UWorld Family Medicine Board

What's the difference between Stevens Johnson Syndrome and Toxic Epidermal Necrolysis? What's the pathophysiology?

<10% body surface area: Stevens-Johnson 10-30% bsa: SJS/TEN overlap >30% TEN 4-28 days after exposure to trigger (2 days after repeat exposure). Acute influenza-like prodrome. Rapid-onset erythematous macular, vesicles, bullpen. Necrosis & soughing of epidermis. Mucosal involvement. Drugs: Allopurinol, Antibiotics (Sulfonamides), Anticonvulsants (carbamazepine, lamotrigine, phenytoin), NSAIDs (piroxicam), Sulfasalazine. Other Mycoplasma pneumonia, vaccination, graft-vs-host disease

65yo Asian woman presents to your office with red eye on right. Pain is severe, decreased in vision and sees halos. Started after watching movie with her grandsons. Had used OTC medication recently for recent cough and cold. Exam: red right eye, moderately dilated pupil, sluggish to light. Pain with movement. Vision markedly reduced. Dx and Plan.

Acute Angle-Closure Glaucoma -- ocular emergency. Hyperopic older patients (most commonly), esp. in Asians. Optic atrophy and vision loss can occur in hours without appropriate treatment. OFten slumped over distress while covering affected eyes, complaining headache, nausea, vomiting. Exam fixed pupil in mid-dilation, red eye, ciliary flush, elevated ocular pressures, and no discharge. Precipitated by sympathomimetic and anticholinergic drugs.

53 yo female recently treated with ear infection of amoxicillin comes to physicians or itchy rash on trunk and upper extremities. Lab shows Cr. 2.1 and eosinophilia. WHat's going on? And What you expect on other urine study finding?

Acute Insterstitial Nephritis -- new drug exposure, rash, and acute kidney injury. Perugia, microscopic hematuria and white cell casts. Urinary eosinophils (Hansen stain) strongly suggestive of AIN, although they are not sensitivity nor specific. INitial care, discontinue drug, supportive measures. Renal biopsy if uncertain. May need systemic glucocorticoids.

59yo female comes in sudden onset left-sided facial droop. No other sickness. No recent illness, travel, trash or tick bites. Facial asymmetry, drooping of left ankle of mouth, loss of nasolabial fold. What's diagnosis and treatment?

Acute unilateral upper and lower facial weakness -- Bells' Palsy -- acute peripheral facial nerve paralysis possibly due to herpes simplex virus activation. Usually develop suddent onset unilateral facial paralysis, decreased lacrimation and/or loss of taste in anterior 2/3 of tongue. Nearly 70-85% patients recover within 3 weeks. Many studies suggest that glucocorticoids (re, prednisone) given with 3 days of symptom onset significantly improve recovery. Antiviral therapy alone is not effective for treating Bell's Palsy, although some studies suggest that adding valacylocivr to glucocorticoids may provide a small benefit to patients with severe facial paralysis.

40yo obese man with PMH diabetes presents with abdominal distinction, flats, low-volume fecal incontinence over the past 2 weeks. Been on metformin for years, recently started on exenatide and orlistat. Abdomen is distended, tympanic, nontender. What's going on, and what do you want to do?

Adverse effects form Orlistat. Orlistat is used to treate obesity and works by inhibiting pancreatic lipase to alter fat digestion, decrease fat absorption, and increased fecal fat wasting. As a result, high dietary fat intake can develop symptoms similar to fat malabsorption (e.g., flatus, fecal incontinence, abdominal distinction). A low-fat diet (<= 30% of total calories) can reduce these symptoms. Orlistat can also decrease absorption of fat-soluble vitamins so patients should take a daily multivitamin.

67yomale with decreased vision left eye. 2 weeks prior noticed vision distorted or "missing". Difficulty reading despite getting new glasses for several months. No headache, eye pain, double vision. History of hypertension and past smoker 40ppy.

Age-related macular degeneration (AMD) Progressive, painless, monocular vision loss. Major cause of blindness of blindness and visual impairment in older adults (age > 50). Damage to macula may initially be asymptomatic but eventually lead to progressive distortion and vision loss, primarily in the center of the visual field (central scotomas). 2 forms: dry and wet. Dry - cellular debris called drunken accumulations between retina and the choroid, sometimes leading to retinal detachment. Wet - more severe, blood vessels grow up form choroid behind the retina, and retina become detached. Often associated with retinal hemorrhage. Peripheral vision spared.

What Infection Control Isolations precautions are there? Airborne, Contact, Droplet

Airborne Bacterial (Tuberculosis) Viral (Varicella, SARS, measles) Contact MRSA, VRE Enteric (C. Diff, E. coli 0157:H7) Parasite (scabies) Droplet Bacterial (Neisseria meningitidis, Haemophilus influenza type B, mycoplasma pneumoniae) Viral (influenza, adenovirus, RSV)

46yo homeless male with PMH of alcoholism presents to emergency room with frequent falls and unsteadiness. Symptoms worsen over last 6 months. Exam broad-based, unsteady gait. Single tap on patellar tendon elicit is persistent, slow, back and forth swinging of the leg. Nystagmus and truncal ataxia as well. What's diagnosis? What other physical findings?

Alcoholic Cerebellar Degeneration - Evidence of cerebellar degeneration, progressive gait dysfunction, truncal ataxia, nystagmus, intention tremor or dysmetria (limb-kinetic tremor when attempting to touch a target), and impaired rapid alternating movements (dysdiadochokinesia). Muscle hypotonia can also be present, leading to a. Pendular knee reflex with persistent swinging movements of the limb after eliciting a DTR (more than 4 swings is considered abnormal). Pendular reflexes are not brisk, unlike clonus, which would suggest pyramidal tract disease.

35yo manicurist for past 10 years presented with swelling around fingers in all fingers for 2 weeks, rash stinging pain, bruning. Wore artificial nails intermittently for past couple years. Exam mild warmth, edema, tenderness to palpating and fissures. Diagnosis and Plan

Allergic COntact Dermatitis due to artificial nails. Delayed hypersensitivity response to exogenous agents such as latex, nickel, soaps/cleaning agents, cosmetic products, rubber and formaldehyde. Artificial nails often contain formaldehyde and acrylates. This can occur to both manicurists and customers. Clinical findings: periungual edema or eczema, nail dystrophy, periungual hyperkeratosis, fingertip dermatitis and paresthesias. Treatment removal of artificial nails.

23yo female w/ PMH of asthma was stung by a wasp, presents wth chest tightness. Has already had 2 puffs of rescue albuterol, breathing improved. Some generalized itching and abdominal pain. Saturating well on room air, mild wheezing with good air entry on lung. Abdomen slightly tender, and slightly increased bowel sounds. Plan

Allergic reaction to wasp/Hymenoptera sting -- typical early features of anaphylaxis, which si a severe allergic reaction characterized by skin and/or mucosal involvement and possible respiratory compromise, hypotension and GI distress. Wheezing, pruritus, rash, angioedema, headache, flushing, urticaria, abdominal (nause,a vomiting, diarrhea, cramps, bloating). Initial symptoms may be subtle and minor but progress rapidly to life-threatening and cardiovascular collapse. IM epinephrine first-line for severe allergic reactions and anaphylaxis. Reduce airway compromise and treat shock. Advised even for patients with mild to moderate clinical features. Unstable patient needs aggressive fluid resuscitation and airway management. All patients with anaphylaxis should be prescribed auto-injectable epinephrine and referred to an allergist on discharge.

