U23

Diagnostic test for 60 yo M developed SOB and orthopnea 8 weeks after CABG. SPO2 96% while sitting and 90% while spine. JVP 6cmH2O. CXR raised left hemidiaphragm. Spirometry FVC 70% predicted in upright position and 59% in supine position 
->
Fluoroscopic “sniff test”
Unilateral diaphragmatic paralysis likely due to phrenic nerve injury during cardiac surgery 
Diagnosis is confirmed by asking patients to sniff forcefully under fluroscopy

Management of renal cyst. US shows a 2.4cm renal cyst that is round, has smooth walls, is anechoic and demonstrates strong posterior wall enhancement
->
Reassurance and observation 
Posterior wall enhancement (a technical artifact seen on US that indicates US wave transmission beyond the cyst. It doesn’t equate with contrast enhancement on CT/MRI)

Management of 28 yo M with elevated BP. K 3.1. plasma renin activity undetectable. Plasma aldosterone concentration 35 (normal 7-30). CT abdomen normal adrenal grands
->
Adrenal venous sampling 
Plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA) ratio > 20 suggests primary hyperaldosteronism. Once PH is confirmed, adrenal imaging to differentiate bilateral adrenal hyperplasia (50-60%) from aldosterone-producing adrenal adenoma. However, CT is low sensitivity. If CT doesn’t reveal a discrete unilateral mass, adrenal venous sampling should be obtained 

Where does renin come from
->
Released by the juxtaglomerular cells in the kidney 

Management of 75 yo M c/o “noise in his head”.  High-pitched ringing which is always present. The sound doesn’t pulsate.
->
Audiometric testing
Non-pulsatile tinnitus: usually dysfunction within the auditory system
Pulsatile tinnitus: significant underlying vascular pathology -> ENT consult and brain imaging 

Management of 20 yo M had head injury during football. Had LOC. HA/mild confusion, dizziness for several days after the injury, which resolved. Comprehensive neurological exam and computerized cognitive test are unremarkable.
->
Graduated return to play protocol
Evaluation for recurrence of symptoms while performing stepwise increase in physical activity 

Management of 29 yo F c/o amenorrhea. No menstrual period since uncomplicated vaginal delivery 13 months ago. Stopped breastfeeding 7 months ago. Still has some milky discharge from both breasts. FSH 4.2 LH 3.1 prolactin 209 TSH 5.5
->
MRI of the head
Prolactin level increases during pregnancy and normalize within 1-2 months after delivery even with continued breastfeeding. Significantly elevated prolactin (>200) level usually indicates a prolactinoma

Management of 80 yo F developed lethargy. Has had diarrhea for a few days. BP 90/45 HR 115 Na 158 Cl 109 Cre 1.7 
->
Isotonic fluid first
Hypovolemic hypernatremia: correction of effective circulating volume deficit with isotonic fluid should be done before the replacement of water deficit.

Dx and diagnostic test of 18 yo F c/o headache for 3 months. HA occurs almost daily. Holo-cranial, pulsatile. Especially bothersome at night. No photophobia, N,V, fever. Neurological exam and imaging study negative
->
Idiopathic intracranial hypertension / lumbar puncture
HAs are chronic, holo-cranial and pulsatile in nature

Dx of 52 yo s/p liver transplant developed fever, cough, and HA. Left hand weakness and difficulty grasping objects. CXR patchy alveolar opacities in the right upper lobe and a 3-cm abscess. Head CT shows an abscess
->
Nocardiosis 
Usually lung infection and brain abscess 

Dx and diagnostic test of 60 yo M p/w weakness, and weight loss. Nontender mass palpable in the left upper abdominal quadrant. Pancytopenia. Peripheral smear shows WBC with surface projections
->
Hairy cell leukemia / peripheral blood flow cytometry
Pancytopenia and splenomegaly 

When to give aspirin and lovenox sc as prophylaxis in the setting of stroke with tPA administration 
->
Both ASA and lovenox sc after 24 hours 

Management of 67 yo M hospitalized for CHF. On 6th day, PLT dropped from 210000 on admission to 62000. Sc unfractionated heparin was discontinued for DVT prophylaxis.
->
Start Argatroban (or fondaparinux)
Type 2 heparin-induced thrombocytopenia. Patient should receive an alternate rapidly acting anticoagulant as at the high risk of thrombosis 

Screening for hyperlipidemia 
->
Male > 35 yo and female > 45
Or younger with risk factors (smoking, family history, ..)

Dx of intensely pruritic, erythematous papules, vesicles, and bullae on the extensor surface of the elbows, knees and buttocks
->
Dermatitis herpetiformis

Wernicke encephalopathy caused by what conditions other than alcohol absue
->
Anorexia nervosa, hyperemesis gravidarum

Management of 76 yo with T2DM developed right ear pain with some discharge. Not responded to oral ciprofloxacin. T 98.0 WBC 9800. ESR 22. CT scan of the base of the skull reveals areas of bony erosion involving the right auditory canal. Cx obtained
->
Biopsy of the lesion 
Ddx: malignant otitis externa and squamous cell cancer
MOE: invasive pseudomonal infection in older patients with DM. Severe pain and purulent discharge. Progress to osteomyelitis of the skull. Respond to oral fluoroquinolone
SSC: moderate to severe pain. Elevated ESR. 
Not respond to Tx form MOE and indicated to exclude SCC

Management of 35 yo F on warfarin for MS and Afib found pregnant
->
Stop warfarin and start sc low-molecular-weight heparin
Warfarin a/w teratogenicity. Low-dose warfarin (<5) appears to provide a higher safety margin

Can HPV vaccine be given for pt with CD4<200
->
Yes

Dx of 46 yo F with recurrent compression fractures. Amenorrhea.
->
Cushing syndrome

Cause organism of struvite stones
->
Klebsiella and proteus
-> elevated UA pH 

Dx and management of 26 yo M. Threatening suicide after hearing his girlfriend will leave him. History of mood swings. Rages attacks when feeling that people are unsupportive. H/o self-harming behavior
->
Borderline personality disorder / psychotherapy 
No medication approved by FDA

Management of 52 yo F, h/o rheumatoid arthritis, smoker, BMI 18, on methotrexate, became menopausal at 51.
->
Bone mineral density
DXA before 65 yo for higher-risk women (RA, smoking, low BMI)

Dx of 57 yo M with T2DM c/o chronic watery diarrhea. + nocturnal symptoms and fecal incontinence
->
Small bowel bacterial overgrowth 
Due to gastrointestinal hypomotility in long-standing DM
Nocturnal diarrhea rule out IBS

Dx of 52 yo M developed well-defined plaques covering by thick, silvery scales on scalp, near ear and gluteal cleft. Mildly pruritic. 
->
Plaque psoriasis 

Characteristic CSF finding in Guillain-Barre syndrome
->
Elevated protein and normal WBC

Management of 27 yo F 29 weeks gestation developed pyelonephritis. T 102. HR 96 BP 124/83. Appears uncomfortable, but not in acute distress
->
Admission and iv ceftriaxone
Pyelonephritis during pregnancy causes an increased risk for complications (ARDS, pulmonary edema). Particularly in the later stages of pregnancy. Guideline recommends inpatient management with IV ABX until afebrile and improvement for 24-48h

Blood test predicting worse outcome in rheumatoid arthritis 
->
High titers of anti-CCP Ab and positive rheumatoid factor

Dx of 20 yo M with cystic fibrosis developed chronic cough. Wheezing. WBC 12000 eosinophil 8% ESR 67 immunoglobulin E 1000. CXR bilateral patchy upper-lobe infiltrates 
->
Allergic bronchopulmonary aspergillosis 
Occurs in asthma or cystic fibrosis patients. Wide spectrum of radiographic changes (fleeting pneumonia, central bronchiectasis, mucus-filled bronchi). Dx: serum IgE > 417 and serum Ab against aspergillosis 

Severe MS or MR patients need prophylactic ABX prior to dental procedure?
->
No

Severe MR or MS patient without AF need anticoagulant?
->
MS need
MR doesn’t need

What type of intervention recommended for severe MR when indicated
->
Mitral valve Repair

Who need prophylactic ABX prior to dental procedure
->
Mechanical valve or h/o endocarditis

Dx of 38 yo M states his skin is being eaten away by flesh-eating bacteria. He has repeatedly washed the area he insisted is infected.
->
Delusional disorder

Dx of 46 yo M c/o recurrent abdominal pain. Drinks 8-10 beers on the weekends and frequently throughout the week. Abdominal x-ray shows focal calcifications anterior to the spine over the epigastric area. EGD shows normal esophagus, gastric varices in the fundus of the stomach and a normal duodenum
->
Splenic vein thrombosis (chronic pancreatitis)
Chronic pancreatic inflammation can lead to thrombosis 
Splenic vein thrombosis leads to gastric varices near the gastric fundus only

Dx of 55 yo M recent induction chemotherapy for AML developed fever, abdominal pain, and bloody diarrhea. WBC 800 neutrophil 25%. PLT 7000 CT marked wall thickening, intramural edema, and pneumatosis of the cecum and ascending colon. No free air or fluid collection 
->
Neutropenic enterocolitis 
life-threatening necrotizing infection 

Dx of pain when first stepping out of bed
->
Plantar fasciitis 

Likely timing of thrombocytopenia when immune-mediated heparin induced thrombocytopenia 
->
5-10 days or < 1 day if prior heparin exposure within 30 days
(PLT drop > 50% -> 2 points)

Complication of patent ductus arteriosus
->
Infective endarteritis 
Progress to pulmonary hypertension and Eisenmenger syndrome (right-to-left shunt)

Most common cause of hypercalcemia 
->
Primary Hyperparathyroidism (parathyroid adenoma)

Upper limit of daily vitamin D3 intake
->
4000 units
Ingestion of very high doses of vitamin D is required for the development of toxicity 

What is clue cell?
->
Vaginal epithelial cell covered with bacteria, indicating bacterial vaginosis

Management of 75 yo F with osteoporosis receiving risedronate for 2 years. Compression Fx twice during the Tx. DXA T-score decreased from -2.8 to 3.6
->
Stop risedronate and start teriparatide
Recombinant parathyroid hormone. Useful for Pt who fail first-line Tx. Prescribed for 2 years, then bisphosphonate is resumd

Management of newly diagnosed hyperparathyroidism, no CKD, kidney stone, compression fracture or osteoporosis 
->
24-hour urinary calcium measurement 
Excessive urinary Ca loss (> 400mg/day) -> elevated risk of complication -> indication for parathyroidectomy

Management when physician potentially refers patients to a medical facility where the physician is investing
->
There is a conflict of interest and the physician’s investment should be disclosed to patients

Management of 45 yo M with bipolar disorder developed low-amplitude resting tremor and muscle stiffness 2 months after starting risperidone
->
Change risperidone to quetiapine
Drug-induced Parkinsonism 
Some Atypical antipsychotics (risperidone) cause DIP

What anti-hypertensive med could contribute to following condition? 
66 yo F with bipolar disorder on lithium developed agitation, slurred speech, muscle jerks, after starting an anti-hypertensive medication started
->
ACE inhibitor (or diuretic, verapamil)
Lithium toxicity 
Lithium is cleared by the kidneys. Medications that reduce glomerular filtration can precipitate a rise in blood lithium levels.

Tx for microscopic colitis
->
Oral budesonide and withdrawal of possible triggering medications (NSAIDs, PPI, SSRI)

Dx and management of 22 yo F with h/o non-Hodgkin lymphoma s/p chemo 2 weeks ago. Had MVA. Received O-negative blood transfusion. 2 days later, she developed fever, diarrhea, maculopapular rash. Hb 9.5 PLT 180000 WBC 3800. T-bil 2.3 AST 187 ALT 224 INR 1.0
->
Transfusion-associated graft-versus-host disease
No treatment and most cases are fatal -> prevention is paramount
Should have received irradiated blood products

Management of 64 yo M with pleural effusion with spiculated lesion in the peripheral lung area. Pleural cytology with Thoracentesis was negative for malignancy 
->
Repeat thoracentesis with cytology
The first pleural cytology study can detect malignant cells in up to 60% of effusions. 3 separate thoracentesis can detect up to 90% of malignant effusions. The older degenerated cells are largely removed in the earlier thoracentesis, leaving a higher percentage of fresher cells to be detected

Dx of 44 yo M with h/o plaque psoriasis developed painful, erythematous patches followed rapidly by the appearance of several small pustules on hands, neck, torso and extremities
->
Generalized pustular psoriasis 
Systemic manifestation (fever, malaise, arthlagita)
Different from erythroderma (extensive, red, scaly skin covering > 90% of the body)

Bilateral hilar adenopathy in advanced sarcoidosis
->
Stage III and IV patients don’t have the classic bilateral hilar adenopthy
III: reticular opacities (upper lobes) and shrinking hilar nodes
IV: reticular opacities and volume loss

Dx of holosystolic murmur increased by inspiration 
->
Tricuspid regurgitation 

Management of 47 yo M developed scaly rash on his face. Pruritic erythematous plaques with fine, loose, yellow scales on eyebrwos, nasolabial folds. Also on arms and legs. Didn’t respond to topical corticosteroids and antifungal agent
->
HIV test
Seborrheic dermatitis 
Seborrheic dermatitis tends to be more severe and extensive in HIV patients. HIV patients can develop lesions in unusual sites (extremities) and may be resistant to topical corticosteroids and antifungals (appropriate Tx)

Management of 32 yo M developed nausea and malaise for a week. Sexually active with multiple partners. T-bil 4.5 AST 934 ALT 1200 INR 1.2 Hep A IgG +, HBsAg +, HBeAg +, anti-HBsAg -, Anti-HBc IgM +, HBV load 2340000 copies/ml, HCV Ab-, HIV -
->
Supportive care
Acute hepatitis B virus infection
Vast majority of adults (>95%) clinically improve and clear the infection 
Antiviral Tx considered only in those with a severe (INR>3) or prolonged (>4weeks) course or with acute liver failure

Management of 32 yo M developed malaise. T-bil 3.3 AST 72 ALT 64 ALP 520 liver biopsy reveals intrahepatic ductal obliteration with moderate lymphocytic infiltration and periductal “onion skin” fibrosis 
->
Colonoscopy 
Primary sclerosing cholangitis
Nearly 90% of PSC patients a/w inflammatory bowel disease -> risk of colon cancer
Tx of PSC: transplant

Site of morton neuroma
->
Between 3rd and 4th toes

Management of 18 yo healthy M found to have proteinuria. Asymptomatic. UA protein 2+ no blood cell. Cre 0.8. TP 7.0 Alb 4.2, 24-hour urine protein 2100mg/24h
->
Spot urine protein/creatinine ratio upon arising and at the end of the day
Orthostatic proteinuria
Seen in children, adolescents, and young adults. Significant proteinuria in the upright position. Resolution with advancing age in most patients. Generally less than 1g/day, but may surpass 3g/day in select patients

Dx of 36 yo M developed pruritic serpiginous reddish rashes on foot after recent travel to Caribbean 
->
Larva migrans
Hookworm infection
Serpiginous: 蛇行生の

Dx and diagnostic test of 22 yo F developed amenorrhea and excessive body hair. Weight gain. No purple striae. Frontal baldness. Testosterone 105 (normal 20-60).
->
Nonclassic 21-hydroxylase deficiency (nonclassic (late-onset) congenital adrenal hyperplasia) 
Check 17-hydroprogesterone level
Virilization (frontal balding, voice deepning, clitoromegaly) make other etiology, such as androgen-producing tumors (ovary, adrenal) and nonclassic (late-onset) congenital adrenal hyperplasia more likely than PCOS
Androgen-secreting ovarian tumor generally present in postmenopausal women with significantly elevated testosterone (>150)
Dx of nonclassic CAH is suggested by elevated 17-hydroxyprogesterone 

What is his son’s risk of developing his father’s condition
29 yo M c/o SOB, difficulty ambulating. JVD 12. The point of maximal impulse displaced to the left. The proximal extremity muscle atrophied, but both calves are prominently enlarged
->
0%
Calf muscle pseudodystrophy suggestive of Becker musclar dystrophy (early adulthood) and Duchenne muscular dystrophy (around age 2-3). Both disorders are inherited in an X-linked recessive manner
Father XY and Mother XX
-> son XY (0%) vs daughter XX or XX (all daughters are carrier)
If carrier mother (XX), daughters have 50% chance of being carrier and sons have 50% chance of being affected

What happens to tendon reflexes when having transverse myelitis
->
Areflexia, absent babinski sign, flaccidity (spinal shock)

Tx for menopausal vasomotor Sx in the setting of contraindication for estrogen 
->
SSRI
Hot flashes are mediated in part by serotonergic pathways

Dx of 19 yo F developed increasing vaginal discharge. Started taking a combined estrogen/progestin oral contraceptive 6 mo ago. Mild vulvar irritation. Thin, slightly malodorous, clear, yellow discharge throughout the vaginal vault. No discharge from the cervical os. Microscopy shows numerous epithelial cells and occasional polymorphonuclear leukocytes. pH of the discharge 4.2
->
Physiologic leukorrhea 
Occurs due to Elevated estrogen level. No further evaluation of treatment
(Bacterial vaginosis: pH > 4.5)

Dx of 64 yo M with h/o cardiomyopathy s/p ICD placement. developed lightheadedness. A sense of Heaviness in his head with squatting. ICD lead revision 1 month ago. Neck and upper chest veins distended. Lung clear. Trace bilateral leg edema. 
->
Superior vena cava syndrome
Most commonly due to tumor compression. Transvenous ICD implantation also can induce thrombosis, resulting in SVC syndrome 

Management of 60 yo F with h/o CKD.
Cre 3.4 Ca 7.9 Alb 3.8 Phos 5.4 parathyroid hormone 90 (normal: 10-65)
->
Dietary phosphate restriction 
Secondary hyperparathyroidism. Result from impaired phos excretion and decreased synthesis of active vitamin D. Elevated phos triggers the parathyroid glands to overproduce PTH to increase phos excretion 
Dietary phos restriction -> noncalcium phos binder (sevelamer) -> (PTH still high) -> vitamin D (Ca<9.5, phos<5.5) or calcimimetic (phos.5.5 or Ca>9.5)

Tx of rhinitis medicamentosa
->
Cessation of medication and intranasal fluticasone
Due to Overuse of over-the-counter nasal decongestant sprays

Does cardiac myxoma cause weight loss?
->
Yes
Overproduction of interleukin-6 -> fever and weight loss 

Management of heel pressure ulcer
->
Usually managed conservatively as removing tissue around the heel can increase the risk of osteomyelitis

What is cosyntropin stimulation test?
->
= ACTH (cosyntropin) stimulation test 
Differentiate between adrenal insufficiency and pituitary gland issue by checking cortisol response 

Management of 42 yo F had MVA with head injury and LOC 3 weeks ago. CT head negative. She is not able to focus, and has a sensation of mental clouding. Intermittent HA and dizziness. MRI brain negative
->
Reassurance and symptomatic Tx
Post-concussive syndrome following mild Traumatic brain injury. Most likely improve (70-80%) within 3 months. 
Neuropsychological testing should be considered for moderate to severe TBI or significant cognitive symptoms, especially if not improve within the expected time frame

Tx for anal fissure
->
Topical Nitroglycerin, topical CCB, botox injection, sphincterotomy 

Dx of 56 yo F found to have hypercalcemia. Ca 11.1 Alb 4 PTH 60 (normal 10-65)
->
Parathyroid hormone-mediated hypercalcemia
nonsuppressed PTH level. Although PTH is elevated in a majority of patients with primary hyperparathyroidism, approximately 10-20% of these patients have PTH levels that are only borderline elevated or in the upper half of the normal range
Even mild hypercalcemia suppresses PTH to very low (usually < 20)

Management of 76 yo M developed intermittent blurry vision. Eating less. Has had HA. H/o TIA.  Visual acuity 20/40 in the L, 20./100 in the R. No scalp tenderness. ESR 52
->
High-dose glucocorticoids 
Temporal A biopsy and ophthalmology consultation required, but glucocorticoids needs to be given immediately. Many Pt have no scalp tenderness. 

Cause of budding yeast from respiratory sample
->
Histoplasma and balstomyces or candida

Management of asymptomatic lung nodule of histoplasmosis 
->
Observation 
No evidence that antifungal Tx has any impact on those nodules and Tx is not recommended 

Most common long-term side effects from radiation Tx for localized prostate cancer
->
Sexual dysfunction 

Management of 40 yo F with T2DM. On metformin for 3 years. Glucose 90-130. Has been adherent and lost significant weight. Has had irregular menstrual periods. Found to have IDA. Hb 9.0 HbA1c 7.6 (6.8 (6 months ago)). Started on iron supplement
->
no change and repeat HbA1c in 3 months
Reduced blood red cell production (IDA) have a lower proportion of new red cells and a misleadingly high HbA1c (opposite in hemolytic anemia, HbA1c low)
 

Management of patellofemoral pain syndrome
->
PT
Typically worsens after prolonged rest and with activity 

Dx of 51 yo M returned from Bangladesh developed fever. Abd pain. Rash. T 103. BP 120/70 HR 72. Tenderness in LLQ. Erythematous, macular, patchy rash across lower abdomen. Hb 11 PLT 230000 WBC 13400 AST 212 ALT 314 ALP 320 T-bil 0.3
->
Typhoid fever
Caused by salmonella typhi. Relative bradycardia. Normal PLT. Elevated LFT. Abdominal pain -> perforation in severe case

Dx of 34 yo F developed N/V, early satiety. S/p gastric bypass surgery 3 months ago
->
Stomal stenosis
Typically 3-6 months after surgery 

Dx of 35 yo F developed tongue lesion. No pain. Oral sex a few months ago. 2-cm ulcer with induration on the dorsal aspect of the tongue. Cervical adenopathy positive. 
->
Chancre (primary syphilis)
This occurs most commonly on the external genitalia, other sites include the posterior pharynx, anus, and vagina

 
Tx for fibromyalgia refractory to exercise and good sleep hygiene 
->
Amitriptyline (TCA)
Pregabalin, duloxetine are alternative

Dx and Tx of 51 yo M developed swelling over the left mandible for 3 moths. Once improved with ABX and returned. PMH: T2DM. T 98.6, 4cm mass extending from the mandible, firm and nontender. There is a sinus tract extending to the skin with purulent and blood-tinged drainage. Oral cavity show poor dentition with gingivitis. No cervical adenopathy
->
Cervical actinomycosis / penicillin 
Commonly seen in the mandible region. Actinomyces: gram positive and filamentous branching bacteria. Colonize in oral cavity. Slowly growing. Non-tender and indurated mass. draining fistula. 

Management of 52 yo F with elevated BP 140/100. BMI 27. PMH: GERD. asymptomatic. Na 142 K 3.9 Cre 1.1 Glu 95. Follow-up BP 138/100 4 weeks after
->
Check TSH
Hypothyroidism and hyperthyroidism both can raise BP. Hypothyroidism typically causes increased diastolic pressure. Guideline recommends patients with HTN warrant screening for thyroid disease as a part of the initial evaluation regardless of Sx

Management of rectovaginal fistula in Crohn disease
->
Asymptomatic: observation (majority heals spontaneously)
Mild Sx: ABX (often requires 6-12 months)
Moderate to severe: infliximab (anti-TNF) -> persistent -> surgery

Hemodynamic effects to SGLT-2 inhibitors
->
Can lead to hypotension (induce osmotic diuresis)
Can decrease renal perfusion (GFR could lower)
Still Better continue if possible due to slowing progression of diabetic kidney disease 

Dx and management of 24 yo M who was diagnosed with secondary syphilis for skin rash and received penicillin Im two days ago. He now developed fever, body aches. Scattered macular, erythematous regions on his abdomen, back, shoulder and lower extremity, progressed since 2 days ago
->
Jarisch-Herxheimer reaction / supportive care
Fever, myalgias and rash progression within 24 hours of secondary syphilis Tx
Attributed to the release of Treponema pallidum components with organism death

Conservative fluid management with diuretic Tx in ARDS is most likely to positively affect what
->
Ventilator-free days
(No mortality benefit)

Difference between acute stress disorder and PTSD
->
ASD < 1 month
PTSD >1 month

Tx of acute stress disorder
->
Cognitive-behavioral therapy

Management of 82 yo M with depression on sertraline became severely depressed. Not eating or drinking. Visual hallucinatinos. Express suicidal ideation
->
Initiate electroconvulsive Tx
Major depression with psychotic features: first line Tx: antidepressants + antipsychotic or ECT
ECT is preferred for pt who is not eating or drinking as it provides rapid clinical response. Severe suicidality is other indication for ECT

Medical Tx for anorexia nervosa
->
Olanzapine (accelerate weight gain)

Medical Tx for bulimia nervosa
->
SSRI

What is the strategy to prevent recurrent stroke in Sickle cell disease 
->
Chronic simple transfusion Tx
Every 4-6 weeks with goal HbS < 30% and total Hb 9-12.5
Superior to hydroxyurea

Effect of Autoimmune hemolytic anemia on red blood cells 
->
Spherocytosis (partial phagocytosis of IgG-coated red blood cells)
Elevated MCV (due to reticulocytosis / reticulocyte larger than mature red blood cells)

Role of molecular profile test for small cell lung cancer
->
None
Patients with NSCLC usually undergo molecular profiling 

Dx of 35 yo F developed right arm weakness. Started several months ago. It worsened recently. Denied HA, or visual problems. H/o acute lymphocytic leukemia and received chemo and cranial radiation at age 7
->
meningioma
Meningeal cells are the most susceptible to cranial radiation. Most meningiomas are slow growing with symptoms resulting from compression of the underlying brain parenchma
(Glioblastoma multiforme is highly aggressive and often a/w extensive vasogenic edema. Usually presents with seizure and symptoms/signs of increased intracranial pressure)

Source of hematuria with blood clots
->
Non-glomerular source

Dx of 35 yo F manicurist developed rash on fingers. With pain and burning. Edematous, tender to palpation, hyperkeratosis, decreased sensation
->
Allergic contact dermatitis 
Delayed hypersensitivity response 

Management of 31 yo F with recently diagnosed SLE was found to be pregnant
->
Check antiphospholipid antibodies
Antiphospholipid syndrome A/w poor maternal and fetal outcomes

What could increase tacrolimus level
->
Grapefruit juice, lansoprazole
Metabolized by hepatic cytochrome P450
Compounds interacting with P450 can alter the drug’s level

Management of men on leuprolide for prostate cancer
->
Bone density screening
Androgen deprivation Tx is Risk for osteoporosis 

Diagnostic test of optic neuritis 
->
Fundoscopic exam and MRI
All patients with optic neuritis should undergo brain MRI to evaluate for demyelinating plaques and assess the risk of MS

Management of 74 yo F with Alzheimer’s developed a sacral ulcer. 3-4 cm ulcer, visible subcutaneous tissue, grayish slough, foul smelling drainage. No surrounding erythema or fluctuation
->
Debridement and topical antibiotic 
Stage III pressure ulcer. Necrotic tissue with local infection (foul-smelling drainage) without cellulitis (no erythema)
-> MRI and bone biopsy if no improvement 

Tremor worse at action 
->
Essential tremor
(Parkinson: worse with rest)

What is miliaria 
->
汗疹 (“Heat rash”)
Obstruction of the sweat glands, causes small, thin-walled, noninflammatory vesicles.

Management of 41 yo health M developed necrotizing pancreatitis. Complicated with bilateral infiltrates and intubated. Treated with broad ABXs. CXR persistent infiltrates. BCx/UCx negative. Sputum Cx grew candida
->
No antifungal drug treatment
Bronchial tree colonization of candida species is common in critically ill patients 
Candida pneumonia is rare
Not recommend antifungal Tx for immunocompetent patents with candida from respiratory sputum 

Management rule of hyperthyroidism during pregnancy 
->
Maintain mild hyperthyroid state to avoid fetal hypothyroidism
First trimester: prophylthiouracil (methimazole a/w congenital defect)
2nd & 3rd trimester: switch to methimazole (prophylthiouracil a/w hepatotoxicity)

Dx of 70 yo M has two lumps on skin. One on lower lip and other on ear. Gray-blue to purple papulonodules. Lesions reduce in size when compressed
->
Venous lake
Dilated venules in the superficial dermis. Diagnostic feature: disappears when compressed

Indication for prophylaxis for recurrent herpes simplex labialis 
->
> 4 / year
Secondary herpes simplex type-1. Viral Reactivation within the trigeminal sensory ganglion

Dx of 35 yo F c/o abd bloating, diarrhea 3-4 times a week. No weight loss. H/o gastric bypass. Hb 11 MCV 103 WBC 9000 CRP 0.3
->
Small-bowel bacterial overgrowth
Macrocytic anemia from vitamin B12 deficiency is common. Severe case leads to weight loss.
IBS: Anemia suggests an alternate diagnosis 

Ddx of Ring-enhancing lesion on brain in HIV patients
->
Toxoplasma: toxoplasma IgG positive, almost always CD4 < 100
Primary CNS lymphoma: > 4cm, almost always CD4 < 50
Abscess: vasogenic edema

Dx of 52 yo F became hypertensive and tachycadiac while receiving midazolam for colonoscopy. BP 240/140 HR 180 Afib rhythm. 
->
Pheochromocytoma
May be clinically silent in many patients until Sx is unmasked by a precipitating factor (anesthesia induction)

Dx of 45 yo F s/p gastric bypass developed frequent falls. On vit B12, Ca carbonate, iron sulfate. Vit D, multivitamin. Taking zinc supplement. Bilateral weakness of ankle extensors and flexors. Loss of proprioception. Unstable in Romberg position. Hb 10.4 MCV 86 WBC 3100 Vit B12 450
->
Copper deficiency 
Clinical presentation similar to vit B12 deficiency
Zinc competes with copper absorption in the GI tract

Management of 35 yo F found to have persistently elevated BP at PCP office. BP nearby pharmacy 3 times are about 120/80. EKG, blood test unremarkable 
->
24-hour ambulatory blood pressure monitoring 
Record BP/HR every 15-20 min during the day and every 30-60min during the nigh

Follow up of papillary thyroid cancer s/p thyroidectomy and radioactive iodine ablation
->
Check TSH, FT4, thyroglobulin annually 
Neck US 6-12m (year 1) -> 1-3y (year 2-20) -> 3-5y (> year 20)
Diagnostic radioiodine scan if abnormal 
Thyroglobulin is a useful marker of recurrent or persistent cancer following Tx

Management of 24 yo F diagnosed with asthma 3 years ago, recurrent wheezing even with maximum Tx. Throat and chest tightness. Triggered by stress. No nocturnal Sx. No acid reflux or nasal drip. FEV1 97% predicted, FEV1/FVC 0.94. CXR normal
->
Spirometry with a flow-volume loop
Paradoxical vocal fold motion: abnormal adduction of the true vocal cords during inspiration 
Misdiagnosed as asthma, but it lacks some typical asthma characteristics (nighttime Sx, response to beta-agonist/steroid). Psychosocial stressors are the most common trigger

Most common cause of erythema multiforme
->
Herpes simplex virus infection 

Management of rheumatoid arthritis with initial response to methotrexate, but developed treatment-resistant disease
->
Skin tuberculin test
Adding biologic disease-modifying antirheumatic drug (TNF antagonist) is the next step
All pt should undergo TB screening before TNF blockers 

Tx of congenital long QT syndrome
->
Propranolol or nadolol 
Non-selective beta-blockers are more effective 

Untreated hyperprolactinemia could cause what
->
Osteoporosis 
Hyperprolactinemia suppresses gonadotropin secretion 

Most sensitive test for Cushing syndrome
->
Late-night salivary cortisol
Low-dose dexamethasone suppression test could be affected by oral contraceptives (estrogen increases cortisol-binding globulin)

Herbal medication increasing bleeding risk
->
Ginkgo biloba (and Ginseng)

Management of 24 yo African American male developed left upper abdominal pain during vacation on the mountain. Also feels pain on the top of left shoulder. Tenderness to palpation on LUQ. CXR blunting of the left costophrenic angle
->
Hemoglobin electrophoresis 
Splenic infarction due to Sickle cell trait
Splenic infarction can occur with exposure to hypoxic conditions

Management of urgency incontinence 
->
Bladder training with timed voids
Overactive bladder
Antimuscarinics (oxybutynin) are used if urgency Sx persists 

Management of stress urinary incontinence 
->
Pelvic floor exercise and pessary placement 
Leakage by cough or sneezing 

How many litter of fluid intake recommended to prevent kidney stone
->
More than 2L/day

Chemotherapy causing cardiotoxicity 
->
Doxorubicin (anthracycline) -> cardiomyopathy 

Dx of 36 yo M with h/o celiac disease developed fatigue, low-grade fever, abdominal pain and diarrhea for 3 months. 
->
Enteropathy-associated T cell lymphoma 
Commonly seen in celiac disease patient with poos dietary compliance

What is goal lung-protective ventilation and for who
->
TV: 6ml/kg ideal body weight for all patients

