Uworld 6/28/13

Front 1

Steps in breaking bad news?

Back 1

1. Privacy and ask if want other people want others around
2. assess family's perception/knowlege (what do you think is going on
3. Ask how much they want to know
4. warn that is bad news, give information straightforward and simple, check for understanding
5. respond to questions/emotions empathically
6. summarize and create follow through plan (end of life discussion here if needed)

Front 2

Pt w/ enlarged L side scrotum, increases on vasalva, negative transilluminaton.
ML Dx?
Pathophys?

Back 2

Varicocele
-dilation pampiniform plexus from incompitent valves testicular veins, more on L side "bag of worms"

Front 3

70yo pt w/ shoulder pain, tender, worse when raising his arm 60degrees, but has full range of motion, worse on lifting overhead.
ML Dx?
Why pain?
Physical exam test?
Dx Test?
Confirmatory test?

Back 3

Rotator cuff tendonitis
-pain from rotator cuff impingement
-Neer test (passive motion of arm above head, positive if pain and guarding during = impingement)
-Lidocaine injection w/ relief (if not relieved=rotator cuff tear)
-MRI

Front 4

What does alkalosis do to calcium level?

Back 4

causes ionized calcium to lower (increased binding to albumin) but no change in total ca

Front 5

Pt s/p cataract extraction 5 days ago, now w/ decreasing vision and dull ache of L eye. Eye is swollen, conjunctiva edematous, exudate in anterior chamber, decreased visual acuity.
ML Dx?
Cause?
Dx Test?
TMT?

Back 5

Postop endopthalmitis
-up to 6wks after eye surgery w/ infxn of vitreous causing pain and decreased visual acuity w/ swollen eyelids
-gram stain and culture vitreous
-Intravitreal abx injection or vitrectomy

Front 6

Pt wears contact lens, has sensation of "foreign body" on eye, blurred vision, photophobia, pain.
ML Dx?
Findings of exam?

Back 6

Corneal Ulceration
-Common w/ contacts, recent trauma, ocular dz, red eye w/ ciliary injection, purulent exudates in conjunctival sac and ulcer on surface

Front 7

Pt w/ sluggish bilat ankle reflexes, proximal muscle weakness, myalgia, elevated CK, difficulty getting up from chair.
ML Dx?
Why not others?
Dx Test?

Back 7

Hypothyroidism (can present very early w/ CK elevated myopathy)
-differentiate from polymositis by decreased ankle reflexes (they would be normal in polymyositis->do muscle bx to dx this)
-TSH and T4

Front 8

How to confirm cirrhosis?
Findings?
Most common causes to look for?

Back 8

Perc needle bx
-gynecomastia, spider angiomata, palmar erythema, nail changes, caput medusae, hair oloss, parotid swelling, testicular atrophy (ascites, caput med, nemorrhoids=portal htn)
-ETOH, hep B/hepC chronic infxn

Front 9

Pt w/ several exophytic purple skin masses on lower abd, exam w/ tender hepatomegaly, CT abd w/ nodular enhancing intrahepatic lesions, liver bx w/ severe hemorrhage.
ML Dx?
Pathophys?
TMT?

Back 9

Bacillary Angiomatosis (caused by bartonella henselae)
-immunocompromised, AIDS, chemo, organ transplant pts w/ constitutional sx, cut manifestations of large pedunculated exophytic papules (like pyogenic granuloma or cherry angioma) and similar visceral ones (ie. enhancing lesion that bled easily->caution on bx)
-Abx

Front 10

Initial tmt of anal fissure?
What if fails?

Back 10

diet mod w/ hi fiber and fluids, stool softener, and local anesthetic
-surgery w/ lateral spinchterotomy

Front 11

Conditions that can have blood smear w/ spherocytes w/ central pallor?
How to differentiate?