What is treatment for alopecia areata? What is treatment for Androgenetic alopecia?

Alopecia areata (circumscribed patches of hair loss): Topical corticosteroid (occasionally used). Androgenetic alopecia (chronic, gradual thinning of hair, in women commonly vertex): Finasteride, Minoxidil.

How do you diagnose acute pericarditis?

At least 2 of the follow criteria: - Typical pleuritic chest pain - pericardial friction rub - ECG changes (diffuse, concave ST segment elevation precrodial and limb leads, receiprocal ST depression in leads aVR and V1). PR segment elevated in aVR, depression in other limb leads. - new or worsening pericardial effusion

Amiodarone induced low or high thyroid? And what's your treatment if that happens?

Both If Hypothyroidism -- continue amiodarone and starte levothyroxine. If Hyperthyroidism -- do radioiodince scane to check if nodule or goiter --> Type 1 or 2 AIT Amiodarone Induced Thyrotoxicosis. THere is an algorithm.

What's the difference or how would you differentiate Iron Deficiency Anemia vs Thalassemia?

Both are Microcytic Anemia. Iron Deficiency Anemia - Increase RDW Decrease RBCs Peripheral smear Microcytosis, Hypochromia. Iron decrease, Ferritin decrease, TIBC increase Response to Iron supplement. Normal electrophoresis. Thalassemia - Normal RDW Normal RBCs Peripheral smear Target Cells. Iron Normal, Ferritin Normal NO response to Iron supplement Electrophoresis: normal in a-thalassemia. Inc. Hgb A2 in B-thalassemia.

Tests to order for some geriatric male patient who had ground level fall and fractured hip. DEXA showed osteoporosis.

CBC, CMP, Liver function tests, albumin, total serum protein, alkaline phosphates, TSH and 25-hydroxyvitamin D. 24hr urine Ca assay. PTH. Tissue transglutaminase. Early-morning testosterone (hypogonadism).

What does CREST Syndrome stand form

Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangiectasias

47yo male presents with abdominal discomfort and diarrhea. It started out with fatigue, fever, with periumbilical abdominal cramps 3 days prior. Then started having diarrhea that woke him up at night, small-volume stools. No mucus or blood. 5-10 x bowel movements/day. VSS. Exam mild periumbilical tenderness. Rectal exam no blood. What are you suspecting?

Campylobacter Jejuni. Inflammatory diarrhea originates from the large bowel and is usually due to Campylobacter, Shigella or Salmonella. OFten has abrupt onset of periumbilical crampy abdominal pain and frequent, SMALL-volume diarrhea. OFten but not always contain BLOOD or mucus. May associated with febrile prodrome. Symptoms delayed with incubation period of 3 days. Noninflammatory diarrhea originates form the small bowel and is usually due to bacterial ingestion from contaminated food. Bacteria release toxin in the intestine that leads to LARGE-volume watery diarrhea with possible nausea, vomiting, abdominal cramps, or bloating. There is usually NO FEVER. Noninflammatory diarrhea is most commonly due to Clostridium perfringens and enterotoxigenic E. COli.

45yo obese man with diabetes (on metformin) presents with a rash for 3 weeks or so. No pruritus. Rash is on abdomen. Diagnosis and Plan

Candidate intertrigo. Fungi grow well in warm, moist environment of skin folds. Risk: skin friction (obesity), increase moisture (tight clothing, hyperhidrosis) or promote fungal overgrowth (diabetes, immunosuppression). Erythematous plaques and erosions, sometime with satellite papules and pustules. Can be pruritic or painful if significant skin breakdown. Can do KOH examination. Topical antifungals (e.g., miconazole, nystatin, terbinafine) are preferred initial treatment of intertrigo. Skin-drying agents and address the underlying predisposing conditions can reduce the risk of recurrence.

84yo male w/ PMH COPD presents with progressively worsening throbbing headache, nausea and dizziness for 1 week. Patient lives alone, and given cold temperature, stayed indoors most of time. VVS. What do you suspect? Plan?

Carbon Monoxide Poisoning - CO is an odorless/tasteless gas produced by hydrocarbon combustion that can impair O2 utilization due to its high affinity to Hgb. Mild-moderate intoxication typically have headache (most common) and other nonspecific symptoms such as altered mental status, dizziness, malaise, nause. Severe - seizure, coma, myocardial toxicity (ischemia, arrhythmia) and death. OFten during cold winter climates in setting of smoke inhalation (most common). Toxicity can also occur with use of defective heating systems, fuel-burning appliances, or motor vehicles in poorly ventilated areas. Diagnosis is confirmed by checking a Carboxyhemoglobin level with co-oximetry of arterial or venous blood. The dissolved oxygen in blood is not affected by CO; therefore, pulse oximetry and blood PO2 levels are usually normal. All patients , get ECG (everyone), Cardiac enzymes (in elderly and cardiac risk factors or signs ischemia). Mainstay treatment is removal of CO source and delivery of 100% oxygen with non-rebreather get face mask.

42yo male with recent "bad flu" presents with fatigue, chest pain, sob for 5 days. BP 84/40, pulse 112/min. Lower extremities cold and pulses not palpable during deep inspiration. JVP distended in seated. Xray showed enlarged heart. Dx and Tx.

Cardiac Tamponade as a result of recent viral infection and pericardial effusion and resulting in cardiac tamponade. Chest pain, dyspnea, tachycardia, hypotension, elevated JVP, pulsus paradoxus (dec bp/nonpalpable pulse on inspiration) along w/ CXR enlarged cardiac silhoutette. ECG low-voltage QRS, eletrical alternans. ECHO: right atrial & ventricular collapse, plethora of the IVC. Treatment for hemodynamic unstable patient --> immediate percutaneous pericardial fluid drainage (pericardiocentesis).

Sudden onset, painless vision loss in one eye. Diagnosis and what other exam findings

Central Retinal Artery Occlusion (CRAO) -- acute retinal ischemia due to thrombosis or emboli in the central retinal artery (branch of ophthalmic artery). Cherry red macula and retinal pallor on exam. Relative afferent pupillary defect (Marcus gunn pupil). Bright light causes pupil to dilate and pupils become different size.

Acute, painless loss of vision differential diagnosis

Central Retinal Artery Occlusion - one eye. Cherry red macula and retinal pallor on exam. Marcus Gunn pupil.

60yo male presents with nausea and abdominal pain 5 days or so after procedure coronary stenting procedure. Exam showed painless, patchy purple mottling of skin of extremities. Dx and Tx.

