Uworld 7/10/13

Front 1

Name 3 normal phys changes of heme in neonatal period

Back 1

1. switch from fetal to adult hgb
2. drop 30% in hgb
3. drop in mean MCV

Front 2

How can you differentiate between isoimmune hemolytic dz of newborn and hereditary spherocytosis?

Back 2

Both will have spherocytes on smear (since hemolytic dz of newborn = ABO incompat = type of AIHA)
-differentiate w/ coomb's test (only + in hemdz newborn)

Front 3

TMT of dermatitis herpetaformis
Dx test?
What is seen on immunofluorescence?
location?

Back 3

Dapsone (pruritis alleviates rapidly)
-None, improvement on dapsone is dx
-IgA at tips dermal papillae
-extensors, butt, elbow, knee, nape neck

Front 4

randomization controls what?
blinding controls what?

Back 4

confounders
observers bias

Front 5

30yo female on OCPs w/ chronic dull abd pain and palpable RUQ mass.
ML Dx?
Causes?
Dx Tests?
TMT?

Back 5

Hepatic Adenoma
-young/middle age women, OCPs, anabolic androgens, pregnancy, DM, glyc storage dz (hormonally mediated growth)
-U/S or CT, labs w/ up alkphosph/GGT but normal AFP (differentiate from HCC), NO BIOPSY (these can bleed->but histo shows sheets of enlarged adenoma cells w/ glycogen and lipids)
-Resection

Front 6

How to treat pts w/ scarlet fever and penicillin allergy?

Back 6

azythromycin (macrolide), clindamycin, (1st gen cephalosporin)

Front 7

Criteria Kawasaki dz?
TMT

Back 7

Fever of ≥5 days' duration associated with at least 4† of the following 5 changes
Bilateral nonsuppurative conjunctivitis
One or more changes of the mucous membranes of the upper respiratory tract, including pharyngeal injection, dry fissured lips, injected lips, and "strawberry" tongue
One or more changes of the extremities, including peripheral erythema, peripheral edema, periungual desquamation, and generalized desquamation
Polymorphous rash, primarily truncal
Cervical lymphadenopathy >1.5 cm in diameter
-IVIG and salycilate (aspirin)

Front 8

What is herpangina?
What causes it??

Back 8

throat infxn w/ hi fvr, sever sorethroat, (may be unable to swallow needing IV hydration), ulcers on palate, tonsils, and pharynx. If ulcers on hands/feet=hand-foot-mouth dz
-Enterovirus cocsackie A

Front 9

breaking bad news in 7 steps:

Back 9

1. take pt to quiet, private, comfortable environ
2. ask how much he knows or what he thinks of the sx
3. ask how much he wants to know
4. give warning shot "unfortunately sit worse than thought earlier"
5. break the news if he wants "cancer"
6. give prognosis, keep him aware of options to make life comfortable
7. explain all as clearly and simply as possible

Front 10

70yo M w/ HTN, CAD, PVD, having chronic abd pain when eating food, so avoids it and lost 15lb. abd CT and XR unremarkable.
ML Dx?
DX Test?

Back 10

Abdominal Angina (atherosclerosis of mesenteric arteries)
-Dopper u/s or angiography (abd exam may reveal bruit)

Front 11

older M w/ increasing abd pain, hx of afib not anticoagulated, CAD, hyperlipidemia, cholecystectomy, no ETOH. Serum Na 140, Cl 103, bicarb 14, amylase 255.
ML Dx?

Back 11

Bowel ischemia: not pancreatitis since no ETOH use or gallbladder so less likely even w/ amylase (can be elevated from bowel necrosis), Can check by seeing anion gap met acidosis=lactic acid from ischemia

Front 12

What to do in kids <24mo w/ UTI?

Back 12

Renal/bladder U/S if: <24mo w/ 1st febrile UTI, recurrent febrile UTI any age, UTI child w/ famHx GU dz/HTN/poor growth, nonresponsive to abx

Voiding cystourethrogram if: findings on renal/bladder u/s (hydro, renal scar, reflux, obstruction), recurrent febrile UTI in child, 1st UTI febrile w/ fam hx, 1st febrile UTI w/ non -e.coli org

TMT all kid UTI w/ 7-14days abx

Front 13

Differentiate mono from HIV initial infxn?

