Internal med

Question 0

Thin basement membrane disease

Answer 0

• familial disorder
• presents in adulthood as microscopic hematuria without proteinuria
• thinned BM

Question 1

Alport’s syndrome

Answer 1

• familial disorder which usually presents in childhood as recurrent gross hematuria and proteinuria
• sensorineural deafness usually occurs!
• EM findings include alternating areas of thinned and thickened capillary loops w/ splitting of the GBM

Question 2

Recurrent episodes of hematuria, sensorineural deafness, and a family hx of renal failure

Answer 2

Alport’s syndrome

Question 3

Hydroxyurea

Answer 3

-decreases the frequency and severity of pain crises in pts w/ sickle cell anemia by increasing hemoglobin F levels

Question 4

tx of choice for pts w/ autoimmune hemolytic anemia?

Answer 4

prednisone

Question 5

Erythropoietin

Answer 5

-tx of choice for anemia of chronic disease, chronic kidney disease, and transient bone marrow failure after chemo or bone marrow transplant

Question 6

splenectomy

Answer 6

• tx of choice for moderate, symptomatic, hereditary spherocytosis.
• also a tx option in autoimmune hemolytic anemia and for those w/ massive splenomegaly associated w/ B-thalassemia major or hemoglobin H disease

Question 7

B-thalassemia minor (trait)

Answer 7

• usually asymptomatic w/ mild anemia, disproportionately high RBC count, low MCV, and hemoglobin >10 g/dL.
• commonly confused w/ iron deficiency anemia, however, iron deficiency has low RBC count and rarely becomes microcytic until the hemoglobin is <10g/dL.
• no specific therapy is required for B-thalassemia minor

Question 8

P. jiroveci

Answer 8

• opportunistic pathogen, and an important cause of pneumonia in immunocompromised hosts
• bilateral diffuse interstitial infiltrates beginning in the perihilar region is characteristic finding on chest x-ray
• tachypnea, tachycardia, cyanosis w/ minimal chest findings

Question 9

Aspergillosis

Answer 9

• seen in immunocompromised pts.

- chest x-ray shows solid mass surrounded by a radiolucent crescent (crescent sign, Monod’s sign)

Question 10

True or False: candida is an extremely rare organism to cause pneumonia in any patient.

Answer 10

True

Question 11

Ménière’s disease

Answer 11

• typically presents w/ a combination of vertigo, ear fullness, tinnitus, and hearing loss
• first line therapy consists of environmental and dietary modifications, including maintenance of a low-salt diet
• other triggers include alcohol, caffeine, and nicotine
• medical therapy w/ diuretics, antihistamines, or anticholinergics may be tried

Question 12

Diabetic ketoacidosis

Answer 12

• type 1 diabetics
• younger age
• less pronounced altered mentation compared to HHS
• more rapid onset of hyperglycemic symptoms
• hyperventilation and abdominal pain common
• glucose 250-500 mg/dL
• bicarb <320 mOsm/kg

Question 13

Hyperosmolar hyperglycemic state

Answer 13

• type 2 DM
• older age
• more pronounced altered mentation (compared to diabetic ketoacidosis)
• gradual onset of hyperglycemic symptoms
• hyperventilation and abdominal pain less common
• glucose >600
• bicarb >18
• normal anion gap
• negative or small serum ketones
• serum osmolality >320

Question 14

an increase in extracellular pH (alkalemia) promotes the binding of calcium to albumin and lowers serum ionized calcium concentration

Answer 14

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Question 15

hyperglycemia and glucosuria-induced osmotic diuresis cause free water loss that exceeds sodium loss

Answer 15

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Question 16

Despite normal or elevated serum potassium levels, pts w/ hyperosmolar hyperglycemic state (HHS) or diabetic ketoacidosis have a total body potassium deficit due to excessive urinary loss caused by glucosuria-induced osmotic diuresis. Aggressive insulin therapy for HHS can lower serum potassium levels further and cause severe hypokalemia!

Answer 16

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Question 17

Neuroleptic Malignant Syndrome (NMS)

Answer 17

• typically presents w/ fever, muscle rigidity, autonomic instability and mental status change. Serum CK is often elevated.
• Dantrolene, a muscle relaxant, is the most common drug used to reverse the condition, followed by bromocriptine (a dopamine agonist) and amantadine (an antiviral drug w/ dopaminergic properties)

Question 18

Premature Ventricular Complexes (PVCs)

Answer 18

• common in pts post-MI and can be recognized by their widened QRS (>120msec), bizarre morphology, and compensatory pause.
• even though they may indicate a worse prognosis, tx is not indicated unless the patient is symptomatic (beta-blockers are first line therapy for symptomatic pts)

Question 19

Amiodarone

Answer 19

-second line therapy for symptomatic PVCs

Question 20

Digoxin

Answer 20

-can be used to treat atrial arrhythmias like atrial flutter and atrial fibrillation. It has no role in the treatment of ventricular arrhythmias!

Question 21

Brain death

Answer 21

• clinical diagnosis
• characteristic findings are absent cortical and brain stem functions
• the spinal cord may still be functioning; therefore, deep tendon reflexes may be present
• an isoelectric EEG can be used as a confirmatory test, but is not absolutely necessary
• note that the heart rate fails to accelerate after atropine injection because vagal control of the heart is lost, and the heart rate becomes invariant

Question 22

Timolol

Answer 22

eye drops used to treat glaucoma

Question 23

Mannitol

Answer 23

• osomotic diuretic used to reduce intracranial pressure associated w/ cerebral edema
• its an IV infusion and requires careful monitoring of renal function and electrolytes
• used in inpatient setting for severely elevated intracranial pressure (obtunded pts)

Question 24

what is the first line medical tx for idiopathic intracranial hypertension?

Answer 24

- Acetazolamide (inhibits choroid plexus carbonic anhydrase, thereby decreasing CSF production and intracranial hypertension) w/ or w/o furosemide - optic nerve sheath decompression or lumboperitoneal shunting is recommended for pts refractory to medical therapy - corticosteroids and serial lumbar punctures are not recommended as long-term primary tx, however, they may be used as bridging therapies for pts awaiting definitive surgical tx

Question 25

Lumbago

Answer 25

- "Lumbosacral strain" - usually related to physical strain and has less dramatic onset - usually paravertebral muscle tenderness rather than spinal tenderness is the feature

Question 26

common complication of advanced osteoporosis

Answer 26

- compression fracture of vertebrae - usually manifests as acute back pain w/o an obvious preceding trauma in a predisposed patient. Neuro exam will be normal - NOTE: absent ankle reflex can be seen in elderly pts as part of the normal aging process

Question 27

Note that serum creatinine does not usually become elevated in obstructive uropathy unless both ureters are obstructed

Answer 27

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Question 28

Renal vein thrombosis

Answer 28

-usually occurs in pts w/ a predisposing condition such as hypercoagulabilit

Question 29

Serum creatinine usually does not become elevated in obstructive uropathy unless both ureters are obstructed.

Answer 29

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Question 30

Hepatorenal syndrome

Answer 30

- can occur in pts w/ severe liver disease; they develop systemic hypoperfusion and subsequent renal failure - the diagnosis is suggested by an elevated creatinine and a very low urine sodium level, typically less than 10 mEq/L

Question 31

how do pts w/ cerebellar hemorrhage present?

Answer 31

- ataxia, vomiting, occipital headache, gaze palsy, and facial weakness - there is no hemiparesis

Question 32

Lichen planus

Answer 32

-inflammatory condition characterized by pruritic, violaceous, flat-topped papules w/ fine white streaks on the surface called Wickham's striae

Question 33

Dermatitis herpetiformis

Answer 33

- pruritis, papules, and vesicles mainly over the elbows, knees, buttocks, posterior neck, and scalp. - associated w/ HLA B8, DR3, and DQw2, and is see in pts w/ gluten-sensitive enteropathy

Question 34

Miliaria

Answer 34

- heat rash - superficial aggregated small vesicles, papules, or pustules over the trunk, which are associated w/ burning and itching - commonly seen in people living in hot and moist climates

Question 35

Molluscum contagiousum

Answer 35

- single or multiple rounded, dome-shaped papules w/ central umbilication - causative agent is poxvirus - usually self- limited and resolves spontaneously in immunocompetent individuals - genital lesions should be treated to prevent sexual transmission - best form of tx is curettage or application of liquid nitrogen

Question 36

what happens to the murmur intensity in a person w/ hypertrophic cardiomyopathy who stands up from a supine position?

Answer 36

-decreased venous return causes increased intensity of ejection systolic murmur

Question 37

Paradoxical splitting of second heart sound

Answer 37

- normal splitting is best heard during INSPIRATION. In paradoxical splitting, A2 follows P2 w/ maximal splitting noted during EXPIRATION and being less pronounced during inspiration. - seen in pts w/ fixed left ventricular outflow tract obstruction (ie. aortic valve or subaortic stenosis, Left BBB, right ventricle paced rhythm)

Question 38

Dressler's syndrome

Answer 38

- present WEEKS after an MI w/ chest pain that is improved by leaning forward - diffuse ST elevation w/ the exception of reciprocal depression in aVR due to pericarditis - NSAIDs are the tx of choice - anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion

Question 39

Essential tremor

Answer 39

- bilateral action tremor of the hands, usually w/o leg involvement - possible isolated head tremor w/o dystonia - usually no other neurologic signs - relieved w/ alcohol in many cases

Question 40

Parkinson's disease tremor

Answer 40

- resting tremor (4-6Hz) that decreases w/ voluntary movement - usually involves legs and hands - facial involvement less common

Question 41

Cerebellar tremor

Answer 41

- usually associated w/ ataxia, dysmetria, or gait disorder | - tremor increases steadily as the hand reaches its target

Question 42

Physiologic tremor

Answer 42

- low amplitude not visible under normal conditions - acute onset w/ increased sympathetic activity (drugs, hyperthyroidism, anxiety, caffeine) - usually worse w/ movement and can involve the face and extremities

Question 43

Parkinson's disease triad

Answer 43

- resting tremor - rigidity - postural instability - bradykinesia

Question 44

Resting tremor

Answer 44

- often the presenting symptom of Parkinson's disease - usually a "pill-rolling" tremor that starts in one hand and can progress to involve other extremities, jaw, face, tongue, and lips.

Question 45

Cerebellar dysfunction

Answer 45

-can cause postural, action, or intention (worsens as the hand moves closer to its target) tremors. The tremors have a lower frequency. Although severe cerebellar dysfunction can cause resting tremor, pts usually develop other signs (nystagmus, ataxia, dysmetria)

Question 46

the most common tremor

Answer 46

- essential tremor - familial in 50% of cases and affects 5% of the population - typically present as action/postural tremors in upper extremities that worsen at the end of goal-directed activities - usually affect bilateral upper extremities but can also involve the head, chin, voice, and trunk

Question 47

Pneumocystis pneumonia

Answer 47

- more common in HIV pts w/ CD4 < 200 - typically present w/ subacute respiratory symptoms w/ diffuse infiltrates on chest x-ray and an increased alveolar-arterial gradient

Question 48

Isoniazid causes idiosyncratic liver injury w/ histological features similar to those seen in pts w/ viral hepatitis.

Answer 48

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Question 49

acute asthma exacerbation

Answer 49

-an elevated or even normal arterial partial pressure of carbon dioxide suggests decreased respiratory drive (likely due to respiratory muscle fatigue) and impending respiratory failure. In these pts, tx involves endotracheal intubation and mechanical ventilation, inhaled short-acting beta-2-agonist, inhaled ipratropium, and systemic corticosteroids.

Question 50

Squamous cell carcinoma

Answer 50

- second most common form of non-melanoma skin cancer (after basal cell) - single most important risk factor is exposure to sunlight

Question 51

Ehrlichiosis

Answer 51

-should be suspected in a patient from an endemic region w/ a history of tick bite, febrile illness w/ systemic symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases. Rash is uncommon, and the drug of choice is DOXYCYCLINE

Question 52

drug of choice to treat Lyme disease

Answer 52

Ceftriaxone

Question 53

Peritonsillar abscess

Answer 53

- a muffled voice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis - a peritonsillar abscess is a potential complication of tonsillitis and requires both IV antibiotic therapy and urgent drainage of the abscess - deviated of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis

Question 54

Primary hypothyroidism

Answer 54

-characterized by low circulating levels of thyroid hormones w/ TSH levels of more than 10 IU/L

Question 55

Secondary and tertiary hypothyroidism

Answer 55

-characterized by low circulating thyroid hormone levels w/ low or inappropriately normal TSH levels

Question 56

Subclinical hypothyroidism

Answer 56

- mildly elevated serum TSH levels and normal circulating thyroid hormone levels - pts do not have clinical features of overt hypothyroidism

Question 57

Pts w/ generalized resistance to thyroid hormones

Answer 57

- have high serum T4 and T3 levels w/ normal to mildly elevated TSH levels - pts typically have features of hypothyroidism despite having elevated free thyroid hormones

Question 58

Pts w/ upper GI bleeding who have a depressed level of consciousness and ongoing hematemesis should be intubated to protect the airway as a part of initial stabilization and resuscitation. Prompt endoscopic tx w/ band ligation or sclerotherapy should then be performed to stop the bleeding.

Answer 58

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Question 59

most common form of skin cancer in the US?

Answer 59

basal cell carcinoma (75%)

Question 60

Mohs surgery

Answer 60

- special type of surgery wherein microscopic shaving is done, such that 1-2 mm of clear margins are excised. - this technique currently has the highest cure rate for basal cell cancer, but is indicated only in pts w/ high-risk features, as well as those w/ lesions in functionally critical areas (perioral

Question 61

primary pulmonary hypertension

Answer 61

- can be seen in middle-aged pts, and it presents w/ exertional breathlessness - lungs will be clear to ausculatation - chest x-ray would show enlargement of the pulmonary arteries w/ rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle

Question 62

Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the tx of choice for symptomatic gallstone disease.

