1.

Entamoeba histolytica- A protozoal infection seen in developing nations (travel/residence),

contaminated food/water. 90% of pts are asymptomatic but some have Colitis (diarrhea, bloody
stool w/ mucus, abd pain), Liver abscess (RUQ pain, fever) which can rupture. Dx w/ stool ova &
parasites, stool antigen testing (colitis) or E histolytic serology (liver abscess). Treat w/
metronidazole & untraluminal abx (paromomycin).
- Imaging: round, well-defined hypoechoic mass. Diagnose w/ serology, aspiration not req.
Aspirate if done is anchovy paste and negative gram stain.
2. Acute prostatitis- usually caused by gram negative rods such as E. coli but gram stain done in all
pts. Empiric ABX include TMP/SMX but fluoroquinolones can be used. 4-6week tx required since
difficult to reach prostate.
3. Esophageal coin ingestion- Ingestion <24 hour AND asymptomatic then observe & repeat xrays in
12-24 hours. If ingestion time >24 hours or unknown OR symptomatic- retrieve w/ flexible
endoscopy.
4. AAA- Surgery if >5.5cm, grow >0.5 over 6 months or severe abd or back pain. If <5.5cm &
asymptomatic, then US or CT at regular intervals (q6m to 2y)
5. Primary hyperparathyroidism- the mcc of hypercalcemia. Can be incidental finding. Surgery rec. if
symptomatic (osteoporosis) or severe hypercalcemia. Patients <50yo are more likely to develop
complications later in life & should undergo surgery. If asymptomatic, pt should have regular f/u
over time we serum Calcium, Creatitine & DXA testing
6. Childhood femur fractures- in pts <2yo, 50-80% associated with abuse. Spiral fxs are suspicious
unless history is specific for a planted foot and rotation. Need skeletal survey.
7. Return to work after MI- if uncomplicated MI (no recurrent angina, arrhythmias, CHF) can resume
normal activity after 2 weeks from event.
8. High-intensity statins: Atorvastatin & Rosuvastatin are the only 2. Several trials have
demonstrated the benefit of high-dose compared to standard therapy on subsequent risk of MI,
stroke or overall cardiovascular death.
9. Breast lump- Women >35yo w. breast mass should get diagnostic mammogram & either an US or
FNAB (fine needle aspiration biopsy). If FNAB is positive (atypical cells suspicious for CA) then
core needle or excisional biopsy is needed.
10. LBP & red-flag symptoms- hx of CA, wt loss, night pain, urinary symptoms or fever.
Symmetrically decreased ankle reflexes are nonspecific and does not count if no other
symptoms are present.
11. Liver Cells- Liver parenchyma is where HCC arises no the interstitial cells of the liver.
12. Organ donation network- members of the treating medical team should not approach the
patients next of kin regarding organ donation, as this could be viewed as a conflict of interest.
13. Prostate CA treatment- treatment if symptomatic (or high Gleason score) treat with
prostatectomy or radiation therapy. No evidence to support one or the other. Both can cause
sexual dysfunction & urinary incontinence but these symptoms tend to be more temporary &
less sever in patients undergoing radiation therapy.
14. Pertussis- Catarrhal (1-2 weeks) w/ mild cough, rhinitis. Paroxysmal (2-6 weeks) w/ cough w/
inspiratory whoop & posttussive emesis. Convalescent period (weeks months). Diagnose with
pertussis culture or PCR & lymphocyte-predominate leukocytosis. Treat w/ macrolides and
prevent w/ acellular pertussis vaccine. Prophylaxis is recommended for all close contacts
regardless of their vaccination status 2/2 waning immunity.
15. Childhood inguinal hernias- usually asymptomatic, reducible mass. Prompt surgical correction is
required to prevent complications (incarcertation & strangulation). In infants w/ undescended
testicle, it is appropriate to wait until 6mo before definitive treatment as it may descend
spontaneously.
16. Menopausal hormone therapy (MHT)- short-term (3-5 years) combo estrogen/progesterone
hormone therapy is most effective if <60yo. The risk is higher in women age >60yo. C/i include
established Coronary heart disease, active liver disease & history of breast cancer, venous
thromboembolism or stroke.
17. Statin-induced myositis- severe elevations of creatine kinase can be seen. Pts will also have
generalized weakness, body aches and muscle tenderness. Can occur any time in their course
(but usually in the first few months of therapy) but can also occur if taking a med that inhibits
CYP3A4 such as HIV protease, cyclosporine, gemfibrozil, macrolides, etc.
18. Zoster vaccination- Recommended (ACIP) for adults >60yo (FDA approved for >50yo). It is live-
attenuated so do not give if immunodeficiency, HIV/AIDS, solid organ transplant, CA tx w/
radiation or chemotherapy, hematologic malignancy and women who are or may be pregnant.
19. Atrial flutter treatment- similar to atrial fibrillation such that rate control, rhythm control and
anticoagulation to prevent systemic embolization is key.
20. Recurrent cellulitis- typically associated with tinea pedis infection, lymphedema or chronic
venous insufficiency. Treatment for tinea pedis associated cellulitis is antifungals.
21. Recurrent UTIs w/ E. coli & Bacteroides- could be enterovesical fistulas as a complication of
Crohns disease.
22. Atypical fibroids- typically present with heavy, regular menstrual bleeding. This patients
intermenstrual bleeding & sudden onset of heavy, prolonged menses are atypical of fibroids and
concerning for anther etiology, particularly endometrial cancer. Women <45 with AUB & risk
factors require evaluation of the endometrial lining with an Endometrial biopsy (EMB)
23. C. diff infection clues- high fever, leukocytosis, elevated platelet count (inflammatory response
to infection), nausea, loose stools.
24. GFR & dialysis- pts w/ CKD w/ GFR <30 should receive education on renal replacement therapy
although they dont need dialysis until GFR <15.
25. Recurrent otitis media risk factors- day care, cigarette smoke, pacifiers, and bottle feeding
26. Varicocele- leads to elevated scrotal temps which may cause testicular atrophy and subsequent
infertility in some patients.
27. Choanal atresia- difficulty breathing & cyanosis w/ feeding that improves w/ crying. Inability to
pass a nasal catheter from the nostrils to the oropharynx is high suggestive.
28. PCP and steroids- steroids given to those with partial pressure of oxygen <70mmHg or an AA
gradient >35 mmHG.
29. Indications for ICD therapy- Prior MI & LVEF <30%, Cardiomyopathy with NYHA class II & III
symptoms & LVEF <35%
30. Indications for cardiac resynchronization therapy (CRT)- LVEF <35% & sinus rhythm w/ one of the
following: QRS duration >150msec & NYHA class III or IV, QRS >120 but <150. NYHA class I or II
symptoms on optimal medical therapy underoing pacemaker or ICD implantation with
anticipated frequent ventricular pacing. LVEF <30%, QRS duration >150msec w/ LBBB, & NYHA
class I or II symptoms on optimal medical therapy.
31. Prolactinoma treatment- Diagnosis is confirmed w/ an elevated prolactin & MRI of the brain.
Initial treatment consists of a dopamine agonists such as carbegoline or bromocriptine
regardless of tumor size or severity of neurologic symptoms.
32. Delusional disorder vs illness anxiety disorder- Illness anxiety disorder fear having serious
undiagnosed medical illness but do not have a ridigly fixed delusion that they have a disease.
33. EHEC vs Shigella- Shigella has bloody diarrhea w/ FEVER & severe abdominal cramps. EHEC has
abdominal tenderness W/O fever. Diagnose w/ stool culture using sorbitol-MacConkey agar or
by finding of Shiga-toxin. HUS is a complication- triad of ARF, MAHA and thrombocytopenia.
34. Polyomavirus- BK virus is a polyomavirus that is well-known to cause nephritis in renal transplant
recipients who are immunosuppressed with a prevalence of about 5%. UA will show interstitial
nephritis and urine cytology often shows infected cells with an enlarged nucleus & a single
basophilic intranuclear inclusion. Treatment consists of DECREASING the immunosuppression
and in some cases, antiviral therapy.
35. Intubation & hypotension- Positive pressure ventilation increases the intrathoracic pressure,
decreasing venous return & CO and potentially causing hypotension. Use of PEEP and if the
patient is hypovolemic will heighten the hypotension. IV crystalloids are indicated.
