SII: SUMMATIVE EXAM
1. If Atrial fibrillation began less than _____ hours ago, you can assume no clot has formed and cardiovert the patient immediately. 2. What are the requirements if A fib began prior to this time?
1. 48 2. MUST anticoagulate at least 3 weeks before cardioversion OR do a TEE to prove that there is no clot All patients that receive cardioversion for Afib must be on anticoagulation for 4 weeks!
How do you treat cerumen impaction?
Hydrogen peroxide
What is are the major/minor Jones criteria associated w/ Rheumatic Fever?
MAJOR: Joint - migratory polyarthralgias Oh, my heart - carditis Nodules - extensor surfaces Erythema marginatum Sydenham's chorea MINOR Fever Arthralgia ↑ acute phase reactants Prolonged PR interval on EKG Patients need 2 major or 1 major & 2 minor to be diagnosed w/ Rheumatic fever (as well as evidence of a recent GABHS infection)
What is the Duke criteria for endocarditis?
MAJOR: sustained bacteremia (2+) endocardial involvement (confirmed w/ echo; new regurgitation) MINOR: pre-disposing conditions fever vascular/embolic phenomena bacteremia or echo (not meeting major requirement) Need 2 major, 1 major/3 minor, or 5 minor.
How do you treat acute heart failure?
LMNOP: Lasix, Morphine, Nitrates, Oxygen, Position (upright)
Patient presents with painless otorrhea that is a yellowish color on his R year. It has a strong odor. He says that he has been feeling dizzy and has ringing in his ears. On otoscopic exam, you see a collection of cellular debris posterior to the TM. Weber lateralizes to R ear, and BC > AC on R ear. What is the most likely cause?
Cholesteatoma. Surgical excision is needed w/ reconstruction of the ossicles.
What needs to be done prior to starting any biologic DMARD (ex. MTX)?
TB test
What is the MCC of new, permanent vision loss in individuals 25-74? a) HTN retinopathy b) DM retinopathy c) Giant Cell Arteritis d) Retinal Detachment
b! DM retinopathy retinal blood vessel damage leads to retinal ischemia and glycosylation of the vessels. you will see flame-shaped hemorrhages/hard exudates on non-proliferative. You will see neovascularization on proliferative. Patients will have central vision loss w/ maculopathy.
How do you treat Aortic Regurgitation?
Valve replacement and afterload reduction (ACEIs, Hydralazine, Nitrates)
CT is the test of choice for sinusitis if imaging is needed. Which view is the best?
Water's
40 y/o patient presents w/ a "painful rash" x 1 day. He states that the day prior he felt pain, burning, and tingling on his arm. It has now developed into a unilateral vesicular rash that you notice is in a dermatomal pattern on his R arm. Based on the likely diagnosis, how would you treat? a) Acyclovir b) Oral corticosteroid c) Gabapentin d) Supportive treatment
a! Acyclovir This is mostly shingles from the Varicella Zoster virus. The patient is no longer infectious when the lesions crust over.
50 y/o patient presents w/ sudden onset of painless monocular vision loss. On fundoscopic exam, you see a blood and thunder appearance and retinal hemorrhages. What is the most likely diagnosis? a) Central Retinal Vein Occlusion b) HTN Retinopathy c) Central Retinal Artery Occlusion d) Macular Degeneration
a! Central Retinal Vein Occlusion There is no definitive treatment.
Which of the following inhibits intestinal cholesterol absorption and may cause a rise in LFTs (especially when used with statins? a) Ezetimibe b) Gemfibrozil c) Niacin d) Colesevelam
a! Ezetimibe
Which of the following is a glucose-dependent insulin secretagogue that is used for treatment of DM? a) Nateglinide b) Metformin c) Rosiglitazone d) Glipizide
a! Nateglinide The meglitinides (-glinide) are glucose-dependent; therefore, they have less risk of causing hypoglycemic events than the sulfonylureas.
Which lipid lowering agent is known for causing flushing, hyperuricemia, and hyperglycemia? a) Niacin b) Gemfibrozil c) Rosuvastatin d) Colesevelam
a! Niacin It is often recommended to take ASA or ibuprofen with Niacin to reduce flushing.
What is the most common type of retinal detachment? a) Rhegmatogenous b) Tractional c) Exudative d) Transudative
a! Rhegmatogenous This a full thickness retinal tear that caused the retinal inner sensory layer to detach from the choroid plexus. Tractional is caused by adhesions, and exudative is caused by fluid accumulation.
