IM ROSH Boost Practice Test Reviw

varicocele cause

dilation of pampiniform plexus of spermatic veins

varicocele sx

left-sided scrotal fullness with Valsalva maneuver to large and soft left-sided scrotal mass- “bag of worms”

varicocele tx

tx= most do not need tx, surgical ligation or percutaneous venous embolization

complication: atrophy of left testicle and infertility

Salmonellosis

abd cramping, fever, N/V/D

self-limited

isolation of Salmonella on stool cx

tx: oral rehydration solution

Mobitz type II AV block

not prolonged PR interval then drop

tx: permanent pacemaker placement

Lyme disease

borrelia burgdorferi- causative organism spread via Ixodes scapularis tick

Tx: Doxycycline

chronic venous insufficiency

RF: prior DVT

eczematous rash, scaling, weeping erosions- stasis dermatitis

chronic= fibrosis of SQ tissue causes hardening of skin, erythema and hyperpigmentation- lipodermatosclerosis

orthostatic hypotension

systolic blood pressure decreasing ≥ 20 mm Hg or diastolic blood pressure decreasing ≥ 10 mm Hg with the change in position.

Sjogrens syndrome

dry eyes, dry mouth, rope-like secretions out of eye in the morning

anti-Sjögren syndrome A antibody (anti-SS-A) and anti-Sjögren syndrome B antibody (anti-SS-B), rheumatoid factor, and antinuclear antibodies.

tx: supportive

Sialiogogues and artificial tears help relieve symptoms of dry mouth and dry eyes. Medications, including pilocarpine and cevimeline, are used to treat xerostomia.

gastric CA

25% have hx of gastric ulcer

left supraclavicular node (Virchow node), a periumbilical nodule (Sister Mary Joseph node), or a left axillary node (Irish node)

RF: H pylori!!

Reactive arthritis M/C pathogen

Campylobacter jejuni

often follows GI/GU infection

IBS

related to defecation, symptoms associated with a change in stool frequency, or symptoms associated with a change in stool appearance.

diarrhea-predominant subtype, medical treatment with loperamide

constipation-predominant subtype, treatment with osmotic laxatives is recommended if dietary modifications such as increased fiber intake are unsuccessful.

Immune thrombocytopenia

mc cause: viral-CMV, VZV, EBV

autoimmune- SLE, RA, antiphospholipid syndrome

immunodeficiency syndrome- HIV

sx: bleeding, easy bruising, petechiae, purpura

cbc: isolated thromobocytopenia

tx: most do not need tx

For patients with minor bleeding or severe thrombocytopenia without bleeding, as in the vignette above, glucocorticoid therapy with dexamethasone is preferred. For severe or critical bleeding due to ITP, treatment with platelet transfusions, intravenous immune globulin, and glucocorticoids is indicated.

epididymitis

tx: ceftriaxone and doxycycline

achalasia

dx: esophageal manometry, incomplete relaxation of lower esophageal sphincter

tx: pneumatic balloon dilation

atrial fibrillation

sx: chest pain, palpitations

EKG: irregularly irregular rhythm, no P waves, and narrow QRS

tx: Synchronized electrical cardioversion is indicated for unstable patients, including those with acute hypotension, active ischemia, or severe heart failure

Rate control therapeutics include use of a beta-blocker (metoprolol, esmolol) or a calcium channel blocker (diltiazem, verapamil). Rhythm control can be achieved by percutaneous catheter ablation, synchronized cardioversion if Afib is present < 48 hours or the patient has been anticoagulated for 4 weeks, or with an antiarrhythmic medication such as ibutilide, flecainide, or sotalol.

chronic bacterial prostatitis

mc pathogen: E coli

recurrent UTI

Tx: fluoroquinolone, such as ciprofloxacin or levofloxacin. Trimethoprim-sulfamethoxazole is an appropriate alternative. The recommended duration is at least 6 weeks.

SIADH

Hyponatremia (serum sodium < 135 mmol/L) with hypo-osmolality (serum osmolality < 280 mOsm/kg) is the hallmark of SIADH.

