Uworld 9/4/15

Front 1

Patient with complete bell's palsy->next step?

What if has preservation of brow movements at forehead?

What if was in Maine recently?

Back 1

No workup->po steroids w/in 3 days to improve chance complete recovery (and artificial tears and eye patching) (usually due to zoster reactivation)

-Do brain MRI->since central facial palsy worrisome for upper motor neuron/intracranial lesion

-check for LYME ELISA

Front 2

15yo AA F, dad died of "ruptured blood vessel", long extrem, scoliosis, 2/6 early diastolic murmur L sternal border, clear lungs=?

Cause?

Findings?

Risk of what?

Back 2

Marfan Syndrome

-Aut dom due to fibrillin 1 glycoptn defect

-skeletal (arachnodactyly, lo upper-to-lower bod ratio, up arm-to-height ratio, pectus deformity, scoliosis/kyphosis, joint hypermobile), Ectopia Lentis, Aortic dilation->regurg->dissection, MVP, spontaneous pneumtx from apical blebs, recurrent hernias, skin striae

-Risk of aortic dissection! (do TTE at initial dx and q6mos after)

Front 3

14yo F w/ 2 episodes tonic clonic seizures in 1hr (has h/o epilepsy but recently stopped phenytoin), eyes are open but nonresponsive to commands, slight twitching in mouth and arms

-Steps?

Back 3

Status Epilepticus (seizure lasting longer than 5-10min)

-IV benzo/ativan

-fingerstick glucose

-urine tox screen

-cbc/bmp

Front 4

50yo M w/ knuckle pain worse in morning 1/2 hr, swelling 2nd/3rd MCPs, XR shows calcification triangular ligament, random blood glucose 203, fasting blood glucose 136, normal cbc/bmp/LH/FSH/testosterone/prolactin, no HTN, skin slightly pigmented over face and upper extrem, mild hepatomegaly=?

Dx test?

Back 4

Hemochromatosis (bronze DM, with osteophytes hook type on MCPs from iron depot)
-do iron studies (transferrin sat and ferritin)

-liver bx is gold standard if elevated

Front 5

Counseling for sun-exposure in high risk patients:

Back 5

sunscreen SPF 15 or more, maintain hydration wear clothing/protective behaviors

Front 6

First step in tmt of baby with shaken baby syndrome and concern for head tauma?

Back 6

CT scan head first (will eventually need a skeletal survey) but have to rule out subdural hematoma (crescent shaped)->most common

Front 7

6mo old baby has been "spitting up". usually at night, composed of curdled formula, nonbilious, not projectile, infant has decreased appetite but good weight, mildly irritable after feeds=?

TMT?

Back 7

Gastroesophageal reflux (normal up to 24mos old)

-thicken formula with cereal

-if fail->then H2 blocker/ranitidine

Front 8

When is CMV answer for CNS findings?

When is Herpes?

When is Arbovirus?

Back 8

ONLY IN HIV/TRANSPLANT/IMMUNOSUPPRESSED

-In adults with encephalitis findings

-in kids with encephalitis findings

Front 9

Common side effects of OCPs?

Copper IUD?

others?

Back 9

All: breakthru bleeding, breast tenderness

Ring: vag irritation

Patch: irritation skin or rash at site

-longer/heavier menses

-bleeding is always the side effect

Front 10

25yo HIV M w/ painful swallowing, burning chest pain, on HAART, failed fluconazole, endoscopy w/ bx showed giant ulcers but no viruses=?

Back 10

Esophagitis->trial of antifungal first (since likely candidal)

-if fails->endoscopy

-giant ulcers w/o virus=Aphthous ulcers

TMT: PO prednisone

-if CMV (give gancyclvir), if HSV (give acyclovir)

Front 11

When to do rapid strep testing on patient with sore throat?

Back 11

Only if 2/4 Centor criteria positive (if only 1/4, high neg predictive value->then supporitve tmt)

-tonsillar exudate

-tender anterior cerv lymphadenopathy (includes submandibular)

-fever

-absence of cough

Front 12

Patient with acute asthma exacerbation nonresponsive to inhaled albuterol x4 times

-Next step?

Back 12

po corticosteroid (DO NOT NEED CXR, INHALED STEROID IS NOT THE ACUTE ANSWER->used longterm)

-supplemental O2 to maintain O2 sat >90

-if severe (FEV1 or PEF<40%): add hi-dose inhaled albu + ipratropium neb q20min or continuously for 1hr

-if resp arrest/or distress: IV steroid, mech vent and intubate->ICU

Front 13

52yo F going thru menopause with irregular menses=?

TMT?

Dx criteria?

Back 13

Menopausal transition w/ Anovulatory Uterine bleeding (they shouldn't be bleeding at all->amenorrhea >1yr = menopause)

-if age =>45 do endometrial biopsy

-then treat with OCPS

Front 14

Contraindications for metformin?