What is the most common benign skin tumor that presents as a round velvety warty lesion w/ a greasy "stuck on" appearance? a) Seborrheic keratosis b) Molluscum Contagiosum c) Lichen Planus d) Condyloma Lata
a! Seborrheic keratosis No treatment necessary (benign!)
1. Which DM medication should you not give to patients that are prone to UTIs? a) Miglitol b) Canagliflozin c) Sitagliptin d) Glimepiride
b! Canagliflozin These work by increasing the urinary excretion of glucose.
Which of the following works for DM by delaying intestinal glucose absorption and causes flatulence? a) Glyburide b) Repaglinide c) Sitagliptin d) Acarbose
d! Acarbose The alpha-glucose inhibitors (ex. Acarbose and Miglitol) cause mainly GI adverse effects.
Patient presents w/ CC of dizziness and dyspnea on exertion. You note that he is hypotensive. On PE, he has bounding pulses and a wide pulse pressure. You also notice fingernail bed pulsation w/ light compression. He has a diastolic blowing decrescendo murmur best heard at the LUSB and a diastolic rumble at the apex. 1. What is the most likely diagnosis? a) Pulmonic Regurgitation b) Mitral Stenosis c) Tricuspid Stenosis d) Aortic Regurgitation
d! Aortic Regurgitation AR is associated w/ many different findings. Fingernail bed pulsation w/ light compression is known as Quincke's sign. Additionally, bounding pulses (pulsus bisferiens) is a common finding. The diastolic rumble at the apex is known as an Austin Flint murmur, which is also associated w/ AR.
Patient presents w/ leg pain x 2 months. He states that the pain is exacerbated w/ standing and alleviated w/ elevation. He states that his lower legs have been itchy. On PE, you note bilateral edema, dark purple hyperpigmentation of the skin, and an ulcer on the medial malleolus. The temperature and pulses are normal. What is the most likely diagnosis? a) Deep vein thrombosis b) Peripheral Artery Disease c) Thromboangiitis Obliterans d) Chronic Venous Insufficiency
d! Chronic Venous Insufficiency Treat w/ compression stockings, leg elevation, and exercise.
Pregnant woman 20 weeks gestation presents for a well check visit. Upon drawing labs, you see the following: LDL - 250 HDL - 48 TG - 175 Which of the following would be the best option for this patient? a) Ezetimibe b) Gemfibrozil c) Rosuvastatin d) Colesevelam
d! Colesevelam Bile acid sequestrants should be used for pregnant patients to lower lipids! Bile acid sequestrants work by blocking the enterohepatic reabsorption of bile acids and reducing the cholesterol pool.
Which of the following DM medications is a non-glucose dependent insulin secretagogue and may cause weight gain? a) Nateglinide b) Metformin c) Rosiglitazone d) Glipizide
d! Glipizide The sulfonylureas (Glipizide, Glyburide, and Glimepiride) are secretagogues. They are non-glucose dependent, so they increase risk of hypoglycemia.
Which of the following is the most specific test for Rheumatoid Arthritis diagnosis? a) Rheumatoid Factor b) anti-Ro and anti-La c) anti-mi 2 d) anti-CCP
d! anti-CCP
What is the biggest risk factor for OA? a) cigarette smoking b) family history c) hx of thyroid disease d) obesity
d! obesity
What is the treatment goal for hypertensive emergency?
gradually reduce BP 10-20% in FIRST HOUR and by 5-15% over next 23 hours → goal = <160/100
What is the first line therapy for tinea pedis, tinea cruris ("jock itch"), and tinea corporis
topical antifungals (such as terbinafine or -azoles) These are typically caused by T. rubrum.
What is the definitive treatment for Afib?
radiofrequency ablation
1. What is considered an elevated BP? 2. What is considered Stage I HTN? 3. What is considered Stage II HTN?
1. 120-129 SBP, < 80 DBP 2. 130-139 SBP, 80-90 DBP 3. 140+ SBP, 90+ DBP
Name the following drugs for HF: 1. negative inotrope that reduced HR and mortality, but cannot be used in acute or unstable settings 2. positive inotrope that increases the availability of Ca2 (used in pts w/ CHF or Afib) 3. beta agonist that increases contractility and CO 4. aldosterone antagonist that is used in symptom management to rid excess fluid and decrease cardiac workload
1. BB 2. digoxin 3. dobutamine 4. spironolactone
Name the following phenomena associated with diabetes: 1. rise in serum glucose between 2am-8am from ↓ insulin sensitivity 2. nocturnal hypoglycemia followed by rebound hyperglycemia
1. Dawn phenomenon 2. Somogyi Effect
1. Which IV hypersensitivity reaction is characterized by target lesions w/ a dusky, central area surrounded by pale ring of edema (erythematous halo)? 2. How do you treat?