Answer 62

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Question 63

3 most common causes of aortic stenosis

Answer 63

- senile calcific aortic stenosis - bicuspid aortic valve - rheumatic heart disease

Question 64

Myxomatous valve degeneration

Answer 64

-typical pathologic entity that causes mitral valve prolapse

Question 65

Bicuspid aortic valve

Answer 65

-the cause of aortic stenosis in the majority of pts under 70 years old

Question 66

Clostridium perfringens

Answer 66

- spore forming organism - spores germinate in foods such as meats, poultry, or gravy - ingestion results in watery diarrhea due to production of toxin in the gut - symptom onset is later than w/ preformed toxins (8-14 hrs after ingestion)

Question 67

Bacillus cereus

Answer 67

- causes nausea and vomiting after eating rice | - symptom onset is within one to six hours

Question 68

vitamin D deficiency

Answer 68

-causes osteomalacia and hypocalcemic tetany in adults

Question 69

vitamin E deficiency

Answer 69

-can cause RBC fragility, hyporeflexia, muscle weakness, and blindness

Question 70

A tea and toast diet is associated w/ folic acid deficiency. Folic acid is heat sensitive. Folic acid deficiency causes macrocytic anemia.

Answer 70

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Question 71

Neoplastic epidural spinal cord compression

Answer 71

- presents w/ worsening focal back pain, bilateral lower-extremity weakness, sensory loss, and gait ataxia - bowel/bladder disturbances are late findings - in the acute phase of spinal cord injury, pts can develop spinal shock w/ absence of reflexes and flaccid paraplegia as a result

Question 72

Tx of actively bleeding esophageal varices

Answer 72

- hemodynamic support, pharmacologic tx (octreotide), endoscopic therapy, and prophylactic antibiotics. - coagulopathy, anemia, and thrombocytopenia are common complications and may also require correction

Question 73

Winter's formula

Answer 73

- used to calculate the expected decrease in pCO2 during metabolic acidosis - pCO2= 1.5(HCO3) + 8 - if the pCO2 is not within 2 of this number, then there is another acid-base process occurring at the same time

Question 74

Type II Renal tubular acidosis

Answer 74

- defective tubular bicarb reabsorption. - oftentimes inherited, and may be a component of Fanconi syndrome - can also occur w/ use of drugs like carbonic anhydrase inhibitors

Question 75

Type 1 Renal tubular acidosis

Answer 75

- low tubular ammonium production is a component - primary defect is failure to excrete sufficient H+ in the urine - w/o sufficient hydrogen ions in the tubular fluid, ammonium cannot be produced

Question 76

Renal tubular epithelial cells exchange chloride for bicarb. Thus, when the urine chloride is increased, bicarb resorption into the plasma is increased and urinary excretion of H+ is increased.

Answer 76

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Question 77

Tachypnea causes further lowering of the pCO2 because CO2 is more readily diffusable than O2.

Answer 77

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Question 78

Erythema nodosum

Answer 78

- presents as painful nodules on the anterior legs that can progress to appear as bruises w/ eventual scarring - can be associated w/ infections (strep, TB) or sarcoidosis or can be idiopathic

Question 79

Lambert-Eaton syndrome

Answer 79

- NMJ disorder that presents most commonly w/ muscle weakness and dry mouth - most often associated w/ small cell lung cancer or lymphoproliferative disorders (Hodgkin lymphoma)

Question 80

Polyarteritis nodosa

Answer 80

- more commonly associated w/ hepatitis B - necrotizing vasculitis in small and medium vessels likely due to the deposition of circulating antigen-antibody immune complexes in blood vessel walls

Question 81

Chronic hepatitis C

Answer 81

- can be asymptomatic or present w/ fatigue and nonspecific symptoms (arthralgias, myalgias, etc) - Pts usually have waxing and waning elevations in transaminase levels - extrahepatic sequelae can include essential mixed cryoglobulinemia, porphyria cutanea tarda, and membranoproliferative glomerulonephritis

Question 82

3 main categories of diabetic retinopathy

Answer 82

- background or simple (microaneurysms, hemorrhages, exudates, retinal edema) - pre-proliferative (cotton wool spots) - proliferative or malignant (neovascularization) - visual impairment occurs w/ the development of macular edema. - Argon laser photocoagulation is performed for the prevention of complications

Question 83

Lumbar spinal stenosis

Answer 83

- most commonly caused by degenerative joint disease - "neuropathic claudication" is often used to describe lumbar stenosis - refers to exacerbation of leg symptoms w/ walking (similar to PVD) - Unlike PVD, the symptoms are positional and remain while standing still. Pain is relieved by flexion of the spine. Diagnosis is made based on clinical hx and classic findings on spinal MRI

Question 84

ACE inhibitors, ARBs, beta-blockers, and spironolactone all confer a survival benefit in CHF. While digoxin and furosemide (loop diuretics) can reduce CHF symptoms and hospitalizations, they do not improve survival.

Answer 84

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Question 85

murmur of hypertrophic cardiomyopathy

Answer 85

-systolic murmur decreases w/ squatting and increases w/ straining

Question 86

Patients w/ cardiac tamponade

Answer 86

- usually have clinical features of Beck's triad: hypotension, distended neck veins, and muffled heart sounds - these symptoms are due to an exaggerated shift of the interventricular septum toward the left ventricular cavity, which reduces left ventricular preload, stroke volume, and cardiac output

Question 87

Enterococci, especially Enterococcus faecalis, are a common cause of endocarditis associated w/ nosocomial urinary tract infections

Answer 87

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Question 88

Monoclonal gammopathy of uncertain significance (MGUS)

Answer 88

- can be differentiated from multiple myeloma by an absence of renal insufficiency, hypercalcemia, anemia, and lytic bone lesions. - although MGUS is asymptomatic, there is a 1% per year risk of progression to multiple myeloma

Question 89

Suppurative hidradenitis

Answer 89

- chronic follicular occlusive disease most commonly affecting the intertriginous skin, including the axillary, groin and inframammary regions - it appears as painful inflammatory nodules and draining sinus tracts that can last weeks or longer

Question 90

Allergic contact dermatitis

Answer 90

- inflammatory skin condition caused by allergens such as poison sumac, cosmetics, and nickel - it presents days to weeks after exposure w/ an intensely pruritic erythematous rash w/ vesicles at the site of exposure - secondary infection as a result of excessive scratching is possible, and is suggested by pus filled vesicles

Question 91

Active hepatitis B infections typically presents w/ positive HB surface antigen, positive Be antigen, and absent surface antibody. Health care workers exposed to blood from HB patients (ocular, mucous membrane, or skin) should receive post-exposure prophylaxis. Unvaccinated individuals should receive both the HB vaccine and HB immune globulin as soon as possible.

Answer 91

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Question 92

Interventricular free wall rupture and papillary muscle rupture

Answer 92

-typically occur 3-7 days after MI and present w/ new onset systolic murmur

Question 93

Ventricular free wall rupture

Answer 93

- typically occurs 3-7 days after anterior wall MI - presents w/ rapid deterioration secondary to pericardial tamponade - pulseless electrical activity is common

Question 94

Pulmonary infarction secondary to pulmonary embolism

Answer 94

- can cause chest pain, but it should not cause diffuse ST elevations on ECG - while the pain of PE is pleuritic, it should not improve w/ leaning forward

Question 95

Ventricular aneurysms

Answer 95

- complication of anterior wall MI that can occur days to months after the initial infarction - presents w/ akinesis of the involved portion of the left ventricular wall, ventricular arrhythmias, and systemic embolization

Question 96

Acute pericarditis

Answer 96

- typically occurs in the first several days after MI - characterized by sharp, pleuritic pain that is worse in the supine position and improved by sitting up and leaning forward - diffuse ST elevations, especially w/ PR depressions, are typical ECG findings

Question 97

Brain death

Answer 97

- refers to a total loss of brain function and is a legally acceptable definition of death - criteria include: absent cranial nerve reflexes, fixed and dilated pupils, no spontaneous breaths, and agreement of two physicians

Question 98

bowel ischemia

Answer 98

- the diagnosis depends on a high index of clinical suspicion in pts w/ known risk factors for thromboembolic disease (atrial fibrillation, peripheral vascular disease) - typical features include acute abdominal pain out of proportion to exam findings, and associated metabolic acidosis (increased serum lactate levels) - Mesenteric angiography is the gold standard for diagnosis

Question 99

Recent studies have suggested that a brain that has seized for > 5 minutes (status epilepticus) is at increased risk of developing permanent injury due to EXCITATORY CYTOTOXICITY. Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures.

Answer 99

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Question 100

Aldosterone secretion from the zona glomerulosa is ACTH-independent. As a result, secondary (central) adrenal insufficiency does not cause hyperkalemia or salt wasting

Answer 100

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Question 101

Secondary (central) adrenal insufficiency

Answer 101

- most commonly due to pituitary masses (adenoma) - in contrast to primary adrenal insufficiency, secondary adrenal insufficiency does not cause salt wasting, hyperkalemia, or hyperpigmentation

Question 102

Eaton-Lambert syndrome

Answer 102

-associated w/ SMALL CELL carcinoma of the lung, and results from autoantibodies directed against VOLTAGE-GATED CALCIUM CHANNELS in the PRESYNAPTIC motor nerve terminal

Question 103

Multiple sclerosis (MS)

Answer 103

- Multicentric CNS inflammation and demyelination are indicative - rare in people younger than 15 and older than 60 - sensory loss, spasticity, cerebellar symptoms, optic neuritis, depression, etc.

Question 104

ALS

Answer 104

- upper and lower motor neuron degeneration | - initially presents w/ bulbar symptoms, followed by upper and lower limb weakness

Question 105

Polymyositis

Answer 105

- immune-mediated muscle inflammation - presents as proximal weakness characterized by difficulty ascending and descending stairs, combing hair, kneeling down, etc - CPK level is typically high and it is not associated w/ absent reflexes

Question 106

Myasthenia gravis

Answer 106

- autoantibodies against postsynaptic receptors - reduction of postsynaptic ACh receptors leads to muscle weakness - the muscle weakness is provoked by repetitive or sustained use of the muscles involved - deep tendon reflexes are usually preserved, and may be somewhat brisk in clinically weak muscles

Question 107

Anserine bursitis

Answer 107

- presents w/ sharply localized pain over the anteromedial part of the tibial plateau just below the joint line of the knee - Valgus stress test fails to reproduce the pain, thereby ruling out damage to the medial collateral ligament, and radiographs are classically normal - Tx is w/ rest, ice and maneuvers to reduce pressure on the bursa. Corticosteroid injections into the bursa are also helpful.

Question 108

Prepatellar bursitis

Answer 108

- presents w/ pain and swelling directly over the patella - exam shows cystic swelling over the patella w/ variable signs of inflammation - the most common cause is trauma

Question 109

Medial collateral ligament injury

Answer 109

- presents w/ pain along the medial joint line and is aggravated by walking - caused by valgus stress applied on the lateral aspect of the knee when it is partially flexed - the knee pain is aggravated by valgus stress testing

Question 110

Medial compartment osteoarthritis

Answer 110

- presents w/ pain along the medial joint line typically in pts older than 40 - morning stiffness of less than 30 minutes, crepitus and bony tenderness on examination - x-ray of the knee shows narrowing of the joint space and osteophyte formation - anserine bursitis may accompany medial compartment osteoarthritis due to the chronic gait abnormality caused by the arthritic pain

Question 111

Patellofemoral syndrome

Answer 111

- common overuse pain syndrome of the knee - pts present w/ peripatellar pain worsened by activity or prolonged sitting (due to sustained flexion) and may also complain of crepitus w/ motion of the patella

Question 112

Decubitus ulcers

Answer 112

- elderly and critically ill pts w/ immobility, poor nutrition, and sensory impairment are at risk of developing decubitus ulcers - ulcers form as a result of uninterrupted pressure on the tissue overlying bony prominences - the elbows, coccyx, hips and heels are sites at especially high risk - patient repositioning every two hours and pressure reducing devices (air/foam mattresses) are important methods of prevention

Question 113

Hyponatremia

Answer 113

- can be classified according to the patient's volume status (hypovolemic, euvolemic, hypervolemic) - hypovolemia increases the activity of the RAAS and sympathetic nervous systems, and stimulates ADH release from the pituitary - The elevated ADH increases renal water reabsorption to cause hyponatremia until correction of the hypovolemia - Tx w/ normal saline usually

Question 114

Peripheral neuropathies

Answer 114

-typically present w/ motor abnormalities such as distal muscle weakness, sensory abnormalities, and decreased deep tendon reflexes on physical exam

Question 115

Proximal muscle weakness w/ or w/o muscle atrophy can occur in 60-80% of pts w/ untreated hyperthyroidism and correlates to the duration of the hyperthyroid state. Hip flexors and quadriceps are predominantly affected, and the weakness can gradually progress to involve the proximal muscles of the upper extremities.

Answer 115

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Question 116

Collagenous colitis

Answer 116

- uncommon disorder producing chronic watery diarrhea - the colon is frequently involved, but colonoscopy shows normal mucosa - biopsy shows mucosal subepithelial collagen deposition

Question 117

IBS

Answer 117

- chronic disorder characterized by distressing GI symptoms such as diarrhea, constipation, pain, and bloating - biopsy results are normal in irritable bowel syndrome, and features of malabsorption should prompt a search for an alternate explanation

Question 118

Celiac disease

Answer 118

- should be suspected in any patient w/ malabsorption and iron deficiency anemia - IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of celiac disease but may be absent if there is concurrent selective IgA deficiency (which is common in Celiac pts)

Question 119

Celiac disease

Answer 119

- autoimmune reaction to gluten which affects the small bowel - symptoms include diarrhea, weight loss and fatigue - it may also lead to malabsorption of vitamin D, K, B12, calcium, folic acid, and zinc

Question 120

Vitamin A deficiency

Answer 120

- may be caused by nutritional deficiency or malabsorption | - symptoms include blindness, dry skin, and impaired immunity

Question 121

Selenium deficiency

Answer 121

- like zinc deficiency, may result from chronic TPN - may also result from malabsorption or malnutrition (food sources include nuts, meat, and fish) - the most important feature of deficiency is cardiomyopathy!