Bartter-Schwartz criteria

mainstay of tx= fluid restriction

chronic pts tx= fluid restriction

metabolic syndrome

three or more of the following signs: fasting glucose ≥ 100 mg/dL, blood pressure ≥ 130/85 mm Hg, triglyceride level ≥ 150 mg/dL, HDL < 40 mg/dL in men or < 50 mg/dL in women, and waist circumference > 102 cm in men or > 88 cm in women

tx: lifestyle modifications

SLE discoid rash

discrete, erythematous, somewhat indurated plaques that are photodistributed on the dorsal arms and face.

tx: topical clobetasol for discoid rash

Bronchiectasis

assoc with CF, alpha-1 antitrypsin deficiency

purulent foul-smelling sputum, dyspnea, hemoptysis

CT: tram tracks.” Bronchial dilation with a lack of tapering toward the periphery and the signet ring sign

Tx: antibiotics, chest physiotherapy, and inhaled bronchodilators

acute cholangitis

charcot triad: fever, RUQ pain, jaundice

abnormal liver enzymes

tx: abx and ERCP

jaundice

serum bilirubin level >3

Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction and disorders of impaired bilirubin conjugation. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage.

Excretion of conjugated bilirubin is impaired in Dubin-Johnson syndrome- autosomal recessive disorder, mutation in gene responsible for cMOAT protein/MRP2/ ABC2, black liver

tx: benign and no tx needed

dermatomyositis

dusky red heliotrope rash commonly seen around the eyes and facial erythema that mimics the butterfly shaped rash seen in patients with systemic lupus erythematosus. However, patients with dermatomyositis will have erythema that involves the nasolabial folds (lupus spares nasiolabial folds)

CK elevated

anti-Jo-1 antibodies, anti-Mi-2, anti-SRP

tx: PO corticosteroids

resistance: MTX, azathioprine, or rituximab

free wall rupture

rare complication after MI

can present as cardiac tampoande- hypotn, muffled heart sounds, and JVD

postherpetic neuralgia

affected by herpes zoster (shingles)- pain and vesicles along a dermatome, reactivation of VZV

tx: gabapentin, pregabalin, and TCAs

myasthenia gravis

autoantibodies against postsynaptic acetylcholine receptors.

associated with thymoma and thymic cancer

fluctuating muscle weakness that worsens with activity and increases later in the day. The ocular muscles are most commonly affected with symptoms of diplopia, ptosis, and cranial nerve palsies.

ice pack test and sustained upward gaze test

tx: pyridostigmine, neostigmine) to increase acetylcholine in the neuromuscular junction.

overmedication= cholinergic crisis

thymoma= ectomy

rheumatic heart disease

caused by Group A Streptococcus pharyngeal infxn

MCC mitral stenosis- rheumatic heart disease

antiphospholipid syndrome

arterial or venous thrombosis, recurrent fetal loss, or thrombocytopenia.

mc assoc with SLE

mc sx- Livedo reticularis appears as localized or widespread, patchy, reticulated, vascular network with a blue, red, or violaceous hue

dx: lupus anticoagulant test, an immunoassay for anti-beta-2 glycoprotein 1 antibodies, or an immunoassay for anticardiolipin antibodies.

tx: warfarin (INR goal 2.5-3.5)

alpha 1 antitrypsin deficiency

toxic loss of function caused by an imbalance between the lung neutrophil elastase, which destroys elastin, and the elastase inhibitor alpha-1 antitrypsin, which protects against proteolytic degradation of elastin

stroke RF

HTN!!!

mc ischemic stroke

mc= MCA

difficulty speaking, altered mental status, vision changes or loss, weakness, sensory loss, imbalance, ataxia, and vertigo.

initial management= reperfusion therapy, alteplase within 4.5 hrs!!

mechanial thrombectomy w/in 24 hrs- ant circulation stroke

NSTEMI

The recommended anticoagulant for patients undergoing invasive treatment (coronary angiography with early revascularization) is unfractionated heparin.

