distinguish between portal hypertension and other causes of ascites (trauma, infection, pancreatitis, and malignancy)?

Back 855

SAAG - the serum ascites albumin gradient.

Subtract ASCITES albumin concentration from SERUM albumin concentration. Difference greater than 1.1 g/dL is consistent with a transudative process i.e. portal hypertension or increased hydrostatic pressure within the liver's capillary beds.

Front 856

Most common causes of syringomyelia?

Back 856

Arnold Chiari malformations and prior spinal cord injuries (whiplash of the cervical spine is often an inciting injury).

Front 857

Mechanism of syringomyelia?

Back 857

CSF drainage from central canal of the SC is disrupted leading to a fluid-filled cavity that compresses surrounding neural tissue.

Causes decreased strength and diminished pain/temp affecting arms/hands or having a cape-like distribution.

Front 858

Cervical spondylosis results from?

Back 858

disc degeneration in patients over 40 years.

Front 859

How do cutaneous lesions of blastomycosis appear?

Back 859

either verrucous or ulcerative. Verrucous lesions are initially papulopustular and then progressively become crusted, heaped up and warty with a violaceous hue. These lesions have sharp borders and may be surrounded by microabscesses. Wet preparation of purulent material expressed from these lesions shows the BROAD-based budding yeast form of the organism.

Front 860

How to distinguish between HSV/VZV retinitis versus CMV retinitis (common in HIV patients)?

Back 860

HSV/VZV - SEVERE, acute retinal NECROSIS associated with PAIN, keratitits, uveitis, and fundoscopy findings of PALE peripheral and central NECROSIS of the retina.

CMV - More common than HSV/VZV but typically painLESS and NOT associated with keratitis or conjunctivitis. Fundoscopy shows hemorrhages and FLUFFY or GRANULAR lesions around the retinal vessels.

Front 861

MCC of mitral regurg?

Back 861

mitral valve prolapse - involves myxomatous degeneration of the mitral valve. Typically causes a pansystolic murmur radiating to the AXILLA but in some cases a midsystolic CLICK can also be appreciated.

Front 862

Vaccinaton against hepatitis B decreases the incidence of _________, especially in Asia and Africa.

Back 862

hepatocellular carcinoma

Note: chronic hep B 2dry to vertical mother-to-child transmission is a major cause of hepatocellular CA in Asia and Africa. Contact with infected blood is the major cause in the U.S.

Front 863

Most common cause of superior vena cava syndrome?

Back 863

lung cancer - especially small cell and non-Hodgkins lung cancer

other possible causes include fibrosing mediastinitis (2dry to histoplasmosis or TB infection) or thrombosis 2dry to indwelling central venous device.

Front 864

A biophysical profile score of 4 or less means?

Back 864

severe fetal asphyxia - deliver immediately if >26 weeks

Front 865

When is a contraction stress test indicated?

Back 865

an equivocal non-stress test or biophysical profile

Front 866

What is a possible negative side effect of using norepinephrine as pressors in hypotensive patients?

Back 866

norepinephrine-induced vasospasm - it has alpha-1 agonist properties which cause vasoconstriction. This is useful in hypotensive states but can cause ischemia and necrosis of distal fingers/toes in some patients with decreased blood flow. A similar phenomenon can also occur in the intestines resulting in mesenteric ischemia or kidney causing renal failure.

Front 867

2 important causes of hypOmagnesemia?

Back 867

chronic alcoholism and diuretic intake

Front 868

An important cause of refractory hypokalemia?

Back 868

hypOmagnesemia - Mg is an important cofactor for potassium uptake and maintenance of intracellular potassium levles.

Front 869

Possible things that can provoke benign intracranial hypertension?

Back 869

glucocorticoids, vitamin A, and oral contraceptive pills

Front 870

Difference between bleeding from Mallory-Weiss tears vs esophageal varices?

Back 870

Mallory-weiss tears - ruptured submucosal ARTERIES

rupture of esophageal varices - rupture of dilated submucosal VEINS

Note: endoscopy will show dilated varices at risk for bleeding whereas mallory-weiss tear is an acute presentation and will not appear until bleeding has started.

Front 871

Mechanism of radioiodine ablation of thyroid?

Back 871

taken up by "active" tissue and ablated via beta-emissions.

Since the entire thyroid gland is overactive in Grave's , it is more likely to result in hypOthyroidism whereas multinodular goiter or toxic adenomas end in a euthyroid state usually.

Front 872

Zinc deficiency?

Back 872

zinc is digested primarily in the jejunum so results sometimes from malabsorption in IBD or can result from TPN preparations that lack zinc.

Symptoms include alopecia, abnormal taste, bullous/pustulous lesions surrounding body orifices/extremities, and impaired wound healing.

Front 873

Possible long-term neurologic sequelae associated with BACTERIAL meningitis?

Back 873

1) hearing loss
2) loss of cognitive functions due to neuronal loss in the DENTATE gyrus of the HIPPOCAMPUS)
3) seizures
4) mental retardation
5) spasticity or paresis

Front 874

DOC in cachexia related weight loss and anorexia?

Back 874

progestins such as megestrol acetate and medroxyprogesterone acetate.

Beware of increased risk of DVT however!

Front 875

antipseudomonal cephalosporins?

Back 875

ceftazidime and cefepime

Front 876

How to distinguish between an absence sizure and a complex partial seizure?

Back 876

absence seizure - hyperventilation during EEG reveals a generalized "SPIKE and WAVE" pattern on a normal background. NO post-ictal state.

complex partial - EEG is usually normal or may show brief discharges but will not respond to hyperventilation. Post-ictal state of confusion common.

Automatisms are common in both types of seizures.

Front 877

Drugs that may cause folate deficiency leading to megaloblastic anemia?

Back 877

1) anti-epileptics such as phenytoin, primidone, and phenobarbital by impairing absorption of folic acid in the small intestine
2) TMP and methotrexate by inhibiting dihydrofolate reductase.

Note: most common cause of deficiency is poor diet and/or alcoholism however.

Front 878

difference btn two-sample t test and a two-sample z test?

Back 878

both compare two means but the t-test uses a "sample" variance whereas a z-test uses a "population" variance.

Population variances are not usually known, so the t test has more applicability.

Front 879

Benefits of bronchoscopy in intrapulmonary bleeding?

Back 879

can simultaneously localize AND control site of intrapulmonary bleeding. Rigid bronchoscopy has the additional benefit of providing good control of the airway.

Front 880

Medical term for a common staphylococcal abscess of the eyelid?

Back 880

external hodeolum or stye

Front 881

First step in management of ALL ELDERLY patients who present with acute renal failure?

Back 881

Foley catheter due to possible bladder outlet obstruction from BPH - large amount of urine collection from catheter insertion indicates a likely diagnosis of BPH.

Note: bladder outlet obstruction for >2 weeks can result in permanent kidney damage.

Note: first line treatment of BPH withOUT bladder outlet obstruction is alpha-blockers.

Front 882

What part of the prostate does BPH effect?

Back 882

the central portion

Prostate cancer effects the Periphery

Front 883

Principle cause of lacunar strokes?

Back 883

hypertension leading to thickening of small vessels.

4 common types: pure motor, pure sensory, ataxic-hemiparesis, dysarthria-clumsy hand syndrome

Front 884

lacunar infarction in the posterior limb of the internal capsule leads to?

Back 884

a pure motor hemiparesis OR an ataxic-hemiparesis

Front 885

lacunar infarct of the VPL nucleas of the thalamus leads to?

Back 885

pure SENSORY stroke

Front 886

lacunar infarct of the basal pons leads to?

Back 886

dysarthria-clumsy hand syndrome

Front 887

Management of INR<5 with no significant bleeding?

Back 887

omit NEXT warfarin dose

Front 888

Management of INR 5-9 with no significant bleeding?

Back 888

stop warfarin temporarily

Front 889

Management of INR > 9?

Back 889

stop warfarin, give oral vitamin K

Front 890

Management of pt with serious bleeding due to excess anticoagulation with warfarin?

Back 890

give fresh frozen plasma for RAPID reversal of anticoagulation

Front 891

What should be closely monitored on a DiGeorge pt undergoing surgery?

Back 891

Ca levels - absence of parathyroid leads to hypOcalcemia which can lead to prolonged QT intervals, laryngeal spasm, convulsions and cramping.

Front 892

Syncope in a young patient with a murmur at the left sternal border?

Back 892

likely hypertrophic cardiomyopathy

Front 893

Suspect what with acute onset severe eye pain and blurred vision (sometimes assoicated with nausea and vomiting) that occured following pupillary dilation (ex. in a darkened movie theater or due to drug intake)?

Back 893

acute angle closure glaucoma - moderately dilated pupil will be non-reactive to light. Anterior chamber is shallow. Tonometry reveals incr intraocular pressure.

Tx with IV acetozolamide with subsequent oral administration. Permanent cure is offered with laster peripheral irodotomy.

Note: open angle glaucoma has a more insidious onset with gradual loss of peripheral vision resulting in tunnel vision. May also feature persistently increased intraocular pressure and pathologic CUPPING of the optic disc.

Front 894

What can happen with an eschar that develops due to a burn?

Back 894

it can naturally slough off or require surgical debridement because it begins to compromise both blood and lymph circulation. In these cases, doppler sono is used to document peripheral pulses and estimate tissue compartment pressure. A pressure of 25-40 is the threshold to perform escharotomy.

Front 895

Diagnosis of blisters that show IgG and C3 deposits linearly along basement membrane (that target HEMIdesmosomes)?

Back 895

Bullous pemphigoid - often triggered by culpit meds like furosemide, NSAIDS, captopril, pecillamine, and various ABX. Skin findings include TENSE bullae, urticarial plaques, and pruritus.

Note: blisters of pemphigus are INTRAepidermal with IgG deposits BETWEEN epidermal cells that target the DESMOGLEINS. Bc these blisters form at a more superficial layer of the skin, they tend to be more flaccid and fragile than bullous pemphigoid.

Front 896

Somatization disorder:

Back 896

MULTIPLE recurrent somatic complaints that have persisted for several years and been evaluated by many to no avail.

Requires at least 4 PAIN symptoms, 2 GI symptoms, sexual OR reproductive symptoms other than pain, and 1 PSEUDONEUROLOGICAL symptom such as blindness, deafness, weakness, seizure, loss of consciousness or impaired balance.

Front 897

2 causes of hypocalcemia with CONCORDANT changes in phosphate levels (hypophosphatemia)?

Back 897

1) Vitamin D deficiency (e.g. due to malabsorption)
2) acute pancreatitis

Front 898

Hypocalcemia due to albuminemia is unique because?

Back 898

there are NO symptoms of hypocalcemia (bc ionized Ca levels remain unchanged).

Front 899

Solid ovarian tumors (viewed by ultrasound) are almost always malignant and demand immediate and aggressive evaluation/treatment in ALL age groups EXCEPT one scenario which is?

Back 899

pregnancy! they are most likely pregnancy luteomas which appear BILATERAL, multinodular, SOLID masses on both ovaries bc of luteinized stromal cells from the influence of hCG. Common in AA multiparous women and 1/3 will develop sudden onset hirsutism/virilization.

Front 900

Which type of tumor (infra or supra-tentorial?) are most common in the pediatric population?

Back 900

infratentorial (60%)
supratentorial (25%)

benign ASTROCYTOMAS are the most common histologic type in BOTH groups.

Front 901

A major cause of blindness WORLDwide?

Back 901

Trachoma caused by Chlamydia trachomatis serotype A-C. Often CONCURRENT infection of the NASOPHARYNX. Look for FOLLICULAR conjunctivitis and pannus (NEOVASCULARIZATION) in the cornea.