Question 122

SLE

Answer 122

- multisystem autoimmune disease which may present w/ malar and discoid rashes, oral ulcers, and alopecia - fever, weight loss, arthritis, as well as renal, neurologic, and hematologic symptoms are also common

Question 123

Zinc deficiency

Answer 123

- may result from chronic total parenteral nutrition or malabsorption - symptoms include alopecia, skin lesions, abnormal taste, and impaired wound healing

Question 124

leading cause of blindness in industrialized countries

Answer 124

macular degeneration

Question 125

Lens opacification

Answer 125

-cause of visual loss from cataracts

Question 126

enlarged blind spot

Answer 126

-may be seen w/ papilledema

Question 127

increased intraocular pressure

Answer 127

-cause of glaucoma, which does NOT typically present w/ distortion of straight lines

Question 128

Macular degeneration

Answer 128

- the most common cause of blindness in industrialized nations - activities that require fine visual acuity are usually the first affected, and pts w/ this condition may report that straight grid lines appear curved

Question 129

Idiopathic intracranial hypertension

Answer 129

- presents w/ headache, vision changes (blurry or double vision), papilledema, and/or cranial nerve palsies (usually CN VI) - CSF exam shows increased opening pressure (>250) and normal studies - IIH is most common in young obese women - growth hormone, tetracyclines, and excessive vitamin A and its derivaties (ie isotretinoin, all-trans-retinoic acid) can cause IIH - Withdrawal of these meds leads to symptom resolution. Weight loss and acetazolamide for idiopathic cases.

Question 130

Multiple sclerosis

Answer 130

- usually presents w/ >2 distinctive episodes of CNS dysfunction w/ at least some resolution - classic features include optic neuritis, Lhermitte's sign, Uhthoff's phenomenon (worsening symptoms w/ increased body temperature), motor and sensory deficits, and bowel or bladder dysfunction

Question 131

Normal pressure hydrocephalus

Answer 131

- the result of impaired absorption of CSF - Pts present w/ the triad of impaired gait, cognitive difficulties, and urinary incontinence - CT scan shows enlarged ventricles - typically seen in elderly pts

Question 132

Viral encephalitis

Answer 132

- may present w/ fever, headaches, neurologic deficits, and altered mental status - CSF exam shows a moderate WBC count (lymphocyte predominant) and elevated protein

Question 133

Large artery atherosclerosis and cardiac emboli are typically characterized by more prominent clinical manifestations because larger vessels are involved, although this is not always true

Answer 133

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Question 134

Berry aneurysms

Answer 134

-can cause compression symptoms (most typically oculomotor abnormalities) before rupture, and is devastating on rupture secondary to subarachnoid hemorrhage

Question 135

Always suspect lacunar stroke if a patient presents w/ a limited neuro deficit. The typical lacunar stroke scenarios are pure motor stroke, pure sensory stroke (thalamus), ataxic-hemiparesis, and dysarthria-clumsy hand syndrome. The principle cause of lacunar stroke is hypertension.

Answer 135

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Question 136

Hepatic hydrothorax

Answer 136

- cause of transudative pleural effusions in pts w/ cirrhosis who have no underlying cardiac or pulmonary disease to account for development of such an effusion - usually results in a right-sided pleural effusion - initial tx is usually w/ salt restriction and diuretics - TIPS placement is considered in pts w/ refractory hepatic hydrothorax

Question 137

what is the most frequent precipitant of Guillain-Barre Syndrome (GBS)?

Answer 137

Campylobacter jejuni | -(Herpes virus, Mycoplasma, and Hemophilus influenzae have also been associated)

Question 138

Ascending aortic dissection

Answer 138

- arises from an intimal tear that allows a false lumen to be created between the media and adventitia of the aorta - Pts present w/ severe chest pain that radiates to the back and neck - hypertension is a major risk factor - the chest x-ray may reveal a widened mediastinum

Question 139

Pulmonary emboli

Answer 139

- cause dyspnea, tachycardia, pleuritic chest pain, and tachycardia - while there are suggestive chest x-ray findings, the chest x-ray is normal in most cases - the most common ECG finding is a sinus tachycardia

Question 140

Chest x-ray findings in Pulmonary emboli

Answer 140

- usually normal chest x-ray - may see dilatation of the pulmonary artery proximal to the clot and collapse of the vessels distal to the clot (Westermark's sign) - Pleural infiltrates corresponding to areas of pulmonary infarction (Hampton's hump)

Question 141

The nephrotic syndrome

Answer 141

- can result in alterations in lipid metabolism - this dyslipidemia puts affected pts at increased risk for accelerated atherosclerosis - this atherosclerotic tendency, along w/ intrinsic hypercoagulability, places pts w/ nephrotic syndrome at risk for complications such as stroke and MI

Question 142

Distinction between case control and retrospective cohort studies

Answer 142

-the order in which outcomes are risk factors are assessed: case control studies determine the outcome and then look for associated risk factors; retrospective cohort studies ascertain risk factor exposure and then determine the outcome

Question 143

retrospective cohort study

Answer 143

- similar to a prospective cohort study except that risk factor exposure and the outcome of interest both occur in the past and are assessed through review of records. - unlike a case control study, risk factor exposure is determined before the outcome is known, thus allowing calculation of the relative risk

Question 144

Premature atrial complexes (PAC's)

Answer 144

- tobacco and alcohol are reversible risk factors | - Beta-blockers are often helpful in pts who are symptomatic

Question 145

Screening for bladder cancer

Answer 145

-is NOT recemmended, even in pts who are at risk of developing the disease (due to its low incidence and poor PPV of the current screening tests)

Question 146

Contrast-induced nephropathy

Answer 146

- presents as a transient spike in creatinine within 24 hrs of contrast administration, w/ a return to normal renal function within 5-7 days - pts w/ diabetes and elevated baseline Cr are at especially high risk - Adequate IV hydration w/ isotonic bicarb or normal saline and administration of acetylcysteine help to minimize the risk of contrast-induced nephropathy

Question 147

Gout has NEGATIVELY birefringent crystals!

Answer 147

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Question 148

Gout is a common manifestation of myeloproliferative disorder-induced increases in uric acid production, because there is increased catabolism and turnover of purines. Note that Polycythemia vera commonly causes splenomegaly and characteristic pruritis w/ hot baths due to histamine release from an increased number of circulating basophils.

Answer 148

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Question 149

CKD can cause gouty attacks by decreasing the amount of uric acid excreted in the urine.

Answer 149

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Question 150

Hemochromatosis

Answer 150

- autosomal recessive iron overload syndrome most often due to mutation of the HFE gene. - the symptoms are related to iron accumulation in various organs: hepatic dysfunction progressing to cirrhosis, diabetes, hypogonadism, skin pigmentation, and arthritis

Question 151

Lesch-Nyhan syndrome

Answer 151

- caused by genetic deficiency of the enzyme hypoxanthine-guanine phosphoribosyl transferase (HPRT) - characterized by overproduction of uric acid, behavioral problems (especially self-injurious actions), and neurologic disability, and is generally diagnosed in childhood

Question 152

Hyperparathyroidism

Answer 152

- increases bone resorption and can thus elevate serum calcium concentrations - a high serum calcium concentration can cause chondrocalcinosis and calcium pyrophosphate dihydrate deposition disease (pseudogout). The crystals in pseudogout are POSITIVELY birefringent.

Question 153

Gout is a common manifestation of myeloproliferative disorder-induced increases in uric acid production

Answer 153

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Question 154

Vaccinations for pts w/ chronic liver disease?

Answer 154

- hepatitis A and B - influenza - invasice pneumococcal disease - like all adults, they should get a Td booster at least every 10 years w/ the Tdap once in place of the Td

Question 155

Guillain-Barré syndrome

Answer 155

- most commonly presents w/ ascending flaccid paralysis - involvement of respiratory and bulbar muscles puts pts at high risk for respiratory failure - serial measurements of forced vital capacity are the best means of monitoring respiratory function

Question 156

In a normal (bell-shaped) distribution:

Answer 156

- 68% within 1 SD from mean - 95% within 2 SD from mean - 99.7% within 3 SD from mean

Question 157

Pancreatic cancer

Answer 157

- can be due to hereditary (first degree relative w/ pancreatic cancer, hereditary pancreatitis) or environmental (cigarette smoking, obesity) risk factors. - cigarette smoking is the most consistent reversible risk factor for pancreatic cancer

Question 158

Noninvasive evaluation w/ compression ultrasonography is recommended as an initial test in pts w/ moderate or high probability of DVT. In pts w/ low probability, a D-dimer assay can further assess risk. An US can be performed on pts w/ a positive D-dimer; pts w/ a negative D-dimer require no further testing.

Answer 158

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Question 159

The most important steps in the management of lactic acidosis from septic shock is what?

Answer 159

-IV normal saline w/ or w/o vasopressor therapy to maintain the intravascular pressure and antibiotics to correct the underlying infection

Question 160

ARDS

Answer 160

- associated w/ hypoxemia (PaO2/FiO2 <300 mmHg) and bilateral alveolar infiltrates - Objective assessment (echo) is needed to definitively exclude hydrostatic pulmonary edema in pts w/o ARDS risk factors

Question 161

Cholesterol embolization

Answer 161

- can cause acute renal failure, skin changes in the lower extremities including bluish discoloration or livedo reticularis, GI symptoms, elevated eosinophils in the blood or urine, and decreased complement levels - while it may occur spontaneously, a hx of recent angiography in a patient w/ abdominal aortic atherosclerosis is often the main clue to the diagnosis

Question 162

Echinococcus granulosus

Answer 162

- the majority of human infections are asymptomatic - HYDATID CYSTS can be found in almost any part of the body but liver (most commonly) is involved in 2/3 of pts and the lungs are involved in 25% of pts. It is most commonly seen in areas where sheep are raised.

Question 163

4 causes of microcytic anemia

Answer 163

- iron deficiency - anemia of chronic disease - thalassemias and other hemoglobinopathies - lead poisoning, sideroblastic anemia

Question 164

indicator of iron reserves in the body

Answer 164

-serum ferritin

Question 165

Carpal tunnel syndrome

Answer 165

- occurs in approx 30% of pts w/ HYPOTHYROIDISM - deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve is thought to be primary responsible for its pathogenesis

Question 166

The current vaccination schedule for HIV-infected individuals

Answer 166

- includes all routine vaccinations for adults, as well as serial pneumococcal boosters - men who have sex w/ men should also receive hepatitis A immunization - pts w/ CD4 cell counts <200 should not receive live vaccines

Question 167

causes of hypomagnesemia

Answer 167

-poor nutrition, diuretic use, malabsorption, and alcohol abuse

Question 168

Cushing's syndrome

Answer 168

- caused by corticosteroid excess - hypokalemia and hypernatremia are the electrolyte abnormalities most commonly observed because most corticosteroids have some mineralocorticoid activity and will bind to aldosterone receptors in the kidney, causing renal potassium wasting

Question 169

Electrical cardioversion is indicated for sustained monomorphic ventricular tachycardia pts who are hemodynamically unstable, pulseless, or severely symptomatic. Hemodynamically stable pts can first be given antiarrhythmics (ie. IV amiodarone) as these may lead to sinus rhythm and avoidance of the need for cardioversion

Answer 169

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Question 170

Acute angle-closure glaucoma

Answer 170

- usually seen in older pts - may present w/ a red, painful eye and blurred vision - corneal opacification can be present, but ulceration is not typical - the pupil is fixed and mid-dilated - extraocular symptoms such as headache and nausea are common

Question 171

the murmur in hypertrophic cardiomyopathy

Answer 171

- crescendo-decrescendo | - increases w/ the Valsalva maneuver

Question 172

AV fistula

Answer 172

- causes high-output cardiac failure by shunting the blood from the arterial to venous side, thereby increasing cardiac preload - the patient develops heart failure despite maintaining a normal or high cardiac output because the circulation is unable to meet the oxygen demand of the peripheral tissues

Question 173

Choriocarcinoma

Answer 173

- metastatic form of gestational trophoblastic disease - may occur after molar pregnancy or normal gestation, and the lungs are the most frequent site of metastatic spread - suspect choriocarcinoma in any postpartum woman w/ pulmonary symptoms and multiple nodules on chest x-ray - an elevated beta hCG helps to confirm the diagnosis

Question 174

Trypanosoma cruzii

Answer 174

- cause of Chagas' disease - endemic in South America and may cause megacolon, megaesophagus, and cardiac disease - causes both systolic and diastolic heart failure - may also cause arrhythmias and mitral/tricuspid regurgitation

Question 175

Constrictive pericarditis

Answer 175

- caused by pericardial scarring and thickening that result in diastolic heart dysfunction - pts present w/ signs of decreased cardiac output and venous overload - common etiologies in the U.S. include viruses, cardiac surgery, chest radiation, and idiopathic causes. - Tuberculosis is the most common cause in developing countries and endemic areas such as Africa, India, and China

Question 176

Severe pain in a patient w/ a mild urinary obstruction, such as BPH, may cause urinary retention due to inability to Valsalva

Answer 176

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Question 177

Studies have shown that the risk for sepsis is present up to 30 yrs and probably longer after splenectomy. Current recommendations?

Answer 177

-State that pts should receive anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks before the operation, and daily oral penicillin prophylaxis for 3-5 yrs following splenectomy.

Question 178

Thrombocytopenia and hypercoagulation within days of initiating anticoagulant therapy are most likely caused by what?

Answer 178

-unfractionated heparin; Heparin-induced thrombocytopenia is often associated w/ abnormal intravascular thrombosis.

