Uworld 9/2/15

Front 1

9yo boy 2mo h/o clear rhinorrhea, nasal/orbital itching, dry cough usually after playing with neighbor dog, excoriations external nares=?

TM?

Differentiate from nonallegic type?

Back 1

Allergic rhinitis

-avoidance of neighbors dog

-if fails, or unable to identify source->nasal corticosteroids first line therapy

Nonallergic rhinitis usually later age >20, changes w/ seasons, same tmt

Front 2

70 yo M w/ h/o CAD, MI, CHF, HTN, DM2, had LOC while sitting watching TV, witnessed, no seizure activity, normal exam, CXR, EKG, trops->next step?

Back 2

admit for 24hr EKG tele monitoring (since likely due to cardiac arryhthmia and may need), will also need echo to r/o ACS type event

Front 3

Which diabetic meds give you:

hypoglycemia?

lactic acidosis?

hepatotoxicity?

Pancreatitis?

HA/Nasopharyngitis?

Diarrhea/flatulance?

polyuria/UTIs?

Back 3

1. sulfonylureas and the meglitinides

2. metformin (biguanide)

3. thiazolidinediones (pio/rosiglitazone)

4. GLP1 agonists (exenatide/liraglutanide)

5. alpha-gluc inhib (acarbose/miglitol)

6. SGLT2 inh (canaglifozin)

Front 4

Patient with schizo on antipsychotic w no positive sx of delusions but has flat affect, slow response, disinterest, social withdrawal=?

Next step?

Back 4

Prominent negative sx

-social skills training / psychosocial intervention (found to be better than switiching meds)

Front 5

Patient presents w/ fatigue, loss energy, shaky, loss weight, not hungry, for 2 weeks, smoker, DM2, CHF, CAD w/ coronary stenting one month ago, CXR normal, LFTs normal=?

Next step>

TMT?

Back 5

Iodine induced thyrotoxicosis from iodine administation during coronary angio (will have firm enlarged irregular nontender thyroid and tachy)

-Thyroid function tests

-control symptoms w/ b blocker and nsaids

Front 6

42yo F w/ R neck pain, cough, SOB x3 days, h/o HTN, obesity, smoker, decreased breath sounds RU lung, CXR w/ R side opacity, Mod swelling erythema neck and R JVD=?

Next step?

Back 6

Superior vena Cava syndrome (from tumor compression)

-CT scan w/ con chest/neck

Front 7

How to evaluate ascitic fluid?

Dx based on it?

Back 7

SAAG (serum alb-ascit alb gradient)->if >=1.1 then serous from CHF, cirrhosis, ETOH hepatitis, noninfectious/malignant

if <1.1 tehn malignancy, peritoneal carcinomatosis, peritoneal TB, nephrotic syndrome, pancreatitis

Front 8

Patient w/ hypercalcemia on routine blood work, asx, Ca 10.9, normal-high PTH, lo urine Ca, normal Vit D, mom had similar thing=?

Next step?

Why not primary hyperparathyroidism?

Back 8

Familial hypocalciuric hypercalcemia (from mutation calcium sensing receptor kidneys)

-No treatment (as long as asx and mild)

-if primary, would not have low urine calcium (would be greater than 100-200)

Front 9

55yo F w/ 2mo malaise, mild fever, difficulty walking up stairs and rising from chair, weight loss, weakness bilat upper and lower extrem, violaceous papules/plaques dorsum bilat hands=?

Lab findings?

Associated sx?

Dx test?

TMT?

Associated dz?

Back 9

Dermatomyositis (proximal symmetric weakness equal in upper and lower extrem w/ gottron's papules and heliotrope rash/face

-hi CPK, aldolase, LDH

-interstital lung dz, dysphagia, myocarditis

-Do antibody serologies for ANA (first test since positive in 80%) Anti-RNP, Anti-Jo-1, anti-Mi2->CXR to screen for interstitial lung dz->muscle biopsy if all negative/nondiagnostic/EMG

-Hi dose steroids + steroid sparing agent)

-screen for Cancer (malignancy associated/many)

Front 10

26yo student bit by bat

Rabies ppx?

Back 10

pre-exposure ppx: vaccine on day 0,7,21, or 28

Post-exposure ppx if never vaccinated: rabies vaccine on days 0,3,7,14 AND rabies IG on day 0

Post exposure ppx if prev vaccinated: only rabies vaccine on day 0 and 3

Front 11

Steps of evaluating hypokalemia?

Sx?

Back 11

Measure plasma aldosterone to renin ratio (if >30=excessive ald secretion from adrenal gland)->Conn's Syndrome/Hyperaldosteronism

-hypokalemic metabolic alkalosis w/ HTN

-confirm with CT adrenals

-TMT w/ surgical resection if single adenoma vs. spironolactone for hyperplasia

-Patients will also have nephrogenic diabetes insipidus (look for polyuria, polydipsia, normal gluocse), will have motor weakness from hypokalemia

Front 12

nursing staff came in contact with person with active TB infection->steps?

Back 12

PPD->if pos->INH 9mos

if neg->rpt PPD in 3months to confirm

Front 13

How does sarcoidosis cause hypercalcemia?

