Cardiology Review Notes

An AWESOME REVIEW OF Cardiac Physiology - Ischemia - Workup of Ischemic heart disease - Acute Coronary syndromes - Complications of Ml - Congestive Heart Failure - Hypertension - Aneurysms - Congenital Heart diseases - Arrhythmias Chart 13-1 Heart Soun ds Open ing Closure Atrial Valves V entricular Valv es Snap Click including M VP loud: • MS • Short PR (WPW) • Tachycardia • Thyrotoxicosis So ft: • MR • Long PR • 1' LVEDP Chart 13-2 Aortic valve A2 Clo ses f irst Pulm onary valve p2 Closes last Physiologic al Split B o t h C l o s e a t sam e t im e Closes much earli e r: • MR, VSD Clo ses much Later: • PS, Pulmonary HTN (Loud P2) • RBBB • ASD Closes much later: • Aortic stenosis • HTN • LBBB ) $3 : Increased flow; • • • • • Chronic MR CHF TR,PDA B en ign in kids an d Pregnancy Awesome Review, Inc.® Copyright 201 4 Do not photocop y without permission Page 547 S4 : Decreased compliance; • Acute M R • HOCM • • • LVH AS Ischemia Pericardia ! frict ion r u b : Superficial scratchy sound best heard when Pt. is upright and leaning forward and deep breath in pericarditis. Pericardia I knock in constrictive p ericarditis is a sharp early diastolic sound (early 3rd sound). �1. Physiologic during Expiration <.: r--- 2.HTN,AS,LBBB Matching A. A2 before P2 B. Single S2 � . ASD C. Paradoxical split __L4. Calcified AS D. Fixed split _£__s.HTN �6. PulmonaryHTN ___6_7. Physiologic split E. Single S2 (soft A2) F. Loud A2 G. Loud P2 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 548 Chart 13-3 Pulses • Aortic Stenosis • HCM • Severe heart failure Pulses Paradoxus: • l..""-':( (. k<NY • Cardiac tamponade SVC obstruction Pulmonary obstructn. ---� Pulsus tardus: r\..ow '('/� pv-Li"L --------:;::. Pulsus Bisferiens: ) vfStro "-< rv> f".. ,-.._�\; "''-'"""" f:l,.:,:fcl I -t..-1[--{J- ) ) ) ) 't Jvf, ()(> .J- L Jc¥ �sp:,...v..:<-: -----....:;. Hypokinetic: ('1\.. � iNfoYC""'- -.iti:J( S l'c;.-c:.. .ux.,.. - { "11 B p lt J;-t. • H i gh output states: PDA Thyrotoxicosis etc • Low output states , Oblt.-..f:.'-'"" �(<..o. p..w,., PGt:.--(' • ) ) l3 f' .L ) • • ) ) , HI\ 1 c....u .... �j ) ) ) Awesome Review, Inc.® C opyr ight 2014 Do not photocopy without permission Page 549 � �y ""'tv p I"<) -1 � p� ciow"'Lc...t Chart 13·4 Auscultation C space (Pulmo ry area) • PS �\ • \ PDA Ap r (Mi a area) s • • MR • • - VSD H OCM p.. R, · Chart 13-5 Palpation lift (heave): RV hypertr hy (MS, P. HTN PS) � rthyro d, Anemia, primary R, AR with nl EF, PDA, VSD) Sustained Apex itt/impulse: LVH (HTN, Dil. Cardiomyopathy, IHD, AR w/ Low EF) �ifid or trifid apical impulse with -7 1-1 0 (A..tv Awesome Review, lnc.e Copyright 2014 Do not photocopy without permission Page 5 5 0 Chart 13-6 Murmurs lll 4 �L.';"- '.!» �\\ t;tW. All Out flow from the ventricles creates Systol ic murmurs �� Sl AV valves: Holosystolic murmur; 52 AV valves: �d.-_ S�JtA.. col.-"( _II_P___ 1 Late systolic murmur·,___M Sec�L<..r¥- �ec t. All in-flow into the ventricles creates Diastolic murmurs AV valves: �� _ ....__ ..._ .... .:..; ....,; ;. ' _ ) ) .______. __ hAV valves: Late -diastolic murmur; ) V valves: MI\4MI\41�� Mid-diastolic murmur; yvt.f; 1.S Early diastolic murmur; p..R., f r<_ Continuous murmur; 1. Pt. with fixed split 2nd heart sound and mid-diastolic rumble. Most likely diagnosis? )¥.' A. ASD Mitral Stenosis ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 551 �rv::;lep�� / 1' A:ft.. t.,..,c.J.. � ��p srtf.;.--J. - Y"CV.�"J S' �-�. f.;, l£1 A"""JI""'"t..« < .!, AI.J �-.�) - S'�::J _ .. Increased volume \ Decreased volu � {Hand Grip)1- Af�LA>"-.11. '2. HOCM .. �� J, MVP "t vV\.: 1 t f1Jd Lo c.t:l (After PVC] ::� � 1' ('Y'.<.U'2 .... ..., � 11 l!r1'5 i"''j J.. .:'f'M� 1' !"'A ( ').. � rv-tL -v i"-�:u.C\s 1' AS H -=>t.M - 1' vJ\. __,. .} vJ\' � J; 1' M.vt f'M..l/ fv'AI.......V Chart 13-7 What happens to murmur during flow? 1' � 1' Flow Murmur; except in HOCM & MVP w What happens to flow in different positions? 1' Flow: • Sitting • Squatting • Leg raising w Flow: • Standing • Valsalva What happens to flow in Respiration? tt --rs f1 Inspiration: 1' Flow to the Right side of the heart. So all Right sided murmurs 1' Expiration: 1' Flow to the Left side of the heart. So all Left sided murmurs 1' Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Pag e 5 5 2 What happens to murmur during handgrip or Phenylephrine? Handgrip increases after load, LV cavity size increases, so All murmurs including MR1', except HOCM, MVP, AS..V pi. What happens to murmurs with amyl nitrate use? �mylnltrate decreases afterload, so its easy for blood to be pushed Into the systemic rirculation. LV cavity size Is decreased. So, • • • ) ) • M R decreases MVP increases HOCM increases Aortic stenosis increases . What happens to murmur post PVC? ost PVC veslume potentiation and decreased afterload, so -7 HOCM & AS murmurs increase -7 MVP decreased 4. What happens to blood that returns to the heart during Valsalva maneuver ) ) ) ) ) A. Increases intrathoracic pressure and increases blood return to the heart vB. Increases intrathoracic pressure and decreases blood return to the heart C. Decreases intrathoracic pressure and increases blood return to the heart Kussmaul's sign Neck vein distension on inspiration • Constrictive pericarditis • Cardiac tamponade • Rt. ventricular infarct A. Normal jugular venous pressure vB· Increased jugular venous pressure ) ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 553 Chart 13-8 Increase Inspiration Decrease TS Right sided murmurs Left sided murmurs Left sided murmurs R ight sided murmurs Standing/Valsalva HOCM, MVP All other murmurs Squatting/Sitting All other murmurs HOCM, MVP Hand grip Others including MR, MVP (Intensity 1') HOCM, AS, MVP (duration w) Post PVC HOCM, AS MVP Expiration ' Matching Standing Valsalva Post-PVC Hand grip ']> l. AS f-- A. 1' 1' 1' w c 2. MR f-- B. 1' 1' w c. w w , J -Jt w -Jt 1' � 3. MVP �4. HOCM D. 1' t1h--�l Jt I IV\.v.. --.5:...., 1' ) ,� -Jt Q6. 16 y/o man presents for routine check-up. Physical exam reveals a murmur at the left sternal border radiating throughout the precordium. here is no change In Valsalva maneuver or respi ration. EKG reveals mild LVH. Most likely diagnosis Is A. ASD _.$' VSD -r M LVl1, NV .. R.v� �""" C. PDA C. t�"' IY\"( 1 ) D. HOCM Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 554 Chart 13-9 I<, V i"j-c.C- .f w""" (J'-U Blood supply of Heart Area supplied Artery RCA LAD -7 -7 II, Ill,aVF -7 V1,V2 Right Ventr -7 Antrero- -7 V2-V4 Inferior *" Posterior -7 Branch) -7 * V3R-V4R S' septal Anterior lntervent. �wJ-oJ )< 'Y� Leads V3- VS -7 Apical/lateral -7 Apical/lateral -7 VS-V6 Circumflex PDA -7 Apical VS-V6 Circumflex -7 High lat I, aVL ,...;) f\ .--� /.... --J V1 Vl.. V.J"-; V:r Vr. VS-V6 Branch/Diag. of LCA ) ) Postr. lntervent. branch Matching �1. Pt. with history of CP has EKG stress study which A. Non cardiac CP reveals depression in lateral leads. Nuclear imaging reveals antero-septal ischemia. Where is the lesion? � 2. 48 y/o woman c/o exertional CP,stress test done. ) Stopped in 5 minutes due to CP and ST depression B. High grade LAD stenosis V4- V6. What is the diagnosis ) ) C. Left main stenotic lesion Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 555 Epidemiology • • • • • • • 900,000 deaths/year 1/3'd of all deaths are from Heart disease Smoking doubles risk of heart disease Increased LDL & total cholesterol risk factor for CAD 1% decrease in LDL � 2-3% decrease in risk of CAD Every 1mm decrease in BP �2-3% decrease in risk of MI. Death rates with heart disease more i n females Risk factors for Atherosclerosis Modifiable Strongest modifiable risk factors for Ml in descending order are • Dyslipidemia • Smoking • Diabetes mellitus • • • • • • Age Male sex Family history of premature CAD [lp(a)] Psychosocial stressors Hypertension Obesity • Alcohol consumption • Diet low in fruits and vegetables • Unmodifiable Physical activity 7. Pt. with no med. history wants advice on decreasing CAD risk. Which one of the ollowlns Is the most importalitt advice. He Is a smoker, hypertensive and LDL of pecreasing cholesterol of 150 SfQuitting smoking A. Controlling BP of 100. 160/90 B. r Acute Coronary syndromes L Chart 13-10 ST elevation -�>� Q wave Ml NSTEMI Non ST ------'�Unstable Angina Elevation Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 5 5 6 Workup for suspected CAD !lS. A middle aged Pt. presents with chest pain, chest discomfort or atypical chest pain. w.t.d 9. If EKG normal. w.t.d QlO. If the above Pt. can walk easily, then Qll. If the above Pt. has COPD, then _ _ _b -7 Induce 'stress' with __'1>o vt.. t_"..;. _rvv. ·� ----- , cLo E� 'D.:.bvti:.-.�"-f. E-GJ.w . y, o woman wltfi vague chest pressure on exertiQn. EKG normal. xerclse stress test with non specific changes. The next step Is ;v."Exercise stress test with imaging A. Cardiac cath. ' I ) I ) ) C. Repeat Exercise stress test if medical therapy fails. If the above Pt. cant walk either because of PVD,amputation, or has non specific ST- T wave changes such as LBBB, LAHB,repolarizing abnormalities,then Persantine Thallium studies or other scintigraphy with sestamibi or teboroxime. 6'b�� 13. Which one o tfiese can unifergo exercise Et(G ) c..B�t..) A. Pacemaker B. LBBB X. RBBB A. Dipyridamole or Adenosine stress test ) vVDrA(/'o'\, re&S testing vB· Dobutamine stress test c.. "L � As ft::'tvvl C. Cardiac cath. D. Clear for surgery ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 557 Who gets gated pool studies or MUGA scan? � In Pts. to determine LVEF and wall motion abnormalities. Decreased LVEF is a poor prognostic factor on MUGA QlS. When NOT to do a stress test? 16. A 45 y/o Type I I OM woman with chest pain. EKG Is negative. he test L EAST likely to be accurate Is A. Persantine thallium test B. Dobutamine ECHO test �· Exercise stress test (-t et � / 1' ,nv, t PP ) P,17. Obese woman with atypical CP undergoes exercise stress test. She stops the test b M.c.«i""-c.l 1'-Jo E KG changes. w.t.d p fter S min. due to fatigue but no chest pain. HR increase� by 50%. L s"' s t:xJ;oJ t1-1 L J A. Observe B. Repeat Stress test later L Adenosine stress or Stress ECHO 18. When Is an exercise stress test considered positive? � Flat or down sloping ST depression>1mm & longer than 0.08 s � If ST elevated, then there is high grade stenosis. 19. When do you stop a stress test? � ST depression >2mm � SBP decrease >15mm Hg � Ventricular tachycardia � Chest pain/ Shortness of breath Poor prognostic factors on Stress test: • >2mm ST depression • Persistent ST depression 5 mins post exercise • Fall in BP > 15mm Hg • ST elevation • Ventricular ectopi/ Ventricular tachycardia • Global ischemic changes Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 5 5 8 Who gets cardiac catheterization/angiogram? � Presence of poor prognostic factor on stress test � Post infarct angina � Unstable angina on medical treatment, still with symptoms or ST depression or troponin positive. Unstable Angina • New onset severe angina < 2 months • Angina at rest • Recent increased frequency • Post infarct angina 20. Pt. with angina controlled on p blockers, ASA & nitrates presents with recent ncreased frequency and now chest pain lasting for >30mlns. KG� ST depression In II, Ill, aVF. Most likely mechanism of chest pain In this Pt. is A. Fixed atherosclerotic plaque B. Vasospasm /Atherosclerotic plaque with intermittent rupture and thrombolysis 21. A Pt. with history of chronic angina controlled on ASA and nitrates with increasing requency of angina. w.t.d l ) 2. Above Pt. now on ASA, Nitrates (with 12 hr. nitrate free Interval) and P blocker with ncreasing frequency of angina t.d • • � Check c.r3c.. for anemia OR ) ) (increased HR-7 ischemia) 23. Above Pt. with low Hb and E KG reveals ST depression. PRBCs transfused, w.t.d ,w.kA...&. A. Observe B. Colonoscopy � Coronary angiogram D. Heparin 4. Pt. on ASA, Nitrates, p blockers, statin for high cholesterol. b normal and N O signs of Infection or stress w1th Increasing episodes of angina on xertion. Angiogram reveals multivessel disease not amenable to revascularlzation. est management? (Decreased frequency of anginal episodes and improved exercise tolerance) Awesome Review, Inc.<!> Copyright 2014 Do not photocopy without permission Page 559 Q25. In a Pt. with Chest pain. ST depression present � L MV H c ("" H.<pc.,;r.) +- A &A. --------� 8P Zb j 3 A ;1"\�b;W,. � cl..o p; d-o �....e. L 26. I f Angina or ST depression persists with or without troponln (+). 27. Pt. had stopped ASA because of PUD 2 mths. ago. He was started on PPI. ow Pt. presents with chest pain. W.t.d vi(' Start ASA --------� B. Don't start ASA P,28. A 45 y/o man, otherwise healthy, non-smoker, no diabetes, presents with new pnset chest pain more than half hour duration while shoveling snow. n the ER � EKG with no changes. w.t.d 29. I n the above Pt., next day, cardiac enzymes negative, troponln negative, NO EKG hanges. w.t.d 30. A 65 y o man, woke up •arlv. AM with severe retrosternal chest pain lasting 40 Ins., with sweatlns and dlaphor-esls .. Jn �Eft� EI(G reveals ST depression and T wave nverslon. Pt. Is started on ASA, l.v nitrates, � blockers, LMWH and spllb/llla inhibitors. nglnal pain resolves, but 24 hrs. later, ST depression still persists. This represents A. Non specific ST-T wave changes A. Silent ischemia C. EKG artifact 31. The most appropriate diagnostic step for this Pt. Is A. Reassurance B. Exercise Stress test C. Persantine thallium test �· Coronary angiogram 32. If angioplasty was done lmmedl�tely In this Pt. What has It shown? Y, Decreased recurrent ischemia at 6 mths. A. Decreased M l c.l-.� st�� \ M(,{: <•l Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission 1:;c c:v..� ......, ;J � C<l\.f."P w-e_, c tvo ,.,,,,,f ..:c .. bet� iJ'�� Page 560 33. Multislice computed tomography is helpful to evaluate chest pain in what group of Pts.? ' !k" Exclude diagnosis in low risk Pts. B. Exclude diagnosis in high risk Pts. ) ) ) ) Exertional dyspnea without chest pain in a Pt. may represent an anginal equ ivalent in the absence of pulmonary disease. It is most commonly seen in Pts. with • Diabetes mellitus • Women "(< • Elderly • Post CABG Pathogenesis of SOB: lschemia-7 increased LVEDP-7 Pulmonary edema. ) Diagnosis by -7 Empiric NTG or Stress test or Radionuclide studies. ) �34. A 65 y/o has a murmur MR during exercise and disappears post exercise. ) ) ) ) ) ) ) ) �4 (+) ECHO reveals mild hypokinesia and ejection fraction Is 60%. fv1ost likely etiology Is //( Ischemic B. HOCM C. Infiltrative process D. Normal �35. 46 Y/O man wltti cliest paln-lasting-15 mlns. l n ttfe ER cfiest pain Is resolved - . �R I s 72/min a n d B P I s 118/76. EKG reveals n o S T elevation, only deep T wave inversion rom Vl to V4. This represents {Wellen's syndrome/LAD T-wave inversion syndrome) "' w.t.d for the above Pt.? c'"" �� <{� t. w�e&:.J 36. The LEAST likely to be true In the following Pts. with O M A. CAD lesions are proximal B. CABG is better than PTCA in Pt. with CAD C. OM Pts. are more likely to have silent ischemia D. Among diabetics, more women than men, die of CAD E. Diabetics are more prone to CAD than non diabetics. PTCA is better than CABG in Pt. with CAD. y Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 561 37. Pt. presents with CP, EKG negative. hallium Stress test with reversible ischemia. oronary arteriography Negative. Dx: Microvascular angina 38. Elderly man with history of syncope. EKG on presentation normal. e feels dizzy after dinner. EKG shows ST depression in II, Il l and aVF. epeat EKG after 15 mins Is normal. Dx: Post prandial Ischemia. w.t.d Q39. The LEAST likely to cause ST elevation Is --------�--� A. Transmural Ml B. Left ventricular aneurysm post Ml -1 C. Acute pericarditis D. Prinzmetal's angina \K.' Unstable angina G� 40. Young man brought to the ER with severe che$t pain. EKG shows ST elev.at1ons and I is diagnosed. This Is most likely caused by which drug. A. Heroin JY. Cocaine C. Phencyclidine 41. Best management for above Pt.? ../( PCI B. Oxygen C. tPA D. p blocker Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 562 Troponin • Positive in 3-6 hrs after Ml • Peak i n 10-25 hrs • Return to normal in 5-15 days CPK-MB • positive by about 3-8 hrs • Peaks by 10 -36 hrs • Returns to normal by 3 days LDH • • ) ) ) • Positive in 8 to 18 hrs Peaks in 2-3 days Returns to normal in 6-10 days Myoglobin: (0-85 ng/ml normal) • increases immediately and peaks in 1 to 4 hrs and normal in 24 hrs. 42. Pt. with chest pain, ST elevations and troponln elevated. /p tPA, ST resolve, chest pain resolved. ext Blood draw Troponln much more elevated. w.t.d ?----�----------�-------- ) ) ) ) ) ) ) • Pts. who are reperfused will have a faster peak and a higher peak of troponin levels than those not successfully perfused. 43. Pt. presents with acute chest pain with ST elevation. PTCA Is done. ext day has chest pain. Which Is the best marker to diagnose M l ? Troponin B. LDH C. CPK 0Y. Myoglobin A. �44. A 65 y/o man admitted with pneumonia to the MICU on IV a ntibiotics. E KG reveals normal sinus rhythm. Troponln Is 1.3 ns per ml. What to do? Low level troponins can be seen in • CHF • Critical illness • LVH • Coronary vasospasm • Pulmonary embolism • Chronic kidney disease ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 563 45. Pt. presents witll chest pain an low blood pressure. You suspect right ventricular nfarct. Next diag nostic step? �----��------------------------------------------� -7 f< t Si c)..ul. E-l(.� l"v' R I) 3 R. R V� ((. Acute Ml • Q wave Ml and non Q wave Ml, both have similar long term survival • Always admit Pt. with new onset classic chest pain, which is relieved by sublingual NTG, even if Pt. is young or EKG is normal. • PTCA better than TPA • Thrombolytic therapy not given for non-Q wave MI. Instead use, gpllb/llla inhibitors, just like for Unstable angina or ST depression. Indications for Thrombolysis: • Chest pain typical for infarction > 30 min. with LBBB • ST elevation 1 mm in two contiguous leads • <12 hour post Ml • Pt. > 2hrs away from PTCA center and NOT in shock Contraindications for Thrombolytic therapy Absolute: • Previous hemorrhagic stroke • Other CVA events< 1 year • Intracranial neoplasm • Active internal bleed Relative • CVA > 1 year • Recent internal bleed or major trauma <2-4 weeks • BP >180/110 • Pregnancy • Active peptic ulcer disease Indications for PTCA (PCI or Angioplasty) Acute ST elevation Ml • ST elevation with chest pain > 12 hrs • Ml with shock and Pt. is< 2hrs away from PTCA center &<75 yr • STEMI post CABG Pts. • If tPA contraindicated • True or False about Clopidogrel A. It is a Thienopyridine ADP Platelet inhibitor T - B. If Pt. with Ml is allergic to ASA, then use Clopidogrel C. In Pt. going for PTCA, Clopidogrel should be used D. In Pt. going for CABG, Clopidogrel should NOT be used Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 564 Q46. When is CABG better than PTCA? � Left main disease � Three vessel disease with decreased LVEF � Two vessel disease with proximal LAD & decreased LVEF � Diabetes mellitus with CAD • Mortality rate for CABG = PTCA 47. Pt. with CAD s/p PTCA with stent placement. What meds. upon discharge A. ASA $.ASA + Clopidogrel C. ASA + Warfarin ) 48. A 60 y/o Pt. undergoes CABG, couple of months later he Is (lolng fine, 6ut as problem with keeping accounts occasionally. This represents \,f( Neurocognitive defect B. Early onset of dementia ) ) ) ) ) ) ) Q49. Pt. with retros1ermil.chest pain > lllour, alapnoretic. EKG-+ LBBB, ST elevated In anterior leads. Old EKG not available to comp�re. Creatinine kinase and troponin pending. w.t.d SO. Pt. with chest pain ST elevation in anterior leads. s p tPA with BP of 90 60. hrs. later, ST elevation in lateral leads. BP systolfc drops to 80 and Pt. Is short of breath. N o e w murmurs at LSB o r apex. XR-+ pulmonary edema. w.t.d next 51. Above Pt. had PTCA done and is allergic to ASA. w.t.d? 52. Elderly Pt. with IWMI and receives tPA. Pt. becomes hypotensive and HR is 8/min. w.t.d Q53. HR Is 74, BP stable. Pt. then becomes confused, both pupils are dilated. What Is the diagnosis? Y, Anticholinergic delirium A. Hem morhagic stroke Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 565 Matching �1. Pt. presents with 13 hrs. of chest pain. She had taken antacids without relief. EKG reveals ST elevations in anterior leads. BP 140/80. She is given ASAto chew, i.v nitrates, i.v� blockers & i.v morphine. The closest PTCA facility is at least an hour away. w.t.d �2. A 60 y/o man presents to a small community hospital with chest pain and is found to have an anterior wall MI. The nearest tertiary center is 2 hours away. What is the best management? A. tPA now B. Transfer & do PTCA C. tPA & then transfer to do PTCA Q54. Pt. admitted with Ml, 3 days later with chest pain relieved with NTG. W.t.d 55. A Pt. has a cardiac cath. 2 days later, presents with pain In the right groin. xam reveals an erythematous and pulsatile mass. w.t.d ? KUitrasound B. i.v Heparin 56. Pt. with Ml, 9 days later with persistent chest pain, worse on deep breath. ericardlal friction rub. XR with effusion. KG: diffuse ST elevations concavity upwards. Tx:-7 (>,J'A Factors shown to improve survival in Ml • • • • • • • • • PTCA Thrombolytic therapy after Q wave Ml �blockers ASA ACE in EF<40% Stop smoking Statins Warfarin for 3-6months in large AWMI with Low LVEF lCD {40 days later) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 566 57. Pt. with CP with ST elevations i n II, Ill, avF. II the following are true EXCEPT A. ACE inhibitor i mprove survival B. � blockers improve survival C. Statins improve survival _.{Y." Calcium channel blockers improve survival 058. Pt. presents with chest pain. iagnosed with AWMI and treated in CCU without complications, EF 30%. pon discharge, what meds? --------� • • • • • • • ASA Clopidogrel � blocker ACE inhibitor Warfarin 3-6 months HMG Co A reductase inhibitor lCD (40 days later. In the meantime, if high risk for VT, make them wear cardiac defibrillator vest) �59. 65 y/o with angina, had CABG 2 yrs ago. HR is 72/mln, BP 124/84. No Diabetes. LVE F normal. He Is currently on ASA, � blockers & Nitrates. Which drug will decrease the likelihood of another cardiac event? --------� i ) ) ) A. Angiotensin receptor blockers B. Calciu m channel blockers C. Digoxin / ACE inhibitor (Ramipril) 60. A Pt. ad an M I . He was stabilized. A few mths later, Stress test was abnormal so e underwent Cardiac Cath. which shoWed 7096 stenosis tn Left Circumflex artery. e Is started on Aspirin now. hlch of the following will Increase his Ions term survival: A. PTCA A.Start HMG-CoA reductase inhibitors C. CABG ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 567 Chart 13-11 Complications of M l Mechanical ruptures Arrhythmias <48 hrs: • V-tach t "'rt • NSVT • Blocks • • ....,_...\t.') .... tp pc.1 ·,s,, • � Papillary muscle rupture-? Ac. MR Septal rupture-? Ac. VSD Free wall rupture-? Tamponade >48 hrs: • V-tach t drt. sc.c...... t1 s ) _. t,�c s�"t'"'""-'e..�. • NSVT u.��vc.,�:;.,...._ _. �c�.<ctu-.. � 1:..c..l) Ventricular Arrhythmias during Acute Ml • VI �ooott JI'Bf _, s-r�-w Ventricular ectopy or Non sustained Ventricular tachycardia during acute M l should NOT be treated. Cl.v(..., 1/ c.tt • V-Tach & V-fib occurring within 24 hrs after Ml are independent risk factors for in house mortality, BUT not risk for subsequent mortality from arrh thmia after discharge. • These DON'T nee ong erm an arr y m1c t erapy. 61. Pt. presents with ctlest pain. EKG reveals a M l and Is treated with tPA, Heparin, Nitrates blocker and ACE Inh ibitor. ithin 24 hours Pt. develops a non sustained Ventricular tachycardia of <30 seconds. w.t.d Q62. Mechanism of reperfuslon arrhythmias? -7 Triggered activity; change in cardiac frequency due to accumulated calcium 63. Above Pt. develops sustained Ventricular tachycardia w.t.d If unstable-? c.o.��· v<..r.i... If Stable -7 Atvvioctv""'<w.t.d next -7 ___, � f'.L}Ct_ c. �ole..-""" c�.o.ft_ 64. The above Pt. reverts to NSR and is uneventful. 5 days later, Pt. ready for discharge. oes the Pt. require long term anti-arrhythmic Tx. 65. Pt. with V-tach o r V-flb 48 hrs after M I. No evidence of relnfarction. w.t.d Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 568 This represents independent risk factor for mortality after discharge from ospital. So, after acute treatment w.t.d 66. Q67. Above Pt. had What to do next? 2 discharges from lCD in the past 2 months. Above Pt., fou r months later with 4 shocks on lCD and amiodarone. hat is the best management? --- �68. 69. Pt. with M l with refractive V-tach. w.t.d -7 Adequate oxygenation and correct electrolytes -7 Treat with Amiodarone ) ) ) ) The risk of reinfarction is highest in the first 3 months post infarction, ranging from �o 1.Z2iand declines to less than 5% after 6 months. So recommend elective surgeries 6 months post M I . P"70. A middle aged man clutches his chest and complains o f severe chest pain. n the ER, EKG reveals a diffuse ST elevation with concavity up and PR depression. w.t.d trhe Pericarditis pain resolved. The best medication for prophylaxis Is p11. Pt. with recurrent pericarditis. Treated with NSAIDs & Steroids. �72. If the above Pt.'s CXR shows cardiomegaly or JVD (+) or pulsus paradoxus. W hat is the best test to confirm diagnosis Constrictive Pericarditis Rigid pericardium-7 impaired cardiac filling. Cl.ft: gradual onset dyspnea, fatigue, ascites, Kussmaul's sign positive. Sharp early diastolic sound following S2. Ec. .... � S3 JVP-7 Increased with prominent 'x' & 'y' descent (Square root sign) EKG-7 Normal CXR-7 SO% show pericardia! calcification on CXR. ECH0-7 thickened pericardium, Early diastolic filling of ventricles and pressures >15 and within 5 mm of each other. Swan-7 RA=RV=PAP=PCWP Tx: Pericardia! stripping Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 569 Risk factors: • Post Cardiotomy C AVR. , C Pd.3 C.. ) • Infections: Viral, TB, fungal o Radiation exposure to chest in the past Q73. Most sensitive test to measure pericardia! thickness is ------ 074. Pt. post CABG or AVR 4 yrs. ago, now with increasing shortness of breath for the past 3-4 months. Exam reveals JVD 9 ems, Hepatomegaly and pedal edema. KG and CXR normal. Most likel dia nosis? A Pericarditis B. Tamponade C. Dilated cardiomyopathy True or False about Constrictive pericarditis 1- 1. JVP increases on inspiration T 2. Pericardia I knock also known as sharp early 3'd heart sound can be heard. I ---- 3. ECHO can reveal pericardia! thickening -r 4. CXR can show pericardia! calcification I 5. Treatment is surgical stripping I 6. MRI is most sensitive to detect the thickness of the pericardium. T -- Congestive Heart Failure • Most common cause of CHF -7 Ischemia> dilated cardiomyopathy> HTN, Valvular disease, Congenital HD • Always rule out ischemia in a Pt. with new onset CHF and sudden decompensation in stable CHF. • Most common precipitant of decompensation in CHF. -7 Increased Sodium intake Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 570 Chart 13-12 Congestive Heart Failure Systolic dysfunction E Contractility Problem 1' LVED P Diastolic dysfunction HFPEF E Relaxation 1' LVEF Normal Dilated ECHO Treatment ) • • • ) • ) ) ··! c.-1' Jt>1· ACE lnh . .-, H'JM-1•1,.1... t rJtt-ck � blocker Angiotensin II Diuretics: • Loop • Spironolactone Digoxin Hydralazine + Nitrate lCD & CRT • • • • Candesartan � �blockers Ca channel blockers (long acting) Diuretics 100-250 pg/ml-7 Significant LV dysfunction with compensated congestion 250- 500 -7 CHF with both systolic and diastolic dysfunction -7 Decompensated CHF 500-1000 -7 Severe CHF > 1000 � ) • • ) ) • Hypertrophy BNP (B type natriuretic peptide) is increased in CHF 75. Elevated BNP levels can be seen in A. Left Heart failure due to diastolic dysfunction B. Left Heart failure due to systolic dysfunction C. Right heart failure due to COPD D. Right heart failure due to PE ,A(. All the above 76. A 60 ylo woman is evaluatea for a 3 month history of sliortness of breath on xertion. She does not complain of chest pain. Her past medical history is significant or hypertension, type 2 diabetes and hypercholesterolemia, for which ·o s. t /1{ TTE B. TEE Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 571 77. Echo with inferior wall hypokinesia and an ejection fraction 40%. hat is the best management? A. Dobutamine stress echo /. Coronary angiography 78. A 50 y/o man presents to the ER with Increasing shortness of breath for the past days. e has a past medical h istory significant for hypertension. ody mass Index is 40. JVP Is 14 em. !lateral basal crackles are heard. An Sa Is heard. !lateral pitting pedal edema present. NP Is 160pg/ml hat Is the appropriate management for this Pt.? � Intravenous furosemide A. Intravenous heparin shown what? 79. BNP levels serial monitorin ghas --� --------------------------------------� \JI("oecreased mortality in Pts. aged less than 75 years B. Decreased mortality in Pts. more than 75 years C. No change i n mortality Q80. Pt. presents with exercise Intolerance and dyspnea on exertion. Exam reveals: JVD 10 ems, few basal rales, Sa (+). Pt. Is diagnosed with CHF. rdlac enzymes and troponln are normal. Pt. Is treated wftb diuretics and Pt. sets better. ransthoraclc ECHO reveals EF of 35%. hat do ou rescrlbe at the time of dlschar e? A. � blocker viY. ACE inhibitor C. Angiotensin receptor blocker Q81. In the above Pt., creatinine went up from 1.1 to 2 and otasslum went up from 4 to 5.6. What is the best management? ------- 82. Pt. with CHF on lisinopril Smg /day and furosemide 40 mg p.o qd, presents for ollow up visit to office. Still with fatigue. JVD 12 ems, bilateral scattered rales (+), . ltting pedal edema (+). How to manage this Pt. with CHF. --------� -7 Maximize lisinopril dosage and start i.v (loop diuretic) furosemide. (no difference between bolus vs infusion; dosages as well) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 572 83. Can you start P blocker In the above Pt.? -7 Not yet! But once the volume overload is corrected, then start low dose� blocker and titrate up the dose. 4. Above Pt. Is being discharged after treatment for acute decompensated CHF. hat is the most appropriate managemeAt at this time? A. Visiting nurse to check in 1 week � Follow up Appointment in 1 week C. Follow up Appointment in 2 weeks ) 85. The above Pt. is taking lisJnoprll lOmg dally. What will you start next? ...X: Carvedilol B. Spironolactone ) �0/C K supplement and start low dose spironolactone Il ) ) ) B. Start low dose spironolactone C. Spironolactone should not be used Y, Hyperkalemia A. Renal failure A. 0/C Spironolactone and start Eplerenone ,.AY. Biopsy C. Reassurance Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 573 91. A 58 y/o woman presents with CHF and she takes lasix 20 mg, Lisinopril 5 mg aily, Atorvastatin 20mg daily, Carvedilol 6.125mg twice daily, spironolactone 25mg (jaily and ASA 81 mg daily. JVP is 12 em of water. Lungs revealed mid-lung crackles. 3+ here is 2+ pitting pedal edema bilaterally. KG reveals QRS of 0.13 sees. Echo reveals an ejection fraction of 35%. Pt. was begun on i.v furosemide. What is the best management for this Pt.? /. Optimize medical treatment B. Start lCD with Cardiac resynchronization therapy Q92. 1 week later, above Pt. presents for follow up. Stle is taking Lisinopril 30 mg daily, J\torvastatin 40 mg daily, Carvedilol 25 mg twice daily, spironolactone 25 mg daily and J\SA 81 mg dally. Lasix was increased to 40 mg and then to 60 mg dally. VP is 10 em of water. Lungs revealed crackles are bibasilar only now. 53+ EKG reveals QRS of 0.13 sees. Echo reveals an ejection fraction of 35%. What is the best mana ement? �----------------------------------------� \..k:' Start Metolazone 30 mins prior to Lasix B. Start lCD with Cardiac resynchronization therapy 3:,----- 93. months later, above Pt. presents with CHF is taking Lisinopril 40 mg daily, torvastatin 40 mg dally, Carvedilol 25 mg twice daily, spironolactone 25 mg dally and �SA 81 mg daily, lasix 60 mg dally with metolazone 30 mins prior. G reveals QRS of 0.13 sees. cho reveals an ejection fraction of 35%. hat is the best management for this Pt.? S A. Optimize medical treatment Y,Start lCD with Cardiac resynchronization therapy � Optimization of medical therapy with atleast three month before lCD placement Q94. A 54 y/o man with chronic congestive heart failure. Echo reveals an ejection raction of 35%. What target blood pressure will prevent any coronary event in this Pt.? Less than 140/80 B. Less than 130/80 A. ,£. Less than 120/80 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 574 95. A 76 y/o woman presents with complaints of progressive shortness of breath for he past months. Her past medical history significant for hypertension. ungs revealed blbasilar crackles. S1-S2 heard, no murmurs. here Is pitting pedal edema bilaterally. cho reveals LVH and an ejection fraction of 65%. hat is the best management for this Pt.? 2 1+ A. Start digoxin A. Start candesartan C. Start calcium channel blocker Q96. Apart from hypertension, In which of the following conditions will you come across Increased left ventricular mass? /.Diabetes mellitus B. Hyperlipidemia C. Older age D. Atrial fibrillation J. Obesity J) Q97. Which Pts. have a higher incidence of heart failure with preserved ejection fraction [HFPEF]? ) A. Men age more than 75 with systolic heart failure _w.- Women age more than 75 with systolic hypertension C. Men and women with diabetes D. Younger men CHF are • 53 • Hyponatremia • PCWP >12 • PAP> 50 • Peak 02 uptake< 14ml/kg Drugs that improve mortality in CHF • ACE inhibitors • Angiotensin II blockers • Spironolactone (low dose) for NYHA Ill or IV • Hydralazine + Nitrates • �blockers Poor prognostic factor in ) ) ) What drugs DON'T improve survival Digoxin: improves functional capacity decreases hospitalizations Calcium channel blockers Furosemide (Lasix®) • • • ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 575 98. A 55 y/o woman is brought to the E R with onset of severe substernal chest ain which has been present for the past 2 days. It is increased with breathing. he recently lost custody of her grandchild. VP is normal. Heart rate 120 per minute. ungs are clear with summation gallop. roponin level is 36 ng per ml. KG reveals 1 mm ST segment elevation in leads V1 to V4. cho reveals anterior wall and lateral wall hypokinesis with ejection fraction of 35% nd ballooning of the left ventricle. coronary angiogram shows no coronary obstruction. hat is the most likely diagnosis? -----------------------------------------� -J A. Dressier's syndrome B. Cardiac tamponade �· Takotsubo cardiomyopathy D. Left ventricular aneurysm 99. Can you use ACE Inhibitor in asymptomatic Pt. with left ventricular dysfunction? Q100. ACE inhibitors are useful for all the following EXCEPT A. Scleroderma renal crisis �· After acute myocardial infarction C. Congestive heart failure D. Diabetes with microalbuminuria E. Hypertension with 54 (+) F. Viral myocarditis �Pregnancy H. lg A nephropathy 101. In a Pt. taking ACE Inhibitors, the LEAST likely you would follow Is A. Blood pressure B. Serum K C. Serum creatinine vt1.' Serum calcium Side effects of ACE inhibitors Include • Cough: due to increased bradykinin • First dose syncope • Angioedema and laryngeal edema • Decreased constriction of efferent arterioles� Renal failure in marginal Pts. • Neutropenia "<4A<\;A<:..h""' •J @�je.-U\.1- Which drugs not to be used in CHF Pts. • NSAIDs, Glitazones ins_ulin sensitizing agents, calcium channel blockers, Cilostazol """"Y--'�� Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 576 0102. Combination of ACE l n h. and ARB together has shown what? A. Less proteinuria, no effect on kidney Y, Less proteinuria, poorer renal outcomes Q103. A 70 y/o woman presents to ER with an episode of pulmonary edema. �he has had two earlier similar episodes. The pulmonary edema responds well to l.v aiuretics. Hx of HTN with current blood pressure 160/95. Lungs are clear. She has no chest pain. There Is a systolic murmur I I/VI at apex radiating �o axilla. ECHO reveals mild LVH and EF of 60%. Most likely etiology is A. Systolic dysfunction B. Increased sodium intake C. Anxiety Y, Coronary artery disease Q104. 65 y/o woman presents with new onset CHF. Loud S4 and soft S.s (+) �VD 12 ems. Few basal rales. EKG reveals bundle branch block. ECHO reveals EF of 25%. Pt. is started on i.v furosemide and � .v ACE inhibitor and her symptoms Improve. What is the most appropriate next diagnostic test. ReReat ECHO A. Exercise stress test with perfusion B. Pulmonary function tests ,)2:': Coronary angiogram . ) l I ) ) Q105. If the above Pt. has three vessel disease. what Is the best treatment . A. PTCA B. Medical therapy Y,CABG 106. Which of the following are Joint commission Hospital core measures for eart failure? >1 correct A. Discharge instructions B. Use of ACE lnh. or ARBs C. Document ejection fraction D. Smoking cessation counselling E. Flu shot Y, All the above Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 577 \ Dilated Cardiomyopathy 'Congestive' Etio: • Alcohoi/Peripartu m/Doxorubicin • Ischemia • Hemochromatosis Tx: • Similar to Systolic dysfunction. • I n severe CHF: inotropic agents such as dobutamine. Restrictive Cardiomyopathy 'Diastolic dys unction' secondary to fibrosis or • Amyloid: thickened septum, refractile on ECHO -7 normal systolic function and diastolic dysfunction (early restrictive filling) CHF & Arrhythmias. • Hemochromatosis • E ndomyoca rdial fibrosis Hypertrophic Cardiomyopathy (HCM) • • • • • • • • Dysfunction is -7 111 �st.�\-: L Autosomal dominant 30% Mortality rate 4%/year Sudden syncope, death after vigorous exercise . Sudden death is most frequent in familial form in a young Pt.. Chest pain, dyspnea also occur. �J-ic.l J i,.;<f-t J... Carotid & peripheral pulses with brisk upstroke, bisferiens pulse. (usually no radiation to the carotids) Early systolic Murmur at left lower sternal border increases with decreased flow. (i.e standing, valsalva) Etio: Asymmetric hypertrophy of left ventricle -7 s '1f'N"'U�L·L Dx: -7 with Ec..Jv::> h.:J P•, t,.,.P ":J H0 C.M---....- Ai:I-. L e t�.r �t Tx: 13 blockers improves symptoms. Ca channel blockers for chest pain. Defibrillator, Septal myotomy. Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 578 0107. Do HOCM Pts. need endocarditis prophylaxis? Poor prognostic factors in HOCM • Ventricular tachycardia • Age <30 • Septal thickness >3cms • Syncope • Failure to increase BP by 20 mm upon exercise • Familial form and family history of sudden death. True or False about HCM 1. 18 y/o basketba ll player with sudden death after vigorous play. Autopsy may reveal hypertrophied interventricular septum. - -- 2. Pts. can present with syncope, dyspnea or chest pain. ) ) 3. Ventricular tachycardia on holter monitor increases the risk of sudden death and these pts. need an lCD. T -r- 4. Murmur i ncreases on standing, valsalva and decreases with handshake and t- sitting. I - T - 'T 0108. An asymptomatic 18 y/o wants to join soccer team and presents for a routine physical exam which reveals ejection murmur & brisk carotid upstroke. CHO reveals 16 mm thickened upper portion of interventricular septum. w.t.d I -7 Can ck How to treat his symptoms: Chest pain-7 � blocker long acting Calcium channel blocker The Pt. doesn't respond to medical treatment. w.t.d 7 Atrio-ventricular sequential pacing or surgical myotomy J If the Pt. has Ventricular tachycardia OR has NSVT on holter & family history of sudden cardiac death. w.t.d Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 579 (AOrtic Stenosi-s) Most common valvular disease in adults Presents with • Syncope (not enough blood to brain), left u ntreated time to death is 3 years • Chest pain (not enough blood to coronaries), left untreated time to death is 3 yrs • CHF (backed up blood), left untreated time to death <2 years 1J1 Signs: • Pulsus tardus, Systolic crescendo-decrescendo murmur at right sternal border radiating to the carotids. • Delayed & Slow carotid u pstroke Signs of severe AS: S4, Paradoxical split S2, late peaking of murmur, ECHO with gradient >50, valve <0.5 sqcms on ECHO. � -- tR ,._.,.;.lA A J' --1 �t e� --- --� -� ---� � u �-� � � � � � _, l - 2 � -� ---� .� � -� � -109. w.t.d i n an asymptomatte- Pt? 3-f .:;r� �J 75 y/o with AS -7 Balloon valvuloplasty prior to hip surgery 'T A V'1. ( TYC.tV cW ...__ (.lro Y'ti ' v t.A.v<. -7 Swan (Cardiac hemodynamic monitoring) during surgery -7 LVH 116. AV malformation With 61 bteetf natated W -7 AS Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 580 Aortic Regurgitation • Present with dyspnea (backed up blood) • Early d iastolic murmur at left sternal border. • Severe cases with Austin flint murmur (mid-diastolic murmur like MS) Tx: Even with severe AR, Asymptomatic & EF >50%, then according to LV dimensions __, End Diastolic Dimension(mm) < 40 <60 60-70 70-75 40- 50 ) ) / End Systolic Dimension(mm) so - ss >55 CHF rate/yr 0% 6% 19% tl''f' >75 w.t.d? ECHO in 12 mths ECHO i n 12 mths fl.!:y> J - c. � � Surgery If EF <50%. with symptoms-7 then Do surgery ) ) � Normal vaginal delivery ) ) ) ) ) B. C-section 118. The best candidate for use of SUderiatl A. Pt. with angina B. Pt. with Aortic stenosis , Y Pt. with aortic regurgitation & preserved LVEF ) ) ) ) ) ) Dx: Mitral Stenosis Complications: Dilatation of left atri u m7At r ial fibrillation-7 thromboembolism & CHF Q120. The reason for using Diltiazem or IS blocker Jn Mitral stenosis: Is 7 to 1' cA;. �tot.:... -PILi":{ �� . Awesome Review, Inc.® Copyrig ht 20 1 4 Do not photocopy without permission Page 581 Mitral Regurgitation .- .,_ -..,. -;,.. Q121. Pt. with llllVI holosystolic murmur at apex, radiating to the axilla. Pt. is asymptomatic or mild dizziness. BP 130/84. HR 86/min. ECHO is done which reveals severe Mitral regurgitation. LVEF is 50%. LV measures 72mm in diastole (nl 37-57 mm). LV measures 51 mm in systole (nl 28-44 mm). 1\ppropriate management is A. ACE inhibitors B. Diuretics C. �blocker J:Y. Surgery - • � · en even thoug)'l asympto -* -7 LV systolic dysfunction. : EF < 60% r -7 Pul. HTN -7 Atrial fibrillation -7 Symptoms � If 122. Pt. with h/o aortic aneurysm is scheduled for surgery is getting a stress test. ecent EKG, PFTs, chest X-ray are normal. During stress test has ST depression in ateral leads and 2/6 s stolic murmur at a ex but 5 minutes after test there is no murmur A HOCM /,Ischemic M R ASD ( Atrial septal defect) -' Secundum defect 70% (NO need for antibiotic prophylaxis} tv\1/P Fixed split S2 (pulmonary valve closes later than aortic valve} Parasternal impulse, prominent 'a' & 'v' wave, mid-systolic murmur at LSB. EKG with right ventricular strain & \partial RBBB. • • • ) • Q123. When to do closure surgery? -7 L} L _, R sh. , .. . ,J > 1· 1 : I Q124. What If the Pt. is asymptomatic and L�R shunt >2:1? --------� 125. What if there is a R -7 L shunt (Eisenmenger's syndrome) -7 NO Surgery in Eisenmenger's syndrome of any defect. It denotes onset of Pulmonary Hypertension. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Pag e 582 0126. What is the best long term management for atrial septal aneurysm? Do you need to resect it? - No I .L ) ) -7 p,: o· r.� ) ) ) ) ) ) ) ) ) � .... "' tt..,..�o �·\..r,.., ) -4; S"t,.!i.., ) IY\ .J R. Incomplete covering of foramen ovale-EY septum primum Incomplete fusion of septum primum Septum primum does not connect to Endocardial cushion -7 S£C.4t'\Jv..ryo.. f\JD P., J'D Ideal candidate for VSD (Ventricular septal defect) • Common in children • Systolic murmur at LLSB, radiating to the precordium • split 2nd heart sound • No endocarditis prophylaxis unless within 6 mths of su rgery • lf L-7 R shunt > 1.7:1, -7 'Do S\N\.� Uj PDA (Patent ductus arteriosus) • Crescendo-decrescendo continuous murmur best heard at the Left parasternal area • (Lt 3'd intercostal space). Soft S3 (+) • Surgery helps at a.ll "';tO • Antibiotic prophylaxis before high risk procedures is wot. needed. Bicuspid Aortic valve , ---� � � ----� � � -� � � -0127. 35 y/o asymptomatic man presents for-routine physical o r -a younger Pt. presents for clearance for competitive sports. Exam reveals brisk carotid upstrokes and an ejection click followed by systolic ejection murmur at base of heart. There is also a II/VI diastolic murmur at left sternal border. w.t.d next --------� If ECHO reveals mild dilatation of left ventricle w.t.d to prevent further dilatation and systolic dysfunction. Awesome Review, lnc.e Copyright 201 4 Do not photocopy without permission Page 583 C.�ll. L•- 6- t Coarctation of Aorta - ex£ "'i' Ito� 3 • Most common associated congen. cardiac abnorma l ity?7 • Bf '- r.J."' -::J"Of w,"tt B.; '-'""" pi &t. Delayed femora l- Brachial pulse or an � bsent femoral pulse. Early systolic murmur. • Persistent HTN after surgical correction • CXR shows rib notching due to collateral vessels. '3' sign present • vc..l vc. · BP higher i n upper than lower extremities • Need for Endocarditis prophylaxis ? 7 No! Marfan's syndrome • Decreased strength & d ilation of aorta with aortic regurgitation and dissection. The best way to monitor 7 '<< (ly.<l.:J EC4..:1 if it reaches 4.5 cms7 G<-h> The best way to prevent dissection l ' IV\. >5.5 cms7 kpav.'�' 128. A Pt. with Marfan's syndrome has ECHO every 6 mths. You have explained 2 yrs. go, that repair should be done If It reaches 5.5 ems. Current ECHO reveals aorta of .3 ems and you discuss the possibility for repair now and Pt. says he will walt another mths and see. W.t.d? dissection in the meantime A right to left shunt7 Eisenmenger's syndrome. The most common presentation of Eisenmenger's is Hypertension BP more important than diastolic BP as CVD risk factor. 129. I n a Pt. with normal BP, after age 18, how often do you screen for HTN ? ...)¥. Every 2 years A. Every year 130. What systolic BP would you aim for In an elderly Pt. with HTN? A. < 170 mm of Hg ....8":" < 150 m m of Hg C. < 130 mm of Hg ...., 1> B P < C5 Diastolic heart failure is more common i n 7 Women > 7 5 w i t h systolic hypertension Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 584 • • • :? HTN with LVH (S4 +) HTN with Renal insufficiency • HTN with Ischemic heart disease • HTN with OM/proteinuria • HTN with CHF • • • • -7 Thiazide d i u retic/Chlorthalidon : 1 c.cfJ. -7 ACE i n h i b itor 1 (>.!?. (] �,... P•t.d Isolated systolic HTN and in elderly -7 Thiazide d i u retics 12.5-2Smg/ ay Mild to moderate HTN HTN post Ml -7 ACE inhibitor I /V�8. -7 � blocker, Ca channel blockers -7 ACE i n h i b itors / �(J -7 ACE inhi bitors, Diuretics, Carved ilol -7 � blocker + ACE inhibitor -7 Losartan (ARB) � HTN with Gout -7 Labetalol, Methyldopa, Hydralazine (NO ACE in h.) HTN with pregnancy Thiazides can cause • Hypercalcemia • Hypoka lemia • Increase levels of Lithium and Digoxin • • ) Hyperuricemia Hyponatremia 131. Does Angiotensin I I blocker induce cough? ) ) ) 132. Pt. on HCTZ 25mg day. BP is still high. W.t.d next? A. Increase HCTZ to 50 mg/day \.-8:' Restrict fluid and salt in diet 133. Pt. w i t h HTN on HCTZ 25mg/day. BP drops from 160 90 to 148/86. Exam reveais s. (+). w.t.d A. I n creased HCTZ B. Do nothing ) ) VC. Add ACE inhi bitor 134. Ma huang causes --KHTN B. D M c:.,·, � � 1' blu.l:'j' �u-. � ...:, 135. 18 v/o woman 170/105. w.t.d next? b I.4.P..:.'J .,_ B 7 1' 6 T --------� L Urine for toxicology B. BP of lower extremities C. Aldosterone level 136. 2 1 y/o Pt. with chest pain, Cocaine + in urine. BP 160/100. . t.d n ext? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 585 Q137. How to prevent chest pain in the future in this Pt.? --------� A . � blocker B. ACE inhibitor � Calcium channel bl o c ke r Chart 13-13 Aneurysms Thoracic Abdominal Symptoms • • Chest pain radiating to back. • Interscapular pain Acute AR murmur Widened mediastinum • f. f Surgery Asymptomatic /' Symptomatic A tv-:1 � 1A-- • • ) s <..tV'- (; C..tv\.. (, cr � H,L.� s� €I('t..'\1<. .r""':J 'j Usually dissecting Abdominal aortic aneurysms treated medically first with f3 blockers & nitroprusside if pain persists, then surgery. t Dissecting Thoracic ortic aneurysms have more serious compl ications, hence straight to surgery. J>'\l _, • .,.'l _ , ., ��c.Wi<- _, ,.. <N.� �""- ) 138. 68 y7o man admitted for URGENT repair of 7.5 em AAA. Pt. with OM, and ncreased cholesterol. Family History of Ml l n father at a e 57. What is the a �No further testing B. Stress test _, S\.'\vM The US Preventive Services Task Force (USPSTF} recommendations for AAA screening. 7 Anytime Smoker Age 65 to 75 man should have abdominal ultrasound screening one time for AAA ONCE in their lifetime. NO screening in women. 139. 73 y/o man chronic smoker with family history of abdominal aortic aneurysm as a negative abdominal ultrasound for AAA. When to do next---ultrasound ? ----� A. 1 year y.No additional US needed B. 6 mths Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 586 Q140. 73 y/o man ex-smol<er with no family nistory of abdominal aortic aneurysm has a small aneurysm on abdominal ultrasound /. Repeat US in B. 141. 6 mths No additional US needed 60 y/o a m n with h/o CAD with severe chest pain radiating to the back. P 190/100. HR 90/min. Decrescendo murmur. ) Dx: Aortic dissection. Best test to Dx: � T t E' ""'1t When endoscopy not available � c T ) """'ti--� t. w.t.d next -7 P blockers + i.v nitroprusside� Sx 142. Aloose/ large fitting cuff of BP apparatus will A smal l/tight cuff will� ove.- e.r�""c..f4- ttL. B f Mise: Porcine valves � No anticoagulation Prosthetic valve� Need a nticoagulation Valvu loplasty � Tricuspid Stenosis, P u lmonary Stenosis, Mitral stenosis, temporary in Aortic Stenosis. ) ) ) ) ) ) TEE (transesophageal ECHO): Lab of choice in • • • Prosthetic valve endocarditis Descending aortic aneurysm Left atrial thrombus, PFO Atrial Fibrillation • At r i a is fibrillating, hence NO 'p' w�ves. • Some impulses from fibrillation are conducted to the ventricles giving • Na rrow QRS except in aberrant condition. rise to an irregularlyirreg11larventricular response. 1 IV\ r.n -t .fc...tA ;., (./) p'P, C Hf -1 t.. IM"t oz.. ' Can prese n t as • • • New onset �jib Paroxysmal (terminates spontaneously) Chronic Convert to NSR • Amiodarone • lbutilide (prolongs QT) * R.-..� c..c-.t.-•1 l<lr1o _, J. �'P•t d.,.,_�"·c. .v .r 1:.-ok<. • Quinidine • Procainamide • Dofetilide (prolongs QT) • Dronedarone • Electrical cardioversion (only med shown to decrease hospitalization. Avoid dronedarone in Pts. with CHF with ejection fraction less than 35%) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 587 Chart 13-14 less Validated/ Weaker Risk Factors Moderate Risk Factors • • • • • ( \1 /).'1) Female gender • Age 65-74 yrs. • Coronary artery disease • Thyrotoxicosis • I Heart failure Hypertension 1 Age > 75 yrs LVE F $ 35% I I Diabetes mellitus I High Risk Factors • • • ;L.. "2... Previous stroke, TIA, or embolism 2 Mitral stenosis z. Prosthetic heart valve 2.. Risk Category Recommended Therapy No risk factors ASA 81 mg daily One moderate risk factor ASA 81 mg daily or Warfarin I N R 2.0-3.0 Any high risk factor or >1 Warfarin I N R 2.0-3.0 moderate risk factor •Bf ;,. L£ CHAD VASe sa p ;"- U. G V = vascular disease = 1 point A = age 65-75 = 1 point Sc = female = 1 point 143. Heart disease with major contralndftatt o n to warfarin • • • • • Atrial fibrillation can present with WPW as wide complex tachycardia. Then, treat with procainamide No Digoxin No � blockers No Ca channel blockers � Matching 0 1 . 62 y/o Pt. presents with palpitations. EKG reveals � Afib H R of 100/min. You start him on � blocker. A. ASA ECHO shows no valvula abnormalities and normal wall thickness. BPJ }0/84. w.t.d \ ' II �2 . 76 y/o Pt. with HTN presents with palpitations. HR is 110/min. You start him on � blocker. w.t.d �. B. Warfarin i 65 y/o with Afib, hx of r A in the past. Awesome Review, Inc.� Copyright 201 4 Do not photocopy without permission Page 588 Q144. What dose of Warfarin would you start in the above Pt.? Q145. Pt. with chronic Afib on Warfarin going for minor surgery. w.t.d -7 Continue Warfarin Q146. Pt. with chronic Afib on Warfarin going for major surgery. w.t.d ) ) IF CHAD score 2 or less -7 D/C Warfarin 5 days prior, No need to bridge IF CHAD score 3 or higher -7 D/C Warfarin 5 days prior and bridge with 1. LMWH twice daily dose and last dose 24 hrs prior to surgery. OR 2. LMWH once daily dose, last dose Yi on morning of procedure Q147. On day of Sx, Pts. I N R Is 1.6. w.t..d -7 Clear for Surgery Q148. Rate control and anticoagulation In Aflb compared to cardloverslon has shown ) A. Decreased mortality Y, Decreased stroke ) I A. Decreased mortality ) %. Decreased hospitalizations ) ) -7 AV -7 Do you need anticoagulation for this Pt.? -7 YES! because atria continues to fibrillate. \ ) A. ASA B. ASA + Dipyridamole C. ASA + Heparin Z. Heparin + Warfarin ---1 Awesome Review, Inc.® Copyright s � br;o�.r":: 2014 Do not photocopy without permission Page 589 153. How to prevent rate related cardiomyopathy (CHF) in atrial fibrillation -7 Control resting heart rate to -7 < no; � 154. A 48 ylo man presents with acute onset of periumbilical pain. xam reveals a heart rate of 130/min irregularly irregular. P is 1 10/70. Temp Is 99°F. w.t.d � Arteriography A. CT Abdomen C. Ultrasound D. Abd. X-ray 155. A Pt. had Affb. You were treating him with Diltiazem with rate control. Echo had tructurally normal heart. Few days later Pt. comes back with Increased symptoms of alpltations. 24 hr. Holter showed many episodes of Affb while he had symptoms urlng those episodes. What to do? �Add Beta blocker A. Increase dose of Calcium channel blocker C. Add Digoxin D. Start Propafenone 156. Which drug will bring Atrial fibrillation Into NSR. --------� A. Diltiazem f. lbutilide B. � blocker Atrial Flutter Atria flutters around 250-350/min. Mechanism is intra-atrial macro-entrant tachycardia. • Usually 1 in 2 flutter waves get through. Hence ventricular rate is @ 125-175/min. • • • • Etio: Cardiac or pulmonary disease. Can be a presentation of WPW. Tx: First slow AV conduction with � blockers, Diltiazem, then cardiovert with Amiodarone/Quinidine. Low energy cardioversion or atrial pacing can also be done Recurrent flutter, Do EPS & cardiofrequency catheter ablation 157. A 32 y7o woman with mitral stenosis has sudden palpitations. ulse rate is 150/min and regular. Carotid sinus massage decreased the pulse ate to 76/min, with the rapid return to 150/mln when massage is stopped. These ymptoms are o f A('Atria l flutter ( IV'O.(re B. Atrial fibrillation � Cl\t:vc:..c Cov"""-'1 ) C. Paroxysmal atrioventricular reentry tachycardia. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 590 f>.,V !(V I<. I \!-.) Matching (S)(cor--) ) A __ drt At..:.� � ,....� ,._.,( ;,.,p� <D MO.. Si <:Jf 1 . AVNRT (Atrioventricular node reentry tachycardia) _, 0 1\o\.u-.PS:."" L2. AVRT (Atrioventicular reentry tachycardia) �3. Orthodromic reentrant tachycardia \ ) ) f�L P"'-J ) +t- \J ) d.oW C lLwf 1- ' v, u,.. t-'1 ) 158. The first step In management for EKG A. � Carotid sinus massage Next step -7 Next step -7 f\d...t.fV)� A d.t..'\-0 1-V--- {; rr-f '1-v --1 ( � �� / 2. 'j _, CC.. B c: u : VI. 159. Adenosine would work for which o f the following Atrial flutter A. f. + AVNRT + ) fi"'t &,,..o � C. wi� c..of"-1)\.c� u. ' "t AoJ 1\A>� 1"1, l>l..oock, "t.J '\] Vl 'l. (< Afib + + Awesome Review, Inc.® Copyright 2 0 1 4 Do not photocopy without permission Page 591 Q160. 22 y/o with palpitations and pounding sensation In neck for several years, ow has gotten worse. She gets slightly dizzy at times. Symptoms occur without arning while resting. When she breathes slowly and deeply, the palpitations resolve n its own. EKG at presentation is normal. Most likely vt{ Paroxysmal SVT C p.,v B. Ventricular tachycardia @ �7 ) C. Atrial flutter D. Atrial fibrillation. WPW • Impulse via accessory pathway reach ventricle earlier than the one via AV Node� delta wave-7 shortened PR interval. • WPW can present with Atrial fibrillation, Atrial flutter or Ventricular fibrillation • DO EPS if associated with any arrhythmias or unexplained syncope • Never treat a wide complex tachycardia with � blockers, Ca channel blockers or Digoxin 161. A Pt. Fias SVT an respon s to carotii:l sinus massage. Pt. as s how she can revent future episodes? v e.. N A 1-A�.,. {.Vt.-\.. -7 Teach her --� ---------Q � Q162. 25 y7o with palpitations, gradual onset. During episodes sinus tachycardia f 140/mln were noted on EKG. Asymptomatic resting EKG normal. ECHO normal. Pt. diagnosed with Inappropriate sinus tachycardia. Best mangement? -7 p bl..o<..lc:d' Q163. Young athlete on routine physical found to have E KG with WPW, asymptomatic. Can he play basketball? l c .....tl P tc.a � tt..llr} 164. Pt. presents with palpitations. E KG Afib or SVT. After p blocker Pt. feels better nd repeat EKG reveals a shortened PR Interval. w.t.d next? --------� � EPS & ablation of errant tract A. Start long term blocker C. Cardiac cath. D. ECHO Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 592 WPW with accessory pathway conduction lA A '<::: 1- - al R lli V-lJv·I'-' \:�IWI.J�r-• lv ��11"-��rt�""'I\"' A A n - 1 ./1. ) ) - II �� f1- 'J!{Irf�)/!��v� ��71\: \ Pvt'-JII� fJr- - 14 �- x u f-!t-;--.) � [V � I r-- - - rl- - H- ' "' "' ,J_ t:::_ � fl. - - - - 1- - j/ 1-�-�- I� a\1ll�';J1]1 1 ) r "'!L lt� IY - _ II IL IJL Ill" '\. jl--j p165. Pt. presents with wide complex tactlycarctia. ) - \ - f��- H R 200/min. QRS 0.14 sees, P R <0.12 sees. Pt. has hx of WPW. � nable to decide If it Is SVT with aberration or V-tach. �ou would treat this Pt. with A. Propranolol B. Digoxin C. Ca channel inhibitors vef. Procainamide Chart 13-15 ) Multi focal atrial tachycardia (MAT) ) 3 or > d istinct morphological types of 'p' wave Seen i �COPD, result of theophylline use . C..I-11= Tx: 1'1: Oxygen, Mg and Inhaled bronchodilators 2nd: Ca channel blockers Digoxin is of No use. Awesome Review, Inc.® Copyri gh t 201 4 Do not photocopy without permission Page 593 PVC 166. Pt. with multiple PVCs w.t.d 1X -7 Look for organic heart disease: ECHO, Stress test, gated pool studies. -7 If heart disease negative, asymptomatic -7 No -7 If heart disease negative but symptoms +-7 -7 If heart disease positive with LOW LVE F -7 Sustained Ventricular tachycardia -7 P b\..o c. �c..e....- '"l. L 'D 7C..!j) 167. 45 y/o healthy man who exercises everyday and asymptomatic, Is going or e lective major surgery. EKG reveals multiple PVCs. w.t.d A Clear for surgery B. EPS studies C. Cancel OR Ventricular tachycardia 1 <-� 11 f � � jYentialPVCs. 3 or more consec Diff Diagnosis: • SVT with aberrancy • • WPW LBBB ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 594 �4 secs Ventricular tachycardia more likely, if: • • • • • • • • QR Left axis deviation negative Fusion beat Capture beats: (normal conducted sinus beats interrupting wide complex tachycardia} Presence of organic heart disease Cannon 'a'waves Concordance of QRS in precordial leads Rate>lOO 168. 30 y/o AA Pt. Is brought to the ER with palpitations, he Is found to have a n rrhythmla and Is hypotensive. H e I s defibrillated twice and a n Intravenous medication Is ) tarted. hysical exam reveals Cervical, Axillary and Epitrocheal LN ++ ost likely underlying disease Is ) vK Sarcoidosis B. Infectious Mononucleosis ) ) ) ) J ' Prolonged QT inte rva l • • • • • • • • • • -Jt , } ' w1 Quinidine, Disopyramide Methadone Azithromycin It Procainamide a. 1 JR-t'V· Hypokalemia, hypomagnesemia Pentamidine Erythromycin Phenothiazines <.. �, 'l'l""""1 ) TCAs, Moxifloxacin1' Aripiprazole I I ) • • • D/C offending drug Overdrive pacing Magnesium sulfate ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 595 V-Tach or V-tib. with Sudden Cardiac death • • 1st year. 300,00 to 400,000 of sudden cardiac death/year. Most don't survive. Of the people who survive, 30% w i l l die at the end of 169. The most common cause of Sudden cardiac death is 170. What will decrease short term mortality in a Pt. with V-fib /.Defibrillate B. Amiodarone C. CPR 1 7 1 . What is the most effective timing of defibrillation In the above case? � --------� '2- """ i� 4. CPR and then defibrillate B. Defibrillate immediately Q172. Pt. with V-Fib and collapses in tile ER. Pt. is efi6rlllate hile later again goes into V-Fib and he is shocked twice more successfully llut a short • .t.d next --------�--� is given. w.t.d next vi(. Amiodarone B. Lidocaine C. Repeat Epinephrine D. Procainamide Q173. The best management for a Pt. with family history of sudden cardiac death is Indications for lCD: • Sudden Cardiac death: V-Tach or V-Fib • • EF <35% with CHF irrespective of the etiology: Non ischemic � 3 �� after medical therapy Ischemic � Lt� "-(p after M l HOCM with NSVT and family history of sudden death. Q174. A 2 1 y/o woman Is awakened by alarm clock and minutes later has syncope. EKG reveals prolonged QT Interval and T wave inversions. ful---is ------------------------------------------�--------------------�Histo most likely to be help---A. Hx of Cocaine inhalation in the past 24 hrs y. Family Hx of sudden cardiac death Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 596 175. A 60 y7o woman complains of recurrent exercise induced palpitations with ear syncope. Family hx of near syncope in her elderly mother and daughter as well. KG shows a QTc interval of 460 msecs. LVEF 55%. schemia workup is negative. what is the next step in management ) <. s o t d Jl A. p blocker therapy B. Amiodarone C. Procainamide D. Pacemaker E. Quinidine 176. A 42 y/o Asian man has a Sudden cardiac arrest. EKG revealed V-fib and Pt. was efibrlllated successfully. EKG now reveals ST elevation In Rt. precordial leads; V1, V2, ) 3 & is asymptomatic. Family hx of Father dying at age 40. Most likely diagnosis ? ) 177. Best management for above patient? � Brugada syndrome ) A. CAD ) ) ) ) ) A. Cardiac cath. )(. lCD placement ( N c. c. � L A'!:> NL ) Matching � 1 . Pt. with dizziness and passing out for a few A. Continuous loop recorder seconds. History of palpitations. �2. Pt. with palpitations lasting 2-15 mins. No syncopal episodes. (Holter Monitor) B. Transtelephonic recorder (King of Hearts monitor,need to press button to start) ) ) J PR>0.2 sec JI PR in te rval prolonged but constant • Conduction of impulse to the ventricles is delayed • Hence PR>0.2 sees • lntranodal block with benign prognosis • No need for Pacemaker Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 597 2° AV type I block (Mobitz I or Wenckebach) Dropped QRS Progressively prolonging PR interval and then dropped QRS • Usually No need for a pacemaker unless low heart rate with hemodynamic problems. Q178. Pt. had an lnf. wall Ml, had PCI and is now stable. 3 days later telemetry monitor �hows do? 2"d degree Type I heart block with HR SO/min. Pt. has no symptoms. What should you A. Pacemaker placement. � Close monitoring as Out patient. II A . Temp. pacemaker � Reduce � blocker dose rtype II AV block • ?• f• <. p b�.-o� .t- ,.,.,.. ,�,1 ""� ) (or Mobitz II block) PR interval prolonged but constant and sudden drop of QRS If secondary to Inferior wall or right ventricular M l � usually AV block transient and ' don t require permanent pacing If secondary to Anterior wall M l � more extensive damage� may require permanent pacing Awesome Review, Inc.® Copyright 2 0 1 4 Do not photocopy without permission Page 598 3°AV block • Atria and ventricle beat at their own rates. Cannon 'a' waves on JVP ) • ) Indications for Pacemaker: ) Treat with pacemaker. • Acute M l with a new bifascicular block � high risk for progression to Complete Heart • block. 2Q Mobitz I I AV block • 3Q AV block • Pause dependent ventricular tachycardia • Sinus node dysfunction: - Heart rate < 40/min while awake 1f7 ) - Carotid sinus hypersensitivity with drug induced HR <40 ) CHF with prolonged QRS complexes, use biventricular pacemaker ) ) ) ) - Pauses > 3 seCE>nds - Mobitz I I AV block with bifasciular block - Post operative AV block. 179. 75 y/o man presents with Intermittent palpitations. enies SOB or syncope. Pt. Is on p blocker and ACE Inhibitor for HTN. KG reveals NSR 66/mln. Holter monitor reveals varying HR. 35-106 during the day. .t.d A. Reassure ) ) B. EPS J;C' Pacemaker Q180. 80 y/o for regular check up and found to have HR of 45. akes HCTZ for HTN. A 24 hr. Holter monitor Is done which shows, the rates vary from max of 55 during day a n d drops to 38 at one point during the night. ) Pt. denies any symptoms. w.t.d --------�--�--� A. Pacemaker ) ) ..)r.' Reassurance 181. A 65 y/o woman with shortness of breath on exertion. he has been diagnosed with CHF last EF 22%. She Is on Nitrates, p blocker, CE i n hibitor, Spironolactone and Digoxin. QRS complexes > 0.12 sees. what else can you do to decrease symptoms? � (i; vtr�t,...; c...W ., f�ou. �l<.v' ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 599 @ f Junctional rhythm • • • Junctional tachycardia VR 70-130 'p' wave may be i nverted, buried beneath QRS or follow QRS Causes: Q • Digoxin toxicity ( wt lo� ) _, � • • • Inferior wall M l � 6) ,..,.J t.t>v. P v c.. . G) CVVo �.k.� , 11 pt. Myocarditis Post cardiac surgery (/>'. 1t cA:1.ax..V. .,...,. 1"\Jt- """ - 1 "ilo�"',v. t..x;"J. H<.TZ p �:>v' �<.... Chl!-4(< _ rJov <A.:.f<>>rM bt.� R.ft.{{ • �· Sinus Bradycardia: • H R <60 • Hypothermia • Hypothyroidism Sick sinus syndrome: SA node problem causing bradycardia, block, arrest or tachy-brady syndrome. NO need for EPS Tx: Pacemaker if 1. Symptomatic 2. Treatment of tachyarrhythmias causing significant bradycardia Antiarrhythmics drugs Class 1: decrease upslope of action potential Ia: Disopyramide, Procainamide, Quinidine lb: Lidocaine, Tocainide, Mexiletine, Phenytoin lc: Flecainide and Propafenone Class II: decreases sympathetic activity 13 blockers Class I l l : prolongs action potential Amiodarone, Sotalol, Bretylium Class IV: Calcium channel blockers Others: Adenosine: slows AV conduction Digoxin Toxicity of Antiarrhythmics Quinidine -7 Prolongs QT, decrease platelets , viU A b 1'1'7W C. "' I M ) Procainamide -7 Lupus lidocaine -7 Seizures � '/Ye..,... .. o�tt. ) I).,I.A" r .f'1 -7 Pulmonary fibrosis, hypo/hyperthyroidism, corneal deposits Amiodarone .u ()( 2 F rJ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 600 Digoxin: (normal level <lng/ml) H & P � Anorexia & Weight loss C. "J W"'t\:.; ""''� PE � Regularized Afib EKG � J unctional Tachycardia PAT with block, PVCs Dr�gs that increase Digoxin level : • Quinidine Predisposing factors for toxicity: • • • • ) ) ) ) ) ) low K low Mg • Amiodarone 11 • Spironolactone � • low Renal function low oxygen • Verapamil Chlorthalidone p HCTZ ff? Treatment of Digoxin toxicity: • Correct electrolytes 1')1 • • • • � blockers Lidocai ne/Phenytoin Digoxin binding antibodies � NO Quinidine, NO Procainamide l:.j<- It ��'J P.n-"-,k,._.· "' ':! ,_, .. 182. Pt. with Aftb started on Digoxin. EKG reveals regular Aflb. w.t.d ) ) ) 183. Elderly Pt. with Creat. of 1.3 on Llsinopril, Gllpizide, Mirtazaplne and Digoxin 0.2Smg/day with gradual weight loss. w.t.d ) ) __K. Decrease Dig. dose B. Decrease Mirtazapine C. Decrease Lisinopril and Glipizide 0.184. Pt. Is on Digoxin & Amlodarone Is added. w.t.d /. Decrease Digoxin dose \ ) B. Increase Digoxin dose ) ) ) C. Decrease Amiodarone dose Q185. 78 v/o m a n with SOB with creat. 1.5 on Digoxin and Warfarin. EKG with HR of 96/mln, looks regular with retrograde 'P wave'. Dx: � ) ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 601 An AWESOME REVIEW OF 3% Awesome Review Inc.� Copyright 2014. Do not photocopy without permission. J - I AS v'1)J C{-l.J) / � � .-- C � c."", � 1s �cl. At.ovc.J't,NR.,AJ\,<. 9oc.t � @ "10 _P;> )-o Ll>L - Li c ._'D < ) 3s /,....,, ) ) J \l ) ) � (.\SC.VD] 'DM.. I L'DL - ) ) ) 'DM' ) ) 1·S J', Ase VO �SK © 1Alt:�� P t>'D, ) Ccro"(} R.ps-..... - D P.->p) so/. f\W\. (j) f.\f\.r''V, M1, 4° -f-J ;r>, I� �( JkL ) I -I �W...k M�S::..'S ..J ' t .. d·,:"-' ( "\ 'l>IV\. .JJ """'c ) ) ) C..Pr'D ) fV-r-. ;"tu, �11 I ) A-() pt ) ) ) ) ) ) ) ) ' } ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 604 J J ) Chart 14-1 GP Al, A2, Cll TGA Chol ) VLDL Chylo micro Cil J GJ Muscle & Fat ) ) ) ) Awesome Review, I nc." Copyright 2014 Do not photocopy without permission Page 605 Chart 14-2 Content Defect !Type I (:hylomicrons TGAs Familial LPL w Familial Cll w !Type I I LDL LDL w LDL receptors Tendon Xanthomas TGAs LDL+ Abnormal Apo© TGAs Familial LPL w Familial Cll w Pal mar/Tuberous Xanthomas / Yf.iw� Eruptive Xanthomas !Type Ill I DL Type IV VLDL Familial LPL w Familial Cll w TGAs Type V VLDL+ Chylomicrons Skin Lesions -- Eruptive Xanthomas - - - - Eruptive Xanthomas 11 - . Chart 14-3 Used for Statins 1°LDL Tx LDL ww TGAs HDL Side effects - 1' 1' • • Fi bric Acid derivates 1°TGAs Tx Bile Acid derivates 2° LDL Tx Nicotinic Acid 1° HDL 2°LDL/ TGAs Tx 2°LDL Ezetimibe 1'/N ww LFTs, CPK, wt. gain Glucose intolerance Gall stones, hepatoma 1' II w w w w ww w 1' 1'1' - ) Bloating, Constipation, Nausea ) - Abdominal pain, Nausea, Flushing, Dry Skin t,. J, PISf\ ( (Jl't Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission f-ivc Ni<,> t Page 606 Matching �1. Apo protein E deficiency (3 2. Deficiency of LDL receptors - �3. Tendon xanthomas _£_4, Pancreatitis A. Type I B. Type Ila C. Type Ill m D. Type IV E. Type V F. A, D & E Q.1. Pt. with LDL 140mg/dl, TGAs 600mg/dl. Family history of hypertrlglyceridemla. w.t.d A. Statin (pravastatin, atorvastatin) � Fibric acid derivative (Gemfibrozil, fenofibrate}-1 C. Bile acid derivative (Cholestyramine, Colestipol) D. Nicotinic acid ) ) ) ) ) \ I A. Eating fish rich in omega-3 fatty acids .JY. Losing 5-10% of body weight 3. Most likely defect is A. LDL receptor B. Apo E ,_,.,e: Cll deficiency D. Lp(a) Eruptive Xanthomas 4. Most likely respond to ) A. Statin /.Gemfibrozil C. Cholestyramine D. Diet Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 607 Palmar Xanthoma 5. Most likely defect Is A. LDL receptor �Apo E C. Cll deficiency D. Lp(a) Chart 14-4 NCEP guidelines Dlgoal No CAD, 0-1 risk factor <160mg/dl <160mg/dl <130mg/dl CAD equivalent factors: DM Other vascular disease: AAA, Peripheral artery disease, Carotid stenosis Multiple risk factors with 10 yrs. risk of CAD> 20% by Framingham score • • • First Line of Treatment is Diet: Prefer monounsaturated fatty acids: Olive oil, Canoia, Peanut Oil S\.c":f�"V(A. uVl Omega 3 and 6 fatty acids <30% of calories from fat (<7% saturated, 10% polyunsat., 20% monounsat.) <200mg of cholesterol 15% of cal. from Proteins Fiber 20-30 g/day Exercise Stop smoking • 1 • • • • • • • In comparison to Framingham risk score, Reynold's risk score includes High-sensitivity serum C-reactive protein (USPSTF Not FOR or AGAINST using it.) Parental history of myocardial infarction ) • • 6. Pt. wants alternattve ltlldlclne for preventfon of CAD. w.t.d A. Vitamin E & C _.,-ff. Omega 3 fatty acids ( J-l<..x JM) C. Omega 6 fatty acids D. Linoleic acid 7. 40 y/o with no risk factors for CAD with LDL 175mg/dl. w.t.d next Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 608 8. The most likely finding in a Pt. with OM is -7 1' LD L '1' J -,: c. I .); H'D L 9. The primary target for therapy in a Diabetic Pt. is ./f(_ LDL B. HDL C. TGA D. VLDL 10. 62 y/o woman with HTN and type 2 OM requests advise about coronary risk reduction. P is 162/92, HbAlc 7.6%, Plasma Chol. Is 268, LOL is 180, HOL Is 42. he most a�pro riate treatmentwouldbe �-----�--------�---- A. Statin lipid lowering drug to reduce her LDL to <130 B. Statin lipid lowering drug to reduce her LDL to <100 C. Statin lipid lowering drug to reduce her LDL to <160 �"-��· J. - 1. ". ..,.u fYViJ <M.Jc. .,,._ rl'· <.""'f> JtcJV.. /:..I At..v,. 'l-0-�b ()IW.f<. '-trr:�� .x. ControI HTN to 140/90 _ • I ?Oc.l {; L.Z>l ( 3;, .JO'/. ) 11. What Is the initial drug you will start In a Pt. with OM who has the following, OL 160mg/dl, TGA 250mg/dl, HOL 45mg/dl. Prcv<.Jt..JV. 4;:> - �o R.>.tv.11"� • 1 0- i.o A. Niacin ...-B. Statin C. Fibrate D. Ezetimibe E. Bile sequestrant ) 12. A 57 y/o woman with OM has an Ml, she quits smoking and changes her diet. he Is started on Slmvastatln 20mg/day. he LDL decreases from 180mg/dl to 140mg/dl. The TGAs decrease from 50mg/dl to 250mg/dl in about 3 months. HOL is 48mg/dl. w.t.d next ----7 Lr.� (SM S;f"'l\/wt-t ....h'.,. sw-tu.. 1::> to L.i0"':/ At.v ..st" W.. /d/. 4o - <rv ( l�L "'::! , tJ.,,>p (Z<>Jv. ) S"u/.) u. � 0 • 13. A Pt. over the age of 50, serum LDL 130 mg dl, C-reactlve protein more than 2 mg7L. hat has shown to decrease mortality? ) A. Aspirin Y, Statin 14. Pt. on Slmvastatln, 8 weeks later presents with generalized myalgias, PK 75, AST/ALT 30/40. Most likely diagnosis? -��-��-��-�-A. Statin induced Polymyositis B. Statin induced Rhabdomyolysis ,..x::' Statin induced Myalgia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 609 Q15. What is the best management for the above Pt.? 'I- r.<Je ..w.+<S itch to Pravastatin (Of") Rvsv.vc.J�!Y- f>iltu B. Decrease the dose of Sirnvastatin c:l<Uj 16. A 67 y/o man presents with complaints of pain and weakness in his legs. ifficult to get up from a sitting position. e had stopped taking Atorvastatin about 3 months ago after CPK was found to be levated. epeat CPK now is 1925 which has not changed much from before. uscle biopsy reveals necrotizing muscle fibers with no inflammation and no vacuoles. hat is the most likel'l dia nosis? A Statin induced myopathy secondary to 200/100 . (anti-3 hydroxy-methylglutaryl-coenzyrne A reductase HMGCR B. Dermatomyositis C. Inclusion body myositis 17. What is the best management of hyperlipidemia in pregnancy? ��- -7 Co leseve� Q18. Atorvastatin 40mg 6 mths ago DL 180 HDL 40 3 260 ST/ALT 30/45 C Well c."st) Atorvastatin 80mg 3 mths ago LDL 105 HDL 55 200 40/50 Atorvastatin 80mg now LDL SO HDL 59 135 70/80 A. D/C Atorvastatin B. Change to 40 Atorvastatin� if- p.,r-r IM 1 S/. Continue current dosage 1 > x 3 -t <--� t> Lt 0 ) 19. A 40 y/o man with a strong family history of premature coronary artery disease Father <Jied of Ml at age 45. LDL 130mg, HDL 28mg, TGAs 175mg. hat is most likely elevated in thisPt.? ..v �� A. Homocysteine level /(! Lp(a) Q20. Best treatment for above Pt.? 021. Best way to prevent the flushing associated with Niacin? Awesome Review, Inc.«> Copyright 2014 Do not photocopy without permission Page 610 22. A 55 y7o man with strong family history of premature coronary artery disease. ather died of Ml at age 45. LDL 180mg, HDL 29mg, TGAs 375mg. t. is started on Simvastatin 40 mg/da d 12 weeks later LDL is 120mg/dl, DL 35 mg/di and TGAs 245 mg/d .t.d next � B. o·scontin Simvastatin, Start Niacin C. Con e Simvastatin, add Fibrate D. C ntinue present medication. · Q23. Pt. on Slmvastatin with weakness, CPK 850. w.t.d Q24. A Pt. presents for a regular checkup and found to have LDL of 150, riglycerides of 160 and HDL of 80. His total cholesterol ls 260. ement? hat is the best mana-��----' = A. Start a Statin ,.JY.''No need for medication Chart 14-5 Dermatology Eczema ) \ Time line Etiologic Acute Eczema Sub acute Eczema Chronic Eczema •vesicular •bullae •erythema •Crust & •Erythema •No bullae/ vesicles • Licheni-fication � Exogenous Endogenous •Contact dermatitis •Atopic dermatitis •Seborrheic dermatitis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 611 • • • • Tx: • Associated with Asthma & Rhinitis. Increased lgE. Childhood with erythematous pruritic rashes. Later on or in adulthood become scabbed or excoriated lesions mainly on flexural surfaces. (antecubital/popliteal) Hydrants, emollients Hydrocortisone r::"cl:>ol'r�·c. 'D�""c.tt.:..rj • White flakes onface, scalp, upper chest and auditory canal. Caused by Pityrosporum Severe cases seen in HIV Pts. • • • Tx: Oral or topical ketoconazole tir,·c.ut se L<.� .....,_, .ru l_J> i N. 25. 40 y/o ex IVDU with severe Seborrhelc dermatitis. w.t.d h2.V • • • • ke.,,..(;.to�J c..o"tA.c. t • Tx: • fS"e..bof'Y"-€--\'c. Warty brownish plaques in the elderly (Barnacles of elderly). Give a stuck upon skin impression on face, back and neck in the exposed and non exposed areas. Can be pigmented or dark. NOT malignant, NOT PREMALIGNANT Usually no treatment required. �------ • • t..,t, Delayed type IV reaction common y cause (poison ivy, poison oak), rubber, etc. Cool compresses * Local steroids '1 pois""' ) ) ium, oleoresin iv<:J c.u-..tc..<� ¥ 1-i. "-1� wc..1Jt....;'J is ft.... ) t,x ) . ) 26. A young woman suffers a laceration on flnger while chopping vegetables, hlch Is cleaned and sutured. An antibiotic cream applied with occlusive dressing. days later, Pt. presents with complaints of Itching sensation and pain. n exam, the band-aid Is uncovered, which reveals the suture line appears clean, but here Is surrounding erythema and eruptive vesicular lesions. Most likely diagnosis Is ) ) A. Streptococcal fasciitis �Contact dermatitis 27. A mectical recor<is clerk presents with vesicular eslons which are ltc y on Flis ngers. What is the most likely diagnosis? 28. Lady with itchiness and eczema of her upper eyelids. Most likely etiology? ) _,,,K. Nail polish B. Lip stick Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ) I Page 612 Q29. Pt. presents after exposure to poison Ivy within 2 hrs .. w.t.d A. Topical steroids /. Showering Milia: • Small Keratin containing cysts on the eyelids, cheeks, nose and forehead • Tx with l&D Open and closed comedones Papular acne (inflammatory acne) ) Cystic and nodular Acne: Represents severe acne Q30. Female with severe acne, wants Accutane. w.t.d �Must be on OCP & another method of contraception during and one month after completing therapy, because Accutane is a teratogen ) Q31. Pt. with predominantly Comedone acne. W.t.d ) Top. Benzoyl peroxide Top. Tretinoin Oral Tretinoin Oral Abx A. � ) \ + + + + + Acne Rosacea Acne like lesions on face in middle aged women. flushing with exertion or sun exposure. Fine telangiectases and scattered tender papules Rhinophyma can also occur. Dx: Acne Rosacea Tx: Oral Tetracyclines • Topical Metronidazole.:; )f: • Lichen planus • Papulosquamous lesions of skin or mucous membranes. • purplish papules with white lines on surface. • Can occur with use of NSAIDs. • Cutaneous Graft vs host reaction most resembles Lichen planus. • Etiology unknown Tx: • High potency topical steroids. Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 613 Hidradenitis suppurativa Chronic inflammatory scarring involving apocrine gland areas. ( P\vr-.. p'it ) Tx: Tetracycline or erythromycin Surgery definitive therapy Quit smoking � l' • • • Q32. A middle aged woman presents with recurring episodes of lumps in her axilla hat drains a serous fluid. Every episode resolves by itself after spontaneously draining. xam does not reveal any enlargement of lymph nodes. he Pt. has a cat for the past 2 mths. and loves to do gardening. ost likely diagnosis? �� A. Cat scratch disease � Hidradenitis suppurativa 0.33. What is your recommendation for the above Pt.? /,Quit smoking B. Lose weight ) • • Seen in measles. Precede skin lesions by several days. Hairy Leukoplakia Ribbed whiteness on lateral aspect of tongue Seen in HIV Pts. Caused by Epstein-Barr virus, NOT malignant lesion. Treatment usually not required ) • • • • Oral Thru sh Seen commonly in HIV Pts. with T cells < 200, or Pts. on inhaled steroids for asthma. Treat with oral nystatin swish and spit or Fluconazole in severe cases. ) • ) • • Macroglossia Associated with Amyloidosis Multiple myeloma Acromegaly Downs syndrome • • • • Geographic tongue Asymptomatic and Benign Strawberry tongue Associated with scarlet fever and Kawasaki syndrome. Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 614 Chart 14-6 Drug reactions Exanthematous or Morbilliform Sulfonamides , B Lactam; PCN Urticaria & Angioedema ASA, PCN, Blood products Fixed drug reactions Rash occuring at the same spot after rechallenge. Erythema multiforme Recurrent HSV, Mycoplasma, PCN, Sulfa, Phenytoin Erythema multiforme Tetracyclines Exanthematous or Morbllliform rash Erythema multiforme • with Target lesions • • ) ) ) \I Pt. with recurrent Erythema multiforme-7 rule out HSV infections. Treat/prophylax. with Acyclovir. Pt. with cough & CXR with infiltrate with Erythema multiforme, cold agglutinins + -7 Mycoplasma infection Other causes: • • I mucous membranes may be involved. • Phenytoin Sulfa drugs Penicillins A more severe reaction with mucocutaneous involvement is called Steven Johnson syndrome and it is more often drug induced. Tx: Admit and Remove offending agent i.v lmmunoglobulins or Steroids may be used. • • • • • Erythematous skin rash-? Blisters-? Necrolysis, denudation of skin, Hemorrhagic crusting. Hypotensive and tachycardic Ox: TEN (Toxic epidermal necrolysis) Etio: Idiopathic Drugs: Sulfonamides, Macrolides Dilantin Erythromycin Tx: D/C offending drug IVF, i.v lgG, Plasmapheresis NO Sulfadiazine cream (it's a SULFA!) • • • • • • • Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 615 Q34. Pt. presents with generalized erythema, exfoliating dermatitis with bullae. Punch biopsy Is done. If cleavage plane in stratum corneum �----��----�-- If cleavage plane in stratum germinativum dVIAj � 2V 1.8 1.a)c1c. '1.tt.1c.--< """""'1.!: " -------�-----::: �--Q35. Pt. calls you with onset of bullous lesions on his chest after taking Bactrlm. w.t.d -7 T �N z. _, A. Stop Bactrim and go to the Dermatologist B. Stop Bactrim and see MD in a week ,,,JC. See MD right away Swimmer's itch aka Cercarial dermatitis Ponds, lakes, oceans Larvae enter skin and die -7 skin eruption with itching • • Seabather's eruption ( co"c."i'j °'� ) ab ) Salt water Jelly fish larvae get stuck between clothing. Drying, or showering with fresh water kills them -7 skin eruption with itching ) NFLAMMATORV SKIN DISEASES Psoriasis Well defined erythematous skin lesion with distinct silvery scales. ) • • Two cutaneous types: • • Erythrodermic psoriasis Pustular psoriasis pee-l � Le�c.-n, _, ) ) pvJ\. t� � ) ) Koebner's phenomenon: Abrasion will lead to psoriatic lesion in that area. Erythrodermic Psoriasis Erythematous skin with silver scales. Pt. unable to regulate temperature. Common sequalae: Dehydration Hypo/Hyperthermia Hypoalbuminemia � Anemia of chronic disease -t: 1' f\.f\iu- i'f , J • • • • I \ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 616 Precipitated or exacerbated by Sunburn Viral or bacterial infections Drugs: Anti malarial, Gold, Lithium 13 blockers. Anti - N F therapy! Systemic Steroids & taper can precipitate pustular psoriasis. • • • • • • • Alcohol and Malignancy DON'T exacerbate psoriasis. Pustular psoriasis 'pustular ponds of pus' 36. • • Pt. with bipolar disorder on lithium presents with psorlatic skin lesions. w.t.d Ice pick like pitting of nails. Onycholysis (separation of distal nail from nail bed) Treatment of Psoriasis Acitretin Topical steroids Synthetic Vit D3 analog Methotrexate Psoralen + UV rays PUVA • • • • • ) = Addison's disease • • • Hyperpigmented spots in oral mucosa and a tan. Low BP, High K Most common cause7 Autoimmune adrenalitis Cutaneous lupus Subacute Cutaneous lupus • • • • • Dlscoid lupus Ro/La+ {SSA/SSB) ANA (-) Anti ds DNA (-) Speckled ANA + Anti ds DNA (-) Anti Sm (-) Anti Sm (-) Lesional direct lmmunofluorecence + Ro antigen can cross placenta and cause congenital heart block in the new born. SLE Discoid lupus • • • • _, �.,i.,..,x '.) <-h\-� �wN. CREST C7 Calcinosis cutis (sq nodules) R7 Raynaud's phenomenon E7 Esophageal dsymotility S7 Sclerodactyly T7 Telangiectasia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 617 37. Most likel will have A. CPK elevation B. Anti Scl-70 (anti topoisomerase) A:: Anti Centromere Abs / Ee.ho ;f D. ANCA L.:>v-&. P2 Erythema Nodosum • Red Painful Warm nodules on the shin. • Young � 7 with hilar adenopathy or 1' 1,25 [OHh 03 7Sarcoidosis • • • Pt. in twenties with abdominal pain, cramping, diarrhea,+/- hematochezia7 Inflammatory bowel disease.