UWORLD/Step 2 IM

What are the MC brain tumors in adults?

"*MGM* *S*tudios" Metastasis Glioblastoma Meningioma Schwannoma *all supratentorial*

Inhibitors of P-450?

"CRACK AMIGOS" Cimetidine Ritonavir Amiodarone Ciprofloxacin Ketokonazole Acute alcohol use Macrolides Isoniazid Grapefruit Juice Omeprazole Sulfonamides

Inducers of P-450?

"Guinness, Coronas, Quilas and PBRS induce Chronic alcoholism" Griseofulvin Carbamazapine Quinidine Phenytion Barbituate Rifampin St. Johns Wart Chronic Alcoholism

What the MC cancer locations that metastasize to the brain?

"Lots of Bad Stuff Kills Glia" Lung Breast Skin Kidney GI (colon)

A 50 yr old pt is hospitalized for a acute anterior wall MI 4 days ago and was tx with thrombolytic therapy. Day 4 of hospitalization she develops recurrent CP similar in quality and severity as the one felt on admission. Vitals are normal and lungs are clear. What are the test to order next?

CK-MB and EKG

26 yr old with fever, fatigue, muscles aches, and arthralgias. Vitals are normal. PE reveals splenomegaly. Peripheral smear shows basophilic lymphocytes with a vacuolated appearance. Heterophile antibodies are negative. Whats the cause?

CMV mononucleosis

A 30 yr old female pt with a prolong history of OTC use comes in complaining of RUQ pain and fullness. PE reveals a hepatomegaly. Labs reveal elevated Alk Phos, and GGT, but normal bilirubin levels. Biopsy of the mass shows mildly atypical enlarged hepatocytes containing glycogen and lipid deposits. AFP is normal. Dx? Tx? Why?

Hepatic Adenoma Surgical Resection because of the risk of rupture or malignant growth

Management of Toxic Megacolon?

IV Fluids, Bowel Rest Broad Spectrum ABx IV Steroids - if IBD induced Surgery if colitis doesn't resolve

An HIV pt presents with a gradual onset of left hemiparesis, difficulty speaking, hyperreflexia, and difficulty walking for the past month. His CD4 is 70. CT of the head shows multiple, hypodense, non-enhancing lesions with no mass effect in the cerebral white matter. What is the most likely cause of this pts symptoms and what imaging is used for a definitive dx? a) whats the name of the disease?

JC virus and MRI of the head. a) Progressive Multifocal Leukoencephalopathy

A 40 yr old pt is coming in complaining of fatigue and nausea for the past couple months. His vitals show hypotension. Labs show hyponatremia, hypernatremia, and eosinophillia. What is the dx if the cosyntropin test does not elevate his cortisol levels? What is the dx if the cosyntropin test elevates his cortisol levels?

No elevation of cortisol after the test = Primary Adrenal Insufficiency Elevation of cortisol after the test = 2ndary or tertiary Adrenal Insufficiency

Do you shock Asystole or PEA?

No, do CPR

An obese pt comes in with complaints of daytime somnolence. He snores at night and wakes up with morning headaches. What is the best next step in this pts management?

Nocturnal Polysomnography (Gold Standard dx)

A pt with a history of cirrhosis, comes in after an episode of coffee-ground emesis and lightheadedness. What are the steps to their management? a) What happens if pt undergoes the proper steps of management and still has bloody emesis?

1. IV Fluids and Empiric Abx 2. *Endoscopy* + *Octreotide* - somatostatin analogue, causes release of vasodilators, which indirectly leads to splanchnic vasoconstriction and *decreased portal flow* a) Balloon Tamponade --> then maybe TIPS or Shunt Surgery

A pt with an acute limb ischemia from an embolus blocking an arterial supply. Management?

1. IV Heparin 2. Surgical Embolectomy or *Intra-Arterial* Fibrinolytics

What artery supplies the midbrain? What cranial nerves are affected in an infarct? What is the presentation?

1. Paramedian Branches of the Posterior Cerebral Artery 2. CN III, CN IV 3. *Contralateral* hemiparesis of upper and lower limbs *Ipsilateral Ptosis, Pupillary Dilation, Lateral Strabismus* (CN III palsy)

What artery supplies the occipital cortex and visual cortex? What is the presentation in an infarct?

1. Posterior Cerebral Artery 2. *Contralateral* hemianopia with macular sparing

Stepwise approach to the tx of cirrhotic ascites?

1. Sodium and Water Restriction 2. Spirinolactone 3. Loops (not more than 1L/day of diuresis) 4. Frequent paracentesis

What serologic marker in an acute Hep B infected pt can be detected during the "window period"?

Anti-HBc IgM

What arteries are the most commonly occluded in thrombotic ischemic stroke?

Basilar and Vertebral Arteries Middle Cerebral Artery

A hyperthyroid pt presenting with hyperthyroid sxs is tx with PTU. 2 weeks later the pts sxs resolve, but new sxs arised. Pts complain of sore throat. Vitals reveal a temp of 101. PE reveals a red and swollen tonsils. What is the cause? What is the next step in management?

SE of PTU which is agranulocytosis *Stop drug and get a CBC*

Unstable Angina Vs Prinzmetal Angina EKG readings?

ST Depresesion vs ST Elevation

A 28 yr old sexually active women comes in complaining about multiple joint pain for the past week. They are located on her knee, wrist, and ankle. Vitals show she is febrile. PE reveals a warm, tender, and swollen left knee joint. Synovial fluid analysis reveals WBC count of 50k. What is cause of her sx? Tx?

She has Gonococcal Septic Arthritis Tx with Ceftriaxone, and give prophylatic azithromycin for Chlamydia coverage *Classic Px* -Tenosynovitis -Pustular Lesions -Polyarthralgias

A 40 yr old pt with myasthenia gravis comes in presenting with pneumonia. She has been on pyridostigmine for the past few months. Pt is febrile. Pulse ox reveals 86% O2 sat on room air but improves to 95% on 40% facemask O2. Her respiratory efforts are weak. There is decline in serial measurements of Vital Capacity. What is the next steps of management?

This pt is undergoing Myasthenia Crisis 1.*Intubate* 2.*Plasmapheresis* (preferred) or IVIG 3.*Glucocorticoids*

A pt with a history of daily alcohol use px with jaundice, anorexia, RUQ pain, and hepatomegaly. There is no evidence of ascites or cirrhosis. What are the expected values of AST, ALT? What else do you expect to be elevated?

*AST x 2 > ALT* (Both values will be less than 500 IU/L) *GGT* (gamma-glutamyltransferase) and *Ferritin*

What is the relationship between hypercalcemia and malignancy?

*80% of Hypercalcemia in the setting of malignancy is due to PTHrP. * -Breast CA commonly does this Other mechanisms include *bone metastasis causing a release of cytokines and inducing osteoclast activity*

60 yr old pt comes in for a routine visit. A pulsatile umbilical mass is found. It is non-tender. Pt has hx of HTN, MI, and peripheral vascular dz. He quit smoking 10 yrs ago. His BP is 160/90, HR is 76. What is the best next step in management?

*Abdominal U/S to look for a AAA*

A 20 yr old female comes in complaining of lower back pain for the past 3 months. She states she has morning stiffness that lasts longer than an hour. She states that exercise helps improve the pain. PE reveals decreased lumbar spine mobility, and tenderness over the sacroiliac joints. What is suspected dx and what is the next best step to dx?

*Ankylosing Spondylitis*. Dx with *Sacroiliac Xray*

What are the extra-artricular manifestations of ankylosing spondylitis?

*Anterior Uveitis* (MC) Inflammatory Bowel Dz Aortic Regurg

40 yr old pt px with -Morning stiffness lasting hours but improves with activity -Symmetric Joint pains in PIP,MCP, Knee -Joints are tender to touch, swollen and limited ROM -There are nodules on back of their forearms -They have cervical neck pain -ESR is elevated What tests will you order to confirm dx?

*Anti-CCP* and Xray for RA -soft tissue swelling, joint space narrowing, and bony erosions

What parameters is an indication for O2 therapy in COPD pts?

*Any one of these criteria* PaO2<55 SaO2<88% Hematocrit >55% Evidence of cor pulmonale

A 56 yr old women is found to have high calcium levels on routine lab testing. She is a 30 pack year smoker. No one else in the family has high serum calcium. Vitals and PE are normal. Serum calcium is 11.2 mg/dL. The pts serum calcium a year ago was 10.9 mg/dL. What is the next best test in the management of her hypercalcemia? Why?

*Check serum PTH levels* because a high level will confirm our suspicions, and a low PTH in a setting of high calcium will clue us on a non-PTH causes such as malignancy

What does a CT scan in an Alzheimer pt look like?

*Diffuse Cortical and Subcortical atrophy*. Temporal > Parietal Lobes.

A pts comes in complaining of SOB recently. His hx indicated that he had an URI 2 weeks ago. His vitals show hypotension. EKG shows alternating amplitude heights between QRS complexes, and overall low voltage. Sinus Tachy was also noted. Whats the next step of mangement?

*Emergent Pericardiocentesis for suspected pericardial effusion* If his vitals were stable, Echo would confirm dx

Acute Angle Closure Glaucoma -Gold standard dx? -What if you can't get a opthalmologic consult?

*Gold standard is Opthalmologic Consult*, where they do a *Gonioscopy* to visualize the iridocorneal angle If that can't be done, then a suspected AAC Glaucoma can be dx via Tonometry

A 30 yr old pt comes in complaining of 2 days of small drops of bright red blood after defecation. He does not see blood mixed into the stool. He has no history or family history of cancers. What is suspected and what is the best next step? a) what if the above test shows nothing?

*Hemorrhoids* are suspected. *Anoscopy* is the next best step. a) If anoscopy doesn't reveal anything then, we do *colonoscopy or sigmoidoscopy*

Asthma vs COPD Long-term Maintenance therapy?

*Inhaled Corticosteroids* vs *Long acting Anticholinergic Inhaler* (Salmeterol)

What do you give a pt if the come in presenting with impetigo? What organism does it cover?

*Mupirocen*. Covers Staph *It can also eradicate MRSA in the nares*

What are some drugs that can lead to Folate deficiency? Via what mechanism?

*Phenytoin, Primadone, Phenybarbital* --> Impair folate absorption *Methotrexate and Trimethoprim* --> inhibiting dyhydrofolate reductase (enzyme in reaction to form active folate) -reverse by *Leucovorin*

What are some of the diabetic autonomic neuropathies?

-Esophageal dismotility -Gastric Emptying problems -Intestinal Malfunction (Diarrhea, Constipation, Incontinence)

BB's vs Octreotide Setting of Esophageal Varices?

*Prophylaxis* tx to reduce likelihood of hemorrage vs Use as a tx during *active* bleeds

The release of aldosterone from the adrenal glands is regulated by what?

*Renin-Angiotensin axis*, NOT ACTH

A 40 yr old man comes in for recurrent falls. During ambulation, the pt prominently flexes his right hips and knees. His right foot slaps to the floor with each step. Romberg sign is absent. What type of gait abnormality is it and what is a probable cause?

*Steppage gait* and probably due to a neuropathy of common fibular nerve

What are the complications seen in acute pancreatitis and why?

-Pleural effusion -ARDs -Ileus -Renal Failure 2/2 to release of pancreatic enzyme systemically causing inflammation and release of cytokines

What are the risk factors of osteoporosis?

-Post-menopause -Poor calcium/vitamin D intake -smoking -corticosteroid use -lack of weight bearing exercise -low BMI -heavy alcohol use

What are the toxic side effects of Amiodarone?

-Pulmonary Fibrosis -hyper/hypo thyroidism -Hepatotoxicity -QT prolongation --> torsades -Smurfism -Corneal deposits

What are PE findings in a pt with Macular degeneration?

-Straight Grid lines appear wavy -Drusen deposits in the macula

How many years does it take a pt to develop diabetic nephropathy after dx of diabetes?

10-15 yrs

A male pt comes in with complaint of severe headache for the past month. The pt states it is unilateral, mainly located behind the right eye. It is a stabbing pain. He denies any associated nausea or visual disturbances. What is the best treatment to abort this pts headaches?

100% Oxygen

Ventricular Free Wall Rupture vs Interventricular Wall Rupture Px?

3-5 days after MI, Pericardial Effusion, Distant Heart Sounds, Cardiogenic Shock, JVD vs 3-5 days after MI, VSD, New Holosystolic Murmur, Hypotension

40 yr old man comes with a complaint of epigastric pain and diarrhea. He has a significant hx of PUD. He has a 20 pack year smoking history, but does not use alcohol or drugs. PE shows abdominal tenderness without rebound or rigidity. EGD shows prominent gastric folds, 3 duodenal ulcers, and upper jejunal ulceration. Which of the following is the next step and why?

A *serum Gastrin test* should be performed because of a *suspected gastrinoma*. Having ulcers reach as far as the jejunum suggest very high acid secretions.

What is orthostatic hypotension? How does it commonly present?

A drop in systolic BP greater than 20mmHg when a person goes from supine to standing. It is common in pts who are elderly, are hypovolemic, or have autonomic neuropathy. Also in pts who take vasodilators, diuretics, and alpha-receptor blockers. Also people with prolonged recumbence.

What is Ecthyma Gangrenosum?

A hemorrhagic pustule with surrounding erythema that evolves into a necrotic ulcer. Often due to *Pseudomonas aeruginosa infection, in a setting of profound neutropenia*

What are the meds that improve the mortality and morbidity of CHF pts?

ACE Inhibitors ARBs Aldosterone Antagonists (Spirinolactone) Beta-Blockers

12 yr old AA boy is found to have murmur during a sports physical. His family has a history of sudden death at a young age. It is harsh crescendo-decrescendo murmur that begins after S1 and is best heard at the lower left sternal border. Valsalva makes the murmur louder. What is the most likley mitral valve abnormality? What else is the cause of the murmur? Dx?

Abnormal Mitral Leaflet Motion Septal Hypertrophy *This kid has hypertrophic cardiomyopathy*

What is the classic presentation of normal pressure hydrocephalus? What is the underlying mechanism?

Abnormal gait, dementia, and urinary incontinence Decrease reabsorption of CSF in ventricles or obstructive hydrocephalus

A 50 yr old women complains of pain behind her right heel for a day. The pain is worse is activities and relieves with rest. She has no fever, back pain, swelling, or a rash. She eats a healthy diet and has no chronic medical problems. Her history reveals she has been taking ciprofloxacin for her UTI for the past 4 days. PE reveals tenderness of the calcaneus. There is no leg swelling. What is the cause of the pts heel pain?

Achilles Tendinopathy

Course facial features, arthralgias, uncontrolled HTN, increase ring size, and carpal tunnel syndrome. What is the dz?

Acromegaly -elevated GH

Gram (+) Anaerobic branching bacteria vs Gram (+) Aerobic branching bacteria. What are they? Tx?

Actinomyces. Tx via penicillin vs Nocardia. Tx via bactrim

A 34 yr old women comes to the ER for right leg swelling, redness, and pain. It s suggest as a DVT via compressive U/S. Further eval reveals an elevated plasma homocysteine level. She is started on Heparin and Warfarin therapy. What other additional therapy is indicated?

Adding Vit B6 (Pyridoxine) and Folate/Vit B12 to reduce the Homocysteine

What intervention reduces the mortality and MI rates of pts with ACS?

Admin of *Aspirin*

What clinical criteria can be used to dx OA?

Age > 50 Minimal or no morning stiffness Bony tenderness Bone enlargement Crepitus No warmth of joint

70 yr old man comes your office for difficulty hearing. His wife states he has been raising the volume on his television much more recently. Pt claims he can hear well when talking to family members, but difficulty hearing in settings such as restaurants. He worked as a shipbuilding for 30 years and has no history significant noise exposure. What is the cause of his sxs?

Age related Sensorineural hearing loss

What is Tamsulosins effect on pts with ureteric stones?

Alpha1 antagonists like Tamsulosin can relax the muscles of the ureter, helping with passing of the stone

Complications of high PEEP?

Alveolar Damage Tension Pneumothorax

60 yr old with anemia, painless GI bleeding, and murmur of aortic stenosis. What dx?

Angiodysplasia

What are ACE-Inhibitors or NSAIDs effects on the renal vasculatare?

Angiotensin II leads to efferent arterioles of the kidney--> increase GFR. *ACE-Inhibitors prevent efferent vasoconstriction* Prostaglandins dilate the afferent arterioles of the kidney. *NSAIDs inhibit prostaglandin formation, thus causes afferent constriction*

A pt is coming in complaining of LE swelling and pain. He has a history of DVT and is being treated with warfarin after being dx with DVT 2 weeks ago. His INR is currently 1.3. A venous doppler US reveals a right popliteal vein thrombus extending to the femoral vein that is worse compared to his image a week ago. What is the best next step in management?

Anti-coagulate him with Rivaroxaban

Mefloquine (low teratogenic), Atovaquone, or Doxycycline vs Chloroquine, Hydroxychloroquine vs Primaquine Malaria chemoprophylaxis in what situations?

Areas w/ *chloroquine resistant P. falciparum* (Sub-Saharan Africa, Southeast Asia) vs Areas with *Chloroquine sensitive P. falciparum* vs Areas without P. falciparum, but other forms of malaria (Mexico, Korea, South America)

What are the MC brain tumors in children?

Astrocytoma Medulloblastoma Ependymoma *Infratentorial*

What is the most common site of ulnar nerve entrapment?

At the *elbow* where the *ulnar nerve lies at the medial epicondylar groove*

What arrhythmia is specific to digitalis toxicity?

Atrial Tachycardia and AV Block

A pt comes in complaining of recurrent and brief episodes where he experiences the room spinning. It usually happens with predictable head movements and position changes. The pt has no tinnitus or hearing loss. What is the dx? What technique can be used to dx? What is the underlying cause? What is the Tx?

BPPV Can use *Dix-Hallpike maneuver* --> will *trigger vertigo and nystagmus* Caused by *canaliths* in the semicircular canals Tx symptoms with *Epley maneuver*. Usually resolves on its own.

Px of Uremic Pericarditis?

BUN >60 Sharp CP, worsened by breathing, better w/ leaning EKG does not show diffuse ST elevations

A 24 yr old man from New York presents with fever, drenching sweat, and malaise for the past week. Past few days he has noted jaundice and dark-colored urine. He recalls being bitten by a tick. He does not smoke or drink. His vitals reveal fever and tachycardia. PE reveals jaundice and no rash. What is the possible dx?

Babesiosis

An immunocompromised pt with cutaneous angioma like blood vessel growths on the skin. Also U/S shows nodular, contrast-enhanced intrahepatic lesions of variable size as well. Dx?

Bacillary Angiomatosis caused by Bartonella henselae -angioma like lesions on skin and visceral organs -Dx via skin biopsy

What is the MCC of isolated aortic regurg in developed vs developing countries?

Bicuspid Aortic Valve vs Rheumatic Heart Dz

25 yr old man from Wisconsin presents to his physician for fever, night sweats, productive cough, and unintentional weight loss. Several days ago he notice multiple skin lesions. He has no known medical problems and takes no meds. He doesnt smoke or drink. He works outdoors as a wood cutter. His temp is 101.1F. Skin exam reveals multiple, well-circumscribed, verrucous, crusted lesions. CXR shows left upper lobe consolidation and two lytic lesions in the anterior rib. What is the possible cause of the mans sx?

Blastomycosis

A young obese female on OCP is complaining of headache. PE reveals papilledema. If left untreated, what is the complication?

Blindness

What are the major SE's of Mycophenolate?

Bone Marrow Suppresion

What are the SE's of Cyclosporine vs Tacrolimus?

Both have nephrotoxicity, hyperkalemia, HTN, and neurotoxicity. Cyclosporine as *Gum hypertrophy and Hirsutism*

What is more common in a pt with a history of abestosis; Bronchogenic CA or Mesothelioma?

Bronchogenic CA

What are the steps to screen for ovarian cancer in a pt with significant family history and tested positive for BRCA gene mutation?

CA-125 and Pelvic Ultrasound

Dx of Spinal Epidural Abscess via MRI. What do you do next?

CT aspiration and culture to guide ABx Surgical Decompression

A 40 yr old pt has Burkitts Lymphoma. He is being tx with combo of chemotherapy and allopurinol. On 3rd day of tx, he noted having decrease urine output and increase BUN and Cr. The pt developed tumor lysis syndrome. What is expected in terms of calcium, phosphate, potassium, and uric acid?

Calcium - Decreases Phosphate - Increases Potassium - Increases Uric Acid - Increases

What is the most common cause of death in a dialysis pt?

Cardiovascular dz

What is the underlying mechanism in Graft-Versus-Host-Disease?

Cell-mediate immune response from "Donor" T-cells

What brainstem structure is commonly damaged by chronic alcohol abusers? Whats the common px?

Cerebellar Dysfunction -gait instability -*truncal ataxia* -*intention tremor* -*difficulty with rapid alternating movements* -hypotonia

A 64 yr old man comes in complaining of frequent falls. For the past 2 months, he cannot stand straight, he keeps falling to his left. He claims his left side has become weak. He also complains of headache, and nausea for the past 3 months. His Vitals are normal. PE reveals difficulty standing with his feet together, even with his eyes open. He also has problems performing rapid alternating movements. Dx?