Cholesterol Crystal Embolism (Artheroembolism) -- systemic atheroembolism form disruption of atheroslectortic aortic plaques. Common during aortic instrumentation, coronary/peripheral angiography or intraaotic ballooon pump insertion. Risks: smoking, diabetes, hypertension, hyperlipidemia. Livedo reticularis - reticular, erythematous, or purple discoloration of skin that blanches on pressure. Skin manifestations, renal manifestations, central nervous system, ocular, GI manifestations. Labs: Eosinohilia, eosinophiluria, hypocomplementemia. Skin or renal biopsy.

67yo male presents with fatigue and low energy for months. Has not had nausea, vomiting, abdominal pain, bleeding, diarrhea, or black stools. Hgb 9.4, MCV 72, LFT normal, Ferritin low. Office-based fecal occult blood test negative. What's your plan?

Colonoscopy. Microcytic anemia, low ferritin > iron deficiency anemia. In older adults, commonly due to GI blood loss (malignancy, peptic ulcer disease). FOBT (Fecal Occult Blood Test) is a reasonable component of initial IDA work up; however it has low sensitivity for detecting colonic cancer.

38yo female w/ PMH of HIV and poor medical follow-up presents to emergency room with 2 weeks of worsening headache and low-grade fever. Exam stiff neck. No muscle weakness. CD4 count 44. CT head normal. LP showed opening pressures 250mmHg, glucose 35, protein 120, lueckotyes 45, no RBC. CSF encapsulated yeast. What do you think?

Cryptococcal Meningoencephalitis -- invasive fungal infection caused by Cryptococcus Neoformans -- begins w/ inhalation of spores, leading to focal penumonitis (may be asymptomatic. Immunocompromised patients especially those with advanced HIV (CD4 < 100) may have subsequent seeing of CNS. Fever, lethargy, headache, altered mentation, coma. CT/MRI imaging, LP. CSF INdia Ink encapsulated yeast, CSF cryptococcal culture. Treatment: 2 weeks IV amphotericin B (AmB) and lfucytosine, followed by fluconazole for consolidation (8 weeks) and maintenance therapy (>= 1 year). May need serial LP to reduce increased intracranial pressure.

50yo with PMH Hepatitis C presents with itchy rash on extremities for past few weeks. Exam showed papulosquamous rash that are paper in color, and on the flexor surface. What are you suspecting? Plan?

Cutaneous Lichen Planus (LP) - immunologically mediated skin disorder affecting mainly middle-aged adults. Unknown etiology, but associated in some cases with Hepatitis C. Papulosquamous rash that can involve the skin, nails, mucous membranes of the mouth, and external genitalia. Classic skin lesions are characterized by the 4Ps (pruritic, purple, polygonal shape, and papules/plaques) and most commonly occur on the flexural surfaces of ankles and wrists. Lesions may also show lacy white markings Wickham's stria. Dx: clinical, may do punch biopsy. Topical high-potency corticosteroid preferred first-line. Not responding can use oral corticosteroids or phototherapy.

Patient has recurrent herpes simplex virus and got a new partner. What can you do to prevent the new partner getting the condition?

Daily suppressive therapy Daily valacyclovir (best studied, once-daily dosing) Daily acyclovir (more affordable) decreases asymptomatic viral shedding, decreases the number of outbreaks, and shortens shortens outbreak duration.

Proton Pump Inhibitors (PPIs) Side Effects

Decreased GI absorption of Calcium and inhibition of osteoclasts activity and can lead to accelerated bone loss and increased risk of fractures. This is especially true in patients with additional risk factors for osteoporosis (e.g., smoking). Bone loss is directly proportional to the dose and duration of PPI therapy. Other side effect include: atrophic gastritis, B12 and iron malabsorption, hypomagnesemia, and increased risk of infections such as Clostridium difficult colitis and pneumonia (community- and hospital-acquired).

What is Diabetic Gastroparesis and how do you manage it?

Diabetic Gastroparesis -- common complication of longstanding or poorly controlled diabetes, primarily due to autonomic dysfunction. Characterized by delayed gastric emptying and manifests with nausea/vomiting, bloating, early satiety and abdominal pain. Dx confirmed with sicntigraphic gastric emptying study. Initial tx: optimization of glycemic control, adequate fluid intake, frequent and small meals with low fat content. Watch out for side effects of Prokinetic agents like Metoclopramide -- dopamine receptor antagonist, for extrapyramidal adverse effects (dystonia, tardive dyskinesia).

What conditions are associated with digital clubbing?

Digital Clubbing denies bulbous enlargement and broadening of the fingertips due to connective tissue proliferation at the nail bed and distal phalanx. Diagnosed when the angle between the nail fold and nail plate (Lovibond angle) is > 180 degrees. Clubbing can occur by itself or in association with hypertrophic osteoarthropathy, which causes painful joint enlargement, periostsis of bone nad synovial effusions. May be hereditary but most often due to pulmonary or cardiovascular diseases. Most common causes of clubbing are lung malignancies, fibrotic lung disease, suppurative lung disease (cystic fibrosis, bronchiectasis), and congenital heart disease with right-to-left cardiac shunts.

Where do patients lose hair in Androgenetic alopecia? (Male vs Female). What is the plan?

Drivem by both polygenetic inheritance, hormonal factors (dihydrotestosterone). Men: vertex, frontal hairline, temporal areas. Women: vertex, center scalp (sparing hairline) Management: Men: Minoxidil, Finasteride. Women: Minoxidil.

67yo male with left total knee arthroplasty (3 months earlier) presents with pain and swelling in left knee. NO erythema. There is swelling and decreased range of motion. X-ray showed hardware in place. Dx and Plan.

Early-onset PRosthetic Joint Infection. Persistent pain and other features of infection (joint effusion, wound drainage, fever, erythema). Can present as early as <3 months, delayed 3-12 months, or late > 12 months after surgery. Diagnostic arthrocentesis should be performed. CBC, BMP, CRP, ESR, X-ray left knee, Blood culture.

Treatment for Temporomandibular joint (TMJ) dysfunction

Education: soft diet, warm compresses, passive stretching. NSAIDs, especially naproxen, 1st line medication. Muscle relaxant (Cyclobenzaprine) can be added for acute pain and muscle spasm.

In Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH), what Serum Osmolality, Urine Na, Urine Osomlality would you expect? Hyper-, Euv- or Hypovolemic?

Elevated ADH > increased renal water reabsorption (increase urine osmolality > 100mOsm/kg) and lower plasma osmolality (< 290mOsm/kg). Increase urinary Na excretion (>40mEq/L) which worsens worsens hyponatremia. Patient is euvolemic.

26yo male with history of asthma presents with difficulty swallowing, intermittent sensation of food getting stuck in chest. Piece of steak stuck there. Occasional heartburn. No vomiting, hematemesis, Melina, weight loss. Diagnosis.

Eosinophilia esophagitis. Chronic, immune-mediate esophageal inflammation. Dysphasia, chest/epigastric pain, reflux/vomiting, food impaction (solids), associated autopsy. Diagnosis by endoscopy & esophageal biopsy (15 eosinophils hpf) Treatment dietary modification +- topical glucocorticoids.

