Usmle Ck - Git

Front 1

old man with back pain and constipation?

Back 1

- always look for hyperCa2+ as cause of constipation e.g. MM or other cancer

Front 2

s/p stomach surgery now with diarrhea, weight loss, bloating?

Back 2

- bacterial overgrowth from stagnant affernt limb => sx of vitamin deficiency and abd distention with succussion splash = soft fluid-filled loops of bowel
- note: not short gut syndrome b/c lots of bowel wasn't taken out!

Front 3

ascites tx

Back 3

1. Na and water restrict
2. spironolactone
3. furosemide, don't aggressive diurese b/c can cause hepato-renal syndrome
4. frequent abd paracentesis (2-4L/day) w/ frequent renal monitoring

other tx: porto-caval shunt will improve ascites but worsen encephalopathy; peritoneo-jugular shunt has bad side effects (peritonitis, sepsis, DIC)

Front 4

Initial tx of anal fissure?

Back 4

- stool softener, anaesthetic
- chronic = lateral sphincterectomy

Front 5

sx of UC? pt now with sepsis?

Back 5

- UC sx: abd pain, blood diarrhea, tenesmus
- UC dx: sigmoidoscopy with biopsy
- UC epi: females, ashkenazi jews
- sepsis most likely 2/2 toxic megacolon => get KUB, tx with NGT, bowel rest, steroids/abx

Front 6

crohns' vs UC path?

Back 6

- crohns: transluminal, affects all intestine, perianal fistual
- UC: contained to mucosal layers, mucosal inflammation, increased primary sclerosing cholangitis

Front 7

UC and CRC?

Back 7

- increased risk of CRC in UC so start screening 8-10 years after dx is made

Front 8

pt with foul smelling diarrhea s/p area with poor sanitation (S. America, rocky mountains)

Back 8

- giardia: trophozoites adhere to mucosal surface => malabsorption
- tx: empirically with metronidazole, no need for O+P

Front 9

best abx for infx diarrhea?

Back 9

- cipro unless you know metronidazole is indicated etc

Front 10

findings of ZE syndrome?

Back 10

- prominent gastric folds, ulcer located beyond duodenal bulb, e.g. in jejunum

Front 11

dx tests of ZE syndrome?

Back 11

- dx by serum gastrin level > 1000pg/ml, also measure gastric pH to r/o secondary hypergastronemia 2/2 achlorydia
- secretin stimulation test: do when suspect ZES but w/ nondiagnostic fasting gastrin levels; secretin => increased gastrin secretion by gastronoma cell only; secretin otherwise inhibits normal gastric G cell secretion, thus if no increase in gastrin then hypergastrinemia is not 2/2 gastrinoma
- calcium infusion test: pt with negative secretin test, but still suspect gastrinoma; Ca2+ infusion => increased secretin = gastrinoma

Front 12

pt with antral gastric ulcer?

Back 12

- biopsy
- if adenocarcinoma, do CT test b/c many present in stage III/IV where surgery is complicated or impossible

Front 13

gastric Ca associated with H pylori?

Back 13

- gastric lymphoma

Front 14

lightly touching area of skin causes pain?

Back 14

- VZV, herpes zoster esp in immunocompromised pts (chemo, HIV)

Front 15

complication of TPN?

Back 15

- cholecystitis 2/2 impaired gall bladder contraction
- CCK causes contraction but pts on TPN never activate CCK b/c food bypasses duodenum where stimulation occurs

Front 16

causes of cholecystitis?

Back 16

- estrogen => increased HMG-CoA reductase => increased cholesterol secretion
- hemolytic anemia => pigment gallstones
- TPN => decreased CCK => decreased gallbladder contraction
- decreased enterohepatic recyling of bile acids => icnreased cholesterol gallstone formation e.g. Crohns

Front 17

pt with fever, chills, LUQ pain, splenic fluid

Back 17

- infective L endocarditis with septic emboli to spleen; can embolize to brain, kidney, liver
- note pt may have increased LFTs suggestive of hepC and thus IV drug user
- note drug users also get right endo where emboli to lungs

Front 18

3 month hx of diarrhea, weight loss, night sweats, lymphadenoapthy, arthralgias?

Back 18

- test for HIV esp w/ long term diarrhea
- sx are from acute HIV, mono like

Front 19

tissue transglutamase Ab?

Back 19

- celiac dz: diarrhea, arthralgias

Front 20

Man with a year of diarrhea, flushing, heart murmur?