Back 13

macrophages in the noncaseating granulomas produce 1-alpha-hydroxylase that converts 25vit D to 125 vit D (calcitriol) that increases intestinal absorption of calcium and urine calcium excretion while inhibiting PTH

Front 14

Which childhood vaccines have contraindications?

Back 14

Only DTaP (only hold if anaphylaxis on previous DTP or DTaP w/in 5 days or encephaolopathy within 7 days or patient having severe illness currenty

Front 15

Managmenet of lobular carcinoma in situ found in breast core bx?

Back 15

excisional bx (nonmalignant but associated with development of invasive breast cancer)

-you DO NOT need sentinal node bx until true malignant lesion (not in situ shite)

Front 16

Patient with DM1 poorly controlled with blurry vision, increased urination/thirst/weight loss, eye exam 6 weeks showed no changes in fundus=?

TMT?

What if exam shows hard exudates, dot hemorrhages, vitreous bleeding?

Back 16

Likely macular edema from vascular permeability of retinal blood vessels from developing diabeting retinopathy

-Improve glycemic control

-diabetic retinopathy->tmt with laser photocoagulation (risk of retinal detachment and blindness)

Front 17

TMT of diaper rash?

Back 17

Diaper dermatitis

-topical zinc oxide paste

Front 18

67yo M w/ fatigue and lower extrem edema, had CABG and MV repair 7mos ago, w/ parox afib on amiodarone, DM2, smoker, echo shows enlarged atria w/ normal ventricles and EF, mild mitral regure, normal CXR w/ spotty calcifications L , JVD 16

heart border=?

Dx findings?

TMT?

Back 18

Constrictive Pericarditis (with right heart failure)

-fatigue, SOB, edema, ascites, up JVD, pericardial knock (mid-diastolic sound), pulsus paradoxus, kussmaul's sign (increased JVP on inspiration)

-EKG w/ afib, imaging w/ pericardial thickening or calcifications, JV pulse tracing w/ prominent X and Y descents

-tmt w/ supportive care and pericardiectomy if not resolve

Front 19

Mgmt of HSIL in pap smear?

Back 19

1. either immediate colposcopy or LEEP/conization

2. if CIN1->f/u colpo and cytology in 6 and 12 mos

2. if CIN2/3->cryotherapy/ablation/LEEP/cold knife->f/u w/ rpt PAP q4-6mos for 2 years (or PAP +colpo or HPV DNA)->if recurrent->hysterectomy

3. if invasive SCC->met eval w/ CT->hysterectomy (+/-rad and chemo if met or +margins)

Front 20

Followup after colonoscopy with polyps found?

Back 20

small rectal=10yrs

1 or 2 <1cm tub adenomas=5yrs

3-10 or >1cm or villous/hi grade=3yrs

>10=<3yrs

large >2cm sessile or adenocarcinoma=2-6mos

Front 21

GBS screening pregnancy?

Back 21

rectovag culture at 35-37wks gestation

Give penicillin if:

-prior birth w/ GBS

-GBS bacturia/UTI anytime

-GBS + w/in 5wks of labor

-unknown GBS status and: <37wks, ROM >18hrs, intrapartum fever

Front 22

Patient with hyponatremia, n/v/confusion, h/o DM2, HTN, drinking lots water 3 days, schizo on chlorpromazine, serum Na 120, urine Na 80, serum osmol 258, urine osmol 400, CXR w/ 3cm hilar mass R=?

Workup?

Why not other causes?

Back 22

SIADH

-high urine Na >40, high urine osmol >100, low serum osmol <290

-causes (lung dz, CNS dz, sulfonylureas, carbamazepine, SSRIs /NOT CHLORPROMAZINE, cancer)

TMT: water restrict->if sx saline infusion w/ loop diuretics o hypertonic 3% saline, don't correct more than 10-12 mEq in 24hrs or 18 in 48hrs->central pontine myelinosis

1. if hypovol hypoNA (dehydration): will have low urine Na <20 (unless diuretic)

2. if hypervol (edema)->correct underlying cause

3. if psychogenic: will have urine osmol <100

Front 23

45yo M w/ difficulty walking, decreased balance, shooting/burning pain legs, no other h/o, truck driver, bilateral small pupils reduce to accomodation but not to light, normal muscle bulk, reduced sensation lower extrem and absent reflexes, positive romberg=?

Other findings?

TMT?

Back 23

Tabes Dorsalis from late neurosyphilis and Argyll Robertson Pupils

-Syphilis from treponum palidum spirochete starts w/ chancre and adenopathy (darkfield micro->VRDL/RPR dx, tmt w/ single IM penicillin, doxy if allergic)->2ndary syphilis w/ rash, mucus patch, alopecia areata, condylomata (dx w/ RPR and FTA, tmt w/ IM single penicillin)->tertiary w/ tabes, argyll robertson, general paresis, gummas, aortitis (dx w/ RPR & FTA, then LP for neurosyph->tmt w/ IV penicillin, desensitize if pen allergic

Front 24

Why do you treat strep throat? how long?

