steroids inhibit IL-1 production

methotrexate folic acid antagonist, inhibits DHF reductase, S-phase specific, inhibits
DNA synthesis
cyclosporine calcineurin inhibitor; inhibits IL-2 production; nephrotoxic, gum
hypertrophy, hursutism
tacrolimus (FK506) calcineurin inhibitor; inhibits signaling thru T cell receptor
mycophenylate mofeil prevents T cell activation
azathioprine antineoplastic; cleaved to mercaptopurine; inhibits DNA/RNA
synthesis; BM suppression
antithymocyte globulin (OKT3) antibody against CD3 on T cells; causes
pulmonary edema
basiliximab, daclizumab monoclonal antibody to IL-2 receptor
fetal heart tones begin at 10-12 weeks
fetal quickening (movement) occurs at 17-18 weeks
4 measurements that can be taken from fetal US crown-rump length, biparietal
diameter, femur length, abdominal circumference
abdominal circumference most reliable parameter for set. fetal weight in cases of
fetal growth restriction
Gestational sac is visible by what gestational age? five weeks
b-hCG peaks when? 10 weeks GA
average increase in weight during pregnancy 25 lb (11 kg)
additional kcal needed during pregnancy 100-300 kcal/day
when should supplemental iron be started in a pregnant woman? first prenatal
visit
What 2 supplement to pregnant vegans need? Vit D, Vit B12
What cardiovascular parameters DECREASE during pregnancy? blood
pressure and peripheral vascular resistance
What happens to electrolytes during pregnancy? NOTHING! Remain unchanged.
What causes herpangina? coxsackievirus (an enterovirus)
How do you screen for Hep C on the first prenatal visit? What about Hep B? Hep C
- history. Hep B - HBsAg
When is gestational diabetes screened for in pregnancy? weeks 24-28
How are AFP results reported? multiples of the median (MoM)
Quad screen shows "pan-low". trisomy 18 (low AFP, low estriol, low b-hCG, low
inhibin A)
Quad screen shows low AFP, low estriol, high b-hCG, high inhibin A. Down
syndrome
Risk of fetal loss during chorionic villus sampling 1%
Third trimester test used to detect presence of phosphatidylglycerol
amniocentesis
tetratogen that can cause lack of cranial ossification ACEI
tetratogenic defects of streptomycin or kanamycin hearing loss; CN VIII
damage
2 tetratogens causing anotia or microtia thalidomide, Vit A
can cause neonatal nasal hypoplasia an stippled bone epiphyses warfarin
tetratogen assoc. w/ neonatal bowel atresia cocaine
Woman with hyperhomocysteinemia loses a 19 week pregnancy. What enzyme is
deficient? methylene tetrahydrofolate reductase
Amount of caffeine required to cause spontaneous abortion >500 mg/day
Deficiency of what hormone increases risk for spontaneous abortion? (estrogen,
progesterone, growth hormone, testosterone, or FSH) progesterone
Prophylactic med for toxo during pregnancy spiramycin
Cardiac defect assoc. w/ congenital rubella PDA
treatment for congenital CMV postpartum ganciclovir
Pregnant HIV+ women should receive what prenatal meds? AZT or nevirapine
When does an HIV+ women get a C-sec? viral load >1000
eye disease in late congenital syphilis interstitial keratitis
Tx for threatened AB pelvic rest for 24-48 hrs, then follow up US
How can misoprostol be administered? oral, vaginal, sublingual, buccal
2 meds used for first-trimester therapeutic abortions misoprostol, mifepristone
How does oxytocin work to induce or augment labor? binds receptors on
myometrium, increases Ca influx to stimulate contractions
Components of a Bishop score dilation, effacement, station, cervical position,
cervical consistency
Prolonged active stage of labor due to cephalopelvic disproportion
things that can decreases fetal heart rate variability hypoxia, opioids,
magnesium, sleep cycle
drug assoc. w/ a "pseudosinusoidal" variability pattern on fetal heart rate tracings
meperidine
complication of a supine nonstress test maternal hypotension
What is "15-15-2-20"? Normal "reactive" nonstress test: 2 FHR accelerations
15 bpm above baseline lasting 15 sec over a 20 min period
Next step if nonstress test is nonreactive? biophysical profile
How can you induce contractions in a contraction stress test? nipple stimulation or
oxytocin
Next step if contraction stress test is positive delivery
components of a biophysical profile fetal tone, fetal breathing, fetal
movement, amniotic fluid volume, nonstress test
what is a modified biophysical profile? NST + amniotic fluid index
reversal of umbilical artery diastolic flow indicates what? IUGR
nerve responsible for perineal pain during delivery pudendal (S2-S4)
lab values seen in hyperemesis gravidarum high b-hCG, high estradiol, large
ketonuria (get a UA)
First step in dx of hyperemesis gravidarum? rule out molar pregnancy w/
ultrasound +/- b-hCG
Tx for hyperemesis gravidarum Vit B6, antihistamines (doxylamine,
promethazine, dimenhydinate). If severe, metoclopramide, ondansetron,
prochlorperazine. If dehydrated, IVFs, NPO, parental nutrition, IV dimenhydrinate.
First step in management of gestational diabetes ADA diet, exercise, glucose
monitoring. Insulin only if all this fails
Management of pregestational diabetic during labor IV insulin drip and hourly
glucose measurements
antihypertensive meds in pregnancy methyldopa (#1), metoprolol, nifedipine,
hyralazine
Most likely cause of hemolytic anemia, elevated liver enzymes, and
thrombocytopenia in pregnancy (HELLP syndrome) Vasospasm leading to
hemorrhage and organ necrosis
Tx for preeclampsia if far from term? modified bed rest and expectant
management
How to administer magnesium for seizure prophylaxis in preeclampsia
continuous MgSO4- IV drip
Dx: Pregnant woman present w/ vaginal bleeding & abdominal pain. US shows a
retroperitoneal clot. placental abruption
Next step in management for mild placental abruption with premature fetus bed
rest
Management of placenta previa No vaginal exam. Tocolytics. Betamethasone for
lung maturity. C-sec delivery.
Next step in assessing a reproductive age woman w/ acute onset abdominal pain, +
pregnancy test and empty uterus on US serial hCG to confirm ectopic pregnancy
medical management for small, unruptured ectopic pregnancy methotrexate
What should be given to an IUGR fetus near due date? steroids (betamethasone)
48 hrs prior to delivery to accelerate fetal lung maturity
fetal anomalies assoc. w/ polyhydramnios duodenal atresia, TE fistula, anencephaly
What can be done for Rh isoimmunization hemolysis prior to delivery?
intrauterine blood transfusion
Woman has gestational trophoblastic disease. What dietary modifications could
have prevented this? Increase dietary folate and/or beta-carotene
chemo tx for malignant gestational trophoblastic tumors MTX or
dactinomycin
Uterus is evacuated of a "mass of grapes." Next step? weekly b-hCG
recoil of the perineum during second stage of labor indicates impending...
shoulder dystocia (this is called "turtle sign")
When is cervical ripening indicated? failure to progress in latent stage; failure
to have progressive cervical change
What medicine is used for cervical ripening? misoprostol (a prostaglandin)
Next step if pregnant woman presents w/ "gush of blood"? nitrazine paper test,
fern test, or indigo carmine dye test
what is contraindicated on pts w/ PROM? digital vaginal exam (increases risk for
infection)
What effect does ABx have during tx of PROM, other than preventing infection?
they prolong the latency period
ABx given in cases of rupture of membrane ampicillin and gentamicin
What is tachysystole? > 5 uterine contractions in 10 min
ABx given for GBS ppx if preterm delivery is likely penicillin or ampicillin
murmur likely heard in a premie continuous machine-like murmur of PDA
fetal head position at risk for failure to progress occiput posterior
#1 risk factor for fetal malpresentation prematurity
Most common form of breech presentation? frank breech: thighs flexed, knees
extended
What should be given to decrease gastric acidity during c-sec? sodium citrate
fistula assoc. w/ episiotomy rectovaginal
First step in managing uterine atony bimanual uterine massage
Difference btw placenta accreta/increta/percreta accreta: partial invasion of
myometrium
increta: further/full invasion
percreta: penetrates uterine serosa
Next step once Sheehan syndrome is diagnosed by MRI cortisol replacement
When will lactose intolerance be evident? Within 1 week postpartum. (Mature milk
does not have lactose until 1 week)
ABx for mastitis dicloxacillin, cephalexin
thelarche begins when? 8-11 years old
menarche begins when? 10-16 years old
What is the lipid profile during menopause? high cholesterol, low HDL
What malignancy/malignancies are postmenopausal pts on HRT at risk for? breast
cancer
What malignancy/malignancies are postmenopausal pts on HRT protected from?
endometrial cancer, ovarian cancer
Name IUDs effective for 3, 5, and 10 years, respectively. Implanon (progestin-only
IUD) - 3 years
Mirena (IUD w/ progestin) - 5 years
ParaGard (copper IUD) - 10 years
When must the "morning after pill" be taken to be effective? within 120 hours (5
days) of unprotected sex
16 yo w/ amenorrhea has normal smell, negative pregnancy test, normal 46 XX
karyotype and normal breasts. Next step? bone age x-ray (PA left hand)
How do you treat premature ovarian failure? combined estrogen/progestin HRT
Excess levels of what mediator are present in primary dysmenorrhea? PGF-2a
MCC of infertility in menstruating women >30 years old endometriosis
First line treatment for endometriosis. First line for adenomyosis. Combined
OCPs (endometriosis). NSAIDs (adenomyosis).
Major complication of adenomyosis can progress into endometrial carcinoma
(rare)
Postmenopausal woman w/ abnormal uterine bleeding has a 5 mm endometrium on
US. Next step? endometrial biopsy
Tx for CAH? Glucocorticoids
What are the 17-ketosteroids? DHEA and androstenedione
First enzyme in glucocorticoid synthetic pathway cholesterol desmolase
CAH when 11-DOC is elevated 11b-hydroxylase deficiency
Woman with skin rash and US that shows subcapsular follicles in a "pearl necklace"
pattern PCOS (rash is acanthosis nigricans)
first line tx for ovulatory stimulation in PCOS clomiphene +/- metformin
PCOS incr risk of what cancer(s)? breast, endometrial (not ovarian)
Tx for asymptomatic Bartholin gland cyst no treatment +/- warm soaks
Tx for trichomoniasis single-dose PO metronidazole or TINIDAZOLE for pt
and partner(s)
grayish-white vaginal discharge vs. yellow-green, frothy vaginal discharge
grayish-white = bacterial vaginosis
yellow-green, frothy = trichomoniasis
If not managed appropriately, TSS can lead to death by what mechanism? ARDS
(most common), or severe hypotension or hemorrhage 2 to DIC.
Dx: 23 yo F present w/ vomiting, watery diarrhea, T 103F, and and desquamating
rash. Blood cx negative. toxic shock syndrome
What should women w/ fibroids be told re: pregnancy and menopause?
Fibroids may grow during pregnancy and shrink during menopause, as they
are estrogen and progesterone sensitive.
