Step Up Q's

Front 1

1st thing you do in a patient with hemoptysis (2)?

Back 1

CXR followed by Bronchoscopy

Front 2

In developed countries, what are the two most common causes of hemoptysis?

Back 2

Bronchogenic Cancer & Bronchitis

Front 3

67 yo male with LLQ pain, fever, and leukocytosis = what? Confirm this diagnosis how? Treatment?

Back 3

Dx: Diverticulitis.
Test: CT scan of abdomen
Tx: Broad spectrum IV Abx, NPO (bowel rest), IV fluids....surgery if persist for >5 days

Front 4

First line tx for patient with suspected MI? Tests?

Back 4

TX: ASPIRIN, B blocker, ACE inhibitor, Oxygen, Nitro, consider morphine
Tests: Cardiac enzymes, 12 lead ECG when patient having chest pain, repeat when not having pain.

Front 5

Patient complains of sudden episode of vision loss, like "curtain coming down over eye", which resolves after a few minutes. First test? What's this called?

Back 5

Carotid Ultrasound. Amaurosis Fugax (caused by opthalmic artery emboli from carotid plaque)

Front 6

2yr post-gastrectomy patient has increased DTR's in legs, stumbles, and has weakness at end of day. Dx? Tests to order?

Back 6

B12 deficiency (due to intrinsic factor loss).
Test: Check for high MCV & anemia, B12 levels, and serum homocysteine & MMA

Front 7

Test used to diagnose Cushings? Once this test is done, what do you do next if it's positive?

Back 7

Overnight Dexamethasone suppression test.
Next: High dose Dexa suppression to determine if high cortisol is ACTH dependent or independent.

Front 8

How do you treat someone who is having an acute ST elevation MI (STEMI)? Non-STEMI's?

Back 8

STEMI: If less than 2 hours--> catheterization
Non STEMI: thrombolytics

Front 9

Patient with 3 day history of profuse vomiting, mild diarrhea, abdominal pain (ie, viral gastro) probably has what acid/base disorder? Treatment?

Back 9

Metabolic Alkalosis (more vomiting than diarrhea).
Tx: Normal Saline + Potassium and an anti-emetic

Front 10

62 yo male with no pain and bloody stool most likely has? Diagnostic test?

Back 10

Diverticulosis.
Test: Colonoscopy (R/O cancer!)

Front 11

Patient with history of prolonged NSAID use presents to ED after vomiting several hundred ml of blood. Vitals/Labs are: 90/55, RR:20, HR: 119, Hb: 7.3, Hct: 22. What is initial mgmt and testing?

Back 11

Initial mgmt: Stabilize hemodynamic shock via IVF or even transfusion.
Test: Upper Endoscopy

Front 12

74 yo pt with HTN and previous MI presents with 6 hour h/o R facial droop & decreased strength in R arm and leg. What area is affected in brain? 1st test to order? 1st line therapy?

Back 12

Location: Left MCA (left cerebral hemisphere)
Test: Noncontrast CT of head (r/o hemorrhage or mass)
Therapy: >3 hours give Aspirin, prevent aspiration, manage BP. If it were less than 3 hours, give thrombolytics.

Front 13

72 yo female with 2 week history of increased frequency of loose stool and left lower quadrant pain, all vitals and PE normal. She most likely has? 1st test you order? Tx?

Back 13

Diverticulosis.
Test: Barium Enema
Tx: High fiber foods

Front 14

23 yo female with h/o heavy menses since menarche, epistaxis every two weeks, and tendency to bruise easily. CBC shows Hb=7.8, Hct=24%, MCV=69, with normal platelet count. She most likely has? Tests to order? Tx?

Back 14

Think Von Willebrand b/c she has normal platelets and it's the most common inherited bleeding disorder (hemophilia presents with low platelets)
Tests: Bleeding time, [vWF antigen], ristocetin platelet aggregation test
Tx: DDAVP (Desmopressin promotes vWF release)

Front 15

25 yo presents with episode of numbness in L leg that lasted several hours. PMH: transient unilateral loss of vision 2 yrs ago which resolved and never recurred. VS normal; PE reveals "numbness" in left leg, nothing else. Most likely dx? Initial workup?

Back 15

Multiple Sclerosis (key presenting feature: transient sensory deficits)
Workup: MRI of brain to look for any demyelinating lesions

Front 16

59 yo woman with SOB, cough, normal VS, coarse breath sounds b/l on auscultation, & prominent basilar lung markings most likely has? Major complications of this disease?