[UC or CD) Other causes: Oral contraceptives, Sulfa drugs TB, Streptococcal or Fungal infections • • Pyoderma gangrenosum Occurs in Inflammatory bowel disease Rheumatoid arthritis Leukemia, etc. • \ · • • Painful? ) 7 '(e.S ) Are antibiotics of help? ) No • } Treat with Steroids Pellagra Niacin deficiency • Dermatitis �it • Diarrhea • Dementia J Vitamin A deficiency • • Night blindness White spots in the conjunctiva Vitamin C deficiency (Scurvy) • • Bleeding gums Perifollicular hemorrhages in a Pt. on bread and tea diet Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 618 Angular cheilitis in Riboflavin deficiency After therapy Vitamin B 12 deficiency • Atrophic glossitis {bald tongue) with cheilitis Gum Hypertrophy: • • Dilantin Nifedipine Zinc deficiency • • Eczematoid red rash on nasolabial folds, extensor surfaces and perineum/ scrotum/anal area Usually Pt. is on TPN and develops rash and alopecia. Bacterial skin infections Erythrasma • • ) ) ) • • Well defined reddish lesion in the axilla, groin and toe webs. Caused by Gram positive Corynebacterium. Under Wood lamp-7 fluoresce with bright red. Treat with oral erythromycin. Erysipel�s: • • Stfepor Staph Tx with PCN Disseminated gonococcal infection • • ) papular petechial lesions that become pustular. Culture of exudate is usually negative. <12 8. Young Pt. presents with fever, malaise and sore throat. It Is followed by vesicular eslons on the tongue, buccal mucosa. later, followed by painful vesicular lesions on he dorsum of hand and feet. Dx: Hand foot and mouth disease 2° Coxsackie virus Ecthyma gangrenosum: ) ) ) • Neutropenic Pt. with Pseudomonas infection Fever, headache, myalgias, macular rash -7petechial rash Dx: RMSF • Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 619 Verrucous Wart 39. Young Pt. with papule on finger for several months and gradually Increased In size. It auses pain occasionally on holding a pen. xam reveals verrucous � cm pa pules on sides of the fingers in the DIP. vJ. o \A/) w o..n... v e, ..--- (Common warts) Ox: 7 ---- in form of plasters, liquid, cream, etc. Condyloma Lata (painless broad plaques) % <!/'-<-t c,.(, w qr{ - i ,....._.; tl.4.-\ (ho.{ Condyloma Acuminata (pedunculated or sessile) 7 Hpv 6,,11 40. Young woman presents to you with unprotectei::I sexual encounter with a person ho has multiple sexual partners and he had a wart on his penis. t. ls worried, she ml ht catch It. w.t.d n=e=xt=?----- - -is negative. - - �----- The best management is A. Reassurance %.Repeat Pap smear in 6-12 mths C. HPV viral load Molluscum Contagiosum -J .rp�d... to �r 41. A bisexual man with lesions on the face. Best treatment Is K. Cryotherapy ) B. Acyclovir C. Gancyclovir D. Doxycycline ) Caused by ) Smooth umbilicated papules. Seen in HIV Pts. Most commonly spreads to Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 620 42. Dew drop appearance of vesicular rash, appears in crops. Herpes zoster -7 Painful lesions: (Refer to ID notes) T.corporis T. pedis 43. Pt. with erythematous, annular, scaly rash wit central clearing. ctive advancln red border. Scra(!....ln.._w I ------------O.... H....,w 11.... e...., a... _ .,,. lt....h....K... re ....1... ....v.... ) Management ) ) ) ) ) ) • • Chronic tinea pedis is the most common form of tinea pedis. Slowly progressive pruritic, erythematous lesions between the toes, especially in the 4th digital interspace. Fissures are often present. Extension onto the sole follows and later on to the sides or even the top of the foot. Tinea on Head -7 Tinea Capitis Tinea on Beard-7 Tinea Barbae Tinea on body -7 Tinea Corporis Tinea on superficial skin-7 Tinea Versicolor Tinea on Foot -7 Tinea Pedis A Pt. with hx of Tlnea pedls with maceration between his toes presents with erythema f the foot. Most llkely etiology of the cellulltis Is 44. A. Staph. aureus y. Streptococcus -) ) ) 45. A 38 y/o man presents with complaints of a bald patch which has started over he past several weeks. Exam reveals 'black dots' {btoken hair follldest Mlcr<J$coplc xam reveals broken hair follicles and under Wood's lamp there Is a bdgbtgreen Most llkely diagnosis is A.. Alopecia areata _,iY Tinea capitis C. Male pattern baldness ) 46. How to treat above Pt.? -7 Griseofulvin or Terbinafine or Ketoconazole Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 621 Q47. A 24 y/o woman presents to you with hair loss. She gave birth to a baby about 2 months ago. w.t.d A. Start topical minoxidil B. Start Spironolactone / Reassurance ( Tel.:,� EJJL....vll..V""-) 0.48. Pt. presents In summer, after tanning finds untanned areas. Exam reveals Hypoplgmented patches. Yeast like ball and slicks (meatball & spaghetti) on microscopy Tx: • • Oral Ketaconazole :JI Topical antifungal or selenium sulfide 49. A 55 y/o woman presents with generalized Itching, especially at night. xam reveals widespread excoriations between ring and middle finger. y/o granddaughter has slmllar s mptoms Sarcoptes scabiei Tx: • • Permethrin 5%, apply from neck to toe and wash off in AM. PO med� 1.ver,,...ec..t:."- Skin Cancers • • • ) Basal cell carcinoma Squamous cell carcinoma Melanoma ) ) with systemic findings • • • Sezary syndrome Mycosis fungoides Paget disease ) ) Cancers with skin findings • • • Peutz-jeghers syndrome Sweet syndrome Glucagonomas ) Basal cell Carcinoma Most common cause of skin cancer. Arises from epidermal basal cells. Etio: UV radiation associated with sun exposure and found onsun exposed or other areas. Translucent pearly papules with telangiectasias. (rodent eaten appearance) Spreads by local extension. Low metastatic potential <0.1% • • • • • Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 622 Squamous cell Carcinoma • • • • • Arises from keratinizing epidermal cells in exposed areas like dorsum of hands, forearms, ears and lower lip. Arises from Actinic kera tos is. It occurs in fair skin individuals. Higher metastatic potential than Basal cell carcinoma. Lower lip lesions7 13% mets. A. Keloid ) ) ) _...K Squamous cell carcinoma QSl. A middle aged lady comes back from vacation from Florida, Gulf coast, or :arlbbean and presents with a lesion on the back of her neck, which is keratotlc area with erythematous base. Most likely diagnosis? 7Actinic keratosis. Best management? A. f/u in 6 mths. /' Bx now ) ) Dysplastic nevi • ) • • ) 52. A y/:o m�m's brother diagnosed with malignant melanoma. he 45 y/o rnarr has tnUldple nevi and has not s�en any -changes In them. ou wlll do all the followln EXCEPT ) ) ) ) A. Photograph nevi and follow them periodically B. Check for nevi in the family and advise follow up C. Counsel on avoiding sun exposure and use sunscreens � Remove all nevi immediately Lentigo maligna Melanoma elanoma Risk factors • • • • • • ) Pigmented Irregular borders Dysplastic nevi predispose to Melanoma especially in a Pt. with family history of melanoma. Multiple sunburn in childhood Dysplastic nevus> 6mm in diameter Family history of Melanoma >25 nevi Fair, blond hair Immune suppression � s� C,.oJ\c:c.v Most important Prognostic factor Depth of tumor: <0.76mm7 99% alive at 5 yrs. >3.0 mm7 < 50% alive at 5 yrs. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 623 Q53. 70 y/o Pt. presents for routine checkup. Says lesion on cheek has grown bigger and olgmented gradually over about 10 yrs. No itching, no pain. No complaints about the skin eslon. w.t.d -7 Refer for biopsy of lesion to rule out Lentigo maligna melanoma Lentigo maligna is seen after age 60 in chronic sun exposed areas. Precursor to melanoma. Treat with excision biopsy. Laser, liquid nitrogen therapy is inappropriate. • • • • 54. A 40 y/o was diagnosed with melanoma. His greatest risk factor for acquiring elanoma Is ) A. 2 weeks African safari last year B. Yi a dozen tanning sessions Y,Multiple sunburns during childhood. D. Playing occasional Tennis on weekends for the several years. ) 5. 24 ylo for routine check up found to have >25 moles. No recent change In color or haracters of lesions. w.t.d ) -7 Avoid sun exposure -7 Picture documentation and follow up -7 Tanning salons DON'T decrease risk of Melanoma -7 Periodic self exams looking for following changes Asymmetry Border irregularity Color variegation Diameter> 6mm ) • • ) • • ) 6. The above Pt. asks you If high SPF lotfon7Q'e'm wtll help protect her. You ould say high SPF Is most likely to help her against developing l ,//(, Solar keratoses and Squamous cell carcinoma B. Melanoma C. Basal cell carcinoma ) ) 7. You tell the Pt. that avoldins sun exposure helps prevent .._ ,_ - A. Melanoma B. Squamous cell carcinoma --- ) True or False: C. Basal cell carcinoma. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission T ) I ) T Page 624 ) ) Q58. 55 y/o Pt. with melanoma on the leg. LN(+). Lesion was excised and further lymph ode dissection was done. Which of the following would Improve survival? A. Radiation B. Systemic chemotherapy ,,,,.e Alpha interferon Q59. A 60 y old Pt. with history of renal transplant on tacrolimus. What Is the most common cancer In this Pt. on immune suppression therapy? Above Pt. on Tacrolimus develops a squamous cell carcinoma of the skin which Is xclsed and treated. What will improve carcinoma free survival? 60. A. Decrease Tacrolimus dosage .Z. Switch from Tacrolimus to Sirolimus 61. The above Pt. presents 6 months later with shortness of breath and diffuse ulmonary Infiltrates. BAL shows lymphocytes and macrophages. What is the best anagement? A d/c Sirolimus B. decrease dosage of Sirolimus C. Begin steroids ) utaneous T cell lymphoma Mycosls fungoldes • • • ) • • • Discrete or coalescing patches, plaques or nodules. Later Lymph nodes & other organs affected. Severe pruritus + Sezary cells + in blood smear Biopsy 7 Eosinophilic infiltrate Sezary cell-7 Lymphocytes with hyperchromatic and convoluted nuclei. Treatment: Topical nitrogen mustard Psoralen PUVA • • • • • • ) The most common cause of this eczematous lesion of nipple is Contact dermatitis. If it doesn't respond to adequate treatment consider PAGET's disease of nipple. Paget's disease associated with ductal carcinoma of breast. Treat with wide excision. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 625 • • • Autosomal dominant vascular disorder with red to violet telangiectasia on lips, tongue, extremities. Can bleed7 Epistaxis or GI bleed 7tron deficiency anemia. Dx: Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome). Peutz Jegher's syndrome • • • • • Pigmented lesions on lips and mouth. Associated with multiple hamartomatous polyps in the GI tract7 Increased malignancy _, c..SG n.--:>�1°1 Beefy red tongue associated with glucagonoma. Glucagonoma also associated with skin rash with central clearing. (Necrolytic migratory erythema) Occurs in perineum and perioral areas with cheilitis. Hyperglycemia, islet cell tumor and weight loss. Sweet's Syndrome 7 Refer Hematology (. P.fY\ L ) Blistering Skin Lesions Pemphigus vulgaris • • • • Multiple oral ulcers large loose bullae and some with denuded skin lntraepidermal bullae with antibodies against Desmoglein 1 & 3 proteins ) Pressure applied to one end will cause extension of the other end. 7 Nikolsky sign. Ruptures easily. 62. A 60 y/o man comes to you because of a 10 day history of severe oral ores and a rash on his trunk and upper arms. n physical examination, multiple oral erosions are present on the buccal ucosa and tongue. There are numerous edematous papules and bullae (1.0 to .5 cm in diameter) Pressure applied to the edge of one of the blisters results in 'ts extension. Most likely diagnosis is ) ) A. Bullous Pemphigoid � Pemphigus vulgaris ) Bullous Pemphigoid • • • • • Tense blisters in> 60 y old. Pressure on one end doesn't extend other end. Don't rupture easily. Antibodies against Bullous Pemphigoid Antigen 1 & 2 (BPAG 1 & 2) located at the dermal-epidermal junction. lg G +, C3 & Eosinophils deposition at the dermal-epidermal junction Treat with oral Tetracycline or steroids. 63. Pt. presents with complaints of lesions on legs, which hasn't gotten better in couple of months Pt. had received blood transfusion in 1990 and was diagnosed with Hep C. Exam reveals palpable purpura in the extremities. B/Cr 60/7.2. erum complement CHSO and C 4 decreased. This represents A. Dermatitis herpetiformis ..)Y.1V1 ixed cryoglobulinemia C. Henoch-schonlein purpura Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 626 Dermatitis Herpetiformis Grouped Bullous/vesicular skin lesions in a Pt. with fatigue, Anemia & fatty, foul smelling stools. Very pruritic. Endoscopy negative for bleed, atrophic villi, Small bowel biopsy reveals mononuclear infiltrate in lamina propria. Dx: Celiac Sprue • • Granuloma annulare • • Ring worm like lesion without scaling in the extremities in young women, children. Self limiting in months or years. Pityriasis Rosea / bo� • Herald patch followed 1-2 weeks later by more lesions. • Pruritic small papu losguamous oval lesions in young adults and children. • Christmas tree pattern. Usually in summer months. Treatment: • • Symptomatic Self limited. VitiIigo Macular depigmentation associated with other autoimmune diseases Addison's disease or adrenal insufficiency • ) ) ) • Graves disease • Pernicious anemia • OM • Thyroid dysfunction Cate au lait spots • • _) ) ) I' Acanthosis Nigricans • • • • Hyperpigmented skin with thickened velvety appearance. axillae, back and sides of neck, inguinal creases, inframammary Seen in obese Pts. Associated with gast ric adenocarcinoma Others: • • ) Brown macular lesions that occur in neurofibromatosis (van Recklinghausen disease) If Pt. has HTN -7 rule out Pheochromocytoma PCO Insulin resistance Kaposi's sarcoma (HHV 8) 1> a.lArv:> ru � � > Tx:7 'D 0 x o Y'\Abi � / Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 627 Eruptive Xanthomas Hyperlipidemias 1, 4 & 5 Necrobiosis lipoidica diabeticorum Diabetic foot ulcers, if infected I Diabetic foot ulcers, if NOT infected to keep pressure off the ulcer cc.At Chronic Venous Ulcers Chronic Venous Ulcers with pain What is the best way to monitor for prevention of Diabetic foot ulcers? � ('V\;J'(V> pA� s-_ i.e.� Urticaria Acute: Drugs: •Antibiotics •Antipyretics Infections: •Viral • Bacterial • Parasitic, foods _, J, J e NC ,_ ...., . ""'- -7 pJ·... J. · t. ' '..c. ''"' '-C. '-' .1..u,ot \../4i:a..v -;,i ) ) ) Chronic: Physical factors (heat, cold, touch, press) ) Infections: SLE Serum sickness Pregnancy ) ) Q64. Pt. with raised erythematous area with itching for the past couple of months on and off. Pt. takes Loratadine. When she stops it, it gets worse. W.t.d ) ) ��--�� Q65. Pt. with recurrent itching, wheezing, SOB, dizziness with hypotensive episodes, bdominal pain and diarrhea. Exam may or may not reveal hepato-splenomegaly (50-70% of cases). Most likely diagnosis? A. VIPOMA ) v8". Sytemic Mastocytosis ) Next screening test for above? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 628 Atheroembolism s/p cardiac cath, painful and don't blanch Diagnosis: Fundus shows small crystals Skin biopsy Treatment: Supportive care Control BP • • • • • Others: • ) \ Hyperviscosity, SLE Melasma: Mask like hyperpigmentation Etio: Pregnancy OCP Tx: Sunscreen Bleaching agent (Hydroquinone cream) • • • • I I Exophthalmos -1 Ste..-v\.t � ""\ � &. i:,� ....,;L --7.f'� ) With Hyperthyro� �c.o".)\..c...c/-t.. ?c.1...c.) Tx: with � s � c ,...r·o-t R..A 1. 1-c..&.;.c.1-:"') ) Pseudohypoparathyroidism ) (low calcium and high phosphorus, with normal PTH� end organ resistance) in a Pt. with short stature, short neck, short metacarpals and phalangeals, soft tissue calcification. Nail Disorders • \ I • • Leukonychia Paronychia Koilonychia Leukonychia: • ) ) • Hypoalbuminemia Renal failure Psoriasis • • Placing hands in water for long periods. Pain, redness, swelling of the nail folds. Ox: Paronychia Etio: Staph, Candida Koilonychia • Iron deficiency anemia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 629 Onychomycosis: Ser<-()� Fungal; candida - 'Dx Tx: Terbinafine (Lamisil®) or Griseofulvin _, Splinter hemorrhages • • Endocarditis ( � Trichinellosis C G � e..w. ,..,,.. <P""1'Lt,...c f'V"U,f-) L I<. OH tA-Ln r<>�t) 4 · P"'f �t·· A; o. Onycholysis: Lifting off of the nail Idiopathic Trauma 1' Psoriasis fJ Hyperthyroidism • • • • 66. Which of the following is a manifestation of Hyperthyroidism? A. Yellow nails B. Pitting of nails A. Onycholysis D. Leukodystrophy J Clubbing: • • • • • • • Familial Hypertrophic osteoarthropathy Lung: Cancer, Empyema, Idiopathic lungfibrosis 6 AL_, �t...fl..l'l Heart: Congenital heart disease, Bacterial endocarditis GI: Cirrhosis, Inflammatory bowel disease Cancers Pregnancy _, ) ) Chart 14-7 ) Allergy and Immunology Hypersensitivity reactions Type I Immediate, lgE mediated : ) Weed, pollen, dust, grass, Mold, cat or Dog proteins (Atopic), hives, urticaria, peanuts, shellfish, Bee sting, drugs Type II Cytotoxic, lg G/M Hemolytic reactions, Goodpasture's, hyperacute graft rejection rrype Ill Immune complex lgG/M: Serum sickness, SLE, PSGN, PAN, ,... R.Arth .-Arthus reaction, Hypersensitive pneumonitis. rrype IV Cell mediated PPD, Poison Ivy, Nickel, Type I OM, Acute and chronic graft rejection,Latex. Awesome Review, ) -Z:�l"l -t... �Gi Inc.® Copyright 2014 Do not photocopy without permission Page 630 Matching A 1. lgE mediated �2. Cytotoxic cell mediated A. Type I C. Ab mt.A:.:..�) �3. Immune complex mediated �4. Cell mediated/delayed ...fl_s. Allergic bronchopulmonary aspergillosis ) B. Type II C. Type Ill D. Type IV ._f_._6. Hypersensitive pneumonitis �7. Rh. incompatibility l.£L8. ABO incompatibility ) L'-9. Arthus reaction �10. Serum sickness ....£_11. SLE, PAN, Rheumatoid arthritis, Hep B �12. PPD, Poison Ivy, Nickel, Latex l-...f3_i3, Hyperacute graft rejection �14. Acute or chronic graft rejection le.....is. Allergic rhinitis/Urticaria t ) ) ) LB.JG. Wheal and flare Q67. Pt. with sorethroat' hematuria� Prerenal azotemla. What Is the atho h slolo ? ...._, ..._ __,, ..._�� - Q68. A Pt. is receiving i.v antibiotics for endocarditis. Pt. complains of arthralgias. Mechanism of arthral las Is Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 631 RAST (Radioallergosorbent test) measures lgE in serum. (quantitative immunoglobulins) Skin testing (pin prick test) more specific and sensitive. • • 069. Pt. with rhinitis, ocular itching exacerbated by pollen. Best test? A. RAST ..)Y.'Pin Prick test 70. Can you do skin testing If Pt. is on anti-histamine? ------- � N'J1 y�J.,... 41 �c..Kv11_; <>J S k....'.r, J-u1 "' '°"""t 1 � 4a'1 71. Nursing student started using latex glove for the first time and resents with hives. Best test to confirm Is ) /A RAST for allergy to latex. B. Skin test (pin prick test) for allergy to latex Q72. Can you give allergy Injections In Allergic bronchopulmonary aspergillosls? 73. Can you give a ergy n ec ons to prevent contrast dye reactions or tiypersensltive neumonltfs 74. How can you diagnose ABPA? 75. Effective lmmunotherapy causes an Increase In which antibody lsotype? ) 76. Which med wlll you NOT use during lmmunotherapy? ) as it can interfere with epinephrine tx ) 77. Pt. on P blocker, receives lmmunotherapy and gets anaphylactic reaction. n addition to Epinephrine, what else will you give? ) to reverse 13 blocker effect. 78. Pt. has allergy to ASA. Which NSAID can you use 1 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 632 79. The best way to reduce reaction in a Pt. allergic to radiocontrast media? -7 Diphenhydramine, steroids and lower osmolar radiocontrast. HLA I antigen on most body tissues except RBCs-7 presented to T 8 cells. Responsible for Transplant rejection reaction and destroying tumor cells. • HLA II antigen on B cells, macrophages, Langerhan cells, Dendritic cells Presented to T 4 helper cells. Responsible for cell mediated immunity. • 80. Pt. gets urticaria when exposed to cold \ 81. Which of the following is NOT T cell mediated A. Nickel B. Poison Ivy C. PPD D. Cosmetics/hair dyes /, NSAIDs ) 82. Which anti-Inflammatory drug Is contraindicated in Pt. with sulfa allergies? -7 Celecoxib {Celebrex®) ) 83. A Pt. with latex allergy when using condoms. w.t.d ) 84. Pt. after seeing needle or blood, becomes anxious, pale and diaphoretlc and asses out. BP 80 60 and HR 40 min. ) Dx:-7 Vc...so Vc.t cul .f '(f' Ul f'K' 85. Pt. post IWMI receives tPA. About 30 min. later, HR 35 and BP 70/40. w.t.d At-op I rv. ) to treat the increased vagal tone. 86. Pt. gets urticaria when exposed to heat or hot shower? ) 87. You suspect Allergic Rhinitis. w.t.d ��-- -? N� a� Je.�t,ov"'- s� -fw � e.. 0hr... r � l .r 88. What is effective in any type of rhinitis including perennial allergic rhinitis -7 Cromolyn helpful only in allergic rhinitis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 633 89. Pt. stung by a bee presents with bronchospasm, urticaria, flushing. P 94/60 & HR is 100/min. IVF started. w.t.d next J<."'sQ Epinephrine B. Diphenhydramine C. l.V Epinephrine D. Steroids 90. Which of the following would benefit from immunotherapy? A. Pt. with ABPA with Asthma B. Pt. with Hypersensitive pneumonitis � A bee keeper 91. Pt. with wasp sting with local wheal, burning sensation. w.t.d 7 Cool compression, Antihistamines, topical calamine, elevate for local reaction. 92. Young man was picking apples and was stung by a bee. Next day, he presents to ou with a large wheal on his ri ht arm which Is Itch . w.t.d A. Topical steroid B. SQ Epinephrine ./. Reassure that this is a normal reaction to insect bite. • • ) ) Bee stings on face, neck or throat area can lead to swelling of lips, tongue & laryngeal edema. Bee stings on other parts of the body usually cause a local reaction. ) ) Chart 14-8 ) Immune deficiencies • Multiple myeloma • AIDS • • • ) � Antibodies (Immune globulins) • l Increased risk for capsulated bugs: S.pneumo, H.influ, Meningococcus Asplenia ALL/CLL ) CVID ) B cells 7 Plasma cells 7 Antibodies (HLA I I ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 634 93. Most common lmmunoglo6ulin Cleficiency 94. Does i.v immunoglobulins help in lgA deficiency Q95. In lgA nephropathy, what is complement level? ) ) 96. A. Hepatitis A vaccine B. Hepatitis B vaccine C. FFP � IVIG E. Platelets ) 97. 32 y o Pt. witn recurrent sinusitis for the past 5 yrs. He had a nasal endoscopic urgery done couple of years ago. Now presents with facial pain and X-ray shows total aclfication of maxilla sinuses. w.t.d next \ ) ) ,,.K.immunoglobulin titers ) ) \ ) A Pt. has severe lgA deficiency. which of the following would be contraindicated? B. Allergy testing C. Antral puncture for c/s 98. Pt. witll recurrent bronchitis for the past 25 yrs. Wilen fie tal<es TMP-SMZ tlis infection esolves. CXR normal. w.t.d A. CT sinuses ,.)Y.'l mmunoglobulin titers • ) ) Neutropenia: Bacterial: Pseudomonas, Corynebacterium jeikeium Fungal: Candida, Aspergillus, Mucor Tx: Increase count with G-CSF and treat appropriate infection. Phagocytic defect: Staph aureus, gram negatives, Fungal, Nocardia. Able to ingest and unable to digest, recurrent infections, family hx, NBT abnormal.(failure to produce 02 super radicals) • Dx:� c, h. � 'i}.,,.� � """h,...., ol/ J' NADPH oxidase deficiency. Tx: Interferon 'i and antibiotics (. O c... tt r-if""V ) Page 635 • Chronic mucocutaneous Candidiasis Candidiasis of skin and mucus membranes. Severe, recurrent thrush, onychomycosis, vaginitis, and chronic skin lesions. The skin lesions may assume a hyperkeratotic, crusted appearance on the face, scalp, and hands. Q99. Solitary furuncle infection 4 times in the past 5 years. Easil treated with incision and draina e. Pt. is otherwise health . Dx: Nasal colonization with Staph. ,,..... f'\."-y<A '- � 0J..:.'".Jo Can eradicate with Mupirocin oint. and Rifampin • c--- l'\.c..:Jv, Complement C 1 esterase inhibitor deficiency: Hereditary angioedema. Don't respond to Epinephrine but to FFP. :f 100. Pt. after a pillow fight, or after camping with nQn pitting faclal ed,ema. o itching. Pts. sister had similar s m toms sometime ago. Most likely diagnosis 101. A teenager presents with swelling of his arm and forearms, no erythema or tchin . Sister had similar com lalnts some time a o. what do ou ex ect? A. Eosinophilia B. lgE elevation ,,Jc. Low C4/CHSO 102. Pt. post exercise, develops swelling of his arms, no hx of trauma. amil Hx, Father died at an earl-a-e.�� w.t.d � � A. Cl ,,%."C2, C4 C. C3 ) 103. Pt. was hiking In the Shenandoah mountains and presents with facial swelling, ....-.z ...u.:.: r.:.i.:.:� � �g !.1..1&.... l.l.l.ll .. rallol"--��-- ) A. C 1 level ) 0Y."C 1 esterase inhibitor activity level. ) 104. What is the best management for a Pt. with facial swelling, laryngeal edema ith hx of C 1 esterase inhibitor deficienc ? A. SQ Epinephrine ·UY. FFP 105. The above Pts. acute episode resolved. What is the best long term management? A. FFP monthly B. IVIG monthly Y,Danazol Page 636 Matching Complement 5-9: Neiserrial Infections: Meningococcus & Gonococcus. A 1. SLE 0 2. lgA nephropathy c .J t-- A. Complement decreased 11' ) C4 B. r-- h._3. PSGN CJ J, Complement normal � NI.. L4. Wegener Ui-5. Churg Strauss JL6. PAN } �7. Cryoglobulinemia C41 .V )' C 3 �8. Goodpasture's syndrome ) \ I ' I , \ ) I \ I ) ) \ I L..A.9._ . Membranoproliferative nephritis 0106. Pt. with hx of meningococcemia and gonorrhea. Which test would you order? A. Cl B. C2 C. C3 D. C4 E. CHSO -7 � olt..CNU.M _, c� k .fw Cs - c..5 0107. Pt. with SLE. CHSO is undetectable. which complement component deficiency ill you suspect A. C 5-8 B. C 9 ...-(. C3 D. CS 0108. Pt. with recurrent Infections Including skin, sinusitis, pneumonia and now with iver abscess. lmmunoglobulins are normal. CHSO is low. Which complement Is going to be deficient? vt( C3 B. Properdin . c. cs Major Opsonin of the complement system responsible for defense against encapsulated bacteria. / Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 637 An AWESOME REVIEW OF • I • 8% Pituitary gland Prolactinoma - Thyrotoxicosis Hypothyroidism Diabetes Mellitus Diabetes lnsipidus - Calcium metabolism - Cushing's syndrome - Addison's disease Perimenopause - Sexual dysfunction - Amenorrhea Hirsutism Awesome Review lnc.1t Copyright 2014. Do not photocopy without permission. J Chart 1-3 The Pituitary Hypothalamus GnRH I I I I I I I I Prolactin I I TSH FSH & LH ACTH Oxytocin ADH Chart 2-3 5creening for axis function Hypothalamus-Pituitary- Gonadal axis ; Serum LH, FSH Hypothalamus-Pituitary-Thyroid axis .;;. TSH/T4 Hypothalamus-Pituitary-Adrenal axis ;; ACTH Most sensitive determinant of Pituitary function 7 FSH/LH level �creening for h ormone excess Prolactinoma 7 Prolactin level Hyperthyroidism 7 FTl/T4, TSH �cromegaly 7 IGF-1 level �ushings syndrome7 1 mg DMS Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 94 Ql. In a Pt. with MVA, CT head was done which revealed no bleed, but a 0.8 cm. solid mass onfined to the pituitary. Pt. is nulliparous and menstruation is regular. w.t.d next vK Check Prolactin, T4/TSH, IGF-1, 1 mg OMS test B. C o sy nt rop in test, Insulin stimulation test, TSH Chart 3-3 The Pituitary Dopamine , , , ) \ ) ) } ' "' , , , �Prola� , , , , , , , , , TRH GnRH ..j; , � T 1-i�pa�viri ct t .s � FSH&LH 1.rv\p.:>tert.� "" d'7 A�..Y� N. � ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 95 Chart 4-3 Hyperprolactinemia Drugs: Prolactinoma Pituitary tumors Dopamine Nipple manipulation (prolactin ma y be nl) Phenothiazines Reserpine Methyldopa Amitryptiline Estrogens Marijuana 1' _, NW.W(A f,f'\ ...,.,,.� f'j, 1:£ l:t. .11.v....,..., ..... "J� C bett:- ) Pregnancy � hyroidism Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 96 Chart 5-3 Prolactinoma Prolactin level >2007 Macroadenoma <2007 Microadenoma Dopamine Cl ft: Galactorrhea & Amenorrhea in � Impotence in CS ) Tx: Cabergoline failure (Dopamine agonist) If elevated prolactin level <100 & NO symptoms7 Obf<Nl Q 7., MR..Z \ I ) ) ) Surgery J oyoL c.orl'I...-� u.rt.:v<- t Prolactin 2. Middle aged male presents with decreased libido and fatigue. Testosterone level low, SH low. Next diagnostic test ) ) ) A. CT head B. Ultrasound testicles _.&;- Prolactin + TSH D. Repeat Testosterone level. 3. Pt. has galactorrhea. what to check next? 4. Young woman presents with galactorrhea on manipulation of nipple. TSH + Prolactin are ormal. w.t.d 7Avoid manipulation of nipple J ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 97 5. 35 yr. old woman presents with galactorrhea and amenorrhea for past 6 months. regnancy test negative. Prolactin level 184 ng/ml. Thyroid function tests normal. w.t.d next? A. Start Cabergoline � Do MRI ( �\.,...;? U>..-Jir"" bJti tx ) 6. Pt. postpartum continues to have galactorrhea after finishing nursing the baby. TSH is .8. Prolactin level is 281. She takes no medications. Most likely cause of her galactorrhea is A. Lactation C Nevt-v '? '2.v<:> ) ( � '! 2CJ\J -1 �d MR1 ) Y, Prolactinoma C. Hypothyroidism l7. A 45 yr. old male presents c7o fatigue anddecreased libido for the past year. Serum testosterone Is 18ng/dl (nl 300-1200ng/dl) Serum prolactin Is 2500ng/ml Serum FSH Is 2.2mU/ml (nl 3-15) Most likely cause is A. Primary hypogonadism B. Testicular tumor C. Brain tumor ......0: Prolactinoma E. Addison's disease 8. Pt. with prolactinoma (micro or macroadenoma) has amenorrhea and wants o conceive. w.t.d? -7 MM.D"'Qptil"\.L to reduce prolactin level and induce ovulation. (Pariodel®) .stc....t cA...o� Ar-t Nl4.. 9. Pt. treated with bromocryptine for macroadenoma and gets pregnant. w.t.d then w.t.d -?monitor visual fields every three months -? no changes -7 do nothing -?changes in visual fields -7 �"' bvo fYVO c..(1pt..:A..t.. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 98 'Increasing shoe size/hat size/Ring size, hyperglycemia' Prominent jaw, wide space between teeth, big tongue, Fleshy (increased soft tissues) palms and soles. Osteoarthritic changes on X-rays. I C.C-1 Best screening test7 Confirm with Also for following disease activity �k..U>t<.. J\ffrCRh C...t. failure to suppress GH to <2ng after 100 g of Glucose OYC .. t 7 Tx: Transsphenoidal surgery ) \ ) ) I 7 (. .1 $'�� 'tostc. h/- � Ol...o � ,.., ' ·) t 0 (. ,...e<> � c.\L _ - e.� I,,.. 1_.,,, .L -y$<. C.vt. �':J ve.,Yl c.< e q;_GA-c....I VZPOM/), Complications: • HTN, LVH, CHF - �8";J�"' • Sleep Apnea syndrome • Colonic polyps and Carcinoma: Surveillance colonoscopy indicated • b-rev:s ) Carpal Tunnel syndrome (_ Abcli,,ct..v eoll-1 t..: s labetes Mellltus Diagnosis < 1 o-o fY'J / ol L Normal blood sugar 7 Fasting blood sugar > 1 2 6 rvj j oLL 7 b. 5 HbAlC criteria for Dx. 7 x 2 Fasting blood sugar 7 I o o - l 2-Cc. ) ) Random blood sugar 7 / 2VO w.tt.. � rf� 75g 2hrs GTT Pt. had a fasting blood sugar of 127, what to do next? 7 t<t.pe,,.f Pt. had a fasting sugar of 118 and HbAlc of 6.5%. What to do next? Repeat th labnormal test! 7 Repeat H AIC. ) A 35 year old Pt. with blood pressure of 135/80 OR A 36 year old Pt. with body mass index 26 with sedentary l ifestyle OR A 40 year old Pt. What will you check next? ) 7 ,:,(35_ (o., hAIG ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 99 10. Pt. had FBS of 129. Repeat FBS is 127. This Pt. has A. DM, but no risk for Retinopathy and Nephropathy now jY."DM and at risk for Retinopathy and Nephropathy now 11. 24 yr. old Pt. with FBS of 140mgldl. Relatives ave Type II OM. How would you ifferentiate if this Pt. has Type I or Type II OM? -?Check for Antibodies to Glutamic acid dehydrogenase, the earliest ab to appear in Type I DM. Later presence of antibodies to islet cells as well. reatment Options: Diet and Exercise fj. .Jt / y. M t1 �l:J Type I -7 Insulin / y, � /1 '3 S Type 11-? S ulfonylureas +/- Biguanide +/-Repaglinide +/- Glitazone +/- Insulin o,I?- ''I· +/- Exenatide/ lncretin drugs C c..v->" ri"" R.uv1 Jc.-t.-> No �B� o.G- o.�y. Insulin: • • • • • � 1 y, All Type I DM Type II not responding to Oral hypoglycemics/Type II with normal weight Type II on oral medications hospitalized; Major Sx./ Infections/Vas. acc. Hospitalized Pt.s with increased glucose i rrespective of the reason for increase in blood glucose (steroids, stress, etc.) 140 - 180 mg/di Pregnancy 1k Hospitalized Pt. with diabetes, treat with basal insulin and rapid acting agent / c.u"CA/k.L. o--A- pt. . C\lt'.A r., �11 Sulfonylureas: Glipizide (Glucotrol®), Glyburide (Diabeta®, Micronase®), Glimepiride (Amaryl®) Increase release of Insulin from p cells. By itself or as adjunctive Tx. Use in normal weight. Avoid in obese. � Meglitinides: Repaglinide Increase release from p cells. Excreted through bile. Hence drug of choice in Renal insufficiency. Rapid acting. Biguanides: Metformin (Glucophage®) � Hepatic gluconeogenesis, � Insulin resistance, �Weight� TGAs/Chol. Tx of choice in Obese Pt.s and with 1'TGAs. 5% with lactic acidosis. Avoid in Renal Insufficiency/Failure. Glucosidase inhibitors: Acarbose (Precose®) M ti �� &.. Inhibits breakdown of Carbohydrates and decreases absorption of glucose. Mainly for postprandial hyperglycemia. a }v<- pw.<. d.ex ��. �G.l\f' J...:� �v: 1l l-lM: M "b.>wb � ''f,:' /£• Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission pt t,,.Jw, Al.�U t!ot,�· !/J ,v, {· ., (,I Page 100 Thiazolidinediones 'Glitazones': Pioglitazone (Actos®) Bind PPAR 'i receptors-71'Glucose transport, -i- Insulin resistance -i-TGAs, 1'LDL, 1'HDL. Should be avoided in Pts. with CHF NYHA II. Edema �(iv �o"' l ncretin mimetics : Exenatide (Byetta®): GLP 1 agonist. -.lthepatic gluconeogenesis, -.ltGastric emptying, Weight loss, early Satiety, 1'cell growth. Good agent for Obese pts failing Metformin +/-Glitazone+/-Sulfonylureas. Other mimetics: DDP-4 inhibitors: Sitagliptin (Januvia®), Vildagliptin (Galvus®). Side effect of Exenatide -7 Nt:."4 Su;.. Side effect of all lncretin mimetic drugs-7 pc.(\c.,.�t�s Amylin analogue: \ ) } I Pramlintide (Symlin®): Slows gastric emptying, -.It Glucagon secretion, Weight loss and early satiety. Complementary to Insulin. No hypoglycemia by itself. Good for obese Pt.s failing Insulin therapy with high post prandial BS and gaining weight on short acting insulin agents. All Treatments cause weight gai �XCEP±J Metformin, lncretin drugs (Exenatide) and Amylin analog Pramlintide. ADA recommended Blood sugar goals in DM: -7 < + Y. HbAlC '\ o 1:..o I 3 ° -7 Preprandial glucose between Peak 2 hrs Postprandial glucose -7 <. \ N ) 12. A Pt. with BMI of 32. His FBS Is 115. Family Hx. is significant for OM. est way to prevent onset of OM? ) A. Start Metformin B. Start Glitazone (Pio) ,../Diet and exercise ( A e...-.:i b ,· l \Yo ) ) II ) FBS -7 < '1 o 1 hrPP -7 < 14 o 2 hrPP -7 < I 2-.::> ) } Pregnancy PL""" 'r(:. �St. cvv-c. f:-vc:M "'-' NI .J ) Drugs that can cause hyperglycemia Statins • Beta blocker • 1>4* Hydrochlorothiazide • Niacin • Olanzapine • Protease inhibitors • Steroids • I Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 0 1 Q13. A 45 yr. old woman was diagnosed with Type I I OM 4 months ago with FBS of HOmg/dl, HbAlC 8.9, weight of 205 lbs. She Is started on an Intensive exercise and :fiet regimen. Repeat FBS is 165mg/dl. w.t.d next? A. Start a Sulfonylurea (Glyburide, Glipizide) Xstart a Biguanide (Metformin) C. Start Insulin D. Start a Glucosidase inhibitor (Acarbose) E. Insulin + Sulfonylurea 0.14. Pt. with type II OM and obese, not well controlled with Sulfonylurea. w.t.d �Add Metformin B. Add another Sulfonylurea C. Add Acarbose. 15. In the above Pt., whichdrug improves insulin sensitivity? �Glitazone B. Metformin C. Sulfonylurea Which has shown to improve mortality in diabetes and early heart failure? -7 Metformin 16. Above Pt. with Type II OM responded well to Metformln and Sulfonylurea for everal years, but now with Increasing blood sugars. No Infections. HBAlC 9%. W.t.d. next -7 Acl<l 24 �v' ]la' 0 Tf\S� 17. In the above Pt. what drug do you Intend to keep with Insulin. A. Glitazone _,,,8".' Biguanide C. Sulfonylurea 18. The above Pt. does well on Glarglne Insulin at bed time and Metformln for a year. Later BAlC Is 8%, but FBS 115-130 range. W.t.d next? A. Increase dose of Metformin B. Increase dose of Glargine insulin v(. Start Lispro insulin Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 02 \ in jections. w.t.d next 19. The above Pt. refuses Insulin� ----�-�----�-�---��-A. Continue Metformin .......!)."'C ontinue Metformin, add a Sulfonylurea or glitazone C. Add Acarbose D. D/C Metformin, Start Sulfonylurea or glitazone 20. In about 5% of the Pt.s Metformln can cause 21. When is metformln contraindicated? ------ \ Serum Creatinine �? 1. "t µ.. <>x / ) 1. S ;,n c?' i f>ir;I\/� Ch� 22. Pt. with OM on multiple medications. Cr Is > 1.5 and CHF with E F <35%. wt.d � J ) ) ) ) ) ) ) ) I v<.'dfc Metformin & Glitazone, Start Glargine or Detemir & Lispro or Aspart 8. d/c Metformin, continue Glitazone and start Sulfonylurea 23. Pt. Is going for Cardiac cath or any radlocontrast study. Which drug will you stop on the a of the procedure? A. 13 blocker 8. Insulin C. ACE inhibitor � Metformin ( stc:vvt 2.'1- '18' "'-"",. c;.,tt.... c>--.r.c.1c<.":I c.,.. ) �24. 60 yr. old Pt. diagnosed with type II diabetes and B/Cr Is 40/3.7. W hich Is the best medication to start? A. Glyburide (Diabeta® Micronase®) 8. G limepiride C. Pioglitazone ft, Repaglinide L:.f\.c,. �P � �d.. <. � B f:.v:> 25. A 40 yr. old Pt. with type 2 OM was treated with Metformln. A year later, he starts alnin wei ht, as he had stop�ed exerclsln His blood su ars o u as well. w.t.d _____, • A. Increase Metformin dose 8. Start Glitazone C. Start Sulfonylurea .)?f. Start Exenatide ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 103 awn's Phenomenon: J, (1'4-7 am glucose 2° Insulin resistance/hormonal factors. Tx: 1' PM NPH ) ( Pt. with fatigue, increased sweating and waking up with headaches+/ vivid dreams (nightmares} ( f\.«�t ....,"J. � 6l:JtU'-°• ) ) FBS ranges between 120-145. Takes NPH at supper. What to do next? .f'WA b� _ l '/. ,,.. 2/. ::. "f'I. -7Check nocturnal BS, if ..V-7 reduce NPH or move NPH to bed time or change to long acting (glargine or detemir) rr>s c...� wt l Z.Lr /.w') r-o c:J "l "1 pt I�1-J/,kA<c. - � Matching - Po1t �·L 1" • H Alt. ::: l2J. -' Diabetic Pt. on NPH/R In A.M & supper or Glarglne hs. Each of the following w.t.d ,b. Palpitations, excessive sweating, nocturnal A. awakening, AM headaches. w.t.d next B 2. Blood sugar at 3 am is 40mg/dl. w.t.d c 'lw) (,r....µ,1c, 1-1!::> �lf.c..t...p"-..cAo\ 3 am blood sugar B. Change NPH to hs or switch to long acting Insulin analogue hs (Glargine} - C:....J . Persistently elevated FBS. 3 am blood sugar 200mg. w.t.d C. Increase supper NPH or Glargine dose 'l> 4. Blood sugar 30 and Pt. passes out at 12 noon, D. D/C = R in AM on 20 U NPH & 6 U 'R' in AM w.t.d �I< 4!i """' ' 6 5. Blood sugar 180mg at 5 pm. w.t.d F 6. Blood sugar at 4pm is 25mg and at 10 pm it is 210mg. Pt. is on 36 U NPH in AM. w.t.d ' E. Increase NPH in AM F. Change to 24 U NPH in AM and 12 U NPH in PM Matching iLJ.. A Pt. with following Blood sugars. Pre Meal Post Meal Breakfast 160 165 Lunch 170 175 Dinner 176 178 Pt is on Glargine Insulin 20 U at night and Lispro insulin 4 U before breakfast, Lunch and Dinner. w:t.d A. Switch to twice daily NPH �2. Pre Meal Post Meal B. Increase dose of Long Breakfast 128 196 acting Insulin analogue. Lunch 132 210 116 Dinner 202 Pt. is on Glargine Insulin 20 U at night and Lispro insulin 4 U before Breakfast, Lunch and Dinner. w.t.d :k__3. A Pt. with FBS of 115. HbAlC is 7.5%. He takes NPH or C. Increase dose of short Glargine at night and Metformin. w.t.d next? acting Insulin before breakfast, Lunch & Dinner. D. Check post prandial blood sugar Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 04 26. A 65 year otd man wit dla etes was starte<t on glarglne Insulin 30 units every evening n addition to the metformln he was taking. Blood sugars are as follows 7 AM 12 PM Day 1 Ill 97 130 120 102 112 104 133 113 lO PM 202 194 203 S PM 212 201 196 What is the best management? A. Increase the dosage of glargine B. Switch to Detemir insulin / Change glargine to twice daily D. Increase aspart or lispro insulin in the evening \ \. 2 . H ow woulCI you start an Insulin reg men of Glarg ne anct flspro n a Pt. wlttl 601<gs? Glargine insulin with -7 .Si--fPe-... J ) Give other Yi i.e as lispro divided as tid. i.e 5 units B-L-S ) J A. Glucometer malfunction Y, Hemoglobinopathy " �� ) Falsely elevated HbAlC "' Chart 6-3 Falsely lower HbA1c Decreased RBC turnover Increased RBC turnover ( Decreased reticulocyte count) (increased reticulocyte count) Iron deficiency anemia, Folate, B12 def. Hemolytic anemias, lj]Y Hemoglobinopathies (not because of ..\e1«- """' Treating iron deficienc� anemia, Folate, illf� RBC turnover) , o� � �"'t3',,.. t B12 def. Or Blood transfusions Sickle cell trait, thalassemia trait, etc. c."-"""Pt. with HbAlc of 6.6%. Preprandial and postprandial blood sugars range between 90-150 except at 5 PM blood sugar is 280. She has fresh fruit snack around 4 PM. - What is the etiology? -7She is most likely not \.JM'h:.":J � after eating fruit and checking blood glucose. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 05 29. Pt. With diabetes with BS: 340, with TG 2400, is hospitalized with pancreatitis. he fastest wa to control the triglycerides would be to give. ��A. Metformin � Insulin C. Gemfibrozil Q30. Pt. with IDDM with abdominal pain has OKA, started on Insulin drip at 10 U/hr. and IVF. Blood sugar decreased to 250 and IVF changed to 95N5 and Insulin drip decreased to 5 U/hr. :!> s Y'J. rJ S abs as follows 3 hrs later 138 4.2 109 16 275 Admission Na 135 K 4.7 Cl 102 HC03 9 Glu 675 w.t.d Now 138 4.4 106 13 375 If' r>r � A. Continue same �Increase Insulin drip to 10 U/hr. Above Pt., blood sugar down to 175 and ketones are negative. IV Insulin stopped and sliding scale regimen is started. Couple of hours later blood sugar is 325 and ketones are again positive with an anion gap. How could you have prevented the Pt. from going back into DKA? -7 Giving subcutaneous insulin 30 mins before stopping IV insulin drip 6 hours later, ketones are positive and anion gap is normal. What to do? -?Continue current management (the ketone here that has shown up is acetone which is biochemically N EUTRAL and takes a longer time to be cleared. The ketone that caused acidosis in DKA is �-hydroxybutyric acid which has cleared as suggested by the 31. Pt. presents with Diabetic ketoacidosls. BS 725mg/dl, Ketones strongly ++ +, Pt. Is tarted on i.v Insulin drl and l.v fluids at 10 am. At about 7PM BS is 250mg/dl. w.t.d next -7 s"tc...,t iv � U\:Jv. f..{ '4 �"(( 'J) 5 � N s 2. GJY\�""""- ..VU � �.,.;,p The best way to follow diabetic ketoacidosis management is Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 106 32. A Pt. witfl OM aamitteet for surgery in AM. He is on Glargine and llspro. w.t.a on ttie ornin of sur ery? IF the Pt. receives�----��-Glar ine in AM w.t.d? A. d/c both and start sliding scale insulin ___.IY. Yi Glargine and d/c lispro Q.33. If the Pt. received Glarglne last PM. W.t.d --��--��-�-��-��-- vK d/c lispro B. d/c lispro and start sliding scale insulin iot:..l Matching .\ _12_i. 24 yr. old pregnant woman 24th week. FBS 115, repeat FBS A. Insulin .}2__2 . 26 yr. old diabetic pregnant woman 24th week with FBS 120 B. Exenatide 114. w.t.d? and Post prandial 180 on Glucotrol and metformin. w.t.d ct-',.., o .....l. St:c..-• N..s...L.'.,. ) \ ) ) ) ) ) ) Il ) } ) ) <.'JD I 1ov PP < / '1 ° 2 "-" Pp < 12<> C. Pioglitazone D. Metformin I ) F(3S 34. Elderly Pt. with Type II OM brought with an episode of seizure. lood sugar 1050mg/dl, BUN SOmg/dl Creat 1.8mg, Ketones + Dx: Hyperosmolar nonketotic coma. w.t.d next Next-? Insulin '-' � V\. '\.. ) __, ('{<. J,. z. s �\...<,.:>� 1lii>' ciS of 1f. � J c,i� � :4_: ----35. Pt. with Type I OM presents with OKA. Blood sugar 725mg/dl and ketones strongly +++. (_ 1.r\J'"U-, 6> - t. Is started on l.v insulin drip at 10 AM. By 10 PM the same day, the BS Is 200 and ketones eg. Bicarb. has gone up to 18 from 4. K dropped from 5. 7 to 4.5. Pt. complaints of difficulty reathlng and muscle weakness + .CPK MM Increased. JVO 3cms. ost likely cause Is A. Hypermagnesemia B. Hypercalcemia C. Hypocalcemia Y, Hypophosphatemia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 07 36. A nurse calls you to let you know, that a Pt.'s FBS Is 62mg/dl 1. Asymptomatic. W.t.d? 7Adjust treatment regimen 2. Symptomatic with tachycardia, sweating what to do? 715 g of carbohydrate [glucose tablets, candy or sweetened fruit juice] If Pt. is on Acarbose, then pure glucose [dextrose] and adjust treatment regimen. 37. Newly diagnosed Pt. with BG of 350. On Insulin when BG drops to 130. Pt. becomes ach cardlc and dla horetlc. W.t.d? Complications: Macrovascular: CAD, PAD: Aggressive Microvascular: Nephropathy: Microalbuminuria: Retinopathy: Non Proliferative: Proliferative: Neuropathy: Peripheral Neuropathy>Autonomic Neuropathy Peripheral sensory motor polyneuropathy: > � o.��t'lt.,..,, �, 'De.s;f""� , 7 n r ·o Stock & Glove paresthesias Autonomic neuropathy: 7 ph.osp�<'U est.c..-� 1'l"��v.s Impotence: * Neurogenic bladder: Urinary hesitancy, dribbling, incomplete evacuation. Urodynamic studies with retained Uri '}¢ 7 Ii� b c:. � 'l"'V\/'M v; P..t ( � e7 be-fl:\.. CV\..L<.hc/\. Orthostatic hypotension: & high salt diet. �1�0.....oc.01�J'crN.Gastroparesis: Wide fluctuations of BS 50-400mg/day '7,.c.lo�perit...:.. u 2. hr) · Foot Drop or Wrist drop Diabetic foot ulcers: Most common bug: st'T'"'- Pru. , � hemolytic Strep. Cause of foot ulcer L J..:.fl. j �r I . v (/(\..O \J Best way to prevent ulcer7 ,..,/\ l-e; f�,..... L-' �J _. £)_te.c..t,.."\,£_ fl'\J fV> t wC'V\.. . Best Test Su. f\.ti .J<-c..r.J' of residual gastric contents. Ingest isotope and scan immediately and then two to four hours later Tx7 Small frequent meals of � '1\Nd<..m pwt.e?- with low fat and low in non digestible fiber � 7Metoclopramide/Domperidone Awesome Review, Inc.® Copyright c;l..-et -- 2014 Do not photocopy without permission Page 108 True or False about Diabetes Mellitus 1. A type I DM Pt. should have an annual eye exam after about 5 yrs after onset of DM or age 30 which ever occurs first. I 2. A type II DM Pt. should have an annual eye exam from onset of disease. I >-- T 3. A Diabetic Pt. who has difficulty driving at night will probably have erectile dysfunction. I- ) ) ) ) ) } ) ) 4. According to ACCORD trial HbA1C <6% compared to 7-7.9% had increased mortality I 5. According to ACCORD trial HbA1C <6% compared to 7-7.9% had increased hypoglycemic events I 6. According to ACCORD trial BP <120/80 compared to <140/80 had more J, side effects. 135/ 8-0 T (�\/CA.� "1,V[E I 1... oJ'I J 1' o rv> v-""" c... IV'\ b..d; P"'f> i I , �) f>r u. o"""J...c..h' o..... - f<t.j-L&,. ..... a.N1 . .,...,.,it ""'c.�""" -r e,c.c..� k � t" ��pe,,.e..�r. 39. What a re the current recommendations for follow up In a OM Pt .. HbAlC Microalb. Lipid panel Ophthal exam A. Semiannual Semiannual Semiannual Semiannual � Quarterly Semiannual Annual Annual -7 Ao\�t i 7..V '.DextY-o.re. �Urine +/- serum Sulfonylurea screen B. CT pancreas C. Glucose tolerance test 42. Above Pt. continues to be hypoglycemlc. An amptµte-of. 050% 1$ �en .a,nd tv extrose Is started. What Is the best management? ) ) j Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 09 Chart 7-3 rT3 Systemic illness Inactive �-----��.,,;.l 'j> 3 t II\' "'·. s� [ Propranolol Glucocorticoids PT U C 1.f.t t.rlr.MJ tt..) Amiodarone ( i oct.N. , )-+ 7� t,, T3 ( .Jj�-lJ 'l.) '--------------------------.--------� •t.;u.MSingle best test to screen for Thyroid disease Si<.f< � ft..!:)�tl f _, J; T S>-i � T3 c.c..�<UG..<.. C.4 � 't" rfj: _., 7Next confirm with T4/FTI (.: � •:t> 12 't>">') Best test to follow for Hypothyroidism treatment 7 IS'1 Best test to follow for Hyperthyroidism treatment py...;.od..AYr.r.> "¥ t,. ""- In Thyrotoxicosis T3 Radioiodine uptake (RAIU): Hyperthyroid states: • • Graves disease Hot nodules J, Thyroiditis • • Exogenous Amiodarone Radionuclide scan: To differentiate Hot Vs Cold nodules � ......(. .r�1t.::i 'lT1 'Y C.kttc. C..CAA OIL-"" re� NL(Jt COJ..A.JA- 7J'>1 . i=; ft: - nA"'··� cu..t.; ;<f\A.'t'U t -t < s r. "'f� k ( �Yvkli f;;J) J, h It._� -t �� c. Pi(">. � po.,.J. h Jt:c..1-c. _, I�" �/ �<. 111--1 1 G WC.. <.A"t4-L NL. Fine needle aspiration/Biopsy-7 Cold nodules Ultrasound-7 differentiate Solid Vs. Cystic nodule Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 110 Chart 8-3 Hyperthyroid states II Graves Disease u iD GD GD �8lob...u"'1' 00: 'Th.;,�/iif3:� GD GD ) ) } ) ) ) 1' Qw Q Jt 'I t I T3 Thyrotoxicosis N/J t Thyroiditis . • , .· . - . . . . II t 1' T4 ) 1' t Exogenous (Factitious) Tl 1 ) TSH Toxic Nodule TSH adenoma ' J TJ RIA 1' Multinodular goiter t 1' Jt t t 1' Hypothyroid states , (}{) '111 (U) . Hypopituitary Hypothyroidism . , J j; ' Jt 1' )3�/. 1' 6 6 .Jt 1' J 1' � r t 6 � 6 J, - Primary Hypothyroidism RAI l'i t'k) FT4I <. sr. J, J, J, J, � - ' 6 1' J; $ �'--- .... .. ( R, � t.. 43. Pt. presents with weight loss, feels warm in winter, tremors {+), appetite Increased, larrhea, palpitations, Aflb /E: Thyroid enlarged. abs: FTI 1', TSH .J...J.., w.t.d next? 1- Di ffuse 7 C,Ye., � 1- Focal 7 k j, Upta e 7' � Tox;c.. rvoJ...,J..L, l h.... ...,)il: C,.J r O"") L' · J Areas of 1' & w uptake 7 �a;t.:t:IA-I T1.v:3 v->t<»)(I' (..o � (Y\..,.(t_- "'°""� a cf\.tv Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 1 44 .Pt. with hyperthyroidism and decreased Radlolodlne uptake. How wlll you differentiate etween Thyrolditis and Factitous thyrotoxlcosls? • ��N\cli�_i; 1' Thyroglobulin -7 � Thyroglobulin -7 !=act t'.UIM 1 TBG -7 Any Pt. with Afib -7 Es��' L p-.pi ll c;; ) f\/Ut tvu..cl..-t � �:Jvotox ,· (..a:.:J Pr:f(\.� --r� yO t:.y ,·w N" Rf.:;, ( Ft)l�t� R.Q..i:.,'t\""•L (� __.., � T3 NL TSH NL ( tLA.�..,.;.A. 1�>4i/')-\.;c.,.) 0.45. Elderly Pt. presents with weakness. EKG reveals Aflb. TSH decreased. M ost likely etiology of Aftb Is 46. Elderly Pt. brought with apathy, weight loss, arrhythmias, CHF, diarrhea, epresslon, sleepiness and muscle Wt!akriess. TSH decreased T4 tow normal, T3RU >30%. D,.1, A.,,,MRI ,< brain ( 1>""' _,,,x. B. Repeat T4 level -T�, , ., .. n Tf''-'" 1' ) TfH �� Nl,.. A. She has Graves disease B. She has thyroiditis /,She is taking thyroxine D. Her symptoms are related to exercise. 1n lnsurahce exam. Dx: Subclinical Hyperthyroidism. w.t.d -?Treat only if Osteoporosis or Cardiovascular disease is present Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 2 Treatment of Thyrotoxicosis {TSHr Abs (+), antiTPO (+)) ( S.E: Agranulocytosis, ANCA + Abs , Pregnancy fY\.'j<� P�"x,'t(.rv<- Others 7Radioactive lodine7 >50% become hypothyroid in < 2 mths Thyroid ophthalmopathy 7Subtotal Thyroidectomy II 50. A 52 yr. old woman is admitted with Pneumonia. Exam reveals the Pt. is confused and itting the medical staff and inattentive. She has diarrhea as well and family says she lost 15 bs. in the past 6 mths. Temp of 104.S f, HR 140/min, Rales on both bases. CXR reveals a right ower lobe consolidation. On antibiotics, 2 days later she becomes hypotensive and then omatose. \ Tx:7 I -t J Infections, Surgery or Trauma can precipitate this. ��·��-- 51. Can you cardiovert Afib to NSR at this time. ) 7 No. Not for atleast 3 months after Euthyroidism. Spontaneous conversion is common. ) 52. Pt. with Graves disease had Radioiodine ablation. 8 wks. later he has gained weight. SH Is 0.2 (0.5-5) Free T4 is 0.2(0.8-1.8) w.t.d next? T .r,., o. z L "Low) b...t "" } ) 53. Above Pt. presents 2 mths. later with watery eyes, scleral injection and perlorbital dema. Exam reveals an afferent pupillary defect on right eye. Painful eye movements. ost likely diagnosis is ) ) ) � A. Repeat TSH in 5 mths. ystart T4 7 Thyroid ophthalmopathy l.Nl11\. op�c.. f'IV Nv°'-pit'\.(Y� -4 ..l'te.-vi..d... 54. Pt. with thyrotoxicosis with ophthalmopathy. Best management? 'i �Surgery B. RAI ablation Thyroiditis • • • All have '°11 RAI uptake. May present with hyper, hypo or euthyroid states. Release of preformed hormones7Thyrotoxicosis7 Returns to normal Thyroglobulin increased. ) ) ) Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 1 1 3 55. Pt. presents following URI, soreness in neck. O/E: enlarged, Tender thyroid. SR1', TJRU 1', T4 wnl. How to establish diagnosis? (sub acute granulomatous, de Quervain's thyroiditis) w.t.d? Tx: Palpitations and tachycardia 7 P bw<.1'.(" 7 Ast\ Pain NSA1.'D r Don't use Anti-thyroid drugs. Checking for antibodies of NO HELP in diagnosis. Q56. Young Pt. with nervousness, insomnia, irritability after having uncomplicated ifolivery. She is breast feeding. O/E: Thyroid enlarged, Non tender. TSH 0.01, T4 mildly elevated. x: lymphocytic thyroiditjj . ow to manage this Pt.? ,,A< � blockers alone & nothing else B. RAI Uptake & � blockers C. Methimazole Usually transient hyperthyroidism7 hypothyroidism7 Euthyroidism after several months. The Antibodies most likely to differentiate Graves disease vs thyroiditis is 7 ISn �t...>-t Prv.-t.c.r-t:.bM.M Gw'c....-<-1 Anti TPO is positive in both conditions. 7TBG is elevated in both. Q57. Young woman 4 months postpartum with uncomplicated course, with decreased �nergy, weight gain, Amenorrhea, delayed deep tendon reflexes. Pregnancy test negative. w.t.d next of Chronic Lymphocytic thyroiditis. Q58. 30 yr. old postpartum with tremors and depression. T4 hish. You reassure her, but she omes back a month later, sti l l with depression and now fatigue. epeat T4 is low and TSH is 26 (high). w.t.d A. Reassure and repeat TFTs in 3 months vK'start synthroid, reassure and repeat TFTs in <3 months. C. Check for Thyroid stimulating antibodies. Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 1 1 4 Q.59. Pt. presents with tremor and tachycardia. Pt is on ASA, Digoxin and Amiodarone/IFN. 3, T4 high and TSH low. RAIU is <5%. Most likely etiology? A. Digoxin or HCTZ 0Amiodarone or alpha Interferon C. Graves disease or Multi nodular goiter. Q.60. Pt. with acute illness intubated and hospitalized in the ICU. Episode of hypotension on aso�ressors. T4 nl/.J,, T3.J,, TSH nl/.J,, rT3* 1' Ox:� ) ) ) Sick. fu�:J.,V.�L f �Tx underlying cause. ( No Tl-t c� T3 T>c ) Repeat TSH 2-3 weeks after complete recovery. Hypothyroidism 'Cold intolerance, constipation, coarsening of features, delayed tendon reflexes/hung up reflexes, amenorrhea, elevated prolactin' ) TSH1' and T4'1t ) TSH -¥-.it and T4'1t'1t + rT3'1t ) TSH 1' and T4 nl ) ) c ri.-., ""xiN- _, - - �-� - - - �- --�� - - Q.61. Pt. presents with fatigue, cold intolerance and de laye d de ep te n do n re flexe s. ----SH 6.0 (0.5-5), T4 1.2 (0.8-1.8). Most likely diagnosis? L> ...,. LD L , Nl:)f:. vv-c....:1h.f f-.oj:-j ) A. Factitious thyroiditis �Hashimoto's thyroiditis ) 0.62. What Abs will most likely be positive in the above Pt.? ) 63. A 28 yr. old woman witll fatigue ani:t weal<ness an llas i:tlfficulty getting up from a itting to standing position. She also has some pain in the joints of her hands. CPK 2tbDTRs + and slow. w.t.d next? l.W · ) h64. In a Pt. with CAD or Elderly, start ) ) ) �ow dose B. Normal dose ( off.J,,....;k pt. IH'ill aet- M.7 -t '' 1' � ) Start with 2 5mcg and increase by 25mcg q 4-6 weeks and measure TSH. If ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 5 65. Pt. taking synthroid for hypothyroidism. T4 nl, T3 nl, TSH 1'. w.t.d 66. Hypothyroid Pt. on thyroxine goes on <l week vacation anCI forgets to take edicatlons with her. w.t.d 7 Restart Thyroxine (T4) upon arrival 7Yi life of T4 is 7 days. 67. Hypothyroid Pt. started on Levothyroxine 200mcg. 3 mths. later, TSH 2(0.5-5), T4 1.6 0.8-1.8), T3 6(1.5-7). Pt. c/o of not losing weight despite diet and exercise. Ml is elevated. w.t.d A. Increase T4 dose � Continue same dose of T4 cst.t... p:wo� 1. Lr ...... Jt TLi a.o� iiif. � Al�•-t!V'-"!-c- •v·. ) / 68. Pt. with refractive arrhythmias, responding to Amiodarone. 4 months later with m toms of h oth roidlsm. TSH 1', T4w..V. w.t.d • • • The Leading cause of Hypothyroidism is Hashimoto's thyroiditis CPK levels can be elevated years before clinical manifestations of Hypothyroidism. Indications for treating subclinical hypothyroidism are -Increased LDL -Antithyroid peroxidase abs 69. Pt. with bipolar Cllsorder responds very well to Lithium for >8 yrs. Over the past several onths, with weight gain, delayed deep tendon reflexes. T4 borderline normal, TSH in reased, w.t.d ��--' 70. Pt. found to have slight y e evated TSH. Repeat TF Ts confirm elevation of TSH 12.0, ut T4 3 normal. Pt. is as m tomatlc. BMI 30 & LDL of 160 �� Dx: Subclinical Hypothyroidism. Tx: with Levothyroxine would result in �wering LDL B. Weight loss. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 6 71. Pt. with 3 vessel CAD going for CABG. TSH is 11.0. w.t.d 72. Pt. with Angina had cardiac cath. He develops thyroid swelling. T4 is 1.6 and TSH 5 w.t.d /.Repeat T4 in 4 weeks B. Start Thyroxine C. RAI uptake 73. Pt. with 15 lb. weight gain, over past several months and unable to lose them. /E: delayed deep tendon reflexes. TSH increased. w.t.d � Start Levothyroxine ) B. RAI uptake C. M RI head D. Check serum prolactin 74. Pt. is brought to the ER on a cold winter day. Pt. is stuporous, hypothermic, radycardic with H R of 40/mln. O/E: periorbital edema, pubic hair loss & axillary hair loss ) Ox: Myxedema coma Best Tx: � .v hydrocortisone Plus T4 Plus T3 Plus antibiotics ( MA.ft c� B. i.v T3 C. i.v hydrocortisone ) ) ) ) ) ) ) ) ) c� 0.j �.'.lxc.� " �<.t.:�) 75. Pt. with hypothyroidism well controlled on synthrold, gets pregnant. hen is the requirement of thyroxine Increased? 7 Elevated during pregnancy � l.f.!:. tvi f'V\.e.t � 30_ so/ " Y4Y\..� s e Lt.vc. l-c4. ;,,.. c.IL trimesters of 76. A pregnant Pt. as anti-TPO a s an you start evot yroxlne. ou check the TSH in 6 weeks. What is your target TSH ? Thyroid nodules Hot and cystic7 Benign Cold and solid7 R/O malignancy Asymptomatic nodule on routine physical. w.t.d next 7 T5h Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 7 'Q.77. Above Pt. TSH 1.5 (0.5-5). Ultrasound reveals hypoechoic nodule w.t.d � ne needle biopsy B. RAIU If TSH decreased and T4 increased. w.t.d next 7 RA L v-pti;"-<If RAI uptake increased and Pt. with Graves disease. w.t.d next? Tx: 7 Anti thyroid meds7 Radio Active lodine7 Sx �0.78. Pt. with multinodular goiter on synthroid for > 1 year presents with palpitations and eight loss. F TI 1', TSH w . Synthroid dosew. 8 weeks later, T4 is still high, TSH still w, the T4 ose is again lowered and repeat TSH still low. w.t.d next? ��---'" If uptake 1'7 Pt. is now euthyroid or developed Thyrotoxicosis. w.t.d 7 Stop Synthroid and repeat TSH in 6-8 weeks. A. TSH � Free T4 80. Pt. with longstanding Hx. of goitrous Hashimoto's thyroiditis presents with enlarging oiter, SOB, hoarseness of voice and dysphagia for the past few weeks. Exam reveals a goiter hat is hard and does not move on swallowing. Most likely diagnosis (60 times more common in Hashimotos) 81. In a nuc ear power plant ommunity? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 1 8 Chart 9-3 Vit D Calcitonin C. PTH ( ,i, p�) � -tt..... �:J h,,,� J 0 ( 1' N--. Scvc.o1'd,.....� ) �Skin �� p� Ct..:>t'vU..�G.o-\, Mc...�1'� 1' C.c,L'-'1..v> - ) 1' M Ai:>�p t.:(A.. f..,... G, "L EJ.�j rrt- ..,.1t ��4- .fc-lv .r.,_,,p41 v,t. 'Z> ct.t ) ) ) ) ) 4i UI • Vitamin D deficiency -7 Vitamin D insufficiency -7 Vitamin D sufficiency -7 < 2.0 ":J/,...,..,L < io ":!I rvvl 7 30 f";J I rv--l Tx:-7 501CfVO zu/""'11. Tx:-7 / 00 O - 2- OVt> J< 8 , fF....v.. 1�2k Lu/� 7.-U/ d_� Maintenance <70 yrs-7 Ci> uo -z,u. /D ps3. At what Vitamin D dose intake has fractures found to be preventable? ) ) I 084. Pt. with Serum Calcium of 11.Smg/dl. Repeat is 11.Gmg/dl. .t.d next to identify etiology -7 Sey\-VY' PTh Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 19 Chart 10-3 If Ca1', PTH 1' Primary Hyperparathyroidism (P04WW) Lithium Tx. If Ca1', PTH N/1' F amilial Benign Hypocalciuric Hypercalcemia (F BHH) abnormal Ca sensor in Kidney. Mild high serum Ca. Urine calcium to creatinine ratio <0.01. No Tx ' If Ca 1', PTH ww -A_ f>'\.:>tt c� H C.t. -t c.orvv"·""" 13YC..c..,-t. c.� ) ' Malignancy (MM), most common cause of Hypercalcemia. PTH like substance not measured by regular test. 7 Do Skeletal survey. Vitamin D intoxication 7 tv\t..'"' """- isl oh ) v-t 'D 3 �also for Vit D deficiency) Sarcoidosis Other causes of Hypercalcemia: Thiazide diuretics (decreased Ca excretion) Lithium induced hypercalcemia (Increased threshold of Ca needed to decrease PTH production). w.t.d • Flash back -Lithium induced Hypothyroidism7Treat with Levothyroxine. -Lithium induced Hyperparathyroidism7 Discontinue Lithium Hyperparathyroidism: • • • • • • 1'PTH, 1'Ca, w P04 Band keratopathy, Subperiosteal bone resorption (moth eaten appearance of Phalangeal cortex on X-ray hand.) Skull X-ray with tiny punched out lesions ('salt and pepper appearance') Renal stones and muscle weakness. 50% of Pts. have coexisting Vitamin D deficiency May be present in any MENs syndromes (Multiple endocrine Neoplasia), autodominant 85. The leading cause of Secondary Hyperparathyroidism is Vitamin D deficiency. n a Pt. with PTH elevation. What will you measure? 7 2 5 c 011 ) J>3 ��-- Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 20 \ Chart 11-3 PTH Vit D 1' Ca P04 J 1' 1' Sarcoidosis l � 1' 1' Hyperparathyroidism ) 1 1' Malignancy � J; f 1" • Milk Alkali syndrome - J,- J; w ENs synilrome iType I: ) ) ) ) ) ) ) ) ) ) Parathyroid: increased calcium Pituitary � M �Z "i..r Pancreas: Hypoglycemia Type II: Pheochromocytoma: HTN, Palpitations Ca Medullary thyroid: Calcitonin increased Parathyroid: increased calcium Type Ill: Ca Medullary thyroid ( C.Q.l ci t.o� , flbit d)'\,"°F Pheochromocytoma Mucosal neuromas ) 86. Pt. with thyroid mass. Calcium increased, calcitonin increased, dense calcification n mass. Medullary carcinoma was diagnosed. How to screen family members? ___ _ _ _..... 87. 45 yr. old woman with thyroid nodule of 2.5 ems, asymptomatic. TF Ts normal. F NAB eveals a medullary carcinoma of thyroid. Serum calcitonln is 1200pg/ml (nl <30). t. is scheduled for thyroidectomy. Prior to surgery, what tests would you do. A. Repeat Serum calcitonin B. CT Head .)/."24 hrs. urine for metanephrine and catecholamines. D. ERCP of pancreas Q.88. 34 yr. old with recurrent nephrolithlasis. Ca 11.Smg/dl, P04 2.3, Serum PTH 225pg/ml (10-65). Most appropriate management is �Surgical exploration of neck B. Start Prednisone Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 2 1 Indications for Surgery (to prevent long term comps.) ge < yrs. • Serum Calcium >lmg above normal (11.Smg/dl) • 30% reduction in creatinine clearance • Symptomatic (Osteoporosis T score >-2.5, dehydration, stones) Q89. 40 yr. olCI asymptomatic woman is found to have minimal hypercalcemia. TH 125pg/ml (n 10-65pg/ml). You would A<'Refer for surgery B. Start Pamidronate C. Start Calcitonin D. Repeat PTH level Q90. A Pt. with hyperparathyroidism refused parathyroid surgery. W.td? �Cinacalcet (Sensipar®) B. Alendronate (Fosamax®) 91. Asymptomatic Pt. found to have serum calcium of 10.Smg/dl. erum PTH is 45pg/ml (n 10-65). No Hx. of stones. w.t.d next A. ACE level vi{ Measure Urinary excretion of calcium C. Serum electrophoresis. 92. 35 yr. old, health conscious and does regular exercise and takes lot of vitamins. /o fatigue, constipation. Mucus membranes are dry. erum Calcium Is 11.2mg/dl, Phos. 4.1, PTH Is 10pg/ml. Most likely has 7 Vit 1) ii\ to >e l c..aA; """ ( 2. 5 ( O H ) 'D3 ) ----��-- 93. A 45 yr. old woman presents with complaints of getting up at night to urinate. She Is constipated and mucus membranes are dry. She Is nauseous. Her only other history is Clyspepsla. Serum Calcium Is 11 mg/di, Phos 2.5 mg/di and PTH Is 15. Most likely Ox.? Best management? 94. Pt. with lung Ca is brought to ER with mental obtundation. Ca is 17mg/dl. he next step in management of this Pt. Is A. Alendronate B. Calcitonin / Aggressive i.v fluids Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 22 ) \ 95. Best long term management of hypercalcemia in the above Pt. is better than Pamidronate 96. The fastest acting hypocalcemic agent is ) \ I ) ) > ) ) ) Q97. The LEAST likely cause of Hypercalcemia is A. Vitamin D intoxication B. Sarcoidosis C. Lithium treatment D. Thiazide diuretics E. Multiple Myeloma F . Carcinoma Breast G. FBHH H. Milk Alkali syndrome J. Prostate cancer 98. A 32 yr. old woman presents with a serum Ca of 11.Smg/dl, P04 4.0 mg/di XR-+ bilateral hllar adenopathy. The following would most likely be elevated. ��--- A. Serum PTH B. Serum 25 {OH} Vit D J/. Serum 1,25 {OH}i Vit D3 D. Serum globulins 99. A 28 yr. old woman presents with kidney stone. Serum Ca Is 11.2, P04 is 4.lmg/dl. erum PTH Is 7 (nl 10-65 g/ml). Most likely etiology is /.sarcoidosis ( f. � / 1' P� 1 PT11J,r&.) B. Malignancy C. Hyperparathyroidism D. Lithium treatment E. Familial benign hypocalciuric hypercalcemia 100. The best treatment for the above Pt.s after controlling hypercalcemia is ) ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 23 Chart 12-3 I Hypoparathyroidism - Hypomagnesemia Vit D deficiency PTH resistance Pseudohypoparathyroidism Chronic Renal failure I Ca PTH L J - J; 1' 'I I J; 1' J., 1' J, Jt � Other P04 r 1 - J. K ' ' t Alk �H I -- ( p' 13 I II� L\ >-0 �t..:., P.Jl.:;� ... r·� �'ti'Q. p� c:J,l.r '1 6..... ) - -- Q.101. Young Pt. presents with history of irritability, depression, muscle weakness, ataracts, Chvostek's/Trousseau's sign (+). '1.-Ca, '1.-PTH, 1'P04 102. A 65 yr. old man presents with bone pains and osteopenia on X rays. erum Calcium is 7mg/dl. PO. ls 1.9mg/dl. Alkaline phos. !45mg/dl. lb. is 2.2mg/dl, Serum proteins are 4.Smg/dl. X-ray shows Looser's zones (bands of radlolucence) Most likely cause Is A. Multiple myeloma /.Osteomalacia due to vitamin D deficiency. C. Osteoporosis D. Paget's disease 103. Pt. develops fracture on alendronate therapy. Ca 7.4mg, PO• 2.2mg and alkaline hos. 135. Most likely diag�� nosis -- 104. Pt. with x-ray showing short 4th and 5th metacarpals. Most likely diagnosis P TH Awesome Review, Inc.® Copyright 2 0 1 4 Do not photocopy without permission Page 1 24 Chart 13-3 - Osteoporosis: How to Diagnose Osteoporosis? FRAX (Fracture Risk Assessment Tool): Clinical risk factors + femoral neck BMD with DXA (More than -2.5) Clinical risk factors: '!' Age � :f-0 ':x &S / Steroids Sf\";f /'I> \ ) J \ x 3 IV\M"I� Parental history of Hip fracture - Low BMI Drugs: Hyperthyroidism Steroids Sedentary Life style - � Aromatase inhibitors �Vit D - - ' LHRH agonists ) ) � -- Chronic liver disease ( Lt.. p i\/""- ) P P 1 7 1 � .... Premature menopause - ETOH Long term Heparin - Malabsorption Cigarette smoking currently r Dilantin - - Multiple Myeloma Hypogonadism - - Secondary osteoporosis: Hyperparathyroidism Previous fracture - . -- . - Inflammatory bowel disease Rheumatoid arthritis ' 106. Which is a bigger risk factor for osteoporosis?��-- ,,--KSedentary lifestyle B. Obesity ) 5 107. Pt. on preClnlsone � g Clally for > 3 months. ��- -7 DEXA baseline, then once yearly if still on steroids ) } ) 108. DEXA reveals T score -1.5. Pt. is already on Calcium and Vitamin D. hat Is the best management? Ol\. .s tc�v\."-A. Nothing / Start alendronate I ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 125 09. A 52 yr. old man presents with complaints of pain in the right grom anct thigh for the ast couple of weeks. He denies any trauma and walks a mile a day. Alk phos. normal. erum calcium 9.2mg, ESR 23. X ray shows mild osteopenia. MRI reveals- Tl diffuse ecreased enhancement of femoral head, T2 diffuse increased enhancement of femoral head. Most likely diagnosis? A. Avascular necrosis ._)¥.' Transient osteoporosis 0110. Right groin pain with Rheumatoid arthritis & osteophytes on X ray 7 . 2. oA 111. Right groin pain with Rheumatoid arthritis, X ray negative, MRI double line sign on T2 Bisphosphonates: Alendronate, Risedronate, Zoledronate (Fosamax®) (Actonel®) (Zometa®) E�egiRif Olil� Calcium lSOOmg/day Vitamin D 1--v----' '-,..._"'f _. ( e S<lfl..A.f'. ..!I .. .. )/' (o>1 �E-R 'D < ;re y 7 6 CX) J.,V., I D 7 � i. u./ 1> I :ro Raloxifene G]cfU',..; "' :f- Teriparatide (Forteo®) -1 (. vrt 1> NL, � o s t(..A.) bl ....,t.:.. �v.� , pt � f.\\ ��.. i-.. � # ) '»/c. A l ��c..I<- , (_ 1'w Z 'Y 112. 65 yr. old post menopausal woman wants to know risk for Osteoporosis. er past history include Renal stone 5 yrs. ago. XA reveals: T score of -2.5, Z score of -1.5 he MOST likely you would recommend Is: Gu; (f) vt<.'Alendronate + Calcium + Vitamin D B Calcitonin C. Estrogen D. Alendronate Nephrolithiasis not a contraindication for 1' Ca in diet 113. Elderly female presents with hip fracture. DEXA is -1.4. The most Important indicator or starting Alendronate Is A. Her T score JY. Hip fracture Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 26 114. What is a more important risk factor for fracture? \/C'H x. of hip fracture with normal T score (<-2.5) B. Poor T score (> -2.5), no Hx. of hip fracture 0.115. A 70 yr. o Cl Pt. is found to have Serum Calcium of 11.5 and PTH of 1 15. Dexa eveals T score of -2.5 on hip and -1.5 at the spine. Most likely etiology of her osteoporosis is A. Her age yr. Hyperparathyroidism 116. 70 yr. old woman comes to you to renew her Estrogen for Osteoporosis. w.t.d \ vK.' Stop Estrogen, Start Alendronate, Calcium and Vitamin D B. Continue Estrogen, Add Calcium e111. Which medication has shown to decrease mortality In a Pt. with steoporosls and fracture? \ ) ) ) A. Alendronate \}Y."'Zoledronate Most common side effect of Zoledronate-7 � ,_ /Y\.yc.I �c... 118. 65 yr. old woman with osteoporosis and renal Insufficiency. ) -7 Denosumab (Xgeva®) ) fl119. A Pt. Is taking Vit. D and Calcium. She Is 48 yrs. old, and she develops hot flashes. What medication would help for both bone health and hot flashes? ) ) A. SSRI � Estrogen & Progestin ) I ) Awesome Review, Inc.® Copyright 2 0 1 4 Do not photocopy without permission Page 1 27 - ._ True or False about Hormone replacement therapy - A. Local Estrogen therapy helpful for vulvo vaginal atrophy. T T B. Local estrogen therapy didn't relieve dyspareunia. C. Local estrogen therapy can reduce the risk of recurrent UTls -r -.._ - F. The risk of Heart Disease is increased if hormonal therapy is started decades G. Estrogen progestin therapy increases the risk for ischemic stroke in women more than 60. T -- T T H. Increased risk of DVT, however the risk is lower if started below age 60. -- I. Unopposed estrogen therapy at increased risk of endometrial cancer. So use concomitant progestogens. T J. Breast cancer risk increases with estrogen progestin therapy used for more than 5 years. -r K. Hormonal therapy less than 5 years has significant impact on breast cancer. i:: - L. Hormonal therapy if started after age 65 can increase the risk for dementia. I M. Hormonal therapy started soon after menopause decreases the risk for dementia later on in life. T N. Hormonal replacement therapy in premature menopause that is in premature ovarian failure has protective effect on CHO but don't extrapolate data to women experiencing menopause at a typical age. T 0. Transdermal estrogen therapy can be reconsidered if Pt. has concerns for DVT. I - - - T - after menopause. - � -- D. Hormonal therapy does not reduce postmenopausal osteoporotic fractures. E. Hormonal therapy within 10 years of menopause in age less than 60 and use of hormone therapy more than 5 years associated with the reductions in 30% total mortality and incidence of heart disease. It is not recommended as a sole reason for therapy. - - - - - t- - P. Estrogen therapy decreases the risk of colon cancer. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission - 1 Page 1 28 120. 58 yr. old woman with long standing history of hypothyroidism on synthroid. hat appropriate diagnostic test to do for this Pt.. 0121. 58 yr. olCI woman with long stanaing lllstory of hypothyroidism on synthroid, iagnosed to have osteoporosis by DEXA. w.t.d next ��-7 c. N..<.K. TS 11 � If TSH w -7 '1t T-4 cloµ better than bisphosphonate. 122. A 62 yr. old woman has a DEXA scan done which reveals: T score at LS spine is -1.1 nd at Hip is -2.5. What is the most likely reason for discrepancy in the T score? ��---' A. Machine error /,osteoarthritis of spine 123. A Pt. with Osteoporosis T score -2.6 is started on Alendronate 70 mg7wk. 2 yrs. later, as a fall with fracture T score is -2.5 w.t.d ) ) A. Increase dose of Alendronate to 140mg/week ,JJ<'D/C Alendronate and start Teriparatide (Forteo®). Q124. How long can you prescribe Teriparatide? \ l ) ) ) ) ) ) ) ) 125. A 70 yr. old man with hip fracture, X ray shows osteopenla. Serum Calcium, phosphate re normal. Skeletal survey radlographs show no lytlc lesions but osteopenla(+). Total rotelns are wnl. Protein electrophoresis with slightly Increased lgG. No M spike. w.t.d next -7 'De-;< � SCc.f\- � (+) for Osteoporosis. w.t.d next A. Treat with Testosterone �Treat with Alendronate 126. 79 yr. old with prostate cancer on antiandrogens sustains hip fracture. e Is also an alcoholic. DXA reveals Osteoporosis. Most likely reason Is ��--- /Decreased Androgens B. Alcoholism C. Decreased vitamin D Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 29 Q127. Side effect of Bisphosphonate? O Ste o 11.e(.NQp..; J -7 0.j j c..w / ""G..l\.cl.:. . bk ( tG.�')' B.!.sp i....op i.... O(\.A/c. �" l-O"::f � ) ckc.f<. o\.e..At c;. b� fuv<- c:\ICU\.�>"'"""'k----. 0128. A 70 yr. old woman comes to you reading on the internet that bisphosphonates can cause osteonecrosis. She has been taking alendronate for the ast 7 rs. w.t.d? Ad/c Alendronate B. Continue Alendronate If Pt. received bisphosphonate for > 5 yrs and stops it, the effect continues for several years. Paget's Disease Alkaline phosphatase1'1', Bone Scan (+) Management: Asymptomatic: No treatment Symptomatic: Treat with Alendronate/Calcitonin • Bone pain • Spinal cord compression fx • High output Heart failure 7j< ou will find-----------------��-0129. In Paget's disease, y .;._ - Calcium Phosphorus ""- NL Alkaline Phosphatase 1' PTH l'IL- Peri menopause '50s, with irregular menstrual cycle, hot flashes with mood changes, insomnia -7 fatigue during day.' Other: Vaginal dryness, Stress incontinence, '1.- Memory R x:-7 8tn:>� Comps: -7 -f I- Low ThYV'l"' b:> �b4;.t. <:Lo� pv<> aeJte...- tn"e �-fr Best way to diagnose? Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 30 Q130. 49 yr. old woman with irregular menstrual cycles, insomnia and fatigue. w.t.d -7 Estrogen challenge, to see if symptoms improve. FSH unreliable. 0.131. 35 yr. old woman with hot flashes and early menopause. w.t.d next If elevated-? f.x vv,'fr: P, 132. 52 yr. old with irregular menstrual cycle, hot flashes and fatigue. Hx. of DVT in the past. fhe refuses to go on Estrogen 22 risk of thrombus or post Breast cancer treatment, cancer \ l isk. w.t.d ()...l..a./-> J. p o� t. /,sSRls (Venlafaxine, �aroxetine or Sertraline) B. Black Cohosh IQ133. A Pt. has severe moo swings prior to her periods, it is so 6a !work every month. What is the diagnosis? ---�� --' �� -? Premenstrual dysphoric disorder (Paxil®) ) ) ) ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 3 1 Chart 14-3 Adrenal Cortex Hyperaldosteronism Adrenal adenoma Adrenal cancer < < _[ Awesome Review, Inc.® Copyright .-v ACTH 1' Zona Glomerulosa7 Aldosterone (\lb If' Zona fasciculata7 Corticosteroids Jt 1' Zona Reticularis7 Sex steroids .j,, t Adrenal Medulla7 Epi & nor Epi <...h� NU cJ....""j t. 2014 Do not photocopy without permission Page 1 32 Chart 15-3 ) \ I \ progesterone 17(0H) progesterone 11-deoxy corticosterone 11-deoxy cortisol DHEA ' ) ) ) ) Testosterone Urine: 17 keto steroids Aldosterone Paired Aldosterone: Renin activity Cortisol � Urine: Free cortisol 134. Pt. with hypopltultarlsm. Pt. started on T4 and Prednlsone. hat Is the best way to find out the adequacy of the adrenal gland? A. DMS suppression test ) ) ) B. CRH ....£: ACTH stimulation test (Cosyntropin test) D. Clinically 135. Young woman with hirsut1sm, irregular periods, normal BP. 17(0H) progesterone level levated. This Pt. most likely has A. 17 � hydroxylase deficiency A< 2 1 � hydroxylase deficiency C. 11 � hydroxylase deficiency ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 133 Chart 16-3 Aldosterone x f'r P.. B ·( �� Angiotensin II x � A , L. ·t I< Angiotensin I Ren in o c. i l \J ,'t ... .'. 1'f3 f � Angiotensinogen '-._ f sP BP Primary Hyperaldosteronism Reninomas Hyporeninemic hypoaldosteronism (t 't J, t iMlock ECF K Aldosterone Renin � ff 1-t -Yj-H tt 1"' J,, Jt J; Q136. A 45 yr. old presents for routine physical exam. BP 140/110 and Serum K is 3.3, creat. 0.8mg/dl, HC03 27mEq on ACE inhibitor, Spironolactone &�� blocker. w.t.d �� Hold ACE inh. and Spironolactone, then the best screening test is A Paired serum aldosterone & renin activity The best diagnostic study is � Replete K, 2 Its N/S over 4 hrs and recheck serum aldosterone level. Awesome Review, lnc.° Copyright 201 4 Do not photocopy without permission Page 1 34 137. 42 yr. old has been checking his blood pressure for the past 6 mths. and has noticed a radual increase in BP. His brother and sister also have HTN. BP is 158/101. Serum Na is 134, � Serum K is 2.9. w.t.d A. 24 hr. urine catecholamines & metanephrines _)Y. Aldosterone: Renin ratio or 24 hr. urine Aldosterone. pl38. Pt. Ox. wit Primary hyperaldosteronism with Aldosterone:Renin ratio 20:1, iVou confirm with suppression test. w.t.d next? 7 CT Abdomen 7 w.t.d next? ---- \ ) A. 24 hr. urine aldosterone ""'l"-J /'>. �,...... _, J f. Bilateral adrenal vein sampling -P r -.... H(Jf"?YP�" _.,. .tp•"•of\.o �t..(\JL b d d 139. A 55 yr. ol long stan ing Dia etic, on insulin 20 U NPH bid. BP 95/65, K 5.3, icarb 20, Creat 2.1. BS 165mg/dl. The most likely etiology is ��-A. Cushing's syndrome B. Cushing's disease /. Hyporeninemic hypoaldosteronism D. Dehydration 140. In which of the following conditions will the renin be low? ) ) ) ) A. CHF /.Primary Hyperaldosteronism C. ACE inhibitor Best way to confirm Hyporeninemic hypoaldosteronism -7 A CT 11 s�,....,.....Lc. h'.'-" t:>.-t.. -- j v.-.-c.k; t- µ.... c...o � ut L.....-l. How to treat? ,) } ) Cushing's syndrome Pt. presents with proximal muscle weakness, Abdominal striae, fullness of face, swelling back of neck, acne, facial hair, irregular menstrual cycles. Hyperglycemia. w.t.d next? Cushing's workup 1. 24h free cortisol in urine -7 >100mcg/day-7 Confirms Cushings 2. Figure out where the excess cortisol is coming from Awesome Review, Inc." Copyright 201 4 Do not photocopy without permission Page 135 Chart 17-3 Differentiating Cushing's syndromes - Cushings disease Pituitary/Ectopic ... - Adrenal Adenoma Adrenal Carcinoma Exogenous Steroids Cortisol/ Urine cortisol DHEA/ 17 keto steroids t t 'f 1 - J - - .j.J Tx 1' s,. "" - 1t- Sx � J,t 1' 1' J, ACTH J,. s)t .1>1t.. s� c;L Q141. 25 yr. old with 10 lb. weight gain, amenorrhea, acne, hirsutism and Is irritable. O/E: osterior cervical fullness. w.t.d next A. 8 am cortisol B. Serum ACTH level Y,Urine free cortisol D. CT scan head and adrenals p142. Above Pts. 24 h urine cortisol is 260 pg and Cushings syndrome is diagnosed. e�rum ACTH is SO pg (nl 9-52pg/ml). After 8mg Dexamethasone suppression, the CTH is <5 pg and Serum cortisol is <5 mcg. w.t.d next? ��--/. MRI brain B. MRI chest C. Do nothing 143. If MRI n egative in the above Pt. Or ACTH couldn't be suppressed, then do pet:Afc{.. � j� - I -J -7 CT ch..c.., t 0144. How would you differentiate hypercortisolism? ,/!(. ACTH level B. Cosyntropin test Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 136 145. Pt. presents with history of hyperpigmentatlon, high blood pressure, muscle eakness. No history of weight loss. K "' and blood sugar high. CT scan shows nodule in the lung. ��-j)x: ACTH producing tumor. w.t.d 7Correct K, Check Cortisol, Surgery 146. Pt. with ACTH mediated Cushing's disease. ource of ACTH cannot be localized. w.t.d \l 147. Pt. s/p adrenalectomy for Cushing's disease presents with headaches, yperpigmentatlon of skin. ----Dx: � Ne Lrc.vv f 7 Pituitary irradiation Addison's Disease I ) ) Hyperpigmentation especially palmar creases, oral mucosa, unexplained weight loss, salt craving, nausea, vomiting, weakness and postural hypotension. Hx. of pernicious anemia. How to confirm Addison's disease? ) 7 ACTH stimulation test 7 Cortisol level < 18mcg/dl p· >18mcg/dl Pi t...� ) ) I ) 148. In any Pt. with hypotension and shock, wNa, 1'K. R/O Addlsonian crisis ) } ) ) 149. Pt. with history of Addison's on hydrocortlsone and fludrocortlsone presents with a iral URI. You prescribe no antibiotics. What�� to do? ��-- Y,tncrease Hydrocortisone dosage B. Increase Fludrocortisone dosage C. No change ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 37 QlSO. Pt. diagnosed with Hypothyroidism and Addison's disease. what to treat FIRST? 7Treat with Steroids FIRST and then with Thyroxine, otherwise Adrenal crisis will occur. QlSl. A Pt. diagnosed with pneumonia and started on ceftriaxone and azithromycin. Past history significant for Asthma with an exacerbation about a month ago treated with pebulization and tapering doses of steroids for couple of weeks. BP 90/70 and orthostatic. i.v fluids are begun. What is the next step in management? Pheochromocytoma 'Palpitations, sweating, headache, episodic in nature, labile BP' 1'urinary excretion of catecholamines and their metabolites. Part of MEN II & Ill Best way to screen or diagnose? 7 24 hour urine for metanephrine and catecholamines. If > 10 ems. w.t.d?7 to rule out mets. Tx: Surgery Prior to Sx, w.t.d blockade with 7 P,-G z u t..:.tv p blockade with 7 P .,,-o p c.rv::> Wt- a Adrenal incidentaloma >4-6 cms7 1'risk of malignancy <4-6 cms7 benign Pt. found to have Adrenal incidentaloma . w.t.d next 7 Check if its functioning by 1 mg overnight OMS suppression test 7 Cushing's disease Urine catecholamines and their metabolites 7 Pheochromocytoma Paired Renin/Aldosterone, K levels 7 Hyperaldosteronism 17(0H) ketosteroids 7 Adrenal carcinoma Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 38 Sx removal if: • >6cms: Irrespective whether functioning or not. • <4-6 ems and functioning No Sx if: <4-6 ems, non functioning and not getting bigger on serial CTs Q152. A Pt. with CT Scan has 2 cm. mass on the adrenal gland. BP 148/86, 1 mg OMS suppression test and 17 (OH) keto steroids normal. w.t.d A. Observe $ Renin: Aldosterone level C. Surgery ) Similar Pt. as above but with BP 120/80 w.t.d ) A. Observe VY. Urine for Catecholamines ) ) ) ) ) ) I ' ) p153. A Pt. was found to have a 3 cm. mass on the adrenal on CT scan. Workup reveals all hormones within normal limits. w.t.d �� 0154. 45 yr. o a with severe headache not relieved with pain medications. Next day with �tiff neck, fever and double vision. No rash. (bitemporal or homonymous Hemianopsia or Ill, Iv, VIII) BP: 80/60, spinal tap: few wees and RBCs. CT head: lesion in th eipi tuitary/dense lesion in Sella } c;;; Dx: Pituitary apoplexy, most Pt.s with preexisting macroadenoma DD: Meningitis Subarachnoid hemorrhage (1'BP) -7Neurosurgical consult for urgent decompression. -) Random cortisol and i.v glucocorticoids '!ft ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 39 155. 25 yr. old Postpartum Pt. had a difficult labor and delivery, she lost a lot of blood. She as unable to breast feed the baby, later she had no restoration of her menses. he was fatigued, developed cold intolerance and hung up reflexes. TSH & FSH are low. Ox: Sheehan's syndrome with Hypopituitarism w.t.d 156. 32 r. old pregnant woman presents with new onset evere headach ssoclated with s on chan es She also has fatigue and weakness. BP 90/70 supine and 80 systolic on sitting p. HR goes up from 90 to 110 from supine to sitting. What Is the most likely diagnosis? A. Sheehan' s syndrome Y, Lymphocytic hypophysitis 157. 18 yr. ol wittl Headaches, visual disturbances, poor sexual development. rine osmolarity decreased. Prolactin Increased. Xray/CT-7 dense suprasellar calcification Male Hypogonadism: � S 1-1 1' _, D)o k c:;,r::J 0to P ""! Primary Testicular failure-? small testes-7Gynecomastia Tall stature, low normal testosterone Klinefelter's syndrome: 47 XXY ,· FG<ll � GnRH deficiency and cant smell Kallman's syndrome: Anabolic steroids: Muscular with small testes 0· '1 / o. r 158. A 14 yr. o Cl presents with small penis and testis. Exam reveals lack of pubertal nd axillary hair. Testosterone, LH, FSH are normal. w.t.d �� Testosterone > 350 -7 normal Testosterone 200-350 -?equivocal Testosterone <200 -?abnormal Awesome Review, Inc.fl Copyright 2014 Do not photocopy without permission Page 140 ) 159. Man with testosterone level < 350. w.t.d? 160. Man with testosterone level < 350. BMI 35 OR El erly w.t.CI? Obesity and Older age -7 r Gei ) v / iA.ft-c.. L T J,. 161. Man with Testosterone levels < 200. w.t.d? ) ) ) 162. A 70 yr. old man presents wltfl atigue. He tal<es steroiCls for COPD. is testosterone level is 140mg/dl (250 - 800 ng/dl). What Is the most likely etiology? Best management? -7 d/c steroids. IF steroids cant be discontinued ) ) ) ) ) ) ) replacement therapy. Pt. asks you if it will cause prostate cancer -7 1t will not change composition of prostatic tissue. It can exacerbate prostate cancer if present. So follow up with PSA level. Baseline level 0.5. 6 mths later on testosterone replacement PSA 2. wtd? -7 ol/ c. TestoJ tev""""- J � � .l::lz!ia r3x . PSA level should not rise more than double with replacement therapy. (. ,V.. I j .r ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 4 1 Erectile dysfunction: Hypothalamus-Pit-Gonadal axis Prolactinoma Hypothyroidism Radiation induced hypopituitarism Klinefelters syndrome 1' F SH Kallman syndrome .J; F.Sf-1 Vascular supply Penile to Brachia I index <6 Diabetic neuropathy: If they have difficulty accommodating with pupillary reflex, they have it. Nerves Psychogenic Thiazide diuretis, SSRls, TCAs, Finasteride / Drugs (3 bL.o c.E<ev Q.163. The most common sexual dysfunction is 7 �c. M....