Dx: 40 yo F present w/ urinary frequency, pelvic pressure and a "cobblestone
uterus" on exam. uterine leiomyoma (fibroids)
Medical management of BLEEDING assoc. w/ uterine fibroids
medroxyprogesterone acetate or danazol
poor prognostic factors for endometrial cancer p53 gene mutation, serous or clear
cell histology
When can cervical cancer screening stop women 70 yo w/ 3 normal Paps, or total
hysterectomy
T or F: Women who have had Gardasil no longer need to be screened for cervical
cancer. False
A 30 yo F has had 3 consecutively normal Paps. Next step? Pap once every 3
years
Next step if cervical cytology (Pap) shows ASCUS. HPV DNA testing
Next step if cervical cytology (Pap) shows ASCUS and HPV DNA test is negative? Is
positive? If negative: repeat Pap in 1 year
If positive: colposcopy
Only time a pregnant woman should get colposcopy Pap shows HSIL (high-
grade squamous intraepithelial lesion)
HPV subtypes assoc. w/ vulvar cancer 16, 18, 31
Which is a risk factor for vulvar cancer: lichen planus or lichen sclerosus? lichen
sclerosus
Diagnosis of vulvar cancer vulvar punch biopsy
female organ prolapse increases risk for what cancer? vaginal cancer
Other than colon cancer, Lynch II syndrome (or HNPCC) is assoc w/ what other
cancer(s)? ovarian, endometrial, breast
benign or malignant: 5 cm calcified cystic Right adnexal mass with unilocular
septations benign
increased CA-125 is assoc. w/ what benign condition? endometriosis
Tx for ovarian mass w/ LDH+ genetics surgery + postop chemo + RADIATION
(dysgerminoma)
what is "procidentia"? marked uterine prolapse
MCC of infectious vulvovaginitis in kids Group A strep
Dx: little girl has a "bunch of grapes" within the vagina sarcoma botryoides
(rhabdomyosarcoma)
Dx: 6 yo F w/ precocious puberty and dark skin spots that stop at the midline
McCune-Albright syndrome (precocious puberty, polyostotic fibrous
dysplasia [bone disorder], unilateral cafe-au-lait spots)
mechanism of fibrocystic breast change exaggerated stromal tissue response to
hormones & growth factors
What dietary modification can be suggested to help w/ fibrocystic change? reduce
caffeine intake (methylxanthine abstention)
phylloides tumor is a subtype of what? fibroadenoma (benign)
Tx for fibroadenoma & phylloides tumors excision
dietary risk factors for breast cancer high fat, low fiber
supraclavicular LAD indicates breast cancer stage ___ IV
comedocarcinoma is a subtype of what? DCIS (ductal carcinoma in situ)
tumor markers for *recurrent* breast cancer CEA, CA 15-3, CA 27-29
Breast cancer receptor status w/ poor prognosis Triple negative: ER-, PR-, EGFR-
(HER2/neu is an EGF receptor)
lumpectomy + axillary dissection + postop radiation has equal efficacy as what?
modified radical mastectomy (total mastectomy + axillary dissection)
MCC of infertility in menstruating women < 30 years old PID
nodularities on the broad ligament and a retroverted uterus suggest
endometriosis
"strawberry cervix" or cervical petechiae trichomonas
Tx for chlamydia doxycycline x 7 days OR azithromycin once. If pregnant,
erythromycin or azithromycin
T or F: Automatically give gonorrhea treatment to pts w/ chlamydial infection.
False. Give pts w/ gonorrhea infection treatment for suspected chlamydia.
Dx: normal looking 16 yo girl w/ breasts but no axillary or pubic hair and
amenorrhea androgen insensitivity
Tx for mastitis due to MRSA Bactrim (TMP-SMX) or clindamycin
30 yo F who uses an IUD for contraception develops PID. Most likely organism?
Actinomyces israelii
A 20 yo F on OCPs requires elective surgery. What should you tell her about her OCP
use? Stop 1 month before surgery, and do not restart until 1 month after surgery.
Guy w/ skin fifth metacarpal fracture gets hand infection. Boxer's fracture w/
human oral pathogens (Eikenella). Give ABx.
+ Thompson test squeezing gastrocnemius elicits no foot plantar flexion;
indicates Achilles rupture. (+ test may be a normal finding in elderly pts.)
Tx for carpal tunnel syndrome splint wrist + NSAIDs. Surgery for intolerable
symptoms.
subacromial bursa lies between acromion and supraspinatus muscle
trochanteric bursitis located at insersion of what muscle? gluteus medius
21 yo college student w/ painful, swollen elbow. No history of gout or trauma.
olecronon bursitis
most common site for lumbar disc herniation L5-S1 (L4-L5 is second most
common)
50 yo man w/ low back pain. X ray shows facet hypertrophy and degenerative
changes. Next step? (Spinal stenosis) NSAIDs and abdominal muscle strengthening
Dx: 65 yo M w/ knee pain and crepitus, X-ray shows subchondral bone cysts,
aspiration of joint fluid is straw-colored. osteoarthritis
Dx: During a Super Bowl party, a 40 yo M goes on a drinking binge and develops
severe acute foot pain. gout
anti-cyclic citrullinated peptide antibodies rheumatoid arthritis (anti-CCP
antibodies)
First line therapy for ACUTE gout attacks NSAIDs (e.g., indomethacin)...NOT
acetaminophen, which has no anti-inflammatory properties
Tx for gout: overproducers vs. undersecretors overproducers: allopurinol
undersecretors: probenecid
60 yo F w/ HTN on lasix gets acute foot pain gout (remember, POSTmenopausal
women!)
Tx of choice for acute gout in pts w/ renal disease steroids (oral prednisone)
+ Schober test decr spinal flexion seen in ankylosing spondylitis
What are two extra-articular manifestations of ankylosing spondylitis?
anterior uveitis (or iridocyclitis), heart block
20 yo M w/ skin rash, dactylitis and abnormal hand x-ray psoriatic arthritis
("pencil in cup" deformity)
Pts w/ dermatomyositis are at risk for what malignancies? lung & breast cancer
Which of the following is assoc. w/ polymyositis and dermatomyositis?
A. endocarditis
B. myocarditis
C. pericarditis B. myocarditis
antibody assoc. w/ polymyositis & dermatomyositis anti-Jo-1 antibodies
anti-smooth muscle antibody autoimmune hepatitis
anti-RNP antibody mixed connective tissue disease
anti-topoisomerase 1 antibody scleroderma
anticentromere antibody CREST syndrome
anti-Ro antibody neonatal lupus
c-ANCA Wegener's (granulomatosis w/ polyangiitis)
p-ANCA microscopic polyangiitis
type of anemia assoc. w/ rheumatoid arthritis anemia of chronic disease
Dx: 40 yo F w/ ulnar deviated hands, LUQ mass, and low WBC count Felty's
syndrome (RA, splenomegaly and neutropenia)
best initial disease-modifying antirheumatic drug (DMARD) for RA methotrexate
Dx: inflammatory myopathy affecting M>F, distal muscles, loss of deep tendon
reflexes and no autoantibodies inclusion body myositis
anti-Mi-2 antibodies polymyositis/dermatomyositis
anti-synthetase antibodies another name for anti-Jo-1 antibodies assoc. w/
polymyositis/dermatomyositis
anti-signal recognition antibodies cardiac conduction manifestations assoc. w/
polymyositis/dermatomyositis
features of CREST syndrome calcinosis, Raynaud's, esophageal dysmotility,
sclerodactyly, telangiectasias
drug used for cutaneous scleroderma penicillamine
Tx for Raynaud's CCBs (vasospasm)
Pt w/ calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly and
telangiectasias develops acute renal failure. What could have prevented this? ACEIs
(scleroderma renal crisis)
anti-leucine aminopeptidase antibody Sjogren's syndrome
lupus often affects which heart valve? mitral valve (Libman-Sacks endocarditis)
what tests should be ordered for neonates w/ lupus? EKG and echo (for
congenital heart block and transposition of great vessels, respectively)
involvement of which organ system(s) excludes drug-induced lupus? CNS and/or
renal (these are spared in drug-induced lupus)
temporal artery biopsy in giant cell arteritis will show what? thrombosis, necrosis
of media, presence of lymphocytes and/or plasma cells
<11 tender points in a 50 yo F w/ depression and anxiety myofascial pain
syndrome
cause of death in Duchenne muscular dystrophy cardiac fibrosis -> high-output
heart failure -> pulmonary congestion
What immunostain is used to diagnose Duchenne muscular dystrophy?
Western blot
endocrinopathy assoc. w/ slipped capital femoral epiphysis hypothyroidism.
Rule out w/ TSH
Tx for scoliosis based on degree of involvement <20 degrees: observation
20-49 degrees: brace
>50 degrees: surgery
Dx: boy w/ arthritis, daily high/spiking fevers and an evanescent, salmon-colored
rash Still's disease (acute febrile/systemic juvenile idiopathic arthritis)
Tx for juvenile idiopathic arthritis NSAIDs
Which organisms causing pneumonia can be diagnosed with a urine antigen test?
Legionella and Strep pneumo
Pneumonia diagnosed w/ serum cold agglutinin test Mycoplasma
Dx: Pt w/ fever, productive cough, and sputum Gm stain shows lancet-shaped Gm+
diplococci S. pneumoniae
Pt being treated for TB complains of new vision problems. Cause? side effect of
ethambutol is optic neuritis
Pt being treated for TB now has elevated liver enzymes. Cause? side effect of INH is
hepatitis
Who should be notified of new TB diagnosis ALL cases of TB (both latent &
active) must be reported to local and state health departments.
MCC of bacterial diarrhea? Tx? Campylobacter. Erythromycin
Choroidal tubercles on eye exam in a pt w/ a cough suggests what? miliary TB
Next step in TB pt treated w/ 2 months of RIPE. 4 months of INH + rifampin
What is an alternative to ethambutol in RIPE tx of TB? streptomycin
Tx for strep throat penicillin x 10 days
Dx: Pt w/ strep throat develops thrombophlebitis of the jugular vein Lemierre's
syndrome, due to oral anaerobe Fusobacterium
First-line tx for acute bacterial sinusitis amoxicillin/clavulanicate 500 mg PO TID
x 10 days
What are hemagglutinin and neuraminidase? glycoproteins assoc. w/ influenza
A
Antigenic drift is specific for which influenza virus(es)? only influenza A
What phenomenon allows individuals to be affected w/ influenza more than once?
antigenic drift
How old do you have to be to get a flu shot? 6 months old
When is LP contraindicated in meningitis? papilledema or focal neurologic deficits
Close contacts of pts w/ meningococcal meningitis should receive what for ppx?
rifampin
Tx for seizures due to meningitis benzos and phenytoin
What is the only live vaccine you can give an HIV+ patient? MMR
Dx: HIV pt w/ cough and sputum stain shows folded cysts containing comma-shaped
spores Pneumocystis jiroveci pneumonia
T of F: Mycobacterium avium complex (MAC) is only a disease of
immunocompromised individuals. False. 1 pulmonary MAC occurs in apparently
healthy non-smokers (Lady Windermere syndrome)
What is the most common serious medical complication of pregnancy?
pyelonephritis
First-line med for uncomplicated pyelonephritis PO fluoroquinolones
MCC of sepsis in IVDUs? Staph aureus
mechanism of Gm+ shock? Gm- shock? Gm+ is exotoxin. Gm- is endotoxin
(lipopolysaccharide)
MCC of catheter-related sepsis? Staph aureus or Staph epidermidis
Top 2 DDx for fever of unknown origin. If you're forced to choose 1, which is it?
infection (#1) and cancer (#2)
Tx for Lyme disease in children <8 yo and in pregnant pts? oral amoxicillin
disease transmitted by American dog tick Rocky Mountain Spotted Fever
RMSF is a disease of
A. large arteries
B. medium arteries
C. medium veins
D. large veins
E. capillaries capillaries
Tx for RMSF in pregnant women chloramphenicol
Other than Pseudomonas, what causes otitis externa? Enterobacteriaceae
mechanism of pulmonary anthrax hemorrhagic mediastinitis
Vascular or immunologic: Janeway lesions? Roth spots? Osler's nodes? Janeway
lesions - vascular
Roth spots - immunologic
Osler's nodes - immunologic
Drug of choice for anthrax? Second-line? Cipro first, then doxycycline
pneumonia-causing organism in COPD pts? Haemophilus influenzae
Most likely cause of pneumonia in a college student or soldier? Mycoplasma
(atypical)
What is the primary Tx for Pneumocystic pneumonia? What are 3 alternatives?