Dx of 73 yo M with h/o melanoma developed diplopia, mild weakness and spasticity of the right arm and ataxic gait
->
Leptomenigeal carcinomatosis
Cancer (melanoma, breast cancer, lung cancer) spread to the meninges and cerebrospinal fluid surrounding the brain and spinal cord

Tx for acute chest syndrome in sickle cell disease 
->
Prodromal phase: incentive spirometry (shown to reduce the likelihood of developing ACS), cautious hydration, pain control
Mild ACS: simple transfusion 
Mod-severe ACS; exchange transfusion 

Measure decreasing risk for developing catheter=related infection
->
Chlorhexidine baths 
(chlorhexidineの染み込んだbath (布)で体を拭く)

Management of 66 yo F who had been adequately screened for cervical cancer having a new partner
->
Screen can be discontinued for F > 65 If negative prior screen and low risk regardless of sexual history

Dx of 52 yo M with h/o iv drug abuse developed necrosis of fingers. Has had fatigue and arthralgias for 6 months. ANA 1:160, low C3 and C4, RF 560 (normal < 15)
->
Hepatitis C / cryoglobulinemia
Vasculitis may manifest as skin ulceration and necrosis
Excess production of immunoglobulin, which can lead to false-positive serologies (ANA and RF)

Tx for PTSD
->
SSRI

Dx and Tx of 34 yo F developed R-sided CP, worsens by inspiration. Has had dry cough, fever and rhinorrhea 3 days. Scratching sound in the right base. CXR negative. D-dimer negative
->
Pleurisy (pleuritis) / NSAIDs
Inflammation of the lung pleura
Viral pleurisy, one of the more common causes of pleuritis 

Management of 38 yo F developed fever, and fatigue. Bilateral pedal edema, ankle pain. Hepatomegaly, violaceous, tender, raised lesions over both pretibial areas.
->
CXR / Lofgren’s syndrome
A variant of sarcoidosis. Hilar adenopathy, erythema nodosum, acute polyarthritis 
Arthritis typically involves both ankles

Management of 32 yo male without PMH developed fever, sore throat, rash and malaise. HIV RNA level markedly elevated
->
Start antiretroviral Tx
For acute HIV syndrome, Tx should not be delayed pending the results (genotype and resistance), as the antiretroviral regimen can be modified if needed

Contraindication for percutaneous mitral balloon valvotomy in MS 
->
Concurrent moderate to severe MR
PMBV can cause or significantly worsen MR

What makes Homan’s sign positive
->
Popliteal (Baker) cyst and DVT

What is thyroglobulin 
->
Precursor of thyroid hormone

Management of 60 yo M s/p DES placement 4 mo ago will have knee surgery 
->
Elective noncardiac surgery should be postponed until at least 6 months after stent placement  whenever possible 

Management of newly diagnosed medullary thyroid cancer
->
Germline RET mutation analysis 
RET mutation test is helpful in defining prognosis and occurrence of other endocrinopathies in MEN2 patients

Dx of 72 yo M c/o intermittent dysuria for 3 months. Temporally Improved with ABX. Digital rectal exam reveals tender prostate
->
Chronic prostatitis
Prolonged course of ABX (4-6 wks) required 

Management of 71 yo F had acute vertebral compression fracture refractory to NSAID/acetaminophen. 
->
Nasal calcitonin 
Improvement of acute fracture-related pain when given shortly after Fx

Management of 75 yo F developed vertebral compression fracture after slipping in the bathtub. DXA T-score -2.0. h/o CKD with GFR 21
->
Denosumab sc
Bisphosphonate contraindicated for GFR < 30-35
Denosumab can be used in renal insufficiency. Can block osteoclast formation
Teriparatide: no first-line drug unless severe osteoporosis. Not studied in pt with CKD
Compression Fx after Ground-level fall has clinical osteoporosis (regardless of DXA results)

NSAIDs during pregnancy 
->
Should be used only in brief courses
A/w fetal toxicity in the 1st and 3rd trimesters

Management of 56 yo with lupus nephritis, had been on high-dose corticosteroid, since 6 moths ago and tapered off 3 weeks ago. Will have hemicolectomy in 2 weeks for colon cancer
->
Stress-dose corticosteroids perioperatively
Normal hypothalamic-pituitary-adrenal axis function after corticosteroid use may not fully recover for up to 6-12 months after discontinuation of the medication

Dx and management of 27 yo F developed hair loss. S/p vaginal delivery 3 months ago. Diffuse hair loss across the scalp with no other abnormality. Labs normal
->
Telogen effluvium / reassurance 
Acute, diffuse, noninflammatory hair loss, often triggered by a stressful event (pregnancy, major illness). Self-limited disorder

Management of 26 yo F with hypothyroidism. On levothyroxine for 2 years. TSH 2.2 FT4 1.6 (normal: 0.9-2.4). C/o fatigue, dry skin, hair loss
->
Continue current Tx and evaluate other etiologies
Normal TSH indicates that sh is in a biochemically euthyroid state
Sx of Hypothyroidism are nonspecific and overlap extensively with other common conditions 

Symptoms of campylobacter infection 
->
Frequent small-volume diarrhea +/- blood and mucus
Invade large bowel
(Clostridium perfringens and enterotoxigenic E.coli Affect Small bowel and lead to large-volume watery diarrhea)

Management of patient developed myopathy after taking atorvastatin and amiodarone
->
Switch to rosuvastatin

Side effect of sacubitril-valsartan
->
Cough
Sometimes needs to discontinue it

Dx and management of 66 yo M c/o scrotal discomfort for 3 months. Standing position shows a palpable, soft, irregular, nontender mass, and disappears in the spine position 
->
Varicocele / scrotal support and analgesics
Tortuous dilation of the pampiniform plexus of veins surrounding the spermatic cord and testis 

Spot Urine sodium when pre-renal condition 
->
Na < 20mEq/dL

Cause of increase of creatinine without decreasing GFR
->
Trimethoprim, cimetidine
Compete with creatinine for tubular secretion 

Tx for restless leg syndrome
->
Gabapentin, pregabalin
Dopamine agonists (pramipexole) are not recommended for most patients due to the risk of augmentation of symptoms with long-term use

Management of asymptomatic large gallstone
->
No intervention 

Management of patient  with T2DM, HTN on hydrochlorothiazide is starting SGLT-2 inhibitor
->
Decrease or discontinue HCTZ
SGLT2 inhibitor works by decreasing the tubular reabsorption of glucose. 
excessive loss of sodium and glucose in the urine -> increase risk of UTI and osmotic diuresis, which can lead to hypotension and decreased renal perfusion 

Dx criteria and Tx for mycobacterium avium-intracellulare complex
->
Two positive sputum Cx (or BAL or biopsy)
Clarithyromycin, ethambutol, and rifampin

Management of female developing hirsutism 
->
Check testosterone level
Androgen includes testosterone, dhidrotestosterone (DHT), androstenedione, androstenediol dehydroepiandrosterone sulfate (DHEAS) and dehydroepiandrosterone

Management of post-obstructive diuresis in female with extensive ovarian cancer s/p urethral catheter placements. Making 600cc/hr over the 2 hours
->
NS at 200cc/hr
Attempts to completely match the urine volume lead to overall volume expansion and even worse diuresis
Replace volume with isotonic saline at a rate of < 50% of urine volume

Dx of 37 yo landscaper developed 3 tender papules on top of the dorsal aspects of the right index finger, wrist and the distal right upper extremity. One open nodule has a small crust on the top. No adenopathy 
->
Sporotrichosis 
Reddish nodule forms at the site of inoculation. Similar lesions subsequently develop more proximately and follow a lymphatic chain (referred to as nodular lymphangitis)

Management of suspected infected necrotizing pancreatitis 
->
Empirical ABX (carbapenem)
Or 
CT-guided FNA to determine sterile necrosis or infected necrosis 

What is latent autoimmune diabetes of adulthood
->
Onset 30-50, subacute onset, slow insulin deficiency (initially oral agents, insulin eventually required), positive for GAD Ab

Medical Tx for bulimia nervosa
->
Fluoxetine

Medical Tx for anorexia nervosa 
->
Olanzapine

Effect of milrinone for decompensated heart failure
->
Alleviate Sx of dyspnea
Phosphodiesterase inhibitor that decrease cAMP degradation, increased cellular cAMP, and is Both an arterial and venous vasodilator. Increase Myocardial contractility. 
Side effect: hypotension, arrhythmia, non-statistically significant increase in mortality 

TSH after radioactive iodine for Graves’ disease
->
TSH may remain suppressed for months after the resolution of hyperthyroidism and does not always indicate ongoing hyperthyroidism 

Indication of endarterectomy 
->
Asymptomatic: >70%
Symptomatic (TIA, stroke): male with > 50% or female with > 70%

Management of plaque psoriasis on knees and elbows
->
High-potency topical steroid
(Low-potency topical steroid for facial and intertriginous plaque (can cause skin atrophy))

Dx and Tx for 23 yo M c/o daytime sleepiness. At night, fall asleep quickly. Wakes up frequently throughout the night. Has begun to hear “demonic” voices at night. Multiple sleep latency test shows a short latency of 4 minutes (normal > 10 minutes)
->
Narcolepsy /. Modafinil (stimulant)

Management of 43 yo M with depression, has improved after the dose of sertraline increased from 50 to 100. Now complains of sexual dysfunction 
->
Augmentation with sildenafil
Phosphodiesterase-5 inhibitor 
Decreased the dose or discontinuation of sertraline could cause the loss of the antidepressant response 

Dx of 65 yo F with 10 years h/o dry eyes and mouth. Swelling parotid glands, several mildly enlarged, nontender, mobile cervical and supraclavicular lymph nodes. ANA 1:80, Anti-SS-A Ab 4 (normal<1), Anti-SS-B Ab 5 (normal < 1), RF 480
->
B-cell lymphoma 
Long-standing Sjogren’s syndrome has nearly 5% lifetime risk of developing into non-Hodgkin lymphoma. Malignant transformation of lymphoproliferative glandular tissue in SS patients

Dx of multinucleated giant cellls with positive CD15 and CD30
->
Hodgkin lymphoma

Dx of 34 yo M developed fever, headache, maculopapular rash with petechiae on the arms and legs. WBC 11000, PLT 90000, AST 162 ALT 174. BCx negative. Like outdoor activities
->
Rocky Mountain spotted fever
Can occur throughout the US. Thrombocytopenia and elevated liver enzymes

Management of CCB-related peripheral edema
->
Add ACEI
Result from preferential arterial dilation, which increases the pressure gradient between the capillaries and interstitium, leading to extravasation of intravascular fluid
ACEI promotes venule dilation and decreasing the pressure gradient between the capillaries and interstitium

Dx of 40 yo F c/o pelvic pain. Urgency and frequency. Pain relieved by voiding. No urinary leakage. Tenderness to palpation over the urethra. UA negative
->
Interstitial cystitis 
Etiology poorly understood
In contrast, Interstitial nephritis causes pyuria 
Overactive bladder causes urinary leakage

Dx of 34 yo M c/o itchiness in perianal area. Pronounced at night. Shows excoriation in the perianal region 
->
Pinworm infection caused by enterobius vermicularis

Dx and management of 24 yo M c/o R eye pain. Feels a foreign body sensation. S/p hitting in the face with tree branches during hiking. No penetrating injury. Anterior chamber is clear. Fluorescein stain under cobalt blue filter shows a small linear stain across the central cornea. 
->
Corneal abrasion / topical antibiotic for prophylaxis 

Management of 84 yo M with Alzheimer disease and increasing agitation and confusion 
->
Behavioral and environmental therapy
Establish structured routines, using distraction and redirection. Avoiding environmental trigger
Exercise, music, touch, removing offending stimuli. Caregiver education 

Dx of 37 yo F with h/o mitral prolapse developed arthralgia for 3 weeks. T 100.4 3/6 holosystolic murmur at cardiac apex. Splenomegaly. No rash. Hb 9.4 WBC 11000 C3 15 (55-120), total complement 12 (37-55) RF 53 (<40)
->
Infective endocarditis 
Normochromic/normocytic anemia is common
Splenomegaly sometimes seen, due to immune response 
Decreased complement level

How long sertraline needs to be continued for 52 yo M diagnosed with depression 6 months ago. Started on sertraline. Now Sx improved. H/o two prior depressive episodes without Tx
->
1-3 years
History of highly recurrent illness (≧3 lifetime depressive episodes)
In contrast, Following response to acute Tx, patients with a single episode of unipolar major depression should continue antidepressants for an additional 6 months

Management of 62 yo M c/o lower back pain. Worse at night. S/p acute prostatitis and Tx 3 weeks ago, resolved. No fever. No tenderness on any of the spinal processes. No neurological abnormalities. Labs were pending
->
MRI scan of lumbar spine
Red flags (recent UTI, age>50, nocturnal pain)
Vertebral osteomyelitis: spinal percussion tenderness and decreased range of motion could be unremarkable 

Dx and Tx for 40 yo F c/o warm burning sensation and redness in her feet during the night. Worse in winter when feet are covered.
->
Erythromelalgia / aspirin
Due to intermittent blood vessel obstruction
Triggered by heat, exertion, stress, insomnia and pressure
Aspirin reduces symptoms and prevents vascular events

FVC in COPD
->
Normal or reduce
The maximum amount of air person can forcibly exhale from their lungs after taking the deepest breath 

Cause of chylothorax
->
Disruption of the thoracic duct
Non-traumatic: obstruction from malignancy, sarcoidosis, TB, filariasis
Traumatic: surgery, central venous catheter placement 

Dx of 34 yo M immigrated from Brazil developed heart failure. TTE shows EF 35% and a left ventricular apical aneurysm 
->
Chagas cardiomyopathy 
Caused by Trypanosoma Cruzi

Dx of acute onset of pulmonary edema and shock after MI due to RCA obstruction 
->
Papillary muscle rupture
Posteromedial papillary muscle is supplied solely from the posterior descending artery 
Acute pulmonary edema and shock due to acute mitral regurgitation 

Isopropyl alcohol has osmolal gap and/or anion gap?
->
Has osmolal gap but not anion gap

Tx of unknown duration of syphilis
->
Benzathine penicillin weekly for 3 weeks

Management of 55 yo M developed acute gout attack while taking allopurinol 100mg. Uric acid level 9mg/dL (11mg/dL 6 months ago)
->
Start NSAIDs or colchicine and continue allopurinol
Stopping allopurinol or adjusting the dose of it during acute attack could worsen the acute attack. The allopurinol dose may be adjusted 3-4 weeks after the acute inflammation subsides

Straight leg test for spinal stenosis
->
Negative
Positive for herniated disc

Tx for HFpEF
->
Aldosterone receptor antagonist (spironolactone) and sodium-glucose cotransporter 2 inhibitor
Reduce hospitalization and possible mortality 

Dx and management of 65 yo M c/o aching pain in hip, groin and low back. Ca 9.4 ALP 310 PSA 2.1. x-rays reveal thickening of the femoral neck and diffuse sclerosis of bone, most prominent in the left-hemi-pelvis
->
Paget disease / bone scan / bisphosphonate 
Abnormal osteoclasts causing focal area of accelerated bone absorption, resulting in formation of structurally weaker bone with areas of sclerosis 
Mixed lytic/sclerotic lesions seen
Bone Scan to determine the extent of lesions 

Morning testosterone measure should be total one or free one
->
Total testosterone (standard)

The most effective Non-pharmacological Tx for hypertension 
->
Low-sodium dietary approaches to Stop Hypertension (DASH) diet (↓11mmHg)
(Weight loss: ↓6mmHg/10kg, exercise: ↓7mmHg)

Management of 75 yo F c/o HA, blurry vision, jaw pain. ESR 88. Sx improved after initiation of prednisone a week ago. Biopsy of the right temporal A came back negative
->
Obtain biopsy of the left temporal A
Negative biopsy results occur in up to 40%


Dx of 48 yo obese M c/o recurrent painful lumps in both axillae. Unpleasant smell. Spontaneously rupture. Inflamed nodules. With purulent discharge
->
Hidradenitis suppurativa
Chronic inflammatory disorder, characterized by occlusion of folliculopilosebaceous units. In intertriginous areas (axillae). Painful, inflamed nodule, progress to abscess with purulent or serosanguineous drainage 

Management of 49 yo F with T2DM, c/o leakage of urine. S/p vaginal delivery complicated with by a large perineal laceration. Leakage of urine increases with Valsalva. Postvoid residual volume increased
->
Overflow incontinence / intermittent self-catheterizaiton 
(Stress incontinence also cause leakage by Valsalva. But not a/w elevated post residual volume. Treated with pelvic floor muscle exercise and midurethral slings)

Management of 64 yo with CHF, BPH c/o frequent urination. BPH had caused mild hesitancy and occasional nocturia. But the past 8 weeks, 2-3 times nocturia and increased urinary urgency. Bilateral basal crackles, 2+ pitting edema. Meds: furosemide, carvedilol, lisinopril, spironolactone, atorvastatin
->
Increase furosemide
Nighttime recumbency improves renal perfusion and sodium excretion, resulting in nocturia. Uncontrolled HF (volume overload) can worsen symptoms of BPH. The first step is to optimize volume status 

Management of 40 yo M with T2DM developed abdominal distention, flatus and low-volume fecal incontinence after starting orlistat 
->
Low-fat diet
Orlistat: Tx for obesity. Inhibits pancreatic lipase to reduce fat absorption and increase fecal fat excretion. Fat intake > 30% of total calories can develop side effects similar to fat malabsorption

What type of WBC predominant in asbestos-related pleura effusion
->
Eosinophil (> 50%)

Pattern of conductive hearing loss in Weber and Rinne test
->
Weber shows lateralization to the affected ear
Rinne shows bone conduction better than air conduction (tuning fork heard better when held on the mastoid than held in front of ear)

Choice of rhythm control of 
1. Afib without CAD or structural heart disease
2. Afib with CAD without HF
3. Afib with HF
->
1. Flecainide
2. sotalol
3. Amiodraone,  dofetilide

Management of 27 yo M c/o ear pain and decreased hearing. Started on amoxicillin 3 days ago without improvement. No fever, ear drainage, or HA. Cloudy, red, bulging tympanic membrane. No posterior ear pain. 
->
Changed to amoxicillin plus clavulanate
Acute otitis media
Amoxicillin: first-line Tx -> ABX failure -> amoxicillin-clavulanate to cover beta-lactamase-producing H influenza

Dx of episodic rectal pain
->
Proctalgia fugax
Recurrent and severe rectal pain, functional disorder, diagnosis by excluding other GI causes
Pathophysiology is possibly due to anal sphincter spasm, pudendal nerve compression, neuralgia or psychological factors

Dx of 42 yo F c/o amenorrhea for 3 months. Fatigue, weight gain. S/p C-section and a bilateral tubal ligation 10 years ago
->
Pregnancy 
Tubal sterilization considered an effective form, but failure rates are as high as 36 per 1000 procedures

Management of 62 yo M having chest pain on exertion. Exercise radionuclide stress test shows EKG 2-mm horizontal ST depression in lead II,aVF and V4-6 with chest pain. But myocardial perfusion images were negative.
->
Refer to Cath
Suggestive of the presence of balanced ischemia, which is present when coronary flow is equally impaired. Resulting in pattern of perfusion appear mostly homogeneous, creating a false negative 

Management of 38 yo F c/o constipation for 3-4 months. Previously normal BM. No weight loss. No family h/o colon cancer. Eats mainly hamburgers pizza and fried food. Hb 11.6 MCV 102. PMH: vitiligo, anxiety, fibromyalgia 
->
Check TSH
Alarm features (unexplained change in BM) -> evaluate for secondary causes (hypothyroidism, malignancy).
Autoimmune disease (vitiligo). Macrocytic anemia present in 10% of hypothyroidism due to pernicious anemia

Management of 19 yo with irregular menstrual cycle. Excessive body hair. BMI 30. Striae on the abdominal wall. Urine free cortisol 24μg/24h, FSH 5 LH 20, dehydroepiandrosterone sulfate 480 (148-408), 17-hydroxyprogesterone 55 (15-250), testosterone 75 (15-70), prolactin 8 TSH 2.3
->
Prescribe oral contraceptives 
PCOS: 2 of the 3 following criteria 
1. irregular or absence of ovulation 
2. Hyperandrogenism (hirsutism or elevated testosterone)
3. Polycystic ovaries on US
Doesn’t necessarily require US if the first 2 are met
Oral contraceptives are preferred T for oligomenorrhea and hirsutism in pt who don’t desire pregnancy 
Striae -> obesity 
Androgen-secreting tumor -> DHEA-S > 700
Androgen-secreting ovarian tumor -> testosterone > 150

Calcium level in secondary hyperparathyroidism due to vitamin D deficiency 
->
Borderline low to normal
If Ca high, PTH slightly high, low 25-hydroxy vitamin D -> primary hyperparathyroidism with concurrent vitamin D deficiency 

Tx for MRSA pneumonia 
->
Vancomycin or linezolide
(pulmonary surfactant inhibits Daptomycin)

Management of 65 yo M had hip fracture. DXA reveals T-score -2.5 in the lumbar spine
->
Check testosterone level
Cause of osteoporosis in men: hypogonadism, hyperthyroidism, vit D deficiency, DM, hypercortisolism, hyperparathyroidism, malabsorption

Benefit of cinacalcet
->
Decrease need for parathyroidectomy 
For secondary hyperparathyroidism
Cinacalcet increases sensitivity of the calcium-sensing receptors of the parathyroid glands, leading to decreased PTH secretion and resultant in serum phos and Ca level

Cause of 43 yo F developed pain, weakness and numbness in left forearm and Horner syndrome. H/o left breast cancer s/p lumpectomy and radiation 
->
Brachial plexopathy related to cancer invasion 
Radiation injury also causes plexopathy, but no Horner syndrome and develops pain later in the symptoms course

Tx for hypertension due to bilateral renal artery stenosis 
->
ACEI 
Shown to decrease mortality, rate of MI, progression to ESRD and stroke
ACEI/ARB are no longer thought to be contraindicated as most patients only experience a small decline in GFR
Pt fails optimal medical Tx or recurrent flash pulmonary edema or HF, should be considered for angioplasty 

Indication for toxoplasma gondii prophylaxis in HIV patients
->
CD4 < 100 and positive Toxoplasma IgG

How often does it need echocardiography for mild to moderate AS patient
->
Mild: 3-5 years
Moderate: 1-2 years

Cause of gastroparesis 
->
Viral infection (gastroenteritis)

Dx of 64 yo M c/o difficulty seeing. Reduced distance vision. Normal near vision. Eye exam 6 months ago was normal. 
->
Nuclear cataract 
Due to increased thickness at the center of the lens and a change in dioptric power
Myopic shift typically occurs before visible opacification of the lens 

Dx of 87 yo F developed a lesion on her back for 3-4 years. H/o sunburn in the area. Granulomatous papule, Producing Foul-smelling discharge 
->
Squamous cell cancer

Management of 54 yo F with depression developed irritability, insomnia, headache and fatigue. She had been on paroxetine for 2 years and decided to discontinue it 3 days ago because she was concerned about sexual side effects.
->
Restart paroxetine and taper
Antidepressant discontinuation syndrome: abrupt discontinuation of shorter half-life antidepressants (paroxetine, venlafaxine)

Dx of 52 yo M s/p renal transplant 10 months ago declined renal function. On prednisone, tacrolimus, mycophenolate, and acyclovir. Cre 2.7 UA protein 1+ WBC 20-30 RBC 20-30. Cytology show atypical cells with intranuclear inclusions
->
Polyomavirus-induced nephropathy 
Polyoma virus (BK). Onset 10-15 months after transplant
Allograft rejection difficult to differentiate from BK infection. But allograft rejection does not cause intranuclear inclusion on urine cytology

Dx and Tx for 23 yo M developed slow-growing lesion on the lower lip. No pain, or itching. Rough and hyperkeratotic papule.
->
Verruca vulgaris (common wart) / topical salicylic acid and cryotherapy 
Cause by human papillomavirus 

Management of 18 yo F developed metatarsal shaft stress fracture. She is a ballet dancer. BMI 17. Irregular menses and last menstrual period was 12 weeks ago. 
->
Screen for an eating disorder

Management of 65 yo F with COPD, 50 pack-year history of smoking developed pain in both knees and warmth in her fingers. + finger clubbing. Tenderness to palpation on bilateral knees and fingers
->
Hypertrophic osteoarthropathy -> chest imaging study
Characterized by abnormal proliferation of the skin and osseous tissue. Most commonly due to an intrathoracic process, frequently non-small cell lung cancer

Dx of 74 yo M developed forgetfulness. Over the 2 years, missed important appointments, often forget medication. 2 months ago, got lost in his neighborhood. He is a retired mathematic professor. Mini mental state examination score 26/30.
->
Alzheimer’s disease
Highly educated patients with dementia can have normal MMSE scores

Management of 80 yo M hospitalized for COPD exacerbation. Developed Afib with RVR. TSH 0.07 FT4 1.3.
->
Check T3 level
Euthyroid sick syndrome: due to decreased conversion of T4 to T3, decreased T4 production and TSH suppression. 
Afib is likely due to underlying illness. But need to rule out thyrotoxicosis. T3 is high in thyrotoxicosis. And low in ESS. 

Management of 35 yo M developed fatigue, palpitation and weight loss. Ca 10.9 Cre 0.8 TP 5.5 Alb 3.7 parathyroid hormone 7. 1,25-dihydroxyvitamin D 19 (25-65). 25-hydroxyvitamin D 30 (15-80)
->
Check TSH
Thyrotoxicosis-associated hypercalcemia 
Thyroid hormone acts on osteoclasts to increase bone turnover. Leads to osteoporosis. Induces mild hypercalcemia. 
(Parathyroid hormone-related peptide secretion by malignancies typically causes moderate to severe hypercalcemia)

Dx of 45 yo M with PMH of T2DM developed pruritus in both axillary areas. Well-demarcated, red-brown plaques. Wood’s lamp shows red fluorescence in the affected areas
->
Erythrasma 
Caused by corynebacterium minutissimum (bacteria)

Management of 53 yo F. Pap test showed atypical squamous cells of undetermined significance
->
Check human papillomavirus 
Atypical squamous cells of undetermined significance is the most common abnormal pap test result. If HPV positive, require further evaluation (colposcopy/endocervical curettage). If negative, low risk for cervical intraepithelial neoplasia, and followed by pap and HPV in 3 years

Management of 64 yo M. Started on testosterone for its deficiency 6 months ago. Now Hct 56%. Serum testosterone 504 (300-1200)
->
Decrease testosterone dosage
Testosterone supplementation should be decreased / discontinued if Hct > 54%.
Polycythemia a/w venous thromboembolism and cardiovascular complications 

ESR could be normal in PMR?
->
Yes
Up to 20%. CRP (>22) in nearly all PMR patients 

Management of 60 yo M developed fever, chills, shaking, diaphoresis, muscle pains, headache and dark urine. Hospitalized 3 weeks ago for GI bleed and received blood transfusions. T 103.6 Hb 7.8 PLT 80000 Cre 0.9 T-bil 3.1 D-bil 0.7 AST 177 ALT 149. Coagulation study normal. UA negative for erythrocytes
->
Peripheral blood smear -> parasites within the red blood cells
Transfusion-transmitted babesiosis 
(Delayed hemolytic reaction seen within month of a transfusion. But usually with mild hemolysis and low-grade fever)

Management of neck pain, sustained contraction of the posterior neck muscles associated with neck extension and tenderness after receiving metoclopramide
->
Acute dystonia (retrocollis)
Anticholinergic (benztropine) or antihistamine (diphenhydramine)

What type of precaution for meningococcal infection 
->
Droplet precaution

Management of 38 yo F developed abdominal pain. Crampy and periumbilical pain every 4-5 minutes. Vomited x 3. Last BM 18 hours ago. H/o appendectomy for ruptured appendix 20 years ago. T 99.1 no abd distention. WBC 12000. HCO3 24 liapse 152 amylase 621 ALP 130
->
Plain upright chest and abdominal radiographs
Proximal SBO. Lipase elevated in intestinal obstruction or ileus.
Plain x-ray usually enough. CT if nondiagnostic. 
Conversion of crampy into persistent pain and presence of fever, lactic acidosis, and worsening leukocytosis indicate likely severe obstruction leading to strangulation with necrosis 

Suggestive of depression in cancer patient
->
Withdrawal from family (loss of interest and pleasure)
Somatic symptoms overlap with cancer (low energy, weight loss, sleep disturbance)
Others: worthlessness, excessive guilty, suicidality 


Dx of 51 yo M with h/o renal cell carcinoma on sunitinib developed rashes on hand and foot. Tingling, burning, but no pruritus. Tender, erythematous lesions on palms an soles with areas that look like blisters
->
Hand-foot skin reaction 
A/w small molecule tyrosine kinase inhibitors (imatinib, sorafenib, sunitinib)

Dx of 32 yo F developed L flank pain and gross hematuria. Scattered small pits in her teeth. US shows a 10-cm echogenic mass in the left kidney. Small echogenic mass and 3 renal cysts in the right kidney. CT shows 10x13cm mass in the left kidney with attenuation similar to perirenal fat. 
->
Tuberous sclerosis complex
Dental pitting
May present with angiomyolipoma
Renal lesion may cause pain, hemorrhage, hematuria and loss of kidney function 
Skin: hypopigmented macules (ash leaf spots)

Management of 62 yo M with cirrhosis found to have 2cm nodule with poorly defined border in the light lower lobe by US abdomen. Elevated AFP
->
MRI of liver
MRI better than CT scan 
Bleeding and tumor seeding are risks a/w percutaneous biopsy. Recommended only when initial imaging do not provide a clear diagnosis

Dx of knee twisting injury. Unable to squat due to pain. Click during mid-extension. Negative instability testing
->
Meniscal tear

Knee injury with positive anterior drawer test
->
Anterior cruciate ligament injury

Knee injury with positive valgus stress test
->
Medial collateral ligament injury 

Dx of 22 yo F developed rashes. Numerous small erythematous papules with a fine scale on proximal extremities. Mildly pruritic. Had sore throat 2 weeks ago
->
Guttate psoriasis 
A variant of psoriasis. Acute onset, typically 2-3 weeks after streptococcal infection. Often resolves in a few months 

Dx of 58 yo F developed right thigh pain. A tender, nodular cord is palpated along the inner upper-right thigh
->
Superficial thrombophlebitis 

Hospital implemented a more comprehensive database of drug-drug interactions in its computerized order entry system. However, number of prescribed drugs with high-risk interactions has increased since the database update. What is the cause?
->
Alert fatigue
Health care workers become desensitized to all clinical alarms and alerts

Dx of 23 yo F developed syncope, fever, throbbing pain behind the eyes, myalgias, abdominal pain. Erythematous skin rash on the trunk and extremities. Episodes of epistaxis. Hct 52, PLT 90000, WBC 3300. Returned from southern Mexico 10 days ago 
->
Dengue fever
Retro-obrbital pain/HA, bleeding complications, maculopapular rashes, capillary leakage -> hypotension/shock, leukopenia, thrombocytopenia, elevated hematocrit due to hemoconcentration

Dx of 21 yo F having repetitive binge eating. Not vomiting. Using laxatives. BMI 21
->
Bulimia nervosa
Inappropriate compensatory behavior (vomiting, laxative, exercise)
(In contrast, binge-eating disorder lacks compensatory behavior)

Management of 42 yo M c/o dull headache, malaise, neck pain. Had transient rash a few months ago. RPR 1:50. Positive FTA-ABS. Negative HIV. CSF: WBC 73 neutrophil 85%. VDRL negative. H/o Anaphylactic reaction to penicillin 
->
Aqueous penicillin after desensitization 
Early neurosyphilis. CSF VDRL may be negative in up to 70% of patients.
Treponema pallidum extremely sensitive to penicillin
Penicillin desensitization taking 4-8 hours to complete

Indication for antibiotics for skin abscess
->
Abscess > 2cm, surrounding cellulitis, systemic signs of infection

Management of 65 yo F developed right eye pain, followed by both horizontal and vertical binocular diplopia, ptosis, nonreactive to light.
->
MR angiography of the head
Non-pupil-sparing third nerve palsy
Frequently caused by mass effect (intracranial aneurysm)

What is cobalamin 
->
Vitamin B12

Management of 23 yo M. Hb 11.6 MCV 78 red cell distribution 20% (11-15). splenomegaly. Blood smear 3-5 spherocytes
->
Direct antiglobulin test
Spherocyte seen hereditary spherocytosis, autoimmune hemolytic anemia, and others
Direct antiglobulin test helps differentiate between the two conditions 
AIHA also causes splenomegaly 

Intracellular body in Tick bite diseases
->
Babesiosis: intraerythrocytic pleomorphic ring form (RBC)
Anaplasmosis: morulae (neutophil (WBC))
Human monocytic ehrlichiosis: morulae (monocyte (WBC))