<. ej�c.. h:. o-rv ( < 2 �s ) w.t.d 7 S .s R. 7.. cory s,' I <A.. efLc:;.;hA. 164. Can SSRls cause retrograde ejaculation ? 7 Yes Q.165. Pt. with decreased libido. Testosterone level is 150 mg. w.t.d next? � FSH B. LH Q.166. Pt. with impotence with normal testosterone. w.t.d differentiates Psychogenic Vs. Organic Nocturnal penile tumescence is normal w.t.d 7 r/o Psychogenic causes or drugs related. Nocturnal penile tumescence decreased in organic impotence • DM neuropathy • Vascular insufficiency • HP gonadal axis problem • Prolactinoma • Hypothyroidism Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 42 167. The mechanism of action of Sildenafil is -7 Phosphodiesterase 5 inhibitor-? increase Nitrous oxide-? increased c@ MP n,\. tr-c.k. 0168. Married couple come to you because they are not having kids. w.t.d next 169. How to manage erectile dysfunction in pts. on nitrates? A. Sildenafil ,.JY.' Penile tumescent devices \ ) ) 0170. How soon after using sildenafil or tadalafil can nitrates be used? -7 2 4 hours after sildenafil -7 L\ l?'" hours after tadalafil Sildenafil or Tadalafil work irrespective of Testosterone level, however hypogonadism should be treated first. ) 0171. Pt. presents with chest pain and was given nitrates and suddenly systolic load pressure dropped to 70. He a arentl had taken tadalafil 6 hours a o. w.t.d? -7 Place Pt. in Trendelenburg position and start IV fluids. w.t.d next? 5 t a.rt ) P��I e.p h.,..:,"'" l o<. ') not norepinephrine Gynecomastia •Puberty • Elderly •Obesity •Cirrhosis •Germ cell tumors (testicular mass +) •Klinefelter's syndrome 172. A 15 yr. old boy brought with enlargement of his breast. w.t.d ) -7 Rea.s�Y <>.t\U I 1<.. t.... K.A t.. P"'\>t/ ':J Can be unilateral or bilateral. ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 143 0173. A Pt. presents with complaints of decreased libido. He has decreased nocturnal penile umescence. He had received radiation to the head. FSH 5 (nl 5-15), LH 4 (NL 3-15} estosterone 160mg (nl 300-1200 , Prolactin 22. Most likely diagnosis is A. Prolactinoma B. Primary testicular failure � Gonadotropin deficiency D. Depression 174. A 38 yr. old woman doing well on Fluoxet1ne for depression presents to you with omplaints of unable to achieve orgasm for the past 2 months. W.t.d? -7 Ad.A Ov S w'1tch to B v. p..-opi C/\"\.. {_ v.. L b lA t...� ) Primary Amenorrhea 'Never had menses' Primary Amenorrhea with web neck, short stature, low set ears and intact smell, rudimentary ovaries-7 T�r'J t -1 s ,x Primary Amenorrhea with No Vagina, No Uterus Ovaries OK -7 Breasts normal -7 Rokitansky-Kuster-Hauser Syndrome -7 1 {, 'j. � Primary Amenorrhea with Acne, clitoromegaly, hirsutism No Ovaries-7 No Breasts -7 4 b x y �ct...t �iCJ\.e c..:.r �0 N>t <!.KpMltA � Primary Amenorrhea with atrophic vagina, no cervix. Breasts (+). No pubic or axillary hair. 1 1 Chromosome Y expresses testes formation in the fetus, which produce testosterone, but because of lack of androgen receptor, there is end organ resistance. This leads to production of vagina and uterus as a default. Since the excess testosterone can't work, it gets, converted to estrone -7 Breast formation. The testes remain undescended. The androgen Receptor is coded for by the X chromosome. Primary Amenorrhea with anosmia, wLH/FSH -7 I< �ll- 1"\..C...J'\. f Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 44 Chart 18-3 Pit ) TSH Prolactin ) LH, FSH i it � 2 Estrogen/ Hypothyroid ism Prolactinoma Hypothal. failure ) Polycystic ovary l L � .., n1-1 ) � : I Dz Primary ovarian failure � bl � � ) ) ) ) ) Polycystic Ovarian Disease 'Irregular menstrual cycle from puberty, obesity, acne and hirsutism' 1'Testosterone, 1'DHEA PCO 1'LH/FSH ratio >3.0 Gastric carcinoma Hyperglycemia Insulin resistance C -1' M.J� , 1' B i el. Hypertriglyceridemia Obesity c,L...,..c...,. ,... ) Acanthosis nigricans Tx: • • • anti androgen OCP Metformin Spironolactone Awesome Review, lnc.111 Copyright 2014 Do not photocopy without permission Page 145 Premature Ovarian Failure Ovary fails-7wwEstradiol -7 first, 1' LH PCOD with OM or Graves disease-7 Polyglandular deficiency Abs against multiple organ systems ( Addison's Dz, Vitiligo, etc) 0175. Etiology of skin lesions in Vitiligo? Q176. Amenorrhea with galactorrhea. Prolactin level>200. w.t.d next -7 (. T I MrL 7. 0177. 17 yr. old with amenorrhea. BMI normal. Pregnancy negative. Pt. was prescribed rogesterone and she got her periods. w.t.d next? Q178. 47 yr. old, otherwise with regular periods presents with amenorrhea for the past 2 months. w.t.d next Ql 79. A young woman on oral contraceptive with no breakthrough bleed. w.t.d next? 180. Pt. stopped taking OCP several months ago. Still with no menses. Pregnancy test egative. LH/FSH normal. Estrogen challenge with no bleed. Most likely etiology \.A te,,1,.... 5� f\ c!.' t.h.: e "--------, Asherman's syndrome or ------� Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 146 181. A young marathon runner presents with complaints, that she had only couple of eriods in the past year. w.t.d? A. Pregnancy test. Y, No further testing Q.182. The above Pt. asked you how to get her periods back.�� w.t.d? ��-- ) -7 Cut down on the exercise program 183. The a bove Pt. asks you how to prevent bone loss, in addition to alcium and Vitamin D? ) A. Start Alendronate � OCP 0184. Mechanism of above Pt.s amenorrhea? -? Excess exercise-? inhibits LHRH release -7 ) ) ) Hirsutism DHEA 1' (Adrenal) ) ) ) ) ) � P" J0 1\."' � (Y\... Chart 19-3 > ) Hjp.D 0' 0 rv. d.. o f.-op.'c. c. tuv'- u ) .. ACTH 1', Cortisol 1', 17 (OH) keto steroids 1' c�� ct/..f ACTH w, Cortisol 1' 17(0H) keto steroids 1' A�L cc;.,,,L,.l'\,O l"""4 ACTH 1', Cortisol w w 1 7 (OH) keto steroids 1' 17 (OH) progesterone 1' C A l-f Testosterone 1' Testosterone 1'1'1' (Ovarian) Testosterone 1' 17 (OH) keto steroids 1' LH/FSH >3.0 O Vc<.,..; � c CV\. (:..(A.. PC D 5 J ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 4 7 185. Pt. with hlrsutism. what lab tests to do next 7 Testosterone level, DHEA (17 OH ketosteroids}, Urine free cortisol 186. Pt. with hirsutism. Testosterone level very high, Cortisol normal. w.t.d next 187. An 18 yr. old woman comes to you with increased hair on her arms and legs. er famil� has similar hair. w.t.d Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 48 - Ophthalmology - ENT - Alcoholism Psychiatry - Geriatrics - Pregnancy and Disease - Ethics Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 486 Ql. Wnat i s the overall prevalence ofperiplieral arteryaisease in Pts. witli ge 50-69 yrs with Diabetes, smokers, or Age > 70 yrs. 2. Pt. with above risk factors & you suspect PAD. w.t.d next NL )1 1 < o , 'j' is S(jf d;X . p3. A 68 y/o man presents witn intermittent clauaication of legs wflen he walks a block. He �uit smoking 10 years ago. �lood pressure left arm 138/84 load pressure right arm 134/82 load pressure right l ower extremity 128/80 he ankle brachial index [ABI) is l� so(> ue u"3�e.r a p J � � [ ) v<. 128/138= 0.92 B. 125/134 = 0.93 c. 138/125 = 1.10 What do you do next to the above Pt.? 4. How to manage PVD Modify risk factors Good BP control/ Good glycemic control/ Good Cholesterol control Anti platelet agents: -7 P,s A y /- PIA .:.,•,� Treat claudication: -7 Su.pe... v;kd. exuc;.yc. P""�rc.t"'- >Cilostazol > Pentoxifylline • • ) • 5. Which medication used in PAD has reduced coronary events, independent of BP effect? } ) T/F In Pts. with PAD, aggressive control of hyperlipidemia with a statin drug, was associated with f---- - 1. Reduced overall mortality I 2. Reduced vascular mortality T 3. Reduced coronary artery disease events ; ' Matching 1. 1. DM 1. LDL < 100 & BP < 140/90 2. LDL < 100 & BP < 140/80 Awesome Review, lnc.° Copyright 201 4 Do not photocopy without pe rmissio n Page 487 Q6. Pt. witn suaaen onset of pain i n tlie foot. Discoloration of foot. x of A-fio. Pedal and posterior tibial pulses not felt. w.t.d next? -7 f\Yte.r,· o �(CW\. Q7. Pt. with sudden onset of black and blue toes and foot. Pulses felt. Had cardiac cath. earlier and BP elevated. w.t.d next Chart 12-1 Metabolic Syndrome Obesity waist in Males -7 Females -7 TGAs Low HDL BP FBS -7 Males -7 Females -7 -7 -7 ) 1 o?. (.JV\-/"' .:> 8 fi' (N'I. 1 3s I( /I >ISO "'"'j'frAL ASic..r. > 3'5 II > 3 I /1 < <f. " "":f j ell <sor;Jjdl > I 30/85 >Joe Tx: Diet/ Exercise/ Drugs QS. Which antl-li ld medication would treat a com onent of Metabolic s n. Obesity one of the leading cause of death in the US Body Mass Index = Weight/Ht in mt/sq .&rlhw-W"'""' u� --- 19- '2 s -7 Normal Overweight -7 / '-S 50-60% of US population , Check FBS, BP, Lipids -7 Obese Stage I > 3o 30% of US population, Drugs indicated for Tx Obese Stage II -7 ) 35 ( bG.Yi(t..._-<- S""':j(/Vo_}) - -4 (JM1. > 3S 2 �1t. 1>rr.. _, b a.,_; c.. t...;'- J'w:f� Morbidly Obese -7 /�0 b".-ktw.. S""":j'J ( J' t.-�8t.:t ) �� -� �----------��--�----� 9. The LEAST likely complication of Obesity Is ------------------------�--�----� Yc.,. J0 . .3 A. Type II DM B. Cancer; Endometrial> Breast, Prostate, Colon C. Elevated LDL, TGAs, & decreased HDL D. Increase Coronary artery disease risk and sudden cardiac death E. Osteoarthritis F. Non alcoholic steatohepatitis (NASH) G. Obstructive sleep Apnea --it:"" Osteoporosis I. Focal segmental Glomerulosclerosis Awesome Review, Inc.\!) Copyright 2014 Do not photocopy without permission Page 488 Q10. A 45 y/o woman gaining weight and BMI 31. FBS 10Smg. hat is the next step in management? ��..;"�-:f A. Exercise Jr Reduce caloric intake by 500 to 1000 cal./day oJ pl"'J --"* / hr / 7> -Jv.- 5 � eke,..c.,'se 1 1 . A Pt. with B I 32 on reduced caloric intake and exercise, 3 months later with Ml 3 1 . Which medication has NOT been approved for long term use ? \ A. Orlistat 120 mg tid (Pancreatic lipase inhibitor) -1 t..,�e._ A, 'D, �� k vitc;,� B. Lorcaserin 10 mg bid (Serotinin-2C receptor agonist) C. Phentermine-topiramate 3.75mg/23mg once daily (nor adrenergic-anti convulsant) Y,Phentermine 15 mg once daily (nor adrenergic sympathomimetic) .fu... slv>.-t Cerl"' w.c. � Indications for Bariatric surgery: • B MI > 3 5 with DM or Hyperchol. or HTN or CHF or Sleep Apnea B MI > 40 and no other conditions • y� True or False: f-Bariatric surgery has shown to decrease mortality I T 1 2. Post gastric bypass surgery, next day with horizontal nystagmus and phthalmoplegia. Most likely diagnosis? (J.... Y -1 """'rl LvL G11 .. k rv.t...-. � k � rt 1f l,, (} l.(y-. Lcp b�L·. C.: f --KThiamine deficiency B. Stroke ) ) 13. PO$t barlatrlc surgery, next day with complaints of weakness and has dark colored rlne, Has tenderness of his back muscles. rlne dip stfck positive for blood but negative for RBCs. Most likely diagnosis? --------� �'-.qbJ....rr.� �s,· J' � 14 .Pott tierlttrlc surgery, tfiree days later with tachycarC:Iia and tachypne�. • ost lfkelyetlagnosls? 15. Pt. post gastric bypass (bariatric) surgery, couple of days later with R 22/mln, HR 120/mln. Temp of 10o.s•F. Most likely diagnosis? A. Bleeding __..8-:" Anastomotic suture/staple leak. _, a-c:At,..1rc.JJ-V. � 16. long term deficient post Bariatric surgery a re Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 489 � 17.A 38 y/o woman with body mass index of 40 underwent bariatric surgery 5 years . o, presents for a regular physical exam. er body mass index has been steady at 25. emoglobin 10.5 g/dl CV 105, WBC count 4000, Platelet count 115,000 eticulocyte count 1% hat to do next? A. Observe A. Cyanocobalamin level C. TSH D. Ferritin level 18. A 34 y/o woman has Roux-en-y surgery about 8 months ago. Her BMI dropped rom 40 to 28 three months ago. Now her BMI has gone up to 35. She complains of heart burn. Most likely diagnosis? A. Suture leak v8': Gastrogastric fistula 0.19. A 35 y/o woman post bariatrlc surgery dropped BMI from 40 to 25 over 6 mths. She has no kids. She is nauseous and has bloating sensation. w.t.d --------�� 20. Waist to Hip ratio (>0.9 In Men & 0.85 In women) is considered as a risk factor A. Only if BMI >25 B. Only if the Pt. has cardiovascular disease V.At any rate 0.21. Increased Waist to Hlp ratio Is considered a coronary artery disease risk factor In hlch group of Pts.? ------ A. BMI > 25 v3'. Older Age 22. Exercise Is associated with all the followingEXCEPT: ------------------------�--��----�--� A. Protects against CAD B. decreases LDL, TGAs & increases HDL C. Improves glucose tolerance D. Reduces weight E. Reduces Blood pressure F. Reduces Stress G. Reduces mortality from all causes 0;1( Doesn't protect against exertional related M l Awesome Review, Inc.® Copyright 2014 D o not photocopy without permission Page 490 3. Pt. status post IWMI being discharged with ASA, P blocker, ACE inhibitor and tatfn. What else would decrease mortality in this Pt.? vKExercise 1 hr/day, 5 days/week B. Exercise Yz hr/day, 3 days/week 24. Pt. presents with flashes or streaks of light showers of black dots wavy curtain. obweb always move where-ever the Pt. looks. nitfally with normal visual acuity. undosco : Retfna a ears folded or elevated w.t.d -7 Emergent Ophthal evaluation for laser treatment ) 5. Pt. with Aflb w�l--...:: undoscopy � Etio: Emboli ) ) ) ) 7. Elderly man presen n In the center, peripheral vision spared. undoscopy reveal yellowish spots (druzen). Tx:-7 �i. s(V\,O�i' 1 R"tox�·ctc.At ,fit.""""""1 �grt:.:t�'::j' 8'i.<:.J-1 28. Pt. going for cataract surgery takes ASA or Warfarin. w.t.d? --------� ASA + Clopidogrel also continue 29. Young woman with blurring of vision, especially after exercise. egalns vision gradually. w.t.d -7 hr\.1. 1:, '}'.:> f'Y\.. s Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 491 Q30. Optic nerve Infarction -7 Tx:-7 lu---�.,-c:A. ------a.. 'ltt.irt..:.J stuui c;L Q31. Pt. with long standing OM, mild vision. Fundoscopy � aneurysms with hemorrhage an xudates Tx: Tighter glucose control HAle. < �.s ;/. Q32. Pt. long standing OM with blurry vision Fundoscopy � neovascularization Effect of above therapy -7 peripheral & night vision decreased. Central vision spared. Q33. Pt. with HbAlC of 7% has laser tx for diabetic retinopathy, with no response. w.t.d? A. Repeat lasertx JV,'Tighter glucose control Matching 2..__1. Pt. with right eye pain with facial pain, nausea, A. Retinal artery occlusion _!:_2. 25 y/o woman with decreased vision in left eye with B. Retinal vein occlusion �3. Elderly man with progressive loss of central vision, C. Macular degeneration �4. Sudden loss of vision in one eye. Fundoscopy -7 D. Glaucoma vomiting, headache, and blurry vision. Right pupil mid dilated and sluggishly reactive. Ciliary flush (+). Hazy cornea with congestion. pain, paresthesias in feet. says edge of door blurry Cherry red spot �5. Sudden loss of vision in one eye. Fundoscopy Multiple hemorrhages and exudates. -7 E. Optic neuritis �. New onset shower of floaters with flashes of light and F. Retinal detachment cobweb . ...!:::_7. Magnifying Glass (Low vision Aids) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 492 Q34. The above picture shows? A. Normal vlf.' Cholesterol emboli f'...f:l:o 'f C. Roth's spots Hollenhorst plaques ) �35. Pt. with intermittent visual loss. Fundoscopy reveals crystals in Retinal art. �ext diagnostic step? A. ECHO vr('Carotid duplex ultrasound ) ) _, T>o ASA Q36. This Pt. most likely has A. Cholesterol emboli vff.' Infective endocarditis C. CMV retinitis 37. The test most likely to establish diagnosis is A. HIV test vif. Blood cultures C. T cell count p38. A 60 y/o Pt. presents with difficulty driving at night time due to glare from oncoming vehicles, difficulty reading road signs and fine print. Most likely diagnosis is ) A Cataract B. Macular degeneration �39. A Pt. who had cataract surgery one week ago presents with eye ache and � ecreaslng vision. Otherwise feels well. � xam reveals Afebrile. Injected conjunctiva. There Is a layering of WBCs in the anterior ) hamber. Slit lamp exam reveals Intraocular WBCs. �otton wool spots on fundus. �ost likely diagnosis A. Uveitis \.%. Endophthalmitis C. Normal Post. op changes Conjunctivitis: vt. � • Viral -7 A� • Bacterial • Allergic ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 493 p.40. Pt. presents with conjuctivitis with serous discharge. You prescribe him �ulfacetamide/Neomycin eye drops. On the fourth day he comes back and says it's �otten worse. w.t.d Dx: Allergy to medication A. Start i.v abx \)Y. D/C neomycin/sulfacetamide eye drops 41. Red eye with itchiness 042. Pt. with red eye with Grave's disease or Rheumatoid arthritis with dry eyes and ritty sensation. �43. Tx: Artificial tears Red eye with pain and photophobia, constricted irregular pupil, ciliary flush. Normal ornea and normal intraocular pressure. Slit lamp� WBC In aqueous humor or on corneal plthelium. Consensual eye reflex with pain. Dx:-7 \Yid..o�cl..'"ti.c ( �'k..:....r �veit..l s) w.t.d-7 Emergent referral to Ophthalmologist • Intensive topical steroids to reduce inflammation and scarring. • Cycloplegics to prevent synechiae 44 Pt. with red eyes and foreign body sensation with pain. Corneal exam with endri 7 hSV ulcer (branching pattern) with fluorescln stain positive. I k_e,..�tt·.r 45. Pt. is intubated and on mechanical ventilation develops one eye redness. Cornea Is hlte. Tx: topical antipseudomonal i.v antipseudomonals 046. Pt. with contact lenses develops conjunctivitis. __. ____________________________ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 494 Glaucoma • Increased intraocular pressure-7 Progressive visual loss due to Optic nerve damage. • Complications of Glaucoma is gradual loss of peripheral vision. Open angle Glaucoma: • Gradual loss of peripheral vision • Cup to disc ratio >50% • Incidence increased in African Americans 47. 45 y/o woman presents with right eye pain and temporal headache. xam reveals conjunctival injection in the right eye and vision is 20/200. t Pupil is mid-dialated, fixed, non reactive. w.t.d ) -7 Urgent referral to Ophthalmologist. ) Before transfer, what drops will you instill in her? A. Atropine B. Homatropine C. Acetazolamide V.Pilocarpine ) } ) ) 0. 48. A 22 y/o presents to the ER with teary eyes. He got hit In the eye with a paintball. xam reveals a mild conjunctival injection. Pupillary reflexes are normal. Vision normal. slit lamp exam reveals a linear abnormality. he best management is A. Patch the eye and follow up B.y pical anesthetic � No therapy, follow up PRN D. Follow up daily until healing is complete II#. Topical steroids Oh� � �c:...., � 49. Pt. presents with teary eye. Pupillary reflex normal. Wood's lamp after fluorescin eveals pattern of parallel lines of vertical abrasion. lslon normal. w.t.d next? ) and remove the foreign body High velocity and industrial injury with hyphema (blood in the anterior chamber) -7 Emergent referral to Ophthalmologist SO. A Pt. with conjunctivitis. Exams reveals a layers of WBCs in the anterior chamber. w.t.d A. Do nothing �efer to ophthalmologist Hypopyon i s layering of white cells in anterior chamber. Could represent ophthalmitis or keratitis and requires urgent referral to ophthalmologist. Awesome Review, Inc.® C o pyri g ht 2014 Do not photocopy without permission Page 495 Q51. Pt. with cough, exam reveals a redness i n the conjunctiva. w.t.d A. Refer to ophthalmologist $. Do nothing Subconjunctival hemorrhages resolve spontaneously in 1-2 weeks Q52. Pt. presents with diplopia of a few days duration with headache. On Exam while looking straight, the left Is Inward and the right eye Is also slightly Inward. A diagnosis of bilateral lateral rectus palsy Is made. Most likely diagnosis is A. Pancoast tumor vB:" Cavernous sinus thrombosis C. Increased ICP 53. Cellulitis of periorbital area with warmth, swelling around eye. w.t.d _, _______ 7 CT/MRI-7 Orbital cellulitis-7 Cavernous sinus thrombosis Tx: i.v antibiotics Q54. Pustule on lid margin Tx: Warm compress, may need surgery 0.55. Vascular structure In conjunctiva, can spread to cornea and Impair vision Tx: Sx QSG. Inflamed eye lid QS7. Small nodule under tarsus Etio: obstruction of the Meibomian glands Tx: Warm compress, Sx may be needed 58. AIDS Pt. with blurry vision Fundoscopy with cheese, ketchup appearance Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 496 Q59. How to manage Otitis media? vf(. Amoxicillin B. Clarithromycin �60. A Pt. with recurrent chronic ear infection presents with discharge and a mass protruding through the tympanic membrane. He has hearing loss on that side. Most likely diagnosis? A. Mastoiditis VY," Cholesteatoma 61. Pt. presents with complaints of hearing loss especially in crowded areas. w.t.d next? ) . \ , Q62. Above test abnormal. Keeping tuning fork at mastoid with no response . Kee ing tunln fork at the forehead with no res�onse. Most llkel diagnosis? ) I.Af.. Bilateral presbycusis B. Acoustic neuroma Q63. A 30 y/o woman presents with gradual hearing loss. Whisper test abnormal. Can hear better with tuning fork at the mastoid process than near the ear. Keeping the tuning fork at the forehead with better hearing In both ears. Most likely diagnosis? A. Bilateral presbycusis � Bilateral otosclerosis C. Unilateral otosclerosis ,) ) ) 64. A Pt. has hearing loss In the right ear. Weber's test localizes to the right ear. xam reveals obstruction of m anlc membrane by cerumen. W.t.d ) vr(' Saline irrigation with manual removal B. Oil based ear drops 65. Pt. presents with c/o o dischar from right ear. xam reveals pain on pulling the ear upwards and outwards. here Is a discharge and debris In the external auditory canal and partial bstruction of t m anlc membrane. Dx: �Swimmer's ear B. Malignant Otitis externa w.t.d A. Saline irrigation jv. Polymyxin drops Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 497 Q66. Pt. with Otitis externa in OM. Red ear. Cover with two antipseudomonal antibiotics -7 Ceftazidime with Amikacin/Tobramycin Q67. Which Is a greater risk factor for surgery? Matching �1. Pt. is going for surgery. Surgeon refers to you, the Pt. A. Clear for Sx �2. Pt. with severe peripheral vascular disease going for B. Cardiac cath. as LBBB and asymptomatic. W.t.d vascular surgery Or Aneurysm repair. w.t.d prior to O.R clearance? �3. Pt. for elective surgery, has multiple PVCs. Asymptomatic. No evidence of ischemia. w.t.d _.!:.___4. 70 y/o Pt. with HTN and Osteoarthritis going for hip replacement surgery. w.t.d C. Exercise stress test with imaging D. Dipyridamole thallium stress test or Dobutamine stress test. p68. 57 y/o Pt. with colon cancer going for colon surgery. Father had Ml at age What to do prior to sur e ? ------ A. Nuclear imaging study B. Stress ECHO VC. Clear Pt. for surgery 49. � Q69. Pt. with hx o CABG 7 yrs. ago wit occasional CP on exertion has een scheduled or ur ent AAA of 7.5 ems in AM. Abdominal tenderness with pulsatile mass. w.t.d f\AI"' <...N\ftt...LI;..:� (> �-- vr..>oV"'-§-c-1.. GtL<,.£.1c:, ol�..<.<_ L, tlt c k.-.. .f\Y """"! � vv.'clear for surgery B. Cardiac cath. Q70. After a Ml, when should elective surgeries be done? Q71. Pt. with Stable angina going for surgery. w.t.d Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 498 72. Pt. postop after CABG in the CCU with confusion, is disoriented, doesn't follow ommands, inattentive and pulling out ET tube. HR 100/min. How to treat this Pt.? 73. Which medication can cause delirium in the elderly during postop period? 7 Mepiri dine (Demerol®) 74. Pt. in the recovery room and BP 160/104. Not a known hypertensive. w.t.d ' I J 75. Pt. with severe abdominal pain. Abdominal X-ray reveals air under diaphragm. he surgeon consults you for clearance. While doing the consult the Pt. vomits and ecomes bradycardlc. KG reveals H R 48/min and some non conducted P waves and diffuse 1mm T de ression. w.t.d ��----------------------------------------------� A. Postpone surgery uv.' Clear for surgery C. EPS D. Stress test H R is decreased due to increased vagal tone from vomiting. 76. What has shown to decrease risk of perloperative complications? ------------------� l �Lung expansion interventions (incentive spirometry, deep breathing exercises, ) CPAP) B. Laparoscopy C. Epidural anesthesia ) 77. What has been recognized as a risk factor post non cardiac surgery? ) 7 1' t1-0porW- T Le-veL < 12 h.r Alj S�eY) Alcoholism 78. A 40 y/o woman Is admitted to the hospital with a pneumonia. ext morning, Pt. says, she can see 'little green people' in her room. r a 40 y/o man admitted for Gl bleed, next day sees 'spiders hanging from the ceiling'. Exam evea ls Temp of 98.8•F, H R 84/min, RR 16/mln, BP 130/84. There Is mild tremulousness. here Is family history of alcohol abuse. Thiamine is given. ost llkel diagnosis is --------------------------�----------------------� A. Minor withdrawal symptoms ....JY.' Alcoholic hallucinosis <. 12-1� !....... ) 1 """ ( L..>....<4::f Delirium tremens c 2 �- � "k) -. HRt, D. Acute withdrawal seizure E. Korsakoff's psychosis C. Bf 1 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 499 79. Pt. llaCJ urgent surgery yesterCJay. ToCJay Pt. Is oriente x2. Temp 101 of R 105/mln. Mild tremor. Most likely diagnosis? A. Surgical site infection JY.' Alcohol withdrawal 80. Pt. with anxiety, tremors, confusion, H R 104/min, BP 150/92. elusional and has an episode of seizure. Dx:-7 lh-L:. '�'ik.M Tx: -7 7J-.' c.:a.pc.M ( � C.� o ol G "2-<-p o.x i ..V.. Lorazepam -7 Phenobarb-7 Propofol _, Jt B P 1 std·� ) A f< F 81. 54 y/o chronic alcoholic brought to the ER with confusion, ataxia, nystagmus and iplopia. N'(pt'-M-W cA &.o ku\ VV11i: T�"'"""""" rut 82. Chronic alcoholic with anterograde and partial retrograde amnesia. onfabulatory speech. Chn>�""'" 83. Pt. with SOB, tachycardia with bounding pulse. CXR� cardiomegaly IV' 1.. <..u. pt N-- T PN d.et'L.� sl..">v-t ---1 1' iA. IJtck. s '-'! t:./ 1\/' 2. (,(A. Eitw� ��·-1-t J, ( jf\- T. (...v-.. �J 84. Pt. with history of ETOH In hospital, receives thiamine, glucose and Is being fed ell. About 5 days later with muscular weakness, SOB. PK Increased, Hb decreased & Retic count Increased. p-t.. .1\•J'\ttc.;.� 1\"TN fl.._ ) 1 ) 85. Chronic alcoholic has muscle spasms. erum calcium low, K low. How to treat 86. Pt. undergoes surgery, post operatively has a seizure, tachycardia, confused and achypneic. This Is A. Drug reaction vB. ETOH withdrawal Awesome Review, Inc.<!> Copyright 20 1 4 Do not photocopy without permission Page 500 • • Life time incidence of Alcohol abuse and drugs is 20%. Only about 10 % of alcoholics receive care. So grossly under diagnosed. What is the best way to spot Alcohol abuse • AUDIT • CAGE questions • 4 drinks on one occasion in men or 3 in women C-7 Ever thought of Cutting down on drinking A-7 Do people Annoy you by criticizing your drinking G-7 Every felt Guilty about drinking E-7 Do you drink in AM (Eye opener drink) to keep your nerves steady or to rid yourself of a hangover. ) ) The most effective strategy for addressing alcohol abuse erral for � tment Screening, � Intervention and � � e_s� Abuse Dependence Problems: Keeps drinking: Work, school, social obligations sacrificed • Tolerance: needs larger quantities • Desire to cut down use but continues • Withdrawal symptoms ) Fails to fulfil work, school or social obligations • Use in hazardous situations • Legal problems due to ETOH use • Continued use despite social problems ) P,87. Pt. presents to your office for a routtne check up, appears depressed. ) ) ) ) ) ) • • abs: I ncreased MCV, Increased GGT. What Is going to establish that he Is a chronic alcoholic L-K Increased Carbohydrate free transferrin B. Increased GGT C. Increased Alkaline phosphatase D. Increased Uric acid E. Increased Triglycerides ) ) ) ) �Alcoholic neuropathy B. Cord compression fracture. 89. The most common cause of death In Alcoholics ) Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 501 T/F abo ut Alcoholism II 1. Increased incidence of malign ancy 2. Increased Motor vehicle accid ents 3. Increased suicides and overdose of drugs 45 T T T l-r 4. Increased sexually transmitte d diseases - Q90. The best d rug to treat Alcohol addiction in addition to support groups is A. Diazepam JY.' Naltrexone C. Methadone D. Flurazepam Vitamins Q91. Pt. with normal FBS. Whitish/grayish spots on conjunctiva. Q92. Pt. taking multiple vitamins presents with dizziness, headache, abdominal pain, ausea and vomiting.(llver enzymes elevate c;9 Ca 10.7mg/dl. here is xerosis of skin. · Dx:-7 Vit A - t'oxi ct:, 93. A Pt. presents with nausea. Labs reveals Ca of 11. undoscopy reveals blurring of the disk margin. t. takes multiple vitamins. Most likely diagnosis? --------�--� � Vitamin A toxicity B. Vitamin D toxicity 94. Elderly Pt. lives alone on tea and toast diet presents with bleeding gums. xam shows perifollicular hemorrhages and non healing ulcer. PT/PTT, platelets normal. Dx:-7 Scu1J ( v1 t c L(fl) \:.>1 13 J., Q95. PPD (+) Pt. o INH presents for follow-up with c7o pin pricks and tingling ensation in the legs. MCV low. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 502 0.96. Pt. taking multiple vitamins presents with headaches. Fundoscopy� Papilledema. Dx:-7 P�t:.,...IY\,.(.) ... ce.re�: Cause: Vita min A intoxication Ox: Subacute degeneration of the cord 2• Vitamin B12 deficiency 0.98. A health conscious person takes multiple vitamins and presents with nausea, norexia, fatigue, severe constipation. Mucous membranes are dry. Her Ca is 11.3 and Phos. is 5.2 Most likely diagnosis is --------� ) A. Vitamin A intoxication \)Y.'Vitamin D intoxication ) Q99. Pt. with dementia, diarrhea and dermatitis Dx:-7 Pe\�?Y� ( Nic.e-V, �� ) ) QlOO. Diarrhea and linear vertical lines on the nails ) } ) ) Q101. Pt. with prolonged ICU stay on TPN with alopecia, a hyperkeratotic rash, anemia and loss of taste. Dx:-7 Zir.c. do.tf!c<� Q102. Pt. post surgery, NPO on i.v fluids with prolonged PT. Most likely etiology? ) o\VVOS ·� � (\_f i...a.z. ...,. 103. Pt. post surgery anCJ in t e C , lias nau - se_,a -a""'n�a"" si .,...g � . iv:-e..n ,. .., p .,. ... e..,....,.....,n ..,..ot �li"" in.... e .. -0Ji....... ext day Pt. has horizontal nystagmus and ophthalmoplegia. ost likely diagnosis ...:....;. :.... ...., __ ) ) ) �6 'brv-1 ilr. "-- (V'1t- A.t..F- � clc.;r ) A. Acute dystonic reaction vB-:' Wernicke's encephalopathy ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 503 Others: Cheilosis, glossitis, dermatitis� Vit B2 deficiency Iodine � Goiter or hypothyroidism Bleeding diathesis� Vit K deficiency Cardiomyopathy, CHF � • Selenium • Hypophosphatemia � r.'�t..:.... � .. • Thiamine ( � 2-"3 1)0, P ) Anxiety Disorders • • • • • Panic disorder General anxiety disorder Phobias Obsessive Compulsive disorder Post Traumatic disorder 104. Discrete period of Intense fear and anxiety with somatic symptoms 08, palpitations, trembling, diaphoresis, chest pain or discomfort, etc. Dx: Panic disorder In perceived 'difficult to escape situations' �Agoraphobia Tx: TCAs/SSRis long term. Benzodiazepines short term. 105. Excessive anxiety out of proportion of fear to Impact of fear event. Dx: Generalized anxiety disorder. Tx: • Buspirone • Cognitive behavioral therapy A. Do ECHO B. Stress test JC, Start Benozodiazepines and re-evaluate in 2 weeks D. Holter monitor 107. Best long term management for the above Pt. 1 --------�--� Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 504 108. Pt. with feeling of vibration sense inside the body. She has had chest pain, alpltations andshortness of breath. Exam reveals a mid-systolic click. Most likely diagnosis A. Conversion disorder B. Generalized anxiety disorder �Panic attack Best management A. Metoprolol B. Buspirone �Paroxetine ) �109. Persistent distressing thought� Obsession �epet1tive response to the persistent thought� Compulsion -------� Dx: Obsessive Compulsive disorder Tx: • Fluoxetine SSRI • Fluvoxamine • Clomipramine (TCA) • Behavior modification }- ) 1 10. Fear of public speaking with sweating and trembling. -------� Tx: • � blocker • TCA �111>. Vletoam vet. who saw his friends die, presents with nightmares, avoidance of emlhder of event, flashbacks and intrusive memories Tx: • Psychotherapy • SSRis �2 ) ... YOung woman with multiple complaints referable to multiple organ systems >8. Exam reveals no matching physical findings to symptoms. Dx:� .S"Otv'\.t\�'2.c..liCA c:(;o Tx: • These Pts. have high rate of utilization of health care. • Needs a PCP and Psychiatrist. • Monthly appointments with PCP for reassurance and decrease utilization of health care resources. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 505 p113. Pt. presents with alteration or loss of physical function without a pathologic basis. Pt. is [unaware/ unconscious] NOT consciously producing symptoms. Tx:-7 Usually respond to .>� �t;b k. ft.. e�pc \..\ -t c �"t:J Qll4. Young woman of high socioeconomic status related to health field with PMHx of emotional trauma presents with deliberate production of signs and symptoms. �---- Dx:-7 �act.:. t..(ow, ct; ..::J 0.115. A man of low socioeconomic status with deliberate production of signs and ymptoms, pathological lying and wandering. ------ Qll6. Intentional production of signs and symptoms for secondary gains. uch as avoiding military duty or court case, etc. Matching �1. Physical findings don't match multiple complaints �2. Doctor shopping and high utilization of health care A. Somatization B. Conversion �3. Needs PCP with q 1 month appointments C. Factitious ,L4. Weakness of one side of the body but work up normal D. Munchausen J;_s, Young white female nurse deliberate production of E. Malingering with MRI. symptoms and signs . .l__o. Factitious disorder with pathologic lying and wandering. � . Exaggerated symptoms compared to physical exam. Pending court case or military service. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 506 Depression Depressed mood loss of interest in pleasurable activities Weight loss or Weight gain Insomnia or Hypersomnia Fatigue Diminished ability to concentrate .Ju"od�L -7 ru.p.-(.U:"""' If above symptoms > 2 weeks If above symptoms after death in family and symptoms i < 2 months -7 13e If above symptoms > 2 years -7 -7 ��<:\. If above symptoms with delusions/hallucinations � • • • • • • ye c:ve/V\.tl'oi � "n 'Ni/>;. Epidemiology: • • • • • • ) • • • ) '2. _ G '4 "¥ MD�-<. � 5',))�7. 6 .....pn:>p'u._,l'\, �!:'sr<z * • Treatment of Choice: • • • )I _ SSR.I • ) ) 10 million/ year with depression. Most common cause of suicide in US. Only 20% seek attention and 1/3'd of them misdiagnosed Treatment with any antidepressant for about -7 4 'i' """""t.., .:fru· I!!: episode. How soon can you see response -7 wl<..J' When to switch if there is no response -7 co_ s \N'\1( Recurrent >2 episodes of depression -7 ';jV'.J' When stopping drug -7 To.pev ·,t Psychotherapy: Cognitive therapy: Thought-? Emotion-? Behavior Interpersonal therapy: Interpersonal social functioning. 117. The most common cause of suicide In US Is A. Metastatic cancer ._,;v.'Major Depression C. Bipolar disorder • • • • • -7 Any antidepressant Depression Enuresis -7 Imipramine (TCA) Panic disorder -7 Alprazolam SSRI Obsessive-compulsive disorder -7 Fluoxetine Clomipramine Fluvoxamine Chronic pain +/- depression -7 Amitriptyline Smoking cessation -7 Nicotine replace. -7 Bupropion-7 Varenicline Insomnia -7 Amitriptyline ( . ..,p>< u.·c-) Overdose with low lethal potential -7 Citalopram (SSRI) 118. A 45 y/o man presents to you with depression. You start him on Fluoxetine and e starts feeling better In 3 weeks time. How long will ou continue the medication. A. 3 months _!Y."'4 to 9 months C. Start tapering fluoxetine now D. Continue fluoxetine as long as he feels better. Awesome Review, Inc.��> Copyright 2014 Do • • • Not "' not photocopy without permission 't'\ Page 507 83 y/o woman, awake, but doesn't respond to stimuli for the past couple f months. Reflexes intact, power Intact. Most likely diagnosis �Depression B. Alzheimer's disease C. Parkinson's disease D. Multi-infarct dementia Q120. Pt. terminally ill with Lung cancer and is depressed, loss of appetite, loss of interest in life. w.t.d 7 Methylphenindate7 elevates mood within days and can be used with other antidepressants which takes weeks to work. Q119. Matching �1. Drug-drug interactions i--S. HTN crisis r--f2_3 . Orthostatic hypotension �4. Anticholinergic side effects (dilated pupil, tachycardia, secretions dry) � . Sexual dysfunction �6. Least sexual dysfunction �7. Avoid in Anorexia �8. Avoid in Bulimia �9. Treat Bulimia A. TCAs (Imipramine, Clomipramine, Amitriptyline, Nortriptyline) B. MAOis (Phenelzine, Tranylcypromine, Selegiline) C. SSRis (Fiuoxetine, Fluvoxamine, Citalopram, Sertraline) D. Bupropion 121. A 62 y/o man with HTN & depresSion Is being treated Wltb;f;J,tl U'ntl luoxetine. He also takes vitamins dally. He presents with comp�ofi ��d rectfons and unable to have an orgasm for the past couple oh.nonthl� w.td A. Marriage counseling �tart phosphodiesterase inhibitor C. Discontinue f3 blocker D. Check testosterone level " {. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 508 SSRI side effects and Management: 1-4 weeks: Suicidal ideation� D/c drug, consider another drug 2-6 weeks: Restlessness/Akathisia� Switch drug or Add Benzodiazipine 2-4 weeks: Angry outbursts/lack of sleep, silliness, giggling 70% seen in Bipolar disorder� switch to Lithium or mood stabilizer 10% seen in SSRis� alternative antidepressant or lower dose. 122. Pt. started on SSRI presents with cloudy urine? • • Electroconvulsive therapy is Indicated for: Refractory depression Psychotic features Suicidality Catatonic stupor Side effects: Acute confusion, Seizures Long term: Impaired memory Relative contraindication: Recent Ml, aneurysms, CHF, COPD 123. You would stop Bupropion In A. Anxiety \JY."Mania • • • • I ) ) Bipolar disorder: ) ) Manic depressive� L�M.ot--;a-i� Manic or hypomanic (mild manic) Euphoria Inflated self esteem and ideas of grandiosity Decreased need for sleep Tx: Lithium or Valproic acid/ Atypical �psychotic P,124. 22 yjo was started on FJuoxetlne (SSRt) for depression, �e starts playing musfc all night. w.t.d A. D/C SSRI and start Bupropion ,.--B'· D/C SSRiand startlithium olCJlzc:pu ( ,Yr.: C. Continue SSRI • • • ) • (CJYI c- .p ""� , qo ,...:_ ) _,_,., Side effects of Lithium: Diabetes Insipidus: impaired renal concentration Hypothyroidism Hypercalcemia Hand tremors Toxicity: 1.5-2.0 >2.5 Fasciculations N/V Delirium Slurred speech Coma Nystagmus Death Ataxia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission • • • • • • • • • • • • Page 509 Chart 12-2 Anti-Psychotic agents Typical agents: Phenothiazines Non Phenothiazines • • • • Chlorpromazine Fluphenazine Thioridazine • Haloperidol (Haldol®) loxapine Atypicals • • • • Clozapine (most efficacious, agranulocytosis) Olanzapine ( Bt <�. �¥ 1 1- wt Quetiapine (well tolerated) (Seroquel®) Risperidone (efficacious and used in elderly) 1' 125. Are anti-psychotics (typical and atypical) FDA approved for management of delirium? & �126. Pt. on Paroxetfne (Paxll•) Olanzapine for Major depression develops Increasing ,_, lood sugars. Most likely caused by A. Paroxetine VV. Olanzapine Side Effects of Typical agents: • Acute dystonic reaction Tx:-7 'b.; P�t./\..� &.-(4�� /Benztropine • Akathisia: • Tardive dyskinesia: • Neuroleptic malignant syndrome • Prolonged QT interval ? M.t-1t-c;,otW\J.. � Motor restlessness, keeps wandering around Tx: decrease dose or D/C drug smacking lips and tongue c.....w<- .,.. 0.1 127. Pt. with hallucinations, smacking lips. Says he takes some nerve pills, he doesn't now for what psychiatric disorder. Most likely disorder he is suffering from Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 510 ) Q128. Pt. has not been taking her meds. and moves in with her son. 6 mths. later, says daughter in law is trying to kill her. On exam she has smacking of lips and tongue. Most likely etiology is � Phenothiazines that she used to take more than 6 mths. ago. Underlying disease� Paranoid Schizophrenia Q129. Pt. with Schizophrenia develops Parkinson's disease. He develops psychosis. He refuses blood tests because of needle sticks. w.t.d \.k.""Queti9 pine B. Haldol Q130. Pt. with Parkinson's disease, dementia, BPH and Glaucoma becomes agitated and confused. What Is the best antipsychotic to use? A. Haloperidol B. Risperidone ..._e: Quetiapine Q131. Hyperthermia with mental status changes, tremor and autonomic Instability (increased HR, decreased BP, N/V/0) & hyperreflexia. � SSR 1 f ( Ssr<.z MA o'LI ) (� 5'S R 'L 1' L..·,�.e:t.Jl;ol SSR.2 Tx: D/C med and start� �z,..o � Q132. Hyperthermia with mental status changes, autonomic dysfunction with �!!!�� with rhabdomyolysls � N�\A'(A)�e.-p�c. """c:.�s� t c P�"fh.:-..u"' I- H�Lctcll ) .,. ) ) t � d..dl. J --* ..,. ) } ) ) ) Q133. Hyperthermia with sustained muscle contraction, HTN, difficulty ventilating Pt. lth sudden increase In end tidal COz. CPK Increased. Family history of death or fever on the table during anesthesia. (inhalation anesthetics) Tx: Rapid cooling /Dantrolene 134. Pt. with hyperthermia, delirium, HTN, tachycardia and diaphoresis � J''::l � tt-... "'-4.1"'>.\ t..'c C...i �..r (Amphetamines+ Cocaine) Prescription diet pills 135. Hyperthermia with mental status changes, tachycardia, decreased bowel movements nd urinary retention --------� Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 511 0136. 69 y/o woman, husband passed away about 2 years ago and now lives alone. �-II\,10 mg dally. he takes several medications including Zolp1oem he appears confused and has periods of not being able to be aroused. CT head mild atrophy. Most likely cause of her condition is \k."" Drug induced B. Frontal lobe tumor C. Dementia 137. Pt. with depression. Also takes Zolpidem for insomnia. On exam he has amnesia and ppears confused. w.t.d --------� --------� Matching �1. 70 y/o man. Wife died a couple of years ago. He has loss of appetite with weight loss for the past 6 months. He appears A. Schizophrenia depressed. Pt. says he is hearing voices or seeing things on the wall. Most likely diagnosis? �2. 70 y/o man. Wife died a couple of years B. Depression with psychotic features ago. He has loss of appetite with weight loss for the past 6 months. Pt. says he sees her when he closes his eyes and this causes him to frequently wake up at night thinking she is next to him. He does not indulge in any pleasurable activities. Most likely diagnosis? C. Complicated grief D. Malingering Borderline Personality: • • • • • • Instability in their self image, mood states, interpersonal relationships, and impulse control. Social history usually includes many stormy relationships Pts. acknowledge chronic problems with anger control. Marked swings in mood throughout the course of a single day. At one moment a friend or romantic partner may be viewed as a trusted confidant. A week later, this same individual may be viewed as cruel and betraying. Most commonly Pts. are misdiagnosed as having Depression, OCD or bipolar. 138. Best management for Pt. with Borderline personality? \..IJ<': Behavioral psychotherapy B. SSRis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 512 Eating Disorders Anorexia: • • • • • <15% of ideal body weight Feel they are too fat Decreased BP, hypokalemia, hypoalbuminemia At risk for sudden death from V-Tach Don't treat with antidepressants-7 suppress appetite Bulimia: NOT <15% of ideal body weight Eat and purge: Vomiting-7 Callus on knuckles, submandibular LN , """'i .s t or Laxatives Parotid enlargement, loss of inner dental enamel Esophagitis Low Cl, Low K and Metabolic alkalosis Urine Cl�low fl139. Young woman with new onset upper Gl bleed at a party. Na 136, K 2.7, Cl 80, �lcarb. 35. BMI 24. Most likely diagnosis? LPC"Bulimia nervosa B. Anorexia nervosa 140. How to treat Bulimia after psychotherapy • • + • • • ) ) 141. A 38 y/o woman on various antidepressants and analgesics for pain, onsumes several extra pills of one of her meds. n arrival to the ER she is awake, soon after, becomes hypotensive, tachycardlc and ) hen has a seizure. elemetry monitor reveals widening of QRS complexes. ) BG reveals Respiratory acidosis. his Pt. most likely took ) v;( TCA B. SSRI ) C. MAOis D. ASA E. Acetaminophen P142. 50 y/o Is brought with overdose of hypertension and angina medication. �ook 30 pills of metoprolol. �P 70 systolic, HR 35/mln with AV block. VF bolus given with atropine and still not much change. w.t.d '-7 Glucagon (cAMP) increases contractility of mycocardium �-7 Epinephrine drip ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 513 Q143. Pt. took overdose of calcium channel blocker. BP 80 systolic, HR 42/min. Pt. is started on IVF bolus and atropine. �hat else would you start for this Pt.. 7 slow i.v calcium chloride to counteract peripheral vasodilatory effects of Ca channel blockers. Q144. Pt. presents with increased secretion (salivation, etc), profuse sweating, Nausea & vomiting, shortness of breath, tremors and fasclculations. Exam reveals Pupils constricted and HR <50/min. Most likely_Qoisonin_g? A. � blocker overdose B. Ca blocker overdose � Organophosphorus poisoning D. Cocaine poisoning Q145. 1n above Pt. what to measure? 146. How to treat above Pt. 7 Remove contaminated clothing 7 Activated charcoal 7 i.v atropine C b\.otlr. MWC.G.v·,,w. �W) 7 i.v pralidoxime ®) �147. Pt. and family feel tired, fatigued and somnolent. Pt. goes out and shovels the r;now and feels better. Dx: CO poisoning w.t.d7 Call Emergency services and get the whole family out the of house Q148. Firefighter brought after fighting fire. ABG shows saturation of 94% on f40% ventimask. Soot seen in nares. Pt is intubated. What FIOz is required? A. 25% c;B S I M.G JY,' lOO% c, }:A.otl< 1\.\�t.: ""G -t 149. Heroin addict or Pt. on morphine or codeinedevelops URI with profuse lacrimation, sweating, rhinorrhea, yawning, restlessness & diarrhea. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 514 Matching A. Hallucinogenic mushrooms r2-1. A 24 y/o Pt. came back from a party and became agitated and talking fast but fluent. Exam: Alert but acting paranoid, Diaphoresis (+). BP 160/100, HR 110/min, Temp 100.6•F. <ji Burn on oral mucosa. Po.Q.rdentition. Excoriations on skin. Picking skin. Hyperreflexia (+) _i:_2. A 24 y/o Pt. came back from a party agitated D. Methamphetamine (Meth, speed) and has a seizure. Diaphoresis (+). BP 160/100, HR 110/min, Temp 100.6•F. Hyperreflexia (+) �3. A 24 y/o Pt. came back from a party agitated C. MDMA (Ecstasy) and is not following commands. Diaphoresis (+). BP 160/100, HR 110/min, Temp 100.6•F. Hyperreflexia (+). Serum Na 124. Matching ) ) II ) ) c. r---1 . Fever �2. Hypertension �3. Tachycardia U2._ 4. Hyponatremia _fi_s. Agitated, psychotic but alert �6. Agitated, mental status changes �- Skin Picking _t_s. Oral mucosa burns �9. Mydriasis �10. Hyperreflexia (j 11. Serotonergic and SIADH ) Awesome Review, Inc.® Copyright A. Methamphetamine B. MDMA (Ecstasy) C. Both D. Neither 2014 Do not photocopy without permission Page 5 1 5 150. Your Pt. Is receiving Morphine sulfate and benzodlazeplnes for leg pain from an njury. He agrees not to abuse the drugs. mths. later, Urine toxicology reveals Benzodlazeplnes, Opiates, Cocaine, and arljuana positive. w.t.d? A. D/C all meds immediately I.)Y.' D/C Morphine and taper Benzos. �151. 80 y/o woman with history of depression was treateCI wlffi Imipramine �OOmg dally and haldol 10mg dally. Now admitted with delirium, neck rigidity and spasticity. � P 150/100, HR 100/mln. w.t.d next. vA. Dantrolene I a�ovipt.:.l'\(. B. Trihexyphenidyl C. Cooling blanket. 152. The most common cause of admission to hospital in the elderly -------"--��---___. Delirium * Jf .:..... Fluctuating course of {6natt-e-nti-.o-r})a. nd altered consciousness Etio: Side effects of poly pharmacy Meperidine (Demerol®), Morphine Fever, Metabolic abnormality & electrolyte disturbances Hypoxia Medical and Surgical Pts. > 65 yr. Alcohol withdrawal Anticholinergics & Antihistamines Antidepressants Alzheimer's medications: Donepezil, Rivastigmine..,( f...,I L ) c.4-o Sedatives such as Zolpidem (Ambien®), etc. Tx: Correct underlying cause. 153. 72 y7o woman appears w th eplso es of Inattentiveness and confusion, specially at night time. She takes Enalaprll for her HTN & diphenhydramine for nsomnla. This re �resen�t;.;s;. vK Drug reaction B. Depression with psychotic features 154. w.t.d for the above Pt.? • • • • • • • • • t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___, Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 5 1 6 True or False: Delirium i n hospital settings has been related to I Increased mortality 2. Increased dementia 3. Increased institutionalization 1. J -r Pt. post hlp surgery 2 days later, awake until 2 am and confused. Prior to Sx, he was on HCTZ, Enalaprll, MVI, Atorvastatin and Lorazepam. Post surgery the meds. for BP and hyperlipidemia were restarted. Most likely etiology is �155. Best treatment for Insomnia ? 7 Sleep hygiene (bed comfort, noise level, temp. in bedroom, don't drink caffeine drinks, avoid naps during day, bed for sleep and sex, not TV or office work. Fixed time to bed and wake up.) 157. Best medication to initiate sleep 156. ) ) ) ) \ I ) \ Dementia Progressive deterioration in cognitive functioning, impaired memory, judgement and abstract thinking. First, rule out treatable causes: Degenerative diseases: Drugs Alzheimer's disease Vitamin B12 deficiency Dementia with Lewy bodies Hypothyroidism Parkinson's disease Normal pressure hydrocephalus Pick's disease ( J.<!.ft�'-tK O«.. �cov i o r ) Heavy metal poisoning: Lead Infectious: Syphilis, Whipple's, Lyme's, Meningitis • • • • • • • • • • J Dementia: Assessing cognitive status ) Mini mental state exam (MMSE) score > 23 normal. Other screening tests for cognitive status Clock drawing test Making change test. • • J Functional assessment lv Basic activities of daily i ing(BADL) Eating, bathing, dressing, transferring and toileting. Instrumental activities of daily livingtest (IADL) complex activities to maintain household: shopping, driving and managing finances. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 517 Falls Ways to decrease fall: Discontinue psychotropics/targeted reduction in meds Muscle strengthening and balance exercises, Tai Chi Improve lighting Decrease hazards Extra support in the toilet and shower 159. Best test to predict mobility and falls? � � t. 7 li� \.\f Arise from chair, walk 10 feet, turn around and return to sit in the same chair. > l<j .s 7 high risk for falling Major predictor for fracture with a fall -7 osteo p o.ro r....;,s 0.158. • • • • • 1 Elderly Pt. with frequent falls. What deficiency do you suspect? A. Vitamin A B. Vitamin C ....e:' Vitamin D D. Vitamin 812 161. A 85 y/o woman in the nurstns home trips and falls. She. uses a ane occasionally .t.d? A. Prescribe walker JY.' Physical therapy 160. • A. Early ambulation JY. Surgery and three parallel pins 163. An elderly Pt. fell and sustained displaced fracture of the femoral nt�ck. est management? A. Surgery and internal reduction -.J( Arthroplasty Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 5 1 8 164. In a Pt. with displaced fracture of neck of the femur, meta analysis has shown hich procedure had better hip outcome? �Total hip arthroplasty (femur + ball + socket).-t.f\1fC-vl� B. Hemiarthroplasty (femur + ball only) Intertrochanteric fracture -7 k.tr c.or--peJ True or False tIn an elderly Pt. with acute compression vertebral fracture, there was no advantage of vertebroplasty over Rehab. and analgesia J.\ c.v.. �C.�"�w.r 165. Above Pt. with vertebral compression fracture with no response to conservative easures for a month. w.t.d 'I ) ) } 166. Elderly Pt. with hip fracture, s/p ORIF, is confused and agitated In evenings sundowning). w.t.d A. SSRI JYAtypical antipsychotics 167. Pt. with dementia, can swallow, but eats only half of his meals. Sometimes, you find ood In the side of his mouth. w.t.d A. PEG tube J. Aid with feedings Q168. lower rates of feeding tubes In nursing home reflects what? A. Poor feeding � Values of resident autonomy A. To improve nutritional status � No change in ·nutritional status 170. 82 y/o with history of frequent falls. BP 140/90. what would you D/C? A. ASA JV Diphenhydramine Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 519 Drugs causing depression � blockers Alcohol Steroids Psychotropics Others: Parkinson's CVAs • • • • • • Chart 12-3 Incontinence Problem Detrusor overactivity Treatment j l3 • • Decreased sphincter Cough tone Cough ! ontinence Overflow Incontinence • I Urethral obstruction Prostate hyperplasia Detrusor underactivity DM neuropathy, MS Drugs: anticholinergics R yyJr. Ke �rs Bladder training exercises Anticholinergics {TCAs) o x !:l '- "'t.�� Strengthen pelvic muscles @i0 -7 Estrogen cream -7 Sx alfa blockers: Terazosin/Tamsulosin {Fiomax®) Cholinergics: Bethanechol .. True or False Incontinence is a normal consequence of aging. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 520 ) ) ) ) ) ) ) ) ) ) Matching �1. Most common cause of incontinence A 2. Detrusor overactivity �3. Decreased sphincter tone ;Q.__4 . Side effects of anticholinergics A. Urge incontinence B. Stress incontinence C. Urethral obstruction D. Detrusor underactivity (overflow incontinence) �' 8 5. Post void normal C, 'D6. Post void residual > 100mI � . Bladder training helpful > TCAs (imipramine) � !S.J2_8. Urodynamic studies �9. Response to Prazosin or Finasteride �10. Responds to � adrenergics (Bethanechol) �11. Timed Bathroom visits and diapers � 2. Oxybutynin(Ditropan®)/Tolterodine (Detrol®) ) ) ) ) ) ) Matching L1. 78 y/o woman with CVA, however independent with activities of daily living including toileting admitted with pneumonia. Pt. appears confused � Restraints applied. Diazepam was given for sleep. She is now incontinent of urine. (::$ 2. 67 y/o woman with OM has urge to urinate almost every 30-60 mins. She leaks urine on her dress. She has started wearing diapers. _f_3. 94 y/o female in NH comes back after hip surgery. Meds. include tylenol with codeine. Mental status in intact. She is upset and complains that she is leaking urine and smells bad. She has never been like this before. A. Functional incontinence B. Urge Incontinence C. Overflow incontinence ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 521 80 y/o man In NH is diagnosed with depression & started on desipramine (TCA). weeks later, nurses complain Pt. smells of urine. 171. Dx: Overflow incontinence w.t.d next -7 Change TCA to another class 67 v7o woman with NO OM has urine leakage. Has to use bathroom with increasing frequency, including getting up at night. No dysuria or fever. w.t.d 172. Matching �1. 65 y/o man with symptomatic BPH. BP 90/65. PSA A. Finasteride (Proscar ®) �2. 65 y/o man with BPH. BP 140/85 B. Terazosin (Hytrin®) A 3. BPH + Hematuria C. Tamusulosin (Fiomax®) normal. Best Tx? A. Wear dia pers at night \.Jr." Discontinue diphenhydramine (overflow incontinence) C. Start anticholinergics D. Timed bathroom visit Pressure ulcers Stage 1 : Skin intact with non-blanchable redness. Tx: -7 Po S'd:� ""'-i"j a. SV-f p ()-It Stage II: f- lc.V. 'o r�« lc.. Shallow ulcer red pink with wound bed. Tx: -7 Occlusive or semipermeable dressing that will maintain a moist wound environment. Stage Ill: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Tx:-7 Debridement and antibiotics as necessary Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Tx:-7 Debridement and anti biotics as necessary Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 522 Chart 12-4 Prugs to avoid i n Pregnancy � Drugs safe in Pregnancy Valproic acid Carbamazepine (S.E: neutropenia, SIADH} Mg sulfate • • � ACE inhibitors • • ) ) Ciprofloxacin • Nitrofurantoin Amoxicillin Ampicillin • PTU • • Methimazole� 1 - t.-.M..�ttt 0� Radio Iodine 1-131 .t� le le 1- Most antihistamines ) 1- · Warfarin Smg or more-? ··"- l_e tY•""V 1- ) � Nitroprusside - Hydroxyzine Chlorpheniramine • Hepann • 1-Jt.f� < ) rvj -4 CCA \.<M. � � Most Aminoglycosides • Gentamycin ) !e Doxycycline/Tetracycline �..c+l..o rv>,.,;U • � lactams ) Pregnancy ID 174 .Pt. with asymptomatic bacteriuria. w.t.d ) "2� ' .. J':! t j f.&. - C l<.... !-"' lj • -7 ) _. • ) ) 7 r fY'! Clonidine, � blocker Calcium channel blocker Procainamide • • ) , .-<4 {'v\(. � M c z_,A. � '2 .. 3 t..:""" • • S1 A7J 1-1 Labetalol Furosemide alpha methyl dopa Hydralazine • • • £s�c; c"" c;Lt. c. � • • k)C Ampicillin, Nitrofurantoin No Bactrim or Cipro. 175. Pregnant Pt. with dental caries with ache. Which antibiotic to use? A. Cipro. B. Bactrim /- Augmentin 176. Pt. presents postpartum with fever and chills Dx: � ry.., Post pc.rtw- £��e_f:y,t;1 Most common Etio. -7 Group B strep. C �1<. e 3'1 - 3l �s ) Most common cause of mortality associated with pregnancy in US Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 523 0177. Will Immune globulin prevent Rubella. 0178. Pregnant woman exposed to Hepatitis A-7 I mmune globulin Hepatitis B-7 Hepatitis B Immune globulin Measles -7 Immune globulin within week Varicella -7 Va ricella Immune globulin within 1 10 days 179. Can Pt. get Hepatitis B vaccine? 180. What vaccines are CONTRAINDICATED • • • • • Live vaccines MMR Va ricella Oral Polio Yellow fever )' 2 VO M M R. Vcz r i-z e:JL., Q181. Can a lactating woman receive vaccines? Q182. Pt. visits 3rd world country and back and has jaundice. e atitis A and B are negative. w.t.d -7 Hepatitis E serology. Mortality 20% 183. Can HIV (+) Mother breast feed baby? 184. Can you treat LTBI/PPD in a pregnant woman 185. Can you treat MTB during pregnancy 186. In which 60 y/o can Herpes zoster vaccine be given? � On steroids and methotrexate B. On Anti-TNF alpha agents C. CLL asymptomatic D. Non Hodgkin's lymphoma Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 524 �187. A 22 y/o Pt. with rheumatoid arthritis o n Etanercept (Enbrel•). Can she receive HPV vaccine? � Ye..s 188. What would you prescribe for a 65 y/o Pt.? �olysaccharide PPSV23 B. Polyconjugated PCV13 189. What would you prescribe for a 65 y/o Pt. who had PPSV23 at age 59? 190. 40 y/o Pt. with OM, HIV, CRF or Asplenia. Wtd? ) � PPs v z 3 191. 45 y/o Pt. with OM, HIV, CRF or Asplenia received PPSV23 at age 40. Wtd? 192. 65 y/o Pt. with OM, HIV, CRF or Asplenla received PPSV23 at age 40, 45. Wtd? ) ) � p r .s v 2 3 193. 6$ y/o Pt. with OM received PPSV23 at age SO. Wtd? � ) P f> S V )o 2J I o\.Ot<. ) 195. A 40 y/o diabetic was treated for DKA and discharged with PPSV23. w.t.d? ) ) ) � .pc v I3 c.J L�t 196. 65 y/o woman is being d ischarged in November. w.t.d? --------� A. G ive flu shot today and discharge tomorrow with PPSV23 B. Give flu shot and PPSV23 today in the same arm ,;;:. Give flu shot and PPSV23 same day on different arms 197. How often flu shots? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 525 Q198. If Pt. a lergic to eggs. W.t.a Q199. If Pt. has anaphylactic reaction to eggs .f LubLOk. 200. What vaccine for youth joining college? \//( Tdap B. Dt booster 0201. Pt. presents with laceration. He had a Tetanus shot last year. W.t.d A. Nothing � Tdap 202. Pregnant Pt. had a td booster shot last year. W.t.d A. Nothing )Y.' Tdap 203. Pregnant woman 20 week. Had tetanus shot last year. W.t.d? ..A("Tdap now B. Tdap after delivery �204. A 60 y/o man had a Tdap vaccine and presents next day with swollen arm more han @% bigger than the other arm with same soreness. Ranse of movements are 1 normal. Best management? A. Heparin B. Steroids �Reassurance 205. >60 y/o Pt. with history of shingle$ wants to prevent shingles In the future .t.d -7 H z v even if they had it before. No need to ask if they had it before. Q206. Who would be the best candidate to receive l.v lgG.? ,.Pt. with prior vaccination for Rabies with dog bite u..,.:.-.. cl.> jV' Open wound fracture at a gym. Tdt 12 yr. ago. 207. In which of the following Pts. will you NOT give VZV vaccine? A. Elderly B. Had flu shot today ,;:: CLL/Lymphoma ·' • - • v c.. GG;f\.C. )0 "l va. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission k. Page 526 A. Shingles and pneumococcal vaccine at the same time, in different arms �Shingles and pneumococcal vaccine, 4 weeks apart Card i o l ogy Q209. Which of the following is contraindicated In pregnancy? A. Electrical cardioversion for an unstable rhythm B. Procainamide C. Digoxin for MS with CHF D. Verapamil �· None of the above 1 Q210. Pt. with mitral stenosis Mild -7 > 1.5 sq em Moderate -7 1.0-1.5 sq ems Severe -7 <1.0 sq em -7 rvo -7 � tx bloc.k.<?Y 1- -7 v clv\kpLMij �pe;..d..:. 'j eN- S"':Jf"'Pt� 211. Pt. with mitral stenosis with Aftb. How to treat ) ) -7 Digoxin and � blockers & anticoagulation Q212. Pregnant Pt. with mitral stenosis started on P blockers. She develops SOB lth Increased JVD. Furosemide Is en. w.t.d ) A. Start Digoxin ___z. Mitral valvuloplasty ) ) Q213. Pt. with ASD wants to get pregnant. w.t.d If shunt < 2:1 -7 u:>J'- �r Pvc.3(\.� If shunt >2:1 -7 f4� <fr.rt ) \ ) Contra indications to pregnancy: • • • • • Pulmonary HTN Eisenmenger's syndrome Marfan's syndrome with dilated aortic root Dilated Cardiomyopathy with CHF Severe Aortic stenosis 214. Which of the following is LEAST tolerated during pregnancy? ) ) A. ASD B. MR C. MS _./!). VSD with central cyanosis E. Pulmonary artery systolic pressure of 22 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 527 Q215. Can HOCM and Mitral valve prolapse get pregnant? 0.216. 10 days postpartum, Pt. comes with fatigue and short of breath. JVD (+). ECH07 dilated cardiomyopathy with EF 30% Occurs mainly in the 3rd trimester or postpartum. 0.217. The above Pts. cardiac function normalizes. Can she become pregnant again? ---� -7 Chances for peripartum cardiomyopathy are increased. Q218. Otherwise normal pregnant woman 14'h week. Routine prenatal visit has 3 (+) and II/VI systolic murmur at the apex. --------� 7 Functional heart sound and murmur due to normal volume overload of pregnancy Q219. Pt. with HTN. what can you use 7 • Labetalol • alpha methyl dopa • Hydralazine what NOT to use -7 •ACE inhibitor • Nitroprusside 220. 33 wks. pregnant woman, presents with BP 160/104 and bilateral pedal edema. latelets 90,000. PT/PTI 16/50. ric acid 12. rine7 Proteinuria UN/Creat : 40/1.3 Dx: -7 <D 7. C 7.. t., Tx: -7 '1) � \..; V(/\'j R,.c . e. c. L � p c-.'c. b�� 221. What are the other causes of DIC In pregnancy? • • • • • Dead fetus Abruptio placentae Amniotic fluid embolism AFLP Pre-clampsia Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 528 222. Pre-eclampsia with seizure 0223. Best way to treat seizure � M. g s � Q224. Which anti-seizure NOT to use --------�--�--� ) ) Q225. Pt. lactating postpartum with Prolactin level >200. Dx: Prolactinoma � IV\ Je'Z "i .r --------� Tx: Bromocriptine Q226. Best treatment for Thyrotoxicosis (Grave's disease) ) NO Methimazole 1'1 trimester NO Radioiodine ) -- ) -- True or False: 1. Thyroxine requirement increases during pregnancy and gets back to normal postpartum. 2. Most common cause of amenorrhea is pregnancy ) -r I" True or False: ) ) Insulin requirement increases by about 50% during pregnancy. Needs tight control, otherwise increased fetal loss and fetal malformations --r Q227. Pregnant woman with OM on oral medications. w.t.d � D/C oral meds, start multiple insulin injections for tight glycemic control FB s < 1 1.) Post P....,_.t: c)- (J S < J Z...O ( 2 �-,.... ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 529 Q228. O M Pt. wants to conceive. w.t.d 7 Screen for retinopathy and treat if present before conception, otherwise tough to treat retinopathy during pregnancy. Q229. In a non-diabetic woman, when to screen for gestational OM Q230. Do people with gestational OM have a higher risk for OM In the future? at the end of 5-10 yrs. Q231. Pt. in labor with Iron deficiency anemia. Most commonly seen In Pts. with Q232. Pt. with SLE gets pregnant. ESR decreased. w.t.d 7 Stop all drugs and monitor for spontaneous remission. Q233. If Pt. had recent exacerbation of SLE. w.t.d 7 Continue steroids 234. Pt. complaints of Itching. what drugs can you use In pregnancy 7 • Hydroxyzine • Chlorpheniramine 235. Pregnant woman wants to fly from NY to LA. What Is the optimal time if she has 0 fl 7 A. 1'1 trimester ¥. 2"d trimester C. 3'd trimester 236. Which of the following pregnant women can be allowed to fly --------� A. History of Pre-eclampsia B. History of OM, HTN or Anemia C. History of Premature delivery D. History of incompetent cervix J/None of the above Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 530 True or False: Young women with pulmonary HTN should avoid pregnancy with progesterone only Meds. NOT estrogen containing meds. T 237. Pt. on OCP going for elective surgery. w.t.d -7 $ �1' 1 (Y\ltr.-f; p--- i ()V True or False: 1. Pregnant more prone to DVT & PE 2. Pregnant women can use steroids ) ) ) Intrahepatic cholestasis of pregnancy • Cholestasis-7 1' Serum bile acids-? pruritus • AST/ALT 1' but <200 • Alk. phos. elevated. • PT normal, Platelets normal, NO DIC. Tx: • Cholestyra mine • Ursodeoxycholate • Early delivery at the sign of fetal distress 1 -r p<;A..C ,..c.. � i tu..:."AM ,z,. 1"- P�� (mild intrahepatic cholestasis of pregnancy.} Acute Fatty liver of pregnancy: • Carnitine deficiency or Choline deficiency or Tetracycline use • Pt. presents with malaise, headache, nausea, poor appetite & abdominal pain. • Moderate elevations of AST/ALT >150, Ammonia 1', Bili 1' • Often associated with pre-eclampsia & DIC • Liver biopsy-? Microvesicular fatty change. Treatment: • AFLP resolves rapidly after delivery of the baby. GYN 239. 40 y/o with dysfunctional uterine bleed. 240. 16 y/o asks for OCP. w.t.d -7 ' � stU\/- P�I- 238. 22 y o Pt., 34 weeks pregnant with pruritus. ST/ALT 20/22. Alk. Phos. mildly elevated. w.t.d --------�� -7 Reassurance for R-�..�."'tw {jt¢ v ; d qv..,... <-a.r...w -1 --------� � iv-G ·,t Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 531 241. Pt. wants to know timing of start of OCP. Her last menstrual period was a week o. When to start Q242. Pt. with ysmenorrhea, CJyspareunla. Pelvic exam reveals enlarged ovaries and palpable bands on ligaments. No pelvic motion tenderness. w.t.d 7 l c.. p ...os c..oY') to rule out Endometriosis ( Endometrial tissue in other places) Q243. Pt. wants post coital contraception. w.t.d within 72 hrs. How do they work? -7 ovw i-{V\ ·,hk; C;.,-t c Oft! L �� l "f ) i r--p�t c.HCA ' and delay onset of next menstrual period 44. Pt. on OCPs missed 3 days of pills and had no sexual activity during that period t.d • • -7 Take only the most recently missed pill and another method of contraception for 1 week. Complication of OCPs: • HTN (increased Renin substrate) DVT Stroke, PE Peliosis hepatis (rupture of cyst-7 Shock -7 CT -7 Surgery) Budd-Chiari syndrome (hepatic v. thrombus): abd. pain, ascites, ped. edema Elevates Theophylline level & causes toxicity � l'Y\AT c :VV G k. c. ) ..., t)o Euthyroid thyroxenemia "" Cl-1� • COf>D ., rut:it ' "!IJ... Mood swings Erythema nodosum PCT • • • • • • • 1 � p:11 t � CAM � rJc"' � � � , • • 245. When NOT to use OCP -7 • History of DVT • Pregnancy • CAD • HTN • Migraine Headaches Breast Cancer • Smoker >35 yrs • Chronic hepatitis • 246. OCP failure can occur with use of --------� -7 )t Tc.\..1\o�J -7 To e..� L"Z.. ""- �!:> o,..J o (f; I n.. i'.j-'V"'Pif\.. 247. Pt. on oral contraceptives for a long time. She Is brought to the ER with shock. P 80/60 and H R 120 min. You sus ect ru tured live r� ad� eno m� a. ------------�----� � Tx: -7 S)C Best test to Dx: -7 CT S(.p..f"' Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 532 248. Pt. presents with crampy abdominal pain and vaginal spotting. Last menstrual erlod was a month ago. Pregnancy test Is positive. What Is the next best diagnostic test? 249. What Is the effect of HRT on fibrolds? -7 May increase size but no increase in malignancy 250. 26 y/o on OCP for the past 2 mths. c/o mid-cycle spotting. w.t.d? A. D/C OCP & biopsy B. D/C OCP J/.' Continue OCP 51. A 19 y7o on QCP c70 moderate to severe mid-cycle bleeding for the past 2 mths. o family history of endometrial cancer. w.t.d A. D/C OCP B. D/C OCP and transvaginal ultrasound ,... . __. o\ i t U...-, .:.u II - Y�� ( ncl;I\-0 1'\'\.<.(A, ) -l t"� J JC, DIC OCP an d use rntrautenne d ev1ce - ' - ·� Can also use higher dose Estrogen containing pill. c. st:..,J:>. \.� . 1h.. l!n.clo�t..; �....J- ) • ) ) · A. Ask Pt. to exercise less \)Y.'Ovulation kit to check body basal temp for ovulation A. Splenic vein th rombosis .JY.' Hyperstimulation syndrome A. Cystocele JY. Rectocele C. Thrombosed hemorrhoids D. Uterine prolapse--> sitting on a lump, dyspareunia ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 533 T/F: The fo l l ow i ng are never events in health care settings? ----r A. Decubitus ulcers stage Ill or IV -- B. Vascular catheter associated infections T -C. Catheter associated UTis ---- I D. DVT or embolism in hospital r- E. Hospital acquired pneumonia F. ABO incompatibil ity -G. Pt. fall -- ( Bu.. <II �..no. CO'): ) H. Disability or death from hypoglycemia -r T -I 'T C. L t'vo!l..o>x� u... ) -r T/F Time out before surgical procedure is to confirm -A. Correct Pt. identification -- I T B. Correct side -C. Correct site -- D. The type of procedure • "j(;5 t- .,. -r Medicare Part A covers hospital, skilled nursing home, home-health, and hospice services. • • • • • Medicare Part B covers physicians, nurse practitioners, social workers, psychologists, therapists, laboratory tests and durable medical equipment. Medicare part D covers some of the cost of prescription medications. Medicare Part C provides the benefits offered under Medicare Parts A, B, and D through Medicare Advantage plans, which are managed care plans. tHMo P� ) Medigap supplemental insurance plans are available that cover Medicare Part A and Part B deductibles and co-insurance costs, as well as preventive care and other health-related goods and services. Medicaid is a joint federal and state program that provides supplemental health insurance (including long-term custodial care in nursing homes) to people of all ages who have low income and limited savings. Advanced Directive It is a means for the Pt. to state what treatment they accept or refuse if they lose their decision making capacity. They can also have a 'proxy' or 'su rrogate' who will make the decisions for them, when they cannot make the decisions for themselves. Surrogate or Proxy is a person authorized to make decisions on behalf of an incapacitated person. Usually next of kin. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 534 255. Can a surrogate withdraw all life support Including nutritional support In an ncapacitated Pt. • • • ) ' ) ) ) ) If Pt. is awake, alert and oriented, the health care proxy has no role in decision making. If Pt. is awake, alert and oriented, the family has no role in decision making, including consent for procedures. Decisions made by the Pt. while awake, alert and oriented stand if the Pt. becomes unresponsive. Living Will More focused advanced di rective in which Pt. refuses life support in a terminal condition. You DON'T need a lawyer to make a living will. 256. Pt. brought in, barely conscious and confused. Has terminal condition. Living will states Pt. doesn't want to be Intubated or resuscitated. Family Insists on doing everything and threaten to sue If he Is not Intubated and resuscitated not taken. w.t.d 257. The fiduciary relationship between physician & Pt. Is based on which 4 of the oil owing? A. Altruism �Justice C. Entitlement �Autonomy E. Risk management /. Non maleficence Jl?. Benefecience ) 258. Pt. brought In unconscious with terminal condition. Pts. famlly wants everything one. Proxy says Pt. didn't want to be Intubated and re$uscitated. and wants to make t. DNR. w.t.d ) -7 �s'te"' t, �'J 259. Pt. brought in by family doesn't have living will. Pt. is terminally II and family wants DNR. w.t.d --------� -7 Determine Pts. wishes! Awesome Review, Inc.* Copyright 201 4 Do not photocopy without permission Page 535 260. Can a Physician give a telephone order to nurse for DNR---order? ----� � _o N _ _ _ _ A physician should write on order sheet and document the circumstances in progress notes. �261. A 30 'flo man, a Pt. ot yours comes to you ana says-nis sister nas cnronic renal allure. His sister, parents and his sister's nephrologist want him to donate a kidney to �is sister. He doesn't want to go through surgery. w.t.d � Reassure him that you will be his advocate and represent his interests 262. Husband wishes to discuss something personal and important about wife who is a Pt . t.d • A. Listen to husband and keep it secret from wife. vJY. Listen to husband and decide whether to keep secret or not keeping Pts. best interest in mind. 263. Pt. wit pneumonia with pleural effusion. Pt. has said that if he is going to e ent. dependent, not to intubate. w.t.d � Intubate and put chest tube B. Comfort measures C Si/\..4. ·,t c,o� � �v.J\,c...Ni - s::, ,.,�l!J .,v CelL 'D 0 H -i Le...:t.. � c..c:: IL �J �� rtve.- � b � ) True or False l-In a terminally ill Pt., palliative care along with standard care has decreased mortality. 264. When would vou insert lCD In a Pt. with severe heart failure? � life expectancy _ _ _ _ _ _ _ _ _ ____; _ .._ f _ _ _ 65. A 70 y/o man Is brought to the ER wUh anterior wall M l and shock. Mng will $tates, that lf hls COf'ldltlon Is 1rraverslble, he should not be resuscitated. You o a PT<;A which Is unsucceSsful and Pt. Is Intubated. e becomes hypotensive and ECHO with EF of 25%. rlne output decreases to 12Scc. What Is the best course of action? --------� A. Consult Ethics committee B. Start vasopressor support Withdraw all life support D. Check with family, what they want. � Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 536 266. A Pt. with severe dementia and DNR in hospice care develops pneumonia. hat Is comfort care? A. Antibiotic therapy _..(Y." Oxygen therapy C. i.v hydration D. Enteral nutrition 267. Pt. with end stage lung cancer with SOB and Pain. He is on 02 4 1t. via nasal cannula • .t.d A. Increase Oz Y, Morphine 268. Terminally Ill cancer Pt. with coarse rates. w.t.d? \./!( Glycopyrrolate B. Lasix p269. Pt. with chronic COPD had told you In office, he doesn't want to be Intubated or resuscitated. Pt. now In ER with severe COPD exacerbation. As you see him In the ER, �e reminds you what he had told you about Intubation. f\ few minutes later, Pt. becomes lethargic with severe hypercapnia on ABG. Pt. doesn't have a living will. w.t.d ·' ) 270. Pt. with exacerbation of COPD, has living will which states ONR, but In the R, he tells you to Intubate .w.t.d --------------------� ) i . ) 7 FoiWY.J pt �-viS� 2. i"t�.,(,c.J-e 71. Elderly Pt. with ESRD, refuses hemodialysis I n will, couple of month$- latet rought to the E R comatose. Son wants hemodialysis. w.t.d 72. Elderly Pt. refusing hemodialysis In living will, brought to the ER, son 58Y$ ecently father told him he wanted hemodialysis. Pt. Is now confused & lethargic. w.t.d ) 273. An elderly Pt. Is diagnosed with breast cancer. She makes an advanced directive hat she wants to be DNR. er son moves In with her. He lost his job recently. Couple of months later the Pts. ondltlon deteriorates and Pt. becomes increasingly short of breath. Pts. son says ecently she told him she doesn't want to be DN R and wants you to Intubate Pt . t.d? • ) A. Rescind DNR status B. Intubate Pt. \,)/.'Refer to ethics committee Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 537 �274. Pt. wants comfort measures only has durable power of attorney to her son. Doesn't want to prolong life and wants only comfort measures if she becomes ncapacitated. She now has severe dementia. �he develops pneumonia with shortness of breath. �he son wants you to start her on an a ntibiotic. �ou will consider starting an antibiotic for which---reason ----� A. To treat the infection JY.'if it will relieve her symptoms 275. Pt. has hemiplegia after a stroke 2 yrs ago. durable power of attorney to son. he takes part in activities at the assisted living center. Has excellent cognitive function. he visits you occasionally to keep her appointments. he wants to have a colonoscopy done. on agrees with colonoscopy but wants to be there for consent as well because he Is 1 oncerned that the mother may not take the explanation of findings In the right way. Ml.t.d A. Agree with the son and tell him you will not proceed without taking consent of both of them. � Tell the son, you will take consent from the mother and proceed accordingly. 276. A Pt. tlas Metastatic Colon cancer. He Is on a w eel c air an has a tree eostomy. e is able to communicate in writing. Daughter Is durable power of attorney. She efuses his enrollment in an ex erimental clinical trial. A. Agree with daughter B. Persuade the daughter 0alk to Pt. 277. Your 74 y/o cantankerous and reclusive neighbor, who lives alone, calls you to ake a look at her. She says she Is fatigued and unable to get around. She has not poken to her daughter In more than 15 yrs. and doesn't want yoq to call her. /E: Afebrile, H R 90/min sitting and 105 standing. BP sitting 120/80 and tanding 105/70. Crackles at both lung bases and 53 (+). Pitting pedal edema noted. he refuses admission to hos ital. w.t.d A. Ask her to find a different physician B. Call a Psychiatrist for advice. C. Give her a diuretic and check on her in a day. D. Call daughter to persuade mother to go to hospital. /. Initiate proceedings to have her declared incompetent. 278. 45 y/o Pt. with Gl bleed and hypotensive. Refuses blood transfusion. w.t.d Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 538 Q279. 80 y/o Vietnamese man diagnosed with Colon cancer. Family tells you not to tell he dia nosis to their father. w.t.d -7 Tell the Pt. he is very sick and ask him who he wants to make decisions for him. If Pt. says family to make decisions If Pt. says he wants to know everything and will make decisions himself -7 Comply with the request. 280. 35 y/o woman with Multiple sclerosis with poor prognostic factors requests Physician a ssisted suicide. w.t.d -7 Respond with empathy, compassion and assess if she is getting adequate palliative care. Q281. 95 y/o Pt. noted in NH to have a mass in the left breast. She refuses any orkup or treatment. w.t.d depends upon A. Her wishes Y,Her ability to understand the disease and its consequences ) 282. Pt. Is brain dead. Can Pts. organs be donated without his prior approval If the roxy gives permission ) 83. Can you stop treatment If Pt. Is brain dead. ) 284. Is an EEG required to confirm Brain dead. ) I \ ) 3 cardinal signs of brain death are • • • Coma Absence of brainstem reflexes Apnea -7 Respiratory drive and motor posturing signs are incompatible with brain death. �285. You observe a nurse entering airborne isolation room without mask on several pccaslons and point it out to him. Next time you observe him touching a Pt. with contact isolation without gloves. What will you tell the nurse? A. Plead with to listen to you y�Y. You are required to report his actions Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 539 Q286. 25 y/o with family hx of familial adenomatous polyps. Referred to you for colonoscopy, but HMO refusing to pay for procedure. w.t.d --------� Q287. GO y/o with recurrent rectal bleeds. Hemorrhoids negative. Pt. tells you he cannot afford further testing. w.t.d 288. You are covering for your partner and his Pt. comes to you to get a premarital ertificate signed. Labs reveal RPR (+) and FTA neg. w.t.d cr.M... p o �'f.;- Medical hold • I f the Pt. is unable to express preference, you can perform life saving procedures, the alternative of which would be death or severe disabil ity. • Pts. with certain psychiatric conditions and suicide attempts should be treated despite their wishes. • In transient conditions such as drug induced delirium/confusion, depression and abnormal metabolic states, You should get a psych. consult to determine -? cc;:p "' c.:."t::J 289. Pt. with attempted suicide brought to the ER and refuses tx. w.t.d Pt. is in a pathological mental state, which may be treatable. Q290. Nurse became (+) with Hepatitis Be Ag. Request you not to tell supervisor. w.t.d Q291. Pt. diagnosed with menigococcal meningitis and wants to sign out AMA. w.t.d p.292. Pt. with history of indolent N H L and told therapy Is not needed. �e Is aware that It Is a slow growing tumor. He stops eating and drinking because he �oesn't want to die a slow death. He Is started on Sertrallne, but 2 weeks 1ater with no esponse. Pt. says, he Is only depressed about his illness.---w.t.d ----� A. Respect his wishes and don't feed him Y, Get a Psych. consult 293. A 45 y/o Pt. with pneumonia with blood cultures growing gram negative rods. On the third day, the Pt. wants to sign out against medical advice. hat to do? A. Tell the Pt., Insurance will not pay and he will be responsible for the bills JV Tell the Pt., there is improper transition to out Pt. care. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 540 �294. Pt. with AWMI, mentally competent, refuses admission. Situation explained I n �etail about consequences. Pt. understands but still refuses admission. w.t.d � Give Nitrates, � blocker, ASA, ACE inhibitor and arrange for Home Visiting Nurse. Q295. A Pt. of yours keeps calling you 10 times for one prescription. Demands to be een right away and wants clarification on simple things. w.t.d ls ) ) ) ) ) ) Q296. A Pt. is referred for medical clearance for cataract surgery by an Ophthalmologist. Hx reveals that he reads a lots of books and falls asleep while reading. w.t. A. Clear for surgery _....W, Report physician to Ethics committee Q297. You find your physician colleague with unethical behavior or chemically impaired. w.t. � Report Physician to __ E__ �·_ L.s__ t..:l(v) ___ �· _ -t.t. u.. ______________ Q298. Pharmaceutical company invites you to an exotic location for free. w.t.d ) ) ) ) ) ) ) ) ) ) Q299. A Pt. bought a plane ticket and now wants to cancel it. Tells you to write a note � hat he was Ill and couldn't travel to get his refund back. w.t.d 300. For which of the following is a parental consent required? A. To treat a sexually transmitted disease in a 16 y/o girl B. To perform abortion on a 15 y/o C. To prescribe OCP to a 14 y/o. D. To Treat 17 y/o with substance abuse JY. To administer a tetanus vaccine booster in a 17 y/o. 301. A 35 y7o woman with multiple injuries to arms and legs. She nods i n agreement o husband's history. You suspect Domestic abuse. w.t.d � Ask Husband to step outside and interview Pt. ) If injuries are non life threatening � Don't call Police, Discuss situation with her. Encourage her to seek help and give her hotline # �302. Pt. with bruises on her Inner arms. Tells you she fell. �xam reveals bruises on her Inner arms; both old and new. �he has 2 children 5 and 2 yr. She recently had dental work done. w.t.d ) A. CBC with platelet count Domestic abuse counselling /- Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 541 Q303. What Is Not considered a HIPAA violation? A. Discuss rare case with your colleague so he may benefit J Pt asks for referral to a specialist and later calls for the records to be sent to specialist without written consent. T/F: Periodic health evaluation has shown improved rates of screening for -- A. Colon cancer -r B. HTN I The following Pt. education have improved outcomes. • Tobacco • Firearm ...... Nat M. • Alcoholism • Physical activity • Self Skin exam • STD • Self breast exam� Quitting smoking: Chances get better with recurrent trying. Q304. The most likely reason for quitting smoking Is �Intention to quit B. Transdermal nicotine Bupropion c. 305. A Pt. with COPD secondary to smoking comes for a visit. You Initiate a discussion n quitting smoking. Pt. says he would like to quit smoking. W.t.d Above Pt. w t.d next? � Begin K� ni co� ( � + \1\h. .. Lt/ I ) Q306. Pt. wants help to quit smoking. Nicotine lozenges and patch failed. w.t.d7 307. If the Pt. says, he has h istory of seizure disorder, then w.t.d � No Bupropion, erL p t: t. t_ ll.__ t._ c t __ e · "" �_ _ i c_ __ V a.-' en. _ c:wt:. __ �_t _ _ _ __ __ __ pt 'J �vel Awesome Review, Inc.® Copyright 2014 D o not photocopy without permission 1 wift. t. u.IL /Yl]) i:f MorJL fkh.