1
Q
GERD is dx using what?
what are primary ssx of GERD?
A
- ambulatory 24 hr pH monitoring (Barretts is dx with EGD and biopsy)
- heartburn, regurg, and dysphagia
2
Q
what should you do next if a pt has refractory GERD or warning signs (dysphagia, odynophagia, or GI bleeding)?
A
- EGD with biopsy
- if no warning signs, then lifestyle mod followed by H2 blocker or PPI if no response to lifestyle mod
3
Q
what is the agent of choice to manage GERD during preg?
A
- sucralfate: surface agent that heals and protects from peptic injury
4
Q
first line agents for HTN Tx in non-blacks?
A
- ace inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide (ACE or ARBs are preferred in CKD pts with proteinuria)
5
Q
first line agents for HTN Tx in blacks?
A
- thiazide diuretic or calcium channel blocker
- IF they have CKD AND proteinuria then use an ACE or ARB (if no proteinuria, then thiazide or ACE or ARB)
6
Q
can you use ACE (-pril) and ARBs (-sartan) at the same time?
A
- heck NO! you crazy?
7
Q
what BP is defined as HTN?
A
<60 y/o >140/90
>60 y/o >150/90
8
Q
what is Dermatitis Herpetiformis?
A
rash associated with Celiacs dz and seen mainly on extensor surfaces
9
Q
what serologic test will confirm Dermatitis Herpetiformis?
A
anti-gliadin, anti-transglutiminase, and anti-endomysium antibodies
10
Q
what is the most common form of scoliosis?
A
Adolescent idiopathic scoliosis
11
Q
in scoliosis, what COBB angle requires bracing in skeletally immature pts (non-adults)?
A
- <20 is managed with serial observation
- 20-45 degrees is managed with bracing and serial odservation
- > 45 is managed with surgical fusion
12
Q
what HTN med can cause an acute Gout flare?
A
- thiazide diuretics as they inhibit the secretion of uric acid (don’t use in Gout pts)
13
Q
what are the best drugs for sleep onset-insomnia (can’t fall asleep)?
A
the Z drugs… zolpidem, zaleplon, and triazolam
14
Q
what drugs are best for sleep maintenance-insomnia (goes to sleep ok but can’t stay asleep)?
A
benzos as they have a slower rate of elimination (ex: estazolam or flurazepam, etc)
15
Q
what drugs are best for depression related insomnia?
A
antidepressant agents with sedative properties such as trazodone (adverse: priapism) or amitriptyline (adverse: anti-cholinergic ssx).
16
Q
you should never give this to any pt who is known to abuse alcohol…
A
hypnotic agents like benzos, sleep aids, etc as it leads to CNS depression
17
Q
what nerve is compromised, and where, in pts suffering with hypoesthesia of the anterolateral leg and foot drop?
A
the common peroneal (fibular) nerve (L4-S2) at the fibular head
18
Q
what is the tibial nerve responsible for?
A
plantar flexion and sensory of the posterior leg
19
Q
what is the sural nerve responsible for?
A
sensory of the the postero-lateral leg, lateral foot, and 5th toe… NO motor!!
20
Q
what is meralgia paresthetica?
A
hypoesthesia and paresthesias of the lateral thigh due to compression of the lateral femoral cutaneous nerve
21
Q
what nerve innervates hip adductors?
A
obturator nerve (also does sensory of small circle on medial thigh)
22
Q
what nerve is responsible for knee jerk reflex?
A
femoral nerve (innervates quads also does sensory to the medial and middle thigh and the medial lower leg.)
23
Q
what nerve root is impacted by a L3-4 herniation?
A
L4 (will have diminished knee jerk reflex)
24
Q
pt complains on rhinorrhea, congestion for 3 mths and has nasal polyps and takes an old NSAID daily… what does he have?
A
aspirin-related respiratory disease
25
what causes aspirin-related respiratory dz?
| and how is it treated?
- elevated leukotrienes (not a true allergic rxn)
| - avoid aspirin if possible and take a leukotriene receptor antagonist such as montelukast, zileuton, or zafirlukast.
26
what are the MCC of peptic ulcer dz (gatric and/or duodenal ulcers)?
H. pylori (MC-ly in duodenum) and NSAID use
27
pt has a gnawing abd pain that sometimes wakes her at night and gets better after she eats... what does she have?
duodenal ulcer
28
what dz causes gastric acid hypersecretion, peptic ulcers and diarrhea?