Breast cancer screening for 68 yo F with h/o ESRD on dialysis, CHF with EF 15%, 3 times admissions for heart failure last year. Has had normal biennial mammography in the past
->
No additional routine screening 
In general, breast cancer screen recommended from 40 yo through 74 yo
A life expectancy of < 10 years should not undergo routine cancer screening 

Dx of 42 yo M developed left-sided facial swelling and pain. similar episode 6 months ago. Tender, nonerythematous, spongy swelling in the preauricular area extending to the angle of the mandible. C/o dry mouth, nocturnal wheezing
->
Sialolithiasis

Reason for increased risk of kidney stone in patients s/p bariatric surgery 
->
High urinary oxalate and low urinary citrate
Malabsorption causes more intestinal fatty acid biding to calcium, which increases coloinc oxalate absorption and renal excretion. Malabsorption also causes low urinary citrate due to unclear reasons. Citrate is An inhibitor of kidney stones

Management of 35 yo M c/o anxiety a/w public speaking. Recently promoted to a manager. Profusely sweats and heart races when speaking in public. He can not avoid these situations and his anxiety of public speaking is excessive.
->
SSRI (sertraline)
Social anxiety disorder
Propranolol can be used as needed for rarely occurring performance situations

Test with Highest negative predictive value for celiac disease
->
Human leukocyte antigen testing
Approximately 90% of cases are a/w HLA-DQ2 and almost all of the remainder are a/w HLA-DQ8

Dx of tremor relieved with alcohol
->
Essential tremor

When steroid is given in patients with thyroid storm
->
Later in the treatment of thyroid storm to decrease peripheral T4 to T3 conversion and improve vasomotor stability 
(In contrast, in myxoedema, steroid should be given before thyroid hormone replacement)

Neurological signs of lower extremities in normal-pressure hydrocephalus 
->
Increased tone with brisk reflexes

Type of incontinence induced by cough and sneezing and management
->
Stress urinary incontinence / behavioral changes (weight loss, dietary change, medication changes) and pelvic muscle exercises

Management of 37 yo M c/o sore throat. Feels subjective fever. Has cough. Enlarged tonsils with grayish-white exudates. Small and slightly tender anterior cervical nodes
->
Rapid streptococcal antigen test
Centor criteria: fever, tender cervical lymphadenopathy, tonsillar exudates, absence of cough
0-1: no test or Tx, 2-3: RSAT, 4: empiric Tx or RSAT

Dx of 55 yo M who had alcohol-induced pancreatitis 4 weeks ago. Now good appetite but mild fullness in the abdomen. Mild tenderness in the epigastric region. Lipase 1154
->
Pancreatic pseudocyst
Usually occurs 4-6 weeks after the initial pancreatitis episode 
Persistent elevation of lipase can indicate complications (pancreatic duct blockage, pseudocyst)

Dx of 52 yo M developed foggy vision. On linezolid for osteomyelitis for 4 weeks. Visual acuity 20/400 in both eyes with considerable optic disc edema, hyperamia and reduced color perception
->
Drug induced optic neuropathy 
Linezolid a/w optic neuropathy. Also bone marrow suppression, peripheral neuropathy 

Actinic keratosis covers a half of scalp?
->
Yes

BP med for gout patient
->
Losartan 
Has a mild uricosuric effect

Hematologic condition causes peripheral polyneuropathy 
->
Plasma cell dyscrasia (multiple myeloma, monoclonal gammopathy of undermined significance)

Dx of 24 yo M frequently traveling to Africa developed hematuria. WBC neutrophil 65% eosinophil 9% UA WBC 10-20 RBC many
->
Genitourinary schistosomiasis (due to S haematobium)

Which has more significant effect in slowing the progression of renal disease, weight loss or dapagliflozin
->
Dapagliflozin
Weight loss has not been shown to slow progression for most etiologies of CKD, except for obesitiy-related focal segmental glomerulosclerosis

Tx for toxic adenoma (thyroid)
->
Radioactive iodine ablation 
Thioamides (methimazole, propylthiouracil) can be given before ablation or only for patients who are poor candidates for ablation or surgery

Which is more beneficial for reduction of cardiovascular disease in moderately obese patients, low-carbohydrate diet or Mediterranean-style diet
->
Mediterranean-style diet (plant-based foods)
Low-carbohydrate diet is effective for weight loss, but evidence for reduced cardiac risk is weak

Management of 16 yo F c/o constipation. Exercise 2 hours a day, which she says “is necessary so I don’t become any fatter than I am ready”. BP 80/55 HR 39, BMI 16.5. K 3.2 Cre 0.7, glucose 68
->
Hospitalization 
Hospitalization Indication in anorexia nervosa: unstable vitals, BMI < 15, syncope, electrolyte disturbances, seizure, cardiac failure, or dysrhythmias 

Dx of 35 yo F c/o headache. For 3 months. Unilateral, throbbing, a/w ipsilateral lacrimation and conjunctival injection. Occurs 6-10 times a day and each lasts about 10min. Dramatically improves with indomethacin 
->
Paroxysmal hemicarnia
Trigeminal autonomic cephalalgias includes paroxysmal hemicrania, hemicrania continua, and cluster headache. Main features differentiating paroxysmal hemicranias from cluster headaches are the higher frequency and shorter duration of attacks and the response to indomethacin

When chemoprophylaxis for pneumocystis jiroveci can be discontinued in HIV patients
->
CD4 > 200 for > 3 months

Management of 46 yo M c/o loss of libido, and erectile dysfunction. Cre 2.87 LH 4 (6-23). Testosterone 240 (264-916). TSH 2.4
->
Check serum prolactin level
Central/secondary hypogonadism
Hyperprolactinemia causes central hypogonadism due to the downregulation of GnRH secretion and is common in CKD due to decreased prolactin clearance. 
MRI of the pituitary is appropriate for most patients with central hypogonadism. But prolactin should be measured first to guide choice of test and better interpret incidental imaging findings. In patients with CKD who have hyperprolactinemia with no other clinical or biochemical evidence of a pituitary tumor, MRI may not be necessary.

Management of 42 yo M with h/o acute myeloid leukemia, developed renal failure 4 days after chemotherapy. Has been on rasburicase and aggressive hydration. Cre 3.4 Ca 5.4 Phos 15.2 uric acid 4.5.
->
Hemodialysis 
Tumor lysis syndrome. AKI caused by the formation of uric acid and/or calicium phosphate stones in the renal tubules. Although urate-lowering Tx prevents urate stone formation, calcium phosphate stones remain a relatively common cause of AKI. Aggressive hydration and urgent hemodialysis required  in severe cases

Management of 34 yo F developed fever, and malaise. Is a flight attendant and Returned from Thailand. Lives with her husband and 2 years old child. AST 161 ALT 149 ALP 220 hepatitis A IgM positive. Hepatitis B Ag and core Ab negative. Hepatitis C Ab negative
->
Administer HAV vaccine to all household contacts
Acute hepatitis A infection is managed by supportive care
Unvaccinated adults exposed to household contacts with acute HAV infection are at high risk for HAV infection and should receive postexposure prophylaxis as soon as possible 

DVT prophylaxis for hemorrhagic stroke patients
->
Intermittent pneumatic compression device
Below-knee-high elastic compression stockings not reduce the risk of proximal LE DVT
Thigh-high graduated compression stockings may be harmful (skin breaks, blisters, necrosis)

Dx of 80 yo M developed rash on his legs. S/p cardiac stent placement for unstable angina 2 weeks ago. Mottled, lace-like, purplish discoloration of both leg extremities. WBC 8500 eosinophil 13%, Cre 2.9 UA WBC 10-20 RBC 5-10
->
Atheroembolic disease (cholesterol crystal emboli)
Occurs within hours to days or up to several weeks
Cause eosinophilia 

Management of 38 yo admitted for presumed viral encephalitis. Started on acyclovir iv.
->
iv normal saline at 125ml/hr
Acyclovir is relatively insoluble in urine and can precipitate within the renal tubules, leading to urinary obstruction and AKI

H.pylori test indication for GERD patients
->
Not routinely indicated

Management of 67 yo M c/o nocturia. 2-3 times per night. Occasionally has to strain to initiate urination. Prostate mildly enlarged, symmetric, nontender. Normal Cre. 
->
Behavior modification and observation 
Mild symptoms: shifting fluid intake to earlier, decreasing caffeine and alcohol intake, double voiding to more thoroughly empty the bladder
Moderate to severe symtoms: medications
Many experts also check PSA

Management of newly found WPW pattern on EKG. Asymptomatic
->
Exercise EKG
To identify patients at greatest risk. Low-risk patients with intermittent loss of preexcitation during faster heart rates can be managed conservatively without further evaluation of Tx

Dx and management of 20 yo F c/o heel pain. Experienced bilateral hip pain 6-8 moths ago. Difficulty tying her shoelaces in the morning due to back pain and stiffness. No limitation when performing daytime activities. Episode of intense pain, photophobia and redness involving her left eye. Occasionally has mouth ulcers. Tenderness and swelling of the heel, no synovitis or effusion. CRP 10 (normal < 8)
->
Ankylosing spondylitis /. Pelvic x-ray
Enthesitis at the heel and hips. Inflammatory back pain. Uvitis. Oral ulcer often seen
Anteroposterior x-ray of pelvis revealing arthritis and erosions of the sacroiliac joints

Dx of 55 yo M developed bizarre behavior during sleep. He screams as if being attacked and swings his arms wildly while still asleep. His wife was hit several times
->
REM behavior disorder
Loss of REM atonia
Highly a/w parkinson disease and dementia with lewy bodies
In younger patients, a/w narcolepsy or antidepressant medications 

Anti-hypertensive medication associated with risk of developing diabetes 
->
Thiazide
Dose-depedent decrease in pancreatic insulin release and impairment of glucose uptake in peripheral tissues

Tx for chronic myeloid leukemia 
->
Tyrosine kinase inhibitor (imatinib)

Tx for acute promyelocytic leukemia
->
All-trans retinoic acid plus anthracycline-based chemotherapy 

Dx of 52 yo M developed sore throat, nocturnal high fever, weight loss. Enlarged cervical lymph nodes. Scarce macular, nontender, purple rash on both arms, splenomegaly. Synovitis in both hands, wrists, and elbows. WBC 18500 PLT 620000 CRP 12 ESR 112 RF 15 ferritin 8430
->
Adult-onset Still’s disease
May have hepatosplenomegaly
Rheumatologic serologies negative
Felty syndrome: long-standing rheumatoid arthritis, positive RF, splenomegaly and leukopenia (neutropenia)

Tx for jet lag
->
Melatonin 

Dx of 73 yo F developed hand shaking over the couple of weeks. She ran out of atenolol for HTN a month ago. Occurs especially when pouring tea and knitting
->
Essential tremor
Presents in the 5th or 6th decade of life
Beta blocker therapy withdrawal can present with HA, palpitations, sweating and postural hand tremors. Sx typically can acutely occur within 24-36h following discontinuation of Tx. This Pt continues for many weeks, making beta blocker withdrawal unlikely

Dx of 3/6 short systolic murmur, heard at the left lower sternal border and the apex in the spine position. Murmur gets longer with standing
->
Mitral valve prolapse with mitral regurgitation 

EKG change at Acute phase and one week after in patients with acute pericarditis 
->
Diffuse ST elevation and PR depression at acute phase
Diffuse T wave inversion one week after

Risk of tamoxifen 
->
DVT, Uterine cancer 

Management of persistent dyspnea in patients with end-stage COPD
->
Morphine
Effective Tx for the relief of dyspnea

Dx of 75 yo M admitted for pneumonia. Improved with ABX. Developed right knee pain on 3rd day. Knee swollen. Synovial fluid analysis: WBC 20600, neutrophil 90%. Gram stain negative. No crystal seen.
->
Pseudogout (calcium pyrophosphate dihydrate deposition disease)
Can be triggered by acute illness
CPPD crystals are small and often scarce and crystal microscopy alone has low sensitivity 

Management of pituitary incidentaloma 7mm
->
< 10mm:
Evaluation to look for pituitary hormonal hyperfunction (hypofunction and visual field not required)
No clinical feature of hyperfunction -> check prolactin level only 
Clinical feature of hyperfunction -> targeted hormone testing
> 10mm: check hyperfunction (Cushing, acromegaly, prolactin) / hypofunction and visual field / acuity test

Management of 25 yo F whose sexual partner was diagnosed with primary syphilis 2 weeks ago. She is asymptomatic 
->
Administer a single dose of benzathine penicillin 
A Patient exposed within 90 days prior to the diagnosis of primary, secondary or early latent syphilis in a sex partner should receive presumptive Tx
A patient exposed > 90 days before diagnosis of primary, secondary or early latent syphilis in a sex partner can undergo serologic test and Tx accordingly 

Patient with thyroid nodules. What is risk factor for malignancy 
->
Elevated TSH
(Exposure to ionizing radiation, family history, size>1cm, ..)
(Radiology technicians moderately increased risk, but not nuclear medicine technician)

Dx and management of 75 yo M c/o dizziness. Syncope twice. Lightheadedness occasionally in the morning, but the more severe episodes usually occur between 2 and 3PM and around 8PM. 
->
Postprandial hypotension / smaller and more frequent meals
>20mmHg decrease in systolic BP within 2 hours after eating a meal. Unclear Mechanism 
Distinct from typical orthostatic hypotension 

Dx of 67 yo F c/o SOB, and leg edema. Echo shows normal LV cavity size, LVEF 70%, biatrial dilation, severe LVH
->
Infiltrative cardiomyopathy (amyloidosis or sarcoidosis)
Ventricular wall thickening eventually leads to diastolic dysfunction, RV dysfunction, and biatrial enlargement. May be misdiagnosed as LVH

Cause of fecal incontinence of 78 yo F c/o urinary incontinence and fecal incontinence. H/o longstanding urinary incontinence. Fecal incontinence started one week ago. Had been on laxative for chronic constipation, and the laxative discontinued. Remains in bed most of the day
->
Overflow of stool due to fecal impaction 
Fecal impaction is common in the elderly and is a/w impaired mental function, immobility, inadequate fluid/fiber intake, and chronic constipation
Fecal incontinence occurs when loose or liquid stool flows around the impaction in the rectum

Management of 51 yo female was diagnosed with DVT in lower extremity. She has h/o breast cancer with metastasis to brain.
->
Long-term Tx with low-molecular-weight heparin
Patients with brain metastasis from most cancer types can safely receive anticoagulation without increased risk of intracranial hemorrhage
LMWH is superior to warfarin
High risk of intracranial hemorrhage: melanoma, choriocarcinoma, thyroid cancer, renal cell carcinoma 

Dx of 63 yo M c/o R shoulder pain. 40-pack-year history. Sensation to light touch diminished in the right 4th and 5th fingers. Active and passive ROM of the R shoulder normal.
->
Superior pulmonary sulcus (Pancoast) tumor
Tumor arises in teh apical pleuropulmonary groove adjacent to to the subclavian vessels, brachial plexus, and C8-T2 nerve roots

Dx of 45 yo F with joint pain fro 3 months. Swelling and tenderness of several proximal interphalangeal joints, metacarpophalangeal joints and both wrists. ESR 55. ANA negative. RF negative. Anti-cyclic citrulinated peptide negative
->
RA
diagnosis based on clinical features. RF positive in 50% of patients at the time of diagnosis 
anti-CCP Ab sensitivity 50-75%
Many patients have seronegative RA, especially early in the disease 

Dx of 62 yo M developed gait instability. Horizontal nystagmus. Dysarthria. CXR show a lung mass. MRI of the brain +/- contrast normal.
->
Paraneoplastic Cerebellar degeneration 
Cytotoxic T-cells and antibodies (anti-Yo, anti-Hu) attack neurons in the cerebellum

Dx of 29 yo M developed right eye pain, redness and blurry vision for 2 days. White exudate accumulates in the anterior chamber
->
Anterior uveitis 
Hypopyon (leukocytic exudate in the anterior chamber)

Cardiac sound best heard when sitting up, leaning forward, hold breath at end-expiration while placing the diaphragm at the mid-left sternal border
->
Aortic regurgitation murmur

Management of 65 yo M with polymyalgia rheumatica with giant cell arteritis. Started on 60mg/day of prednisone. T-score -1.3
->
Start risedronate (bisphosphonate)
All men > 50 yo and postmenopausal women taking > 7.5mg/day of prednisone for an anticipated course > 3 months should be started on bisphophonate as initial Tx

Flexor Plantar response 
->
Normal
Extensor response -> Babinski sign

Management of 67 yo M found to have elevated total protein. Hb 14.2 WBC 5500 Ca 9.2 Cre 0.8 TP 8.6 Alb 3.8. protein electrophoresis gamma globulin 2.3g/dL. Immunofixation: IgG. 
->
Bone marrow biopsy 
Monoclonal gammopathy of undetermined significance: M-protein < 3g/dL, < 10% bone marrow clonal cells, and no end-organ damage
Bone marrow biopsy required to confirm the diagnosis

How to obtain Vibrio vulnificus
->
Raw/undercooked shellfish (oysters) or exposing open wounds to warm coastal/brackish waters
Fatal infections in patients with chronic liver disease and cirrhosis 

Management of 76 yo M developed lethargy. Ca 16.0 Cre 1.6 GFR 41 TP 6.5 Alb 3.7. received NS iv hydration and calcitonin 
->
Zoledronic acid
Although zoledronic acid is not recommended for use in non-oncologic conditions (osteoporosis) if GFR < 35, it may be used for humoral hypercalcemia of malignancy in patients with significant renal impairment (Cre < 4.5) or may be considered for those with Cre > 4.5

Dx test for immune thrombocytopenic purpura
->
History, Physical exam, CBC, and peripheral blood smear (do not suggest other etiologies for isolated thrombocytopenia)
Bone marrow aspiration indicated for those > 60 yo to rule out MDS

Management of 71 yo M who recovered from gas gangrene of thigh. Blood cx grew clostridium septicum
->
Colonoscopy 
Clostridium septicum commonly a/w spontaneous gas gangrene
Most patients have underlying colonic malignancy have been a/w C.septicum

Management of 27 yo F with MS. on glatiramer acetate. Will be started on natalizumab for progressive disease
->
Check JV virus Ab titers
Natalizumab (recombinant monoclonal antibody against alpha-4 integrins that prevents adhesion of inflammatory lymphocytes and monocytes to vascular endothelium) a/w the development of progressive multifocal leukoencephalopathy, caused by JC virus reactivation 

Condition a/w coarctation of aorta 
->
Turner syndrome (short stature, ..)
Bicuspid aortic valve

Does Pulmonary edema causes hemoptysis?
->
Yes

Cause of actinic purpura
->
Blood vessel fragility after years of sun-related damage to the dermis
(= senile (solar) purpura)

Dx of 35 yo M developed bloating, excessive flatus and loose stools since an episode of food poisoning several months ago
->
Secondary lactose intolerance 
Can develops after acute infection or inflammation due to inflammatory destruction of the terminal villi and subsequent loss of the lactase enzyme

liver span indicating hepatomegaly
->
> 15cm

Management of 71 yo M with hip osteoarthritis, significant reduction in internal and external rotation, accompanied by pain. Some relief from PT and NSAIDs, but now more pain
->
Replacement surgery
Intraarticular corticosteroids injections do not provide long-term benefit in hip OA and not routinely recommended 

Dx and management of 42 yo M developed skin lesions in neck, chest and arms. Painful edematous papules. Central yellowish discoloration similar to target lesions. Also fever, arthalgias. Had URI 3 weeks ago. T 100.8 WBC 14000. BCx negative. Biopsy of the skin lesions shows a dense neutrophilic infiltrate without vasculitis
->
Sweet syndrome / topical or systemic corticosteroids 
Malignancy-associated (hematologic)

Test having prognostic value in RA
->
Anti-cyclic citrullinated peptide Ab
High titers can predict erosive RA
(Elevated ESR/CRP can also predict poorer functional outcomes)

Effect of discontinuation of oral estrogen in patient taking levothyroxine for hypothyroidism 
->
Iatrogenic thyrotoxicosis 
Estrogen decreases thyroxine-binding globulin. Increased TBG leads to lower T4. Discontinuation of estrogen results in decrease in circulating TBG combined with unchanged levothyroxine dose, which likely results in iatrogenic thyrotoxicosis 

Dx and management of 47 yo F developed ear discomfort. Recovering from URI. Feels that her R ear is “plugged” and hears popping sounds when chewing or yawning. Slight pain. R tympanic membrane mildly retracted. Tuning fork placed in the middle of head lateralizes to R. 
->
Eustachian tube dysfunction / oral decongestant 
The eustachian tube connects the air-filled middle ear to the nasopharynx and equalizes pressure across the tympanic membrane 
Functional obstruction (viral URI, allergic rhinitis). Diagnosis is clinical. 
Oral decongestant often effective for Sx a/w acute viral infection (glucocorticoid nasal spray for Sx a/w allergic rhinitis)

Management of 30 yo F recent hospitalization for bloody diarrhea. Sx resolved. Labs: PLT 210000 INR 1.0 aPTT 53sec
->
Mixing study (1:1 ratio with normal plasma and patient’s plasma)
Mixing study first (deficiency or inhibitor), then confirm factor deficiency 
Normal PT and prolonged aPTT
Prolonged aPTT without clinical bleeding: deficiency of XII, …
Prolonged aPTT with clinical bleeding: deficiency of VIII,IX,XI, von Willebrand disease
Prolonged aPTT with thrombosis: antiphospholipid Ab

Dx of 35 yo M developed a lesion in natal cleft. Painful. With sinus opening. No fever
->
Pilonidal disease (毛巣病)
Natal cleft: 臀裂
A skin and/or subcutaneous infection near the natal cleft of the buttocks 
Tx: incision and drainage

Management of 57 yo M c/o R thigh pain while walking. PMH: T2DM, HTN, HLD, CKD. 40 pack-year history. A small ulcer at the tip of R big toe. ABI 1.0 
->
Exercise testing with repeat ABI
Typical intermittent claudication can have normal ABI at rest. Those with a High likelihood of PAD should be evaluated with exercise testing with repeat ABI

What is 5-hydroxyindoleacetic acid 
->
5-HIAA: carcinoid syndrome 

Tx for severe rosacea
->
Oral ABX (tetracycline)
Topical metronidazole for mild-moderate case

Management of 37 yo M developed dysphagia and pain on swallowing. H/o HIV. Last CD4 80. Plaques on the tongue and soft palate. Bright red erythematous fissures present at the angles of the mouth. 
->
Oral fluconazole
Candida esophagitis 
Dysphagia and mild-moderate odynophagia (CMV/herpes esophagitis cause severe pain)
Empiric Tx for pt with thrush and Sx consistent with candidal esophagitis. 
EGD if Sx fails to improve within 72 hours

Tx for depression and diabetic neuropathy
->
Duloxetine
Serotonin-norepinephrine reuptake inhibitor
No specific antidepressant has demonstrated superior efficacy over any other
SSRI less evidence on the effectiveness in treating pain 

Tx for episcleritis
->
Self-limited / topical lubricants

Chemoprophylaxis for malaria
->
Atovaquone-proguanil

Management of insomnia
->
Going to bed only when feeling sleepy

Tx for xerostomia
->
Cevimeline (cholinergic) to stimulate salivary muscarinic receptors 
(Prolonged use of Hydrogen peroxide mouthwash causes mucous membrane irritation)

Dx of 26 yo F developed HA, fever, muscle aches, returned from Africa. multiple urticaria-type lesions on the trunk and upper extremities. WBC 12000 eosinophils 40% 
->
Schistosomiasis 
Fever, urticarial lesions, eosinophilia
Hypersensitivity reaction against schistosomal eggs and larvae

Management of 40 yo F diagnosed with celiac disease. Significant improvement after strict gluten-free diet. 
->
Bone densitometry 
Bone loss is very common due to malabsorption of vitamin D and resultant secondary hyperparathyroidism 
DXA at the time of diagnosis of celiac disease, regardless of age or menopausal status

Management of 55 yo M developed painful rash on back. Bullae and erosions. Sore in mouth
->
Skin biopsy 
Pemphigus vulgaris
Diagnosis must be confirmed with skin biopsy because Tx is often lifelong and involves systemic corticosteroids and other immunosuppressants 

Tx for bipolar depression 
->
Quetiapine
Second-generation antipsychotic 
Antidepressant monotherapy should be avoided in bipolar depression due to the risk of precipitating mania

Physical exam for ankylosing spondylitis
->
Chest wall expansion 
Limited chest wall expansion is due to costovertebral rigidity 

Dx of 40 yo M returning from Bangladesh developed small white papules on the buccal mucosa and conjunctivitis 
->
Measles
Need air-born isolation 

Dx of 40 yo M developed bilateral flank pain. H/o AIDS. Non-compliant. Recently started on sulfadiazine. Cre 2.2 (baseline 1.2). UA WBC 20-30, RBC 20-30
->
Crystal induced AKI due to sulfadiazine (ABX for toxoplasmosis)
Poorly soluble drugs precipitate within the renal tubules

Dx of 67 yo M with h/o polycythemia vera developed fatigue. Used to undergo phlebotomy for 7 years. But no phlebotomy for the last year. Splenomgaly present. Hb 8.6 MCV 82 PLT 130000 WBC 12000
->
Myelofibrosis
post-PV myelofibrosis
PV at the risk of DVT, post-PV myelofibrosis, AML, MDS

Highest risk of aneurysm expansion and rupture, smoking or elevated LDL
->
Smoking

Adverse effect of low-carbohydrate diet
->
Unpleasant GI effects (bloating, diarrhea, constipation)

Dx of 55 yo F developed facial rash. Get worse when staying outside. Also developed a 1-cm ulcer in the roof of the hard palate. Recent diagnosis of DM and HTN
->
SLE

Dx of 70 yo M with h/o CKD, DM, gout developed muscle weakness and pain. WBC 5100. CPK 1200. ESR 17. Eelectromyogram shows slowed sensory and motor nerve conduction velocity. Muscle biopsy shows widespread cytoplasmic vacuolization but no inflammation 
->
Colchicine neuromyopathy 
Seen in CKD and colchicine take
Cytoplasmic vacuolization (空胞変性) is characteristic

Dx of 76 yo M developed lethargy. PMH: seizure, stroke, dementia. On ASA, phenytoin, levetiracetam, vit D. Recently started on omeprazole for reflux Sx. Narrow-based, unsteady gait. Slurred speech, horizontal nystagmus, poor finger-nose maneuvers bilaterally
->
Phenytoin toxicity 
Horizontal nystagmus, gait unsteadiness
Omeprazole inhibits P450 and leads to increased serum phenytoin level

Management of 71 yo F with chronic constipation. No alarm features. Normal labs. Radio marker study shows delayed motility in the proximal colon.
Bulk-forming laxative vs osmotic laxative?
->
Bulk-forming laxative (methylcellulose, psyllium)
Osmotic laxative (polyethylene glycol) also effective in slow transit constipation, but excessive use of these agents may result in volume overload and electrolyte abnormalities. Current guidelines recommend a trial of supplemental fiber as first-line Tx

At what GFR AV fistula recommended to place
->
< 25 (not 15) 

Cervical cancer screening starting age and interval 
->
21 yo
Pap smear every 3 years 
Or 
Pap smear and HPV test every 5 years

Erythropoietin level in patient with polycythemia secondary to hypoxia 
->
Low 

Dx and management of 56 yo developed nephrotic syndrome. Normal C3/4, negative ANA, hep B/C negative. HIV negative protein electrophoresis with immunofixation normal. Free light chain negative. Antiphospholipase A2 receptor Ab positive
->
Primary membranous nephropathy / no additional test
Secondary MN negative for antiphospholipase A2 receptor Ab
If Secondary MN suspected, screen for malignancy, hepatitis screen, autoimmune disease work-up

Dx of 36 yo M with recurrent sinus infection and pneumonia. H/o vitiligo
->
Common variable immunodeficiency 
A/w autoimmune disorder (vitiligo, RA, thyroid) and malignancy (lymphoma)

Management of COPD on albuterol PRN and tiotropium. 3 exacerbations last year. No hospitalization last year
->
Pulmonary rehabilitation 
May add long-acting beta agonist
Corticosteroid inhaler is second-line options, exception for pt with concomitant asthma 

Management of 70 yo M with BPH initially improved with a long-acting alpha adrenergic blocker. Now develops intermittent urinary incontinence and strong urge to void. Exam shows slightly enlarged, smooth, non-tender prostate. Residual volume 60ml
->
Add an antimuscarinic agent
Urge incontinence caused by detrusor hypersensitivity
Persistent Sx with alpha-adrenergic agent often responds to antimuscarinic agent (tolterodine, oxybutynin). Postvoid residual volume should be measured prior to initiation. Should avoid in patients with postvoid residual volume > 200ml

Dx of 38 yo M from Laos developed abdominal pain. Diagnosed with asthma 2 years ago. WBC 8200 eosinophil 15% CT abdomen normal. Stool for ova and parasite negative
->
Strongyloidiasis / serology test (ELISA IgG Ab)
Intermittent abdominal pain, pulmonary Sx misdiagnosed with asthma

Dx of 33 yo F developed knee pain. S/p parathyroidectomy a week ago. WBC 9600 ESR 46 synovial fluid: WBC 20400
->
pseudogout
Hyperparathyroidism can lead to chondrocalcinosis in the articular cartilage. Parathyroidectomy can precipitate a pseudogout attack due to an abrupt drop in serum Ca levels, which triggers crystal shedding into the synovial fluid

Can sildenafil be given to patients on dialysis?
->
Yes
Most men with ESRD experience sexual dysfunction 

Management of 27 yo F c/o irregular menstrual period and failure to conceive. FSH 6 LH 4 prolactin 25 testosterone 45 (normal 20-75) TSH 7.6 FT4 1.0 anti-thyroperoxidase Ab positive. Mid-luteal phase progesterone very low, indicating no ovulating
->
Levothyroxine
Ovulatory dysfunction is common in both overt and subclinical hypothyroidism and usually improves with levothyroxine Tx

Management of 45 yo F with depression. One month after initiation of sertraline, some improvement, but developed anorgasmia. The dose was decreased. Still having anorgasmia.
->
Add bupropion and taper sertraline
SSRI a/w sexual dysfunction
Bupropion no effect on sexual function 
SNRI (venlafaxine) also a/w sexual dysfunction 

Tx for 82 yo F with depression, appetite loss and weight loss
->
Mirtazapine
Effective in treating geriatric depression a/w weight loss and poor sleep

Dx of 42 yo M developed bilateral tingling and electric shock-like pain on the lateral aspect of palms and first three fingers. Fatigue. Malodorous sweat. Oily skin with skin tags on neck
->
Acromegaly 
Carpal tunnel syndrome, skin tags, oily skin, excessive sweat

Side effect of topiramate
->
Weight loss, kidney stone

Management and prognosis of acute otitis media complicated with perforation of the tympanic membrane 
->
Complete resolution with topical and oral antibiotics

Management of 27 yo M with type 1 von Willebrand disease. H/o severe epistaxis. Scheduled for elective craniotomy for brain tumor
->
VWF preparations
Desmopressin effective for mild/moderate type 1 VWD
VWF preparations (high-purity VWF concentrate, recombinant VWF,..) for severe bleeding and perioperatively for invasive surgeries 

Most likely to achieve HbA1c < 6% in one year in 50 yo F with T2DM. On metformin. BP 152/92 BMI 39 HbA1c 9.0% LDL 132
By Insulin Tx  or  intensive nutritional counseling  or  bariatric surgery
->
Bariatric surgery 
Roux-en-Y bypass is more effective than conventional medical Tx (lifestyle change, weight management counseling, oral hypoglycemics, insulin)

Pulmonary manifestation and Tx for mycobacterium avium complex 
->
Similar to M tuberculosis: nodular or cavitary lesions or multifocal bronchiectasis and nodules
Combination Tx with macrolide (clarithromycin, azithromycin), ethambutol and rifamycin

Dx of 23 yo M developed jaundice, dark urine and fatigue. S/p trimethoprim-sulfamethoxazole 4 days ago for sinusitis. Hb 9.6 reticulocytes 15% LDH 1200. Many bite cells. Direct and indirect Coombs’ test negative. Red blood cell glucose-6-phophate dehydrogenase level normal
->
Glucose-6-phosphate dehydrogenase deficiency 
Bite cells: characteristic 
Testing for G6PD deficiency during an acute hemolytic episode may produce a false negative result as the older and more deficient erythrocytes are destroyed and replaced by reticulocytes that commonly have normal G6PD levels

Management of Colonic pseudoobstruction 
->
Supportive Tx and serial abdominal examinations
Neostigmine if fail 24-48h of conservative Tx
Metoclopramide: only limited anecdotal experience and not first-line Tx
Etiology is unclear (Ogilvie syndrome)

Dx of 62 yo M with T2DM, HLD c/o R hip pain. The pain is brought on by walking (especially uphill) and goes away quickly with standing still. Sometimes accompanied by leg weakness. 
->
Peripheral artery disease
Localized hip or buttock area pain suggests aortoiliac occlusive disease 

Diagnostic test for brain death
->
Apnea testing
Mechanical ventilation discontinued for 10 minutes to observe for spontaneous breathing
EEG is not recommended as it is susceptible to to excessive artifact from other electrical devices

Management of somatic symptom disorder
->
Cognitive-behavioral therapy 
Has the best evidence 

Management of 84 yo M developed leg gangrene. Amputation was recommended as a life-saving procedure. He refused. No evidence of delirium or psychosis. Appetite normal. No change in sleep. Able to provide a summary of his medical condition and acknowledge that refusing surgery may result in his death. Montreal cognitive assessment 24/30
Need to obtain a psychiatric consult to evaluate the patient’s capacity?
->
No
Decision making capacity
-Communicate: able to clearly indicate preferred Tx option
-Understand: understand conditions and Tx option
-Appreciate consequences: acknowledge having condition and likely consequences 
-Rationale: able to weigh risk and benefits and offer reason for decision 
MoCA 24/30 indicates mild cognitive impairment. There is no single scores with high sensitivity and specificity to assess capacity 

Management of 66 yo M with parkinson disease c/o painful involuntary contractions affecting both feet. Occurs soon after he wakes up in the morning, occasionally wake him up from sleep. On immediate-release carbidopa/levodopa twice daily for 5 years
->
Switching to long-acting carbidopa/levodopa at night
Motor fluctuations occur as episodes between levodopa doses when the drug wears off. dystonia is a common painful Sx. 

