TEST 35

QId: 2380
Osteoporosis risk factors
-elderly >60yo asx.... routine preventive exam.
Q = which screening test is appropriate?
A = Dual energy Xray absorptiometry

-------
wrong:
*Colonoscopy should start at age 50. repeat q10rs . (this pt had no polyps & doesn't need
repeat colonoscopy for another 6 yrs)
Medicine - Rheumatology/Orthopedics & Sports

QId: 2740
Eplerenone - improves long term survival in ppl w/LV systolic dysfunction

-beta blockers
-ACEi
-Angiotensin II receptor blockers (ARBs)
-mineralocorticoid receptor antagonists (Eplerenone and spironolactone)

-------
Medicine - Cardiovascular System

QId: 3165
Ankylosing Spondylitis

case: 24yo woman gradual low back pain*** and buttock pain. severe in morning and fades as
day progresses. Relieved with over the counter analgesics.
a/w STIFFness, no fever or GI sx.
limited ROM lumbar spine.
Q = risk of developing?
A = Anterior Uveitis (intense pain & photophobia in one eye)

*Inflammatory back pain

(gradual onset <40yo); sx >3months; relieved with exercise but no rest; nocturnal pain

exam: arthritis (sacroiliitis); ?chest expansion & spine mobility; enthesitis (tenderness at tendon
insertion sites)
-dactylitis (swelling of fingers & toes); uveitis

complications: osteoporosis/vertebral fractures, aortic regurgitation, cauda equina

Lab: elevated ESR & CRP

imaging: XR of sacroiliac joints

Pt has chronic back pain & stiffness that improves w/activity (stretching), warm showers, NSAID
= inflammatory back pain.

1
------
*Episcleritis = inflamed at white of eye, w/o involvement of uveal tract.
Medicine - Rheumatology/Orthopedics & Sports

QId: 3266
Rubella virus (german measles) (prodrome: mild fever, LN large ex: posterior auricular &
suboccipital lymphadenopathymalaise, blanching, erythematous maculopapular rash erupts on
face and spreads caudal w/in 24 hrs. spares palms/soles)*****
teens/females - joint arthritis

presentation:
congenital:
-sensorineural hearing loss
-cataracts
-patent ductus arteriosus

chidren
-fever
-cephalocaudal spread of maculopapular rash

teen/adults
-same as children + arthralgias/arthritis

dx = serology
prevention - live attenuated rubella vaccine
Pediatrics - Infectious Diseases

QId: 4203
Lacunar Stroke @(posterolateral thalamus) dt atherothrombotic occlusion of small, penetrating
branches of posterior cerebral artery

Thalamus stroke in this area ss: contralateral sensory loss involves all sensory modalities (pure
sensory stroke)

Several weeks to months LATER after the stroke, sensory deficits can improve; however some
pt's = get thalamic pain syndrome***
burning pain over affected area & exacerbated by light touch

------wrong
*Damage to itnernal capsule occur w/lacunar infarcts
(contralateral pure motor or combined sensiorimotor deficit)

*Lateral medulla infarction dt posterior inferior cereellar artery occlusion.

pt develops loss of pain/temperature sense over ipsilateral face and contralateral body

*Midbrain strokes ss: ipsilateral oculomotor nerve palsy, ataxia (damage superior cerebellar
peduncle), contralateral hemiparesis (cerebral peduncle)

*Embolic/thrombotic occlusion of MCA, ACA

2
Medicine - Nervous System

QId: 4247
Management of DKA & HHS

23yoF msk weakness, vomiting, abdominal pain.

pt also experience increased frequency of urination, leg cramps, blurry vision.
Oral mucosa dry.
Lab K 5.4
Q = which is most likely cause of increased potassium leel in this pt?
A = Extracellular shift (dt plasma tonicity increased)

or loss of insuline-dependent potassium uptake across cell membranes

-------
tx: IVF high flow 0.9% nml saline initially recommended; add dextrose 5% when glucose
<200mg

Insulin
-initial continuous IV insulin infusion then switch to SQ basal bolus insulin if able to eat

