CV
GI
Alphabet soup
MSK
It's All in your head
3rd year tips
Resp
Important Apps
Pharm
Stats
Skin
100
What artery supplies the SA node?
Right coronary
100
What do these results mean?
Active Hep B infection
------
100
WNL
within normal limits
100
16 yo c/o right knee pain for 1 month. Described as dull and achy. She also reports weight loss over this interval. On physical she tender over distal femur and is afebrile. Knee exam is normal. Xray shows a bone-forming mass arising from the distal femoral meta diaphysis with sunburst-like periosteal reaction. What is the most likely diagnosis?
Osteosarcoma---malignant bone producing tumor that typically occurs in the 2nd - 3rd decades of life. It is the most common primary bone malignancy.
Buzz word: sunburst appearance or Codman's triangle
femur-->tibia-->humerus-->skull-->pelvis and jaw
Usually has a poor prognosis
100
52 yo M is being evaluated for brain mass. He stated he did not want to know the MRI findings. However, the patient's wife asks you about the results. What is the best course of action
Withhold results from pt and wife. ---He did not give permission to tell her.
100
Outpatient rotations
100
What is more evidenced based Uptodate or Dynamed?
Dynamed
100
59 yo M was started on HTN medication 4 weeks ago. He has been compliant with medication and his BP is wnl. However, he experienced a 5lb weight gain and new onset LE edema on exam. what medication likely caused these side effects?
Amlodipine---a dihydropyridine CCB that decreases contractility in vascular smooth muscle resulting in vasodilation. Nifedipine is also in this class.
Other CCB are nondihydropyridine: verapamil, diltiazem
100
What is the defining feature of an experimental vs an observational study?
An investigator controlled intervention
100
32 yo F presents c/o new rash that developed after going into the woods near her home. Rash began as small, red, raised bumps that began to drain clear fluid. This patient most likely experienced which type of hypersensitivity?
Type IV--from poison ivy. delayed hypersensitivity mediated by T cells. other examples: TB tests and contact dermatitis
Type 1- IgE mediated release of histamine, leukotrienes, and prostaglandins which causes vasodilation and smooth muscle contraction: hives, itchiness, anaphylaxis
Type 2 - antibodies produces against antigens on patients cell surfaces. ex: bullous pemphigoid and pemphigus vulgaris
Type 3 - deposition of immune complexes in tissues. ex: lupus
200
22 yo F presents to the ED for evaluation of palpitations and SOB. EKG shows SVT. Carotid massage is performed and results in resolution of her symptoms. This resulted in the following physiologic change?
increased refractory period of the AV node
---
carotid massage-->inc pressure on carotid sinus and increase in stretch of baroreceptors-->inc parasympathetic output-->inc AV node refractory period-->decrease heart rate
200
39 yo M presents with abdominal pain occurs after eating and improves with antacid. He has lost 6 lbs in the last 2 months. He also noticed dark stools and his is anemic. EGD shows a gastric ulcer. What is the most common cause of gastric ulcer in adults?
H Pylori- gram negative bacillus
200
CTAB
clear to auscultation bilaterally
200
34 yo is an unrestrained driver in a MVA and his right knee forcefully collided with the dashboard. Upon evaluation his right foot is pale and pulseless. Xray shows a comminuted distal femoral fracture with a posterior knee dislocation. What vessel was likely injured?
popliteal artery - has a 40-50% risk of injury with knee dislocations due to tethering in the popliteal fossa
200
35 year old man repeatedly wears female clothing including lingerie and dresses to achieve sexual excitement. He has sexual intercourse with women only and is not sexually attracted to men. He complains of significant psychological distress. What is the diagnosis?
Transvestic disorder: must have cross dressing with distress. In DSM5
200
Presenting
200
Outpatient Apps
ASCVD calculator
200
What antihypertensives are safe during pregnancy?
Labetalol, Hydralazine, Nifedipiine, Methyldopa
200
What type of distribution is this?
200
29 yo G3P2 complains about skin changes. Her pregnancy has been uncomplicated and her labs are normal. On exam she has uniform and symmetric regions of hyperpigmentation along the nose and cheeks. What is the next step in management?
Reassurance---Melasma
300
8 mo M recently immigrated from Somalia for first appt. Mom received minimal prenatal care. Child is in good health but there is a continuous machine like murmur heard over the scapula. What prenatal exposure is most associated with this child's condition?