Back 13

HIV has rash and diarrhea (gi sx)
mono has tonsillar exudate

Front 14

When to think angiodysplasia in painless lower GI bleeding pt?

Back 14

>60yo
has aortic stenosis (disrupts vWF multimers causing easy bleeding)->aka Heyde's syndrome
has ESRD (uremic plt disruption)

Front 15

Pt w/ several hyperplastic polyps on colonoscopy=in months future?

Back 15

NOT colon cancer (hyperplastic=most benign polyp common)

Front 16

Malaria ppx?

Back 16

Mefloquine in chloroquine resistant areas (africa, india subcontinent/pakistan/bangladesh), otherwise chloroquine

Front 17

Steps of intervention for increacranial bleed? (4)

Back 17

1. head elevate: increase venous outflow from head
2. Sedate: decrease metabolic demand and control HTN
3. IV mannitol: extract water from brain tissue->osmoticc diuresis
4. Hyperventilate: washout Co2->cerebral vasoconstriction
5. if due to anticoagulation excess->give FFP for rapid reversal
6. evaluate for surgical decompression

Front 18

TMT of alzheimer's dementia?

Back 18

Reversible Achesterase inhibitors (since dz due to loss of cholinergic neuorns): donepezil, rivastigmine, galantamine, tacrine, Vitamin E (possible)

Front 19

Tests for multiple myeloma?
TMT?

Back 19

1. XR for punched out lytic lesions
2. Serum immuno (ptn) electrophoresis: IgG or IgA spike
3. BUN: Cr: will see renal failure
4. up ESR, hi Ca, hi uric acid (cell turnover)`
5. Bence Jones ptn in urine
6. Most accurate: bone marrow bx
-dezamethasone + bortezomib/lenalidomide

Front 20

What is NASH?
Top 3 risk factors? Others?
Pathophys?
Dx Tests and findings?
TMT?

Back 20

hepatitis in non-drinker (non-alcoholic steatohepatitis)
-Obesity, DM, hyperlipidemia. Steroids, TPN, cushings, HAART, amiodarone, diltiazem (meds causing up lipids)
-impaired response fat cells to insulin causing fat accumulation in liver->steatohepatitis->fibrosis 2/2 lipid peroxidation and ox stress
-mild up LFTs, alk phosph (ratio less than 1), Dx based on perc liver bx w/ macrovesicular steatosis
-control underlying condition, ursodeoscyhoolic acid can help

Front 21

noncaseating granulomatous condition of liver=?

Back 21

primary biliary cirrhosis

Front 22

TMT of CAP?

Back 22

Outpt: macrolide (azithro vs. clarithro) or doxy or (if comorbidities/copd/chf/renal fail/liverdz or abx past 3mos) fluroquin (levo vs moxi)
Inpt: fluoroquin (levo vs moxi) or ceftriaxone w/ azithromycin

Inpt if CURB65 or comorbid (CHF/COPD/Cancer/renal fail//liv dz)

Front 23

38yo F w/ dysmenorrhea, menorrhagia, symmetrically enlarged uterus=?
Dx Test?

Back 23

Adenomyosis (endometrial glands in uterine muscle)
-do endometrial curretage if >35yo to r/o endometrial ca

Front 24

Pt infertile, very stressed, workouts out allot, here for infertility workup, labs lo FSH, lo LH, normal prolactin, TSH
ML Dx?
TMT?

Back 24

Acquired hypogonadotropic hypogonadism (from stress, excercise, eating disorder)
-TMT: decrease stressors and workout 1, pulsatile GnRH 2

Front 25

Pt w/ progressive ascending paralysis over 12hrs, afebrile, CSF is normal, labs normal, was hiking in colorado.
ML Dx?
Next step?
How to differentiate from others?

Back 25

Tick-borne paralysis (from neurotoxin in tick salivary gland)
-Meticulous search for tick
1. GBS=albumin-cytologic dissociation CSF, give IVIG or plasmaphersis
2. Botulism= DESCENDING paralysis: botulinim antitoxin
3. Spinal cord tumor=slow ascending paralysis: IV steroids

Front 26

Name 6 side effects of OCPs and 4 protective factors:

Back 26

SE:
1. DVT
2. CV event/Stroke
3. hypertrygliceridiemia
4. cholestasis/cholecystitis
5. DM
6. HTN

Protects: ovarian cyst/ca, endometrial ca, benign breast dz, dysmenorrhea/anemia

Front 27

TMT of 3rd degree heart block?