K: add IV K if lower than 5.2; hold insulin if K<3.3

Medicine - Endocrine, Diabetes & Metabolism

QId: 4271
Guillain-Barre syndrome (ascending weakness and areflexia)
test = SPIROMETRY!!!

moa: immune mediated demyelinating polyneuropathy

-preceding GI (campylobacter) or resp infxn

ss: paresthesia, neuropathic pain

-symmetric, ascending weakness
-decr/absent deep-tendon reflexes
-autonomic dysfunction (arrhythmia, ileus)
-resp compromise

dx = clinical
-CSF: ?protein, nml WBC

mgmt: resp infxn; IV immunoglobulin or plasmapheresis

------wrong
*elective intubation: yes if resp distress (tachypnea, accessory msk use) dysautonomia (HR &
BP unstable0 or wide pulse pressure = then intubate.

*
Pediatrics - Nervous System

3
QId: 4374
Androgen Abuse (competitive athletes)

types of androgens:
-exogenous (testosterone replacement therapy)
-synthetic (stanozolol, nandrolone)
-androgen precursors (DHEA)

side effects/ss:
reproductive:
-Men: decr testicle function & sperm production, gynecomastia
-women: acne, hirsute, deep voice, menses irregularities

-heart: LV hypertrophy, possible ?HDL & ?LDL

-psychiatric: aggressive behavior (men); mood disturbances
-hematologic: polycythemia; possible hypercoagulability

---------
Medicine - Hematology & Oncology

QId: 4437
Autoimmune hemolytic anemia

18yoAA
worsening fatigue and exertional dyspnea
had URI treated w/amoxi 2 wks ago.
SPLEEN enlarged, icterus
Hb 7.8
retic 10%
Q = additional findings likely seen in pt?
A =Positive Direct Coombs Test

-----wrong:
*Increased hemoglobin S
(Sickle cell will have normocytic hemolytic anemia with ?sickle cell & ?HbS)...... sickle cell
doesn't have splenomegly***
Medicine - Hematology & Oncology

QId: 4445
Recent URI, dyspnea, elevated jugular venous pressure, clear lungs fields, increased cardiac
silhouette on CXR.

-early cardiac tamponade dt LARGE pericardial effusion

(mc idiopathic likely from VIRAL illness)

case: 42yoF fatigue, sob over last 2 weeks**. had Recent URI.
BP 98/55; P105, neck JVD***
Q = Additional finding in this pt?
A = Nonpalpable point of maximal impulse

4
-----wrong:
*audible 4th heart sound - if VIRAL MYOCARDITIS then similar story RUI, fatigue, dyspnea,
elevated JVP & cardiomegaly on imaging...+ audible S3**** (not S4) + lung vessel congestion
seen

(S4 = LV noncompliant stiff in htn heart dz, aortic stenosis, Hypertrophic cardiomyopathy)
Medicine - Cardiovascular System

QId: 4477
Influenza vaccine, pap smear, & Tdap/Td vaccine

*woman to be screen for cervical cancer with a pap smear every 3 yrs at age 21-65 (or with pap
smear and HPV testing ever 5 yrs at age 30-65)

Single dose of Tdap (tetanus toxoid, reduced diptheria toxoid, acellular pertussis) recommended
at age 11, with Td (tetanus and diphtheria toxoids) q10yrs therafter
Medicine - General Principles

QId: 4657
Ischemic Thrombotic strokes

-hemiparesis
-difficulty speaking, numbness
-facial droop
noncontrast CT head shoes no abnormalities
Q = which therapies most likely to reverse this patient's acute neurologic deficits?
A = Intravenous Alteplase
(thrombolytic) within 4.5hrs of sx onset

-----------wrong
*Treat hyperglycemia (if glucose >180) w/insulin in ppl w/ischemic stroke - hyperglycemia will
augment brain injury....but 1st thrombolytic to reestablish circulation!!