1. Erythema Multiforme 2. Systemic corticosteroids (or acyclovir is HSV is a risk factor) This is MCly caused by sulfonamides, and HSV is a large risk factor.
What are the following goals for lipid management: 1. LDL 2. HDL 3. Total cholesterol 4. TG
1. LDL < 100 2. HDL > 60 3. Total < 200 4. TG < 150
7 y/o patient presents w/ the chief complaint of an "itchy rash" x 2 days. His mother states that he had a fever the night prior to the rash eruption, and he is otherwise a healthy child. On PE, you note clusters of erythematous vesicles on an erythematous base throughout the body. The facial rash has crusted over. 1. What is the best way to confirm your diagnosis? 2. Based on the most likely diagnosis, how would you treat? a) Acyclovir b) Cefdinir c) Topical Steroid d) Supportive treatment
1. PCR 2. d! Supportive treatment (such as Acetaminophen or calamine lotion) This is most likely chickenpox from the varicella zoster virus (HHV-3). If the child is under 13, supportive treatment is indicated. If the child is over 13 (or immunocompromised), they should be treated w/ acyclovir.
1. If a patient w/ acute endocarditis has hx of IVDA, how would you treat? 2. If a patient w/ endocarditis has a prosthetic valve, how would you treat?
1. Nafcillin + Gentamicin (or Vancomycin) 2. Vancomycin + Gentamicin + Rifampin
1. What is the most common causative agent of subacute endocarditis? 2. What is the most common causative agent of endocarditis in IVDA (acute)? 3. What is the most common causative agent of endocarditis in patients w/ prosthetic valves?
1. S. Viridians 2. S. Aureus 3. S. epidermidis
Patient presents w/ photopsia (flashing lights) and floaters in his right-sided vision. He has a hx of myopia. He states that he now feels as though there is a shadow coming down on the outside of his R eye, blocking his vision. 1. Which sign should you look for? 2. How do you treat?
1. Shafer's signs (clumping of brown pigment cells in anterior vitreous humor) 2. ophthalmologist emergency (keep supine) This is a case of retinal detachment.
1. Which of DM medication works as an insulin-sensitizing agent at peripheral receptors? a) Pioglitizone b) Repaglinide c) Sitagliptin d) Acarbose 2. In which of the following patients would this drug be contraindicated in? a) Patient w/ sulfa allergy b) Patient over 75 c) Patient with cirrhosis d/t chronic alcohol use d) Patient with CHF
1. a! Pioglitizone 2. d! Patient with CHF These are the thiazolidnediones (-glitazone).
Patient started a new medication earlier this morning and now presents w/ blanchable, edematous pink wheals on the skin. 1. What type of reaction is this? 2. What is this known as? 3. How do you treat?
1. Type I - IgE mediated 2. Urticaria 3. anti-histamines (H1 blockers), such as Loratadine Darier's sign is a localized urticaria that presents where skin is rubbed.
1. What cranial nerve is followed in Herpes Zoster Ophthalmicus? 2. What cranial nerve is followed in Herpes Zoster Oticus?
1. V 2. VII If lesions are on the tip of the nose (Hutchinson's sign), they need an emergent ophthalmology consult.
Patient has an irregularly irregular cardiac rhythm w/ fibrillatory waves. On EKG you see no discernible P waves and a narrow QRS complex. He occasionally experiences palpitations, but he denies any other complaints. His BP is 130/85 in office. 1. Which is the most appropriate management for the patient at this time? a) Atenolol b) Synchronized Cardioversion c) Captopril d) Transcutaneous Pacing 2. How can you determine stroke risk in this patient? a) TIMI score b) HEART score c) CHA2DS2-VASc score d) Duke Criteria
1. a! Atenolol 2. CHA2DS2-VASc score This patient has stable A fib, which means you can use a BB or non-DHP CCB (ex. Verapamil) for rate control. If the patient were unstable (ex. hypotensive or AMS), synchronized cardioversion is the best option.
1. Which diabetes medication works by mimicking incretin, increasing insulin secretion, and delaying gastric emptying? a) Liraglutide b) Repaglinide c) Sitagliptin d) Acarbose 2. What is the most common adverse effect?
1. a! Liraglutide 2. Pancreatitis The GLP-1 agonists (-glutide) also can be good for weight loss.
