USMLE Step 3

Slipped Capital Femoral Epiphysis on X ray and treatment

IMMEDIATE SURGICAL PINNING

30 yo F comes in w/vaginal lacerations and says it is from consensual rough sex w/her husband. Next statement from physician?

" HOW ARE YOU FEELING ABOUT YOUR RELATIONSHIP WITH YOUR HUSBAND?" - this is considered empathetic and open ended Wrong ans: - These types of injuries are concerning for sexual abuse. Are you sure your husband is not being too forceful - this statement above is too confrontational

What biostatistical factors are unaffected by prevalence?

- FP, FN, LR, specificity, sensitivity

What is the indication to start fibrate therapy?

- pt w/severe hypertriglyceridemia >880 mg/dL

What is the normal range for bicarbonate?

22-28

What is the age range for pap smear?

Age 21-65

Where is the abdominal pain typically located in diverticulitis?

LLQ abd pain

In addition to treatment with rifampin, isoniazid, pyranidamide and a fluoroquinolone or IV aminoglycoside, what adjuvant therapy is used to reduce morbidity and mortality in TB meningitis? Will this prevent longterm sequelae?

ADJUVANT GLUCORTICOID THERAPY This does not prevent longterm neurological sequelae

4 yo M w/fever, productive cough, L CP that onset 1d ago. This is in July. Goes to preschool w/children who have cough and rhinorrhea. Up to date on immunizations. T 103.1, BP 98/64, HR 104, RR 25, SpO2 97%. PE shows intermittent coughing. LLL has dec'd breath sounds. CXR shows mild alveolar consolidation w/air bronchograms in LLL. What abx should he get?

AMOXICILLIN

Why do pregnant women develop gestational DM?

Placenta secretes hormones like human placental lactogen which induces maternal insulin resistance. This ensures that there is enough glucose available for the fetus to develop. If pt have inadequate pancreatic fxn they are at risk for developing gestational DM.

What are the phases of clinical trials?

Preclinical - Laboratory and animal models Phase I - 20-100 pts Phase 2 - a few hundred pts. Lasts several mo to 2 yrs Phase 3 - large number of pts like 300-3000 Phase 4 - Postmarketing surveillance to identify rare and longterm adverse effects amongst a large number of patients

Explain what SPIN and SNOUT mean for specificity and sensitivity

Specificity = TN/(TN+FP) - SP-P-IN - if a test is positive for a disease then it rules IN that disease. Use a highly specific test after a screening test to confirm that the person actually has that disease - low rate of false positives Sensitivity = TP/(TP+FN) - SN-N-OUT - if a test is negative for a disease then it rules OUT that disease. Use a highly sensitive test on screening tests to rule out diseases - low rate of false negatives

What is the order for family members designated as surrogate?

Spouse, adult children, parent, adult sibling, nearest living relative, close friend

38 yo prim gravid F comes in for prenatal counseling. She wants to know her baby's risk for Down Syndrome. You explain that triple screening may detect up to 60% of cases of chromosomal abnormalities and amniocentesis detects 90%. When explaining that amniocentesis detected a higher percentage of cases compared to triple screening , what statistical term are you referring to?

THE HIGHER SENSITIVITY OF AMNIOCENTESIS - sensitivity reflects a test's ability to correctly detect cases w/the disease Wrong answers: - PPV - this is wrong bc PPV is the probability of a person having the disease given a positive test. So it would be the probability of chromosomal abnormalities if amniocentesis was positive, not which test detects a higher percentage of cases

What is diagnosed using "thick and thin smears"?

Dx: MALARIA

What is the #1 complication of untreated hereditary hemochromatosis?

HEPATOCELLULAR CARCINOMA - cirrhosis increases the risk of HCC 200 fold - accounts for 30-45% of the deaths in hereditary hemochromatosis

Metzner's index

MCV/RBC. Helps to differentiate IDA from beta-thalassemia. Alpha or Beta-thalassemia if <13 IDA if > 13

Why is there an elevated BUN:Cr in GI bleeders?

- Pt bleeds into intestines and digests the blood increasing protein absorption and nitrogen in the blood

The USMLE does not give you WBC count for CSF. What WBC count is suggestive of bacterial meningitis?

>1000

what is the formula for anion gap? what is normal anion gap?

Na+ - (Cl- + HCO3-)

What is enucleation?

surgical removal of the eyeball

Is urinary Ca high or low in primary hyperparathyroidism and familial hypocalciuric hyeprcalcemia?

urinary Ca excretion (high in primary hyperparathyroidism and low in familial hypocalciuric hyeprcalcemia)

What pulmonary artery pressure measured during RHC is diagnostic for pulmonary artery hypertension?

≥ 25 mmHg

2 wk old F admitted for dehydration and vomiting. Born at home w/o newborn screening. Breastfeeding not going well bc lethargic and vomits too much. PE shows hypotension, tachycardia, sunken fontanelle, ambiguous genitalia. Labs Na 130 K 6.7 Cl 92 HCO3- 15 BUN 14 Cr 0.5 Glucose 50 1) Deficiency in which enzyme is causing this? 2) What lab test can you do to confirm this dx? 3) What is the treatment?

