NBME Step 2 Form 8
In addition to preoperative antiseptic skin prep and sterile surgical technique, prophylactic antibiotics can help reduce surgical site infections Administered prior to incision, prophylactic antibiotics reduce the microorgansim burden at the surgical site and are indicated when there is a high risk of infection (trauma tic wounds) or when infection would cause signficant morbidity/mortality For clean wounds (cardiac, neurological , orthopedic, vascular) What are the microorganisms to worry about What antibiotic prophylaxis should you use
- Skin flora : Strep, Staph aureus, coagulase neg staph First line: Cefazolin Alternatives in case of allergy: Vancomycin/Clindamycin
What are symptoms of acute cellular rejection? When does it occur? When is it often suspected (lab findings) How do you make definitive diagnosis?
- some pts have fevers, malaise, lethargy, but many are asymptomatic - within the first three months after transplant, results from the patient's own immune system targeting the allograft - LFT abnormalities (eg rise in aminotransferases, bilirubin, and alk phos) - def dx with liver biopsy - mixed inflammatory infiltration of the portal tracts involving eosinophils, neutrophils, and lymphocytes - interlobular bile duct destruction (often called nonsuppurative cholangitis) - endotheliitis (ie lymphocytic subendothelial invasion of the portal and hepatic veins) - most reliable
Third degree AV block (complete heart block)
-Rhythm: atrial-regular, ventricular-regular -every P has a QRS - no relationship between P waves and QRS complexes, independent rhythms -rate - atrial-60-100 bpm, ventricular- 15-60 bpm -PR interval - not measurable -QRS length - WNL if junctional escape rhythm, >0.12 sec if ventricular escape rhythm -ST segment - ST segment and T wave may be abnormal, depending on location of block TX: immediate pacemaker therapy.
What are endometrial polyps?
-sessile: no stalk -pedunculated: stalk -projections of over grown endometrium -can cause infertility
Older patient with fever, weight loss, and hemoptysis. CXR reveals suspicious lesion. CT scan confirms lung cancer. Other than biopsy, which three steps should be performed next?
1. Stage cancer with PET-CT 2. PFTs 3. Chemo, radiation, and/or surgery
{{c1::Tetralogy of Fallot}} is a congenital heart disease that is characterized by:
1. {{c2::Pulmonary infundibular stenosis}} 2. {{c3::Right ventricular hypertrophy}} 3. {{c4::Overriding aorta}} 4. {{c5::Ventricular septal defect (VSD)}} mnemonic: PROVe; overriding aorta is the positioning of the aorta directly over the VSD
Steatohepatitis (NASH) - what do you see on biopsy - AST:ALT ratio - Best test
AST/ALT ratio <1 An obese pt presents w/ s/s of cirrhosis. Workup for all common etiologies is unfruitful. You suspect NASH. What is the best diagnostic test? {{c1::Bx}, but do US first }
What is the likely diagnosis in a sexually active woman that presents with postcoital bleeding and mucopurulent discharge with a friable cervix on pelvic examination?
Acute cervicitis
Read this question
After birth, the ductus arteriosus normally closes within two or three days. In premature infants, the connection often takes longer to close. If the connection remains open, it's referred to as a patent ductus arteriosus. The abnormal opening causes too much blood to circulate to the baby's lungs and heart.