Front 902

Most common nerve injury in association with fracture of the midshaft humerus?

Back 902

radial nerve - leads to wrist drop and/or marked limitation of extension at wrist joint

Front 903

Extrahepatic complaints/sequelae of chronic hepatitis C?

Back 903

arthralgias (may be false-positive rheumatoid factor), myalgias, cryoglobulinemia, porphyria cutanea tarda, and glomerulonephritis.

Front 904

How to distinguish between herpes simplex keratitis versus herpes zoster ophthalmicus?

Back 904

herpes simplex keratitis - dendritic ulcers are the most common presentation with epithelial scrapings that show multi-nucleated giant cells. Usually precipitated by sun exposure or outdoor activities, fever, or immunodeficiency. Hx of prior episodes present.

Herpes zoster ophthalmicus -caused by varicella-zoster. Most episodes in the ELDERLY. Presents with a vesicular rash in the distribution of the cutaneous branch of the first division of the trigeminal nerve. Conjunctivits and ulcers seen in eye.

Front 905

Marfan's features + mental retardation + thromboembolic events (e.g. stroke) + DOWNward dislocation of the lens =

Back 905

homocystinuria caused by errors in methionine metabolism 2dry cystathionine synthase deficiency - tx involves high doses of Vitamin B6.

Front 906

Sudden onset of photopsia (flashes of light) and floaters (spots in the visual field)?

Back 906

retinal detachment with classic description of "a curtain coming down over my eyes." Usually inciting event occurs months before and is some type of trauma. Fundoscopy shows GREY, elevated retina

Note: central retinal artery occlusion also presents with sudden painLESS loss of vision but fundoscopy shows pallor of the optic diisc, cherry red fovea, and boxcar segmentation of blood int he retinal VEINS.

Front 907

Common meds that cause hyperkalemia?

Back 907

ACE-I, spironolactone, and TMP

Front 908

Diagnosis in thromboctyopenia and hypercoagulation within days of initiating anticoagulation therapy?

Back 908

HIT - vascular thrombosis in 50% of patients - will show a prolonged aPTT.

Front 909

Surgical excision of what kind of tumor can cause facial droop? (presents as a firm, nontender swelling of the cheek and fullness of the parapharyngeal space)

Back 909

parotid gland neoplasm bc the two lobes of the parotid gland are separated by the facial nerve.

Front 910

Hoarseness can result from injury to the recurrent laryngeal branches of the vagus nerved during what type of surgery?

Back 910

surgery on the thyroid or parathyroids

Front 911

what is tic douloureux?

Back 911

trigeminal neuralgia

Front 912

hypoglossal nerve injury causing tongue palsy may result from surgical excision of this kind of tumor?

Back 912

submandibular salivary gland tumor (or any tumor below the mandible).

Front 913

What test best EXCLUDES a pulmonary embolism?

Back 913

a negative D-dimer bc it has a 95% negative predictive value

Front 914

How long should warfarin be continued in a VTE?

Back 914

6 months in a 1st-time clot, lifetime with a 2nd episode

Front 915

gold standard for evaluating peripheral artery disease?

Back 915

contrast arteriography however it is used less frequently bc it is more invasive. Sono is first imaging of choice.

Front 916

Treatment for Candida vulvovaginits?

Back 916

oral fluconazole OR
TOPICAL nystatin

Front 917

Suspect what when an MRI shows MULTIPLE demyelinating, NON-enhancing lesions with NO mass effects in patient with advanced HIV?

Back 917

Progressive multifocal leukoencephalopathy - no treatment; mean survival is 6 months from time of diagnosis

Note: cerebral toxoplasmosis shows multiple ring-ENHANCING lesions on MRI

Front 918

What are Howell Jolly bodies?

Back 918

nuclear remnants within RBCs typically removed by the spleen. Their presence strongly indicates physical or functional asplenia. Seen as single, round, blue inclusions on Wright stain.

Note: do not confuse with Heinz bodies which are hemoglobin precipitants and may also appear blue to violet.

Front 919

Major source of protein in human milk?

Back 919

whey which is more easily digested than casein and helps to improve gastric emptying.

breast milk has an INadequate supply of vitamin D and should be supplemented to exclusively breast fed infants.

Front 920

A NEW fourth heart sound is a classic finding for?

Back 920

MI - ischemic damage leads to diastolic dysfunction and a stiffened left ventricle --> atrial kick or "gallop"

Front 921

Suspect what in an infant born with a small body size, microcephaly, DIGITAL/NAIL hypOplasia, midfacial hypoplasia, hirsutism (excess hair), cleft palate, and rib abnormalities?

Back 921

fetal hydantoin syndrome from anticonvulsant meds such as phenytoin or carbamazepine.

Front 922

What is the most probable cause of a patient experiencing "floating spots" and blurred vision in one eye AFTER a penetrating injury to the opposite eye several weeks prior?

Back 922

Sympathetic ophthalmia aka "spared eye injury" - caused by uncovering of "hidden" antigens during a penetrating injury. Once these natural barriers are broken, an immune response against these antigens can result in the healthy (sympathetic) eye.

Front 923

Dx with >25% lymphoBLASTS that LACK peroxidase positive granules but CONTAIN cytoplasmic aggregates of PAS positive material? Immunostaining for terminal deoxynucleotydyltransferase (TdT) is also usually positive (expressed by pre B and pre T lymphoblasts).

Back 923

ALL

Front 924

When is Winter's formula used?

Back 924

To estimate how much pCO2 should decrease to compensate for a metabolic acidosis (i.e. bicarb decrease).

pCO2=1.5[HCO3] + 8

Front 925

In which type of arthritis is morning stiffness > 1 hour?

Back 925

RA

Front 926

Why is it well documented that rheumatoid arthritis patients are at increased risk of developing osteopenia and osteoporosis?

Back 926

Due to the combined effects of the dz process itself, glucocorticoid therapy, predilection for female sex, and decreased ability to perform weight-bearing exercises that prevent osteoperosis.

Front 927

What is another name for osteitis deformans?

Back 927

Paget's dz

Front 928

Cause of osteitis fibrosis cystica (Von Recklinghausen disease) ?

Back 928

hyperparathyroidism - when osteoclastic resorption of bone leads to replacement iwth fibrous tissue (brown tumors).

Front 929

Suspect what in a pt with recurrent kidney stones since childhood, a positive family hx, a positive urinary cyanide nitroprusside test, and urinalysis that shows hexagonal crystals? Stones are hard and radioopaque.

Back 929

Cystinuria - an inherited dz due to impaired amino acid TRANSPORT. Problem lies with defective transport of dibasic amino acids (cystine, lysine, arginine, and ornithine) by brush borders of renal tubular and intestinal epithelial cells. Cystine is poorly soluble in water leading to hard, radioopaque renal stones. The urinary cyanide nitroprusside test detects elevated cystine levels!

Front 930

3 main categories of diabetic retinopathy?

Back 930

1) backround or simple (usually asymptomatic) - microaneurysms, hemorrhages, exudates, retinal edema
2) pre-proliferative - cotton wool spots
3) proliferative or malignant - neovascularization

Note: visual impairment occurs with the development of MACULAR EDEMA. Argon laster photocoagulation is performed for the prevention of complications.

Front 931

Risk factors for a polyp to progress to a malignancy?

Back 931

1) VILLOUS compartment
2) sessile (most villous adenomas are sessile, not pedunculated)
3) > 2.5 cm in size

Front 932

Recommendation for pneumococcal vaccine?

Back 932

1) 1 dose for ALL healthy adults >65
2) 1 dose for adults <65 wiht chronic medical conditions plus a BOOSTER 5 years later

Front 933

Next step in management of a CT scan that reveals a complex loculated effusion with a thick surrounding peal in the pleural space? (A chest tube is placed with little drainage).

Back 933

empyema - infection of the pleural space. Old residual blood is an excellent medium for bacterial growth and pt will present with fever. Best diagnosed with CT scan and SURGERY is best treatment. Thick pleural peel is removed, pus removed, and chest drained.

Front 934

Cholecystectomy is indicated in what patients?

Back 934

ALL patients with SYMPTOMATIC gallstones who are medically stable enough to undergo surgery.

Front 935

What does a prolonged QRS interval suggest?

Back 935

a bradyarrhythmia

Front 936

What does a prolonged QT interval suggest?

Back 936

a tachyarrhythmia

Front 937

Why are blood cultures and cultures from cutaneous pustules (usually from the extremities) usually negative?

Back 937

The specific strain of N. gonorrhoeae that causes this disseminated form of infection has very specific growth requirements. Dissemination is most likely to occur during menstrual periods.

Front 938

How can invasive aspergillosis (almost always in immunocompromised patients) be diagnosed?

Back 938

CXR will show a rapidly rogressive dense consolidation.

CT scan will show pulmonary nodules with a HALO SIGN or lesions with an AIR CRESCENT.

Front 939

What kind of bias does a loss to follow- up cause?

Back 939

selection bias

Front 940

3 possible Schilling test results:

Back 940

1) normal urinary excretion of radiolabeled B12 - suggests normal absorption and excretion of by the kidney
2) Diminished urinary excretion of radiolabeled Vit B12 --> pernicious anemia OR malabsorption
a) Normal excretion AFTER addition of intrinsic factor --> pernicious anemia
b) LOW excretion AFTER addition of intrinsic factor --> malabsorption

Front 941

A PERSISTENT cough with elevationo f the left main stem bronchus may suggest?

Back 941

mitral stenosis - left atrium gets very large and tends to push up on the left main stem bronchus. Irritation on the left main stem (and phrenic nerve) by the enlarged left atrium can produce a persistent cough.

Front 942

What should be suspected in smokers who present with Horner's syndrome?

Back 942

lung cancer until proven otherwise - 1st step in mgmt is a CXR

Front 943

DOC in hairy cell leukemia?

Back 943

cladribine

Front 944

What type of neuropathy is expected in diabetes?

Back 944

SYMMETRIC DISTAL sensorimotor polyneuropathy characterized by the classic "stocking glove" pattern of SENSORY loss.

Type of sensory involvement depends on the type of nerve fibers involved. PURE SMALL fiber neuropathy results in more pain, allodynia, and parestheisas with ankle jerks PRESERVED. PURE LARGE fiber neuropathy results in less pain but MORE NUMBESS with pressure, proprioception and vibratory sensations DECR and LOST ankle jerks.

Front 945

What does a "corkscrew" esophagus on barium swallow suggest?

Back 945

diffuse esophageal spasm

Front 946

What might a manometry show of an esophagus in scleroderma?

Back 946

loss of DISTAL peristalsis of the esophagus and a lower esophageal sphincter that is INCOMPETENT (i.e. low tone).

Front 947

Drugs of choice for fibromyalgia?

Back 947

Amitriptyline with goal of increasing the amount of restorative phase 4 sleep. Cyclobenzaprine can be used in a similar way.

Note: If pt had concurrent depressive symptoms, begin SSRIs as well.

Front 948

Most common bone in the body to be affected by stress fractures?

Back 948

classic locations:
1) anterior part of hte MIDDLE third of the tibia in jumping sports
2) POSTEROmedial part of the DISTAL third of the tibia in runners.

Note: XR is usually normal. Use a CT or bone scan to evaluate.

Front 949

What should be suspected in ANY postpartum woman with pulmonary symptoms and multiple nodules on CXR?

Back 949

choriocarcinoma - may occur after molar pregnancy or NORMAL GESTATION or abortion. Irregular vaginal bleeding beyond 8 weeks post-partum should raise suspicion for this Dx.

Obtain hCG for Dx.

Front 950

Most common cause of painless hematuria in adults?