- 21 HYDROXYLASE - remember the mnemonic with the arrows. Turn every 1 into an up arrow and then you can figure it out which of the 3 it is HTN Testosterone 1 7 2 1 1 1 - lab test = 17-HYDROXYPROGESTERONE - treatment = HYDROCORTISONE

40 yo M evaluated for peri oral paresthesias and b/l hand cramping. PMH ETOH cirrhosis admitted 24 hours ago for hematemesis 2/2 esophageal varices now s/p 4 u pRBC and 4 u FFP. Now he has tingling and numbness around mouth, hand and leg muscle spasms. VS wnl. JVP wnl. PE shows ascites, generalized muscle weakness, periodic spontaneous twitching. Labs at admission were: Hgb 5.5 PLT 90k WBC 4100 Na 132 K 20 Cl 95 BUN 26 Cr 1.0 Ca 9.2 Mg 1.9 Glucose 106 Hgb after transfusion 8.9. IV administration of what will improve his sx?

- >10 U pRBC transfused --> watch for sx of hypocalcemia (musc twitching, numbness around mouth, tingling) bc blood has citric acid and sodium citrate which binds ionized calcium --> ionized calcium deficiency. Serum calcium may be normal so order an ionized calcium level. Correct by giving CALCIUM GLUCONATE or calcium chorlide. - pRBCs contain citrate which is poorly cleared in hepatic disease, renal failure, hypothermia, shock - Citrate metabolism results in production of bicarbonate --> metabolic alkalosis --> K+/H+ exchange --> hypokalemia Wrong answers: - dextrose and thiamine - give for wernicke's encephalopathy. Sx are oculomotor dysfunction, ataxia, AMS, but there is no numbness or cramping - lorazepam - this is for seizures but he has no post-octal features - KCl - see above - Na HCO3 - this is a treatment for metabolic acidosis but he will have metabolic alkalosis bc of the citrate

What are the only antibiotics that cover pseudomonas?

- Anti-pseudomonal penicillins - Cephalosporins - 3rd & 4th gen - Monobactams - Carbapenems - Fluoroquinolones

How can you tell inflammatory acne from comedonal and nodular acne? What is the difference in treatment?

- Basically inflammatory looks almost the same as comedomal but in inflammatory the lesions are inflamed papules and pustules. In comedomal they start off as closed or open comedones but can then progress to inflamed populous and nodules. - For both comedonal and inflammatory you give topical retinoids. For inflammatory you add benzoyl peroxide and then topical antibiotics - you never give PO abx except for nodular aka cystic acne - in general the tx steps for all types are in order: topical benzoyl peroxide>topical retinoids > topical abx > PO abx > PO retinoids

What is the treatment for diffuse esophageal spasm?

- CCBs like diltiazem - if pt has primarily chest pain then give TCAs

36 yo F G1P0 @ 10 wk gestation comes in for initial prenatal visit. She has mild nausea. Partner has male factor infertility d/t low sperm count and this is an intrauterine insemination. She has had all norm pap smears. Takes her prenatal vitamins. PE wnl including pelvic exam. Transvaginal US shows intrauterine pregnancy w/cardiac activity. What test does she need at this visit?

- CELL FREE FETAL DNA

43 yo M in bar fight presents intoxicated and evidence of fight. He has contusions and lacerations on face, unilateral pupil dilation in R eye and appears sleepy. You want head CT but her refuses and becomes belligerent. What is the next step?

- CHEMICALLY SEDATE THE PATIENT AND PERFORM HEAD CT SCAN - pt not decisional and this is an emergency Wrong answer - Contact next of kin for consent - no bc this is an emergency. only in non-emergency would you pursue a surrogate

How do you determine the next test to perform after diagnosing unstable angina or NSTEMI?

- Calculate the TIMI score to determine if pt needs to go to cath rn

What does seborrheic dermatitis look like? HOW DO YOU TREAT IT?

- Erythematous white to yellow scaling papules and patches, greasy appearance - they will describe it as itchy, scaling over eyebrows and ears. Oily skin w/erythema. Will look like normal skin w/some flakes in the picture and make it sound like lice or scabies - when it is on the scalp it is called "dandruff" so this is what it looks like in the pics - Malassezia app play a role in it so you treat w/topical antifungals like ketoconazole or SELENIUM SULFIDE SHAMPOO - you can also give topical glucocorticoids, keratolytic agents like salicylic acid, coal tar shampoo or topical calineurin inhibitors like pimecrolimus or tacrolimus

How is a funnel plot interpreted? What type of bias does it assess?

- Funnel plots graph a treatment on the X axis and on the Y axis is a study's size or precision. That means that the higher on the graph a dot is, the more people were in the study - For bias, if there is no bias, you expect the dots to be scattered on both sides of the plot. If there is asymmetry which means there is PUBLICATION BIAS. This means that studies that showed null or increased effect of drug X on mortality were absent bc they were less likely to be published - A small sample size means there were a low number of patients in the study. These would be at the base of the triangle bc they have lower power and larger standard error

Physician gets a call from parent about 3yo M who is choking and gagging suddenly while playing with a small toy just a moment ago. Boy looks blue and is unable to speak. In addition to calling 911 what maneuver should the parent administer to the boy?

