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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

1. Which dietary Which dietary modifications should be 4. A pt presents to the A pt presents to the clinic after passing out
modifications should advised for gout? clinic after passing at home. H&P rules out vasovagal syncope
be advised for gout? Decreased fructose; decreased EtOH; out at home. H&P and orthostatic hypotension.
[...] decreased red meat; decreased fish rules out vasovagal Echocardiogram rules out mechanical heart
syncope and disease. You suspect an arrhythmia as the
orthostatic cause. What diagnostic tests are indicated?
hypotension. EKG (typically negative unless
Echocardiogram rules symptoms are occuring at that time);
2. A pt is suspected to A pt is suspected to have testicular cancer.
out mechanical heart Holter monitor (24 hr EKG); Event/loop
have testicular Why is FNA biopsy of the testicle a very bad
disease. You suspect recorder (1 month monitoring)
cancer. Why is FNA idea?
an arrhythmia as the
biopsy of the testicle It can cause seeding and induce
cause. What
a very bad idea? spreading of the disease
diagnostic tests are
[...]
indicated?
[...]
Needle biopsy is always the wrong answer
in testicular cancer
5. What is the "FAT RN" What is the "FAT RN" mnemonic for the
mnemonic for the classic pentad of symptoms seen in TTP?
3. A 45 y/o pt presents A 45 y/o pt presents c/o painful hematuria.
classic pentad of (see below)
c/o painful Vitals are WNL except for BP (elevated).
symptoms seen in
hematuria. Vitals are Physical exam reveals bilaterally palpable
TTP?
WNL except for BP flank masses. The pt states that his father
[...]
(elevated). Physical also had this problem and died of renal
exam reveals failure. Which genetic cause of renal failure
bilaterally palpable is the most likely Dx?
flank masses. The pt ADPCKD 6. A pt is found to have A pt is found to have a GI bleed. The pt is
states that his father a GI bleed. The pt is stabilized and the appropriate
also had this problem stabilized and the medications/infusions/labs are performed.
and died of renal ADPCKD key points: appropriate EGD rules out UGIB. The bleeding rate is
failure. Which genetic - Autosomal dominant; the cysts have medications/infusions/labsslow and found to be < 0.5 cc/min. What is
cause of renal failure random size/orientation (vs. the radial are performed. EGD the next step in workup?
is the most likely Dx? distribution of ARPCKD) rules out UGIB. The Colonoscopy
[...] - s/s: pain and hematuria; commonly bleeding rate is slow
mistaken for nephrolithiasis, however stones and found to be < 0.5
can form cc/min. What is the
- pyelonephritis is a common presention next step in workup?
- malignant HTN can be present and is 2/2 [...]
RAAS activation
- Dx is via U/S
- Tx is supportive, manage complications
and transplant once ESRD/CKD sets in
- Cysts can also form in the liver, pancreas,
and cerebral vasculature
- Screen these pts for berry aneurysms as
they have a risk for SAH
- Remember to test family members and
offspring

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

7. ACLS protocol is ACLS protocol is started on a pt. EKG 9. In which pole of the In which pole of the kidney does renal cell
started on a pt. EKG reveals atrial fibrillation. The pt feels weak kidney does renal cell carcinoma typically manifest?
reveals atrial but has no other s/s. BP is 110/70 mmHg. carcinoma typically Superior pole
fibrillation. The pt His PMHx is significant for migraines only. manifest? Renal Cell Carcinoma key points:
feels weak but has no What is/are the first choice [...] - While its not present everytime, the triad of
other s/s. BP is pharmacotherapy in this case? flank pain, flank mass, and hematuria
110/70 mmHg. His BBs, CCBs (rate control without should be considered cancer until proven
PMHx is significant presence of CHF) otherwise
for migraines only. - Major risk factors include smoking, ESRD
What is/are the first and von-Hippel Lindau
choice ACLS Intervention key points: - Investigate w/ U/S or CT
pharmacotherapy in - If unstable, use electricity - F/u w/ surgical resection
this case? - If stable, use pharmacotherapy; there are - Definitive Dx is via Bx after resection
[...] typically 4 options in general: - Never ever biopsy a suspected RCC in
--- if the rhythm is fast and narrow, use vivo; the risk of hematoma and/or seeding
adenosine is high; always Bx s/p resection
--- if the rhythm is fast and wide, use - hematogenous spread
amiodarone - Renal vein thrombosis is a big risk
--- if the rhythm is slow, use atropine - Either anaemia or polycythemia can be
--- if the rhythm is AFib or AFlutter, rate present (anaemia 2/2 to the tumour or
control = rhythm control (use BBs and increased EPO release as a paraneoplastic
CCBs; or digoxin and amiodarone if there syndrome)
is CHF)
- Remember, wide is QRS > 0.12 msec
10. What is the most What is the most common risk factor for
common risk factor COPD?
8. A 80 y/o pt presents A 80 y/o pt presents c/o of a pigmented for COPD? Tobacco smoking
c/o of a pigmented lesion on his face. Physical exam reveals a [...]
lesion on his face. large, brown, greasy-looking, and
Physical exam crusted pigmented lesion that appears Remember, COPD is a result of the loss of
reveals a large, stuck on the pt's face. What is the most lung elastin (which facilitates passive
brown, likely Dx? exhalation from its elasticity).
greasy-looking, and Seborrheic keratosis Tobacco destroys elastin fibres.
crusted pigmented Very common in the elderly
lesion that appears
11. A pt c/o dizziness A pt c/o dizziness that manifests upon
stuck on the pt's
that manifests upon head movement. He states that the
face. What is the
head movement. He sensation lasts for < 1 min. You suspect
most likely Dx?
states that the BPPV. What is the best diagnostic test?
[...]
sensation lasts for < Dix-Hallpike maneuver (if it reproduces
1 min. You suspect the rotary nystagmus, it is diagnostic)
BPPV. What is the
best diagnostic test?
[...]

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

12. Which age group is Which age group is typically affected by 14. ACLS protocol is ACLS protocol is started on a pt. EKG
typically affected by bullous pemphigoid? started on a pt. EKG reveals the rhythm shown below. The pt is
bullous pemphigoid? 70-80 reveals the rhythm stable. What is the most appropriate initial
[...] shown below. The pt intervention?
is stable. What is the Pace only (this is 2nd degree AV block,
Pemphigus vulgaris = 30-60 y/o most appropriate Mobitz II)
Bullous pemphigoid = 70-80 y/o initial intervention?
[...]
AV Block and ACLS key points:
13. A pt presents c/o A pt presents c/o colicky flank pain that
- the most simple slow rhythm is sinus
colicky flank pain radiates to the groin and hematuria. He
brady, give atropine
that radiates to the is Dx w/ nephrolithiasis following a
- 1st degree AV block
groin and non-contrast CT which reveals a 40 mm
--- A regularly prolonged PR interval that
hematuria. He is Dx stone. What is the next step in
does not change; there are no dropped
w/ nephrolithiasis management following hydration and pain
beats; give atropine
following a control?
- 2nd degree AV block, Mobitz type I
non-contrast CT Nephrostomy (or surgery); analyze the
--- involves a constantly prolonging PR
which reveals a 40 stone once retrieved
interval until a dropped QRS; give
mm stone. What is
atropine
the next step in
- 2nd degree AV block, Mobitz type II
management Nephrolithiasis management key points:
--- involves a constant and normal PR
following hydration - Always start w/ hydration and pain
interval that does not prolong and
and pain control? control
randomly dropped QRS complexes
[...] - If the stone is < 5 mm, let it pass
--- atropine is no longer recommended
- If the stone is < 30 mm, perform
as the pt can convert into total AV block
lithotripsy and then let it pass
- 3rd degree (total) AV block
- If the stone is > 30 mm or there is
--- involves total AV node dissociation
hydronephrosis/-ureter, perform
with no regular intervals between P waves
nephrostomy
and QRS complexes
- Either strain the urine or analyse it after
--- although controversial, it's
retrieval to Dx the stone and pinpoin risk
recommended to avoid atropine and pace
factors
only

15. A pt presents c/o A pt presents c/o chest pain w/


chest pain w/ odynophagia and dysphagia. You
odynophagia and suspect esophagitis. What is the best
dysphagia. You diagnostic test?
suspect esophagitis. EGD w/ Bx
What is the best
diagnostic test?
[...] No matter the cause of esophagitis, get dat
dere EGD w/ Bx brah.

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

16. ACLS protocol is ACLS protocol is started on a pt. EKG 18. What is the best What is the best initial test for ALL?
started on a pt. EKG reveals the rhythm shown below. The pt is initial test for ALL? PBS (looking for blasts)
reveals the rhythm stable. What is the most appropriate initial [...]
shown below. The pt pharmacological intervention?
is stable. What is the Atropine (this is 2nd degree AV block,
most appropriate Mobitz I)
initial
pharmacological
19. What is the best What is the best initial test for celiac
intervention? AV Block and ACLS key points:
initial test for celiac disease?
[...] - the most simple slow rhythm is sinus
disease? Autoantibody testing (anti-endomysial;
brady, give atropine
[...] anti-tissue-transglutaminase)
- 1st degree AV block
Note that we do not test for anti-gliadin
--- A regularly prolonged PR interval that
antibodies as they have low sensitivity
does not change; there are no dropped
and low specificity. They are not useful.
beats; give atropine
- 2nd degree AV block, Mobitz type I
--- involves a constantly prolonging PR
interval until a dropped QRS; give
atropine
- 2nd degree AV block, Mobitz type II
--- involves a constant and normal PR 20. Hemophilia exists in Hemophilia exists in 2 forms: A or B. Which
interval that does not prolong and 2 forms: A or B. factors are deficient in them respectively?
randomly dropped QRS complexes Which factors are A = VIII, B = IX
--- atropine is no longer recommended deficient in them "A8, B9"
as the pt can convert into total AV block respectively?
- 3rd degree (total) AV block [...]
--- involves total AV node dissociation
with no regular intervals between P waves 21. Hepatic Hepatic encephalopathy is a possible
and QRS complexes encephalopathy is a complication of liver failure/cirrhosis. What
--- although controversial, it's possible complication is the treatment?
recommended to avoid atropine and pace of liver Lactulose; start transplant workup
only failure/cirrhosis. What
is the treatment?
[...]

17. A pt presents c/o A pt presents c/o progressive hair loss. 22. A pt present c/o of A pt present c/o of hair loss. Physical exam
progressive hair Physical exam reveals loss of hair at the hair loss. Physical reveals multiple, small patches of
loss. Physical exam crown of the head with thinning of the exam reveals well-demarcated hair loss in a sporadic
reveals loss of hair hair at the edges of the crown area. What multiple, small pattern around the body. What is the most
at the crown of the is the most likely dx? patches of likely dx?
head with thinning Male Pattern Baldness well-demarcated Alopecia areata
of the hair at the Note that MPB follows this specific pattern hair loss in a
edges of the crown of hair loss (crown thins --> crown hair sporadic pattern
area. What is the loss --> progressive thinning/loss from around the body.
most likely dx? the crown outwards). What is the most
[...] likely dx?
[...]

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23. A pt states he was A pt states he was exposed to Hepatitis A 1 26. A pt w/ a history of A pt w/ a history of SLE presents c/o
exposed to Hepatitis week ago. What is the post-exposure SLE presents c/o severe joint pain. You suspect a lupus
A 1 week ago. What prophylaxis protocol? severe joint pain. You flare. Your smart medical student suggests
is the post-exposure IgG w/ the HAV vaccine within 2 weeks suspect a lupus flare. that we should check compliment levels.
prophylaxis protocol? of exposure Your smart medical How do compliment levels change in a
[...] student suggests that lupus flare?
we should check Decrease
compliment levels.
How do compliment
24. Which drug has been Which drug has been shown to increase
levels change in a If complement levels are normal, it is likely
shown to increase CFTR gene activity in cystic fibrosis?
lupus flare? not a flare.
CFTR gene activity in Ivacaftor
[...] If complement levels are decreased, it is
cystic fibrosis?
likely a flare.
[...]

27. What is the treatment What is the treatment for polycythemia


25. What is the genetic What is the genetic inheritance of cystic
for polycythemia vera?
inheritance of cystic fibrosis?
vera?
fibrosis? AR (in the CFTR gene)
[...]
[...]

Mutations in the CFTR gene result in 28. A pt presents w/ A pt presents w/ severe epigastric pain
impaired chloride and water transport severe epigastric that radiates to the back and is relieved
across the apical surface of epithelium in pain that radiates to by leaning forward. He also complains of
exocrine glands throughout the body. the back and is nausea, vomiting, fever and anorexia.
Hence, there is: relieved by leaning Physical exam reveals Cullen's and Grey
- thick mucous in the lungs (causing a list forward. He also Turner sign. Pancreatic lipase is elevated
of problems such as recurrent infection, complains of nausea, and he is Dx w/ acute pancreatitis. What
bronchiectasis, wheezing, hemoptysis, vomiting, fever and is the first step in management?
dyspnea) anorexia. Physical IVF, NPO, analgesia
- meconium ileus in infants exam reveals
- pancreatic insufficiency (seen in 90% of Cullen's and Grey
cases); typically involving steatorrhea and Turner sign. NPO provides bowel rest and prevents
fat-soluble vitamin deficiency (Vit ADEK); Pancreatic lipase is pancreatic secretion
beta-cells and the islets are spared until elevated and he is Dx IVF keeps them hydrated
late-stage disease w/ acute Analgesia for comfort
- recurrent pancreatitis pancreatitis. What is Ppx Abx are not needed (no difference in
- biliary cirrhosis the first step in outcome)
- azoospermia (in 95% of male cases) management? ERCP if there is a stone.
- vas deferens agenesis (in 20% of cases) [...] In NEJM, Nov 20, 2014 Vol 371, No. 21;
- female infertility is also seen and is 2/2 "Early versus On-demand Nasoenteric
alteration of menstrual cycle and thick Tube Feeding in Acute Pancreatitis" Dutch
cervical mucous (that can block sperm investigators showed that early nasogastric
entry) tube feedings (at 24 hours) did the same as
starting oral or NG tube feeds at 72 hours.
The idea was that early feedings may
prophylax the gut and reduce infection
rates. These guys found out that, for
patients in their study, it didn't matter

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

29. A pt is found to have A pt is found to have a solitary pulmonary 34. AML can develop as AML can develop as a "blast crisis" from
a solitary pulmonary nodule with intermediate-probability of a "blast crisis" from other hematological cancers. Which 2
nodule with malignancy. You continue workup with other hematological conditions are known to do so?
intermediate-probabilitysputum cytology which is positive for cancers. Which 2 CML; MDS
of malignancy. You malignancy. What is the most appropriate conditions are known
continue workup with next step in management? to do so?
sputum cytology Resection [...]
which is positive for
malignancy. What is
35. What type of fluids What type of fluids are typically used as
the most appropriate Sputum cytology is highly specific. So if
are typically used as maintenance fluid?
next step in positive, malignancy is ruled in. However,
maintenance fluid? 1/2 NS or 1/4 NS (either of them with or
management? negative cytology does not rule out
[...] without D5)
[...] malignancy.

30. How does How does reticulocyte count typically


reticulocyte count change in microcytic and macrocytic
36. A pt presents A pt presents complaining of difficulty
typically change in anaemia?
complaining of getting out of chairs, muscle pain and
microcytic and Decrease
difficulty getting out rashes. Physical exam reveals proximal
macrocytic anaemia?
of chairs, muscle muscle weakness with intact distal
[...]
pain and rashes. muscle strength. You also find a purple
Microcytic and macrocytic anaemias are
Physical exam rash around the eyes with periorbital
typically production anaemias which is
reveals proximal edema and scaly lesions distributed
almost synonymous with low reticulocyte
muscle weakness symmetrically over the wrists, elbows and
count.
with intact distal knees. You suspect myositis. What is the
muscle strength. best test to achieve a definitive diagnosis?
31. Arteriovenous Arteriovenous malformations can possibly You also find a
malformations can cause UGIB or LGIB. What valvular heart purple rash around
possibly cause UGIB disease is it associated with? the eyes with Biopsy
or LGIB. What Aortic Stenosis periorbital edema
valvular heart and scaly lesions
disease is it distributed Remember, the myositides all present
associated with? symmetrically over similarly, but have different underlying
[...] the wrists, elbows pathology. Definitive diagnosis requires Bx.
and knees. You - Heliotrope rash = purple rash around the
suspect myositis. eyes w/ periorbital edema
32. What component of What component of blood is
What is the best test - Gottron's papules are pathognomonic
blood is cryoprecipitate typically used to replace?
to achieve a definitive of myositis and are scaly areas around the
cryoprecipitate Fibrinogen
diagnosis? major joints
typically used to
- note that an EMG is done to rule out
replace?
nerve cause of pain or if there is a
[...] Cryoprecipitate has use in DIC, but is
[...] conduction issue
never the first choice blood product for
anything.

33. What is the treatment What is the treatment for urticaria?


for urticaria? Antihistamines or Leukotriene receptor
[...] antagonists

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37. A pt has elevated A pt has elevated TSH, but normal T3/T4. 40. A pt is in a state of A pt is in a state of unconsciousness. EEG
TSH, but normal What should you test for next? unconsciousness. reveals absent cerebral function.
T3/T4. What should Autoantibodies (antithyroglobulin and EEG reveals absent Physical exam reveals a positive caloric
you test for next? antithyroid peroxidase) cerebral function. test and response to painful stimuli.
[...] Physical exam What is the most likely Dx?
reveals a positive Persistent Vegetative State (PVS)
This is subclinical hypothyroidism. caloric test and
- if the pt is antibody positive, they will response to painful
likely progress to hypothyroidism stimuli. What is the
- if the pt is antibody negative, they may most likely Dx?
get better [...]
- regardless, follow these pts and start
treatment when symptoms manifest or
41. A pt is found to have A pt is found to have microcytic anaemia.
when TSH > 10
microcytic anaemia. An iron panel is then ordered and reveals
An iron panel is then decreased ferritin, increased TIBC and
38. An elderly pt An elderly pt presents c/o back pain that ordered and reveals decreased iron. What is the dx?
presents c/o back began after she slipped and fell on her butt. decreased ferritin, Iron Deficiency Anaemia
pain that began after Her PMHx is significant for hysterectomy increased TIBC and On the iron panel, ferritin is the most
she slipped and fell and osteoporosis. Physical exam reveals decreased iron. sensitive.
on her butt. Her point tenderness at the lumbar spine What is the dx? - if ferritin is low, it is IDA. Period.
PMHx is significant and vertebral step-off. What is the most [...]
for hysterectomy and likely Dx?
osteoporosis. Compression fracture
Physical exam
reveals point
42. Acute infectious Acute infectious diarrhea can be separated
tenderness at the
diarrhea can be into invasive and
lumbar spine and
separated into enterotoxic/non-invasive. What are the
vertebral step-off.
invasive and features of enterotoxic diarrhea?
What is the most
enterotoxic/non-invasive.
Watery stool without leukocytosis,
likely Dx?
What are the features fever, bloody stool, and fecal WBCs
[...]
of enterotoxic
diarrhea?
39. What is the treatment What is the treatment for bronchiectasis? [...] Remember, enterotoxic diarrhea is 2/2
for bronchiectasis? Mostly supportive toxins. They are typically self-limiting and
[...] require hydration. Loperamide can be
used.
Bronchiectasis key points:
- chest physiotherapy and postural
drainage are essential in dislodging
plugged-up bronchi
43. What are the most What are the most common risk factors for
- treat each infection as they come; use the
common risk factors pseudogout (Calcium-pyrophosphate
same coverage as in COPD exacerbations,
for pseudogout deposition disease)?
however rotate Abx (1 weekly each
(Calcium-pyrophosphate Hemochromatosis; hyperPTH
month)
deposition disease)?
- surgical resection of focal lesions may
[...]
be indicated

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44. A single episode of A single episode of thyroid storm is an 47. What is the first line What is the first line therapy for plantar
thyroid storm is an indication for definitive therapy. What therapy for plantar fasciitis?
indication for therapy is involved? fasciitis? Stretching + arch support + NSAIDs
definitive therapy. Thyroidectomy [...]
What therapy is
involved? Plantar Fasciitis key points:
[...] - involves very severe pain at the sole of
the foot near the calcaneus that is worse
in the morning and improves w/ use;
45. What is the first and What is the first and most important thing to
unclear etiology
most important thing assess when a pt complains of back pain?
- exam is typically benign but typically
to assess when a pt The presence of alarm s/s
involves point tenderness where the
complains of back
fascia inserts into the calcaneus at the
pain?
bottom of the foot
[...]
- Tx begins w/ stretching + arch support
+ NSAIDs; steroids are used if ineffective;
surgical releasae of the fascia is rarely
46. A pt presents c/o of a A pt presents c/o of a rash and nail necessary
rash and nail pitting. Physical exam reveals a
pitting. Physical symmetric, well-demarcated rash
48. A pt is thought to A pt is thought to have Cushing's
exam reveals a consisting of silvery-scales on an
have Cushing's disease/syndrome. A 24 hr urine cortisol
symmetric, erythematous base. The rash is found on
disease/syndrome. A test confirms hypercortisolism. Follow up
well-demarcated the extensor surface of the elbows and
24 hr urine cortisol ACTH testing is high. As a follow up to
rash consisting of knees. Nail beds are pitted and mild
test confirms that, high dose DST yields suppression.
silvery-scales on an onycholysis is seen at the upper
hypercortisolism. What is the diagnosis?
erythematous base. digits.The pt adds that the scales bleed
Follow up ACTH Cushing's Disease 2/2 pituitary tumour
The rash is found on easily when picked. You suspect psoriasis.
testing is high. As a (get MRI to confirm; if MRI is equivocal
the extensor What is the first line treatment?
follow up to that, consider inferior petrosal sinus
surface of the UV Light (either natural or artificial)
high dose DST sampling)
elbows and knees.
yields suppression. - Pituitary tumours still retain feedback
Nail beds are pitted
What is the mechanisms
and mild
diagnosis? - Suppression after high dose DST =
onycholysis is seen
[...] ACTH secreting pituitary tumour
at the upper
(Cushing's Dz) as the pituitary retains
digits.The pt adds
feedback mechanisms.
that the scales bleed
- No suppression after high dose DST =
easily when picked.
ACTH secretion via paraneoplastic
You suspect
syndrome from a tumour elsewhere.
psoriasis. What is the
first line treatment?
[...]

49. A 60 y/o, A 60 y/o, posmenopausal, female pt is


posmenopausal, diagnosed w/ iron deficiency anaemia.
female pt is What follow up imaging test should be
diagnosed w/ iron done?
deficiency anaemia. Colonoscopy (to look for GI source of
What follow up bleeding/cancer)
imaging test should
be done?
[...]

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54. What is the best What is the best overall diagnostic test for
50. What cause of What cause of invasive acute diarrhea is overall diagnostic test prolactinoma?
invasive acute associated w/ raw hamburgers? for prolactinoma? MRI
diarrhea is Enterhemorrhagic Escherichia coli [...]
associated w/ raw (O157:H7)
hamburgers? Remember, only get the MRI if prolactin
[...] levels are confirmed to be high and
secondary causes + pregnancy have all
been ruled out.

51. What is the most What is the most accurate and best overall
accurate and best test for hereditary spherocytosis?
overall test for Osmotic fragility test 55. What is the most What is the most accurate test for G6PD
hereditary Remember, a PBS is not enough for accurate test for deficiency?
spherocytosis? diagnosis and you must order osmotic G6PD deficiency? G6PD level but only 4-8 weeks after an
[...] fragility to confirm [...] acute hemolytic event
G6PD during an attack is NORMAL:
- this is because all of the cells that lacked
G6PD are already dead, bruh (i.e. the older
cells)
52. A pt is found to have A pt is found to have hyponatremia. What - newer cells will have G6PD (despite being
hyponatremia. What is the best first test to establish the deficient); however, during an attack,
is the best first test to diagnosis? because all of the bad cells are hemolyzed
establish the Serum osmolality and hence not part of the test, measured
diagnosis? g6pd levels will be artificially normal
[...]

56. What is the treatment What is the treatment for moderate


53. A 60 y/o female pt A 60 y/o female pt presents c/o of > 60 for moderate hypernatremia?
presents c/o of > 60 min of morning hand stiffness that hypernatremia? IV NS
min of morning improves with use as the day progresses. [...]
hand stiffness that Physical exam reveals subcutaneous
improves with use nodules. A Bx of the nodules reveals
as the day cholesterol deposits in all of them. What
progresses. Physical is the most likely diagnosis?
exam reveals Rheumatoid Arthritis 57. What is the "ABCDE" What is the "ABCDE" mnemonic for
subcutaneous mnemonic for assessing pigmented skin lesions for
nodules. A Bx of the assessing pigmented malignancy?
nodules reveals Cholesterol deposits in nodules is skin lesions for (see below)
cholesterol pathognomonic for RA. malignancy?
deposits in all of [...]
them. What is the
most likely
diagnosis?
[...]

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58. A pt presents c/o of a A pt presents c/o of a skin lesion on his 62. Which drugs are Which drugs are more commonly known to
skin lesion on his face. Physical exam reveals an more commonly cause drug reactions (such as erythema
face. Physical exam erythematous pigmented lesion with a known to cause drug multiforme, SJS, TEN)?
reveals an sandpaper-like yellow-brown scaly reactions (such as Sulfa drugs; anticonvulsants; NSAIDs;
erythematous appearance. The pt states that he spends erythema multiforme, PCNs
pigmented lesion a lot of time in the sun working in SJS, TEN)?
with a construction. What is the most likely dx? [...]
sandpaper-like Actinic Keratosis Note that sulfa drugs includes thiazides,
yellow-brown scaly furosemide and sulfonylureas
appearance. The pt
states that he spends
63. What type of What type of bleeding is seen in DIC?
a lot of time in the
bleeding is seen in Platelet and factor type bleeding
sun working in
DIC?
construction. What is
[...]
the most likely dx?
Remember, DIC involves widespread fibrin
[...]
clot formation that consume both
platelets and factors, setting the stage for
59. Which seronegative Which seronegative spondyloarthropathy is bleeding from everywhere.
spondyloarthropathy associated w/ keratoderma
is associated w/ blennorhagicum, a skin lesion that
keratoderma resembles pustular psoriasis?
blennorhagicum, a Reactive arthritis (Reiter syndrome)
skin lesion that
resembles pustular
psoriasis?
[...]

60. A pt is diagnosed w/ A pt is diagnosed w/ secondary adrenal


secondary adrenal insufficiency. What is the treatment?
insufficiency. What Prednisone only
is the treatment?
[...]
Secondary adrenal insufficiency is 2/2
pituitary failure (no ACTH). So replace only
what is needed (cortisol)

61. How do IgE levels How do IgE levels change in atopic


change in atopic dermatitis?
dermatitis? Increased
[...]

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64. A pt presents w/ GI A pt presents w/ GI bleed. What is the first 66. What type of GI What type of GI bleed is associated w/
bleed. What is the step in management every time? bleed is associated hematochezia?
first step in Stabilize the pt w/ hematochezia? Typically LGIB; possible UGIB if severe
management every [...] enough
time?
[...] Everytime, brah. Do not get that EGD until
stabilization measures have been done.
Stabilization in GI Bleed key points:
- always done first
- involves both supportive and prophylactic
measures:
--- obtain 2 peripheral, large bore IV
67. Hereditary Hereditary Spherocytosis involves
access points
Spherocytosis hemolysis due to a lack of RBC membrane
--- start IVF
involves hemolysis structural proteins. Which proteins are/can
--- start IV PPIs; PPIs in this setting helps
due to a lack of RBC be deficient?
the stomach/esophagus heal (by increasing
membrane structural Ankyrin, spectrin, band 3.1, pallidin
pH) if the bleeding source is
proteins. Which
gastric/esophageal; if it isn't, the PPIs do
proteins are/can be
not cause any harm, so it is better to give it
deficient?
empirically at the start
[...]
--- order a CBC to monitor changes
--- order a blood type and cross to
prepare for tranfusions; if severe enough, 68. What is the treatment What is the treatment for severe
go ahead and order blood for severe hyponatremia?
--- order coags (PT/PTT) hyponatremia? IV 3% NaCl solution
--- if mesenteric ischemia is suspected, get [...]
an EKG
--- if the pt is a known cirrhotic, start IV In severe hyponatremia, the pts need
octreotide (to target variceal bleeding) and hypertonic solution.
IV ceftriaxone/FQ (to ppx against SBP)

69. Paroxysmal nocturnal Paroxysmal nocturnal hemoglobinuria


hemoglobinuria involves complement fixation on RBCs that
involves complement then leads to hemolysis. Complement
65. What is the treatment What is the treatment for von Willebrand's fixation on RBCs that fixation occurs every time, so why is the
for von Willebrand's disease? then leads to disease linked to nighttime?
disease? Replacement clotting factor only while hemolysis. Transient hypoxemia at night
[...] the pt is actively bleeding; mild cases Complement fixation accelerates complement fixation
may improve with desmopressin occurs every time, so
why is the disease
linked to nighttime? The paroxysmal and nocturnal nature of
[...] PNH:
- the paroxysmal and nocturnal nature is
thought to be 2/2 transient hypoxemia 2/2
hypoventilation at night
- this is thought to accelerate complement
fixation, leading to the morning urine being
dark
- the dark urine is 2/2 bilirubin and Hgb, not
actual blood

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74. Which HAART drug Which HAART drug is routinely given


70. What is the treatment What is the treatment for hypovolemic is routinely given intrapartum to every pregnant HIV pt?
for hypovolemic hyponatremia? intrapartum to every Zidovudine (AZT)
hyponatremia? IVF pregnant HIV pt?
[...] Note that Vaptans are c/i in [...]
hyponatremic hyponatremia and are Baby is also given AZT intrapartum and for
never the right answer. 6 weeks after.

75. If a pt is suspected to If a pt is suspected to have meningitis, but


have meningitis, but has s/s of increased ICP (papilledema,
has s/s of increased seizures, FNDs, confusion), an LP is
71. What is the treatment What is the treatment for folate deficiency? ICP (papilledema, contraindicated and a CT should be
for folate deficiency? Folic acid, 1 mg, PO, qD seizures, FNDs, ordered. What should be done prior to the
[...] confusion), an LP is CT?
contraindicated and a Start empiric Abx
CT should be
72. What is the safest What is the safest antidiabetic drug to use ordered. What should
antidiabetic drug to in newly diagnosed diabetics? be done prior to the If there is a contraindication to immediate
use in newly Metformin CT? LP, give Abx asap to help keep the pt alive
diagnosed diabetics? [...]
[...]
It does not cause hypoglycemia. 76. What is the What is the diagnostic test for Molluscum
It does not cause weight gain. diagnostic test for Contagiosum?
It typically causes GI upset and/or Molluscum None, it's clinical
diarrhea. Contagiosum?
C/I in renal failure/impairment1 [...]
Look for the characteristic vesicles with
73. A pt is dx with A pt is dx with pyelonephritis and empiric IV central umbilication.
pyelonephritis and Abx are started. After 72 hrs, the pt shows While not an ulcerative disease, questions
empiric IV Abx are no improvement. What is the most often ask to differentiate vs. the usual
started. After 72 hrs, appropriate next step in management? suspects (HSV, Chancroid, Syphilis)
the pt shows no CT to look for abscess (U/S if preggo) Tx is to freeze them off.
improvement. What
is the most
appropriate next step Pyelonephritis Tx key points:
in management? - notice how initial Tx is IV? Pyelonephritis
[...] needs to be admitted for IV abx until the
pt is afebrile and shows improvement
- once afrebrile, d/c with PO FQ abx for 14d
- if there is no improvement, order a CT to
r/o abscess

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77. A pt is given a A pt is given a penicillin and develops a 80. A pt presents with A pt presents with dysuria, urinary
penicillin and widespread rash. Physical exam reveals a dysuria, urinary frequency and urgency. He denies any
develops a rash with widespread loss of sheets of frequency and fever, n/v, or chills. Physical exam reveals
widespread rash. skin with a positive nikolsky sign urgency. He denies mild suprapubic tenderness. You suspect a
Physical exam affecting > 30% of body surface area. any fever, n/v, or UTI. What is the most likely Dx?
reveals a rash with Biopsy reveals total epidermal thickness chills. Physical exam Cystitis
widespread loss of necrosis. What is the most likely reveals mild
sheets of skin with a diagnosis? suprapubic
positive nikolsky Toxic Epidermal Necrolysis tenderness. You
sign affecting > 30% suspect a UTI. What
of body surface area. is the most likely Dx?
Biopsy reveals total [...]
epidermal thickness
necrosis. What is
81. What type of rash is What type of rash is seen in Lyme
the most likely
seen in Lyme disease?
diagnosis?
disease? Erythema migrans, a target-shaped
[...]
[...] (bull's eye) rash

78. A pt presents with A pt presents with fever, cough, night


fever, cough, night sweats, weight loss and hemoptysis. He
sweats, weight loss has risk factors for TB. You suspect TB. A
82. What type of chest What type of chest pain is often associated
and hemoptysis. He CXR is positive. What is the most
pain is often with pneumonia?
has risk factors for appropriate next step in management?
associated with Pleuritic chest pain
TB. You suspect TB. Isolate the pt and AFB smear and
pneumonia?
A CXR is positive. culture
[...]
What is the most Collect early morning sputum and get
appropriate next step atleast 3 cultures 8 hrs apart.
in management? To help ensure a true result, get 3 early 83. A pt presents with A pt presents with fever and cough
[...] morning sputums 24 hrs apart. fever and cough productive of sputum. Physical exam
Your last ditch effort if you have a very high productive of sputum. reveals crackles in the left lung. CXR
suspicion of TB is nucleic acid assay. Physical exam reveals unilateral lobar consolidation.
reveals crackles in The pt states that he has not been
the left lung. CXR hospitalized in the past 90 days. You
reveals unilateral suspect community-acquired pneumonia.
lobar consolidation. What is the most appropriate treatment if
The pt states that he this pt is sent home?
79. What is the most What is the most accurate diagnostic test
has not been Macrolide only
accurate diagnostic for infective endocarditis?
hospitalized in the
test for infective TEE
past 90 days. You
endocarditis?
suspect
[...]
community-acquired
Looking directly at the valves for vegetation
pneumonia. What is
(often a TTE is done first due to ease and
the most appropriate
to quickly identify any valvular defects if
treatment if this pt is
present)
sent home?
[...]

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84. Which antibiotic is Which antibiotic is added to ceftriaxone 89. A pt w/ SLE suffers A pt w/ SLE suffers from severe joint pain
added to ceftriaxone (+vancomycin) in the empiric treatment of from severe joint pain and asks to get an x-ray. What joint XR
(+vancomycin) in the meningitis in an immunocompromised and asks to get an findings are seen in SLE?
empiric treatment of pt? x-ray. What joint XR Normal (there is no deformation or joint
meningitis in an Ampicillin findings are seen in erosion in SLE arthritis)
immunocompromised SLE?
pt? [...]
[...] Listeria is resistant to all
cephalosporins but is sensitive to
90. A pt is diagnosed w/ A pt is diagnosed w/ an acute leukostasis
penicillins.
an acute reaction. What is the most appropriate
- if a risk factor for Listeria is present, add
leukostasis initial therapy?
ampicillin
reaction. What is the Leukapheresis
- risk factors include:
most appropriate
initial therapy?
85. Which cause of Which cause of community acquired [...] It is more important to remove the excess
community acquired pneumonia is associated with leukocytes than to establish a specific
pneumonia is contaminated water sources, air diagnosis/etiology. Diagnosis is not as
associated with conditioning units or ventilation systems? important as treatment.
contaminated water Legionella sp.
sources, air
91. Reducing future Reducing future flares and inducing
conditioning units or
flares and inducing remission are important parts of treating
ventilation systems?
remission are SLE. Which DMARD is preferred to
[...]
important parts of achieve this in SLE?
treating SLE. Which Hydroxychloroquine
86. Albinism and Albinism and piebaldism are both DMARD is preferred Notice the difference here vs. Rheumatoid
piebaldism are both hypopigmenting disorders. What is the to achieve this in Arthritis:
hypopigmenting difference? SLE? - in SLE, this is achieved via
disorders. What is (see below) [...] hydroxychloroquine (methotrexate is 2nd
the difference? line)
[...] - in RA, this is achieved via methotrexate
Albinism = normal melanocytes, deficient
tyrosinase = depigmentation everywhere
Piebaldism = abnormal melanocyte
92. What PBS findings What PBS findings are associated w/
migration = white forelock on the scalp
are associated w/ myelofibrosis?
myelofibrosis? Teardrop-shaped cells; nucleated RBCs
87. A pt has HIV/AIDS. A pt has HIV/AIDS. At what CD4 count [...]
At what CD4 count does miliary TB become a worry?
does miliary TB < 200
become a worry?
[...]

88. Which area of the Which area of the skin is affected in


skin is affected in cellulitis?
cellulitis? Dermis
[...]

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93. A pt is given a A pt is given a penicillin and develops a 97. A pt presents w/ A pt presents w/ hypercalcemia. She is
penicillin and rash. Physical exam reveals multiple, hypercalcemia. She currently receiving treatment for breast
develops a rash. widespread, small, target-shaped is currently receiving cancer. Labs reveal elevated Ca, elevated
Physical exam lesions over the back, trunk, palms, and treatment for breast PO4 and decreased PTH. What is the
reveals multiple, soles. The oral mucosa is spared. You cancer. Labs reveal most likely dx?
widespread, small, suspect erythema multiforme. What is the elevated Ca, Hypercalcemia of malignancy (in this
target-shaped treatment? elevated PO4 and cause likely 2/2 metastasis)
lesions over the Remove the causal drug decreased PTH. Hypercalcemia of malignancy involves
back, trunk, palms, What is the most elevated Ca and PO4 (from metastasis to
and soles. The oral likely dx? bone) or elevated Ca and decreased
mucosa is spared. However, it is prudent to consider chronic [...] PO4 (from paraneoplastic PTH-rp
You suspect HSV, and if a possibility, pursue testing and release; typically in SCC of the lung).
erythema multiforme. tx w/ acyclovir. Because PTH is low in meta, the kidney
What is the cannot win and hence PO4 levels are
treatment? high.
[...] Because PTH is low but PTH-rp is high in
paraneoplastic syndrome, the kidney wins
and PO4 levels are low.
94. What is the best What is the best diagnostic test for plantar
diagnostic test for fasciitis?
plantar fasciitis? None
[...]

XRay is not useful as there is no correlation


w/ heel spurs. 98. Which component of Which component of blood is fresh frozen
blood is fresh frozen plasma typically used to replace?
plasma typically Clotting factors
95. A pt is thought to A pt is thought to have Cushing's
used to replace? However, FFP is not a choice in
have Cushing's disease/syndrome. A 24 hr urine cortisol
[...] Hemophilia A or B.
disease/syndrome. A test confirms hypercortisolism. Follow up
24 hr urine cortisol ACTH testing is low. What is the
test confirms diagnosis? 99. What is the long What is the long term therapy for
hypercortisolism. Cushing's Syndrome 2/2 adrenal tumour term therapy for angioedema?
Follow up ACTH (get CT/MRI to confirm) angioedema? Androgens (danazole or stanazole)
testing is low. What [...]
is the diagnosis?
[...] Dan and Stan.