Back 11

AIHA, hereditary spherocytosis
-Hereditary sphere: family hx (aut dom), positive osmotic fragility test, NEGATIVE coombs
-AIHA: no fam hx, POSITIVE coombs, jaundice, splenomegaly, hepatomegaly

Front 12

Types of autoimmune hemolytic anemia?
What antibody causes them?
Associations?
TMT?

Back 12

Warm: IgG, autoimmune (SLE, CLL, methyldopa, ribavirin), TMT=steroids, rituximab (CD20 ab), splenectomy, or immunosuppresives

Cold: IgM, autoimmune triggered by cold, mycoplasma, mono, TMT=warm pt and RBC transfuse

Front 13

Pt w/ back pain, hematuria, blood smear w/ heinz bodies, took some drugs.
ML Dx?
Causes?
Pathophys?

Back 13

G6PD deficiency (xlinked)
-oxidant stress (sulfas, fava beens, antimalarials, dapsone, infxn)
-RBCs susceptible to oxidant stress due to decreased glutathione from low G6PD

Front 14

Anti-mitochondrial ab= ?
Pathophys?
Cutaneous association?
Clinical lab features?

Back 14

Primary biliary Cirrhosis
-autoimmune dz w/ immune-mediated destruction intrahepatic duct=bile stasis and cirrhosis
-Xanthomas and Xanthelasma (from fat collection)
-pruritis, jaundice, steatorrhea, HSM, up alk phsoph, bili, see lipid filled macrophages

Front 15

Pt w/ rash for 2days, was healthy till 5days ago had fever, fatigue, HA. Then rash on face that progressed to trunk and extrem. Has tender auricular and post cervical lymphadenopathy.
ML Dx?
Course?
TMT?

Back 15

Rubella (RNA togavirus)
1. exposure via respiratory drop
2. fever malaise, tender suboccipital tendinitis (auricular lymph) after 14 days (adults get polyarthralgia)
3. rash (maculopapular) on face then spreads down (starts 1-5days after fever, lasts 3days)
-Acetaminophen for symptomatic relief (are infxious 1wk after), Live attenuated rubella vaccine protects as kid.

Front 16

Steps tmt nonketotic hyperglycemic coma?

Back 16

1. IV NS fluid replacement (sometimes 8-10L)
2. Regular insulin
3. Switch to 0.45% saline when hypovolemia stabilized
4. Add Potassium when K level reaches normal level
5. Switch to 5% dextrose when blood glucose less than 250 from insulin therapy (prevents cerebral edema)

Front 17

Pt in tent w/ bat, cleaned hunted squirrel and rabbit, bitten by rat.
Next step?
Why?

Back 17

Rabies ppx
-Bat is greatest rabies reservoir (only need human contact or salive, no need for bite)
-only rabies for animal bites if animal was rabid acting

Front 18

Pt w/ MVC to ED, blood at urethral meatus, scrotal hematoma, hi riding prostate.
ML Dx?
Dx Step?

Back 18

Posterior Urethral Injury (high ride and unable to void)
-Retrograde urethrogram

Front 19

Alternative name pagets dz bone?
Finding in urine?

Back 19

Osteitis deformans
-elevated urinary hydroxyproline, deoxypyridinoline, N-telopeptide, C-telopeptide

Front 20

What is used to slow the long term progression of MS?
What about acute attack?

Back 20

Interferon-beta (decreases freq relapse)
-Hi dose steroids

Front 21

15yo boy w/ mild sensinoreal deafness bilat, hematuria and ptnuria w/ elevated BUN/Cr, renal bx w/ foam cells, EM of glomerulus w/ splitting of GBM and thickened alternating thin capillary loops.
ML Dx?

Back 21

Alport's Syndrome
-look for sensorineural deafness, fam hx renal failure, recurrent episodes hematuria

Front 22

Pt w/ hx smoking, ETOH, type 2 DM, HTN, w/ whitish patch on anterior floor mouth that cannot be scraped off.
ML Dx?
Causes?
Risk of what?