(V/DV) Page 542 Q308. You prescribe Varenicllne (Chantix•) . What else do you do? 7 Monitor Pt., his fa mily and friends for behavioral disturbances Q309. A chronic smoker doesn't want to quit smoking. W.t.d 7 Address barriers to quitting smoking Q310. In your discussion with your Pt'. about quitting smoking, what other information would hel motivate Pt. to gult smokin ? ) ) 7 Quitting smoking is the only thing that will help prevent rate of lung function decline. Not steroids, albuterol or tiotropium 311. The leading cause of mortality for age group 10-24 y/o. --------� ) ) 312. The leading cause of preventable premature death in US ) ) 7 ) ) ) ) ) ) �� ytf{., Srvv> �'j True or False: • I njury from firearm at home is greater than injury from intruder I • Seat Belts decrease mortality by 50% I • Front airbags decrease mortality rate even further T • Child < 13 y should be seated in the back seat -r • Helmets for bicycles and motor cycles reduced mortality and morbidity I • Fencing of pool and life vest on boat decrease mortality I - } ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 543 Q313. Drowning victim brought out of the water which was 70°F. w.t.d --------� �CPR B. Abdominal thrust C. Sternal thump l I '/ I J -Wo.Yl: II "-""' "-- Q314. An elderly homeless man is brought on a cold wintery day with bradycardia, ecreased reflexes, dilated pupils. EKG reveals above findings with 'J' waves. This Pt. most likely has A. Acute Ml B. Myxedema coma /. Hypothermia 315. Best Tx. for above Pt.? X Passive rewarming with blankets B. Place in hot tub Q316, 28 vlo woman runs a marat on an collapses. Ox: � l..<!.c.. . f On exam she Is confused, hypotensive� tachycardlc, flushed with dry skin. Temp. 4 1 oc. stvo� w.t.d � Transfer to hospital � Evaporative cooling (sponge with ice packs or sprinkle regular water with fans. No Tylenol or ASA.) Complication is Rhabdomyoiysis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 544 @ An AWESOME REVIEW OF .. • I I 6% Anemias Hemolytic anemias Transfusion reactions Platelet disorders Coagulation disorders Thrombotic disorders Myeloproliferative disorders Leukemias Awesome Review Inc.® Copyright 2014. Do not photocopy without permission. J Chart 1-1 Stem cells7 Proerythroblast7 Normoblast7 Reticulocyte7RBC tt�t"wM<t;c.. � Reticulocyte count 7 Blood loss 7 GI, vaginal, hemorrhage, etc I (Bone marrow working or appropriately) Destruction: I I Extrinsic: ,} • DIC, Autoimmune hemolysis, etc Intrinsic: Membrane protein Metabolic enzyme Globinopathies : Hereditary Spherocytosis : GGPD .: • d - /-Ila ..,...rt?·�st,,,lt:., l.':Jf'-fV'J1 C -f--AIIL Production: ( wEpo) wFe wGlobin wDNA BM failure Reticulocyte count 7 : SS, Hb C, etc ..- •. /0� o9 ) 7 Chronic Renal disease 7 Iron deficiency anemia 7 Thalassemia 7 Megaloblastic anemia 7 Aplastic anemia C <3M �c.Nf�t) Chart 2-1 Anemias Microcytic MCV <80 • Iron nficiency am L'b • lf,Aliemia of Inflammation ) • Thalassemia CA"' IHX Sideroblastic anemia £ I Macrocytic MCV >100 • Vit B 12 deficiencY1 )llS • i • Folate deficiency J • • • Myelodysplasia • • Alcoholic Liver Dz Liver Dz Blood loss Hypothyroidism 10 11 10-i Normocytic MCV 80-100 Renal failure Hypothyroidism 16', <J1. (1'c Pl\) l:j�.,.,;J\ Anemia of Inflammation Aplastic anemia 'i: 11 sz, f'J _, 1'Retic: Hemolysis Blood loss Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 4 Chart 3-1 "tvCNjeM {lq_Cfl.(l'C,;,1 � (:,J. i"""' 13.;,...t.j c..:. ,.; ... s Iron 50-160 Transferrin T I BC Saturation 220-420 mg/di 20-45% <SD W C (IS/.) t1Cv\A� �(;./ Iron Deficiency T.c.t-1,j<r..,.@ . tVlcU:x 1' 'Tit -p;: )2 *''* I if'<12 8' O)< r7Bc Jt ,;.. >2.0-7 1. 2. 3. (C et.;41.. sp� ) u11·c... � t-1 e.pc; .t..:,. .J, (Aoc..D� • Jt-1- �L) '1lc,.,- < c.t:-. h.vpt.t�S 'fe-.oP"' t..ft ) ( � p.vl- F<. �� 1. The most sensitive assay for Iron deficiency anemla Is Ratio of-7 'D.cp� -t Fe R Fe ( f't'.<>Jt Jpl'tJ1'- Hemochromatosis >20 -1- )ti- � /N �l�-2-Zj) -f;,c.,,-S'ju·(\.. @Jt F e rritin �p:;t./\,. bec,.,'Y\'\.I. mt er("\,&, j,.,7.<Ji ) • 1' R-rvi t...:.. ( SLcE� �A ) ·t:;.Cl'-jc.nn. R..e_upw (Transferrin receptor index) Locf �c..:,. L.'l)A <1.0-7 Ao CD Serum Iron TIBC RBC Ferritin A 100 300 5 mil 70 B 45 180 3 mil 45 c 45 520 4 mil 10 Normal Iron Deficiency Anemia C.. Anemia of Inflammation 43 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 5 Iron deficiency anemia: Anemia of Inflammation: -.V Erythropoietin Pica (corn starch), Pagophagia (eating ice) Esophageal webs 1' Platelets Etio: RBC cannot utilize Iron from Reticuloendothelial stores (due to Hepcidin) in chronic inflammatory Etio: Definitive Iron loss: Menstrual bleed diseases like Rheumatoid arthritis, SLE GI bleed r�� '-1:..� nd infections such as Endocarditis, ( �1'J<l pr.:.,..-1" �t. FNH c P!0)\.. l�!? )_, TB, etc. 7 Iron filled macrophages / 1'Demand : Pregnancy � fl«vt in Bone marrow. c.� -t... 1,...M "\ M;. ft;.....,v..,h. 3, (le\v:c � -tc..,,,...,�,is ) I 0.2. If Hb 10 g, MCV 85, TIBC low, Transferrln saturation 22%, Ferrltf n 120, What will the bon marrow show? 7 '1' i \ .. ,<:;.J'f-"> 'v\. r'"\<.c- ( ) Wf\. ( R l:.5 ) J V SI cAe,..o loL C0 Lr'. b.3. A 70 year o man or a post menopausa woman w t .t.d "'l W'->fk u.f . 7 Y� JCC(i) ��-- dl� __, -t dt.utw� p4. 25 year old woman with Hb 9 g7dl, MCV 63, Ferrltfn �. ROW 17%. Smear: hypochromlc tnlcrocytfc, anlsocytosls, target cells, pencil/Cigar cells. Dx: Either Menstrual loss or Pregnancy with increased need. Tx:7 po FcS� 5. A Pt. Is started treatment for Iron def anemia with Iron and Vlt C. What is the earliest to heck the results? goes up in about 5 days. {Nol 1-'tb, 6. A 60 y o ct woman wit a history of OM anct Renal Insufficiency presents with fatigue. H s 9.0 g/dl. Stool for occult blood Is negative. Serum Erythropoletfn Is 10mg/dl (nl <30) Pt. Is tarted on Erythropoletin therapy. 4 weeks later, Hb Is 9.2 g/dl. w.t.d ��-- A. Check Repeat Erythropoietin level c)r.'Start supplemental Ferrous sulfate C. Transfuse packed RBCs D. Check peripheral smear for fragmented RBCs Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 6 Matching Pregnant woman in second trimester: B p.. 1. If Hemoglobin 10.5 g/dl, MCV 80, peripheral smear normal, ROW 14% 2. If Hemoglobin 10.5 g/dl, MCV 75, hypochromic A. Iron deficiency anemia I B. Increased plasma volume microcytic, ROW 17% 7. An elderly man presents with nausea, abdominal pain and diarrhea. Exam reveals slight onfuslon and gait abnormality along with decreased vibration sensation. Hb 9g/dl, MCV 78 . .:= .t.d A. 812 level JV,' Urine for heavy metal screen Sideroblastic anemia seen with use of INH without 86, alcoholics, battery workers, porcelain worker, etc. 'F<ut.,, 13 Atr"'<M-:l Bone marrow will show ringed sideroblasts. 8. An elderly Pt. who works at a factory that makes batteries, or lives in an old building, or I chronic a lcoholic, presents with history of anemia, and gout. Hb 9g , MCV 80. ------- a-1 chain ••• ··� a-2 chain 13-2 chain 13-1 chain 2 a. cha ins . 2 13 chains } Hb A 2 a. chains 2 l5 chains } Dz } -J, a chains7 a Thalassemia _J, 13 chains 7 13 Thalas semia Point mutation of 13 chai ns7 Sickle cell } Hb A2 2 a chains 2 't chain s } . Hb F (good prognostic factor} 1' Mediterranea n/Asia n: Italian , Greek, lndian ,etc 1'African Americans Awesome Review, Inc.® Copyright 2014 Do not photocopy without pe rmi ss ion Page 7 . Depending on the amount of Hb A2: B Thalassemia Trait: mild Anemia, Hb A21', � L:..14.t. �€ow normaD 'D>- � hi? B Thalassemia lntermedia :.J, MCV, mod Anemia, Hb A21'1', Non transfusion dependent B Thalassemia Major (Cooley's anemia) elect... P�t!S 1' MA :.J, MCV, severe Anemia, Hb A21' 1'1', Hb F1' Hemolysis-7Transfusion dependent-7 Iron overload Hepatosplenomegaly, Target cells, Tear drop cells a chains ppt -7 Heinz bodies f fV1 � ow Q9. A young woman or man presents for a regular check up. BC reveals Hb is 12.2g CV 70 13.5%. (< 14.5%) mear shows Hypochromlc microcytic cells. Target cells +. How to establish Ox? � Hemoglobin electrophoresis B. Ferritin f,10. Pt. from Asia (India/Vietnam/ Laos/Cambodia) presents with Hb 12g and MCV 75. Hb lectrophoresis normal. His blood was refused while trying to donate blood for his friend's urgery. Smear shows target cells. Most likely diagnosis? A. Iron deficiency anemia V""'S. a Thalassemia trait c D ..... ,. Sickle cell Dz: Point mutation of � globin chain Hb AS-7�1: normal �2 : Glutamate-7Valine Hb SS-7�1: G-?V �2: G-?V Hb SC-7�1: G-?V �2: G-?L } } } h... , J _ v N .., o'i'\ 0- Chart 4-1 Sickle cell trait p l P.. G.A ... �· ) Hb S<50%, Rest Hb A Crisis with severe hypoxia Splenic sequestration * * � 7,., . Hematuria i;. Sickle cell Anemia s R�<- 12. -z...v�.-t.) l " '"' '""' Hb S 75-95%, Hb F 2-20% Hb A2 < 4% Functional asplenia: 1' infections with capsulated bugs: Strep. Pneumo, H.influ, Kleb. usive crisis V � Hb SC Dz ( L�el:.'j cc�INV- i u.e.. tr:. ,,, Prc..-1« c..1-.L.1.. f' ) h �SS Aseptic necrosis of femur/humerus Retinal infarcts� S � �;"':! Vasoocclusion may occ ur 11. An AA man presents with sickle cell anemia with joint pains, fever. Hb 10g, LOH1', etic 1', normal ferritin. Dx: Painful vaso occlusive crisis. Treated with Hydration, Analgesics and Oxygen. What is the best way to reduce the crisis in future? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 8 13. I n a Pt. with severe sickle cell anemia with recurrent crisis, what recent advances lgnlflcantly reduce the percentage of circulating sickle cells to very low---levels? ---7Reduced intensity conditioning regimen followed by peripheral blood stem cell allogeneic transplant from an HLA matched donor. Don't use Meperidine for analgesia as it can cause seizures 14. An AA man with SC disease presents with right hip pain. No Hx. of recent trauma. X-ray Ip� diffuse articular S'ai rosls and patches of decalclflcatfon Dx: Avascula r necrosis of head of femur k- mR1. J' C. • c\Js /V\.ol't. �S:-.tiY<- -t�t. Pt. with sickle cell anemia with chest pain, fever. Sputum: no PM Ns, CKR JI morphine Is given Infiltrate. (Leading cause of mortality in sickle cell pts) w.t.d next -7i.v a ntibiotics. 02 if hypoxic. PRBCs if severe anemia. If hypoxia persists despite 02 and PRBCs. W.t.d next?-7 £)(c "'-� tc--.df'-- h'. W\... Etio: f't'\�,J..rav� w\..c.,, )"tcvfs 16%, Fat embolism 9% 7. Pt. with Sickle cell trait with left upper quadrant pain, enlarging spleen and rapping Hb/Ht. BP 100/80 supine and 80 systolic sitting up. H R 96 supine and 114 ltlfng up. Dx: Splenic se J 1.4..est.,.c..f-\.c:r- c_..., �s Tx: Next step after IV fluids -7 PR.& s -J fv\ n:....,... swro 18. Pt. with sickle cell dz with joint pains and rash on the trunk. Hb 6.0, platelets and WBC I. Retie count 0.0%. ANA (+) Anti cardlollpln abs (+) Parvovlrus a bs (+) 1 Dx:-7 P·wv ov: rw f3 1 induced a plastic crisis Dx by-7 L.gM Tx:-7 /_. V Ab co� Pc.R ----------- p,r.r� Z. O C, Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 9 'P� (CVU.. wu.,l<.e,v _ _ _ 19. School-teaGher with arthralgias. Hb 8 g/dl. No history of bleeds. No rash. Retfc count .2% Dx: -7 fG.vvo y; VV\/.l r3 l ') 20. A pregnant teactier comes to you worried t at t ere is a rea out o Aepatitis A or Parvovirus B 19 or Hep B) In the school. With which of the following can you safely eassure her. A. lgM (-), lgG (-) v1V'lgM (-), lgG (+) 021. Commonest cause of Osteomyelltfs In Sickle cell dz A.-7 Sd""'-.:>ru.1� / Staph 2:1 I 22. Couple presents for genetfc counseling. (S Hb AS, 9Hb AS. What are the chances for H b SS in their child? 9 A s A AA As s AS S'S IV � 25/. � SS dt/f Hb Electrophoresis s F A A B D E j3 � c L.; .r.r<."""' .; /3 ·fi:...c;lc:�<. tY- o... t M..�� Kb SS' 3. A Pt. ha<t tiemoglotiln 13 g d[ Bl MCV 70 f Hemoglol>ln electrophoresis was done. emoglobln,A.75%, hemoglobin S 25% & hemoglobin F 0.3% hat Is the most likely diagnosis? • A. � Thalassemia B. Sickle cell trait 0· Sickle cell trait and alpha thalassemia c � is ,.-.- H.b P. z Awesome Review, Inc.� Copyright 201 4 Do not photocopy without permission Page 1 0 Macrocytic Anemia MCV> 100 MCV > 110 • • Vit B12 deficiency ( C.OA pr(.f</\� vv,(l �CAj�) Folate deficiency MCV < 110 • Myelodysplasia / � _, • Liver Dz, ETOH • Smooth tongue, cheilosis, Postr. column dz Ineffective erythropoiesis, lntramedullary destruction 1' LOH, 1'Bilirubin, -.V Retie. Smear: Oval macrocytes, hypersegmented PMNs BM: Hypercellular marrow with megaloblasts If Vit 812-.V, then no need for BM biopsy • Hypothyroidism I Blood loss ( 1'retics) � Folic Acid deficiency • • • • • • • Alcohol Methotrexate Pyrimethamine Phenytoin Tropical Sprue Chronic hemolysis Hereditary spherocytosis 2S. SS y old chronic alcoholic with anemia, MCV Increased. Follc acid decreased. Pt. Is lagnosed with follc acid deflclency anemia. He Is started on treatment with dally follc acid. n follow up visit a couple of weeks later, the platelet count has Increased from 1SO,OOO to S0,000. w.t.d 7 Co"'\A"""l. fo\,.:c.. �··L. , P�"- kld:s are known to increase with folic acid tx 6. A primary care physician started a 60 y old Pt. with MCV of 120, Hb 10g/dl, on follc acid everal years later, Hb Is 11.2g/dl. Pt. has mild dementia and problem balancing. w.t.d next Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 11 27. Above Pt. Folate level normal and 812 level 300 (nl 200-800). w.t.d -7Check If increased-7 A 74-year-old woman Is brought with symptoms offorgetfulness. Exam reveals omberg sign poslttve. 812 level Is 310. Hemoglobin Is 13 g, MCV Is 103. w.t.d next? • Me.� fv\a.A..O(\,dc. -7 �L. 9. Which medication has shown to decrease absorption of Vitamin 812 30. Best to treat 812 deflclenc In the above Pt.? �Oral cobalamin 8. Intramuscular cobalamin 1. "(he best way to differentiate between Vitamin 812 (cobalamln} and Vlt 86 (pyrfdoxlne) eftcteney Is A. Homocysteine level ..JV High MCV. .--t ( t- � 01-z.I . .,.... ) o, , �\.... a.. A long time dock worker, now aged 80 yrs Is brought with complaints of Improper gait fJ.f '9.J.#f)t(n..ss. Unable to l'(tmember names. Exam reveals romb,ra's sign Is po$llive. �ylJ>Mton tense Mlf la lO.Sf, v i.111112 taval 275ftlnll (!11 t-004DOl1 �JQC\1$tttne:1evel ts 22 (nl 4·16). Most I ely dlagnosrs Is �� A. lead poisoning � Vitamin 812 deficiency Matching c 1. Folate deficiency A. Methylmalonate & Homocysteine levels high p.. 2. Vitamin 812/cobalamin 8. Only Methylmalonate level high g 3. Vitamin 86/Pyridoxine C. Only Homocysteine level high. deficiency deficiency Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 12 34. Leukopenia, anemia and thrombocytopenia Is more likely to be in � 'Elderly Pt.s presenting with anemia and o t bocytopenia and or leukopenia With °fiypo -segmented PMNs.' n Macrocytic picture with dysfunctional plate ets and hypo-segmented PMNs. Stem cell defect Refractory anemia with normocellular or hypercellular marrow. BM: Marrow precursor dysplasia with ringed sideroblasts.(survival 6 y) . MOS with isolated Sq gene deletion (su rvival 12 yrs) > 10% blasts7 worse prognosis and may transform t �Mll(s �rvival <1 yr) Tx: <SS yrs7 >SS yrs7 GM-I All..:i a-vv:c.. f.\'2.ac1t�""' G-CSF to increase WBC. + Supportive with Blood transfusions Erythropoietin < SOO 7 &�poie� Erythropoietin > SOO 7 If cant tolerate ATG 7 rrL:b....t.J.. ..f\r.f:..: ��·k. Oj-e LPsp0......M-- Sq gene deletion 7 - Len..c.t...:.4. 0�� Le.A.cl� v,..._tU_ Hemochromatosis: 'Iron overload with transferrin saturation >45%' Best screening too17 Serum transferrin saturation.� 4, /'is J. Diagnostic test?7 HF£ � te...1t Iron overload in pancreas -------" ---------- Skin -------" ---------- Heart ------"-------------Liver ------" -------------Pituitary ------"-------------Joints } �;erpigmentation, !Porphyria Cutanea Tarda -:) HFf �� tut Bronzed OM 7 Cardiomyopathy 7abnormal LFT7Cirrhosis7 Hepatoma 7 Hypogonadism 7Arthropathy Ferritin > 1,000. To find out extent of Iron overload, w.t.d 7 '})..., L\ vc..... Tx:7 F"4"'-e/\t Gx p�bo, > Deferoxamine Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 3 35. �O y old man presents wittl pa n n s fingers. e also gives story of ecrease i ido or the past few years. Pt. is a chronic alcoholic and admits to high stress environment at ork. O/E: t•t and 2nd metacarpal joint swelling, Bronzed skin (+) b 16 g, MCV 90 BS 180mg/dl ST 76, ALT65 ron 195, Transferrin saturation 75% erritin level 2400 rolactin level 10 The most likely diagnosis is Best way to screen is A. Primary Testicular failure B. Alcoholic liver disease C. Prolactinoma D. Rheumatoid arthritis if. Hemochromatosis Aplastic Anemia A. Ferritin level \)Y.' Transferrin saturation C. TIBC D. Iron level Chart 5-1 . I 'Pancytopenia with hypocellular bone marrow' Etio: Idiopathic I� no r I Drugs: Sulfonamides, Chloramphenicol Radiation - - i Tx: < 50 yrs-7 f)illo� B1'Y\T »JI. I > SO yrs-7 Anti-thymocyte globulin + Cyclosporine �·Vi Refractory to ATG - 7 AleMtu. 'Z.�!:> • MDS • Fanconi syndrome • I Viral Hepatitis • Hypersplenism • I • • - B12 deficiency • • Viral: Parvovirus, CMV, EBV, Hep B, C, HIV B12 deficiency Pancytopenla: HIV Hairy cell leuk. Bact rim Copper deficiency 2 RTA - - I I�-,-, � �- L - ;, L ( �" Yl0 c, t..... s�) 36. 40 y old with ecchymosls, pancytopenla. Most likely consistent with �Viral hepatitis B. Viral gastroenteritis C. Pneumonitis D. G6PD deficiency 90% of the Pt.'s were working at the end of 20 years Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 14 37. Pt. with Uremia. Hb low. Peripheral smear with Burr cells Ox: Anemia of Renal failure 38. Pt. with alcoholic cirrhosis and worsening anemia. Blllrubln leedlng. Smear: RBC with Irregular splculatlons of liver disease. Dx:7 Spu.« c..e..l\ A V\ Blood transfusion can still result in spurr cells. Bad prognosis. .. 39. Pt. with unstable angina Is started on l.v nitrates. Or Pt post EGO or Post ronchoscopy, Pt. suddenly turns cyanotlc and short of breath. KG.+ No acute ST, T wave changes BG.+ P02 96 Pulse ox 85% Tx: • • 7 • • Methylene blue Vitamin C Immune hemolytic anemias Autoimmune : Warm AIHA, Cold agglutinins, Paroxysmal Cold Hemoglobinuria Traumatic (microangiopathic) hemolytic anemia 7Acq ulred Intracellular Defects • Paroxysmal nocturnal hemoglobinuria 7 Inherited Intracellular Defects • Membrane abnormalities Hereditary spherocytosis • Enzyme abnormalities G6PD deficiency Hemoglobinopathies Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 15 Chart 6-1 Coombs test I t Antibodies In Serum Antibodies on RBC Cold antibody Warm antibody Antigen Direct Coombs Ab Etio: ?" . Rh Ag >- "( i Ag. @f- C3 SLE, CLL, Lymphoma Drugs: Methyldopa Penicillin (hapten) Procainamide Quinidine (innocent bystander) Lymphoma Viral: IM, Influenza Mycoplasma Steroids, Danazol Splenectomy lmmunosuppressive drugs Cyclophosphamides Chlorambucil NO role for Steroids Matching .£5... 1. Penicillin/Cephalosporin/ Methyldopa A_ 2. SLE - � '1 RTA � 3. CU/Lymphoma � 4. Quinidine A. Warm Antibody (Anti lgG) B. Cold Antibody (Anti lgM) C. Both D. Paroxysmal Cold Hemoglobinuria .f2.... 5. Infections (Mycoplasma, Infectious Mono) � 6. Role of steroids � 7. Influenza Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 16 40. 43 y ol on Bactrlm for URI. Pt develops anemia. LOH & Reties Increased. yco lasma titer (+). Cold alJBlutlnln (+). Most likely cause of anemia Is A. Bactrim induced hemolysis B. PNH 0/.'Mycoplasma induced hemolysis 41. 48 y old man presents with colicky abdominal pain. U/A-+ No RBCs or wees, emostderln (+) b 81/dl, MCV 83, Retie count 7% Ott 210, Amylase/Lipase: 16/35, PT/m� 1!/38 secs lrect Coombs-+ neptive ndlrect Coombs -+ nesatlve hdomfnal Ultrasound-+No gall stones, No Renal stones, Mesenterlc vein thrombosis (+) he most flkely diagnosis is A. Pancreatitis B. Cold agglutinin disease C. Warm autoimmune hemolytic anemia D. Myelodysplasia JY.'Paroxysmal nocturnal hemoglobinuria 'FLow Dx: (DAF) assay/ �to�fq 0} CDSS/59 Tx: Allogeneic Bone marrow transplant/Eculizumab -?Give � 1:f ccc.ec.L vaccine 2 weeks prior 'Spherocytes with chronic hemolysis, family hx and gall stones' Autosomal dominant-? fa_!!'i ly historyof anemia Commonest rryembranedefect (spectrin deficiency)-7RBC rigid & spherocyte 1'MCHC Phagocytosed by Spleen-? Splenomegaly -7 Chronic Hemolysis-7Anemia -?Gall stones -7 1' LDH, Bili. & retie. Smear-7Spherocytes with Polychromatophilia (reticulocytes) Dx:-7 os�t. Tx:-7 ... FolMt€ ftc. ��t_, t.cz.,,t. supplements-? Splenectomy Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 1 7 A. Globin chain defect Y,Cytoskeletal spectrin membrane defect 43. 35 y old woman had recent URI Tx wit Amoxlctllln or PCN presents wlth fatiaue and allor. Blood indices normal a year ago. Hb now 9g/dl. MCV 92, MC1'iC � Reties �2%. olychromasia (+). Spherocytes (+). This Pt. most likely has A. Hereditary spherocytosis /,Autoimmune hemolytic anemia. 6PD deficiency: @ 'Anemia after oxidative stress with bite/blister cell' X-Linked, Males suffer, mainly African American. Oxidative stress: • Quinine • Sulfonamides • Dapsone • Primaquine • Fava beans. When hemolysis occurs, older cells destroyed -7 1' Reticulocytes, Blister/Bite cells. Younger cells normal-7G6PD level normal. ( 'T'(tr'- z_ c "71> ,, .Repeat -7 Gib P'D l.rz..vc-L N-. 2� J �"'-..s-. Fc. l c.- Nej <; t..\.-c. ) Hemolysis with fragmented RBCs (Schistocytes) Endothelial damage , ..A £... r. Mitomycin, Verotoxin __, \_M."-c.tvo l Clopidogrel, Pregnancy dzs Cyclosporine, Tacrolimus Cancers < II§ • a -- < Ill • • � • } ·11er @:::• • - .... Hemolysis-7Anemia (..s c.h..stn.!ltz.) Fragmented RBCs Thrombocytopenia Clotting factors not Deficient-7 PT/PTT normal EXCEPT in DIC Micro -thrombi f\s.r;. ,, • , u o I 51 H l �c.St. a • RS diffuse ---- TTP Neuro: Headache forgetfullness, Tinnitus, weakness Renal: hematuria Renal failure Other: Fever 'M� t,>o;?:. F�r=' ---J, Tx: Plasmapheresis Contraindication: Platelets �-------=-J,.-- Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission 1' · fi:;,., ,..i, oi:.-; C Coll� A d.o..1v·J;· L J .J, Lecv<� \/l,IVF1 �� Page 18 Chart 7-1 Renal HUS Bloody diarrhea Renal failure after eating uncooked meat Verotoxin from Enteropathogenic Ecoli 0157:H7 No neuro changes No fever Tx: Supportive No A/ <3 HD prn / Liver HELLP . Hemolytic anemia � < 3? wk-< .rte:.-v:,1... Elevated Liver enzymes Low Platelets � >..J 2. v-.k .tc. �� 3rd trimester or Postpartum ...... diffuse DIC Schisto Only Pregnancy Involves clotting factors7 1' PT 1'PTT Prosthetic valves / /"'\F't.gn.c.1vt h/ rJ H ELLP, Pre-eclampsia, Acute Fatty liver of Pregnancy, TTP. /.Hemolytic Uremic syndrome B. TTP C. ITP D. Sepsis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 19 Q45. 25 yr old has a normal labor and 7 days Postpartum presents with fatigue. O/E: petechiae over arms. b Sg/dl latelets 20,000 Retie 7% LDH:850 PT /PTT normal BUN 30mg/dl, Creatinine 1.Gmg/dl AST 120/ALT 250 Peripheral smear: Anisocytosis with polychromasia, schistocytes (+) Dx:-7 In third trimester: < 32 w -7 s--te,,.vl•'> 32 w -7 Gw-l::J cl�J..: ve 'J ��..;.,i-·�� 46. A �� young woman brought by family with mild confusion or headache for the past 2 ays. Physical exam reveals pallor. Temp is 100.4. F. Labs reveal Hb 9.5g, WBC 7000, Platelets 5,000. Smear shows RBC fragments, Polychromasia (+) BUN/Cr 40/2.5. T/PTT 12/25. Best treatment for this condition is A. Glucocorticoids B. Platelets transfusion with lmmunoglobulin v(. Plasmapheresis pt-c..I� e.x(J.,.CJf" No plasmapheresis machine w.t.d -7 � --?t plc.Af'NI �t;'v.-v fl47. In a Pt. with a platelet count of 50,000 with pneumonia. What wlll help establish � lagnosis of TTP? _LPeripheral smear B. Adamts 13 protein Q48. Which of the following conditions will you see a schlstocyte? A. ITP, Thalassemia, Hereditary spherocytosis, Autoimmune Hemolysis .JV DIC, HUS, HELLP, TIP ransfuslon reactions: 49. Pt. Is getting a l:ilooa transfusion. Wit In one our, e ecomes rest ess, i:lyspne1c, complains of low back pain, fever and chills. Temp: 101.5°F, HR Increases from 80 to UO/ in. Urine Is dark red, Hb drops from 9g/dl to 7g/dl. Direct Coombs test Is positive for lgG bs. Dx: Major hemolytic reaction due to-7 «AOO "\O � i n. c..or r '4 ct; � ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 20 O. What I s the most likely cause in the above Pt.? A. Viral contamination of blood B. Bacterial contamination of blood .yc1erica l error with ABO mismatch D. Special antibody not detected in blood screen E. Rare antigen on donor erythrocyte that is not routinely checked. 1. Pt. receives blood transfusion 2 units packed RBCs during surgery. Pt. is lscharaed and returns a week later with an episode of dark urine and mild scleral icterus. Hl> ropped from 11g to 9g/dl. Etio: Rh incompatibility. Alloimmunization with prior blood transfusion and Pregnancy. Coombs test is usually negative after a week, when all the hemolysis is finished. w.t.d Tell the Pt. to receive7 R"'-G • la� i�IA�Vh. Rote of steroids? A. None at this time. A. Potassium B. Magnesium /.Calcium cd s:., vv1"t pl�f"".i: pl·v»< � *"Jlc presents with G I bleed. A month ago, he had been hospitalized with & bad received 2U of PRBCs. On exam, his BP Is 80/60 and HR Is 120/ ecetv.es vigorous IVF and 2 units of packed RBCs and PPI. 2 days later, ""'11m·11ed, when he complains of light headedness. Temp Is 101.S°F and t IS the best test to explain physical and lab findings? A. Repeat EGO B. CT scan chest, abdomen C. Colonoscopy �Coomb's test 56. Pt. with history of urticaria and allergies needs BT w.t.d -7Transfuse washed PRBCs Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 21 57. Pt. gets fever and chills every time he Is transfused. Hb/Ht doesn't drop. w.t.d7 Leukocyte poor PRBCs in future transfusions. 58. What would the above transfusion prevent A. Hemolytic reaction � Non hemolytic reaction 59. Pt. was started on PRBC transfusion, a few minutes later, the HR Increased to 110/mln nd BP d!llr>S- to 8Q/60. Pt. appears short of breath with RR 28/mln. Swelllng of lips. Temp 9F. Most Hkety caused by A. ABO incompatibility B. Rh incompatibility � gA deficiency 6 0. Pt. with severe lgA deflclen.cv needs PRBCs. w.t.d? , :2 hrs filter WJjh.Jever, hypetensfon, h.Udlch:e. 1lO r... colored urlne. Most llkely diagnosis ..A< Bacterial contamination B. ABO incompatibility �3 hrs later with CO!fSh, fever, SOB. fo,;J!iifs�Jl�P�bo�%t•tf}. , Ucme normal color. Md ltkelY. cau.s� ls A. Rh incompatibility Transfusion Related Acute Lung Injury (TRALI) C. lgA deficiency D. TTP � Etiology: 7 A"t. �" .?jb d-v"""' 7HLA matched WBCs in donor blood cause GVHD.(4-30 days later.) 71rradiate father's blood products to prevent Graft vs host disease (GVHD) 64. Pt. WJ&KQJu ransfustan. w.t.d. Gum aiecewes allogene c Bone marrow transplant anct neeCls blood 7Transfuse irradiated PRBCs Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 22 65. Pt. s/p Bone marrow transplant, CMV negative requires blood transfusion w.t.d. 7Transfuse irradiated CMV negative blood products 25 66. y olil woman wat 3 kl s presents Wltti severe menorrhagia with low Hb and Is 1ven blood tral'lsfllsfbn. She present& 1 week latet with diffuse purpura. PT/PTT normal. fatelets+. . Dx:7 Post transfusion purpura. Etio: PLA-1 a ntibodies, alloimmunized with prior transfusion or pregnancy. 67 ft. uniferp.es �ltuted CABG procedu.re and receives 12 units of PRBCs and 12 unit i: t� � toosn wtth:.oo,iJRI of WJ.ilillh• drain sites and --- -�··· fif/P.tt n•ntat � •,_c». Etio: Massive PRBC transfusion without replacing platelets. 7 Give F='F-P vKIV heparin during surgery followed by subcutaneous fondaparinux postoperatively. B. IV heparin during surgery followed by subcutaneous LMWH . . C. LMWH Matching Pt. with severe MVA needs urgent blood transfusion. Ji_ 1. Any blood group [O+, 0-, A+, A-, B+, B-, A. Any blood [O+, 0-, A+, A-, B+, B-, AB+, AB-] �2. AB+ B. 0- AB+, AB-] Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 23 leedlng disorders Primary hemostasis 7 Platelets Secondary hemostasis7Clotting factors Chart 8-1 - Primary hemostasis Secondary hemostasis Bleeding after injury Immediate Delayed Site Superficial: Petechiae Ecchymosis Purpura Deep: Joint bleeds Hematomas Bleeding time PT/PTI Ii -- 1' Normal Normal Abnormal c't PT: Extrinsic pathway 't PTT: Intrinsic pathway Chart 9-1 Primary Hemostasis disorder I ! l Dysfunctional platelets Decreased platelets (Thrombocytopenla) .,,. clo ""o.r • Von Willebrand dz • Artifact (due to EDTA) • Bernard Soulier dz • ITP • Cyclooxygenase inhibitors • TTP/HUS/HELLP (--VPlatelets with w Hb) • DIC ( wPlatelets with w Clotting factors) • Heparin (w platelets with ·2<ro·� 'i 6 c ) roj. "'-r) 1'thrombus) ..t{Sb � £.,tO • Glanzmann's dz Others: • Multiple myeloma • Renal failure - j I I • • • I I Dilutional Transfusion purpura lv T1flii Gestational thrombocytopenia - Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 24 Chart 10-1 Platelet dysfunction disorders: BT1' in all Cyclooxygenase inhibitors: ASA, NSAIDs Von Willebrand disease: Leading autodominant � J?t. tc�j RSA, Bleeding disorder Autosomal dominant, BT1', PTI nl/1', PT normal Ristocetin cofactor assay-l- � Tx: Mild 7 DDAVP (stimulates vWF/facVlll) Severe 7 Fae VIII concentrates (also contains vWF)7 No cryoprecipitates1 f'fO Fi; P b�'L. Gp !lb/Illa ___. Glanzmann's dz: BT1', Platelet count normal Abnormal platelet aggregation p llb/llla inhibitors: (abciximab/eptifibatide/ tirofiban) • U nstable Angina ReoPro® lntegrilin® Aggrastat ® • Post PTCA Pt. with 1'BT,1'PTT, w Ristocetin factor assay7 V WF- eA.IJ Pt. with 1'BT, normal PTT, giant platelets7 Pt. with 1'BT, nl PTT, nl Platelets, abnormal platelet aggregation7 Gi L�" �'J o) tJ' A. ASA � Von Willebrand disease 72. Pt. with ESRO with mucus membrane bleeds. Most likely etiology? A. Thrombocytopenia � Platelet dysfunction. � 'l)Pf.\VP Awesome Review, lnc.(I) Copyright 2014 Do not photocopy without permission Page 25 73. 24 y old In third trimester, Platelets 85,000.(>70,000) Dx: -7 C. e..d:..c.1-LV'-<L �l"V'--'=>0�1P�Benign course. Monitor platelets q 1-2 weeks fp 'Isolated thrombocytopenia +/-superficial bleeds almost normal Hb, normal PT/ PTT' Thrombopoietin N/ 1', Platelet production w, Platelet destruction 1' Dx: Antibodies may or may not be detectable & not needed for diagnosis. Diagnosis of exclusion. Smear-7-.V Platelets, megakaryocyte, RBCs OK. PT/PTT, LDH, Retie normal. Etio: Idiopathic Drugs: Quinidine, Heparin Lymphoproliferative disorders, Collagen vascular dz ( J-ilVL,Hepatitis C ) I....""" Pit � c N...t-1<. 1-t 1-v, !-'Lip c Ant:/Dµo Tx: Platelets> 30,000-7 Nb I� < 30,000-7 fk..V-.-JCtN- -7 -r.,.n.c,, -7Rituximab -7Splenectomy < 50,000 going for Surgical procedure-7 � �.. ) ( Hep < 50,000 with bleed �� '!.: � c· , �i. pit _, 1' sauo pit ) � W1-1- ,. P� ..., L� < 100,000 with intracerebral bleed � 1-v 1.-f ,.. pl..t No need for HLA matched platelets. They are used only in Pt.s alloimmunized to HLA antigens. Matching � 1. Pt. presents with large ecchymotic area 8x12 ems in the thigh area. Platelet count of 12,000. PT/PTT normal. Blood smear shows low platelets and a megakaryocyte. Management? A. Start Prednisone � 2. Pt. with multiple bruises. Platelet count 15,000. PT/ B. Give platelets � 3. Pregnant Pt. with ITP is on steroids. Platelets 9,000. C. Plasmapheresis PTT nl. Most appropriate management? w.t.d next :£.._ 4. Young female was diagnosed with ITP, earlier this year. She presents with menorrhagia, Hb 9g, multiple bruises on legs. Platelets 9000, w.t.d ? D. i.v lmmunoglobulin E. FFP Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 26 74. All above Pts. what testing will you do? A. Antiplatelet antibodies ...i<'HIV and Hepatitis C serology ...... ( LiS c;s 'I) -ye�U"-<.. rt<.p (_ 5. 1 unJt ef pJaterets wlll lm:rease platelet count 1 hour later by - ln-a Pt, who Is �hedulad fer splenectomV; wllat do yoa1jf&prfer.ao-splena�to.my? Ox: HIT (Heparin induced thrombocytopenia) induced thrombosis. , _, a..... WtLu-. - -:.J -..J A. Lepirudin (Refludan®) -' E.�� JV- Argatroban (Acova®) G"x L.<. tu.. l,..V<-v - ,.., Platelets must drop at least by 50% on heparin 3-10 days later If 1. PT INR was 1.27 � 2. PT INR was 2.57 A A. d/c Heparin, d/c Warfarin and Start Lepirudin B. d/c Heparin, Continue Warfarin and Start Lepirudin 1 can l.MWtt .,, used In HIT 7No. LMWH cross reacts with Heparin. Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 27 P:t. with platelet cot11lt-tf 2$UO� 0Redmlsslo11 Nat day p,latef•t �unt s,ooo. No vmltlowa,,__nttfeed: No drop ln Hb. PT/PTT nl, LDK nl.w.t.d Why? 7EDTA in blood tubes may cause clumping-? Artifact. A. Switch to LMWH (Fragmin®, Lovenox®, lnnohep®) JY. Switch to Fondaparinux (Arixtra®) Chart 11-1 Coagulation: Secondary hemostasis Intrinsic Extrinsic Tissue factor No bleed -- rare bleed Anti thrombin-7 PIT mod bleed severe bleed XI i IX i x Prothrombin ---7 v rVTT fh.ro�"' ·--Y '1!\1-i; �;{ .. s( Thrombin -----7 J, Fibrin Monomer Le.pi YV<tA.rJ' (Refludan®) AY0�t:Yo 1.:>W\o 0;vc;.L.i� Fibrinogen (Angiomax®) J, Fibrin polymer J, �XIII Cross linked Fibrin Awesome Review, Inc." Copyright 2014 Do not photocopy without permission PT2 PT � Cru.s-t)L<Z vir� v� j,, 'i CA� �· T,fV"l "Q.,-t.::J; pc,'It;.. v-.1'1J Page 28 1' PT, 1' PTT Secondary hemostasis disorders or Both 1' PTT, nl PT in Pt. • on Heparin • with no bleed • with mild or rare bleed • with moderate bleed • with severe bleed with bleed corrected by 1:1 mix of normal plasma -7 Fa.<t,,, �L.� with bleed not corrected by 1:1 mix of normal plasma with no bleed NOT corrected by 1:1 mix of nl plasma with increased risk of thrombosis/abortions. -7 Ac'j'-YVL �f> ....,,\,..4 ( i't°'-1-... '2..rt,.,./ <>J -7 LlA.() � � Q wcz.� <'lo YVY TT Ct f2...: J 1c..._ "'J r= � ) -fl;..,...,.,._.1o., L. ) A. Anti DNA antibodies JV Antiphospholipid antibodies C. Plasma factors D. Lyme titer PT INR-7 2-3 What if Recurrent DVT with INR of 2.5 -7 + > 3 ( 'l� ) · Anti B2 glycoprotein 1 > Lupus anti coagulant > Antiphospholipid syndrome r I C.wvv ( � 1-) A. Factor XI deficiency y. Lupus anticoagulant syndrome. Awesome Review, Inc.(!) Copyright 2014 Do not photocopy without permission Page 29 1'PT, nl PTI in Pt. • • • with Vitamin K deficiency with Factor VII deficiency on Warfarin (Coumadin) 1'PT &1'PTI • • • • • • T Common pathway defect ..., V v-rT Multiple factors deficiency DIC Liver disease Warfarin (Coumadin) Brodifacoum (Super warfarin poisoning) �XII, XI, IX, or VIII B. V or VII C. II D. XIII Matching __:j2_1. Pt. post. op. or ICU NPO with prolonged PT INR 2.4. Not on Warfarin. Admission INR normal. Most likely deficiency? __L 2. Which factor deficiency would not have excessive bleed post surgery? A. XIII B. XII C. VIII 0. VII Awesome Review, Inc ® Copyright 2014 Do not photocopy without permission . Page 30 9. A 20-year-old man with eplstaxls for the past 2 day$. Den1es taktoa any medlcattons and o family history of bleeding. Post FFP & Vit K high dose Admission Mixing studies PT I N R >9 1.2 PTI (secs.) >90 34 24 hrs later 3.3 >9 62 >90 Most likely diagnosis is A. Acquired factor VIII inhibitor _J/Brodifacoum poisoning Hemophilia A (fac VIII deficiency) 'deep bleeds; hematomas or hemarthroses, 1'PTT, nl PT, nl Platelets, nl BT' X linked; females carry, males suffer. Deficiency Treatment <5% moderate Desmopressin NOT effective Any Sx or during bleeds7 Factor VIII concentrates o. Pt. '*h mHct Hemophilia A WJtb 10% factor VUt; s 7 Desmopressin spray +/- Aminocaproic acid swish (anti-fibrinolytic agent) 7 Factor V I I I concentrate and keep level >50% for at least 2 weeks. 92. Pt. with Hemop Illa A golns for major surgery. wot. 7 Factor VI 1 1 concentrate prior to surgery and upto 48-72 hrs later. 93. Pt. with hemophilia has developed ab's to Fae Vm llhd tjas tr..,..e. wA.cff 7 N� VII w __. '[A..d...�-t.-� �irt.<h � 94. Pt. with fac IX deficiency, sustains trauma with fracture of femur. w.t.d 7 fc..<. tv CJ � U/'lt-� (()Y) r:=r=-p ��--- Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 3 1 S. You prescribe Warfarln fGF i3 Pt, �ldl :AfllJ 11nd; hlgh CHAO SCQre. Pt. does a GOOGLE earch and finds out that It's a rat olion. w.t.d 96. Pt. with Aftb on Warfarln and JNl ld S.O No adlw !Jleed. w.t.d - Hower dose by 5-20% +/- Hold one dose . • 7 �NR S.O to 9.0. No actlW4t btiel W.t4 s tup vv/;./Jc..M -r L.:.w � v;t k p-::. C 2. Srv:J ) recheck INR, when it drops to 3.0, then restart Warfarin at a lower dose. lNR >9J> Withhold Warfarin, high dose Vit K +/- FFP, recheck INR, when it drops to 3.0, then restart -7Warfarin at a lower dose. Vit Kl =Phytonadione -7 High dose Vit. K and FFP. A. Malnutrition Hypersplenism vf{ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 32 11c SP ( .....- ) /D-dimer (+) 1', 1'PT, 1'PTT, Platelets '1.- , Fibrinogen '1-- , Schistocytes(+) :on s &-J m ption coagulopathy'71' PT/PTT, '1-- Platelets :tio: rv" a ssive trauma 0 B complications: ruptured placenta, Amniotic fluid embolism, Reta ined dead fetus, Preeclampsia s e psis • I N F from tumors, AML • Tx: -rr e at u nderlying disorder FFP p l a telet s • • • A ntithrombin Ill concentrates 10 3 . ts.Ji., PT/PIT normal or sllghtly1', LFTs nl, Flbrlnogen nl. l at e le Pt. with metastatic lung cancer develops sudden onset of bluish toes and fingers. Ox: � c. h� 'D1C. t to c a..1 , a,; (solid tumors) Tx : If t h rombi7Heparin. i.o4. Pt. develops abruptio placentae with retained dead fetus. Hb 'll, Platelets Le.p� �?-c:..L fV\tf""\o...� M.eJ /X� � ... ... , z pTT ll' . w.t . d 7 evc.c ui;.I< ff:..._ /e t..M 1os . Awoman withexcessive bleed following D&C. Platelets count Is45,000. D-dimers are ted. Best wa to follow Pt Is te a A. Platelet count J D-dimers Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 33 Congenital • • • • • Factor V leiden defect (activated protein C resistance) [>SOy] Factor I I 20210 defect Protein C, S deficiency [20-SOy) Antithrombin Ill deficiency Dysfibrinogenemia & thomocysteine levels [young arterial] Acquired • • • • • • • Antiphospholipid (lupus anticoagulant) syndrome Paroxysmal nocturnal hemoglobinuria (PNH) Heparin induced thrombocytopenia (HIT) Cancers Nephrotic syndrome "Dlfl Oral contraceptives (not progestin only OCPs) Tamoxifen/Raloxifene All the above with INCREASED Age & immobility increase risk of thrombus • Asymptomatic Pts. with above conditions don't need to be anticoagulated unless during periods of increased thrombotic risk; surgery, immobilization, etc. 106. A 35 y old man plans to travel to Tokyo from New York. He has family history of Leiden actor V defect and Is himself positive as heterozygous. What Is your recommendation? A. ASA 0V'[eg exercises and hydration during flight C. Low molecular weight heparin D. Warfarin SS otd man Is goJns from NY to Hawaii. History o OVT In the past. hat Is the best management In addition to adequate hydration and leg exercises? 107. A. ASA ,,.$." Graduated knee high compression stockings. ( f\>l '2. �t'.f' ) 108. Pt. with a history of Leiden factor V defect or protein C deficiency presents with DVT. est management ts 7 Wa rfa rin ft.w 6 fV"\M-ltv) 0.109. Above Pt. 1 yr later, develops another DVT. w.t.d 7Anticoagulation with Warfarin ln.c\.tsf-iN.�� · Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 34 Q110. A 55 y o Cl o caucasian descent presents with leg pain and found to have DVT after stie ew from Hong Kong to LA. Most likely cause is 111. Pt. is iagnosea wit i:leep vein t rom osls and Is started on Coumadin to achieve an NR of 3.0. Three days later presents with weakness left side. 112. When to measure protein C In this Pt .. A. Once 3-6 months of anti coagulation is completed and Pt. is no longer on a nticoagulants for at least 2 weeks --- 113. Pt. found to have prolonged PTT. Does not correct on mixing with adding regular lasma. Corrects on adding phosphollplds. No DVT. w.t.d If above Pt. has DVT. w.t.d 7Start anticoagulation with 7 H..e.c.-v. ..p 114. Pt. with hx of Breast cancer and dexerops nvt Best mana.1ement? A. Long term Warfarin A. Long term LMWH 15. 25-year-old pregnant woman 8 weeks with SQB, QVif Jn the rtaht tq. est management? 7Low molecular weight heparin through pregnancy and up to 6 weeks after delivery Treat as PE Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 35 Matching A 1. 25-year-old pregnant woman 8 weeks with SOB. - DVT in the right leg. A. During pregnancy and 6 weeks postpartum of LMWH or heparin l'3 2. 26-year-old woman test positive for pregnancy. 5 B. 6 weeks postpartum of LMWH - years ago after a knee surgery she developed a DVT and treated with anticoagulation for 6 months C 3. Woman with prosthetic valve on Warfarin daily - becomes pregnant & in the 5th week or heparin or warfarin C. Stop Warfarin 5th week, Start Heparin. At 13th week start Warfarin and continue upto mid third trimester, then start Heparin upto delivery & post delivery 6 hrs later restart Warfarin. OR LMWH/UFH antepartum and restart Warfarin postpartum. 1) 4. 25 y old with history of 3 abortions in pt ,____ trimester. Pt. is 8 weeks pregnant. She has no history of bleeding or hematomas in the past. D. Heparin/LMWH plus aspirin PT normal, PTT t, Platelets normal. On mixing 1 : 1 antepartum and postpartum with normal plasma, PTT does not correct. On mixing with phospholipids PTT corrects and Pt. is diagnosed with Antiphospholipid syndrome � 1. Reversible cause (OCP) of DVT Matching '3 2. Leiden factor V defect or protein C deficiency with ,__ DVT. � Cancer with DVT. 3. 1) -- 4. Lupus anticoagulant with PTT 58 seconds, and DVT. L s. Lupus anticoagulant with PTT 58 seconds, and no DVT A. Warfarin for 3 months. B. Warfarin for 6 months. C. Extended Low molecular weight heparin. D. Warfarin indefinitely. E. Observe. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 36 116. 4 days after discharge, for a large OVT In the leg and thigh, repeat PT/INR Is 1.1 on mg of Coumadln. What Is the best management? ,.A<.' Begin LMWH and increase warfarin to 7.5 mg B. Increase warfarin to 7.5 mg 117. What Is appropriate transitioning from LMWH to warfarln In above Pt.? A. At least 3 days of LMWH plus warfarin with target INR of 2 for 24 hours y. At least 5 days of LMWH plus warfarin with target INR of 2 for 24 hours Warfarin (Coumadin) skin necrosis 118. Pt. with skin necrosis. This Pt. most likely has which of the foUowlng? A. Leiden factor defect .-8':'15rotein C deficiency C. Antithrombin Ill deficiency D. Cellulitis 119. The best treatment for above is A. Factor VIII B. Factor IX /, FFP Myeloproliferative disorders Polycythemia Vera Myelofibrosis with myeloid metaplasia General features: Autonomous & unchecked proliferation of one or more cell lines. Risk of bleeding or thrombosis Can burn out to myelofibrosis • Splenomegaly • Risk of Acute leukemia • Can clog blood vessels�Acute vaso-occlusive crisis • • • Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 37 Chart 12-1 Polycythemia Vera '1' RBC mass, -.itErythropoietin, P02 nl, pruritus after bathing' W BC 1' 1'RBC mass 7 '1tErythropoietin 1'risk of thrombosis, Splenomegaly 1'Retinal vein involvement Erythrome�aeli � p� --. -� � rl... .--1 t>o � 1-.1 <\H t.. (<\JI'\ Pruritus May have Iron deficiency Can burn out7 Myelofibrosis Dx: Hct > 60% + Splenomegaly or JAK2 mutation Tx: Phlebotomy to keep Hct<45% / Hydroxyurea = A. Parvovirus B 19 /.Myelofibrosis f3 C. Severe hemolytic anemia. 121. How to manage above Pt. A. lmmunoglobulins B. Steroids /.Blood transfusion Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 38 122. 65 y old man presents with complaints of dyspnea and headaches. e Is a chronic smoker l PPD for >35 yrs. b 23g/dl CV 78 BC 14,000 latelets 550,000 lk phos. n l a02 o n room air 94% It 812 level 1100pg/ml (nl 200-800). he most appropriate treatment for this Pt. Is A. Nasal 02 B. Steroids C. Plasmapheresis D. Azathioprine VV. Phlebotomy + LOW DOSE ASA 123. What Is seen more commonly with P. Vera? A. Engorged Retinal Veins vfV'Splenomegaly Secondary Erythrocytosis Hypoxia: COPD, R-H shunts High altitude Neoplasm: Renal tumors, Cerebellar tumors Others: Polycystic disease, Steroids Androgen ( �J 1 i"-�tit.3, -Ir l=SH, � U1, vc.. 'J 1.,....., ) Essential Thrombocytosis 1'platelets, vaso-occlusive symptoms; headache, paresthesias, stroke' Uncontrolled proliferation of platelets >600,000 ischemic symptoms usually >1.5 million. Vasomotor symptoms: Erythromelalgia, Livedo reticularis migraines, paresthesias of hands and feet. Peripheral smear: 1'Platelets, clumps. JAK2 + in 50% BM: Megakaryocytes clusters and fibrosis Tx: Stroke -7 Plateletpheresis Non urgent �_Hydroxyurea, Anagrelide to keep platelets <600,000 Low dose f\SA for Vasomotor symptoms. Reactive Thrombocytosis: 'Platelet� <800,000, 2° factor usually present' Etio: Iron d eficiency Chronic infection/Inflammation Neoplasms Chronic blood loss Splenectomy Post megaloblastic anemia treatment. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 39 124. A 20 year old woman presents with fatigue anCf pallor. Menses tiave 6een tieavy. b is 9.0 g/dl BC is 8,000 latelets are 800,000 CV is 64 ost likely cause of her thrombocytosis is A. Myeloproliferative disorder /,Reactive thrombocytosis secondary to Iron deficiency anemia 125. A 25 y old woman has a routine physical exam. She has no complaints and takes o medications. Platelet count is 800,000. w.t.d A. Hydroxyurea B. Anagrelide Y,Observation D. Plateletpheresis 126. Pt. with history of polycythemla vera presents with burning sensation In his foot. Exam rythema, warmth, tender, gangrene of toe. Dx: � E->j�f"'e l p;.. c. Cause: Platelets (Essential thrombocytosis) or RBCs (P vera) � Tx: 7 ASA l..o w cLo � CML [[ ) wLAP: '1' WBC, wLAP score, Ph chromosome (+), Splenomegaly' CML 1' WBC >50,000 myeloid series: Neutrophils, eosinophils, PNH basophils and monocytes , fV".<-tc; "'O LA� Wilson's dz ( f\.e""'"' p>'-:}u-..,; t.t;... tc,......,, , 7.. 7J A wLAP Leukocyte alkaline phosphatase A \ c.l!> '4,.c,,I, Hf.�lk. A'f. ) Diagnosis: FISH (fluorescent in situ hybridization) for t(9,22) Ph chromosome or PCR analysis for the abl/bcr fusion gene. 25%/year transform7blast crisis7AML (fever, night sweats, bone pain, blast cells) 7 Poor prognosis Tx: <50 yrs7 ; MCitl� b 7allogeneic Bone marrow Transplant >50 yrs7 ) M'-'t:.f\.\ b mesylate (Gleevec®; 7 i;'j vt> h.A.e kinase inhibitor) a interferon, Hydroxyurea, Busulfan ·1., ' ->f Splenomegaly7early satiety, left upper quadrant fullness. ALL 15 I CML t 7 cLL <o o (,h� � � ..-1 I b�t < 2./. bla.,-t. :> s /. Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 40 Myelofibrosis with myeloid metaplasia 'Splenomegaly, Tear drop cells, "dry tap", anemia, variable cytopenia' Other myeloproliferative disorders can 'burn out' to Myelofibrosis. 7 Extra medullary hematopoiesis7 Splenomegaly. Smear: Tear drop cells, nucleated RBCs, giant platelets BM aspiration: -? °"':J te;.p BM biopsy: 7 1' <A>l�� on reticulin stain, dysmorphic megakaryocytes. Jo' lo,;<> f-U Tx: <SS yrs7A ll ogene i c BMT (bone marrow transplant) -? No S'p l eAfc.!:..o� >SS yrs-? Supportive with blood transfusions +/- Thalidomide ( h 7-v w,e:. "'fh � v.Lu.... '1'"'� .it, . ) AML (Acute myelogenous leukemia) 'Young adult with superficial bleeds/infections, Leukocytosis, Auer rods, blast cells, Previous alkylating agents and topoisomerase inhibitors previous Myeloproliferative disorders: CML, Myelodysplasia or fibrosis' Infiltration of marrow with WBCs 71' immature WBCs 7 Blast cells in smear and BM 7 Infections 7 ..VPlatelets 7 Superficial bleeds 7 ..V H b 7 Anemia, fatigue Myeloperoxidase stain (+) in M2 to MS. M3. Acute Pro myelocytic leukemia t(lS,17), Auer rods. -f 'D 1 C < '2. [t Bad Prognosis: T(9,22) abr/bcl, previous cancers & multiple cytogenetic abnormalities. �is with � M biopsy with cytogenetic studies & immunophenotypic studies T_ B_fV\ Tx: <SO y7 Allogeneic _ _ ___ >50 y7 ara-C (cytarabine) and DNR (Daunorubicin) _, ( l·n.v l<V't M3 7 aM. � �t· NJ\.t- � _ Kc.. p <>)<;c.. sew'-"""'" ':f> "'t'· ->i · J 127. 42-year-old man with AML M3 Is begun with all-trans-retinolc acid (ATRA]. Next week resents with low-grade fever, shortness of breath and lower extremity edema, no chest aln, no cough. Weight has Increased by 10 pounds in the past week. Creatinlne has gone up rom 1 to 2 . 1. Most likely diagnosis? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 4 1 128. You would find Myeloperoxidase stain (+) in which of the following? A. CLL, ALL, Myelodysplasia � Acute Promyelocytic leukemia, Microscopic polyarteritis angiitis C. Myelodysplasia 129. 50 y old Pt. presents with sudden onset of�r, l�ukocytosis & erythematous plaques nd nodules on face and extremities. Lesions are tender. Biopsy� Dense eutrophllic infiltrate.= w.t.d 7 Dx:7 Associated with Leukemias mainly7 A /V\.. L Treatment: Steroids. CLL '>60 yrs with lymphocytosis, Lymph nodes (+), smudge cells, AIHA, infections' Lymphocytes: small, mature, smudge cells Hypogammaglobulinemia7 recurrent infections Autoantibodies7 Autoimmune hemolytic anemia. Lymphocytes express T cell marker CD 5 and B cell marker CD20 & CD 23 Tx: Asymptomatic: No treatment Symptomatic: Fludarabine, Chlorambucil, Rituximab {Fludara®) (Leukeran®) (Rituxan®) IVlgG for infections L-'"'"''""� ) 130. 62 y old man presents with an upper respiratory tract Infection. wee 18,000. redomlnantly lymphocytes. Smear shows mature lymphocytes, smudge cells. Dx: 7 C. LL 131. A. Pt. presents with wee 40,000, lymphocyte count 80% 7CLL I ndications for treatment in CLL. Lymphocytosis alone7 Lymphocytosis + Anemia Hb < 11g7 tvc.t.J Lymphocytosis + Thrombocytopenia < 100,0007 � Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 42 132. Pt. with CLL. Hb < 10g Platelets < 100,000. Best management? /chemotherapy B. Splenectomy 133. 70 y old with pneumonia twice In the past year. History of CLL diagnosed couple of ears ago. He was told treatment was not necessary as his Hb was 13g and his Platelets were 40,000. Now his Hb Is 12 g. Retie count 3%. LOH 250. Polychromasla +. The most likely cause f his recurrent pneumonia Is A. Hypergammaglobulinemia � Hypogammaglobulinemia C C LL / c v L'D .... U:>� vc....t.. �lt. ,v..,.,.� '� '-� $) 134. How would you prevent recurrent Infections In this Pt .. A. Continuous antibiotic prophylaxis /. Monthly i.v immuneglobulin C. No need for intervention. 135. What Is the reason for the above Pts. sudden onset Anemia and spherocytes on the mear. Ox: A. CLL progression _)Y.'Warm Autoimmune hemolytic anemia 136. What to do next for the above Pt.? No response to above7 1mmunosuppressive agents (Dexamethasone, cyclophosphamide, rituximab) (Rituxan®) (Cytoxan®) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 43 Hairy cell leukemia 'Pancytopenia, hairy cells, TRAP(+)' Elderly Pt. with pancytopenia, marked splenomegaly Smear7 filamentous 'hairy cells' TRAP (+) BM: fibrosis Tx: Cladribine7Add Rituximab Complications: Infections Vasculitis ju� c_ L �, _ .,. ;· 137. Which of the following Is more llkelv to so to AML. A. Polycythemia vera B. Myelofibrosis C. Essential thrombocytosis � CML E. CLL F. Non Hodgkins lymphoma G. ALL Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 44 Chart 13-1 Peripheral Smear Bl ister/Bite cell G-6-P-D deficiency Acanthocyte/Spurr cell Liver disease Alcoholic disease anemia Echinocyte/Burr cell Uremia anemia Howell Jolly bodies Splenectomy and functional �plurV Normoblast Severe hemolysis Myelofibrosis Polychromatophilia (Reticulocytes) Hemolysis Blood loss Bone marrow working Schistocytes TTP HUS tv HJ1'1 D · B" I. HELLP/Pre-eclampsia/Fatty liver DIC Prosthetic valves Spherocytes Hereditary spherocytosis Autoimmune Hemolytic anemia Target cells • • • • Tear d rops •-�::.....:...----� • Sideroblasts 1.------'�• • • • • � 1' Thalassemia Sickle cell HbC HbE ETOH Myeloid metaplasia with myelofibrosis Thalassemia Myelodysplasia Alcoholism Vit B6 deficiency Sideroblastic anemia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 45 An AWESOME REVIEW OF 9% Endocarditis Meningitis Urinary tract infections Fungal Infections - STDs (Includes PID) - Tick Borne Diseases Infectious Rashes - Osteomyelit is - Skin and Soft Tissue Infections - Animal Bites Diarrhea - Travel Medicine PPD Bioterrorism HIV - Antibiotics Awesome Review Inc.® Copyright 2014. Do not photocopy without permission. J Chart 1-6 Endocarditis Empiric treatment Organism Native valve Prosthetic valve I St aph aureus Strep bovis Strep group D (Enterococci) Vancomycin Staph . epi ( M • kill b..J Streptococci f'tr... ) Gram neg. Fungi Vanco. + Rifampin St aph .aureus Enterococcus Gram neg. Strep.virid ans Van co. + Gentamicin + Gentamicin I IVDU + Gentamicin M ost common cause of bact erial endocarditi s ·world wid e is Indications for Surgery • • • • • Severe CHF Persist ent bact eremia - - - . Recurrent embo li Valve abscess C i E-E 'i.J ) Large f ungal veget ation repeat BC pos. in 48 hrs~ cont. Abx repeat BC pos. in 7 days~ SurgerY. Dapto mycin can be used in rt. sided endocarditis with septic emboli. (Cubicin®) Awesome Review, Inc.® Copyright 2014 Do not photocopy without perm ission Page 208 pl. Pt. with symp. of Endocarditis. Blood cultures done and Vancomycin and Gentamicin are ~tarted. 72 hrs. later, Blood culture results are positive for Pen sens. Strep. Abx changed to Penicillin & Gentamycin was discontinued. Repeat Blood cultures are done and 24 hrs. later he blood cultures are again positive for Strep. w.t.d A. Add Gentamycin & call Cardiothoracic consult JV,"Continue antibiotics and repeat Blood cultures in 48 hrs. C. Restart Vancomycin ) Q2. Pt. witll history o injecting drugs, recently presents with fever, cough with emoptysis and pleuritic chest pain. 0/E: II/VI grade systolic murmur at the left sternal border, best heard on inspiration. CXR: 2-3 nodular densities. ) Empric TX :-7 Vc.rvu> -t- ~(\t.&.. Bovls. w.t.d ) ) p4. IVDU Is suspectea·of enaocarditis and empiric Vanco + Gentamicin is started. ~ultures are positive for PCN sensitive enterococci. Vanco. Is stopped and PCN Is ~tarted and a few hours later, Pt. with generalized pruritus, Itching of eyes and ~welling of lips. w.t.d ) -7 D/C PCN and restart Vancomycin. ) ) ) ) 5. Pt. on Vancom cin eve ops itching and redness on the back oft e necl(. Dx: -7 Tx:-7 r.1::• -, v - - J S'volri .s.. R.e..t;l.~' ..r U.IV'- ( -· I""L<V-"'-~ ""'· s'"---' \Ao-.1•-1. O.:v<- o· ----------------~ KACt.:~) beAA ~(. ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 209 6. Pt. s/p TURP (transurethral prostatectomy) 2 weeks later with fever and growing nterococcl. The .!JASI.Iikely treatment you would choose is ----------------------~ A. Ampicillin + Gentamicin B. Vancomycin +Gentamicin V1. ..1\ "' .L C. Piperacillin-tazobactam (Zosyn®) .Jrt . ;:r c.e o:..W 1 f'rl RS' -t .L ' "'-""' l vt> c ~'"c' l ... ./ . ·~ D. Linezo lid (Zyvox®) ~ \..1\JY\4 ~ .,,.... 1tf ~.. ~ t;.pc.,,a, f'\MA. t.?ptr-• , ~c..~ I C .J',tt~-+ J<.ve..-+~ Ceftriaxone H ~'4-1"') ~ c~ -7 Lc.tti,; a<:,;d....hf " "' F. Quinupristin/dalfopristin (Synercid®) ..-4 0 """"" -'-•r 1/R £. ;N-ut ·,.. opt.· c. ~1:;. r 1",..~ 4 "" l --· J ·-1. G. Daptomycm EnterococcaiiE mainly seen in elderly men, involves Aorti c valve> mitral valve. M ore CHF than embolic events, lower mortality. Aortic valve endocarditis most commonly associated with conduction defects. ( 1-t! h;J«t!. Av bL.cock ) A. Pt. with severe CHF not responsive to medical treatment. ECHO reveals severe Aortic regurgitation B. Pt. with endocarditis is febrile in the first week on appropriate antibiotic treatment. In the second week develops a heart block. A trans-esophageal ECHO is done and shows va lvular abscess. Afebrile currently on antibiotics. VC. Pt. with endocarditi s febrile on i.v antibiotics. Repeat blood cultures 48 hrs. later positive. Mild aortic regurg. with EF 60%. BUN/Creat 25/2.0 J Af~~J ~of!:\. sp<>tS'<::t::7' Av~ Ab c..o..-p\Lx- . ·, ,.,..~ =r-fk.o< .te r"At., ( 1' c..,.) A , t\1:> (IIJ""l"w.>. 8 t.o"t;.f\M(, A"t.i:o;ot,.<... J~ rl~ l.i.\~c.w C (lecrease. 8. Pt. being treateCJ for endoearCJI s defervesces and KG shows a 1° heart block. Is this a cause for concern? A Yes B. No. W.t .d next? A. Observe ._)Y. Transesophageal ECHO Q9. Pt. on lmlpenem/cllastatfn (Prlmaxin• ) for nosocomial Infection In ICU. History of seizure (fisorder. Pt. has a selzure. ls this llkel related to lml enem? Increased incidence of seizures with higher doses. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 210 rst ow risk conditions, then know High risk procedures Endocarditis antibiotic prophylaxis required ONLY for high risk procedures in high risk conditions. HI h risk conditions • All prosthetic valves • Previous history of endocarditis • Congenital heart disease; Unrepaired cyanotic CHD, including shunts • Repaired Congenital heart disease within 6 mths. of repair • Post transplant Heart with valvular disorders • Repaired congenital heart disease with prosthesis or a patch in place or residual defect. lgti r s procecture (likely to cause bleeding and induce bacteremia) ) ) • Dental: Extraction, periodontal procedures, root canal, dental implants ~ot High risk anymore. • Gl or GU procedures (only if there is a risk of mucosal damage) low risk conditions • ASD secundum type _, M 1/ P • ) ) ) ) • • • • P..ro c e,itv'~> ._, M f<. . 6 months after repair of ASD, VSD, PDA previous CABG/HOCM Pacemaker MVP with murmur OR redundant leaflets, MS, AS, HOCM, Bicuspid valve Functional murmurs low risk procedures (unlikely to cause bleeding and induce bacteremia) • Dental: Filling cavities • Respiratory: Endotrach. intubation, flexible bronchoscopy with or without biopsy • Gl: All Gl & GU procedures are now considered low risk. • GU: Vaginal hysterectomy, C-section, D&C, therapeutic abortion, IUD insertion or removal. • Others: Cardiac catheterization, Circumcision. Chart 2-6 ) Antibiotic prophylaxis for Endocarditis ) ~[Qce!;!y[e Antibiotic of choi!;;e NQ_£Q Dental Amoxicillin 2g po 1 hr prior Ampicillin i.v ~c~ allergy gost grocedure Azithromycin (Zithromax®) Or Clindamycin Nothing ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 211 ___ 10. Pt. with PDA going for cystoscopy. Do tlley need prophylaxis for endocarditis? ~ GLM.u... B;or~ - No __, rvo A"t:.~;o;ot;...;. 11. Pt. with bacteremia wit Staph. aureus due to i.v line. i.v line removed, Vanco i.v , tarted. w.t.d --------------------------------------------------------~ if negative. w.t.d -7Tx with antibiotics 1V fw 2 v-,k.r If ECHO positive -7Tx with antibiotics fo.t ~- ~ wiu' A. Clindamycin & Metronidazole (Fiagyl®) ( RuNov<- ~ Vancomycin & lmipenem c_q_~~te.r) Q13. The above Pt. weighs 240 lbs. What dose of Vanco. would you start? A. 1 g i.v q12h ..z. 1.5 g i.v q12h IS- 2° ~}I<~ Q14. What is effective to prevent surgical site infections? A. Decolonization of MRSA ~ Parental antibiotics one hour prior to surgery and 24 hrs. after surgery lS. 35 yr. old with IVDA admitted with fever and chills and has a murmur, found to ave vegetation on the tricuspid valve, blood ex has MRSA. hat is the most appropriate treatment E JC Daptomycin B. Cefepime (Maxipime®) C. Nafcillin D. Ceftriaxone Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 212 Av. . u~;, ~1,.\ ... P,.cJ,..oy/1 hM,,...;sw :Jt,· (. ( ;z; ( ~e. pt..Op\A. Jc..."- pl. Chart 3-6 '-c., "tt-..111(. ~------------------------------------------------------------~ Empiric Tx of M eningitis Head trauma/ Neuro Sx Staph. aur. Strep. pneumo. Gram neg. bacilli Vanco. + Ceftazidime (Fortaz® ) 60 y listeria Strep. pneumo. Neisseria. mening. Ampicillin Ceftriaxone + Van co. 15 y Strep. pneumo. Neisseria. mening. H. influenza Ceftriaxone 2m Strep. agalactiae E.coli listeria Ceftriaxone + Ampicillin ON;) · .... ~. G M · o.IL Pf.. l"i ViY<.L 'j f'·"1.. ) k.-·~ _, 1f:..u... ~ ... pt 1-vv, k.~ ,.,;k:.,,,,.Jev,:~ . \ \ ) ) ) ) Chart 4-6 ) CSF findings in Meningitis ) Normal Cell count Type Glucose Protein Other <5 lymph. 40-80 15-45 ~ ) --:.:; f-1' oP 1' w. Bacterial 10-100 K PMNs .Jt 1' WNV 10-1 K lymph. .Jt 1' muscle weakness, rash, wDTRs TB 10-1 K lymph. .Jt 1'1' €cJ.v0 I Aseptic 10-2 K lymph. N 1'/N Enteroviruses, OKT3 ~~b NSAIDs, Bactrim Early Bacteria l 10-1 K 1' CSF to Ser. Glu <0.4 Encephalitis HSV Encephalitis lymphs. .Jt > PMNs ).. Sf 1-2 K lymph. N 1'/N 1-2 K lymph. N 1'/N RBCs (+) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ~ 11 svz -MR6C.. -::.lo, v-.-6C ::: to (IV\. R./J( ; \4C ) = /(lUi) ; I '1 / ·, I t}tt~ -t Ac.aw~ ;y,v> 'l "'"'' Page 213 Ql6. A 70 yr. old Pt. with OM presents with mental status changes. Spinal tap shows many WBCs, mainly PMNs. Gram stain negative. Cultures are pending. w.t .d to cover Resistant Strep. Pneuma A. Strep Pneuma. B. Nocardia JL Listeria monocytogenes Best Tx A. Ceftriaxone + Vanco. B. Vanco. +Ampicillin Y, Ampicillin + Gentamicin .v All~ _, f:>c..c.t,iM- <ou ; • Q18. 24 yr. old male presents with neck pain and headache. Neck signs positive. Spinal tap reveals WBC 105, 100% lymphs, No RBCs, Glucose SO. Most likely cause? A. Herpes encephalitis JY,' Entero/Echo virus meningitis • • Also remember NSAIDs, Bactrim, OKT 3 Abs as causes of aseptic meningitis. where initially t~ill ~rophilic pleocytosis in CSF. Q19. A 70 yr. old man with history of COPD and pneumonia twice In the past year presents with cough, fever, chills and mental status changes. BC .........17 K, 70% PMNs CXR ............ left lower lobe consolidation CT scan head.........No bleed Spinal tap ...............WBCs> 2000, mainly PMNs. Glucose .J.,, Protein 1', Gram stain shows cocci In pairs. Blood and CSF cultures ending. You would start vt(' Ceftriaxone +Vancomycin +DMS B. Ampicillin + Ceftriaxone C. lmipenem D. Ceftriaxone Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 214 A. Vancomycin plus Ceftriaxone B. i.v acyclovir Jc.' Ceftriaxone plus Ampicillin D. Fluconazole i.v ~21. A Pt. presents with meningitis. umbar puncture shows WBC 75 with Glu 28, Protein elevated, opening pressure 290, \ ~rypt. Ag negative, Gram stain neg. You will treat this Pt. for .loc.vo"' M-~'~"" P,..h.ct.'\.<. vc.L.,...L A. Cryptococcal meningitis JY,'Bacterial meningitis ~22. 16 yr. ola wlfn mental status ctiange, hign fever. BP 80/60. Exam reveals a mictline ~car on the abdomen. Lab reveals Leukocytosis. Hx. of a Motor vehicle accident 2 yrs. ~go with splenectomy. Most likely organism Is vK Strep. pneumonia ) ) ) ) ) B. Listeria monocytogenes C. Staph. D. Strep. pyogenes. 23. Pt. with meningitis by history and physical. What to do next? A. CT brain ----s:i.v Antibiotics C. Lumbar puncture ) ) ) Q24. A Pt. presents with headache of 2 days duration. He f~lt dizzy and now lethargic. Exam reveals meningeal signs(+). This Is his 7th episode In the past 6 years. CSF reveals granular cells (monocytes). What Is the most likely diagnosis? ~ r'\. o;,Jlc.ret'J (Benign and recurrent lymphocytic meningitis caused 11 SV 2 ~ft:J Tx: ~ Supportive, Antiviral s have not shown to benefit Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 215 25. Pt. presents witll ~ lleaCiaclle, vomiting, ana episoae of seizure. e had been confused In the past week and complains of smelling 'burning rubber', fishy odor', and auditory hallucinations. Rl brain~ hyperintensity (Increased signal) from the temporal lobes. EG~ sharp and slow waves from temporal lobes pinal tap~ WBCs 200 mainly lymph's, glucose 45 and protein 75mg/dl, RBCs 65 (+) Ox: ~ Herpes Encephalitis Confirm by:~ PCR assay of CSF Q26. A 70 yr. old Pt. is brought with headaches, fever for the past 5 days. Slightly confused, complains of ocular pain and diplopia. His hiking partner had similar ymptoms which resolved. Mild neck signs(+) OR focal weakness of one side of the body ith DTRs absent. pinal tap reveals: WBC 55, 100% lymphs, Protein 90mg/dl, Glucose SOmg/dl. w.t.d next A. WNV PCR B. HSV PCR .J/.WNV lgM antibodies l 'te.lt-t.4 Most important prognostic factor? A. Creatinine ( RM S ~ 1' MoDYt.. ~tcJ ) ~ Age >75 yrs. C. OM The reservoir for WNV is ~ 13: rd...r The transmitting agent is~ Mto.r'liM to 27. Pt. presents with fever and headaches of 2 days duration. xam reveals neck stiffness. BC Is 8,800 with 68% PMNs, 8% bands. (. ) l Y. iJ Si &"'cfi c..c.l\t ) pinal tap reveals: WBC 85 with 54 % PMNs, 33% lymphocytes. RBCs 0. lucose is 26 and serum Glucose is 86, Protein Is 68mg/dl. hat Is the most likely diagnosis? A. Viral meningitis ¥. Early bacterial meningitis C. HSV Encephalitis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 216 28. A 20 yr. old woman is brought from college with a tonic clonic seizure. rlends says last week she was complaining of headaches and actin& weird with nxiety and paranoid behavior. She has no psychiatric or drug abuse history. Exam reveals orthostatic hypotension, Choreiform movements and she has lfflculty choosing right words. SF: 40 WBCs, 96% lymphs, 3 RBCs Glucose 62mg, Total protein 30mg/dl head normal. t. was treated for HSV encephalitis without improvement and HSV PCR negative. ost likely diagnosis? A. West nile virus encephalitis JY. NMDA receptor encephalitis J ) ) ( S~'2\N\.t:, wc.iYol, ":1~:t~t.v- ~""") ...... tt.. HUt.;,~ •:1 -'~"' t....~.- ...:_..~ct. Q29. Pt. is brought with headache, confusion, and diffuse petechial maculopapular rash. CT scan Is negative and spinal tap reveals WBCs > 2000, mainly PMNs and low glucose. Gram stain shows gram negative diplococci. Pt. Is diagnosed with meningococcal meningitis, treated with Ceftrlaxone and 3 days later he oes into hypotensive shock. w.t.d . If the Pt. works in day care. w.t.d -?Prophylax day care/nursery school contacts. ) ) -?Prophylax house hold contacts. • • • • Prophylax with Rifampin 600mg po bid for 2 days. If contraindicated then cipro. one dose. If on OCP, change contraception method while using Rifampin. If pregnant -7 Ceftriaxone 250 mg IM x 1 dose Ai" bo"'"<- p,.c.c~ ... t.:""'(V\.ec.,j \ . . . Droplet precaution . (.~c~c.u- po~ ;r. c..cL-lt - Aiv bV't'"7'-'..~ ~t.<-<1-- ) 30. Pt. is being treated for meningococcal meningitis since yesterday morning. ow Jon will ou continue Isolation? A. d/c isolation now J C A/13 :!"->/ 24 h.v ) C. d/c isolation when antibiotics are stopped VY.' djc isolation tomorrow Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 217 p31. A 52 yr. old man presents with heaaac e. t xam reveals fever and neck signs. A spinal tap Is done which reveals the following: t pening pressure 142mm, WBC 45 predominantly lymphocytes, Protein 52mg/dl, Glucose 6Smg/dl. Serum glucose 120mg/dl. Pt. is started on adequate empirical overage for Strep. Pneumo. and HSV. Two days later, cultures are neg. SV PCR is ne ative. What is a ro riate now? 7 dfc. ·a.lt 1"\LA...r HSV-2 causes aseptic meningitis, can be accompanied by genital ulcers and HSV-1 encephalitis Urinary Tract infections Cystitis Pyelonephritis Catheter related Prostatitis 7 mostly E.coli, young ~ Staph. saprophyticus E'lc.lt...v':J ~ _. sf.cpl.. ¥; Cc..o~) 'T1< Stof .w.A~..h:...,. / c' ( P"-e.....!...rV.t.s / ""f"'~W') Uncomplicated cystitis 7 • 3 day course of Nitrofurantoin/Bactrim/Cipro. (Macrodantin®) No need for c/s • If symptoms persist >3 days-? c/s and treat for 7 days. ~ N1'trofuranto'1n/ --, Cystiti s ·m Pregnancy Am~;~ x 'l 'j) Asymptomatic bacteriuria in Pregnancy Asymptomatic bacteriuria in Diabetes mellitus 7 O.o"Jt. tru.t Asymptomatic bacteriuria in post transplant 7 Asymptomatic funguria with foley catheter 7 Asymptomatic bacteriuria in foley catheter 7 Recurrent cystitis 7 c/s and treat, then suppressive regimen with Bactrim/Cipro. Pyelonephritis 'Chills, fever, flank pain and tenderness, 1'WBC in urine' u T -r w,t. GSB L ~ -fo.rf<> ""J cAt'- Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 218 requency. If above Pt. is pregnant, w.t.d -7 Ao\rv...'t t J'tc..vf U -d txlc; x~ (NO Bactrim/quinolone) If Pt. doesn't defervesce in >72 hours. w.t.d -7 Renal ultrasound to R/0 structural abnormalities ) If above Pt. penicillin allergic w.t.d J 33. 32 yr. o witfl nan pa n an UA wltfl WBC >20 anCI many acter a. emp 102 F and HR 110/mln. Pt. Is begun on Amplclllln-sulbactam. 3 days later, Pt. Is ating and ambulating. Temp is 99F, HR 86/mln. You are contemplating dlschar:ge when ab calls you to report, Pt. Is growing ESBL E.collln urine culture and blood culture has Gram negative rods. What Is the best management? } A. Switch to lmipenem ) JY. Continue discharge planning and switch to Amox.-clavulanate c pi c. ~,;lc.l~ '• ""~"""~ ) (Augmentin®) ) ) 34. Elderly male with dysuria and 1'frequency, tender prostate. common bug in elderly is E.Coli 35. Nursing home Pt. with Foley cath. and recurrent UTis. Prophylaxis? A. Bactrim J- Nothing effective Awesome Review, lnc.i!) Copyright 2014 Do not photocopy without permission Page 219 Q36. A Pt. wit Foley catfleter <feve ops urosepsis. Wflat is the 6est management? A. Begin antibiotics \)( Change Foley and begin antibiotics 37. Nursing Home Pt. witfl stroke and a chronic Foley cath. with urosepsis sev~ral ·mes a year. Best way to minimize risk of UTis Is ----------~------------~----~ A. Daily meatal care with antibiotics \)( Closed drainage catheter system er y Pt. to promote healing? --------------~ A. Stage II sacral ulcer JY. Stage IV sacra l ulcer • No Ulcers • No Adenopathy • Discharge(+) Gonococcus -7 Ceftriaxone Chlamydia -7 Doxycycline, Others: Azithromycin Drugs for GC & Ch lamydia-7(ceftriaxone + Azithromycinp r Azithromycin 2g one dose 2 So "";j I ~ Presentations: • Urethritis • Epididymitis • Mucopurule nt cervicitis • Dysuria, Pyuria* without bacteriuria • Pelvic Inflammatory disease • Disseminated Gonococcal infection 39. 24 yr. old woman, college student, sexually active presents with c/o fever, chills, ausea and vomiting for the past 3 days. Denies any vaginal discharge. 0/E: Temp. 02F, HR 106/mln, mucus membranes dry, left flank tenderness and mild suprapubic enderness. elvlc exam: No cervical motion tenderness. regnancy test negative. U/A: 30 WBCs/hpf, Urine c/s pending. w.t.d ~~------~--------~ 'J( Admit, do blood cultures and treat with i.v ciprofloxacin or Bactrim B. Start oral ciprofloxacin and monitor in the next couple of days. C. Ceftriaxone i.m and Doxycycline p.o Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 220 Chart S-6 I Features Treatment Trichomonas profuse yellow discharge. Strawberry cervix. pH>5 Metronidazole 2g x 1 dose or Tinidazole 2 g x 1 dose -- Yes Bacterial vaginosis (Gardnerella) 'thin discharge', clu e cells, fishy odor. pH> 5 Metronidazole SOOmg bid x 7 days Or Met. gel 0.75% qd x 5 d. Or Clinda. cream 2% qd x 7 d No Candidiasis non foul smelling, thick white discharge, adherent to the walls. Fluconazole 150mg x 1 or Topical Clotrimazole for 3-7 days (use in pregnancy 7 d.) - ) J Partner Tx Vaginitis S' ~ c.bo·~ .-.. t,. I d.A1'4 ~ ' J""-~ st.-.,.bc.f>q- Only if ~itisis ~nt. 40. Pt. with scanty foul smelling discharge uses over the counter vaginal azole for days without improvement. Physician prescribes oral fluconazole and still without ellef. w.t.d 71t is NOT Candidiasis, treat for Gardenerella/Trichomonas with Flagyl or Clindamycin 7p.o or cream. 7Diagnostically check Vaginal 7 ) } ') ) pH or if scraping 7 bleed 7 CI).Lc;N\!1~c:;. 41. Pt. presents with dysuria. On exam discharge Is noted. rlne analysis reveals WBCs 7 and 'clue' cell (epithelial cell with Indistinct margin.) hat Is the best management? ----Y!Nv-f ~·v. ( 14 - 2.-4) _, o..~t..~~(., ~ A. Bactrim Y Metronidazole C. Nitrofurantoin f?t.o~tC Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ol.jc... Page 221 PID {Pelvic inflammatory disease) 'Lower abdom inal pain, Cervical motion tenderness*, a~ l tenderness*, mucopurulent cervicitis, uterine tenderness' Etio: • N. gonorrh ea • Chlamydia • Vaginal anaerobes Complications: • Infertility • Ectopic pregnancy • Perihepatitis • Tuba- Ovarian abscess Treatment: PCN allergy Ceftriaxone 250mg IM Ofloxacin + Out Pt. In Pt. (vom iting/ severe pain) Doxycycline 100mg bid to§ Cefoxitin/Cetotetan + Clinda./Fiagyl Clinda./Fiagyl + Genta. + Doxycycline 100mg bid torS + Doxycycline 42. A 25 yr. ola woman presents with progressive lower abdominal pain for the ast 4 days with nausea, vomiting and fever. She denies dysuria or flank pain. emp 101 F, HR 100/mln. lower abdominal tenderness (+). elvlc exam shows cervical discharge and motion tenderness. BC Is 17 K, 70% PMNs. regnancy test negative. Chlamydia, Gonococcal, blood cultures are pending. You would. -__,;j / .Admit and treat with i.v Cetoxitin and i.v Doxycycl ine B. Out Pt. Ceftriaxone i.m and Doxycycline p.o C. Admit and treat with i.v Flagyl, i.v Gentamycin and i.v Acyclovir D. Out Pt. Ofloxacin p.o and Clindamycin p.o 43. 24 yr. ola sexually active man presents witt\ urettlral alsctlarge. e is given Ceftrlaxone 250mg IM x 1 and discharged. e feels better, but 10 days later comes back with urethral discharge. e denies any sexual activity in the past 10 days. Dx: Chlamyd ia. w.t.d {Gonococcus -7 2-6 days incubation) (Chlamydia -7 1-4 weeks incubation) Doxycycline 100mg po bid for 7 days Or Azithromycin 1 g x 1. Always treat for both N.gonorrhea and chlamydia together. Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 222 Q44. A young woman takes OCP, sexually active with one partner presents with yellow ~ucoid discharge. On exam: non tender, when swab Is inserted, there Is bleeding and cervix is erythematous and swollen. Smear shows WBCs, some bacteria, but no _r8g4a_n_is....,m--.._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_____. hy~hae. Most likely._o v Kc hlamydia B. Gardnerella \ Which test ? A. Serum abs Jr. Urine nucleic acid C Pcrz ) c. ex culture J' (Zithromax<ll) Tx:-7 ) Is asymptomatic, l:)ut " .Jl• Jl> ~ 3 w1<s post treatm ent ( 'D('IA reM.. OJ'\.""'~s) > 3 w eeks -7 True positive test. Retreat Pt. and partn er. ) ) ) ~7. A stuaent goes on spring rea • He presents a out a weel< ater wltti tenCierness n is posterior testes. Stripping of the urethra reveali some dlscharge. hat Is the most likely diagnosis? A. Gonococca l epididymitis \,)Y. Chlamydia epididymitis ( f"'sh..t~c.b;t~ L"'l<) - i I \;"Jt Lc.~ Mycoplas ma genitalium - associated with acute and persistent, non gonococcal urethriti s and is treated with Azithromycin. ) e-48. 24 yr. old sexually active woman presents with pain on movement of wrist joint. /E: Fever, Single pustular lesion over dorsum of hand. Swollen Right knee. Left knee normal he reatest leld of the source would be from A.)31ood cultures \.,)r. Cervical cultures or History C. Jo int flu id cultures ) Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 223 49. Gay Pt. c o constipation, severe pain on defecation and generalized weakness. leer In the perineal area. Anoscopy with ulcer Involving anal canal. Most likely diagnosis? ~HSV B. Gonococcus c p~ lLY.I ) ~ltrasound normal. A diagnosis of epididymitis was made. Most likely organism? __ 50. Pt. with acute testicular pain, Hx. of several sexual encounters. No Hx. of trauma. ___. 1. <35 yrs~ c "-1a~ tt\ 'I 2. >35 yrs ~ r;~, 9~1'\.0rY~ ( f3 ) E~te...obuto/ l A) Best Tx? A. Levofloxacin B. Azithromycin Always do HIV on a Pt. with genital ulcer. 51. An uncircumcised Pt. presents with pearly penile papules. W.t.d? A. Biopsy ~ Do nothing enltal Ulcers: • • • • • Herpes Simplex virus Syphilis H. ducreyi Lymphogranuloma venereum Granuloma Inguinale Dx: ~ h.fl/ ( 'D ('.~(>. viYw ) Tx: P 1 episode ~ 2"d episode ~ Recurrent>6 episodes/yr. ~ Severe disease ~ Acyclovir for 10 days Acyclovir for 5 days Continuous Acyclovir prophylaxis, indefinit~ ly i.v acyclovir Acyclovir reduces duration of symptomatic and asymptomatic viral shedding. Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 224 53. Pt. presents with painful genital ulcers, irregular lior ers, ini apules~ painful adenopathy~ fluctuant~ Rupture. icroscopy : 'schools of fish' or 'box car' appearance. Gram negative bacillus. Dx: -7 H du.c~ yi Tx: • • • Ceftriaxone 250mg IM or ( No Azithromycin l.Og single dose or Erythromycin SOOmg qid x 7 days. ci-oX\j ) 4. Pt. presents with painless genital ulcer~ disappears in a week ~2-6 weeks later with deno ath ~buboes~flstulae~Rectal scarring'!:,._ _ _ _ _ _ _ _ _ _ _ _ ____. Dx:-7 L c; V Tx : Doxycycline 100mg bid x 21 days. ~Q Etio: Klebsiella granulomatis ~~ Microscopy: Donovan bodies (bipolar safety pin-shaped intracytoplasmic inclusions) Tx: Doxycycline 100 bid x 21 days or Bactrim/Erythromycin. 56. A young woman presented about 4 mths. ago with painless genital ulcer. ark fteld microscopy was positive and RPR was negative at that time. he was successfully treated with PCN. he resents now with several small ulcers which are tender. RPR Is w.t.d ) S~r?h.ii.<J - tJo p~ C pt ~IJ' N.vl N.-p~ A. Doxycycline vt( Acyclovir C. PCN ) Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 225 QS7. Asymptomatic Pt. RPR screening 1:8 positive FTA(+). If this Pt. had RPR negative last year-? Early latent Syphilis -7 Benz. PCN 2.4 million units x 1 If this Pt. had RPR negative> 1 year ago-7 Late Latent Syphilis-? 2.4 million units weekly x 3 5' ~ ( Lc..!q; QSS. Pt. with painless genital ulcer, raised with indurated margin & clean l:lase. W.t.d next? A. RPR JY.'Dark field microscopy Tx: Benzathine PCN 2.4 million units IM x 1 or Doxycycline 100 mg bid x 14 days. QS9. Pt. presents with fever, headache, generalized adenopathy, maculopapular rash on -palms and soles. ( z.' .r'J~J AST1', ALT1', Alk. phos1' Heterophile Ag (-) . d_~-------~-----~--' .t_ w_ ELISA(-), HIV PCR RNA< 50 cps _ -7 VDRL/RPR to R/0 2• Syphilis FTA (+)for life Tx: Benzathine PCN 2.4 mu q x 1. If repeat VDRL titers~ 4 fold-? Tx success. ( 1.' 2 J'6 _, I : l'l f' _... I ) G'r ~ j .- 32 - 1: 16) If repeat VDRL titers 1'-7 do spinal tap to R/0 Neurosyphilis QGO. A 40 Yr. old man presents or a regular checkup. Exam reveals pupils are 4mm and when you bring your finger close to his nose, Is eyes converge and plijiiiSartlm.ro. n flashing light the left pupil does not constrict. w.t.d.next? A. Spinal tap RPR v!f.' Spinal tap VDRL Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 226 A. Benzathine PCN 2.4 million units x 3 B. Doxycycline for 2 weeks ve(PCN G 2m units Q4h x 2 weeks If Pt. is PCN allergic. w.t.d -7Desensitize in the ICU & give PCN. -7Repeat Spinal tap q 6 months till WBCs normal. ) Dx: Jarisch Herxheimer reaction. w.t.d -7 Bed rest, ASA and continue PCN . 63. A 45 yr. old man presents with headache, difficulty walking with imbalance and fever. e has double vision as well. Is ast medical history Includes HIV with T cells of 395 and VL <25 copies last month. ) What is the most likely diagnosis? What will you do next? ..A( Neurosyphilis A. Serum Cryptococcal antigen B. Cryptococcal meningitis JV,"Spinal tap C. Progressive multifocalleukoencephalopathy < ·,~l. l-'<., ('10 ~~, 1 t..t.ll <IS ) - I .. ( It ~"" -t L ~ ~tc.NM) Tick Borne: ~'ti'f~ ~to:~ • RMSF • Lyme • Ehrlichia • Babesia • Tularemia • STARI (southern tick associated rash illness) ) 64. 22 yr. old at a North Carolina camp c/o of headache, fever and myalgias. 3 days later lth a macular rash In the extremities. Next day it becomes petechial. Tx: Doxycycline/Tetracycline Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 227 A. Babesia B. Ehrlichia (a.k.a Anaplasma Phagocytophila) C. Lyme disease ~ r £=h-Y'I.<<..l:.:;: ( 'l of t- rf."N).-:.J ~ o ,\ ,.-(<t 1(1'\MUN"•jl""'~· nJf "'1 ) P(..-·rw·" J NVA _, f'll-" n-<L«L '"b· '1... D. RMSF ~66. Pt. vacationing on Nantucket island71ong lslana presents wltfi Fever*, shaking chills*, drenching sweats•. No rash*. ~lood smear-+ 'ring forms', 'maltese cross' or 'tetrads'. Hb~, Retic1'(hemolysls) Tx: Severe ~ -, r. •A •\ A ' .... """"""·v ' '"' • V ~(\_c;\,,e.. M.A-1 C...:f\J ~67. Pt. presents to a doctor's office In New Jersey, with c/o a skin lesion on the thigh. P/E: Erythematous lesion about 6 ems diameter, slightly raised with partial central learlng. The Pt. says the lesion was smaller a few days ago. Dx:-7 G"":)ii-~ c.~~ ~(JY0."-:1 2° Lyme's Disease st age I Serology is NOT reliable. ( F~ l s:<- Nfc.t.-......e ) ~ 2 el""¥ _................- - -.... Diagnosis is mainly clini cal. Other features of stage 1: Fever, headache, Lymphadenopathy and arthralgias. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 228 Ff68. Pt. was fishing on Nantucket Island. Pt. noticed a rash on the leg which ~isappeared a few days later. Couple of weeks later, Pt. presents with dizziness. .--------"';;.:.k:.:.. KG~ UO IUO heart bl."oc Tx : PCN/Ceftriaxone Other features: Cardiac: 1•/W/IW heart blocks Neurology: Aseptic meningitis Bell's palsy/foot drop. 70. 22 yr. old presents with c7o wea ness of left foot. Pt. denies any trauma. He ecalls having gone hiking several weeks ago and had noticed an asymptomatic rash hlch had cleared In a few days. He doesn't recall a tick bite. /E: "'power left foot, "'reflexes left foot. Dx: -7 hA>t d..>Np 2' ~Me olts ..J'~ 1f ) Stage Ill disease occurs months to years later and presents as monoarticular arthritis or chronic neurologic syndromes. J 71. Pt. went hiking In North East on Friday and found a tick attached on Monday ornfng. No rash, no symptoms. w.t.d ) A. Observe f- C < 2 ~ ) ) I JY'Doxycycline ( ~c. I( 4 '( ~" -t _, ~Y< d.J:>)Cj Q ttcc.L. -jw ) 2t., " ) 3-'"\-<.. '1).;,~ 2W"':j I d..o~ ) 72. Pt. goes hiking In Northeast for lr<f watclllng. He presents wit facial palsy. xam reveals clusters of vesicular eruptions over his auditory canal. Most likely Ox? 7 'Df\JA vi~"\.0 ) ) Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 229 0.73. A 40 yr. o ld woman was referred to you with a rash with partial central clearing and you treated her with Doxycycline for 3 weeks. The rash got better, but she had lllalaise so she went to an Urgent care center and received Doxycycline for a couple of weeks. She followed up with her primary care physician who ordered serologic testing nd found 7 of 10 lgG bands positive and all bands positive for lgM. he Pt. is referred to you again . Most likely diagnosis? A. Recurrence of Lyme Y ,Post Lyme syndrome w.t.d for the above Pt.? A. Do spinal tap B. Start i.v Ceftriaxone ~eassure that she has received enough treatment for Lym e disease. Q74. Pt. presents with tick attached. w.t.d? -7 place forceps at the base of the tick and lift it gently. p7s. 22 yr. old Pt. hiking in Wisconsin, was brought to the ER with new onset of weakness of poth legs. DTR absent. Denies any tick bite. w.t.d -7Search scalp for tick. Tick paralysis gets better in hours once the tick is removed. 0.76. Elderly Pt. presents with fiery red, well demarcated cellulitis on face. Dx:-7 &~ si peLas Etio: Strep. Tx: -7 ----------------~ c. c.'-' eMf\.) PC.I\J Q77. Female from Singapore, honey colored crusty lesions around mouth and chin. A. Herpes ~ Staph. C. Strep. < elMs~) Strep. throat complicaton? -7 A<-v-1-t. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 230 0.78. A Pt. presents with cellulitis of leg. He is started on i.v 1st generation cephalosporin. 72 hrs. later, the cellulitis gets worse. No brawny edema or bullous eslons. No OM. w.t.d A. Increase dose of i.v antibiotic ~/C cephalosporin and start Baf trim or Vancomycin or Clindamycin. "{ 1,Y. f<J\j:it.\loCj --=-~-- 079. A 32 yr. old with cellulitis on left leg. What would you start? A. Bactrim JY.'Bactrim and Cephalexin 80. Invasive MRSA commonly presents as vKBacteremia B. Meningitis 81. Daptomycln is used for Gram positive organisms Including MRSA (not for Pneumonia). hat would you follow In a Pt. on Daptomycln? 82. Pt. had venacaval filter placement, 48 hours later presents with rythema at Incision site, diffuse rash, hypocalcemia, hyponatremia, creatinine, ~BP, fever. Wound gram stain negative. ox: T"xit ) ) si.y,d:. or ( Strep] early onset<24 h cultures usually(+) Tx:-7 [StaR@ late onset>24 h cultures usually (-) c ~.U."":JW'\. PeN r s~r~(.c.-l 41\.e b.nd.etv'\.vd - 1 ( 2.,.1.) -ft:.u,. --J ( I tl: ) 83. Pt. slipped and hit his leg at the bed railing in the hospital, or a Pt. fishing, ell and scraped his arm and two days later with brawny edema and ~e enderness followed by erythema. Next day with bullous lesions, fever. Aspiration of ullae~ Gram positive cocci. Pt. started on l.v antibiotics. Pt. hypotensive. Pt. is on llndamycin and 1 st gen. Cephalosporin. Dx:-7 ~r' A stnp ~c.v<>-t:."'Wj ~J'C.iCr w.t.d. A. Just Continue Abx B. Call Surgical consult in AM \fl. Call Surgical consult now ) Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 231 Q84. Best imaging study for confirming diagnosis? A. CT scan f MRI QSS. The LEAST likely cause of Toxic shock syn_d_ro_m _e _ is_ _ _ _ _ _ _ _ _ _ _ __. A. Menstruating woman wearing tampons B. Post operative wound C. Breast implant s D. Prolonged nasa l packing for epistaxis ~ Nursing home Pt. wearing diapers. 86. Pt. fishing In Gulf coast/Florida (warm waters) presents with cellullts with hemorrhagic bullae and necrosls. LN (+) Dx : ~ v; bno V~.A.~j-i c..,..s c uvc... dfJ L L:~M. t-c..N ptu-/ pt.. 1' .... s "- J Other features : Liver transplant Pts. at 1'risk with raw shell fish. Tx: Aggressive debridement i.v Ill gen ceph. or Tetracycline/Gentamycin Q87. Pt., a fish tank cleaner presents with non healing skin ulcerations. tarted as a single lesion on the hand and now multiple lesions across the forearm. lopsy of lesion-+ AFB (+) 88. Pt. had a cut while In the water, now the leg Is swollen, he Is septic and he has /o alcoholic liver disease. What Is the bacteria? ~ Ae..,-of"\.D"M ~c,\,.op\..v:!~c. --------------------------------~ 89. Florist7Gardener presents with multiple nodules on tlaniJ and along ttle forearm (lymphatic channels). Dx: Sporotrichosis Etio: Sporothrix schenkii Tx: Local Dz~ it..-.: (A (\.G. -z.&\;.. .[ Disseminated Dz~Amphotericin B L (DM, transplant Pt.s) Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 232 90. Pt. presents with folllculitic rash. History of being In Jacuzzi/bath tub. Dx: Hot tub rash Etio :-7 ps~~ (due to improperly chlorinated hot tubs.) ~91. Pt. with cough, CXR with infiltrates and thin walled cavities. ~ses Indoor hot tub 3 days/week. Diagnosis? A. MTB vr.'MAI ) 92. Pt. receiving chemotherapy develops neutropenia. Develops cellulitis with I ck lesion and central ulceration. ) Tx: Anti pseudomonal ~ lactam+Amg./Cipro. Or lmipenem -7 C~s~ C P~ f"''..'::JX if\., ) ) ) ) ) ) ) ) 93. The LEAST likely about Pseudomonas aeuroglnosa is A. Can cause malignant otitis externa in DM B. Can cause Osteomyelitis in nail puncture wounds C. Can cause Endocarditis in IVDUs D. Can cause Sepsis in Neutropenics E. Can cause Ecythema gangrenosum F. Can cause Hot tub folliculitis Can be treated with Ampicillin-sulbactam .Ji· ~94. 