Back 27

pacemaker insertion!

Front 28

Side effects of Ca channel blockers?

Back 28

Edema (dilates precapillary sphincter/peripheral vessels)
Constipation (verapimil)
Heart block (rare)
Amlodipine, nifedipine, verapemil, diltiazem

Front 29

Common causes of aortic stenosis?

Back 29

<70yo: bicuspid aortic valve
>70yo: senile calcification

Front 30

Different therapies of types incontinence?

Back 30

Stress: Kegel excercise->urethropexy
Urge: Oxybutinin
Overflow: bethanechol, alpha-blockers

Front 31

Calcium to albumin change based on pH?

Back 31

AlCalosis = alkalosis = more Ca bound to Albumin->hypocalcemia

Acidosis is opposite

Front 32

Molluscum Contagiosum=?
Warts=?

Back 32

-rounded-dome shaped papules w/ central umbilication, poxvirus, asx (trunk in kids, penis/pubes, thigh in adults), is STD, AIDS CD4<100, tmt w/ curretage/liquid nitro
-HPV, verrucous "cauliflower" papules anywhere, genital HPV=risk cervical ca

Front 33

pruritic violaceous flat topped papules w/ fine white streeks=?

Back 33

Lichen planus (white streaks=Wickham's Striae)

Front 34

Differentiate XR findings of joints for OA, RA, Gouty A, pseudogout A, septic A

Back 34

OA: narrowing joint space w/ osteophyte formation
RA: periarticular osteopenia and joint margin erosions
Gout: punched out erosions w/ rim cortical bone
Pgout: calcification of cartilaginous structure
SeptA: normal joint space w/ soft tissue swelling

Front 35

Class 1C antiarrythmics?
Side effects?
What other class has this?
Use?

Back 35

Flecainide, propafenone
-slowed conduction thru AV node (by blocking Na channels)->increase in QRS complex >0.12sec w/ increase HR (use-dependence phenomenon=more effective at higher HR since no time to dissociate from receptor btwn beats)
-Class IV (verapimil and dilt) have use-dependence but not QRS prolongation
-Ventricular arrythmias and intractable SVT (afib)

Front 36

TMT for variceal bleeding/emesis?

Back 36

1. IV volume repletion
2. FFP admin to correct coagulopathy (liver failure causes up PT and PTT since liver normally produces clotting factors)
3. usually bleeding stops on own, can give vasoconstrictors (octreotide, vasopressin), do endoscopic banding/sclerotherapy

Front 37

What is in cryoprecipitate?

Back 37

factor VIII, fibrinogen, vWF, factor XIII (give for deficiency in these)

Front 38

How does hyper thyroid hormone affect BP?

Back 38

HTN mostly systolic BP up via hyperdynamic state/circulation (hi HR)

Front 39

What is cyclical vomiting?

Back 39

vom/nausea in kids w/out any other suggested dx, more common in parents w/ migrains
-complication: anemia/dehydration
-give anti-emetics and reassure parents

Front 40

16yo w/ anemia, bloody diarrhea, hi tbili, jaundice, thrombocytopenia=?
What organ is at risk for damage?

Back 40

HUS from e.coli shiga toxin (jaundice is from rapid hemolysis)
-kidney (renal failure)

Front 41

What is workup for pt initially presenting w/ HTN?

Back 41

1. U/A for occult hematuria and ptn/cr ratio
2. chem panel
3. lipid profile (risk stratify for CAD)
4. baseline ekg (evaluate CAD or LVH)

Front 42

Pt w/ DM w/ difficulty controlling glucose levels on insulin, w/ nausea/early satiety/anorexia/abd bloating for mos. ML Dx?
Dx Test
TMT steps?

