Uiuc M2 2010 Fcp Exam_4

Front 1

undiferentiated spondyloarthropathy

criteria: (6)

Back 1

1) Inflammatory axial arthritis (sacroiliitis and spondylitis)
2) Peripheral arthritis (often asymmetric and oligoarticular)
3) Enthesitis (inflammation at tendinous/ligamentous insertions)
4) HLA-B27 positivity
5) XRay evidence of erosions +/- hyperostosis (reactive bone)
6) Extra-axial, Extra-articular Features

Front 2

Patients are said to have Systemic Sclerosis (SSc) by ACR criteria:

Back 2

one major criterion,
or
2 of the 3 minor criteria

Major:Proximal scleroderma
Minor:
1)Sclerodactyly
2) Digital pitting scar
3) Interstitial change on chest x-ray

Front 3

spondyloarthropathy:

Associated Extraarticular Features: (7)

Back 3

1) Periarticular: Enthesitis, tendinitis, 2) dactylitis (sausage-digit)
3) Ocular: Uveitis, Conjunctivitis
4) GI: Painless oral ulcerations, asymptomatic gut inflammation, symptomatic colitis
5) GI: urethritis, vaginitis, balanitis
6) Cardiac: Aortitis, valvular insufficiency, heart block
7) Cutaneous: keratoderma blennorrhagicum, psoriasis or nail lesions (onycholysis, dystrophy, pitting).

Front 4

Acute Cutaneous Lupus:

features:

Back 4

Butterfly rash’
• Spares nasolabial folds
• Erythematous, elevated, puritic/painful
• Strong association with systemic lupus erythematosus

Front 5

Spondyloarthopathies
ESSG Criteria:

Back 5

Inflammatory Spinal Pain
or
Synovitis (Asymmetrical or Predominantly lower limbs)
AND (one of following)

1) Alternate buttock pain
3) Sacroiliitis
3) Positive family history
4) Psoriasis
5) Inflammatory bowel disease
6) Urethritis or cervicitis or acute diarrhea occurring within 1 month before the onset of arthritis

Front 6

Proximal scleroderma

features in systemic sclerosis:

Back 6

Major criterion for Sclerosis

Thick skin of fingers and hands, (or forearm, torso, face,.
Atrophic (Thin) skin of face

Front 7

HLA-B27

Back 7

Class I MHC, important in antigen presenation → CD8 T cells

Associated with the spondyloarthropathies.

normal gene found in 8% of Caucasians, 3-4% of AA

risk of developing AS in ANY HLA-B27: 1-2%
> 95% of patients with AS are B27+

HLA-B27+ → ↑risk uveitis, more severe clinical course
HLA-B27neg → peripheral arthropathritis, skin and nail disease, or IBD.

Front 8

Esophageal CA: change with fundus involvement?

Change going higher up in esophagus?

Radiation, chemo + radiation remission?

Back 8

Can't remove fundus; excludes surgery.

Higher in esophagus = poorer prognosis (can’t replace esophagus).

Rads: 80%; both: 85%

Front 9

ANKYLOSING SPONDYLITIS

Modified New York Criteria-
Clinical criteria:
Radiographic criteria::

Back 9

1) Low back pain and stiffness for >3 mo, improves w/ exercise, not relieved by rest.
2) Limited lumbar spine motion
3) Limitations of chest expansion

EITHER Bilateral sacroiliitis ≥ Grade 2 or Unilateral sacroiliitis ≥ Gr 3

Definite AS = ≥1 clinical plus 1 radiographic criteria

Probable AS = 3 clinical criteria and no radiologic criteria or
1 radiologic criterion and no clinical criteria

Front 10

Sclerodactyly

features in systemic sclerosis:

Back 10

Minor criterion for Systemic Sclerosis

early puffy fingers
Taut, thick skin of (just) fingers

Front 11

ANKYLOSING SPONDYLITIS

demographic

Back 11

More common in Caucasians than African-Americans
Male Predominant 5:1 to 10:1
onset 16-30 yrs. Rare after 45 yrs

Front 12

Subacute Cutaneous Lupus:

features:

Back 12

• ‘non-fixed, nonscarring, exacerbating and remitting’
• Originate as erythematous papules or small plaques with slight scale that can evolve to larger plaques
• Ro (SS-A) Ab often present

Front 13

Triad: Inflammatory back pain, immobility, AM Stiffness

Back 13

ANKYLOSING SPONDYLITIS

Front 14

Digital pitting scar

features in systemic sclerosis:

Back 14

Minor criterion for Systemic Sclerosis

Front 15

ANKYLOSING SPONDYLITIS

Severe Complications: (6)

Back 15

1) Spinal stiffness/ankylosis in kyphotic position
2) Osteoporosis/spinal fractures
3) Severe uveitis (25-40%)
4) Neurologic complications
5) Other organ involvement: heart, lung, kidney
6) Mortality

Front 16

Melanoma

% of all cancer cases?
risk factors:

Back 16

5% of all cancer cases

1) family history (melanoma, dysplastic nevus)
2) dysplastic nevi
3) sunburns
4) fair skin (2-3x risk)
5) UV exposure, both A or B, including tanning beds.