96. What is the genetic What is the genetic inheritance of sickle


inheritance of sickle cell anaemia?
cell anaemia? AR
[...]

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100. A pt presents c/o of A pt presents c/o of an evolving rash. He


103. A pt present c/o hair A pt present c/o hair loss. Physical exam
an evolving rash. He states that a few weeks ago he noticed a
states that a few single, flat, elliptical, salmon-coloured loss. Physical exam reveals patchy alopecia on the scalp w/
weeks ago he macule that has now spread. Physical reveals patchy scales and erythema. You suspect tinea
noticed a single, exam reveals multiple salmon-coloured alopecia on the capitis. What is the best diagnostic test?
flat, elliptical, scaly lesions with trailing scales. The scalp w/ scales and KOH prep (to visualize the fungus)
salmon-coloured palms and soles are spared. What is the erythema. You
macule that has now most likely dx? suspect tinea capitis.
spread. Physical Pityriasis rosea What is the best Tinea Capitis (vs. other alopecia) key
exam reveals Note that in darked skin pts, the lesions diagnostic test? points:
multiple may be hyperpigmented. [...] - tinea capitis involves well-defined
salmon-coloured Note that a trailing scale is a scaly lesion circular patch of alopecia with
scaly lesions with whose scales do not reach the edge of scales/erythema and hairs at equal
trailing scales. The the lesions. length
palms and soles are Pityriasis Rosea typically begins with a - alopecia areata involves patchy alopecia
spared. What is the herald patch (single, flat, elliptical, without scales or erythema
most likely dx? salmon-coloured macule) that then evolves - trichotillomania involves patchy alopecia
[...] into multiple macules. without equal hair length at the lesion

104. Septic arthritis is Septic arthritis is typically split into


typically split into non-gonococcal and gonoccocal
101. What is the best What is the best initial therapy for non-gonococcal arthritis. Which type is typically 2/2 direct
initial therapy for osteoporosis? and gonoccocal inoculation and/or hematogenous
osteoporosis? Vitamin D + Ca + bisphosphonates arthritis. Which type spread?
[...] is typically 2/2 direct Non-gonococcal (i.e. Staphylococcus)
inoculation and/or Staph can get into the joint via:
Osteoporosis treatment key points: hematogenous - direct inoculation (i.e. the arrow sticking
- vit D and Ca are 1st line spread? out of the pt's knee)
- bisphosphonates come into play when [...] - hematogenous spread typically from
DEXA scan is < -2.5 (i.e. osteoporosis, but IVDA or endocarditis
not osteopenia); remember the association
with osteonecrosis of the jaw and 105. Mammography is the Mammography is the most commonly used
pill-induced esophagitis most commonly used imaging technique when screening for or
- consider estrogen replacement in imaging technique working up breast cancer. In which
postmenopausal women when screening for situations is ultrasound appropriate?
- consider raloxifene as an alternative to or working up breast If the lesion is painful or varies in
estrogen as it reduces breast cancer risk cancer. In which size/pain w/ menstruation
and decreases LDL situations is
- consider teriparatide, a PTH analogue ultrasound
that stimulates new bone matrix formation; appropriate? U/S is the best for seeing if a breast lesion
may cause osteosarcoma and [...] is cystic or solid.
hypercalcemia
- consider nasal calcitonin to decrease
106. A pt is dx w/ A pt is dx w/ Stevens-Johnson Syndrome.
the risk of vertebral fractures
Stevens-Johnson Why is respiratory failure a risk in this pt?
Syndrome. Why is SJS involves sloughing of respiratory
102. What is the most What is the most common cause of respiratory failure a epithelium as well
common cause of hypercortisolism? risk in this pt?
hypercortisolism? Cushing's disease (pituitary tumour) [...]
[...]

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107. Dermatitis Dermatitis herpetiformis is an 110. Rituximab can be Rituximab can be used to control
herpetiformis is an autoimmune cutaneous disorder that used to control rheumatoid arthritis that does not response
autoimmune resembles bullous disease, but truly isn't. rheumatoid arthritis to DMARDs + anti-TNF agents. What is
cutaneous disorder What protein/enzyme in the dermis is that does not the notable side effect of rituximab?
that resembles targeted? response to Infection
bullous disease, but Transglutaminase (via IgA) DMARDs + anti-TNF
truly isn't. What Dermatitis herpetiformis is really a agents. What is the
protein/enzyme in deposition disease at the dermal notable side effect of
the dermis is papillae and is the cutaneous rituximab?
targeted? manifestation of Celiac disease (and has [...]
[...] the same pathology of targeting
transglutaminase). This causes extension
111. A pt w/ HTN and A pt w/ HTN and hypokalemia is
of the epidermis and manifests as
hypokalemia is suspected to have hyperaldosteronism.
multiple, small, pruritic eruptions on the
suspected to have Aldosterone:renin ratio is high (> 20),
extensor surfaces or legs/buttocks.
hyperaldosteronism. with decreased renin. What is the most
Aldosterone:renin appropriate next step in management?
ratio is high (> 20), Salt Suppression Test (200g Na load
with decreased should normally decrease aldosterone)
renin. What is the
108. A pt presents c/o of A pt presents c/o of multiple, small, scaly most appropriate
multiple, small, patches with varying pigmentation. You next step in Workup of Hyperaldosteronism key
scaly patches with suspect tinea versicolour. KOH prep management? points:
varying confirms. What is the treatment? [...] - it's similar to the workup for Cushing's:
pigmentation. You Selenium sulfide (topical) first determine whether or not there really
suspect tinea is an excess of aldosterone
versicolour. KOH (aldosterone:renin ratio); then determine
prep confirms. What the cause (i.e. is it renin dependent?)
is the treatment? - First determine the presence of
[...] hyperaldosteronism:
--- aldosterone:renin ratio is the best
initial test; be sure to d/c
109. Which blistering skin Which blistering skin disease is associated
antihypertensives as ACE-I, CCBs, and
disease is associated with hemochromatosis?
diuretics can confound the test
with Porphyria cutanea tarda
--- elevated renin rules out Conn'
hemochromatosis?
Syndrome, and points towards a
[...]
secondary cause
PCT is often seen with a history of (or
- if Conn syndrome (primary) is
brought upon by) these disorders:
suspected, order salt suppression test
- Hepatitis C
(200 g Na load should normally decrease
- EtOH use
aldosterone levels); follow up with CT/MRI
- OCPs (or just estrogen use in general)
to localize the lesion if positive
- Hemochromatosis (or other iron
- remember to do adrenal vein sampling
overload)
to localize the lesion to a side and look for
an "incidentaloma"

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112. What is the best What is the best initial empiric therapy for 116. A pt presents c/o of A pt presents c/o of asymmetrical,
initial empiric therapy septic arthritis? asymmetrical, bilateral artheritis at the lower back and
for septic arthritis? Vanco + ceftriaxone bilateral artheritis at hands. He also complains of itchy eyes.
[...] the lower back and His PMHx is negative except for a recent
hands. He also history of Chlamydia urethritis. Physical
complains of itchy exam reveals mildly red, injected
113. What is the What is the diagnostic criteria for diabetes
eyes. His PMHx is conjuncitvae indicative of conjunctivitis.
diagnostic criteria for mellitus using random blood glucose?
negative except for a You suspect reactive arthritis. What is the
diabetes mellitus 1 measurement > 200
recent history of best initial diagnostic test?
using random blood
Chlamydia Swab + PCR/culture for the STD
glucose?
urethritis. Physical Note that it's typically with nongonococcal
[...]
exam reveals mildly urethritis.
red, injected Here, we are essentially looking for the
114. A pt is given A pt is given procainamide and soon after conjuncitvae STD. So if it presents this way, you can
procainamide and develops a malar rash and indicative of avoid arthrocentesis and look for the STD.
soon after develops polyarthralgia. You suspect drug-induced conjunctivitis. You If urethral discharge is not present,
a malar rash and SLE. Anti-histone antibody testing is suspect reactive consider swabbing elsewhere for the STD
polyarthralgia. You positive. What is the tx? arthritis. What is the (i.e. anywhere semen can go, including the
suspect Stop the drug best initial diagnostic anus and oropharynx)
drug-induced SLE. test?
Anti-histone antibody [...]
testing is positive.
What is the tx?
[...]

115. What is the curative What is the curative treatment for CML? 117. What is the treatment What is the treatment for SIADH?
treatment for CML? Bone marrow transplant for SIADH? Water restriction; reverse underlying
[...] [...] cause; demeclocycline if needed
Water restriction allows the body to get
Imatinib is the best initial therapy. rid of the excess water by any means
necessary.
Demeclocyline can induce nephrogenic
DI if needed

118. What is the first line What is the first line therapy for
therapy for fibromyalgia?
fibromyalgia? Amitriptyline
[...]

Other options include milnacipran (SNRI)


or pregabalin

119. Which thyroid cancer Which thyroid cancer has the worst
has the worst prognosis?
prognosis? Anaplastic
[...]

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120. Which demographic Which demographic is most commonly 124. Which major cerebral Which major cerebral vessel is the most
is most commonly affected by sickle cell anaemia? vessel is the most common site of stroke?
affected by sickle cell AA common site of MCA
anaemia? stroke?
[...] [...]
90% of cases

121. A pt presents w/ A pt presents w/ hypercalcemia. She is


hypercalcemia. She currently receiving treatment for squamous 125. Which visual deficit is Which visual deficit is seen following an
is currently receiving cell carcinoma of the lung. Labs reveal seen following an MCA stroke?
treatment for elevated Ca, decreased PO4 and MCA stroke? Contralateral homonymous hemianopia
squamous cell decreased PTH. What is the most likely [...]
carcinoma of the dx?
lung. Labs reveal Hypercalcemia of malignancy (in this i.e. loss of visual field on the opposite side
elevated Ca, cause likely 2/2 paraneoplastic PTH-rp of the stroke, thereby causing eye
decreased PO4 and release; confirm with specific PTH-rp deviation to the ipsilateral side
decreased PTH. testing) "Eyes look towards the lesion"
What is the most
likely dx?
126. What speech deficits What speech deficits are seen following an
[...] Hypercalcemia of malignancy involves
are seen following an MCA stroke?
elevated Ca and PO4 (from metastasis
MCA stroke? Aphasia
to bone) or elevated Ca and decreased
[...]
PO4 (from paraneoplastic PTH-rp
release; typically in SCC of the lung).
Obvious, but remember that 10% of pts
Because PTH is low in meta, the kidney
are left handed (i.e. right brain dominant)
cannot win and hence PO4 levels are
The speech center is always located in the
high.
dominant hemisphere (90% of the time it's
Because PTH is low but PTH-rp is high in
on the left).
paraneoplastic syndrome, the kidney wins
and PO4 levels are low.
127. What is the classic What is the classic triad of symptoms
triad of symptoms following an ACA stroke?
following an ACA Personality/cognitive changes (i.e.
stroke? confusion); urinary incontinence; lower
[...] extremity weakness

122. What is the 3rd most What is the 3rd most common cause of
common cause of death in the USA?
Or more lower extremity weakness vs.
death in the USA? Stroke
upper.
[...]

128. What is the best What is the best initial test for stroke?
123. What is the most What is the most common type of stroke?
initial test for stroke? CT w/o contrast
common type of Ischemic
[...]
stroke?
[...]
MRI is the most accurate, but a CT is
85% ischemic (thrombotic; embolic: AFib,
needed initially to rule out hemorrhage
valvular disease, DVT via PFO)
prior to treatment
15% hemorrhagic
CT needs 4-5 d to have > 95% sensitivity;
MRI needs 1-2

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129. What is the best What is the best initial therapy for an 133. Which drug(s) are Which drug(s) are most effective at
initial therapy for an ischemic stroke? most effective at preventing stroke?
ischemic stroke? tPA (if < 3 hrs); aspirin (if > 3 hrs) preventing stroke? Aspirin (± dipyradimole) OR clopidogrel
[...] [...]

Do not give both together (hemorrhage


risk; however the CHANCE study in 2013
showed benefit in TIA and mild ischemic
stroke).
130. What is the threshold What is the threshold duration from the
ASA is the mainstay treatment unless:
duration from the onset of stroke for the use of tPA?
- ASA allergy
onset of stroke for < 3 hrs
- active GI bleed
the use of tPA?
- past stroke while on ASA
[...]
In such cases, switch to Plavix.
Some places use < 4.5 hrs.
Thrombolytics are the standard of care
< 3 hours. 134. Which class of Which class of antihyperlipidemics should
antihyperlipidemics be added to a stroke pt's regimen
should be added to a regardless of LDL?
131. What is the best What is the best initial therapy for
stroke pt's regimen Statins
initial therapy for hemorrhagic stroke?
regardless of LDL?
hemorrhagic stroke? Nothing
[...]
[...]
LDL target is currently unclear, but we
should aim for < 70 or atleast < 100.
There's really no treatment to reverse the
stroke.
Surgical drainage will not help outside of 135. What is the target What is the target INR in a patient with atril
the posterior fossa. INR in a patient with fibrillation/flutter?
atril fibrillation/flutter? 2-3
[...]
132. Which drug should Which drug should be added to the
be added to the management of stroke in a pt that was
management of already on aspirin? 136. Which diagnostic Which diagnostic tests should be
stroke in a pt that Dipyridamole tests should be considered when evaluating the cause of a
was already on considered when stroke?
aspirin? evaluating the cause Echocardiogram; EKG; carotid duplex
[...] Or you switch to clopidogrel. of a stroke? U/S
Dipyridamole inhibits platelet aggregation [...]
by increasing intraplatelet [cAMP], an
inhibitor of platelet function. In high doses, Echo: looks for valvular disease,
its PDE5 inhibitory function can cause intraventricular thrombus, PFO
vasodilation. Chronic use offers antiplatelet EKG: looks for AFib/flutter; consider a
activity. Holter monitor if EKG and telemetry is
normal
Carotid duplex: looks for carotid stenosis
(a very common cause of embolic stroke)

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137. What percentage of What percentage of carotid stenosis is an 142. What is the rationale What is the rationale for the use of tPA in
carotid stenosis is an indication for surgical intervention? for the use of tPA in stroke?
indication for surgical > 70% stenosis with symptomatic stroke? Clot buster; rescues ischemic tissue
intervention? cerebrovascular disease [...] and can save the penumbra
[...] Contraindicated if: surgery in 21 days or
s/p head trauma
Endarterectomy is the intervention of Only indicated within 3 hrs of onset of
choice and is superior to carotid symptoms
angioplasty. Never, ever used in hemorrhagic stroke
Endarterectomy has no value for (and there is a risk of ischemic stroke
stenosis < 50%. transforming into hemorrhagic)
If there is 100% stenosis, then no Permissive hypertension s/p tPA use may
intervention is needed. aid the penumbra to recover (as well as
O2 > 95% and tight glycemic control
(60-100)
138. What is the What is the procedure of choice in the
procedure of choice intervention of > 70% carotid stenosis in a
in the intervention of stroke pt?
> 70% carotid Carotid endarterectomy 143. What is the most What is the most common type of primary
stenosis in a stroke common type of headache?
pt? primary headache? Tension
[...] Carotid angioplasty w/ stenting has no [...]
proven value for stroke pts.
However, we rarely see these. Pts simply
take OTCs and are fine.
139. What is the LDL goal What is the LDL goal in a pt with carotid
in a pt with carotid stenosis?
stenosis? < 100 144. Which sex is more Which sex is more commonly affected by
[...] commonly affected cluster headaches?
by cluster Men (10x more)
Carotid stenosis is considered CAD, so the headaches?
goal is < 100 mg/dL. [...]

140. What is the target What is the target HbA1C level in stroke 145. Which type of Which type of primary headache is known
HbA1C level in prevention in a diabetic pt? primary headache is to occur multiple times a day for many
stroke prevention < 7% known to occur weeks but is absent for months to years
in a diabetic pt? multiple times a without symptoms?
[...] day for many weeks Cluster headaches
but is absent for
months to years
141. What should be What should be suspected/considered in a
without symptoms? In fact, this is where the name comes from:
suspected/considered pt that develops painful neck pulsations
[...] its sporadic and grouped presentation
in a pt that develops and grabs their neck in pain?
painful neck Embolic stroke 2/2 carotid dissection
pulsations and
grabs their neck in
pain?
[...]

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146. Which type of Which type of primary headache may 151. Which type of Which type of primary headache is known
primary headache occasionally present with Horner primary headache is to cause a lingering malaise/"hangover"
may occasionally syndrome? known to cause a after it has been aborted?
present with Horner Cluster headache lingering Migraine
syndrome? malaise/"hangover"
[...] after it has been
Classic pentad involves: aborted? Sleep is the most common method of
- eye redness [...] aborting migraines. The hangover can
- rhinorrhea extend into the next morning.
- lacrimation
- injected conjunctiva
152. What is the treatment What is the treatment for mild active
- severe, unilateral, periorbital pain
for mild active migraines?
migraines? NSAIDs
147. Which ophthalmic Which ophthalmic condition should be [...]
condition should be considered with headache + a red eye?
considered with Glaucoma
153. What is the treatment What is the treatment for severe
headache + a red
for severe migraines?
eye?
migraines? Triptan; ergotamine
[...]
[...]

148. In which 2 primary In which 2 primary headaches is brain Start therapy early to reduce the need for a
headaches is brain imaging suggested? back up or add-on drug (e.g. NSAID).
imaging suggested? Migraine; Cluster Avoid ergotamines in CAD as they can
[...] cause vasospasm.

Some studies have shown an association


154. Which drug classes Which drug classes can be used as
with tumours and cluster HA, despite its
can be used as prophylactic therapy for migraines?
vascular nature.
prophylactic therapy BBs; CCBs; TCAs; SSRIs;
for migraines? antiepileptics; botox injections
149. What is the treatment What is the treatment to abort a cluster [...]
to abort a cluster headache?
headache? High flow, 100% O2 Avoidance of triggers is also advised.
[...] Propanolol is considered the best
choice.
If this fails, give triptans, ergotamine, Verapamil is the CCB most used.
prednisone or lithium. Amitriptyline is the TCA most used.
Topiramate is the antiepileptic most used.

150. Which class of drugs Which class of drugs can be used as


can be used as prophylactic therapy for cluster headache? 155. What type of primary What type of primary headache is
prophylactic therapy CCBs headache is associated with chronic analgesic use?
for cluster associated with Analgesic Rebound HA
headache? chronic analgesic
[...] Typically verapamil. use?
However, since cluster headaches come in [...] Any type of analgesics, including triptans
clusters and then disappear for and ergots.
months/year, prophylaxis is still iffy as
many forms take several weeks to have
effect, and the cluster often passes before
then.

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156. What is the treatment What is the treatment for analgesic 160. Which cause of Which cause of secondary headache
for analgesic rebound headache? secondary headache involves progressively worsening
rebound headache? Removal of the causative drug involves headaches that may be worse in the
[...] progressively mornings?
worsening Intracranial tumour
This one is tricky. Pt's need to be headaches that may
counseled on what's going on and advised be worse in the
to tough out the headache and avoid mornings? Order the CT, biopsy, then consider
analgesics. [...] radiation/chemo/Sx
This is essentially a withdrawal syndrome
from analgesics, so symptoms pass if
161. Which cause of Which cause of secondary headache
drugs are withheld.
secondary headache involves a sudden onset, severe headache
involves a sudden often described as "the worst headache
157. What are the What are the common red flag onset, severe in my life?"
common red flag signs/symptoms of a headache that headache often Subarachnoid hemorrhage (SAH)
signs/symptoms of a suggest high danger? described as "the
headache that (see below) worst headache in
suggest high my life?" Order the CT, consult neurosurgery stat,
danger? [...] control blood pressure
[...] - fever + headache (± nuchal tenderness)
- focal neurological deficits
162. What is another What is another name for Pseudotumour
- "worst headache of my life"
name for Cerebri?
- progressively worsening headache over
Pseudotumour Benign/Idiopathic Intracranial HTN
time (± worse in the AM)
Cerebri?
- nocturnal awakening 2/2 headache
[...]
- temporal tenderness (± diffuse muscle
pain, jaw claudication)
163. Which cause of Which cause of secondary headache
secondary headache presents with nausea/vomiting, s/s of
158. Which cause of Which cause of secondary headache
presents with increased ICP, worse with coughing and
secondary headache involves fever, headache and no focal
nausea/vomiting, a negative CT scan?
involves fever, neurological deficits?
s/s of increased Pseudotumour Cerebri
headache and no Meningitis
ICP, worse with (Benign/Idiopathic Intracranial HTN)
focal neurological
coughing and a
deficits?
negative CT scan?
[...] Do an LP, culture the CSF.
[...] i.e. presents like a mass effect headache
Start empiric ceftriaxone.
but without a mass
A negative CT/MRI is required for
159. What cause of What cause of secondary headache diagnosis (intracranial mass must be ruled
secondary headache involves fever, headache and focal out).
involves fever, neurological deficits? Common s/s of increased ICP include:
headache and focal Intracranial abscess - papilledema
neurological - diplopia 2/2 CN VI, abducens palsy
deficits?
[...] Order the CT, drain the abscess (and then
Cx), start Abx

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164. What is the What is the diagnostic test for 167. Which vitamin Which vitamin toxicity can be a cause of
diagnostic test for Pseudotumour Cerebri (Benign/Idiopathic toxicity can be a Pseudotumour Cerebri (Benign/Idiopathic
Pseudotumour Intracranial HTN)? cause of Intracranial HTN)?
Cerebri LP with normal CSF but increased Pseudotumour Vitamin A
(Benign/Idiopathic opening pressure Cerebri
Intracranial HTN)? (Benign/Idiopathic
[...] Intracranial HTN)? Withdraw vitamin supplementation if this is
Remember, a negative CT/MRI is also [...] suspected.
required.

168. What is the preferred What is the preferred diagnostic test for
165. What is the first step What is the first step in management of diagnostic test for primary headaches?
in management of Pseudotumour Cerebri (Benign/Idiopathic primary headaches? None
Pseudotumour Intracranial HTN) in a pt taking OCPs? [...]
Cerebri Withdrawal of the OCPs
(Benign/Idiopathic Tension/migraine/cluster/analgesic
Intracranial HTN) in a rebound headaches are all diagnosed
pt taking OCPs? Do this before considering other clinically.
[...] treatments However, if the syndrome has recently
started or there is suspicion, CT/MRI to
rule out intracranial mass is a good idea.
166. What is the first-line What is the first-line treatment for
treatment for Pseudotumour Cerebri (Benign/Idiopathic
Pseudotumour Intracranial HTN)? 169. What diagnostic tests What diagnostic tests are indicated for
Cerebri Acetazolamide (± furosemide); serial are indicated for giant cell temporal arteritis?
(Benign/Idiopathic LPs/VP shunting if refractory to medical giant cell temporal Biopsy; elevated ESR
Intracranial HTN)? therapy arteritis?
[...] [...]
ESR is typically markedly elevated.
This one is a bit controversial. UWorld and Remember, if giant cell arteritis is
other sources point towards acetazolamide suspected, always administer high
first, others say serial LPs or shunting. It dose roids prior to any diagnostic
seems like the recent trend is towards the testing.
drugs though.
Acetazolamide acts via
170. What is the best What is the best initial step in suspected
carbonic-anhydrase inhibition at the CNS,
initial step in giant cell temporal arteritis?
thereby decreasing CSF production
suspected giant cell Administration of high dose
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908600/).
temporal arteritis? corticosteroids
Lasix is sometimes added to alleviate the
[...]
increased ICP
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908600/).
Typically prednisone
Steroids can help.
Serial LPs function to rapidly decrease
ICP. 171. How many migraines How many migraines per month is the
VP shunt or fenestrating the optic nerve per month is the threshold for considering prophylactic
are options if all else fails. threshold for therapy?
considering ≥3
prophylactic therapy?
[...]
Best choice is propanol

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172. [...] is an idiopathic Trigeminal neuralgia is an idiopathic 176. What is the What is the treatment for postherpetic
neurological disorder neurological disorder characterized by treatment for neuralgia?
characterized by attacks of pain 2/2 chewing, touching the postherpetic (see below)
attacks of pain 2/2 face, or pronouncing certain words. neuralgia?
chewing, touching [...]
the face, or Any of the agents that target neuropathic
pronouncing certain Certain words that involve the tongue pain are strong options: TCAs, gabapentin,
words. hitting the back of the front teeth. pregabalin, carbamazepine, phenytoin.
Dx is clinical. Topical capsaicin can be helpful as well.
Tx w/ oxcarbazepine or carbamazepine Most antiepileptics are beneficial, but only
up to 50-70% of pts.
Typically, each of these are tried until a
173. What is the first line What is the first line treatment for
reliable choice is found. There is no
treatment for trigeminal neuralgia?
reliable first-line treatment for neuropathy.
trigeminal neuralgia? Oxcarbazepine or carbamazepine
[...]
177. At what age is the At what age is the herpes zoster vaccine
Lamotrigine and baclofen have been herpes zoster recommended in all adults?
effective. vaccine > 60 y/o
Gamma knife surgery or surgical recommended in all
decompression is curative if the pain is adults?
refractory to meds. [...] To prevent shingles and mitigate
symptoms if shingles does occur.

174. [...] is a neurological Postherpetic neuralgia is a neurological


pain syndrome that pain syndrome that manifests during 178. What is the What is the VITAMINS mnemonic for the
manifests during herpes zoster reactivation after the VITAMINS etiology of first-time seizure?
herpes zoster resolution of the vesicular lesions. mnemonic for the (see below)
reactivation after the etiology of first-time VITAMINS
resolution of the seizure? - note that I also stands for Ingestion and
vesicular lesions. Seen in ~15% of cases. [...] withdrawal (Benzos, EtOH, other drugs)
- all of these can cause CNS symptoms
prior to seizure (i.e. once they get worse,
175. Which drugs are Which drugs are used to reduce the
seizure occurs) such as, delirium, stupor,
used to reduce the incidence of postherpetic neuralgia?
obtundation, confusion, coma
incidence of Acyclovir; famciclovir; valgancilovir
postherpetic
neuralgia?
[...] i.e. antiherpetics
Steroids do not reduce the incidence.
179. Which sign/symptom Which sign/symptom associated with
associated with seizures is the most specific for seizures?
seizures is the most Post-ictal confustion
specific for seizures?
[...]
The convulsions, bowel/bladder
incontinence, tongue biting and LOC are
all unspecific. Patients may just have
syncope, for example.

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180. What is the most What is the most appropriate next step in 184. Which commonly Which commonly used antiepileptic is
appropriate next step the management of a pt with a first-time used antiepileptic is teratogenic?
in the management seizure that is not actively seizing? teratogenic? Depakote (valproic acid)
of a pt with a Observation; CT; VITAMINS workup; [...]
first-time seizure EEG
that is not actively
185. What is the most What is the most appropriate next step in
seizing?
appropriate next step the management of an active seizure in a
[...]
in the management pt with epilepsy?
of an active seizure Manage ABCs; then abort the seizure;
181. What is the first step What is the first step in management of a in a pt with then assess therapeutic drug levels;
in management of a pt with a first-time seizure that is actively epilepsy? then assess VITAMINS and get EEG
pt with a first-time seizing? [...]
seizure that is Manage ABCs; then abort the seizure;
actively seizing? then assess VITAMINS Remember, epileptics are more prone to
[...] Seizure abortion is achieved medically. VITAMINS to trigger a seizure. Don't
Start at the top of the list until something discount them just because the pt is
works: epileptic.
#1. IV/IM Benzos (typically, lorazepam or Seizure abortion is achieved medically.
diazepam) Start at the top of the list until something
#2. Phenytoin/Fosphenytoin works:
#3. Midazolam + propofol (pts typically #1. IV/IM Benzos (typically, lorazepam or
need to be intubated by this point) diazepam)
#4. Phenobarbital #2. Phenytoin/fosphenytoin
#3. Midazolam + propofol (pts typically
need to be intubated by this point)
#4. Phenobarbital

182. What is the first-line What is the first-line therapy for aborting
therapy for aborting seizures/status epilepticus?
seizures/status IV/IM benzodiazepines
epilepticus? 186. What is the most What is the most appropriate next step in
[...] appropriate next step the management of a pt with epilepsy that
Seizure abortion is achieved medically. in the management is not actively seizing?
Start at the top of the list until something of a pt with epilepsy Assess therapeutic drug levels; then
works: that is not actively assess VITAMINS and get EEG; then
#1. IV/IM Benzos (typically, lorazepam or seizing? assess if pt is on correct medication
diazepam) [...] based on seizure type
#2. Fosphenytoin (or Phenytoin; but Fos
is preferred)
#3. Phenobarbital Remember, epileptics are more
#4. Midazolam + propofol (i.e. susceptible to VITAMINS as a cause. Don't
anaesthesia, hence pts typically need to discount them just because they're
be intubated by this point) epileptic.

183. Which commonly Which commonly used antiepileptic can 187. What is the most What is the most appropriate next step if a
used antiepileptic cause gingival hyperplasia? appropriate next step pt has a seizure while having therapeutic
can cause gingival Phenytoin if a pt has a seizure levels of an antiepileptic?
hyperplasia? while having Switch to another agent
[...] therapeutic levels of
an antiepileptic?
[...]

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194. Which specific type Which specific type of seizure involves


188. What findings on an What findings on an EEG are indicative of of seizure involves preserved muscle tone with LOC?
EEG are indicative of seizure-like activity? preserved muscle Absence
seizure-like activity? Spikes and waves that display tone with LOC? LOC is very brief.
[...] organised neuronal firing [...] Typically these pts appear to be normal
while seizing, they just stare into space.

This is abnormal for adults in an awake Look out for that question that describes
state. possible absence seizures vs. ADHD in a
Can be normal in sleep states. kid. They have multiple absence seizures
during the day and don't realise it. All they
189. Which major type of Which major type of seizure involves see are short clips of their day. In a
seizure involves loss/alteration of consciousness? classroom setting, this can seem like
loss/alteration of Complex seizures ADHD as they don't pay attention, so read
consciousness? carefully.
[...]
195. Which specific type Which specific type of seizure involves
190. Which major type of Which major type of seizure does not of seizure involves jerky muscle movements without LOC?
seizure does not involve loss of consciousness? jerky muscle Myoclonic
involve loss of Partial seizure movements without
consciousness? LOC?
[...] [...]
Seizure is also focal to one part of the
body. 196. Which antiepileptic is Which antiepileptic is preferred in atonic
preferred in atonic seizures?
191. Which antiepileptics Which antiepileptics are generally favoured seizures? Depakote (valproic acid)
are generally in partial seizures? [...]
favoured in partial Carbamazepine; Phenytoin
seizures? Remember, atonic = loss of muscle tone
[...] with no LOC

192. Which antiepileptics Which antiepileptics are generally 197. Which antiepileptic is Which antiepileptic is preferred in absence
are generally preferred in generalized seizures? preferred in absence (petit-mal) seizures?
preferred in Valproic acid; lamotrigine (petit-mal) seizures? Ethosuximide
generalized [...]
seizures?
[...] Remember, absence seizures involve
positive muscle tone with LOC.

193. Which specific type Which specific type of seizure involves


of seizure involves loss of muscle tone without LOC? 198. Which antiepileptic is Which antiepileptic is preferred in
loss of muscle tone Atonic preferred in myoclonic seizures?
without LOC? myoclonic seizures? Depakote (valproic acid)
[...] [...]

199. Which antiepileptic is Which antiepileptic is preferred in tic


preferred in tic douloureux?
douloureux? Carbamazepine
[...]

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200. Why is Keppra Why is Keppra (levitiracetam) favoured for 205. What is the ultimate, What is the ultimate, last-resort therapy for
(levitiracetam) seizure ppx on the wards? last-resort therapy for unresolving seizure?
favoured for seizure It has a favourable side effect profile unresolving seizure? Neuromuscular blocking agent +
ppx on the wards? [...] general anaesthesia
[...]

e.g. succinylcholine + midazolam +


201. Which electrolyte Which electrolyte imbalances are most
propofol
imbalances are most commonly considered in the workup of
This method requires intubation.
commonly seizure?
Note, the neuromuscular blocking agent
considered in the Na, Ca, Mg, Glc
does not actually stop the seizure, just
workup of seizure?
stops external manifestations
[...]
Na: hypo or hyper
Glc: hypo 206. Which type of Which type of seizure is more common in
Ca: hypo seizure is more children?
Mg: hypo (rare) common in children? Absence (petit-mal)
[...]

202. When is an EEG When is an EEG indicated in the workup of


indicated in the seizure? 207. What are the What are the indications for starting
workup of seizure? When all other tests have been ordered indications for chronic antiepileptic use s/p a single
[...] and are negative starting chronic seizure?
antiepileptic use s/p Abnormal EEG; abnormal CT; FHx of
a single seizure? seizures
i.e. what's the use of an EEG if the pt is [...]
hyponatremic. You already have your likely
cause.
208. What is the first What is the first choice drug to treat
choice drug to treat epilepsy?
203. [...] is a neurological Epilepsy is a neurological disorder that is epilepsy? None
disorder that is characterized by seizures of unclear [...]
characterized by etiology.
seizures of unclear All of levetiracetam, phenytoin, valproic
etiology. acid & carbamazepine have the same
efficacy.
Keppra (levetiracetam) has the fewest
204. What is the benefit of What is the benefit of using fosphenytoin
side effects.
using fosphenytoin over phenytoin?
over phenytoin? Fewer adverse effects
[...] 209. What is the next best What is the next best step in the
step in the management of epilepsy if 2 separate
Phenytoin is also a class 1b management of antiepileptics have failed?
antiarrhythmic. When given IV it can cause epilepsy if 2 Combine 2 agents
hypotension and AV block. separate
Fosphenytoin does not have these antiepileptics have
adverse effects and can be given failed?
rapidly. [...]

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210. What is the next best What is the next best step in the 214. What is the most What is the most likely Dx of a pt with a
step in the management of epilepsy if 2 combined likely Dx of a pt with sudden onset of severe headache with
management of antiepileptics have failed? a sudden onset of stiff neck, photophobia, fever and LOC?
epilepsy if 2 Surgical correction can be considered severe headache Subarachnoid hemorrhage (SAH)
combined to resolve recurrences with stiff neck,
antiepileptics have photophobia, fever
failed? and LOC? (not meningitis)
[...] [...] Fever + meningeal irritation (stiff
neck/photophobia) does not always mean
meningitis.
211. What is the indication What is the indication to discontinue
Fever is 2/2 blood irritating the
to discontinue chronic antiepileptic use?
meninges.
chronic antiepileptic Being seizure-free for 2 years
LOC is 2/2 the sudden increase in ICP
use?
(seen in 50% of cases).
[...]
FND are seen in 30% of cases.
That is the standard of care.
Best test for recurrence: sleep deprivation
EEG 215. What causes the What causes the fever in subarachnoid
fever in hemorrhage?
subarachnoid Blood irritating the meninges
212. What is the best test What is the best test to tell if there is
hemorrhage?
to tell if there is possible recurrence of seizure after being
[...]
possible recurrence seizure-free?
of seizure after being Sleep deprivation EEG
seizure-free? 216. What causes LOC in What causes LOC in subarachnoid
[...] subarachnoid hemorrhage?
Sleep deprivation can elicit abnormal EEG hemorrhage? Rapid increase in ICP
activity but the test lacks high sensitivity. [...]

Seen in 50% of cases


213. Which type of Which type of intracranial hemorrhage is
intracranial typically caused by rupture of an aneurysm
hemorrhage is usually located in the anterior portion of 217. What are the key What are the key sign/symptoms of
typically caused by the circle of Willis? sign/symptoms of subarachnoid hemorrhage that point away
rupture of an Subarachnoid hemorrhage (SAH) subarachnoid from meningitis?
aneurysm usually hemorrhage that Very sudden onset; LOC
located in the point away from
anterior portion of the 2% of routine autopsies reveal aneurysms, meningitis?
circle of Willis? so the majority never rupture. [...] Severe HA, fever, and meningeal signs
[...] May be at the Anterior Communicating (stiff neck/photophobia) can be common
Artery between the two.
Conditions where they are more frequent:
- PCKD
218. What is the best What is the best initial diagnostic test for
- Tobacco smoking
initial diagnostic test subarachnoid hemorrhage?
- HTN
for subarachnoid CT without contrast
- HLP
hemorrhage?
- High EtOH use
[...]
95% sensitive

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219. What is the most What is the most accurate/sensitive test 225. What EKG findings What EKG findings are seen with
accurate/sensitive for subarachnoid hemorrhage? are seen with intracranial bleeding?
test for subarachnoid LP intracranial bleeding? Large/inverted T waves
hemorrhage? [...]
[...]
LP will reveal blood. aka Cerebral T waves
Only really indicated for the 5% of Thought to be due to excessive
suspected SAH cases that will have a sympathetic activity.
negative CT (CT is 95% sensitive).

226. What is required for What is required for the Dx of


220. What is What is xanthochromia? the Dx of subarachnoid hemorrhage?
xanthochromia? Yellow discolouring of the CSF 2/2 subarachnoid Symptoms + positive CT (± LP)
[...] breakdown of RBCs in CSF hemorrhage?
[...]

221. How does the CSF How does the CSF WBC count change in
WBC count change subarachnoid hemorrhage? 227. Which imaging Which imaging procedures are used to
in subarachnoid Increased procedures are used localize vessel rupture in subarachnoid
hemorrhage? to localize vessel hemorrhage?
[...] rupture in CT Angio; MRA
This mimics meningitis, therefore always subarachnoid
look at CSF WBC:RBC ratio hemorrhage?
- WBC:RBC ratio is normal in SAH [...]
(1:500-1000)

228. What is the treatment What is the treatment that reverses


222. How does the CSF How does the CSF WBC:RBC ratio that reverses subarachnoid hemorrhage?
WBC:RBC ratio change in subarachnoid hemorrhage? subarachnoid None exist
change in Normal hemorrhage?
subarachnoid [...]
hemorrhage?
[...] Normal is 1:500-1000
229. Which drug is used Which drug is used to prevent
to prevent subsequent ischemic stroke in
223. What is the normal What is the normal CSF WBC:RBC ratio? subsequent subarachnoid hemorrhage?
CSF WBC:RBC 1:500-1000 ischemic stroke in Nimodipine (CCB)
ratio? subarachnoid
[...] hemorrhage?
Ratio is normal in SAH, increased in [...]
meningitis

230. What is the treatment What is the treatment for hydrocephalus


224. When does a head When does a head CT or MRI require for hydrocephalus 2/2 subarachnoid hemorrhage?
CT or MRI require contrast? 2/2 subarachnoid VP shunt
contrast? To detect mass lesions hemorrhage?
[...] (tumours/abscess) [...]

Contrast is not used when looking for


intracranial bleeding.