36. Rx induced esophagitis- caused by tetracyclines, NSAIDs, bisphosphonates, KCl, Fe
37. Bullemia Nervosa tx- CBT is first line treatment.
38. Depression in dementia & post-stroke treatment- SSRI such as Citalopram
39. Furuncle & Carbuncle treatment- usually caused by S. aureus so tx w/ clindamycin, TMP-SMX or
doxycycline
40. Vertebral osteomyelitis work-up- Patients with gram-positive cocci in clusters suggesting
vertebral osteomyelitis due to S. aureus do not need CT guided biopsy however they need work
up for infective endocarditis with a TTE or TEE.
41. Wegeners life threatening complication- Diffuse alveolar hemorrhage.
42. PSC- commonly seen in pts w/ UC causing cholestatic pattern of laboratory abnormalities
including elevated bilirubin & alkaline phosphatase. Confirm dx w/ endoscopic cholangiogram.
43. Hypoplastic left heart syndrome (HLHS) vs Tetralogy of Fallot- HLHS presents with mild cyanosis
at birth and rapid clinical deterioration with closure of ductus arteriosus. Once the ductus
closes, affected neonates rapidly develop shock and acidosis as a result of decreased systemic
perfusion & acidosis as a result of decreased perfusion. Management involves PGE1 (alrostadil)
to maintain patency of the ductus. TOF presents later in life, 4-6 months.
44. TNF & infections- TNF-inhibitors predispose patients to fungal (slower progression), bacterial
(rapid onset w/ severe, necrotizing pna usu LOWER lobe cavitations) and tuberculosis (+ tb skin
test & subacute w/ UPPER lobe cavitations).
45. Gaucher disease- AR lysosomal storage disease caused by deficiency of glucocerebrosidase
resulting in a buildup of GLYCOLIPIDS. Signs/sx are hepatosplenomegaly, anemia,
thrombocytopenia, osteopenia and pathologic fractures.
46. PCOS- Androgen excess (acne, male pattern baldness, hirsutism), oligoovulation or anovulation
(eg, menstrual irregularities), obesity, polycystic ovaries on US. Pathophys- increase
testosterone, increased estrogen and LH:FSH imbalance. Comorbid w/ metabolic syndrome
(HTN, DM), OSA, nonalcoholic steatohepatitis and endometrial hyperplasia/CA. Treatment- first
line is wt loss. Then OCPs or menstrual regulation or Clomiphene citrate for ovulation induction.
47. Infertility workup by age- Age <35: no pregnancy in >12 months, >35: no preg. In 6 m.
48. Sick Sinus Syndrome (SSS) aka bradycardia-tachycardia syndrome- alternating SVT &
bradycardia. SSS is caused by chronic sinoatrial node dysfunction.
49. Parkinsons disease symptoms- bradykinesia in addition to either tremor or rigidity. Other
features are UNILATERAL onset & persistent ASYMMETRY of symptoms.
50. Livedo reticularis or the blue toe syndrome- seen when artherosclerotic fragments are
dislodged from the aortic wall & released into circulation. In the kidneys, may have acute renal
failure with EOSINOPHILIA/URIA
51. Acute pancreatitis management- Fluid resuscitation, pain control and appropriate nutrition.
Current guidelines suggest initiating oral nutrition as soon as the patient has a return of
appetite. If patient is unable to tolerate oral nutrition in 5-7 days, enteral nutrition support
should be pursued within 72 hours of hospitalization via NJ or NG feeding tube. A soft, low-fat,
low residue diet has been shown to be advantageous compared with a clear liquid diet.
52. Acute gout- NSAIDS (indomethacin), colchicine and systemic or intra-articular glucocorticoids
53. Chronic gout- pts w/ frequent gout attacks need a urate-lowering medication such as allopurinol
(xanthine oxidase inhibitor) but this can cause an acute flare, therefore, pts should receive
additional prophylactic therapy during the initiation & titration. Best measure is colchicine
54. CHADS2- risk of stroke in patients with atrial fibrillation. The risk factors are CHS, HTN, AGE >75,
DM, and Stroke (2 points).
55. NNH- first calculate incidence of each cohort. The NNH is the inverse of this 1/x.
56. Polycythemia vera (PV)- PV is a myelodysplastic disorder characterized by an elevated RBC mass.
Patients can be diagnosed most accurately with genetic studies for the JAK2 mutation which is
present in 100% in patients with primary PV but not in secondary polycythemia. Patients
present with splenomegaly, thrombocytosis, increased RBC mass, possible blood clots &
decreased erythropoietin.
57. Postpartum thyroiditis (PT)- patients with mild symptoms need no specific treatment but those
with bothersome symptoms can be treated with beta-blockers (eg, atenolol, propranolol).
Patients with TP usually self-resolve but some patients develop persistent or recurrent
hypothyroidism with a palpable goiter.
58. Drug induced pancreatitis (DIP): Thiazide diuretics (HCTZ, chlorthalidone) and most loop
diuretics (furosemide) belong to sulfonamide class of drugs and have been associated with DIP.
59. Allergic bronchopulmonary aspergillosis (ABPA): A hypersensitivity disorder that occurs in
patients with asthma or CF. Its assoc. w/ a noninvasive colonization of the airways by
Aspergillus. The pathophys is an exaggerated IgE & IgG. Clinical features include recurrent
asthma exacerbations, fever, productive cough, occasional hemoptysis and fleeting infiltrates.
Do skin testing or aspergillus antigen. CT shows central bronchiectasis. Treat with
glucocorticoids and itraconazole
60. Phenytoin toxicity- earliest sign is the presence of nystagmus on far lateral gaze. Other
symptoms include blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness,
lethargy, decreased mentation or coma. Therapeutic range of phenytoin is 10-20mcg but some
patients can have AEs within therapeutic range. Reduce dose helps solve the problem.
61. MDD vs Grief- patients with grief usually have bouts of sadness resolving around reminders of
the deceased.
62. Depression in palliative care- take anticipated life expentancy into consideration. If <1month to
live, typical antidepressants are unlikely to be beneficial and psychostimulants are preferred.
This includes methyphenidate, dextroamphetamine, modafinil.
63. LOC- need ECG to check for cardiac arrhythmia
64. Binswangers disease- a type of vascular dementia that involves white matter infarcs. Patients
with this disease usually present with apathy, agitation and bilateral corticospinal or bulbar
signs.
65. VTE & Menopausal hormone therapy- Because development of VTE while on MHT necessitates a
cessation of hormone therapy, pts can take an SSRI (escitalopram) or SNRI (venlafaxine).
66. How to approach psychotic patient with no insight- maintain interpersonal distance and
attempting to understand the patients experience without challenging the patients delusions.
67. Pylephlebitis- infective suppurative portal vein thrombosis and is a rare but devastating
complication of untreated appendicitis or other intraabdominal or pelvic infections
68. Sydenham chorea- develops 1-8 months after the initial stretptococcal infection. SC is also
known as Saint Vitus dance which is the most common acquired chorea in children. Emotional
lability & decline in school performance are typically the earliest neurologic manifestations,
followed by distal hand movements that progress to facial grimacing and feet jerking. Relaxation
phase of the patellar reflex is usually delayed. Pronator drift (involuntary hyperpronation of
extended arms) is present. TREATMENT- penicillin until adulthood with the goal to eradicate
group A streptococcus to prevent recurrent ARF & worsening rheumatic heart disease.
69. Presbycusis- sensorineural hearing impairment in elderly individuals. Usually progressive and
loss of high-frequency range of hearing first. Decreased ability to discriminate speech is
especially obvious in a noisy, distracting environment.
70. Tuberous sclerosis- Pathophysiology is a AD or de novo mutation of the TSC1 or TSC2 gene.
Dermatologic eval. Shows hypopigmented macules (Ash-leaf spots), angiofibromas of the malar
region and Shagreen patches. Neuro eval shows CNS lesions, epilepsy, cognitive disabilities,
autism & behavior problems. CV shows rhabdomyomas and renal shows angiomyolipomas.
Leading COD in TS patients is neurlogic impairment (epilepsy/uncontrollable seizures)
71. Lithium and diuretics- Lithium has a narrow therapeutic index (0.8-1.2). Levels >1.5 confirm
toxicity and levels >2.5 require emergency management. Risks include low GFR (elderly, renail
failure), volume depletion and drug interactions. Thiazide diuretics such as HCTZ and
chlorthalidone, increase sodium excretion. ACE-Is and NSAIDS also increase lithium levels.