TMP-SMX. Alternatives: pentamidine, atovaquone, dapsone
late, rare complication of measles subacute sclerosing panencephalitis
osteochondritis of tibial tubercle Osgood-Schlatter
Pt is started on hydroxychloroquine for treatment of rheumatoid arthritis. Next
step? eye exam every 6 months (retinal toxicity)
When should Rh typing be done in pregnancy? first prenatal visit
Prenatal measurement that most accurately measures fetal age? biparietal
diameter
Name 3 conditions associate w/ postterm pregnancy (prolonged gestation)
anencephaly, oligohydramnios, placental sulfatase deficiency (x-linked
ichthyosis)
Dx: proteinuria, edema, RUQ pain and hypertension at 12 weeks gestations think
hydatidiform mole (gestational trophoblastic tumor) OR choriocarcinoma
most important risk factor for developing preeclampsia chronic kidney disease
(from SLE or type 1 DM)
What test can be used to calculate the dose of RhoGAM to be given? Kleinhauer-
Betke test (quantifies the amount of fetal blood in maternal circulation)
dyslexia or alexia can result from stroke in what arterial distribution? PCA
T or F: Pt must be 18 yo or older to get tPA for acute stroke. True
In the immediate postictal period, what hormone is likely to be elevated?
prolactin
low leukocyte alkaline phosphatase is assoc w/ what malignancy? CML
large, globular (water bottle shaped) heart on CXR pericardial effusion
treatment for nocardia TMP-SMX
Pt reports severe dizziness after turning in bed and reaching overhead. What
anatomical structure is involved? posterior semicircular canals
What is meclizine (and other antivertigo meds) contraindicated in BPPV? they
inhibit central compensation
labyrinthitis is mimicked by a stroke in what artery? AICA (lateral pontine
syndrome)
vestibular neuritis is mimicked by a stroke in what artery? PICA (lateral
medullary syndrome, Wallenberg syndrome)
How are labyrinthitis and vestibular neuritis different? Labyrinthitis includes
auditory symptoms (unilateral tinnitus, ear fullness, hearing loss). Vestibular
neuritis does not.
Dx: 25 yo pt has N/V, vertigo and unsteady gait. Bedside head impulse test shows
left-beating nystagmus. acute peripheral vestibulopathy (vestibular neuritis or
labyrinthitis), on the RIGHT b/c nystagmus beats opposite of lesion
Dx: 22 yo F presents w/ 24 hrs of vertigo, N/V, and photophobia. She denies
tinnitus, aural fullness or hearing loss. Her gait is normal. What other condition does
she most likely have? migraine headaches (this is a vestibular migraine)
Difference in muscle stimulation test in myesthenia gravis and Lambert-Eaton
MG: decremental response (worsens w/ repetitive stimulation. LE:
incremental response (improves)
Lambert-Eaton antibodies attack what? pre-synaptic Ca++ channels
Myesthenia gravis antibodies attack which type of receptors?
A) muscarinic
B) nicotinic
C) calcium
D) TSH
E) presynaptic nicotinic acetylcholine receptors
Drugs that can exacerbate myesthenia symptoms antibiotics (aminoglycosides,
tetracyclines), beta-blockers, anti-arrhythmics (lidocaine, procainamide, quinidine)
most common subtype of multiple sclerosis relapsing-remitting
What would you tell a pregnant pt w/ MS about what to expect regarding her
symptoms? improvement of symptoms during pregnancy
Pt treated for MS develops severe CNS deterioration. Medication responsible?
Natalizumab (Tysabri) - risk for JC virus-mediated progressive multifocal
leukoencephalopathy (PML)
What is the geographic assoc. w/ MS? Incidence is greater at higher latitudes
(more common with further distance from equator)
first line treatment for OCD SSRIs
first line treatment for anxiety SSRIs
first line treatment for post-traumatic stress disorder SSRIs
mechanism of flumazenil COMPETITIVE antagonist at GABA receptor (antidote to
benzo intoxication)
Lactate (as in lactated Ringer's) can cause what psychiatric disorder? panic attacks
Pt is has been treated for panic disorder with a bezno. Today, she is started on an
SSRI. Next step? Slowly taper benzo (Do Not stop "cold turkey")
1st and 2nd MCC of PTSD in men 1st - rape. 2nd - combat
What 2 neurotransmitters are deficient in Alzheimer's? NE and ACh
An ICU pt is disoriented to person, place, and time. Once the underlying etiology is
resolved, which will he regain orientation to first? Person, then place, then
time.
depression involves what cortex of the brain? left prefrontal cortex
Dx: A pt is has been treated for a mood disorder for the last 2 years. Today she
presents w/ poor appetite, sad mood, excessive guilt, weight gain and suicidal
ideations. Double depression (major depressive episode on top of dysthymia)
Is electroconvulsive therapy for depression safe in pregnancy? YES
A 30 yo F undergoes ECT for major depression. What is the most likely adverse
effect that she will experience? anterograde amnesia
A 60 yo M has depression 6 months after a stroke. Which artery is most likely
involved? Anterior cerebral artery
T or F: hallucinations and illusions are a normal part of normal bereavement True,
as long as pt recognizes them as hallucinations/illusions
40 yo F is treated w/ fluoxetine for MDD. If she starts an MAOI, when should she
stop taking fluoxetine? 5 weeks before starting MAOI (for other SSRIs, stop 2
weeks before)
A pregnant woman give birth to a baby who develops pulmonary hypertension. She
was being treated for major depression. Most likely drug? paroxetine
25 yo M treated for depression has BP of 130/110. Most likely cause? Venlafaxine -
causes diastolic hypertension
how does isocarboxazid treat depression? inhibits monoamine oxidase (MAOI)
ICU pt w/ h/o depression is given an MAOI. BP is now 210/100. Best therapeutic
step? Phentolamine (alpha blocker)
What is the prevalence of bipolar type I? 1%
What percentage of bipolar pts commit suicide? 10-15%
If you have to choose between a mood stabilizer and an antidepressant to treat
bipolar depression, which do you choose first? Why? Mood stabilizer to avoid
antidepressant-induced mania
Activity of what enzyme is decreased by lithium? adenylyl cyclase
How is lithium eliminated from the body? What chronic condition precludes its use?
renally excreted; avoid in pts w/ poor renal function
Pt present w/ excessive thirst and "urinating a lot." UA shows low urine osmolality.
Pt has h/o of bipolar disorder (treated). Dx? diabetes insipidus caused by
lithium, which acts as an ADH antagonist
Bipolar pt is started on a new medicine. 2 weeks later, her ammonium levels are
way high. Cause? Valproic acid
Dx: corpus callosum atrophy, decreased dendritic branching, chromosome 22,
frontal hypoactivity, limbic hyperactivity schizophrenia
Suicide rate among schizophrenics is 10%
hallucinations + "waxy flexibility" catatonic schizophrenia
EEG pattern in schizophrenia normal
antipsychotic causing retinal pigmentation thioridazine (th-EYE-oridazine)
What test should be done before starting quetiapine? slit lamp eye exam (risk of
cataracts)
Most common side effect of atypical antipsychotics (risperidone, quetiapine,
aripiprazole, etc) weight gain (T2DM is #2)
Difference between pemozide and pemoline pemozide - dopamine receptor
antagonist used for Tourette's. pemoline - psychostimulant used for ADHD
What pediatric infection may lead to autism? congenital rubella
MCC of inherited mental retardation Fragile X syndrome
MCC of congenital mental retardation Down syndrome
T or F: weight gain is not a side effect of combined oral contraceptive pills true
T or F: bilateral renal agenesis is incompatible with life true
First line treatment for cancer-causing anorexia progestins
What secondary malignancy does Tamoxifen predispose to? endometrial cancer
T or F: Reason UTIs are more common in females is closer proximity of urethra to
anus. False - It's b/c the urethra is shorter.
Withdrawal from what two substances can lead to nightmares and increased
appetite? amphetamines and cocaine
A pt in the ED is belligerent, threatening and has nystagmus. His urine toxicology
screen is negative. He's given haldol and placed in isolation. He appears to calm
down. 3 hours later, he becomes acutely violent. By what mechanisms did this
occur? PCP - recurrence due to reabsorption in GI tract
What street drugs have no withdrawal syndrome? LSD and marijuana (So
remember that the "munchies" occur during marijuana use, not withdrawal.)
T or F: caffeine withdrawal can lead to weight gain true
Pt in the ED says he just stopped "using" because he is engaged and no longer wants
to be a druggy. His pupils are dilated, he has piloerection, rhinorrhea and excessive
yawning. He is at risk for what?
A. withdrawal seizure
B. sudden cardiac death
C. vivid flashbacks
D. weight gain
E. no life threatening event Opioid withdrawal is not life-threatening and does not
lead to seizures, weight gain, cardiac problems or flashbacks.
A 17 yo F gymnist w/ BMI 16 is admitted for electrolyte abnormalities. What cardiac
condition is she most likely to develop?
A. aortic stenosis
B. mitral stenosis
C. mitral valve prolapse
D. hypertrophic cardiomyopathy
E. aortic insufficiency mitral valve prolapse is a common complication of
anorexia nervosa
Dx: A man is arrested for rubbing his genitals on an old lady on the subway. He tells
police he enjoys doing this all the time. Frotteurism
Dx: A 40 yo F presents w/ strap-like red marks on her wrists, ankles and neck. She
says she enjoys being bound before sex with her lover. masochism
Sleep disorder w/ decreased REM sleep latency narcolepsy (reach REM sleep
faster)
Tx for cataplexy assoc. w/ narcolepsy SSRI
Tx for obstructive vs. central sleep apnea OSA: CPAP, weight loss. CSA: BiPAP
(mechanical ventilation)
Pt has a new job working the night shift (8PM-6AM) at a convenient store. He says
he cannot fall asleep when he gets home and wants to try melatonin. What should
you tell him about melatonin?
A. Take it when you get to work.
B. Take it when you get home from work.
C. Take it 5 1/2 hours before going to sleep.
D. An SSRI would be a better choice.
E. Take diphenhydramine 5 hours before going to sleep. Take melatonin 4-6 hours
before sleep in circadian rhythm sleep disorders
Number of specific complaints to diagnose somatization disorder 4 pain, 2 GI, 1
sexual, 1 neurologic
30 yo F present w/ 10lb weight gain. She started a new medicine for depression. She
denies sexual dysfunction, N/V, tremor or insomnia. Most likely med? mirtazapine
increased P wave amplitude P pulmonale (right atrial enlargement)
increased P wave width, or notched P waves P mitrale (left atrial enlargement)
2 pulmonary conditions where pulsus paradoxus is seen asthma and COPD
Tx for A-fib ABCD: Anticoagulant (warfarin), Beta blocker, Cardioversion/CCB,
Digoxin
MCC of 2nd degree AV block Mobitz II fibrosis of conduction system
If left untreated, what are pts w/ Mobitz II at risk for developing? 3rd degree
AV block
cannon A waves 3rd degree AV block
Most common indication for pacemaker placement sick sinus syndrome
(tachycardia-bradycardia syndrome)
What are the CHADS2 criteria? What is it used for? Risk for stroke in pts w/ A-
fib.