53 y/o patient presents w/ painful joints x 4 months. She states that it is the worst on both hands, but she also experiences pain on both ankles and knees. She states that she is often stiff in the morning for at least an hour after she wakes up. On PE, you note symmetric swollen, tender, erythematous, and boggy joints on the hands, knees, and ankles. 1. Based on the likely diagnosis, what is the first line treatment? a) Methotrexate b) Indomethacin c) IV Ceftriaxone and Vancomycin d) Hydroxychloroquine 2. Which deformities are often seen with this diagnosis? 3. What will you see on x-ray?
1. a! Methotrexate 2. Boutonniere and Swan Neck Deformity 3. symmetric narrowed joint space and possibly wink sign (C1/C2 subluxation) The most likely diagnosis here Rheumatoid Arthritis! This is associated w/ symmetric polyarthritis and is a T-cell mediated inflammatory disease. Patients will often have morning stiffness.
Patient presents w/ CC of SOB x 2 months. He states that this is exacerbated when he is working out or going on his morning walks. He states that he has been much more tired lately. On PE, you note a blowing holosystolic murmur that radiates to the axilla. Is it best heard at the apex. 1. What is the most likely diagnosis? a) Mitral Regurgitation b) Pulmonic Stenosis c) Aortic Stenosis d) Tricuspid Regurgitation 2. What is the most common cause in the US?
1. a! Mitral Regurgitation 2. MVP MR presents w/ symptoms of pulmonary edema (ex. dyspnea and fatigue). They may also have hemoptysis. This is d/t retrograde flow from LV to LA.
Patient presents w/ chest pain x 3 days. She states that it increases when she breathes and lays down, and it is reduced when she is leaning forward. Upon listening to the heart, you hear a friction rub (best heard during inspiration when she is leaning forward). 1. What would you expect to see on the EKG? a) sinus tachycardia, deep S wave in lead I, and T wave in version in lead III b) tachycardia with no discernible P waves c) diffuse ST elevations in precordial leads w/ PR depression d) ST elevations in 2 consecutive leads 2. What is the first line treatment? a) Metoprolol b) Corticosteroids c) Alteplase d) Naproxen
1. a! diffuse ST elevations in precordial leads w/ PR depression 2. d! Naproxen This is pericarditis. It is best to treat w/ NSAIDs or ASA.
Match the hormone w/ its function: 1. stimulates follicular growth and estrogen secretion 2. develops endometrium, stimulates LH secretion (in follicular phase), and inhibits FSH/LH (in luteal phase) 3. surge causes ovulation, develops corpus luteum, and stimulates progesterone secretion 4. thickens endometrium and inhibits LH and FSH (in luteal phase) a) LH b) FSH c) Progesterone d) Estrogen
1. b - FSH 2. d - estrogen 3. a - LH 4. c - progesterone
67 y/o patient presents w/ stiffness x 3 months. He states that he feels it mostly in his R knee and L hip in the evenings. On PE you notice slightly reduced AROM of these joints. Additionally, you notice nodules on the DIP and PIP joints of both hands. He denies inflammation. 1. Based on the likely diagnosis, what is the first line treatment? a) Methotrexate b) Acetaminophen c) Steroid injections d) Colchicine 2. What will you see on x-ray?
1. b! Acetaminophen (NSAIDs can also be used but are associated w/ more AE in the elderly) 2. asymmetric narrowed joint space, osteophytes, and sclerosis The most likely diagnosis is: osteoarthritis! OA usually asymmetrically occurs on weight-bearing joints (ex. hip, knees, L spine). Additionally, pain/stiffness will be worse in the evenings and changes w/ weather. Pts will often have reduced ROM. The nodules are known as Herbeden's nodes (DIP) and Bouchard's nodes (PIP)
1. What is the MCC permanent legal blindness & vision loss in older adults that is characterized by bilateral central vision loss and small, round yellow/white spots on the outer retina. a) Retinal Detachment b) Macular Degeneration c) Cataract d) Diabetic Retinopathy 2. What can you use to diagnose this?
1. b! Macular Degeneration 2. Amsler Grid The small, round yellow/white spots are Drusen bodies, which are characteristic of dry macular degeneration. Wet MD is associated w/ neovascularization and hemorrahges. You can give patients Zinc and Vitamin C/E to slow the progression of dry MD.
30 y/o patient presents w/ CC of increased thirst and fatigue x 1 month. He states has has been peeing a lot as well. His BMI is 35. You suspect T2DM, and it is confirmed by a Fasting Plasma Glucose of 140. 1. After lifestyle modifications, what is the first line treatment? a) Insulin b) Metformin c) Rosiglitazone d) Glipizide 2. What may you want to supplement if the patient starts this drug?