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231. Which antiepileptic is Which antiepileptic is typically used as 236. What class of drugs What class of drugs are used to treat
typically used as seizure ppx in subarachnoid hemorrhage? are used to treat spinal trauma?
seizure ppx in Phenytoin spinal trauma? Glucocorticoids
subarachnoid [...]
hemorrhage?
[...] However, antiepileptic treatment in this Some studies show a decrease in mortality
case is controversial. following high doses of methylprednisolone
within 8 hrs. However, this is pretty
controversial due to GI bleeding risk and
232. Which Which neuroradiological procedure is
wound infection.
neuroradiological performed at the site of bleeding to prevent
procedure is a repeated subarachnoid hemorrhage?
performed at the site Catheter embolization 237. Which spinal cord Which spinal cord disorder presents with
of bleeding to disorder presents pain/temperature loss on the
prevent a repeated with contralateral side and
subarachnoid This interventional neuroradiological pain/temperature motor/position/vibration loss on the
hemorrhage? procedure involves placement of a loss on the ipsilateral side of the lesion?
[...] platinum wire to the site of hemorrhage contralateral side Brown-Séquard Syndrome
and subsequent embolization/coiling to and
"clog up" the site of the bleed. motor/position/vibration
Embolization is superior to surgical loss on the
clipping in terms of survival and ipsilateral side of
complications. the lesion?
[...]

233. What percentage of What percentage of subarachnoid


subarachnoid hemorrhage re-bleeds die? 238. What is the most What is the most appropriate next step in
hemorrhage 50-70% appropriate next step the management of Brown-Sequard
re-bleeds die? in the management Syndrome 2/2 a mass lesion?
[...] of Brown-Sequard Surgical decompression
Syndrome 2/2 a
mass lesion?
234. What vitamin What vitamin deficiency is associated with
[...]
deficiency is subacute combined degeneration of the
associated with spinal cord?
subacute combined B12 (cobalamin) 239. Which spinal cord Which spinal cord disorder involves a
degeneration of the disorder involves a fluid-filled, dilated central canal in the
spinal cord? fluid-filled, dilated spinal cord?
[...] Results in positional and vibratory central canal in the Syringomyelia
sensation loss. spinal cord?
[...]
The widened bubble or cavitation first
235. Which infectious Which infectious disease is associated
damages neural fibers passing near the
disease is associated with subacute combined degeneration of
center of the spine.
with subacute the spinal cord?
Can be 2/2 tumour/trauma or congenital.
combined Neurosyphilis
degeneration of the
spinal cord?
[...] Involves positional and vibratory sensation
loss.

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240. Which spinal cord Which spinal cord disorder most commonly 245. What is the most What is the most accurate test for brain
disorder most presents with pain/temperature loss accurate test for abscess?
commonly presents bilaterally across the upper back and brain abscess? Biopsy
with arms? [...]
pain/temperature Syringomyelia
loss bilaterally Basically the issue here is abscess vs.
across the upper tumour. Biopsy is needed to confirm.
back and arms? The buzzword "capelike distribution of
[...] deficits" is often used.
246. Why is an LP Why is an LP contraindicated with a
Also presents with loss of DTRs and
contraindicated with suspected brain mass (abscess, tumour,
muscle atrophy in the same bilateral
a suspected brain etc)?
distribution.
mass (abscess, Possibility of herniation
tumour, etc)?
241. What is the most What is the most accurate test for [...]
accurate test for Syringomyelia? In many cases, the CSF is not going to
Syringomyelia? MRI help much anyway.
[...]

247. Which diagnostic Which diagnostic procedure is essential in


242. What is the best What is the best treatment of procedure is the workup/management of brain
treatment of Syringomyelia? essential in the abscess?
Syringomyelia? Surgery (with drainage of the fluid from workup/management Biopsy
[...] the cavity) of brain abscess?
[...]
A bx must be performed in order to:
Surgical interventions also typically involve - differentiate between abscess and
one of: tumour
- removal of the causative tumour/mass - identify the causative organism (in the
- correction of a congenital anomaly case of abscess)

243. How do you How do you differentiate between a brain 248. What is the most What is the most common cause of brain
differentiate between abscess and tumour without biopsy? common cause of abscess?
a brain abscess and You can't brain abscess? Unknown
tumour without [...]
biopsy?
[...] They will both have HA, N/V, fever, Can be due to streptococcus,
seizures, FNDs (yes, cancer can cause staphylococcus, gram-negative bacilli, and
fever). anaerobes.
Presentation of both is pretty nonspecific, Can occur 2/2 contiguous infection at
even with a CT/MRI. the sinuses, mastoid air cells, or middle
Biopsy is done for final differentiation. ear.
Can occur 2/2 bacteremia (hence
pneumonia and endocarditis are up there).
244. What is the best What is the best initial test for suspected
Brain abscesses are often
initial test for brain abscess?
polymicrobial, hence biopsy and culture
suspected brain CT/MRI with contrast
is very important given that Abx regimens
abscess? Both tumour and abscess will be a contrast
are rather long (6-8 wks IV followed by 2-3
[...] enhancing lesion with surrounding edema
months of oral Abx).
and mass effect. You cannot differentiate
the two via CT alone.

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249. Which combination Which combination of antibiotics are 253. Which Which neurocutaneous disorder is
of antibiotics are commonly used as empiric therapy for a neurocutaneous associated with cardiac rhabdomyomas?
commonly used as brain abscess? disorder is Tuberous Sclerosis
empiric therapy for Penicillin + metronidazole + associated with
a brain abscess? ceftriaxone/cefepime cardiac
[...] rhabdomyomas?
[...]
Vancomycin can be used in place of a
penicillin if there was recent NeuroSx
254. Which Which neurocutaneous disorder presents
(higher risk of staph infection).
neurocutaneous with soft, flesh-coloured lesions
Remember, a biopsy is absolutely vital
disorder presents attached to peripheral nerves?
in the accurate treatment of a brain
with soft, Neurofibromatosis (von
abscess. The pt should not be on empiric
flesh-coloured Recklinghausen Disease)
therapy for a long time (really only until
lesions attached to
cultures are confirmed). Bx and
peripheral nerves?
subsequent culture/susceptibility testing
[...]
are indispensible.

255. Which Which neurocutaneous disorder involves


250. Which Which neurocutaneous disorder presents
neurocutaneous hyperpigmented lesions and CN VIII
neurocutaneous with adenoma sebaceum (reddened facial
disorder involves tumours?
disorder presents nodules) and Shagreen patches (leathery
hyperpigmented Neurofibromatosis (von
with adenoma patches on the trunk)?
lesions and CN VIII Recklinghausen Disease)
sebaceum Tuberous Sclerosis
tumours?
(reddened facial
[...]
nodules) and
aka café au lait spots (hyperpigmented
Shagreen patches CNS abnormalities include: seizure,
lesions)
(leathery patches on progressive psychomotor retardation,
Also involves neurofibromas,
the trunk)? slowly progressive mental deterioration
meningioma, and glioma
[...] Also involves ash leaf patches
(hypopigmented patches)
Also involves retinal lesions and cardiac 256. What is the specific What is the specific treatment for
rhabdomyomas. treatment for Neurofibromatosis (von Recklinghausen
Neurofibromatosis Disease)?
(von Recklinghausen None
251. What is the specific What is the specific treatment for Tuberous
Disease)?
treatment for Sclerosis?
[...]
Tuberous Sclerosis? None
CN VIII lesions may need to be
[...]
excised/surgical decompression to
preserve hearing
Control seizures and other symptoms.

257. Which Which neurocutaneous disorder commonly


252. Which Which neurocutaneous disorder involves
neurocutaneous presents with seizures and port-wine
neurocutaneous retinal lesions?
disorder commonly staining of the face?
disorder involves Tuberous Sclerosis
presents with Sturge-Weber Syndrome
retinal lesions?
seizures and
[...]
port-wine staining
of the face? Other CNS abnormalities include:
[...] homonymous hemianopsia,
hemiparesis, mental subnormality

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258. Which Which neurocutaneous disorder is 264. Which area of the Which area of the brain is primarily
neurocutaneous associated with calcification of angiomas brain is primarily affected in Parkinsons Disease?
disorder is on skull XR? affected in Substantia nigra
associated with Sturge-Weber Syndrome Parkinsons Disease?
calcification of [...]
angiomas on skull
XR?
265. What is the most What is the most common cause of
[...]
common cause of Parkinsonism?
Parkinsonism? Idiopathic
259. What is the treatment What is the treatment for Sturge-Weber [...]
for Sturge-Weber syndrome?
syndrome? None
266. [...] is a GI Metoclopromide is a GI pro-kinetic agent
[...]
pro-kinetic agent and and dopamine antagonist that can cause
dopamine antagonist parkinsonism.
Control seizures
that can cause
parkinsonism.
260. Which type of tremor Which type of tremor occurs both at rest
occurs both at rest and with intention (i.e. reaching for
267. What is the What is the diagnostic test for
and with intention something)?
diagnostic test for parkinsonism?
(i.e. reaching for Essential tremor
parkinsonism? None; Dx is clinical
something)?
[...]
[...]
Often greatest in the hands, but can be
seen at the head as well. 268. [...] is a neurological Parkinsonism is a neurological disorder
Physical exam is otherwise normal. disorder commonly commonly seen in the elderly that presents
Tremor can effect manual skills such as seen in the elderly with tremor, muscle rigidity,
handwriting or the use of a keyboard. that presents with bradykinesia, and shuffling gait with
tremor, muscle unsteadiness on turning.
rigidity,
261. How does caffiene How does caffiene change the severity of
bradykinesia, and
change the severity an essential tremor?
shuffling gait with
of an essential Increase
unsteadiness on
tremor?
turning.
[...]

269. [...] is a neurological Cogwheel rigidity is a neurological finding


262. What is the treatment What is the treatment for essential tremor?
finding described as described as the slowing of movement on
for essential tremor? Propanolol
the slowing of passive flexion or extension of an
[...]
movement on extremity.
passive flexion or
263. A pt complains of a A pt complains of a tremor that's present at extension of an
tremor that's present rest and exertion. He states that it extremity.
at rest and exertion. improves after a drink of alcohol. What is
He states that it the most likely diagnosis?
270. What is hypomimia? What is hypomimia?
improves after a Essential tremor
[...] Limited facial expression
drink of alcohol.
What is the most
likely diagnosis?
Seen in parkinsonism and other disorders.
[...]

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271. What is What is micrographia?


276. What constitutes What constitutes severe Parkinsonism?
micrographia? Small handwriting
[...] severe Inability of the pt to take care of
Parkinsonism? themselves; Orthostatic hypotension
Seen in parkinsonism and other disorders. [...]

272. What causes the 277. Which dopamine Which dopamine agonists are preferred in
What causes the postural instability in
postural instability in parkinsonism? agonists are the treatment of severe parkinsonism?
parkinsonism? Orthostatic hypotension preferred in the Pramipexole; ropinirole
[...] treatment of severe
parkinsonism?
Stems from an inability of the pulse and [...]
blood pressure to reset appropriately when
the pt stands up. 278. What is the most What is the most effective treatment of
As a result, there is orthostatic effective treatment severe parkinsonism?
hypotension, postural lightheadedness of severe Levodopa/carbidopa
and subsequent instability/falls. parkinsonism?
[...]
273. Which anticholinergic Which anticholinergic agents are preferred Associated with "on/off" phenomena:
agents are preferred in the treatment of tremor & rigidity in - off = insufficient dopamine =
in the treatment of mild parkinsonism? bradykinesia
tremor & rigidity in Benztropine; trihexyphenidyl - on = too much dopamine = dyskinesia
mild parkinsonism?
[...] 279. What is the "on/off" What is the "on/off" phenomenon
It is still unclear why increasing ACh levels phenomenon associated with levodopa/carbidopa?
help improve symptoms of low dopamine. associated with (see below)
ADEs include: dry mouth, worsening levodopa/carbidopa? "On/off" phenomena:
BPH, constipation [...] - off = insufficient dopamine = bradykinesia
ADEs are more common in older pts. - on = too much dopamine = dyskinesia

274. Which antiparkinson Which antiparkinson agent is preferrably 280. Which antiparkinson Which antiparkinson agents are associated
agent is preferrably given to > 60 y/o pts with mild agents are with the "On/Off" Phenomenon?
given to > 60 y/o pts parkinsonism that cannot tolerate associated with the Levodopa/carbidopa
with mild anticholinergics? "On/Off"
parkinsonism that Amantadine Phenomenon?
cannot tolerate [...]
anticholinergics?
[...] Works by increasing dopamine release
281. Which COMT Which COMT inhibitors are used in the
from the substantia nigra.
inhibitors are used treatment of parkinsonism?
If the question talks about an old pt with
in the treatment of Tolcapone; entacapone
parkinsonism that is complaining of
parkinsonism?
anticholinergic side effects, choose
[...]
amantadine if asked.
Only used in pts that are also taking
levodopa/carbidopa
275. What is the What is the mechanism of action of Used to extend the duration of
mechanism of action amantadine in the treatment of levodopa/carbidopa by decreasing
of amantadine in the Parkinsonism? peripheral metabolism of dopamine
treatment of Unclear; thought to increase dopamine
Parkinsonism? release from the substantia nigra
[...]

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282. What is the only What is the only indication for the use of 287. Psychosis is a known Psychosis is a known adverse effect of
indication for the use COMT inhibitors in the treatment of severe adverse effect of antiparkinson agents. What is the best way
of COMT inhibitors in parkinsonism? antiparkinson agents. to treat this psychosis?
the treatment of To extend the duration of What is the best way Antipsychotics with the fewest
severe levodopa/carbidopa to treat this extrapyramidal symptoms
parkinsonism? Hence only used in pts that are taking psychosis?
[...] levodopa/carbidopa. [...]
Most of the time, you cannot stop
Acts by inhibiting the peripheral antiparkinson agents as there is a risk of
metabolism of dopamine. the patient becoming "locked in" with
Used to smooth out "on/off" severe bradykinesia. This is even more
phenomena to even out dopamine levels. likely if the pt has severe parkinsonism.
Also used when the response to therapy is Use antipsychotics.
inadequate.

288. [...] is a cause of Lewy Body Dementia is a cause of


283. Which MAO Which MAO inhibitors are used in the dementia that dementia that involves parkinsonism.
inhibitors are used in treatment of severe parkinsonism? involves
the treatment of Selegiline; rasagiline parkinsonism.
severe
parkinsonism?
289. [...] is a neurological Shy-Drager Syndrome is a neurological
[...] Used either alone or as an adjunct to
syndrome syndrome characterized by parkinsonism
levodopa/carbidopa.
characterized by and orthostasis.
Act by blocking metabolism of
parkinsonism and
dopamine.
orthostasis.

284. Tyramine-containing Tyramine-containing foods can precipitate


290. [...] is a Spasticity is a neuromuscular
foods can precipitate hypertension if taken while on a specific
neuromuscular phenomenon occurring in many disorders
hypertension if taken class of drugs. What is that class?
phenomenon that is described as painful, contracted
while on a specific MAO inhibitors
occurring in many muscle 2/2 to CNS damage.
class of drugs. What
disorders that is
is that class?
described as painful,
[...] Tyramine is found in cheese, for example.
contracted muscle More often associated with MS.
2/2 to CNS damage. No single treatment is preferred.
285. Which surgical Which surgical procedure is highly Baclofen, dantrolene and tizanadine
procedure is highly effective in the treatment of tremors and (centrally-acting alpha agonist) may all
effective in the rigidity in pts with severe parkinsonism? work.
treatment of tremors Deep Brain Stimulation
and rigidity in pts
291. Which neurological Which neurological disorder often presents
with severe
disorder often with pts complaining of an uncomfortable,
parkinsonism?
presents with pts "creepy crawly" feeling in the legs at night?
[...]
complaining of an Restless Leg Syndrome
uncomfortable,
286. Which class of Which class of antiparkinson agents is "creepy crawly"
antiparkinson agents associated with slowing the progression feeling in the legs at Often their bed partners complain of being
is associated with of parkinsonism? night? kicked at night as moving the leg relieves
slowing the MAO inhibitors [...] the sensation.
progression of Caffeine makes it worse.
parkinsonism?
[...]

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292. How does caffeine How does caffeine change the severity of 297. What is most What is most commonly the first
change the severity Restless Leg Syndrome? commonly the first manifestation of the movement disorder in
of Restless Leg Increase manifestation of the Huntington Disease?
Syndrome? movement disorder "Fidgetiness"
[...] in Huntington
Movement of the limb usually relieves Disease?
discomfort. [...] This fidgeting quickly progresses into
restlessness. Then dystonia, dystonic
posturing and dyskinesia (with
293. What class of drugs What class of drugs is used to treat
choreiform movement). Then rigidity and
is used to treat Restless Leg Syndrome?
akinesia in later stages.
Restless Leg Dopamine agonists
Syndrome?
[...] 298. What is the What is the diagnostic test of choice for
Most often pramipexole diagnostic test of Huntington Disease?
choice for Huntington Genetic analysis
Disease?
294. What is the etiology What is the etiology of Huntington
[...]
of Huntington Disease?
The genetic test for HD is 99% sensitive -
Disease? CAG trinucleotide repeats on
it looks for CAG trinucleotide repeats on
[...] chromosome 4
chromosome 4
The symptom triad
295. [...] is a neurological Huntington Disease is a neurological (movement/dementia/behaviour) only
disorder disorder characterized by a classic triad of confirms the genetic test.
characterized by a choreiform movement, dementia, and CT/MRI can show caudate nucleus
classic triad of behavioural changes. atrophy but that is not specific for HD.
choreiform
movement,
299. What is the curative What is the curative treatment for HD?
dementia, and The movement disorder can progress to
treatment for HD? None
behavioural full on rigidity in severe cases.
[...]
changes. Behavioural changes vary, but typically
involve irritability, moodiness and
Treat the dyskinesia with tetrabenazine
antisocial behaviour.
Treat the psychosis with haloperidol,
Pts will also often have a strong family
quetiapine or other antipsychotics.
history (autosomal dominant inheritance)

300. What head CT/MRI What head CT/MRI findings are associated
296. In which age range In which age range does Huntington
findings are with Huntington Disease?
does Huntington Disease present?
associated with Caudate nucleus atrophy
Disease present? 30-50 y/o
Huntington Disease?
[...]
[...]

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301. Which monoamine Which monoamine reuptake inhibitor is 304. Weakness is a very Weakness is a very common complaint
reuptake inhibitor is used to treat the dyskinesia in common complaint that can be 2/2 demyelination, NMJ
used to treat the huntington disease? that can be 2/2 dysfunction, spinal/nerve lesions, cortical
dyskinesia in Tetrabenazine demyelination, NMJ lesions or even muscular lesions. Which
huntington Tetrabenazine is a reversible human dysfunction, disorder most commonly targets the spinal
disease? vesicular monoamine transporter type 2 spinal/nerve lesions, cord specifically?
[...] inhibitor (Ki = 100 nM). It acts within the cortical lesions or ALS
basal ganglia and promotes depletion of even muscular
monoamine neurotransmitters serotonin, lesions. Which
norepinephrine, and dopamine from disorder most Okay, this is a poor card, but I wanted to
stores. It also decreases uptake into commonly targets get you thinking about DDx of weakness
synaptic vesicles. Dopamine is required for the spinal cord and to localize disorders to where they
fine motor movement, so the inhibition of specifically? occur along the motor pathways.
its transmission is efficacious for [...]
hyperkinetic movement. Tetrabenazine
exhibits weak in vitro binding affinity at the
dopamine D2 receptor (Ki = 2100 nM).
305. Which neurological Which neurological cause of weakness
(from www.drugbank.ca)
cause of weakness involves antibodies against myelin that
involves antibodies develop following exposure to
302. [...] is a Tourette disorder is a neuropsychiatric against myelin that environmental triggers and genetic
neuropsychiatric disorder characterized by vocal tics, develop following susceptibility?
disorder grunts and coprolalia. exposure to MS
characterized by environmental
vocal tics, grunts triggers and genetic
and coprolalia. Can involve motor tics as well (sniffling, susceptibility? What these triggers and genes are - we
blinking, frowning) [...] don't know yet.
Can also involve obsessive-compulsive
behaviour.
306. Which area of the Which area of the body is primarily
Tx with neuroleptics (e.g. fluphenazine,
body is primarily affected in MS?
clonazepam, pimozide) and ADHD meds
affected in MS? Anywhere
(e.g. methylphenidate)
[...]
Coprolalia = repetitive, involuntary use of
profanity
This is part of what makes MS a tough
disease to diagnose.
303. Which Which demographic(s) is more commonly The neurological symptoms are often
demographic(s) is affected by MS? separated by space and time in a way
more commonly Women; white; colder climates (i.e. that a single cause/lesion cannot explain
affected by MS? northern hemisphere) symptoms (i.e. blurry vision 5 years ago
[...] that resolved and returned, tingling in the
hands 2 years ago that resolved and
returned, and now tingling in the
contralateral foot).
However the first complaint is often blurry
vision/diplopia 2/2 to optic neuritis.
(Remember, the optic tract and associated
pathways are very highly myelinated for
fast conduction, especially the MLF. As
such, demyelination in these areas if felt
first. Intranuclear ophthalmoplegia (INO)
2/2 MLF demyelination is common as
well.)

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311. Which drug is Which drug is preferred in the treatment of


307. What is the most What is the most common first complaint preferred in the urinary retention in multiple sclerosis?
common first in multiple sclerosis? treatment of urinary Bethanecol
complaint in multiple Blurry vision/diplopia 2/2 optic neuritis; retention in multiple
sclerosis? or focal sensory deficits sclerosis?
[...] [...] Remember, MS can cause any type of
lesion in the spinal cord.
White lady with blurry vision = think MS,
brah.
312. Which drug is Which drug is preferred in the treatment of
Intranuclear ophthalmoplegia (INO) =
preferred in the urinary incontinence in multiple
think MS, brah
treatment of urinary sclerosis?
Some sources say optic neuritis is no
incontinence in Amitriptyline
longer as common, so consider focal
multiple sclerosis?
sensory deficits (± gait/balance problems)
[...]
as well.
Remember, MS can cause any type of
lesion in the spinal cord.
308. Which imaging study Which imaging study is the best choice in
is the best choice in suspected multiple sclerosis?
313. Which drug is Which drug is preferred in the treatment of
suspected multiple MRI
preferred in the spasticity in multiple sclerosis?
sclerosis?
treatment of Baclofen
[...]
spasticity in multiple
A positive MRI involves periventricular
sclerosis?
plaques, multiple lesions or lesions to
[...] Or well, baclofen is useful in spasticity in
the corpus callosum and is most
general.
accurate.
Remember, MS can cause any type of
However, because MS is a
lesion in the spinal cord.
relapse-remitting disease, an MRI can be
negative. In such cases, do an LP and see
if there is pleocytosis, oligoclonal IgG or 314. What is the most What is the most accurate diagnostic test
evoked potentials. However, LP's are accurate diagnostic in multiple sclerosis?
typically not done anymore. test in multiple MRI
sclerosis?
309. Which drug is [...]
Which drug is preferred for the chronic
Oligoclonal bands on LP are only seen in
preferred for the management of multiple sclerosis?
85% of pts and are not specific to MS.
chronic Interferon-beta
However, if the MRI is unequivocal or
management of
nondiagnostic, consider LP.
multiple sclerosis?
[...] Prevents relapse. Visual and auditory evoked potentials
are always the wrong answer.
Can use glatiramer to prevent relapse as
well.

310. Which drug is Which drug is preffered for the treatment of


preffered for the acute flareups in multiple sclerosis?
treatment of acute High-dose Steroids
flareups in multiple
sclerosis?
[...] Roids also mitigate the severity/duration of
the exacerbation.

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315. A pt w/ multiple A pt w/ multiple sclerosis develops


319. What must first be What must first be ruled out in a pt before
sclerosis develops worsening FNDs while on chronic
worsening FNDs suppressive therapy. New MRI shows ruled out in a pt giving a Dx of ALS?
while on chronic new, multiple white matter lesions. Which before giving a Dx of Spinal lesions (either via
suppressive therapy. monoclonal antibody is most likely to have ALS? CT/MRI/SpinalXR)
New MRI shows caused this? [...]
new, multiple white Natalizumab
matter lesions. 320. Which demyelinating Which demyelinating disorder is
Which monoclonal disorder is associated with superoxide dismutase
antibody is most It targets alpha-4 integrin involved in associated with mutations?
likely to have caused It has been known to predispose to superoxide ALS
this? progressive multifocal dismutase
[...] leukoencephalopathy (PML). mutations?
[...] Only in 10% of cases though, so don't
316. What is the etiology What is the etiology of ALS? bank on this in vignettes.
of ALS? Unknown
[...] 321. A pt with known ALS A pt with known ALS presents with
presents with difficulty in chewing and swallowing, a
Involves asymmetric UMN and LMN difficulty in decreased gag reflex, and a weak
lesions, but typically spares the eyes and chewing and cough. What is this patient at highest risk
sphincters. swallowing, a for?
There is no sensory loss no matter what decreased gag Aspiration
the gunner says on rounds. reflex, and a weak
cough. What is this
317. A pt presents with A pt presents with muscle atrophy, patient at highest risk Saliva will often pool in the pharynx.
muscle atrophy, fasciculations of the tongue and for? This is a pretty serious presentation of ALS
fasciculations of the extremities, upwards babinski and [...] that offers poor prognosis,.
tongue and hyper-reflexia of the extremities. Which Can progress to a total loss of
extremities, upwards demyelinating disorder is the most likely swallowing.
babinski and Dx?
hyper-reflexia of the ALS 322. How do creatine How do creatine phosphokinase (CPK)
extremities. Which Involves asymmetric UMN and LMN phosphokinase levels change in ALS?
demyelinating lesions, with LMN symptoms (CPK) levels change Increased
disorder is the most predominating in later stages. in ALS?
likely Dx? Typically spares the eyes and [...]
[...] sphincters. Remember, LMN lesions cause muscle
There is no sensory loss no matter what atrophy which would raise CK levels.
the gunner says on rounds.
Other symptoms may include emotional
lability and weight loss.

318. Which diagnostic test Which diagnostic test confirms ALS?


confirms ALS? EMG
[...]

The Dx is typically clinical. EMG confirms.


EMG will show loss of neural innervation
at multiple muscle groups.
A spinal lesion must first be ruled out
via CT/MRI/SpinalXR

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323. [...] is a drug that Riluzole is a drug that may prevent the 325. What is the most What is the most common cause of death
may prevent the progression of ALS by reducing common cause of in ALS?
progression of ALS glutamate buildup in neurons. death in ALS? Respiratory failure
by reducing [...]
glutamate buildup
in neurons. Riluzole, a member of the benzothiazole CPAP and BiPAP can improve respiratory
class, is indicated for the treatment of weakness.
patients with amyotrophic lateral sclerosis Tracheostomy and mechanical
(ALS). Riluzole extends survival and/or ventilation is the end point of ALS
time to tracheostomy. It is also progression.
neuroprotective in various in vivo
experimental models of neuronal injury
326. Which treatment Which treatment modalities are
involving excitotoxic mechanisms. The
modalities are recommended to help with respiratory
etiology and pathogenesis of amyotrophic
recommended to difficulties 2/2 muscle weakness in ALS?
lateral sclerosis (ALS) are not known,
help with respiratory CPAP; BiPAP
although a number of hypotheses have
difficulties 2/2
been advanced. One hypothesis is that
muscle weakness in
motor neurons, made vulnerable through
ALS?
either genetic predisposition or
[...]
environmental factors, are injured by
glutamate. In some cases of familial ALS
the enzyme superoxide dismutase has 327. What type of What type of neurological deficits are seen
been found to be defective. neurological deficits in Charcot-Marie-Tooth (CMT) disease?
The mode of action of riluzole is unknown. are seen in Motor and sensory
Its pharmacological properties include the Charcot-Marie-Tooth
following, some of which may be related to (CMT) disease?
its effect: 1) an inhibitory effect on [...] Motor and sensory innervation are both
glutamate release (activation of glutamate lost. Hence, deficits can include:
reuptake), 2) inactivation of - weakness
voltage-dependent sodium channels, and - sensory loss
3) ability to interfere with intracellular - muscle wasting
events that follow transmitter binding at - decreased DTRs
excitatory amino acid receptors. - tremor
(www.drugbank.ca)
328. [...] is a foot Pes cavus is a foot deformity seen in
324. What is the preferred What is the preferred treatment for deformity seen in Charcot-Marie-Tooth disease that is
treatment for spasticity in ALS? Charcot-Marie-Tooth describes as a foot with a high arch.
spasticity in ALS? Baclofen disease that is
[...] describes as a foot
with a high arch.
Seeing a trend here? Spasticity? Baclofen!
329. Which genetic cause Which genetic cause of weakness and
of weakness and sensory deficits is associated with pes
sensory deficits is cavus (a foot with a high arch)?
associated with pes Charcot-Marie-Tooth (CMT) disease
cavus (a foot with a
high arch)?
[...]

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330. Which genetic cause Which genetic cause of weakness and 335. A pt complains of A pt complains of pain in his 4th and 5th
of weakness and sensory loss is associated with "having pain in his 4th and digits on the right side. He states that he
sensory loss is legs that look like inverted champagne 5th digits on the is a cyclist and places pressure on the
associated with bottles"? right side. He states palms of his hands for extended periods.
"having legs that look Charcot-Marie-Tooth (CMT) disease that he is a cyclist On examination, he has wasting of the
like inverted and places pressure hypothenar eminence. Which nerve is
champagne bottles"? on the palms of his most likely affected?
[...] And here I am trying to figure out a good hands for extended Ulnar
calf routine... periods. On Pts can also be s/p trauma to the medial
examination, he has elbow
wasting of the
331. What is the most What is the most accurate test for
hypothenar
accurate test for Charcot-Marie-Foot (CMT) disease?
eminence. Which
Charcot-Marie-Foot EMG
nerve is most likely
(CMT) disease?
affected?
[...]
[...]

332. What is the treatment What is the treatment for


336. A pt presents A pt presents complaining of numbness &
for Charcot-Marie-Foot (CMT) disease?
complaining of tingling on the dorsum of the right
Charcot-Marie-Foot None
numbness & hand. He recently tore his quadriceps
(CMT) disease?
tingling on the femoris muscle and has been using
[...]
dorsum of the right crutches for the past week. On physical
hand. He recently exam he has wrist drop. Which nerve is
333. What is the most What is the most common cause of tore his quadriceps most likely affected?
common cause of peripheral neuropathy? femoris muscle and Radial
peripheral Diabetes Mellitus has been using
neuropathy? crutches for the past
[...] week. On physical
Other causes include uremia, alcoholism, exam he has wrist
paraproteinemias (e.g. MGUS) drop. Which nerve is
most likely affected?
334. What is the best What is the best initial therapy for [...]
initial therapy for peripheral neuropathy?
peripheral Pregabalin; Gabapentin 337. A pt presents A pt presents complaining of numbness &
neuropathy? complaining of tingling o ver the dorsum of his right hand.
[...] numbness & tingling Last night, he fell asleep on a chair with his
Either of them. If NBME makes you o ver the dorsum of right arm extended over the back of the
choose between the two... das not it mane. his right hand. Last chair. Which nerve is most likely affected?
TCAs and antiepileptics are effective in night, he fell asleep Radial
some, but not most. on a chair with his
right arm extended
over the back of the This is "Saturday night palsy"
chair. Which nerve is
most likely affected?
[...]

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338. A morbidly obese pt A morbidly obese pt presents with pain 341. A pt presents A pt presents complaining of
presents with pain and numbness over the lateral aspect of complaining of pain/numbness in the right hand. She
and numbness over her right thigh. She practices yoga and pain/numbness in the works as a medical intern and says her
the lateral aspect of states that the symptoms worsen when right hand. She symptoms started ever since she started
her right thigh. She she crosses her legs. Which nerve is most works as a medical typing 50 page-long patient notes for her
practices yoga and likely affected? intern and says her attending. On physical exam, you discover
states that the Lateral cutaneous nerve of the thigh symptoms started that the symptoms are localized to the first
symptoms worsen ever since she 3 digits. Which nerve is most likely
when she crosses started typing 50 affected?
her legs. Which page-long patient Median
nerve is most likely notes for her There may also be thenar wasting, but
affected? attending. On that would srsly suck for an intern.
[...] physical exam, you
discover that the
symptoms are
339. A pt presents with A pt presents with pain/numbness in the
localized to the first 3
pain/numbness in the ankle and sole of her right foot that
digits. Which nerve is
ankle and sole of her worsens with walking. Which nerve is most
most likely affected?
right foot that likely affected?
[...]
worsens with Tibial nerve
walking. Which nerve
is most likely 342. What is the most What is the most common cause of CNVII,
affected? This is Tarsal tunnel syndrome common cause of Facial Palsy?
[...] CNVII, Facial Palsy? Idiopathic
[...]

340. A pt presents A pt presents complaining of bilateral foot


It is not Lyme disease no matter what the
complaining of weakness. He is a skiier and wears high
gunner tells you to say during rounds.
bilateral foot ski boots for his daily training sessions. On
weakness. He is a physical exam, both feet show decreased
skiier and wears high dorsiflexion and eversion. Which nerve is 343. What is the key What is the key difference between true
ski boots for his daily most likely affected? difference between CN VII, Facial palsy and facial palsy 2/2
training sessions. On Peroneal true CN VII, Facial stroke?
physical exam, both palsy and facial palsy In stroke, only the bottom half of the
feet show decreased 2/2 stroke? face is affected
dorsiflexion and [...]
eversion. Which
nerve is most likely This is due to the dual innervation of the
affected? face. The upper half of the face received
[...] innervation from both hemispheres.
If the pt can wrinkle her forehead, its
stroke.
If the pt cannot wrinkle her forehead, its
Bell palsy.

344. Facial/Bell palsy can Facial/Bell palsy can sometimes involves


sometimes involves hyperacusis. Why?
hyperacusis. Why? CN VII innervates the stapedius muscle,
[...] which mitigates the volume of sounds
transmitted through the ossicles

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345. Facial/Bell palsy can Facial/Bell palsy can sometimes involve 350. Which demyelinating Which demyelinating disorder can present
sometimes involve taste disturbance. Why? disorder can present s/p flu vaccination or 1-3 weeks s/p
taste disturbance. CN VII, supplies taste sensation to the s/p flu vaccination Campylobacter jejuni diarrhea?
Why? anterior 2/3 of the tongue or 1-3 weeks s/p Acute Inflammatory Polyneuropathy
[...] Campylobacter (Guillain-Barré Syndrome)
jejuni diarrhea?
[...]
346. What is the most What is the most accurate test for
accurate test for Facial/Bell palsy?
Facial/Bell palsy? EMG (or other nerve conduction 351. Which symptoms of Which symptoms of Acute Inflammatory
[...] studies) Acute Inflammatory Polyneuropathy (Guillain-Barré Syndrome)
Polyneuropathy is always present?
(Guillain-Barré Ascending paralysis/weakness;
However, no test is typically done. Dx is Syndrome) is always Hyporeflexia
clinical based off presentation. present?
[...]
Paresthesia and autonomic
347. What is the best What is the best initial therapy for
dysregulation may or may not be
initial therapy for Bell/Facial palsy?
present.
Bell/Facial palsy? Prednisone
[...]
352. What is the most What is the most appropriate first step in
However, 60% of pts recover without appropriate first step the management of a pt in whom Acute
treatment. in the management Inflammatory Polyneuropathy
Acyclovir can be added, but whether or not of a pt in whom (Guillain-Barré Syndrome) is suspected?
it helps is unclear. Acute Inflammatory Assess the need for intubation (i.e.
Polyneuropathy order PFTs)
(Guillain-Barré
348. What is the most What is the most common complication of
Syndrome) is
common Bell/Facial palsy?
suspected? Due to the ascending paralysis inevitably
complication of Corneal ulceration
[...] reaching the diaphragm, you should first
Bell/Facial palsy?
assess whether or not that pt requires
[...]
intubation. After that you can confirm
This is 2/2 the muscle weakness and an
diagnosis.
inability to close the eye, especially at
FVC and peak inspiratory pressure
night. This leads to dryness and eventual
decreases are the best way to gauge for
ulceration.
impending respiratory failure (and the need
Avoid this by taping the eyelid shut and
to intubate)
using lubricating eye drops often.
ABG abnormalities mean you're already
too late.
349. Which demyelinating Which demyelinating disorder involves Nerve conduction studies are good for
disorder involves ascending paralysis? accurate diagnosis, but that doesn't solve
ascending Acute Inflammatory Polyneuropathy the impending respiratory failure issue.
paralysis? (Guillain-Barré Syndrome)
[...]

No CNS involvement
Due to circulating antibodies vs. myelin
Reversible and not permanent

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353. Which diagnostic test Which diagnostic test is most helpful in 357. A pt presents with s/s A pt presents with s/s that strongly suggest
is most helpful in diagnosing Acute Inflammatory that strongly suggest Acute Inflammatory Polyneuropathy
diagnosing Acute Polyneuropathy (Guillain-Barré Acute Inflammatory (Guillain-Barré Syndrome). What is the
Inflammatory Syndrome)? Polyneuropathy most appropriate next step, that should be
Polyneuropathy EMG (Guillain-Barré done urgently?
(Guillain-Barré Syndrome). What is PFTs
Syndrome)? the most appropriate
[...] EMG will show decreased conduction next step, that should
velocity however this may take 2-3 be done urgently? FVC and peak inspiratory pressure
weeks to manifest. [...] decreases are the best way to gauge for
LP will show CSF with increased proteins impending respiratory failure (and the need
and normal or decreased cell count to intubate)
ABG abnormalities mean you're already
too late.
354. What is the treatment What is the treatment for Acute
Nerve conduction studies are good for
for Acute Inflammatory Polyneuropathy
accurate diagnosis, but that doesn't solve
Inflammatory (Guillain-Barré Syndrome)?
the impending respiratory failure issue.
Polyneuropathy IVIG; or plasmapharesis
(Guillain-Barré They both have equal efficacy and
Syndrome)? combining both does nothing. 358. Which phase of Which phase of breathing is affected in
[...] Steroids do not help and is always a breathing is affected Acute Inflammatory Polyneuropathy
wrong answer. In fact, never give in Acute (Guillain-Barré Syndrome)?
steroids in GBS. Inflammatory Inspiration
IVIG and plasmapharesis combined is Polyneuropathy
also always a wrong answer. (Guillain-Barré
Syndrome)? Important to remember this because peak
[...] flow only gauges expiration and is better
355. What are the most What are the most common causes of
in obstructive lung diseases.
common causes of death in GBS?
Make sure you order the right test: PFTs
death in GBS? Autonomic regulation; respiratory
with a focus on FVC and peak inspiratory
[...] failure
pressure

356. How does FVC How does FVC change in a pt with Acute
359. Which Which neuromuscular junction structure is
change in a pt with Inflammatory Polyneuropathy
neuromuscular affected in Myasthenia Gravis?
Acute Inflammatory (Guillain-Barré Syndrome) that has
junction structure is Post-synaptic ACh receptor
Polyneuropathy affected the diaphragm?
affected in
(Guillain-Barré Decreased
Myasthenia Gravis?
Syndrome) that has
[...]
affected the
diaphragm? There is a decrease in FVC and peak
[...] inspiratory pressure.
Remember, inspiration is the active
portion of breathing. This is the major
pathophysiological factor regarding
respiratory failure in GBS. PFTs may be
able to reveal impending death in GBS.

