Step 3 Uworld
What are the causes of abnormal uterine bleeding?
"PALM COEIN" polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
What is the incidence rate?
# new cases in a specified time period / population at risk during same time period
Pregnant woman with truncal rash. Cause?
*pemphigoid gestationalis* - autoimmune dz presents in 2nd or 3rd trimester with pruritis that precedes truncal rash - periumbilical, urticarial papules and plaques that develop into vesicles and bullae - treat with high potency topical steroids and antihistamines
What are the clinical features of thyrotoxicosis in older patients?
- Cardiac: afib, tachycardia, HF - Neuro: apathy, *confusion*, tremor, prox muscle weakness - Endocrine: proptosis, lid lag, thyromegaly - GI: dec appetite, constipation
How do you treat candida diaper dermatitis?
- beefy red rash involving skin folds with satellite lesions - topical antifungal therapy
Massive transfusion, then perioral tingling and cramping of hands. Next step?
- give calcium gluconate - PRBC transfusions have citrate which can bind calcium - iCal required for diagnosis, usually serum Ca wnl
What is a contraindication to the use of OCPs?
- migraine with aura - >15 cig/day and age >35yo - HTN >160/100 - heart disease - DM2 with end organ damage - h/o thromboembolic disease, stroke - antiphospholipid antibody syndrome - breast cancer - cirrhosis - major surgery and immobilization
How do you treat contact diaper dermatitis?
- spares creases/folds - rx: topical barrier ointment/paste (petroleum, zinc oxide)
Screening for gestational diabetes?
-24-28 wks with a 1 hour glucose tolerance test - use a fasting glucose and a one-hour glucose following a 50g glucose load - if fasting >126 OR one-hour glucose is greater than 140 then the patient is considered to have a positive result - if positive the pt should undergo a three-hour GTT with 100g glucose load
How to screen for lead poisoning?
1) fingerstick capillary levels 2) confirm with venous lead levels if capillary lead elevated 3) chelation
Treatment of asymptomatic lead toxicity
5-44, mild, no rx 45-69, moderate, rx with succimer >70, severe, rx with dimercaprol + EDTA
Who should get statin therapy?
ALL patients age 40-75 with DM2 who have baseline LDL > 70
28yo M with palpitations. II/VI mid systolic murmur at LUSB. RA and RV dilation. Cause?
ASD - L to R shunt, wide fixed splitting of S2
What is the next step after biochemical confirmation (metanephrines) for a pheochromocytoma?
Abdominal imaging (CT or MRI); pts w/neg abd imaging usually require further testing, such as the metaiodobenzylguanidine scan
T/F: Stimulant therapy are associated with increased incidence of substance use
FALSE
3 day old boy with anemia and really high indirect bili. DAT negative. Cause?
G6PD deficiency - presents in the neonatal period on day of life 2-3 with unconjugated hyperbilirubinemia and anemia
Vaccines for HIV infected patients?
HAV - chronic liver dz, MSM, IVDU HBV - all pts without immunity HPV - all pts 11-26yo Flu - annually Meningococcus - all pts Pneumococcus - PCV13 once, PPSV23 Tdap - once, then every 10 yrs
60yo w/HTN, started new med. Went on a summer trip, now with erythematous rash on exposed parts of body. Med?
HCTZ; photosensitivity reaction
Nontender lump on neck, 2cm white plaque on R inner cheek, scraped and showed hyperemia. Next step?
HIV testing since pt has oropharyngeal candidiasis
What is the first line contraceptive method for adolescents?
IUDs
Patients with syphilis + neuro sx require what prior to treatment?
LP to rule out neurosyphilis
What are the first stages of labor?
Latent phase: From beginning of regular contractions to 6 cm cervical dilation; characterized by slow cervical change. Active phase: From 6 cm to 10 cm (complete) cervical dilation; characterized by rapid (>1 cm/2 hr) cervical change. Active phase protraction is defined as cervical dilation ≤1 cm/2 hr. give oxytocin
How to diagnose urethral diverticulum?
MRI of the pelvis or transvaginal ultrasound
55yo M w/hx chronic back pain; 3wk h/o of progressive R shoulder pain and 1wk h/o worsening back pain. CXR with R superior lobe mass. What addt finding would have worse prognosis?