Back 950

Bladder tumors

Note: erythrocytes in urine should also be confirmed microscopically bc gross red urine may also occur in myoglobinuria, hemoglobinuria, porphyria, following the consumption of a large amount of beets or as an adverse effect of certain meds like rifampin.

Front 951

What does a triad of systemic vasculitis, upper/lower airway granulomatous inflammation, and glomerulonephritis suggest?

Back 951

Wegener's granulomatous - UPPER respiratory tract is most common site of involvement with epistaxis, purulent rhinorrhea, otitis, sinusitis, and over time a saddle nose deformity. Cutaneous manifestations can include painful subQ nodules, palpable purpura and/or pyoderma gangrenosum-like lesions.

Lab tests usually demonstrate a positive C-ANCA due to antiboidies against proteinase-3 and an elevated CRP. Urinalysis shows RBC casts, proteinuria, and sterile pyuria if glomerulonephritis is present. Tx is with CYCLOPHOSPHAMIDE.

Front 952

The most distinctive feature of MEN type 2b?

Back 952

mucosal neuromas (present in more than 90% of cases) and MARFANoid habitus.

Front 953

The most distinctive feature of MEN type 2a?

Back 953

primary hyperparathyroidism due to parathyroid HYPERPLASIA not adenoma.

Front 954

the 3 Ps in MEN type?

Back 954

MEN type 1:
Pituitary adenoma
hyperParathyroidism
Pancreatic islet cell tumor

Front 955

The 2 Ps in MEN type?

Back 955

MEN type 2a:
medullary thyroid cancer
Pheochromocytoma
Primary parathyroid hyperplasia

Front 956

The 1 P in MEN type?

Back 956

MEN type 2B:
Medullary thyroid cancer
Pheochromocytoma
Mucosal neuromas and Marfanoid habitus

Front 957

Bilateral breast tenderness and swelling that typically presents 24-72 hours post-partum, peaks 3-5 days after delivery and resolves spontaneously?

Back 957

breast engorgement

Front 958

Management of a sickle cell child with probable stroke?

Back 958

exchange transfusion - decr percentage of sickle cells and prevents a second infarct from occurring. Stroke is 2dry to sludging and occlusion in the cerebral vasculature.

Front 959

Treatment for atrophic vaginitus in post-menopausal wmen?

Back 959

LOCAL estrogen therapy

Note: UTI can present with similar symptoms so rule out!

Front 960

Treatment for the 10-20% of pts on isoniazid that develop mild aminotransferase elevations within first few weeks of tx?

Back 960

As long as levels are <100 IU/L, do nothing except regularly monitor for further elevations.

Front 961

Testing for what serologica markers off ther best SCREENING for acute hepatitis B?

Back 961

HBsAg and IgM anti-HBc

Front 962

investigation of choice to diagnose an intraabdominal abscess?

Back 962

CT scan - such infections are usually from hematogenous spread from the skin, commonly due to S. aureus

Front 963

First line treatment for otitis media?

Back 963

10 day course of amoxicillin - if regimen fails, amoxicillin-clavulanic acid, cefuroxime axetil, and IM ceftriaxone are good alternatives.

Front 964

Triad of polyarthralgias, tenosynovitis, and vesiculopustular skin lesions suggests?

Back 964

disseminated gonoccal infection

Note: all patients with this finding should undergo HIV screening

Front 965

DOC for nocardiosis?

Back 965

TMP-SMX - common in patients with deficient cell-mediated immunity. Can present with pulmonary, CNS, or cutaneous manifestations. 1/3 will have empeyema, 1/2 will have EXTRA-pulmonary dissemination (brain being most common).

Sputum gram stain shows crooked, branching, beaded, gram-positive and partially acid-fast filaments

Front 966

CSF of a multiple sclerosis patient will show?

Back 966

oligoclonal bands in 85-90% of cases

Front 967

A large number of molluscum contagiosum lesions should rise suspicion for?

Back 967

HIV unless explained by some other type of cellular immunodeficiency such as chemotherapy or corticosteroid use.

Front 968

A mid-diastolic rumbling PLUS the presence of a mass in the left atrium indicates?

Back 968

Either a thrombus or an intracardiac tumor. Constitutional complaints of low-grade fevers and weight loss make a tumor more likely.

Front 969

Most common diabetic MONOneuropathy?

Back 969

somatic component of CN III causing a "down and out" gaze due to ISCHEMIA.

Parasympathetic fibers have a separate blood supply so light and accomodation reflexes remain intact.

Front 970

Best form of treatment for molluscul contagiosum?

Back 970

Curettage or application of liquid nitrogen.

Front 971

Acute, MASSIVE increases in the AST and ALT with milder increases in the total bilirubin and ALP with a setting of hypotension indicates?

Back 971

ischemic hepatic injury - if the patient survives the inciting condition, liver enzymes should return to normal within 1-2 weeks.

Front 972

Metabolic acidosis with BOTH an anion gap and an osmolar gap indicates possible?

Back 972

ethylene glycol, methanol, or ethanol intoxication

Front 973

rectangular, EVELOPE-shaped crystals are seen in?

Back 973

ethylene glycol poisoning (antifreeze) - these are calcium oxalate crystals

Front 974

Calculation for serum osmolality?

Back 974

2Na + Glu/18 + BUN/2.8

Front 975

Anti-mitochondrial antibodies indicate?

Back 975

primary biliary cirrhosis - disappearing bile duct dz due to autoimmune destruction - pruritus is usually the first symptom and may be very severe especially at night.

DOC=Ursodeoxycholic acid (slows dz progression)

Definitive treatment is liver transplantation.

Front 976

Most specific arrhythmia for digitalis toxicity?

Back 976

atrial tachycardia with AV block - digitalis causes increased ectopy in hte atria or ventricles. It can also increase vagal tone and decr conduction through the AV node, potentially causing AV block.

Front 977

How to distinguish atrial tachy from atrial flutter?

Back 977

Atrial tachy has a somewhat slower rate - 150-200 vs. 250-350 bpm in flutter. P-waves are also present but may appear different from normal p-waves.

Front 978

SIADH is commonly associated with what type of cancer?

Back 978

Small cell carcinoma of the lung

Front 979

Common symptoms of stimulant (cocaine, amphetamine) INTOXICATION?

Back 979

Psychosis (more common with amphetamines), DILATED pupils, hypertension, and tachy.

Front 980

Unexplained fever and cough in an HIV patient with CD4 count < 50/mm3 with no past hx of or exposure to tuberculosis is suspicious for?

Back 980

Mycobacterium avium - pts with CD4 count < 50 should receive azithromycin as prophylaxis.

Front 981

increased hCG and AFP in a young male is indicative of?

Back 981

a NONseminomatous germ cell tumor of the MEDIASTINUM.

Note: elevation of ONLY hCG with normal AFP indicates a seminomatous germ cell tumor.

Front 982

Immediate management of gastroschisis versus omphalocele?

Back 982

the same - wrap exposed bowel in sterile saline dressing and plastic wrap to minimize heat/fluid losses.

gastroschisis look "angry" and matted, is NOT covered by a membrane, and is NOT associated with other abnormalities.

Omphalocele is herniation that IS covered by a membrane and IS associated with OTHER congenital abnormalities.

Front 983

Treatment for actinomycosis?

Back 983

high-dose penicillin for 6-12 weeks.

Presents as slowly progressive, non-tender indurated mass which evolves into multiple abscesses, fistula, and draining tracts with sulfur granules which appear YELLOW.

Front 984

Treatment for moderate-to-severe acne that is predominantly nodulocystic and to those who have developed scars?

Back 984

ORAL isotretinoin

Front 985

Urinary urgency, frequency, and nocturia plus chronic pelvic pain that is exacerbated by sexual intercourse,filling of the bladder, exercise, spicy foods, and certain beverages is suspicious for?

Back 985

interstitial cystitis aka painful bladder syndrome

Front 986

How should carotid artery stenosis of 60-99% in ASYMptomatic men be treated?

Back 986

carotid endarterectomy - men with lesions greater than 80% benefit the most.

Front 987

Status epilepticus is defined as seizure activity greater than?

Back 987

5-10 minutes that does not respond to 1st line treatment with benzodiazepines. In these cases, first step in management is secure airway. Then try 2nd line antiseizure medication.

Front 988

linear IgG antibodies against alpha-3 chain of type IV collagen along the glomerular and alveloar basement membranes?

Back 988

Goodpasture's

Front 989

what type of organism is most common in a UTI that causes ALKALINE urine?

Back 989

Proteus

Front 990

The preferred form of hormonal contraception for lactating mothers?

Back 990

progestin-only

note: combined estrogen-progestin pills may DECR milk production and pass into the milk

Front 991

What type of patients have a 10% per year risk of experiencing reactivation tuberculosis?

Back 991

HIV patients.

Front 992

How to distinguish a Chlamydial pneumonia versus RSV bronchiolitis in a young infant?

Back 992

Chlamydia pneumonia usually does NOT have FEVER and WHEEZING is RARE.

Front 993

The most important changes necessary to reducing blood pressure?

Back 993

Weight control is most important followed by physical activity, salt restriction, and moderation of alcohol consumption.

Front 994

How does Zollinger-Ellison syndrome lead to malabsorption?

Back 994

it is a gastrin producing pancreatic tumor that causes parietal cell hyperPLASIA --> significantly increased stomach acid production --> increased stomach acid INACTIVATES pancreatic enzymes --> fat malabsorption and steatorrhea

Front 995

An over the counter drug that has potent anticholinergic effects that may cause eye and oropharyngeal drynesss as well as urinary retention (2dry to detrusor inactivity), especially in older males who may have some underlying BPH?

Back 995

first-generation H1 antihistamines such as diphenhydramine, chlorpheniramine, doxepin, and hydroxyzine

Front 996

How to distinguish between CHF versus COPD exacerbation?

Back 996

Both will show hypoxia.

COPD - pts will retain CO2 (hypERcapnia) and be in respiratory ACIDOSIS.

In CHF pts will blow off CO2 (hypOcapnia 2dry to hyperventilation) and have respiratory ALKALOSIS.

Front 997

Pulmonary hypertension is defined as?

Back 997

mean pulmonary arterial pressure greater than 25 mmHg at rest or 30 mmHg with exercise.

Front 998

A tea and toast type of diet is associated with what type of anemia?

Back 998

macrocytic anemia due to folic acid deficiency

Note: B12 stores remain sufficient for at least 3-4 YEARS whereas folic acid stores can become depleted within 4-5 months

Front 999

What type of metals in jewelry can cause a contact dermatitis?

Back 999

nickel

Front 1000

Retinal hamartoma versus optic glioma in what neurocutaneous syndrome?

Back 1000

retinal hamartoma in tuberous sclerosis.

optic glioma in neurofibromatosis type 1.

Front 1001

common drugs that cause priapism?

Back 1001

prazosin and trazodone

Front 1002

Criteria to diagnose a MASSIVE pulmonary embolism?

Back 1002

right atrial pressure > 10

pulmonary artery systolic pressure > 40

Note: massive PE can lead to symptoms of shock such as hypotension, tachycardia, and cool extremities.

Front 1003

normal RIGHT atrial pressures

Back 1003

4-6 mmHg

Front 1004

normal pulmonary ARTERY pressure

Back 1004

does not exceed 25/15

Front 1005

normal PCWP?

Back 1005

6-12 mmHg

Front 1006

dx of infant with pruritus and skin lesions typically distributed symmetrically over the face, scalp, chest, and extensor surfaces of the extremities but SPARING the diaper region?

Back 1006

atopic dermatitis

Front 1007

Clues to Boerhaave's syndrome?