65yo smoker (extensive) presents with 1-month of shoulder pain that radiates down arm. Worse at night time. Shoulder range of motion normal. Mild hand grip weakness. What's diagnosis? What's plan?

Extensive smoking + shoulder pain + handgrip weakness --> superior sulcus tumor (Pancost Tumor). Extensive smoking history, shoulder pain and handgrip weakness Tumors grow in apical pleura-pulmonary groove and can involve branches of C8-T2 spinal nerves. Most common presentation is shoulder pain due to tumor invasion of the brachial plexus or other neighboring structures. Weakness &/or atrophy of intrinsic hand muscles. Pain and paresthesias of 4th and 5th digits, medial arm & forearm. Supraclavicular lymph node enlargement. Weight loss Horner Syndrome (ipsilateral ptosis, mitosis, anhidrosis) can occur due to sympathetic chain involvement. diagnosis is often delayed as symptoms are attributed to bursitis or cervical arthritis. most tumors represent non-small cell lung carcinomas. Due to the peripheral location of the tumor, pulmonary symptoms may not occur until late in the disease. Chest X-ray is the preferred diagnostic test. Patients with normal chest x-ray and at high suspicion for a superior sulcus tumor shoulder undergo chest CT.

How to diagnose Asthma and COPD on spirometry?

FEV1 decrease FEV1/FVC decrease Reversibility for asthma in FEV1 DLCO Diffusion Capacity of lung for carbon monoxide can be either normal or decrease in early COPD. In late COPD, decrease in DLCO.

What drugs (top 2) most commonly associated with prolonged QT?

Flouroruqinlones, Antipsychotics. Diuretics > electrolyte Ondansetron Antipsychotics (haloperidol, quetiapine, risperidone) TCA SSRI (citalopram) Antiarrhythmics (amiodarone, sotalol, flecainide) ANtianginal drugs (ranolazine) Antibiotic (macrolides, fluoroquinolones, antifungal)

70yo male w/ PMH lacunae infarction (left-sided hemiparesis) presents with weakness and clumsiness of left leg. Drags his foot over while walking, fell when foot caught on step. Hemiparesis is improving with physical therapy. Exam: reduced strength in left leg abduction, let foot inversion, eversion, toe extension. DTR's normal. WHile walking, flexes left thigh higher and left foto slaps on floor. What's diagnosis and plan?

Foot Drop -- weakness of anterior tibialis muscle. Most often due to common peroneal nerve injury or L5 radiculoapthy. Common peroneal nerve originates from L5-S1 but may be distinguished by presence of back pain and extent of weakness. Common Peroneal Nerve Compression -- weakness of foot dorsiflexion, eversion and toe extension, Pain is uncommon. L5 Radiculopathy -- more extensive weakness involving foot dorsiflexion, eversion and INVERSION; toe extension; and possible weakness of LEG ABDUCTION. BACK PAIN radiating down the leg is common. Sensation may be decreased along the lateral leg and dorsum of the foot in both disorders, and reflexes are typically normal. Patients with back pain and extensive deficits likely has a lumbosacral (L5) radiculopathy. Younger patients with radiculopathy typically have acute, severe pain and weakness from a herniated disk, whereas elderly patients often have more gradual, progressive symptoms due to osteopath formation, foraminal stenosis and degenerative changes of intervertebral discs and facet joints. MRI lumbar spine can show compression of the nerve root. Although immediate imaging is not necessary for most patients with acute uncomplicated radiculopathy, it's appropriate for an elderly patient with significant neurological deficits and a history of falls.

32yo male s/p chemo for sarcoma presents to emergency room for malaise and chills started 24 hours ago, has vague right-sided abdominal pain and diarrhea. 38.9C (102F), pulse 102/min. Pale man. Leukocyte 690, 20% neutrophils. CXR, UA normal.

Get blood culture, start on broad-spectrum. Febrile Neutropenia High risk vs Low risk High risk = profound neutropenia ANC < 100, neutropenia expected > 7 days, Hemodynamic instability or mental status change, significant comorbidities or complications (oral mucositis, GI symptoms, hypoxia, hepatitis). Inpatient IV abx (antipseudomonal b-lactate monotherapy, add vanco if suspect line infection, hemodynamics instability, skin infection), add fungal after 4-7 days if still febrile or evidence of invasive fungal. Low risk neutropenia < 7 days, clinical stable, no significant complications. Tolerant PO or not. If not, go above. If yes, D.C. Home with PO Cipro and Augmentin.

25yo male comes to urgent care with 2 weeks of watery diarrhea. Stools pale, voluminous, foul smelling and non-bloody. Lost 5 lbs over the 2 weeks despite appetite normal. Bloating and flatulence. No fever or abdominal pain. Avid hiker. Vital signs within normal limit. Abd soft and no tenderness. What are you suspecting?

Giardiasis. Stool microscopy. Clinical features of Giardiasis: Diarrhea, Steatorrhea, Fatigue and Malaise, Abdominal Cramps, Flatulence and Bloating. Significant weight loss despite good intake.

Indication for cystoscopy

Gross hematuria with no evidence of gloemrular disease or infection Microscopic hematuria with no evidence of glomerular disease or infection but increased risk of malignancy Recurrent urinary tract infections Obstructive symptoms with suspicion for stricture, stone Irritating symptoms without urinary infection Abnormal bladder imaging or urine cytology

What is Hair Pull Tests?

Hair Pull Test: small tracts of hair (50-60 fibers) pulled firmly, extraction > 10-15% fibers abnormal and suggests TE

What is a grid test? What Is it for?

Have patient cover one eye and look at small spot on a grid made of parallel vertical and horizontal lines. Look for Macular Degeneration.

What should you order for someone who you're suspecting to have pancreatic cancer?

Hepatic labs (bilirubin, alkaline phosphates, transaminases) and pancreatic (lipase) markers. Imaging: transabdominal ultrasound or CT

Young guy came in with wart on his lip. What's your plan. What's contraindicated in one type of wart treatment, what is it and why?

Human Papilloma Virus (HPV) infection -- common in individuals who handle meat, poultry, and fish, as well as those with atopic dermatitis. Immunosuppressed individuals (e.g., HIV) are also commonly develop warts. Frequent sites include genital area,s plantar and palmar surfaces, and the digits. Dx: observation. If uncertain, scrapings of lesions evaluated microscopically for thrombosis capillaries ("seeds"). Observation is an option for all warts since rate of spontaneous resolution is 60-70% over 2 years. However, warts are more easily treated when they are smaller and sooner rather than later. All treatments involve some form of tissue destruction and often must be repeated at interveals for removal without recurrence. Some may take weeks or months. Over-the-counter salicyclic acid or liquid nitrogen applied in an office setting removes many warts. However, liquid nitrogen use is contraindicated in patients with peringual warts due to the risk of nail bed dystrophy.

What are Chest X-ray changes in late COPD?