1. b! Metformin 2. Vitamin B12 Metformin works by decreasing hepatic glucose production. It is also good for weight loss. It may cause B12 deficiency. You can not use it in hepatic or renal failure. If the A1c is > 9, go straight to insulin
35 y/o patient presents w/ SOB x 3 months. He states that is has gotten progressively worse and now he has been throwing up blood. On PE, you notice that his face looks very flushed. You hear a rumbling diastolic murmur (best heard at the apex) w/ an opening snap. 1. What is the most likely diagnosis? a) Pulmonic Regurgitation b) Mitral Stenosis c) Tricuspid Stenosis d) Aortic Regurgitation 2. What is the MC cause?
1. b! Mitral Stenosis 2. Rheumatic Heart Disease The opening snap is associated w/ forceful opening of the mitral valve. Patients will often present w/ pulmonary sx (dyspnea and hemoptysis). They also may have mitral facies (flushed cheeks w/ facial pallor).
Patient has a hx of HTN and T2DM. On his lipid panel you see the following findings: LDL - 250 HDL - 48 TG - 175 1. Based on the findings, what would be the best medication to start the patient on (if there are no contraindications)? a) Niacin b) Simvastatin c) Fenofibrate d) Cholestyramine 2. What may be a side effect of this medication? a) gallstones b) hyperuricemia c) severe flushing d) rhabdomyolysis
1. b! Simvastatin 2. d! rhabdomyolysis Statins are first line in lowering LDL (which is the main problem here). Bile acid sequestrants are 2nd. Statins may cause myalgias and rhabdomyolysis (and also increase LFTs), so have your patients watch for muscle or joint pain. These drugs work by inhibiting the rate-limiting step in hepatic cholesterol synthesis.
Patient presents w/ chief complaint of leg pain x 2 months. He states that the pain occurs primarily when he is walking. On PE, you note decreased dorsalis pedis pulses and thin, shiny skin w/ hair loss on the lower legs. The patients feet appear red when they are hanging over the bed, but when you elevate them, they become pale. 1. Based on the likely diagnosis, what is the best initial test for this patient? a) arteriography b) ankle-brachial index c) venous doppler u/s d) contrast venography 2. Which test is gold standard? a) arteriography b) ankle-brachial index c) venous doppler u/s d) contrast venography 3. What is the best treatment?
1. b! ankle-brachial index 2. a! arteriography 3. exercise is first line; can also give platelet inhibitors (cilostazol, ASA, clopidogrel, pentoxyifylline) The most likely diagnosis is Peripheral Artery Disease. The ABI indicates PAD if it is < 0.9 (normal is 1-1.2).
1. Which of the following cardiac enzymes is most specific for MI and is detectable within 1-3 hrs? a) CK-MB b) Troponin I c) Myoglobin d) LDH 2. Which of the following cardiac enzymes appears within 6-12 hrs and returns to normal in 3-4 days? a) CK-MB b) Troponin I c) Myoglobin d) LDH 3. Which of the following cardiac enzymes rises the fastest (<2 hrs)? a) CK-MB b) Troponin I c) Myoglobin d) LDH
1. b! troponin I 2. a! CK-MB 3. c! Myoglobin
65 y/o African American patient presents for his well check. You perform vitals and notice his BP is 160/95. He denies history of COPD, Asthma, CHF, or Renal disease. 1. After confirming with an additional reading on a follow-up visit, what would be the best treatment option for the patient? (Alongside lifestyle modifications, of course) a) Metoprolol b) Lisinopril c) Verapamil d) Losartan 2. What is his BP goal?
1. c! Verapamil 2. <150/90 The usual goal is <140/90, except in patients 60+ (150/90). Thiazide diuretics and CCBs are the best treatment options for African American patients.
55 y/o patient presents after an episode of "passing out" on his morning walk. He states that he has been experiencing some chest pain and SOB, as well. On PE, you notice a delayed and weak carotid pulse. When listening to the heart, you hear a harsh systolic ejection murmur best heard on the R sternal border 2nd ICS that radiates to the carotid. 1. What is the most likely diagnosis? a) Mitral Regurgitation b) Mitral Stenosis c) Aortic Stenosis d) Aortic Regurgitation 2. What will you see on the echo (TEE)?
1. c! Aortic Stenosis 2. LVH, LAE The small, delayed pulse is known as pulsus parvus et Tardus, and it is commonly associated w/ aortic stenosis. The common triad of symptoms for AS is SAD: syncope, angina, and dyspnea. Additionally, this murmur is a crescendo-decrescendo systolic ejection murmur (best heard at RUSB) that often radiates to the carotid.