Back 42

Diabetic gastroperesis from diabetic neuropathy (related to duration of dz and glycemic control, involved stomach=gastroperesis w/ delayed emptying, small intestine=diarrhea from bacterial overgrowht, large inte=constipation)
-Dx w/ nuclear medicine scintigraphy after ingestion of radiolabel meal
1. improve glycemic control
2. frequent small meals
3. dopamine agonist (metoclopramide/domperidone) b4 meals
4. bethanechol
5. erythromycin (promits gastric emptying by interacting w/ motilin receptors)

Front 43

What is megestrol acetate used for?

Back 43

anorexia in cancer pts

Front 44

What are signs/sx of steroid abuse?

Back 44

gynecomastia, erythrocytosis (+ Side effect), HTN, decreased testes size, hepatotoxic (enlarged), dyslipidemia (lo HDL, hi LDL), pscych disturbance, increased coagulation, virulization

Front 45

bone marrow infiltration vs aplasia?

Back 45

infiltration refers to malignancy (leukemia/lymphoma) but aplasia refers to aplastic anemia (parvo B19)

Front 46

HIV pt CD4 46 w/ bloody diarrhea and normal stool exam.
Diff Dx?
Dx Test?
TMT?

Back 46

HIV hematochezia = CMV, c. dif, shigella, e. histolytica, campy (CMV colitis most common)
-colonoscopy w/ bx
-large cells w/ eosinophilic intranuclear and basophlic intracytoplsamic inclusions (owl eye)=CMV=ganciclovir

-

Front 47

most common hypercoagulable state?

Back 47

Factor V leiden (mut in factor V makes it resistant to ptn C inactivation)

Front 48

What has been shown to reduce morbidity and mortality in measles?
How?

Back 48

Vit A
immune enhancement

Front 49

How it the best tmt for CHF from alcoholic dilated cardiomyopathy?

Back 49

alcohol abstincence->can actually reverse condition if started early

Front 50

Pt w/ jaundice, smear w/ bite cells and rbc inclusions on crystal violet staining.
ML Dx?
What is rbc finding
Who gets this?

Back 50

G6PD deficiency
-Heinz body (oxidized hgb since gluthatione is absent are denatured into heinz body->disrupts cell membrane)
-blacks, x-linked (when taking sulfa, antimalarials, infxn, fava)

Front 51

What is infxn in endometritis?
TMT?

Back 51

polymicrobial infxn
-IV Clindamycin and gentamicin (aminoglycoside)

Front 52

D=xylose test?

Back 52

give 25g D-xylose simple sugar, urine collect (4.5g in 5hr in normal). Will be normal in pancreatic insuff, terminal ileal/crohns dz/lactose def. Will be normal when antibiotics added in bacterial overgrowth. Will be abnormal in celiac since damaged small intestine mucosa impairs its absorption

Front 53

What is seen in mixed cyroglobulinemia? Who gets it?

Back 53

membranoproliferative glomerulonephritis, arthralgias, palpable purpura, neuropathy, HSM, lo complement
-HEPATITIS C!!!

Front 54

Name 3 main causes of pulm HTN?

Back 54

left-sided heart failure, COPD, PE!!

Front 55

TMT of perforated appendix?

Back 55

-Suspect on psoas sign: pain on flexion R hip to resistance)
if w/in 72hrs of sx: emergent laparotomy and appe
if >5days: likely have contained abscess->abx, IV fluids, bowel rest, CT scan to confirm, perc drainage (interval appe 6-8wks later)

Front 56

Gram+ diplococci=?

Back 56

strep pneumonia

Front 57

gram+ cocci in clusters=

Back 57

staph aureus

Front 58

gram- cocci=

Back 58

neisseria gon vs men

Front 59

gram+ rods=

Back 59

listeria vs bacillus

Front 60

GNR=

Back 60

pseudomonas, haemophilus, klebsiella, legionella

Front 61

Pt w/ recurrent oral ulcers, genital ulcers, anterior uveitis, skin lesions that are painful and nodular on extremities=?
Criteria?
Typical pts?
TMT?

Back 61

Behcet's Syndrome (multi-systemic inflammatory dz)
-recurrent oral ulcers + 2 of: recurrent genital ulcers, eye lesions (ant or post uveitis), retinal vascularization, skin lesions (e. nodosum, acneiform nodules, papulopustular lesions), +pathergy test (sterile pustules). May also have GI, arthritis, CNS MS-like sx.
-Asian, Turkish, Middle-east (the uveitis can cause blindness)
-Steroids (but don't protect from dementia or blindness)

Front 62

What is pulsus bisferiens?