Difference between rotator cuff tendinitis and tear
->
Tear exhibits weakness with external rotation, but not in tendinitis 

Management of 38 yo F with recent diagnosed duodenal ulcer with positive H pylori. Finished triple-drug Tx. Still having abdominal bloating. On omeprazole. Urea breath test becomes positive
->
Administer quadruple Tx (PPI, bismuth, metronidazole, tetracycline) for H pylori
Or different triple Tx
PPI decreases the sensitivity of urea breath test so it should generally be withheld for 2 weeks prior to test. If positive urea test in the setting of continued PPI is highly suggestive of active infection 

Dx of 49 yo F developed rash on back and shoulders for 2 years. No pruritus. Spontaneously resolve after a few days. Recurrence every 2-3 months. Erythematous and scaly papules with crusted margins
->
Subacute cutaneous lupus erythematosus
Photosensitive rash (shoulder, forearm, neck, upper torso). No malar pattern (頬). 
Not positive ANA. 

Cause of hypotension in patient with Right atrial pressure 2, right V pressure 20/4, pulmomary artery pressure 18/10, pulmonary capillary wedge pressure 5, cardiac index 2.2, systemic vascular resistance 1525
->
Hypovolemic shock
Normal SVR 1150. 
Septic shock: increased CI, decreased SVR

Dx of 38 yo F developed numbness and parasthesias.  Pale right optic disc. Right relative afferent pupillary defect, reduced sensation on the left side of the face. Slight pronator drift in the R upper extremity with increased tone and hyperflexia. MRI brain +/- gadolinium shows multifocal ovoid white matter lesion in the periventricular areas
->
MS
Systemic embolization affects the cortex rather than the periventricular regions

Dx of 65 yo M sees floaters in his R eye. Right-sided visual field detect. Normal funduscopic exam
->
Retinal detachment
Funduscopy has low sensitivity and may be normal

Difference between anti-glomerular basement membrane antibody disease and granulomatosis with polyangiitis
->
Systemic Sx: absent in anti-GBM Ab disease and present in ANCA disease 
anti-GBM Ab disease: Classic liner immunofluorescence IgG deposition along the GBM
ANCA-glomerulonephritis: pauci-immune necrotizing inflammation (minimal or non IF). Direct damage to small vessels 
Complement level often normal in both diseases 

Management of 46 yo M c/o sexual dysfunction. H/o SSS s/p pacemaker placement. FSH 5 (5-15), LH 4 (3-15), testosterone 175 (300-1200)
->
Evaluate for hereditary hemochromatosis 
Secondary hypogonadism due to iron accumulation in the pituitary gonadotrophs
Cardiac conduction abnormalities in about 31% of cases 

Dx and diagnostic test for 26 yo M. 65kg and 190.5cm. faint early diastolic murmur heard in the second right intercostal space. Mild scoliosis. Positive wrist and thumb signs due to long slender fingers
->
Marfan syndrome / echocardiogram
Aortic regurgitation a/w MFS
Dx based on the presence of aortic root dilation, ectopia lentis, family history, fibrillin-1 gene mutation, and other signs of MFS

Dx of 22 yo African American M developed hematuria. Hct 40 PLT 240000 Cre 0.8 UA specific gravity 1.010 protein trace WBC 1-2 RBC many cast none. US unremarkable
->
Sickle cell trait
Hematuria and impaired ability to maximally concentrate the urine are the renal abnormalities encountered in patients with sickle cell trait. Renal pailla is a hypoxic and hypertonic environment, and papillary blood velocity is relatively slow - all conditions which favor sickling of cells. This results in renal papillary infarction and possible papillary necrosis 

Dx of 34 yo M developed skin lesions on face, scalp, and neck. Mild pruritus. Worsens with sun exposure. Red, inflamed, scaly and round lesions. Some atrophic hypopigmented scarring. Some hair loss. 
->
Discoid lupus erythematosus 

Dx of 45 yo F with rheumatoid arthritis developed right foot pain. Nighttime numbness at the bottom of the right foot. No focal tenderness on foot exam. Light tapping behind the right medial malleolus elicits tingling 
>
Tarsal tunnel syndrome
Due to posterior tibial nerve compression 

Management of 43 yo F developed epigastric pain. BP 90/60 HR 112. Cre 1.8 Ca 6.7 T-bil 1.6 AST 186 ALT 100 ALP 120 liapse 512 TG 2600. US normal CBD
->
Therapeutic plasma exchange
If TG > 1000 or severe pancreatitis, therapeutic plasma exchange (apheresis) should be considered
If TG > 500, insulin infusion can correct TG level within 3-4 days

Acute septic embolic stroke indicated for surgical intervention for endocarditis?
->
Yes if patient is already on appropriate antibiotic therapy

Dx of 24 yo M developed diarrhea for 2 weeks. Pale, voluminous, foul smelling and non-bloody. Avid hiker
->
Giardia 
Diarrhea with steatorrhea

Criteria of pCO2 for obesity hypoventilation syndrome
->
pCO2 > 45

Management of 32 yo M developed diarrhea and abdominal pain. Some blood in the stool. 4 months ago, had C.diff colitis, treated with oral Vanco. WBC 11400. Stool PCR for C.diff toxin is negative
->
Colonoscopy with biopsy 
Inflammatory bowel disease 
Patients with IBD have a high prevalence of of C. Difficile colonization 

Management of 33 yo primigravida at 32 weeks developed itching. PLT 260000 T-bil 2.3 AST 338 ALT 340 ALP 130 INR 1.0 US normal liver echogenicity and CBD
->
Ursodeoxycholic acid 
Intrahepatic cholestasis of pregnancy 
Not usually cause significant maternal complications, But increases risk of fetal complications. 
Recommend delivery at 37 weeks. First-line Tx: ursodeoxycholic acid
HELLP syndrome: elevated AST/ALT, thrombocytopenia, hemolysis -> prompt delivery
Acute fatty liver of pregnancy: elevated AST/ALT, elevated INR, thrombocytopenia -> prompt delivery 

Dx of 40 yo F developed weakness. Discomfort in RUQ. PMH: T2DM, HLD. C/o low back pain and bilateral knees. Right knee has mild crepitus. BMI 36. T-bil 1.0 AST 110 ALT 126 ALP 120 hepatitis panel negative. US hyperechoic, enlarged liver. 
->
Nonalcoholic fatty liver disease
Hemochromatosis: arthritis affects the 2nd and 3rd metacarpophalangeal joints. Premenopausal women unlikely to develop symptomatic iron overload due to regular menstruation

Management of 41 yo M recently diagnosed with celiac disease
->
Pneumococcal vaccination 
Although the pathogenesis is unknown, hyposplenism has been reported. Pneumococcal vaccination is recommended in patients with celiac disease, regardless of age

Management of 32 yo at 16 weeks gestation developed depression. Still symptomatic with psychotherapy 
->
Sertraline
SSRI is First-line Tx for antenatal depression 
The risks to the fetus and mother from untreated maternal depression generally outweigh the potential and unproven risks of treatment

What is WBC of synovial fluid in septic joint
->
> 50000

Dx of 68  yo F presented with SOB. Lung exam: bronchial breath sounds at the left base. Dullness to percussion at the left lung base. Increased tactile fremitus
->
Pneumonia
Palpable vibration felt on the chest wall is known as fremitus
Sounds travels faster in solid (consolidation) Than in the aerated lung
Fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in pleural effusion or pneumothorax

Dx and management of 45 yo F developed headache, trouble concentrating. Physical exam normal. Hb 8.2 PLT 25000 WBC 7900 Cre 1.1T-bil 2.5 D-bil 0.8 AST 78 ALT 55 LDH 1950 INR 1.1 UA WBC 1-2 RBC 5-10. Direct Coombs test negative. Blood smear schistocytes
->
Thrombotic thrombocytopenic purpura / plasma exchange 
It is rare to have Classic pentad (fever, microangiopathic hemolytic anemia, renal failure, neurological symptoms). The presence of MAHA and thrombocytopenia (not due to other causes) is enough to diagnose suspected TTP and initiate treatment with plasma exchange. Measurement of ADAMTS13 activity is not required to make the Dx

Dx and management of 43 yo F with migraine without aura developed vertigo, occipital headache, and lip numbness. Has seen “floating lights”. Mild dysarthria. MRI +/- contrast negative
->
Migraine with brainstem aura / MRA of head and neck
H/o migraine with brainstem symptoms (vertigo, dysarthria, ataxia) and normal MRI
MBA can mimic dysfunction of the posterior cerebral circulation. Ddx includes TIA, basilar aneurysm and temporal epilepsy. MRA to rule out posterior vascular lesions first

Dx of 45 yo F in jail developed pain and swelling of right knee. Fatigue, weight loss. Several white-to-yellowish flaky scales on the scalp, nasolabial folds. Effusion in R knee joint. L 2nd toe swollen with slight bluish discoloration and tender. Synovial fluid from Knee: WBC 10000 neutrophils 55%, GS/crystal negative
->
Destructive psoriatic arthritis / HIV
Acute oligoarthritis with inflammatory knee effusion, dactylitis and erythematous plague with sliver scales. Psoriatic arthritis more aggressive when a/w HIV

Management of chronic fatigue syndrome
->
Cognitive-behavioral therapy 
To target thoughts or behaviors that hinder recovery and graded exercise therapy (slowly increasing exercise tolerance over time)

Medication causes vitamin B12 deficiency 
->
Metformin 
Reduces intestinal absorption of vitamin B12 

Management of medication-overuse headache
->
Discontinue offending analgesic agent and short oral steroid taper (bridging Tx) +/- prophylaxis Tx 

Dx of 45 yo F with T2DM developed reddish spots on her legs. Annular lesions with a yellowish-brown hue and central epidermal atrophy on pretibial areas
->
Necrobiosis lipoidica diabeticorum
Typically occur in the pretibial areas in diabetic patients

Management of 18 yo F having painful menstrual periods for 6 months. Disturb daily activities, Menarche at 13 yo, followed by irregular menstrual periods for the first year. Now monthly. Negative pregnancy test. 
->
Combination oral contraceptives
Primary dymenorrhea, based on clinical diagnosis and normal pelvic exam 
Empiric Tx with combination oral contraceptives or NSAIDs
If persistent for 3 months with Tx, -> pelvic US (adenomyosis), if negative US, -> diagnostic laparoscopy (endometriosis) or GnRH agonist (leuprolide)

Management of HFpEF
->
Spironolactone -> reduce hospitalization 
Exercise training-> improve functional capacity and overall QOL

Dx of 28 yo F with bilateral parotid glands swelling. Slightly elevated serum bicarbonate 
->
Bulimia nervosa
Parotid gland hypertrophy due to self-induced vomiting

Orthostatic hypotension is increased risk of what?
->
All-cause mortality 
Symptomatic and asymptomatic 
Also increase risk of cardiovascular disease 

Ddx of foot drop
->
Common peroneal nerve compression 
L5 radiculopathy (back pain, possible weakness of leg abduction)
L5 radigulopathy typically has normal reflexes  

Management of 50 yo M with hepatitis C developed itchy rashes on arms. Purple polygonal papules
->
Topical corticosteroids/ lichen planus
Polygonal: 多角形の

Dx of 32 yo F initially developed sore throat and fever. Followed by hand pain and swelling. Oropharyngeal exam shows mild tonsillar swelling with normal mucosa. Non-tender lymph nodes in cervical region. Small joints of hand and wrists are swollen and tender. Hb 11 
->
Parvovirus infection 
Slapped cheek rash less common in adults. Flu-like symptoms, followed by acute symmetrical arthralgias/arthritis (hands/wrists) that can resemble RA. Patients with preexisting hematologic disease (sickle cell) can develop aplasitc anemia, while immunocompromised patients can develop anemia

Indication of ICD placement after MI
->
EF< 30% at least 3 months after revascularization or 40 days post-MI

Management of 34 yo M developed 2 months of fatigue and nonproductive cough. Mild joint pain and night sweat. No lymphadenopathy. No hepatosplenomegaly. Normal CBC. CXR reveals right paratracheal and bilateral hilar lymphadenopathy 
->
Endobronchial US and nodal aspiration 
Sx suggests sarcoidosis. Dx of sarcoidosis requires exclusion of other diseases. Diagnostic tissue sampling should usually be obtained from the most accessible site. 

Management of chronic urticaria 
->
Loratadine (second-generation antihistamine) first
First-generation antihistamine (diphenhydramine or hydroxyzine) a/w significant sedation
Second line Tx in patients who don’t respond include a first-generation antihistamine, leukotriene receptor antagonist and H2 blocker. Oral glucocorticoids may be used in brief courses in patients who fail initial Tx

Prophylactic ABX required for patient with h/o endocarditis undergoing colonoscopy?
->
No
For Dental procedure or respiratory tract procedure with incision or biopsy 

Management of 63 yo M c/o back pain. No weight loss or night sweat. Hb 8.4 MCV 84 Cre 1.8 Ca 11.7 TP 7.5 Alb 4.0 PSA 0.9. Lumbar spine shows multiple lytic lesions. Serum protein agar gel electrophoresis and immunofixation do not reveal a monoclonal spike
->
Urine immunofixation 
Nomocytic anemia, hypercalcemia, renal insufficiency and lytic lesions are highly suggestive of multiple myeloma. 20% of patients generate only monoclonal immunoglobulin light chains rather than full immunoglobulin. Light chain rarely increase total serum protein and are not easily detected on SPEP. The patient should undergo serum free light-chain analysis and urine protein electrophoresis with immunofixation 

Dx of 35 yo F without PMH found to have kidney cysts. US abdomen shows three cortical cysts in the R kidney and tow in the left kidney and two liver cysts. Her father died at the age of 52 from a stroke
->
Autosomal dominant polycystic kidney disease 
US characteristic of autosomal dominant polycystic kidney disease
Known family history: 
Age 15-39: ≧ 3 unilateral or bilateral kidney cysts
Age 40-59: ≧ 2 cysts in each kidney 
Age ≧ 60: ≧ 4 cysts in each kidney 
Stroke likely due to cerebral aneurysm. Multiple benign cysts at this age is less common, rarely bilateral, and are not usually a/w live cysts

Dx of 23 yo M. IV/VI holosystolic murmur best heard at the 4th intercostal space along the left sternal border. Accompanied by a palpable thrill
->
VSD

Dx of 47 yo M with AML s/p human leukocyte antigen-matched allogeneic stem cell transplant 1 years ago developed skin changes and joint pain. Eye dryness. Extensive skin thickening with areas of hypopigmentation. Hand joints limited mobility. Cre 1.4 T-bil 3.2 AST 37 ALT 24 ALP 570. 
->
Chronic Graft-versus-host disease 
Chronic GVHD resembles an autoimmune vascular disease. Skin rash resembling lichen planus or scleroderma with areas of hypo-or-hyperpigmentation. Increased liver enzymes. Dry oral mucosa with ulcerations
Acute GVHD occurs within 100 days of transplantation

Tx for 38 yo F diagnosed with depression. C/o no libido. Weight gain. 
->
Bupropion
Although SSRIs are commonly selected as initial Tx for depression, efficacy is generally comparable across antidepressant classes. 
Bupropion: fewer sexual side effects. Least weight gain
SSRI/SNRI a/w weight gain and sexual side effects 

Dx of 73 yo M c/o fatigue. Hb 8.0 MCV 114 PLT 160000 WBC 3400 folate/vitamin B12 normal. Peripheral blood smear: ovalomacrocytic red cells and reduced granulocyte segmentation
->
MDS
Peripheral blood smear: signifcant dysplasia (ovalomacrocytosis, hyposegmented neutrophils)
(Vitamin B12 deficiency: hyperlobulated neutrophils)

U2

Diagnostic test for 60 yo M developed SOB and orthopnea 8 weeks after CABG. SPO2 96% while sitting and 90% while spine. JVP 6cmH2O. CXR raised left hemidiaphragm. Spirometry FVC 70% predicted in upright position and 59% in supine position 
->
Fluoroscopic “sniff test”
Unilateral diaphragmatic paralysis likely due to phrenic nerve injury during cardiac surgery 
Diagnosis is confirmed by asking patients to sniff forcefully under fluroscopy

Management of renal cyst. US shows a 2.4cm renal cyst that is round, has smooth walls, is anechoic and demonstrates strong posterior wall enhancement
->
Reassurance and observation 
Posterior wall enhancement (a technical artifact seen on US that indicates US wave transmission beyond the cyst. It doesn’t equate with contrast enhancement on CT/MRI)

Management of 28 yo M with elevated BP. K 3.1. plasma renin activity undetectable. Plasma aldosterone concentration 35 (normal 7-30). CT abdomen normal adrenal grands
->
Adrenal venous sampling 
Plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA) ratio > 20 suggests primary hyperaldosteronism. Once PH is confirmed, adrenal imaging to differentiate bilateral adrenal hyperplasia (50-60%) from aldosterone-producing adrenal adenoma. However, CT is low sensitivity. If CT doesn’t reveal a discrete unilateral mass, adrenal venous sampling should be obtained 

Where does renin come from
->
Released by the juxtaglomerular cells in the kidney 

Management of 75 yo M c/o “noise in his head”.  High-pitched ringing which is always present. The sound doesn’t pulsate.
->
Audiometric testing
Non-pulsatile tinnitus: usually dysfunction within the auditory system
Pulsatile tinnitus: significant underlying vascular pathology -> ENT consult and brain imaging 

Management of 20 yo M had head injury during football. Had LOC. HA/mild confusion, dizziness for several days after the injury, which resolved. Comprehensive neurological exam and computerized cognitive test are unremarkable.
->
Graduated return to play protocol
Evaluation for recurrence of symptoms while performing stepwise increase in physical activity 

Management of 29 yo F c/o amenorrhea. No menstrual period since uncomplicated vaginal delivery 13 months ago. Stopped breastfeeding 7 months ago. Still has some milky discharge from both breasts. FSH 4.2 LH 3.1 prolactin 209 TSH 5.5
->
MRI of the head
Prolactin level increases during pregnancy and normalize within 1-2 months after delivery even with continued breastfeeding. Significantly elevated prolactin (>200) level usually indicates a prolactinoma

Management of 80 yo F developed lethargy. Has had diarrhea for a few days. BP 90/45 HR 115 Na 158 Cl 109 Cre 1.7 
->
Isotonic fluid first
Hypovolemic hypernatremia: correction of effective circulating volume deficit with isotonic fluid should be done before the replacement of water deficit.

Dx and diagnostic test of 18 yo F c/o headache for 3 months. HA occurs almost daily. Holo-cranial, pulsatile. Especially bothersome at night. No photophobia, N,V, fever. Neurological exam and imaging study negative
->
Idiopathic intracranial hypertension / lumbar puncture
HAs are chronic, holo-cranial and pulsatile in nature

Dx of 52 yo s/p liver transplant developed fever, cough, and HA. Left hand weakness and difficulty grasping objects. CXR patchy alveolar opacities in the right upper lobe and a 3-cm abscess. Head CT shows an abscess
->
Nocardiosis 
Usually lung infection and brain abscess 

Dx and diagnostic test of 60 yo M p/w weakness, and weight loss. Nontender mass palpable in the left upper abdominal quadrant. Pancytopenia. Peripheral smear shows WBC with surface projections
->
Hairy cell leukemia / peripheral blood flow cytometry
Pancytopenia and splenomegaly 

When to give aspirin and lovenox sc as prophylaxis in the setting of stroke with tPA administration 
->
Both ASA and lovenox sc after 24 hours 

Management of 67 yo M hospitalized for CHF. On 6th day, PLT dropped from 210000 on admission to 62000. Sc unfractionated heparin was discontinued for DVT prophylaxis.
->
Start Argatroban (or fondaparinux)
Type 2 heparin-induced thrombocytopenia. Patient should receive an alternate rapidly acting anticoagulant as at the high risk of thrombosis 

Screening for hyperlipidemia 
->
Male > 35 yo and female > 45
Or younger with risk factors (smoking, family history, ..)

Dx of intensely pruritic, erythematous papules, vesicles, and bullae on the extensor surface of the elbows, knees and buttocks
->
Dermatitis herpetiformis

Wernicke encephalopathy caused by what conditions other than alcohol absue
->
Anorexia nervosa, hyperemesis gravidarum

Management of 76 yo with T2DM developed right ear pain with some discharge. Not responded to oral ciprofloxacin. T 98.0 WBC 9800. ESR 22. CT scan of the base of the skull reveals areas of bony erosion involving the right auditory canal. Cx obtained
->
Biopsy of the lesion 
Ddx: malignant otitis externa and squamous cell cancer
MOE: invasive pseudomonal infection in older patients with DM. Severe pain and purulent discharge. Progress to osteomyelitis of the skull. Respond to oral fluoroquinolone
SSC: moderate to severe pain. Elevated ESR. 
Not respond to Tx form MOE and indicated to exclude SCC

Management of 35 yo F on warfarin for MS and Afib found pregnant
->
Stop warfarin and start sc low-molecular-weight heparin
Warfarin a/w teratogenicity. Low-dose warfarin (<5) appears to provide a higher safety margin

Can HPV vaccine be given for pt with CD4<200
->
Yes

Dx of 46 yo F with recurrent compression fractures. Amenorrhea.
->
Cushing syndrome

Cause organism of struvite stones
->
Klebsiella and proteus
-> elevated UA pH 

Dx and management of 26 yo M. Threatening suicide after hearing his girlfriend will leave him. History of mood swings. Rages attacks when feeling that people are unsupportive. H/o self-harming behavior
->
Borderline personality disorder / psychotherapy 
No medication approved by FDA

Management of 52 yo F, h/o rheumatoid arthritis, smoker, BMI 18, on methotrexate, became menopausal at 51.
->
Bone mineral density
DXA before 65 yo for higher-risk women (RA, smoking, low BMI)

Dx of 57 yo M with T2DM c/o chronic watery diarrhea. + nocturnal symptoms and fecal incontinence
->
Small bowel bacterial overgrowth 
Due to gastrointestinal hypomotility in long-standing DM
Nocturnal diarrhea rule out IBS

Dx of 52 yo M developed well-defined plaques covering by thick, silvery scales on scalp, near ear and gluteal cleft. Mildly pruritic. 
->
Plaque psoriasis 

Characteristic CSF finding in Guillain-Barre syndrome
->
Elevated protein and normal WBC

Management of 27 yo F 29 weeks gestation developed pyelonephritis. T 102. HR 96 BP 124/83. Appears uncomfortable, but not in acute distress
->
Admission and iv ceftriaxone
Pyelonephritis during pregnancy causes an increased risk for complications (ARDS, pulmonary edema). Particularly in the later stages of pregnancy. Guideline recommends inpatient management with IV ABX until afebrile and improvement for 24-48h

Blood test predicting worse outcome in rheumatoid arthritis 
->
High titers of anti-CCP Ab and positive rheumatoid factor

Dx of 20 yo M with cystic fibrosis developed chronic cough. Wheezing. WBC 12000 eosinophil 8% ESR 67 immunoglobulin E 1000. CXR bilateral patchy upper-lobe infiltrates 
->
Allergic bronchopulmonary aspergillosis 
Occurs in asthma or cystic fibrosis patients. Wide spectrum of radiographic changes (fleeting pneumonia, central bronchiectasis, mucus-filled bronchi). Dx: serum IgE > 417 and serum Ab against aspergillosis 

Severe MS or MR patients need prophylactic ABX prior to dental procedure?
->
No

Severe MR or MS patient without AF need anticoagulant?
->
MS need
MR doesn’t need

What type of intervention recommended for severe MR when indicated
->
Mitral valve Repair

Who need prophylactic ABX prior to dental procedure
->
Mechanical valve or h/o endocarditis

Dx of 38 yo M states his skin is being eaten away by flesh-eating bacteria. He has repeatedly washed the area he insisted is infected.
->
Delusional disorder

Dx of 46 yo M c/o recurrent abdominal pain. Drinks 8-10 beers on the weekends and frequently throughout the week. Abdominal x-ray shows focal calcifications anterior to the spine over the epigastric area. EGD shows normal esophagus, gastric varices in the fundus of the stomach and a normal duodenum
->
Splenic vein thrombosis (chronic pancreatitis)
Chronic pancreatic inflammation can lead to thrombosis 
Splenic vein thrombosis leads to gastric varices near the gastric fundus only

Dx of 55 yo M recent induction chemotherapy for AML developed fever, abdominal pain, and bloody diarrhea. WBC 800 neutrophil 25%. PLT 7000 CT marked wall thickening, intramural edema, and pneumatosis of the cecum and ascending colon. No free air or fluid collection 
->
Neutropenic enterocolitis 
life-threatening necrotizing infection 

Dx of pain when first stepping out of bed
->
Plantar fasciitis 

Likely timing of thrombocytopenia when immune-mediated heparin induced thrombocytopenia 
->
5-10 days or < 1 day if prior heparin exposure within 30 days
(PLT drop > 50% -> 2 points)

Complication of patent ductus arteriosus
->
Infective endarteritis 
Progress to pulmonary hypertension and Eisenmenger syndrome (right-to-left shunt)

Most common cause of hypercalcemia 
->
Primary Hyperparathyroidism (parathyroid adenoma)

Upper limit of daily vitamin D3 intake
->
4000 units
Ingestion of very high doses of vitamin D is required for the development of toxicity 

What is clue cell?
->
Vaginal epithelial cell covered with bacteria, indicating bacterial vaginosis

Management of 75 yo F with osteoporosis receiving risedronate for 2 years. Compression Fx twice during the Tx. DXA T-score decreased from -2.8 to 3.6
->
Stop risedronate and start teriparatide
Recombinant parathyroid hormone. Useful for Pt who fail first-line Tx. Prescribed for 2 years, then bisphosphonate is resumd

Management of newly diagnosed hyperparathyroidism, no CKD, kidney stone, compression fracture or osteoporosis 
->
24-hour urinary calcium measurement 
Excessive urinary Ca loss (> 400mg/day) -> elevated risk of complication -> indication for parathyroidectomy

Management when physician potentially refers patients to a medical facility where the physician is investing
->
There is a conflict of interest and the physician’s investment should be disclosed to patients

Management of 45 yo M with bipolar disorder developed low-amplitude resting tremor and muscle stiffness 2 months after starting risperidone
->
Change risperidone to quetiapine
Drug-induced Parkinsonism 
Some Atypical antipsychotics (risperidone) cause DIP

What anti-hypertensive med could contribute to following condition? 
66 yo F with bipolar disorder on lithium developed agitation, slurred speech, muscle jerks, after starting an anti-hypertensive medication started
->
ACE inhibitor (or diuretic, verapamil)
Lithium toxicity 
Lithium is cleared by the kidneys. Medications that reduce glomerular filtration can precipitate a rise in blood lithium levels.

Tx for microscopic colitis
->
Oral budesonide and withdrawal of possible triggering medications (NSAIDs, PPI, SSRI)

Dx and management of 22 yo F with h/o non-Hodgkin lymphoma s/p chemo 2 weeks ago. Had MVA. Received O-negative blood transfusion. 2 days later, she developed fever, diarrhea, maculopapular rash. Hb 9.5 PLT 180000 WBC 3800. T-bil 2.3 AST 187 ALT 224 INR 1.0
->
Transfusion-associated graft-versus-host disease
No treatment and most cases are fatal -> prevention is paramount
Should have received irradiated blood products

U

Tx for Cat bite injury with penicillin allergy
->
Doxycycline and metronidazole or clindamycin

Suspect of bacterial meningitis, CT or ABX first?
->
Requires CT head if AMS, immunocompromised, h/o CNS disease, seizure, papilledema, focal neurological deficit
Empiric antibiotics first -> CT -> LP
(LP -> ABX if no CT required)

Non-stoppable nose bleed in patient on dialysis 
->
Platelet dysfunction (PLT-von Willebrand factor interactions) -> desmopressin 

Hemoglobin 7.0 -> hematocrit ?%
->
21% (Hct = Hb x 3)

Dx of erythema migrans, leukopenia, thrombocytopenia, and elevated LFT
->
Lyme coinfection with human granulocytic anaplasmosis

Molulae caused by 
->
Both ehrlichia and anaplasma 

Tx should have done for patient with SAH developed increasing headache and cardiac arrest a few hour later
->
Endovascular Tx (rebleeding is the major cause of death within 24h, nimodipine prevents vasospasm, which usually occurs after 3 days)

Emergent next step for pt who was recently found to have elevated prolactin and loss of livido, now developed severe headache, ptosis, bitemporal visual field defects
->
High-dose glucocorticoid Tx for pituiatary apoplexy, complicated with acute central adrenal insufficiency. Glucocorticoid should be given immediately, not wait result of CT head or MRI 

Assessment of effectiveness of dabigatran before emergent surgery 
->
Thrombin time (dabigatran: direct thrombin inhibitor)

Dx of Patient with septic abortion developed thrombocytopenia and hemolytic anemia 
->
TTP (can be associated with pregnancy (formation of autoantibodies (acquired))

Management of persistent penile erection in patient with sickle cell anemia
->
Blood aspiration from the corpus cavernosum (persistent priapsim (>12h) may require sugical shunting (glans-spongiosum shunt))

Tx for Gram positive bacilli in CSF
->
Ampicillin only for listeria monocytogenes

Discharge plan for anaphylaxis from bee sting
->
Referral for immunotherapy (venom immunotherapy reduces the risk of recurrence)

Management of patient with respiratory failure from severe kyphoscoliosis with pulmonary hypertension 
->
Intermittent NIPPV

Earliest and mot sensitive echocardigraphic sign of cardiac tamponade
->
Right atrial collapse during end diastole 

Preventive Tx for Meniere disease
->
Low salt diet and diuretics (HCTZ)

Dx of patient with cough, fever, arthralgia and erythema nodosum and recent trip to southwest 
->
Coccidiodomycosis

How does NPPIV work for CHF
->
Decrease preload (increase intrathoracic pressure -> reduce venous return -> decrease RA/RV preload)

Dx of 22 yo F with h/o recurrent nose bleed developed seizure
->
Hereditary hemorrhagic telangiectasia (-> cerebral AVM: epilepsy, ischemic or hemorrhagic stroke)

Blood product type for transfusion for patient with IgA deficiency 
->
Washed red cells (to remove as much plasma (containing IgA) as possible)

Management of HIV patient with toxoplasmosis receiving sulfadiazine and pyrimethamine
->
Leucovorin (folic acid analog): pyrimethamine is a folic acid antagonist. Could cause bone marrow suppression

CD4 of the patient above is 126. Any additional prophylactic medication?
->
No (sulfadiazine also provides PCP prophylaxis)

Management of acute lower back pain (lumbosacral radigulopathy), PT or pain med?
->
Light exercise with NSAIDs (PT and spinal manipulation have shown inconsistent results in Tx of ALSR)

Prevention of further kidney injury by iv contrast (CAG) for patient with fluid overload due to CHF, acute on chronic kidney injury; 1, NS iv, 2, discontinue lisinopril, 3, iv lasix
->
iv lasix: AKI with volume overload likely due to cardiorenal syndrome (iv lasix reduce renal venous pressure and increase the glomerular perfusion gradient). Discontinuing ACEI or ARB prior to arterial contrast administration has not been shown to reduce the risk of CA-AKI

What medication as initial Tx for acute pericarditis likely causes recurrent episodes
->
Prednisone should be avoided because it is a/w a higher rate of recurrence. Only indicated in refractory pericarditis despite NSAID. iv immunoglobulin may maintain long-term remission in corticosteroid-dependent patients with recurrent episodes of pericarditis

The cause of AKI in patient with lymphoma who started chemotherapy. Received rasburicase. Ca 6.6, phos 11.2, Uric acid 5.8
->
Acute nephrocalcinosis; caused by tumor lysis syndrome. Phosphate nephropathy (phos binds to Ca to form calcium phosphate stones that deposit within the renal tubules and interstitium) / uric acid nephropathy (severe hyperuricemia predisposes to urate stone formation and deposition within the distal tubules and collecting ducts). 