Question 179

Postoperative cholestasis

Answer 179

-can develop after a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement

Question 180

Nonsense and frameshift mutations are typically more severe than missense mutations. Silent (same sense) mutations do not affect the structure of the protein

Answer 180

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Question 181

Neurofibromatosis type 2

Answer 181

- subcutaneous neurofibromas, hyperpigmented cafe-au-lait spots, deafness due to acoustic neuromas (typically BILATERAL), and a family hx of the disease - autosomal dominant mutation in tumor suppressor gene on chromosome 22 - Wishart is the severe form - Gardner is the milder form

Question 182

Blastomycosis

Answer 182

- fungal infection endemic to the central U.S. - usually causes a mild pulmonary illness, but disseminated infection may occur even in immunocompetent individuals - cutaneous blastomycosis manifests as well-circumscribed verrucous nodules and plaques that progress to microabscesses

Question 183

Actinomyces and Nocardia

Answer 183

- Gram positive rods (and Nocardia is also weakly acid-fast) - Nocardia often presents as a subacute pneumonia that mimics tuberculosis infection. The majority of pts are immunocompromised. - Actinomyces causes abscesses primarily at the head and neck w/ characteristic granular yellow pus ("sulfur granules"). It can also cause indolent pulmonary disease.

Question 184

Blood cultures from separate venipuncture sites should be obtained over a specified period in all pts w/ suspected infective endocarditis prior to initiating antibiotic therapy.

Answer 184

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Question 185

Viral infection may present w/ symmetric arthritis. Viral arthritis is distinguished from rheumatoid arthritis and other causes of symmetric arthritis by its acute onset, lack of elevated inflammatory markers, and resolution within 2 months.

Answer 185

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Question 186

Arthritis must be present for at least 6 weeks in order to diagnose rheumatoid arthritis.

Answer 186

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Question 187

Psoriatic arthritis

Answer 187

- often affects the distal interphalangeal joints | - Dactylitis (sausage digit), nail findings, and psoriasis of the skin are characteristic

Question 188

Acute rheumatic fever

Answer 188

- occurs in the setting of recent strep infection - polyarthritis, carditis, chorea, erythema marginatum and subcutaneous nodules are characteristic - the arthritis of rheumatic fever is migratory in nature and usually first affects the joints of lower extremities

Question 189

IV adenosine

Answer 189

-causes temporary AV block, which is useful in identifying and in some cases terminating supraventricular tachycardias

Question 190

Amiodarone

Answer 190

- antiarrhythmic used in many cases of supraventricular and ventricular tachyarrhythmias - not used in cases of bradycardia because it slows the SA and AV nodes

Question 191

Symptomatic sinus bradycardia

Answer 191

- should be treated w/ IV atropine, followed by transcutaneous pacing - medications that slow the heart rate should be replaced w/ alternative therapeutic regimens - if the bradycardia does not resolve, a permanent pacemaker may be necessary

Question 192

Torsades de pointes

Answer 192

- polymorphic ventricular tachycardia which occurs in the setting of a prolonged QT interval and is seen in pts w/ familial long QT syndrome, malnourished pts predisposed to hypomagnesemia (such as alcoholics), and in pts taking certain drugs (tricyclic antidepressants), certain antiarrhythmics (amiodarone, sotalol), and anti-infective agents (moxifloxacin, fluconazole) - Tx includes cessation of any offending agents, and initiation of magnesium sulfate!

Question 193

Sotalol

Answer 193

-class III antiarrhythmic which inhibits inward potassium ion channels, thereby prolonging the QT interval

Question 194

Calcium gluconate

Answer 194

-cardio-protective in cases of hyperkalemia (peaked T waves, followed by lengthening of the PR and QRS intervals)

Question 195

Amiodarone

Answer 195

- class III antiarrhythmic used for both ventricular and atrial tachycardia - causes QT prolongation

Question 196

Adenosine

Answer 196

- used to induce transient heart block at the AV node | - useful in identifying and sometimes terminating supraventricular tachycardia

Question 197

sodium bicarb

Answer 197

-used in TCA and aspirin overdose

Question 198

Atropine

Answer 198

- used in cases of bradycardia, asystole and pulseless electrical activity - acts by competitively antagonizing muscarinic ACh receptors, suppressing the parasympathetic input to the heart

Question 199

COPD

Answer 199

- have increased total lung capacity, functional residual capacity, and residual volume leading to hyperinflation and diaphragmatic flattening - flattening of the diaphragm increases the work of breathing

Question 200

Both seizures and syncope can cause sudden loss of consciousness, and it can sometime be difficult to distinguish between them.

Answer 200

- Seizures typically have a preceding aura, delayed return to neurologic baseline, head deviation or unusual body posturing, and tongue laceration - Syncope is associated w/ loss of postural tone and spontaneous return to baseline neurologic function

Question 201

what is an effective and rapid method used to abort an acute attack of cluster headache?

Answer 201

-100% oxygen (nasal) high yield!!

Question 202

Diuretic abuse

Answer 202

- leads to increased excretion of water and electrolytes by the kidneys - dehydration, weight loss, orthostatic hypotension as well as hypokalemia and hyponatremia result - urinary sodium and potassium will be elevated - pts w/ eating disorders sometimes abuse diuretics to induce weight loss

Question 203

Negative predictive value (NPV)

Answer 203

- the probability of being free of a disease if the test result is negative - remember, the NPV WILL VARY WITH THE PRETEST PROBABILITY OF A DISEASE - a patient w/ a high probability of having a disease will have a low NPV, and a patient w/ a low probability of having a disease will have a high NPV

Question 204

The sensitivity and specificity of a test are FIXED VALUES, which do not vary w/ the pretest probability of a disease.

Answer 204

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Question 205

If the outcome of a case-control study is not common in the population, the odds ratio is close to the relative risk ("rare disease assumption"). In other words, if the prevalence of the disease is low, the exposure odds ratio approximates the relative risk.

Answer 205

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Question 206

Increased intragastric pressure during vomiting can cause tears in the mucosa of the distal esophagus and proximal stomach. These are called Mallory-Weiss tears, and account for 10% of upper GI bleeds.

Answer 206

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Question 207

Pts w/ coarctation of the aorta have what?

Answer 207

-"brachial-femoral" delay (due to differential blood pressure in the upper and lower extremities) or hypertension in the upper extremity

Question 208

All patients w/ suspected pneumonia should be assessed w/ a chest x-ray. Sputum testing for microbial diagnosis is optional in the outpatient setting due to low yield of culture results and high success rate of tx w/ empiric antibiotics.

Answer 208

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Question 209

Approx. 10-20% of pts on isoniazed will develop mild aminotransferase elevation within first few weeks of treatment. This hepatic injury is typically self-limited and will resolve without intervention.

Answer 209

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Question 210

name 1 phosphodiesterase type 5 inhibitor

Answer 210

Sildenafil (tx for erectile dysfunction)

Question 211

preferred therapy for prolactinoma

Answer 211

dopaminergic agonist

Question 212

Red flags for other secondary causes of hypogonadotropic hypogonadism include significant headaches, very low testosterone levels (

Answer 212

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Question 213

Theophylline toxicity

Answer 213

- can manifest as CNS stimulation (headache, insomnia, seizures), GI disturbances (nausea, vomiting) and cardiac toxicity (arrhythmia). - inhibition of the cytochrome oxidase system by other medications, diet, or underlying disease can alter its narrow therapeutic window

Question 214

Typical antipsychotics (ie haloperidol) should NOT be used in pts w/ Lewy body dementia, who may exhibit neuroleptic hypersensitivity (severe parkinsonism and impaired consciousness w/ neuroleptic administration)

Answer 214

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Question 215

Toxic-metabolic and infectious etiologies are the most common causes of delirium in a hospitalized patient. Patients w/ dementia have an increased risk of developing agitated delirium in the hospital. Typical and atypical antipsychotics are useful for treating acute agitation in elderly pts w/ dementia. Benzo's are typically not recommended in this setting.

Answer 215

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Question 216

common adverse effects of beta-blockers

Answer 216

- bradycardia - AV block - bronchoconstriction (esp in asthma and COPD pts) - male sexual dysfunction

Question 217

Nitrates adverse effects

Answer 217

-can cause headaches, hypotension, and development of tolerance to the drug w/ continuous use

Question 218

side effect of Clopidogrel

Answer 218

-thrombotic thrombocytopenic purpura

Question 219

statin side effects

Answer 219

-hepatotoxicity and myopathy

Question 220

most common cause of acquired angioedema

Answer 220

- ACE-inhibitors - note that angioedema can occur at ANYTIME, not just within weeks of starting the meds - other adverse effects of ACE-I's are cough, hyperkalemia, and precipitation of acute renal failure in pts w/ bilateral renal artery stenosis

Question 221

Pancytopenia is common in pts w/ SLE. It usually indicates concurrent peripheral immune-mediated destruction of all 3 cell lines.

Answer 221

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Question 222

Selection bias

Answer 222

-results from the manner in which people are selected for the study, of from the selective losses from follow-up.

Question 223

Recall bias

Answer 223

- results from the inaccurate recall of past exposure by people in the study - it applies mostly to case-control studies, not cohort studies

Question 224

Confounding

Answer 224

-refers to the bias that can result when the exposure-disease relationship is mixed w/ the effect of extraneous factors

Question 225

Observer's bias and measurement bias

Answer 225

- distort the measure of associated by misclassifying exposed/unexposed and/or diseased/non-diseased subjects. - confounders influence both the exposure and outcome

Question 226

hypertensive urgency

Answer 226

-severe hypertension (usually >180/120 mmHg) w/ no symptoms or acute end-organ damage

Question 227

Hypertensive emergency

Answer 227

- severe hypertension w/ acute, life-threatening, end-organ complications - Malignant hypertension: severe hypertension w/ retinal hemorrhages, exudates, or papilledema - Hypertensive encephalopathy: severe hypertension w/ cerebral edema and non-localizing neurologic symptoms and signs

Question 228

Hypertensive emergency

Answer 228

- defined as marked, severe hypertension associated w/ malignant hypertension or hypertensive encephalopathy - malignant hypertension is defined as the presence of severe hypertension (usually >180/120mmHg) associated w/ retinal hemorrhages, exudates, and/or papilledema - hypertensive encephalopathy is associated w/ cerebral edema

Question 229

The CDC recommends that all adults receive the influenza vaccine annually. Certain healthy individuals may receive the intranasal live vaccine while the inactivated intramuscular influenza vaccine is recommended for all other adults.

Answer 229

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Question 230

High-dose niacin therapy

Answer 230

- treats lipid abnormalities frequently produces cutaneous flushing and pruritis. - this side effect is explained by prostaglandin-induced peripheral vasodilatation and can be reduced by low-dose aspirin.

Question 231

Diabetic autonomic neuropathy

Answer 231

- involves the cardiovascular, genitourinary, and gastrointestinal systems - some of the most commonly encountered problems are gastroparesis, enteropathy, postural hypotension, abnormal sweating, cystopathy and erectile dysfunction

Question 232

mononeuropathy multiplex

Answer 232

-pts experience multiple mononeuropathies, thus presenting as an asymmetric polyneuropathy

Question 233

Symmetric distal sensorimotor polyneuropathy

Answer 233

- the most common type of diabetic neuropathy, and is characterized by the classic "stoking glove" pattern of sensory loss - aside from symmetric distal sensorimotor polyneuropathy, diabetes can also cause mononeuropathies of cranial and peripheral nerves

Question 234

Ulcerative colitis screening

Answer 234

- pts w/ ulcerative colities are at an increased risk for the development of colorectal cancer - most quidelines state that pts should begin colonoscopy surveillance 8 yrs after the diagnosis, possibly longer if only the left colon is involved - once a surveillance program is started, colonoscopy should be repeated every 1-2yrs to assess for development of colonic dysplasia

Question 235

Cardiac tamponade

Answer 235

- can occur as a catastrophic complication of acute aortic dissection - it should be suspected in pts w/ hypotension, tachycardia, distended neck veins, and pulsus paradoxus who have sudden onset of severe tearing chest pain radiating to the back

Question 236

Recurrent bacterial infections in an adult patient may indicate a humoral immunity defect. what helps to establish the diagnosis?

Answer 236

-Quantitative measurement of serum immunoglobulin levels

Question 237

Hepatitis C is a risk factor for what?

Answer 237

-cirrhosis, hepatocellular cancer, cryoglobulinemia, and glomerulonephritis

Question 238

Smoking is a risk factor for what cancers?

Answer 238

-squamous cell, small cell, pancreatic, cancers of the upper aerodigestive tract

Question 239

Most cases of active TB in the US occur in foreign-born individuals who have recently emigrated from endemic areas (especially mexico, the philippines, china, vietnam, india, Dominican Republic, and haiti) w/ the highest rates for those arriving in the last 5 years.

Answer 239

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Question 240

The rapid plasma reagin test

Answer 240

- aka "RPR" test - is a nontreponemal antigen test used to screen for syphilis - congenital syphilis can be associated w/ stillbirth, anemia, and thrombocytopenia

Question 241

Idiopathic thrombocytopenic purpura

Answer 241

- usually diagnosed after excluding other possible causes of thrombocytopenia - these patients should be tested for hepatitis C and HIV as thrombocytopenia may be the initial presentation of HIV infection (up to 5-10% of pts). - tx of the underlying infection can affect the platelet count

Question 242

Pts w/ infectious mononucleosis are at risk for splenic rupture. Advise pts to avoid contact sports to prevent this hazard until the spleen regresses in size and is no longer palpable (usually after one to three months).

Answer 242

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Question 243

Technetium bone scan is less specific than gallium imaging in the diagnosis of vertebral osteomyelitis as it also detects fractures and may result in false-positive findings. The study may also be negative in the early phases of infection.

Answer 243

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Question 244

Vertebral osteomyelitis

Answer 244

- usually presents w/ fever, back pain, and FOCAL spinal tenderness - evaluation includes blood cultures and inflammatory markers (ESR and CRP) - MRI is the modality of choice for diagnosis, followed by CT-guided bone biopsy

Question 245

Chemical peritonitis due to perforated peptic ulcer should be suspected in pts presenting w/ sudden onset of severe epigastric pain that spreads over the entire abdomen. Upright chest and/or abdominal radiographs typically reveal free air under the diaphragm.