The recommended second antiplatelet agent for patients who are undergoing early (within 24 hours) percutaneous coronary intervention is either ticagrelor or prasugrel, which are both P2Y12 inhibitors

OA

weight-bearing joints, joint pain

worsens with activity, joint line tenderness

x-ray joint space narrowing, osteophytes

tx: W/L, total joint replacement

Sick sinus syndrome, or sinus node dysfunction, is most often associated with age-dependent sinus node fibrosis

sinus brady, tachy, arrest

presyncope, palpitations, exertional dyspnea, exercise intolerance

primary aldosteronism

mcc of refractory hypertension in youths

Too much aldosterone causes an increase in sodium retention, leading to renin suppression and increased potassium secretion leading to hypokalemia.

plasma k level dec

random plasma aldosterone to plasma renin activity (PRA) ratio. Plasma aldosterone will be elevated, while PRA will be low. A plasma aldosterone to PRA ratio of > 20–25 may indicate primary aldosteronism.

tx: spironolactone

interstitial cystitis

Cystoscopy is performed and shows reddened lesions on the bladder mucosa with attached fibrin deposits.

n increase in discomfort with bladder filling and relief w/ voiding

tx: pain mgmt, pelvic floor muscle therapy, amitriptyline

DKA

Blood glucose in DKA is often between 350 and 500 mg/dL and is typically > 250 mg/dL and < 800 mg/dL. DKA is characterized by an anion gap metabolic acidosis, so the anion gap will be > 12, and serum pH will be < 7.30. Serum bicarbonate will be < 15 mEq/L. Ketones will be present in the serum and urine. Plasma osmolality is variable in DKA and may be low, normal, or high

zollinger ellison syndrome

hypersecretion of gastric acid, fasting serum hypergastrinemia, and peptic ulcer disease with diarrhea.

tx: ppi, surgical excision

multiple myeloma

malignancy where proliferation of plasma cells in the bone marrow and overproduction of a monoclonal immunoglobulin

Commonly, patients present with bone pain or pathologic fractures due to underlying lytic lesions. They may also have nonspecific symptoms, including fatigue, weight loss, nausea, or vomiting.

Laboratory evaluation may reveal normocytic, normochromic anemia, hypercalcemia, and elevated creatinine.'

UPEP will also reveal proteinuria with evidence of Bence Jones proteins

Two- or three-drug regimens such as bortezomib, lenalidomide, and dexamethasone (VRd), daratumumab, lenalidomide, and dexamethasone (DRd), or cyclophosphamide, bortezomib, and dexamethasone (CyBorD) are commonly used,

idiopathic pulmonary fibrosis

progressive exertional dyspnea and a persistent dry cough

bibasilar crackles on lung auscultation

peripheral, basilar opacities with honeycombing and traction bronchiectasis

spirometry: restrictive pattern of lung disease demonstrating decreased FVC

tx: antifibrotic therapies, lung transplant

small cell lung cancer

smoking exposure

rapid growth

sx: cough, dyspnea, hemoptysis

includes hyponatremia and SIADH

mc presentation= large centrally located hilar mass

tx: platinum-based chemo

atrial fibrillation

RF: HTN, obesity, pulmonary disease, CAD

Anticoagulation therapy is recommended for men with a CHA2DS2-VASc score ≥ 2 and for women with a CHA2DS2-VASc score ≥ 3. Therefore, anticoagulation, such as rivaroxaban or apixaban, is recommended for this patient since he has a score of 2.

CAP Legionella

secondary to exposure to contaminated man-made water reservoirs- showers, pools, hot tubs

N/V/D

CXR- patchy unilobar infiltrates

hyponatremia, elevated serum transaminases, C-reactive protein levels > 100 mg/L, and failure to respond to treatment for pneumonia with beta-lactam monotherapy.

nucleic acid detection with PCR

cx= gold standard

tx: levofloxacin or azithromycin

guillain barre syndrome

prog ascending symmetric muscle weakness

often following c jejuni infxn

reflexes dec or absent

CSF: high protein levels

tx: IVIG, plasmapheresis

HTN emergency

reduce BP by 25% in first hour

Crohn’s disease

aphthous ulcers or dysphagia.

multiple sclerosis

immune-mediated demyelinating neuro condition

mc relapsing-remitting, secondary prog, and primary prog (most aggressive)

optic neuritis, vision loss, diplopia

MRI: periventricular and juxtacortical white matter lesions

upper motor neuron signs- hyperreflexia, positive Babinski reflex, Marcus Gunn pupil, pos Lhermitte sign- electric shock sensation in the spine and extremities with flexion of the neck

tx: glatiramer acetate, interferon beta

modafinil- fatigue

baclofen-spasticity

exacerbation- high-dose corticosteroid

right heart failure and volume overload

furosemide

CML

white blood cell count is typically over 100,000 cells/µL with very few blasts.

dx: bone marrow bx

Allogeneic hematopoietic cell transplantation is curative

Tuberculosis is a microbiologic diagnosis requiring identification of Mycobacterium tuberculosis on _________

culture

AAA

A large aneurysm is > 5.5 cm. These aneurysms should be referred for surgical consultation for elective repair (risk of rupture!)