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360. Which muscles are Which muscles are typically affected the
363. What is the best What is the best initial test for
typically affected the most in Myasthenia Gravis?
most in Myasthenia Eye muscles (diplopia/ptosis); throat initial test for Myasthenia Gravis?
Gravis? muscles (dysphagia); difficulty chewing Myasthenia Gravis? Anti-ACh Receptor antibody test
[...] Don't memorize this. Understand it: [...]
MG involves progressive daily
fatigability due to the post-synaptic AChR 80-90% sensitive
blockade. This means that high Better than the edrophonium test.
concentrations of ACh are needed in If AChR antibodies are negative, consider
the synapse to yield the same muscle testing for anti-MUSK antibodies (muscle
strength. Since repetitive use exacerbates specific kinase)
the receptor blockade, the muscles that
are used the most are effected the most 364. What is the most What is the most accurate test for
(in fact, this is the direct opposite of accurate test for myasthenia gravis?
Lambert-Eaton syndrome). myasthenia gravis? EMG w/ repetitive stimulation
[...]

EMG will show decreased amplitude w/


361. A pt presents A pt presents complaining about double repeated stimulation.
complaining about vision and difficulty swallowing that is
double vision and worse at the end of the day. She states 365. Which drug is the Which drug is the first-line and best initial
difficulty that rest makes it better and that she first-line and best treatment for myasthenia gravis?
swallowing that is feels close to normal every morning. What initial treatment for Pyridostigmine; neostigmine
worse at the end of physical exam findings may be noted at myasthenia gravis?
the day. She states the eye? [...]
that rest makes it Ptosis; intact pupillary reflexes i.e. long acting AChE inhibitors, thereby
better and that she increasing ACh concentrations in the
feels close to normal synapse
every morning. What Very severe MG can affect respiratory
physical exam muscles
366. What is the most What is the most appropriate next step in
findings may be
appropriate next step the management of myasthenia gravis that
noted at the eye?
in the management is refractory to medical treatment?
[...]
of myasthenia gravis Thymectomy if < 60 y/o; Prednisone if >
that is refractory to 60 y/o
362. How do pupillary How do pupillary reflexes change in medical treatment?
reflexes change in myasthenia gravis? [...]
myasthenia gravis? Normal Thymectomy in MG is often curative (or
[...] atleast markedly improves symptoms).
AZT, tacrolimus, cyclophosphamide, or
MG involves progressive daily mycophenolate mofetil are all typically
fatigability due to the post-synaptic AChR used to wean pts off steroids to avoid long
blockade. This means that high term use and complications.
concentrations of ACh are needed in The point here is that T-cell function
the synapse to yield the same muscle needs to be suppressed to decrease
strength. Since repetitive use exacerbates antibody formation. All of the above would
the receptor blockade, the muscles that achieve this.
are used the most are effected the most
(in fact, this is the direct opposite of
Lambert-Eaton syndrome).

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367. Which imaging study Which imaging study should be ordered if 372. What neuromuscular What neuromuscular junction structure is
should be ordered if a pt is Dx with myasthenia gravis? junction structure is targeted in Lambert-Eaton Syndrome?
a pt is Dx with Chest imaging targeted in Presynaptic Ca channels
myasthenia gravis? Lambert-Eaton
[...] Syndrome?
To look for thymoma. [...] Resulting in decreased ACh release
Can be anything really: CT, MRI, CXR. downstream.
CT with contrast would technically be the
best study.

368. Which autoimmune Which autoimmune cause of weakness is 373. Which muscles are Which muscles are effected the most in
cause of weakness is associated with thymoma? effected the most in Lambert-Eaton syndrome?
associated with Myasthenia Gravis Lambert-Eaton Proximal musculature
thymoma? syndrome? LES involves daily weakness that
[...] [...] improves with repeated use as
successive impulses create a positive Ca
gradient that is able to more easily
369. A pt is strongly A pt is strongly suspected to have
overcome circulating antibodies. As a
suspected to have myasthenia gravis. Initial antibody testing
result, the muscles that are used the
myasthenia gravis. is negative for AChR-antibodies. Which
least are affected the most.
Initial antibody other autoantibodies can you consider
testing is negative for testing for?
AChR-antibodies. Anti-MUSK antibodies
Which other 374. What is the What is the difference in the weakness
autoantibodies can difference in the seen in myasthenia gravis vs.
you consider testing Anti-muscle specific kinase weakness seen in lamber-eaton syndrome?
for? myasthenia gravis MG weakness worsens through the
[...] vs. lamber-eaton day; LES weakness improves
syndrome? MG involves progressive daily
[...] fatigability due to the post-synaptic AChR
370. [...] is a short-acting Edrophonium is a short-acting AChE
blockade. This means that high
AChE inhibitor that is inhibitor that is used to test for myasthenia
concentrations of ACh are needed in
used to test for gravis.
the synapse to yield the same muscle
myasthenia gravis.
strength. Since repetitive use exacerbates
the receptor blockade, the muscles that
Positive test = clear improvement in
are used the most are effected the most
symptoms for a few minutes
(in fact, this is the direct opposite of
Lambert-Eaton syndrome).
371. A pt with known A pt with known myasthenia gravis
myasthenia gravis presents to the ER in life-threatening
presents to the ER in condition. She has diffuse, severe, LES involves daily weakness that
life-threatening overwhelming muscle weakness with improves with repeated use as
condition. She has respiratory involvement. What is the best successive impulses create a positive Ca
diffuse, severe, treatment for this crisis? gradient that is able to more easily
overwhelming IVIG; or plasmapharesis overcome circulating antibodies. As a
muscle weakness result, the muscles that are used the
with respiratory least are affected the most.
involvement. What is This is acute myasthenic crisis
the best treatment for
this crisis?
[...]

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375. What is the best test What is the best test for Lambert-Eaton 380. What is the most What is the most appropriate next step in
for Lambert-Eaton syndrome? appropriate next step the management of a pt in whom
syndrome? EMG in the management dementia has been established?
[...] Dx is clinical, however you can check of a pt in whom Rule out all reversible causes
anti-Ca-Receptor antibodies and do an dementia has been
EMG established?
EMG will show improvement with [...]
repeated use (opposite of MG)

376. Which imaging study Which imaging study should be ordered in 381. What is the most What is the most common cause of
should be ordered in a pt diagnosed with Lambert-Eaton common cause of organic dementia?
a pt diagnosed with Syndrome? organic dementia?
Lambert-Eaton Chest imaging Alzheimer's Disease
Syndrome? [...]
[...]
I suppose anything would be fine:
382. Which organic cause Which organic cause of dementia is
CT/MRI/CXR. However, CT is the best
of dementia is associated with neurofibrillary tangles,
test.
associated with neurotic plaques and amyloid
neurofibrillary deposition?
377. Which cancer is most Which cancer is most commonly tangles, neurotic Alzheimer Disease (AD)
commonly associated with Lambert-Eaton syndrome? plaques and
associated with Small cell lung cancer amyloid
Lambert-Eaton deposition?
syndrome? [...]
[...] Which responds well to chemo.

383. Which test is able to Which test is able to offer definitive


378. What is the cure for What is the cure for Lambert-Eaton offer definitive diagnosis of Alzheimer Disease?
Lambert-Eaton syndrome? diagnosis of Biopsy on autopsy
syndrome? Curing the cancer that caused it Alzheimer Disease?
[...] [...]
Initial Dx is clinical; autopsy will confirm s/p
Remember, it is a paraneoplastic death.
syndrome. Biopsy will reveal neurofibrillary tangles,
If a cure is not feasible, then prednisone neurotic plaques and amyloid
can control symptoms (but this is deposition.
considered a palliative measure).

384. Which organic cause Which organic cause of dementia is


379. What 2 neurological What 2 neurological findings are essential of dementia is classically associated with an insidious
findings are essential to the diagnosis of dementia? classically onset and loss of memory first?
to the diagnosis of Memory loss; and cognitive function associated with an Alzheimer's
dementia? insidious onset and
[...] loss of memory
Having trouble finding your keys is not first? Social graces are spared until later
sufficient to diagnose dementia. [...] disease.
A MMSE must be done to assess cognitive
changes (especially attention,
concentration and/or executive
function)

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385. Which CT findings Which CT findings are seen in Alzheimer's 390. What is the preferred What is the preferred diagnostic test for
are seen in Disease? diagnostic test for Pick's Disease?
Alzheimer's Diffuse cortical atrophy Pick's Disease? None
Disease? [...]
[...]
Dx is clinical

386. Which organic cause Which organic cause of dementia is


of dementia is associated with chromosome 21 trisomy? 391. What is the treatment What is the treatment for Pick's Disease?
associated with Alzheimers for Pick's Disease? None
chromosome 21 [...]
trisomy?
[...] A large number of Down Syndrome pts >
392. Which transplant Which transplant procedure can be
40 y/o have Alzheimer's Disease.
procedure can be associated with prion transmission?
associated with Corneal transplant
387. Which class of Which class of autonomic drugs is typically prion transmission?
autonomic drugs is used in the treatment of Alzheimer's [...]
typically used in the Disease? However, the most common way to get a
treatment of Cholinergics (namely, AChE inhibitors) prion disease is spontaneous mutation.
Alzheimer's
Disease?
393. Which organic cause Which organic cause of dementia should
[...] Aricept (donepezil) is used most often.
of dementia should be considered in a pt that is too young for
Rivastigmine and galantamine are also
be considered in a pt dementia and displays a rapid decline in
options.
that is too young for cognitive function (within 1 year)?
All 3 have equal efficacy and slow
dementia and Creutzfeldt-Jakob Disease (CJD)
progression of the disease.
displays a rapid
- remember, in Alzheimer's the
decline in cognitive
hippocampus is affected first. Increasing
function (within 1
[ACh] at the hippocampus helps w/ the
year)?
memory deficits and slows progression of
[...]
the disease. ACh also regulates DA
release at the Basal Ganglia, thereby
helping w/ movement. 394. Which brain CT/MRI Which brain CT/MRI findings are seen in
findings are seen in Creutzfeldt-Jakob Disease (CJD)?
Creutzfeldt-Jakob Normal
388. Which organic cause Which organic cause of dementia involves
Disease (CJD)?
of dementia involves behavioural changes before memory
[...]
behavioural loss?
changes before Pick's Disease; Frontotemporal
memory loss? dementia
[...]

389. How do the brain CT How do the brain CT findings in


findings in Alzheimer's Disease differ from Pick's
Alzheimer's Disease Disease?
differ from Pick's AD = diffuse cortical atrophy; PD =
Disease? frontal and hypothalamic degeneration
[...]

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395. A 25 y/o pt A 25 y/o pt complains of rapidly 399. A pt has a stroke and A pt has a stroke and suffers an abrupt
complains of rapidly progressing memory loss, suffers an abrupt decline in cognitive function. MMSE and a
progressing inattentiveness and myoclonus over the decline in cognitive good history by the medical intern
memory loss, past 1 year. CT and MRI of the brain are function. MMSE and establishes dementia. What is the most
inattentiveness and both normal. LP reveals 14-3-3 protein. a good history by the likely diagnosis?
myoclonus over the What is the most likely diagnosis? medical intern Multi-infarct (vascular) dementia
past 1 year. CT and Creutzfeldt-Jakob Disease (CJD) establishes
MRI of the brain are dementia. What is
both normal. LP the most likely So, the issue with vascular dementia (VD)
reveals 14-3-3 Key points: younger patient, rapid diagnosis? is that individuals with Alzheimer's (or
protein. What is the progression, myoclonus, normal [...] other organic dementia) will also have
most likely MRI/CT and the 14-3-3 protein in CSF risk factors for stroke (HTN, HLP, T2DM,
diagnosis? Tx is palliative etc.). But since there already is dementia
[...] (and strokes in these pts can lack a FND),
diagnosing a stroke can be difficult. Hence,
diagnosing vascular dementia is tricky.
396. Which organic cause Which organic cause of dementia is
Abrupt declines that can be tied to a
of dementia is classically associated with myoclonus?
stroke can help in diagnosis (see
classically Creutzfeldt-Jakob Disease (CJD)
below). MRI can reveal past infarcts but
associated with
those may be coincidental (vs. causal).
myoclonus?
At the end of the day: if you are unsure,
[...]
treat it as Alzheimer's and control risk
factors for stroke
397. An elderly male pt An elderly male pt presents complaining
presents complaining of acute onset delirium. He adds that he
400. Which cause of Which cause of dementia is both organic
of acute onset has been having visual hallucinations for
dementia is both and reversible?
delirium. He adds the past year, but finds that they are not
organic and Normal Pressure Hydrocephalus (NPH)
that he has been bothersome. MMSE reveals cognitive
reversible?
having visual deficits in executive function and attention.
[...]
hallucinations for What is the most likely Dx?
the past year, but Lewy-Body Dementia
finds that they are 401. An elderly pt An elderly pt presents complaining of
not bothersome. presents complaining memory loss. A thorough history reveals
MMSE reveals of memory loss. A that he also has balance issues and
cognitive deficits in thorough history urinary incontinence. MMSE reveals
executive function reveals that he also cognitive deficits in executive function.
and attention. What has balance issues There is no papilledemaWhich imaging
is the most likely Dx? and urinary study should be ordered?
[...] incontinence. Head MRI (or CT)
MMSE reveals
cognitive deficits in
398. Which organic cause Which organic cause of dementia is
executive function. So here I should be thinking of Normal
of dementia is associated with Lewy bodies on biopsy?
There is no Pressure Hydrocephalus (NPH).
associated with Lewy Body Dementia; Parkinsons
papilledemaWhich MRI or CT will reveal whether or not there
Lewy bodies on
imaging study should is hydrocephalus (even if it is present,
biopsy?
be ordered? ICP is normal)
[...]
[...]

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402. An elderly pt An elderly pt presents with dementia, 406. What is the What is the diagnostic test for Normal
presents with urinary incontinence and an ataxic gait. diagnostic test for Pressure Hydrocephalus (NPH)?
dementia, urinary MRI reveals cortical atrophy with Normal Pressure Serial LPs
incontinence and an ventricular volume expansion. What is the Hydrocephalus
ataxic gait. MRI most likely diagnosis? (NPH)?
reveals cortical Normal Pressure Hydrocephalus (NPH) [...] If symptoms improve (and clinical picture
atrophy with fits), you got your Dx.
ventricular volume
expansion. What is However, be very careful when it comes
407. CAD is a group of CAD is a group of cardiac disorders that
the most likely to that MRI finding.
cardiac disorders consists of 4 hallmark conditions. What are
diagnosis? Cortical atrophy and subsequent volume
that consists of 4 they?
[...] expansion can be seen in other causes of
hallmark conditions. (see below)
dementia. NPH has specific criteria.
What are they? The underlying pathophysiology is
[...] progressive atherosclerosis of the
403. Which organic cause Which organic cause of dementia is coronary vessels resulting in an imbalance
of dementia is associated with the triad of urinary between cardiac demand and supply,
associated with the incontinence, ataxic gait and dementia? especially when cardiac demand goes
triad of urinary Normal Pressure Hydrocephalus (NPH) up.
incontinence,
ataxic gait and
dementia? aka Wet, Wobbly and Wacky
408. Which illicit drug is a Which illicit drug is a risk factor for CAD?
[...]
risk factor for CAD? Cocaine
[...]
404. Which surgical Which surgical procedure can improve
procedure can symptoms in Normal Pressure
409. A pt presents with A pt presents with crushing retrosternal
improve symptoms in Hydrocephalus (NPH)?
crushing CP that worsens with activity and
Normal Pressure VP shunt
retrosternal CP that improves with rest/nitrates. What type of
Hydrocephalus
worsens with chest pain is this?
(NPH)?
activity and Typical chest pain
[...] In NPH, its the increased CSF that causes
improves with
issues (the dilated ventricles stretch the
rest/nitrates. What
corona radiata).
type of chest pain is Typical CP must involve the following:
Serial LPs are also beneficial (and can aid
this? - retrosternal origin
in diagnosis if symptoms improve).
[...] - worsens with activity
- improves with rest/nitrates
405. Which nonsurgical Which nonsurgical procedure can help Having 3/3 = typical CP; 2/3 = atypical
procedure can help improve symptoms in Normal Pressure CP; <2 = non-anginal CP
improve symptoms in Hydrocephalus (NPH)?
Normal Pressure Serial LPs
410. What are the What are the features of typical chest
Hydrocephalus
features of typical pain?
(NPH)?
chest pain? (see below)
[...] VP shunting would be the neurosurgery
[...]
procedure I'm alluding to.

Typical CP must involve the following:


- retrosternal origin
- worsens with activity
- improves with rest/nitrates
Having 3/3 = typical CP; 2/3 = atypical
CP; <2 = non-anginal CP

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411. A pt w/ newly A pt w/ newly diagnosed STEMI develops 417. What is the most What is the most appropriate next step in
diagnosed STEMI pulmonary edema. What may this be a appropriate next step the management of a pt w/ chest pain after
develops pulmonary sign of? in the management an EKG has revealed STEMI?
edema. What may L heart failure 2/2 the MI and necrosis of a pt w/ chest pain Cardiac catheterization
this be a sign of? after an EKG has
[...] revealed STEMI?
[...] The magic number w/ the cath lab is 60. If
you can get the pt to a cath lab/PCI
412. A pt w/ newly A pt w/ newly diagnosed STEMI develops
facility within 60 minutes, then go for it.
diagnosed STEMI hypotension and peripheral edema.
If you cannot, administer tPA.
develops What may this be a sign of?
hypotension and R heart failure 2/2 the MI and necrosis
peripheral edema. 418. What laboratory tests What laboratory tests need to be ordered
What may this be a need to be ordered to rule out acute MI?
sign of? to rule out acute MI? Cardiac biomarkers (troponin, CKMB,
[...] [...] etc.)

413. Which type of Which type of myocardial infarction is


These are important. They separate
myocardial infarction known to cause arrhythmias?
angina from STEMI/NSTEMI.
is known to cause All of them
CBC, TSH, CMP are typically all done as
arrhythmias?
well, but they do not help with diagnosis
[...]
and ruling out.

414. A pt presents to the A pt presents to the ER w/ chest pain.


419. What is the most What is the most appropriate diagnostic
ER w/ chest pain. Which question during the HPI is vital to
appropriate test for a pt w/ chest pain, but no STEMI or
Which question determine the severity of the cardiac
diagnostic test for a NSTEMI?
during the HPI is vital ischemia, if any?
pt w/ chest pain, but Stress test
to determine the Does the pain improve with rest or
no STEMI or
severity of the nitrates?
NSTEMI?
cardiac ischemia, if
[...]
any?
[...]
420. Which type of stress Which type of stress test requires the
test requires the patient to have a normal EKG and to be
415. What is the best, first What is the best, first test in the workup of
patient to have a able to exercise (up to 80% of max HR)?
test in the workup of a pt w/ chest pain?
normal EKG and to Treadmill
a pt w/ chest pain? 12 lead EKG
be able to exercise
[...] The EKG is quick, cheap and accurate. It
(up to 80% of max
is also prudent, as it establishes a baseline
HR)? The pt exercises until there are:
at admission.
[...] - EKG changes, and/or
- chest pain
416. What do ST segment What do ST segment elevations on EKG
elevations on EKG signify?
421. What is the most What is the most appropriate next step in
signify? Transmural infarction
appropriate next step the management of a pt w/ unstable
[...]
in the management angina that has a positive stress test?
of a pt w/ unstable Cardiac catheterization
angina that has a
positive stress
test?
[...]

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422. Which type of Which type of cardiac stress test involves 425. Which cardiac stress Which cardiac stress test involves the use
cardiac stress test a pharmacological challenge and test involves the use of thallium to identify healthy and infarcted
involves a concurrent echocardiogram? of thallium to identify cardiac tissue?
pharmacological Dobutamine stress test healthy and infarcted Nuclear stress test
challenge and Typical performed b/c of the pt being cardiac tissue?
concurrent unable to exercise. [...]
echocardiogram? Echocardiogram looks at the tissue while The thallium looks like sodium to the body
[...] the heart is both under stress and at rest: and is taken up by healthy myocytes,
- Normal cardiac tissue will yield normal lighting them up in the process.
findings under stress & at rest Ischemic (at risk) and infarcted (dead)
- Ischemic ("at risk) cardiac tissue will tissue respond similarly to the dobutamine
yield akinesia/dyskinesia/hypokinesia stress test:
under stress and normal findings at rest; - Normal tissue will light up at rest &
this identifies which tissue is salvageable under stress
via cardiac cath - Ischemic (at risk) tissue will light up at
- Infarcted (dead) cardiac tissue will yield rest, but not under stress; this reveals
akinesia/dyskinesia/hypokinesia under salvageable tissue
stress & at rest - Infarcted (dead) tissue will never light
up

426. What is the best test What is the best test for the diagnosis of
for the diagnosis of CAD?
423. Which type of Which type of cardiac stress test is CAD? Cardiac catheterization
cardiac stress test is recommended for pts that cannot [...]
recommended for pts exercise?
that cannot Dobutamine stress test Can assess severity and location of
exercise? stenosis.
[...] Important in ruling out Prinzmetal angina

424. Which chemical Which chemical element is used in 427. Which type of angina Which type of angina occurs in the setting
element is used in nuclear cardiac stress tests? occurs in the setting of clean coronary arteries?
nuclear cardiac Thallium of clean coronary Prinzmetal angina
stress tests? arteries?
[...] [...]
It looks like sodium to the heart and is Remember, this is 2/2 vasospasm and is
taken up by healthy myocytes, thereby treated with a CCB
lighting them up.

428. What is the LDL goal What is the LDL goal in a pt w/ active
in a pt w/ active CAD?
CAD? Atleast <100; preferrably < 70?
[...] Conflicting LDL goals of peace and
prosperity...
There are different recommendations from
multiple top sources, but in general
everyone agrees that LDL should at least
be < 100

Achieve with statins

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429. What is the HbA1C What is the HbA1C target for a pt with 434. Which surgical Which surgical procedure is indicated in
target for a pt with CAD? procedure is the mangagement of multi-vessel CAD
CAD? < 7% indicated in the with left mainstem involvement?
[...] mangagement of CABG
multi-vessel CAD
with left mainstem
involvement? If multiple stents would be required, do
430. What is the BP goal What is the BP goal of a pt with CAD?
[...] CABG.
of a pt with CAD? < 140/90
If the occlusions are global and stenting
[...]
won't help, do CABG.

Achieve with ACE-I and beta-blockers


(who also help to reduce arrhythmias) 435. What are the 2 main What are the 2 main types of stents used
types of stents used in coronary angioplasty (PCI)?
in coronary Drug-elusing (DES; requires
431. How is the long-term How is the long-term risk of thrombosis
angioplasty (PCI)? clopidogrel); Bare-metal (does not
risk of thrombosis reduced in a pt with CAD?
[...] require clopidogrel)
reduced in a pt with ASA or clopidogrel
CAD?
[...] 436. Which type of Which type of coronary vessel stent
coronary vessel stent requires the use of clopidogrel?
requires the use of Drug-eluding (DES)
432. A pt w/ presents to A pt w/ presents to the ER with chest pain.
clopidogrel?
the ER with chest An EKG reveals STEMI and the pt is taken
[...]
pain. An EKG to the cath lab upstairs. Which monoclonal
reveals STEMI and antibody is helpful as an additional
the pt is taken to the antiplatelet agent during the 437. What are the What are the indications for the use of tPA
cath lab upstairs. catheterization? indications for the in the management of NSTEMI/STEMI?
Which monoclonal Abciximab (Gp IIb/IIIa inhibitor) use of tPA in the < 12 hrs of onset of symptoms; and
antibody is helpful as Especially useful in pts that are receiving management of cath lab cannot be reached in 60
an additional stents. NSTEMI/STEMI? minutes; and Dx must be NSTEMI or
antiplatelet agent [...] STEMI
during the
catheterization?
[...] If tPA is unavailable or contraindicated,
use heparin.

433. What is the What is the MONA-BASH mnemonic for


MONA-BASH the treatment of acute CAD (e.g. ACS)? 438. Which 4 drugs are Which 4 drugs are used to manage a pt
mnemonic for the (see below) used to manage a pt with chest pain and suspected ACS?
treatment of acute with chest pain and "MONA"
CAD (e.g. ACS)? suspected ACS?
[...] [...]

439. What is the most What is the most common cause of


common cause of non-cardiac chest pain?
non-cardiac chest GERD
pain?
[...]
In general, it's likely a GI disorder. PUD,
cholelithiasis, duodenitis and gastritis can
all present with CP.

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440. At what age do the At what age do the rates of CAD in women 446. What change in a What change in a pt's lipid profile is
rates of CAD in begin to equal those in men? pt's lipid profile is considered to be the most dangerous for
women begin to 55-60 considered to be the CAD (in terms of the lipid profile alone)?
equal those in men? most dangerous for Elevated LDL
[...] CAD (in terms of the
The protective effects of menstruation and lipid profile alone)?
naturally ocurring estrogen wear off by [...] Low HDL is associated w/ poor long term
then. However, estrogen replacement prognosis, but is less of a factor than high
does not help CAD. LDL.
Menstruating women very rarely have MI. Elevated triglycerides have an effect but
the outcomes are not as poor as with high
LDL.
441. Overall, which sex Overall, which sex experiences more
experiences more death 2/2 heart disease?
death 2/2 heart Women 447. A postmenopausal A postmenopausal woman develops
disease? woman develops chest pain after hearing that her husband
[...] chest pain after has passed away in a car accident. En
hearing that her route to the ER she develops dyspnea,
husband has passed diaphoresis and SOB. EKG reveals
442. What are the age What are the age cutoffs for increased
away in a car ST-segment elevations. In the cath lab,
cutoffs for increased CAD risk in men and women respectively?
accident. En route to her coronary vessels are clean and no
CAD risk in men and 45 in men; 55 in women
the ER she develops vasospasm is seen on provocation. An
women respectively?
dyspnea, diaphoresis echo is performed and shows apical LV
[...]
and SOB. EKG ballooning. What is the most likely dx?
reveals ST-segment Tako-Tsubo Cardiomyopathy
443. What is considered What is considered the worst risk factor elevations. In the
the worst risk factor for CAD? cath lab, her
for CAD? DM coronary vessels Tako-Tsubo key points:
[...] are clean and no - acute myocardial damage seen most
vasospasm is seen commonly in postmenopausal women
444. What is the most What is the most common risk factor for on provocation. An after overwhelming emotional/stressful
common risk factor CAD? echo is performed news or events (e.g. divorce, financial
for CAD? HTN and shows apical LV issues, death, earthquake, lightning strike,
[...] ~20% of the US population, half of whom ballooning. What is hypoglycemia)
do not even know they are hypertensive the most likely dx? - can involve apical ballooning of the LV
[...] w/ LV dyskinesis
- manage with BB/ACEI like in ischemic
445. A pt's risk for CAD is A pt's risk for CAD is increased if there is a
heart disease
increased if there is a FHx of premature CAD. What makes it
FHx of premature premature?
CAD. What makes it CAD occurring before 55 in men, 65 in
premature? women
[...]

FHx and CAD risk:


- Increased risk if a first-degree relative
has CAD
- Increased risk if any relative has
premature CAD

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448. [...] is a type of Taku-Tsubo cardiomyopathy is a type of 451. What are the main What are the main features of ischemic
cardiomyopathy and cardiomyopathy and cause of acute features of ischemic chest pain?
cause of acute myocardial damage that is associated with chest pain? Dull/sore; squeezing/pressure-like
myocardial damage "ballooning" of the LV apex and LV [...]
that is associated dyskinesia.
with "ballooning" of Ischemic pain is never pleuritic (changes
the LV apex and LV w/ respirations), positional (changes w/
dyskinesia. Tako-Tsubo key points: body position) or reproducible by
- acute myocardial damage seen most palpation (tender).
commonly in postmenopausal women The presence of any of those 3 excludes
after overwhelming emotional/stressful ischemic chest pain w/ a 95% negative
news or events (e.g. divorce, financial predictive value. In real life this isn't wise
issues, death, earthquake, lightning strike, (1 in 20 would go misdiagnosed), but for
hypoglycemia) the exam, roll with it.
- can involve apical ballooning of the LV
w/ LV dyskinesis
452. What percentage of What percentage of chest pain complaints
- manage with BB/ACEI like in ischemic
chest pain in the ER have a cardiac etiology?
heart disease
complaints in the ER < 50%
have a cardiac
449. A pt comes to your A pt comes to your clinic for an annual etiology?
clinic for an annual health check-up. She states that her 68 y/o [...]
health check-up. She mother is beginning to develop CAD. How
states that her 68 y/o does this affect your pt's risk for CAD?
453. A pt presents with A pt presents with chest pain. On physical
mother is beginning No change
chest pain. On exam he has a tender chest wall. What is
to develop CAD.
physical exam he the most likely Dx?
How does this affect
has a tender chest Costochondritis
your pt's risk for CAD in elderly relatives does not
wall. What is the
CAD? increase an individual's risk.
most likely Dx?
[...]
[...] Most accurate test is physical exam

450. Which major risk Which major risk factor towards CAD
454. A pt presents with A pt presents with chest pain that radiates
factor towards CAD offers the most immediate benefit if
chest pain that to the back. On physical exam, he has
offers the most corrected?
radiates to the unequal blood pressure between his
immediate benefit if Smoking cessation
back. On physical UE. What is the most likely Dx?
corrected?
exam, he has Aortic dissection
[...]
unequal blood
1 year s/p quitting = 50% decreased CAD
pressure between
risk
his UE. What is the
2 years s/p quitting = 90% decreases■d
most likely Dx?
CAD risk
[...]

455. A 30 y/o pt presents A 30 y/o pt presents with chest pain. He


with chest pain. He states that it is worse when lying flat and
states that it is better when sitting up. What is the most
worse when lying likely Dx?
flat and better when Pericarditis
sitting up. What is
the most likely Dx?
[...]

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456. A pt presents with A pt presents with chest pain. He states 461. What is the most What is the most appropriate initial
chest pain. He states that it is better when eating. On physical appropriate initial diagnostic test in the management of
that it is better when exam he has mild epigastric tenderness diagnostic test in the acute chest pain in an outpatient
eating. On physical and discomfort. What is the most likely management of setting?
exam he has mild Dx? acute chest pain in Transfer to the ER; or EKG and then
epigastric Duodenal ulcer an outpatient transfer
tenderness and setting?
discomfort. What is [...]
the most likely Dx? The point to remember is that you should
[...] never check for cardiac enzymes in the
outpatient setting. Get that pt to an ER
stat.
457. A pt presents with A pt presents with chest pain. She also
chest pain. She also complains of cough, hoarseness in the
complains of cough, morning and a metallic taste in her 462. Which 2 major Which 2 major factors in the workup of
hoarseness in the mouth whenever she lays down. What is factors in the workup chest pain influence whether or not an
morning and a the most likely Dx? of chest pain exercise stress test is appropriate?
metallic taste in her GERD influence whether or The pt's EKG is readable; and the pt
mouth whenever not an exercise can exercise
she lays down. What stress test is
is the most likely Dx? appropriate?
[...] [...] Exercise = getting HR > 85% of maximum.
Max HR = 200 - age
If not, consider other types of stress testing
458. A pt presents with A pt presents with chest pain. She
(dobutamine, nuclear)
chest pain. She describes it as a sharp, knife-like pain
describes it as a that worsens on inspiration. What is the
sharp, knife-like most likely Dx? 463. What are the most What are the most common causes of
pain that worsens Pneumothorax common causes of baseline EKG abnormalities?
on inspiration. What baseline EKG LBBB; LVH; pacemaker use; digoxin
is the most likely Dx? abnormalities?
[...] [...]
In such cases, EKG's are not reliable to
detect ischemic changes. Especially w/
459. How does SOB in How does SOB in the setting of chest pain
LBBB (all left bundles have ST elevation).
the setting of chest influence prognosis?
Hence, to detect ischemia in such cases,
pain influence Worse prognosis
we perform an echo or stress test (or
prognosis?
combine the two).
[...]

464. What are the What are the pharmacological cardiac


460. What is the most What is the most appropriate next step in
pharmacological stress tests?
appropriate next step the management of chronic/stable chest
cardiac stress tests? Dipyridamole/adenosine +
in the management pain in an outpatient setting?
[...] thallium/sestamibi; Dobutamine + echo
of chronic/stable EKG
chest pain in an
outpatient setting?
Avoid dipyridamole in asthma due to risk
[...]
of bronchospasm.
These methodologies are equal in
sensitivity and specificity.

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465. In the general sense, In the general sense, when is a cardiac 472. What is the ROA of What is the ROA of nitroglycerin when
when is a cardiac stress test indicated? nitroglycerin when managing acute coronary syndrome?
stress test indicated? Chest pain of unclear etiology w/ a managing acute Sublingual; IV; paste
[...] non-diagnostic EKG coronary
syndrome?
[...]
466. Which diagnostic test Which diagnostic test is used to detect the
is used to detect the anatomical location of CAD?
anatomical location Coronary Angiography 473. How many How many antiplatelet medications should
of CAD? antiplatelet a pt with ACS receive?
[...] medications should a 2
Also determines what the next best step is: pt with ACS receive?
angioplasty vs. CABG [...]
Typically ASA and one of clopidogrel,
prasugrel, or ticagrelor.
467. What is the most What is the most accurate test for CAD?
All 3 inhibit P2Y12 receptors on platelets
accurate test for Coronary Angiography
CAD?
[...] 474. Which antiplatelet Which antiplatelet agents are most
Sometimes used if EKG and stress testing agents are most effective at preventing re-stenosis of a
are equivocal. effective at stent if angioplasty w/ stenting is planned?
preventing Prasugrel; ticagrelor
re-stenosis of a
468. What percentage of What percentage of stenosis is an
stent if angioplasty
stenosis is an indication for surgical intervention?
w/ stenting is The above 2 and clopidogrel are all
indication for surgical > 70%
planned? beneficial, but the above 2 are most
intervention?
[...] beneficial.
[...]

475. Which 2 drug classes Which 2 drug classes offer the best
469. What findings on What findings on coronary angiography
offer the best mortality benefit in a pt w/ chronic
coronary are an indication for CABG?
mortality benefit in angina?
angiography are an ≥ 3 vessel disease; left main disease; ≥
a pt w/ chronic ASA; BBs
indication for CABG? 2 vessel disease in diabetics
angina?
[...]
[...]

1-2 vessel disease = stenting


476. What are the main What are the main indications for the use
indications for the of clopidogrel in the setting of CAD?
470. Is the Holter monitor Is the Holter monitor useful for detecting
use of clopidogrel in (see below)
useful for detecting ischemia (ST segment changes)?
the setting of CAD?
ischemia (ST No; it's useful in detecting rhythm
[...]
segment changes)?
Main indications/uses include:
[...]
1. In combination w/ ASA in the
management of ACS
471. What is the ROA of What is the ROA of nitroglycerin when 2. ASA intolerance/allergy
nitroglycerin when managing chronic angina? 3. s/p recent coronary stenting
managing chronic Oral; Transdermal
angina?
[...]

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477. A pt > 75 y/o is A pt > 75 y/o is planned to undergo 481. A pt w/ CAD and an A pt w/ CAD and an ejection fraction of
planned to undergo angioplasty w/ stenting following an ejection fraction of 20% is taking lisinopril as part of his
angioplasty w/ NSTEMI. The cardiology fellow opts to use 20% is taking management. On an annual check-up, you
stenting following an the antiplatelet ticagrelor for the lisinopril as part of notice that he is hyperkalemic. Which
NSTEMI. The procedure instead of prasugrel. Why? his management. On vasodilating agent should you switch him
cardiology fellow Prasugrel has an increased risk of an annual check-up, to?
opts to use the hemorrhagic stroke in pts > 75 you notice that he is Hydralazine (with nitrates)
antiplatelet hyperkalemic.
ticagrelor for the Which vasodilating
procedure instead of agent should you Hydralazine is a direct-acting arterial
prasugrel. Why? switch him to? vasodilator. Hydralazine will decrease
[...] [...] afterload and has been shown to have a
clear mortality benefit in patients with
systolic dysfunction. Hydralazine should
478. A pt w/ acute A pt w/ acute coronary syndrome has an
be used in association with nitrates to
coronary syndrome ASA allergy and is intolerant to
dilate the coronary arteries so that blood is
has an ASA allergy clopidogrel. Which anti-platelet
not "stolen" away from coronary perfusion
and is intolerant to medication can be used in this pt?
when afterload is decreased with the use
clopidogrel. Which Ticlopidine
of hydralazine
anti-platelet
Despite the fact that ACE-i/ARBs have
medication can be
proven mortality benefit in CAD w/ systolic
used in this pt? Can cause neutropenia and TTP.
dysfunction, changing this ACE to an ARB
[...]
would not mitigate the hyperkalemia as
aldosterone is still inhibited downstream.
479. Ticlopidine is an Ticlopidine is an anti-platelet agent that is
anti-platelet agent used when a pt is intolerant to ASA and
482. Which 5 conditions Which 5 conditions are considered to be
that is used when a clopidogrel (for reasons other than
are considered to be CAD equivalents when it comes to LDL
pt is intolerant to bleeding risk). Which adverse effects
CAD equivalents goal?
ASA and clopidogrel should be monitored for?
when it comes to PAD; Carotid disease; Aortic disease
(for reasons other Neutropenia; TTP
LDL goal? (not the valve); Stroke; DM
than bleeding risk).
[...]
Which adverse
effects should be
monitored for? 483. Which class of Which class of antihyperlipidemics is
[...] antihyperlipidemics is associated with a definite mortality benefit
associated with a in managing HLP in any setting?
definite mortality Statins
480. Which class(es) of Which class(es) of drugs offer the best
benefit in managing
drugs offer the best mortality benefit for CAD w/ low EF or
HLP in any setting?
mortality benefit for regurgitant valvular disease?
[...] In fact, only statins
CAD w/ low EF or ACEIs; ARBs
regurgitant valvular
disease? 484. What is the most What is the most common side effect of
[...] common side effect statins?
of statins? Liver dysfunction
[...]

LFTs are indicated in pts taking statins


even if they are asymptomatic.

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485. Which class of Which class of antihyperlipidemics has an 490. What are the most What are the most common side effects w/
antihyperlipidemics antioxidant effect on endothelium? common side effects statins?
has an antioxidant Statins w/ statins? Elevated LFTs; myositis
effect on [...] Follow up LFTs are indicated when starting
endothelium? statins
[...] This is an added benefit on top of lowering
LDL.
Statins are by far the best initial
491. What are the most What are the most common side effects of
antihyperlipidemic and has the best
common side effects niacin?
mortality benefit in CAD.
of niacin? Hyperglycemia; Hyperuricemia;
[...] Pruritus
486. Statins can aid in Statins can aid in increasing HDL levels.
increasing HDL Which other class of antihyperlipidemics is
levels. Which other a great choice to add on top of statins?
class of Niacin
492. What are the most What are the most common side effect of
antihyperlipidemics is
common side effect fibrates (e.g. gemfibrozil)?
a great choice to add
of fibrates (e.g. Increased risk of myositis when
on top of statins? Niacin is a great choice to add on if statins
gemfibrozil)? combined w/ statins
[...] are not effective. It also increases HDL.
[...]
Niacin is associated w/ glucose
intolerance, hyperuricemia, and pruritis
(2/2 histamine release)
493. What are the most What are the most common side effects of
common side effects bile acid sequestrants (e.g.
487. Combining fibrates Combining fibrates (e.g. gemfibrozil) and
of bile acid cholestyramine)?
(e.g. gemfibrozil) and statins can increase the risk of a common
sequestrants (e.g. Flatus; abdominal cramping; GI upset
statins can increase side effect. What is it?
cholestyramine)?
the risk of a common Myositis
[...]
side effect. What is
it?
[...] 494. What are the most What are the most common side effects of
common side effects ezetimibe?
of ezetimibe? None
488. Which class of Which class of antihyperlipidemics has
[...]
antihyperlipidemics significant interactions w/ other
has significant medications in the gut lumen?
But it's also useless
interactions w/ other Bile Acid Sequestrants (e.g.
medications in the cholestyramine)
gut lumen? 495. Which CCBs are Which CCBs are effective at lowering
[...] effective at lowering mortality in CAD?
Namely by hindering their absorption. mortality in CAD? None
Can also cause GI upset, constipation and [...]
flatus
CCBs increase HR and hence do not
improve mortality. They are negative
489. When should other When should other antihyperlipidemic
inotropes, but the increase in HR results
antihyperlipidemic agents be considered to be added on top
in a net increase in myocardial oxygen
agents be of statins?
consumption.
considered to be When statins alone cannot reach the
Nifedipine is notorious for causing reflex
added on top of LDL goal (< 70-100)
tachycardia
statins?
So don't use CCBs in CAD.
[...]