Cyclophosphamide urotoxicity 
->
Hemorrhagic cystitis

Dx of the swollen gums with some evidence of bleeding
->
Vitamin C deficiency: gingivitis, vitamin C is crucial for collagen syntehsis

Dx of 30 yo M developed weakness in bilateral extremities, hyporeflexia, palpitation, pupils react sluggishly to light, dysarthria, vibration and proprioception reduced
->
Guillain-Barre syndrome: bulbar symptoms (ophthalmoplegia, facial diplegiam dysarthria, dysphasia) can develop. Also can develop dysautonomia (tachycardia, diaphoresis, sluggish pupils)

Dx of 82 yo M had rectal bleed. EGD/colonoscopy negative. Developed dizziness and diaphoresis during bloody bowel movement
->
Aortic stenosis: likely has intestinal angiodysplasia (negative scopes). Angiodysplasia associated with aortic stenosis. In aortic stenosis, turbulent blood flow through the valve causes disruption of von Willebrand multimers.

Central retinal artery occlusion is painful or painless
->
Painless (funduscopic exam shows cherry red spots)

Seizure Medication choice for young female
->
Levetiracetam or lamotrigine (valproic acid has potential teratogenic effects)

DVT Tx for cancer patient
->
Apixiaban (or LMWH. Factor Xa inhibitors preferred due to similar efficacy and side effect profiles)

Dx of ipsilateral ocular motor palsy and contralateral lower facial weakness, hemiplegia
->
Medbrain stroke

Dx of ipsilateral Horner syndrome and contralateral loss of body pain and temperature
->
Lateral medulla stroke (Horner syndrome: ptosis, miosis, anhidrosis) (medulla:延髄)

Dx of ipsilateral tongue weakness and contralateral hemiplegia 
->
Medial medulla stroke 

Digoxin toxicity 
->
Anorexia, nausea, vomiting, abdominal pain
Visual symptoms (changes in color vision, blurred vision, scotomas, blindness)

What is symptoms of malaria
->
Fever, scleral icterus, splenomegaly, thrombocytopenia, anemia

Contraindications for fibrinolytic Tx for STEMI
->
Ischemic stroke within 3 months, BP > 180/110

Tx for aspirin-exacerbated respiratory disease
->
Leukoctrine receptor antagonist (arachidone acid metabolic pathway, not an IgE-mediated allergic response)

Dx of 32 yo F developed unremitting fever, joint pains, after trip to the Dominican Republic. Hb 12.6 PLT 180000 WBC 3400 AST 44 ALT 32
->
Chikungunya fever (persistent fever and severe polyarthralgias. Some patients develop a rash and conjunctivitis (3-58%))

Management of patient on digoxin, K 6.4 Cre 2.2 digoxin level 1.8 (normal < 2). EKG SR narrow QRS. No P waves. Had asymptomatic 9-beats run of nonsustained VT
->
Digoxin-specific antibody fragments 
Digoxin toxicity causes cardiac arrhythmia. Not correlate well with serum level. Dx should be based on clinical presentation and EKG findings. Digoxin-specific antibody fragments indicated  for: life-threatening cardiac arrhythmia, end-organ dysfunction, hyperkalemia. Digoxin toxicity causes hyperkalemia

Cause of 24 yo healthy F developed fever, sore throat, not reponded to amoxicillin. Tonsillar enlargement without exudates. Neck is swelling and tender. CXR showed 2 round opacities 
->
Anaerobic infection (Lemierre’s syndrome)
Caused by fusobacterium necrophorum. Septic thrombophlebitis involving the internal jugular vein. Septic emboli are common

Cause of acute severe anemia in sickle cell disease
->
Splenic sequestration crisis (vasoocclusion in spleen causing pooling of red blood cells)
Aplastic crisis (usually due to infection (parvovirus B19, EB virus, strept pneumoniae, salmonella))
hyperhemolytic crisis (unclear etiology, but possible delayed transfusion reaction)

23 yo F developed meningococcal meningitis. Boyfriend who received meningococcal vaccine 1 year ago needs post-exposure measure?
->
Requires antibiotics as post-exposure prophylaxis 
Household members, roommate or intimate contacts (Regardless of vaccination status)
Health care workers with close proximity and prolonged duration or exposure to respiratory secretions

Dx of 83 yo M abd x-ray showed a large, air-filled sigmoid colon with absence of air in the rectum
->
Sigmoid volvulus 

20 yo F attended a party. Developed agitation, confusion, seizure. T 103. HR 135 diaphoretic. Pupils dilated. Na 116 AST 314 ALT 406 CPK 22656. What is likely ingestion causing these findings
->
3,4-methylenedioxymethamphetamine (MDMA, ecstasy)
Serotonin syndrome secondary to MDMA presets with delirium, hyperthermia, autonomic instability. It may result in end-organ damage, rhabdomyolysis, renal failure, hepatic failure, coagulopathy. Heat from a party and MDMA-induced hyperthermia can easily lead to excessive water intake and severe hyponatremia

Management of 70 yo F with breast cancer, found to have bone metastasis to arm. No Fx. No pain. Cre 1.4 (GFR 30).
->
Denosumab
For bone metastasis, osteoclast-inhibiting agents such as denosumab and bisphosphonates significantly decrease the risk of skeletal-related events (fracture, instability/loss, spinal cord compression). Denosumab: human monoclonal antibody inhibits an important step in osteoclast activation. Unlike with zoledronic acid (contraindicated for GFR < 35), renal dose adjustments are not required. Irradiation can provide symptomatic relief of bone pain

Management of 53 yo F developed kidney stone. Ca 10.8 urine pH 6.2
->
Check serum parathyroid hormone level
Mildly elevated Ca and nephrolithiasis raise suspicion for symptomatic hyperparathyroidism. Hypercalcemia a/w primary hyperparathyroidism is usually mild (< 11). Primary hyperparathyroidism with nephrolithiasis or other complications (osteoporosis, CKD, symptomatic hypercalcemia) should be considered for parathyroidectomy 

Treatment for myasthenia crisis
->
Plasma exchange or IVIG
Glucocorticoids are added to provide longer-term symptoms relief 
Myasthenia: autoimmune disease, autoantibodies attack acethylcholine receptors 

Management of 55 yo alcoholic cirrhosis presented with AMS. Sign of hepatic encephalopathy. Sign of ascites. No sign of pain or infection.
->
Identification and correction of precipitating causes of HE. If no obvious cause is evident, pt with ascites should have a diagnostic paracentesis to r/o SBP

Management of a solitary brain lesion in patient with likely lung cancer
->
Surgical resection 
Options of treating solitary lung-brain metastasis include surgical resection followed by whole-brain radiation or stereotactic radiosurgery with or without WBRT. Patient with likely primary lung cancer should undergo resection without the need for brain biopsy 

What type of precaution for meningococcal meningitis patients
->
Droplet precaution (surgical mask)
N meningitidis Transmitted by aerosolized droplets and highly contagious 

Which is Likely responsible for pt with left homonymous hemianopia, right forced gaze deviation, reduced sensation on the left side of face. Left-sided hemiplegia, Sx fluctuating
1, atherothrombosis of a large artery, 2, embolism from a cardiac source, 3, lipohyalinosis of a small vessel
->
Atherothrombosis. Consistent with A right middle cerebral artery stroke. Thrombotic strokes are usually fluctuating symptoms. Embolic strokes have maximum symptoms at onset. Small-vessel lipohyalinosis causes lacunar infarcts. Usually develop limited focal motor and/or sensory symptoms without cortical signs (homonymous hemianopia, gaze preference)

Likely diagnosis for patient with weakness of the right lower face and right arm, mild weakness of the right leg. Can say 1 or 2 words at a time with great effort
1.Lenticulostriate artery stroke, 2. Middle cerebral artery stroke
->
2. Middle cerebral artery stroke. Infarction of the lenticulostriate arteries can lead to lacunar infarcts. Cortical signs (aphasia, neglect) are not typically present

Dx of 72 yo M with h/o CABG, developed JVP elevation, ascites. Clear lung
->
Right-sided heart failure : constrictive pericarditis 
Long-standing right-sided heart failure can eventually cause cardiac cirrhosis
Cirrhosis itself doesn’t normally cause JVP

Likely cause of pneumonia in patient with renal transplant 3 weeks ago, on immunosuppression, valganciclovir, S/T
->
Pseudomonas (or MRSA, similar to other postoperative patients in the first month)
1-6 months: with PCP/viral prophylaxis: BK polyoma, hep C, C.diff, TB
> 6 months: similar to general population

Dx and Tx for 23 yo F with T1DM, SLE developed fever, headache, blurry vision, Right-sided periorbital swelling and tenderness over the maxilla
->
Rhino-orbital-cerebral mycormycosis (devastating mold infection)
Surgical debridement and iv amphotericin B

Dx of 22 yo M with h/o asthma developed dysphagia for the past few hours. Difficulty swallowing his saliva. Food impaction. Drooling
->
Eosinophilic esophagitis 
Th2-mediated inflammatory response triggered primarily by food antigen exposure

Dx of endoscopic finding of dilated esophagus with distal tapering
->
Chronic distal obstruction, such as achalasia or pseudo-achalasia (gastric fundic tumor)

Dx of 40 yo F developed SOB, cough 48 hours after C-section at 39 weeks gestation. BP 196/112 SPO2 86%. No JVD. UA Protein 3+. CXR diffuse alveolar infiltrates
->
Preeclampsia 
Definition: new-onset HTN + proteinuria and/or end-organ damage (thrombocytopenia, Cre elevation, tramiaminitis, pulmonary edema, cerebral symptoms). It can occur after delivery and up to 6 weeks postpartum. 

Peripheral blood smear of 60 yo F fatigue, low grade fever, lymphadenopathy, Hb 5.0 MCV 84. PLT 70000. WBC 70000 (neut 10%, lymph 90%). Reticulocyte 12%
1.Bite cells, 2. Fragmented red cell, 3. Red blood cell inclusions, 4. Spherocytes, 5. Tear drop cells
->
Spherocytes
Dx is CLL. CLL a/w hemolytic anemia. The partial RBC phagocytosis by the splenic macrophages causes excessive surface membrane loss and results in spherocytes. 
Bite cell: G6PD deficiency. Fragmented RBC (schistocyte): DIC, TTP/HUS. RBC inclusion: asplenia or splenic hypofunction (sickle cell disease) (dark purple DNA remnants inside RBC because spleen isn’t removing them). Tear drop cell: extramedullary hematopoiesis (myelofibrosis). Basophilic stippling: lead poisoning 

Type of insulin use for ICU patients
->
Short-acting insulin (allow for frequent dosing changes)

Pattern of syncope in AS patient
->
Exertional syncope

Management of 64 yo M with neutropenic fever s/p chemo. CXR showed infiltrate. Started on Vanco and cefepime. Fever once resolved and recurred. BP 120/70. HR 96 RR 18 SPO2 96%on RA. Repeat CXR showed a slight increase in the size of the infiltrate. Galactomannan and beta-D-glucan negative. Cx still pending. ANC 200 -> 1800
->
Monitor without change
Myeloid reconstitution syndrome: fever and the appearance or progression of an inflammatory focus (lung infiltrate) in temporal relationship to myeloid recovery 

Dx and etiology of 69 yo M immunosuppressed for RA. Developed fever and diarrhea. BCx growing gram positive rods
->
Listeria monocytogenes / consumption of infected food

Evaluation of syncope
->
EKG and orthostatic VS

Tilt-table testing for
->
Vasovagal syncope evaluation 

Cause of AKI in 65 yo M with recent ischemic stroke found confused and urinary incontinence on his bed. BUN 24 Cre 2.0 K 4.9 Phos 5.2 Ca 8.4 UA 4+blood,1+ protein, 0-1 erythrocyte/hpf, 1-2 leukocytes/hpf. FeNa 0.8
->
Rhabdomyolysis 
Likely due to seizure. Positive blood on urine dipstick in the absence of RBC suggests myoglobinuria. FeNa unexpectedly low in AKI due to rhabdomyolysis 

DRESS stand for
->
Drug reaction with eosinophilia and systemic symptoms 
Doesn’t cause erosion 

Dx of 36 yo healthy M developed cough, fever. After staying in an old and dusty rental house and relaxed in a hot tub. WBC 11800. CXR mildly increased interstitial markings in the middle and lower lung fields bilaterally
->
Mycobacterium avium complex (MAC)
Most healthy individuals have little risk of infection. But MAC can induce a hypersensitivity pneumonitis (hot tub lung). Acute flu-like illness

Diagnostic test for 20 yo M developed abdominal pain and diarrhea. Stool occult blood positive. Rash over both thighs. PLT 162000. INR 1.0 UA protein 1+ blood 1+
->
Skin biopsy
Henoch-Schonlein purpura: skin (petechiae, purpura), musculoskeletal (arthritis), gastrointestinal (abd pain, GI bleed), renal (hematuria, renal insufficiency)
Leukocytoclastic vasculitis accompanied by IgA immune complex within affected organs (autoantibody is negative. Organ biopsy (skin/kidney) is most sensitive and specific test to confirm Dx)

Management of multifocal atrial tachycardia
->
Correct underlying disturbance (COPD exacerbation, hypokalemia, )

Cause of urine osmolarity < 100
->
SIADH and malnutrition (low dietary sodium intake)

Urine sodium of Hypovolemic hyponatremia 
->
UNa < 40: nonrenal salt loss (vomiting, diarrhea)
UNa > 40: renal salt loss (diuretic, adrenal insufficiency)

Urine osmolarity of Hyponatremia due to Hypothyroidism 
->
Uosm > 100

Medications cause non-anion gap acidosis
->
Acetazolamide, topiramate (cause bicarbonate diuresis)
(Chemo, aminoglycoside, S/T, amphotericin B, lithium, rifampin)

Management of common peroneal nerve injury
->
PT and ankle foot orthotic 
Causes foot drop and seppage gait. Risk: prolonged hospitalization, trauma and leg casting

Management of 42 yo F with h/o breast cancer s/p radiation developed pleural effusion. Analysis: predominantly lymphocyte, TP 5.2 (serum 7.2), pH 7.35, LDH 250 (serum 340), cytology negative. Gram stain and Cx negative
->
CT scan of chest to evaluate metastatic lesions
Exudative pleural effusion by light criteria (P-TP/S-TP > 0.5, P-LDH/S-LDH > 0.6)
Low pH suggests high malignant cell burden a/w high sensitivity of fluid cytology, wheres relatively high pH (> 7.3) a/w low fluid cytology sensitivity 

Distinguish relapse vs pseudorelapse in MS patient
->
Presence of fever/infection or not. Worsening of prior symptoms or new neurological symptoms. 

Management of 70 yo M with unknown PMH found altered. T 35. BP 120 HR 55 RR 10. Pupils normal. Puffy face and enlarged tongue. Glu 69. EKG sinus bradycardia. Other labs pending
->
IV corticosteroids and thyroid hormone
Myxedema coma. life-threatening condition. Tx should be initiated without waiting for the result of TSH and FT4

Microbiological indication for catheter removal in central venous catheter-associated infectino
->
Staphylococcus aureus, pseudomonas aeruginosa, fungi, mycobacteria

Antibiotics for meningitis after neurosurgery
->
Cefepime and vancomycin 

Indication of ampicillin for meningitis
->
> 50 yo or immunocompromised 

Cause of recurrent pneumonia in 65 yo F with h/o dermatomyositis on prednisone. CXR shows a right lower lobe lung infiltrate
->
Esophageal dysfunction -> aspiration
Dermatomyositis cause weakness of the esophageal and striated muscles in the upper third of the esophagus.  (Systemic sclerosis causes esophageal dysmotility/fibrosis)

Management of asymptomatic candiduria 
->
Remove/exchange urine catheters
Treat as disseminated candidiasis if neutropenic host
Consider systemic antifungals prior to urological procedure

Possible causes of stridor after thyroidectomy 
->
Immediately upon extubation: bilateral laryngeal nerve injury
Within a few hours of surgery: wound hematoma
Later: hypocalcemia from transient hypoparathyroidism, transient hypocalcemia common in teh first 24 hours after total thyroidectomy. Laryngospasm from hypocalcemia 

Dx of patient taking NSAIDs c/o odynophagia 
->
Medication-induced esophagitis
(NSAID, bisphosphonate, tetracycline, )

Management of paroxysmal Afib with severe mitral stenosis
->
Warfarin
Warfarin for valvular AF (severe MS, mechanical valve), CHA2-DS2-VASc not applicable
Direct oral anticoagulants are not approved

Dx of 45 yo M with HIV and CD4 50 developed a rash in arms, shoulders and ears. No itching. Erythematous patches that progress to prominent scales, crusting and malodorous fissures.
->
Crusted scabies
Overwhelming infestation of scabies mites in immunocompromised. Little or no itching. 

Tx of 45 yo M found unresponsive on the street. T 84.2 BP 88/60
->
Active external rewarming and large volumes of warmed crytalloids (moderate hypothermia with significant hypotension)
Severe (< 82): active internal rewarming (warmed pleural or peritoneal irrigation)

Tx for reactive arthritis 
->
NSAIDs

Management of physician colleague who is obviously abusing alcohol and having influence over patient care
->
Report the physician to the state’s physician health program, instead of reporting to his supervisor 

Can nitroprusside be given to pregnant patient
->
No
Contraindicated in pregnancy due to possible risk of fetal cyanide poisoning 

Dx and management of 73 yo M with COPD, Zenker diverticulum, T2DM developed fever, night sweat, productive cough for 4 weeks. CXR shows a right lower-lobe cavitary lesion with an air-fluid level
->
Lung abscess / iv ampicillin-sulbactam
Lung abscess has night sweat, lesion in dependent portions of the lung (lower lobe). This Pt no risk factor for TB. Aspiration risk factor (Zenker diverticulum) and lower lobe cavity lesion make lung abscess far more likely than TB

Normal RA pressure
->
0-8mmHg (mean 4)

Normal PCWP 
->
4-12 mmHg (mean 9)

Normal cardiac index
->
2.8-4.2L/min/m2

Normal SVR
->
1150 dyne-sec/cm5 (systemic vascular resistance)

Pressure parameter of Cardiac tamponade
->
Equalization of diastolic pressure
Example: RA 18, RV 35/18, PA 35/20, PCWP 18

Management of 52 yo M admitted for coffee-ground emesis. Not taking NSAIDs. Treated with PPT iv drip. EGD showed PUD. Gastric mucosal biopsies are negative for H.pylori
->
Outpatient urea breath testing
Test for H.pylori with biopsy could become false-negative due to bleeding or PPI use

Management of 25 yo M was found to have hypoglycemia 36. No PMH. His father has T2DM on glyburide. Improved with dextrose iv. Hospitalized for observation. Recurrent hypoglycemia on the second day. Insulin level 20 (normal: 5-20). C-peptide 0.67 (normal: 0.17-0.66).
->
Oral hypoglycemic drug screen
Glyburide has a relatively long duration of action and can develop recurrent hypoglycemia
Factitious hypoglycemia: insulin normal to high, C-peptide normal to high
Factitious insulin injection: insulin very high, C-peptide low
Insulinoma: insulin normal to high, C-peptide normal to high
Insulin autoantibody: bind to endogenous insulin, causing unpredictable blood sugar swings. A maker for developing T1DM before Sx appears

Dx of 57 yo M undergoing bronchoscopy with local anesthesia, developed cyanosis. SPO2 85%. Breath sounds heard bilaterally. Myoclonic jerks in all extremities. ABG: PaO2 120 PaCO2 39. 
->
Methemoglobinemia
Result from exposure to exogenous oxidizing substances (local/topical anesthesia, nitrate, dapsone). Saturation gap (low oxygen saturation and normal PaO2). Sx: cyanosis, lethargy, seizure. Tx: methylene blue. Blood transfusion/exchange transfusion for shock patient

Management of 54 yo M was admitted for DVT. Heparn iv drip was started. No recent hospitalization. PLT on admission 210000. On 2nd day PLT dropped to 130000
->
Continue heparin iv drip and observe
2 types of HIT
Type1: non-immune-mediated, unknown pathophysiology. 1-4 days after heparin. > 100000. Recover spontaneously regardless of heparin continuation or discontinuation 
Type2: immune-mediated. 5-10 days after heparin or < 1day if prior heparin exposure. Usually > 20000. Dx by serotonin assay. Should discontinue heparin

Warning sign of presumed irritable bowel syndrome
->
Anemia, hypokalemia, bleeding, nocturnal Sx, weight loss
Need further diagnostic evaluation 

Management anticoagulant of 56 yo M with h/o mechanical AVR on warfarin found to have pancreatic mass. sinus rhythm. No recent DVT. Will undergo biopsy 
->
Stop warfarin for 5 days until INR < 1.5, then proceed the biopsy
No need heparin iv bridge. Contrary, mechanical MVR has very high thrombotic risk (relatively stagnant blood flow surrounding the mitral valve). Need heparin iv bridge

Management of 52 yo F with T2DM. HgA1c 10.5 1 year ago. Become Compliant with meds, diet and exercise. On glargine and metformin. Now HbA1c 8.1. develops hypoglycemic Sx when missing diet. Fasting glucose average is 112.
->
Check 2 hour postmeal glucose level.
Goal HbA1c < 7. Still above goal. If significant postprandial hyperglycemia is noted, better control may be achieved with a combination basal-bolus insulin regimen with continuing the long-acting basal insulin. 

Dx of 67 yo M developed HA, N, blurry vision a few hours after leuprolide administration for prostate cancer. T 100.2, right eye ptosis and hemianopia. R eye in downward abducted position. Neck stiffness. N 128 GLU 70.
->
Pituitary apoplexy (hemorrhage or infarction)
GnRH agonist (leuprolide) increase blood flow to the pituitary and can trigger hemorrhage. Sx can resemble those of meningitis. Loss of ACTH can cause hyponatermia and hypoglycemia. 

Management of 63 yo M developed dyspepsia
->
EGD 
Pt > 60 with new-onset of dyspepsia -> EGD
Pt < 60 without compelling indication of EGD -> PPI trial or H.pylori test

Management of 78 yo M with h/o severe AS developed intraabdominal perforation 
->
Emergency exploratory laparotomy
A high-risk cardiac conditions (severe AS) should be evaluated and treated prior to nonemergency surgery, but it should not delay emergency, life-threatening noncardiac surgery 

Management of 29 yo M developing abrupt onset of severe psoriasis 
->
HIV test
Abrupt onset of large, widespread psoriatic lesions is often associated with HIV infection

Management of 78 yo M developed epigastric pain. Unknown PMH. T 100.4 BP 144/90 HR 112. Tender to palpation in the epigastric and RUQ areas. WBC 11000 T-bil 1.2 AST 22 ALT 19. EKG Afib. US abd small gallstone wihout wall thickening or edema around the gallbladder. Normal CBD
->
CT angiography of abdomen 
Untreated Afib should raise suspicion for acute mesenteric ischemia 

Dx of 25 yo F with multiple oral ulcers painful, low grade fever, 5 year h/o genital herpes with intermittent flares. Have vesicular lesions on her buccal and gingival mucosa and acneiform lesions on her face and back. Scars on the vulvar area
->
Behcet disease 
Vasculitis. Recurrent oral ulcers and genital ulcers. Skin manifestation: acneiform, nodules, erythema nodosum. Eye: uveitis. Vulvar scarring occurs very rarely in conditions other than Behcet disease 

Do Inhaled corticosteroids increase pneumonia in COPD patients?
->
Yes (slightly)

Management of 29 yo F immigrating from India developed mild sore throat. Patient had a h/o febrile illness a/w loss of motor control in childhood. Mild erythema of posterior pharynx. A low-pitched diastolic murmur with presystolic accentuation at the apex. TTE shows doming of the mitral valve leaflets in diastole. MV area is 1.7cm2. + mild mitral reguargitation.
->
Initiate penicillin G benzathine injection every 4 weeks
ABX prophylaxis for secondary prevention of rheumatic fever. Childhood h/o a febrile illness a/w movement disorder (chorea) is consistent with previous rheumatic fever complicated with valvular disease (mitral stenosis). This patient’s current presentation is not consistent with rheumatic fever recurrence, but the sore throat raise suspicion for GAS pharyngitis. With repeated exposure to GAS, pt with prior rheumatic fever are at high risk for recurrent rheumatic fever. Pt should receive continuous ABX prophylaxis to prevent GAS pharyngitis. 
Duration: 5 years or until 21 yo for uncomplicated RF. 10 years or until 21 yo with carditis but no valvular disease. 10 years or until 40 yo with carditis and valvular disease

Dx and its cause of 18 yo M found weak and confused. Flaccid weakness of all extremities. Na 142 K 2.4 Cl 116 HCO3 16 Cre 0.8 Phos 2.0 pH 7.3 pO2 94 pCO2 29. UA pH 6.4 ketone negative. U Na 70 K 20 Cl 65 
->
Distal RTA / solvent inhalation
Non-anion gap acidosis. Hypokalemia. Urianry anion gap (Na + K - Cl) positive -> renal acidification defect. Distal RTA cause by autoimmune (sjogren, RA), drugs (amphotericin), or toxin ingestion (toluene). Toluene solvent inhalation can cause distal RTA with cognitive impairment 

What is Todd’s palsy
->
Temporary weakness or paralysis following a seizure 

Cause of sudden onset of erectile dysfunction while continuing to have intact early morning erections
->
Psychogenic etiology (mood disorder, )
Organic ED (DM, low testosterone, hypothyroidism, ) typically slowly progressive. Ability to have early morning erections rule out it

Management of newly diagnosed osteoporosis 
->
Basic laboratory evaluation (Ca, phos, Alb, TP, renal/hepatic Fx) and 25-hydroxyvitamin D level
Intake of adequate amounts of vitamin D and Ca helps reduce bone loss

Dx of 44 yo M developed N/V/fatigue. Recent back injury. Has been taking over-the-counter pain med. Drink alcohol heavily on weekends. Occasional use of iv heroin. T 99. BP 94/50 HR 112. Moderate RUQ tenderness. Cre 1.7 Alb 3.8 T-bil 3.2 AST 3578 ALT 4235 ALP 190 INR 1.7
->
Medication toxicity (acetaminophen toxicity)
Acetaminophen toxicity should be suspected in any pt with markedly elevated AST/ALT. Develop RUQ pain. Develops picture like shock in severe case. Alcoholic hepatitis AST>ALT. Liver abscess usually has fever and mildly elevated AST/ALT. Acute hepatitis C is asymptomatic in most patients and less likely to cause elevated INR

What is melanocytic nevi
->
Mole (common benign pigmented lesions)

Myasthenia gravis cause diplopia?
->
Yes 
Also ptosis, dysarthria, dysphagia

What is Miller-Fisher syndrome 
->
Variant of Guillain Barre syndrome 
Eye muscle paralysis, ataxia and areflexia

Dx of diplopia resolving when covering either eye
->
Fatigable diplopia -> MG

Ptosis in MG patient could be unilateral?
->
Yes

Dx of tear drop cells and splenomegaly
->
Primary myelofibrosis 
extramedullary hematopoiesis

Dx of 49 yo M developed right-sided neck, shoulder and arm pain, 2 day after chopping firewood. Remarkable tenderness over the right occipital area. Mild edema of the fingers on right hand. Motor, sensation and reflex intact. Cervical x-ray normal. R shoulder x-ray show some patchy bone demineralization.
->
Complex regional pain syndrome
Commonly occurs after injury. Involves a reflex arc along the sympathetic nervous system leading to autonomic symptoms (sweating, abnormal hair growth, tissue swelling, and coldness). X-ray show patchy bone demineralization

Dx of 79 yo M. Less interested in participating in his usual activities. Insomnia. SOB. BMI 19. HR 114 Afib rhythm. 4/5 proximal muscle strength in lower extremities. Geriatric depression screen 1/5. 
->
Hyperthyroidism
Pattern recognition approach often doesn’t work in Geriatric population. Typical Sx of hyperthyroidism may not be present in the elderly population. 1/3 demonstrates apathy rather than hyperactivity. Weight loss (low BMI). Insomnia. Afib. Weakness in proximal muscles

Dx of 2x2 cm beefy red granulomatous plaque with mild creamy exudate. Foot CT two lytic lesions and a large focal cyst in the mid foot. CXR patchy alveolar opacities
->
Blastomycosis 
Extrapulomonary Sx: cutaneous plaques/ulcerations. Bone lesions 

extrapulmonary Sx of histoplasmosis 
->
Hilar/mediastinal lymphadenopathy. Hepatosplenomegaly. Pancytopenia

Tx for obsessive-compulsive disorder
->
SSRI +/- cognitive-behavioral Tx

Management of 52 yo F recently diagnosed rheumatoid arthritis. Developed decreased appetite, sore throat, mild nausea. On daily naproxen and methotrexate weekly. Shallow oulcer on the buccal mucosa. Mild pharyngeal erythema. No abdominal tenderness.
->
Folic acid supplement
Methotrexate toxicity includes stomatitis and megaloblastic anemia. folic acid supplementation usually improve stomatitis

Indication for hypoxia altitude simulation test
->
SpO2 92-95% on RA with risk factors (forced expiratory volume in 1 sec < 50%, moderate to severe pulmonary hypertension)
No test required: SPO2 ≧ 96%. 92-95% without risk factor. < 92% (-> supplemental oxygen without testing). On home oxygen (increase flow rate 1-2L/min)
Air-travel contraindicated for pt on oxygen ≧ 4L

Dx of 40 yo M with 3/6 systolic murmur heard at the mid-and upper sternum bilaterally. Carotid upstroke are delayed. Intensity of murmur decreases when assuming a standing position from a sitting position 
->
AS
Intensity of murmur decrease when venous return and LV blood volume decrease (abrupt standing). Murmur of HCM increases with abrupt standing (LV blood volume decrease -> worsens obstruction). HCM has a brisk carotid upstroke with abrupt collapse (rapid blood ejection in early systole followed by progressive outflow tract obstruction in late systole)

Dx of 55 yo F with hair thinning and loss. Vertex and center of the scalp since menopause 4 years ago. No itching. 
->
Androgenic alopecia
Affect both sexes. In women, it affects the vertex and center of the scalp with sparing of the hairline

Management of refractory constipation for patient with cancer on fiber, Senna-docusate, oral lactulose
->
Methylnaltrexone 
Peripherally acting opioid antagonsit. Doesn’t cause opiate withdrawal. Improve constipation

Management of newly diagnosed dermatomyositis 
->
Cancer screening 
Fivefold increased risk of malignancy

Dose of prednisone for dermatomyositis
->
High dose (1mg/kg) for several months 

Management of 70 yo F c/o pain and redness in R elbow. T 101. Fluctuant swelling on the back of elbow. Passive ROM intact. WBC 9200. Aspiration: clear yellowish fluid. WBC 10500. Gram stain and crystal negative
->
anti-staphylococcal ABX
Septic bursitis: fever, tenderness, fluid WBC > 3000 
nonseptic bursitis: no fever, less tender, fluid WBC < 1500
Gouty bursitis fluid WBC 3000-5000. Without h/o gout or RA, fluid WBC 3000-5000 suggests septic bursitis even if gram stain negative

Management of disfiguration of great toe nail, looking like onychomycosis 
->
KOH preparation of nail scraping before starting anti-fungal Tx
Similar appearance includes psoriasis, eczema, and lichen planus
Oral terbinafine (topical Tx is less effective, but for less severe cases)

Management of 78 yo F with PMH of T2DM, peripheral neuropathy developed red, hot and swollen right foot after bumping her foot against a car. R foot warmth, erythematous and edematous. No ulcer. No WBC. X-ray negative. Fluid aspiration 200/mm of WBC. No crystal. Gram stain negative
->
Casting and avoidance of weight bearing
Neuropathic (Charcot) arthropathy: repetitive bone&joint trauma. Tx for Acute neuropathic arthropathy is foot cast to reduce edema and help avoid weight bearing, thereby protecting the foot from further injury 

Management of adhesive capsulitis 
->
Range of motion exercise
(Frozen shoulder syndrome) result from chronic inflammation, fibrosis, and contracture of the joint capsule. Self-limited condition. And respond to conservative management in > 90% of patients. Steroid injection is reserved for patients with persistent AC symptoms 6-8 weeks after range of motion exercise

76 yo M with AS. TTE showed normal EF. AV calcified with restricted opening. Meant gradient > 50mmHg. Will undergo cardiac catheterization for what?
->
Define coronary anatomy
Cardiac catheterization recommended prior to valve surgery, since approximately 40% of patients require concurrent CABG.
Cardiac cath only needed to measure the gradient if the TTE is inadequate or if some inconsistency (measurement indicates mild stenosis, but the leaflets are calcified and restricted)

Management of 58 yo M intubated for COPD 2/2 pneumonia. On 3rd day, ventilator alarmed. HR 85-> 125 RR 16->32. Peak pressure 44. Plateau pressure 24. Breath sound coarse and mildly decreased on the left-side
->
Airway suctioning
Peak pressure = resistive pressure + plateau pressure. 
Plateau pressure = elastic pressure + PEEP -> lung compliance, typical goal < 30
Increased peak pressure with normal plateau pressure: bronchospasm, mucus plug, biting endotracheal tube
Increased peak pressure and increased plateau pressure: pneumothorax, pulmonary edema, pneumonia, atelectasis, R mainstem intubation

Core needle biopsy used for what
->
Site Not easily accessible 

Is Supraclavicular node easily accessible for biopsy?
->
Yes 

What is adynamic bone disease
->
Renal osteodystrophy due to overtreatment of secondary hyperparathyroidism (PTH < 100, low or normal ALP) (due to excessive use of vitamin D analogues). Tx: discontinue calcitriol
CKD -> low active vitamin D and high phos -> low Ca -> overstimulate parathyroid glands
Osteitis fibrosa cystica: due to secondary hyperparathyroidism. Tx: decrease PTH

Management of 64 yo had AMI 3 days ago, occlusion not revascularized. Developed chest pain. Positive friction rub. Trivial pericardial effusion
->
Increase aspirin to higher dose
Peri-infarction pericarditis. Occurs within days of MI. Usually self-limiting. Guideline recommends the use of higher dose of aspirin 

Management of 70 yo F with post-herpetic neuralgia
->
Pregabalin or gabapentin (tricyclic antidepressant has the most evidence of efficacy, but not for elderly due to side effects)
(Carbamazepine for trigeminal neuralgia)

Bone marrow stained with Prussian blue for iron. Dx of dense iron staining in macrophages but no staining of erythrocyte precursor 
->
Anemia of chronic disease
(IDA: no iron staining in either macrophages or red cell precursors)

Dx of 34 yo F developed HA followed by seizure. 10/10 HA. Blurry vision. BP 210/140. Fundoscopic exam: copper and sliver wiring in the retina. CT negative. MRI increased signal abnormalities in the subcortical white matter of the posterior occipital-parietal lobes
->
Posterior reversible encephalopathy syndrome (PRES)
Often seen in the setting of hypertensive crisis. PRESS due to brain edema. Posterior regions of brain are more susceptible to injury from high mean arterial pressure
Copper and silver wiring in the retina: due to chronic high blood pressure 

Dx of 40 yo M developed nephrotic syndrome after URI
->
Minimal change disease 
Accounts for a large percentage (70-90%) of childhood and 10-15% of adult non-diabetic nephrotic syndrome 

Tx for panic attack
->
Benzodiazepine and SSRI or SNRI
SSRI/SNRI typically require 2-4 weeks to take effect. Benzodiazepine have the advantage of rapid onset of action

Cause of ascites in patient with serum Alb 3.7. ascitic leukocyte 350 (neutrophil 20% lymphocyte 80%). Ascitic TP 3.3 and Alb 2.0
->
Heart failure
SAAG > 1.1 -> portal hypertension -> TP < 2.5: cirrhosis or TP > 2.5: heart failure

Management of 54 yo F developed dry cough, SOB, fever. Not responded to moxifloxacin. S/p radiation for R breast cancer 6 weeks ago. T 101. Crackles over the right lower lung. WBC 13000. Normal TTE
->
Prednisone
Acute radiation pneumonitis. Fever, dyspnea, cough and pleuritic Chest pain are common as is leukocytosis. 