Zollinger-Ellison Synd (Gastrinoma)
| -dt a pancreatic islet cell tumor (can mets mcc to liver) that secretes high Gastrin
29
how do you dx Zollinger-Ellison Synd (Gastrinoma)?
Secretin injection test
| - secretin should decrease Gastrin but in ZES, the opposite occurs
30
how do you tx Zollinger-Ellison Synd (Gastrinoma)?
high dose PPI and resection if possible
31
how is PUD dx?
Esophagogastroduodenoscopy with biopsy
| - if PUD dt H. pylori, follow EGD with Urease breath test or H pylori stool antigen assay after Tx to ensure eradication
32
how do you Tx an H pylori infection?
- triple therapy (1 ppi for tl of 4 weeks and 2 antibiotics for 2 weeks)
- quad therapy (triple plus Bismuth) if triple therapy fails
33
pt has pain and tenderness at the radial styloid near the anatomical snuffbo and while grasping the thumb and adducting the hand toward the ulna... what does he have?
DeQuervain’s disease (stenosing tenosynovitis) of the abductor pollicus longus (APL)
- dx with Finkelstein test (grasp thumb and adduct hand)
34
what is the MC secondary cause of HTN?
- renal artery stenosis (activates RAAS)
| - suspect in the young and do NOT give ACE or ARB if bilat stenosis
35
what does a pt with cyclical hypertension, flushing, HA, sweating and diarrhea have?
- Pheochromocytoma
| - tumor of adrenal glands. Dx with metanephrine, vanillymandelic acid or homovanillic acid screens
36
what does a pt with arthritis, pericarditis, photosensitivity, renal disease, and a malar rash have?
- Systemic lupus erythematosis (SLE)
- will be ANA positive and tx with steroids for acute exacerbations and Hydroxychloroquine for long term control (watch for renal toxicity)
37
what presents like Lupus except NO CNS or renal involvement and has Antihistone antibodies?
- drug induced lupus
38
what is the best test to order if you suspect HTN dt Renal Artery Stenosis?
- duplex Doppler ultrasonography of the kidneys (can consider CTA or MRA)
39
what is the most common spinal cord disorder in persons older than 55 years of age?
- Cervical myelopathy: compression of the spinal cord dt spinal stenosis.
- Patients typically describe a heavy feeling in their legs, slow gait, and shooting pains into the arms and legs.
40
what does Adson’s test show (diminished or absent radial pulse during test?
Thoracic outlet syndrome: compression of the brachial plexus and subclavian artery bw the anterior and middle scalenes.
- Symptoms can involve pain, numbness, loss of blood to the neck, shoulder, and/or hand.
41
what is abandonment?
- when a dr stops caring for a pt or make appropriate arrangements in his absence for a pt that he has an established relationship with.
- a dr is not obligated to see or refer a pt he has never seen
42
what can happen when a pt is given high doses of Warfarin (admin orally)?
- warfarin induced skin necrosis which usually happens within the first week
- start warfarin in small doses and increase gradually until therapeutic (at which point heparin is stopped)
- note: enoxaparin is given subQ
43
what is the best initial diagnostic test for any suspected cardiac valvular disease?.
- echocardiogram.
| - use Doppler echo to assess the severity of stenosis
44
describe aortic stenosis
| >70 mc-ly dt degenerative calcific aortic stenosis, <70 dt bicuspid aortic valve
A crescendo-decrescendo murmur heard at the right upper sternal border right after 1st heard sound that is associated with syncope, exertional dyspnea and angina
45
what is the most commonly fractured carpal bone?
- scaphoid
| - fractures at the proximal end are extremely likely to undergo nonunion or avascular necrosis (AVN)
46
what is the Tx of choice for a non-displaced scaphoid (<1mm)?
- thumb spica cast for 3 (distal to waist) to 5 (proximal to waist) mths
47
what is a ulnar gutter splint for?
- boxer’s fractures (fracture through the neck of the fifth metacarpal
48
after Tx of a scaphoid frx, what imaging do you get before clearing the pt to return to activities?
- If there is any question of scaphoid fracture union or prior to return to high-impact activities, a CT scan is the best study to verify osseous union
49
what is the MC inherited bleeding disorder and is AD?
von Willebrand dz
| - pt will have low or deficient von Willebrand factor AND low factor VIII as VW carries factor VIII
50
describe the lab findings for vWD
normal platelet count
normal PT
prolonged PTT (dt Factor VIII def)
prolonged bleeding time
51
describe lab findings for thrombocytopenia
low platelet count
normal PT and PTT
prolonged bleeding time
52
what do pts with vWD suffer with and how do you Tx acute episodes?