72. Pemphigoid gestationis- autoimmune inflammatory disease and antibody reaction to basement
membrane. Occurs during 2nd or 3rd trimester and has prodromal pruritic, periumbilial papules &
plaques with rapid eruption of tense bullae and spares mucous membranes. The diagnosis is
clinical but biopsy can be done. Treat w/ high-potency topical steroids and antihistamines and
usually resolves after delivery.
73. Constitutional pubertal delay- defined as the absence of any signs suggestive of puberty by 14
years of age. Patients will have positive family history, retarded bone age, and absence of
syndromic features or systemic illness. Treatment is follow-up 3-6 months.
74. Alternative medications and their side effects
a. Ginkgo biloba- Used for memory enhancement. S/e increased bleeding risk
b. Ginseng improved mental performance and can cause increased bleeding risk
c. Saw palmetto for BPH and increase bleeding risk
 d. Black cohosh for postmenopausal symptoms (hot flashes & vaginal dryness) can cause
hepatic injury and increase bleeding (antiplatelet properties)
e. St Johns wort for depression and insomnia. Can interact with antidepressants (serotonin
syndrome), OCs, anticoagulants (decreased INR), digoxin.
f. Kava for anxiety and insomnia can cause severe liver damage
g. Licorice for stomach ulcers, bronchitic/viral can cause hypertension and hypokalemia.
h. Echinacea for treatment & prevention of cold & flue can cause anaphylaxis (more common
on asthmatics).
i. Ephedra for wt loss & athletic performance can cause HTN, arrhythmia/MI/sudden death,
stroke or seizure.
75. Gonococcal arthritis- most common cause of acute non-traumatic mono- & oligoarthritis in
young healthy adults. Usual synovial fluid leukocyte count in gonococcal arthritis is around
50,000 cells/mm3 however counts below 10,000 is can present. Diagnose is made with joint
culture and the mucosal surfaces (urethral, cervical, rectal and oral mucosa).
76. St. Johns Wort P450 effect- SJW is a P450 inducer and can decrease the effect of other drugs
metabolized by P450 such as OCP, immunisuppresives, narcotics, anticoagulants and
antifungals.
77. Chronic Urticaria- Presents with episodes of well-circumscribed & raised erythematous plaques
with central pallor. Lesions can be oval, round or serpiginous up to sever cm in diameter. Intese
pruritic and up to 40% of patients have angiedema. Individuals lesions can worsen over minutes
to hours then resolve without 24 hours. Things that make it worse- physical stimuli (cold, hot,
heat or tight clothing), NSAIDS, stress (physical or psychological), idiopathic (most common) and
hypothyroidism, or autoimmune (celiac, sjogrens, SLE)
78. Chronic urticaria treatment- initial treatment is done with a 2nd gen antihistamine (cetirizine or
loratadine (zyrtex/allegra)). If that doesnt work, either increase dose or add an H1 blocker
(hydroxyzine but can be sedating). Most patients will have spontaneous resolution within 2-5
years.
79. OCD treatment- first non-pharm is exposure therapy followed by SSRIs. High doses and
prolonged titration.
80. Narcotizing fasciitis- Caused by Group A strep (strep pyogenes), S. aureus, clostridium
perfringens or polymicrobial. Bacterial spread rapidly through subq tissue & deep fascia,
undermining the skin. Clinically, often antecedent history of minor trauma, erythema of
overlying skin, swelling & edema present, pain out of proportion to examination findings and
systemic symptoms (eg, fever & hypotension). Treatment requires surgical debridement and
broad-spectrum ABX.
81. ABX choice for C. diff- depends if it is mild-moderate defined as WBC <15,000 &/or Cr <1/5x
baseline. If so, then give PO metronidazole. If severe defined as WBC >15,000, Cr >1.5x baseline
or serum albumin <2.5 then give PO Vanco. If ileus present, add IV metronidazole & switch to
rectal vancomycin. If toxic megacolon and/or severe ileus present, consider subtotal colectomy
and/or diverting loop ileostomy with colonic lavage.
82. Amiodarone & warfarin- Amiodarone is a CYP2C9 inhibitor (cytochrome P450) and thus
increases the effect of warfarin. If a patient is started on amiodarone, check INR but the dose
can usually be decreased by 25%-50% to compensate for this effect.
83. Nelsons syndrome- a name for pituitary enlargement and hyperpigmentation following bilateral
adrenalectomy for Cushings disease. The enlargement is secondary to loss of feedback by
adrenal steroids.
84. Sexual history- sexual history should be obtained routinely in health visits. Physicians should
normalize sexual health concerns and provide patients with the opportunity to openly discuss
these issues.
85. Subclinical hypothyroidism associations- increased risk for a number of pregnancy complications
including recurrent miscarriages. Anti-TPO are associated with increased risk of pregnancy loss
even if bioclinically euthyroid.
86. Pulmonary contusion- blunt trauma to the lungs results in accumulation of edema and blood in a
localized area of the lung parenchyma. CXR shows irregular, localized opacification at the site of
injury. Depending on size, respiratory distress w/ significant hypoxemia can develop. Symptoms
and cxr can be delayed up to 24 hours. Treatment with supportive care only usch as pain control
to avoid hypoventilation, pulmonary hygiene (chest physiotherapy, suctioning) and
supplemental oxygen.
87. Cushings features- HTN, hyperglycemia, osteoporosis, mood swings, hypokalemia, & metabolic
alkalosis. Screening can be done with overnight dexamethasone suppression test or
measurement of 24 hour urinary free cortisol level.
88. Hyperthyroidism & sympathetic- CV manifestations (SV arrhythmias) are common in
hyperthyroidism due to excessive sympathetic activity. Patients w/ symptomatic tachycardia or
those in atrial fibrillation must be treated initially with beta blockers to control symptoms &
heart rate.
89. HIV-associated thrombocytopenia (HIV-TP)- can appear at any time at is thought to be due to
immune dysfunction or viral destruction of megakaryocytes. ART improves the count.
90. Viral loads after ART at 6 months- ART should decrease viral load to <50 copies/mL within 6m.
91. Bacterial vaginosis (BV)- based on thin, malodorous vaginal discharge and clue cells (stippled
epithelial cells) on wet mount. Change in pH causes an overgrowth of anaerobic vaginal flora
(Gardnerella vaginalis and Mycoplasma hominis). Treat with oral or vaginal metronidazole or
clindamycin (good anaerobic coverage).
92. Screening in Turner patients- Most important is cardiac defects such as coarctation of the aorta,
bicuspid aortic valve, mitral valve prolapse and hypoplastic heart.
93. OCP failure and antiseizure meds- Phenytoin, carbamazepine, ethosuximide, phenobarbital,
topiramate decrease the efficacy of OCPs by incuding cytochrome P450.
94. Restless legs syndrome- Urge to move the legs and other criteria. Secondary causes include iron
deficiency anemia, uremia (ESRD, CKD), DM, MS, Parkinsons, pregnancy, drugs). Treatment with
iron supplement when serum ferritin <75, use supportive measures (leg massage, heating pads,
exercise), avoid aggravating factors (eg, sleep deprivation, meds). First line if severe is dopamine
agonists (pramipexone) or alpha-2-delta calcium channel ligands (gabapentin enacarbil).
95. HELLP syndrome- Hemolysis, Elevated liver enzymes, and a low platelet count and is a variant of
preeclampsia. HELLP occurs >20 weeks but can occur during the postpartum period. Signs and
symptoms include malaise, HA, visual changes, N/V, epigastric/right upper quadrant pain, HTN
and proteinuria. Treat with magnesium sulfate
96. Aortic stenosis exam findings- a soft, single second heart sound (S2), a delayed & diminished
carotid pulse (Parvus and tardus), loud and late-peaking systolic murmur.
97. Adrenal mass (incidentaloma)- although a patient may have no symptoms to suggest adrenal
pathology, all adrenal masses require workup for hormone hypersecretion or malignancy. In any
patient with an adrenal mass, essential laboratory studies include serum electrolytes,
dexamethasone suppression testing, & 24-hour urine catecholamine, metanephrine,
vanillymandelic acid & 17-ketosteroid measurement.