Cerebellar Tumor

What are sx of Phenytoin overdose?

Cerebellar ataxia, confusion, and *horizontal nystagmus*

A 30 yr old female who went on a vacation to the Carribeans and came back complaining of a fever, malaise, multiple joint pains, and a macupapular rash on her back. CBC shows lymphopenia and low platelets. Dx? How to Confirm?

Chikungunya Fever, and can be confirmed by serology -transmitted by Aedes Mosquito

What are the most common causes of avascular necrosis of bone?

Chronic Corticosteroid and Chronic excessive alcohol use.

Which of the anti-arrhythmic drugs prolong QRS? Why?

Class IC Sodium Channel Blockers -*Flecainide*, Propafenone They have slow dissociation from the sodium channels. When pts have an increased heart rate, the drug is not clearing fast enough, thus slowing depolarization and causing widening QRS.

A 28 yr old female complains about abdominal pain, diarrhea, and 5 pound weight loss in the past 2 months. She states the pain is located in her right lower quadrant and it occurs intermittently. Her vitals are normal. PE reveals several shallow ulcers in her mouth. Abdomen exam reveals tenderness in RLQ with no rebound. Rectal exam reveals mucus. Rectosigmoidoscopy is unremarkable. X-ray of abdomen reveals gas in small and large bowels. Labs show Hb of 10.2 and platelets of 420,000. What is the dx?

Crohns Dz

What geographic area is common for Histoplasmosis, and how is it distributed?

Common in the central and southern US Present in bird and bat droppings

42 yr old man comes to the physician because of progressive swelling of the legs over the past 2 months. He has a hx of stage IIA Hodgkin's disease treated 1 yr ago with radiation therapy to the neck and chest. His temperature is 37C (98.6F), BP is 102/80 mm Hg, HR is 110/min, and RR are 22/min. Exam shows JVD that increases with inspiration. The lungs are clear to auscultation. Cardiac exam shows a nondisplaced point of maximal impulse; heart sounds are distant. An early diastolic sound is heard at the apex. Abdominal exam shows mild distention with shifting dullness. The liver is pulsatile, and its edge is palpated 4 cm below the right costal margin. There is 2+ peripheral edema extending up to the knees. What is causing this pts increased in central venous pressure?

Constrictive Pericarditis

60 yr old Pt comes in presenting with LE edema and increasing abdominal discomfort. He has PMH of DM and s/p mitral valve repair 12 years ago. PE reveals JVD, ascites, and 4+ LE edema. PE also reveals mid-diastolic sound on heart auscultation. CXR reveals clear lungs bilat, and a spotty calcification along the left heart border. Echo reveals enlarged atria, but normal LV, normal RV, and EF of 65%. What is the most likely cause of the pts presentation?

Constrictive Pericarditis

A pt who is severely hyponatremic presents to the ER room. At what rate and with what do you correct the sodium at and why? What happens if the pt is hypernatremic and rapid correction occurs?

Correct sodium at 0.5 mEq/L/hr with 3% hypertonic saline. This is done to *avoid irreversible brain damage from osmotic demyelination* a) Leads to *cerebral edema*

A pt is undergoing status epilepticus. What is the hallmark effect of prolonged seizures?

Cortical Laminar Necrosis

A 30 yr old pt comes in history of severe persistent bronchial asthma requiring multiple medications presents with weight gain over the past several months. He denies changes in diet and activity, or use of alcohol, tobacco, or drugs. Vitals reveal hypertension. PE reveals supraclavicular fullness, areas of easy bruising, and acne. Neuro exam reveals decreased proximal muscle strength. What is the dx? What lab abnormality do you expect to find?

Cushing Syndrome excessive steroid use Labs will reveal hypokalemia and hypernatremia

A 14 yr old pt comes in presenting with recurrent sinupulmonary infections (pneumonia, sinusitis), chronic cough, nasal polyps, and digital clubbing in the context of parental consanguinity suggests what dx? a) What tests will confirm dx?

Cystic Fibrosis a) Quantitative Pilocarpine iontophoresis and measurement of sweat chloride concentration

What hormone deficiencies are seen in panhypopituitarism and what are the presentations?

Deficiency in: 1. *Glucocorticoids* (via low ACTH and low Cortisol) - hypoglycemia, hyponatremia, eosinophilia 2. *Testosterone* (low GnRH) - low libido, erectile dysfunction, small and soft testes 3. *Hypothyroidism (low TSH) - cold intolerance, constipation, bradycardia

What is an infection to medial cathal region of the eye called? What organisms?

Dacryocystitis -commonly caused by Staph aureus and GAS

A 52-year-old woman comes to the physician because of decreased libido; this sx began 8 months ago, after she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata uteri and menorrhagia. She has been taking hormone replacement therapy with conjugated estrogen since the operation. Exam shows a moist, rugated vagina. Which of the following is the most likely cause of these findings? Why?

Decreased Androgens, because the loss of her libido is mainly regulated by androgens. This resulted from losing her ovaries and the fact that estrogen reduces free testosterone

What is the most reliable and predictive sign of opioid intoxication?

Decreased Respiratory Rate

A pt is brain dead, what neurological function is still intact?

Deep Tendon Reflexes -Spinal cord may still function

Hypothyoidism vs Pregnancy (especially third trimester) Mechanism in Carpal Tunnel Syndrome

Deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve, as well as the tendons and synovial sheaths that can cause direct pressure to the nerve vs Accumulation of fluid in the carpal tunnel

A pt had peptic ulcer perforation, so he underwent surgery. Postoperatively, he was complicated with fever and hypotension, which was treated with anti-biotics and fluids. He recovers until post-op day 7 which he developed nausea, vomiting, abdominal pain, and profused watery diarrhea. His temp is 102. HR 120. Lungs are clear. Abdominal exam reveals a healing midline scar with no pus, and tenderness on LLQ. Lab reveals WBC of 17,500 with 75% PMNs. What is dx and whats is the next best step?

Development of *C. Diff Colitis* and we should get a *stool toxin test*

Strabismus vs Amblyopia Definition?

Deviation of the eye due to dysfunction of the EOM vs Loss of function from 1 eye due to developmental defect from lack of neurological use via strabismus, cataracts, etc

A 50 yr olds opthalmoscopic exam reveals microaneurysms, dot and blot hemorrhages, hard exudates, and macular edema in both eyes. His vision has been worsening for the past 5 years. Dx?

Diabetic Retinopathy

30 yr old male from Brazil comes in complaining about exertional dyspnea for the past couple weeks. There is no CP, palpitations, or syncope. PMH is significant for an episode of megacolon, which was tx 2 yrs ago. PE reveals mild JVD and pedal edema. Cardiac exam reveals an S3, but no mumurs. What is the cause of his condition?

Dilated Cardiomyopathy secondary to Trypanosoma Cruzi infection (Chagas Dz) -assoc highly with megacolon and latin america

What is the MOA, and the side effects of diphenhydramine overdose? and how do you reverse it?

Diphenhydramine works by being an anti-histamine and anti-cholinergic drug. Toxicity --> confusion, drowsyness, dry mouth, dilated pupils, blurred vision, reduce gut motility, and urinary retention Tx with cholinesterase inhibitors like physostigmine

What are Sx of anticholinergic toxicity?

Dry Skin Dry Mouth Constipation Urinary Retention Flushing Vision Changes Confusion

A pt is with pyelonephritis comes in and she is treated with IV Ceftriaxone for 3 days. She is improving. Her temperature is dropping and her white count is normalizing. Her sensitivities show she is sensitive to Bactrim. What is the next step in management?

Discontinue the Ceftriaxone and give Bactrim to finish the 10-14 day treatment

69 yr old pt with LLQ pain for 3 days. Complains of sweats and chills. Hasnt passed a bowel movement in 4 days, but there has been flatus. Vomited once and has nausea. Pt has a history of constipation. Vitals shows a temp of 101.3, HR of 110, and RR of 24. PE reveals a tender abdomen to palpation of the LLQ. No organomegaly, bowel sounds are decreased. CVA tenderness is negative. WBC is 14,500. What is the dx? What is the best way to confirm?

Diverticulitis Confirm with *CT abdomen*

In anterior spinal artery infarct, what spinal function is spared and what is not?

Dorsal Columns are sparred (supplied by posterior spinal artery) Corticospinal tract, Spinothalamic tract are affected

What are the major SE's of Azathioprine?

Dose-related diarrhea Leukopenia Hepatotoxicity

What PE findings would you seen in a pt with a damaged CN III? Why?

Down and outward gaze (Inability to look up or medial) Blown Dilated pupil (loss of PNS fxn from the CN III)

A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temp is 37.2 C (99 F), BP is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, HR is 110/min, and RR is 28/min. Exam shows JVD to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An CXR shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. What is the most appropriate next step and why?

Due to pts stable vitals. Perform an Echo to confirm cardiac tamponade

A pt with Crohns dz has a worsening ulcer on her leg for the past 2 months. It started as an inflammatory papule/nodule, and it then progressed to an expanding ulcer with a purulent base and violaceous borders. Dx? Verify with? Tx?

Dx is probably Pyoderma Gangrenosum, and it can verified via Skin biopsy Tx is Corticosteroids

What are the side effects of Levodopa/Carbidopa?

Early on --> *hallucinations*, confusion, agitation, dizziness, and nausea Long term (10 yrs) --> Involuntary movements (dyskinesia and dystonia)

Lewy Body Dementia vs Parkinsons Dz Px?

Early onset of dementia. Has hallucinations vs Early onset of motor symptoms

Px of Diabetic Peripheral Neuropathy?

Early signs of symmetric lower extremity paresthesias, sensory deficits in a stocking-glove distribution, and loss of ankle reflexes. *motor weakness is a late finding*. Seen after years of diabetes

55 yr old pts comes in with epigastric pain that radiates to the back. She is febrile and has a history of asymptomatic gallstones diagnosed 4 yrs ago. He labs show elevated Lipase. She is tx via pain control, IV fluids, and NPO. She recovers and her enzymes tend downwards over the next couple days. What is the next step in management?

Elective Cholescystectomy because gallstones are one of the most common causes of acute pancreatitis

A 19 yr old pt with melena comes in. He denies fever and has normal vital signs. Labs reveal he is anemic. Colonoscopy reveals hundreds of polyps, which were identified as adenomatous polyps with biopsy. What is the next step in tx and why?

Elective Procto-colectomy because if not, 100% risk of cancer

Basal Cell Carcinoma on the Trunk vs Basal Cell Carcinoma on the Face Tx?

Electrodissection/Curettage or Surgical Excision vs Mohs micrographic surgery

Meningitis vs Encephalitis Px?

Encephalitis have more AMS, and focal neurologic defects Also Encephalitis is more commonly caused by viruses, while meningitis is more commonly caused by bacteria

What other cancers beside colon cancer is associated with HNPCC?

Endometrial CA

Metronidazole vs Drainage and Abendazole Tx of Liver Abscess

Entamoeba histolytica vs Echinococcus

70 yr old pt presents with 2 weeks of fevers and generalized weakness. PMH includes hospitalization for pyelo requiring IV abx 3 months ago. He also had an episode of Rheumatic Fever as a child. His temp is 100, BP is 150/86, and HR and RR are normal. There is a new II/VI holosystolic murmur at the apex and tender erythematous lesions affecting the fingertips. The remainder of the PE is normal. What organism is most likely responsible?

Enterococci due to setting of nosocomial UTI

What is the first line treatment of Meniere's Dz?

Environmental and Dietary Mods -low-salt diet

35 yr old presents with a non-painful and firm skin bump that resolves and returns after a couple weeks. The bump is not puritic. The pt has no PMH and no history of smoking, or alcohol. PE reveal a firm subcutaneous nodule, with no drainage. The lesion DOES NOT change shape when pinched at the edges. What is the probable dx? a) what if this nodule was soft and did not regress and recur? b) what if this nodule was hyperpigmented and dimpled at the center when pinched?

Epidermal Inclusion Cyst a) Lipoma b) Dermatofibroma

Rupture of dilated submucosal veins at the gastroesophageal junction vs Rupture of the submucosal arteries of the distal esophagus In the setting of hematemesis?

Esophageal Varices vs Mallory Weiss

What conditions are associated w/ Hep C

Essential Mixed Cryoglobulinemia Membranoproliferative GN Prophyria Cutanea Tarda

A pt px with sx of weight loss, excessive sweating, palpitations, lid lag, but no propoptosis for the last 5 months. Labs show she has low TSH, but high T3/T4. PE reveals a small thyroid gland without nodules or tenderness. Radioiodine uptake by the gland was diffusely decreased. Whats would you her thyroglobulin measurement to be? Possible Eitology? What if her thyroglobulin reading was opposite?

Extremely low -She probably is consuming alot of exogenous thryoid hormone If she had a high Thyroglobulin count then -Thyroiditis (lasts less than 8 weeks) -Iodine exposure (prevents uptake) -T3/T4 hormone production from another source

What are the criteria to differentiate pleural fluid as exudative vs transudative?

Exudative if *fluid protein/serum protein > 0.5* OR Exudative if *fluid LDH/serum LDH > 0.6* OR Exudative if *pleural fluid LDH is 2/3 > upper normal limit of normal LDH*

A pt has HIV. UA shows 3+ proteinuria. What is the most common form of kidney disease in this pt?

Focal and Segmental Glomerulosclerosis

What is Todds Paralysis?

Focal neurologic deficit last several days after a Sz Generally seen with partial Sz

A 50 yr old pt just had an anterior wall MI, verified by EKG. His vitals are 110/80, HR of 60, RR of 30 and O2 sat of 90% on 4L nasal canula. PE reveals bibasilar crackles halfway up the lung fields. He is given aspirin, clopidogrel, and statin. What else do we need to give him?

Furosemide for the pulmonary edema 2/2 to MI

What are the common SE's of Methotrexate? What can be given to reduce the adverse effects?

GI *Oral ulcers* *Hepatotoxicity* Pulmonary Toxicity Bone Marrow Suppression *Give Folate*

Which Anti-Diabetic Drugs prevent weight gain?

GLP-1 Analogs (Exenatide, Liraglutide) SGLT-2 Inhibitors

Pt presents with hypothyroid sxs. Labs reveal increased serum free T3 and T4. TSH is normal. What can explain the px in the setting of these labs? a) what is seen in subclinical hypothyroidism?

Generalized Resistance to Thyroid Hormone a) No sxs of hypothyroidism, normal circulating T3/T4 and high TSH.

28 yr old man comes in for complaint of bilateral LE weakness. He had an URI 2 weeks ago, which resolved. PE reveals flaccid paralysis, mild parasthesias, and hyporeflexia. Sensation is intact. Dx? What will you see on CSF? Tx?

Guillian Barre CSF will show elevated protein, with everything else normal Tx is Plasmapharesis or IVIG

What cancer is HPV associated with in men?

HPV strains 16 and 18 are associated with Sqaumous Cell CA of the anus, genitals, and throat

What is the most common risk factor for aortic dissection?

HTN

A 50 yr old man with progressively worsening exertional dyspnea over the last 4 months comes to your office. He has no fever, orthopnea, cough, or ankle swelling. He does not use tobacco or alcohol. The pt works for a home insulation and plumbing company. He has no pets or had recent travels. His vitals are normal. PE shows digital clubbing and fine bibasilar end-inspiratory crackles. Jugular venous pressure is 5 cm. There is no peripheral edema. What is the dx? What mechanism is causing his sxs?

He has *asbestosis*, which a restrictive lung disease. He has *decreased diffusion lung capacity*

A pt of European Descent has a shiny tongue, ataxis gait, and loss of vibration of his lower extremities for last 2 months. He has a history of becoming a vegan in the past 5 months. Labs show macrocytic anemia. Was this pts symptoms cause by pernicious anemia or vegan diet? Why?

He has Vitamin B12 Deficiency 2/2 to Pernicous anemia because Vit B12 stores takes 3-5 yrs to deplete. Being a Vegan for 5 months woulnd't be the cause of these symptoms.

What does a combination of normocytic anemia, elevated reticulocyte count and a predominantly indirect hyperbilirubinemia suggest?

Hemolytic Anemia

Spherocytes Microcytic Anemia Increase MCHC Coombs Negative Dx?

Hereditary Spherocytosis

What is Ichthyosis Vulgaris?

Hereditary condition where skin is normal at birth but gradually progresses to dry scaly skin. Px-Dry, and rough with horny plates over the extensor surfaces of the limbs

A 26 yr old female presents with a new onset seizure. For the past 2 days she has been having HAs and a fever, which ibuprofen and tylenol have not helped. This AM the family found the pt behaving strangely. The pt has no family Hx of seizures. Pt is lethargic and confused. She is febrile. PE reveals hyperreflexia. CBC and CT head scan came back normal. Spinal tap of CSF reveals 90% lymphocytes, high protein and normal glucose. What do you suspect is going on? a) what part of this pts brain is being affected? b) what test will verify the cause. and what is the best tx?

Herpes Encephalitis by HSV-1 a) temporal lobe b) PCR for HSV DNA. Best tx with acyclovir

80 yr old man presents with rash over his forehead, tip of his nose, and left eye. There is complaint of pain and decreased vision. He has fever and a burning sensation over left eye for past 5 days. PE reveals a vesicular rash over the left periorbital region and eyelids. Left eye is red, with chemosis of the conjunctiva. Dendriform ulcers are seen on cornea. What is the Dx?

Herpes Zoster Opthalmicus

45 yr old immigrant comes in complaining of worsening sore throat, and difficulty swallowing for the past 24 hours. His voice is muffled and he is drooling. He also has a harsh shrill associated with respiration. He is febrile, blood pressure is 120/80, HR is 106, and RR is 22. PE reveals enlarged cervical LNs and tender larynx. What are the 2 most common organisms that cause this?

Hib and Strep pneumo

Give Heparin prior to Dx Testing vs Dx Testing then Heparin if needed Setting of suspected PE

High Suspicion of PE vs Low Suspicion of PE

Post-transplant pt, what do you do if there is an acute rejection?

High dose steroids

A 70-year-old man comes to the physician because of urinary hesitancy and frequency for 9 months. His temperature is 37.5 C (99.5 F). Exam shows a circumcised penis with no urethral discharge. Testicular exam shows no abnormalities. Rectal exam shows an enlarged rubbery prostate that is nontender to palpation. Urinalysis shows many leukocytes and no erythrocytes. Gram's stain of urine shows gram-negative rods. Which of the following is the most likely cause of this patient's condition? Infection of prostate or Outflow obstruction of bladder? Why?

His symptoms are due to BPH causing obstruction outflow. The UTI is secondary to the obstruction outflow. Also he currently doesn't have prostatitis right now cause his prostate is nontender.

What two modalities in the tx of COPD pts have shown to decrease mortality?

Home O2 therapy and Smoking Cessation

CO Poisoning vs Cyanide Poisoning vs Methemoglobinemia Hx/Px?

Hx of smoke inhalation, Pinkish-red skin vs Hx of burning rubber or plastic, Bitter almond breath vs Cyanosis and bluish discoloration of skin and oral mucosa

An asian-american pt comes in complaining of abdominal cramps, bloating, flatulence, and explosive watery diarrhea for the past week. She notices symptoms occur after eating meals. She admits to eating alot of diary products. She denies weight loss, bruising, or bone pain. What tests would you run on her to help confirm the dx? a)what if the tests came back positive, what is the dx? b)will the pt have an increase or decrease stool osmotic gap?

Hydrogen Breath Test a) the pt has Lactose Intolerance b) increase stool osmotic gap

40 yr old with a significant smoking hx comes in presenting with 2 days of bilateral hand pain that is most severe at his wrists. PE reveals bilateral wrist tenderness, thickening of distal fingers, and convex nail beds. Chest exam reveals decreased breath sounds and prolonged expiratory phase. What is the dx? a) What is the most appropriate next step, why?

Hypertrophic Pulmonary Osteoarthropathy -*arthropathy and digital clubbing in setting of lung diseases* a) CXR because we need to see if lung pathology is present (TB, COPD, Lung CA)

Hypertensive Nephropathy vs Diabetic Nephropathy Affects on kidney structure?

Hypertrophy and fibrotic narrowing of the renal arterioles vs Basement membrane and mesangial thickening

Besides being idiopathic, what conditions are associated with Pseudogout?

Hypomagnesemia Hyperparathyroidism Hemochromatosis

70 yr old female is coming in complaining of difficulty remembering important things. She describes poor concentration and daytime sleepiness. She has a Fam hx of chronic leukemia. She is not a smoker or consumer of alcohol. Her appetite is decreased but she is gaining weight. She has visited an otolaryngologist for hoarseness of recent onset. She takes OTC laxatives for constipation, and occasional aspirin for knee pain. PE reveals a non-tender and mild enlargement of her anterior throat. What is the likely cause of her presentation? a) Why is it not Alzheimer's?

Hypothyroidism a) Early signs of Alzheimer's are visuospatial problems like getting lost in their own neighborhood and anterograde memory formation, NOT old memories.