C - CHF (1)
H - HTN (1)
A - Age 75 (1)
D - Diabetes mellitus (1)
S2 - prior Stroke, TIA, or Thromboembolism (2)
When do you anticoagulate a pt w/ A-fib? When do you cardiovert? Anticoagulate
if CHADS2 score of 2 or more, or for A-fib >48hrs. Cardiovert for new A-fib (<48hrs),
no left atrial clot, or after 3-6 weeks of warfarin w/ INR 2-3.
T or F: atrial rate is nearly twice the ventricular rate in atrial flutter true (atrial
rate 240-320, ventricular rate ~ 150)
What lifestyle modifications can reduce risk of A-fib? decreased alcohol
consumption
What is an example of atrioventricular reciprocating tachycardia? WPW
(ectopic connection btw atrium and ventricle)
Dx: 60 yo M c/o SOB and lightheadedness. EKG shows retrograde P waves and
tachycardia. atrioventricular reciprocating tachycardia
Tx of choice for symptomatic PVCs beta-blockers
3 broad causes of PVCs hypoxia, electrolyte abnormalities, hyperthyroidism
Drug of choice for wide-complex V-tach amiodarone
A pediatric pt has congenital deafness and an abnormal EKG. Most likely arrhythmia
to develop? Torsades de pointes (assoc. w/ congenital deafness)
Treatment for acute pulmonary congestion in CHF LMNOP: Lasix, Morphine,
Nitrates, O2, Position (upright)
Pt has CHF and is "maxed out" on all available meds. His EF is now <35%. What is a
reasonable next step? implantable biventricular cardiac defibrillator (ICD)
What is torsemide? Loop diuretic (same suffix as furosemide)
T or F: spironolactone, amiloride, and triamterene are all aldosterone receptor
antagonists F - only spironolactone. Amiloride and triamterene are K+ sparing
ENaCs (sodium channel blockers)
Pt is on diuretics and has hemolysis with bite cells. He has an abnormally low G6PD
level. Most causative agent? acetazolamide (carbonic anhydrase inhibitor) - sulfa
allergy
What complication of mannitol makes it contraindicated in CHF? pulmonary
edema
HIV pt present w/ SOB and nocturnal cough. He is compliant w/ all meds. CD4 count
is 150. S3 gallop on exam. Echo shows dilated ventricles. Most causative agent?
AZT can cause dilated cardiomyopathy
Pt w/ acromegaly is at risk for developing what heart condition? dilated
cardiomyopathy (systolic HF)
What "heart meds" should be avoided during CHF? CCBs
Hypertrophic cardiomyopathy is assoc w/ which of the following conditions?
A. fragile X syndrome
B. trisomy 21
C. trisomy 18
D. Friedreich's ataxia
E. Marfan syndrome Friedreich's ataxia
Pts w/ hypertrophic cardiomyopathy may have a defect in which protein?
A. frataxin
B. collagen
C. elastin
D. ankyrin
E. hyaluronidase frataxin
What chromosome is Friedreich's ataxia assoc with? 9
A 19 yo football player collapses during practice. ECG shows LVH. Echo shows a
dynamic outflow obstruction. What med would you choose to start first? beta
blocker
Young pt comes in for a sports physical. Workup reveals hypertrophic
cardiomyopathy. FHX is positive for early death of an uncle. Advice to pt:
A. You are well enough to compete in sports.
B. Follow up in 6 months.
C. You may compete in non-contact events.
D. You should avoid intense athletic competition and training. Avoid intense
athletic competition and training.
Restrictive cardiomyopathy is best described as
A. autoimmune
B. neoplastic
C. infiltrative
D. inflammatory
E. obliterative infiltrative (amyloidosis, sarcoidosis, hemochromatosis)
Pt w/ hereditary iron overload is diagnosed w/ restrictive heart disease. Most likely
finding would be
A. bibasilar crackles
B. dullness to chest percussion
C. neck vein distension
D. history of nocturnal cough
E. left atrial enlargement neck vein distension. Right sided HF signs/symptoms
are more predominant in restrictive cardiomyopathy
Pts w/ what conditions are considered to have "coronary artery disease risk
equivalents"? DM, symptomatic carotid artery disease, PAD, AAA
Describe the following features of Printzmetal's (variant) angina: ST changes,
cardiac enzyme levels, mechanism of symptoms ST-segment elevations, normal
cardiac enzyme levels, coronary vasospasm
Which of following carry a mortality benefit in treating angina?
A. beta blockers and aspirin
B. ACEIs and ARBs
C. CCBs
D. supplemental oxygen
E. heparin beta blockers and aspirin
Cardiac enzyme levels in unstable angina normal
How do abciximab, eptifibatide, and tirofiban work to treat angina? inhibit
glycoprotein IIb/IIIa
A 55 yo M has a new MI. What is the best predictor of survival? left ventricular
ejection fraction
Most sensitive & specific cardiac enzyme:
A. CK-MB
B. troponin I
C. troponin T
D. myosin light chain
E. LDH troponin I
Man presents w/ chest pain radiating to his neck and L arm. EKG shows ST
depression in leads V1-V2. Next step? posterior EKG (leads V7-V9) to asses for
posterior wall/transmural MI (will see ST elevations in V7-V9)
Most common complication leading to death following acute MI is
A. fatal arrhythmia
B. ventricular free wall rupture
C. interventricular septal rupture
D. atheroembolic stroke
E. ventricular septal defect
F. papillary muscle rupture
G. reinfarction fatal arrhythmia
Dx: Pt presents for follow up 2 months from MI. T 101, chest discomfort. CXR shows
pleural effusions. EKG shows diffuse ST elevations. WBC 12,000, ESR is 30. What is
the Tx? Dressler's syndrome (autoimmune). Tx is aspirin.
Lipid profile diagnostic of dyslipidemia Total cholesterol >200
LDL > 130
HDL < 40
Triglycerides > 150
When should fasting lipid profiles occur? Starting at age 35 if no CAD risk factors.
Start at age 20 if CAD risk factors. Then repeat every 5 years.
Pt is started on a new cholesterol medicine. She presents to the ED the next day with
facial swelling, wheezing, and decreased O2 sats. Most likely causative agent?
ezetimibe (cholesterol absorption inhibitor) can cause angioedema
Single most effective lifestyle modification for hypertension weight loss
Single most effective lifestyle modification for hypertension in a non-obese patient
DASH diet
Pt has an aldosterone-secreting adrenal adenoma. Describe pH, K+ and renin levels.
metabolic alkalosis (incr pH), hypokalemia, low renin
What feature of labetalol makes it a good choice for hypertensive emergencies?
it's an alpha- and beta-blocker
ECG finding of pericarditis other than diffuse ST segment elevation PR
depression
A 50 yo M recently had an MI. He develops acute pericarditis on hospital day 3 and
is started on daily corticosteroids. He is at risk for what? ventricular free wall
rupture due to corticosteroids
Which of the the following would you expect to be low in a pt on a beta blocker?
A. aldosterone
B. renin
C. androstenedione
D. angiotensin converting enzyme
E. cortisol beta blockers can decrease renin release
A man w/ HTN and DM is taking lisinopril and losartan. His WBC count today is
4500. Could this be an effect of the medicine? Yes - ACEIs and ARBs can cause
leukopenia
What determines the severity of cardiac tamponade? the RATE of fluid formation
Dx: Pt presents w/ dyspnea and tachycardia. ECG shows electrical alternans
pericardial tamponade
MCC of valvular heart disease in the US mechanical degeneration
Indications for valve replacement in aortic stenosis "ACS" - angina, CHF,
syncope
Dx: physical exam reveals a paradoxically split S2 sound aortic stenosis (P2 then A2,
delayed emptying of left ventricle)
What is a Duroziez's bruit (or Duroziez's sign)? femoral bruit heard in aortic
regurgitation
A 65 yo M w/ a 20 pack-year smoking history but quick 20 years ago. He has HTN
and is here for a routine appointment. What screening, if any, should he receive?
A one-time abdominal ultrasound for AAA is recommended for all men ages
65-75 who have ever smoked.
murmur likely to be heard in a proximal aortic dissection aortic regurgitation
(early diastolic murmur)
Pt presents w/ "blue toes" after undergoing a carotid endarterectomy. Mechanism?
cholesterol atheroembolism ("blue toe syndrome")
Most likely reason that a pt's ABI could read 1.4 for example (normal is 0.9)
calcification of arteries
Most likely diagnosis if child present w/ lower extremity lymphedema Milroy's
disease (hereditary lymphedema of childhood)
Best initial management for lymphedema?
A. prophylactic antibiotics
B. diuretics
C. exercise and massage therapy
D. surgical decompression exercise and massage therapy and pressure garments
Pt presents to ED w/ syncopal episode. Further workup reveal a cardiac origin.
What is this pt's risk of sudden cardiac death in the next year?
A. less than 5%
B. greater than 5% but less than 20%
C. 40%
D. 75%
E. >90% up to 40%
T or F: Unstable angina is caused by increased O2 demand of myocardium. False.
O2 demand is unchanged in unstable angina, as opposed to stable angina where O2
demand is increased. Unstable angina is caused by reduced resting coronary BF.
Drug of choice for anticoagulation following and NSTEMI. enoxaparin
What can be given during coronary angiography to induce Prinzmetal's angina?
IV ergonovine
Pt has chest pain and Q waves on EKG. This finding is specific for
A. subendocardial injury
B. transmural injury
C. right heart injury
D. necrosis
E. panic-induced chest pain necrosis (ST depression = subendocardial, ST elevation
= transmural)
First EKG feature seen in MI peaked T waves
Drug of choice for post-MI pericarditis aspirin
As an alternative to ARBs in pts w/ CHF who are intolerable to ACEIs, what else can
be given? hydralazine/isosorbide dinitrate combination
Which post-MI dysrhythmia carries the worst prognosis?
A. atrial fibrillation
B. atrial flutter
C. ventricular tachycardia
D. supraventricular tachycardia
E. sinus bradycardia V-tach
Next step for V-fib?
A. synchronized direct current cardioversion
B. synchronized indirect current cardioversion
C. unsynchronized direct current cardioversion
D. unsynchronized indirect current cardioversion
E. adenosine defibrillation = unsynchronized direct current cardioversion
Good antiarrhythmic drug for WPW procainamide (does not affect AV node)
how does atropine work to treat bradycardia? blocks vagal stimulation to SA
node
Most likely location of delay in first degree AV block is
A. within the atrial myocardium
B. in the SA node
C. in the AV node
D. in the bundle of His
E. along either bundle branch in the AV node
Vitamin and mineral deficiency assoc. w/ dilated cardiomyopathy thiamine
(wet beriberi), selenium
Dx: on physical exam, a bisferious pulse is seen in the carotid arteries pulsus
bisferiens can be seen in HOCM
What causes elevated and equal diastolic pressures in all 4 heart chambers?
pericarditis and/or tamponade
A pt w/ mitral stenosis present w/ hemoptysis. How can mitral stenosis cause
hemoptysis? elevated LA pressure can rupture anastomoses of small bronchial
veins
Dx: 50 yo M w/ SOB and angina has a bobbing uvula on physical exam. aortic
regurgitation/insufficiency (this is Mller's sign)
Dx: Pt has a Cullen sign, severe back pain, and BP 190/100. AAA about to
rupture (can cause Cullen or Grey Turner sign)
Lysosomal storage disease w/ hypotonia, cherry red spot and hepatomegaly?