98. SBP- presents with fever (>37.8), abd pain/tenderness, AMS, hypotension, hypothermia,
paralytic ileus w/ severe infection. Diagnosis from ascetic fluid shows PMNs >250 (careful that
sometimes reported as Leuk count & PMN%), positive culture often gram negative (eg E. coli,
Klebsiella), protein <1.0, SAAG >1.1. Treat w/ empiric ABX (third gen ceph such as cefotaxime,
ceftazidime or ceftriaxone), fluoroquinolones for SBP prophylaxis.
99. MELD score (Model for End stage Liver Disease) used to determine 90 day survival and to
calculate a patients priority on the transplant list. Need INR, Creatinine & bilirubin
100. Cryptorchidism- orchiopexy before age 1 year but testes that havent dropped by 6 months are
unlikely to drop and should be done to improve fertility and testicular growth.
101. ADPKD- ACE-inhibitors are drug of choice to treat HTN & prevent progression of renal failure in
these patients. If HTN is controlled, regular BP checks should be done. The most common
extrarenal manifestation is hepatic cysts.
102. Family screening for ADPKD- Abd ultrasound is the most cost-effective screening procedure for
asymptomatic family members of a patient with ADPKD. The presence of at least 3-5 cysts in
each kidney is require to make a diagnosis of ADPKD.
103. Breast discharge evaluation- depends if it is bilateral or unilateral. If bilateral, check pregnancy
test and galactorrhea evaluation. If unilateral, and <30 get US +/- mammogram. If >30yo get US
+ mammogram. The MCC of pathologic nipple discharge is a benign papillary tumor (ie,
papilloma) from the breast duct lining.
104. Adenosine deaminase- suggests TB. If fluid contains that in the lung, a pleural biopsy is often
required for diagnosis.
105. Pericarditis workup- Patients have sharp, retrosternal chest pain worsened by inspiration &
relieved by leaning forward. Differential includes PE, PNA, GERD & MSK pain. Patients should get
cardiac monitoring, ECG which may show diffuse STEMI. Causes of pericarditis to work up are
viral agents, neoplasm, uremia, autoimmune, TB and trauma. Patients should get CBC (infection,
inflammation), BMP(uremia), CXR, Echo (r/o tamp), blood cultures (if febrile), and ESR. Get
cardiac enyzmes. Skin testing for TB, ANA, HIV may be considered if the underlying etiology is
not clear (hx of URI, uremia, post-MI or cardiac surgery). Pericardial effusion does not mean
tamponade and pericardiocentesis is not indicated in effusion w/o tamponade. NSAIDS are
helpful to reduce pain and inflammation, but do not alter the course. Colchicine can be used for
3 months and NSAIDS for <2 weeks. Avoid NSAIDs (other than ASA) in post-MI pericarditis.
Steroids can be used if resistant to NSAIDs & colchicine. Steroids are indicated in pericarditis due
to autoimmune disease. Treat w/ hemodialysis in uremia.
106. Schistosomiasis- parasitic blood fluke infection that affects more than 200 million worldwide
w/ greatest prevalence is in sub-Saharan Africa. Pts are usu asymptomatic initially but chronic
infection can cause dysuria, urinary frequency and terminal hematuria. Peripheral eosinophilia is
seen & anemia 2/2 chronic blood loss. Diagnosis requires the identification of eggs using urine
sediment microscopy. Treatment w/ praziquantel is usually curative.
107. Clinical features of compartment syndrome- Common is pain out of proportion to injury, Pain
increased on passive stretch, rapidly increasing & tense swelling and paresthesia (early).
Uncommon (or late) is decreased sensation, motor weakness (within hours), paralysis (late) and
decreased distal pulses (uncommon).
108. Complications of compartment syndrome- Causes anoxic muscle necrosis (rhabdomyolysis) and
released myoglobin is filtered and degraded in the kidney. The heme pigment is directly toxic to
proximal tubular cells, combines with Tamm-Horsfall protein to form tubular casts and induces
vasoconstriction, reducing medullary blood flow. All this leads to ARF particularly in volume-
depleted states (eg, hemorrhage) which worsens vasoconstriction & cast formation.
109. Compartment pressures- Pressure >30 mmHg or delta pressure (DBP compartment pressure)
< 20-30 mmHg. Serial measurements should be performed even if initial pressure are within
normal limits.
110. Cyclosporine & gout- this rx decreases uric acid excretion and can cause gout flare. Diagnosis is
confirmed on synovial fluid analysis which shows inflammatory effusion and negatively
birefringent needle shaped urate crystals. Treatment in patients with ARF is intraarticular or
systemic glucocorticoids as NSAIDs can further hurt kidneys.
111. Bells palsy- No work up is required if patients have no traveld to Lyme endemic areas or
present with no other concerns features (forehead wrinkles indicating upper neural issue).
Corticosteroids & supportive eye care are the mainstays of treatment.
112. Condyloma acuminate- patients can proceed w/ vaginal delivery as C-section deliver does not
prevent vertical transmission of HPV.
113. Psychotic symptoms in parkinsons patients- Due to dopaminergic drugs, psychosis can be
common. After ruling out dementia, delirium or other medical causes, the least potent meds
should be withdrawn first before considering reducing carbidopa/levodopa. This includes first
anticholinergics then amantadine then MAO-B inhibits then COMT-inhibitors then dopamine
agonsits then carbidopa/levodopa.
114. Stress ulcers- critically ill patients may have uremic toxins and reflux of bile salts into the
stomach and can disrupt the protective glycoprotein layer predisposing to ulcer formation.
115. Condylomata acuminate treatment- chemical or physical destruction, immunotherapy &
surgical excision. Chemical is preferred with trichloracetic acid (repeat applictions required).
Podophyllin has similar effects but cannot be used internally such as on mucosal surfaces and is
contraindicated in pregnancy.
116. GBS pulmonary- patients have high risk of rapid-onset respiratory failure and frequent
measurement of vital capacity (not PEFR used in COPD). 30% of patients with GBS require
mechanical ventilation.
117. Recurrent C. diff infection. First recurrence treat with metronidazole for non-severe,
vancomycin for severe. Second recurrence- pulsed tapering oral vancomycin for 6-7 weeks,
subsequent relapse tx w/ fidaxomicin or consider fecal microbiota transplant.
118. DKA & glucose <200- When serum glucose falls to <200 but the patient still has an AGAP, the
rate of insulin infusion should be halved & dextrose added to the IV fluids to prevent
hypoglycemia.
119. Insulin in DKA- Initial continuous IV insulin. Then switch to SQ (basal bolus) insulin when patient
is able to eat, glucose <200, anion gap closed (<12) and serum HCO3 >15.
120. Levothyroixine intake timing- should be taken on an empty stomach with water 30-60 minutes
before breakfast. Calcium and iron supplements can impair the absorption of levothyroxine
should be separated from it by 3-4 hours.
121. Hip or vertebral fractures- regardless of T-score, patients should be started on bisphosphonate,
calcium and vitamin D (1200 mg/day calcium and 800 IU/day vitamin D).
122. Cryptococcal meningoencephalitis- the yeast and capsular polysaccharides can clog the
arachnoid villi which prevents CSF outflow and can increase ICP. Treat with serial lumbar
punctures.
123. JME- treat with valproic acid. EMG shows bilateral polyspike and slow discharge.
124. Warfarin after HIT- first stop heparin, do lab testing, but warfarin is started after tx w/ a non-
heparin anticoagulant and platelet count recovery to >150,000.
125. Solo elevated Alk phos- usually pagets disease. For asymptomatic patients, a radionuclide bone
scan is more sensitive than xray .
126. Infant botulism- ingestion of Clostridium botulinum spores from environmental dust. Seen in
CA, Utah, Penn. Descending flaccid paralysis. C botulinum spores or toxins in stool is diagnostic.
Treat with human-derived botulism immune globulin. Infants require 1-3 months of
hospitalization but have a complete recovery.
127. Diagnosis of hypercalcemia- First correct for albumin concentration or measure ionized
calcium. Then measure PTH level. If high-normal or elevated PTH (then it is PTH-dependent). If
PTH is low then measure PTHrP, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D (causes-
malignancy mcc).
128. OCPs and TBG- OCPs increase the serum concentration of thyroid binding globulin. In normal
patients, feedback loops promote increased endogenous production of thyroid hormones to
compensate for the increased number of bound thyroid hormone molecules. However patients
with hypothyroidism cannot adequately compensate and an increased dose of levothyroxine is
usually necessary.