Patient has a hx of HTN and T2DM. On his lipid panel you see the following findings: LDL - 110 HDL - 48 TG - 375 1. Based on the findings, what may be the best medication to start the patient on (if there are no contraindications)? a) Niacin b) Simvastatin c) Fenofibrate d) Cholestyramine 2. What may be a side effect of this medication? a) gallstones b) hyperuricemia c) severe flushing d) hyperglycemia
1. c! Fenofibrate 2. a! gallstones Fibrates are the best at lowering TGs, and since this is the main problem, they may be the best option. They may cause gallstones and myalgias. Fibrates work bu inhibiting TG synthesis and increasing lipase.
Patient presents w/ persistent fever and fatigue. On PE, you note erythematous macules on his hands and feet that he says do not cause him any pain. He also has reddish-brown lesions under his nails. On an eye exam, you note retinal hemorrhages w/ central clearing. You also hear a murmur. He denies alcohol, tobacco, or drug use. He also denies recent travel. 1. Based on the likely diagnosis, what is the best treatment option? a) Ciprofloxacin + Ceftriaxone + Rifampin b) IV Vancomycin only c) PCN + Gentamicin d) Ceftriaxone + Nafcillin 2. What additional test do you want to order?
1. c! PCN + Gentamicin 2. Echo (TTE FIRST, then TEE because it is more sensitive) The most likely diagnosis is subacute endocarditis. Since he does not have a hx of drug use, you can start the patient on PCN + Gentamicin (or Vanco). The erythematous macules are known as Janeway lesions. He also has splinter hemorrhages, Roth spots, and a new murmur. Osler nodes (painful purple nodules on pads of digits) are also common). Think: FROM JANE (fever, roth spot, osler notes, murmur, janeway lesions).
Patient presents w/ CC of fever and joint pain x 4 days. He notes that he noticed a rash appear on his chest and arms, as well. On PE, you note several swollen joints that are warm and red. He states that the pain started on his legs, but now are primarily in the upper extremities. He has a macular, erythematous, annular rash w/ sharply demarcated borders. He denies itchiness. He admits to "feeling sick" w/ a sore throat a few weeks prior. 1. What is the most likely diagnosis? a) Endocarditis b) Scarlet Fever c) Rheumatic Fever d) Rubella 2. How would you treat?
1. c! Rheumatic Fever 2. PCN G (and ASA) This patient is experiencing migratory polyarthritis and erythema marginatum. He also has a fever (which is one of the minor criteria). This is primarily caused by GABHS (2-6 wks prior).
Patient presents w/ nasal congestion and facial pressure x 2 weeks. She states that he has facial pain worse w/ bending down and purulent nasal discharge. 1. What is the most common causative agent? a) Moraxella Catarrhalis b) Hemophilus influenzea c) Streptococcus pneumoniae d) Staphylococcus aureus 2. What is the treatment of choice? a) Cefdinir b) Augmentin c) Doxycycline d) Bactrim
1. c! Streptococcus pneumoniae 2. b! Augmentin This is most likely bacterial rhinosinusitis. It often follows a URI.
Patient presents w/ palpitations and heat intolerance x 1 month. He states that he has been constantly sweating. On PE, you note exophthalmos, proptosis, and swollen red patches on legs. He has a diffusely enlarged non-tender thyroid w/ a bruit. 1. What is often associated w/ this disease? a) antithyroid peroxidase b) increased cortisol levels c) TSH-receptor antibodies d) substantial weight gain 2. What is the first line treatment? a) ablation b) methimazole c) transsphenoidal surgery d) levothyroxine
1. c! TSH-receptor antibodies 2. b! methimazole Methimazole and PTU will prevent thyroid hormone synthesis. PTU is preferred in thyroid storm or pregnancy. Can also use BB or glucocorticoids. Think Grave's if an elderly patient has new onset Afib.
30 y/o male patient presents with patches of hair loss with black dots on his head. He has no family hx of hair loss. He has no significant medical history. 1. What is the most likely diagnosis? a) Alopecia areata b) Androgenic alopecia c) Tinea capitus d) Intertrigo 2. Based on this diagnosis, what is the first line treatment? a) Oral Griseofulvin b) Oral Fluconazole c) Topical Minoxidil d) Intralesional corticosteroids
1. c! Tinea capitus 2. a! Oral Griseofulvin You would diagnose this w/ a KOH prep. Alopecia areata presents somewhat similarly, but it is autoimmune disorder associated w/ exclamation point hairs. It is also commonly associated w/ other AI diseases.