Back 22

Leukoplaka
-smoking, alcohol, ill-fit dentures
-Squamous cell cacinoma transformation

Front 23

3yo boy w/ 2days decreased appetite, neck swelling, irritable, head rotated to R resists flexion.
ML dx?
Dx Test?
TMT?

Back 23

Acquired torticollis (wryneck)-neck twisting from asymmetric muscle activity
-Xray neck (to r/o cervical spine fracture or dislocation)
-find underlying cause: retropharyngeal abscess, URI, trauma, cervical lymphadenitis

Front 24

Most common side effect in sickle cell trait?
Type of inheritance
How to detect?

Back 24

painless microscopic or gross hematuria, isosthenuria (impaired concentrating ability w/ nocturia/polyuria)
-Aut recessive
-Hgb electrophoresis

Front 25

23yo M w/ abd pain, naus/vom, brother w/ similar problem needed surgery, febrile, tenderness RUQ, liver span 7cm, spleen 2cm below costal margin.
ML Dx?
Pathophys?
Suggestive findings?
Dx Test?
TMT?

Back 25

Hereditary Spherocytosis w/ acute cholecystitis
-aut dom disorder of spectrin scaffolding ptn in RBCs so not deformable and gets trapped in spleen's red pulp
-splenomegaly, family hx, chronic hemolysis causing jaundice and PIGMENTED GALLSTONES
-blood smear w/ spherocytes and increased reticulocytes, positive osmotic fragiliity test
-Folate supplement and splenectomy

Front 26

10yo boy w/ bone pain, hepatosplenomegaly, anemia, low plts
ML Dx?
Dx Test?

Back 26

Gaucher's Dz (have painful cortical erosions)
-gaucher cells w/ eccentric nucleoli and periodic acid-schiff PAS positive inclusions

Front 27

65yo F w/ 6mo worsening SOB and dry cough, was completely normal before w/ no cardiac risk factors but HTN, has dry late inspiratory crackles and finger clubbing. CXR w/ honeycombing.
ML Dx?
Findings on PFTs?

Back 27

Idiopathic Pulmonary Fibrosis (unknown etiology) w/ chronic progressive SOB, dry cough, clubbing
-decreased TLC, FEV1, FVC, normal FEV1/FVC, normal to decreased PaCO2, increased A-a gradient (from congestion)

Front 28

What does elevated Alk phosph w/ elevated GGT=
Elevated Alk phosph w/ normal GGT=

Back 28

Liver
bone

Front 29

Which has stronger association?
Correlation coefficent -0.25, +0.35, -0.64

Back 29

-0.64 (range from -1 to 1 w/ 0 being weak and closer to 1 or -1 being strong)

Front 30

Lesion in upper thoracic spinal cord=?

Back 30

paraplegia, bladder/fecal incontinence, absent sensation nipple down

Front 31

lesion in lower thoracic spinal cord=

Back 31

absent sensation umbilicus down

Front 32

lesion supratentorially?

Back 32

partial or complete hemiparesis

Front 33

Most common predisposing factor for sinusitis?
Dx Test?
TMT?

Back 33

viral URI
-CT sinus (but usally dx clinical)
-amoxicillin-clavulonate

Front 34

Pt had shingles, now treated, but still has pain in that area.
ML dx?
tmt?

Back 34

Postherpetic neuralgia
-TCAs (amitryptiline, nortryptiline)

Front 35

abortion = fetal death b4 when?

Back 35

20 wks

Front 36

Pt w/ missed abortion suspected.
First step?
TMT?

Back 36

Pelvic U/S to dx absence fetal heart motion
-3 options: Dilate & curretage, medical w/ misoprostol or mifepristone, expectantly w/ AT HOME monitoring (don'tneed hsopital)

Front 37

Patient w/ whatever story w/ unexplained unprovoked seizures.
1st dx step?