Answer 245

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Question 246

Digital clubbing

Answer 246

- Lung malignancies, cystic fibrosis, and right-to-left cardiac shunts are the most common causes of secondary digital clubbing - COPD (with or without hypoxemia) does not cause digital clubbing, and the presence of clubbing should prompt a search for occult malignancy. - hypertrophic osteoarthropathy refers to digital clubbing along w/ painful joint enlargement, periostosis of long bones, and synovial effusions - pathogenesis involves magakaryocytes that skip the normal route of fragmentation within pulmonary circulation (due to circulatory disruption from tumors, chronic lung inflammation) to enter systemic circulation. Megakaryocytes become entrapped in the distal fingertips due to their large size and release PDGF and VEGF

Question 247

CHF exacerbation

Answer 247

- can cause tachypnea as left ventricular dysfunction allows fluid to pool in the lugns, causing a pleural effusion and hypoxemia due to reduced ventilation - tachypnea causes hypocapnia and respiratory alkalosis - exam typically shows signs of fluid overload, S3 and S4 gallops, cardiomegaly, and bibasilar crackles in the lungs

Question 248

Nonallergic rhinitis

Answer 248

- usually presents w/ one of the chronic rhinitis symptoms (nasal congestion, rhinorrhea, sneezing, and postnasal drainage) w/o a specific etiology. - routine allergy testing is not necessary prior to initiating empiric treatment - depending on the severity of the symptoms, pts should be treated w/ an INTRANASAL ANTIHISTAMINE, INTRANASAL GLUCOCORTICOIDS, or combination therapy

Question 249

IgA nephropathy

Answer 249

- the most common cause of glomerulonephritis in adults - pts have recurrent episodes of gross hematuria, usually within 5 days after an upper respiratory infection (SYNPHARYNGITIC) presentation - IgA nephropathy is differentiated from postinfectious GN based on earlier onset of upper respiratory tract infection-related GN and normal serum complement levels. - kidney biopsy can also help differentiated these 2 processes

Question 250

Acute interstitial nephritis

Answer 250

- acute inflammatory process involving the renal tubules and interstitium following exposure to a drug (antibiotics, NSAIDs, PPI) - other findings can include fever, skin rash, eosionophilia, eosinophiluria, or WBC casts

Question 251

Alport syndrome

Answer 251

- X-linked defect in collagen IV formation and presents w/ hearing loss, ocular abnormalities, hematuria, and progressive renal insufficiency - kidney biopsy usually shows thinning of the glomerular BM

Question 252

Anti-glomerular BM disease

Answer 252

-due to anti-GBM antibodies against collagen IV (alpha-5 chain) damaging the glomeruli and alveolar lining -manifests as either a renal limited process (rapidly progressive GN) or alveolar hemorrhage (pulmonary renal syndrome) -Goodpasture's syndrome refers to a pulmonary-renal syndrome that is a manifestation of anti-GBM disease -

Question 253

Benign recurrent hematuria (aka thin BM nephropathy)

Answer 253

-benign familial condition that presents as isolated microscopic hematuria

Question 254

Henoch-Shonlein purpura

Answer 254

- systemic form of IgA involvement of the glomeruli, skin, joints, and intestines - more common in children and presents as an erythematous and papular skin rash involving the dorsal aspect of lower extremities, abdominal pain, arthralgia/arthritis, and microscopic hematuria/proteinuria

Question 255

Lupus nephritis

Answer 255

- can present as nephritic syndrome, nephrotic syndrome, rapidly progressive GN, or pulmonary-renal syndrome - pts usually have low complement levels (C3 and C4) and positive lupus antibodies (anti-nuclear antibodies, anti-dsDNA, anti-smith antibodies)

Question 256

Crohn's disease

Answer 256

- can involve any component of the GI tract from mouth to anus, and characteristically has skip ares of involvement - although nonspecific, aphthous ulcers in the mouth can be seen in Crohn's disease - Granulomas are identified pathologically in up to 30% of pts w/ Crohn's

Question 257

CN III neuropathy due to nerve compression

Answer 257

- causes include transtentorial (uncal) herniation or aneurysm of the posterior communicating artery - both somatic and parasympathetic fibers of CN III are equally affected in this condition

Question 258

Lacunar strokes

Answer 258

- result from obstruction of the penetrating arterioles that supply white matter - these strokes manifest w/ pure motor or pure sensory syndromes

Question 259

Diabetic mononeuropathy often involves CN III

Answer 259

- Nerve damage is ISCHEMIC, and only the SOMATIC nerve fibers are affected - Parasympathic fibers of CNIII retain function - Ptosis and a "down and out" gaze in conjunction w/ normal light and accomodation reflexes indicate diabetic CNIII neuropathy

Question 260

Peptic ulcer perforation is associated w/ free air under the diaphragm

Answer 260

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Question 261

Emphysematous cholecystitis

Answer 261

- common form of acute cholecystitis in elderly diabetic males - it arises due to infection of the gallbladder wall w/ gas-forming bacteria

Question 262

Situational syncope

Answer 262

- should be considered in the differential diagnosis of syncopal episodes - the typical scenario would include a middle age or older male, who loses consciousness immediately after urination, or a man who loses consciousness during coughing fits

Question 263

Erythema nodosum

Answer 263

- a condition of painful, subcutaneous, pretibial nodules - it can be a symptom of more serious disease processes including sarcoidosis, TB, histoplasmosis, recent streptococcal infection, and inflammatory bowel disease - the association of EN w/ sarcoidosis is particularly strong in young, african-american women - cough, arthritis, uveitis and hilar adenopathy on chest x-ray are also associated w/ sarcoidosis

Question 264

Lumbar spinal stenosis

Answer 264

- most commonly caused by degenerative changes in the spine and presents w/ low back and leg pain - the leg pain of neurogenic claudication is position-dependent (exacerbated by lumbar extension) and persists while standing still - vascular claudication is exertion-dependent and resolves w/ standing still. - Arterial pulses and ankle-brachial index can differentiate between vascular and neurogenic claudication

Question 265

Acute glaucoma

Answer 265

-presents over days w/ unilateral vision changes, red eye, and headache

Question 266

Intracranial hypertension

Answer 266

- diagnosed when the intracranial pressure equals or exceeds 20mmHg - it may be due to a number of different causes and typically presents w/ headaches, vision changes, nausea and vomiting, changes in awareness, and/or focal neurologic deficits

Question 267

Acute interstitial nephritis

Answer 267

- usually associated w/ exposure to meds such as beta lactams and PPI's - usually occurs 7-10 days after drug exposure - skin rash, eosinophilia, eosinophiluria, and pyuria

Question 268

Pre-renal azotemia

Answer 268

- often due to volume depletion w/ hypoperfusion to the kidneys - lab studies typically show a BUN to creatinine ratio >20:1

Question 269

High-dose IV acyclovir

Answer 269

- can cause crystalluria w/ renal tubular obstruction | - administering IV fluids concurrently w/ the drug can help reduce the risk of AKI

Question 270

what is the most common form of glomerulopathy associated w/ HIV?

Answer 270

- Collapsing focal and segmental glomerulosclerosis | - typical presentation of FSGS includes nephrotic range proteinuria, azotemia, and normal sized kidneys

Question 271

common causes of nephrotic syndrome

Answer 271

- FSGS - minimal change disease - membranous nephropathy - diabetes - primary amyloidosis - IgA nephropathy

Question 272

when does postinfectious GN usually occur?

Answer 272

-10-21 days after a strep or staph infection

Question 273

Cryoglobulinemia

Answer 273

- immune complex disorder (IgM against anti-hepatitis C virus IgG) most commonly due to chronic hepatitis C - Pts may develop vasculitis involving the skin, kidney, nerves, or joints - low complement levels, increased rheumatoid factor, increased liver transaminases, serum cryoglobulins, and kidney/skin biopsy can confirm the diagnosis

Question 274

Thrombotic thrombocytopenic purpura

Answer 274

- due to decreased ADAMTS13 activity - fever, microangiopathic hemolytic anemia, thrombocytopenia w/ possible purpura, renal failure, and neuro findings (headache, confusion)

Question 275

Antiphospholipid antibody syndrome

Answer 275

- due to elevated anti-cardiolipin antibodies - pts usually develop findings such as recurrent arterial or venous thrombosis, loss of pregnancy, neuro findings (cognitive deficits), or microangiopathic hemolytic anemia

Question 276

serum protein electrophoresis

Answer 276

-can detect abnormally high gamma globulin levels (M protein spike) typically seen in monoclonal gammopathy (ie. multiple myeloma, monoclonal gammopathy of undetermined significance)

Question 277

Folic acid supplementation is beneficial in pts w/ folate deficiency and hereditary spherocytosis

Answer 277

.

Question 278

The anemia of CKD

Answer 278

- due to erythropoietin deficiency - one must be careful to ensure adequate iron stores prior to EPO replacement because the EPO-induced surge in RBC production can precipitate an iron-deficient state

Question 279

what is the treatment of choice for cellulitis w/ systemic signs?

Answer 279

-IV nafcillin or cefazolin

Question 280

Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic evaluation is not needed when a patient presents w/ his first renal stone.

Answer 280

.

Question 281

Digoxin

Answer 281

- cardiac glycoside w/ adverse effects that include nausea, vomiting, diarrhea, vision changes, and arrhythmias - pts chronically taking digoxin should have close and routine monitoring of their digoxin levels

Question 282

mild elevations of prolactin in the context of otherwise normal pituitary function are typically due to what?

Answer 282

- medications (ie. certain antipsychotic drugs) | - other causes include: hypothyroidism and renal failure

Question 283

Primary hypothyroidism may cause mild-to-moderate hyperprolactinemia, which is thought to be due to thyrotropin releasing hormone-induced stimulation of lactotrophs -LH in such pts may be normal or mildly low

Answer 283

.

Question 284

Prolactinoma

Answer 284

- the most common primary pituitary tumor | - serum prolactin levels correlate w/ the size of prolactinoma, and levels >200 ng/mL are essentially diagnostic

Question 285

Amiodarone

Answer 285

-can cause pulmonary toxicity and should be avoided in pts w/ preexisting lung disease since they have less pulmonary reserve

Question 286

Pneumococcal polysaccharide vaccine (PPSV)

Answer 286

should be given once to all adults age > or = to 65 - should also be given to all adults age < 65 w/ chronic cardiovascular, pulmonary, hepatic, renal, or metabolic disease (ie. diabetes) or immunosuppression - persons vaccinated before age 65 need a booster 5 years later

Question 287

Acute decompensated heart failure

Answer 287

- can present w/ acute pulmonary edema - tx for pts who have normal or elevated BP includes supplemental oxygen, assisted ventilation as needed, aggressive IV diuresis, and possible vasodilator therapy (nitroglycerine, nitroprusside)

Question 288

Graves' disease vs. Hashimoto thyroiditis

Answer 288

- Graves' disease is an autoimmune disorder associated w/ antibodies to the TSH receptor that stimulate release of thyroid hormone - Hashimoto thyroiditis is associated w/ thyroid peroxidase (TPO) antibodies and can cause transient hyperthyroidism due to inflammatory destruction of thyroid follicles and release of thyroid hormone - the hyperthyroidism in both of these common disorders is TSH independent, and TSH is suppressed

Question 289

Atrial fibrillation can be seen in 10% of patients w/ hyperthyroidism!

Answer 289

.

Question 290

Infiltrative ophthalmopathy

Answer 290

-from the accumulation of glycosaminoglycans in the retro-orbital muscles and tissue leads to proptosis (as seen in Graves')

Question 291

Untreated hyperthyroid pts are at risk for what?

Answer 291

- rapid bone loss resulting from increased osteoclastic activity in the bone cells - also at risk for cardiac tachyarrhythmias, including atrial fibrillation

Question 292

Bisphosphonates

Answer 292

-used for hypercalcemia, osteoporosis prevention, and as an adjunctive tx for certain malignancies (ie multiple myeloma)

Question 293

Dexamethasone

Answer 293

-used to treat autoimmune, inflammatory, and allergic conditions, and cerebral edema

Question 294

D5W

Answer 294

-hypotonic solution used to treat hypernatremia rather than hyponatremia

Question 295

Effective management of SIADH

Answer 295

- requires the infused fluid to have a higher electrolyte concentration than the urine (not just that of the plasma)! - NS (0.9%) has an electrolyte concentration of nearly 300 mOsm/kg, which is only slightly higher than the serum osmolality and leads to NaCl excretion. However, the excessive ADH causes more water retention, further concentrates the urine, dilutes the serum, and worsens hyponatremia. Hypertonic saline (3%) has a concentration of nearly 1025 mOsm/kg and minimizes this effect

Question 296

Sodium bicarb is used to treat what?

Answer 296

- severe metabolic acidosis - hyperkalemia - some drug overdoses (TCAs)

Question 297

Asymptomatic pts or those w/ mild symptoms from SIADH usually respond to fluid restriction (

Answer 297

.

Question 298

other manifestations of ulcerative colitis

Answer 298

- arthritis - uveitis - erythema nodosum - pyoderma gangrenosum

Question 299

Acute intermittent porphyria

Answer 299

- acute presentation, occurs more commonly in females and is episodic (triggered by certain drugs) - abdominal pain, nausea, vomiting, diarrhea, and sweating - agitation, anxiety, paraesthesia, and confusion - unlike the other porphyrias, there is an absence of photosensitivity in this subtype

Question 300

Pts w/ diabetes for > 10 years can develop diabetic microangiopathy, nephropathy, and glomerulosclerosis. Risk factors include poor glycemic control, elevated BP, smoking, increasing age, and ethnicity (black and mexican). Clinical findings include mild to moderate proteinuria and CKD w/ elevated creatinine.

Answer 300

.

Question 301

what is the goal INR in patients w/ prosthetic heart valves?

Answer 301

2.5-3.5

Question 302

Warfarin dosing should be adjusted to maintain a goal INR appropriate for the condition being treated. For pts w/ idiopathic VTE or atrial fibrillation, what is the target INR?

