Brosencephalon's Internal Medicine

Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08
1. Which dietary Which dietary modifications should be 4. A pt presents to the A pt presents to the clinic after passing out
modifications should advised for gout? clinic after passing at home. H&P rules out vasovagal syncope
be advised for gout? Decreased fructose; decreased EtOH; out at home. H&P and orthostatic hypotension.
[...] decreased red meat; decreased fish rules out vasovagal Echocardiogram rules out mechanical heart
syncope and disease. You suspect an arrhythmia as the
orthostatic cause. What diagnostic tests are indicated?
hypotension. EKG (typically negative unless
Echocardiogram rules symptoms are occuring at that time);
2. A pt is suspected to A pt is suspected to have testicular cancer.
out mechanical heart Holter monitor (24 hr EKG); Event/loop
have testicular Why is FNA biopsy of the testicle a very bad
disease. You suspect recorder (1 month monitoring)
cancer. Why is FNA idea?
an arrhythmia as the
biopsy of the testicle It can cause seeding and induce
cause. What
a very bad idea? spreading of the disease
diagnostic tests are
[...]
indicated?
[...]
Needle biopsy is always the wrong answer
in testicular cancer
5. What is the "FAT RN" What is the "FAT RN" mnemonic for the
mnemonic for the classic pentad of symptoms seen in TTP?
3. A 45 y/o pt presents A 45 y/o pt presents c/o painful hematuria.
classic pentad of (see below)
c/o painful Vitals are WNL except for BP (elevated).
symptoms seen in
hematuria. Vitals are Physical exam reveals bilaterally palpable
TTP?
WNL except for BP flank masses. The pt states that his father
[...]
(elevated). Physical also had this problem and died of renal
exam reveals failure. Which genetic cause of renal failure
bilaterally palpable is the most likely Dx?
flank masses. The pt ADPCKD 6. A pt is found to have A pt is found to have a GI bleed. The pt is
states that his father a GI bleed. The pt is stabilized and the appropriate
also had this problem stabilized and the medications/infusions/labs are performed.
and died of renal ADPCKD key points: appropriate EGD rules out UGIB. The bleeding rate is
failure. Which genetic - Autosomal dominant; the cysts have medications/infusions/labsslow and found to be < 0.5 cc/min. What is
cause of renal failure random size/orientation (vs. the radial are performed. EGD the next step in workup?
is the most likely Dx? distribution of ARPCKD) rules out UGIB. The Colonoscopy
[...] - s/s: pain and hematuria; commonly bleeding rate is slow
mistaken for nephrolithiasis, however stones and found to be < 0.5
can form cc/min. What is the
- pyelonephritis is a common presention next step in workup?
- malignant HTN can be present and is 2/2 [...]
RAAS activation
- Dx is via U/S
- Tx is supportive, manage complications
and transplant once ESRD/CKD sets in
- Cysts can also form in the liver, pancreas,
and cerebral vasculature
- Screen these pts for berry aneurysms as
they have a risk for SAH
- Remember to test family members and
offspring
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7. ACLS protocol is ACLS protocol is started on a pt. EKG 9. In which pole of the In which pole of the kidney does renal cell
started on a pt. EKG reveals atrial fibrillation. The pt feels weak kidney does renal cell carcinoma typically manifest?
reveals atrial but has no other s/s. BP is 110/70 mmHg. carcinoma typically Superior pole
fibrillation. The pt His PMHx is significant for migraines only. manifest? Renal Cell Carcinoma key points:
feels weak but has no What is/are the first choice [...] - While its not present everytime, the triad of
other s/s. BP is pharmacotherapy in this case? flank pain, flank mass, and hematuria
110/70 mmHg. His BBs, CCBs (rate control without should be considered cancer until proven
PMHx is significant presence of CHF) otherwise
for migraines only. - Major risk factors include smoking, ESRD
What is/are the first and von-Hippel Lindau
choice ACLS Intervention key points: - Investigate w/ U/S or CT
pharmacotherapy in - If unstable, use electricity - F/u w/ surgical resection
this case? - If stable, use pharmacotherapy; there are - Definitive Dx is via Bx after resection
[...] typically 4 options in general: - Never ever biopsy a suspected RCC in
--- if the rhythm is fast and narrow, use vivo; the risk of hematoma and/or seeding
adenosine is high; always Bx s/p resection
--- if the rhythm is fast and wide, use - hematogenous spread
amiodarone - Renal vein thrombosis is a big risk
--- if the rhythm is slow, use atropine - Either anaemia or polycythemia can be
--- if the rhythm is AFib or AFlutter, rate present (anaemia 2/2 to the tumour or
control = rhythm control (use BBs and increased EPO release as a paraneoplastic
CCBs; or digoxin and amiodarone if there syndrome)
is CHF)
- Remember, wide is QRS > 0.12 msec
10. What is the most What is the most common risk factor for
common risk factor COPD?
8. A 80 y/o pt presents A 80 y/o pt presents c/o of a pigmented for COPD? Tobacco smoking
c/o of a pigmented lesion on his face. Physical exam reveals a [...]
lesion on his face. large, brown, greasy-looking, and
Physical exam crusted pigmented lesion that appears Remember, COPD is a result of the loss of
reveals a large, stuck on the pt's face. What is the most lung elastin (which facilitates passive
brown, likely Dx? exhalation from its elasticity).
greasy-looking, and Seborrheic keratosis Tobacco destroys elastin fibres.
crusted pigmented Very common in the elderly
lesion that appears
11. A pt c/o dizziness A pt c/o dizziness that manifests upon
stuck on the pt's
that manifests upon head movement. He states that the
face. What is the
head movement. He sensation lasts for < 1 min. You suspect
most likely Dx?
states that the BPPV. What is the best diagnostic test?
[...]
sensation lasts for < Dix-Hallpike maneuver (if it reproduces
1 min. You suspect the rotary nystagmus, it is diagnostic)
BPPV. What is the
best diagnostic test?
[...]
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12. Which age group is Which age group is typically affected by 14. ACLS protocol is ACLS protocol is started on a pt. EKG
typically affected by bullous pemphigoid? started on a pt. EKG reveals the rhythm shown below. The pt is
bullous pemphigoid? 70-80 reveals the rhythm stable. What is the most appropriate initial
[...] shown below. The pt intervention?
is stable. What is the Pace only (this is 2nd degree AV block,
Pemphigus vulgaris = 30-60 y/o most appropriate Mobitz II)
Bullous pemphigoid = 70-80 y/o initial intervention?
[...]
AV Block and ACLS key points:
13. A pt presents c/o A pt presents c/o colicky flank pain that
- the most simple slow rhythm is sinus
colicky flank pain radiates to the groin and hematuria. He
brady, give atropine
that radiates to the is Dx w/ nephrolithiasis following a
- 1st degree AV block
groin and non-contrast CT which reveals a 40 mm
--- A regularly prolonged PR interval that
hematuria. He is Dx stone. What is the next step in
does not change; there are no dropped
w/ nephrolithiasis management following hydration and pain
beats; give atropine
following a control?
- 2nd degree AV block, Mobitz type I
non-contrast CT Nephrostomy (or surgery); analyze the
--- involves a constantly prolonging PR
which reveals a 40 stone once retrieved
interval until a dropped QRS; give
mm stone. What is
atropine
the next step in
- 2nd degree AV block, Mobitz type II
management Nephrolithiasis management key points:
--- involves a constant and normal PR
following hydration - Always start w/ hydration and pain
interval that does not prolong and
and pain control? control
randomly dropped QRS complexes
[...] - If the stone is < 5 mm, let it pass
--- atropine is no longer recommended
- If the stone is < 30 mm, perform
as the pt can convert into total AV block
lithotripsy and then let it pass
- 3rd degree (total) AV block
- If the stone is > 30 mm or there is
--- involves total AV node dissociation
hydronephrosis/-ureter, perform
with no regular intervals between P waves
nephrostomy
and QRS complexes
- Either strain the urine or analyse it after
--- although controversial, it's
retrieval to Dx the stone and pinpoin risk
recommended to avoid atropine and pace
factors
only
15. A pt presents c/o A pt presents c/o chest pain w/

chest pain w/ odynophagia and dysphagia. You
odynophagia and suspect esophagitis. What is the best
dysphagia. You diagnostic test?
suspect esophagitis. EGD w/ Bx
What is the best
diagnostic test?
[...] No matter the cause of esophagitis, get dat
dere EGD w/ Bx brah.
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16. ACLS protocol is ACLS protocol is started on a pt. EKG 18. What is the best What is the best initial test for ALL?
started on a pt. EKG reveals the rhythm shown below. The pt is initial test for ALL? PBS (looking for blasts)
reveals the rhythm stable. What is the most appropriate initial [...]
shown below. The pt pharmacological intervention?
is stable. What is the Atropine (this is 2nd degree AV block,
most appropriate Mobitz I)
initial
pharmacological
19. What is the best What is the best initial test for celiac
intervention? AV Block and ACLS key points:
initial test for celiac disease?
[...] - the most simple slow rhythm is sinus
disease? Autoantibody testing (anti-endomysial;
brady, give atropine
[...] anti-tissue-transglutaminase)
- 1st degree AV block
Note that we do not test for anti-gliadin
--- A regularly prolonged PR interval that
antibodies as they have low sensitivity
does not change; there are no dropped
and low specificity. They are not useful.
beats; give atropine
- 2nd degree AV block, Mobitz type I
--- involves a constantly prolonging PR
interval until a dropped QRS; give
atropine
--- involves a constant and normal PR 20. Hemophilia exists in Hemophilia exists in 2 forms: A or B. Which
interval that does not prolong and 2 forms: A or B. factors are deficient in them respectively?
randomly dropped QRS complexes Which factors are A = VIII, B = IX
--- atropine is no longer recommended deficient in them "A8, B9"
as the pt can convert into total AV block respectively?
- 3rd degree (total) AV block [...]
with no regular intervals between P waves 21. Hepatic Hepatic encephalopathy is a possible
and QRS complexes encephalopathy is a complication of liver failure/cirrhosis. What
--- although controversial, it's possible complication is the treatment?
recommended to avoid atropine and pace of liver Lactulose; start transplant workup
only failure/cirrhosis. What
is the treatment?
[...]
17. A pt presents c/o A pt presents c/o progressive hair loss. 22. A pt present c/o of A pt present c/o of hair loss. Physical exam
progressive hair Physical exam reveals loss of hair at the hair loss. Physical reveals multiple, small patches of
loss. Physical exam crown of the head with thinning of the exam reveals well-demarcated hair loss in a sporadic
reveals loss of hair hair at the edges of the crown area. What multiple, small pattern around the body. What is the most
at the crown of the is the most likely dx? patches of likely dx?
head with thinning Male Pattern Baldness well-demarcated Alopecia areata
of the hair at the Note that MPB follows this specific pattern hair loss in a
edges of the crown of hair loss (crown thins --> crown hair sporadic pattern
area. What is the loss --> progressive thinning/loss from around the body.
most likely dx? the crown outwards). What is the most
[...] likely dx?
[...]
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23. A pt states he was A pt states he was exposed to Hepatitis A 1 26. A pt w/ a history of A pt w/ a history of SLE presents c/o
exposed to Hepatitis week ago. What is the post-exposure SLE presents c/o severe joint pain. You suspect a lupus
A 1 week ago. What prophylaxis protocol? severe joint pain. You flare. Your smart medical student suggests
is the post-exposure IgG w/ the HAV vaccine within 2 weeks suspect a lupus flare. that we should check compliment levels.
prophylaxis protocol? of exposure Your smart medical How do compliment levels change in a
[...] student suggests that lupus flare?
we should check Decrease
compliment levels.
How do compliment
24. Which drug has been Which drug has been shown to increase
levels change in a If complement levels are normal, it is likely
shown to increase CFTR gene activity in cystic fibrosis?
lupus flare? not a flare.
CFTR gene activity in Ivacaftor
[...] If complement levels are decreased, it is
cystic fibrosis?
likely a flare.
[...]
27. What is the treatment What is the treatment for polycythemia

25. What is the genetic What is the genetic inheritance of cystic
for polycythemia vera?
inheritance of cystic fibrosis?
vera?
fibrosis? AR (in the CFTR gene)
[...]
[...]
Mutations in the CFTR gene result in 28. A pt presents w/ A pt presents w/ severe epigastric pain
impaired chloride and water transport severe epigastric that radiates to the back and is relieved
across the apical surface of epithelium in pain that radiates to by leaning forward. He also complains of
exocrine glands throughout the body. the back and is nausea, vomiting, fever and anorexia.
Hence, there is: relieved by leaning Physical exam reveals Cullen's and Grey
- thick mucous in the lungs (causing a list forward. He also Turner sign. Pancreatic lipase is elevated
of problems such as recurrent infection, complains of nausea, and he is Dx w/ acute pancreatitis. What
bronchiectasis, wheezing, hemoptysis, vomiting, fever and is the first step in management?
dyspnea) anorexia. Physical IVF, NPO, analgesia
- meconium ileus in infants exam reveals
- pancreatic insufficiency (seen in 90% of Cullen's and Grey
cases); typically involving steatorrhea and Turner sign. NPO provides bowel rest and prevents
fat-soluble vitamin deficiency (Vit ADEK); Pancreatic lipase is pancreatic secretion
beta-cells and the islets are spared until elevated and he is Dx IVF keeps them hydrated
late-stage disease w/ acute Analgesia for comfort
- recurrent pancreatitis pancreatitis. What is Ppx Abx are not needed (no difference in
- biliary cirrhosis the first step in outcome)
- azoospermia (in 95% of male cases) management? ERCP if there is a stone.
- vas deferens agenesis (in 20% of cases) [...] In NEJM, Nov 20, 2014 Vol 371, No. 21;
- female infertility is also seen and is 2/2 "Early versus On-demand Nasoenteric
alteration of menstrual cycle and thick Tube Feeding in Acute Pancreatitis" Dutch
cervical mucous (that can block sperm investigators showed that early nasogastric
entry) tube feedings (at 24 hours) did the same as
starting oral or NG tube feeds at 72 hours.
The idea was that early feedings may
prophylax the gut and reduce infection
rates. These guys found out that, for
patients in their study, it didn't matter
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29. A pt is found to have A pt is found to have a solitary pulmonary 34. AML can develop as AML can develop as a "blast crisis" from
a solitary pulmonary nodule with intermediate-probability of a "blast crisis" from other hematological cancers. Which 2
nodule with malignancy. You continue workup with other hematological conditions are known to do so?
intermediate-probabilitysputum cytology which is positive for cancers. Which 2 CML; MDS
of malignancy. You malignancy. What is the most appropriate conditions are known
continue workup with next step in management? to do so?
sputum cytology Resection [...]
which is positive for
malignancy. What is
35. What type of fluids What type of fluids are typically used as
the most appropriate Sputum cytology is highly specific. So if
are typically used as maintenance fluid?
next step in positive, malignancy is ruled in. However,
maintenance fluid? 1/2 NS or 1/4 NS (either of them with or
management? negative cytology does not rule out
[...] without D5)
[...] malignancy.
30. How does How does reticulocyte count typically

reticulocyte count change in microcytic and macrocytic
36. A pt presents A pt presents complaining of difficulty
typically change in anaemia?
complaining of getting out of chairs, muscle pain and
microcytic and Decrease
difficulty getting out rashes. Physical exam reveals proximal
macrocytic anaemia?
of chairs, muscle muscle weakness with intact distal
[...]
pain and rashes. muscle strength. You also find a purple
Microcytic and macrocytic anaemias are
Physical exam rash around the eyes with periorbital
typically production anaemias which is
reveals proximal edema and scaly lesions distributed
almost synonymous with low reticulocyte
muscle weakness symmetrically over the wrists, elbows and
count.
with intact distal knees. You suspect myositis. What is the
muscle strength. best test to achieve a definitive diagnosis?
31. Arteriovenous Arteriovenous malformations can possibly You also find a
malformations can cause UGIB or LGIB. What valvular heart purple rash around
possibly cause UGIB disease is it associated with? the eyes with Biopsy
or LGIB. What Aortic Stenosis periorbital edema
valvular heart and scaly lesions
disease is it distributed Remember, the myositides all present
associated with? symmetrically over similarly, but have different underlying
[...] the wrists, elbows pathology. Definitive diagnosis requires Bx.
and knees. You - Heliotrope rash = purple rash around the
suspect myositis. eyes w/ periorbital edema
32. What component of What component of blood is
What is the best test - Gottron's papules are pathognomonic
blood is cryoprecipitate typically used to replace?
to achieve a definitive of myositis and are scaly areas around the
cryoprecipitate Fibrinogen
diagnosis? major joints
typically used to
- note that an EMG is done to rule out
replace?
nerve cause of pain or if there is a
[...] Cryoprecipitate has use in DIC, but is
[...] conduction issue
never the first choice blood product for
anything.
33. What is the treatment What is the treatment for urticaria?

for urticaria? Antihistamines or Leukotriene receptor
[...] antagonists
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37. A pt has elevated A pt has elevated TSH, but normal T3/T4. 40. A pt is in a state of A pt is in a state of unconsciousness. EEG
TSH, but normal What should you test for next? unconsciousness. reveals absent cerebral function.
T3/T4. What should Autoantibodies (antithyroglobulin and EEG reveals absent Physical exam reveals a positive caloric
you test for next? antithyroid peroxidase) cerebral function. test and response to painful stimuli.
[...] Physical exam What is the most likely Dx?
reveals a positive Persistent Vegetative State (PVS)
This is subclinical hypothyroidism. caloric test and
- if the pt is antibody positive, they will response to painful
likely progress to hypothyroidism stimuli. What is the
- if the pt is antibody negative, they may most likely Dx?
get better [...]
- regardless, follow these pts and start
treatment when symptoms manifest or
41. A pt is found to have A pt is found to have microcytic anaemia.
when TSH > 10
microcytic anaemia. An iron panel is then ordered and reveals
An iron panel is then decreased ferritin, increased TIBC and
38. An elderly pt An elderly pt presents c/o back pain that ordered and reveals decreased iron. What is the dx?
presents c/o back began after she slipped and fell on her butt. decreased ferritin, Iron Deficiency Anaemia
pain that began after Her PMHx is significant for hysterectomy increased TIBC and On the iron panel, ferritin is the most
she slipped and fell and osteoporosis. Physical exam reveals decreased iron. sensitive.
on her butt. Her point tenderness at the lumbar spine What is the dx? - if ferritin is low, it is IDA. Period.
PMHx is significant and vertebral step-off. What is the most [...]
for hysterectomy and likely Dx?
osteoporosis. Compression fracture
Physical exam
reveals point
42. Acute infectious Acute infectious diarrhea can be separated
tenderness at the
diarrhea can be into invasive and
lumbar spine and
separated into enterotoxic/non-invasive. What are the
vertebral step-off.
invasive and features of enterotoxic diarrhea?
What is the most
enterotoxic/non-invasive.
Watery stool without leukocytosis,
likely Dx?
What are the features fever, bloody stool, and fecal WBCs
[...]
of enterotoxic
diarrhea?
39. What is the treatment What is the treatment for bronchiectasis? [...] Remember, enterotoxic diarrhea is 2/2
for bronchiectasis? Mostly supportive toxins. They are typically self-limiting and
[...] require hydration. Loperamide can be
used.
Bronchiectasis key points:
- chest physiotherapy and postural
drainage are essential in dislodging
plugged-up bronchi
43. What are the most What are the most common risk factors for
- treat each infection as they come; use the
common risk factors pseudogout (Calcium-pyrophosphate
same coverage as in COPD exacerbations,
for pseudogout deposition disease)?
however rotate Abx (1 weekly each
(Calcium-pyrophosphate Hemochromatosis; hyperPTH
month)
deposition disease)?
- surgical resection of focal lesions may
[...]
be indicated
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44. A single episode of A single episode of thyroid storm is an 47. What is the first line What is the first line therapy for plantar
thyroid storm is an indication for definitive therapy. What therapy for plantar fasciitis?
indication for therapy is involved? fasciitis? Stretching + arch support + NSAIDs
definitive therapy. Thyroidectomy [...]
What therapy is
involved? Plantar Fasciitis key points:
[...] - involves very severe pain at the sole of
the foot near the calcaneus that is worse
in the morning and improves w/ use;
45. What is the first and What is the first and most important thing to
unclear etiology
most important thing assess when a pt complains of back pain?
- exam is typically benign but typically
to assess when a pt The presence of alarm s/s
involves point tenderness where the
complains of back
fascia inserts into the calcaneus at the
pain?
bottom of the foot
[...]
- Tx begins w/ stretching + arch support
+ NSAIDs; steroids are used if ineffective;
surgical releasae of the fascia is rarely
46. A pt presents c/o of a A pt presents c/o of a rash and nail necessary
rash and nail pitting. Physical exam reveals a
pitting. Physical symmetric, well-demarcated rash
48. A pt is thought to A pt is thought to have Cushing's
exam reveals a consisting of silvery-scales on an
have Cushing's disease/syndrome. A 24 hr urine cortisol
symmetric, erythematous base. The rash is found on
disease/syndrome. A test confirms hypercortisolism. Follow up
well-demarcated the extensor surface of the elbows and
24 hr urine cortisol ACTH testing is high. As a follow up to
rash consisting of knees. Nail beds are pitted and mild
test confirms that, high dose DST yields suppression.
silvery-scales on an onycholysis is seen at the upper
hypercortisolism. What is the diagnosis?
erythematous base. digits.The pt adds that the scales bleed
Follow up ACTH Cushing's Disease 2/2 pituitary tumour
The rash is found on easily when picked. You suspect psoriasis.
testing is high. As a (get MRI to confirm; if MRI is equivocal
the extensor What is the first line treatment?
follow up to that, consider inferior petrosal sinus
surface of the UV Light (either natural or artificial)
high dose DST sampling)
elbows and knees.
yields suppression. - Pituitary tumours still retain feedback
Nail beds are pitted
What is the mechanisms
and mild
diagnosis? - Suppression after high dose DST =
onycholysis is seen
[...] ACTH secreting pituitary tumour
at the upper
(Cushing's Dz) as the pituitary retains
digits.The pt adds
feedback mechanisms.
that the scales bleed
- No suppression after high dose DST =
easily when picked.
ACTH secretion via paraneoplastic
You suspect
syndrome from a tumour elsewhere.
psoriasis. What is the
first line treatment?
[...]
49. A 60 y/o, A 60 y/o, posmenopausal, female pt is

posmenopausal, diagnosed w/ iron deficiency anaemia.
female pt is What follow up imaging test should be
diagnosed w/ iron done?
deficiency anaemia. Colonoscopy (to look for GI source of
What follow up bleeding/cancer)
imaging test should
be done?
[...]
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54. What is the best What is the best overall diagnostic test for
50. What cause of What cause of invasive acute diarrhea is overall diagnostic test prolactinoma?
invasive acute associated w/ raw hamburgers? for prolactinoma? MRI
diarrhea is Enterhemorrhagic Escherichia coli [...]
associated w/ raw (O157:H7)
hamburgers? Remember, only get the MRI if prolactin
[...] levels are confirmed to be high and
secondary causes + pregnancy have all
been ruled out.
51. What is the most What is the most accurate and best overall
accurate and best test for hereditary spherocytosis?
overall test for Osmotic fragility test 55. What is the most What is the most accurate test for G6PD
hereditary Remember, a PBS is not enough for accurate test for deficiency?
spherocytosis? diagnosis and you must order osmotic G6PD deficiency? G6PD level but only 4-8 weeks after an
[...] fragility to confirm [...] acute hemolytic event
G6PD during an attack is NORMAL:
- this is because all of the cells that lacked
G6PD are already dead, bruh (i.e. the older
cells)
52. A pt is found to have A pt is found to have hyponatremia. What - newer cells will have G6PD (despite being
hyponatremia. What is the best first test to establish the deficient); however, during an attack,
is the best first test to diagnosis? because all of the bad cells are hemolyzed
establish the Serum osmolality and hence not part of the test, measured
diagnosis? g6pd levels will be artificially normal
[...]
56. What is the treatment What is the treatment for moderate

53. A 60 y/o female pt A 60 y/o female pt presents c/o of > 60 for moderate hypernatremia?
presents c/o of > 60 min of morning hand stiffness that hypernatremia? IV NS
min of morning improves with use as the day progresses. [...]
hand stiffness that Physical exam reveals subcutaneous
improves with use nodules. A Bx of the nodules reveals
as the day cholesterol deposits in all of them. What
progresses. Physical is the most likely diagnosis?
exam reveals Rheumatoid Arthritis 57. What is the "ABCDE" What is the "ABCDE" mnemonic for
subcutaneous mnemonic for assessing pigmented skin lesions for
nodules. A Bx of the assessing pigmented malignancy?
nodules reveals Cholesterol deposits in nodules is skin lesions for (see below)
cholesterol pathognomonic for RA. malignancy?
deposits in all of [...]
them. What is the
most likely
diagnosis?
[...]
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58. A pt presents c/o of a A pt presents c/o of a skin lesion on his 62. Which drugs are Which drugs are more commonly known to
skin lesion on his face. Physical exam reveals an more commonly cause drug reactions (such as erythema
face. Physical exam erythematous pigmented lesion with a known to cause drug multiforme, SJS, TEN)?
reveals an sandpaper-like yellow-brown scaly reactions (such as Sulfa drugs; anticonvulsants; NSAIDs;
erythematous appearance. The pt states that he spends erythema multiforme, PCNs
pigmented lesion a lot of time in the sun working in SJS, TEN)?
with a construction. What is the most likely dx? [...]
sandpaper-like Actinic Keratosis Note that sulfa drugs includes thiazides,
yellow-brown scaly furosemide and sulfonylureas
appearance. The pt
states that he spends
63. What type of What type of bleeding is seen in DIC?
a lot of time in the
bleeding is seen in Platelet and factor type bleeding
sun working in
DIC?
construction. What is
[...]
the most likely dx?
Remember, DIC involves widespread fibrin
[...]
clot formation that consume both
platelets and factors, setting the stage for
59. Which seronegative Which seronegative spondyloarthropathy is bleeding from everywhere.
spondyloarthropathy associated w/ keratoderma
is associated w/ blennorhagicum, a skin lesion that
keratoderma resembles pustular psoriasis?
blennorhagicum, a Reactive arthritis (Reiter syndrome)
skin lesion that
resembles pustular
psoriasis?
[...]
60. A pt is diagnosed w/ A pt is diagnosed w/ secondary adrenal

secondary adrenal insufficiency. What is the treatment?
insufficiency. What Prednisone only
is the treatment?
[...]
Secondary adrenal insufficiency is 2/2
pituitary failure (no ACTH). So replace only
what is needed (cortisol)
61. How do IgE levels How do IgE levels change in atopic

change in atopic dermatitis?
dermatitis? Increased
[...]
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64. A pt presents w/ GI A pt presents w/ GI bleed. What is the first 66. What type of GI What type of GI bleed is associated w/
bleed. What is the step in management every time? bleed is associated hematochezia?
first step in Stabilize the pt w/ hematochezia? Typically LGIB; possible UGIB if severe
management every [...] enough
time?
[...] Everytime, brah. Do not get that EGD until
stabilization measures have been done.
Stabilization in GI Bleed key points:
- always done first
- involves both supportive and prophylactic
measures:
--- obtain 2 peripheral, large bore IV
67. Hereditary Hereditary Spherocytosis involves
access points
Spherocytosis hemolysis due to a lack of RBC membrane
--- start IVF
involves hemolysis structural proteins. Which proteins are/can
--- start IV PPIs; PPIs in this setting helps
due to a lack of RBC be deficient?
the stomach/esophagus heal (by increasing
membrane structural Ankyrin, spectrin, band 3.1, pallidin
pH) if the bleeding source is
proteins. Which
gastric/esophageal; if it isn't, the PPIs do
proteins are/can be
not cause any harm, so it is better to give it
deficient?
empirically at the start
[...]
--- order a CBC to monitor changes
--- order a blood type and cross to
prepare for tranfusions; if severe enough, 68. What is the treatment What is the treatment for severe
go ahead and order blood for severe hyponatremia?
--- order coags (PT/PTT) hyponatremia? IV 3% NaCl solution
--- if mesenteric ischemia is suspected, get [...]
an EKG
--- if the pt is a known cirrhotic, start IV In severe hyponatremia, the pts need
octreotide (to target variceal bleeding) and hypertonic solution.
IV ceftriaxone/FQ (to ppx against SBP)
69. Paroxysmal nocturnal Paroxysmal nocturnal hemoglobinuria

hemoglobinuria involves complement fixation on RBCs that
involves complement then leads to hemolysis. Complement
65. What is the treatment What is the treatment for von Willebrand's fixation on RBCs that fixation occurs every time, so why is the
for von Willebrand's disease? then leads to disease linked to nighttime?
disease? Replacement clotting factor only while hemolysis. Transient hypoxemia at night
[...] the pt is actively bleeding; mild cases Complement fixation accelerates complement fixation
may improve with desmopressin occurs every time, so
why is the disease
linked to nighttime? The paroxysmal and nocturnal nature of
[...] PNH:
- the paroxysmal and nocturnal nature is
thought to be 2/2 transient hypoxemia 2/2
hypoventilation at night
- this is thought to accelerate complement
fixation, leading to the morning urine being
dark
- the dark urine is 2/2 bilirubin and Hgb, not
actual blood
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74. Which HAART drug Which HAART drug is routinely given

70. What is the treatment What is the treatment for hypovolemic is routinely given intrapartum to every pregnant HIV pt?
for hypovolemic hyponatremia? intrapartum to every Zidovudine (AZT)
hyponatremia? IVF pregnant HIV pt?
[...] Note that Vaptans are c/i in [...]
hyponatremic hyponatremia and are Baby is also given AZT intrapartum and for
never the right answer. 6 weeks after.
75. If a pt is suspected to If a pt is suspected to have meningitis, but

have meningitis, but has s/s of increased ICP (papilledema,
has s/s of increased seizures, FNDs, confusion), an LP is
71. What is the treatment What is the treatment for folate deficiency? ICP (papilledema, contraindicated and a CT should be
for folate deficiency? Folic acid, 1 mg, PO, qD seizures, FNDs, ordered. What should be done prior to the
[...] confusion), an LP is CT?
contraindicated and a Start empiric Abx
CT should be
72. What is the safest What is the safest antidiabetic drug to use ordered. What should
antidiabetic drug to in newly diagnosed diabetics? be done prior to the If there is a contraindication to immediate
use in newly Metformin CT? LP, give Abx asap to help keep the pt alive
diagnosed diabetics? [...]
[...]
It does not cause hypoglycemia. 76. What is the What is the diagnostic test for Molluscum
It does not cause weight gain. diagnostic test for Contagiosum?
It typically causes GI upset and/or Molluscum None, it's clinical
diarrhea. Contagiosum?
C/I in renal failure/impairment1 [...]
Look for the characteristic vesicles with
73. A pt is dx with A pt is dx with pyelonephritis and empiric IV central umbilication.
pyelonephritis and Abx are started. After 72 hrs, the pt shows While not an ulcerative disease, questions
empiric IV Abx are no improvement. What is the most often ask to differentiate vs. the usual
started. After 72 hrs, appropriate next step in management? suspects (HSV, Chancroid, Syphilis)
the pt shows no CT to look for abscess (U/S if preggo) Tx is to freeze them off.
improvement. What
is the most
appropriate next step Pyelonephritis Tx key points:
in management? - notice how initial Tx is IV? Pyelonephritis
[...] needs to be admitted for IV abx until the
pt is afebrile and shows improvement
- once afrebrile, d/c with PO FQ abx for 14d
- if there is no improvement, order a CT to
r/o abscess
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77. A pt is given a A pt is given a penicillin and develops a 80. A pt presents with A pt presents with dysuria, urinary
penicillin and widespread rash. Physical exam reveals a dysuria, urinary frequency and urgency. He denies any
develops a rash with widespread loss of sheets of frequency and fever, n/v, or chills. Physical exam reveals
widespread rash. skin with a positive nikolsky sign urgency. He denies mild suprapubic tenderness. You suspect a
Physical exam affecting > 30% of body surface area. any fever, n/v, or UTI. What is the most likely Dx?
reveals a rash with Biopsy reveals total epidermal thickness chills. Physical exam Cystitis
widespread loss of necrosis. What is the most likely reveals mild
sheets of skin with a diagnosis? suprapubic
positive nikolsky Toxic Epidermal Necrolysis tenderness. You
sign affecting > 30% suspect a UTI. What
of body surface area. is the most likely Dx?
Biopsy reveals total [...]
epidermal thickness
necrosis. What is
81. What type of rash is What type of rash is seen in Lyme
the most likely
seen in Lyme disease?
diagnosis?
disease? Erythema migrans, a target-shaped
[...]
[...] (bull's eye) rash
78. A pt presents with A pt presents with fever, cough, night

fever, cough, night sweats, weight loss and hemoptysis. He
sweats, weight loss has risk factors for TB. You suspect TB. A
82. What type of chest What type of chest pain is often associated
and hemoptysis. He CXR is positive. What is the most
pain is often with pneumonia?
has risk factors for appropriate next step in management?
associated with Pleuritic chest pain
TB. You suspect TB. Isolate the pt and AFB smear and
pneumonia?
A CXR is positive. culture
[...]
What is the most Collect early morning sputum and get
appropriate next step atleast 3 cultures 8 hrs apart.
in management? To help ensure a true result, get 3 early 83. A pt presents with A pt presents with fever and cough
[...] morning sputums 24 hrs apart. fever and cough productive of sputum. Physical exam
Your last ditch effort if you have a very high productive of sputum. reveals crackles in the left lung. CXR
suspicion of TB is nucleic acid assay. Physical exam reveals unilateral lobar consolidation.
reveals crackles in The pt states that he has not been
the left lung. CXR hospitalized in the past 90 days. You
reveals unilateral suspect community-acquired pneumonia.
lobar consolidation. What is the most appropriate treatment if
The pt states that he this pt is sent home?
79. What is the most What is the most accurate diagnostic test
has not been Macrolide only
accurate diagnostic for infective endocarditis?
hospitalized in the
test for infective TEE
past 90 days. You
endocarditis?
suspect
[...]
community-acquired
Looking directly at the valves for vegetation
pneumonia. What is
(often a TTE is done first due to ease and
the most appropriate
to quickly identify any valvular defects if
treatment if this pt is
present)
sent home?
[...]
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84. Which antibiotic is Which antibiotic is added to ceftriaxone 89. A pt w/ SLE suffers A pt w/ SLE suffers from severe joint pain
added to ceftriaxone (+vancomycin) in the empiric treatment of from severe joint pain and asks to get an x-ray. What joint XR
(+vancomycin) in the meningitis in an immunocompromised and asks to get an findings are seen in SLE?
empiric treatment of pt? x-ray. What joint XR Normal (there is no deformation or joint
meningitis in an Ampicillin findings are seen in erosion in SLE arthritis)
immunocompromised SLE?
pt? [...]
[...] Listeria is resistant to all
cephalosporins but is sensitive to
90. A pt is diagnosed w/ A pt is diagnosed w/ an acute leukostasis
penicillins.
an acute reaction. What is the most appropriate
- if a risk factor for Listeria is present, add
leukostasis initial therapy?
ampicillin
reaction. What is the Leukapheresis
- risk factors include:
most appropriate
initial therapy?
85. Which cause of Which cause of community acquired [...] It is more important to remove the excess
community acquired pneumonia is associated with leukocytes than to establish a specific
pneumonia is contaminated water sources, air diagnosis/etiology. Diagnosis is not as
associated with conditioning units or ventilation systems? important as treatment.
contaminated water Legionella sp.
sources, air
91. Reducing future Reducing future flares and inducing
conditioning units or
flares and inducing remission are important parts of treating
ventilation systems?
remission are SLE. Which DMARD is preferred to
[...]
important parts of achieve this in SLE?
treating SLE. Which Hydroxychloroquine
86. Albinism and Albinism and piebaldism are both DMARD is preferred Notice the difference here vs. Rheumatoid
piebaldism are both hypopigmenting disorders. What is the to achieve this in Arthritis:
hypopigmenting difference? SLE? - in SLE, this is achieved via
disorders. What is (see below) [...] hydroxychloroquine (methotrexate is 2nd
the difference? line)
[...] - in RA, this is achieved via methotrexate
Albinism = normal melanocytes, deficient
tyrosinase = depigmentation everywhere
Piebaldism = abnormal melanocyte
92. What PBS findings What PBS findings are associated w/
migration = white forelock on the scalp
are associated w/ myelofibrosis?
myelofibrosis? Teardrop-shaped cells; nucleated RBCs
87. A pt has HIV/AIDS. A pt has HIV/AIDS. At what CD4 count [...]
At what CD4 count does miliary TB become a worry?
does miliary TB < 200
become a worry?
[...]
88. Which area of the Which area of the skin is affected in

skin is affected in cellulitis?
cellulitis? Dermis
[...]
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93. A pt is given a A pt is given a penicillin and develops a 97. A pt presents w/ A pt presents w/ hypercalcemia. She is
penicillin and rash. Physical exam reveals multiple, hypercalcemia. She currently receiving treatment for breast
develops a rash. widespread, small, target-shaped is currently receiving cancer. Labs reveal elevated Ca, elevated
Physical exam lesions over the back, trunk, palms, and treatment for breast PO4 and decreased PTH. What is the
reveals multiple, soles. The oral mucosa is spared. You cancer. Labs reveal most likely dx?
widespread, small, suspect erythema multiforme. What is the elevated Ca, Hypercalcemia of malignancy (in this
target-shaped treatment? elevated PO4 and cause likely 2/2 metastasis)
lesions over the Remove the causal drug decreased PTH. Hypercalcemia of malignancy involves
back, trunk, palms, What is the most elevated Ca and PO4 (from metastasis to
and soles. The oral likely dx? bone) or elevated Ca and decreased
mucosa is spared. However, it is prudent to consider chronic [...] PO4 (from paraneoplastic PTH-rp
You suspect HSV, and if a possibility, pursue testing and release; typically in SCC of the lung).
erythema multiforme. tx w/ acyclovir. Because PTH is low in meta, the kidney
What is the cannot win and hence PO4 levels are
treatment? high.
[...] Because PTH is low but PTH-rp is high in
paraneoplastic syndrome, the kidney wins
and PO4 levels are low.
94. What is the best What is the best diagnostic test for plantar
diagnostic test for fasciitis?
plantar fasciitis? None
[...]
XRay is not useful as there is no correlation

w/ heel spurs. 98. Which component of Which component of blood is fresh frozen
blood is fresh frozen plasma typically used to replace?
plasma typically Clotting factors
used to replace? However, FFP is not a choice in
[...] Hemophilia A or B.
disease/syndrome. A test confirms hypercortisolism. Follow up
24 hr urine cortisol ACTH testing is low. What is the
test confirms diagnosis? 99. What is the long What is the long term therapy for
hypercortisolism. Cushing's Syndrome 2/2 adrenal tumour term therapy for angioedema?
Follow up ACTH (get CT/MRI to confirm) angioedema? Androgens (danazole or stanazole)
testing is low. What [...]
is the diagnosis?
[...] Dan and Stan.
96. What is the genetic What is the genetic inheritance of sickle

inheritance of sickle cell anaemia?
cell anaemia? AR
[...]
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100. A pt presents c/o of A pt presents c/o of an evolving rash. He

103. A pt present c/o hair A pt present c/o hair loss. Physical exam
an evolving rash. He states that a few weeks ago he noticed a
states that a few single, flat, elliptical, salmon-coloured loss. Physical exam reveals patchy alopecia on the scalp w/
weeks ago he macule that has now spread. Physical reveals patchy scales and erythema. You suspect tinea
noticed a single, exam reveals multiple salmon-coloured alopecia on the capitis. What is the best diagnostic test?
flat, elliptical, scaly lesions with trailing scales. The scalp w/ scales and KOH prep (to visualize the fungus)
salmon-coloured palms and soles are spared. What is the erythema. You
macule that has now most likely dx? suspect tinea capitis.
spread. Physical Pityriasis rosea What is the best Tinea Capitis (vs. other alopecia) key
exam reveals Note that in darked skin pts, the lesions diagnostic test? points:
multiple may be hyperpigmented. [...] - tinea capitis involves well-defined
salmon-coloured Note that a trailing scale is a scaly lesion circular patch of alopecia with
scaly lesions with whose scales do not reach the edge of scales/erythema and hairs at equal
trailing scales. The the lesions. length
palms and soles are Pityriasis Rosea typically begins with a - alopecia areata involves patchy alopecia
spared. What is the herald patch (single, flat, elliptical, without scales or erythema
most likely dx? salmon-coloured macule) that then evolves - trichotillomania involves patchy alopecia
[...] into multiple macules. without equal hair length at the lesion
104. Septic arthritis is Septic arthritis is typically split into

typically split into non-gonococcal and gonoccocal
101. What is the best What is the best initial therapy for non-gonococcal arthritis. Which type is typically 2/2 direct
initial therapy for osteoporosis? and gonoccocal inoculation and/or hematogenous
osteoporosis? Vitamin D + Ca + bisphosphonates arthritis. Which type spread?
[...] is typically 2/2 direct Non-gonococcal (i.e. Staphylococcus)
inoculation and/or Staph can get into the joint via:
Osteoporosis treatment key points: hematogenous - direct inoculation (i.e. the arrow sticking
- vit D and Ca are 1st line spread? out of the pt's knee)
- bisphosphonates come into play when [...] - hematogenous spread typically from
DEXA scan is < -2.5 (i.e. osteoporosis, but IVDA or endocarditis
not osteopenia); remember the association
with osteonecrosis of the jaw and 105. Mammography is the Mammography is the most commonly used
pill-induced esophagitis most commonly used imaging technique when screening for or
- consider estrogen replacement in imaging technique working up breast cancer. In which
postmenopausal women when screening for situations is ultrasound appropriate?
- consider raloxifene as an alternative to or working up breast If the lesion is painful or varies in
estrogen as it reduces breast cancer risk cancer. In which size/pain w/ menstruation
and decreases LDL situations is
- consider teriparatide, a PTH analogue ultrasound
that stimulates new bone matrix formation; appropriate? U/S is the best for seeing if a breast lesion
may cause osteosarcoma and [...] is cystic or solid.
hypercalcemia
- consider nasal calcitonin to decrease
106. A pt is dx w/ A pt is dx w/ Stevens-Johnson Syndrome.
the risk of vertebral fractures
Stevens-Johnson Why is respiratory failure a risk in this pt?
Syndrome. Why is SJS involves sloughing of respiratory
102. What is the most What is the most common cause of respiratory failure a epithelium as well
common cause of hypercortisolism? risk in this pt?
hypercortisolism? Cushing's disease (pituitary tumour) [...]
[...]
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107. Dermatitis Dermatitis herpetiformis is an 110. Rituximab can be Rituximab can be used to control
herpetiformis is an autoimmune cutaneous disorder that used to control rheumatoid arthritis that does not response
autoimmune resembles bullous disease, but truly isn't. rheumatoid arthritis to DMARDs + anti-TNF agents. What is
cutaneous disorder What protein/enzyme in the dermis is that does not the notable side effect of rituximab?
that resembles targeted? response to Infection
bullous disease, but Transglutaminase (via IgA) DMARDs + anti-TNF
truly isn't. What Dermatitis herpetiformis is really a agents. What is the
protein/enzyme in deposition disease at the dermal notable side effect of
the dermis is papillae and is the cutaneous rituximab?
targeted? manifestation of Celiac disease (and has [...]
[...] the same pathology of targeting
transglutaminase). This causes extension
111. A pt w/ HTN and A pt w/ HTN and hypokalemia is
of the epidermis and manifests as
hypokalemia is suspected to have hyperaldosteronism.
multiple, small, pruritic eruptions on the
suspected to have Aldosterone:renin ratio is high (> 20),
extensor surfaces or legs/buttocks.
hyperaldosteronism. with decreased renin. What is the most
Aldosterone:renin appropriate next step in management?
ratio is high (> 20), Salt Suppression Test (200g Na load
with decreased should normally decrease aldosterone)
renin. What is the
108. A pt presents c/o of A pt presents c/o of multiple, small, scaly most appropriate
multiple, small, patches with varying pigmentation. You next step in Workup of Hyperaldosteronism key
scaly patches with suspect tinea versicolour. KOH prep management? points:
varying confirms. What is the treatment? [...] - it's similar to the workup for Cushing's:
pigmentation. You Selenium sulfide (topical) first determine whether or not there really
suspect tinea is an excess of aldosterone
versicolour. KOH (aldosterone:renin ratio); then determine
prep confirms. What the cause (i.e. is it renin dependent?)
is the treatment? - First determine the presence of
[...] hyperaldosteronism:
--- aldosterone:renin ratio is the best
initial test; be sure to d/c
109. Which blistering skin Which blistering skin disease is associated
antihypertensives as ACE-I, CCBs, and
disease is associated with hemochromatosis?
diuretics can confound the test
with Porphyria cutanea tarda
--- elevated renin rules out Conn'
hemochromatosis?
Syndrome, and points towards a
[...]
secondary cause
PCT is often seen with a history of (or
- if Conn syndrome (primary) is
brought upon by) these disorders:
suspected, order salt suppression test
- Hepatitis C
(200 g Na load should normally decrease
- EtOH use
aldosterone levels); follow up with CT/MRI
- OCPs (or just estrogen use in general)
to localize the lesion if positive
- Hemochromatosis (or other iron
- remember to do adrenal vein sampling
overload)
to localize the lesion to a side and look for
an "incidentaloma"
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112. What is the best What is the best initial empiric therapy for 116. A pt presents c/o of A pt presents c/o of asymmetrical,
initial empiric therapy septic arthritis? asymmetrical, bilateral artheritis at the lower back and
for septic arthritis? Vanco + ceftriaxone bilateral artheritis at hands. He also complains of itchy eyes.
[...] the lower back and His PMHx is negative except for a recent
hands. He also history of Chlamydia urethritis. Physical
complains of itchy exam reveals mildly red, injected
113. What is the What is the diagnostic criteria for diabetes
eyes. His PMHx is conjuncitvae indicative of conjunctivitis.
diagnostic criteria for mellitus using random blood glucose?
negative except for a You suspect reactive arthritis. What is the
diabetes mellitus 1 measurement > 200
recent history of best initial diagnostic test?
using random blood
Chlamydia Swab + PCR/culture for the STD
glucose?
urethritis. Physical Note that it's typically with nongonococcal
[...]
exam reveals mildly urethritis.
red, injected Here, we are essentially looking for the
114. A pt is given A pt is given procainamide and soon after conjuncitvae STD. So if it presents this way, you can
procainamide and develops a malar rash and indicative of avoid arthrocentesis and look for the STD.
soon after develops polyarthralgia. You suspect drug-induced conjunctivitis. You If urethral discharge is not present,
a malar rash and SLE. Anti-histone antibody testing is suspect reactive consider swabbing elsewhere for the STD
polyarthralgia. You positive. What is the tx? arthritis. What is the (i.e. anywhere semen can go, including the
suspect Stop the drug best initial diagnostic anus and oropharynx)
drug-induced SLE. test?
Anti-histone antibody [...]
testing is positive.
What is the tx?
[...]
115. What is the curative What is the curative treatment for CML? 117. What is the treatment What is the treatment for SIADH?
treatment for CML? Bone marrow transplant for SIADH? Water restriction; reverse underlying
[...] [...] cause; demeclocycline if needed
Water restriction allows the body to get
Imatinib is the best initial therapy. rid of the excess water by any means
necessary.
Demeclocyline can induce nephrogenic
DI if needed
118. What is the first line What is the first line therapy for
therapy for fibromyalgia?
fibromyalgia? Amitriptyline
[...]
Other options include milnacipran (SNRI)

or pregabalin
119. Which thyroid cancer Which thyroid cancer has the worst
has the worst prognosis?
prognosis? Anaplastic
[...]
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120. Which demographic Which demographic is most commonly 124. Which major cerebral Which major cerebral vessel is the most
is most commonly affected by sickle cell anaemia? vessel is the most common site of stroke?
affected by sickle cell AA common site of MCA
anaemia? stroke?
[...] [...]
90% of cases
121. A pt presents w/ A pt presents w/ hypercalcemia. She is

hypercalcemia. She currently receiving treatment for squamous 125. Which visual deficit is Which visual deficit is seen following an
is currently receiving cell carcinoma of the lung. Labs reveal seen following an MCA stroke?
treatment for elevated Ca, decreased PO4 and MCA stroke? Contralateral homonymous hemianopia
squamous cell decreased PTH. What is the most likely [...]
carcinoma of the dx?
lung. Labs reveal Hypercalcemia of malignancy (in this i.e. loss of visual field on the opposite side
elevated Ca, cause likely 2/2 paraneoplastic PTH-rp of the stroke, thereby causing eye
decreased PO4 and release; confirm with specific PTH-rp deviation to the ipsilateral side
decreased PTH. testing) "Eyes look towards the lesion"
What is the most
likely dx?
126. What speech deficits What speech deficits are seen following an
[...] Hypercalcemia of malignancy involves
are seen following an MCA stroke?
elevated Ca and PO4 (from metastasis
MCA stroke? Aphasia
to bone) or elevated Ca and decreased
[...]
PO4 (from paraneoplastic PTH-rp
release; typically in SCC of the lung).
Obvious, but remember that 10% of pts
Because PTH is low in meta, the kidney
are left handed (i.e. right brain dominant)
cannot win and hence PO4 levels are
The speech center is always located in the
high.
dominant hemisphere (90% of the time it's
Because PTH is low but PTH-rp is high in
on the left).
paraneoplastic syndrome, the kidney wins
and PO4 levels are low.
127. What is the classic What is the classic triad of symptoms
triad of symptoms following an ACA stroke?
following an ACA Personality/cognitive changes (i.e.
stroke? confusion); urinary incontinence; lower
[...] extremity weakness
122. What is the 3rd most What is the 3rd most common cause of
common cause of death in the USA?
Or more lower extremity weakness vs.
death in the USA? Stroke
upper.
[...]
128. What is the best What is the best initial test for stroke?
123. What is the most What is the most common type of stroke?
initial test for stroke? CT w/o contrast
common type of Ischemic
[...]
stroke?
[...]
MRI is the most accurate, but a CT is
85% ischemic (thrombotic; embolic: AFib,
needed initially to rule out hemorrhage
valvular disease, DVT via PFO)
prior to treatment
15% hemorrhagic
CT needs 4-5 d to have > 95% sensitivity;
MRI needs 1-2
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129. What is the best What is the best initial therapy for an 133. Which drug(s) are Which drug(s) are most effective at
initial therapy for an ischemic stroke? most effective at preventing stroke?
ischemic stroke? tPA (if < 3 hrs); aspirin (if > 3 hrs) preventing stroke? Aspirin (± dipyradimole) OR clopidogrel
[...] [...]
Do not give both together (hemorrhage

risk; however the CHANCE study in 2013
showed benefit in TIA and mild ischemic
stroke).
130. What is the threshold What is the threshold duration from the
ASA is the mainstay treatment unless:
duration from the onset of stroke for the use of tPA?
- ASA allergy
onset of stroke for < 3 hrs
- active GI bleed
the use of tPA?
- past stroke while on ASA
[...]
In such cases, switch to Plavix.
Some places use < 4.5 hrs.
Thrombolytics are the standard of care
< 3 hours. 134. Which class of Which class of antihyperlipidemics should
antihyperlipidemics be added to a stroke pt's regimen
should be added to a regardless of LDL?
131. What is the best What is the best initial therapy for
stroke pt's regimen Statins
initial therapy for hemorrhagic stroke?
regardless of LDL?
hemorrhagic stroke? Nothing
[...]
[...]
LDL target is currently unclear, but we
should aim for < 70 or atleast < 100.
There's really no treatment to reverse the
stroke.
Surgical drainage will not help outside of 135. What is the target What is the target INR in a patient with atril
the posterior fossa. INR in a patient with fibrillation/flutter?
atril fibrillation/flutter? 2-3
[...]
132. Which drug should Which drug should be added to the
be added to the management of stroke in a pt that was
management of already on aspirin? 136. Which diagnostic Which diagnostic tests should be
stroke in a pt that Dipyridamole tests should be considered when evaluating the cause of a
was already on considered when stroke?
aspirin? evaluating the cause Echocardiogram; EKG; carotid duplex
[...] Or you switch to clopidogrel. of a stroke? U/S
Dipyridamole inhibits platelet aggregation [...]
by increasing intraplatelet [cAMP], an
inhibitor of platelet function. In high doses, Echo: looks for valvular disease,
its PDE5 inhibitory function can cause intraventricular thrombus, PFO
vasodilation. Chronic use offers antiplatelet EKG: looks for AFib/flutter; consider a
activity. Holter monitor if EKG and telemetry is
normal
Carotid duplex: looks for carotid stenosis
(a very common cause of embolic stroke)
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137. What percentage of What percentage of carotid stenosis is an 142. What is the rationale What is the rationale for the use of tPA in
carotid stenosis is an indication for surgical intervention? for the use of tPA in stroke?
indication for surgical > 70% stenosis with symptomatic stroke? Clot buster; rescues ischemic tissue
intervention? cerebrovascular disease [...] and can save the penumbra
[...] Contraindicated if: surgery in 21 days or
s/p head trauma
Endarterectomy is the intervention of Only indicated within 3 hrs of onset of
choice and is superior to carotid symptoms
angioplasty. Never, ever used in hemorrhagic stroke
Endarterectomy has no value for (and there is a risk of ischemic stroke
stenosis < 50%. transforming into hemorrhagic)
If there is 100% stenosis, then no Permissive hypertension s/p tPA use may
intervention is needed. aid the penumbra to recover (as well as
O2 > 95% and tight glycemic control
(60-100)
138. What is the What is the procedure of choice in the
procedure of choice intervention of > 70% carotid stenosis in a
in the intervention of stroke pt?
> 70% carotid Carotid endarterectomy 143. What is the most What is the most common type of primary
stenosis in a stroke common type of headache?
pt? primary headache? Tension
[...] Carotid angioplasty w/ stenting has no [...]
proven value for stroke pts.
However, we rarely see these. Pts simply
take OTCs and are fine.
139. What is the LDL goal What is the LDL goal in a pt with carotid
in a pt with carotid stenosis?
stenosis? < 100 144. Which sex is more Which sex is more commonly affected by
[...] commonly affected cluster headaches?
by cluster Men (10x more)
Carotid stenosis is considered CAD, so the headaches?
goal is < 100 mg/dL. [...]
140. What is the target What is the target HbA1C level in stroke 145. Which type of Which type of primary headache is known
HbA1C level in prevention in a diabetic pt? primary headache is to occur multiple times a day for many
stroke prevention < 7% known to occur weeks but is absent for months to years
in a diabetic pt? multiple times a without symptoms?
[...] day for many weeks Cluster headaches
but is absent for
months to years
141. What should be What should be suspected/considered in a
without symptoms? In fact, this is where the name comes from:
suspected/considered pt that develops painful neck pulsations
[...] its sporadic and grouped presentation
in a pt that develops and grabs their neck in pain?
painful neck Embolic stroke 2/2 carotid dissection
pulsations and
grabs their neck in
pain?
[...]
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146. Which type of Which type of primary headache may 151. Which type of Which type of primary headache is known
primary headache occasionally present with Horner primary headache is to cause a lingering malaise/"hangover"
may occasionally syndrome? known to cause a after it has been aborted?
present with Horner Cluster headache lingering Migraine
syndrome? malaise/"hangover"
[...] after it has been
Classic pentad involves: aborted? Sleep is the most common method of
- eye redness [...] aborting migraines. The hangover can
- rhinorrhea extend into the next morning.
- lacrimation
- injected conjunctiva
152. What is the treatment What is the treatment for mild active
- severe, unilateral, periorbital pain
for mild active migraines?
migraines? NSAIDs
147. Which ophthalmic Which ophthalmic condition should be [...]
condition should be considered with headache + a red eye?
considered with Glaucoma
153. What is the treatment What is the treatment for severe
headache + a red
for severe migraines?
eye?
migraines? Triptan; ergotamine
[...]
[...]
148. In which 2 primary In which 2 primary headaches is brain Start therapy early to reduce the need for a
headaches is brain imaging suggested? back up or add-on drug (e.g. NSAID).
imaging suggested? Migraine; Cluster Avoid ergotamines in CAD as they can
[...] cause vasospasm.
Some studies have shown an association

154. Which drug classes Which drug classes can be used as
with tumours and cluster HA, despite its
can be used as prophylactic therapy for migraines?
vascular nature.
prophylactic therapy BBs; CCBs; TCAs; SSRIs;
for migraines? antiepileptics; botox injections
149. What is the treatment What is the treatment to abort a cluster [...]
to abort a cluster headache?
headache? High flow, 100% O2 Avoidance of triggers is also advised.
[...] Propanolol is considered the best
choice.
If this fails, give triptans, ergotamine, Verapamil is the CCB most used.
prednisone or lithium. Amitriptyline is the TCA most used.
Topiramate is the antiepileptic most used.
150. Which class of drugs Which class of drugs can be used as

can be used as prophylactic therapy for cluster headache? 155. What type of primary What type of primary headache is
prophylactic therapy CCBs headache is associated with chronic analgesic use?
for cluster associated with Analgesic Rebound HA
headache? chronic analgesic
[...] Typically verapamil. use?
However, since cluster headaches come in [...] Any type of analgesics, including triptans
clusters and then disappear for and ergots.
months/year, prophylaxis is still iffy as
many forms take several weeks to have
effect, and the cluster often passes before
then.
22 of 340
156. What is the treatment What is the treatment for analgesic 160. Which cause of Which cause of secondary headache
for analgesic rebound headache? secondary headache involves progressively worsening
rebound headache? Removal of the causative drug involves headaches that may be worse in the
[...] progressively mornings?
worsening Intracranial tumour
This one is tricky. Pt's need to be headaches that may
counseled on what's going on and advised be worse in the
to tough out the headache and avoid mornings? Order the CT, biopsy, then consider
analgesics. [...] radiation/chemo/Sx
This is essentially a withdrawal syndrome
from analgesics, so symptoms pass if
161. Which cause of Which cause of secondary headache
drugs are withheld.
secondary headache involves a sudden onset, severe headache
involves a sudden often described as "the worst headache
157. What are the What are the common red flag onset, severe in my life?"
common red flag signs/symptoms of a headache that headache often Subarachnoid hemorrhage (SAH)
signs/symptoms of a suggest high danger? described as "the
headache that (see below) worst headache in
suggest high my life?" Order the CT, consult neurosurgery stat,
danger? [...] control blood pressure
[...] - fever + headache (± nuchal tenderness)
- focal neurological deficits
162. What is another What is another name for Pseudotumour
- "worst headache of my life"
name for Cerebri?
- progressively worsening headache over
Pseudotumour Benign/Idiopathic Intracranial HTN
time (± worse in the AM)
Cerebri?
- nocturnal awakening 2/2 headache
[...]
- temporal tenderness (± diffuse muscle
pain, jaw claudication)
secondary headache presents with nausea/vomiting, s/s of
presents with increased ICP, worse with coughing and
secondary headache involves fever, headache and no focal
nausea/vomiting, a negative CT scan?
involves fever, neurological deficits?
s/s of increased Pseudotumour Cerebri
headache and no Meningitis
ICP, worse with (Benign/Idiopathic Intracranial HTN)
focal neurological
coughing and a
deficits?
negative CT scan?
[...] Do an LP, culture the CSF.
[...] i.e. presents like a mass effect headache
Start empiric ceftriaxone.
but without a mass
A negative CT/MRI is required for
159. What cause of What cause of secondary headache diagnosis (intracranial mass must be ruled
secondary headache involves fever, headache and focal out).
involves fever, neurological deficits? Common s/s of increased ICP include:
headache and focal Intracranial abscess - papilledema
neurological - diplopia 2/2 CN VI, abducens palsy
deficits?
[...] Order the CT, drain the abscess (and then
Cx), start Abx
23 of 340
164. What is the What is the diagnostic test for 167. Which vitamin Which vitamin toxicity can be a cause of
diagnostic test for Pseudotumour Cerebri (Benign/Idiopathic toxicity can be a Pseudotumour Cerebri (Benign/Idiopathic
Pseudotumour Intracranial HTN)? cause of Intracranial HTN)?
Cerebri LP with normal CSF but increased Pseudotumour Vitamin A
(Benign/Idiopathic opening pressure Cerebri
Intracranial HTN)? (Benign/Idiopathic
[...] Intracranial HTN)? Withdraw vitamin supplementation if this is
Remember, a negative CT/MRI is also [...] suspected.
required.
168. What is the preferred What is the preferred diagnostic test for
165. What is the first step What is the first step in management of diagnostic test for primary headaches?
in management of Pseudotumour Cerebri (Benign/Idiopathic primary headaches? None
Pseudotumour Intracranial HTN) in a pt taking OCPs? [...]
Cerebri Withdrawal of the OCPs
(Benign/Idiopathic Tension/migraine/cluster/analgesic
Intracranial HTN) in a rebound headaches are all diagnosed
pt taking OCPs? Do this before considering other clinically.
[...] treatments However, if the syndrome has recently
started or there is suspicion, CT/MRI to
rule out intracranial mass is a good idea.
166. What is the first-line What is the first-line treatment for
treatment for Pseudotumour Cerebri (Benign/Idiopathic
Pseudotumour Intracranial HTN)? 169. What diagnostic tests What diagnostic tests are indicated for
Cerebri Acetazolamide (± furosemide); serial are indicated for giant cell temporal arteritis?
(Benign/Idiopathic LPs/VP shunting if refractory to medical giant cell temporal Biopsy; elevated ESR
Intracranial HTN)? therapy arteritis?
[...] [...]
ESR is typically markedly elevated.
This one is a bit controversial. UWorld and Remember, if giant cell arteritis is
other sources point towards acetazolamide suspected, always administer high
first, others say serial LPs or shunting. It dose roids prior to any diagnostic
seems like the recent trend is towards the testing.
drugs though.
Acetazolamide acts via
170. What is the best What is the best initial step in suspected
carbonic-anhydrase inhibition at the CNS,
initial step in giant cell temporal arteritis?
thereby decreasing CSF production
suspected giant cell Administration of high dose
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908600/).
temporal arteritis? corticosteroids
Lasix is sometimes added to alleviate the
[...]
increased ICP
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908600/).
Typically prednisone
Steroids can help.
Serial LPs function to rapidly decrease
ICP. 171. How many migraines How many migraines per month is the
VP shunt or fenestrating the optic nerve per month is the threshold for considering prophylactic
are options if all else fails. threshold for therapy?
considering ≥3
prophylactic therapy?
[...]
Best choice is propanol
24 of 340
172. [...] is an idiopathic Trigeminal neuralgia is an idiopathic 176. What is the What is the treatment for postherpetic
neurological disorder neurological disorder characterized by treatment for neuralgia?
characterized by attacks of pain 2/2 chewing, touching the postherpetic (see below)
attacks of pain 2/2 face, or pronouncing certain words. neuralgia?
chewing, touching [...]
the face, or Any of the agents that target neuropathic
pronouncing certain Certain words that involve the tongue pain are strong options: TCAs, gabapentin,
words. hitting the back of the front teeth. pregabalin, carbamazepine, phenytoin.
Dx is clinical. Topical capsaicin can be helpful as well.
Tx w/ oxcarbazepine or carbamazepine Most antiepileptics are beneficial, but only
up to 50-70% of pts.
Typically, each of these are tried until a
173. What is the first line What is the first line treatment for
reliable choice is found. There is no
treatment for trigeminal neuralgia?
reliable first-line treatment for neuropathy.
trigeminal neuralgia? Oxcarbazepine or carbamazepine
[...]
177. At what age is the At what age is the herpes zoster vaccine
Lamotrigine and baclofen have been herpes zoster recommended in all adults?
effective. vaccine > 60 y/o
Gamma knife surgery or surgical recommended in all
decompression is curative if the pain is adults?
refractory to meds. [...] To prevent shingles and mitigate
symptoms if shingles does occur.
174. [...] is a neurological Postherpetic neuralgia is a neurological

pain syndrome that pain syndrome that manifests during 178. What is the What is the VITAMINS mnemonic for the
manifests during herpes zoster reactivation after the VITAMINS etiology of first-time seizure?
herpes zoster resolution of the vesicular lesions. mnemonic for the (see below)
reactivation after the etiology of first-time VITAMINS
resolution of the seizure? - note that I also stands for Ingestion and
vesicular lesions. Seen in ~15% of cases. [...] withdrawal (Benzos, EtOH, other drugs)
- all of these can cause CNS symptoms
prior to seizure (i.e. once they get worse,
175. Which drugs are Which drugs are used to reduce the
seizure occurs) such as, delirium, stupor,
used to reduce the incidence of postherpetic neuralgia?
obtundation, confusion, coma
incidence of Acyclovir; famciclovir; valgancilovir
postherpetic
neuralgia?
[...] i.e. antiherpetics
Steroids do not reduce the incidence.
179. Which sign/symptom Which sign/symptom associated with
associated with seizures is the most specific for seizures?
seizures is the most Post-ictal confustion
specific for seizures?
[...]
The convulsions, bowel/bladder
incontinence, tongue biting and LOC are
all unspecific. Patients may just have
syncope, for example.
25 of 340
180. What is the most What is the most appropriate next step in 184. Which commonly Which commonly used antiepileptic is
appropriate next step the management of a pt with a first-time used antiepileptic is teratogenic?
in the management seizure that is not actively seizing? teratogenic? Depakote (valproic acid)
of a pt with a Observation; CT; VITAMINS workup; [...]
first-time seizure EEG
that is not actively
185. What is the most What is the most appropriate next step in
seizing?
appropriate next step the management of an active seizure in a
[...]
in the management pt with epilepsy?
of an active seizure Manage ABCs; then abort the seizure;
181. What is the first step What is the first step in management of a in a pt with then assess therapeutic drug levels;
in management of a pt with a first-time seizure that is actively epilepsy? then assess VITAMINS and get EEG
pt with a first-time seizing? [...]
seizure that is Manage ABCs; then abort the seizure;
actively seizing? then assess VITAMINS Remember, epileptics are more prone to
[...] Seizure abortion is achieved medically. VITAMINS to trigger a seizure. Don't
Start at the top of the list until something discount them just because the pt is
works: epileptic.
#1. IV/IM Benzos (typically, lorazepam or Seizure abortion is achieved medically.
diazepam) Start at the top of the list until something
#2. Phenytoin/Fosphenytoin works:
#3. Midazolam + propofol (pts typically #1. IV/IM Benzos (typically, lorazepam or
need to be intubated by this point) diazepam)
#4. Phenobarbital #2. Phenytoin/fosphenytoin
#3. Midazolam + propofol (pts typically
need to be intubated by this point)
#4. Phenobarbital
182. What is the first-line What is the first-line therapy for aborting
therapy for aborting seizures/status epilepticus?
seizures/status IV/IM benzodiazepines
epilepticus? 186. What is the most What is the most appropriate next step in
[...] appropriate next step the management of a pt with epilepsy that
Seizure abortion is achieved medically. in the management is not actively seizing?
Start at the top of the list until something of a pt with epilepsy Assess therapeutic drug levels; then
works: that is not actively assess VITAMINS and get EEG; then
#1. IV/IM Benzos (typically, lorazepam or seizing? assess if pt is on correct medication
diazepam) [...] based on seizure type
#2. Fosphenytoin (or Phenytoin; but Fos
is preferred)
#3. Phenobarbital Remember, epileptics are more
#4. Midazolam + propofol (i.e. susceptible to VITAMINS as a cause. Don't
anaesthesia, hence pts typically need to discount them just because they're
be intubated by this point) epileptic.
183. Which commonly Which commonly used antiepileptic can 187. What is the most What is the most appropriate next step if a
used antiepileptic cause gingival hyperplasia? appropriate next step pt has a seizure while having therapeutic
can cause gingival Phenytoin if a pt has a seizure levels of an antiepileptic?
hyperplasia? while having Switch to another agent
[...] therapeutic levels of
an antiepileptic?
[...]
26 of 340
194. Which specific type Which specific type of seizure involves

188. What findings on an What findings on an EEG are indicative of of seizure involves preserved muscle tone with LOC?
EEG are indicative of seizure-like activity? preserved muscle Absence
seizure-like activity? Spikes and waves that display tone with LOC? LOC is very brief.
[...] organised neuronal firing [...] Typically these pts appear to be normal
while seizing, they just stare into space.
This is abnormal for adults in an awake Look out for that question that describes
state. possible absence seizures vs. ADHD in a
Can be normal in sleep states. kid. They have multiple absence seizures
during the day and don't realise it. All they
189. Which major type of Which major type of seizure involves see are short clips of their day. In a
seizure involves loss/alteration of consciousness? classroom setting, this can seem like
loss/alteration of Complex seizures ADHD as they don't pay attention, so read
consciousness? carefully.
[...]
190. Which major type of Which major type of seizure does not of seizure involves jerky muscle movements without LOC?
seizure does not involve loss of consciousness? jerky muscle Myoclonic
involve loss of Partial seizure movements without
consciousness? LOC?
[...] [...]
Seizure is also focal to one part of the
body. 196. Which antiepileptic is Which antiepileptic is preferred in atonic
preferred in atonic seizures?
191. Which antiepileptics Which antiepileptics are generally favoured seizures? Depakote (valproic acid)
are generally in partial seizures? [...]
favoured in partial Carbamazepine; Phenytoin
seizures? Remember, atonic = loss of muscle tone
[...] with no LOC
192. Which antiepileptics Which antiepileptics are generally 197. Which antiepileptic is Which antiepileptic is preferred in absence
are generally preferred in generalized seizures? preferred in absence (petit-mal) seizures?
preferred in Valproic acid; lamotrigine (petit-mal) seizures? Ethosuximide
generalized [...]
seizures?
[...] Remember, absence seizures involve
positive muscle tone with LOC.

of seizure involves loss of muscle tone without LOC? 198. Which antiepileptic is Which antiepileptic is preferred in
loss of muscle tone Atonic preferred in myoclonic seizures?
without LOC? myoclonic seizures? Depakote (valproic acid)
[...] [...]
199. Which antiepileptic is Which antiepileptic is preferred in tic

preferred in tic douloureux?
douloureux? Carbamazepine
[...]
27 of 340
200. Why is Keppra Why is Keppra (levitiracetam) favoured for 205. What is the ultimate, What is the ultimate, last-resort therapy for
(levitiracetam) seizure ppx on the wards? last-resort therapy for unresolving seizure?
favoured for seizure It has a favourable side effect profile unresolving seizure? Neuromuscular blocking agent +
ppx on the wards? [...] general anaesthesia
[...]
e.g. succinylcholine + midazolam +

201. Which electrolyte Which electrolyte imbalances are most
propofol
imbalances are most commonly considered in the workup of
This method requires intubation.
commonly seizure?
Note, the neuromuscular blocking agent
considered in the Na, Ca, Mg, Glc
does not actually stop the seizure, just
workup of seizure?
stops external manifestations
[...]
Na: hypo or hyper
Glc: hypo 206. Which type of Which type of seizure is more common in
Ca: hypo seizure is more children?
Mg: hypo (rare) common in children? Absence (petit-mal)
[...]
202. When is an EEG When is an EEG indicated in the workup of

indicated in the seizure? 207. What are the What are the indications for starting
workup of seizure? When all other tests have been ordered indications for chronic antiepileptic use s/p a single
[...] and are negative starting chronic seizure?
antiepileptic use s/p Abnormal EEG; abnormal CT; FHx of
a single seizure? seizures
i.e. what's the use of an EEG if the pt is [...]
hyponatremic. You already have your likely
cause.
208. What is the first What is the first choice drug to treat
choice drug to treat epilepsy?
203. [...] is a neurological Epilepsy is a neurological disorder that is epilepsy? None
disorder that is characterized by seizures of unclear [...]
characterized by etiology.
seizures of unclear All of levetiracetam, phenytoin, valproic
etiology. acid & carbamazepine have the same
efficacy.
Keppra (levetiracetam) has the fewest
204. What is the benefit of What is the benefit of using fosphenytoin
side effects.
using fosphenytoin over phenytoin?
over phenytoin? Fewer adverse effects
[...] 209. What is the next best What is the next best step in the
step in the management of epilepsy if 2 separate
Phenytoin is also a class 1b management of antiepileptics have failed?
antiarrhythmic. When given IV it can cause epilepsy if 2 Combine 2 agents
hypotension and AV block. separate
Fosphenytoin does not have these antiepileptics have
adverse effects and can be given failed?
rapidly. [...]
28 of 340
210. What is the next best What is the next best step in the 214. What is the most What is the most likely Dx of a pt with a
step in the management of epilepsy if 2 combined likely Dx of a pt with sudden onset of severe headache with
management of antiepileptics have failed? a sudden onset of stiff neck, photophobia, fever and LOC?
epilepsy if 2 Surgical correction can be considered severe headache Subarachnoid hemorrhage (SAH)
combined to resolve recurrences with stiff neck,
antiepileptics have photophobia, fever
failed? and LOC? (not meningitis)
[...] [...] Fever + meningeal irritation (stiff
neck/photophobia) does not always mean
meningitis.
211. What is the indication What is the indication to discontinue
Fever is 2/2 blood irritating the
to discontinue chronic antiepileptic use?
meninges.
chronic antiepileptic Being seizure-free for 2 years
LOC is 2/2 the sudden increase in ICP
use?
(seen in 50% of cases).
[...]
FND are seen in 30% of cases.
That is the standard of care.
Best test for recurrence: sleep deprivation
EEG 215. What causes the What causes the fever in subarachnoid
fever in hemorrhage?
subarachnoid Blood irritating the meninges
212. What is the best test What is the best test to tell if there is
hemorrhage?
to tell if there is possible recurrence of seizure after being
[...]
possible recurrence seizure-free?
of seizure after being Sleep deprivation EEG
seizure-free? 216. What causes LOC in What causes LOC in subarachnoid
[...] subarachnoid hemorrhage?
Sleep deprivation can elicit abnormal EEG hemorrhage? Rapid increase in ICP
activity but the test lacks high sensitivity. [...]
Seen in 50% of cases

213. Which type of Which type of intracranial hemorrhage is
intracranial typically caused by rupture of an aneurysm
hemorrhage is usually located in the anterior portion of 217. What are the key What are the key sign/symptoms of
typically caused by the circle of Willis? sign/symptoms of subarachnoid hemorrhage that point away
rupture of an Subarachnoid hemorrhage (SAH) subarachnoid from meningitis?
aneurysm usually hemorrhage that Very sudden onset; LOC
located in the point away from
anterior portion of the 2% of routine autopsies reveal aneurysms, meningitis?
circle of Willis? so the majority never rupture. [...] Severe HA, fever, and meningeal signs
[...] May be at the Anterior Communicating (stiff neck/photophobia) can be common
Artery between the two.
Conditions where they are more frequent:
- PCKD
218. What is the best What is the best initial diagnostic test for
- Tobacco smoking
initial diagnostic test subarachnoid hemorrhage?
- HTN
for subarachnoid CT without contrast
- HLP
hemorrhage?
- High EtOH use
[...]
95% sensitive
29 of 340
219. What is the most What is the most accurate/sensitive test 225. What EKG findings What EKG findings are seen with
accurate/sensitive for subarachnoid hemorrhage? are seen with intracranial bleeding?
test for subarachnoid LP intracranial bleeding? Large/inverted T waves
hemorrhage? [...]
[...]
LP will reveal blood. aka Cerebral T waves
Only really indicated for the 5% of Thought to be due to excessive
suspected SAH cases that will have a sympathetic activity.
negative CT (CT is 95% sensitive).
226. What is required for What is required for the Dx of

220. What is What is xanthochromia? the Dx of subarachnoid hemorrhage?
xanthochromia? Yellow discolouring of the CSF 2/2 subarachnoid Symptoms + positive CT (± LP)
[...] breakdown of RBCs in CSF hemorrhage?
[...]
221. How does the CSF How does the CSF WBC count change in
WBC count change subarachnoid hemorrhage? 227. Which imaging Which imaging procedures are used to
in subarachnoid Increased procedures are used localize vessel rupture in subarachnoid
hemorrhage? to localize vessel hemorrhage?
[...] rupture in CT Angio; MRA
This mimics meningitis, therefore always subarachnoid
look at CSF WBC:RBC ratio hemorrhage?
- WBC:RBC ratio is normal in SAH [...]
(1:500-1000)
228. What is the treatment What is the treatment that reverses

222. How does the CSF How does the CSF WBC:RBC ratio that reverses subarachnoid hemorrhage?
WBC:RBC ratio change in subarachnoid hemorrhage? subarachnoid None exist
change in Normal hemorrhage?
subarachnoid [...]
hemorrhage?
[...] Normal is 1:500-1000
229. Which drug is used Which drug is used to prevent
to prevent subsequent ischemic stroke in
223. What is the normal What is the normal CSF WBC:RBC ratio? subsequent subarachnoid hemorrhage?
CSF WBC:RBC 1:500-1000 ischemic stroke in Nimodipine (CCB)
ratio? subarachnoid
[...] hemorrhage?
Ratio is normal in SAH, increased in [...]
meningitis
230. What is the treatment What is the treatment for hydrocephalus

224. When does a head When does a head CT or MRI require for hydrocephalus 2/2 subarachnoid hemorrhage?
CT or MRI require contrast? 2/2 subarachnoid VP shunt
contrast? To detect mass lesions hemorrhage?
[...] (tumours/abscess) [...]
Contrast is not used when looking for

intracranial bleeding.
30 of 340
231. Which antiepileptic is Which antiepileptic is typically used as 236. What class of drugs What class of drugs are used to treat
typically used as seizure ppx in subarachnoid hemorrhage? are used to treat spinal trauma?
seizure ppx in Phenytoin spinal trauma? Glucocorticoids
subarachnoid [...]
hemorrhage?
[...] However, antiepileptic treatment in this Some studies show a decrease in mortality
case is controversial. following high doses of methylprednisolone
within 8 hrs. However, this is pretty
controversial due to GI bleeding risk and
232. Which Which neuroradiological procedure is
wound infection.
neuroradiological performed at the site of bleeding to prevent
procedure is a repeated subarachnoid hemorrhage?
performed at the site Catheter embolization 237. Which spinal cord Which spinal cord disorder presents with
of bleeding to disorder presents pain/temperature loss on the
prevent a repeated with contralateral side and
subarachnoid This interventional neuroradiological pain/temperature motor/position/vibration loss on the
hemorrhage? procedure involves placement of a loss on the ipsilateral side of the lesion?
[...] platinum wire to the site of hemorrhage contralateral side Brown-Séquard Syndrome
and subsequent embolization/coiling to and
"clog up" the site of the bleed. motor/position/vibration
Embolization is superior to surgical loss on the
clipping in terms of survival and ipsilateral side of
complications. the lesion?
[...]
233. What percentage of What percentage of subarachnoid

subarachnoid hemorrhage re-bleeds die? 238. What is the most What is the most appropriate next step in
hemorrhage 50-70% appropriate next step the management of Brown-Sequard
re-bleeds die? in the management Syndrome 2/2 a mass lesion?
[...] of Brown-Sequard Surgical decompression
Syndrome 2/2 a
mass lesion?
234. What vitamin What vitamin deficiency is associated with
[...]
deficiency is subacute combined degeneration of the
associated with spinal cord?
subacute combined B12 (cobalamin) 239. Which spinal cord Which spinal cord disorder involves a
degeneration of the disorder involves a fluid-filled, dilated central canal in the
spinal cord? fluid-filled, dilated spinal cord?
[...] Results in positional and vibratory central canal in the Syringomyelia
sensation loss. spinal cord?
[...]
The widened bubble or cavitation first
235. Which infectious Which infectious disease is associated
damages neural fibers passing near the
disease is associated with subacute combined degeneration of
center of the spine.
with subacute the spinal cord?
Can be 2/2 tumour/trauma or congenital.
combined Neurosyphilis
degeneration of the
spinal cord?
[...] Involves positional and vibratory sensation
loss.
31 of 340
240. Which spinal cord Which spinal cord disorder most commonly 245. What is the most What is the most accurate test for brain
disorder most presents with pain/temperature loss accurate test for abscess?
commonly presents bilaterally across the upper back and brain abscess? Biopsy
with arms? [...]
pain/temperature Syringomyelia
loss bilaterally Basically the issue here is abscess vs.
across the upper tumour. Biopsy is needed to confirm.
back and arms? The buzzword "capelike distribution of
[...] deficits" is often used.
246. Why is an LP Why is an LP contraindicated with a
Also presents with loss of DTRs and
contraindicated with suspected brain mass (abscess, tumour,
muscle atrophy in the same bilateral
a suspected brain etc)?
distribution.
mass (abscess, Possibility of herniation
tumour, etc)?
241. What is the most What is the most accurate test for [...]
accurate test for Syringomyelia? In many cases, the CSF is not going to
Syringomyelia? MRI help much anyway.
[...]
247. Which diagnostic Which diagnostic procedure is essential in

242. What is the best What is the best treatment of procedure is the workup/management of brain
treatment of Syringomyelia? essential in the abscess?
Syringomyelia? Surgery (with drainage of the fluid from workup/management Biopsy
[...] the cavity) of brain abscess?
[...]
A bx must be performed in order to:
Surgical interventions also typically involve - differentiate between abscess and
one of: tumour
- removal of the causative tumour/mass - identify the causative organism (in the
- correction of a congenital anomaly case of abscess)
243. How do you How do you differentiate between a brain 248. What is the most What is the most common cause of brain
differentiate between abscess and tumour without biopsy? common cause of abscess?
a brain abscess and You can't brain abscess? Unknown
tumour without [...]
biopsy?
[...] They will both have HA, N/V, fever, Can be due to streptococcus,
seizures, FNDs (yes, cancer can cause staphylococcus, gram-negative bacilli, and
fever). anaerobes.
Presentation of both is pretty nonspecific, Can occur 2/2 contiguous infection at
even with a CT/MRI. the sinuses, mastoid air cells, or middle
Biopsy is done for final differentiation. ear.
Can occur 2/2 bacteremia (hence
pneumonia and endocarditis are up there).
244. What is the best What is the best initial test for suspected
Brain abscesses are often
initial test for brain abscess?
polymicrobial, hence biopsy and culture
suspected brain CT/MRI with contrast
is very important given that Abx regimens
abscess? Both tumour and abscess will be a contrast
are rather long (6-8 wks IV followed by 2-3
[...] enhancing lesion with surrounding edema
months of oral Abx).
and mass effect. You cannot differentiate
the two via CT alone.
32 of 340
249. Which combination Which combination of antibiotics are 253. Which Which neurocutaneous disorder is
of antibiotics are commonly used as empiric therapy for a neurocutaneous associated with cardiac rhabdomyomas?
commonly used as brain abscess? disorder is Tuberous Sclerosis
empiric therapy for Penicillin + metronidazole + associated with
a brain abscess? ceftriaxone/cefepime cardiac
[...] rhabdomyomas?
[...]
Vancomycin can be used in place of a
penicillin if there was recent NeuroSx
254. Which Which neurocutaneous disorder presents
(higher risk of staph infection).
neurocutaneous with soft, flesh-coloured lesions
Remember, a biopsy is absolutely vital
disorder presents attached to peripheral nerves?
in the accurate treatment of a brain
with soft, Neurofibromatosis (von
abscess. The pt should not be on empiric
flesh-coloured Recklinghausen Disease)
therapy for a long time (really only until
lesions attached to
cultures are confirmed). Bx and
peripheral nerves?
subsequent culture/susceptibility testing
[...]
are indispensible.
255. Which Which neurocutaneous disorder involves

250. Which Which neurocutaneous disorder presents
neurocutaneous hyperpigmented lesions and CN VIII
neurocutaneous with adenoma sebaceum (reddened facial
disorder involves tumours?
disorder presents nodules) and Shagreen patches (leathery
hyperpigmented Neurofibromatosis (von
with adenoma patches on the trunk)?
lesions and CN VIII Recklinghausen Disease)
sebaceum Tuberous Sclerosis
tumours?
(reddened facial
[...]
nodules) and
aka café au lait spots (hyperpigmented
Shagreen patches CNS abnormalities include: seizure,
lesions)
(leathery patches on progressive psychomotor retardation,
Also involves neurofibromas,
the trunk)? slowly progressive mental deterioration
meningioma, and glioma
[...] Also involves ash leaf patches
(hypopigmented patches)
Also involves retinal lesions and cardiac 256. What is the specific What is the specific treatment for
rhabdomyomas. treatment for Neurofibromatosis (von Recklinghausen
Neurofibromatosis Disease)?
(von Recklinghausen None
251. What is the specific What is the specific treatment for Tuberous
Disease)?
treatment for Sclerosis?
[...]
Tuberous Sclerosis? None
CN VIII lesions may need to be
[...]
excised/surgical decompression to
preserve hearing
Control seizures and other symptoms.
257. Which Which neurocutaneous disorder commonly

252. Which Which neurocutaneous disorder involves
neurocutaneous presents with seizures and port-wine
neurocutaneous retinal lesions?
disorder commonly staining of the face?
disorder involves Tuberous Sclerosis
presents with Sturge-Weber Syndrome
retinal lesions?
seizures and
[...]
port-wine staining
of the face? Other CNS abnormalities include:
[...] homonymous hemianopsia,
hemiparesis, mental subnormality
33 of 340
258. Which Which neurocutaneous disorder is 264. Which area of the Which area of the brain is primarily
neurocutaneous associated with calcification of angiomas brain is primarily affected in Parkinsons Disease?
disorder is on skull XR? affected in Substantia nigra
associated with Sturge-Weber Syndrome Parkinsons Disease?
calcification of [...]
angiomas on skull
XR?
265. What is the most What is the most common cause of
[...]
common cause of Parkinsonism?
Parkinsonism? Idiopathic
259. What is the treatment What is the treatment for Sturge-Weber [...]
for Sturge-Weber syndrome?
syndrome? None
266. [...] is a GI Metoclopromide is a GI pro-kinetic agent
[...]
pro-kinetic agent and and dopamine antagonist that can cause
dopamine antagonist parkinsonism.
Control seizures
that can cause
parkinsonism.
260. Which type of tremor Which type of tremor occurs both at rest
occurs both at rest and with intention (i.e. reaching for
267. What is the What is the diagnostic test for
and with intention something)?
diagnostic test for parkinsonism?
(i.e. reaching for Essential tremor
parkinsonism? None; Dx is clinical
something)?
[...]
[...]
Often greatest in the hands, but can be
seen at the head as well. 268. [...] is a neurological Parkinsonism is a neurological disorder
Physical exam is otherwise normal. disorder commonly commonly seen in the elderly that presents
Tremor can effect manual skills such as seen in the elderly with tremor, muscle rigidity,
handwriting or the use of a keyboard. that presents with bradykinesia, and shuffling gait with
tremor, muscle unsteadiness on turning.
rigidity,
261. How does caffiene How does caffiene change the severity of
bradykinesia, and
change the severity an essential tremor?
shuffling gait with
of an essential Increase
unsteadiness on
tremor?
turning.
[...]
269. [...] is a neurological Cogwheel rigidity is a neurological finding

262. What is the treatment What is the treatment for essential tremor?
finding described as described as the slowing of movement on
for essential tremor? Propanolol
the slowing of passive flexion or extension of an
[...]
movement on extremity.
passive flexion or
263. A pt complains of a A pt complains of a tremor that's present at extension of an
tremor that's present rest and exertion. He states that it extremity.
at rest and exertion. improves after a drink of alcohol. What is
He states that it the most likely diagnosis?
270. What is hypomimia? What is hypomimia?
improves after a Essential tremor
[...] Limited facial expression
drink of alcohol.
What is the most
likely diagnosis?
Seen in parkinsonism and other disorders.
[...]
34 of 340
271. What is What is micrographia?