1. What is the most common skin eruption caused by "bright-red" macules and papules that coalesce to form plaques 2-14 days after a new medication initiation? 2. What type of reaction is this?
1. exanthematous or morbilliform rash 2. Type IV
Patient presents w/ a dry, rough, and erythematous macular rash that "feels like sandpaper". It has a small projection that you recognize as a cutaneous horn. Upon biopsy, you find atypical epidermal keratinocytes. 1. This is a premalignant skin condition known as what? a) Seborrheic keratosis b) Molluscum Contagiosum c) Lichen Planus d) Actinic keratosis 2. How would you treat?
1. d! Actinic keratosis 2. Cryotherapy (for singular lesion) or Imiquimod (for multiple lesions) Diagnose via punch biopsy.
1. What is the gold standard for diagnosing T1DM? a) 2-Hour glucose tolerance tolerance test b) Hemoglobin A1c c) Random plasma glucose d) Fasting plasma glucose 2. What is the first step in treatment? a) Insulin b) Metformin c) Nateglinide d) Glipizide
1. d! Fasting plasma glucose 2. a! Insulin These patients often first present in DKA. Fasting plasma glucose > 126 indicates diabetes. 2h GTT > 200, A1c, > 6.5, and random plasma glucose > 200 is also indicative.
Patient presents with fever, jaundice, and tender hepatomegaly. Labs show mallory bodies, and increased AST (2x ALT). Based on the likely diagnosis, how would you want to treat this patient? a) Lactulose b) Spironolactone c) Metoprolol d) Thiamine (B1)
1. d! Thiamine (B1) This is likely alcoholic liver disease. Patients can develop Wernicke Encephalopathy, where they develop confusion, cerebellar ataxia, oculomotor disturbance, and peripheral neuropathy.
What are the best treatment options for hypertensive emergency associated w/ the following: 1. neurologic symptoms 2. aortic dissection 3. ACS
1. nicardipine or labetalol 2. beta blocker 3. nitroglycerin
1. What is the MC cause of senorineural hearing loss? What are the Rinne and Weber findings? 2. What is the MC cause of conductive hearing loss? What are the Rinne and Weber findings?
1. presbycusis; weber lateralizes to normal ear and Rinne AC > BC 2. cerumen impaction; weber lateralized to affected ear and Rinne BC > AC in affected ear
What is the difference between Diabetes Type 1A and Type 1B?
1A: autoimmune and absolute 1B: non-autoimmune and relative
What is the A1C goal for DM patients?
< 7
Patient has a large pupil that does not constrict with light but responds to accommodation?
Adie's pupil
How would you treat papilledema (blurring of optic disc d/t malignant HTN)?
Acetazolamide
Patient presents w/ ear pain, fullness, and moderate hearing after flying on a plane. What is this?
Barotrauma
Patient presents w/ weight gain and proximal muscle weakness. You notice that the patient has central obesity and a roundly shaped face w/ facial puffiness. He has striae on his abdomen. You notice a buffalo hump. How do you diagnose this?
Dexamethasone suppression test If both the low and high dose suppression have no suppression, it is Cushing Syndrome. If low dose has no cortisol suppression, but there is suppression on high dose, it is Cushing disease (d/t pituitary).
What is the only Fibrate approved for combination with a statin?
Fenofibric acid
What is the treatment of post-herpetic neuralgia?
Gabapentin This can be prevented w/ VZV vaccine.
What are the LeFort Classifications (I, II, and III)
I: maxilla II: maxilla, nasal bones, medial orbit III: maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base
What is the difference between Erythema Multiforme major and minor?
Minor: no mucosal involvement Major: mucosal involvement
What can you give a patient with alcohol dependence?
Naltrexone Will have CAGE screening.
Trauma patient has facial malocclusion. They present w/ mandibular pain, tenderness, and ecchymosis in the floor of the mouth. You suspect a mandibular fracture. What do you need to get to diagnose?
Panoramic X-rays or AP & lateral You should get this for mandibular fractures.
How do you treat a patient in DKA?
SIPS saline --> insulin --> potassium --> search for cause
What is the difference between hypertensive urgency and hypertensive emergency?
Urgency: BP > 180/120 without evidence of end organ damage Emergency: BP > 180/120 with evidence of end organ damage (ex. stroke, encephalopathy, ACS, etc.) HA is the most common sx of both.
How do you treat Aortic Stenosis?
aortic valve replacement is the only effective tx In young patients, think bicuspid aortic valve. In older patients, think calcified valve.