RLE hyperreflexia - *Pancoast tumor*; shoulder pain, Horner syndrome, hand muscle atrophy and weakness - asymmetric LE reflexes suggest that tumor has spread to the spinal cord
What is the 'power' of a study?
ability to detect a difference between groups when such a difference truly exists
What do you see on endoscopy if someone has pernicious anemia?
absent rugae in fundus - pernicious anemia is assoc with gastritis called autoimmune metaplasmic atrophic gastritis - main components are glandular atrophy, intestinal metaplasia, and inflamm
23yo M s/p MVA. Now SOB, diminished breath sounds. Best test?
bedside US - test of choice for dx pneumothorax in trauma setting - high sensitivity/specificity and rapidly performed - inability to detect lung sliding is c/w pneumothorax
Most likely cause of 10mth old's anemia?
breast milk predominant diet - hgb <11, low MCV, metzler index (MCV/RBC) > 13
What are the Centor criteria?
clinical features most suggestive of strep throat (FLEA) f - fever l - lack of cough e - exudate a - anterior cervical adenopathy
47yo M w/2wk hx of rash. Dx with HIV, not on HAART. Multiple small papules with central umbilication on face, neck, trunk, upper thighs. Some of the lesions have central necrosis and hemorrhagic crust. Dx?
cutaneous cryptococcosis - biopsy of the lesion would show hyperplasia of the dermis with underlying granulomas surrouding encapsulated yeasts - treat with >2 weeks of amphotericin B and oral flucytosine then year of oral fluconazole
26yo F with fever, neck pain, neck tenderness, elevated ESR, TSH undetectable, free T4 high. Radioactive iodine will show what?
decreased uptake - subacute thyroiditis; postviral inflammatory process, release of stored thyroid hormone - treat with NSAIDs and a beta blocker since it is caused by release of preformed thyroid hormone so methimazole/PTU won't help
What are the symptoms of disseminated gonoccocal infection?
dermatitis, tenosynovitis, polyarthralgias
Reactive arthritis - what is the most likely finding?
elevated WBCs in synovial fluid with negative bacterial culture
53yo F, postmenopausal. Next step?
encourage calcium and vit D intake - recommended daily allowance is Ca 1200mg/day and vit D 600-800U
26yo M with 5yr hx of asthma. CT shows central bronchiectasis and RLL infiltrate. Review of prior CXRs shows lingular infiltrate and LLL infiltrate. Cause?
exaggerated IgG and IgE response to antigen - ABPA - hypersensitivity reaction in pts with asthma and CF - characterized by fleeting infiltrates, recurrent asthma exacerbations, central bronchiectasis
What are the risk factors for pyloric stenosis?
first born boy, erythromycin, bottle feeding
19yo M, MVA. Anterior chest bruises and peripheral cyanosis. Dx?
flail chest - tachypnea, tachycardia, shallow breathing, anterior chest bruises, cyanosis
What is first line therapy for bacterial conjunctivitis in *contact lens wearers?*
fluoroquinolones (pseudomonas) otherwise erythromycin ointment or polymyxin-trimethoprim drops
What to give for MTX induced macrocytic anemia?
folinic acid
54yo F recently dx with DM2. Started on forearm as small, elevated red area. Then became erythematous and itchy, didn't respond to topical steroids. Borders are elevated and crusty, also with angular cheilosis. Dx?
glucagonoma - *necrolytic migratory erythema*
65yo M w/severe HA localized to L frontal temporal region since 4 hrs ago. Also w/transient vision impairment in L eye. Constricted pupil. Next step?
head and neck CTA - L carotid artery dissection
Step up in oxygen sat between RA and RV. Phys exam finding?
holosystolic murmur at L sternal border - VSD, palpable thrill
When do you do GBS ppx in pregnancy for unknown status?
if pregnancy is preterm (<37wks), if they develop intrapartum fever, or rupture of membranes >18hrs - if they tested + GBS in last preg but neonate healthy, not a reason to give ppx!
When to start colonoscopy in patients at increased risk?
increased risk = 1st degree relative <60yo w/colon cancer OR >2 1st degree relatives w/colon cancer at any age - colonoscopy at age 40 or 10yrs prior to first dx - repeat every 3-5 years
First line rx for acute gout flare in pts with kidney dz?
intraarticular corticosteroids (if only 1 joint involved)
How do you treat a keloid?
intralesional glucocorticoids
What precautions for herpes zoster?
localized infection - standard precautions and lesion covering disseminated infection - standard precautions + contact + airborne
What is subclinical hyperthyroidism?
low TSH with nl thyroid hormone concentrations - those with increased risk due to age >65yo or comorbidities warrant consideration for treatment with antithyroid meds or radioactive iodine
How do you diagnose compartment syndrome?
lower extremity tissue pressures - pressure > 30mmHg
78yo M with decreased vision in both eyes and bilateral anterior cortical cataracts?
macular degeneration
Breakthrough seizure in kid with epilepsy. Next best step?
measure serum carbamazepine levels - nonadherence to meds
What is the first line treatment for toxic megacolon?
medical management to lessen degree of colitis, *glucocorticoids*
How do you diagnose Tourettes?
multiple motor and vocal tics present >1yr
Difficulty swallowing solids then liquids. Dx step?
nasophayngeal laryngoscopy
Symptoms of vasovagal syncope?
nausea, pallor, and fatigue prodrome and after
Symptoms of salicylate toxicity?
nausea, vomiting, tachypnea with resp alkalosis, lactic acidosis, hyperthermia, AMS
What antibiotics to use for a UTI in pregnancy?