276. What constitutes What constitutes severe Parkinsonism?
micrographia? Small handwriting
[...] severe Inability of the pt to take care of
Parkinsonism? themselves; Orthostatic hypotension
Seen in parkinsonism and other disorders. [...]
272. What causes the 277. Which dopamine Which dopamine agonists are preferred in
What causes the postural instability in
postural instability in parkinsonism? agonists are the treatment of severe parkinsonism?
parkinsonism? Orthostatic hypotension preferred in the Pramipexole; ropinirole
[...] treatment of severe
parkinsonism?
Stems from an inability of the pulse and [...]
blood pressure to reset appropriately when
the pt stands up. 278. What is the most What is the most effective treatment of
As a result, there is orthostatic effective treatment severe parkinsonism?
hypotension, postural lightheadedness of severe Levodopa/carbidopa
and subsequent instability/falls. parkinsonism?
[...]
273. Which anticholinergic Which anticholinergic agents are preferred Associated with "on/off" phenomena:
agents are preferred in the treatment of tremor & rigidity in - off = insufficient dopamine =
in the treatment of mild parkinsonism? bradykinesia
tremor & rigidity in Benztropine; trihexyphenidyl - on = too much dopamine = dyskinesia
mild parkinsonism?
[...] 279. What is the "on/off" What is the "on/off" phenomenon
It is still unclear why increasing ACh levels phenomenon associated with levodopa/carbidopa?
help improve symptoms of low dopamine. associated with (see below)
ADEs include: dry mouth, worsening levodopa/carbidopa? "On/off" phenomena:
BPH, constipation [...] - off = insufficient dopamine = bradykinesia
ADEs are more common in older pts. - on = too much dopamine = dyskinesia
274. Which antiparkinson Which antiparkinson agent is preferrably 280. Which antiparkinson Which antiparkinson agents are associated
agent is preferrably given to > 60 y/o pts with mild agents are with the "On/Off" Phenomenon?
given to > 60 y/o pts parkinsonism that cannot tolerate associated with the Levodopa/carbidopa
with mild anticholinergics? "On/Off"
parkinsonism that Amantadine Phenomenon?
cannot tolerate [...]
anticholinergics?
[...] Works by increasing dopamine release
281. Which COMT Which COMT inhibitors are used in the
from the substantia nigra.
inhibitors are used treatment of parkinsonism?
If the question talks about an old pt with
in the treatment of Tolcapone; entacapone
parkinsonism that is complaining of
parkinsonism?
anticholinergic side effects, choose
[...]
amantadine if asked.
Only used in pts that are also taking
levodopa/carbidopa
275. What is the What is the mechanism of action of Used to extend the duration of
mechanism of action amantadine in the treatment of levodopa/carbidopa by decreasing
of amantadine in the Parkinsonism? peripheral metabolism of dopamine
treatment of Unclear; thought to increase dopamine
Parkinsonism? release from the substantia nigra
[...]
35 of 340
282. What is the only What is the only indication for the use of 287. Psychosis is a known Psychosis is a known adverse effect of
indication for the use COMT inhibitors in the treatment of severe adverse effect of antiparkinson agents. What is the best way
of COMT inhibitors in parkinsonism? antiparkinson agents. to treat this psychosis?
the treatment of To extend the duration of What is the best way Antipsychotics with the fewest
severe levodopa/carbidopa to treat this extrapyramidal symptoms
parkinsonism? Hence only used in pts that are taking psychosis?
[...] levodopa/carbidopa. [...]
Most of the time, you cannot stop
Acts by inhibiting the peripheral antiparkinson agents as there is a risk of
metabolism of dopamine. the patient becoming "locked in" with
Used to smooth out "on/off" severe bradykinesia. This is even more
phenomena to even out dopamine levels. likely if the pt has severe parkinsonism.
Also used when the response to therapy is Use antipsychotics.
inadequate.
288. [...] is a cause of Lewy Body Dementia is a cause of

283. Which MAO Which MAO inhibitors are used in the dementia that dementia that involves parkinsonism.
inhibitors are used in treatment of severe parkinsonism? involves
the treatment of Selegiline; rasagiline parkinsonism.
severe
parkinsonism?
289. [...] is a neurological Shy-Drager Syndrome is a neurological
[...] Used either alone or as an adjunct to
syndrome syndrome characterized by parkinsonism
levodopa/carbidopa.
characterized by and orthostasis.
Act by blocking metabolism of
parkinsonism and
dopamine.
orthostasis.
284. Tyramine-containing Tyramine-containing foods can precipitate

290. [...] is a Spasticity is a neuromuscular
foods can precipitate hypertension if taken while on a specific
neuromuscular phenomenon occurring in many disorders
hypertension if taken class of drugs. What is that class?
phenomenon that is described as painful, contracted
while on a specific MAO inhibitors
occurring in many muscle 2/2 to CNS damage.
class of drugs. What
disorders that is
is that class?
described as painful,
[...] Tyramine is found in cheese, for example.
contracted muscle More often associated with MS.
2/2 to CNS damage. No single treatment is preferred.
285. Which surgical Which surgical procedure is highly Baclofen, dantrolene and tizanadine
procedure is highly effective in the treatment of tremors and (centrally-acting alpha agonist) may all
effective in the rigidity in pts with severe parkinsonism? work.
treatment of tremors Deep Brain Stimulation
and rigidity in pts
291. Which neurological Which neurological disorder often presents
with severe
disorder often with pts complaining of an uncomfortable,
parkinsonism?
presents with pts "creepy crawly" feeling in the legs at night?
[...]
complaining of an Restless Leg Syndrome
uncomfortable,
286. Which class of Which class of antiparkinson agents is "creepy crawly"
antiparkinson agents associated with slowing the progression feeling in the legs at Often their bed partners complain of being
is associated with of parkinsonism? night? kicked at night as moving the leg relieves
slowing the MAO inhibitors [...] the sensation.
progression of Caffeine makes it worse.
parkinsonism?
[...]
36 of 340
292. How does caffeine How does caffeine change the severity of 297. What is most What is most commonly the first
change the severity Restless Leg Syndrome? commonly the first manifestation of the movement disorder in
of Restless Leg Increase manifestation of the Huntington Disease?
Syndrome? movement disorder "Fidgetiness"
[...] in Huntington
Movement of the limb usually relieves Disease?
discomfort. [...] This fidgeting quickly progresses into
restlessness. Then dystonia, dystonic
posturing and dyskinesia (with
293. What class of drugs What class of drugs is used to treat
choreiform movement). Then rigidity and
is used to treat Restless Leg Syndrome?
akinesia in later stages.
Restless Leg Dopamine agonists
Syndrome?
[...] 298. What is the What is the diagnostic test of choice for
Most often pramipexole diagnostic test of Huntington Disease?
choice for Huntington Genetic analysis
Disease?
294. What is the etiology What is the etiology of Huntington
[...]
of Huntington Disease?
The genetic test for HD is 99% sensitive -
Disease? CAG trinucleotide repeats on
it looks for CAG trinucleotide repeats on
[...] chromosome 4
chromosome 4
The symptom triad
295. [...] is a neurological Huntington Disease is a neurological (movement/dementia/behaviour) only
disorder disorder characterized by a classic triad of confirms the genetic test.
characterized by a choreiform movement, dementia, and CT/MRI can show caudate nucleus
classic triad of behavioural changes. atrophy but that is not specific for HD.
choreiform
movement,
299. What is the curative What is the curative treatment for HD?
dementia, and The movement disorder can progress to
treatment for HD? None
behavioural full on rigidity in severe cases.
[...]
changes. Behavioural changes vary, but typically
involve irritability, moodiness and
Treat the dyskinesia with tetrabenazine
antisocial behaviour.
Treat the psychosis with haloperidol,
Pts will also often have a strong family
quetiapine or other antipsychotics.
history (autosomal dominant inheritance)
300. What head CT/MRI What head CT/MRI findings are associated
296. In which age range In which age range does Huntington
findings are with Huntington Disease?
does Huntington Disease present?
associated with Caudate nucleus atrophy
Disease present? 30-50 y/o
Huntington Disease?
[...]
[...]
37 of 340
301. Which monoamine Which monoamine reuptake inhibitor is 304. Weakness is a very Weakness is a very common complaint
reuptake inhibitor is used to treat the dyskinesia in common complaint that can be 2/2 demyelination, NMJ
used to treat the huntington disease? that can be 2/2 dysfunction, spinal/nerve lesions, cortical
dyskinesia in Tetrabenazine demyelination, NMJ lesions or even muscular lesions. Which
huntington Tetrabenazine is a reversible human dysfunction, disorder most commonly targets the spinal
disease? vesicular monoamine transporter type 2 spinal/nerve lesions, cord specifically?
[...] inhibitor (Ki = 100 nM). It acts within the cortical lesions or ALS
basal ganglia and promotes depletion of even muscular
monoamine neurotransmitters serotonin, lesions. Which
norepinephrine, and dopamine from disorder most Okay, this is a poor card, but I wanted to
stores. It also decreases uptake into commonly targets get you thinking about DDx of weakness
synaptic vesicles. Dopamine is required for the spinal cord and to localize disorders to where they
fine motor movement, so the inhibition of specifically? occur along the motor pathways.
its transmission is efficacious for [...]
hyperkinetic movement. Tetrabenazine
exhibits weak in vitro binding affinity at the
dopamine D2 receptor (Ki = 2100 nM).
305. Which neurological Which neurological cause of weakness
(from www.drugbank.ca)
cause of weakness involves antibodies against myelin that
involves antibodies develop following exposure to
302. [...] is a Tourette disorder is a neuropsychiatric against myelin that environmental triggers and genetic
neuropsychiatric disorder characterized by vocal tics, develop following susceptibility?
disorder grunts and coprolalia. exposure to MS
characterized by environmental
vocal tics, grunts triggers and genetic
and coprolalia. Can involve motor tics as well (sniffling, susceptibility? What these triggers and genes are - we
blinking, frowning) [...] don't know yet.
Can also involve obsessive-compulsive
behaviour.
306. Which area of the Which area of the body is primarily
Tx with neuroleptics (e.g. fluphenazine,
body is primarily affected in MS?
clonazepam, pimozide) and ADHD meds
affected in MS? Anywhere
(e.g. methylphenidate)
[...]
Coprolalia = repetitive, involuntary use of
profanity
This is part of what makes MS a tough
disease to diagnose.
303. Which Which demographic(s) is more commonly The neurological symptoms are often
demographic(s) is affected by MS? separated by space and time in a way
more commonly Women; white; colder climates (i.e. that a single cause/lesion cannot explain
affected by MS? northern hemisphere) symptoms (i.e. blurry vision 5 years ago
[...] that resolved and returned, tingling in the
hands 2 years ago that resolved and
returned, and now tingling in the
contralateral foot).
However the first complaint is often blurry
vision/diplopia 2/2 to optic neuritis.
(Remember, the optic tract and associated
pathways are very highly myelinated for
fast conduction, especially the MLF. As
such, demyelination in these areas if felt
first. Intranuclear ophthalmoplegia (INO)
2/2 MLF demyelination is common as
well.)
38 of 340
311. Which drug is Which drug is preferred in the treatment of

307. What is the most What is the most common first complaint preferred in the urinary retention in multiple sclerosis?
common first in multiple sclerosis? treatment of urinary Bethanecol
complaint in multiple Blurry vision/diplopia 2/2 optic neuritis; retention in multiple
sclerosis? or focal sensory deficits sclerosis?
[...] [...] Remember, MS can cause any type of
lesion in the spinal cord.
White lady with blurry vision = think MS,
brah.
Intranuclear ophthalmoplegia (INO) =
preferred in the urinary incontinence in multiple
think MS, brah
treatment of urinary sclerosis?
Some sources say optic neuritis is no
incontinence in Amitriptyline
longer as common, so consider focal
multiple sclerosis?
sensory deficits (± gait/balance problems)
[...]
as well.
Remember, MS can cause any type of
308. Which imaging study Which imaging study is the best choice in
is the best choice in suspected multiple sclerosis?
suspected multiple MRI
preferred in the spasticity in multiple sclerosis?
sclerosis?
treatment of Baclofen
[...]
spasticity in multiple
A positive MRI involves periventricular
sclerosis?
plaques, multiple lesions or lesions to
[...] Or well, baclofen is useful in spasticity in
the corpus callosum and is most
general.
accurate.
Remember, MS can cause any type of
However, because MS is a
relapse-remitting disease, an MRI can be
negative. In such cases, do an LP and see
if there is pleocytosis, oligoclonal IgG or 314. What is the most What is the most accurate diagnostic test
evoked potentials. However, LP's are accurate diagnostic in multiple sclerosis?
typically not done anymore. test in multiple MRI
sclerosis?
309. Which drug is [...]
Which drug is preferred for the chronic
Oligoclonal bands on LP are only seen in
preferred for the management of multiple sclerosis?
85% of pts and are not specific to MS.
chronic Interferon-beta
However, if the MRI is unequivocal or
management of
nondiagnostic, consider LP.
multiple sclerosis?
[...] Prevents relapse. Visual and auditory evoked potentials
are always the wrong answer.
Can use glatiramer to prevent relapse as
well.
310. Which drug is Which drug is preffered for the treatment of

preffered for the acute flareups in multiple sclerosis?
treatment of acute High-dose Steroids
flareups in multiple
sclerosis?
[...] Roids also mitigate the severity/duration of
the exacerbation.
39 of 340
315. A pt w/ multiple A pt w/ multiple sclerosis develops

319. What must first be What must first be ruled out in a pt before
sclerosis develops worsening FNDs while on chronic
worsening FNDs suppressive therapy. New MRI shows ruled out in a pt giving a Dx of ALS?
while on chronic new, multiple white matter lesions. Which before giving a Dx of Spinal lesions (either via
suppressive therapy. monoclonal antibody is most likely to have ALS? CT/MRI/SpinalXR)
New MRI shows caused this? [...]
new, multiple white Natalizumab
matter lesions. 320. Which demyelinating Which demyelinating disorder is
Which monoclonal disorder is associated with superoxide dismutase
antibody is most It targets alpha-4 integrin involved in associated with mutations?
likely to have caused It has been known to predispose to superoxide ALS
this? progressive multifocal dismutase
[...] leukoencephalopathy (PML). mutations?
[...] Only in 10% of cases though, so don't
316. What is the etiology What is the etiology of ALS? bank on this in vignettes.
of ALS? Unknown
[...] 321. A pt with known ALS A pt with known ALS presents with
presents with difficulty in chewing and swallowing, a
Involves asymmetric UMN and LMN difficulty in decreased gag reflex, and a weak
lesions, but typically spares the eyes and chewing and cough. What is this patient at highest risk
sphincters. swallowing, a for?
There is no sensory loss no matter what decreased gag Aspiration
the gunner says on rounds. reflex, and a weak
cough. What is this
317. A pt presents with A pt presents with muscle atrophy, patient at highest risk Saliva will often pool in the pharynx.
muscle atrophy, fasciculations of the tongue and for? This is a pretty serious presentation of ALS
fasciculations of the extremities, upwards babinski and [...] that offers poor prognosis,.
tongue and hyper-reflexia of the extremities. Which Can progress to a total loss of
extremities, upwards demyelinating disorder is the most likely swallowing.
babinski and Dx?
hyper-reflexia of the ALS 322. How do creatine How do creatine phosphokinase (CPK)
extremities. Which Involves asymmetric UMN and LMN phosphokinase levels change in ALS?
demyelinating lesions, with LMN symptoms (CPK) levels change Increased
disorder is the most predominating in later stages. in ALS?
likely Dx? Typically spares the eyes and [...]
[...] sphincters. Remember, LMN lesions cause muscle
There is no sensory loss no matter what atrophy which would raise CK levels.
the gunner says on rounds.
Other symptoms may include emotional
lability and weight loss.
318. Which diagnostic test Which diagnostic test confirms ALS?

confirms ALS? EMG
[...]
The Dx is typically clinical. EMG confirms.

EMG will show loss of neural innervation
at multiple muscle groups.
A spinal lesion must first be ruled out
via CT/MRI/SpinalXR
40 of 340
323. [...] is a drug that Riluzole is a drug that may prevent the 325. What is the most What is the most common cause of death
may prevent the progression of ALS by reducing common cause of in ALS?
progression of ALS glutamate buildup in neurons. death in ALS? Respiratory failure
by reducing [...]
glutamate buildup
in neurons. Riluzole, a member of the benzothiazole CPAP and BiPAP can improve respiratory
class, is indicated for the treatment of weakness.
patients with amyotrophic lateral sclerosis Tracheostomy and mechanical
(ALS). Riluzole extends survival and/or ventilation is the end point of ALS
time to tracheostomy. It is also progression.
neuroprotective in various in vivo
experimental models of neuronal injury
326. Which treatment Which treatment modalities are
involving excitotoxic mechanisms. The
modalities are recommended to help with respiratory
etiology and pathogenesis of amyotrophic
recommended to difficulties 2/2 muscle weakness in ALS?
lateral sclerosis (ALS) are not known,
help with respiratory CPAP; BiPAP
although a number of hypotheses have
difficulties 2/2
been advanced. One hypothesis is that
muscle weakness in
motor neurons, made vulnerable through
ALS?
either genetic predisposition or
[...]
environmental factors, are injured by
glutamate. In some cases of familial ALS
the enzyme superoxide dismutase has 327. What type of What type of neurological deficits are seen
been found to be defective. neurological deficits in Charcot-Marie-Tooth (CMT) disease?
The mode of action of riluzole is unknown. are seen in Motor and sensory
Its pharmacological properties include the Charcot-Marie-Tooth
following, some of which may be related to (CMT) disease?
its effect: 1) an inhibitory effect on [...] Motor and sensory innervation are both
glutamate release (activation of glutamate lost. Hence, deficits can include:
reuptake), 2) inactivation of - weakness
voltage-dependent sodium channels, and - sensory loss
3) ability to interfere with intracellular - muscle wasting
events that follow transmitter binding at - decreased DTRs
excitatory amino acid receptors. - tremor
(www.drugbank.ca)
328. [...] is a foot Pes cavus is a foot deformity seen in
324. What is the preferred What is the preferred treatment for deformity seen in Charcot-Marie-Tooth disease that is
treatment for spasticity in ALS? Charcot-Marie-Tooth describes as a foot with a high arch.
spasticity in ALS? Baclofen disease that is
[...] describes as a foot
with a high arch.
Seeing a trend here? Spasticity? Baclofen!
329. Which genetic cause Which genetic cause of weakness and
of weakness and sensory deficits is associated with pes
sensory deficits is cavus (a foot with a high arch)?
associated with pes Charcot-Marie-Tooth (CMT) disease
cavus (a foot with a
high arch)?
[...]
41 of 340
330. Which genetic cause Which genetic cause of weakness and 335. A pt complains of A pt complains of pain in his 4th and 5th
of weakness and sensory loss is associated with "having pain in his 4th and digits on the right side. He states that he
sensory loss is legs that look like inverted champagne 5th digits on the is a cyclist and places pressure on the
associated with bottles"? right side. He states palms of his hands for extended periods.
"having legs that look Charcot-Marie-Tooth (CMT) disease that he is a cyclist On examination, he has wasting of the
like inverted and places pressure hypothenar eminence. Which nerve is
champagne bottles"? on the palms of his most likely affected?
[...] And here I am trying to figure out a good hands for extended Ulnar
calf routine... periods. On Pts can also be s/p trauma to the medial
examination, he has elbow
wasting of the
331. What is the most What is the most accurate test for
hypothenar
accurate test for Charcot-Marie-Foot (CMT) disease?
eminence. Which
Charcot-Marie-Foot EMG
nerve is most likely
(CMT) disease?
affected?
[...]
[...]
332. What is the treatment What is the treatment for

336. A pt presents A pt presents complaining of numbness &
for Charcot-Marie-Foot (CMT) disease?
complaining of tingling on the dorsum of the right
Charcot-Marie-Foot None
numbness & hand. He recently tore his quadriceps
(CMT) disease?
tingling on the femoris muscle and has been using
[...]
dorsum of the right crutches for the past week. On physical
hand. He recently exam he has wrist drop. Which nerve is
333. What is the most What is the most common cause of tore his quadriceps most likely affected?
common cause of peripheral neuropathy? femoris muscle and Radial
peripheral Diabetes Mellitus has been using
neuropathy? crutches for the past
[...] week. On physical
Other causes include uremia, alcoholism, exam he has wrist
paraproteinemias (e.g. MGUS) drop. Which nerve is
most likely affected?
334. What is the best What is the best initial therapy for [...]
initial therapy for peripheral neuropathy?
peripheral Pregabalin; Gabapentin 337. A pt presents A pt presents complaining of numbness &
neuropathy? complaining of tingling o ver the dorsum of his right hand.
[...] numbness & tingling Last night, he fell asleep on a chair with his
Either of them. If NBME makes you o ver the dorsum of right arm extended over the back of the
choose between the two... das not it mane. his right hand. Last chair. Which nerve is most likely affected?
TCAs and antiepileptics are effective in night, he fell asleep Radial
some, but not most. on a chair with his
right arm extended
over the back of the This is "Saturday night palsy"
chair. Which nerve is
[...]
42 of 340
338. A morbidly obese pt A morbidly obese pt presents with pain 341. A pt presents A pt presents complaining of
presents with pain and numbness over the lateral aspect of complaining of pain/numbness in the right hand. She
and numbness over her right thigh. She practices yoga and pain/numbness in the works as a medical intern and says her
the lateral aspect of states that the symptoms worsen when right hand. She symptoms started ever since she started
her right thigh. She she crosses her legs. Which nerve is most works as a medical typing 50 page-long patient notes for her
practices yoga and likely affected? intern and says her attending. On physical exam, you discover
states that the Lateral cutaneous nerve of the thigh symptoms started that the symptoms are localized to the first
symptoms worsen ever since she 3 digits. Which nerve is most likely
when she crosses started typing 50 affected?
her legs. Which page-long patient Median
nerve is most likely notes for her There may also be thenar wasting, but
affected? attending. On that would srsly suck for an intern.
[...] physical exam, you
discover that the
symptoms are
339. A pt presents with A pt presents with pain/numbness in the
localized to the first 3
pain/numbness in the ankle and sole of her right foot that
digits. Which nerve is
ankle and sole of her worsens with walking. Which nerve is most
right foot that likely affected?
[...]
worsens with Tibial nerve
walking. Which nerve
is most likely 342. What is the most What is the most common cause of CNVII,
affected? This is Tarsal tunnel syndrome common cause of Facial Palsy?
[...] CNVII, Facial Palsy? Idiopathic
[...]
340. A pt presents A pt presents complaining of bilateral foot

It is not Lyme disease no matter what the
complaining of weakness. He is a skiier and wears high
gunner tells you to say during rounds.
bilateral foot ski boots for his daily training sessions. On
weakness. He is a physical exam, both feet show decreased
skiier and wears high dorsiflexion and eversion. Which nerve is 343. What is the key What is the key difference between true
ski boots for his daily most likely affected? difference between CN VII, Facial palsy and facial palsy 2/2
training sessions. On Peroneal true CN VII, Facial stroke?
physical exam, both palsy and facial palsy In stroke, only the bottom half of the
feet show decreased 2/2 stroke? face is affected
dorsiflexion and [...]
eversion. Which
nerve is most likely This is due to the dual innervation of the
affected? face. The upper half of the face received
[...] innervation from both hemispheres.
If the pt can wrinkle her forehead, its
stroke.
If the pt cannot wrinkle her forehead, its
Bell palsy.
344. Facial/Bell palsy can Facial/Bell palsy can sometimes involves

sometimes involves hyperacusis. Why?
hyperacusis. Why? CN VII innervates the stapedius muscle,
[...] which mitigates the volume of sounds
transmitted through the ossicles
43 of 340
345. Facial/Bell palsy can Facial/Bell palsy can sometimes involve 350. Which demyelinating Which demyelinating disorder can present
sometimes involve taste disturbance. Why? disorder can present s/p flu vaccination or 1-3 weeks s/p
taste disturbance. CN VII, supplies taste sensation to the s/p flu vaccination Campylobacter jejuni diarrhea?
Why? anterior 2/3 of the tongue or 1-3 weeks s/p Acute Inflammatory Polyneuropathy
[...] Campylobacter (Guillain-Barré Syndrome)
jejuni diarrhea?
[...]
accurate test for Facial/Bell palsy?
Facial/Bell palsy? EMG (or other nerve conduction 351. Which symptoms of Which symptoms of Acute Inflammatory
[...] studies) Acute Inflammatory Polyneuropathy (Guillain-Barré Syndrome)
Polyneuropathy is always present?
(Guillain-Barré Ascending paralysis/weakness;
However, no test is typically done. Dx is Syndrome) is always Hyporeflexia
clinical based off presentation. present?
[...]
Paresthesia and autonomic
dysregulation may or may not be
initial therapy for Bell/Facial palsy?
present.
Bell/Facial palsy? Prednisone
[...]
352. What is the most What is the most appropriate first step in
However, 60% of pts recover without appropriate first step the management of a pt in whom Acute
treatment. in the management Inflammatory Polyneuropathy
Acyclovir can be added, but whether or not of a pt in whom (Guillain-Barré Syndrome) is suspected?
it helps is unclear. Acute Inflammatory Assess the need for intubation (i.e.
Polyneuropathy order PFTs)
(Guillain-Barré
348. What is the most What is the most common complication of
Syndrome) is
common Bell/Facial palsy?
suspected? Due to the ascending paralysis inevitably
complication of Corneal ulceration
[...] reaching the diaphragm, you should first
Bell/Facial palsy?
assess whether or not that pt requires
[...]
intubation. After that you can confirm
This is 2/2 the muscle weakness and an
diagnosis.
inability to close the eye, especially at
FVC and peak inspiratory pressure
night. This leads to dryness and eventual
decreases are the best way to gauge for
ulceration.
impending respiratory failure (and the need
Avoid this by taping the eyelid shut and
to intubate)
using lubricating eye drops often.
ABG abnormalities mean you're already
too late.
349. Which demyelinating Which demyelinating disorder involves Nerve conduction studies are good for
disorder involves ascending paralysis? accurate diagnosis, but that doesn't solve
ascending Acute Inflammatory Polyneuropathy the impending respiratory failure issue.
paralysis? (Guillain-Barré Syndrome)
[...]
No CNS involvement
Due to circulating antibodies vs. myelin
Reversible and not permanent
44 of 340
353. Which diagnostic test Which diagnostic test is most helpful in 357. A pt presents with s/s A pt presents with s/s that strongly suggest
is most helpful in diagnosing Acute Inflammatory that strongly suggest Acute Inflammatory Polyneuropathy
diagnosing Acute Polyneuropathy (Guillain-Barré Acute Inflammatory (Guillain-Barré Syndrome). What is the
Inflammatory Syndrome)? Polyneuropathy most appropriate next step, that should be
Polyneuropathy EMG (Guillain-Barré done urgently?
(Guillain-Barré Syndrome). What is PFTs
Syndrome)? the most appropriate
[...] EMG will show decreased conduction next step, that should
velocity however this may take 2-3 be done urgently? FVC and peak inspiratory pressure
weeks to manifest. [...] decreases are the best way to gauge for
LP will show CSF with increased proteins impending respiratory failure (and the need
and normal or decreased cell count to intubate)
ABG abnormalities mean you're already
too late.
354. What is the treatment What is the treatment for Acute
Nerve conduction studies are good for
for Acute Inflammatory Polyneuropathy
accurate diagnosis, but that doesn't solve
Inflammatory (Guillain-Barré Syndrome)?
the impending respiratory failure issue.
Polyneuropathy IVIG; or plasmapharesis
(Guillain-Barré They both have equal efficacy and
Syndrome)? combining both does nothing. 358. Which phase of Which phase of breathing is affected in
[...] Steroids do not help and is always a breathing is affected Acute Inflammatory Polyneuropathy
wrong answer. In fact, never give in Acute (Guillain-Barré Syndrome)?
steroids in GBS. Inflammatory Inspiration
IVIG and plasmapharesis combined is Polyneuropathy
also always a wrong answer. (Guillain-Barré
Syndrome)? Important to remember this because peak
[...] flow only gauges expiration and is better
355. What are the most What are the most common causes of
in obstructive lung diseases.
common causes of death in GBS?
Make sure you order the right test: PFTs
death in GBS? Autonomic regulation; respiratory
with a focus on FVC and peak inspiratory
[...] failure
pressure
356. How does FVC How does FVC change in a pt with Acute
359. Which Which neuromuscular junction structure is
change in a pt with Inflammatory Polyneuropathy
neuromuscular affected in Myasthenia Gravis?
Acute Inflammatory (Guillain-Barré Syndrome) that has
junction structure is Post-synaptic ACh receptor
Polyneuropathy affected the diaphragm?
affected in
(Guillain-Barré Decreased
Myasthenia Gravis?
Syndrome) that has
[...]
affected the
diaphragm? There is a decrease in FVC and peak
[...] inspiratory pressure.
Remember, inspiration is the active
portion of breathing. This is the major
pathophysiological factor regarding
respiratory failure in GBS. PFTs may be
able to reveal impending death in GBS.
45 of 340
360. Which muscles are Which muscles are typically affected the
363. What is the best What is the best initial test for
typically affected the most in Myasthenia Gravis?
most in Myasthenia Eye muscles (diplopia/ptosis); throat initial test for Myasthenia Gravis?
Gravis? muscles (dysphagia); difficulty chewing Myasthenia Gravis? Anti-ACh Receptor antibody test
[...] Don't memorize this. Understand it: [...]
MG involves progressive daily
fatigability due to the post-synaptic AChR 80-90% sensitive
blockade. This means that high Better than the edrophonium test.
concentrations of ACh are needed in If AChR antibodies are negative, consider
the synapse to yield the same muscle testing for anti-MUSK antibodies (muscle
strength. Since repetitive use exacerbates specific kinase)
the receptor blockade, the muscles that
are used the most are effected the most 364. What is the most What is the most accurate test for
(in fact, this is the direct opposite of accurate test for myasthenia gravis?
Lambert-Eaton syndrome). myasthenia gravis? EMG w/ repetitive stimulation
[...]
EMG will show decreased amplitude w/

361. A pt presents A pt presents complaining about double repeated stimulation.
complaining about vision and difficulty swallowing that is
double vision and worse at the end of the day. She states 365. Which drug is the Which drug is the first-line and best initial
difficulty that rest makes it better and that she first-line and best treatment for myasthenia gravis?
swallowing that is feels close to normal every morning. What initial treatment for Pyridostigmine; neostigmine
worse at the end of physical exam findings may be noted at myasthenia gravis?
the day. She states the eye? [...]
that rest makes it Ptosis; intact pupillary reflexes i.e. long acting AChE inhibitors, thereby
better and that she increasing ACh concentrations in the
feels close to normal synapse
every morning. What Very severe MG can affect respiratory
physical exam muscles
findings may be
appropriate next step the management of myasthenia gravis that
noted at the eye?
in the management is refractory to medical treatment?
[...]
of myasthenia gravis Thymectomy if < 60 y/o; Prednisone if >
that is refractory to 60 y/o
362. How do pupillary How do pupillary reflexes change in medical treatment?
reflexes change in myasthenia gravis? [...]
myasthenia gravis? Normal Thymectomy in MG is often curative (or
[...] atleast markedly improves symptoms).
AZT, tacrolimus, cyclophosphamide, or
MG involves progressive daily mycophenolate mofetil are all typically
fatigability due to the post-synaptic AChR used to wean pts off steroids to avoid long
blockade. This means that high term use and complications.
concentrations of ACh are needed in The point here is that T-cell function
the synapse to yield the same muscle needs to be suppressed to decrease
strength. Since repetitive use exacerbates antibody formation. All of the above would
the receptor blockade, the muscles that achieve this.
are used the most are effected the most
(in fact, this is the direct opposite of
Lambert-Eaton syndrome).
46 of 340
367. Which imaging study Which imaging study should be ordered if 372. What neuromuscular What neuromuscular junction structure is
should be ordered if a pt is Dx with myasthenia gravis? junction structure is targeted in Lambert-Eaton Syndrome?
a pt is Dx with Chest imaging targeted in Presynaptic Ca channels
myasthenia gravis? Lambert-Eaton
[...] Syndrome?
To look for thymoma. [...] Resulting in decreased ACh release
Can be anything really: CT, MRI, CXR. downstream.
CT with contrast would technically be the
best study.
368. Which autoimmune Which autoimmune cause of weakness is 373. Which muscles are Which muscles are effected the most in
cause of weakness is associated with thymoma? effected the most in Lambert-Eaton syndrome?
associated with Myasthenia Gravis Lambert-Eaton Proximal musculature
thymoma? syndrome? LES involves daily weakness that
[...] [...] improves with repeated use as
successive impulses create a positive Ca
gradient that is able to more easily
369. A pt is strongly A pt is strongly suspected to have
overcome circulating antibodies. As a
suspected to have myasthenia gravis. Initial antibody testing
result, the muscles that are used the
myasthenia gravis. is negative for AChR-antibodies. Which
least are affected the most.
Initial antibody other autoantibodies can you consider
testing is negative for testing for?
AChR-antibodies. Anti-MUSK antibodies
Which other 374. What is the What is the difference in the weakness
autoantibodies can difference in the seen in myasthenia gravis vs.
you consider testing Anti-muscle specific kinase weakness seen in lamber-eaton syndrome?
for? myasthenia gravis MG weakness worsens through the
[...] vs. lamber-eaton day; LES weakness improves
syndrome? MG involves progressive daily
[...] fatigability due to the post-synaptic AChR
370. [...] is a short-acting Edrophonium is a short-acting AChE
blockade. This means that high
AChE inhibitor that is inhibitor that is used to test for myasthenia
concentrations of ACh are needed in
used to test for gravis.
the synapse to yield the same muscle
myasthenia gravis.
strength. Since repetitive use exacerbates
the receptor blockade, the muscles that
Positive test = clear improvement in
are used the most are effected the most
symptoms for a few minutes
(in fact, this is the direct opposite of
Lambert-Eaton syndrome).
371. A pt with known A pt with known myasthenia gravis
myasthenia gravis presents to the ER in life-threatening
presents to the ER in condition. She has diffuse, severe, LES involves daily weakness that
life-threatening overwhelming muscle weakness with improves with repeated use as
condition. She has respiratory involvement. What is the best successive impulses create a positive Ca
diffuse, severe, treatment for this crisis? gradient that is able to more easily
overwhelming IVIG; or plasmapharesis overcome circulating antibodies. As a
muscle weakness result, the muscles that are used the
with respiratory least are affected the most.
involvement. What is This is acute myasthenic crisis
the best treatment for
this crisis?
[...]
47 of 340
375. What is the best test What is the best test for Lambert-Eaton 380. What is the most What is the most appropriate next step in
for Lambert-Eaton syndrome? appropriate next step the management of a pt in whom
syndrome? EMG in the management dementia has been established?
[...] Dx is clinical, however you can check of a pt in whom Rule out all reversible causes
anti-Ca-Receptor antibodies and do an dementia has been
EMG established?
EMG will show improvement with [...]
repeated use (opposite of MG)
376. Which imaging study Which imaging study should be ordered in 381. What is the most What is the most common cause of
should be ordered in a pt diagnosed with Lambert-Eaton common cause of organic dementia?
a pt diagnosed with Syndrome? organic dementia?
Lambert-Eaton Chest imaging Alzheimer's Disease
Syndrome? [...]
[...]
I suppose anything would be fine:
382. Which organic cause Which organic cause of dementia is
CT/MRI/CXR. However, CT is the best
of dementia is associated with neurofibrillary tangles,
test.
associated with neurotic plaques and amyloid
neurofibrillary deposition?
377. Which cancer is most Which cancer is most commonly tangles, neurotic Alzheimer Disease (AD)
commonly associated with Lambert-Eaton syndrome? plaques and
associated with Small cell lung cancer amyloid
Lambert-Eaton deposition?
syndrome? [...]
[...] Which responds well to chemo.
383. Which test is able to Which test is able to offer definitive

378. What is the cure for What is the cure for Lambert-Eaton offer definitive diagnosis of Alzheimer Disease?
Lambert-Eaton syndrome? diagnosis of Biopsy on autopsy
syndrome? Curing the cancer that caused it Alzheimer Disease?
[...] [...]
Initial Dx is clinical; autopsy will confirm s/p
Remember, it is a paraneoplastic death.
syndrome. Biopsy will reveal neurofibrillary tangles,
If a cure is not feasible, then prednisone neurotic plaques and amyloid
can control symptoms (but this is deposition.
considered a palliative measure).

379. What 2 neurological What 2 neurological findings are essential of dementia is classically associated with an insidious
findings are essential to the diagnosis of dementia? classically onset and loss of memory first?
to the diagnosis of Memory loss; and cognitive function associated with an Alzheimer's
dementia? insidious onset and
[...] loss of memory
Having trouble finding your keys is not first? Social graces are spared until later
sufficient to diagnose dementia. [...] disease.
A MMSE must be done to assess cognitive
changes (especially attention,
concentration and/or executive
function)
48 of 340
385. Which CT findings Which CT findings are seen in Alzheimer's 390. What is the preferred What is the preferred diagnostic test for
are seen in Disease? diagnostic test for Pick's Disease?
Alzheimer's Diffuse cortical atrophy Pick's Disease? None
Disease? [...]
[...]
Dx is clinical

of dementia is associated with chromosome 21 trisomy? 391. What is the treatment What is the treatment for Pick's Disease?
associated with Alzheimers for Pick's Disease? None
chromosome 21 [...]
trisomy?
[...] A large number of Down Syndrome pts >
392. Which transplant Which transplant procedure can be
40 y/o have Alzheimer's Disease.
procedure can be associated with prion transmission?
associated with Corneal transplant
387. Which class of Which class of autonomic drugs is typically prion transmission?
autonomic drugs is used in the treatment of Alzheimer's [...]
typically used in the Disease? However, the most common way to get a
treatment of Cholinergics (namely, AChE inhibitors) prion disease is spontaneous mutation.
Alzheimer's
Disease?
393. Which organic cause Which organic cause of dementia should
[...] Aricept (donepezil) is used most often.
of dementia should be considered in a pt that is too young for
Rivastigmine and galantamine are also
be considered in a pt dementia and displays a rapid decline in
options.
that is too young for cognitive function (within 1 year)?
All 3 have equal efficacy and slow
dementia and Creutzfeldt-Jakob Disease (CJD)
progression of the disease.
displays a rapid
- remember, in Alzheimer's the
decline in cognitive
hippocampus is affected first. Increasing
function (within 1
[ACh] at the hippocampus helps w/ the
year)?
memory deficits and slows progression of
[...]
the disease. ACh also regulates DA
release at the Basal Ganglia, thereby
helping w/ movement. 394. Which brain CT/MRI Which brain CT/MRI findings are seen in
findings are seen in Creutzfeldt-Jakob Disease (CJD)?
Creutzfeldt-Jakob Normal
388. Which organic cause Which organic cause of dementia involves
Disease (CJD)?
of dementia involves behavioural changes before memory
[...]
behavioural loss?
changes before Pick's Disease; Frontotemporal
memory loss? dementia
[...]
389. How do the brain CT How do the brain CT findings in

findings in Alzheimer's Disease differ from Pick's
Alzheimer's Disease Disease?
differ from Pick's AD = diffuse cortical atrophy; PD =
Disease? frontal and hypothalamic degeneration
[...]
49 of 340
395. A 25 y/o pt A 25 y/o pt complains of rapidly 399. A pt has a stroke and A pt has a stroke and suffers an abrupt
complains of rapidly progressing memory loss, suffers an abrupt decline in cognitive function. MMSE and a
progressing inattentiveness and myoclonus over the decline in cognitive good history by the medical intern
memory loss, past 1 year. CT and MRI of the brain are function. MMSE and establishes dementia. What is the most
inattentiveness and both normal. LP reveals 14-3-3 protein. a good history by the likely diagnosis?
myoclonus over the What is the most likely diagnosis? medical intern Multi-infarct (vascular) dementia
past 1 year. CT and Creutzfeldt-Jakob Disease (CJD) establishes
MRI of the brain are dementia. What is
both normal. LP the most likely So, the issue with vascular dementia (VD)
reveals 14-3-3 Key points: younger patient, rapid diagnosis? is that individuals with Alzheimer's (or
protein. What is the progression, myoclonus, normal [...] other organic dementia) will also have
most likely MRI/CT and the 14-3-3 protein in CSF risk factors for stroke (HTN, HLP, T2DM,
diagnosis? Tx is palliative etc.). But since there already is dementia
[...] (and strokes in these pts can lack a FND),
diagnosing a stroke can be difficult. Hence,
diagnosing vascular dementia is tricky.
Abrupt declines that can be tied to a
of dementia is classically associated with myoclonus?
stroke can help in diagnosis (see
classically Creutzfeldt-Jakob Disease (CJD)
below). MRI can reveal past infarcts but
associated with
those may be coincidental (vs. causal).
myoclonus?
At the end of the day: if you are unsure,
[...]
treat it as Alzheimer's and control risk
factors for stroke
397. An elderly male pt An elderly male pt presents complaining
presents complaining of acute onset delirium. He adds that he
400. Which cause of Which cause of dementia is both organic
of acute onset has been having visual hallucinations for
dementia is both and reversible?
delirium. He adds the past year, but finds that they are not
organic and Normal Pressure Hydrocephalus (NPH)
that he has been bothersome. MMSE reveals cognitive
reversible?
having visual deficits in executive function and attention.
[...]
hallucinations for What is the most likely Dx?
the past year, but Lewy-Body Dementia
finds that they are 401. An elderly pt An elderly pt presents complaining of
not bothersome. presents complaining memory loss. A thorough history reveals
MMSE reveals of memory loss. A that he also has balance issues and
cognitive deficits in thorough history urinary incontinence. MMSE reveals
executive function reveals that he also cognitive deficits in executive function.
and attention. What has balance issues There is no papilledemaWhich imaging
is the most likely Dx? and urinary study should be ordered?
[...] incontinence. Head MRI (or CT)
MMSE reveals
cognitive deficits in
executive function. So here I should be thinking of Normal
of dementia is associated with Lewy bodies on biopsy?
There is no Pressure Hydrocephalus (NPH).
associated with Lewy Body Dementia; Parkinsons
papilledemaWhich MRI or CT will reveal whether or not there
Lewy bodies on
imaging study should is hydrocephalus (even if it is present,
biopsy?
be ordered? ICP is normal)
[...]
[...]
50 of 340
402. An elderly pt An elderly pt presents with dementia, 406. What is the What is the diagnostic test for Normal
presents with urinary incontinence and an ataxic gait. diagnostic test for Pressure Hydrocephalus (NPH)?
dementia, urinary MRI reveals cortical atrophy with Normal Pressure Serial LPs
incontinence and an ventricular volume expansion. What is the Hydrocephalus
ataxic gait. MRI most likely diagnosis? (NPH)?
reveals cortical Normal Pressure Hydrocephalus (NPH) [...] If symptoms improve (and clinical picture
atrophy with fits), you got your Dx.
ventricular volume
expansion. What is However, be very careful when it comes
407. CAD is a group of CAD is a group of cardiac disorders that
the most likely to that MRI finding.
cardiac disorders consists of 4 hallmark conditions. What are
diagnosis? Cortical atrophy and subsequent volume
that consists of 4 they?
[...] expansion can be seen in other causes of
hallmark conditions. (see below)
dementia. NPH has specific criteria.
What are they? The underlying pathophysiology is
[...] progressive atherosclerosis of the
403. Which organic cause Which organic cause of dementia is coronary vessels resulting in an imbalance
of dementia is associated with the triad of urinary between cardiac demand and supply,
associated with the incontinence, ataxic gait and dementia? especially when cardiac demand goes
triad of urinary Normal Pressure Hydrocephalus (NPH) up.
incontinence,
ataxic gait and
dementia? aka Wet, Wobbly and Wacky
408. Which illicit drug is a Which illicit drug is a risk factor for CAD?
[...]
risk factor for CAD? Cocaine
[...]
404. Which surgical Which surgical procedure can improve
procedure can symptoms in Normal Pressure
409. A pt presents with A pt presents with crushing retrosternal
improve symptoms in Hydrocephalus (NPH)?
crushing CP that worsens with activity and
Normal Pressure VP shunt
retrosternal CP that improves with rest/nitrates. What type of
Hydrocephalus
worsens with chest pain is this?
(NPH)?
activity and Typical chest pain
[...] In NPH, its the increased CSF that causes
improves with
issues (the dilated ventricles stretch the
rest/nitrates. What
corona radiata).
type of chest pain is Typical CP must involve the following:
Serial LPs are also beneficial (and can aid
this? - retrosternal origin
in diagnosis if symptoms improve).
[...] - worsens with activity
- improves with rest/nitrates
405. Which nonsurgical Which nonsurgical procedure can help Having 3/3 = typical CP; 2/3 = atypical
procedure can help improve symptoms in Normal Pressure CP; <2 = non-anginal CP
improve symptoms in Hydrocephalus (NPH)?
Normal Pressure Serial LPs
410. What are the What are the features of typical chest
Hydrocephalus
features of typical pain?
(NPH)?
chest pain? (see below)
[...] VP shunting would be the neurosurgery
[...]
procedure I'm alluding to.
Typical CP must involve the following:

- retrosternal origin
- worsens with activity
- improves with rest/nitrates
Having 3/3 = typical CP; 2/3 = atypical
CP; <2 = non-anginal CP
51 of 340
411. A pt w/ newly A pt w/ newly diagnosed STEMI develops 417. What is the most What is the most appropriate next step in
diagnosed STEMI pulmonary edema. What may this be a appropriate next step the management of a pt w/ chest pain after
develops pulmonary sign of? in the management an EKG has revealed STEMI?
edema. What may L heart failure 2/2 the MI and necrosis of a pt w/ chest pain Cardiac catheterization
this be a sign of? after an EKG has
[...] revealed STEMI?
[...] The magic number w/ the cath lab is 60. If
you can get the pt to a cath lab/PCI
412. A pt w/ newly A pt w/ newly diagnosed STEMI develops
facility within 60 minutes, then go for it.
diagnosed STEMI hypotension and peripheral edema.
If you cannot, administer tPA.
develops What may this be a sign of?
hypotension and R heart failure 2/2 the MI and necrosis
peripheral edema. 418. What laboratory tests What laboratory tests need to be ordered
What may this be a need to be ordered to rule out acute MI?
sign of? to rule out acute MI? Cardiac biomarkers (troponin, CKMB,
[...] [...] etc.)
413. Which type of Which type of myocardial infarction is

These are important. They separate
myocardial infarction known to cause arrhythmias?
angina from STEMI/NSTEMI.
is known to cause All of them
CBC, TSH, CMP are typically all done as
arrhythmias?
well, but they do not help with diagnosis
[...]
and ruling out.
414. A pt presents to the A pt presents to the ER w/ chest pain.

419. What is the most What is the most appropriate diagnostic
ER w/ chest pain. Which question during the HPI is vital to
appropriate test for a pt w/ chest pain, but no STEMI or
Which question determine the severity of the cardiac
diagnostic test for a NSTEMI?
during the HPI is vital ischemia, if any?
pt w/ chest pain, but Stress test
to determine the Does the pain improve with rest or
no STEMI or
severity of the nitrates?
NSTEMI?
cardiac ischemia, if
[...]
any?
[...]
420. Which type of stress Which type of stress test requires the
test requires the patient to have a normal EKG and to be
415. What is the best, first What is the best, first test in the workup of
patient to have a able to exercise (up to 80% of max HR)?
test in the workup of a pt w/ chest pain?
normal EKG and to Treadmill
a pt w/ chest pain? 12 lead EKG
be able to exercise
[...] The EKG is quick, cheap and accurate. It
(up to 80% of max
is also prudent, as it establishes a baseline
HR)? The pt exercises until there are:
at admission.
[...] - EKG changes, and/or
- chest pain
416. What do ST segment What do ST segment elevations on EKG
elevations on EKG signify?
signify? Transmural infarction
appropriate next step the management of a pt w/ unstable
[...]
in the management angina that has a positive stress test?
of a pt w/ unstable Cardiac catheterization
angina that has a
positive stress
test?
[...]
52 of 340
422. Which type of Which type of cardiac stress test involves 425. Which cardiac stress Which cardiac stress test involves the use
cardiac stress test a pharmacological challenge and test involves the use of thallium to identify healthy and infarcted
involves a concurrent echocardiogram? of thallium to identify cardiac tissue?
pharmacological Dobutamine stress test healthy and infarcted Nuclear stress test
challenge and Typical performed b/c of the pt being cardiac tissue?
concurrent unable to exercise. [...]
echocardiogram? Echocardiogram looks at the tissue while The thallium looks like sodium to the body
[...] the heart is both under stress and at rest: and is taken up by healthy myocytes,
- Normal cardiac tissue will yield normal lighting them up in the process.
findings under stress & at rest Ischemic (at risk) and infarcted (dead)
- Ischemic ("at risk) cardiac tissue will tissue respond similarly to the dobutamine
yield akinesia/dyskinesia/hypokinesia stress test:
under stress and normal findings at rest; - Normal tissue will light up at rest &
this identifies which tissue is salvageable under stress
via cardiac cath - Ischemic (at risk) tissue will light up at
- Infarcted (dead) cardiac tissue will yield rest, but not under stress; this reveals
akinesia/dyskinesia/hypokinesia under salvageable tissue
stress & at rest - Infarcted (dead) tissue will never light
up
426. What is the best test What is the best test for the diagnosis of
for the diagnosis of CAD?
423. Which type of Which type of cardiac stress test is CAD? Cardiac catheterization
cardiac stress test is recommended for pts that cannot [...]
recommended for pts exercise?
that cannot Dobutamine stress test Can assess severity and location of
exercise? stenosis.
[...] Important in ruling out Prinzmetal angina
424. Which chemical Which chemical element is used in 427. Which type of angina Which type of angina occurs in the setting
element is used in nuclear cardiac stress tests? occurs in the setting of clean coronary arteries?
nuclear cardiac Thallium of clean coronary Prinzmetal angina
stress tests? arteries?
[...] [...]
It looks like sodium to the heart and is Remember, this is 2/2 vasospasm and is
taken up by healthy myocytes, thereby treated with a CCB
lighting them up.
428. What is the LDL goal What is the LDL goal in a pt w/ active
in a pt w/ active CAD?
CAD? Atleast <100; preferrably < 70?
[...] Conflicting LDL goals of peace and
prosperity...
There are different recommendations from
multiple top sources, but in general
everyone agrees that LDL should at least
be < 100
Achieve with statins
53 of 340
429. What is the HbA1C What is the HbA1C target for a pt with 434. Which surgical Which surgical procedure is indicated in
target for a pt with CAD? procedure is the mangagement of multi-vessel CAD
CAD? < 7% indicated in the with left mainstem involvement?
[...] mangagement of CABG
multi-vessel CAD
with left mainstem
involvement? If multiple stents would be required, do
430. What is the BP goal What is the BP goal of a pt with CAD?
[...] CABG.
of a pt with CAD? < 140/90
If the occlusions are global and stenting
[...]
won't help, do CABG.
Achieve with ACE-I and beta-blockers

(who also help to reduce arrhythmias) 435. What are the 2 main What are the 2 main types of stents used
types of stents used in coronary angioplasty (PCI)?
in coronary Drug-elusing (DES; requires
431. How is the long-term How is the long-term risk of thrombosis
angioplasty (PCI)? clopidogrel); Bare-metal (does not
risk of thrombosis reduced in a pt with CAD?
[...] require clopidogrel)
reduced in a pt with ASA or clopidogrel
CAD?
[...] 436. Which type of Which type of coronary vessel stent
coronary vessel stent requires the use of clopidogrel?
requires the use of Drug-eluding (DES)
432. A pt w/ presents to A pt w/ presents to the ER with chest pain.
clopidogrel?
the ER with chest An EKG reveals STEMI and the pt is taken
[...]
pain. An EKG to the cath lab upstairs. Which monoclonal
reveals STEMI and antibody is helpful as an additional
the pt is taken to the antiplatelet agent during the 437. What are the What are the indications for the use of tPA
cath lab upstairs. catheterization? indications for the in the management of NSTEMI/STEMI?
Which monoclonal Abciximab (Gp IIb/IIIa inhibitor) use of tPA in the < 12 hrs of onset of symptoms; and
antibody is helpful as Especially useful in pts that are receiving management of cath lab cannot be reached in 60
an additional stents. NSTEMI/STEMI? minutes; and Dx must be NSTEMI or
antiplatelet agent [...] STEMI
during the
catheterization?
[...] If tPA is unavailable or contraindicated,
use heparin.
433. What is the What is the MONA-BASH mnemonic for

MONA-BASH the treatment of acute CAD (e.g. ACS)? 438. Which 4 drugs are Which 4 drugs are used to manage a pt
mnemonic for the (see below) used to manage a pt with chest pain and suspected ACS?
treatment of acute with chest pain and "MONA"
CAD (e.g. ACS)? suspected ACS?
[...] [...]

common cause of non-cardiac chest pain?
non-cardiac chest GERD
pain?
[...]
In general, it's likely a GI disorder. PUD,
cholelithiasis, duodenitis and gastritis can
all present with CP.
54 of 340
440. At what age do the At what age do the rates of CAD in women 446. What change in a What change in a pt's lipid profile is
rates of CAD in begin to equal those in men? pt's lipid profile is considered to be the most dangerous for
women begin to 55-60 considered to be the CAD (in terms of the lipid profile alone)?
equal those in men? most dangerous for Elevated LDL
[...] CAD (in terms of the
The protective effects of menstruation and lipid profile alone)?
naturally ocurring estrogen wear off by [...] Low HDL is associated w/ poor long term
then. However, estrogen replacement prognosis, but is less of a factor than high
does not help CAD. LDL.
Menstruating women very rarely have MI. Elevated triglycerides have an effect but
the outcomes are not as poor as with high
LDL.
441. Overall, which sex Overall, which sex experiences more
experiences more death 2/2 heart disease?
death 2/2 heart Women 447. A postmenopausal A postmenopausal woman develops
disease? woman develops chest pain after hearing that her husband
[...] chest pain after has passed away in a car accident. En
hearing that her route to the ER she develops dyspnea,
husband has passed diaphoresis and SOB. EKG reveals
442. What are the age What are the age cutoffs for increased
away in a car ST-segment elevations. In the cath lab,
cutoffs for increased CAD risk in men and women respectively?
accident. En route to her coronary vessels are clean and no
CAD risk in men and 45 in men; 55 in women
the ER she develops vasospasm is seen on provocation. An
women respectively?
dyspnea, diaphoresis echo is performed and shows apical LV
[...]
and SOB. EKG ballooning. What is the most likely dx?
reveals ST-segment Tako-Tsubo Cardiomyopathy
443. What is considered What is considered the worst risk factor elevations. In the
the worst risk factor for CAD? cath lab, her
for CAD? DM coronary vessels Tako-Tsubo key points:
[...] are clean and no - acute myocardial damage seen most
vasospasm is seen commonly in postmenopausal women
444. What is the most What is the most common risk factor for on provocation. An after overwhelming emotional/stressful
common risk factor CAD? echo is performed news or events (e.g. divorce, financial
for CAD? HTN and shows apical LV issues, death, earthquake, lightning strike,
[...] ~20% of the US population, half of whom ballooning. What is hypoglycemia)
do not even know they are hypertensive the most likely dx? - can involve apical ballooning of the LV
[...] w/ LV dyskinesis
- manage with BB/ACEI like in ischemic
445. A pt's risk for CAD is A pt's risk for CAD is increased if there is a
heart disease
increased if there is a FHx of premature CAD. What makes it
FHx of premature premature?
CAD. What makes it CAD occurring before 55 in men, 65 in
premature? women
[...]
FHx and CAD risk:

- Increased risk if a first-degree relative
has CAD
- Increased risk if any relative has
premature CAD
55 of 340
448. [...] is a type of Taku-Tsubo cardiomyopathy is a type of 451. What are the main What are the main features of ischemic
cardiomyopathy and cardiomyopathy and cause of acute features of ischemic chest pain?
cause of acute myocardial damage that is associated with chest pain? Dull/sore; squeezing/pressure-like
myocardial damage "ballooning" of the LV apex and LV [...]
that is associated dyskinesia.
with "ballooning" of Ischemic pain is never pleuritic (changes
the LV apex and LV w/ respirations), positional (changes w/
dyskinesia. Tako-Tsubo key points: body position) or reproducible by
- acute myocardial damage seen most palpation (tender).
commonly in postmenopausal women The presence of any of those 3 excludes
after overwhelming emotional/stressful ischemic chest pain w/ a 95% negative
news or events (e.g. divorce, financial predictive value. In real life this isn't wise
issues, death, earthquake, lightning strike, (1 in 20 would go misdiagnosed), but for
hypoglycemia) the exam, roll with it.
- can involve apical ballooning of the LV
w/ LV dyskinesis
452. What percentage of What percentage of chest pain complaints
- manage with BB/ACEI like in ischemic
chest pain in the ER have a cardiac etiology?
heart disease
complaints in the ER < 50%
have a cardiac
449. A pt comes to your A pt comes to your clinic for an annual etiology?
clinic for an annual health check-up. She states that her 68 y/o [...]
health check-up. She mother is beginning to develop CAD. How
states that her 68 y/o does this affect your pt's risk for CAD?
453. A pt presents with A pt presents with chest pain. On physical
mother is beginning No change
chest pain. On exam he has a tender chest wall. What is
to develop CAD.
physical exam he the most likely Dx?
How does this affect
has a tender chest Costochondritis
your pt's risk for CAD in elderly relatives does not
wall. What is the
CAD? increase an individual's risk.
most likely Dx?
[...]
[...] Most accurate test is physical exam
450. Which major risk Which major risk factor towards CAD
454. A pt presents with A pt presents with chest pain that radiates
factor towards CAD offers the most immediate benefit if
chest pain that to the back. On physical exam, he has
offers the most corrected?
radiates to the unequal blood pressure between his
immediate benefit if Smoking cessation
back. On physical UE. What is the most likely Dx?
corrected?
exam, he has Aortic dissection
[...]
unequal blood
1 year s/p quitting = 50% decreased CAD
pressure between
risk
his UE. What is the
2 years s/p quitting = 90% decreases■d
most likely Dx?
CAD risk
[...]
455. A 30 y/o pt presents A 30 y/o pt presents with chest pain. He

with chest pain. He states that it is worse when lying flat and
states that it is better when sitting up. What is the most
worse when lying likely Dx?
flat and better when Pericarditis
sitting up. What is
the most likely Dx?
[...]
56 of 340
456. A pt presents with A pt presents with chest pain. He states 461. What is the most What is the most appropriate initial
chest pain. He states that it is better when eating. On physical appropriate initial diagnostic test in the management of
that it is better when exam he has mild epigastric tenderness diagnostic test in the acute chest pain in an outpatient
eating. On physical and discomfort. What is the most likely management of setting?
exam he has mild Dx? acute chest pain in Transfer to the ER; or EKG and then
epigastric Duodenal ulcer an outpatient transfer
tenderness and setting?
discomfort. What is [...]
the most likely Dx? The point to remember is that you should
[...] never check for cardiac enzymes in the
outpatient setting. Get that pt to an ER
stat.
457. A pt presents with A pt presents with chest pain. She also
chest pain. She also complains of cough, hoarseness in the
complains of cough, morning and a metallic taste in her 462. Which 2 major Which 2 major factors in the workup of
hoarseness in the mouth whenever she lays down. What is factors in the workup chest pain influence whether or not an
morning and a the most likely Dx? of chest pain exercise stress test is appropriate?
metallic taste in her GERD influence whether or The pt's EKG is readable; and the pt
mouth whenever not an exercise can exercise
she lays down. What stress test is
is the most likely Dx? appropriate?
[...] [...] Exercise = getting HR > 85% of maximum.
Max HR = 200 - age
If not, consider other types of stress testing
458. A pt presents with A pt presents with chest pain. She
(dobutamine, nuclear)
chest pain. She describes it as a sharp, knife-like pain
describes it as a that worsens on inspiration. What is the
sharp, knife-like most likely Dx? 463. What are the most What are the most common causes of
pain that worsens Pneumothorax common causes of baseline EKG abnormalities?
on inspiration. What baseline EKG LBBB; LVH; pacemaker use; digoxin
is the most likely Dx? abnormalities?
[...] [...]
In such cases, EKG's are not reliable to
detect ischemic changes. Especially w/
459. How does SOB in How does SOB in the setting of chest pain
LBBB (all left bundles have ST elevation).
the setting of chest influence prognosis?
Hence, to detect ischemia in such cases,
pain influence Worse prognosis
we perform an echo or stress test (or
prognosis?
combine the two).
[...]
464. What are the What are the pharmacological cardiac

pharmacological stress tests?
appropriate next step the management of chronic/stable chest
cardiac stress tests? Dipyridamole/adenosine +
in the management pain in an outpatient setting?
[...] thallium/sestamibi; Dobutamine + echo
of chronic/stable EKG
chest pain in an
outpatient setting?
Avoid dipyridamole in asthma due to risk
[...]
of bronchospasm.
These methodologies are equal in
sensitivity and specificity.
57 of 340
465. In the general sense, In the general sense, when is a cardiac 472. What is the ROA of What is the ROA of nitroglycerin when
when is a cardiac stress test indicated? nitroglycerin when managing acute coronary syndrome?
stress test indicated? Chest pain of unclear etiology w/ a managing acute Sublingual; IV; paste
[...] non-diagnostic EKG coronary
syndrome?
[...]
466. Which diagnostic test Which diagnostic test is used to detect the
is used to detect the anatomical location of CAD?
anatomical location Coronary Angiography 473. How many How many antiplatelet medications should
of CAD? antiplatelet a pt with ACS receive?
[...] medications should a 2
Also determines what the next best step is: pt with ACS receive?
angioplasty vs. CABG [...]
Typically ASA and one of clopidogrel,
prasugrel, or ticagrelor.
467. What is the most What is the most accurate test for CAD?
All 3 inhibit P2Y12 receptors on platelets
accurate test for Coronary Angiography
CAD?
[...] 474. Which antiplatelet Which antiplatelet agents are most
Sometimes used if EKG and stress testing agents are most effective at preventing re-stenosis of a
are equivocal. effective at stent if angioplasty w/ stenting is planned?
preventing Prasugrel; ticagrelor
re-stenosis of a
468. What percentage of What percentage of stenosis is an
stent if angioplasty
stenosis is an indication for surgical intervention?
w/ stenting is The above 2 and clopidogrel are all
indication for surgical > 70%
planned? beneficial, but the above 2 are most
intervention?
[...] beneficial.
[...]
475. Which 2 drug classes Which 2 drug classes offer the best
469. What findings on What findings on coronary angiography
offer the best mortality benefit in a pt w/ chronic
coronary are an indication for CABG?
mortality benefit in angina?
angiography are an ≥ 3 vessel disease; left main disease; ≥
a pt w/ chronic ASA; BBs
indication for CABG? 2 vessel disease in diabetics
angina?
[...]
[...]
1-2 vessel disease = stenting

476. What are the main What are the main indications for the use
indications for the of clopidogrel in the setting of CAD?
470. Is the Holter monitor Is the Holter monitor useful for detecting
use of clopidogrel in (see below)
useful for detecting ischemia (ST segment changes)?
the setting of CAD?
ischemia (ST No; it's useful in detecting rhythm
[...]
segment changes)?
Main indications/uses include:
[...]
1. In combination w/ ASA in the
management of ACS
471. What is the ROA of What is the ROA of nitroglycerin when 2. ASA intolerance/allergy
nitroglycerin when managing chronic angina? 3. s/p recent coronary stenting
managing chronic Oral; Transdermal
angina?
[...]
58 of 340
477. A pt > 75 y/o is A pt > 75 y/o is planned to undergo 481. A pt w/ CAD and an A pt w/ CAD and an ejection fraction of
planned to undergo angioplasty w/ stenting following an ejection fraction of 20% is taking lisinopril as part of his
angioplasty w/ NSTEMI. The cardiology fellow opts to use 20% is taking management. On an annual check-up, you
stenting following an the antiplatelet ticagrelor for the lisinopril as part of notice that he is hyperkalemic. Which
NSTEMI. The procedure instead of prasugrel. Why? his management. On vasodilating agent should you switch him
cardiology fellow Prasugrel has an increased risk of an annual check-up, to?
opts to use the hemorrhagic stroke in pts > 75 you notice that he is Hydralazine (with nitrates)
antiplatelet hyperkalemic.
ticagrelor for the Which vasodilating
procedure instead of agent should you Hydralazine is a direct-acting arterial
prasugrel. Why? switch him to? vasodilator. Hydralazine will decrease
[...] [...] afterload and has been shown to have a
clear mortality benefit in patients with
systolic dysfunction. Hydralazine should
478. A pt w/ acute A pt w/ acute coronary syndrome has an
be used in association with nitrates to
coronary syndrome ASA allergy and is intolerant to
dilate the coronary arteries so that blood is
has an ASA allergy clopidogrel. Which anti-platelet
not "stolen" away from coronary perfusion
and is intolerant to medication can be used in this pt?
when afterload is decreased with the use
clopidogrel. Which Ticlopidine
of hydralazine
anti-platelet
Despite the fact that ACE-i/ARBs have
medication can be
proven mortality benefit in CAD w/ systolic
used in this pt? Can cause neutropenia and TTP.
dysfunction, changing this ACE to an ARB
[...]
would not mitigate the hyperkalemia as
aldosterone is still inhibited downstream.
479. Ticlopidine is an Ticlopidine is an anti-platelet agent that is
anti-platelet agent used when a pt is intolerant to ASA and
482. Which 5 conditions Which 5 conditions are considered to be
that is used when a clopidogrel (for reasons other than
are considered to be CAD equivalents when it comes to LDL
pt is intolerant to bleeding risk). Which adverse effects
CAD equivalents goal?
ASA and clopidogrel should be monitored for?
when it comes to PAD; Carotid disease; Aortic disease
(for reasons other Neutropenia; TTP
LDL goal? (not the valve); Stroke; DM
than bleeding risk).
[...]
Which adverse
effects should be
monitored for? 483. Which class of Which class of antihyperlipidemics is
[...] antihyperlipidemics is associated with a definite mortality benefit
associated with a in managing HLP in any setting?
definite mortality Statins
480. Which class(es) of Which class(es) of drugs offer the best
benefit in managing
drugs offer the best mortality benefit for CAD w/ low EF or
HLP in any setting?
mortality benefit for regurgitant valvular disease?
[...] In fact, only statins
CAD w/ low EF or ACEIs; ARBs
regurgitant valvular
disease? 484. What is the most What is the most common side effect of
[...] common side effect statins?
of statins? Liver dysfunction
[...]
LFTs are indicated in pts taking statins

even if they are asymptomatic.
59 of 340
485. Which class of Which class of antihyperlipidemics has an 490. What are the most What are the most common side effects w/
antihyperlipidemics antioxidant effect on endothelium? common side effects statins?
has an antioxidant Statins w/ statins? Elevated LFTs; myositis
effect on [...] Follow up LFTs are indicated when starting
endothelium? statins
[...] This is an added benefit on top of lowering
LDL.
Statins are by far the best initial
491. What are the most What are the most common side effects of
antihyperlipidemic and has the best
common side effects niacin?
mortality benefit in CAD.
of niacin? Hyperglycemia; Hyperuricemia;
[...] Pruritus
486. Statins can aid in Statins can aid in increasing HDL levels.
increasing HDL Which other class of antihyperlipidemics is
levels. Which other a great choice to add on top of statins?
class of Niacin
492. What are the most What are the most common side effect of
antihyperlipidemics is
common side effect fibrates (e.g. gemfibrozil)?
a great choice to add
of fibrates (e.g. Increased risk of myositis when
on top of statins? Niacin is a great choice to add on if statins
gemfibrozil)? combined w/ statins
[...] are not effective. It also increases HDL.
[...]
Niacin is associated w/ glucose
intolerance, hyperuricemia, and pruritis
(2/2 histamine release)
493. What are the most What are the most common side effects of
common side effects bile acid sequestrants (e.g.
487. Combining fibrates Combining fibrates (e.g. gemfibrozil) and
of bile acid cholestyramine)?
(e.g. gemfibrozil) and statins can increase the risk of a common
sequestrants (e.g. Flatus; abdominal cramping; GI upset
statins can increase side effect. What is it?
cholestyramine)?
the risk of a common Myositis
[...]
side effect. What is
it?
[...] 494. What are the most What are the most common side effects of
common side effects ezetimibe?
of ezetimibe? None
488. Which class of Which class of antihyperlipidemics has
[...]
antihyperlipidemics significant interactions w/ other
has significant medications in the gut lumen?
But it's also useless
interactions w/ other Bile Acid Sequestrants (e.g.
medications in the cholestyramine)
gut lumen? 495. Which CCBs are Which CCBs are effective at lowering
[...] effective at lowering mortality in CAD?
Namely by hindering their absorption. mortality in CAD? None
Can also cause GI upset, constipation and [...]
flatus
CCBs increase HR and hence do not
improve mortality. They are negative
489. When should other When should other antihyperlipidemic
inotropes, but the increase in HR results
antihyperlipidemic agents be considered to be added on top
in a net increase in myocardial oxygen
agents be of statins?
consumption.
considered to be When statins alone cannot reach the
Nifedipine is notorious for causing reflex
added on top of LDL goal (< 70-100)
tachycardia
statins?
So don't use CCBs in CAD.
[...]
60 of 340
496. What are the few What are the few indications for the use of 501. What is the best What is the best intervention for STEMI?
indications for the non-dihydropyridine CCBs (e.g. intervention for PCI
use of verapamil; diltiazem) in CAD? STEMI?
non-dihydropyridine (see below) [...]
CCBs (e.g. PCI has no added benefit in stable CAD,
verapamil; diltiazem) but may decrease dependence on meds
in CAD? Common indications include: and decrease the frequency of angina
[...] - Severe asthma that makes episodes
beta-blockers contraindicated
- Prinzmetal angina (remember this is 2/2
502. What abnormal heart What abnormal heart sound is associated
vasospasm)
sound is associated with acute coronary syndrome?
- Cocaine-induced chest pain
with acute coronary
(beta-blockers are contraindicated)
syndrome? S4
497. What are the most What are the most common side effects of [...]
common side effects CCBs? Ischemia causes noncompliance of the LV
of CCBs? Edema; constipation (namely
[...] verapamil); heart block (rare)
503. What is Kussmaul What is Kussmaul sign?
sign? Increased JVP on inspiration
498. CABG has been CABG has been shown to lower mortality [...]
shown to lower only in very severe CAD. What are these
mortality only in very circumstances? Typically associated w/ constrictive
severe CAD. What (see below) pericarditis or restrictive cardiomyopathy
are these
circumstances?
504. Which condition is Which condition is Kussmaul sign
[...] Severe CAD & performing CABG:
Kussmaul sign classically associated with?
- 3 vessel disease w/ > 70% stenosis
classically Constrictive pericarditis; restrictive
- Left main disease
associated with? cardiomyopathy
- 2 vessel disease in T2DM
[...]
- persistent symptoms despite maximal
medical therapy
505. A pt complains of A pt complains of severe chest pain. On
severe chest pain. examination he has kussmaul sign and a
499. How long to internal How long to internal mammary artery
On examination he triphasic "scratchy" sound is heard.
mammary artery grafts last s/p CABG?
has kussmaul sign What is the most likely Dx?
grafts last s/p ~ 10 yrs
and a triphasic Pericarditis
CABG?
"scratchy" sound is
[...]
heard. What is the
IMA ~ 10 yrs
most likely Dx?
Saphenous ~ 5 yrs
[...]
500. How long do How long do saphenous vein grafts remain