How do patients with secondary angiosarcoma present? Hx of illness? Strongest risk factor
Angiosarcomas are relatively rare maglinant tumors derived from the internal lining of blood vessels or lymphatic vessels Primary angiosarcoma can occur anywhere in the boyd (eg liver, breast) but angiosarcoma secondary to breast cancer therapy is typically confined to the skin Patients present with multiple ecchymoses or purpuric masses on the skin of the breast, axilla, or upper arm 4-8 years following completion of breast cancer therapy The majority of patients received localized radiation therpay, which is the strongest risk factor
RMSF
Dog/wood tick bite, spirochete called Rickettsia rickettsia. Treatment with doxycycline 100mg PO/IV for minimum of 7 days
Patients with severe penicillin allergy should receive what treatment for syphilis
Doxy for two weeks
How do you diagnose C diff
PCR detection of Toxin A and B genes in stool
Why do kids with tetralogy of fallot squat
Patients with Tetralogy of Fallot may {{c1::squat}} in response to cyanotic spells, which decreases right-to-left shunting by increasing {{c2::systemic vascular resistance (SVR)}} inhaled O2 may help stimulate pulmonary vasodilation and systemic vasoconstriction, which can further decrease right-to-left shunting
A person with a simple breast cyst : what do you do and when do you do more
Patients with a symptomatic simple breast cyst can undergo fine needle aspiration for pain relief Further management depends on the results of hte FNA If the aspirated fluid is clear (not bloody) and the breast mass reolves completely...patients are at low risk for cancer and may undergo observation with a repeat breast exam in 4-6 weeks If the fluid is bloody or the mass does not resolve (remains palpable)...patients are at increased risk for breast cancer and require core needle biopsy which can provide definitive histologic diagnosis
What is the next step in diagnosis for a woman that presents with stress urinary incontinence with an irregularly enlarged uterus on physical exam?
Pelvic ultrasound
What is the likely diagnosis in an IV drug abuser with fever, an early diastolic murmur (left sternal border), and 2nd-degree AV block?
Perivalvular abscess (secondary to aortic valve endocarditis development of AV block in a patient with IE should raise suspicion for perivalvular abscess extending into adjacent cardiac conduction tissues
Patient with metastatic breast cancer suddenly has hypotension/orthostasis and hyperkalemia and hyponatremia Diagnosis?
Primary Adrenal Insufficiency Adrenal glands are a common site of metastatic cancer spread, especially for primary tumors of the lung, breast, kidney, and skin
Patients with Tetralogy of Fallot often experience "{{c1::tet}} spells" which may be caused by crying, fever, and exercise due to exacerbation of
RV outflow tract obstruction
What is the likely diagnosis in a child that presents with generalized erythema, fever, and superficial flaccid bullae with a positive Nikolsky sign?
Staphylococcal scalded skin syndrome typically a self-resolving process that only requires supportive care; the Nikolsky sign is positive if gentle lateral pressure on the skin surface causes detachment of the superficial skin
Which congenital infection is associated with rhinorrhea, desquamating skin rash, and hepatomegaly?
Syphilis also may have abnormal long-bone radiographs
Acute renal allograft rejection is predominately a __ cell mediated response to antigens within the donor kidney When it occurs it is most commonly wthin the first ____ (time) Diagnostic confirmation requires renal biopsy, which characteristically reveals... What is a key clinical presentation
T cell mediated first 6 mo Lymphocytic infiltration of the intima with inflammatory tubular disruption. Intimal arteritis is often present as well . Look for an asymptomatic rise in creatinine
Specificity equation
TN/(TN+FP)
A 24-year-old male who just moved to town for a new job presents to your office with a 2-week history of a rash. His previous medical records are not available. The physical examination reveals pink, scaling papules and plaques on the trunk and proximal aspect of the arms and legs. You suspect pityriasis rosea. To complete the diagnostic evaluation you should order (check one) A. a fungal culture B. heterophile antibody testing C. a platelet count D. a rapid plasma reagin (RPR) test E. a TSH level
The differential diagnosis of multiple small scaling plaques includes drug eruptions, secondary syphilis, guttate psoriasis, and erythema migrans. If the diagnosis cannot be made conclusively by clinical examination, a test for syphilis should be ordered. The rash of secondary syphilis may be indistinguishable from pityriasis rosea on initial examination, particularly when no herald patch is noted. The rashes associated with hyperthyroidism, infectious mononucleosis, idiopathic thrombocytopenic purpura, and fungal infections are not in the differential diagnosis for this patient.