129. Fetal descent timing- no change in fetal station after nulliparous patients push for >3 hours
without an epidural (>4 hours with an epidural). Management is cesarean delivery.
130. Hepatic encephalopathy- usually triggered by elevated ammonia levels due to an underlying
precipitating event. A common trigger of HE is excessive diuresis, which reduces intravascular
volume & results in hypokalemia & metabolic alkalosis. Treatment involves volume & electrolyte
repletion & using meds (eg, lactulose) to reduce ammonia levels.
131. Stone size- <10mm treat with hydration, pain control, alpha blocker and stroke urine. If pain is
uncontrolled or no stone in 4-6 weeks then get urology consult.
132. Familial adenomatous polyposis (FAP)- dominantly inherited and due to germline mutations in
the tumor suppressor gene, APC. Patients can develop >1,000 polyps. Patients are at risk of
developing exracolonic neoplasms, both gastric and duodenal tumors (upper GI Cancers, thyroid
ca, desmoids and osteomas and medulloblastoma).
133. HTN and wt loss- Weight loss is best to reduce BMI <25, 5-20 Systolic BP drop per 10kg
134. PE and troponin- PE can cause elevated Troponin levels which indicates a worse prognosis.
135. Need for glucocorticoid taper- No taper needed if <3 weeks of use or <5mg/day of prednisone
or equivalent or alternate day dosing. Slow taper needed if >3 weeks, mod-high dose, evening
dose or cushingoid signs or sympto
136. ms. Slow taper or low-dase ACTH stimulation test.
137. Radiation-induced cardiotoxicity include coronary disease with myocardial ischemia and/or
infarction, restrictive cardiomyopathy (as opposed to anthracycline dilated cardiomyopathy w/
decreased EF), with diastolic dysfunction, pericardial disease, valvular abnormalities and/or
conduction defects.
138. Varenicline- partial agonist of the subunit of the nicotinic ach receptor that controls nicotine
dependence. Multiple trials against placebo and bupropion have shown it to be superior. It can
cause suicidal ideating and erratic or bizarre behavior so it is second line in patients with
unstable psychiatric symptoms or a history of depression.
139. Pain relief from sunburn- NSAIDs are best at reducing pain. Antihistamines can be used to
reduce pruritic. Benzocaine anesthetic spray should not be used because of can cause allergic
contact dermatitis in injured skin.
140. Isotretinoin s/e- metabolic effects, hepatoxicity, mucocutaneous rxs, blood dyscrasias and
ocular toxicity. Also a teratogen in females (not males) and females should use 2 types of
contraception.
141. Thiazolidinedione meds- result in fluid retention via PPAR-gamma agonist effects on renal
collecting tubule resulting in sodium reabsorption. Usu. Seen in pts w/ underlying HF.
142. Somatic symptom disorder- excessive anxiety & preoccupation with >1 somatic symptoms.
They may have concurrent medical illness or the symptoms may represent misinterpretations of
normal bodily sensations. Contrast to illness anxiety disorder in which patients have no (or
minimal) symptoms but patients fear having something bad.
143. -Hypoglycemia- defined as <60 mg/dL. Normal fasting blood sugar is 70-100 mg/dL.
144. Treatment resistant depression
a. Nonresponder- consider switching to monotherapy w/ a different antidepressant,
psychotherapy, ECT, repetitive transcranial magnetic stimulation
b. Partial responder- consider augmentation with second-generation antipsychotic,
antidepressant with different MOA, lithium, thyroid hormone, or psychotherapy.
145. PCP PNA sen- induced sputum samples in 50-90% of cases, negative results necessitate further
testing if PCP is suspected.
146. Cat & Dog bites- treated prophylactically with Amoxicillin/clavulanate. Tetatnus toxoid should
be given to individuals with dirty wounds who have not received a booster in >5 years or
patients with clean wounds who havent received booster in >10 years. Immune globulin in
required in dirty wounds & unclear in insufficient immunization history.
147. Posterior communicating artery aneurysm- CN III palsy is a typical finding in patients.
148. Factorial study design- one where patients are randomized to different types as well as a
placebo and combination of types.
149. SBO vs Ileus- SBO patients will have prior surgery (weeks to years), abdominal distension and
increased bowel sounds, small bowel dilation and large bowel dilation is absent. Ileus patients
will have recent surgery (hours to days), metabolic cause (hypokalemia), or medication induced.
Patients may have distension but will have reduced or absent bowerl sounds. Small bowel
dilation will be present and so will large bowel dilation (unlike SBO).
150. Intussusception- telescoping of a proximal portion of the intestine into a distal portion. Occurs
due to lymphoid hyperplasia (Peyer patches) in the setting of viral infection or a pathologic lead
point (eg, Meckel Diverticulum). Occurs at 6m to 3 years. Symptoms include severe,
intermittent, crampy abdominal point accompanied by nonbilious emesis & drawing up legs into
 abdomen. Palpabe sausage-shaped mass in the right abdomen and currant jelly stools (late
finding indicated bowel ischemia). US is the imaging methodology of choice with Target Sign. If
classic presentation is seen, get a abd xray to rule out intestinal perforation (free air under the
diaphragm). Radiographs may demonstrate SBO (dilated bowel loops with air-fluid levels).
Treatment involved reduction via air (pneumatic) or water-soluble (hydrostatic constrast)
enema.
151. Intestinal perforation after enema reduction of intussusception- patients with acute pain after
reduction should undergo radiographs of the abdomen to rule out perforation.
152. Familial hypocalciuric hypercalcemia vs Primary hyperparathyroidism- Difference is that in FHH,
Urinary calcium excretion will be low (CCCR <0.01) vs high in PHPT (>0.02)
153. B12 monitoring- monitor potassium level since the initial 48 hours patients can have severe
hypokalemia.
154. Subacute thyroiditis (de Quervain thyroiditis)- Likely postviral inflammatory process, prominent
fever & hyperthyroid symptoms, painful/tender goiter. Diagnose with elevated ESR & CRP, low
radioiodine uptake. It is a self-limited condition and may last a few weeks. Treatment is mainly
supportive with NSAID to relieve pain, steroids in severe or refractory cases. Patients can also be
given a beta-blocker (propranolol, atenolol, to minimize hyperadrenergic symptoms of
thyrotoxicosis (eg, sweating, palpitations).
155. Gonococcal conjunctivitis- copious exudate & eyelid swelling around 2-5 days. Diagnose with
gram stain with gram negative intracellular diplococci. Positive culture on modified Thayer-
Martin agar. Treat with one dose of IM ceftriaxone or cefotaxime. Prevent with Erythromycin
ointment.
156. Diphenhydramine & driving and diving- Should not use it in either situation since it can cause
drowsiness, dizziness, disturbed coordination and fatigue.
157. Wallenberg syndrome- Vestibulocerebellar symptoms such as vertigo, falling to side of the
lesion, diplopia & nystagmus. Sensory symptoms such as loss of pain & temp in ipsilateral face
and contralateral trunk & limbs. Ipsilateral bulbar muscle weakness with dysphagia, aspiration
and hoarseness. Autonomic dysfunction with ipsilateral Horners syndrome (miosis, ptosis &
anhidrosis), intractable hiccups. This is localized to lateral medullary area/infarction most likely
due to an occluded intracranial vertebral artery.
158. Sulfonylurea overdose- Overdose on glyburide (or others) can cause severe hypoglycemia.
Initial treatment is dextrose , however, this can cause a transient hyperglycemia and may elicit
even higher levels of insulin secretion and cause subsequent rebound hypoglycemia. Ocreotide
is a somatostatin analog which decreases insulin secretion and can also be used.
159. ASC-US aged 21-24- findings of atypical squamous cells of US or LGSIL, repeat cytology at 1 year
is recommended. Women aged >25 ASC-US should have reflex HPV testing.
160. False positive lung cancer screening- carries a <10% chance. It has a 20% relative reduction
161. Corneal foreign bodies bacteria- coagulase negative Staphylococcus.
162. Thyroid nodules- first eval with TSH level and thyroid ultrasound. Patients with high or normal
TSH & a confirmed nodule >1cm in diameter on US shoulder undergo FNA. Patients with low
TSH should have a radionuclide thyroid scan.
163. Hypocalcemia- can occur during or immediately after surgery, especially in patients undergoing
major surgery and requiring extensive transfusions. Hyperactive deep tendon reflexes may be
 the initial manifestation. Hypermagnesemia, on the other hand, results in LOSS of deep tendon
reflexes.