506. Which type of Which type of pericarditis can occur as a
saphenous vein patent s/p CABG?
pericarditis can occur complication of MI?
grafts remain patent ~5 yrs
as a complication of Dressler syndrome
s/p CABG?
MI?
[...]
[...]
61 of 340
507. ST elevation in which ST elevation in which EKG leads is 511. A pt presents c/o of A pt presents c/o of substernal chest pain.
EKG leads is associated w/ the worst prognosis? substernal chest EKG reveals STEMI in V2-V4. What is the
associated w/ the V2-V4 pain. EKG reveals first drug/intervention that should be
worst prognosis? STEMI in V2-V4. given/performed?
[...] What is the first ASA
i.e. the anterior wall/LAD leads drug/intervention that
- Inferior wall MI: in leads II, III, aVF; should be
untreated mortality < 5% given/performed? Aspirin lowers mortality in ACS and
- Anterior wall MI: in leads V2-V4; [...] should be given STAT.
untreated mortality is 30-40% - Morphine, oxygen and NO are mostly for
- Posterior wall MI: reciprocal ST symptoms and do not decrease mortality
depression in V1-2; untreated mortality is However, still understand that this patient
very low still needs to get to the cath lab within 1
hour. But the first thing you should do is
slingshot an aspirin down the pt's throat
508. Which cardiac Which cardiac disorder is classically
(not actually, just adding dramatic effect
disorder is classically associated w/ a PR interval > 200 msec?
here), often on the way to the cath lab.
associated w/ a PR First-degree AV block
Plavix (clopidogrel) is indicated if the pt
interval > 200
has an ASA allergy or prior stenting.
msec?
After ASA is given, get the pt to the cath
[...] Little pathogenic potential; does not
lab or administer tPA.
require therapy when in isolation
Regardless, aspirin is recommended to
be given first and then some form of
509. A pt w/ STEMI A pt w/ STEMI develops PVCs on his revascularization.
develops PVCs on EKG. What is the most appropriate
his EKG. What is the treatment for this new finding?
most appropriate None
appropriate next step the management of a STEMI after the pt
treatment for this
in the management has received ASA?
new finding?
of a STEMI after the Angioplasty
[...] PVCs should not be treated, even if they
pt has received
are 2/2 MI.
ASA?
Treatment of these PVCs worsens
[...] Angioplasty has a very high mortality
outcome.
benefit vs. other steps in management (all
of which the pt is going to get anyway; e.g.
510. ST depression in ST depression in leads V1-V2 can be MONA-BASH)
leads V1-V2 can be associated w/ MI. In which anatomical
associated w/ MI. In region of the heart would this MI be
513. How is troponin How is troponin excreted?
which anatomical localized?
excreted? Via kidneys
region of the heart Posterior wall infarct
[...]
would this MI be
localized?
Hence, a pt w/ renal insufficiency can have
[...] V1 and V2 are often read in the opposite
a false positive troponin result.
direction.
i.e. ST depression in these leads could
very easily by ST elevation in other leads
and should be treated as such
In general, posterior wall MI have low
mortality.
62 of 340
514. Which cardiac Which cardiac biomarker is used to assess 518. What are the most What are the most common complications
biomarker is used to the presence of a reinfarction? common of PCI?
assess the presence CK-MB complications of (see below)
of a reinfarction? PCI?
[...] [...]
CK-MB levels normalize after 48 hrs. So - Rupture of the ballooned coronary artery
if there is a rise in CK-MB after 48 hrs of - Re-stenosis of the stent s/p PCI
admission, a reinfarction is likely. From - Hematoma at the catheter insertion site
here do an EKG (or well, this should be (i.e. femoral area hematoma)
first before CK-MB) to assess for new ST
segment changes.
519. What type of PCI What type of PCI stenting has been shown
stenting has been to have the greatest effect in reducing the
515. What is the most What is the most common cause of death shown to have the risk of re-stenosis s/p PCI?
common cause of the first few days s/p MI? greatest effect in Drug eluding stent (DES)
death the first few Ventricular arrhythmia reducing the risk of
days s/p MI? re-stenosis s/p PCI?
[...] [...] Remember, DES involves the presence
This is why pt's should be admitted to the of paclitaxel and/or sirolimus.
ICU or CCU s/p PCI. Continuous - inhibiting the T-cell response at the site of
monitoring/telemetry is vital in improving stenting is vital in preventing re-stenosis
mortality. If needed, the ICU/CCU is - Heparin is typically only used during the
equipped w/ electrical cardioversion. So procedure and not long term; Warfarin is
"admission to ICU/CCU" can be a correct not used
answer. Re-stenosis rates 6 months s/p PCI:
- No stent: 30-40%
- Bare metal stent: 15-30%
516. What is the gold What is the gold standard "door to balloon
- DES < 10%
standard "door to time" in terms of PCI?
balloon time" in 60-90 min
terms of PCI? 520. What are the What are the absolute contraindications to
[...] absolute tPA use in ACS?
I see 60 some places, 90 in others. contraindications to (see below)
tPA use in ACS?
[...]
517. What is the superior What is the superior intervention in terms
Absolute contraindications to tPA in
intervention in terms of survival, mortality and complications:
ACS:
of survival, mortality PCI or tPA?
- Major GI bleed
and complications: PCI
- Hemorrhagic stroke or intracranial
PCI or tPA? PCI's effect on complications:
hemorrhage; ischemic stroke in the past 6
[...] - fewer arrhythmia
months
- less CHF
- Recent surgery within 2 weeks
- fewer septal ruptures
- fewer free wall ruptures
- fewer papillary muscle/valvular ruptures
63 of 340
521. What percentage What percentage mortality benefit is seen 526. Which type of Which type of Heparin is superior in terms
mortality benefit is w/ tPA use in ACS? Heparin is superior in of mortality benefit?
seen w/ tPA use in 50% relative risk reduction if given in terms of mortality LMWH
ACS? the first 2 hours benefit?
[...] [...]
vs. unfractionated heparin
A pt coming in w/ CP found to have
NSTEMI/STEMI should get tPA within 30
527. What is the common What is the common sign/symptom in all of
minutes of walking through the door ("door
sign/symptom in all the complication of MI?
to needle time").
of the complication of Hypotension
MI?
522. What is the benefit of What is the benefit of tPA in ST [...]
tPA in ST depression ACS? Hence, hypotension is not going to help
depression ACS? None determining the Dx.
[...]
528. Which sign/symptom Which sign/symptom is vital in

If there is no ST elevation, there is no
is vital in distinguishing between the complications
benefit to tPA.
distinguishing of MI and establishing a diagnosis?
between the Heart rate
523. A pt presents c/o A pt presents c/o chest pain for the last complications of MI
chest pain for the last hour. It is crushing and radiates up to the and establishing a
hour. It is crushing jaw and down his left arm. EKG reveals ST diagnosis? Bradycardia = likely sinus brady (very
and radiates up to depression in V2-V4. ASA is given and [...] common) or 3rd degree AV block
the jaw and down his the pt is admitted. What is the most Tachycardia = likely RV infarction,
left arm. EKG reveals appropriate next step? tamponade/free wall rupture, VTach/VFib,
ST depression in LMW Heparin valve rupture, septal rupture
V2-V4. ASA is given
and the pt is
529. A pt s/p recent A pt s/p recent STEMI is found to have
admitted. What is the Heparin & ST Depression ACS:
STEMI is found to bradycardia. Physical exam does not
most appropriate - Heparin must be given urgently to
have bradycardia. reveal any abnormalities. What is the most
next step? prevent clot growth and further coronary
Physical exam does likely Dx?
[...] occlusion.
not reveal any Sinus bradycardia
- Remember, heparin does not break
abnormalities. What
down clots
is the most likely Dx?
There is no shown benefit of tPA in ST
[...] Sinus bradycardia is very common after
depression ACS
MI due to vascular insufficiency at the
SA node.
524. In which type of ACS In which type of ACS is tPA is most Lack of cannon A waves points away from
is tPA is most beneficial? AV block, but get an EKG to confirm.
beneficial? STEMI
[...]
525. Which Which anticoagulation agent is considered

anticoagulation agent best for NSTEMI?
is considered best for Heparin
NSTEMI?
[...]
64 of 340
530. A pt s/p recent MI A pt s/p recent MI develops bradycardia. 534. A pt s/p recent A pt s/p recent STEMI suddenly develops
develops Physical exam reveals cannon A waves STEMI suddenly pulseless electrical activity (PEA). On
bradycardia. at the JVP. What is the most likely Dx? develops pulseless physical exam, lung sounds are clear
Physical exam 3rd degree/complete AV block electrical activity and there is JVD. What is the most likely
reveals cannon A (PEA). On physical Dx?
waves at the JVP. exam, lung sounds Cardiac Tamponade 2/2 ventricular free
What is the most Get an EKG to confirm (rule out sinus are clear and there wall rupture
likely Dx? brady). is JVD. What is the It typically takes several days after an MI
[...] Can be associated with RV infarction most likely Dx? for the wall to scar and weaken enough to
Cannon A Waves: [...] rupture.
- classical of complete AV block Seeing "sudden loss of pulse" in the
- produced 2/2 right atrial contraction vignette is common.
against a closed tricuspid valve (closed Dx w/ emergency echocardiogram
2/2 AV block and the resulting Tx w/ emergency pericardiocentesis (on
atrial/ventricular uncoordination) the way to the OR) and surgical repair of
the rupture
treatment for symptomatic bradycardia?
symptomatic Atropine
bradycardia? 535. What is the best What is the best diagnostic test for
[...] diagnostic test for suspected cardiac tamponade 2/2
suspected cardiac ventricular free wall rupture in a pt s/p
tamponade 2/2 MI?
532. A pt s/p recent A pt s/p recent inferior wall MI develops
ventricular free wall Emergency echocardiogram
inferior wall MI tachycardia on hospital day 2. On
rupture in a pt s/p It typically takes several days after an MI
develops physical exam, the lungs are CTABL.
MI? for the wall to scar and weaken enough to
tachycardia on Overnight, the pt self-administered a dose
[...] rupture.
hospital day 2. On of nitroglycerin and she developed
Seeing "sudden loss of pulse" in the
physical exam, the hypotension. What is the most likely Dx?
vignette is common.
lungs are CTABL. RV infarction
Dx w/ emergency echocardiogram
Overnight, the pt Up to 40% of IWMIs w/ have RV infarction
Tx w/ emergency pericardiocentesis (on
self-administered a (due to RCA supplying the RV, AV node,
the way to the OR) and surgical repair of
dose of and inferior wall).
the rupture
nitroglycerin and Nitroglycerin markedly worsens cardiac
she developed filling and hence causes hypotension.
hypotension. What Treatment should involve high volume
is the most likely Dx? fluid replacement
[...] 536. What is the treatment What is the treatment for cardiac
for cardiac tamponade 2/2 ventricular free wall
tamponade 2/2 rupture in a pt s/p MI?
ventricular free wall Emergency pericardiocentesis
533. How can you How can you diagnose RV infarction via
rupture in a pt s/p (typically en route to the OR); surgical
diagnose RV EKG?
MI? repair of the rupture
infarction via EKG? (see below)
[...] It typically takes several days after an MI
[...]
for the wall to scar and weaken enough to
rupture.
- switch EKG leads to right side
Seeing "sudden loss of pulse" in the
- ST elevation in RV4 is most specific
vignette is common.
for RV infarction
Dx w/ emergency echocardiogram
Tx w/ emergency pericardiocentesis (on
the way to the OR) and surgical repair of
the rupture
65 of 340
540. A pt s/p MI is A pt s/p MI is suspected to have developed

537. A pt s/p recent MI A pt s/p recent MI develops tachycardia. suspected to have a mural thrombus as a complication.
develops Physical exam reveals a new murmur developed a mural Which diagnostic test is the next best
tachycardia. best heard at the apex w/ radiation to the thrombus as a step?
Physical exam axilla and rales on lung auscultation. CXR complication. Which Echocardiogram
reveals a new reveals pulmonary congestion. What is diagnostic test is the
murmur best heard the most likely Dx? next best step?
at the apex w/ Mitral regurgitation 2/2 valve rupture 2/2 [...] If precent, Tx w/ heparin and then bridge
radiation to the MI to warfarin.
axilla and rales on
lung auscultation.
541. A pt s/p ACS needs A pt s/p ACS needs to be worked up for
CXR reveals Involves a new onset murmur and
to be worked up for any residual ischemia prior to discharge.
pulmonary pulmonary congestion.
any residual What is the best diagnostic test?
congestion. What is Most accurate diagnostic test is ECHO
ischemia prior to Stress test
the most likely Dx?
discharge. What is
[...]
the best diagnostic
test? And then angiography/stenting if
538. A pt s/p recent MI A pt s/p recent MI develops tachycardia. [...] needed.
develops Physical exam reveals a new murmur
tachycardia. best head at the LLSB. Blood sampling
542. A pt s/p recent MI is A pt s/p recent MI is about to be
Physical exam from the heart reveals 72% O2 sat in the
about to be discharged from the hospital. Which 4
reveals a new RA and 85% O2 sat in the RV. What is
discharged from the medications must be added to this pt's
murmur best head the most likely diagnosis?
hospital. Which 4 regimen if not already present?
at the LLSB. Blood Ventricular septum rupture 2/2 MI
medications must be (see below)
sampling from the
added to this pt's
heart reveals 72%
regimen if not
O2 sat in the RA Best diagnostic test: ECHO
already present? Postinfarction pts should go home on:
and 85% O2 sat in The "step-up" in oxygen saturation is
[...] 1. Aspirin (or
the RV. What is the the buzzword here, but read the numbers
clopidogrel/prasugrel/ticagrelor if intolerant
most likely bruv.
to ASA or s/p stenting; never give
diagnosis?
dipyridamole in CAD, that's for stroke)
[...]
2. BBs (preferrably metoprolol)
3. Statin
539. Which cardiovascular Which cardiovascular intervention is a 4. ACE inhibitor (or ARBs if ACE-I C/I)
intervention is a good good choice in the setting of acute pump
choice in the setting failure 2/2 anatomical problem that can
543. ACE inhibitors are ACE inhibitors are best for pts s/p anterior
of acute pump be fixed in the OR?
best for pts s/p wall MI. Why?
failure 2/2 Intraaortic Balloon Pump (IABP)
anterior wall MI. AWMI has a high-likelihood of causing
anatomical problem
Why? systolic dysfunction
that can be fixed in
the OR? IABP sits in the descending aorta and [...]
[...] contracts/relaxes in sync w/ the heart,
thereby "pushing" the blood forward.
IABP is never permanent - serves as a
24-48 hrs bridge to surgery for valve
replacement or transplant.
66 of 340
544. A pt s/p recent MI is A pt s/p recent MI is admitted to the ICU 548. A pt s/p MI is given A pt s/p MI is given patient education
admitted to the ICU for observation and management of any patient education information on discharge. He reads them,
for observation and complications. A cheeky ICU intern opts to information on but calls your office w/ a question: "Doctor,
management of any use amiodarone as prophylaxis against discharge. He reads when can I start working out again?" What
complications. A developing VTach or VFib. Was this a them, but calls your do you tell him?
cheeky ICU intern wise choice? office w/ a question: As tolerated, so long as the post-MI
opts to use No; postinfarction, prophylactic "Doctor, when can I stress test was normal
amiodarone as antiarrhythmics actually increase start working out
prophylaxis against mortality again?" What do you
developing VTach or tell him? Including sex
VFib. Was this a [...]
wise choice? Do not be fooled by the question saying
[...] "frequent PVCs and ectopy"
549. What are the types of What are the types of heart failure?
heart failure? Systolic; diastolic; left; right
545. Nitrates are Nitrates are contraindicated alongside [...]
contraindicated sildenafil. Why?
alongside sildenafil. Hypotension can result
Why?
[...]
Both are strong vasodilators
550. Which type of heart Which type of heart failure involves a
failure involves a failure of the heart to pump blood forward?
546. A pt s/p recent MI A pt s/p recent MI presents to the failure of the heart to Systolic
presents to the outpatient clinic complaining of erectile pump blood forward? Typically 2/2 to one (or a combination) of:
outpatient clinic dysfunction. He is currently taking ASA, [...] - Leakiness (regurgitating valves)
complaining of metoprolol, atorvastatin, lisinopril and - Dead (ischemic/infarcted myocardium)
erectile metformin. What is the most likely cause? - Floppy (weak myocardium: HTN, EtOH,
dysfunction. He is Anxiety drugs, nonischemic cardiomyopathy)
currently taking ASA,
metoprolol,
atorvastatin, lisinopril However, beta-blockers are a cause of
and metformin. What erectile dysfunction.
551. Which type of heart Which type of heart failure involves
is the most likely
failure involves inability of the heart to fill w/ blood?
cause?
inability of the heart Diastolic
[...]
to fill w/ blood? Typically 2/2 one of:
[...] - Pericarditis
547. A pt s/p MI is given A pt s/p MI is given patient education - Restrictive cardiomyopathy
patient education information on discharge. He reads them, - HCM
information on but calls your office w/ a question: "Doctor,
discharge. He reads when can I start having sex again?" What
them, but calls your do you tell him?
office w/ a question: Immediately, so long as you are
"Doctor, when can I symptom-free
start having sex
again?" What do you
tell him? Sexual activity typically does not last long
[...] enough to constitute an excessive
increase in myocardial oxygen
consumption.
67 of 340
552. What is the most What is the most common cause of 555. A pt is diagnosed w/ A pt is diagnosed w/ right heart systolic
common cause of chronic heart failure? right heart systolic failure. What critical step must be
chronic heart failure? HTN; infarction and valvular disease are failure. What critical performed in order to determine the
[...] also up there step must be indicated treatment?
performed in order to Determining NYHA HF class
determine the
Pretty simple to understand why: indicated treatment?
- HTN --> increased PVR --> heart must [...]
pump harder --> hypertrophic/dilatory
myocardial changes to compensate --> low
EF ---> failure
556. Many pts may have Many pts may have both R and L heart
- Initially, the HTN and PVR are overcome
both R and L heart failure concurrently. As a result, some
by increased catecholamine stimulation
failure concurrently. aspects of their symptomology can
- Subsequently, neural-hormonal
As a result, some overlap. Which 2 physical signs of heart
remodelling occurs at the myocardium,
aspects of their failure are signs of acute CHF
leading to cardiac toxicity and fibrosis
symptomology can exacerbation?
overlap. Which 2 S3 (LCHF); JVD (RCHF)
553. A pt presents c/o of A pt presents c/o of SOB on exertion. Via physical signs of
SOB on exertion. the history, you discover that he has SOB heart failure are
Via the history, you when lying down and occassionally signs of acute CHF S3 and JVD are poor prognostic signs in
discover that he has wakes up at night gasping for air. exacerbation? acute CHF.
SOB when lying Physical exam reveals crackles at the [...]
down and lung bases bilaterally. What is the most
occassionally likely Dx?
wakes up at night L heart failure
557. What is the most What is the most common cause of left
gasping for air. Recognize this classic triad of LHF:
common cause of heart failure?
Physical exam orthopnea, exertional dyspnea, and
left heart failure? Right heart failure
reveals crackles at paroxysmal nocturnal dyspnea.
[...]
the lung bases
bilaterally. What is
the most likely Dx? 558. What is the best What is the best diagnostic test for
[...] diagnostic test for suspected heart failure?
suspected heart 2D Echocardiogram
failure? Although heart failure can be Dx on s/s.
554. A pt presents c/o of A pt presents c/o of SOB on exertion. He
[...]
SOB on exertion. also reveals that he has noticed some
ECHO interpretation in the setting of CHF
He also reveals that swelling in his legs and feet. Physical
isn't too difficult:
he has noticed some exam reveals an elevated JVP and a liver
- If EF < 55%, then systolic dysfunction
swelling in his legs span of 14 cm. What is the most likely
- If EF is normal (± diastolic filling
and feet. Physical Dx?
defects), then diastolic dysfunction
exam reveals an R heart failure
Nuclear Stress Testing can be more
elevated JVP and a
definitive as it can provide the exact EF
liver span of 14 cm.
and identify areas of ischemia.
What is the most
LHC is also more definitive in providing EF
likely Dx?
and localizing ischemia.
[...]
68 of 340
559. What is the role of What is the role of measuring BNP in the 564. Treatment in heart Treatment in heart failure is aimed to
measuring BNP in workup of suspected heart failure? failure is aimed to reduce fluid load and afterload. What
the workup of Useful in determining the presence of reduce fluid load and restriction to salt (NaCl) intake aids w/
suspected heart volume overload afterload. What reducing fluid load?
failure? restriction to salt < 2 g/day
[...] (NaCl) intake aids w/
reducing fluid load?
[...] Reducing fluid load:
560. What is the role of an What is the role of an EKG in the w/u of
- reduce salt intake
EKG in the w/u of suspected heart failure?
- reduce water intake
suspected heart To identify ischemia/arrhythmia
- furosemide if ≥ class 2
failure?
Reducing afterload:
[...]
- ACE-I/ARB
EKG, along w/ CXR and troponins, are
- Spironolactone if ≥ class 3
appropriate, but not required.
- Isosorbide dinitrate + hydralazine if ≥
class 3
561. What is the role of a What is the role of a CXR in the w/u of
CXR in the w/u of suspected heart failure?
suspected heart Assess cardiomegaly & pulmonary
failure? edema/effusion
[...] CXR, EKG and troponins are appropriate
565. Treatment in heart Treatment in heart failure aims to reduce
in the w/u but not required.
failure aims to fluid load and afterload. What daily water
reduce fluid load and restriction helps to reduce fluid load?
afterload. What daily < 2 L H2O/day
562. What is the role of What is the role of measuring troponins in water restriction
measuring the w/u of suspected heart failure? helps to reduce fluid
troponins in the w/u To identify acute ischemia load? Reducing fluid load:
of suspected heart [...] - reduce salt intake
failure? - reduce water intake
[...] CXR, EKG and troponins are appropriate - furosemide if ≥ class 2
in the w/u but not required. Reducing afterload:
- ACE-I/ARB
563. What are the main What are the main goals of treatment in - Isosorbide dinitrate + hydralazine if ≥
goals of treatment in heart failure? class 3
heart failure? Reduce fluid load; Reduce afterload
[...] Reducing fluid load:
- reduce salt intake
- reduce water intake
- furosemide if ≥ class 2
Reducing afterload:
- ACE-I/ARB
class 3
69 of 340
566. Treatment in heart Treatment in heart failure is aimed to 568. Which Which antihypertensive agents used to
failure is aimed to decrease fluid load and afterload. What antihypertensive treat CHF have the greatest mortality
decrease fluid load diuretic is useful in reducing fluid load in agents used to treat benefit of any drug used in CHF?
and afterload. What the management of ≥ class II heart CHF have the ACE-I; ARB; (any agent in these
diuretic is useful in failure? greatest mortality classes)
reducing fluid load in Lasix (furosemide); however, any loop benefit of any drug
the management of ≥ diuretic can be used used in CHF?
class II heart failure? [...] They are effective at reducing afterload as
[...] well as mitigating cardiac remodelling in
Reducing fluid load: chronic CHF.
- reduce salt intake Reducing fluid load:
- reduce water intake - reduce salt intake
- furosemide if ≥ class 2 - reduce water intake
Reducing afterload: - furosemide if ≥ class 2
- ACE-I/ARB Reducing afterload:
- Spironolactone if ≥ class 3 - ACE-I/ARB
- Isosorbide dinitrate + hydralazine if ≥ - Spironolactone if ≥ class 3
class 3 - Isosorbide dinitrate + hydralazine if ≥
class 3
567. Treatment in heart Treatment in heart failure is aimed to

failure is aimed to decrease fluid load and afterload. Which 569. Which 4 treatment Which 4 treatment modalities/drugs should
decrease fluid load agents are preferred in decreasing modalities/drugs all pts diagnosed w/ CHF be on?
and afterload. Which afterload in CHF? should all pts (see below)
agents are preferred ACE-I; ARB diagnosed w/ CHF
in decreasing be on?
afterload in CHF? [...] The 4 "everyone" gets:
[...] Reducing fluid load: 1. <2 g NaCl/day to reduce fluid load
- reduce salt intake 2. <2 L H2O/day to reduce fluid load
- reduce water intake 3. ACE-i or ARB to reduce afterload; also
- furosemide if ≥ class 2 gives greatest mortality benefit
Reducing afterload: 4. BB to reduce the risk of sudden cardiac
- ACE-I/ARB death, arrhythmia, and to reduce cardiac
- Spironolactone if ≥ class 3 remodelling
class 3
70 of 340
570. Treatment in heart Treatment in heart failure is aimed towards 572. Treatment in heart Treatment in heart failure is aimed to
failure is aimed reducing fluid load and afterload. What failure is aimed to reduce fluid load and afterload. Which
towards reducing diuretic can be added for ≥ class III heart reduce fluid load and class of drugs are also added to reduce
fluid load and failure? afterload. Which risk of sudden cardiac death and
afterload. What Spironolactone; can also add class of drugs are improve mortality?
diuretic can be ISDN+hydralazine to help reduce also added to Beta-blockers [namely metoprolol (b1),
added for ≥ class III afterload reduce risk of bisoprolol (b1), carvedilol (a,b)]
heart failure? sudden cardiac
[...] death and improve
Reducing fluid load: mortality? BBs act to reduce:
- reduce salt intake [...] - occurrence of ventricular arrhythmia
- reduce water intake (and hence sudden cardiac death)
- furosemide if ≥ class 2 - occurrence of ischemia (and hence
Reducing afterload: sudden cardiac death)
- ACE-I/ARB - neuro-hormonal cardiac remodelling
573. What is the ejection What is the ejection fraction cutoff for the
class 3
fraction cutoff for the placement of an AICD in non-palliative
placement of an pts w/ heart failure?
AICD in < 35% (in the setting of ischemic
non-palliative pts w/ cardiomyopathy)
heart failure?
571. Treatment in heart Treatment in heart failure is aimed to [...]
failure is aimed to reduce fluid load and afterload. However, AICDs have up to 25% relative
reduce fluid load and for severe heart failure (Class IV) reduction of risk of death.
afterload. However, inotropes can be used in preparation for What's the most common cause of death
for severe heart transplant or VAD. Which one is in CHF? Arrhythmia/sudden cardiac death
failure (Class IV) preferred?
inotropes can be Dobutamine (as a drip)
574. How does Digoxin How does Digoxin change mortality in
used in preparation
change mortality in heart failure?
for transplant or
heart failure? No change
VAD. Which one is In the ICU, a Dobutamine drip can help the
[...]
preferred? pt make it to transplantation or insertion of
[...] a ventricular assist device (which acts as a
Digoxin is primarily used for symptom
bridge to transplantation).
relief and to mitigate/reduce future
exacerbations/hospitalizations.
In real life, the use of Digoxin is typically
limited to in-hospital control of atrial
fibrillation or by a heart failure
specialist trying to get the person a
little more comfort in their life with
advanced heart failure.
- Digoxin is a good drug for rate control in
AFib in the setting of CHF w/o CKD/AKI (±
acute CHF exacerbation)
71 of 340
575. How often is Digoxin How often is Digoxin used in heart failure? 579. What are the main What are the main treatment goals in
used in heart failure? Rarely; in fact digoxin is barely used treatment goals in acute CHF exacerbation?
[...] anymore overall acute CHF (see below)
Digoxin is primarily used for symptom exacerbation?
relief and to mitigate/reduce future [...]
exacerbations. The goals are similar to the chronic
In real life, the use of Digoxin is typically management of CHF, but w/ more
limited to in-hospital control of atrial emphasis on the acute presentation:
fibrillation or by a heart failure 1. Reduce afterload (via nitrates,
specialist trying to get the person a hydralazine and anti-hypertensives)
little more comfort in their life with 2. Reduce preload (via nitrates,
advanced heart failure. morphine)
- Digoxin is a good drug for rate control in 3. Reduce pulmonary edema/fluid (via IV
AFib in the setting of CHF w/o CKD/AKI (± furosemide)
acute CHF exacerbation) Heparin is never involved in management
unless there is a clot.
Then pts are discharged on appropriate
576. A pt w/ chronic CHF A pt w/ chronic CHF presents c/o of SOB
changes to their ACE/BB/diuretic regimen.
presents c/o of SOB at rest. You suspect acute CHF
at rest. You suspect exacerbation. What is the most
acute CHF appropriate diagnostic test that should be 580. What is the "LMNOP" What is the "LMNOP" mnemonic in the
exacerbation. What done first? mnemonic in the management of acute CHF exacerbation
is the most Give O2 and then get an EKG management of that is not 2/2 to ischemia or
appropriate While CHF exacerbation is a clinical Dx, acute CHF arrhythmia?
diagnostic test that EKG is the most important test to do exacerbation that is (see below)
should be done first? acutely as any signs of not 2/2 to ischemia
[...] ischemia/arrhythmia will change or arrhythmia?
treatment. [...] "LMNOP":
If ischemia is present, treat the ACS as - Lasix (furosemide; to get fluid off the
that is the likely cause of the exacerbation. lungs and reduce fluid load)
If arrhythmia is present, then perform - Morphine (effective venodilator, thereby
cardioversion. reducing ventricular preload; aids in pt
All the other tests for other causes (CXR, comfort as well; anxiolytic)
ABG, ECHO, BNP, etc) will be done if the - Nitrates (venodilator; decreases afterload
EKG is nondiagnostic. and preload)
- Oxygen
- Position (to alleviate orthopnea)
577. What is the most What is the most severe form of acute
severe form of acute CHF exacerbation?
CHF exacerbation? Acute Pulmonary Edema
[...]
578. Which laboratory test Which laboratory test is highly specific for
is highly specific for acute CHF exacerbation if the finding is
acute CHF elevated?
exacerbation if the BNP
finding is elevated?
[...]
Remember, BNP is produced 2/2 to atrial
stretching.
72 of 340
581. A pt w/ chronic CHF A pt w/ chronic CHF presents w/ chest 585. A pt presents w/ A pt presents w/ dyspnea of slow onset.
presents w/ chest pain and SOB at rest. He is diagnosed w/ dyspnea of slow He also complains of fever and
pain and SOB at RV MI. The intern is about to give the pt onset. He also productive cough w/ sputum. Physical
rest. He is diagnosed nitrates (among other meds) but is complains of fever exam reveals unilateral rales. What is the
w/ RV MI. The intern stopped by his attending. Why are nitrates and productive most likely Dx?
is about to give the pt a bad idea? cough w/ sputum. Pneumonia
nitrates (among The RV is preload dependent and Physical exam
other meds) but is dropping preload will worsen the RV reveals unilateral
stopped by his function rales. What is the
attending. Why are most likely Dx?
nitrates a bad idea? [...]
[...] Drugs to avoid in RV MI:
- Nitrates as they reduce RV preload
586. A pt presents w/ A pt presents w/ dyspnea. There are
- Diuretics as they reduce RV preload
dyspnea. There are decreased breath sounds on the right
- Opiates as they reduce RV preload
decreased breath side and tracheal deviation to the left.
- Bladder catheterization as it can
sounds on the right What is the most likely Dx?
increase vagal tone, acutely decrease
side and tracheal Pneumothorax
RV preload and trigger cardiogenic
deviation to the left.
shock
What is the most
likely Dx?
582. What is the most What is the most common cause of [...]
common cause of hospital admission of adults in the USA?
hospital admission of CHF; acute CHF exacerbation
587. A pt presents w/ A pt presents w/ dyspnea. She also
adults in the USA?
dyspnea. She also complains of circumoral numbness.
[...]
complains of PMHx is positive for anxiety and HTN.
circumoral SHx is positive for smoking, alcohol and
583. A pt presents w/ A pt presents w/ dyspnea. It has a numbness. PMHx is caffeine use. What is the most likely Dx?
dyspnea. It has a sudden onset. Lungs are CTABL. What is positive for anxiety Panic Attack
sudden onset. the most likely Dx? and HTN. SHx is
Lungs are CTABL. PE positive for smoking,
What is the most alcohol and caffeine
likely Dx? use. What is the
[...] most likely Dx?
[...]
584. A pt presents w/ A pt presents w/ dyspnea of sudden

dyspnea of sudden onset. Lung auscultation reveals 588. A pt presents w/ A pt presents w/ dyspnea of very slow
onset. Lung wheezing. Studies reveal an increased dyspnea of very onset. Physical exam reveals
auscultation reveals expiratory phase. What is the most likely slow onset. Physical conjunctival pallour. What is the most
wheezing. Studies Dx? exam reveals likely Dx?
reveal an increased Asthma conjunctival Anaemia
expiratory phase. pallour. What is the
What is the most most likely Dx?
likely Dx? [...]
[...]
73 of 340
589. A pt presents w/ A pt presents w/ dyspnea. Physical exam 593. What is the best What is the best initial test to gauge
dyspnea. Physical reveals decreased heart sounds, JVD initial test to gauge cardiac ejection fraction?
exam reveals and pulsus paradoxus. What is the most cardiac ejection Transthoracic echocardiogram
decreased heart likely cause? fraction?
sounds, JVD and Cardiac Tamponade [...]
pulsus paradoxus. Most accurate = nuclear
What is the most ventriculography or multiple-gated
likely cause? acquisition scan (MUGA)
[...] TEE is better for assessing valvular
function. It is not necessary in CHF
unless the suspected cause is valvular.
590. A pt presents w/ A pt presents w/ dyspnea. He was
dyspnea. He was recently discharged following an elective
recently discharged cholecystectomy. Physical exam reveals 594. What is the most What is the most accurate test of ejection
following an elective cyanosis of the extremities. Lungs are accurate test of fraction?
cholecystectomy. CTABL. A nurse pages you and states ejection fraction? Nuclear ventriculography;
Physical exam that his blood looked brown, when she [...] multiple-gated acquisition scan (MUGA)
reveals cyanosis of drew labs. What is the most likely Dx?
the extremities. Methemoglobinemia
Lungs are CTABL. A Rarely ever needed, but if it asks for best
nurse pages you and precision, especially for wall motion
states that his blood abnormalities. Choose this.
looked brown, when - e.g. if a pt receiving chemotherapy
she drew labs. What (doxorubicin) needs to be assessed for
is the most likely Dx? cardiomyopathy
[...]
595. A pt presents w/ A pt presents w/ acute dyspnea. After a

591. A pt presents w/ A pt presents w/ dyspnea. He states that acute dyspnea. thorough history, the etiology is unclear.
dyspnea. He states they were camping and cooking food in After a thorough Which laboratory test can be ordered to
that they were their cabin. What is the most likely Dx? history, the etiology rule out CHF (potentially if an echo cannot
camping and cooking Carbon monoxide poisoning is unclear. Which be done in time)?
food in their cabin. laboratory test can BNP
What is the most be ordered to rule
likely Dx? out CHF (potentially
[...] if an echo cannot be Normal BNP = no CHF
done in time)?
[...]
592. What is the most What is the most important test in the
important test in the w/u of CHF?
w/u of CHF? Echocardiogram 596. What is best test to What is best test to diagnose CHF?
[...] diagnose CHF? None, it is a clinical Dx
[...]
There is no other way to discern b/w
systolic and diastolic.
597. What is the best test What is the best test to determine the type
Every CHF pt should get an updated
to determine the of CHF?
ECHO (if indicated) during a hospital stay
type of CHF? Echo (TTE)
to evaluate EF.
[...]
74 of 340
598. What are the What are the common side effects of
605. What CXR findings What CXR findings are seen in acute CHF
common side effects spironolactone?
of spironolactone? Hyperkalemia; gynecomastia are seen in acute exacerbation?
[...] CHF exacerbation? Pulmonary vascular congestion w/
[...] cephalization of flow; ± cardiomegaly; ±
pleural effusion
599. A pt w/ class IV CHF A pt w/ class IV CHF is taking
Cephalization of flow = filling of the blood
is taking spironolactone as part of his regimen. He
vessels towards the head.
spironolactone as develops gynecomastia. Which drug
part of his regimen. should spironolactone be switched to?
He develops Eplerenone
606. Which acid-base Which acid-base imbalance is seen in
gynecomastia.
Which drug should imbalance is seen in acute CHF exacerbation?
spironolactone be Eplerenone acute CHF Respiratory alkalosis
switched to? - same class as spironolactone exacerbation?
[...] - also has a proven mortality benefit [...]
- does not have any anti-androgenic These pt's are typically tachypneic, hence
effect the CO2 leaving the body causes
alkalosis.
600. How do loop How do loop diuretics change the mortality

607. What is the best What is the best diagnostic test for valvular
diuretics change the in CHF?
mortality in CHF? No change diagnostic test for heart disease?
[...] valvular heart TEE
disease?
They simply control symptoms. [...]
TEE > TTE in terms of sensitivity and
specificity, however TTE is often
601. What is the most What is the most common cause of death considered the best "initial" test due to its
common cause of in CHF? ease
death in CHF? Arrhythmia/sudden cardiac death
Heart Cath is the most accurate test
[...]
608. What is the grade of What is the grade of a murmur that is

602. What is the indication What is the indication for the insertion of a a murmur that is softer than S1 and S2?
for the insertion of a biventricular pacemaker in CHF? softer than S1 and I
biventricular EF < 35% w/ a QRS > 120 ms S2?
pacemaker in CHF? [...]
[...] Murmur grading:
Effective at resynchronizing the heart I: S1/S2 > murmur
when there is a conduction defect. II: S1/S2 = murmur
III: S1/S2 < murmur
603. What is the role of What is the role of CCBs in systolic CHF? IV: palpable thrill
CCBs in systolic Nothing V: “almost six” can hear w/ steth half off
CHF? chest
[...] VI: heard w/o steth
In fact, some may increase mortality.
604. What drugs offer What drugs offer mortality benefits in

mortality benefits in systolic CHF?
systolic CHF? (see below)
[...]
75 of 340
609. What is the grade of What is the grade of a murmur that has 612. What is the grade of What is the grade of a murmur that can be
a murmur that has equal volume as S1/S2? a murmur that can be heard w/ the stethoscope only halfly on the
equal volume as II heard w/ the chest?
S1/S2? stethoscope only V
[...] halfly on the chest? This one is weird, but basically, if it has a
Murmur grading: [...] thrill and is "almost a six" it's a five.
I: S1/S2 > murmur Murmur grading:
II: S1/S2 = murmur I: S1/S2 > murmur
III: S1/S2 < murmur II: S1/S2 = murmur
IV: palpable thrill III: S1/S2 < murmur
V: “almost six” can hear w/ steth half off IV: palpable thrill
chest V: “almost six” can hear w/ steth half off
VI: heard w/o steth chest
VI: heard w/o steth
610. What is the grade of What is the grade of a murmur that is

a murmur that is louder than S1/S2? 613. What is the grade of What is the grade of a murmur that has a
louder than S1/S2? III a murmur that has a palpable thrill and can be heard without
[...] palpable thrill and a stethoscope?
can be heard VI
Murmur grading: without a
I: S1/S2 > murmur stethoscope?
II: S1/S2 = murmur [...] Murmur grading:
III: S1/S2 < murmur I: S1/S2 > murmur
IV: palpable thrill II: S1/S2 = murmur
V: “almost six” can hear w/ steth half off III: S1/S2 < murmur
chest IV: palpable thrill
VI: heard w/o steth V: “almost six” can hear w/ steth half off
chest
VI: heard w/o steth
611. What is the grade of What is the grade of a murmur that has a
a murmur that has a palpable thrill?
palpable thrill? IV 614. Which type of Which type of murmurs always need to be
[...] murmurs always worked up?
need to be worked Diastolic; Systolic > grade III
Murmur grading: up?
I: S1/S2 > murmur [...]
II: S1/S2 = murmur w/u w/ a TEE first
III: S1/S2 < murmur
IV: palpable thrill
V: “almost six” can hear w/ steth half off
chest
VI: heard w/o steth
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615. In general, what In general, what causes 618. Which common Which common murmurs get softer with
causes insufficient/regurgitant valves? murmurs get softer an increase in preload?
insufficient/regurgitantInfection; infarction/ischemia; or with an increase in MVP; HOCM
valves? anything that dilates the heart preload?
[...] [...]
HOCM:
Insufficient/regurgitant valves: - involves the hypertrophic septum
- 2/2 to infection (i.e. endocarditis), blocking the aortic valve
infarction (i.e. papillary muscle/chordae - w/ increased preload the septum is
tendinae rupture), or aortic dissection (in pushed back and the aortic valve opening
AR) is not as occluded
- presentation is either acute or chronic - sounds exactly like AS, but will
- acute presentation often involves acute DECREASE w/ increased preload
CHF w/ cardiogenic shock and requires - Tx w/ “avoiding dehydration” and BBs to
emergent valve replacement slow the HR and increase diastolic filling
time
MVP:
616. In general, what is In general, what is the cause of stenotic
- involves valves that are too large/loose
the cause of heart valves?
to close, hence they prolapse into the
stenotic heart Atherosclerosis (w/ subsequent
atrium upon closer
valves? calcification); Rheumatic fever
- increasing preload expands the
[...]
ventricle (and hence the valvular ring),
thereby allowing the valve to close
Stenotic valves:
properly and decreasing the murmur
- more insidious in onset, hence more AFib
presentation (than CHF)
- 2/2 to atherosclerosis (AS) or rheumatic 619. Which physical exam Which physical exam maneuvers increase
fever (MS) maneuvers increase preload?
preload? Squatting (then standing up); leg raise
[...]
617. Which common Which common murmurs get louder with
murmurs get louder an increase in preload?
Squatting or leg lift = increase preload
with an increase in MS/MR/AS/AR
Valsalva = decrease preload
preload?
[...]
"Mr. and Ms. Asar get louder w/ more 620. Which valvular Which valvular disorder is caused almost
blood" disorder is caused exclusively by rheumatic fever?
Squatting or leg lift = increase preload almost exclusively by Mitral stenosis
Valsalva = decrease preload rheumatic fever? Treat dat strep throat properly, brah
[...]
621. What arrhythmia may What arrhythmia may develop as a result

develop as a result of of mitral stenosis?
mitral stenosis? AFib
[...]
2/2 to stretching of the atrium
77 of 340
622. A 30 y/o pt comes in A 30 y/o pt comes in for a regular health 624. What is the only What is the only (common) heart murmur
for a regular health exam. She states that she had a sore (common) heart that is susceptible to balloon
exam. She states throat in the past few weeks, but has been murmur that is valvotomy/valvuloplasty?
that she had a sore pretty healthy otherwise. On physical susceptible to Mitral stenosis
throat in the past few exam, you hear a grade II, descrescendo balloon
weeks, but has been murmur during diastole w/ an opening valvotomy/valvuloplasty?
pretty healthy snap. What is the most likely Dx? [...] In fact, valve replacement is not preferred
otherwise. On Mitral Stenosis 2/2 to rheumatic fever in this case as MS is typically seen in
physical exam, you The louder the opening snap, the more younger pts 2/2 rheumatic fever.
hear a grade II, severe the stenosis. Replacement valves will likely need to be
descrescendo Almost exclusively caused by rheumatic replaced.
murmur during fever The threshold for critical narrowing of the
diastole w/ an Tx (valvuloplasty; preload reduction) valve is a surface area of < 1 cm2.
opening snap. What should be started right away before However the main indication for treatment
is the most likely Dx? CHF or AFib sets in is the presence of symptoms.
[...]
625. What is the etiology What is the etiology of aortic stenosis?

of aortic stenosis? Calcification 2/2 Atherosclerosis
[...]
623. What is the treatment What is the treatment for mitral stenosis?
for mitral stenosis? Preload reduction; valvuloplasty; valve This also applies to bicuspid valves,
[...] replacement if very severe which simply calcify faster
Commisurotomy is no longer done for MS.
Tx needs to start as soon as symptoms
626. An elderly male pt An elderly male pt comes in for a health
start to prevent CHF or AFib from settling
comes in for a health exam. You find a grade III, systolic,
in.
exam. You find a crescendo-decrescendo murmur heard
Balloon valvuloplasty/valvotomy are
grade III, systolic, loudest at the base. What is the most
preferred over valve replacement
crescendo-decrescendo likely Dx?
- MS is often seen in younger pts 2/2
murmur heard Aortic Stenosis likely 2/2 calcification
rheumatic fever. Valve replacement in
loudest at the base. 2/2 atherosclerosis
younger pts is not ideal as the replacement
What is the most
will likely need to be replaced itself.
likely Dx?
The threshold for critical narrowing of the
[...] Key points:
valve is a surface area of < 1 cm2.
- AS more commonly seen in elderly men;
However the main indication for treatment
younger presentation likely 2/2 to bicuspid
is the presence of symptoms.
valve
- crescendo-decrescendo systolic murmur
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627. An elderly male pt An elderly male pt presents c/o chest 629. What is the treatment What is the treatment for aortic stenosis?
presents c/o chest pain and SOB that are both worse w/ for aortic stenosis? Preload reduction; AVR
pain and SOB that activity. Physical exam reveals a systolic, [...]
are both worse w/ crescendo-decrescendo murmur at the
activity. Physical RUSB and rales bilaterally. BNP is Commisurotomy and valvotomy are not
exam reveals a elevated. What is the most likely Dx? possible as the calcifications are often
systolic, Aortic Stenosis (in the setting of CHF too thick and the valve is too stiff.
crescendo-decrescendo and likely CAD) If AVR is considered, do a cardiac cath
murmur at the before boarding the pt for surgery (and
RUSB and rales vice versa if you are doing CABG, get an
bilaterally. BNP is Remember: this murmur typically also echo). This is because the ostia of the
elevated. What is the radiates to the carotids coronary vessels are just distal to the
most likely Dx? This presentation of AS has the worst aortic valve (or basically, inside the valve).
[...] prognosis (1-3 year survival rate from So before doing open heart surgery, you
time of Dx if acute CHF is part of the may as well see if anything else needs to
presentation). be done (i.e. AVR or CABG). Sometimes
Tx w/ preload reduction & valve CABG is done w/ AVR regardless of the
replacement presence of CAD if they ostia might be
lost.
628. An elderly male pt An elderly male pt presents c/o of

presents c/o of multiple syncopal episodes while 630. A pt is Dx w/ aortic A pt is Dx w/ aortic stenosis. A cheeky
multiple syncopal jogging. Physical exam reveals a stenosis. A cheeky medical student things that valvotomy
episodes while systolic, crescendo-decrescendo medical student should be done. Why is this not feasible?
jogging. Physical murmur at the RUSB. What is the most things that valvotomy Calcifications of the aortic valve make it
exam reveals a likely Dx? should be done. Why too thick/stiff for balloon valvotomy
systolic, AS is this not feasible?
crescendo-decrescendo [...]
murmur at the
RUSB. What is the Remember: this murmur typically also
most likely Dx? radiates to the carotids
[...] Remember, syncope can be a classic
631. Which type of Which type of valvular defects can present
sign of aortic stenosis, especially when
valvular defects can acutely as cardiogenic shock and acute
cardiac demand sharply increases.
present acutely as pulmonary edema?
cardiogenic shock Regurgitation
and acute
pulmonary edema?
[...]
79 of 340
632. A pt presents in A pt presents in acute cardiogenic 636. A pt comes in for an A pt comes in for an annual health exam.
acute cardiogenic shock. A CXR reveals acute pulmonary annual health exam. Your medical student reports that the pt
shock. A CXR edema. EKG reveals AFib. Physical exam Your medical student has a systolic murmur heard at the
reveals acute reveals a holosystolic murmur that reports that the pt cardiac apex that radiates to the axilla,
pulmonary edema. radiates to the axilla. What is the most has a systolic but he is unsure if it is MR or MVP. What
EKG reveals AFib. likely Dx? murmur heard at the physical exam maneuver can discern
Physical exam Acute Mitral regurge cardiac apex that between the two?
reveals a radiates to the Squatting (and then standing); or leg lift
holosystolic axilla, but he is
murmur that - AFib 2/2 to atrial stretching unsure if it is MR or
radiates to the - cardiogenic shock 2/2 decreased MVP. What physical Both will increase preload, but in MVP it
axilla. What is the forward flow of blood exam maneuver can will decrease the murmur; in MR it will
most likely Dx? - acute pulmonary edema/CHF 2/2 discern between the increase the murmur.
[...] pulmonary congestion 2/2 backwards flow two? MVP involves valves that are too
of blood [...] large/loose to close, hence they prolapse
- Tx is emergent valve replacement into the atrium upon closer. Increasing
preload expands the ventricle (and hence
the valvular ring), thereby allowing the
633. A pt presents c/o of A pt presents c/o of exertional dyspnea
valve to close properly and decreasing the
exertional dyspnea and fatigue. He states that these
murmur.
and fatigue. He symptoms have been developing
Common anatomical variant (2-5%),
states that these gradually. Physical exam reveals a
especially in women.
symptoms have been holosystolic murmur at the apex that
developing gradually. radiates to the axilla and bilateral rales.
Physical exam What is the most likely Dx?
reveals a Chronic mitral regurgitation
holosystolic - treat the heart failure as needed, but 637. What is the Tx for What is the Tx for MVP?
murmur at the apex replace the valve before MVP? Avoiding dehydration; BBs
that radiates to the CHF/AFib/dilatation occurs [...]
axilla and bilateral
rales. What is the - Avoiding dehydration helps keep
most likely Dx? preload maximized, thereby improving the
[...] murmur and valvular insufficiency
- BBs work to decrease HR, thereby
increasing diastolic filling time and
634. A pt presents w/ A pt presents w/ cardiogenic shock.
aiding to maximize preload
cardiogenic shock. Physical exam reveals a diastolic,
- HOCM is approached the same way
Physical exam decrescendo murmur at the RUSB. What
reveals a diastolic, is the most likely Dx?
decrescendo Acute aortic valve insufficiency
murmur at the
RUSB. What is the 638. Which common heart Which common heart murmur presents as
most likely Dx? Tx is emergent AVR murmur presents as a diastolic, decrescendo murmur w/ an
[...] a diastolic, opening snap best heard at the apex?
decrescendo Mitral Stenosis
murmur w/ an
635. What is the treatment What is the treatment for acute valvular
opening snap best
for acute valvular insufficiency?
heard at the apex?
insufficiency? Emergent valve replacement
[...]
[...]
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639. Which common heart Which common heart murmur presents as 644. Which type of Which type of echocardiogram is best for
murmur presents as a systolic, crescendo-decrescendo echocardiogram is investigating valvular disorders?
a systolic, murmur best heard at the RUSB? best for investigating TEE
crescendo-decrescendo
AS valvular disorders?
murmur best heard [...]
at the RUSB? TEE is more sensitive and more specific
[...] than TTE.
640. Which common heart Which common heart murmur presents as 645. What is the most What is the most accurate test for
murmur presents as a holosystolic murmur that radiates to accurate test for valvulvar disorders?
a holosystolic the axilla and is best heard at the apex? valvulvar disorders? Cardiac catheterization
murmur that MR; MVP [...]
radiates to the
axilla and is best Heart cath allows for a more precise
heard at the apex? Increase preload via squatting (and then measurement of valvular diameter, as well
[...] standing) or leg lift to differentiate: as the exact pressure gradient across the
- MR will increase w/ increased preload valve.
- MVP will decrease w/ increased
preload
646. Which valvular Which valvular disorders can benefit from
disorders can benefit diuretics?
641. Which common heart Which common heart murmur presents as from diuretics? All of them
murmur presents as a diastolic, decrescendo murmur best [...]
a diastolic, heard at the RUSB?
decrescendo AR At some point, all of them involve the
murmur best heard backup of fluid to the lung (or CHF
at the RUSB? symptoms).
[...]
647. Regurgitant valves Regurgitant valves respond best to

642. Which valvular Which valvular disorders increase in respond best to vasodilator therapy. Which drugs are
disorders increase intensity w/ inhalation? vasodilator therapy. typically used?
in intensity w/ Right-sided valvular lesions Which drugs are ACE-i; ARBs; nifedipine; hydralazine
inhalation? typically used?
[...] [...]
Inhalation = increased venous return to the ACE-Is and ARBs are best as they
right side of the heart decrease the rate of progression of the
regurgitant lesion.
Remember, surgical replacement must
643. Which valvular Which valvular disorders increase in
be done before dilatory changes/CHF
disorders increase intensity w/ exhalation?
sets in:
in intensity w/ Left sided valvular lesions
- if the dilatory changes are excessive,
exhalation?
valve replacement will not alleviate the
[...]
systolic dysfunction and the heart will not
Exhalation "pushes" blood out of
return to normal size
pulmonary circulation and into the left side
- ventricular size is based off end-systolic
of the heart
diameter and ejection fraction
- an increase in end-systolic diameter
(ESD) >40 mm is an indication for valve
replacement
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648. Which common heart Which common heart murmur is 652. Which heart murmur Which heart murmur is associated w/
murmur is associated associated with immigrants? is associated w/ biphasic P waves in leads V1 and V2 on
with immigrants? Mitral stenosis biphasic P waves in EKG?
[...] i.e. individuals from areas where acute leads V1 and V2 on Mitral stenosis
rheumatic fever is still common EKG?
[...]
LA hypertrophy 2/2 MS
649. Which heart murmur Which heart murmur is commonly
is commonly associated w/ young adults?
associated w/ young Mitral stenosis 653. Which valvular heart Which valvular heart disease is associated
adults? disease is associated w/ straightening of the left heart border,
[...] w/ straightening of elevation of the left mainstem
the left heart bronchus, and a 2nd "bubble" behind
border, elevation of the heart on CXR?
650. A 35 y/o pt presents A 35 y/o pt presents c/o dysphagia,
the left mainstem Mitral Stenosis
c/o dysphagia, hemoptysis, and hoarseness. She has
bronchus, and a
hemoptysis, and recently immigrated here from Pakistan.
2nd "bubble"
hoarseness. She Physical exam reveals a diastolic
behind the heart on
has recently murmur w/ an opening snap. What is the
CXR?
immigrated here from most likely cause of her complaints?
[...]
Pakistan. Physical Mitral Stenosis
exam reveals a
diastolic murmur w/ 654. What is the best What is the best initial test to assess
an opening snap. Remember, MS has a unique initial test to assess cardiac valvular disease?
What is the most presentation: cardiac valvular TTE
likely cause of her - Dysphagia 2/2 compression of the disease?
complaints? esophagus 2/2 LA dilatation [...]
[...] - Hoarseness 2/2 compression of the left This one is tricky:
recurrent laryngeal nerve 2/2 LA dilatation - TTE is best initial due to ease
- AFib and stroke 2/2 LA dilatation - TEE is better than TTE due to
- Hemoptysis 2/2 blood backing up into increased sensitivity & specificity, but is
the pulmonary circuit invasive and hence sometimes done after
- Heart cath is the most accurate test
651. A pt presents c/o of A pt presents c/o of dyspnea. Physical

dyspnea. Physical exam reveals a diastolic murmur best 655. A pt presents for an A pt presents for an annual health
exam reveals a heard at the mitral area. EKG in the ER annual health checkup. Physical exam reveals a wide,
diastolic murmur reveals biphasic P waves in leads V1 checkup. Physical bounding pulse w/ pulsating nail beds.
best heard at the and V2. CXR reveals elevation of the left exam reveals a Which heart murmur should be considered
mitral area. EKG in mainstem bronchus. What is the most wide, bounding in this pt?
the ER reveals likely Dx? pulse w/ pulsating Aortic regurge
biphasic P waves in LA hypertrophy 2/2 mitral stenosis nail beds. Which Remember, AR has some unique features:
leads V1 and V2. heart murmur should - wide pulse pressure
CXR reveals be considered in this - Water-hammer pulse (wide & bounding)
elevation of the left Atrial rhythm disturbances are quite pt? - Quincke pulse (pulsating nail beds)
mainstem common in MS, especially AFib. [...] - Hill sign (BP in LE up to 40 mmHg more
bronchus. What is LA hypertrophy yields biphasic P waves than UE)
the most likely Dx? in leads V1 and V2. - de Musset sign (head bobbing w/ heart
[...] Elevation of the left mainsteam pulse)
bronchus on CXR is 2/2 to LAH.
82 of 340
656. Which common heart Which common heart murmur presents as 660. What is the best test What is the best test to diagnose dilated
murmur presents as a decrescendo systolic murmur w/ a to diagnose dilated cardiomyopathy?
a decrescendo midsystolic click? cardiomyopathy? Echocardiogram
systolic murmur w/ MVP [...]
a midsystolic click?
[...] CXR will show an enlarged heart/dilatory
changes but ECHO is diagnostic.
661. What is the treatment What is the treatment for dilated

657. Regardless of Regardless of etiology, all for dilated cardiomyopathy?
etiology, all cardiomyopathies have the same cardiomyopathy? Treated as systolic HF; transplant in
cardiomyopathies underlying pathophysiology. What is that? [...] refractory cases
have the same Impaired contraction or relaxation of
underlying heart muscle
pathophysiology. ACE/ARB, BBs (metoprolol, carvedilol),
What is that? and spironolactone all lower mortality (w/
[...] In fact, most of the time the etiology ACE/ARBs being the most effective)
doesn't even influence Diuretics & digoxin are used to control
treatment/management. symptoms
If EF < 35% and QRS > 120 ms, a
biventricular pacer will improve
658. A pt presents c/o A pt presents c/o worsening dyspnea on
symptoms and survival.
worsening dyspnea minimal exertion. PMHx involves CAD, MI
AICD is effective in some pts.
on minimal exertion. s/p CABG, and severe alcoholism.
PMHx involves CAD, Echocardiogram reveals dilated
MI s/p CABG, and ventricles w/ thinned ventricular walls. 662. A young athlete is Dx A young athlete is Dx w/ HOCM. During
severe alcoholism. What is the most likely Dx? w/ HOCM. During the the physical exam, his systolic murmur
Echocardiogram Dilated cardiomyopathy (likely 2/2 EtOH physical exam, his decreases during leg lift. Why?
reveals dilated and/or ischemia in this pt) systolic murmur (see below)
ventricles w/ CXR will likely show an enlarged heart, but decreases during
thinned ventricular echocardiogram is diagnostic. leg lift. Why?
walls. What is the Tx this as systolic CHF [...] In HOCM, the asymmetrically enlarged
most likely Dx? septum blocks the aortic outlet. With an
[...] increase in preload (i.e. s/p leg lift) the
septum is pushed back and the aortic
valve is revealed.
659. What type of heart What type of heart failure is seen in dilated
The murmur sounds very similar to AS, so
failure is seen in cardiomyopathy?
this change on physical exam is very
dilated Systolic
important.
cardiomyopathy?
[...]
Remember, in dilated cardiomyopathy,
stretching of the myocyte sarcomeres
2/2 ventricular dilatation results in 663. What is the genetic What is the genetic inheritance of HOCM?
decreased contractility. inheritance of AD
ECHO is diagnostic and will show HOCM?
decreased EF, dilated ventricles and [...]
thinned ventricular walls.
83 of 340
664. A young pt presents A young pt presents c/o of shortness of 668. What type of heart What type of heart failure is seen in
c/o of shortness of breath and chest pain w/ minimal activity. failure is seen in restrictive cardiomyopathy?
breath and chest Echocardiogram reveals an restrictive Diastolic; although systolic dysfunction
pain w/ minimal asymmetrically enlarged cardiomyopathy? may be present, the diastolic
activity. interventricular septum. What is the [...] dysfunction is always more severe
Echocardiogram most likely Dx?
reveals an HOCM
asymmetrically Restrictive cardiomyopathy is centered
enlarged around difficulty relaxing the ventricles.
interventricular - Autosomal dominant Hence, diastolic filling is impaired.
septum. What is the - commonly seen in young athletes (look This is 2/2 to the underlying disease
most likely Dx? out for the "sudden death during a process: myocardial infiltration (e.g. 2/2 to
[...] sporting event" buzz-phrase) sarcoidosis, amyloidosis,
- Tx w/ avoiding dehydration (preserving hemochromatosis, cancer, fibrosis)
preload) and BBs (increased diastolic time
to maximize preload)
669. What is the What is the diagnostic test for restrictive
diagnostic test for cardiomyopathy?
665. What is the treatment What is the treatment for HOCM? restrictive Echocardiogram
for HOCM? Avoiding dehydration (preserving cardiomyopathy?
[...] preload); BBs (increased diastolic time [...]
to maximize preload) Endomyocardial biopsy can reveal the
underlying diagnosis, but since an
infiltrative process is most often the cause,
Anything that increases HR will increase biopsy from elsewhere in the body can
symptoms (e.g. exercise, dehydration, give a clue towards what the underlying
diuretics) etiology is.
Anything that decreases LV size will
increase symptoms (e.g. ACE-Is, ARBs,
670. What is the treatment What is the treatment of restrictive
digoxin, hydralazine, valsalva, standing
of restrictive cardiomyopathy?
suddenly)
cardiomyopathy? Tx the underlying cause; gentle
[...] diuresis; rate control
666. What type of heart What type of heart failure is seen in
failure is seen in HOCM?
HOCM? Systolic This one is tricky:
[...] - treating the underlying cause will stop
progression, but will likely not reverse the
cardiomyopathy
667. What is the What is the diagnostic test for HOCM?
- gentle diuresis aids in symptom control,
diagnostic test for Echocardiogram
especially w/ pulmonary HTN and RCHF
HOCM?
symptoms
[...]
- rate control aids in prolonging diastolic
The interventricular septum is often ≥ 1.5x
filling and maximizing preload
thicker than the posterior wall.
- transplant in refractory cases
84 of 340
671. What class of drugs What class of drugs is typically given to all 673. What is the What is the difference betwen
is typically given to pts w/ cardiomyopathy to control difference betwen Hypertrophic Cardiomyopathy (HCM) and
all pts w/ symptoms? Hypertrophic HOCM?
cardiomyopathy to Diuretics, except in HOCM Cardiomyopathy (see below)
control symptoms? (HCM) and HOCM?
[...] [...]
Additional treatment is based on the type HCM:
of cardiomyopathy, but all of them typically - reactive hypertrophic changes of the
receive diuretics except in HOCM. heart to stressors such as HTN (most
common cause)
- ventricular wall loses compliancy and
672. Which cardiac Which cardiac disorders have murmurs
hence has a difficulty relaxing during
disorders have that do not increase w/ expiration (i.e.
diastole
murmurs that do not increased LV preload)?
- S4 gallop is common
increase w/ HOCM; MVP
HOCM:
expiration (i.e.
- autosomal dominant disorder in myocyte
increased LV
sarcomeres that causes asymmetrical
preload)? HOCM:
hypertrophy of the interventricular septum
[...] - involves the hypertrophic septum
that blocks the aortic outflow tract
blocking the aortic valve
- w/ increased preload the septum is
pushed back and the aortic valve opening 674. A 24 y/o pt presents A 24 y/o pt presents c/o of worsening
is not as occluded c/o of worsening dyspnea and intermittent
- sounds exactly like AS, but will dyspnea and lightheadedness. Echocardiogram
DECREASE w/ increased preload intermittent reveals systolic anterior motion (SAM)
- Tx w/ “avoiding dehydration” and BBs to lightheadedness. of the mitral valve. What is the most likely
slow the HR and increase diastolic filling Echocardiogram Dx?
time reveals systolic HOCM
MVP: anterior motion
- involves valves that are too large/loose (SAM) of the mitral
to close, hence they prolapse into the valve. What is the This is a classic finding of HOCM.
atrium upon closer most likely Dx? The movement of the mitral valve 2/2 to
- increasing preload expands the [...] the assymetrically hypertrophied septum
ventricle (and hence the valvular ring), contributes to the obstruction seen in
thereby allowing the valve to close HOCM.
properly and decreasing the murmur
initial therapy for HOCM?
HOCM? BBs
[...]
Remember, BBs decrease the HR to

maximize diastolic filling and preload.
85 of 340
676. What is the best What is the best initial therapy for 680. A young pt presents A young pt presents c/o of worsening
initial therapy for hypertrophic cardiomyopathy? c/o of worsening dyspnea and lightheadedness. EKG
hypertrophic BBs dyspnea and reveals septal Q waves in the inferior
cardiomyopathy? lightheadedness. and lateral leads. What cardiomyopathy is
[...] EKG reveals septal the likely Dx?
Strongly negative inotropes (e.g. Q waves in the HOCM
verapamil, disopyramide) can help. inferior and lateral
Diuretics may also help to control leads. What
symptoms, but they are contraindicated cardiomyopathy is This EKG finding is common in HOCM,
in HOCM. the likely Dx? and not common in MI.
[...]
677. What is the role of What is the role of diuretics in the

diuretics in the treatment of Hypertrophic 681. A pt w/ known A pt w/ known HOCM presents c/o of
treatment of Cardiomyopathy? HOCM presents c/o multiple syncopal episodes. What
Hypertrophic Alleviates symptoms in HCM; of multiple cardiointervention should be added to this
Cardiomyopathy? contraindicated in HOCM syncopal episodes. pt's therapy?
[...] What Implantable defibrillator
cardiointervention
Remember, in HOCM you want to should be added to
preserve preload. this pt's therapy? Septal ablation either via cath or surgery
[...] should be considered if symptoms persist
despite maximal medical therapy.
678. Why are diuretics Why are diuretics contraindicated in
contraindicated in HOCM?
HOCM? You need to preserve preload in HOCM 682. A pt w/ known A pt w/ known HOCM presents c/o of
[...] HOCM presents c/o persistent symptoms (dyspnea,
of persistent lightheadedness and chest pain). He is
symptoms (dyspnea, already on maximal medical therapy and
679. A pt is Dx w/ A pt is Dx w/ hypertrophic cardiomyopathy.
lightheadedness and has an implantable defibrillator. Which
hypertrophic He is started on metoprolol and is given a
chest pain). He is cardiointerventional procedure should be
cardiomyopathy. He diuretic to aid w/ symptoms. Your medical
already on maximal considered?
is started on student asks if adding digoxin and
medical therapy and Septal ablation
metoprolol and is spironolactone will help this pt. What do
has an implantable
given a diuretic to you say?
defibrillator. Which
aid w/ symptoms. No, they do not
cardiointerventional Ablation, if tried, should be done with a
Your medical student
procedure should be catheter first by placing absolute alcohol
asks if adding
considered? in the myocardium, thereby causing
digoxin and
[...] small infarctions and removing the
spironolactone will
hypertrophic tissue.
help this pt. What do
If this fails then the next step would be
you say?
surgical myomectomy.
[...]
683. What is the What is the considered to be the ultimate

considered to be the therapy in HOCM?
ultimate therapy in Surgical myomectomy
HOCM?
[...]
Removing the hypertrophic portion of the
septum.
That or transplant.
86 of 340
684. HOCM and HCM HOCM and HCM differ in the approach to
differ in the approach treatment. What is the major difference?
to treatment. What is ACE-Is/ARBs and diuretics are both common cause of pericarditis?
the major difference? useless in HOCM pericarditis? None
[...] [...]
In HCM, they have unclear benefit, but In general, causes are infectious,
may help. autoimmune, traumatic, or neoplastic
(from proximal/adjacent tissue)
There is a long list of etiologies for
685. What is the major What is the major difference in the pericardial disease, the point is to
difference in the treatment of dilated cardiomyopathy and understand how they effect the
treatment of dilated hypertrophic cardiomyopathy? pericardium:
cardiomyopathy and Spironolactone and digoxin are not - acute conditions tend to cause
hypertrophic used in HCM pericarditis due to inflammation
cardiomyopathy? - chronic conditions tend to cause
[...] constrictive peridcarditis due to the
chronic inflammation surrounding the
686. How does standing How does standing from a squat and pericardium
from a squat and valsalva influence preload? - if the etiology makes fluid, then
valsalva influence Decrease pericardial effusion or pericardial
preload? tamponade is likely. Tamponade being
[...] the worst form.
Both of these cause decreased venous - most common infectious cause is viral
return and are akin to diuretic use: - most common connective
- Standing from a squat: opens the tissue/autoimmune cause is SLE
venous capacitance of leg vessels - most common cause of idiopathic cases
- Valsalva: increases intrathoracic are thought to be viral (Coxsackie B)
pressure and hence decreases venous
return
Hence, stenotic valve lesions will
improve w/ these maneuvers and
MVP/HOCM will worsen
687. How does the How does the handgrip technique

handgrip technique influence LV emptying?
influence LV Decrease
emptying?
[...]
Handgrip = increased PVR = increased
afterload = decreased LV emptying =
stenotic valve lesion will worsen
688. How does amyl How does amyl nitrate influence LV

nitrate influence LV emptying?
emptying? Increase
[...]
Amyl nitrate is a direct arteriolar

vasodilator and stimulates the effect of
ACE-Is or ARBs
87 of 340
690. A pt presents c/o of A pt presents c/o of intermittent chest 692. What is the best test What is the best test to diagnose
intermittent chest pain. He states that the pain worsens to diagnose pericarditis?
pain. He states that when he takes a deep breath and that it pericarditis? EKG
the pain worsens is relieved when he leans forward. [...] EKG will show diffuse PR depression
when he takes a Physical exam reveals a multiphasic and ST elevation
deep breath and friction rub on heart auscultation. What is Echo can help but will only reveal an
that it is relieved the most likely Dx? etiology, not the presence of pericarditis.
when he leans Pericarditis MRI can reveal pericarditis and is
forward. Physical theoretically the best test, but it is an
exam reveals a expensive test and takes more time.
multiphasic friction Key points:
rub on heart - pleuritic chest pain and positional
auscultation. What is chest pain due to the heart rubbing
the most likely Dx? against an inflamed pericardium w/ every
[...] heartbeat. The pain is often constant but
693. What is the best What is the best therapy for pericarditis?
typically worsens w/ inspiration or
therapy for NSAIDs + Colchicine
improves when leaning forward. This is
pericarditis?
thought to be due to alterations in the
[...]
tension/stretch of the pericardium.
Remember, NSAIDs are C/I in
- EKG is the best test and will show
CKD/thrombocytopenia
diffuse ST elevation and PR segment
Steroids are used in refractory cases
depression
Colchicine helps reduce recurrence
- Tx w/ NSAIDs (± colchicine) or steroids
NSAIDs + colchicine are considered first
line in recurrent pericarditis
- if the question has NSAIDs + Colchicine,
choose that. If not, pick NSAIDs first.
691. A pt presents c/o of A pt presents c/o of chest pain. EKG
chest pain. EKG reveals diffuse PR segment depression.
694. Which Which anti-inflammatory is used to reduce
reveals diffuse PR What is the most likely Dx?
anti-inflammatory is the recurrence rate of pericarditis?
segment Pericarditis
used to reduce the Colchicine
depression. What is
recurrence rate of
the most likely Dx?
pericarditis?
[...] Pericarditis is associated w/ diffuse ST
[...]
elevation and PR depression. However,
PR segment depression is the most
specific to pericarditis and is
considered pathognomonic
88 of 340
695. A pt presents c/o of A pt presents c/o of chest pain. 697. A pt presents w/ A pt presents w/ severe, acute dyspnea.
chest pain. Echocardiogram reveals a small severe, acute Physical exam reveals JVD and muffled
Echocardiogram pericardial effusion. EKG reveals PR dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24,
reveals a small segment depression. What is the most exam reveals JVD and HR is 120. What is the most likely Dx?
pericardial effusion. likely Dx? and muffled heart Pericardial tamponade
EKG reveals PR Pericarditis w/ pericardial effusion sounds. Her BP is Tamponade key points:
segment 80/50, RR is 24, and - often 2/2 to rapid effusion or ventricular
depression. What is HR is 120. What is wall rupture s/p MI
the most likely Dx? The point here is to understand that the most likely Dx? - involves the inability of the heart to fill
[...] pericardial effusion (and/or tamponade) [...] in diastole, causing a life-threatening
is often a sequelae to the etiology of hemodynamic crisis
pericarditis. In such a case, treating the - Beck's triad: JVD, hypotension and
pericarditis will treat the effusion. muffled heart sounds
However, as little as 50 mL of effusion - pts may also have pulsus paradoxus
can cause tamponade in which case and electrical alternans (2/2 to the heart
pericardiocentesis is indicated. "swinging" in the pericardial sac)
- compression of the chambers starts at - Pericardiocentesis or emergent
the R side as the myocardial wall is pericardial window is life saving
thinner on the R side - if an intervention is not possible, load the
- the pericardium can accommodate up to pt up w/ IVF to preserve preload as long
2L of fluid if the accumulation is chronic as possible
696. A pt has a Hx of A pt has a Hx of recurrent pericarditis that

recurrent pericarditis also yields a mild pericardial effusion.
that also yields a Which surgical procedure may be helpful
mild pericardial in this pt?
effusion. Which Pericardial window
surgical procedure With slowly developing effusions, the
may be helpful in this myocardium/pericardium may have time to
pt? compensate for the hemodynamic
[...] changes. However, having the ability to
continually drain the effusion takes a lot of
strain off the heart and preserves
hemodynamics. The pts also feel better.
89 of 340
698. A pt presents w/ A pt presents w/ severe, acute dyspnea. 700. A pt presents c/o of A pt presents c/o of dyspnea. Physical
severe, acute Physical exam reveals JVD and muffled dyspnea. Physical exam reveals Kussmaul sign and a
dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24, exam reveals pericardial knock on heart auscultation.
exam reveals JVD and HR is 120. What intervention will save Kussmaul sign and What is the most likely Dx?
and muffled heart this pt's life? a pericardial knock Constrictive pericarditis
sounds. Her BP is Pericardiocentesis; IV fluids; pericardial on heart If pericarditis is allowed to settle in long
80/50, RR is 24, and window auscultation. What is enough, fibrosis can set in and lead to
HR is 120. What the most likely Dx? Constrictive Pericarditis:
intervention will save [...] - the pericardium becomes very rigid; as
this pt's life? This is cardiac tamponade the ventricles fill, they can hit the
[...] Tamponade key points: pericardium and cause an audible "knock"
- often 2/2 to rapid effusion or ventricular during diastole
wall rupture s/p MI - systolic function is not affected, but
- involves the inability of the heart to fill diastolic filling is restricted by the rigid
in diastole, causing a life-threatening pericardium
hemodynamic crisis - Tx is w/ diuretics first to decompress
- Beck's triad: JVD, hypotension and the filling of the heart and relieve
muffled heart sounds edema/organomegaly; then
- pts may also have pulsus paradoxus pericardiectomy
and electrical alternans (2/2 to the heart
"swinging" in the pericardial sac)
- Pericardiocentesis or emergent
701. A pt presents c/o of A pt presents c/o of dyspnea. Physical
pericardial window is life saving
dyspnea. Physical exam reveals Kussmaul sign and a
- if an intervention is not possible, load the
exam reveals pericardial knock on heart auscultation.
pt up w/ IVF to preserve preload as long
Kussmaul sign and What is the Tx for this condition?
as possible
a pericardial knock Diuretics; then Pericardiectomy
on heart If pericarditis is allowed to settle in long
auscultation. What is enough, fibrosis can set in and lead to
the Tx for this Constrictive Pericarditis:
condition? - the pericardium becomes very rigid; as
699. A pt presents w/ A pt presents w/ severe, acute dyspnea. [...] the ventricles fill, they can hit the
severe, acute Physical exam reveals JVD and muffled pericardium and cause an audible "knock"
dyspnea. Physical heart sounds. Her BP is 80/50, RR is 24, during diastole
exam reveals JVD and HR is 120. Emergent - systolic function is not affected, but
and muffled heart pericardiocentesis is not possible at this diastolic filling is restricted by the rigid
sounds. Her BP is time. What is the next best step to keep pericardium
80/50, RR is 24, and this patient alive? - Tx is w/ diuretics first to decompress
HR is 120. Emergent IV fluids the filling of the heart and relieve
pericardiocentesis is This is cardiac tamponade. edema/organomegaly; then
not possible at this pericardiectomy
time. What is the If a needle/surgeon is not available. Give
next best step to this dude some IV fluids. You're going to
keep this patient do this w/ tamponade anyway, but
702. What is pulsus What is pulsus paradoxus?
alive? especially so in this case.
paradoxus? > 10 mmHg decrease in BP on
[...] Although tamponade presents similar to
[...] inhalation
acute CHF, administering fluids will
actually help as it will help to preserve
preload.
Seen in cardiac tamponade
For this same reason, do not give
diuretics in tamponade!!
90 of 340
703. What is considered What is considered the best initial test in 707. A pt w/ T2DM, HTN, A pt w/ T2DM, HTN, HLP presents c/o of
the best initial test suspected cardiac tamponade? HLP presents c/o of calf pain on minimal exertion. He states
in suspected cardiac Echocardiogram calf pain on minimal that he can only walk 1 block before
tamponade? Echo will show RA and RV collapse exertion. He states feeling pain in his right calf and that
[...] during diastole that he can only walk stopping to rest improves the pain. He
1 block before feeling is a chain smoker, but does not drink
EKG typically shows nothing (electrical pain in his right calf alcohol. What is the most likely Dx?
alternans is not a reliable thing to pursue) and that stopping to PAD
CXR can often be normal w/ acute rest improves the
tamponade, but may show a "globular pain. He is a chain
heart" as the cardiac shadow expands smoker, but does not PAD pain classically occurs in the calves
Heart cath should never be the first test in drink alcohol. What is during activity and improves w/ rest.
tamponade but will show equalization of the most likely Dx? Best initial test is ABI
pressures in diastole [...] Most accurate test is angiogram
MRI/CT can reveal the fluid, but takes time
and is more expensive than echo.
708. What is the best What is the best initial test for suspected
initial test for peripheral artery disease?
704. What is kussmaul What is kussmaul sign? suspected peripheral Ankle-brachial index (ABI)
sign? Increased JVP on inhalation artery disease?
[...] [...]
ABI is the ratio of BP in the ankles to
Normally JVP should decrease on that of the brachial arteries.
inhalation. ABI < 0.9 (i.e. > 10% difference in BP) is
Seen in constrictive pericarditis diagnostic of PAD.
Angiogram is the most accurate test but is
typically only done if revascularization is
705. What is the best What is the best initial test for constrictive
planned.
initial test for pericarditis?
constrictive CXR
pericarditis? 709. What is the most What is the most accurate test for
[...] accurate test for peripheral artery disease?
CXR will reveal calcifications and peripheral artery Angiogram
fibrosis of the pericardium disease?
CT/MRI are more accurate, but CXR [...]
should be done first and if positive, However this is typically not done unless
CT/MRI is not done specific revascularization is planned.
Echo is helpful at gauging the presence of
cardiomyopathy. In constrictive
710. What is the treatment What is the treatment for peripheral artery
pericarditis, the myocardium moves
for peripheral artery disease?
normally
disease? ASA; cilostazol; smoking cessation;
[...] surgery in refractory cases
706. What is the Tx for What is the Tx for constrictive pericarditis?
constrictive Diuretics first; then pericardiectomy
pericarditis?
[...]
Diuretics will decompress the filling of the
heart and relieve edema/organomegaly
91 of 340
711. What is the single What is the single most effective therapy in 714. What is the treatment What is the treatment for aortic dissection?
most effective peripheral artery disease? for aortic dissection? BBs; then nitroprusside; surgical
therapy in peripheral Cilostazol [...] correction if feasible
artery disease?
[...]
Bypass Surgery is only done if medical BBs act to decrease the shearing force
therapy is unfruitful. being placed on the aorta and alleviates
Cilostazol and several of its metabolites BP.
are cyclic AMP (cAMP) phosphodiesterase Nitroprusside aids in bringing down the
III inhibitors (PDE III inhibitors), inhibiting BP and also decreases shearing force.
phosphodiesterase activity and You do not give nitroprusside before
suppressing cAMP degradation with a beta-blockade as the reflex tachycardia
resultant increase in cAMP in platelets and from nitroprusside will exacerbate the
blood vessels, leading to inhibition of dissection.
platelet aggregation and vasodilation.
715. A pt presents c/o of A pt presents c/o of severe chest pain

712. A pt presents c/o of A pt presents c/o of severe chest pain severe chest pain that radiates to the back in between his
severe chest pain that radiates to the back in between his that radiates to the scapulae. Physical exam reveals BP of
that radiates to the scapulae. Physical exam reveals BP of back in between his 169/108 in the left arm and 120/70 in the
back in between his 169/108 in the left arm and 120/70 in the scapulae. Physical right arm. A dx of aortic dissection is
scapulae. Physical right arm. What is the best initial test? exam reveals BP of made after a CXR and the pt is given
exam reveals BP of CXR 169/108 in the left nitroprusside and then beta-blockers.
169/108 in the left arm and 120/70 in The pt becomes tachycardic and begins
arm and 120/70 in the right arm. A dx of to crash. Why?
the right arm. What is This is aortic dissection. aortic dissection is Because some fool gave nitroprusside
the best initial test? While CXR is not as sensitive, it is quick, made after a CXR before beta-blockade
[...] cheap and widening of the mediastinum and the pt is given
on CXR is a big clue. nitroprusside and
CXR is the best initial test then beta-blockers. Nitroprusside causes strong reflex
Angiogram is the most accurate test The pt becomes tachycardia, which can exacerbate the
All other tests are helpful, but have the tachycardic and shearing forces on the dissection if
same accuracy (MRA = CTA = TEE) begins to crash. beta-blockade is not already established.
Why? Always give beta-blockers before
[...] nitroprusside in the management of
713. A pt presents c/o of A pt presents c/o of severe chest pain
aortic dissection.
severe chest pain that radiates to the back in between his
that radiates to the scapulae. Physical exam reveals BP of
back in between his 169/108 in the left arm and 120/70 in the 716. What is the guideline What is the guideline for the screening of
scapulae. Physical right arm. What is the most acurrate test? for the screening of abdominal aortic aneurysm?
exam reveals BP of Angiogram abdominal aortic Men who have ever smoked and is > 65
169/108 in the left aneurysm? y/o
arm and 120/70 in [...]
the right arm. What is This is aortic dissection
the most acurrate CXR is the best initial test Done via U/S
test? Angiogram is the most accurate test but AAA > 5 cm is an indication for
[...] also the most invasive. It can cause surgical/catheter-directed repair
anaphylaxis or AKI, but is the most New onset back pain in all pts > 65 should
sensitive and most specific. trigger U/S to look for AAA.
All other tests are helpful, but have the Otherwise, in nonsmokers and women,
same accuracy (MRA = CTA = TEE) the rate of AAA is so low that screening is
not justified
92 of 340
717. A previously healthy A previously healthy pregnant woman 718. A pt develops A pt develops Peripartum Cardiomyopathy
pregnant woman develops severe LV dysfunction Peripartum after giving birth to her child. Her LV
develops severe LV post-partum. Her pregnancy was Cardiomyopathy dysfunction does not improve w/ medical
dysfunction uneventful and she gave birth to a after giving birth to therapy. What is the only treatment option
post-partum. Her beautiful, healthy baby boy. What is the her child. Her LV that remains?
pregnancy was most likely Dx? dysfunction does not Transplantation
uneventful and she Peripartum cardiomyopathy improve w/ medical
gave birth to a therapy. What is the
beautiful, healthy only treatment option Peripartum cardiomyopathy key points:
baby boy. What is Peripartum cardiomyopathy key points: that remains? - unknown cause
the most likely Dx? - unknown cause [...] - involves autoantibodies against
[...] - involves autoantibodies against myocardium in pregnant women
myocardium in pregnant women - the LV dysfunction is often short term and
- the LV dysfunction is often short term and reversible, but if not reversed the only Tx
reversible, but if not reversed the only Tx is transplant
is transplant - medical therapy involves the use of
- medical therapy involves the use of ACE-Is/ARBs, BBs, spironolactone,
ACE-Is/ARBs, BBs, spironolactone, diuretics, digoxin (i.e. like heart
diuretics, digoxin (i.e. like heart failure/DCM)
failure/DCM) - medical therapy can be used as the
- medical therapy can be used as the cardiomyopathy typically develops
cardiomyopathy typically develops post-partum (ACE-I/ARBs are C/I in
post-partum (ACE-I/ARBs are C/I in pregnancy)
pregnancy) - repeat pregnancy in such cases will
- repeat pregnancy in such cases will provoke massive autoantibody production
provoke massive autoantibody production against the myocardium
against the myocardium
719. What is the worst What is the worst cardiac disease that can
cardiac disease that manifest in pregnant women?
can manifest in Peripartum cardiomyopathy
pregnant women?
[...]
If this question comes up, the ranking is:
1. Peripartum cardiomyopathy
2. Eisenmenger syndrome
3. Mitral stenosis (worsens significantly
due to the 50% increase in plasma volume
during pregnancy)
720. Which obstructive Which obstructive lung disease is more

lung disease is more commonly associated with children and
commonly young adults with allergies?
associated with Asthma
children and young
adults with
allergies? Remember, asthma is IgE/eosinophil
[...] mediated and involves inflammation of
the airways and bronchoconstriction.
93 of 340
721. A young pt presents A young pt presents w/ cough, wheezing 724. What is the next step What is the next step in the w/u of asthma
w/ cough, wheezing and dyspnea. His PMHx is significant for in the w/u of asthma for a pt that has normal PFTs (i.e. normal
and dyspnea. His allergic rhinitis, nasal polyps, and for a pt that has FEV1/FVC)?
PMHx is significant eczema. Physical exam reveals wheezing normal PFTs (i.e. Methacholine challenge (> 20%
for allergic rhinitis, in the BL upper lobes and a prolonged normal FEV1/FVC)? decrease in FEV1 is diagnostic)
nasal polyps, and expiratory phase. What is the most likely [...]
eczema. Physical Dx?
exam reveals Asthma Normal PFTs in the w/u of asthma do not
wheezing in the BL rule out asthma. It simply means that the
upper lobes and a pt is not in an asthmatic state when PFTs
prolonged Asthma key points: were tested. If an asthma attack occurs
expiratory phase. - seen in younger pts, especially if there is after methacholine is given, then its
What is the most a Hx of allergies/eczema asthma.
likely Dx? - wheezing, dyspnea, cough (remember, Methacholine induces bronchoconstriction.
[...] wheezing is simply the flow of air through a Remember, in asthma, the decrease in
constricted airway) PFTs is both inducible and reversible.
- PE: wheezing, prolonged expiratory This is not the case in COPD.
phase
- PE: hyperinflation & hyperresonance
725. What is the next step What is the next step in the w/u of asthma
are ominous signs and signify greater
in the w/u of asthma for a pt that has abnormal PFTs (i.e.
airway constriction
for a pt that has decreased FEV1/FVC)?
- PE: severe dyspnea (accessory muscle
abnormal PFTs (i.e. Bronchodilator challenge (> 12% or 200
use and/or no lung sounds) = status
decreased mL FEV1 increase is considered
asthmaticus = medical emergency
FEV1/FVC)? reversal and diagnostic of asthma)
- chronic vs. acute management has big
[...] Decreased FEV1/FVC does not
difference.
automatically mean asthma, it just
means that an obstructive process is
722. A pt presents w/ A pt presents w/ acute onset dyspnea present.
acute onset and wheezing. You suspect asthma. What Bronchodilator challenge will discern
dyspnea and is the most appropriate next step in between asthma & COPD. Because, once
wheezing. You management? again, decreased PFTs in asthma are
suspect asthma. Start treatment right away both inducible and reversible.
What is the most Reversing of the decreased PFTs is
appropriate next step diagnostic of asthma at this point of the
in management? In this case: nebulizer treatment/oxygen work-up; > 12% increase (or 200 mL) is
[...] The point is: if it's acute onset, treat right considered reversal
away.
- Don't waste time getting PFTs
- Treat this fool first, then pursue PFTs
726. A pt presents c/o of A pt presents c/o of intermittent dyspnea
once stablilized or as outpatient
intermittent dyspnea and wheezing for the past year. You
and wheezing for decide to do a sputum study which reveals
723. What is the best What is the best diagnostic test for the past year. You Charcot-Leyden crystals and
diagnostic test for asthma? decide to do a Curschmann spirals. What is the most
asthma? PFTs sputum study which likely Dx?
[...] reveals Asthma
Charcot-Leyden
crystals and
Curschmann Other tests exists to workup suspected
spirals. What is the asthma, but PFTs (and subsequent
most likely Dx? methacholine/bronchodilator challenge)
[...] are the gold standard.
94 of 340
732. What is the treatment What is the treatment for intermittent