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496. What are the few What are the few indications for the use of 501. What is the best What is the best intervention for STEMI?
indications for the non-dihydropyridine CCBs (e.g. intervention for PCI
use of verapamil; diltiazem) in CAD? STEMI?
non-dihydropyridine (see below) [...]
CCBs (e.g. PCI has no added benefit in stable CAD,
verapamil; diltiazem) but may decrease dependence on meds
in CAD? Common indications include: and decrease the frequency of angina
[...] - Severe asthma that makes episodes
beta-blockers contraindicated
- Prinzmetal angina (remember this is 2/2
502. What abnormal heart What abnormal heart sound is associated
vasospasm)
sound is associated with acute coronary syndrome?
- Cocaine-induced chest pain
with acute coronary
(beta-blockers are contraindicated)
syndrome? S4

497. What are the most What are the most common side effects of [...]
common side effects CCBs? Ischemia causes noncompliance of the LV
of CCBs? Edema; constipation (namely
[...] verapamil); heart block (rare)
503. What is Kussmaul What is Kussmaul sign?
sign? Increased JVP on inspiration
498. CABG has been CABG has been shown to lower mortality [...]
shown to lower only in very severe CAD. What are these
mortality only in very circumstances? Typically associated w/ constrictive
severe CAD. What (see below) pericarditis or restrictive cardiomyopathy
are these
circumstances?
504. Which condition is Which condition is Kussmaul sign
[...] Severe CAD & performing CABG:
Kussmaul sign classically associated with?
- 3 vessel disease w/ > 70% stenosis
classically Constrictive pericarditis; restrictive
- Left main disease
associated with? cardiomyopathy
- 2 vessel disease in T2DM
[...]
- persistent symptoms despite maximal
medical therapy
505. A pt complains of A pt complains of severe chest pain. On
severe chest pain. examination he has kussmaul sign and a
499. How long to internal How long to internal mammary artery
On examination he triphasic "scratchy" sound is heard.
mammary artery grafts last s/p CABG?
has kussmaul sign What is the most likely Dx?
grafts last s/p ~ 10 yrs
and a triphasic Pericarditis
CABG?
"scratchy" sound is
[...]
heard. What is the
IMA ~ 10 yrs
most likely Dx?
Saphenous ~ 5 yrs
[...]

500. How long do How long do saphenous vein grafts remain


506. Which type of Which type of pericarditis can occur as a
saphenous vein patent s/p CABG?
pericarditis can occur complication of MI?
grafts remain patent ~5 yrs
as a complication of Dressler syndrome
s/p CABG?
MI?
[...]
[...]

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507. ST elevation in which ST elevation in which EKG leads is 511. A pt presents c/o of A pt presents c/o of substernal chest pain.
EKG leads is associated w/ the worst prognosis? substernal chest EKG reveals STEMI in V2-V4. What is the
associated w/ the V2-V4 pain. EKG reveals first drug/intervention that should be
worst prognosis? STEMI in V2-V4. given/performed?
[...] What is the first ASA
i.e. the anterior wall/LAD leads drug/intervention that
- Inferior wall MI: in leads II, III, aVF; should be
untreated mortality < 5% given/performed? Aspirin lowers mortality in ACS and
- Anterior wall MI: in leads V2-V4; [...] should be given STAT.
untreated mortality is 30-40% - Morphine, oxygen and NO are mostly for
- Posterior wall MI: reciprocal ST symptoms and do not decrease mortality
depression in V1-2; untreated mortality is However, still understand that this patient
very low still needs to get to the cath lab within 1
hour. But the first thing you should do is
slingshot an aspirin down the pt's throat
508. Which cardiac Which cardiac disorder is classically
(not actually, just adding dramatic effect
disorder is classically associated w/ a PR interval > 200 msec?
here), often on the way to the cath lab.
associated w/ a PR First-degree AV block
Plavix (clopidogrel) is indicated if the pt
interval > 200
has an ASA allergy or prior stenting.
msec?
After ASA is given, get the pt to the cath
[...] Little pathogenic potential; does not
lab or administer tPA.
require therapy when in isolation
Regardless, aspirin is recommended to
be given first and then some form of
509. A pt w/ STEMI A pt w/ STEMI develops PVCs on his revascularization.
develops PVCs on EKG. What is the most appropriate
his EKG. What is the treatment for this new finding?
512. What is the most What is the most appropriate next step in
most appropriate None
appropriate next step the management of a STEMI after the pt
treatment for this
in the management has received ASA?
new finding?
of a STEMI after the Angioplasty
[...] PVCs should not be treated, even if they
pt has received
are 2/2 MI.
ASA?
Treatment of these PVCs worsens
[...] Angioplasty has a very high mortality
outcome.
benefit vs. other steps in management (all
of which the pt is going to get anyway; e.g.
510. ST depression in ST depression in leads V1-V2 can be MONA-BASH)
leads V1-V2 can be associated w/ MI. In which anatomical
associated w/ MI. In region of the heart would this MI be
513. How is troponin How is troponin excreted?
which anatomical localized?
excreted? Via kidneys
region of the heart Posterior wall infarct
[...]
would this MI be
localized?
Hence, a pt w/ renal insufficiency can have
[...] V1 and V2 are often read in the opposite
a false positive troponin result.
direction.
i.e. ST depression in these leads could
very easily by ST elevation in other leads
and should be treated as such
In general, posterior wall MI have low
mortality.

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

514. Which cardiac Which cardiac biomarker is used to assess 518. What are the most What are the most common complications
biomarker is used to the presence of a reinfarction? common of PCI?
assess the presence CK-MB complications of (see below)
of a reinfarction? PCI?
[...] [...]
CK-MB levels normalize after 48 hrs. So - Rupture of the ballooned coronary artery
if there is a rise in CK-MB after 48 hrs of - Re-stenosis of the stent s/p PCI
admission, a reinfarction is likely. From - Hematoma at the catheter insertion site
here do an EKG (or well, this should be (i.e. femoral area hematoma)
first before CK-MB) to assess for new ST
segment changes.
519. What type of PCI What type of PCI stenting has been shown
stenting has been to have the greatest effect in reducing the
515. What is the most What is the most common cause of death shown to have the risk of re-stenosis s/p PCI?
common cause of the first few days s/p MI? greatest effect in Drug eluding stent (DES)
death the first few Ventricular arrhythmia reducing the risk of
days s/p MI? re-stenosis s/p PCI?
[...] [...] Remember, DES involves the presence
This is why pt's should be admitted to the of paclitaxel and/or sirolimus.
ICU or CCU s/p PCI. Continuous - inhibiting the T-cell response at the site of
monitoring/telemetry is vital in improving stenting is vital in preventing re-stenosis
mortality. If needed, the ICU/CCU is - Heparin is typically only used during the
equipped w/ electrical cardioversion. So procedure and not long term; Warfarin is
"admission to ICU/CCU" can be a correct not used
answer. Re-stenosis rates 6 months s/p PCI:
- No stent: 30-40%
- Bare metal stent: 15-30%
516. What is the gold What is the gold standard "door to balloon
- DES < 10%
standard "door to time" in terms of PCI?
balloon time" in 60-90 min
terms of PCI? 520. What are the What are the absolute contraindications to
[...] absolute tPA use in ACS?
I see 60 some places, 90 in others. contraindications to (see below)
tPA use in ACS?
[...]
517. What is the superior What is the superior intervention in terms
Absolute contraindications to tPA in
intervention in terms of survival, mortality and complications:
ACS:
of survival, mortality PCI or tPA?
- Major GI bleed
and complications: PCI
- Hemorrhagic stroke or intracranial
PCI or tPA? PCI's effect on complications:
hemorrhage; ischemic stroke in the past 6
[...] - fewer arrhythmia
months
- less CHF
- Recent surgery within 2 weeks
- fewer septal ruptures
- fewer free wall ruptures
- fewer papillary muscle/valvular ruptures

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

521. What percentage What percentage mortality benefit is seen 526. Which type of Which type of Heparin is superior in terms
mortality benefit is w/ tPA use in ACS? Heparin is superior in of mortality benefit?
seen w/ tPA use in 50% relative risk reduction if given in terms of mortality LMWH
ACS? the first 2 hours benefit?
[...] [...]
vs. unfractionated heparin
A pt coming in w/ CP found to have
NSTEMI/STEMI should get tPA within 30
527. What is the common What is the common sign/symptom in all of
minutes of walking through the door ("door
sign/symptom in all the complication of MI?
to needle time").
of the complication of Hypotension
MI?
522. What is the benefit of What is the benefit of tPA in ST [...]
tPA in ST depression ACS? Hence, hypotension is not going to help
depression ACS? None determining the Dx.
[...]

528. Which sign/symptom Which sign/symptom is vital in


If there is no ST elevation, there is no
is vital in distinguishing between the complications
benefit to tPA.
distinguishing of MI and establishing a diagnosis?
between the Heart rate
523. A pt presents c/o A pt presents c/o chest pain for the last complications of MI
chest pain for the last hour. It is crushing and radiates up to the and establishing a
hour. It is crushing jaw and down his left arm. EKG reveals ST diagnosis? Bradycardia = likely sinus brady (very
and radiates up to depression in V2-V4. ASA is given and [...] common) or 3rd degree AV block
the jaw and down his the pt is admitted. What is the most Tachycardia = likely RV infarction,
left arm. EKG reveals appropriate next step? tamponade/free wall rupture, VTach/VFib,
ST depression in LMW Heparin valve rupture, septal rupture
V2-V4. ASA is given
and the pt is
529. A pt s/p recent A pt s/p recent STEMI is found to have
admitted. What is the Heparin & ST Depression ACS:
STEMI is found to bradycardia. Physical exam does not
most appropriate - Heparin must be given urgently to
have bradycardia. reveal any abnormalities. What is the most
next step? prevent clot growth and further coronary
Physical exam does likely Dx?
[...] occlusion.
not reveal any Sinus bradycardia
- Remember, heparin does not break
abnormalities. What
down clots
is the most likely Dx?
There is no shown benefit of tPA in ST
[...] Sinus bradycardia is very common after
depression ACS
MI due to vascular insufficiency at the
SA node.
524. In which type of ACS In which type of ACS is tPA is most Lack of cannon A waves points away from
is tPA is most beneficial? AV block, but get an EKG to confirm.
beneficial? STEMI
[...]

525. Which Which anticoagulation agent is considered


anticoagulation agent best for NSTEMI?
is considered best for Heparin
NSTEMI?
[...]

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530. A pt s/p recent MI A pt s/p recent MI develops bradycardia. 534. A pt s/p recent A pt s/p recent STEMI suddenly develops
develops Physical exam reveals cannon A waves STEMI suddenly pulseless electrical activity (PEA). On
bradycardia. at the JVP. What is the most likely Dx? develops pulseless physical exam, lung sounds are clear
Physical exam 3rd degree/complete AV block electrical activity and there is JVD. What is the most likely
reveals cannon A (PEA). On physical Dx?
waves at the JVP. exam, lung sounds Cardiac Tamponade 2/2 ventricular free
What is the most Get an EKG to confirm (rule out sinus are clear and there wall rupture
likely Dx? brady). is JVD. What is the It typically takes several days after an MI
[...] Can be associated with RV infarction most likely Dx? for the wall to scar and weaken enough to
Cannon A Waves: [...] rupture.
- classical of complete AV block Seeing "sudden loss of pulse" in the
- produced 2/2 right atrial contraction vignette is common.
against a closed tricuspid valve (closed Dx w/ emergency echocardiogram
2/2 AV block and the resulting Tx w/ emergency pericardiocentesis (on
atrial/ventricular uncoordination) the way to the OR) and surgical repair of
the rupture

531. What is the first line What is the first line treatment for
treatment for symptomatic bradycardia?
symptomatic Atropine
bradycardia? 535. What is the best What is the best diagnostic test for
[...] diagnostic test for suspected cardiac tamponade 2/2
suspected cardiac ventricular free wall rupture in a pt s/p
tamponade 2/2 MI?
532. A pt s/p recent A pt s/p recent inferior wall MI develops
ventricular free wall Emergency echocardiogram
inferior wall MI tachycardia on hospital day 2. On
rupture in a pt s/p It typically takes several days after an MI
develops physical exam, the lungs are CTABL.
MI? for the wall to scar and weaken enough to
tachycardia on Overnight, the pt self-administered a dose
[...] rupture.
hospital day 2. On of nitroglycerin and she developed
Seeing "sudden loss of pulse" in the
physical exam, the hypotension. What is the most likely Dx?
vignette is common.
lungs are CTABL. RV infarction
Dx w/ emergency echocardiogram
Overnight, the pt Up to 40% of IWMIs w/ have RV infarction
Tx w/ emergency pericardiocentesis (on
self-administered a (due to RCA supplying the RV, AV node,
the way to the OR) and surgical repair of
dose of and inferior wall).
the rupture
nitroglycerin and Nitroglycerin markedly worsens cardiac
she developed filling and hence causes hypotension.
hypotension. What Treatment should involve high volume
is the most likely Dx? fluid replacement
[...] 536. What is the treatment What is the treatment for cardiac
for cardiac tamponade 2/2 ventricular free wall
tamponade 2/2 rupture in a pt s/p MI?
ventricular free wall Emergency pericardiocentesis
533. How can you How can you diagnose RV infarction via
rupture in a pt s/p (typically en route to the OR); surgical
diagnose RV EKG?
MI? repair of the rupture
infarction via EKG? (see below)
[...] It typically takes several days after an MI
[...]
for the wall to scar and weaken enough to
rupture.
- switch EKG leads to right side
Seeing "sudden loss of pulse" in the
- ST elevation in RV4 is most specific
vignette is common.
for RV infarction
Dx w/ emergency echocardiogram
Tx w/ emergency pericardiocentesis (on
the way to the OR) and surgical repair of
the rupture

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540. A pt s/p MI is A pt s/p MI is suspected to have developed


537. A pt s/p recent MI A pt s/p recent MI develops tachycardia. suspected to have a mural thrombus as a complication.
develops Physical exam reveals a new murmur developed a mural Which diagnostic test is the next best
tachycardia. best heard at the apex w/ radiation to the thrombus as a step?
Physical exam axilla and rales on lung auscultation. CXR complication. Which Echocardiogram
reveals a new reveals pulmonary congestion. What is diagnostic test is the
murmur best heard the most likely Dx? next best step?
at the apex w/ Mitral regurgitation 2/2 valve rupture 2/2 [...] If precent, Tx w/ heparin and then bridge
radiation to the MI to warfarin.
axilla and rales on
lung auscultation.
541. A pt s/p ACS needs A pt s/p ACS needs to be worked up for
CXR reveals Involves a new onset murmur and
to be worked up for any residual ischemia prior to discharge.
pulmonary pulmonary congestion.
any residual What is the best diagnostic test?
congestion. What is Most accurate diagnostic test is ECHO
ischemia prior to Stress test
the most likely Dx?
discharge. What is
[...]
the best diagnostic
test? And then angiography/stenting if
538. A pt s/p recent MI A pt s/p recent MI develops tachycardia. [...] needed.
develops Physical exam reveals a new murmur
tachycardia. best head at the LLSB. Blood sampling
542. A pt s/p recent MI is A pt s/p recent MI is about to be
Physical exam from the heart reveals 72% O2 sat in the
about to be discharged from the hospital. Which 4
reveals a new RA and 85% O2 sat in the RV. What is
discharged from the medications must be added to this pt's
murmur best head the most likely diagnosis?
hospital. Which 4 regimen if not already present?
at the LLSB. Blood Ventricular septum rupture 2/2 MI
medications must be (see below)
sampling from the
added to this pt's
heart reveals 72%
regimen if not
O2 sat in the RA Best diagnostic test: ECHO
already present? Postinfarction pts should go home on:
and 85% O2 sat in The "step-up" in oxygen saturation is
[...] 1. Aspirin (or
the RV. What is the the buzzword here, but read the numbers
clopidogrel/prasugrel/ticagrelor if intolerant
most likely bruv.
to ASA or s/p stenting; never give
diagnosis?
dipyridamole in CAD, that's for stroke)
[...]
2. BBs (preferrably metoprolol)
3. Statin
539. Which cardiovascular Which cardiovascular intervention is a 4. ACE inhibitor (or ARBs if ACE-I C/I)
intervention is a good good choice in the setting of acute pump
choice in the setting failure 2/2 anatomical problem that can
543. ACE inhibitors are ACE inhibitors are best for pts s/p anterior
of acute pump be fixed in the OR?
best for pts s/p wall MI. Why?
failure 2/2 Intraaortic Balloon Pump (IABP)
anterior wall MI. AWMI has a high-likelihood of causing
anatomical problem
Why? systolic dysfunction
that can be fixed in
the OR? IABP sits in the descending aorta and [...]
[...] contracts/relaxes in sync w/ the heart,
thereby "pushing" the blood forward.
IABP is never permanent - serves as a
24-48 hrs bridge to surgery for valve
replacement or transplant.

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544. A pt s/p recent MI is A pt s/p recent MI is admitted to the ICU 548. A pt s/p MI is given A pt s/p MI is given patient education
admitted to the ICU for observation and management of any patient education information on discharge. He reads them,
for observation and complications. A cheeky ICU intern opts to information on but calls your office w/ a question: "Doctor,
management of any use amiodarone as prophylaxis against discharge. He reads when can I start working out again?" What
complications. A developing VTach or VFib. Was this a them, but calls your do you tell him?
cheeky ICU intern wise choice? office w/ a question: As tolerated, so long as the post-MI
opts to use No; postinfarction, prophylactic "Doctor, when can I stress test was normal
amiodarone as antiarrhythmics actually increase start working out
prophylaxis against mortality again?" What do you
developing VTach or tell him? Including sex
VFib. Was this a [...]
wise choice? Do not be fooled by the question saying
[...] "frequent PVCs and ectopy"
549. What are the types of What are the types of heart failure?
heart failure? Systolic; diastolic; left; right
545. Nitrates are Nitrates are contraindicated alongside [...]
contraindicated sildenafil. Why?
alongside sildenafil. Hypotension can result
Why?
[...]
Both are strong vasodilators
550. Which type of heart Which type of heart failure involves a
failure involves a failure of the heart to pump blood forward?
546. A pt s/p recent MI A pt s/p recent MI presents to the failure of the heart to Systolic
presents to the outpatient clinic complaining of erectile pump blood forward? Typically 2/2 to one (or a combination) of:
outpatient clinic dysfunction. He is currently taking ASA, [...] - Leakiness (regurgitating valves)
complaining of metoprolol, atorvastatin, lisinopril and - Dead (ischemic/infarcted myocardium)
erectile metformin. What is the most likely cause? - Floppy (weak myocardium: HTN, EtOH,
dysfunction. He is Anxiety drugs, nonischemic cardiomyopathy)
currently taking ASA,
metoprolol,
atorvastatin, lisinopril However, beta-blockers are a cause of
and metformin. What erectile dysfunction.
551. Which type of heart Which type of heart failure involves
is the most likely
failure involves inability of the heart to fill w/ blood?
cause?
inability of the heart Diastolic
[...]
to fill w/ blood? Typically 2/2 one of:
[...] - Pericarditis
547. A pt s/p MI is given A pt s/p MI is given patient education - Restrictive cardiomyopathy
patient education information on discharge. He reads them, - HCM
information on but calls your office w/ a question: "Doctor,
discharge. He reads when can I start having sex again?" What
them, but calls your do you tell him?
office w/ a question: Immediately, so long as you are
"Doctor, when can I symptom-free
start having sex
again?" What do you
tell him? Sexual activity typically does not last long
[...] enough to constitute an excessive
increase in myocardial oxygen
consumption.

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552. What is the most What is the most common cause of 555. A pt is diagnosed w/ A pt is diagnosed w/ right heart systolic
common cause of chronic heart failure? right heart systolic failure. What critical step must be
chronic heart failure? HTN; infarction and valvular disease are failure. What critical performed in order to determine the
[...] also up there step must be indicated treatment?
performed in order to Determining NYHA HF class
determine the
Pretty simple to understand why: indicated treatment?
- HTN --> increased PVR --> heart must [...]
pump harder --> hypertrophic/dilatory
myocardial changes to compensate --> low
EF ---> failure
556. Many pts may have Many pts may have both R and L heart
- Initially, the HTN and PVR are overcome
both R and L heart failure concurrently. As a result, some
by increased catecholamine stimulation
failure concurrently. aspects of their symptomology can
- Subsequently, neural-hormonal
As a result, some overlap. Which 2 physical signs of heart
remodelling occurs at the myocardium,
aspects of their failure are signs of acute CHF
leading to cardiac toxicity and fibrosis
symptomology can exacerbation?
overlap. Which 2 S3 (LCHF); JVD (RCHF)
553. A pt presents c/o of A pt presents c/o of SOB on exertion. Via physical signs of
SOB on exertion. the history, you discover that he has SOB heart failure are
Via the history, you when lying down and occassionally signs of acute CHF S3 and JVD are poor prognostic signs in
discover that he has wakes up at night gasping for air. exacerbation? acute CHF.
SOB when lying Physical exam reveals crackles at the [...]
down and lung bases bilaterally. What is the most
occassionally likely Dx?
wakes up at night L heart failure
557. What is the most What is the most common cause of left
gasping for air. Recognize this classic triad of LHF:
common cause of heart failure?
Physical exam orthopnea, exertional dyspnea, and
left heart failure? Right heart failure
reveals crackles at paroxysmal nocturnal dyspnea.
[...]
the lung bases
bilaterally. What is
the most likely Dx? 558. What is the best What is the best diagnostic test for
[...] diagnostic test for suspected heart failure?
suspected heart 2D Echocardiogram
failure? Although heart failure can be Dx on s/s.
554. A pt presents c/o of A pt presents c/o of SOB on exertion. He
[...]
SOB on exertion. also reveals that he has noticed some
ECHO interpretation in the setting of CHF
He also reveals that swelling in his legs and feet. Physical
isn't too difficult:
he has noticed some exam reveals an elevated JVP and a liver
- If EF < 55%, then systolic dysfunction
swelling in his legs span of 14 cm. What is the most likely
- If EF is normal (± diastolic filling
and feet. Physical Dx?
defects), then diastolic dysfunction
exam reveals an R heart failure
Nuclear Stress Testing can be more
elevated JVP and a
definitive as it can provide the exact EF
liver span of 14 cm.
and identify areas of ischemia.
What is the most
LHC is also more definitive in providing EF
likely Dx?
and localizing ischemia.
[...]

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559. What is the role of What is the role of measuring BNP in the 564. Treatment in heart Treatment in heart failure is aimed to
measuring BNP in workup of suspected heart failure? failure is aimed to reduce fluid load and afterload. What
the workup of Useful in determining the presence of reduce fluid load and restriction to salt (NaCl) intake aids w/
suspected heart volume overload afterload. What reducing fluid load?
failure? restriction to salt < 2 g/day
[...] (NaCl) intake aids w/
reducing fluid load?
[...] Reducing fluid load:
560. What is the role of an What is the role of an EKG in the w/u of
- reduce salt intake
EKG in the w/u of suspected heart failure?
- reduce water intake
suspected heart To identify ischemia/arrhythmia
- furosemide if ≥ class 2
failure?
Reducing afterload:
[...]
- ACE-I/ARB
EKG, along w/ CXR and troponins, are
- Spironolactone if ≥ class 3
appropriate, but not required.
- Isosorbide dinitrate + hydralazine if ≥
class 3
561. What is the role of a What is the role of a CXR in the w/u of
CXR in the w/u of suspected heart failure?
suspected heart Assess cardiomegaly & pulmonary
failure? edema/effusion
[...] CXR, EKG and troponins are appropriate
565. Treatment in heart Treatment in heart failure aims to reduce
in the w/u but not required.
failure aims to fluid load and afterload. What daily water
reduce fluid load and restriction helps to reduce fluid load?
afterload. What daily < 2 L H2O/day
562. What is the role of What is the role of measuring troponins in water restriction
measuring the w/u of suspected heart failure? helps to reduce fluid
troponins in the w/u To identify acute ischemia load? Reducing fluid load:
of suspected heart [...] - reduce salt intake
failure? - reduce water intake
[...] CXR, EKG and troponins are appropriate - furosemide if ≥ class 2
in the w/u but not required. Reducing afterload:
- ACE-I/ARB
- Spironolactone if ≥ class 3
563. What are the main What are the main goals of treatment in - Isosorbide dinitrate + hydralazine if ≥
goals of treatment in heart failure? class 3
heart failure? Reduce fluid load; Reduce afterload
[...] Reducing fluid load:
- reduce salt intake
- reduce water intake
- furosemide if ≥ class 2
Reducing afterload:
- ACE-I/ARB
- Spironolactone if ≥ class 3
- Isosorbide dinitrate + hydralazine if ≥
class 3

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566. Treatment in heart Treatment in heart failure is aimed to 568. Which Which antihypertensive agents used to
failure is aimed to decrease fluid load and afterload. What antihypertensive treat CHF have the greatest mortality
decrease fluid load diuretic is useful in reducing fluid load in agents used to treat benefit of any drug used in CHF?
and afterload. What the management of ≥ class II heart CHF have the ACE-I; ARB; (any agent in these
diuretic is useful in failure? greatest mortality classes)
reducing fluid load in Lasix (furosemide); however, any loop benefit of any drug
the management of ≥ diuretic can be used used in CHF?
class II heart failure? [...] They are effective at reducing afterload as
[...] well as mitigating cardiac remodelling in
Reducing fluid load: chronic CHF.
- reduce salt intake Reducing fluid load:
- reduce water intake - reduce salt intake
- furosemide if ≥ class 2 - reduce water intake
Reducing afterload: - furosemide if ≥ class 2
- ACE-I/ARB Reducing afterload:
- Spironolactone if ≥ class 3 - ACE-I/ARB
- Isosorbide dinitrate + hydralazine if ≥ - Spironolactone if ≥ class 3
class 3 - Isosorbide dinitrate + hydralazine if ≥
class 3

567. Treatment in heart Treatment in heart failure is aimed to


failure is aimed to decrease fluid load and afterload. Which 569. Which 4 treatment Which 4 treatment modalities/drugs should
decrease fluid load agents are preferred in decreasing modalities/drugs all pts diagnosed w/ CHF be on?
and afterload. Which afterload in CHF? should all pts (see below)
agents are preferred ACE-I; ARB diagnosed w/ CHF
in decreasing be on?
afterload in CHF? [...] The 4 "everyone" gets:
[...] Reducing fluid load: 1. <2 g NaCl/day to reduce fluid load
- reduce salt intake 2. <2 L H2O/day to reduce fluid load
- reduce water intake 3. ACE-i or ARB to reduce afterload; also
- furosemide if ≥ class 2 gives greatest mortality benefit
Reducing afterload: 4. BB to reduce the risk of sudden cardiac
- ACE-I/ARB death, arrhythmia, and to reduce cardiac
- Spironolactone if ≥ class 3 remodelling
- Isosorbide dinitrate + hydralazine if ≥
class 3

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570. Treatment in heart Treatment in heart failure is aimed towards 572. Treatment in heart Treatment in heart failure is aimed to
failure is aimed reducing fluid load and afterload. What failure is aimed to reduce fluid load and afterload. Which
towards reducing diuretic can be added for ≥ class III heart reduce fluid load and class of drugs are also added to reduce
fluid load and failure? afterload. Which risk of sudden cardiac death and
afterload. What Spironolactone; can also add class of drugs are improve mortality?
diuretic can be ISDN+hydralazine to help reduce also added to Beta-blockers [namely metoprolol (b1),
added for ≥ class III afterload reduce risk of bisoprolol (b1), carvedilol (a,b)]
heart failure? sudden cardiac
[...] death and improve
Reducing fluid load: mortality? BBs act to reduce:
- reduce salt intake [...] - occurrence of ventricular arrhythmia
- reduce water intake (and hence sudden cardiac death)
- furosemide if ≥ class 2 - occurrence of ischemia (and hence
Reducing afterload: sudden cardiac death)
- ACE-I/ARB - neuro-hormonal cardiac remodelling
- Spironolactone if ≥ class 3
- Isosorbide dinitrate + hydralazine if ≥
573. What is the ejection What is the ejection fraction cutoff for the
class 3
fraction cutoff for the placement of an AICD in non-palliative
placement of an pts w/ heart failure?
AICD in < 35% (in the setting of ischemic
non-palliative pts w/ cardiomyopathy)
heart failure?
571. Treatment in heart Treatment in heart failure is aimed to [...]
failure is aimed to reduce fluid load and afterload. However, AICDs have up to 25% relative
reduce fluid load and for severe heart failure (Class IV) reduction of risk of death.
afterload. However, inotropes can be used in preparation for What's the most common cause of death
for severe heart transplant or VAD. Which one is in CHF? Arrhythmia/sudden cardiac death
failure (Class IV) preferred?
inotropes can be Dobutamine (as a drip)
574. How does Digoxin How does Digoxin change mortality in
used in preparation
change mortality in heart failure?
for transplant or
heart failure? No change
VAD. Which one is In the ICU, a Dobutamine drip can help the
[...]
preferred? pt make it to transplantation or insertion of
[...] a ventricular assist device (which acts as a
Digoxin is primarily used for symptom
bridge to transplantation).
relief and to mitigate/reduce future
exacerbations/hospitalizations.
In real life, the use of Digoxin is typically
limited to in-hospital control of atrial
fibrillation or by a heart failure
specialist trying to get the person a
little more comfort in their life with
advanced heart failure.
- Digoxin is a good drug for rate control in
AFib in the setting of CHF w/o CKD/AKI (±
acute CHF exacerbation)

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575. How often is Digoxin How often is Digoxin used in heart failure? 579. What are the main What are the main treatment goals in
used in heart failure? Rarely; in fact digoxin is barely used treatment goals in acute CHF exacerbation?
[...] anymore overall acute CHF (see below)
Digoxin is primarily used for symptom exacerbation?
relief and to mitigate/reduce future [...]
exacerbations. The goals are similar to the chronic
In real life, the use of Digoxin is typically management of CHF, but w/ more
limited to in-hospital control of atrial emphasis on the acute presentation:
fibrillation or by a heart failure 1. Reduce afterload (via nitrates,
specialist trying to get the person a hydralazine and anti-hypertensives)
little more comfort in their life with 2. Reduce preload (via nitrates,
advanced heart failure. morphine)
- Digoxin is a good drug for rate control in 3. Reduce pulmonary edema/fluid (via IV
AFib in the setting of CHF w/o CKD/AKI (± furosemide)
acute CHF exacerbation) Heparin is never involved in management
unless there is a clot.
Then pts are discharged on appropriate
576. A pt w/ chronic CHF A pt w/ chronic CHF presents c/o of SOB
changes to their ACE/BB/diuretic regimen.
presents c/o of SOB at rest. You suspect acute CHF
at rest. You suspect exacerbation. What is the most
acute CHF appropriate diagnostic test that should be 580. What is the "LMNOP" What is the "LMNOP" mnemonic in the
exacerbation. What done first? mnemonic in the management of acute CHF exacerbation
is the most Give O2 and then get an EKG management of that is not 2/2 to ischemia or
appropriate While CHF exacerbation is a clinical Dx, acute CHF arrhythmia?
diagnostic test that EKG is the most important test to do exacerbation that is (see below)
should be done first? acutely as any signs of not 2/2 to ischemia
[...] ischemia/arrhythmia will change or arrhythmia?
treatment. [...] "LMNOP":
If ischemia is present, treat the ACS as - Lasix (furosemide; to get fluid off the
that is the likely cause of the exacerbation. lungs and reduce fluid load)
If arrhythmia is present, then perform - Morphine (effective venodilator, thereby
cardioversion. reducing ventricular preload; aids in pt
All the other tests for other causes (CXR, comfort as well; anxiolytic)
ABG, ECHO, BNP, etc) will be done if the - Nitrates (venodilator; decreases afterload
EKG is nondiagnostic. and preload)
- Oxygen
- Position (to alleviate orthopnea)

577. What is the most What is the most severe form of acute
severe form of acute CHF exacerbation?
CHF exacerbation? Acute Pulmonary Edema
[...]

578. Which laboratory test Which laboratory test is highly specific for
is highly specific for acute CHF exacerbation if the finding is
acute CHF elevated?
exacerbation if the BNP
finding is elevated?
[...]
Remember, BNP is produced 2/2 to atrial
stretching.

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581. A pt w/ chronic CHF A pt w/ chronic CHF presents w/ chest 585. A pt presents w/ A pt presents w/ dyspnea of slow onset.
presents w/ chest pain and SOB at rest. He is diagnosed w/ dyspnea of slow He also complains of fever and
pain and SOB at RV MI. The intern is about to give the pt onset. He also productive cough w/ sputum. Physical
rest. He is diagnosed nitrates (among other meds) but is complains of fever exam reveals unilateral rales. What is the
w/ RV MI. The intern stopped by his attending. Why are nitrates and productive most likely Dx?
is about to give the pt a bad idea? cough w/ sputum. Pneumonia
nitrates (among The RV is preload dependent and Physical exam
other meds) but is dropping preload will worsen the RV reveals unilateral
stopped by his function rales. What is the
attending. Why are most likely Dx?
nitrates a bad idea? [...]
[...] Drugs to avoid in RV MI:
- Nitrates as they reduce RV preload
586. A pt presents w/ A pt presents w/ dyspnea. There are
- Diuretics as they reduce RV preload
dyspnea. There are decreased breath sounds on the right
- Opiates as they reduce RV preload
decreased breath side and tracheal deviation to the left.
- Bladder catheterization as it can
sounds on the right What is the most likely Dx?
increase vagal tone, acutely decrease
side and tracheal Pneumothorax
RV preload and trigger cardiogenic
deviation to the left.
shock
What is the most
likely Dx?
582. What is the most What is the most common cause of [...]
common cause of hospital admission of adults in the USA?
hospital admission of CHF; acute CHF exacerbation
587. A pt presents w/ A pt presents w/ dyspnea. She also
adults in the USA?
dyspnea. She also complains of circumoral numbness.
[...]
complains of PMHx is positive for anxiety and HTN.
circumoral SHx is positive for smoking, alcohol and
583. A pt presents w/ A pt presents w/ dyspnea. It has a numbness. PMHx is caffeine use. What is the most likely Dx?
dyspnea. It has a sudden onset. Lungs are CTABL. What is positive for anxiety Panic Attack
sudden onset. the most likely Dx? and HTN. SHx is
Lungs are CTABL. PE positive for smoking,
What is the most alcohol and caffeine
likely Dx? use. What is the
[...] most likely Dx?
[...]

584. A pt presents w/ A pt presents w/ dyspnea of sudden


dyspnea of sudden onset. Lung auscultation reveals 588. A pt presents w/ A pt presents w/ dyspnea of very slow
onset. Lung wheezing. Studies reveal an increased dyspnea of very onset. Physical exam reveals
auscultation reveals expiratory phase. What is the most likely slow onset. Physical conjunctival pallour. What is the most
wheezing. Studies Dx? exam reveals likely Dx?
reveal an increased Asthma conjunctival Anaemia
expiratory phase. pallour. What is the
What is the most most likely Dx?
likely Dx? [...]
[...]

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589. A pt presents w/ A pt presents w/ dyspnea. Physical exam 593. What is the best What is the best initial test to gauge
dyspnea. Physical reveals decreased heart sounds, JVD initial test to gauge cardiac ejection fraction?
exam reveals and pulsus paradoxus. What is the most cardiac ejection Transthoracic echocardiogram
decreased heart likely cause? fraction?
sounds, JVD and Cardiac Tamponade [...]
pulsus paradoxus. Most accurate = nuclear
What is the most ventriculography or multiple-gated
likely cause? acquisition scan (MUGA)
[...] TEE is better for assessing valvular
function. It is not necessary in CHF
unless the suspected cause is valvular.
590. A pt presents w/ A pt presents w/ dyspnea. He was
dyspnea. He was recently discharged following an elective
recently discharged cholecystectomy. Physical exam reveals 594. What is the most What is the most accurate test of ejection
following an elective cyanosis of the extremities. Lungs are accurate test of fraction?
cholecystectomy. CTABL. A nurse pages you and states ejection fraction? Nuclear ventriculography;
Physical exam that his blood looked brown, when she [...] multiple-gated acquisition scan (MUGA)
reveals cyanosis of drew labs. What is the most likely Dx?
the extremities. Methemoglobinemia
Lungs are CTABL. A Rarely ever needed, but if it asks for best
nurse pages you and precision, especially for wall motion
states that his blood abnormalities. Choose this.
looked brown, when - e.g. if a pt receiving chemotherapy
she drew labs. What (doxorubicin) needs to be assessed for
is the most likely Dx? cardiomyopathy
[...]

595. A pt presents w/ A pt presents w/ acute dyspnea. After a


591. A pt presents w/ A pt presents w/ dyspnea. He states that acute dyspnea. thorough history, the etiology is unclear.
dyspnea. He states they were camping and cooking food in After a thorough Which laboratory test can be ordered to
that they were their cabin. What is the most likely Dx? history, the etiology rule out CHF (potentially if an echo cannot
camping and cooking Carbon monoxide poisoning is unclear. Which be done in time)?
food in their cabin. laboratory test can BNP
What is the most be ordered to rule
likely Dx? out CHF (potentially
[...] if an echo cannot be Normal BNP = no CHF
done in time)?
[...]
592. What is the most What is the most important test in the
important test in the w/u of CHF?
w/u of CHF? Echocardiogram 596. What is best test to What is best test to diagnose CHF?
[...] diagnose CHF? None, it is a clinical Dx
[...]
There is no other way to discern b/w
systolic and diastolic.
597. What is the best test What is the best test to determine the type
Every CHF pt should get an updated
to determine the of CHF?
ECHO (if indicated) during a hospital stay
type of CHF? Echo (TTE)
to evaluate EF.
[...]