Deficiency? Neimann-Pick. Sphingomyelinase deficiency
Lysosomal storage disease w/ hypotonia, cherry red spot, but not hepatomegaly.
May have exaggerated startle response. Deficiency? Tay-Sachs. Hexosaminidase
deficiency
Erythema nodosum affects which of the following?
A. dermal-epidermal junction
B. subcutaneous fat
C. dermal lymphatics
D. epidermal granular layer
E. periosteal matrix subcutaneous fat (it is a panniculitis)
2 neoplasms that secrete ectopic ACTH small cell lung cancer, (bronchial)
carcinoid tumor, medullary thyroid carcinoma
A 50 yo F on long-term prednisone complains of weight gain and purple striations
on her abdomen. Which of the following is most likely absent from her history or
physical exam?
A. unwanted facial hair
B. depression
C. retrocervical fat pad
D. hypertension
E. easy bruisability Unwanted facial hair. Iatrogenic cushing's (syndrome) does not
have the androgen excess seen in cushing's disease (ACTH-dependent Cushing's).
A pt has episodic HTN, palpitations, tremor and diaphoresis. A CT and MRI are
negative for adrenal lesions. What other test could be done to make the diagnosis?
MIBG nuclear scan - able to locate extra-adrenal or metastatic
pheochromocytoma/paragangliomas. Octreotide scan is also good for
neuroendocrine tumors
Most common location for extra-adrenal pheo aortic bifercation (organ of
Zuckerkandl)
Pt w/ psych history present w/ dilute urine. After a water deprivation test, his urine
osm increases. Dx? psychogenic polydipsia. (note: in diabetes insipidus, urine osm
would remain dilute after water deprivation test.)
A 30 yo F presents for routine checkup. She is drinking her third cup of coffee this
morning, as is her usual. Today she appears jittery and diaphoretic. She recalls
having palpitations at work that usually resolve throughout the day, but she often
gets a headache at the end of the day. She does not smoke, drink alcohol or use
drugs. She denies family history of cancer. BP 135/85, P 100, R 16, T 98.6. Plasma
free metanephrines are normal. Urine vanillylmandelic acid is elevated. MRI of
abdomen and MIBG scan are negative. Most likely diagnosis? Coffee and tea can
falsely elevate VMA. She is most likely experiencing symptoms related to her coffee.
A pt has hypercalcemia, elevated calcitonin levels, long arms and fingers, and
mucosal neuromas. What chromosome is most likely implicated? MEN 2B
(here) and 2A are caused by RET proto-oncogene mutation. Located on
chromosome 10. (Think "MEN on TEN")
Confirmatory test for adrenal insufficiency 8AM plasma cortisol level (will be
low). Confirm w/ synthetic ACTH stimulation test (cortisol will fail to rise much).
Dx: A pt has weight loss, hypoglycemia and abdominal pain. Morning plasma cortisol
is low and does not correct w/ ACTH stimulation. She is an asthmatic and takes a
daily inhaled corticosteroid. She ran out of meds last week and has not had them
refilled. Her BP is 120/80. She should receive
A. aldosterone
B. hydrocortisone
C. 3% normal saline
D. spironolactone
E. aldosterone and hydrocortisone Adrenal insufficiency due to cessation of long-
term glucocorticoids should be treated with replacement of glucocorticoids ONLY.
Chronic use reduces ACTH, but mineralocorticoids are not ACTH-dependent, so they
will be unchanged.
CBC finding in adrenal insufficiency? eosinophilia
The presence of antibodies to which of the following confirms the diagnosis of
diabetes mellitus?
A. cyclic citrullinated peptide
B. parietal cells
C. transglutaminase
D. glutamic acid decarboxylase
E. human leukocyte antigen anti-GAD (glutamic acid decarboxylase) antibodies are
specific for DM. (anti-CCP = RA, anti-parietal cell = pernicious anemia, anti-
transglutaminase = celiac disease. HLA-DR3 and -DR4 are assoc. w/ DM, but not
assoc. w/ antibody production.)
Screening recommendations for diabetes in pts w/ NO RISK FACTORS:HbA1c at age
45, then every 3 years
Before giving insulin to a pt in DKA, what should be given first? potassium
What is a criteria for metabolic syndrome?
A. high LDL
B. low HDL
C. high random glucose
D. high fasting glucose
E. HbA1c Criteria for metabolic syndrome:
Abd. circumference: > 40in Men, >35in Women
HDL < 40 (M) OR < 50 (W)
Trig 150
BP 130/85 or need for HTN meds
FASTING glucose 100
Mechanism of glipizide, glyburide, glimepiride increased endogenous insulin
secretion (Think "SELFonylureas")
Acarbose and miglitol act on what enzyme to treat hyperclycemia? alpha-
glucosidase inhibitors (a GI brush-border enzyme), reduce intestinal absorption of
carbohydrates
Dx: A nurse has anti-insulin antibodies surreptitious insulin use
Whipple's triad of hypoglycemia 1. fasting hypoglycemia with symptoms
2. blood glu < 50 during symptoms
3. giving glucose improves symptoms
What leukemia presents w/ a chloroma? AML
Other causes of infectious esophagitis besides Candida HSV, CMV
Risk factors for SCC of esophagus smoking, alcohol (top 2); dietary deficiencies of
thiamine (B1), beta-carotene, zinc, selenium; hot foods/beverages; nitrosamines;
toxin-producing fungi
Why does esophageal cancer metastasize early? it lacks serosa
Tx for esophageal cancer chemoradiation and surgery
3 stimulator of HCl ACh, histamine, gastrin
What are GERD "alarm symptoms"? blood in stool, dysphagia/odynophagia,
weight loss
What will bronchoscopic aspirate show in GERD pts? lipid-laden macrophages
from phagocytosis of fat in gastric contents
Type A chronic gastritis is assoc. what what malignancies? gastric
adenocarcinoma and carcinoid tumors
Pt has a elevated urine 5-HIAA and pernicious anemia. He most likely has pathology
of which of the following?
A. upper esophagus
B. gastric fundus
C. gastric antrum
D. adrenal cortex
E. hypothalamus gastric fundus - site of chronic gastritis type A, assoc. w/
pernicious anemia and carcinoid tumors
Most common location for chronic gastritis antrum (type B) - where H. pylori
lives
Which indicates CURRENT H. pylori gastritis: serum IgG antibodies or H pylori stool
antigen? H pylori stool antigen (current infection), IgG antibodies = history of
exposure
Triple therapy for gastritis. What about pt allergies? amoxicillin +
clarithromycin + omeprazole (2 ABx + PPI). Metronidazole instead of amoxicillin if
penicillin-allergic.
Krukenberg tumor is gastric SCC or adeno? adeno
How do you treat MALT lymphoma? antibiotics (only cancer curable with
antibiotics) - give triple therapy (same as gastritis)
Blood types assoc. w/ PUD? type O assoc. w/ duOdenal ulcers; type A assoc. w/
gAastric ulcers
45 yo F presents w/ a 5 yr h/o recurrent PUD, unresponsive to meds. Today she has
dull, burning epigastric pain. What test show you order now? serum gastrin level
(look for MEN type 1 w/ gastrinoma/ZES)
Jejunal ulcers = ZE syndrome (pathognomonic)
Stain used to detect diarrhea bugs in HIV pts? acid-fast (Cryptosporidium and
Isospora)
drug assoc. w/ pyloric stenosis in babies erythromycin
Tx for traveler's diarrhea Cipro
Pt w/ entamoeba histolytica causing diarrhea is treated w/ steroids. What is he at
risk for? fatal perforation
Why are ABx and anti-diarrheal therapy contraindicated in E. coli O157-H7
infections? they increase risk of HUS
Infectious diarrhea preceded by a "prodrome"? Tx? Salmonella. Tx: oral
quinolone (cipro) or TMP-SMX
Dx: Young pt develops bloody diarrhea and febrile seizures. Shigella
Dx: Pt has just recovered from a 3 day h/o vomiting and diarrhea that resolved
without medication. He now has flatulence, diarrhea, low stool pH and an increased
stool osmotic gap. transient lactose intolerance following acute gastroenteritis
Amino acid deficiency in carcinoid syndrome Tryptophan
Mechanism that prevents most carcinoid tumors from creating carcinoid syndrome
first pass metabolism by liver
Length of symptoms req'd for dx of IBS? at least 3 months
Mechanism of leukocytosis in SBO bowel ischemia/necrosis
Most likely location of thrombosis causing mesenteric ischemia? Most common risk
factor? proximal SMA; atherosclerosis
"thumbprinting" on abdominal Xray represents what, and is found in what disease?
bowel wall edema; mesenteric ischemia
What labs are elevated in mesenteric ischemia? LDH, lactate, WBC, amylase, CK
Difference in Tx btw arterial vs. venous thrombosis causing mesenteric ischemia
arterial: anticoagulation + surgery (angioplasty or laparotomy). venous:
anticoagulation alone
Imaging study of choice for CHILDREN and PREGNANT pts suspected to have
appendicitis? ultrasound (not CT)
Tx for appendiceal abscess 1. broad spec ABx, 2. PERCUTANEOUS drainage, 3.
elective appy 6-8 weeks later
Tx for perforated diverticulitis Hartmann's bowel resection w/ temporary
colostomy
Which screening is indicated in a pt who is 2 years post-op from colon resection due
to colon cancer?
A. abdomonial ultrasound
B. CA-19-9
C. CXR
D. serum ferritin
E. anoscopy Metastatic screening after colon cancer resection includes CEA,
colonoscopy, LFTs, CXR and abdominal CT.
The majority of colorectal cancers begin as what premalignant lesion? adenomatous
polyps
A 48 yo M presents for routine follow up. He is asymptomatic. His dad was dx'd w/
colon cancer at age 38. What is your advice today?
A. colonoscopy in 2 years
B. colonoscopy if pt becomes symptomatic
C. colonoscopy today
D. DRE and stool guaiac today
E. prophylactic colectomy colonoscopy today
Recommended screening for pediatric pts w/ FHX of familial adenomatous
polyposis? HNPCC? FAP: genetic testing @ age 10, colonoscopy every 1-2 yrs
starting @ puberty. HNPCC: genetic testing @ age 21. If +, colonoscopy every 2 yrs
until age 40, then every year.
Skin rash assoc. w/ IBD pyoderma gangrenosum
Dx: 19 yo presents w/ bloody diarrhea, episcleritis and pseudopolyps on
colonscopy. ulcerative colitis. IBD can occur in teens! Episcleritis/uveitis and
pseudopolyps are characteristic of UC vs. Crohn's.
character of diarrhea in UC vs. Crohn's UC: bloody. Crohn's: watery
Pt presents w/ RUQ pain radiation to R scapula. He is 6 months post-op from
emergent small bowel resection after a GSW. Abdominal US shows gallstones. Most
likely mechanism? loss of enterohepatically circulated bile after resection
40 yo F was diagnosed w/ AML 8 weeks ago. Her weight at dx was 135. Today her
weight is 115. She is most at risk for GI disorder?