nitrofurantoin, amoxicillin, augmentin, cephalexin, fosfomycin
How do you prevent the Jarish-Herxheimer reaction?
no prevention available but usually self limited to 48hrs
Can a tick transmit lyme disease if only attached a short time?
no, tick attached <36hrs does not have time to move borrelia to salivary glands - you can have cutaneous irritation from tick saliva
What screening to do for side effects of tamoxifen?
none, only do if symptoms develop
Elevated risk of ACS. Initial testing negative. Next step?
observe with repeat ECG and trop levels
What is the standardized mortality ratio?
observed # of deaths/expected # of deaths - usually used in occupational studies
What complication is most commonly associated with papulopustular rosacea?
ocular manifestations - recurrent chalazion
How do you treat opioid withdrawal?
opioid agonists - methadone, buprenorphine nonopioids - clonidine, antiemetics
Severe malnutrition. First step in management?
oral rehydration solution - avoid IVFs unless in shock since they can get volume overloaded
Anterior uveitis
pain, redness, variable vision loss, constricted/irreg pupil, visualization of leukocytes in anterior segment
How does keratitis present?
photophobia, blurred vision, foreign body sensation in the eye
What is Nelson's syndrome?
pituitary enlargement and hyperpigmentation following bilateral adrenectomy for Cushing's disease
7yo girl with epistaxis. Best next step?
place cotton pledget with topical vasoconstrictor - most epistaxis originates at Kisesslebach plexus; nostril pinching is first step - topical vasoconstrictor if that doesn't work
34yo M with pleural effusion that is adenosine deaminase +. HIV +. Next step in management for pleural effusion?
pleural biopsy; to diagnose TB
29yo pregnant woman with itching. Cause?
pregnancy induced skin changes - intense abd pruritis w/no primary skin lesions - treat with oatmeal baths, UV light exposure, antihistamines
What is the purpose of an "intention to treat" approach?
preserve randomization - intention to treat is the idea that participants in trials should be analyzed in the groups to which they were randomized - avoid the effects of crossover or dropout
10yo boy with Ca 6, albumin 3.8, phos 8.2, PTH 150. CT shows calcification of basal ganglia. Cause?
pseudohypoparathyroidism - end organ resistance to PTH
What complication is a patient at highest risk of developing post IVC filter placement?
recurrent DVT
Treated for urethritis but still has sx. Nest step?
repeat urethral swab and Gm stain -pts with nongonoccal urethritis freq have continued sx after azithromycin therapy due to reinfection or infection with Mycoplasma genitalium
What is sensitivity analysis?
repeating primary analysis calculations after modifying certain criteria or ranges; goal is to determine whether these modifications affect the results
HbA and HbS in 60:40 ratio
representative of sickle cell trait and not characteristic of anemia, usually asx
What is the most frequent complication of TURP?
retrograde ejaculation
PAD. What drug to add?
rosuvastatin - high intensity statin therapy - first line rx: supervised exercise program - cilostazol can be added for pts with persistent sx, then revascularization
Acute hep B infxn can present with what?
serum sickness like infection with dermatitis, fever, polyarthralgias due to circulating immune complexes
Pruritic rash, white lines in mouth, violaceous papules and plaques. Next step in dx?
skin biopsy; *lichen planus* has pruritic, polygonal, violaceous papules and plaques on the flexor surfaces of the extremities, Wickham striae on buccal mucosa lichen planus is assoc with hep C
What are the intervals for follow up colonoscopy after polypectomy?
small rectal hyperplastic polyps - 10 yrs small tubular adenomas - 5 years many adenomas OR adenoma >1cm OR adenoma with villous features - 3 years >10 adenomas - <3 years large sessile polyp - 2-6mths polyp w/adenocarcinoma - 2-3 mths
What would decrease likelihood of expansion of an aortic aneurysm?
smoking cessation
Newborn girl with tachypnea. Otherwise nl. Most likely outcome?
spontaneous resolution with no long term effect - transient tachypnea of the newborn; retained lung fluid after delivery - most common in babies born via Csection
Likelihood Ratio (LR)
summarize the relationship between sensitivity/specificity LR + = sensitivity / (1-specificity) LR - = (1-sensitivity) / specificity
How do you treat ocular melanomas?
surveillance exam if small radiation therapy if large
How do you treat hereditary hemochromocytosis?
therapeutic phlebotomy w/removal of 1U blood per week until iron stores normalize
How do you treat tinea pedis with onychomycosis?
topical antifungals but if that doesn't work, oral terbinafine
How do you treat papulopustule rosacea?
topical metronidazole
Chronic urticaria
treat with daily citirizine usually is self limited and resolves spontaneously within 2-5 years
Stress incontinence. Most likely cause?
urethral hypermobility
Patients with chronic HCV require?
vaccination against HAV and HBV
When should you have cholecystectomy after gallstone pancreatitis?
within 7 days of clinical improvement, usually during same hospitalization