Back 37

noncon CT brain

Front 38

Pt in for c-section, given lumbar epidural anesthesia, now w/ BP 90/55, HR 120, normal fetal HR and contractions.
ML Dx?
Causes?

Back 38

hypotension as side effect of anesthesia
-from sympathetic fiber block causing vasodilation of lower extrem vessels leading to blood venous pooling causing decreased cardiac output, hypotension, increased HR

Front 39

Pt sitting in arm chair, sudden LOC, no warning sign, had clonic jerks while unconscious, no hx this, PMH of MI 6mos ago, HTN, exam has mild holosystolic apical murmur radiating to axilla.
Cause of syncope?

Back 39

Arrythmia: see structural heart dz (MR) , sudden onset w/out warning signs, meds likely thiazide diuretic causing electorlyte disturbance

Front 40

Define HIT
When to suspect?
Dx Assay?
TMT?

Back 40

Heparin-Induced Thrombocytopenia
-Recent start of heparin >5days AND at least one of: plts<50% from baseline 5days prior, arterial or venous thrombosis, necrotic lesion at hep injection site, anaphylactoid rxn
-Serotonin Release Assay (gold standard), but start therapy immediately
-Stop heparin, start direct thrombin inhibitor (argatroban) or synthetic pentasaccharide (fondaparinux)

Front 41

risk of TB reactivation in HIV pts?

Back 41

10% per year

Front 42

Finding on CXR in PCP
Sx?

Back 42

diffuse ground glass infiltrate
-fever, sob, dry cough

Front 43

Urticaria in chest w/ acute onset SOB?

Back 43

laryngeal edema causing upper resp obstuction (thik food allergy)

Front 44

What is tecnetium 99m pertechnetate scan used for?

Back 44

"meckels scan" detects gastric mucosa in meckel's diverticulum

Front 45

24yo pregnant 26wk gestation complaining of aching and swelling both legs worse at night.
ML Dx?
TMT?

Back 45

Benign edema of pregnancy (occur in 1/3 pregnancies), make sure no hypertension (signifies pree)
-routine follow-up

Front 46

Soccer player w/ travel to maine for soccer camp 1mo ago, now w/ swollen joint, states has had several "achy" joints but attributed them to working out.
ML Dx?
Findings expected in synovial fluid analysis
Dx Test?
TMT?

Back 46

Lyme dz (recent travel to northeast/upper midwest), the erythema migrans only occur in 80% pts and can be overlooked. Monoarticular arthritis w/ migratory arthralgias common in 60% as early disseminated wk-mos after.
-leuk count average 25000, w/ yellow color, negative gram stain (big give away)
-ELISA and Western blot testing
-oral doxycycline or amoxicillin

Front 47

Pt w/ no bowel movement 3days no flatus, tender distended abdomen, several nbnb emesis. pH 7.3
ML Dx?
why pH?
TMT?

Back 47

SBO w/ bowel strangulation causing ischemic necrosis w/ lactic acidosis
-lactic acidosis
-Laparotomy

Front 48

TMT of diabetic ulcer?
Stages diabetic ulcer

Back 48

1. off loading (1/2)
2. debridement (1/2)
3.wound dressing (1/2)
4. abx (3)
5. revascularize (stage 4/5)
6. amputate (4/5)

1. superficial, full skin thickness involved, not underlying tissue
2. deep ulcer to ligament or muscle, no bone
3. deep ulcer w/ cellulitis/abscess/osteomyelitis
4.localized gangrene
5. extensive gangreen o f whole foot

Front 49

What is role hCG in pregancy?

Back 49

Maintenance of corpus luteum (secreted by syncytiotrophoblast to conserve corpus and maintain progesterone until placenta can do so). doubles every 48hrs until 6wks gestation. 2subunits: alpha (like TSH, LH, FSH) and beta (tested for)

Front 50

What hormone responsible for promotion and maintenance of implantation to endometrium?