Cause of 85 yo F with h/o HTN developed moderate-sized, left frontoparietal lobar hemorrhage with mass effect. Had intracerebral hemorrhage into the right occipital lobe 6 months ago
->
Cerebral amyloid angiopathy
Second most common cause of ICH. Spontaneous lobar ICH. CAA probable in pt > 75 with multiple lobar (cortical and subcortical white matter) hemorrhage. 
ICH due to arteriovenous malformation usually occurs between 10 and 40
Hypertensive hemorrhage are most common and occurs most frequently in the basal ganglia followed by thalamus, pons and cerebellum

Most common cause of all gastroenteritis in adults and children 
->
Norovirus

Management of primigravid 32 yo F at 24 weeks gestation. C/o excessive fatigue, feels sleepy throughout the day. Overnight sleep poor. Doesn’t refresh on awakening in the morning
->
Polysomnography 
Similar to nonpregnant patients, pregnant patients with excessive fatigue, snoring, and daytime somnolence should be evaluated with overnight polysomnography. OSA linked to gestational diabetes, gestational HTN, and preeclampsia 

What cm above sternal notch indicate elevated jugular venous pulse
->
≧ 4cm (approximate 4-5cm distance from the sternal angle to the right atrium) -> 9cm total from the right atrium 

Dx of painful ulcer with a purulent base and violaceous borders on leg. Also having frequent diarrhea
->
Pyoderma gangrenosum / IBD

Common complication of primary biliary cholangitis 
->
Osteoporosis (unknown cause) up to 50%
Malabsorption of Fat-soluble vitamins (A,D,E,K)

Dx and management of 65 yo F developed pruritic rash, onset of winter. Lower legs. Rough, scaly, Dry, Red, itchy. 
->
Xerosis (skin dryness) / moisturizing 

High-intensity statin can cause a small increase of what?
->
Risk of new-onset DM or worsening glycemic control in DM patients (-1%)
Rhabdomyolysis: 0.1%
Myalgia: up to 10%

BRCA gene test indicated for 
->
Breast cancer in a first-degree relative (mother, sister, daughter) diagnosed under 50,
And …

Dx and related condition of 56 yo M developed non-pruriticc skin rash. Skin irritation followed by blistering and then crusting. Affecting Back of hands, and sometimes neck. Exam: erosion, crusting, skin hyperpigmentation and fine scarring
->
Porphyria cutanea tarda / HCV

Management of 64 yo M with erectile dysfunction. Taking isosorbide mononitrate. Normal testosterone level. No spontaneous morning erection. 
->
Intraurethral alprostadil (vasodilator)
Increase blood flow
(Phosphodiesterase inhibitor as first Tx. No concurrent use with nitrate)

Dx and management of 35 yo F c/o right thigh numbness. Started a few weeks prior to delivering her first child. Paresthesias along the anterolateral aspect of right thigh. No weakness. Somewhat improved after the delivery. 
->
Meralgia paresthetica / reassurance and conservative Tx (avoid tight garments and weight loss)
Injury to lateral femoral cutaneous nerve. No motor deficit. Self-limited condition.

Dx of 36 yo F developed recurrent abdominal pain. Sweating and restlessness. Urine turn dark. CT scan negative. Has chronic constipation. BP 165/97 HR 112 T 98.0 WBC 9000 Na 128 UA negative
->
Acute intermittent porphyria
Abd pain, with constipation, dark urine. Hyponatremia
Precipitating factor: infection, starvation, stress, alcohol, drug (hormones and sulfonamides)

Management of HFpEF on amlodipine 10mg, spironolactone 12.5mg, lasix 40mg iv c/o SOB, JVP 9cm, bibasilar crackles and leg edema
->
Increase lasix dosage

Medications for HFpEF
->
SGLT-2 inhibitors added first. Aldosterone antagonist (spironolactone) added secondary 
To reduce hospitalization & possibly mortality 

Dx of 70 yo M c/o headache, Weakness, intermittent blurry vision. Weight loss. Liver edge is palpable at the costal margin. Hb 10.8 normal LFT. Ferritin 390. ESR 120
->
Temporal arteritis
Liver lower border can be felt just below the ribs, often indicating hepatomegaly or sometimes a normal finding
Hepatomegaly is not common symptom in TA

Tx for alopecia areata 
->
Intralesional corticosteroid injection
Chronic, recurring inflammatory diorder 

Test for invasive aspergillosis 
->
Galactomannan antigen (present in aspergillus cell walls)

Medication for diabetes and weight loss
->
GLP1a (glucagon-like peptide 1 receptor agonist)

GLP1a contraindicated for
->
Pancreatitis, severe renal failure

Medication for diabetes, cardiac risk factor and CKD
->
SGLT2i (sodium-glucose cotransporter 2 inhibitor)

Dx of 43 yo avid tennis player c/o right groin pain. It is present with moderate activity and improves with rest. Hip exam reveals pain along the anterior hip worsened with internal and external rotation 
->
Osteoarthritis of the hip
Groin pain, aggravated by movement 

Dx of 68 yo M with T2DM developed worsening glucose control, weight loss and decreased motivation to perform daily activities 
->
Pancreatic cancer
Up to 25% of patients have atypical T2DM, acutely worsening hyperglycemia

Choice of antithyroid drug for Graves disease
->
Methimazole preferred due to the risk of hepatotoxicity with propythiouracil, although propylthiouracil recommended in the first trimester of pregnancy 

Dx of 39 yo M developed rash on legs. 2 weeks ago he had a sore throat. Received amoxicillin. No joint pain, abdominal pain, diarrhea or urinary symptoms. Palpable and nonblanching rash. UA negative PLT 160000
->
Drug-induced vasculitis
Medication-induced cutaneous small vessel vasculitis 
Skin-isolated leukocytoclastic vasculitis. Caused by drug exposure. Palpable purpura and/or petechiae. No visceral organ involvement. 

Dx and management of sharply demarcated, erythematous plaques with an overlying thick, silvery scale on extensor surfaces of knees.
->
Plaque psoriasis / topical corticosteroids and calcipotriene
Topical vitamin D (calcipotriene)

Follow-up CXR indicated for patient with recent pneumonia 
->
Do not require radiographic imaging if patents respond appropriately. Patient who do not completely respond to ABX generally require additional evaluation

Tickborne disease causes leukopenia and thrombocytopenia
->
Human granulocytic anaplasmosis and human monocytic ehrlichiosis 

Morulae caused by 
->
Human granulocytic anaplasmosis and human monocytic ehrlichiosis 

Dx of 19 yo M developed fever and HA. Severe pain in groin and axillary areas. Changing carpet and found a dead rat a few days prior. Multiple severely tender, non-fluctuant, enlarged nodules in the axillary and groin regions
->
Yesinia pestis / Bubonic plague 
Transmitted by infected fleas from rodents. Unexplained fever and regional lymphadenitis. 
（ペスト、依然存在）

Triad of Felty’s syndrome
->
RA, neutropenia, splenomegaly

Extra-articular manifestations of Felty’s syndrome
->
Vasculitis (mononeurtitis multiplex, necrotizing skin lesion (ulcer))

Associated condition with skin tag
->
Insulin resistance (DM) (acrochordons)

Central retinal artery occlusion painful or painless
->
Painless

Dx of progressive distortion and vision loss, primarily in the center of the visual field
->
Age-related Macular degeneration (黄斑変性症)

Does Varenicline increase the risk of depression or suicidality 
->
no (there was initially concern, but black box warning was removed)

Cause of 31 yo M developed high-grade fever and multiple painful skin nodules. H/o allogenic bone marrow transplantation for acute leukemia 3 months ago.
->
Fusarium moniliforme (the second most common pathogenic mold)
Invasive disease most commonly occurs in severely immunocompromised patients (neutropenia, lymphopenia. Graft-vs-host disease), particularly those with hematologic malignancies receiving induction chemotherapy or bone marrow transplantation 

Dx of 58 yo F admitted for aortic valve endocarditis developed new 1st degree AV block
->
Perivalvular abscess
Abscess can extend from the aortic valve into the adjacent conduction tissue near the AV node and lead to various heart blocks

Cause of elevated AST 58 ALT 78 ALP 100 in patient with h/o IDA, hypothyroidism and vitiligo
->
Celiac disease
In the setting of autoimmune disease and iron deficiency anemia
Cause elevated aminotransferases

Management of 30 yo F without PMH developed raynaud phenomenon
->
Nail bed capillaroscopy
Primary RP: idiopathic response to cold or stress
Secondary RP: vasoconstriction due to vascular pathology. Autoimmune disease (systemic sclerosis), drugs (amphetamines), trauma (frostbite)
Nail bed capillaroscopy can help differentiate between primary and secondary RP

How many days supply of hydrocodone/acetaminophen after uncomplicated laparoscopic cholecystectomy 
->
3 days

What infection risk is greatest in HIV patient with CD4 730, working as a nurse and from Ecuador
->
TB
HIV and TB co-infection can occur at any CD4 level
PCP: < 200, toxoplasma: < 100, histoplasma: < 150

Dx of 24 yo M developed psychosis. Father died from liver failure. Liver palpable 3 cm below the right costal margin. 
->
Wilson disease
Neuropsychiatric Sx: parkinsonian-like tremor, rigidity, personality change, depression, paranoia, catatonia 
Others: Hemolytic anemia

Diagnostic criteria of hypertrophic cardiomyopathy 
->
LV wall thickness ≧ 15mm

What is athlete’s heart
->
Physiologic increase in LV wall thickness. Generally symmetric and ≦ 12mm
(HCM: LVH is frequently asymmetric)

What is benign epidermal tumor, “stuck-on”, pigmented and sharply demarcated appearance (気持ち悪い)
->
Seborrheic keratosis 
No Tx required unless irritating or cosmetic issue
(Seborrheic dermatitis: red, greasy, flaky or scaly patches on scalp, face, zinc/selenium shampoo)

Cause of rapid eye movement sleep behavior disorder
->
Early Parkinson disease and dementia with Lewy bodies
Early Parkinson also can cause anosmia (無嗅覚)

Dx and management of isolated unconjugated hyperbilirubinemia
->
Gilbert’s syndrome / no further testing or specific Tx

What is ursodeoxycholic acid
->
Bile acid supplement 
For primary biliary cholangitis

Mimic Statin myopathy
->
Hyper/hypothyroidism, vitamin D deficiency
Alcohol, hypoK, connective tissue disease, Addison disease, ..

Dx of schizophrenic patient on haloperidol developed anxiety, motor restlessness and difficulty sitting still
->
Akathisia
Extrapyramidal symptoms, antipsychotic side effects 

Dx of 65 yo F with PMH of chronic pain syndrome has had N/V. followed by epigastic pain, pain in all joints and muscles, rhinorrhea, hyperactive bowel sounds, diaphoresis
->
Opioid withdrawal

Renal manifestation of Sjogren syndrome
->
Chronic interstitial nephritis, distal renal tubular acidosis, diabetes insipidus

Normal range of vitamin B12
->
> 300: normal
< 200: low / B12 deficiency
200-300: borderline -> check methylmalonic acid level

Dx of colonoscopy shows edematous, multiple ulcerations, and exudates involving the entire colon. Biopsy reveals mononuclear cell infiltrates, cryptitis, and crypt abscess
->
Ulcerative colitis
Colonoscopy show rectal (and Continuous proximal) inflammation.
Cryptitis/crypto abscess seen in both UC and Crohn disease

Greater trochanteric pain syndrome includes
->
Bursitis, tendonitis

Management of atypical anal fissure
->
Colonoscopy to rule out Crohn disease
Eccentrically located (lateral, anterior), multiple
Failure to respond after 8 weeks of optimal Tx 
In patients with Crohn disease, anal fissure frequently present

Hyperthyroid state from Suppression of TSH after thyroidectomy for cancer could induce
->
Osteoporosis, Afib, HTN

Indication of fibrate for hypertriglyceridemia
->
TG > 500
Pancreatitis prevention 

Dx of pleura effusion: low pH, very low glucose (< 30), extremely high LDH (> 1000)
->
Empyema and rheumatoid pleurisy (common manifestation of rheumatoid arthritis)
Empyema: WBC > 50000 and neutrophilc predominance
Rheumatoid effusion: WBC < 5000 with predominantly lymphocytes

Management of 62 yo M p/w episodes of lightheadedness for 6 mo. happens primarily in the morning when getting dressed. He feels that the room is Getting dark and he is going to pass out. Negative orthostasis. Normal EKG. 
->
Carotid sinus massage
History is suggestive of carotid sinus hypersensitivity 
Triggered by pressure on the carotid sinus by a tight collar and neck movement
Carotid sinus massage diagnostic, if develop syncope and/or fall in SBP > 50

Does warfarin need to be held before cataract surgery in patient with Afib
->
no

Dx of 60 yo M, difficulty ambulating, unknown PMH. Emigrated from china. Early diastolic murmur  in the aortic area. Bilateral lower extremity reflexes are diminished. Vibration and position sensation is decreased. Gait unsteady. CXR widened mediastinum. Calcification of the ascending aorta and aortic arch
->
Syphilis 
Affect posterior columns of spinal cord. Cardiovascular syphilis affects the ascending aorta. Aortic insufficiency

Dx of 49 yo F developed food stuck in her chest. EGD showed a lower esophageal ring. It was dilated by EGD
->
Esophageal rings (Schatzki)
Congenital or acquired (due to damage fro gastroesophageal reflux)

Dx of itchy, red, vesiculo-bullous rash. Streak lesions
->
Poison ivy dermatitis
One of the most common causes of allergic contact dermatitis

Diagnostic test of Henoch-Schonlein purpura
->
Skin biopsy 
Finding of leukocytoclastic vasculitis 

Management of stage IIIA invasive ductal breast cancer with triple negative
->
Surgery + chemo + radiation 

Could hypersensitivity pneumonitis develop digital clubbing?
->
Yes

Untreated acromegaly is risk of what
->
Colon cancer
Likely IGF-1 stimulating mucosal cell proliferation 
Others: esophageal, gastric, melanoma

Management of thyroid nodule, TSH 1.3. 16mm round, hypoechoic, no lymphadenopathy
->
FNA
In most cases, patients with normal/elevated TSH and nodule > 1cm in diameter should be evaluated further with fine needle aspiration 

Dx and management of 87 yo M developed confusion, SOB. He fell out of bed last night. SPO2 92% on RA. In respiratory distress. No JVD. Many small purplish discoloration on the chest that do not blanch with pressure. WBC 8200. CXR peripheral haziness. X-ray shows hip fracture. 
->
Fat embolism / supportive care
Following long bone fracture. Hypoxemia, neurologic abnormalities and petechial rash

Management of poor visualization on colonoscopy. 3 small adenomatous polyps removed 5 years ago
->
Colonoscopy within a year
CT colonography: every 5 years can be considered for colorectal cancer screening in average-risk individuals. Not recommended for surveillance in patients with a history of polyps because it is less sensitive in detecting small polyps 

Management of diarrhea of 22 yo M with Crohn disease s/p resection of terminal ileum
->
Cholestyramine 
Bile acid sequestrant (封鎖剤)
Bile acids are actively reabsorbed in the terminal ileum and returned to the liver through enterohepatic recirculation. 

Combination oral contraceptive vs levonorgestrel for Emergent contraception 
->
Levonorgestrel: efficacy 92-98%
Oral contraceptives: efficacy 75-89% (second line, causes persistent nausea)
Ulipristal: efficacy 98-99%

Dx and management of 35 yo healthy F developed a firm, dome-shaped papule with a shiny surface and central indentation on face
->
Molluscum contagiosum / HIV test
Infection due to poxvirus. More common in children
Common in patients who have immunosuppressive conditions

Different manifestation between primary hyperparathyroidism and hypercalcemia of malignancy 
->
Primary hyperparathyroidism: presents insidiously. Ca mildly elevated (< 11)
hyperCa of malignancy: due to PTH-related peptide, presents acutely. Severe hyperCa (> 13)

Skin and cardiac manifestation of carcinoid syndrome
->
Skin: telangiectasia, flushing
Cardiac: valvular disease (tricuspid regurgitation)
Also hepatomegaly due to metastasis 

Management of patient with h/o atypical ductal hyperplasia of the breast on tamoxifen prior to elective hip replacement surgery
->
Hold tamoxifen 2-4 weeks prior to surgery
It exerts estrogen-mimetic effects on the coagulation system and is a/w increased rates of venous thromboembolism 

Difference between factitious disorder and malingering
->
Factitious disorder: to assume the role of a patient, psychological need (attention)
Malingering: for external rewards (disability pay or drugs)

Interpretation of tuberculin skin test in close contact individual 
->
≧ 5mm considered positive

Window period from infection to detectable TST 
->
2-12 weeks

Tx for primary raynaud phenomenon 
->
CCB

Management of 26 yo F with PCOS started oral contraceptive 4 months ago. Menstrual cycle has become regular. Hirsutism improved but still present
->
Continue oral contraceptive
Oral contraceptive: first-line Tx. PCOS may require up to 6 months of Tx before a significant decrease in terminal hair is seen. Anti-androgen (spironolactone) is added if there is a poor cosmetic response after 6 months of OC Tx

Liver failure or vitamin K deficiency with normal factor 5 and 8, and decreased factor 7
->
Vitamin K (decrease in 7 (and 2,9,10))
Factor 5 and 7 both decrease in liver failure

Which factor increase in liver failure
->
Factor 8

Dx of 29 yo recent trip to Costa Rica developed fever, hepatomegaly and redness of the conjunctivae 
->
Leptospirosis
Conjunctival suffusion (redness of the conjunctivae with no inflammatory exudate) is characteristic 
Others: proteinuria, contact with water

Sx of Dengue fever
->
High fever, severe HA, intense muscle/joint/bone pain (“breakbone fever”)

Dx of sharp tenderness of the radial styloid at the wrist
->
De Quervain tendinopathy

Dx of 42 yo F raped 3 months ago developed social isolation. Frequent nightmares. Unusual episodes of feeling a sense of unreality. And as if she is detached from her physical body
->
PTSD
depersonalization/derealization (feeling of unreality or being detached from one’s body) is also characteristic of PTSD

Difference of PTSD and acute stress disorder
->
Acute stress disorder: experiencing post-traumatic stress and functional impairment for the first 30 days
PTSD: patient remains symptomatic after 30 days

Dx and Tx of 30 yo F developed cauliflower-like plaques in finger nail folds. She is handling raw meat and fish at restaurant
->
Verruca vulgaris / salicylic acid 
“Butcher’s warts”. Caused by human papillomavirus
Salicylic acid breaks down the protein (keratin) in the wart

Tx fort ankylosing spondylitis refractory to NSAIDs
->
Tumor necrosis factor (etanercept, adalimumab

Essential thrombocythemia is related to what
->
Acquired von Willebrand disease 
Likely due to the consumption of large von Willebrand factor multimers 2/2 PLT activation 

Dx of 43 yo construction worker c/o SOB, cough. CXR shows bilateral pleural-based dense infiltrates involving upper and lower lobes. The infiltrates spare the central and perihilar lung regions
->
Eosinophilic pneumonia

Which site of injury causes foot drop?
->
Fibular head
Common peroneal nerve in the fibular head region 

Tx for gonorrhea when allergic to ceftrixone

Gentamicina and azithromycin 

Management of 27 yo F diagnosed gestational diabetes. Blood glucose: fasting 110-120. 2 hours after meals: 130-140 after a week of diet control
->
Prescribe insulin
Tight glycemic control to prevent maternal and fetal complications 
Glycemic target: fasting < 95. 2 hours postprandial: < 120

Dx of 29 M developed malaise, maculopapular rash on trunk and extremitiers. Lymphadenopathy in anterior and posterior cervical areas. Hair loss on the scalp. Mildly elevated liver enzymes 
->
Secondary syphilis 
“Moth-eaten” alopecia. Mild hepatitis

Achalasia is risk for what
->
Esophageal cancer (squamous cell carcinoma)
Stasis and fermentation cause mucosal inflammation, epithelial hyperplasia

Dx of pneumonia, hyponatremia, bradycardia, elevated LFT
->
Legionella pneumonia 

Antibody specific for granulomatosis with polyangiitis
->
Anti-proteinase 3 antibody 
c-ANCA (cytoplasmic pattern) is caused by anti-proteinase 3 antibody
ANCA: anti-neutrophil cytoplasmic antibody 

Does non-Hodgkin lymphoma cause bone lucency?
->
Yes
Osteolysis through massive, often mottled or permeative, destruction of the bone marrow

Management of 30 yo F with thyroid nodule. 2cm. TSH 0.12 T3 serum 190 FT4 1.8 (normal 0.9-2.4)
->
Thyroid scintigraphy
Subclinical hyperthyroidism 
Hyperfunctioning nodule (low TSH) is rarely malignant and FNA not necessary 
(Normal serum T3: 60-180)

Management of 34 yo M developed chest pain after cocaine use. EKG show ST elevation in II,III,aVF. CP improved from 8/10 to 3/10 after NTG, ASA and benzodiazepine
->
Cardiac catheterization as STEMI

Dx and management of pruritic facial rash. Erythematous plaques with fine, loose, yellow and greasy scales
->
Seborrheic dermatitis / low-potency steroid cream and antifungal cream
Etiology is unclear but is thought to be due to the growth of lipid-dependent Malassezia fungus
Could worsen by ABX use. Possibly by disrupting skin microbiome balance

Diagnosis of nonalcoholic fatty liver disease
->
Rule out other secondary cause (vital hepatitis, hemochromatosis, alcoholic hepatitis)

Management of 27 yo M s/p splenectomy for MVA developed fever of 101 for 2 days. 
->
Prompt aggressive antibiotic Tx and ED visit for urgent diagnostic evaluation
Asplenic patient can progress within hours to fulminant disease with severe shock, sepsis and DIC. 

Management of 35 yo M with tuberculin skin test: 2mm induration with 22mm erythema 48 hours after. Occasional cough. Moved from Haiti to US at age 5.
->
No further test or Tx
Measurement of induration, not erythema
< 5mm: negative for all individuals
≧ 5mm positive for HIV, recent contact, CXR shows previous healed TB, organ transplant recipients


Dx of 55 yo M with swelling of the finger joints. Boggy swelling and tenderness to palpation involving all the proximal and distal interphalangeal joints. Cyclic citrullinated peptide Ab negative
->
Psoriatic arthritis 
DIP joint arthritis are considered the most specific for psoriatic arthritis

Management of 20 yo M playing varsity basketball. Diagnosed with HCM. Asymptomatic. TTE interventricular septal thickness 1.8cm. posterior LV wall thickness 0.9cm. LVEF 75%. No LV outflow gradient at rest. Valsalva maneuver generates a gradient of 30mmHg
-> 
Avoid high-intensity physical activity 
HCM is the most common cause of sudden cardiac death in young athletes
Alcohol septal ablation or surgical septal myectomy is indicated for severe LVOT obstruction and heart failure symptoms that are refractory to optimal medical management 

Indication of AVR for asymptomatic severe AR
->
EF < 55 or LV end-systolic dimension > 50mm

Dx of 81 yo F c/o constant ringing in ears. Difficulty hearing. 2 episodes of near falls. Normal external ear. No cerumen impaction. Normal tympanic membranes
->
Presbycusis
Or Age-related hearing loss
Common condition, affect > 50% of adults by 75 yo. Sensorial hearing loss. Accompanied with tinnitus, vertigo, and disequilibrium 

Rheumatology F

Q: First tests in acute monoarthritis

A: Joint aspiration and synovial fluid analysis

Q: Diseases characterized by inflammation of axial skeleton, enthesitis, positive HLA-B27

A: Spondyloarthritis (ankylosing spondylitis, psoriatic arthritis, IBD-associated arthritis, reactive arthritis)

Enthesitis: 腱付着部炎

Q: Most sensitive imaging test for bony erosions

A: CT

(Than MRI)

Q: Imaging test in suspected spondyloarthritis with normal radiograph

A: MRI of SI joint

Q: Noninflammatory synovial cell count

A: <2000/µL

(No cut off, but > 50000/μL high likelihood of infection)

Q: Indications for prophylactic bisphosphonate therapy in chronic glucocorticoid therapy

A: Age > 40 years, moderate-high risk for osteoporotic fractures, taking ≥ 2.5 mg of prednisone for ≥ 3 months

Q: Safest drug treatment in elderly patients with OA

A: Topical NSAIDs

Q: Coadministration with colchicine reduces hepatic catabolism and could lead to colchicine overdose

A: CYP3A4 inhibitors (such as clarithromycin and fluconazole)

Q: Hematologic complications of methotrexate

A: Megaloblastic anemia, pancytopenia

Cause folate deficiency

Q: Therapy to decrease methotrexate complications

A: Folic acid

Q: Risk assessment for azathioprine-induced myelosuppression

A: Thiopurine methyltransferase enzyme testing

Q: Concomitant use with azathioprine is contraindicated

A: Xanthine oxidase inhibitors (allopurinol, febuxostat)

Azathioprine is metabolized by xanthine oxidase

Q: Highly teratogenic RA medications

A: Methotrexate, leflunomide

Leflunomide: disease-modifying antirheumatic drug

Q: Preferred therapy if immunosuppressive agent is imperative in SLE during pregnancy

A: Azathioprine

Q: Screening before TNF inhibitor therapy

A: Interferon-γ release assay (TB), HBV and HCV serologic testing, HIV screening

Q: Common nonpharmacologic measure for osteoarthritis

A: Physical therapy

Q: Common modifiable risk factor for RA

A: Cigarette smoking

Q: Most specific serologic test for RA

A: Anti–cyclic citrullinated peptide antibody

Q: RA radiographic findings

A: Periarticular osteopenia, marginal erosions, joint-space narrowing

Q: Preoperative imaging in long-standing RA

A: Cervical spine radiography to assess for atlantoaxial subluxation

Q: Most common ocular manifestation in RA

A: Dry eye (keratoconjunctivitis sicca)

Q: RA pleuritis pH and glucose values

A: pH < 7.3, pleural fluid glucose < 60 mg/dL

Mimicking bacterial or tubercular infection and malignancy

Q: RA cause of hoarseness, sore throat, dysphagia, stridor

A: Cricoarytenoid arthritis

Q: The major cause of excess death in patients with RA

A: Atherosclerotic heart disease

Q: RA, neutropenia, splenomegaly

A: Felty syndrome

Q: Benefits of treating RA to remission or low disease activity

A: Less radiographic damage, reduced CV risk, increased work productivity

Radiographic damage: visible changes in bones and joints that can be seen on x-rays

Q: Preferred initial monotherapy for RA

A: Methotrexate

Q: Major benefit of NSAIDs in RA

A: Symptom control

Q: Most important modifiable risk factor for knee OA

A: Obesity

Q: Most commonly involved joints in erosive OA

A: DIP and PIP

Q: Radiographic findings in erosive OA

A: Symmetric central interphalangeal joint erosions with “gull (かもめ)-wing” deformity

Whether erosive OA comprises a separate disease entity or is part of the continuum of OA remains controversial

Q: Factors differentiating diffuse idiopathic skeletal hyperostosis from ankylosing spondylitis

A: Noninflammatory back pain and lack of SI joint involvement

Diffuse idiopathic skeletal hyperostosis: calcification and ossification (骨化) of spinal ligaments and entheses. DISH lacks involvement of the sacroiliac joints

Q: Radiographic findings in diffuse idiopathic skeletal hyperostosis

A: Confluent right-sided spinal ligamentous ossification of ≥ 4 contiguous vertebral levels

(Right-sided predilection)

Q: First imaging modality to assess inflammatory arthritis and OA

A: Radiography

Q: Radiographic findings in OA

A: Asymmetric joint-space narrowing, osteophytes, subchondral sclerosis

Q: Nonpharmacologic treatment for knee OA

A: Leg muscle strengthening exercise program

Q: Goal of OA drug therapy

A: Symptom control

Absence of disease-modifying OA drugs

Q: Common adverse effect of topical NSAIDs

A: Skin irritation and rash

Q: Antidepressant for knee OA

A: Duloxetine

SNRI, shown efficacy for pain from knee OA

Q: OA indications for arthroscopic surgery

A: Symptomatic mechanical disorder or joint buckling/instability/locking

Q: Widespread chronic pain, nonrestorative sleep, fatigue, cognitive dysfunction

A: Fibromyalgia

Q: Nonpharmacologic fibromyalgia therapy

A: Disease education, aerobic exercise, psychosocial support

Q: Pharmacologic treatment for fibromyalgia

A: Gabapentin, pregabalin, duloxetine, milnacipran, tricyclic antidepressants

Milnacipran: SNRI

Q: Treatments for fibromyalgia with depression

A: Duloxetine, milnacipran, tricyclic antidepressants

Q: Spondyloarthritis most strongly associated with HLA-B27

A: Ankylosing spondylitis

Q: Spondyloarthritis most frequently involving SI joints

A: Ankylosing spondylitis

SI joint: sacroiliac joint

Q: Common sites of enthesitis in psoriatic arthritis

A: Achilles tendon, plantar fascia

Q: IBD-related arthritis that parallels IBD activity

A: Spondyloarthritis

Q: Acute peripheral oligoarticular arthritis with enthesitis and dactylitis

A: Reactive arthritis

Dactylitis: “sausage fingers”