A 50 yr old pt with extensive history of diabetes controlled with insulin comes in for a follow up. He denies any alcohol or drug use. The pts last Flu shot was last year, and his Tdap was 12 yrs ago. Which of the follow vaccinations should this pt receive this visit? a) What if he had no spleen, what would vaccine would you give him? b) What if he had no comorbidities, but was 67 yrs old?

IM Flu Shot Tdap PPSV23 a) IM Flu Shot Tdap PCV13, and PPSV23 (8 weeks later) b) PCV13, and PPSV23 (8 weeks later)

A pt is in the ER after a MVA. He has severe pains in his right thigh. There is evidence of deformity. He has a history of extensive opioid drug abuse, and he finished his rehab 2 years ago. He has been clean ever since. What do you give him as an analgesic?

IV morphine -ethical responsibility to treat pain

PET scan or Biopsy vs Surgical Resection Which initial step of management to perform in a setting of a incidental discovery of solitary pulmonary nodule?

If pt has low-intermediate risk factors for malignancy and if the nodule size is > 8mm vs High risk factors for malignancy, regardless of size

A 60 yr old women comes in complaining of recurrent lung infections. She was given azithromycin 2 weeks ago and it did not help. She also has complaints of low back pain. She does not drink or smoke. PE reveals bilateral scattered rales. Labs shows Hb 8.4, BUN/Cr of 34/2, and Calcium of 10.9 What mechanism is causing this pt to have recurrent infections?

Inability to produce effective antibodies because she has Multiple Myeloma

How does Benzos affect sleep?

Increase N2 Sleep, but decrease N3 Sleep (*where night terrors and nocturnal enuresis occur*)

How is diabetes associated with Non-alcoholic Steatohepatitis?

Increase insulin resistance leads to increased peripheral lipolysis, TG synthesis, and hepatic uptake of fatty acid. This leads to increase intrahepatic FA oxidation, which increases oxidative stress and inflammation undergone by the liver

Hypodense vs Hyperdense (more white) CT Findings of Cerebral Vascular Accidents?

Infarct/Stroke vs Hemorrhage

35 yr old man comes in with a complaint of low grade fever and progressive weakness for the past 2 weeks. He has a long history of a heart murmur and does not use illicit drugs. PE reveals splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur. His ESR is 96. UA reveals hematuria, and +1 protein. What is the Dx? a) What cardiac valve abnormality does this pt most likely have?

Infective Endocarditis a) MVP or Mitral Regurg.

Joint aspiration reveals translucent or opaque fluid, with 2000 - 100,000 WBCs, and 50% PMNs. Whats happening? a) What if it was 50,000 - 150,000 WBCs, and 80% PMNs?

Inflammatory Joint. Seen in RA or Crystal Arthropathies a) A Septic Joint

Joint aspiration reveals clear fluid, with < 200 WBC, and < 25% PMNs. Whats happening? a) What if it was 200 - 2000 WBC and 25% PMNs?

Its a normal joint. a) Non-inflammatory joint aspiration. Seen in OA.

What are the 3 Classifications of intestinal polyps? Among the neoplastic polyps, what characteristics dictate malignant potential?

Intestinal Polyps -Hyperplastic --> MC non-neoplastic -Hamartomatous --> Juvenile polyps, non-malignant -Adenomas --> MC type of polyp. Potential to be malignant Types of Adenomas -*Sessille* (more malignant) or Stalked -Histologically *Villous* (more malignant) or Tubular

Unilateral Optic Nerve Lesion Vs Unilateral Optic Tract Lesion vs Unilateral Visual Cortex Lesion Visual Field Px?

Ipsilateral Anopsia (total blindness) vs Homonymous Hemianopsia of Contralateral Side vs Hemianopsia w/ Macular Sparing of Contralateral Side

A pt has ACS, what would happen if they got administered lidocaine?

It decreases the risk of V-Fib but *INCREASES the risk of asystole*

What are Estrogens affect on Thyroid Binding Globulin? a)What happens with increase TBG in a pt who is hypothyroid?

It increases the production of TBG -Increase Total T4 in serum -Unchanged in Free T4/T3 a) Increase TBG will show a increase in Total T4 in blood work, but it is masking the hypothyroidism, thus pts will need thyroid treatment

How does Acetazolamide help tx Pseudotumor Cerebri? What to do if it is refractory to medical tx?

It inhibits choroid plexus carbonic anhydrase --> *decreasing CSF production* Then perform *Optic Nerve Sheath Decompression or Lumboperitoneal Shunt*

68 yr old pt comes in with sudden chest pain. Her HR is 60, BP is 80/50, and RR is 14. PE shows elevated jugular venous pressure and positive Kussmauls sign. Her lungs are clear. EKG shows ST elevation in leads II, III, AVF. and ST depression in leads I and AVL. What is the dx and what is the first step in management?

It is a *right ventricular MI* *Give IV fluids* and NOT Nitroglycerin or Diuretics. Need high preload to sustain blood pressure

Membranoproliferative Glomerulonephritis type 2. What is seen on kidney biopsy? Via what mechanism?

Kidney Biopsy under EM --> dense deposits with GBM -stained positive for C3 -IgG antibodies targeting the *C3 convertase* of the alternative complement pathway --> *persistent compliment activation and kidney damage*

What are the Urease producing UTI organisms?

Klebsiella Staph Proteous Pseudomonas Providencia

What infections are associated with iron overload states like hemochromatosis?

Listeria Vibrio vulnificus Yersinia enterocolitica

What intervention has been proven to reduce morbidity and mortality of COPD pts?

Long-term supplemental O2

What is the tx of choice of treating acute agitation in elderly pts who have delirium?

Low-dose Haloperidol

A pt is diagnosed with PAD. What is the pt expected to suffer from in the next 5 yrs; MI or Below-the knee amputation?

MI because having PAD is a coronary artery disease equivalent.

An HIV pt with a CD4 count of 400 is coming in for a check up. He has no complaints and has an unremarkable exam. He is currently not any medications. He has lived abroad as a child and has claimed to have gotten all his childhood immunizations. What live vaccines are warranted for this HIV pt? a) what if his CD4 was less than 200?

MMR and Varicella Zoster Vaccine a) he would not warrant any live vaccine injection

A Crohns Dz pt comes in presenting with bilateral numbness/paresthesias, impaired proprioception and vibration sense, and a ataxic gait. What is the first test to dx her new sxs? What would be seen on CBC? What else is specifically elevated in this pts condition?

Measure serum Vit. B12 levels Macrocytic anemia *Elevated Methylmalonic Acid*

What is the first line treatment for all prolactinomas (Micro or Macro)? a) What are the sxs of prolactinomas? And what do you do if medical tx does not resolve pts sxs?

Medical Therapy with *Bromocriptine or Cabergoline* a) *Sxs are amenorrhea, galactorrhea, bitemporal heminopsia, hypogonadism in men.* If Sxs do not resolve, *surgically remove tumor*

Pt presents with recurrent episodes of vertigo, ear fullness, unilateral hearing loss and tinnitus. What is the dx?

Menieres Dz

A 62 yr old comes in for fatigue and weight loss. He smokes 1 pack a day for the past 35 yrs. He has not seen a doctor in 15 yrs. His vitals are normal. PE is normal except for a an enlarged liver. Rectal exam reveals a slightly enlarge prostate that is nontender. CT scan shows multiple lesions on the liver. What is the most likely cause?

Metastatic malignancy

Homeless male. Increased osmolar gap. Headache. Nausea. Vomiting. Optic Disc hyperemia. What is the cause? a) if it showed renal damage, and presence of calcium oxalate crystals (retangular, enveloped shaped) ?

Methanol a) Ethylene glycol

What are the risk factors for C.Diff colitis?

Recent Abx use Hospitalizations Comorbid Illness (ESRD, Dialysis) Prolong PPI or H2 Blocker use

A 25 yr old pt with a hx of AIDs is coming in complaining about painful discharge and redness in her left eye for the past 10 days. She also has scattered lesions that arose 3 weeks ago. The lesions are 2-5mm and are pale, shiny, dome shaped papules with centrla umbilication. Her CD4 count is 100. Dx? Organism?

Molluscum Contagiosum, caused by Poxvirus

A 48 yr old overweight man comes to the physician for evaluation of a right foot ulcer that he noticed 3 weeks ago. PMH of HTN, DM2, and HLD. 20 pack year smoker. Does not drink. Vitals are normal. PE reveals a 2x2 cm ulcer on the plantar surface of the great toe. What test will best assess the pts risk of foot ulcers?

Monofilament testing for Diabetic Neuropathy

A pt presents with footdrop, excessive hip and knee flexion , and slapping foot sounds while walking. The pt also has sensory loss and weakness. What is the cause of this pts symptoms?

Motor Neuropathy -usually *L5 radiculopathy* or *neuropathy of common fibular nerve*

What arrhythmia is associated with COPD?

Multifocal Atrial Tachycardia

What demyelinating disease is associated with trigeminal neuralgia?

Multiple Sclerosis

Normal Neuro Exam, Negative SLR, Possible Paraspinal Tenderness. Older Age. vs L4-L5 Radiculopathy, Positive SLR, Possible Neuro Deficits vs Seen in Older age, Better with Flexion, worse with Extension vs Better with activity, no improvement with rest, gradual onset. Normal Neuro. Younger Age. vs Difficulty voiding, saddle anesthesia, LMN signs, weight loss, worse at night. What are the different etiologies of Low Back Pain?

Muscle Spasm, or DDD vs Herniated Disk vs Lumbar Stenosis vs Ankylosing Spondylitis and other seronegative spondylarthropathies vs Metastatic Cancer

Reactive Arthritis vs Gonococcal Septic Arthritis Tx?

NSAIDs vs Abx

Would you expect to see splenomegaly in the setting of aplastic anemia?

No

A pt comes in to the ER complaining of severe pain and swelling of her left leg. She fell 2 days ago playing soccer and suffered a mild painful abrasion on her posterior left thigh. Pain has worsened, and spread to the proximal butt and calf. Pt also complains of fatigue and chills. Vitals show hypotension, tachypnea, and fever. PE reveals swelling and moderate erythema of the traumatized area. CT scan shows air under the deep tissue. What is the Dx? What is the next best step in management? What is the etiology?

Necrotizing Fasciitis Surgical Debridgement and Broad-Spectrum Abx Polymicrobial

Whats the mechanism behind Niacin induced facial flushing?

Niacin causes the release of histamines and prostaglandins causing vasodilation and flushing

Thorocentesis vs Diuretics In the setting of pleural effusion on CXR. What test to do first?

No Signs of Cardiac Heart Failure vs Signs of Heart Failure

What are the general contraindications to thrombolytic therapy in a ischemic stroke pt?

Recent Surgery Anticoagulation Recent Hemorrhage BP > 185/100

What is the px of Reactive Arthritis?

Non-gonococcal Urethritis Asymmetric Oligoarthritis (spine and knees) Conjunctivitis Also -Mucocutaneous lesions -Enthesitis (tendon pain)

Non-ketotic Hyperosmolar Syndrome. How does it Px? Whats its mechanism behind causing acute blurry vision?

Non-ketotic Hyperosmolar Syndrome -DM2 -Highly elevated glucose -Dehydration and Hyperosmolarity 2/2 to osmotic pull from glucose Acute blurry vision is due to *myopic increase in lens thickness and intraocular hypotension* 2/2 to hyperosmolarity

A 60 yr old male with recent cardiac cath 6 days ago is coming in complaining of nausea and abdominal pain. PE reveals painless, purple mottling of the skin of both feet. What lab results do you expect to see on CBC, BUN, and Cr, and compliment proteins? What is the cause of these sxs?

Normal CBC except *eosinophila*. *Elevated BUN and Cr* *Decrease in Compliment* Dislodge cholesterol embolisms

Pseudotumor Cerebri vs Normal Pressure Hydrocephalus Imaging and LP opening Pressure?

Normal ventricles, and elevated opening pressure vs Dilated ventricles and normal pressure

BMI > 30, Daytime hypercapnia, and complaints of somnolence, fatigue, and exertional dyspnea. Dx?

Obesity Hypoventilation Syndrome

A 30 yr old asymptomatic pt comes in for a general check up. EKG reveals premature atrial beats. What is the next step in management?

Observation

21 yr old asymptomatic pt with no PMH is shown to have multiple non-tender, rubbery cervical lymph nodes at 1cm in size. Whats the next step in management?

Observation -soft LNs in an asymptomatic pt is often benign

A pt came in after a grand-mal seizure. The pts vitals and PE was unremarkable. His labs show metabolic acidosis. What do you do?

Observe and Repeat labs after 2 hours -it is a transient metabolic acidosis secondary to increase lactic acid

A women under 35 years old comes in complaining of a rubbery, firm, mobile, and painless mass on her upper outer quadrant of her right breast. US shows fluid. Fine needle aspiration yields clear fluid. Then the mass disappears. Whats the next step? a) what was the cause?

Observe for 4 weeks. a) Fibrocystic Changes

A 35 yr old pt with Ulcerative Colitis of both left and right side of the colon for 8 years comes in for a routine check up. He complains of occasional abdominal cramping and infrequent diarrhea, but overall his condition is under control. His last flare up was 6 months ago. What should be the next step in managing this pts condition?

Offer Colonoscopy now and then start surveying Colonoscopies every 1-2 years after. -An UC pt that had the dz for 8 yrs should start getting colonoscopies every 1-2 years.

A 25 yr old pt with a significant smoking history comes in complaining of cough, chest discomfort and SOB on exertion. He has also noticed a 10 pound wt loss over 2 months. PE is unremarkable. CXR reveals a large anterior mediastinal mass. Blood work shows elevated B-HCG and AFP. What is the diagnosis?

One of the nonseminomatous germ cell tumors

Moderate vs Severe Management of COPD Exacerbation in addition to inhaled bronchodilators (Albuterol, Ipratropium)

Oral Prednisolone vs IV MethylPrednisolone

What is the most common adverse effect associated with inhaled corticosteroid use?

Oral Thrush

A 45 yr old female noticed that for the past 3 months she has excessive hair growth on her face and body. She normally has regular cycles but she has missed her period for the last 3 months. She denies any hot flashes or vaginal discomfort. PE reveals a normal weight female, with what appears to be a masculine and enlarged clitoris. What is the next step in management, and what is the possible cause?

Order *serum testosterone and DHEAS* levels. Possible due to an *androgen secreting ovarian or adrenal tumor.*

A 30 yr old farmer comes in for attempted suicide. His body and clothes are soiled with vomitus. He has no PMH or meds. His vitals reveal BP of 11/60, HR of 50, temp 98F, and RR of 22. PE reveals watering eyes, and miosis bilaterally. Lung reveals widespread rhonchi, and abdomen reveals increased bowel sounds. Neuro exam reveals muscle fasciculations. Dx? Next step?

Organophosphate poisoning 1. Remove his clothes 2. Give Atropine and Pralidoxime

34 yr old female pt comes in complaining of purulent vaginal discharge and lower abdominal pain. She has no hx of illicit drug use. PE reveals a friable cervix coated with mucupurulent discharge. Gram stain reveals intracellular gram(-) diplococci. She is started on azithromycin and ceftriaxone. What other tests does she need and why?

Pts with PID should be screened for other STDs such as -HIV -Syphillis -Hep B -Cervical Cancer

50 yr old women with a strange itchy rash on her left areola for the past month. The lesions does not resolve with any OTC steroids. PE reveals an exzematous plaque on the left nipple. Biopsy shows large cells surrounded by halo-like areas invading the epidermis. Dx?

Pagets Dz of the Breast -it is an Adenocarcinoma

How does Trousseau's Syndrome present and what does it indicate?

Pain, itching, and red streaks (unexplained superficial venous thrombi) It *indicates an underlying cancer* -*mc pancreas* -lung, prostate, stomach, and colon

How does Erythema Nodosum px? Dz where you can see Erythema Nodosum?

Painful, subcutaneous nodules developing on the anterior surface of the lower legs Seen in -Sarcoidosis -TB -Histoplasmosis -Coccidioidomycosis -Inflammatory Bowel Dz -Recent Strep Infection

What are the renal complications of a pt with sickle cell trait?

Painless Hematuria (via renal papillary necrosis) UTI Renal Medullary CA

A 45 yr old pt with hyperparathyroidism presents with hypercalcemia. He has asymptomatic. DEXA scan shows no osteoporosis and his GFR is normal. What is the tx plan?

Parathyroidectomy -use a sestamibi scan to localize lesion

A pt presents with short steps and shuffling gait. They also have associated resting tremor, postural instability, and bradykinesia. What is the cause?

Parkinsons Disease

24 yr old female comes in complaining of knee pain. Pain located over anterior knee and has gradually worsened. Atraumatic. Sharp pain when climbing stairs. Ibuprofen did not help. No PMH. Vitals normal. PE of knee is normal. What is the suspected dx and what is the next step to help confirm it? a) How do you tx?

Patellofemoral Syndrome *Perform Extension of the knee, while compressing patella*. Pain = highly suggestive of PFS a) Tx - Exercises to strengthen and stretch thigh muscles.

A 40 yr old pt comes in complaining of sudden onset of blisters on his body. He first noticed them in his mouth a couple days ago. His vitals are normal. PE reveals flaccid bullae over the normal-appearing skin, and large erosion sites of where the bullae had ruptured. Slight rubbing of the uninvolved skin causes easy ripping of the epidermis. Immunofluorescence shows deposits of IgG intracellularly in the epidermis. Whats the Dx? a) What is used for Tx?

Pemphigus Vulgaris a) steroids

A 50 yr old man comes in with complaints of worsening weakness and exertional dyspnea over the past 2 days. He recently recovered from a URI 3 weeks ago. He denies CP or palpitations. Vitals reveal that he is hypotensive and tachycardic. PE reveals JVD and muffled heart sounds. Lung exam was unremarkable. What is the dx and what underlying mechanism is leading to his symptoms?

Pericardial Effusions or Cardiac Tamponade Underlying mechanism is a decrease in venous return to the heart due to increase intrapericardial pressure. Overall leads to to *decreased preload, stroke volume, and cardiac ouput.*

A 30 yr old man is being treated for renal failure secondary to post-strep glomerulonephritis. On the third day of hospitalization he complains of retrosternal, non-radiating chest pain that is relieved by leaning forward. His vitals are normal. PE reveals muffled and squeaking heart sounds at the left sternal border. ECG shows non-specific T-waves. Echo reveals trivial pericardial effusion. CXR is normal. UA reveals hematuria, red cell casts, and mild proteinuria. Labs reveal a BUN of 62 and a Cr of 3.8. What is the dx and what is the cause of it? What is the next best step in management?

Pericarditis, caused by Uremia. Tx it with hemody

What is the mechanism behind the anemia, leukopenia, and thrombocytopenia in SLE pts?

Peripheral Immune-mediated Destruction

What is the characteristic presentation of Parkinsons?

TRAPS -Tremor (Resting) -Rigidity (Cogwheel) -Akinesia/Bradykinesia -Postural Instability -Shuffling Gait

What is the most common cause of bleeding, ecchymosis, or epistaxis in pts with chronic renal failure? How? Tx?

Platelet Dysfunction secondary to elevation in uremia, and other various toxins. -PTT and PT are norma -*abnormal Bleeding Time* -*Platelet Count is normal* Tx w/ *Desmopressin (DDAVP)* to increase release of factor VIII -Cryoprecipitate and Conjugated Estrogens are used as well

An IV drug user comes to the hospital complaining of right arm redness, swelling, and pain. His temp was 102. He was given clindamycin. The next day his temp improved and the swelling and redness has improved. However, he developed nausea, vomiting, abdominal cramps, and diarrhea. The pt is restless and asks for pain meds to treat his aching muscles and joints. His vitals are normal, except an elevated BP. Labs show a normal white count. What is the cause of his acute symptoms?

Possible drug withdrawals

What drugs/substances can cause esophagitis from consumption?

Potassium Chloride Aspirin and NSAIDs Alendronate Tetracycline

A history of a middle age man that has to hold his books at arms length in order to read is a classic presentation for what condition?

Presbyopia -*age related decrease in lens elasticity* --> *prohibits accommodation* for object brought close up

How to prevent radioactive iodine induced ophthalmopathy in pts being treated for Graves Dz?

Pretreat with Glucocorticoids -decreaes peripheral conversion of T4 to T3 --> blunting activity of thyroid hormone

Destruction of Intrahepatic Bile Ducts vs Fibrosis of Intra and Extrahepatic Bile Ducts Dz?

Primary Biliary Cirrhosis vs Primary Sclerosing Cholangitis

45 yr old male comes in presenting with complaint of pruritis, jaundice, and dark urine for the past 2 weeks. Vitals are normal. PE reveals xanthelasmas and yellow sclerae. Abdominal exam is normal. Lab findings show elevated Alk Phos and Conjugated bilirubin. Liver Biopsy reveals chronic destruction of the small interlobar bile ducts, but no fibrosis. Dx? How to Confirm? What else would you see on labs?

Primary Biliary Cirrhosis, confirm by *anti-mitochondrial Ab* Other associated lab findings are elevated cholesterol and IgM

A 56 yr old pt comes in for a follow up. She has chronic kidney disease secondary to NSAID use. She has a history of kidney stones. Labs reveal hypercalcemia, elevated PTH, and normal phosphorus. Her baseline Cr is 1.6. DEXA scan reveals osteoporosis. What is the cause of these symptoms?