What is the cause of adenomyosis
The presence of endometrial tissue (endometriosis) in the uterine myometrium is known as {{c1::adenomyosis}}
Positive Predictive Value (PPV)
The proportion of patients/clients with a positive test result who have the condition of interest
Membranous nephropathy - what do you see - etiologies
Thick glomerular basement membrane on H&E, due to immune complex deposition. , Immune complexes deposit SUBEPITHELIALLY. They have a granular immunofluorescence and a ________ appearance on EM. This is because epithelial cells lay down basement membrane when they get pushed off by immune complexes. - Adenocarcinoma (breast and lung) - NSAIDS - HBV - SLE
What is the recommended treatment for localized non-bullous impetigo?
Topical antibiotics (e.g. mupirocin oral antibiotics (e.g. cephalexin, clindamycin) are indicated for widespread non-bullous impetigo or extensive bullous impetigo
Which breast cancer chemo drugs cause dose dependent and independent CHF
Trastuzumab : CHF, REVERSIBLE, EARLY DOXORUBICIN: CHF, IRREVERSIBLE, LATE
Treatment of SIADH
Water restriction If hyponatremia is severe then use hypertonic saline and loop diuretics. Persistent hyponatremia should be treated with demeclocycline or conivaptan
Treatment for carpal tunnel syndrome
What is the next step in management for a patient with suspected carpal tunnel syndrome? There is no thenar or hypothenar atrophy on physical exam. {{c1::Wrist splinting}} glucocorticoids and/or decompression surgery may be considered in patients with significant weakness or refractory symptoms
Preferred treatment for breast cancer with estrogen receptor positive cancer : pre and post menopausal
What is the preferred adjuvant treatment for ER+ breast cancer in postmenopausal women? {{c1::Aromatase inhibitors (e.g. anastrozole)}} What is the preferred adjuvant treatment for ER+ breast cancer in premenopausal women? {{c1::Tamoxifen}}
What do you do to diagnose PE in a high probability setting
What is the test of choice to diagnose pulmonary embolism in clinically stable patients with a high likelihood of PE (modified Wells > 4)? {{c1::CT angiography}} Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism.
pneumoconiosis(-es) Which interstital lung diseases are associated with occupational exposures? {{c1:_______________}, which is caused by inhalation of coal dust and associated with Caplan Syndrome (rheumatoid arthritis) {{_______________}}, which presents with pleural plaques on CXR and ↑risk for bronchgenic adenocarcinoma and malignant mesothelioma {{_____________}}, which is caused by rock dust and sand blasting, presents with upper lobe nodules, and can lead to TB {{__________}, which can present with skin lesions and ↑Ca2+
Which interstital lung diseases are associated with occupational exposures? {{c1::Coal worker's pneumoconiosis}}, which is caused by inhalation of coal dust and associated with Caplan Syndrome (rheumatoid arthritis) {{c2::Asbestosis}}, which presents with pleural plaques on CXR and ↑risk for bronchgenic adenocarcinoma and malignant mesothelioma {{c3::Silicosis}}, which is caused by rock dust and sand blasting, presents with upper lobe nodules, and can lead to TB {{c4::Berylliosis}}, which can present with skin lesions and ↑Ca2+
What is the treatment for Tourette
alpha-agonists (e.g. clonidine, guanfacine) the only FDA approved drugs are the first-generation antipsychotics haloperidol and pimozide; second-generation antipsychotics (e.g. risperidone) are increasingly preferred due to favorable side effect profile What is the most effective nonpharmacological treatment for Tourette disorder? {{c1::Habit reversal training (a form of CBT)}}
How do you diagnose pericarditis
besides EKG, echo!
Evaluation of atypical glandular cells on Pap test in women > 35 years old includes What cancer(s) are associated with atypical glandular cells on Pap testing? Which is more cancerous : AGC-NOS ( atypical glandular cells not otherwise specified) or HSIL
colposcopy, {{c1::endocervical curettage}}, and {{c1::endometrial biopsy}} {{c1::cervical and endometrial adenocarcinoma}} AGC-NOS
Psychogenic Polydipsia diagnosis
contrast with SIADH Note that you are euvolemic
The three etiologies of breast cancer
estrogen RADIATION GENES
Basis of AMS in a patient with HHS
hyperosmolality
Besides sun/UV light, what are other risk factors for squamous cell carcinoma of skin
immunosuppression chronic scars/wounds/burn injuries
Mobitz Type I (Wenckebach)
progressive lengthening of PR interval until a beat is 'dropped' (P wave not followed by a QRS complex) usually asymptomatic group beating
neurogenic bladder causes
stroke, spinal cord injury, Parkinson's, MS, peripheral neuropathies
What type(s) of fibroids are most associated with heavy menstrual bleeding and/or recurrent pregnancy loss?