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598. What are the What are the common side effects of
605. What CXR findings What CXR findings are seen in acute CHF
common side effects spironolactone?
of spironolactone? Hyperkalemia; gynecomastia are seen in acute exacerbation?
[...] CHF exacerbation? Pulmonary vascular congestion w/
[...] cephalization of flow; ± cardiomegaly; ±
pleural effusion
599. A pt w/ class IV CHF A pt w/ class IV CHF is taking
Cephalization of flow = filling of the blood
is taking spironolactone as part of his regimen. He
vessels towards the head.
spironolactone as develops gynecomastia. Which drug
part of his regimen. should spironolactone be switched to?
He develops Eplerenone
606. Which acid-base Which acid-base imbalance is seen in
gynecomastia.
Which drug should imbalance is seen in acute CHF exacerbation?
spironolactone be Eplerenone acute CHF Respiratory alkalosis
switched to? - same class as spironolactone exacerbation?
[...] - also has a proven mortality benefit [...]
- does not have any anti-androgenic These pt's are typically tachypneic, hence
effect the CO2 leaving the body causes
alkalosis.

600. How do loop How do loop diuretics change the mortality


607. What is the best What is the best diagnostic test for valvular
diuretics change the in CHF?
mortality in CHF? No change diagnostic test for heart disease?
[...] valvular heart TEE
disease?
They simply control symptoms. [...]
TEE > TTE in terms of sensitivity and
specificity, however TTE is often
601. What is the most What is the most common cause of death considered the best "initial" test due to its
common cause of in CHF? ease
death in CHF? Arrhythmia/sudden cardiac death
Heart Cath is the most accurate test
[...]

608. What is the grade of What is the grade of a murmur that is


602. What is the indication What is the indication for the insertion of a a murmur that is softer than S1 and S2?
for the insertion of a biventricular pacemaker in CHF? softer than S1 and I
biventricular EF < 35% w/ a QRS > 120 ms S2?
pacemaker in CHF? [...]
[...] Murmur grading:
Effective at resynchronizing the heart I: S1/S2 > murmur
when there is a conduction defect. II: S1/S2 = murmur
III: S1/S2 < murmur
603. What is the role of What is the role of CCBs in systolic CHF? IV: palpable thrill
CCBs in systolic Nothing V: “almost six” can hear w/ steth half off
CHF? chest
[...] VI: heard w/o steth
In fact, some may increase mortality.

604. What drugs offer What drugs offer mortality benefits in


mortality benefits in systolic CHF?
systolic CHF? (see below)
[...]

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609. What is the grade of What is the grade of a murmur that has 612. What is the grade of What is the grade of a murmur that can be
a murmur that has equal volume as S1/S2? a murmur that can be heard w/ the stethoscope only halfly on the
equal volume as II heard w/ the chest?
S1/S2? stethoscope only V
[...] halfly on the chest? This one is weird, but basically, if it has a
Murmur grading: [...] thrill and is "almost a six" it's a five.
I: S1/S2 > murmur Murmur grading:
II: S1/S2 = murmur I: S1/S2 > murmur
III: S1/S2 < murmur II: S1/S2 = murmur
IV: palpable thrill III: S1/S2 < murmur
V: “almost six” can hear w/ steth half off IV: palpable thrill
chest V: “almost six” can hear w/ steth half off
VI: heard w/o steth chest
VI: heard w/o steth

610. What is the grade of What is the grade of a murmur that is


a murmur that is louder than S1/S2? 613. What is the grade of What is the grade of a murmur that has a
louder than S1/S2? III a murmur that has a palpable thrill and can be heard without
[...] palpable thrill and a stethoscope?
can be heard VI
Murmur grading: without a
I: S1/S2 > murmur stethoscope?
II: S1/S2 = murmur [...] Murmur grading:
III: S1/S2 < murmur I: S1/S2 > murmur
IV: palpable thrill II: S1/S2 = murmur
V: “almost six” can hear w/ steth half off III: S1/S2 < murmur
chest IV: palpable thrill
VI: heard w/o steth V: “almost six” can hear w/ steth half off
chest
VI: heard w/o steth
611. What is the grade of What is the grade of a murmur that has a
a murmur that has a palpable thrill?
palpable thrill? IV 614. Which type of Which type of murmurs always need to be
[...] murmurs always worked up?
need to be worked Diastolic; Systolic > grade III
Murmur grading: up?
I: S1/S2 > murmur [...]
II: S1/S2 = murmur w/u w/ a TEE first
III: S1/S2 < murmur
IV: palpable thrill
V: “almost six” can hear w/ steth half off
chest
VI: heard w/o steth

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615. In general, what In general, what causes 618. Which common Which common murmurs get softer with
causes insufficient/regurgitant valves? murmurs get softer an increase in preload?
insufficient/regurgitantInfection; infarction/ischemia; or with an increase in MVP; HOCM
valves? anything that dilates the heart preload?
[...] [...]
HOCM:
Insufficient/regurgitant valves: - involves the hypertrophic septum
- 2/2 to infection (i.e. endocarditis), blocking the aortic valve
infarction (i.e. papillary muscle/chordae - w/ increased preload the septum is
tendinae rupture), or aortic dissection (in pushed back and the aortic valve opening
AR) is not as occluded
- presentation is either acute or chronic - sounds exactly like AS, but will
- acute presentation often involves acute DECREASE w/ increased preload
CHF w/ cardiogenic shock and requires - Tx w/ “avoiding dehydration” and BBs to
emergent valve replacement slow the HR and increase diastolic filling
time
MVP:
616. In general, what is In general, what is the cause of stenotic
- involves valves that are too large/loose
the cause of heart valves?
to close, hence they prolapse into the
stenotic heart Atherosclerosis (w/ subsequent
atrium upon closer
valves? calcification); Rheumatic fever
- increasing preload expands the
[...]
ventricle (and hence the valvular ring),
thereby allowing the valve to close
Stenotic valves:
properly and decreasing the murmur
- more insidious in onset, hence more AFib
presentation (than CHF)
- 2/2 to atherosclerosis (AS) or rheumatic 619. Which physical exam Which physical exam maneuvers increase
fever (MS) maneuvers increase preload?
preload? Squatting (then standing up); leg raise
[...]
617. Which common Which common murmurs get louder with
murmurs get louder an increase in preload?
Squatting or leg lift = increase preload
with an increase in MS/MR/AS/AR
Valsalva = decrease preload
preload?
[...]
"Mr. and Ms. Asar get louder w/ more 620. Which valvular Which valvular disorder is caused almost
blood" disorder is caused exclusively by rheumatic fever?
Squatting or leg lift = increase preload almost exclusively by Mitral stenosis
Valsalva = decrease preload rheumatic fever? Treat dat strep throat properly, brah
[...]

621. What arrhythmia may What arrhythmia may develop as a result


develop as a result of of mitral stenosis?
mitral stenosis? AFib
[...]

2/2 to stretching of the atrium

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622. A 30 y/o pt comes in A 30 y/o pt comes in for a regular health 624. What is the only What is the only (common) heart murmur
for a regular health exam. She states that she had a sore (common) heart that is susceptible to balloon
exam. She states throat in the past few weeks, but has been murmur that is valvotomy/valvuloplasty?
that she had a sore pretty healthy otherwise. On physical susceptible to Mitral stenosis
throat in the past few exam, you hear a grade II, descrescendo balloon
weeks, but has been murmur during diastole w/ an opening valvotomy/valvuloplasty?
pretty healthy snap. What is the most likely Dx? [...] In fact, valve replacement is not preferred
otherwise. On Mitral Stenosis 2/2 to rheumatic fever in this case as MS is typically seen in
physical exam, you The louder the opening snap, the more younger pts 2/2 rheumatic fever.
hear a grade II, severe the stenosis. Replacement valves will likely need to be
descrescendo Almost exclusively caused by rheumatic replaced.
murmur during fever The threshold for critical narrowing of the
diastole w/ an Tx (valvuloplasty; preload reduction) valve is a surface area of < 1 cm2.
opening snap. What should be started right away before However the main indication for treatment
is the most likely Dx? CHF or AFib sets in is the presence of symptoms.
[...]

625. What is the etiology What is the etiology of aortic stenosis?


of aortic stenosis? Calcification 2/2 Atherosclerosis
[...]
623. What is the treatment What is the treatment for mitral stenosis?
for mitral stenosis? Preload reduction; valvuloplasty; valve This also applies to bicuspid valves,
[...] replacement if very severe which simply calcify faster
Commisurotomy is no longer done for MS.
Tx needs to start as soon as symptoms
626. An elderly male pt An elderly male pt comes in for a health
start to prevent CHF or AFib from settling
comes in for a health exam. You find a grade III, systolic,
in.
exam. You find a crescendo-decrescendo murmur heard
Balloon valvuloplasty/valvotomy are
grade III, systolic, loudest at the base. What is the most
preferred over valve replacement
crescendo-decrescendo likely Dx?
- MS is often seen in younger pts 2/2
murmur heard Aortic Stenosis likely 2/2 calcification
rheumatic fever. Valve replacement in
loudest at the base. 2/2 atherosclerosis
younger pts is not ideal as the replacement
What is the most
will likely need to be replaced itself.
likely Dx?
The threshold for critical narrowing of the
[...] Key points:
valve is a surface area of < 1 cm2.
- AS more commonly seen in elderly men;
However the main indication for treatment
younger presentation likely 2/2 to bicuspid
is the presence of symptoms.
valve
- crescendo-decrescendo systolic murmur

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627. An elderly male pt An elderly male pt presents c/o chest 629. What is the treatment What is the treatment for aortic stenosis?
presents c/o chest pain and SOB that are both worse w/ for aortic stenosis? Preload reduction; AVR
pain and SOB that activity. Physical exam reveals a systolic, [...]
are both worse w/ crescendo-decrescendo murmur at the
activity. Physical RUSB and rales bilaterally. BNP is Commisurotomy and valvotomy are not
exam reveals a elevated. What is the most likely Dx? possible as the calcifications are often
systolic, Aortic Stenosis (in the setting of CHF too thick and the valve is too stiff.
crescendo-decrescendo and likely CAD) If AVR is considered, do a cardiac cath
murmur at the before boarding the pt for surgery (and
RUSB and rales vice versa if you are doing CABG, get an
bilaterally. BNP is Remember: this murmur typically also echo). This is because the ostia of the
elevated. What is the radiates to the carotids coronary vessels are just distal to the
most likely Dx? This presentation of AS has the worst aortic valve (or basically, inside the valve).
[...] prognosis (1-3 year survival rate from So before doing open heart surgery, you
time of Dx if acute CHF is part of the may as well see if anything else needs to
presentation). be done (i.e. AVR or CABG). Sometimes
Tx w/ preload reduction & valve CABG is done w/ AVR regardless of the
replacement presence of CAD if they ostia might be
lost.

628. An elderly male pt An elderly male pt presents c/o of


presents c/o of multiple syncopal episodes while 630. A pt is Dx w/ aortic A pt is Dx w/ aortic stenosis. A cheeky
multiple syncopal jogging. Physical exam reveals a stenosis. A cheeky medical student things that valvotomy
episodes while systolic, crescendo-decrescendo medical student should be done. Why is this not feasible?
jogging. Physical murmur at the RUSB. What is the most things that valvotomy Calcifications of the aortic valve make it
exam reveals a likely Dx? should be done. Why too thick/stiff for balloon valvotomy
systolic, AS is this not feasible?
crescendo-decrescendo [...]
murmur at the
RUSB. What is the Remember: this murmur typically also
most likely Dx? radiates to the carotids
[...] Remember, syncope can be a classic
631. Which type of Which type of valvular defects can present
sign of aortic stenosis, especially when
valvular defects can acutely as cardiogenic shock and acute
cardiac demand sharply increases.
present acutely as pulmonary edema?
cardiogenic shock Regurgitation
and acute
pulmonary edema?
[...]

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632. A pt presents in A pt presents in acute cardiogenic 636. A pt comes in for an A pt comes in for an annual health exam.
acute cardiogenic shock. A CXR reveals acute pulmonary annual health exam. Your medical student reports that the pt
shock. A CXR edema. EKG reveals AFib. Physical exam Your medical student has a systolic murmur heard at the
reveals acute reveals a holosystolic murmur that reports that the pt cardiac apex that radiates to the axilla,
pulmonary edema. radiates to the axilla. What is the most has a systolic but he is unsure if it is MR or MVP. What
EKG reveals AFib. likely Dx? murmur heard at the physical exam maneuver can discern
Physical exam Acute Mitral regurge cardiac apex that between the two?
reveals a radiates to the Squatting (and then standing); or leg lift
holosystolic axilla, but he is
murmur that - AFib 2/2 to atrial stretching unsure if it is MR or
radiates to the - cardiogenic shock 2/2 decreased MVP. What physical Both will increase preload, but in MVP it
axilla. What is the forward flow of blood exam maneuver can will decrease the murmur; in MR it will
most likely Dx? - acute pulmonary edema/CHF 2/2 discern between the increase the murmur.
[...] pulmonary congestion 2/2 backwards flow two? MVP involves valves that are too
of blood [...] large/loose to close, hence they prolapse
- Tx is emergent valve replacement into the atrium upon closer. Increasing
preload expands the ventricle (and hence
the valvular ring), thereby allowing the
633. A pt presents c/o of A pt presents c/o of exertional dyspnea
valve to close properly and decreasing the
exertional dyspnea and fatigue. He states that these
murmur.
and fatigue. He symptoms have been developing
Common anatomical variant (2-5%),
states that these gradually. Physical exam reveals a
especially in women.
symptoms have been holosystolic murmur at the apex that
developing gradually. radiates to the axilla and bilateral rales.
Physical exam What is the most likely Dx?
reveals a Chronic mitral regurgitation
holosystolic - treat the heart failure as needed, but 637. What is the Tx for What is the Tx for MVP?
murmur at the apex replace the valve before MVP? Avoiding dehydration; BBs
that radiates to the CHF/AFib/dilatation occurs [...]
axilla and bilateral
rales. What is the - Avoiding dehydration helps keep
most likely Dx? preload maximized, thereby improving the
[...] murmur and valvular insufficiency
- BBs work to decrease HR, thereby
increasing diastolic filling time and
634. A pt presents w/ A pt presents w/ cardiogenic shock.
aiding to maximize preload
cardiogenic shock. Physical exam reveals a diastolic,
- HOCM is approached the same way
Physical exam decrescendo murmur at the RUSB. What
reveals a diastolic, is the most likely Dx?
decrescendo Acute aortic valve insufficiency
murmur at the
RUSB. What is the 638. Which common heart Which common heart murmur presents as
most likely Dx? Tx is emergent AVR murmur presents as a diastolic, decrescendo murmur w/ an
[...] a diastolic, opening snap best heard at the apex?
decrescendo Mitral Stenosis
murmur w/ an
635. What is the treatment What is the treatment for acute valvular
opening snap best
for acute valvular insufficiency?
heard at the apex?
insufficiency? Emergent valve replacement
[...]
[...]

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639. Which common heart Which common heart murmur presents as 644. Which type of Which type of echocardiogram is best for
murmur presents as a systolic, crescendo-decrescendo echocardiogram is investigating valvular disorders?
a systolic, murmur best heard at the RUSB? best for investigating TEE
crescendo-decrescendo
AS valvular disorders?
murmur best heard [...]
at the RUSB? TEE is more sensitive and more specific
[...] than TTE.

640. Which common heart Which common heart murmur presents as 645. What is the most What is the most accurate test for
murmur presents as a holosystolic murmur that radiates to accurate test for valvulvar disorders?
a holosystolic the axilla and is best heard at the apex? valvulvar disorders? Cardiac catheterization
murmur that MR; MVP [...]
radiates to the
axilla and is best Heart cath allows for a more precise
heard at the apex? Increase preload via squatting (and then measurement of valvular diameter, as well
[...] standing) or leg lift to differentiate: as the exact pressure gradient across the
- MR will increase w/ increased preload valve.
- MVP will decrease w/ increased
preload
646. Which valvular Which valvular disorders can benefit from
disorders can benefit diuretics?
641. Which common heart Which common heart murmur presents as from diuretics? All of them
murmur presents as a diastolic, decrescendo murmur best [...]
a diastolic, heard at the RUSB?
decrescendo AR At some point, all of them involve the
murmur best heard backup of fluid to the lung (or CHF
at the RUSB? symptoms).
[...]

647. Regurgitant valves Regurgitant valves respond best to


642. Which valvular Which valvular disorders increase in respond best to vasodilator therapy. Which drugs are
disorders increase intensity w/ inhalation? vasodilator therapy. typically used?
in intensity w/ Right-sided valvular lesions Which drugs are ACE-i; ARBs; nifedipine; hydralazine
inhalation? typically used?
[...] [...]
Inhalation = increased venous return to the ACE-Is and ARBs are best as they
right side of the heart decrease the rate of progression of the
regurgitant lesion.
Remember, surgical replacement must
643. Which valvular Which valvular disorders increase in
be done before dilatory changes/CHF
disorders increase intensity w/ exhalation?
sets in:
in intensity w/ Left sided valvular lesions
- if the dilatory changes are excessive,
exhalation?
valve replacement will not alleviate the
[...]
systolic dysfunction and the heart will not
Exhalation "pushes" blood out of
return to normal size
pulmonary circulation and into the left side
- ventricular size is based off end-systolic
of the heart
diameter and ejection fraction
- an increase in end-systolic diameter
(ESD) >40 mm is an indication for valve
replacement

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648. Which common heart Which common heart murmur is 652. Which heart murmur Which heart murmur is associated w/
murmur is associated associated with immigrants? is associated w/ biphasic P waves in leads V1 and V2 on
with immigrants? Mitral stenosis biphasic P waves in EKG?
[...] i.e. individuals from areas where acute leads V1 and V2 on Mitral stenosis
rheumatic fever is still common EKG?
[...]
LA hypertrophy 2/2 MS
649. Which heart murmur Which heart murmur is commonly
is commonly associated w/ young adults?
associated w/ young Mitral stenosis 653. Which valvular heart Which valvular heart disease is associated
adults? disease is associated w/ straightening of the left heart border,
[...] w/ straightening of elevation of the left mainstem
the left heart bronchus, and a 2nd "bubble" behind
border, elevation of the heart on CXR?
650. A 35 y/o pt presents A 35 y/o pt presents c/o dysphagia,
the left mainstem Mitral Stenosis
c/o dysphagia, hemoptysis, and hoarseness. She has
bronchus, and a
hemoptysis, and recently immigrated here from Pakistan.
2nd "bubble"
hoarseness. She Physical exam reveals a diastolic
behind the heart on
has recently murmur w/ an opening snap. What is the
CXR?
immigrated here from most likely cause of her complaints?
[...]
Pakistan. Physical Mitral Stenosis
exam reveals a
diastolic murmur w/ 654. What is the best What is the best initial test to assess
an opening snap. Remember, MS has a unique initial test to assess cardiac valvular disease?
What is the most presentation: cardiac valvular TTE
likely cause of her - Dysphagia 2/2 compression of the disease?
complaints? esophagus 2/2 LA dilatation [...]
[...] - Hoarseness 2/2 compression of the left This one is tricky:
recurrent laryngeal nerve 2/2 LA dilatation - TTE is best initial due to ease
- AFib and stroke 2/2 LA dilatation - TEE is better than TTE due to
- Hemoptysis 2/2 blood backing up into increased sensitivity & specificity, but is
the pulmonary circuit invasive and hence sometimes done after
- Heart cath is the most accurate test

651. A pt presents c/o of A pt presents c/o of dyspnea. Physical


dyspnea. Physical exam reveals a diastolic murmur best 655. A pt presents for an A pt presents for an annual health
exam reveals a heard at the mitral area. EKG in the ER annual health checkup. Physical exam reveals a wide,
diastolic murmur reveals biphasic P waves in leads V1 checkup. Physical bounding pulse w/ pulsating nail beds.
best heard at the and V2. CXR reveals elevation of the left exam reveals a Which heart murmur should be considered
mitral area. EKG in mainstem bronchus. What is the most wide, bounding in this pt?
the ER reveals likely Dx? pulse w/ pulsating Aortic regurge
biphasic P waves in LA hypertrophy 2/2 mitral stenosis nail beds. Which Remember, AR has some unique features:
leads V1 and V2. heart murmur should - wide pulse pressure
CXR reveals be considered in this - Water-hammer pulse (wide & bounding)
elevation of the left Atrial rhythm disturbances are quite pt? - Quincke pulse (pulsating nail beds)
mainstem common in MS, especially AFib. [...] - Hill sign (BP in LE up to 40 mmHg more
bronchus. What is LA hypertrophy yields biphasic P waves than UE)
the most likely Dx? in leads V1 and V2. - de Musset sign (head bobbing w/ heart
[...] Elevation of the left mainsteam pulse)
bronchus on CXR is 2/2 to LAH.

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656. Which common heart Which common heart murmur presents as 660. What is the best test What is the best test to diagnose dilated
murmur presents as a decrescendo systolic murmur w/ a to diagnose dilated cardiomyopathy?
a decrescendo midsystolic click? cardiomyopathy? Echocardiogram
systolic murmur w/ MVP [...]
a midsystolic click?
[...] CXR will show an enlarged heart/dilatory
changes but ECHO is diagnostic.

661. What is the treatment What is the treatment for dilated


657. Regardless of Regardless of etiology, all for dilated cardiomyopathy?
etiology, all cardiomyopathies have the same cardiomyopathy? Treated as systolic HF; transplant in
cardiomyopathies underlying pathophysiology. What is that? [...] refractory cases
have the same Impaired contraction or relaxation of
underlying heart muscle
pathophysiology. ACE/ARB, BBs (metoprolol, carvedilol),
What is that? and spironolactone all lower mortality (w/
[...] In fact, most of the time the etiology ACE/ARBs being the most effective)
doesn't even influence Diuretics & digoxin are used to control
treatment/management. symptoms
If EF < 35% and QRS > 120 ms, a
biventricular pacer will improve
658. A pt presents c/o A pt presents c/o worsening dyspnea on
symptoms and survival.
worsening dyspnea minimal exertion. PMHx involves CAD, MI
AICD is effective in some pts.
on minimal exertion. s/p CABG, and severe alcoholism.
PMHx involves CAD, Echocardiogram reveals dilated
MI s/p CABG, and ventricles w/ thinned ventricular walls. 662. A young athlete is Dx A young athlete is Dx w/ HOCM. During
severe alcoholism. What is the most likely Dx? w/ HOCM. During the the physical exam, his systolic murmur
Echocardiogram Dilated cardiomyopathy (likely 2/2 EtOH physical exam, his decreases during leg lift. Why?
reveals dilated and/or ischemia in this pt) systolic murmur (see below)
ventricles w/ CXR will likely show an enlarged heart, but decreases during
thinned ventricular echocardiogram is diagnostic. leg lift. Why?
walls. What is the Tx this as systolic CHF [...] In HOCM, the asymmetrically enlarged
most likely Dx? septum blocks the aortic outlet. With an
[...] increase in preload (i.e. s/p leg lift) the
septum is pushed back and the aortic
valve is revealed.
659. What type of heart What type of heart failure is seen in dilated
The murmur sounds very similar to AS, so
failure is seen in cardiomyopathy?
this change on physical exam is very
dilated Systolic
important.
cardiomyopathy?
[...]
Remember, in dilated cardiomyopathy,
stretching of the myocyte sarcomeres
2/2 ventricular dilatation results in 663. What is the genetic What is the genetic inheritance of HOCM?
decreased contractility. inheritance of AD
ECHO is diagnostic and will show HOCM?
decreased EF, dilated ventricles and [...]
thinned ventricular walls.

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664. A young pt presents A young pt presents c/o of shortness of 668. What type of heart What type of heart failure is seen in
c/o of shortness of breath and chest pain w/ minimal activity. failure is seen in restrictive cardiomyopathy?
breath and chest Echocardiogram reveals an restrictive Diastolic; although systolic dysfunction
pain w/ minimal asymmetrically enlarged cardiomyopathy? may be present, the diastolic
activity. interventricular septum. What is the [...] dysfunction is always more severe
Echocardiogram most likely Dx?
reveals an HOCM
asymmetrically Restrictive cardiomyopathy is centered
enlarged around difficulty relaxing the ventricles.
interventricular - Autosomal dominant Hence, diastolic filling is impaired.
septum. What is the - commonly seen in young athletes (look This is 2/2 to the underlying disease
most likely Dx? out for the "sudden death during a process: myocardial infiltration (e.g. 2/2 to
[...] sporting event" buzz-phrase) sarcoidosis, amyloidosis,
- Tx w/ avoiding dehydration (preserving hemochromatosis, cancer, fibrosis)
preload) and BBs (increased diastolic time
to maximize preload)
669. What is the What is the diagnostic test for restrictive
diagnostic test for cardiomyopathy?
665. What is the treatment What is the treatment for HOCM? restrictive Echocardiogram
for HOCM? Avoiding dehydration (preserving cardiomyopathy?
[...] preload); BBs (increased diastolic time [...]
to maximize preload) Endomyocardial biopsy can reveal the
underlying diagnosis, but since an
infiltrative process is most often the cause,
Anything that increases HR will increase biopsy from elsewhere in the body can
symptoms (e.g. exercise, dehydration, give a clue towards what the underlying
diuretics) etiology is.
Anything that decreases LV size will
increase symptoms (e.g. ACE-Is, ARBs,
670. What is the treatment What is the treatment of restrictive
digoxin, hydralazine, valsalva, standing
of restrictive cardiomyopathy?
suddenly)
cardiomyopathy? Tx the underlying cause; gentle
[...] diuresis; rate control
666. What type of heart What type of heart failure is seen in
failure is seen in HOCM?
HOCM? Systolic This one is tricky:
[...] - treating the underlying cause will stop
progression, but will likely not reverse the
cardiomyopathy
667. What is the What is the diagnostic test for HOCM?
- gentle diuresis aids in symptom control,
diagnostic test for Echocardiogram
especially w/ pulmonary HTN and RCHF
HOCM?
symptoms
[...]
- rate control aids in prolonging diastolic
The interventricular septum is often ≥ 1.5x
filling and maximizing preload
thicker than the posterior wall.
- transplant in refractory cases

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671. What class of drugs What class of drugs is typically given to all 673. What is the What is the difference betwen
is typically given to pts w/ cardiomyopathy to control difference betwen Hypertrophic Cardiomyopathy (HCM) and
all pts w/ symptoms? Hypertrophic HOCM?
cardiomyopathy to Diuretics, except in HOCM Cardiomyopathy (see below)
control symptoms? (HCM) and HOCM?
[...] [...]
Additional treatment is based on the type HCM:
of cardiomyopathy, but all of them typically - reactive hypertrophic changes of the
receive diuretics except in HOCM. heart to stressors such as HTN (most
common cause)
- ventricular wall loses compliancy and
672. Which cardiac Which cardiac disorders have murmurs
hence has a difficulty relaxing during
disorders have that do not increase w/ expiration (i.e.
diastole
murmurs that do not increased LV preload)?
- S4 gallop is common
increase w/ HOCM; MVP
HOCM:
expiration (i.e.
- autosomal dominant disorder in myocyte
increased LV
sarcomeres that causes asymmetrical
preload)? HOCM:
hypertrophy of the interventricular septum
[...] - involves the hypertrophic septum
that blocks the aortic outflow tract
blocking the aortic valve
- w/ increased preload the septum is
pushed back and the aortic valve opening 674. A 24 y/o pt presents A 24 y/o pt presents c/o of worsening
is not as occluded c/o of worsening dyspnea and intermittent
- sounds exactly like AS, but will dyspnea and lightheadedness. Echocardiogram
DECREASE w/ increased preload intermittent reveals systolic anterior motion (SAM)
- Tx w/ “avoiding dehydration” and BBs to lightheadedness. of the mitral valve. What is the most likely
slow the HR and increase diastolic filling Echocardiogram Dx?
time reveals systolic HOCM
MVP: anterior motion
- involves valves that are too large/loose (SAM) of the mitral
to close, hence they prolapse into the valve. What is the This is a classic finding of HOCM.
atrium upon closer most likely Dx? The movement of the mitral valve 2/2 to
- increasing preload expands the [...] the assymetrically hypertrophied septum
ventricle (and hence the valvular ring), contributes to the obstruction seen in
thereby allowing the valve to close HOCM.
properly and decreasing the murmur

675. What is the best What is the best initial therapy for
initial therapy for HOCM?
HOCM? BBs
[...]

Remember, BBs decrease the HR to


maximize diastolic filling and preload.

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676. What is the best What is the best initial therapy for 680. A young pt presents A young pt presents c/o of worsening
initial therapy for hypertrophic cardiomyopathy? c/o of worsening dyspnea and lightheadedness. EKG
hypertrophic BBs dyspnea and reveals septal Q waves in the inferior
cardiomyopathy? lightheadedness. and lateral leads. What cardiomyopathy is
[...] EKG reveals septal the likely Dx?
Strongly negative inotropes (e.g. Q waves in the HOCM
verapamil, disopyramide) can help. inferior and lateral
Diuretics may also help to control leads. What
symptoms, but they are contraindicated cardiomyopathy is This EKG finding is common in HOCM,
in HOCM. the likely Dx? and not common in MI.
[...]

677. What is the role of What is the role of diuretics in the


diuretics in the treatment of Hypertrophic 681. A pt w/ known A pt w/ known HOCM presents c/o of
treatment of Cardiomyopathy? HOCM presents c/o multiple syncopal episodes. What
Hypertrophic Alleviates symptoms in HCM; of multiple cardiointervention should be added to this
Cardiomyopathy? contraindicated in HOCM syncopal episodes. pt's therapy?
[...] What Implantable defibrillator
cardiointervention
Remember, in HOCM you want to should be added to
preserve preload. this pt's therapy? Septal ablation either via cath or surgery
[...] should be considered if symptoms persist
despite maximal medical therapy.
678. Why are diuretics Why are diuretics contraindicated in
contraindicated in HOCM?
HOCM? You need to preserve preload in HOCM 682. A pt w/ known A pt w/ known HOCM presents c/o of
[...] HOCM presents c/o persistent symptoms (dyspnea,
of persistent lightheadedness and chest pain). He is
symptoms (dyspnea, already on maximal medical therapy and
679. A pt is Dx w/ A pt is Dx w/ hypertrophic cardiomyopathy.
lightheadedness and has an implantable defibrillator. Which
hypertrophic He is started on metoprolol and is given a
chest pain). He is cardiointerventional procedure should be
cardiomyopathy. He diuretic to aid w/ symptoms. Your medical
already on maximal considered?
is started on student asks if adding digoxin and
medical therapy and Septal ablation
metoprolol and is spironolactone will help this pt. What do
has an implantable
given a diuretic to you say?
defibrillator. Which
aid w/ symptoms. No, they do not
cardiointerventional Ablation, if tried, should be done with a
Your medical student
procedure should be catheter first by placing absolute alcohol
asks if adding
considered? in the myocardium, thereby causing
digoxin and
[...] small infarctions and removing the
spironolactone will
hypertrophic tissue.
help this pt. What do
If this fails then the next step would be
you say?
surgical myomectomy.
[...]

683. What is the What is the considered to be the ultimate


considered to be the therapy in HOCM?
ultimate therapy in Surgical myomectomy
HOCM?
[...]
Removing the hypertrophic portion of the
septum.
That or transplant.

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684. HOCM and HCM HOCM and HCM differ in the approach to
689. What is the most What is the most common cause of
differ in the approach treatment. What is the major difference?
to treatment. What is ACE-Is/ARBs and diuretics are both common cause of pericarditis?
the major difference? useless in HOCM pericarditis? None
[...] [...]

In HCM, they have unclear benefit, but In general, causes are infectious,
may help. autoimmune, traumatic, or neoplastic
(from proximal/adjacent tissue)
There is a long list of etiologies for
685. What is the major What is the major difference in the pericardial disease, the point is to
difference in the treatment of dilated cardiomyopathy and understand how they effect the
treatment of dilated hypertrophic cardiomyopathy? pericardium:
cardiomyopathy and Spironolactone and digoxin are not - acute conditions tend to cause
hypertrophic used in HCM pericarditis due to inflammation
cardiomyopathy? - chronic conditions tend to cause
[...] constrictive peridcarditis due to the
chronic inflammation surrounding the
686. How does standing How does standing from a squat and pericardium
from a squat and valsalva influence preload? - if the etiology makes fluid, then
valsalva influence Decrease pericardial effusion or pericardial
preload? tamponade is likely. Tamponade being
[...] the worst form.
Both of these cause decreased venous - most common infectious cause is viral
return and are akin to diuretic use: - most common connective
- Standing from a squat: opens the tissue/autoimmune cause is SLE
venous capacitance of leg vessels - most common cause of idiopathic cases
- Valsalva: increases intrathoracic are thought to be viral (Coxsackie B)
pressure and hence decreases venous
return
Hence, stenotic valve lesions will
improve w/ these maneuvers and
MVP/HOCM will worsen

687. How does the How does the handgrip technique


handgrip technique influence LV emptying?
influence LV Decrease
emptying?
[...]
Handgrip = increased PVR = increased
afterload = decreased LV emptying =
stenotic valve lesion will worsen

688. How does amyl How does amyl nitrate influence LV


nitrate influence LV emptying?
emptying? Increase
[...]

Amyl nitrate is a direct arteriolar


vasodilator and stimulates the effect of
ACE-Is or ARBs

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690. A pt presents c/o of A pt presents c/o of intermittent chest 692. What is the best test What is the best test to diagnose
intermittent chest pain. He states that the pain worsens to diagnose pericarditis?
pain. He states that when he takes a deep breath and that it pericarditis? EKG
the pain worsens is relieved when he leans forward. [...] EKG will show diffuse PR depression
when he takes a Physical exam reveals a multiphasic and ST elevation
deep breath and friction rub on heart auscultation. What is Echo can help but will only reveal an
that it is relieved the most likely Dx? etiology, not the presence of pericarditis.
when he leans Pericarditis MRI can reveal pericarditis and is
forward. Physical theoretically the best test, but it is an
exam reveals a expensive test and takes more time.
multiphasic friction Key points:
rub on heart - pleuritic chest pain and positional
auscultation. What is chest pain due to the heart rubbing
the most likely Dx? against an inflamed pericardium w/ every
[...] heartbeat. The pain is often constant but
693. What is the best What is the best therapy for pericarditis?
typically worsens w/ inspiration or
therapy for NSAIDs + Colchicine
improves when leaning forward. This is
pericarditis?
thought to be due to alterations in the
[...]
tension/stretch of the pericardium.
Remember, NSAIDs are C/I in
- EKG is the best test and will show
CKD/thrombocytopenia
diffuse ST elevation and PR segment
Steroids are used in refractory cases
depression
Colchicine helps reduce recurrence
- Tx w/ NSAIDs (± colchicine) or steroids
NSAIDs + colchicine are considered first
line in recurrent pericarditis
- if the question has NSAIDs + Colchicine,
choose that. If not, pick NSAIDs first.
691. A pt presents c/o of A pt presents c/o of chest pain. EKG
chest pain. EKG reveals diffuse PR segment depression.
694. Which Which anti-inflammatory is used to reduce
reveals diffuse PR What is the most likely Dx?
anti-inflammatory is the recurrence rate of pericarditis?
segment Pericarditis
used to reduce the Colchicine
depression. What is
recurrence rate of
the most likely Dx?
pericarditis?
[...] Pericarditis is associated w/ diffuse ST
[...]
elevation and PR depression. However,
PR segment depression is the most
specific to pericarditis and is
considered pathognomonic

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695. A pt presents c/o of A pt presents c/o of chest pain. 697. A pt presents w/ A pt presents w/ severe, acute dyspnea.
chest pain. Echocardiogram reveals a small severe, acute Physical exam reveals JVD and muffled
Echocardiogram pericardial effusion. EKG reveals PR dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24,
reveals a small segment depression. What is the most exam reveals JVD and HR is 120. What is the most likely Dx?
pericardial effusion. likely Dx? and muffled heart Pericardial tamponade
EKG reveals PR Pericarditis w/ pericardial effusion sounds. Her BP is Tamponade key points:
segment 80/50, RR is 24, and - often 2/2 to rapid effusion or ventricular
depression. What is HR is 120. What is wall rupture s/p MI
the most likely Dx? The point here is to understand that the most likely Dx? - involves the inability of the heart to fill
[...] pericardial effusion (and/or tamponade) [...] in diastole, causing a life-threatening
is often a sequelae to the etiology of hemodynamic crisis
pericarditis. In such a case, treating the - Beck's triad: JVD, hypotension and
pericarditis will treat the effusion. muffled heart sounds
However, as little as 50 mL of effusion - pts may also have pulsus paradoxus
can cause tamponade in which case and electrical alternans (2/2 to the heart
pericardiocentesis is indicated. "swinging" in the pericardial sac)
- compression of the chambers starts at - Pericardiocentesis or emergent
the R side as the myocardial wall is pericardial window is life saving
thinner on the R side - if an intervention is not possible, load the
- the pericardium can accommodate up to pt up w/ IVF to preserve preload as long
2L of fluid if the accumulation is chronic as possible

696. A pt has a Hx of A pt has a Hx of recurrent pericarditis that


recurrent pericarditis also yields a mild pericardial effusion.
that also yields a Which surgical procedure may be helpful
mild pericardial in this pt?
effusion. Which Pericardial window
surgical procedure With slowly developing effusions, the
may be helpful in this myocardium/pericardium may have time to
pt? compensate for the hemodynamic
[...] changes. However, having the ability to
continually drain the effusion takes a lot of
strain off the heart and preserves
hemodynamics. The pts also feel better.

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698. A pt presents w/ A pt presents w/ severe, acute dyspnea. 700. A pt presents c/o of A pt presents c/o of dyspnea. Physical
severe, acute Physical exam reveals JVD and muffled dyspnea. Physical exam reveals Kussmaul sign and a
dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24, exam reveals pericardial knock on heart auscultation.
exam reveals JVD and HR is 120. What intervention will save Kussmaul sign and What is the most likely Dx?
and muffled heart this pt's life? a pericardial knock Constrictive pericarditis
sounds. Her BP is Pericardiocentesis; IV fluids; pericardial on heart If pericarditis is allowed to settle in long
80/50, RR is 24, and window auscultation. What is enough, fibrosis can set in and lead to
HR is 120. What the most likely Dx? Constrictive Pericarditis:
intervention will save [...] - the pericardium becomes very rigid; as
this pt's life? This is cardiac tamponade the ventricles fill, they can hit the
[...] Tamponade key points: pericardium and cause an audible "knock"
- often 2/2 to rapid effusion or ventricular during diastole
wall rupture s/p MI - systolic function is not affected, but
- involves the inability of the heart to fill diastolic filling is restricted by the rigid
in diastole, causing a life-threatening pericardium
hemodynamic crisis - Tx is w/ diuretics first to decompress
- Beck's triad: JVD, hypotension and the filling of the heart and relieve
muffled heart sounds edema/organomegaly; then
- pts may also have pulsus paradoxus pericardiectomy
and electrical alternans (2/2 to the heart
"swinging" in the pericardial sac)
- Pericardiocentesis or emergent
701. A pt presents c/o of A pt presents c/o of dyspnea. Physical
pericardial window is life saving
dyspnea. Physical exam reveals Kussmaul sign and a
- if an intervention is not possible, load the
exam reveals pericardial knock on heart auscultation.
pt up w/ IVF to preserve preload as long
Kussmaul sign and What is the Tx for this condition?
as possible
a pericardial knock Diuretics; then Pericardiectomy
on heart If pericarditis is allowed to settle in long
auscultation. What is enough, fibrosis can set in and lead to
the Tx for this Constrictive Pericarditis:
condition? - the pericardium becomes very rigid; as
699. A pt presents w/ A pt presents w/ severe, acute dyspnea. [...] the ventricles fill, they can hit the
severe, acute Physical exam reveals JVD and muffled pericardium and cause an audible "knock"
dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24, during diastole
exam reveals JVD and HR is 120. Emergent - systolic function is not affected, but
and muffled heart pericardiocentesis is not possible at this diastolic filling is restricted by the rigid
sounds. Her BP is time. What is the next best step to keep pericardium
80/50, RR is 24, and this patient alive? - Tx is w/ diuretics first to decompress
HR is 120. Emergent IV fluids the filling of the heart and relieve
pericardiocentesis is This is cardiac tamponade. edema/organomegaly; then
not possible at this pericardiectomy
time. What is the If a needle/surgeon is not available. Give
next best step to this dude some IV fluids. You're going to
keep this patient do this w/ tamponade anyway, but
702. What is pulsus What is pulsus paradoxus?
alive? especially so in this case.
paradoxus? > 10 mmHg decrease in BP on
[...] Although tamponade presents similar to
[...] inhalation
acute CHF, administering fluids will
actually help as it will help to preserve
preload.
Seen in cardiac tamponade
For this same reason, do not give
diuretics in tamponade!!