Front 17

REACTIVE ARTHRITIS

timing:
symptoms:
demographic:
complications:

Back 17

1-3 weeks after infectious event (GU, GI, idiopathic)
self limiting (< 6 mos), chronic, or intermittent

1) Arthritis recurrent in 15-30%, more in chlamydial arthritis pts
2) urethritis (vaginitis)
3) conjunctivitis

HLA-B27+ in 75-80% Caucasians
Post-venereal onset: Sex 5:1 M:F
Post-dysenteric (less common) M=F

complications: Acute anterior uveitis 5%, carditis, fasciitis

Front 18

LeRoy & Medsger have suggested two additional criteria to diagnose mild SSc:

Back 18

Raynaud’s phenomenon (plus both):
1) nailfold capillary abnormalities
and
2) SSc-specific antibodies (anti-centromere, anti-SCL-70, anti-PM-Scl, etc)

Front 19

TRIAD: arthritis + urethritis (vaginitis) + conjunctivitis

Back 19

(classic triad found in < one-third of pts)

REACTIVE ARTHRITIS

Front 20

Discoid Lupus

features:

Back 20

• Most common form of chronic cutaneous lupus
• Begin as flat to slightly-raised red purple macules with scaly surface that evolve into ‘coinshaped’ plaques or larger confluent plaques
• Often involve hair follicles, causing
‘follicular plugging’
• Frequent scarring
• Often involves
external ear and scalp
• Frequent scarring
• Can evolve to
cause central atrophy,
hypopigmentation

Front 21

Infectious Triggers for Reactive Arthritis

COMMON PATHOGENS:

Back 21

Enteric:
1) Shigella flexneri
2) Salmonella typhimurium, S. enteritidis
3) Yersinia enterocololitica
4) Campylobacter jejuni

Urogenital Infections:
Chlamydia trachomatis, C.Pneumoniae
Ureaplasma Urealyticum

Front 22

SSc-specific antibodies

Readily available:
Not so available:

Back 22

Anti-centromere
Anti-SCL 70
Anti-PM/Scl

Anti-Th/To
Anti-RNA polymerase III
Anti-fibrillarin

Front 23

B27+ HIV+ patients

Back 23

may manifest a severe form of:
Reactive arthritis; Psoriatic arthritis; Spondyloarthropathy

asymmetric poly- or oligoarthritis, lower extremitiy arthritis, dactylitis, enthesitis, fasciitis, conjunctivitis, urethritis

Front 24

Postop followup procedures for esophageal surgery (2)?

Gastric side effects (3)?

Back 24

Followup: EGD / CT

Side effects: achlorhydria, B₁₂ deficiency, early satiety

Front 25

Psoriatic arthritis

what is it:
demographic:

Back 25

Inflammatory polyarthritis associated with psoriasis
• May occur prior to the onset of skin disease
• Usually RF seronegative
M=F, Prevalence: 0.1%

Front 26

CREST

Back 26

Calcinosis cutis
Raynauds
Esophageal Dysmotility
Sclerodactyly
Telangiectasias

Front 27

Psoriatic arthritis

presentations: (6)
associated symptoms:

Back 27

1) Inflammatory DIP disease
2) Asymmetic oligoarthritis with large and small joints
3) Symmetric polyarthritis
4) Arthritis mutilans
5) Spondyloarthropathy
6) Spondylitis and sacroiliitis

1) Nail pitting
2) Skin disease
3) Pitting edema
4) Inflammatory eye disease

Front 28

SLE

epidemiology:
demographics:

Back 28

15-124/100,000 in USA
Female:male::9:1
More common in blacks and Asians

Front 29

SAPHO Syndrome

Back 29

Synovitis, Acne, Pustolosis, Hyperostosis, Osteitis
(Pustular Skin Disease + Osteitis or Arthritis)

Front 30

Scotoma

Back 30

an area of depressed vision in the visual field, surrounded by an area of less depressed or of normal vision.

Front 31

BD patients (Crohns disease or Ulcerative colitis)

relationship to arthritis:
risk increase w: (2)

Back 31

5-20% of IBD patients will develop inflammatory arthritis

1) ↑extent of colonic dz
2) extraintestinal manifestations: abscesses, E. Nodosum, uveitis, pyoderma gangrenosum

Front 32

SLE

symptoms/involvement: (7)
labs:

Back 32

1) malar rash, discoid rash, photosensitivity

2) oral ulcers
3) non-erosive arthritis
4) pleuritis or pericarditis
5) renal disorder:
6) seizures or psychosis
7) hematologic: eg: hemolytic anemia, leukopenia...

immunologic: Anti-dsDNA
Anti-SM, anti phospholipid

positive ANA

Front 33

Esophageal cancer risk factors:

which for adenocarcinoma, which for squamous carcinoma?

Barrett’s esophagus, drinking, GERD, obesity, smoking

Back 33

Adenocarcinoma: Barrett’s esophagus, GERD, obesity

Squamous carcinoma: drinking, smoking

Front 34

SLE Nephritis

Types: (7)
Signs/Symptoms:
associated with:
can progress to:

Back 34

Nil, pure mesangial alterations, Focal segmental glomerulonephritis, Focal proliferative GN, diffuse GN, diffuse membranous GN, advanced sclerosing glomerulonephritis.

Often asymptomatic
1) Edema
2) Hypertension
3) Proteinuria (>.5g/24 h or 3+ dipstick),
4) hematuria, cellular casts.

Associated with anti-ds-DNA Ab, higher mortality

end stage renal disease

Front 35

Melanoma

Diagnoses- ABCDE
next step:

Back 35

Asymmetry – ½ vs the other
Border – ragged, notched
Color – uneven
Diameter – larger than a pencil eraser or growth
Evolving

required biopsy- Clark level or Breslow depth

Front 36

Serositis in SLE

Back 36

Inflammation of
1) pericardium: pleuritic chest pain, pericardial effusion, tamponade

2) pleura: pleuritic chest pain, pleural effusions, respiratory compromise

3) peritoneum: abdominal pain, ascites, pseudoobstruction

Front 37

N1 excludes treatment?

Back 37

Excludes radiation: lymph nodes are too far for a local radiation dose.

Front 38

Effusion in SLE

features:

Back 38

typically exudative, normal glucose, moderate lymphocyte count

Front 39

Benefits of treating weight loss/appetite loss in advanced cancer patients?