50 yr. old HIV Pt. presents with vesicular lesions on one side of face including ~xternal auditory canal. c/o severe burning pain. Scraping from vesicles !-+multinucleate giant cells. w.t.d ) vf( i.v Acyclovir B. Doxycycline C. i.v Ceftazidime Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 233 095. A Pt. presents with complaints of burning sensation over the right forehead for ast 36 hrs. xam reveals hyperesthesia over the right forehead and a single vesicular lesion on an rythematous base on the tip of right side of nose. ~hat is the most dreaded complication in this Pt.? t --------------------------------------~ -7 Zoster Ophthalmicus Who will you refer this Pt. to? A. Dermatologist Ophthalmologist JV' 096. Above Pt. is started on Valacyclovir lOOOmg tid, slit lamp exam reveals o corneal involvement. Continues to have severe pain and cant sleep. w.t .d A. Change from Valcyclovir to Acylovir \)¥.' Add prednisone C. Capsaicin cream 97. Above Pt. 1 week later, with post herpetic neuralgia. Best medication? > Gabapentin Single dermatome-? C..:>Ah <t i .rSlc.k"" >2 dermatomes-7 C.lll"\tc£t 't Herpes zoster with single dermatomal rash. Symptoms: ill...b,a; . -7 treat with Valacyclovir, Acyclovir or Famciclovir >72 hrs. -7 supportive care. > 72 hrs. in HIV -7 Treat > 72 hrs. Age> 50 yrs if new lesions appearing ONLY then treat L p99. A 65 yr. old man gets a Herpes zoster vaccine. What precautions for caregivers who have never had chicken pox? Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 234 Non Tuberculous mycobacteria: MAC/Kansasii 7 commonest Lung infection, Hot tub lung Abscessus/Chelonae/Fortuitum 7Water use, Cutaneous or Implant infections. Osteomyelitis can also occur Marinum 7 Fresh and Salt water Non healing cellulitis in Pt. who has pedicure 7 M-� Y" i I'\ WV). 0/ M. Non healing cellulitis or infection post breast implant 7 M. · \ \ \chicken PoJ Small Pox Chest and back Rash7 Vesicles7 pustules evolve concurrently Rash7 Vesicles7pustules evolve in crops. Found in diff stages. • • • Highly contagious Pt. considered contagious until all scabs formed and fall off. Direct contacts who develop fever should be quarantined immediately Vaccine available. 100. Pregnant 24 yr. old, brings 5 yr. old daughter with chicken pox. She is worried bout her 10 year old son, who is scheduled for chemotherapy for a leukemia. The ew Ph slclan assistant cant remember if he had chicken ox In childhood. w.t.d \ Child with Immune deficiency7 ) Pregnant Mother7 ) Physician assistant7 Chu"- ) ) ) Alosc.e..r.JLW Pharynx & face7 Extremities & Trunk • J ] I=0( ti.Li t\..\.(Y\... Cl--Lc.1� V Z 1 Ci t t� tt.... -' 7 1 �w, (Highest risk) V z.z.c, c...,, 4 101. Pt. with lesions on extremities In different stages (veslcle-+pustule,eschar). ost llkel com�llcatfon of this Pt. is -�-�A. Meningitis B. Encephalitis .j/."Pneumonia ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 235 102. A nurse/Resp. therapist presents with vesicular lesions on the finger with erythema nd tenderness. She has a et kitten at home w�How Dx:7 Heri0e.t.:� Etio:7 Hure..J' si¥ex ('])NA ) Tx: Acyclovir Q103.-Voung Pt. presents witn fever, malaise, sore tnroat followect 6y vesicular lesions on tile �ongue, buccal mucosa, later followed by painful vesicular lesions on the dorsum of hand and feet. 104. Pustules on the palms after petting at a fair or petting a wil ost likely diagnosis? og. vP( Monkey pox B. Lyme disease OS. A wee a er returning rom I ngan stay ng a a g e eva on ca n n ashington state (Northwest), Pt. presents with recurring episodes of fever accompanied by variety of other manifestations, Including headache, myalgla, arthralgia, chills, vomiting, nd abdominal aln 7 8orre4� Hu fV\..S ii is a tick borne illness present in the western US. ( 'to Se� te. ) Animal Bites and Scratches 107. Pt. bit by a cat. w.t.d Also for Human bites and dog bites Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 236 Q108. Pt. with fiistory of splenectomy for ITP plays witfi pet Clog anct sustains a scratch/laceration. Next morning hy otensive. ��---' 109. Pt bit by a cat several hours ago present with a swollen hand. Most likely? A. Capnocytophaga canimorsus (DF 2) B. Eikenella Corrodens -t AJ:f .j-t st j-i5h.t .._,R:: Pasteurella multocida 110. Pt. with tooth ache and (+) sub mandibular LN. PCN allergic. w.t.d? A. Levaquin/Cipro. B. Azithromycin ..J2. Clindamycin J 111. Pt. wlttl a cat presents wltfi pustular esion on tlanct ana tender lymph node n the axllla. Tx: Doxycycline/Erythromycin J �112. HIV Pt. presents with multiple nodular lesions on extremities. AST1', ALT1'. Biopsy-+ modified sliver stain (+)/ warthtn starry organisms (+) Jver-+ pellosls hepatis (cystic spaces with blood). ) Etio: Bartonella henslae ) Tx: Doxycycline/Erythromycin Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 237 Q.113. Pt. with HIV, T cells 150 cmm, tiomeless, lives in stielters and streets, presents with severe itching and excoriations of skin. Pt. Is disheveled. 'AST/ALT elevated, spiking tem(!s. Holos stollc murmur at apex. B _l_ o o _d _c � l_ s_ ne _,g,._._____ � n v<\f 1:o "e tL4fi.I' Dx: -, et\.<Mc. OJc{;.UJ i 80J to"-<-IG< . <\ l.Uf\tc..l\.c.. 0 (Trench fever) Q.114. You would treat exposure to all of the following with Rabies Immune globulin and vaccine, EXCEPT A. Dog bite B. Bat bite/scratch C. Fox bite D. Racoon bite Y, Rat bite Q.115. Pt. presents aft:er a dog 6ite in Mexico. He tias had Rabies vaccine a year ago. w.t.d? A. HRIG � Vaccine x 2 doses C. Vaccine plus HRIG (Ma lariaJ P. falclparum resistant P. falclparum sensitive and others Almost every where Parts of Caribbean, Central America, Near East. Prophylaxis Start 1 week prior to departure and 4 weeks after arrival into the U.S me td \..0 1�� Treatment Quinine sulfate + Doxy Or Atovaquone/Proguanil (Malarone) Quinidine gluconate + Clinda Or Artemisinin-Amodiaquine Or Chloroquine + Primaquine Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 238 ( 0 ro ro ro ro 'L: ·c ro ro I '\, 1 � � ro ) 1 <lJ > ..... c Q) V) Q) 0:: Q) Q) ·c ro :e � ro � ·� � y ..... c � � � ·� . ::J rr . ::J Q) rr o:: 0 0 ' ''- ·.p 0 0- - - ::J 66� eoo u ·- E ) QJ "'C c LI.I 0 v "' J ·- ' I � L. "' "' ) ) ....._ JI� 5 .- � t J 1 J' ..0.. j� I � N J � j > v ] = • ..,,� .JI. ..., .Jl I 3 f 3 d \J a � r j ...Q J z Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 239 116. Pt. returns after a trip to Nigeria 2 wee s ater presents witll complaints of haklng chills and fever, with drenching sweats and then becomes comatose. . b is llg. Retie 4% lood smear shows gametocytes. he Pt. Is diagnosed with cerebral Malaria. ou would elect to treat with Chloroquine A LIV Quinidine gluconate + Doxycycline 117. Pt. presents with fever and chills after returning from Nigeria 4 weeks ago. hat Is a more sensitive test for malaria? A. Blood smear Antigen based malaria rapid diagnostic test @ 118. What would be the best management for the above Pt.? A. Quinidine gluconate Artemether-lumefantrine � 119. Pt. <lid not ta�e mefloqulne regularly for prop ylaxls and now has developed alarla. Best mana ement? A. Mefloquine '1'N.A.. c. � Q) Malarone (Atovaquone/Proguanil) Ol\U. d.c.l� Mefloqume not used in Cardiac conduction defects 120. A Pt. presented to an ER In NY with fever, rash, myalglas, arthralglas and etro orbital headache for the past several days. He just got back from a vacation to he florlda keys and Miami. Temp Is 101.6f, HR 96/mfn. alnt morbllllform rash on his trunk with a few petechlae on his arms. BC 4500 Platelet count 55 000. Most llkel diagnosis ? �� ---' A. Malaria vB". Dengue Q121. Pt. presents with lower abdomlna pain and fever. Pelvic exam reveals .w.t.d dnexal tenderness cervical motion tenderness and a retained IUD ��- Actinomyces delicate branching filaments and sulfur granules. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 240 I 122. Pt. with extensive dental caries presents with tenderness over the mandible. /o difficulty opening mouth. O/E: Brawny edema over the upper neck with tenderness. Dx:� �ctwi�'; (.)�A..S> Etio: � Pe.pwt..cpt:.::>�o� ��e.A ,...,1:. c..no.ev-obe.J Tx: Amoxicillin-clavulante/Ampicillin-sulbactam Neutropenlc Fever ) Pt. with neutropenia absolute PMN<SOO s/p chemotherapy presents with fever. Pt. is started on G-CSF. w.t.d. l Cover gram negatives (pseudomonas with a � lactam like Ceftazidime or efepime ith Aminoglycoside (Fortaz®) Or (Maxipime®) 1 �� (-> If�"" j'Jf lmipenem Neutropenia: • Staph aur. • Pseudomonas • Aspergillus l If i.v line present, add Vancomycin {for MRSA) If no i.v line and fever> 3 days, add Vancomycin l ) ) If continues to spike 7th day, Add Amphotericin B to cover fungal infections l (Ambi some®) 123. Which anti fungal has shown to improve mortality when prophylaxed in a Pt. Ith ost chemotherapy neutro enia? 1 ) vv."Posaconazole (Noxafil®) B. Caspofungin (Cancidas®) Transplant infections Herpfs reactivate lm MRSA Line sepsis Pneumonia Viral, Atypical bacterial, Fungal °"'"'�··2m ""'� Fungal 4m 3m Sm Gm Cryptococcus CMVf MTB, Listeria Candida " EBV Nocardi� , BK virus ( �cl.Ai,t """'J cv • 0i>»tf ., 1.01"' !I, 1'1f...�t.i>U.� v c-t, �''°"' Ac..<cl :14tt Aspergillosis �vJ<.I\ I(,. I . ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 241 Q124. Pt. s p chemotherapy develops neutropenia and fever. Pt. is startea on Vancomycin and Prlmaxin, 5 days later still with high fever. CXR/CT7 Left lower lobe infiltrate with dense core and rim of ground glass appearance (halo sign). The most likely cause of this disease 1s A. Mucormycosis vB':' Aspergillosis C. Strep. pneumo D. Methicillin resistant Staph. aureus E. Pseudomonas Creat is 2.2. what is best management? �''t-:4.-J A. Amphotericin CM. lG� ..,.,s. Voriconazole ( � Ruvl iv--('..;., ' ) Q125. The most likely that will be positive in the above Pt.? A. Serum �-D-Glucan v-fi. Serum Galactomannan 126. A 55 yr. olct un ergoes renal transplant. He develops rejection couple of weeks later on lmmunosuppreslve drugs, so another suppresive agent such as Tacrollmus Is added. everal months after transplantation, ground glass intranuclear lncluslons ere seen in urine. Most likely diagnosis? A. CMV �BK (human polyoma virus nephropathy) Q127. 2 months after transplant, Pt. presents wlttl fever anCI cougli. ot responding to Levofloxacln (Levaquin•) for 1 week. ABG reveals P02 of 65. XR shows bilateral Interstitial Infiltrates. CMV (+) before transplant. ung biopsy reveals lntracytoplasmic Inclusion bodies. Tx with: �Ganciclovir (Cytovene®) and CMV immuneglobulin B. Acyclovir C. lmipenem D. Foscarnet (Foscavir®) \Nocardia!]lung, skin and brain lesions. Filamentous and branching, Gram (+), weakly acid fast positive. Tx: Sulfonamides Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 242 Q128. 40 yr. old HIV (+) with T cells of 25 and viral load of 225,000cps/ml presents with c/o fever and cough. CXR� thin walled cavity In the Right lower lobe. A BAL Is done� grows CMV, Candida, HSV and Nocardla. You would treat the Pt. with A. Ganciclovir for CMV B. Fluconazole for Candida C. Acyclovir for HSV �Trimethoprim-sulfamethoxazole (Bactrim®) for Nocardia E. No treatment at this time. \ Q129. Pt. with liver transplant on high dose steroids and lmmunosuppresslves OR LE Pt. on steroids presents with cough, fever, nausea and vomiting. Exam of skin with a nodular lesion. CXR reveals nodular lesion. CT Brain reveals a ring enhancing lesion. Most likely diagnosis is A. CMV B. EBV � Nocardia Osteomyelltis ) ) ) Hematogenous Contiguous spread Diabetic foot 7 } Prosthetic implants7 Long bones (children) Vertebrae (adults) Polymicrobial flora St.tph. ep I } c..f c..vlL.:... N } 7Vanco. + Gentamycin + Rifampin 7 Necrotic bone (Sequestrum)7 Chronic Osteo. 7 cl eb.....;c.\.e.IYW\t ) Sickle cell with Osteo. 7Salmonella incidence increased > Staph Q.130. Most common cause of Osteomyelltis In US Is 7 Staph. aureus Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 243 CI k h h ti h 131. Older ad ults with >a i cteremia, presen ng ater wit fever • an low ac ac e wit oint tenderness•. w.t.d Blood cultures, Imaging with CT/MRI, Antibiotics for 4-6 weeks. 132. How to diagnose Infection in prosthetic hip implanted 3 mths.--ago? ��-- vCCT guided aspiration and culture B. Bone Scan C. WBC scan D. MRI Q133. Pt. who 11ad a UTI with blood cultures positive. Tx with i.v abx, on TLC, 3 days ater with spiking temps, confused. Hyper-reflexla in the lower extremities and ypo-reflexia in the upper extremities. CSF: Glu 80 Protein 295 WBCs 75 with 60% PMNs. Most likely Ox? ��-- �ina epidural abscess 1 B. Meningitis 134. Pt. slp cflemotflerapy, no Hx. of metastasis, recovering from neutropenta Ith high fevers. CT scan abdomen with nodules In the liver. ��-Dx: -7 Hepc.t.iJp W\Ac. C.c./'\c;U�c. r;:s .. . 135. Pt. with poorly controlled OM with bloody nasal discharge. /E: Black necrotic spot near nostril. Redness of one eye. iopsy of lesion� filaments branchin at--�--��--� rl ht angles --��------ > Amphotericin B 136. Pt. with CRF on hemodlalysis with recurrent Staph. aureus Infections duding MRSA Infections from infected catheters, successfully treated � Ith Vancomycln l.v. in the past. Recent infection with Staph. not responding to ancomycin for 3 days. w.t.d -7do an epsilon (e-test) to accurately measure MIC. If > 2, then GISA (Glycopeptide insensitive or Vancomycin insensitive Staph aureus). V1.SA w.t.d -7Treat with _______ or Quinupristine/dalfopristin (Synercid0) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 244 Q137. Pt. is started on an antibiotic for pos. blood cultures of Enterobacter. Pt. defervesces and feels better, but on the 61h day, Pt. starts spiking temperature and blood culture is again positive for enterobacter and now it Is resistant to the antibiotic. what antibiotic was the Pt. receiving? Q138. Pt. with Enterobacter infection sensitive to cephalosporins, few days later, after treatment with cephalosporlns, Enterobacter becomes resistant to cephalosporlns. what happened? -?plasmid mediated resistance A kA (J'BL,{_Mu�ts ) w.t.d -7 Meropenem > lmipenem > Ertapenem (Merrem®) {lnvanz®) Q139. Pt. growing ESBL Klebsiella resistant to lmipenem. w.t.d? ) 140. Pt. w1tti UTI with ESBL sensitive to on y Collstin an Tigecycllne (Tygacil•J. hat is the best management? v( Colistin B. Tigecycline c. u11 '1> ]l\'i,J' \ol 't") ) ) 81.u k"- olw �,. i " ) LC!cd..-'."J c C. IH-<- •J J, �� t.'.c. F b.-op,!/" --�� ( C 141. Best management for Stenotrophomonas (Xanthomonas) maltophllia? • � 13 c. (. t..; ""' d..t.c t Which organisms can be treated with abx and without discontinuing the central enous catheter? 142. 143. What is the best way to do blood culture in a Pt. with triple lumen Cath.? A. through catheter B. peripheral blood Timed paired cultures from peripheral blood and catheter i}! ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 245 144. Pt. in ICU starts spiking temps. of 102 F. i.v Abx are started, the triple lumen th. Is changed over guide wire and the tip Is sent off for culture. ext day the cath. tip culture grows gram neg. rods which is sensitive to abx. Pt. feels better and the temp is about 100.5 F. w.t.d A. Continue antibiotics \NI� f-r"P... ,...wlk. st<.� Replace the triple lumen catheter and continue antibiotics flt! Change the antibiotics � 145. Pt. in ICU with triple lumen catheter inserted >3days ago. ow with hi h fever and se sis. Dx: Nosocomial line sepsis. w.t.d 146. Best way to prevent TLC infection? A. Antibiotic i.v pMaximum barrier protection while insertion 147. Best way to prevent nosocomlal Infection outbreaks? 148. Best way to prevent Vent. associatedpneumonia? ��-- -? b\.tvc.k Be.c:L ) � s' _, c"'Lo,...i.-ex;ct,;r... f'Nl"'fr.. wc..i"'-, 11w W"<ti-\....1 ET .rv.ct,.:""-' Q149. 15 yr. old presents with low grade fever, sore throat, fatigue, myalgla and cervical ymphadenopathy. Exam reveals petechlae over palate. No posterior phalangeal lesions. Monospot test Is negative for heterophlle abs. w.t.d next? A. Glucocorticoids B. RPR J/. EBV Viral capsid antigen {VCA lgM) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 246 150. The above Pt. received Ampicillin and gets a morbilliform rash. his Pt. most likely has A. Strep. throat B. Measles ve'."rnv 151. Pt. with LN (+), Monospot test (+) with increasing shortness of breath. /E: Lar e tonsils. w.t.d 0152. Pt. with Infectious mononucleosis an left: upper quadrant pain. w.t.d 7CT scan abdomen. Complications7 Splenic rupture. Tx: Splenectomy ) ) \ I 153. A Pt. In t e MICU on l.v TPN for severa <:fays wlttl fever an<:t c Ills an<:t C:teve ops phthalmltls. Most llkel etiolo Is 'vi('. Candida B. Aspergillus C. Staph. aureus D. E.coli Candida in BAL ) ) ) Asymptomatic Candiduria Asymptomatic Candida in blood ) A. Restart Fluconazole J3-:' Start Caspofungin C f'/O �""-t� tc.lt) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 247 Anthrax: Skin form: necrotizing form rare, animal hides GI: in estion with severe diarrhea. Inhalation Non specific symptoms: Headache, chills, Vomiting, SOB emorrhagic meningitis G) Preterminal events. CXR with widened mediastinum } � @ (VO i"'!tH�c.t< \t � ejt'-' t . �"""' P ' Treat with: Fluoroquinolone or PCN. Other characteristics: Person to person transmission DOES NOT occur. * Isolation NOT required. Blood culture show gram (+) bacilli. Prophylaxis shown to be effective One day after exposure. Vaccine available for defense personnel. 155. Farmer goes hunting for rabbits and gets tick bites. Presents wit ulcers, evers, chills, myalglasand pneumonia. Tender Inguinal and femoral lymph odes and conjunctivitis. Gram stain reveals gram neg. pleomorphlc organisms. Ulcers +glands = ulceroglandular fever Lab test7 wound biopsy or serology Tx: Streptomycin for 7- 10 days. 156. Good Samaritan removes dead deer from highway In Arkansas Oklahoma. resents a couple of days later with tender e�hematous papule that became !cerated with black eschar. Most likel or anlsm.---- 157. A 45 yr. old presents with headache, cough, myalgias. Temp. 101.5F. CXR with lght lobar Infiltrate. He was watching a tennis match at US Open In NY. Two other eople present with similar symptoms. One of them dies after admission. ost llkel dla nosls? A. Anthrax vff. Tularemia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 248 158. 2 days after super bowl there is an increased number of people presenting to the ERs n the area with fever, cough, chest pain, hemoptysls and prostration. Several eo�le have died within 24 hrs of admission. Most llkel'l dla nosls? A. Anthrax B. Tularemia u/Plague 159. What is appropriate for the above Pt.? \.fl('Droplet isolation - Doxy. for Pt.- Doxy for exposed close contacts B. Airborne isolation - PCN for Pt.- PCN for exposed close contacts } ) ) ) I } ) 160. Which is most commonly aerosolized? A. Rickettsia prowazekii B. Rickettsia typhi C. Brucella vef. Coxiella burnetii (Q fever) 161. A randier wit fever, cu ture negatvi e endocardltis. CTYoalot>ulins positive and Hep. C e alive. Most likely diagnosis? A. Q fever vff'. Brucella 162. Q fever Is Infected most lt<ely by A. Food handlers ) ) � Vets, Abattoir workers, farmers handling infected goat, sheep & cattle. C. Immigrants 163. young male presents w t fever, myale as an petectlla rastraffiri ret1,1rnlng rom a rafting trip from Puerto Rico or Costa Rlca. He Is tcterlc with mildly elevated ransamlnases and ve hi h t.blll. what Is the dla nosls Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 249 Matching � 1. Most likely inhaled-7 resp. symptoms with atypical pneumonia, A. Q fever _fl.2. Most commonly with contaminated soil and animal products. B. Brucellosis �3. Caused by Rickettsia C. Leptospirosis headache & fevers. �4. Skin contact or aerosolized-? RE system: Splenomegaly, hepatitis, D. Erysipelothrix LN (+) with fever and drenching sweats � 5. Gram neg. coccobacilli L6. Sewage worker contact-7 fever, hepatitis, jaundice with conjunctiva! suffusion and liver hemorrhage. !::__7. Vet with fever, mental status change, jaundice, Renal failure, ecchymosis _8. Doxycycline A Gt']) _l_g, Butcher with fever, HA, palpable spleen tip. ..1._10. Fisherman or fish handler with burning or throbbing pain with erythematous lesion on the finger. ' 164. Pt. tal<es a wall< on a l>each In West F or a an presents w t lld shortness of breath. No wheeze or rhonchl. t. found some dead fish on the beach. Most likely diagnosis? caused by Karenia Brevis Q165. Pt. presents with diarrhea, high fever, non productive cough, has hyponatremla. e drinks from ta water. Most consistent with w<' Legionella B. Pseudomonas C. Mycoplasma Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 250 166. A sewage worker who loves to hunt deer and squirrels, presents with fever, at1gue, abdominal pain and generalized aches. xam reveals conjunct1val suffusion. A few scrapes on his hands, but no ulcers. abs Reveal: WBC 9,500/cmm PK 765, Bllirubin 6.8mg/dl ST/ALT 58/80, BUN/Creat 110/8.0 he best management of this disease is A. Azithromycin � Doxycycline Most likely etiology of above is A. Francisella tularensis (Tularemia) vK Leptospira interrogans (Leptospirosis) C. Brucella melitensis (Brucellosis) D. Coxiella burnetii (Q fever) } ) 167. 21 yr. old Iraq or Afghanistan veteran presents with 3cms lesion on arm; !cerated with irregular margins, eschar with surrounding erythema. ) ) 168. 40 yr. old Immigrant from rural Turkey or middle east with enlarged liver. Most likely ) ) ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 251 Chart 6-6 Stand. \..{tW f"\c.J' Ii: 3 • "f a<.. Droplet '1d pt Contact Airborne CMV colitis MRSA v' VRSA,V R E v HZV ,_ HZV >2 derm '1 - v v' C.diff Scabies v vc.iY'"ltc."' ' ' v - - : v Measles v ,_ Varice Ila v' ...__ v v MTB - Neisseria v -- - Influenza ,___ Plague - -- - -- v v - - HIV Epidemiology • • • 850,00-950,000 cases in the US 1'MSM Anal receptive intercourse with highest risk. Other STDs increase risk of transmission of HIV Contaminated blood products • • 1 in 500,000 to 3,000,000 screenings Nucleic acid testing used to screen Mother to Child • • • Mainly during delivery Postpartum with breast feeding <2% with ART Occupational risk • For high risk exposure, recommend 1 Protease inhibitor + 2 NRTls Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 252 0.169. Pt. with HIV on ART and undetectable viral becomes pregnant. w.t.d -7 Continue ART to term 170. She insists on breast feeding the baby. W.t.d? -7 Recommend her to continue taking ART to maintain undetectable viral load -?to prevent mother to child transmission of HIV ) ) ) 171. A Pt. presents about 3 weeks after high risk sexual encounter or an IVDU presents wit omplalnts of fever, sore throat, rash. xam reveals lymphadenopathy including cervical, submandlbular LN. phthous ulcers +. Atypical lymphocytes seen on peripheral blood smear. IV ELISA (-) onospot or heterophlle Ab test (-) w.t.d next -?HIV RNA PCR (Viral load) to rule out Acute Retroviral syndrome. 172. Nurse with needle stick exposure to a Pt. witllHIV or Pt. with lligll ris ) actors for HIV. w.t.d \ -?Baseline HIV ELISA test for documentation purposes -?Start treatment with 1 protease inhibitor+ 2 NRTls for 4 weeks. Repeat HIV test. If negative, d/c meds. ) ) ) 173. Sexual assault victim by IVDU unknown HIV Hx. 24 hrs. ago. W.t.d -7 Offer 1 protease inhibitor+ 2 NRTls \ ) ) J Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 253 Opportunistic Infections In >200Icells: T Cells 600 MTB>Cryptosporidium Community acquired Pneumonia: Strep. pneumoniae PPD (+) : Tx PPD >5mm with INH for 9 months. Kaposi's sarcoma: Dark brownish plaques on legs, Pulmonary infiltrates, Pulmonary nodule: purplish red on bronchoscopy. HHV8 � Lymphoma 1>�"'"'0yv.�L.'"-' In <200Tcells; Pneumocystis Jlroveci pneumonia; dry cough >1 week, shortness of breath, gradual onset and progressive. ABG with hypoxemia. LDH 1', CXR: bilateral interstitial infiltrates or Pneumothorax Dx: Sputum for silvs,r methenamine staining (+) (sens 55-92%) e BAL with stain (sens 97-100%), Transbronch. biopsy (100%) Tx: Trimethoprim-sulfamethoxazole (Bactrim) Allergy to Bactrim7i.v Pentamidine OR Clindamycin + Primaquine If P02 <707 Add steroids 174. What Is tile t>est test In a suspected mild to moderate ctisease w ere BAL s not planned In the diagnosis of PJP? A. Serum LDH J¥. Serum � - D-glucan 175. Above Pt., couple of <fays later on Bactr m, and creatinlne goes up from 0.8 OK. w.t.d o 1.7mg/dl. Urine out put ��--�� 7 Continue Bactrim. Q176. Ttie Increase In creatinine reflects wtiat? Vt;(Decreased tubular secretion of creatinine by Trimethoprim B. Decreased Glomerular filtration rate. 177. Pt. with PJP on Bactrim develops rash and spiking temps. w.t.d 7Change Bactrim to i.v pentamidine or 7Clindamycin + Primaquine Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 254 178. Pt. on Bactrim proptiylaxis Clevelops reaction. w.t.d �� ....... -7 Change Bactrim to Dapsone OR Atovaquone ( be. be y; ot-: f ) 0179. Wtiic arug wou a cover oxoplasmosis PJP propfiylaxis ana seconaary prop ylax1s or \,}(. Dapsone + Pyrimethamine B. Dapsone Candidiasis: Oro-pharyngeal, white patches adherent to oral mucosa. Tx: Fluconazole Recurrent Candidiasis on Fluconazole-7 ltraconazole suspension ) C � ut 0 f'f "t......v.rt..:. NU-c �(/\ 180. HIV + with T cells SS with severe heart 6urn. w.t.CI -7 Empiric oral Fluconazole for suspected Esophageal candidiasis. ) ) l ) -7 If no response, then do upper endoscopy. n <100 T cells: HIV Pt. with CD4 of 45 cells presents with headaches for the past couple of weeks not relieved with analgesics. CT scan head negative. w.t.d -7Spinal tap to R/O Cryptococcal meningitis. Headache may be the only presentation without meningeal signs. Spinal tap: India ink (+) in 75% and crypt Ag (+) in 90%, in blood and CSF. Tx: Amphotericin B + 5 FC induction and then change to long term Fluconazole. n< ) cells: MAI: Fevers, hepatomegaly, lymphadenopathy Alkaline phosphatase 1' Blood cultures + for AFB Tx: Clarithromycin + Ethambutol +/- Rifabutin (Biaxin®) (Myambutol®) (Mycobutin®) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 255 <25 CMV retinitis: blurring of vision Tx: Gancyclovir {Cytovene®) Cidofovir {Vistide®) Foscarnet {Foscavir®) Progressive multifocal leukoencephalopathy White matter lesions caused by JC virus. Also seen with use of Natalizumab {Tysabri® for MS), Efalizumab {Raptiva® for Psoriasis), Rituximab {Rituxan®), lnfliximab {Remicade®) Prophylaxis against Opportunistic infections: <200 T cells: PJP7 Bactrim, Dapsone, Atovaquone <50 T cells: MAl7 Azithromycin 1200mg/week or Clarithromycin 500 bid 181. Pt. wlttl T cells of 25 starte on ART, Bactrlm and Azlthromycln. 6 mths. ater T cells are 150. w.t.d 7 d/c Azithromycin for MAI prophylaxis. 182. Above Pt. 4 mths later, the T cells are 250. w.t.d 7 d/c Bactrim for PJP prophylaxis, even if the Pt. had PJP in the past. Q183. Which of the fol owing ftnCllngs ru es out Cryptococcal meningitis A. Normal Glucose �· Negative Crypt Antigen in CSF Ring enhancing lesions: • • • Toxoplasmosis Brain Abscess Lymphoma Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 256 CT scan show ring enhancing lesion. w.t.d -7Treat for presumptive Toxoplasmosis with Sulfadiazine and Pyrimethamine and repeat CT scan of brain in 2-3 weeks. -71f no change in size of lesion, then do biopsy of lesion for definitive diagnosis and treatment. CNS lymphoma is seen in Pt.s with < 50 T cells. EBV antigen is (+) in almost all of them. In peripheral lymphoma which is mainly non Hodgkins B cell lymphoma, EBV is (+) in 40%. �185. HIV Pt. with T cells of 45 and viral load of 150,000, presents with weakness of left leg. CT scan of Head shows a ring enhancing Lesion, CMV (+). rhe LEAST likely cause of the lesion Is ) ) A. Toxoplasmosis B. Lymphoma C. Brain abscess $. CMV(CMV usually has biventricular enhancement) 186. Ml ale age Latin American Immigrant living In the U.S Is brought with recent onset o elzures. brain-+ multiple cystic lesions with calcification. mild hydrocephalus present. ) \ ) ) ) Tx: A. Albendazole (Albenza®) ...,-8". Phenytoin (Dilantin®) C. Steroids ) ) ) ) 187. A Hog farmer presents with fever, myalglas. Exam reveals perlorbltal edema, splinter nd conjunctlval hemorrhages. Muscle tenderness. No murmurs. EosinophJl count 8% and DH 400, CPK 700. What will establish dla nosls? A. ECHO B. blood culture Y,Muscle biopsy/Trichinella antibodies ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 257 0188. The most common cause of Pneumonia in a Pt. with T cells of 150 is A. PJP Y, Strep. Pneumo 0189. Pt. is diagnosed with HIV. T cells are 45 and viral load is 105,000 cp/ml. He is symptomatic. He is started on a regimen of Nelfinavir (Viracept®), Lamivudine (Epivir®), tavudine (Zerlt®) and bactrim. What else would you start on this Pt. at this time. A. Fluconazole 200mg O.D JY."Azithromycin 1200mg q week or clarithrorncyin SOOrng bid C. Ganciclovir for CMV prophylaxis D. Sulfadiazine for Toxoplasma prophylaxis Indications for starting Highly effective anti retroviral therapy (ART) • • • • • Viral load > 100,000cps/ml T cells < 500 Acute Retroviral syndrome Opportunisitic infections Pregnancy Chart 6-7 Entry lnh. • Enfuvirtide (Fuzeon®) • Maraviroc (Selzentry®) LC RS '""-'i.."t-1 c.1-tu:. c.c.�r b� Protease lnh. • Darunavir (Prezistae) • Tenofovir (Viread®) • Lopinavir/Rit. (Kaletra®) • Emtricitabine (Erntriva®) • Nevirapine (Viramune®) • Atazanavir (Reyataz0) Zidovudine (Retrovir®) • Entravirine (lntelence®) Abacavir (Ziagen®) • Rilpivirine (Edurant®) t)O 1' "lt\ • G;\:.�i,.:. • 1" Tipranavir (Aptivus®) Fosamprenavir (Lexiva®) • j.t.;� Jf;.rM, lndinavir (Crixivan®) 1!'1\1.�""' i�>J;t.,,,. Ritonavir (Norvir®) lntegrase lnh. Once a day Co mbinations NNRTI • • • • Efavirenz (Sustiva®) • . Raltegravir 1. Atripla® Efavirenz (lsentress•) + Emtricitabine + Tenofovir Dolutegravir (Tivicay®) 2. Complera® Emtricitabine + Rilpivirine + Tenofovir • • 3. Stribild® Elvitegravir + Cobicistat + Emtricitabine + Tenofovir Lamivudine (Epivir®) t'!M,..pc� Didanosine (Videx®) Stavudine (Zerit0) I -I - - . ,f( f'�r·:-:·.:·:17r-r . � . ; . � . - ---_L_.- -••· . •- NRTI Nucleoside Reverse Transcriptase inhibitor NNRTI= Non nucleoside Reverse Transcriptase inhibitor = Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 258 Side effects lndinavir Atazanavir Ritonavir -? Hyperlipidemias, Insulin resistance, Liver toxicity Lipodystrophy (fat accumulation behind neck, abdomen and fat wasting in thighs and legs). -? Nephrolithiasis -?1' Indirect bilirubin -?1'TGAs,1'Chol. NNRTls Nevirapine Efavirenz -? Rash, Steven Johnson rash - ? Rash, Steven Johnson rash, Liver toxicity -? CNS effects; confusion, abnormal dreams, agitation Pis NRTls Abacavir -? Lactic acidosis, hypersensitivity reactions, Neuropathy -? Life threatening hypersensitivity, fever, rash, vomiting, malaise, lactic acidosis. Didanosine (ddl)-? Neuropathy, Pancreatitis Stavudine -? Neuropathy, lactic acidosis Zalcitabine -? Neuropathy, Pancreatitis Zidovudine (AZT)-? Anemia ( 1'MCV), neutropenia. ( 131"\. ""f?f>"� w-) Tenofovir -? Renal insufficiency t- H'- ) ) ) ) ) Drug causing bone marrow suppression - ? AZT 190. Best statin for Hyper I ldemtas In HI -7 Pravastatin (Provachol®) 191. Which statin NOT to use In HIV -7 Simvastatin (Zocor®) -=-=--=- '="='" ) ) Flash back: - - ------------- Metformin- Drug of choice - -�---�--�-�---y �p_erg _ _ly_c_em _ _la ��-�--� in Hyperglycemia due to ...-.--..--.- � -- - - � _____ -? Glitazones / Metf>'""""" • • • • -------- ----- • -...-tiiii """"' c?.-n_,,A=1'1:-:se__ o ... _u_ t_ ast .,,_.,_,.._,... Type II OM PCO Lipodystrophy -7 Beclamethasone ) -7 Raltegravir (lsentress®) Insufficiency? 195. Drug causing renal -------------------------A. Lopinavir B. Efavirenz dTenofovir Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 259 Q196. HIV Pt. has been on ART with lndinavir, Zidovudine, Lamivudine for 3 years. He has recently noticed that the back of his neck has a large lump. O/E: 'buffalo hump' present. Pt. obese All the following mav be abnormal EXCEPT: A. Lipids B. Blood glucose C. Weight A Cortisol 197. HIV Pt. wit anorexia, letnargy, weigtit loss and dizziness. Hyperpigmentation of skin. P is 80/60 and HR 100 lying and 115 supine. a Is 135 and K Is 5.0 ost likely diagnosis Is A. Lymphoma yE(. Addison's disease Q198. A 33 year old woman HIV + comes to the emergency department because of nausea and back pain. She was started on Stavudlne, Lamlvudlne and lndlnavlr. On examination, the Pt. has left flank tenderness. Her labs presently: K Is 5.2, creatinlne 3.2mg/dl. Previous creat O.Smg/dl Urine analysis: RBCs 7-10/hpf �ou would ..,,K. Discontinue lndinavir B. Administer Captopril C. Schedule dialysis D. Discontinue Lamivudine Other drugs causing renal stones: acyclovir and atazanavir/Ritonavir Immune Reconstitution syndrome: In Pt.s with advanced HIV with low T cells and high viral load. Started on ART, react to latent pathogens due to inflammation (increased immunity on ART). MAl/MTB-7 Lymphadenopathy Continue ART Q199. Pt. with T cells 25 and VL 250,000. Pt. started on ART. 3 weeks later resents with cervical I m hadeno athv.. Dx: Immune reconstitution syndrome to MAl/MTB. ,,A" Viral Load should be done Q month until VL <SOcp/ml and then q3-6 months. / T cell should be done every 3-6 months. / The drop in viral load should be at least 1 log in 1 month and <50 cps/ml by the end of 6 months. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 260 ) ) 200. HIV Pt. starteCI on Nelfinavlr, Lamivudine7 Zidovudlne (Comblvir ). Months post Tx Tcells Viral load 0 120 80,000 3 123 64,000 6 130 31,595 9 135 10,165 12 140 6427 ) ) ) ) ) ) ) ) ) ) ) } ) ) ) ) Most likely reason for above findings? 7 Non adherence to therapy 7 Resistance Or Infected with resistant virus w.t.d for above Pt.? 7 HIV genotyping and change tx accordingly Q201. T e ear iest cnange seen in HIV therapy failure is A. Decreasing T cells JY.' Increasing viral load Q202. Tile earliest opportunistic infection seen n AIDS Is 7 Oral Thrush (is not an AIDS defining lesion) Q203. Pt. is iagnose with HIV and Is started on Norvir, lndinavir,AZT and Epivir. months later the viral load is <50 and T cells 500. Pt. develops pulmonary TB and Is started on Rifampln, Ethambutol, PZA. Repeat viral load 2 months later Is 15,000. he Pt. claims to be adherent. what ha �ened 7Rifampin decreases levels of protease inhibitors. w.t.d ) 7Change Rifampin to Rifabutin (causes less decrease of Pis) OR ) 7Change Protease inhibitors to NNRTI (Efavirenz) ) ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 261 204. Pt. diagnosed with T B and begun on 4 anti T B meds. He Is also concurrently ound to be HIV positive. When to begin ART? �Within 2-4 weeks B. After 4-8 weeks Labs & monitoring disease Once HIV diagnosis is established, then following labs should be done. • • • • • • • • • HIV RNA PCR (viral load ) T cells CBC Serum chemistry Liver function tests RPR Toxoplasmosis lgG Hepatitis A, B & C PPD Vaccines: Hepatitis A vaccine Hepatitis B vaccine Influenza virus vaccine ( Pneumococcal vaccine Inactivated Polio vaccine Tdt No liv e vaccines J, MOlt•l..-S _;,, "° pD ) 205.Whlcfi..one of the following vaccines can you use In HIV Pt.s A. Oral polio vaccine B. MMR C. Varicella D. Yellow fever y. Hepatitis B vaccine Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 262 An AWESOME REVIEW OF Nephrology Pulmonary Gastroenterology General Int. Med. Cardiology Dermatology Immunology & Misc Awesome Review Inc.• Copyright 2014. Do not photocopy without permission. J An AWESOME REVIEW OF .. • I 6% - Acid Base disorders - Hypernatremia - Hypernatremia - Hyperkalemia - Urine analysis - Nephrotic syndrome - Nephritis - Prerenal azotemia - Intrinsic renal failure - Post renal failure - Chronic renal failure - Nephrolithiasis Awesome Review Inc.® Copyright 2014. Do not photocopy without permission. J Copyright® 2014 Awesome Review Inc. All rights reserved. This publication is protected by copyright. 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"The Newark Beth Israel Medical Center designates this live activity for a maximum of 48 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity." Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 332 Chart 9-1 Acid Base disorders uv{"'- ) ) . Acid ) ) • • pH-pC02-P02- H COr� 7.4 40 >70 24 ( 1 s -1 ""'"t At""-l>""' �Ir 4 o1J\.: tx ptJVl-J � (llll{.c\A� Al ka Ii • 1 vJt·. �p1c.hi>. 0L Identify a primary disorder Check for compensation Check Gap 12 Chart 9-2 ) ) ) Primary Disorder Compensati on w HC03 w P C02 1' HC03 1' PC02 1' PC02 1' HC03 Ac. w P C02 w HC03 Ac. Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis How much Respiratory Alkalosis Respiratory Acidosis Metabolic Alkalosis Metabolic Acidosis = 40 + 0.7 {ll in HC03) Chr. Chr. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission 1 for 10 3.5 for 10 2 for 10 5 for 10 Page 333 �� Na• } · .L 11 � hart9- 3 Normal Gao J HCO,- I l��- +Gao I - - - � - I - ---- - 1' - - - . II - Matching B {::. 1. M ultiple myeloma 1' �tu- (.°"'I d _,� 2,J H) A. Increased gap 2. Hypoalbuminemia B. Decreased gap Metabolic Acidosis Gapped Acidosis Non Gapped Acidosis Add Acid= Gapped Acidosis Loss of Bicarb. or Unable to excrete H+ i HC03= a h� Gf. •-v 4DKA a in Gap � "' } la HC03 in gcr � • NRT I. • Lactic Acidosis ----4Mt t<fw"""-, • • •*Ethylene gl ycol � ��l<>.><i'-':5 • Methanol �t! �'� � c.t:,<PI.:� �.i.. � (,$.;"->c:.;. 1< • • • End Stage Renal Disease co..-t-ox c.��1c.i� A1N 'l.. • Acetaminophen(pyroglutamate) (iQ- Li- c. '·v) " 't • ASA toxicity (salicylate poisoning) ( -ii OV- �1' / S"0 _, �� - � C.\ �� Rc.p i"f Al C<f}vt -i 1' O.Yr- 'Jc.f ( Ac.� to M ) � No f>rc.:.t)..P FJ (> ()1,,f(/IV Sew-WV\. OJ'M :: : 1 OJ'i"' � 2 (Ne;.) 'f Gu($ 2. f? 2 ( I 3f) ,. I0 3�,) - °2-Jlo ..:: l Ci> Gil:." \..IN. 3 t, Jl (j) ML but N O d in Gap "1 -i t- cl awwff:,:v- Renal Tubular Acidosis G(M.(, � J..of! 'i 11� Diarrhea ( v..,v...... c..l +) - · Ureterosigmoidostomy �!. -'J IM'� 1' Q � c..<-C: VV"' Early Renal Failure u.,,\ � )\� -ft.., LJ\..,... I Post Hyperventilation � wc.rl.. o� 1-\(J);, • U1'-<) �) N v. t:4 _, t \/CJ\tJ,l... h'v., O.U f1 f<>11c.1.1--· +- = J � fWut 'l' /1 � �VC.�'- S.:> tt.... rvlL Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission · Page 334 n (,,(>}. �o .i, t\ S" Respiratory Acidosis ..,_.'.l l-'1 V1 ,,pt -It 7J'I. P<Cj "-CJW:J -' NL z 1· S" 7. s fX.Az. 3Z . " ..,. \, AJ� __, e..vvv Pt»i. � J� 'Lungs not moving air or Hypocapnic or anything that blocks breathing' (<li'pl'-. ""1') • ( ht <..b-.1-L "i .f 1. ) COPD/Pneumonia/pulmonary edema/ Interstitial fibrosis "Jl'<lv<A'�.(. ,1-ui 1...... i • Drug overdose: Cocaine/ Heroin/ Barbiturates d: 1'k.A p-f>o' f • Severe Asthma "J\c.IV ,�, • Thoracic wall disorders: Chest wall trauma • Foreign body t- frt� � tcA't.c.A::1 '\.. • PNS: Guillain-Barre syndrome clv.<. t. 'f"" C.: � c..�" J..) Respiratory Alkalosis -1 cc."' o,..,.f' • • • I ) • • • Hypoxemia: High altitude, Pneumonia, PE Drugs: Salicylates, xanthines, progesterone CNS tumor, trauma 1' �· c..tl\tu.Anxiety/Hysteria Sepsis Assisted ventilation Metabolic Alkalosis ) -l J, �]... .J; 1. '). 2-..:> "' • • - 5 (AZ .b I 'f ( �;\.V"- ,. u c1- > 15 • ASA-' ').'! -5 -II I 1 20 u c1- < 15 • u.,, �p; 1tvv Alk .. t..� 2;) __, flJ I Aci >.,;.,i.-.; Md hi,,.'.> .) 16 ulv-I' !>t z- ) , ) v.pH "..IT 'Volume expanded' 'W lost but HC03 NOT lost' 'Chloride lost and HC03 absorbed' Diuretics recent High BP • Hyperaldosteronism • Cushing's syndrome • Licorice ingestion A\do>s--te..vrv• Liddle's syndrome Low/Normal BP • Hypomagnesemia • Hypokalemia • Bartter's syndrome • Gitelman's syndrome Diuretics remote Volume depletion Vomiting NGT aspiration Exogenous alkali • • ) ) ) v 30 'l-'1 fchloride unresponsive'J • ) �o \1'.h loride responsive'] 'Volume depleted' 'Chloride lost an.cl HC03 absorbed' ) 11 l.D.J Go}. - f\Sc..."t.<A Chart 9-4 What happens in Bartter's - Liddle's syndrome - I:. U>l':,c.,e. Gitelman's ( L�:>c) (t;c.lZ.) Mt t. i.J\.Vf'L ) ; "- c..1--1 F lfJ f""-tc. i..J\..o ('.,.(,, Pv'"" (. 3 '> � LL.t-'.)< ) if t c;Lr" ye. t..'J P.,.xi t-.l L.vop N(' <...I.. clV" l rvwr<- "'' • f<, Loi'! t <...1? c. i.- p 'll� ,,Z. ve.::'> � H1 -t -J 1-1" -f ,,. 0-!Jt..l I-A/'· ; t-if) -t <A.. \,\ c..t · + �ro kf t > rr V.C.L. / 1.r rvwl- �lk<l.:>� Gr' rJi, bPD I<.. lA c.,l Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission )' ' j' Al f<..V.'-" ap 1' rw� Page 335 Matching A 1 . Decreased transportation defect in ascending A. Bartter's syndrome B 2. Decreased transportation defect in distal tubule B. Gitelman's syndrome 3 . Increased (aldosterone independent) transport defect in distal tubule C. liddle's syndrome loop of henle c �4. Hypertension L D. All the above � . Hypokalemia -1L..§ . Urine Cl > 15 A 7. Loop diuretics {3 8. Thiazide diuretics �1. Pt. presents after ingesting unknown substance. pH 7.18 PC0223 P0298 .. -t � \NI� r"L CJ Wl.t. ....-' ��...... u-\L..Vnl Hco 1. r Ch":>) 1 G' Thi � Pt. has Na 136, K 5.2, Cl 100, Hco © ® .s x I v( Gapped metabolic acidosis ., ., G' -- 2. .J B. Non-gapped metabolic acidosis C. Gapped and non-gapped acidosis Q2. The above Pts. urine showed rectangular shaped Calcium oxalate crystals. his Pt. most likely ingested A.. Ethanol B. Methanol ve'. Ethylene glycol (� se... os"' __.,, 0.1-"" CH' ) 3. The best treatment for this Pt. is -?Inhibit alcoholic dehydrogenase with -7 -7 �'ft.l.n,vl 1:•1 fOIVJ.p. i-'1t< ______ h 1> if osmolar gap >20 if osmolar gap >50 Q4. Pt. is brought with confusion, convulsions and blindness after ingesting unknown substance. pH 7.24, PC0228, P0298, HC03 14. Na 136, K 5.2, Cl 100, HC03 15. Most likely diagnosis A. Ethanol poisoning JV,' Methanol poisoning ( BlAf\l\i\M1) C. lsopropyl alcohol poisoning Awesome Review, Inc."" Copyright 2014 Do not photocopy without permission Page 336 5. Pt. presents to the ER. Appears depressed and somnolent. Friend says he was nltially excited. I ngested unknown substance. Smells acetone. esp. rate Is 10/mln. Temp 96. BS 65mg/dl. Urine Acetone(+). BUN/Creat. 20/0.Smg/dl. Na 135, K 4.8, Cl 105, HC03 23mEq. Most likely ingested A. Ethyl alcohol B. Methanol -e:-'lsopropyl alcohol ( N1J D. DKA \ f>t�tN>t.:.. Of) 6. An 18 y/o boy is brought to E R with confusion, seizure & ataxia. xam reveals DTRs are decreased. Breath has a fruity odor. lu: 90, pH 7.2, PCOz 24, HC03 14. a 135, K 2.5, Cl 104, HC03 12. Phos. 1.5, Ca 6.5mg. Most likely diagnosis Is �� --- A. Methamphetamine use vK Toluene toxicity(glue sniffing) C. Ethylene glycol toxicity D. lsopropyl alcohol ) 7. Pt. with tinnitus, lethargy & tachycardia. a 140, K 4.9, Cl 100, HC03 16. H 7.48, PCOz 21, HC03 l6. his Pt. most likely has �� A. Vomiting and Renal failure 4( ASA toxicity C. COPD ) ) ) ) ) ) ) .... ..;.... A N _ _ _ ___ _ (}) ft4p: AIK.,t.>c...· G:> c.,or-p t..('\ .rc. n tH>. overdose cause Respiratory alkalosis followed by Metabolic acidosis. 8. A 76 y/o Pt. needs to Increase volume on TV to hear better. C/O ringing sound In he ear. Mild dizziness. Pt. with HTN and also takes ASA for the past 10 yrs. Ital signs normal. Most likely diagnosis \.}k""ASA toxicity B. Presbycusis (high frequency hearing loss) (, 1-,..,.W. foS{.\ t.o)< i<.o'S Confusion, fever, Hyperventilation, Acidosis 9. Na 132, K 3.3, Cl 110, HC03 18. his Pt. could have any of the following conditions EXCEPT A. Diarrhea B. Ureterosigmoidostomy C. Renal tubular acidosis D. Early Renal failure /.Chronic Renal failure u.w zV..Nc: t""k -:: )A -t "° 4.:> - -= Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission - "U> _c,,L -60 GO ( l,t, w N�<h�) _,'DA�) Page 337 10. 28 y/o O M Pt. with nausea. BS is 310. Matching B 1. Na 135, K 5.6, Cl 94, HC01 20 A. Type IV RTA A 2. Na 135, K 5.6, Cl 104, HC03 20 B. DKA 1 1 . 80 y/o taking NSAID and Tylenol for osteoarthritis. BS 180mg/dl. a 138, Cl 100, Bicarb. 16, K 5.2. BG pH 7.30 PC02 32. Most likely etiology? A. NSAID J(' Acetaminophen ( w Ptc.:.� ) 12. Na 135, K 5.7, Cl 80, HCOs 24. Bun/Creat. 110/11 H 7.4, PC02 37, HCOs 22. his Pt. most likely has A. Normal Acid base � Metabolic acidosis with Metabolic alkalosis C. Metabolic alkalosis with Respitory alkalosis I 3.:T - ( � +- 1-'1 ) 1 '.Ir-'"� 3 1 -12 =f� 13. The a bove Pt. most likely has �Chronic Renal failure with Vomiting B. Chronic Renal failure C. DKA A. Diuretic induced metabolic alkalosis � Licorice ingestion I p· n�::)P�'"tbJt&..,.;i.... ,, -t.iftV+· . l:.ci.cll.. f C. Bartter's syndrome D. Gitelman's syndrome 15. Pt. with exacerbation of COPD with PCOz of 70, pH 7 .45 edal edema-+ Intubated & ventilated.+ PCOz of 50, Furosemlde, extubated nd later discharged on Tlotroplum, Albuterol, steroids and Furosemlde. ne week later, on follow up pH 7.46, POz 55, PCOz of 60 and bicarb. of 40. .........Y, .. �-,\'./ ��- o�-t A. Exacerbation of COPD vB"." Diuretics (_ f>..u.. I:... z.J\c....:1\1 t� .,.. bV: f\.f _, 16. COPD Pt. with PC02 of SO and P02 of 60, Bicarb. of 28. Pedal edema (+). reated with ttotroplum and diuretics. A week later, PCOz 60 & Bicarb. of 40. t. on oxygen and pedal edema is decreased. w.t.d � '\ p� " "" 11. 1' f-t.l.P3 ifvvc... Ki� to ex C:r<. t;d"" • Cxv< t... • h (.0.3' J Page 338 �p->k�Len-.J<---1 Jtc.,.,t k.U. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Matching j) � 1. pH.7.6, PC0230, P0270, bicarb. 3 (l.J_,pi A-tl.\..oi.· A 2. pH 7.3, PC02of 50, HC03 22. Na 135, K 3.4, HC03 24, Cl 82. rw.� Al\t..)w� 1tt,; A11<.i.. ""4t t\u,i..."' E 3. pH 7.5, PC0230, HC03 24 /JIU Na 144, Cl 80, HC03 E 4. pH 7.48, PC0232, P0290, HC03 24 Na 135, K 3.9, Cl 84, HC03 24 ) Ql7. A chronic alcoholic Pt. presents for follow up. Exam reveals ascites. BG: 7.42/24/16/94% Na 135, K 5.2, HC03 15, Cl 115 Urine pH 6.8. Most likely reason for above findings? ) ) \ A. Resp. Acidosis, Metabolic alkalosis & Metabolic Acidosis B. Metabolic alkalosis & Resp. Acidosis (j) pc..� G> U:> r-'(><J'\Jt.SC> Ac, .. 13-s�t"' C. Metabolic alkalosis & Metabolic Acidosis .DY'r D. Resp. alkalosis & metabolic alkalosis (]) p' (.� E. Resp. alkalosis, Metabolic Alkalosis & Metabolic Acidosis @ � Coa,.. �.° -1- 1� J, 'ZP ::: z..� , i_,.ti.. Ci> "1 Cl J.. : f'l"\.d (<\l 14L.. fi (,:).::r ..JI - CV\. u. .u rt/ fNo-f hU>J r1,,...J: �� l-"1 ,y ,, J,. 1'1 A. RTA type I vB'.' Ascites C. Cirrhosis Ql8. What Is the acid base In the above? \//(, Chronic respiratory alkalosis with normal gap acidosis B. RTA C. Normal gap metabolic acidosis ' ) I Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission f>rt ..: 11.Ji Page 339 Chart 9-5 Proximal RTA Distal RTA Classic Distal Type I V RTA Type I Reabsorption of H C03 H & K excretion H excretion Type II Defect Diseases • • • • • Fanconi's syndrome MM Acetazolamide, Zonisamide Topiramate � Osteomalacia Stones +/- Serum K � U pH • • • • • Sjogren's SLE Stones * Obstructio + � CV <5.5/>5.5 • Hypoaldosteronism Diabetes Mellitus >5.5 "* <5.S Nl1 (,l Matching 03 1. Fanconi's syndrome A. RTA I 13 ? . Osteomalacia B. RTA I I ']> 3 . Hypokalemia C. RTA IV ___'.g_4, Nephrolithiasis D. A & B A 5. Urine pH >5.5 c. 6. Hyperkalemia c. 7. Diabetes mellitus B 8. M u ltiple myeloma, Acetazolamide A �. Dry mouth, enlarged parotids, arthralgias �10. Sjogren's Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 340 Chart 9-6 Ser N a _S:0G 135-145 Normal ' ) ) ' Nephrogenic DI f ) f"''l<'.i ".... ) SIADH 1.A..W .... • 1' I) ' I Na Osm. dep Ur. Osm DDAVP U r.Osm >20 600 (50-1200) 1' 1' 1' ... 1' 1' .:f-W J, ..Lt (VJ ej. � -� J J, .J lf>le 1' •• o..,tp( : '2.. L - ' 1.A..W.. otr--. J,- \Al'JL-t pv 1', bvf. 1' u Ne. Matching ,. LJ � Sp �p ' - {\A L) :re • ' G) -l- ••• ) Post ;f- ' Psychogenic polydypsia ) Post H20 - DI ( A'Dl1 ) Urine •• ) ) Urine f'Vl c...i...w.y -1-t '1 <) 1 1 tJ"/A NJf\ B 2. Ser. Na 148 Urine Na 12, Urine Osm 71, Post HiO B. Nephrogenic DI �- c.L...S<. hl T Z LovJ , A. DI restriction U.Osm 75, Post DDAVP U.Osm 77 Low 1. <.n>S f>i 1 Ser Na 146, Urine Na 10, Urine Osm 73. Post HiO restriction U.Osm 76, Post DDAVP U.Osm. 600 -1-' T>c � :>y.> _1f' f ,fV.,) C ----1: Ser Na 1 3 11 Urine Na 12, Urine Osm. 65, Post H20 restriction U.Osm 500, Post DDAVP 600. C. Psychogenic Polydipsia � Ser Na 132 Urine Na 45, U.Osm 600. J'r 8'1 -'>I•-''},!' Young female recent Sx or Lung Ca. �� 5 '> NH Pt. Ser Na 160, Urine Na 10, Urine Osm. 800. E. Hypernatremic dehydration F h Ser Na 130, Urine Na 5. Hx of Liver disease F. Hepatorenal syndrome __, �ve.--t.•lo i.. '-CJ\ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission r"' A_, pt. � t........_ �,\,..,+ � #y?"'- � Page 341 19. Best long term management of SIADH Chart 9-7 1'' 06 c;�f< Hyponatremia Hypertonic Hyponatremia Hypotonic Hyponatremia Isotonic/pseudo Hyponatremia G -..· 1-( 6 C. N � Osmolarity J ,, , ""'.1 N" vp t,... ::J<IQ J, f, - c.. -= - � I lf\/O I 2-0 ..,_ -r- 2 '2. I� 2. \Y If" f\/•' ' f'�Y· i' W•W Volume Hypovolemic Hypotonic Hyponatremia lsovolemic Hypotonic Hyponatremia Hypervolemic Hypotonic Hyponatremia �I#/ - S1.A:I>l-I • s...i, <"" c,.l...iM A M.J-' Ucl � w�t..:')' I ) M .. ��tt- ,,.� LO� S �It • f-.S/ , wot<- 1.->i, .,. zrJ. £.st .. 'j (Jf ,v•,-r w�) m-t" �� SI..'� NL vUl.· Acute symptomatic Hyponatremia (mental status changes like lethargy or seizures), requires aggressive treatment with 3% saline >lmEq/h for several hours usually 12 mEq/hr 24 hrs. and diuresis. a V2 receptor antagonist may also be used. ,). o� "'"� e.x��c,..v • • • Chronic Hyponatremia should NEVER be corrected >0.5 mEq/h . Correction >0.SmEq/h in Chronic Hyponatremia can lead to ? � Pontine Myelinolysis: Pseudobulbar palsy Quadriplegia 11 N<.. c..t Lo-f J <V· 11 W<-w w:rr .rt""J N- E<..F Volume depleted Hyponatremia treat with 0.9% NaCl In Hyperosmolar hyponatremia, every lOOmg increase in glucose decreases Serum Na by l.6mEq Ne." Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission (.OY"f'(.<.liU\ - � 1 'l: Li t-v ( '1'4 / h,v) (o.:r � /h..- ) Page 342 20. Pt. undergoes Cardiothoracic surgery. H e is started on DSW , � -- I lternating with Yz NS. I ' , "" 1. c. r , 42. is ay 1 his Serum Na is 142, Urine Na ay 6 his serum Na is 118, Urine Na is 20. \. __;....-- - -;t fl/J is NGT is draining 1.2 Its. daily. hat is the best management? __ \ Qj NL s"� --=---��....... �� A. Normal Saline �Normal Saline with Lasix C. Hypertonic saline with Lasix p2 1. 70 y/o Pt. presents with Pneumonia. Na at presentation is 135 mEq/I. he Pt. is started on 0.9% saline at 100 cc/hr. days later on antibiotics, Pt. defervesces and WBCs decrease, but Pt. becomes confused nd has an episode of seizure. Current Na Is 110. 3.4, C02 18, Cl 88, Bun 10, Creat. 0.8. rine Na is 80, K is 40. The most likely Ox is l ) 7 SIADH Similar presentation in Pt. with Small cell Ca Lung or Postop in young women. How to treat? ) ) ) \ I ) 7 Stop i.v 0.9% saline, Start i.v 3% saline & Start Diuretics l 22. A 35 y/o man was found in the bathroom and brought to the ER. lucose Is 90mg/dl, Pulse Oxlmetry Is 96% on room air. t. has history of Schizophrenia. BP 130/84 erum Na-110mEq/I erum K-4 . 0 erum Cl-88mEq/I erum C02 -18mEq/I U N -8, Creat.-0.7 erum Osmolarity Is 230 mOsm/kg of water rine Na-lOmEq/lt rine Osmolarity-40 mOsm/kg. Urine drug screen Is pending he most likely diagnosis Is A. SIADH B. Drug Abuse C. Addison's disease yPsychogenic polydipsia E. H ypothyroidism Awesome Review, Inc."' Copyright 201 4 Do not photocopy without permission Page 343 23. The most appropriate management of this Pt. is A. i.v 0.9% NaCl B. i.v Dextrose 5% and diuretics c. i.v Dextrose 5% and 0.45% NaCl and diuretics Fluid restriction, i.v 3% NaCl and d iuretics vef 24. 45 y/o with long standing history of bipolar disorder on lithium found to be omatose. Serum Na is 169 mEq. Most likely diagnosis is 7 Hypernatremia related to lithium therapy. How to replace water deficit? 7 Replace half in 24 hrs. and the rest later. Use D5W with 0.25% Nacl. If hypotensive until stable. Q.25. 24 y/o woman, building body for competition comes to you with complaints of weakness and cramps. She admits to having polyurla and Is slightly dizzy when she gets up. Serum Na Is 148 mEq/dl, K of 2.7, bicarb. 28. Urine Osm. Is 80 and Urine spot lytes with K >25 .st?t.:<. s'-..ot1<. � 3o rv-J. /I� cJ- Lu:.., f.. � .... 1.. • Q26. Pt. sustains a head injury and presents with urinary Incontinence, U. osm Is 42 (nl 40-1400), Plasma osm. 310 (nl 280), Na 150 and BUN/Creat. S0/1.8mg/dl. The most likely etiology is ��-- w.t.d next 7 Give Desmopressin and monitor decrease in urine output and increase urine osmolarity. 27. Pt. presents with polyuria. He has severe polydipsia. rlne osm is 60. Blood sugar Is 120mg/dl. fter Water deprivation, Urine Osm. changes from 60 to 72. fter DDAVP lnj. the Urine osm. changes to 82. hat is the most likely diagnosis? A. Psychogenic Polydipsia /Nephrogenic Diabetes lnsipidus Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 344 Hyperkalemia • Factitious ( L(i; � c.c.W\C. ) Breakdown of cells • • Hemolysis Rhabdomyolysis Adrenal hypofunction (decreased excretion) • • Hyporeninemic hypoaldosteronism (Type IV RTA) Addison's disease Acidosis • • OKA Renal failure Hyperkalemia causes EKG changes: Peaked T waves, flattened P waves-? sine wave-7 V-fib "" t5f' Treatment: Stabilize cardiac membrane-? Calcium gluconate Next, push K back into cells-7 Insulin, Albuterol, HC03 Defin itive excretion -7 Sodium polystyrene sulfonate resin or Hemodialysis Hypophosphatemia Renal wasting • • Hyperparathyroidism Fanconi's syndrome Decreased absorption • • \ • • Vitamin D deficiency Malabsorption Alcoholism Phosphate binders l Al k '!Ph.o f' ) Increased Cellular uptake • \ ) • Treatment of OKA Carbs repletion in alcoholics - Re.�":i refeeding syndrome Hypomagnesemia � ��t_;. j; C 'll.:p�r>i '- , N c 7..- J c.,n{. 1>Pi:; � ) Decreased mtake • • • Starvation Alcoholism NGT aspiration Renal loss Diuretics Aminoglycosides 7 c\ • Ampho. B Pancreatitis -7 precipitate as Mg soaps Parathyroidectomy-7 deposit in bone 'hungry bone syndrome'. Present with lethargy, anorexia, nausea, tetany, and convulsions. • • Cannot correct Kand Calcium unless you correct Magnesium. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 345 28. Pt. presents with weakness, anorexia and lethargy. a 136, K 3.0, Cl 105, HC03 20. Calcium is 6.0mg/dl, Phos 1.3. • t. Is started on l.v fluids with 40 mEq of K In each liter of fluid. ext day, K level 3.2 and Calcium 6.2. Most llkel cause of K still beln low is A. Diarrhea v8". Hypomagnesemia C. Insufficient repletion. Urine Analysis Proteinuria 1. Overflow of proteins: Multiple Myeloma MGUS 2. Increased filtration of Proteins: 3. Decreased Tubular Reabsorption: 4. Tra nsient: Tubulointerstitial Nephritis Protein <2g/day Fever, Exercise, Upright position Seizures Normally<100mg proteins excreted/day Normally <30mg Albumin excreted/day Microalbuminuria7 30-300mg/day seen in early OM nephropathy Best test to measure microalbuminuria is7 Jr"t "' ...;""- � L • • • • Dipstick mai nly measures Albumin. Therefore, in MM, MGUS. Urine dipstick will be 1 + 7 24 hours collection of urine7 >Sg of protein 7 Do Protei n electrophoresis to r/o MM, MGUS • 1X Glomerular diseases: Nephrotic Protein >3g/day Nephritic Protein <2g/day 29. Pt. with fever and UTI, Urine (+) for protein. w.t.d 7 Repeat Urine analysis after fever and UTI have resolved 30. Pt. on NSAIDs for pain. UA (+) for protein. w.t.d 31. Pt. with protein (+) In upright position. w.t.d 7 Check first void AM urine specimen. If neg, no further workup. 32. Pt. with proteinuria on dipstick post exercise. w.t.d ��-- 7 R.afw LlA A/ t st.. p/i':J e.xe,,c..'Je . C '1 - J � �) · Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 346 Chart 9-8 Hematuria Nephronal RBC casts & proteinuria > RBC casts > • Glomerular diseases • Renal Cysts Sickle cell disease Interstitial disease • • Non Nephronal No ) ) RBC casts or proteinuria Renal Pelvis l > • > • > • Tip of Urethra • Others ) ) ) -) • r A. Rhabdomyolysis B. High vitamin C i ntake C. Paroxysmal nocturnal hemoglobinuria D. Contamination with Povidine � Nephrolithiasis pt Dx: Extreme Exercise induced hematuria. w.t.d� Repeat UA in a few weeks. c_ NO �s A. Cystoscopy JY. Follow up renal evaluation in 1 year ) 2 i.-i(. __, 33. Pt. with urine dipstick (+) for blood, RBCs negative. CEPT: his finding can be caused by gEX alt the foltowln ----�� ---�� --- Ao+ 20-30 RBCs, wee negative, protein 1(+) t No casts. lstory of having run the marathon the day prior. ) Coagulopathies Post Extreme Exercise --��- �..,,,_--� 34. 20 y/o presents with asymJ)tomafl.c.h1maturr1. ) Tumors Nephrolithiasis UTl/Hemorrhagic cystitis ) F;'u c-1 YllW'j - �) < '},s �., "1 o lc:l --> '(ft..' "°PJ Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 347 Q.36. A SO y/o male on routine physical . UA-�>S RBCs, No casts. w.t.d Repeat UA a few weeks later with persistent microhematuria. w.t.d Q37. Pt. with sickle cell disease presents withsudden onset flank pain, fever and assage of dark tissue in urine. A7 RBCs, No casts. BU N/Creat. increased. w.t.d next Q38. All the following can cause papillary necrosis EXCEPT: A. Analgesics B. Sickle cell tra it C. Sickle cell disease D. DM E. Pyelonephritis V. Aminoglycosides (. P.,T('J) 39. A 30 y/o with sickle cell trai resents with microhematuria. UN/Cr 14/0.8. Urine analysis shows RBC >20/hpf, No casts, No protein. 4 hrs. �roteins In the urine Is 300mg/day. w.t.d next? -------- A. Cystoscopy JY,"IVP C. Renal biopsy D. Do nothing 40. Above Pt. IVP negative. w.t.d next? A. CT scan VS: Cystoscopy Q41. A 22 y/o college student presents with hematuria and dysurla for the past 3 days. UA7 > 30 RBCs, WBCs 10-15. No casts. Dx: 7 HeJ'IV'r-rl,_c:y;c. c.!:1Jt;t; J w.t.d Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 348 Q42. A 21 y/o Pt. had recurrent UTI. He is sexually active with one partner for last year. his is his 3rd episode in last 6 months. Each episode resolved on treatment with �uinolone. No H/O of Urethral discharge and O/E no discharge. Best way to establish the cause? ------ �r in e Chlamydia and Gonococcal test. B. U/S of Kidneys and collecting System. 43. A 20 y/o presents with cola colored urine. She is an athlete. She had sore tnroat days ago. UA� RBCs 10-20/hpf, RBC Cast (+), Protein 1(+). erum complement level is normal. This Pt. most likely has ) ) A. Exercise induced hematuria ost streptococcal Glomeruloneph ritis \.K. lgA neph ropa thy C. 1:" Ac.. G.1 , f>sl.... <Ti\ ) steroid �:J 44. A 60 y/o man presents with complaints of dull aches In the left flank region. eview of systems reveals a 9 lb. involuntary weight loss. xam reveals BP of 140/90. b 17 g/dl alclum 1 1 g/dl UA reveals RBCs 15/hpf, no wees or casts. ost llkely diagnosis is ) ) ) ) ) ) ) ) A. Urinary TB B. Renal stones 0Y.'Renal cell carcinoma (f'MQt'(f:o'J �,....bop1-<1:.1,.c,:.,, D. Polycystic kidney disease L.efh h� v"'"''-"�l.c... ) 45. Pt. with flan!< pain, nematuria, RTN and history of OT s In ttle past. enal US shows a stone. Family hlstor of stones and renal fallure. Dx: ADPKD (Autosomal dominant polycystic kidney disease) H istory of parents or close relative with renal failure. Complication: Gradual increase in serum Creatinine leading to Renal failure. Associated with Hepatic cysts and Berry aneurysms. What has shown to preserve renal function in ADPKD? Tolvaptan 46. Mother wants to donate l<iClney to son with Polycystic kidneydisease wittl Renal failure. w .t.d -------� Q'47. Autosomal dominant polycystic ney lsease is requently associate Ith all the following EXCEPT --�--A. Cerebral aneurysms B. Hepatic cysts C. Elevated Hematocrit D. Mitral valve proiapse ( PiS'l> - sec,u"'�) �Aortic Stenosis ( AV M ·1'\. �) Asso with Colonic AVM Ns".\'-H"" ? Awesome Review, Inc.® Copyright 201 4 Do not pnotocopy without permission Page 349 Medullary Sponge disease • Hematuria • Hypercalciuria� Stones • Does not cause Renal failure. • IVP� outpouchings of renal papillary ducts Alpert's syndrome • X-linked • Hematuria • Proteinuria • Renal failure in 2"d or 3rd decade of life • Problem in collagen IV & V synthesis Associated with deafness. Urine Analysis WBCs in urine (pyuria): • Tubular injury • Interstitial nephritis • UTls • Pyelonephritis 48. Pt. presents with polyurla and nocturla. No complaints of dysurla or flank pain. o urethral discharge. UA-+ 10 WBCs/hpf. No casts. Pt. treated with antibiotics. Repeat UA 2 weeks later-+ persistent WBCs. enal ultrasound-+ one kidney smaller than the other. VP-+ multiple strictures. w.t.d next � IAvN Jut f)F-8 � ({/o '2.t_tvl Te, j PP'D ( 1G,RA ) Chart 9-9 Urine Analysis Casts Nephrotic syndrome Hyaline casts, fatty casts, oval fat bodies Nephritis RBC casts Prerenal Azotemia Hyaline casts Acute Tubular necrosis Muddy/Dirty brown, Pigmented Granular casts I nterstitial nephritis WBC casts, Granular casts, Eosinophils Chronic Renal Failure Broad casts Chronic progressive Renal Failure Waxy casts Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 350 Hyaline casts • Nephrotic syndrome • Prerenal azotemia Fatty oval bodies • Nephrotic syndrome Granular cast • Tubular necrosis • Interstitial nephritis Waxy cast • Chronic Renal failure RBC casts Nephritis • ) ) ) ) ) WBC cast • Interstitial nephritis 49. Eoslnophllurla can be seen In all the following EXCEPT: A. Interstitial nephritis . '�_,, ..i.,;�c. \t.l"'U'\t l-<>1-1, 111 r t,t1p\..u •l E .,...,_.. ,B. At h eroem b OI Ism -- · r C. NSAIDs D. Rapidly proliferative Glomerulonephritis E. Acute Prostatitis t t� - .ti- c. vtk.s ) _. C ) Matching B 1. Hyaline casts A. Acute tubular necrosis A 2. Muddy brown casts B. Prerenal Azotemia '} 3 . RBCs C. Glomerulonephritis 4. RBC casts D. Nephrolithiasis "· Oval fat bodies E. Interstitial disease c F E 6. Eosinophils A complicated urinary tract infection, whether localized to the lower or upper tract, is associated with an underlying condition that increases the risk of failing therapy, including the following: ●Diabetes ●Pregnancy ●Symptoms for seven or more days before seeking care ●Hospital acquired infection ●Renal failure ●Urinary tract obstruction ●Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion ●Recent urinary tract instrumentation ●Functional or anatomic abnormality of the urinary tract ●History of urinary tract infection in childhood ●Renal transplantation ●Immunosuppression F. Nephrotic syndrome Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 351 Chart 9-10 I Renal Imaging • X ray -7 All stones show up EXCEPT Uric Acid • Renal Ultrasound -7 Size, Obstruction, masses, screening for Polycystic Dz, Stones >Smm • IVP -7 Non glomerular hematurla, Renal stones, voiding diseases, Unexplained flank/Abdomen pain. • Spiral CT without contrast -7 Stones, Perlrenal hemorrhage • CT with contrast -7 Staging of Renal masses • Radionuclide Scan -7 To assess Renal Perfusion MRA/ Renal arteriography -7 Renal a rtery disease • MRI -7 Renal vein thrombosis • Renal Biopsy -7 Glomerular diseases 1· Chart 9-11 Presentation of Glomerular Diseases: Nephrotic syndrome Nephritis Urinary Findings Fatty casts, fat oval bodies RBC casts Cola/Smoky urine Proteinuria >3g/day <2.Sg/day Hematuria +/- + Cl. features Generalized edema, Perlorbltal edema HTN HTN Histopath Presentations Minimal Change Focal Segmental Membranous Membranoproliferative Post Strep. GN lgA nephropathy Henoch-schonlein RPGN Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 352 Glomerular Diseases • • • First, Know the two major cl inical presentations of Glomerular disease: Nephrotic syndrome and Nephritis Second, Know the histopathological patterns that cause Nephrotic syndrome and Nephritis. (Minimal change, FSG, Membranous, MPGN, PSGN, lgA, HS, RPGN, etc) Third, Know the diseases associated with these histological patterns (NSAI Ds, Tumors, I nfections, Systemic diseases, etc.) Chart 9-12 Structure of Glomerular Capillary ) ) ) } 1 ) G�� 1\,\1{ t-...MW I J�l'IM\.: J S M-��<-L � {3 LVl l ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 353 Chart 9-13 Nephrotic syndrome: Histopath presentations & their etiologic diseases (Tumors, Meds & Systemic infections) Minimal change Etio • • • • Hodgkins Leukemia NSAIDs Lithium Focal Segmental • • • • • Blacks HIV Heroin Sickle Dz Obesity - Membranous • • • • • • • Hep B, C Syphilis Tumors malaria NSAIDs SLE ACE I, Gold, Pcn'ine Membranoproliferative • • • • C Hep B, SLE Cryoglobulinemia SBE -- - Bx/LM Normal sclerosis of part of glomerulus in few glomeruli Thickened capillary loops Tramtrack IM Normal lgM + C3 Granular lgG + C3 Mesangial deposit EM Effacement of Epithelial foot processes Effacement of Epithelial foot processes Sub epithelial deposits Ribbon/sausaging of membrane in type II Complement Normal Normal Normal Low if Treatment Same Same Same +/-ASA Steroids, Cyclophos. ( t)< Ul\cltA�,,.., olt J ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 354 Chart 9-14 Complications of Nephrotic syndrome Protelnurla > 3g/day7 Hypoalbuminemia 7 Edema Hypogammaglobuli r\emia7 Infections t c LL I ) ) c v 1. 'D ) Loss of Antithombin I l l, Anti-plasmin 7 Thrombosis & PE loss of Transferrin 7 Iron deficiency anemia Loss of Vit D protein 7 Osteomalacia Liplduria 7 Fat bodies, Fatty casts in Urine Hyperlipidemia Treatment: • • • ) ) ) • QSO. A 21 y/o football player, with mlcrohematurla. He has used Heroin lntermlttently In �ast. His father had difficult to treat HTN. Pts. BP Is 140/94. Urine analysis RBC cast pos. Urine Sp. gravity Is 1.025 and 4+ protein. Most likely diagnosis - A. Minimal change disease B. Membranous nephropathy %Focal segmental glomerulosclerosis D. Sickle cell disease -J ) ' I ACE inhibitors reduce Proteinuria and Hyperlipidemia Low salt Loop diuretics H MG CoA reductase inhibitors Matching B 1. African Americans A. Minimal Change A ? . Hodgkins disease B. Focal segmental B C. Membranous ::!. Heroin use tA 4. NSAIDs f>, s. Hematological malignancies (CLL) c 6. Solid tumors (Lung Ca, Colon Ca, Stomach Ca) A 7. Lithium D. Diffuse deposition 13 8. Obesity '::P q. Amyloid (Rh. Arthritis, Crohn's, MM) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 355 Chart 9-15 Nephritis: Histopath. presentations & their etiologic diseases Henoch- RPGN Rapidly Schonlein proliferative GN Post Strep. lgA nephropathy GN Etio Strep. infection Most common Post Exercise, URI Idiopathic Abd. pain, Palpable purpura Type I Goodpasture JI Type I I d-pcn' amine RPC.N Type I l l P- ANCA 7PAN C-ANCA 7Wegener Bx/ LM Hypercellularity Mesangial proliferation same Crescents (Extracapillary) formation IM granular lumpy bumpy lg + C3. lg A, lgG, C3 deposit in Mesangium. same Linear lgG -- - granular complex Negative (pauciimmune) Normal/ low Normal Ab�tv �1:.ot.,.,·(. .._v EM Sub. epi. deposits Complement LowC3, CHSO normal C4 Treatment Supportive Fish Oil Antibiotics (Omega 3 FA) ACE inh. 7 Steroids Normal Normal Normal Supportive I m mu no supp Pl' pharesis Steroids Cyclophos Serum Complement levels decreased in (mainly nephritic presentations) • • • • • • Post Streptococcal GN (up to 8 weeks) l 3 J.1 Membranoproliferative GN SLE C 3 w / C.ti Cryoglobulinemia C � � 7 C 3 Subacute bacterial endocarditis Atheroembolism C.Li rJL Serum Complement levels NOT decreased in • • • • • ( lgA nephropathy Minimal change Focal segmental Membranous nephropathy Goodpasture/Wegeners (pauci immune) L.wv� ·· " � Mt.A.; Lupus Nephritis can present with varied Renal manifestations • • • • • • Nephrotic or Nephritis No Renal findings Mesangial disease Focal proliferative Membranous Membranoproliferative Awesome Review, Inc.� Copyright 201 4 Do not photocopy without permission Page 356 Tx: • • Cyclophosphamide i.v monthly + Oral Steroids7 fY\. !J e. c..;, � Le. !-<. To get pregnant Pt. should have Lupus inactive for atleast 6 months. f'vvl � t.;,t. [oM) others: • • • • • • ) ) ) Papillary necrosis Perinephric abscess ( c T s tGJ\, ) Acute Pyelonephritis Neurogenic bladder -1 T)< b( tc.. f\.< cJJ\.. UTls/Bacteriuria Type IV RTA What is the best way to obtain an accurate measurement of Renal function? 51. Pt. with type 2 OM with HbAlC 6.2%. Urine albumin <5mg724 hrs. A. Serum Creatinine B. 24 hrs. urine Creatinine clearance. %. Cockroft-Gault or Modification of Diet in Renal Disease equation. = Ideal Body Wt (140-Age)/ 72 x Serum Creatinine ) I ) ---1 ) 52. 55 y/o man presents with hematuria and edema. ast history significant for recurrent palpable lesions on his legs associated with joint aches. xam reveals crops of palpable purpura. A reveals Protelnurla 4+ ab reveals ANA + nti dsDNA negative ntl smith negative epatitis C a ntibodies + 3 normal but C4 Is low. ost likely diagnosis? A. Goodpasture's .;<.' Mixed cryoglobulinemia C. SLE D. Drug induced lupus E. Wegener's \,. p CIO ...\ � Vasculitide s: ,/' � PAN ( M PA)7 P-ANCA +, Hep B s Ag + Wegener's-7 C-ANCA + Prot.1\.... 1<- .3 Pauci-immune/No immune deposits A'b CtJ Best way to confirm Renal manifestations of vasculitis 7 Biopsy NOT Angiography Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 357 Matching B (>.. 1. Minimal change & Focal segmental A. Basement membrane 2. Membranous B. Epithelial cell foot processes ') 3. Mesangioprolif./Glomerulosclerosis C. Epithelial cell C 4. Cresentic RPGN D. Mesangial cell E E. Endothelial cell c; , ARF 53. A 2 y o college stuCfent presents wlttl c/o cora colorect urine after playing occer match. No h/o trauma, rash or fever. Pt. had sore throat less than a week ago. erum BU N/Creat. normal. Serum complement normal. /A' RBCs, RBCs casts, Protein 1+. Most llkel'l dia nosis A. Minimal change disease B. Focal segmental sclerosis C. Post Streptococcal Glomerulonephritis � lgA nephropathy 54. In the above Pt., renal Biopsy Is likely to show \...-1<." igA, lgG & C3 deposition in the mesangium B. lgG & C3 linea r deposit Q55. A 50 y/o with persistent mlcrohematurla BP 130/80. kJA: RBCs 20/hpf, NO protein, no casts. Ultrasound showed normal kidneys, �ystoscopy was negative. Pt. underwent renal biopsy which showed lgA pattern, ho ffbrosls, no capillary Involvement. What will be the outcome for this Pt.? A. Will need HD in 20 yrs. JY.'Will remain stable in 20 .yrs. Q.56. A 2 1 y/o college student with cola colored urine. H/O sore throat a week ago/cellulltis 2 weeks ago. Bun/Creat. 40/4.5. ASO titer Increased, ANA negative. U/A' RBCs, RBC casts, Protein 1+ S erum C3 decreased, C4 normal, CH50 decreased. Most likely diagnosis Is A. Minimal change disease B. Focal segmental sclerosis /.Post streptococcal Glomerulonephritis D. lgA nephropathy Awesome Review, Inc."' Copyright 20 1 4 Do not photocopy without permission Page 358 Matching A 1 . 45 y/o woman presents with hemoptysis. H/O recurrent sinusitis in the past. BU N/Creat. 50/5. 1 U/A7 1+ protein RBCs 15-20/hpf RBC casts +, ANA negative, Serum Complement normal. Renal biopsy7 No immune deposits A N CA + B 2. 24 y/o presents with cough, hemoptysis & cola colored urine. O/E: SOB +, BU N/Creat. increased. U/A750-100 RBCs RBC casts + 1+ protein CXR 7 bilateral hilar/patchy infiltrates Renal biopsy7 Linear lgG deposit. Complement studies normal. A. Wegener's Disease fl,tf£:> ·3 f'\ y ·l .Hf t_,. Rl\•- w d . c.. c vo't:i Ll.""'- B. Goodpasture's syndrome ) 57. A 24 y7o woman presents with arthralglas, low grade fevers, Raynaud's p enomenon. alar flush +, Biiaterai pedal edema + ilateral Metacarpophalangeal & lnterphalangeal joints swollen. UN/Creat. 35/2.2, Serum complement decreased, ANA & a nti DNA Increased. /A? RBCs 15-20, RBC casts +, Protein 4+ 4 hrs urine for proteinuria? 4g/day. W.t.d ) would most likely show ) } ) A. Mesangial lupus nephritis B. Focal proliferative nephritis C. Membranous nephritis � Membranoproliferative nephritis (diffuse proliferative) 58. All the following will have low complement EXCEPT: A. Post Streptococcal GN CJ J B. SLE c 1 Jt ) C� C. SBE D. Cryoglobulinemia c., JI > <-J E. MPGN I & I I inimal change disease � Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 359 QS9. All the following have normal complement EXCEPT: A. Minimal change disease B. Focal segmental sclerosis C. Membranous nephropathy D. lgA nephropathy E. Henoch-Schonlein nephropathy F. Wegener's/PAN \Ji( Cryoglobulinemia 60. A 45 y/o had MVA In 1990 and received multiple blood transfusions at the time. e presents with C/O fatigue and occasional arthralglas. etechlal purpurlc rash in Legs +, B UN/Creat. 30/2.2 �3 1ow k:4 1ow HSO low NA, Anti DNA Negative /A� RBC +, RBC Casts +, Protein 1+ hat other tests would be of help in diagnosis A. Hepatitis B test B. Hepatitis A test � Hepatitis C & cryoglobulin determination D. Anti GBM antibody E. ASO titers Acute Renal Failure Defined as sudden drop in GFR7 increased BU N/Creat. Seen in 1/3'd of ICU patients Prerenal Azotemia is the most common cause of ARF Prerenal: I ntrinsic Renal: • Decreased Renal perfusion • Glomerular diseases Acute Tubular Necrosis Tubulointerstitial disease • • Post Renal: • Obstruction Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 360 Chart 9-16 Prerenal Azotemla '1tRenal Perfusion: Volume depletion: Vomiting/diarrhea/Diuretics/bleeds/Burns Volume overload: CHF, Cirrhosis, Nephrotics NSAIDs, ACE inhibitors, RAS. Others: tf' rJ s fl1..j) � A.S _, OIL. R &vi � fc..� 1' BUN/Creat Serum: Urinary findings: '1t Urine volume-7 1' U. Osm '1t Urine sodium-7 FENa <1, except in Diuretic FENa >1 Urine sediments negative or Hyaline Casts Optimize volume status Treat underlying disease Treatment: ) FENa (Fractional excretion of Na) )o = ) ) ) ) ACE inhibitors: Decreased Efferent constriction via increased bradykinin NSA I Ds: (_ V'-.r<> <Ul•H c.. •d 1� ) '1- .. l/c..1 .i�.a l{c...v Constricts afferent blood supply -7 Precipitates ARF in a patient with underlying renal compromise. 61. What Is the mechanism of ACE Inhibitors? ,;;:rer�erfusion. A. Relaxing Efferent constriction to increase h viY.' Increased Bradykinin with decreased Efferent constriction C. I ncreased Afferent arteriolar pressure and decreased GFR D. Relaxing Afferent arteriolar pressure \ ) 62. Elderly man with history of Hypercholesterolemla, OM II & HTN on blockers, Statfns & HCTZ. Blood pressure sttll remains at 170/115. erum Creat. Is 1.6mg/dl. Pattent Is started on ACE lnhlbltor/Anglotensln Inhibitors. ne week later, BP controlled to 145/90. U N/Creat. � 70/2.6, K 5.6, U/A� No sediment. he most likely cause of ARF Is A. Tubulointerstitial disease B. Acute Tubular necrosis C. Rhabdomyolysis 2° to Statin '\..D:"Prerenal " Azotemia due to ACE inhibitor/Angiotensin inhibitor 63. In the a bove case, w.t.d -7 D/C ACE inhibitor and recheck BU N/Creat, K. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 361 ;Q64. Pt. with HTN started on ACE inhibitor. He also takes Ibuprofen for bsteoarthrltic pain. Creat. increases from 1.4 to 1.9. w.t.d ��-A. Discontinue ACE inhibitor � Discontinue Ibuprofen 65. Pt. with HTN started on ACE inhibitor. Creat. increases from 1.4 to 1.8. w.t.d � Discontinue ACE inhibitor � Continue ACE inhibitor 66. Pt. with HTN started on ACE inhibitor. Creat. increases from 1.0 to 1.8. w.t.d vf(. Discontinue ACE inhibitor B. Continue ACE inhibitor 67. Pregnant woman 18 w gestation, hardly gains any weight. /0 persistentnausea and vomiting for the past 3 months. reatinine Increases from O.Smgto 1.9mg/dl. 68. Pt. with HTN started on ACE Inhibitor, Serum creatinlne goes from 1.2 to 2.5. ost llkel etiology? A. Prerenal azotemia B. Diabetic nephropathy Y,Renal artery stenosis True or False In Renal artery stenosis, medical therapy versus surgical treatment had imilar rate of decline in serum creatinine. 69. 65 y/o withh/o HTN, Ventricular arrhythmias controlled on Amlodarone, TN controlled with p blocker, Osteoarthritis controlled with NSAIDs, presents with ufflness of face on waking up. B/L pltttng pedal edema. /A..!J 3+ protein, 15·20 WBCs, RBCs S. 4 hrs urinary proteln ..!J4g/day, BU N/Creat. '+80/5.0. erum Albumln 2.5 (n 3.2·4), TSH normal. The most likely diagnosis is A. Amiodarone induced Hypothyroidism B. RPGN NSAIDs induced Nephrotic syndrome & Interstitial nephritis. / Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 362 Hepatorenal syndrome 'Functional renal failure' • Renal failure occuring with normal tubular function. • Prerenal azotemia picture with Na <10, FENa <1.0. • Often precipitated with vigorous diuretic therapy for ascites (not pedal edema), large volume paracentesis or spontaneous bacterial peritonitis. • Even after fluid challenge or discontinuing nephrotoxic drugs, renal failure continues. • After Liver transplantation, kidney function gets back to normal. Chart 9-17 Intrinsic Acute Renal Failure FENa >1 ------'>� Glomerular Diseases RPGN Urine: RBC casts • Acute Tubular Neer� �- s o (r-<> t. • • ) r-f A(�. · Aminoglycosiaes, Ampho B, Radiocontrast Rhabdomyolysis, Tumor Lysis, Atheroembolism Urine: Muddy/dirty brown casts, pigmented ) granular casts ) Tubulointerstitial Nephritis: Al ergic: � lactam, PCN, Sulfa, Phenytoin, • ) • Quinolone, mesalamine NSAI Ds (no eosinophils) L;� Urine: WBCs, Eosinophils } ) ) ) Radiocontrast nephropathy: • • Usually occurs 12 hrs. after radiocontrast use. Precipitated by underlying renal compromise. 70. Patient with post Infarct angina scheduled for cardiac catheterlzation tomorrow. /0 OM. Serum Creat. Is 1.6mg/dl. The best way to prevent radlocontrast nephropathy is c ��.,t.,k .JI c_ ,Uw � s t..r p P 1 ) vKN/S 12 hrs. pre and 12 hrs. post procedure +/- acetylcysteine B. 0.9 N/S with diuresis at the end of procedure 71. If the a bove Pt. is going immediately for cath. The best way to prevent adioconstrast nephropathy Is vt<. Give Sodium Bicarb, N-acetylcysteine and start N/S B. Start 0.9 N/S with diuresis at the end of the procedure Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 363 pn. Pt. with h/o chronic smoking, atherosclerosis, Diabetes, HTN on medical treatment /o Chest pain. Patient undergoes a cardiac catheterization. Post catheterlzation patient develops patchy discoloration of skin, 'nger tips and toes. ESR e levated. .:p BC elevated, Eoslnophilia, complement decreased. Creat. increases from 0.9mg to 2.2mg/(U. · Dx: Livedo reticularis due to-7 A-fl\.en:i e.."" b�S M.Best way to confirm -7 Biopsy of skin-7 small arteries with biconcave clefts This is an irreversible cause of renal failure. The best way to treat is A. Start steroids B. Start anticoagulation ,,,,e::' Supportive therapy & good HTN control D. Thrombectomy (RhabdomyolysiJ Breakdown of muscle cells: 1' CPK c.1'Po4 7 --Vca) �K 1'UA Reason for breakdown . n i Jr ) • dv Cocame c s e..;� ·1.� • Crush injury: MVA, prolonged lithotomy position >6 h, Bariatric surgery • Strenous exercise • Heat, ETOH • Statins Dx: U/A-7 Heme dipstick + Muddy brown casts + UNa >20 Tx: 4f u 1' • Hydrate-7 Diurese-7 Alkalanize nly if Renal failure (to dissolve heme pigments) • Treat Hyperkalemia G::umor Lysis syndrom:;) • • • • • • Usually 3 days post Chemotherapy. May occur before Chemo as well. U ric acid Urine UA >l.O Serum UA Serum Ca low & Phos. high K elevated U/A-7 Granular cell casts, rare WBCs Treatment: Allopurinol-7 Hydrate-7 Diurese Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 364 Chart 9-18 \ CPK UA K Rhabdomyolysis tft 1 1 "" 1 Tumor Lysis 1' tit 1 J; 1 ().. Matching Ca Phos. Dip stick for heme (J) � ,,. , • .,. L·r...t LA 1. 26 y/o with non hodgkin's lymphoma, LDH < 2 U LN. Pretreatment? (3 2. 26 y/o with non hodgkin's lymphoma, LDH > 2 U LN. Pretreatment? - A. Allopurinol B. Rasburicase 1--4 P><-up•t+I--- 8 3. 35 y/o with diffuse large cell lymphoma. with bulky disease. N �""I"'" pt Gi <>P D " � � 'YC,) (>'M,&.'i.-Jj, ' Pretreatment? ) B 4. 35 y/o with diffuse large cell lymphoma. with stage Ill. Pretreatment? A 5. Diffuse large cell lymphoma stage Ill with G6PD deficiency. Pretreatment? B f;, 25 y/o A M L WBC > 100,000. Pretreatment? ) ()., 7. 65 y/o CLL WBC <100,000. Pretreatment? } {3 R . Any of the above Pt. developed tumor lysis syndrome on Allopurinol l l ) ) ) ) or rasburicase pretreatment? Ct73. A SS y/o man, chronic alcoholic, Is found lethargic on the street after a binge and t>rought to the ER. BUN 25 mg/di, Creatf nine 5.0 mg/di. Urine analysis reveals 4+ blood, 1 + protein, No R BCs, granular casts + Most likely diagnosis Is A. Prerenal acute renal failure B. I nterstitial nephritis � Rhabdomyolysis D. Hepatorenal syndrome 74. Elderly Pt. lives alone found lethargic with empty Etoh bottles around. rine di stick pos. for blood. Bicarb. 17. Most likely Is . i/Ethylene glycol (jYRhabdomyolysis Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 365 Q75. Acute tubular necrosis can be caused by ANY of the following EXCEPT A. Ami noglycosides: Streptomycin>Gentamycin>Tobramycin B. Amphotericin B C. Cyclosporine D. Rhabdomyolysis vE".' NSAIDs 76. NSAIDs can cause all the following EXCEPT A. Prerenal Azotemia B. Acute interstitial nephritis C. Chronic interstitia l nephritis (analgesic nephropathy) D. Nephrotic syndrome E. Papillary necrosis vF.'Acute tubular necrosis G. Type IV RTA H . Lymphocytic interstitial inflammation and tubular atrophy -1 c.. � us(. Q77. 65 y/o woman presented with abdominal pain and fever. Patient Is started on Ampiclllln, Gentamycln & Flagyl. CT abdomen with contrast is done. Next day patient with decreased urine output to 300cc/24 hrs. Serum BUN/Cr 40/2.2 U/A shows no sediment. FENa <1.0 The most likely diagnosis Is A. Ampicillin induced interstitial nephritis B. Gentamycin induced toxicity vc!.' Rad iocontrast induced nephrotoxicity D. Prerenal azotemia Q78. 45 y/o woman presented with fever, chills and flank pain. /A shows WBCs>20/hpf. Patient Is started on Ampiclllin + Gentamycin. week later, B UN/Creat. Increases to 40/3.5 Mgneslum 1.0mg/dl (nl 1.5-2.5mg) alclum 7.5mg/dl (nl 9-10.5mg) Repeat U/A shows wees <5/hpf, no R BCs, granular casts + Urine Na Is 40 and FENa >1.0 he most likely cause of her renal failure is A. Pyelonephritis B. Ampicillin induced interstitial nephritis � Gentamycin induced neph rotoxicity D. Acute Glomerular nephritis Interstitial Nephritis • • Acute a llergic interstitial nephritis Chronic tubulointerstitial nephritis (analgesic nephropathy) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 366 Q79. All the following drugs can cause interstitia l nephritis EXCEPT A. Antibiotics (Penicillin, Methicillin, Ampicillin, Cipro, Su lfa drugs) B. NSAIDs (no eosinophils) C. Diuretics (Thiazides, Furosemide) D. Phenytoin � ACE inhibitors 80. 60 y/o Pt. presents with cellulitis of leg. She Is started on Cllndamycln and enlclllin, Pt. defervesces In 24 hours. 5 days later, cellulltis is much improved and Pt. as a sudden onset of fever and a maculopapular rash with Itching. ou sto12 the dru s. She has no d surla or fole 's catheter. What will yo_ u_d_ o _n_e_ x_ t ____ �Urine ana lysis and Hansel/Wright's stain for Eosinophils B. Change antibiotics to cephalosporin 81. The U/A shows 10 WBCs, 7 RBCs, Eoslnophlls +, Casts negative. hat Is the most likely diagnosis '' ) ) ) A. � socomial UTI __..1¥.'Penicillin induced interstitial nephritis C. Clindamycin induced nephrotoxicity 82. Middle aged woman presents with complaints of long standing headaches and low back aches. Also has h/o peptic ulcer disease. he denies analgesic abuse. She has polyurla and nocturla. Hb 9.0g/dl, MCV 69, BU N/Creat. 22/2.2 U/A� wees 10/hpf, RBCs 5-10/hpf. No casts. Urine c/s� no growth. Ultrasound� normal sized kidneys and papillary necrosis Dx: Analgesic nephropathy (chronic tubulointerstitial nephritis) causing Papillary necrosis Other causes o Papillary necrosis • Pyelonephritis • Obstruction • Sickle cell disease • TB • Chronic ETOH • Analgesics abuse • RV thrombosis fluvl VUJ'V • Diabetes mellitus POSTCARD Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 367 Post Obstructive Renal failure: • • • • • • • Adhesions post surgery Tumors Radiation therapy Methysergide Nephrolithiasis Drugs: Acyclovir & lndinavir Prostate enlargement Partial ureteral obstruction can cause polyuria, or oliguria with increased Creatinine. Urine indices are NOT reliable in Post Obstructive Renal failure. 83. In a patient with suspected Obstructive renal failure. w.t.d next ��___. -7 Renal ultrasound and rule out hydronephrosis Q84. In a patient with history of adhesions post surgery and coming with renal failure. hat to d o before considering hemodlalysls. -7 Rule out obstruction. If Ultrasound is equivocal. w.t.d -7 Do CT/MRI 0.85. 75 y/o presents with Increased BU N/Creat. ecreased urine output. w.t.d next 86. Renal Ultrasound reveals enlarged bladder, ureteral distension and ydronephrosls. w.t.d -7 insert Foley catheter. Foley catheter is placed: • Distinguish between Post obstructive physiological diuresis Replace 2/3'd fluids & electrolytes Vs • Pathological diuresis-7 volume depletion -7prerenal azotemia replace fluids & electrolytes more aggressively. 87. 