727. What is the What is the symptomatic criteria for for intermittent asthma?
symptomatic criteria intermittent asthma? asthma? A rescule inhaler
for intermittent ≤ 2 daytime/wk; ≤ 2 nighttime/month; [...] Typically a SABA, but may be an inhaled
asthma? FEV1 ≥ 80% anticholinergic as well
[...]
733. What is the treatment What is the treatment for mild persistent
728. What is the What is the symptomatic criteria for mild for mild persistent asthma?
symptomatic criteria persistent asthma? asthma? SABA + low dose ICS
for mild persistent ≤ 1 daytime/day; > 2 nighttime/month; [...]
asthma? FEV1 ≥ 80%
[...]
734. What is the treatment What is the treatment for moderate

for moderate persistent asthma?
729. What is the What is the symptomatic criteria for persistent asthma? SABA + LABA + low-dose ICS
symptomatic criteria moderate persistent asthma? [...] You cannot give LABA without an
for moderate ≥ 1 daytime/day; > 1 nighttime/week; ICS/steroids. That will increase mortality
persistent asthma? FEV 60-80% and is always the wrong answer.
[...] If the patient is on a LABA, they must
be on an steroids. Period.
730. What is the What is the symptomatic criteria for severe

symptomatic criteria persistent asthma?
for severe ≥ 1 daytime/day; frequent nighttime;
persistent asthma? FEV1 < 60%
[...] 735. What is the treatment What is the treatment for severe
for severe persistent asthma?
persistent asthma? SABA + LABA + high-dose ICS
731. Which two Which two pathological elements of [...] You cannot give LABA without an
pathological asthma are targeted in its management? ICS/steroids. That will increase mortality
elements of asthma Inflammation; bronchoconstriction and is always the wrong answer.
are targeted in its If the patient is on a LABA, they must
management? be on steroids. Period.
[...] Simple to understand, but important to If the pt is already on a LABA and ICS and
keep in mind when manaing asthmatics. more treatment is needed, increase the
Inflammation is targeted by steroids dose of the ICS (as is done w/ severe
(mostly inhaled, but PO steroids used in persistent)
refractory cases)
Bronchoconstriction is targeted primarlily
by beta-agonists (however other agents
can add support)
Stabilizers are helpful in pts w/ milder
disease that know their triggers and are
going to be exposed to them (e.g. the
athlete w/ exercise induced asthma about
to play a game)
95 of 340
736. What is the treatment What is the treatment for refractory 739. A pt presents w/ A pt presents w/ severe dyspnea,
for refractory severe persistent asthma? severe dyspnea, wheezing and cough. PMHx is significant
severe persistent SABA + LABA + high-dose PO steroids wheezing and for moderate persistent asthma and
asthma? Yes, this not a real class of asthma. But cough. PMHx is eczema. Physical exam reveals the use of
[...] many asthmatics are refractory to significant for accessory muscles of respiration and
treatment when they progress to the moderate lung auscultation reveals an absence of
severe stage, so knowing the management persistent asthma lung sounds. The lungs are
is important. and eczema. hyperresonant to percussion. What is the
You cannot give LABA without an Physical exam most likely Dx?
ICS/steroids. That will increase mortality reveals the use of Status asthmaticus
and is always the wrong answer. accessory muscles
If the patient is on a LABA, they must of respiration and
be on steroids. Period. lung auscultation Status asthmaticus key points:
If the pt is already on a LABA and ICS and reveals an absence - pts are in respiratory distress w/ signs
more treatment is needed, increase the of lung sounds. The of severe dyspnea (accessory muscle
dose of the ICS or transition to PO lungs are use, absent lung sounds, hyperresonance)
steroids(as is done w/ severe persistent or hyperresonant to - begin treatment immediately w/ O2,
refractory cases) percussion. What is Duoneb (albuterol/ipratropium) and
the most likely Dx? corticosteroids
[...] - if that fails, add racemic, nebulized
epinephrine or SQ epinephrine
737. The treatment The treatment /management of asthma

/management of now involves more agents than
asthma now involves beta-agonists and steroids. Which class of
more agents than drugs can be used in the management of
beta-agonists and asthma in place of LABA alongside ICS?
steroids. Which class Leukotriene Agonists
of drugs can be used The different MOA allows LTAs to have
in the management fewer side effects.
of asthma in place
of LABA alongside
ICS?
[...]
738. Which adenosine Which adenosine antagonist can be used

antagonist can be to control bronchoconstriction in asthma?
used to control Theophylline
bronchoconstriction
in asthma?
[...]
96 of 340
740. What is the initial What is the initial management of status 741. Following the initial Following the initial management of status
management of asthmaticus? management of asthmaticus, which PFT aids to determine
status asthmaticus? O2; albuterol/ipratropium; steroids (IV status asthmaticus, the next step in management?
[...] or PO) which PFT aids to Peak Expiratory Flow Rate (PEFR)
determine the next PEFR is based on height and age, not
step in weight, and is an acute
Initial management of status asthmaticus: management? assessment/approximation of FVC.
- O2 should be given until pulse-ox ≥ 90% [...] After initial management has been
- Duoneb (albuterol/ipratropium) q20x3 performed for 3 hours, assess the pt's
- Steroids can be given IV or PO PEFR and do a physical exam to
- Continue the pt's scheduled home determine the next step in management:
medications. You do not stop chronic - If PEFR > 70% of the pt's max PEFR and
asthma management during status there are no s/s, discharge the pt home
asthmaticus - If PEFR 50-70% of the pt's max PEFR
- Do all of the above and observe for 3 and there are mild/moderate s/s, admit
hours before deciding the next step in the pt to the floor
management - If PEFR < 50% of the pt's max PEFR and
- Peak Expiratory Flow Rate (PEFR) and there are severe s/s, admit the pt to the
physical exam decides the next step (d/c, ICU
admit to floor, or admit to ICU)
- You do not give inhaled ABGs are also helpful, but in general:
corticosteroids as an ED treatment for - If PaCO2 > 42 mmHg, admit to the ICU
Asthma. ICS, LABA, and LTA are
long-term chronic medications.
742. Following the initial Following the initial management of status
- Epinephrine is not any more effective
management of asthmaticus, what Peak Expiratory Flow
than albuterol and has more systemic side
status asthmaticus, Rate (PEFR) signifies that the pt is stable
effects
what Peak Expiratory enough to be discharged home?
- Magnesium can be used but is not as
Flow Rate (PEFR) > 70% of the pt's max PEFR
effective as albuterol, but can help with
signifies that the pt is After initial management has been
bronchodilation
stable enough to be performed for 3 hours, assess the pt's
discharged home? PEFR and do a physical exam to
[...] determine the next step in management:
- If PEFR > 70% of the pt's max PEFR and
there are no s/s, discharge the pt home
- If PEFR 50-70% of the pt's max PEFR
and there are mild/moderate s/s, admit
the pt to the floor
- If PEFR < 50% of the pt's max PEFR and
there are severe s/s, admit the pt to the
ICU
ABGs are also helpful, but in general:

- If PaCO2 > 42 mmHg, admit to the ICU
- A-a gradient will likely be elevated
97 of 340
743. Following the initial Following the initial management of status 744. Following the initial Following the initial management of status
management of asthmaticus, what Peak Expiratory Flow management of asthmaticus, what Peak Expiratory Flow
status asthmaticus, Rate (PEFR) signifies that the pt should be status asthmaticus, Rate (PEFR) signifies that the pt should be
what Peak Expiratory admitted to the floor for observation? what Peak Expiratory admitted to the ICU?
Flow Rate (PEFR) PEFR 50-70% of the pt's max w/ mild to Flow Rate (PEFR) PEFR < 50% of the pt's max PEFR w/
signifies that the pt moderate s/s signifies that the pt severe s/s
should be admitted Essentially, if there is some improvement, should be admitted
to the floor for but not full reversal. Admit these "in to the ICU?
observation? between" pt's to the floor where all they're [...] After initial management has been
[...] really going to get is q4 duoneb. performed for 3 hours, assess the pt's
PEFR and do a physical exam to
After initial management has been determine the next step in management:
performed for 3 hours, assess the pt's - If PEFR > 70% of the pt's max PEFR and
PEFR and do a physical exam to there are no s/s, discharge the pt home
determine the next step in management: - If PEFR 50-70% of the pt's max PEFR
- If PEFR > 70% of the pt's max PEFR and and there are mild/moderate s/s, admit
there are no s/s, discharge the pt home the pt to the floor
- If PEFR 50-70% of the pt's max PEFR - If PEFR < 50% of the pt's max PEFR and
and there are mild/moderate s/s, admit there are severe s/s, admit the pt to the
the pt to the floor ICU
- If PEFR < 50% of the pt's max PEFR and
there are severe s/s, admit the pt to the ABGs are also helpful, but in general:
ICU - If PaCO2 > 42 mmHg, admit to the ICU

- If PaCO2 > 42 mmHg, admit to the ICU
98 of 340
745. A pt presents to the A pt presents to the ER in status 746. A pt presents to the A pt presents to the ER in status
ER in status asthmaticus. His PEFR after initial ER in status asthmaticus. After initial management, his
asthmaticus. His management is 60% of his max PEFR. asthmaticus. After PEFR is 40% of his max PEFR. Physical
PEFR after initial Physical exam at this point reveals mild initial management, exam reveals no change and the pt is still
management is 60% wheezing. What is the next best step in his PEFR is 40% of wheezing and in respiratory distress.
of his max PEFR. this pt's management? his max PEFR. You decide to admit him to the ICU.
Physical exam at this Admit to the floor; give q4 Duoneb Physical exam Following admission, what is the next step
point reveals mild (albuterol+ipratropium) reveals no change in management?
wheezing. What is and the pt is still Intubation; then continuous nebulizer
the next best step in wheezing and in treatment and IV steroids
this pt's Essentially, if there is some improvement, respiratory In the ICU, these pts are essentially going
management? but not full reversal. Admit these "in distress. You decide to get continuous duoneb
[...] between" pt's to the floor where all they're to admit him to the (albuterol/ipratropium) and IV steroids.
really going to get is q4 Duoneb. ICU. Following ECMO is a last resort.
After initial management has been admission, what is
performed for 3 hours, assess the pt's the next step in After initial management has been
PEFR and do a physical exam to management? performed for 3 hours, assess the pt's
determine the next step in management: [...] PEFR and do a physical exam to
- If PEFR > 70% of the pt's max PEFR and determine the next step in management:
there are no s/s, discharge the pt home - If PEFR > 70% of the pt's max PEFR and
- If PEFR 50-70% of the pt's max PEFR there are no s/s, discharge the pt home
and there are mild/moderate s/s, admit - If PEFR 50-70% of the pt's max PEFR
the pt to the floor and there are mild/moderate s/s, admit
- If PEFR < 50% of the pt's max PEFR and the pt to the floor
there are severe s/s, admit the pt to the - If PEFR < 50% of the pt's max PEFR and
ICU there are severe s/s, admit the pt to the
ICU
- If PaCO2 > 42 mmHg, admit to the ICU ABGs are also helpful, but in general:
- A-a gradient will likely be elevated - If PaCO2 > 42 mmHg, admit to the ICU
99 of 340
747. What is the most What is the most common cause of 749. A 55 y/o pt presents A 55 y/o pt presents c/o of dyspnea and
common cause of COPD?? c/o of dyspnea and chronic cough. He has a ~50 pack year
COPD?? Smoking chronic cough. He hx of smoking. Physical exam reveals
[...] has a ~50 pack year barrel chesting w/ increased AP diameter
hx of smoking. and hyperresonance on percussion. The
Only 20% of smokers get COPD, but 90% Physical exam pt is sitting in front of you breathing w/
of COPDers are/were smokers. reveals barrel pursed lips w/ a prolonged expiratory
Ultimately, COPD requires the right chesting w/ phase. Which type of COPD is the most
combination of environmental and genetic increased AP likely Dx?
factors (e.g. alpha-1 antitrypsin). diameter and Emphysema
The pathogenesis of COPD types differ but hyperresonance on
lead to similar presentations: percussion. The pt is
- Emphysema involves destruction of sitting in front of you These are your "pink puffers"
alveolar walls w/ fibrosis, leading to a loss breathing w/ pursed
of elasticity and air trapping lips w/ a prolonged
- Bronchitis involves chronic productive expiratory phase.
cough 2/2 mucous production in the large Which type of COPD
airways is the most likely Dx?
- Both will involve: loss of ciliary cells, [...]
increased goblet cells, increased mucous
production and then subsequent decrease
750. Which type of heart Which type of heart failure is associated w/
in gas exchange/airway diameter/elasticity.
failure is associated chronic bronchitis?
The ultimate result is obstructive disease
w/ chronic RCHF
w/ chronic CO2 retention.
bronchitis?
- long term sequelae include: pulmonary
[...]
hypertension 2/2 to increased pulmonary
With the classic signs of JVD, edema and
resistance 2/2 to chronic alveolar hypoxia
hepatosplenomegaly.
748. A 55 y/o pt presents A 55 y/o pt presents c/o of dyspnea and

c/o of dyspnea and chronic cough. He has a ~50 pack year
chronic cough. He hx of smoking. Physical exam reveals
has a ~50 pack year cyanosis of the extremities, peripheral
hx of smoking. edema and clubbing of the digits. What
Physical exam type of COPD is the most likely Dx?
reveals cyanosis of Chronic Bronchitis
the extremities, Your bronchitis pts are your "blue
peripheral edema bloaters"
and clubbing of the
digits. What type of
COPD is the most
likely Dx?
[...]
100 of 340
751. What is the best What is the best (most accurate) 753. What is the What is the "COPDER" mnemonic for the
(most accurate) diagnostic test for COPD? "COPDER" treatment of COPD?
diagnostic test for PFTs mnemonic for the (see below)
COPD? treatment of COPD?
[...] [...]
PFT major points:
- Asthma is both inducible and
reversible
- COPD is not inducible nor reversible
754. What drug classes What drug classes are used to achieve
COPD testing major points:
are used to achieve bronchodilation in the treatment of COPD?
- PFTs are by far the best diagnostic test,
bronchodilation in the Anticholinergics; Beta-agonists
however other tests offer helpful
treatment of COPD? Anticholinergics are the most effective
information. PFTs will show irreversible
[...] in COPD.
obstructive disease (decreased FEV1,
- Notice the difference here: an asthmatic
FEV1/FVC; increased RV, TLC;
not controlled with SABA alone? Add an
decreased DLCO if its emphysema)
ICS. A COPDer not controlled with SABA
- CXR can show flattened diaphragm,
alone? Add tiotropium and then maybe
translucent air fields, and a rotated
an ICS.
heart silhouette; and can rule out other
acute processes in acute COPD
exacerbation
- EKG can show RVH or RAD; and can
rule out ACS in exacerbation 755. Which drug class is Which drug class is preferred for
- ABG can show hypoxic, hypercapneic preferred for bronchodilation in elderly pts w/ COPD?
respiratory acidosis bronchodilation in Anticholinergics
- CBC can show erythrocytosis 2/2 to elderly pts w/
hypoxia COPD?
[...] Due to the risk of tachyarrhythmia w/
beta agonists.
752. What are the main What are the main goals of treatment in
goals of treatment in COPD?
COPD? (see below) 756. Which vaccines are Which vaccines are recommended for
[...] recommended for COPD patients?
COPD patients? Annual influenza; pneumococcal (> 60
COPD treatment goals: [...] y/o)
1. Decrease inflammation: done via
steroids
2. Bronchodilation: done via
anticholinergic and/or beta-agonists
3. Maintain oxygenation: done via O2
(4. Infection control: via vaccination)
101 of 340
757. What is the indication What is the indication for beginning 760. A pt comes in w/ A pt comes in w/ acute worsening
for beginning chronic home O2 therapy in COPD pts? acute worsening dyspnea. PMHx is positive for COPD. You
chronic home O2 PaO2 < 55 on ABG or SpO2 < 88% on dyspnea. PMHx is suspect COPD exacerbation. What is the
therapy in COPD pulse-ox positive for COPD. first step in your management?
pts? You suspect COPD Oxygen
[...] exacerbation. What
The goal would be to titrate SpO2 > 90%. is the first step in
The degree of mortality benefit is directly your management? For suspected COPD exacerbation, give
proportional to the number of hours spent [...] oxygen at first while a Dx is made. With
on oxygen. acute dyspnea, the worry of reducing
However, oxygen therapy in COPD is hypoxic respiratory drive is vastly
tricky: overshadowed by this pt's dire need of
- COPDers are chronic CO2 retainers; oxygen.
as a result, these pt's lose the CXR is helpful is ruling out another acute
hypercapneic drive to breathing and rely pulmonary process that may be causing
on the hypoxic drive to breathe symptoms.
- If we give too much O2, they may lose EKG is helpful in ruling out cardiac causes
respiratory drive of acute dyspnea (esp since many COPD
- However, if a COPD pt ever needs pts also have CHF)
oxygen (e.g. ACS), give it to them as
you're not going to affect their respiratory
761. A pt w/ COPD comes A pt w/ COPD comes in w/ acute
drive in the short term.
in w/ acute dyspnea. A diagnosis of COPD
dyspnea. A exacerbation is made after EKG and CXR
diagnosis of COPD are negative for other likely causes. The pt
exacerbation is made is started on oxygen. What is the next step
after EKG and CXR in therapy?
are negative for other Nebulizer treatment, q6h
758. Which two Which two interventions in COPD are likely causes. The pt Nebulizer treatment in COPD exacerbation
interventions in known to increase survival? is started on oxygen. key points:
COPD are known to Smoking cessation; chronic O2 therapy What is the next step - given every q6hrs
increase survival? in therapy? - Ipratropium > albuterol in terms of
[...] [...] efficacy and side effects, but they are often
Note that there is a lag between smoking given together.
cessation and the decrease in - IV Steroids can be added if no
inflammation. These pt's may get worse improvement, but continue q6 nebulizer tx
prior to showing improvement/stabilization.
759. What are the main What are the main treatment goals in the
treatment goals in management of acute COPD
the management of exacerbation?
acute COPD First, help the dude breath; cover
exacerbation? potential infection
[...]
And then determine the cause of

exacerbation.
102 of 340
762. A pt w/ COPD comes A pt w/ COPD comes in w/ acute 764. What are the 2 types What are the 2 types of pleural effusion?
in w/ acute dyspnea. A diagnosis of COPD of pleural effusion? Transudate; exudate
dyspnea. A exacerbation is made after EKG and CXR [...]
diagnosis of COPD are negative for other likely causes. The pt
exacerbation is made is started on oxygen and q6h nebulizer Transudate:
after EKG and CXR treatment, but does not improve clinically. - fluid w/o a lot of "stuff"
are negative for other What is the next step in therapy? - can be UL or BL
likely causes. The pt IV steroids (IV methylprednisone, 125 - often 2/2 to intravascular pathology
is started on oxygen mg); or PO steroids (e.g. increased intravascular hydrostatic
and q6h nebulizer pressure in CHF or a decrease in
treatment, but does intravascular oncotic pressure in nephrotic
not improve clinically. IV is preferred. syndrome)
What is the next step If steroids are on board, rememebr to give Exudate:
in therapy? a PO tapered dose at discharge. - fluid w/ a lot of "stuff"
[...] If there is no further improvement, admit to - can be UL or BL
the ICU and consider mechanical - often 2/2 to extravascular pathology
ventilation (e.g. increase in oncotic pressure outside
the vessels, such as in infection or
malignancy)
763. A pt w/ COPD comes A pt w/ COPD comes in w/ acute
in w/ acute dyspnea. A diagnosis of COPD
dyspnea. A exacerbation is made after EKG and CXR 765. What CXR finding is What CXR finding is highly suggestive of
diagnosis of COPD are negative for other likely causes. The pt highly suggestive of pulmonary effusion?
exacerbation is made is started on oxygen and q6h nebulizer pulmonary effusion? Blunting of the costovertebral angles
after EKG and CXR treatment, but does not improve clinically. [...]
are negative for other IV steroids are administered and the pt
likely causes. The pt improves overnight and is stable for - This requires about 250 mL of fluid to
is started on oxygen discharge. What medications should this pt become apparent on CXR
and q6h nebulizer be discharged on? - if more fluid is present, you may see
treatment, but does PO steroid taper; prophylactic air-fluid levels
not improve clinically. antibiotics - remember to get a follow-up
IV steroids are recumbant CXR to assess if the fluid is
administered and the free moving (i.e. not loculated) and is in
pt improves If steroids are given inpatient, send the pt sufficient quantity (> 1 cm from wall to fluid
overnight and is home with a PO taper. level) to be tapped via thoracentesis
stable for discharge. Always give prophylactic abx even if there
What medications are no signs of infection. Even though
should this pt be most infectious triggers are viral, give
discharged on? anything that will cover the typical bugs
[...] (amoxicillin, bactrim, ceftriaxone or other
3rd gen, or FQ)
103 of 340
766. A pt w/ CHF c/o A pt w/ CHF c/o SOB. CXR reveals a right 770. What is the treatment What is the treatment for a
SOB. CXR reveals a sided pleural effusion. Follow-up for a parapneumonic pleural effusion where
right sided pleural recumbant CXR reveals that the fluid is not parapneumonic there is insufficient fluid to be drained via
effusion. Follow-up loculated and sufficient to be drained via pleural effusion thoracentesis or if the fluid is loculated?
recumbant CXR thoracentesis. What clinical set of criteria where there is
reveals that the fluid aids in the interpretation of the drained insufficient fluid to be
is not loculated and fluid? drained via Treat the cause; Tube Thoracostomy
sufficient to be Lights criteria thoracentesis or if (i.e. chest tube)
drained via Light's criteria compared serum/effusion the fluid is loculated?
thoracentesis. What protein/LDH.
clinical set of criteria The next step would be to do a complete This is done to prevent the formation of
aids in the w/u if indicated. [...] an empyema
interpretation of the
drained fluid?
771. What is the treatment What is the treatment of a pleural
[...]
of a pleural effusion effusion that has become an empyema?
that has become an Thoracotomy
767. How many CXR How many CXR views are needed to empyema?
views are needed to properly work up a pleural effusion? [...]
properly work up a Atleast 2 (atleast 1 upright, and 1 If the effusion is not drained, it can become
pleural effusion? recumbent) an empyema.
[...] Tx w/ chest tube first to prevent empyema
formation.
768. What is the most What is the most appropriate first test in 772. What is the treatment What is the treatment of a pleural effusion
appropriate first test the work up of pleural effusion? of a pleural effusion that can be drained by thoracentesis?
in the work up of CXR that can be drained Thoracentesis
pleural effusion? by thoracentesis?
[...] [...]
CT is helpful, but often only done if there is Basically, don't consult CT-Sx for a chest
an exudate without clear etiology. tube when you don't need to or they'll yell
CXR must be done upright and recumbent. at you. True story.
769. A pt presents c/o of A pt presents c/o of acute worsening 773. What is the treatment What is the treatment for pleural effusion
acute worsening dyspnea. Echocardiogram reveals an EF for pleural effusion w/ w/ a known cause?
dyspnea. of 30%. BNP is elevated. CXR reveals a known cause? Treat the underlying cause
Echocardiogram bilateral, non-loculated pleural [...]
reveals an EF of effusions. Would it be helpful to perform
30%. BNP is thoracentesis in this pt? There is no need to tap or put in a chest
elevated. CXR No tube if the fluid is minimal and the cause is
reveals bilateral, already known (i.e. CHF/pneumonia).
non-loculated
pleural effusions. Well, not at this time.
Would it be helpful to This pt's effusion is likely 2/2 to their CHF.
perform In such a case, treat the CHF/CHF
thoracentesis in this exacerbation first (diuretics in this case).
pt? If the effusion does not improve, then do a
[...] thoracentesis and follow up w/ light's
criteria and the appropriate workup.
104 of 340
774. What is the What is the underlying pathogenesis of 776. What is the What is the diagnostic test for ARDS?
underlying ARDS? diagnostic test for None
pathogenesis of Increased permeability at pulmonary ARDS?
ARDS? capillaries [...]
[...] Often the Dx is clinical (i.e. pt w/ systemic
disease and pulmonary edema).
Understand this and you understand CXR can reveal BL white out
ARDS. ABGs may help too as PaO2:FiO2 ratio
Increased permability at pulmonary will be < 300 in ARDS
capillaries allows for transudation of Swan-ganz catheterization can
fluid from capillaries into the definitively diagnose ARDS vs. CHF by
interstitium. measuring PCWP
- As a result, the transudated material - wedge pressures are normal/decreased
causes pulmonary edema and a in ARDS and will be increased if there is
diffusion barrier for oxygen LV dysfunction
- Because oxygen is diffusion limited - LV function is normal/increased in
and CO2 is perfusion limited, this ARDS and obviously decreased in HF
diffusion barrier causes impaired
oxygenation, but CO2 loss is not
777. What CXR findings What CXR findings are associated w/
impaired
are associated w/ ARDS?
- hypoxemia results
ARDS? Bilateral white out
[...]
775. A pt presents w/ A pt presents w/ acute dyspnea and
acute dyspnea and coughing. She has no PMHx. The pt has
778. A pt presents w/ A pt presents w/ acute dyspnea and
coughing. She has a very sickly presentation and is in
acute dyspnea and coughing. She has no PMHx. The pt has
no PMHx. The pt has respiratory distress. Physical exam reveals
coughing. She has a very sickly presentation and is in
a very sickly crackles in all lung fields. CXR reveals
no PMHx. The pt has respiratory distress. Physical exam reveals
presentation and is in bilateral white out of the lungs. How
a very sickly crackles in all lung fields. CXR reveals
respiratory distress. would the pulmonary capillary wedge
presentation and is in bilateral white out of the lungs. What is
Physical exam pressure change in this pt?
respiratory distress. the first line therapy for this pt?
reveals crackles in Normal/no change (this pt likely has
Physical exam Intubation + oxygen (w/ addition of
all lung fields. CXR ARDS)
reveals crackles in PEEP soon after)
reveals bilateral
all lung fields. CXR
white out of the
reveals bilateral
lungs. How would the Remember, ARDS is 2/2 to widespread
white out of the This is ARDS.
pulmonary capillary increases in pulmonary capillary
lungs. What is the ARDS treatment key points:
wedge pressure permeability.
first line therapy for - First line: intubation + oxygenation (w/
change in this pt? Unless there is CHF, hydrostatic
this pt? the addition of PEEP after intubation)
[...] pressures in ARDS stay normal (hence,
[...] - Tx of the underlying cause
normal PCWP)
- low-tidal volume mechanical ventilation
- In CHF, there is LV dysfunction and
is the best support; use 6 mL/kg of tidal
hydrostatic pressure/PCWP increases as
volume
blood backs up into the lung capillaries
- steroids not clearly beneficial
- In ARDS, LV function is normal, hence
PCWP is normal (~10)
- In real life, we don’t measure PCWP for
ARDS. We can just get an ECHO/BNP that
will reveal normal LV function. Look out for
this question on tests though.
105 of 340
779. A pt presents w/ A pt presents w/ acute dyspnea and 781. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP following
acute dyspnea and coughing. She has no PMHx. The pt has placed on PEEP intubation. Shortly after, the pt's dyspnea
coughing. She has a very sickly presentation and is in following intubation. continues to worsen. All vitals remain
no PMHx. The pt has respiratory distress. Physical exam reveals Shortly after, the pt's stable. What complication of PEEP should
a very sickly crackles in all lung fields. CXR reveals dyspnea continues be considered?
presentation and is in bilateral white out of the lungs. The pt is to worsen. All vitals Barotrauma
respiratory distress. Dx w/ ARDS, intubated, and started on remain stable. What
Physical exam oxygen. Why should PEEP be added to complication of
reveals crackles in this pt's treatment? PEEP should be Complications of PEEP:
all lung fields. CXR (see below) considered? - Barotrauma; typically involves worsening
reveals bilateral PEEP in ARDS: [...] SOB after PEEP has been given to the pt
white out of the - PEEP = positive end-expiratory pressure - Pneumothorax; suspect this if the pt
lungs. The pt is Dx - PEEP works by increasing pulmonary becomes hypotensive and mediastinal
w/ ARDS, intubated, interstitial pressure and forcing fluid back shift/tracheal deviation; Dx w/ CXR; Tx
and started on into the capillaries/recruiting more alveoli; w/ needle decompression; can be 2/2
oxygen. Why should PEEP also alleviates the decrease in lung barotrauma
PEEP be added to compliance (2/2 to fluid transudation 2/2 to
this pt's treatment? increased pulmonary capillary
782. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP after
[...] permeability)
placed on PEEP intubation. Short after, he develops
- this does not alleviate the increase in
after intubation. hypotension. A medical student noticed
pulmonary capillary permeability, but does
Short after, he tracheal deviation to the left during
maximize oxygenation as oxygen is
develops rounds. What test should be ordered to
diffusion limited
hypotension. A confirm the most likely Dx?
- and remember, since CO2 is perfusion
medical student CXR to dx tension pneumothorax
limited we don't really worry about CO2 in
noticed tracheal
ARDS, as it can still be blown off; on top of
deviation to the left
that, there typically aren't any ventilation
during rounds. What Complications of PEEP:
issues in ARDS; in fact, ventilator settings
test should be - Barotrauma; typically involves worsening
are kept on low in the management of
ordered to confirm SOB after PEEP has been given to the pt
ARDS
the most likely Dx? - Pneumothorax; suspect this if the pt
- PEEP also helps to decrease FiO2 (>
[...] becomes hypotensive and mediastinal
50% is toxic to the lungs)
shift/tracheal deviation; Dx w/ CXR; Tx
- maintain a plateau pressure of 30
w/ needle decompression; can be 2/2
cmH2O
barotrauma
780. A pt w/ ARDS is A pt w/ ARDS is placed on PEEP after

783. Why does a clot in Why does a clot in the deep veins of the
placed on PEEP intubation. Which 2 complications should
the deep veins of leg have a risk of embolizing up the IVC
after intubation. be monitored for?
the leg have a risk of towards the heart/lungs?
Which 2 Barotrauma; PTX
embolizing up the There are no valves in the deep veins
complications should
IVC towards the
be monitored for?
heart/lungs?
[...] Complications of PEEP:
[...] Typically the femoral and popliteal veins
- Barotrauma; typically involves worsening
are the sites of clot formation.
SOB after PEEP has been given to the pt
- Pneumothorax; suspect this if the pt
becomes hypotensive and mediastinal
shift/tracheal deviation; Dx w/ CXR; Tx
w/ needle decompression; can be 2/2
barotrauma
106 of 340
784. A pulmonary A pulmonary embolism can present as a 786. A pt on bed rest A pt on bed rest presents w/ SOB,
embolism can life-threatening condition. What effect does presents w/ SOB, tachypnea, tachycardia and pleuritic
present as a the clot have at the lungs that causes such tachypnea, chest pain. Physical exam reaveals lungs
life-threatening a presentation? tachycardia and that are CTABL. CXR is clear. What is the
condition. What (see below) pleuritic chest pain. most likely Dx?
effect does the clot Physical exam Pulmonary embolism
have at the lungs reaveals lungs that
that causes such a Key points of PE pathogenesis: are CTABL. CXR is
presentation? 1. Limited gas exchange 2/2 the clot clear. What is the PE presentation key points:
[...] blocking blood flow most likely Dx? - SOB & tachypnea 2/2 to the limited gas
2. Right heart strain 2/2 increased [...] exchange and increased R heart strain
pulmonary vascular resistance 2/2 fewer - Tachycardia is 2/2 a need to maxmize
patent vessels gas exchange (via increased CO)
3. Widespread pulmonary inflammation - Pleuritic chest pain is 2/2 pleural
2/2 platelet derived mediators ischemia
- Homan's sign is highly suggestive of a
current DVT, but its absence doesn't rule
785. Even the smallest of Even the smallest of clots can cause a
out anything
clots can cause a severe pulmonary embolism w/ a
- Hemoptysis may be involved and is 2/2
severe pulmonary life-threatening presentation. Why?
necrosis of lung parenchyma
embolism w/ a Platelet-derived mediators
life-threatening
presentation. Why? 787. Which set of clinical Which set of clinical criteria do we use to
[...] Key points of PE pathogenesis: criteria do we use to help w/ the workup of pulmonary
1. Limited gas exchange 2/2 the clot help w/ the workup of embolism?
blocking blood flow pulmonary Wells Criteria
2. Right heart strain 2/2 increased embolism?
pulmonary vascular resistance 2/2 fewer [...]
patent vessels; this can affect pulmonary
perfusion, and hence CO2 blow off
(remember, CO2 is perfusion limited)
3. Widespread pulmonary inflammation
788. What CXR findings What CXR findings are associated w/
2/2 platelet derived mediators; this
are associated w/ pulmonary embolism?
widespread inflammation causes fluid to
pulmonary Normal findings
leak out of pulmonary vasculature and
embolism?
creates a diffusion barrier for oxygen (but
[...]
not CO2 because, once again, CO2 is
Did I get you?
perfusion limited & oxygen is diffusion
limited)
789. What EKG findings What EKG findings are associated w/
are associated w/ pulmonary embolism?
pulmonary "S1Q3T3"
embolism?
[...]
"S1-Q3-T3"
- prominent S in lead I
- Q wave in lead III
- T-wave inversion in lead III
- indicative of R heart strain
107 of 340
790. What ABG findings What ABG findings are associated w/ 794. What is the treatment What is the treatment for massive
are associated w/ pulmonary embolism? for massive pulmonary embolism?
pulmonary Hypoxemic respiratory alkalosis pulmonary Intra-arterial tPA; or thrombectomy
embolism? embolism?
[...] [...]
Hypoxia causes increased respiratory PE treatment key points:
drive which causes respiratory alkalosis - The first step is obviously giving oxygen
- In massive embolism, it is imperative to
attack the clot right away. Give
791. What change in What change in D-Dimer levels is
intra-arterial tPA or perform
D-Dimer levels is diagnostic of a pulmonary embolism?
thombectomy
diagnostic of a None
- Platelet-derived inflammatory
pulmonary
mediators are controlled w/ heparin;
embolism?
heparin alost stabilizes existing clots
[...] The only D-Dimer measurement that is
- Recurrence is targeted w/ long term
useful in suspected PE is if it is normal
anticoagulation, typically w/ warfarin
- a normal D-Dimer reliably rules out a PE
(target INR of 2-3)
- an elevated D-Dimer can be 2/2 anything
- Bridge to warfarin w/ heparin
- If warfarin cannot be tolerated or there is
792. Which diagnostic Which diagnostic tests can provide a PE while having therapeutic INR,
tests can provide definitive Dx of a PE? consider an IVC filter
definitive Dx of a Spiral CT; Pulmonary angiogram
PE?
795. What are the What are the treatment goals in most
[...]
treatment goals in cases of pulmonary embolism?
Spiral CT is preferred as it is non-invasive
most cases of Shut off platelet mediators causing
Angiogram is not superior to spiral CT
pulmonary widespread pulmonary inflammation;
However, if the patient cannot tolerate
embolism? prevent recurrence
IV contrast a CT scan is not feasible, in
[...]
such a case, perform a V/Q scan and
stratify the pt into low, medium, or high risk
PE treatment key points:
- The first step is obviously giving oxygen
- In massive embolism, it is imperative to
attack the clot right away. Give
793. A pt is thought to A pt is thought to have a PE but cannot intra-arterial tPA or perform
have a PE but tolerate IV contrast do to severe renal thombectomy
cannot tolerate IV disease. What other diagnostic test can be - Platelet-derived inflammatory
contrast do to severe ordered to help in the workup? mediators are controlled w/ heparin;
renal disease. What V/Q scan heparin also stabilizes existing clots
other diagnostic test - Recurrence is targeted w/ long term
can be ordered to anticoagulation, typically w/ warfarin
help in the workup? (target INR of 2-3)
[...] - Bridge to warfarin w/ heparin
- If warfarin cannot be tolerated or there is
a PE while having therapeutic INR,
consider an IVC filter
108 of 340
796. How soon can How soon can Heparin-induced 800. What are the 3 main What are the 3 main methods of obtaining
Heparin-induced Thrombocytopenia (HIT) present following methods of obtaining a biopsy of a suspected lung cancer?
Thrombocytopenia first-time exposure to heparin? a biopsy of a (see below)
(HIT) present 7 days suspected lung
following first-time cancer?
exposure to [...] Lung biopsy key points:
heparin? - Bx depends on the type of lesion and its
[...] location (and clinical situation)
- Endobronchial Ultrasound (EBUS) is
used for central lung masses
797. How soon can How soon can Heparin-induced
- Percutaneous CT-guided biopsy is
Heparin-induced Thrombocytopenia (HIT) present following
used for peripheral lung masses
Thrombocytopenia a repeat exposure to heparin?
- VATS is used for deep,
(HIT) present 3 days
intraparenchymal lesions
following a repeat
exposure to
heparin? 801. Which common lung Which common lung cancer is typically not
[...] cancer is typically not associated w/ smoking?
associated w/ Adenocarcinoma
smoking?
798. What is the first What is the first diagnostic test preferred
[...]
diagnostic test for the workup of suspected lung cancer?
preferred for the CXR
workup of suspected 802. Which lung cancer is Which lung cancer is associated w/
lung cancer? associated w/ PTH-rp release as a paraneoplastic
[...] Remember though, there is no screening PTH-rp release as a syndrome?
for lung cancer. paraneoplastic Squamous cell carcinoma
CXR, then CT, then Bx syndrome?
[...]
799. A pt presents c/o of A pt presents c/o of hemoptysis and

hemoptysis and unintended weight loss for the past 6 803. Which lung cancer is Which lung cancer is associated with
unintended weight months. What spectrum of disease must associated with SIADH as a paraneoplastic syndrome?
loss for the past 6 be considered? SIADH as a Small cell carcinoma
months. What Lung cancer paraneoplastic
spectrum of disease syndrome?
must be considered? [...]
[...] Start testing w/ CXR, then CT, then Bx if
indicated
804. Which lung cancer is Which lung cancer is associated w/
Presentation of lung cancer key points:
associated w/ Cushing's syndrome as a paraneoplastic
- Lung cancer typically presents in 2 ways:
Cushing's syndrome?
hemoptysis+weight loss or incidental
syndrome as a Small cell carcinoma
lung lesion
paraneoplastic
syndrome?
[...]
109 of 340
805. Which lung cancer is Which lung cancer is associated w/

810. A pt w/ a solitary A pt w/ a solitary pulmondary nodule
associated w/ Lambert-Eaton syndrome as a
Lambert-Eaton paraneoplastic syndrome? pulmondary nodule received a CT scan. It is < 2 cm in
syndrome as a Squamous cell carcinoma received a CT scan. diameter and shows signs of calcification.
paraneoplastic It is < 2 cm in Is this a high or low risk lesion?
syndrome? diameter and shows Low
[...] signs of Calcification of pulmonary nodules is a
calcification. Is this good thing. Spiculation is not.
a high or low risk 2 cm diameter is the threshold size for risk
806. Which lung cancer is Which lung cancer is typically already lesion? stratification.
typically already metastasized at the time of Dx? [...] Risk is also influenced by the pt (smoking,
metastasized at the Small cell carcinoma age, FHx, PMHx, etc.)
time of Dx?
40 y/o is the threshold for age.
[...]
Is it often too small to cause obstructive
pneumonia or hemoptysis.
811. Which type of renal Which type of renal failure is 2/2
failure is 2/2 decreased renal perfusion?
807. Which lung cancer is Which lung cancer is known to be decreased renal Prerenal
known to be especially sensitive to chemo and perfusion? Typical causes involve the following
especially sensitive radiation therapy? [...] pathophysiology:
to chemo and Small cell carcinoma - decreased cardiac output
radiation therapy? - 3rd spacing
[...] - decreased vessel diameter
All other lung cancers are treated w/ In this case, the kidney's think they are
surgery first. dehydrated. As a result, they hold onto
Small cell carcinoma is almost never salt and urine
operated on due to its sensitivity to - FeNa < 1% (use FeUrea and Uurea if the
chemo/rads. pt is on a diuretic)
- UNa < 10
808. Which common lung Which common lung cancer is known to - BUN:Cr > 20
cancer is known to present peripherally? Tx via IVF or managing the causative
present peripherally? Adenocarcimoma condition
[...]
Adenocarcinoma of the lung is often stuck 812. What FeNa What FeNa measurement is associated w/
to the pleura, causing it to pucker measurement is prerenal failure?
This makes sense: associated w/ < 1%
- The other cancers are more commonly prerenal failure?
caused by smoking. Smoke passes the [...]
large, central airways w/ every puff. So it In this case, the kidney's think they are
makes sense for small cell and dehydrated. As a result, they hold onto
squamous cell to present centrally salt and urine
- There's also a handy mnemonic: Small - FeNa < 1% (use FeUrea and Uurea if the
cell & Squamous = Sentral pt is on a diuretic)
- UNa < 10
809. What is the most What is the most appropriate, initial test in - BUN:Cr > 20
appropriate, initial the workup of a solitary pulmonary nodule? Tx via IVF or managing the causative
test in the workup of CT condition
a solitary pulmonary
nodule?
[...]
110 of 340
813. What level of urinary What level of urinary sodium (UNa) is 816. What FeNa level is What FeNa level is associated w/
sodium (UNa) is associated w/ prerenal failure? associated w/ intrarenal failure?
associated w/ < 10 intrarenal failure? > 1%
prerenal failure? [...]
[...]
In this case, the kidney's think they are Intrarenal failure is typically a disease of
dehydrated. As a result, they hold onto the nephron:
salt and urine - FeNa > 1% as the tubules cannot
- FeNa < 1% (use FeUrea and Uurea if the reabsorb Na
pt is on a diuretic) - UNa > 20 as the tubules cannot reabsorb
- UNa < 10 Na
- BUN:Cr > 20 - UA is typically enough to diagnose
Tx via IVF or managing the causative - Bx is definitive diagnosis
condition
817. A pt presents w/ A pt presents w/ acute renal failure. You

814. What BUN:Cr ratio is What BUN:Cr ratio is associated w/ acute renal failure. attempt to calculate FeNa to assess for a
associated w/ prerenal failure? You attempt to prerenal etiology, but realise that the pt is
prerenal failure? > 20 calculate FeNa to using a loop diuretic that interferes w/ Na
[...] assess for a prerenal excretion. Which fractional excretion
etiology, but realise measurement can you use in place of
In this case, the kidney's think they are that the pt is using a FeNa?
dehydrated. As a result, they hold onto loop diuretic that FeUrea
salt and urine interferes w/ Na
- FeNa < 1% (use FeUrea and Uurea if the excretion. Which
pt is on a diuretic) fractional excretion If the pt is on a drug that interferes w/ Na
- UNa < 10 measurement can excretion (e.g. loop diuretic, ACE-i/ARB,
- BUN:Cr > 20 you use in place of spironolactone), use FeUrea instead of
Tx via IVF or managing the causative FeNa? FeNa.
condition [...] FeUrea < 35% suggests prerenal failure.
815. Which type of renal Which type of renal failure involves 818. A pt presents in A pt presents in acute renal failure. What is
failure involves obstruction to urinary outflow at any level? acute renal failure. the first step in the workup?
obstruction to urinary Postrenal failure What is the first step Rule out prerenal failure (BUN:Cr, UNa,
outflow at any level? in the workup? FeNa)
[...] [...]
Order an U/S to look for residual urine
and hydroureter/hydronephrosis.
819. A pt presents in A pt presents in acute renal failure.

acute renal failure. Prerenal failure has been ruled out. What
Prerenal failure has is the next step in workup?
been ruled out. What Rule out postrenal failure (KUB U/S)
is the next step in
workup?
[...]
111 of 340
820. A pt is suspected to A pt is suspected to have intrarenal failure. 823. A pt presents in A pt presents in acute renal failure. He is
have intrarenal What is the best initial diagnostic test? acute renal failure. Dx w/ acute tubular necrosis. On hospital
failure. What is the UA He is Dx w/ acute day 2, the pt's creatinine continues to rise,
best initial diagnostic While Bx would offer a definitive diagnosis, tubular necrosis. On but he becomes oliguric. Which phase of
test? UA is often enough to arrive at a diagnosis hospital day 2, the acute tubular necrosis is this pt in?
[...] (with the help of the history & presentation) pt's creatinine Phase 2: oliguric phase
continues to rise, but
he becomes oliguric.
Which phase of The phases of ATN:
821. A pt presents in A pt presents in acute renal failure.
acute tubular 1. Prodrome: creatinine rises while urine
acute renal failure. BUN:Cr is < 10. FeNa is > 1%. UA reveals
necrosis is this pt in? output remains constant
BUN:Cr is < 10. muddy brown casts. What is the most
[...] 2. Oliguric phase: creatinine continues to
FeNa is > 1%. UA likely Dx?
rise, but urine output plummets; diuretics
reveals muddy Intrarenal failure; likely ATN
are helpful here to reduce fluid load and
brown casts. What
help kidney function improve
is the most likely Dx?
3. Polyuric phase: creatining continues to
[...] Acute Tubular Necrosis key points:
rise, but urine output increases
- thought to be 2/2 prolonged ischemia or
- Tx throughout these phases is
toxic exposure (esp. IV contrast or
supportive
myoglobin 2/2 rhabdomyolysis), resulting
in the necrosis and sloughing off of renal
tubules 824. A pt w/ stage II CKD A pt w/ stage II CKD is admitted to the
- muddy brown casts are typical on UA is admitted to the hospital. She needs to receive IV contrast
and represent the sloughed tubular hospital. She needs prior to imaging. What interventions may
epithelium, however this is not specific to to receive IV contrast help to reduce the risk of
ATN prior to imaging. contrast-induced acute tubular
- presents in 3 phases: prodrome, What interventions necrosis?
oliguric phase, polyuric phase may help to reduce (see below)
the risk of
contrast-induced
822. What are the three What are the three phases of Acute
acute tubular If a pt has pre-existing renal damage or is
phases of Acute Tubular Necrosis?
necrosis? at increased risk. Reduce the risk of
Tubular Necrosis? Prodrome; oliguric phase; polyuric
[...] contrast-induced ATN via:
[...] phase
- vigorous hydration
- prophylactic N-Acetyl-Cysteine
- stop drugs such as ACE-Is/ARBs,
The phases of ATN:
diuretics or common nephrotoxic agents
1. Prodrome: creatinine rises while urine
like metformin
output remains constant
The idea here is to minimize the contact of
2. Oliguric phase: creatinine continues to
the tubules w/ the contrast.
rise, but urine output plummets; diuretics
These measures are useless if contrast is
are helpful here to reduce fluid load and
already given.
help kidney function improve
3. Polyuric phase: creatining continues to
rise, but urine output increases 825. What type of casts What type of casts found on UA are
- Tx throughout these phases is found on UA are associated w/ Acute Tubular Necrosis?
supportive associated w/ Acute Muddy Brown Casts
Tubular Necrosis?
[...]
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826. A pt presents w/ A pt presents w/ acute renal failure. 829. Which type of casts Which type of casts on UA are associated
acute renal failure. BUN:Cr is < 10. FeNa is > 1%. UA reveals on UA are w/ glomerulonephritis?
BUN:Cr is < 10. WBC and WBC casts. What is the most associated w/ RBC
FeNa is > 1%. UA likely Dx? glomerulonephritis?
reveals WBC and Intrarenal failure likely 2/2 acute [...]
WBC casts. What is interstitial nephritis (AIN) Glomerulonephritis general key points:
the most likely Dx? - the differential for the type of
[...] glomerulonephritis is extensive
AIN key points: - RBC casts are typical of GN
- involves immune cell invasion of the - Definitive Dx is via biopsy
interstitium 2/2 to drugs, infection or - Important to r/o nephrotic syndrome w/
deposition disease (e.g. multiple myeloma) UA spot test or 24 hr urine collection
- common drugs are: TMP-SMX,
cephalosporins, penicillins, NSAIDs
830. Which type of Which type of glomerulonephritis is known
- pts can have fever, rash and elevated
glomerulonephritis is to present after a viral infection?
Cr
known to present IgA Nephropathy
- UA will reveal WBCs and WBC casts
after a viral
- Tx by removing the offending agent,
infection?
treating the infection, or mitigating the
[...] Glomerulonephritis general key points:
damage; steroids may be helpful
- the differential for the type of
glomerulonephritis is extensive
827. What type of casts What type of casts on UA are associated - RBC casts are typical of GN
on UA are w/ Acute Interstitial Nephritis? - Definitive Dx is via biopsy
associated w/ Acute WBC casts - Important to r/o nephrotic syndrome w/
Interstitial Nephritis? UA spot test or 24 hr urine collection
[...]
831. Which type of Which type of glomerulonephritis

828. A pt presents w/ A pt presents w/ acute renal failure. glomerulonephritis commonly presents after pharyngitis or
acute renal failure. BUN:Cr ratio is < 10. FeNa is > 1%. UA commonly presents impetigo?
BUN:Cr ratio is < 10. reveals RBC casts. What is the most likely after pharyngitis or Post-streptococcal glomerulonephritis
FeNa is > 1%. UA Dx? impetigo? (PSGN)
reveals RBC casts. Intrarenal failure 2/2 glomerulonephritis [...]
What is the most (GN)
likely Dx? Glomerulonephritis general key points:
[...] - the differential for the type of
Glomerulonephritis general key points: glomerulonephritis is extensive
- the differential for the type of - RBC casts are typical of GN
glomerulonephritis is extensive - Definitive Dx is via biopsy
- RBC casts are typical of GN - Important to r/o nephrotic syndrome w/
- Definitive Dx is via biopsy UA spot test or 24 hr urine collection
- Important to r/o nephrotic syndrome w/
UA spot test or 24 hr urine collection
113 of 340
832. Which type of Which type of glomerulonephritis 835. A pt is diagnosed w/ A pt is diagnosed w/ glomerulonephritis.
glomerulonephritis commonly presents w/ hemoptysis glomerulonephritis. What renal disorder needs to be ruled out
commonly presents alongside the hematuria? What renal disorder in the next step in management?
w/ hemoptysis Goodpasture's syndrome needs to be ruled out Nephrotic Syndrome
alongside the in the next step in
hematuria? management?
[...] Glomerulonephritis general key points: [...] While it is important to determine the
- the differential for the type of specific type/etiology of glomerulonephritis.
glomerulonephritis is extensive It is also important to rule out nephrotic
- RBC casts are typical of GN syndrome. The latter is easier (as the
- Definitive Dx is via biopsy former often requires Bx).
- Important to r/o nephrotic syndrome w/ Ruling out Nephrotic Syndrome key
UA spot test or 24 hr urine collection points:
- can be done via UA spot test or 24 hr
urine collection
833. Which type of Which type of glomerulonephritis is
- > 3.5 g proteinuria/day suggests
glomerulonephritis is associated w/ asthma alongside the
nephrotic syndrome
associated w/ hematuria?
- hyperlipidemia also supports nephrotic
asthma alongside Churg-Strauss syndrome
syndrome
the hematuria?
- edema can be seen as well (2/2
[...]
decreased oncotic pressure 2/2
Glomerulonephritis general key points:
proteinuria)
- the differential for the type of
glomerulonephritis is extensive
- RBC casts are typical of GN 836. A pt has elevated A pt has elevated creatinine and reduced
- Definitive Dx is via biopsy creatinine and GFR that does not return to normal after
- Important to r/o nephrotic syndrome w/ reduced GFR that repeated outpatient testing. For how long
UA spot test or 24 hr urine collection does not return to must his GFR remain reduced before a
normal after diagnosis of chronic kidney disease can be
repeated outpatient made?
834. What do dysmorphic What do dysmorphic RBCs on urine
testing. For how long > 3 months
RBCs on urine microscopy signify?
must his GFR remain
microscopy signify? (see below)
reduced before a
[...]
diagnosis of chronic
kidney disease can
Dysmorphic RBCs = "RBCs w/ mickey
be made?
mouse ears"
[...]
- The presence of dysmorphic RBCs tells
us that the bleeding is coming from the
glomerulus 837. What laboratory What laboratory measurement is used to
- The "mickey mouse ears" are blebs that measurement is stratify Chronic Kidney Disease into
form as the RBC is sheared while crossing used to stratify stages?
through the abnormal glomerulus Chronic Kidney GFR
- This is helpful in the work up of hematuria Disease into stages?
(microscopic, frank, or gross) as it points [...]
us away from malignancy, stones, UTI, It is not BUN or Cr no matter what the
etc. gunner on rounds says.
838. What GFR level is What GFR level is seen in stage I CKD?
seen in stage I CKD? > 90
[...]
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839. What GFR level is What GFR level is seen in stage II CKD? 846. What are the What are the indications of acute dialysis?
seen in stage II 60-89 indications of acute "AEIOU"
CKD? dialysis? It has nothing to do w/ creatinine no matter
[...] [...] what the gunner during rounds says.
Indications for acute dialysis: "AEIOU"

840. What GFR level is What GFR level is seen in stage III CKD?
- Acidosis
seen in stage III
- Electrolytes (namely Na and K)
CKD? 30-59
- Ingestion (of dialyzable toxins/drugs)
- Overload (of fluid; e.g. CHF)
[...]
- Uremia (NOT azotemia)
841. What GFR level is What GFR level is seen in stage IV CKD?
847. Which neurological Which neurological symptoms are
seen in stage IV 15-29
symptoms are associated w/ hypokalemia?
CKD?
associated w/ Areflexia; flaccid paralysis; paresthesia
[...]
hypokalemia?
[...]
842. What GFR level is What GFR level is seen in stage V CKD?
seen in stage V < 15
848. A pt presents gets a A pt presents gets a CMP that reveals a K
CKD?
CMP that reveals a K level of 6. There are no other abnormalities
[...]
level of 6. There are or symptoms. What is the most appropriate
no other next step in the management of this pt's
843. What is the BP goal What is the BP goal in a pt w/ chronic abnormalities or hyperkalemia?
in a pt w/ chronic kidney disease? symptoms. What is Repeat the lab
kidney disease? < 130/80 the most appropriate Very commonly, lab samples involve
[...] next step in the busted cells/RBCs which can falsely
management of this elevate K. In this case, the pt is
BP control is much more vigorous in pts w/ pt's hyperkalemia? symptomatic, but it's still prudent to rule
CKD or other renal disease. [...] out this error.
The preferred agent is an ACE-I or ARB
Note that additional comorbidities must be
mitigated as well.
844. Pts w/ ESRD or high Pts w/ ESRD or high stage CKD are at a
stage CKD are at a higher risk of developing secondary
higher risk of hyperparathyroidism. What interventions
developing aid in reducing this risk?
secondary Ca; Vit D; phosphate binders
hyperparathyroidism.
What interventions
aid in reducing this
risk?
[...]
845. What is the What is the hemoglobin goal in a pt w/

hemoglobin goal in a ESRD or late stage CKD?
pt w/ ESRD or late 11-12
stage CKD?
[...]
115 of 340
849. A pt presents gets a A pt presents gets a CMP that reveals a K 851. A pt gets a CMP in A pt gets a CMP in the ER that reveals a K
CMP that reveals a K of 6. Repeat CMP confirms true the ER that reveals a of 7. Repeat CMP confirms hyperkalemia.
of 6. Repeat CMP hyperkalemia. What is the most K of 7. Repeat CMP EKG reveals widened QRS and
confirms true appropriate next step? confirms prolonged PR. What is the treatment for
hyperkalemia. What EKG hyperkalemia. EKG this pt's electrolyte imbalance?
is the most reveals widened (see below; this is unstable
appropriate next QRS and prolonged hyperkalemia)
step? It is imperative to get an EKG in PR. What is the Unstable Hyperkalemia Tx key points:
[...] hyperkalemia to determine if it is stable or treatment for this pt's - Phase I = stabilization (of the
unstable. electrolyte myocardium): done via IV Ca gluconate
EKG in Hyperkalemia key points: imbalance? - Phase II = sequestration (of
- EKG changes include peaked T-waves, [...] extracellular K): done via insulin+glucose
widened QRS, and prolonged QT & PR; or bicarbonate (or beta2-agonists)
the end point is sine wave EKG, which is - Phase III = excretion (of K): done via
bad news, homey kayexalate, K-wasting diuretics (e.g.
- If EKG changes are present, its called loop diuretics), or hemodialysis if in renal
unstable hyperkalemia and Tx is failure
emergent and slightly different - Phase I protects what we're worried
- If EKG changes are absent, its called about the most: the heart. Phase II is a
stable hyperkalemia quick fix for extracellular hyperkalemia, but
it does not actually correct total body K;
Phase III brings it home and involves
facilitating excretion of K via GI, renal, or
dialysis if CKD/ESRD is present
850. A pt is Dx w/ A pt is Dx w/ hyperkalemia. What are the 3
hyperkalemia. What phases of treating unstable hyperkalemia?
are the 3 phases of (see below)
treating unstable
hyperkalemia? 852. A pt presents w/ a A pt presents w/ a potassium level of 6. All
[...] Unstable Hyperkalemia Tx key points: potassium level of 6. other labs are normal and the pt is
- Phase I = stabilization (of the All other labs are asymptomatic. EKG reveals NSR w/ no
myocardium): done via IV Ca gluconate normal and the pt is abnormalities. What is the treatment for
- Phase II = sequestration (of asymptomatic. EKG this pt's electrolyte imbalance?
extracellular K): done via insulin+glucose reveals NSR w/ no Kayexalate (this is stable hyperkalemia)
or bicarbonate (or beta2-agonists) abnormalities. What
- Phase III = excretion (of K): done via is the treatment for
kayexalate, K-wasting diuretics (e.g. this pt's electrolyte Stable Hyperkalemia Tx key points:
loop diuretics), or hemodialysis if in renal imbalance? - Kayexalate is a K chelator that facilitates
failure [...] K excretion via GI
- Phase I protects what we're worried - Stop any K-sparing diuretics (e.g.
about the most: the heart. Phase II is a spironolactone, amiloride, triamterene)
quick fix for extracellular hyperkalemia, but
it does not actually correct total body K;
Phase III brings it home and involves
facilitating excretion of K via GI, renal, or
dialysis if CKD/ESRD is present
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853. A pt is dx w/ unstable A pt is dx w/ unstable hyperkalemia. IV Ca 855. A pt w/ diarrhea is Dx A pt w/ diarrhea is Dx w/ hypokalemia after

hyperkalemia. IV Ca gluconate is given and the pt is given w/ hypokalemia after 2 lab tests showing a K level of 2. What is
gluconate is given insulin w/ glucose. Which class of 2 lab tests showing a the most appropriate next step in
and the pt is given adrenergics can also be given to decrease K level of 2. What is management of this pt's hypokalemia?
insulin w/ glucose. K levels? the most appropriate EKG
Which class of Beta2-agonists next step in
adrenergics can also management of this
be given to decrease pt's hypokalemia? This one is weird. The book says to get an
K levels? e.g. Albuterol [...] EKG, but in real life you're going to end up
[...] Beta-2 agonists and hyperkalemia key replacing the K anyway, so what's the
points: point of getting an EKG? It doesn't hurt,
- Not frequently used, but can and should but it likely isn't going to change your
be considered as transient therapy in pts management (STAT K replacement)
that have s/s or serious EKG abnormalities Hypokalemia key points:
despite Ca gluconate and insulin therapy - less sexy than hyperkalemia, but still
- Acts the same way as insulin: activates deadly
the Na/K ATPase pump in skeletal - re-check the initial lab value to confirm
muscle the abnormality
- They also activate the Na/K/2Cl - Tx involves K replacement
cotransporter that drives K into cells - PO replacement is always better than
- Side effects include tachycardia and IV
increases the risk of angina/ACS - If the pt is on a K-wasting diuretic, add a
- Is additive w/ insuline+glucose therapy K-sparing diuretic or consider long-term
- Should not be used as monotherapy in supplementation
pts w/ ESRD
- Should not be used at all in pts w/ active
856. What are the more What are the more common causes of
CAD
common causes of hypokalemia?
hypokalemia? (see below)
854. A pt taking a loop A pt taking a loop diuretic has a K level of [...]
diuretic has a K level 2 on CMP. What is the most appropriate
of 2 on CMP. What is next step in the workup of this pt's Hypokalemia causes key points:
the most appropriate hypokalemia? - Typically it's GI loss (diarrhea, vomiting,
next step in the Repeat the lab laxatives) or renal loss (loop/thiazide
workup of this pt's diuretics)
hypokalemia? - In isolated hypokalemia, consider RTA,
[...] Similar to hyperkalemia, repeat the lab to Barter syndrome, or Gittleman
confirm if it is a true lab abnormality. syndrome
- If part of a syndrome, look for
hyperaldosteronism
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857. What is the treatment What is the treatment for hypokalemia? 859. What is the What is the diagnostic test for polycystic
for hypokalemia? Replacement K diagnostic test for kidney disease?
[...] polycystic kidney U/S (or CT)
disease?
Hypokalemia Tx key points: [...]
- PO replacement is preferred over IV ADPCKD key points:
replacement - Autosomal dominant
- IV replacement burns, but the PO - s/s: pain and hematuria; commonly
replacement pill is massive mistaken for nephrolithiasis, however
- Generally, try and keep the replacement stones can form
≤ 10 mEq/hr (i.e. increasing K by 0.1/hr) - pyelonephritis is a common presention
- If the IV is peripheral, infusion rate must - malignant HTN can be present and is
be ≤ 10 mEq/hr to prevent burning 2/2 RAAS activation
- If the IV is central, ≤ 20 mEq/hr, not to - Dx is via U/S
prevent burning but to prevent local - Tx is supportive, manage
hyperK near the catheter complications and transplant once
- If the pt is on K-wasting diuretics, ESRD/CKD sets in
consider adding a K-sparing diuretic or - Cysts can also form in the liver,
outpatient potassium supplementation pancreas, and cerebral vasculature
- Screen these pts for berry aneurysms
as they have a risk for SAH
858. What percentage of What percentage of ESRD and dialysis pts
- Remember to test family members and
ESRD and dialysis have polycystic kidney disease?
offspring
pts have polycystic 5-10%
kidney disease?
[...] 860. Polycystic kidney Polycystic kidney disease can be
Pretty useless card, but the point is: you're disease can be autosomal dominant or autosomal
likely going to see PCKD this at some autosomal dominant recessive. What is the difference between
point. Know it, brah. or autosomal the cysts in ADPCKD and ARPCKD?
recessive. What is (see below)
the difference
between the cysts in
ADPCKD and In ADPCKD, the cysts have a random
ARPCKD? orientation and size
[...] In ARPCKD, the cysts have a radial
orientation
861. What is the treatment What is the treatment for polycystic kidney
for polycystic kidney disease?
disease? Supportive; manage complications;
[...] transplant when ESRD/CKD sets in
118 of 340
862. A pt undergoing A pt undergoing elective cholecystectomy 864. A pt presents c/o of A pt presents c/o of flank pain and gross
elective receives an abdominal U/S that flank pain and hematuria. Physical exam reveals a
cholecystectomy incidentally reveals a renal cyst. It is small, gross hematuria. palpable flank mass on the R side. What
receives an non-loculated, and non-septated. No Physical exam renal disorder must be ruled out?
abdominal U/S that echoes are seen on the U/S. What is the reveals a palpable Renal Cell Carcinoma
incidentally reveals a most likely Dx? flank mass on the R
renal cyst. It is small, Simple Renal Cyst side. What renal
non-loculated, and Simple Renal Cyst key points: disorder must be Renal Cell Carcinoma key points:
non-septated. No - must be small, non-loculated, ruled out? - While its not present everytime, the triad
echoes are seen on non-septated and no echoes on U/S [...] of flank pain, flank mass, and hematuria
the U/S. What is the - If truly simple, and asymptomatic, let it be should be considered cancer until proven
most likely Dx? - If s/s develop, consider excision or otherwise
[...] biopsy - Major risk factors include smoking,
ESRD and von-Hippel Lindau
- Investigate w/ U/S or CT
- F/u w/ surgical resection
863. A pt undergoing A pt undergoing elective cholecystectomy
- Definitive Dx is via Bx after resection
elective receives an abdominal CT that incidentally
- Never ever biopsy a suspected RCC in
cholecystectomy reveals a renal cyst. It is large, septated,
vivo; the risk of hematoma and/or seeding
receives an and loculated. What is the most
is high; always Bx s/p resection
abdominal CT that appropriate next step?
- hematogenous spread
incidentally reveals a Biopsy (this is a complex renal cyst)
- Renal vein thrombosis is a big risk
renal cyst. It is large, Complex Renal Cyst key points:
- Either anaemia or polycythemia can be
septated, and - must be large, septated, or loculated
present (anaemia 2/2 to the tumour or
loculated. What is - more likely to cause symptoms than
increased EPO release as a
the most appropriate simple cysts
paraneoplastic syndrome)
next step? - common s/s: flank mass, hematuria,
[...] pyelonephritis, pain
- If truly complex, biopsy that sucker to r/o
malignancy
- CT-guided needle Bx is typically the
method of choice
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865. A pt presents c/o of A pt presents c/o of flank pain and gross 867. A pt presents c/o A pt presents c/o colicky flank pain that
flank pain and hematuria. Physical exam reveals a colicky flank pain radiates to the groin. He states that this
gross hematuria. palpable flank mass on the R side. You that radiates to the started 2 days ago and that yesterday he
Physical exam suspect renal cell carcinoma. What is the groin. He states that had hematuria. He also complains of
reveals a palpable most appropriate next step? this started 2 days nausea and vomiting. He denies any
flank mass on the R U/S or CT to visualize the kidneys ago and that fever or chills. What is the most likely Dx?
side. You suspect yesterday he had Nephrolithiasis
renal cell carcinoma. hematuria. He also
What is the most Renal Cell Carcinoma key points: complains of nausea
appropriate next - While its not present everytime, the triad and vomiting. He
step? of flank pain, flank mass, and hematuria denies any fever or
[...] should be considered cancer until proven chills. What is the
otherwise most likely Dx?
- Major risk factors include smoking, [...]
ESRD and von-Hippel Lindau
- Investigate w/ U/S or CT
- F/u w/ surgical resection
colicky flank pain radiates to the groin. He states that this
- Definitive Dx is via Bx after resection
that radiates to the started 2 days ago and that yesterday he
groin. He states that had hematuria. He also complains of
this started 2 days nausea and vomiting. He denies any
ago and that fever or chills. You suspect nephrolithiasis.
yesterday he had What is the most appropriate initial test?
hematuria. He also UA
complains of nausea UA is the best initial test.
and vomiting. He CT (or KUB U/S if preggo) is the best
denies any fever or diagnostic test
chills. You suspect While the pt denied fever or chills, a UA is
nephrolithiasis. What still prudent to rule out other causes
866. How does renal cell How does renal cell carcinoma spread? is the most (pyelo, glomerulonephritis, etc.)Radiation
carcinoma spread? Haematogenously appropriate initial to the groin is not always present.
[...] Renal Cell Carcinoma key points: test?
- While its not present everytime, the triad [...] Nephrolithiasis will have hematuria w/o
of flank pain, flank mass, and hematuria casts.
should be considered cancer until proven -
otherwise If hematuria (including microscopic) does
- Major risk factors include smoking, not exist, stones are ruled out
ESRD and von-Hippel Lindau - hematuria on UA is a very sensitive
- Investigate w/ U/S or CT test for stones; stones get lodged in the
- F/u w/ surgical resection ureter, peristalsis causes shredding of the
- Definitive Dx is via Bx after resection ureter epithelium and hematuria ensues
120 of 340
869. A pt presents c/o A pt presents c/o colicky flank pain that 871. A pt presents c/o A pt presents c/o colicky flank pain that
colicky flank pain radiates to the groin. He states that this colicky flank pain radiates to the groin and hematuria. He
that radiates to the started 2 days ago and that yesterday he that radiates to the is Dx w/ nephrolithiasis following a
groin. He states that had hematuria. He also complains of groin and non-contrast CT which reveals a 2 mm
this started 2 days nausea and vomiting. He denies any hematuria. He is Dx stone. What is the next step in
ago and that fever or chills. You suspect nephrolithiasis. w/ nephrolithiasis management following hydration and pain
yesterday he had What is the best diagnostic test? following a control?
hematuria. He also Non-contrast CT; or KUB U/S if preggo non-contrast CT Nothing, let the stone pass; strain the
complains of nausea UA is the best initial test. which reveals a 2 urine
and vomiting. He CT (or KUB U/S) is the best diagnostic mm stone. What is Nephrolithiasis management key points:
denies any fever or test. the next step in - Always start w/ hydration and pain
chills. You suspect - CT will reveal the stone (most are management control
nephrolithiasis. What radio-opaque) and potentially following hydration - If the stone is < 5 mm, let it pass
is the best diagnostic hydroureter/-nephrosis and pain control? - If the stone is < 30 mm, perform
test? - KUB U/S may or may not reveal the [...] lithotripsy and then let it pass
[...] stone but may potentially show - If the stone is > 30 mm or there is
hydroureter/-nephrosis hydronephrosis/-ureter, perform
- Never, never order an abdominal/pelvic nephrostomy
CT on a pregnant woman - Either strain the urine or analyse it
after retrieval to Dx the stone and pinpoin
risk factors

colicky flank pain radiates to the groin and hematuria. He
that radiates to the is Dx w/ nephrolithiasis following a
groin and non-contrast CT. What is the first step in
hematuria. He is Dx management? 872. A pt presents c/o A pt presents c/o colicky flank pain that
w/ nephrolithiasis Hydration; pain control colicky flank pain radiates to the groin and hematuria. He
following a Nephrolithiasis management key points: that radiates to the is Dx w/ nephrolithiasis following a
non-contrast CT. - Always start w/ hydration and pain groin and non-contrast CT which reveals a 10 mm
What is the first step control hematuria. He is Dx stone. What is the next step in
in management? - If the stone is < 5 mm, let it pass w/ nephrolithiasis management following hydration and pain
[...] - If the stone is < 30 mm, perform following a control?
lithotripsy and then let it pass non-contrast CT Lithotripsy; then let it pass and strain
- If the stone is > 30 mm or there is which reveals a 10 urine
hydronephrosis/-ureter, perform mm stone. What is
nephrostomy the next step in
- Either strain the urine or analyse it management Nephrolithiasis management key points:
after retrieval to Dx the stone and pinpoin following hydration - Always start w/ hydration and pain
risk factors and pain control? control
[...] - If the stone is < 5 mm, let it pass
- If the stone is < 30 mm, perform
lithotripsy and then let it pass
- If the stone is > 30 mm or there is
hydronephrosis/-ureter, perform
nephrostomy
- Either strain the urine or analyse it
after retrieval to Dx the stone and pinpoin
risk factors
121 of 340
877. What are the risk What are the risk factors for Cysteine renal
873. A pt presents c/o A pt presents c/o colicky flank pain that factors for Cysteine stones?
colicky flank pain radiates to the groin and hematuria. He renal stones? None, it's genetic
that radiates to the is Dx w/ nephrolithiasis following a [...] Or well I guess, family history?
groin and non-contrast CT. He is given IVF and
hematuria. He is Dx morphine for the pain. After a few hours of
w/ nephrolithiasis agony, the stone passes. What test should
878. A pt presents c/o A pt presents c/o chest pain w/
following a be ordered for this pt and how long after
chest pain w/ odynophagia and dysphagia. What
non-contrast CT. He discharge should it be ordered?
odynophagia and group of esophageal disorders should be
is given IVF and 24 hr urine analysis > 6 weeks later
dysphagia. What considered?
morphine for the
group of esophageal Esophagitis (as well as esophageal
pain. After a few
disorders should be spasm)
hours of agony, the The next step after this would be to correct
considered?
stone passes. What risk factors.
[...]
test should be
Esophagitis key points:
ordered for this pt
- all are Dx by EGD ± Bx
and how long after
- common causes: "PIECE"
discharge should it
-- Pill induced (NSAIDs, Abx, NRTIs,
be ordered?
bisphosphonates)
[...]
-- Infectious (CMV, HIV, HSV, Candida)
-- Eosinophilic (Asthma, eczema, allergy)
874. What are the risk What are the risk factors for Ca Oxalate -- Caustic (alkaline (drain cleaner) or
factors for Ca renal stones? acidic)
Oxalate renal (see below) -- Everything else (GERD and other rare
stones? Calcium Oxalate stones risk factors key stuff)
[...] points:
- Increased Ca absorption
879. What is the "PIECE" What is the "PIECE" mnemonic for the
(Hypervitaminosis D, HyperPTH)
mnemonic for the causes of esophagitis?
- Increased oxalate (decreased red meat,
causes of (see below)
increased fruits/veggies/vitamin C)
esophagitis?
[...]
875. What are the risk What are the risk factors for Mg Esophagitis key points:
factors for Mg Ammonium PO4 (Struvite) renal stones? - all are Dx by EGD ± Bx
Ammonium PO4 Alkaline urine (commonly 2/2 frequent - common causes: "PIECE"
(Struvite) renal UTIs w/ urea-splitting bacteria) -- Pill induced (NSAIDs, Abx, NRTIs,
stones? The urea byproducts increase the pH of bisphosphonates)
[...] urine, facilitating precipitation of struvite -- Infectious (CMV, HIV, HSV, Candida)
stones. -- Eosinophilic (Asthma, eczema, allergy)
-- Caustic (alkaline (drain cleaner) or
acidic)
876. What are the risk What are the risk factors for uric acid -- Everything else (GERD and other rare
factors for uric acid kidney stones? stuff)
kidney stones? Hyperuricemia (2/2 either Gout or
[...] Tumour Lysis Syndrome)
Tx w/ allopurinol or rasburicase.
It's important to tackle this risk factor by
inhibiting xanthine oxidase instead of
increasing Urate excretion (i.e.
probenecid)
122 of 340
880. A pt presents c/o A pt presents c/o chest pain w/ 881. A pt presents c/o A pt presents c/o chest pain w/
chest pain w/ odynophagia and dysphagia. Cardiac chest pain w/ odynophagia and dysphagia. He is Dx w/
odynophagia and causes have been reliably ruled out. You odynophagia and esophagitis. Physical exam reveals
dysphagia. Cardiac suspect esophagitis. Physical exam dysphagia. He is Dx thrush. What is the treatment for the most
causes have been reveals thrush. What is the most likely w/ esophagitis. likely cause of his esophagitis?
reliably ruled out. cause of his esophagitis? Physical exam Nystatin + Fluconazole
You suspect Candida reveals thrush. What Nystatin swish and swallow (apparently
esophagitis. Physical is the treatment for there's a nystatin swish and spit? So make
exam reveals the most likely cause sure you pick/order the right one)
thrush. What is the Infectious Esophagitis key points: of his esophagitis? Infectious Esophagitis key points:
most likely cause of - uncommon; pts must have some sort [...] - uncommon; pts must have some sort
his esophagitis? of immunocompromising risk factor for of immunocompromising risk factor for
[...] there to be a high suspicion there to be a high suspicion
(transplantation, leukemia, lymphoma, (transplantation, leukemia, lymphoma,
AIDS, steroids, etc) AIDS, steroids, etc)
- as such, common causes are the - as such, common causes are the
opportunistics candida, HSV, CMV, or opportunistics candida, HSV, CMV, or
HIV HIV
- Definitive Dx is via EGD with Bx, but - Definitive Dx is via EGD with Bx, but
differentiate by clinical presentation and/or differentiate by clinical presentation and/or
findings: findings:
-- HSV is associated w/ oral ulcers -- HSV is associated w/ oral ulcers
(herpes labialis) (herpes labialis)
-- Candida is associated w/ thrush -- Candida is associated w/ thrush; Tx w/
-- CMV causes large, longitudinal, linear nystatin swish and swallow + fluconazole
ulcers -- CMV causes large, longitudinal, linear
-- HSV causes small ulcers ulcers; Tx w/ ganciclovir or foscarnet
-- HSV causes small ulcers; Tx w/
acyclovir or valacyclocvir
123 of 340
chest pain w/ odynophagia and dysphagia. He is Dx w/ chest pain w/ odynophagia and dysphagia. He is Dx w/
odynophagia and esophagitis. Physical exam reveals oral odynophagia and esophagitis. Physical exam reveals oral
dysphagia. He is Dx ulcerations. What is the most likely cause dysphagia. He is Dx ulcerations. What is the treatment for the
w/ esophagitis. of his esophagitis? w/ esophagitis. most likely cause of his esophagitis?
Physical exam HSV (this is herpes labialis) Physical exam Acyclovir or valacyclovir (HSV
reveals oral reveals oral esophagitis)
ulcerations. What is ulcerations. What is
the most likely cause Infectious Esophagitis key points: the treatment for the
of his esophagitis? - uncommon; pts must have some sort most likely cause of Infectious Esophagitis key points:
[...] of immunocompromising risk factor for his esophagitis? - uncommon; pts must have some sort
there to be a high suspicion [...] of immunocompromising risk factor for
(transplantation, leukemia, lymphoma, there to be a high suspicion
AIDS, steroids, etc) (transplantation, leukemia, lymphoma,
- as such, common causes are the AIDS, steroids, etc)
opportunistics candida, HSV, CMV, or - as such, common causes are the
HIV opportunistics candida, HSV, CMV, or
- Definitive Dx is via EGD with Bx, but HIV
differentiate by clinical presentation and/or - Definitive Dx is via EGD with Bx, but
findings: differentiate by clinical presentation and/or
-- HSV is associated w/ oral ulcers findings:
(herpes labialis) -- HSV is associated w/ oral ulcers
-- Candida is associated w/ thrush; Tx w/ (herpes labialis)
nystatin swish and swallow + fluconazole -- Candida is associated w/ thrush; Tx w/
-- CMV causes large, longitudinal, linear nystatin swish and swallow + fluconazole
ulcers; Tx w/ ganciclovir or foscarnet -- CMV causes large, longitudinal, linear
-- HSV causes small ulcers; Tx w/ ulcers; Tx w/ ganciclovir or foscarnet
acyclovir or valacyclocvir -- HSV causes small ulcers; Tx w/
124 of 340
odynophagia and esophagitis after EGD reveals large, odynophagia and esophagitis after EGD reveals large,
dysphagia. He is Dx longitudinal, linear ulcerations in the dysphagia. He is Dx longitudinal, linear ulcerations in the
w/ esophagitis after esophagus. What is the most likely cause w/ esophagitis after esophagus. What is the treatment for the
EGD reveals large, of his esophagitis? EGD reveals large, most likely cause of his esophagitis?
longitudinal, linear CMV longitudinal, linear Ganciclovir or foscarnet
ulcerations in the Infectious Esophagitis key points: ulcerations in the
esophagus. What is - uncommon; pts must have some sort esophagus. What is
the most likely cause of immunocompromising risk factor for the treatment for the Infectious Esophagitis key points:
of his esophagitis? there to be a high suspicion most likely cause of - uncommon; pts must have some sort
[...] (transplantation, leukemia, lymphoma, his esophagitis? of immunocompromising risk factor for
AIDS, steroids, etc) [...] there to be a high suspicion
- as such, common causes are the (transplantation, leukemia, lymphoma,
opportunistics candida, HSV, CMV, or AIDS, steroids, etc)
HIV - as such, common causes are the
- Definitive Dx is via EGD with Bx, but opportunistics candida, HSV, CMV, or
differentiate by clinical presentation and/or HIV
findings: - Definitive Dx is via EGD with Bx, but
-- HSV is associated w/ oral ulcers differentiate by clinical presentation and/or
(herpes labialis) findings:
-- Candida is associated w/ thrush; Tx w/ -- HSV is associated w/ oral ulcers
nystatin swish and swallow + fluconazole (herpes labialis)
-- CMV causes large, longitudinal, linear -- Candida is associated w/ thrush; Tx w/
ulcers; Tx w/ ganciclovir or foscarnet nystatin swish and swallow + fluconazole
-- HSV causes small ulcers; Tx w/ -- CMV causes large, longitudinal, linear
acyclovir or valacyclocvir ulcers; Tx w/ ganciclovir or foscarnet
125 of 340
odynophagia and esophagitis after EGD reveals small odynophagia and esophagitis after EGD reveals small
dysphagia. He is Dx ulcerations in the esophagus. What is the dysphagia. He is Dx ulcerations in the esophagus. What is the
w/ esophagitis after most likely cause of his esophagitis? w/ esophagitis after treatment for the most likely cause of his
EGD reveals small HSV EGD reveals small esophagitis?
ulcerations in the Infectious Esophagitis key points: ulcerations in the Acyclovir or valacyclovir
esophagus. What is - uncommon; pts must have some sort esophagus. What is
the most likely cause of immunocompromising risk factor for the treatment for the
of his esophagitis? there to be a high suspicion most likely cause of Infectious Esophagitis key points:
[...] (transplantation, leukemia, lymphoma, his esophagitis? - uncommon; pts must have some sort
AIDS, steroids, etc) [...] of immunocompromising risk factor for
- as such, common causes are the there to be a high suspicion
opportunistics candida, HSV, CMV, or (transplantation, leukemia, lymphoma,
HIV AIDS, steroids, etc)
- Definitive Dx is via EGD with Bx, but - as such, common causes are the
differentiate by clinical presentation and/or opportunistics candida, HSV, CMV, or
findings: HIV
-- HSV is associated w/ oral ulcers - Definitive Dx is via EGD with Bx, but
(herpes labialis) differentiate by clinical presentation and/or
-- Candida is associated w/ thrush; Tx w/ findings:
nystatin swish and swallow + fluconazole -- HSV is associated w/ oral ulcers
-- CMV causes large, longitudinal, linear (herpes labialis)
ulcers; Tx w/ ganciclovir or foscarnet -- Candida is associated w/ thrush; Tx w/
-- HSV causes small ulcers; Tx w/ nystatin swish and swallow + fluconazole
acyclovir or valacyclocvir -- CMV causes large, longitudinal, linear
ulcers; Tx w/ ganciclovir or foscarnet
888. A pt taking daily A pt taking daily NSAIDs c/o chest pain