Primary Hyperparathyroidism

32 yr old women complains of a nagging cough over the last 8 weeks. The cough is present during the day and awakens her at night. There is no associated SOB, CP, or wheezing. She has a PMH of chronic rhinorrhea and occasional itching skin rash. CXR was normal. One week of tx with chlorpheniramine significantly improved her symptoms. What was the cause of her symptoms?

Probably Post-nasal drip, which the anti-histamines help stop

52 yr old male comes in complaining of dark urine for the past 2 days. Has hx of alternating bouts of bloody diarrhea and constipation for the past year. Vitals are normal. PE reveals a pale, cahetic male with no apparent distress. Mild hepatomegaly is present. Labs reveal elevated bilirubin and Alk phos. CBC shows microcytic anemia. AFP is normal. U/S shows multiple hepatic nodules of varying sizes. Whats the cause of this pts condition?

Probably a colonic cancer metastasized to the Liver causing the above symptoms.

A 78 yr old pt has cancer. They are losing weight and have no appetite for the past 2 months. Pt denies nausea or vomiting. What is the best tx for this pts anorexia?

Progestin or Corticosteroids

What is Tick-Borne Paralysis?

Progressive Ascending Paralysis after a Tick Bite, and release of neurotoxin -no fever -no autonomic dysfunction -normal sensation -CSF is normal Tx by removing tick

What to do with a HIV pt who is PPD positive but asymptomatic and has a negative chest xray?

Prophylactic INH w/ pyridoxine for 9 months

What is the best initial tx of hyperthyroidism until the underlying cause is identified?

Propranolol

What are the 3 inputs that help maintain balance in a person? Romberg tests what function?' Finger to nose tests what function?

Proprioception Vision Vestibular apparatus Romberg tests proprioception (dorsal column function) Finger to nose tests cerebellar function

What is Aspirin Exacerbated Respiratory Disease?

Pseudoallergic reaction to NSAIDs. Due to blocking of the COX pathway, the LOX pathway is upregulated, leading to increase Leukotrienes that causes bronchospasms. -common in pts with *comorbid asthma, chronic rhinosinusitis with nasal polyps*

A 34 yr old obese female comes in complaining of headache, blurry vision, and a whooshing sound in her ears for the past 3 months. PE reveals papilledema. An MRI was ordered and there was no mass, no hemorrage, and no thrombosis. A lumbar puncture was done and showed opening pressure of 280 and an unremarkable CSF analysis. What is the dx?

Pseudotumor Cerebri

How to manage exercise induced bronchoconstriction?

Pt exercises couple times a week --> *Short acting B-Agonists 10 minutes before exercise* Pt exercises every day --> *Inhaled Steroids or Oral Antileukotrienes (Monteluekast) before exercises*

A 43 yr old pt experiences severe RUQ pain, jaundice, and fever. U/S reveals a dilated common bile duct with stones in both duct and gallbladder. Dx? What to do if initial tx doesn't work?

Pt has Cholangitis, and should be given IV fluids and Abx If Abx don't work, then do *ERCP to remove the obstruction*

48 yr old man comes to the ER of generalized bone pain. He had small-bowel resection 4 months ago. He is on mesalamine and infliximab, but not on prednisone. His pain is more severe at the pelvis and lower extremities. X-ray of L-spine shows decreased bone density with blurring of the spine. X-ray of the femoral neck shows pseudofractures bilaterally. What levels of serum Calcium, Phosphate, and PTH are expected?

Pt has Osteomalacia from Vit D Malabsorption -Ca is low -Phosphate is Low -PTH is high due to the above

An AIDs pt with CD4 of 80 presents to the ER with 3 week of cough, fatigue, and night sweats. Pt states he has lost 10 pounds in the past month. Pt is febrile but stable and PE reveals hepatomegaly, and 2 large small ulcers on his hard palate. CXR reveals diffuse reticulonodular opacities. What organism is causing this pts symptoms and what is the best initial test for dx? a) how do you tx this pt?

Pt is infected with Histoplasmosis and first step of dx is urine or serum Histoplasma Antigen. (can use fungal cultures to confirm) a) Itraconzaole (mild to moderate dz) Amphotericin B (severe dz, such as fungemia)

A pt had an ischemic stroke. What is the antiplatelet/antithrombotic management of these pts?

Px within 3.5-5 hours of sx and no contraindications --> IV Alteplase Stroke w/ no prior antiplatelet therapy --> *Aspirin* Stroke while being Aspirin --> *Clopidogrel* or Aspirin + Dipyridamole Stroke while being on Aspirin and pt has intracranial large artery atherosclerosis --> Aspirin and Clopidogrel Stroke with evidence of A-Fib --> *Long term Anti-coagulation*

What is the presentation of diabetic induced gastroparesis? a) how do you tx it?

Px-anorexia, nausea, vomiting, early satiety, or postprandial fullness. *hypoglycemia can occur with insulin admin prior to meals d/t impaired gastric emptying and absorption* a) Control DM, dietary modifications (increase fiber and frequent small meals), and meds that increase motility (*metoclopramide*)

What are the characteristics of laxative abuse?

Px-very frequent, watery, nocturnal diarrhea Biopsy will show *dark brown discoloration of the colon with lymph follicles shining as pale patches (melanosis coli)*

30 yr old Italian man comes in for a routine check up. He is asymptomatic. Labs reveal Hb of 10.8 and a MCV of 61. Peripheral smear shows target cells. What to do next?

Reassurance, this pt probably has B-thalasemmia minor, which requires no treatment

A pt comes in presenting with HA, restlessness, fear of water ingestion, and alternating mania and stupor after getting bit by a bat. What causes the fear of water? What would be found in the neurons of the bat? Tx?

Rabies causes laryngeospasm thus the mouth foams alot and the person is unable to swallow The bat neurons will have *negri bodies* (round eosinophilic inclusions) Tx - Empiric admin of Rabies Immunoglobulin and vaccine

Painless, sudden vision loss or haze. Fundoscopy shows dilated and tortuous veins leading to scattered and diffuse hemorrhages, disk swelling, and/or cotton wool spots. What is going on?

Retinal *Vein* Occlusion from venous thrombosis

A pt see's floaters and light flashes. Fundoscope reveals wrinkled retina. What is going on?

Retinal Detachment

Pt is hospitalized for tonic-clonic seizure. He is a heavy alcohol user and had prior hospitalizations for alcohol induced seizures. Lab values show hyperkalemia, and Cr of 2.4. UA shows large amounts of blood. What is the cause of the UA results?

Rhabdomyolysis

What is the most common cause of amyloidosis induced nephropathy in the USA?

Rheumatoid Arthritis -confirm with staining with Congo Red --> shows apple-green birefringence under polarized light

67 yo man comes to the ER 1 hour after onset of vertigo, nausea, and imbalance. He has a 20 yr history of poorly controlled hypertension. His pulse is 70, respirations are 20 and BP is 210/115. Exam shows a small right pupil, mild right ptosis, and nystagmus. Neuro exam shows weakness of the right palate. Sensation to pinprick is decreased over the right side of the face and left extremities. There is incoordination on finger-nose testing and heel-knee-shin testing on the right. Which of the following arteries is most likely to be occluded?

Right Vertebral Artery (includes R-PICA)

42 yr old women comes to the office with 4 month history of heartburn. The patient is an active member of her church but hasn't participated much due to dyspnea on exertion and joint pain. She does not use tobacco, alcohol, or drugs. Lung exam reveals bilateral end-inspiratory crackles. Endoscopic exam reveals mild hyperemia in the distal esophagus. Esophageal manometry reveals lack of peristaltic waves in the lower 2/3 of the esophagus and significant decrease in lower esophageal sphincter tone. What is probable dx and whats the mechanism behind it? a) What if the manometry showed esophageal hypercontractility?

Scleroderma. Due to systemic sclerosis, which leads to *atrophy and fibrosis of the smooth muscle* in the lower esophagus a) possible Eosinophilic Esophagitis

What is Akathisia?

Sensation of restlessness that causes the pt to move frequently

An 80 yr old women with severe hx of osteoarthritis comes in complaining of fatigue. Her meds consist of Naproxen for her OA and Aspirin as a prophylaxis for her heart. PE reveals conjunctival pallor. What anemia does this pt most likely have? Why?

She probably has Iron Deficiency Anemia because she is on to drugs that irritate the gut and cause gastritis/gastric ulcers that can lead to blood loss.

What are characteristic radiographic findings of a pts hand in a pt with hemochromatosis-associated arthropathy?

Squared-off bone ends and hooked-like osteophytes in the 2nd and 3rd MCP joints

What is the most common cause of pneumonia in nursing home pts and community acquired pneumonia?

Strep Pneumo

What organism is the most common cause of endocarditis following a dental procedure? a) MCC of endocarditis is prosthetic valve pts?

Strep Viridans (mitis, mutans, sanguis, salivarius) a) Staph epi

A 60 yr old pt comes in with a dx of prostatitis. He has difficulty urinating and is retaining urine. What is the next step?

Suprapubic Cath of the Bladder *do not urinary cath* because there is possible inflammation of the urethra

An HIV pt has a CD4 count of 30. What prophylactic abx is recommended for this pt and for what?

TMP-SMX for PCP and Toxo prophylaxis Azithromycin for MAC prophylaxis

What is Dystonia?

Sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures

What is the difference in tactile fremitus in a pneumonia pt vs a pleural effusion pt? a) whats the difference in the percussion sounds in both diseases?

The *tactile fremitus in a pneumonia pt will be increased due to consolidation* vs in *pleural effusion, the fremitus will be decreased* due to less dense fluid. a) both will have dullness to percussion

A 39 yr old pt comes in complaining of double vision. She feels weak all over, especially at the end of the day. It has lasted for the past 8 months. She does not complain of pain. Her vitals are normal. She has diplopia and mild ptosis. Her CBC and BMP are normal. EMG test reveals a decremental response to action potentials. Acetylcholine receptor antibody test is positive. What is the Dx? What is the next step in management?

The Dx is *Myasthenia Gravis* A *Chest CT* should be performed to *screen for Thymoma* Surgical removal if one is found.

A pt comes in complaining of blurry vision on the right eye for a day. He denies pain, ocular discharge, or gritty sensation. Visual acuity on the right eye is decreased as well. Fluorescein exam reveals a corneal abrasion. Why is the pt not feeling any pain? a) what are classic symptoms of pts with corneal abrasion?

The afferent fibers from CN V are damaged via foreign body a) pain, photophobia, normal/decrease visual acuity

A pt with ZES has increase fat in his stool. Why?

The increase in intestinal acid leads to an inactivation of the pancreatic enzymes

Does TSH stimulate the release of prolactin in the Anterior Pituitary? Does Prolactin inhibit the release of GnRH Does Primary Hypothyroidism cause hyperprolactinemia?

Yes Yes Yes

A 72 yr old man presents to the ER complaining of non-productive cough, fever, maliase, runny nose, and severe body aches. The symptoms came on suddenly last night. His vitals show a temp of 102 and O2 sat of 88%. PE reveals diffuse crackles of the bilateral lungs. Labs reveal a WBC of 4,100 with 32% lymphocytes. CXR reveals diffuse interstitial infiltrates. What is the dx? What is the tx?

The pt has a *viral pneumonia. Probably due to influenza.* Give pt *Oseltamivir*

A 54 yr old man comes in for SOB. Exam shows dullness to percusion over the right lower lobe. The breath sounds are louder, especially during expiration over the right lung base as compared to the left lung base. Cardiac exam is normal. Why is it louder on expiration on the right lung base?

There is a possible consolidation. Consolidation conducts sound better. Usually expiratory phases are inaudible but with the consolidation, there will be bronchial breath sounds on expiration. *only if the airways are patent*

Simple Renal Cyst (no tx needed) vs Malignant Cystic Mass Characteristics on imaging and px?

Thin, smooth Unilocular No Septae Absence of contrast enhancement Asymptomatic vs Thick, irregular wall Multilocular Multiple septae Contrast enhancement Symptomatic (Hematuria, HTN, Pain)

Can a person who does not eat pork still acquire Neurocysticercosis?

Yes because it is due consumption of T. Solium eggs (excreted in feces) and not the adult tapeworm that reside in pork

An healthy and asymptomatic 20 yr old comes in for a pre-work physical. Vitals and physical are normal. Labs show an incidental finding of hypercalcemia. PTH is upper normal. Urine calcium/Cr clearance ratio is <0.01. What is the mechanism of this disease?

This is *Familial Hypocalciuric Hypercalcemia* -abnormal calcium-sensing receptors on the renal tubules and parathyroid cells. Thus the renal tubules cannot regulate PTH levels. PTH is a upper normal.

A very tall pt with long fingers, long arms, and protruding chest comes in for excruciating chest pain. He denies prior SOB, Chest pain, or lower extremity edema. Whats his current condition? What additional cardiac findings are in this pt?

This pt is undergoing *Aortic Dissection* -*most dangerous complication of Marfans* -Aortic Regurg is a complication of the dissection --> presents with an early diastolic murmur

Anterior vs Middle vs Posterior Tumors of the Mediastinum?

Thymoma, Lymphoma, Teratoma, Thyroid Tumors vs Bronchogenic Cyst, Tracheal Tumors, Pericardial Cysts, Aortic Aneurysms, Lymphoma vs Neurogenic tumors - Neuroblastoma, Meningocele, Enteric Cysts, Esophageal Tumor, Aortic Aneurysms, Lymphoma

A 35 yr old pt presents with palpitations, weight loss, increased appetite, and diarrhea for the past 2 months. Vitals are normal. PE reveals exophthalmos, lid lag, lid retraction, and enlarged and non-tender thyroid gland. What are the medical managements of this disease? What are the worrisome adverse effects of these medications?

Tx for Graves Dz. Methimazole and Propylthiouracil -*Agranulocytosis* -Methimazole - *1st semester teratogen*, cholestasis -PTU - *Hepatic failure*

What is the most common arrhythmia responsible for sudden cardiac arrest post-MI? What is the mechanism behind it?

V-fib -2/2 to *reentry*

A pt arrives to the ER room after losing consciousness for a few seconds after going to the bathroom. The pt admitted to nausea, pallor, and diaphoresis prior to the syncopal episode. What is the cause?

Vaso-vagal response

What would you see on a hand X-ray of a pt with Osteoarthritis?

Would see *subchondral sclerosis, joint space narrowing, and osteophytes* mainly on the *DIP and PIP.*

Pt recently had a viral URI. Now he is complaining of vertigo that has been lasting for days. He has ear pain on the left side, and he feels like he is always falling to that side. He denies hearing loss. What is the dx?

Vestibular Neuritis

Main difference between Waldenstrom's Macroglobulinemia and Multiple Myeloma? Common Sx-hepatosplenomegaly, anemia, visual problems, pain and numbness

Waldenstrom's is characterized by *Hyperviscosity* (bleed and bruise easily) and *IgM spike*. MM does not have the above. They have *IgA or IgG Spike*

A 64 yr old female pt with long history of smoking presents with a 1.5 cm right cervical LN. Biopsy shows Squamous Cell CA. CT scan of the chest was negative. Whats the next best step? Why?

We must do *Panendoscopy (EGD, Bronchoscope, Laryngoscope)* to find the primary tumor, so we can biopsy and dx it.

When is the screening of diabetes indicated?

When a pt has a *sustained blood pressure of 135/80 or higher.* Or screening can be done starting at the age of 45

When do you get a CT head before doing a LP? Why?

When increase ICP is suspected such ass.. -*Seizures or focal neurologic deficits* (due to mass) -*Papilledema* (sign of increase ICP) The reason is to avoid an uncal herniation

A CXR shows a widened mediastinum. What does it indicated? What is the next step to confirm Dx?

Widened Mediastinum on CXR *indicates thoracic aortic aneurysm*. It can also indicate tortuous aorta. Confirm Dx via CT w/ contrast

20 yr old child with recent onset of resting tremor, muscle rigidity, slurred speech, and clumsy gait for the past couple months. PE reveals Hepatomegaly. Labs reveal AST and ALT in 300's. Hepatitis Serology and Biliary Dz Serology were negative. Liver biopsy reveals Mallory Bodies. Dx?

Wilsons Dz

What are the sxs of hypercalcemia?

constipation, abdominal pain, polyuria, and polydipsia

What is hemiballismus?

Unilateral, violent arm flinging caused by damage to the contralateral *subthalamic nucleus*

SLE Arthritis vs Rheumatoid Arthritis Prognosis?

Less erosion, synovial abnormality, and permanent joint deformity as compared to RA. *non-deforming arthritis*

A 50 yr old DM pt has had DM for 15 yrs. His current HbA1c is 6.5% What complications will he reduce by lowering his HbA1c below 6%?

*Microvascular Complications* - nephropathy, retinopathy *NO Reduction* in macrovascular complications (MI, stroke) or Mortality

Pt is suspected of a DVT. What are the steps of management?

Unlikely DVT 1. D-Dimer - if elevated then do *Compression US* Likely DVT 1. *Compression US* - positive test will indicate anticoagulation

What are the Red Flag symptoms of Back Pain? a) What is the initial management of back pain that presents with red flag symptoms?

-Age > 50 -Hx of previous CA -Constitutional Sxs -Night time pain --> difficulty sleeping -Pain > 1 month -No response to prior therapy -Neurologic Sxs a) Back X-ray and ESR MRI (if neurological signs present)

What are common causes of Primary Adrenal Insufficiency? Common lab findings?

-Autoimmune -Infection: *TB*, Histoplasmosis -Hemorrhagic: *Meningococcemia*, anticoagulants -Metastatic Cancer *Hypotention, Hyponatremia, Hyperkalemia, Hypoglycemia, Eosinophilia*

A pt presents with a staggering wide-based gait (Ataxic). He has a positive Romberg test. What are potential causes?

-Cerebellar dysfunction -Drug/ETOH intoxication -Vit. B12 Deficiency

How does moderate to severe chronic kidney disease increase PTH levels?

-Decrease excretion of Phosphorus -Decrease production of Vit D

Whats Ramsay Hunt Syndrome?

-Herpes Zoster Infection that causes Bells Palsy -Vesicles in the outer ear

What diseases would you see hypercalcemia in a setting of low PTH?

-Malignancy -Vit D toxicity -granulomatous diseases (ex. sarcoidosis)

What are Alarm Sxs for GERD?

-Melena, hemetemesis, dysphagia, persistent vomiting, weight loss, anemia.

What are the 2 major criterias needed to diagnose Infective Endocarditis? What step is done first?

-Need 3 Blood cultures that are positive for typical organisms found in IE (*do this first*) -Echocardiogram showing valvular Vegetations

What are the stagings of pressure ulcers?

Stage 1: Nonblanchable redness with *intact skin* Stage 2: Shallow open ulcer, with *partial thickness loss of dermis* Stage 3: *Visualization of subcutaneous fat* with a full thickness tissue loss Stage 4: *Exposed bone, tendon, or muscle*. Possible slough or eschar

An obese male comes in complaining of poor sleep. Complains of frequent choking sensation at night. Also complains of leg swelling. He denies any tobacco, alcohol, or drug abuse. BMI is 46. What physiological changes do you expect to see in this pts condition?

-Pulmonary HTN -Hypoxia induce Erythrocytosis -Chronic Hypercapnia/ Respiratory acidosis -Decrease chloride d/t increase bicarbonate retention

A women was found unconscious at a scene of a house fire. Exam reveals no burns, but she does have black soot present near the pts nares and mouth. Her cap refill time is 4 seconds. She is tachycardic and tachypnic. Supplemental O2 by non-rebreather mask is administered. What type of poisoning is she possibly suffering from and why?

*CO and Cyanide Poisoning* -CN is produced from combustion of nitrogen-containing products such as synthetic products (silk, paint, cotton, foam)

What are the EEG readings of a person going from awake to REM Sleep?

"*BATS* *D*rink *B*lood" Awake - Beta Waves Relaxed but Awake - Alpha Waves N1 - Theta waves N2 - Sleep Spindles and K Complexes N3 (Deep Sleep) - Delta Waves REM - Beta Waves

What are causes of Eosinophila?

"DNAAACP" D - Drugs N - Neoplasms A - Allergic causes A - Addisons A - Acute Interstitial Nephritis C - Collagen Vascular Dz P - Parasitic Infections

A 40-year-old man is brought to the ER 1 hour after a high-speed motor vehicle collision. On arrival, he is awake and alert but has severe pain over the sternum. His systolic BP is 80 mm Hg, HR is 80/min, and RR is 10/min. An ECG shows multifocal premature ventricular contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of lactated Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4 L/min of oxygen by nasal cannula. Pulmonary capillary wedge pressure has increased from 14 mm Hg to 24 mm Hg. What is a cause of this pts condition? Why?

"This pt probably had a Myocardial Contusion secondary to the MVA. I do not believe the lungs were affected because they were fine before fluid resusciatation. The cardiogenic shock of the cardiac contusion would cause the back up of fluids."