164. Diagnosis of parkinsons- dx of physical exam (bradykinesia in addition to tremor or rigidity). A
brain MRI is usually performed to exclude alternative diagnoses; the striatal dopamine
transporter can be considered when the diagnosis of Parkinson disease is equivocal.
165. PD treatment- initial treatment should be with dopamine agonists such as bromocriptine and
pramipexone. Levodopa is the most effective in controlling symptoms but there are potential
concerns regarding its prolonged use.
166. What additional test to run before HAART- test for hepatitis B as some treatment regiments
can target both infections.
167. Pediatric constipation- intitially treat with dietary modification and secondarily with osmotic
laxatives. Treatmetn with stimulant laxatives or enemas is generally reserved for acute relief of
fecal impaction.
168. Dengue fever- Flue-like febrile illness with marked myalgias and joint pains (break-bone fever).
Retro-orbital pain. Rash (white islands in sea of red). Dengue hemorrhagic fever signs of
increased vascular permeability, thrombocytopenia (<100k), spontaneous bleeding shock.
Positive tourniquet test (petechiae after sphygmomanometer cuff inflammation for 5 minutes).
Management is supportive care.
169. Adolescent depression- presents with irritability or somatic symptoms rather than depressed
mood & may be mistakn for normal adolescent behavior. Other symptoms include educational
and social functioning.
170. Herpes zoster precautions- lesion covering & standard precautions if they have localized
disease (one dermatome or immediately adjacent dermatomes). Those with disseminated
disease also require contact & airborne isolation.
171. Recovery expectation- is an important predictor of work outcome for patients with
occupational back pain. Education to improve patients understanding of natural history and
prognosis may improve the likelihood of returning to work.
172. Medical contraindications to pregnancy.
a. LVEF <40%
b. NYHA class III-IV HF
c. Prior peripartum cardiomyopathy
d. Severe obstructive cardiac lesions
e. Severe pulmonary HTN (Eisenmenger syndrome)
f. Unstable aortic dilation >40 mm
- Estrogen-containing contraceptives are c/I due to increased risk of thromboembolism.
173. Amiodarone-induced pulmonary toxicity- the most serious AE of this drug and chronic
interstitial pneumonitis is the most common presentation of amiodarone-induced pulmonary
toxicity. Discontinuation of this rx is treatment.
174. DM drugs causing hypoglycemia- sulfonylureas (eg, glyburide, glipizide, glimepiride) and
meglitinides (eg, nateglinide, repaglinide). These drugs increase insulin secretion by pancreatic
beta cells even when blood glucose levels are normal.
175. Graves in pregnancy- First treat with propylthiouracil during first trimester (think PTU =
pregnancy) then methimazole during 2nd and 3rd trimester (think M = nearing Maternity).
176. Lactational mastitis- caused by S. aureus. First line is oral dicloxacillin (antistaphylococcal
penicillin) & cephalexin (first gen cephalosporin). It can progress to breast abscess and should be
diagnosed with US and treat with aspiration of fluid. Going directly to an I&D can increase risk of
complications (eg, milk fistulas), slower recovery time, and a less desirable cosmetic outcome.
177. VSD- patients with a VSD typically have a harsh holosytolic murmur with maximal intensity over
the left 3rd & 4th intercostal spaces accompanied by a thrill.
178. Opioid withdrawal- Acute opioid cessation/dose after prolonged use can cause GI
(N/v/d/cramping/ increased bowel sounds), cardian (increased BP, pulse & diaphoresis),
psychological (insomnia, yawning, dysphoric mood), and other (myalgias, arthralgias,
lacrimation, rhinorrhea, piloerection, mydriasis). Treatment is with an opioid agonist
(methodone preferred vs. buprenorphine not preferred due to partial agonism worsening
symptosm). Nonopioid rx such as Clonidie or adjunctive meds (antiemetics, antidiarrheals,
benzodiazepine) can also be used.
179. Nighttime back pain- is a red flag for back pain. Patients should get an ESR and low back xray. If
either are abnormal, pt should get an MRI.
180. When is Tacrolimus (calcineurin inhibitor) indicated in eczema- when topical glucocorticoids
are relatively contraindicated for atopic dermatitis on the face, eyelids or flexural areas.
181. Sarcoid biopsy- not indicated for confirmation in an asymptomatic patient with typical
symptoms & chest xray findings. If indicated, biopsy sites include lacrimal gland, salivary gland
(parotid), skin lesions OTHER than erythema nodosum & palpable superficial lymph nodes as
these sites will not have noncaseating granulomas.
182. Underlying CT disease- patients are at risk for acute mitral valvel regurgitation (MR) due to
chordae tendinae rupture. Typical presentation is with sudden-onset pulmonary edema,
hypotension, and a hyperdynamic precordium with a holosystolic murmur but can be absent in
up to 50% of patients.
183. Acute severe anemia in sickle cell disease- aplastic crisis results in decreasted reticulocyte
count usually secondary to infection such as parvovirus B19. Another cause is splenic
sequestration crisis with splenic vaso-occulsion rapidly enlarging spleen and occurs in
children prior to autosplenectomy. Increased retic. Count in these cases.
184. Adults at risk for influenza complications- Age >65, women who are pregnant & up to 2 weeks
postpartum, underlying chronic medical illness (eg, chronic pulmonary, cardiovascular, renal or
hepatic), immunosuppression, morbid obesity, native americans, and nursing home or chronic
care facility residents. These patients are at risk for secondary pneumonia. Use CURB=65 score
to help dertermine appropriate care setting.
185. Rabies- Transmission of rabies virus by bite from infected animal (bats are most common in the
US vs dogs in developing world). Hydrophobia, aerophobia, pharyngeal spasm/spastic paralysis
and agitation leading to ascending flaccid paralysis. Rabies immune globulin & rabies vaccine
immediately after exposure to high-risk wild animals. Prognosis- Coma, respiratory failure and
death within weeks. The treatment stops progression but in patients with severe symptoms,
prognosis is very poor with death.
186. Bone scan in prostate CA- radioisotope bone scans detect areas of increased bone turnover &
are very sensitive for osteoblastic bone metastases of prostate & other cancers.
187.

188. Why stop glyburide in renal failure- If a patient has renal failure, stop metformin (especially if
an AGAP metabolic acidosis is present) but renal failure with increase the half-life of glyburide
leading to pronounced adverse effects such as hypoglycemia.
189. Cat scratch disease- Caused by Bartonella henselae with papules at scratch/bite site and
regional adenopathy +/- FUO (>14 days). Usually clinical diagnosis. Treat with azithromycin.
190. CEA & hypoglossal nerve injury- inadvertent retraction or transection of the hypoglossal nerve
causes tongue deviation to the site of injury.
191. Hypophosphatemia- continuous glucose infusion are the leading cause. Hypophosphatemia can
impair ATP generation (needed in skeletal muscle)
192. Menieres- triad of periodic vertigo, unilateral hearing loss & tinnitus (unlike aspirin tox which is
bilateral loss & tinnitus).
193. Ophthalmopathy in graves- in addition to RAI, treat with prednisone. Follow these patients
with Total T3 and free T4 levels in 4-6 weeks and most patients will develop hypothyroidism in
2-6 months.
194. Garlic-like odor from clothing- typical of organophosphate poisoning resulting in wheezing,
miosis (pinpoint pupils), confusion, lethargy, bradycardia, skin flushing. RBC cholinesterase can
be used to measure degree of toxicity.
195. Chikungunya fever- occurs in central and south America, tropical regions of Africa, south asia.
Vector is Aedes mosquito (same as dengue fever). Incubation is 3-7 days and patient will
describe high fevers, severe polyarthralgias (virtually always present), HA, myalgias,
conjunctivitis and maculopapular rash, lymphopenia, thrombocytopenia and elevated liver
enzymes. Management is supportive care (self-resolved in 7-10 days), development of chronic
arthralgias, which may require methotrexate in approximately 30%.
196. Diagnosis of MS- done with MRI of the brain and spine. This may show avoid-shaped
periventricular white matter lesions. Lumbar puncture can confirm the diagnosis in equivocal
 case and may demonstrate oligoclonal bands and an elevated IgG index. Treat exacerbations
with oral and IV corticosteroids (equal efficacy) but depends if it is severe or not.