Anything above 6.0 cm is considered a very large aneurysm.

pulmonary nodule

Solitary solid nodules are considered benign and do not require serial imaging if they measure < 6 mm and the patient does not have risk factors for lung cancer. These patients can be reassured. Pulmonary lesions measuring > 30 mm are considered pulmonary masses and should undergo surgical resection.

spontaneous PTX

Rupture of subpleural apical bullae in response to high negative intrapleural pressure is the etiology of primary spontaneous pneumothorax. These have a higher incidence among patients of the male sex between ages 10 and 30 years who are tall and thin. Other risk factors include family history and cigarette smoking.

carcinoid syndrome

episodic flushing and diarrhea

dx: 24-hour urinary excretion of 5-hydroxyindoleacetic acid levels.

superficial phlebitis

RF: varicose veins, recent vein excision or ablation, pregnancy or postpartum period, estrogen therapy, and intravenous catheter use.

sx: no palpable cord, pain, tenderness, pain along course of superficial vein

tx:warm or cool compresses, nonsteroidal anti-inflammatory drugs, an

ankylosing spondylitis

pain and progressive stiffening of spine, worst in AM

sacroiliitis

bamboo spine

pos HLA-B27

Tx: NSAIDs

non-obstructing nephrolithiasis

Kidney stones measuring > 5 mm but < 10 mm may require medication expulsion therapy such as tamsulosin to aid in stone passage.

f/u outpt

glioblastoma

mc malignant primary brain tumor, high-grade glioma

right-sided hyperreflexia and a right grasping reflex. Papilledema is noted on funduscopic examination.

h/a, seizures, weakness, memory loss

MRI

surgical resection

cerebral toxoplasmosis

ingestion of infected meat that is improperly cooked, contaminated water, or oocysts excreted by cats. Symptoms include headache, neurological symptoms, and often a fever.

CD4 count <100 cells

MRI- multiple ring-enhancing brain lesions

polymyalgia rheumatica

pain in shoulders and pelvic girdle, concomitant anemia

ESR elevated!!!

tx: low-dose prednisone

COPD

hyperinflation (evidenced by hyperresonance to percussion), decreased breath sounds, wheezing, distant heart sounds, and decreased tactile fremitus, may be present.

What increases UTI risk?

Use of spermicide-coated condoms, diaphragms, or spermicides

hyperkalemia

bradycardia, muscle weakness, and ECG with peaked T waves and widened QRS

can be with CKD

nonsteroidal anti-inflammatory drugs (NSAIDs) can precipitate or worsen hyperkalemia by inhibiting renal prostaglandin synthesis, leading to afferent arteriole vasoconstriction

ventricular fibrillation

CPR, rhythm check, defibrillation, and epinephrine administration is repeated

atenolol- BB side efx

insomnia and sleep changes in some patients.

dilated cardiomyopathy

reduced EF < 40%

produces a third heart sound (S3), caused by deceleration of blood against a dilated, compliant ventricle. The sound is classically low-pitched and best appreciated at the cardiac apex

tx: BB, ACE/ARB

Decorticate posturing occurs due to damage to the

cortex and includes flexion of the upper extremities with lower extremity extension.