- LEAN THE CHILD FORWARD AND ADMINISTER ABDOMINAL THRUSTS - remember if the child is <1yo then you do alternative sequences of 5 back blows and 5 chest thrusts

79 yo F w/PMH mild dementia, HTN, DM, OA w/cc of bloody stools x3d. Home rx = ASA QD and NSAIDS. T 36.7, HR 89, BP 146/82, RR 16. DRE shows bright red blood in rectal vault w/o tenderness. Nasogastric aspirate shows copious amounts of bilious fluid. Labs: Hct 28 PLT 200K BUN 14 Cr 0.8 INR 0.8. You start IVF and order type and crossmatch. Next step?

- Likely a lower GIB - to dx in HDS pts do COLONOSCOPY - if unstable then do EGD first bc this could be a vigorous upper GIB

What is the mechanism behind tertiary hyperparathyroidism and what is the treatment?

- Occurs in CKD and renal osteodystrophy when you have inability to excrete phosphate and inability to convert inactive vitamin D3 to active 1,25 dihydroxyvitamin D resulting in hypercalcemia due to bone losses of Ca2+ - Initially you start making more PTH in response to hypocalcemia and hyperphosphatemia. Then as Ca2+ and PO43- increase you have uncontrolled secretion of PTH and elevation in Ca2+ and PO43- - The only treatment is PARATHYROIDECTOMY bc the parathyroid will just continue making PTH forever. A renal transplant will not fix this

61 yo M w/PMH DM, HTN, HLD, 45 pack yr smoker canes in for routine visit. Reports weight loss in the last 6 wk and mild constipatino. Home rx = metformin, atorvastatin, amlodipine, valsartan, ASA. BMI 30, PE wnl. Labs: Ca 12.1 BG 120 Alb 4 A1c 7 What is the next test to order?

- SERUM PARATHYROID HORMONE - even when malignancy is suspected PTH is the first step - subsequent testing can include CXR for malignancy, UPEP and SPEP for MM, PTHrp for malignancy, vitamin D for humoral hypercalcemia of malignancy and urinary Ca excretion (high in primary hyperparathyroidism and low in familial hypocalciuric hyeprcalcemia) Sx: - hypercalcemia often asx but initial sx include constipation, fatigue, N, nephrolithiasis

In a septic patient with hyperglycemia how can you tell if the hyperglycemia is due to undiagnosed DM? What is another cause of hyperglycemia in these patients?

- Septic patients often have high BG bc of elevated cortisol release, pro-inflammatory cytokines and catecholamine release but they may not actually have DM. This is called STRESS HYPERGLYCEMIA - If the pt has random BG >200 + signs of hyperglycemia like polyuria, polydipsia, weight loss (in children w/DM1), polyphagia OR HbA1c ≥ 6.5 OR fasting plasma glucose >126 OR oral glucose tolerance test 2 hr later w/BG>200 then this is DM - Always check an A1c and this will tell you if there is a chronic elevation in BG signifying undx'd DM1 or 2

What is the difference between standardized incidence ratio and incidence?

- Standardized incidence ratio looks at how the incidence in a study group compared to the population as a whole - incidence = # of new cases/# ppl at risk - SIR = observed # cases/ expected # cases

What is the prognosis in patients infected with rabies?

- THE PROGNOSIS IS POOR WITH DEATH AS THE TYPICAL OUTCOME - post-exposure treatment is actually only ppx to prevent sxs and only works if given before sxs onset - ppx is rabies immunoglobulin + antirabies vaccine as 3 IM doses over 28d - after disease onsets the tx is mainly palliative, which occurs w/in weeks of onset of sxs - pts who survive have longterm neurological deficits

3 yo F w/PMH chronic constipation presents w/2d back pain, fever 104, vomiting, HR 110, RR 20. PE shows R CVA tenderness. Labs show WBC 16000. UA is positive for ketones, LE, nitrites, WBC 50, sm RBC. ED gives 20 ml/kg NS bolus and started on IV abx. What should be done to prevent recurrence of this condition?

- children can do stool withholding or incomplete defecation which can cause rectal distention which leads to compression of the urethra and dysfunctional voiding --> stagnant urine in bladder --> UTI Tx: increasing dietary fiber and water intake and titrating LAXATIVES like polyethylene glycol to produce soft regular BMs

How can you tell apart the different types of studies? - clinical trial - prospective cohort - retrospective cohort - case-control - cross-sectional

- cross sectional - snapshot of a population in time - cohort - pt identified as exposed or not exposed, then followed over time to assess the outcome

In patients with gestational diabetes mellitus how do you monitor them to BG control? When should you start anti hyperglycemic medications and what are your options for these medications?

- fasting BG ≤95 - 1 hr post prandial ≤140 or 2 hr post prandial ≤120 - if the patient is doing dietary modifications and exercise and life style changes but still has elevated numbers past these goals then you need to start insulin, metformin, or glyburide

21 yo F G1P1 comes to ED w/abd pain and HA w/blurry vision for 2d. Started in epigastrium and radiates to the RUQ. No longer responding to acetaminophen. 1 wk ago had uncomplicated vaginal delivery @ 39 wk gestation. PMH migraines and stopped taking sumatriptan while pregnant. BP 150/90, HR 94, hepatomegaly, tender epigastrium and RUQ, B/L 2+ pitting edema. Labs: HCT 26 PLT 60k Tbili 1.6 Dbili 0.5 ALP 220 AST 137 ALT 149 LDH 436 Next step?