- nosebleeds, oral bleeding, menorrhagia, easy bruising or postincisional bleeding
- Tx with Desmopressin (is a synthetic analog of ADH and stimulates release of vW factor)
53
how do you confirm the Dx of vWD?
- ristocetin cofactor assay (measures platelet agglutination bc ristocetin is an antibiotic that causes vW factor to bind to platelets)
54
what does the joint aspirate of Gout (monosodium urate monohydrate crystals and can be in any mono-joint) look like?
- 2k-50k WBC and negatively birefringent needle-shaped crystals
55
what does the joint aspirate of calcium pyrophosphate deposition disease CPDD or "pseudogout" (MC-ly in glenohumeral joint) look like?
- 2k-50 k WBC and positively birefringent rhomboid-shaped crystals
56
what is the most sensitive and most specific marker for rheumatoid arthritis (RA)
- Anti-cyclic citrullinated peptide
57
what food has been shown to reduce Gout flares?
- low-fat dairy products (thiazide diuretics, meats, alcohol, and high fructuse/high sugar drinks makes flares worse)
58
what drug is typically used for acute flares of gout?
| what about chronic control?
- NSAIDs for acute flares (indomethacin, etc)
| - allopurinol
59
which hemorrhoid causes pain?
- external hemorrhoids (below dentate line)
60
which hemorrhoid normally bleeds?
- internal hemorrhoids (above dentate line)
61
what is anemia?
- anemia is a deficiency in the # of RBCs or decreased Hemoglobin Hb
62
what are the different types of anemia and their MCV (mean corpuscular volume: the average RBC volume)
- microcytic: <80 fL
- normocytic: 80-100 fL
- macrocytic: >100 fL (Vit B12 or Folate deficiency)
63
what is haptoglobin?
- is a blood plasma protein what binds free Hb released from RBCs during intravascular hemolytic anemia (so haptoglobin will be decreased)
64
what is Ferritin?
- ferritin is the major storage form of Iron. If ferritin is low, iron is low and you have iron deficiency anemia
65
what is transferrin?
- transferrin carries/transfers iron in the blood and how much is being transferred is Measured as TIBC
66
what is TIBC?
- TIBC is the Total Iron Binding Capacity. This is a measurement of Transferrrin and tells you how much Iron is bound to transferrin
67
what is ferritin?
what is transferrin?
how is TIBC related to Ferritin?
- storage form of iron
- transporters of iron (to & from cells for storage or use)
- TIBC is elevated when ferritin is low bc more Iron needs to be collected from the blood and delivered to cells for RBCs synthesis so the liver makes more transferrin to capture any/all free iron -> increased TIBC because there are more transferrins for iron to bind to
68
what are some signs of Iron deficiency anemia?
- conjunctiva pallor
- glossitis (inflammed tongue)
- koilonychia (spoon shaped nails)
- Pica (craving for non-nutrient materials like dirt, ice, etc)
69
what is hepcidin?
- a protein produced in the liver during an inflammatory response dt sickness or chronic Dz. it tells cells to retain their iron intracellularly. So ferritin will be increased when hepcidin is increased.
70
what is the ration of Hg to Hct?
- 1:3 so one packed RBC will raise Hg by 1 and Hct by 3
71
what are Packed RBCs?
- just RBCs... no platelets or clotting factors
72
what is FFP?
- fresh frozen plasma and contains all clotting factors but no RBC/WBC/Platelets
73
what is cryoprecipitate?
- contains Fibrinogen, Factor VIII, and von Willebrand factor (for hemophilia A, DIC, and vWD)
74
what is sideroblastic anemia?
- microcytic anemia caused by a defect in iron metabolism. Sideroblasts are abnormal nucleated erythroblasts w/granules of iron that accumulate w/in cellular mitochondria. The iron granules form in a ring around the nucleus as seen w/ Prussian blue staining
75
describe lab values for:
- Iron deficiency anemia (microcytic anemia)
- sideroblastic anemia (microcytic anemia)
- anemia of chronic dz (normocytic anemia)
- B12 deficiency (macrocytic anemia)
- IDA: Ferritin is low, TIBC is high, RDW is high
- SDA: ferrritin is nl/high, TIBC is high, RDW is high
- ACD: ferritin is high, TIBC is nl/low, RDW is nl, ESR high
- B12: cant make RBC so low RBC, large RBC, hypersegemented neutrophils
76
describe lab findings for Thalassemias and Tx
| dt inadequate production of either alpha or beta Hg chains
- nl RDW, Target Cells on blood smear
| - A-Thalassemia major (Hg H) and B-Thalassemia major are treated with packed RBC transfusions
77
what is the NEER test?