Back 62

biphasic pulse from 2 strong systolic peaks of aortic pulse seen in aortic regurg and HOCM

Front 63

Water-bottle shape cardiac silhouette on CXR=?

Back 63

pericardial effusion, look for difficult to palpate PMI and diminished heart sounds

Front 64

Mole that has been present for years becomes pruritic=?

Back 64

Melanoma (if it gets symptomatic in any way: painful/bleed/pruritic or changes color (darker or lighter)

Front 65

State the changes in liver w/ ETOH use and which ones are reversible

Back 65

All are reversible if ETOH abstinent
1. fatty liver: steatosis
2. Alcohol hepatitis: mallory bodies, PMN infiltration, liver cell necrosis, periventricular inflammation
3. alcoholic cirrhosis: fibrosis (only early fibrosis is reversible, true cirrhosis w/ regenerative nodules is never)

Front 66

pneumatosis intestinalis on abd xr in newborn=?
Who gets it?
Presentation?
TMT?

Back 66

Necrotizing Enterocolitis
-premature preterm infant, perinatal asphyxia
-3-10days after birth (from bowel injury due to asphyxia)->vomiting, abd distention, feeding difficulty, fever, will have frank/occult bloody stool
-Dx w/ abd XR w/ air in bowel wall
-bowel rest 1, IV fluids 2, NGT for decompression 3, surgery if no resolution 4

Front 67

Neonate w/ ground glass in CXR=?
Who gets it?

Back 67

Hyaline membrane dz
-preterm neonates (will be in resp distress)

Front 68

TMT of renal artery stenosis?
Causes
Typical presentation?

Back 68

Interventional therapy better than medical = do angioplasty w/ stenting. If fails in pt w/ fibromuscular dysplasia->do surgery
-Two types: if young: fibromuscular dysplasia, if old: atheromatous plaque
-Pt w/ HA, elevated refractory BP, renal bruit

Front 69

What is susceptibility bias?

Back 69

subgroup of selection bias: when treatment regimen selected for pt in study depends on severity of there dz (ie. person initially on med therapy for carotid art dz has CEA as stenosis gets more): it negates randomization benefit

Front 70

What is recall bias? What study does it happen in?

Back 70

when participant's knowledge of study affects how they answer a question
-seen mostly in case-control studies

Front 71

What is seen in alpha-1-antitrypsin dz on histology?
Increased risk of what?
TMT options?

Back 71

in liver: hepatocytes w/ granules/inclusions that stain positive w/ periodic acid-Schiff (PAS) reagent & resist diastase digestion
-Hepatocellular cancer and liver cirrhosis
-A1At supplementation, Liver or Lung transplant if failure

Front 72

Polymyositis labs?
Pathophys?
TMT?

Back 72

up ESR, CPK, aldolase, ANA, anti-jo (in lung fiborsis), anti Mi-2/helicase (in dermatomyositis)
-Inflammatory myopathy (does NOT affect face like MG)
-Steroids (immunosuppressives if fail)

Front 73

Pt w/ adenocarcinoma in gastric bx on endoscopy.
Next step?

Back 73

CT scan to stage the dz (since usually dxed very late)
2. surgical removal if possible

Front 74

Pt postop w/ hypotension, RBBB on ekg, JVD, syncope =?

Back 74

JVD + RBB on ekg = R heart strain
R heart strain + hypotension, sycope = MASSIVE PE!!! will cause bradycardia, L heart pump failure, cardio shock->neuro effects w/ unresponsive, slow HR, dilated pupils

Front 75

bloody circumcision=?
Pathophys?
Dscribe?
TMT?