- give MAGNESIUM SULFATE to reduce seizure risk - if BP 160/110 then give IV antihypertensives like hydralazine or labetalol - if AST>2000 or LDH>3000 then there is fulminant hepatic dz and you need to do exchange transfusion

How do you test for gestational diabetes mellitus?

- if the pt has risk factors for GDM like possible undiagnosed DM2 like obesity or prior macrocosmic infant then screen them at the initial prenatal visit - if the pt has no risk factors then screen then at 24-28 weeks - screening is a 2 step process: 1. Glucose challenge test - give pt 50g glucose load then measure BG 1 hr later. If BG≥140 then reflex to step 2 2. 3 hour glucose tolerance test - measure fasting BG and then give 100g glucose load and measure levels at 1, 2 and 3 hours after. If ≥2 of the GTT values are elevated then this is a dx of GDM Wrong answers: - HbA1c - this is actually falsely low in pregnancy bc there are physiologic increases in RBC mass and cell turnover

What is the cause of sudden cardiac death in young athletes?

- most commonly results from ventricular arrhythmias triggered by undiagnosed structural heart disease like HCMP, anomalous origin of a coronary artery, arrhythmogenic RV cardiomyopathy roles commonly congenital condition abnormalities like long QT syndrome, Brugada syndrome

How long after a concussion can someone return to full contact sports?

- rest for 24 hr and gradually inc activity daily - no full contact sports for 1 week

Leg Calve Perthe disease

- risk factors - female and breech presentation - occurs in infants - aka idiopathic avascular necrosis of the hip - XR or MRI looks like the head of the femur is crushed in the joint - ESR and CRP wnl

How often do you need to measure bHCG after a patient is diagnosed w/ pregnancy?

- then after that you only do it pt has sxs like vaginal bleeding or pelvic pain concerning for spontaneous abortion, hydatidaform mole or ectopic pregnancy - bHCG has no effect on mgmt of normal pregnancy

59 yo M w/PMH tobacco use and ETOH use on weekends is found to have upper esophageal mass. What type of cancer is it? What are the risk factors for each type of cancer found here?

2 main types of esophageal cancer: - location of each determines incidence 1. adenocarcinoma - distal to mid esophagus - bottom 2/3 - risk factors: chronic GERD and Barrett's esophagus 2. SQUAMOUS CELL CARCINOMA - upper esophagus - upper 1/3 - risk factors - chronic ETOH and tobacco use

What CD4 count do AIDS opportunistic infections develop?

<100

After starting HAART in HIV pt what should the expected viral load be at 6 months?

<50 copies at 16wk-6 mo <500 copies at 8-16 wk <5000 copies at 4 wk Failure of HAART is defined as >200 viral load at 6 months. D/t noncompliance or drug resistance

A cohort of patients with myotonic dystrophy was retrospectively analyzed from 1993 to 2010 to identify indecent cases of cancer. The researcher identified 2 cases of thyroid cancer and reports a standardized incidence ratio of 7.4 (p value 0.02). This was ratio was derived using what formula?

OBSERVED NUMBER OF CASES DIVIDED BY EXPECTED NUMBER OF CASES

What is lead time bias?

One of the interventions diagnoses the disease earlier than the others without and effect on outcome

What is the difference between open-angle and closed-angle glaucoma?

Open-angle - gradual onset - less severe - refer to this as "chronic open angle glaucoma" to try to remember it Closed-angle - red eye, acute onset, involved pupil is dilated and nonreactive - opthamological emergency - refer to this as "acute closed angle or angle closure glaucoma"

82 yo F w/PMH CVA, HTN, DM2 evaluated for positive urine culture. 2d ago presented to ED from SNF for AMS. At that time she was mildly hypoglycemia but everything else was WNL. At that time US showed 5-10 WBC and occasional bacteria. Once her hypoglycemia was corrected her confusion rapidly resolved and her insulin regimen was changed. Ucx came back today w/>100u CFUs/mL of E coli sensitive to TMP-SMX and cipro. On PE pt has no sxs. Next step?

Ans: REASSURANCE AND CLOSE OBSERVATION ONLY - her sx resolved once her BG was fixed - she has no UTI sx so no tx unless a pt is pregnant, undergoing urologic procedures, or w/in 3 mo of kidney transplantation - no need to order confirmatory U cx - only tx or order more tests if she develops sx of UTI or confusion recurred

A national gov agency is reviewing data from a paper to decide on a screening method to fund. They acknowledge that the prevalence of cancer varies throughout the country. For this reason, a reliable epidemiological parameter is needed to compare the significance of negative and positive results obtained in individual patients, irrespective of prevalence. What parameter is most useful in comparing these screening tests in individual patients? A. FP and FN rates B. LR C. OR D. PPV and NPV E. RR

Answer: LIKELIHOOD RATIO - This compared the probability of a given test result occurring in a patient with a disorder compared to the probability of getting the same result in a pt w/o the disorder - Looks at the INDIVIDUAL level - Is NOT affected by prevalence Wrong answers: - FP and FN. This is unaffected by prevalence - PPV and NPV depend on prevalence

How can you tell the difference btw A fib w/RVR and multifocal atrial tachycardia?