Hyperinflation, loss of lung markings

62yo male with advanced renal disease due to diabetic nephropathy, with normal serum Ca, high phosphate. What's diagnosis? What lab expected to be high?

Hyperphosphtemia with chronic kidney disease -- typical presentation of secondary hyperparathyroidism (SHPT). In CKD, decreased production of calcitriol 1, 25 dihydroxyvitamin D) leading to dec. intestinal asborption Ca. GFR dec. cannot excrete phosphate --> high phosphate. Increase.d serum phosphate binds to Ca forming CaPO3 lowering serum Ca. Therefore low Ca --> increase PTH. Level PTH elevation usually correlates with severity of renal failure. In advanced CKD, more significant phosphate retention and hypocalcemia may develop, need to maintain low phosphate diet and/or phosphate binds (Ca carbonate, Calcium acetate, sevelamer) and supplement on Ca and vitamin D.

Gradual, painless, binocular vision loss and headaches. What are you suspect? And what exam finding are you looking for?

Hypertensive Retinopathy -- most of time patients have no visual symptoms initially. Funduscopic exam: "copper and silver wiring," hard exudates, flame hemorrhages, arteriovenous nicking, arteriolar narrowing, and ischemic changes "cotton wool spots".

24yo obese female presents to you with pulsatile headaches for past 2 months. No fever, vision changes, muscle weakness. Neuro exam normal. Funduscopy: bilateral papilledema. Brain MRI no mass lesions. Lumbar puncture will show. Dx and Plan.

Idiopathic Intracanrial Hypertension (IIH) -- more common in obese women of childbearing age. Consequence of elevated intracranial pressure and are not specific. Headache, transient visual loss, pulsatile tinnitus, diplopia. Can show CN VI palsy, visual field defects, and bilateral papilledema. Visual loss can be progressive and potentially result in blindness. Neuroimaging necessary to r/o seoncdary causes of intracranial hypertension. Brain MRI with and without gadolinium and MR venography have the highest sensitivity in detecting intracranial masses and cerebral venous thrombosis, respectively. If no identifiable secondary cause, lumbar puncture should be performed to evaluate for elevated opening pressure (>250mmH2O) that confirms the diagnosis. CSF typically normal. Thx: Loseweight and Azetazolamide.

What are some eyes symptoms that require immediate ophthalmology evaluation?

Impaired vision, inability to open eye due to foreign body sensation, photophobia, significant eye pain, diminished pupil reactivity and the presence of corneal opacity.

Dietary interventions for calcium stones Increase on what decrease on what

Increase Calcium -- dec. oxalate absorption in GI tract. Fluid - incr. urine flow (decreases solute concentration). Citrate - behinds urinary Ca (makes soluble Cal Citrate). Fruits & vegetables - (inc. citrate excretion in kidney) Decrease Na - decreases Calcium excretion in kidney Aninmal Protein - decreases acid load & Ca excretion in kidney.

What is the likely causative agent for Paronychia? What is Treatment?

Infection and painful inflammation around the nail. Due to bacterial infection (Staphylococcus aureus, Streptococcus pyrogens) skin flora type, others being (Fusobacterium, streptococci in area exposed to oral flora. Treatment warm compresses, antibiotics for more severe cases. Drainage if associated abscesses.

Patient with PMX of reduced ejection fraction heart failure presents with bilateral hearing loss. What's the culprit agent?

Lasix (Furosemide) -- frequent cause of ototoxicity. Loops diuretics are associated with hearing loss and reversible or permenent tinnitus. Risk of ototoxicity is greater in patients who have comorbid renal failure, receive other ototoxicity medications (e.g., aminoglycoside antibiotics), or taking high doses of furosemide.

What is Trousseau sign? When do you see it?

Latent tetany, seen in patients with low Calcium. Blood pressure cuff around patient's arm, and inflated to pressure greater than systolic pressure, held in place for 3 minutes. Very uncomfortable and painful carpopedal spasm (flexion at wrist, flexion at MCP joints, extension IP, adduction of thumb and fingers)

62yo male tobacco dependence (chewing tobacco) presents with white patch on buccaneers mucosa. Lesion appears to have granular texture, not indurated. Not removed by tongue depressor. No regional lymphadenopathy. Dx and Plan.

Leukoplakia - reactive lesion that represents hyperplasia of the squamous epithelium and is associated with an increased risk of malignant transformation. RIsk: smokeless tobacco and alcohol use. Can present to squamous carcinoma in 10 years. Fortunately most lesions resolve within a few weeks after cessation of tobacco use. Area with induration and/or ulceration should prompt biopsy to use out malignant transformation of the lesion.

What are you pharmacological options for smoking cessation? What side effects?

Long-acting NRT (nicotine patch) -- decrease craving & daytime withdrawal symptoms. Long-acting may be combined with short-acting NRT ("patch plus", nasal spray, gum, lozenge, inhaler). No side effects, safe in most. Bupropion/Wellbutrin - decrease post-cessation weight gain. Good choice for patients with unipolar depression. Contraindicated if seizure or eating disorders. Varenicline/Chantix - more effective than bupropion or NRT. Possible increase risk of cardiovascular events. Monitor behaviors (hostility, agitation, depressed mode, suicidal ideation).

Initial workout for cognitive impairment?

MMSE ( <24/30 suggests MCI/dementia) MOCA (<26/30) Mini-Cog (abnormal 3-word recall, clockdraw test) CBC, Vitamin B12, TSH, CMP Selective (risk dependent): Folate, Syphilis, vitamin D Atypical (early onset): CSF Routine CT scan or MRI of brain Atypical: EEG

34yo male presents with a cough. Felt sick 5 days ago and was improving initially but then developed fever and cough, shortness of breath. Exam fever 39.1C (102.4F), pulse 104, respiration 22. 90% on room air. Ill-appearing and mild respiratory distresss. CXR right lower lobe consolidation. Dx and Tx

MRSA pneumonia -- secondary bacterial infection (fever, productive cough with pure lent sputum, lung consolidation on X-ray) on top of influenza pneumonia. Initial antibiotic should include vancomycin + typical CAP coverage (Azithromycin + cetriaxone) until MRSA is ruled out.

USPSTF recommendation on breast cancer. What's not recommended? What are the high risk family history?

Mammogram every 2 years for women age 50 - 74. Genetic counseling & possible testing for women with evidence of high-risk family history Breast self-exam at any age. Genetic testing for women without high-risk family history. Two first-degre relatives with breast cancer (1 age < 50), three or more 1st- or 2nd-degree relatives with breast cancer, 1st- or 2nd-degree relative with breast & ovarian cancer, 1-st degree relative with bilateral breast cancer. Breast cancer in male relative. Ashkenazi Jewish women with any 1st- or 2nd degree relatives with breast or ovarian cancer.

What's Mediterranean Diet? What's DASH Diet?