Back 16

COPD (Chronic Bronchitis)
Complications: Cor pulmonale & Pulmonary HTN

Front 17

Aside from ortho consult, what must you do in an elderly patient that has a fractured hip (or any other fracture) with no history of falling or trauma?

Back 17

Search for possible primary neoplasms via CT scan of chest, abdomen, pelvis; also bone scan, lab studies, and PSA levels

Front 18

72 yo female with 2 week history of increased frequency of loose stool and left lower quadrant pain, all vitals and PE normal. She most likely has? 1st test you order? Tx?

Back 18

Diverticulosis.
Test: Barium Enema
Tx: High fiber foods

Front 19

23 yo female with h/o heavy menses since menarche, epistaxis every two weeks, and tendency to bruise easily. CBC shows Hb=7.8, Hct=24%, MCV=69, with normal platelet count. She most likely has? Tests to order? Tx?

Back 19

Think Von Willebrand b/c she has normal platelets and it's the most common inherited bleeding disorder (hemophilia presents with low platelets)
Tests: Bleeding time, [vWF antigen], ristocetin platelet aggregation test
Tx: DDAVP (Desmopressin promotes vWF release)

Front 20

25 yo presents with episode of numbness in L leg that lasted several hours. PMH: transient unilateral loss of vision 2 yrs ago which resolved and never recurred. VS normal; PE reveals "numbness" in left leg, nothing else. Most likely dx? Initial workup?

Back 20

Multiple Sclerosis (key presenting feature: transient sensory deficits)
Workup: MRI of brain to look for any demyelinating lesions

Front 21

59 yo woman with SOB, cough, normal VS, coarse breath sounds b/l on auscultation, & prominent basilar lung markings most likely has? Major complications of this disease?

Back 21

COPD (Chronic Bronchitis)
Complications: Cor pulmonale & Pulmonary HTN

Front 22

Aside from ortho consult, what must you do in an elderly patient that has a fractured hip (or any other fracture) with no history of falling or trauma?

Back 22

Search for possible primary neoplasms via CT scan of chest, abdomen, pelvis; also bone scan, lab studies, and PSA levels

Front 23

What are the ONLY radiographic findings that are reliable for a benign lung lesion are?

Back 23

Lack of growth for at least two years (when compared with old CXRs) & distinctive central laminated calcification pattern

Front 24

70 yo patient with h/o two MI's complains of fatigue & dyspnea for 2 months with no other symptoms. ECG--> brady with VR of 35bpm, regular P waves & QRS complexes with no relationship b/t the two. What does she have? Management?

Back 24

3rd degree heartblock
Mgmt: If unstable, temporary pacing should be performed until permanent pacemaker can be placed. Pacemaker is always indicated in type 3 hb and type 2 hb with symptoms.

Front 25

How do you initially manage a patient with h/o suspected PUD (ie, intermittent epigastric pain not related to food intake)

Back 25

Endoscopy & acid suppression via H2 blocker or PPI

Front 26

32 yo female with h/o intermittent ab cramping with flatus, diarrhea on and off for years, and constipation. No PMH, PE reveals LLQ tenderness w/out guarding or rebound, and no occult blood in stool. What do you do?

Back 26

Nothing further. She has a clinical diagnosis of IBS.

Front 27

What are the signs and symptoms of CHF? What are the initial tests needed for someone presenting with these S&S? Tx?

Back 27

S&S: progressive SOB, bibasilar crackles, exp wheezes, pitting edema, LVH, pulmonary congestion, cardiomegaly, nonspecific ST changes/Q waves/T wave inversions.
Tests: serial enzymes/ECG to r/o MI, transthoracic echo to look at heart chambers, valves, and systolic function
TX: O2 & Diuretics and watch urine output

Front 28

What are the major causes of CHF?

Back 28

Long standing HTN, previous MI, high Na+ intake, illness or infection, and myo infarction or ischemia

Front 29

52 yo male has gripping chest pain that radiates to neck while sitting in a chair. What does he have and how do you tx it?

Back 29

Unstable Angina (b/c he's at rest).
Tx: Admit & give heparin, aspirin, B blocker, nitrates, & O2

Front 30

What is the appropriate next step in mgmt of patient with fever, nausea, vomiting, and flank pain/CVA tenderness?