Answer 302

2.0-3.0

Question 303

Light criteria to classify an exudate

Answer 303

must have AT LEAST ONE of the following: - pleural fluid protein/serum protein ratio >0.5 - pleural fluid LDH/serum LDH ratio >0.6 - pleural fluid LDH greater than 2/3 of the upper limit of normal for serum LDH

Question 304

causes of exudative effusions

Answer 304

- infection (pneumonia, TB) - malignancy - PE - connective tissue disease - iatrogenic

Question 305

PE should be suspected in all pts at risk for DVT who present w/ acute-onset tachypnea, dyspnea, and chest pain. The diagnostic test of choice is what?

Answer 305

- helical CT scan of chest | - pleural effusions associated w/ PE are usually small and almost always exudative

Question 306

Recurrent pneumonia in the same anatomic location is a red flag for what?

Answer 306

- bronchial obstruction - smoking is the primary risk factor for bronchogenic carcinoma - CT of the chest is indicated for suspected lung cancer - Bronchoscopic or CT guided biopsy may be performed for any suspected lesion seen on CT scan

Question 307

Vitamin B6 (pyridoxine) deficiency

Answer 307

-associated w/ peripheral neuropathy, which is usually seen in pts who are on INH therapy for TB

Question 308

Suspected vitamin B12 deficiency in strict vegetarians w/ anemia and neurologic complications. In such pts, folic acid supplementation may correct the anemia, but not the neurologic complications.

Answer 308

.

Question 309

Necrotizing fasciitis

Answer 309

- characterized by purplish discoloration of the skin w/ gangrenous changes and systemic signs of toxicity - thorough surgical debridement of all the necrotic tissues is the most important therapy - empiric antibiotic therapy should cover aerobic and anaerobic organisms (ampicillin and sulbactam plus clindamycin)

Question 310

Thrombophlebitis

Answer 310

-palpable, indurated, cord-like, tender, subcutaneous venous segments

Question 311

Erythema induratum

Answer 311

- appears as a nodular eruption in pts w/ TB | - there are crops of small, tender, erythematous nodules involving the shins and calves

Question 312

Alcohol abuse is the most common cause of nutritional folate deficiency in U.S. and would cause megaloblastic anemia.

Answer 312

.

Question 313

Diagnostic criteria for SIADH

Answer 313

- Sosm < 270 - Uosm > Sosm - UNa > 20 mEq/L - absence of hypovolemia - normal renal, adrenal and thyroid function - no obvious surgical, traumatic or painful stimulus known to activate the neuroendocrine stress response, including ADH release - absence of other known causes of hyponatremia

Question 314

SIADH

Answer 314

-characterized by euvolemic hyponatremia, decreased serum osmolarity, elevated urine osmolarity (often greater than serum osmolarity), increased urine sodium concentration, and failure to correct w/ normal saline infusion

Question 315

First-generation H1-antihistamines have potent anticholinergic effects and may cause eye and oropharyngeal dryness as well as urinary retention, especially in older males who may have some underlying BPH.

Answer 315

.

Question 316

Detrusor-sphincter dyssynergia

Answer 316

- typically occurs in the setting of neurologic disease - the detrusor muscle contracts while the urethral sphincter contracts causing difficulty in initiating urination and inadvertent interruption of the urinary stream

Question 317

Management of hepatic encephalopathy

Answer 317

- supportive care, treating the precipitating cause (volume depletion, electrolyte abnormalities) and lowering serum ammonia. - Disaccharides (lactulose, lactitol) are initially preferred for lowering serum ammonia - Rifaximin can be added to lactulose in pts w/o improvement after 48 hrs or used as monotherapy in those unable to take lactulose

Question 318

In low risk pts (ie

Answer 318

.

Question 319

Cerebral septic emboli are treated with what?

Answer 319

antibiotics

Question 320

Histopathologically, demonstration of invasion of the capsule and blood vessels is required for differentiating follicular cancers from follicular adenomas. Follicular thyroid cancers have the propensity to invade blood vessels and metastasize to distal organs. Unlike papillary cancer, follicular cancer is encapsulated, and does not have distinctive nuclear features.

Answer 320

.

Question 321

secretion of calcitonin is a feature of what thyroid cancer?

Answer 321

medullary

Question 322

Papillary thyroid cancer

Answer 322

- most common thyroid malignancy - characterized by a slow, infiltrative local spread affecting other parts of the thyroid gland and regional lymph nodes - presence of psammoma bodies are a characteristic histopathological feature - FNAB typically reveals large cells w/ ground glass cytoplasm, and pale nuclei w/ inclusion bodies and central grooving - unencapsulated - prognosis is excellent, even in the presence of metastasis

Question 323

Genetic testing (RET proto-oncogene germline mutation) is more sensitive than biochemical measurement (serum calcitonin) and is the recommended screening test for suspected MEN type 2 syndromes. Total thyroidectomy is indicated for pts w/ positive genetic testing; no further monitoring is required for pts w/ negative testing.

Answer 323

.

Question 324

the sudden onset of a sharply-demarcated, erythematous, edematous, tender skin lesion w/ raised borders in a febrile patient suggests what?

Answer 324

ERYSIPELAS | -the most frequently implicated organism is group A beta-hemolytic streptococcus

Question 325

Amitriptyline

Answer 325

-tricyclic antidepressant used to treat depression, insomnia, and neuropathic pain

Question 326

GERD

Answer 326

- characterized by a retrosternal burning sensation after eating and with lying down. - it may also be accompanied by hoarseness and chronic cough, especially while recumbant. - the initial tx is an H2-receptor antagonist or a PPI

Question 327

what test establishes the diagnosis of diffuse esophageal spasm?

Answer 327

-manometry

Question 328

the basic pathology in myasthenia gravis lies at the NMJ (that's why it's called myasthenia) and is mediated by auto-antibodies against the ACh receptor.

Answer 328

.

Question 329

Primary hyperaldosteronism (Conn's syndrome)

Answer 329

- causes hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis - the diagnosis is suggested by low renin and elevated aldosterone levels

Question 330

what is the most common form of nephrotic syndrome associated w/ carcinoma?

Answer 330

Membranous nephropathy

Question 331

what is the most common form of nephrotic syndrome seen in pts w/ Hodgkin lymphoma?

Answer 331

-Minimal change disease

Question 332

Acute pericarditis can cause what changes on ECG?

Answer 332

-ST elevation (diffuse) and PR depression

Question 333

Multiple observational studies have demonstrated that pts w/ hypertension have approximately 4 times the risk of stroke when compared to non-hypertensive subjects.

Answer 333

.

Question 334

Hypokalemia

Answer 334

- causes weakness, fatigue, and muscle cramps - when severe, it can lead to paralysis and arrhythmia - ECG may show U waves, flat and broad T waves, and premature ventricular beats

Question 335

Sodium bicarbonate narrows the QRS complex, preventing the development of arrhythmia in pts w/ tricyclic antidepressant toxicity by alleviating the cardio-depressant action on sodium channels. Sodium bicarb is a critical part of tx in TCA intoxication.

Answer 335

.

Question 336

AML

Answer 336

-hematogenous disorder w/ increased risk of occurrence in pts w/ underlying myeloproliferative disorders (CML, myelodysplasia) and certain meds (topoisomerase inhibitors)

Question 337

a nonhealing, painless, bleeding skin ulcer that develops associated w/ a chronic scar

Answer 337

- Squamous cell carcinoma - exposure to derivates (from tobacco smoke) or radiation, and immunosuppression (transplant recipients) increase the risk of SCC. - biopsy is recommended

Question 338

Persistent diarrhea causes a NON-anion gap metabolic acidosis

Answer 338

.

Question 339

Chloride-resistant metabolic alkalosis

Answer 339

- characterized by a urinary chloride level >20 mEq/day and ECF volume expansion - some disorders associated w/ this are primary hyperaldosteronism, Bartter syndrome, Gitelman's syndrome, and excessive black licorice ingestion - NOT corrected by saline infusion

Question 340

ALL forms of renal tubular acidosis cause NON-anion gap metabolic acidosis

Answer 340

.

Question 341

Metabolic alkalosis

Answer 341

- can be classified into 2 broad categories, chloride-sensitive and chloride-resistant, based on urinary chloride levels and ECF volume status - chloride-sensitive metabolic alkalosis is associated w/ low urinary chloride excretion (< 20 mEq/day) and volume contraction. volume contraction causes increased mineralocorticoid action, which in turn causes bicarb retention, H+ loss and K+ loss. The urinary chloride remains low due to avid renal retention of NaCl and water - common causes: diuretics, loss of gastric secretions, such as w/ surreptitious vomiting. - this condition can be corrected w/ saline infusion to restore ECF volume

Question 342

a mobile cavitary mass in the lung, which presents w/ intermittent hemoptysis

Answer 342

aspergilloma

Question 343

asthma causes intrapulmonary obstruction. in asthmatics, bronchoconstriction decreases airflow during the passive phase of exhalation, causing flow-volume loops to have a "scooped out" pattern on exhalation

Answer 343

.

Question 344

a fixed upper airway obstruction will decrease the airflow rate during inspiration, active expiration, and passive expiration

Answer 344

.

Question 345

Cerebellar tumors

Answer 345

- usually produce ipsilateral ataxia, nystagmus, intention tremors, and loss of coordination - they will often sway to the AFFECTED side, and may exhibit titubation, which is a forward and backward movement of the trunk

Question 346

Ascending aortic aneurysms are most often due to CYSTIC MEDIAL NECROSIS or CONNECTIVE TISSUE DISORDERS. Descending aortic aneurysms are usually due to ATHEROSCLEROSIS. Chest x-ray can suggest thoracic aortic aneurysm by showing a widened mediastinal silhouette, increased aortic knob, and tracheal deviation.

Answer 346

.

Question 347

Pancoast tumor

Answer 347

a neoplasm in the pulmonary apex at the thoracic inlet that compresses the inferior portion of the brachial plexus resulting in shoulder pain radiating in an ulnar distribution

Question 348

what meds improve mortality in CHF patients?

Answer 348

- ACE inhibitors - B-blockers - angiotension II receptor blockers - spironolactone

Question 349

Acute pancreatitis complication by hypotension, mechanism?

Answer 349

- thought to arise from intravascular volume loss secondary to local and systemic vascular endothelial injury - causes vasodilation, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension

Question 350

Massive pulmonary embolism

Answer 350

-likely in a postoperative patient w/ jugular venous distention and new-onset right bundle branch block

Question 351

phenytoin toxicity

Answer 351

-horizontal nystagmus, cerebellar ataxia, and confusion

Question 352

lithium toxicity

Answer 352

-tremor and hyperreflexia, ataxia and seizures

Question 353

benzodiazepine overdose

Answer 353

- slurred speech, unsteady gait and drowsiness - distinguished from opioid overdose by the lack of severe respiratory depression and the lack of pupillary constriction - furthermore, while alcohol and phenytoin intoxication also share similarities w/ benzo overdose, they can be distinguished by the presence of NYSTAGMUS

Question 354

Cardiogenic shock

Answer 354

- causes a reduced cardiac index and elevated pulmonary capillary wedge pressure due to ventricular pump failure - systemic vascular resistance is typically increased to maintain adequate tissue perfusion pressure

Question 355

a pelvic fracture w/ urethral injury is commonly accompanied by ED. The causes of ED in this case are nerve injury and altered arterial supply.

Answer 355

.

Question 356

The nocturnal penile tumescence helps differentiate psychogenic from organic causes of male erectile dysfunction. It is positive in psychogenic causes and negative in organic causes.

Answer 356

.

Question 357

HITT (heparin-induced thrombocytopenia)

Answer 357

- Excessive platelet aggregation known to occur in a small percentage of pts started on heparin therapy - paradoxical pro-thrombotic state, is autoimmune mediated and can lead to skin necrosis as well as hemorrhage

Question 358

Warfarin

Answer 358

- commonly used for anticoagulation because it can be administered orally - during the first few days it is given, it can have a paradoxically pro-coagulant effect in susceptible pts by inhibiting protein C production - affected pts may present w/ skin necrosis secondary to thrombus formation

Question 359

The classic triad of renal cell carcinoma (RCC)

Answer 359

- hematuria, abdominal mass, and flank pain | - on abdominal CT, RCC presents as a lesion WITHIN the kidney parenchyma that enhances w/ contrast

Question 360

Cryptosporidium parvum is a major cause of chronic diarrhea in HIV-infected pts w/ CD4 counts less than 180 cells/mm3. It is identified as oocysts in stool that are stained w/ a modified acid-fast stain

Answer 360

.

Question 361

G6PD deficiency

Answer 361

- causes hemolytic anemia due to oxidative injury to RBCs - hemolytic episodes can be precipitated by infection or medications (esp. sulfa drugs, antimalarials, and nitrofurantoin)

Question 362

Parkinsonism

Answer 362

- caused by overactivity of cholinergic neurons and underactivity of dopaminergic neurons in the substantia nigra - a shuffling gait (the pts appears as if he was chasing his center of gravity) is characteristic of the disease

Question 363

a normal of increased FEV1/FVC ratio w/ a low Vital Capacity is seen in restrictive lung disease. The DLco is decreased w/ interstitial lung disease. Neuromuscular disorders are not associated w/ a decreased DLco

Answer 363

.

Question 364

Most pts will require pharmacotherapy for BP control, but lifestyle changes can make a significant difference in motivated pts. WEIGHT CONTROL is the most effective intervention in overweight pts. Other effective measures include the DASH DIET, low sodium intake, moderation of alcohol intake, regular moderate exercise, and smoking cessation.

Answer 364

.

Question 365

tx of cluster headaches

Answer 365

- sumatriptan and high-flow oxygen | - cluster headaches last longer (minutes) and are accompanied by autonomic symptoms (rhinorrhea, nasal congestion)

Question 366

tx of herpetic neuralgia

Answer 366

-acyclovir

Question 367

methotrexate

Answer 367

-chemotherapeutic agent used in various disorders of malignancy, vasculitis, and rheumatoid arthritis

Question 368

what is the drug of choice for trigeminal neuralgia?