A. carcinoid syndrome
B. cholelithiasis
C. small bowel obstruction
D. malabsorptive diarrhea
E. ischemic colitis Rapid weight loss is a risk factor for gallstones
Cure for acalculous cholecystitis percutaneous drainage
Mechanism of gallstone ileus is
A. infectious
B. malabsorptive
C. hypersecretory
D. erosive
E. infiltrative erosive (cholecystoduodenal fistula)
Which is true about ERCP with regards to primary sclerosing cholangitis?
A. both diagnostic and therapeutic
B. only diagnostic
C. definitive treatment
D. neither sensitive nor specific
E. absolutely contraindicated Both diagnostic and therapeutic. Shows multiple
bile duct strictures and dilatations ("beading"). ERCP w/ dilation and stenting of
strictures is helpful, but only liver transplantation is definitive treatment.
A 22 yo M with IBD present w/ jaundice, fatigue and generalized itching. ERCP
shows multiple strictures and dilatations of the intra- and extrahepatic bile ducts.
He should be screened for what malignancy? 1 sclerosing cholangitis
cholangiocarcinoma
Dx: A middle aged women presents w/ jaundice, fatigue and generalized itching. She
reports easy bruisability, poor night vision, and shortened height since last year.
1 biliary cirrhosis (middle aged women, vs 1 sclerosing cholangitis, which
occurs in young men). Also assoc. w/ other autoimmune conditions and fat-soluble
vitamin deficiencies (A, D, E, K).
3 familial causes of hepatitis Wilson's disease, hemochromatosis, alpha1-
antitrypsin deficiency
Tx of Crigler-Najjar II phenobarbital
Mechanism of Dubin-Johnson and Rotor's syndromes defective excretion of bile
(both conjugated hyperbilirubinemia)
Difference btw Dubin-Johnson and Rotor's Dubin-Johnson has grossly black
liver (epinephrine metabolites in lysosomes)
When do you use lamivudine (3TC), adefovir, ribavirin and interferon for hepatitis?
HBV: IFN plus lamivudine (3TC) or adefovir
HCV: IFN plus ribavirin
Which is a poor prognostic factor in cirrhosis?
A. jaundice
B. spider nevi
C. prolonged PT
D. anemia
E. scleral icterus prolonged PT - synthesis of clotting factors is not significant
until liver disease is advanced
Pt presents w/ ascites and a serum-ascites albumin gradient <1.1. Most likely cause?
A. cirrhosis
B. portal hypertension
C. constrictive pericarditis
D. schistosomiasis
E. splenic vein thrombosis
F. cor pulmonale
G. Budd-Chiari syndrome
E. nephrotic syndrome Nephrotic syndrome, TB, or malignancy w/ peritoneal
carcinomatosis cause ascites w/ SAAG <1.1. Options A-G have a SAAG >1.1.
Management of SBP: acutely? prophylaxis? acute SBP: 3rd gen cephalosporine
(ceftriaxone). prophylaxis: fluoroquinolone (cipro)
Definitive Tx for hepatorenal syndrome? liver transplantation
Viral associons with HCC: US vs. developing countries US = HCV. Developing
countries = HBV
Nonsurgical pts w/ HCC can be treated w/
A. infliximab
B. gemcitabine
C. sorafenib
D. ursodiol
E. rituximab Sorafenib (a multikinase inhibitor). Infliximabe is for Crohn's.
Gemcitabine is for pancreatic cancer. Rituximab is for non-Hodgkin lypmhoma and
RA.
Gene assoc. w/ hemochromatosis:
A. HFE
B. ret
C. ras
D. bcr-abl
E. p53 HFE
Dx: Pt presents w/ bilateral joint pain in his hands. His serum iron:TIBC ratio is
>45%. hemochromatosis (this ratio = transferrin saturation)
During a diagnostic workup for an autosomal recessive disease, a pt is found to have
deposits in Decemet's membrane, which is located in the
A. scrotum
B. eye
C. articular cartilage
D. inner ear
E. hepatic lobules eye - Wilson's disease (hepatolenticular degeneration)
A pt is diagnosed w/ Wilson's disease. Which dietary supplement do you now
recommend?
A. iron
B. copper
C. zinc
D. niacin
E. vitamin E Zinc increases fecal copper excretion
How can you treat pruritus and jaundice in pts. w/ pancreatic cancer? ERCP w/
biliary stenting
Elevation of which of the following is a poor prognostic indicator in pancreatitis?
A. calcium
B. amylase
C. lipase
D. LDL
E. SGOT SGOT = AST. (The others are not part of Ranson's criteria.)
Dx: Old man w/ abdominal pain. Biopsy of colon shows inner circular muscle layer
hypertrophy with area of mucosal and lymphoid herniation. diverticulosis (inner
circular muscle layer is characteristically hypertrophied)
Dx: Peds pt w/ ASD, first degree heart block and absent radii on bilateral arm x-ray.
Holt-Oram syndrome (a "phenocopy" of thalidomide toxicity)
Type of ASD presenting in early childhood? Late childhood and early adulthood?
early childhood = ostium primum defect. late childhood/early adulthood =
ostium secundum defect (most common)
valvular defect seen in Turner syndrome bicuspid aortic valve
Dx: Premature infant has a murmur and lower extremity clubbing. PDA
Tx for erythema multiforme supportive/symptomatic treatment
When is indomethacin contraindicated in PDA? if baby has intraventricular
hemorrhage (indomethacin is an NSAID)
Factor(s) required for survival in newborns w/ transposition of great arteries
Both PDA and a septal defect (ASD or VSD)
Newborn with transposition of great arteries is not responding to PGE1. What can
be done to improve oxygenation? Balloon atrial septostomy to create or enlarge an
ASD. Arterial or atrial switch is definitive treatment.
What maternal metabolic condition is a risk factor for tetralogy of Fallot? PKU -
phenylalanine hydroxylase deficiency
Age: ties shoelaces 5 yo
Age: copies circle 3 yo
Age: parallel play 2 yo
Age: says Mama, Dada 9-10 mos
Age: knows name/age/gender 3 yo
Age: knows left from right 5 yo
Infant born at 3.5 lbs. What should weight be at 6 months? 12 months? 24 months?
Doubles by 6 mod (7 lbs), triples by 1 year (10.5 lbs), quadruples by 2 years
(14 lbs)
Age: uses 2 finger pincer grasp 1 yo
Delayed puberty in boys is defined as
A. no pubic hair
B. no axillary hair
C. no testicular enlargement
D. no deepened voice
E. no growth spurt no testicular development by age 14
Delayed puberty in girls is defined as
A. no axillary hair
B. no pubic hair or breast development
C. no menses
D. imperforate hymen no axillary or pubic hair by age 13
Chromosome assoc w/ CF 7
Down syndrome babies are at risk for what malignancy? ALL ("We ALL fall Down")
Treatment for 47, XXY testosterone
Most likely karyotype for an very tall inmate w/ severe acne, antisocial behavior and
otherwise phenotypically normal 47, XYY (double Y male)
Dx: Low tetrahydrobiopterin cofactor PKU
Pediatric pt has large testes, large ears and autistic behavior. Pathology involves
inappropriate
A. translation
B. axonal transport
C. hydroxylation
D. phosphorylation
E. methylation Fragile X syndrome involves methylation of FMR1 gene
Differential if a young white male has a positive sweat chloride test but a negative
genetic workup for CF. Mucopolysaccharidosis, ectodermal dysplasia, adrenal
insufficiency, nephrogenic DI, myxedema
Pt presents w/ ongoing sever arm and leg pain with joint swelling. Later develops
angiokeratomas and telangiectasias. He finally dies of an MI at age 36. Dx? Etiology?
Inheritance? Fabry's disease, alpha-galactosidase A deficiency, X-linked recessive.
First present w/ neuropathic limb pain (acroparesthesias). Risk of renal failure, MI
or stroke.
Dx: galactocerebrosidase deficiency Krabbe's disease
Dx: glucocerebrosidase deficiency Gaucher's disease
Dx: arylsulfatase A deficiency metachromatic leukodystrophy
Enzymes deficient in Hurler's vs. Hunter's syndromes Hurler's: alpha-L-
iduronidase (has an "L" in it). Hunter's: iduronate sulfatase
What vasculitis is assoc. w/ intussusception? Henoch-Schnlein purpura
Dx: 2 yo male present abdominal pain, vomiting, diarrhea, and an "empty" RLQ on
examination intussusception (Dance's sign on abdominal exam); assoc. w/ HSP
18 month old male presents w/ sudden, intermittent, painless rectal bleeding. Next
step?
A. abdominal ultrasound
B. CT abdomen
C. colonscopy
D. technetium scintigraphy scan
E. ari-contrast barium enema technetium-99 pertechnetate (Meckel's) scan
Dx: A male neonate born at 30 weeks gestation has feeding intolerance and bloody
stools one week after delivery. Today his BP is 80/60, P 160, T 103, R 30 and his
abdomen is erythematous. AXR shows portal venous gas. Necrotizing
enterocolitis
Gene mutations assoc. w/ SCID common gamma chain for cytokine receptors,
JAK-3 kinase, recombinase activity gene (RAG1, RAG2), adenosine deaminase (ADA)
deficiency, IL-7 receptor alpha chain, CD45 gene
Ataxia-telangiectasia increases risk for
A. duodenal atresia
B. leukemia
C. pernicious anemia
D. chronic candidiasis
E. autosplenectomy increased incidence of non-Hodgkin's lymphoma, leukemia,
and and gastric carcinoma
Inheritance pattern of a pt w/ eczema, thrombocytopenia, and recurrent infections
Wiskott-Aldrich syndrome is X-lined recessive (males only)
Tx for chronic granulomatous disease TMP-SMX, IFN gamma; Bone marrow
transplant and gene therapy are new therapies
immunodeficiency presenting w/ omphalitis in the newborn leukocyte adhesion
deficiency (delayed umbilical cord separation)
Leukocyte adhesion deficiency is assoc. w/ which of the following?
A. CD18
B. HLA-DR3
C. adenosine deaminase
D. glycoprotein IIb/IIIa
E. autosomal translocation CD18
What to look for on blood smear of pts w/ Chediak-Higashi syndrome
(oculocutaneous albinism) giant granules in neutrophils
How is hereditary angioedema inherited? autosomal DOMINANT. Event though it's
an enzyme deficiency (C1 esterase inhibitor)
What looks like Bruton's agammaglobulinemia but B cells are not decreased?
transient hypogammaglobulinemia of infancy (THI)
When is the chronic phase of Kawasaki disease complete? once ESR returns to
baseline
Tx for acute otitis media high dose amoxicillin x 10 days
Of the following, which causes bronchiolitis?
A. metapneumovirus
B. cytomegalovirus
C. herpes simplex virus
D. Ebstein-Barr virus
E. Norwalk virus Bronchiolitis: RSV (#1), influenza, parainfluenza, and human
metapneumovirus
Recommended RSV prophylaxis high risk pts (CHD, chronic lung disease,
prematurity)
2 years old
injectable poly- or monoclonal antibodies (RSV-IVIG or palivizumab)
in winter
Tx for moderate to severe laryngotracheobronchitis nebulized racemic
epinephrine (croup)
Endoscopy finding in children w/ tracheitis pseudomembrane
Most common neurologic complication of meningitis in kids hearing loss
Tx of meningitis in neonates? In older children?Why the difference? Neonates:
ampicillin + cefotaxime or gentamicin
Older children: ceftriaxone + vancomycin
*Neonates should not be given ceftriaxone in light of increased risk of biliary
sludging and kernicterus!
most contagious stage of pertussis catarrhal stage
Tx for pertusssis ERYTHROMYCIN to pt and close contacts (including day care
contacts)
Pt develops subacute sclerosing panencephalitis later in life. Prophylactic protection
against what could have prevented this? measles (paramyxovirus)
Dx: HIGH fever in a kid, followed by a rash once the fever breaks and lasts <24 hrs.