197. Beta inferno- aka glatiramer acetate is indicated for chronic maintenance therapy in patients
with relapsing-remitting MS as they decrease the frequency of relapses. There is an increased
risk of assisted delivery (eg, vacuum, forceps) and C-section compared to non-MS patients.
198. MS muscle cramp treatment- baclofen or tizanidine. Amantadine can be used for fatigue.
Anticholinergics such as oxybutynin and tolterodine can be used for urge urinary incontinence.
199. Acute UC flares- get an xray to rule out toxic megacolon and CT scan can be used for early
detection of complications. Treat with steroids (glucocorticoids) and not 5-aminosalicylic acid
compaints in acute flares as this can worsen symptoms.
200. ABIs- <0.9 is abnormal, 0.91-1.30 is normal and >1.3 suggestive of calcified & uncompressible
vessels; additional vascular studies should be considered.
201. Achalasia vs Stricture- Patient presentation might hint at GERD in which stricture is a
complication of GERD. Achalasia typically presents with difficulty with water & food.
202. Tourette treatment- psychotherapy and or medication. Habit reversal therapy (HRT), a form of
CBT, is most effective non-pharm treatment. First-line is first generation antipsychotics such as
fluphenazine, pimozide, haloperidol, however, 2nd-gen such as risperidone and aripiprazole are
typically preferred due to lower SE profile. Other treatments include alpha-2 adrenergic
receptor agonists.
203. Acute hemolytic transfustion reaction is a life-threatening rxn from transfusion of mismatched
blood (ABO mistatch). Patients rapidly develop fever, flank pain, hemolysis, oliguric renal failure,
and DIC within an hour of transfusion. Treatment is stopping transfusion nd treat with normal
saline (not Ringers or dextrose) to treat the hypotension and prevent renal failure.
204. UTI in <24mo old- first-time febrile UTI should be treated with >7 days of ABX followed closely
for any recurrence. Renal and bladder US should be done to evaluate for any anatomic
abnormalities. Voiding cystourethrogram is indicated in children with abnormal US or those with
recurrent infections.
205. Pheochromocytoma- triad of episode HA, sweating and tachycardia. May have family history or
individual is young and has HTN or refractory HTN. Measurement with 24-hour fractionated
urinary metanephrines & catecholamine levels is one fo the preferred scnreening tests for the
biochemical diagnosis of pheochromocytoma. If test are normal, recheck during a spell. If
levels are increased (2-3x nl limit) then get a CT or MRI of abdomen. If positive, get surgical
intervention, genetic testing, alpha and beta blockade prior to surgery. If CT/MRI is negative, get
further imaging with MIBG scan, octrotide scan, whole body MRI or PET scan. If patients become
hyptertensive due to catecholamine release due to ET intubation or adrenal gland manipulation,
treat w/ IV nitroprussive, phentolamine or nicardipine. If patients are hypotensive due to long
acting alpha blocade (phenoxybenzamine) then give normal saline (unless unresponsive, then
give pressors). If they become hypoglycemic from insulin secretion after tumor removal, give IV
dextrose and for cardiac tachyarrhythmias, give IV lidocaine or esmolol.
206. Sudden onset hyperglycemia in a patient receiving TPN should lead to suspicion of sepsis.
207. ASD- patients w/ unexplained right atrial or ventricular dilation should be evaluated for
possible ASD. Cardiac auscultation in patients with an ASD (w/ large left-to-right shunt & normal
pulmonary artery pressure) typically reveals a characteristic wide and fixed-splitting of the 2nd
heart sound.
208. Unilateral headache & horner syndrome- should be considered a carotid artery dissection until
proven otherwise. Head and neck vasculature imaging is the initial diagnostic modality of choice.
209. Gastric bypass surgery- causes malabsorption in a majority of patients. Patients will require at
least 2,000-3,000 IU/day of cholecalciferol (vitamin D3) to maintain normal vitamin D levels. B1,
B12, folic acid and iron, calcium and trace minerals should be supplemented also.
210. Treatment of Allergic bronchopulmonary aspergillosus- Systemic steroids are mainstay during
acute exacerbations. Antifungal therapy with either itraconazole or voriconazole should also be
considered.
211. Maternal hyperglycemia may result in excessive glycogen deposition in the fatal myocardium.
This causes fetal hypertrophic cardiomyopathy & possibly CHF.
212. Hepatic adenoma- benign epithelial tumor of the liver seen primarily in young women on OCP.
Usually discovered incidentally but they can grow large and cause episodic abdominal pain,
rupture and.or hemorrhage. CT scan will show well-demarcated lesion in the right lobe of the
liver that shows peripheral enhancement with IV contrast (early phase). If <5cm, it is often
managed conservatively and discontinue OCP. Larger ones may need to be removed. They dont
progress to malignant but AFP levels are typically required.
213. PMS/PMDD- SSRIs are first line
214. Orthostatic proteinuria- common cause of proteinuria in adolescents. Usually only mild amount
but diagnosis can be made by split (day & night) 24-hour urine collection showing elevated
daytime but normal nighttime protein excretion rates. No further treatment or workup req.
215. Anti-dsDNA and complement levels can be used to monitor the disease activity in SLE patients.
ANA and anti-smith titers are not used to monitor the disease activity.
216. PCP intoxication (NMDA receptor antagonist) and symptoms include agitations, anger, bizarre
behaviors, nystagmus (horizontal, vertical or rotary nystagmus). Benzodiazepines are used first-
line and physical restraints may be required.
217. HIV vaccines- should receive pneumococcal vaccination (13 valent and 23 valent in series).
Most patients with HIV should also receive hep a and b if no documented immunity.
218. HA (acne inversa)- mild cases can be treated with topical abx such as clindamycin. Moderate
cases with sinus tracts and scar require oral abx (tetracycline preferred). TNF-alpha inhibitors
such as infliximabj and wide surgical excision.
219. Thrombotic thrombycytopenic purpura- decreased ADAMTS13 level leading to uncleaved vWF
multimers leading to platelet trapping and activation. Can be acquired (autoantibody against
ADAMTS13) or hereditary. Clinical features include hemolytic anemia (increased LDH, dec.
haptoglobin, elecated indirect bilirubin) with schistocytes. Thrombocytompenia causing
increased bleeding time but normal PT/PTT. Sometimes may have renal failure, neurologic
manifestations and fever. Management is plasma exchange.
220. Nonbacterial prostatitis tx- Sitz baths and anti-inflammatories.
221. HTN after kidney transplant- can be 2/2 renal artery stenosis. This leads to renal hypoperfusion
due to RAS leads to RAAS system that in turn causes HTN & maintains GFR. administration of an
ACE-inhibitor lowers the angiotensin II level acutely, leading to a decrease in GFR (by >30%) and
acute kidney injury (rapid rise in creatinine). RAS should be suspected in transplant recipients
with resistant hypertension, flash pulmonary edema, or progressive loss of renal function.
222. Otitis-conjunctivitis syndrome- typically caused by nontypeable H influenzae. Signs and
symptoms are concurrent otitis media and purulent conjunctivitis.
223. Malignant otitis externa- granulation tissue is hallmark and tympanic membrane usually intact.
Pseudomonas aeruginosa is usually causative agent. Treat with IV ciprofloxacin then switch to
PO for 6-8 weeks. Can also treat with anti-pseudomonal penicillins such as piperacillin or
ticarcillin with or without aminoglycosides or 3rd gen cephalosporin such as ceftazidime.
224. TB meningitis- causes 2-3 weeks prodromal symptoms followed by signs of meningeal
irritation. Suspicion is often raised in patients with choroidal tubercles, basilar meningeal
enhancement and characteristic CSF eval (elevated protein 100-500, low glucose <45,
lymphocytic pleocytosis 100-500 and elevated adenosine deaminase). Patients treated with 2
months of 4-drug therapy (isoniazid, rifampin, pyrazinamide & either a flurorquinolone or
injectable aminoglycoside) followed by 9-12 months of isoniazid + rifampin. Give steroids also to
reduce morbidity and mortality.
225. Subphrenic abscess- typically develop after 14-21 days after abdominal surgery. Clues include
recent surgery, swinging fever, and leukocytosis. Cough and shoulder-tip pain may be presenting
symptoms. Diagnosis can be made with abdominal ultrasound.