Back 39

1) patients may feel better
2) studies have shown no survival benefits, patient gain fat, not lean muscle.

Front 40

Arthritis in SLE

features:

Back 40

Most common presenting feature of SLE

– Symmetric, somewhat inflammatory, nonerosive

Front 41

Iron deficiency anemia from perimenopause

If gastric adenocarcinoma found on biopsy, next diagnostic step?

Followup? Supplementation?

Back 41

(Do MMA as substitute for Schilling test.)

After gastric scope, do a CT to find other lymph node involvement.

Followup: PET/CT fusion (radio F attached to glucose) @ 5 years, consider 10

Provide iv iron, Vitamin B12 supplementation.

Front 42

Osteonecrosis in SLE

features:

Back 42

Seen in hip and shoulder joints

– Related to previous arthritis, steroid use, and treatment with cytotoxic drugs

Front 43

Clark level
levels: (5)

Breslow Depth
advantages: (2)

Back 43

1 epidermis – in situ disease
2 invasion of papillary dermis
3 through papillary but not into reticular dermis
4 invasion of reticular dermis
5 invasion of deep tissue

Breslow:
-more predictive of nodal involvement, better correlation with survival:
<1mm >95% survival,
1-2mm 80-96%
2.1-4mm 60-75%
>4mm 37-50%

Front 44

Myositis in SLE

features:

Back 44

Mild inflammatory changes associated with proximal muscle weakness and CK elevations

Front 45

HER2neu link to GI cancer?

Back 45

Gastric adenocarcinoma. (Also breast CA, of course.)

Front 46

Neuropsychiatric Manifestations in SLE

symptoms:
findings:
pathogenesis:

Back 46

Hallucinations, delusions, thought
disorganization, Headaches, Seizures, Peripheral neuropathy, Transverse myelitis

–Multiple micro infarcts seen in postmortem studies
–Pathogenesis – inflammatory and noninflammatory thickening of cerebral vessel.

Front 47

Teichopsia

Back 47

the sensation of a luminous appearance before the eyes, with a zigzag, wall-like outline. It may be a migraine aura

Front 48

Hematological Manifestations of SLE

types: (2)
features of each:

Back 48

Anemia most common, due to
1) Autoimmune hemolytic anemia
2) Renal insufficiency
3) Anemia of chronic disease
4) Leukopenia
Often parallels disease activity

Thrombocytopenia
-Anti-platelet antibodies often present
–Associated w/ antiphospholipid antibody syndrome

Front 49

Tumor of head of pancreas: best evaluation by?

Tx: Whipple procedure? outcome?

Another option?

Back 49

ERCP, image-guided needle biopsy (issues: miss area of interest; may not get enough tissue; core biopsy may induce pancreatitis)

Whipple: resect head of pancreas, duodenum/jejunum into stomach, reroute bile duct

Best option: gemcitabine (nucleoside analog)/erlotinib (EGFR inhibitor)

Front 50

SLE- cause of death

Back 50

ACTIVE SLE 15-50%

NEPHRITIS 20-30% (renal involvement increases mortality)

INFECTION 20-35%

STROKE, MI 10-30%

Front 51

Melanoma:

Primary therapy: (2)
adjuvent therapy-
when used:
Rx:

Back 51

1) Wide excision
In situ – 1 cm margins in all directions
Invasive – 2 cm margins
-May require skin grafting

2) Sentinel Node Biopsy
Considered with 1-2 mm invasion (or greater)
Predictive of outcome
If (+) consider full nodal dissection

Adjuvent tx:Only in node (+) disease or invasion >4mm.
1) Hi dose IFN (survival benefit at 6 yrs but not 12, Follow-up study – no benefit)
Pooled analysis of 3 studies: ↑DFS, no benefit in overall survival.)

Front 52

DM Diagnostic Criterion

Back 52

Symptoms + Casual PG >= 200
or
Fasting PG >= 126
or
2-hr post-load PG >= 200

Front 53

How to treat "in transit lesions"?

Back 53

melanomas on way to lymph node...
If limited in number and/or scope: excise, + sentinal lymph node biopsy.

Front 54

Types of headaches:
primary: (3)
secondary: (...)

Back 54

1) Tension
2) Cluster
3) Migraine

2nd: tumor, infection, bleeding, concussion, temporal arteritis, glaucoma

Front 55

How to tx metastatic melanoma:

systemic treatments: (4)

Back 55

Single or localized: consider excision
1) Tx systemically for a short time and reassess
2) If no significant progression then excise.

1) Dacarbazine
2) Temozolomide
3) Taxol based regimen (eg Carbo/taxol)
4) IL-2

Front 56

Hydocele in left testicle

anatomy?
potential malignant cause?

Back 56

L testicular vein goes into renal vein where right testicular vein goes into IVC.

Kidney tumor causing obstruction of L testicular vein.

Front 57

Side-effects of IL-2 treatment in metastatic melanoma:

Back 57

Highly toxic

-capillary leak syndrome

Front 58

Scenario: Sudden onset of left-sided headachs, with tearing of the left eye, and left-sided runny nose. Intense immediately. lasted only about an hour.
3x/day each day this week.

Back 58

Cluster Headache

Front 59

OncoVex

what is it?