Patient presents w/ areas of hypopigmentation on his back that have gotten more prominent in the summertime. On KOH prep, you note hyphae & spores in a "spaghetti and meatball" appearance and yellow-green fluorescence on Wood's lamp. 1. Based on the most likely diagnosis, what is the treatment? a) Griseofulvin b) Selenium Sulfide c) Topical corticosteroids d) Self-limiting
b! Selenium Sulfide Based on the findings, the most likely diagnosis is tinea versicolor. If systemic therapy is needed, an -azole can also be used.
40 y/o woman presents w/ fatigue x 1 month. She has been feeling itchy and her states that her stomach has been aching. You note mild jaundice and hepatomegaly. Labs show increased alkaline phosphatase and GGT. She has (+) AMA antibody. How would you treat? a) Thiamine b) Ursodeoxycholic acid c) Diazepam d) Symptomatic treatment
b! Ursodeoxycholic acid This is a case of primary biliary cirrhosis.
What is the most important lab to determine the severity of DKA?
bicarbonate
67 y/o patient presents w/ new onset Afib. She has a history of HTN, HLD, and T2DM. Based on this information, what is her CHA2DS2-VASc score to determine her risk for embolization? a) 9 b) 6 c) 4 d) 2
c! 4 This patient should be on anti-coagulation, as patients w/ score > 2 are at high risk. The criteria is as follows: CHF (1), HTN (1), Age > 75 (2), DM (1), Hx of stroke or TIA (2), Vascular dz (1), Age 65-74 (1), Female sex (1) This patient has HTN (1), DM (1), is a female (1), and is 67 y/o (1); therefore, she has a score of 4.
What is the MCC of blindness in the world that is characterized by lens thickening and slow, progressive vision loss over months to years and absent red eye reflex? a) Retinal Detachment b) Macular Degeneration c) Cataract d) Diabetic Retinopathy
c! Cataract
60 y/o patient presents w/ sudden monocular vision loss x 1 hour. He has a history of atherosclerotic disease. On fundoscopic exam, you see a pale retina w/ a cherry red macular and segmental blood flow of the retinal vessels. What is the most likely diagnosis? a) Central Retinal Vein Occlusion b) HTN Retinopathy c) Central Retinal Artery Occlusion d) Macular Degeneration
c! Central Retinal Artery Occlusion Treatment involves CO2 rebreathing, 100% oxygen, or ocular massage.
Patient presents w/ confusion and lethargy. You notice a flapping tremor w/ wrist extension. Labs show increased ammonia. What is the treatment of choice? a) Mannitol b) Spironolactone c) Lactulose d) Cholestyramine
c! Lactulose This is a case of hepatic encephalopathy. Spironolactone (and Na) can treat ascites.
Patient presents w/ history of MS presents unilateral painful loss of central vision over the last 5 hours. Swinging the light from unaffected to affected eye will cause the pupils to dilate. Based on the most likely diagnosis, how would you want to treat? a) Acetazolamide b) 100% oxygen c) Methylprednisolone d) Acyclovir
c! Methylprednisolone This is likely optic neuritis. IV methylprednisolone is indicated. Swinging the light from the unaffected to affected eye will cause the pupils to dilate is known as "Marcus Gunn pupil".
Which of the following DM medications inhibits the breakdown of incretin hormones? a) Miglitol b) Canagliflozin c) Sitagliptin d) Glimepiride
c! Sitagliptin These are the DPP-4 inhibitors (-gliptin)
What are the MC causes of cirrhotic liver disease (irreversible liver fibrosis w/ nodular regeneration)?
chronic Hepatitis C and alcohol May have ascites, caput medusa, hepatic encephalopathy, or esophageal varices.
What is the best treatment option for hypertensive urgency? What is a common complication of this medication?
clonidine (no more than 25% in 24-48 hrs); rebound HTN
What is the most commonly affected area for acute rhinosinusitis?
maxillary sinuses
What is the first sign of nephropathy in diabetes patients?
microalbuminuria
Patients has bilateral small pupils. The pupil constricts on accommodation but does not react to bright light. What do they most likely have?
neurosyphilis
What is the abnormal bony overgrowth of the stapes that causes conductive hearing loss?
otosclerosis Can treat w/ stapedectomy.
How do you treat Mitral Stenosis?
percutaneous balloon valvuloplasty is the best tx for symptomatic younger patients w/o calcification, but valve replacement may be necessary
How do you treat Mitral Regurgitation?
symptom control (ACEIs, Hydralazine, Nitrates) and repair of valve
What is the main complication of Rheumatic Fever?
valvular disease (mostly mitral)