Mediterranean Inc. intake: fruits, vegetables, whole grains, legumes, nuts, olive oil, poultry, fish. Dec. intake: red meat, salt, saturated fats. Moderate intake: red wine (optional) DASH Inc. intake: fruits, vegetables, whole grains, low-fat dairy, nuts, fish, poultry. Dec. intake: red meat, fats, sweets. Na < 2300mg/day (< 1500 lower Na DASH diet)

63yo male with extensive small cell lung cancer on caboplatin and ego poised presented with unstable gait and slowing of movements. This was after patient was having projectile vomiting, volume depletion that required him being on IV fluids, ondansetron and metoclopramide and dexamethasone. Exam bilateral incre muscular tone but not weakness. What's diagnosis and plan.

Metoclopramide and some other dopaminergic antagonists are occasionally used for chemotherapy-induced nausea and vomiting. Metoclopramide is a pro kinetic agent that acts as a central and peripheral dopamine receptor blocker. Use to treat (and prevent) chemotherapy-induced emesis; however, its use has been associated with extrapyramidal symptoms. Common CNS effects: akathisia, dystonia and Parkinson-like symptoms. When drug used in high doses, incidence of these side effects may exceed 30%. Has been largely replaced by sertonin receptor antagonists (e.g., ondansetron) and appreciating.

26yo female comes in for evaluation of "tired easily". Heavy menses monthly, listings 4-5 days. Diagnosed with anemia from previous provider 6 months ago, prescribed oral iron supplement already. You did labs: Hgb 10.8, MCV 64, Erythrocytes 5.8 million, RDW 14.2% (normal), Ferritin 324 (normal range). What is your differential diagnosis? What othe work up do you want?

Microcytic anemia (MCV < 80) differential diagnosis include: iron deficiency (most common), thalassemia, sideroblastic anemia, or lead toxicity. Sideroblastic anemia usually causes Hgb < 7, lead toxicity is rare in adults. Heavy menses > Iron Deficiency IDA (severity of anemia, mcirocytosis generally correlate, MCV < 80 is unlikely with Hgb > 10), ferritin is typically low and RDW is usually high due to greater variation in cell sizes (smaller erythrocytes produced). Mild anemia (despite 6 months if Fe supplement) with significantly low MCV, normal RDW (all cells of same size), mildly elevated Ferritin, and Mentzer Index (= ratio MCV to erythrocytes count) < 13 all suggest Thalassemia rather than IDA. Hemoglobin electrophoresis is needed for the diagnosis. Beta Thalassemia minor (decreased beta chains) is usually asymptomatic but with increased Hgb A2 and Hemoglobin F on hemoglobin electrophoresis. Alpha Thalassemia minor clinically resembles beta thalassemia minor but has normal Hgb electrophoresis.

45yo female with PMH of diabetes presents with "reddish spots" on her legs. Had them since 3 months ago and has been slowly spreading. Rash is in the pretibial area. Erythematous papules, annular in shape. What do you suspect and what's plan?

Necrobiosis Lipooidica Diabeticorum (NLD) - skin condition frequently seen in diabetics (though nondiabetics as well). May precede onset of diabetes, should screen for diabetes. Typically occur in the pretibial areas, starting as erythematous papules that later evolve into annular lesions with a yellowish-brown hue, dilated blood vessels, and central epidermal atrophy. Patients are usually asymptomatic but can develop pain, pruritus, of dysesthesia. Histology: interstitial granulomatous dermatitis confirms Dx. Occasionally ulcerated. In absence of ulceration, treat with high-potency topical or intralesional glucocorticoids.

What is the most common cause of epidemic gastroenteritis?

Norovirus. Most common cause of all gastroenteritis ina dust and children. Fecal-oral contamination. Vomiting is more prominent*. Can be transmitted from food, water, fomites, airborne droplets from vomitus. Often at institutionalize and travel settings (nursing homes, healthcare facilities, restaurants, cruise ships). Fever, watery diarrhea, and in severe illness (fever, vomiting, headache and other systemic symptoms). But can also be asymptomatic.

Gradual, painless loss of vision differential diagnosis

Open Angle Glaucoma - optic nerve atrophy with increased optic cup size and cup-to-disk ratio. Tonometry shows elevated intraocular pressure. Hypertensive retinopathy -- bilateral loss + headaches. Copper and silver wiring, hard exudates, flame hemorrhages, AV nicking, arteriolar narrowing, ischemic changes, cotton wool spots. Age-related Macular Degeneration (AMD) - progressive, painless monocular vision loss. Distortion and vision loss, loss of center visual field (central scotomas.

65yo female did routine bone density screening by DEXA. No other problems. Menopause at 52. DXA scan T score -1.5 both femoral necks, -1.9 at the lumbar spine. Vitamin D level normal. Diagnosis? What's your plan?

Osteopenia. Estimate 10-year fracture risk. Antiresorptive therapy is recommended for patients with: Osteoporosis on DXA (T score <= -2.5) Low trauma hip or vertebral fracture Osteopenia (T-score between -1 and -2.5) and 10-year probability of hip fracture >=3% or major osteorortic fracture >=20%.

When do you order X-ray for ankle and foot?

Ottawa Ankle Rules Pain at the malleolar zone AND Tender at posterior margin/tip of medial malleolus Tender at posterior margin/tip of lateral malleolus Unable to bear weight 4 steps (2 on each foot) Ottawa Foot Rules Pain at the mid foot zone AND Tender at the navicular Tender at the base of the 5th metatarsal Unable to bear weight 4 steps (2 on each foot)

Varenicline/ Chantix -- How does it work? What do we need to be monitored?

Partial nicotine acetylcholine agonist. Possible increase risk of cardiovascular events (myocardial inschemia, arrhythmia) but risk is minimal. Despite the initial black box warning (removed in 2016) of increase risk of suicidality or depression.

What diabetes medication can predispose a patient into heart failure?

Pioglitazone, Thiazolidinedione class -- increase renal Na reabsorption with resulting fluid retention. 4-6% of patients can have clinically significant fluid retention especially those with underlying heart failure.

50yo female realtor comes in with nail discolorationfor many months and cannot shake her clients' hands. Exam nail pitting and nai separation from nail bed. Diagnosis and Plan

Pitting (small depressions on nail plate) and distal onycholysis (nail separation form nail bed), -- typicall presentation of Psoriasis. Check on other part of skin. Tx: high-potency topical steroid. Mild nail psoriasis 1 or 2 digits can be treated with topical steroids and/or vitamin D analogs (calcipotriol). Widespread nail involvement needs systemic therapy (tumor necrosis factor-a inhibitors, methotrexate).

27yo male presents with malaise and dark urine for 2 days. Recently treated with oral dicloxacillin for blistering skin infection 3 weeks ago. VSS. Exam periorbital swelling. UA 8 RBC/hpf, red blood cell casts, mild proteinuria. Lab low serum C3 levels, BUN 40, Cr 2. Diagnosis and plan.

Post-streptococcal glomerulonephritis (PSGN) - 10-20 days after streptococcal throat or skin infections. Presenting symptoms: generalized (including periorbital) EDEMA, HEMATURIA, oliguria and HYPERTENSION, which may be severe. UA shows hematuria, RED BLOOD CELL CASTS, variable proteinuria, and sometimes pyuria. Serum C3 complement levels are LOW. Management: supportive care, control BP, loop diuretics if needed for edema. Most patients would have spontaneous remission. DDX: IgA Nephropathy: hematuria with pharyngitis or upper respiratory infection, but it's more RAPID in ONSET, NORMAL complement, and a recurrent or progressive course.