Decerebrate posturing occurs due to damage to the

brainstem and includes extension of the upper and lower extremities. T

c diff from abx tx ppx

oral vancomycin ppx for pts receiving systemic abx

finasteride for bph

sexual dysfunction, including decreased libido, ejaculatory disorder, and impotence

obesity hypoventilation syndrome

elevated serum bicarbonate, which is defined as a serum bicarbonate > 27 mEq/L, due to chronic hypercapnia.

tx: noninvasive positive airway pressure and lifestyle modifications for weight loss.

scleroderma/systemic sclerosis

thickened, hardened skin

sausage-like fingers

rapid progression of skin involvement and earlier development of internal organ manifestations, such as interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), renal crisis, and cardiac involvement

PE

CTA

Patients who are hemodynamically stable with a pulmonary embolism should be started on anticoagulation unless they are at a high risk of bleeding. Low-molecular-weight heparin, such as enoxaparin

acute angle closure glaucoma

ight conjunctival redness, conjunctival vessels injected, cloudy cornea, and a mid-dilated pupil that does not react to light

CI: atropine- anticholinergic that will cause pupillary dilation (mydriasis) and induce angle narrowing and increased intraocular pressure.

Common causes of transudative effusions include

heart failure, cirrhosis, and nephrotic syndrome.

Common causes of exudative effusions include

malignancy, bacterial or viral pneumonia, tuberculosis, pulmonary embolism, pancreatitis esophageal rupture, collagen vascular disease, chylothorax, and hemothorax.

niacin

helps dec LDL-C

side efx: flushing, hyperuricemia, hyperglycemia

CI: active PUD and hepatic disease

tricuspid stenosis

low-frequency mid-diastolic murmur heard best at the lower left sternal border that increases with inspiration.

cardiac tamponade

Beck triad refers to three classic physical examination findings seen with cardiac tamponade: hypotension, jugular venous distention, and muffled heart sounds.

echocardiogram, is the best diagnostic test, as it can confirm a pericardial effusion and show chamber collapse

ECG often shows sinus tachycardia and low voltages. Electrical alternans is a classic cardiac tamponade ECG finding that has high specificity but low sensitivity.

tx: pericardiocentesis

STEMI

The S4 heart sound is a common finding in the early (acute) phase of a myocardial infarction

SAH comp

Vasospasm is a common complication of subarachnoid hemorrhage, occurring no earlier than 3 days after the onset of hemorrhage. It can reach its peak at day 7 or 8. This is due to the substances released as a result of the lysis of blood products, primarily nitric oxide and endothelin.

fibromuscular dysplasia

mc involved: renal arteries

htn from renal A stenosis: beaded appearance of renal artery

headache, pulsatile tinnitus, neck pain, and cervical bruit. However, patients may present with abdominal pain, flank pain, an abdominal bruit, a transient ischemic attack, or a stroke.

tx: antihypertensive drug therapy and revascularization

paget’s disease of bone

elev alk phos, x-ray :lytic lesions and thickened bone cortices

myasthenia gravis

def dx: single fiber electromyography

varicocele

Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen.

AML

Auer rods present!!

huntington’s disease

autosomal dominant

triad: dementia, chorea, pattern of inheritance

tx: tetrabenazine

Patients with a vegan diet are prone to____deficiency as it can only be obtained through animal sources.

vit b12

delirium

fluctuating level of consciousness, the presence of hallucinations, disorientation, and abnormal vital signs.

polycystic kidney disease

abdominal fullness due to enlarged kidneys, abdominal pain due to bleeding into cysts, microscopic or gross hematuria, depending on the extent of the disease, and hypertension

sickle cell disease can lead to

avascular necrosis- affecting acetabulum, head of femur, and head of humerus

hypernatremia tx

infuse 5% dextrose solution as it is the fluid of choice in treating hypernatremia that has been symptomatic for >48hr

g6pd deficiency

episode of hemolysis triggered by drug exposure (glipizide, a sulfonylurea).

celiac disease GOLD STANDARD test

endoscopic mucosal bx of small intestine

copd

Recommend influenza and pneumococcal vaccines

primary adrenal insufficiency

hypoglycemia, hyperkalemia, metabolic acidosis

low levels of cortisol and aldosterone in early AM

dx: cosyntropin stimulation test

HCC

elev AFP

pulmonary fibrosis

ground-glass infiltrates on CXR

foodbourne botulism

blurry vision and vertical diplopia after prodromal gastrointestinal symptoms following ingestion of home-canned foods

pnuemocystis

TMP-SMX is the drug of choice for all forms of pneumocystis. Prophylaxis is provided for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.