Murmur is suggestive of a patent ductus arteriosis (PDA) (left to right shunt, does not cause cyanosis)which is associated with prematurity, RUBELLA, and down syndrome
Other tidbits
Lithium causes Ebstein anomaly which is displacement of triscupid valve downwards to rt ventricle
NSAIDs after 32 weeks can cause premature closure of the ductus arteriosis
300
A pt with chronic diarrhea has a colonoscopy with biopsies taken of the rectal mucosa. Gross examination reveals continuous, friable mucosa from the rectum to the transverse colon. Histopathological analysis reveals crypt abscesses and submucosal inflammation w/o evidence of inflammation in deeper layers of the mucosa. What is the most likely diagnosis?
Ulcerative Colitis
300
QOD
every other day
300
24 yo M is brought to the ED after being involved in a motocross accident. He was thrown from the bike and landed on his left shoulder, at which time he heard a sound and felt immediate pain. His arm is now fixed in internal rotation. Shoulder radiographs are below and show an anterior shoulder dislocation. What nerve is most at risk for injury?
Axillary nerve and to a lesser extent radial and suprascapular nerve are at risk.
300
a 17 yo that is enlisted in the army is brought into the ED by police. He is suspected of ingested illicit medications to avoid arrest. Police request a NG aspirate for evidence but the patient refuses. What do you do?
Honor pt request because he is emancipated (minor who joins the military or gets married) and can make his own decisions. Doctors cannot perform a procedure without pt's consent.
300
Inpatient
300
OB/GYN APPS
LactMed
ASCCP
Pregnancy Wheel
300
20 yo M presents for his yearly exam. His exam is normal. His family history is positive for coronary artery disease and both his brother and father had MI prior to age 30. His fasting lipid panel shows:
Total Chol = 310
LDL = 200
HDL = 55
TG = 160
Further testing reveals defective LDL receptors prone to degradation. What type of medication would he benefit from?
PCSK9 inhibitor - Alirocumab
Pt has Type II familial dyslipidemia which has defective or absent LDL receptors. Cholesterol ranges from 300-700. Patients are at risk of accelerated atherosclerosis, MI, and tendon xanthomas
PCSK9 binds to LDL receptors causing their degradation and recycling. These rx cause increased LDL removal from the bloodstream.
300
Researchers are studying a new asthma drug. During the year long trial, 20% of control have an exacerbation, and 15% of treated have an exacerbation. How many children with asthma would need to be treated to prevent 1 child having an asthma exacerbation?
20 is the Number needed to treat.
----
The difference in risk is known as absolute risk reduction (ARR) and represents the amount that the study drug reduces the outcome: 20%-15% = 5% or 0.05. NNT = 1/ARR = 1/0.05 = 20.
300
44 yo F is referred to derm for scaly lesions on the elbow. She has a history of Crohn's disease. Lesions come and go and very itchy.They are raised plaques of pink scaly appearing skin. They range in size from 1-1.5cm and located on elbows and knees. What is the diagnosis?
Psoriasis- chronic relapsing immune mediated condition.
Buzz words: scaly pruritic plaques
Higher prevalance in pts with Crohns
400
23 yo with polysubstance abuse presents for eval of 3 hours of chest pain. He is s/p surgical management for perforation of his nasal septum. HR 135 BP 190/95. Labs show elevated troponin. EKG sinus tach. What medication should he be treated with?
Lorazepam---pt with cocaine induce MI.
Cocaine inhibits reuptake of Norepinephrine resulting in excess stimulation of both alpha and beta receptors. This causes tachycardia, vasoconstriction, coronary artery vasospasm--> severe HTN and MI.
Benzos counter sympathetic stimulation which will lower bp and hr
400
50 yo F with ESLD 2/2 chronic ETOH abuse presents to the ED altered. 2 days ago she was dx with a UTI and started on ciprofloxacin. On exam she has abdominal distention, scleral icterus, and a flapping tremor when she outstretches her arms. What is the cause of her presentation?
Accumulation of ammonia causing hepatic encephalopathy due to her UTI.
Common offenders: infection, GI, bleeding, electrolyte imbalances, hypovolemia, and opiates
400
NTTP
non tender to palpation
400
45 yo M postal worker presents with right arm pain. Pain is localized to the medial side of his right arm, forearm, and hand. Pain is pins and needles in his little finger and ring finger and getting worse. Grip strength on the right is diminished. You note wasting of the right hypothenar and thenar eminence. What is the likely site of the injury?
Lower trunk of the brachial plexus C8- T1- he has combined ulnar and median nerve dysfunction.