Back 1007

1) acute, severe chest or epigastric pain after an episode of retching
2) tachycardia and tachypnea
3) subcutaneous or mediastinal emphysema
4) WIDENED mediastinum
5) UNILATerally decreased breath sounds
6) UNILATeral pleural effusion (usually left)
7) HIGH AMYLASE concentration in pleural fluid

Front 1008

Acute treatment of hypercalcemia?

Back 1008

IV saline hydration followed by a loop diuretic to decrease calcium reabsorption by the loop of Henle

Front 1009

Symptoms of hypercalcemia usually begin when Ca levels exceed?

Back 1009

12 mEq/L

symptoms are nonspecific like abdominal pain, constipation, polyuria and neuropsychiatric disturbances.

Front 1010

B-cell deficiencies predispose to infection by?

Back 1010

bacteria

Front 1011

T-cell deficiencies predispose to infection by?

Back 1011

viruses and fungi

Front 1012

Recurrent infections after passing 6 months of age is suggestive of?

Back 1012

GENETIC B-cell deficiencies bc this is when the level of maternal antibodies drop.

Front 1013

2 forms of analgesic nephropathy?

Back 1013

papillary necrosis and chronic tubulointerstitial nephritis.

Front 1014

Early versus late manifestations of analgesic nephropathy (papillary necrosis and chronic tubulointerstiital nephritis)?

Back 1014

early - polyuria, sterile puria, and sometimes WBC casts. Microscopic hematuria and renal colic following sloughing of renal papilla.

later - hypertension, mild proteinuria, and impaired urinary concentration.

severe - nephrOtic range proteinuria

Note: Pts with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract CANCER.

Front 1015

3 types of PARTIAL seizures:

Back 1015

simple: NO loss of consciousness and patient remembers the event well.

complex: +LOC, AURA present (=simple partial seizure), automatisms (lip smacking, chewing, hand movements).

with 2dry generalization: +LOC, AURA present, TONIC CLONIC activity

Unwitnessed seizures with presence of tongue biting or bladder/bowel incontinence makes seizure with tonic clonic activity more likely (so partial with 2dry generalization or generalized seizures).

Front 1016

Lennox-Gastaut syndrome

Back 1016

seizure disorder where patients are younger than 7 with coexisting mental retardation.

Front 1017

congenital AROMATASE deficiency?

Back 1017

total absence or poor functioning conversion of androgens into estrogens:

IN UTERO, lack of estrogen leads to masculinization of the mother and virilized XX fetuses with ambiguous external genitilia but normal internal genitilia.

LATER IN LIFE, patients present with delayed puberty, primary amenorrhea,osteoporosis, UNDETECTABEL circulating estrogens, high concentrations of gonadotropins and polycystic ovaries.

Note: congenital adrenal hyperplasia causes virilization in XX fetuses too, as well as salt wasting.

Front 1018

How can you distinguish from psychogenic polydipsia versus diabetes insipidus?

Back 1018

water deprivation test - urine WILL CONCENTRATE if proper levels of ADH present, which indicates a psychogenic problem

Front 1019

How do you distinguish between central DI and nephrogenic DI?

Back 1019

First, do a water deprivation test, and make sure the patient canNOT concentrate urine.

2nd, administer arginine vasopressing or desmopressin. If urine now CONCENTRATES, it indicates a lack of CENTRAL release. If it does NOT concentrate, it indicates that renal tubules are resistant to the hormone.

Front 1020

Less well known side effects of amiodorone?

Back 1020

corneal deposits (bc secreted by the lacrimal gland) and a blue-gray skin discoloration (most prominent on the face).

Front 1021

Test of choice for diagnosing a suspected ectopic pregnancy with b-hCG levels between 1,500-6,500?

Back 1021

transVAGINAL ultrasound - if ultrasound fails to reveal an intrauterine OR adnexal sac in this setting, then SERIAL beta-hCG measurements are necessary to rule in/out ectopic pregnancy. Doubling of b-hCG every 48 hours suggests a normal pregnancy, and a slower rate of rise suggests an ABNORMAL pregnancy.

Front 1022

Hepato-jugular reflex is ________ in patients with liver disease related edema.

Back 1022

negative

it is positive in heart related edema and indicates elevated venous pressure.

Front 1023

What kidney pathology is associated with cerebral aneurysms and a positive family hx of stroke/sudden death?

Back 1023

polycystic kidney disease

Front 1024

What kind of arthritis classically features morning stiffness, involves DIP joints, dactylitis ("sausage digits"), nail pitting, and onycholysis (separation of nail bed)?

Back 1024

psoriatic arthritis

tx = NSAIDs, anti-TNF agents, and methotrexate

Note: systemic corticosteroids are relatively contraindicated.

Front 1025

What kind of arthrits is common in diabetics, syphilis, and alcoholism?

Back 1025

Neuropathic arthropathy (Charcot joint) - most commonly affects the lower limbs. Peripheral neuropathy is believed to result in decreased proprioception which leads to frequent trauma and eventual destruction of the joint.

Front 1026

What should be suspected in an elderly lady with severe osteoporosis who presents after a fall with bilateral leg weakness, increased deep tendon reflexes, and low back pain?

Back 1026

compression fracture with disk herniation causing spinal CORD COMPRESSION. no other SINGLE lesion would explain bilateral leg weakness. Can also occur due to an abscess, trauma, or malignancy.

Note: other related clues might include saddle anesthesia or compromised bladder/bowel control.

Front 1027

Atelectasis is the most common respiratory complication during the first 24 hours after surgery due a fall in vital capacity (by 50%) and decreased functional residual capacity (by 30%). What 5 methods can help increase the FRC and prevent atelectasis in the immediate postop period?

Back 1027

1) chest physiotherapy
2) incentive spirometry
3) coughing
4) frequent repositioning - simply moving the pt from supine to sitting reduces the intrabdominal pressure acting on the undersurface of the diaphragm thereby permitting greater alveolar expansion at end expiration and increasing the FRC.
5) EARLY ambulation

Front 1028

What cellular mechanism is responsible for TCA-induced QRS prolongation (> 0.10 seconds)?

Back 1028

inhibition of cardiac FAST SODIUM channels is responsible for QRS prolongation. This is reversed by sodium bicarbonate in instances of intoxication.

Note: urine alkalinazation is a mechanism by which sodium bicarbonate increases salicylate secretion, thus alleviating aspirin overdose.

Front 1029

Steps in management of variable decelerations of FHR?

Back 1029

variable decels represent a non-reassuring fetal heart pattern due to umbilical cord compression. Management should be:
1) oxygen administration and have mother lie on her side
2) if variable decels persist, pt should be placed in the Trendelenburg position and the presenting fetal part should be elevated.
3) Persistent variable decels may require amnioinfusion into the amniotic cavity but should be used after conservative measures have failed.

Front 1030

Most appropriate management of progressive pain in a patient with prostate cancer and vertebral bone metastases after androgen ablation (orchiectomy)?

Back 1030

radiation therapy

Front 1031

Otoscopic finding of granulation tissue in the external auditory canal is consistent with?

Back 1031

malignant otitis externa - usually seen in elderly patients with poorly controlled diabetes and presents with ear pin, drainage, and granulation tissue. Can be exacerbated with chewing in early stages and ivolves the cranial nerves sometimes.

DOC=IV ciprofloxacin (due to anti-psuedomonal coverage).

Note: this is an external ear infection but requires SYSTEMIC therapy.

Front 1032

Differential for bloody diarrhea but no travel?

Back 1032

1) EHEC - no fever but ABDOMINAL pain.
2) Shigella, salmonella, or campylobacter - FEVER but NO abdominal pain.

Note: viral gastroenteritis usually results in VOMITING and DIARRHEA

Front 1033

Possible hematological complication that may occur with infectious mononucleosis?

Back 1033

autoimmune hemolytic anemia and thrombocytopenia - this is due to the CROSS reactivity of the EBV-induced antibodies against red blood cells and platelets. These antibodies are IgM COLD agglutinin antibodies aka anti-i antibodies.

Note: onset of hemolytic anemia can be 2-3 weeks after the onset of symptoms.

Front 1034

Definition of intracranial hypertension?

Back 1034

intracranial pressure >/= 20 mmHg. Typical symptoms include diffuse headaches that tend to be worse in the morning, nausea and vomiting early in the day, vision changes, papilledema, cranial nerve deficits, somnolence, confusion, unsteadiness, and Cushing's reflex (HTN and bradycardia). Etiologies include trauma, space-occupying lesions, hydrocephalus, and impaired CNS venous outflow.

CT and MRI can help diagnose this.

Front 1035

Prodrome of fever, irritability and skin tenderness is followed by generalized erythemy and superficial flaccid blisters with a positive Nikolsky sign. Scaling and desquamation follow, before resolution of the disease process. Usually affects children below age 10 but adults with kidney disease or immune compromise may also be affected.

Back 1035

Staphylococcal scalded skin syndrome caused by exfoliative toxin-producing strains of S. aureus.

Front 1036

Screening for ovarian cancer in patients with positive family history?

Back 1036

Testing for BRCA1 and BRCA2 genes could be condsidered if positive family history is VERY strong. However, NO screening is officially recommended for ovarian cancer. If BRCA1/BRCA2 genes are positive, follow up CA 125 and pelvic ultrasound to look for ovarian cancer should be performed.

Front 1037

Post exposure prophylaxis for possible rabies from dog?

Back 1037

immediat prophylaxis for exposures involving head or neck or if status of animal cannot be determined (then it is assumed that dog is RABID).

Otherwise, observe dog for 10 days and give prophylaxis if features of rabies within dog manifests.

Front 1038

Treatment for diphenhydramine overdose?

Back 1038

physostigmine

Front 1039

Recommended screening for abdominal aortic aneurysm?

Back 1039

active or former male smokers aged 65-75 years with a one-time abdominal ultrasound to evaluate for abdominal aortic aneurysm.

Front 1040

Management of communicating versus non-communicating hydroceles?

Back 1040

Most cases of both types of hydrocele will spontaneously resolve by age 12.

Front 1041

Symptomatic sarcoidosis most commonly presents with?

Back 1041

cough, erythema nodosum, anterior uveitis, and arthritis.

Hilar adenopathy and reticular opacities on CXR are classic findings.

Front 1042

The relative risk (RR) can help determine what percent of an "exposed" population with a "given" disease is actually ATTRIBUTABLE to that exposure. Referred to as attributable risk percent (ARP).

Back 1042

ARP=(RR-1)/RR

Front 1043

Management of a painLESS, hard testicular mass PLUS ultrasound suggestive of tumor?

Back 1043

orchiectomy - removal of the testis and its associated cord

Front 1044

Procedure of choice for both diagnostic and therapeutic purposes in suspected foreign body aspiration?

Back 1044

direct laryngoscopy and RIGID bronchoscopy.

Flexible bronchoscopy is useful for diagnosis but NOT retrieval of the foreign body.

Front 1045

Most accepted and recommended management for the eradication of H. pylori in patients with gastric mucosa-associated lymphoid tissue lymphoma withOUT metastasis?

Back 1045

antibiotic therapy - give combo of omeprazole, clarithromycin and amoxicillin

Front 1046

Management of patients who present after >5 days after the onset of symptoms of appendicitis and have localized right lower quadrant findings?

Back 1046

IV hydration, antibiotics and rest. Antibiotics should cover enteric gram-negative organisms and anaerobes. Cefotetan is adequate monotherapy.

Front 1047

Treatment for myasthenia crisis?

Back 1047

endotracheal intubation and withdrawal of anticholinesterases for several days.

Typical cause for myasthenic crisis is an intercurrent infection and so antibiotics are an important part of management.