Roseola infantum (HHV-6 and -7)
Virus causing chickenpox VZV
When must VZIG be given in order to be effective once exposed? within 4 days
of exposure
APGAR if acral cyanosis, pulse <100, grimace 2/ cough, some activity, irregular
respiratory effort 6 for this pt
Appearance: pale/blue (0), pink trunk w/ acral cyanosis (1), all pink (2)
Pulse: absent (0), <100 (1), >100 (2)
Grimace w/ stim.: none (0), grimace (1), grimace and cough (2)
Activity: limp (0), some (1), active (2)
Respiratory effort: none (0), irregular (1), regular (2)
Most likely orientation of herniated contents in congenital diaphragmatic hernia?
posterior left (Bochdalek)
Dx of congenital diaphragmatic hernia can be made by
A. in utero ultrasound
B. postnatal EGD
C. air enema
D. barium esophagram
E. technetium 99 pertechnetate scan in utero ultrasound
Treatment for gastroschesis:
A. delay closure until 6 mos old
B. single-staged closure during this hospital stay
C. emergency surgery followed by staged closure
D. spontaneous resolution emergency surgery and staged closure
A premature newborn develops acute respiratory distress. What maternal risk
factor increased the likelihood of have this condition?
A. hypertension
B. diabetes mellitus
C. obesity
D. alcohol abuse
E. smoking maternal DM is a risk factor for ARDS (insulin affects surfactant
production)
What causes transient tachypnea of the newborn? retained amniotic fluid
Which is a marker of fetal lung maturity?
A. lecithin:sphingomyelin ratio <2:1
B. presence of phosphatidylglycerol in serum
C. presence of phosphatidylcholine in serum
D. presence of phophadidylglycerol in amniotic fluid
E. presence of phosphatidylcholine in amniotic fluid presence of
phosphatidylglycerol in amniotic fluid
A simple febrile seizure is characterized by which of the following?
A. generalized
B. increased risk of epilepsy
C. occurs several days following fever
D. usually occurs multiple times per day
E. assoc. w/ low grade fever generalized (everything else is characteristic of complex
febrile seizures0
T or F: Acetaminophen can reduce recurrences of febrile seizures. False:
antipyretics do not reduce febrile seizure recurrence
A 12-month-old his seen for a routine visit. She is allergic to eggs. Which of the
following vaccines is contraindicated at this visit?
A. Hepatitis B
B. Pneumococcal
C. MMR
D. Hepatitis A
E. Haemophilus influenzae type b Pts allergic to eggs cannot have MMR or
influenza vaccine
Drug of choice for flu in pregnancy oseltamivir
Before starting a vigorous exercise program in a pt > 40 yo w/ 2 or more cardiac
risk factors, you must first perform a __________ before initiating the exercise regimen.
exercise stress test
Asthma is a type ___ hypersensitivity reaction type I
What 2 cells are involved in atopic hypersensitivity reactions? mast cells and
basophils
Rheumatic fever is a type ___ hypersensitivity reaction. type II (cytotoxic, antibody-
mediated)
Hypersensitivity pneumonitis is similar to what type of hypersensitivity reaction?
Arthus reaction - local reaction to antigens by preforemed Abs; characterized
by vascular necrosis and thrombosis
Eczema (atopic dermatitis) is caused by decr synthesis of what cell layer?
cornified cell layer
What two things should you ask about in a pt w/ atopic dermatitis (eczema)?
asthma and allergic rhinitis
T or F: eczema is a pediatric disorder False: Adults can have eczema
characterized by lichenification and dry, fissured skin in flexural distribution. Hands
and eyelids often involved.
Dx: 2 day old infant has an erythematous, papulovesicular rash w/ surrounding
erythematous halos. Vesicles have incr eosinophils in them. At 2-week follow-up,
rash has resolved w/out treatment. erythema toxic neonatorum
When can patch testing be used for contact dermatitis? After the acute-phase rash
has been treated
Organism involved in seborrheic dermatitis Pityrosporum ovale
Tx for seborrheic dermatitis of the scalp selenium sulfide or zinc pyrithrione
shampoos
3 meds that can induce/exacerbate psoriasis lithium, beta-blockers, ACEIs
Dx: Skin biopsy shows thickened epidermis, elongated rete ridges, absent granular
cell layer, parakeratosis, and sterile neutrophilic infiltrate in stratum corneum
Psoriasis. Parakeratosis = preservatio of nuclei in s. corneum. Neutrophilic
infiltrate in s. cornum = Monro's microabscess.
Urticaria involves
A. monocytes
B. plasma cells
C. eosinophils
D. mast cells
E. cytotoxic T cells mast cells
Tx for urticaria systemic antihistamines (not topical or systemic
corticosteroids, or topical antihistamines)
When do drug eruptions usually occur? 1-2 weeks after starting drug (not 1-2
days)
Dx: Pt has a severe dusky red mucocutaneous skin rash involving 35% body surface
area after being treated for a UTI. toxic epidermal necrolysis (>30% BSA). SJS
involves <10% BSA.
Biopsy difference btw SJS and TEN? SJS: degeneration of basal layer of
epidermis
TEN: full-thickness eosinophilic epidermal necrosis
Dx: Fungal lung infection w/ painful subcutaneous nodules on LEs.
Coccidiomycosis
Antibodies assoc. w/ pemphigus vulgaris anti-desmoglein Abs
Pemphigus vulgaris involves
A. desmosomes
B. hemidesmosomes
C. stratum granulosum
D. spectrin
E. connexins desmosomes
Pt presents w/ severe cold sores in her mouth. This is her eight time this year with
this complaint. Next step? Daily acyclovir, valacyclovir or famciclovir suppressive
therapy. Also, consider HIV screening.
T or F: Symptomatic HSV infection lasting > 1 month can be considered an HIV-
defining illness. true
Tzanck smear from vesicular fluid shows mutinucleated giant cells. Dx? Either
HSV or VZV infection. Tzanck smear cannot distinguish between the two. Get a good
history.
Tx for molluscum contagiosum Often left untreated in children (resolve
spontaneously over months to years). Or curetting, freezing or trichloroacetic acid.
A 12 month old child is found to have laryngeal warts during examination. Mom
received no prenatal care. Most likely mechanism?
A. sexual abuse
B. aspiration
C. disseminated infection
D. metastatic neoplasia
E. result of immunization Most likely aspiration during delivery. Mom probably
had genital HPV. Long latency period, so children may not present until years after
birth.
Causative organism of impetigo:
A. strep pneumo
B. strep pyogenes
C. viridans strep
D. strep epidermidis
E. strep agalactiae Strep pyogenes (GAS). Bullous impetigo caused by Staph
aureus
Bug and Tx for erysipelas GAS, penicillin
Dx: small pink papules ("rose spots") on trunk plus fever and GI complaints?
Salmonella typhi
Things that warrant IV ABx use for cellulitis systemic toxicity, DM, very young
or very old, hand involvement, eye involvement
Tx for GAS necrotizing fasciitis? For anaerobic coverage? GAS: penicillin G
(first line), clindamycin (second line)
Anaerobes: metronidazole or 3rd gen cephalosporin
Most cases: Broad spec - Vanc, piperacillin-tazobactam, ampicillin-sulbactam
25 yo pt w/ unstable mood develops acne. Most likely cause? Lithium
19 yo F wants birth control. She has severe acne and worries about it getting worse
w/ birth control. What is the least optimal option? Mirena IUD - causes acne
Topica ABx for pustulocystic/inflammatory acne erythromycin or clindamycin
In addition to b-hCG, what tests must you order before refilling a teenage girl's oral
isotretinoin for acne? LFTs, cholesterol, triglycerides (can be transiently
elevated)
Organism assoc. w/ pilonidal cyst
A. Propionobacterium ances
B. Clostridium perfringens
C. Bacteroides fragilis
D. Clostridium difficil
E. Staph aureas bacteroides
If left untreated, pilonidal cysts may be complicated by what? my develop into
perianal fistulas
T or F: Tinea versicolor is caused by normal skin flora True. Malassezia furfur is a
yeast that's part of normal skin flora
Tx of tinea versicolor TOPICAL ketoconazole or selenium sulfide
Tx for diaper rash topical nystatin
Dermatophyte that causes hair to fluoresce under Wood's lamp Microsporum
Protein required for dermatophyte survival keratin
Dx: 40 yo F present w/ itching knuckles for 1 week. PE reveals erythematous
papules on her right hand between the knuckles. Her 10 yo daughter who lives with
has had generalized pruritus for 3 day. Scabies
Pt is admitted after being stabilized after a knife wound to L thigh. 5 days later, his
leg appears swollen and goes from pale to dark red. Dx? Next step? Gas gangrene
(C. perfringens). Next step: hyperbaric O2
SCC of the palm is most likely assoc. w/ what risk factor?
A. sun exposure
B. smoking
C. radiation
D. arsenic exposure
E. osteomyelitis arsenic (SCC in palmoplantar distribution)
What cancers get Mohs surgery? SCC or BCC of skin
What skin cancers have genetic counterparts? BCC and melanoma (inherited
basal cell nevus syndrome and familial atypical mole and melanoma syndrome)
What lab marker is elevated in cases of distant melanoma mets? LDH
Kaposi's sarcoma is best described as
A. vascular proliferative
B. hematogenous
C. dermatomal
D. bacterial
E. lymphomatous vascular proliferative
What is Kaposi's "look-alike"? Bacillary angiomatosis (Bartonella). Tx is
erythromycin
Mainstay treatment for mycosis fungoides is
A. topical antifungals
B. topical corticosteroids
C. systemic antifungals
D. systemic corticosteroids
E. phototherapy phototherapy
What skin disease has Lutzner cells? mycosis fungoides (cutaneous T cell
lymphoma). Aka, Szary cells. Seen on EM as "cerebriform lymphocytes".
Next step in workup for hyperosmolar hyponatremia? measure glucose
Causes of "spurious" hyponatremiaSpurious = false. Isotonic hyponatremia
(pseudohyponatremia). Hypertriglyceridemia, paraproteinemia (eg, myeloma),
glucose, mannitol
Extreme leukocytosis or thrombocytosis can cause what electrolyte abnormality?
hyperkalemia
Pt recently had a kidney transplant and is taking calcineurin inhibitors. What
electrolyte abnormality can be expected? hyperkalemia
How to albuterol and metoprolol affect K+? albuterol (beta agonist) increases
cellular K+ uptake, causing hypokalemia. Metoprolol (beta blocker) inhibits cellular
K+ uptake, causing hyperkalemia.
6 yo pt comes in after bee sting. He is hypotensive with audible wheezing. He is
intubated and stabilized. 2 hours later, his EKG shows flattened T waves.
Mechanism? epinephrine is a beta2 agonist and can cause hypokalemia. commonly
seen in trauma pts!
How does pH affect K+ and H+ cellular shifts? K+ and H+ undergo reciprocal
shifts based on pH. Acidosis: K+ shifts out, H+ shifts in. Alkalosis: K+ shifts in, H+
shifts out.