Back 50

progesterone

Front 51

What hormone induces prolactin production from pituitary during pregnancy?

Back 51

Estrogen

Front 52

Pt w/ advanced HIV has pain and difficulty w/ swallowing.
ML initial Dx?
TMT?
2wks later still w/ pain
Next step?
Finging linear irregular ulcers in esophagus.
ML Dx?
Dx Test and finding?
TMT?

Back 52

Candida esophagitis
-po fluconazole
-Endoscopy
-CMV esophagitis
-bx showing intranuclear and intracytoplasmic inculsions
-IV gancyclovir

Front 53

Findings in HSV esophagitis.
What pop is it common in?
TMT?

Back 53

ulcers that are multiple small wellcircumscribed "volcano-like" cells w/ ballooning degenration and eosinophilic intranuclear inclusions
-Acyclovir

Front 54

Pt w/ short stature, round fascies, cataracts, and short 4th metacarpal bone
ML Dx?
What else to expect?

Back 54

Albright herediatry osteodystrophy
-pseudohypoparathyroidism w/ lo Ca, hi phosphate, increased PTH

Front 55

Pt complaining of sx of claudication.
first step?
Findings and significance?
Gold standard for Dx?

Back 55

ABI
-if 1.0-1.3 normal
-if <0.9 = 50% occlusion: give aspirin and cilostazol
-if <0.4 = limb ischemia (do contrast arteriography for intervention)
Contrast Arteriography

Front 56

When is cervical mucus abundant, clear, and lifted vertically extends as long tthread? How long?
What is pH?
What else is seen on test?

Back 56

Ovulatory phase, 6cm stretch (spinnbarkeit)
=>6.5
ferning on microscope

Front 57

How is cervical mucus in follicular phase?
in mid and late luteal phases?

Back 57

thick, scant, opaque, and acidic
-becomes progressively more thick and inhospitable

Menses->follicular->ovulatory->luteal->Rpt

Front 58

54yo male difficulty reading newspaper, has to hold it far away.
ML Dx?
Pathophys?

Back 58

Presbyopia (age related dz starting in 40s)
-loss of elasticity in lens (prevents accomodation of lens to focus on near objects)

Front 59

What dz is primary polydypsia related to?

Back 59

Schizophrenia

Front 60

Pt w/ hx of ischemic stroke w/ loss of sensation on all R side, now wk later have transient pain in the R side also.
ML Dx?
location stroke?

Back 60

Dejerine-Roussy Syndrome (thalamic pain phenomenon)
-VPL Thalamus

Front 61

40yo asian male presents complaining of dark urine. has scleral icterus and jaundice skin. Urine dipstick positive for bilirubin. LFTs normal.
ML Dx?
Pathophys?

Back 61

Rotor Syndrome (benign condition of abnormal liver storage of conjugated bili, will have normal lfts)
-unconjugated bili does not get out via urine since tightly bound to albumin whereas conjugated bili does since loosely bound.

Front 62

23yo woman complains of bilat breast pain 2days after 1st child, breasts are tense, warm, tender to touch.
ML Dx?
TMT?

Back 62

Breast engorgement (coccurs 24-72hrs after birth from milk accumulation)
-coll compresses, acetaminophen, NSAIDs

Front 63

Pt w/ fatigue, +HbsAg, +HBeAg, + anti-HBcAg IgG ab, hi titer HBV DNA. has icterus and mild hepatomegaly, AST 60, ALT 120.
ML Dx?
TMT?

Back 63

Chronic Hep B
-if serum ALT >2x upper limit normal, then interferon or lamiivudine

Front 64

15yo F comes in no menses yet, tanner stage 2, decreased femoral pulses.
Next step in Dx?
ML Dx?
Other common features?

Back 64

Turner Syndrome
-Karyotype analysis (45XO)
-short stature, webbed neck, hypogonad (streak ovaries), lymphedema, hi-arched palat, congenital bicuscipid aortic valve, coarctation of aorta (decreased fem puls)

Front 65

Pt w/ flail chest.
TMT?