Back 59

Vaccine for metastatic melanoma

28% partial response rate in Phase II trials
16% complete response
Seemingly durable – 4 years
Now in Phase III trials

Front 60

Department of transportation tests only five things: (5)

Back 60

Opiates
Amphetamines
Cocaine
Marijuana
PCP

Front 61

Cluster Headache

frequency:
demographic:
symptoms:
precipitating:
timing/duration:

Back 61

<1% of Headaches
Males>Females, Ages 25-50

1) unilateral
2) Begins quickly
3) Maximum intensity in minutes
4) Deep, excruciating, continuous
5) Begins around eyes or temple usually
6) Patient restless, may pace around
7) associated: lacrimation, rhinorrhea, sweating, Horner's.

alcohol can precipitate

Lasts 15min – 3 hrs
Each Cluster lasts 6-12w
Remission lasts approximately 6 months
Usually @night (9pm-9am)

Front 62

Risk in lung biopsy for cancer:

Back 62

pnemothorax
<risk if peripheral vs. central

Front 63

Claster Headache

pathophysiology:

Back 63

-Unclear-
• Trigeminal pain distribution
• Ipsilateral cranial autonomic features
• Episodic/circadian pattern

Likely: extra cranial vasodilatation secondary to neuronal dysfunction

Hypothalamus:
anterior: circadian rhythm.
posterior: autonomic function.

Front 64

Impaired Glucose Tolerance Diagnostic Criterion

Back 64

Fasting PG < 126
and
2-hr post-load PG 140-199

Front 65

Tension Type Headache

symptoms: (3)
affected by: (3)

Back 65

1) pressure/tightness around head
2) mild to moderate pain
3) no nausea, vomiting, phonophobia, photophobia, and aura

Psychological factors, diet, and sleep

Front 66

Adenocarcinoma starting in the following, often metastasize to where?

colon:
rectal:

Back 66

Colon: goes to liver first
Rectal: can go to lung first b/c different blood flow.

Front 67

Tension Type Headache

pathophysiology: (2)

Back 67

-Controversial-

1) (older) Head and neck muscle contraction causing vasoconstriction and ischemia

2) Headache continuum TTH<->Migraine
• Trigeminal neurovascular system and serotonin

Front 68

♂ or ♀ more likely to have a stroke?
♂ or ♀ more likely to die from a stroke? Black or white?

Back 68

Men more likely to have a stroke.
Women more likely to die from a stroke.
Stroke death rate: black ♂ > black ♀ > white ♀ > white ♂

Front 69

stabbing unilateral frontal headache. Nauseated, and light and sound sensitive

Back 69

Migraine

Front 70

♀ w/ bloating, distension, ascites, increased girth

symptoms suggestive of:
marker elevated?
first step in management:

Back 70

Ovarian CA symptoms:
CA-125 (not for screening, OK to follow)
1) pelvic ultrasound
2) if BRCA1/2 positive, MRI brain for mets

Front 71

Migraine:

types:

Back 71

Migraine with aura
Migraine w/o aura (80%)
Variants:
1) retinal
2) opthalmoplegic
3) familiar hemiplegic

Front 72

Impaired Fasting Glucose Diagnostic Criterion

Back 72

Fasting PG 100-125

Front 73

Migraine

frequency/demographic:

Back 73

17% of ♀ and 6% of ♂ each year
-Most common between 30-39 y.o.
-often familial

Front 74

Most lethal gynecological cancer

Back 74

Ovarian CA

Front 75

Migraine

pathophysiology theories:

Back 75

1) Trigeminovascular system
• imbalance: brainstem nuclei regulating antinociception and vascular control.
• substance P, calcitonin gene-related peptide(CGRP): pain and vasodilation

2) Cortical Spreading Depression (CSD): aura
• Self propagating wave of neuronal and glial depolarization
• Activates trigeminal nerve afferents causing inflammation in meninges

3) Serotonin: ↓ →cranial vessel dilation and sensitization of meningeal afferents of trigeminal nerve.

4) CGRP: Expressed in trigeminal ganglia nerves, potent vasodilator

Front 76

Detection periods, and non-obvious pros and cons:

blood:
oral fluid:
urine:
sweat:
hair:

Back 76

Blood: Minutes to days

Oral fluid: Minutes to days.
pro: difficult to adulterate. correlation w/impairment.
con: saliva production variable.

Urine: Hours to days

Sweat: Weeks.
pro: difficult to adulterate, noninvasive.
con: possible envir. contamination. variability.

Hair: Days to years
pro: 2nd collection capability.
con: environ. contamination. not detect recent use. few controlled studies.

Front 77

Stages of Migraine (4)

Back 77

1) premonitory symptoms: precede migraine by several hours to 2 days. Fatigue, neck stuff, light/sound sensitive, nausea, blurred vision, yawning, pallor

2) Aura: progressive neurolgic deficit or disturbance with subsequent complete recovery.
-caused by CSD
-usually occur before headache.

-visual disturbance (99%)
-sensory disturbance (31%)
-motor weakness (18%)
-speech disturbance (6%)
-autonomic, sinus, cutaneous allodynia.

3) Headache: usually AM, rarely awaken, one-sided usually, dull, deep, steady or throbbing/pulsitile.
worse with head movement, sneeze,...
photophobia, phonophobia

4) postdrome- tired and sluggish

Front 78

Prophylactic oopherectomy in BRCA1 and 2 patients
taking out too soon may:

Back 78

May affect cognition. yup, that's what he said.

Front 79

Cutaneous allodynia

Back 79

-Innocuous stimulation of skin produces pain
-Brushing hair, shaving, tight clothes

Front 80

DM A1c testing schedule

Back 80

2/yr if stable control, 4/yr if suboptimal (caution if RBC turnover is altered)

Front 81

Prolonged neurological migraine symptoms can be associated with:

Back 81

migraine infarction or seizures

Front 82

Abnormal vaginal bleeding

suspicious for:
risk factors:

Back 82

Uterine CA- usually adeno or adenosquamous.

unopossed estrogen (eg: tamoxifen)

Front 83

Menstrual Migraine

timing:
pathophysiology:
aura?

Back 83

2 d before to 3 days after menstration

Due to ↓ estrogen levels

No aura

Front 84

Most common type of stroke? 2 subtypes?