Answer 368

carbamazepine

Question 369

Parathyroidectomy is recommended for asymptomatic hypercalcemia pts who have at least one of the following clinical features:

Answer 369

- serum calcium level >1 mg/dL above the upper limit of normal - young age (< 50 yrs) - bone mineral density < T -2.5 at any site - reduced renal function (eGFR < 60)

Question 370

The 24 hour urinary calcium can help distinguish Primary Hyperparathyroidism (24hr urinary calcium >250mg) from familial hypercalcemia (

Answer 370

.

Question 371

Donepezil

Answer 371

-acetylcholinesterase inhibitor used to slow the progression of Alzheimer's dementia

Question 372

normal pressure hydrocephalus

Answer 372

- abnormal gait, incontinence, and dementia | - tx w/ large volume lumbar punctures and, if successful, ventriculoperitoneal shunting

Question 373

sample distortion bias

Answer 373

-seen when the estimate of exposure and outcome association is biased because the study sample is not representative of the target population w/ respect to the joint distribution of exposure and outcome

Question 374

Information bias

Answer 374

- occurs due to the imperfect assessment of association between the exposure and outcome as a result of errors in the measurement of exposure and outcome status. - can be minimized by using standardized techniques for surveillance and measurement of outcomes, as well as trained observers to measure the exposure and outcome

Question 375

Confounding bias

Answer 375

- occurs due to the presence of one or more variables associated independently w/ both the exposure and the outcome - for example, cigarette smoking can be a confounding factor in studying the association between maternal alcohol drinking and low birth weight babies, as cigarette smoking is independently associated w/ both alcohol consumption and low birth weight babies

Question 376

bias can decrease the validity of the study results

Answer 376

.

Question 377

Hawthorne effect

Answer 377

- the tendency of the study population to affect the outcome since they are aware that they are being studied - think about "nathaniel hawthorne and the scarlet letter"

Question 378

after identifying a primary acid-base disorder, the calculated expected pCO2 or HCO3- should be compared to measured values to distinguish between appropriate compensation and a mixed disorder

Answer 378

.

Question 379

what is the most important step in the management of non-ketotic hyperglycemic coma?

Answer 379

- FLUID REPLACEMENT W/ NORMAL SALINE - switch to 0.45% NS after NS - 5% dextrose once blood glucose levels lowered to 250 mg/dl by insulin therapy

Question 380

If a patient presents w/ priapism, always check the meds first. This symptom is often drug-induced. The most common drug that causes Priapism is Prazosin, although for the boards, its important to remember the association of priapism w/ TRAZODONE ("trazo-bone")

Answer 380

.

Question 381

Obstructive sleep apnea

Answer 381

- under-diagnosed in the obese population - snoring, daytime sleepiness, and apneic episodes during sleep should raise suspicion for OSA - affected pts are at risk for hypertension, heart disease, cor pulmonale, and accidents - Polysomnography is used for diagnosis!!

Question 382

TMJ dysfunction

Answer 382

- can result in referred pain to the ear that is worsened w/ chewing - pts typically report a hx of nocturnal teeth grinding

Question 383

A lesion in the upper thoracic spinal cord

Answer 383

-results in paraplegia, bladder and rectal incontinence, and absent sensation from the nipple downwards

Question 384

embolic strokes usually have a sudden onset w/ maximal symptoms at the beginning. they occur more commonly in pts w/ a hx of structural cardiac disease (a. fib, endocarditis). pts w/ a. fib PLUS existing structural heart disease have an increased risk of cardioembolic strokes.

Answer 384

.

Question 385

Paget disease of bone

Answer 385

- characterized by increased bone remodeling and abnormal osteoid formation - pts may be asymptomatic or present w/ headaches, deafness, neuropathy, or bone/back pain - lab data show elevated alk phosph but normal calcium, phosphorus, and other liver enzymes

Question 386

Primary hyperaldosteronism

Answer 386

- should be suspected in any hypertensive patient presenting w/ low renin levels - pts typically develop hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis - the elevated aldosterone suppresses renin secretion through a feedback inhibition

Question 387

Hemochromatosis

Answer 387

- associated w/ calcium pyrophosphate dihydrate deposition in joints, leading to chondrocalcinosis and associated symptoms including acute episodic synovitis (pseudogout) and chronic arthropathy. - other manifestations include diabetes, hyperpigmentation, dilated cardiomyopathy, and liver disease w/ hepatomegaly and fibrosis. - Diagnosis is suggested by iron overload on serum iron studies, and can be confirmed by genetic tests (HFE) or liver biopsy - the primary treatment is phlebotomy

Question 388

The receiver operating characteristic (ROC) curve of a quantitative diagnostic test demonstrates the trade-off between the test's sensitivity and specificity at various cutoff points. Changing the cutoff point to increase the true-positive rate (directly proportional to sensitivity) will also increase the false-positive rate (inversely proportional to specificity).

Answer 388

.

Question 389

Pts w/ non-inflammatory chronic prostatitis

Answer 389

- afebrile and have irritative voiding symptoms - expressed prostatic secretions show a normal number of leukocytes and culture of these secretions is negative for bacteria

Question 390

CHA2DS2-VASc score

Answer 390

- recommended for assessment of stroke risk in pts w/ nonvalvular atrial fibrillation - Congestive heart failure (1), Hypertension (1), Age >75 (2), Diabetes mellitus (1), Stroke/TIA/thromboembolism (2), Vascular disease (prior MI, peripheral artery disease, or aortic plaque; 1), Age 65-74 (1), Sex category (female, 1). Max score of 9 - Score of 0 = low risk = no antithrombotics - Score of 1 = intermediate = none or aspirin or oral anticoagulants - Score of 2 or greater = high = oral anticoagulants

Question 391

70% of cases w/ interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol. Discontinuing the offending agent is the tx of drug-induced interstitial nephritis. Symptoms include fever, rash, and arthralgias.

Answer 391

.

Question 392

pulsus paradoxus

Answer 392

- defined as an exaggerated fall in systemic blood pressure > 10 mmHg during inspiration. - its a frequent finding in cardiac tamponade but can also occur in conditions w/o pericardial effusion such as SEVERE ASTHMA or COPD (think of lungs expanding and preventing heart from filling during inspiration)

Question 393

muddy brown granular cast

Answer 393

ATN

Question 394

RBC cast

Answer 394

-glomerulonephritis

Question 395

WBC cast

Answer 395

-Interstitial nephritis and pyelonephritis

Question 396

Fatty casts

Answer 396

-nephrotic syndrome

Question 397

broad and waxy casts

Answer 397

-chronic renal failure

Question 398

findings in ATN

Answer 398

- BUN/Cr ratio less than 20:1 - Urine osmolality of 300-350 (but never < 300) - urine Na of > 20 - FENa > 2%

Question 399

tx for primary syphilis

Answer 399

- single dose of IM benzathine penicillin G - in nonpregnant pts w/ penicillin allergy, a 2 week course of doxycycline can be used - pregnant pts w/ penicillin allergy should undergo desensitization before penicillin therapy

Question 400

Pts w/ massive pulmonary embolism usually present w/ signs of low arterial perfusion (ie hypotension, syncope) and acute dyspnea, pleuritic chest pain, and tachycardia. The thrombus increases pulmonary vascular resistance and right ventricular pressure, causing right ventricular hypokinesis and dilation, decreased preload, and hypotension

Answer 400

.

Question 401

HIV pts w/ odynophagia and visible oral thrush likely have candidal esophagitis and should receive 1-2 weeks of empiric oral fluconazole therapy. If symptoms persist or no thrush is apparent, endoscopy w/ biopsy should be performed. Herpes simplex esophagitis is characterized by small, well-circumscribed round/ovoid ulcers and intranuclear inculsions; it is treated w/ acyclovir. CMV esophagitis is characterized by large linear ulcers and intranuclear and intracytoplasmic inclusions; its treated w/ GANGICLOVIR.

Answer 401

.

Question 402

statins

Answer 402

-inhibit intracellular HMG-CoA reductase enzyme, prevent conversion of HMG-CoA to mevalonic acid, and increase the number of cell membrane LDL receptors. Statins also decrease coenzyme Q10 synthesis, which is involved in muscle cell energy production and possibly contributes to statin-induced myopathy.

Question 403

an elevated A-a gradient is commonly seen in pts w/ pulmonary embolism

Answer 403

.

Question 404

septic shock

Answer 404

- decrease in systemic vascular resistance due to overall peripheral vasodilation - low PCWP, low SVR, increased CO, high mixed venous oxygen saturation

Question 405

sodium thiosulfate

Answer 405

- antidote for cyanide poisoning, generally seen in the setting of fires or occupational exposure (mining, pesticides) - pts w/ cyanide poisoning have markedly elevated lactate levels (typically > 10 mEq/L)

Question 406

Ethylene glycol

Answer 406

- associated w/ hypocalcemia and calcium oxalate deposition in the kidneys - leads to flank pain, hematuria, oliguria, AKI, and anion gap metabolic acidosis - tx involves administration of FOMEPIZOLE or ETHANOL to inhibit alcohol dehydrogenase, sodium bicarb to alleviate the acidosis, and hemodialysis in cases of severe acidosis and/or end-organ damage

Question 407

viral arthritis

Answer 407

- can present w/ symmetric small joint inflammatory arthritis - its distinguished from other causes of symmetric inflammatory arthritis by the fact that it tends to resolve within two months - positive inflammatory markers such as ANA and rheumatoid factor may occur - Tx involves use of NSAIDs for resolution of symptoms - antiviral therapy is unnecessary as the symptoms are self-limited

Question 408

vitamin B12 deficiency is common after a total or partial gastrectomy. Its a necessary cofactor in the pathway leading to purine synthesis. B12 deficiency decreases DNA synthesis and erythropoiesis, leading to megaloblastic anemia

Answer 408

.

Question 409

TCA overdose

Answer 409

- characterized by CNS depression, hypotension, hyperthermia, and anticholinergic effects including dilated pupils, dry flushed skin, and intestinal ileus. - also causes QRS prolongation on EKG, leaving the patient susceptible to ventricular arrhythmias - by obtaining an EKG and evaluating the QRS complex, the physician can obtain valuable prognostic info; namely the likelihood of developing arrhythmia and seizure - Sodium bicarb shortens the QRS interval in TCA overdose, decreasing the likelihood of arrhythmia

Question 410

HIV and hepatitis C infection should be suspected in patients w/ weight loss and history of IV drug abuse! Patients w/ HIV are at risk of developing depression and dementia

Answer 410

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Question 411

Wernicke encephalopathy is the acute neurologic complication of thiamine deficiency, with confusion, nystagmus, ataxia, and ophthalmoplegia. Korsakoff syndrome is the chronic complication, w/ short term memory loss and confabulations

Answer 411

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Question 412

what is the preferred study for the diagnosis of melanoma?

Answer 412

- EXCISIONAL BIOPSY WITH NARROW MARGINS - if the depth of the lesion is less than 1mm, the melanoma can be excised w/ a 1 cm tumor free margin and they have a 99% 5-year survival - tumors greater than 1 mm in depth should have a sentinel lymph node study

Question 413

what is the drug of choice in pts who present w/ hypertension and a benign essential tremor?

Answer 413

Propranolol

Question 414

when pts present w/ symptoms suggesting an increased intracranial pressure, always do neuroimaging (ie CT) before doing an LP to avoid any chances of herniation.

Answer 414

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Question 415

Amaurosis fugax

Answer 415

- painless loss of vision from emboli, and is a warning sign for an impending stroke - most emboli occur from the carotid bifurcation; hence, a duplex ultrasound of the neck should be performed

Question 416

Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic and drug levels and renal function must be monitored closely during therapy.

Answer 416

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Question 417

Primary HIV infection

Answer 417

-can present w/ a mononucleosis-like syndrome consisting of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea

Question 418

most hypercalcemic pts are asymptomatic and identified only through routine chemistry testing. In asymptomatic pts, a single elevated serum calcium level must always be confirmed by a second serum calcium value. After hypercalcemia has been confirmed, the next step is to distinguish between parathyroid hormone mediated and non-PTH mediated hypercalcemia.

Answer 418

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Question 419

Whipple's disease

Answer 419

-multi-systemic illness characterized by arthalgias, weight loss, fever, diarrhea, and abdominal pain. PAS-positive material in the lamina propria of the small intestine is a classical biopsy finding of Whipple's disease.

Question 420

Most colon cancers develop from polyps. The risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size > 2.5 cm. Only adenomatous polyps are clearly premalignant, but

Answer 420

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Question 421

Stevens-Johnson syndrome

Answer 421

-characterized by the sudden onset of target-shaped, mucocutaneous lesions and systemic signs of toxicity. The pathology involves immune complex mediated hypersensitivity

Question 422

Pts suffering from ankylosing spondylitis for 2 decades or longer are at an increased risk of vertebral fracture due to decreased bone mineral density. Vertebral fractures in these pts may occur w/ minimal trauma; therefore, the clinical suspicion for vertebral fracture in pts w/ longstanding ankylosing spondylitis must be high

Answer 422

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Question 423

Ramsay Hunt syndrome

Answer 423

-herpes zoster infection in the ear that presents w/ facial nerve palsy and vesicles in the auditory canal and auricle

Question 424

Malignant otitis externa

Answer 424

- serious infection of the ear seen in elderly pts w/ poorly controlled diabetes, and is most commonly caused by Pseudomonas aeruginosa. -the characteristic presentation consists of ear pain and ear drainage, and granulation tissue may be seen within the ear canal on exam - progression of the infection can lead to osteomyelitis of the skull base and destruction of the facial nerve

Question 425

Delirium

Answer 425

- acute confusional state characterized by a reduced or fluctuating level of consciousness, along w/ inabilitiy to sustain attention, anxiety, agitation, and/or hallucinations. - common precipitating causes of delirium include infections (UTI), polypharmacy, medication side effects, volume depletion, and electrolyte or metabolic disturbance

Question 426

The classic triad of carcinoid syndrome

Answer 426

- flushing, diarrhea, and wheezing - tx w/ surgical resection or octreotide injection - pathognomic plaque-like deposits of fibrous tissue occur most commonly on the endocardium on the right side of the heart

Question 427

tx for torsades de pointes

Answer 427

magnesium sulfate

Question 428

tx for organophosphate poisoning

Answer 428

Atropine and pralidoxime

Question 429

TCA overdose

Answer 429

- CNS depression, hypotension, and other anticholinergic effects including dilated pupils, hyperthermia, and intestinal ileus. - can also cause QRS prolongation on EKG, leaving the pt susceptible to ventricular arrhythmias - stabilize ABC's and give sodium bicarb to improve BP, shorten QRS interval, and prevent arrhythmia

Question 430

typical EKG findings of acute pericarditis

Answer 430

-diffuse ST elevation that is typically concave up, and elevation of the PR segment in lead aVR

Question 431

Indications for hemodialysis

Answer 431

1. Refractory hyperkalemia 2. Volume overload or pulmonary edema not responding to diuretics 3. Refractory metabolic acidosis (< 7.2) 4. Uremic pericarditis 5. Uremic encephalopathy or neuropathy 6. Coagulopathy due to renal failure

Question 432

Aspirin sensitivity syndrome

Answer 432

- believed to be a pseudo-allergic reaction - results from aspirin-induced prostaglandin/leukotriene misbalance in susceptible individuals - tx includes avoidance of NSAIDs and the use of leukotriene receptor antagonists (drug of choice)

Question 433

The most common renal vascular lesions seen in hypertension are arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts. Diabetes mellitus nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis.