60 yr old pt comes to the ER for sudden onset of left-sided weaknes. She reports fatigue, low grade fevers, and occasional palpitations over the last 3 moths. She has lost 6 pounds during this time. Her vital are normal. PE reveals a mid-diastolic rumble at the apex. Lungs are clear. TEE shows a mass in the left atrium. Dx?

*Cardiac Myxoma* -Common in left atrium -Mimics mitral stenosis -Can cause emoblization

A 33 yr old pt suffers tonic - clonic seizures and is brought to the ER. Pt complains of muscle pain. Labs reveal CPK of 11,200. What is the next step in management? Why?

*Immediate Fluid Resuscitation*. Pt has *Rhabdomyolysis*.

What is the tx for TTP-HUS and why?

*Immediate Plasmapharesis* (plasma exchange) because the etiology is due to an autoantibody against the bodies vWF-protease (ADAMTS-13), which will cause vWF-multimers and platelet aggregation -see *microthrombi causing schistiocytes* -*do not give platelets --> will cause more thrombi*

Post-bite management of rabies.

*Bit by a dog or cat* -Observe animal for 10 days --> PEP only if animal is positive. -If animal cannot be observe --> start PEP and discontinue if not positive High Risk Animals (bats, raccoon, fox) -Unable to test animal --> start PEP -Able to test animal --> start PEP only if animal is positive

What is the mechanism behind the cause of exophthalmos in a pt with Graves Dz?

*It is the stimulation of orbital fibroblasts by anti-TSH receptor autoantibodies* NOT high levels of Thyroid hormone *Radioactive Iodine tends to exacerbate the Graves Ophthalmopathy*

57 yr old male comes in for a complaint of 2 episodes of bloody urine. Also has fatigue and fever for the last 4 weeks. He has no PMH or takes any meds. Pt has a 50 pack year smoking history. Vitals are normal. PE reveals left sided varicocele that fails to empty when the pt is recumbent. Labs show Hgb of 18, WBC of 7000, and platelets of 580,000. UA shows >10 RBC/hpf. What is the most appropriate next step in dx? Dx?

*Abdominal CT for a suspected Renal Cell CA* -Hematuria -Polycythemia -Varocele that does not empty while recumbent indicates obstruction

A 24 yr old pt is brought in to the ER after stating that she ingested twenty 500mg acetaminophen tablets 2 hours ago after an argument with her husband. She has no sxs. The pt denies smoking and alcohol use. Her vitals are normal. PE is normal. Labs are normal. What is the next best step? a) what is the toxic dose from ingestion of acetaminophen? b) what if the pt stated she ingested the 20 pills 5 hours ago?

*Administer charcoal and obtain serum acetaminophen levels* a) single dose of *>7.5 grams* b) acquire serum acetaminophen. If above tx line or >10ug/ml or evidence of liver injury -->*N-acetylcysteine*

Increase binding of Calcium to albumin vs Decrease binding of Calcium to albumin What conditions? Result?

*Alkalotic* Conditions. Leads to decrease ionized calcium vs *Acidic* Conditions. Leads to increase ionized calcium

45 yr old Mexican man comes in with fever, anorexia, and RUQ pain. He had a hx of bloody diarrhea 6 months ago after a trip from Mexico. He denied contact with any animals. Does not drink or smoke, and is in a monogamous relationship. U/S shows a single thin wall uniform cyst on the superior surface of the right lobe of the liver. What is the possible Dx? How to confirm? Tx?

*Amebic Liver Abscess via Entamoeba histolytica*. Confirm by *examining stool for trophozoites or serology.* Tx via Metronidazole

Same Region of the Lung vs Different Regions of the Lung Setting of Recurrent Pneumonia?

*Anatomic Obstruction* (neoplasm, bronchiectasis, foreign body) and *Recurrent Aspiration* (Ethanol use, AMS, Sz) vs Sinopulmonary Dz (Cystic Fibrosis, Immotile Cilia) Immunodeficiency (HIV, Leukemia )

A 30 yr old SLE pt has had multiple miscarriages. What is antibody is expected to be found in her blood? Whats her PTT value expected to be?

*Anti-phospholipid Antibody* -example is *lupus anticogulant --> hypercoagulability* -PTT is prolonged

What is the management of hypercalcemia?

*Asx or mild (Calcium <12 mg/dL)* -no immediate tx -avoid thiazide diuretics, lithium, volume depletion, and prolong bed rest *Moderate (Calcium 12-14 mg/dL)* -no tx if Asx -Tx is similar to severe hypercalcemia *Severe (>14 mg/dL) or Symptomatic* -Saline, Calcitonin -Bisphosphonates (zoledronic acid, pamidronate)

Primary Biliary Cirrhosis vs Primary Sclerosing Cholangitis Dz associations?

*Autoimmune Conditions* (CREST, Sjogrens, RA, Celiac Dz) vs *P-ANCA* *Ulcerative Colitis* > Crohns Cholangiocarcinoma

What are the 3 drugs used to treat stable angina, and in what settings are they used in?

*Beta-Blocker* - first line. Improves survival. Decreases anginal symptoms. *Calcium Channel Blockers* - Alternative therapy. Improves angina by peripheral and coronary vasodilation *Nitrates* - Shortacting and used for acute attacks of angina. Long acting form can be used as add on therapy for persistent angina.

23 yr old female comes in complaining of frequent, foul smelling, bulky stools and weight loss for over 6 months. She also has poor energy and occasional joint pains. She has no PMH and takes no meds. She does not use drugs or alcohol. PE shows pallor, no hepatosplenomegaly. CBC reveals Hb of 10.2. IgA Anti-tissue transglutaminase Ab screen is negative. Small bowel biopsy shows villous atrophy. Dx? Why was the IgA screen negative?

*Celiac Dz confirmed by biopsy* IgA Anti-tissue transglutaminase is very specific for the dz but it could be negative sometimes due to a *concurrent IgA deficiency*

60 yr old man is brought by his son due to worsening insomnia, confusion, and memory loss for the past 3 weeks. He has muscle twitching and gait problems. He denies any fever, HA, or urinary problems. Vitals are normal. He is poorly groomed and very disoriented. PE reveals nystagmus, hypokinesia, and positive extensor plantar response. CT head was normal. EEG shows periodic sharp waves. Dx? Gold Standard for Dx?

*Creutzfeldt-Jakob Dz* -rapid demetia -2/4 of *myoclonus*, akinetic mutism, *visual disturbance*, and *hypokinesia* -*Periodic Sharp waves* *Gold Standard is Brain Biopsy*

28 yr old HIV pt comes with chronic diarrhea associated with malaise, nausea, anorexia and abdominal cramps. CD4 count is 84. A modified acid-fast stain of the stool reveals 4-6 oocysts. Which organism is the likely causative agent?

*Cryptosporidium parvum* Isospora belli also stain in acid-fast, but it is not as common as Cryptosporidum

A 40 yr old pt comes complaining of severe left flank pain. The pt states this is common in his family, and it presents similarly multiple times. UA shows hexagonal crystals. Urinary Cyanide Nitroprusside Test is positive. Dx? Mechanism behind it?

*Cystinuria*, due to the impaired amino acid transport in the renal tubules --> precipitation of the poorly soluble Cystine. -the stones are radioopaque (visible) on Xray

52 yr old women comes in with a rash over her face that began a few weeks ago. She has difficulty rising from a seated position. Exam reveals erythematous rash on the upper chest and violaceous periorbital edema. She also has slightly scaly papules overlying the joints of her hands. She has proximal muscle weakness in the legs. What is the Dx? What are the dx lab findings? Tx? What conditions is it often associated with?

*Dermatomyositis* Labs will show elevated CK and Aldolase. Positive Anti-Jo-1 and Anti-Mi2 *Dx via Skin Biopsy* Tx via *High dose glucocorticoids* *Associated with Malignancy*

What is the px of Osler-Weber-Rendu Syndrome (Hereditary Telangiectasia)?

*Diffuse Telangiectasias* *Recurrent Epistaxis* *Widespread AV malformations* -if its in the lungs, the AV shunting can cause chronic hypoxemia --> reactive polycythemia and digital clubbing

Which group of HTN drugs cause peripheral edema? What antihypertensive drug can you add to reduce the edema?

*Dihydropyridine CCB's such as Amlodipine and Nifedipine. * -they cause arteriolar dilation --> increase capillary hydrostatic pressure *Adding an ACE Inhibitor*, which causes post-capillary venodilation will reduce the capillary hydrostatic pressure

70 yr old man comes in complaining about a tremor. Over the past several months, he has noticed he becomes tremulous when trying to hold a newspaper or when he reaches for his morning cup of coffee. The tremor is not as noticeable when he lays down to sleep at night. His vitals are normal, and PE revealed no neurologic deficits. What is the dx and how do you tx it? a) What else relieves this tremor?

*Essential Tremor* and tx it with *propranolol* a) Alcohol

Ischemic Stroke vs Intracerebral Hemorrhage Px?

*Focal symptoms can stutter in progression*, with periods of improvement. Could be abrupt and show *maximal symptoms from the start* vs *Focal symptoms progressive from minutes to hours*. Which then *sxs of increase intracranial pressure px* (vomiting, headache, bradycardia, stupor)

Besides dysphagia, raynauds, telangiectasia, sclerodactyly, and extensive skin thickening, what else is a complication of diffuse Scleroderma? What complications are their leading cause of death?

*GI* -Angiodysplasia (watermelon stomach) -Malabsorption due to bacterial overgrowth *Pulmonary (MCC of death)* -Pulmonary Fibrosis (mc) -Pulm Arterial HTN *Renal* -Renal Crisis *Cardio* -Myocarditis, Pericarditis -Pericardial effusion

A 65 yr old male px with a 4 week history of weakness and vague postprandial epigastric pain. PMH is insignificant. Does not take any meds. Smokes 1 pack daily. Fecal occult blood is positive. Gastroduodenoscopy shows an antral ulcer, which 4/7 biopsies displayed adenocarcinoma. What is the next step in management?

*Get a CT abdomen to stage the cancer*, so next step of management can be determiend.

30 yr old arrives to the ER due to an episode of hematemesis. He has hx of PUD. NG tube yields coffee-ground like material. PE reveals poor capillary refill, pallor, but no cyanosis. His BP is 85/40 and HR is 125. What is the best first step in management?

*Give Fluids!*

A 65 yr old women comes in complaining of HA in the temporal region and visual disturbances. Biopsy of scalp artery confirms Giant Cell Arteritis. 6 months later, she saids the therapy has improved her symptoms but she is developing progressive muscle weakness. Vitals are normal. PE reveals 4/5 muscle strength in the proximal extremities bilaterally. ESR and CK are normal. Whats the cause of the new complaint?

*Glucocorticoid Induced Myopathy* -mechanism is increased muscle catabolism and decreased anabolism

What is Cushings Reflex

*HTN* *Bradycardia* *Irregular Respirations* -ICP compresses the cerebral blood supply. The body will increase sympathetics to increase BP in hopes of perfusing the brain more. -Baroreceptors will detect elevated BP in the carotids and increase vagal stimulation to the heart as a reflex bradycardia. -The irregular respirations are a sign of brainstem compression at risk of herniation

60 yr old with a px of headaches, sudden vision loss of one eye. Fundoscopy reveals presence of swollen and pale disc with blurred margins. ESR is elevated. What is the next step in management?

*High Dose Steroids* -pt has *anterior ischemic optic neuropathy*, a complication of giant cell arteritis

Pt comes in with a migraine. What is the acute management?

*IV Antiemetics* (metoclopramide, prochlorperazine) Can be used in *conjunction with Triptans*

What is the single most important intervention for preventing contrast nephropathy?

*IV Fluids* N-Acetylcysteine can be used as well

A 37 yr old Asian immigrant presents to the ER complaining about progressive exertional dyspnea, nocturnal cough, and occasional hemoptysis over the past 6 months. She also describes frequent episodes of palpitations and irregular heart beats. What heart valve abnormality does she most likely possess? Why?

*Mitral Stenosis* -the enlarge left atrium can cause fluid build up in the lungs -the enlarge atrium can lead to development of A-fib

What is the mcc of mitral regurg in developed countries? Via what mechanism?

*Mitral Valve Prolapse is the MCC of MR in developed countries* via *myxomatous degeneration of the mitral valve leaflets and chordae tendonae*

What are the criterias to considered in order to have metabolic syndrome? What is pathogenesis behind this condition?

*Need 3 out of 5* -Abdominal obesity. >40 inches for men and >35 inches for women -TG >150 mg/dL -HDL <40 mg/dL for men and <40 mg/dL for women -BP > 130/85 -Fasting glucose > 100 mg/dL *Insulin Resistance*

58 yr old man comes in with a 1 yr history of diarrhea. The stools are watery and are accompanied by abdominal cramps. He has no fever, or blood or foul smelling stool. He frequently complains of dizziness, facial flushing, wheezing and feeling of warmth. PE reveals a 2/6 systolic murmur on the lower left sternal border that is louder with inspiration. Abdominal exam reveals hepatomegaly but no tenderness. Labs reveal normal CBC, but midly elevated Alk Phos , AST, and ALT. What vitamin/mineral deficiency is this pt at risk of and why?

*Niacin* because this pt has symptomatic Carcinoid Tumor (metastasized to liver). Niacin is a precursor to Serotonin, thus the tumor is consuming it all

What is the first line tx for anyone with a suspected stroke? a) what would it look like if it was a hemorrhagic stroke? b) what would it look like if it was an ischemic stroke?

*Non-contrast* CT a) will be seen as a *white* hyperdense region within brain parenchyma b) usually won't be visible on CT for about 24 hours.

20 yr old pt comes in with nasal breathing, stuffy nose, and occasional cough for more than a year. Her sxs fluctuate in intensity without any obvious inciting factors. She has no eye or ear symptoms, itching, wheezing, or skin rash. She reports no food allergies. Pt tried OTC oral loratadine without significant improvement. PE reveals a nasal mucosa that is boggy and erythematous. Lungs are clear. Dx? Tx?

*Nonallergic Rhinitis* Tx via *Intra-nasal glucocorticoids*

A pt comes in with sudden right-sided hemiplegia, headache, and impaired consciousness. PMH of HTN, hypercholesterolemia, and obesity. He has no history of TIA. PE reveals a carotid bruit on the left side. Which of the following is the most appropriate step and why?

*Noncontrast CT first* to *rule out hemorrhage.*

At what PaO2 or SaO2 values must a COPD pt have in order to qaulify for home O2 Tx?

*PaO2 < 55 mmHg* on room air *SaO2 < 88%* on room air Pts with signs of Pulm HTN or hematocrit > 55% then PaO2 < 60 mmHg

How does Polymyositis Px? How to Dx?

*Painless and slowly progressive muscle weakness of proximal lower extremity muscles.* -usually characterized by difficulty ascending and descending stairs/chairs -Reflexes are usually normal -NO skin findings Dx via *Muscle Biopsy*

63 yr old was admitted for an anterior wall MI, in which he was treated with thrombolytics, morphine, aspirin, nitrates, metoprolol, and morphine. On the third day of hospitalization the pt suddenly develops SOB and hypotension. PE reveals a apical pansystolic murmur radiating to the axilla. Lungs had bibasilar crackles. What is the probable cause of the pts condition? a) what are the common cardiac mechanical complications of post-MI pts?

*Papillary muscle dysfunction leading to mitral regurg. * a) -Mitral Regurg. -LV free wall rupture -Interventricular septum rupture

A pt with GERD presents with alarm Sxs. Endoscopy was performed and no pathology was found. What is the next step?

*Perform Esophageal Manometry* to find diseases that mimic GERD

Dx of Aspergillosis? Tx?

*Positive Aspergillus IgG* and *Radiographic evidence* of mutliple nodules or cavitation (fungal ball) -suspect in pts that are immunocompromised, hx associated with TB, COPD Tx via *Voriconazole or Caspfungin* if invasive *Surgical Resection* if its just the aspergilloma

A patient attempted suicide by drinking sodium hydroxide -based drain cleaner. The pt starts to vomit, have dysphagia, epigastric pain, and hypersalivation. What is the number concern at the moment, and how do you find out? A) What do you do if there was a complication. What do you do if there is not a suspected complication?

*Possible esophageal perforation or mediastinitis* due to chemical burns. I would suspect the above if there were signs of *airway compromise and widen mediastinum on CXR* a) Suspected perforation -->*Upper GI Xray with water soluble contrast* Non-suspected perforation --> *Endoscope* to assess amount of damage.

What are the contraindications to the use of Succinylcholine and why? a)What type of pts should not use Succinylcholine

*Pts who are at high risk of hyperkalemia* because Succinycholine causes significant release of potassium which *can lead to complications like cardiac arrythmias*. a) -Crush or Burn injury pts > 8 hours old -Demyelinating syndromes (ex. Guillain-Barre) -Tumor Lysis Syndrome

What some Tx for Heat Stroke?

*Rapid Cooling* -Ice Water Immersion (preferred. Not for Elderly) -Evaporative Cooling Fluid Resuscitation Electrolyte Correction

A 50 yr old pt has suffered a SAH, and is now status post endovascular coiling. What are the complications that he can suffer 24 hrs after surgery? What about 3 days after surgery? How do you prevent it?

*Rebleeding* is the major cause of death in the first 24 hrs *Vasospasms* can occur 3 days after surgery, can lead to infart -will see neurological deficits -*prevented by Nimodipine*

A pregnant women has a history of chronic Hep C, and has not been immunized for Hep A or B. What should she do and why?

*She should receive Hep A and B immunizations* because acute viral hepatitis can be life threatening, especially in a pt with a hx of viral hepatitis.

1. What does elevated Testosterone with normal DHEAS mean? 2. What does elevated DHEAS with normal Testosterone mean? 3. Where is DHEAS secreted?

1. An *ovarian source* of excess androgen production 2. An *adrenal source* of excess androgen production 3. *DHEAS is secreted from the adrenals*, while DHEA is secreted from both ovaries and adrenals

34 yr old man from Southeast Asia presents with lesion on his left arm. He has no sensation in that part of the arm. He currently denies any other Sx, but he does remember that last month he had an onset of general malaise, HA, and dry cough. PE of the forearm reveals a 4x4 cm hypopigmented plaque with no sensation to pinprick. The left upper arm has significant muscle atrophy. What is the next step in management to make a dx?

*Skin Biopsy* and put it under acid-fast stain to *rule out Mycobacterium Leprae*

40 yr old pt with hx of systemic sclerosis, GERD, and DM2 is coming in complaining of 3 months of daily abdominal bloating and increased flatulence. She also has water, nonbloody diarrhea several times a week, most often at night. She has no relief of her sx after a bowel movement. Vitals are normal. and PE reveals skin hardening on the fingers of both hands. The abodmen is soft and nontender without organomegaly. Stool test for occult blood is negative. CBC shows macrocytic anemia. ESR is 11. Dx? Tx?

*Small Intestinal Bacterial Overgrowth* -caused by anatomical abnormalities (surgery), Motility disorders (scleroderma, DM), and immunocompromised state *Dx is Endoscopy*, showing jejunal aspirate with >10x5 organisms Tx is Abx

A 50 yr old male comes in with lethargy and confusion. PMH is cirrhosis secondary to alcohol. He is febrile and tachycardic. On PE the pt has flapping tremor in hands when they are held out. His lungs are clear. Abdominal exam reveals distension with shifting dullness and tenderness to palpation. He has bilateral pitting edema of lower extremities. AST is 112, ALT is 50, and total bili is 2.5. What is the concern for this pt? What is the next step in management?

*Spontaneous Bacterial Peritonitis* Do a *abdominal paracentesis* (PMNs is > 250 = infection). Then give *empiric ABx.*

A pt has limited neurologic deficits. What kind of cerebral vascular incident happened?

*Suspect Lacunar Strokes* if pts is presenting with limited neurologic deficit -*MC due to HTN*

A pt presents with chest and neck pain, syncope, and history of HTN. CXR reveals mediastinal widening. TTE reveals pericardial effusions. Vitals are within normal limits. Whats the next step in dx?

*TEE* or CT w/ Contrast to dx an aortic dissection

A 45 yr old pt with hx of cirrhosis comes in with abdominal distention and exertional SOB. He had an episode of variceal bleeding 1 yr ago. He admits to drinking occasionally. He takes high doses of furosemide and spironolactone. His vitals are normal. PE reveals abdominal distention and 2+ peripheral edema. He has no jaundice or hand tremor. CXR reveals moderate to severe right sided pleural effusions. Right sided thoracentesis confirms transudative fluid. Next step in management?

*TIPS procedure* because this pt has hepatic hydrothorax that is refractory to diuretic management

A middle age women is found in the streets wandering with an abnormal gait. She is brought to the ER by police. She mumbles when asked her name. She is not oriented to time or place. Her BP is elevated and she is afebrile. Pupils are dilated and reactive to light. Moves all extremities and her DTR are symmetric. What is the best initial tx for this pt?

*Thiamine* for possible Wernicke's Encephalopathy

An HIV pt comes in with AMS, *hemolytic anemia, thrombocytopenia* with normal WBC count, and acute renal failure. Peripheral smear shows schistocytes (helmet cells). What is the dx and what is the tx? a) what is contraindicated in this pt?