Back 20

- carcinoid syndrome triad
- note: need metastasis to cause sx
- tryptophan degraded in liver into 5-HT and 5-HIAA
- have niacin deficiency b/c all of tryptophan is going into making 5-HT

Front 21

*zenker diverticulum

Back 21

- 2/2 upper esophageal sphincter dysfunction and dysmotility => pounch between cricopharyngeal fibers
- copmlications: tracheal compression, ulceration w/ bleeding, pulm aspiration
- not caused by GERD that often occurs with GERD

Front 22

**drugs that cause pancreatitis? must know!

Back 22

- seizure/bipolar: valproic acid
- diuretics: furosemide, thiazides
- drugs of IBD: sulfasalazine, 5-ASA
- immunosuppressive agents - azathioprine, L-asparaginase
- AIDs pt: didanosine, pentemide
- Abx: metronidazole, tetracycline

Front 23

anti-endomysial
anti-Scl 70
ANA
anti-centromere
anti-mitochondrial

Back 23

anti-endomysial - celiac dz
anti-Scl 70 - scleroderma
ANA - autoimmune hep, SLLE
anti-centromere - CREST
anti-mitochondrial - primary biliary sclerosis

Front 24

celiac dz?

Back 24

- bulky foul semlling stool, pallor 2/2 iron deficiency anemia, hyperkeratosis, vit A, K deficiency
- loss of muscle mass or subQ fat, easying bruising

Front 25

pt with painless jaundice, high direct bili, high alk phos?

Back 25

- biliary obstruction most likely malignancy e.g. pancreatic adenoca
- increased direct bili = failed to excrete after conjugation e.g. biliary obstruction

Front 26

pt with high alk phos, only slightly elevated LFTs?

Back 26

- problem with biliary system
- LFTs are mostly preserved and check if serum albumin is pretty ok, then know it's not dz of liver (e.g. infiltrative dz like sarciod, hemochromatosis)

Front 27

chronic hepatitis labs?

Back 27

- high LFTs, can see increased conjugated bili, alk phos should be around normal

Front 28

achalasia vs scleroderma?

Back 28

- sx for both: sticking sensation in throat
- achalasia = low peristaltic waves and increased LES tone
- schleroderm = low peristaltic waves and decreased LES tone

Front 29

most sensitive test for chronic pancreatitis?

Back 29

- stool elastase
- amylase and lipase aren't helpful b/c pancreas may be burned out or fibrosis

Front 30

achalasia

Back 30

- secondary to systemic dz e.g. Chagas, amyloidosis, sarcoidosis
- note ddx= pseudoachalasia 2/2 obstructing neoplasm so if pt is old and losing weight, so upper endoscopy
- tx: pneumatic dilation
- nitrates or Ca2+ blockers aren't usually effective

Front 31

mallory weiss tear?

Back 31

- tear in mucosa of cardia and distal esophagus
- bleeding stops in 90% of pts, if not then use vasopressin, endoscopy injection, electrocautery

Front 32

when do stress ulcers occur?

Back 32

- ICU or burn setting

Front 33

PEX for pt with severe anemia?

Back 33

- 2/6 systolic murmur in 2nd righ intercostal space = FLOW murur
- tachycardia, increased BP with wide pulse pressure e.g. 160/80, low Hg
- scary signs, but do EKG and if ok, don't need to do ECHO
- most importnat is doing Fe studies, occult stool and even if negative, do colonoscopy b/c anemia is always 2/2 GI bleed unless proven otherwise
- radiolabeled isotopes only in actively bleeding pts

Front 34

iron studies in anema

Back 34

low FE, low Ferritin, high TIBC

Front 35

diarrhea associated with laxative abuse in factious d/o?

Back 35

- water, increased in both frequency and volume, + nocturnal BM
- biopsy: brown discoloration of colon with lymph follicles shining through = melanosis coli or pigment in macrophages of lamina propria

Front 36

nocturnal BM

Back 36

laxative abuse
- doesn't ever occur in functional diarrhea e.g IBS

Front 37

Work up of GERD?

Back 37

- uncomplicated: start on PPI, if fails then esophagascopy, if fails then esoph pH monitoring
- complicated = dysphagia, odynophagia, weight loss, occult bleeding, Fe deficiency => do endoscopy to find underlying case, don't start with med therapy

Front 38

complications of GERD?