Back 24

po penicillin x10days for decrease sx and duration, prevent rheum fever, prevent spread to close contacts. Does not help post strep glomerulnephritis (and the 10 days is really for the rheum fever since only 1st day will reduce contagion)

Front 25

What is the most likely cardiac anatomic problem to find after a massive PE?

Back 25

Tricuspid regurg from tricuspid annulus dilation due to acute RV dysfunction increasing RV size and possible RV thrombus

Front 26

What to do with severe unipolar or bipolar depression or mania in pregnancy when refusing to eat/drink and actively suicidal with psychotic features?

Back 26

ECT

Front 27

70yo M w/ pain/stiffness in neck, shoulders, hip x3mos worse in morning lasting 1-2hrs w/ general malaise and weight loss, no synovitis or swollen joings, no tenderness, normal TSH, CK, elevated ESR 85=?

Dx tests?

TMT?

Back 27

Polymyalgia Rheumatica (age >50, bilat pain neck/torso/shoulder/prox arms/thigh/hip >1mo w/ decreased ROM), elevated ESR >40

-low dose prednisone

Front 28

Abx tmt for postpartum endometritis?

-most important risk factors?

Back 28

Clindamycin and gentamycin (flagyl is contraindicated in breastfeeding moms)

-route of delivery (much more common in c-section)

Front 29

Side effect of clozapine?

Monitoring?

Back 29

Agranulocytosis

-weekly CBC for wbc that can be lengthened to one month after initiation

Front 30

TMT for sunburn?

Back 30

NSAIDs minimize pain/erythema

-oral antihistimines if pruritic

Front 31

Side effects of po isoretinoin?

Back 31

Pancreatitis (avoid ETOH)

-in women teratogen (not passed by sex)

-hepatotoxicity

-ocular toxicity

-hypertriglyceridemia (which caues pancreatitis)

Front 32

Match the skin condition with the dz:

1Acanthosis nigricans

2Porphyria cutanea tarda

3Multiple skin tags

4Dermatitis herpetiformis

5seborrheic dermatitis

6sudden multiple itchy seborrheic keratoses

7Pyoderma Gangernosum

8Molluscum Contagiosum

9Sudden psoriasis

10Kaposi Sarcoma

Back 32

1Insulin resist

2hepC

3insulin resist/preg

4celiac

5HIV

6GI malignancy/colon ca

7IBD/crohns

8HIV

9HIV

10HIV

Front 33

Side effect of isoniazid?

Ethambutol?

Back 33

Hepatotoxicity (self-limited transaminitis, no sx)

-ocular toxicity

Front 34

absolute contraindications to OCPs?

Back 34

-migraine w/ aura

->15cigs/day age >35

-stage 2 HTN 160/100

-h/o DVT/PE

-h/o TIA/stroke/ischemic heart dz

-breast ca

-cirrhosis, liver ca

-<3wks postpartum

Front 35

55yo bone marrow tplant for aplastic anemia on antimicrobial ppx and had GVHD treated w/ hi dose steroids now w/ fever, cough, chest pain, CXR w/ patchy LUL infiltrate, nasal bleeding, HA=?

TMT?

Back 35

Invasive aspergillosis (prophyactic fluconazole will not prevent this, more for candida)->respiratory tract, and sinuses typical

-amphotericin, voriconazole

Front 36

54yo DM2 w/ skin rash started 3 wks ago on forearm, 4x5cm erythematous, scaly, w/ central clearing slightly elevated, angular cheilosis, lethargy, diarrhea, cramps, facial flushing=?

Back 36

Glucagonoma w/ necrolytic migratory erythema (can also come from VIPoma, calcitonin, GLP1 tumors)

Front 37

65yo M w/ 3 years new brown dull oval well-demarcated plaques on back stuck on appearance=?

TMT?

What if happened over 1 month?

Back 37

Seborrheic keratoses, benign epidermal tumor

-no tmt needed

-Leser-Trelat sign for Lung or GI tumors

Front 38

acute sinus bradycardia after acute inferior MI

TMT?

what if nonresponsive?

Back 38

If symptomatic: give iv atropine (if asx->nothing)

-if still brady: transvenous cardiac pacing

(bad sign)

Front 39

which lung tumor associated with parathyroid like hormone production and SIADH?

Back 39

trick question:

small cell=SIADH

squamous=PTHrP

Front 40

bipolar patient received IM med to control his verbally threatening behavior, now with neck twisted to side and eyes rolled into head=?

TMT?

Back 40

Acute Dystonic Reaction (EPS type)

-IM diphenhydramine or benztropine (antichol)

Front 41

Patient on warfarin with some life-threatening hemorrhage

Back 41

give FFP

Front 42

20yo M w/ dysphagia, fever, drooling, poor coordination, afraid to drink fluids=?

TMT?

Prognosis?

Back 42

Rabies (hydrophobia is diagnostic, ascending flaccid paralysis)

-rabies IG and rabies vaccine

-coma, resp failure, death w/in weeks

Front 43

Patient started on IV med for treating PCP pna. Hours later, begins seizing->next step?

Reason?

Back 43

IV pentamidine, do finger stick blood test, causes metabolic alterations