Back 84

87% ischemic
thrombosis > embolism

Front 85

Hemiplegic migraine

features:
timing/prognosis:
genetic form pathophysiology:

Back 85

Motor and sensory lost unilateral

Can last weeks, and if recur often, can lead to permanent loss

Familial hemiplegic migraine: dominant. mutation in transmembrane ion channels.

Front 86

Uterine cancer

features:
tx:
post-op treatment:

Back 86

1) tends to be well localized
2) surgery
3) no known post-op that ↓risk of recurrence.

Front 87

Basilar-type migraine

demographic:
symptoms:

Back 87

Young women and children

Dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, bilatral paresthesias and altered consciousness

Front 88

DM Glycemic control: fasting/preprandial glucose

Back 88

Normal < 100, goal 70-130

Front 89

Ophthalmoplegic migraine

frequency:
demographic:
features:

Back 89

Rare
Children and young adults
CN III, IV or VI impaired

Front 90

Recurrence rates/places (in general):

seminomas:
germ cell tumors:
kidney:
breast CA:
melanoma:

Back 90

seminomas: reoccur late in lungs

germ cell tumors: come back quickly if they plan to.

kidney: if >5yrs free, then they don't come back.

breast: can come back after 5 years
menanoma: can come back after 5 years.

Front 91

Retinal (ocular) migraine (rare)

frequency:
features:

Back 91

Rare

monocular scotoma or blindness for < 1 hr with headache

Front 92

Sweat can be used to detect:

(7)

Back 92

1) Ethanol
2) Nicotine/Cotinine
3) Morphine
4) Amphetamine/Methamphetamine
5) PCP
6) Methadone
7) Cocaine

Front 93

Medication Overuse Headache

frequency:
demographic:
drugs:
pathophysiology:

Back 93

1% of population
Women > Men, with previous hx of episodic migraines.
Tylenol, aspirin, butalbital, or any Rx

Continuous analgesic exposure causes antinociceptive tolerance, ↓effectiveness. ”mini-withdrawals” from fluctuating serum drug levels.

Front 94

Adjuvent hormone therapy in obese patients:

Back 94

doesn't work in patients with BMI > 30.

Front 95

facial pain, pressure, fever, anosmia
Pressure-like dull sensation, bilateral and periorbital

Back 95

Sinus Headache

Acute sinus headache with sinusitis, fever, and purulent discharge
-Frequently misdiagnosed, lasts for days at a time.

+congestion,
-nausea, photophobia,

Front 96

DM Glycemic control: bedtime/postprandial glucose

Back 96

Normal < 120, goal 100-160

Front 97

clinical case:
dull preauricular headaches that radiate to his temples. jaw is stiff and sore, take force to move lower jaw into place.

Pain is deep, dull, continuous, and worse in am

Back 97

TMJ Dysfunction Syndrome

Can present as just headache, or
unilateral ear or preauricular pain that can radiate to the jaw, temple, or neck.

Front 98

PSA <10:

tumor marker doubling in 6month/1yr

Back 98

Bone metastasis not likely, although could be in lymph nodes.

probably life threatening.

Front 99

Giant Cell (Temporal) Arteritis

pathophysiology:
demographic:
symptoms: (3)
labs:
dx:
tx:

Back 99

Chronic vasculitis of large and medium sized blood vessels.
Women:men = 3:1, usually ~70y/o, 1:500 people >50y.o

1) 2/3 of patients have headaches, may be temporal, frontal or occipital.
2) fever, jaw claudication, blurred vision, or transient loss of vision in one eye
3) 1/3 have tender temporal or occipital arteries

80% have very elevated sedimentation rate >50
dx:biopsy
tx: steroids

Front 100

Fatty streak forms at what age?
Injures layer of artery?
Fatty streak forms by?
2 other contributors to embolism?

Back 100

By age 20.
↑LDL in intima ⇒ oxidation ⇒ attracts leukocytes
macrophages ⇒ foam cells, visible as fatty streak

• Fibrous plaque (smooth muscle ⇒ ECM, inflammation, fibrous cap)
• Atheroma (core becomes necrotic, hemorrhages and calcifies)

Front 101

Brain tumor

symptoms:

Back 101

1) Headaches occur in 50% of patients, bifrontal but worse ipsilaterally, Worse with bending (32%), cough, sneeze, valsalva
2) Nausea and vomiting in 40%
3) change from baseline headache pattern + abnormal neurologic findings

Front 102

Gross hematuria:

suspicious of:

Back 102

Bladder cancer, until proven otherwise

Front 103

• Severe headache of sudden onset
• worse with bending over, sneezing...
• may have ↓ level of consciousness
• Stiff neck
“sentinal headache” that lasts for only few minutes

Back 103

Ruptured Aneurysm
"Worst headache of life"

Front 104

DM Glycemic control: A1c

Back 104

Normal < 6, goal < 7

Front 105

Cerebral Venous Thrombosis

symptoms: (6)

Back 105

1) 90% have headache
2) papilledema
3) visual loss
4) seizures,
5) neuro deficits,
6) altered consciousness and coma

Front 106

Flank pain and hematuria:

suspicious of:
w/gross hematuria, early stream? end stream?