226. Ulcer grading
a. 1- nonblanchable erythema of intact skin. 2. Superficial ulcers causing a partial thickness loss
of the epidermis, dermis or both. 3. Deeper ulcers causing a full thickness loss with damage
to subcutaneous tissue that may extend to, but not through underlying fascia. 4. Very deep
ulcers causing full thickness loss with extensive tissue destruction that may damage adjacent
muscle, bone or supporting structures.
227. How to research an outbreak- case control study is best to investiage an ID outbreak as it
explores the association between exposure and disease.
228. Croup- parainfluenza viral infection characterized by a barking cough and stridor. Mild croup is
treated with humidified air and corticosteroids; moderate to severe croup is treated with
corticosteroids plus nebulized epinephrine.
229. Reactive arthritis- may develop 1-4 weeks within chlamydia infection. Circinate balantis is an
extraarticular manifestation of ReA that is painless, resolves after several months and is not
associated with inguinal lymphadenopathy. New-onset ReA in pts w/ hx of chlamydia infections
should prompt repeat testing for chlamydia. Test NAAT of urine. Treat with abx and naproxen.
230. Preterm labor management
a. 34-36 6/7- betamethasome, penicillin if GBS + or unknown.
b. 32-34- betamethasone, tocolytics (nifedipine- ccb), pen if GBS + or ?
c. <32 betamethasone, tocolytics, mag sulfate or Pen
231. Sarcoidosis- higher prevalence in AA, Puerto Ricans, Irish and Scandinavians. Involves the lungs,
peripheral and mediastinal lymph nodes, liver, and skin although it can involve nervous system,
salivary glands, heart and other organs may also be involved.
232. SLE pts at risk for premature coronary artherosclerosis and CAD. CV events are the leading
cause of mortality in patients with SLE.
233. Prognostic factor for COPD- FEV1 after adjusting for age
234. Tolvapatan- considered in patients with SHF and symptomatic hyponatremia to raise the serius
sodium above 120 mEq/L when other treatments (water restriction) are unsuccessful.
235. Peri-infarction pericarditis (PIP)- treat with high-dose aspirin (635 mg 3x/daily. Good anti-
inflammatory effect while having relatively small effect on myocardial healing and scar
formation. Avoid NSAID use for this reason. Colchicine or narcotic analgesics may also be given.
236. Primary biliary cholangitis- fatigue and pruritic (most common). Inflammatory arthritis,
hyperpigmented skin, RUQ discomfort, xanthelasmata & xanthomata. Elevated alk phos,
positive AMA and live biopsy if AMA negative. Treat with Ursodeoxycholic acid and liver
transplantation in advanced cirrhosis. Patients are at risk for osteopenia and osteoporosis.
237. Antithrombotic therapy with ASAP & warfarin in patients with mechanical aortic or mitral valve
replacement to reduce the rates of stemtic thromboembolism. Target INR is 2-3 unless they
have risk factors/high-risk features such as atrial fibrillation, LV dysfunction w/ EF <30%, prior
DVT/PE or hypercoagulable & mechanical valves in which case INR should be 2.5-3.5.
238. ABX assoc. w/ C diff- fluroquinolones, penicillins, cephalosporins and clinda.
239. SE of SSRI- GI and activating side effects are common as start of treatment but tolerance
develop over several weeks and patients can remain on it which usually gets better. Patients
should continue for 4 weeks. If a patient has an adequate trial lf 6 weeks.
240. Acute chest syndrome- New pulmonary infiltrate on CXR plus >= 1 of the following: increased
work of breathing, cough, tachypnea, wheezing, temp >101, hypoxemia, chest pain. Intial
treatment is ceftriaxzone PLUS azithromycin, IFV, and pain control.
241. Fluid challenge- can help separate prerenal azotemia from ATN. Prerenal (FENA <1%) will have
improved urine output but ATN wont (FENA >2%)
242. Cardiac tamponade- aortic aneurysm or MI infarction, malignancy or radiation therapy,
infection (viral, TB), connective tissue disease (SLE, etc.),. Signs include beck triad: hypotension,
JVD, and decreased heart sounds & pulsus paradoxus (SBP drops >10 mmHg with inspiration).
Diagnosis is made with ECG (log voltage QRS, electrical alternans), CXR (enlarged cardiac
silhouette), echocardiogram (right atrila nd ventricular collapse, plethora of the IVC) which best
confirms the need for immediate invasive management.
243. Cutaneous cryptooccosis- resembles mulluscum contagiousum. Seen in pts w/ AIDS w/ <100
CD4 counts. A small area of central hemorrhage or necrosis is an important diagnostic clue.
Diagnosis made with biopsy.
244. Type I HIT- nonimmune direct effect of heparin on platelet activation and usually presents
wthin the first two days of heparin exposure. The platelet count then normalizes with continued
heparin therapy and no clinical consequence
245. Type II HIT- more serious immune-mediated disorder due to antibodies to platelet factor 4
(PF4) complexed w/ heparin. This leads to platlet aggregation, thrombocytopenia, and
thrombosis (arterial and venous). Platelet counts usually drop >50% from baseline w. a nadir of
30k-60k. Usually presents 5-10 days. All forms of heparin should be stopped and treated with
direct thrombin inhibitor (eg, argatroban, bivalirudin) started immediately.
246. NSETMI/ACS management- dual antiplatelet therapy with aspirin & platelet P2Y12 receptor
blockers (clopidogrel, prasugrel or ticagrelor), nitrates, beta-blockers, statins and anticoagulant
therapy (unfractionated heparin, LMWH, bivalirudin or fondaparinux).
247. Diagnoisis of MM_ monoclonal protein in serum or urine. >10% clonal plasma cells in bone
marrow soft tissie/bone plasmacytoma. End-organ damage (CRAB)- calcium elevated, renal
failure, anemia (usu. Normocytic), and bone pain (usually due to lytic lesions)
248. MM hyperviscosity syndrome- nasal or oral bleeding, blurry vision, neurologic symptoms (eg,
confusion, headache) and heart failure. Treat with plasmapheresis for symptomatic patients.
249. Clozapine- used in refractory schizophrenia and schizoaffective. Associated with neutropenia
and agranulocytosis. Weekly blood tests done during first 6 months then every other week for
the second 6 months and then 4 weeks thereafter.
250. Bacterial conjunctivitis treatment is erythromycin ointment or polymyxin-trimethoprim drops,
however, fluroquinolones are preferred in contact lense wearers due to higher risk for
pseudomonal infection. This can cause keratitis (inflammation of the cornea) but is more
common in contact lens wearers. Keratitis presents with photophobia, blurred or impaired
vision, and a foreign body sensation. Send to an ophthopmologist urgently.
251. Post-exposure HIV prophylaxis with HAART for 28 days is recommended following high risk
exposure. Triple drug therapy is preferred & should be started within 72 hours of exposure.
252. TSH during pregnancy- normal first trimester TSH is 0.1-2.5, then 2nd 0.2-3.0 then 0.3-3 in 3rd
trimester.
253. ACE (esp. captopril) is drug of choice of HTN in scleroderma renal crisis. Addition of IV meds
such as nitroprusside is needed if CNS manifestations or papilledema is present.
254. Meningitis prophylaxis- give rifampin 600mg PO BID for 2 days, ciprofloxacin 500mg PO once,
or ceftriaxone once.
255. Lead intoxication treatment- mild (5-44) no meds required. 45-69 can be treated with DMSA,
succimer. Severe (>70) requires Dimercaprol PLUS calcium disodium edetate (EDTA)
256. Massive PE- causes pulmonary HTN which can lead to acute right ventricular dysfunction,
tricuspid annulus dilation, and functional tricuspid valve regurgitation. Bedside
echocardiography can aid in the diagnosis of acute, massive PE.
257. Vibrio vulnificus- gram negative free living in marine environments. Ingestions of oysters or
wound infection. Increased risk with cirrhosis or hepatitis. Rapidly progressive (<12 hours),
septicemia (septic shock, bullous lesions), and cellulitis (hemorrhagic bullae, nec fasc). Diagnosis
with blood and wound cultures. Treat with IV ceftriaxone and doxycycline.
258. Serotonin syndrome- Serotonergic meds such as SSRI/SNRI, TCA, tramadol, or linezolid. Drug
interactions with MAOI or intentional overdose. Clinical features of mental status change, ANS
dysregulation (eg, diaphoresis, HTN, tachycardia, hyperthermia, vomiting or diarrhea).
Neuromuscular hyperactivity (eg, tremor, myoclonus, hyperreflexia). Cyproheptadine