Patient undergoing cardiac cath-recs?

Back 14

renal insuff (Cr>1.5), hepatic dz, ETOH abuse, sepsis, severe CHF

-stop day b4 and resume 2 days after (since IV iodine contrast with metformin can cause lactic acidosis

Front 15

Differentiate Obsessions from Compulsions:

Back 15

Obsessions: persistent intrusive thoughts that pt knows are senseless product of her own mind that cuases distress

Compulsions: repetitive intentional BEHAVIOR done to alleviate anxiety

Front 16

Baby being born, head out, but unable to free shoulder=?

TMT?

Back 16

Shoulder Dystocia

BECALM

B-breath, don't push, lower head of bed

E-elevate legs to McRoberts position (hip flexed in supine)

C-call for help

A-apply SP pressure to release anterior shoulder

L-enlarge vag opening with episiotomy

M-maneuvers: deliver posterior arm, Woods corkscrew(pressure baby posterior shoulder anteriorly) or Rubin (posterior & anterior pressure), Gaskin (all fours-mom on hands and knees), Zavanelli (push baby head back in and c-section)

Front 17

Most common cause of recurrent DVTs/PEs in patient with family hx of this?

Back 17

Factor V Leiden (most common hereditery thrombophilia)

Front 18

What is the prognosis of childhood abscense epilepsy?

EEG pattern?

TMT?

Back 18

episodes diminish with age (usually starts 4-8yo) and treatment is very effective

-generalized 3/sec spike with wave activity

-ethosuximide or valproate

Front 19

Workup of palpable breast mass?

Back 19

If <30->U/S->if benign features/solid->mammogram, if atypical->core needle bx, if simple cyst->needle aspirate

If =>30->mammo+/-u/s->then core bx

Front 20

Ear purulent discharge and ganulation tissue on floor external auditory canal=?

What other findings?

TMT?

Back 20

Pathognemonic for Malignant Otitis Externa (invasive infxn external canal and bones forming skull base, marked pain, purulence, granulation, discharge, floor bone-cartilage jnction, normal tymphanic membrane, usually in elderly/DM/HIV, caused by pseudomonas->can cause osteomyelitis if untreated)

-IV cipro or antipseudomonal (piperacillin/ticercillin, ceftazidime)

Front 21

Patients with hospitalizaiton and recent variceal bleeding->most common complication?

Back 21

Infection (SBP vs. UTI vs. resp infction/pna), which is why use of ppx abx cipro is recommended

Front 22

25yo AA w/ infertility eval, trying 2 years, menstrual periods irregular, LMP 10 days ago, BMI 31, facial hirsutism, husband semen analysis normal, glucose 98, U/S shows increased ovarian vol bilat=?

TMT?

Risk of what?

Back 22

PCOS (gradual hirsutism, obesity, irregular menses, infertile), increased testosterone

Dx Test: elevated Lh/FSH 3:1 ratio, bilat enlarged ovaries on u/s

-increased risk of endometrial ca

-for infertility: weight loss 1st->clomiphene citrate

-for irregular bleeding/hirsutism->OCPs +/-spironolactone

Front 23

Risk factor most important for Pelvic inflammatory dz?

Back 23

Multiple sex partners

Front 24

What's the point of the alpha subunit when check thyroid hormones?

Back 24

differentiates btwn the TSH-secreting pit adenoma and thyroid hormone resistance syndrome (when TSH, T4, T3 up, if alpha unit elevated, indicates adenoma)

Front 25

Pt with parkinsons on levodopa/carbidopa w/ mask-like facies, hand tremors, bradykinesia, avoids eye contact, and does not want to answer questions, daughter states he wakes up real early which is unusual

Next step?

Back 25

Add SSRI (do to treat for possible depression before adding another antiparkinson mediction)

Front 26

Type 1 vs Type2 error?

Back 26

Type 2 when study fails to reject null (relates to power of study/sample size)

Type 1 relates to false positives when you reject null incorrectly

Front 27

24yo M cleaning house w/ GF, found to be lethargic and SOB, wheezing, flushed, miosis, garlic like odor on clothes=?

Dx test?

TMT?

Back 27

Organophosphate poisoning (garlic odor-patho, salivate, lacrimate, urinate, diarrhea, wheeze)

-RBC cholinesterase (tells degree of toxicity since they inhibit acetylcholinesterase, usually this aint done)

-Atropine initially (most effective is Pralidoxime), remove all clothes and wash pt

Front 28

pregnant woman with hyperpigmentation cheeks=?

TMT?

Back 28

melasma (occurs in sun-exposed areas), common in preg

-sunscreen use, will resolve after delivery, avoid sun exposure

Front 29

24yo M w/ disorientation, restlesness to ED (had opioid overdose one month ago in ED), BP 160/100, HR 120, not oriented, but recalls name, bilat vertical nystagmus=?

TMT?