Back 106

Kidney cancer

early stream: urethra
late stream: bladder

Front 107

Clinical Scenario:
Sudden severe eye pain, nausea, vomiting, headache
Unilateral blurred vision, halos, profuse tearing

Back 107

Acute Angle- Closure Glaucoma

Front 108

Two part process to drug screen:

step 1:
step 2:

Back 108

1) Immunoassay Screen
• Cross reactivity

2) GC/MS confirmation

Front 109

Acute Angle- Closure Glaucoma

pathophysiology:
demographic:

Back 109

iris pushing against trabecular meshwork (drainage channels)

farsighted people, elderly, Asians, Eskimos

Front 110

abdominal pain

suspicious of:

Back 110

ovarian cancer

Front 111

Bacterial Meningitis

symptoms: (9)
bugs: (3)

Back 111

1) Very ill within 24 hours
2) High fever (95%),
3) nuchal rigidity (88%),
4) altered consciousness (78%);
5) headache, photophobia,
6) petechia,
7) seizures,
8) focal neuro deficit, arthritis
9) Kernig and Brudzinski

Strep Pneumonia, Neisseria Meningiditis, Listeria monocytongenes

Front 112

DM HTN BP goals/schedule

Back 112

Check each visit.
Goal: SBP < 130, DBP < 80.
Sched: Trial lifestyle only < 3 mo, then ACEi/ARBs, then others.

Front 113

Concussion

definition:
causes:
pathophyz:
symptoms: (minutes, vs. hours to days)

Back 113

Mild traumatic brain injury (TBI) with trauma-induced alteration in consciousness ± loss of consciousness.

Vehicle accidents (45%), Falls (30%), occupational (10%), recreational (10%), assault (5%)

Cortical contusion with axonal disruption

Immediate:
headache, dizziness, vertigo or imbalance, lack of awareness of surroundings, and nausea and vomiting
Hours-days:
mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances

Front 114

dysphagia

suspicious of:

Back 114

esophageal cancer

Front 115

Postconcussion syndrome

symptoms: (4)
timing:

Back 115

1) headache, 2) dizziness, 3) neuropsychiatric symptoms, and 4) cognitive impairment

first days after mild TBI and generally resolve few weeks - months

Front 116

Two blood vessel changes that cause hemorrhagic stroke?

Back 116

Aneurysm
AVM

Front 117

Post-traumatic headaches

frequency:
timing:

Back 117

occur in 25 to 78% of patients after mild TBI

onset within 7 days after injury

Front 118

early satiety

suspicious of:

Back 118

gastric cancer

Front 119

Normal Pressure Hydrocephalus

demographic:
pathophysiology:
symptoms: (6)

Back 119

Patients older than 60
-Drainage of CSF impaired

1) demential (memory loss, speech, mood, etc)
2) difficulty focusing eyes
3) Walking problems (freezing, shuffling, etc)
4) Urinary symptoms (incontinenece, polyuria/urgency)
5) nausea
6) Headache

Front 120

DM Lipids goals/schedule

Back 120

Check at least annually.
Goal: TC < 200, LDL < 100 (<70 if frank CAD), HDL > 50, TG < 150.
Sched: Trial lifestyle only, then statins for high LDL (+/- ezetimibe), niacin/fibrates for bad HDL/TG (niacin can ↑Glu at ↑dose).

Front 121

large scrotum in 18y/o, US: 4cm mass.

management:

Back 121

Have to remove, biopsy could seed.

If seminoma, check periaortic lymph nodes.
if non-seminoma cancer, get chemo right away, but offer sperm banking because of infertility.
Keep monitoring blood levels.

Front 122

Breakdown products of Heroin

(2)

Back 122

Heroin → Mono-acetyl morphine (aka 6-am?) → morphine

Front 123

germ cell testicular cancer may metastasize as:

Back 123

large mediastinal mass

Front 124

DM Nephropathy goals/schedule

Back 124

Check urine albumin/GFR yearly. Tx ACEi/ARBs for albuminuria (check K/creatinine). If CKD/albuminuria progresses, refer.

Front 125

Prostate cancer treatment:

options:

Back 125

1) risk for sx high for >70yrs
chemo ineffective.
2) radiation tx: for bone mets
3) Orchiectomy + prosthesis, ↓testosterone, or ketacorazone to block. • hormonal works for ~2years.

Front 126

Treat ↑BP in ischemic stroke?

In intracranial hemorrhage: MAP vs ICP?

Back 126

Don't treat unless malignant (>220/120)

MAP > ICP enough for perfusion

Front 127

DM Retinopathy goals/schedule

Back 127

Dilated eye exam by opthalmologist at dx + yearly. Tx: laser photocoagulation if needed. RR of glaucoma, cataracts, etc higher in DM.

Front 128

Breakdown products of Codeine

(2)

Back 128

Codeine →
Morphine
and
Nor-codeine

Front 129

DM Neuropathy goals/schedule

Back 129

Annual screen.
Distal polyneuropathy: 10g monofilament/vibration.
Autonomic neuropathy: resting tachy, orthostatic hypo, constipation, gastroparesis, ED.
Tx for DPN: glycemic control, TCAs/anticonvulsants/5HT+NE reuptake inhibitors
Tx for gastroparesis: Metoclopramide, erythromycin
Tx for ED: PDE5is, PGs, pumps.

Front 130

Stuttering onset of MCA syndrome: stroke location?

Thrombotic or embolic more likely?

Back 130

ICA

Atherothrombotic > embolic

Front 131

DM overall best therapy

Back 131

MNT (Medical Nutrition Therapy), better than metformin!

Front 132

Reasons for positive (morphine/codeine) urine test: (4)

Reasons for positive 6-acetylmorphine (6-AM) test?

Back 132

1) Ingestion of poppy seeds (type of poppy seed claimed can be correlated with tests)

2) Use of codeine containing products

3) Use of morphine containing products

4) Use of heroin

6-AM: ONLY HEROIN USE

Front 133

DM prevention

Back 133

Education, immunization (flu, 1x pneumococcus, revax >= 65 in nephrotic, CRD, immunosuppression), stop smoking, antiplatelet tx.

Front 134

Gait ataxia: stroke location?

Thrombotic or embolic more likely?