Both are narrow complex tachycardias (QRS<120 bc atrial) w/irregular R-R intervals AFRVR - No P waves MAT - ≥3 different types of P waves seen, HR>100

38 yo F comes in for check up. Asx. PMH HTN, DM2, smoker (1/2 PPD). Rx = HCTZ, lisinopril, metformin, glyburide. Occasional ETOH user. BP 130/85. BMI 32. Fasting BG = 120. HbA1c = 6.7%. What is the most significant predictor of future cardiovascular events in her?

DIABETES MELLITUS CHD risk equivalents = coronary heart disease risk factors that have an all-cause mortality as pts who already are dx'd w/CAD or had prior MI (aka these risk factors are just as bad as CAD and MI) - non coronary atherosclerotic disease - carotid, PAD, AAA - DM - CKD Other risk factors for CHD are - >50 yo in men and after menopause in women - male sex - fam hx of CHD in a 1st degree relative <50 yo in men and <60 yo in women - HTN - HLD - smoking >1 PPD - obesity

23 yo nulligravid F who's only sx is deep pain in the pelvis with penetration. PE shows mild tenderness on bimanual exam of the uterus. Transvaginal US shows small, anteverted uterus & no masses. Tx?

Dx: Endometriosis Sx: Deep dyspareunia down in the pelvis, infertility, dysmenorrhea Dx: bx not req'd Tx: COMBINATION ORAL CONTRACEPTIVE PILLS and nsaids are 1st line - 2nd line are progestin only therapy, GnRH analogs (leuprolide), danazol (synthetic androgen) - definitive tx is hysterectomy and B/L salpinoophrectomy Wrong answers - things that have superficial dyspareunia (like around the introitus) - genitourinary syndrome of menopause aka vulvovaginal atrophy, genitopelvic pain/penetration disorder aka vaginismus, vulvodynia

22 yo M w/ PMH concussion @ 17yo comes in to talk abt labs. He is olympic cross country skiier on high protein diet. Take antacids at home. When he had the concussion his Ca2+ was borderline high. Father also found to have hypercalcemia at a young age. Pt takes no meds and doesnt use tobacco, ETOH or drugs. Labs: HCT 42 WBC 6500 PLT 300k Serum: Na 141 K 4 Cl 105 HCO3 105 BUN 22 Cr 1.1 Glucose 84 Ca 11.6 Alb 4.4 How do you dx his condition? What clinical finding will he have?

Dx: Familial hypocalciuric hypercalcemia MOA: mutation in calcium sensing receptor results in inactivation and higher concentrations of Ca are required to suppress PTH. And there is increased resorption of calcium in renal tubules Sx: Typically asymptomatic Diagnostics: Step 1: Measure PTH. FHH has high-norm PTH Step 2: Measure urinary calcium excretion. Will be high in primary hyperparathyroidism and low in FHH Treatment: None required

53 yo M w/progressive stiffness and pain in hands for several months. PMH DM on metformin. Worse in morning, relieved w/acetaminophen. For 3 wk has had pain in L knee, especially after prolonged rest. Fam hx w/DM. PE shows moderate swelling, warmth, tenderness and decreased ROM in 2nd and 3rd metacarpophalangeal joints in hands. L knee has small effusion and tenderness. XR hands shows joint space narrowing w/subchondral cysts, curved osteophytes. Synoval fluid analyses of knee shows WBC 20,000 w/80% neutrophils. G stain shows no organisms and positively birefringent rhomboid shaped crystals. Etiology?

Dx: HEMOCHROMATOSIS causing pseudogout - remember that gout is NEGATIVELY birefringent NEEDLE shaped crystals

64 yo M develops fever and chills during HD & is sent to ED. WBC 14000. Empirically you start vanc and cefepime. B cx shows MRSA & his tunneled HD catheter is removed. You dc cefepime. On d4 he continues to have intermittent fevers. ROS is positive for worsening LBP. WBC is 16000. Repeat B cx are negative. Lumbar XR are wnl, echo is wnl. Next step?

Dx: Metastatic MRSA infection - 40% of staph bacteremia pts develop distant infection - vertebral OM, epidural abscess, heart valves, lungs, osteoarticular structures Sx: persistent fever, continued leukocytosis, worsening LBP or neck localizing to the infected disc space. +/- fever and leukocytosis, b cx only positive in 50% of cases Diagnostics: OBTAIN MRI OF THE LUMBOSACRAL SPINE - confirmation will req open or CT-guided bx Tx: prolonged vancomycin therapy for months. Pt may have a limited response to vanc in only 4d

Newborn M eval'd 3 hr after birth. Delivered at 40 wk. T 98, HR 124, RR 26. PO shows awake, alert active, strong cry. Appears w/ruddy complexion w/generalized erythema. Blood samples obtained via heel prick show hct of 70 %. What is the next test that you should do?