Ulnar - little and ring finger and hypothenar wasting
Median nerve - thenar wasting
400
16 yo F is a Jehovah's Witness. Prior to a surgical procedure she states she does not want any transfusions. Her parents are also Jehovah's witnesses and will not consent. She expresses understanding of the potential consequences of her decision. The surgery is low risk and elective. During surgery she experiences a life threatening hemorrhage. What do you do?
Give a blood transfusion because she is a minor and by law is deemed legally incomponent. Parents of a minor cannot withhold treatment to save life or limb from their children.
If the danger is not immediate but still critical, a court intervention to an ethics committee may be indicated
400
Boards
400
Preventative Medicine Apps
EPSS
400
What class of blood pressure medication causes dilation of the efferent arteriole and deceases filtration fraction?
AceI---causes decreased conversion of angiotensin I to angiotensin II
400
A new marker is used to create a screening test for detecting MI. The test is performed on 2000 people. The test is positive in 750 people but only 600 have a MI and 150 people had non cardiac chest pain. In total, 1250 people have a negative test but 250 of those are diagnosed with MI. What is the PPV of this test?
600/750
PPV = True Positive/All Positive results
Accuracy/Validity = TP+TN/Total = 600+1000/2000
NPV= True Negative/All Negative = 1000/1250
400
37 yo referred to derm for psoriasis. What layer of epidermis would be histologically reduced or absent?
Stratum granulosum
500
19 yo male with WPW presents to the ED with palpitations and dizziness. His EKG is below. He is hemodynamically stable. What agent would you use at this time?
Procanamide - WPW is a risk factor for developing Afib. First line therapy involves rate control however nodal blockers are CI because WPW bypasses the AV node. Blockage of the AV node will increase conduction through the abnormal pathway which can lead to VTach and Vfib.
500
45 yo M c/o diarrhea, steatorrhea, abdominal pain joint pain and ophthalmoplegia. A biopsy of the small intestine shows PAS positive macrophages. The patient is most likely infected with what organism?
Tropheryma Whipplei, non acid fast gram positive bacillus---this is Whipple's disease, malabsorption : GI, Joint, and CNS symptoms
Treatment: up to 1 year of Bactrim, PCN, Streptomycimn, ampicillin, or chloramphenicol
500
VSS
vital signs stable
500
27 yo F is in a MVA. She was restrained and her airbag deployed. She now c/o left wrist pain. She states that at the time of the accident, her left hand was on the steering wheel and was forcefully driven backward. Xrays show a dislocated bone. Which bone was most likely dislocated?
Lunate - most common dislocated bone in the hand. Occurs with falling on outstretched hand or during forceful hyperextension
Scaphoid is the most common fractured bone in the hand. Occurs with falling on outstretched hand
500
16 yo F admitted to the hospital after a sudden and unexpected outburst at her high school. The psychologist noted that during the interview, the patient was straightening the magazines near her chair, organizing the stationary on the desk, and using hand sanitizer constantly. The patient says that she feels angry when people don't do as she says and she doesn't have many friends because people describe her as a perfectionist. When the doctor asks the patient if she is content with her behavior, the patient says, "this is who I am". She has no distress about her behavior. What is her diagnosis?
Obsessive Compulsive Personality disorder
500
Interest
500
Medication Apps
Epocrates
Lexicomp
500
Patient presents to the ED with decreased level of consciousness. Family members state that she took a bottle of some medication for sleep or anxiety. Her pupils are small and reactive and her face is flushed. Her temp is 93F. She has diminished deep tendon reflexes and shallow respirations. You notice some blistering on her hands and knees. What class of medications is probably responsible for this presentation?
Barbiturates in the sedative hpynotic category----the bullae are a specific finding with this class of meds.
Other features include- heart and bp decreased, with decreased respiratory rate and hypothermia, small pupils, and diminished bowel sounds, decreased diaphoresis
500
What is the Hawthorne effect?
The improvement or behavioral changes in subjects that are due to the special attention received by participating in a study, rather than the study intervention itself.
500
48 yo M with end stage renal disease requiring dialysis for the last year. Has history of dm, htn, obesity and is on glipizide, metformin, and nifedipine. On exam he has innumerable excoriated papules on his arms and legs. What part of his history accounts for these skin lesions?
This is Kyrle disease. Seen in small population of chronic dialysis patients, most commonly in diabetics.
Usually resolves following renal transplant after cessation of dialysis.