Q: Initial evaluation of patient with suspected ankylosing spondylitis

A: Radiography of the SI joint

Q: Radiographic findings in psoriatic arthritis

A: DIP joint involvement, pencil-in-cup deformity

Q: First-line treatment of ankylosing spondylitis

A: NSAIDs

Disease-modifying effect, only in ankylosing spondylitis

Q: Biologic therapies for IBD bowel and joint symptoms

A: TNF inhibitors

Q: SLE-related annular rash with central clearing or erythematous plaques and papules

A: Subacute cutaneous lupus erythematosus (SCLE)

SCLE: sparing the central face

Acute cutaneous lupus erythematous: facial eruption/butterfly rash, fixed rather than transient

Q: Cause of subacute hip pain in SLE

A: Osteonecrosis

Q: Severe neuropsychiatric manifestations of SLE

A: Seizures, psychosis

Q: Life-threatening pulmonary manifestations of SLE

A: Lupus pneumonitis and diffuse alveolar hemorrhage

Q: Clinical manifestations of acute lupus pneumonitis

A: Cough, dyspnea, fever, hypoxemia, pleuritic chest pain, pulmonary infiltrates

Q: Antibody testing for thrombotic risk in SLE

A: Antiphospholipid antibodies/lupus anticoagulant, anti–β2-glycoprotein, anticardiolipin antibodies

Q: Inflammatory marker that may be normal in active SLE

A: C-reactive protein

Some patients with SLE have little to no elevation in CRP during SLE flares

Q: Laboratory findings in acute SLE flare

A: Elevated ESR and anti–double-stranded DNA antibody titer, low complement levels

Q: Drug therapy for all patients with SLE

A: Hydroxychloroquine

Q: SLE indications for high-dose glucocorticoids

A: Profound cytopenias, class III/IV nephritis, seizures, psychosis

Q: Rheumatologic diseases most commonly associated with secondary Sjögren syndrome

A: RA and SLE

Q: Malignancy associated with Sjögren syndrome

A: Non-Hodgkin lymphoma

Q: Antibodies specific for primary Sjögren syndrome

A: Anti-Ro/SSA autoantibodies

(Anti-La/SSB autoantibodies are characteristic, but not included in formal classification criteria)

Q: Test for suspected Sjögren syndrome with negative anti-Ro/SSA antibodies

A: Lip biopsy

Minor salivary gland

Q: Initial management of sicca symptoms

A: Artificial tears and sugar-free candies

Q: Malignancy screening in dermatomyositis and polymyositis

A: Age- and sex-appropriate cancer screening and risk-stratified screening

Stratified by high, intermediate and low risk

Q: Pathognomonic dermatomyositis rashes

A: Gottron papules and heliotrope rashes

Gottron papule: violaceous over the bony prominence on the hands

Heliotrope rash: purple erythema of the eyelids

Q: Antibodies associated with antisynthetase syndrome

A: Anti–aminoacyl-tRNA synthetase (commonly anti–Jo-1)

Antisynthetase syndrome: 30% on Pt with dermatomyositis or polymyositis, with interstitial lung disease, arthritis, raynaud phenomenon

Q: Interstitial lung disease, Raynaud phenomenon, inflammatory arthritis, mechanic's hands

A: Antisynthetase syndrome

Mechanic’s hand: hyperkeratotic, scaly skin on the fingertips and sides of the fingers

Q: Acute severe myopathy and anti-HMG Co-A reductase antibodies

A: Immune-mediated necrotizing myopathy

Q: Insidious onset of proximal and distal symmetric muscle weakness

A: Inclusion body myositis

(Dermatomyositis/polymyositits: proximal muscles)

Q: Sensitive serum marker of muscle pathology

A: Creatine kinase level

Q: Polymyositis and dermatomyositis treatment

A: Glucocorticoids

Glucocorticoid is the cornerstone of Tx

Q: Most common early manifestation of systemic sclerosis

A: Raynaud phenomenon

Q: CREST syndrome

A: Limited cutaneous systemic sclerosis

Systemic sclerosis classification

1. Limited cutaneous systemic sclerosis (CREST syndrome): face, neck hands, feet
2. 2. Diffuse cutaneous systemic sclerosis: distal and proximal skin thickening, commonly visceral organ involvement

3. Systemic sclerosis sine (なし) scleroderma: organ involvement without skin thickening

Q: Pulmonary vascular disease in limited cutaneous systemic sclerosis

A: Pulmonary arterial hypertension

LcSSc less commonly accompanied with fibrosis of internal organ, but more commonly associated with pulmonary artery hypertension

Q: Common cause of GI bleeding in systemic sclerosis

A: Gastric antral vascular ectasia

Q: Diarrhea, bloating, and malabsorption in systemic sclerosis

A: Small intestinal bacterial overgrowth

Q: Risk factors for scleroderma renal crisis

A: Diffuse cutaneous systemic sclerosis, glucocorticoid use, anti-RNA polymerase III antibodies

LcSSc: anti-centromere Ab

DcSSc: anti-Scl-70 Ab, anti-RNA polymerase III Ab

Q: Systemic sclerosis, AKI, severe hypertension, microangiopathic hemolytic anemia, thrombocytopenia, proteinuria

A: Scleroderma renal crisis

Q: Disease-related cause of death in diffuse cutaneous systemic sclerosis

A: Interstitial lung disease

Q: Treatment of scleroderma renal crisis

A: Captopril

(Short-acting)

Q: Treatment of systemic sclerosis–related interstitial lung disease

A: Mycophenolate mofetil

Q: Manifestation of ≥2 of the following: SLE, polymyositis, systemic sclerosis

A: Mixed connective tissue disease

Q: Mixed connective tissue disease antibody

A: Anti–U1-ribonucleoprotein (RNP) antibodies

Q: Major cause of death in mixed connective tissue disease

A: Pulmonary arterial hypertension

Q: Pulmonary manifestations of mixed connective tissue disease

A: Pulmonary arterial hypertension, interstitial lung disease

Q: Soft-tissue manifestations of acute gout

A: Acute bursitis, periarthritis, gouty panniculitis (脂肪織炎) /cellulitis

Q: Gout radiographic findings

A: Punched-out lesions with overhanging edges of cortical bone

Q: Gold standard for diagnosis of gout

A: Negatively birefringent (複屈折), needle-like crystals within neutrophils

Q: Treatment of gouty cellulitis

A: NSAIDs, colchicine, or glucocorticoids

Q: Genetic testing in a patient at high risk for allopurinol sensitivity

A: HLA-B*58:01 allele

Q: IV treatment of recalcitrant tophaceous gout

A: Pegloticase

By breaking down uric acid into allantoin, a substance that is easily eliminated by the body

For patients with severe recurrent and/or tophaceous gout who are intolerant of or resistant to standard Tx

Recalcitrant: 抵抗性の

Febuxostat: oral: for intolerance to allopurinol

Pegloticase: iv: severe, refractory gout

Q: Prophylactic therapies when initiating urate-lowering treatment

A: Colchicine, low-dose glucocorticoids, or low-dose NSAIDs

Q: Cause of CPP crystal arthritis in young patient

A: Hyperparathyroidism, hemochromatosis, hypophosphatasia, or hypomagnesemia

Calcium pyrophosphate deposition disease

Hypophophatasia: inherited metabolic disorder, defective bone and tooth mineralization due to low levels of the alkaline phosphatase enzyme

Q: Acute knee arthritis, OA, chondrocalcinosis

A: Acute CPP crystal arthritis (pseudogout)

Calcium pyrophophate crystal arthritis

Chondrocalcinosis: calcification of cartilage (軟骨)

Q: Inflammatory destructive arthritis of shoulder in elderly women

A: Basic calcium phosphate deposition ("Milwaukee shoulder”)

Basic calcium phosphate deposition in articular cartilage and periarticular tendons and ligaments. Progressive destruction of the rotator cuff and glenohumeral joint

Q: Synovial fluid leukocyte count in infectious arthritis

A: > 50,000/µL

Q: Tenosynovitis, migratory polyarthralgia, and vesiculopustular rash

A: Disseminated gonococcal infection

Q: Risk factors for nongonococcal gram-negative joint infections

A: Injection drug use, advanced age, immunocompromised state

Q: Test for possible tuberculosis monoarthritis with unrevealing synovial fluid analysis

A: Synovial biopsy

Q: Self-limited acute arthritis of hands, feet, wrists, knees

A: Parvovirus B19 infection

Typically involve the proximal small joints of the hands

Q: Most common agent causing prosthetic joint infection

A: Staphylococcus aureus

Q: Treatment of bacterial joint infection

A: Antimicrobial therapy and joint drainage

Q: Time window for temporal artery biopsy in giant cell arteritis after starting glucocorticoids

A: Up to 4 weeks

Q: Treatment of suspected giant cell arteritis

A: Immediate high-dose glucocorticoids

Q: Dose of prednisone pathognomonically effective in polymyalgia rheumatica

A: 12.5-20 mg/d

Pathognomonically: 疾患に特徴的に

Q: Prednisone dose for relapse of polymyalgia rheumatica

A: Last dose that controlled disease

Q: Arm claudication and valve regurgitation in young patient

A: Takayasu arteritis

Q: Constitutional symptoms, purpura, cutaneous ulcers, hypertension

A: Polyarteritis nodosa

Medium-sized vasculitis

Q: Treatment of primary CNS angiitis

A: Cyclophosphamide with high-dose glucocorticoids

Primary angiitis of the central nervous system: affects the blood vessels of the brain and spinal cord. Without systemic vasculitis

Q: Cardiovascular sequela of Kawasaki disease

A: Coronary artery aneurysm

Q: The three forms of ANCA-associated vasculitis

A: Granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis

Q: Most effective treatment for preventing relapse in granulomatosis with polyangiitis

A: Rituximab

GPA: formerly Wegener’s granulomatosis

Q: Treatment of life-threatening granulomatosis with polyangiitis

A: Glucocorticoids plus cyclophosphamide or rituximab

Q: Main causes of death in granulomatosis with polyangiitis

A: Kidney failure and infection

Q: Pulmonary hemorrhage, pauci-immune glomerulonephritis, positive p-ANCA

A: Microscopic polyangiitis

Q: Cause of nonblanching palpable purpura

A: Immune complex–mediated vasculitis

Immune complex-mediated vasculitis: immune complexes can deposit in small vessels, leading to complement and neutrophil activation, with consequent inflammation and tissue damage

Cryoglobulinemic vasculitis, IgA vasculitis (Henoch-Schonlein purpura), hypersensitivity vasculitis

Q: Infectious cause of mixed cryoglobulinemia

A: Hepatitis C virus infection

Q: Palpable purpura, peripheral neuropathy, arthritis, hepatitis C

A: Cryoglobulinemic vasculitis

Q: Purpura, abdominal pain, arthralgia

A: IgA vasculitis (Henoch-Schönlein purpura)

Q: Painful oral and genital ulcers, uveitis, DVT

A: Behçet syndrome

Q: Cause of dyspnea and wheezing in relapsing polychondritis

A: Tracheal ring and bronchial stenosis

Relapsing polychondritis: inflammation and destruction of cartilage

Q: Uveitis, arthritis, inflammatory destruction of ear pinna

A: Relapsing polychondritis

Pinna: 耳介

Q: Fever, pharyngitis, rash, adenopathy, hepatosplenomegaly, elevated serum ferritin

A: Adult-onset Still disease

Salmon-colored macular rash

(vs Felty syndrome: RA + splenomegaly)

Q: Bilateral hilar adenopathy, arthritis, erythema nodosum

A: Löfgren syndrome

Specific form of sarcoidosis, not a separate disease

Q: Immune-mediated tumefaction, fibrosis, and dysfunction of organs

A: IgG4-related disease

Tumefactive: swelling or tumor-like growth

Q: Diagnostic test for suspected IgG4-related disease

A: Biopsy of involved tissue

Pulmonary and Critical care medicine F

Q: Positive bronchial challenge test result

A: ≥ 20% FEV1 reduction

(vs At least 12% increase in FEV1 after bronchodilator)

Q: Diagnosis suggested by TLC < 80% of predicted

A: Restrictive lung disease

(Obstructive disease: FEV1/FVC ration < 70%)

Q: Test for allergic asthma

A: Skin prick or allergen-specific IgE

Q: Test for suspected cough-variant asthma with normal spirometry

A: Methacholine challenge test

Q: Test for exercise-induced bronchoconstriction

A: Methacholine or exercise bronchial challenge test

Q: Test for occupational asthma

A: Spirometry before and after workplace exposure

Q: Diagnosis suggested by asthma, sinusitis, nasal polyp

A: Aspirin-exacerbated respiratory disease

Q: Diagnostic tests for allergic bronchopulmonary aspergillosis

A: Aspergillus-specific IgE and IgG; Aspergillus antigen skin test

Q: Treatment for mild persistent asthma

A: SABA and low-dose inhaled glucocorticoids

Shot-acting beta agonist

Q: Indicators of well-controlled asthma

A: Daytime symptoms < 2 times/week, nighttime symptoms < 2 times/month

Q: Treatment for uncontrolled severe eosinophilic phenotype asthma

A: Mepolizumab, reslizumab, or benralizumab

Inflammatory asthma

1. Non-type 2 inflammatory asthma

2. Type 2 inflammatory asthma

    - IgE elevated -> omalizumab

    - eosinophil elevated -> A      

Q: Most effective class of asthma controller medications

A: Glucocorticoids

Q: Asthma monotherapy associated with increased mortality

A: LABA

Long-acting beta agonist

Q: Asthma indication for adding LAMA

A: Poor control on glucocorticoids/LABA

Long-acting muscarinic antagosit

Q: Treatment for poorly controlled asthma, elevated IgE, and allergies

A: Omalizumab

Q: Lifestyle interventions for asthma

A: Allergen control, weight loss, no smoking

Q: Change in SABA and inhaled glucocorticoid asthma treatment during pregnancy

A: None

(No data to suggest fetal harm)

Q: Indication for COPD screening in asymptomatic patients

A: None

Q: Postbronchodilator FEV1/FVC value consistent with COPD

A: < 0.7

(Asthma: 12% or 200ml increase in FEV1)

Q: Initial treatment for mild COPD

A: Short-acting bronchodilator

Q: Add-on therapy to short-acting bronchodilators in COPD

A: LABA and/or LAMA

Q: Treatment for severe COPD

A: Triple inhaler therapy with LABA, LAMA, inhaled glucocorticoid

Q: PDE-4 inhibitor to reduce severe COPD exacerbations and chronic bronchitis symptoms

A: Roflumilast

Q: Antibiotic class for severe COPD with frequent exacerbations

A: Macrolide

Q: Recommended vaccinations for all patients with chronic lung disease

A: Pneumococcal vaccine and annual influenza

P conjugate vaccine 21 / 20 / 15 + polysaccharide vaccine (23-valent)

Q: COPD indications for supplemental oxygen

A: PO2 ≤ 55 mm Hg, O2 saturation ≤ 88%

Q: Emphysema amenable to lung reduction surgery

A: Upper lobe predominant

Q: Role of sputum culture in COPD exacerbation

A: None

Q: Glucocorticoid treatment for moderate to severe COPD exacerbation

A: Oral prednisone 40 mg for 5 days

Q: COPD indication for systemic glucocorticoid

A: Acute COPD exacerbation

Q: Pulmonary infections suggestive of bronchiectasis

A: Pseudomonas aeruginosa, Aspergillus, non-TB mycobacteria

Q: Common symptoms of bronchiectasis

A: Chronic productive cough, frequent respiratory infections

Q: Bronchiectasis CT findings

A: Bronchial wall thickening, cysts, dilated airways without distal tapering

Q: Empiric antibiotic class for bronchiectasis exacerbation

A: Fluoroquinolone

(To ensure pseudomonas coverage)

Q: Diagnosis suggested by chronic productive cough, recurrent sinus and pulmonary infections, GI disease

A: Cystic fibrosis

GI: loose stools, abdominal pain, pancreatic insufficiency

Q: Initial test for cystic fibrosis

A: Sweat chloride

Q: Symptoms most suggestive of DPLD

A: Subacute/chronic nonproductive cough and dyspnea

Diffuse parenchymal lung disease

Q: High-prevalence condition in young patients with DPLD

A: Connective tissue disease

Q: Most common DPLD associated with autoimmune disorders

A: Nonspecific interstitial pneumonia

Q: Diagnosis suggested by environmental exposure, fever, fatigue, cough

A: Acute hypersensitivity pneumonitis

Q: Treatment for severe radiation pneumonitis

A: Glucocorticoids

Q: DPLD commonly associated with clubbing

A: Idiopathic pulmonary fibrosis

Q: Treatment for IPF

A: Nintedanib (tyrosine kinase inhibitor) or pirfenidone (antifibrotic agent)

Q: Diagnosis suggested by subacute cough, fever, malaise, patchy infiltrates unresponsive to antibiotics

A: Cryptogenic organizing pneumonia

Q: DPLD mimic of ARDS

A: Acute interstitial pneumonia

Q: Diagnosis suggested by asymptomatic bilateral hilar lymphadenopathy

A: Pulmonary sarcoidosis

Q: Sarcoidosis management for asymptomatic patients without organ dysfunction

A: Observation

(Spontaneous resolution without treatment is common)

Q: Most common causes of pleural effusion

A: Heart failure, pneumonia, malignancy

Q: Most sensitive test for small pleural effusions

A: Ultrasonography

Q: Underlying causes of neutrophil-predominant pleural effusion

A: Acute pneumonia, PE

Q: Most common causes of lymphocyte-predominant pleural effusion

A: TB, cancer

Q: Treatment for complicated parapneumonic effusion

A: Thoracostomy tube drainage

Q: Pleural fluid pH and glucose level characteristic of complicated parapneumonic effusion

A: pH < 7.2, glucose < 60 mg/d

Q: Diagnoses suggested by elevated pleural fluid amylase

A: Pancreatitis, esophageal rupture

Q: Pleural fluid enzyme test for TB

A: Adenosine deaminase

Sensitivity 90% (acid-fast smear 5%, culture 10-20%)

Q: Pleural-fluid LDH level in exudative pleural effusion

A: > 2/3 upper limit of normal for serum LDH

Q: Ratio of pleural fluid LDH level to serum LDH level in exudative pleural effusion

A: > 0.6

Q: Number of pleural fluid cytology exams for maximum yield

A: Two

Diagnostic yield doesn’t significantly increase with additional sample beyond the second

Q: Management for malignant pleural effusion

A: Repeat thoracentesis, indwelling pleural catheter, or chemical pleurodesis

Q: Diagnosis suggested by respiratory distress, unilateral absent breath sounds, tracheal deviation

A: Tension pneumothorax

Q: PSP indication for pleurodesis

A: Second ipsilateral occurrence

Primary spontaneous pneumothorax: without any prior lung disease or injury (not the first time)

Q: Treatment after first occurrence of SSP

A: Pleurodesis

Secondary spontaneous pneumothorax: with underlying lung disease (COPD, ..)

Q: Emergency treatment for tension pneumothorax

A: Needle thoracostomy

Q: Common causes of PH

A: Left-sided heart disease, hypoxic lung disease

PH: pulmonary hypertension

Q: Initial test for PH

A: Transthoracic echocardiography

Q: Initial imaging for CTEPH

A: V/Q scan

Chronic thromboembolic pulmonary hypertension

V/Q offers improved sensitivity over CTA when evaluating for CTEPH

Q: Systemic sclerosis variant associated with PAH

A: Limited cutaneous systemic sclerosis

Limited cutaneous systemic sclerosis: limited to face, extremities, (+) organ involvement

Diffuse systemic sclerosis: larger areas, (+) organ involvement

Q: Test before advanced PAH therapy

A: Nitric oxide vasoreactivity testing

Calcium channel blockers for vasoreactive patients who demonstrate marked improvement in mPAP with administration of nitric oxide during right heart catheterization

Q: Treatment for vasoactive-positive PAH

A: CCB

Q: Treatment for CTEPH

A: Pulmonary thromboendarterectomy and anticoagulation

Q: First step in evaluating solid pulmonary nodule > 8 mm

A: Estimate risk of malignancy

Q: Imaging for evaluation of solid lung nodule > 8 mm

A: CT and PET

Q: Lung cancer associated with SIADH

A: SCLC

Q: Criteria for lung cancer screening with low-dose CT

A: Age 50-80 years, asymptomatic, ≥ 20 pack-years, smoker in last 15 years

Q: Most common asbestosis radiographic finding

A: Pleural plaques

Q: Diagnosis suggested by asbestos exposure, chest pain, pleural effusion

A: Mesothelioma

Q: Diagnostic test for mesothelioma

A: Pleural biopsy

Q: Diagnosis suggested by anterior mediastinal mass, MG

A: Thymoma

Myasthenia gravis

Q: Anterior mediastinal mass entities

A: Thymoma, teratoma, lymphoma, thyroid

Q: Most common anterior mediastinal tumor

A: Thymoma

Q: Most common middle mediastinal mass

A: Lymphadenopathy

Q: Most common posterior mediastinal mass

A: Neurogenic neoplasms

Q: First step in evaluating excessive daytime sleepiness

A: Actigraphy or sleep diary

Wrist actigraphy: a device measures movement and ambient light during a period of 1-2 weeks

Q: Most common cause of excessive daytime sleepiness

A: Insufficient sleep syndrome

A condition where individuals consistently fail to get enough sleep to maintain alertness and wakefulness

Q: Preferred test for high-probability OSA

A: Home sleep testing

Highly sensitive in diagnosing OSA in those with a pretest likelihood of moderate to severe disease

Q: Conditions warranting in-lab polysomnography

A: Cardiopulmonary or neuromuscular disease

Q: OSA symptom most responsive to treatment

A: Daytime sleepiness

Q: Treatment for snoring and mild OSA

A: Weight loss

Q: CPAP treatment alternative for mild/moderate OSA

A: Oral appliance

Q: Diagnosis suggested by nocturnal absence of respiratory effort and airflow

A: CSA

Central sleep apnea

Q: Primary risk factor for CSA

A: Heart failure

Q: Physical manifestation of CSA due to heart failure

A: Cheyne-Stokes breathing

Q: Common drug cause of CSA

A: Opioids

Q: OHS defining parameter

A: Daytime hypercapnia

Defined as a Pco2 greater than 45mmHg

OHS: Obesity hypoventilation syndrome

Q: Diagnosis suggested by headache, nausea, disturbed sleep at altitude

A: Acute mountain sickness

High altitude illness

- acute mountain sickness

- high altitude cerebral edema

- high altitude pulmonary edema

Q: Medications for acute mountain sickness

A: Acetazolamide or dexamethasone

For Cerebral edema

Q: Treatment for high-altitude cerebral edema

A: Dexamethasone, oxygen, descent

Q: Drug treatments for high-altitude pulmonary edema

A: Nifedipine, PDE-5 inhibitor

PDE-5 inhibitor: for erectile dysfunction, pulmonary hypertension, BPH

Q: Possible complication in air travel for patients with asthma or COPD

A: Pneumothorax

Q: Oxygen saturation level requiring supplemental O2 during air travel

A: < 92%

Cabins are pressurized in an inspired oxygen tension between 110 and 120mmHg (about 70% of the level encountered at sea level). The resultant arterial Po2 of approximately 60mmHg

Q: Test to determine need for supplemental O2 during air travel

A: Hypoxia altitude simulation testing

Breathe through a mask connected to a machine that delivers the simulated altitude gas mixture

Q: Preferred agents for continuous sedation during mechanical ventilation

A: Propofol, dexmedetomidine

(Benzo associated with increased delirium)

Q: Strategies to decrease delirium during mechanical ventilation

A: Daily interruptions of sedation and analgesia; protocolized light sedation

Q: Nondrug management for ICU delirium

A: Mobilize patient early, remove catheters, provide visual and hearing aids

Q: Only indications for benzodiazepines in delirium treatment

A: Alcohol withdrawal, seizures

Q: Preferred route for nutrition in critically ill patients

A: Enteral

Q: Timing of initiation of enteral nutrition in ICU

A: 24-48 hours after admission

Q: Nonventilatory oxygen support for acute hypoxemic respiratory failure

A: High-flow nasal cannula

Q: Ventilation mode that improves survival in neuromuscular disease

A: NPPV

Q: Contraindications to NPPV

A: Altered mental status, increased secretions, vomiting, inability to protect airway

Q: Assessment test before liberation from mechanical ventilation

A: Spontaneous breathing trial

Q: Role of synchronized intermittent mandatory ventilation in ventilator weaning

A: None

Q: Prevention of extubation failure in high-risk patients

A: Early NPPV

Q: Type of IV catheter with highest flow rate

A: Peripheral wide-bore

Q: Target MAP in septic shock

A: 65 mm Hg

Q: Bedside tool to evaluate ICU-acquired weakness

A: Medical Research Council muscle scale

Q: Basic strategies to minimize ICU-acquired weakness

A: Early mobilization, glucose control

Q: Physiology of hypoxemic respiratory failure not improving with oxygen

A: V/Q mismatch

Uneven distribution of ventilation and perfusion across different lung areas, leading to areas with either too much ventilation or too much perfusion relative to the other

Shunt: a specific type of V/Q mismatch where blood passes through the lungs without participating in gas exchange, essentially bypassing ventilated areas

Q: Most common complication of smoke inhalation injury

A: Pneumonia

Smoke from fire. Secondary infections after inhalational injury are common

Q: Common causes of systemic toxicity in smoke inhalation

A: Carbon monoxide, cyanide

Q: Primary treatment for ARDS

A: Mechanical ventilation with PEEP

Q: ARDS tidal volume

A: 4-8 mL/kg predicted body weight

Q: Treatment for PE with hemodynamic collapse

A: Thrombolytic therapy

If Thrombolytic Tx is contraindicated, surgical or percutaneous catheter-based embolectomy is an option

Q: Ventilatory treatment of acute hypercapnic respiratory failure attributable to OHS

A: BPAP

Bilevel positive airway pressure

Q: Measures in ventilatory assessment of neuromuscular weakness

A: Maximum inspiratory and expiratory pressures, positional changes in vital capacity

Comparing vital capacity in the sitting and supine positions helps evaluate diaphragmatic function

Q: Timing of antibiotic therapy in suspected sepsis

A: Within first hour

Q: Initial fluid resuscitation bolus for sepsis

A: 30 mL/kg of crystalloid solution

60kg->1800mL

Q: First-line vasopressor for septic shock

A: Norepinephrine

Q: Treatment for shock refractory to fluids and vasopressors

A: Hydrocortisone

Q: Treatment for anaphylaxis

A: Epinephrine

Q: Treatment for nonexertional heat stroke

A: Evaporative cooling (with or without ice packs)

Exertional heat stroke: can occur when high ambient temperatures are combined with physical activity and high humidity

For Exertinal heat stroke, evaporative cooling may be effective, but sometimes require immersion in ice water to bring the core temperature down rapidly

Q: Diagnosis suggested by hyperthermia, rigidity, inhaled anesthetic

A: Malignant hyperthermia

Autosomal dominant derangement  in response to inhaled anesthetic agents

Q: Treatment for malignant hyperthermia

A: Discontinue triggering agent, begin active cooling, administer dantrolene

Q: Diagnosis suggested by hyperthermia, hyperreflexia, dysautonomia, mental status changes

A: Serotonin syndrome

Q: Diagnosis suggested by hyperthermia, mental status changes, dysautonomia, muscle rigidity, neuroleptic drug use

A: Neuroleptic malignant syndrome

Evidence for phamacotherapy is anecdotal, but options include benzo, dantrolene, and bromocriptine

Q: Treatment for cardiac arrest with hypothermia

A: Prolonged CPR and active rewarming

Reports of CPR lasting hours and resulting in full recovery when a severely hypothermic patient  has cardiac arrest

Q: Treatment for isopropyl alcohol ingestion

A: Supportive care

Isopropyl alcohol has no toxic metabolites

Q: Diagnosis suggested by CNS depression, increased osmolar gap, normal anion gap

A: Isopropyl alcohol ingestion

Does not elevate the anion gap

Q: Drug treatment for methanol and ethylene glycol poisoning

A: Fomepizole

Both elevate anion gap and have toxic metabolites

Q: Diagnostic test for carbon monoxide exposure

A: Arterial blood gases, including co-oximetry

Q: Carboxyhemoglobin level indication for hyperbaric therapy

A: > 25%

Carboxyhemoglobin: a stable compound formed in red blood cells when carbon monoxide binds to hemoglobin, replacing oxygen

Q: Treatment for cyanide poisoning

A: Hydroxocobalamin

Q: Treatment for benzodiazepine overdose

A: Supportive care (not flumazenil)

Flumazenil: reversing the effect of benzodiazepines can lead to life-threatening CNS activation, including seizures, which are most likely in patients receiving benzodiazepine chronically

Q: Treatment for opioid overdose

A: Naloxone

Oncology F

Q: Preferred term for “progression-free survival”

A: “Progression-free interval”

The time from when a Tx is started until that Tx is no longer controlling the cancer

Q: Checkpoint inhibitor toxicity

A: Autoimmune disease

Checkpoint inhibitors: a type of cancer immunotherapy that works by blocking proteins called checkpoints that normally prevent the immune system from attacking cancer cells

Releasing the brakes on the body’s immune system -> attack cancer cells

Q: Prevention of BRCA-mutation ovarian cancer

A: Bilateral salpingo-oophorectomy

(Removal of ovaries and fallopian tubes)

Q: Genetic mutation indication for annual mammography and breast MRI

A: BRCA gene mutation

Q: Treatment of breast cancer with HER2 overexpression

A: Trastuzumab

(Human epidermal growth factor receptor 2)

Q: Mammogram features of ductal carcinoma in situ

A: Calcifications

DCIS: early form of breast cancer where abnormal cells are found in the milk ducts but have not spread outside the ducts. Considered stage 0

in situ: その場で

Q: Treatment of extensive ductal carcinoma in situ

A: Mastectomy

DICS: lumpectomy + irradiation or mastectomy if extensive

Q: Surgical breast cancer staging with clinically negative axillary nodes

A: Sentinel node biopsy

Done at the time of surgery -> axillary dissection not required if no more than 2 sentinel nodes involved

Q: Scaly red rash with ulceration of the nipple and areola

A: Paget disease of the breast

Q: Antiestrogen therapy not effective in premenopausal women

A: Aromatase inhibitors (letrozole, anastrozole)

Tamoxifen: selective estrogen receptor modulator, effective for both pre-and-post menopausal

Aromatase inhibitor: not effective for premenopausal, prevent conversion of adrenal androgen to estrogen but don’t inhibit ovarian estrogen production

Q: Duration of postmenopausal breast cancer endocrine therapy

A: 5-10 years

Q: Breast cancer hormone therapy associated with musculoskeletal syndrome

A: Aromatase inhibitors (letrozole, anastrozole)

1/3 develop symmetric arthralgia, joint stiffness and bone pain

(vs tamoxifen slows bone loss by acting as estrogen agonist in postmenopausal women)

Q: Adjuvant treatment of premenopausal, hormone receptor-positive, low-risk breast cancer

A: Tamoxifen

Q: Treatment of premenopausal hormone receptor–positive, high-risk early breast cancer

A: Ovarian suppression (leuprolide) plus antiestrogen therapy (exemestane)

Leuprolide: gonadotropin-releasing hormone agonist, initially stimulating, then subsequently suppressing the release of LH and FSH, leading to a decrease in estrogen

Exemesane: aromatase inhibitor

Q: Adverse effects of trastuzumab

A: Infusion reactions and cardiomyopathy

Trastuzmab: monoclonal Ab that targets HER2-positive cancer

Q: Fertility preservation in women undergoing adjuvant chemotherapy

A: Oocyte (卵母細胞) or embryo (胚: 受精卵が分裂を始めてから8週目まで) banking

Q: Breast cancer mimic of infectious mastitis

A: Inflammatory breast cancer

Q: Role of routine breast cancer surveillance blood tests and imaging studies

A: None

(Should have Annual mammograms of remaining breast tissue)

Q: Management of lymphedema after axillary dissection

A: Physical therapy

Q: Management of nocturnal hot flushes post breast cancer therapy

A: Gabapentin

(Menopausal Sx should be managed with nonhormonal options)

Q: Treatment of breast cancer with bone metastases

A: Chemotherapy and bisphosphonates

Bone-modifying agents decrease fracture, pain and need for irradiation

Q: Painful bone metastases treatment

A: Radiation therapy

(Palliative radiation)

Q: Diagnostic management of presumed breast cancer metastases

A: Biopsy; assess hormone receptor, HER2, and biomarker status (e.g., PIK3CA/ESR1 mutations, programmed death ligand 1).