Back 30

Since she probably has pyelo and that can lead to sepsis:
Admit to hospital and administer IV Abx (cipro or amp+gent)
Tests: CBC, renal panel, urinalysis, urine & blood cultures

Front 31

If a patient with h/o HTN suddenly loses consciousness and awakes with a headache/vomiting and altered mental status, what has occurred? Management?

Back 31

Hemorrhagic Stroke
Mgmt: ABC's 1st, then CT scan to look for hemorrhage if she's stable

Front 32

When a patient has had a hemorrhagic stroke due to high BP, what must you NOT do during treatment?

Back 32

Lower BP too fast. Lowering BP too fast will hypoperfuse the brain--> further damage

Front 33

72 yo female with 2 day h/o lower abdominal pain that becomes severe. PMH includes CAD & HTN. PE: stool positive for blood and mild mid abdomen pain. Dx? Next step in evaluation?

Back 33

Since the sudden onset of severe abdominal pain is disproportional to physical findings--> Acute Mesenteric Ischemia
Next step: Emergent mesenteric angiogram

Front 34

What are the findings you expect if someone has acute pericarditis? Tx?

Back 34

-Pericardial friction rub
-Positional and pleuritic chest pain (hurts more when breathing in and sitting upright)
-Recent h/o upper resp illness (viral)
-ST elevation
-PR depression (specific to AP)
TX: NSAIDs only

Front 35

What is the first step in managing spontaneous pneumothorax if pt is stable? Treatment?

Back 35

First step: Obtain CXR, start 100% 02
Treatment: Chest tube

Front 36

What are the steps taken to manage a person with a fib that is stable?

Back 36

If tachycardic: give B blocker (atenolol) or Ca+ channel blockers and digoxin to lower rate
If duration unknown: start anticoagulation for 3 weeks, then cardiovert. Continue anticoagulation for 4 weeks following cardioversion

Front 37

What are the three classic findings in aortic stenosis? What would an AS murmur sound like? What is the only definitive treatment?

Back 37

Classic findings: Angina, Syncope, Heart Failure
Murmur: 4/6 crescendo/decrescendo heard at R upper sternal border w/ radiation to carotid arteries
Tx: Valve replacement (avoid nitrates!)

Front 38

Older patient with anterior knee pain that is worse with climbing or descending stairs most likely has? Evaluation? Treatment?

Back 38

Patellofemoral Arthritis
Testing: Plain radiograph
Tx: PT to strengthen/stretch quads/hams to unload patella and shift load to thigh muscles is very effective

Front 39

What are the next steps taken in a patient with DM type II if diet/exercise fail?

Back 39

Drugs: metformin or glipizide (oral hypoglycemic agents)
Tests: HbA1c (gives avg blood glucose for past 2 months or so)
PE: thorough exam with attn to feet
General: screen for microalbuminuria, refer to opthalmology

Front 40

What are the simple criteria in diagnosing DM II?

Back 40

Two separate fasting blood glucose values of greater than 126 mg/dl

Front 41

75 yo man with 3 weak h/o weakness, esp in hands & shoulders, foot drops while walking, has dysphagia, and has decreased DTR's b/l with atrophy of hand mm's. Dx?

Back 41

Amyotrophic Lateral Sclerosis

Front 42

What anti-hypertensive is contraindicated in pt with cocaine abuse? What would you use instead?

Back 42

B-blockers (causes shift to alpha receptors!)
Use lorazepam instead, b/c HTN is probably due to w/d

Front 43

Azotemia + friction rub (heart) + pericardial irritation S&S, what is diagnosis? Treatment?

Back 43

Uremic Pericarditis
Tx: Emergent hemodialysis

Front 44

What causes the three types of azotemia (high nitrogen products, Cr/BUN/etc, in blood indicating failure of kidney to filter blood) and how do you distinguish them?

Back 44

Prerenal: decreased CO results in inadequate blood to kidney; BUN:Cr > 20, Urine Na<10, urine osmolarity<500
Renal: intrinsic kidney dz, usually due to parenchymal problems; BUN:Cr<15
Postrenal: blockage of outflow; BUN:Cr>15

Front 45

When is meperidine administration for renal colic strictly contraindicated?

Back 45

If pt is taking MAO-I's (phenylzine, selegiline...)

Front 46

AIDS patient with P. jiroveci pneumonia treated how?

Back 46

TMP-SMX