NSAIDs c/o chest w/ dysphagia and odynophagia. EGD
pain w/ dysphagia reveals erosive esophageal ulcerations.
and odynophagia. What is the most likely Dx?
EGD reveals erosive Pill-induced esophagitis
esophageal Pill-induced esophagitis key points:
ulcerations. What is - 2/2 to prolonged exposure of the mucosa
the most likely Dx? to the offending agent (often a cheaper pill
[...] that lacks enteric coating)
- common causes also include
bisphosphonates
- ppx is taking the pill erect w/ lots of water
- healing takes time, so don't start the pill
right away after removal
126 of 340
889. A pt taking daily A pt taking daily HAART c/o chest pain 891. A pt presents to the A pt presents to the ER w/ chest pain,
HAART c/o chest w/ dysphagia and odynophagia. EGD ER w/ chest pain, odynophagia and dysphagia. She claims
pain w/ dysphagia reveals erosive esophageal ulcerations. odynophagia and to have ingested drain cleaner as a
and odynophagia. Infectious causes have been ruled out. dysphagia. She suicide attempt. On physical exam she is
EGD reveals erosive What is the most likely Dx? claims to have drooling. Auscultation reveals stridor.
esophageal Pill-induced esophagitis ingested drain What is the most likely Dx?
ulcerations. cleaner as a suicide Caustic esophagitis
Infectious causes attempt. On physical Caustic esophagitis key points:
have been ruled out. Pill-induced esophagitis key points: exam she is - often accidental (i.e. children) or
What is the most - 2/2 to prolonged exposure of the mucosa drooling. purposeful (i.e. adult suicide attempt)
likely Dx? to the offending agent (often a cheaper pill Auscultation reveals - often involves an alkaline substance
[...] that lacks enteric coating) stridor. What is the (e.g. lye, drain cleaner) but acid is also a
- common causes also include most likely Dx? cause
bisphosphonates [...] - drooling is 2/2 the odynophagia and an
- ppx is taking the pill erect w/ lots of water avoidance of swallowing
- healing takes time, so don't start the pill - stridor (or wheezing) is 2/2 laryngeal
right away after removal damage
890. A pt taking daily A pt taking daily NSAIDs c/o chest pain 892. A pt presents to the A pt presents to the ER w/ chest pain,
NSAIDs c/o chest w/ dysphagia and odynophagia. EGD ER w/ chest pain, odynophagia and dysphagia. She claims
pain w/ dysphagia reveals erosive esophageal ulcerations. odynophagia and to have ingested drain cleaner as a
and odynophagia. What is the Tx for the most likely Dx? dysphagia. She suicide attempt. On physical exam she is
EGD reveals erosive (Pill-induced esophagitis) EGD to claims to have drooling. Auscultation reveals stridor. He
esophageal remove the pill; PPI for sxs ingested drain is Dx w/ caustic esophagitis. A cheeky
ulcerations. What is cleaner as a suicide med student asks, "Why don't we just
the Tx for the most attempt. On physical induce vomiting?" Why is this a bad idea?
likely Dx? Pill-induced esophagitis key points: exam she is Vomiting gives the substance another
[...] - 2/2 to prolonged exposure of the mucosa drooling. pass through the anatomy; either let it
to the offending agent (often a cheaper pill Auscultation reveals pass through the GI or NG suction it out
that lacks enteric coating) stridor. He is Dx w/ if indicated
- common causes also include caustic esophagitis. Caustic esophagitis key points:
bisphosphonates A cheeky med - often accidental (i.e. children) or
- ppx is taking the pill erect w/ lots of water student asks, "Why purposeful (i.e. adult suicide attempt)
- healing takes time, so don't start the pill don't we just induce - often involves an alkaline substance
right away after removal vomiting?" Why is (e.g. lye, drain cleaner) but acid is also a
this a bad idea? cause
[...] - drooling is 2/2 the odynophagia and an
avoidance of swallowing
- stridor (or wheezing) is 2/2 laryngeal
damage
- never induce vomiting as vomiting
allows for a second pass through the
anatomy
- never attempt to neutralize the
substance as that will cause a thermal
burn in the stomach (and a nice fat lawsuit
for your ass)
- either let it pass through the GI tract or
NG suction it out if indicated
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893. A pt presents to the A pt presents to the ER w/ chest pain, 894. A pt presents to the A pt presents to the ER w/ chest pain,
ER w/ chest pain, odynophagia and dysphagia. She claims ER w/ chest pain, odynophagia and dysphagia. She claims
odynophagia and to have ingested drain cleaner as a odynophagia and to have ingested drain cleaner as a
dysphagia. She suicide attempt. On physical exam she is dysphagia. She suicide attempt. EGD reveals edema,
claims to have drooling. Auscultation reveals stridor. He claims to have erythema, and shallow ulcers in the
ingested drain is Dx w/ caustic esophagitis. A cheeky ingested drain esophagus. When can this pt's diet be
cleaner as a suicide med student asks, "Why don't we try to cleaner as a suicide advanced?
attempt. On physical neutralize the fluid in his stomach?" Why is attempt. EGD (this is Low severity) In 24 hrs starting
exam she is this a bad idea? reveals edema, w/ liquids; solids by 48 hrs
drooling. This will cause a thermal burn in the erythema, and
Auscultation reveals stomach; either let it pass through the shallow ulcers in
stridor. He is Dx w/ GI or NG suction it out the esophagus. Caustic esophagitis key points:
caustic esophagitis. When can this pt's - often accidental (i.e. children) or
A cheeky med diet be advanced? purposeful (i.e. adult suicide attempt)
student asks, "Why Caustic esophagitis key points: [...] - often involves an alkaline substance
don't we try to - often accidental (i.e. children) or (e.g. lye, drain cleaner) but acid is also a
neutralize the fluid in purposeful (i.e. adult suicide attempt) cause
his stomach?" Why is - often involves an alkaline substance - drooling is 2/2 the odynophagia and an
this a bad idea? (e.g. lye, drain cleaner) but acid is also a avoidance of swallowing
[...] cause - stridor (or wheezing) is 2/2 laryngeal
- drooling is 2/2 the odynophagia and an damage
avoidance of swallowing - never induce vomiting as vomiting
- stridor (or wheezing) is 2/2 laryngeal allows for a second pass through the
damage anatomy
- never induce vomiting as vomiting - never attempt to neutralize the
allows for a second pass through the substance as that will cause a thermal
anatomy burn in the stomach (and a nice fat lawsuit
- never attempt to neutralize the for your ass)
substance as that will cause a thermal - either let it pass through the GI tract or
burn in the stomach (and a nice fat lawsuit NG suction it out if indicated
for your ass)
128 of 340
895. A pt presents to the A pt presents to the ER w/ chest pain, 896. A pt presents to the A pt presents to the ER w/ chest pain,
ER w/ chest pain, odynophagia and dysphagia. She claims ER w/ chest pain, odynophagia and dysphagia. She claims
odynophagia and to have ingested drain cleaner as a odynophagia and to have ingested drain cleaner as a
dysphagia. She suicide attempt. EGD reveals black dysphagia. She suicide attempt. She is Dx w/ high severity
claims to have necrosis, circumferential burns, and claims to have caustic esophagitis. For which
ingested drain deep ulcers in the esophagus. When can ingested drain complication should this pt be followed for?
cleaner as a suicide this pt's diet be advanced? cleaner as a suicide Strictures (70% of pts develop
attempt. EGD (this is high severity) In 72 hrs starting attempt. She is Dx w/ strictures); f/u w/ EGD
reveals black w/ liquids (due to high risk of high severity caustic
necrosis, perforation/bleeding/strictures/fistulae) esophagitis. For
circumferential which complication Caustic esophagitis key points:
burns, and deep should this pt be - often accidental (i.e. children) or
ulcers in the Caustic esophagitis key points: followed for? purposeful (i.e. adult suicide attempt)
esophagus. When - often accidental (i.e. children) or [...] - often involves an alkaline substance
can this pt's diet be purposeful (i.e. adult suicide attempt) (e.g. lye, drain cleaner) but acid is also a
advanced? - often involves an alkaline substance cause
[...] (e.g. lye, drain cleaner) but acid is also a - drooling is 2/2 the odynophagia and an
cause avoidance of swallowing
- drooling is 2/2 the odynophagia and an - stridor (or wheezing) is 2/2 laryngeal
avoidance of swallowing damage
- stridor (or wheezing) is 2/2 laryngeal - never induce vomiting as vomiting
damage allows for a second pass through the
- never induce vomiting as vomiting anatomy
allows for a second pass through the - never attempt to neutralize the
anatomy substance as that will cause a thermal
- never attempt to neutralize the burn in the stomach (and a nice fat lawsuit
substance as that will cause a thermal for your ass)
burn in the stomach (and a nice fat lawsuit - either let it pass through the GI tract or
for your ass) NG suction it out if indicated
897. A young boy c/o of A young boy c/o of dysphagia and
dysphagia and burning chest pain. PMHx is positive for
burning chest pain. asthma and food allergy. EGD w/ Bx
PMHx is positive for shows eosinophilia (> 15/hpf). What is the
asthma and food most likely Dx?
allergy. EGD w/ Bx Eosinophilic esophagitis
shows eosinophilia
(> 15/hpf). What is
the most likely Dx?
[...]
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898. A young boy c/o of A young boy c/o of dysphagia and

902. What type of What type of dysphagia is seen in
dysphagia and burning chest pain. PMHx is positive for
burning chest pain. asthma and food allergy. EGD w/ Bx dysphagia is seen in esophageal spasm?
PMHx is positive for shows eosinophilia (> 15/hpf). What is the esophageal spasm? Motility/functional
asthma and food Tx for the most likely Dx? [...]
allergy. EGD w/ Bx (Eosinophilic esophagitis) PPI for sxs;
shows eosinophilia withdrawal of any new foods
(> 15/hpf). What is This is typically a local allergic reaction in
the Tx for the most response to new food allergens as these
likely Dx? pts usually have eosinophilic diseases 903. What type of What type of dysphagia is seen w/ a
[...] (allergies, asthma, atopy [AAA]). dysphagia is seen w/ Schatzki ring?
a Schatzki ring? Mechanical/obstructive
[...]
899. Esophageal Esophageal disorders typically present w/
disorders typically dysphagia and/or odynophagia. What
present w/ are the 2 types of dysphagia that we use in
dysphagia and/or differential diagnosis?
odynophagia. What Functional (motility); Mechanical 904. What type of What type of dysphagia is seen w/
are the 2 types of (obstructive) dysphagia is seen w/ esophageal strictures?
dysphagia that we esophageal Mechanical/obstructive
use in differential strictures?
diagnosis? Types of dysphagia key points: [...]
[...] - Functional/motility dysphagia is 2/2
muscle dysfunction and will involve
dysphagia to everything at once
- Mechanical/obstructive dysphagia is
905. What type of What type of dysphagia is seen w/
2/2 obstruction and will involves
dysphagia is seen w/ esophageal cancer?
dysphagia to solids first, then
esophageal cancer? Mechanical/obstructive
progresses to include liquids; as motility
[...]
is not as issue, manometry is typically not
used
- in either case:
-- best initial test is Ba swallow
-- best diagnostic test is EGD w/ Bx
dysphagia is seen in Plummer-Vinson syndrome?
Plummer-Vinson Mechanical/obstructive
syndrome?
[...]
dysphagia is seen in achalasia?
achalasia? Motility/functional
[...]

dysphagia is seen in scleroderma?
scleroderma? Motility/functional
[...]
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907. A pt presents c/o of A pt presents c/o of dysphagia. He states 909. A pt presents c/o of A pt presents c/o of dysphagia. He states
dysphagia. He that it feels like a knot or ball of food is dysphagia. He that it feels like a knot or ball of food is
states that it feels stuck in his chest. Barium swallow reveals states that it feels stuck in his chest. You suspect achalasia.
like a knot or ball of a "bird's beak" sign. Manometry reveals like a knot or ball of Barium swallow reveals a "bird's beak"
food is stuck in his elevated LES tone. EGD is performed food is stuck in his sign. What is the most appropriate next
chest. Barium and a Bx reveals an absent Auerbach chest. You suspect test?
swallow reveals a plexus at the LES. What is the most likely achalasia. Barium Manometry
"bird's beak" sign. Dx? swallow reveals a
Manometry reveals Achalasia "bird's beak" sign.
elevated LES tone. Achalasia key points: What is the most Achalasia key points:
EGD is performed - Ba swallow is the best initial test appropriate next - Ba swallow is the best initial test
and a Bx reveals an - Manometry follows here and offers more test? - Manometry follows here and offers more
absent Auerbach info [...] info
plexus at the LES. - EGD must be done to r/o cancer - EGD must be done to r/o cancer
What is the most - Tx is preferred w/ Heller myotomy - Tx is preferred w/ Heller myotomy
likely Dx? (balloon dilatation can cause perforation; (balloon dilatation can cause perforation;
[...] botox is less effective) botox is less effective)
908. A pt presents c/o of A pt presents c/o of dysphagia. He states 910. A pt presents c/o of A pt presents c/o of dysphagia. He states
dysphagia. He that it feels like a knot or ball of food is dysphagia. He that it feels like a knot or ball of food is
states that it feels stuck in his chest. You suspect Achalasia. states that it feels stuck in his chest. You suspect achalasia.
like a knot or ball of What is the best initial test? like a knot or ball of Barium swallow reveals a "bird's beak"
food is stuck in his Ba swallow food is stuck in his sign. Manometry reveals increased LES
chest. You suspect chest. You suspect tone. What is the most appropriate next
Achalasia. What is achalasia. Barium test?
the best initial test? Achalasia key points: swallow reveals a EGD w/ Bx (you must r/o cancer)
[...] - Ba swallow is the best initial test "bird's beak" sign.
- Manometry follows here and offers more Manometry reveals
info increased LES Achalasia key points:
- EGD must be done to r/o cancer tone. What is the - Ba swallow is the best initial test
- Tx is preferred w/ Heller myotomy most appropriate - Manometry follows here and offers more
(balloon dilatation can cause perforation; next test? info
botox is less effective) [...] - EGD must be done to r/o cancer
- Tx is preferred w/ Heller myotomy
(balloon dilatation can cause perforation;
botox is less effective)
131 of 340
911. A pt presents c/o of A pt presents c/o of dysphagia. He states 913. A 30 y/o female pt A 30 y/o female pt presents c/o of
dysphagia. He that it feels like a knot or ball of food is presents c/o of dysphagia w/ refractory burning chest
states that it feels stuck in his chest. He is Dx w/ achalasia. dysphagia w/ pain. Physical exam reveals
like a knot or ball of What is the preferred Tx? refractory burning sclerodactyly and telangiectasias. You
food is stuck in his Heller myotomy chest pain. Physical suspect esophageal dysmotility 2/2
chest. He is Dx w/ exam reveals scleroderma. What is the best initial test?
achalasia. What is sclerodactyly and Ba swallow
the preferred Tx? Achalasia key points: telangiectasias. You
[...] - Ba swallow is the best initial test suspect esophageal
- Manometry follows here and offers more dysmotility 2/2 Esophageal dysmotility in Scleroderma
info scleroderma. What is key points:
- EGD must be done to r/o cancer the best initial test? - common in women of reproductive age
- Tx is preferred w/ Heller myotomy [...] (as are all autoimmune disorders)
(balloon dilatation can cause perforation; - Is 2/2 collagen deposition at the LES and
botox is less effective) esophageal muscles, resulting in an
inability to contract
- Hence, manometry reveals minimal or
no LES tone w/ a relaxed esophagus
- Presents w/ relentless GERD, start
high-dose PPI right away
- f/u w/ the appropriate antibody tests
912. A 30 y/o female pt A 30 y/o female pt presents c/o of
(scl-70/topoisomerase-I in systemic;
presents c/o of dysphagia w/ refractory burning chest
anti-centromere in CREST)
dysphagia w/ pain. Physical exam reveals
refractory burning sclerodactyly and telangiectasias. What
chest pain. Physical is the most likely diagnosis?
exam reveals Esophageal dysmotility 2/2 scleroderma
sclerodactyly and 914. A 30 y/o female pt A 30 y/o female pt presents c/o of
telangiectasias. Esophageal dysmotility in Scleroderma presents c/o of dysphagia w/ refractory burning chest
What is the most key points: dysphagia w/ pain. Physical exam reveals
likely diagnosis? - Is 2/2 collagen deposition at the LES and refractory burning sclerodactyly and telangiectasias. You
[...] esophageal muscles, resulting in an chest pain. Physical suspect esophageal dysmotility 2/2
inability to contract exam reveals scleroderma. What is the best diagnostic
- Hence, manometry reveals minimal or sclerodactyly and test?
no LES tone w/ a relaxed esophagus telangiectasias. You EGD w/ Bx
- Presents w/ relentless GERD, start suspect esophageal
high-dose PPI right away dysmotility 2/2
- f/u w/ the appropriate antibody tests scleroderma. What is
(scl-70/topoisomerase-I in systemic; the best diagnostic Esophageal dysmotility in Scleroderma
anti-centromere in CREST) test? key points:
[...] - Is 2/2 collagen deposition at the LES and
esophageal muscles, resulting in an
inability to contract
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917. A pt presents c/o a A pt presents c/o a crushing retrosternal

915. A 30 y/o female pt A 30 y/o female pt presents c/o of crushing chest pain w/ dysphagia. He stats that
presents c/o of dysphagia w/ refractory burning chest retrosternal chest his pain relieved following nitrates. EKG
dysphagia w/ pain. Physical exam reveals pain w/ dysphagia. shows NSR w/ no abnormalities.
refractory burning sclerodactyly and telangiectasias. She He stats that his pain Troponins are negative. You suspect
chest pain. Physical is Dx w/ esophageal dysmotility 2/2 relieved following esophageal spasm. What is the best
exam reveals scleroderma. What is the Tx? nitrates. EKG shows diagnostic test?
sclerodactyly and High-dose PPIs; nothing much for the NSR w/ no Manometry
telangiectasias. She Scleroderma abnormalities.
is Dx w/ esophageal Troponins are
dysmotility 2/2 negative. You Esophageal spasm key points:
scleroderma. What is Esophageal dysmotility in Scleroderma suspect esophageal - looks like an MI, even responds to
the Tx? key points: spasm. What is the nitrates
[...] - common in women of reproductive age best diagnostic test? - after ruling out MI, Dx via manometry;
(as are all autoimmune disorders) [...] EGD not needed
- Is 2/2 collagen deposition at the LES and - Ba swallow may show a corkscrew
esophageal muscles, resulting in an esophagus, but is not usually done
inability to contract - Tx w/ nitrates/CCBs PRN
918. A pt presents c/o a A pt presents c/o a crushing retrosternal
crushing chest pain w/ dysphagia. He stats that
retrosternal chest his pain relieved following nitrates. EKG
pain w/ dysphagia. shows NSR w/ no abnormalities.
He stats that his pain Troponins are negative. Manometry
916. A pt presents c/o a A pt presents c/o a crushing retrosternal relieved following reveals diffuse, uncoordinated
crushing chest pain w/ dysphagia. He stats that nitrates. EKG shows esophageal contractions. What is the tx
retrosternal chest his pain relieved following nitrates. EKG NSR w/ no for the most likely Dx?
pain w/ dysphagia. shows NSR w/ no abnormalities. abnormalities. Nitrates or CCBs PRN
He stats that his pain Troponins are negative. What is the most Troponins are
relieved following likely Dx? negative. Manometry
nitrates. EKG shows Esophageal spasm reveals diffuse, Esophageal spasm key points:
NSR w/ no Esophageal spasm key points: uncoordinated - looks like an MI, even responds to
abnormalities. - looks like an MI, even responds to esophageal nitrates
Troponins are nitrates contractions. What - after ruling out MI, Dx via manometry;
negative. What is the - after ruling out MI, Dx via manometry is the tx for the most EGD not needed
most likely Dx? - Ba swallow may show a corkscrew likely Dx? - Ba swallow may show a corkscrew
[...] esophagus [...] esophagus, but is not usually done
- Tx w/ nitrates/CCBs PRN - Tx w/ nitrates/CCBs PRN
133 of 340
919. A pt presents c/o of A pt presents c/o of episodic dysphagia 921. A female pt presents A female pt presents c/o of dysphagia.
episodic dysphagia w/ odynophagia. He denies any chest c/o of dysphagia. Physical exam reveals conjunctival
w/ odynophagia. He pain. Barium swallow reveals narrowed Physical exam pallour. A CBC reveals iron deficiency
denies any chest lumen at the LES. Manometry is normal. reveals conjunctival anaemia. Barium swallow reveals webs.
pain. Barium swallow EGD reveals fibrous deposition at the pallour. A CBC EGD reveals esophageal rings and
reveals narrowed LES. What is the most likely Dx? reveals iron webs. What is the most likely Dx?
lumen at the LES. Schatzki Ring (Steakhouse dysphagia) deficiency anaemia. Plummer-Vinson syndrome
Manometry is Schatzki Ring key points: Barium swallow Plummer-Vinson syndrome key points:
normal. EGD - very episodic dysphagia, that typically reveals webs. EGD - These pts have a special type of ring at
reveals fibrous occurs w/ larger diameter foods reveals esophageal the upper esophagus (different than
deposition at the - Barium swallow may be normal rings and webs. Schatzki ring at the LES)
LES. What is the - Dx via EGD + Bx What is the most - Involves an increased risk of
most likely Dx? - Tx by breaking the ring likely Dx? squamous cell carcinoma of the
[...] [...] esophagus
- There is no Tx, but you should screen
for cancer; ppx esophagectomy is not
indicated
920. A pt presents c/o of A pt presents c/o of episodic dysphagia

episodic dysphagia w/ odynophagia. He denies any chest
w/ odynophagia. He pain. Barium swallow reveals narrowed
denies any chest lumen at the LES. You suspect a Schatzki
pain. Barium swallow ring. What is the best diagnostic test? 922. A female pt presents A female pt presents c/o of dysphagia.
reveals narrowed EGD w/ Bx (will reveal the fibrous ring c/o of dysphagia. Physical exam reveals conjunctival
lumen at the LES. at the LES) Physical exam pallour. A CBC reveals iron deficiency
You suspect a reveals conjunctival anaemia. You suspect plummer vinson
Schatzki ring. What pallour. A CBC syndrome. What is the best diagnostic
is the best diagnostic Schatzki Ring key points: reveals iron test?
test? - very episodic dysphagia, that typically deficiency anaemia.
[...] occurs w/ larger diameter foods You suspect EGD
- Manometry is typically normal (only plummer vinson
abnormal in motility dysphagia, syndrome. What is
remember?) the best diagnostic Again, if its a mechanical dysphagia: Ba
- Barium swallow may be normal test? swallow is the best initial; EGD w/ Bx is
- Dx via EGD + Bx the best diagnostic
- Tx by breaking the ring [...] Plummer-Vinson syndrome key points:
- These pts have a special type of ring at
the upper esophagus (different than
Schatzki ring at the LES)
- Involves an increased risk of
squamous cell carcinoma of the
esophagus
- There is no Tx, but you should screen
for cancer; ppx esophagectomy is not
indicated
134 of 340
923. A female pt presents A female pt presents c/o of dysphagia. 925. A pt w/ GERD A pt w/ GERD presents w/ new onset
c/o of dysphagia. Physical exam reveals conjunctival presents w/ new progressive dysphagia. He admits to
Physical exam pallour. A CBC reveals iron deficiency onset progressive being non-compliant with his PPI
reveals conjunctival anaemia. Barium swallow reveals webs. dysphagia. He medication. Barium swallow reveals
pallour. A CBC EGD reveals esophageal rings and admits to being circumferential narrowing of the lumen.
reveals iron webs. She is Dx w/ Plummer-Vinson non-compliant with EGD w/ Bx does not reveal malignancy.
deficiency anaemia. syndrome. What is the Tx? his PPI medication. What is the Tx?
Barium swallow None; screen for esophageal cancer Barium swallow High-dose PPIs; resection of the
reveals webs. EGD (scc); Tx the IDA though reveals strictures
reveals esophageal circumferential
rings and webs. narrowing of the
She is Dx w/ Plummer-Vinson syndrome key points: lumen. EGD w/ Bx Esophageal Stricture key points:
Plummer-Vinson - These pts have a special type of ring at does not reveal - Caused by chronic inflammation of the
syndrome. What is the upper esophagus (different than malignancy. What is mucosa leading to scarring 2/2 grade 4
the Tx? Schatzki ring at the LES) the Tx? GERD
[...] - Involves an increased risk of [...] - Also caused by reactive scarring 2/2
squamous cell carcinoma of the caustic ingestion
esophagus - Weight loss is atypical
- There is no Tx, but you should screen - Dx via Ba swallow as best initial and
for cancer; ppx esophagectomy is not then EGD+Bx to confirm and r/o cancer
indicated - Tx w/ high dose PPI and resection of
the stricture.
924. A pt w/ GERD A pt w/ GERD presents w/ new onset

presents w/ new progressive dysphagia. He admits to 926. A pt w/ GERD A pt w/ GERD presents w/ new onset
onset progressive being non-compliant with his PPI presents w/ new progressive dysphagia. He admits to
dysphagia. He medication. Barium swallow reveals onset progressive being non-compliant with his PPI
admits to being circumferential narrowing of the lumen. dysphagia. He medication. You suspect strictures. What
non-compliant with EGD w/ Bx does not reveal malignancy. admits to being is the best diagnostic test?
his PPI medication. What is the most likely Dx? non-compliant with EGD w/ Bx
Barium swallow Strictures his PPI medication.
reveals Esophageal Stricture key points: You suspect
circumferential - Caused by chronic inflammation of the strictures. What is Esophageal Stricture key points:
narrowing of the mucosa leading to scarring 2/2 grade 4 the best diagnostic - Caused by chronic inflammation of the
lumen. EGD w/ Bx GERD test? mucosa leading to scarring 2/2 grade 4
does not reveal - Also caused by reactive scarring 2/2 [...] GERD
malignancy. What is caustic ingestion - Also caused by reactive scarring 2/2
the most likely Dx? - Weight loss is atypical caustic ingestion
[...] - Dx via Ba swallow as best initial and - Weight loss is atypical
then EGD+Bx to confirm and r/o cancer - Dx via Ba swallow as best initial and
- Tx w/ high dose PPI and resection of then EGD+Bx to confirm and r/o cancer
the stricture. - Tx w/ high dose PPI and resection of
the stricture.
135 of 340
927. A 70 y/o pt presents A 70 y/o pt presents c/o progressive 928. A 70 y/o pt presents A 70 y/o pt presents c/o progressive
c/o progressive dysphagia and weight loss. PMHx is c/o progressive dysphagia and weight loss. PMHx is
dysphagia and positive for GERD. She has a 40 pack dysphagia and positive for GERD. She has a 40 pack
weight loss. PMHx year Hx of smoking. Barium swallow weight loss. PMHx year Hx of smoking. Barium swallow
is positive for GERD. reveals asymmetric narrowing of the is positive for GERD. reveals asymmetric narrowing of the
She has a 40 pack lumen. What is the most likely Dx? She has a 40 pack lumen. She is Dx w/ Stage III
year Hx of smoking. Esophageal cancer year Hx of smoking. adenocarcinoma of the esophagus. What
Barium swallow Esophageal cancer key points: Barium swallow is the Tx?
reveals asymmetric - GERD = adenocarcinoma = lower 1/3 reveals asymmetric Resection+chemo
narrowing of the - EtOH/smoking = scc = upper 1/3 narrowing of the
lumen. What is the - Ba swallow must be done first to localize lumen. She is Dx w/
most likely Dx? the tumour; you don't want to perforate the Stage III Esophageal cancer key points:
[...] upper 1/3 during EGD because you did adenocarcinoma of - GERD = adenocarcinoma = lower 1/3
expect a mass the esophagus. What - EtOH/smoking = scc = upper 1/3
- Dx is via EGD + Bx is the Tx? - Ba swallow must be done first to localize
- If positive, stage the pt w/ PET CT [...] the tumour; you don't want to perforate the
- Tx is resection and chemo upper 1/3 during EGD because you did
- Notice how this presentation is similar expect a mass
to other esophageal disorders (esp. - Dx is via EGD + Bx
mechanical w/ progressive dysphagia). - If positive, stage the pt w/ PET CT
Hence the EGD and Bx is imperative in - Tx is resection and chemo
the workup of dysphagia. - Notice how this presentation is similar
to other esophageal disorders (esp.
mechanical w/ progressive dysphagia).
Hence the EGD and Bx is imperative in
the workup of dysphagia.
929. An 80 y/o male pt An 80 y/o male pt presents c/o

presents c/o dysphagia. He adds that when he eats, he
dysphagia. He adds hears an odd gurgling in this throat and
that when he eats, coughs furiously. Physical exam reveals
he hears an odd halitosis. What is the most likely Dx?
gurgling in this Zenker's diverticulum
throat and coughs Zenker's Diverticulum key points:
furiously. Physical - 2/2 decades of increased pressure in the
exam reveals pharynx; false diverticulum
halitosis. What is
the most likely Dx?
[...]
136 of 340
930. A pt presents w/ A pt presents w/ colicky RUQ pain that 934. A pt presents c/o of A pt presents c/o of constant RUQ pain.
colicky RUQ pain radiates to the right scapula. She adds constant RUQ pain. He also complains of fever, nausea and
that radiates to the that she feels bloated after a meal, and He also complains of vomiting. Physical exam reveals positive
right scapula. She then the pain manifests. U/S reveals fever, nausea and Murphy's sign. Labwork reveals mild
adds that she feels cholelithiasis but no signs of vomiting. Physical leukocytosis, elevated liver enzymes,
bloated after a meal, inflammation. What is the most likely Dx? exam reveals and elevated direct bilirubin. U/S reveals
and then the pain Biliary colic positive Murphy's gallstones and dilation of the common
manifests. U/S sign. Labwork bile duct. What is the most likely Dx?
reveals reveals mild Choledocholithiasis
cholelithiasis but no leukocytosis, Choledocholithiasis key points:
signs of elevated liver - Due to passage of a gallstone into the
inflammation. What enzymes, and CBD, causing outflow obstruction and
is the most likely Dx? elevated direct biliary stasis
[...] bilirubin. U/S - If the blockage is proximal to the
reveals gallstones pancreatic duct, only the liver is affected
and dilation of the - If the blockage is distal to the pancreatic
931. There are 2 types of There are 2 types of gallstones. What are
common bile duct. duct, the liver and pancreas are both
gallstones. What are the risk factors for cholesterol stones?
What is the most affected; gallstone pancreatitis is very
the risk factors for Fat, female, fertile, forty, Native
likely Dx? common
cholesterol stones? American
[...] - ERCP must be done ASAP to
[...]
decompress the biliary tract
932. There are 2 types of There are 2 types of gallstones. What are
gallstones. What are the risk factors for pigmented stones?
the risk factors for Hemolytic disease
935. A pt presents c/o of A pt presents c/o of constant RUQ pain.
pigmented stones?
constant RUQ pain. He also complains of fever, nausea and
[...]
He also complains of vomiting. Physical exam reveals positive
fever, nausea and Murphy's sign. Labwork reveals mild
933. A pt presents w/ A pt presents w/ RUQ pain that radiates vomiting. Physical leukocytosis, elevated liver enzymes,
RUQ pain that to the right scapula. She also complains exam reveals and elevated direct bilirubin. What is the
radiates to the right of fever, nausea, and vomiting. She had positive Murphy's best initial test?
scapula. She also similar pain a few months ago. CBC sign. Labwork U/S; HIDA if equivocal
complains of fever, reveals mild leukocytosis. U/S reveals reveals mild
nausea, and cholelithiasis, pericholecystic fluid, and leukocytosis,
vomiting. She had gallbladder wall thickening. What is the elevated liver Choledocholithiasis key points:
similar pain a few most likely Dx? enzymes, and - Due to passage of a gallstone into the
months ago. CBC Acute cholecystitis elevated direct CBD, causing outflow obstruction and
reveals mild Acute Cholecystitis key points: bilirubin. What is the biliary stasis
leukocytosis. U/S - Due to gallstone blocking the cystic duct, best initial test? - If the blockage is proximal to the
reveals causing inflammation when the GB [...] pancreatic duct, only the liver is affected
cholelithiasis, contracts - If the blockage is distal to the pancreatic
pericholecystic - IVF/NPO/NG tube are to aid the acute duct, the liver and pancreas are both
fluid, and process in cooling down affected; gallstone pancreatitis is very
gallbladder wall common
thickening. What is - ERCP must be done ASAP to
the most likely Dx? decompress the biliary tract
[...]
137 of 340
936. A pt presents c/o of A pt presents c/o of constant RUQ pain. 938. A pt presents c/o A pt presents c/o constant RUQ pain. He
constant RUQ pain. He also complains of fever, nausea and constant RUQ pain. also complains of high fever, chills,
He also complains of vomiting. Physical exam reveals positive He also complains of nausea, vomiting, and yellowing of his
fever, nausea and Murphy's sign. Labwork reveals mild high fever, chills, eyes. Physical exam reveals scleral
vomiting. Physical leukocytosis, elevated liver enzymes, nausea, vomiting, icterus and a temperature of 104 F. The pt
exam reveals and elevated direct bilirubin. U/S reveals and yellowing of his appears very sick. What is the Tx?
positive Murphy's gallstones and dilation of the common eyes. Physical exam Emergent ERCP (STAT!!); IV Abx
sign. Labwork bile duct. What is the Tx? reveals scleral covering for gram-neg+anaerobes (e.g.
reveals mild ERCP (w/ IVF, NPO and analgesia) icterus and a FQ+MTZ)
leukocytosis, temperature of 104
elevated liver F. The pt appears
enzymes, and Choledocholithiasis key points: very sick. What is the Ascending Cholangitis key points:
elevated direct - Due to passage of a gallstone into the Tx? - 2/2 to biliary stasis caused by gallstones
bilirubin. U/S CBD, causing outflow obstruction and [...] - Often involves infection by GI flora
reveals gallstones biliary stasis (Escherichia coli, Klebsiella sp.,
and dilation of the - If the blockage is proximal to the Enterobacter sp.)
common bile duct. pancreatic duct, only the liver is affected - The triad and pentad are big tip-offs. If
What is the Tx? - If the blockage is distal to the pancreatic suspected, work it up ASAP
[...] duct, the liver and pancreas are both - ERCP must be STAT
affected; gallstone pancreatitis is very - IV Abx for gram-neg (FQ) and
common anaerobes (MTZ) must be started STAT
- ERCP must be done ASAP to
decompress the biliary tract
939. Which area of the Which area of the body typically yellows
body typically first in the setting of jaundice?
yellows first in the Sublingual region
937. A pt presents c/o A pt presents c/o constant RUQ pain. He setting of jaundice?
constant RUQ pain. also complains of high fever, chills, [...]
He also complains of nausea, vomiting, and yellowing of his Jaundice key points:
high fever, chills, eyes. Physical exam reveals scleral - involves yellowing of tissue 2/2 elevated
nausea, vomiting, icterus and a temperature of 104 F. The pt bilirubin
and yellowing of his appears very sick. What is the most likely - Sublingual region is 1st; sclera 2nd;
eyes. Physical exam Dx? and skin 3rd
reveals scleral Ascending Cholangitis - due to a defect in 1 or more of the
icterus and a Ascending Cholangitis key points: regions involved:
temperature of 104 - 2/2 to biliary stasis caused by gallstones -- Prehepatic jaundice is 2/2 hemolysis,
F. The pt appears - Often involves infection by GI flora causing unconjugated bilirubinemia from
very sick. What is the (Escherichia coli, Klebsiella sp., increased RBC turnover
most likely Dx? Enterobacter sp.) -- Intrahepatic jaundice is 2/2 defects in
[...] - The triad and pentad are big tip-offs. If bilirubin uptake, metabolism or excretion
suspected, work it up ASAP -- Posthepatic jaundice is 2/2
- ERCP must be STAT mechanical obstruction
- IV Abx for gram-neg (FQ) and
anaerobes (MTZ) must be started STAT
138 of 340
940. Bilirubin is found in Bilirubin is found in either its conjugated 943. Which type of Which type of hyperbilirubinemia involves
either its conjugated (direct) or unconjugated (indirect) form. hyperbilirubinemia dark urine that is positive for blood on
(direct) or Which form is considered to be the worst? involves dark urine UA?
unconjugated Unconjugated/indirect that is positive for Direct/conjugated
(indirect) form. Which blood on UA?
form is considered to [...]
be the worst? Unconjugated bilirubin is lipid soluble, The +blood on UA is for the bilirubin, there
[...] thereby allowing it to cross the BBB and isn't actually hematuria.
cause kernicterus.
Unconjugated bilirubin cannot be renally
944. A pt presents w/ A pt presents w/ asymptomatic jaundice.
excreted.
asymptomatic Labs reveals conjugated
jaundice. Labs hyperbilirubinemia. Which enzyme
reveals conjugated disorders should be considered?
hyperbilirubinemia. Dubin-Johnson syndrome; Rotor
941. A pt presents c/o A pt presents c/o signs of jaundice. His Which enzyme syndrome
signs of jaundice. urine has become dark. What type of disorders should be
His urine has bilirubin is most likely elevated in this pt? considered?
become dark. What Conjugated/direct [...] "Jaundice makes U Go Crazy, so C a
type of bilirubin is Only conjugated bilirubin is renally DR"
most likely elevated excreted, thereby resulting in dark urine. - Unconjugated = Gilbert & Crigler-Najjar
in this pt? - Conjugated = Dubin-Johnson & Rotor
[...]
945. A pt presents w/ A pt presents w/ asymptomatic jaundice.

asymptomatic Labs reveals conjugated
jaundice. Labs hyperbilirubinemia. Somehow the pt
942. A pt presents w/ A pt presents w/ asymptomatic reveals conjugated dies, and autopsy reveals black liver.
asymptomatic unconjugated hyperbilirubinemia. A hyperbilirubinemia. What is the most likely Dx?
unconjugated CBC and blood smear do not reveal any Somehow the pt Dubin-Johnson Syndrome
hyperbilirubinemia. abnormalities. Which enzyme deficiencies dies, and autopsy
A CBC and blood are the most likely cause? reveals black liver.
smear do not reveal Gilbert syndrome; Crigler-Najjar What is the most
any abnormalities. syndrome likely Dx?
Which enzyme "Jaundice makes U Go Crazy, so C a [...]
deficiencies are the DR"
most likely cause? - Unconjugated = Gilbert & Crigler-Najjar
946. A pt presents w/ A pt presents w/ painful obstructive
[...] - Conjugated = Dubin-Johnson & Rotor
painful obstructive jaundice. U/S confirms the presence of a
Unconjugated Hyperbilirubinemia
jaundice. U/S gallstone in the common bile duct. What is
- Think hemolysis or
confirms the the Tx?
Gilbert/Crigler-Najjar
presence of a ERCP to remove the obstruction
- Crigler-Najjar is typically fatal early on
gallstone in the
(total enzyme deficiency)
common bile duct.
- Gilbert becomes apparent when the
What is the Tx?
body is under stress (e.g. infection,
[...]
dehydration, etc.)
- Whatever the cause, bilirubin is not
being conjugated, causing a build up of 947. What type of What type of hyperbilirubinemia is seen in
indirect bilirubin hyperbilirubinemia is obstructive jaundice?
- Urine will not be dark as indirect bili is not seen in obstructive Conjugated/direct
renally excreted jaundice?
[...]
139 of 340
948. Which sex is more Which sex is more commonly affected by 951. A pt presents w/ A pt presents w/ painless obstructive
commonly affected Primary Biliary Cirrhosis (PBC)? painless jaundice. You suspect strictures as PSC
by Primary Biliary Women obstructive and cancer are very unlikely. What is the
Cirrhosis (PBC)? jaundice. You diagnostic test for biliary strictures?
[...] suspect strictures as MRCP
PBC = bitches PSC and cancer are
very unlikely. What is
the diagnostic test for Strictures and jaundice key points:
949. A female pt presents A female pt presents w/ jaundice. Labs
biliary strictures? - presents similar to how cancer would
w/ jaundice. Labs reveal conjugated hyperbilirubinemia.
[...] (insidious, dilated biliary ducts w/
reveal conjugated Which autoimmune disorder should be
conjugated hyperbilirubinemia)
hyperbilirubinemia. considered in this pt?
- Dx via MRCP
Which autoimmune Primary Biliary Cirrhosis
- Confirm w/ ERCP
disorder should be
- Tx w/ stenting; we do not stent in PSC
considered in this pt?
- Typically 2/2 iatrogenic causes such as
[...] Jaundice in PBC:
previous biliary surgery or ERCP
- the intrahepatic ducts are affected in
PBC, hence it is a conjugated
hyperbilirubinemia 952. A pt presents c/o A pt presents c/o burning retrosternal
burning chest pain. He states that it is worse when
retrosternal chest he lays down and better when he sits
950. A male pt presents A male pt presents w/ jaundice. PMHx is
pain. He states that upright. He adds that he has also
w/ jaundice. PMHx positive for ulcerative colitis. Labs
it is worse when he developed a cough and hoarseness. You
is positive for reveals conjugated hyperbilirubinemia.
lays down and suspect GERD. What is the first step in
ulcerative colitis. MRCP reveals a "beads on a string"
better when he sits management?
Labs reveals pattern. ERCP w/ Bx reveals onion-skin
upright. He adds Lifestyle modifications ± PPI trial for 4-6
conjugated fibrosis. What is the most likely Dx?
that he has also wks
hyperbilirubinemia. Primary Sclerosing Cholangitis (PSC)
developed a cough
MRCP reveals a
and hoarseness.
"beads on a string"
You suspect GERD. GERD key points:
pattern. ERCP w/ Bx PSC key points:
What is the first step - the first step is management is not
reveals onion-skin - common in males
in management? diagnosis, it is lifestyle modifications (±
fibrosis. What is the - Associated w/ ulcerative colitis and
[...] PPI trial for 4-6 wks if the symptoms are
most likely Dx? p-ANCA
troublesome)
[...] - affects extrahepatic ducts
- Life modifications: smaller meals,
- MRCP is diagnostic and will show beads
avoiding spicy foods, not eating soon
on a string patterning
before recumbency, elevating the head of
- ERCP is not required, but Bx will reveal
the bed, stopping EtOH/smoking
onion-skin fibrosis
- Atypical symptoms involve coughing,
hoarsness, wheezing, SOB due to
tracheal/laryngeal irritation
- However, if there are alarm symptoms
(odynophagia, dysphagia, weight loss, n/v,
anaemia), then go straight to EGD to r/o
cancer/Barrett's
- EGD only shows the effect of the acid, 24
hr pH monitoring is the best test but is
rarely done
- Tx depends on EGD/Bx findings
140 of 340
954. A pt presents w/ s/s A pt presents w/ s/s of GERD. Lifestyle

953. A pt presents c/o of A pt presents c/o of retrosternal burning of GERD. Lifestyle modifications do not resolve his sxs. What
retrosternal chest pain that is worse when he lays modifications do not is the most appropriate next step in
burning chest pain down. He adds that he suffers from resolve his sxs. What management?
that is worse when coughing, SOB and wheezing at night, is the most EGD w/ Bx
he lays down. He but never during the day. You suspect appropriate next step
adds that he suffers nocturnal asthma. What is the most likely in management?
from coughing, SOB cause? [...] GERD key points:
and wheezing at Nocturnal Asthma 2/2 GERD - the first step is management is not
night, but never diagnosis, it is lifestyle modifications (±
during the day. You PPI trial for 4-6 wks if the symptoms are
suspect nocturnal GERD key points: troublesome)
asthma. What is the - the first step is management is not - Life modifications: smaller meals,
most likely cause? diagnosis, it is lifestyle modifications (± avoiding spicy foods, not eating soon
[...] PPI trial for 4-6 wks if the symptoms are before recumbency, elevating the head of
troublesome) the bed, stopping EtOH/smoking
- Life modifications: smaller meals, - Atypical symptoms involve coughing,
avoiding spicy foods, not eating soon hoarsness, wheezing, SOB due to
before recumbency, elevating the head of tracheal/laryngeal irritation
the bed, stopping EtOH/smoking - However, if there are alarm symptoms
- Atypical symptoms involve coughing, (odynophagia, dysphagia, weight loss, n/v,
hoarsness, wheezing, SOB due to anaemia), then go straight to EGD to r/o
tracheal/laryngeal irritation cancer/Barrett's
- However, if there are alarm symptoms - EGD only shows the effect of the acid, 24
(odynophagia, dysphagia, weight loss, n/v, hr pH monitoring is the best test but is
anaemia), then go straight to EGD to r/o rarely done
cancer/Barrett's - Tx depends on EGD/Bx findings
rarely done
141 of 340
955. A pt presents w/ s/s A pt presents w/ s/s of GERD. Lifestyle 956. A pt presents w/ s/s A pt presents w/ s/s of GERD. Lifestyle
of GERD. Lifestyle modifications do not resolve his sxs. EGD of GERD. Lifestyle modifications do not resolve his sxs. EGD
modifications do not w/ Bx does not reveal Barrett's esophagus. modifications do not w/ Bx reveals Barrett's esophagus
resolve his sxs. EGD What is the next step in management? resolve his sxs. EGD (metaplasia). What is the next step in
w/ Bx does not Begin (or continue) PPIs w/ Bx reveals management?
reveal Barrett's Barrett's esophagus Begin high-dose PPI, bid; increased
esophagus. What is (metaplasia). What is EGD frequency
the next step in GERD key points: the next step in GERD key points:
management? - the first step is management is not management? - the first step is management is not
[...] diagnosis, it is lifestyle modifications (± [...] diagnosis, it is lifestyle modifications (±
PPI trial for 4-6 wks if the symptoms are PPI trial for 4-6 wks if the symptoms are
troublesome) troublesome)
- Life modifications: smaller meals, - Life modifications: smaller meals,
avoiding spicy foods, not eating soon avoiding spicy foods, not eating soon
before recumbency, elevating the head of before recumbency, elevating the head of
the bed, stopping EtOH/smoking the bed, stopping EtOH/smoking
- Atypical symptoms involve coughing, - Atypical symptoms involve coughing,
hoarsness, wheezing, SOB due to hoarsness, wheezing, SOB due to
tracheal/laryngeal irritation tracheal/laryngeal irritation
- However, if there are alarm symptoms - However, if there are alarm symptoms
(odynophagia, dysphagia, weight loss, n/v, (odynophagia, dysphagia, weight loss, n/v,
anaemia), then go straight to EGD to r/o anaemia), then go straight to EGD to r/o
cancer/Barrett's cancer/Barrett's
- EGD only shows the effect of the acid, 24 - EGD only shows the effect of the acid, 24
hr pH monitoring is the best test but is hr pH monitoring is the best test but is
rarely done rarely done
- Tx depends on EGD/Bx findings - Tx depends on EGD/Bx findings
142 of 340
957. A pt presents w/ s/s A pt presents w/ s/s of GERD. Lifestyle 958. What is the best test What is the best test in the diagnosis of
of GERD. Lifestyle modifications do not resolve his sxs. EGD in the diagnosis of GERD?
modifications do not w/ Bx reveals dysplasia. What is the next GERD? 24 hr pH monitoring, however it is
resolve his sxs. EGD step in management? [...] rarely done
w/ Bx reveals Ablation (laser or cryo); also increased
dysplasia. What is EGD frequency; consider 24 hr pH
the next step in monitoring and Nissen GERD key points:
management? - the first step is management is not
[...] diagnosis, it is lifestyle modifications (±
GERD key points: PPI trial for 4-6 wks if the symptoms are
- the first step is management is not troublesome)
diagnosis, it is lifestyle modifications (± - Life modifications: smaller meals,
PPI trial for 4-6 wks if the symptoms are avoiding spicy foods, not eating soon
troublesome) before recumbency, elevating the head of
- Life modifications: smaller meals, the bed, stopping EtOH/smoking
avoiding spicy foods, not eating soon - Atypical symptoms involve coughing,
before recumbency, elevating the head of hoarsness, wheezing, SOB due to
the bed, stopping EtOH/smoking tracheal/laryngeal irritation
- Atypical symptoms involve coughing, - However, if there are alarm symptoms
hoarsness, wheezing, SOB due to (odynophagia, dysphagia, weight loss, n/v,
tracheal/laryngeal irritation anaemia), then go straight to EGD to r/o
- However, if there are alarm symptoms cancer/Barrett's
(odynophagia, dysphagia, weight loss, n/v, - EGD only shows the effect of the acid, 24
anaemia), then go straight to EGD to r/o hr pH monitoring is the best test but is
cancer/Barrett's rarely done
- EGD only shows the effect of the acid, 24 - Tx depends on EGD/Bx findings
rarely done
143 of 340
959. A pt presents w/ s/s A pt presents w/ s/s of GERD. Lifestyle 961. A pt presents w/ A pt presents w/ gnawing epigastric pain
of GERD. Lifestyle modifications do not resolve his sxs. EGD gnawing epigastric that worsens when eating a meal. EGD
modifications do not w/ Bx reveals adenocarcinoma. What is pain that worsens reveals multiple, punctuate, shallow
resolve his sxs. EGD the next step in management? when eating a meal. lesions in the gastric mucosa. What is the
w/ Bx reveals Resection + chemo EGD reveals most likely cause?
adenocarcinoma. multiple, punctuate, NSAIDs
What is the next step shallow lesions in
in management? GERD key points: the gastric mucosa.
[...] - the first step is management is not What is the most
diagnosis, it is lifestyle modifications (± likely cause?
PPI trial for 4-6 wks if the symptoms are [...]
troublesome)
- Life modifications: smaller meals,
962. A pt presents w/ A pt presents w/ gnawing epigastric pain
avoiding spicy foods, not eating soon
gnawing epigastric that worsens when eating a meal. EGD
before recumbency, elevating the head of
pain that worsens reveals a singular, large, deep lesion in
the bed, stopping EtOH/smoking
when eating a meal. the gastric mucosa. What is the most likely
- Atypical symptoms involve coughing,
EGD reveals a cause?
hoarsness, wheezing, SOB due to
singular, large, H. pylori or cancer
tracheal/laryngeal irritation
deep lesion in the
- However, if there are alarm symptoms
gastric mucosa.
(odynophagia, dysphagia, weight loss, n/v,
What is the most
anaemia), then go straight to EGD to r/o
likely cause?
cancer/Barrett's
[...]
rarely done 963. A pt presents w/ A pt presents w/ gnawing epigastric pain
- Tx depends on EGD/Bx findings gnawing epigastric that worsens when eating a meal. He
pain that worsens also complains of diarrhea. He was Dx w/
when eating a meal. PUD in the past, but never recovered
He also complains of despite aggressive therapy and
diarrhea. He was Dx compliancy to medications. What cancer
w/ PUD in the past, syndrome should be considered?
960. A pt is Dx w/ GERD A pt is Dx w/ GERD and started on PPIs.
but never recovered Zollinger-Ellison syndrome
and started on PPIs. After 1 year, he is still having sxs but no
despite aggressive
After 1 year, he is longer wishes to take medication. Which
therapy and
still having sxs but no surgical procedure should be considered
compliancy to
longer wishes to take as ppx against Barrett's esophagus?
medications. What
medication. Which Nissen fundoplication
cancer syndrome
surgical procedure
should be
should be considered
considered?
as ppx against Prior to heading to surgery, complete a
[...]
Barrett's esophagus? final EGD, 24 hr pH monitoring and
[...] manometry.
144 of 340
964. A pt presents w/ A pt presents w/ gnawing epigastric pain 968. A pt presents w/ A pt presents w/ gnawing epigastric pain
gnawing epigastric that worsens when eating a meal. You gnawing epigastric that worsens when eating a meal. You
pain that worsens suspect PUD. Where would this ulcer(s) pain that worsens suspect PUD. EGD reveals a large, single
when eating a meal. most likely be located? when eating a meal. ulcer. What is the most appropriate next
You suspect PUD. Stomach You suspect PUD. step in the workup?
Where would this Gastric ulcers= ~75% associated w/ H. EGD reveals a large, CLO + pathology of the Bx to r/o cancer
ulcer(s) most likely pylori = pain worsens w/ meal due to single ulcer. What is or H. pylori
be located? gastric acid release the most appropriate
[...] Duodenal ulcers = ~100% associated w/ next step in the
H. pylori = pain improves w/ meal as the workup?
chyme is neutralized while entering the [...]
duodenum; however, duodenal ulcers are
tricky; pain can flare up well after a meal
as gastric acid is emptied
gnawing epigastric that worsens when eating a meal. You
pain that worsens suspect PUD. EGD reveals multiple,
when eating a meal. shallow ulcers. He is diagnosed w/ PUD
You suspect PUD. 2/2 NSAIDs. What is the treatment?
EGD reveals PPI; stop the NSAIDs or add
965. A pt suffers burns A pt suffers burns and is rushed to the ER multiple, shallow misoprostol or switch to celecoxib
and is rushed to the where he is started on PPI ppx for ulcers. ulcers. He is
ER where he is Which type of ulcers are associated w/ diagnosed w/ PUD
started on PPI ppx burns? 2/2 NSAIDs. What is Also, stop smoking/drinking as with all
for ulcers. Which Curling ulcers the treatment? ulcers.
type of ulcers are [...]
associated w/ burns?
[...] Curling irons are hot and can burn you.

pain that worsens suspect PUD. EGD reveals a single, large
966. A pt sustains head A pt sustains head trauma and is brought when eating a meal. ulcer. CLO testing is positive. He is Dx w/
trauma and is to the ER. He shows signs of increased You suspect PUD. PUD 2/2 H. pylori. What is the treatment?
brought to the ER. ICP. What type of ulcers are associated w/ EGD reveals a Triple Therapy (clarithromycin,
He shows signs of increased ICP? single, large ulcer. amoxicillin, PPI)
increased ICP. What Cushing ulcers CLO testing is
type of ulcers are positive. He is Dx w/
associated w/ PUD 2/2 H. pylori.
increased ICP? What is the
[...] treatment?
[...]

pain that worsens suspect PUD. What is the best diagnostic
when eating a meal. test?
You suspect PUD. EGD w/ Bx
What is the best
diagnostic test?
[...]
145 of 340
971. A pt presents w/ A pt presents w/ gnawing epigastric pain 975. A pt w/ a history of A pt w/ a history of refractory PUD
gnawing epigastric that worsens when eating a meal. You refractory PUD presents c/o of persistent PUD symptoms.
pain that worsens suspect PUD. What is the best diagnostic presents c/o of You suspect Zollinger-Ellison syndrome.
when eating a meal. test for H. pylori? persistent PUD Serum gastrin level is non-confirmatory.
You suspect PUD. Biopsy symptoms. You What is most appropriate next step?
What is the best suspect Secretin stimulation test (causes a
diagnostic test for H. Zollinger-Ellison paradoxical increase in gastrin if
pylori? Serology sucks as its almost always syndrome. Serum positive)
[...] positive and not very useful. gastrin level is
non-confirmatory.
What is most
appropriate next
step?
[...]

gnawing epigastric that worsens when eating a meal. You 976. A pt w/ a history of A pt w/ a history of refractory PUD
pain that worsens suspect PUD. What is the best initial test refractory PUD presents c/o of persistent PUD symptoms.
when eating a meal. for H. pylori? presents c/o of You suspect Zollinger-Ellison syndrome.
You suspect PUD. Urease breath test; however the pt must persistent PUD Serum gastrin level is non-confirmatory but
What is the best be off PPIs symptoms. You a secretin stimulation test confirms your
initial test for H. This is also considered the best suspect suspicion. What is most appropriate next
pylori? non-invasive diagnostic test. Zollinger-Ellison step?
[...] syndrome. Serum
gastrin level is Somatostatin scintigraphy (or CT) to
non-confirmatory but localize/stage
a secretin stimulation
test confirms your
suspicion. What is
most appropriate
next step?
pain that worsens suspect PUD. What is the best test to
when eating a meal. guage for the eradication of H. pylori?
[...]
You suspect PUD. Stool antigen
What is the best test
to guage for the 977. What is the treatment What is the treatment for Zollinger-Ellison
eradication of H. for Zollinger-Ellison syndrome?
pylori? syndrome? Resection of the tumour; f/u for gastric
[...] [...] cancer screen
The tumour itself is benign, but the ulcers
are severe and diffuse and set the stage
for gastric cancer.
974. A pt w/ a history of A pt w/ a history of refractory PUD
refractory PUD presents c/o of persistent PUD symptoms.
presents c/o of You suspect Zollinger-Ellison syndrome.
persistent PUD What is the best initial test?
symptoms. You Serum gastrin level
suspect
Zollinger-Ellison
syndrome. What is
the best initial test?
[...]
146 of 340
978. A pt w/ longstanding, A pt w/ longstanding, uncontrolled T2DM 982. A pt presents c/o of A pt presents c/o of early satiety and
uncontrolled T2DM presents c/o feeling bloated, gassy and of early satiety and weight loss. EGD w/ Bx reveals a mass
presents c/o feeling mild abdominal pain. He states that his weight loss. EGD w/ w/ signet ring cells on microscopy. Which
bloated, gassy and pain is relieved by vomiting. You suspect Bx reveals a mass w/ lymph node does this cancer typically
of mild abdominal gastroparesis. What is the best initial test? signet ring cells on metastasize to first?
pain. He states that Nuclear emptying study microscopy. Which Supraclavicular node (Virchow's Node)
his pain is relieved If > 50% of the dye is present 2 hrs lymph node does this
by vomiting. You post-prandial, the Dx is gastroparesis cancer typically
suspect EGD is often done prior to Tx to r/o cancer. metastasize to first?
gastroparesis. What [...]
is the best initial
test?
983. A pt presents w/ A pt presents w/ early satiety and weight
[...]
early satiety and loss. You suspect gastric carcinoma. What
weight loss. You is the best diagnostic test?
979. A diabetic pt w/ A diabetic pt w/ gastroparesis has frequent suspect gastric EGD w/ Bx
gastroparesis has hypoglycemic episodes. Why? carcinoma. What is
frequent (see below) the best diagnostic
hypoglycemic test? Bx will reveal signet ring cells.
episodes. Why? [...]
[...] Hypoglycemia w/ gastroparesis:
- Delayed gastric emptying + taking insulin
984. What is the "VW What is the "VW HAPPENS" mnemonic for
at proper times = excess insulin, as the
HAPPENS" the etiologies of cirrhosis?
food has yet to leave the stomach and get
mnemonic for the (see below)
absorbed. Hence, hypoglycemic episodes.
etiologies of
cirrhosis?
980. A pt w/ longstanding, A pt w/ longstanding, uncontrolled T2DM [...]
uncontrolled T2DM presents c/o feeling bloated, gassy and of
presents c/o feeling mild abdominal pain. He states that his
985. A pt presents w/ A pt presents w/ cirrhosis and chorea.
bloated, gassy and pain is relieved by vomiting. Nuclear
cirrhosis and You suspect Wilson's Disease. What is the
of mild abdominal emptying study reveals poor gastric
chorea. You suspect best initial test?
pain. He states that emptying. He is dx w/ gastroparesis. What
Wilson's Disease. Slit-lamp test for Kayser-Fleischer rings
his pain is relieved is the Tx?
What is the best at the eye
by vomiting. Nuclear Control diabetes; prokinetics
initial test?
emptying study (erythromycin, metoclopramide)
[...]
reveals poor gastric Get an EGD to rule out cancer prior to Tx.
emptying. He is dx w/
gastroparesis. What
is the Tx?
[...]
981. A pt is Dx w/ A pt is Dx w/ MALToma after an EGD ruled

MALToma after an out gastric carcinoma. What is the Tx?
EGD ruled out Triple therapy (for H. pylori)
gastric carcinoma.
What is the Tx?
[...]
147 of 340
986. A pt presents w/ A pt presents w/ cirrhosis and chorea. 989. A pt presents c/o of A pt presents c/o of bronzing of the skin.
cirrhosis and You suspect Wilson's Disease. What is the bronzing of the skin. He also complains of polydipsia, polyuria
chorea. You suspect best diagnostic test? He also complains of and nocturia. Synthetic and metabolic
Wilson's Disease. Biopsy (will reveal > 250 ugCu/g of liver polydipsia, polyuria liver functions are all abnormal. You
What is the best dry weight); however, slit-lamp test is and nocturia. suspect hemochromatosis. What is the
diagnostic test? also diagnostic Synthetic and best diagnostic test?
[...] Lab studies just help support the Dx: metabolic liver Bx
- serum ceruloplasmin is low as functions are all
ceruloplasmin is busy binding all the free abnormal. You
copper suspect
- urine copper is high hemochromatosis.
- serum copper is useless What is the best
diagnostic test?
[...]
987. A pt presents w/ A pt presents w/ cirrhosis and chorea. 990. A pt presents c/o of A pt presents c/o of bronzing of the skin.
cirrhosis and Slit-lamp testing reveals Kayser-Fleischer bronzing of the skin. He also complains of polydipsia, polyuria
chorea. Slit-lamp rings. Bx reveals > 250 ugCu/g of liver He also complains of and nocturia. Synthetic and metabolic
testing reveals dry weight. What is the treatment? polydipsia, polyuria liver functions are all abnormal. Ferritin is
Kayser-Fleischer Penicillamine (chelates the Cu and and nocturia. very elevated. MRI reveals a black liver.
rings. Bx reveals > allows for urinary excretion); transplant Synthetic and Bx confirms hemochromatosis. What is
250 ugCu/g of liver is curative metabolic liver the Tx?
dry weight. What is functions are all Deferoxamine (iron chelator); or serial
the treatment? abnormal. Ferritin is phlebotomy
[...] very elevated. MRI Phlebotomy is the better choice.
reveals a black liver. - titrate to an iron saturation < 30 or
Bx confirms ferritin < 50
hemochromatosis. Transplant only cures the cirrhosis, not
988. A pt presents c/o of A pt presents c/o of bronzing of the skin.
What is the Tx? the disease, and hence sets the stage
bronzing of the skin. He also complains of polydipsia, polyuria
[...] for recurrence.
He also complains of and nocturia. Synthetic and metabolic
- The defect is in the gut, not the liver
polydipsia, polyuria liver functions are all abnormal. You
and nocturia. suspect hemochromatosis. What is the
Synthetic and best initial test?
metabolic liver Ferritin
functions are all Transferrin is actually more sensitive, but
abnormal. You ferritin is easier to interpret as its usually 991. A pt presents w/ A pt presents w/ COPD and cirrhosis.
suspect very elevated. COPD and You suspect alpha1-antitrypsin deficiency.
hemochromatosis. F/u w/ Bx to confirm. cirrhosis. You What is the best diagnostic test?
What is the best suspect Genotyping
initial test? alpha1-antitrypsin PiZZ genotype is the worst form; PiMM
[...] deficiency. What is genotype is normal
the best diagnostic Bx can be done and would show PAS+
test? macrophages, but genotyping is
[...] confirmatory
148 of 340
992. A pt presents w/ A pt presents w/ COPD and cirrhosis. 996. A female pt presents A female pt presents w/ cirrhosis. She is
COPD and Genotyping reveals a PiZZ genotype, w/ cirrhosis. She is asymptomatic. You suspect PBC. What is
cirrhosis. confirming A1AT Deficiency. What is the asymptomatic. You the first step in diagnosis?
Genotyping reveals a treatment? suspect PBC. What Anti-mitochondrial antibodies (AMA)
PiZZ genotype, Transplant (curative); replacement is the first step in Unlike PSC, PBC shows nothing on
confirming A1AT enzyme may help the emphysema diagnosis? imaging as it is a micoductal disease.
Deficiency. What is [...] As such, f/u your suspicion w/
the treatment? anti-mitochondrial antibodies.
[...] Bx is confirmatory.
993. A male pt w/ A male pt w/ ulcerative colitis presents

ulcerative colitis w/ signs of obstructive jaundice. You
presents w/ signs of suspect PSC. What antibodies may you 997. A female pt presents A female pt presents w/ cirrhosis. She is
obstructive test for to aid in diagnosis? w/ cirrhosis. She is asymptomatic. You suspect PBC.
jaundice. You p-ANCA asymptomatic. You Anti-mitochondrial antibodies are
suspect PSC. What suspect PBC. positive. What is the best diagnostic test?
antibodies may you Anti-mitochondrial Bx
test for to aid in antibodies are Unlike PSC, PBC shows nothing on
diagnosis? positive. What is the imaging as it is a microductal disease.
[...] best diagnostic test? As such, f/u your suspicion w/
[...] anti-mitochondrial antibodies.
Bx is confirmatory.
ulcerative colitis w/ signs of obstructive jaundice. You
presents w/ signs of suspect PSC. Testing for p-ANCA is
obstructive positive. What is the best diagnostic test?
jaundice. You MRCP (will reveal beads on a string 998. A female pt presents A female pt presents w/ cirrhosis. She is
suspect PSC. pattern) w/ cirrhosis. She is asymptomatic. Anti-mitochondrial
Testing for p-ANCA ERCP w/ Bx is not necessary but will asymptomatic. antibodies are positive. Bx confirms
is positive. What is show onion-skin fibrosis if performed. Anti-mitochondrial Primary Biliary Cirrhosis. What is the Tx?
the best diagnostic antibodies are Immunosuppression, w/ downstream
test? positive. Bx confirms transplantation
[...] Primary Biliary
Cirrhosis. What is the
Tx? However, as this is autoimmune,
[...] transplant may set the stage for
ulcerative colitis w/ signs of obstructive jaundice. Testing
recurrence.
presents w/ signs of for p-ANCA is positive. MRCP reveals
obstructive 'beads on a string'. He is dx w/ PSC.
jaundice. Testing for What is the Tx?
p-ANCA is positive. Cholestyramine/ursodeoxycholic acid
MRCP reveals for sxs; transplant if needed 999. A pt presents w/ s/s A pt presents w/ s/s of cirrhosis. Workup
'beads on a string'. Never place a stent in PSC, it may help in of cirrhosis. Workup for etiologies is unfruitful. SHx is positive
He is dx w/ PSC. the short term but only makes transplant for etiologies is for severe alcoholism. AST:ALT is > 2.
What is the Tx? down the line much harder. unfruitful. SHx is What is the most likely Dx?
[...] Transplant is not curative and may set the positive for severe EtOH Cirrhosis
stage for recurrence. alcoholism.
AST:ALT is > 2.
What is the most Is a Dx of exclusion (but before NASH)
likely Dx?
[...]
149 of 340
1004. A female pt w/ a A female pt w/ a PMHx of autoimmune

1000. An obese pt An obese pt presents w/ s/s of cirrhosis. PMHx of disorders presents w/ AST and ALT in
presents w/ s/s of Workup for all common etiologies is autoimmune the 1000s after an outpatient lab test.
cirrhosis. Workup unfruitful. You suspect NASH. What is the disorders presents Anti-smooth muscle and anti-LKM
for all common best initial test? w/ AST and ALT in antibodies are both positive. She is Dx w/
etiologies is U/S the 1000s after an autoimmune hepatitis after a Bx. What is
unfruitful. You outpatient lab test. the Tx?
suspect NASH. Anti-smooth Steroids --> transplant
What is the best muscle and
initial test? anti-LKM antibodies
[...] are both positive.
She is Dx w/
1001. An obese pt An obese pt presents w/ s/s of cirrhosis. autoimmune
presents w/ s/s of Workup for all common etiologies is hepatitis after a Bx.
cirrhosis. Workup unfruitful. You suspect NASH. What is the What is the Tx?
for all common best diagnostic test? [...]
etiologies is Bx
unfruitful. You 1005. A pt presents w/ A pt presents w/ nonbloody diarrhea and
suspect NASH. nonbloody diarrhea acute hepatitis. He denies having
What is the best and acute hepatitis. received HAV vaccination. Serology
diagnostic test? He denies having reveals IgM against HAV. What is the
[...] received HAV most likely Dx?
vaccination. Acute Hepatitis A
1002. A female pt w/ a A female pt w/ a PMHx of autoimmune Serology reveals
PMHx of disorders presents w/ AST and ALT in IgM against HAV.
autoimmune the 1000s after an outpatient lab test. You What is the most
disorders presents suspect autoimmune hepatitis. Which likely Dx?
w/ AST and ALT in antibodies are associated w/ this [...]
the 1000s after an disorder?
outpatient lab test. Anti-smooth muscle; Anti-LKM 1006. How soon before How soon before travel to an endemic
You suspect travel to an endemic region should a Hepatitis A booster be
autoimmune region should a given?
hepatitis. Which Hepatitis A booster > 2 wks before
antibodies are be given?
associated w/ this [...]
disorder?
[...]
1007. What is the What is the treatment for Hepatitis A?
treatment for Vaccination
1003. A female pt w/ a A female pt w/ a PMHx of autoimmune Hepatitis A?
PMHx of disorders presents w/ AST and ALT in [...]
autoimmune the 1000s after an outpatient lab test. You Hepatitis A is typically self-limiting, but the
disorders presents suspect autoimmune hepatitis. What is HAV vaccine can help.
w/ AST and ALT in the best diagnostic test?
the 1000s after an Bx
outpatient lab test.
You suspect
autoimmune
hepatitis. What is the
[...]
150 of 340
1008. A pt w/ suspected A pt w/ suspected hepatitis comes in to

1013. Chronic carrier's of Chronic carrier's of HBV have a risk of
hepatitis comes in to review his serology results. He is positive
review his serology for HBsAb-IgG only. What does this HBV have a risk of developing hepatocellular carcinoma.
results. He is mean? developing How are these pt's screened for HCC?
positive for He is immune hepatocellular Alfa-fetoprotein (AFP); U/S
HBsAb-IgG only. carcinoma. How are
What does this these pt's screened
mean? for HCC?
[...] [...]
1009. A pt w/ suspected 1014. What is the What is the treatment for HBV?
A pt w/ suspected hepatitis comes in to
hepatitis comes in to review his serology results. He is positive treatment for HBV?
review his serology for HBsAb-IgG and HBcAb. What does Pegylated IFN-a for 48 wks + antivirals
results. He is this mean? [...]
positive for He is immune, but has been exposed
HBsAb-IgG and Antivirals such as lamivudine, adefovir,
HBcAb. What does telbivudine, entecavir
this mean? Vaccination is also given
[...] Ppx is IgG

1015. A pt suspected for A pt suspected for Hepatitis C comes in to
review his serology for HBsAg and HBsAb-IgM only. What
results. He is does this mean? Hepatitis C comes in review his serology results. He is
positive for HBsAg He has an acute infection to review his negative for Anti-HCV Ab but positive
and HBsAb-IgM Remember, IgM = acute infection, IgG = serology results. He for HCV RNA. What is the Dx?
only. What does this past exposure/immunity is negative for Early HCV infection
mean? Anti-HCV Ab but
[...] positive for HCV
RNA. What is the
Dx?
[...]
1016. A pt suspected for A pt suspected for Hepatitis C comes in to
review his serology for HBsAg and HBeAg. What does this
results. He is mean? Hepatitis C comes in review his serology results. He is positive
positive for HBsAg He is actively infected and infectious to review his for Anti-HCV Ab and positive for HCV
and HBeAg. What serology results. He RNA. What is the Dx?
does this mean? is positive for Chronic HCV infection (this is the most
[...] Anti-HCV Ab and common serology)
positive for HCV Remember, HCV is always chronic
RNA. What is the hepatitis.
1012. A pt w/ suspected A pt w/ suspected hepatitis comes in to Dx?
[...]
review his serology for HBeAb-IgG, but negative for HBeAg.
results. He is What does this mean?
positive for He is immune, but has had active
HBeAb-IgG, but infection in the past
negative for HBeAg.
What does this
mean?
[...]
151 of 340
1017. Which hepatitis virus Which hepatitis virus can cause both 1022. Which hepatitis Which hepatitis viruses are associated w/
can cause both acute and chronic hepatitis? viruses are hepatocellular carcinoma?
acute and chronic HBV associated w/ HBV; HCV; HDV
hepatitis? hepatocellular
[...] carcinoma?
A = acute only [...] i.e. the ones that cause chronic
B = both acute and chronic hepatitis
C = chronic only - chronic hepatitis = chronic inflammation
D = chronic only, but requires HBV = stage is set for HCC
E = acute only
1023. A pt presents w/ A pt presents w/ severe epigastric pain

1018. A pt suspected for A pt suspected for Hepatitis C comes in to severe epigastric that radiates to the back and is relieved
Hepatitis C comes in review his serology results. He is positive pain that radiates to by leaning forward. He also complains of
to review his for Anti-HCV Ab but negative for HCV the back and is nausea, vomiting, fever and anorexia.
serology results. He RNA. What is the Dx? relieved by leaning Physical exam reveals Cullen's and Grey
is positive for Immunity from past exposure forward. He also Turner sign. You suspect acute
Anti-HCV Ab but There is no HCV vaccine atm, so complains of pancreatitis. What is the best initial and
negative for HCV immunity can only be from prior exposure nausea, vomiting, diagnostic test?
RNA. What is the fever and anorexia. Pancreatic enzymes (+ clinical
Dx? Physical exam presentation)
[...] reveals Cullen's and Lipase is more sensitive and specific
Grey Turner sign. than amylase.
You suspect acute Amylase is typically > 3x the ULN
1019. What is the What is the treatment for HCV?
pancreatitis. What is U/S should follow if stones are suspected.
treatment for HCV? Direct Acting Antivirals (the -ivir's)
the best initial and ERCP is the Tx in taht case.
[...]
diagnostic test? CT scan should only be done if you are
[...] unsure of etiology or to assess for
complications (i.e. if you suspect
1020. Which hepatitis virus Which hepatitis virus requires presence of necrotizing pancreatitis).
requires presence of HBV? CT should be done initially if lipase is
HBV? HDV normal but you still suspect pancreatitis.
[...]
1024. A pt is suspected to A pt is suspected to have acute

Requires a protein coded by the HBV
have acute pancreatitis. Which set of clinical criteria
genome.
pancreatitis. Which aids in determining the prognosis of pt's
Transmitted the same way as HBV.
set of clinical criteria w/ pancreatitis?
Causes a severe hepatitis w/ faster
aids in determining Ranson criteria
progression to cirrhosis.
the prognosis of pt's
w/ pancreatitis?
1021. Which hepatitis virus Which hepatitis virus is associated w/ [...] Checked at admission then at 48 hrs.
is associated w/ pregnant women in 3rd world countries?
pregnant women in HEV
1025. What is the most What is the most common complication of
3rd world countries? Think of this as the HAV of women in 3rd
common pancreatitis?
[...] world countries.
complication of Pancreatic pseudocyst
pancreatitis?
[...]
152 of 340
1026. A pt Dx w/ A pt Dx w/ pancreatitis < 6 wks ago now