- test for Impingement Syndrome (suprespinatus). dr internally rotates humerus (rotate thumb down while shoulder flexed 90 degrees in sagital plane) and dr forcefully elevates the arm in the sagital plane to 180 degrees (+ test is pain illicited)
78
what is the drop arm test?
- test for rotator cuff tear of labrum. Have pt max abd shoulder in coronal plane and slowly lower arm. if arm drops uncontrollably then there is a rotator cuff tear
- empty can test also tests for rotator cuff tears of labrum
79
what is the hawkins test?
- test for Impingement Syndrome (suprespinatus). pt holds arm like a hawk is about to land on their arm. dr then forcefully internally rotates the humerus by pushing hand inf. pain is a + test
80
what is the MC shoulder dislocation?
- anterior shoulder dislocation. arm will be slightly abd and ext rotated. get X-ray to dx
81
what is a traction brachial plexopathy?
- aka: stinger: acute pain and radicular burning or electric sensations down the upper extremity after trauma. Trauma may result in either traction or compression of the brachial plexus both with similar Sx
82
what four muscles make up the rotator cuff?
- SITS: supraspinatous, infraspinatous, teres minor and subscapularis muscles
83
what 3 test are used to access rotator cuff tears?
- drop arm test
- empty can test
- Apley scratch test
84
what is the cross arm test?
- test the AC for injury. Dr adducts arms to 90 degrees. Pain is a positive test
85
how do you test for Bicep tendonitis?
- Yergasons Test (elbow flexed to 90 and pronated. Pt tries to flex and supinate)
- Speeds Test
86
what is Spurlings Test?
- test for cervical rediculopathy. Pt head is ext, rotate towards painful side and axial loaded. reproduction of pain is positive
87
what is scapular winging dt?
- serratus anterior (long thoracic nerve) or trap probs. pts will have trouble pushing or pulling items
88
what is the difference between dementia and delirium?
- dementia is a GRADUAL and progressive decline is memory and cognitive function while maintaining consciousness (multiple forms of dementia)
- delirium is an acute disturbance of consciousness (fluncuating levels) along with confusion, disorientation, and hallucinations (dt infecs, meds, intox)
89
what is the initial test for pts with cognitive complaints?
- mini mental state exam
| - most sensitive cognitive function test is the "draw clock face" test
90
what is the most common form of dementia?
| what are some common findings in it?
- Alzheimer's disease
- senile plaques (eosinophilia and amyloid-A beta deposition) and Neurofibrillary tangles (intraneuronal aggregates of abnormally modified microtubule-associated tau proteins)
- hippocampus is mainly impacted
91
describe Huntingtons Dz
- neuronal loss of caudate and putamen that leads to chorea (rapid movement of face or limbs) and personality changes
92
describe Lewy Body Dz
- Accumulation of eosinophilic intranuclear inclusions, called Lewy bodies (abnormal alpha-synuclein conformation) in the substantia nigra. Hippocampus is normal. Pt will have visual hallucinations
93
what do you treat dementia with?
- Donepezil (cholinestrase inhibitor that inhibs the production of acetylcholine)
94
what is a Myxedema Coma/crisis?
- severe hypothyroidism -> decreased mental status, hypothermia, and other symptoms related to slowing multiple organs.
- Tx with IV T4
95
what drug is disease modifying for Dementia pts?
- Memantine: N-methyl-D-aspartate (NMDA) receptor antagonist that prevents excitotoxicity of the hippocampus
96
describe hypertrophic obstructive cardiomyopathy (HOCM) and how is it Dx and Tx?
- the ventricle and interventricular septum undergo hypertrophy dt to autosomal dominance inheritance. this leads to early death dt MI, double carotid pulse, and double apical tap
- Dx: with echo
- Tx: Beta Blockers which Decrease inotropy and increase filling time to increase cavity preload -> decreased risk of obstruction. Pt will need a surgical myomectomy to thin septum (standing decreases preload and makes murmur louder)
97
when do you need to aspirate a knee?
- A red, hot, swollen joint requires aspiration to confirm/rule out gout, pseudogout, or septic arthritis. (you do not get in regular OA)
98
what should you do first in a pt with an incedental lung nodule finding?
- compare it to prior imaging studies. If a nodule demonstrates stability, no further work up is necessary.
99
what are the recommended annual screenings for DM pts?
- dilated eye exam, foot exam, and microalbumin urine check
Comlex Level 2
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