Back 134

Vertebrobasilar

Atherothrombotic = embolic

Front 135

DM microvascular complications

Back 135

Retinopathy > Nephropathy > Neuropathy

Front 136

What level of the following generally indicates abuse?

morphine:
codeine:

Back 136

>5000 ng/mL → morphine abuse.

>300ng/mL with a morphine/codeine ratio of <2 → codeine abuse.

Front 137

DM management

Back 137

Step 1: Lifestyle + metformin (titrate dose over 1-2 mo)
Step 2: Add second agent within 2-3 mo (sulfonylurea, TZD, insulin, DPP-IV agonist)
Step 3: Insulin start/increase (discontinue secretagogues), try 3rd oral agent if A1c < 8.5%, check A1c x 3mo until < 7%, then x 6mo.

Front 138

Pure motor hemiparesis: stroke location?

Back 138

Penetrating vessels

Front 139

Dx of Hyperglycemic Hyperosmolar Syndrome

Back 139

Glu > 600
Osm > 320
No ketoacidosis

Front 140

Breakdown products of Cocaine: (1)

Specific to cocaine: ?

Back 140

Cocaine (Methylbenzoylecgonine) → Benzoylecgonine

Yes. Other "caines" (eg. lidocaine) structurally unrelated. No cross-reactivity.

Front 141

HHS Risk Factors

Back 141

Age > 70 y/o, nursing home, infection, MI, CVA, un-dx/tx DM2, drugs (steroids, diuretics, b-blockers).

Front 142

Homonymous hemianopia, choreoathetosis: stroke location?

Associated nerve palsy?

Thrombotic or embolic more likely?

Back 142

PCA

CN III palsy

Embolic > atherothrombotic (same for ACA, MCA)

Front 143

HHS mental status

Back 143

Alert: ~315 mOsm/kg
Drowsy: ~325 mOsm/kg
Stupor: ~340 mOsm/kg
Coma: ~350 mOsm/kg

Front 144

Metabolism of methamphetamine:

Back 144

Methamphetamine → amphetamine

Front 145

HHS Mortality Risk Factors

Back 145

Coma, age, osm, Na, BUN.
NOT SIG: glu, HCO3.

Front 146

Aphasia: words that don't make sense?

Back 146

Wernicke's

Front 147

HHS management

Back 147

FLUIDS! 1L/hr isotonic saline, continue until volume deficit corrected, then change to half-saline until free water deficit corrected, then add 5% dextrose when glu <= 300.
INSULIN! 0.15 bolus, then 0.1 infusion, double infusion rate if glu doesn't drop by at least 50/hr, when glu <= 300 lower rate to 0.05-0.1 and adjust PRN to keep glu at 250-300 until osm is <= 315.
POTASSIUM! if K < 3.3, give 40 mmol (2/3 KCl, 1/3 KPO4) until K > 3.3, then reduce to 20-30. if K > 5.0, monitor every 2 hr. if 3.5 < K < 5.0, 20-30.

Front 148

Amphetamine

isomers: (2)

Back 148

Levo-amphetamine: turns screening test positive, but not confirmatory tests.
(L (think: LEGAL)-isomer metabolite of Seligiline or Vick's Inhaler)

Dextro-amphetamine: need confirmatory to test for to prove.

Front 149

DM2 insulin resistance + therapy concept

Back 149

DM2 has both insulin resistance and relative lack of insulin. Loss of b-cell function progressive; therapy needs to intensify with time.

Front 150

Aphasia: difficulty forming complete sentences?

Back 150

Broca's

Front 151

Cannabis

metabolism:
other positive results due to:

Back 151

∆9-THC → 11 hydroxy THC

Dronabinol (legal THC for chemo)
Passive inhalation

Front 152

Aphasia: difficulty in understanding and forming sentences?

Back 152

Global

Front 153

Phencyclidine
cross reactivity on screening test:

Back 153

(PCP)

-Dextromethorphan (eg: Robitussin)

Front 154

Epilepsy is?

Pathogenesis?

Back 154

Recurrent seizures

Paroxysmal and disorderly neuronal depolarization, spread through brain tissue

Front 155

Alcohol:
short term tests for:
speed of metabolism:

long term tests for:

Back 155

Breath/Saliva/Blood testing
0.015 mg/dL per 60-90 minutes (~1 drink = 0.02-0.03mg/dL)

MCV: ↑after drinking

GGT (enzyme: ↑3-4weeks after alcohol drinking)

Ethyl glucuronide: Good for up to 7 days after heavy drinking and up to 2 days after last drink. false positives possible.

Front 156

Seizure type: consciousness not impaired?

Back 156

Simple partial seizure

Front 157

Detectability in Urine Stimulants (time after use)

Amphetamine:
Methamphetamine:
MDMA
Cocaine
Benzoylecgonine (cocaine metabolite):

Back 157

Amphetamine: 2-3 days
Methamphetamine: 48 hours
MDMA: 30-48 hours
Cocaine: 6-8 hours
Benzoylecgonine (cocaine metabolite): 2-3 days

Front 158

Seizure type: impaired consciousness at onset?

Back 158

Complex partial seizure

Front 159

Detectability in Urine: Sedatives

Barbiturates and benzos:
Ultra short acting and short acting (eg: thiopental, secobarbital):

Intermediate acting (pentobarbital):

Long-acting barbit: (phenobarbital):

Long-acting benzo: (diazepam)

Back 159

Ultra short acting and short acting (eg: thiopental, secobarbital): 24h

Intermediate acting benzo/barbit (pentobarbital)
~40-80 hours

Long-acting barbit: (phenobarbital):
16 days or more

Long-acting benzo: (diazepam):
7 days or more

Front 160

Imaging for stroke? Seizure?