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703. What is considered What is considered the best initial test in 707. A pt w/ T2DM, HTN, A pt w/ T2DM, HTN, HLP presents c/o of
the best initial test suspected cardiac tamponade? HLP presents c/o of calf pain on minimal exertion. He states
in suspected cardiac Echocardiogram calf pain on minimal that he can only walk 1 block before
tamponade? Echo will show RA and RV collapse exertion. He states feeling pain in his right calf and that
[...] during diastole that he can only walk stopping to rest improves the pain. He
1 block before feeling is a chain smoker, but does not drink
EKG typically shows nothing (electrical pain in his right calf alcohol. What is the most likely Dx?
alternans is not a reliable thing to pursue) and that stopping to PAD
CXR can often be normal w/ acute rest improves the
tamponade, but may show a "globular pain. He is a chain
heart" as the cardiac shadow expands smoker, but does not PAD pain classically occurs in the calves
Heart cath should never be the first test in drink alcohol. What is during activity and improves w/ rest.
tamponade but will show equalization of the most likely Dx? Best initial test is ABI
pressures in diastole [...] Most accurate test is angiogram
MRI/CT can reveal the fluid, but takes time
and is more expensive than echo.
708. What is the best What is the best initial test for suspected
initial test for peripheral artery disease?
704. What is kussmaul What is kussmaul sign? suspected peripheral Ankle-brachial index (ABI)
sign? Increased JVP on inhalation artery disease?
[...] [...]
ABI is the ratio of BP in the ankles to
Normally JVP should decrease on that of the brachial arteries.
inhalation. ABI < 0.9 (i.e. > 10% difference in BP) is
Seen in constrictive pericarditis diagnostic of PAD.
Angiogram is the most accurate test but is
typically only done if revascularization is
705. What is the best What is the best initial test for constrictive
planned.
initial test for pericarditis?
constrictive CXR
pericarditis? 709. What is the most What is the most accurate test for
[...] accurate test for peripheral artery disease?
CXR will reveal calcifications and peripheral artery Angiogram
fibrosis of the pericardium disease?
CT/MRI are more accurate, but CXR [...]
should be done first and if positive, However this is typically not done unless
CT/MRI is not done specific revascularization is planned.
Echo is helpful at gauging the presence of
cardiomyopathy. In constrictive
710. What is the treatment What is the treatment for peripheral artery
pericarditis, the myocardium moves
for peripheral artery disease?
normally
disease? ASA; cilostazol; smoking cessation;
[...] surgery in refractory cases
706. What is the Tx for What is the Tx for constrictive pericarditis?
constrictive Diuretics first; then pericardiectomy
pericarditis?
[...]
Diuretics will decompress the filling of the
heart and relieve edema/organomegaly

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711. What is the single What is the single most effective therapy in 714. What is the treatment What is the treatment for aortic dissection?
most effective peripheral artery disease? for aortic dissection? BBs; then nitroprusside; surgical
therapy in peripheral Cilostazol [...] correction if feasible
artery disease?
[...]
Bypass Surgery is only done if medical BBs act to decrease the shearing force
therapy is unfruitful. being placed on the aorta and alleviates
Cilostazol and several of its metabolites BP.
are cyclic AMP (cAMP) phosphodiesterase Nitroprusside aids in bringing down the
III inhibitors (PDE III inhibitors), inhibiting BP and also decreases shearing force.
phosphodiesterase activity and You do not give nitroprusside before
suppressing cAMP degradation with a beta-blockade as the reflex tachycardia
resultant increase in cAMP in platelets and from nitroprusside will exacerbate the
blood vessels, leading to inhibition of dissection.
platelet aggregation and vasodilation.

715. A pt presents c/o of A pt presents c/o of severe chest pain


712. A pt presents c/o of A pt presents c/o of severe chest pain severe chest pain that radiates to the back in between his
severe chest pain that radiates to the back in between his that radiates to the scapulae. Physical exam reveals BP of
that radiates to the scapulae. Physical exam reveals BP of back in between his 169/108 in the left arm and 120/70 in the
back in between his 169/108 in the left arm and 120/70 in the scapulae. Physical right arm. A dx of aortic dissection is
scapulae. Physical right arm. What is the best initial test? exam reveals BP of made after a CXR and the pt is given
exam reveals BP of CXR 169/108 in the left nitroprusside and then beta-blockers.
169/108 in the left arm and 120/70 in The pt becomes tachycardic and begins
arm and 120/70 in the right arm. A dx of to crash. Why?
the right arm. What is This is aortic dissection. aortic dissection is Because some fool gave nitroprusside
the best initial test? While CXR is not as sensitive, it is quick, made after a CXR before beta-blockade
[...] cheap and widening of the mediastinum and the pt is given
on CXR is a big clue. nitroprusside and
CXR is the best initial test then beta-blockers. Nitroprusside causes strong reflex
Angiogram is the most accurate test The pt becomes tachycardia, which can exacerbate the
All other tests are helpful, but have the tachycardic and shearing forces on the dissection if
same accuracy (MRA = CTA = TEE) begins to crash. beta-blockade is not already established.
Why? Always give beta-blockers before
[...] nitroprusside in the management of
713. A pt presents c/o of A pt presents c/o of severe chest pain
aortic dissection.
severe chest pain that radiates to the back in between his
that radiates to the scapulae. Physical exam reveals BP of
back in between his 169/108 in the left arm and 120/70 in the 716. What is the guideline What is the guideline for the screening of
scapulae. Physical right arm. What is the most acurrate test? for the screening of abdominal aortic aneurysm?
exam reveals BP of Angiogram abdominal aortic Men who have ever smoked and is > 65
169/108 in the left aneurysm? y/o
arm and 120/70 in [...]
the right arm. What is This is aortic dissection
the most acurrate CXR is the best initial test Done via U/S
test? Angiogram is the most accurate test but AAA > 5 cm is an indication for
[...] also the most invasive. It can cause surgical/catheter-directed repair
anaphylaxis or AKI, but is the most New onset back pain in all pts > 65 should
sensitive and most specific. trigger U/S to look for AAA.
All other tests are helpful, but have the Otherwise, in nonsmokers and women,
same accuracy (MRA = CTA = TEE) the rate of AAA is so low that screening is
not justified

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717. A previously healthy A previously healthy pregnant woman 718. A pt develops A pt develops Peripartum Cardiomyopathy
pregnant woman develops severe LV dysfunction Peripartum after giving birth to her child. Her LV
develops severe LV post-partum. Her pregnancy was Cardiomyopathy dysfunction does not improve w/ medical
dysfunction uneventful and she gave birth to a after giving birth to therapy. What is the only treatment option
post-partum. Her beautiful, healthy baby boy. What is the her child. Her LV that remains?
pregnancy was most likely Dx? dysfunction does not Transplantation
uneventful and she Peripartum cardiomyopathy improve w/ medical
gave birth to a therapy. What is the
beautiful, healthy only treatment option Peripartum cardiomyopathy key points:
baby boy. What is Peripartum cardiomyopathy key points: that remains? - unknown cause
the most likely Dx? - unknown cause [...] - involves autoantibodies against
[...] - involves autoantibodies against myocardium in pregnant women
myocardium in pregnant women - the LV dysfunction is often short term and
- the LV dysfunction is often short term and reversible, but if not reversed the only Tx
reversible, but if not reversed the only Tx is transplant
is transplant - medical therapy involves the use of
- medical therapy involves the use of ACE-Is/ARBs, BBs, spironolactone,
ACE-Is/ARBs, BBs, spironolactone, diuretics, digoxin (i.e. like heart
diuretics, digoxin (i.e. like heart failure/DCM)
failure/DCM) - medical therapy can be used as the
- medical therapy can be used as the cardiomyopathy typically develops
cardiomyopathy typically develops post-partum (ACE-I/ARBs are C/I in
post-partum (ACE-I/ARBs are C/I in pregnancy)
pregnancy) - repeat pregnancy in such cases will
- repeat pregnancy in such cases will provoke massive autoantibody production
provoke massive autoantibody production against the myocardium
against the myocardium

719. What is the worst What is the worst cardiac disease that can
cardiac disease that manifest in pregnant women?
can manifest in Peripartum cardiomyopathy
pregnant women?
[...]
If this question comes up, the ranking is:
1. Peripartum cardiomyopathy
2. Eisenmenger syndrome
3. Mitral stenosis (worsens significantly
due to the 50% increase in plasma volume
during pregnancy)

720. Which obstructive Which obstructive lung disease is more


lung disease is more commonly associated with children and
commonly young adults with allergies?
associated with Asthma
children and young
adults with
allergies? Remember, asthma is IgE/eosinophil
[...] mediated and involves inflammation of
the airways and bronchoconstriction.

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721. A young pt presents A young pt presents w/ cough, wheezing 724. What is the next step What is the next step in the w/u of asthma
w/ cough, wheezing and dyspnea. His PMHx is significant for in the w/u of asthma for a pt that has normal PFTs (i.e. normal
and dyspnea. His allergic rhinitis, nasal polyps, and for a pt that has FEV1/FVC)?
PMHx is significant eczema. Physical exam reveals wheezing normal PFTs (i.e. Methacholine challenge (> 20%
for allergic rhinitis, in the BL upper lobes and a prolonged normal FEV1/FVC)? decrease in FEV1 is diagnostic)
nasal polyps, and expiratory phase. What is the most likely [...]
eczema. Physical Dx?
exam reveals Asthma Normal PFTs in the w/u of asthma do not
wheezing in the BL rule out asthma. It simply means that the
upper lobes and a pt is not in an asthmatic state when PFTs
prolonged Asthma key points: were tested. If an asthma attack occurs
expiratory phase. - seen in younger pts, especially if there is after methacholine is given, then its
What is the most a Hx of allergies/eczema asthma.
likely Dx? - wheezing, dyspnea, cough (remember, Methacholine induces bronchoconstriction.
[...] wheezing is simply the flow of air through a Remember, in asthma, the decrease in
constricted airway) PFTs is both inducible and reversible.
- PE: wheezing, prolonged expiratory This is not the case in COPD.
phase
- PE: hyperinflation & hyperresonance
725. What is the next step What is the next step in the w/u of asthma
are ominous signs and signify greater
in the w/u of asthma for a pt that has abnormal PFTs (i.e.
airway constriction
for a pt that has decreased FEV1/FVC)?
- PE: severe dyspnea (accessory muscle
abnormal PFTs (i.e. Bronchodilator challenge (> 12% or 200
use and/or no lung sounds) = status
decreased mL FEV1 increase is considered
asthmaticus = medical emergency
FEV1/FVC)? reversal and diagnostic of asthma)
- chronic vs. acute management has big
[...] Decreased FEV1/FVC does not
difference.
automatically mean asthma, it just
means that an obstructive process is
722. A pt presents w/ A pt presents w/ acute onset dyspnea present.
acute onset and wheezing. You suspect asthma. What Bronchodilator challenge will discern
dyspnea and is the most appropriate next step in between asthma & COPD. Because, once
wheezing. You management? again, decreased PFTs in asthma are
suspect asthma. Start treatment right away both inducible and reversible.
What is the most Reversing of the decreased PFTs is
appropriate next step diagnostic of asthma at this point of the
in management? In this case: nebulizer treatment/oxygen work-up; > 12% increase (or 200 mL) is
[...] The point is: if it's acute onset, treat right considered reversal
away.
- Don't waste time getting PFTs
- Treat this fool first, then pursue PFTs
726. A pt presents c/o of A pt presents c/o of intermittent dyspnea
once stablilized or as outpatient
intermittent dyspnea and wheezing for the past year. You
and wheezing for decide to do a sputum study which reveals
723. What is the best What is the best diagnostic test for the past year. You Charcot-Leyden crystals and
diagnostic test for asthma? decide to do a Curschmann spirals. What is the most
asthma? PFTs sputum study which likely Dx?
[...] reveals Asthma
Charcot-Leyden
crystals and
Curschmann Other tests exists to workup suspected
spirals. What is the asthma, but PFTs (and subsequent
most likely Dx? methacholine/bronchodilator challenge)
[...] are the gold standard.

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732. What is the treatment What is the treatment for intermittent


727. What is the What is the symptomatic criteria for for intermittent asthma?
symptomatic criteria intermittent asthma? asthma? A rescule inhaler
for intermittent ≤ 2 daytime/wk; ≤ 2 nighttime/month; [...] Typically a SABA, but may be an inhaled
asthma? FEV1 ≥ 80% anticholinergic as well
[...]

733. What is the treatment What is the treatment for mild persistent
728. What is the What is the symptomatic criteria for mild for mild persistent asthma?
symptomatic criteria persistent asthma? asthma? SABA + low dose ICS
for mild persistent ≤ 1 daytime/day; > 2 nighttime/month; [...]
asthma? FEV1 ≥ 80%
[...]

734. What is the treatment What is the treatment for moderate


for moderate persistent asthma?
729. What is the What is the symptomatic criteria for persistent asthma? SABA + LABA + low-dose ICS
symptomatic criteria moderate persistent asthma? [...] You cannot give LABA without an
for moderate ≥ 1 daytime/day; > 1 nighttime/week; ICS/steroids. That will increase mortality
persistent asthma? FEV 60-80% and is always the wrong answer.
[...] If the patient is on a LABA, they must
be on an steroids. Period.

730. What is the What is the symptomatic criteria for severe


symptomatic criteria persistent asthma?
for severe ≥ 1 daytime/day; frequent nighttime;
persistent asthma? FEV1 < 60%
[...] 735. What is the treatment What is the treatment for severe
for severe persistent asthma?
persistent asthma? SABA + LABA + high-dose ICS
731. Which two Which two pathological elements of [...] You cannot give LABA without an
pathological asthma are targeted in its management? ICS/steroids. That will increase mortality
elements of asthma Inflammation; bronchoconstriction and is always the wrong answer.
are targeted in its If the patient is on a LABA, they must
management? be on steroids. Period.
[...] Simple to understand, but important to If the pt is already on a LABA and ICS and
keep in mind when manaing asthmatics. more treatment is needed, increase the
Inflammation is targeted by steroids dose of the ICS (as is done w/ severe
(mostly inhaled, but PO steroids used in persistent)
refractory cases)
Bronchoconstriction is targeted primarlily
by beta-agonists (however other agents
can add support)
Stabilizers are helpful in pts w/ milder
disease that know their triggers and are
going to be exposed to them (e.g. the
athlete w/ exercise induced asthma about
to play a game)

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736. What is the treatment What is the treatment for refractory 739. A pt presents w/ A pt presents w/ severe dyspnea,
for refractory severe persistent asthma? severe dyspnea, wheezing and cough. PMHx is significant
severe persistent SABA + LABA + high-dose PO steroids wheezing and for moderate persistent asthma and
asthma? Yes, this not a real class of asthma. But cough. PMHx is eczema. Physical exam reveals the use of
[...] many asthmatics are refractory to significant for accessory muscles of respiration and
treatment when they progress to the moderate lung auscultation reveals an absence of
severe stage, so knowing the management persistent asthma lung sounds. The lungs are
is important. and eczema. hyperresonant to percussion. What is the
You cannot give LABA without an Physical exam most likely Dx?
ICS/steroids. That will increase mortality reveals the use of Status asthmaticus
and is always the wrong answer. accessory muscles
If the patient is on a LABA, they must of respiration and
be on steroids. Period. lung auscultation Status asthmaticus key points:
If the pt is already on a LABA and ICS and reveals an absence - pts are in respiratory distress w/ signs
more treatment is needed, increase the of lung sounds. The of severe dyspnea (accessory muscle
dose of the ICS or transition to PO lungs are use, absent lung sounds, hyperresonance)
steroids(as is done w/ severe persistent or hyperresonant to - begin treatment immediately w/ O2,
refractory cases) percussion. What is Duoneb (albuterol/ipratropium) and
the most likely Dx? corticosteroids
[...] - if that fails, add racemic, nebulized
epinephrine or SQ epinephrine

737. The treatment The treatment /management of asthma


/management of now involves more agents than
asthma now involves beta-agonists and steroids. Which class of
more agents than drugs can be used in the management of
beta-agonists and asthma in place of LABA alongside ICS?
steroids. Which class Leukotriene Agonists
of drugs can be used The different MOA allows LTAs to have
in the management fewer side effects.
of asthma in place
of LABA alongside
ICS?
[...]

738. Which adenosine Which adenosine antagonist can be used


antagonist can be to control bronchoconstriction in asthma?
used to control Theophylline
bronchoconstriction
in asthma?
[...]

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740. What is the initial What is the initial management of status 741. Following the initial Following the initial management of status
management of asthmaticus? management of asthmaticus, which PFT aids to determine
status asthmaticus? O2; albuterol/ipratropium; steroids (IV status asthmaticus, the next step in management?
[...] or PO) which PFT aids to Peak Expiratory Flow Rate (PEFR)
determine the next PEFR is based on height and age, not
step in weight, and is an acute
Initial management of status asthmaticus: management? assessment/approximation of FVC.
- O2 should be given until pulse-ox ≥ 90% [...] After initial management has been
- Duoneb (albuterol/ipratropium) q20x3 performed for 3 hours, assess the pt's
- Steroids can be given IV or PO PEFR and do a physical exam to
- Continue the pt's scheduled home determine the next step in management:
medications. You do not stop chronic - If PEFR > 70% of the pt's max PEFR and
asthma management during status there are no s/s, discharge the pt home
asthmaticus - If PEFR 50-70% of the pt's max PEFR
- Do all of the above and observe for 3 and there are mild/moderate s/s, admit
hours before deciding the next step in the pt to the floor
management - If PEFR < 50% of the pt's max PEFR and
- Peak Expiratory Flow Rate (PEFR) and there are severe s/s, admit the pt to the
physical exam decides the next step (d/c, ICU
admit to floor, or admit to ICU)
- You do not give inhaled ABGs are also helpful, but in general:
corticosteroids as an ED treatment for - If PaCO2 > 42 mmHg, admit to the ICU
Asthma. ICS, LABA, and LTA are
long-term chronic medications.
742. Following the initial Following the initial management of status
- Epinephrine is not any more effective
management of asthmaticus, what Peak Expiratory Flow
than albuterol and has more systemic side
status asthmaticus, Rate (PEFR) signifies that the pt is stable
effects
what Peak Expiratory enough to be discharged home?
- Magnesium can be used but is not as
Flow Rate (PEFR) > 70% of the pt's max PEFR
effective as albuterol, but can help with
signifies that the pt is After initial management has been
bronchodilation
stable enough to be performed for 3 hours, assess the pt's
discharged home? PEFR and do a physical exam to
[...] determine the next step in management:
- If PEFR > 70% of the pt's max PEFR and
there are no s/s, discharge the pt home
- If PEFR 50-70% of the pt's max PEFR
and there are mild/moderate s/s, admit
the pt to the floor
- If PEFR < 50% of the pt's max PEFR and
there are severe s/s, admit the pt to the
ICU

ABGs are also helpful, but in general:


- If PaCO2 > 42 mmHg, admit to the ICU
- A-a gradient will likely be elevated

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743. Following the initial Following the initial management of status 744. Following the initial Following the initial management of status
management of asthmaticus, what Peak Expiratory Flow management of asthmaticus, what Peak Expiratory Flow
status asthmaticus, Rate (PEFR) signifies that the pt should be status asthmaticus, Rate (PEFR) signifies that the pt should be
what Peak Expiratory admitted to the floor for observation? what Peak Expiratory admitted to the ICU?
Flow Rate (PEFR) PEFR 50-70% of the pt's max w/ mild to Flow Rate (PEFR) PEFR < 50% of the pt's max PEFR w/
signifies that the pt moderate s/s signifies that the pt severe s/s
should be admitted Essentially, if there is some improvement, should be admitted
to the floor for but not full reversal. Admit these "in to the ICU?
observation? between" pt's to the floor where all they're [...] After initial management has been
[...] really going to get is q4 duoneb. performed for 3 hours, assess the pt's
PEFR and do a physical exam to
After initial management has been determine the next step in management:
performed for 3 hours, assess the pt's - If PEFR > 70% of the pt's max PEFR and
PEFR and do a physical exam to there are no s/s, discharge the pt home
determine the next step in management: - If PEFR 50-70% of the pt's max PEFR
- If PEFR > 70% of the pt's max PEFR and and there are mild/moderate s/s, admit
there are no s/s, discharge the pt home the pt to the floor
- If PEFR 50-70% of the pt's max PEFR - If PEFR < 50% of the pt's max PEFR and
and there are mild/moderate s/s, admit there are severe s/s, admit the pt to the
the pt to the floor ICU
- If PEFR < 50% of the pt's max PEFR and
there are severe s/s, admit the pt to the ABGs are also helpful, but in general:
ICU - If PaCO2 > 42 mmHg, admit to the ICU

ABGs are also helpful, but in general:


- If PaCO2 > 42 mmHg, admit to the ICU
- A-a gradient will likely be elevated

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745. A pt presents to the A pt presents to the ER in status 746. A pt presents to the A pt presents to the ER in status
ER in status asthmaticus. His PEFR after initial ER in status asthmaticus. After initial management, his
asthmaticus. His management is 60% of his max PEFR. asthmaticus. After PEFR is 40% of his max PEFR. Physical
PEFR after initial Physical exam at this point reveals mild initial management, exam reveals no change and the pt is still
management is 60% wheezing. What is the next best step in his PEFR is 40% of wheezing and in respiratory distress.
of his max PEFR. this pt's management? his max PEFR. You decide to admit him to the ICU.
Physical exam at this Admit to the floor; give q4 Duoneb Physical exam Following admission, what is the next step
point reveals mild (albuterol+ipratropium) reveals no change in management?
wheezing. What is and the pt is still Intubation; then continuous nebulizer
the next best step in wheezing and in treatment and IV steroids
this pt's Essentially, if there is some improvement, respiratory In the ICU, these pts are essentially going
management? but not full reversal. Admit these "in distress. You decide to get continuous duoneb
[...] between" pt's to the floor where all they're to admit him to the (albuterol/ipratropium) and IV steroids.
really going to get is q4 Duoneb. ICU. Following ECMO is a last resort.
After initial management has been admission, what is
performed for 3 hours, assess the pt's the next step in After initial management has been
PEFR and do a physical exam to management? performed for 3 hours, assess the pt's
determine the next step in management: [...] PEFR and do a physical exam to
- If PEFR > 70% of the pt's max PEFR and determine the next step in management:
there are no s/s, discharge the pt home - If PEFR > 70% of the pt's max PEFR and
- If PEFR 50-70% of the pt's max PEFR there are no s/s, discharge the pt home
and there are mild/moderate s/s, admit - If PEFR 50-70% of the pt's max PEFR
the pt to the floor and there are mild/moderate s/s, admit
- If PEFR < 50% of the pt's max PEFR and the pt to the floor
there are severe s/s, admit the pt to the - If PEFR < 50% of the pt's max PEFR and
ICU there are severe s/s, admit the pt to the
ICU
ABGs are also helpful, but in general:
- If PaCO2 > 42 mmHg, admit to the ICU ABGs are also helpful, but in general:
- A-a gradient will likely be elevated - If PaCO2 > 42 mmHg, admit to the ICU
- A-a gradient will likely be elevated

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747. What is the most What is the most common cause of 749. A 55 y/o pt presents A 55 y/o pt presents c/o of dyspnea and
common cause of COPD?? c/o of dyspnea and chronic cough. He has a ~50 pack year
COPD?? Smoking chronic cough. He hx of smoking. Physical exam reveals
[...] has a ~50 pack year barrel chesting w/ increased AP diameter
hx of smoking. and hyperresonance on percussion. The
Only 20% of smokers get COPD, but 90% Physical exam pt is sitting in front of you breathing w/
of COPDers are/were smokers. reveals barrel pursed lips w/ a prolonged expiratory
Ultimately, COPD requires the right chesting w/ phase. Which type of COPD is the most
combination of environmental and genetic increased AP likely Dx?
factors (e.g. alpha-1 antitrypsin). diameter and Emphysema
The pathogenesis of COPD types differ but hyperresonance on
lead to similar presentations: percussion. The pt is
- Emphysema involves destruction of sitting in front of you These are your "pink puffers"
alveolar walls w/ fibrosis, leading to a loss breathing w/ pursed
of elasticity and air trapping lips w/ a prolonged
- Bronchitis involves chronic productive expiratory phase.
cough 2/2 mucous production in the large Which type of COPD
airways is the most likely Dx?
- Both will involve: loss of ciliary cells, [...]
increased goblet cells, increased mucous
production and then subsequent decrease
750. Which type of heart Which type of heart failure is associated w/
in gas exchange/airway diameter/elasticity.
failure is associated chronic bronchitis?
The ultimate result is obstructive disease
w/ chronic RCHF
w/ chronic CO2 retention.
bronchitis?
- long term sequelae include: pulmonary
[...]
hypertension 2/2 to increased pulmonary
With the classic signs of JVD, edema and
resistance 2/2 to chronic alveolar hypoxia
hepatosplenomegaly.

748. A 55 y/o pt presents A 55 y/o pt presents c/o of dyspnea and


c/o of dyspnea and chronic cough. He has a ~50 pack year
chronic cough. He hx of smoking. Physical exam reveals
has a ~50 pack year cyanosis of the extremities, peripheral
hx of smoking. edema and clubbing of the digits. What
Physical exam type of COPD is the most likely Dx?
reveals cyanosis of Chronic Bronchitis
the extremities, Your bronchitis pts are your "blue
peripheral edema bloaters"
and clubbing of the
digits. What type of
COPD is the most
likely Dx?
[...]

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751. What is the best What is the best (most accurate) 753. What is the What is the "COPDER" mnemonic for the
(most accurate) diagnostic test for COPD? "COPDER" treatment of COPD?
diagnostic test for PFTs mnemonic for the (see below)
COPD? treatment of COPD?
[...] [...]
PFT major points:
- Asthma is both inducible and
reversible
- COPD is not inducible nor reversible
754. What drug classes What drug classes are used to achieve
COPD testing major points:
are used to achieve bronchodilation in the treatment of COPD?
- PFTs are by far the best diagnostic test,
bronchodilation in the Anticholinergics; Beta-agonists
however other tests offer helpful
treatment of COPD? Anticholinergics are the most effective
information. PFTs will show irreversible
[...] in COPD.
obstructive disease (decreased FEV1,
- Notice the difference here: an asthmatic
FEV1/FVC; increased RV, TLC;
not controlled with SABA alone? Add an
decreased DLCO if its emphysema)
ICS. A COPDer not controlled with SABA
- CXR can show flattened diaphragm,
alone? Add tiotropium and then maybe
translucent air fields, and a rotated
an ICS.
heart silhouette; and can rule out other
acute processes in acute COPD
exacerbation
- EKG can show RVH or RAD; and can
rule out ACS in exacerbation 755. Which drug class is Which drug class is preferred for
- ABG can show hypoxic, hypercapneic preferred for bronchodilation in elderly pts w/ COPD?
respiratory acidosis bronchodilation in Anticholinergics
- CBC can show erythrocytosis 2/2 to elderly pts w/
hypoxia COPD?
[...] Due to the risk of tachyarrhythmia w/
beta agonists.

752. What are the main What are the main goals of treatment in
goals of treatment in COPD?
COPD? (see below) 756. Which vaccines are Which vaccines are recommended for
[...] recommended for COPD patients?
COPD patients? Annual influenza; pneumococcal (> 60
COPD treatment goals: [...] y/o)
1. Decrease inflammation: done via
steroids
2. Bronchodilation: done via
anticholinergic and/or beta-agonists
3. Maintain oxygenation: done via O2
(4. Infection control: via vaccination)

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757. What is the indication What is the indication for beginning 760. A pt comes in w/ A pt comes in w/ acute worsening
for beginning chronic home O2 therapy in COPD pts? acute worsening dyspnea. PMHx is positive for COPD. You
chronic home O2 PaO2 < 55 on ABG or SpO2 < 88% on dyspnea. PMHx is suspect COPD exacerbation. What is the
therapy in COPD pulse-ox positive for COPD. first step in your management?
pts? You suspect COPD Oxygen
[...] exacerbation. What
The goal would be to titrate SpO2 > 90%. is the first step in
The degree of mortality benefit is directly your management? For suspected COPD exacerbation, give
proportional to the number of hours spent [...] oxygen at first while a Dx is made. With
on oxygen. acute dyspnea, the worry of reducing
However, oxygen therapy in COPD is hypoxic respiratory drive is vastly
tricky: overshadowed by this pt's dire need of
- COPDers are chronic CO2 retainers; oxygen.
as a result, these pt's lose the CXR is helpful is ruling out another acute
hypercapneic drive to breathing and rely pulmonary process that may be causing
on the hypoxic drive to breathe symptoms.
- If we give too much O2, they may lose EKG is helpful in ruling out cardiac causes
respiratory drive of acute dyspnea (esp since many COPD
- However, if a COPD pt ever needs pts also have CHF)
oxygen (e.g. ACS), give it to them as
you're not going to affect their respiratory
761. A pt w/ COPD comes A pt w/ COPD comes in w/ acute
drive in the short term.
in w/ acute dyspnea. A diagnosis of COPD
dyspnea. A exacerbation is made after EKG and CXR
diagnosis of COPD are negative for other likely causes. The pt
exacerbation is made is started on oxygen. What is the next step
after EKG and CXR in therapy?
are negative for other Nebulizer treatment, q6h
758. Which two Which two interventions in COPD are likely causes. The pt Nebulizer treatment in COPD exacerbation
interventions in known to increase survival? is started on oxygen. key points:
COPD are known to Smoking cessation; chronic O2 therapy What is the next step - given every q6hrs
increase survival? in therapy? - Ipratropium > albuterol in terms of
[...] [...] efficacy and side effects, but they are often
Note that there is a lag between smoking given together.
cessation and the decrease in - IV Steroids can be added if no
inflammation. These pt's may get worse improvement, but continue q6 nebulizer tx
prior to showing improvement/stabilization.

759. What are the main What are the main treatment goals in the
treatment goals in management of acute COPD
the management of exacerbation?
acute COPD First, help the dude breath; cover
exacerbation? potential infection
[...]

And then determine the cause of


exacerbation.

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762. A pt w/ COPD comes A pt w/ COPD comes in w/ acute 764. What are the 2 types What are the 2 types of pleural effusion?
in w/ acute dyspnea. A diagnosis of COPD of pleural effusion? Transudate; exudate
dyspnea. A exacerbation is made after EKG and CXR [...]
diagnosis of COPD are negative for other likely causes. The pt
exacerbation is made is started on oxygen and q6h nebulizer Transudate:
after EKG and CXR treatment, but does not improve clinically. - fluid w/o a lot of "stuff"
are negative for other What is the next step in therapy? - can be UL or BL
likely causes. The pt IV steroids (IV methylprednisone, 125 - often 2/2 to intravascular pathology
is started on oxygen mg); or PO steroids (e.g. increased intravascular hydrostatic
and q6h nebulizer pressure in CHF or a decrease in
treatment, but does intravascular oncotic pressure in nephrotic
not improve clinically. IV is preferred. syndrome)
What is the next step If steroids are on board, rememebr to give Exudate:
in therapy? a PO tapered dose at discharge. - fluid w/ a lot of "stuff"
[...] If there is no further improvement, admit to - can be UL or BL
the ICU and consider mechanical - often 2/2 to extravascular pathology
ventilation (e.g. increase in oncotic pressure outside
the vessels, such as in infection or
malignancy)
763. A pt w/ COPD comes A pt w/ COPD comes in w/ acute
in w/ acute dyspnea. A diagnosis of COPD
dyspnea. A exacerbation is made after EKG and CXR 765. What CXR finding is What CXR finding is highly suggestive of
diagnosis of COPD are negative for other likely causes. The pt highly suggestive of pulmonary effusion?
exacerbation is made is started on oxygen and q6h nebulizer pulmonary effusion? Blunting of the costovertebral angles
after EKG and CXR treatment, but does not improve clinically. [...]
are negative for other IV steroids are administered and the pt
likely causes. The pt improves overnight and is stable for - This requires about 250 mL of fluid to
is started on oxygen discharge. What medications should this pt become apparent on CXR
and q6h nebulizer be discharged on? - if more fluid is present, you may see
treatment, but does PO steroid taper; prophylactic air-fluid levels
not improve clinically. antibiotics - remember to get a follow-up
IV steroids are recumbant CXR to assess if the fluid is
administered and the free moving (i.e. not loculated) and is in
pt improves If steroids are given inpatient, send the pt sufficient quantity (> 1 cm from wall to fluid
overnight and is home with a PO taper. level) to be tapped via thoracentesis
stable for discharge. Always give prophylactic abx even if there
What medications are no signs of infection. Even though
should this pt be most infectious triggers are viral, give
discharged on? anything that will cover the typical bugs
[...] (amoxicillin, bactrim, ceftriaxone or other
3rd gen, or FQ)

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766. A pt w/ CHF c/o A pt w/ CHF c/o SOB. CXR reveals a right 770. What is the treatment What is the treatment for a
SOB. CXR reveals a sided pleural effusion. Follow-up for a parapneumonic pleural effusion where
right sided pleural recumbant CXR reveals that the fluid is not parapneumonic there is insufficient fluid to be drained via
effusion. Follow-up loculated and sufficient to be drained via pleural effusion thoracentesis or if the fluid is loculated?
recumbant CXR thoracentesis. What clinical set of criteria where there is
reveals that the fluid aids in the interpretation of the drained insufficient fluid to be
is not loculated and fluid? drained via Treat the cause; Tube Thoracostomy
sufficient to be Lights criteria thoracentesis or if (i.e. chest tube)
drained via Light's criteria compared serum/effusion the fluid is loculated?
thoracentesis. What protein/LDH.
clinical set of criteria The next step would be to do a complete This is done to prevent the formation of
aids in the w/u if indicated. [...] an empyema
interpretation of the
drained fluid?
771. What is the treatment What is the treatment of a pleural
[...]
of a pleural effusion effusion that has become an empyema?
that has become an Thoracotomy
767. How many CXR How many CXR views are needed to empyema?
views are needed to properly work up a pleural effusion? [...]
properly work up a Atleast 2 (atleast 1 upright, and 1 If the effusion is not drained, it can become
pleural effusion? recumbent) an empyema.
[...] Tx w/ chest tube first to prevent empyema
formation.

768. What is the most What is the most appropriate first test in 772. What is the treatment What is the treatment of a pleural effusion
appropriate first test the work up of pleural effusion? of a pleural effusion that can be drained by thoracentesis?
in the work up of CXR that can be drained Thoracentesis
pleural effusion? by thoracentesis?
[...] [...]
CT is helpful, but often only done if there is Basically, don't consult CT-Sx for a chest
an exudate without clear etiology. tube when you don't need to or they'll yell
CXR must be done upright and recumbent. at you. True story.

769. A pt presents c/o of A pt presents c/o of acute worsening 773. What is the treatment What is the treatment for pleural effusion
acute worsening dyspnea. Echocardiogram reveals an EF for pleural effusion w/ w/ a known cause?
dyspnea. of 30%. BNP is elevated. CXR reveals a known cause? Treat the underlying cause
Echocardiogram bilateral, non-loculated pleural [...]
reveals an EF of effusions. Would it be helpful to perform
30%. BNP is thoracentesis in this pt? There is no need to tap or put in a chest
elevated. CXR No tube if the fluid is minimal and the cause is
reveals bilateral, already known (i.e. CHF/pneumonia).
non-loculated
pleural effusions. Well, not at this time.
Would it be helpful to This pt's effusion is likely 2/2 to their CHF.
perform In such a case, treat the CHF/CHF
thoracentesis in this exacerbation first (diuretics in this case).
pt? If the effusion does not improve, then do a
[...] thoracentesis and follow up w/ light's
criteria and the appropriate workup.

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774. What is the What is the underlying pathogenesis of 776. What is the What is the diagnostic test for ARDS?
underlying ARDS? diagnostic test for None
pathogenesis of Increased permeability at pulmonary ARDS?
ARDS? capillaries [...]
[...] Often the Dx is clinical (i.e. pt w/ systemic
disease and pulmonary edema).
Understand this and you understand CXR can reveal BL white out
ARDS. ABGs may help too as PaO2:FiO2 ratio
Increased permability at pulmonary will be < 300 in ARDS
capillaries allows for transudation of Swan-ganz catheterization can
fluid from capillaries into the definitively diagnose ARDS vs. CHF by
interstitium. measuring PCWP
- As a result, the transudated material - wedge pressures are normal/decreased
causes pulmonary edema and a in ARDS and will be increased if there is
diffusion barrier for oxygen LV dysfunction
- Because oxygen is diffusion limited - LV function is normal/increased in
and CO2 is perfusion limited, this ARDS and obviously decreased in HF
diffusion barrier causes impaired
oxygenation, but CO2 loss is not
777. What CXR findings What CXR findings are associated w/
impaired
are associated w/ ARDS?
- hypoxemia results
ARDS? Bilateral white out
[...]
775. A pt presents w/ A pt presents w/ acute dyspnea and
acute dyspnea and coughing. She has no PMHx. The pt has
778. A pt presents w/ A pt presents w/ acute dyspnea and
coughing. She has a very sickly presentation and is in
acute dyspnea and coughing. She has no PMHx. The pt has
no PMHx. The pt has respiratory distress. Physical exam reveals
coughing. She has a very sickly presentation and is in
a very sickly crackles in all lung fields. CXR reveals
no PMHx. The pt has respiratory distress. Physical exam reveals
presentation and is in bilateral white out of the lungs. How
a very sickly crackles in all lung fields. CXR reveals
respiratory distress. would the pulmonary capillary wedge
presentation and is in bilateral white out of the lungs. What is
Physical exam pressure change in this pt?
respiratory distress. the first line therapy for this pt?
reveals crackles in Normal/no change (this pt likely has
Physical exam Intubation + oxygen (w/ addition of
all lung fields. CXR ARDS)
reveals crackles in PEEP soon after)
reveals bilateral
all lung fields. CXR
white out of the
reveals bilateral
lungs. How would the Remember, ARDS is 2/2 to widespread
white out of the This is ARDS.
pulmonary capillary increases in pulmonary capillary
lungs. What is the ARDS treatment key points:
wedge pressure permeability.
first line therapy for - First line: intubation + oxygenation (w/
change in this pt? Unless there is CHF, hydrostatic
this pt? the addition of PEEP after intubation)
[...] pressures in ARDS stay normal (hence,
[...] - Tx of the underlying cause
normal PCWP)
- low-tidal volume mechanical ventilation
- In CHF, there is LV dysfunction and
is the best support; use 6 mL/kg of tidal
hydrostatic pressure/PCWP increases as
volume
blood backs up into the lung capillaries
- steroids not clearly beneficial
- In ARDS, LV function is normal, hence
PCWP is normal (~10)
- In real life, we don’t measure PCWP for
ARDS. We can just get an ECHO/BNP that
will reveal normal LV function. Look out for
this question on tests though.