*Thrombotic Thrombocytopenic Purpura* Tx with *plasmapheresis* a) do not give platelet transfusions

28 yr old coming in complaining of an itchy rash across his trunk. Vitals are normal. PE reveals 4 circular patches with central clearing and scaly borders, measuring approx 3-8cms in diameter. Whats the likely dx? How to confirm? Tx?

*Tinea Corporis* Confirm by doing a KOH stain showing hyphae Tx with *topical terbinafine or IV griseofulvin (severe)*

20 yr old has a 1 month history of 4-6 watery bowel movements a day with occasional tenesmus, urgency, and abdominal cramps. He also has 2 week history of intermittent bright red blood in his rectum. He has no PMH, and does not use tobacco, alcohol, or drugs. Sigmoidoscopy reveals mild erythema and rectal biopsy confirms acute mucosal inflammation. What is his dx, and what potential complication can he have that requires regular surveillance?

*Ulcerative Colitis* *Colorectal Carcinoma*

Marfans vs Homocystinuria Difference in Lens Dislocation?

*Upward* Lens Dislocation vs *Downward* Lens Dislocation

65 yr old man comes to the physician with several month hx of dysphagia and coughing during his meals. He has noticed a right sided neck mass which increases in size while drinking fluids. His wife reports his breath odor is worsened. He occasionally regurgitates his meds in the morning. Whats the Dx and whats the mechanism to his condition? Dx and Tx?

*Zenker Diverticulum* The outpouching is due to upper esophageal sphincter dysfunction and esophageal dysmotility. Dx it via *Barium Esophagram* and Tx via *Surgery* (cricopharyngeal myotomy)

What two measurements indicate that a pleural fluid is most likley turned into an empyema and needs to be drained by a chest tube?

*pH* < 7.2 *Glucose* < 60 mg/dL

A 64 yr old comes in to the ER with sudden onset of HA and AMS. She has a history of HTN and A-Fib, which she takes CCB, BB, and Warfarin. Past couple days she has been using OTC cough and cold meds for cough symptoms. Her BP is 172/80 and HR is 68. CT shows an intracerebral bleed. PTT is 30, PT is 48, and INR is 6. What is the next steps in management? Cause to her condition?

-Reverse her high INR via *Vit K and prothrombin complex concentrate* -Avoid all anticoagulants, and antiplatelets The pt probably had a warfarin induced hemorrhage. Her INR was probably elevated due to the use of the OTC meds which prob contain acetominophen.

Indications to perform urgent dialysis?

-pH < 7.1 and refractory to medical therapy -Severe hyperkalemia (>6.5) refractory to medical therapy -Ingestion of Toxins -Volume overload refractory to diuretics -Uremic Encephalopathy

What is the px of Erythema Infectiosum? What is the cause? What is the dx and tx?

1) Flu like symptoms, malar rash, *symmetrical polyarthritis (resembles RA)*, aplastic anemia. Common in children, and occupations close to children. 2) Parvovirus B19 3) B19 IgM Ab's and Tx is supportive (self resolves)

A pt is complaining of left leg pain. 1 day ago, the pt was seen and treated medically for an anterior STEMI. PE reveals the leg is cold with mottled appearance. There is minimal swelling with absence of distal pulses. What is dx and what caused it? What are the next steps of management?

1. *Arterial Occlusion* from possible embolus from *LV thrombus.* 2. Immediate *Anti-coagulation*, *Consult Vascular Surgery*, and *Trans-thoracic Echo*

A pt is suffering from ARDS after an infection. 1. What are the FiO2 goals of a pt and why? 2. If a pts ABGs is still showing hypoxemia (low PaO2), and their FiO2 is already high, what can you do to improve oxygenation?

1. *FiO2 refers to the Fraction of inspired O2, and we want it be below 40%*, because the higher it is, the higher risk of O2 toxicity. 2. *Adding PEEP*, will help prevent alveolar collapse, and may even open up collapsed alveoli caused by ARDS

68 yr old just had an uncomplicated left total knee replacement. On his 5th day of post-op, the pt complains of new onset abdominal pain. Over the past 12 hrs he has spontaneously voided 200 ml of urine. Review of his medical chart shows infrequent recording of fluid input/output over the last 4 days. His vitals are normal. CBC is normal, and BMP reveals Na of 130, and BUN/Cr of 70/3.5. His renal function prior to surgery was normal. What are the next steps in managing this pt?

1. *Portable Bladder Scan* for suspected post-op urinary retention 2. If above is positive *then do Foley Cath*

Pt with Conjugated Hyperbilirubenemia. What is indicated if they have... 1. Normal AST, ALT, and Alk Phos 2. Predominately Elevated AST and ALT 3. Predominately Elevated Alk Phos

1. *Prob a disease lacking bilirubin conjugation enzyme* (Dubin-Johnson or Rotor's) 2. *Disease of the Liver* (Viral Hepatitis, Autoimmune Hep, Hemochromatosis, Alcoholic Hep, Ischemic Hep, etc) 3. *Intra or Extra-hepatic Biliary Duct Pathology* (Primary Biliary Sclerosis, Choledocholithiasis, Cholangiocarcinoma, etc)

A pt is presenting with Hepatic Encephalopathy. What is the order of management?

1. *Supportive care* (volume repletion, correct electrolytes) 2. *Treat Precipitating cause* (GI bleed, hypovolemia, infection, electrolyte abnormality, etc) 3. *Lower Serum Ammonia* via Lactulose or Rifaximin

Primary Hyperaldosteronism is suspected? Steps of management?

1. Aldosterone/Renion Ratio measurement 2. If Ald/Renin > 20, then do adrenal suppression test via salt loading 3. If adrenal suppresion is positive, then CT abdomen (should see unilateral adenoma, or normal) 4. If normal CT, then do venous sampling (to see if it is bilateral adrenal hyperplasia) 5. Adenoma, do surgery. Adrenal Hyperplasia, manage medically

What supplies the lateral pons? What structures are damaged in an infarct? What is the presentation?

1. Anterior Inferior Cerebellar Artery 2. Cranial nerve nuclei, vestibular nuclei, facial nucleus, spinal trigeminal nucleus, cochlear nuclei, sympathetic fibers, cerebellar peduncles 3. Vomiting, Vertigo, Nystagmus *Facial paralysis, decrease lacrimation and salivation, decrease taste from anterior 2/3 tongue, decrease corneal reflex* (CN V, VII) *Ipsilateral hearing loss* (CN VIII) *Ipsilateral * decrease in pain and temp sensation on face, but *Contralateral* body Ipsilateral Horners Syndrome Ataxia, Dysmetria (cerebellar)

What artery supplies the medial medulla? What is structures are damaged in an infarct? What is the presentation?

1. Anterior Spinal Artery 2. Medial Lemniscus, Lateral Corticospinal tract, and CN VII nucleus 3. *Contralateral* Hemiparesis of upper and lower limbs, *Ipsilateral* CN XII dysfunction

What are the indications for valve replacement in pts with aortic stenosis?

1. Dyspnea, Syncope, or Angina in pts with AS 2. Pts with AS undergoing CABG or other valve surgery 3. Asymptomatic AS pt with severe AS and poor LV systolic function, LV hypertrophy (>15mm), valve area < 0.6cm or abnormal response to exercise

How do you manage spinal cord compression?

1. Get *MRI*, while concurrently having them on *Glucocorticoids* 2. Radiation or Neurosurgery

What are the indications of giving statin therapy?

1. Hx of ACS, Stroke, TIA, PAD, CAD --> High Intensity Statin. Moderate Statin (if older than 75) 2. LDL > 190 --> High Intensity Statin 3. Age 40 - 75 w/ DM --> 10 yr ASCVD risk > 7.5% use High Intensity Statin, otherwise Moderate Intensity 4. 10 yr ASCVD risk >7.5% --> Moderate Intensity Statin

A pt with symptomatic bradycardia. Steps of management?

1. IV Atropine 2. IV Epi or Dopamine or Transcutaneous Pacing

A 30 yr old man comes in to evaluation of pale patches on his back. He noticed these lesions during a summer vacation in the Bahamas. These lesions have scales on scraping. The pt also states that the patches never tan. What will be seen on microscopy of a KOH prep? What is the treatment?

1. Large *blunt hyphae* and thick walled *budding spores* 2. *Topical Selenium Sulfide or Ketoconazole*

What supplies the medial pons? What strucutres are damaged in an infarct? What is the presentation?

1. Paramedian Branches of Basilar Artery 2. Corticospinal tracts, paramedian pontine reticular formation, trigeminal nucleus 3. *Contralateral* hemiparesis of upper and lower limbs *Paralysis of gaze to side of lesion* (PPRF, CN VI)

What supplies the lateral medulla? What structures are damaged in an infarct? What is the presentation?

1. Posterior Inferior Cerebellar Artery 2. Vestibular nuclei, Lateral Spinothalamic tract, Spinal Trigeminal nucleus, Nucleus Ambiguous, Sympathetic Fibers, cerebellar peduncle 3. Vomiting, Vertigo, Nystagmus *Ipsilateral* decrease in pain and temperature sensation on face, but *Contralateral* body *Dysphagia, hoarseness, decrease gag reflex* (CN IX, X) Ipsilateral Horners Syndrome Ataxia, Dysmetria (cerebellar)

What is seen in a Basilar Artery Infarct? What structures are affected?

1. Preserved consciousness and blinking BUT *quadriplegia, loss of voluntary facial, mouth, and tongue movements* 2. Damage to lower midbrain, pons, and medulla

What is the order of investigation in suspected lung opacity?

1. Sputum Culture 2. Induced Sputum 3. Bronchoscope 4. Thorocentesis 5. VATS (Video-assisted Thoroscopic Surgery) 6. Open Thoracotomy

What are the management principles of pain management to pts with terminal illnesses (i.e stage 4 cancer)?

1. Try Non-narcotics first 2. Short-acting narcotics 3. Long-acting narcotics, once dosage is set

A 60 yr old man has episodes of syncope during the past few weeks. They occur during exertion. He does not feel confused or tired after episodes. They last for a few seconds. His wife denies observing jerking movements. His vitals are normal. PE reveals an S4 and harsh 3/6 systolic murmur that radiates to the carotids. The murmur is accentuated with expiration. Lungs are clear. Echo confirms dx. What is the dx? What is the tx?

Aortic Stenosis Tx is aortic valve replacement, since this pt is presenting with sxs of syncope

Early Diastolic Murmur heard along the Left Sternal Border vs Early Diastolic Murmur heard along the Right Sternal Border Aortic Regurg Etiology?

Aortic Valvular Dz (via infection) vs Aortic Root Dz

65 yr old pt is coming in for SOB and abdominal distension. He was treated for Hodgkins Lymphoma with radiation and chemo 18 yrs ago, and was cured. His vitals are normal. PE reveals JVD, distended abdomen with positive fluid wave, and hepatomegaly. There is bilateral LE pitting edema. CBC and BMP are wnl. CXR reveals pericardial calcifications. Dx?

Constrictive Pericarditis

What hormones are secreted from a Small Cell Carcinoma of the lung? a) what is hormone is secreted from Squamous Cell Carcinoma?

ACTH and ADH a) PTHrP

Muddy Brown Cast RBC Cast WBC Cast Fatty Cast Broad and Waxy Casts Hyaline Cast What renal conditions are they seen in?

ATN Glomerulonephritis Pyelonephritis or AIN Nephrotic Syndrome Chronic Renal Failure Pre-renal Azotemia

Pts with acute attack of MS symptoms. What to do? What to do for chronic tx of MS?

Acute = Corticosteroids Chronic = Beta-interferon or Glatiramer acetate

This murmur is best heart while the pt sits up, leans forward, and holds his breath in full expiration while the stethescope is place at the left sternal border. A decrescendo early diastolic murmur is heard. What is it?

Aortic Regurg

34 yr old male comes back with complaint of 4 weeks of diarrhea. He recently came back from a trip in South America, where he developed foul-smelling stools, abdominal cramps and bloating. He took a 3 day course of Cipro that did not provide relief. Vitals are normal. PE is normal. What is next step in management, and why? What is the underlying pathology?

Give *Oral Metronidazole* for suspected *Giardiasis* Underlying mechanism for malabsorption is *adhesive disks to the intestinal wall*

An IV drug user suffers a seizure. His BP is 154/90, and the rest of his PE is normal. Labs reveal elevated AST and ALT. HBsAg and Anti-HBsAg is negative. Anti-HCV is positive. What preventative management should be done on this pt?

Give pt Hep B vaccination.

20 yr old pt presents with sore throat, fever, malaise, hepatosplenomegaly and cervical lymphadenopathy. What is one of the conditions hematologic complications?

Autoimmune Hemolytic Anemia and Thrombocytopenia -via cross reactivity of EBV induced antibodies against RBCs and platelets. -IgM cold-agglutinins

60 yr old pt with a history of HTN, DM, and back pain is coming complaining of a blister on his skin. He takes multiple meds, such as furosemide, NSAIDs, captopril. PE reveals a tense bullae overlying both normal and erythematous skin in the groin and axillae and on the legs. He has no oral blisters. What will be seen on biopsy under direct immunoflourescence?

IgG and C3 deposits at the dermal-epidermal junction

What is Paroxysmal Nocturnal Hemoglobinuria? Px?

Autoimmune hemolytic disorder characterized by intravascular and extravascular hemolysis and hemoglobinuria. Due to lack of CD55 and CD59 on cell surfaces which inhibit complement MAC hemolysis Px -*Hemolysis* (low haptoglobin, high LDH, anemia) -*Cytopenias* -*Hypercoagulable state* -Dx via *Flow Cytometry*

What is Riley-Day Syndrome?

Autosomal Recesive Dz Seen in Children of Ashkenazi Jews Gross dysfunction of autonomic nervous system with severe orthostatic hypotension

What Abx is used to tx Cat Scratch Dz?

Azithromycin

A 30 yr old female pt presents with recurrent oral ulcers that are extremely painful. She has recurrent genital ulcers and has anterior uveitis. She has hyper-pigmented areas over her extremities and few painful, nodular lesions. Dx? Tx?

Behcet's Syndrome Tx w/ corticosteroids

45 yr old pt comes in to the ER complaining of 2 day hx of fever, SOB, abdominal pain, and diarrhea. He has no chest pain, but has a dry cough. 3 months ago, he underwent a bone marrow transplantation for his AML. He is febrile. PE reveals oral thrush. Lungs have bilateral diffuse rales. Heart sounds normal. Abdomen is tender. CXR reveals multifocal diffuse patchy infiltrates. What organism is involved?

CMV

What CN's are located on the side of the medulla?

CN IX,X, XII, and XII (medial)

What CN's are located between the pons and medulla?

CN VI, VII, VIII

Pt has hyperkalemia. EKG shows peaked T waves followed by lengthening of the PRS and QRS intervals. What to you give this pt to reduce possibility of cardiotoxicity?

Calcium Gluconate

What is the mcc of death in acromegaly pts?

Cardiovascular in Etiology Excess levels of GH leads to increase incidence of coronary heart dz, cardiomyopathy, arrhtyhmias, LVH, and diastolic dysfunction

What are the causes and sxs of spinal cord compression?

Causes-injury, malignancy, infection (epidural abscess) Sxs -worsening local back pain -*pain worse in recumbent position* -Early: bilateral LE weakness, hypoactive reflexes -Late: bilateral Babinski's, decrease rectal tone, parasthesia, parapalegia with increased DTR's

What is Acyclovir's impact on the kidneys? Mechanism? Tx?

Crystal-Induced AKI -elevated Cr within 1-7 days -UA showing hematuria, pyruria, and crystals -Mechanism --> precipitation of crystals in the renal tubules causing intratubular obstruction Tx-discontinue drug and give IV fluids

60 yr old man comes in complaining of 10 days of back pain and weakness. He has a history of BPH, and a recent UTI which was tx with Cipro. Vitals shows a temp of 101 F, BP 120/76, HR of 90, and RR of 16. PE shows an exquisite tenderness over the L4-L5 vertebrae and local paravertebral muscle spasm. Neuro exam was normal. Straight leg raise test was normal. Labs show normal CBC, but ESR was elevated. Xray shows mild DDD. Next best step? Why?

MRI spine for suspected Osteomyelitis

A pt is recovering from a URI and is coming in complaining of a persistent cough for the past 2 weeks. He denies any fever, SOB, CP, congestion, or HA. He admits that coughing is worse at night and he feels fluid dripping behind his throat. His vitals are normal and PE is normal except for a visible post-nasal drip. What is the next step in management? a) what if after therapy, the symptom still persists for 2 more weeks? b) what are other causes of chronic cough?

Give pt anti-histamines for cough suppressant a) if sxs still persist, then get a CXR b) GERD, ACE inhibitor use, Asthma

A pt who has been bed ridden for a week due to foot infection is coming in for acute loss of consciousness. His BP was 80/40, and HR was 120. His skin is cold and clammy. Right heart cath reveals increased RA pressure, increased pulmonary artery pressure, and normal pulmonary capillary wedge pressure. What is the cause of these symptoms? a) What is the cause if you saw a decrease in all the pulmonary pressure, warm extremities and normal BP?

Pulmonary Embolism a) Septic Shock

A 25 yr old Eastern European man is being evaluated for right shoulder pain and swelling. He also complain about heel pain. PE reveals tenderness over the heels, iliac crest, and tibial tuberosities. What is the dx? What dz is it associated with?

Dx is Enthesitis --> inflammation of tendons and ligaments Commonly seens with Ankylosing Spondylitis.

A 35 yr old pt comes in complaining of pain and stiffness of her MCP and PIP joints for the past several months. Her morning stiffness lasts longer than an hour. She complaints of joint swelling too. She takes indomethicin which relieves the pain but it returns right back if she doesn't take it. Xray shows periarticular osteopenia and erosions. What is the dx and what is the tx? a)what if symptoms persist for 6 months?

Dx is RA and Tx is methotrexate a) add a biologic like TNF inhibitor

What are common atypical presentations of ACS? What population is common to see atypical presentation of ACS?

Dyspnea, epigastric pain, nausea and vomiting a) women, the elderly, and pts with DM

What is the tx to hypersensitivity pneumonitis? -dry cough, fever, breathlessness -CXr reveals haziness (ground glass appearance)

Removal of offending agent

A 50 yr old pt is admitted to the hospital for a productive foul smelling cough, fever, and SOB. He has a PMH of HTN and HLD. Pt was admitted 6 months ago for pneumonia. He smokes a pack a day for 25 yrs. He drinks 5 beers a day. Vitals reveal 102 fever, tachycardia, and tachypnea. CXR reveals right lower lobe consolidation. What in the hx is causing this pts symptoms?

Excessive Alcohol ingestion.

43 yr old complains of frequent epigastric burning not relieved by antacids. The sensation occurs after lifting heavy objects at work and takes 10 mins to go away. He denies any associated arm, or neck pain, cough, SOB, or difficulty swallowing. His PMH is significant for SLE, which he takes low-dose prednisone everyday. Vitals is normal. PE reveals no abnormalities. EKG is normal. What is the next step and why?

Exercise EKG because this is probably *atypical px of stable angina. * -cardiac pathology is supported by atherosclerotic risk factors --> SLE and daily prednisone

Hyperkalemia w/ no EKG abnormalities vs Hyperkalemia w/ EKG abnormalities What is the management?

Removal of potassium from body via diuretics, kayexalate, or hemodialysis (refractory to above) vs Rapidly correct potassium via insulin, or B2-adrenergic agonists

Excisional Biopsy vs Incisional Biopsy

Removing the entire lesion vs Removing a part of the lesion

What coagulation complication is associated with nephrotic syndromes? How does it Px? Which Nephrotic Sydrome is it most commonly associated with?

Renal Vein Thrombosis is seen in nephrotic syndrome. Due to loss of antithrombin III in the urine. Px-gradual worsening of renal function and proteinuria. However, can be acute and px with abdominal pain, fever, and hematuria. *mc associated with membranous nephropathy*

A bulemia pt comes in with progressive weakness and loss of energy. Lab results show hypokalemia, hyponatremia, hypochloremia, and elevated bicarb. In addition to potassium supplementation, what is the best tx to correct this pts lab anormalities and why? a) How do I know if this is Saline-resistant or Saline-responsive metabolic alkalosis?

Give the pt *normal saline* because due to vomiting she is excreting all her H+ ions and thus forcing her body to generate Bicarb. Also the volume loss from vomiting leads to hypoperfusion to the kidneys, thus increase Ang-Renin system, which leads to increase Na2+ reabsorption, and K+ and H+ secretion. Thus, more Bicarbproduction. a) Saline-responsive will have a urine chloride of < 20mEq/L, while saline-resistant will be >20mEq/L

A pt with dx breast cancer and positive HER2 gene is beginning Trastuzumab therapy. What should be done before the start of therapy?

Get an Echo Trastuzumab in addition to chemotherapy has increased risked of cardiotoxicity

40 yr old female has atraumatic hip pain that has been progressively getting worse for the past 2 weeks. She has SLE and is on prednisone and hydroxycholoroquine. There is no local tenderness and ROM is normal. Hip Xrays are normal. Next step and why?