70 y/o Pt. with HSV encephalltls, started on l.v acyclovir. BU N/Cr Increases. w.t.d next -7 Continue Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 368 Chronic Renal Failure: Presentation: • • • • • • • Fatigue, leg cramps, polyuria, HTN, Fluid overload Anemia Decreased Calcium, Increased Phosphorus G F R <33 ml/min Elevated BUN/Creatinine X-ray with su bperiosteal bony lesions Ultrasound/CT7 Small Kidneys (except Amyloid, polycystic disease, HIV) Complications of Chronic Renal Failure: Acid Base & Electrolytes: Early7 Non Gap Acidosis Late 7 Gap Acidosis Anemia Cardiac: • • \ • • • Hyperlipidemia CAD HTN Pericarditis Tamponade Neuro: • • '\ Others: • • ) } ) I I Peripheral neuropathy cognitive impairment when creatinine is > 2.0 Pseudogout, arthropathy with variable birefringence (Ca. oxalate) Gastritis, Colitis, constipation Management: Strict HTN control 7 ACE inhibitors/Angiotensin inh ibitors first treatment of choice. Anemia 7 Erythropoietin Acidosis 7 Bicarb. 22 Hyperparathyroidism7 Oral calcium, P04 binders, vitamin D3 to decrease PTH level, Parathyroidectomy if PTH levels > 1000. 12. • Statin has shown to decrease mortality in early renal failure. Statin have NOT shown to decrease mortality in a patient on hemodialysis . Indications for Hemodialysis: • • • • • • • G F R <lSml/min Fluid Overload Metabolic Acidosis Severe Hyperkalemia Malnutrition (decreased albumin) Pericarditis Encephalopathy Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 369 Complications of Hemodialysis: • Disequilibration syndromes • Infections of A-V fistula • Hepatitis B & C • Arrhythmias • Aluminum toxicity • Amyloidosis • Renal cysts • Renal carcinoma • Bleeding diathesis 88. A Pt. with ESKD presents with shortness of breath. Creat. 8.0, K is 6.0. xam reveals bilateral pedal edema. P is 150/90. JVD elevated. XR shows bilateral pleural effusions. KG reveals a low voltage EKG. What is the best management? A. Pericardiocentesis vB".' Hemodialysis C. Kayexalate 89. 90 y/o woman in assisted living center, tired after walking a block and no other complaints. She loves her great grand children and is looking forward for attending raduation of the first Harvard graduate In the family In 3 months. outine exam shows BUN 90 and Creatinine 9. w.t.d? A. Begin hemodialysis Monitor Discuss outcomes with Pt. (and family) and recognize goals set by Pt. (and family). @ 90. 82 y/o in nursing home walks with a walker and has mild confusion, is found to have UN/Cr. 80/8. I nitiating hemodial sis in this Pt. would result in? A. Improved mortality B. Improved functional status A, Decreased functional status 91. What is the best management for an ESKD patient ? vA. w Na B. � Na - w Water w K 1' Water Regular K w Phos. Regular Phos. No Ca restriction w ca True or False 1. The commonest cause of Chronic Renal failure in US is Diabetes mellitus 2. The mortality rates at the end of 5 yrs are higher in H D patients T -------i compared to lower rates in Renal transplant patients. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission T Page 370 Q92. A 55 y/o OM Pt. presents for routine follow up. He Is on Glipizide, ACE and calcium carbonate. BP 138/84. Hb/Ht 8.8/24. BUN/Creat. 36/3.2, Ca 9.0, phos 4.5. I ron, TIBC are normal. w.t.d A. Increase ACE I ,,..-8:" Start Darbepoetin Alpha Plus Iron C. Transfuse 2 U PRBCs D. Decrease Calcium carbonate ) 93. What antacids would you avoid in ESKO? 94. What kind of enema can cause Renal failure? 95. Pt. with ESKO. PTH 1', Calcium 1', Phos 1' . lschemlc skin lesions. Ox. ) 96. A 55 ylo man wittl ESKO presents with thickening of his skin in his legs and arms, like a eau d'orange appearance. Most likely diagnosis? ) ) ) ) ) ) ) � � t.:J rA ey,,.,..p 4 � � e_, ,..,... , ,. � Nephrogenic fibrosing dermopathy Q97. I n a Pt. with renal Insufficiency, keeping serum bicarbonate a bove 2 2 mEq has shown. True or False 1. decreased rate of lung function decline - 2. improved nutritional status Nephrolithiasis 1-5% of population. Males> Females 'moderate to severe colicky flank pain, radiating to the lower abdomen or perineum, with urgency or increased frequency with gross or microscopic hematuria' Diagnostic workup: • First stone, asymptomatic, hydration and observation • First stone symptomatic or recurrent stones, then do further workup Family H/o stone -->W/u • • • • X-ray Abdomen -7 shows all stones except Uric acid Renal Ultrasound > Smm in size IVP Spiral CT ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 371 Predisposing factors: Hypercalcemia (Hyperparathyroidism, Sarcoidosis} Hypercalciuria >300mg/day in men & >250mg/day in women Hyperoxal u ria >40mg/day(IBD, Short bowel syndrome}, Vitamin C, meat / .sp c:� l lv post bariatric syndrome Hyperuricosuria > 750mg/day Hypercystinuria i. t,:""" High Na diet -1 1' C... c eKc.-<. <fl Hypocitraturia <300mg/day (I BD, RTAs) 98. What would you ei:cpect in a patient with short bowel syndrome or Crohn's? A. Decreased Calcium absorption vw.' Increased Oxalate absorption , Decrease citrate absorption C. I ncreased Fatty acids a bsorption 99. All the following are formed In Acidic urine EXCEPT: A. Uric acid stone B. Calcium Oxalate stone c.e"vol... r< ) C. Cysti ne stone Q �truv te stone ( c:;>Jti"- ) Alkali urine J C... N PJ.J. po'i ( Pro<:...- ) 100. All the following are a risk factor for stones- EXCEPT A. Hypercalcemia B. Hypercalciuria C. Hyperuricosuria D. Hyperoxaluria E. Hypocitraturia F. Cystinuria G. Renal tubular acidosis H. Inflammatory bowel disease I. Hypervitaminosis C J. High sodium diet � Hyperuricemia without hyperuricosuria 101. You would do further diagnostic workup for all the following EXCEPT: A. 45 y/o with kidney stone. H istory of passing a stone a year ago as well. B. 28 y/o with kidney stone. Family history of kidney stones. � 33 y/o man with stone for the first time and mildly symptomatic. D. 40 y/o man with flank pain, hematuria and kidney stone for the first time. 102. Kidney stone most likely NOT to be seen on X-ray Is A. Calcium oxalate B. Calcium phosphate C. Struvite -15. Uric acid Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 372 103. 32 y/o with dysurla, Increased frequency. H istory of recurrent UTls In the past ouple of years treated with antibiotics. No flank pain or hematuria. /A pH 6.6, RBCs 10-15, wees 40-50/hpf, Nitrites (+), Gram neg. rods present. bdominal X-ray shows Staghorn calculus. he disease is most likel caused by A. Calcium oxalate A. Magnesium ammonium phosphate {Struvite) Proteus, Providencia, Klebsiella, Pseudomonas, enterococci C. Cysti n e D . Uric acid 104. The most common cause of recurrent nephrollthlasls is ) ) ) ) ) ) ) ) ) ) ) ) ) I I ) A. HCTZ Y, ldiopathic hypercalciuria 105. A Pt. with renal collc. Kidney stone 5mm on CT scan. W.t.d? A. Lithotripsy ,,fr.' Fluids 106. A Pt. with renal colic with 4mm stone at the ureteropeMc Junction. lulds are encouraged. Pt. still In pain. W.t.d? A. Lithotripsy _)Y.lamsulosin (Flomax®) 107. Pt. Is diagnosed with Inflammatory boweJ l�ff&se. You may expect all the ollowlng EXCEPT --------�A. Hypero xaluria B. Hypocitraturia � Cystin uria .,._,.1; qa.. t...: t:.. "':l"� r� � 108. Pt. Is diagnosed withdistal RTA I and has a kidne¥ stone-. T.lle stone's omposltion is most llkelyto be Also RTA II A. Ca oxalate yea phosphate C. Cystine D. Uric acid True or False tv.uL t.. h-1,-;. ox� L<.,_., �tory of renal stone is contraindication for adequate calclum in the diet. I F - Q.109. A Pt. with short bowel syndrome. You prescribe added calcium In the diet to A.yecrease absorption of phosphate )Y. Decrease absorption of Oxalate Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 373 p.110. 40 y/o man presents with Renal colic and found to have Calcium oxalate stone. � !story of passing a similar stone a year ago. Cr 0.8mg/dl. PTH level SSpg/ml. - negative for adenopathy or Infiltrates. FXR p/A shows 40-50 RBCs, WBCs <5. �4 hours urine collection shows alcium 370mg/day (n <300mg/day) rlc acid 730mg/day (n <750mg/day) xalate 35mg/day (n <40mg/day) ltrate 660mg/day (n 300-700mg/day) he best way to decrease urinary calcium excretion and prevent stone formation n the urine is A. Low dietary Calcium B. Lasix C. PO citrate D. High Na diet /HCTZ Nephrolithiasis is not a contraindication for increased calcium in the diet. Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 374 An AWESOME REVIEW OF 4% - Headache - Tumors - Cranial Nerves - Cerebrovascular diseases - Subarachnoid hemorrhage - Vertigo - Dementia - Multiple sclerosis - Parkinson's disease - Neuromuscular disease - Seizure disorder !Char t 1-7 Headache Cluster Migraine Tension Distribution F>M M>F F>M How often Qfew weeks 1-2/day Variable/Chronic Onset X hour 2-15 mins Variable How long Hours to days (4-72 hrs) X hr-2 hrs X hr-7days Where Frontal/Temporal One side/both Orbital One side Diffuse What kind Throbbing Excruciating Non-throbbing Features Nausea, Vomiting, Aura, Photophobia A M, menses, menarche, weather, stress, barometric changes. worse with movement Rhinorrhea, Ipsilateral Horner's, Unilateral lacrimation Band like Treatment Tyleno NSAI Ds/ 100%02, ASA-� umatriptan(s) Intranasal lidocaine, -?intranasal or s.g_ Sumatriptan Prochloreerazin� ( f\'D pt Chlorpromazine/ Metoclopramide Analgesics How to prevent f3 blockers Tricyclics Riboflavin (Vit B2) Coenzyme Q10 Topiramate Botox f3 blockers Tricyclics � Verapamil Valproate (Depakote®) Gabapentin (Neurontin®) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 264 1. A 25 yr. old woman presents with chronic headaches for several years. otfced It from puberty. Mainly with waking up, and it persists for several hours every ouple of weeks. The pain Is throbbing type and Is associated with nausea and ccaslonal vomiting. She has no auras. Several Tylenol and Motrln don't help her nymore. This Pt.s acute pain will most likely respond to A. Propranolol B. Ca channel blocker � Sumatriptan D. Nasal 02 E. Antidepressants A 25 yr. old woman with flashes of light moving across eyes for a few minutes with oss of vision In one eye. /E: left homonymous defect t. Is normal after 45 minutes. • 3. Young woman C /0 wea ness of rlgllt arm an rigllt eg. Slle llas past medical lstory of migraines. She feels better after a couple of hours. arotfd ultrasound, MRI brain & TEE are normal. ) ) Don't use triptans in CAD. tSv> VM�'t·s 4. A 52 yr. old man presents with moderately severe blfrontal throbbing headache. t Is associated with nausea. He has been having headaches for the past couple of years. xam reveals a normal temp, BP 150/90 and Fundoscopy Is normal. eck Is supple and there Is no head trauma. Pupils are reactive. No focal eurologlcal deficits. PMHx significant for Coronary artery disease. w.t.d______ next? ___, A. CT head B. Spinal tap � NSAID with prochlorperazine D. Cyclobenzaprine ) 5. Acute migraine with nausea and vomiting, Fastest relief Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 265 6. Severe acute migraine not responding to sumatrlptan or for more than 72 hours. -7 -z.v �p�('.( ��o�Jt -7 1.1/ � f'�� c;W-c,tvv\1\L [prochlorperazine or metoclopramide] plus ___, _, [to prevent acute dystonic reactions] _ _ e'::lc. .rt�o.cl< , rv> """"�� 7. Severe acute migraine for more than 72 hours, last sumatriptan >24 hrs ago with ittle response. 8. Pregnancy with migraine headaches once a week Acetc.,....;.nopN..,.. -7 9. (0-n rJSA1.Ds ------- Pregnanc:y with migraine headaches no response to NSAIDs -7 Metoclopramide or Chlorpromazine or Ondansetron (Zofran®) 10. Migraine prophylaxis for -7> � times per week -7 Beta blockers, Amitriptyline, Topiramate, Sodium valproate 12. Prophylaxis for migraine > 15 times a month -7 l0 pire..� Sfr: c st"""' �l) Q13. -7 -7 eot.>x ( i�tt.t.'c.-.-.) Prophylaxis for migraine with Asthma �blocker contraindicated-? \M.A- (.>.,...,.... iv-•'P'tcr� 1 Topr'-ra. rvv..k 14. Prevention of menstrual headaches -?mefenamic acid 2 days prior and upto end of menstruation (Ponstel®) 15. Migraine with aura -7 � contraindicated Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 266 16. Pt. with Hx. of migraine headaches takes NSA IDs, recently has had to take NSA IDs nd Tylenol daily but continues to have headache every day from morning to evening .t.d • A. Increase the dose of the NSA IDs $Discontinue all analgesics <- if\c.\...J...;"f �W) � ove.-v..� H ��"'c.�-.< 17. A 42 yr. old woman presents c/o chronic non throbbing headache, gets worse at he end of the day. Band like around neck. \ Q18. A 35 yr. old woman presents with c/o excruciating Ice pick like retro-orbltal headache. History of rhinorrhea, lacrimation and Ipsilateral horner's syndrome. ............................... ... � . 19. Pt. with recurrent headaches > 5-6/day lasting 15-20 mlns, unilateral nd retro orbital. ) ) 20. A 32 yr. ola obese woman B MI >30, witti Clally tieadaches. P/E: horizontal diplopia. Fundus: Blurring of optic disc margins. <. p�nle-tc""'-& ) pressure Spinal Tap with Increased ----� - -------- -------� --�.... .... . .... . .... . .... . . ............... ........... ... .... . .. . .... ... . � -- } > } Causes: Obesity, Vitamin A toxicity, Tetracycline, steroids and contraceptives, Nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen and Levothyroxine. Lumbo peritoneal shunt. ) 21. Complications of pseudotumor cerebrl --------�--� ) ) � Peripheral visual field loss� Centra l visual field loss. 22. Pt. known hypertensive with headache and ataxia. scan with large cerebellar bleed. w.t.d -----otherwise it may cause brainstem compression. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 267 Matching C. 1. A 6S yrs old with headache. ESR 7S mm/hr �. Headache with rhinorrhea l_3.100%02 f).. 4. Headache with zigzag wavy lines, photophobia and aura A/!l Sumatriptan �6. Thunderclap headache, CT scan negative, CSF with xanthochromia �7. Chronic headache, increased on lying down �. Young obese pregnant female with headache and horizontal nystagmus <')) 9. Acetazolamide _s. A. Migraine B. Cluster headache C. Tension headache D. Pseudotumor cerebri E. Subarachnoid hemorrhage F. Brain tumor G. Temporal arteritis Matching �1. SO yr. old woman with seizure or focal weakness, A. Meningioma headache worse on coughing and lying down. CT: 4 ems lesion, large edema, mass effect. No calcification. �2. SO yr. old woman with headache, worse on coughing, B. Glioblastoma/Astrocytoma and lying down. CT: intraventricular tumor. P... 3. SO yr. old woman with history of seizure disorder for C. Choroid plexus papilloma about 4 yrs. CT head 3 ems tumor in the sylvian fissure. Diffuse enhancement with contrast. 23. The LEAST likely tumor to metastasize to tile brain Is A. Breast B. Lung C. Melanoma D. Lymphoma E. Renal ...-(." Prostate Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 268 Q24. A 45 yr. old woman with lightning pain jabs in her gums, cheek and chin, several 'mes a day lasts a few seconds at a time. o focal neurological signs, oral exam normal. You would A. Do CT scan/MRI of head B. Reassurance t.e:"' Carbamazepine(Tegretol®l-�c �� sp&o.Jt.·•) D. Antidepressants � ��. � l"c ;W\M. ,;,.. .. LU<.c�t ,.;., ,.,...Jt..')?l.. �� "J- lc.t.....,..� _ litv-Qu;'W\.M. "fU'� Chart 2-7 • Supranuclear: CVA • Upper face spared. H U N G U P • Intranuclear: • • • ) • • ) • J Bell's palsy Acoustic neuroma Ramsay Hunt syndrome Guillain-Barre Lyme disease Sarcoidosis Both upper & lower face involved. Chart 3-7 ) Motor Neuron Disease } ) ) ) lesion Lower Motor {LMN) Infra-nuclear Neuron Upper Supra-nuclear Motor(UMN) Neuron = Normal =Active = Reflexes Muscle tone Fasciculations � � + t t Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission - - Page 269 Matching �1. yr. old with erythema chronicum migrans 4 weeks 30 ago, now with left sided upper and lower face paralysis, preceded by headache. (3 2, 55 yr. old with vesicular lesions on Right side of face with pain, involving the ear. A 3. 65 yr. old man with slurred speech and lower face paralysis. �4. 55 yr. old presents with right sided facial paralysis of unknown etiology. A. Supranuclear lesion B. Intranuclear lesion 25. A 60 yr. old man presents with sudden onset right sided facial weakness, drooling f the saliva and Inability to close right eye. /E: Mouth deviating the left side. Unable to raise the eyebrows. Rest of the eurologlcal exam Is normal. You would A. Give TPA B. Start Aspirin and Warfarin y. Artificial tears, Patch Right eye at night and start prednisone therapy. ( f\IP P.'-':1 Lov•" ) to c. Q26. Young woman with c/o diplopia. Closing one eye, diplopia persists. ost likely diagnosis? Chart 4-7 Ill nerve palsy RT U/L LT <Et> <l> B/L <Et> � �� 5 '----+- A""e,., "'.1 .s"" o.:f PO.rt. '-""''._,,,..,;(.� A � -. <..<>"'1>"<.#1 3l:!!rw ( 'D;.V..t<t"" l pt..s:.-J) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 270 Q27. A 48 yr. olil Pt. witn pupils nglit siile 6mm anil left 3mm wittl rignt Clroopy eye i No facial palsy is seen. Unable to look up, down or inward. This Pt. has A. Diabetic neuropathy B. Eaton Lambert syndrome ..Y, 3rd cranial nerve palsy --------� 28. Where is the lesion in the above Pt.? A. Anterior cerebral artery B. Internal Carotid artery f. Posterior comm. artery ) 29. w.t.d for the above Pt.? A. CXR y8': MRA brain p30. A Pt. wittl motor vellicle acciilent is tirougtlt to ttie ER witti lieailaclle, �nd neck pain. Physical exam reveals right pupil is 2 mm and left pupil is 4 mm. �here Is ptosis of the right eye. What should we do next? ) ) A. Chest x-ray 1), ��""'"'J"'LcA h-e-r� J;Y'tT angiogram of neck ) Q31. What is the most likely diagnosis? ) A. Third cranial nerve palsy ) � Carotid artery dissection ) 32. Pt. with acute onset of diplopia. Hx of OM, Ptosis. } ----1 ) ) ) .,..,.-p: c Not. LM hJH ) 33. Pt. with hyperthyroidism and exophthalmos unable to completely abduct nd has double vision. Most likely cause is A. 61h cranial n.palsy y. Thyroid Ophthalmopathy 5 t(.v1f\·cA _ _, ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 271 . opt:<.r-..1 o�· wc:..tt ortM- l /.j R*"�'""' II ;..:: 'I'' 1. Complete blindness one eye Bitemporal hemianopia <. ptM '-h.i C41V'4 J Prt.-.,..,�� '3' ��1. 3. Left homonymous hemianopia c_ R ort.• t..-"<-t �(Pi J 4. Left homonymous quadrantanopia/dense hemianopia/ macular sparing ( t<. or�<- ra..M� t.>w.} 2. o � • "L<-.pii;(lt L.obc.] A. Right optic neuritis B. Tumor pressing on the optic chiasma (Acromegaly) C. Left optic tract D. Left optic radiation (occipital lobe) (3 1. Bitemporal hemianopia ( 2. Right dense homonymous hemianopia ] 3. Right homonymous quandrantanopia A 4. Multiple sclerosis with blindness of right eye Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 272 Chart 5-7 Cerebrovascular Disease days (transient ischemic attack) Ipsilateral visual loss (amaurousis fugax) 'shfJ<fw in front of the eye' Contralateral motor or sensory changes Stroke •TIA •Carotid artery syndrome: 50% preceded By TIA. Gradual onset. •Embolic: More rapid onset •Thrombotic: •Hemorrhagic: \ HTN, Amyloid angiopathy •Vertebrobasilar syndrome: _. fV'I A o� � t..ettb� A DOD \ Dizziness, Diplopia, Dysarthria Sudden weakness of legs-7drop attacks Bilateral weakness Tx: Aspirin l t •Duration>10 mins •Speech disturbance •Age >60 •DM \ ) ) ) ) A>60, BP: ----, C: Clinal Feature, Duration+ Speech disturbance --> 2 PT, DM, >2PT --> ADMIT) Q34. Most lm ortant risk factor for Stroke? H1N 35. Pt. with TIA. w.t.d next PTT ) r G(...h.o ) I ) J ) ) -7 c..cwv� ei'\.J.�YteYe'-t.o""':! t AsA 37. Pt. with TIA and 90% stenosis and inoperable. w.t.d -7 S'�t 'i,J / st"'� v, S\1\A�) sw:r<A:J 38. Pt. with Tl/an d carotid ultrasound with < 50% stenosis. w.t.d -7ASA+dipyridamole {Persantine®) or Clopidogrel(Piavix®) -1 __, LU? (...�c... .,� Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission �� r�4 Page 273 Q39. Pt. with Hx. of TIA. No PAD. Best management? �ASA B. Clopidogrel C. Dipyridamole Also can add ACE inhibitor (Perindopril) +/-lndapamide to decrease recurrence 40. Pt. has TIA on ACE inh., ASA 81mg and statin. What is the best management? A. Increase ASA dose to 325mg B. Add Clopidogrel � y. d/c ASA and start Clopidogrel Don't use ASA + Clopidogrel. It will increase bleeding complications Chart 6-7 Endarterectomy Mortality � Stroke 8 Worse High carotid bifurcation 41. Pt. with TIA and found to have Affb. w.t.d Stent Higher Higher (setteU Q42. Pt. with CAD going for CABG. what other workup before CABG. 43. If in above Pt., carotid ultrasound reveals significant stenosis. w.t.d -7 Carotid endarterectomy first. Q44. Pt. with diplopia, dysarthria, dizziness. Ox. with vertebrobasilar ischemia. w.t.d -7 AsA Awesome Review, Inc.® C opyright 2014 Do not photocopy without permission Page 274 045. What is the best test to establish diagnosis in the above Pt.? A. CT head B. MRI head �MRA of posterior cranial vessels Q46. The above Pt. started having occasional epistaxis especially with sneezing. hat Is the most likelydiagnosis? vK.Von Willebrand disease B. Fat soluble Vitamin K deficiency ----------------------------------------------� ) \Inclusion Criteria for Tx. with t-PA\ � • • Ischemic stroke with clearly defined symptom onset No evidence of intracranial blood on CT scan of the brain Time from symptom onset to the delivery of rt-PA is less than "2.:fo minutes C.4 Y2 t,.,. ) Exclusion Criteria ) \ ) I ) ) Rapidly improving stroke symptoms Stroke or serious head trauma within 3 months/Major surgery within 14 days Suspected sub�rachnoid hemorrhage des�it� a normal CT scan of the brain l 'lv ca-- ·..,._ Systolic BP ;r ?ss mm Hg or diastolic BP > lfo mm Hg /J'l-> Current use of anticoagulants PT > 15 seconds, platelet count < 100,000/�-tl, glu < SO mg/dl or> 400 mg/dl • • • • -1 • • ..-f L.:.'<>ete,...(. ---i } 48. 70 yr. old man with Hx. of Aftb presents with sudden onset weakness of one side. ) ) r�.-< t.pA t.PA -7 ) CC,... Q47. 65 yr. old man woke up In AM and then had stroke. CT negative for bleed. Presents within 3 to 4.5 hrs. w.t.d ) ) � T scans negative. w.t.d --------�--� -7 t- PA 49. Above Pt. receives t- PA. What else to do for Pt.? A. ASA now �ASA 24 to 48 hrs later C. Heparin now Q50. 65 yr. old man found in AM in bed with stroke. w.t.d (Since the duration is unknown) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 275 051. Pt. with ischemic stroke, time of onset 60 mins. CT no bleed. BP 200/120 w.t.d \)(,'labetalol i.v when BP <185/110, then tPA B. Observe Q52. Pt. not taking HTN meds for 1 week. BP In office 240/130 with headache, isual disturbances with hemianopsia/Auras/cortical blindness. Rl brain reveals white matter edema In the Parieto-occlpltal regions. Dx: Posterior Reversible Encephalopathy Syndrome. ( p r<. Es ) Q53. Above Pt. sent to ER and started on i.v Nitroprusside. 2 hrs later BP 140/90, lurry speech but headache better. w.t.d next A. Acetaminophen vB:"Taper the Nitroprusside ( pt �pr Jt,...., 14 J C. t-PA Matching When should anti-hypertensive be started? �1. In a Pt. who is having a hemorrhagic stroke ____0_2. In a Pt. who is having an uncomplicated ischemic stroke not eligible for t-PA �3. In a Pt. who has ischemic stroke and post t-PA A. BP > 220/120 B. BP > 190/100 C. BP > 170/100 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 276 ACA C/L weakness of leg/foot WIT H sensory loss Urinary incontinence Primitive reflexes • • ) • } \ ) ) ) I MCA Parietal lobe Left (dominant): • Temporal lobe: ) • ) • ) Acalculia, Agraphia, Lt . Rt. Disorientation, Finger Agnosia, Tactile agnosia, Astereognosis, Paresthesias Aphasia Parietal lobe Right (non dominant) • Spatial neglect Unable to dress ) ) ) ) 1 PCA • • • U/L: Homonymous hemianopia 1/L 3'd N. Palsy(WEBER's syndrome) Contralateral sensory abnormalities ) Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 277 C Lateral Medullary Syndrome {Wallenberg Syndrome) fYl_Cf\ ) •1/L loss pain & temp. from face •1 /L palsy U & L. face •1 /L loss of lacrimation & salivation •1/L taste loss ant. 2/3'd tongue •Vertigo, Nystagmus, nausea, vomiting •Tending to fall to same side, wavy images •Hoarseness, dysphagia Medial Medullary Syndrome (Dejerine Syndrome) c ,::\A�"" .rp>tvl A ) 0 •Contralateral hemiparesis and paresthesias •Affected eye looks DOWN & towards the nose •1/L tongue palsy ¥'1. WCA.W-- � ""'..... ( c\.: v<c../c k I 1{:.( I�· �MeJ..c.1l (/l - �v.-, .J�C jloftit;... Ill;!.-<'+) �ltl\t.y.. "\ i.-v7 Basilar Artery Stroke •Hemiparesis with involuntary shaking movements •Bulbar muscles involvement with loss of function in the throat . Unable to move tongue, only eye movements present and called Locked-in syndrome. •Quadriplegia Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 278 pv.jtt--J-isl... Asc.� pqy.r.�� \ ) ) ) ) ) ) ) Matching A. Right Anterior cerebral artery �1. Pt. with right sided hemiplegia with sensory deficits, right hemianopsia and has aphasia B. left Middle cerebral artery �2. Pt. with Left leg & foot weakness, urinary incontinence(+) �3. Pt. with right sided sensory abnormalities, Ptosis of C. Left Posterior cerebral artery left eye, with pupillary dilation. D. Basilar artery 'D !l. Pt. with diplopia, dysarthria with one sided weakness with perioral numbness and shaking/shivering movements of the affected limbs E. Left Lateral medullary 1) 5. Pt. with quadriplegia, cant speak, cant put tongue syndrome out. Eye movements may be ok. rE--.6. Pt. with dizziness, nausea and vomiting, loss of pain and temp. sensation on left half of face and right side of body, wavy lines, tends to fall to the left while trying to sit up. Hoarseness, dysphagia. I� 54. 32 yr. old woman without any PMHx presents with stroke. Exam reveals ain and tenderness over the calf or thigh. Most likelyetiology TTf. A. .Afib $ Paten1 foramen ovale ( 1>V1 �b)t.· ·R-d. M,...;..- �.,..;. Tf f � b k�-u 55. A 45 yr. old woman wltli lupus wltli an p ospllollpl synctrome with history of DVT In he past now on warfarin with PT INR 3.4 presents with TIA with right eye blurry vision which esolves In 10 mlns. What Is the next appropriate test for this Pt.? A. CT angiogram of head ......-fY.' ECHO with bubble studies C. Factor II level 56. An 82 yr. old man Is brought with headaches and right sided weakness. ----------------------�--� _,_ _ ....bblt .) ......f -t .rt.-o"<.. _, �� r� f vvtft b"'� Jt...t{.,·<-� T reveals hyperdens lesion in the parietal area suggestive of subarachnoid ematoma. BP is 35/7 No Hx. of trauma. Most likely cause is A l � my oid angiopathy B. Berry aneurysm Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 279 Chart 7-7 Aphasia Broca's aphasia -7 non f luent speech, can comprehend Wernicke's aphasia -7 fluent but non-sense Cant comprehend branch of middle cerebral artery Conductive aphasia -7 Can't repeat.. Can comprehend and read Global Aphasia -7 Sensory and motor aphasia Pure word blindness-? Can't read -?branch of middle cerebral or Internal carotid artery -7 Posterior cerebral artery Subarachnoid hemorrhage QS7. ' Thunderclap headache', 'hit by a hammer headache', 'worst headache of my life' with nausea, vomiting, altered consciousness, neck stiffness, seizure, Ill n. palsy. w.t.d next -7 CT head >90% sensitive during acute episode. If CT head negative -7 Lumbar puncture-? Xanthochromia(+} If LP neg. -7 MRA -t.-> R.;o Best test to confirm prior to surgery -7 Cerebral angiogram Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 280 Complications: Rebleed: 24 h-1 month Vasospasm: 4-lO'h day ( 0tJ sw-n Hydrocephalus: late 58. � s�1"'- ) The Best drug to treat Vasospasm QS9. Best time to do su rge ry ��-------------------------------------� (ASAP) \ Q60. A week after aneurysm surgery he develops stroke. Most likely cause is /vasospasm induced infarct B. Hypotension Chart 8-7 Central Brain stem/cerebellar diseases: Multiple sclerosis, cerebellar atrophy, basilar infarct, Arnold chiari malformation Peripheral � R. L �e>. �(. rt( t< L rv.S t&.ffV\ .,.j '1.. Vestibular neuritis, Labyrinthitis, Meniere's disease, ) Benign positional vertigo ( ""�s t Nystagmus Horizontal OR vertical ONLY horizontal '*"� Visual fixation Hearing loss/ tinnitus No inhibition of nystagmus +I- Inhibition of nystagmus *' ) ' I ) -l I) ) Vertigo - Causes Nausea, vomiting Severity I! - � t � - + Labyrinthitis (Vestibular neuritis (-)) Meniere's disease {+l ++ + ++ ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 281 Chart 9-7 6 1. Pt. with vertigo and horizontal nystagmus. On visual fixation nystagmus isappears. 62. Above presentation with involvement of vestibular portion of the 8th nerve ith dizziness lasting hours to days. 0 deafness. Upper respiratory tract Infection a week ago. Ox: Vestibular neuritis(Labyrinthitis) 63. A 35 yr. old man with recurrent attacks of dizziness and tinnitus or sensation of fullness n the ear for the past several months, associated with nausea and vomiting. xam reveals a horizontal nystagmus which disappears with visual fixation. Audiogram uctuating hearing loss. --------� Ox: -7 I'Y\<- M<=-re .t /.S -7 diuretics-? surgical ablation 64. A 70 yr. old man with new onset of sudden dizziness for the past 2 hours. BP high. .t .d? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 282 65. Pt. with vertigo, unilateral tinnitus and progressive hearing loss. Arises from f�l-/� Cf..'VL.t A Pt . presents with above symptoms w.t.d? A. Reassurance B. HCTZ v(. MRI D. Meclizine 66. Pt. with vertigo • • • while turning in bed/getting in and out of bed Bending over and straightening up Extending neck to look up, episodes last about 30 sees. Denies hearing loss. ) ) 67. Pt. with vertigo, dysarthria, diplopia and ataxia. ) ) Duration of Vertigo ) Seconds • • I ) B PPV T IA Minutes • • • Migraine Orthostatic hypotension TIA Hours • • Migraine Meniere's Days • • • Migraine Labyrinthitis Meniere's Weeks • Labyrinthitis ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 283 NL Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 284 Matching �1. Vertigo with fluctuating hearing loss, tinnitus lasts ) ) ) ) I ) ) ) ) A. Meniere's disease hours to days �. Vertigo with progressive hearing loss and tinnitus. B. Acoustic neuroma Whisper test decreased. Tuning fork on left mastoid without response, tuning fork on the forehead with better hearing on right. �3. Vertigo lasting 30 seconds and wakes up Pt.. C. Benign positional vertigo No hearing loss ___§_4. Vertigo with sudden onset dizziness, dysarthria, D. Vestibular neuritis diplopia and weakness (Labyrinthitis) �5. Vertigo post URI. Horizontal nystagmus, E. Vertebrobasilar ischemia disappears on visual fixation. --.S:_6. Most common cause of vertigo F. Presbycusis F 7. Tinnitus with gradual onset hearing loss . Whisper f-'-test decreased. Tuning fork on mastoid doesn't elicit response. Tuning fork on forehead with no localization. Audiology with high frequency hearing loss. Most common cause of Dementia is Alzheimer's disease: 760 yrs., Cognitive impairment. Poor short term memory, can't name names 7paranoid delusions Path: CT/MRI: Brain atrophy(enlarged sulci)- Meynert area and temporal lobe. And�dilated ventricles. Increased �amyloid from amyloid precursor protein; increased Presenilin activity and Apo protein E4. Neurofibrillary tangles consist of microtubule-associated protein Tau Treatment: MMSE score "1\-'2-S 7 Cholinergic augmentation(with Anticholinesterase) Donepezil(Aricept0), Galantamine(Razadyne0) Rivastigmine(Exelon°). MMSE score 11-20 7 Cholinergic augmentation Plus NMPAantagonist Memantine MMSE 10 or less 7 Severe dementia, consider palliative care. (Namenda®) Stop � c.o.h'<N\dilated Brain atrophy; ventricles dilated sulci .V - LNPH':l"-,.,'erc.LIM) .} .. ._ tA:.\...c:f-;;1-\"'" ") vv-.1:.-·vt. + Nb B-rc..V-. At...P) AYi""ft ..(13,... "'-Jtc:.tA.'< 'L :{f ) ·: 'Dv.,t p...t rt t.. Pl'f"'- ..�--��--�--, �� ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 285 68.What is more likely with the use of cholinesterase inhibitor? vK,'Improvement on neuropsychiatric score B. Improvement in cognitive function C . Improved quality of life 69. Pt. with Alzheimer's disease. Family asks you about memantlne. What's your advice? � Memantine will slow down the progression of dementia 70. Pt. with Alztleimer's on Donepezll, has hlp surgery, post surgery stle is gltated and confused. What Is the most likely diagnosis? --------� A. Worsening of Alzheimer's dementia vfl. Post-operative delirium 71. An 82 yr. old man with Alzheimer's disease for several years, has been getting onepezll and Memantlne, Chlorthalidone for HTN, Metformln for OM, and ortrlptyllne for depression Is getting progressively agitated. What Is the best management? A. Start atypical antipsychotic Y,Discontinue anticholinergics In the above Pt. what is going to delay nursing home placement? � S (.,o!.-fP0rr � Enroll the wife in a ---�------------------------ What has been seen with the above? � Decreased caregiver ___b_�_'('_�-- --------------------72. Oonepezll, galantamlne and rivastlgmlne are cholinesterase Inhibitors and used to treat ementta. They have been associated with? 1' A. Syncope B. Bradycardia with increased pacemaker placement 1' C. Hip fracture -r 73. Who is more likely to experience severe disability In performance of daily living ctlvltles? vA. Advanced dementia B. Cancer Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 286 � 74. A 62 yr. old sales executive presents to you with complaints of forgetfulness. MSE is 27/30 (nl >23). ather had Alzheimer's disease. --------� ) Dx:-7 �A-"'- �tV-1.:� 7 ReQJi<.A? ;._, I 'j,.. · i""p4..-vl"'\t..-.� Rate of progression to Alzheimers is 15%/year. ) 75. What has shown to improve cognitive function in the above Pt.? ) \,.J'C6 months program of physical activity and cognitive training B. Ginkgo biloba (. 't bl«A:.'1 ) c;;·,l'\.� ) ) 76. A 75 yr. ola Pt. is rougtlt in oy Ills son, complaming tliat tlls father Is behaving rrationally. The father thinks the son is an Impostor and is being kept in a prison, hich has been made to look like his home. e gets lost In the mall frequently and doesn't go there anymore. He hasn't been here for the past year. e has a mild tremor and some rigidity. Urinary and fecal incontinence have been oticed in recent months. scan of the head reveals brain atrophy and dilation of the ventricles. Most likely diagnosis Is --------� ) A. Normal pressure hydrocephalus JY. Alzheimer's disease C. Dementia with Lewy bodies c �"'II.... c..:"""''D. Parkinson's disease ) ) }) ) �L.. �:..·c...) .. Q77. Pt . with dementia, parkinsonian symptoms of bradykinesia and postural instability. ��u.w�i&I.U.IIU.I.li:J.I.ol.l.' No resting tremor. Extreme rigidity. Histopath. cytoplasmic Inclusion bodies in the subcortical tissue. Dx: -7 ) fV'o � �� \N>"'t\ Lewy b o�u ( Se.t..Vj t d.ui.:t ;,...c.p'Pro'p.-ic...k �"j's ) Q78. A 35 or 45 yr. old Pt. with dementia, Father had dementia at age 40. horeiform movements(+). ) J ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 287 Matching }2_1. Memantine(Namenda®) l2. Loss of interest, disinhibition; urinates in A. Alzheimer's disease B. Normal pressure hydrocephalus neighbor's lawn, hypersexual I]} 3. Contaminated corneal transplants & growth C. Multi-infarct dementia hormone 1) 4. EEG: intermitte ith a slow D. Creutzfeldt-jakob disease background. � �5. A 65 yr. old man with chronic HTN, Hx. of stroke E. Fronto-temporal dementia 3 yrs. ago with rapid onset dementia. No problem pic.l< O.ts naming names. 0/E: Ataxia and diplopia, Extensor reflex(+), No Sensory loss. CT scan:multiple non-enhancing hypodense lesions. A 6. A 65 yr. old man with onset of memory loss, F. Dementia with LEWY bodies noticed by family. Difficulty naming names. No motor symptoms. Paranoid delusions. !2J. An 80 yr. old woman presents with onset of dementia, urinary incontinence and wide based gait. CT scan: enlarged ventricles and sulci not enlarged. �. A 55 yr. old man onset of dementia with rapid deterioration. Myoclonic jerks+. NO incontinence. �9. Pt. sees roaring lions or bears. Stiffness(+), Tremor(+) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 288 Demyelination of white matter in Brain and Spinal cord emyelination -7 Plaques in the white matter on MRI. Gadolinium enhancement. -7Active plaque. -7 Optic nerve: Optic neuritis Brain -7 Medial longitudinal fasciculus: Internuclear ophthalmoplegia .. -7 Dorsal columns: sensory changes, vibration and position sense loss. Spinal cord -7 Corticospinal tracts : Motor symptoms : •Weakness •Spasticity •Hyper-reflexia ;p >fI. U.t\. ,� €0 fOII\f\.J L h""' WI...... l.v>k ""� L Inflammation of Optic nerve ) ) ) ) ) } ) t Optic neuritis • Subacute decrease in vision+/- periocular pain • Vision blurry post exercise or heat or smoking or stress. • Relative afferent pupillary defect • Respond to i.v Methylprednisone. Other presentations: • Bladder dysfunction • Bowel dysfunction • Sexual dysfunction • Trigeminal neuralgia • Cognitive dysfunction: thinning of corpus callosum • Spasticity: Carbamazepime helps • Fatigue: Treat with Amantadine • NO Seizures • NO Aphasia • NO Headache Diagnosis: Clinical presentation with imaging study Best imaging study � is -7 MRI: Increased @sign� nd decreased T1 signal. Enhancement with gadolinium in active lesions. If MRI inconclusive: -7 E�okedpotential studies which measure conduction velocity. _ __ I I CSF: Cells <10. > 2 lgG oligoclonal bands suggestive of MS. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 289 Treatment: Acute Relapses: • INO • Optic neuritis • Functional impairment } * i.v Methylprednisone 1g q.d for 3-5 days and then taper. Active disease or to prevent relapses: • IFN � 1a (avonex®) • IFN � 1b (betaseron®) • IFN � 1c (copaxone®) • >f• • Infections can precipitate acute relapse. Before starting high dose steroids, ALWAYS rule out infection and treat it. Young women shouldbe on contraception to avoid teratogenicity. If Inadvertently becomes pregnant on Interferon therapy, NO need for therapeutic abortion. 79. Most common presentation in Multiple---sclerosis is ----�--�--� J(. Paresthesias, tingling sensation, loss of vibration sense B. Internuclear Ophthalmoplegia C. Optic neuritis D. Weakness E. Spasticity 80. A presentation of Multiple sclerosis Is A. Seizure B. Aphasia ve:" Diplopia or blurry vision D. Headache Matching �1. Methylprednisone i.v 1 g/day for 5 days followed A. Acute Relapse by tapering �2. alfa Interferon �3. � Interferon C. Fatigue �4. Amantadine D. None of the above B. Prophylaxis for relapse Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 290 ) ) Matching ,..i:J_ 1. Optic neuritis A. Better prognosis � 2. Sensory symptoms B. Worse prognosis �3. Relapsing remitting r--!2.-4- . Progressive relapsing MS 'l>;c. (3 �5. Age> 40 yrs. at diagnosis - \ 1.N � 32 yr. old with intermittent diplopia. Numbness and paresthesias of left leg. P,81. A �ttempted adduction of the affected eye leads to horizontal nystagmus in the other eye. eye-+20/20 �isual acuity: left eye and right ._�------------------------------� ______ Dx: -7 1-NO ( 'tnteri"'\A.'-� o\)�cl.<.."""p�c..) Affection of:MLF (Medial longitudinal fasciculus in MS) 82. Young woman develops 'thick tongue' and blurry vision after taking a hot shower, after xercise or after being in hot weather. Most likely diagnosis ) vi( Optic neuritis B. Internuclear ophthalmoplegia C. Migraine ) Q83. Pt. with multiple sclerosis and not responding to P interferon. w.t.d? ) \ I ) ) Parkinson's D ise ase •Movement disorder due to decreased dopamine from cells in substantia nigra. • Diagnose clinically •CI.ft:RRRR -Resting tremor:4 to 7 Hz, pill rolling character at rest, Pronation/supination -Rigidity:Cog wheel rigidity and decreased arm swing -Retarded movement:Bradykinesia and dyskinesia -Reflex lost: Postural reflex lost-7 frequent falls ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 291 Tx: Start only when symptoms have negative impact on ability to function 1. Replete dopamine in Brain: t:L� L-ow P�4.w �· Levodopa (but its peripheral effects not needed) so ADD Carbidopa (prevents peripheral conversion of Levodopa.) _, �k£ c...o..-�a...r, �- :JotvW-. a1i LLvo J..oP• .:, pe 2. Dopamine agonist (start in younger Pt. <70): Pramipexole (Mirapex®), Cf., N 2.-1/ . Ropinirole (Requip®), Bromocriptine. 3. Inhibitors of Dopamine breakdown: Selegillne (Eidepryl®), Tolcapone (Tasmar®) allows higher doses of L-dopa to cross blood brain barrier. 4. Anti-cholinergics to decrease side effects of Levodopa: Trihexyphenidyl (Artane®), Benztropine (Cogentin®) Complications of Treatment: L-Dopa side effects • Involuntary movements: facial lingual dystonia, chorea and athetosis. • Psychiatric symptoms: confusion, depression, hallucinations and Psychosis. • On-Off phenomenon: alternating hyperkinesia-hypokinesia. 84. A 55 yr. old man presents with slow shuffling galt, resting tremor and radyklnesla. Activities of dally living with difficulty. /E: cogwheel rigidity and spasticity of muscles. You would now start --------� A. Alpha methyldopa $. Levodopa and Carbidopa C. Phenothiazines True or False 1. Drug therapy in Parkinson's disease should be started only when symptoms have an impact on Pt.s ability to function. T -7 Take with low protein meal or Carbidopa 30 mins prior to levodopa. 86. Pt. with long standing Parkinson's disease on L & Carbldopa. ow complains of weakness and bradyklnesfa. What happened? -7 Ci'"\. ojj �I\;Orvvz.t\.vrv -7 Increase dose/dosing frequency+/- Selegiline. C Q-ue t· �II'U C'orJ c.L,.? 2-Af'i;u.) .ft..,.> l ....L.. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 292 88. A Pt. with refractory schizophrenia is started on clozapine. 3 weeks later, he Pt. develops agranulocytosis, WBC count 500. What to do? A. Continue Clozapine, start Filgrastim (Neupogen®) -...)¥. Discontinue Clozapine p89. Pt. with Parkinson's disease hospitalized with pneumonia is confused and agitated at r ight. w.t.d A. Start Haloperidol (Haldol®) B. Start Risperidone (Risperdal®) V,Start Lorazepam Matching ___§____ 1. Parkinson's related dementia A. Lorazepam or Quetiapine (Seroquel®) A 2. Parkinson's related delirium B. Quetiapine or Clozapine (Ciozaril®) ) ) 0. Pt. presents wtth. radykinesia, abnormal gait, Increased muscle tone nd mUd demeAtJa. Exam rrtvee(J e�ct.posture with hyperextension of neck. o tremor. Verttcal ophthalmopl Ia; trouble walking downstairs, eattng ()r reading. ) ) ) ) Dx:-7 �reU,'Vt. S'-"f"t;; �c.(u,..... r�\'j Tx:-7 �C.'j<Mc... ?' Plf'tcA.e..p-eJSc.l\tf Hec.A �o-,ot ( INf>' tA..o......_) -I l,�e R<>�· Essential or Familial/Kinetic tre mor ) ) ' 'I ) • • • • • • Autosomal dominant, mainly hands and head Intentional tremor at 7-10Hz (Parkinsons:4-7 Hz, physiologic tremor> 9Hz) Aggravatedby anxiety. Antero-posterior flapping of hands Gets better at rest Decreased by ETOH Treat with -7 f'v<> pc.M\.Il --- p,. ,· � � ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 293 Q91. Pt. with creepy-crawly sensations, itchiness, pain, paresthesias, jerky fovements every 20-40 seconds while sleeping � fatigue during day. �ymptoms transiently relieved with movement or walking. Can occur with or without Parkinson's disease. ssociated with Iron deficiency anemia. � Dx: Restless leg syndrome Established by: History& Physical I 'l Mt..l' La.� __. "'" re.Jpot'l.te ---1 'il.>p<. �""' If Iron deficiency present-7 Iron therapy -7 Dopamine agonists (pergolide, pramipexole or ropinirole No Iron deficiency or Gabapentin. Levodopa/carbidopa is second line tx. A�...;J t. Periodic Limb Movement disorder with jerky movements during sleep is diagnosed by v/1(' Polysomnography B. EMG 92. Pt. while writing, hand goes into spasm; phalen and tinel's sign (-). Serum Calcium is 9mg/dl. Q93. Pt. gets phenothiazine for nausea and vomiting. Couple of hours later, t.'s eyes are stuck in a particular Gaze (left or right, etc). w .t.d A. Diazepam ,)¥. Diphenhydramine ( �e u�;� i<\C.Ot'\t.;/\CAC ) Other manifestations of Acute dystonia. Torticollis • / Blepharospasm •/ Writer's cramp \Y' 94. 18 yr. old man with twitching of face, grimacing & movements of the neck. Dx:-7 To'-'rette.& (tics) Tx: Neuroleptics Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 294 r3 1. Tremor best seen at rest Matching A. Essential/Kinetic �2. Aggravated by anxiety B. Parkinson f>dC. 3. Decreased by rest C. Cerebellar �4. Relieved by alcohol C, p., f3s. Aggravated by action l PGAM.J'CI'I' ) *' �6. Head, Voice tremors _&f_7. Chin tremors ) �B. Fa m ilial �9. Flexion-Extension ___:Q_1o. Pronation-supination �11. Tremor a t rest and on movement * Neuromuscular diseases ) ) ) ( c(@ • ) ) ) � Diplopia: Myasthenia gravis • + Ptosis + weakness� MG Autoimmune • + INO � .MS.synaptic Ach receptors Antibodies t • + dysarthria+ ataxia+ dizziness Low level of Ach receptor � Vertebrobasil. TIA + Cauda equina � Leptomeninge.pl metastases • • • • • • • Weakness as the day progresses (repetitive acts), Reflexes normal. Extraocular & ocular m uscles� Ptosis, Diplopia Facial m uscles � Difficulty chewing, Dysarthria Bulbar muscles� difficulty swallowing Proxima l limb muscles�weakness while brushing hair Intercostal and diaphragmatic weakness� Respiratory failure (Myasthenic crisis) Edrophonium challenge test (Tensilon test) � Ptosis should get better Ach receptor antibodies (+) in 90% of Pt.s of generalized MG and 50% in ocular MG. ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 295 95. Pt. with diplopia, fatigue at the end of the day. Difficulty brushing air. Recently while eating, she regurgitated through the nose. 0/E: d iplopia, ptosis both eyes. w.t.d to establish diagnosis? \,..A('Ach receptor Abs B. Nerve conduction studies. 96. A 35 yr. old with proximal muscle weakness, ptosis and diplopia. EOMi intact. ision 20/20. Deep tendon reflexes normal. w.t.d next? A. EMG �Repetitive nerve stimulation studies ------M e.., �� A Single fiber Electromyography (SFEMG) is more sensitive than Nerve stimulation studies (100% SFEMG vs 65% NCS) but SFEMG is operator dependent. 097. Pt. diagnosed with Myasthenia gravis. w.t.d next to rule out thymoma. I f present� Resection. Q98. A 40 yr. old woman works on a farm.. lately she gets tfred. Exam reveals diplopia. Extraocular movements Intact. PupllsOK Reflexes normal. VIsion 20/20 both eyes. Most likely diagnosis? A. Organophosphorus toxicity ( Pi/\. p01'-� p..,: I ) Y. Myasthenia gravis This Pt. will most likely respond to A. Amitriptyline B. Pralidoxime X. Physostigmine D. � interferon 99. A 30 yr. old chronic smoker, with diplopia, becomes tired at the end of t he day. as difficulty swallowing, chewing and has nasal resurgl lops rogresslve weakness and goes Into respiratory failure. fRs normal Most likely d iagnosis A. Guillain-Barre syndrome J., B. Multiple sclerosis 1' �Myasthenia gravis D. Lambert-Eaton syndrome. J, Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 296 What can make Myasthenia weakness worse? -7 • Aminoglycoside antibiotics • Antiarrhythmic agents • Electrolytes disorder � '(r • J3 blockers • Infections .v rv ,.•.r • OYI· •.... W" ffl. o,.lY'V 100. Pt. with myasthenic crisis w.t.d ------ -7 Admit to ICU -7 Plasma exchange -7 Immunoglobulins/steroids -7 Elective intubation for Vital capacity < 15ml/kg '2-0 tv-A J "--a �101. Pt. with Myasthenia gravis on pyrldostigmlne. Now with acute � xacerbation . w.t.d ) ) ) -7 1 .V. r,.,.._""�d Lo �:,....c.:,. 1.v 1. 8 Eaton-Lambert syndrome • Autoimmune/Oat cell carcinoma • Antibodies to pre-synaptic receptors • Weakness gets better with repetitive acts • Hypo-reflexia • Ptosis (- ) • Diplopia (-) ) 02. Pt. with weakness, Inability to get up from chair. Gets better with exercise. ast history of chronic smoker, 30 pack years. /E: no ptosis, Reflexes decreased. epetitive nerve stimulation shows Incremental Increase In responses of action potential. ost likely diagnosis Is ) ) ) vJ{Eaton-Lambert syndrome 2" Small cell Lung cancer. B. Gullain-Barre syndrome C. Multiple sclerosis D. Myasthenia gravis ) Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 297 �1. Better with repetition �2. Worse with repetition Matching A. Myasthenia gravis B. Eaton-Lambert syndrome �3. H ypo-reflexia C. Both P.. 4. Normal reflex D. Neither A 5. Antibiotics/Infections �6. Small cell carcinoma .t_7. Thymoma �8. Pre-synaptic antibodies J2_9. Post-synaptic anti-acetylcholine receptors antibodies �10. Ptosis/ Diplopia �11. Muscle weakness 103. A 60 yr. old man presents witn comp aints of pain in is snou ers. He Is tired at the end of the day and cant even keep his head up. He choked recently on food and has slurring of speech. He has some lfficulty wearing his s and shirt. Exam reveals mild weakness of neck uscles. There is witching f shoulder muscles. There Is spasticity of ex1a. Sensory exam Intact. Most likely diagnosis Is uscles an vK. ALS B. Multiple sclerosis C. Syringomyelia D. Myasthenia Gravis How to diagnose above Pt.? � �M � Tx: � �t a-L.... �k Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 298 Spinal Cord '· • rJ Myelopathy -7 Lt. h' ""'" .U""' Radiculopathy-7 L M (') L.e.�w.. - ) \ _, 1' 'ln � w 'DT R.. Cervical spondylitis: Compression of cervical cord -7 UMN with.· sensory changes UMN changes: Spasticity, hyper-reflexia of deltoid, biceps, triceps. Extensor plantars . Sensory changes: Loss of position and vibration sense in lateral arm and lateral fingers. 3 Syringomyelia: Cavitation of central spinal cord -7 LMN with sensory changes. LMN changes: Weakness of upper limbs; start with hands and proceeds proximally to shoulders Sensory changes: Lateral column changes:Temperature and pain sensation lost. Touch and vibration preserved. Dx:-7 fY'\ A-1 Tx:-7 � t.,,.. � -tt � �v€. _, s\M- ) ) ) Matching �1. Pt. with weakness of hand now progresses to A. Cervical Spondylitis �2. Pt. with deep ache in the buttocks and thighs B. Syringomyelia �3. Pt. with pain in the thoracic area, flu one week C. Spinal stenosis E 4. Pt. with stock and glove distribution of tingling D. Transverse myelitis shoulder. Pain and temp. sensations lost but touch and vibration preserved. MRI with cavitary lesion of the spinal cord. when standing, disappears on sitting. ) ) ) ago or SLE. Now with weakness of legs and bladder disturbances, getting worse. Reflexes1' sensation. Pt. confused, has ataxia, spasticity and clonus �5. Pt. with loss of vibration in lateral three fingers. Hyper-reflexia of deltoid, biceps and triceps E. Subacute combined degeneration of spinal cord ) Awesome Review, lnc.i!l Copyright 2014 Do not photocopy without permission Page 299 Chart 10-7 Foot drop LS Radiculopathy Pe r one al Nerve injury Invert Foot? Evert Foot? No ND y� Yu Yes No Chart 11-7 Ankle Jerk LS 'Dwsi j/txl c,.... � 51 r lcJ\,.1: ....... .. fl e)C i """ NL � � p-104. Elderly Pt. with complaints of back pain. Increases on wal�ing (especially � ownhill) and standing, with numbness In the legs. It decreases while sitting � own. MRI will most likei.Y. reveal 1:1105. A 55 yr. old man after lifting heavy weights develops low back pain. Fxam:leg raising >45 degrees with pain. Anal sphincter tone good. orslflexlon of right foot slightly decreased. Ankle jerk decreased. P A. Refer for Surgery B. Refer for Physical therapy Y,Analgesics and activity as tolerated 106. If anal sphincter tone was lost or bladder dysfunction. w.t.d to rule out CIA�\ �� Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission syndrome. Page 300 107. Sensory loss on lateral aspect of the thigh. which spinal segment is involved? 108. One of the most common causes for mononeuritis multiplex is � �-(l>AN --------� B. HUS C. Takayasu's disease Gulllain-Barre syndro : Inflammation of the nerves with segmental demyelination. LMN lesion:Ascending paralysis. Areflexia. CSF: increased protein/Normal WBCs Nerve conduction studies: slow conduction Tx:IVIG-7 Plasmapheresis. ( f\fb ste,.111·tA ) Elective intubation if respiratory muscles involved. ) ) ) ) ) ) ) I ) Botulism: Descending paralysis with blurred vision, diplopia, dysarthria, dysphagia, diarrhea and vomiting in a young Pt.. Dilated pupils. Labs: Demonstrate toxin in serum or vomitus or stool Tx:Anti-toxin Matching � B 1. Cyclist with paresthesias in little finger and inability A. Radial neuropathy {::. 2._ . Nocturnal awakening with pain and paresthesias A B. Ulnar neuropathy �3. C Alcoholic with diplopia and weakness of the right C. Median nerve 'D 4. Difficulty standing on toes. Reflexes decreased D. Sciatica A 5 . Wrist drop E. Peroneal nerve compression to adduct little and index finger, hypothenar wasting. in hand. hand. E 6. Foot drop ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 301 T�tL;t.e. -} Nc-r A-fib ..1- bt"tt... ""' �""'"'· " (;{."""""' Q109. Antibody induced acute polyneuropathy occurs in A. Rh. Arthritis 0¥. Guillain-Barre syndrome C. Chronic inflammatory demyelinating polyneuropathy ( vvk.r -7 f"VW"� ) Q110. Young Pt. with ankle sprain. Takes NSAIDs. Complaints of extreme tenderness when bed sheet touches it. Exam reveals bluish discoloration. Most likelY. dia nosis is -7 Complex regional pain syndrome (Reflex sympathetic dystrophy) -7 1 f Pt. has patchy demineralization, bisphosphonates are effective treatment even in the absence of osteoporosis Eonfused upon immediate examination. He has no loss of consciousness. Te L;pe ; t:.tc. - z ·:v "'.1 : 111. A 19yr. old playing football has a sudden impact and falls to the ground. He appears 15 minutes later, repeat exam reveals normal cognition, vision and finger-nose test. What to do? . • of' .3. .V OS{e.o bL'0t c.c.f..'v;f;; . Concussion is defined as a trauma-induced alteration in mental status that may or may not involve a loss of 112. A 20 yr. old playing football, has a concussion injury. He has no loss of consciousness consciousness. Grade 1 ut appears In a daze on an immediate exam. 20 minutes later, he appears alert and oriente concussion is characterized by lth some amnesia which resolves 15 mins later. What will you do next? transient confusion -7 Monitor symptoms closely, If no symptoms for I Me. � p� G.� without amnesia or loss of consciousness that resolves completely 113. A 24 yr. o a n a a concussion p aying ice oc ey. He lost consciousness for 30 within 15 minutes. Grade econds, upon awakening is awake alert, and oriented, finger to nose test Is normal, 2 concussion also islon Is normal as well. What to do next? involves transient less than 1 minute LOC with normal physical exam) confusion without loss of consciousness but is -7Send home with family observation and withhold from competition. If remains associated with a period asymptomatic can go back to play in 1 wee.k. of amnesia and mental status abnormalities lasting longer than 15 114. A 24 yr. old had a concussion playing contact sports. He lost consciousness for minutes. Grade 3 0 seconds and upon �akenlng was In daze).yhlch cleared up on the way to the ER. concussion is defined as a hat to do next? (less than a minute LOC, with abnormal physical exam upon awakening) brief (seconds) or prolonged (minutes) loss -7 ER evaluation with CT/MRI. Withhold from competition. If remains asymptomatic can go of consciousness. A back to play in 2 weeks. focused neurologic examination is necessary Q115. Concussion with LOC > 1 min with normal physical --------� in the acute setting, with investigation of cognition -7 ER evaluation with CT/MRI. Withhold from competition. If remains asymptomatic can go (orientation, language, back to play in 2 weeks. and memory), vision (acuity, visual fields, and extraocular movements), Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 302 and coordination (gait and extremities) being of 1 Chart 12-7 Seizure Disorder Generalized / �Absence/Petit mal: Tonic-Clonic without aura or post-ictal symptoms. 3 sec spike and wave pattern on EEG Complex Simple Generalized Focal seizures that affect a small volume of cortex. Consciousness is preserved. Ex:Epigastric rising sensation, psychic sensation, deja vu. Involves large enough cortex to cause loss of consciousness. ) • ' ) • • • • • ) • • Cocaine Alcohol withdrawal Hypoglycemia l le11" �.,;.r.c. �ev- c:� Jwt� �r"()":J ,.. � ._ ) Syncopal convulsions ( G c.£.-.o "V' ) Pseudoseizures No need for antiseizure treatment �15sence Petit mal: • Ethosuximide • Valproate • Lamotrigine -:¥'" "" f.... e l�b ( 6e.rt ) ') • • • • • • lmipenem Tramadol Bupropion Haldol Mepiridine PRBCs Par tial • Carbamazepine • Phenytoin (Dilantin®) • Valproate • Levetiracetam • Lamotrigine • Gabapentin as adjunctive II ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 303 116. Best anti-seizure medication in elderly Pt. 117. Best anti-seizure medication with liver disease 118. Best anti-seizure medication with H IV disease 119. Best anti-seizure me 1cation In pregnancy Q120. Which anti-seizure mediation causes kidney stones? --�------��- -7 TopirG.M-" � 121. After the first seizure, the best diagnostic Imaging Is then do an EEG:Epileptiform spike+/- slow waves Normal EEG DOES NOT rule out Seizure disorder. �122. Pt. making presentation to supervisor slumps fn ttie ctiarr. Dlaptioretic. Has jerks of his arms and legs several times. Completely recovers In 0 seconds and has pallor. BP normal. Cardiac and Neuro exams normal. Ox: � A. Partial seizure B. Complex seizures J "Syncopal convulsions d D. H ypoglycemic attack Pl23. A Pt. Indental chair passes out and has jerkymovements ofarms and legs. fie completely recovers In 30 seconds. He Is dfaJ)horetfc. �imllar episode has happened once before. ThJs represents A. Seizure disorder B. Arrhythmia � N eurocardiogenic syncope P,124. A 2 2 yr. old with headaches, smells of burning rubber and feels strange. f-Jo convulsions seen. Most likely diagnosis. A. Migraine --IY."Partial seizure/psychomotor epilepsy C. Petit mal seizure Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Concussion is defined as a trauma-induced alteration in mental status that may or may not involve a loss of consciousness. Grade 1 concussion is characterized by transient confusion without amnesia or loss of consciousness that resolves completely within 15 minutes. Grade 2 concussion also Page 304 involves transient confusion without loss of consciousness 125. Pt. has generalized seizures that don't get better with Dllantin. erum calcium is low. Calcium chloride Injections don't help either. w.t.d A. Give more calcium i.v XGive Magnesium sulfate i.v 126. A 22 yr. oli:t woman compla ns o we ri:t sensation In ttie stomac followe by udden freezing, swallowing/chewing/lip smacking Is seen. About a minute later, she tarts talking and doesn't recall the episode. Most likely diagnosis --------� A. Absence seizure �Partial seizures C. Generalized seizures 127. A 30 y old woman Is brought to the office. Sister complaints that she has been avlng recurrent spells of staring for several seconds and then having Intense amlliarlty with the surroundings and strangers. Most likely affected lobe Is __. _ _ _ _ _ _ _ I J \ ) A. Parietal lobe B. Frontal lobe J/ . Temporal lobe D. Occipital lobe J 128. Young woman with epigastric rising sensation. Most likely diagnosis? } ) ) JK."Simple partial seizure B. Complex partial seizure Most likely lobe affected? t)C'remporal lobe ) ) ) B. Parietal lobe 129. A 22 yr. old woman comes with her husband and narrating complaints. er leg starts jerking, which gets worse and continues on and off for several m ins. t. becomes short of breath. he holds her head tight and after 3 m inutes jerking stops and she says she feels dizzy nd has a headache. Most likely diagnosis -----------------------------------------A. Partial seizure .....a:' Pseudoseizures C. Basilar migraine ) ) ) ) Awesome Review, Inc. fl Copyright 2014 Do not photocopy without permission Page 305 �130. A 55 yr. old Is brought by her family. She has been having these episodes �here she stops what she is doing and gives a blank look for several seconds. $he then shakes her hand repeatedly for few minutes and then feels tired. Exam reveals no focal neurological deficits and MRi is normal. w.t. d A. Tilt table test B. Spinal tap C. Psychiatric referral .-IY. Sleep deprived EEG E. Carotid ultrasound Most likely diagnosis? A. Simple partial ....8':' Complex partial C. Absence seizures D. Generalized seizures �131. Pt. wllh onset of seizure of his left arm and then spreads to the left leg. After the �plaode, th.•te ls weakness of the left arm and leg. Most likely �tagnosls? : ·: vK.'J acksonian seizure B. Deja vu Most likely affected lobe7 A. Temporal lobe � Frontal lobe C. Parietal lobe Concussion : a trauma-induced alteration in mental status that may or may not involve a loss of consciousness. Treatment of Status Epilepticus Grade 1 concussion {seizures> 30 mins. or loss of consciousness between 2 or more seizures} = transient confusion without amnesia or loss of consciousness that resolves completely within 15 minutes. i.v Glucose + 100 meg Thiamine Grade 2 involves transient confusion without loss of consciousness but is associated with a period of Lorazepam {Ativan®} amnesia and mental status abnormalities lasting longer than 15 minutes. Grade 3 a brief (seconds) or prolonged (minutes) loss of Loading dose Phenytoin 2-0r:ff (� or Fosphenytoin {Cerebyx®} consciousness. A focused neurologic examination in the acute setting, with investigation of cognition (orientation, language, Maximize Phenytoin and memory), vision (acuity, visual fields, and extraocular movements), and coordination (gait and extremities) being of greatest importance. Head CT or brain MRI is recommended for persons Phenobarb. {Luminal®} or Midazolam {Versed®} with grade 2 and 3 concussions with persistent abnormalities on examination or symptoms lasting longer than 1 week because shear injury may result in intracranial hematomas or parenchymal edema, both of General anesthesia and neuromuscular blockade which evolve over time. � � � � � Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 306 � o driving B. N o Alcohol I I I I /.No swimming B. No Alcohol Chart 13-7 C., Lc.\..1 C.OMR - �0... �LAtuL \ h I \AVe.'it.;-S l I) ( SLG ) �)Q�'Q,. ( r3 4 �kJ ) , I? C. ,.. '=' i -l:.u.v o. k d ve..- cA-ot:-<. A"'t; c.h.P �1'\..e "".f'U r3 o't.u. L.: s ,_... <fi c.a...·rv.. ·- I J I ) ) \ J � 0 pol� , p t:Jr.-t. k '6 (� W'-'Oph-v..l p\o-.-, � \..L �'W\. p 0 i J:'(JYV ) ) ) Athletes with grade 1 concussions should be removed from the contest and examined immediately and then at 5-minute intervals. If all mental status and postconcussive symptoms (at rest and with exertion) clear within 15 minutes, they may return to the contest. A second grade 1 concussion on the same day should eliminate the athlete from competition until he or she is asymptomatic for 1 week at rest and with exercise. Athletes with grade 2 concussion should be removed from the contest and prohibited from returning to competition that day; they should be examined frequently on site and reexamined the next day. If asymptomatic for 1 week at rest and with exertion and if neurologic examination findings are normal, they may return to competition. After a second grade 2 concussion, return to play should be deferred until the athlete is free of symptoms at rest and with exertion for a minimum of 2 weeks. Athletes with a grade 3 concussion should be transported to the nearest emergency department if unconsciousness is prolonged or if any worrisome signs, such as confusion, ataxia, slurred speech, or visual anomalies, are detected on examination. The management of grade 3 concussions in athletes is outlined in Table 7. The immediate postconcussion assessment and cognitive testing (ImPACT) test is a validated instrument now applied to most athletes competing at the high school, collegiate, or professional level. The ImPACT test provides computerized neurocognitive assessment tools and services used by physicians, athletic trainers, and other licensed health care professionals to help determine an athlete's ability to return to play after a concussion. Return to competition is often based on resolution of symptoms and return to baseline on the ImPACT test. Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 307 MRI/CT findings in different diseases Infarct � Hypodense area. No enhancement Bleed � H yperdense area, no need for contrast CT Multi-infarct dementia� Multiple hypodense areas. No enhancement Tumor � Enhancing lesion Brain abscess � Ring enhancing lesion Toxoplasmosis � Multiple ring enhancing lesions Cerebral atrophy � Dilated ventricles and dilated sulci Normal pressure Hydrocephalus � Dilated ventricles. Sulci not dilated Multiple sclerosis � White matter plaques, enhance with active disease Alzheimer's � Brain atrophy.+/- Periventricular white matter lesions l"'\l<.:z. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 308 An AWESOME REVIEW OF 7% Colon cancer Breast cancer Prostate cancer Lung cancer - Testicular cancer Hodgkins disease Lymphoma Cervical cancer Endometrial cancer Ovarian cancer Cancer of Unknown Origin - Toxicity of Chemotherapy Awesome Review Inc.® Copyright 2014. Do not photocopy without permission. J Colon Cancer Most common cause of Gastrointestinal cancer. 60,000 deaths/year Risk factors: Age > 50 Diet rich in fat, red meat, sucrose. Born in western world Pelvic irradiation Long standing Ulcerative colitis & Crohn's disease >8 yrs. 1Q relatives with colon cancer History of other cancer: Breast, ovarian or Endometrial cancer Familial polyposis (Gardner's syndrome, Familial adenomatous polyposis} S 1 r IAbf'A... H N PCC [Hereditary non polyposis colon cancer] Adenomas • • • • • • • • • Decreased risk: • • • • • · Non smokers NSAIDs ASA >20 yrs. Celecoxib & � ulindac-7 J, po�r.r Loc..rJ.. Calcium & folic acid, Estrogens ) Colon cancer usually arises from adenomas. Hyperplastic polyp has no malignant potential. Familial adenomatous polyposis: • • • • • Family history of adenomatous polyposis and cancer. Mutation of the APC gene. -7 C"'-v- 5 t Hundreds of polyps begin at about age 16 >95% develop cancer. Colectomy indicated before malignancy begins. Gardner syndrome: • • • • Adenomatous polyps involving the colon. >95% develop cancer. Extraintestinal manifestations include: Osteomas of mandible, skull and long bones, soft tissue tumors, thyroid and adrenal tumors, epidermoid and sebaceous cysts. Colectomy should be performed before malignancy develops Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 150 Peutz-Jegher syndrome: • hamartomas of small intestine. • Pigmented lesions on skin, lips, mouth. • Juvenile Polyposis: Hyperplastic polyps in colon, presents as Gl bleed or intussusception \ HNPCC (hereditary • • • ) non polyposis colon cancer) or Lynch syndrome Autosomal dominant Need to have at least t hree relatives with colon cancer. One must be 1° of the other two. Two generations with colon cancer. May have extracolonic cancer as well. At least one relative <50 yrs. with colon cancer. Jc.fl.u;- s� "' J<.tN..'J p..·st.c....v 1. SO yr. old woman with HNPCC had a colonoscopy done, which revealed adenomatous olyps. W.t.d? _ __ �ransvaginal Ultrasound B. Endometrial biopsy 2. 55 yr. old man, asymptomatic for routine check up. Fecal occult blood test (-) [FIT), igmoidoscopy � Polyp ) A. If biopsy of polyp � Hyperplastic polyp w.t.d 3- s } 'j (J or � Double contrast Barium Enema q Syrs. B. If biopsy of polyp-7 Adenoma w.t.d C. If biopsy of polyp -7 Adenocarcinoma w.t.d ) ) ) 3. 55 yr. olo man asymptomatic for routine check up. Sigmoiaoscopy (-), FIT + ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 151 4,_Male or postmenopausal female with unexplained Iron deficiency anemia. W.t.d �J (.or':) -7 I \j �q � - GC, :b 5. Elderly Pt. with hematochezla. History of hemorrhoids. w.t.d 6. Pt. on routine health maintenance exam had FIT. 1 out of 6 cards (+ for occult blood. Pt. akes high doses of VItamin C. W.t.d A. Stop Vitamin C and recheck FIT JV Coionoscopy 7. 55 yr. old woman had screening colonoscopy done. 2 polyps removed, showed were yperplastlc. When to do the next Colonoscopy? A. 3-5 yrs. d 10yrs. 8. Pt. had 2 adenomas (<1cm) removed. When to repeat colonoscopy? 5- I o �6 -7 • Pt. had 1 tubular adenoma 1 em. Next colonotcopy? 10. Pt. had 1 tubular ai:lenoma 2.5 ems. Next co onoscopy? 1 1. Pt. had 3·10 tubular adenomas <1 em. Next colonoscopy? 12. Pt. had 1 villous adenoma <1 em. Next c.olonoscopy? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 152 13. Pt. with (a) Obstructive Colon cancer. Pt. had colonic resection. W.t.d next? -7 Full Colonoscopy to r/o other concomitant lesions. (b) If the pre operative Colonoscopy with no other lesions. -7Colonoscopy in 1 yr. then in 3yrs., then q Syrs. Measure CEA q 3-6 months for 2 yrs., then q ly x 5 y in all cases. ) ) 14. What Is the best diagnostic test to rule out Colon cancer --------� ) \ 15. When do you stop colonoscopy screening? ) ) ') I I -7 'JS 'jV' pe-p .r� �fr� ---1 s-t,., p -1 � c..( s-c..� �s '1"'.s -::}:1 'jrJ ""' s� "'-- � ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without pe rmiss io n Page 153 Chart 1-4 Oth.iI' • • • SOy • 40y • Post colonic resection for Colon Ca Ulcerative Colitis Crohn's disease • • Colonoscopy after 8 yrs., then q 1-2 yrs + Sigmoidoscopy q 3-5 yrs. or General population or FIT '\ l ':V distant Family Hx. of Colon Ca Colonoscopy now & q 10yrs. 1 Firsto relative with Colon Ca after age 60 yrs. or two Secondo relatives or 10 yrs. younger than the youngest affected relative 40y Colonoscopy in 1 yr., then in 3 yrs., then q 5 yrs. + Sigmoidoscopy q 3-5 yrs. or FIT � ('jt' Colonoscopy now & q 10 yrs. Colonoscopy q 5 yrs. 2 Firsto relatives or 1 Firsto relative diagnosed before age 60 with Colon Ca 25y or 10 yrs. younger than the youngest affected relative H N PCC 12y Familial adenomatous Polyposis Colonoscopy q 2 yrs, up to age 40. then q 1 yr Sigmoidoscopy q 1-2 yr. Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 154 !Matching I �1. 35 yrs. old asymptomatic. Father had Colon Ca A. FIT + Sigmoidoscopy q yrs. or Colonoscopy q 10 yrs. �2. 40 yrs. old asymptomatic. Father had B. FIT + Sigmoidoscopy q yrs. or Colonosocopy q 10 yrs. starting age 40 �3. 35 yrs. o l d asymptomatic. C. Colonoscopy now & q 5 yrs. at age 45. Colon Ca at age 60 & brother at age 52 Father had Colon Ca at age H 4. - \ l I ) 25 65. yrs. old asymptomatic. Family history of Hereditary non polyposis colon cancer 3-5 3-5 D. Barium enema. 16 yrs. old _!_s. Pt. with Ulcerative colitis diagnosed recently E. Colonoscopy age _5_6 . Pt. with Colon Ca Duke B and underwent F. Colonoscopy 8 yrs. lat�r & resection of colon. �7. SO yrs. old asymptomatic. Family history negative for colon cancer. E 8 . Young Pt. with family history of Familial 1- adenomatous polyposis . then q 2 yrs. G. Colonoscopy in 1 yr., then in yrs., then q yrs. 3 5 H . Colonoscopy now & then q yrs. upto age 40, then q yr. 2 1 ) �9. 40 y old asymptomatic, Father had Colon Ca at age 55 yrs } Q16. A yr. old man presents with history that his father had Colon cancer at age rother had Colon cancer at age SO. Aunt had Uterine cancer at age 48. What is more likely. ) ) 37 65. A. Familial adenomatous polyposis coli B. gene deletion JY,'HNPCC (micro satellite mis-match repair genes MSH) p53 Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 155 Chart 2-4 Treatment Stages distant mets. Duke D • • Survival Resection palliative SFU +Leucovorin+l'tecam/B'zumab 7% Resection of solitary Liver Met., if you had pursued a curative intent in the past !Matching I �1. Pt. with Colon ca. underwent hemicolectomy. A. Observe �2. Pt. with Colon ca. infiltrating the serosa. After B. Chemotherapy (SFU + Leucovorin) �3. Pt. with Colon ca. not infiltrating the serosa. 4/10 lymph C. Chemotherapy plus RT � Pt. with stage 82 Rectal ca. Local resection was done. D. RT Histopathology revealed infiltration of the muscularis but serosa is clear. LN(-). W.t.d? hemicolectomy, w.t.d? nodes (+). After hemicolectomy, what else will you do? 4. what else will you do? Anal Cancer: Cancer of anal margin. How to treat? Cancer of anal canal mucosa: � �UNl � -t '5 &:4, T Rc-J.:.c...t(,¥V Awesome Review, Inc.<'> Copyright 2014 Do not photocopy without permission Page 156 \ Chart 3-4 Breast lump/Suspicious mass workup Re-examine in mid cycle 6 weeks later Mass disappears � Mass persists � t Positive Indeterminate/Negative \ t Ultrasoun ) Solid ) Fine needle aspiration biopsy neg Fine needle asp bx Mixe CHO • t • Jsk factors for Breast Cancer Highest risk High rlsl< Moderate risk • • • • • ) I Cystic 'l lf9' Excisional biopsy Intraoperative biopsy • ' \��t� • • ) gram • Female older > 50 yrs. Personal Hx. of Breast Ca Strong Family Hx. of Premenopausal Breast Ca Genetic BRCA 1 & 2 • • • • \ll Excisional biopsy Any 1 • relative with Breast Ca Personal Hx. of Ovarian Ca or Endometrial Ca. Late pregnancy Nulliparous Dense breasts • • • • Early Menarche Late menopause OCPs> 15 yrs . Alcohol Obesity Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 157 • • • • • • Women > 50 yrs. or< 5-10 yrs. prior to age in 1o relative with Breast Ca and then q 2 yrs. 10% of Breast Ca found on physical exam is missed by mammogram. BRCA 1 & BRCA 2 present in 5-10% of Breast Cancers. BRCA 1: Chrom 17; Breast, ovarian cancer in women and prostate cancer in men. High penetrance. Otherfamily members should be made aware. BRCA 2: Chrom 13. BRCA 1 testing is recommended for Pt.s with strong family history of Breast AND Ovarian cancer. Chart 4-4 Local disease in Situ Lumpectomy + RT Or Mastectomy Tamoxifen/Aromatase inh. if ER receptor (+) Lobular carcinoma in Situ Observation or if ER (+)� Tamoxifen Infiltrating ductal carcinoma with LN (- ) Wide excision of mass + RT Adjuvant chemo for size> 1cm Tamoxifen/Aromatase inh. if ER receptor (+) Infiltrating ductal carcinoma with LN (+) [Wide excision + RT =Modified radical mastectomy) + Adjuvant Chemo + Tamoxifen/ Aromatase inh if ER receptor (+) Locally invasive disease involving skin OR chest wall � Chemotx followed by Mastectomy + Tamoxifen/Aromatase inh if ER (+) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 158 Most important prognostic factor i @ Tumor size > Receptor > grade Adjuvant therapy for Node (+ ) disease ER (+ ) ER (-) Pre menopausal Chemotx + Tamoxifen Chemotx Post menopausal Aromatase inhibitors + Chemotx Chemotx ) Adjuvant therapy for Node (-) disease ) ER (+ ) ER (-) Pre menopausal Tamoxifen * * Post menopausal Aromatase* inhibitors * *Chemotx O N LY if Pt. has tumor size > 1 ems, high g rade. If< 1 em -7 NO chemotherapy Types of Breast Cancer • • • ) ) Intraductal 80% Lobular 10% Others 10% Principles of Management of Breast Cancer Who gets Primary therapy alone? Who gets Adjuvant-therapy? • ) • • • ) • • Excision of mass with free margin + RT = Modified radical mastectomy+ RT LN dissection: If sentinel node biopsy (+ ) -7 Further LN dissection If sentinel node biopsy (-) -7 No need for further LN dissection. -7 Adjuvant therapy: Chemotherapy +/If Lymph node (+ ) Tamoxifen (Aromatase inh. in post menopausal) Tamoxifen/Aromatase inh. can be used in LN (-) Pt.s with ER (+). It decreases the rate of recurrence of Breast Cancer. ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 159 17. 37 yr. old woman wlttl family h istory of carcinoma of Breast In mother at age 65 yrs, lster with Hx. of Breast cancer at age 35 yrs. The most Important risk factor for the t. to get Breast cancer Is A. Her age JY,"Her family history 18. 65 yr. old woman with family history of mother with breast cancer at age 67 yrs. he most Important risk factor for her to acquire breast cancer Is vt( Her age B. Her Family history 19. The highest Risk factor for Breast cancer would be �Early menarche-late 1st pregnancy-late menopause-strong fam Hx.-No deodorant B. Early menarche- Early menopause- strong family Hx.- Deodorant use 0. Pt. with breast cancer. 1•relative with history of breast cancer and ovarian cancer. his Pt. Is most likely to have vt(' BRCA 1 mutation B. BRCA 2 mutation C. p53 mutation 1. Young female genetic testing showed BRCA1 mutation. What to do next .....K. Mammogram screening now . B. Earlier transvaginal ultrasound screening now. 2. 50 yr. old woman presents for regular checkup. The best way to screen her r Breast cancer Is vKClinical breast exam and mammogram annually. B. Pt.s self exam and mammogram annually. 3. How to screen for Breast cancer In a woman with breast Implants? A. MRI B. CT scan Mammogram / 24. Mammogram Is the best test In a woman who 1../'1( is Post menopausal B. has Dense breast tissue 7 cU r"t.� p� �-) e.� � lo..O...,"- ---+ ��'W.. �� Awesome Review, Inc.<!) Copyright 201 4 Do not photocopy without permission Page 1 60 �25. 40 yr. old woman presents with new onset thickening in her leff ��pper and outer breast �hile taking a shower. No family h istory of breast cancer. She Is currently menstruating. Exam eveals diffuse nodularity In both breasts and a vague thickening In the left upper and outer �uadrant. You advise her to come back in a couple of weeks in midcycle. After 3 weeks the Iague thickening persists. Mammogram is done which reveals no calcifications or dominant mass. You would A. Reassure Pt. and follow up in 6 months. JV,"Uitrasound and Fine needle aspiration biopsy C. CT scan chest D. MRI chest E. Repeat mammography in 2 months. ) 26. Above Pt. U ltrasound shows mass with mixed ECHO. FNAB� no malignancy. w.t.d ) A. Repeat Mammo in 3 mths. $ Excision biopsy C. MRI •) ) ) ) 27. 50 yr. old diagnosed with breast cancer. Most important prognostic factor Is -7 L.;rJ(tl 8. 35 yr. ol woman with 1.5 em. mass. Excision Biopsy reveals infiltrating d uctal cancer nd margins are free of cancer. Axillary LN (-). ER (+). She does not want mastectomy. w.t.d . Y. RT with adjuvant chemotherapy and Tamoxifen for 5 yrs. B. Radiotherapy. + Anastrozole C. Radiotherapy only D. Radiotherapy with chemotherapy �9. 63 yr. old woman with a lump In the breast. Lumpectomy was done which reveals nflltrating adenocarcinoma free margins. Axillary LN (+). ER(+). Adjuvant chemotherapy was �dmlnlstered. w.t.d ) A. Radiotherapy only B. Radiotherapy + Tamoxifen vC'Radiotherapy + Aromatase inhibitors ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ) Page 16 1 Q30. 59 yr. old woman with painful breast. Rt. upper outer quadrant painful, red, thickened rea of about 7 ems. No nipple discharge, no lymph nodes. Warmth +, Mammogram no mass iagnosis A. Mastitis f. Inflammatory breast Ca C. Paget's disease 31. Pt. s/p breast cancer treatment with surgery, RT and chemotnerapy presents with ymphedema of right arm. What is the best management? ....K. Progressive resistance training B. Begin Warfarin Decreases risk of new breast cancer. Effective for treatment of metastatic breast cancer. Works only if tumor is ER & PR (+) Effective in reventing cancer in high risk women. Tamoxifen has both Estrogenic an a s rogenic effects [Anti estrogenic effect: • • Anti Breast tumor effect, hence used in treatment Menopausal symptoms ssR 7. .s Estrogenic effects • • • Increased risk of Endometrial cancer x 3x Increased bone density Increased thromboembolic risk/PE Also causes Hypercalcemia. If serum calcium<14 � c..!f'f\ �""""" T.. """"')( •' f-er-' 32. 35 yr. old Pts. sister diagnosed with Breast Cancer. Your Pt. asks you how to ecrease risk of Breast Cancer in her? A. ASA B. OCP /- Tamoxifen Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 162 33. Post menopausal woman with Breast cancer. After surgery, RT and adjuvant chemotx. R+. w.t.d A. Tamoxifen B. Raloxifene (Evista®) f. Aromatase inhibitors ( Letrozole, Anastrozole, Exemestane) 3 • Sill yr. ola woman Cllagnosea with Infiltrating aucta carcinoma with LN 3/15 (+).Pt. has reast cpnservlng surgery + RT + Chemotherapy + Tamoxlfen. he Is most llkel to be at risk for p/{( Endometrial cancer B. Cervica I cancer H 'P" . L �, li' C. Ovarian cancer C �t:r""<f.� ""'c.�t.s, B R.cA ) ) l ) ) ) ) ) ) ) ) �Hypercalcemia B. Hypocalcemia C. Hypophosphatemia � Abo�4 Pt.bes a schedule of yearly mammogram & pap smear. 'ifsi'i\idd you recommend for this Pt.? A. Pelvic US annually B. Endometrial biopsy annually C. Reassurance �Ask for GYN symptoms every visit. di!� . {��@.U�!' Pt. continued taking tamoxifen 20 mg PO dally. 3 yrs. later, she presents for ml.81�!JtJJIIaJ1itts.'of a one time bloody discharge per vagina which resolved by No other complaints exceptoccasional hot flashes. No other Mammogram and Pap smear negative. w.t.d next A. Repeat pap smear in 3 months B. Reassurance �Endometrial biopsy ) ) ) J Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 163 Pregnant women with breast cancer Treat like regular Pt., Surgery in 2"d-3rd trimester, Chemotherapy in 3'd trimester Treat Breast cancer in males similar to females. 38. What is the long term complication of Aromatase inhibitors? A. Endometrial cancer � Osteoporosis ( CofV"i'.-c.�w. C. DVT 'if- ) 0.39. What is the best management of hot flashes from Tamoxifen or Aromatase inhibitors reatment? A. Black Cohosh .JY. SSRis 40. Pt. presents with nipple discharge. Exam reveals eczematous scaly lesion at nipple. regnancy test negative. Prolactin level is normal. Dx: Paget's disease. '-l """''cU.. l'<.J'ec.�""·� if there is no mass Tx: � L 0 .__ Treat as Breast cancer for underlying mass. 41. Pt. with Hx. of Breast ca s/ p lumpectomy and Chemotherapy 5 yrs. ago presents with ain in the hlp and lower back. X-ray of hip reveals 3 em. lytic lesion and X-ray of lS spine ppears normal. w.t.d A. RT to lesion B. Chemotherapy ..J/. MRI of LS spine 42. What is the first symptom of Epidural compression fracture? --------� /.Pain B. Loss of sensation Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 164 Q43. A 60 y/o woman with Hx. of Breast cancer, s/p resected ER/PR + and had chemotherapy and Aromatase inhibitors started. Current meds. include ACE inhibitor, � blocker and lasix. he is urinating more frequently. Exam is normal. Labs are normal except calcium of 11.2. hat is the next best management. JY.'bone scan B. d/c lasix ( ) The leading solid y2 I..<J<. , "'-' ) � "u· ''1..! -. rvo .... t.... ..:" <-> j 'L "1l" 1'\. tumor causing hypercalcemia is Breast cancer. 0.44. A 65 yr. old woman is diagnosed with infiltrating ductal carcinoma. She undergoes umpectomy with free margins, Radiotherapy and adjuvant chemotherapy. 6 months after ' I ) T, she presents for follow up. She has no complaints. Exam reveals no new mass or lymph odes. A mammogram is done which is negative. hat else would you recommend for this Pt.? A. Bone scan � Mammogram yearly C. Mammogram in 6 mths. l ) ) ) 45. Pt. s/p Mastectomy for Breast Ca with metastasis, on increasing meperidine for pain ontrol. She Is lethargic with decreased responsiveness. Pupils non reactive, diplopia, tongue eviated to right, absent gag reflex, absent Lt. ankle reflex. Urinary retention(+). brain- no parenchymal lesion. Most likely diagnosis A. Meperidine OD �/Leptomeningeal spread ) 46. Pt. with metastatic Breast cancer. ER negative and HERR receptor+. Best Medication is ) -7 Trastuzumab (Herceptin®) ) ) ) 47. 34 yr. old with breast lump which was excised and found to be fibroadenoma. randmother with hx of Breast Ca. How to follow up in this Pt.. A. Repeat Mammogram in 6 months B. Repeat Mammogram in 1 year J?!.' Repeat Mammogram at age 50 0.48. A. 65 yr. ol(f man nas been taking spironolactone for ascites presents with one sided reast mass. w.t.d A. Reassure that it is from Spironolactone . fl Biopsy ) ) ) Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 165 Endometrial cancer Risk factors: • Obesity • Early menarche • Late menopause • Nulliparity • Tamoxifen use L.c.t-4P � s v.:t.-v<. -' (311. -'1 kAt:. 1 ( l�k,..��, 1'\l..'-'t..ftM' J� (_...._1..< "1-·t....� Presents with post menopausal bleeding. 49. Obesity is associatea more often with which cancer �Endometrial cancer B. Cervical cancer C. Ovarian cancer D. Adenocarcinoma stomach Pap Smear: Screening between age 21-65 every 'f For women above 30, pap smear with HPV DNA negative, every -7 3 ':V -7 5 ':Jr' Don't do HPV DNA-7 <. 30 yrs., UNLESS pap smear is abnormal. High risk (multiple sex partners, STDs, HIV) Stop Pap smear screening at HPV DNA testing <30 yrs.: NO testing for WARTS (low risk HPV usually transient and clears in 2 yrs. in 70%) -7 repeat Pap in 1 yr. NO testing unless AS-CUS + >30 yrs.: With primary Pap: If ASC-US+ AND HPV +-7Colposcopy If ASC-US+ AND HPV- -7No Colposcopy, repeat Pap in 1 yr. If ASC-US- AND HPV + -7No Colposcopy, repeat Pap & DNA in 6 mnts.-1 yr. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 166 SO. 24 yr. old woman with vaginal discharge. Pap smear shows clue cells and some S-CUS. w.t.d next? v:<: Treat with Metronidazole ---1 B. HPV testing C. Colposcopy 1tv-. �c:.t . next? 51. 24 yr. old woman, Pap smear shows AS-CUS. w.t d A. Treat with Metronidazole JY.' HPV testing C. Colposcopy H pv - "', ' ' tC. , ; _, wo..;f; _, <::� 52. 22 yr. old woman with AS-CUS. Infected with HPV 16. Can she still receive HPV vaccine? It will help other 3 serotypes prevention. ' ) l ) ) ) ) � c 53. What Pt. is contraindicated for HPV vaccine? 54. SO yr. old Pt. with Hx. of fibroids. 