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779. A pt presents w/ A pt presents w/ acute dyspnea and 781. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP following
acute dyspnea and coughing. She has no PMHx. The pt has placed on PEEP intubation. Shortly after, the pt's dyspnea
coughing. She has a very sickly presentation and is in following intubation. continues to worsen. All vitals remain
no PMHx. The pt has respiratory distress. Physical exam reveals Shortly after, the pt's stable. What complication of PEEP should
a very sickly crackles in all lung fields. CXR reveals dyspnea continues be considered?
presentation and is in bilateral white out of the lungs. The pt is to worsen. All vitals Barotrauma
respiratory distress. Dx w/ ARDS, intubated, and started on remain stable. What
Physical exam oxygen. Why should PEEP be added to complication of
reveals crackles in this pt's treatment? PEEP should be Complications of PEEP:
all lung fields. CXR (see below) considered? - Barotrauma; typically involves worsening
reveals bilateral PEEP in ARDS: [...] SOB after PEEP has been given to the pt
white out of the - PEEP = positive end-expiratory pressure - Pneumothorax; suspect this if the pt
lungs. The pt is Dx - PEEP works by increasing pulmonary becomes hypotensive and mediastinal
w/ ARDS, intubated, interstitial pressure and forcing fluid back shift/tracheal deviation; Dx w/ CXR; Tx
and started on into the capillaries/recruiting more alveoli; w/ needle decompression; can be 2/2
oxygen. Why should PEEP also alleviates the decrease in lung barotrauma
PEEP be added to compliance (2/2 to fluid transudation 2/2 to
this pt's treatment? increased pulmonary capillary
782. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP after
[...] permeability)
placed on PEEP intubation. Short after, he develops
- this does not alleviate the increase in
after intubation. hypotension. A medical student noticed
pulmonary capillary permeability, but does
Short after, he tracheal deviation to the left during
maximize oxygenation as oxygen is
develops rounds. What test should be ordered to
diffusion limited
hypotension. A confirm the most likely Dx?
- and remember, since CO2 is perfusion
medical student CXR to dx tension pneumothorax
limited we don't really worry about CO2 in
noticed tracheal
ARDS, as it can still be blown off; on top of
deviation to the left
that, there typically aren't any ventilation
during rounds. What Complications of PEEP:
issues in ARDS; in fact, ventilator settings
test should be - Barotrauma; typically involves worsening
are kept on low in the management of
ordered to confirm SOB after PEEP has been given to the pt
ARDS
the most likely Dx? - Pneumothorax; suspect this if the pt
- PEEP also helps to decrease FiO2 (>
[...] becomes hypotensive and mediastinal
50% is toxic to the lungs)
shift/tracheal deviation; Dx w/ CXR; Tx
- maintain a plateau pressure of 30
w/ needle decompression; can be 2/2
cmH2O
barotrauma

780. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP after


783. Why does a clot in Why does a clot in the deep veins of the
placed on PEEP intubation. Which 2 complications should
the deep veins of leg have a risk of embolizing up the IVC
after intubation. be monitored for?
the leg have a risk of towards the heart/lungs?
Which 2 Barotrauma; PTX
embolizing up the There are no valves in the deep veins
complications should
IVC towards the
be monitored for?
heart/lungs?
[...] Complications of PEEP:
[...] Typically the femoral and popliteal veins
- Barotrauma; typically involves worsening
are the sites of clot formation.
SOB after PEEP has been given to the pt
- Pneumothorax; suspect this if the pt
becomes hypotensive and mediastinal
shift/tracheal deviation; Dx w/ CXR; Tx
w/ needle decompression; can be 2/2
barotrauma

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784. A pulmonary A pulmonary embolism can present as a 786. A pt on bed rest A pt on bed rest presents w/ SOB,
embolism can life-threatening condition. What effect does presents w/ SOB, tachypnea, tachycardia and pleuritic
present as a the clot have at the lungs that causes such tachypnea, chest pain. Physical exam reaveals lungs
life-threatening a presentation? tachycardia and that are CTABL. CXR is clear. What is the
condition. What (see below) pleuritic chest pain. most likely Dx?
effect does the clot Physical exam Pulmonary embolism
have at the lungs reaveals lungs that
that causes such a Key points of PE pathogenesis: are CTABL. CXR is
presentation? 1. Limited gas exchange 2/2 the clot clear. What is the PE presentation key points:
[...] blocking blood flow most likely Dx? - SOB & tachypnea 2/2 to the limited gas
2. Right heart strain 2/2 increased [...] exchange and increased R heart strain
pulmonary vascular resistance 2/2 fewer - Tachycardia is 2/2 a need to maxmize
patent vessels gas exchange (via increased CO)
3. Widespread pulmonary inflammation - Pleuritic chest pain is 2/2 pleural
2/2 platelet derived mediators ischemia
- Homan's sign is highly suggestive of a
current DVT, but its absence doesn't rule
785. Even the smallest of Even the smallest of clots can cause a
out anything
clots can cause a severe pulmonary embolism w/ a
- Hemoptysis may be involved and is 2/2
severe pulmonary life-threatening presentation. Why?
necrosis of lung parenchyma
embolism w/ a Platelet-derived mediators
life-threatening
presentation. Why? 787. Which set of clinical Which set of clinical criteria do we use to
[...] Key points of PE pathogenesis: criteria do we use to help w/ the workup of pulmonary
1. Limited gas exchange 2/2 the clot help w/ the workup of embolism?
blocking blood flow pulmonary Wells Criteria
2. Right heart strain 2/2 increased embolism?
pulmonary vascular resistance 2/2 fewer [...]
patent vessels; this can affect pulmonary
perfusion, and hence CO2 blow off
(remember, CO2 is perfusion limited)
3. Widespread pulmonary inflammation
788. What CXR findings What CXR findings are associated w/
2/2 platelet derived mediators; this
are associated w/ pulmonary embolism?
widespread inflammation causes fluid to
pulmonary Normal findings
leak out of pulmonary vasculature and
embolism?
creates a diffusion barrier for oxygen (but
[...]
not CO2 because, once again, CO2 is
Did I get you?
perfusion limited & oxygen is diffusion
limited)
789. What EKG findings What EKG findings are associated w/
are associated w/ pulmonary embolism?
pulmonary "S1Q3T3"
embolism?
[...]
"S1-Q3-T3"
- prominent S in lead I
- Q wave in lead III
- T-wave inversion in lead III
- indicative of R heart strain

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790. What ABG findings What ABG findings are associated w/ 794. What is the treatment What is the treatment for massive
are associated w/ pulmonary embolism? for massive pulmonary embolism?
pulmonary Hypoxemic respiratory alkalosis pulmonary Intra-arterial tPA; or thrombectomy
embolism? embolism?
[...] [...]
Hypoxia causes increased respiratory PE treatment key points:
drive which causes respiratory alkalosis - The first step is obviously giving oxygen
- In massive embolism, it is imperative to
attack the clot right away. Give
791. What change in What change in D-Dimer levels is
intra-arterial tPA or perform
D-Dimer levels is diagnostic of a pulmonary embolism?
thombectomy
diagnostic of a None
- Platelet-derived inflammatory
pulmonary
mediators are controlled w/ heparin;
embolism?
heparin alost stabilizes existing clots
[...] The only D-Dimer measurement that is
- Recurrence is targeted w/ long term
useful in suspected PE is if it is normal
anticoagulation, typically w/ warfarin
- a normal D-Dimer reliably rules out a PE
(target INR of 2-3)
- an elevated D-Dimer can be 2/2 anything
- Bridge to warfarin w/ heparin
- If warfarin cannot be tolerated or there is
792. Which diagnostic Which diagnostic tests can provide a PE while having therapeutic INR,
tests can provide definitive Dx of a PE? consider an IVC filter
definitive Dx of a Spiral CT; Pulmonary angiogram
PE?
795. What are the What are the treatment goals in most
[...]
treatment goals in cases of pulmonary embolism?
Spiral CT is preferred as it is non-invasive
most cases of Shut off platelet mediators causing
Angiogram is not superior to spiral CT
pulmonary widespread pulmonary inflammation;
However, if the patient cannot tolerate
embolism? prevent recurrence
IV contrast a CT scan is not feasible, in
[...]
such a case, perform a V/Q scan and
stratify the pt into low, medium, or high risk
PE treatment key points:
- The first step is obviously giving oxygen
- In massive embolism, it is imperative to
attack the clot right away. Give
793. A pt is thought to A pt is thought to have a PE but cannot intra-arterial tPA or perform
have a PE but tolerate IV contrast do to severe renal thombectomy
cannot tolerate IV disease. What other diagnostic test can be - Platelet-derived inflammatory
contrast do to severe ordered to help in the workup? mediators are controlled w/ heparin;
renal disease. What V/Q scan heparin also stabilizes existing clots
other diagnostic test - Recurrence is targeted w/ long term
can be ordered to anticoagulation, typically w/ warfarin
help in the workup? (target INR of 2-3)
[...] - Bridge to warfarin w/ heparin
- If warfarin cannot be tolerated or there is
a PE while having therapeutic INR,
consider an IVC filter

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796. How soon can How soon can Heparin-induced 800. What are the 3 main What are the 3 main methods of obtaining
Heparin-induced Thrombocytopenia (HIT) present following methods of obtaining a biopsy of a suspected lung cancer?
Thrombocytopenia first-time exposure to heparin? a biopsy of a (see below)
(HIT) present 7 days suspected lung
following first-time cancer?
exposure to [...] Lung biopsy key points:
heparin? - Bx depends on the type of lesion and its
[...] location (and clinical situation)
- Endobronchial Ultrasound (EBUS) is
used for central lung masses
797. How soon can How soon can Heparin-induced
- Percutaneous CT-guided biopsy is
Heparin-induced Thrombocytopenia (HIT) present following
used for peripheral lung masses
Thrombocytopenia a repeat exposure to heparin?
- VATS is used for deep,
(HIT) present 3 days
intraparenchymal lesions
following a repeat
exposure to
heparin? 801. Which common lung Which common lung cancer is typically not
[...] cancer is typically not associated w/ smoking?
associated w/ Adenocarcinoma
smoking?
798. What is the first What is the first diagnostic test preferred
[...]
diagnostic test for the workup of suspected lung cancer?
preferred for the CXR
workup of suspected 802. Which lung cancer is Which lung cancer is associated w/
lung cancer? associated w/ PTH-rp release as a paraneoplastic
[...] Remember though, there is no screening PTH-rp release as a syndrome?
for lung cancer. paraneoplastic Squamous cell carcinoma
CXR, then CT, then Bx syndrome?
[...]

799. A pt presents c/o of A pt presents c/o of hemoptysis and


hemoptysis and unintended weight loss for the past 6 803. Which lung cancer is Which lung cancer is associated with
unintended weight months. What spectrum of disease must associated with SIADH as a paraneoplastic syndrome?
loss for the past 6 be considered? SIADH as a Small cell carcinoma
months. What Lung cancer paraneoplastic
spectrum of disease syndrome?
must be considered? [...]
[...] Start testing w/ CXR, then CT, then Bx if
indicated
804. Which lung cancer is Which lung cancer is associated w/
Presentation of lung cancer key points:
associated w/ Cushing's syndrome as a paraneoplastic
- Lung cancer typically presents in 2 ways:
Cushing's syndrome?
hemoptysis+weight loss or incidental
syndrome as a Small cell carcinoma
lung lesion
paraneoplastic
syndrome?
[...]

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805. Which lung cancer is Which lung cancer is associated w/


810. A pt w/ a solitary A pt w/ a solitary pulmondary nodule
associated w/ Lambert-Eaton syndrome as a
Lambert-Eaton paraneoplastic syndrome? pulmondary nodule received a CT scan. It is < 2 cm in
syndrome as a Squamous cell carcinoma received a CT scan. diameter and shows signs of calcification.
paraneoplastic It is < 2 cm in Is this a high or low risk lesion?
syndrome? diameter and shows Low
[...] signs of Calcification of pulmonary nodules is a
calcification. Is this good thing. Spiculation is not.
a high or low risk 2 cm diameter is the threshold size for risk
806. Which lung cancer is Which lung cancer is typically already lesion? stratification.
typically already metastasized at the time of Dx? [...] Risk is also influenced by the pt (smoking,
metastasized at the Small cell carcinoma age, FHx, PMHx, etc.)
time of Dx?
40 y/o is the threshold for age.
[...]
Is it often too small to cause obstructive
pneumonia or hemoptysis.
811. Which type of renal Which type of renal failure is 2/2
failure is 2/2 decreased renal perfusion?
807. Which lung cancer is Which lung cancer is known to be decreased renal Prerenal
known to be especially sensitive to chemo and perfusion? Typical causes involve the following
especially sensitive radiation therapy? [...] pathophysiology:
to chemo and Small cell carcinoma - decreased cardiac output
radiation therapy? - 3rd spacing
[...] - decreased vessel diameter
All other lung cancers are treated w/ In this case, the kidney's think they are
surgery first. dehydrated. As a result, they hold onto
Small cell carcinoma is almost never salt and urine
operated on due to its sensitivity to - FeNa < 1% (use FeUrea and Uurea if the
chemo/rads. pt is on a diuretic)
- UNa < 10
808. Which common lung Which common lung cancer is known to - BUN:Cr > 20
cancer is known to present peripherally? Tx via IVF or managing the causative
present peripherally? Adenocarcimoma condition
[...]

Adenocarcinoma of the lung is often stuck 812. What FeNa What FeNa measurement is associated w/
to the pleura, causing it to pucker measurement is prerenal failure?
This makes sense: associated w/ < 1%
- The other cancers are more commonly prerenal failure?
caused by smoking. Smoke passes the [...]
large, central airways w/ every puff. So it In this case, the kidney's think they are
makes sense for small cell and dehydrated. As a result, they hold onto
squamous cell to present centrally salt and urine
- There's also a handy mnemonic: Small - FeNa < 1% (use FeUrea and Uurea if the
cell & Squamous = Sentral pt is on a diuretic)
- UNa < 10
809. What is the most What is the most appropriate, initial test in - BUN:Cr > 20
appropriate, initial the workup of a solitary pulmonary nodule? Tx via IVF or managing the causative
test in the workup of CT condition
a solitary pulmonary
nodule?
[...]

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813. What level of urinary What level of urinary sodium (UNa) is 816. What FeNa level is What FeNa level is associated w/
sodium (UNa) is associated w/ prerenal failure? associated w/ intrarenal failure?
associated w/ < 10 intrarenal failure? > 1%
prerenal failure? [...]
[...]
In this case, the kidney's think they are Intrarenal failure is typically a disease of
dehydrated. As a result, they hold onto the nephron:
salt and urine - FeNa > 1% as the tubules cannot
- FeNa < 1% (use FeUrea and Uurea if the reabsorb Na
pt is on a diuretic) - UNa > 20 as the tubules cannot reabsorb
- UNa < 10 Na
- BUN:Cr > 20 - UA is typically enough to diagnose
Tx via IVF or managing the causative - Bx is definitive diagnosis
condition

817. A pt presents w/ A pt presents w/ acute renal failure. You


814. What BUN:Cr ratio is What BUN:Cr ratio is associated w/ acute renal failure. attempt to calculate FeNa to assess for a
associated w/ prerenal failure? You attempt to prerenal etiology, but realise that the pt is
prerenal failure? > 20 calculate FeNa to using a loop diuretic that interferes w/ Na
[...] assess for a prerenal excretion. Which fractional excretion
etiology, but realise measurement can you use in place of
In this case, the kidney's think they are that the pt is using a FeNa?
dehydrated. As a result, they hold onto loop diuretic that FeUrea
salt and urine interferes w/ Na
- FeNa < 1% (use FeUrea and Uurea if the excretion. Which
pt is on a diuretic) fractional excretion If the pt is on a drug that interferes w/ Na
- UNa < 10 measurement can excretion (e.g. loop diuretic, ACE-i/ARB,
- BUN:Cr > 20 you use in place of spironolactone), use FeUrea instead of
Tx via IVF or managing the causative FeNa? FeNa.
condition [...] FeUrea < 35% suggests prerenal failure.

815. Which type of renal Which type of renal failure involves 818. A pt presents in A pt presents in acute renal failure. What is
failure involves obstruction to urinary outflow at any level? acute renal failure. the first step in the workup?
obstruction to urinary Postrenal failure What is the first step Rule out prerenal failure (BUN:Cr, UNa,
outflow at any level? in the workup? FeNa)
[...] [...]
Order an U/S to look for residual urine
and hydroureter/hydronephrosis.

819. A pt presents in A pt presents in acute renal failure.


acute renal failure. Prerenal failure has been ruled out. What
Prerenal failure has is the next step in workup?
been ruled out. What Rule out postrenal failure (KUB U/S)
is the next step in
workup?
[...]

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820. A pt is suspected to A pt is suspected to have intrarenal failure. 823. A pt presents in A pt presents in acute renal failure. He is
have intrarenal What is the best initial diagnostic test? acute renal failure. Dx w/ acute tubular necrosis. On hospital
failure. What is the UA He is Dx w/ acute day 2, the pt's creatinine continues to rise,
best initial diagnostic While Bx would offer a definitive diagnosis, tubular necrosis. On but he becomes oliguric. Which phase of
test? UA is often enough to arrive at a diagnosis hospital day 2, the acute tubular necrosis is this pt in?
[...] (with the help of the history & presentation) pt's creatinine Phase 2: oliguric phase
continues to rise, but
he becomes oliguric.
Which phase of The phases of ATN:
821. A pt presents in A pt presents in acute renal failure.
acute tubular 1. Prodrome: creatinine rises while urine
acute renal failure. BUN:Cr is < 10. FeNa is > 1%. UA reveals
necrosis is this pt in? output remains constant
BUN:Cr is < 10. muddy brown casts. What is the most
[...] 2. Oliguric phase: creatinine continues to
FeNa is > 1%. UA likely Dx?
rise, but urine output plummets; diuretics
reveals muddy Intrarenal failure; likely ATN
are helpful here to reduce fluid load and
brown casts. What
help kidney function improve
is the most likely Dx?
3. Polyuric phase: creatining continues to
[...] Acute Tubular Necrosis key points:
rise, but urine output increases
- thought to be 2/2 prolonged ischemia or
- Tx throughout these phases is
toxic exposure (esp. IV contrast or
supportive
myoglobin 2/2 rhabdomyolysis), resulting
in the necrosis and sloughing off of renal
tubules 824. A pt w/ stage II CKD A pt w/ stage II CKD is admitted to the
- muddy brown casts are typical on UA is admitted to the hospital. She needs to receive IV contrast
and represent the sloughed tubular hospital. She needs prior to imaging. What interventions may
epithelium, however this is not specific to to receive IV contrast help to reduce the risk of
ATN prior to imaging. contrast-induced acute tubular
- presents in 3 phases: prodrome, What interventions necrosis?
oliguric phase, polyuric phase may help to reduce (see below)
the risk of
contrast-induced
822. What are the three What are the three phases of Acute
acute tubular If a pt has pre-existing renal damage or is
phases of Acute Tubular Necrosis?
necrosis? at increased risk. Reduce the risk of
Tubular Necrosis? Prodrome; oliguric phase; polyuric
[...] contrast-induced ATN via:
[...] phase
- vigorous hydration
- prophylactic N-Acetyl-Cysteine
- stop drugs such as ACE-Is/ARBs,
The phases of ATN:
diuretics or common nephrotoxic agents
1. Prodrome: creatinine rises while urine
like metformin
output remains constant
The idea here is to minimize the contact of
2. Oliguric phase: creatinine continues to
the tubules w/ the contrast.
rise, but urine output plummets; diuretics
These measures are useless if contrast is
are helpful here to reduce fluid load and
already given.
help kidney function improve
3. Polyuric phase: creatining continues to
rise, but urine output increases 825. What type of casts What type of casts found on UA are
- Tx throughout these phases is found on UA are associated w/ Acute Tubular Necrosis?
supportive associated w/ Acute Muddy Brown Casts
Tubular Necrosis?
[...]

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826. A pt presents w/ A pt presents w/ acute renal failure. 829. Which type of casts Which type of casts on UA are associated
acute renal failure. BUN:Cr is < 10. FeNa is > 1%. UA reveals on UA are w/ glomerulonephritis?
BUN:Cr is < 10. WBC and WBC casts. What is the most associated w/ RBC
FeNa is > 1%. UA likely Dx? glomerulonephritis?
reveals WBC and Intrarenal failure likely 2/2 acute [...]
WBC casts. What is interstitial nephritis (AIN) Glomerulonephritis general key points:
the most likely Dx? - the differential for the type of
[...] glomerulonephritis is extensive
AIN key points: - RBC casts are typical of GN
- involves immune cell invasion of the - Definitive Dx is via biopsy
interstitium 2/2 to drugs, infection or - Important to r/o nephrotic syndrome w/
deposition disease (e.g. multiple myeloma) UA spot test or 24 hr urine collection
- common drugs are: TMP-SMX,
cephalosporins, penicillins, NSAIDs
830. Which type of Which type of glomerulonephritis is known
- pts can have fever, rash and elevated
glomerulonephritis is to present after a viral infection?
Cr
known to present IgA Nephropathy
- UA will reveal WBCs and WBC casts
after a viral
- Tx by removing the offending agent,
infection?
treating the infection, or mitigating the
[...] Glomerulonephritis general key points:
damage; steroids may be helpful
- the differential for the type of
glomerulonephritis is extensive
827. What type of casts What type of casts on UA are associated - RBC casts are typical of GN
on UA are w/ Acute Interstitial Nephritis? - Definitive Dx is via biopsy
associated w/ Acute WBC casts - Important to r/o nephrotic syndrome w/
Interstitial Nephritis? UA spot test or 24 hr urine collection
[...]

831. Which type of Which type of glomerulonephritis


828. A pt presents w/ A pt presents w/ acute renal failure. glomerulonephritis commonly presents after pharyngitis or
acute renal failure. BUN:Cr ratio is < 10. FeNa is > 1%. UA commonly presents impetigo?
BUN:Cr ratio is < 10. reveals RBC casts. What is the most likely after pharyngitis or Post-streptococcal glomerulonephritis
FeNa is > 1%. UA Dx? impetigo? (PSGN)
reveals RBC casts. Intrarenal failure 2/2 glomerulonephritis [...]
What is the most (GN)
likely Dx? Glomerulonephritis general key points:
[...] - the differential for the type of
Glomerulonephritis general key points: glomerulonephritis is extensive
- the differential for the type of - RBC casts are typical of GN
glomerulonephritis is extensive - Definitive Dx is via biopsy
- RBC casts are typical of GN - Important to r/o nephrotic syndrome w/
- Definitive Dx is via biopsy UA spot test or 24 hr urine collection
- Important to r/o nephrotic syndrome w/
UA spot test or 24 hr urine collection

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832. Which type of Which type of glomerulonephritis 835. A pt is diagnosed w/ A pt is diagnosed w/ glomerulonephritis.
glomerulonephritis commonly presents w/ hemoptysis glomerulonephritis. What renal disorder needs to be ruled out
commonly presents alongside the hematuria? What renal disorder in the next step in management?
w/ hemoptysis Goodpasture's syndrome needs to be ruled out Nephrotic Syndrome
alongside the in the next step in
hematuria? management?
[...] Glomerulonephritis general key points: [...] While it is important to determine the
- the differential for the type of specific type/etiology of glomerulonephritis.
glomerulonephritis is extensive It is also important to rule out nephrotic
- RBC casts are typical of GN syndrome. The latter is easier (as the
- Definitive Dx is via biopsy former often requires Bx).
- Important to r/o nephrotic syndrome w/ Ruling out Nephrotic Syndrome key
UA spot test or 24 hr urine collection points:
- can be done via UA spot test or 24 hr
urine collection
833. Which type of Which type of glomerulonephritis is
- > 3.5 g proteinuria/day suggests
glomerulonephritis is associated w/ asthma alongside the
nephrotic syndrome
associated w/ hematuria?
- hyperlipidemia also supports nephrotic
asthma alongside Churg-Strauss syndrome
syndrome
the hematuria?
- edema can be seen as well (2/2
[...]
decreased oncotic pressure 2/2
Glomerulonephritis general key points:
proteinuria)
- the differential for the type of
glomerulonephritis is extensive
- RBC casts are typical of GN 836. A pt has elevated A pt has elevated creatinine and reduced
- Definitive Dx is via biopsy creatinine and GFR that does not return to normal after
- Important to r/o nephrotic syndrome w/ reduced GFR that repeated outpatient testing. For how long
UA spot test or 24 hr urine collection does not return to must his GFR remain reduced before a
normal after diagnosis of chronic kidney disease can be
repeated outpatient made?
834. What do dysmorphic What do dysmorphic RBCs on urine
testing. For how long > 3 months
RBCs on urine microscopy signify?
must his GFR remain
microscopy signify? (see below)
reduced before a
[...]
diagnosis of chronic
kidney disease can
Dysmorphic RBCs = "RBCs w/ mickey
be made?
mouse ears"
[...]
- The presence of dysmorphic RBCs tells
us that the bleeding is coming from the
glomerulus 837. What laboratory What laboratory measurement is used to
- The "mickey mouse ears" are blebs that measurement is stratify Chronic Kidney Disease into
form as the RBC is sheared while crossing used to stratify stages?
through the abnormal glomerulus Chronic Kidney GFR
- This is helpful in the work up of hematuria Disease into stages?
(microscopic, frank, or gross) as it points [...]
us away from malignancy, stones, UTI, It is not BUN or Cr no matter what the
etc. gunner on rounds says.

838. What GFR level is What GFR level is seen in stage I CKD?
seen in stage I CKD? > 90
[...]

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839. What GFR level is What GFR level is seen in stage II CKD? 846. What are the What are the indications of acute dialysis?
seen in stage II 60-89 indications of acute "AEIOU"
CKD? dialysis? It has nothing to do w/ creatinine no matter
[...] [...] what the gunner during rounds says.

Indications for acute dialysis: "AEIOU"


840. What GFR level is What GFR level is seen in stage III CKD?
- Acidosis
seen in stage III
- Electrolytes (namely Na and K)
CKD? 30-59
- Ingestion (of dialyzable toxins/drugs)
- Overload (of fluid; e.g. CHF)
[...]
- Uremia (NOT azotemia)

841. What GFR level is What GFR level is seen in stage IV CKD?
847. Which neurological Which neurological symptoms are
seen in stage IV 15-29
symptoms are associated w/ hypokalemia?
CKD?
associated w/ Areflexia; flaccid paralysis; paresthesia
[...]
hypokalemia?
[...]
842. What GFR level is What GFR level is seen in stage V CKD?
seen in stage V < 15
848. A pt presents gets a A pt presents gets a CMP that reveals a K
CKD?
CMP that reveals a K level of 6. There are no other abnormalities
[...]
level of 6. There are or symptoms. What is the most appropriate
no other next step in the management of this pt's
843. What is the BP goal What is the BP goal in a pt w/ chronic abnormalities or hyperkalemia?
in a pt w/ chronic kidney disease? symptoms. What is Repeat the lab
kidney disease? < 130/80 the most appropriate Very commonly, lab samples involve
[...] next step in the busted cells/RBCs which can falsely
management of this elevate K. In this case, the pt is
BP control is much more vigorous in pts w/ pt's hyperkalemia? symptomatic, but it's still prudent to rule
CKD or other renal disease. [...] out this error.
The preferred agent is an ACE-I or ARB
Note that additional comorbidities must be
mitigated as well.

844. Pts w/ ESRD or high Pts w/ ESRD or high stage CKD are at a
stage CKD are at a higher risk of developing secondary
higher risk of hyperparathyroidism. What interventions
developing aid in reducing this risk?
secondary Ca; Vit D; phosphate binders
hyperparathyroidism.
What interventions
aid in reducing this
risk?
[...]

845. What is the What is the hemoglobin goal in a pt w/


hemoglobin goal in a ESRD or late stage CKD?
pt w/ ESRD or late 11-12
stage CKD?
[...]

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849. A pt presents gets a A pt presents gets a CMP that reveals a K 851. A pt gets a CMP in A pt gets a CMP in the ER that reveals a K
CMP that reveals a K of 6. Repeat CMP confirms true the ER that reveals a of 7. Repeat CMP confirms hyperkalemia.
of 6. Repeat CMP hyperkalemia. What is the most K of 7. Repeat CMP EKG reveals widened QRS and
confirms true appropriate next step? confirms prolonged PR. What is the treatment for
hyperkalemia. What EKG hyperkalemia. EKG this pt's electrolyte imbalance?
is the most reveals widened (see below; this is unstable
appropriate next QRS and prolonged hyperkalemia)
step? It is imperative to get an EKG in PR. What is the Unstable Hyperkalemia Tx key points:
[...] hyperkalemia to determine if it is stable or treatment for this pt's - Phase I = stabilization (of the
unstable. electrolyte myocardium): done via IV Ca gluconate
EKG in Hyperkalemia key points: imbalance? - Phase II = sequestration (of
- EKG changes include peaked T-waves, [...] extracellular K): done via insulin+glucose
widened QRS, and prolonged QT & PR; or bicarbonate (or beta2-agonists)
the end point is sine wave EKG, which is - Phase III = excretion (of K): done via
bad news, homey kayexalate, K-wasting diuretics (e.g.
- If EKG changes are present, its called loop diuretics), or hemodialysis if in renal
unstable hyperkalemia and Tx is failure
emergent and slightly different - Phase I protects what we're worried
- If EKG changes are absent, its called about the most: the heart. Phase II is a
stable hyperkalemia quick fix for extracellular hyperkalemia, but
it does not actually correct total body K;
Phase III brings it home and involves
facilitating excretion of K via GI, renal, or
dialysis if CKD/ESRD is present
850. A pt is Dx w/ A pt is Dx w/ hyperkalemia. What are the 3
hyperkalemia. What phases of treating unstable hyperkalemia?
are the 3 phases of (see below)
treating unstable
hyperkalemia? 852. A pt presents w/ a A pt presents w/ a potassium level of 6. All
[...] Unstable Hyperkalemia Tx key points: potassium level of 6. other labs are normal and the pt is
- Phase I = stabilization (of the All other labs are asymptomatic. EKG reveals NSR w/ no
myocardium): done via IV Ca gluconate normal and the pt is abnormalities. What is the treatment for
- Phase II = sequestration (of asymptomatic. EKG this pt's electrolyte imbalance?
extracellular K): done via insulin+glucose reveals NSR w/ no Kayexalate (this is stable hyperkalemia)
or bicarbonate (or beta2-agonists) abnormalities. What
- Phase III = excretion (of K): done via is the treatment for
kayexalate, K-wasting diuretics (e.g. this pt's electrolyte Stable Hyperkalemia Tx key points:
loop diuretics), or hemodialysis if in renal imbalance? - Kayexalate is a K chelator that facilitates
failure [...] K excretion via GI
- Phase I protects what we're worried - Stop any K-sparing diuretics (e.g.
about the most: the heart. Phase II is a spironolactone, amiloride, triamterene)
quick fix for extracellular hyperkalemia, but
it does not actually correct total body K;
Phase III brings it home and involves
facilitating excretion of K via GI, renal, or
dialysis if CKD/ESRD is present

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853. A pt is dx w/ unstable A pt is dx w/ unstable hyperkalemia. IV Ca 855. A pt w/ diarrhea is Dx A pt w/ diarrhea is Dx w/ hypokalemia after


hyperkalemia. IV Ca gluconate is given and the pt is given w/ hypokalemia after 2 lab tests showing a K level of 2. What is
gluconate is given insulin w/ glucose. Which class of 2 lab tests showing a the most appropriate next step in
and the pt is given adrenergics can also be given to decrease K level of 2. What is management of this pt's hypokalemia?
insulin w/ glucose. K levels? the most appropriate EKG
Which class of Beta2-agonists next step in
adrenergics can also management of this
be given to decrease pt's hypokalemia? This one is weird. The book says to get an
K levels? e.g. Albuterol [...] EKG, but in real life you're going to end up
[...] Beta-2 agonists and hyperkalemia key replacing the K anyway, so what's the
points: point of getting an EKG? It doesn't hurt,
- Not frequently used, but can and should but it likely isn't going to change your
be considered as transient therapy in pts management (STAT K replacement)
that have s/s or serious EKG abnormalities Hypokalemia key points:
despite Ca gluconate and insulin therapy - less sexy than hyperkalemia, but still
- Acts the same way as insulin: activates deadly
the Na/K ATPase pump in skeletal - re-check the initial lab value to confirm
muscle the abnormality
- They also activate the Na/K/2Cl - Tx involves K replacement
cotransporter that drives K into cells - PO replacement is always better than
- Side effects include tachycardia and IV
increases the risk of angina/ACS - If the pt is on a K-wasting diuretic, add a
- Is additive w/ insuline+glucose therapy K-sparing diuretic or consider long-term
- Should not be used as monotherapy in supplementation
pts w/ ESRD
- Should not be used at all in pts w/ active
856. What are the more What are the more common causes of
CAD
common causes of hypokalemia?
hypokalemia? (see below)
854. A pt taking a loop A pt taking a loop diuretic has a K level of [...]
diuretic has a K level 2 on CMP. What is the most appropriate
of 2 on CMP. What is next step in the workup of this pt's Hypokalemia causes key points:
the most appropriate hypokalemia? - Typically it's GI loss (diarrhea, vomiting,
next step in the Repeat the lab laxatives) or renal loss (loop/thiazide
workup of this pt's diuretics)
hypokalemia? - In isolated hypokalemia, consider RTA,
[...] Similar to hyperkalemia, repeat the lab to Barter syndrome, or Gittleman
confirm if it is a true lab abnormality. syndrome
- If part of a syndrome, look for
hyperaldosteronism

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857. What is the treatment What is the treatment for hypokalemia? 859. What is the What is the diagnostic test for polycystic
for hypokalemia? Replacement K diagnostic test for kidney disease?
[...] polycystic kidney U/S (or CT)
disease?
Hypokalemia Tx key points: [...]
- PO replacement is preferred over IV ADPCKD key points:
replacement - Autosomal dominant
- IV replacement burns, but the PO - s/s: pain and hematuria; commonly
replacement pill is massive mistaken for nephrolithiasis, however
- Generally, try and keep the replacement stones can form
≤ 10 mEq/hr (i.e. increasing K by 0.1/hr) - pyelonephritis is a common presention
- If the IV is peripheral, infusion rate must - malignant HTN can be present and is
be ≤ 10 mEq/hr to prevent burning 2/2 RAAS activation
- If the IV is central, ≤ 20 mEq/hr, not to - Dx is via U/S
prevent burning but to prevent local - Tx is supportive, manage
hyperK near the catheter complications and transplant once
- If the pt is on K-wasting diuretics, ESRD/CKD sets in
consider adding a K-sparing diuretic or - Cysts can also form in the liver,
outpatient potassium supplementation pancreas, and cerebral vasculature
- Screen these pts for berry aneurysms
as they have a risk for SAH
858. What percentage of What percentage of ESRD and dialysis pts
- Remember to test family members and
ESRD and dialysis have polycystic kidney disease?
offspring
pts have polycystic 5-10%
kidney disease?
[...] 860. Polycystic kidney Polycystic kidney disease can be
Pretty useless card, but the point is: you're disease can be autosomal dominant or autosomal
likely going to see PCKD this at some autosomal dominant recessive. What is the difference between
point. Know it, brah. or autosomal the cysts in ADPCKD and ARPCKD?
recessive. What is (see below)
the difference
between the cysts in
ADPCKD and In ADPCKD, the cysts have a random
ARPCKD? orientation and size
[...] In ARPCKD, the cysts have a radial
orientation

861. What is the treatment What is the treatment for polycystic kidney
for polycystic kidney disease?
disease? Supportive; manage complications;
[...] transplant when ESRD/CKD sets in

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862. A pt undergoing A pt undergoing elective cholecystectomy 864. A pt presents c/o of A pt presents c/o of flank pain and gross
elective receives an abdominal U/S that flank pain and hematuria. Physical exam reveals a
cholecystectomy incidentally reveals a renal cyst. It is small, gross hematuria. palpable flank mass on the R side. What
receives an non-loculated, and non-septated. No Physical exam renal disorder must be ruled out?
abdominal U/S that echoes are seen on the U/S. What is the reveals a palpable Renal Cell Carcinoma
incidentally reveals a most likely Dx? flank mass on the R
renal cyst. It is small, Simple Renal Cyst side. What renal
non-loculated, and Simple Renal Cyst key points: disorder must be Renal Cell Carcinoma key points:
non-septated. No - must be small, non-loculated, ruled out? - While its not present everytime, the triad
echoes are seen on non-septated and no echoes on U/S [...] of flank pain, flank mass, and hematuria
the U/S. What is the - If truly simple, and asymptomatic, let it be should be considered cancer until proven
most likely Dx? - If s/s develop, consider excision or otherwise
[...] biopsy - Major risk factors include smoking,
ESRD and von-Hippel Lindau
- Investigate w/ U/S or CT
- F/u w/ surgical resection
863. A pt undergoing A pt undergoing elective cholecystectomy
- Definitive Dx is via Bx after resection
elective receives an abdominal CT that incidentally
- Never ever biopsy a suspected RCC in
cholecystectomy reveals a renal cyst. It is large, septated,
vivo; the risk of hematoma and/or seeding
receives an and loculated. What is the most
is high; always Bx s/p resection
abdominal CT that appropriate next step?
- hematogenous spread
incidentally reveals a Biopsy (this is a complex renal cyst)
- Renal vein thrombosis is a big risk
renal cyst. It is large, Complex Renal Cyst key points:
- Either anaemia or polycythemia can be
septated, and - must be large, septated, or loculated
present (anaemia 2/2 to the tumour or
loculated. What is - more likely to cause symptoms than
increased EPO release as a
the most appropriate simple cysts
paraneoplastic syndrome)
next step? - common s/s: flank mass, hematuria,
[...] pyelonephritis, pain
- If truly complex, biopsy that sucker to r/o
malignancy
- CT-guided needle Bx is typically the
method of choice

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865. A pt presents c/o of A pt presents c/o of flank pain and gross 867. A pt presents c/o A pt presents c/o colicky flank pain that
flank pain and hematuria. Physical exam reveals a colicky flank pain radiates to the groin. He states that this
gross hematuria. palpable flank mass on the R side. You that radiates to the started 2 days ago and that yesterday he
Physical exam suspect renal cell carcinoma. What is the groin. He states that had hematuria. He also complains of
reveals a palpable most appropriate next step? this started 2 days nausea and vomiting. He denies any
flank mass on the R U/S or CT to visualize the kidneys ago and that fever or chills. What is the most likely Dx?
side. You suspect yesterday he had Nephr