Get and *MRI* for hip to rule out *avascular necrosis from predinisone use.* *alcohol* is another big cause of non-traumatic avascular necrosis of the hip

Pt presents with weight loss, palpitations, mild SOB, heat intolerance, tremors and sweating. PE reveals a 2x2 cm nodule on her left thyroid. Eye exam reveals no proptosis, or chemosis. Serum TSH is very low, Total T3 and T4 are elevated. Radioactive Iodine scan shows uptake in only the left sided nodule. What is the dx and what is the pt at risk of developing in her bones?

She has a *toxic thyroid adenoma.* Due to the hyperthyroid induced osteoclastic activity, she is at risk for *Bone Loss*

30 yr old IV drug user comes in for right sided weakness starting 2 hours ago. All his vitals are elevated. MRI of the brain shows acute left sided infarct of the middle meningeal artery. TEE shows small mobile vegetations on the aortic valve. What is the next step in management? a) Can you give this guy any anti-coagulants? b) when is surgery considered?

Get cultures and start *IV Abx* a) no, this guy has an acute cardioembolic stroke. Do not want to risk hemorrhaging b) Significant valvular dysfunction, persistent/difficult to treat infection, or recurrent emoblism

A pt presents with polymorphic ventricular tachycardia with a cyclic or sinusoidal alteration of QRS axis on EKG. What is the first line tx? What to do if pts vitals are unstable?

First line is IV magnesium Unstable pts require immediate synchronized cardioversion

29 yr old women complaining of right knee pain for last 3 months. Ibuprofen did not help. Vitals are normal. No PMH. PE reveals mildly swollen and tender right knee with decrease ROM. X-ray shows expansile and eccentrically placed lytic area in the epiphysis of the distla femur. CBC and BMP were normal. Dx?

Giant Cell Tumor -young pt -distal femur at the epiphysis -soap bubble appearance -Tx = Surgery

A pt comes in for a puritic rash after an ingestion of amoxicillin. The rash developed 20 minutes after she ingested the pills. She has no dyspnea, nausea, diarrhea, vomiting, or abdominal cramps. Vitals are normal. PE reveals normal heart and lung exam. She does have multiple urticaria and mild excoriations over the upper and lower extremities. The tonsils show no exudates and are not enlarged. There is no cervical lymphadenopathy. What is the next best step in management? a) What if she did have SOB, and her lung exam revealed wheezes?

Give the pt anti-histamines a) give pt epinephrine, then subsequent oral steroids to prevent recurrence

74 yr old male with comes in complaining of urinary frequency over the last 2 months. He also has nocturia. There is also mild straining during urination as well. Past few weeks he has 2 episodes of bloody urine that cleared spontaneously. He has no PMH. He has a 30 pack yr smoking history. Rectal exam reveals an enlarged and smooth prostate with no nodules, and normal rectal sphincter tone. PSA is normal. UA shows no WBC, and 2-3 RBC. What is the best next step in managment?

Get a *Cytoscopy to rule out bladder CA* If it is negative, then we can focus on tx the BPH with alpha-blockers with/without 5-alpha reductase inhibitors

A pt with history of SLE is suspected to have Lupus Nephritis, what is the next step in management?

Get a *Kidney Biopsy* -different tx based on different classes of nephritis

40 yr old women comes to the physician complaining of pressive fatigue, myalgias, and muscle weakness in both lower extremities for the past month. She has difficulty getting up from chairs and climbing stairs. She has weakness and cramping after walking short distances. She has no PMH. She does not smoke or drink alcohol. Vitals are normal. PE reveals mildly decrease strength in the proximal muscles of the lower extremities with sluggish ankle reflexes. Labs show normal ESR and elevated CK. Electrolytes are normal. What is the next step and why?

Get a *TSH for suspected hypothyroidism induced myopathy*

A solitary pulmonary nodule was found incidentally on CXR. It was not there in prior CXR. What do you do next?

Get a CT. -If benign, then serial CT to observe -If is suspicious looking, then biopsy -If it is highly suspcious of malignancy, then surgical excision

What are the earliest renal abnormalities present in DM pts? a) How does it cause renal damage, and how do you prevent it? b) What is the first quantified renal abnormality in DM pts?

Glomerular hyper-filtration a) The *hyperfiltration leads to intraglomerular HTN* which leads to progressive glomerular damage and renal function loss. Prevent it by *use ACE inhibitors. It reduces the intraglomerular HTN.* b) *Thickening of Glomerular Basement Membrane*

A 25 yr old pt comes in complaining of SOB, and coughing blood tinged sputum for the past couple days. He denies fever, arthralgias, or weight loss. He never had these symptoms before. He is a non-smoker. His vitals are normal. Lung exam reveals bilateral rales. CXR reveals bilateral pulmonary infiltrates. His Cr is 2.6 and his UA shows dysmorphic red cells and cast. What is the most likely dz and what is its pathogenesis?

Good Pastures The disease is an autoimmune disease where IgG targets Type IV collagen in the body, which includes basement membrane.

A 33 yr old lady just gave birth to a healthy full term baby male by spontaneous vaginal delivery. Lab work on her last prenatal visit a week ago showed positive HBsAg, negative Anti-HBsAg, positive IgM Anti-HBcAg, positive HBeAg, and negative Anti-HBeAg. What does this women have? What is the next best step for the infant?

She has acute Hep B Infection Give baby *Hep B Immunoglobulin and Hep B vaccine*

35 yr old man came in with an exacerbation of his heart failure. His vitals revealed a BP of 220/120. He has a history of drinking 4 beers a day and smoking 1 pack a day. His last drink was 4 days ago. His Cr is 2.1 mg/dL. The pt was admitted and started on IV furosemide and nitroprusside. His sx improved. The next morning the nurse found him confused, agitated, and had tonic clonic seizures. BP is 176/95, HR 102, and Temp is 36.7. Lung exam was unremarkable. What is the dx?

He had *Cyanide Toxicity from the nitroprusside* -his renal failure increased the risk of building up of cyanide ions from the break down of nitroprusside -alcohol withdrawal would of occurred 2-3 days without a drink

A 55 yr old pt comes in for 2 yrs of episodic cough and productive yellow sputum. She complains of copious amounts of sputum and sometimes blood tinged. The pt saw went to an urgent care and got Abx which helps her symptoms every time. She denies fever, chills, chest pain, or recent travel. She is a 30 pack yr smoker. Her vitals are normal. PE reveals diffuse rhonchi and wheezes with bilateral crackles. What is the next step in management to dx her condition?

High-resolution CT scan of chest to dx bronchiectasis -Then sputum cultures should be done to verify etiology, then tx appropriately via Abx and steroids.

Surgical Resection vs Whole Brain Radiation Therapy Which is indicated in what setting of brain metastases?

Single mass, accessible location, and good performance status of pt vs Multiple brain metastases or poor performance status

42 yr old pt with a hx of large alcohol abuse comes in with acute pancreatitis. The pt is given opioids, and fluids. On day 2, his blood pressure drops to 80/60 and his increases to 120 and regular. His O2 Sat is 92% on 2L nasal canula. PE reveals no JVD. Bilateral Crackles are head on the lungs. His abdomen is mildly distended and tender. His urine output is 8ml/hr. Bun/Cr is 45/1.9. What is the cause of this pts current condition? Tx?

His *acute pancreatitis progressed to severe pancreatitis* which presents as shock and multiple organ failure. -due to *releases of activated pancreatic enzymes and inflammatory mediators* -Tx w/ supportive care (lots of fluids)

A pt who is a vegan and alcoholic has been more fatigued lately. He has pallor. Iron studies are normal. Hb is 10.8. His MCV is 109. What happens if this pt is only given folate?

His megaloblastic anemia and folate deficiency will be correct, but he will still be lacking Vitamin B12 --> *loss of vibration sense and proprioception will occur*

Marginally high values of hematocrit. High normal electrolytes. BUN/Cr>20. What would you give this pt?

IV Crystalloid (usually Normal Saline)

54 yr old male with PMH of DM2 comes in to the ER complaining of SOB. His BP is 146/92, RR is 26, and O2 sat is 82%. PE reveals S3 sounds over the apex. Base on the above findings, what is the best initial therapy? a) What is the dx?

IV Diuretics a) decompensated CHF

Occurs within 5 days of URI. Gross Hematuria. Normal serum compliments. Mesangial Immunoglobulin Deposits. vs Occurs 10-21 days of URI. Gross Hematuria. Low C3 compliment. Subepithelial humps consisting of C3 Compliment. What Nephritic Syndrome?

IgA Nephropathy vs Post-infectious GN

Pt presents with V-fib on the EKG. What is the next step in management?

Immediate Defibrillation

A pt with underlying Protein C deficiency receives warfarin by accident. She developed dark necrotic lesions over her breast and trunk. Whats the Tx?

Immediate removal of Warfarin Administer Protein C

A 30 yr old women have migraines with aura. What risk do they put themselves in by taking OCPs?

Increase risk of stroke

A pituitary tumor less than 10mm means what?

It is a microadenoma. It does not cause mass effects.

What is Primidone used to tx? What are its SEs?

It is used to tx Essential Tremors SE is acute intermittent porphyria -*abdominal pain, neurologic (HA and confusion) and psychiatric abnormalities (hallucinations)*

What is pulsus paradoxus and in what diseases is it presented in?

It is when there is a drop of systolic BP greater than 10mmHg during inhalation. It is commonly seen in cardiac tamponade, but it can be seen in asthma pts and COPD pts.

What nerve does Diabetic Mononeuropathy often involve? How is it different from a compression of the nerve?

It often involve *CN III,* and the nerve damage is *schemic*, thus mainly affecting somatic functions. (*sparing of the light and accomodation reflex*) If it was a* compression* of CN III, it will *lose both somatic and parasympathetic functions.* -Ptosis, down and out gaze -Loss of accommodation and light reflex

What metabolic abnormalities are seen in hypothyroidism besides low thyroid and high TSH?

It reduces the activity of LDL receptors and Lipoprotein Lipase --> to *Hyperlipidemia* *Hyponatremia* *Elevated CK*

A 44 yr old man comes in vomiting small amounts of red blood and passing dark stool. He is a known IV drug user. On day 2 of hospitalization, the pt is confused and disoriented. His vitals are normal. His pupils are round and reactive to light. PE reveals abdominal distension with shifting fullness. When the pt holds his arms in from of him with wrist extended, he repeatedly jerks his hands up and down. Labs show hyponatremia, hypokalemia, and BUN of 34. What is the tx for the pts AMS? a)What can be added if the above tx doesnt work?

Lactulose a) Rifaximin, and abx to kill ammonia producing bacteria.

79 yr old pt comes in complaining about loss of memory for the past couple months. She has been having difficulty remembering names of new friends and increasing difficulty balancing her check book. Her other complaint is urinary incontinence, which she attributes to old age. She denies HA, vision changes, rash, vomiting or nausea. Vitals are normal. PE is normal. Neuro exam is normal. However, her gait is slow and shuffling. Mini-mental exam scored a 24/30. What is the treatment to relieve her sxs?

Large volume lumbar punctures, then ventriculoperitoneal shunting.

A 40 yr old pt who is on chronic steroids presents with progressive right hip pain. The pain is localized on the right hip and states that pain is present on weight bearing and rest. PE shows round face and fullness in supraclavicular area. Purple striae are present on skin. What is the most definitive test and what will they find?

MRI and they will find avascular necrosis of the bones

34 yr old man comes in to the ER complaining of headaches, fatigue, and bouts of fever for the past 3 days. He has multiple episodes of intense cold and chills that precede the onset of high grade fever and profused sweating. He and his wife just returned from Kenya 2 weeks ago. They did not visit the travel clinic prior to the trip. PE shows no rash and conjunctival pallor. No neurologic deficits. Labs shows anemia and thrombocytopenia. What is the cause?

Malaria -cyclic episodes of fever and chills -anemia -thrombocytopenia -hx of edemic area

What resolves Essential Tremor?

Sleep and Alcohol

What is Athetosis? a)What dz is it seen in?

Slow, writhing movements. a)Seen in Huntingtons Dz

Howell Jolly Bodies vs Heinz Bodies

Nuclear Remnants within RBCs that typically removed from by the spleen. *Presence indicates absence of Spleen*. vs *Hemoglobin precipitation* seen in G6PD Deficiency

A 70 year old chronic smoker. Comes in for cough and SOB. CXR shows a 2.5 cm left perihilar mass. WBC is normal. BMP shows Sodium at 119. Plasma Osmolality is 250 and Urine Osmolality is 310. What is the cause of this pts condition?

Small Cell Carcinoma of the Lung

Persistent, nodular, erosive, or ulcerative lesions w/ surround erythema or induration in the buccal mucosa vs white granular patch or plaque on the buccal mucosa In the setting of alcohol and oral tobacco use. Dx?

Squamous Cell CA vs Leukoplakia

A 67-year-old man is brought to the ER because of a 3-day history of fever and headache. Five years ago, he underwent placement of a mechanical aortic valve for treatment of sequelae of rheumatic fever. He appears ill. His temperature is 40 C (104 F), BP is 110/65 mm Hg, HR is 110/min, and RR is 22/min. A grade 3/6, systolic ejection murmur is heard. Neurologic examination shows mild left hemiparesis. Babinski's sign is present on the left. There is no nuchal rigidity. Possible cause to his condition? What complication would be most concerning?

Septic Emobli secondary to possible valve vegetation Complications could be Brain Abscess

65 year old pt is coming to the ER for palpitations. She complains of HA, insomnia, and vomiting yesterday morning. PMH of COPD, HTN, and HLD. Had a puncture wound last week of her foot, so she is being tx with ciprofloxacin. Her other meds include tiotropium, theophylline, fluticasone/salmeterol, lisinopril, and HTZ. EKG shows MAT with a single PVC. What is likely causing her symptoms and what is the next step?

Probably Theophylline toxicity and we should check her serum theophylline levels.

27 yr old women presents to the ER for severe vomiting and abdominal pain. Her vitals are normal. PE reveals a non-distended and soft abdomen, without hepatosplenomegaly. She is tx with IV fluids and metoclopramide. Several hours later she complains of neck pain and stiff neck muscles. What happened?

She has *Metoclopromide induced EPS symptoms*. It is a dopamine antagonists

46 yr old women complains of 2 months of pain and numbness of her right index and middle fingers. They turn white when subjected to cold, and they hurt until she thoroughly warms them. There is no problem with her left fingers. PMH reveals GERD. She has a 28 pack yr smoking hx. PE reveals 2 small ulcers on the tip of her right index finger. Dx? Why? Next Step in management?

She has *Secondary Raynauds* due to her smoking (thromboangiitis obliterans). Secondary Raynauds is asymmetric while, primary is symmetric. Pts with suspected secondary Raynauds -*ANA and Rheumatoid Factor* -ESR and Compliment Levels

A 40 yr old pt comes in with epigastric fullness and/or discomfort after eating. She denies cough at night, weight loss, heartburn, dysphagia, hemoptysis, or melena. She does not take any meds. PE is normal. Occult blood test in stool is normal. LFT test and CBC are normal. What is the appropriate management of this pt? Why?

She has *no GERD sx or NSAID use. No Alarm Sx.* Thus we will run a *H. Pylori serology.* If she had GERD sx --> empiric PPI If she had NSAID use --> d/c or add PPI If she had alarm Sx --> Endoscopy

A 26-year-old woman is brought to the ER because of marked confusion for 2 hours; she also has had a flu-like illness for 3 days. Over the past 6 weeks, she has had increased fatigue, weakness, and nausea. She recently started thyroid hormone replacement therapy for autoimmune thyroiditis; 1 week ago, her serum TSH level was 3 uU/mL. Her temp is 38 C (100.4 F), BP is 80/40 mm Hg, and HR is 140/min. She appears confused and lethargic. Examination shows cool, mottled skin. There is generalized hyperpigmentation, especially involving the palmar creases. The lungs are clear to auscultation. Abdominal examination shows diffuse mild tenderness and no rebound. Labs show normal CBC. Na of 124, K+ of 6.4 Imaging and UA was unremarkable. Dx? How to Confirm?

Pt probably has *Primary Adrenal Insufficiency* (Addisons) and we can *confirm by doing a ACTH Stimulation Test* -Adrenal gland does not secrete glucocorticoids or mineralcorticoids -Hyperpigmentation from elevated ACTH

A pt with advance prostate CA and bony metastases is complaining of low back pain for 2 weeks. He already underwent orchiectomy 8 months ago, which afterwards freed him from back pain. Bone scan reveals increased uptake in the lower back. What is the next best step?

Radiation Therapy

A 28 yr old man comes in for a complete PE for his job. He is healthy with no PMH. Does not smoke or drink alcohol. Vitals are normal. PE is normal except for a painless, hard mass in the left testicle. U/S reveals a suspicious mass. What is the next best step?

Radical Orchiectomy!!!

A 20 yr old nurse was recently stuck with a needle while drawing blood from a pt with acute Hep B. Her history shows she recieved Hep B vaccine series 5 years ago. Upon starting her job, she was found to be HBsAB-positive. What is the next best step for this pt? a) What if her immunity status was unknown?

Reassurance, because she is already immune to Hep B. a) then give both Hep B vaccine and Hep B Immunoglobulins

A pt has recurrent painless, nodular and rubbery lesions on her eyelid. They usually go away via hot compresses. What is a possible concern?

Recurrent Chalazions are a concern for meibomian gland carcinoma. Also Basal Cell CA of the eyelids appear similarly. *Examine histologically*

A 16 yr old pt with Hereditary Spherocytosis is expected to undergo Splenectomy. What are they at risk for in their lifetime? What should they do to prevent it?

Risk of infections from Pneumococcus, Meningococcus, and Haemophilus (all encapsulated bacteria) Reduce risk by -Getting vaccinated to all of the above organisms several weeks before operation -Daily Oral PCN as prophylaxis for th next 5 yrs

A 67-year-old man is brought to the ER 4 hours after the onset of severe midlumbar back pain. He is anxious, pale, and diaphoretic. His temperature is 37.1 C (98.8 F), blood pressure is 105/65 mm Hg, and pulse is 120/min. Examination shows no other abnormalities. X-ray films of the lumbar spine show degenerative disc disease with calcifications anterior to the vertebral bodies. What life threatening situation should be in my differential?

Ruptured Aortic Aneurysm

89 yr old pt comes in complaining of episodic skin discoloration over the last several months. PE reveals hyperpigmented skin with several flat, dark purple ecchymotic areas over the dorsum of both forearms. CBC and Coagulation studies are normal. What is the dx? What is the underlying mechanism?

Senile Purpura -common elderly non-inflammatory skin disorder that occurs with extensive sunlight exposure. -*it is due to loss of elastic fibers in perivascular connective tissue*

What is the management step to confirm dx of a Entamoeba histolytica induced liver abscess?

Serology

A 25-year-old woman comes to the physician because of a 3-month hx of the unexplained urge to eat a few tablespoons of cornstarch daily. The amount of cornstarch ingested has increased gradually during this time. She has leiomyomata uteri; she is otherwise healthy. Her weight is unchanged from her last visit 1 year ago; she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her BP is 120/80 mm Hg, and HR is 100/min. PE shows mild pallor. Neuro examination shows no abnormalities. She is embarrassed about her problem. She has no compulsive behavior or obsessive thoughts. An ECG shows sinus tachycardia. Dx? Most appropriate next step in management?

She has PICA - psychiatric disorder where one has odd hunger cravings. Usually foods that are no nutritious. Most appropriate next step is to get a CBC to see if she has any anemia

What is the Px of Cavernous Venous Thrombosis?

Setting of uncontrolled skin infection, recurrent sinusitis Px - HA, bilateral periorbital edema, EOM palsy

40 yr pt recently suffered 3rd degree burns. He is hospitalized and given IV fluids and ABx. On the third day he complains of severe RUQ pain, vomiting, and fever. WBC is 16,000. U/S reveals dilated gallbladder with thickening of its wall but no gallstones. Besides extensive burns what else can lead to this condition? Why?

Severe Trauma Prolonged TPN Prolonged Fasting Mechanical Vent All these can lead to Acalculous Cholecystitis, because it can cause localized ischemia, *biliary stasis*, *infection*, or external compression of cystic duct.

How do you tx a pt with moderate to severe hypercalcemia (calcium > 12)

Short term tx -*Normal saline* because pts usually are volume depleted Long term tx -*Bisphosphonates*

A pt presents with Parkonsonian symptoms but also have autonomic dysfunctions such as orthostatic hypotension, impotence, incontinence, dry mouth, etc. Dx? Management?

Shy-Drager Syndrome (Multiple System Atrophy) Management -Fludrocortisone, salt supplementation, a-adrenergic agonists to improve vascular function

What is Attrition bias and how can you prevent it?

Significant loss of study participants may cause bias if those lost to follow-up differ significantly from remaining subjects. This may lead to overestimating or underestimating the association between the exposure and the cause. Prevent by trying to achieve higher rates of follow-up.

ABCDE of Melanoma?