1030. What is the best What is the best diagnostic test for
pancreatitis < 6 wks complains of early satiety and
ago now complains abdominal fullness. CT scan reveals a < diagnostic test for diverticulosis?
of early satiety and 6 cm pancreatic pseudocyst. What is the diverticulosis? Colonoscopy
abdominal fullness. treatment? [...]
CT scan reveals a < Observation; if its < 6 cm and < 6 wks
6 cm pancreatic out from diagnosis, let it resolve CT scan can reveal them, but you still
pseudocyst. What is spontaneously need to scope.
the treatment? If > 6 cm or > 6 wks out, drain it and Bx
[...] - done via surgery, percutaneously, or 1031. On which side of the On which side of the body do colonic
pancreaticogastrosomy body do colonic diverticula most commonly occur?
diverticula most Left, as stool is harder in the
commonly occur? descending/sigmoid colon
1027. A pt presents to the A pt presents to the ER w/ s/s of acute [...]
ER w/ s/s of acute pancreatitis. Ranson criteria on admission
pancreatitis. Ranson was low. At 48 hrs, the pt develops
criteria on admission hypotension and Ranson criteria is now 1032. A 65 y/o pt w/ A 65 y/o pt w/ diverticulosis presents c/o
was low. At 48 hrs, high. CT scan of the abdomen reveals diverticulosis of post-prandial LLQ abdominal pain
the pt develops pancreatic necrosis. What is the most presents c/o of that is relieved w/ a bowel movement.
hypotension and likely Dx? post-prandial LLQ What is the most likely Dx?
Ranson criteria is Necrotizing Pancreatitis abdominal pain that Diverticular spasm
now high. CT scan In this setting, add meropenem to the is relieved w/ a The pain stems from the gastrocolic reflex
of the abdomen treatment to reduce mortality. bowel movement. that trigger colonic motility/contraction.
reveals pancreatic What is the most This reads a lot like IBS, so to differentiate
necrosis. What is likely Dx? always look at age: IBS is seen in young
the most likely Dx? [...] women, diverticula in older pts.
[...]
1028. A pt presents to the A pt presents to the ER w/ s/s of acute 1033. A 70 y/o pt w/ a A 70 y/o pt w/ a PMHx of diverticulosis
ER w/ s/s of acute pancreatitis. Ranson criteria on admission PMHx of presents c/o brisk, painless rectal
pancreatitis. Ranson was low. At 48 hrs, the pt develops diverticulosis bleeding. He states that the bleeding was
criteria on admission hypotension and Ranson criteria is now presents c/o brisk, very rapid w/ bright red blood. Physical
was low. At 48 hrs, high. CT scan of the abdomen reveals painless rectal exam is normal. NG tube and EGD r/o
the pt develops pancreatic necrosis. What is the Tx for bleeding. He states UGIB. Arteriogram reveals bleeding from
hypotension and the most likely Dx? that the bleeding the hepatic flexure of the colon. What is
Ranson criteria is NPO, IVF, analgesia; and meropenem; was very rapid w/ the most likely Dx?
now high. CT scan also, consider an ICU xfer bright red blood. Diverticular hemorrhage
of the abdomen Meropenem reduces mortality in Physical exam is Remember, diverticula are more likely
reveals pancreatic necrotizing pancreatitis. normal. NG tube and to bleed from the right side despite
necrosis. What is Surgical debridement may also be EGD r/o UGIB. being more commonly found on the
the Tx for the most required. Arteriogram reveals left.
likely Dx? bleeding from the
[...] hepatic flexure of the
colon. What is the
1029. A 60 y/o pt comes in A 60 y/o pt comes in for colonoscopy most likely Dx?
for colonoscopy which reveals diverticulosis. What is the [...]
which reveals Tx?
diverticulosis. What High-fiber diet (± stool softener)
is the Tx?
[...]
153 of 340
1034. On which side of the On which side of the body are colonic 1037. A 60 y/o pt presents A 60 y/o pt presents c/o of LLQ pain. The
body are colonic diverticula more likely to bleed? c/o of LLQ pain. The pt also complains of fever. Physical exam
diverticula more Right (however they are more pt also complains of reveals LLQ tenderness w/o guarding.
likely to bleed? commonly found on the left) fever. Physical CBC reveals leukocytosis. You suspect
[...] exam reveals LLQ diverticulitis. What is best diagnostic test?
tenderness w/o CT
guarding. CBC
reveals
1035. A 70 y/o pt w/ a A 70 y/o pt w/ a PMHx of diverticulosis
leukocytosis. You
PMHx of presents c/o brisk, painless rectal
suspect diverticulitis.
diverticulosis bleeding. He states that the bleeding was
What is best
presents c/o brisk, very rapid w/ bright red blood. Physical
diagnostic test?
painless rectal exam is normal. NG tube and EGD r/o
[...]
bleeding. He states UGIB. Arteriogram reveals diverticular
that the bleeding hemorrhage. What is the Tx?
was very rapid w/ Embolization; cautery; resection 1038. A 60 y/o pt presents A 60 y/o pt presents c/o of LLQ pain. The
bright red blood. c/o of LLQ pain. The pt also complains of fever. Physical exam
Physical exam is pt also complains of reveals LLQ tenderness w/o guarding.
normal. NG tube and fever. Physical CBC reveals leukocytosis. CT scan
EGD r/o UGIB. exam reveals LLQ confirms mild diverticulitis. What is the
Arteriogram reveals tenderness w/o Tx?
diverticular guarding. CBC Bowel rest (i.e. liquid diet); PO Abx
hemorrhage. What is reveals Abx needs to cover gram-neg and
the Tx? leukocytosis. CT anaerobes.
[...] scan confirms mild - e.g. Ampicillin-Gentamicin + MTZ
diverticulitis. What - e.g. cipro + MTZ
is the Tx? - e.g. zosyn (pip+tazo)
1036. A 60 y/o pt presents A 60 y/o pt presents c/o of LLQ pain. The
[...]
c/o of LLQ pain. The pt also complains of fever. Physical exam
pt also complains of reveals LLQ tenderness w/o guarding.
fever. Physical CBC reveals leukocytosis. You suspect
exam reveals LLQ diverticulitis. What is the most appropriate 1039. A 60 y/o pt presents A 60 y/o pt presents c/o of LLQ pain. The
tenderness w/o first step in the workup? c/o of LLQ pain. The pt also complains of fever. Physical exam
guarding. CBC Upright and flat U/S to rule out pt also complains of reveals LLQ tenderness w/o guarding.
reveals perforation/free air fever. Physical CBC reveals leukocytosis. CT scan
leukocytosis. You exam reveals LLQ confirms severe diverticulitis. What is
suspect diverticulitis. tenderness w/o the Tx?
What is the most guarding. CBC NPO, IVF, IV Abx
appropriate first step reveals
in the workup? leukocytosis. CT
[...] scan confirms Abx needs to cover gram-neg and
severe anaerobes.
diverticulitis. What - e.g. Ampicillin-Gentamicin + MTZ
is the Tx? - e.g. cipro + MTZ
[...] - e.g. zosyn (pip+tazo)
154 of 340
1040. A 60 y/o pt presents A 60 y/o pt presents c/o of LLQ pain. The 1043. What is the What is the diagnostic criteria for
c/o of LLQ pain. The pt also complains of fever. Physical exam diagnostic criteria for hypertension?
pt also complains of reveals LLQ tenderness w/o guarding. hypertension? 2 separate BP readings <140/90 taken
fever. Physical CBC reveals leukocytosis. CT scan [...] at 2 separate office visits
exam reveals LLQ confirms severe diverticulitis w/
tenderness w/o abscess formation. What is the Tx?
guarding. CBC NPO, IVF, IV Abx; and surgical/IR Hypertension diagnosis key points:
reveals drainage - Requires 2 separate measurements
leukocytosis. CT from 2 separate occurrences; interval is
scan confirms not clear, but patient should be in a calm
severe diverticulitis Abx needs to cover gram-neg and state
w/ abscess anaerobes. - Most common disease in USA; most
formation. What is - e.g. Ampicillin-Gentamicin + MTZ common risk factor for the most common
the Tx? - e.g. cipro + MTZ cause of death in USA (MI)
[...] - e.g. zosyn (pip+tazo) - Best test is actually ambulatory BP
monitoring; this is more accurate and
helps to rule out white coat hypertension
- As a general rule, the stage of
hypertension denotes how many
1041. A pt is Dx w/ A pt is Dx w/ refractory diverticulitis.
medications the pt may require to lower
refractory What is the Tx?
BP towards the goal (i.e. 2 meds in stage
diverticulitis. What Hemicolectomy
II)
is the Tx?
[...]
1044. A pt presents to the A pt presents to the ED with a BP of
ED with a BP of 190/125 mmHg. No end organ damage is
190/125 mmHg. No revealed through history, physical
end organ damage examination or labwork. What is the
1042. A pt is dx w/ A pt is dx w/ diverticulitis. How soon after
is revealed through diagnosis?
diverticulitis. How the acute portion of the disease is
history, physical Hypertensive Urgency
soon after the acute colonoscopy indicated?
examination or
portion of the 2-6 wks
labwork. What is the
disease is
diagnosis? Hypertensive Urgency vs. Emergency
colonoscopy
[...] key points:
indicated? Never perform colonoscopy in the acute
- Urgency is > 180/110 without end
[...] phase of diverticulitis due to high risk of
organ damage and is treated with PO
perforation (and a nice fat lawsuit!)
meds
- Emergency/Crisis is >180/110 with
end organ damage and is treated with IV
meds (stroke, MI, papilledema, flash
pulmonary edema, headache, chest pain,
etc...)
-- In emergency, the goal is to decrease
MAP by 25% within 2-6 hrs of admission
and to achieve normal MAP by 24 hrs
-- In emergency, you cannot lower BP to
normal right away as it may provoke a
stroke
155 of 340
1045. A 65 y/o pt is A 65 y/o pt is diagnosed with HTN. He 1049. A pt is placed on an A pt is placed on an ACE-Inhibitor to
diagnosed with HTN. has no comorbidities. What is his BP ACE-Inhibitor to manage hypertension. What are the
He has no goal? manage notable side effects?
comorbidities. What < 150/90 mmHg hypertension. What Cough; Angioedema; (and
is his BP goal? are the notable side hyperkalemia)
[...] effects?
[...]
If a pt taking an ACE ever gets
1046. An 80 y/o An 80 y/o African-American man is
angioedema, stop the ACE and never put
African-American diagnosed with HTN. He also has CKD.
them on one again.
man is diagnosed What class of medications should be the
In both cases (cough or angioedema),
with HTN. He also first medication given in his management?
switch to an ARB.
has CKD. What ACE-I
class of medications CKD trumps the no ACE-I rule for AA's
should be the first and pts > 75 y/o
medication given in
his management? 1050. A pt is switched to A pt is switched to an ARB as part of his
[...] an ARB as part of hypertension management after
his hypertension developing a dry cough and angioedema
management after from an ACE-I. What are the notable side
1047. An 80 y/o An 80 y/o African-American man is
developing a dry effects of an ARB?
African-American diagnosed with HTN. He has no other
cough and Hyperkalemia
man is diagnosed diseases. What class of medications
angioedema from an
with HTN. He has no should not be the first medication given in
ACE-I. What are the
other diseases. his management?
notable side effects Both ACE-I's and ARBs can cause
What class of ACE-I
of an ARB? hyperkalemia
medications should
[...]
not be the first
medication given in
his management?
[...] 1051. A pt taking A pt taking spironolactone to manage
spironolactone to HTN develops gynecomastia. He is
manage HTN upset and wishes it would go away. What
1048. A pt is placed on a A pt is placed on a CCB to manage their
develops medication should he be switched to?
CCB to manage their HTN. What side effect should be
gynecomastia. He Eplerenone
HTN. What side monitored?
is upset and wishes
effect should be Peripheral edema
it would go away.
monitored?
What medication
[...]
should he be
switched to?
[...]
1052. A pt is given A pt is given spironolactone to manage

spironolactone to his hypertension. What are the notable
manage his side effects?
hypertension. What Hyperkalemia; Gynecomastia
are the notable side Switch to eplerenone if it becomes an
effects? issue.
[...]
156 of 340
1053. Comorbidities Comorbidities alongside HTN can often 1057. Comorbidities Comorbidities alongside HTN can often
alongside HTN can dictate the anti-hypertensives chosen in alongside HTN can dictate the anti-hypertensives chosen in
often dictate the management. What drugs are used in a often dictate the management. What drugs are used in a
anti-hypertensives patient with HTN and CAD? anti-hypertensives patient with HTN and CKD?
chosen in BB, ACE-I, ISMN, CCB chosen in ACE-i
management. What management. What
drugs are used in a drugs are used in a
patient with HTN patient with HTN
and CAD? and CKD?
[...] [...]
1054. Comorbidities Comorbidities alongside HTN can often 1058. A 25 y/o pt presents A 25 y/o pt presents to the clinic for a
alongside HTN can dictate the anti-hypertensives chosen in to the clinic for a hypertension check-up. His HTN has
often dictate the management. What drugs are used in a hypertension been refractory to 3 anti-hypertensives,
anti-hypertensives patient with HTN and CHF? check-up. His HTN one being HCTZ. What type of
chosen in BB, ACE-I, ISDN + hydralazine, has been refractory hypertension is this?
management. What spironolactone to 3 Secondary
drugs are used in a anti-hypertensives,
patient with HTN one being HCTZ.
and CHF? What type of Aight... borderline poor card. Just let me
[...] hypertension is this? have this one.
[...] Secondary Hypertension key points:
- numerous causes
1055. Comorbidities Comorbidities alongside HTN can often
- should always be considered in
alongside HTN can dictate the anti-hypertensives chosen in
hypertension before 35 y/o and/or
often dictate the management. What drugs are used in a
hypertension refractory to 3 meds,
anti-hypertensives patient with HTN and CVA?
where 1 must be a diuretic
chosen in ACE-I
- mcc is CKD/ESRD
management. What
drugs are used in a
patient with HTN 1059. A pt presents with A pt presents with refractory HTN. Labs
and CVA? refractory HTN. Labs reveal hypokalemia and an
[...] reveal hypokalemia aldosterone:renin > 20. What cause of
and an secondary HTN should be considered?
aldosterone:renin > Primary Hyperaldosteronism (Conn's
1056. Comorbidities Comorbidities alongside HTN can often
20. What cause of Syndrome)
alongside HTN can dictate the anti-hypertensives chosen in
secondary HTN
often dictate the management. What drugs are used in a
should be
anti-hypertensives patient with HTN and T2DM?
considered?
chosen in ACE-I
[...]
management. What
drugs are used in a
patient with HTN
and T2DM?
[...]
157 of 340
1060. A pt w/ refractory A pt w/ refractory HTN presents c/o 1063. A pt w/ refractory A pt w/ refractory HTN presents c/o
HTN presents c/o weight loss, sweating, heat intolerance HTN presents c/o episodic pallour, palpitations, pain, and
weight loss, and palpitations. What endocrine cause episodic pallour, perspirations that come and go on
sweating, heat of secondary HTN should be considered? palpitations, pain, random occassions. What endocrine
intolerance and Hyperthyroidism and perspirations cause of secondary HTN should you
palpitations. What that come and go on consider?
endocrine cause of random occassions. Pheochromocytoma
secondary HTN What endocrine
should be cause of secondary
considered? HTN should you
[...] consider?
[...]
1061. A pt w/ refractory A pt w/ refractory HTN presents c/o

HTN presents c/o polyuria, AMS, and flank pain that 1064. A young, 25 y/o A young, 25 y/o female pt is being worked
polyuria, AMS, and radiates to the groin. What cause of female pt is being up for hypertension. Physical exam
flank pain that secondary HTN should be considered? worked up for reveals a continuous bruit heard at the
radiates to the Hypercalcemia hypertension. right flank. What is the most likely cause
groin. What cause Physical exam of this pt's HTN?
of secondary HTN reveals a continuous Renal Artery Stenosis 2/2
should be bruit heard at the fibromuscular dysplasia
considered? right flank. What is
[...] the most likely cause
of this pt's HTN? If this was an old man, think renal artery
[...] stenosis 2/2 atherosclerosis.
1062. A pt w/ refractory A pt w/ refractory HTN presents to the
HTN presents to the clinic for a check-up. Your cheeky medical
clinic for a check-up. student reports that his BP is lower in his 1065. What is the best What is the best initial therapy for
Your cheeky medical legs vs. his arms. Aside from wondering initial therapy for hypertension?
student reports that why he measured BP in the pt's legs, hypertension? Lifestyle modifications (weight loss, Na
his BP is lower in what cause of secondary HTN should you [...] restruction, exercise, dietary changes,
his legs vs. his consider? smoking cessation.
arms. Aside from Aortic Coarctation
wondering why he
measured BP in the HTN Lifestyle modifications key points:
pt's legs, what cause CXR will likely reveal rib notching. - weight loss is the most effective (an
of secondary HTN attending of mine explained it well: think
should you of all the vasculature that's added with
consider? that weight, that's how much more
[...] resistance and distance the heart has to
pump against; luckily, the effect is just as
beneficial when you lose the weight)
- HTN dietary changes typically involve
less fat/red meat and more
fish/vegetables
- Smoking cessation does not stop HTN
progression, but it is vital in preventing
further cardiovascular disease
158 of 340
1066. Which class(es) of Which class(es) of antihypertensives are 1068. A 65 y/o man with a A 65 y/o man with a PMHx of uncontrolled
antihypertensives safe to use in pregnancy? PMHx of hypertension presents to the ER c/o AMS,
are safe to use in (see below) uncontrolled blurry vision, headache and dyspnea.
pregnancy? hypertension Physical exam reveals papilledema.
[...] presents to the ER There are no other abnormalities. He is
Pregnancy-safe antihypertensives: c/o AMS, blurry diagnosed with hypertensive emergency.
- BBs (Labetalol); first choice vision, headache What is the best initial treatment?
- CCBs and dyspnea. IV Labetalol or nitroprusside
- Hydralazine Physical exam Hypertensive Emergency treatment key
- Alpha-methyldopa reveals points:
papilledema. There - Emergency/Crisis is >180/110 with
are no other end organ damage and is treated with IV
1067. A 65 y/o man with a A 65 y/o man with a PMHx of uncontrolled
abnormalities. He is meds (stroke, MI, papilledema, flash
PMHx of hypertension presents to the ER c/o AMS,
diagnosed with pulmonary edema, headache, chest pain,
uncontrolled blurry vision, headache and dyspnea.
hypertensive etc...)
hypertension Physical exam reveals a BP of 200/140
emergency. What is - In reality, there are many acceptable
presents to the ER mmHg and papilledema. There are no
the best initial choices (enalapril, CCBs, esmolol,
c/o AMS, blurry other abnormalities. What is the most
treatment? hydralazine in addition, for example)
vision, headache likely diagnosis?
[...] - So long as the drug is given IV it's
and dyspnea. Hypertensive Emergency/Crisis
fine; the choice of drug is not as important
Physical exam
as administering enough of it to control
reveals a BP of
BP
200/140 mmHg and Hypertensive Urgency vs. Emergency
- The goal is to decrease MAP by 25%
papilledema. There key points:
within 2-6 hrs of admission and to achieve
are no other - Urgency is > 180/110 without end
normal MAP by 24 hrs
abnormalities. What organ damage and is treated with PO
- You cannot lower BP to normal right
is the most likely meds
away as it may provoke a stroke
diagnosis? - Emergency/Crisis is >180/110 with
[...] end organ damage and is treated with IV
meds (stroke, MI, papilledema, flash 1069. A pt has an LDL A pt has an LDL level of 200. Should he
pulmonary edema, headache, chest pain, level of 200. Should be on a high-intensity statin?
etc...) he be on a Yes
-- In emergency, the goal is to decrease high-intensity statin?
MAP by 25% within 2-6 hrs of admission [...]
and to achieve normal MAP by 24 hrs The age range for groups 3-4 is 40-75 y/o.
-- In emergency, you cannot lower BP to Having ≥ 2 risk factors is considered high
normal right away as it may provoke a risk.
stroke
1070. A pt has active CAD. A pt has active CAD. Should he be on a

Should he be on a high-intensity statin?
high-intensity statin? Yes
[...] The age range for groups 3-4 is 40-75 y/o.
Having ≥ 2 risk factors is considered high
risk.
159 of 340
1071. A pt has carotid A pt has carotid stenosis. Should he be on 1075. A 60 y/o pt has an A 60 y/o pt has an LDL level of 135. His
stenosis. Should he a high-intensity statin? LDL level of 135. His PMHx is significant for migraines and
be on a Yes PMHx is significant hypertension. His SHx is significant for 1
high-intensity statin? The age range for groups 3-4 is 40-75 y/o. for migraines and ppd smoking. Should he be on a
[...] Having ≥ 2 risk factors is considered high hypertension. His high-intensity statin?
risk. SHx is significant for Yes
1 ppd smoking.
Should he be on a
high-intensity statin? The age range for groups 3-4 is 40-75 y/o.
[...] Having ≥ 2 risk factors is considered high
1072. A pt suffers from a A pt suffers from a stroke. Should she be
risk.
stroke. Should she started on a high-intensity statin?
be started on a Yes
high-intensity statin?
[...]
The age range for groups 3-4 is 40-75 y/o. 1076. A 60 y/o pt w/ T2DM A 60 y/o pt w/ T2DM comes to the clinic
Having ≥ 2 risk factors is considered high comes to the clinic for a check-up. Recent labwork revealed
risk. for a check-up. that his LDL level is 105. A high intensity
Recent labwork statin is going to be added to his regimen.
revealed that his Which antihyperlipidemics are considered
LDL level is 105. A to be high-intensity (and at what dosage)?
high intensity statin Atorvastatin (40 or 80 mg);
1073. A pt has an LDL A pt has an LDL level of 65. Should he be
is going to be added rosuvastatin (20 or 40 mg)
level of 65. Should on a high-intensity statin?
to his regimen.
he be on a No
Which
high-intensity statin?
antihyperlipidemics The age range for groups 3-4 is 40-75 y/o.
[...]
are considered to be Having ≥ 2 risk factors is considered high
The age range for groups 3-4 is 40-75 y/o.
high-intensity (and at risk.
Having ≥ 2 risk factors is considered high
what dosage)? Typically the pt is started on a
risk.
[...] moderate-intensity dose and is slowly
increased to high.
If there is concomitant liver or renal
disease, start at and stay at a
1074. A 50 y/o pt has an A 50 y/o pt has an LDL level of 120. His moderate-intensity statin.
LDL level of 120. His PMHx is significant for migraines, T2DM,
PMHx is significant and asthma. Should he be on a
for migraines, T2DM, high-intensity statin?
and asthma. Should Yes
he be on a The age range for groups 3-4 is 40-75 y/o.
high-intensity statin? Having ≥ 2 risk factors is considered high
[...] risk.
160 of 340
1077. A pt is started on a A pt is started on a high-intensity statin 1080. A pt taking niacin for A pt taking niacin for hyperlipidemia
high-intensity statin (atorvastatin, 40 mg) and develops hyperlipidemia comes into the clinic c/o of flushing. You
(atorvastatin, 40 mg) statin-induced myositis. What is the most comes into the clinic conclude that this is a side effect of niacin.
and develops appropriate initial step in management? c/o of flushing. You What is the most appropriate therapy?
statin-induced Stop the statin; then restart it at a conclude that this is ASA prophylaxis
myositis. What is the lower dose when s/s resolve; this is a side effect of
most appropriate also true for statin-induced hepatitis niacin. What is the
initial step in most appropriate No need to d/c the niacin.
management? therapy?
[...] Statin Maintenance key points: [...]
- Acquiring baseline levels of lipids,
HbA1c, CK, and liver enzymes is required
1081. A pt presents to the A pt presents to the clinic stating that he
prior to starting any patient on a statin
clinic stating that he passed out at home after a coughing
- Lipids are measured annually
passed out at home episode triggered by dust. He adds that
- CK and liver enzymes are only ever
after a coughing prior to passing out, he felt nauseous,
re-checked if the patient has s/s of
episode triggered by lightheaded and sweaty. What type of
statin-toxicity; it is also prudent to order a
dust. He adds that syncope is the most likely diagnosis?
UA if you suspect rhabdomyolysis
prior to passing out, Vasovagal syncope
--- Statin-induced myositis present w/
he felt nauseous, Vasovagal Syncope key points:
soreness, weakness, or muscle pain
lightheaded and - a result of vagus nerve overstimulation
--- Statin-induced hepatitis presents w/
sweaty. What type of which leads to bradycardia and
RUQ pain and/or jaundice
syncope is the most hypotension, which then causes enough
likely diagnosis? cerebral hypoperfusion to cause syncope
1078. What is the best What is the best initial therapy for [...] - lots of things can cause it (like JD
initial therapy for hyperlipidemia? whenever he has to poop)
hyperlipidemia? Lifestyle modification (diet, exercise) - situational and reproducible
[...] - very commonly associated with a
prodrome
If it's an option, it's most likely the right - BBs to Tx
answer. --- But don't BBs also cause
bradycardia/hypotension? Yes, but in this
case they work by blocking/mitigating the
1079. A pt with A pt with hyperlipidemia cannot take a
initial surge in vagal activity
hyperlipidemia statin and has failed with lifestyle
cannot take a statin modifications. Which class of
and has failed with antihyperlipidemics is considered second
lifestyle line after statins?
modifications. Which Fibrates
class of Similar side-effect profile as statins and
antihyperlipidemics effective at increasing HDL.
is considered
second line after
statins?
[...]
161 of 340
1082. A pt presents to the A pt presents to the clinic after he passed 1084. A pt presents to the A pt presents to the clinic after passing
clinic after he out in his home. He states that he stood clinic after passing out at home. H&P rules out vasovagal
passed out in his up and suddenly passed out. He denies out at home. H&P syncope and orthostatic hypotension.
home. He states that feeling any symptoms prior to the event. rules out vasovagal Echocardiogram rules out mechanical
he stood up and Physical exam is positive for orthostatics. syncope and heart disease. And an implantable loop
suddenly passed What type of syncope is the most likely orthostatic recorder rules out arrhythmia. You
out. He denies diagnosis? hypotension. suspect vertebrobasilar insufficiency.
feeling any Orthostatic Hypotension Echocardiogram What is the diagnostic test of choice?
symptoms prior to Orthostatics: rules out mechanical CT Angio
the event. Physical - decrease in systolic BP of ≥ 20 mmHg heart disease. And
exam is positive for - decrease in diastolic BP of ≥ 10 mmHg an implantable loop
orthostatics. What - increase in HR of ≥ 10 bpm recorder rules out Neurogenic Syncope key points:
type of syncope is Orthostatic Hypotension key points: arrhythmia. You - Rule out other (more likely; or mimicker)
the most likely - Dx is easy: perform orthostatic vitals suspect Dx first
diagnosis? - If positive, rehydrate first. If it resolves, vertebrobasilar --- seizure may involve a post-ictal state,
[...] you know it was volume depletion. If not, insufficiency. What tongue biting, bowel/bladder incontinence
consider causes of autonomic dysfunction is the diagnostic test --- stroke involves focal deficits; order
of choice? CT/MRI
[...] --- narcolepsy involves the pt feeling
1083. A pt comes to your A pt comes to your clinic after passing
refreshed after waking up
clinic after passing out. H&P rule out orthostatic hypotension
- vertebrobasilar insufficiency is pretty
out. H&P rule out and vasovagal syncope. You suspect that
rare, but is typically the only neuro
orthostatic it may be a mechanical cardiac defect.
diagnosis that involves true syncope
hypotension and What is the best diagnostic test?
vasovagal syncope. Echocardiogram
You suspect that it Mechanical Cardiac Syncope key 1085. ACLS protocol is ACLS protocol is started on a patient.
may be a points: started on a patient. EKG reveals tachycardia with a QRS
mechanical cardiac - typically sudden, hence no prodrome EKG reveals complex width of < 0.12 msec. What
defect. What is the - you may or may not hear a murmur from tachycardia with a anatomical location of the heart is the
best diagnostic test? the lesion QRS complex width likely source of this rhythm?
[...] - confirm with ECHO and treat by fixing of < 0.12 msec. Atrium
the lesion What anatomical
location of the heart
is the likely source of ACLS General key points:
this rhythm? 1. What rhythm are they in? Use the three
[...] points below to narrow it down
--- > 100 bpm is tachycardia; < 60 bpm is
bradycardia
--- QRS > 0.12 msec is a ventricular
rhythm; < 0.12 is atrial
--- regular vs. irregular
2. What type of intervention is needed?
--- If there are no s/s, pursue routine care
(IVF, O2 and telemetry)
--- If there are s/s, determine if the pt is
stable or unstable
--- Unstable warrants electrical
intervention and typically involves CP,
AMS, SOB, or systolic BP < 90
--- Stable warrants pharmacotherapy
and typically involves s/s that are not
considered unstable
162 of 340
1088. ACLS protocol is ACLS protocol is started on a pt. EKG

1086. ACLS protocol is ACLS protocol is started on a pt. EKG started on a pt. EKG reveals bradycardia. The pt feels weak
started on a pt. EKG reveals narrow-complex SVT. The pt reveals but has no other s/s. BP is 110/70 mmHg.
reveals feels weak but has no other s/s. BP is bradycardia. The pt What is the first choice pharmacotherapy
narrow-complex 110/70 mmHg. What is the first choice feels weak but has in this case?
SVT. The pt feels pharmacotherapy in this case? no other s/s. BP is Atropine (stable with a slow rhythm)
weak but has no Adenosine (stable with a narrow 110/70 mmHg. What
other s/s. BP is complex rhythm) is the first choice
110/70 mmHg. What ACLS Intervention key points: pharmacotherapy in ACLS Intervention key points:
is the first choice - If unstable, use electricity this case? - If unstable, use electricity
pharmacotherapy in - If stable, use pharmacotherapy; there [...] - If stable, use pharmacotherapy; there
this case? are typically 4 options in general: are typically 4 options in general:
[...] --- if the rhythm is fast and narrow, use --- if the rhythm is fast and narrow, use
adenosine adenosine
--- if the rhythm is fast and wide, use --- if the rhythm is fast and wide, use
amiodarone amiodarone
--- if the rhythm is slow, use atropine --- if the rhythm is slow, use atropine
--- if the rhythm is AFib or AFlutter, rate --- if the rhythm is AFib or AFlutter, rate
control = rhythm control (use BBs and control = rhythm control (use BBs and
CCBs; or digoxin and amiodarone if CCBs; or digoxin and amiodarone if
there is CHF) there is CHF)
- Remember, wide is QRS > 0.12 msec - Remember, wide is QRS > 0.12 msec
1087. ACLS protocol is ACLS protocol is started on a pt. EKG 1089. ACLS protocol is ACLS protocol is started on a pt. EKG
started on a pt. EKG reveals wide-complex tachycardia. The started on a pt. EKG reveals atrial fibrillation. The pt feels
reveals pt feels weak but has no other s/s. BP is reveals atrial weak but has no other s/s. BP is 110/70
wide-complex 110/70 mmHg. What is the first choice fibrillation. The pt mmHg. His PMHx is significant for
tachycardia. The pt pharmacotherapy in this case? feels weak but has migraines and CHF only. What is/are the
feels weak but has Amiodarone (stable with a wide no other s/s. BP is first choice pharmacotherapy in this case?
no other s/s. BP is complex rhythm) 110/70 mmHg. His Digoxin, amiodarone (rate control with
110/70 mmHg. What PMHx is significant presence of CHF)
is the first choice for migraines and
pharmacotherapy in ACLS Intervention key points: CHF only. What
this case? - If unstable, use electricity is/are the first choice ACLS Intervention key points:
[...] - If stable, use pharmacotherapy; there pharmacotherapy in - If unstable, use electricity
are typically 4 options in general: this case? - If stable, use pharmacotherapy; there
--- if the rhythm is fast and narrow, use [...] are typically 4 options in general:
adenosine --- if the rhythm is fast and narrow, use
--- if the rhythm is fast and wide, use adenosine
amiodarone --- if the rhythm is fast and wide, use
--- if the rhythm is slow, use atropine amiodarone
--- if the rhythm is AFib or AFlutter, rate --- if the rhythm is slow, use atropine
control = rhythm control (use BBs and --- if the rhythm is AFib or AFlutter, rate
CCBs; or digoxin and amiodarone if control = rhythm control (use BBs and
there is CHF) CCBs; or digoxin and amiodarone if
- Remember, wide is QRS > 0.12 msec there is CHF)
- Remember, wide is QRS > 0.12 msec
163 of 340
1090. ACLS protocol is ACLS protocol is started on a pt. EKG 1093. ACLS protocol is ACLS protocol is started on a pt. EKG
started on a pt. EKG reveals the rhythm below. The pt is started on a pt. EKG reveals the rhythm below. The pt is stable.
reveals the rhythm deemed stable. What is the most reveals the rhythm What is the most appropriate initial
below. The pt is appropriate initial pharmacological below. The pt is pharmacological intervention?
deemed stable. intervention? stable. What is the Atropine
What is the most Adenosine (this is SVT) most appropriate
appropriate initial initial
pharmacological pharmacological This is sinus brady.
intervention? SVT key points: intervention?
[...] - an aberrante re-entry rhythm from the [...]
atria
- distinguished from sinus tachy by
resting HR > 150 bpm and no p-waves
started on a pt. EKG reveals the rhythm shown below. The pt is
- give adenosine
reveals the rhythm stable. What is the most appropriate initial
shown below. The pt intervention?
1091. ACLS protocol is ACLS protocol is started on a pt. EKG is stable. What is the Pace only (this is 3rd degree AV block)
started on a pt. EKG reveals the rhythm shown below. The pt is most appropriate
reveals the rhythm deemed stable and has a pulse. What initial intervention?
shown below. The pt pharmacological intervention is the most [...] AV Block and ACLS key points:
is deemed stable approrpriate choice? - the most simple slow rhythm is sinus
and has a pulse. Amiodarone brady, give atropine
What - 1st degree AV block
pharmacological --- A regularly prolonged PR interval
intervention is the VTach key points: that does not change; there are no
most approrpriate - wide complex without p-waves (only dropped beats; give atropine
choice? QRS, as it originates from the ventricles) - 2nd degree AV block, Mobitz type I
[...] - responds to amiodarone or lidocaine --- involves a constantly prolonging PR
(older, cheaper, but less effective) interval until a dropped QRS; give
atropine
--- involves a constant and normal PR
started on a pt. EKG reveals the rhythm shown below. The pt is
interval that does not prolong and
reveals the rhythm deemed stable. What is the most
randomly dropped QRS complexes
shown below. The pt appropriate initial pharmacological
--- atropine is no longer recommended
is deemed stable. intervention to correct this rhythm?
as the pt can convert into total AV
What is the most BBs, CCBs (for rate control)
block
appropriate initial If CHF is present, BBs and CCBs are
- 3rd degree (total) AV block
pharmacological not recommended. Use
intervention to Digoxin/Amiodarone for rate control
with no regular intervals between P
correct this rhythm? instead.
waves and QRS complexes
[...]
--- although controversial, it's
recommended to avoid atropine and
pace only
164 of 340
1095. ACLS protocl is ACLS protocl is started on a pt. EKG 1098. A pt presents c/o of A pt presents c/o of back pain. He states
started on a pt. EKG reveals an idioventricular rhythm. The back pain. He states his pain is an ache and started when he
reveals an pt is stable. What is the most appropriate his pain is an ache lifted a heavy box. His pain is symmetric,
idioventricular initial intervention? and started when he in a belt-like distribution. Physical exam
rhythm. The pt is Pace only lifted a heavy box. does not reveal any neurological deficits.
stable. What is the His pain is What is the most appropriate initial step in
most appropriate symmetric, in a management?
initial intervention? belt-like NSAIDs, stretching, and activity as
[...] distribution. tolerated (this is MSK back pain)
Idioventricular rhythm Physical exam does - If sxs do not improve after 4-6 weeks,
- a rhythm without any atrial activity at all; not reveal any get an XR/MRI to investigate.
only the ventricles are conducting and neurological deficits. - Never tell the pt to get bed rest, this will
contracting What is the most exacerbate any MSK back pain;
- resembles 3rd degree AV block (as it is appropriate initial stretching and exercise as tolerated is
a slow rhythm) but will lack any p-waves step in recommended
- As the rhythm is purely ventricular, management?
atropine will not work [...]
- Pace only
1099. A pt presents c/o of A pt presents c/o of back pain. He states

1096. A pt c/o back pain. A pt c/o back pain. He adds that he has back pain. He states that he has shooting pain down his right
He adds that he has been having bladder incontinence and that he has leg that is exacerbated by hip flexion,
been having bladder bilateral lower extremity weakness as shooting pain down coughing and movement. Physical exam
incontinence and well. What is the most appropriate first his right leg that is reveals weak right-sided dorsiflexion
bilateral lower step in management? exacerbated by hip and big toe extension. What is the most
extremity Dexamethasone (this pt has alarm s/s flexion, coughing likely Dx?
weakness as well. of cord compression) and movement. Disk herniation (or osteophyte if older)
What is the most While imaging will be necessary to Physical exam
appropriate first step accurately dx this pt's supposed cord reveals weak
in management? compression, giving steroids is fast right-sided
[...] and can prevent permanent paralysis. dorsiflexion and
Cord Compression key points: big toe extension.
- a neurological emergency What is the most
- Dexamethasone can mitigate and likely Dx?
shorten the duration of symptoms and [...]
improve outcome.
- first do an XR to look for something
obvious
- if negative, order MRI
- any interventions that follow will be
disease specific
1097. What is the most What is the most common cause of back
common cause of pain?
back pain? Musculoskeletal (i.e. muscle strain)
[...]
165 of 340
1100. A pt presents c/o of A pt presents c/o of back pain. He states 1102. A pt presents c/o of A pt presents c/o of back pain. He states
back pain. He states that he has shooting pain down his right back pain. He states that he has shooting pain down his right
that he has leg that is exacerbated by hip flexion, that he has leg that is exacerbated by hip flexion,
shooting pain down coughing and movement. Physical exam shooting pain down coughing and movement. Physical exam
his right leg that is reveals weak right-sided dorsiflexion his right leg that is reveals weak right-sided dorsiflexion
exacerbated by hip and big toe extension. You suspect disk exacerbated by hip and big toe extension. You suspect disk
flexion, coughing herniation. What is the best initial flexion, coughing herniation. What is the best therapeutic
and movement. diagnostic test? and movement. intervention at the 6 month mark of this
Physical exam XR Physical exam pt's condition?
reveals weak reveals weak Neurosurgery
right-sided right-sided
dorsiflexion and dorsiflexion and
big toe extension. big toe extension.
You suspect disk You suspect disk
herniation. What is herniation. What is
the best initial the best therapeutic
diagnostic test? intervention at the 6
[...] month mark of this
pt's condition?
[...]
1101. A pt presents c/o of A pt presents c/o of back pain. He states
back pain. He states that he has shooting pain down his right
that he has leg that is exacerbated by hip flexion, 1103. An elderly pt An elderly pt presents c/o of back pain.
shooting pain down coughing and movement. Physical exam presents c/o of back He states that he has shooting pain
his right leg that is reveals weak right-sided dorsiflexion pain. He states that down his right leg that is exacerbated by
exacerbated by hip and big toe extension. You suspect disk he has shooting hip flexion, coughing and movement.
flexion, coughing herniation. What is the best diagnostic pain down his right Physical exam reveals weak right-sided
and movement. test? leg that is dorsiflexion and big toe extension. You
Physical exam MRI exacerbated by hip suspect osteophytes. What is the best
reveals weak flexion, coughing therapeutic intervention?
right-sided and movement. Neurosurgery
dorsiflexion and Physical exam Osteophytes present very similarly to disk
big toe extension. reveals weak herniation. The difference is that it's
You suspect disk right-sided typically in older pts and there is often no
herniation. What is dorsiflexion and triggering event. Also, surgery is better
the best diagnostic big toe extension. than waiting.
test? You suspect
[...] osteophytes. What is
the best therapeutic
intervention?
[...]
166 of 340
1104. An elderly pt An elderly pt presents c/o back pain that 1106. An elderly pt An elderly pt presents c/o back pain. He
presents c/o back began after she slipped and fell on her presents c/o back states that the pain shoots down his right
pain that began after butt. Her PMHx is significant for pain. He states that leg, but is alleviated when he is
she slipped and fell hysterectomy and osteoporosis. Physical the pain shoots hunched over forward. You suspect
on her butt. Her exam reveals point tenderness at the down his right leg, spinal stenosis. What is the best
PMHx is significant lumbar spine and vertebral step-off. but is alleviated diagnostic test?
for hysterectomy and You suspect a compression fracture. when he is MRI
osteoporosis. What is the best initial diagnostic test? hunched over
Physical exam XR forward. You
reveals point suspect spinal
tenderness at the stenosis. What is the
lumbar spine and best diagnostic test?
vertebral step-off. [...]
You suspect a
compression
1107. CNS function can be CNS function can be separated into
fracture. What is the
separated into cerebral and brainstem function. When it
best initial diagnostic
cerebral and comes to the levels of unconsciousness,
test?
brainstem function. which branch of CNS function is typically
[...]
When it comes to lost first?
the levels of Cerebral
1105. An elderly pt An elderly pt presents c/o back pain that unconsciousness, - Cerebral function is considered the
presents c/o back began after she slipped and fell on her which branch of most sophisticated and what makes us
pain that began after butt. Her PMHx is significant for CNS function is human; however, since it is the most
she slipped and fell hysterectomy and osteoporosis. Physical typically lost first? evolutionarily new, it is the least required
on her butt. Her exam reveals point tenderness at the [...] for survival; as such, it is sacrificed first
PMHx is significant lumbar spine and vertebral step-off. whenever there is a metabolic/toxic insult
for hysterectomy and You suspect a compression fracture. (this can cause coma)
osteoporosis. What is the best diagnostic test? - Brainstem function is evolutionarily old
Physical exam MRI and holds neurons/pathways vital for
reveals point survival; many actions can persist despite
tenderness at the unconsciousness (breathing, sleep/wake,
lumbar spine and heart beat, etc)
vertebral step-off. - Brain death is seen when both
You suspect a brainstem and cerebral function is lost;
compression heart function is the only thing keeping
fracture. What is the this person from total death
[...]
167 of 340
1108. A pt is in a state of A pt is in a state of unconsciousness. 1110. A pt codes and CPR A pt codes and CPR is started. After 20
unconsciousness. EEG reveals depressed cerebral is started. After 20 minutes, his pulse returns but the pt is in a
EEG reveals function and he does not exhibit any minutes, his pulse state of unconsciousness. EEG reveals
depressed cerebral response to internal or external stimuli. returns but the pt is absent cerebral function. Exam reveals
function and he You suspect coma, as brainstem function in a state of a lack of brainstem function and no
does not exhibit any is present. What is part of the "coma unconsciousness. respiratory drive. Caloric testing is
response to internal cocktail"? EEG reveals absent negative and there is no corneal reflex.
or external stimuli. Coma cocktail = thiamine, D50, oxygen, cerebral function. What is the diagnosis?
You suspect coma, naloxone Exam reveals a lack Brain death
as brainstem Pretty much anything can cause coma. of brainstem There's no coming back from this and
function is present. Full recovery from coma is possible. function and no total death a step away. Withdrawal of
What is part of the respiratory drive. care is recommended at this point.
"coma cocktail"? Caloric testing is
[...] negative and there
is no corneal reflex.
What is the
1109. When gauging a pt's When gauging a pt's state of
diagnosis?
state of unconsciousness, it is important to test
[...]
unconsciousness, it brainstem reflexes. What are the 3 main
is important to test tests/maneuvers we use to gauge
brainstem reflexes. brainstem function? 1111. A pt presents in a A pt presents in a suspected state of
What are the 3 main Corneal reflex; Caloric testing suspected state of unconsciousness. MRI reveals a pontine
tests/maneuvers we (typically cold water); VOR testing (i.e. unconsciousness. stroke. EEG reveals aroused cerebral
use to gauge Doll's Eyes) MRI reveals a function. Exam reveals intact brainstem
brainstem function? pontine stroke. function, but a lack of withdrawal to
[...] EEG reveals painful stimuli. Vitals are WNL. The pt
Remember this from the neuro block, aroused cerebral appears to be communicating with eye
brah?!?! function. Exam movements. What is the likely diagnosis?
Brainstem reflexes key points: reveals intact Locked-in syndrome
1. Corneal reflex (pretty self explanatory) brainstem function, There is no recovery from this, so it
2. Caloric testing (typically with cold but a lack of better not be iatrogenic, homey.
water) withdrawal to painful
--- cold water = slow phase towards stimuli. Vitals are
same side; fast response is nystagmus WNL. The pt
towards opposite side appears to be
--- warm water = vice versa = slow phase communicating with
towards opposite side; fast response eye movements.
towards same side What is the likely
--- remember the mnemonic COWS or c = diagnosis?
cold = contralateral fast phase [...]
3. VOR testing (i.e. Doll's Eyes)
--- negative VOR = negative Doll's Eye's
= eyes fixed upon head rotation =
brainstem lesion
--- positive VOR = positive Doll's Eye's
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1112. What is the most What is the most important and first thing 1114. A pt presents c/o of A pt presents c/o of chronic,
important and first to ask a pt that complains of dizziness? chronic, progressive, and persistent dizziness.
thing to ask a pt that What do you mean? (i.e. determine progressive, and History is positive for vertigo and exam
complains of between presyncope and vertigo) persistent reveals focal neurological deficits. What
dizziness? - Do you feel lightheaded or like you're dizziness. History is is best initial diagnostic test?
[...] going to pass out? If yes, it's presyncope positive for vertigo MRI
- Do you have SOB or CP? If yes, likely and exam reveals Posterior Fossa Lesion key points:
presyncope focal neurological - FNDs with vertigo is pathognomonic for
- Does it feel like the room is spinning? If deficits. What is a posterior fossa lesion; especially if there
yes, likely vertigo best initial diagnostic are neighbourhood signs (i.e. ataxia)
- Do you feel unsteady on your feet? If test? - can be due to many things but typically
yes, likely vertigo [...] its a tumour or demyelination; rarer
causes include vertebrobasilar
insufficiency, stroke, abscess, seizure
and chronic migraine
1113. A pt c/o of dizziness. A pt c/o of dizziness. Through careful
- Get an MRI first then an MRA
Through careful questioning, you discern that it is truly
questioning, you vertigo. What is the next step in work up?
discern that it is truly Differentiate between central and
vertigo. What is the peipheral
next step in work Types of Vertigo key points:
up? - Central vertigo is typically a structural 1115. A pt c/o dizziness A pt c/o dizziness that manifests upon
[...] lesion and requires an MRI of the that manifests upon head movement. He states that the
posterior fossa to confirm; typically head movement. sensation lasts for < 1 min. The
chronic and progressive and involves He states that the Dix-Hallpike maneuver yields rotary
cranial nerve deficits due to the sensation lasts for < nystagmus during physical examination.
tendency to be located at the poster 1 min. The What type of peripheral vertigo is the
fossa; can also involve neighbourhood Dix-Hallpike likely Dx?
signs such as ataxia maneuver yields Benign Paroxysmal Positional Vertigo
- Peripheral vertigo is typically an rotary nystagmus (BPPV)
ear/vestibular apparatus issue and does during physical
not require an MRI; typically acute with examination. What
associated ear symptoms (loss of type of peripheral
hearing, tinnitus, ear pain, etc); use the vertigo is the likely
duration of vertigo to differentiate Dx?
between types [...]
1116. A pt c/o dizziness A pt c/o dizziness that manifests upon

that manifests upon head movement. He states that the
head movement. sensation lasts for < 1 min. The
He states that the Dix-Hallpike maneuver yields rotary
sensation lasts for < nystagmus during physical examination.
1 min. The You suspect BPPV. What is the first-line
Dix-Hallpike treatment?
maneuver yields Epley Maneuver (which repositions the
rotary nystagmus displaces otolith)
during physical
examination. You
suspect BPPV. What
is the first-line
treatment?
[...]
169 of 340
1119. A pt c/o of dizziness A pt c/o of dizziness that started 2 days

1117. A pt c/o of dizziness. A pt c/o of dizziness. History reveals that that started 2 days ago. He states that he had a sore throat 2
History reveals that it it is true vertigo. The pt adds that he has ago. He states that weeks ago and denies any head trauma
is true vertigo. The also suffered hearing loss, ear fullness he had a sore throat or new medications. He adds that
pt adds that he has and tinnitus, and that his symptoms 2 weeks ago and alongside his vertigo, he feels nauseous
also suffered occur repetitively. He also adds that his denies any head and has had hearing disturbances. You
hearing loss, ear vertigo lasts ~30 min. What is the most trauma or new suspect labyrinthitis. Which class of drugs
fullness and likely Dx? medications. He can you give now to mitigate the duration
tinnitus, and that his Meniere's Disease adds that alongside and severity of labyrinthitis?
symptoms occur Meniere's Disease key points: his vertigo, he feels Corticosteroids (if given within 72 hrs
repetitively. He also - idiopathic nauseous and has of onset)
adds that his vertigo - vertigo lasts much longer than BPPV had hearing
lasts ~30 min. What (>30 min vs. < 1 min) disturbances. You
is the most likely - alongside diuretics and salt-restriction; suspect labyrinthitis.
Dx? treat symptoms with meclezine (Antivert) Which class of drugs
[...] can you give now to
mitigate the duration
and severity of
labyrinthitis?
1118. A pt c/o of dizziness. A pt c/o of dizziness. History reveals that [...]
History reveals that it it is true vertigo. The pt adds that he has
is true vertigo. The also suffered hearing loss, ear fullness 1120. A pt c/o of dizziness A pt c/o of dizziness that started 2 days
pt adds that he has and tinnitus, and that his symptoms that started 2 days ago. He states that he had a sore throat 2
also suffered occur repetitively. He also adds that his ago. He states that weeks ago and denies any head trauma
hearing loss, ear vertigo lasts ~30 min. She is Dx with he had a sore throat or new medications. He adds that
fullness and meniere's disease. What is the treatment 2 weeks ago and alongside his vertigo, he feels nauseous
tinnitus, and that his if so? denies any head and has had hearing disturbances. All
symptoms occur Diuretics; salt restriction; meclezine trauma or new common causes have been ruled out.
repetitively. He also (Antivert) for symptom control medications. He What is the most likely diagnosis?
adds that his vertigo Meniere's Disease key points: adds that alongside Labyrinthitis or vestibular neuritis
lasts ~30 min. She - idiopathic his vertigo, he feels
is Dx with meniere's - vertigo lasts much longer than BPPV nauseous and has
disease. What is the (>30 min vs. < 1 min) had hearing
treatment if so? - alongside diuretics and salt-restriction; disturbances. All
[...] treat symptoms with meclezine (Antivert) common causes
have been ruled out.
What is the most
likely diagnosis?
[...]
1121. Inhaled Inhaled corticosteroids are considered the

corticosteroids are 2nd step in managing asthma (if
considered the 2nd indicated). What are the notable side
step in managing effects?
asthma (if indicated). Dysphonia; Oral candidiasis
What are the notable
side effects?
[...]
170 of 340
1122. Leukotriene Leukotriene modifiers are alternative 1126. What is the best What is the best initial test for suspected
modifiers are long-term agents used to control asthma, initial test for COPD?
alternative long-term especially in patients with concomittent suspected COPD? CXR
agents used to atopic conditions. What vasculitis is [...]
control asthma, zafirlukast associated with?
especially in patients Churg-Strauss Syndrome Shows increased AP diameter, air
with concomittent trapping, and flattened diaphragms.
atopic conditions.
What vasculitis is It is also hepatotoxic
1127. What changes on a What changes on a CBC may be a result
zafirlukast
CBC may be a result of COPD?
associated with?
of COPD? Increased hematocrit 2/2 chronic
[...]
[...] hypoxia
1123. Which monoclonal Which monoclonal antibody can be added

1128. What is the What is the indication for beginning
antibody can be to asthma treatment regimens in pt's that
indication for chronic home O2 therapy in COPD pts
added to asthma have increased IgE levels associated
beginning chronic that have concomittant right-sided HF?
treatment regimens with their asthma?
home O2 therapy in PaO2 < 60 on ABG or SpO2 < 90% on
in pt's that have Omalizumab
COPD pts that have pulse-ox
increased IgE levels
concomittant The degree of mortality benefit is directly
associated with their
right-sided HF? proportional to the number of hours spent
asthma? It binds to IgE
[...] on oxygen.
[...]
However, oxygen therapy in COPD is
tricky:
1124. Prednisone (PO) is Prednisone (PO) is considered a last - COPDers are chronic CO2 retainers;
considered a last resort medication in the control of asthma as a result, these pt's lose the
resort medication in when all other agents have failed. What hypercapneic drive to breathing and rely
the control of asthma are some of the notable side effects of on the hypoxic drive to breathe
when all other systemic corticosteroids? - If we give too much O2, they may lose
agents have failed. See below respiratory drive (although this theory of
What are some of hypoxic drive is controversial)
the notable side - Bottom line, give enough oxygen to
effects of systemic Notable harsh ADE's of systemic get SpO2 > 90%
corticosteroids? corticosteroids: - However, if a COPD pt ever needs
[...] - Osteoporosis oxygen (e.g. ACS), give it to them as
- Cataracts you're not going to affect their respiratory
- Adrenal suppression drive in the short term.
- Fat redistribution
- Hyperlipidemia
- Hyperglycemia
- Acne
- Hirsutism (esp in women)
- Thinning of the skin/easy bruising
- Striae
1125. Which 2 vaccines Which 2 vaccines are typically always

are typically always given in asthma patients?
given in asthma Influenza; Pneumococcal
patients?
[...]
171 of 340
1129. A pt presents c/o of A pt presents c/o of recurrent episodes of 1131. A pt presents c/o of A pt presents c/o of recurrent episodes of
recurrent episodes high volume, purulent sputum recurrent episodes high volume, purulent sputum
of high volume, production and cough. He states that of high volume, production and cough. He states that
purulent sputum sometimes hemoptysis, wheezing and purulent sputum sometimes hemoptysis, wheezing and
production and dyspnea occur as well. What is the most production and dyspnea occur as well. You suspect
cough. He states likely diagnosis? cough. He states bronchiectasis. What is the best initial
that sometimes Bronchiectasis that sometimes diagnostic test?
hemoptysis, hemoptysis, CXR
wheezing and wheezing and
dyspnea occur as Bronchiectasis key points: dyspnea occur as
well. What is the - uncommon; esp. since we now have well. You suspect CXR will show dilated, thickened
most likely better control of lung infections (who in bronchiectasis. What bronchi and potentially "tram-tracks",
diagnosis? past lead to weakening of bronchial walls) is the best initial which signify thickening of the bronchi.
[...] - a permanent anatomic abnormality diagnostic test? Bronchiectasis key points:
- mcc is cystic fibrosis (50%); other [...] - uncommon; esp. since we now have
causes include TB, PNA, abscess, ABPA, better control of lung infections (who in
RA past lead to weakening of bronchial walls)
- classic presentation is recurrent - a permanent anatomic abnormality
episodes of high volume purulent - mcc is cystic fibrosis (50%); other
sputum production; causes include TB, PNA, abscess, ABPA,
- hemoptysis can occur RA
- dyspnea and wheezing seen in 75% of - classic presentation is recurrent
cases episodes of high volume purulent
- best initial test is CXR sputum production;
- most accurate/best test is high-res CT - hemoptysis can occur
- dyspnea and wheezing seen in 75% of
cases
- best initial test is CXR
common cause of bronchiectasis?
- most accurate/best test is high-res CT
bronchiectasis? Cystic fibrosis (50% of cases)
[...]
Other causes include:

- TB, PNA, abscess
- tumour
- ABPA
- RA
172 of 340
1132. A pt presents c/o of A pt presents c/o of recurrent episodes of 1134. What is the most What is the most accurate (and first)
recurrent episodes high volume, purulent sputum accurate (and first) diagnostic test for cystic fibrosis?
of high volume, production and cough. He states that diagnostic test for Sweat Chloride (induce via pilocarpine)
purulent sputum sometimes hemoptysis, wheezing and cystic fibrosis?
production and dyspnea occur as well. You suspect [...]
cough. He states bronchiectasis. What is the best Cystic Fibrosis diagnosis key points:
that sometimes diagnostic test? - most accurate is the sweat chloride
hemoptysis, High-res CT (increased > 60 mEq/L is diagnostic)
wheezing and You cannot make this diagnosis without - genotyping is not as accurate as any
dyspnea occur as some sort of lung imaging. Typically the CFTR mutation can cause CF
well. You suspect CT is always done to confirm. CT will - nothing on imaging helps with CF Dx but
bronchiectasis. What show widening of bronchi in multiple can identify associated conditions (such
is the best diagnostic areas. as PNA, PTX, bronchiectasis, scarring,
test? atelectasis, hyperinflation)
[...] Bronchiectasis key points: - ABG can reveal hypoxemia or resp
- uncommon; esp. since we now have acidosis in advanced cases
better control of lung infections (who in - PFTs yield a mixed obstructive and
past lead to weakening of bronchial walls) restrictive pattern (decreased FVC, TLC;
- a permanent anatomic abnormality decreased diffusion for CO)
- mcc is cystic fibrosis (50%); other - sputum Cx is helpful w/ infections
causes include TB, PNA, abscess, ABPA,
RA
1135. In cystic fibrosis, In cystic fibrosis, neutrophils dump a lot of
- classic presentation is recurrent
neutrophils dump a DNA into airway secretions, making
episodes of high volume purulent
lot of DNA into mucous plugs even thicker. Which class
sputum production;
airway secretions, of drugs can be used to breakdown these
- hemoptysis can occur
making mucous DNA deposits?
- dyspnea and wheezing seen in 75% of
plugs even thicker. Recombinant human
cases
Which class of drugs deoxyribonucleases (rhDNase's)
- best initial test is CXR
can be used to
- most accurate/best test is high-res CT
breakdown these
DNA deposits?
1133. What is the What is the treatment for Allergic [...]
treatment for Allergic Bronchopulmonary Aspergillosis (ABPA)?
Bronchopulmonary Oral steroids for severe cases;
1136. What chest CT What chest CT findings are seen in
Aspergillosis itraconazole PO for recurrent episodes
findings are seen in ARDS?
(ABPA)?
ARDS? Air bronchograms
[...]
[...]
Inhaled steroids are not effective in ABPA
They are a sign of dense consolidation

of the lung air space
1137. What pO /FiO ratio What pO2/FiO2 ratio is diagnostic of

2 2
is diagnostic of ARDS?
ARDS? < 300
[...]
FiO2 is expressed as a decimal (21% O2

= 0.21)
pO2 is typically measured via ABG
173 of 340
1138. What is the msot What is the msot commonly identified 1142. What pulmonary What pulmonary pressures are diagnostic
commonly identified cause of obstructive sleep apnea (OSA)? pressures are of pulmonary hypertension?
cause of obstructive Obesity (especially truncal) diagnostic of Systolic > 25 mmHg; diastolic > 8
sleep apnea (OSA)? pulmonary mmHg
[...] hypertension? Pulmonary Hypertension key points:
[...] - if primary, it is idiopathic
- if secondary, the cause is increasing
1139. A pt presents c/o of A pt presents c/o of daytime
pulmonary artery pressure
daytime somnolence and the need to take naps
--- typically a result of hypoxemia, which
somnolence and during the day. He is accompanied by his
causes vasoconstriction of pulmonary
the need to take wife who states that he snores very
vasculature so as to shunt blood away
naps during the day. loudly. When questioned, the pt also
from poorly oxygenated alveoli; in turn this
He is accompanied complains of headache, erectile
only adds to the hypoxemia
by his wife who dysfunction and impaired memory.
- Dx is confirmed by right-heart or
states that he What is the most likely Dx?
Swan-Ganz catheterization; PA
snores very loudly. Obstructive Sleep Apnea
pressure >30/10 mmHg is diagnostic;
When questioned,
EKG and ECHO will show signs of
the pt also
RAH/RVH
complains of OSA key points:
- Tx if secondary is focusing on the
headache, erectile - mcc is obesity
underlying cause
dysfunction and - most accurate test is polysomnography
- Tx if primary are prostacyclin
impaired memory. (sleep study)
analogues (epoprostenol, trepostinil,
What is the most - Tx involves weight loss, CPAP,
iloprost, beraprost), endothelin
likely Dx? avoidance of alcohol/sedatives, oral
antagonists (bosentan, ambrisentan),
[...] appliances to keep tongue out of the way
and/or phosphodiesterase inhibitors
(sildenafil)
accurate test for diagnosing obstructive sleep apnea?
diagnosing Polysomnography (sleep study)
obstructive sleep
apnea?
[...]
1141. What is the What is the treatment for obstructive sleep

treatment for apnea?
obstructive sleep Namely weight loss and CPAP; (see
apnea? below)
[...] OSA key points:
- mcc is obesity
- most accurate test is polysomnography
(sleep study)
- Tx involves weight loss, CPAP,
avoidance of alcohol/sedatives, oral
appliances to keep tongue out of the way
174 of 340
1143. A pt presents w/ A pt presents w/ dyspnea, fatigue and 1144. A pt presents w/ A pt presents w/ dyspnea, fatigue and
dyspnea, fatigue chest pain. Physical exam reveals dyspnea, fatigue chest pain. Physical exam reveals
and chest pain. wide-splitting of S2 with a loud P2 and chest pain. wide-splitting of S2 with a loud P2
Physical exam component. You suspect pulmonary Physical exam component. You suspect pulmonary
reveals hypertension. What is the best initial reveals hypertension. What is the best (most
wide-splitting of S2 diagnostic test? wide-splitting of S2 accurate) diagnostic test?
with a loud P2 CXR; CT with a loud P2 Right heart cath or Swan-Ganz cath
component. You component. You
suspect pulmonary suspect pulmonary
hypertension. What Imaging is the best initial test here and will hypertension. What Pulmonary Hypertension key points:
is the best initial reveal dilation of proximal pulmonary is the best (most - if primary, it is idiopathic
diagnostic test? arteries with narrowing/pruning of accurate) diagnostic - if secondary, the cause is increasing
[...] distal vessels. However, dx cannot be test? pulmonary artery pressure
confirmed until pressures are measured. [...] --- typically a result of hypoxemia, which
Pulmonary Hypertension key points: causes vasoconstriction of pulmonary
- if primary, it is idiopathic vasculature so as to shunt blood away
- if secondary, the cause is increasing from poorly oxygenated alveoli; in turn this
pulmonary artery pressure only adds to the hypoxemia
--- typically a result of hypoxemia, which - Dx is confirmed by right-heart or
causes vasoconstriction of pulmonary Swan-Ganz catheterization; PA
vasculature so as to shunt blood away pressure >30/10 mmHg is diagnostic;
from poorly oxygenated alveoli; in turn this EKG and ECHO will show signs of
only adds to the hypoxemia RAH/RVH
- Dx is confirmed by right-heart or - Tx if secondary is focusing on the
Swan-Ganz catheterization; PA underlying cause
pressure >30/10 mmHg is diagnostic; - Tx if primary are prostacyclin
EKG and ECHO will show signs of analogues (epoprostenol, trepostinil,
RAH/RVH iloprost, beraprost), endothelin
- Tx if secondary is focusing on the antagonists (bosentan, ambrisentan),
underlying cause and/or phosphodiesterase inhibitors
- Tx if primary are prostacyclin (sildenafil)
1145. What EKG changes What EKG changes can be seen in
can be seen in pulmonary hypertension?
pulmonary RAD; RAH; RVH
(sildenafil)
hypertension?
[...]
Same with an ECHO.
175 of 340
1146. A pt presents w/ A pt presents w/ dyspnea, fatigue and 1149. A young, AA, A young, AA, female pt presents c/o of
dyspnea, fatigue chest pain. Physical exam reveals female pt presents SOB on exertion. She is otherwise
and chest pain. wide-splitting of S2 with a loud P2 c/o of SOB on healthy and has no PMHx. Physical exam
Physical exam component. A right-heart catheterization exertion. She is reveals erythema nodosum,
reveals reveals a pulmonary artery pressure of otherwise healthy lymphadenopathy and fine rales on
wide-splitting of S2 30/10 mmHg. He is diagnosed with and has no PMHx. lung auscultation. CXR reveals hilar
with a loud P2 pulmonary hypertension. What drug Physical exam adenopathy. What is the most likely Dx?
component. A classes can be used in treatment? reveals erythema Sarcoidosis
right-heart Prostacyclin analogues; Endothelin nodosum,
catheterization antagonists; Phosphodiesterase lymphadenopathy
reveals a pulmonary inhibitors and fine rales on Sarcoidosis key points:
artery pressure of Pulmonary Hypertension key points: lung auscultation. - common in young, AA, females
30/10 mmHg. He is - if primary, it is idiopathic CXR reveals hilar - presents as SOBOE with occasional fine
diagnosed with - if secondary, the cause is increasing adenopathy. What rales on exam; no wheezing
pulmonary pulmonary artery pressure is the most likely - can be associated with erythema
hypertension. What --- typically a result of hypoxemia, which Dx? nodosum and lymphadenopathy; if
drug classes can be causes vasoconstriction of pulmonary [...] present, the diagnosis is likely
used in treatment? vasculature so as to shunt blood away - best initial test: CXR (hilar adenopathy
[...] from poorly oxygenated alveoli; in turn this seen in > 95% of cases)
only adds to the hypoxemia - most accurate test: lymph node Bx to
- Dx is confirmed by right-heart or look for noncaseating granulomas
Swan-Ganz catheterization; PA - Tx is prednisone; if asymptomatic, do
pressure >30/10 mmHg is diagnostic; not treat
EKG and ECHO will show signs of
RAH/RVH
1150. A young, AA, A young, AA, female pt presents c/o of
- Tx if secondary is focusing on the
female pt presents SOB on exertion. She is otherwise
underlying cause
c/o of SOB on healthy and has no PMHx. Physical exam
- Tx if primary are prostacyclin
exertion. She is reveals erythema nodosum,
otherwise healthy lymphadenopathy and fine rales on
and has no PMHx. lung auscultation. You suspect
Physical exam sarcoidosis. What is the best initial
reveals erythema diagnostic test?
(sildenafil)
nodosum, CXR
lymphadenopathy
1147. Which demographic Which demographic is more commonly and fine rales on
is more commonly affected by sarcoidosis? lung auscultation. Sarcoidosis key points:
affected by African-American You suspect - common in young, AA, females
sarcoidosis? sarcoidosis. What is - presents as SOBOE with occasional fine
[...] the best initial rales on exam; no wheezing
diagnostic test? - can be associated with erythema
[...] nodosum and lymphadenopathy; if
1148. Which sex is more Which sex is more commonly affected by
present, the diagnosis is likely
commonly affected sarcoidosis?
- best initial test: CXR (hilar adenopathy
by sarcoidosis? Females
seen in > 95% of cases)
[...]
- most accurate test: lymph node Bx to
look for noncaseating granulomas
- Tx is prednisone; if asymptomatic, do
not treat
176 of 340
1151. A young, AA, A young, AA, female pt presents c/o of 1154. A young, AA, A young, AA, female pt presents c/o of
female pt presents SOB on exertion. She is otherwise female pt presents SOB on exertion. She is otherwise
c/o of SOB on healthy and has no PMHx. Physical exam c/o of SOB on healthy and has no PMHx. Physical exam
exertion. She is reveals erythema nodosum, exertion. She is reveals erythema nodosum,
otherwise healthy lymphadenopathy and fine rales on otherwise healthy lymphadenopathy and fine rales on
and has no PMHx. lung auscultation. You suspect and has no PMHx. lung auscultation. CXR reveals hilar
Physical exam sarcoidosis. What is the most accurate Physical exam adenopathy. F/u lymph node biopsy
reveals erythema diagnostic test? reveals erythema reveals noncaseating granulomas. She
nodosum, Lymph node Bx nodosum, is Dx with sarcoidosis. What is the
lymphadenopathy lymphadenopathy treatment?
and fine rales on and fine rales on Prednisone (clear top choice and most
lung auscultation. Sarcoidosis key points: lung auscultation. pts respond)
You suspect - common in young, AA, females CXR reveals hilar
sarcoidosis. What is - presents as SOBOE with occasional fine adenopathy. F/u
the most accurate rales on exam; no wheezing lymph node biopsy Sarcoidosis key points:
diagnostic test? - can be associated with erythema reveals - common in young, AA, females
[...] nodosum and lymphadenopathy; if noncaseating - presents as SOBOE with occasional fine
present, the diagnosis is likely granulomas. She is rales on exam; no wheezing
- best initial test: CXR (hilar adenopathy Dx with sarcoidosis. - can be associated with erythema
seen in > 95% of cases) What is the nodosum and lymphadenopathy; if
- most accurate test: lymph node Bx to treatment? present, the diagnosis is likely
look for noncaseating granulomas [...] - best initial test: CXR (hilar adenopathy
- Tx is prednisone; if asymptomatic, do seen in > 95% of cases)
not treat - most accurate test: lymph node Bx to
look for noncaseating granulomas
- Tx is prednisone; if asymptomatic, do
1152. Sarcoidosis involves Sarcoidosis involves the formation of
not treat
the formation of noncaseating granulomas. Some cases
noncaseating can involve hypercalciuria and/or
granulomas. Some hypercalcemia. Why?
cases can involve Granulomas make and secrete Vit D
hypercalciuria
and/or
hypercalcemia. Elevated ACE levels seen in up to 60%.
Why? Hypercalciuria seen in up to 20%.
[...] Hypercalcemia seen in up to 5%.
1153. How do PFTs How do PFTs change in sarcoidosis?

change in They exhibit restrictive lung disease
sarcoidosis? (decreased FEV1, FVC, and TLC with
[...] normal FEV1:FVC)
177 of 340
1155. A pt presents c/o A pt presents c/o dyspnea that worsens 1156. A pt presents c/o A pt presents c/o dyspnea that worsens
dyspnea that on exertion. Physical exam reveals fine dyspnea that on exertion. Physical exam reveals fine
worsens on exertion. rales on auscultation, a loud P2 heart worsens on exertion. rales on auscultation, a loud P2 heart
Physical exam sound, and clubbing of the fingers. What Physical exam sound, and clubbing of the fingers. You
reveals fine rales on interstitial lung disease is the most likely reveals fine rales on suspect pulmonary fibrosis. What is the
auscultation, a loud diagnosis? auscultation, a loud best initial test?
P2 heart sound, Pulmonary Fibrosis P2 heart sound, CXR/high-res CT
and clubbing of the and clubbing of the
fingers. What fingers. You suspect
interstitial lung Pulmonary Fibrosis key points: pulmonary fibrosis. Pulmonary Fibrosis key points:
disease is the most - involves thickening of the interstitial What is the best - involves thickening of the interstitial
likely diagnosis? septum of the lung between the initial test? septum of the lung between the
[...] arteriolar space and alveolus which [...] arteriolar space and alveolus which
interferes with gas exchange in both interferes with gas exchange in both
directions directions
- can be idiopathic - can be idiopathic
- can be secondary to inflammatory - can be secondary to inflammatory
conditions, radiation, drugs (bleomycin, conditions, radiation, drugs (bleomycin,
busulfan, amiodarone, methylsergide, busulfan, amiodarone, methylsergide,
nitrofurantoin, cyclophophamide), or toxic nitrofurantoin, cyclophophamide), or toxic
exposure (the pneumoconioses) exposure (the pneumoconioses)
- all forms present w/ dyspnea, fine - all forms present w/ dyspnea, fine
rales/crackles, loud P2 heart sound and rales/crackles, loud P2 heart sound and
clubbing of the fingers clubbing of the fingers
- best initial test is CXR; high-res CT is - best initial test is CXR; high-res CT is
more accurate more accurate
- most accurate test is lung Bx - most accurate test is lung Bx
- most causes are untreatable; if the Bx - most causes are untreatable; if the Bx
reveals WBC/inflammatory infiltrate, give reveals WBC/inflammatory infiltrate, give
steroids steroids
178 of 340
1157. A pt presents c/o A pt presents c/o dyspnea that worsens 1158. A pt presents c/o A pt presents c/o dyspnea that worsens
dyspnea that on exertion. Physical exam reveals fine dyspnea that on exertion. Physical exam reveals fine
worsens on exertion. rales on auscultation, a loud P2 heart worsens on exertion. rales on auscultation, a loud P2 heart
Physical exam sound, and clubbing of the fingers. You Physical exam sound, and clubbing of the fingers. You
reveals fine rales on suspect pulmonary fibrosis. What is the reveals fine rales on suspect pulmonary fibrosis. Lung Bx
auscultation, a loud most accurate test? auscultation, a loud reveals granulomas. Which
P2 heart sound, Lung Bx P2 heart sound, pneumoconioses is the likely diagnosis?
and clubbing of the and clubbing of the Berylliosis (associated with
fingers. You suspect fingers. You suspect granulomas on Bx)
pulmonary fibrosis. Pulmonary Fibrosis key points: pulmonary fibrosis.
What is the most - involves thickening of the interstitial Lung Bx reveals
accurate test? septum of the lung between the granulomas. Which Pulmonary Fibrosis key points:
[...] arteriolar space and alveolus which pneumoconioses is - involves thickening of the interstitial
interferes with gas exchange in both the likely diagnosis? septum of the lung between the
directions [...] arteriolar space and alveolus which
- can be idiopathic interferes with gas exchange in both
- can be secondary to inflammatory directions
conditions, radiation, drugs (bleomycin, - can be idiopathic
busulfan, amiodarone, methylsergide, - can be secondary to inflammatory
nitrofurantoin, cyclophophamide), or toxic conditions, radiation, drugs (bleomycin,
exposure (the pneumoconioses) busulfan, amiodarone, methylsergide,
- all forms present w/ dyspnea, fine nitrofurantoin, cyclophophamide), or toxic
rales/crackles, loud P2 heart sound and exposure (the pneumoconioses)
clubbing of the fingers - all forms present w/ dyspnea, fine
- best initial test is CXR; high-res CT is rales/crackles, loud P2 heart sound and
more accurate clubbing of the fingers
- most accurate test is lung Bx - best initial test is CXR; high-res CT is
- most causes are untreatable; if the Bx more accurate
reveals WBC/inflammatory infiltrate, give - most accurate test is lung Bx
steroids - most causes are untreatable; if the Bx
reveals WBC/inflammatory infiltrate, give
steroids
179 of 340
1159. What high-res CT What high-res CT findings are associated 1160. Which type of Which type of pneumoconiosis is
findings are with pulmonary fibrosis? pneumoconiosis is associated with coal?
associated with Thick alveolar walls known as associated with Coal Worker's Pneumoconiosis
pulmonary fibrosis? "honeycombing" coal?
[...] [...]
Pulmonary Fibrosis key points:
Pulmonary Fibrosis key points: - involves thickening of the interstitial
- involves thickening of the interstitial septum of the lung between the
septum of the lung between the arteriolar space and alveolus which
arteriolar space and alveolus which interferes with gas exchange in both
interferes with gas exchange in both directions
directions - can be idiopathic
- can be idiopathic - can be secondary to inflammatory
- can be secondary to inflammatory conditions, radiation, drugs (bleomycin,
conditions, radiation, drugs (bleomycin, busulfan, amiodarone, methylsergide,
busulfan, amiodarone, methylsergide, nitrofurantoin, cyclophophamide), or toxic
nitrofurantoin, cyclophophamide), or toxic exposure (the pneumoconioses)
exposure (the pneumoconioses) - all forms present w/ dyspnea, fine
- all forms present w/ dyspnea, fine rales/crackles, loud P2 heart sound and
rales/crackles, loud P2 heart sound and clubbing of the fingers
clubbing of the fingers - best initial test is CXR; high-res CT is
- best initial test is CXR; high-res CT is more accurate
more accurate - most accurate test is lung Bx
- most accurate test is lung Bx - most causes are untreatable; if the Bx
- most causes are untreatable; if the Bx reveals WBC/inflammatory infiltrate, give
reveals WBC/inflammatory infiltrate, give steroids
steroids
180 of 340
1161. Which type of Which type of pneumoconiosis is 1162. Which type of Which type of pneumoconiosis is
pneumoconiosis is associated with sandblasting, rock pneumoconiosis is associated with shipyard workers, pipe
associated with mining, and tunneling? associated with fitting, and insulators?
sandblasting, rock Silicosis (typically affects the apex of shipyard workers, Asbestosis
mining, and the lungs) pipe fitting, and
tunneling? insulators?
[...] [...] Pulmonary Fibrosis key points:
Pulmonary Fibrosis key points: - involves thickening of the interstitial
- involves thickening of the interstitial septum of the lung between the
septum of the lung between the arteriolar space and alveolus which
arteriolar space and alveolus which interferes with gas exchange in both
interferes with gas exchange in both directions
directions - can be idiopathic
- can be idiopathic - can be secondary to inflammatory
- can be secondary to inflammatory conditions, radiation, drugs (bleomycin,
conditions, radiation, drugs (bleomycin, busulfan, amiodarone, methylsergide,
busulfan, amiodarone, methylsergide, nitrofurantoin, cyclophophamide), or toxic
nitrofurantoin, cyclophophamide), or toxic exposure (the pneumoconioses)
exposure (the pneumoconioses) - all forms present w/ dyspnea, fine
- all forms present w/ dyspnea, fine rales/crackles, loud P2 heart sound and
rales/crackles, loud P2 heart sound and clubbing of the fingers
clubbing of the fingers - best initial test is CXR; high-res CT is
- best initial test is CXR; high-res CT is more accurate
more accurate - most accurate test is lung Bx
- most accurate test is lung Bx - most causes are untreatable; if the Bx
- most causes are untreatable; if the Bx reveals WBC/inflammatory infiltrate, give
reveals WBC/inflammatory infiltrate, give steroids
steroids
181 of 340
1163. Which type of Which type of pneumoconiosis is 1164. Which type of Which type of pneumoconiosis is
pneumoconiosis is associated with cotton? pneumoconiosis is asociated with electronic
associated with Byssinosis asociated with manufacturing?
cotton? electronic Berylliosis (associated with
[...] manufacturing? granulomas on Bx)
Pulmonary Fibrosis key points: [...]
- involves thickening of the interstitial
septum of the lung between the Pulmonary Fibrosis key points:
arteriolar space and alveolus which - involves thickening of the interstitial
interferes with gas exchange in both septum of the lung between the
directions arteriolar space and alveolus which
- can be idiopathic interferes with gas exchange in both
- can be secondary to inflammatory directions
conditions, radiation, drugs (bleomycin, - can be idiopathic
busulfan, amiodarone, methylsergide, - can be secondary to inflammatory
nitrofurantoin, cyclophophamide), or toxic conditions, radiation, drugs (bleomycin,
exposure (the pneumoconioses) busulfan, amiodarone, methylsergide,
- all forms present w/ dyspnea, fine nitrofurantoin, cyclophophamide), or toxic
rales/crackles, loud P2 heart sound and exposure (the pneumoconioses)
clubbing of the fingers - all forms present w/ dyspnea, fine
- best initial test is CXR; high-res CT is rales/crackles, loud P2 heart sound and
more accurate clubbing of the fingers
- most accurate test is lung Bx - best initial test is CXR; high-res CT is
- most causes are untreatable; if the Bx more accurate
reveals WBC/inflammatory infiltrate, give - most accurate test is lung Bx
steroids - most causes are untreatable; if the Bx
steroids
182 of 340
1165. Which type of Which type of pneumoconiosis is 1167. A pt presents c/o A pt presents c/o dyspnea that worsens
pneumoconiosis is associated with moldy sugar cane? dyspnea that on exertion. Physical exam reveals fine
associated with Bagassosis worsens on exertion. rales on auscultation, a loud P2 heart
moldy sugar cane? Pulmonary Fibrosis key points: Physical exam sound, and clubbing of the fingers. You
[...] - involves thickening of the interstitial reveals fine rales on suspect pulmonary fibrosis. Lung Bx
septum of the lung between the auscultation, a loud confirms the suspicion and shows
arteriolar space and alveolus which P2 heart sound, inflammatory infiltrates. What is the
interferes with gas exchange in both and clubbing of the treatment?
directions fingers. You suspect Prednisone
- can be idiopathic pulmonary fibrosis.
- can be secondary to inflammatory Lung Bx confirms
conditions, radiation, drugs (bleomycin, the suspicion and Pulmonary Fibrosis key points:
busulfan, amiodarone, methylsergide, shows - involves thickening of the interstitial
nitrofurantoin, cyclophophamide), or toxic inflammatory septum of the lung between the
exposure (the pneumoconioses) infiltrates. What is arteriolar space and alveolus which
- all forms present w/ dyspnea, fine the treatment? interferes with gas exchange in both
rales/crackles, loud P2 heart sound and [...] directions
clubbing of the fingers - can be idiopathic
- best initial test is CXR; high-res CT is - can be secondary to inflammatory
more accurate conditions, radiation, drugs (bleomycin,
- most accurate test is lung Bx busulfan, amiodarone, methylsergide,
- most causes are untreatable; if the Bx nitrofurantoin, cyclophophamide), or toxic
reveals WBC/inflammatory infiltrate, give exposure (the pneumoconioses)
steroids - all forms present w/ dyspnea, fine
rales/crackles, loud P2 heart sound and
clubbing of the fingers
1166. How do PFTs How do PFTs change in pulmonary
- best initial test is CXR; high-res CT is
change in pulmonary fibrosis?
more accurate
fibrosis? Restrictive lung disease pattern
- most accurate test is lung Bx
[...] (normal FEV1/FVC; decreased DLCO)
- most causes are untreatable; if the Bx
steroids
DLCO decreases in direct proportion to
alveolar septum thickening.
1168. You discover a You discover a solitary lung nodule on
solitary lung nodule chest imaging of one of your pts. What is
on chest imaging of the best initial step in workup?
one of your pts. Compare with older chest imaging
What is the best
initial step in
workup?
[...]
183 of 340
1169. A pt is found to have A pt is found to have a solitary pulmonary 1173. A pt has a solitary A pt has a solitary pulmonary nodule with
a solitary pulmonary nodule with high-probability of pulmonary nodule intermediate malignany probability. The pt
nodule with malignancy. What is the most with intermediate does not want to undergo biopy. What
high-probability of appropriate intervention? malignany diagnostic test can gauge the malignancy
malignancy. What Resection probability. The pt of a pulmonary nodule without biopsy?
is the most does not want to PET scan
appropriate undergo biopy. What
intervention? When many features of high-probability diagnostic test can
[...] are present, sputum cytology, needle gauge the PET Scan and pulmonary nodule key
biopsy, and PET scanning should not be malignancy of a points:
done as any negative results may likely pulmonary nodule - 85-95% sensitivity
be false-negative. Choose resection without biopsy? - most accurate with larger lesions (> 1
instead. [...] cm)
- malignant nodules have increased
uptake of tagged glucose
1170. A pt is found to have A pt is found to have a central solitary
- a negative PET scan points away from
a central solitary pulmonary nodule with intermediate
malignancy
pulmonary nodule probability of malignancy. What is the
with intermediate most appropriate next step in
probability of management? 1174. What is the most What is the most sensitive and specific
malignancy. What is Bronchoscopy w/ Bx sensitive and form of testing a solitary pulmonary
the most appropriate specific form of nodule?
next step in testing a solitary Video-assisted thoracic surgery
management? If it is a peripheral lesion, perform pulmonary nodule? (VATS)
[...] transthoracic needle Bx. [...]
Frozen section in the OR allows for