Dx: Neonatal polycythemia - usually observed 2-3hr of life - most are asx and hct goes back to baseline w/in 24 hr of life - cx include hypoglycemia, hyperbilirubinemia, hyper viscosity, hypo perfusion, tissue hypoxia - you need to double check the hct by taking a sample from the PERIPHERAL VENOUS BLODD which is more reliable than heel capillary prick Wrong answers: - check blood type and coombs test for ABO incompatibility - no bc this results in hemolytic anemia and this pt has elevated hct - check BUN and Cr to determine dehydration - dehydrated pts can have falsely elevated RBC ct but first you need to confirm that the pt actually has high hct before doing further work up - check TSH - this can cause polycythemia but 1st you need to confirm w/peripheral blood draw

54 yo M w/DM goes for DM eye screening & ophthalmologist finds small, densely pigmented lesion w/irregular boarders in peripheral R choroid. It is 8 mm in diameter by 1 mm raised. He is supposed to come back for a f/u appt 3 mo later but instead comes back 2 years later w/intermittent blurry vision. Now the lesion is 18 mm in diameter and height is 4 mm. Tx?

Dx: Ocular melanoma Tx: RADIATION THERAPY Wrong answers: - enucleation - this is cutting out the entire eye. You only do this for very large tumors, severe pain, or extrascleral extension. Enucleation has worse functional and psychologic morbidity and no proven survival advantage - chemotherapy - doesnt work for intraocular melanoma for some reason

56 yo M w/ARDS intubated in ICU for 7d then extubated. 1 wk later he is irritable and confused in evenings and prescribed zolpidem to help w/sleeping. Montreal Cognitive assessment shows 25/30 w/deficits in memory and attention. He has flattened affect and psychomotor retardation. Long term prognosis?

Dx: Post-intensive Care Syndrome (PICS) Risk factors: ARDS, prolonged ventilation, ICU delirium Pathophysiology: CNS hypoxia, neuroinflmmation, metabolic dysruption, massive inflammation Outcome: LIKELY TO HAVE MEMORY AND CONCENTRATION DEFECTS FOR YEARS - Usually they have deficits in one or more of the three areas for years

26 yo F w/excessive fatigue for weeks. She delivered healthy baby boy 5 mo ago and thinks this is just baby blues. She enjoys spending time w/her son and is excited to return to work. She reports some weight gain. Vitals WNL. PE shows mild non pitting edema of hands and feet. Labs: CBC HGB 11.2 MCV 92 PLT 320k WBC 8200 BMP Na 128 K 4.4 Cl 90 BUN 14 Cr 0.8 BG 102 TSH 244 S osm 270 (n 275-295) U osm 380 (n 300-900) U Na 80 (n 15-267) Definitive treatment?

Dx: Post-partum thyroiditis - autoimmune disorder considered to be a variant of chronic lymphocytic aka Hashimoto thyroiditis - three phases: 1) brief thyrotoxic phase 2) self limited hypothyroid phase 3) eventual return to euthyroid state Tx: THYROID HORMONE REPLACEMENT Wrong answers: - free H2O restriction - this is not a definitive therapy - glucocorticoids - this would be the answer in adrenal insufficiency but she has no other sx of this like hyperpigmentation, wt loss, hypotension, hyperkalemia - isotonic saline - use for hypovolemic hyponatremia. can worsen hyponatremia in SIADH though - vasopressin-R antagonists like tolvapatan - no bc only use in refractory severe euvolemic or hypervolemic hyponatremia

56 yo M comes in for initial eval bc of tiredness and decreased exercise tolerance for a few weeks. SOB on exertion. 1 mo ago had severe burning pain in upper abdomen and chest but no dark stools. Take ranitidine for GERD and ibuprofen for OA. 30 pack yr smoker. BP 144/89, HR 94, BMI 32. Deep palpation in epigastric region shows mild tenderness. Labs show Hgb 12.2 MCV 82 A1c 6.9 Cr 1.5 T Chol 251 Trigs 441 HDL 31 EKG shows T inversions in II, III, AVF and pathologic Q waves in III and AVF. What rx are you going to start?

Dx: Prior MI RX: beta blockers (METOPROLOL), anti platelet med (like asa), high intensity statin, ACE/ARB/ARNI - even if it is an old MI. If the pt never got tx for it then you need to start it now

38 yo F w/DOE for 6 mo. BP 143/91. SpO2 94% on RA. BMI 34. PE shows prominent S2 w/o murmurs. Lungs clear. Peripheral pulses ok and no clubbing present. No peripheral edema. CXR shows prominent pulmonary arteries and no infiltrates. ECG shows NSR w/RAD. Dx? Next test?

Dx: Pulmonary artery HTN Next test: ECHOCARDIOGRAM Wrong answers: (echo needs to be done before all of these) - High res chest CT - eval for interstitial lung dz (group 3) - definitive dx req RHC - VQ scan - eval for chronic thromboembolic PH (group 4) - polysomnography - eval for OSA/OHS

A 20 yo M comes to ED w/fever, dysphagia, drooling, poor coordination. Sx onset 1 wk ago w/fever, throat pain, malaise. Unable to drink bc feels like his throat is closing up. Recent school trip 2 months ago to cave. PE shows febrile, tachycardia, dehydration, lethargic, ataxia, drool pooling in mouth. Dx?