Back 29

PCP intox (vert nyst is patho)

-place in quiet environment

Front 30

1positive whiff test=

2pH>4.5=

3pH 3.8-4.2=

4pseudohyphae=

5motile trichomonads=

6clue cells=

7amine odor on KOH=

8thin yellow green=

9thin off white=

10fishy odor=

11frothy discharge=

12vaginal inflammation=

13when to treat partner

Back 30

1Bacterial Vaginosis (gardnerella vag)-BV->use flagyl

2BV vs. trichomoniasis (T)

3candida vaginosis (CV)->use fluconazole

4CV

5T->use flagyl 2g once or 7days 500

6BV

7BV

8T

9BV

10BV

11T

12T vs CV

13 only in T

Front 31

MGMT of C.diff?

Back 31

if mild-mod (wbc <15, cr <1.5x baseline)->po flagyl

if severe->po vanco (if ileus->iv flagyl and rectal vanco instead)

ANSWER IS NEVER IV VANCO-doesn't get spread to colon

Front 32

When to do CEA?

Back 32

symptomatic carotid stenosis >70% (asx is controversial)

Front 33

Which steroids to use in pregnancy?

Back 33

betamethasone or dexamethasone

Front 34

35yo M states excessive daytime sleepiness for months falling asleep at inappropriate times, no other sx

First step?

Back 34

Overnight polysomnography->if suspect narcolepsy then multple sleep latency test (narcolepsy treated with methylphenidate +/-antidepressants)

Front 35

What has the highest risk of MALE breast ca?

Back 35

Klinefelter's syndrome (47 XXY, hypogonadism, low T, gynecomastia)

Front 36

what treatable risk factor for ischemic stroke in atherosclerotic dz is most effectable if modified?

Back 36

HTN! (not smoking, DM, HLD)

Front 37

What is the single most important prognostic factor in patients with COPD?

Back 37

FEV1 (if below 40%= severe obstruction)

Front 38

30yo M w/ salmonella enteritis

TMT?

Back 38

supportive therapy (only need to treat with cipro/bactrim/or ceftiraxone if kid 12mos younger or immunocompromised)

Front 39

What is serum sickness?

Back 39

prodrome phase of Hep B->get fever, rash, arthralgias that resolve once jaundice starts, due to type 3 rxn w/ circulating immune complexes (will also see elevated AST/ALT and Tbili)

Front 40

Patient in house fire to ED w/ nausea, HA, AMS, vitals stable=?

Sx?

Test?

TMT?

Back 40

Carbon Monoxide poisoning

-SOB, lightheaded, HA, disorientated, met acidosis (basically anemia and asphyxiation since COhgb does not release O2 to tissues)->look for an entire family with fatigue and HA after being in home snowed in and feels better shoveling snow

-Check CO oximetry (PO2 venous and arterial will be normal, puls ox will show normal Ox sat since can't differentiation CO vs O2hgb)

-give 100% O2

Front 41

Recall bias is also known as?

Back 41

Misclassification of exposure (or misclassification of outcome if the survey is asking about what they got disease wise)

Front 42

What meds to give in acute STEMI?

Back 42

1. O2

2. Nitrates (don't if hypotn or RV infarct)

3. ASA 162-325 chew + P2Y12 blocker

4. BBlock (not if severe airway dz or brady)

5. Anticoag (esp. if undergoing PCI)

6. intensive statin

7. PCI w/in 90min or TPA w/in 30min

NOT CCBs (increase mortality)

Front 43

Criteria for acute Rheum Fever?

Back 43

1 Major (JONES: Joints/mig arthritis, Carditis, Nodules/subq, Erythema marginatum, Sydenham chroea) + 2 Minor (fever, arthralgia, hi ESR or CRP, prolonged PR)

-late finding: mitral regurg or stenosis

-TMT: penicillin (for GAS strep pyo pharyngitis) and will continue to adulthood

Front 44

Fat AA or hispanic kid presents w/ acute R hip pain that started as a little bit 3 wks ago but can't walk now w/ pain to thigh and knee, no injuries, avss, pain on hip external rotation=?

TMT?

Back 44

SCFE (slipped capital femoral epiphysis)

-Immediate internal fixation w/ pins as soon as possible (risk of avascular necrosis if delatyed tmt)

Front 45

Rules of undescended testicle in Male?

Back 45

spont descent rare after 6months->do orchiopexy then to decrease risk fertility and torsion

-Increased risk of malignancy remains same after surgery

Front 46

5wk old boy in winter to ED w/ intermittent respiratory pauses and cyanosis w/ rhinorrhea and nasal congestion. Father and old sibling had nasal congestion adn rhinorhea. Has bilat crackles and wheezes w/ intermittent apnea=?

ML organism?

TMT?

Back 46

Bronchiolitis (kids <2), esp in winter

RSV

Supportive care only

Front 47

What seat belt to wear in pregnancy?

Back 47

Where the whole thing