Indications for Implantable cardio enter-defibrillator placement

Primary Prevention Prior MI & LVEF <= 30% NYHA Class II or III symptoms & LVEF <= 35% Secondary Prevention Prior VF or unstable VT without reversible cause Prior sustained VT with underlying cardiomyopathy

50 some yo woman with severe heartburn. with joint pain, skin hardening at fingertips, white lumps on both forearms, small red blanching lesions over face. what's she at risk of developing?

Pulmonary Hypertension. She most likely has systemic sclerosis (SSc). either limited and diffuse forms depending on skin distribution. Limitedis restricted mainly to the hands and distal forearm and to lesser extent on face and neck. Diffuse extends to abdomen and upper arms. CREST Syndrome = a variant of limited form. anti-centromere-antibody positive and carry a more favorable prognosis than diffuse form. They are more prone to developing pulmonary hypertension, often without interstitial fibrosis. Diffuse form may develop severe forms interstitial lung disease.

What's Corrected QT interval (QTc) ? What's considered as long? Why does it matter?

QT interval / differential RR interval >450msec in male and > 470msec in female Prolonged QT is associated with higher risk of Torsade de pointes Faster heart rate QT is shorter. SLower heart rate QT is longer. That's why we correct.

What kind of errors is case-control designs subjected to?

Recall bias -- inaccurate recall of past exposure y participants in a study. Individuals with a disease are more likely to search their memories to try to identify whether an exposure has contributed to their condition.

Differential diagnosis for microscopic hematuria

Renal (e.g., renal cell cancer, IgA neprhopathy), ureteral (stricture, stone), bladder (cancer, cystitis), and prostate/urethral (BPH, prostate cancer, urethritis).

Acute loss of vision + flashes of light, floaters, eyes feeling heavy. What do you suspect?

Retinal Detachment -- acute vision loss with flashes of light (photopsia), numerous floaters (drifting spots or strings in the visual field), and eye heaviness. Patient may describe the impression of a veil or curtain being drawn over the field of vision. Both peripheral and central vision are affected.

Antibiotic Prophlaxis for people who are at risk being around invidiuals who contracted meningococcal disease.

Rifampin, Ciprofloxacin and Ceftriaxone. Household members Roommates or intimate contacts Child care center workers Persons directly exposed to respiratory or oral secretions (kissing, mouth-to-mouth resuscitation, ET intubation/management) Person seated next to an affected person for >= 8 hours (airline traveler).

Management of Abdominal Aortic Aneurysm

Risk Factors: AAA Formation include age >60, male sex, cigarette smoking, white ethnicity, atherosclerosis , and family history of AAA. Major risk ;for aneurysmal exapnsion and rupture: large diameter (>= 5.5cm), expansion rate of >=0.5cm in 6 months or >1cm in a year,and active cigarette smoking. Elective repair is recommended for AAAs with diameter >= 5.5cm (when the risk of rupture exceeds the risks of repair.

52yo male with PMH untreated Hep C presented with progressive abdominal dissension over past few months. Gained 15 lbs. Exam fluid wave and shifting dullness. Pitting edema. Na 131, K3.5, Cr 1, Albumin 3.4. US moderate amount ascites, moderate splenomegaly. Asictic fluid uncleared cell count of 200, protein 2.3, albumin 2. What's your plan?

SAAG >= 1.1g/dL --> portal hypertension and low total ascetic protein < 2.5 confirms cirrhosis. Abstain alcohol. Restrict dietary Na 2g/day. Na >120 so okay with spironolactone and furosemide. 100:40, reduces fluid retention while preventing hyperkalemia. REfractory symptoms > large-volume paracentesis LVP. Midodrine, TIPS, Liver transplant Manage cause of cirrhosis.

What is the most effective way of differentiating Asthma and Chronic Obstructive Pulmonary Disease (COPD)?

SPirometry before and after administration of bronchodilator (albuterol). Reversal of airway obstruction >= 12% increase in FEV1, or absolute increase in FEV1 of >= 200ml in response to bronchodilator.

Which bacteria causes inflammatory diarrhea? (Mucus and blood) Which bacteria causes watery diarrhea?

Salmonella (both typhoid and non-typhi), Campylobacter, Shiga toxin producing E. COli, Shgella, Enterobacter, Vibrio (usually parahaemolyticus), Yersenia. Clostridium perfringens, Enterotoxic E. COli, Enteric viruses, Cryptosporiidium, Cyclospora, Intestinal tapeworms

What are the causes of SIADH?

Small Cell Lung Cancer, Pneumonia, CNS disorders (stroke, infection), medications (carbamazepine, SSRI), and surgery.

29yo male former drug user and alcoholic presents with back pain, lower extremity weakness, difficulty walking for few days. VSS. Muscle strength reduced in lower extremity only, sensation decreased, hyperreflexia noted bilaterally in lower extremities. Stroking soles of feet elicits extension great toe. What is diagnosis and plan?

Spinal cord compression: symmetric lower extremity weakness, loss sensation, upper motor neuron disease (weakness without fascinations, hyperreflexia, positive Babinski sign). Lesion can be localized in spinal cord > symptoms bilateral and lower extremities. DDx: disc herniation, abscess, malignancy. Epidural abscess (even without fever) is of particular concern in setting of IV drug use. Spinal cord compression is medical emergency nad must be evaluated immediately with MRI spine.

Which foodborne illness causes vomiting predominant (non-diarrhea)?

Staphylococcus aureus, Bacillus cereus, Noroviruses (e.g.,Norwalk).

68yo female w/ PMH of heart failure on lasix, found out have hypokalemia K 3. What do you plan to do?

Start daily potassium chloride. Diuretic therapy with loop or thiazide diuretics is associated with several electrolyte abnormalitieis: hypokalemia, hypomagnesemia, hyponatremia, hyperureicemia, and metabolic alkalosis. Low potassium > muscle weakness, cardiac arrhythmia, renal dysfunction, and glucose intolerance. Need to replete with potassium supplements. Potassium Chloride is preferred. Chloride is primarily an extra cellular anion that remains in the extra cellular space nad helps retain potassium in the serum. Patients on diuretic therapy are also often chloride-depleted, which enhances renal bicarbonate resabsorption and causes metabolic alkalosis. Therefore, KCl is the preferred replacement therapy in patients with diuretic-induced hypokalemia as it is able to raise serum potassium levels fathers than other formulations and also helps correct metabolic alkalosis. As opposed to Potassium Citrate and Potassium Acetate are precursors to potassium bicarbonate, which enters cells more readily than potassium chloride. These formulations are preferred in hypokalemia with metabolic acidosis (e.g., renal tubular acidosis, diarrhea). Potassium phosphate is used in hypokalemia with low serum phosphate (e.g., proximal type 2 renal tubular acidosis associated with Fanconi Syndrome).