Signs of malignancy in Melanoma *A*symmetry *B*order Irregularities *C*olor Variation *D*iameter >6mm *E*volving (changing in size, shape, or color)

57 yr old women with breast cancer comes to the physician of increasing neck pain for the last 3 days. She has fallen frequently because of muscle weakness. Vitals are normal. PE shows hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum Calcium is 11 mg/dL. Xray shows metastasis to the C-spine. What should be next step in management?

Spinal Cord Decompression and Cervical Stabilization because she is showing UMN signs and we don't want the further nerve damage in the c-spine

What is the difference between these two aldosterone antagonist, Spironolactone and Eperolone?

Spironolactone is also binds to and *inhibits progesterone and androgen receptors* in both men and women. This leads to *gynecomastia and decreased labido in men*, and *breast tenderness and menstrual irregularities in women*. *Eperolone DOES NOT* antagonize the above receptors

40 yr old female is brought in to the ER for bloody vomiting. She was hospitalized 5 months ago for variceal band ligation. Upon admission is somnolent and barely arrousable. Her vitals show hypotension and tachycardia. Abdomen is distended with a positive fluid shift. She has peripheral edema. Her Hg is 8.2, platelets are 59,00, and INR is 1.9. Two large bore needles are in placed and IV fluids are given. While in ER, another episode of bloody vomiting took place. What is the next best step?

Stabilize her airways. Intubate her.

"Three days after being hospitalized for treatment of a hip fracture sustained in a fall, a 62-year-old woman becomes acutely short of breath and coughs up a small amount of blood-tinged sputum. She appears anxious. Her blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min. Examination shows no other abnormalities. Arterial blood gas analysis on 40% oxygen by face mask shows: pH 7.40, PCO2 is 38, and PO2 is 70 VQ scan shows multiple segmental areas of mismatch on the right. Whats the next best step in management?

Start Heparin Therapy for suspected PE

21 yr old pt with no PMH has acutely developed difficulty grasping objects. He had sinusitis a week ago. Vitals reveal Temp of 100F. CT reveals a ring-enhancing lesion in the left frontal love and fluid collection in the left ethmoid sinus. HIV antibody is negative. Which organism is more likely to the be cause Strep Viridans or Staph Aureus?

Strep Viridans

Neurogenic Claudication in Spinal Stenosis vs Vascular Claudication in Peripheral Artery Dz

Sx of pain, weakness, and numbness. Relieve is provided with postures that flex that spine (leaning forward) vs Sx of pain, cramping, and coolness. Relief with rest.

A 35 yr old comes in with a 1 yr history of fatigue, and weakness. Has significant loss of appetite and energy. Also reports cold intolerance, constant headaches, erectile dysfunction, low libido, and constipation. The pt has no neck swelling, skin rash, head injury, or excessive urination. His vitals reveals a BP of 96/ 72 and a HR of 50. His skin is pale and dry. His testes are small and soft. Labs reveals 5000 WBC with 10% eosinophils. Sodium is 132, glucose is 52, and potassium is 4. What kind of changes do you expect to see on T4, Cortisol, and Aldosterone?

T4 - Low Cortisol - Low Aldosterone - Normal

26 yr old px to the ER after an attempted suicide. He suffered 2 seizures in the past hour. His temp is 102F. His A&Ox0. Pupils are dilated, but reactive to light. Skin is flushed and dry. Abdominal exam shows reduce bowel sounds. EKG shows prolong QRS complex. Toxicology is pending. What is the probable substance? What determines the severity of intoxication?

TCA's -Cardiac Arrhythmias -Convulsions -anti-Cholinergic effects The *QRS prolongation reflects severity*, thus admin of *Sodium Bicarb is used to shorten QRS interval*

An immunocompromised pt comes in presenting with systemic symptoms, lung nodules, and brain abscess. The culture grows gram(+), partially acid fast, filamentous, branching rods. What is the tx of choice? a) what is the organism?

TMP-SMX a) Nocardia

A 55 yr old man just underwent a renal transplantation. He is on prednisone and cyclosporine. What should be added to prevent opportunistic infections?

TMP-SMX Ganciclovir

A 50 yr old pt comes in with 2 days of intermittent pain. He vomited 3 times over past couple hours and has not passed gas or had bowel movement for the last 3 days. On PE, his abdomen is distended and tender to palpation. There is no guarding or rebound. Bowel sounds are hyperactive during rushes of pain. The pt is febrile and has a elevated white count. Plain film reveals multiple air-fluid levels of the abdomen. ABG also shows pH of 7.26, pO2 of 90, pCO2 28, and HCO3 of 15. What is the dx and what is the next step in treatment?

This pt has a SBO but is at risk of impending strangulation due signs of necrosis (metabolic acidosis are signs of ischemia) Pt needs emergent laparatomy

A 40 yr old comes to the ER with sob, cough, and hemoptysis for the past 2 days. He has never had this before. His medical hx reveals a non-healing leg ulcer and chronic purulent nasal discharge. He has a 20 pack year history. Vitals are unremarkable. PE reveals patchy rales bilaterally. 2x3 cm ulcer is with rolled, undetermined border is noted on right lower leg. Lab reveals a positive C-ANCA. What is dx and tx?

This is *Wegeners (Granulomatosis w/ Polyangiitis)* Tx with *Cyclophosphamide*

A health care worker comes in complaining of throbbing pain over the pulp of his left index finger for the last 2 days. He has been feeling warm for the last 3 days. He denies having any STDs or core sores in the past. PE reveals a swollen, soft, and tender distal pulp space of the left index finger with some non-purulent vesicles. What is the suspected Dx? How would you confirm it? Tx?

This is Herpatic Whitlow. -confirm dx via positive hx of exposure and Tzanck smear showing multinucleated giant cells Tx is usually self-limiting but oral acyclovir can be given

An asymptomatic 57-year-old man comes to the physician for a routine health maintenance examination. He has smoked one pack of cigarettes daily for 37 years. His blood pressure is 180/112 mm Hg, and pulse is 82/min. Abdominal exam shows a bruit in the RUQ and no masses. His hematocrit is 42%, serum BUN is 23 mg/dL, and serum creatinine level is 1.4 mg/dL. Which of the following is the most likely cause of this patient's bruit? a) what if this pt was younger and did not smoke? Dx?

This is a AAA so the bruit is caused by accumulation of lipids in the arterial wall a) Then Fibromuscular Dsyplasia would be more suggestive. The pt would have hypertrophy of the arterial wall media

A pt has history of known cirrhosis presents with BP 95/60, leg edema, hyponatremia, and elevated Cr. The pt was giving IV fluids and there was no change in serum Cr. US of the kidneys were unremarkable. What condition is this and what is the tx?

This is hepatorenal syndrome. The treatment is Liver Transplant

A 62-year-old woman comes to the physician because of bloating and cramping abdominal pain and intermittent diarrhea over the past 5 years. Her symptoms have increased over the past month since she started a new diet that emphasizes yogurt and cottage cheese as low-fat sources of calcium and protein. Vital signs are within normal limits. Abdominal exam shows diffuse tenderness to palpation with no rebound tenderness; there are no masses or organomegaly. Bowel sounds are increased. Test of the stool for occult blood is negative. What is the most likley dx and why? Underlying mechanism?

This looks like *Irritable Bowel Syndrome* -Intermittent Diarrhea -Worsened with dairy products The underlying mechanism is *impaired intestinal motility*

A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last tx was 2 hours ago. She appears toxic. Her temp is 39 C (102.2 F), and BP is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Dx? Which of the following is the most appropriate next step?

This looks like Spontaneous Bacterial Peritonitis Next step is to get a paracentesis of peritoneal fluid to measure the PMNs and get a gram stain

A 20 yr old pt comes in complaining of intermittent bloody diarrhea, lower abdominal cramps, rectal urgency, and tenesmus. PE reveals rectal tenderness and mucus mixed with blood. What is the likely diagnosis? a) what if his symptoms worsen in the next couple days, by having a fever, elevated white count, tachycardia, and hypotension. What is the concern, what to do initially to verify?

This patient probably has Ulcerative Colitis a) worry about development of toxic megacolon. Get initial abdominal xray

A 60 yr old man has acute back pain that radiates down is right leg after lifting a heavy box. The pt also complains of inability to urinate since the pain started. PE reveals no lower extremity weakness or numbness. Pin pricking of the perianal area elicits a quick spasm of the anal sphincter. DRE reveals an enlarged, smooth, and non-tender prostate. What does this pt have? What is causing the urinary retention?

This probably has a herniated disc. Most likely a L4/L5. It is likely that he has BPH and that the pain stops him from generating enough pressure to urinate. It is NOT a nerve damage issue, such as Cauda Equina Syndrome

78 yr old women with hx of HTN and DM2 px to the ER for complaint of week long worsening left sided ear pain and drainage. The pain is unrelenting and it hurts to chew. She reports fullness in the ear and mild hearing loss. Vitals reveal temp of 101F, BP of 140/90, and HR of 98. PE revelas left external auditory canal is edematous with purulent discharge and granulation tissue in the floor. TM is clear. ESR is 89. Ear swab was obtained. What is the best initial tx of this pt? Why?

This pt has Malignant Otitis Externa -severity due to comorbid conditions and severity of sxs *Tx them with IV Cipro (or other anti-psuedomonals)* -Topical anti-pseudomonal agents are reserved for Otitis Externa

19 yr old female immigrant from Romania comes in the ER with fever, joint pain, and rash. The rashes started yesterday and is quickly spreading down her trunk. Her joint pains are located on her wrists and knees. Her immunization status is unknown. She is febrile. PE reveals a macupapular rash that covers the face and trunk, but spares the hands and feet. She has posterior, cervical, and suboccipital lymphadenopathy. She has bilateral conjunctival injections. Oropharynx is clear. Lungs are clear. What is the dx?

This pt has Rubella infection

A previously healthy 52-year-old man comes to the emergency department because of hiccups for 1 week. He has smoked two packs of cigarettes daily for 30 years. He does not drink alcohol. He is alert and oriented. His temperature is 37 C (98.6 F), blood pressure is 150/95 mm Hg, pulse is 70/min, and respirations are 12/min. Physical and neurologic examinations show no abnormalities. His serum sodium level is 120 mEq/L. An x-ray film of the chest shows a right hilar mass. Which of the following is the most appropriate next step in treatment? Why?

This pt has Small Cell CA of the Lung and is secreting ADH For pts with SIADH --> *Fluid restriction if asymptomatic* *Symptomatic pts (lethargy, confusion, coma) need 3% Hypertonic Saline*

A 43 yr old pt is being evaluated for 3 yrs of upper abdominal pain. He describes episodes of dull epigastric pain and LUQ pain that lasts for hours and not relieved by antacids. He also complains of occasional diarrhea. The pt has lost 15 pounds in the past yr. Three yrs ago he was hospitalized for 3 days with acute abdominal pain. He consumes alcohol daily. What is the suspected Dx? What would you use to dx it? Tx?

This pt has suspected *Chronic Pancreatitis*, and *dx is made via CT abdomen.* Tx -managing the pain, and cessation in alcohol. -Frequent Small Meals and supplement Pancreatic Enzymes

A pt who is recovering from a recent URI started developing a high fever, SOB, and a productive cough with blood streaks. CXR reveals infiltrates in the lungs bilaterally as well as multiple thin-walled cavities. Dx? Mostly likely organism?

This pt is having a secondary bacterial pna by *Staph aureus* Staph aureus is known to cause *post-viral URI necrotizing pulmonary bronchopneumonia* -CXR shows multiple nodular infiltrates that can cavitate

32 yr old comes to the ER for severe left sided chest pain. He is tachycardic and hypertensive. PE reveals dilated pupils and atrophic nasal mucosa. Cardiac exam is normal. EKG reveals ST depression and T wave inversion in leads V4-V6. His initial trops and CK-MB are negative. CXR is normal. What is the best next step and why? Should I give this pt a Beta blocker?

This pt should be started on Benzo' s to reduce anxiety and improve cardiovascular symptoms via his cocaine abuse. Also give Aspirin to reduce thrombus formation, and give nitrates or CBB to reduce coronary vasoconstriction *Do not give BB's because it will cause unopposed activation of Alpha-adrenergic receptors --> HTN Crisis*

A 33 yr old pt comes in with 1 day history of localized, small swelling along the margin of the upper eyelid. He feels pain, which does not seem to come from the conjunctival surface. He has a 10 pack year smoking history. He is sexually active and does not use condoms. He is worried about swelling. What is the dz and what is the next step in management? a) what if it does not improve over the next 2 days?

This seems to be a *Stye*, and treat it with a *warm compress.* a) Incision and Drainage

A female pt presents with a complaint of weight gain, lethargy, and constipation for 2 months. PE reveals a diffuse rubbery enlargement of the thyroid gland without any discrete nodularity. Lab shows decrease T4 levels and elevated TSH. She is positive for anti-thyroperoxidase antibodies. Which thyroid malignancy is she at risk of acquiring? What next step to confirm dx?

Thyroid Lymphoma Confirm via core needle biopsy

28 yr old female develops tachycardia while in Post-Op. She recently had right femoral surgery after a MVA. While in recovery, she started having nausea, vomiting, and became anxious and agitated. She no hx of known medical problems. She drinks 1-2 glasses a wine on weekends. Her temp is 103 F, BP is 160/90, HR is 148, and RR is 24. O2 sat is 98% on RA. PE reveals delerium and fine tremors. Mild lid lag is present. She has no muscle rigidity and DTR are normal. Labs are normal except for an elevated CK. Dx? and Next Step in management?

Thyrotoxic Storm 1. *BB's* 2. *PTU*, followed by Iodine solution to decrease T3/T4 synthesis 3. Glucocorticoids to decrease peripheral T4 to T3 conversion 4. Treat underlying cause/trigger

What is the manifestations of theophylline toxicity and what metabolizes theophylline?

Toxicity --> CNS (HA, insomnia, seizures), GI (nausea, vomiting), Cardiotoxic (arrhythmias) Theophylline is metabolized by CYP-450

A 62-year-old man has had the gradual onset of fatigue and SOB over the past 3 years. There is striking JVD with a large wave occurring with S2. The carotid upstroke is normal. Cardiac examination shows a lifting systolic motion of the sternum and no palpable point of maximal impulse. A grade 3/6, holosystolic, plateau-shaped murmur that is loudest on inspiration is heard at the lower left sternal border. The liver is enlarged and tender, and the abdomen is swollen with a fluid wave. There is marked ankle edema. What heart condition caused this murmur?

Tricuspid Regurg

What are the SE's of taking Lithium therapy?

Tremors Hypothyroidism Epsteins Anomaly DI (nephrogenic)

22 yr old pt complains of 4 days of double vision, and painful swelling around his eyes. He also has significant muscle pains in his neck. He recently returned from a trip in Mexico. His vitals show a temp of 101F. PE reveals splinter hemorrhages, periorbital edema, and chemosis. Lungs, Heart, and Abdominal exam is normal. Labs reveal eosinophilia. Dx?

Trichinellosis

What are some triggers and px for vasovagal syncope? How is the dx made?

Triggers - Prolong standing, emotion distress, painful stimuli Px - Pts have prodrome of nausea, pallor, dizziness, sense of warmth Dx - Mainly clinical dx, but *Upright Tilt Table Test* in uncertain cases

25 yr old comes in complaining of constant diarrhea for 6 weeks. Hx reveals he was living in Peurto Rico for 3 months. Sx include crmaps, fatigue, and progressive weight loss. PE shows hyperactive bowel sounds. CBC shows macrocytic anemia. Stool exam was negative. Small intestinal biopsy shows blunting of the villi with infiltration of chronic inflammatory cells such as lymphocytes, plasma cells, and eosinophils. Dx?

Tropical Sprue

What is the most sensitive and specific test in the setting of MI? a)What is a sensitive test to detect a recurrent MI?

Troponins. -they are slow to return to normal a) CK-MB

A 40 yr old pt comes in presenting with chronic fatigue. He has an extensive hx of IV drug abuse, and alcohol intake. Vitals are normal. PE shows mild hepatomegaly with no ascites. LAbs showed AST 550, ALT 600. INR is 1.2 and PT time is 11 sec. CBC and BMP are normal. PCR shows serum Hep C Virus RNA. Liver Biopsy shows moderate inflammation with some portal and bridging fibrosis. Whats the management at this time? a) Why did we not screen for Esophageal Varices? b)What if he had signs of cirrhosis?

Tx Hep C with *Pegylated-IFN and Ribavirin* a) Though this pt has Hep C, he has no clinical signs of portal HTN or Cirrhosis b) *Signs of cirrhosis = SCREEN for Varices + Hepatocellular CA every 6 months*

A reaction occurs when an allergen binds and cross-links two IgE molecules attached to the mast cell. What type of reaction is this? What are some examples?

Type I Hypersensitivity Reaction Ex. Urticaria and Anaphylaxis

Cytotoxic reactions involve specific reactions of IgG or IgM to cell-bound antigens. The Antibodies then activate compliment resulting in cell damage. What type of reaction? What are some examples?

Type II Hypersensitivity Reaction Ex. Immune hemolytic anemia, Rh hemolytic disease in newborns

Antibodies of IgG or IgM form complexes with antigens and non-specifically activate the compliment cascade and other inflammatory processes. What type of reaction is this?

Type III Hypersensitivity Reaction

Where are typical locations for pressure ulcers to develop. How can they be managed?

Typical locations are *Heel, Sacrum, Elbows, Ears.* Pts should be *repositioned* occasionally to relieve the pressure

A 45 yr old pt with a hx of CAD and DM came in for left sided weakness, which resolved spontaneously after 24 hours. Why should this pt get a US of his carotids and Echo of his heart?

US of the carotids is to rule out a carotid stenosis that could of lead to the TIA Echo of the Heart is to rule out -Aortic Stenosis -PFO -Septic Emboli -Mural Thrombus

Which anticoagulant is preferred in pts with severe renal disease?

Unfractionated Heparin -due to its ability to be monitored (PTT)

A pt has chronic back pain, and development of hearing loss recently. Labs show an elevated Alk Phosphatas, normal calcium, phosphorus, and liver enzymes. What would you use to dx this pt and what is the tx?

Use *Bone Scan* to dx Pagets Dz Tx this pt with *Bisphosphonates*

30 yr old man comes in for a routine physical .He has no complaints except for occasional headaches in the morning. Pt has a BP of 175/103. Lungs are clear and heart sounds are normal. PE reveals bilateral, nontender, upper abdominal masses are palpated on exam. His Hb level is 15.2 and Cr is 0.8. What is the next step in management and why? What is the common px of this dz? Management?

We need a renal U/S to confirm the dx of Autosomal Dominant Polycystic Kidney Dz Common Px -HTN -Hematuria, Proteinuria -Palpable Renal Masses -*Progressive Renal Insufficiency* -Kidney Stones, *Cerebral Aneurysms*, Cardaic Valve Dz Management -Aggresive control of HTN (ACE inhibitors) and Renal Dz (dialysis)

a 40 yr old female px to the ER with palpitations and lightheadedness of acute onset. Also, she has been experiencing insomnia, fatigability, and weight loss lately. Negative Social hx. Takes no meds. BP is 110/80, HR is 120 and irregular. PE reveals lid lag and fine tremor of the outstretched hand. EKG reveals A-fib with RVR. Next step in management and why?

We should give her a BB like propranol because this pt has A-Fib due to hyperthyroidism. *No reason to perform cardioversion if the underlying cause is not managed. Also the pt has stable vitals*

A liver body reveals Mallory Bodies. What diseases is it associated with?

Wilsons Dz Primary Biliary Cirrhosis Non-alcoholic Cirrhosis Hepatocellular CA

A pt has Crohns Dz. They present with a complaint of a skin rash and hair loss. He is currently on total parenteral nutrition. When he does eat, he complains of lack of taste. PE reveals alopecia, bulbous and pustular lesions around perioral area. He also has impaired wound healing. What are they deficient in?

Zinc

A pt is coming to the ER with muscle weakness. Labs revealed her potassium to be 7.2 and EKG reveals prominent T waves in precordial leads. a) What is the first step to management? b) What can be used to drive the potassium back into the cells?

a) *Calcium Gluconate to stabilize the cardiac membrane*, so no cardiac complications will occur b) -Insulin (or give glucose) -Sodium Bicarb -*Beta-2 Agonists*

a) In a case of witnessed cardiac arrest of < 5 minutes duration. What is the best management? b) In a setting of unwitnessed cardiac arrest or a witnessed arrest occuring > 5 minutes before a defibrillator arrives. What is the best management?

a) Immediate Defib b) A cycle of CPR before Defib

A 40 yr old pt presents with periodic epigastric pain, especially when lying down. Tums make it better. a) What is the management at this moment? b) What if Sxs persist? c) What if pts presents the above PLUS melena, vomiting, hematemesis, weight loss, anemia, or dysphagia??? d) What if pts was >50 and sxs lasted for more than 5 years, or pt has history of CA?

a) PPI for 2 months b) Endoscopy or Esophageal pH Monitor c) Endoscopy d) Endoscopy

Pure Small Fiber Neuropathy vs Pure Large Fiber Neuropathy

more pain, allodynia, and parasthesias. Ankle reflex preserved vs less pain, more numbness, decreased priopioception and vibration. Ankle reflex lost