There may be treatment altering discordance in the receptors in the metastatic lesion compared with the primary breast cancer in 10-15%

Q: Most common ovarian cancer susceptibility genes

A: BRCA and mismatch repair genes (MMR)

(MMR gene mutation associated with Lynch syndrome (colorectal, endometrium, small bowel, transition cell carcinoma of ureter or renal pelvis))

Q: Genetic testing for women with epithelial ovarian cancer

A: BRCA1 and BRCA2

Q: Criteria for genetic testing in women with ovarian cancer

A: Should be offered to all women with ovarian cancer

Q: Treatment of stage III ovarian cancer after surgical debulking

A: IV and intraperitoneal chemotherapy

Surgical Debulking: aims to remove as much of a cancerous tumor as possible, even if complete removal isn’t achievable

Q: Ovarian cancer posttreatment surveillance

A: History and physical exam

Other testing is recommended only to evaluate symptoms or findings suggesting recurrence

Q: Effective cervical cancer prevention

A: HPV vaccination

Q: Fertility-preserving treatment of stage IA cervical cancer

A: Conization

(Cone biopsy)

Q: Cervical cancer posttreatment surveillance

A: History and physical examination

(Annual vaginal cytology, cervical cytology or both recommended)

Q: Role of PET scans in colorectal cancer management

A: None

(Colonoscopy, contrast CT of chest/abdomen/pelvis)

Q: Stage I rectal cancer treatment

A: Surgical resection

Q: Stage II or III rectal cancer adjuvant treatment options

A: Irradiation or chemotherapy

(Chemotherapy and irradiation given before surgery is widespread practice)

Q: Low-risk stage I-II colorectal cancer adjuvant treatment

A: None

Q: Treatment of oligometastatic colorectal cancer

A: Surgical resection

Complete resection of oligometastaticfoci confied to a single organ can be curative in 25%

Q: Stage III colorectal cancer adjuvant treatment

A: Chemotherapy (e.g., FOLFOX)

Q: Role of routine radiation therapy for colon cancer

A: None

Q: Genetic studies for metastatic colorectal cancer

A: KRAS, NRAS, BRAF, mismatch repair genes

These studies rarely affect the choice of 1st line Tx, but will define subsequent Tx options

Q: Major chemotherapeutic agent for most metastatic colorectal cancers

A: 5-FU

Q: Panitumumab and cetuximab common skin adverse effect

A: Acneiform rash (painful)

Q: Antibody that potentiates metastatic colon cancer chemotherapy

A: Bevacizumab

Anti-vascular endothelial growth factor (VEGF) monoclonal antibody

Q: Anal cancer associated virus

A: HPV

Q: Treatment of locally invasive advanced anal cancer

A: Irradiation and concurrent chemotherapy

Unlike rectal cancer (adenocarcinoma), anal cancer is a squamous cell carcinoma. Often curable with combined irradiation and chemotherapy

Q: Role of surgery for anal cancer

A: Local recurrence or incomplete response to irradiation and chemotherapy

Q: Role of routine PET scans in pancreatic cancer management

A: None

CT chest and abdomen are appropriate for staging

Q: Resected pancreatic cancer adjuvant treatment

A: Chemotherapy (gemcitabine, capecitabine)

Q: Procedure to determine esophageal cancer depth and involved lymph nodes

A: Endoscopic ultrasound

Q: Hormonal testing for upper gastrointestinal tumors

A: HER2

Human epidermal growth factor receptor 2, 25% of gastroesophageal cancer overexpress HER2

Q: Infection associated with gastric mucosa-associated lymphoid tissue lymphoma

A: Helicobacter pylori

MALT lymphoma strongly linked to H.pylori

(vs EB virus -> Burkitt lymphoma)

Q: Liver metastases, diarrhea, facial flushing

A: Gastrointestinal neuroendocrine tumor

(Formerly called carcinoid tumor)

Q: Initial management of nonfunctional metastatic neuroendocrine tumors

A: Observation

Asymptomatic patients may do well, with minimal growth and no symptoms for years, even with metastatic disease

Q: Genetic marker in gastrointestinal stromal tumors

A: Overexpression of KIT gene

GIST is sarcoma

Stroma: 間質

Q: Therapy following resection of high-risk gastrointestinal stromal tumors

A: Imatinib

Tyrosine kinase inhibitor

Q: Assessment of pulmonary reserve before lung cancer lobectomy

A: FEV1 and DLCO

Q: Treatment of nonresectable early-stage lung cancer

A: Irradiation

No data supporting the use of chemotherapy combined with irradiation in patients with stage I or II disease

Q: Stage II-III NSCLC treatment

A: Surgery and cisplatin-based chemotherapy

Q: Metastatic NSCLC treatment in absence of driver mutations

A: Platinum-based chemotherapy

(Cisplatin, carboplatin, oxaliplatin)

Q: Genetic testing for all nonsquamous metastatic NSCLC

A: EGFR, ALK, ROS1 genes

EGFR, ALK, ROS1 mutations are less common in squamous cell carcinoma

-epidermal growth factor receptor (EGFR)

-human epidermal growth factor receptor 2 (HER2) particularly breast cancer

Q: Treatment of EGFR-positive NSCLC

A: Erlotinib or osimertinib

Q: Metastatic NSCLC cancer treatment after response to first-line chemotherapy

A: Maintenance chemotherapy

Q: Treatment of metastatic NSCLC positive for PD-L1

A: Pembrolizumab

Programmed death-ligand 1 is protein (not gene mutation), checkpoint molecule, interacting with the PD-1 receptor on immune cells, particularly T cells to suppress their activity

Pembrolizumab: immunotherapy, helping the immune system fight cancer cells by blocking a protein called PD-1

Q: Testing for all patients with metastatic NSCLC to guide therapy

A: PDL1 expression

Q: Treatment of limited SCLC

A: Concurrent chemotherapy and irradiation

Q: SCLC staging procedures

A: Bone scan; brain MRI; chest, abdomen, pelvis CT

Q: Complication of cranial irradiation in older patients with SCLC

A: Cognitive impairment

Q: Infectious agent with increased risk of oropharynx cancers

A: HPV

Q: Biopsy procedure for suspected head and neck cancer

A: Fine-needle aspiration

Q: Oropharynx cancer with positive p16 stain

A: HPV positive

p16 immunohistochemistry, to detect the presence and pattern of p16 protein expression.

When a cell is infected with HPV, the virus can interfere with the function of p16, leading to its overexpression

Q: Treatment of locally advanced head and neck cancer

A: Irradiation plus either cetuximab or chemotherapy

Cetuximab: monoclonal epidermal growth factor receptor antibody

Q: Therapy of advanced programmed death ligand 1–positive head and neck cancer

A: Pembrolizumab alone with platinum chemotherapy

Q: Genetic testing for metastatic prostate cancer

A: BRCA gene mutation

(Risk for Breast cancer, ovarian cancer, and also other cancer including prostate)

Q: Treatment of high-risk prostate cancer

A: Combined radiation and GnRH therapy

Gonadotropin (FSH/LH)-releasing hormone agonist, known as androgen deprivation therapy. GnRH agonist or antagonist interfere with the hypothalamic-pituitary-testis axis, which regulates testosterone production

Q: Nontreatment option for low-risk prostate cancer

A: Active surveillance

DRE, serial measurement of serum PSA and repeat biopsy

Q: Management of asymptomatic early-stage prostate cancer with multiple comorbidities

A: Observation

(Active surveillance)

Q: Bone complication of androgen deprivation therapy

A: Osteoporosis

Q: Prevent flare reactions when starting GnRH agonist for metastatic prostate cancer

A: Antiandrogen therapy

GnRH agonist initially stimulate FSH/LH, leading to temporary surge in testosterone production

Q: Lower fracture risk in men with castrate-resistant metastatic prostate cancer

A: Bisphosphonates or denosumab

Castrate: 去勢する, castrate-resistant prostate cancer: disease continues to progress despite androgen deprivation therapy. Osteoclast (破骨細胞) inhibitor (bisphosphonate or denosumab) will reduce bone pain and lower fracture risk

Q: Surgical approach to diagnose testicular cancer

A: Radical inguinal orchiectomy

Diagnosis is made most commonly through radical inguinal orchiectomy

Biopsy: risk of cancer cell spread

Q: Most common site of testicular cancer metastases

A: Retroperitoneal lymph nodes

Q: Tumor markers to evaluate testicular mass

A: α-fetoprotein and β-HCG

Beta-human chorionic gonadotropin

Q: Primary treatment of metastatic renal cell carcinoma

A: Nephrectomy

Resection or debulking of the primary renal cell cancer improves survival for select patients with metastatic disease

Q: Erythrocytosis, markedly elevated erythropoietin, hematuria

A: Renal cell cancer

Q: Primary treatment of muscle-invasive bladder cancer

A: Cystectomy

Most patients found to have non-muscle invasive disease -> transurethral resection of bladder tumor

Q: Infection associated with Burkitt lymphoma

A: Epstein-Barr virus

Swollen lymph nodes, particularly in the neck, armpit and groin. Could involve abdomen, including ileocecal region

Q: Diagnostic procedure for suspected lymphoma

A: Lymph node excisional or core biopsy

(Fine-needle aspiration cytology is generally inadequate to make a specific diagnosis)

Q: Asymptomatic advanced-stage follicular lymphoma management

A: Observation

Most indolent B-cell lymphoma. Many patients are not symptomatic at diagnosis and may not require therapy for many years

Q: Follicular lymphoma, new systemic symptoms, progression of localized disease

A: Transformed follicular lymphoma

Histologic transformation, most typically to a diffuse large B-cell lymphoma, occurs in 30% of patients with follicular lymphomas and is associated with an aggressive course and poor prognosis

Q: Management of transformed follicular lymphoma

A: Biopsy, then appropriate treatment of new lymphoma

Biopsy to confirm transformation

Q: Treatment of H pylori-associated gastric MALT

A: PPI plus antibiotics

Generally indolent behavior and a low propensity for transformation

Q: Elevated lymphocyte count, smudge cells, lymphadenopathy

A: CLL

Smudge (しみ、ぼかされた部分) cell: lymphocytes appear flattered or ditorted

Q: Test to establish the diagnosis of CLL

A: Peripheral blood flow cytometry

Q: Common CLL-related autoimmune diseases

A: Hemolytic anemia and ITP

Q: B-cell disorder, cytopenia, splenomegaly, characteristic lymphocyte morphology

A: Hairy cell leukemia

Thread-like cytoplasmic projections

Q: Treatment of hairy cell leukemia

A: Cladribine or pentostatin

Purine nucleoside agent

Q: Management of double-hit lymphoma

A: Aggressive chemotherapy, up-front autologous HSCT (自己移植)

Double-hit lymphoma is an aggressive subtype of diffuse large B-cell lymphoma. It involves rearrangements in the MYC gene along with either the BCL2 or BCL6 gene. Associated with worse prognosis. (MYC + BCL2 or BCL6)

Q: Management of most advanced-stage large B-cell lymphomas

A: Rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)

Q: Young man from Africa with large jaw mass

A: Burkitt lymphoma

Q: Dav 1 (?day 1) complication of Burkitt lymphoma

A: Tumor lysis syndrome

The tumor is quite chemosensitive

Q: Erythroderma, circulating malignant T cells

A: Sézary syndrome

Cutaneous T-cell lymphoma

Q: Lymphoma, Reed-Sternberg cells

A: Hodgkin lymphoma

Q: Staging of Hodgkin lymphoma

A: Physical exam, PET/CT

Q: Likely primary of poorly differentiated carcinoma presenting as midline lymphadenopathy

A: Germ cell cancer

In particular, young men with predominantly midline poorly differentiated carcinoma, such as those with large retroperitoneal or mediastinal lymphadenopathy

Q: Tumor markers to assess poorly differentiated CUP with mediastinal adenopathy

A: α-fetoprotein and β-HCG

CUP: Cancer of unknown primary site

Q: Likely primary of CUP presenting as isolated cervical lymphadenopathy

A: Head and neck cancer

Q: Likely primary of isolated axillary lymph-node adenocarcinoma in a woman

A: Stage II breast cancer

Even if mammography/MRI are negative, still assumed to have a presumptive stage II breast cancer

Q: Treatment of CUP with poor performance status

A: Hospice care

Q: Treatment of widely metastatic melanoma

A: Checkpoint immunotherapy (nivolumab, pembrolizumab)

Anti-programmed cell death protein 1 antibody that can result in significant melanoma response rates

Q: Localized melanoma prognostic determinant

A: Depth of tumor invasion

Q: Syndrome of dyspnea, facial swelling, and mediastinal mass

A: Superior vena cava syndrome

Q: Initial treatment of symptomatic brain metastases

A: Glucocorticoids

Resulting in elevated intracranial pressure. Dexamethasone is used

Q: Metastatic spinal cord compression treatment

A: Glucocorticoids, then surgery and irradiation

Q: Treatment of rapidly recurring malignant pleural effusion

A: Indwelling pleural catheter or pleurodesis

Q: Tumor lysis syndrome prophylaxis

A: Rasburicase, IV hydration

Rasburicase: urate oxidase enzyme that metabolize uric acid

Q: Treatment of symptomatic hypercalcemia of malignancy

A: IV normal saline, denosumab, calcitonin, bisphosphate (zoledronic acid)

Denosumab: human monoclonal IgG2 antibody that targets the protein RANKL, which is essential for the formation, function and survival of osteoclasts, the cell type responsible for bone resorption

Q: Secondary prevention of chemotherapy-related febrile neutropenia

A: G-CSF

Q: Risks of erythropoietin in treating cancer-related anemia

A: Cancer progression, VTE

Q: Standard antiemetic regimen for moderate-to-severe emetogenic chemotherapy

A: Ondansetron or palonosetron plus glucocorticoids

Palonosetron: longer-acting serotonin receptor antagonist.

Dexamethasone is commonly used

Q: Chemotherapeutic agents causing hand-foot syndrome

A: 5-FU and capecitabine

Palmar-plantar erythrodysesthesia: redness, peeling, and tenderness of the palms and soles

Q: Chemotherapeutic agent most commonly associated with acute kidney injury

A: Cisplatin

Associated with Acute tubular necrosis

Q: Prerequisite to chemotherapy in reproductive-age men and women

A: Fertility preservation counseling

Q: Chest wall radiation–associated cancer

A: Breast cancer

Neurology F

Q: Red flags for secondary headache

A: Focal neurologic findings, worst/progressive headache, new headache after age 50 years, thunderclap headache, onset after exertion

Q: Imaging for reversible cerebral vasoconstriction syndrome

A: Brain and neck MRA or CTA

Severe, sudden headaches, often thunderclap, and reversible narrowing of the blood vessels in the brain. The arteries temporarily constrict, then return to normal within a few weeks or months

Q: Thrombosis-associated painful ophthalmoplegia, proptosis, chemosis

A: Cavernous sinus thrombosis

Chemosis: 結膜浮腫

Proptosis: 眼球突出

Q: Acute neck pain, eye pain, partial Horner syndrome, ipsilateral cerebral ischemia

A: Carotid artery dissection

(Vertebral artery dissection: dysarthria, dysphagia, ataxia, hemifield visual loss)

Q: Woman of childbearing age with obesity, headaches, visual symptoms, pulsatile tinnitus

A: Idiopathic intracranial hypertension

(Pseudotumor cerebri), 90% are women of childbearing age with an elevated BMI, visual Sx: blurred, doubled, or periodically dim in the brief episodes

Q: Drug treatment for idiopathic intracranial hypertension

A: Acetazolamide

Q: Treatment for post–dural-puncture headache

A: Epidural blood patch

Injecting a small amount of the patient’s own blood into the epidural space, helping to seal the leak

Q: Trigeminal neuralgia treatment

A: Carbamazepine

Q: Monthly pain medication threshold for diagnosis of medication overuse headache

A: ≥10 days/month for triptans, ergot alkaloids, opioids, or combination analgesics; ≥15 days/month for simple analgesics

Q: Refractory daily headaches with triptans, ergot alkaloids, opioids, or combination analgesics ≥10 days/month

A: Medication overuse headache

Q: Mnemonic for migraine characteristics

A: POUND (Pulsatile quality of headache, One-day duration, Unilateral location, Nausea/vomiting, Disabling intensity)

Q: Migraine treatment when unresponsive to NSAIDs

A: Triptans

Q: Drug prophylaxis for migraine

A: Metoprolol, propranolol, timolol, valproate, topiramate, candesartan

Q: Tension-type headache treatments

A: Acetaminophen, aspirin, NSAIDs, caffeine-containing compounds

Q: Cluster headache prophylaxis options

A: Verapamil, galcanezumab

Cluster headache: most common trigeminal autonomic cephalalgias

Q: Initial TBI imaging test

A: Noncontrast head CT

Q: Arterial O2 and BP goals in severe head injury

A: Arterial Po2 > 60 mm Hg, SBP > 90 mm Hg

Q: Signs of basilar skull fracture

A: Bilateral periorbital or mastoid bruising, hemotympanum

Q: Head injury, lucid interval, neurologic deterioration

A: Epidural hematoma

Q: Acute subdural hematoma surgery indications

A: Hematoma ≥10 mm, GCS score < 9, pupillary asymmetry/fixation

Q: Temporal lobe epilepsy symptoms

A: Aura, loss of awareness, staring, behavior arrest, amnesia

Q: Seizure, tunnel vision, < 1 min loss of consciousness, immediate recovery

A: Convulsive syncope

Syncope often presents with shaking, differs from seizure

Q: Evaluation of first unprovoked seizure

A: MRI and EEG

Q: Features of psychogenic nonepileptic spells

A: Closed eyes, long duration of waxing/waning shaking, no postictal confusion

Q: Test for psychogenic nonepileptic spells

A: Video EEG monitoring

Q: Confirmatory test for nonconvulsive status epilepticus

A: Continuous EEG monitoring

Q: Unprovoked seizure treatment indications

A: 2 unprovoked seizures or 1 unprovoked seizure with EEG or MRI abnormalities

Q: Seizures not treated with antiepilepsy drugs

A: Alcohol- or benzodiazepine-withdrawal seizures

Q: Antiepileptic drugs with mood-stabilizing effects

A: Lamotrigine, valproic acid

Q: Seizure type requiring lifelong treatment

A: Juvenile myoclonic epilepsy

Q: Test to determine candidacy for epilepsy surgery

A: Video EEG monitoring

Q: First-line treatments for epilepsy in older patients

A: Gabapentin, lamotrigine, levetiracetam

Q: Epilepsy drug therapy for reproductive-age women

A: Levetiracetam, lamotrigine, or oxcarbazepine

Q: Status epilepticus therapy for a fosphenytoin-intolerant patient

A: IV valproic acid, IV levetiracetam

(First choice: Fosphenytoin)

Q: First-line treatment of convulsive status epilepticus

A: IV benzodiazepines, then IV fosphenytoin

Q: Test for suspected subarachnoid hemorrhage and normal head CT

A: Lumbar puncture

Q: Initial TIA vascular study

A: Carotid duplex ultrasonography

Patients with high-grade extracranial internal carotid artery stenosis who have a TIA in a downstream neurologic territory have the greatest short-term risk for stroke

Q: Expedited evaluation for TIA

A: ICA imaging and monitoring for atrial fibrillation

Q: Outpatient test for embolic stroke of unknown source

A: Prolonged rhythm monitoring

Q: Potential physical exam findings in subarachnoid hemorrhage

A: Confusion, somnolence, nuchal rigidity, unilateral pupillary dilation, subhyaloid hemorrhages on funduscopy

Q: Time to initiation of VTE prophylaxis after hemorrhagic stroke with no evidence of active bleeding

A: 48 hours

Q: Goal BP after stroke thrombolysis

A: <180/105 mm Hg

Q: Short-term acute therapy for cardioembolic stroke before anticoagulation

A: Aspirin

Q: Target SBP in intracerebral hemorrhage

A: 140 mm Hg

Q: Drug treatment of subarachnoid hemorrhage

A: Nimodipine

CCB, cerebral vasospasm with resultant cerebral ischemia may develop beginning near day 5

Q: Indications for posterior circulation aneurysm surgery

A: Symptomatic aneurysms, aneurysms >7 mm

(Anterior circulation: >12mm)

Q: Indication for stenting in intracranial atherosclerosis for secondary stroke prevention

A: None

Aggressive medical therapy is superior to stenting in reducing stroke recurrence

Q: Management of asymptomatic carotid stenosis <70%

A: Statin therapy

(For Asymptomatic stenosis, evidence of antiplatelet Tx is limited)

Q: Asymptomatic ICA revascularization indication

A: Stenosis >70%

Primary prevention

Internal carotid artery

Q: Antiplatelets for secondary prevention of stroke

A: Aspirin, clopidogrel, or aspirin-dipyridamole

(Other antiplatele agents, such as ticagrelor or prasugrel, have not been examined in long-term trials of secondary stroke prevention)

Q: Threshold stenosis for carotid endarterectomy for secondary stroke prevention

A: 50%

Q: Treatment of ischemic stroke–related symptomatic cerebral edema

A: Decompressive hemicraniectomy

Q: CSF findings that predict Alzheimer disease

A: Decreased Aβ42 peptide, increased tau protein and p-tau

(42-residue form of amyloid-β peptide)

Q: Blood tests for slowly progressive dementia

A: Serum chemistries, CBC, vitamin B12, TSH; consider RPR

Q: Cognitive decline greater than expected for age without significant functional disability

A: MCI

Mild cognitive impairment

Q: Medication to prevent progression of MCI to dementia

A: None

Q: Mild to moderate Alzheimer disease drug treatment

A: Acetylcholinesterase inhibitors: donepezil, rivastigmine, galantamine

Q: Cholinesterase inhibitor contraindications

A: Bradycardia, sick sinus syndrome, LBBB

(Donepezil often causes bradycardia)

Q: Diagnosis suggested by dementia, apathy, disinhibition, changes in eating behaviors, hyperorality, compulsiveness

A: Behavioral-variant frontotemporal dementia

Hyperorality: excessive tendency to put objects in the mouth

Disinhibition: impulsive actions that disregard social norms or potential consequences

Q: Diagnosis suggested by language loss before cognitive dysfunction

A: Language-variant frontotemporal dementia (primary progressive aphasia)

Frontotemporal dementia: language-variant and behavioral variant

Q: Cognitive slowing, disorganized thought processing, parkinsonism after head trauma

A: Traumatic encephalopathy syndrome

Substantial exposure to repetitive head impacts from contact sports, military service, or other causes

Q: Effect of first-generation neuroleptics in dementia with Lewy bodies

A: Worsening of symptoms resembling neuroleptic malignant syndrome

NMS: fever, muscle rigidity, AMS, autonomic nervous system dysfunction

Patients with DLB are extremely sensitive to neuroleptic meds, particularly 1st generation agents (haloperidol, chlorpromazine)

Q: Medication for behavioral symptoms of dementia with Lewy bodies

A: Acetylcholinesterase inhibitors

Q: Procedure confirming normal pressure hydrocephalus diagnosis

A: Lumbar puncture with opening pressure and large-volume CSF removal

Q: MRI finding of normal pressure hydrocephalus

A: Ventriculomegaly

Q: Two major signs of vascular cognitive impairment

A: Early gait impairment, pseudobulbar affect (“emotional incontinence”)

Pseudobulbar affect: 情動調節障害, outbursts of uncontrolled or inappropriate laughing or crying

Bulbar: 延髄の

Q: Treatment of vascular cognitive impairment

A: Cerebrovascular risk factor modification and acetylcholinesterase inhibitors

Q: Rapidly progressive dementia, myoclonus, gait problems, visual compromise

A: Creutzfeldt-Jakob disease

Q: Risk of antipsychotic agents in dementia

A: Increased mortality in older persons

Q: Dopamine transporter scan indication

A: Differentiate Parkinson disease from essential tremor or drug-induced parkinsonism

Dopamine transporter scan: single-photon emission CT scan of the brain using ioflupane-123

Q: Screening for backward falls in Parkinson disease

A: Pull test

Q: Indication for deep brain stimulation in Parkinson disease

A: Responsive to but intolerant of carbidopa-levodopa

(Also motor fluctuations or refractory tremor)

Q: Adverse events associated with dopamine agonists

A: Psychosis, impulse control disorder, sleep attacks, confusion

Q: Initial Parkinson disease therapy for patients aged < 60 years with high dyskinesia risk

A: Pramipexole or ropinirole

(Levodopa: dopamine precursor, pramipexole/ropinirole: dopamine agonist, less effective but lower risk for dyskinesia (involuntary, uncontrollable movements))

Q: Initial Parkinson disease therapy for motor symptoms

A: Levodopa

Q: Parkinsonism, cerebellar ataxia, dysautonomia, falls

A: Multiple system atrophy

Dysautonomia: orthostatic hypotension, urinary dysfunction

Parkinson plus syndrome:

Progressive supranuclear palsy: eye movement (vertical gaze)

Multiple system atrophy:

Corticobasal degeneration: asymmetric Parkinsonism

Q: Action and rest tremor, dystonia, a null point

A: Dystonic tremor

Dystonia: involuntary muscle contractions leading to twisting, repetitive movements and abnormal postures

Null point: particular posture or position of the affected body part where the tremor activity is significantly reduced or absent

Q: Essential tremor drug treatment

A: Propranolol, primidone, or topiramate

Q: Nonrandom, repetitive, directional twisting and posturing movements

A: Dystonia

Q: Chorea, ataxia, psychiatric disease

A: Huntington disease

(Chorea: コーリア)

Q: Myoclonus after hypoxic brain injury

A: Posthypoxic myoclonus

Q: Drug therapies for Tourette syndrome

A: Aripiprazole, clonidine, guanfacine, topiramate, levetiracetam, tetrabenazine

Tourette (トゥレット) syndrome: childhood-onset motor and phonic tics. Phonic tics include vocalizations, echolalia (repetition of other words), and coprolalia (utterance of obscenities (猥褻))

Q: Sleep disorder and triple-flexion leg kicks

A: Periodic limb movements of sleep (differ from RLS)

RLS: urge to move the legs, often accompanied by uncomfortable sensation

Periodic limb movement disorder: repeat in 20-second cycles during sleep

Q: Restless leg syndrome evaluation

A: Iron studies

Q: Diagnostic test for periodic limb movements of sleep

A: Polysomnography

Q: Dopamine-blocking agent–related movement disorder

A: Tardive dyskinesia

Q: Dopamine-blocking therapy, fever, confusion, rigidity, elevated CK

A: Neuroleptic malignant syndrome

(vs Malignant hyperthermia: severe reaction to particular medications used during general anesthesia. Muscle rigidity, fever, muscle breakdown, hyperkalemia)

Q: MS exacerbation treatment

A: High-dose glucocorticoids

Q: First-line treatment of relapsing-remitting MS

A: Glatiramer acetate or interferon beta

Q: Secondary progressive MS treatment

A: Mitoxantrone

Q: Primary progressive MS treatment

A: Ocrelizumab

Relapsing-remitting MS: most common form. Periods of new or worsening Sx followed by periods of recovery or remission

Secondary progressive MS: many individuals with RRMS eventually transition into SPMS. The disease progresses with a steady worsening or Sx, and the periods of remission become less pronounced or disappear altogether

Primary progressive MS: the disease progresses from the start without clear relapses or remissions. Sx gradually worsen over time

Q: Required monitoring with fingolimod therapy

A: Ophthalmic examinations (macular edema)

Fingolimod: Oral agent. Effective Tx for relapsing-remitting MS

Q: Neurologic complication of natalizumab therapy

A: Multifocal leukoencephalopathy

Highly effective Tx for MS, but limited to use due to the risk of progressive multifocal leukoencephalopathy, CNS demyelinating infection caused by reactivation of the JC virus

Q: MS fatigue drug treatment

A: Modafinil, armodafinil, amantadine

Modafinil: CNS stimulant, armodafinil: promote wakefulness, amantadine: treat dyskinesia a/w parkinsonism

(Memantine: for dementia)

(Mycophenolate mofetil: immunosuppressant)

Q: MS medication for impaired mobility

A: Dalfampridine

Voltage-gated potassium channel antagonist: improve walking speed, leg strength, and gait

Q: Test for suspected spinal cord compression

A: Emergent MRI

Q: Treatment for metastatic spinal cord compression

A: Glucocorticoids, decompressive surgery, or radiation therapy

Q: Complete myelitis, no CSF oligoclonal bands or IgG index, no brain MRI lesions

A: Idiopathic transverse myelitis

(CSF oligoclonal bands: typically found in MS, CSF IgG index: used for Dx of MS)

ITM: inflammation of the spinal cord, unknown cause

Q: Initial treatment of idiopathic transverse myelitis

A: IV methylprednisolone

Q: Treatment of refractory idiopathic transverse myelitis

A: Plasmapheresis and/or cyclophosphamide

Q: Common causes of subacute combined degeneration

A: Vitamin B12 and copper (銅) deficiencies

Subacute combined degeneration: dysfunction of the corticospinal and dorsal sensory tracts of the spinal cord that manifests as spastic paresis with reduced vibration and position sense and ataxia

Q: Syndrome of progressive weakness with spasticity, reduced vibration/position sense, ataxia

A: Subacute combined degeneration

Q: Flaccid paralysis after prolonged aortic surgery

A: Anterior spinal artery infarct

Q: Carpal tunnel syndrome surgery indications

A: Weakness, thenar atrophy, refractory pain, active denervation on EMG

(Thenar: mound formed at the base of the thumb on the palm)

Q: Bell palsy treatment

A: Prednisone

Facial nerve palsy: Bell’s palsy (unknown cause), infection (Lyme disease, Herpes zoster)

Q: Subacute transient shoulder pain followed by progressive weakness

A: Idiopathic brachial plexopathy (unknown cause)

Branchial plexopathy caused by DM., malginancy, radiation and trauma

Q: Diabetes-related acute truncal dermatomal pain and paresthesia

A: Diabetic mononeuropathy

Involves cranial nerves and truncal nerve roots (dermatomal pattern of pain and paresthesia in the chest or abdomen)

Truncal: 胴体の

Q: Test for Miller-Fisher variant of GBS

A: Antibodies to GQ1b ganglioside protein

Miller-Fisher syndrome: ophthalmoplegia, ataxia and areflexia

GQ1b antibodies in serum supports the Dx of MFS

Q: Respiratory function monitoring in GBS

A: Serial FVC and negative inspiratory force

Negative inspiratory force: measure the strength of a person’s respiratory muscles, specifically the ability to inhale against a closed airway

Q: Guillain-Barré syndrome treatment

A: Plasmapheresis or IVIG

Q: Peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes

A: POEMS syndrome

Paraneoplastic syndrome caused by a clone of aberrant plasma cells

Q: Familial amyloidosis genetic test

A: Transthyretin (TTR) genetic testing

AL amyloidosis: primary amyloidosis, amyloid light chain, caused by abnormal plasma cells

AA amyloidosis: secondary amyloidosis, amyloid A protein, caused by infection, inflammation

Familial amyloidosis: misfolded thransthyretin protein primarily produced by liver

Q: Upper and lower motor neuron signs without sensory involvement

A: ALS

Q: ALS drug treatment

A: Riluzole, edaravone, sodium phenylbutyrate–taurursodiol

Q: Initial treatment of ocular and mild generalized myasthenia

A: Pyridostigmine

Q: Medications that may exacerbate myasthenia gravis

A: Aminoglycosides, fluoroquinolones, magnesium, β-blockers, hydroxychloroquine

Q: Antibody test in myasthenia gravis with weakness of cervical extension

A: Anti–muscle-specific kinase (MuSK)

Typical MG: acetylcholine receptor antibody

5% have Anti-MuSK antibody, a/w focal, or severe bulbar, cervical or respiratory weakness

Bulbar weakness: muscles controlled by the lower cranial nerves (IX,X,XI,XII), speech, swallowing, chewing, facial expression

Q: Treatment of immune-mediated necrotizing myopathy

A: Prednisone and discontinuation of statin

Severe proximal muscle weakness, elevated CPK, and muscle fiber necrosis

Linked to statin use

Q: Exercise-induced weakness, cramping, myoglobinuria

A: McArdle disease

Glycogen storage disease type V

Genetic disorder where muscle cells can’t break down a type of sugar called glycogen

Q: Meningioma resection indications

A: Neurologic deficits, drug-resistant seizures, severe headaches, peritumoral edema

Q: Test in biopsy-inaccessible suspected primary CNS lymphoma

A: Vitreous fluid sampling (眼球の硝子体液)

Q: Emergent treatment of brain tumor–related herniation

A: Dexamethasone

Q: Emergent treatment of brain herniation

A: Elevation of the head of the bed, hyperventilation, mannitol, glucocorticoids

Q: Initial treatment of PE in primary brain tumor

A: IV heparin

(Higher hemorrhage risk when rapid reversal may required)

Q: VTE treatment in CNS malignancy

A: Therapeutic anticoagulation

Despite the risk of intracranial hemorrhage, therapeutic anticoagulation is generally recommended

Q: Autoimmune cause of choreoathetosis, psychosis, seizures, autonomic instability

A: Anti-NMDAR antibody encephalitis

(NMDA receptor: type of glutamate receptor in brain, playing a curial role in synaptic plasticity, learning and memory)

Choreoathetosis: 舞踏病アテトーゼ

Q: New-onset status epilepticus, subacute progressive confusion, normal MRI

A: Autoimmune limbic encephalitis

Limbic system (辺縁系), inflammation especially hippocampus and amygdala, short-memory loos, psychiatric symptoms and seizure