submucosal and intracavitary fibroids (leiomyomata)
What type(s) of fibroids are most associated with bulk-related symptoms and irregular uterine enlargement?
subserosal and pedunculated fibroids (leiomyomata) e.g. constipation, incomplete voiding, pelvic pressure
The symptoms of cardiac tamponade are due to what
symptoms are due to an exaggerated shift of the interventricular septum toward the left ventricular cavity (decreases LV preload, SV, and CO) - Distant heart sounds - Distended jugular veins - decreased arterial pressure
What is the recommended treatment for adults with scabies?
topical permethrin or oral ivermectin
Treatment of heart problems due to cocaine
treatment is similar to NSTEMI due to other causes except beta blockers are avoided and IV benzodiazepines are administered (alleviates psychomotor agitation and sympathomimetic effects)
What is the likely diagnosis in a women age > 30 with a well-circumscribed, soft, mobile breast mass?
{{c1::Breast cyst (benign)}} breast cysts are soft and most common after age 30, versus a fibroadenoma, which is hard and most common before age 30
What primary CNS tumor is associated with Homer-Wright rosettes?
{{c1::Medulloblastoma}}
Menopausal women with vasomotor symptoms and contraindications to HRT are typically managed with non-hormonal therapy, such as
{{c1::SSRIs}} contraindications include history of coronary heart disease, thromboembolism, TIA/stroke, breast cancer, or endometrial cancer
What is the single most important prognostic consideration in the treatment of patients with breast cancer?
{{c1::Tumor burden (based on TNM staging)}}
Treatment of a patent ductus arteriosus involves ___________ which ___________-, resulting in PDA closure when should you shop giving these in pregnancy
{{c1::indomethacin}}, decreases PGE When can NSAIDs be given until in preg? Why must they be stopped at this point? 32 weeks Risk of premature closure of ductus arteriosus
Uncorrected patent ductus arteriosus may eventually result in late cyanosis in the_______ extremities
{{c1::lower}} In the neonatal period, a patent ductus arteriosus becomes a {{c1::left}}-to-{{c1::right}} shunt as pulmonary vascular resistance decreases
The degree of shunting in Tetralogy of Fallot is determined by the degree of
{{c1::right ventricular outflow tract obstruction (from pulmonary stenosis)}}
What is the next step in management for a postmenopausal woman with a suspected granulosa cell tumor that presents with vaginal bleeding and a thickened endometrial stripe on ultrasound?
Endometrial biopsy
What is the classic clinical picture of adenomyosis Classic age etc
Enlarged, boggy, soft, uterus presents with dysmenorrhea, menorrhagia, and a uniformly enlarged, soft, globular uterus Adenomyosis typically causes dysmenorrhea and heavy menstrual bleeding in multiparous women > {{c1::40}} years of age new-onset dysmenorrhea in later reproductive years is classic
Fibroids - benign _____ growths - non malignant - _________ responsive What hormone causes fibroids to grow? What medication can be given to keep them from growing?
Estrogen Gonadotropin-releasing hormone agonists
PFTs in asthma
FEV1 decreased FVC normal TLC increased
What is the next step in management for an adolescent that presents with a tender breast mass a few days prior to menstruation?