Front 1048

Paget's dz is often asymptomatic and usually found incidentally by x-ray findings like FEMORAL BOWING or ELEV ALP. Symptoms when present may include?

Back 1048

skeletal deformities, bone or joint pain, fractures, nerve entrapment (especially cranial nerve 8 leading to hearing loss), or osteosarcoma.

Front 1049

The single most common cause of asymptomatic isolated elevation of ALP in an elderly patient?

Back 1049

Paget's disease of bone (osteitis deformans)

Front 1050

Suspect ________ in a child who recently recovered from a diarrheal illness and presents with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia, and characteristic peripheral smear finding of schistocytes?

Back 1050

HUS

Front 1051

Management of hyperthyroid-related atrial fibrillation?

Back 1051

beta blocker, not cardioversion (unless hemodynamically unstable or shows signs of angina or heart failure).

Front 1052

Mechanism behind autoimmune hemolytic anemia in malignant lymphoproliferative disorders like CLL?

Back 1052

due to anti-red blood cell IgG immunoglobulins of the WARM type covering the cell membranes and causing removal from the circulation by the spleen.

Treatment is PREDNISONE in divided doses and if INeffective, then splenectomy.

Front 1053

Current recommendations to prevent complications from splenectomy?

Back 1053

pts should receive anti-pneumococcal, Haemophilu, and meningococcal vaccines several weeks before the operation and DAILY oral penicillin for 3-5 years following splenectomy. Thereafter, at home antibiotics should be made available for immediate treatment of any signicant fever.

Front 1054

Hypercalcemia can occur following __________ in patients with preEXISTING HIGH bone turnover such as children, young adults, and patients with Paget's disease.

Back 1054

immobilization - bisphosphonate therapy is helpful in reducing hypercalcemia and preventing osteopenia.

Front 1055

Handling of amputated parts from injury?

Back 1055

wrap in saline-mostened gauze, seal in a plastic bag, and place on ice to bring with to emergency department.

Front 1056

Superior sulcus tumor can compress various areas leading to symptoms:

Back 1056

1) sympathetic trunk (Horner's)
2) brachial plexus (Pancoast syndrome)
3) right recurrent laryngeal nerve (hoarse voice)
4) superior vena cava (SVC syndrome)

Note: Pancoast syndrome is usually shoulder pain radiating into the arm in an ulnar distribution. Caused by tumor invasion of C8 and T1.

Front 1057

Among what population is pellagra common?

Back 1057

People eating CORN-based diets in parts of INdia, Africa, and China as well as alcoholics, carcinoid syndrome, and Hartnup's dz.

Note: Diarrhea, dementia, dermatitis and eventually death.

Front 1058

Signs common in exertional heat stroke?

Back 1058

body temp > 105 which can also cause rhabdomyolysis and organ system damage. Large blood with NO RBCs on U/A is suggestive of rhabdo. Also, dry skin/mucosa, hypOtension, tachycardia, tachypnea.

Front 1059

definition of fulminant liver failure?

Back 1059

hepatic encephalopathy that develops wi 8 weeks of the onset of acute liver failure - more common in pts who are heavy users of acetaminophen, alcohol, methamphetamines, or coinfected with hepatitis B & D.

Front 1060

Management of fulminant hepatic failure?

Back 1060

Liver transplantation bc these pts have a mortality rate > 80%. Contraindications for transplantation include IRREVersible cardiopulmonary dz, incurable or recent (<5 years) malignancy external to the liver, and ACTIVE alcohol/drug abuse.

Front 1061

Management of an unvaccinated individual with needle stick exposure from a patient with active hepatitis B?

Back 1061

administration of both Hep B vaccine as well as immune globulin.

If vaccinated, then immune globulin is sufficient.

Front 1062

Why is hyperkalemia in the setting of diabetic ketoacidosis referred to as "paradoxical"?

Back 1062

bc body potassium reserves are actually depleted!

Front 1063

Sudden loss of vision and onset of floaters with a fundus that is hard to visualize in a diabetic patient?

Back 1063

vitreous hemorrhage - difficult to visualize fundal details is an important clue!

Front 1064

Absolute contraindication to the use of bupropion?

Back 1064

history of seizure disorder

Front 1065

First step in management of primary biliary cirrhosis?

Back 1065

ursodeoxycholic acid - relieves symptoms and lengthens transplant-free survival time.

methotrexate and colchicine have also been shown to be of moderate benefit.

Front 1066

Increased homocysteine levels PLUS increased levels of methylmalonic acid indicate?

Back 1066

cobalamin deficiency - bc this is not only necessary for conversion from homocysteine to methionine but also for conversion from methylmalonyl-CoA to succinyl-CoA.

Front 1067

Increased homocysteine levels but NOT methylmalonic acid?

Back 1067

folic acid deficiency bc it is required in conversion from homocysteine to methionine but not for conversion of methylmalonyl-CoA to succinyl-CoA.

Front 1068

What medications are contraindicated in acute glaucoma?

Back 1068

meds that cause mydriasis such as atropine.

Mannitol, acetazolamide, pilocarpine, or timolol can be used for acute glaucoma tx.

Front 1069

Treatment for pheochromocytoma paroxysms?

Back 1069

NEVER beta-block without adequate ALPHA-block FIRST. Blocking beta-receptors leads to unopposed stimulation of vascular alpha-receptors which can result in rapid, catastrophic rise in BP.

Therefore, alpha-blockers are preferred initial drugs. Beta-blockers can be added to treat tachycardia and other symptoms of sympathetic hyperactivity like tremor but only after adequate alpha block is in place. Non-selective blockers such as labetelol can be used safely as initial treatment.

Front 1070

How is pH helpful in evaluating parapneumonic effusions?

Back 1070

Pleural fluid pH is NORMally around 7.64. Therefore a pH < 7.3 indicates pleural inflammation and a pH < 7.2 indicates need for chest tube aspiration to prevent aspiration. Values that do NOT fall below that threshold can be considered transudative effusions.

Note: pleural fluid to serum fluid protein and LDH ratios are also helpful.

Front 1071

Suspect what if a middle-aged adult complains of superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (as when lying on the affected side in bed) OR with external rotation OR resisted abduction?

Back 1071

trochanteric bursitis - inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur's greater trochanter.

Front 1072

difference btn Mobitz type I or Mobitz type II heart block?

Back 1072

type I - progressive beat-to-beat increase in PR interval until a ventricular beat is dropped, then the sequence is repeated. A benign arrhythmia and is transient.

Type II - a NORMAL PR interval followed by a SUDDEN dropped QRS complex.

Front 1073

Drooping of the contralateral pelvis that occurs when the patient stands on one foot is called the __________ sign.

Back 1073

Trendelenburg - Normally the gluteus medius and gluteus minimus muscles, which are both innervated by the superior gluteal nerve function to counteract this. Weakness of these muscles in neuromuscular dz, impingement of or trauma to the SUPERIOR GLUTEAL nerve, or inflammatory myopathies, results in a positive Trendelenburg sign and gait.

Front 1074

treatment for UREMIC pericarditis?

Back 1074

hemodialysis - NSAIDS may worsen renal failure and therefore not the appropriate choice in this type of pericarditis.

Front 1075

Suspect what in a pt who presents with confusion, flank pain, acute renal failure, anion gap metabolic acidosis, and hypOcalcemia?

Back 1075

ethylene glycol poisoning - Treatment involves fomepizole or ethanol to achieve alcohol dehydrogenase inhibition, sodium bicarb to alleviate the severe acidosis and/or hemodialysis in the case of resistant acidosis and/or end organ damage.

Front 1076

Management of a solitary pulmonary nodule in LOW risk patients (<40 years and non-smokers) versus HIGH risk?

Back 1076

low risk - ask for an old XR to look for change in last 12 months. No change is considered benigh. Follow nodule by CXR every 3 months for the next 12 months to look for growth or symptoms.

high risk - full workup - CT scan of the chest to get a better picture of the lesion followed by fine needle aspiration.

Front 1077

Most common malignant tumor of the eyelid?

Back 1077

basal cell carcinoma - most commonly on the lower eyelid margin as a slow-growing papule with pearly, rolled borders and overlying telangiectasia.

Front 1078

Diffuse cortical and subcortical atrophy which is disproportionately greater in the temporal and parietal lobes especially the hippocampi is indicative of?

Back 1078

Alzheimer's dz.

Note: frontotemporal dementia shows marked atrophy of the frontal and temporal lobes.

Front 1079

Differences in Alzheimer's versus frontotemporal dementia?

Back 1079

frontotemporal dementia usually presents earlier than alzheimer's at around 40-60 years (alzheimers almost always presents after 60). Initially, frontotemporal lobe dementia has LESS disorientation and memory loss and MORE personality changes and loss of social restraints. Alzheimer's BEGINS with memory loss symptoms that progress to loss of cognitive abilities, reduced daily activities, later leading to confusion and disorientation.

Front 1080

Pleural fluid with a pH<7.2 or glucose < 60 mg/dL is an indication for?

Back 1080

low pH means fluid needs to be drained. low glucose is indication for tube thoracos
tomy.

Front 1081

What does a peripheral smear with spherocytes with NO central pallor indicate?

Back 1081

Either AIHA (autoimmune hemolytic anemia) or heridtary spherocytosis.

Note: AIHA usually has a NEG family hx and is positive for the Coomb's test. If Coomb's test is negative, perorm a micro-Coomb's test to confirm diagnosis.


Hereditary spherocytosis has a POS family hx, positive osmotic fragility test, and NEG Coomb's test.

Front 1082

Patients on MAOIs like phenelzine should avoid foods with tyramine bc?

Back 1082

potential to cause a hypertensive crisis

Front 1083

DOC for congenital long QT syndrome?

Back 1083

beta-blockers

Front 1084

Mode of inheritence for hypertrophic cardiomyopathy?

Back 1084

autosomal dominant

Front 1085

Distinguishing factors btn orbital versus prespetal cellulitis?

Back 1085

orbital - decr eye movements, decr visual acuity, double vision, proptosis. In addition fever, malaise and systemic symproms are a bit more common with this scenario.

preseptal - eyelid discoloration is much more indicative. Eyelid swelling, tenderness, and erythema are also a bit more common in this scenario.

Front 1086

Management of acute exacerbation of COPD?

Back 1086

ipratropium, albuterol nebulization, and systemic steroids.

Front 1087

Contraindications to breastfeeding?

Back 1087

ACTIVE drug abuse, TB or HIV

Front 1088

Suspect what when a pt presents with a unilateral NECK mass that causes difficulty swallowin and increases in size while drinking fluids? And what is the mechanism responsible for this?

Back 1088

Zenker's diverticulum - develops immediately above the upper esophageal sphincter by herniating posteriorly btn the fibers of cricopharyngeal muscle.

Upper esophageal sphincter dysfunction and esophageal dysmotility are believed to cause this problem. Incoordination btn the two results in herniationof the mucosa via a PULSION mechanism.

Surgical treatment includes excision and frequently cricopharyngeal myotomy.

Front 1089

Cause of Meniere's dz?

Back 1089

abnormal accumulation of endolymph within the inner ear.

Front 1090

What is the dx when a child is verbal and talkative at home but refuses to speak in select settings like school?

Back 1090

selective mutism

Front 1091

What nerve is affected if there is paralysis of the deltoid and teres minor muscles as well as loss of sensation over the lateral upper arm?

Back 1091

axillary nerve

Front 1092

Other than resultant hypOthyroidism, what is another side effect of radioiodine therapy for the treatment of Grave's dz?

Back 1092

exacerbation of ophthalmopathy.