Dx: RABIES - takes 30-90 d after exposure to see sx - hydrophobia is pathognomic

3 mo F w/2d of fussiness. Afebrile. Can't get her to stop crying. Breastfed every few hr but less than usual lately. 2 wet diapers in last 24 hr. Born by C sect @ 34 wk for breech presentation. Vaccinated at 2 mo. VS WNV except RR 40/min. PE shows L leg flexed, externally rotated, held very still compared to the R leg. There is dec ROM of the L hip. Labs show WBC 16,000 and CRP 8.5. L hip US shows sm effusions. What is the most likely dx?

Dx: SEPTIC ARTHRITIS OF THE HIP Work up: High WBC, CRP, ESR. Blood cx (+/- positive for Staph aureus, GBS or GNR if <3 mo OR if age ≥ 3 mo then Staph aureus, GAS), effusion on US or MRI, joint aspiration w/synovial WBC ct of >50,000 Tx: surgical joint drainage and debridement AND parenterally abx Wrong ans: - developmental dysplasia - occurs in female in breach presentation, Positive Barlow and Ortolani tests w/hip dislocation, limited hip abduction, asymmetrical gluteal folds. No effusion on US - Legg-Calve Perthe disease - aka idiopathic avascular necrosis of hip. Insidious onset. XR or MRI shows femoral head deformity (looks broken/collapsed), ESR and CRP wnl - Transient synovitis - positive hip effusion on US or MRI. Usually is in children age 3-8yr. Follows a viral illness. Children are consolable. Norm or mild inflam in ESR and CRP

70 yo M w/syncopal episode comes to ED. PMH DM2, gout. BP 100/80, HR 90, BMI 28. Rx metformin. PE w/delayed carotid pulses, harsh crescendo-decrescendo murmur at heart base. 2nd heart sound soft w/inaudible A2. Lungs clear. Bo LE pit ed. ECG shows ventricular hypertrophy, secondary ST and T wave changes. TTE shows severe calcification of aortic valve w/area 0.78 cm^2 and mean transvalulvar gradient of 50 mmHg. Labs show norm CBC and Cr. Tx?

Dx: Severe AS Tx: AORTIC VALVE REPLACMENT - here they mean surgical or transcutaneous - there is also a balloon valvulotomy which is actually not a replacement. This is just a temporary procedure which has lots of risks involved so you dont do this first. It is only be a bridge to surgical/transcatheter aortic valve replacement - you cannot do conservative medical therapy bc he is symptomatic which is automatically an indication for tx. AS is preload dependent so diuretics and vasodilators can lead to inferior outcomes bc of decrease in CO

56 yo M comes in w/CP that occurred at rest while watching TV. He's has 2 similar episodes this week w/exertion that resolved w/in 20 min. He has no palpitations, syncope, SOB< diaphoresis. PMH HTN on lisinopril. BP 150/80, HR 78. EKG w/T wave inversions in V5 & V6. He is started on ASA, metoprolol, ASA, clopidogrel, SQ enoxaparin. 8hr later still no CP and ECG unchanged, trop still norm. What is next step?

Dx: Unstable angina - if trop was elevated this would be NSTEMI STRESS TEST

50 yo M w/anal pain. PE shows fluctuant mass that is hot, tender. T 100.6, BP 128/86, HR 90. Tx?

Dx: anal mass Tx: INCISION AND DRAINAGE Wrong answers: - this pt does not need admission and IV abx bc this is considered a localized infection - he will only need PO abx if he has DM, immunosuppression, extensive cellulitis, valvular heart dz

13 yo M w/copius purulent discharge from R eye. PMH myopia & wears contact lenses. What antibiotic drops should he use? What is the complication that can happen?

Dx: bacterial conjunctivitis Spp: In contact lens wearers this can be due to pseudomonas. Norm it is d/t S aureus, S pneumo, H flu, Moraxella Tx: In contact lens wearers need to give topical FLUOROQUINOLONE bc covers pseudomonas. In others can give topical macrolide Cx: KERATITIS

3 yo F w/2d back pain, fever 104, vomiting, HR 110, RR 20. PE shows R CVA tenderness. Labs show WBC 16000. UA is positive for ketones, LE, nitrites, WBC 50, sm RBC. ED gives 20 ml/kg NS bolus. Should she be given PO or IV abx? And what is the reasoning for giving PO vs IV?

Dx: pyelonephritis Tx: 3rd generation cephalosporin - give IV if pts are hemodynamically unstable, unable to tolerate PO meds (like in VOMITING), or failure to improve on PO abx - she is vomiting and cant keep PO down so you need to give her IV

50 yo F w/routine labs showing TSH 9 (n 0.35-5) and free T4 1.3 (n 0.8-1.8). Asx. Fam hx w/mother w/hypothyrodism. Next test to order?