Back 65

Positive pressure mech ventilation
-pain control and supplemental O2

Front 66

7yo boy w/ femur fracture, hx of multiple fractures in past w/ minor trauma, decreased muscle tone throughout, blue sclera
ML Dx?
Pathophys?
Other features/

Back 66

Osteogenesis Imperfecta
-aut dom disorder type 1 collagen cause weak bone matrix
-blue sclera, early hearing loss, discolored blue/yellow teeth, weak (dentinogenesis imperfecta), bowing of bones w/ frequent fractures, hyperlaxity joints (type II most severe form)

Front 67

Pt w/ acute pancreatitis of unknown cause now being treated.
Top 2 causes?
Next Step?
What to do prior to discharge?

Back 67

-ETOH and gallstones
-RUQ ultrasound for gallstones
-if gallstone-cholecystectomy

Front 68

55yo F w/ L ear pain, itchy, worse on chewing, has DM2, febrile to 101F, exam w/ granulation tissue L ear canal and discharge.
ML Dx?
Cause?
TMT?

Back 68

Malignant Otitis Externa (MOE)
pseudomonas (sever ear pain, drainage, fever, granulation tissue->can progress to TMJ infxn or osteo)
-Ciprofloxacin (pseudomonal coverage)

Front 69

12yo white boy w/ severe pain in L knee for wks w/ swelling, no erythema. bone XR w/ central lytic lesion distal femur, onion skining.
ML Dx?
Most common location?
TMT?

Back 69

Ewing's Sarcoma (hi malignant in 10-20yo white males)
-femur diaphysis/metaphysis>tibia>humerus
-surgery, radiation, and chemo

Front 70

Pt w/ 2days fever, HA, malaise, myalgias, from arkansas had tick bite, AST/ALT 98/105
ML Dx?
Dx Test?
TMT?

Back 70

Ehrlichiosis (tickborne dz gram negative bacteria in southeast, cali, and midwest, in sprin/summer)="spotless rocky mountain spotted fever", mild elevated LFTs
-NO test, just treat!
-Doxycycline

Front 71

TMT for legionnaire's dz?

Back 71

Erythromycin

Front 72

TMT for rocky mountain spotted fever in pregnant woman?

Back 72

chloramphenicol

Front 73

baby w/ capillary hemangioma = ?

Back 73

STRAWBERRY hemangioma (cherry in adults)

Front 74

Differentiate meconium ileus from Hirschsprungs

Back 74

Hirschsprungs: rectosigmoid obstruction, normal meconium
Meconium Ileus: ileum obstruction, inspissated meconium (thick as glue)

Consider these in any neonate w/out meconium passage 1st 2days birth

Front 75

What is associated w/ meconium ileus?
Dx Test?

Back 75

cystic fibrosis=will have sinopulmonary dz w/ opacification by age 8mos, chronic lung inflamation , recurrent pnas w/ GNR aerobes (pseudomonas) treated w/ aminoglycosides->sensorineural hearing loss over time
-Sweat chloride test

Front 76

How to differntiate SJS from erythema multiforme minor?

Back 76

-minor does not have oral involvement and usually happens after herpes simplex
-SJS=erythema multiforme major and has shock symptoms w/ "target" appearnce lesions everywhere

Front 77

Differentiate toxic shock syndrome from SJS?

Back 77

SJS has "target" rash
TSS has multi organ involvment, no targets, (need at least 3 organs for dx)

Front 78

Pt w/ CIN II/III
Recommendations?

Back 78

Pap smear w/ or w/out colpo and endocervical curretage q6mos until 3 negative samples (or HPV testing and cytology), then resum yearly screening until 65.

At 65, increase interval to q2-3yrs until 3consecutive negative smears w/ monogamous partner