Front 1093

Post operative condition that presents with painful swelling of the parotid gland and is aggravated by chewing?

Back 1093

Acute bacterial parotitis usually caused by S. aureus - can be prevented with adequate fluid hydration and oral hygiene

Front 1094

How does the hemoglobing curve change with CO poisoning?

Back 1094

it causes a LEFT shift and a shape change from sigmoid to ASYMPTOTIC.

Front 1095

Which of the following markers has the most impact on the future management of a breast cancer pt?
a) DNA content by flow cytometry
b) oncogene amplification by FISH
c) p53 gene mutations by gel electrophoresis
d) S-phase fraction by flow cytometry

Back 1095

B - overexpression of the oncogene HER2 - positivity predicts a positive response to TRASTUZUMAB and anthracycline chemotherapy.

Note: The other answers indicate negative prognostic factors but will NOT change the MANAGEMENT of the pt.

Front 1096

Best treatment for acute rejection of a transplant?

Back 1096

IV steroids

Front 1097

Best ACUTE treatment for migraines?

Back 1097

IV antiemetics such as chlorpromazine, prochlorperazine, or metoclopramide

Front 1098

Why does furosemide sometimes lead to ventricular arrhythmias?

Back 1098

Bc it commonly causes electrolyte abnormalities like hypOkalemia and hypOmagnesemia. Furthermore, it potentiates side effects of digoxin.

Therefore first step in mgmt would be to order electrolyte and digoxin levels.

Front 1099

Most common cuase of HIV dysphagia/odynophagia?

Back 1099

candidal esophagitis - try a 1-2 week course of empiric oral fluconazole. If symptoms persist, endoscopy with biopsy should be performed to look for CMV esophagitis or HSV esophagitis.

Front 1100

How to distinguish btn CMV and HSV esophagitis?

Back 1100

CMV
1) focal substernal burning pain with odynophagia
2) LARGE, SHALLOW, superficial ulcers
3) presence of intranuclear and intracytoplasmic inclusions

HSV
MULTIPLE, well circumscribed, and SMALL, DEEP ("volcano like") ulcers

Front 1101

How to distinguish a cerebral hemorrhage from a cerebral infarct on CT?

Back 1101

hemorrhage - HYPERdense area

infarct- hypOdense area

Note: atrial fibrillation with warfarin treatment should make you suspicious for EITHER scenario. Some pts are over anticoagulated (especially if on multiple drugs, some of which slow warfarin metabolism) and at higher risk for bleeding. Others are under anticoagulated and at risk for an embolism.

Front 1102

Management of a pt with DVT that has a hx of intracerebral hemorrage?

Back 1102

placement of IVC filter

Note: mgmt would be the same in others whom anticoagulation is contraindicated (recent surgery, bleeding diathesis, or active bleeding).

Front 1103

What is Mulder sign?

Back 1103

A clicking sound/sensation between the 3rd & 4th toes on the plantar surface when simultaneously palpating this space and squeezing the metatarsal joints. Indicates MORTON NEUROMA - mechanically induced degenerative neruopathy commonly seen in runners. Treatment is conservative with bilat show inserts.

Front 1104

Treatments avaliable for condymomata acuminata?

Back 1104

1) chemical/physical agents - trichloroacetic acid, 5-fluorouracil epinephrine gel, and podophyllin

2) Immune therapy - imiquimod, interferon alpha
3) surgery - cryosurgery, excisional procedures, laser treatment

Front 1105

A long term disease modifying treatment for MS?

Back 1105

Glatiramer acetate - works by modulating T-cell mediated autoimmunity to myelin basic protein

Front 1106

When is the drug argatroban used?

Back 1106

It is a selective and reversible thrombin inhibitor - used mainly to prevent thrombosis in pts with HIT who need anticoagulation

Front 1107

Three phases of Trichinellosis (aka trichinosis) caused by eating undercooked pork?

Back 1107

1) during 1st wk of infection - larvae invade intestinal wall and causes abdominal pain, n/v, and diarrhea.
2) during 2nd wk of infection - larval migration causes a local/systemic hypersensitivity reaction causing splinter hemorrhages, conjunctival/retinal hemorrhages, periorbital edema, and chemosis.
3) Larvae enters skeletal muscle causing muscle pain, tenderness, swelling, and weakness.

Front 1108

Management of CHADS2 score of 0, 1-2, and >2?

Back 1108

0 = tx with aspirin
1-2 = tx with either aspirin or anticoagulation
> 2 = tx with anticoagulation

Front 1109

Treatment for aortic regurg (typically a diastolic decrescendo murmur heard best in the LEFT intercostal space!)?

Back 1109

AFterload reduction! Use Ca ch blockers (such as nifedipine) or ACE inhibitors.

Note: DO NOT use beta-blockers as this slows the heart and extends the time of diastole when REGURG can take place thereby worsening AR.

Front 1110

ALL patients suspected of having Zollinger-Ellison syndrome should have what lab investigation?

Back 1110

FASTING SERUM gastrin levels. if this is non-diagnostic, then perform a secretin stimulation test. NORMAL gastric G cells are inhbited by secretin whereas gastrinOMA cells are stimulated. Secretin stimulation resulting in an increased serum gastrin concentration indicates ZE syndrome.

NOT gastric acid secretion study (this is an older study no longer used).

Front 1111

Treatment for CMV vs. HSV esophagitis?

Back 1111

CMV - gancyclovir
HSV - acyclovir

Front 1112

Modality of choice in diagnosing an AAA?

Back 1112

abdominal ultrasound NOT CT. Has nearly 100% sensitivity and specificity, facilitates measurement of aneurysm size, can show associated thrombus, relatively inexpensive compared to CT/MRI, and does not require contrast.

Front 1113

Acute versus long-term treatment of panic attacks?

Back 1113

acute = benzodiazepines

long-term=SSRIs with benzos tapered off to prevent dependence

Front 1114

Management of young child with a simple seizure plus evidence of fever and otitis media?

Back 1114

Treat fever and discharge home. Febrile seizures are commonly associated with viral illnesses or otitis media and a rapid rise in temperature to above 102.2 (39 C). Routine lab tests (such as lumbar puncture) are usually not indicated unless an infectious source is not identified and meningitis is suspected.

Front 1115

Treatment for specific or simple phobias?

Back 1115

benzodiazepines

Front 1116

Management of dyspepsia?

Back 1116

Two categories:
1) Age > 55 with NEW-onset symptoms OR those who have ALARM symptoms (weight loss, dysphagia, or persistent vomiting) should have an upper endoscopy.

2) Others should either undergo empiric treatment with PPIs or should have Helicobactor pylori serology.

Front 1117

Suspect what in a patient who just underwent CABG that begins having fever and chest pain and shows leukocytosis and mediastinal widening on chest XR?

Back 1117

Mediastinitus - complicates 5% of sternotomies. Like an abscess, treatment requires drainage, debridement and ABX therapy.

Note: A postpericardiotomy syndrome (autoimmune in nature) classically occurs several weeks later whereas this occurs soon after surgery.

Front 1118

Major cause of chronic diarrhea in HIV-infected pts with CD4 counts < 180 cells/mm3?

Back 1118

Cryptosporidium parvum

Front 1119

What is unique about the neuromuscular blocking agent ATRACURIUM?

Back 1119

Not metabolized by liver or kidneys. It degrades spontaneously in the plasma and is also hydrolyzed by serum esterases. Safe in liver or renal dysfunction.

Note: Succinyl choline has an an ultra-short duration of action and should be used with extreme caution in pts with hyperkalemia.

Pancuronium and mivacurium are metabolized by the kidneys.

Rocuronium is cleared by the liver.

Front 1120

Gold standard test for diagnosis of acromegaly?

Back 1120

Measure growth hormone levels following an oral glucose load. Most NORMAL individuals will suppress serum GH levels after administration of glucose but patients with ACROMEGALY are unable to suppress and sometimes paradoxically increase the serum GH levels following an oral glucose load.

Note: IGF-1 levels are a very good SCREENING test for acromegaly but should be followed by the gold standard test is still needed for confirmation of the diagnosis.

Front 1121

An important complication of nephrotic syndrome due to antithrombin III lost in the urine?

Back 1121

renal vein thrombosis - antithrombin II deficiency increases risk of venous AND arterial thrombosis. This can occur with any tyope of nephrotic syndrome but most commonly caused by MEMBRANOUS glomerulonephritis in adults.

Front 1122

How is positive predictive value and negative preditive value related to prevalance?

Back 1122

higher the prevalance, the higher the PPV, the lower the NPV.

the lower the prevalance, the lower the PPV, and the higher the NPV

Front 1123

Contraindications to triptans?

Back 1123

1) familial hemiplegic migraine
2) uncontrolled HTN
3) CAD
4) Prinzmetal angina
5) pregnancy
6) ischemic stroke
7) basilar migraine

Front 1124

What kind of murmurs ALWAYS require workup?

Back 1124

diastolic and continuous bc the probability of an organic cause is high.

Front 1125

Criteria for oxygen therapy in COPD?

Back 1125

PaO2 </= 55

SaO2 </= 88%

erythrocytosis (Hct > 55%)

or evidence of cor pulmonale

Front 1126

Bronchogenic cysts are usually found in the _________ mediastinum?

Back 1126

middle

Front 1127

Thymoma is usually found in the __________ mediastinum?

Back 1127

anterior

Front 1128

effect of pH on calcium?

Back 1128

increased pH causes an increased affinity of serum ALBUMIN to calcium --> albumin-bound calcium INCR, ionized calcium level DECR

Decr levels of ionized calcium can result in manifestations of hypocalcemia since ionized calcium is the only physiologically active form.

Front 1129

Treatment of choice for cellulitis WITH systemic signs and WITHOUT systemic signs?

Back 1129

WITH systemic signs - IV nafcillin or if high prevalence of MRSA in area, can use vanco

WITHOUT systemic signs - ORAL dicloxacillin

Front 1130

Most frequently effected dermatomes in shingles?

Back 1130

T3-L3

Front 1131

Drug of choice for herpes zoster?

Back 1131

Valacyclovir but acyclovir is cheaper and also effective.

Note: EARLY antiviral therapy reduces the duration of rash and associated pain and also thought to reduce the likelihood of developing postherpetic neuralgia.

Front 1132

Seborrheac dermatitis occurs with increased frequency in what 2 diseases?

Back 1132

Parkinson's dz

HIV

Front 1133

Pityriasis rosea is caused by what organism?

Back 1133

human herpesvirus 7 - eruption begins iwth a large lesion known as a herald patch and spreads to a "christmas tree" pattern on the trunk

Front 1134

Cholecystectomy is recommended for those with porcelain gallbladder because?

Back 1134

11-33% eventually develop gallbladder carcinoma. Porcelain gallbladder can develop in some patients with chronic cholecystitis and is thought that calcium salts are deposited intramurally secondary to chronic irritation from gallstones or the natural progression of chronic inflammation.

Front 1135

Management of acute symptomatic hypOnatremia versus chronic hyponatremia?

Back 1135

ACUTE - is a medical emergency requiring a prompt increase in the serum sodium concentration. HypERtonic saline solutions can be used in this scenario.

chronic - requires slow correction bc the cells of the brain have adjusted to the hyponatremic milieu and rapid increases in the serum sodium can cause osmotic demyelination syndrome.

Front 1136

A very common side effect of electroconvulsive therapy?

Back 1136

amnesia - anterograde amnesia tends to resolve rapidly while retrograde amnesia may persist longer.

Front 1137

Interesting note:

Back 1137

Both SLE and chronic steroid use are risk factors for ACCELERATED coronary atherosclerosis.

Front 1138

Causes of EXUDATIVE pleural effusions?