Answer 433

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Question 434

Chronic GI disease can cause vitamin D deficiency due to malabsorption. Pts usually develop hypocalcemia, low phosphorus, and elevated PTH. Pts can be asymptomatic or complain of bone pain or tenderness, muscle weakness or cramps, and gait abnormalities.

Answer 434

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Question 435

Benign paroxysmal positional vertigo

Answer 435

- most common cause of vertigo - triggered by changes in head position, and the diagnosis is confirmed w/ the Dix-Hallpike maneuver (vertigo and nystagmus on quickly lying back into a supine position w/ the head rotated 45 degrees) - note that dizziness related to CV causes (arrhythmia, aortic stenosis, hypovolemia) is usually due to global cerebral hypoperfusion and presents as lightheadedness or near-syncope rather than true vertigo

Question 436

Cavernous hemangiomas of the brain and viscera

Answer 436

von Hippel-Lindau disease

Question 437

Cystic hygromas

Answer 437

Turner syndrome

Question 438

Cherry hemangiomas

Answer 438

- small red cutaneous papules common in aging adults - do not regress spontaneously and typically increase in # w/ age - light microscopy of these lesions shows proliferation of capillaries and postcapillary venules in the papillary dermis

Question 439

Increased gut absorption of lactic acid may occur in cases of intestinal blind loop syndrome where excessive production and absorption of D-lactate causes a hypochloremic metabolic acidosis

Answer 439

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Question 440

Lactic acidosis resulting from poor oxygen delivery to the tissues is known as type A lactic acidosis. Causes include CO poisoning and circulatory failure (shock).

Answer 440

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Question 441

Suspect multiple myeloma in an elderly patient w/ anemia, renal failure, and hypercalcemia

Answer 441

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Question 442

Pts who develop serious bleeding (ie intracerebral hemorrhage) due to excess anticoagulation w/ warfarin should be given fresh frozen plasma for the rapid reversal of anticoagulation.

Answer 442

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Question 443

evaluation of dyspepsia

Answer 443

- pts w/ dyspepsia who have risk factors for gastric or esophageal cancer- age >55, weight loss, gross or occult bleeding, anemia, dysphagia, or early satiety- should be evaluated w/ upper GI endoscopy - Pts w/ NSAID induced dyspepsia should receive a PPI - Pts from high-prevalence areas or w/ possible exposure to H. pylori may have testing for active infection and treatment as an initial step

Question 444

Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using TTE. Midsystolic soft murmurs (grade I-II/VI) in an asymptomatic young patient are usually benign and need no further work-up.

Answer 444

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Question 445

Anaphylactic reactions to transfused blood products are characterized by rapid onset (within seconds to minutes) of respiratory distress and hypotension, which quickly progress to respiratory failure and shock. Individuals w/ IgA deficiency are at risk due to the presence of anti-IgA antibodies. Acute management includes epinephrine and circulatory and respiratory support.

Answer 445

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Question 446

Drug-induced type 1 hypersensitivity reactions are immediate onset and mediated by IgE and mast cells/basophils. Mild manifestations of a drug allergy (ie urticaria and pruritis w/o systemic symptoms) are usually treated w/ antihistamines and discontinuation of the offending drug.

Answer 446

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Question 447

Elevated serum alk phos levels are indicative of cholestasis. These pts (w/ or w/o hyperbilirubinemia) should be evaluated w/ RUQ ultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction.

Answer 447

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Question 448

prophylaxis against Mycobacterium avium complex in HIV-positive patients w/ CD4+ T cell counts less than 50?

Answer 448

Azithromycin

Question 449

Fluconazole

Answer 449

-used for prophylaxis against Cryptococcus neoformans and Coccidioides immitis in HIV positive pts who have had these diseases in the past. It is also used in pts w/ frequent Candida infections

Question 450

TMP/SMX is used in HIV positive pts to prevent opportunistic infections caused by Pneumocystis jiroveci and T. gondii.

Answer 450

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Question 451

Hereditary spherocytosis

Answer 451

- usually autosomal dominant disorder that presents w/ the classic triad of hemolytic anemia, jaundice, and splenomegaly - lab studies show spherocytes on peripheral blood smear, anemia w/ reticulocytosis, low MCV, and an increased MCHC - splenectomy can improve anemia and reduce gallstone risk in most pts

Question 452

Gastric contents are rich in hydrogen, chloride, and potassium. Therefore vomiting causes hypochloremic metabolic alkalosis and hypokalemia. Bicarb levels rise as a result of hydrogen loss and activation of the RAAS. The administration of isotonic sodium chloride and potassium is used to reverse these electorlyte abnormalities.

Answer 452

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Question 453

Hypocalcemia, hyperphosphatemia, and increased PTH levels are characteristic biochemical abnormalities of secondary hyperparathyroidism in chronic renal failure.

Answer 453

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Question 454

In atrial fibrillation w/ rapid ventricular response, rate control should be attempted w/ beta blockers or calcium channel blockers. Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable pts w/ rapid atrial fibrillation.

Answer 454

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Question 455

indicators of a severe asthma attack

Answer 455

- normal or increased PCO2 values - speech difficulties - diaphoresis - altered sensorium - cyanosis - "silent" lungs

Question 456

Pts w/ new-onset atrial fibrillation should have TSH and free T4 levels measured to screen for occult hyperthyroidism as an underlying cause.

Answer 456

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Question 457

Know that low leukocyte alkaline phosphatase w/ leukocytosis is classic for chronic myelogenous leukemia (CML).

Answer 457

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Question 458

Tartrate resistant acid phosphatase is present in hairy cell leukemia!

Answer 458

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Question 459

Hyperkalemia is a medical emergency! Therapy involves what 3 steps?

Answer 459

-membrane stabilization w/ calcium -shifting potassium intracellularly -decreasing total body potassium content Insulin/glucose administration is the quickest way to decrease the serum potassium concentration

Question 460

Initial hematuria suggests urethral damage. Terminal hematuria indicates bladder or prostatic damage, and total hematuria reflects damage in the kidney or ureters. Clots are not usually seen w/ renal causes of hematuria.

Answer 460

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Question 461

Pts w/ Hashimoto's thyroiditis are at increased risk for developing what?

Answer 461

Thyroid lymphoma

Question 462

Fat malabsorption predisposes to the formation of calcium oxalate stones because it leads to increased absorption of oxalic acid because the unabsorbed fatty acids chelate calcium, making oxalic acid free for absorption.

Answer 462

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Question 463

75%-90% of kidney stones are what type?

Answer 463

calcium oxalate

Question 464

Calcium phosphate stones are common in what conditions?

Answer 464

- primary hyperparathyroidism | - renal tubular acidosis

Question 465

Struvite stones

Answer 465

formed when urine is ALKALINE because of infection w/ urease producing bacteria (ie Proteus)

Question 466

Cysteine stones

Answer 466

formed when there is increased excretion of cysteine, which is an inborn error of metabolism

Question 467

Uric acid stones

Answer 467

formed when the urine is ACIDIC or when there is increased cell turnover, thereby resulting in hyperuricemia and hyperuricosuria. Dehydration is another important risk factor.

Question 468

Colicky flank pain w/ radiation to the groin indicates renal colic. 75-90% of the kidney stones are composed of calcium oxalate. Small bowel disease, surgical resection or chronic diarrhea can lead to malabsorption of fatty acids and bile salts; this in turn predisposes to the formation of calcium oxalate stones.

Answer 468

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Question 469

what is the single most important prognostic consideration in the treatment of pts w/ breast cancer?

Answer 469

Tumor burden as based on the TNM staging system

Question 470

A supervised graded exercise program is the most useful intervention to improve functional capacity and reduce symptomatic claudication in pts w/ peripheral artery disease. Antiplatelet agents (ie aspirin, clopidogrel) reduce overall cardiovascular mortality. Lipid-lowering therapy w/ statins should also be given to all pts w/ clinically significant atherosclerotic cardiovascular disease.

Answer 470

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Question 471

Fatty liver (steatosis), alcoholic hepatitis and early fibrosis of the liver can be reversible w/ the cessation of alcohol intake. True cirrhosis (w/ regenerative nodules) is irreversible, regardless of alcohol abstinence.

Answer 471

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Question 472

Analgesic nephropathy

Answer 472

- most common form of drug-induced chronic renal failure - papillary necrosis and chronic tubulointerstitial nephritis are the most common pathologies seen - Pts w/ chronic analgesic abuse are also more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer

Question 473

Unilateral varicoceles that fail to empty when a patient is recumbant raise suspicion for an underlying mass pathology, such as renal cell carcinoma (RCC), that obstructs venous flow. CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC.

Answer 473

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Question 474

Pyridoxine supplementation should be given to patients taking isoniazid therapy

Answer 474

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Question 475

Hemolytic anemia in a patient w/ a malignant lymphoproliferative disorder is likely to be of the warm autoimmune type, caused by anti-red blood cell IgG antibodies. If prednisone therapy is ineffective, splenectomy is usually indicated.

Answer 475

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Question 476

Development of AV block in a patient w/ infective endocarditis should raise suspicion for what?

Answer 476

- Perivalvular abscess extending into the adjacent cardiac conduction tissues - aortic valve endocarditis and IV drug abuse are associated w/ an increased risk of periannular extension of endocarditis

Question 477

The best initial screening test for pts w/ suspected adrenal insufficiency are early-morning cortisol, ACTH, and cosyntropin (analogue of ACTH) stimulation. An increase in serum cortisol levels >20, 30-60 minutes after the administration of 250 ug cosyntropin virtually rules out primary adrenocortical insufficiency (Addison's disease)

Answer 477

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Question 478

The development of clubbing and sudden-onset joint arthropathy in a chronic smoker is suggestive of what?

Answer 478

- Hypertrophic osteoarthropathy - this condition is often associated w/ lung cancer, and therefore a chest x-ray is indicated to rule out malignancy and/or other lung pathology

Question 479

Gonadotropin-independent (peripheral) precocious puberty

Answer 479

- LH levels are low at baseline and do NOT increase after stimulation w/ a GNRH agonist (the pump has to be primed first to put out gonadotropins right away in children) - advanced bone age, coarse axillary and pubic hair, and severe cystic acne are seen in late-onset (nonclassic) congenital adrenal hyperplasia caused by 21-hydroxylase deficiency

Question 480

Idiopathic precocious puberty

Answer 480

- characterized by premature activation of the hypothalamic-pituitary-gonadal axis - accounts for 80% of gonadotropin-dependent precocious puberty and occurs almost exclusively in girls - basal levels of LH are usually elevated and will increase w/ GnRH stimulation

Question 481

Anemia of prematurity

Answer 481

- most common cause of anemia in preterm infants - due to diminished EPO levels, shortened RBC life span, and blood loss from phlebotomy - lab studies show decreased Hgb and Hct and a relatively low reticulocyte count

Question 482

Acute otitis media

Answer 482

- common cause of otalgia and is characterized by the presence of middle ear effusion and signs of eardrum inflammation - fluid in the middle ear space limits eardrum mobility on pneumatic insufflation - bulging is the most specific sign of eardrum inflammation

Question 483

Cholesteatoma

Answer 483

- abnormal growth of squamous epithelium in the middle ear | - large growths can damage the ossicles, resulting in conductive hearing loss

Question 484

chronic suppurative otitis media

Answer 484

- common pediatric problem | - hearing loss, tympanic membrane perforation, otorrhea > 6 wks

Question 485

Acute liver failure (fulminant hepatitis)

Answer 485

- defined as acute onset of severe liver injury w/ encephalopathy and impaired synthetic function (INR > 1.5) in a pt w/o cirrhosis or underlying liver disease - most commonly due to drugs (acetaminophen) and viral hepatitis (hep A and B) - pts w/ rapidly rpogressing liver failure can have DECREASING transaminases (less functional liver tissue) w/ WORSENING PT/INR (most important prognostic factor) and bilirubin

Question 486

chronic supraphysiologic doses of glucocorticoids cause central adrenal insufficiency (AI). Lab studies typically show low ACTH and cortisol levels and a relatively normal aldosterone level. In contrast, pts w/ primary AI have elevated ACTH, low aldosterone, and significant electrolyte effects (hyponatremia, hyperkalemia).

Answer 486

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Question 487

ash-leaf spots

Answer 487

-tuberous sclerosis

Question 488

port-wine stain

Answer 488

Sturge-Weber syndrome

Question 489

Mongolian spots

Answer 489

-commonly found in African, Asian, Hispanic, and Native American infants and usually fade spontaneously during childhood