1171. A pt is found to have A pt is found to have a peripheral solitary
immediate conversion to open thorascopy
a peripheral solitary pulmonary nodule with intermediate
and lobectomy if the lesion is malignant.
pulmonary nodule probability of malignancy. What is the
with intermediate most appropriate next step in
probability of management?
malignancy. What is Transthoracic Needle Bx
next step in
management? Most common complication is PTX
[...]
1172. What is the most What is the most common adverse effect
common adverse of a transthoracic needle biopsy?
effect of a Pneumothorax (PTX)
transthoracic needle
biopsy?
[...]
184 of 340
1175. It is important to It is important to think of pneumonia in 1176. A pt presents w/ A pt presents w/ fever and cough
think of pneumonia terms of risk factors, exposure, and fever and cough productive of sputum. Physical exam
in terms of risk severity. Which broad type of pneumonia productive of reveals crackles on auscultation. You
factors, exposure, should be considered when there is no sputum. Physical suspect pneumonia. SpO2 is measured
and severity. Which association with healthcare? exam reveals and WNL. What is the most appropriate
broad type of Community-acquired pneumonia (i.e. crackles on next step in work-up?
pneumonia should the usual suspects) auscultation. You CXR
be considered when suspect pneumonia. Pneumonia/lung infection workup key
there is no SpO2 is measured points:
association with Pneumonia overview/bugs/typing key and WNL. What is - fever and cough? get a CXR
healthcare? points: the most appropriate - theoretically, the best test is sputum Cx;
[...] - clinically, we rely on exposure, history, next step in however, it is very difficult to get a good
and risk factors to determine management work-up? sample (more often than not the sample is
of a lung infection [...] contaminated with oral flora), making a
- Community-acquired PNA should be culture a poor choice; is only useful if
considered when there is no association there are < 10 squams and > 25
w/ healthcare (> 90 d, including nursing PMN/lpf
homes OR < 48 hrs from admission) - blood Cx rarely yields anything that will
--- most common bug is always change your management; even the
Streptococcus pneumoniae simplest PNA can cause septicemia for a
- Hospital-acquired PNA should be period
considered if there is an association w/ - bronchoalveolar lavage is reserved for
healthcare acutely ill pts w/ HIV/AIDS to rule out PCP
- Opportunistic PNA should be which can be rapidly fatal
considered if the pt is - if definitive dx is required, serum/urine
immunocompromised (think of bugs like antigen or PCR can be used to identify
TB, fungi, MAC, and especially PCP) the bug
- Aspiration PNA should be considered if - empiric treatment is often enough
there is risk (i.e. MS, stroke, DM, EtOH when relying on history and risk factors
abuse, intubation, seizures; think of
anaerobes)
185 of 340
1177. A pt presents w/ A pt presents w/ fever and cough. 1179. A pt presents with A pt presents with fever and cough
fever and cough. Physical exam reveals foul breath. CXR fever and cough productive of sputum. Physical exam
Physical exam reveals a cavitary lesion in the right lung. productive of reveals rhonchi on lung auscultation that
reveals foul breath. You suspect a lung abscess. What is the sputum. Physical disappear after coughing. A CXR is
CXR reveals a best diagnostic test to rule out fungus or exam reveals normal. The pt is otherwise healthy and
cavitary lesion in TB? rhonchi on lung has no PMHx. What is the most likely Dx?
the right lung. You I&D w/ Bx & culture auscultation that Bronchitis
suspect a lung Lung Abscess key points: disappear after
abscess. What is the - abscesses don't just form out of coughing. A CXR is
best diagnostic test nowhere; these pts typically have an normal. The pt is Bronchitis key points:
to rule out fungus or aspiration risk otherwise healthy - can be seen as a "not so bad
TB? - empiric treatment with clindamycin is and has no PMHx. pneumonia"
[...] recommended (again, due to the What is the most - presents with fever, cough and sputum
aspiration risk; most lung abscesses likely Dx? production
involve anaerobes) [...] - CXR is typically normal without
- aspiration risk is typically 2/2 seizure, consolidation
alcoholism, MS or strome - typically can be treated outpatient;
- give proper treatment once culture and inpatient typically involves a COPD
sensitivity return exacerbation (if COPD is present of
course)
- can progress into chronic bronchitis
- Tx like a URI: amoxicillin, 3rd gen
cephalosporin, and macrolide/FQ
1178. A pt presents w/ A pt presents w/ fever and cough. 1180. A pt presents with A pt presents with fever and cough
fever and cough. Physical exam reveals foul breath. CXR fever and cough productive of sputum. Physical exam
Physical exam reveals a cavitary lesion in the right lung. productive of reveals crackles in the left lung. CXR
reveals foul breath. You suspect a lung abscess. An I&D w/ sputum. Physical reveals unilateral lobar consolidation.
CXR reveals a culture is done. Until the culture is exam reveals The pt states that he has not been
cavitary lesion in complete, what is the most appropriate crackles in the left hospitalized in the past 90 days. You
the right lung. You empiric treatment? lung. CXR reveals suspect pneumonia. What is the most
suspect a lung Clindamycin unilateral lobar likely organism?
abscess. An I&D w/ consolidation. The Streptococcus pneumoniae (Moraxella
culture is done. Until pt states that he has catarrhalis and Haemophilus
the culture is Lung Abscess key points: not been influenzae are 2nd and 3rd)
complete, what is - abscesses don't just form out of hospitalized in the
the most appropriate nowhere; these pts typically have an past 90 days. You
empiric treatment? aspiration risk suspect pneumonia.
[...] - empiric treatment with clindamycin is What is the most
recommended (again, due to the likely organism?
aspiration risk; most lung abscesses [...]
involve anaerobes)
- aspiration risk is typically 2/2 seizure,
alcoholism, MS or stroke
- give proper treatment once culture and
sensitivity return
186 of 340
1181. A pt presents with A pt presents with fever and cough

1184. In general, what is In general, what is the treatment for
fever and cough productive of sputum. Physical exam
productive of reveals crackles in the left lung. CXR the treatment for hospital-acquired pneumonia?
sputum. Physical reveals unilateral lobar consolidation. hospital-acquired Vanco + Zosyn
exam reveals The pt states that he has not been pneumonia? (piperacillin+tazobactam)
crackles in the left hospitalized in the past 90 days. You [...]
lung. CXR reveals suspect community-acquired pneumonia.
unilateral lobar What is the most appropriate treatment if To cover for higher virulence, resistance
consolidation. The this pt is admitted? and Pseudomonas sp.
pt states that he has 3rd gen cephalosporin + macrolide
not been
hospitalized in the
past 90 days. You
suspect
community-acquired 1185. Which cause of Which cause of pneumonia should be
pneumonia. What is pneumonia should considered in a pt with s/s of PNA and GI
the most appropriate be considered in a pt (abdominal pain, diarrhea) & CNS
treatment if this pt is with s/s of PNA and (headache, confusion) s/s?
admitted? GI (abdominal pain, Legionnella sp.
[...] diarrhea) & CNS
(headache,
1182. A pt that was A pt that was admitted 4 days ago for confusion) s/s?
admitted 4 days ago diverticulitis develops fever and cough. [...]
for diverticulitis Physical exam reveals crackles in the left
develops fever and lung. CXR reveals new lobar 1186. Which cause of Which cause of pneumonia should be
cough. Physical consolidation on the left with an effusion. pneumonia should considered in alcoholics?
exam reveals You suspect hospital-acquired be considered in Klebsiella sp.
crackles in the left pneumonia. What is the most appropriate alcoholics?
lung. CXR reveals treatment? [...]
new lobar Vancomycin + Zosyn i.e. due to the aspiration risk
consolidation on the (piperacillin+tazobactam)
left with an effusion.
You suspect
hospital-acquired
pneumonia. What is
treatment?
[...]
1183. In general, what is In general, what is the treatment for

the treatment for community-acquired pneumonia that is
community-acquired treated inpatient?
pneumonia that is 3rd gen cephalosporin + macrolide; or
treated inpatient? respiratory fluoroquinolone
[...]
e.g. ceftriaxone + azithromycin
187 of 340
1187. A pt presents c/o of A pt presents c/o of fever and cough. He

1189. A pt with HIV/AIDS A pt with HIV/AIDS presents c/o of fever
fever and cough. states that his fever came on slowly, but
He states that his does not feel acutely ill. Physical exam presents c/o of fever and cough. Physical exam reveals
fever came on reveals mild crackles in both lungs. CXR and cough. Physical crackles in both lungs. CXR reveals
slowly, but does not reveals bilateral infiltrates. You suspect exam reveals bilateral fluffy infiltrates. An ABG
feel acutely ill. atypical community acquired pneumonia. crackles in both reveals a PaO2 of 60. Bronchoalveolar
Physical exam What is the most appropriate outpatient lungs. CXR reveals lavage is done and the Dx of PCP
reveals mild treatment? bilateral fluffy pneumonia is confirmed via silver stain.
crackles in both Macrolide infiltrates. An ABG What is the most appropriate treatment?
lungs. CXR reveals Atypical PNA key points: reveals a PaO2 of Bactrim IV + steroids
bilateral infiltrates. - often involves fever with insidious onset 60. Bronchoalveolar
You suspect atypical - pts typically don't present as acutely ill; lavage is done and
community acquired this is sometimes called "walking PNA" the Dx of PCP HIV and pneumonia key points:
pneumonia. What is - associated with Mycoplasma PNA and pneumonia is - if the pt has HIV, the risk of PCP is high,
the most appropriate IgM cold agglutinin dz confirmed via silver so PCP must be ruled out immediately;
outpatient stain. What is the failure to do so may allow the pt to
treatment? most appropriate progress into ARDS if PCP is present
[...] treatment? - bronchoalveolar lavage or sputum Cx
[...] are indicated and the sample must be
silver stained STAT
- "induced" sputum testing involves
administration of a saline solution that
1188. A pt with HIV/AIDS A pt with HIV/AIDS presents c/o of fever induces coughing
presents c/o of fever and cough. Physical exam reveals - Tx w/ bactrim IV w/ corticosteroids
and cough. Physical crackles in both lungs. CXR reveals (steroids decrease inflammation and
exam reveals bilateral fluffy infiltrates. An ABG increase gas exchange)
crackles in both reveals a PaO2 of 60. You suspect PCP
lungs. CXR reveals pneumonia. What is the most appropriate
bilateral fluffy next step in workup?
infiltrates. An ABG Bronchoalveolar lavage or
reveals a PaO2 of induced-sputum culture then silver
60. You suspect staining of the sample
PCP pneumonia. HIV and pneumonia key points:
1190. Which clinical Which clinical scoring system is currently
What is the most - if the pt has HIV, the risk of PCP is high,
appropriate next so PCP must be ruled out immediately; scoring system is being used to assess the admit potential
step in workup? failure to do so may allow the pt to currently being used (or ICU need) for a patient with suspected
[...] progress into ARDS if PCP is present to assess the admit pneumonia?
- bronchoalveolar lavage or sputum Cx potential (or ICU CURB-65
are indicated and the sample must be need) for a patient
silver stained STAT with suspected
- "induced" sputum testing involves pneumonia?
administration of a saline solution that [...]
induces coughing
- Tx w/ bactrim (TMP/SMX) IV w/ 1191. What is the most What is the most common infectious
corticosteroids (if PO2 < 70 or A-a common infectious cause of death in the USA?
gradient > 35; steroids decrease cause of death in the Community-acquired pneumonia
inflammation and increase gas exchange) USA?
[...]
188 of 340
1192. Which cause of Which cause of community acquired 1197. Which cause of Which cause of community acquired
community acquired pneumonia is associated with COPD? community acquired pneumonia is associated with
pneumonia is Haemophilus influenzae pneumonia is veterinarians and farmers?
associated with associated with Coxiella burnetti
COPD? veterinarians and
[...] farmers?
[...]
1193. Which cause of Which cause of community acquired

community acquired pneumonia is associated with a recent 1198. Bronchitis and Bronchitis and pneumonia may present
pneumonia is viral infection (e.g. influenza)? pneumonia may similarly. Which complaint from the history
associated with a Staphylococcus aureus present similarly. is most commonly used to distinguish
recent viral infection Which complaint PNA from bronchitis?
(e.g. influenza)? from the history is Dyspnea
[...] most commonly
used to distinguish
PNA from Bronchitis typically does not yield dyspnea
bronchitis? unless COPD is also present.
[...]
community acquired pneumonia is associated with young,
pneumonia is healthy pts?
associated with Mycoplasma pneumoniae (typically 1199. Which cause of Which cause of community aquired
young, healthy pts? atypical PNA) community aquired pneumonia is associated w/ "currant jelly"
[...] pneumonia is sputum?
associated w/ Klebsiella pneumoniae
"currant jelly"
sputum?
[...]

community acquired pneumonia is associated with birds? 1200. What are the specific What are the specific criteria for a sputum
pneumonia is Chlamydia psittaci criteria for a sputum gram stain to be considered
associated with gram stain to be accurate/adequate?
birds? considered > 25 PMNs/lpf and < 10 squamous
[...] accurate/adequate? cells/lpf
[...]
1196. Which cause of Which cause of community acquired 1201. Which cause of Which cause of pneumonia involves PCR
community acquired pneumonia is associated with pneumonia involves and cold agglutinin testing in diagnosis?
pneumonia is hoarseness? PCR and cold Mycoplasma pneumoniae
associated with Chlamydia pneumoniae agglutinin testing in
hoarseness? diagnosis?
[...] [...]
1202. Which cause of Which cause of pneumonia is associated

pneumonia is with urinary antigen testing?
associated with Legionella
urinary antigen
testing?
[...]
189 of 340
1203. Which cause of Which cause of pneumonia may need 1206. Ventilator-associated Ventilator-associated pneumonia (VAP)
pneumonia may culturing on charcoal-yeast extract for pneumonia (VAP) has an incidence as high as 5% per day in
need culturing on diagnosis? has an incidence as the first few days of being on a ventilator.
charcoal-yeast Legionella high as 5% per day Why?
extract for in the first few days Mechanical ventilation interferes with
diagnosis? of being on a mucociliary clearance and coughing;
[...] ventilator. Why? PEEP makes this even harder
[...]
1204. Which cause of Which cause of pneumonia involves

Ventilator-associated pneumonia key
pneumonia involves bronchoalveolar lavage for diagnosis?
points:
bronchoalveolar Pneumocystis jiroveci (PCP)
- common amongst ventilated pts
lavage for
- Dx can be difficult; look for new
diagnosis?
infiltrate on CXR and purulent
[...]
secretion from the ET tube; rising WBC
or fever help with clues; diagnostic
1205. In general, what is In general, what is the outpatient methods from easiest to hardest (but least
the outpatient treatment of community-acquired to most accurate) are:
treatment of pneumonia? --- tracheal aspiration involves placing a
community-acquired Macrolide or doxycycline; FQ if any suction cath into the ET tube to aspirate
pneumonia? comorbiditis or if the pt received Abx contents below the trachea
[...] in the last month --- broncoalveolar lavage (BAL) is
similar but occurs deeper in the lungs and
involves a bronchoscope
Macrolides (e.g. azithromycin; --- protected brush sampling is similar
clarithromycin) to BAL but the tip of the bronchoscope is
Respiratory FQs (e.g. levofloxacin; covered when passing through the
moxifloxacin) nasopharynx, thereby decreasing the risk
and frequency of contamination
--- video-assisted thoracoscopy (VAT)
involves a scope being placed through the
chest wall allowing for biopsy
--- open lung biopsy via thoracotomy
- Tx typically involves 3 drugs (1
antipseudomonal beta-lactam, 1 more
antipseudomonal of another class, 1
anti-MRSA agent); adjust treatment if
culture done
1207. Daptomycin cannot Daptomycin cannot be used in lung

be used in lung infections. Why?
infections. Why? It is inactivated by surfactant
[...]
190 of 340
1208. In general, what is In general, what is the treatment for 1212. An HIV/AIDS pt is An HIV/AIDS pt is admitted with
the treatment for ventilator-associated pneumonia? admitted with suspected PCP pneumonia. His LDH level
ventilator-associated Regimen of 3 antibiotics (see below) suspected PCP is normal. Is PCP still on the differential?
pneumonia? pneumonia. His LDH Yes, but it is much less likely with a
[...] level is normal. Is normal LDH
VAP treatment key points: PCP still on the
- adjust therapy as needed if specific differential?
organism is identified [...]
- involves a 3 drug regimen:
--- 1 antipseudomonal beta-lactam (e.g.
1213. A pt is Dx with PCP A pt is Dx with PCP pneumonia but
cefepime, ceftazidime, Zosyn, or a
pneumonia but cannot tolerate Bactrim (TMP/SMX). What
carbapenem)
cannot tolerate alternatives can you switch to?
--- 1 antipseudomonal of another class
Bactrim (TMP/SMX). Clindamycin + primaquine; or
(e.g. gentamicin, tobramycin,
What alternatives pentamidine
ciprofloxacin, or levofloxacin)
can you switch to?
--- 1 anti-MRSA agent (e.g. vancomycin
[...]
or linezolid)
Look out for questions that describe a
case of PCP and then someone who
1209. Imipenem is often Imipenem is often used in the treatment of cannot tolerate Bactrim as they have
used in the ventilator-associated pneumonia. What undiagnosed G6PD (surprise, you also
treatment of notable CNS side effect is seen with this have a blood disorder!).
ventilator-associated drug? - you cannot switch to clinda + primaquine
pneumonia. What Seizures in this cause as primaquine is also C/I in
notable CNS side G6PD deficiency
effect is seen with
this drug? Esp if there is renal failure as the drug is
1214. A pt w/ AIDS has a A pt w/ AIDS has a CD4 count < 200/uL.
[...] renally excreted (this is very possible
CD4 count < 200/uL. You administer ppx with Bactrim, but the
since ventilated pts are typically in rough
You administer ppx pt develops rash and neutropenia. What
condition).
with Bactrim, but the can you switch to for ppx?
pt develops rash Atovaquone; or dapsone
1210. PCP is a type of PCP is a type of pneumonia caused by and neutropenia.
pneumonia caused Pneumocystic jiroveci that almost What can you switch
by Pneumocystic exclusive occurs in HIV/AIDS pts. Which to for ppx? Note that ppx can stop if CD4 count is >
jiroveci that almost CD4 cell count is associated with PCP? [...] 200/uL for several months. Ppx is based
exclusive occurs in < 200 on CD4 count alone, not viral load.
HIV/AIDS pts. Which
CD4 cell count is
1215. How does TB How does TB spread?
associated with And typically they are not on ppx (bactrim)
spread? Aerosolized respiratory droplets
PCP?
[...]
[...]
1211. What is the most What is the most accurate test in the
1216. Where in the lung Where in the lung does primary TB
accurate test in the diagnosis of PCP pneumonia?
does primary TB typically manifest?
diagnosis of PCP Bronchoalveolar lavage (with silver
typically manifest? Middle or base
pneumonia? stain)
[...]
[...]
191 of 340
1217. Where in the lung Where in the lung does reactivation TB 1221. A pt arrives to get A pt arrives to get his PPD skin test read.
does reactivation typically manifest? his PPD skin test He has 12 cm of induration. He works in
TB typically Apex read. He has 12 cm health care. A CXR rules out infection.
manifest? of induration. He What is the next step in management?
[...] works in health care. INH ppx for 9 months
Due to high oxygen tension. A CXR rules out
Reactivation typically involves cavitation infection. What is the
which can cause hemoptysis. next step in
management?
[...]
1218. There are typically There are typically two types of TB
two types of TB patients: asymptomatic pts with or without
patients: exposure that get screened, or pts with
asymptomatic pts active cavitary TB. Are these pts 1222. A pt arrives to get A pt arrives to get his PPD skin test read.
with or without managed the same? his PPD skin test He has 12 cm of induration. He works in
exposure that get No read. He has 12 cm health care. A CXR reveals infection.
screened, or pts with of induration. He What is the next step in management?
active cavitary TB. works in health care. AFB smear
Are these pts Obvious, but the idea is to remind myself A CXR reveals
managed the same? that the approach changes depending on infection. What is the
[...] the pt, and that there are 2 algorithms to next step in
learn in this case. management?
[...]
1223. A pt arrives to get A pt arrives to get his PPD skin test read.
1219. A pt arrives to get A pt arrives to get his PPD skin test read. his PPD skin test He has 12 cm of induration. He works in
his PPD skin test He had no induration. What is the next read. He has 12 cm health care. A CXR reveals infection and
read. He had no step in management? of induration. He follow-up AFB smear is positive. He is Dx
induration. What is Nothing. works in health care. with active TB. What is the next step in
the next step in A CXR reveals management?
management? infection and Begin RIPE therapy
[...] follow-up AFB smear
is positive. He is Dx
with active TB.
1220. A pt arrives to get A pt arrives to get his PPD skin test read.
What is the next step
his PPD skin test He has 12 cm of induration. He works in
in management?
read. He has 12 cm health care. What is the next step in
[...]
of induration. He management?
works in health care. CXR
What is the next step 1224. A pt arrives to get A pt arrives to get his PPD skin test read.
in management? his PPD skin test He has 12 cm of induration. He works in
[...] read. He has 12 cm health care. A CXR reveals infection and
of induration. He follow-up AFB smear is negative. He is Dx
works in health care. with latent TB. What is the next step in
A CXR reveals management?
infection and INH for 9 months
follow-up AFB smear
is negative. He is Dx
with latent TB. What
is the next step in
management?
[...]
192 of 340
1228. A pt presents with A pt presents with fever, cough, night

1225. A pt presents with A pt presents with fever, cough, night fever, cough, night sweats, weight loss and hemoptysis.
fever, cough, night sweats, weight loss and hemoptysis. sweats, weight loss He has risk factors for TB. You suspect
sweats, weight loss He has risk factors for TB. You suspect and hemoptysis. He TB. A CXR is negative. Follow-up AFB is
and hemoptysis. He TB. What is the first step in management? has risk factors for negative. What is the most appropriate
has risk factors for CXR TB. You suspect TB. next step in management?
TB. You suspect TB. A CXR is negative. TB is ruled out, consider other Dx
What is the first step Follow-up AFB is Collect early morning sputum and get
in management? Look for apical lesions with this acute negative. What is the atleast 3 cultures 8 hrs apart.
[...] picture (i.e. see if its reactivation) most appropriate To help ensure a true result, get 3 early
next step in morning sputums 24 hrs apart.
management? Your last ditch effort if you have a very
[...] high suspicion of TB is nucleic acid
1226. A pt presents with A pt presents with fever, cough, night assay.
fever, cough, night sweats, weight loss and hemoptysis.
sweats, weight loss He has risk factors for TB. You suspect
and hemoptysis. He TB. A CXR is negative. What is the most
has risk factors for appropriate next step in management?
TB. You suspect TB. AFB smear and culture 1229. A pt presents with A pt presents with fever, cough, night
A CXR is negative. Collect early morning sputum and get fever, cough, night sweats, weight loss and hemoptysis.
What is the most atleast 3 cultures 8 hrs apart. sweats, weight loss He has risk factors for TB. You suspect
appropriate next To help ensure a true result, get 3 early and hemoptysis. He TB. A CXR is positive. Follow-up AFB
step in morning sputums 24 hrs apart. has risk factors for smear is also positive. What is the most
management? Your last ditch effort if you have a very TB. You suspect TB. appropriate next step in management?
[...] high suspicion of TB is nucleic acid A CXR is positive. This is a Dx of active TB; start RIPE
assay. Follow-up AFB therapy
smear is also Collect early morning sputum and get
positive. What is the atleast 3 cultures 8 hrs apart.
most appropriate To help ensure a true result, get 3 early
next step in morning sputums 24 hrs apart.
1227. A pt presents with A pt presents with fever, cough, night management? Your last ditch effort if you have a very
fever, cough, night sweats, weight loss and hemoptysis. [...] high suspicion of TB is nucleic acid
sweats, weight loss He has risk factors for TB. You suspect assay.
and hemoptysis. He TB. A CXR is positive. Follow-up AFB is
has risk factors for positive. What is the most appropriate
TB. You suspect TB. next step in management?
A CXR is positive. Start RIPE therapy
Follow-up AFB is
positive. What is the
most appropriate Collect early morning sputum and get
next step in atleast 3 cultures 8 hrs apart.
management? To help ensure a true result, get 3 early
[...] morning sputums 24 hrs apart.
Your last ditch effort if you have a very
high suspicion of TB is nucleic acid
assay.
193 of 340
1230. A pt presents with A pt presents with fever, cough, night 1234. Rifampin, isoniazid Rifampin, isoniazid (INH), pyrazinamide,
fever, cough, night sweats, weight loss and hemoptysis. (INH), pyrazinamide, and ethambutol [RIPE] are the drugs used
sweats, weight loss He has risk factors for TB. You suspect and ethambutol to treat active TB. What is the notable
and hemoptysis. He TB. A CXR is positive. Follow-up AFB [RIPE] are the drugs side effect of rifampin?
has risk factors for smear is negative. What is the most used to treat active Red/orange bodily secretions/urine
TB. You suspect TB. appropriate next step in management? TB. What is the
A CXR is positive. INH for 9 months notable side effect of
Follow-up AFB rifampin?
smear is negative. [...]
What is the most Collect early morning sputum and get
appropriate next atleast 3 cultures 8 hrs apart.
1235. Rifampin, isoniazid Rifampin, isoniazid (INH), pyrazinamide,
step in To help ensure a true result, get 3 early
(INH), pyrazinamide, and ethambutol [RIPE] are the drugs used
management? morning sputums 24 hrs apart.
and ethambutol to treat active TB. What is the notable
[...] Your last ditch effort if you have a very
[RIPE] are the drugs side effect of pyrazinamide?
high suspicion of TB is nucleic acid
used to treat active Hyperuricemia/gout
assay.
TB. What is the
notable side effect of
pyrazinamide? '
[...]
1231. Anyone that has a Anyone that has a +PPD or +CXR when
1236. Rifampin, isoniazid Rifampin, isoniazid (INH), pyrazinamide,
+PPD or +CXR looking for TB will receive 9 months
(INH), pyrazinamide, and ethambutol [RIPE] are the drugs used
when looking for TB prophylaxis with isoniazid (INH). What is
and ethambutol to treat active TB. What is the notable
will receive 9 months the notable side effect of INH?
[RIPE] are the drugs side effect of ethambutol?
prophylaxis with Neuropathy
used to treat active Eye disturbances (optic neuritis,
isoniazid (INH). INH = Neuropathy
TB. What is the colour changes, etc)
What is the notable Can give Vit B6 to ppx.
notable side effect of
side effect of INH?
ethambutol?
[...] A +PPD confers a 10% lifetime risk of TB.
[...] E = ethambutol = eye
Giving INH for 9 months reduces that by
90% to 1% lifetime risk.
1237. [...] is a relatively Gamma-interferon assay is a relatively
new diagnostic test new diagnostic test for TB that is
1232. Isoniazid is a drug Isoniazid is a drug commonly part of the
for TB that is replacing the PPD and is read as either
commonly part of the treatment for active TB or ppx against TB
replacing the PPD "positive" or "negative".
treatment for active that can cause neuropathy. What vitamin
and is read as either
TB or ppx against can be given to ppx against this side
"positive" or
TB that can cause effect?
"negative". - It's fast (can be same day), but more $$
neuropathy. What Vit B6
than PPD
vitamin can be given
- It's a one-time test (no need for return
to ppx against this
visit to read it), so IFN > PPD if Pt
side effect?
unreliable
[...]
- It's the preferred test in Pts w/ Hx of
BCG vaccine
1233. Which side effect is Which side effect is common to all 4
common to all 4 drugs in the RIPE regimen for active TB?
drugs in the RIPE Hepatotoxicity
regimen for active Do not stop them unless liver enzymes
TB? are 3-5x the upper limit of normal
[...]
194 of 340
1238. A pt is diagnosed A pt is diagnosed with latent TB, however 1241. A pt is Dx with active A pt is Dx with active TB. Which drug
with latent TB, he has previously received the BCG TB. Which drug class can be added to her treatment to
however he has vaccine. How does this change his class can be added decrease the risk of constrictive
previously received management? to her treatment to pericarditis?
the BCG vaccine. It doesn't decrease the risk of Glucocorticoids
How does this constrictive
change his pericarditis?
management? Previous BCG vaccination does not [...] RIPE therapy key points:
[...] change management. - includes rifampin, isoniazid,
pyrazinamide, ethambutol
- ethambutol is not needed if sensitivity is
1239. What is the most What is the most accurate test in the
known and present to all TB medications
accurate test in the diagnosis of TB?
- start RIPE for 2 monrhs, then d/c
diagnosis of TB? Pleural biopsy
pyrazinamide and ethambutol and
[...]
continue rifampin and isoniazid for the
next 4 months (standard of care is 6
1240. What is the What is the treatment for active TB? months of therapy)
treatment for active RIPE - extend Tx past 6 months if there is
TB? osteomyelitis, miliary TB, meningitis
[...] - glucocorticoids are useful in
RIPE therapy key points: decreasing the risk of constrictive
- includes rifampin, isoniazid, pericarditis or CNS complications (if it
pyrazinamide, ethambutol is TB meningitis)
- ethambutol is not needed if sensitivity is
known and present to all TB medications
1242. Any infection of the Any infection of the brain will present with
- start RIPE for 2 monrhs, then d/c
brain will present fever and headache. Which type of CNS
pyrazinamide and ethambutol and
with fever and infection will involve stiff neck?
continue rifampin and isoniazid for the
headache. Which Meningitis
next 4 months (standard of care is 6
type of CNS
months of therapy)
infection will involve
- extend Tx past 6 months if there is
stiff neck? i.e. Kernig and Brudzinski signs
osteomyelitis, miliary TB, meningitis
[...] Photophobia, n/v, and seizures are all
- glucocorticoids are useful in
nonspecific symptoms.
decreasing the risk of constrictive
pericarditis or CNS complications (if it
is TB meningitis)
1243. Any infection of the Any infection of the brain will present with
brain will present fever and headache. Which type of CNS
with fever and infection will involve focal neurological
headache. Which deficits?
type of CNS Abscess
infection will involve
focal neurological
deficits? Photophobia, n/v, and seizures are all
[...] nonspecific symptoms.
195 of 340
1244. Any infection of the Any infection of the brain will present with 1247. A pt has fever, A pt has fever, headache, and a stiff
brain will present fever and headache. Which type of CNS headache, and a neck. CT scan rules out intracranial
with fever and infection will involve confusion/AMS? stiff neck. CT scan mass, so an LP is safely performed. LP
headache. Which Encephalitis rules out intracranial reveals thousands of PMNs. The pt is
type of CNS mass, so an LP is immunocompromised. What is the most
infection will involve safely performed. LP appropriate next step in management?
confusion/AMS? Photophobia, n/v, and seizures are all reveals thousands Ceftriaxone + steroids (+ ampicillin if
[...] nonspecific symptoms. of PMNs. The pt is immunocompromised to cover
immunocompromised. Listeria)
What is the most
appropriate next
step in All pts get IV steroids in bacterial
1245. A pt has fever, A pt has fever, headache, and a stiff
management? meningitis.
headache, and a neck. What must you rule out before
[...]
stiff neck. What doing an LP?
must you rule out Increased ICP
before doing an LP? If the pt has s/s of increased ICP, do
[...] not perform the LP; in such cases it can 1248. A pt has fever, A pt has fever, headache, and a stiff
be fatal and trigger herniation of through headache, and a neck. CT scan rules out intracranial
the foramen magnum stiff neck. CT scan mass, so an LP is safely performed. LP
- ICP s/s include papilledema, FND, rules out intracranial rules out bacterial meningitis. The pt has
confusion mass, so an LP is HIV/AIDS with a CD4 count < 100/uL.
- give Abx then get a CT to rule out safely performed. LP What is the most appropriate next step in
mass if s/s present, when negative get rules out bacterial management?
the LP meningitis. The pt Cryptococcus antigen testing
- it sounds backwards to give Abx prior to has HIV/AIDS with a Cryptococcus antigen testing is much
getting your culture sample, however in CD4 count < 100/uL. more sensitive for Cryptococcus (vs.
this case it saves lives so remember to do What is the most India Ink, which is specific but not
it appropriate next sensitive enough to be the diagnostic test)
step in Opening pressure will be > 20 cm H2O
management? with cryptococcus
[...]
1246. A pt has fever, A pt has fever, headache, and a stiff

headache, and a neck. CT scan rules out intracranial
stiff neck. CT scan mass, so an LP is safely performed. LP
rules out intracranial reveals thousands of PMNs. The pt is
mass, so an LP is immunocompetent. What is the most
safely performed. LP appropriate next step in management?
reveals thousands Ceftriaxone + steroids (+ ampicillin if
of PMNs. The pt is immunocompromised to cover
immunocompetent. Listeria)
What is the most All pts get IV steroids (dexamethasone)
appropriate next in bacterial meningitis.
step in - even though it's only been proven to
management? help in S. pneumo meningitis, you won't
[...] get the culture back for a few days so still
give it
196 of 340
1249. A pt has fever, A pt has fever, headache, and a stiff 1251. A pt has fever, A pt has fever, headache, and a stiff
headache, and a neck. CT scan rules out intracranial headache, and a neck. CT scan rules out intracranial
stiff neck. CT scan mass, so an LP is safely performed. LP stiff neck. CT scan mass, so an LP is safely performed. LP
rules out intracranial rules out bacterial meningitis. The pt has rules out intracranial rules out bacterial meningitis. The pt also
mass, so an LP is HIV/AIDS with a CD4 count < 100/uL. mass, so an LP is has a targetoid rash and recent travel to
safely performed. LP Cryptococcal antigen testing is positive. safely performed. LP the north-east American coast. Lyme
rules out bacterial What is the most appropriate next step in rules out bacterial antibody testing returns positive. What is
meningitis. The pt management? meningitis. The pt the most appropriate next step in
has HIV/AIDS with a Amphotericin + fluconazole also has a targetoid management?
CD4 count < 100/uL. rash and recent Ceftriaxone
Cryptococcal antigen travel to the
testing is positive. Cryptococcus antigen testing is much north-east
What is the most more sensitive for Cryptococcus (vs. American coast. Not doxycycline, which is used for Lyme
appropriate next India Ink, which is specific but not Lyme antibody arthralgia, not Lyme meningitis
step in sensitive enough to be the diagnostic test) testing returns
management? Opening pressure will be > 20 cm H2O positive. What is the
[...] with cryptococcus most appropriate
next step in
management?
[...]
1250. A pt has fever, A pt has fever, headache, and a stiff 1252. A pt has fever, A pt has fever, headache, and a stiff
headache, and a neck. CT scan rules out intracranial headache, and a neck. CT scan rules out intracranial
stiff neck. CT scan mass, so an LP is safely performed. LP stiff neck. CT scan mass, so an LP is safely performed. LP
rules out intracranial rules out bacterial meningitis. The pt also rules out intracranial rules out bacterial meningitis. The pt also
mass, so an LP is has a targetoid rash and recent travel to mass, so an LP is has a peripheral rash that spread from
safely performed. LP the north-east American coast. What is safely performed. LP the hands and feet to the trunk. What is
rules out bacterial the most appropriate next step in rules out bacterial the most appropriate next step in
meningitis. The pt management? meningitis. The pt management?
also has a targetoid Lyme antibody testing also has a Rocky Mountain Spotted Fever (RMSF)
rash and recent peripheral rash that antibody
travel to the spread from the
north-east hands and feet to
American coast. the trunk. What is RMSF is caused by Rickettsia sp. and
What is the most the most appropriate you do not need to be in the Rocky
appropriate next next step in Mountains to get it (via tick bite)
step in management?
management? [...]
[...]
197 of 340
1253. A pt has fever, A pt has fever, headache, and a stiff 1255. A pt has fever, A pt has fever, headache and focal
headache, and a neck. CT scan rules out intracranial headache and focal neurological deficits. A CT scan is
stiff neck. CT scan mass, so an LP is safely performed. LP neurological performed and ring enhancing lesions
rules out intracranial rules out bacterial meningitis. The pt also deficits. A CT scan are seen. The pt is HIV+ and has a CD4
mass, so an LP is has a peripheral rash that spread from is performed and count < 200/uL. What is the next step in
safely performed. LP the hands and feet to the trunk. RMSF ring enhancing management?
rules out bacterial antibody is positive. What is the most lesions are seen. Empiric tx with pyrimethamine for 6
meningitis. The pt appropriate next step in management? The pt is HIV+ and weeks
also has a Ceftriaxone has a CD4 count <
peripheral rash that RMSF is caused by Rickettsia sp. and 200/uL. What is the
spread from the you do not need to be in the Rocky next step in If CD4 is < 200/uL, the mass(es) is/are
hands and feet to Mountains to get it (via tick bite) management? toxoplasmosis 90% of the time. In such
the trunk. RMSF [...] pts, Tx empirically with pyrimethamine
antibody is positive. for 6 weeks and print out a picture of
What is the most Martin Shkreli behind bars.
appropriate next - re-CT in 6 weeks and decide then; if
step in improvement, continue with treatment; if
management? no change or worsening, get a Bx
[...] - if empiric treatment with pyrimethamine
is not an option, choose Toxoplasmosis
antibody testing
1254. A pt has fever, A pt has fever, headache and focal
headache and focal neurological deficits. A CT scan is
neurological performed and ring enhancing lesions 1256. A pt presents with A pt presents with fever, headache and
deficits. A CT scan are seen. The pt is HIV+ and has a CD4 fever, headache stiff neck. CT scan is negative. The LP
is performed and count < 200/uL. What is the most likely and stiff neck. CT that follows is inconclusive. Further history
ring enhancing Dx? scan is negative. and testing rules out cryptococcus, Lyme,
lesions are seen. Toxoplasmosis The LP that follows RMSF and TB meningitis. The pt has no
The pt is HIV+ and is inconclusive. PMHx. What is the most likely cause of
has a CD4 count < Further history and this pt's meningitis?
200/uL. What is the If CD4 is < 200/uL, the mass(es) is/are testing rules out Virus
most likely Dx? toxoplasmosis 90% of the time. In such cryptococcus, Lyme,
[...] pts, Tx with pyrimethamine for 6 weeks RMSF and TB
and print out a picture of Martin Shkreli meningitis. The pt The point here being that viral meningitis
behind bars. has no PMHx. What is typically a diagnosis of exclusion and
- re-CT in 6 weeks and decide then; if is the most likely treatment is supportive. You can try HSV
improvement, continue with treatment; if cause of this pt's PCR of the CSF, but it is typically
no change or worsening, get a Bx meningitis? unfruitful.
- if empiric treatment with pyrimethamine [...]
is not an option, choose Toxoplasmosis
antibody testing
198 of 340
1257. A pt presents with A pt presents with fever, headache and 1259. A pt presents w/ A pt presents w/ acute onset fever,
fever, headache focal neurological deficits. CT scan acute onset fever, headache, and confusion. He has no
and focal reveals ring enhancing lesions. LP is headache, and other s/s. A CT scan is negative. LP is
neurological not done as it is c/i w/ intracranial mass. confusion. He has performed and reveals that WBC:RBC is
deficits. CT scan The pt has no PMHx. What is the most no other s/s. A CT normal and lymphocytes are elevated.
reveals ring appropriate next step in management? scan is negative. LP HSV PCR is positive. What is the most
enhancing lesions. Biopsy is performed and appropriate next step in management?
LP is not done as it reveals that IV Acyclovir (this is HSV encephalitis;
is c/i w/ intracranial WBC:RBC is foscarnet if resistant)
mass. The pt has no Biopsy is imperative here since there's normal and
PMHx. What is the really no other way for us to get info (LP is lymphocytes are
most appropriate C/I, remember?) elevated. HSV PCR HSV encephalitis is the only one we can
next step in - if an abscess, look for a primary source, is positive. What is actually treat, so if suspected it is worth
management? culture, start empiric Tx and the most appropriate testing for.
[...] follow-up/alter care as needed next step in - if positive, tx with IV acyclovir; foscarnet
- if cancer, begin radiation and management? if resistant
chemotherapy [...] - all other encephalitides are treated
- remember, the exception to jumping supportively; any specific testing is
to Bx right away is if the pt has purely academic (i.e. testing for West Nile
HIV/AIDS and a CD4 count < 200/uL virus) and does not change management
- note that if the question mentions
anything about "temporal lobe" or
"anosmia", think HSV
1258. A pt presents w/ A pt presents w/ acute onset fever,

acute onset fever, headache, and confusion. He has no
headache, and other s/s. A CT scan is negative. LP is
confusion. He has performed and reveals that WBC:RBC is 1260. What is the most What is the most common cause of
no other s/s. A CT normal and lymphocytes are elevated. common cause of bacterial meningitis?
scan is negative. LP What is the most appropriate next step in bacterial meningitis? Streptococcus pneumoniae
is performed and management? [...]
reveals that HSV PCR of the CSF
WBC:RBC is
1261. If a pt is suspected If a pt is suspected to have meningitis, but
normal and
to have meningitis, has s/s of increased ICP (papilledema,
lymphocytes are HSV encephalitis is the only one we can
but has s/s of seizures, FNDs, confusion), an LP is
elevated. What is actually treat, so if suspected it is worth
increased ICP contraindicated. What test should be
the most appropriate testing for.
(papilledema, performed next?
next step in - if positive, tx with IV acyclovir; foscarnet
seizures, FNDs, CT
management? if resistant
confusion), an LP is
[...] - all other encephalitides are treated
contraindicated.
supportively; any specific testing is
What test should be (papilledema)
purely academic (i.e. testing for West Nile
performed next?
virus)
[...]
- note that if the question mentions
anything about "temporal lobe" or
"anosmia", think HSV
199 of 340
1262. A pt is suspected to A pt is suspected to have meningitis, but 1265. What is the most What is the most accurate test for HSV
have meningitis, but has s/s of increased ICP (papilledema, accurate test for encephalitis?
has s/s of increased seizures, FNDs, confusion), so an LP is HSV encephalitis? HSV PCR of the CSF
ICP (papilledema, contraindicated and a CT is ordered. Abx [...]
seizures, FNDs, are given. The CT is negative and the LP
confusion), so an LP is performed. CSF culture is negative. More accurate than Bx.
is contraindicated What test should be ordered to account Serology is useless.
and a CT is ordered. for a possible false-negative culture? Note that the most accurate test for
Abx are given. The Bacterial Antigen Detection Test (Laten genital lesions is viral culture.
CT is negative and Agglutination Test)
the LP is performed.
1266. What is the best What is the best initial test to diagnose
CSF culture is
initial test to otitis media?
negative. What test This test is similar to gram stain and are
diagnose otitis Pneumatic insufflation
should be ordered to extremely specific if an antigen tests
media?
account for a positive.
[...]
possible - if negative, the infection is not ruled out
A little puff of air is sent into the ear canal
false-negative (sensitivity ranges from 50-90%)
and if there is a tense, immobile
culture? - while less sensitive than a culture, this
membrane it is diagnostic.
[...] test will not become negative following
- this is so sensitive that if the membrane
Abx administration
is fully mobile, otitis media is ruled out
- visualizing a bulging, red tympanic
1263. A pt is dx with A pt is dx with Neisseria meningitidis membrane, or seeing fluid behind the ear,
Neisseria meningitis. His close contacts need or noticing a loss of light reflex of the
meningitidis protection. What are the 3 drugs you can tympanic membrane are all indicative of
meningitis. His close choose from for this purpose? fluid behind the ear but are not
contacts need Rifampin; ciprofloxacin; ceftriaxone pathognomonic
protection. What are - if needed, the most accurate test is
the 3 drugs you can tympanocentesis; but it is typically not
choose from for this Note that close contacts is not done unless there is severe recurrence or
purpose? someone with proximity no response to treatment
[...] - close contacts includes household
contacts, kissing partners, cigarette
1267. What is the best What is the best initial therapy for otitis
sharing or sharing of eating utensils
initial therapy for media?
(i.e. anyone that has exposure to
otitis media? Amoxicillin
respiratory secretions; this can include
[...]
healthcare workers if they intubated the
pt, performed suctioning or came into
- Failure to treat can lead to mastitis or
contact with secretions)
even spread to the
braaaaaaaaaaaaiiiiiiinnnnnn
1264. What is the most What is the most common focal - If the infection does not clear, give
common focal neurological deficit of untreated bacterial amoxicillin/clavulanate
neurological deficit meningitis? - if they recur, consider myringotomy
of untreated CN VIII deficits or deafness with tubes to allow for pressure to
bacterial meningitis? equalize and drainage of fluid
[...]
1268. What are the most What are the most common causes of
common causes of otitis media?
otitis media? Steptococcus pneumoniae;
[...] Haemophilus influenzae; Moraxella
catarrhalis
200 of 340
1274. A pt presents with A pt presents with symptoms of

1269. What is the most What is the most accurate test for symptoms of pharyngitis with membranous exudates
accurate test for sinusitis? pharyngitis with in the pharynx. What is the most likely
sinusitis? Sinus Bx/aspiration membranous Dx?
[...] exudates in the Diphtheria, vinvent angina, or EBV
pharynx. What is the
Remember: when it comes to infectious most likely Dx?
diseases, radiology is never the most [...]
accurate (a culture is)
This is only needed in crazy recurrent
cases or if there is no response to multiple
initial therapy for pharyngitis?
treatments.
pharyngitis? Amoxicillin (or penicillin)
[...]
treatment for sinusitis? If allergic, and the reaction is a rash, give
sinusitis? Amoxicillin/clavulanic acid (+ Keflex (cephalexin)
[...] decongestant) If allergic, and the reaction is
anaphylaxis, give clindamycin or a
1271. A pt presents c/o A pt presents c/o pain on swallowing macrolide
pain on swallowing and fever. There is no cough or
and fever. There is hoarsness. Physical exam reveals an 1276. A pt is dx w/ A pt is dx w/ pharyngitis, but is allergic to
no cough or enlarged lymph node at the neck and pharyngitis, but is penicillin. She says it gives her a rash.
hoarsness. Physical pharyngeal exudates. What is the most allergic to penicillin. What can you give instead?
exam reveals an likely Dx? She says it gives her Cephalexin
enlarged lymph node Streptococcus pharyngitis a rash. What can
at the neck and you give instead?
pharyngeal [...]
exudates. What is
the most likely Dx?
1277. A pt is dx w/ A pt is dx w/ pharyngitis, but has a
[...]
pharyngitis, but has penicillin allergy. She states that it makes
a penicillin allergy. her get a rash and she has difficulty
1272. What is the best What is the best initial test for pharyngitis? She states that it breathing. What can you give instead?
initial test for Rapid Strep test makes her get a Clindamycin or a macrolide
pharyngitis? rash and she has
[...] difficulty breathing.
Tests for group A beta-hemolytic strep What can you give
- negative test is not sensitive enough to instead?
rule out [...]
1273. A pt has symptoms A pt has symptoms of pharyngitis with 1278. A pt has symptoms A pt has symptoms of the flu that began
of pharyngitis with small vesicles/ulcers in the pharynx. of the flu that began less than 48 hrs ago. What is the next
small What is the most likely Dx? less than 48 hrs step in management?
vesicles/ulcers in HSV or herpangina ago. What is the Rapid antigen testing for influenza
the pharynx. What next step in
is the most likely management?
Dx? Note that herpangina is caused by [...]
[...] Coxsackievirus, not HSV
201 of 340
1279. A pt is Dx w/ the flu A pt is Dx w/ the flu that manifested less 1283. What are the criteria What are the criteria for sepsis?
that manifested less than 48 hrs ago. What is the best initial for sepsis? 2 of SIRS and a source of infection
than 48 hrs ago. therapy? [...]
What is the best Oseltamivir/zanamivir
initial therapy? Systemic Inflammatory Response
[...] Syndrome (SIRS) criteria; you need 2 of
As well as symptomatic treatment. 4:
Those are neuraminidase inhibitors vs. - Temperature > 38 C (100.4 F) or < 36 C
influenza A and B (96.8 F)
- HR > 90
- RR > 20, or PaCO2 < 32 mmHg)
1280. A pt is Dx w/ the flu A pt is Dx w/ the flu that started more
- WBC > 12,000, or < 4,000, or > 10%
that started more than 48 hrs ago. What is the best initial
bands
than 48 hrs ago. therapy?
What is the best Symptomatic treatment only
initial therapy? 1284. What are the criteria What are the criteria for severe sepsis?
[...] for severe sepsis? 2 SIRS + infection source + > 1 organ
i.e. analgesia, rest, hydration, antipyretics [...] failure
Systemic Inflammatory Response
Syndrome (SIRS) criteria; you need 2 of
1281. What are the SIRS What are the SIRS criteria?
4:
criteria? (see below)
- Temperature > 38 C (100.4 F) or < 36 C
[...]
(96.8 F)
- HR > 90
- WBC > 12,000, or < 4,000, or > 10%
4:
bands
(96.8 F)
- HR > 90 1285. What are the criteria What are the criteria for septic shock?
- RR > 20, or PaCO2 < 32 mmHg) for septic shock? 2 SIRS + infection source +
- WBC > 12,000, or < 4,000, or > 10% [...] hypotension refractory to fluids (or
bands requiring pressors)
1282. What is the first step What is the first step in early goal directed
4:
in early goal directed therapy of sepsis?
therapy of sepsis? 500-1000 mL fluid bolus
(96.8 F)
[...] - if the pt responds to fluids, nothing more
- HR > 90
is really needed aside from Abx,
supportive measures and removal of
- WBC > 12,000, or < 4,000, or > 10%
infectious sources.
bands
- if the pt fails to respond, pressors will
be needed
- SvcO2 is superior vena cava O2
saturation
- note that typically, severe sepsis is
responsive to fluids
202 of 340
1286. A pt presents c/o of A pt presents c/o of a single, painless 1289. A pt presents c/o of A pt presents c/o of a targetoid,
a single, painless genital ulcer with inguinal a targetoid, maculopapular rash on his palms and
genital ulcer with lymphadenopathy. What stage of maculopapular soles. He states that 1 month ago he
inguinal syphilis may be the diagnosis? rash on his palms noticed a single, painless ulcer on his
lymphadenopathy. Primary Syphilis and soles. He genitals. What stage of syphilis is the
What stage of Note that Syphilitic chancres can become states that 1 month likely diagnosis?
syphilis may be the painful if they are infected by bacteria. ago he noticed a Secondary Syphilis
diagnosis? single, painless Note that Syphilitic chancres can become
[...] ulcer on his genitals. painful if they are infected by bacteria.
What stage of Note that this rash is infectious, so
syphilis is the likely make sure you glove up.
diagnosis? Also, in the secondary stage, syphilis
[...] serology is positive.
1287. A pt presents c/o of A pt presents c/o of a single, painless
a single, painless genital ulcer with inguinal
genital ulcer with lymphadenopathy. You suspect primary
inguinal syphilis. What is the best diagnostic test
lymphadenopathy. at this point?
You suspect primary Dark-field microscopy
syphilis. What is the Serology is typically negative and less 1290. What is the What is the diagnostic test of choice for
best diagnostic test sensitive during the primary stage. diagnostic test of secondary syphilis?
at this point? choice for secondary RPR (or VDRL) then confirm with
[...] syphilis? FTA-ABS
[...]
1288. A pt presents c/o of A pt presents c/o of a single, painless

a single, painless genital ulcer with inguinal
genital ulcer with lymphadenopathy. You suspect primary
inguinal syphilis. Dark field microscopy confirms.
lymphadenopathy. What is the treatment?
You suspect primary PCN IM 1x
syphilis. Dark field
microscopy
confirms. What is the
treatment?
[...]
203 of 340
1291. A pt is suspected to A pt is suspected to have secondary 1293. What is the What is the treatment for tertiary syphilis?
have secondary syphilis. RPR and follow-up FTA-ABS treatment for tertiary PCN IV for 14d
syphilis. RPR and testing are both positive. What is the syphilis?
follow-up FTA-ABS treatment? [...]
testing are both PCN IM 1xwk for 3 wks
positive. What is the Secondary syphilis is termed "latent
treatment? syphilis".
[...] Latent syphilis is further subdivided into
early-latent (less than a year) and
late-latent (more than a year).
1294. A pt is diagnosed A pt is diagnosed with syphilis but has a
Early-Latent syphilis is treated like
with syphilis but has penicillin allergy. What is the best
Primary syphilis.
a penicillin allergy. alternative treatment?
The way the vignette is going to tell you
What is the best Doxycycline for 7d
that there is early-latent syphilis is with
alternative
two time points. They MUST give you a
treatment?
negative time point and a subsequent
[...] Note, this can only be given if it is
positive time point. If you just have
primary or secondary syphilis
"secondary syhpilis" and no history of a
negative RPR titer, then you must assume
late-latent and treat for 3 doses. 1295. A pt is diagnosed A pt is diagnosed with tertiary syphilis but
Essentially: with tertiary syphilis is allergic to penicillin. What is the
1. Primary = Chancre, Dark Field but is allergic to treatment?
Microscopy, One dose of penicillin penicillin. What is Penicillin (via penicillin
2. Early-Latent (secondary part a) = No the treatment? desensitization)
Chancre, RPR, FTA-Abs, One dose of [...]
penicillin
3. Late-Latent (secondary part b) = No You do this if they are pregnant as well.
chancre, RPR, FTA-Abs, 3 doses of
penicillin 1296. A pt is diagnosed A pt is diagnosed with syphilis and is
4. Tertiary = Neuro symptoms, 14 days of with syphilis and is given the appropriate penicillin
penicillin given the treatment. Following treatment, the pt
appropriate develops fever and his symptoms
penicillin treatment. worsen. What is this phenomenon called?
Following treatment, Jarisch-Herxheimer reaction
the pt develops This is 2/2 widespread endotoxin
fever and his release following the death of bacteria.
1292. What is the What is the diagnostic test for tertiary symptoms worsen. - while classically associated with
diagnostic test for syphilis? What is this syphilis and other spirochete diseases, it
tertiary syphilis? RPR then FTA-ABS; can perform CSF phenomenon called? can occur in other cases
[...] RPR [...]
1297. Which tract in the Which tract in the spinal cord is classically
spinal cord is affected in tertiary syphilis?
classically affected Dorsal column-medial lemniscus
in tertiary syphilis? (DCML)
[...]
204 of 340
1298. What is the What is the diagnostic test for Chancroid 1302. What is the What is the treatment for molluscum
diagnostic test for (Haemophilus ducreyi)? treatment for contagiosum?
Chancroid Gram stain and culture molluscum Freeze them off
(Haemophilus contagiosum?
ducreyi)? [...]
[...]
1303. A pt presents with a A pt presents with a singular, painless

singular, painless genital ulcer that is firm on palpation.
1299. What is the What is the treatment for Haemophilus genital ulcer that is There is also inguinal lymphadenopathy.
treatment for ducreyi? firm on palpation. What STD is the most likely diagnosis?
Haemophilus Doxycycline; or azithromycin There is also Syphilis
ducreyi? inguinal Syphilis = single, painless ulcer
[...] lymphadenopathy. Ducreyi = single, painful ulcer
Gram-negative coverage What STD is the HSV = multiple, painful ulcers
most likely Molluscum = multiple, painless ulcers
diagnosis? with central umbilications
[...]
1300. Usually the Usually the diagnosis of genital herpes is 1304. A pt presents w/ a A pt presents w/ a singular, painful
diagnosis of genital clinical. However, if it came to it, what is singular, painful genital ulcer. There is also inguinal
herpes is clinical. the diagnostic test of choice? genital ulcer. There lymphadenopathy. What STD is the most
However, if it came HSV PCR if an option; if not, Tzanck is also inguinal likely Dx?
to it, what is the Smear lymphadenopathy. Chancroid (Haemophilus ducreyi)
diagnostic test of What STD is the
choice? most likely Dx?
[...] Skip the Tzanck prep and go straight to [...] Syphilis = single, painless ulcer
HSV PCR. This is still a bit new. Tzanck Ducreyi = single, painful ulcer
prep is not wrong, but if given the option HSV = multiple, painful ulcers
between the two pick the HSV PCR. Molluscum = multiple, painless ulcers
The sensitivity and specificity of HSV PCR with central umbilications
is so good it is a better test. Even though
there is a significant time lag and cost
associated with it, it is now the standard of
care.
1305. A pt presents w/ A pt presents w/ multiple, painful,
The Tzanck prep is cheap, easy, and is
multiple, painful, roofed genital vesicles on an
specific (useful if positive) but is not
roofed genital erythematous base. The pt states that
sensitive (useless if negative).
vesicles on an he had a painful prodrome before these
erythematous vesicles manifested. What STD is the
base. The pt states most likely Dx?
that he had a HSV
1301. What is the What is the treatment for genital herpes? painful prodrome Syphilis = single, painless ulcer
treatment for genital Acyclovir; foscarnet if resistant before these Ducreyi = single, painful ulcer
herpes? Topical acyclovir is worthless; do not pick vesicles manifested. HSV = multiple, painful ulcers
[...] this as an answer. What STD is the Molluscum = multiple, painless ulcers
Any of acyclovir, valacyclovir and most likely Dx? with central umbilications
famciclovir is fine as they are equal in [...]
efficacy
205 of 340
1306. A pt presents w/ A pt presents w/ multiple, painless 1311. Which cause of Which cause of infectious, bloody
multiple, painless genital vesicles with central infectious, bloody diarrhea (with WBCs in the stool) is
genital vesicles with umbilication. What STD is the most likely diarrhea (with WBCs associated with shellfish and cruise
central Dx? in the stool) is ships?
umbilication. What Molluscum Contagiosum associated with Vibrio parahaemolyticus
STD is the most Syphilis = single, painless ulcer shellfish and cruise
likely Dx? Ducreyi = single, painful ulcer ships?
[...] HSV = multiple, painful ulcers [...]
Molluscum = multiple, painless ulcers
with central umbilications
1312. Which cause of Which cause of infectious, bloody
infectious, bloody diarrhea (with WBCs in the stool) is
diarrhea (with WBCs associated with shellfish, a history of
in the stool) is liver disease and skin lesions?
1307. Which cause of Which cause of infectious, bloody associated with Vibrio vulnificus
infectious, bloody diarrhea (with WBCs in the stool) is shellfish, a history
diarrhea (with WBCs associated with poultry? of liver disease and
in the stool) is Salmonella skin lesions?
associated with [...]
poultry?
[...]
1308. Which cause of Which cause of infectious, bloody diarrhea (with WBCs associated with hemochromatosis,
infectious, bloody diarrhea (with WBCs in the stool) is in the stool) is blood transfusion and having a high
diarrhea (with WBCs associated with Guillain-Barre Syndrome? associated with affinity for iron?
in the stool) is Campylobacter sp hemochromatosis, Yersinia sp.
associated with blood transfusion
Guillain-Barre and having a high
Syndrome? Also the most common cause affinity for iron? In b4 plague
[...] [...]
1309. What is the most What is the most common cause of 1314. What is the best What is the best initial test for infectious,
common cause of infectious, bloody diarrhea? initial test for bloody diarrhea (with WBC in the stool)?
infectious, bloody Campylobacter sp. infectious, bloody Stool lactoferrin if available; if not,
diarrhea? diarrhea (with WBC fecal leukocytes
[...] in the stool)?
[...]
Stool lactoferrin has greater sensitivity
and specificty vs. fecal leukocytes. If it's a
choice, pick it.
diarrhea (with WBCs associated with hemolytic uremic
Most accurate test is stool Cx.
in the stool) is syndrome?
associated with Escherichia coli 0157:H7; or Shigella
hemolytic uremic sp. 1315. What is the most What is the most accurate test for
syndrome? accurate test for infectious, bloody diarrhea (with WBC in
[...] infectious, bloody the stool)?
E. coli > Shigella in terms of commonness diarrhea (with WBC Stool culture
in the stool)?
[...]
206 of 340
1316. What cause of What cause of infectious, nonbloody 1322. How do you How do you differentiate between
infectious, diarrhea (w/o WBC in the stool) is differentiate between urethritis and cystitis, as both classically
nonbloody diarrhea associated with camping/hiking and urethritis and cystitis, present with dysuria with urinary
(w/o WBC in the unfiltered fresh water? as both classically frequency and burning?
stool) is associated Giardia lamblia present with dysuria Urethritis will likely have urethral
with with urinary discharge; cystitis never does
camping/hiking and frequency and
unfiltered fresh burning?
water? [...]
[...]
1323. What is the best What is the best initial test for urethritis?
1317. What cause of What cause of infectious, nonbloody initial test for Urethral swab (with gram stain)
infectious, diarrhea (w/o WBC in the stool) is urethritis?
nonbloody diarrhea associated with AIDS, especially if CD4 [...]
(w/o WBC in the count is < 100/uL? Best initial test is urethral swab; urinary
stool) is associated Cryptosporidium PCR for G&C can be done if swab is not
with AIDS, especially an option
if CD4 count is < Most accurate test is urethral culture,
100/uL? Detect this with a modified acid fast stain. DNA probe, or nucleic acid
[...] amplification test (NAAT) for G&C
1318. [...] is type of food Scombroid is type of food poisoning and 1324. What is the most What is the most accurate test for
poisoning and non-bloody diarrhea from eating accurate test for urethritis?
non-bloody diarrhea contaminated fish and presents with urethritis? Urethral culture, DNA probe, or nucleic
from eating wheezing, flushing, and rash. [...] acid amplification test (NAAT) for G&C
contaminated fish
and presents with
wheezing, flushing, Thought to be 2/2 histamine-esque Best initial test is urethral swab; urinary
and rash. toxin, hence treat with antihistamines. PCR for G&C can be done if swab is not
an option
Most accurate test is urethral culture,
1319. What is the What is the treatment for Scombroid?
DNA probe, or nucleic acid
treatment for Antihistamines
amplification test (NAAT) for G&C
Scombroid?
[...]
1325. What is the What is the diagnostic test for cervicitis?
diagnostic test for Swab for nucleic acid amplification
1320. What is the What is the treatment for Giardiasis?
cervicitis?
treatment for Metronidazole; tinidazole
[...]
Giardiasis?
[...]
1321. What is the What is the treatment for

treatment for Cryptosporidiosis?
Cryptosporidiosis? Nitazoxanide and treatment of
[...] underlying AIDS
207 of 340
1326. A 35 y/o female pt A 35 y/o female pt presents c/o of lower 1331. What is the What is the treatment for
presents c/o of abdominal pain and fever. Physical treatment for Lymphogranuloma Venereum??
lower abdominal exam reveals suprapubic tenderness Lymphogranuloma Doxycycline
pain and fever. and cervical motion tenderness. What Venereum??
Physical exam is always the most appropriate next step [...]
reveals suprapubic in management in such a case? Caused by the L-serotypes of Chlamydia
tenderness and Rule out pregnancy trachomatis
cervical motion
tenderness. What is
1332. What is the most What is the most accurate test for genital
always the most
accurate test for herpes?
appropriate next
genital herpes? HSV culture
step in management
[...]
in such a case?
[...]
1333. Tertiary syphilis Tertiary syphilis typically involve
typically involve neurological symptoms. What is the
neurological Argyll-Robertson pupil?
accurate diagnostic for pelvic inflammatory disease?
symptoms. What is A pupil that reacts to accommodation,
test for pelvic Laparascopy
the Argyll-Robertson but not to light
inflammatory
pupil?
disease?
[...]
[...] It is rarely needed (only if the dx is
unclear, s/s persist despite adequate
treatment or recurrent episodes for 1334. What is the most What is the most sensitive diagnostic test
unknown reason) sensitive diagnostic of CSF for neurosyphilis?
test of CSF for FTA-Abs of the CSF
neurosyphilis?
1328. What is the inpatient What is the inpatient treatment for pelvic
[...]
treatment for pelvic inflammatory disease?
FTA is nearly 100% sensitive in CSF and
inflammatory Cefoxitin or cefotetan + doxycycline
a negative result effectively excludes
disease?
neurosyphilis.
[...]
- VDRL and RPR are positive in only 50%
Targeting G&C
of pts and a negative result is not enough
to rule out
1329. What is the What is the outpatient treatment for pelvic
outpatient treatment inflammatory disease?
1335. What is the What is the diagnostic test for condyloma
for pelvic Ceftriaxone + doxycycline (+
diagnostic test for accuminata?
inflammatory metronidazole)
condyloma None, it is clinical
disease?
accuminata? Caused by HPV
[...]
[...] Tx by cryotherapy or surgery for larger
Targeting G&C
lesions; or podophyllin or imiquimod
1330. What is the What is the diagnostic test for

diagnostic test for Lymphogranuloma Venereum?
Lymphogranuloma Complement fixation titers; NAAT
Venereum?
[...]
208 of 340
1336. What is the What is the treatment for condyloma 1340. What is considered What is considered to be an
treatment for accuminata? to be an uncomplicated UTI?
condyloma Many options exist (see below) uncomplicated UTI at the bladder or below in a woman
accuminata? UTI?
[...] [...]
Treatment of Condyloma Accuminata Due to the commonality of UTI in women
key points: from 18-24 y/o (short urethra and lots of
- cryotherapy is done for small, easy to sex in that age group)
remove lesions
- surgery is an option for larger lesions
1341. What is considered What is considered to be a complicated
- laser removal
to be a complicated UTI?
- podophyllin or trichloracetic acid
UTI? (see below)
- imiquimod (a local immunostimulant
[...]
that leads to slouaghing off of lesions)
Complicated UTI:
1337. What is the What is the treatment for pediculosis (i.e. - any UTI in men (any location)
treatment for crabs)? - any UTI above the bladder in women
pediculosis (i.e. Permethrin; or lindane - any UTI w/ a catheter in place
crabs)? - any UTI associated w/ an anatomical
[...] defect
Lindane is just as effective but is more
toxic
1342. A pregnant pt is A pregnant pt is found to have
found to have asymptomatic bacteriuria on a routine
1338. What is the What is the treatment for scabies? asymptomatic screen. What is the treatment?
treatment for Permethrin bacteriuria on a Nitrofurantoin
scabies? routine screen. What Extremely vital to treat Asxs bacteriuria in
[...] is the treatment? pregnant pts to prevent progression to
Or ivermectin if there is widespread [...] pyelonephritis (or OBGYN related
disease (repeated doses required in complications).
severe cases) Also note that it is very important to
follow-up and rescreen to ensure
eradication.
1339. A pt presents A pt presents complaining of pruritis.
complaining of Physical exam reveals visible burrow
pruritis. Physical marks on the skin and webbed spaces
exam reveals visible between fingers. You suspect scabies.
burrow marks on What is the diagnostic test?
the skin and webbed Scraping and magnification of the 1343. A pt presents with A pt presents with dysuria and increased
spaces between burrows/lesions dysuria and urinary frequency. You suspect UTI.
fingers. You suspect increased urinary What is the best initial diagnostic test?
scabies. What is the frequency. You UA
diagnostic test? suspect UTI. What is Best initial test is UA
[...] the best initial Most accurate test is UCx
diagnostic test?
[...]
209 of 340
1344. A pt presents with A pt presents with dysuria and increased 1348. A pt presents with A pt presents with dysuria with urinary
dysuria and urinary frequency. You suspect UTI. dysuria with frequency and urgency. He also
increased urinary What is the most accurate diagnostic urinary frequency complains of urethral discharge. He
frequency. You test? and urgency. He denies any fever, chills, or n/v. What is the
suspect UTI. What is UCx also complains of most likely dx?
the most accurate Best initial test is UA urethral discharge. Urethritis
diagnostic test? Most accurate test is UCx He denies any fever, Urethritis key points:
[...] chills, or n/v. What is
the most likely dx? - Remember, in urethritis vs. cystitis,
[...] urethral discharge is a big clue
towards the dx.
1345. What is the most What is the most common UTI?
- Dx with urethral swab (best initial is
common UTI? Cystitis
G&C PCR; most accurate is culture)
[...]
- Tx if Neisseria is ceftriaxone, IM, 1x
- Tx if Chlamydia is doxycycline, PO,
100 mg, 7d
1349. A pt presents with A pt presents with dysuria with urinary

1346. A male pt presents A male pt presents with dysuria, urinary
dysuria with frequency and urgency. He also
with dysuria, frequency and urgency. He denies any
urinary frequency complains of urethral discharge. He
urinary frequency fever, n/v, or chills. Physical exam reveals
and urgency. He denies any fever, chills, or n/v. You
and urgency. He mild suprapubic tenderness. He is dx with
also complains of suspect urethritis. What is the best initial
denies any fever, cystitis. What is the treatment?
urethral discharge. test?
n/v, or chills. Bactrim or a FQ for 7-14 d (as this is
He denies any fever, Urethral swab (G&C PCR and/or
Physical exam complicated UTI)
chills, or n/v. You culture)
reveals mild
suspect urethritis. Urethritis key points:
suprapubic
What is the best
tenderness. He is dx
initial test? - Remember, in urethritis vs. cystitis,
with cystitis. What
[...] urethral discharge is a big clue
is the treatment?
towards the dx.
[...]
- Dx with urethral swab (best initial is
G&C PCR; most accurate is culture)
1347. A female pt presents A female pt presents with dysuria, - Tx if Neisseria is ceftriaxone, IM, 1x
with dysuria, urinary frequency and urgency. She - Tx if Chlamydia is doxycycline, PO,
urinary frequency denies any fever, n/v, or chills. Physical 100 mg, 7d
and urgency. She exam reveals mild suprapubic tenderness.
denies any fever, She is dx with cystitis. What is the
n/v, or chills. treatment?
Physical exam Bactrim or a FQ for 3 d (as this is
reveals mild uncomplicated UTI)
suprapubic
tenderness. She is
dx with cystitis.
What is the
treatment?
[...]
210 of 340
1350. A pt presents with A pt presents with dysuria with urinary 1353. A pt presents c/o of A pt presents c/o of dysuria with urinary
dysuria with frequency and urgency. He also dysuria with frequency and urgency. He also
urinary frequency complains of urethral discharge. He urinary frequency complains of fever, chills, and n/v.
and urgency. He denies any fever, chills, or n/v. Urethral and urgency. He Physical exam reveals CVA tenderness
also complains of swab is positive. What is the treatment? also complains of on the right side. UA is positive for WBC
urethral discharge. Ceftriaxone (if Neisseria); doxycycline fever, chills, and casts. He is dx with pyelonephritis. What
He denies any fever, (if Chlamydia) n/v. Physical exam is the treatment?
chills, or n/v. reveals CVA 3rd gen cephalosporin IV or
Urethral swab is tenderness on the ampicillin-gentamycin IV or FQ IV + FQ
positive. What is the Urethritis key points: right side. UA is 14d (as outpatient)
treatment? positive for WBC Pyelonephritis Tx key points:
[...] - Remember, in urethritis vs. cystitis, casts. He is dx with - essentially any gram-negative coverage
urethral discharge is a big clue pyelonephritis. What is acceptable
towards the dx. is the treatment? - notice how initial Tx is IV?
- Dx with urethral swab (best initial is [...] Pyelonephritis needs to be admitted
G&C PCR; most accurate is culture) for IV abx until the pt is afebrile and
- Tx if Neisseria is ceftriaxone, IM, 1x shows improvement
- Tx if Chlamydia is doxycycline, PO, - once afrebrile, d/c with PO FQ abx for
100 mg, 7d 14d
- if there is no improvement, order a CT
to r/o abscess
1351. A pt presents c/o of A pt presents c/o of dysuria with urinary
dysuria with frequency and urgency. He also
urinary frequency complains of fever, chills, and n/v.
and urgency. He Physical exam reveals CVA tenderness
also complains of on the right side. What is the most likely
fever, chills, and Dx? 1354. What is the most What is the most common cause of UTI?
n/v. Physical exam Pyelonephritis common cause of Escherichia coli
reveals CVA Notice how the systemic sxs are present UTI?
tenderness on the here. This is what sets pyelo or a [...]
right side. What is perinephric abscess apart from cystitis
the most likely Dx? and other UTIs.
1355. What is polyuria? What is polyuria?
[...]
[...] Increased urinary volume (not
frequency)
1352. A pt presents c/o of A pt presents c/o of dysuria with urinary It does not refer to frequency. For that we
dysuria with frequency and urgency. He also just say urinary frequency.
urinary frequency complains of fever, chills, and n/v.
and urgency. He Physical exam reveals CVA tenderness
1356. What is the best What is the best initial test for any UTI?
also complains of on the right side. You suspect
initial test for any UA
fever, chills, and pyelonephritis. What is the best initial
UTI?
n/v. Physical exam test?
[...]
reveals CVA UA; then UCx, BCx
tenderness on the
right side. You 1357. What is the most What is the most accurate test for any
suspect Always. UTI? UA! accurate test for any UTI?
pyelonephritis. What UTI? UCx
is the best initial [...]
test?
[...]
211 of 340
1358. A pt presents with A pt presents with dysuria and c/o 1362. A pt is Dx with A pt is Dx with pyelonephritis and started
dysuria and c/o perineal pain. Physical exam reveals a pyelonephritis and on treatment. After 5 days he has
perineal pain. tender prostate. What is the most likely started on treatment. persistent fever and a CT scan is ordered.
Physical exam Dx? After 5 days he has CT reveals a perinephric abscess. What is
reveals a tender Prostatitis persistent fever and the most appropriate next step in
prostate. What is a CT scan is management?
the most likely Dx? ordered. CT reveals I&D of the abscess (w/ culture)
[...] a perinephric
abscess. What is the
most appropriate You must drain the fluid once you have
1359. A pt presents with A pt presents with dysuria and c/o
next step in identified its presence. Follow up with a
dysuria and c/o perineal pain. Physical exam reveals a
management? culture to guide treatment. Continue
perineal pain. tender prostate. You suspect prostatitis.
[...] empiric IV abx until culture returns. Switch
Physical exam What physical exam maneuver can help
treatment accordingly.
reveals a tender increase the diagnostic yield of a urine
prostate. You culture?
suspect prostatitis. 1363. What is the most What is the most common risk factor for
What physical exam common risk factor infective endocarditis in the USA?
maneuver can help Prostatitic massage for infective IV drug abuse
increase the endocarditis in the
diagnostic yield of a USA?
urine culture? [...]
1364. Which type of Which type of infective endocarditis

[...]
infective endocarditis involves virulent organisms infecting
involves virulent normal, native valves?
1360. A pt is dx with A pt is dx with chronic prostatitis. What is organisms infecting Acute endocarditis
chronic prostatitis. the treatment? normal, native
What is the TMP-SMX for 6-8 wks valves?
treatment? [...] Acute Endocarditis key points:
[...] - pts present in a sick, acute picture with
persistent bacteremia and fever,
valvular destruction, and a new
1361. A pt is dx with acute A pt is dx with acute prostatis. What is the
murmur
prostatis. What is the treatment?
- order multiple cultures until they are
treatment? 3rd gen cephalosporin IV or
negative
[...] ampicillin-gentamycin IV or FQ IV (+ FQ
- due to the acute picture, there is no time
PO 14 d as outpatient)
for rhematological complications to set in
i.e. the same as pyelonephritis
212 of 340
1365. Which type of Which type of infective endocarditis 1368. A pt is dx w/ infective A pt is dx w/ infective endocarditis. He
infective endocarditis involves less virulent organisms infecting endocarditis. He received a prosthetic valve < 60 days
involves less abnormal native valves? received a prosthetic ago. What is the best empiric tx?
virulent organisms Subacute endocarditis valve < 60 days Vancomycin + gentamycin + cefepime
infecting abnormal ago. What is the The tables below are empiric treatment
native valves? best empiric tx? and that Abx choice should change
[...] Subacute Endocarditis key points: [...] depending on culture+sensitivity.
- usually caused by lses virulent
organisms (S. bovis, S. viridans, HACEK
group)
1369. A pt is dx w/ infective A pt is dx w/ infective endocarditis. He
- typically insidious and pts are not
endocarditis. He received a prosthetic valve somewhere
acutely ill
received a prosthetic between 60-365 days ago. What is the
- associated w/ the classical vascular and
valve somewhere best empiric tx?
rheumatological sequelae such as Roth
between 60-365 Vancomycin + gentamycin
Spots (at the eyes), janeway lesions
days ago. What is
(painless, at hands), osler nodes (painful,
the best empiric tx?
at digits), and splinter hemorrhages (at
[...] The tables below are empiric treatment
nail beds)
and that Abx choice should change
- order blood Cx until they are positive;
depending on culture+sensitivity.
that's not a typo; in the subacute setting,
these bugs are typically very sneaky but
also very susceptible to Abx; make sure
they are there by waiting for a positive Cx, 1370. A pt is dx w/ A pt is dx w/ endocarditis. He received a
then start Abx endocarditis. He prosthetic valve > 365 days ago. What is
received a prosthetic the empiric tx?
valve > 365 days Vancomycin + gentamycin +
1366. What is the What is the diagnostic criteria for infective
ago. What is the ceftriaxone
diagnostic criteria for endocarditis?
empiric tx?
infective 1 major + 3 minor is typically the case
[...]
endocarditis? w/ a positive ECHO (see definite and
The tables below are empiric treatment
[...] possible below)
and that Abx choice should change
In general it flows like this:
depending on culture+sensitivity.
- in acute endocarditis: identify risk
factors, identify new murmur, then get
cultures and start empiric Abx, get TEE to
confirm, continue cultures and Abx until
they are negative
- in subacute endocarditis: identify any
minor criteria present, get 3 cultures (but
do not start Abx until 1 is positive), get
TEE to confirm
1367. A pt is dx with A pt is dx with endocarditis. He has native

endocarditis. He has valves. What is the empiric treatment?
native valves. What Vancomycin
is the empiric The tables below are empiric treatment
treatment? and that Abx choice should change
[...] depending on culture+sensitivity.
213 of 340
1371. A pt is diagnosed A pt is diagnosed with acute endocarditis. 1374. A pt is diagnosed A pt is diagnosed with endocarditis.
with acute What are the indications for surgery? with endocarditis. Culture comes back positive for
endocarditis. What (see below) Culture comes back Streptococcus bovis. What is the likely
are the indications Surgery in endocarditis key points: positive for source of infection?
for surgery? - aimed towards preventing ( or mitigating) Streptococcus Colon
[...] CHF and/or embolization. bovis. What is the Streptococcus bovis = colon
- CHF can manifest due to chordae likely source of Staphylococcus aureus = skin = likely
rupture or valvular insufficiency infection? IVDA and tricuspid endocarditis
- acute valve rupture and CHF are the [...] Streptococcus anything = think dental
strongest indications for surgery procedure/disease
- the sicker the pt, the sooner surgery
is considered and performed (someone
1375. A pt is diagnosed A pt is diagnosed with endocarditis.
in acute uncompensated cardiogenic
with endocarditis. Culture comes back positive for
shock is going to the OR right away vs.
Culture comes back Streptococcus bovis. What diagnostic
someone with compensated
positive for test should be considered in this pt?
insufficiency); ultimately it's a judgement
Streptococcus Colonoscopy
call
bovis. What Streptococcus bovis = colon = occult
- regarding embolization: it is not a
diagnostic test cancer (consider the same with
judgement call; even if there is stroke or
should be Clostridium sp. or other clsasical GI flora)
MI, surgery in endocarditis is still indicated
considered in this Staphylococcus aureus = skin = likely
- additional surgery indications include:
pt? IVDA and tricuspid endocarditis
new AV block or any fungal
[...] Streptococcus anything = think dental
endocarditis
procedure/disease

1372. What is the first line What is the first line drug used for ppx
drug used for ppx against endocarditis?
Culture comes back Staphylococcus aureus. What is the
against Amoxicillin
positive for likely source of infection?
endocarditis?
Staphylococcus Skin
[...]
aureus. What is the
likely source of
1373. What are the What are the indications for ppx against infection? Streptococcus bovis = colon
indications for ppx infective endocarditis? [...] Staphylococcus aureus = skin = likely
against infective "Bad valve" or "mouth & throat" IVDA and tricuspid endocarditis
endocarditis? Streptococcus anything = think dental
[...] procedure/disease
To make it easier, think of it this way:
- anyone with a "bad valve" (i.e.
congenital defect, prosthetic valve, or a
history of endocarditis)
Culture comes back Streptococcus viridans. What is the
- anyone getting a "mouth and throat"
positive for likely source of infection?
procedure such as dental procedures or
Streptococcus Mouth
Bx of the airway/pharynx
viridans. What is Streptococcus bovis = colon
the likely source of Staphylococcus aureus = skin = likely
infection? IVDA and tricuspid endocarditis
[...] Streptococcus anything = think dental
procedure/disease
214 of 340
1378. What is the best What is the best initial test for 1381. What is the cause of What is the cause of Lyme disease?
initial test for endocarditis? Lyme disease? Borrelia burgdorferi from tick bites
endocarditis? Blood culture (95-99% sensitive) [...] Lyme Disease basics:
[...] - transmission is via the Ixodes
scapularis tick
TTE is 60% sensitive, but 95-100% - only 20% of bite bictims remember being
specific bit
TEE is 95% sensitive and specific' - some models say that the tick must be
EKG is 5-10% sensitive in revealing AV attached for ~24 hrs to transmit the
block if there is dissection of the bacteria
conduction system - the tick is typically only found in the NE
(Connecticut, Massachusetts, NY, NJ,
Maine, etc.)
common cause of culture-negative endocarditis?
culture-negative Coxiella
endocarditis? Culture-negative endocarditis 1382. Where is the tick that Where is the tick that transmits Lyme
[...] - typically involves bugs that have low transmits Lyme disease commonly found?
virulence and difficult to culture (i.e. think disease commonly NE USA (Connecticut, Maine,
subacute endocarditis) found? Massachusetts, NY, NJ, etc.)
- also consider Bartonella and the [...]
HACEK group of bugs
- use ceftriaxone for the HACEK group Lyme Disease basics:
- transmission is via the Ixodes
scapularis tick
- only 20% of bite bictims remember being
bit
1380. A pt is diagnosed w/ A pt is diagnosed w/ culture-negative
- some models say that the tick must be
culture-negative endocarditis. You suspect a bug from the
attached for ~24 hrs to transmit the
endocarditis. You HACEK group. What is the best empiric
bacteria
suspect a bug from therapy?
- the tick is typically only found in the NE
the HACEK group. Ceftriaxone
(Connecticut, Massachusetts, NY, NJ,
What is the best Culture-negative endocarditis
Maine, etc.)
empiric therapy? - typically involves bugs that have low
[...] virulence and difficult to culture (i.e. think
subacute endocarditis)
- also consider Bartonella and the
HACEK group of bugs
- use ceftriaxone for the HACEK group
215 of 340
1383. What is the most What is the most commonly affected joint 1385. What is the most What is the most common cardiac
commonly affected in Lyme disease? common cardiac manifestation of Lyme disease?
joint in Lyme Knee manifestation of Transient AV block
disease? Lyme disease?
[...] [...]
Lyme presentation key points: Lyme presentation key points:
- erythema migrans is the most common - fever and rash are the typical initial
manifestation and is the rash that presentations
develops (85-90% of cases); described as - erythema migrans is the most common
a round, red, target-shaped rash manifestation and is the rash that
- joint pain is the most common long term develops (85-90% of cases); described as
manifestation (60% of untreated cases) a round, red, target-shaped rash
and typically involves the knee - joint pain is the most common long term
- CNS manifestations are seen in 10-15% manifestation (60% of untreated cases)
of cases; most common is CN VII palsy and typically involves the knee
- cardiac manifestations are the rarest - CNS manifestations are seen in 10-15%
(4-10%) and can present as myocarditis of cases; most common is CN VII palsy
or arrhythmia (most common cardiac - cardiac manifestations are the rarest
manifestation is transient AV block) (4-10%) and can present as myocarditis
or arrhythmia (most common cardiac
manifestation is transient AV block)
1384. What is the most What is the most common neurological
common manifestation of Lyme disease?
neurological Bell Palsy (CN VII) 1386. What is the What is the diagnostic test for Lyme
manifestation of Lyme presentation key points: diagnostic test for disease?
Lyme disease? - fever and rash are the typical initial Lyme disease? Dx is clinical; but if needed, serology
[...] presentations [...]
- erythema migrans is the most common
manifestation and is the rash that Lyme Disease Dx key points:
develops (85-90% of cases); described as - Lyme is typically dx clinically, especially
a round, red, target-shaped rash if the classical rash is seen
- joint pain is the most common long term - however, if there are other
manifestation (60% of untreated cases) manifestations, serological testing is
and typically involves the knee needed as Lyme is not a common cause
- CNS manifestations are seen in 10-15% for arthralgia, CN VII palsy, AV block (and
of cases; most common is CN VII palsy other possible manifestations)
- cardiac manifestations are the rarest - if pursued, testing is via IgM, IgG,
(4-10%) and can present as myocarditis ELISA, Western Blot and PCR
or arrhythmia (most common cardiac
manifestation is transient AV block)
1387. A pt is diagnosed A pt is diagnosed with Lyme disease. The
with Lyme disease. only manifestation she has is the rash.
The only What is the treatment?
manifestation she Doxycycline; amoxicillin or cefuroxime
has is the rash.
What is the
treatment?
[...]
216 of 340
1388. A pt is dx with Lyme A pt is dx with Lyme disease. She has the 1391. What is the most What is the most accurate test for HIV?
disease. She has the rash, arthralgia and CNVII palsy. What is accurate test for Western Blot
rash, arthralgia and the treatment? HIV?
CNVII palsy. What is Doxycycline; amoxicillin or cefuroxime [...]
the treatment? HIV Dx, Tx, management key points:
[...]
1. Get the ELISA
2. Confirm with western blot or viral load
1389. A pt is dx with Lyme A pt is dx with Lyme disease. She has the
(if a baby; via PCR-RNA/culture); note
disease. She has the rash, arthralgias and the transient AV
that during the 6 week period following
rash, arthralgias and block associated with the disease. What
infection, only viral load can be used as
the transient AV is the treatment?
antibodies are not yet formed
block associated IV ceftriaxone
3. Perform viral resistance testing (via
with the disease.
genotyping) prior to HAART
What is the
4. Begin HAART
treatment?
5. Use CD4 count to gauge the pt's
[...]
current risk of infection
6. Use viral load to assess for response
1390. What is the best What is the best initial test for HIV? to treatment and to predict impending
initial test for HIV? ELISA changes in CD4 count
[...] HIV Dx, Tx, management key points:
1392. A pt has HIV/AIDS. A pt has HIV/AIDS. At what CD4 count

1. Get the ELISA
At what CD4 count should ppx against PCP be considered?
2. Confirm with western blot or viral load
should ppx against < 200 (with TMP-SMX or dapsone)
(if a baby; via PCR-RNA/culture); note
PCP be considered?
that during the 6 week period following
[...]
infection, only viral load can be used as
antibodies are not yet formed
3. Perform viral resistance testing (via
genotyping) prior to HAART
4. Begin HAART 1393. A pt has HIV/AIDS. A pt has HIV/AIDS. At what CD4 count
5. Use CD4 count to gauge the pt's At what CD4 count should ppx against MAC be considered?
current risk of infection should ppx against < 50 (with Azithromycin)
6. Use viral load to assess for response MAC be
to treatment and to predict impending considered?
changes in CD4 count [...]
1394. A pt has HIV/AIDS A pt has HIV/AIDS with a CD4 count <

with a CD4 count < 200. What can be used for ppx against
200. What can be PCP?
used for ppx against TMP-SMX; or dapsone
PCP?
[...]
217 of 340
1395. A pt has HIV/AIDS A pt has HIV/AIDS with a CD4 count of < 1401. A pt is found to be A pt is found to be HIV+. What other
with a CD4 count of 50. What can be used as ppx against HIV+. What other possible coinfections should you also
< 50. What can be MAC? possible coinfections screen for?
used as ppx against Azithromycin should you also HBV, HCV and cervical cancer
MAC? screen for?
[...] [...]
i.e. infections 2/2 risky behaviour (IVDA
and unprotected sexytime)
1396. A pt has HIV/AIDS. A pt has HIV/AIDS. At which CD4 count 1402. What CD4 count is What CD4 count is the threshold to begin
At which CD4 count does PCP pneumonia become a worry? the threshold to HAART in HIV/AIDS?
does PCP < 200 begin HAART in < 350-500 (depends on your source)
pneumonia become HIV/AIDS?
a worry? [...]
[...] OR viral load > 55000
1397. A pt has HIV/AIDS. A pt has HIV/AIDS. At what CD4 count 1403. What viral load is the What viral load is the threshold to begin
At what CD4 count does HSV/CMV esophagitis become a threshold to begin HAART in HIV/AIDS?
does HSV/CMV worry? HAART in > 55,000
esophagitis become < 100 HIV/AIDS?
a worry? [...]
[...] OR CD4 < 350-500 ("CD4 less than tree
fiddy")
- sources are varying here so please don't
shoot me (MTB says < 500, others < 350)
At what CD4 count does toxoplasmosis become a worry?
does < 100
toxoplasmosis
become a worry?
[...]