Back 38

- Barretts AND peptic strictures (symmetricaly circumferential narrowing, can resolve sx of reflux by closing off esoph)
- adeno: asympt narrowing; occurs in pts with sx >20yrs, weight loss

Front 39

dyspepsia

Back 39

- epigastric pain, bloating, nausea
- NOT associated with mealtime or fatty foods, not secondary to biliary or pancreatic dz = DYSPEPSIA
- ddx = nothing, PUD, gastritis
- work up: screen for H pylori, endoscopy 1st if warning signs = >55, weight loss, dysphagia, persistant vomiting

Front 40

RF esoph adenocarcinoma vs squamous carcinoma?

Back 40

- adeno: barrett's obesity, increased calorie, fat, smoking
- SC: smoking, alcohol, low beta-carotene, vit B-1, zinc, selenium, viral infx, toxin producing fungi, hot food/beverages, pickled veggies, foods rich in N-nitroso

Front 41

pt with ZES has fat malabsorption?

Back 41

- ZES => increased gastrin => increased stomach acid from parietal cells => acid inactivates pancreatic enzymes => steatorrhea

Front 42

MC site for ischemic colitis? sx?

Back 42

- SPLENIC FLEXURE: end arteries btw SMA and IMA
- 2nd watershed = rectosigmoid jx = IMA
- sx: s/p hypotension, bloody diarrhea, increased leukocytosis with left shift
- radiology = thumbprinting, increased lactic acid
- ddx= infx colitis, IBD, crc

Front 43

blood transfusion threshold?

Back 43

- 7 if normal cardiac fx
- 10 with cardiac dz (CAD)

Front 44

type of blood products?

Back 44

- FFP = clotting factors and plasma protein; used to reverse coagulopathy e.g. to lower INR
- cryoprecipitate = factor VIII, fibrinogen, vWF, factor XIII, used in hemophilia, fibrogen def, vWD, and volume sensitive pts
- platelets: give when plts fall <10,000 = the level that spontaenous bleeding occurs

Front 45

pt with gallbaldder dz

Back 45

- if painless, nontender gallbladder that enlarged on U/S with obstruction, get CT b/c cholangioma or other ca
- if painful, U/S shows thickening and pericholecystic fluid, get HIDA scan, ERCP
- HIDA scan for acute cholecystits

Front 46

ddx fat malabsorption?

Back 46

- bacterial overgrowth, pancreatic insuff, celiac dz, crohn's dz

Front 47

d-xylose test?

Back 47

- simple sugar that's absorbed directly without digestion; only needs intact mucosa in proximal small bowel
- measure absorption via level in urine (>4.5-5=normal)
- will be decreased in bacteria overgrowth and celiac
- ddx by giving abx and repeat testand d-xylose should be normal in bacterial overgrowth

Front 48

VIPoma?

Back 48

- diarrhea, hypoK+, leg cramps, decreased stomach acid
- dx: increased VIP in blood, then do CT/MRI for location
- tx. 1. correct dehydration, 2. slow diarrhea with octreotide, 3. surgery

Front 49

diarrhea + hypoK+?

Back 49

- VIPoma

Front 50

complications of crohns vs UC?

Back 50

- crohns: fistural, obstruction
- UC: toxic megacolon

Front 51

s. aureus gastroenteritis

Back 51

- no blood in diarrhea

Front 52

right v left CRC?

Back 52

- right = anemia
- left= obstruction

Front 53

other causes of toxic megacolon?

Back 53

- CMV toxic megacolon in HIV pts
- COPD, immunosuppressive therapy, renal failure

Front 54

which ulcer gets better with eating?

Back 54

- PUD = duodenal ulcer
- dx upper endoscopy

Front 55

angiodysplasia is associated with?

Back 55

- aortic stenosis = right 2nd intercostal systolic ejection

Front 56

pt with jaundice

Back 56

- first do U/S
- do CT if suspect pancreatic carcinoma

Front 57

old man with LLQ pain, increased WBC, no bowel movements?

Back 57

- diverticulitis, do CT

Front 58

types of diarrhea

Back 58

- inflammatory = IBD
- secratory = 2/2 meds, hormones
- osmotic = ingestion of smotic substance
- motility = hyperTH

Front 59

blood results in Crohn's

Back 59

- anemia, reactive thrombocytosis

Front 60

pt s/p travel with diarrhea, anemia, neg O+P

Back 60

- neg O+P r/o entamoeba, giardia, strongloides, crypto, isoprera belli
- most likely tropical sprue (endemic to Peurto Rico)
- sx: malabsorption esp B12, folate => megaloblasic anemia
- dx via biopsy => blunting villi, chronic inflammatory cell infiltration = lymphocytes, plasma cells, eosinophils

Front 61

test of choice for zenkers?

Back 61

- NO ENDOSCOPY - dangerous
- do contrast esophagram

Front 62

esophageal spams sx?