2 yrs. ago, fibroid size of 2 em. Repeat exam now eveals fibroid size 3cms. No complaints of menorrhagia. what Is the best management? A. Uterine artery embolization j}<""Reassess in 1 year 55. Pt. had hysterectomy for severe fibrolds. Post hysterectomy do you need to do ap smear? ) ) ) 56. Pt. had hysterectomy for Ca cervix. Post hysterectomy do you need to do Pap smear? ( v� � '1L) ) ) 57. Pt. wltti lesion In ttie enCiocervical canal. w.t.d ) ) ) Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 167 58. Pt. with pap smear with high grade SIL. Colposcopic biopsy confirms CIN Ill. w.t.d -?Cryotherapy or -7 Cone biopsy especially if endocervical canal is involved. Or Hysterectomy 59. Pt. with invasive cervical cancer. w.t.d -?Hysterectomy OR RT with chemotherapy Ovarian cancer Leading cause of death from GYN cancer. Most cases present in advanced stages. General population screening NOT recommended. No need to do • Pelvic Ultrasound • CA 125 • OCP decreases risk of ovarian cancer. Pelvic Ultrasound of help ONLY in Pt.s with Dermatomyositis or strong family history of Ovarian + Breast cancer. CA 125 helpful in monitoring disease. Tx: Surgical staging and debulking of tumor with salpingo-oophorectomy, hysterectomy, omentectomy followed by chemotherapy (Paclitaxel) 60. Pt. with abdominal distension. Ultrasound shows a serous semi solid 6 em. eptate mass In the right pelvic area. CEA elevated. w.t.d next? -7 C T J'C.OJ\. to localize tumor before -7 LG.f,asc.op j Prostate Cancer • • Most common cancer in males ( 190,000/year) Second l_eading cause of death from cancer Risk factors: • Older age ( median age of onset is 72 yrs) • African American x2 • Family history ( Father had it x 3, Brother had it x 4) • High fat diet PSA screening has NOT shown reduction in mortality Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 168 61. Pt. wants PSA. Wtd? ) Gleason score determines prognosis {differentiation and architectural pattern) 6 or< -7 Good prognosis 7 and above-7Poor prognosis Chart S-4 Staging of Prostate Cancer A 1 < 5% involvement of resected tissue ) [EideriJ Observe, No Sx. A 2 > 5% involvement of resected tissue B 0 Found on needle biopsy after PSA 1' B 1 < Yz of one lobe B 2 > Yz of one lobe J &ouni) Radical Prostatectomy = • ) B 3 Both lobes involved Radiotherapy C Capsule infiltrated/locally invasive RT + Hormonal ) D 1 Pelvic node involvement Hormonal J D 2: Distant metastasis Localized bone Diffuse bone Beam RT Hormonal ) l.___[ ) ) Anti androgens compete with androgens at the receptor level in testes and adrenals. Flutamide {Eulexin°) Nilutamide {Nilandron°) Bicalutamide {Casodex0) • • • ) Anti androgens block flare by LHRH agonists. 62. 60 yr. old Pt. with PSA elevated, rectal exam unremarkable. w.t.d -7 TRUS ) ) ) Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 169 63. 60 yr. old Pt. with PSA normal, Rectal exam reveals nodule. w.t.d 7 TRUS p64. 50 yr. old Pt. on routine exam and rectal exam reveals diffusely enlarged prostate.PSA 70. w.t.d 65. 82 yr. old found to have Prostate cancer stage A2. w.t.d 7 obs�ve 66. 60 yr. old man with elevated PSA and abnormal rectal examfound tohave Stage Bl lsease on biopsy. w.t.d 7 Radical prostatectomy OR External beam RT 67.Above Pt., post radical prostatectomyfollowedbyClecreased PSA levels. 3 yrs. ater, PSA <10. Pt. is asymptomatic. w.t.d Pf P, A. Bone Scan B. CT Liver ve:' Observe ( H i p ) ----- /I 0 '; � Mt fu"tc.n c. ww I� "'"f' "{ J .. 68. Above Pt. comes back 3 yrs. later with back pain. PSA 65. X-Ray shows one etastatfc lesion In the vertebral spine w.t.d A. CT B. MRI ve:"' Bone Scan D. No further testing 69. Bone Scan confirms localized metastasis to bone. w.t.d 70. AbovePt., a year later, presents again with bone pain. Bone Scan diffuse etastasis. w.t.d � -, .1 ,)<'A�--- �� C..�'-t<.H t:\4oNst o (Leuprolide, Goserelin) (Lupron®) (Zoladex®) 7Can combine with antiandrogens to block GnRH induced flares. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 170 p71. 6 months later, with back pain again, Pt. Is treated with mitoxantrone, tans treatment, and continues to have pain. w.t.d === , ==\1.1\'\..Jt.)O\. sc.Luo� -7 i.v Strontium !j for palliation of pain. 72. 62 yr. old with locally invasive Prostatic cancer in Stage C. w.t.d Side effects of LHRH ( Leuprolide) Short term -7 H-=>t f!AJ'h.L..? ostCPpov<>� Long term -7 Best Tx-7 Bisphosphonates ( '2.ol�� 1"\A� or Alendronate) \'side effects of Antiandrogen.s] \ I �a.cpte..+L."""' -?Impaired O.a ... k -7 Breast tenderness � 'T�;K;f<-"- c;u: l \ ) �73. Pt. with metastatic prostate cancer has been started on Leuprollde. What Is most likely common In this Pt.? A. Anorexia and weight loss ) �Fracture ) ) ) ) !Matching I 13 1. 65 yr. old Pt. with Prostate cancer B. Radical prostatectomy �3. 65 yr. old Pt. with prostate cancer C. RT + Hormonal therapy Stage C ) ) A. Observe -- stage B3 � 2. 65 yr. old Pt. with prostate cancer with diffuse metastasis F\ 4. 84 yr. old Pt. with prostate cancer - . wtth stage B2 D. Hormonal therapy ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 171 74. Pt. with Afib on Warfarin and has hematuria. INR 2.2, RBCs In urine 10- 15/hpf, repeat A with persistent hematuria. Rectal exam reveals enlarged prostate. The CT scan, ystoscopy and IVP are negative. Prostate biopsy reveals prostate hyperplasia but no cancer. . t.d to treat hematuria < t"'� B () H C.CJ\. ,__.,. 1-..uv\c �� .. ) A. Decrease Warfarin dosage � Add finasteride ( Proscar<�>) C. Start Ciprofloxacin 75. Pts. family Hx.+ for prostate Ca. He would like something to decrease his risk of getting rostatlc cancer. w.t.d A. Vegetables and Fruits )V'Finasteride 76. 65 yr. old chronic smoker, presents with painless Intermittent gross hematuria ith clots. Most likely diagnosis is--------�--� A. Prostate cancer vff. Bladder cancer 77. A Pt. presented with lower abdominal pain, exam reveals fullness In the supra pubic rea. A foley cath. was Inserted with relief of pain and drainage of urine. A PSA was done 1 e� t ) hlch Is elevated. What to do next? psfl. -?Urinary retention of any etiology will cause an increase in PSA. ungCancer • • • • Most common cause of death in Men AND Women 180,000 cases/year 160,000 deaths/year 85% of Pt.s diagnosed with lung cancer die within 5 yrs. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 172 Chart 6-4 Histologic types Small cell cancer 20% • Oat cell carcinoma Non small cell cancer 80% • Squamous cell carcinoma • Large cell carcinoma • Adenocarcinoma ) • • Assume metastasis at diagnosis, hence non resectable. • Squamous cell ca Small cell ca Large cell ca ) • ) • • ) ) ) ) ) } Evaluate for surgical resection at diagnosis. Decreasing incidence Adenocarcinoma with increasing incidence in both smokers and non smokers. Most common presentation of Lung cancer is persistent or increasing cough, hemoptysis or post obstructive pneumonitis. • Pt. presenting with hemoptysis > 1 week > 40 yrs of age and chronic tobacco history has a 40% chance of having cancer. So always evaluate Pt. further with above symptoms with CT & Bronchoscopy. --ur.....___.., -1 c:r (-) • Hemoptysis presentation in an '(Oung) adult think Bronchitis, Pneumonia, Bronchiectasis • Hemoptysis presentation in an immigrant from South Asia or South America think Mycobacterium Tuberculosis. 78. A > 50 yr. old Pt. Is successfully treated In hospital for a pneumonia with Ceftrlaxone an zlthromycln. 3 months later cough persists. CX R reveals persistent density. ost likely diagnosis /.Malignancy B. Bronchiectasis C. BOOP ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 173 Tx: I : Tumor>2cms from carina, node negative ..-� "'1> t.:, s� 3 A � chemotherapy + Radiotherapy. II : Tumor>2cms from carina, node positive lila: Tumor<2cms from carina, or invading resectable structure or Ipsilateral hilar or mediastinal LN (+) ·chemotherapy -7 followed by Radiotherapy lllb: Tumor invading unresectable structure contralateral mediastinal LN (+) or IV : Metastatic disease: R., supraclavicular LN (+) or pleural effusion with malignant cells (+) l-. rvo� Ext-< t..·�·l 6x ot L�.-p � Small cell cancer Limited to one hemithorax: Chemotherapy + RT Lung Extensive disease: Chemotherapy+ RT Brain Erlotinib/Gefitinib (Tarceva®) (lressa®) Fhp¥�� Elderly Pts. With small cell carcinoma, should also be treated with Chemotherapy 79. 58 yr. old chronic smol<er >30 pac years presents wlttl emoptysfs of >1 week uratlon. CXR negative. w.t.d next 80. A 42 yr. old Pt. presents with streaky hemoptysis for the past 3 weeks. XR Is clear. w.t.d next? A Bronchoscopy B. CT sinuses Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 174 81. 70 yr. old chronic smoker> 50 yrs. presents with seizure and lethargy. CT scan head eveals single ring enhancing lesion with edema. Pt. Is started on Phenytoin. w.t.d next 82. 60 yr. old Pt. has lung cancer in family wants screening. W.t.d? A. CX R B. Sputum for cytology '\.JC,' No screening recommended ) ) \ ) l {J? y.A� 1:5' j" 83. 60 yr. old Pt. with a smoking history of 30 pack years, quit 5 yrs ago presents for a egular check up. W.t.d? A. CX R B. No screening recommended ve:" Low-dose CT _, e� ljt D. Sputum for cytology 84. 70 yr. old, chronic smoker, presents with seizure. CT reveals solitary ring enhancing eslon. Pt. Is started on phenytoin. CT Lung shows hllar adenopathy. What Is the most pproprlate next diagnostic test that would help In management of this Pt.? ) ) ) ) ) A. Brain biopsy B. Mediastinoscopy _,e; Bronchoscopy D. Bone scan 85. To prevent highly emetogenlc chemotherapy (Cisplatin) CO"? ..:.. P.. �P ,.�-...,. -7 c, .,..�� e irof'\.. .s ) -t '])fVVS' ( SIJ.> P /Neurokinin antagonist) 86. Pt. prior to administration of next cycle chemottlerapy Is nauseous ana receives ranlsetron or Ondansetron, but still Is nauseous prior to chemotherapy. w.t.d � Alprazolam (X anax®) B. DMS I Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 175 Chart 7-4 Most common cause of Paraneoplastic syndrome Small cell carcinoma • • • • • Squamous cell carcinoma • • if� Adena carcinoma • • • Large cell carcinoma • • Hyponatremia 2° SIADH Cushing's syndrome 2° increased ACTH Carcinoid: flushing & diarrhea , S-t.<At or,..,.. �'1' <so Eaton lambert syndrome: power increases with repetition. SVC syndrome Hypercalcemia 2° PTH like substances. PTH level decreased. Ca increased &P04 ..V Horners syndrome: Ptosis, miosis, anhydrosis ( S''j""P"-'�k ''- c..t._�) Pancoasts tumor: compress P1 & 2nd thoracic n. ...., (7 � c.."S,'o "d- M.Gi�:. "L.r -?shoulder pain-? pain in the ulnar aspect of hand and little finger _. C.)(�. ( t)c-.. �LO��) Pulmonary osteoarthropathy: Pain in hands or legs. X ray -7 Periosteal thickening Marantic endocarditis with Adenocarcinoma SVC syndrome Gynecomastia 87. 65 yr. old Pt. with squamous cell carcinoma with pleural effusion whlcti s emorrhaglc. BP: 160/100. Hypercalcemia (+). FEV lis 2.4 1ts, Hb 9g/dl. hat prevents him from being a surgical candidate A. Anemia JY.'Hemorrhagic pleural effusion C. FEV 1 of 2.4 Its at 1 sec. D. Hypercalcemia E. HTN 88. What Is the most important prognostic factor In a Pt. with advanced Non small cell ung cancer? --�--�----� A. Pleural effusion v¥ Poor performance status 89. 45 yr. old, status post lung cancer, status post surgery and chemotherapy 5 years go going for elective surgery. ECHO reveals ejection fraction of 35%. What to do? /.start ACE inhibitor B. Stress test Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 176 90. In aPt. withPancoast tumor, which one of the following has a worse prognosis? �hest movement asymmetry B. Horner's syndrome ph�l Nv il'\.vJt�+- 1. The LEAST likely paraneoplastic syndrome associated with small cell carcinoma is -----' A. SIADH B. Cushing's syndrome C. Eaton-Lambert Syndrome D. Carcinoid Syndrome / Hypercalcemia (.rc.c) F. SVC syndrome !Matching �1. 51 yr. old with lung cancer with gynecomastia A. Small cell carcinoma C 2. 62 yr. old chronic smoker with pain in his legs. t- CXR with coin lesion in the periphery of lung B. Large cell carcinoma and increased HCG ) ) ) ) 'D t- 3. 55 yr. oldPt. with lung cancer and hypercalcemia �4. 55 yr. oldPt. with lung cancer and weakness which gets better with repetitive movements. C. Adenocarcinoma D. Squamous cell carcinoma A :JS yr.. old manual taborer, and heavy $moker pr.eJctnts With sfloulde�:, arm� e'dta1 forearm and ring and little finger pafn. w.t.d nen? • v/('CXR B. CT Shoulder ) ) ) ) ) ) ) !Matching I .(2_1. The most common cancer in Smokers and non smokers A. Adenocarcinoma - A 2. The most common cancer in Non smokers B. Small cell carcinoma �3. ACTH producing neoplastic syndrome C. Squamous cell carcinoma B 4. Assume metastasis at diagnosis - 5. a <2% 5 year survival 16 6. Hyponatremia 1- Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 177 !Matching I h_1. Squamous cell cancer 2cms with in carina and A. Surgical resection A 2. Adenocarcinoma > 2cms from carina. LN (-) B. Chemotherapy + RT Lung ipsilateral hilar LN (+) (3 3. Large cell carcinoma at carina and contralateral LN (+) C. Chemotherapy + RT lung � + RT Brain k:' 4. Small cell carcinoma limited to one hemithrorax t-- D. Chemotherapy + RT Brain 'j) 5. Small cell carcinoma, extensive t-- SVC syndrome Lung cancer (NSCLC Bronchogenic Ca most common 65%) Lymphomas • Thymomas -i �x"''�""h. fY\..C, • Catheter induced thrombosis -7dyspnea, facial swelling, arm swelling, cyanosis, plethora and dysphagia. • • -7elevation of head (decreases hydrostatic pressure and edema) Treatment definitive: -7 RT -7 Bisphosphonates (Zoledronate orPamidronate) A. RT \.)¥.' Strontium 89 -71ife expectancy less than -7 c; NWY�� Awesome Review, Inc.<'> Copyright 2014 Do not photocopy without permission Page 178 Chart 8-4 Testicular Cancer Seminomas Non seminomas • • • • Embryonal carcinoma Teratoma Choriocarcinoma Yolksac tumor Approach to a Pt. with testicular mass. 1. Approach solid testicular growth as cancer until proven otherwise. 2. Do a � HCG and alpha feto protein level 3. Biopsy via a high inguinal incision 4. After biopsy proves testicular cancer, then CT scan Chest, Abdomen, and Pelvis to stage disease. Testicular Cancer ) ) ) ) ) Seminomas Non seminomas f3 HCG 0( feto protein ) ) I ) ) ) ) Awesome Review , Inc.® Copyrigh t 2014 Do not photocopy without permission Page 179 Chart 9-4 Treatment of Testicular cancer Semin omas Non se min oma s First DO radical Orchiectomy via high inguinal incision, then according to stage treat as follows Stage I : confined to testes RT Observe, Remove lymph nodes Stage II : lnfradiaphragmatic nodes (+) <5 ems RT Chemotherapy Stage Ill: Beyond retroperitoneal nodes Chemotherapy Chemotherapy NO role for RT 97. 24 yr. old with non semlnomatous tumor. P HCG & alfa feto protein elevated. T Pelvis reveals mass. A radical orchiectomy via Inguinal approach is done. w.t.d next 98. The above Pt. has a lung nodule as well. w.t.d -7 ��t 'at • Same principle for Breast Ca or Colon ca as well. !Matching �1. 13 HCG & alta feto protein elevation �2. alta feto protein normal �3. Inguinal approach for biopsy or orchiectomy S-4. Transscrotal biopsy �5. Respond to RT A. Seminomas B. Non seminomas C. Both D. Neither _Q_6. Don't respond to RT Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 180 �99. 19 yr. old man, with increasing breast enlargement for the last 2 years. No other complaints. P/E: normal external genitalia. Gynecomastia +. w.t.d next? � Testosterone level and Estradiol level Testosterone: 450 (nl}, LH:0.3, FSH:O.S, Estradiol :3041' What is the next step ) \ 100. Young man with testicular mass with dragging sensation, nl AFP, nl HCG. w.t.d \.../( High inguinal orchiectomy B. Trans-scrotal orchiectomy \ Chart 10-4 lymphoma ) Hodgkins lymphoma Best Prognosis B cells, Reed Sternberg cells + ) • ) • • ) • Lymphocyte predomina�ce B� Nodular sclerosis If Mixed cellularity Lymphocyte depletion l Non Hodgkins lymphoma B cells 90% T cells 10% Worst Prognosis ) Pt.s present with lymph node enlargement with contiguous spread +/- paracrine effects: Fever Peripheral granulocytosis Eosinophilia with pruritus Personality changes Reed sternberg cells + ) Ox: Hodgkin's disease • j J Treatment for Hodgkins disease �varying cycles of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine +/- RT. • If Pts. relapse or poor response� High dose chemotherapy followed by autologous hematopoietic stem cell transplant. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 8 1 1' (Y\,o.s t Go� Complications after Hodg �ins treatment Chemotherapy • • • • Radiation therapy • • • • • c� <>\J J . '2. �' . rv\. CAA. 0 1"\ � � e6 Cardiomyopathy AML Myelodysplastic syndrome Infertility, Amenorrhea Constrictive pericarditis ( s�� yV�� t �?" ) Accelerated CAD irrespective of age Solid tumors (Breast Ca, Lung CaJhyroid Ca) Radiation pneumonitis Hypothyroidism !Matching I Complications of Hodgkins disease rS-- 1. 38 yr. old with past history of Hodgkin's disease treated with Radiotherapy lOyrs. ago, presents with chest pain while shoveling snow for >30 mins. A. Constrictive pericarditis � 2. 40 yr. old Egyptian man with past history of Hodgkins Tx. B. Myelodysplasia _§__ 3. 42 yr. old s/p Hodgkin's disease treated with chemotherapy C. Accelerated CAD with mantle RT to chest 10 yrs. ago presents with palpitations, weight loss, JVD (+L ascites, pedal edema (+). ECHO reveals thickened pericardium. >7 yrs. ago presents with easy bruising and fatigue. Hb 9g, Platelets 50,000. Blood smear: anisocytosis, pelger huet anamoly. BM: dysplasia of marrow precursors and hypercellularity. � TSH B. ECHO C. CT scan chest What are they prone to? �Lung, Breast and Thyroid Ca B. AML Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 182 102. 30 yr. ol underwent c emotherapy for Hodgkinsdisease 10 yrs. ago. hlch would be the more likely complication. --------��--�--�� A. Hypothyroidism ur."lncreased incidence of AML • • • • ) • • • • ) • • • • ) • • • ) • Clonal proliferation of cells that have features of lymphoid cells. >60,000/ year and incidence is increasing for unknown reasons Seread hematogenously. ¥of. 90% derived from B cells, 10% from T cells. 40-45%-7 diffuse large cell lymphoma ( BCL 6} 30-35%-7 follicular lymphomas. (t 14:18) Diagnosis by excision of lymph node NOT aspiration. Site-7 S IA. P" c.. clc. v .·,� Staging by Ann Arbor ( like Hodgkins) and CT/PET Chest, Abdomen & Pelvis Treatment based on above and presence of poor prognostic factors. Primary therapy is combination chemotx with R-CHOP or CVP If relapse, repeat aggressive chemotx and Stem cell transplant. Age >60 yrs. Serum LDH ( f.\\ vo 1' tV. Performance status <70 Ann arbor staging Ill or IV Hb <12g/dl. Chart 11-4 ) Non Hodgkin's lymphoma ) Low grade Lymphoma j I PJ P Pri'A ) Intermediate grade lymphoma ) Type Treatment • Follicular: small lymphocytes P� 1'<#--' o. A-w t(.,t...-. Indolent - -70bserve Aggressive transform-7 R-CHOP/CVP Follicular with large cell or small cell Diffuse Mixed CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) Large cell immunoblastic small non cleaved cell CHOP +/- Rituximab -7 Stem cell transplant. • • • High grade lymphoma • Majority of the people who die from Follicular low grade lymphoma have histological progression to Diffuse large cell lymphoma. ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 183 Others: Post Renal transplant lymphomas -7 E B V associated lymphomas CNS lymphoma/Burkitts/Naso pharyngeal carcinoma -7 El3 \1 -7 H . p y Lov1 MALT 'I? c; f\.o �"""� C...:I\.. -7 H 1-t V � Kaposi's Sarcoma -7 KPv 1 61 1 P Ca cervix/Anal Ca -7 H IL V 1 T cell leukemia . 103. 65 yr. old Pt. with asymptomatic cervical lymphadenopathy. Lymph node biopsy eveals fotncular small cell lymphoma, with preserved architecture. one marrow flndin s are ositive. w.t.d 04. A Pt. with abdominal pain, weight loss and fever has bulky Retroperitoneal ymph nodes. Biopsy of mass reveals large cell lymphoma. Tx:-7 R. - cJ-C oP Above Pt. fails Chemotx. Best management - Q$ � � yeJF$1atar presel'\tS with ataxJt, Pt-� lleaail..�nt tJslOn ln the eerebellum. Mostlikely. cause ls /, EBV B. CMV C. Toxoplasmosis D. HHV 8 c. L L A. Osmotic fragility test to rule out Hereditary spherocytosis B. Flow cytometry of CD 55/59 to rule out Paroxysmal nocturnal hemoglobinuria vC Coomb's test to rule out Warm autoimmune hemolytic anemia D. G6PD to rule out G6PD deficiency Best mangement for above Pt.? 7 Steroids Tx:-7 �f\.o.e..-� c!fJ Awesome Review, Inc. <!I Copyright 2014 Do not photocopy without permission Page 184 107. Pt. with large hllar adenopathy diagnosed as small cell ca, presents with hortness of breath. Exam reveals a massive pleural effusion. w.t.d next? A. Chemo Tx B. RT 0- Tap the effusion 108. Above Pt. comes back couple of months later with recurrent effusion. w.t.d A. Local instillation of Talc \..8':' Thoracoscopy with talc poudrage 109. A Pt. who was diagnosed with lymphoma 2 yrs. ago, but did not require treatment at he time presents with shortness of breath. CXR shows effusion. What will you do next? -7 \ ) ) ) } T� 1i:,... p\.c.,.. w• .,L e.� "' �""" What is the best management? A. Pleurodesis .)Y."Chemotherapy s c.L'V'A- � ('JS C L C. C...., � '-� 110. What can you expect one month after two infusions of Rituximab? --------� A. Reduced T ceil count /.Lymphopenia C. Hypogammagiobulinemia (_ c. LL , c V1. �·<...;� ) ) ) J ) ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 185 Multiple M yeloma 'Lytic lesions, bone pain, hypercalcemia, serum & urine protein 'M' spike' Marrow cytosis � Plasma cells� Osteoclasts � Punched out bone lesions �hypercalcemia � lmmuneglobulin�'M' spike in serum and urine�Renal failure ( v.p f:'P t. (faulty lgG) � Rouleaux formation of RBCs t..o w An.ivv rt' � t ESR � Platelet dysfunction � I nfections s pr:;p ) Tx: ltuvl .Jc.·, l....wNo end organ damage (RF, Lytic lesions or Anemia absent) � M onitor Evidence of damage � Le('l... c;,. llcl<>�c;lc.. ______ Melphalan/Prednisone (Aikeran®) For relapse: � Do NOT do induction with Melphalan �Tx with G.!)�te zo�b I H e ,..... c.-t...roi d...:,.; (Velcade®) Prior to Bortezomib, what prophylaxis? H ¥t.t WL 'trc.r-�pW -z..o rtt...v Chart 12-4 Multiple Myeloma ( M M ) Protein Bone Marrow Plasmacytoma Hypercalcemia / 3. 5 f]f d. L �tM. \A_ � w.., Monoclonal gammopathy (MGUS) of u nknown significance - -gj rJ. L lcJk < 3. $ NO / L D l· < 1.-.:l'/. -+ - Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 186 /F about Multiple Myeloma - r-1-1. Hypercalcemia �2. 1' Proteins �3. Renal dysfunction 1-- r-l.-4. Platelet dysfunction �5. Bone pain ;::L 6. Infections 1- �7. Amyloidosis - -r 8. Dilation of Retinal veins Hyperviscosity can be caused by all of the following: • • • -7 Waldenstroms macroglobulinemia Polycythemia vera Leukemia -7 p La..J M. � I' 1-.e ...e. �s -7 . phl�bot.o""q- 7Leukapheresis Radiographic skeletal survey. -7 Lytic lesions in Multiple myeloma. ) ) Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 187 114. A 60 yr. old man presents with headache, blurred vision, ymphadenopathy and fatigue. b 9g/dl. lethargic with decreased power on one side. otal proteins 8.0. Globulin 3.0g. Calcium 9.0 erum protein electrophoresis shows Increased lgM >2g/dl. f\10 M. s p : k.e. I SR Increased. • Caused by lgM (largest immunoglobulin)-7remains intravascular-? Hyperviscosity syndrome. No lytic bone lesions No Hypercalcemia Bone marrow shows 'plasmacytoid lymphocytes' • • • Treatment: • Plasmapheresis • Fludarabine based chemotherapy. (Fiudara®) Tumors of the Pancreas • Pancreatic carcinoma Glucagonoma Gastrinoma VIPomas stu-A o.rM. • • • -7 C T s- u.....t\ frJ C(' pC¥�.c..� < so dA'-'"IL clw.f- A:� ( ot:L.khv- � to rule out pancreatic cancer c. e, l) -? Mainly in the head of the pancreas-? double duct sign + l POJ\ • �) )\ �J } Tx: Pancreatic Ca with no metastasis -7 .f'w-.:1 � C Pc..f\. cyecd·i �o�t t.tq can include minimal invasion of portal or Mesenteric vein c-o 116. Above Pt. refuses surgery w.t.d? --------� A. Comfort measures Y,Gemcitabine chemotherapy Pancreatic Ca with metastasis-? P c. I � ' t,:� t;. �ft �t P � �-t Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 188 117. Pt. with stage IV pancreatic cancer with severe itching. What Is the best management? XBiliary stent B. Cholestyramine 118. 46 yr. old woman with no previous history of pancreatitis has an Incidental finding of .8 em. mass in the head of pancreas seen on multldetector dual phase contrast CT scan • .t.d ) \ A. Observe ,.JY. Surgical excision If the mass was not clearly defined or borderline resectable on CT scan then the best test is 7 Endoscopic Ultrasound ) \ ) ) 119. Diabetics are more prone to what kind of cancer? --------� A. Breast cancer B. Colon cancer Y, Pancreatic cancer 120. What Is more commonly associated with pancreatic cancer? � moking B. Alcohol 121. Pt.s who had Familial adenomatous polyposis are more prone to? 7 Ampulla of vater cancer ( s"'"vc.llc...A.<.<.. �--It £c. 'D 9. ------{;I'LA-:>.Su.pL'c.. u.S' ) 122. Pt. with persistent hyperglycemia, weight loss, anemia. Exam reveals scaly necrotizing dermatitis. Glucagon I njection doesn't tncrease Glucose level. ) ) 123. Pt. wltfl profuse watery diarrhea not responding to fasting. history of weight loss. erum K Is 3.3, and hypochlorhydria. Serum Vasoactive Intestinal polypeptide level Increased tool osmolar gap low. Dx:7 Vlp:J� ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ) Page 189 !Matching I l J:.'N. v•A<.oc.k _£1. Courvoisier's sign ('M�rc:.�'J (.R.cAc.l !;;_2. Trousseau's syndrome �v<>r-.b"f>l-.e h b:. � "' � S C. A. Acute Pancreatitis . . ""MAO\. )B . Ch ronrc pancreatitis . ,__ �3. Double duct sign �4. Sentinel loop sign (small bowel ileus) C. Pancreatic Cancer 124. A Pt. presents wltti dlarr ea. Hx 9 .,sfiln,g se�on. xam revears some telangiectasia-. What WDr you ao 1>1ext? Most likely diagnosis? -7Carcinoid Hepatocellular Carcinoma. 125. What Is the flrst line treatment? -7 Resection or Transplant A. Biopsy \)r. Imaging studies ( MRl (1\" C..T Wit; <.Qf'.t.-c.A t ) 127. Wh t ch agent has sbown sutitiYal lp hep.-cefWiar carcinoma? A. Gemcitabine (Gemzar®) \)( Sorafenib (Nexavar®) Medullary carcinoma Calcitonin increased, RET proto-oncogene r � dense calcification in tumo • associated with M E N II & Ill (check family Hx.) • Tx: Total thyroidectomy • • Follicular • • • } Papillary carcinoma-7cervical LN, pitted calcification (Most common with best prognosis) 90% of thyroid cancer Follicular carcinoma -7mass & distant mets Anaplastic carcinoma-7 with mass (Elderly with worst prognosis) Medullary ca can present with any of the above manifestations Awesome Review, Inc!> Copyright 2014 Do not photocopy without permission Page 190 Best mangement for Papillary and follicular carcinoma after surgery is � R.a�o i ocU"' Ab\.. c.. l-\ c:tYV I t will not work for Pts. with Medullary carcinoma as Radioiodine i s not taken u p by C-cells ) \ ___{j_l.Medullary _ carcinoma recurrence �2 . Papillary carcinoma recurrence !Matching I A. Calcitonin level B. Thyroglobulin level �3 . Follicular carcinoma recurrence C. CEA D. TSH Chart 13-4 ) I � �re.aur ) � .n.c:J..p ) -J oc. EB EB i�c.�c..v ton ) ) ) ) Malignancy esophagus lungs mediastinum • EB par EB ----.-- � ··Jt. t:,ry ( 1:> wli""" + J�"".A . a • ...Lcv LtV ) abdominal t fLA.. L • malignancy c, 1. ) { ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 191 Chart 14-4 Carcinoma of unknown origin Types Poorly differentiated carcinoma Adenocarcinoma 40% Lymph nodes: Cervical & supraclavicular > Mediastinal > axillary 30% Liver, lung, bone In 20% of Pt.s primary cancer will be identified Expected Mean su rvival is 6 months. Adenocarcinoma in females with axillary LN-7 Pursue Breast cancer diagnosis. Do Mammogram +/- MRI, ER/PR receptors Mastectomy +/- radiation +/- chemotx Adenocarcinoma in females with bony involvement -7 Pursue Breast cancer diagnosis Adenocarcinoma in males with bony involvement -7 Pursue prostate cancer Ask for urinary symptoms, Do PSA & Rectal examination Poorly differentiated cancer in young males-7 Pursue germ cell tumor. DO alfa feto protein & � HCG. Platinum based chemotx if (+) Squamous cell cancer: Presentation with cervical LN (+) -7 Pursue Head and neck cancer. present with lower cervical LN (+) -7 Pursue Lung cancer Awesome Review, Inc.® Copyright 20 14 Do not photocopy without permission Page 192 \ JL_l. Most common cause of carcinoma !Matching I A. Adenocarcinoma of unknown origin 'D 2. Most common place of presentation of - B. Undifferentiated cell carcinoma carcinoma of unknown origin A_3. Female with axillary lymph node (+) C. Squamous cell carcinoma __!!_4._ Carcinoma of unknown origin in young male D. lymph node most likely to have what type of ca \I ) �5. Head and neck cancer. 28. 0 yr. o man, smo er with a single su mandl6ular LN (+ which was found to be ndlfferentlated carcinoma. Physical exam of the head and neck Is negative. CXR Is egative. w.t.d next A. CT chest B. RT to submandibular area J2!.' Upper Pan Endoscopy D. Upper Gl series 129. The following screenings have shown to decrease mortality EXCEPT --------� ) ) A. M ammogram B. Pap smear � PSA D. Fecal occult blood testing E. Sigmoidoscopy 130. A Pt. with metastatic cancer with persistent pain. He takes Oxycoaone with tylenol prn e has also taken Morphine sulfate twice a day. w.t.d A. Continue present meds. and add anti-depressants �Use Extended release Oxycodone or Morphine q 8-12 hrs continuously. ) 4 C. Use Oxycodone or Morphine q hrs prn. D. Use lidocaine patch plus oxycodone ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 193 !Matching .2_ A. Methotrexate 1. Myocardial ischemia, myelosuppression I B. S FU _ 2. Reversible pneumonitis, Hepatic fibrosis (TrexaW'>) (Efudex®) 3 c _ . v·mens · ti ne 3. Neuropathy, SIADH (Oncovin®) � D. Doxorubicin 4. Interstitial fibrosis 4 E. Bleomycin 1"- 5. Cardiomyopathy � F. Mitomycin 6. Gynecomastia, pulm. fibrosis, impaired dark adaptation (Doxil®) (Bienoxane®) ( Mutamycin®) � G. Cyclophosphamide (Cytonxan®) ,_.§__ H . Bicalutamide 7. HUS, Blue green urine 8. Hemorrhagic cystitis, Bladder Ca. (Casodex®) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 1 94 ) �1. Neuropathy, Bradycardia !Matching I A. Gemcitabine (Gemzar®) �2. Anal pruritus, HUS, flu, rash B. Paclitaxel (Abraxane®) C 3. Hot flashes, Thromboemboli, Endometrial cancer f- ) ) ' �4. I mpotence, transient cancer flare, Osteoporosis C. Tamoxifen (Nolvadex®) D. LHRH agonists (Lupron®, Zoladex®) G 5. Decreased WBCs, myelosuppression E. Hydroxyurea (Hydrea®) � 6. Myelosuppression, hypotension, weakness, alopecia F. Cisplatin (Piatinol®) f= 7. Nephrotoxic, Ototoxic, Neuropathy G. Etoposide (Etopophos®) - - I ,l ) ) ) - 1:.._8. Flu like symptoms, LFTs1', arthalgias, Hypo/hyperthyroidism H. IL-2 U:l-9. Capillary leak syndrome, Erythema t:�-U,.k. T .J 1-1 I. Interferon alfa ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 195 An AWESOME REVIEW OF = 10% - Pathophysiology - Asthma - COPD - Bronchiectasis - Cystic fibrosis BP and BOOP Interstitial lung disease - Sarcoidosis - Hypersensitive pneumonitis - Pneumoconiosis - Pul. HTN Pulmonary embolism - Sleep Apnea BAL Awesome Review Inc. e Copyright 2014. Do not photocopy without permission. J Chart 10-1 Bronchi Resp. Bronchioles Bronchioles Alveoli (�� :_.._�G8 _ 0 Normal 1�t ·1', �v1 l>LW J, I ) ) F f:V w /L'-1-, Obstructive: Asthma 'DLC.o Nl.f 1 �v 1' "lAt.-• (1.... v� u <- Restrictive: Fibrosis, Sarcoidosis, Pneumoconiosis. � {.boN� c � const t)C C:,..t., ft:-.,1'.......-(. OJ T Lc. �, Rv J, AJ\f'G.JI..; 'D 1... t.o J- �Gv1 J, Fvc. J = 1\JL Restrictive: Chest Cage: Kyphosis, Spondylitis, Obesity. Neuromuscular: M.gravis, GB syndrome, Muscular dystrophy. ( bU. buw-A ) Chart 10-2 ) FEV ,fFVC I ,Normal I I ___ __ __ __ _ __ , •Obstructive Dz __ -------� >80% <80% :Restrictive Dz >80% FVC 2 ) I 1 l ) () 1 imP (seconds) 9 Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 377 Ch art 10-3 FEV 1/FVC FEV, 1' � .J- 1 J N � -J Asthma Restrictive Intrathoracic Restrictive Extrathoracic Q;b #, O.w.j o�d..Pl'<- TLC ..t, COPD j.N p·. IV'jJ �� <jg. N J, -.!, DLCO RV "" 1 NL/t t J, v opt N � 1' � I Lc. <VdtK./\t.·,f.<. R.e_.rt,.;.,t IN-" � Obit;_. t.� TLC IU:. 'IJ(? FVC=Forced Vital Capacity DLCO=Diffusing Lung Capacity for Carbon Monoxide DECREASED in diseases of Alveolar Parenchyma FEV ,=Forced Expiratory Volume 'I � TLC=Total Lung Capacity RV=Residual Volume Chart 10-4 FEV, FEV 1/ FVC TLC DLCO Disease 84% 90% 94% 86% Normal 58% 65% 108% 65% coP'D 55% 92% 55% 64% R.ut;.,.:( r,:-v<- 56% 72% 102% 88% 58% 90% 60% 85% FEV ,=Forced Expiratory Volume TLC=Total Lung Capacity I Obi�""' 7nl;-&. �,u-;c. 'Dr' (>.Jft. fV"oA l<.ut..;c..t;..-.., Ex Ct.:. 11;.ot'c.� (... FVC=Forced Vital Capacity DLCO=Diffusing Lung Capacity for Carbon Monoxide 1. Which test best differentiates Restl'fctWe vs Obstructive lung disease? 7 TLL 2. Which set of PFTs will LEAST likely respond to therapy for Asthma • • \}(. Low FEV,, Normal FEV,/FVC, low TLC -= B. Low FEV1, Low FEV1/FVC, Normal TLC 3. DLCO 140% of predicted, normal FEV,/FVC & TLC. Most likely finding of A. Asthma B. COPD C. Bronchitis vf>. Alveolar hemorrhage Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 378 � DLCO 1'DLCO CHF" (Y\:,t,L ) f\S�MSI coPD J't{IWW GO �st.-\<.li� De Af'D/ VSJ) PE. POA Pv-�\.·. ..: e-.. Po \-y-'1-ft:.trv, P.,rv..,N.c, pois� H7rJ p4. Hyperkyphosis in the elderly is associated with which of the following? V(: FEV .J, FEV 1/FVC nl TLC .J, DLCO nl RV 1' B. FEV 1 .J, FEV 1/FVC nl TLC .,J,. DLCO nl RV .,J,. 1 ) N DLCO #:� C. Falls chart 10-5 } ) 12 ) 10 ) 8 ) ) ) Exhalation -o c 0 u Q) VI VI .._ Q) ·'= 3 6 4 2 0 u::: -2 -4 2 4 5 6 Volume ( liters) Inhalation -6 -8 Max inspiratory flow Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 379 Chart 10-6 Tumors Tracheal Stenosis Tracheomalacia Extrathoracic "0 c 0 u Q) Intrathoracic '0: Q) :t! 3 0 u:: Fixed Extrathoracic Obstruction: • Tumors • Tracheal stenosis oJ, 'D. / \__ 1 Dynamic � Dynamic Intrathoracic obstruction: thoracic Obstruction: f • Epiglottitis • Intrathoracic tracheomalacia • Vocal cord dysfunction --U"':1......, � i1Vp1Yc.Hc,., vo(....l <A o(. � _/ G \--'• Matching - - ..... __ '}) 1. A Pt. with myasthenia gravis presents with weakness with Vital capacity of <15ml/kg, Pt. is intubated, treated for a week, extubated and discharged home. He presents weeks later with shortness of breath and stridor. PFTs reveal the following flow loops. Most likely diagnosis is 2 "' 2. 22 y/o woman presents with shortness of breath and wheezing. She has been on inhaled !32 agonists, inhaled steroids and has used intermittent increasingdose of oral steroids for the past year without much symptomatic relief. Exam reveals a puffy face. Bilateral wheezing during inspiration. The inspiration/expiration ratio is There is some stridor. Pulse ox. is on room air. Most likely diagnosis is 1. --1 ------------ A. COPD exacerbation B. Pulmonary fibrosis C. Vocal cord dysfunction _. _ '"l.Ao,.'l'Ut f': '!\ "t �...'ji'\U>S<.:>�(. .r D. Subglottic tracheal stenosis E. Worsening myasthenia gravis 96% Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 380 • Parxosysmal Inflammatory Non specific Reactive obstructive airway disease. Reactive to • Dust • Viral infection At b.... � J<> ,....,V. � c,.. u,:s-c. . • Cold or Exercise -+ ·,1\�c.l( � _.. ij- """t i""('t"f& a.ctt\ L.-o(Y'.O �"' • Occupational allergens: a;v� P(l;k <fi;>W t?rt. v-IOtt t • • • � lsocyanates (urethane paint) Cotton dust (Byssinosis) Wood dust (cedar or oak) • • Metal workers methacholine Ch test Dec FEV1 >20% -->asthma Usually present with a combination of symptoms. Bronchodilator Inc FEV1 >15%/ 200 ml -->asthma Chronic cough 7 SOB 7 Wheeze • • • ] ) ) "'-oM.(.. • ) ) At D.1agnos1s: � • 1k M ust show reversible bronchospasm • If has Asthmatic symptoms (Cough, SOB, wheeze). what is the next diagnostic step? • PFTs show 7 Obstructive changes with reversible Bronchospasm responding to Bronchodilators by increasing FEV , by about - then Asthma is diagnosed. • If PFTs show NO obstruction, but clinical suspicion highJ then 7 Methacholine challenge test7 Provoke bronchospasm and should respond to bronchodilator by about increase in FEV , 15%, 15% ) ) Asthma: SABA, LABA, Mast cell stabilizer, Steroid, LABA p.s. Young man with history of Asthma had an acute asthmatic attack and was treated ;iUCcessfully with albuterol nebulizations. Pt. comes for follow-up and Is fine. PFTs done now will show 7 ) ) Obst..- ( t; � .,.u.tt- (. i ( �"\A I d ) 35 y o man presents with paroxysmal non productive cough of >6montl1s Cluration. enies any other symptoms of wheezing, cold or heart burn. 1E: Physical Exam normal. CXR and Spirometry normal. t. treated with courses of antihistamine and cough suppresants with no Improvement. ou will now recommend: A. Upper Gl series JY'Methacholine challenge test C. Bronchoscopy D. Treat symptomatically with cough suppresants 7. A woman works In a car factory, gets SOB at work, which is worse at the end of the ay. Feels better at home. Problems in relationship with male supervisor. CXR nl. hat do you suggest A. lsocyanates antibodies JVPeak flow at work and at home Awesome Review, Inc.�'> Copyright 20 1 4 Do not photocopy without permission Page 381 8. Best way to treat Pt. with Asthma PPis have not shown to increase or decrease the symptoms of asthma 9. A 24 y/o woman with history of Asthma and eczema moves Into new apartment. er asthma gets worse. w.t.d -7 Removal of rug, carpeting and use of allergy proof plastic wraps for mattress, pillow and box spring. Chart 10-7 Severe persistent Syms.@ Day Syms. @ Night PFTs ( FEV , ) Continuous Frequent <60% Treatment • • "N Moderate persistent Mild Persistent Daily >5/mth • 60-80% 8 I ,.....rt'1t... ¥ >2/week <1/day >2/mth • • >80% • • • Intermittent <2/week <2/mth • >80% • High dose inhaled steroid + PO steroi s with repeat attempts to wean C.CV\ h-t �� jl\.. �� 8" t-1\t N -ttfV\jl W<>l"'(/\' Low-med dose inhaled steroid + Long acting inhaled �2 agonist Low dose inhaled steroid Cromolyn Na/Nedocromil Leukotriene inhib. or Theophylline � P,... $.cP:Ji v-- � WWS<M-:1 "� PF1 No daily meds short acting �2 PRN Leukotriene modifiers may be effective treatment for • Pts. with mild persistent asthma. • Allow dose reduction of inhaled glucocorticoids in moderate and severe persistent asthma • Aspirin-sensitive asthma 10. Pt. with perennial vasomotor rhinitis and nasal polyps develops Asthma. e has allergy to NSAIDs J.d, i"' <D c..� e;'" s-;b.<>R� 0; c�t S'tvw-1 Most definitive Tx: 0 Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission F -J Bc.J.<. b wUul. � Lo.AJ":f � cf;l AT_. P.pcx b..Jlc...e. Page 382 11. I n a Pt. with ASA sensitivity Asthma. You can use • • • Codeine based analgesic Sodium or choline salicylates NO COX NSAIDs 1 �12. Pt. with shoulder pain and gets Ibuprofen. He comes back a couple of hours later � �--------------� �lth severe shortness of breath and wheezing. Most likely etiology? 13. Pt. with mod. Asthma on Inhaled steroids + long acting P agonist, Theophylline. hat else would you add? --------� A. lpratropium vff. Montelukast C. I ncreased steroid dosage ) ) ;). ) ) SO y/o Pt. post viral U R I several weeks ago, still with persistent cough, Increased t nisht with chest tightness. o heart burn. Recent cardiac workup negative. FTs reveal mild obstruction. w.t.d next etfnlchollne challenge test 14. ) Best treatment for the above Pt. ) 7 ) lr\hc.\e� s-tew\tl ( �qe "v�� <l."(} ) 15. What Is the mainstay maintenance therapy for Asthma ) } 7 Sputum for eosinophils (Non asthmatic eosinophilic bronchitis) ) � 17. Pt. with Asthma on Beta agonists, still with wheeze. w.t.d. A. Montelukast B. Long acting �2 agonist J/i nhaled Steroid 18. Pt. with severe exacerbation of Asthma hospitaiJzed wlth t.v steroids and beta gonists. Upon discharge 7 Switch to tapering dose of oral steroids. Start inhaled steroid. Continue beta agonists PRN. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 383 019. I n addition to reducing severity of acute attacks and chronic symptoms of sthma, what else do inhaled steroids do? --------� A. I ncreased cardiac mortality � Reduction in the progressive loss of lung function in adults p20. Pt. with Asthma on albuterol prn with nocturnal awakening with symptoms of Asthma. Best medication is vK inhaled steroids B. Long acting �2 agonists 021. Pt. with Asthma on inhaled steroids and albuterol prn with nocturnal awakening with ymptoms of Asthma. Best medication Is � LO"'j' q,<�"j P1 A�o"-'st. (Formoteroi/Salmeterol) 22. Increased mortality in Asthma is related to � 023. Pt. with history of Asthma presents with an acute exacerbation to the ER. BG: 7.46/34/70/94%. Pt. receives nebulization treatment with Albuterol. fter the third treatment, exam reveals breath sounds heard bilaterally but decreased. R >30/mln, H R 130/mln. BG: 7.38/46/70/92%. The most appropriate management for this Pt. is A. Start i.v steroids � Intubate the Pt. C. Start i.v antibiotics D. I ncrease 02 to 50% by ventimask 24. Oxygenation goal in Asthma � Pc..Oz. / ,o s s.... ol- / l'oJ. 25. Pt. with history of Asthma being treated with P2 agonists, inhaled steroids and ontelukast. She continues to have symptoms. She removes the carpet and rug, she also leans the house. She has a cat and doesn't want to get rid of it. erum lgE level is high. What to do? A. Continue current management VV. Add Omalizumab ( A"'c r � £ �"'Po ) k1 Q26. An asthmatic is currently on lh agonist prn, inhaled triamcinolone, salmeterol and ....., montelukast. She has frequent exacerbations. he doesn't like to go on long term oral steroids. hat is the best management to decrease her frequent exacerbations? A. Start ipratropium v8.' Start tiotropium ( .fpi.,.ivc.) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 384 Chronic Cough: • Upper airway cough syndrome (formerly Post Nasal drip) • Asthma • Gastr o esopha geal Reflux di se a se • Chronic Bronchitis • ACE inhibitors • Non Asthmatic eosinophilic bronchitis Exercise induced Asthma: Symptoms peak 10-15 mins. after stopping exercise and resolve in 30 mins. Occurs mainly in cold weather. ) ) Dx: Exercise challenge test in cold air; a drop of FEV , by 10-15%. 27. What is the next step In management? � Short acti ng ) ) �2 q,8oMst inhaler 30 mins. prior to exercise 28. What if Pt. continues to get short of breath on above treatment? � AcAoL (.yCf'V\..0�" N� 29. What if Pt. gets short of breath on Cromolyn Na ? ) ) � Inhaled steroids & Montelukast 30. Pt. moved to Minnesota and has been experiencing SOB when he ventures out In cold eather. The next ste would be A. Start steroid inhaler _%.' Start �agonist inhaler C. Start Leukotriene inhibitors D. Add lpratropium E. Cromolyn sodium ) ) 31. Mechanism of action of Cromolyn Na. --------� c e l lr t -' __ --' � � stabilization of --JV\. ___ ______ 32. Pt. sta rted on albuterol inhaler because of shortness of breath while jogging. H e also wakes up 3 times/night to use albuterol inhaler. w.t.d A. Start inhaled steroids B. Long acting �2 agonists C. Cromolyn Na vJ?f ) 1c.J' -r L A.GA Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 385 Matching � 1. Symptoms <2/wk and < 2nights/month A. Intermittent �2. No daily meds needed, short acting �agonist PRN B. Mild Persistent �3. >2/week but <1/day and >2night/mth, Low dose inhaled C. Moderate Persistent steroid c c 4. Daily symptoms, >Snights/mth. D. Severe Persistent 5. Start long acting � agonist and low to mod. dose inhaled steroid E. Exacerbation 'D 6. Continuous symptoms and frequent nocturnal symptoms ']) 7. High dose inhaled steroids + long acting � agonist + PO steroids f; 8. Post viral URI with increasing wheezing and dyspnea f. r3,c 'D 9. Nebulization treatment with short acting �agonists and steroids with rapid tapering. 10. Leukotriene inh ibitor( Montelukast) Allergic Broncho Pulmonary Aspergillosis (ABPA) Colonization of upper airway with Aspergillus in Asthmatics -7 leads to an intense, immediate hypersensitivity type reaction -7 increased lgE level, Skin reaction ( +) to Aspergillus Ag. /P Serologic tests for lgM and lgE ( +), Eosinophils +, Brownish mucus plugs -7 migratory pulmonary infiltrates ( eosinophilic pneumonia) <P 33. Pt. with steroid dependent Asthm• pn�s.ents with cough} whee�lna, and �sh ucus plugs In sputum. H•sa patal(eetVmkeslrlhaltdtrtamctnol�albut4rol'ind romolyn N a. Steroids recently reduced to <20mg/day BC: 15% eoslnophlls, lgE level: >2000 XR recurrent fleeting bilateral Infiltrates. Most l l ke l Ox? Jl(. Allergic bronchopulmonary aspergillosis B. Hypersensitive pneumonitis C. Allergic angiitis of Churg Strauss D. Loeffler's syndrome -t -t- ---- -t + t N -- N 1' Best treatment: A. Remove pa rakeet vi! Increase Steroids dosage C. Thiabendazole Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 386 34. Fungus ball in cavity asym tomatic. w.t.d 35. Fungus ball in cavity with severe hemoptysis w.t.d � ) ) ) ) .n.... r� IJ R.a.ttC. 'C/'N ( �1: (.:vv-p\,..,o I (Vo t. B yVY\ u.v. (.'rl� £IV\ 1:> .m 1.t.. 1-\t- ) Hypersensitive Pneumonitis: - BAL � �""r>L...�C.I-IJ �# 'Farmer's l u ng' Farmer presents with fever, chills, dypsnea after returning from work every day. Or Pt. works in grain elevator Or Pt. with pet birds ( bird fancier's lung) Or Methotrexate , Ni t,.o:fu,-""to,'" Or working with airconditioning systems. Etio: inhaling organic dust with Thermophilic Actinomycetes CXR: infiltrates with ground glass appearance with no eosinophils Labs: Serum Antibodies BAL: CD8>CD4 (Opposite of Sarcoidosis) � l��<-:l t-. � 4}> 41 Dx: Hypersensitive Pneumonitis 36. Pt. has a dog, a cat, 2 parakeets and pigeons. Presents with cough and progressive ) ) ) 08. CXR reveals interstitial/alveolar Infiltrates (ground glass). WBCs � oslnophlls. r, E 1 f PFTs with restrictive pattern � B I YeA. l="a.t'\.C:..:e, .J L� ( h::Jpv-se(\� t.; v;S PtU..u""-'� ""-�s ) �37. A 70 y/o man Is admitted with chills, fever, non productive cough a n d pleuritic chest pain. Recently had acute pharyngitis and hoarseness of voice. Pt. received penicillin/Ampicillin without much Improvement. CXR shows a right lower lobe Infiltrate. �lood cultures neg., Mycoplasma and leglonella serology are neg. The most likely cause Is A. Staph aureus B. Legionella C. Mycoplasma \JY. Chlamydia pneumoniae 38. Which of the following is true about psittacosis A. Photophobia and headaches are uncommon B. Productive cough is seen C. Epistaxis occurs in majority of cases \)( Disease is asymptomatic in birds J( Complement fixation and serology are useful in diagnosis of Psittacosis Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 387 Pt. with Asthma on fluticasone inhaler and oral steroids. ontelukast was added recently and oral steroids were being tapered to less than 20mg/day. Pt. presents with cough, SOB and weakness of the right hand/foot. CBC reveals 25% eosinophils. lgE normal. CXR with bilateral dense pneumonic infiltrates. Most likely Ox Q39. yl(. Allergic angiitis/Churg Strauss pneumonitis B. Hypersensitive pneumonitis C. Wegener's D. PAN Tx: � ( E O�p\.>l T r I (i rvt, ) StutA� 40. Pt. from latin America (Peru/ Ecuador/ Dominican Republic/ Cuba) has been lagnosed with Asthma. She Is a recent Immigrant. ow presents with recurrent cough and wheeze in spite of using P2 agonist Inhalers ore often. CBC�Eosinophlls 20%. XR shows round infiltrates. ANCA neg., ANA neg. ost likely diagnosis �--------------------------------------------------� A. Hypersensitive pneumonitis B. ABPA �Strongyloides infection (Loeffler's syndrome) D. MTB 41. You would treat the above Pt. with Jtr('Thiabendazole B. Steroids C. Metronidazole D. Amoxicillin E. Cipro Chart 10-8 ABPA Hypersens. Pneumonitis Type 1/lgE III/IV Eosinophils + None Dz Asthma Tx Steroids Farmers/AC pigeons/Chem. Remove offending agent Allergic angiitis (Churg-Strauss) Vasculitis + Asthma+ Vasculitis Steroids Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 388 42. A 35 y/o non-smoking woman presents with cough, no sputum, wheezing, night weats and low grade fever. History of Asthma. xam: b/1 crackles � XR: very peripheral infiltrates. PPD neg. AL: high eosinophil count SR very high. A 35 y/o construction worker presents with SOB, no wheeze, no chest pain or hemoptysis. No exposure to toxic fumes. Exam reveals bilateral crackles. ¢XR reveals diffuse opacities (homogenous Infiltrates) or ground glass appearance. �ranch. reveals copious tan colored fluid. Biopsy confirms alveolarprotelnosls. �43. ) ) ) ) Tx: 7 BAL �� --------------------------------� �� Etio: Defective macrophages causing build up of surfactant in the lung. � History of chronic smoking and decreased FEV,/FVC <0. 70 makes a diagnosis of COPD. ) also determines severity of disease. l Chart 10-9 -) ) ) I COPD GOLD criteria Severity Management FEV,/FVC <70% + FEV,>80% Mild Short acting Bronchodilator P.R.N: Albuterol +/· lpratropium FEV1/FVC <70% + FEV1� Moderate Short acting Bronchodilator P.R.N Plus: Long acting Bronchodilator R.T.C: � t� +/- Salmeterol +/- FEV,/FVC <70% + FEV@ Severe Above Plus: Inhaled Steroids �· --4 ,.,.� 1\-;fl. rv-.fJ' o-� i,....p.ov< � Very Severe Above Plus: Long term 0 2 therapy atleast 15 hrs/day Consider Surgery Avoid using short acting and long acting anticholinergic agents together <. llth"'"''""' o)- '-'"1"( Stage IV (very severe disease) with acute exacerbation ( 1' sputum volume change in color and 1'i shortness of breath should be treated like Community Acquired Pneumonia w1th antibotics) AL< 'It-,..,""� w, (. e.. V>.......,. H u-.v.l'\.;)..... 1'\NV'. �pi b"'- .rt:r� ) FEV,/FVC <70% + FEv,§ ed;!-\'-'V\.<j "J M/.f � 'l& ) _, Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 389 - -.... \ .. , .. ....... ....'"' ...... - Matching A 1. FEV, is 65% of predicted and FEV1/FVC A. Add a long-acting anticholinergic 2. FEV, is 50% of predicted and FEV1/ FVC ratio of B. Inhaled steroid 3. FEV1 is 28% of predicted. C. Continuous oxygen ratio of 64%. B c 55% fl44. What is the major risk factor for COPD 45. What is the mainstay of treatment for COPD -7 Bronchodilators, anticholinergics and supplemental 02 to achieve Sa02>90% 46. What therapy has shown Improved survival 15 hrs, preferably 24 hrs. -7 02 supplemental at least 24-28% of 02 at 1-21ts/min. 47. Pt. with COPD with hypoxia on oxygen therapy, POz significantly Improves. ost likely cause of low POz Is 48. Bronchodllators have been shown to do what? A. Reduce mortality JY. Reduce hyperinflation -7 w Residual volume -7improved symptoms and exercise capacity. 49. All are true about Tiotroplum EXCEPT: A. Reduces exacerbations B. Reduces hospitalizations C. Reduces Lung hyperinflation -7 Increase inspiratory capacity-7 1'TV D. Improvement in exercise intolerance E. Works by blocking Muscarinic receptors vr.' lpratropium is better than Tiotropium Tiotropium is more potent than short acting �2 agonists H. It is superior to Salmeterol at 6 mths. G. 50. What would you discuss with Pt. before starting Salmeterol? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 390 QSl. I n a Pt. with COPD and smoker. The most likely to preserve lung function over the next five years is A. Bronchodilators Y,Ou it smoking C. Systemic steroids D. Long term antibiotics 0.52. Increased mortality in COPD is seen with '--/("Decrease in Fat free mass ( B. Decrease in Body Mass Index ""iS, ��iteria for starting o:-;] • • Pa02 < 55 mmHg or 02 saturation of 88% Pa02 <59 mmHg or 02 saturation of > 88% with evidence of Cor Pulmonale Erythrocytosis ( Ht>55%) ¥-It ( R(c., tc.Jt..,,te� Rl� -t-- h c..t ) • � 53. Pt. with COPD exacerbation with hypoxemia. hat is the oxygenation goal? Cj o � Supplement 02 to achieve Sa02 of � _ 9 Sf. 54. What is the best way to manage COPD with secondary erythrocytosis? A. I ntermittent phlebotomy vB. Continuous oxygen therapy l ) ) 55. Consequence of over correction of Hypoxia? 56. What happens if you dcrcrease Oa abruptly � Respiratory arrest. 57. Pt. with COPD loves to play Golf. He gets short of breath wit decreased performance. esting P02 Is 62. w.t.d ) 58. Pt. with COPD with daytime sleepiness, fatigue. Resting POa is 64. w.t.d � CL.. "'C..( k, p 01. c\u.,.>..., J J'-� ----, 1 � . I < SS,, �59. Pt. with COPD wants to travel by plane. Resting POa is 64. w.t.d f estimated PaOa Is <50, then give 02• If already on Oa Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission 1 Page 391 A. Don't fly B. Take your Oxygen tank aboard the plane ( � bc.tte"J powcrecL ox�OU" C.Ot'\i.rtet'J' ) �Arrangements should be made with airline in advance of the flight D. Use on board emergency oxygen masks E. Airlines are not allowed to provide oxygen except in case of emergency. 61. What is the role of inhaled steroids in COPD "-1( Decrease exacerbations B. Decrease hospitalizations C. Decrease chance of pneumonia 62. How to treat an acute exacerbation of COPD with Increased cough and sputum roduction with SOB. � Tiotropium + � agonist H"""�l...l.., - R..�-o·Jtc.A« i.v systemic steroid -rEmpiric antibiotic ( Azithromycin or Doxycycline, NO Erythromycin) 63. How does exercise help In COPDers Hypoxemia� SOB� avoids exercise � Physical deconditioning� decreased exercise tolerance. Exercise� improves Exercise performance. • DOES NOT improve Lung function DOES NOT improve Gas exchange • DOES NOT improve survival rate • An advanced COPD Pt. was discharged from the hospital after being treated for neumonla. He has been sent for pulmonary rehab. hat Is True and False with pulmonary rehab? 64. F T 'T -r T T A. His FEV1 will improve compared to pre rehab. value B. Evidence is insufficient to suggest decrease in mortality. C. Improves dyspnea & quality of life and decreases depression. D. Reduces number of hospital days & health care utilization E. Dynamic hyperinflation is reduced as a secondary effect. F. Reduced dyspnea due to decreased respiratory requirement respiratory A. Increased oxygen delivery B. Increased airflow .-..ft. Improved muscle efficiency 66. What is a required component of Pulmonary Rehab? _.A( Program of exercise training the muscles of ambuiation B. Program of exercise training the muscles of inspiration & anabolic agents. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 392 Q67. A6ove Pt. post pulmonary rehab continued to have low exercise tolerance. f\BG: pH 7 .42, POz 62, .pCOz 48. f FEV < 45% and > 20% & b/1 upper lobe emphysema , -7 l� vcJ\... M.C.. .,.cc\l.ltt..'wv ( l"'"\:.� vj FEV < 20% 1 -7 S �· L;f< J'\AI"�'-"j ,,...,�� Lung transplantation ) Chart 10-10 Altitude sickness �linical features Altitude ) Next step in management? reatment Acute mountain sickness (AMS) Leading cause of Altitude sickness * Headache, nausea, vomiting, fatigue, dizziness 6000 ft High altitude pulmonary edema (HAPE) Leading cause of death with Altitude sickness Headache, nausea, vomiting, fatigue, dizziness Plus Shortness of breath 'f' .,. 12000ft, can occur at 8000 ft as well 'De.sc e.f\t 'i)e.rc.e.l't 'Dexc..I'V'4.1'1:. c;,J' oYV- 1)t! .K "' 1\N-It-"s 0 1'\.L Prevention Ac.c. t. c;:'2 ole: rv" At. � �--+ Au. tc.. -z_ol "IW�, Ni dc-ocpii'L (� .r�clo.N{ ) 2.� � o.J'/.,.V\ t;., p� p-6ll. Pt. goes to Colorado for sl<llng, on the top of the mountain at 8000 ft., he sets short of �reath and develops pulmonary edema. Paramedics start Oz. �hat Is the most Immediate next step? w � A. Give him lasix \ J /.Bring him down to lower altitude C. Intubate D. CXR A. Lasix B. Ace inhibitor C. HCTZ _;1. Acetazolamide Theophylline Clearance decreased by: 'diseases': CHF, Liver disease, Hypoxia, Fever, Cipro, Erythromycin, OCP. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 393 p7o. Young woman with history of Asthma on multiple meds. And OCP presents with c/o �ausea and vomiting. xam reveals tachycardia and tremors. This is most likely related to her use of A. OCP �Theophylline oc...p - � T"t c C..o..lf<.-1 0 (. p q.c.; lW'U... . 71. COPD Pt. with POz 60 and pCOz 50 has exacerbation of COPD. POz is 55 and COz is 60. He is refusin intubation. w.t.d \JJ<( BPAP B. CPAP C. 100% mask �72. 50 y/o Pt. with COPD came in to ER with worsening SOB and Cough. p/E He is awake but in severe distress using accessory muscles. pCOz 74, POz 50, pH 7.18, BP 100/68. �e was given Nebs and Inhaled steroid but HR 120/mln and RR 36/mln. What to do? J!( Intubate and put in Mech. Vent pH < 1· 2S C'O'() B. BPAP C. Try Systemic steroids. rl-R. h� / 35 4 il"'t....b ..� >I zo I,.._; 1' .s-� C.v<- t.: ChV 73. What has been shown to reduce mortality In a Pt. with COPD? JK. Influenza vaccine B. Pneumococcal vaccine 74. A 30 y/o man with extensive bullous emphysema. XR: Bilateral basal bullous cysts. hlch test would you do? A. Sweat Chloride B. Sperm motility test C. CT chest vD· Serum alpha-1 antitrypsin level Bronchiectasis p75. A 58 y/o woman with recurrent cough, foul smelling yellow sputum with hemoptysis. Aistory of Pneumonia >1 yr. ago. CXR: Prominent cystic spaces In Right lower lobe and streaking opacities In the direction pf bronchial tree (tram lines). Ox: Bronchiectasis Confirm by: High resolution CT scan � Tip* History of Pneumonia in the past. Dyskinetic cilia syndrome BronchlectasJs/S musitis!infertility+/- situs inversus Ox: Dyskinetic cilia syndrome/Kartagener's syndrome Screen by: Sperm motility test Confirm by: Testicular Biop.sy or biopsy of bronchi or sinus Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 394 Q76. Recurrent pneumonia with cough and sputum for 1 year, mother died of lung disease. Best test A. Alpha-1 antitrypsin B. ECHO � HRCT D. CXR C Ll, cvrD 'Dx (- Hypogammaglo bulinemia -7 Cystic fibrosis -7 a-1 antitrypsin def. -7 Dyskinetic cilia syndrome -7 r0 �� s�-�Ut 1 �A, C l' 13 fY"v c..N.<.K (ht;.�p� �L J.pe .,,._.. f'V""t:.A-..'S 1Mt � ) Bronchiectasis ) Rh. Arthritis Sjogren's ) ) ) ) ) ) ) ) ) ) Pneumonia ABPA sen-v-- P� c.,, f't..;... <1--w AJ�p!t-. (py! 1..� £ Cystic Fibrosis �77. 22 y/o man with recurrent pneumonia and bronchitis since childhood. No known �llergi s o GERD. lgG electrophoresis nl. �;Xam: lend body habitus and� n the nose. Clubbing (+) �XR: apica ullous changes. w.t.d'il ext ? � vfo· Sweat Chloride >60 B. Alpha-1 antitrypsin C. Sperm motility test Dx: Cystic Fibrosis Increased risk of endobronchial infection with Pseudomonas, Staph and Strep Pneumoniae. Tx: • • • • Chest PT, Antibiotics (anti pseudomonal abx., topical tobramycin spray, Inhaled hypertonic saline), Bronchodilators. Decrease sputum viscosity by Human Ribonuclease Treatment of severe Bronchiectasis with bleed-? Branch. arteryembolization. 78. Wnlctl of the following taken long term as shown to reduce decline In lung function in ts. with c stic fibrosis colonized b seudomonas? A. Levaquin vB( Azithromycin ( No tK.cJ.i'J, j'�-"'t .); i":f-lc:""""c:ht;.... ) C. Bactrim ) Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 395 True or False statements about bronchiectasis include 1. Pulmonary infection or colonization with P.aeruginosa is common T T -+----3. Surgical resection is required for most patients presenting with massive I=' hemoptysis. 79. 35 y/o non-smo er, x. o R eumatold arthritis no history o resents with cough & dyspnea on exertion. istory of viral URI in the recent past. Exam: JVD 6 ems. ungs: no wheeze. CXR 7 normal FTs-7 Severe obstruction with FEV,/FVC 0.6. DLCO 82% o change after using bronchodilator. lpha antitrypsin level normal. Bronchioitis obliterans can also occur after Rheumatoid arthntis Carcinoid tumor Lung transplantation • • • 80. A 35 y/o woman s/p radiation therapy for Carcinoma Breast or 0 y/o man s/p viral URI presents with shortness of breath and cough of several weeks uration. xam: diffuse Inspiratory crackles. XR: patchy or focal infiltrates in the lung. aOz is 52mm COz Is 30. PFTs reveal decreased DLCO t. doesn't respond to l.v antibiotics (previously BOOP) Dx:-7 c..op t�pt..fV"'c. oYfc.t\.-zl"J pN(>. Biopsy: Rapidly proliferative organizing pneumonia or acuteinterstitial pneumonia. Tx: -7 J'f:t.M"'- � Dt..c...OJt Interstitial Lung Disease • • • • • • • Sarcoidosis Idiopathic Pulmonary Fibrosis Hypersensitive Pneumonitis Cryptogenic Organizing Pneumonia (COP formerly BOOP) Allergic Bronchopulmonary Aspergillosis Lymphogio-leiomyomatosis Churg Strauss Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 396 • • • • • • Progressive Pulmonary disease Eye involvement CNS involvement Myocardial involvement Persistant Hypercalcemia Disfiguring lesions 81. 24 ylo woman with fever, pain and swelling of both ankles. /E: tender er hematous nodules. w.t.d next? ) Stage CXR findings Treatment Bilateral hilar adenopathy NO Tx. 60-90% remission II Adenopathy+ Parenchymal infiltrates Steroids if Sym. 50-60% remission Ill Diffuse infiltrates, NO adenopathy Steroids if Sym. <30% remission ) ) ) ) ) 82. Pt. with hllar adenopathy, no infiltrates dx with Sarcoidosis. What is more likely? \k:' 90% remission at the end of 5 yrs. B. 50% remission at the end of 5 yrs. C. Worse at the end of 5 yrs. P,83. Young AA woman presents with cough with clear phlegm. �o fever, night sweats or weight loss. CXR shows bilateral upper lobe infiltrates. ;;erum Ca Is lO.Smg/dl. PPD neg. HIV neg. Most likely diagnosis is ) A. MTB B. Hypersensitive pneumonitis __...e: Sarcoidosis P,84. Farmer with dry cough and SOB for several weeks. CXR reveals b/1 infiltrates. Biopsy eveals non-caseating granulomas, �04:CD8 >5. Most likely diagnosis---is ----�--�-A. Hypersensitive pneumonitis Y. Sarcoidosis ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 397 ! 85. 26 y7o woman witll fever weal<ness ana tenderness overlegs. e/E: Erythematous lesions. fXR shows bilateral mediastinal adenopathy and Infiltrates. EAST likely to ---be true: ----�--� T A. BAL T4/T8: 4:1 B. Transbronchial biopsy with non caseating granulomas 'T C. Start steroids if eye involved r D. Elevated levels of ACE diagnostic 'T Q86. All the following may be elevated In Sarcoidosis EXCEPT A. Hypercalcemia B. Hypercalciuria C. ACE D. Helper T cells X Suppressor T cells A. Biopsy of the lymph nodes JV, Follow up in three months. 1' Nt.... t:.>� "" 6 A L dlopathlc Pulmonary Fibrosis: Presents with insidious onset dry cough, gradual progressive dypsnea, cyanosis, clubbing. Symptoms at least for 6 mths. or more. NO Extrapulmonary symptoms • NO associations with infections and drugs • NO known cause CXR: diffuse infiltrative process; reticular opacities, groundglass appearance and honeycombing. PFTs: FEV , low, FEV ,jFVC= normal. DLCO decreased Rv � TLC. .J, BAL: increased Neutrophils, CD4:CD8<1 Circulating Immune Complexes . Transbronchial/video assisted thoracoscopic biopsy: patchy interstitial fibrosis with honeycombing. High resolution CT • · Tx: Supportive care: Oz prn. Pulmonary rehab, pneumovax, flu shot, N-acetylcysteine +/- steroids c. r-to CAjt.v p\voJ"-•"""-k) Always exclude infectious or cancer etiology before treatment with immunosuppressives. Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 398 False A. Non productive cough without fever and progressive dyspnea True or T -- B. BAL shows increased Neutrophils -r C. Circulating Immune complexes may be present T D. Cyanosis and Clubbing may occur. T 1\sbestosls: Chronic exposure > 10 yrs. Lower lobe fibrosis (PFTs with restrictive pattern) Associated with Mesothelioma, Bronchogenic ca. • Pleural/diaphragm calcified Plaques • • ) ) • Silicosis: • • • Chronic exposure >20 yrs.; sand blasting, stone/granite cutting Upper lobe fibrosis with increased MTB incidence. It Egg shell calcifications with hilar lymph nodes True or False A. Silicosis causes Mesothelioma B. Increased incidence of MTB in Silicosis Pleural plaques in Asbestos exposure don't cause Lung impairment. T ASS. The findings In the x-ray (calcified plaques on the diaphragm and pleura) relate to whiCH bf the _.. :r I c. ) ) .. A. Metastases to the lung B. Pleural plaques which cause restrictive disease y. Pleural plaques related to Asbestos exposure. ) ) ) T -- 89. A 58 y/o man presents with shortness of breath and chest pain, which Is eproduclble on palpation. Weight loss of 15 lbs. In the past couple of months. Is past history Includes having worked with asbestos more than 25 yrs. ago for a ouple of summers. He used to smoke, but quit more than 20 yrs. ago. xam reveals tenderness, but no palpable mass on the chest. ullness to percussion on the left lung. Auscultation confirms no breath sounds In the eft base. XR reveals a left pleural effusion. ost likely explanation of the above findings? A. His smoking history B. Asbestosis /.Mesothelioma c (hCM.Qv>�" �) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 399 Berylliosis: Metal workers: computers, aerospace, electronics and lights before 1950s. Can cause tracheobronchitis. Bx non caseating granuloma Associated with Ca Lung 90. Man, chronic smoker presents with SOB gradual in onset and progressive. XR Interstitial disease with honeycomb appearance In the upper lung fields. FTs (Restrictive) pattern AL: lan erhan cells lant cells . Bx: lant cells with fibrosis Ox: Langerhan cell granuloma or eosinophilic granuloma/Histiocytosis X Complications: Pneumothorax in about 50% of Pts. Tx: � stop J"'-"�'j 91. Premenopausal woman on OCP presents with sudden onset SOB. XR reveals pneumothorax. Normal lung reveals honeycomb appearance diffuse,Jlr hrou hout the fun C h�� ious� effusi on + ------------��--------------� �� • 92. • • • • • What are the consequences of hypoxemia? Pulmonary Hypertension Secondary Erythrocytosis Exercise intolerance Impaired Mental functioning Can precipitate Sleep apnea 93. � Pt. with COPD diagnosed with Pulmonary HTN. Most likely etiology Is haf<=>Xi4 94. Best way to treat Pulmonary hypertension In a Pt. with COPD Is A. � blockers 4. Digoxin C. Oxygen therapy to keep Sa02 90-95% Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 400 1. Pulmonary arterial hypertension {PAH) T'Of"" I • 3. Pulmonary hypertension owing to lung diseases and/or hypoxia • • • • Idiopathic PAH Heritable Drug and toxin induced � Associated with Connective tissue diseases HIV infection Portal hypertension Congenital heart diseases Schistosomiasis Chronic hemolytic anemia Pulmonary vena-occlusive disease (PVOD) and/or pulmonary capillary hemangiomatosis (PCH) • • • • • • • • • • • Chronic obstructive pulmonary disease Interstitial lung disease Other pulmonary diseases with mixed restrictive and obstructive pattern Sleep-disordered breathing Alveolar hypoventilation disorders Chronic exposure to high altitude Developmental abnormalities • N orma l 25/15 mm Hg ( (V\U)JI-) Mean at rest : 14 mm Hg • • Pulmonary hypertension • • • ) ) • • 4. Chronic thromboembolic pulmonary hypertension (CTEPH) • at rest : � Hg during exercise : �m Hg Normal pulmonary capillary wedge pressure Left ventricular end diastolic pressure < 15 mm Pulmonary vascular resistance >120 dynes/sec Thromboembolic occlusion of the proximal or distal pulmonary vasculature \ I ) ) 5. Pulmonary hypertension with unclear multifactorial mechanisms 2. Pulmonary hypertension Hematologic disorders: owing to left heart disease myeloproliferative disorders, Systolic dysfunction splenectomy Diastolic dysfunction � Systemic disorders: Valvular disease sarcoidosis, pulmonary Langerhans cell s�t,...... C£�cu t �Jp histiocytosis, - � .r':J""'fVlymphangioleiomyomatosis, - .rp\At. z� 1-1t .ru--4 , L� P neurofibromatosis, vasculitis Metabolic disorders: glycogen storage disease, Gaucher disease, R. A 1) thyroid disorders Others: tumoral obstruction, fibrosing mediastinitis, chronic renal failure on dialysis Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 401 • • • • • • • • "'"' ,(. IVJI 95. Pt. witti stiortness of oreatti anCJ near syncope, exam reveals suocutaneous alclfication. Split 2"d heart sound. JVP + and pedal edema. What will you do next? -7 T l E ch...o 96. Pt. with telangiectasias and shortness of breath. History of syncope. JVP 10 ems. oud P2. Pansystolic murmur at the left sternal border. ECHO reveals right ventricular dilatio nd Moderate tricus id re ur itation. What will you do next? I Q97. 45 y/o woman with history of PE 4 yrs. ago and treated with anticoagulation prients lth shortness of breath. Loud P2. EKG with right axis deviation and P pulmonale. ECHO reveals right ventricular dilation. ( Most a ro riate next dla nostic ste ? -7 V/Q SC.oJ\. ( t"-.,...,.;<. Pc ) N\!t c T �o Q98. Above Pt. scan reveals absent perfusion in the left upper and lower lobe. W.td? -7 Begin evaluation for thromboembolectomy 99. If responds to vasodilators -7 Nifedipine or Diltiazem 100. If there is no response to vasodilators. w.t.d next If mild disease (no limitation of ordinary physical activity) -7 S1' l cAer.t::J+ \ 1 T � f-·,L (improve exercise performance, symptoms & hemodynamics) c; (3 oJ'V\ t.c....J'\.. 101. IF moderate disease to severe disease (limitations on physical activity) -7 L. v -7 plus above ( i=w 6oJ"ef\� T� t 1lT I ) 102. IF severe disease and hypotensive (does not decrease systemic BP) 103. What is the mainstay maintenance therapy In pulmonary hypertension? A. Calcium channel blocker 0Y.'warfarin C. Sildenafil D. Bosentan Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 402 [Pulmonary Embolism (PE� usually due to DVT from lower extremities, mostly above knee Cl.ft: Sudden onset SOB, tachypnea, pleuritic chest pain, presyncope or syncope, hemoptysis. Loud P2, Split 2"d Heart Sound. CXR: Usually normal EKG: Non specific tachycardia, rarely Sl-Q3-T3. ABG: A-a gradient >20mmHg, if hyperventilating P02 may be normal. Underlying factors: Tamoxifen, OCP, Lenalidomide, Nephrotic syndrome, Leiden factor V defect, Breast Cancer, Protein C & S def., long flight or drive. V/Q Scan Normal PE confirmed -7 T.- ed· or > segmental or larger defects without matching ventilation defects 2 PE low probability or indeterminate Check for DVT, if positive -7 T.,.. -t. c.J· If negative -7 do P�M """:l If Pt. has Cardia pulmonary problems on CXR, a helical CT can be done instead of V/Q scan and same algorithm can be followed. Remember, when clinical suspicion is high and V/Q or helical CT indeterminate you have to evaluate for DVT and if DVT negative (:-) � DO pulmonaryAngiogram. Subsegmental perfusion defects Or matching ventilation and perfusion Defects or single large defect ) ) ) ) Treatment: Anticoagulate with intravenous heparin or LMW heparin for 7-10 days, followed by LMW heparin, Warfarin or adjusted dose heparin for 3-6 months. 104. High clinical suspicion for PE, w.t.d ) ) Matching ) G ) B 1. Best test to rule out LOW probability PE? A. CT contrast 2. Best test to rule out moderate to high probability PE? B. V/Q scan (3 -�.Best test to diagnose chronic PE? C. D-dimers Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 403 Contraindications to anticoagulation? -7 Neurosurgery, Eye Surgery, Open Prostatectomy Indications for T hrombolytics: Acute massive PE causing hypotension Large DVT such as Iliofemoral DVT. Indications for Green field filter: ItPt. has PE and another PE will cause death of Pt. Contraindication to anticoagulation Emboli post anticoagulation • • • • • Q105. A 52 y/o man with the history of mild CHF Is admitted to the hospital with the udden onset of SOB and right sided pleuritic chest pain. He has been on furosemide and digoxin. CXR shows cardiomegaly with mild congestive changes. Second heart ound split. HR 100/min. Blood gases reveals POz 72mmHg, PCOz 36mmHg and pH 7.42. V/Q scan reveals multiple small subsegmental matched and unmatched defects. contrast venography of the lower extremity Is negative. he next step In the management of this Pt. is --�----��---'-'/(' CT angiogram B. Start Warfarin 0106. A 44 y/o man has a multiple pelvic and hip fracture and undergoes hip replacement. wo days after surgery he develops fever, mental confusion, and shortness of breath. Chest -ray diffuse pulmonary Infiltrates. Blood gases reveals POz 44 mmHg, PCOz 30mmHg, pH .48 EKG shows sinus tachycardia. Pt. Is Intubated and transferred to ICU. Based upon the bove Information, the most likely diagnosis is--------� A. ARDS due to sepsis B. Acute Septic Shock y. Non cardiogenic pulmonary edema due to fat emboli Anticoagulate this Pt.? -7 NO ( .fe.� uY-1-,� ) Steroids? 107. Pt. post delivery becomes hypotensive, Shortness of breath --------�� Dx: -7 0 M-M "'�" jl...wd. U"'\1-, dU.r""' Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 404 Matching A 1. Pt. with sudden onset SOB, tachycardia, hypoxemia with A-a gradient increased. what is the next diagnostic test? � . Pt. with Pul HTN with SOB, tachycardia, ECHO reveals Right ventricular strain. what is the next diagnostic test? C.. 3. - B. Pulmonary angiogram Pt. with SOB, tachycardia, ECHO reveals C. Anticoagulation right ventricular strain and V/Q scan shows 2 large defects with normal ventilation . Most appropriate next step. �· Pt. with Pul. HTN with SOB, tachycardia, V/Q scan shows three defects; two matched with ventilatory defects, one with unmatched defect. Doppler US of lower extremities negative. Most appropriate next step? ) A. V/Q scan D. T-PA 'D 5. Pt. with Pul. HTN with SOB, V/Q shows two large unmatched defects. Hypotensive. Most apprppriate management? DVT (Deep vein thrombosis): D-dimers have good negative predictive value for DVT. If d-dimers positive, work up further for DVT True or False A. Infection is an important predictor for DVT B. LMWH decreased DVT but NOT mortality in the hospital ) ) ) ) T · I 108. A Pt. was started on anticoagulation for unprovoked DVT 5 months ago. He now resents to the ER with a bleed. Warfarin was stopped. What is the best management? A. Restart warfarin low dose JY. ASA 325 mg daily Risk and Prop y ax s : hl i � High Risk: Knee replacement 70% risk! TotalH1p 50%, Acute Orthopedic fractures Prophylax with LMWH for 4 weeks Or Warfarin, adjusted dose for 4-6 weeks Or Fondaparinux for 4-6 �eks. IF Creatinine elevated ONLY then unfractionated heparin is an alternative. External Pneumatic compression. Early mobilization. Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 405 Q109. Pt. develops DVT with swelling of leg. Started on anticoagulation, 2 months later there is swelling of the leg. What is the best management? �Below knee compression stockings for 2 yrs B. IVC filter Matching 0 1' 1. An elderly Pt. with history of colon cancer 2 /rs. ago presents A. D-dimers with swelling of leg. What will you do next? {), .:1 . A 45 y/o Pt. presents with swelling and pain in his right leg. What will you do next? B. Duplex ultrasound Hospital-acquired pneumonia (HAP) is the leading cause of death among hospital-acquired infections, that occurs 48 hours or more after admission. Ventilator-associated pneumonia (VAP) refers to pneumonia that develops more than 48 to 72 hours after endotracheal intubation. Healthcare-associated pneumonia (HCAP) includes any Pt. who was either hospitalized within 90 days of the infection; or resided in a NH, received chemotherapy, or wound care within the 30 days prior to the current infection; or attends a hospital or hemodialysis clinic. llO.Pt. with cholecystitis has a cholecystectomy done, Post op develops a pneumonia. hat is the best mana ement? � . < 48 hrs A. lmipenem + Aminoglycoside .J2..2 . >48 hrs B. Ceftriaxone + Macrolide Strep. Pneumo -7 Mycoplasma -7 influenzae/ M. Catarrhalis -7 -7 Legionella Pseudomonas -7 Klebsiella -7 Mixed flora -7 H. most common cause of Pneumonia D-j� · (Y\...J.t.:&u-�"Young adult s / ea..-. ;"¥-1 �"""' COPD, DM cool damp places, water coolers Nosocomial, Neutropenics Alcoholics, Nursing home residents . . Lung abscess � u·. ' Cavities, (2\'Yi_; Good sputum sample: <10 epithelial cells and > 25 WBCs Q111. Pt. presents with c/o cougn ani:l ye lowis expectoration for tile past 2 ays. /E Temp 99°F, HR 84/mln, BP 130/80. Lungs reveal a few scattered rates. How to manage? A. Start Levofloxacin � Over the counter antitussives. C. Azithromycin Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 406 Q112. Pt. with URI symps. for more than 2 week tx. with doxycycline without improvement. ncreaslng cough spells with post tussive vomiting. Exam reveals subconj. hemorrhage. � Most likely organism? -7 Bo-rc:l. ate lk Diagnosis by pu t.... .r P.:(\, 'D tt<..p - e� � Or\.<- ..__.., """fl. , ..-ct. c.-...,t f.,t tCAf:c""' Jl...ot G., < 2 '0,.. A. sputum PCR for Bordetella B. sputum PCR for Mycoplasma \I Q113. Pt. with pneumonia. Tx. witt\ Ceffriaxone and Azit romycin for 5 aays ana then switched to po meds. On Abx. feels better. Pt. continues to have cough. 6 weeks later, the opacity persists. Most likely diagnosis Is --------� A. Abx therapy failure B. Bronchiectasis C. Underlying malignancy Bronchial carcinoid as well. ) �114. Pt. with recurrent pneumonia. CT chest shows fibrosis In the Lt lower lobe area. What is the etiology of recurrent pneumonia? ) ) ) ) \ Q115. 40 y/o Pt. withhemoptysis withstreaks of blood for the past 3 weeks. Pt. has been coughing. He has 4 lb. weight loss. CXR Is normal. What Is the best management?--------�--�--� A. CT sinuses � Bronchoscopy Q116. 25 y/o presents with purulent nasal discharge, HA for the past 2 days. cough (+). ou would treat with vf( decongestants and analgesics B. Erythromycin C. Amoxicillin D. i.v antibiotics <2% of Pts. with symptoms < 7 days have bacterial sinusitis. NOAbx unless sinusitis symptoms > 7 days or have fever or pain CT NOT routinely recommendedto diagnose smus1tis 117. A 22 y/o man presents with complaints of purulent nasal discharge for the past days. Exam reveals temp of 101o F and focal tenderness of the maxillary sinus. hat is the best management? A. No antibiotics B. Amoxicillin Y, Amoxicillin-clavulanate Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 407 Q118. A 40 y/o with sore throat and headache for 3 days. His grandchildren were suffering from a col� Exam reveals; Temp is 99° F, Pharyngeal erythema is seen and anterior cervical ad�oQathy is Qresent. w.t.d next <:1) ('/0 (.o) �"" � Do rapid strep test B. Start oral penicillin for 10 days or Azithromycin for 5 days C. Analgesics and antipyretics Q119. What would be the best confirmatory test in the above Pt.? A. Rapid Strep. Test JVThroat culture 1. Fever 2. Exudates 3. Anterior cervical adenopath All four factors present g1ve emp1nc antibiotics. A Pt. presents wit runny nose g loc e nose, itctly eyes ana sore t roat. Exam appearance of-=posterior pharyngeal eveals some swelling below the eyes. Cobblestone--=... ----.:..-....:.._..; :--- ..:.ucosa. No adenopathy Most likely dia� 120. A. Common cold JY.'Allergic Rhinitis Pt. presents with nasal congestion and rhinorrhea for the past several months. p121. ;;he has history of allergies which is usually controlled with nasal decongestants and ntihistamines. She has been using over the counter medications and It has gotten worse. Exam reveals red edematous mucosa of the nares. Most likely diagnosis � A. Allergic Rhinitis � Rhinitis Medicamentosa Use of vasoconstrictors (Ephedrine or Oxymetazoline)� rebound congestion. Tx: discontinue vasoconstrictors and start� ;"t,..c (\.c;..J cA. .ste �c.t. ... y/o with hot potato voice, high fever, unable to swallow and drooling of secretions. Exam reveals tonsils touching each other and deviation of uvula. p.122. 24 Ox:� Pt. with sore throat of a few days duration, he now presents with severe pain if �e moves his neck and pain on swallowing. xam reveals a brawny edema of the hypopharynx and tenderness on palpation of the �ternocleidomastoid. Most likely diagnosis is 0123. A. Internal Jugular vein thrombosis (Lemierre's disease) B. Ludwig's angina Awesome Review, Inc. ® Copyright 201 4 Do not photocopy without permission Page 408 p124. Pt. witll OM brougllt wlfnfever from N H. No teeth. �XR reveal s right lobar consolidation. Best empiric antibiotic Is A. Ciprofloxacin B. Macrolide C. Cephalexin � Newer Fluoroquinolone 125. Pt. worsens 3 days later, still febrile and hypotensive. IVF started. Etlo? w.t.d �126. Alcoholic Pt. witt\ cougtl anCI expectoration of reCI currant jelly sputum. �putum gram stain with gram negative bacilli with capsule. �XR: bulging fissure ) I I ) ) Dx: -7 Kal;>e --------� K Le. b.n dlc; �127. Above Pt. gets better; blood culture neg. and afebrile. 4 days later, temp. spikes �gain and Pt. has Klebsiella growing In blood cultures again. w.t.d f"\.eroPCI\.� -7 Start "1 r-M �1\e..M- Co-. Ertapenem for ESBL. Same for E.coli J 128. Side effect of Fluoroquinolones (Moxlfloxacln, etc) -7 Ventricular arrhythmias 129. In an elderly Pt., Fluoroqulnolone can also cau$e ) 130. Hypoglycemia Is a side effect of which of the following A. Azithromycin VV. Levofloxacin C. Moxifloxacin Matching How long would you treat? ) p. 1. Community acquired Strep. Pneumoniae B 2 . Hospital acquired pseudomonas pneumonia A. 1 week B. 2 weeks ) Awesome Review, Inc."' Copyright 20 1 4 Do not photocopy without permission Page 409 131. In a Pt. with pneumonia, early ambulation was associated with A. Decreased mortality vff. Early discharge 132. A 65 y/o diabetic Pt. hospitalized with pneumonia, treated successfully ith antibiotics, is being discharged. W.t.d 0133. Pt. with Left lower lobe pneumonia being treated with appropriate antibiotics. erslstent fevers and elevated WBC count for 2 weeks. CXR with persistent Infiltrate �fo Dx: -7 C. T w.t.d -7 L....vj c.bJUN1 0.(' ff"V\, r yU"A.Q �t 134. Pt. with fever, cough, diarrhea, mental confusion, pulmonary Infiltrates, ecreased sodium and increased BUN Le.�o"c.ILA Dx: -7 Lab: Direct fluorescent stain or Urine for Legionella antigen Tx: Macrolide +/-Rifampin for 2 weeks 135. Pt. with AIDS with sudden onset SOB, hypoxic on ABG. XR: Pneumothorax � Chest tube Insert. w.t.d 0136. Acute Ill Pt. with pneumonia and Intubated. Gram stain lancet shapeddiplococci. 15 K, 103°F, BC Tem p t. treated with PCN. Two days later, WBC Temp Increasing greenish ecrel1ons from Endotracheal tube and growing Pseudomonas. w.t.d 11K, too•f. --------� 137. Pt. with pneumonia Temp 103.4•f, WBC 17K, treated with a fluoroquinolone. days later, temp Is too•f, WBC Is 11 K. CXR which revealed lobar Infiltrate t admission remains unchanged. w.t.d now --------�-- -7 No further testing 138. Pt. admitted with right lobar pneumonia. Tem p 10rF and WBC 16,000. He Is tarted on Ceftriaxone, next day blood cultures growing pen sensitive Strep. Pneumo. t. is switched to i.v Penicillin. On the fifth day, Temp is and lab calls with report of eavy growth of Methicillin Resistant Staph. aureus in the sputum culture done at dmlssion. W.t.d gg•f A. Discontinue Penicillin and start i.v Vancomycin V,continue Penicillin C. Discontinue Penicillin and start Levofloxacin Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 4 1 0 139. Pt. with recent seizure, 3 days later develops upper lobe Infiltrate. Most likely organism Is A. Staph. aureus B. H. Influenza � Peptostreptococcus D. B. fragilis 140. Pt. had a seizure 1 month ago. Now presents with fever, foul smelling sputum. XR: cavity with fluid level. Sputum shows mixed flora. ) Ox: 7 l� Tx: 7 pc.('.J f.\bJ (...t.M ""' � c..\:.A dc. "J � 141. Above Pt. on abx. several days later with no fever. WBC count decreasing, avlty remains the same size but fluid Is decreasing. w.t.d A. Chest tube JV,Continue antibiotics ) ) ) 142. 25 y/o with ear ache, fever and cough. /E: Inflamed tympanic membrane with hemmorhage Infiltrates XR: patch y--� � ------------------� ---� Tx: Macrolide (Erythromycin) ) 143. 35 y7o non-smoker presents with gradua onset of cough, of a weeks duration. putum: WBC <5, Epl 25/cmm. XR: bilateral Infiltrates. hat ould y-""' u "'-'Ht� a...._______ vt('Macrolide ) B. Penicillin C. � lactam D. Bactrim [( J others C fVV3 ..., p L<..d � ) • Bullous myringitis • Erythema multiforme • Cold agglutinins ��J 144. SO y/o wit COPO acute onset o symptoms wit XR: Left lowe r lob e� con so� lida tio n ------------------------------------� � � � Etio: Strep. Pneuma Tx: Macrolide + Ceph. Ill 145. Common pathogens in Neutro�enics 7 Pseudomonas aeruginosa, Aspergillus, Staph., Strep. Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 411 Chart 10-11 Clinical factor Points Confusion 1 Blood urea nitrogen > 19 mg per d L 1 Respiratory rate � 30 breaths per minute 1 Systolic blood pressure < 90 mm Hg or Diastolic blood pressure � 60 mm Hg 1 !Age 65 years tTotal points: � 1 5 Chart 10-12 CURB-65 score Mortality {%) Recommendation 0 0.6 Low risk; consider home treatment 1 2.7 Out Pt. 2 6.8 Short inpatient hospitalization or closely supervised outpatient treatment 3 14.0 Severe pneumonia; hospitalize and consider admitting to intensive care 4 or 5 27.8 Q146. A 55 y/o with COPD presents with shortness of breath, cough wltt uputum hich was initially white and now turned green. Exam reveals a low grade temp. Auscultation reveals scattered rhonchi whfth have not hanged from previous visit. Most likely or anlsm Is A. Legionella B. Chlamydia J/,ii e mophilus influenzae non typeable strains D. Mycoplasma Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 4 1 2 Q147. A 5 0 y/o man, farmer, presents with a 3 month history of cough and increasing dyspnea. He has also noticed a skin lesion which has progressed as shown In the pic. (cutaneous skin lesion) He started developing pleuritic chest pain. CXR revealed� alveolar or fibronodular infiltrates Most likely diagnosis? A. Hypersensitive pneumonitis B. Cryptogenic Organizing pneumonia (COP) C. Blastomycosis D. Metastatic basal cell cancer ) ) ) ) 148. 