How can you get metabolic acidosis with hypokalemia? renal tubular acidosis (type
I: defective distal H+ secretion). Most all other cases of hypokalemia are assoc. w/
alkalosis.
In hypercalcemia of malignancy, what are levels of PTH, 1,25 Vit D, and IL-6 low
PTH, high 1,25 Vit D, high IL-6
Increased levels of which of the following can cause hypercalcemia?
A. folic acid
B. Vitamin A
C. Vitamin B1 (thiamine)
D. Vitamin B12
E. Vitamine B3 (niacin) Vitamin A
First step in Tx of hypercalcemia IV hydration!
Most common risk factor for hypomagnesemia alcoholism
Allergic interstitial nephritis is assoc. w/ what pediatric infection? Legionella
pneumophila
Most important risk factor for developing CKD diabetes mellitus
Relationship btw Cr and GFR Always vary INVERSELY. If GFR decreases by
50% (e.g., nephrectomy), Cr increases by 50%.
Why do CKD pts have an increased tendency to bleed? How do you treat this?
Impaired platelet aggregation. Give DDAVP for abnormal bleeding.
Mechanism of calciphylaxis in CKD impaired phosphate excretion -> high phosphate
-> vascular calcification -> skin necrosis
Which diuretics may cause pancreatitis? thiazides
Tx for Wegener's high dose corticosteroids
Tx for Goodpasture's plasma exchange (plasmapheresis) and pulse steroids
Type of hearing impairment seen in Alport's syndrome sensorineural hearing loss
Hodgkin's disease pts most likely to get what type of nephrotic syndrome?
minimal change disease (lipoid nephrosis)
Nephrotic syndrome assoc. w/ HBV and HCV membranous nephropathy
"spike and dome" membranous nephropathy
nephrotic syndrome assoc. w/ solid tumor malignancies membranous nephropathy
nephropathy caused by plasma cell dyscrasia renal amyloidosis (myeloma
kidney)
"tram tracks" nephropathy membranoproliferative nephropathy
C3 nephritic factor membranoproliferative nephropathy
2 glomerular diseases w/ low serum C3 minimal change disease and
membranoproliferative glomerulonephritis
Pathogenesis of hyperlipidemia in nephrotic syndrome increased hepatic synthesis
of LDL and VLDL
Most common site for kidney stone ureteropelvic junction
If proteus is not an option for struvite calculi, what are 3 other bugs? Klebsiella,
Serratia, Enterobacter
Tx for uric acid stones alkalinize urine w/ potassium citrate (which is
converted to HCO3 in the liver). Potassium bicarb may also be used.
Dx: Flank pain with a + urine cyanide nitroprusside test cystine kidney stones
Steatorrhea can lead to kidney stones by what mechanism? increased
absorption of oxalate, causing calcium oxalate stones
Pts w/ PCOS are at risk for what malignancy? RCC
Valvular disease assoc. w/ PCOD mitral valve prolapse
Next step in diagnosing hydronephrosis:
A. MRI
B. ultrasound
C. intravenous pyelogram
D. retrograde urethrogram
E. urinalysis ultrasound
Test of choice for suspected vesicoureteral reflux (eg, recurrent UTIs or UTI in a
young bo) voiding cystourethrogram (VCUG)
Dx: Young male pt present w/ undescended testes. Gentle abdominal pressure and
manual manipulation allow scrotal progression into scrotum. Retractile testes (not
cryptorchidism)
What med can be used to induce testicular descent? IM hCG
Bugs causing epididymitis by age group Children and elderly: E. coli
Young men: Chlamydia, Neisseria
Tx for epididymitis tetracycline, fluoroquinolones
Tx for testicular torsion <6 hours after onset? >6 hours? If < 6 hours, bilateral
orchiopexy. If > 6 hours, testis is unlikely salvageable. May have to do orchiectomy.
3 hormones to check in cases of erectile dysfunction testosterone, GnRH and
prolactin. (PRL inhibits GnRH.)
Advise for pts taking both alpha blockers (for HTN or BPH) and PDE5 inhibitors for
ED: take them in 4-hour intervals to avoid hypotension
Greatest risk factor for prostate cancer is
A. age
B. family history of prostate cancer
C. high fat diet
D. smoking
E. recurrent UTIs age
If prostate cancer is palpable on DRE, how likely is it that it has already spread?
A. <5%
B. 15%
C. 40%
D. 60-70%
E. >95% 60-70%
Definitive diagnosis for prostate CA ultrasound-guided transrectal biopsy
Imaging test for bone mets from prostate CA bone scan
Recommended screening method for prostate cancer annual DRE after age 50
(earlier if AA or first degree relative)
The central (periurethral) prostate zone is sensitive to which hormone?
A. testosterone
B. DHEAS
C. estrogen
D. cortisol
E. prolactin estrogen
Occupational exposure to aniline dye increases risk for what cancer? bladder
Tx for bladder carcinoma in situ intravesicular chemotherapy
method of spread of bladder cancer direct local invasion
intravesicular chemo drugs for bladder CA mitomycin C and BCG (the TB
vaccine)
what is a hypernephroma aka renal cell carcinoma
RCC is squamous cell, clear cell, adenocarcinoma, or something else?
adenocarcinoma
Most common CNS tumors found in pts w/ renal and/or hepatic cysts and RCC
cerebellar hemangioblastomas (von Hippel-Lindau syndrome)
Dx: 50 yo M present w/ hematuria and malaise. Labs: Hct 55% RCC (can have
polycythemia)
How do you treat metastatic prostate CA androgen ablation and chemo. Androgen
ablation options:
orchiectomy
GnRH agonists (leuprolide)
androgen receptor blockers (flutamide)
Pt undergoes left radical nephrectomy for RCC. What all was removed?
kidney, adrenal gland, Gerota's fascia, surrounding lymph nodes
New chemo meds for RCC. Mechanism of action sorafenib, sunitinib - tyrosine
kinase inhibitors that decrease tumor angiogenesis and cell proliferation
elevated hCG in a 40 yo with no liver disease is indicative of what? testicular
choriocarcinoma
Viruses that predispose to penile cancer HSV and HPV 18
Most common tumor to metastasize to adrenals is
A. liver
B. breast
C. lung
D. stomach
E. melanoma lung
Pt recently diagnosed w/ ESRD develops chest pain and back pain immediately after
initiating dialysis. What is happening? "first use" syndrome
protein found in dialysis-associated amyloidosis beta-2 microglobulin in bones and
joints
"triple therapy" for polycythemia vera hydroxyurea, interferon alpha, aspirin
Leukocyte alkaline phosphatase levels in hematologic malignancy vs. leukemoid
reaction LAP high in leukemoid reaction, low in cancer (e.g., CML)
Type of acute leukemia assoc. w/ the following:
testicular involvement
anterior mediastinal mass
skin nodules testicular involvement - ALL
anterior mediastinal mass - T cell ALL
skin nodules - AML
translocation assoc. w/ acute promyelocytic leukemia t(15;17)
Which of the following is a poor prognostic indicator for AML?
A. history of Vitamin A overuse
B. elevated LDH
C. young age
D. need for chemotherapy
E. elevated leukocyte alkaline phosphatase elevated LDH
Most common physical finding in CLL includes?
A. plethora
B. jaundice
C. subcutaneous nodules
D. lymphadenopathy
E. arthralgia lymphadenopathy + splenomegaly
Blood malignancy with increased basophils CML
BCR-ABL CML (Philadelphia chromosome)
Levels of LDH, B12, folate, uric acid, and LAP in CML LDH high, B12 high, folate
normal, uric acid high, LAP low
65 yo M present w/ fever, cough, and SOB for 3 weeks. No LAD preset. ROS + for
10lb weight loss and fatigue. CXR shows bilateral infiltrates. Peripheral smear
shows lymphocytic cytoplasmic projections. Most likely cause of his symptoms?
mycoplasma avium-intracellulare esp. assoc. w/ hairy cell leukemia
Pt is recently diagnosed w/ non-Hodgkin's lymphoma. Most likely translocation?
t(14;18) = follicular lymphoma
Blood cell cancer assoc. w/ autoimmune disorders (e.g., Sjogren's, Hashimoto's)
MALT lymphoma
Translocation and mutation assoc. w/ the following:
Burkitt's lymphoma
follicular lymphoma
mantle cell lymphoma Burkitt's = t(8;14), c-myc activation
Follicular = t(14;18), bcl-2 activation
Mantle cell = t(11;14)
Treatment of NHL based on stage or grade? What about Hodgkin's? NHL - grade
(histologic classification)
Hodgkin's - stage-dependent
Oncogenic virus assoc. w/ Hodgkin's lymphoma is
A. CMV
B. HIV
C. EBV
D. parvovirus
E. HHV-8 EBV
Most likely subtype of Hodgkin's lymphoma in a 20 yo? In a 60 yo? 20s - nodular
sclerosing
60s - lymphocyte-depleting
Dx: A 10 yo M present w/ abdominal pain, fevers, chills and obstipation. He has
high-pitched bowel sounds. Abdominal x-ray shows air-fluid levels. CT reveals an
abdominal mass. He has a chromosomal translocation. Burkitt's lymphoma can
present like this
Dx: 27 yo M present w/ 2 weeks of axillary, groin and neck pain during bouts of
alcohol consumption. ROS reveals several episodes of intermittent fevers over the
last year. Hodgkin's disease can rarely present w/ alcohol-induced pain at nodal
sites; specific finding for Hodgkin's.
Imaging of choice for myeloma bone mets Xray/skeletal survey (Bone scan detects
osteoblastic lesions; myeloma is an osteoclastic process)
Most appropriate for myeloma is
A. infliximab
B. rituximab
C. melphalan
D. mesna
E. palliative care melphalan, an oral alkylating agent
Dx: 65 yo AAF present w/ 5 months of blurry vision, abdominal pain, and confusion.
Bone marrow biopsy shows PAS+ IgM perinuclear deposits. Woldenstrom's
gammaglobulinemia
Tx for MGUS? no treatment, just observation
Cause of the following types of amyloidosis:
infection
heritable
senile-systemic
primary infection - ACUTE-PHASE REACTANT serum amyloid A
heritable - ABNORMAL transthyretin, aka prealburmin
senile-systemic - NORMAL transthyretin/prealbumin
primary - amyloid light chains (BJ proteins)
Kostman syndrome autosomal recessive congenital neutropenia
Felty's syndrome rheumatoid arthritis, splenomegaly, neutropenia
Most appropriate for neutropenic fever would be
A. vancomycin
B. ampicillin
C. clindamycin
D. cefepime
E. gentamycin Need broad spec, so cefepime would be a good choice
Pathogens that may cause neutopenic hypothermia? How would you treat it? fungi,
tx w/ IV amphotericin B
subdural effusions are a complication of meningitis caused by what organism?
H. flu
Most likely organisms causing brain abscess from direct spread from paranasal
sinusitis Strep milleri or Strep intermedius
Dx: 20 yo M w/ headache, seizures, and elevated ESR and CRP. MRI brain shows ring
enhancing lesion. Brain abscess
Organisms assoc. w/ AID cholangiopathy (hepatobiliary involvement) CMV,
microsporidia, cryptosporidia
If left untreated, young males w/ infectious mononucleosis are most likely to die
from what?
A. bacterial superinfection
B. nasopharyngeal carcinoma
C. opportunistic pneumonia
D. fulminant hepatic necrosis
E. disseminated intravascular coagulation fulminant hepatic necrosis