Back 75

Wikott-Aldrich syndrome (WAS)
-x-linked recessive, young boy, eczema, thrombocytopenia, recurrent SHIN infxns, present at birth w/ petechiae, bruises, bleeding from circumsision, blood in stool. Labs: low IgM, hi IgA & IgE, lo T cells and plts, poor ab response to polysaccharide antigens (SHINS)
-bone marrow tplant

Front 76

oculocutaneous albinism=?
pathophys
Dscribe
dx test
tmt

Back 76

Chediak-higashi syndrome
decreased chemotaxis, degranulation
-peripheral & cranial neuropathy, HSM, pancytopenia, partial oculocut albuinism, freqeunt s. aureus infxn, progressive lymphoproliverative syndrome
-neurtopenia & giant lysosomes in neutrophils
-daily bactrim and ascorbic acid

Front 77

chronic pruritic dermatitis + recurrent skin infxn w/ s. aureus=?
pathophys
dscribe

Back 77

Hyper-IgE Job Syndrome
-elevated IgE levels w/ eosinophilia
-coarse faicial features, lots of staph skin and lung infxns, dental abnormal bone fracture

Front 78

Delayed separation of umbilical cord=?

Back 78

Leukocyte-adhesion defect (LAD); failed defense to bacteria, fungi, all organisms from defective tethering/adhesion/targeting of myeloid leuks to microbial invasion sit
-Dx w/ neutrophilia w/out polymorphs in infected tissue

Front 79

EKG findings hypokalemia?
Sx?

Back 79

broad flat T waves, U wave, ST depression, premature ventricular beat
-flaccid paralysis, weakness, fatigue, muscle cramp, arrythmia, vom/diarrhea

Front 80

How to treat dysfunctional uterine bleed?

Back 80

If mild: Fe supplement
Moderate w/ no active bleed: cyclic progestins
Moderate w/ active bleed/sever: hi dose estrogen

If >35: do endometrial bx

Front 81

Differentiate lung findings of histoplasmosis vs blastomycosis vs coccidiomycosis vs aspergillus in HIV?

Back 81

Histo: caves, bats/birds, pancytopenia, HSM, PALATAL ulcers, CXR w/ hilar lymphadenopathy w/ pneumonitis
Blasto: soil, rotting wood, CXR w/ multiple nodules or dense consolidation, skin ulcers, VERRUCOUS lesions/plaque lesions on mucus membranes, osteolytic bone lesions, PROSTATE
Cocc: southwest, similar to histo in lung, maculopapular skin lesions, bone lesions
Asperg: fever, cough, SOB prominent, CD4<50, nothing else

Front 82

UTI w/ u/a pH 8.5=what organism?

Back 82

PROTEUS (urease producing makes urine alkaline)

Front 83

Who gets ABO incompatibility?
How bad?

Back 83

usually moms w/ O having baby w/ A or B (can tell by dad being type AB)->mom produces some IgG ab that cross placental attacking baby rbcs->MILD rxn causing neonatal jaundice->tmt w/ photherapy (worse in blacks)

Rh(D) ab are typically all IgG at hi titers causing hydrops

Front 84

55yo pt w/ lots of tender erythematous cord like veins over L arm and chest-?
Dx Test?

Back 84

Trousseau's Syndrome (Migratory Thrombophlebitis): it is a marker of cancer->specifically adeoncarcinoma (#1 pancreas, #2 lung, #3 prostate)
-Do test to localize based on other complaints: if GI->do CT abd for pancreatic ca (esp in smokers)
-later do coag studies and doppler to confirm thrombi

Front 85

Target cells in microcytic anemia=?

Back 85

Thalasemia! RDW is normal (differentiate from iron)
-do Hgb electrophoresis->elevated Hb A2 & F=B thal minor, ->normal=Alpha thal minor, ->Hb H w/ hi retic=3-gene alpha thal minor

Front 86

What asthma meds are safe in pregnancy?

Back 86

both inhaled steroids and beta agonists

Front 87

Major side effects of cyclosporine, tacrolimus, azathioprine, mycophenolate?

Back 87

Cyclosporine: nephrotoxic, hyperK, HTN, gum hypertrophy, hirsut, tremor
Tacrolimus: same as cyclosporine (same mech calcineurin-inhibitor) but no hirsut or gum hypert
Azathioprine (converts to 6-MP): diarrhea, leukopenia, hepatotoxic
Mychopenolate: bone Marrow Suppression

Front 88

DM screening?

Back 88

Do A1c in pts >45yo w/ no risk factors