22 y o woman on OCP presents with on productive cough and fatigue. XR� No I nfiltrate/No cavity 3 day h istory of fever, pleuritic chest pain, --------�--� Dx: � p�,.. O �M.-; w.t.d � Symptomatic treatment Q149. Pt. had U R I 2 weeks ago. Now with fatigue and Increased JVD. ECHO reveals EF 20%. Most likely cause ) ) QlSO. Pt. from South west (Arizona, NM, Texas) with fever and lung Infiltrates. XR-+thln walled cavities ) ) Tx: � self. �t.A. <Pv'J If disseminates� Arvy>�-..o f3 ) Fever, cough, myalgias. Vaccine: � Pvv.j cJN. Treatment: Influenza A: Oseltamivir or Zanamivir Influenza A or B: Oseltamivir or Zanamivir ) ) 151. Influenza outbreak In Nursing home. Best management Is A. Vaccine alone plus isolate them all B. Oseltamivir vf?. Vaccine + Oseltamivir for 2 weeks It takes 2 weeks for the vaccine to produce protective antibody response. If you don't have Vaccine, then Oseltamivir or Amantadine for 6 weeks Q152. Pts. post Influenza are more prone to --------� � st,.,� l"¥ c.t ;c- I Pne. UftV>MC.. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 413 0153. Which medication would you NOT use In Pt. with Asthma or COPD? A. Oseltamivir ...)k Zanamivir 154. Female Pt. with UTI was on Nitrofurantoin about 3 weeks ago. he now presents with SOB and fever. xam reveals crepltance over the basal lung fields. XR shows ground glass appearance. Most likely diagnosis? A. CHF _,.....8' Nitrofurantoin Chart 10-13 PPD (LTBI) >10mm • • • • '1 l >Smm • HIV + Recent contact ( \NI fi Ac.t.� Til) Chest Xray with old TB(scar) Organ transplants Prednisone >15mg/day • • • • • • >15mm Everybody Etoh Homeless _, Hec..lft. t<Mo(. Pe.op�c. Foreign born with 1'incidence Residents of Nursing Homes Dz with high risk of TB: IV drug use Silicosis, OM, CRF, gastrectomy Chemotx, malnutrition, leukemia, Lymphoma. Rx all PPD +) with increased risk of active disease 155. Pt. is PPD (+). w.t.d next -7 c xtt Q156. CXR shows small patch of flbronodular opacity and Pt. has NO cough. W.t.d -7 TN;l"'(e , sr ...� d-w' f\1=13 � 'Yo At.� Vtf.f Q157. If CXR negative, then treat with INH for c; f"oo'oA(\� .J' 1-n v C-1 .---� C! """"� "' c ""'-i"-' ""w-- "a- f> f'YVJI'I� ) ----- 158. If Pt. cant tolerate INH. (liver enzyme 1' or Hep C +) What is the best regimen? A. Rifampin + PZA for 2 mths v¥ Rifampin for 4 mths Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 4 1 4 Q159. What is the best management for a Pt. who is PPD +? A. INH 300 mg daily for 4 months ylY. INH 900 mg and Rifapentine 900 mg once daity for 3 months ( VOT ) rlkt.:J N(..W t«�IML 160. A Pt. is diagnosed with multi- rug resistant TB, tlis asymptomatic roommate has PO Smm and CXR negative. W.t.d? '-/(' PZA + Ethambutol for 6 mths or PZA + Quinolone for 6mths L<vt.tt.:,.. 1 AvolLx B. PZA + Rifampin for 4 mths 161. Filipino nurse with PPD of 20mm. Has received BCG In childhood. W.t.d? A. IFN y release assay � Begin INH & B6 162. Ukrainian resident PPD 10mm. Has received BCG In childhood. CXR neg. W.t.d? v( IFN y release assay (IGRA) B. Repeat CXR in 3 mths ) ) 163. A Pt. on INA & 86, 3 monttis on ttierapy or PPD + ca s you to say s e eels red and nauseous for �ast cou le of days. What do ou recommend vK.'d/c I N H and get AST/ALT, Bilirubin testing ASAP B. Continue INH & B6 and see me next week. Q164. Infection contro asl<s your opln on on l:)est way to screen for atent TB. �ou will recommend \.-IC IFN y release assay (IGRA) ) ( ,...K.,., $��t;ve B. TST (Tuberculin skin testing /PPD) l .. ,,t.c.oJi'- ) 165. What is the advantage of Gamma Interferon assays over PPD? --------� ) ) Awesome Review, Inc.® Copyright 20 1 4 Do not photocopy without permission Page 4 1 5 Matching c... 1. Inner city Pt. PPD (+), CXR (+) was started A. Continue all 4 meds for 6 months. on 4 Anti TB meds: Rifampin, I N H, PZA, Ethambutol & was isolated until, 3 AFB B. Discontinue I N H & PZA and continue smears negative One month later, above Rifampin and INH for 6 months Pts. culture positive for sensitivedrugs. w.t.d C. Continue 4 meds for another month, ']> 2 Pt. diagnosed with pulmonary MTB. Pt. is then continue only Rifampin and INH homeless and lives in shelter periodically. for 4 more months. You are the department of health physician. w.t.d D. INH, Rifampin, PZA & Ethambutol daily for 2 weeks, then INH, Rifampin, PZA & Ethambutol twice weekly for 6 weeks, then INH & Rifampin twice weekly for 4 months. E. INH, Rifampin, Ethambutol & PZA for months. 9 166. Pt. presents from Eastern Europe llke Albania or Asia with pleural effusion. tap Is done and stain Is negative for AFB. What Is the best management? A. Closed Pleural biopsy � Video assisted Thoracoscopic pleural biopsy A. Cycloserine B. Ethionamide JC. Fluoroquinolone 0168. A homeless Pt. presents with right upp.. r lobe Infiltrate and pleural effusion. What will you do next? \.k:' Place him in airborne isolation B. Place PPD Chart 10-14 Pleural Effusion Transudate Exudate Total protein <3g/dl >3g/dl Fluid/serum protein ratio <0.5 >0.5 Total LDH <200 >200 Fluid/serum LDH ratio <0 6 >0.6 . Awesome Review, Inc. (I) Copyright 20 1 4 Do not photocopy without permission Page 4 1 6 Causes of Pleural Effusion Transudate Exudate • CHF • Neoplastic • Infections • Nephrosis • Cirrhosis • Hypothyroidism • < JO r"J c, l... v ' ... Inflammatory: RA, SLE, Pancreatitis • Esophageal perforation ( A�L......_ 1' ) • Dresslers syndrome Mesothelioma/Malignancy with bloody effusion Chylous effusion >115 TGAs� Tra uma, Mediastinal Lymphoma & Lymphangioleiomyomatosis <115 TGAs � Pseudochylous like in TB, Rh Arth. Glucose of 80 � 1 13 ; 60 � cA ; 30 � R.. A 169. 54 y/o Pt. with pleural effusion. Diagnostic tap reveals Fluid/ Serum ratio is <0.5, LDH 200. Fluid to Serum LDH Is <0.6. ost likely cause Is I ) A. Malignancy B. TB C. Rheumatoid Arthritis Jr.' Cirrhosis 170. Pt. with Rh. arthritis with recurrent effusions after repeated taps. w.t.d ) ) ) ) ) 171. Pleural fluid with glucose 29. Most likely cause A. TB B. Malignancy C. Empyema JY.'Rh. arthritis 172. A 55 y/o man status post Coronary Artery Bypass Surgery 4 weeks ago presents lth History of fever, dypsnea, non-productive cough pleuritic chest pain of the left side. 1E: Bilateral basal rales and a pericardia! friction ru b. Labs: Hb 13g/dl, WBC 9900/ul nd ESR of 68/h. CXR reveals Cardiomegaly, bilateral basal atelectasis and a small leural effusion In the left Base. ABG: POa Is 80 mm Hg, PCOa Is 34 m m Hg, and a pH of .45. A tap Is done and about 350cc fluid Is removed. Fluid to Plasma Protein Is >0.5 nd LDH Is >0.6. V/Q scan shows small segmental matched defects. is:---ased on the above information, the most likely dia=gnosis ----------� A. Parapneumonic Effusion B. Pneumonia C. Pulmonary Embolism JY,'Post cardiotomy syndrome Awesome Review, Inc.<!) Copyright 2014 Do not photocopy without permission Page 4 1 7 173. 25 y/o Athlete develops sudden shortness of breath while sprinting. /0 sharp Pleuritic Chest Pain. 0/E: Breath so�nds decreased on the right side. y_.eerresonance on Percussion. Ox : -7 sr-Y"�tc..I\(.O'Nl p""--'-' """"i\:...:.,V'cX Q174. When to tap a parapneumonic effusion? Effusion is >lOmm on lateral decubitus CXR Pneumonia not responding to Antibiotics -7 Frank empyema needs Chest Tube -7 Loculated fluid needs Thoracotomy �175. A Pt. with pneumonia continues to spike temps. despite antibiotics. �XR reveals pleural effusion with Protein 3.5g and serum to fluid LDH 0.65. � chest tube is put in, 72 hrs. later Pt. is still with temp. of lOr F. CT chest reveals fluid in loculations. w.t.d -7 If -7 A. Monitor and continue abx and chest tube drainage B. Repeat thoracentesis J2(Call Surgical consult (VATS) Chart 10-15 Physical Finding Percussion Pleural Effusion dull Pneumonia dull Pneumothorax Hyperresonance � Breath sounds VF/VR Absent :/lBronchial BS P,176. Best way to differentiate Pneumothorax from Pleural effusion on Physical exam Is A. Breath sounds B. VF 0ercussion 177. Pt. with shortness of breath. Exam reveals decreased breath sounds on the left. ncreased vocal fremitus on left. Most likely diagnosis /Lt. side consolidation B. Pneumothorax C. Mucus plugging Awesome Review, lnc . e Copyright 20 1 4 Do not photocopy without permission Page 418 0178. Pt. is admitted with shortness of breath, CXR shows a left lower lobe infiltrate nd pleural effusion. Temp is 102.5°F and HR 110/min. Pleural tap is done and 50 cc of exudative fluid could be aspirated. Next day the Pt. gets worse and becomes more hypoxic with P02 of 52. Repeat CXR reveals complete white out of the left side. Trachea does not appear to be deviated. Diagnosis?--------� A. left pleural effusion B. Left pneumothorax $. left hemithorax consolidation Management? A. CT guided aspiration B. Chest tube � Intubation ) ) ) ) \ I 0179. A Pt. is admitted with pneumonia. CXR reveals a large consolidation in the left lobe. BG while lying on left side has P02 of 54, whereas lying on the right side has a P02 of 65. Most likely cause of di.-. ffe...... r..,e.-. n .. c ..e .. ., i..,. n .., ....P..;:;. ..0 ..:.2..:.:is;__ A. Dead space on left side .JY. Intrapulmonary shunting on left side C. Too much venous P02 while lying on left side __ __ __ __ __ __ __ __ __ __ __ __ __ __ __. 180. Pt. with cryptogenic cirrhosis with ascites and pedal edema. Pt. gets short of reath on sitting or standing up. Pulse oximetry while lying down Is 92% and while ltting up or standing Is 82%. DLCO Is 70%. Most likely etiology of this Is --------�--� A. Pulmonary HTN JVI ntrapulmonary right to left shunting 1.-<jltj Of!J\,o\e ox i c;. __. .c�t {hepatopulmonary syndrome) doW"' _ v.p --� � s ..t-...1-\v. 1-l�� x ; "' '1. 181. What would help diagnose the above condition? II I vv.i'ransthoracic ECHO with microbubble studies B. Pulmonary function tests �pnea : No�Breathing for atleast 10 seconds M leep Apn _ us l,_v..,J l\.Vj J lA �') g. s� sh.or<- � >10/h � Sleep Apnea Syndrome Tr ue or False: The cause of sleepiness during 1. the -- day in Obstructive Sleep Apnea is lncreased snoring that prevents Pts. from sleeping well at night. 2. Hypoxemia --- I r: 3. Hypoventilation at night time that leads to recurrent arousals -r 4. Night time alkalosis 1= Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission --- Page 419 Q182. Pt. with obstructive sleep apnea with an apnea hypopnea index of > 30 will have �-------�� A. No change in mortality JV! ncreased mortality N' "' l>�• lt.j Sleep Apnea mostly Obstructive >95% Clinical features (CI. ft): • Snoring, wakes up with headache • Disturbed sleep, thick neck 17 inches • Neuropsychiatric manifestatio ns • Somnolence, Accidents or near accidents, Job firing. • Hypoxia with high risk for Ml, CVA, HTN Dx: � p�s " �"'Oa(� r� R/0 treatable causes: Enlarged tonsils, Tumors & Hypothyroid. Tx: • No Sedation, No Alcohol • Mild Obstructive Apnea: Protriptyline • Moderate Obstructive Apnea: � N "'.SoL C P A p • Uvulopalatopharyngoplasty works 50% of the time Q183. A 45 y/o Pt. brought with lethargy. Exam reveals: BP 160/100. BMI 41. ustalned lift in the right parasternal area. <. R1111 ) bdomen reveals panniculus which Is tender. Edema 2+ lower legs. ECHO reveals Tricuspid regurgitation. What will you do next? 184. What Is the likely etiology of the above Pt's leg edema? 185. The leading cause of secondary hypertension in a Pt. with morbid obesity Is 186. The cause of HTN i n Pts. with obstructive sleep apnea Is Therapy for Obstructive sleep apnea has shown to I mprove the quality of life • • Cognitive function • Symptoms of daytime sleepiness • HTN s-- �o """'1\j • Decrease mortality 187. Pt. with d i fficult to treat HTN on 4 medications with obstructive sleep apnea. hat is the best mana ement for HTN? 0 "--'1� ) A. Nasal CPAP ( 61-\S J. '0 f' -t... s t.. I JV'Renal sympathetic denervation · Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 420 188. A 22 y/o with BMI of 24 treats herself for allergic rhinitis with OTC medications onslstently for the past few days. Now she presents with unable to sleep well and red during the day. History of DNS. hat Is the most llkel'l dla nosls? \-/( Rhinitis medicamentosa B. Deviated nasal septum Q189. What is the most likely etiology? ) --------�--� /.side effects of medications B. Deformity of the nose 190. What Is the best management for the above Pt. ? ) ) ) ) ) ) ) ) ) ) ) ) ) ) /. DC OTC medications and start steroids B. Surgery 191. 45 y/o woman with BMI of 35. presents with dyspnea on exertion. ungs clear to auscultate. 52 loud. VD 10 ems and mild pedal edema (+). EV , 2.2 1ts vc 3.2 1ts EV ,/FVC 0. 70 CHO shows right ventricular hypertrophy. No valvular lesions BG: pH 7.38, PCOz 55, POz Sil. Most likely cause of chronic respiratory failure � G'oes:.� �--t()rll��Ld:,:CA f --� P....A..- h'TN __ __ __ __ __ __ __ ....... 192. Why do people with severe obesity have PCOz elevation? � Because of chronic �povCr�tilc..h'c.In the above Pt. w.t.d next 93. A 48 y/o man Is dJasnosed with Obstructive sleep apnea. He Is sleepy during ay, Irritable and complilns of fatigue. 0/E: leg Edema. Thyroid function tests are normal. he most a ppropriate therapy for this Pt. Is: A. Increase Oz during day B. Uvulopalatopharyngoplasty C. B PAP (Y.iiasal CPAP {Nasal Continuous Airway Pressure) ) ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 421 194. Pt. with daytime sleepiness with moderate muscular weakness, at onset of leep gets hallucinations. Brother had similar episodes. �� <.. . (Autoimmune disease) Tx: Modafinil $$$$ (Y\..e �l r�"" "A � .. -7 I So.\.;(....1.1"'\. �x:�b a.� [ e.lf'ec.l�l j ,fw c..�tcp �"'J ) clc.. l< '(c.pe � ) Q195. Elderly Pt. with shortness of breath gradual in onset and progressive in nature. Daytime sleepiness and exam reveals rales & pedal edema. Breathes 'funny or strange' at night where he doesn't breathe for several seconds ut no snoring. BMI 28. ECHO EF 30%. ost Likely cause of his daytime sleeplness? A. Central sleep apnea B. Obstructive sleep apnea j:.-- C HF Chart 10-16 Nodule Size Low risk High risk <4mm No follow up needed Follow up CT at 12 mths; if unchanged, no further follow up >4 to 6 Follow up CT at 12 mth; if unchanged no further follow up Initial follow up CT at 6 to 12 mths then at 18 to 24 mths if no change >6 to 8 Initial follw up CT at 3 to 6 mths Initial CT follw up at 6 to 12 mths, then at 18 to 2'4mth5 if no then at 9 to 12 & 24 mths if no change change >8 Follow up CT at 3, 9, 24 mths, dynamic contrast enchanced CT, PET, and or biopsy - Same as for low risk Fleishchner society guidelines Awesome Review, lnc.° Copyright 2014 Do not photocopy without permission Page 422 196. 60 y/o Pt. found to have 1.5 ems solitary nodule o n CXR. w.t.d next -7 ChM. IC. o\c.l C X f<.. 197. 53 y/o Pt. with pulmonary nodule 1.2 ems. last year it was 0.9 em. w.t.d A. Repeat X-ray in 0¥. Resection ) ) ) I ) . : d-ov-1?\.t. ) Chart 10-17 �esults Cause F- 1% PMNs �15% Lymphs Normal N o Eosinophils -7 CD4>CD8 -7 S'c, c..oi �,_; CD4<CD8 -7 h:J r?v s:<A�t-<:- Pf'LM"" M W ncreased Lymphocytes ncreased Eosinophils -7 :>ilver Methanamine + -7 nclusion bodies B acteria > ) 3 mths � ronchoalveolar Lavage (BAL} ncreased Neutrophils ) c 103 in ARDS -7 oamy with Lamellar nclusions G o J.-V\.0 P""· u c. PJ P 0ID· i 1'\. P f'I'A h'J:.V c.. rvW -7 ) ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 423 An AWESOME REVIEW OF .. I • 8% Rheumatoid Arthritis - Serongegative Spondyloarthropaties - Osteoarthritis Non articular syndromes - Gout & Pseudogout Fibromyalgia Polymyalgia rheumatic Relapsing polychondritis - Vasculitiedes - SLE - Scleroderma - CREST Dematomyositis Awesome Review Inc.• Copyright 2014. Do not photocopy without permission. J DIP Psoriasis Osteoarthritis (Heberden's) PIP Osteoarthritis (Bouchard's) Rheumatoid Arthritis Scleroderma l {U: '1/7 ) C't't.a..,t f MCP - t.....pu.n: A,(; h/7 y� Hemochromatosis ·Rheumatoid Arthritis Scleroderma Diagnostic Criteria for Rheumatoid Arthritis • Joint involvement 2-10 large joints 1 point 1-3 small joints - 2 points 4-10 small joints 3 points >10 joints - 5 points - - • Serological abnormality (Rh factor or Anti-CCP) Low positive - 2 points High positive 3 points - • • • ESR or CRP elevation - 1 point Duration of symptoms> 6 weeks - 1 point Xray changes: -Marginal Bony erosions -Periarticular osteopenia Poor Prognostic factors • • • • Progressive synovitis Joint space loss/erosions l 1'Rh factor ( 18C.. � 7 iM) 1'ESR """ l: f-o �tuv 1·. b 0 l 1ok�IY\, a_CW\#1 I lA� 7 . ) l� c..·,..,U;c , · c;\.. ·,;oJ•h' c...v /" kf'�lCJ'\f ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 48 1 . A 70 y old woman with early morning stiffness > 45min & Symmetrical small joint pain n her 2nd, 3rd, 4th MCP in right hand and 2nd, 3rd, 4th and 5th MCP and PIP in, left hand. Joint ain right knee for the past 6 weeks. ESR 48. Exam reveals swelling of MCPs & PIPs of both ands. Rh factor is ne . w.t.d A. Repeat Rh factor .3 + 8 -1 8'R - 11 jt S ptrir..f I /-4 vvk. f"N"I Y,Start treatment What is most likely positive in the above Pt.? Articular (musculo-skeletal manifestations) ; :· l I I ' Atlanto odontoi<t subluxation: Compress vertebrobasilar artery-? light headedness, syncope 'II-( B;"I '1f"lt..b..:.-l-\v...- r0.., J'� Compress Cord -7 Sen�ory/mofor symptoms Qu'adriplegi� :...., If < Smm and asymptomatic -7 No TX If > 8mm and asymptomatic -7 Sx correction Symptomatic any size -7 Sx correction • !3� c.c...-p.:.L t \..OJl'V\.£ 1.. f' :,-., L:11Jk...<a....� '"1c1: <.f ) c be.�... A .s�lc:A..) \, a 8i..,..h'-' "'-X ;rw /·yve..· ( U/\tr,t. pof\.� f'l\.�c.UIY<>�J' ) Pt.s with Rheumatoid Arthritis can also present with Carpal tunnel/Tarsal tunnel syndromes. Extra articular manifestations: 'spill over of active disease from synovium' • Rheumatoid nodules( 1'Rh factor) ((-) in 15%) • Vasculitis/DR4 ) ' ) I I } ,;1cµ � � up C<>n Heart: • Effusion • Constrictive pericarditis • Myocarditis r. to� J, \Ii�°"-" p c.r. c..�tC.t:..r -i. p �t .r� ( c.p, B �, pe.-;t.t.,..U<-l lc:A.ot Lung: • Rheumatoid nodules (Caplan's syndrome) • Pleural effusion: (low glucose, high LDH, Exudative.) • <::'.3o ""f BO • Interstitial fibrosis ( (.10�v.i.:, �-�iY· ''! 'l.-) • Hypersensitive pneumonitis( Methotrexate) T3 (IM T'Qrl< .ti re.."'�""" Blood: Anemia of Inflammation Vasculitis: Necrosis, ulceration at tip of fingers 1)t I ) � � �e..1 tie 'i>M # --+ t- J't: ra.p ccn ...u t·.r __, st;,c.p Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 49 .fwt. �""'f --1 C Ls pevc......u L Nerve: Mononeuritis multiplex -7 foot drop/hand drop Skin: Rheumatoid nodules: Commonest extra articular manifestatio -7 Rh factor increased Renal: • Usually late stage with amyloid nephropathy. • Drug induced (NSAIDs, Penicillamine Nephrotic syndrome) Eye: • • t f;�4 �.,.ptw-.. � • <t ""'°� c.p� ton U.C. ltv.. � C {'. o;l ,,,, 1,.. Vi(:. (, _. Lt.pto('N.,...;.ryu.. <tu ""':> IV\��"""4� rn�i;>,c. � _, o'b 41') Treatment: HCfU _. - fs �""'\. cth.� � be.st !.\."'- e..J�c1-«.1e. Hec...te:"4. �bU\.\..Ni. 1 -�b� h/A Moderate Severe f'YV.tt �,....,.i:oc,,l. s� - ·· _ 7>, .i.. f'N)rW....] ) h..urvk.r-1.t:.._ p� t.1 l AJ-ler 'I� er; �) Add Methotrexate tr-lo w dose steroids Leflunom +/ide �; �va:� '1.''K JoU<- Prt..; � � Aetl<M.J Ne.pi...,..<U.J Pcy.>ill� �c,v<>H.S R:T p.. (ta� 't) • S'o fY"f) _. methotrexate -7 ? sfY'.Q J M<. . or methotrexate polyglutamate level -7 )' b o "J f-te.,v\cl. -tw ) 3 �rr-.i � 'DE"XP. A�"- ( Oc..c.�"". L� d.n f>tt.h'..._ H-q' CC-UV\ f3) Add Etanercept or lnfliximab or Adalimumab or Anakinra or l(Enbrel®) ( Remicade®) {Humira®) (Kineret®) 1 Add- �� · L"f'""' /> il'\fCf.J'f..:t;,1. c1.1Vj h«..w. "t)C efi>t f<t.C<.C�,,.._ A-tn:..,.tr ) N - FS) c.v 1 Severe Gu..t wY\.ft..:Ltiv<- � J- ( �' tz�h- r-.� persistent synovitis 8-12 weeks No ...:, ( <..' NSA 7.'D) NSAIDs +/- Hydroxychlcrroquine/ Sulfasalazine/Minocycline .L � (Azul fill ine® ) (Minocin®) c..1.,. {Plaqu�nil®) Mild Ev� �""' rJL. W"::J-fJ h e...c.A..-.,1-c.. ) ('.) f A�..,,, �·<.>.- c.�·t cl::. ) yC.«Ct.:.'-"- 3 t1:. rJ r P..-.U:t<-'" H.\..<. ...1.,,u . Chart 1-2 f'I 1 s'j,,- s -"" � r u ( P"Ll:J � NV Ove,. ul'l w;\.r""'" d.J.r ) f/Vrl s.. �c;1.. � S c Ien'ti' s-> QlObe. u Episcleritis � � '!/ ( � f.1 r( � �w-) f.\,.,.t. TrJF . __, 'D<> PPD _, :; '/ s fYVV\- / ex� -i uvh of Nl 1. � Git Eoh �0--l '3' H�.pu ��:..:t... 1,.<. ( 6 """"""'� ) 0 c. p ;11 <f-c.·A.,,,.,.. Golimumab (Simponi®) Certolizumab {Cimzia®) 'iG �1-opCfv\"' /" 'D:.ve-tc...w - Ni t.ofvYl./f\ � Yft'..vv- - Abatacept {Orencia®) Rituximab ( Rituxan®) Tocilizumab (Actemra®) l (),"� L'D Z-o L4 H C> (,\ (Y\L�t""ex �t-<- 9- � A 2. Methotrexate Is contraindicated In all the following In Rheumatoid Arthritis EXCEPT: --��----��--' A . Pt. on TMP-SMX B. Pt. with Hepatitis B or C C. Alcoholic liver disease Pt. with persistent joint pain and swelling �t, P..BPA y( Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission ..... 1' l<jG T Ci) R-idc0p;'\... (]) .rt :fol-J... w«r't ( 1' Ste.,vl1\ ) Co.h""y.l-->l T� f Page 50 3. 45 y old presents with joint stiffness > 1 hr in AM, pain In the MCP, PIP anCI pain wti le limbing stairs for more than 6 weeks. Rh factor (+). Pt. Is started on Tylenol and no relief fter 4 weeks. Tylenol ls stopped and Pt. Is started on Naproxen. 2 months later, Pt. still with oderate symptoms and joint swelling. Rh factor remain high. he next best o�tion would be A . Increase dose of Naproxen \)Y."Add Methotrexate weekly C. Discontinue Naproxen and start Steroids Matching 1) - ) 1. The fastest acting DMARD (disease modifying antirheumatic drugs) �2. Which of the above drugs decrease mortality in RA? . ) D. Methotrexate Q4. What Is the predictor for CVS disease In Rheumatoid Arthritis? 5. Pt. wit R -eumatol art tis on NSAIDs, wit persistent synov tis, met otrexate was dded and pain Improved . 3 months later Pt. presents with fatigue. Hb low, MCV high . The est treatment would be A . Ferrous sulfate B. Erythropoietin Folic acid ) ./. ) ) P-i - 1. NSAIDs lJ1"1 .11.rfJ 3. F 5. Corticosteroids f .,-, stop �I �-t.,, B. Hepatotoxicity, Hypersen. Pne1:1monitis, Aphthous Ulcers C. Macular damage, loss of accommodation. � 4. leflunomide - iVl's A. Nephrotic syndrome, PUD, Int. nephritis � Methotrexate D. Teratogenic E. Reactivation of TB, demyelinating dzs., fungal infn., t,. f.,4JI. _, psoriasis, drug induced lupus ( Pl"� J'"""1t, j� LE 6. lnflixlmab � 7. Etanercept EiF � 8. Cyclosporine J FLoM.t-x __. .JL4t>f'a Matching ._Q_ 2. Hydroxychloroquine ) B. Sulfasalazine C. Penicillamine ) ) A. Hydroxychloroquine r:J" I�'"')C• rna·J Ar-t.- 'J)J' 'Dtvr"t0 F. Osteoporosis, HTN, Cataracts, Avascular necrosis D G. ANA, anti DNA +, flu like symptoms H. ATN, Renal insufficiency, Hirsutism, HT N Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 51 6. Pt. with Rheumatoid arthritis presents with sudden onset of pain behind knee and In the alf. Ultrasound Is negative for DVT. w.t.d: A. NSAIDs Intra-articular steroids ( R"'Ptw-... <>J 3,1:t.C. Anticoagulation / cost.. ) 7. Pt. with history of Rheumatoid arthritis for a long time In the past, undergoes an lective surgery under general anesthesia. Post operatively Pt. is quadriplegic. ost likely etio l og_'l_ _ls �----------_______ _ _ _ _ J.Atlanto odontoid subluxation Cl-C2 B. Cerebral stroke 8. A Pt. with long standing Rh arthritis presents with hoarseness of voice for several weeks. ost likely diagnosis? __c_�i_ <...o _ _' o._.-...., !j� t_ e." _o-\P. __ � _____ joint involvement Q9. 65 y old with Rheumatoid arthritis> 30 yrs with persistent paresthesias in both hands. llateral carpal tunnel release surgery Is done with little change in the parestheslas 3 months ater. He also has occasional dizzy spells. Past history Is significant for total knee arthroplasty nd severe joint deformities. O/E: decreased power & hyperactive reflexes. The Pt. is going or hip replacement surgery, what would you do next? A. MRI Brain _,W, X ray neck ( �lo L'-<xe..h'.CM to �.) C. EMG's to rule out residual Carpal tunnel 10. A Pt. with history of Rheumatoid arthritis on methotrexate for about a year presents Ith few days history of pain and swelling of the knee joint. Fever with leukocytosls _ _ .t.d next • � Ie..p 1t..t_ jol"t 1:o !(/� >tpt<c... Q.-fh..., ts .. 1 1. A tap revealed turbid exudate, labs are pending w.t.d --------��-- A. Start intra-articular steroids /.start i.v Antibiotics C. Start i.v Methotrexate 012. Pt. with long standing Rheumatoid arthritis on NSAIDs, steroids and methotrexate resents with cough, treated empirically with antibiotics. Four weeks later presents with rogresslve shortness of breath, no fever. /E: bilateral crackles heard. XR�lnterstitial Infiltrates +. The LEAST likely cause of her symptoms are A. Methotrexate induced hypersensitivity pneumonitis ( 1->/ 3 � f>IJ� 1:,i. ) B. Interstitial fibrosis c 6 f"'Wl.--fM ) C. BO � CMV Pneumonitis (_ p0rt. t..c.Npl""'*")� Ve;.l_3-cf'\0�Cl.ov1,. :fw 1'2.�� Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 52 Q.13. Pt. with RA on Hydroxychloroquine. w.t.d 7 r<et;f\QA. �c. � bc.A.L� "'-A.,J �c.� 1. Q.14. Leading cause of death in Rheumatoid arthritis? 15. A Pt. was being treated with steroids for Temporal arteritis or Polymyalgla Rheumatica r SLE. Couple of months later steroids were being tapered off because of Improvement in is symptoms. Now Pt. returned with bilateral symmetric joint pain & early morning stiffness nvolving MCP, PIP. No shoulder ache or headaches. Exam reveals +ve nodule on left lecranon area. Most likely diagnosis? �v<A&. c ext.c f>rtt v(Rheumatoid arthritis B. Osteoarthritis C. Polymyositis j ) f16. Pt. on Methotrexate for Rheumatoid a rthritis. What do you follow based on current guidelines A. CBC, ESR, ALT Q 8 weeks B. CBC, Rh factor, AST Q 8 weeks .JC, CBC, Creatinine, AST Q 2-4 w x 3, 8-12 w x 3, then q 12 w ) ) ) ) r�l 7. Pt. with Rh Arthritis with minimal response to Methotrexate 25mg/week. What will you do next? A. Start Anti TNF a vfY.' Place PPD ) ) ) You placed a PPD which is 5 mm. wtd next?_, C...)<. R. A. Start Anti T N F a �tart INH & Pyridoxine ) ;f 7 Give Pneumococcal and Influenza vaccines before biologic DMARDs ' (anti TNF a therapy) and nonbiologic DMARDs such as Methotrexate or Leflunomide. -7 Don't give live vaccines for biologic DMARDs ) 7Don't give DMARDs with active infections. ( S'tevvt ) 18. 35 y old presents with recurrent pain which starts in PIP, then MCP and then In the nee. A few hours later the joints are swollen. Within 24 hours, the pain resolves starting Ith knee, MCP and then PIP. In between the attacks the Pt. is absolutely fine. Diagnosis is _ -7 .. ( P c.l�n.C\.yo (VV\. <- c � 2 ?JilM(,\� P�oC.0((c L 'f'-IM. �i<>V>J-il. 'DMAl'l.'PJ .J'""'" 71/2 will go on to Rheumatoid arthritis v� � b;� b..:<>L-,C.'L 'Dl"AA�'.DS. I P,f'� ""4..ft..o�xi:.k.. � L Gl:flu.lo'l.O�a... No �-ve v� (OV'l Pf<.1...v T('./1: of.. ;·aj-«-�c-v- -th "'r::J G1.1. 1 'DMfl1�'DJ Tx: DMARDs Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 53 19. Pt. with Rheumatoid arthritis with necrotic ulceration of ti s of fingers and foot dro�. o x :� R-�c.t�o.. V c... f'cv. t.. c.r 20. <1% of Pt.s with long standing Rheumatoid arthritis present with Splenomegaly & eukopenia�Recurrent skin and lung Infections. Skin ulcers (+) H�p\.v..�S f\.\layt.r-Jc. Tx : • • • cAuc.W"ioJ.. _,ix __. t>o AL.t"tt;.o""�c....A, Skpf:.:>� DMARDs Steroids G-CSF � Splenectomy � p21. 32 y old woman presents with polyarthritis and fever. �he had a sore throat several weeks ago. She continues to have recurrent f, ever which Is accompanied with an evanescent salmon colored/faint pink ash on the trunk and upper extremities. hroat culture negative. SR 110/hr, Ferrltin level 600 BC 24,000 with 85% PMNs. t. Is started on a course of antibiotics without success. ST/ALT Increased. h factor negative. NA negative. ost likely diagnosis Is A. Severe sepsis Y,Still's disease C. Felty's syndrome D. Post streptococcal GN Q22. What disease Is more likely related to rheumatoid arthritis? A. Lactose intolerance Periodontal disease v{ �11 t\.lvd->(' Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission 1 "- 6 Le.LL>� fVV'-1"'� Page 54 Chart 2-2 Rh(+) ANA(+) Ro, La(+) ESR increased Increased risk of lymphoma * & celiac sprue -( l'.3/4 i:r� \.. bov-el d./ s) Distal RTA I · t IA...>< f'� >s >) Enlarged salivary glands: Dry mouth Dry Eyes ) Diagnosis: Lip biopsy of minor salivaryglands Schirmer test(+) if <Smm wetting in tearing of eyes in S mins (nl lSmm in Smins) Tx: Symptomatic: Hydration, Pilocarpine Steroids i,,l,,Y.... p"- / s..S /Qpo'vc.J'A.•...._ OJ'- Cel4..V- 't v.�- p'rv>tpL....•f-c.. cc.� p� � t)c � �;r-<-'"" H/A 3. 55 y old woman complains of dry eyes and dry mouth. She says she drinks lots of water veryday and uses artlftclal tears. Review of systems reveals she has chronic arthralslas for hlch she takes NSAIDs. Exam reveals parottd 9la,nd swelUna, dani.I caries and dry eyes. he Pt.s symptoms may beneftt from ) ) A. Atropine sulfate B. Visine eye drops � Pilocarpine SJ 05fc:JV' D. Reassurance ) ) ) ) ) Involve spine Asymmetric poly/oligoarthritis(<4 joints affected) Enthesitis (inflammation of ligaments. tendons.joint capsule. etc) Dactylitis (swelling of the entire digit) • • Ankylosing Spondylitis Reactive Arthritis(mucosa I inflammation of GI or GU tract) nkyloslng Spondylltis: ) • • • • • • • Starts after restin ets better with exercise -_.;..... .;..-. � ... cilimp�matic acroiliitis Uveitis pain, photophobia, lacrimation HLA B27(+) , Apical fibrosis i-J"""'l ) ,-.vo.,.e.. Jp<:.<...fl L Xray: Bamboo spine ( u:.r/t � .fw Associated with Aortitis ( 'U.o f;cJ"° J Diminished chest expansion ( T L c Jr / R" 'i ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 55 24.Pt.who loves to do outdoor work with on and off back pain. He presents with omplaints of pain and redness of right eye. Exam reveals he has some loss of forward spinal mobility.Exam of the eye shows injection around the cornea. Fluoresceln eye stain Is negative.What Is most suggestive of Ankyloslng spondylltis In the above Pt.? A. Uveitis B. HLA B 27 /. Loss of spinal mobility r fOtwc,,.J. ) 25. What diagnostic test will you do next for this Pt.? A. HLA B27 vB". X ray of Lumbosacral spine C. Urine culture Most sensitive test ? A. CT scan B. MRI of lumbar spine JY, MRI of sacro-iliac joint 26. What Is the eye manifestation In the above Pt.? A. Conjunctivitis JY.'Uveitis C. Corneal abrasion �7. Pt. presents with low back pain. Xray shows fusion of sacroiliac joints and ankylosls of e s lne (Bamboo s lne . HLA B 27 +).This Is most llkel associated with -----A. Osteoarthritis �ortitis C. Rheumatoid arthritis Tx: Stiffness 1h.uv 7 PT Pain 7·NSAIDs.Comes back in 6 weeks with minimal improvement in pain, fatigue and morning stiffness7 Pt"t TNr:: ol C Ni.st M.t.?\;..o't-c.JC�k ) How to follow up the Pt.? Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 56 The best way to maintain range of motion in Ankylosing Spondylitis is Follow disease activity with Uveitis: • Reiter's syndrome • Behcet's disease • Ankylosing spondylitis 28 . Pt. with history of Ankylosing spondylit1s on NSAIDs complains of new onset back pain. . t.d? A. Physical therapy /,X ray \ Q29. Pt. presents with asymmetric art r tis with pain n t e r g t peciflc urethritis and conjunctivitis. HLA 827(+) 'Non specific urethritis, conjunctivitis and asymmetric arthritis.' Tx: NSAIDs ) } ) ) ) ) •DMARDs in extreme cases. Conjunctivitis, Urethritis with asymmetric arthritis -7Reiter's syndrome Other features: Mouth ulcers Keratoderma blenorrhagica c H c..-vl �jLJ'tc.i.: c,-.., ) What test would you do next? -7 H 1.V te..it. Q.30. 34 y old with Lt ankle arthritis and left achllles tendon area pain. She has had redness o he eye, abdominal pain and diarrhea. Exam reveals pain at the base of the calcaneus. J. Reactive arthritis B. Parvovirus 31. How to treat above Pt. with diarrhea?�� -7 Cipro + NSAID 32. How to treat Pt. with remote Hx. of diarrhea and now enthesitis? A. Cipro JYNSAID 33. Pt. with reactive arthritis with ongoing arthritic pain for more than six months not elleved with NSAIDs or steroids. W.t.d vA. Sulfasalazine/Methotrexate B. Antibiotics Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 57 34. How to treat Pt. with remote hx of urethritis and now enthesltts? 7 Cl-\. la.M.'f J..: c.. f<e.J lex Jt + NSAI D - Other causes of Reactive Arthritis: • Yersm1a • Shigella e.c:. 1<.) • Salmonella L � ->-> ow-br d.!""' • Campylobacter l �'J �c.. • Ureaplasma • c. diff • BCG therapy ( (3WiV-- c� ) - 6c.f:v..v • /;\tc..Jl....t W e...st. 5. Pt. presents with low back pain and pain In the distal lnterphalangeal olnts. HLA 827(+) O/E: pitting natl changes present. • Mild disease 7 NSA"l..D NO Hydroxychloroquine Skin and Nail changes-? v,y,,.....i .. �u.X> 1' � • ,wit.. -r,· C.lic. (' c;e., r· . Cn .a.J-;"C<l �------� Tx: �(/' f l'l""-tc.J� r.:. c.t l ep'-'> L. (V'UV'.r• J'wot ,,.c,..r..1 � f "'U �e.L.--t..:. fY'\,tt\_o�,xc.k What makes psoriasis worse? 7 � blockers -?Sunlight c \PJ B) -?Infection Tx: Steroids A. Sarcoidosis ,JY.'Behcet's Awesome Review, Inc.� Copyright 2014 Do not photocopy without permission Page 58 Matching (3 1. Oral aphthous ulcer and genital ulcer. Refuses needle sticks. A. Sarcoidosis L2. Painful Shin nodules and genital ulcer. Refuses needle sticks. B. Behcet's disease - �3. Painful Shin nodules and oral aphthous ulcers. Aortic aneurysm. Painful red eye with blurry vision. Occasional knee and ankle pain. C. Reiter's syndrome �4. Oral aphthous ulcers, history of urethral discharge in the past. Red eye with knee and ankle pain. \ �8. Pt. returns from lndla, Thailand or Africa with high fever and pain In small Joints of the 1and, wrist and ankle with or without maculopapular rash. Most likely diagnosis? 9. All the following can cause Reactive Arthritis with dactylltls EXCEPT: ) ) ) A . Yersinia B. Shigella C. Salmonella D. Campylobacter �E. coli F. C. difficile G. Ureaplasma H. Inflammatory bowel disease ) ) ) ) ) Ue.�(Y\.:"<..h.A A. DGI ( B. Gout C. Ankylosing spondylitis J Reactive arthritis �t.oc<0L What is most likely positive? A. Knee tap B. HLA B27 C. Monosodium urate crystals � Stool culture Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 59 4 1. A 70 y old diabettc man presents with pain in the mid back area. There is early morning ttffness of the spine. Exam reveals decreased thoracic lateral flexion. X-ray of the thoracic pine reveals flowing ossification of the anterior longitudinal ligaments. Mostlikel diagnosisi_ s_ ? �-�--------�---��--- ____ A. Ankylosing spondylitis vK DISH ( Diffuse Idiopathic Skeletal Hyperostosis) CNS' • • • • • c��SC/C... �J - 'j)')o .f.eY"OLo� Older age History of trauma Obesity, Repetitive use 2° OM, Hyperparathyroidism, Chondrocalcinosis Labs: low titer Rh factor and ANA may be positive. T)C W1it. Al\t: � 'Zi.vv. � < 1 ·.� Clinical features: • • • trri (/'tV p� Joint pain: 1sr CMP, Knees, PIP, DIP, Hip, Cervical and lumbar spine Osteophytes, central erosions in DIPs on X-ray , ec..,.L:J �,rv:.r:J If no Osteop�ytes, then S-torvW-.t • Morning stiffness • Crepitus on movement of joint • Joint fluid <2,000 WBC's Joint deformities PIP7 Bouchard's nodes 1 _, DIP7 Heberden's nodes J Tx: Lose weight! 7 stc...-t VV?ft. tcJle.rv-A � to Lt "1 � 7 NSAIDs/Non-acetylated Salicylates7Celecoxib with PPl7 Intra-articular steroids 7 Hyaluronic acid7 mechanical measures7 replace joint. Awesome Review, Inc.® Copyright 201 4.Do not photocopy without permission Page 60 Chart 3-2 osteophyte formation collapse of joint space subchondral cyst Central erosions ) ) ) ) ) ) ) ) Matching A - 1. Osteophyte formation �2. Periarticular osteopenia J:.._3. Joint space deformity � Marginal bony erosions in PIP & MCPs 4. A. Osteoarthritis B. Rheumatoid arthritis C. Both D. Neither �5. Central bony erosions in P I P & DIP _A_6 . Subchondral sclerosis Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 61 42. Pt. with severe Osteoarttlrltic pain not relleve<I y Ty enol. Hx of upper GI bleeet. w.td A. Low dose of NSAIDs JAraf ado I or Oral long acting morphine <-"'l.lC<.. s�?.IAA(. ) c G.r1't \AC<.. l..n-j � 43. Pt. presents with fatigue and Hb 9g. MCV 75. Hx reveals Pt. Is taking NSAIOs for steoarthrltls. Stool for occult blood Is positive. w.t.d � d/c NSAIDs start Acetaminophen B. Transfuse 2 u P RBCs. 44. Most Important risk factor for Osteoarthritis? A. Sedentary lifestyle � Obesity 45. Elderly Pt. presents with pain fn the thumb while turn Ins keys and opening car oors. xam reveals pain at the base of the thumb on flexlon and Internal rotation re ltus (+). Most llkel dla nosls Is /. Osteoarthritis of 1sr CMP joint B. deQuervain's tenosynovitis 46. Pt. with osteoarthritis, wants to try G lucosamlne or Chondroltln sulfate. w.t.<I ? 7 No difference from placebo 7 Tap the knee + steroids and send Pt. for Physical Tx to strengthen quadriceps 1. Exam reveals 10° valgus deformity with loss of cartilage on lateral knee on X ray. What is a good mechanical measure to reduce pain? 2. Exam reveals 10° varus deformity with loss of cartilage on medial knee on X ray. What is a good mechanical measure to reduce pain? � Medial unloading brace I � )�I Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 62 49. Randomized clinical trials have shown benefit of Acupuncture In -7 OS te-0 '- ( thv1 t:s 6J k.N.e i h.;.p Topical capsaicin shown to benefit osteoarthritis of-7 H G.l'\P- SO. Pt. a brick layer presents with pain and swelling of both PIP and DIPs. X rays show loss o artllage and narrowing of joint space and central erosions. Most likely diagnosis is A. Erosive Rheumatoid arthritis v-8. Erosive Osteoarthritis C. Psoriatic arthritis 5 1. A laborer or farmer presents with URI. He has had Rheumatoid arthritis for more than 15 yrs. Exam reveals swollen PIP and MCP with a boggy feellng. Pt. does not complain of pain trength of hand Is normal. X ray of hand reveals erosions of the PIP and MCR Most llkel dla nosls Is I)(Rheumatoid arthritis(arthritis robustus) \ B. Psoriatic arthritis C. Osteoarthritis D. Gout \ . ) ) 52. Most likely presentation of pain In osteoarthritis of hip Is in the Right groin pain with Rheumatoid arthritis & osteophytes on X ray ) Right groin pain with Rheumatoid arthritis, X ray negative MRI double line sign on T2 AvrJ ) -7 ) Right groin pain in middle aged Pt., X ray with mild osteopenia. MRI reveals- T l diffuse decreased enhancement of femoral head -T2 diffuse increased enhancement of femoral head 53. Pain over anterior aspect of hip or groin� R70 Hip joint problem. Ex: Avascular necrosis I Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 63 S4. Pain over lateral aspect of Hip cant sit In car/cant sleep on that side SS. Pt. less than 40 yrs bilateral groin pain, more on left. Worse with activity and internal otation S6. Pt. with SLE on steroids for> 2yrs presents with pain In the hip, and walks with a limp. he best diagnostic test Is 57. A 45 y old man complains of pain In the right buttock that shoots down the back of the high for the past 3 days. Tenderness over the right sciatic notch when pressure applied by humb and pain on abduction while lying down. Most likely diagnosis? ��- -7 P; yj ��J .f __, N..Ifl 1-. 'D 5 8 1 8(<20) yrs Id man presents with pain In both hips since childhood which has now ecome severe. NSAlDs don't help anymore. Walks with a llmp. ��---�� Next st�p-7 X R.c.y Tx: Weight loss-7 Pe.-; c.u. tcfo...,t_ o.r-tc.o� 9 . Pt. with pain In t e groin. X ray reveals osteoptlytes. You prescrltle analgesia anit a cane. hat are your directions for the use of the cane? A. Use cane on the same side as the affected joint JY.{J se cane on the opposite side of the affected joint. 60. Elderly Pt. with longstanding RA on Mtx, hydroxychloroqulne, NSAIDs with groin pain. ray shows no joint space and severely Impaired mobilization. Dx: Secondary Osteoarthritis w.t.d -7 Replace joint. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 64 Gout & Pseudo-gout Gout Pseudogout -7 �PP!t c.P P'J> It is an asymmetric inflammatory arthritis What precipitates Gout or Pseudogout? • Trauma • Post surgery, about 3 days later • Major medical illness(Ml, CVA, PE) • Fasting • Alcoholism • High fructose drinks • Associated with HTN, DM, HCTZ 61. Do you treat Pt. with asymptornatfi'i'lWJer.ontemfa ) -7 Uric acid level usually -7 N° F=a.IL s during an attack of Gout ,Uric acid levels decrease to normal during Gout attack ) ) ) B. Steroids �olchicine o.i, � 1g).., - f,,P IYJ D. Colchicine + Allopurinol /� --t<.' NSAIDs ) ) B. Steroids C. Colchicine D. Colchicine + Allopurinol Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 65 66. If above Pt. had contraindications to NSAIDs or colchicine with Renal insufficiency, eart failure, PUD w.t.d ? �Steroids B. Methotrexate 67. If Pt. had only one or two joints involvement. w.t.d A<.l ntra-articular steroids B. Systemic steroids 68. If Pt. had poly articular involvement. w.t.d A. Intra articular steroids )Y. Systemic steroids 69. The above Pt's. gouty attack resolved. What do you prescribe at the time of ischarge to begin 2 weeks later? A. Probenecid �Allopurinol C. Steroids 70. A Pt. with tophaceous gout has never had a gouty attack. hat is the best management? c w.-'<- � > A. Colchicine + Probenecid A. Colchicine + Allopurinol C. Observation Q71. Above Pt. with history of Gouty attacks in the past on Colchicine and Allopurinol prophylaxis, now presents with acute gouty attack. w.t.d A. d/c Allopurinol Start NSAID _,..,8':' Continue Allopurinol, Start NSAID 72. Above young Pt. with gouty attacks on allopurlnol and NSAID comes back ith recurrent attacks. w.t.d? -7 Assess Pt. 73. Pt. also with history of HTN takes ACE inhibitor as well. Presents with c/o generalized ash. Exam reveals fever, necrolytic kind of rash WBC 15,000 and eosinophlls 10%, BUN Creat 0/3.2 AST/ALT Increased. This is most likely due to � Allopurinol B. Colchicine C. ACE Inhibitor Allopurinol increases level of -7 (I" A?_c. �·o()Y-ir-t. 1v -t 6 Mf ) _, .s� ..rpc.v\J Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission "'fw N> ZJ3 ']) Page 66 74. Pt. with Hx. of Gout presents with swelling of the knee joint. A tap reveals negatively irefringent crystals and wee count of 40,000. Pt. is started on NSAIDs. He is also taking llopurinol. A week later, the Pt. presents with reaccumulation of fluid in the joint nd still with pain. A retap again reveals negatively birefringent crystals and wee of 46,000. he fluid has been yellow and turbid just like during the previous tap. hat Is the best management A . intra-articular steroids B. p.o steroids .ft i.v Antibiotics 75. Pt. witll HTN on Herz wit uric acla e evation. Asymptomatic. w.t.a asymptomatic hyperuricemia. 76. Pt. with HTN on HCTZ with uric acid elevation. Has gouty attack. w.t.d -7 'I '12/c HLT2 77. Elderly Pt's especially women on HCTZ can present with pain in the PIP and DIP with odules and swelling distal to the nodules. -?This represents I ) ) Ci 04 � A., th,,;�J Most likely will have what deposits? A. Calcium oxalate crystals 0V Monosodium urate Pseudo Gout ) \ ) ) ) (Calcium Pyrophosphate dihydrate disease) Causes: • Hyperparathyroidism • Hemochromatosis • Hypercalcemia • Hypothyroidism • Hypophosphatemia • Wilson's disease CPPD can present as • Pseudo Rheumatoid arthritis • Pseudo Gout • Pseudo Osteoarthritis Diagnosis: l<Aee most commonly affected. Xray -7 C k.OY\.d....-o c.c.{ � i:..·s Joint fluid-? �"-0M ':><Ad.. Weakly(__±_) birefringence Treatment: Similar to Gout, less responsive to Colchicine Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 67 Q.78. 55 y old p resents with complains of pain in the knees and the wrist. He also complains of fatigue and decreased libido. Exam: Swelling of wrists and knees. ray� Calcification of menisci/triangular ligament �ST/ALT elevated FBS 150mg/dl Dx: Pseudogout 2° Hemochromatosis. w.t.d next -7 Serum transferrin saturation and Iron level. 79. Pt. presents with arthritis, X rays reveals multiple areas of joint calcification in ultiple joints. Also complains of fatigue. FBS 158mg/dl. Most likely test you will do in this Pt. is A. ANA A. TIBC F�rt.;. I C. Rh factor w��"' sc.t1.< ..... h:""" Q80. A Pt. with hyperparathyroidism undergoes parathyroldectomy. Post surgery, the 1>t. develops acute onset of pain and swelling of the right knee. Tap Is done. t would reveal A. 55,000 WBCs with negative birefringence ..--13.' 55,000 WBCs with positive birefringence C. 55,000 WBCs with no crystals, Bacteria present 81. Pt. post surgery 3 Clays ater wit Wrist, MCP, P P, DIP ana nee pa ns. Knee o nt wollen. Serum Uric acid is elevated. What do ou ex ect In fluid /calcium pyrophosphate dihydrate crystals B. Monoso�ium urate crystals. Chart 4-2 Joint fluid interpretation Disease process Leukocytes PMNs Glucose 2000-75,000 >50% 25-ser glucose i "":f-lc """"'c. h>'J >50,000 >75% <25 s��c... Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 68 Matching A 1. Pt. complains of pain on abduction of A. Bicipital tendinopathy shoulder mainly anterior tenderness over the bicipital groove. 7 PT Tx:7 NSf\1-D to the tendon in bicipital groove. 7 ste" · ( i"I\ �- R.vp� 'l(f) (3 2. Pt. complains of pain in the shoulder. He ) ) ) } \ I ) started playing tennis after a long time. New shoulder pain while trying to comb hair or lifting dress or lifting weights above head, washing the back while showering. Or pain on the lateral shoulder on lying down especially at night time. Painful abduction beyond 40 degrees & internal rotation. 3. A 75 y old man falls from a height with an outstretched hand. Pt c/o shoulder pain and On exam: Can shrug shoulder. Cannot abduct his .-+.-�- arm and cannot keep the arm up after passive ' I.ii intervention to 90 degrees( drop arm test ). X ray reveals no fracture only mild narrowing of the sub acromial space. Next step after X ray 7 tYW'< '1. J) 4. Pt. complains of pain in the shoulder, increased on abduction, extremes of movement painless. Pain more on active than passive f abduction. Swinging arm back and forth without pain. c. L o.rc. B. Rotator cuff tendinopathy C. Rotator cuff tear D. Sub acromial bursitis Tx: 7 _§_s. Pt. with pain and grinding or popping sensation E. Acromio clavicular joint arthritis in the anterior shoulder while reaching to put seat belt on. Pain on abduction beyond 120° ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 69 Matching 15 1. A 66 y old woman presents with gradual onset and progressive right shoulder pain for the pas Difficulty combing her hair and washing face and head while showering. She had a minor motor vehicle accident couple of years ago. Exam reveals difficulty in abducting and external rotation of the right shoulder wit repitus and tenderness over the shoulder. X ray shows narrowing of the gleno humeral joint space. Tx: NSAIDs & stretching exercises. Persistent symptoms 7 intra articular steroids x 2 7 no response over 6-12 mths period 7 Sx @' A. Adhesive capsulitis � 2. 72 y old woman with right shoulder pain for the past year with gradual onset of symptoms with movement of shoulder and at night time. Exam reveals difficulty abducting shoulder. X ray shows calcification of the ligaments with some effusion which on tap reveals RBCs, WBCs 2000. Alizarin stain shows basic calcium phosphate crystals and occasional hydroxyapatite crystals. Tx: -7 NSAL.D • R.4-fc.c..r Av-tv·o�te� Persistent symptoms-? h1/c c.vt�c-t,..,. .ru..MAdegenerative changes 7 Pl-Y"#\...-o pw71 3. 60 y old woman had a cast for her arm injury. Post removal of cast c/o stiffness, inability to move her shoulder. Exam reveals pain and tenderness around shoulder, loss of both active and passive range of movements. X ray of shoulder appears normal. Injecting steroid into the shoulder joint with resistance. Tx: 7 &c..,;l:J fV'LO �2� � _ B. Glenohumeral osteo arthritis c. Milwaukee shoulder 82. Lying on the side pain Shoulder Left precordial 7 Lateral hip pain 7 GOS to c.h.:>f'I 0...:-t:.:J . ,. AL<oC.. hq(I1C/\'-' -, " .. b·"'. ... ,. ,..... '"" '"' 83. A student presents with pain and swelling of elbow nearing his exams or a carpet layer, roofer, etc.). Can pronate and supinate arm, but cant flex. Dx: Olecranon Bursitis Etiology: Trauma, Gout, Sepsis Tx: NSAIDs, Local steroids Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 70 84. If above Pt . presents with fever and chills. Exam reveals Increased warmth with enderness. Range of movements painless. Tap reveals 9,000 WBCs (could be <20,000) Dx: Septic Olecranon Bursitis Tx: Aspiration, drainage, i.v antibiotics + NSAIDs w.t.d if Pt. presents with recurrent Olecranon Bursitis? -7Excise Bursa. ) ) 85. Pt. presents with pain In lateral elbow and anterior to the lateral epicondyle. Pain on xtenslon of wrist and fingers and supination of the forearm. While in airport he lifted a uitcase (or handshake) and pain came back again. -7 l c.. te,CJL Epi c-.ct.y L:..-C:.r A kA Ter.,...,:J �I bo t-1 Mainly due to lifting heavy objects. Extensor carpi radialis brevis most commonly affected 86. The best way to reduce recurrence In the future Is ) ) ) ) A. Steroid injection �Six weeks of Physical therapy with eccentric exercise Weakness in abductor pollicis brevis most commonly affected. Phalen's sign can be(+). Tinel's sign less sensitive than Phalen's sign. Management: Next step-7 Use neutral splint at night If no response to above treatment or there is thenar atrophy -7 Nerve conduction studies -7 Sx release. Conditions causing Carpal tunnel syndrome: • Rheumatoid Arthritis • Diabetes mellitus • Pregnancy • Menopause • Myxedema • Amyloidosis • Acromegaly Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 71 87. Most likely you will see In a Pt. with median nerve lnvo1vement Is A. Unable to flex wrist � Unable to oppose little finger with thumb Matching .A_ 1. SS y old woman with numbness in both thumbs and A. TSH index fingers upon holding anything for a few minutes. H R S2/min. Fatigue(+). Most appropriate next diagnostic step? _§_2. Pregnant woman complaints of pain and paresthesias in both hands in the thumb and index finger, especially at night. w.t.d? B. Neutral splinting of the wrists �3. 4S y old with long standing Rheumatoid arthritis C. Nerve conduction studies .L4. What is the best treatment for a Pt. who fails D. Surgical release with bilateral tingling sensations in both hands, worsened during night. Thenar muscle wasting present. What is the next best diagnostic step? splinting and has thenar atrophy? ,£s. Numbness of thumb, index finger and middle finger. E. Rheumatoid arthritis Early morning stiffness of an hour. Difficulty opening bottles? - Occurs at ulnar groove in Elbow. 89. Pt. Involved In MVA pres.ents unablt tor disrupting Brachia! blood flow. Tx: Rest the tendon (no gripping or grasping), Splinting -7 local steroids If disability is severe-7 Surgery. Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 72 91. Pt. presents with wrist drop. Decreased sensation on the radial and dorsal aspect of his and . Dx:7Compression of Radial nerve at 7 Spi ,.."'l 5ywv<- in. AKA Saturday night palsy. �4..�� =-- --- -- 1'...c._ c:;.,.""'-. -- 92. Pt. presents with finger stuck at flexlon at PIP. It Is straightened Ith effort of the other hand. Tenderness at the base of finger. � D X : -, ) �r _:.· t---L r -;..., , .1 " .:>v:-LI tuv:>J1. .J • stef\.Mc.tv.i (swelling of flexor tendon aka Trigger finger) w.t.d 93. Pt. with stiffness of ulnar aspect of hand. Unable to extend 3rc1 & 4tli flngers. hlckenlng and contraction of palmar fascia. (OM & ETOH liver disease) ) ) 94 . Pt. fell on outstretched hand. Tenderness over anatomical snuff box. ray report negative for fracture. w.t.d next ��---- & then ) · �Bone Scan or MRI. } ) ) 'DM with burning sensation or numbness in anterior and lateral thigh' Pain worsens on abduction of thigh & with exercise. Palpation of right lower quadrant in the inguin"al region elicits pain in the thigh. Tx: Weight loss/anticonvulsants/Local steroids ) Awesome Review, Inc." Copyright 2014 Do not photocopy without permission Page 73 96. Pt. c/o hip pain. X ray reveals fracture of ramus of pubis. w.t.d 97. Pt. presents with pain In the patellar region. Exam: No skin breakdown. Erythema and enderness over the patellar region Tx: NSAIDs/Local steroids 98. OM Pt. with pelvic girdle and thigh pain. No burning sensation. xam reveals atrophy and weakness of thigh muscles. 99. Elderly Pt. presents with pain in the knee, mainly on the medial aspect about 5 ems C elow joint line, which gets worse on climbing stairs.(semiflexlon) X-rays: No linear lclflcatlon, mild osteoarthritlc changes 11 ) Sv.. p ,-c. f\1..<. G lu_ fr (. f-c.IL an,, C l..< �'J .f�y ) Tx: Local steroids/Rest/NSAIDs o(. """""' 100. A Pt. presents with c/o pain in the side of the knee when he does jogging or cycling. he pain radiates upwards towards the thigh. Exam reveals focal tenderness in the lateral spect of the knee joint just above the mldllne white abductlns and extending the hip. A sna s heard on flexton. On resisted Internal rotation of tibia there Is no pa in. ost likely diagnosis lllotlblal band syndrome Tx: Correct training errors, proper foot wear, stretching the hip abductors 101. 28 y o Cl ong Cllstance runner compla ns of pain In ttie knee. The pa n Is aescrll)ei:f as a urolng sensation on the Inner and outer aspects of the patella and also behind the patella xacerbated by physical activity (running, climbing stairs during squats, scendlng/descendlng stairs or hills). He also has knee stiffness especially after sitting for a ong time(the "movie-goer" sign). What will help establish diagnosis? ( M Vl 'l , .>< Y':> ) A. Check ligament-ligament alignment /. Patellar compression Ox: � ' c hU'Y'\.cl l""U t"'-" Ls:-<... < p ,.b,iL< c pc.�tU: Tx: Decrease running/Quadriceps strengthening/Analgesics Surgical procedure NOT required. Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 74 102. Teenager presents with anterior knee pain just below ttie l<nee joint. xam reveals olnt tenderness just below the knee joint especially on extending knee against resistance. ost likely disease 103 . 20 yr old presents to ER with acute pain in the knee with swelling. He was playing foot all about an hour ago and heard a popping sound followed by pain and swelling. nterlor Drawer sl n & Lachman sign (+) p._.. L J<TYI c....-.d. Dx:7 ) f.\"t-i c..n,lu GL p� L:.u Ly1 v.f' � 104. If a Pt . presents several hours after Injury with swelling . Knee 'locks' or 'gives away'. urlng Injury heard a popping sound. 24 hours later with pain and swelling. Palpation of the edlal joint line with pain and a clicking sound Is heard on flexlon of the knee with the ankle n external rotation. McMurray's test (+) ��- \ 105. 75 y old assisted living home Pt. with pain on the medial Aspect of the knee for the ast several months. Ciiek on palpation. w.t.d ) ) ) ) ) ) 7 PT 106. Pt. presents with pain In the knee on tile medial aspect after an n]ury several tiours go. No hx of popping sound. He can ambulate but cannot pivot or twist. xam: Drawers test neg, Lachman's test neg, varus test neg Valgus test positive with pain long the medial joint . Most likely diagnosis Is Lc...1:.vd L ·�� ) �� 107 . A Pt. presents with pain and swelling of posterior leg. The pain began abruptly > 24 hrs 10 after he played a game of tennis after a long time. xam: Ecchymosls, swelling and tenderness In the mid calf region. o history of Rheumatoid arthritis. What to do next? Tx: Rest/NSAIDs/Crepe bandage Awesome Review, Inc. ® Copyright 2014 Do not photocopy without permission Page 75 108. Pt. presents with pain in the ankle on ambulation. He twisted his ankle while tepplng on an uneven surface. Can walk 4_steps without support. Compression of the osterlor malleoll (medial and lateral) with NO pain. -- f\-A.k.\.t.. sp'f� Dx:-7 No need for an Xray. Tx: • l t �� .f, bvk.1 LsafV'.C,./\+ ) NSAIDs Splint • 109. A long d istance runner comp alns of pain in the lower medial aspect of leg. aln Is worsened when he jogs. ray � negative for fracture. D x : -7 Tx: • Ove;-CAJe f - S� f Rest Ice packs • 110. Pt. presents with pain and burning sensation In 6etween 3rd and 4th toes. It gets worse hlle walking with high heels. Also complains of pain while walking on a hard surface. The aln radiates to the front of the toes alongwith parestbeslasalong the plantar aspect. The aln sets better when the shoes are removed. Most likely diagnosis is? A. Vitamin B12 deficiency � Morton's neuroma (lnterdigital plantar neuroma) C. Diabetic neuropathy b.111. Pt. presents with pain in the heel, stiffness during early morning stride. ._ _ "ets better as the da goes along Dx: -7 Tx: • • • p\.c..r\.t4..- .f c. J' �i tr Ice packs after activities/Arch support/NSAIDs Correct training errors/Steroid injections/Surgery Stretching exercise with dorsiflexion of foot Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 76 112. Above Pt's X ray shows a heel spur. Cause of the pain is A. Calcaneal spur .)¥.' Plantar fasciitis 0.113. Foot pain, more In the morning, difficulty with dorsiflexlon. O/E: tenderness at the ase of calcaneus, with Increased tenderness on squeezing the heel. Most likely diagnosis A Plantar fasciitis B. Calcaneal fracture ) ) 114. Pt. with numbness and burning sensation In the toes. Gets worse on walking and at he end of the day. Thesvmptoms are aRSravated at night time. Radiates to the f ront of the oes. Taking off shoes makes It feel better. On percussion posterior and Inferior to medial alleolus produces pain. Dx: 7 T�YJ'c..l. Tx: • • • I ) ) ) ) ) ) ) t. f\A(.' L {' Arch support 7 s � e. ""'°��Lo.h'.c,.,...., Local steroid Sx decompression b11s. Pt. presents with complains of painful feet, ankles and knees after prolonged standing hlch has happened for the past couple of years. Exam reveals normal feet. Upon standing, he arches of feet collapse and there Is valgus of heel. Dx:7 Pe..s pl c...l\.W (Flat feet) Best treatment? A. Ask them to buy better shoes B. Refer to Podiatrist for custom fitting of Orthotics shoes 116. 45 v old woman presents wittl extreme fatigue, <toesn't want to get out of bed. Also omplalns of diffuse muscle aches. Exam reveals tenderness In most muscle groups. No wellfng of joints or erythema. NO FEVER NA 1:64 SR 30 K 98 u/lt ou would A. Repeat ANA in 3 months B. Do Anti-DNA & Anti Smith antibodies C. Vitamin B12 injection A Start Amitriptyline (oYJ exeo1c,;f e E. Start P rednisone What is the diagnosis? 7 Fibromyalgia (. Nt> j-t.vU') Awesome Review, Inc." Copyright 2014 D o not photocopy wi thout permission Page 77 117. Elderly woman presents with generalized body aches and fatigue. It started a couple o ays ago with pain In the upper arms and neck. It Is associated with morning stiffness. Exam eveals no focal deficit. Xray shows mlnlmal osteoarthritlc changes. SR 52mm/hr lkallne Phosphatase elevated SAIDs provide little relief. ocal steroids for shoulder with tem relief. � ) l t' Tx: Dramatic response to-7 1.-ow M� fNd�sCNV1 18. 85 y old woman with recurrent pain In the neck. ESR 40 and low grade temps. estrlctton of neck movements due to pain. X ray shows calclflcatlon of ligaments In the neck lclflcatlons noted In other joints as well. Dx:-7 t 'Swelling of ears, hoarseness, aortic regurgitation' Pt. presents with hoarseness of voice, episodic swelling of ears(swollen outer ear but ear lobe Normal) and -7 History of intubation 2°subglottic stenosis. Laryngoscopy-7Edema and inflammation. Dx: biopsy of cartilage -7 lmmunosuppressive agents Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 78 Chart 5-2 Vasculitis • • • • Temporal arteritis Takayasu's arteritis Aortitis • • J f'J L Polyarteritis nodosa Granulomatosis with polyangiitis (Wegener 's) Churg Strauss C O""J° \.t N\ll.t ..r>. • • • • • • • } ) \ ) I ) • • Henoch-Schonlein Microscopic polya rteritis angiitis (MPA) Leukocytoclastic angiitis(hypersensitivity vasculits) Churg Strauss Good pastures ( f:.vt>L Ru.c�w. ) Cryoglobulinemia Ji> SBE c 3 J,, > C Li SLE Rh Arthritis ((Li C. 1 ) 119. 65 y old woman complains of frontal headache which Is moderately severe and hrobblng. Scalp hurts when she combs her hair. She says It hurts white chewing. She had an plsode of blurry vision this morning which made her come to the office. OS: low grade fevers over the past month. Exam reveals no focal deficits. w.t.d next A. MRI Brain B. CT Brain � ESR D. Carotid ultrasound �Steroids B. Biopsy 121. ESR Is 85 and temporal artery biopsy Is negative. Most likely diagnosis Is A. Migraine B. Tension headache /.Temporal arteritis J Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 79 122. 65 y old man with headaches, ESR 85, steroids were started and Temporal artery lopsy was negative. BP In both extremities normal. What will you do next? A. MRA of carotid, aorta and neck vessels Y,Ultrasound guided biopsy of the contralateral temporal artery 123. A Pt. presents wit pain an wea ness o tile eft arm a er exercise. Recently some lzzlness and visual disturbances/TIA as well. P Rt arm: 140/80 and Lt arm 15��·----If Pt. age 25 also with history of malaise and low grade fevers 7 Ta. kc;:-y c.s w... If Pt. elderly with normal ESR 7 Aik�os<:. Lero � If Pt. elderly with high ESR 7 TUV'l. p..,..,..,, 1- �l�...r Next?7 S'tuu\.cL Tx: Steroids, Ca channel blockers 125. Ankyloslng spondyHtls Is. associated wlth A. Aortitis B. Uveitis yZ: Both A & B D. Neither 126. Aortltls can be associated with A. Ankylosing spondylitis B. Uveitis C. Syphilis � All the above Awesome Review, Inc.® Copyright 2014 Do not p hoto copy without permission Page 80 127. 50 y old man presents to the E R with complaints of abdominal pain which worsens Ith eating , mainly In the periumbilical area. It gets better when the stomach is empty. The ain has worsened over the past several weeks. He also complains of joint pains In his hands nd feet and has lost about 25 lbs in the past 3 months. Chronic leg ulcers for couple of years xam reveals diffuse tenderness on deep palpation of the abdomen, ulcers on the lower xtremlties. S(+). Purpuric rash on the lower extremities SR lOOmm/hr. Bun/Creat 45/2.0 XR� No infiltrates <. i.,l.AJ'j .rpCA;\A. ) he best test to determine dia is ��gnosis --� � A. C reactive protein B. Rheumatoid factor C. CPK � Abdominal angiogram E. Colonoscopy 128. 40 y old man presents with complaints of weakness of lefthand and abdominal pain. xam reveals power decreased in the left hand. iffuse abdominal pain, rebound (-) b 10g, ESR 96mm/hr /A� 1+ protein, RBCs > 50/hpf UB and Abdomen X ray� No obstruction or perforation ost likely diagnosis Is 'l ) A. Granulomatosis with polyangiitis (Wegener's disease) B. SLE C.j:hurg Strauss \.£( Polyarteritis nodosa Tx: Steroids + Cyclophosphamide ) 129. 35 y old Pt. presents with abdominal pain. Labs reveal renal insufficiency. epatitis Bs Ag positive. This Pt. most likely has ) ) · J<.' PAN B. TTP C . HUS ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 8 1 0.130. 24 y old woman of Italian/Jewish/Arab descent with recurrent abdominal ain every 2 months lasting 1-2 days. Pt. had appendectomy In childhood for bdominal pain. During the attacks of perlumblllcal pain which spreads all ver the abdomen, she gets high fever. Swollen knee. Power normal, o ulcers. Abdomen imaging studies normal. Father had similar symptoms during chi ldhood. -7 Fa�c....- (VLQ<A;. te.,,--� �ve.v (serositis and arthritis) Best treatment? · C...O I c...h.:v �"'e. -7 for prophylaxis Complications of F M F -7 f\ A n -' c.l..o h..r� �' ·· · -Jl-V" -., ..1.� n . · l ;r ru..rv- Causes of Amyloidosis (chronic inflammation): FMF • • Rh arthritis TB • Multiple Myeloma • Presents with proteinuria +/- hematuria -7 Renal failu>W � Biopsy-7 Congo red staining will show fibrils of apple green birefringence. First do an abdominal fat biopsy, if negative, then biopsy affected organ. 131. so y old woman presents with cougfl, SOB, hemoptysls and arthritis. asal septum Is flattened. CXR-+ multiple pulmonary nodules and one cavltary leslo FB smear and c/s negative. BUN/Creat 40/3.4 x-+ Vasculitis with necrotlzlng granulomas (thick walled). l·t: S'f:o 134..r -t:.. /A-+ RBCs >20/hpf, 1+ protein, c-ANCA (protelnase 3) (+), h factor(+) he mostlikel dla nosls Is A. Polyarteritis nodosa B. Microscopic polyarteritis angiitis ve'.' Granulomatosis with polyangiitis (Wegener's) D. Churg Strauss vasculitis Tx : Non severe -?Steroids + rtte �ot.- e >< � I< Relapse Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 82 132. The best treatment for the above Pt. is ( n.. c..s� ..rtpt•L d t<- t te,,� ) _ _ _ A. Prednisone B. Cyclosporine �Cyclophosphamide + prednisone D. Prednisone + Methotrexate 133. Above Pt. relapses 2 years later. w.t.d �� A. Restart Cyclophosphamide /Rituximab 134. A 24 y o d man presents wit ongoing sinusitis for t e past couple o months, ssoclated with cough. He was treated with amoxlclllln for 7 days. Exam reveals Temp of 00.5 F and boggy turbinates with purulent secretions . Rhonchl on auscultation. of sinuses shows total pacification and CXR shows nodular Infiltrates. NA+ rotelnase 3 antibodies (c-ANCA) + yeloperoxldase antibodies (p-ANCA) + ost likely diagnosis? ' ) ) ----) } ) � vKGranulomatosis with Polyangiitis B. Polyarteritis nodosa 135. 40 y old woman with history of Asthma has several allergies. She has no pets. She resents with shortness of breath, wheezing and also complains of weakness of left foot. She ses albuterol, Salmeterol Inhaler and Is being weaned off steroids. Exam reveals rales at left ase. Decreased power In the right foot with hypoactive reflexes. BC� Eosloophll!a (+) "Ij E N \.. XR� Right upper lobe densltv ost llkel dla nosls Is ��--... A . Granulomatosis with polyangiitis (Wegener's disease) B. Polyarteritis nodosa ..--C.Churg Strauss D. SLE A. Anti Nuclear Antibody B. Anti sDNA ,,R!.' Anti-Smith antibody or anti ds DNA titer D. Anti histone antibody Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 83 Other Labs: • ESR increased • J C 3 >, C4, C H SO decreased • Anti dsDNA increased Follow disease activity with anti dsDNA levels. Treatment: Arthritis-? ASA, NSAID-7 Hydroxychloroquine( Plaquenil®) Photosensitivity/rash-7Avoid sun/Use Sunscreen-? top. Steroid-? "'-':lc\,..i:>x :i c.�Lvv-> jl.MA.e. T hrombocytopenia-?Steroids 71VIG Hemolytic anemia-? Steroids In AA and Hispanics Nephritis-? Steroids -7 Mycophenolate mofetil Refractive lupus, not responding to Cyclophosphamide, steroids or Mycophenolate mofetil -7 Ge Ll M \..I. ,.,v;.b ( Benlysta®) 137. Pt. with SLE on steroids, still with symptoms. Match the following. _ _ _ _ _ _ _ __. A Hydroxychloroquine B. Cyclophosphamide /. Musculoskeletal symptoms A 2. Nephritis, CNS symptoms, systemic vasculitis or alveolar hemorrhage. -1 se...-ol-'>r'-"ll; ( f' 1)S Ait.;.....,_ , 'D f'/A / c. � c. .. 1'J 1 �J c..: U\.+ l>iS;J-r t.. ""-4 � '- .-4 ct:.r�4'...c (Vb � -1 ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Nb t3 �. Page 84 0138. Pt. is on Minocycline for acne or Rh arthritis for > 2yrs or Pt. is on ocainamide for >1 year for an arrhythmia or lnfliximab for Rheumatoid arthritis for 6 onths. Hydralazine for CHF for past 2 yrs or INH for PPD for the past 8 months presents wit alaise, low grade temps, arthralgias involving MCP, PIP joints, Early morning stiffness (+). �eight loss (+), irregular menses of several mths duration. ESR 65 and ANA (+) 1:320. C2, 4 hormal. All the following favor a drug induced Lupus diagnosis EXCEPT � A. Normal complement B. No psychosis or seizures C. Urine analysis shows no RBCs, casts or proteinuria D. High ANA titer �High anti ds DNA titer Q139. 24 y old with history of lupus for the past 4 years was found to have lupus anticoagulant syndrome and history of spontaneous abortions twice. she Is on cyclophosphamide and steroids. She asks you about best long term contraceptive method. What would be your recommendation? } ) A. Medroxy progesterone intramuscularly every 3 months ,..-8"." Progesterone only intrauterine device Ql'IO. A Pt. on PTU for nyperttiyroiaism presents wittl pa pal:>le purpuric lesions on ttie extremities and trunk. P-ANCA (Myeloperoxidase) (+), ESR high, Hep B s Ag negative. Biopsy of Purpura� leukocytoclastic vasculitis. Most likely diagnosis? � P T U induced vasculitis 141. A 35 y old woman was diagnosed with SLE and lupus nephritis. Pt. was treated with teroid and l.v cyclophosphamlde. About 2 yrs ago her medications were tapered off and she emalned asymptomatic and healthy. For the past month she has noted low grade fevers and rthralglas. Which of the following would best suggest she has a flare of SLE I ) A. Increased ANA titer and increased complement B. Increased ANA titer and decreased complement C. Anti Sm (+) and decreased complement � Increased Anti ds DNA and decreased complement Pt '"" (51'\, l..:> \ool c:Vr... c.M: �fl-. �A , "' � ' p��c.L..:. � 'l � 1' .r-i<KJ.I.. p� L� � 1 .- V S{�.L 142. The leaaing cause of aeatn is pt witti SLE of 10 yrs is A. Nephritis rardiovascular disease Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 85 True or False about SLE I A. Pt.s have increased risk of stroke B. Pt.s have increased risk of Myocardial infarction I c. Pt. have increased risk of DVT D. Pt.s have increased risk of recurrent spontaneous abortions 'T T T E. Pt.s have increased risk of avascular necrosis 0143. Pt. with recently diagnosed SLE, presents with complaints of decreased urination and weakness of legs. Pain in the back as well. Hyperactive reflexes(+). Exam reveals NO spinal tenderness. w.t.d MRI will show7 edema of Spinal cord c/w inflammation. w.t.d 0144. Pt. with SLE on hydroxychlorquine and Prednisone 20 mg/day presents with psychosis* . Most likely etiology? -f2omg of Steroids 7 .steN.tl. I A,.pl� < 20 mg-7 s L� Its�� (visual & tactile disturbances) (auditory hallucinations) Q145. A 20 y old woman delivers baby who has a complete heart block. The mother has a scaly papular rash. ANA(-) The woman Is likely to have A. Anti ds DNA(+) B. Anti R N P C. Anti Sm SSA(Anti Ro) ___. r"1w- � � b\.o("- , /, Matching '3 - 1. Pt. with l't trimester spontaneous abortion for the 1st time. P.. 2. Pt. with t- 3rd trimester spontaneous abortion for the 1sr time. �3. Pt. with recurrent 3rd spontaneous A. Check for Antiphospholipid antibody B. No need to check for Antiphospholipid abortion in the 1st trimester Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 86 Chart 6-2 • Systemic sclerosis: • • CREST ANA(+) Sci 70(+) Anti-topoisomerase + • Anticentromere(+) • Mi2 Anti Jo + Anti PM 1 ) } • Dermatomyositis • Polydermatomyositis Systemic Sclerosis (Scleroderma) (Anti Sci 70 +) Skin-7 diffuse fibrous thickening: Sclerodactyly Tight face and small mouth Abnormal nail fold capillaries Joints-? Symmetric arthritis, MCP Tendon friction rub(+) --1 P U \/ Y-\ T.l. NSft'\ TD - Raynauds phenomenon -1 Lungs-7 I ) *� Interstitial pneumonitis, Interstitial fibrosis-? CT Pulmonary HTN Renal-? Renal crisis(HTN, proteinuria, edema): Treat with-7 irrespective of serum creatinine level what precipitates it?-7 ste ,... vi.A- s C.. G./'\J A C.t. 7- Dysmotility Er'j"ft;,.o� \..<\-<- 1' ..V v •-t £3 1 2 / Fo PP'T GERD Wide mouth diverticula � / (V\.e i".-o ,.,.:.., el.a.-z.. Jt.e 1 Bacterial overgrowth syndrome c.;. pvO ... Heart-7 Restrictive pericardia! disease Gl-7 146. Pt. can present with whic of the following pu monary findings Y,lnterstitial pneumonitis(fibrosing alveolitis) B. Alveolar pneumonitis C. Lobular pneumonitis D. Obstructive PFTs Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 87 CREST (Anti centromere +) C7 R7 E7 S7 T7 Calcinosis cutis (calcification of soft tissue) -t Raynauds phenomenon Esophageal dysmotility Sclerodactyly Telangiectasias w� Pi./ spkt sc.Wf\.rt. ht J� -- G-c.h...o f>r,..,� , ("uYo cer.t...o � Pulmonary HTN more common than Scleroderma. Can be present even without X ray changes. 147. A 35 y old gardener presents with complaints of painful fingers during cold weather. Fingers turn white when exposed to cold. Next step in management-+ Wear warm gloves. If loves don't work, then which is the best medication to prescribe? 148. How will you recognize a rheumatologlcal (secondary vs primary) disease in a Pt. with aynaud's phenomenon? A. Bilateral hand involvement � Abnormal nail fold capillaries Age > 40 Abnormal nail fold capil laries • Digital ulcerations ( ? ..: R c.. y Ac.A.A.J.. ) All the above suggest Secondary Raynauds phenomenon. • • 149. 45 y old played basket ball for 4 hours at family reunion and now presents with welling of the arms and legs sparing the hands and feet. xam reveals a orange peel llke quality of skin. CBC-+Eosinophlls (+) Dx : 7 f: o .c..""" (.l �;c.. fwiuw HLA DR 3 +, Women>Men Proximal muscle weakness : can't get up from a chair, can't get up from a squatting position, can't comb hair, mechanic's hands(scaly dry, darkened, cracked horizontal lines on the pal mar area, finger pads and lateral aspect.) Abnormal CPK > lOx normal, Increased ANA titers. Biopsy7 myonecrosis with cellular infiltrate Conditions mimicking polymyositis • Colchicine polymyositis • Inclusion body myositis Polymyositis + Skin changes= Dermatomyositis (Anti Mi2) Awesome Review, Inc.* Copyright 2014 Do not photocopy without permission Page 88 Q150. A 66 y old woman presents with complains of difficulty getting up from a chair and a ifficulty combing her hair. Exam reveals rash on her cheeks, forehead and upper eyelids. ifhis Pt. is at risk for developing which disorder A. Amyotrophic lateral sclerosis B. Multiple sclerosis Malignancy: Ovary, Breast or GI. y ) 151. What is more specific for Oermatomyositis? A. Heliotropic rash � Gottrons papules 152. What predicts a poor outcome in Dermatomyositls? pin" ov.f c.Df'Y'VI.. R. MSf: ) -1 - 1'- A-� 1' Lv Chart 7-2 \ ) ) ) ) 7 ) ) Dermatomyositis • • • Heliotrope rash Gottron's papules weakness w.t.d next? -7 c P l<.. • I F CPK elevated. W.t.d? -7 steNcL rvot (Y\L,'f� (:;, � x� f-c.. ) ) Awesome Review, Inc.® Copyright 201 4 Do not photocopy without permission Page 89 p153. A 55 y old woman presents with weakness. Past history is significant for p olymyositis. Labs reveals a CPK of 950 u/I t. is started on prednisone 50 mg/day, she feels better and the CPK decreases to less than 190 u/I. Three months later, CPK level is ithin normal limits, but the Pt. complaints of proximal weakness again. p.154. 65 y old man with progressive weakness of legs, arms, forearms, wrists & fingers. l distal>proximal ). CPK high (<10>< normal). Not responding to steroids ' Methotrexate dded, CPK still high. Biopsy reveals endomyslal Inflammation and basophilic rimmed vacuoles. w.t.d 0.155. Pt. with gouty tophus on colchicine and allopurinol. Hx of Asthma on inhaled steroids rs well, presents with complains of weakness while trying to get up from chair. lower Ext. r.roximal muscle weakness (+). DTRs dee. CPK 850. Muscle biopsy reveals vacuoles �no Inflammation). Most likely Ox A. Polymyositis B. Inclusion body myositis C. Colchicine )Y.'Steroid myopathy 156. 35 'J>,t. c,och..: � A y old Intubated Asthmatic 4 days later on steroids and albuterol, difficulty xtubating. CPK Most likely diagnosis? 925. �· eroid induced myopathy J illness myopathy /'critical · Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 90 Matching Match the autoantibodies B ,____ A. histone L.8__2 . Drug induced SLE B. ds DNA, S m ,_f__3. Subacute cutaneous SLE C. SSA (Ro) 1 . SLE (C; 4. Scleroderma ) ) c:Urt�L D. centromere '"O S . CREST E. Sci 70 c: fi. MCTD F. RNP J:>-_7. Poly/Dermatomyositis G. Jo, Mi2 �8. Sjogren's syndrome H. SSA (Ro)/ SSB(La) J 9. Wegener's ._1_10. Microscopic polyarteritis angiitis R Tf.\ '1 I. P-ANCA (Myeloperoxidase) J. c-ANCA (proteinase 3) ) \ ) Awesome Review, Inc."' Copyright 2014 Do not photocopy without permission Page 9 1 Null Hypothesis It means that the result of the study was random or chance and not by design. How do you know if a clinical trial result is fluke (random or chance) or real? -7 By checking the 'P' value Other definitions for P value; • It measures the probability that the results of study are due to chance alone. • It determines if the results of the study can be explained by chance. P-value expresses statistical significance. P value of <0.05, which means there is a less than 5% chance, that the study results are fluke. If the value is <0.01, then only 1% chance that the study results are fluke. A. 0.06 B. 0.51 c. 0.99 vfi. 0.01 2. Wfiat is the purpose of Randomization in Clinlcal Trials ? -7 • To �c.Vt'.- el�<;,( cJvstYibv.. h' c;..,.,. �vfS � p��t <>J UJ"\.(Y\.�� l/c....-iabl.<../f d-4c.t...,,J tV'I bot. T� 1. c.o"t...fl.. bi�. Intent to Treat analysis: Ignore non compliance or anything that may happen after randomization. Meta-analysis Study of many independent studies concerned with the same topic. Or 'Collection of methods for combining quantitative information from different sources and giving a summary statistic'. Type I error: Investigator declares benefit, when there is none. Fc).,R.. Ci) .- � c. i .s ;..,., pt avv wc.-:Je....�l'v Or7 Type II error: • Investigator declares no difference between outcomes of 2 study groups, when there is a difference. This false error is called Beta. • Ex: Drug X is 50% effective & Drug Y is 30% effective. If Beta is 75%, this means that effectiveness of Drug X by 20% over Drug Y is not being appreciated 75% of the time in the study. \ \ ' Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 198 , Matching What is the most important parameter In Interpreting the results of a 8 A. Type I error 1. Negative Randomized Clinical Trial - A 2. Positive Randomized Clinical Trial B. Type II error - Confidence Interval: • It is the interval which is likely to include the po pulation mean with certain level of confidence. • 95% confidence interval is most commonly used, which means, chances are 95 in 100 for the true mean to fall in that interval. First Order kinetics: • The rate at which a drug is cleared independent of the drug concentration. 3. When is the best time to check blood level of a drug for a first order drug no loading dose) prior to changing dosage of the drug? -7 After ) 3- S Y-i. Lf � 4. Which of the following would be most helpful to rule out pancreatitis? ��-- I Sensitivity Specificity 85% 96% 96% 85% A. Lipase ) VY.' Trypsinogen Best test to diagnose= Specificity 1' PP v 1' N'f' ./ Best test to rule out = Sensitivity Population = True positives + False positives+ False negatives+ True negative {TP + FP + FN +TN) Prevalence = True positive + False negative (TP + FN) ) Sensitivity = Sensitivity tells how many have the disease = True positives True positives + False negatives (TP/TP+FN) Specificity= Specificity tells how many don't have the disease = True negatives True negatives + False positives ) (TN/TN+FP) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Pag e 199 PPV = The chances when you say disease(+) they are truly disease(+) = True positives True positives + False positives (TP/TP+FP) NPV The chances when you say no disease there is really no disease = True negatives True negatives + False negatives (TN/TN+FN) The likelihood ratio represents a measure of the odds of having a disease relative to the prior probability of the disease. The estimate is independent of the disease prevalence. OR The Likelihood Ratio(LR) is the likelihood that a given test result would be expected in a Pt. with the target disorder compared to the likelihood that that same result would be expected in a Pt. without the target disorder OR provides a direct estimate of how much a test result will change the odds of having a disease. A positive likelihood ratio is calculated by dividing sensitivity by 1 minus specificity =(sensitivity/(1-specificity). Chart 1-5 • Population= TP + FP + FN + TN = • Prevalence = TP + FN • Sensitivity= TP/TP+FN = 80/80+20 • Sensitivity tells how many have the diseas • Specificity= TN/TN+FP • Specificity tells ho.w many don't have the disease • PPV =The chances when you say disease(+) they are truly disease(+) = TP/TP+FP � ::: G bf, ( Tf )(A) ' �"0/�ottio f'Of. • � �l· � �b�"° -:: l 1f.7. � M'J) Lio Lc.b t� ( r: N) (C J / �---NPV I '1» • . /00 - s:<A. � �.r. NPV =The chances when you say no disease there is really no disease = TN/TN+FN �c.;i"fO "' Gf 11· Likelihood Ratio= provides a direct estimate of how much a test result a disease will I o-o - f <lo _ Jpt<,.·J; c..::, <j 6 :: 4 j. LR = sensitivity/(1-specificity) = � )/1-(0.96) = � / 100-96 = .J::l... /4 = Vo Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 200 • The prevalence of prostate carcinoma in the community is 10%. PSA has sensitivity of 5% & specificity of 70%. What is the positive predictive value and negative predictive value? Chart 2-5 pPV .,,,.� Population • Prevalence = 10% Ftv- 2rj. • ,30 TN loo 'f<�J;<.J qoo / Tof"' '[, LY'{ = tvtN'I" C F P J -=> :J "A --- tJPI/ =0.21 x 100 = 75 = 21% Specificity = (TN/TN+FP) = 70% Negative predictive value= TN/ TN+FN TN = ....3£..._ x(TN + FP) = 25 FN i =75/345 = = 70% x 900 ) 'l 1-0 =75/ 75+270 = 75% x 100 • -;is I O<JC) Post predictive value = TP/TP+FP TP = 75% x (TP + FN) ) TP c{ Sensitivity = (TP/TP+FN) = 75% \ I l f'a'J"' 2 e,,,...,, • , FP po p....V-1"1'"" "' A\ "''"r 630/630+25 = 630/655 630 = 0.96 x 100 I = 96% Likelihood Ratio: Sen/1-Specificity ) ) = 75/ 100-70 = 6. What Is the relationship between PPV and prevalence } A. PPV decreases if prevalence increases vB(PPV decreases if prevalence decreases ) ) 75/30 = 2.5 7. What Is the relationshl ) between PPV and revalence A. PPV decreases if prevalence increases y. PPV increases if prevalence increases ) ) Matching If prevalence is constant which of the following will give you c 1. Maximum NPV A. sensitivity 60% & specificity 60% __!__ 2. Maximum PPV B . sensitivity 70% & specificity 90% - C. sensitivity 90% & specificity 70% ) ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 201 likelihood ratio is 7? 8. What does it mean if the ��----' A. the sensitivity is 7% B. the PPV i s 7% JC, the post test probability is 7 times that of the pretest probabilit y. 9. An asymptomatic man has a 25% probability of CAD. Considering that a tress test has a sensitivity of 70% and specificity of 90%, if the stress est were to be negative. What is the chance that this was false negative. A. 1% B. 15% c. 20% vl1. 30% Chart 3-5 NoDM OM # Glucose fiiifil®I c 1 D Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 202 • The Relative Risk Rate (RRR) (or risk ratio) equals the incidence in exposed individuals divided by the incidence in unexposed individuals. • Attributable Risk Rate (ARR) reflects the additional risk when exposed to a risk factor. • Odds Ratio: compare a population exposed to a risk developing a disease vs population not exposed to the risk and developing the same disease. or Odds ratio i s a summary statistic that measures association between a cause and condition. Chart 4-5 Lung Ca Smokers 283 A 9717 B Non Smokers 64 9936 D c Incidence of Lung Ca in smokers ) \ ' = Incidence of Lung Ca in Non ) smokers ) Relative Risk Ratio = ) = (RRR) (Attributable Risk Rate) Relative Risk increase 10000 I A/A+B C/C+D A/A+B = 283/283 + 9717 = 283/10000 0.028 = = 64/64 + 9936 = 64/10000 = 0.028/0.006 = 0.006 - = 4.66 - -- = A/A+B- C/C+D = ALA+B- CLC+D C/C+D = 0.028- 0.006 = 0.022 = 3.66 OR 1- RRR Chart 5-5 ) - - Smokers ) 11 - ) ) 10000 C/C+D ) ) l .. Absolute risk increase ) Total No Lung Ca - - -- - Non Smokers Lung Ca No Lung Ca Total 283 A 9717 B 10000 64 9936 D 10000 c Odds of Lung cancer for smokers Odds of Lung cancer for ) non-smokers ) Odds ratio = J I A/B = 283/9717 - 0.039 - = - = C/D =AD/BC = 64/9936 = 0.039/0.006 = 6.5 = 0.006 ) . ) ) Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 203 Chart 6-5 I I /'-->. � Cardiovascular_ __ .... .., ____ ,,-_,, death _ D I I I I I I I I I I I I I I -<>� .-fk BC61. J... "'""':! &Atc..o"""- T....._""""'1. L Cancer death 1k o 0.6 0.7 0.8 0.9 1.0 1.1 Drug better(=-- 1.2 . 1.3 Placebo better Chart 7-5 I -5 -4 -3 -2 1.0 2 I I 3 4 Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 204 . Pt. witn metastatic pancreatic cancer. A clinical trial s owe a new decreased mortality rate of -1.0. Confidence interval Is-5.0 to + 4.0. What will you advise your Pt.? 7 The results of the study are inconclusive Qll. HIV pt has genital herpes. Risk for fetus to get Herpes is 7% witli vaginal aelivery &. 2% with C-section delivery. How many C-section deliveries do you have to do to save one baby rom acauiring HerP-es? 7 Babies saved by C-section more than Vaginal delivery= 7%-2%= 5% So 5 babies saved for every hundred (-sections. ) q12. On using Cf rug X mortality rate is 6% bn using drug Y mortality rate is 3%. How many Pts will you prescribe drugY to save one life? ---�� --- ) ) ) ) Mortality decreases= 6%-3%=3% i.e 3 lives saved per 100 13. In a clinical trial, what would be the best desired outcome Numbers needed to treat ) ) Numbers needed to harm vK. 3 100 B. 100 3 ) ) ) ) j Awesome Review, Inc.® Copyright 2014 Do not photocopy without permission Page 205

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