55yo male comes in 3 month history of upper abdominal pain. Appetite decreased, 22lb weight loss.

Suspect for pancreatic mass. CT abdominal Biliary obstruction --> symptoms (jaundice, dark urine, elevated serum bilirubin and other hepatic markers), back pain, ascites, steatorrhea, thrombophlebitis (Trousseau sign)

63yo male has low libido, decreased morning erections, fatigue. Serum testosterone level consistently low, asks for testosterone replacement therapy. What do you want to screen?

Symptomatic Hypogonadism Low testosterone (confirmed on 3 tests 8-10AM/fasting) Prostate Cancer breast cancer, severe or low urinary tract symptoms, hematocrit > 50%, severe sleep apnea, PSA >4 (>3 in high risk), Heart failure Adverse effects: erythrocytosis, venous thromboembolism, possible increased risk of cardiac events.

What medication(s) causes Tardive dyskinesia?

Tardive dyskinesia - abnormal involuntary movement due to prolonged use of antipsychotics or metoclopramide (dopamine receptor-blocking medications). oral facial dyskinesia (tongue protrusion, lip smacking, grimacing), Limb dyskinesia (dystonic postures, foot tapping, chorea), trunk dyskinesia (rocking, thrusting, shoulder shrugging), greater risk with first-generation antipsychotics)

65yo female w/ PMH of bipolar disorder (on lithium and quetiapine) presents with involuntary facial and mouth movements. Been 6 months, also has protruding and twisting movements of tongue and puckering movement of lips, movements have worsened since then. Foot-tapping movements and uncontrollable twisting of neck to right side. Also has T2Dm and chronic gastroparesis on metformin and metoclopramide respectively. Exam: VSS, tongue protrusion, facial grimacing, cervical torticollis, slow gait, reduced arm swing. What's Dx and tx?

Tardive dyskinesia - abnormal involuntary movement due to prolonged use of antipsychotics or metoclopramide (dopamine receptor-blocking medications). oral facial dyskinesia (tongue protrusion, lip smacking, grimacing), Limb dyskinesia (dystonic postures, foot tapping, chorea), trunk dyskinesia (rocking, thrusting, shoulder shrugging), greater risk with first-generation antipsychotics) Discontinue causative medication if feasible (in this case metoclopramide). Switch to 2nd generation antipsychotic (quetiapine, clozapine) if continued antipsychotic is required. Treat with valbenazine or deutetrabenazine.

27yo female comes into office due to hair loss. Small clumps of hair come out when showers or brushes hair. No pain or itching in scalp. Recently had uncomplicated vaginal delivery 3 months ago. Thyroid lab normal. What's Dx and Tx?

Telogen effluvium - one of the most common causes of hair loss in adults, acute, diffuse, noninflammatory hair loss. Hair follicles has 3 phases: growth/Anagen phase 90% follicles, transformative/catargen <1%, resting/shedding phase 10%. In telogen effluvium, widespread shift into rest/shedding phase, with cessation of growth and subsequent shedding. Susually triggered by Stressful event, such as severe weight loss, pregnancy, major illness/surgery, psychiatric trauma. Dx based on clinical. Widespread thinning of hair, but scalp and hair shafts appear normal. Hair Pull Test: small tracts of hair (50-60 fibers) pulled firmly, extraction > 10-15% fibers abnormal and suggests TE. Check CBC (and ferritin), TSH, CHem panel. Tx: Address underlying cause. Reassurance.

What do you recommend to lactose malabsorption individual?

Temporary avoidance may support a diagnosis. Complete avoidance is NOT recommended as most people can tolerate up to 12g of lactose daily (equal to 1 glass of milk). Can incrementally reintroduce small amounts i of dairy into diet. Live culture yogurt try. Need Ca and vitamin D.

What are the tests for H. Pylor infection? When is it important to ensure tests of cure? Which test can be used for test of cure?

Treatment failure rate ranges 10-30%. Confirmation of Cure is recommended in patients at high risk of complications: Confirmed peptic ulcer, Persistent Symptoms following treatment, H. Pylori-associated MALT lymphoma, Gastric Cancer resection. Options for test of cure: Urea Breath Test and Stool Antigen Test. At least 4 weeks following completion of treatment. PPIs held at least 2 weeks before testing. Serologic testing H. Pylori does not discriminate between active and past infection, not recommended.

Anorexia Nervosa OUtpatient vs Inpatient Management Criteria

Underweight BMI <18.5 Fear of gain weight, distorted body image. Treatment: psychotherapy (individual, family, group), Nutritional rehabilitation, plaza pine if severe/refractory Inpatient Bradycarida, HR <40, Dysrhythmia Hypotension < 80/60, orthostasis Hypothermia < 35C) Electrolyte disturbance, marked dehydration Organ compromise (renal, hepatic, cardiac) < 70% expected weight BMI <15

How does lacunar infarct presents? What are they?

Usually small, noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery (e.g., anterior cerebral, middle cerebral, or basilar arteries). Affected areas typically: basal ganglia, subcortical white matter (internal capsule, corona radiata), and pons. most commonly associated with hypertension and likely due to microvascular thrombotic disease. Other Risks: diabetes, smoking, age, increased LDL cholesterol. Common clinical presentation: pure motor hemiparesis (most frequent), pure sensory stroke, ataxic hemiparesis (ipsilateral weakness and limb ataxia), and dysarthria-clumsy hand. As such, right hemiparesis is the most likely finding in this patient with acute left lacunar stroke.

What's exenatide?

glucagon-like peptide-1 analog (GLP-1 analog) improve glycemic control and induce weight loss in overweight diabetics. Can cause acute pancreatitis.

What are risk factors for predispose patient to urinary kidney stones (neprholithiasis)? What recommendation can you make to your patient?

low urinary volume, idiopathic hypercalciuria, hypocitraturia predisposes patient to develop stones. Calcium undergoes passive reabsoprtion in proximal tubule along with sodium and water. A low-sodium diet (<2300mg/24hours) lead to increased proximal tubule Calcium and Na reasborption, decreased Calcium excretion, and a reduced overall incidence of Calcium stones. High Na intake increases urinary calcium excretion and should be avoided. Citrate can form a complex with calcium, thereby decreasing Calcium stone formation. Dietary sources of citrate (e.g., 40x of lemon juice) can also increase urinary citrate excretion. However, lower-than-normal 24-hour urinary citrate excretion (as seen in this patient) is a risk factor for calcium stone formation; citrate supplementation would be indicated to decrease stone formation.

Different degree of Clostridium difficile infection (CDI) mild severe fulminant

mild - watery diarrhea, cramping abdominal pain oral vancomycin severe - WBC > 15 or Cr > 1.5 oral vancomycin or fidaxomicin Fulminant disease - hypotension, ileus, megacolon high-dose oral vancomycin + IV metronidazole Intracolonic (rather than oral) vancomycin suggested fulminant disease who have significant ileus (to increase colonic abx delivery), but be careful because increased risk of perforation risk.