Back 160

Noncontrast CT or MRI; MRI, SPECT, PET

Front 161

Detectability in Urine: Opioids

Methadone (maintenance dosing):
Codeine/morphine:
6-monoacetyl morphine:
Morphine glucuronides:
Codeine glucuronides:
Propoxyphene/Norpropoxyphene:
Dihydrocodeine:
Buprenorphine:
Buprenorphine conjugates:

Back 161

Methadone (maintenance dosing)
7-9 days
Codeine/morphine
24 hours
6-monoacetyl morphine
2-4 hours
Morphine glucuronides
48 hours
Codeine glucuronides
3 days
Propoxyphene/Norpropoxyphene
6-48 hours
Dihydrocodeine
24 hours
Buprenorphine
48-56 hours
Buprenorphine conjugates
7 days

Front 162

Detectability in Urine: Cannabinoids

Single Use:
Moderate Use:
Heavy Use (daily):
Chronic Heavy Use:

Back 162

Single Use
3 days
Moderate Use
4 days
Heavy Use (daily)
10 days
Chronic Heavy Use
Up to 36 days

Front 163

Detectability in Urine

Methaqualone:
PCP:
LSD:
Nicotine:
Cotinine (Nicotine metabolite):

Back 163

Methaqualone: 7 days or more

PCP: 8 days

LSD: 24 hours

Nicotine: 12 hours

Cotinine (Nicotine metabolite): 2-3 days

Front 164

Alcohol intoxication:

receptor system affected:
effect:

Back 164

GABA
depressant

Front 165

Blood alcohol levels

loss of muscular coordination begins, changes in mood and personality:

prolonged reaction time, ataxia, incoordination, mental impairment:

obvious intoxication, marked ataxia, nausea, vomiting:

hypothermia, several dysarthia, amnesia, anesthesia

onset of alcoholic coma, loss of airway protective reflexes, hypotension, decreased respirations, death

Back 165

20 - 99 mg% (.02-.09)

100 - 199 mg% (.10-.19)

200 - 299 mg% (.2-.29)

300 - 399 mg% (.3-.39)

400 - 799 mg% (.4-.49)

Front 166

Treatment for alcohol intoxication/overdose:

Treatment for alcohol withdrawal:

Back 166

No antidote: supportive ABC. do not use flamazenil.

3 stages, later stages preventable.
prevent seizures.
prevent delerium tremens.
-Use withdrawal assessment (AIWA-Ar): get tx to those who need it, don't over treat.

Benzodiazepines, Barbiturates, Clonidine, Carbamazepine

Front 167

Alcohol withdrawal:
Stage 1
Stage 2
Stage 3

Back 167

Stage 1: mild reactions. First 24 hours--may last 3-5 days.

Stage 2: alcoholic hallucinosis. Occurs within 48 hours. Hallucinations with insight

Stage 3: delerium tremens.
72 hours after last drink, Lasts 2-6 days. Hallucinations without insight
Delerium. Mortality 9-15%

Categories:
-Subjective complaints (anxiety, agitation, hallucinations)
-Objective signs: (hyperreactive reflexes, nystagmus, tremor, hyperthermia, confusion, delirium, seizures)
-hyperadrenergic state: tacycardia, HTN, diaphoresis, mydriasis.

-all three "categories" present in each stage, but ↑ in severity.

Front 168

Alcohol withdrawal seizures

when:
type:

Back 168

Can occur in any stage
-90% within first 48 hours

-Generalized tonic, clonic

-Status epilepticus rare

-First episode requires workup

Front 169

Alcohol withdrawal

important vitamins to give:

Back 169

Thiamine (prevent precipitation of wernicke syndrome before giving glucose)
Folic acid
Magnesium: cardiac arrhythmias.
Multivitamin:

Front 170

Sedative withdrawal

tx:

Back 170

-give substitution theray, prolong wtihdrawal
-carbamazepine
-valproic acid

Front 171

Opioid intoxication:

symptoms:
death due to: (3)
tx:

Back 171

1) respiratory depression

2) aspiration pneumonia
3) non-cardiogenic pulmonary edema

Supportive (ABC) +
Naloxone 0.4-2.0mg

Front 172

Opioid withdrawal

heroin- timing:
methadone- timing:

symptoms caused by:

Back 172

heroin 4-6 hours
methadone 36 hours

Hyperadrenergic activity in the locus ceruleus?

Front 173

Opioid withdrawal

tx:(5)

Back 173

tx:
1) replacement (methadone, buprenorphine)
2) clonidine
3) benzodiazepines
4) NSAIDS
5) Dicyclomine

Front 174

Opioid withdrawal symptoms: (11)

Back 174

1) Tachycardia
2) Hypertension
3) Fever
4) Restlessness, Irritability, Insomnia
5) Craving
6) Yawning
7) Pupillary dilation
8) Lacrimation, Rhinorrhea
9) Piloerection
10) Nausea, Vomiting
11) Diarrhea

Front 175

Stimulant intoxication symptoms: (5)

treatment:

withdrawal: (2)

Back 175

1) Anxiety, Agitation
2) Delusions, Psychosis
3) Hypertension, Tachycardia
4) Seizures
5) Rhabdomyolysis

Supportive:
1) Benzodiazepines for anxiety and seizures
2) Neuroleptics (haloperidol) for psychosis.
3) Vasodilators for hypertension
4) Use beta blockers with caution (don't)

Depression, suicide

Front 176

Cannabis

intoxication:
withdrawal from long term use:

Back 176

(anandamide/cannabinoid receptors)
1) depersonalization
2) altered time sense
3) acute panic
4) delerium (high dose)
no fatalities

1) irritability, restlessness, insomnia
2) anorexia
3) insomnia
4) diaphoresis
5) nausea, diarrhea, flue like syndrome
6) muscle twitches
7) tachycardia, hyperthermia, hypertension.

starts within 24 hours, lasts 1-2 weeks.