Back 1138

infection (pneumonia and tuberculosis), malignancy, pulmonary embolism, connective tissue disease, and iatrogenic causes.

Front 1139

How long should a patient remain on heparin AND warfarin for bridging purposes?

Back 1139

until INR is in the therapeutic range for two consecutive days, at which point warfarin therapy alone is appropriate.

Front 1140

SLE is often associated with false positive tests for?

Back 1140

RPR and VDRL (tests used for the diagnosis of syphillis). Neither are of any use in diagnosing SLE.

Use anti-Smith antibodies and/or anti-double stranded DNA antibodies to confirm SLE.

Front 1141

Differences btn chlamydial and gonococcal urethritis?

Back 1141

chlamydial - MORE common than gonococcal URETHRITS. It has MUCOpurulent urethral discharge and ABSENT bacteriuria and pyuria on U/A.

Gonococcal - Urethral discharge is PURULENT not mucopurulent, and gram stain ususally DOES REVEAL organism.

Front 1142

Major cause of morbidity and mortality in patients with subarachnoid hemorrhage?

Back 1142

Vasospasm at the base of the brain - signs of ischemia usually appear about 7 days after the SAH. Calcium channel blockers (nimodipine) are used to prevent vasospasm.

Front 1143

What causes a transient loss of vision lasting a few seconds with changes in head position and can be confirmed with ophthalmologic examination?

Back 1143

papilledema - caused by increased intracranial pressure which has its own associated symptoms such as morning headaches or changes in headache intensity with position.

Front 1144

PainLESS jaundice plus CONJUGATED hyperbilirubinemia and markedly elevated ALP should raise concern for?

Back 1144

intraabdominal malignancy obstructing the biliary system such as pancreatic adenocarcinoma.

Front 1145

What does beta blocker overdose look like?

Back 1145

bradycardia, hypotension, WHEEZING, AV block, and potential cardiogenic shock.

Atropine and IV fluids are first line treatment. If symptoms do not reverse, glucagon should be administered.

Front 1146

All children aged 2-24 months with a first UTI should undergo?

Back 1146

a VCUG (voiding cystourethrogram) or RNC (radionuclide cystogram).

Front 1147

Management of the incidental finding of several non-tender, rubbery cervical lymph nodes, each approx 1 cm in diameter?

Back 1147

observation for node growth or the development of symptoms. Nodes > 2.0 cm in diameter or firm and immobile are more concerning for malignancy.

Front 1148

Management of a duodenal hematoma (most commonly occurs in children following blunt abdominal trauma) that presents with epigastric pain and vomiting due to failure to pass gastric secretions past the obstructing hematoma?

Back 1148

Treat conservatively with nasogastric suction and parenteral nutrition. Should resolve spont aneously within 1-2 weeks. Surgery (laparoscopy/laparotomy) can be used to evacuate the hemotoma if initial measures fail.

Front 1149

Dx of a rubbery, firm, mobile and painful mass in a young patient who experiences more tenderness during her menses?

Back 1149

fibrocystic dz - treated with aspiration of the cyst which should yield clear fluid and result in the disappearance of the mass. Afterward, pt is typically observed for 4-6 weeks.

Front 1150

Mode of transmission for hereditary spherocytosis?

Back 1150

autosomal DOMINANT

Front 1151

What do patients with hereditary spherocytosis usually begin experiencing by the 3rd decade of life?

Back 1151

Cholelithiasis and/or cholecystitis. Chronic leg ulcers may also be prevalant.

Front 1152

3 common complications of hereditary spherocytosis?

Back 1152

1) Episodes of aplastic crisis in which erythropoiesis is suppressed but the hemolytic process continues.
2) Sometimes intake of folic acid is too low to meet the demands of increased erythropoiesis; therefore all patients should be prescribed folic acid supplementation.
3) If patient has undergone splenectomy, risk is higher for encapsulated organisms so make sure vaccinations are up to date.

Front 1153

What does a shortened PR interval, delta waves, and widening of the QRS complexes signify?

Back 1153

Wolff-Parkinson-White syndrome - an accessory pathway btn the atrium and ventricle

Front 1154

Treatment of choice for an adjustment disorder?

Back 1154

psychodynamic psychotherapy or brief cognitive psychotherapy.

Front 1155

How do patterns of sleep change as people age?

Back 1155

As people age, they tend to sleep less at night and nap during the day. The period of deep sleep (stage 4 sleep) becomes shorter and eventually disappears.

Front 1156

What does a rapidly progressive dementia, myoclonus and an EEG showing sharp, triphasic, synchronous discharges indicate?

Back 1156

Creutzfeldt-Jakob disease - a spongiform encephalopathy caused by a prion. Most pts die within one year of symptom onset.

Front 1157

What is Osgood-Schlatter disease?

Back 1157

A traction apophysitis of the tibial tubercle. During early adolescence, there are periods of rapid growth in which the quadriceps tendon puts traction on the apophysis of the tibial tubrecle (same place where the patellar tendon inserts). This problem is worsened by sports that involve repetitive running, jumping, or kneeling. PE will show edema and tenderness over the tibial tubercle +/- a firm mass (due to heterotropic bone formation). Pain can be reproduced by EXTENDING the knee AGAINST resistance.

Front 1158

Treatment for Osgood Schlatter dz?

Back 1158

activity restriction, stretching exercises, and NSAIDs.

Front 1159

What kind of cancer does SPF protect against?

Back 1159

NON-melanoma skin cancers such as squamous cell carcinoma.

Front 1160

What is the best means of prevention for malignant melanoma?

Back 1160

use of protective clothing! Currently data shows little to no protection against melanoma with the use of sunscreen lotions with SPF 15-30; however, these can protect from non-melanoma skin cancers.

Front 1161

Most common side effects of digoxin toxicity?

Back 1161

GI - anorexia, nausea, vomiting, etc

Front 1162

How should all patients with smoke inhalation be treated?

Back 1162

With 100% oxygen via a non-rebreather facemask due to suspected acute CO poisoning. This competitively removes the binding of CO to hemoglobin and decreases the half life of CO from nearly 5 hours on room air to 1-2 hours.

Front 1163

Appropriate treatment of an anion gap metabolic acidosis following a grand mal (tonic-clonic) seizure?

Back 1163

Most likely due to a postictal lactic acidosis which will resolve within 60-90 minutes following resolution of seizure activity. Therefore observe and repeat labs after 2 hours.

Front 1164

Different types of transfusion reactions?

Back 1164

1) ABO mismatching - an acute HEMOLYTIC transfusion reaction that develops with an HOUR after the transfusion is tarted. Presents with fever, chills, flank pain, and hemoblobinuria and can lead to DIC, renal failure, and shock.

2) febrile NONhemolytic reactions - most common transfusion reaction. Caused by a reaction to CYTOKINES released by stored leukocytes in the transfused blood products. Causes fevers, chills, malaise. The reaction can be prevented by using leukoreduced blood, particularly if the RBCs are washed.

3) IgA deficiency- a major risk for ANAPHYLACTIC reaction to blood products taking place SECONDS to MINUTES of the infusion. Can be prevented by using IgA deficient blood products or performing extra washes of blood product.

4) Despite screening, a very small percentage of blood products are contaminated with infectious organisms. Pts may develop fever within 24 hours.

5) Delayed hemolytic transfusion - results from an anamnestic antibody response to an RBC antigen to which the pt has previously encountered (through exposure in pregnancy, transplant, or transfusion). The antibody is undetectable prior to transfusion but REAPPEARS rapidly following transfusion. It typically causes low-grade hemolysis 2-10 days after the transfusion.

Front 1165

What happens to cardiac index, total peripheral resistance, and left ventricular end-diastolic volume in systolic heart failure?

Back 1165

CI decreases

TPR increases 2dry to neurohumoral activation from SANS activation and the RAAS pathway.

LVEDV increases

Front 1166

Treatment for clavicle fracture in an infant?

Back 1166

no treatment - advise pt to avoid applying tension to the arm. Fracture heals wi 3-6 weeks.

Front 1167

Treatment for lithium induced diabetes insipidus?

Back 1167

This is a nephrogenic DI caused by lithum accumulation in the kidneys that directly damages the renal tubules. In such cases, AMILORIDE is the preferred agent bc it prevents further lithium accumulation in the renal tubules. If CNS dysfunction and significant dehydration, IV normal saline is also recommended.

Front 1168

Gold standard for diagnosing avascular (aseptic) necrosis?

Back 1168

MRI!!! Scintography can also be used. Radiographs are NORMAL!

Front 1169

Well known causes of avascular (aseptic) necrosis?

Back 1169

chronic corticosteroid therapy, alcoholism, and hemoglobinopathies.

Front 1170

Best initial choice of antibiotics in IV drug abuse related endocarditis?

Back 1170

Vancomycin

Front 1171

Indicators of a SEVERE asthma atack?

Back 1171

normal to increased PCO2
speech difficulty
diaphoresis
altered sensorium
cyanosis
"silent" lungs

Note: In an asthma attack, hyperventilation is usually present due to the increased work of breathing. Therefore PCO2 should be DECR. Normal to incr levels indicate CO2 retention bc of severe airway obstruction (air trapping) or respiratory fatigue.

Front 1172

What is the most important drug target in a pt showing an abnormal chromosome 22?

Back 1172

Abnormal chromosome 22 is the Philadelphia chromosome - formed by the reciprocal translocation of chromosomes 9 & 22 resulting in the BCR-ABL fusion gene which leads to abnormal tyrosine kinsase activity. (This is found in CML). Treatment should be tyrosine kinase inhibitors like imatinib (Gleevac) which binds to the ATP binding site of the BCR-ABL protein, prohibiting the confirmation change to its active form.

Front 1173

All trans retinoic acid is a crucial compnent of therapy for what type of leukemia?

Back 1173

acute promyelocytic leukemia

Front 1174

Keys to management of nephrolithiasis?

Back 1174

1) CT scan of abdomen is study of choice (KUB does not detect radioLUCENT stones).
2) Narcotics and NSAIDS - use NSAIDS in normal renal function bc narcotics can exacerbate nausea/vomiting.
3) Stones smaller than 5 mm will pass spontaneously. Increase fluids to greater than 2L daily.

Front 1175

Normal bell shaped distribution?

Back 1175

68% within 1 std deviation

95% within 2 std deviations

99.7 within 3 std deviations

Front 1176

Another name for erythema multiforme major (characterized by sudden onset target-shaped MUCOcutaneous lesions and SYSTEMIC signs of toxicity?

Back 1176

Stevens Johnson syndrome - involves an immune COMPLES mediated hypersensitivity. Most commonly associated with sulfonamides, NSAIDs, and phenytoin. Tx is similar to that of burns - primarily supportive with regular assessment of hemodynamic stability, fluid status, and pain control.

Note: Erythema multiforme minor is similar but usually occurs after a herpes simplex infection, mucosal involvement is rare, and systemic symptoms are less severe.

Front 1177

How long should bereavement last?

Back 1177

A normal grief reaction typically subsides by 6 months after the initial loss and the bereaved individual begins to move forward with their usual daily activities. However symptoms can recur for up to 1 year, especially on particular days such as anniversaries.

Note: Pts who have at least 2 weeks of symptoms of depression 6-8 weeks after a major loss should be considered for BOTH psychotherapy and a trial of antidepressants.

Front 1178

Benefits of note in the use of Bupropion as an antidepressant?

Back 1178

Particularly noted for improving the impaired CONCENTRATION and diminished ENERGY that many depressed patients experience. Does NOT cause SEXUAL dysfunction.

Front 1179

Definition of microalbuminuria?