Follow-up after menses}} What is the next step in management for a healthy adolescent male that presents with tender, subareolar masses on both breasts? {{c1::Reassurance and follow-up}} pubertal gynecomastia is seen in up to 67% of pubertal boys and typically resolves without treatment in a few months to years
Deficiency of serum glucuronosyltransferase What type of bilirubin For the mild version, what are the liver labs like
Gilbert's Disease Unconjugated Hyperbilirubinemia - Think hemolysis or Gilbert/Crigler-Najjar - Crigler-Najjar is typically fatal early on (total enzyme deficiency) - Gilbert becomes apparent when the body is under stress (e.g. infection, dehydration, etc.) - Whatever the cause, bilirubin is not being conjugated, causing a build up of indirect bilirubin - Urine will not be dark as indirect bili is not renally excreted
What medical therapy may be used for short-term treatment of symptomatic fibroids refractory to OCPs and NSAIDs? Should asymptomatic relatively small fibroids be treated?
GnRH agonists (e.g. leuprolide)} not recommended for more than 3 - 6 months; typically used before a hysterectomy or to bridge a woman close to menopause THEY SHOULD NOT BE TREATED
Treatment for adenomyosis
GnRH agonists, hysterectomy
What is the most common side effect of GnRH agonist therapy for fibroids? What happens after they are stopped?
Hot flashes Return of menses (4-10wks), return of myoma and uterus to pretreatment size
What is the likely diagnosis in an afebrile middle-aged woman that presents with unilateral breast warmth, erythema, and swelling refractory to antibiotics?
Inflammatory breast carcinoma lack of fever and no response to antibiotics help distinguish inflammatory breast cancer from mastitis; other distinguishing features include axillary lymphadenopathy and a peau d'orange appearance
Which neuromuscular junction pathology, MG or LEMS, is characterized by diminished or absent deep tendon reflexes?
Lambert-Eaton myasthenic syndrome helps differentiate LEMS from myasthenia gravis (preserved reflexes); other symptoms of LEMS include symmetric proximal muscle weakness and autonomic dysfunction
UGHHH WHAT IS THE TREATMENT OF ASYMPTOMATIC MS
Long-term treatment of multiple sclerosis with {{c1::interferon beta}} slows progression of disease; other options include glatiramer and natalizumab What is the role of interferon beta or glatiramer acetate in patients with MS: relapsing-remitting or secondary, progressive forms of MS No role in the treatment of acute exacerbations
What kind of symptoms would you see with a black widow spider bite
Muscle pain ( a prominent finding), abdominal rigidity (sometimes mimicking a surgical abdomen), and muscle cramps (seen in more than 60% of patients) Also nausea and vomiting
What is the recommended treatment for a young patient with infertility secondary to fibroids?
Myomectomy indicated if the fibroids are of sufficient size or location to be a probable cause of infertility
Blockage of which dopamine pathway is responsible for extrapyramidal symptoms in patients taking antipsychotics?
Nigrostriatal pathway
symptoms of cataracts
Blurred-hazy vision, halo around lights, Yellow, white, or gray discoloration of pupil, gradual loss of vision.
Shape of heart in tetralogy of fallot and why
Boot bc of RV hypertrophy
Bug bite - which bug? Small ulcer developing at the site of a recent bit that happened when the patient was putting her clothes on Eventually a deep skin ulcer develops at the site of bite with an erythematous halo and a necrotic center which can progress to an eschar
Brown recluse spider
Coal miner presents with shortness of breath and dry cough. Upon further questioning, he also complains of arthralgias. Diagnosis?
Caplan Syndrome -Should confirm by checking for Rheumatoid Factor or Anti-CCP Ab A pt w/ rheumatoid arthritis presents w/ pneumoconiosis and lung nodules. What is the dx? {{c1::Caplan syndrome}}
In what diseases/conditions can you see pellagra
Carcinoid syndrome (due to depletion of tryptophan) or Hartnup disease (congenital disorder of tryptophan absorption). Prolonged isoniazid therapy. Niacin is present in a broad variety of foods and can be synthesized endogenously from tryptophan. In developing countries, niacin deficiency is seen in populations that subsist primarily on corn products. It is primarily seen in patients with impaired nutriotional intake (alcoholism, chronic illness).
What is the preferred method of contraception for patients with breast cancer?
Copper IUD