Dx: subclinical hypothyroidism Next test: ANTITHYROID PEROXIDASE (ANTI-TPO) MEASUREMENT - when Anti-TPO abs are present there is a high chance for the pt to become overly hypothyroid Txt: - need to tx when there is also hyperlipidemia, positive anti-TPO abs, sxs or ovulatory or menstrual dysfxn Wrong answers: - thyroid US - no bc this would look for a nodule. only do this if there is thyroid enlargement - Ts, radioactive iodine uptake, thyroglobulin measurement - no (no explanation given). Look at T3 in hyperthyroidism

56 yo M w/several mo of difficulty swallowing. At first solids, now liquids too. Coughs and aspirates food while eating. Persistent R ear pain x 4 week. PMH HTN, smokes 2 PPD, drinks 8 beer on weekends. PE shows no LN in neck or thyromegaly. Lost several lbs in past 2 mo. What test should be done first to assess swallowing function in this patient first?

Dx: upper esophageal mass bc has ear pain (from hypopharyngeal lesion), coughing and aspiration which are consistent oropharyngeal or proximal esophageal disorder. - initially solids and now liquids means that it is a mechanical obstruction like a mass Tests need to be done in this order: 1. NASOPHARYNGEAL LARYNGOSCOPY - 1st bcmass likely in pharynx or proximal esophagus 2. barium esophogram - looks for achalasia or strictures 3. EGD - only do if no dx made on #1 or #2 but mostly for looking for lower esophagus Other wrong answers - CT chest - use to look for mets - video barium swallow - use for NM disorders - manometry - esoph motility disorders

What are the 5 groups of pulmonary hypertension? and what is the treatment for group 1?

ENDOTHELIN-R ANTAGONISTS like bosentan, ambrisentan MOA - endothelia is a potent vasoconstriction hormone. Receptors are abundant in the pulmonary arteries of pts

Which fracture happens from falling on flexion vs extension of the wrist?

Flexion - bending wrist forward. Smith fracture. Extension - falling on an outstretched hand. They will term this "tripping and falling forward", they don't say outstretched hand, you are to assume it. Colles fracture and Ulnar styloid fracture

What is the treatment for neonatal polycythemia?

PARTIAL EXCHANGE TRANSFUSION - this is where you remove some blood and exchange it with NS

In patients with suspected osteomyelitis who cannot undergo MRI what is an alternative test?

PET or gallium imaging are reserved for this w/equivocal results on CT scan and plain XR and who cannot undergo MRI

What is the treatment for a dermatophyte infections? How does treatment of tines on the head differ from other areas of the body?

Head (Tinea capitis)- this is not a scalp infection, but rather an infection of the hair follicles which causes scaling of the skin and hair loss. For tx it requires systemic antifungals like ORAL GRISEOFULVIN or oral terbinafine Skin/other parts of body (Tinea corporis) - this is a skin infection so you treat it with topical terbinafine

Define: Hirsutism

Hirsutism (HUR-soot-iz-um) is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern

Does hypercalcemia cause hyper or hyporeflexia?

Hyperreflexia

How can you tell if a question is asking you to calculate the relative risk? The relative risk reduction? Or the absolute risk reduction?

If the question says "What is the reduction in risk?" then it wants the RRR. If the question says "What is the magnitude of risk between these two treatment groups?" then it wants RR - RR = risk in exposed group/risk in control group If the question says "What is the ARR?" Then it wants ARR

Immune reconstitution syndrome

Immune Reconstitution Syndrome, Immune Restoration Disease. In HIV infection, an exaggerated inflammatory reaction to a disease-causing microorganism that sometimes occurs when the immune system begins to recover following treatment with antiretroviral (ARV) drugs.

What are the common cancers that metastasize to the brain? What is the diagnostic test of choice to evaluate brain mets?

In order: lung, breast, unknown primary, melanoma, colon cancer - test of choice: contrast enhanced MRI of the brain

When would a patient require further cardiac work up before undergoing surgery?

In patients who have reduced functional status defines as exercise capability <4 metabolic equivalents (ex inability to climb 2 flights of stairs) and >1% risk of significant cardiac event req further cardiac eval prior to surgery - that test might be a pharmacologic or exercise ECG stress test, do this in pt w/reduced fxnl status and >1% risk of preoperative event based on the RCRI

Is gout positively or negatively birefringent?

NEGATIVELY

Parents bring teen daughter to ED for cutting herself. No intent to commit suicide per daughter. Does she require hospitalization while you work her up for safety reasons?

NO. There is no intent to commit suicide in curing disorders. Just done to cope w/emotions. Pt will need full psych work up.

You are concerned for a quinton infection in your patient. What prophylactic antibiotics should you start?

VANCOMYCIN + CEFEPIME or gentamicin

31 yo M w/murmur. Jogs 3x/wk. BP 125/70. PE shows harsh, 4/6 holosystolic at the 4th L intercostal space close tot he sternal board accompanied by a thrill. What is the name of this murmur?

VENTRICULAR SEPTAL DEFECT

When would you order a head CT with or without contrast?

With - looks for abscesses or intracranial masses WITHOUT - looks for acute bleeding which appears white. Contrast also appears white and can obscure bleeding. Like in intracranial hemorrhage

What is selection bias?

occurs when samples or participants are selected that differ from other groups in additional determinants of outcome