Back 1179

urine albumin excretion btn 30-300 mg/24 hr (normal urine protein excretion is <30 mg/24 hour).

Front 1180

Good screening method for microalbuminuria?

Back 1180

spot urine collection and timed urine collection for the measurement of urine microalbumin to creatinine ratio.

Note: 24-hour urine collection is slightly more accurate in screening for microalbuminuria but is inconvenient for patients, making it less preferred by physicians.

Front 1181

Manifestations of steroid myopathy, both acute and chronic?

Back 1181

acute - UNcommon - diffuse muscle weakness and rhabdomyolysis during high-dose steroid treatment

chronic - more COMMON - insiduous onset of PROXIMAL muscle weakness withOUT significant pain.

Note: Both conditions improve with discontinuation of steroids.

Note: ESR is NORMAL.

Front 1182

"Risk" is a measure of ________ of a disease.

Back 1182

incidence

Front 1183

Important points to remember about phosphodiesterase inhibitor treatment?

Back 1183

1) Sildenafil is CONTRAINDICATED in patients being treated with NITRATES, and in those who are hyper sensitive to sildenafil.
2) Use with precaution in conditions predisposing to priapism.
3) Concurrent use of drugs which interfere with the metabolism of sildenafil (e.g. erythromycin, cimetidine) may predispose to adverse reactions by prolonging its plasma half-life.
4) While combining with an ALPHA-blocker, it is important to give the drugs at least a 4-hour interval to reduce the risk of hypOtension.

Front 1184

Suspect what in a pt recovering from an URI with sudden worsening of symptoms such as copious amounts of yellowist blood-streaked sputum, temperature of 104, and CXR infiltrates bilaterally as well as multiple, midfield thin-walled cavities?

Back 1184

Secondary bacterial pneumonia (especially common in elderly patients) - this in particular is an acute necrotizing pneumonia with secondary pneumatoceles, i.e. S. aureus causing multiple nodular infiltrates that cavitate to cause small abscesses.

Front 1185

Hodgkin's disease is a curable lymphoma that tends to affect young patients but can, unfortunately, lead to _________ malignancies.

Back 1185

Secondary - highest when chemo is combined with radiation. Up to 3.2% will develop a 2dry malignancy within 20 years of treatment. Lung and breast cancers are among the most common.

Front 1186

Rapidly developing hyperandrogenism with virilization is highly suggestive of?

Back 1186

An androgen-secreting neoplasm of the ovary or adrenal gland. Serum testosterone and DHEAS levels can help differentiate.

ELEV testosterone & NML DHEAS=ovarian source

NML testosterone & ELEV DHEAS=adrenal source

Front 1187

Suspect what with severe pain radiating to the back with difficulty walking due to leg weakness?

Back 1187

aortic dissection - once dissection progresses to include the DESCending aorta, possibly with ischemia of the arteries feeding the spinal cord, it can lead to leg weakness.

Front 1188

Defective bone mineralization is due to?

Back 1188

osteomalacia or Vit D deficiency

Front 1189

Defective mineralization of BOTH bone AND cartilage is due to?

Back 1189

Rickets

Front 1190

Acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues are most commonly due to?

Back 1190

pilonidal disease - most prevalant in young males, particularly those with larger amounts of body hair. Believed to develop following chronic activity involving sweating and friction of the skin overlying the coccyx within the superior gluteal cleft. INfection of hair follicles in this region may spread subcutaneously forming an abscess that then ruptures forming a pilonidal sinus tract. This chronic sinus tract may then collect hair and debris resulting in recurrent infections and foreign body reactions. Treatment is by drainage of abscesses and exision of sinus tracts.

Front 1191

Treatment for type A vs Type B aortic dissections?

Back 1191

Type A - involve the ASCENDING aorta - treat with medical AND surgical therapy.

Type B - involves only the descending aorta - treat with medical therapy alone.

Note: Medical therapy in both types involves beta-blockers (such as labetalol) bc it simultaneously lowers heart rate AND BP.

Front 1192

Recurrent hemarthroses in patients with coagulopathies lead to a joint injury called:

Back 1192

hemophilic arthropathy - characterized by iron (hemosiderin) deposition and synovial thickening with fibrosis.

Front 1193

Differential diagnosis for an ANTERIOR mediastinal mass?

Back 1193

the "4 Ts"
1) thymoma
2) teratoma (and other germ cell tumors)
3) thyroid neoplasm
4) terrible lymphoma

Front 1194

how to distinguish btn seminomas and nonseminomatous (mixed) germ cell tumors?

Back 1194

seminomas - b-hCG is high

nonseminomas - AFP is high and often b-hCG is ALSO high.

Front 1195

Know renal diagnosis based on casts! high yield.
Muddy brown casts?
RBC casts?
WBC casts?
Fatty casts?
Broad/waxy casts?

Back 1195

Muddy brown cast = ATN
RBC casts = glomerulonephritis
WBC casts = interstitial nephritis (eosinophilic casts more specifically) and pyelonephritis
Fatty casts = nephrotic syndrome
Broad/waxy casts = chronic renal failure

Front 1196

What vaccine is known for eliciting a T-cell INDEPENDENT B-cell response?

Back 1196

the adult 23-valent pneumococcal vaccine which contains capsular POLYSACCHARIDES.

Front 1197

What kind of vaccines elicit a T-cell-DEPENDENT B-cell response?

Back 1197

the heptavalent pneumococcal vaccine approved for use in children only - it is conjugated with PROTEIN which induces a T-cell DEPENDENT response. Also many vaccines coupled with bacterial TOXOIDS work in the same way, eg. tetanus toxin.

Front 1198

What is well known vaccine that promotes an IgA response?

Back 1198

oral polio vaccine - promotes the development of anit-poliovirus IgA antibodies in the GI tract.

Front 1199

Manifestation of impetigo?

Back 1199

presents as an itchy, erythematous macule which rapidly evolves into vesicles and pustules that rupture to leave honey-colored, crusted exudates. There are 2 forms:

vesiculo-pustular = streptococcus

bullous = staphylococcus

Front 1200

A defect or deficiency in C1 inhibitor leads to elevated levels of the edema-producing factors _________ and __________.

Back 1200

C2b and bradykinin

Front 1201

The most common cause of small bowel obstruction?

Back 1201

adhesions, usually from abdominal operations or inflammatory processes.

Front 1202

Gold standard for diagnosis of avascular necrosis of the hip?

Back 1202

MRI

Front 1203

The presence of bilirubin in urine is indicative of?

Back 1203

a conjugated hyperbilirubinemia

Front 1204

Class IC antiarrhythmic medications elongate the period of depolarization resulting in a prolongation of the action potential by what mechanism?

Back 1204

blocking sodium channels - this results in slowed conduction through the AV node and HIs-Purkinje system.

Note: Of class I agents, class IC meds have the SLOWEST binding and dissociation from the sodium channel giving it the property of use-dependence, i.e. it is more effective at higher heart rates bc there is not much time btn heartbeats for the medication to dissociate from its receptor.

Front 1205

What is the "use-dependence" phenomena of antiarrhythmics?

Back 1205

certain antiarrhythmics are more effective at higher heart rates bc there is not much time btn heartbeats for the medication to dissociate from its receptor. This is particularly seen with class IC meds such as flecainide and class IV meds. Class I meds prolong QRS whereas class IV meds do not.

Front 1206

A non stress test is considered reactive if...?

Back 1206

2 or more heart rate accelerations of 15 bpm above the baseline that last for 15 seconds over 20 minutes of observation.

Front 1207

Dx for rapidly progressive skin lesions that develop into nontender nodules with central necrosis in immunoCOMPROMISED patients?

Back 1207

ecthyma gangrenosum - disorder associated with Pseudomonas aeruginosa.

Front 1208

Syncope associated with prodromal nausea, pallor, and diaphoresis is due to what cause?

Syncope associated with prodromal dizziness and blurred vision is due to what cause?

Back 1208

vasovagal syncope

orthostatic hypotension

Front 1209

Temporal-based seizures (as in herpes encephalitis) may present with?

Back 1209

seizures, anosmia, gustatory hallucinations, and bizarre or psychotic behavior.

Front 1210

Dx if TLC is decreased, FVC is decreased, FEV1 is decreased, and FEV1/FVC ratio is NORMAL?

Back 1210

Restrictive lung dz such as pulmonary fibrosis. Bibasalar, FINE, DRY crackles are typically heard.

Front 1211

Difference btn protraction of labor and arrest disorders?

Back 1211

protraction - SLOW progression of cervical dilation. Can be categorized into 3 causes: "power, passenger, or pelvis." I.e. uterine contractions are inadequate, the fetus is too large, or the pelivs is too small. Best next step is an amniotomy to help labor along. If this fails, an intrauterine pressure monitor and oxytocin may be used.

arrest disorder - cervix ceases to dilate after reaching at least 4 cm.

Front 1212

How to distinguish a tuberculous effusion from other types of exudative pleural effusions?

Back 1212

A very high total protein concentration of the pleural fluid, typically greater than 4 g/dL. Also fluid is consistent with a lymphocytic leukocytosis and a glucose level that is MILDLY below serum glucose levels.

Note: empyema shows a predominance of PMN leukocytes and a VERY LOW glucose level in the pleural fluid.

Front 1213

Patients who are newly diagnosed with HIV should receive ____________ soon after diagnosis is made when the CD4 count is high enoubh to mount an appropriate antibody response?

Back 1213

pneumococcal vaccine

Note: prophylactic antibiotics are usually not indicated until the CD4 count is below 200/microliter.

Note: Antiretrovirals are recommended when CD4 count is less than 350/microliter.

Front 1214

primary therapy in malignancy related SVC syndrome?

Back 1214

radiation therapy, although this tx is primarily palliative.

Front 1215

Conditions that predispose patients to the development of aspiration pneumonia?

Back 1215

impaired consciousness (such as alcoholics, epileptics, or patients with a recent stroke), the presence of tracheal or nasogastric tubes, and an impaired gag reflex.

Front 1216

Dx in patients with bullae or urticarial plaques in the FLEXural areas?

Back 1216

Bullous pemphigoid - an autoimmune blistering dz. Pruritis is a very common symptom. Dz is usually not life threatening, but pts require long-term therapy with topical or systemic corticosteroids. Biopsy will show a SUBepdermal blister under light microscopy.

Note: pemphigus vulgaris shows an INTRAepidermal blister.

Front 1217

pharmacologic intervention for overflow incontinence (as in diabetes due to detrusor UNDERactivity) vs. for urge incontinence due to detrusor instability?

Back 1217

overflow incontinence - cholinergic AGonists such as bethanechol.

urge incontinence - muscarinic antagonists

Front 1218

DOC for reducing the risk of esophageal variceal hemorrhage?

Back 1218

non-selective beta-blockers such as propranolol or nadolol.

Note: nitrates, endoscopic band ligation, and TIPS are other options if beta-blockers alone are ineffective.

Front 1219

DOC for primary hyperaldosteronism (Conn's syndrome)?

Back 1219

spironolactone, an aldosterone blocking agent.

Note: Conn's is due to bilateral adrenal HYPERPLASIA whereas hyperaldosteronism can also be caused by a functioning adrenal adenoma which would require surgical resection, not pharmacological management.

Front 1220

Dx in a pt with elevated Ph, low Ca, along with renal dysfunction and bone pain?

Back 1220

renal osteodystrophy - where chronic renal failure leads to a REDUCED GFR which leads to phosphate retention AND abnormal processing of Vit D by the kidneys resulting in hypOcalcemia.

Both of these abnormalities serve to stimulate the parathyrod gland, leading to parathyroid hypertrophy and 2ndry hyperparathyroidism.