*Avoid heparin in early phase ischemic stroke...bc risk bleeding

*rivaroxaban (10a inhibitor) for LONG-term treatment of afib....to reduce risk of embolic stroke
Medicine - Nervous System

QId: 4775
Intrauterine Fetal Demise

fetal death at >20weeks.

pt ss: decreased or absent fetal movement
fetal doppler U/S fails to detect fetal HR.

IF doppler US doesn't detect fetal HR in pt w/decreased or absent fetal movement = think fetal
demise
(US needed to confirm diagnosis)

5
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium

QId: 11897
Neuroleptic Malignant syndrome

33yoM psych pt worsening depression

failed to respond to phenelzine, discontinued 3 wks prior.
Citalopram & risperidone started.
2 days later**** develops confustion and high fever 103F
Q = likely provisional diagnosis?
A = Neuroleptic malignant syndrome

ss: fever >104F; confusion, muscle rigidty; autonomic instability (abnl vital signs, sweating)

tx = stop antipsychotics or restart dopamine agents; supportive care (hydration, cooling); ICU
Dantrolene or bromcoriptine if refractory
------
Psychiatry - Psychiatric/Behavioral & Substance Abuse

QId: 11980
Felty syndrome
Autoimmune disorder

*42yoF h/o intermittent skin lesions

she had Ulcerating lesions on lower limbs a/w inguinal adenopathy*** low fevers.

frequent takes ibuprofen for joint pain.

nml bowel sounds & palpable spleen tip on inspiration
*swelling and tenderness of hand joints are BILATERAL

skin = healed lesions on lower legs.

wbc = 1800/mm
Nphils
Q = which is most likely cause of pt's condition?
A = Autoimmune disorder

Felty sd: inflamed arthritis, splenomegaly spleen tip, neutropenia***** (TRIAD)

-mc in ppl w/rheumatoid arthritis
Medicine - Rheumatology/Orthopedics & Sports

QId: 12180
TIA sudden speech arrest; arm weakness resolved after 30mins along with unremarkable
noncontrast CT of head.
= TIA @ MCA

52yoF
speech arrest and right arm weakness; sudden sx at breakfast but resolved after about 30mins.
Pt has h/o relapsing remitting multiple sclerosis - blurry vision in lft eye.
***SMOKING 40yrs; bp 170/96
BM 35**

6
Non contrast CT head unremarkable
Q = next step treat this pt?
A = Initiate aspirin and statin therapy

Initiate aspirin & statin therapy

-----wrong:
*neuro sx dt demyelinating plaque from MS usually lasts for days to weeks*** (vs TIA <24hrs: rf:
htn, hyperlipidemia, tobacco use)
Medicine - Nervous System

QId: 12419
CHYLOTHORAX from lymph flow through THORACIC DUCT disruption ? leaks chyle (lymph
fluid in pleural cavity) (elevated TG)

18month old ICU after heart surgery.

Post op day 4 develops tachypnea and increased oxygen requirement.
CXR: pleural fluid in right hemithorax

Pleural fluid obtained by thoracocentesis

pH 7.45
TG 724mg****
Q = Mechanism causes pt's pleural effusion?
A = Disruption of thoracic duct

exudative effusions
Pleural fluid analysis
Pediatrics - Pulmonary & Critical Care

QId: 12664
Allergic Conjunctivitis
6yoM 3 weeks ITCHY, red eyes***
clear eye drainage**
sister has 2 cats/hamster. sister had rhinorrhea, cough, pharyngitis.
exam: diffuse conjunctiva injection in both eyes and mild eyelid edema
Q = etiology of pt's condition?
A = IgE -mediated hypersensitivity
tx = topical antihistamine
-------
Viral (adenovirus)
UL or BL
duration 1-2weeks
DC: watery/mucoid
a/w: viral prodrome

Bacterial (strep pna; Hib)

UL or BL
duration 1-2weeks
DC: purulent

7
a/w continuous eye DC (alot + eye crusting)

Allergic
always BL
<30mins
watery
eye ITCHY pruritus

Dacryostenosis - obstructed lacrimal gland MC in baby (crusting eyelash&tearing) doesn't itch or

have eyelid edema
Pediatrics - Ophthalmology