Back 62

- chest pain, odynophagia for hot/cold foods

Front 63

crypt abscesses?
intestinal villous atrophy?

Back 63

- UC
- celiac sprue

Front 64

work-up of dysphagia?

Back 64

- with broad ddx, do barium study 1st b/c there are CIs to endoscopy e.g. achalasia and those with tortuous stricutres
- endoscopy if inconclusive
- motility study if first two are negative

Front 65

dysphagia for both solids and liquids?

Back 65

- dysmotility d/o

Front 66

normal values PT, PTT?

Back 66

- PT: 11-20
- PTT: 25-40

Front 67

pt presents with acute variceal bleeding, tachy but not yet severely anemic?

Back 67

- check PT, PTT, most likely have coagulopathy => give FFP
- volume resucitation is first priority over dx test and therapeutic procedures
- about 50% will spontaneously stop bleeding

Front 68

old man with weight loss, dysphagia from solid to liquids, bird beak on barium?

Back 68

- esophageal cancer, NOT achalasia, which can present similarly but note other signs of weight loss, etc
- note upper endoscopy is usually difficult b/c can't pass through gastroesophageal junction => CT is better

Front 69

test of esoph ca?

Back 69

CT scan, not upper endoscopy

Front 70

carcinoid tumor

Back 70

triad: diarrhea, flushing, wheezing
- pathognomonic: plaque like deposits of fibrous tissue on right side endocardium
- vessel dilation => tachy, hypoT
- surgically remove or octreotide

Front 71

HIV pt CD$ 80 with chronic severe diarrhea?

Back 71

- acid fast stain of stool shows oocysts = cryptosporidium

Front 72

Mycobacterium avium

Back 72

- lung infx in immunocompetent pts with chronic lung dz
- can disseminate with bowel infiltration and malabsoprtion if immunocompromised

Front 73

microsporidia?

Back 73

- spores in stool not oocytes

Front 74

ZED aka

Back 74

- NON BETA PANCREATIC ISLET CELL TUMOR = MEN 1

Front 75

** types of colonic polyps?

Back 75

- hyperplasic MC, 2/2 mucosal prolif; benign
- hamartomatous = juvenile (nonmalignant, remove to decrease risk of bleeding), Peutz Jeghers (non malignant)
- adenoma - premalignant < 1% become malignant
------- sessile worse than stalked
------- villous worse than tubularvillous worse than tubular
------ >2.5 is bad; <1.5 is negligible

Front 76

test for lactose intolerance?

Back 76

hydrogen breath test

Front 77

hepatorenal syndrome?

Back 77

- pt with cirrhosis now with renal failure
- severe liver dz => portal HTN => systemic vasodilation => renal hypoperfusion => pre renal failure
- see increased Cr and low urine Na
- check to make sure no protein in blood to suggest glomerular dz

Front 78

zinc deficiency?

Back 78

- alopecia, bullous pustulous lesions surrounding body orifice
- pt on TPN or with IBD

Front 79

selenium deficiency?

Back 79

cardiomyopathy

Front 80

know UC vs CD

Back 80

- terminal ileum =- CD
- granulomas = CD
- ileum = CD
- rectum = UC
- limited to colon but backwash to ileum = UC

Front 81

digoxin toxicity

Back 81

GI sx: anoreixa,N/V
- see in med interactions e.g. CCB => decreases digioxin clearance

Front 82

diverticulitis

Back 82

make dx clinically -> give abx -> if no improvement -> start IV abx -> if no improvement do CT for complications (abscess, fistula)

Front 83

old man with thrombophelbitis, increased PT/PTT, fibrin split products?

Back 83

- systemic coagulation cascade
- check for neoplasm => do CT scan
- if younger pt then would check for deficiency in protein C, S, antithrombin

Front 84

Whipple dz non-GI sx? path?

Back 84

- arthralgias, cardiac failure or valvular regurge, pigmentation
- PAS+, lamina propria

Front 85

dx of abd angia?

Back 85

- doppler U/S or angiography

Front 86

pt on warfarin with back pain?

Back 86

- retroperitoneal hematoma => CT scan

Front 87

steatorrhea is never?

Back 87

found in ostomic diarrhea, e.g. lactase deficiency

Front 88

SBP

Back 88

cirrhosis, ascites + fever and lethargy
- do dx perocentesis => +Cx, PMN >250 isdx

Front 89

stomach ache relieved by food?

Back 89

- duodenal ulcer 2/2 h pylori
- give amox, clarith, pantoprazole