At what CD4 count does disseminated MAC infection become
does disseminated a worry?
MAC infection < 50
become a worry?
[...]

At what CD4 count does CMV retinitis become a worry?
does CMV retinitis < 50
become a worry?
[...]
218 of 340
1404. A pt is diagnosed w/ A pt is diagnosed w/ HIV/AIDS. What is 1405. A cheeky but A cheeky but unfortunate medical student
HIV/AIDS. What is the general rule for deciding which unfortunate medical is stuck with a suture needle during a
the general rule for HAART drugs to use? student is stuck with procedure on a HIV+ patient. What is the
deciding which "2+1" a suture needle recommended post-exposure
HAART drugs to during a procedure prophylaxis?
use? on a HIV+ patient. 2+1 for 4 weeks; f/u w/ viral load
[...] 2+1 approach to HAART: What is the
- involves 2 NRTIs + 1 protease inhibitor recommended
- this is a very effective regimen at post-exposure 2+1 approach to HAART:
reducing viral load and providing prophylaxis? - involves 2 NRTIs + 1 protease inhibitor
exposure prophylaxis [...] - this is a very effective regimen at
- can get viral load to <50 in 4-6 months reducing viral load and providing
and a failure to do so is indicative of either exposure prophylaxis
compliance issues or viral resistance to - can get viral load to <50 in 4-6 months
therapy and a failure to do so is indicative of either
- when viral load is < 50, CD4 typically compliance issues or viral resistance to
rises, preventing opportunistic infections therapy
- a quick fix in this case is to give protease - a quick fix in this case is to give protease
inhibitors a "boost" with low dose inhibitors a "boost" with low dose
ritonavir which is synergistic ritonavir which is synergistic
- use 2+1 for 4 weeks in someone that - use 2+1 for 4 weeks in someone that
has has risk exposure and follow-up by has has risk exposure (needle stick,
testing viral load rape, condom failure, etc.) and follow-up
- 2+1 can prevent vertical transmission by testing viral load
during birth - 2+1 can prevent vertical transmission
during birth
diagnostic test for HIV/AIDS in infants?
HIV/AIDS in infants? Viral load (PCR-RNA)
[...] This is because maternal HIV antibodies
can be present in the baby for up to 6
months.
Also, there's this:
"The Centers for Disease Control and

Prevention no longer recommends the
use of enzyme immunoassay antibody
testing with a confirmatory Western blot
[37]. Instead, laboratory-based fourth
generation assays that detect HIV p24
antigen and HIV antibodies should be
used and, if positive, followed by a
confirmatory HIV-1/HIV-2 antibody
differentiation immunoassay. These tests
are better able to diagnose acute infection
when antibody may not yet be detectable
(ie, during the "window period” of acute
HIV infection)."
219 of 340
1413. What is the notable What is the notable side effect of the
1407. A pt is dx w/ A pt is dx w/ HIV/AIDS. What additional side effect of the anti-HIV drug indinavir?
HIV/AIDS. What test should be performed prior to HAART? anti-HIV drug Nephrolithiasis
additional test Viral resistance testing (genotyping) indinavir?
should be performed [...]
prior to HAART?
[...] This will decrease the likelihood of started
1414. Which HAART drug Which HAART drug is c/i in pregnancy
the wrong meds and maximize treatment
is c/i in pregnancy due to its teratogenicity?
response.
due to its Efavirenz
teratogenicity?
1408. A pt has HIV/AIDS. A pt has HIV/AIDS. What is the best test [...]
What is the best test to gauge treatment response/failure?
to gauge treatment Viral load (RNA-PCR)
1415. Which HAART drug Which HAART drug is recommended to
response/failure?
is recommended to be given to baby's during delivery and for
[...]
be given to baby's 6 weeks afterwards to prevent vertical HIV
While CD4 count does change in
during delivery and transmission during birth?
response to treatment (or failure to
for 6 weeks Zidovudine (AZT)
treatment), it lags behind and is much
afterwards to
slower to change vs. viral load.
prevent vertical HIV
transmission during
1409. A pt has a HLA-B A pt has a HLA-B 4701 mutation. Which birth?
4701 mutation. HAART drug is a dangerous choice? [...]
Which HAART drug Abacavir
is a dangerous
1416. A pregnant woman A pregnant woman has HIV. What is the
choice?
has HIV. What is the threshold viral load (in pregnancy) at
[...]
threshold viral load which a caesarean delivery is indicated?
(in pregnancy) at > 1000 uL
1410. Which drug is used Which drug is used with HIV protease which a caesarean
with HIV protease inhibitors to boost their levels? delivery is indicated?
inhibitors to boost Ritonavir (as a small dose) [...]
their levels?
[...]
1417. Which layer of the Which layer of the skin is affected in
skin is affected in impetigo?
1411. Which 2 HIV entry Which 2 HIV entry inhibitors are used in impetigo? Hypodermis
inhibitors are used in HIV therapy if drug resistance is present? [...]
HIV therapy if drug Maraviroc; enfuvirtide
resistance is
present?
1418. What is the What is the diagnostic test for lice?
[...]
diagnostic test for Inspection (i.e. clinical)
lice?
1412. What is the notable What is the notable side effect of [...]
side effect of zidovudine?
zidovudine? Anaemia
1419. What is the What is the treatment for lice?
[...]
treatment for lice? Promethin shampoo
[...]
220 of 340
1420. A pt presents c/o of A pt presents c/o of swelling and draining 1422. What is the What is the treatment for impetigo?
swelling and draining of the skin. Physical exam reveals a treatment for (see below)
of the skin. Physical honey-coloured, crusted lesion with impetigo?
exam reveals a surrounding swelling, weeping, and [...]
honey-coloured, oozing. Which skin infection is the likely Impetigo treatment key points:
crusted lesion with dx? - many options exist and it depends on
surrounding Impetigo the clinical picture
swelling, weeping, - for mild cases, consider topical agents
and oozing. Which such as mupirocin
skin infection is the - for severe cases, consider oral agents
likely dx? such as dicloxacillin or cephalexin
[...] (Keflex); some sources say to start with
amoxicillin first, then switch if no
response, but other sources say not to
1421. A pt presents c/o of A pt presents c/o of swelling and draining
due to resistance rates
swelling and draining of the skin. Physical exam reveals a
- for cases with suspected MRSA,
of the skin. Physical honey-coloured, crusted lesion with
consider TMP-SMX or clindamycin
exam reveals a surrounding swelling, weeping, and
Skin infection treatment key points:
honey-coloured, oozing. You suspect impetigo. What is
- most skin infections are treated similarly
crusted lesion with the most likely causal organism?
(unless fungal)
surrounding
- for mild disease, use oral agents that
swelling, weeping,
also cover Staphylococcus
and oozing. You Staphylococcus aureus;
--- e.g. dicloxacillin, oxacillin, nafcillin
suspect impetigo. Streptococcus pyogenes
--- e.g. cephalexin, cefadroxyl
What is the most (beta-hemolytic, group A strep)
--- e.g. macrolide if PCN allergic
likely causal
--- e.g. clindamycin or TMP-SMX for
organism?
MRSA
Important to remember S. pyogenes due
- for severe disease, use IV agents such
to the association with poststreptococcal
as:
[...] glomerulonephritis.
--- e.g. oxacillin, nafcillin
--- e.g. clindamycin or vancomycin if PCN
allergic
--- e.g. vancomycin, linezolid, daptomycin
for MRSA
1423. A pt c/o of an itchy A pt c/o of an itchy groin. Physical exam

groin. Physical exam reveals patchy discolouration of the skin
reveals patchy at the groin. You suspect a fungal
discolouration of the infection. What is the best initial test in
skin at the groin. diagnosis?
You suspect a fungal KOH prep (follow up w/ culture)
infection. What is the
best initial test in
diagnosis?
[...]
221 of 340
1424. A pt c/o of an itchy A pt c/o of an itchy groin. Physical exam 1427. A pt presents c/o of A pt presents c/o of a painful rash.
groin. Physical exam reveals patchy discolouration of the skin a painful rash. Physical exam reveals an area of
reveals patchy at the groin. You suspect a fungal Physical exam erythematous, edematous, and warm
discolouration of the infection. KOH prep and culture confirm. reveals an area of skin that is tender to the touch. You
skin at the groin. What is the treatment? erythematous, suspect typical cellulitis. What is the best
You suspect a fungal Topical antifungal (Terbinafine is the edematous, and initial step in workup?
infection. KOH prep best choice) warm skin that is XR to rule out Osteomyelitis
and culture confirm. tender to the touch. Cellulitis is typically a clinical diagnosis
What is the You suspect typical (no need to culture) and it is prudent to
treatment? cellulitis. What is the rule out Osteomyelitis prior to starting
[...] best initial step in treatment. If osteolytic changes are seen
workup? on XR, continue on with the workup for
[...] osteo (MRI --> Bx if needed).
1425. A pt c/o of ugly A pt c/o of ugly toenails. Physical exam
toenails. Physical reveals distal subungual hyperkeratosis
exam reveals distal with yellow-brown discolouration. You
subungual suspect a fungal infection. What is the
hyperkeratosis with treatment?
yellow-brown PO Antifungals 1428. A pt presents c/o of A pt presents c/o of a painful rash.
discolouration. You a painful rash. Physical exam reveals an area of
suspect a fungal Physical exam erythematous, edematous, and warm
infection. What is the reveals an area of skin that is tender to the touch. He is dx
treatment? erythematous, with typical cellulitis. What is the
[...] edematous, and treatment?
warm skin that is Anti-staphylococcal PCN or 1st gen
tender to the touch. cephalosporin (i.e. dicloxacillin or
1426. A pt complains of A pt complains of multiple skin lesions.
He is dx with typical cephalexin)
multiple skin lesions. Physical exam reveals multiple annular
cellulitis. What is the Anti-staphylococcal PCNs are the "OXen"
Physical exam erthematous lesions with scaly
treatment? such as oxacillin, dicloxacillin,
reveals multiple vesiculated borders on the trunk. What
[...] cloxacillin, nafcillin.
annular fungal infection is the likely dx?
Skin infection treatment key points:
erthematous Tinea Corporis
- most skin infections are treated similarly
lesions with scaly
(unless fungal)
vesiculated
- for mild disease, use oral agents that
borders on the
also cover Staphylococcus
trunk. What fungal
--- e.g. dicloxacillin, oxacillin, nafcillin
infection is the likely
--- e.g. cephalexin, cefadroxyl
dx?
--- e.g. macrolide if PCN allergic
[...]
--- e.g. clindamycin or TMP-SMX for
MRSA
- for severe disease, use IV agents such
as:
allergic
for MRSA
222 of 340
1429. A pt presents c/o of A pt presents c/o of a painful rash on his 1433. What is the best What is the best radiographic test for
a painful rash on thigh. Physical exam reveals an area of radiographic test osteomyelitis?
his thigh. Physical erythematous, edematous, and warm for osteomyelitis? MRI
exam reveals an skin that is tender to the touch. Your [...]
area of observant medical student notices sinus
erythematous, draining tracts. What is the most likely
edematous, and diagnosis?
1434. What is the empiric What is the empiric treatment for
warm skin that is Osteomyelitis
treatment for osteomyelitis?
tender to the touch.
osteomyelitis? Vancomycin + piperacillin-tazobactam
Your observant
[...] (Zosyn)
medical student
Change treatment accordingly following
notices sinus
culture results.
draining tracts.
What is the most
likely diagnosis?
[...] 1435. What is the most What is the most common cause of
common cause of ostemyelitis?
ostemyelitis? Staphylococcus aureus
1430. A pt presents c/o of A pt presents c/o of a painful rash on his
[...]
a painful rash on thigh. Physical exam reveals an area of
his thigh. Physical erythematous, edematous, and warm
exam reveals an skin that is tender to the touch. Your
area of observant medical student notices sinus
erythematous, draining tracts. You suspect
edematous, and ostemyelitis. What is the best initial step in 1436. What cause of What cause of osteomyelitis is associated
warm skin that is workup? osteomyelitis is with sickle cell disease?
tender to the touch. XR associated with Salmonella
Your observant sickle cell disease?
medical student [...]
notices sinus Staph aureus is still the most common!
draining tracts. You
suspect ostemyelitis.
What is the best
initial step in 1437. What cause of What cause of osteomyelitis is associated
workup? osteomyelitis is with penetrating sneakers?
[...] associated with Pseudomonas
penetrating
1431. What is the best What is the best initial test for sneakers?
initial test for osteomyelitis? [...]
osteomyelitis? XR
[...]
1438. What cause of What cause of osteomyelitis is associated
osteomyelitis is with erysipelas?
1432. What is the most What is the most accurate test for associated with Streptococcus pyogenes
accurate test for osteomyelitis? erysipelas?
osteomyelitis? Bone biopsy [...]
[...]
223 of 340
1439. A pt presents c/o of A pt presents c/o of a rash on his leg. 1442. A pt presents c/o of A pt presents c/o of a rash on his leg.
a rash on his leg. Physical exam reveals an area of a rash on his leg. Physical exam reveals an area of
Physical exam erythema, edema, and warmth on the Physical exam erythema, edema, and warmth on the
reveals an area of right leg. You also notice crepitus. You reveals an area of right leg. He also exhibits pain out of
erythema, edema, suspect gas gangrene. What is the best erythema, edema, proportion to your palpation and you
and warmth on the initial step in workup? and warmth on the notice bluish-gray cutaneous gangrene.
right leg. You also XR right leg. He also he is dx with necrotizing fasciitis. What is
notice crepitus. You XR will show gas dissecting tissue exhibits pain out of the next step in management?
suspect gas proportion to your Broad surgical debridement + broad
gangrene. What is palpation and you spectrum Abx
the best initial step in notice bluish-gray Hyperbaric O2 can help decrease
workup? cutaneous mortality but it should only be employed if
[...] gangrene. he is dx it does not delay definitive therapy.
with necrotizing - Nec fasc has a mortality of ~50% even
fasciitis. What is the when treated properly
1440. A pt presents c/o of A pt presents c/o of a rash on his leg.
next step in
a rash on his leg. Physical exam reveals an area of
management?
Physical exam erythema, edema, and warmth on the
[...]
reveals an area of right leg. You also notice crepitus. XR
erythema, edema, reveals gas dissecting tissue and he is
and warmth on the dx with gas gangrene. What is the most 1443. A pt presents c/o of A pt presents c/o of a rash on his face.
right leg. You also likely causal organism? a rash on his face. Physical exam reveals a red, hot,
notice crepitus. XR Clostridium perfringens Physical exam swollen lesion w/ erythematous
reveals gas reveals a red, hot, streaks suggesting ascending
dissecting tissue swollen lesion w/ lymphadenitis. He also c/o fever and
and he is dx with gas erythematous chills. What is the most likely dx?
gangrene. What is streaks suggesting Erysipelas
the most likely ascending
causal organism? lymphadenitis. He
[...] also c/o fever and Erysipelas key points:
chills. What is the - more severe than impetigo; involves
most likely dx? deeper skin layers (including dermal
1441. A pt presents c/o of A pt presents c/o of a rash on his leg.
[...] lymphatics and blood vessels)
a rash on his leg. Physical exam reveals an area of
- leukocytosis and bacteremia can be
Physical exam erythema, edema, and warmth on the
seen as it is often systemic
reveals an area of right leg. You also notice crepitus. XR
- the red streaks are characteristic of
erythema, edema, reveals gas dissecting tissue and he is
ascending lymphadenitis known to be
and warmth on the dx with gas gangrene. What is the next
involved with the condition
right leg. You also step in management?
- most often caused by Streptococcus
notice crepitus. XR Emergency debridement (+ PCN +
sp, but Staphylococcus is also seen and
reveals gas clindamycin)
must be treated for as well
dissecting tissue
and he is dx with gas
gangrene. What is A hyperbaric O2 chamber is toxic to C.
the next step in perfringens and is sometimes used as
management? ancillary treatment.
[...]
224 of 340
1444. What is the What is the treatment for erysipelas? 1448. Folliculitis, foruncles, Folliculitis, foruncles, and carbuncles are
treatment for (see below) and carbuncles are all skin infections associated w/ hair
erysipelas? all skin infections follicles. Which of the three is the mildest?
[...] associated w/ hair Folliculitis
Skin infection treatment key points: follicles. Which of
- most skin infections are treated similarly the three is the
(unless fungal) mildest? Folliculitis/furuncle/carbuncle key
- for mild disease, use oral agents that [...] points:
also cover Staphylococcus - Folliculitis is the earliest and mildest
--- e.g. dicloxacillin, oxacillin, nafcillin - Furuncle (shown below) is a small
--- e.g. cephalexin, cefadroxyl abscess that typically forms from
--- e.g. macrolide if PCN allergic folliculitis infected material
--- e.g. clindamycin or TMP-SMX for - Carbuncle is a collection of furuncles
MRSA - all 3 are treated as a typical skin
- for severe disease, use IV agents such infection
as:
1449. What is the best What is the best initial test for all
initial test for all superficial fungal skin infections?
allergic
superficial fungal KOH prep
skin infections?
for MRSA
[...]
Superficial Fungal Skin Infection
1445. What is the most What is the most accurate test for (Tinea) key points:
accurate test for cellulitis? - named by the body part affected
cellulitis? Injection of sterile saline into the skin - best initial test is KOH prep (KOH
[...] and aspiration for culture removes any skin cells in the sample
leaving fungi to be identified)
- most accurate test is fungal culture
However, the diagnostic yield is only 20%, - Tx is topical antifungal if hair/nails are
so typically the dx is clinical. not involved
- Tx is oral antifungal if hair/nails are
involved
common cause of cellulitis?
cellulitis? Staphylococcus sp. 1450. Which antifungal Which antifungal agent is known to cause
[...] agent is known to gynecomastia when given orally?
cause gynecomastia Ketoconazole
when given orally?
1447. What is the only What is the only cephalosporin that
[...]
cephalosporin that covers MRSA?
It has antiandrogenic effects
covers MRSA? Ceftaroline (5th gen)
[...]
1451. What is the best What is the best initial test for both oral
initial test for both and vaginal candidiasis?
oral and vaginal KOH prep
candidiasis?
[...]
225 of 340
1452. A pt presents c/o of A pt presents c/o of a mole. Physical 1455. A pt presents c/o of A pt presents c/o of a skin lesion on his
a mole. Physical exam reveals that it is 7 mm in size with a skin lesion on his face. Physical exam reveals an
exam reveals that it symmetric borders and uniform face. Physical exam erythematous pigmented lesion with a
is 7 mm in size with pigmentation. Should this be biopsied? reveals an sandpaper-like yellow-brown scaly
symmetric borders Technically, yes. erythematous appearance. The pt states that he spends
and uniform pigmented lesion a lot of time in the sun working in
pigmentation. with a construction. You suspect actinic
Should this be If there is 1 of the ABCDE criteria present, sandpaper-like keratosis. What is the diagnostic test of
biopsied? biopsy is warranted. yellow-brown scaly choice?
[...] appearance. The pt Biopsy
states that he
spends a lot of time
in the sun working in This is premalignant, so a biopsy is
1453. A pt presents c/o of A pt presents c/o of a mole. Physical
construction. You definitely a good call, even if your clinical
a mole. Physical exam reveals that it is 7 mm in size with
suspect actinic suspicion is high enough to make Actinic
exam reveals that it symmetric borders and uniform
keratosis. What is Keratosis the Dx.
is 7 mm in size with pigmentation. You decide to biopsy the
the diagnostic test of
symmetric borders lesion. What biopsy technique should be
choice?
and uniform employed?
[...]
pigmentation. You Wide excisional biopsy (do not pick
decide to biopsy the shave biopsy)
lesion. What biopsy 1456. A pt presents c/o of A pt presents c/o of a skin lesion on his
technique should be a skin lesion on his face. Physical exam reveals an
employed? If there is 1 of the ABCDE criteria present, face. Physical exam erythematous pigmented lesion with a
[...] biopsy is warranted. reveals an sandpaper-like yellow-brown scaly
erythematous appearance. The pt states that he spends
pigmented lesion a lot of time in the sun working in
1454. A 80 y/o pt presents A 80 y/o pt presents c/o of a pigmented
with a construction. You suspect actinic
c/o of a pigmented lesion on his face. Physical exam reveals
sandpaper-like keratosis. Is this malignant?
lesion on his face. a large, brown, greasy-looking, and
yellow-brown scaly No, but it can become malignant
Physical exam crusted pigmented lesion that appears
appearance. The pt
reveals a large, stuck on the pt's face. You suspect
states that he
brown, seborrheic keratosis. What is the first-line
spends a lot of time Actinic Keratosis is essentially squamous
greasy-looking, treatment?
in the sun working in cell carcinoma in the making and involves
and crusted
construction. You the same risk factors.
pigmented lesion
suspect actinic - while each individual lesion has a small
that appears stuck Nothing; if stable, leave it alone; if
keratosis. Is this risk, the risk is cumulative and
on the pt's face. You evolving, consider Bx and excision; if
malignant? significant when there are multiple
suspect seborrheic removed for cosmetic reasons
[...] lesions
keratosis. What is consider cryo or surgery
- since multiple lesions typically manifest
the first-line
in pts, treatment is imperative before
treatment?
transformation into Bowen's Disease
- Bowen's Disease is essentiall SCC in
situ
[...]
226 of 340
1457. A pt presents c/o of A pt presents c/o of a skin lesion on his 1460. A pt w/ a history of A pt w/ a history of actinic keratosis
a skin lesion on his face. Physical exam reveals an actinic keratosis present c/o of a lesion on his lower lip.
face. Physical exam erythematous pigmented lesion with a present c/o of a Physical exam reveals a flesh-coloured,
reveals an sandpaper-like yellow-brown scaly lesion on his lower erythematous, crusted lesion on the
erythematous appearance. The pt states that he spends lip. Physical exam lower lip. You suspect squamous cell
pigmented lesion a lot of time in the sun working in reveals a carcinoma. What is the best initial
with a construction. You suspect actinic flesh-coloured, diagnostic test?
sandpaper-like keratosis. What is the first-line treatment? erythematous, Biopsy
yellow-brown scaly Cryosurgery (esp. if it is a small lesion) crusted lesion on
appearance. The pt the lower lip. You
states that he suspect squamous
spends a lot of time cell carcinoma. What
in the sun working in is the best initial
construction. You diagnostic test?
suspect actinic [...]
keratosis. What is
the first-line
1461. A pt w/ a history of A pt w/ a history of actinic keratosis
treatment?
actinic keratosis present c/o of a lesion on his lower lip.
[...]
present c/o of a Physical exam reveals a flesh-coloured,
lesion on his lower erythematous, crusted lesion on the
1458. A pt presents c/o of A pt presents c/o of a skin lesion on his lip. Physical exam lower lip. You suspect squamous cell
a skin lesion on his face. Physical exam reveals an reveals a carcinoma, but a biopsy is negative.
face. Physical exam erythematous pigmented lesion with a flesh-coloured, Months later, the pt comes in for a
reveals an sandpaper-like yellow-brown scaly erythematous, follow-up and reports that the lesion went
erythematous appearance. The pt states that he spends crusted lesion on away on its own. What is the most likely
pigmented lesion a lot of time in the sun working in the lower lip. You diagnosis?
with a construction. You suspect actinic suspect squamous Keratocanthoma
sandpaper-like keratosis. Cryosurgery is not effective. cell carcinoma, but a If it looks and sounds like SCC, but
yellow-brown scaly What treatment should be considered biopsy is negative. mysteriously vanished on its own, it's
appearance. The pt next? Months later, the pt likely keratocanthoma.
states that he Topical 5-FU (esp. if diffuse lesions); or comes in for a
spends a lot of time imiquimod follow-up and reports
in the sun working in that the lesion went
construction. You away on its own.
suspect actinic What is the most
keratosis. likely diagnosis?
Cryosurgery is not [...]
effective. What
treatment should be
1462. A pt with HIV/AIDS A pt with HIV/AIDS presents c/o of weird
considered next?
presents c/o of weird skin lesions. Physical exam reveals
[...]
skin lesions. multiple, raised, purple, painless
Physical exam lesions on the arms, face and trunk.
1459. On which lip does On which lip does squamous cell reveals multiple, What is the most likely Dx?
squamous cell carcinoma of the skin typically manifest? raised, purple, Kaposi Sarcoma
carcinoma of the Lower lip painless lesions on
skin typically "BS": the arms, face and
manifest? BCC = upper lip trunk. What is the
[...] SCC = lower lip most likely Dx?
[...]
227 of 340
1463. A pt with HIV/AIDS A pt with HIV/AIDS presents c/o of weird 1467. A pt presents c/o of A pt presents c/o of a skin lesion on his
presents c/o of weird skin lesions. Physical exam reveals a skin lesion on his nose. Physical exam reveals a waxy,
skin lesions. multiple, raised, purple, painless nose. Physical exam shiny, pearl-like lesion. You suspect
Physical exam lesions on the arms, face and trunk. reveals a waxy, basal cell carcinoma. What is the best
reveals multiple, You suspect Kaposi sarcoma. What is the shiny, pearl-like initial diagnostic test?
raised, purple, treatment? lesion. You suspect Shave biopsy
painless lesions on HAART basal cell carcinoma.
the arms, face and What is the best
trunk. You suspect initial diagnostic Unlike SCC, wide margins are not
Kaposi sarcoma. Treat the AIDS. An increase in CD4 count test? necessary in BCC, so a shave biopsy is
What is the will help resolve the disease. [...] possible.
treatment? If HAART and rising CD4 count is
[...] ineffective, pursue local/systemic
1468. Mohs Micrographic Mohs Micrographic Surgery is a surgical
chemotherapy (liposomal doxorubicin)
Surgery is a surgical procedure that is considered one of the
- local injections of vincristine or
procedure that is most precise methods of excising and
interferon are very successful
considered one of treating skin cancer. What does it entail?
the most precise (see below)
methods of excising
and treating skin
1464. A pt is dx with A pt is dx with melanoma. Which organ cancer. What does it Mohs Micrographic Surgery key points:
melanoma. Which does melanoma have a strong tendency entail? - involves dissection of the skin under
organ does to metastasize to? [...] direct microscopy with immediate
melanoma have a Brain frozen section formation
strong tendency to - the microscopy and frozen sections
metastasize to? together allow for the loss of the smallest
[...] amount of normal tissue
- the procedure is stopped as soon as the
margins are cancer free on frozen section
1465. Sunlight is the Sunlight is the biggest risk factor for
- this procedure removes the necessity of
biggest risk factor for squamous cell carcinoma of the skin. Why
wide margin excision and offers high
squamous cell would an organ-transplant recipient with
precision
carcinoma of the minimal sun exposure have an increased
skin. Why would an risk of SCC?
organ-transplant Long-term immunosuppressive 1469. What is the cause of What is the cause of Kaposi Sarcoma?
recipient with therapy Kaposi Sarcoma? HHV8 2/2 AIDS
minimal sun [...]
exposure have an
increased risk of Remember, HHV8 is oncogenic.
SCC? Interestingly, AIDS acquired from
[...] needles is rarely associated with KS
(AIDS via sexual contact is).
1466. What is the most What is the most common form of skin
common form of skin cancer? 1470. While kaposi While kaposi sarcoma has characteristic
cancer? BCC sarcoma has cutaneous manifestations, it can also
[...] characteristic manifest at other organs. Where?
cutaneous GI tract; Lungs
"BS": manifestations, it
BCC = upper lip can also manifest at
SCC = lower lip other organs.
Where?
[...]
228 of 340
1475. A pt presents c/o of A pt presents c/o of a non-pruritic rash

1471. A pt presents c/o of A pt presents c/o of a rash on his scalp. a non-pruritic rash and nail pitting. Physical exam reveals a
a rash on his scalp. Physical exam reveals a rash on the pt's and nail pitting. symmetric, well-demarcated rash
Physical exam scalp with flaking. Other areas of the Physical exam consisting of silvery-scales on an
reveals a rash on face and head are spared. What is the reveals a erythematous base. The rash is found
the pt's scalp with most likely dx? symmetric, on the extensor surface of the elbows
flaking. Other areas Seborrheic dermatitis well-demarcated and knees and on the back. Nail beds are
of the face and head Not to be confused with seborrheic rash consisting of pitted and mild onycholysis is seen at
are spared. What is keratosis. silvery-scales on the upper digits. The pt adds that the
the most likely dx? If the question mentions a rash on the an erythematous scales bleed easily when picked. What is
[...] scalp, think seborrheic dermatitis. base. The rash is the most likely dx?
found on the Psoriasis
extensor surface of
1472. A pt presents c/o of A pt presents c/o of a rash on his scalp. the elbows and
a rash on his scalp. Physical exam reveals a rash on the pt's knees and on the
Physical exam scalp with flaking. Other areas of the back. Nail beds are
reveals a rash on face and head are spared. You suspect pitted and mild
the pt's scalp with seborrheic dermatitis. What is the onycholysis is seen
flaking. Other areas diagnostic test? at the upper digits.
of the face and head None, it's clinical The pt adds that the
are spared. You scales bleed easily
suspect seborrheic when picked. What
dermatitis. What is is the most likely dx?
the diagnostic test? [...]
[...]
1476. A pt presents c/o of A pt presents c/o of a rash and nail
1473. A pt presents c/o of A pt presents c/o of a rash on his scalp. a rash and nail pitting. Physical exam reveals a
a rash on his scalp. Physical exam reveals a rash on the pt's pitting. Physical symmetric, well-demarcated rash
Physical exam scalp with flaking. Other areas of the exam reveals a consisting of silvery-scales on an
reveals a rash on face and head are spared. You suspect symmetric, erythematous base. The rash is found
the pt's scalp with seborrheic dermatitis. What is the well-demarcated on the extensor surface of the elbows
flaking. Other areas treatment? rash consisting of and knees. Nail beds are pitted and mild
of the face and head Selenium shampoo silvery-scales on onycholysis is seen at the upper
are spared. You an erythematous digits.The pt adds that the scales bleed
suspect seborrheic base. The rash is easily when picked. You suspect
dermatitis. What is found on the psoriasis. What is the best diagnostic
the treatment? extensor surface of test?
[...] the elbows and None, it's clinical; can Bx to rule out
knees. Nail beds are lymphoma if needed
pitted and mild
1474. What is the cause of What is the cause of seborrheic
onycholysis is seen
seborrheic dermatitis?
at the upper
dermatitis? Fungus
digits.The pt adds
[...]
that the scales bleed
easily when picked.
You suspect
psoriasis. What is
the best diagnostic
test?
[...]
229 of 340
1477. A pt presents c/o of A pt presents c/o of a rash and nail 1478. A pt presents c/o of A pt presents c/o of an evolving rash. He
a rash and nail pitting. Physical exam reveals a an evolving rash. He states that a few weeks ago he noticed a
pitting. Physical symmetric, well-demarcated rash states that a few single, flat, elliptical, salmon-coloured
exam reveals a consisting of silvery-scales on an weeks ago he macule that has now spread. Physical
symmetric, erythematous base. The rash is found noticed a single, exam reveals multiple salmon-coloured
well-demarcated on the extensor surface of the elbows flat, elliptical, scaly lesions with trailing scales. The
rash consisting of and knees. Nail beds are pitted and mild salmon-coloured palms and soles are spared. You suspect
silvery-scales on onycholysis is seen at the upper macule that has pityriasis rosea. What is the best
an erythematous digits.The pt adds that the scales bleed now spread. diagnostic test?
base. The rash is easily when picked. You suspect Physical exam
found on the psoriasis. UV light is tried but is reveals multiple
extensor surface of ineffective. What is the second-line salmon-coloured None, dx is clinical; however, RPR
the elbows and treatment? scaly lesions with must be ordered to rule out syphilis
knees. Nail beds are trailing scales. The
pitted and mild palms and soles are
onycholysis is seen Steroids (topical/oral); methotrexate; spared. You suspect Secondary syphilis can present this way
at the upper calcineurin-inhibitors; anti-TNFalpha pityriasis rosea. (even though the palms and soles are
digits.The pt adds agents What is the best typically spared in PR) and you don't want
that the scales bleed Methotrexate is typically a last resort due diagnostic test? to miss it.
easily when picked. to liver and lung side effects. - if the palms and soles are involved, it's
You suspect likely syphilis
psoriasis. UV light is [...]
tried but is
ineffective. What is
1479. Pityriasis rosea is a Pityriasis rosea is a self-limiting condition.
the second-line
self-limiting In how long should it resolve?
treatment?
condition. In how ~6 weeks
long should it
resolve?
[...]
[...]
230 of 340
1480. A pt presents c/o of A pt presents c/o of an evolving rash. He

1483. A pt presents c/o of A pt presents c/o of a a very itchy rash.
an evolving rash. He states that a few weeks ago he noticed a
states that a few single, flat, elliptical, salmon-coloured a a very itchy rash. Physical exam reveals pruritic,
weeks ago he macule that has now spread. Physical Physical exam pinkish-purple, flat-topped papules with
noticed a single, exam reveals multiple salmon-coloured reveals pruritic, a reticulated network of fine white lines
flat, elliptical, scaly lesions with trailing scales. The pinkish-purple, on the wrists and ankles. You suspect
salmon-coloured palms and soles are spared. You suspect flat-topped papules lichen planus. What is the first-line
macule that has pityriasis rosea. What is the treatment? with a reticulated treatment?
now spread. network of fine Topical steroids
Physical exam white lines on the Lichen Planus treatment key points:
reveals multiple None, self-limiting (resolves in ~6 wrists and ankles. - topical steroids are 1st line but should
salmon-coloured weeks) You suspect lichen not be used long term
scaly lesions with planus. What is the - UV light is an adjunct in this case (vs.
trailing scales. The first-line treatment? psoriasis where it is more effective)
palms and soles are [...] - oral steroids can be used for flares or
spared. You suspect severe cases
pityriasis rosea. - immune modulators used in severe
What is the cases
treatment? - if drug-induced, stop the causal agent
[...] 1484. A pt is diagnosed A pt is diagnosed with drug-induced

with drug-induced lichen planus. Which drugs are
1481. A pt presents c/o of A pt presents c/o of a a very itchy rash. lichen planus. considered the common causes?
a a very itchy rash. Physical exam reveals pruritic, Which drugs are BBs; ACE-Is; Thiazides; Furosemide
Physical exam pinkish-purple, flat-topped papules with considered the
reveals pruritic, a reticulated network of fine white lines common causes?
pinkish-purple, on the wrists and ankles. What is the [...]
flat-topped papules most likely dx?
with a reticulated Lichen Planus
network of fine
white lines on the
wrists and ankles.
What is the most
likely dx?
[...]
1482. A pt presents c/o of A pt presents c/o of a a very itchy rash.

a a very itchy rash. Physical exam reveals pruritic,
Physical exam pinkish-purple, flat-topped papules with
reveals pruritic, a reticulated network of fine white lines
pinkish-purple, on the wrists and ankles. You suspect
flat-topped papules lichen planus. What is the best diagnostic
with a reticulated test?
network of fine None, it's clinical
white lines on the
wrists and ankles.
You suspect lichen
planus. What is the
[...]
231 of 340
1485. A pt presents c/o A pt presents c/o pruritic rash that he 1486. A pt presents c/o A pt presents c/o pruritic rash that he
pruritic rash that he cannot stop scratching. His PMHx is pruritic rash that he cannot stop scratching. His PMHx is
cannot stop positive for asthma and allergic rhinitis. cannot stop positive for asthma and allergic rhinitis.
scratching. His Physical exam reveals areas of scaly, scratching. His Physical exam reveals areas of scaly,
PMHx is positive for lichenified skin with erythema at the PMHx is positive for lichenified skin with erythema at the
asthma and allergic flexor surfances of the knees and asthma and allergic flexor surfaces of the knees and elbows
rhinitis. Physical elbows and at the neck. What is the most rhinitis. Physical and at the neck. You suspect eczema.
exam reveals areas likely dx? exam reveals areas What is the treatment?
of scaly, lichenified Atopic Dermatitis (eczema) of scaly, lichenified (see below)
skin with erythema skin with erythema
at the flexor at the flexor
surfances of the Atopic Dermatitis key points: surfaces of the Atopic Dermatitis (Eczema) treatment
knees and elbows - 2/2 overacativity of mast cells knees and elbows key points:
and at the neck. - a/w asthma, allergic rhinitis, FHx of and at the neck. You - moisturize; dry skin tends to become
What is the most atopic disease and early onset (< 5 y/o) suspect eczema. more itchy; use a humidifier in winter or in
likely dx? - pruritic rash is the most common What is the dryer climates; less itching = less
[...] presentation treatment? scratching = less itching
- scratching can cause lichenification [...] - avoid irritants; eczematous skin is
(thickening, drying, and scaling of the hyperirratable; avoid brushes, hot water,
scratched skin) washclothes, long baths, etc; avoid wool
- a/w the flexor surfaces of the knee and - topical steroids are helpful w/ flares
elbow (vs. extensor surfaces in psoriasis) - oral steroids are helpful w/ severe
- scratching can cause skin infection, flares
which can then cause more itching - tacrolimus/pimecrolimus (topical) are
T-cell calcineurin inhibitors that help with
long-term control and to get pts off
steroids
- antihistamines can help
- antibiotics are helpful if impetigo is a
concern
- UV light is helpful in severe
recalcitrant forms
1487. Which psyhiatric Which psyhiatric disorder is associated

disorder is with extensive psoriasis?
associated with MDD
extensive
psoriasis?
[...]
232 of 340
1488. A pt is dx w/ A pt is dx w/ psoriasis and started on 1492. Seborrheic Seborrheic dermatitis is a hypersensitivity

psoriasis and started topical high-potency steroids. As steroids dermatitis is a reaction to dermal infection with
on topical can cause skin atrophy, which vitamins hypersensitivity noninvasive dermatophytes. Which
high-potency can be used to help get pts off steroids? reaction to dermal neurological disorder is associated with a
steroids. As steroids Vitamin A + Vitamin D (calcipotriene) infection with higher risk of seborrheic dermatitis?
can cause skin noninvasive Parkinsons
atrophy, which dermatophytes.
vitamins can be Steroids cause skin atrophy as they inhibit Which neurological
used to help get pts collagen formation and growth; disorder is
off steroids? additionally, steroids drive associated with a
[...] gluconeogenesis and the shuttling of higher risk of
amino acids into that pathway seborrheic
dermatitis?
[...]
1489. As steroids can As steroids can cause skin atrophy, other
cause skin atrophy, drugs that are less potentially deforming
other drugs that are are used to treat psoriasis in sensitive 1493. Pemphigus vulgaris Pemphigus vulgaris is a life-threatening
less potentially areas such as the face or penis. What is a life-threatening autoimmune disorder of the skin. What
deforming are used drugs are typically used? autoimmune desmosomal protein is targeted in this
to treat psoriasis in Calcineurin inhibitors tacrolimus or disorder of the skin. condition?
sensitive areas such pimecrolimus What desmosomal Desmoglein
as the face or penis. protein is targeted in While definitely a step 1 question, it's
What drugs are this condition? important to understand:
typically used? [...] - desmoglein in desmosomes is vital to
[...] establish cell-cell contact
- as a result, cell-cell contact is lost (i.e.
intraepithelial lesions) and skin layers
1490. Which pulmonary Which pulmonary disease can be
separate entirely
disease can be reactivated by TNF inhibitors?
- note that hemidesmosomes are left
reactivated by TNF Tuberculosis
untouched, as a result, the cells
inhibitors?
connected to the basement membrane do
[...]
not separate
Screen for TB with a PPD prior to starting
- a result of all of this is the formation of
a pt on TNF inhibitors.
thin blisters that tear easily (i.e.
positive Nikolsky's Sign)
1491. Seborrheic Seborrheic dermatitis is a hypersensitivity - it is life-treatening due to the
dermatitis is a reaction to dermal infection with widespread loss of fluid and risk of
hypersensitivity noninvasive dermatophytes. Which viral infection; essentially it's a 3rd degree
reaction to dermal infection is associated with a higher risk of burn
infection with seborrheic dermatitis?
noninvasive HIV/AIDS
dermatophytes.
1494. A 40 y/o pt has a A 40 y/o pt has a bullous/blistering
Which viral infection
bullous/blistering disease. Physical exam reveals a
is associated with a
disease. Physical positive Nikolsky's Sign. What is the
higher risk of
exam reveals a most likely diagnosis?
seborrheic
positive Nikolsky's Pemphigus vulgaris
dermatitis?
Sign. What is the
[...]
most likely
diagnosis?
[...]
233 of 340
1495. A 40 y/o pt has a A 40 y/o pt has a bullous/blistering 1497. A 40 y/o pt has a A 40 y/o pt has a bullous/blistering
bullous/blistering disease. Physical exam reveals a bullous/blistering disease. Physical exam reveals a
disease. Physical positive Nikolsky's Sign. You suspect disease. Physical positive Nikolsky's Sign. You suspect
exam reveals a pemphigus vulgaris. What is the best exam reveals a pemphigus vulgaris. Biopsy w/
positive Nikolsky's diagnostic test? positive Nikolsky's immunofluorescence is positive for
Sign. You suspect Biopsy w/ f/u immunofluorescence Sign. You suspect tombstoning. He is dx w/ acute,
pemphigus vulgaris. (which will show tombstoning) pemphigus vulgaris. non-life-threatening pemphigus vulgaris.
What is the best Biopsy w/ What is the treatment?
diagnostic test? immunofluorescence Steroids (prednisone); then
[...] Remember, in PV it is the desmosomes is positive for AZT/mycophenolate to wean off
that are targeted. Hence it is the tombstoning. He is steroids
intraepithelial cell-cell interactions that dx w/ acute,
are lost while the basement membrane non-life-threatening
cells are left in contact with the BM. As a pemphigus vulgaris.
result, tagged antibodies will light up What is the
along the apical and lateral edges of the treatment?
BM cells and around the separated [...]
epithelial cells, yielding a "tombstoning"
like effect.
1498. A pt is dx w/ acute, A pt is dx w/ acute, non-life-threatening
non-life-threatening pemphigus vulgaris. After a course of
pemphigus vulgaris. steroids, the condition is stable and
After a course of controlled. What type of drug should the
1496. A 40 y/o pt has a A 40 y/o pt has a bullous/blistering steroids, the pt be switched to?
bullous/blistering disease. Physical exam reveals a condition is stable AZT. mycophenolate mofetil, or
disease. Physical positive Nikolsky's Sign. You suspect and controlled. What rituximab to wean off steroids
exam reveals a pemphigus vulgaris. Biopsy w/ type of drug should
positive Nikolsky's immunofluorescence is positive for the pt be switched
Sign. You suspect tombstoning. He is dx w/ acute, to?
pemphigus vulgaris. life-threatening pemphigus vulgaris. What [...]
Biopsy w/ is the treatment?
immunofluorescence IVIG
1499. What age group is What age group is commonly affected by
is positive for
commonly affected pemphigus vulgaris?
tombstoning. He is
by pemphigus 30-60
dx w/ acute,
vulgaris?
life-threatening
[...]
pemphigus vulgaris.
What is the
treatment? 1500. Bullous pemphigoid Bullous pemphigoid is an autoimmune
[...] is an autoimmune disorder of the skin. What protein is
disorder of the skin. targeted in this condition?
What protein is Hemi-desmosome
targeted in this Hence it is the cell-basement membrane
condition? interaction that is lost, not cell-cell (that's
[...] desmosomes & pemphigus vulgaris). As a
result, the blister are rigid (negative
Nikolsky).
234 of 340
1501. A pt presents w/ a A pt presents w/ a blistering/bullous 1504. A pt presents c/o A pt presents c/o multiple, small, pruritic
blistering/bullous disease. Physical exam reveals a multiple, small, eruptions on extensor surfaces. You
disease. Physical negative nikolsky's sign. Which bullous pruritic eruptions suspect dermatitis herpetiformis. What is
exam reveals a disease is the most likely diagnosis? on extensor the best diagnostic test?
negative nikolsky's Bullous Pemphigoid surfaces. You EGD+Bx to look for celiac sprue
sign. Which bullous It is the cell-basement membrane suspect dermatitis
disease is the most interaction that is lost, not cell-cell (that's herpetiformis. What
likely diagnosis? desmosomes & pemphigus vulgaris). As a is the best diagnostic
[...] result, the blister are rigid (negative test?
Nikolsky). [...]
1505. A pt presents c/o A pt presents c/o multiple, small, pruritic

multiple, small, eruptions on extensor surfaces. A
pruritic eruptions biopsy is done and reveals neutrophillic
on extensor abscesses at the dermal papillae. What
1502. A pt presents w/ a A pt presents w/ a blistering/bullous surfaces. A biopsy is the most likely dx?
blistering/bullous disease. Physical exam reveals a is done and reveals Dermatitis Herpetiformis
disease. Physical negative nikolsky's sign. You suspect neutrophillic
exam reveals a bullous pemphigoid. What is the best abscesses at the
negative nikolsky's diagnostic test? dermal papillae.
sign. You suspect Biopsy w/ f/u immunofluorescence What is the most
bullous pemphigoid. (which will show an intact epithelium likely dx?
What is the best with subepithelial separation from the [...]
diagnostic test? basement membrane; antibodies will
[...] be at the dermal-epidermal junction)
1506. A pt presents c/o A pt presents c/o multiple, small, pruritic
It is the cell-basement membrane
multiple, small, eruptions on extensor surfaces. A
interaction that is lost, not cell-cell (that's
pruritic eruptions biopsy is done and reveals neutrophillic
desmosomes & pemphigus vulgaris). As a
on extensor abscesses at the dermal papillae. An
result, the blister are rigid (negative
surfaces. A biopsy EGD confirms the diagnosis and also
Nikolsky).
is done and reveals reveals celiac sprue. What is the
neutrophillic treatment?
abscesses at the Dapsone to temporize the skin lesions;
dermal papillae. An avoid gluten
EGD confirms the
diagnosis and also
1503. A pt presents w/ a A pt presents w/ a blistering/bullous reveals celiac sprue. Removing gluten from the diet will lead to
blistering/bullous disease. Physical exam reveals a What is the resolution of the dermatitis (as well as
disease. Physical negative nikolsky's sign. You suspect treatment? management for Celiac's)
exam reveals a bullous pemphigoid. Biopsy w/ [...]
negative nikolsky's immunofluorescence confirms the Dx.
sign. You suspect What is the treatment?
1507. What is the most What is the most common porphyria?
bullous pemphigoid. Dapsone + nicotinamide (if mild);
common porphyria? Porphyria cutanea tarda
Biopsy w/ Topical steroids (if limited); oral
[...]
immunofluorescence steroids (if severe)
confirms the Dx.
What is the
treatment? BP is not lifethreatening and does not
[...] involve the mucosa.
235 of 340
1508. A pt presents c/o of A pt presents c/o of blistering/bullous 1511. A pt presents c/o of A pt presents c/o of blistering/bullous
blistering/bullous disease. Physical exam reveals that the blistering/bullous disease. Physical exam reveals that the
disease. Physical blisters are found in sun exposed disease. Physical blisters are found in sun exposed
exam reveals that areas only. You suspect porphyria exam reveals that areas only. You suspect porphyria
the blisters are cutanea tarda. What is the best initial the blisters are cutanea tarda. Wood's lamp testing is
found in sun diagnostic test? found in sun positive and a follow-up 24 hr urine
exposed areas Examining urine sample w/ Wood's exposed areas collection confirms the dx. What is the
only. You suspect Lamp (coral red urine is diagnostic) only. You suspect treatment?
porphyria cutanea porphyria cutanea Avoid the sun; phlebotomy to remove
tarda. What is the tarda. Wood's lamp iron; avoid EtOH/estrogens
best initial diagnostic testing is positive Time to move to the arctic?
test? and a follow-up 24 hr
[...] urine collection
confirms the dx.
What is the
1509. A pt presents c/o of A pt presents c/o of blistering/bullous
treatment?
blistering/bullous disease. Physical exam reveals that the
[...]
disease. Physical blisters are found in sun exposed
exam reveals that areas only. You suspect porphyria
the blisters are cutanea tarda. What is the most accurate 1512. Which blistering skin Which blistering skin disease is
found in sun diagnostic test? disease is associated with hepatitis C?
exposed areas 24 hr urine collection (increased associated with Porphyria cutanea tarda
only. You suspect uroporphyrins is diagnostic) hepatitis C?
porphyria cutanea [...]
tarda. What is the PCT is often seen with a history of (or
most accurate brought upon by) these disorders:
diagnostic test? - Hepatitis C
[...] - EtOH use
1510. A 24 hr urine A 24 hr urine collection to gauge for
overload)
collection to gauge increased uroporphyrins is the most
for increased accurate test for porphyria cutanea tarda.
uroporphyrins is Which enzyme is deficient in this dz? 1513. Which blistering skin Which blistering skin disorder is
the most accurate Uroporphyrinogen decarboxylase disorder is associated with OCP/estrogen use?
test for porphyria associated with Porphyria cutanea tarda
cutanea tarda. OCP/estrogen use?
Which enzyme is [...]
deficient in this dz? PCT is often seen with a history of (or
[...] brought upon by) these disorders:
- Hepatitis C
- EtOH use
overload)
1514. Which class of Which class of antihypertensives is

antihypertensives is associated with pemphigus vulgaris?
associated with ACE-I's
pemphigus vulgaris?
[...]
236 of 340
1515. What is the best What is the best initial therapy for bullous 1520. A pt comes in c/o of A pt comes in c/o of spots on his skin.
initial therapy for pemphigoid? spots on his skin. Physical exam reveals multiple, small,
bullous pemphigoid? Prednisone (then switch to Physical exam sharply-demarcated patches of hypo-
[...] AZT/cyclophosphamide/mycophenolate reveals multiple, & depigmentation on the face and
to wean off steroids) small, hands. You suspet vitiligo. What is the
sharply-demarcated best initial test?
patches of hypo- & Wood's Lamp testing (will not show
1516. A pt presents c/o of A pt presents c/o of multiple, small,
depigmentation on pigment)
multiple, small, scaly patches with varying
the face and hands.
scaly patches with pigmentation. What is the most likely dx?
You suspet vitiligo.
varying Tinea Versicolour
What is the best
pigmentation. What The patient presentation is in the name.
initial test?
is the most likely dx? Versi-Colour as in Varying-Colours.
[...]
[...]
1521. A pt comes in c/o of A pt comes in c/o of spots on his skin.

1517. What is the cause of What is the cause of tinea versicolour?
spots on his skin. Physical exam reveals multiple, small,
tinea versicolour? Malassezia globosa; Malassezia furfur
Physical exam sharply-demarcated patches of hypo-
[...]
reveals multiple, & depigmentation on the face and
small, hands. You suspect vitiligo. What is the
They are normal GI flora. It is thought that
sharply-demarcated most accurate test?
Cushing's and immunosuppression are
patches of hypo- & Bx (will reveal the absence of
risk factors.
depigmentation on melanocytes)
the face and hands.
1518. A pt presents c/o of A pt presents c/o of multiple, small, You suspect vitiligo.
multiple, small, scaly patches with varying What is the most
scaly patches with pigmentation. You suspect tinea accurate test?
varying versicolour. What is the best diagnostic [...]
pigmentation. You test?
suspect tinea KOH prep (which will reveal hyphae +
1522. A pt comes in c/o of A pt comes in c/o of spots on his skin.
versicolour. What is spores in a "spaghetti & meatball"
spots on his skin. Physical exam reveals multiple, small,
the best diagnostic arrangement)
Physical exam sharply-demarcated patches of hypo-
test?
reveals multiple, & depigmentation on the face and
[...]
small, hands. You suspet vitiligo. Wood's Lamp
sharply-demarcated test does not reveal any pigment and Bx
patches of hypo- & confirms the dx. What is the treatment?
depigmentation on Cosmetics
1519. A pt comes in c/o of A pt comes in c/o of spots on his skin. the face and hands.
spots on his skin. Physical exam reveals multiple, small, You suspet vitiligo.
Physical exam sharply-demarcated patches of hypo- Wood's Lamp test
reveals multiple, & depigmentation on the face and does not reveal any
small, hands. What is the most likely dx? pigment and Bx
sharply-demarcated Vitiligo confirms the dx.
patches of hypo- & What is the
depigmentation on treatment?
the face and hands. [...]
What is the most
likely dx?
1523. Which enzyme is Which enzyme is deficient in albinism?
[...]
deficient in albinism? Tyrosinase (melanocytes are normal)
[...]
237 of 340
1527. A child presents w/ A child presents w/ a single

1524. A child presents w/ A child presents w/ a single a single hypopigmented spot on his skin.
a single hypopigmented spot on his skin. Wood's hypopigmented Physical exam confirms his complaint but
hypopigmented Lamp testing is positive. You suspect spot on his skin. also reveals multiple, elevated, fleshy
spot on his skin. Ash Leaf. What neurocutaneous disorder Physical exam collagen plaques and hyperplastic
Wood's Lamp testing is this pathognomonic for? confirms his blood vessels. What neurocutaneous
is positive. You Tuberous Sclerosis complaint but also disorder should be considered as the dx?
suspect Ash Leaf. reveals multiple, Tuberous Sclerosis
What elevated, fleshy
neurocutaneous collagen plaques
disorder is this and hyperplastic Remember, Tuberous Sclerosis is
pathognomonic for? blood vessels. associated w/:
[...] What - Ash Leaf (a single patch of
neurocutaneous hypopigmentation [not depigmentation])
1525. A child presents w/ A child presents w/ a single disorder should be - Shagreen patches (elevated, fleshy
a single hypopigmented spot on his skin. You considered as the collagen plaques)
hypopigmented suspect Ash Leaf. What is the best initial dx? - Adenoma Sebaceum (hyperplastic
spot on his skin. diagnostic test? [...] blood vessels)
You suspect Ash Wood's Lamp
Leaf. What is the 1528. A pt present c/o of A pt present c/o of hair loss. Physical
best initial diagnostic hair loss. Physical exam reveals multiple, small patches of
test? exam reveals well-demarcated hair loss in a sporadic
[...] multiple, small pattern around the body. You suspect
patches of alopecia areata. What is the best
1526. A child presents w/ A child presents w/ a single well-demarcated diagnostic test?
a single hypopigmented spot on his skin. You hair loss in a None, it's clinical; however it may be
hypopigmented suspect Ash Leaf. Wood's Lamp testing sporadic pattern prudent to do a KOH prep to rule out
spot on his skin. is positive. What imaging test should be around the body. tinea capitis if the scalp is involved
You suspect Ash ordered next? You suspect Remember, hair loss from tinea capitis is
Leaf. Wood's Lamp CT head to visualize tubers (this is alopecia areata. permanent if left untreated.
testing is positive. seen in tuberous sclerosis) What is the best
What imaging test diagnostic test?
should be ordered [...]
next?
[...] 1529. A pt present c/o of A pt present c/o of hair loss. Physical
hair loss. Physical exam reveals multiple, small patches of
exam reveals well-demarcated hair loss in a sporadic
multiple, small pattern around the body. He is dx with
patches of alopecia areata. What is the treatment?
well-demarcated
hair loss in a
sporadic pattern Steroids
around the body. He
is dx with alopecia
areata. What is the
treatment?
[...]
238 of 340
1530. A pt presents c/o of A pt presents c/o of hair loss. Physical 1535. What is the What is the treatment for trichotillomania?
hair loss. Physical exam reveals scarring of the scalp and a treatment for Cognitive-behavioural therapy (CBT)
exam reveals very tight ponytail with very tight trichotillomania?
scarring of the scalp braiding. What is the most likely dx? [...]
and a very tight Traction Alopecia
ponytail with very
1536. A pt present c/o hair A pt present c/o hair loss. Physical exam
tight braiding. What
loss. Physical exam reveals patchy alopecia on the scalp w/
is the most likely dx? Irreversible, but preventable
reveals patchy scales and erythema. What is the most
[...]
alopecia on the likely dx?
scalp w/ scales and Tinea capitis
1531. A pt is dx w/ male A pt is dx w/ male pattern baldness. What erythema. What is
pattern baldness. is the best initial therapy? the most likely dx? Tinea Capitis (vs. other alopecia) key
What is the best Minoxidil (stimulates hair growth) [...] points:
initial therapy? - tinea capitis involves well-defined
[...] circular patch of alopecia with
scales/erythema and hairs at equal
length
1532. A pt is dx w/ male A pt is dx w/ male pattern baldness and is
- alopecia areata involves patchy alopecia
pattern baldness and started on minoxidil. The pt feels it is not
without scales or erythema
is started on helping enough and would like to escalate
- trichotillomania involves patchy alopecia
minoxidil. The pt treatment. What additional drug can you
without equal hair length at the lesion
feels it is not helping consider to add to topical minoxidil?
enough and would Oral finasteride (will decrease 5-DHT
like to escalate levels and mitigate hair loss)
treatment. What 1537. A pt present c/o hair A pt present c/o hair loss. Physical exam
additional drug can loss. Physical exam reveals patchy alopecia on the scalp w/
you consider to add reveals patchy scales and erythema. You suspect tinea
to topical minoxidil? alopecia on the capitis. KOH prep confirms the dx. What
[...] scalp w/ scales and is the treatment?
erythema. You Oral antifungals (e.g. griseofulvin)
suspect tinea capitis.
1533. A female pt presents A female pt presents w/ patchy hair loss.
KOH prep confirms
w/ patchy hair loss. Her PMHx is significant for OCD. Physical
the dx. What is the Remember, any fungal infection that
Her PMHx is exam reveals patchy alopecia and a
treatment? involves hair or nails requires oral
significant for OCD. headful of hair at different lengths. What
[...] antifungals.
Physical exam is the most likely dx?
Hair loss is permanent if not treated.
reveals patchy Trichotillomania
alopecia and a
headful of hair at 1538. What type of What type of hypersensitivity reaction is
different lengths. hypersensitivity involved in urticaria (hives)?
What is the most reaction is involved Type I
likely dx? in urticaria (hives)?
[...] [...]
1534. A pt is dx w/ A pt is dx w/ trichotillomania. Which GI

trichotillomania. disorder should you worry about?
Which GI disorder SBO 2/2 bezoar
should you worry
about?
[...]
239 of 340
1539. A pt presents w/ a A pt presents w/ a rash that appeared 1543. How soon after How soon after exposure to a drug do
rash that appeared after a bee sting. Physical exam reveals exposure to a drug drug reaction rashes manifest?
after a bee sting. annular, blanching, red papules on the do drug reaction 7-14 days
Physical exam arm. Vitals are WNL. What is the most rashes manifest?
reveals annular, likely dx? [...]
blanching, red Urticaria (hives) This is a vital point, esp. in hospitalized
papules on the arm. pts that are getting mulitple drugs. If a
Vitals are WNL. rash appears < 7 days, it's likely not
What is the most drug-induced (or induced by that
likely dx? particular drug).
[...]
1544. What is the fixed What is the fixed drug eruption?

1540. A pt presents of a A pt presents of a rash that appeared drug eruption? A cutaneous drug reaction that
rash that appeared after a bee sting. Physical exam reveals [...] manifests within 24 hrs in the exact
after a bee sting. annular, blanching, red papules on the same way and location each time the
Physical exam arm. Vitals are WNL. He is dx w/ urticaria causal drug is given
reveals annular, (hives). What is the treatment?
blanching, red Anti-histamines; f/u RAST to confirm
papules on the arm. the culprit antigen It is never life-threatening.
Vitals are WNL. He Avoid the drug for spontaneous
is dx w/ urticaria resolution.
(hives). What is the There is no anaphylaxis in this case,
treatment? hence anti-histamines are enough.
1545. A pt is given a A pt is given a penicillin and develops a
[...]
penicillin and rash. Physical exam reveals multiple
develops a rash. (and confluent), widespread, small,
1541. A pt is in A pt is in anaphylaxis. What is the first Physical exam target-shaped lesions over the back,
anaphylaxis. What is drug given in treatment? reveals multiple trunk, palms, and soles. The oral mucosa
the first drug given in Epinephrine (and confluent), is spared. What is the most likely dx?
treatment? widespread, small, Erythema multiforme
[...] target-shaped
Anaphylaxis tid-bit: lesions over the
1. Give epinephrine first back, trunk, palms,
2. Follow that with systemic steroids and soles. The oral
3. Follow that with H1 and H2 blockers mucosa is spared.
4. Monitor What is the most
likely dx?
[...]
1542. A pt is given an A pt is given an antibiotic. After 7 days of
antibiotic. After 7 exposure, he develops a widespread,
days of exposure, pruritic, pink, morbilliform rash on his
he develops a trunk. You suspect that it is a drug
widespread, reaction. What is the treatment?
pruritic, pink, Stop the causal drug (+
morbilliform rash diphenhydramine if mild; +
on his trunk. You corticosteroids if severe)
suspect that it is a Morbilliform refers to a rash that looks
drug reaction. What like measles.
is the treatment?
[...]
240 of 340
1546. A pt is given a A pt is given a penicillin and develops a 1549. A pt is given a A pt is given a penicillin and develops a
penicillin and rash. Physical exam reveals multiple penicillin and widespread rash. Physical exam reveals a
develops a rash. (and confluent), target-shaped lesions develops a rash with widespread loss of sheets of
Physical exam over the back, trunk, palms, and soles. widespread rash. skin with a positive nikolsky sign
reveals multiple The mucosa is not spared. What is the Physical exam affecting > 30% of body surface area. You
(and confluent), most likely dx? reveals a rash with suspect toxic epidermal necrolysis. What
target-shaped Erythema multiforme major widespread loss of is the best diagnostic test?
lesions over the In this case, worry about progression sheets of skin with Biopsy (will reveal full epidermal
back, trunk, palms, into Steven-Johnson Syndrome. a positive nikolsky thickness necrosis)
and soles. The sign affecting > 30%
mucosa is not of body surface
spared. What is the area. You suspect SJS = < 10% BSA + basal cell
most likely dx? toxic epidermal degeneration on Bx
[...] necrolysis. What is TEN = > 30% BSA + full epidermal
the best diagnostic thickness necrosis on Bx
test?
[...]
penicillin and widespread rash. Physical exam reveals a
develops a rash with widespread loss of sheets of
widespread rash. skin with a positive nikolsky sign 1550. A pt is dx with A pt is dx with stevens-johnsons
Physical exam affecting < 10% of body surface area. stevens-johnsons syndrome. What is the treatment?
reveals a rash with Biopsy reveals basal cell degeneration. syndrome. What is IVIG; Discontinue all medications,
widespread loss of What is the most likely diagnosis? the treatment? including steroids; admit to burn
sheets of skin with Stevens-Johnson Syndrome [...] unit/centre
a positive nikolsky In SJS/TEN, steroids can exacerbate
sign affecting < 10% the condition; d/c them and/or avoid use.
of body surface Admitting to the burn unit is helpful as the
area. Biopsy reveals sloughing of the skin greatly increases
basal cell the risk of fluid, heat, electrolyte loss
degeneration. What and risk of infection
is the most likely
diagnosis?
[...]

penicillin and widespread rash. Physical exam reveals a
develops a rash with widespread loss of sheets of
widespread rash. skin with a positive nikolsky sign
Physical exam affecting < 10% of body surface area. You
reveals a rash with suspect stevens-johnsons syndrome.
widespread loss of What is the best diagnostic test?
sheets of skin with Biopsy (will reveal basal cell
a positive nikolsky degeneration)
sign affecting < 10% SJS = < 10% BSA + basal cell
of body surface degeneration on Bx
area. You suspect TEN = > 30% BSA + full epidermal
stevens-johnsons thickness necrosis on Bx
syndrome. What is
the best diagnostic
test?
[...]
241 of 340
1551. Stevens-Johnson Stevens-Johnson Syndrome, toxic 1553. A pt is diagnosed A pt is diagnosed with staphylococcal
Syndrome, toxic epidermal necrolysis, and staphylococcal with staphylococcal scalded skin syndrome. Which antibiotic
epidermal scalded skin syndrome can present very scalded skin can be given to stop toxin production?
necrolysis, and similarly and need a biopsy to syndrome. Which (see below)
staphylococcal differentiate. How do they differ on antibiotic can be
scalded skin biopsy? given to stop toxin
syndrome can (see below) production? SSSS management key points:
present very [...] - similar management vs. SJS/TEN (burn
similarly and need a support), but unlike those two there are
biopsy to SJS = < 10% BSA + basal cell drugs that can help, yay!
differentiate. How do degeneration on Bx - note that antibiotics do not reverse
they differ on TEN = > 30% BSA + full epidermal SSSS, but kill Staphylococcus and
biopsy? thickness necrosis on Bx prevents further toxin production
[...] SSSS = blistering occurs within the - if sensitive, use oxacillin or nafcillin
epidermis around the stratum - cefazolin or clindamycin can be used
granulosum, whereas SJS/TEN are at as well
the dermo-epidermal junction
Note that in SSSS, the blisters
1554. What is the What is the heirarchy of severity of the
themselves are sterile as they are
heirarchy of severity common drug-induced skin reactions?
toxin-mediated, so the biopsy should not
of the common Morbilliform rash < erythema
show S. aureus organisms. The difference
drug-induced skin multiforme < SJS < TEN
is the depth.
reactions?
[...]
1552. Aside from the Aside from the biopsy, how can
biopsy, how can Staphylococcal scalded skin syndrome
1555. A pt is dx with toxic A pt is dx with toxic epidermal necrolysis.
Staphylococcal (SSSS) be differentiated from
epidermal What is the treatment?
scalded skin Stevens-Johnsons Syndrome and/or
necrolysis. What is IVIG; Discontinue all medications,
syndrome (SSSS) Toxic Epidermal Necrolysis?
the treatment? including steroids; admit to burn
be differentiated SSSS does not have mucosal
[...] unit/centre
from involvement and will respond to
Stevens-Johnsons antibiotics
Syndrome and/or
In SJS/TEN, steroids can exacerbate
Toxic Epidermal
the condition; d/c them and/or avoid use.
Necrolysis? Note that SSSS does have positive
Admitting to the burn unit is helpful as the
[...] nikolsky as well.
sloughing of the skin greatly increases
the risk of fluid, heat, electrolyte loss
and risk of infection
242 of 340
1556. A pt has mild acne. A pt has mild acne. What is the first line 1558. A pt has moderate A pt has moderate acne. What is the first
What is the first line treatment? acne. What is the line tx?
treatment? Benzoyl peroxide (a topical first line tx? Topical Vit A derivatives + topical
[...] antibacterial) [...] clindamycin/erythromycin
Acne treatment key points: Acne treatment key points:

- if mild, agents are topical - if mild, agents are topical
--- 1st line: benzoyl peroxide --- 1st line: benzoyl peroxide
--- 2nd line: add topical abx (e.g. clinda --- 2nd line: add topical abx (e.g. clinda
or erythro) or erythro)
- if moderate, agents can be topical or - if moderate, agents can be topical or
oral oral
--- 1st line: topical Vit A derivative (e.g. --- 1st line: topical Vit A derivative (e.g.
tretinoin, adapalene, tazarotene) + tretinoin, adapalene, tazarotene) +
topical abx topical abx
--- 2nd line: add oral abx (e.g. --- 2nd line: add oral abx (e.g.
minocycline or doxycycline) minocycline or doxycycline)
- if severe, agents are oral - if severe, agents are oral
--- 1st line: oral vit A derivative (e.g. --- 1st line: oral vit A derivative (e.g.
isoretinoin) + oral abx. isoretinoin) + oral abx
1557. A pt has mild acne A pt has mild acne and is given benzoyl 1559. A pt has moderate A pt has moderate acne and is started on
and is given benzoyl peroxide as first line tx. It is ineffective. acne and is started topical tretinoin and topical
peroxide as first line Which topical Abx can be added to the on topical tretinoin clindamycin. It is ineffective. What is the
tx. It is ineffective. regimen? and topical second line therapy?
Which topical Abx Clindamycin or erythromycin clindamycin. It is Add oral abx (e.g. minocyline or
can be added to the ineffective. What is doxycycline)
regimen? the second line
[...] Acne treatment key points: therapy?
- if mild, agents are topical [...] Acne treatment key points:
--- 1st line: benzoyl peroxide - if mild, agents are topical
--- 2nd line: add topical abx (e.g. clinda --- 1st line: benzoyl peroxide
or erythro) --- 2nd line: add topical abx (e.g. clinda
- if moderate, agents can be topical or or erythro)
oral - if moderate, agents can be topical or
--- 1st line: topical Vit A derivative (e.g. oral
tretinoin, adapalene, tazarotene) + --- 1st line: topical Vit A derivative (e.g.
topical abx tretinoin, adapalene, tazarotene) +
--- 2nd line: add oral abx (e.g. topical abx
minocycline or doxycycline) --- 2nd line: add oral abx (e.g.
- if severe, agents are oral minocycline or doxycycline)
--- 1st line: oral vit A derivative (e.g. - if severe, agents are oral
isoretinoin) + oral abx --- 1st line: oral vit A derivative (e.g.
isoretinoin) + oral abx
243 of 340
1560. A pt has severe A pt has severe acne. What is the first 1562. Which antibody is Which antibody is sensitive for SLE?
acne. What is the line therapy? sensitive for SLE? ANA
first line therapy? Oral Vit A derivative + oral Abx [...] If ANA is positive, SLE is not confirmed as
[...] it is not specific.
But if ANA is negative, SLE is ruled out.
e.g. isoretinoin + doxycycline
Note that if the acne is severe, oral meds
are used. For mild-moderate acne, all
1563. What antibody is What antibody is specific for drug-induced
drugs are given topically unless it is 2nd
specific for SLE?
line for moderate acne.
drug-induced SLE? Anti-Histone antibodies
Acne treatment key points:
[...]
- if mild, agents are topical
--- 1st line: benzoyl peroxide
--- 2nd line: add topical abx (e.g. clinda
or erythro) 1564. Which antibodies are Which antibodies are specific for SLE (+
- if moderate, agents can be topical or specific for SLE (+ renal involvement)?
oral renal Anti-dsDNA
--- 1st line: topical Vit A derivative (e.g. involvement)?
tretinoin, adapalene, tazarotene) + [...]
topical abx In fact, there is a positive correlation.
--- 2nd line: add oral abx (e.g. The higher the anti-dsDNA level, the
minocycline or doxycycline) worse the lupus nephropathy.
- if severe, agents are oral
--- 1st line: oral vit A derivative (e.g. 1565. Which antibodies are Which antibodies are associated with
isoretinoin) + oral abx associated with autoimmune hepatitis?
autoimmune Anti-smooth muscle Ab
1561. In the workup of joint In the workup of joint pain, what are the 3 hepatitis?
pain, what are the 3 most important features that should be [...]
most important investigated in the history?
features that should Period & pattern of pain; # of joints 1566. Which antibodies are Which antibodies are associated w/
be investigated in involved; degenerative vs. associated w/ primary biliary cirrhosis?
the history? inflammatory primary biliary Anti-mitochondrial antibodies (AMA)
[...] Rheumatology breakdown key points: cirrhosis?
- monoarticular pain typically involves a [...]
disease in that one joint
--- e.g. septic arthritis, trauma, crystals,
1567. Which antibodies are Which antibodies are a/w CREST
reactive arthritis
a/w CREST syndrome?
- polyarticular pain typically involves
syndrome? Anti-centromere ab
systemic disease; can be broken down
[...]
even further
--- if asymmetrical, it's likely
degenerative due to the asymmetry of
use (e.g. OA) 1568. Which antibodies are Which antibodies are a/w Sjogren's
--- if symmetrical, it's likely autoimmune a/w Sjogren's Syndrome?
or inflammatory (e.g. RA, SLE) Syndrome? Anti-Ro (SS-A) and Anti-La (SS-B)
[...]
Ayrobeela = "A-Ro, B-La"
244 of 340
1569. Which antibodies are Which antibodies are a/w rheumatoid 1574. What is the What is the diagnostic criteria for SLE?
a/w rheumatoid arthritis? diagnostic criteria for 4 of 11 criteria from "SOAP BRAIN MD"
arthritis? Anti-RF; Anti-CCP SLE?
[...] [...]
"SOAP BRAIN MD" mnemonic for SLE
dx:
- Serositis (can cause pleuritic chest pain,
1570. Which antibodies are Which antibodies are a/w polymyositis?
pleural effusion, or pericardial effusion)
a/w polymyositis? Anti-Jo ab
- Oral ulcers
[...]
- Arthritis (90% of cases)
- Photosensitivity (gives rise to the malar
and discoid rashes seen in SLE)
1571. Which antibodies are Which antibodies are a/w systemic - Blood (e.g. decreased Plt or Hct; AOCD;
a/w systemic scleroderma? haemolytic anaemia; leukopenia)
scleroderma? Anti-topoisomerase (ATA; Anti-Scl-70) - Renal (i.e. lupus nephropathy,
[...] Systemic scleroderma = glomerulonephritis, membranous
anti-topoisomerase = anti-Scl70 nephropathy)
Limited scleroderma = CREST syndrome - ANA (+ANA in SLE)
= anti-Centromere - Immunological features (anti-dsDNA,
anti-Sm, false-positive RPR)
- Neurological features (cerebritis,
1572. Which sex is more Which sex is more commonly affected by psychosis, seizures)
commonly affected SLE? - Malar rash
by SLE? Women - Discoid rash
[...]
1575. SLE is often SLE is often associated with a malar rash.
associated with a What is a malar rash?
1573. Which race is more Which race is more commonly affected by malar rash. What is Bilateral facial rash that spares the
commonly affected SLE? a malar rash? nasolabial folds
by SLE? Non-white, esp. AA [...]
[...]
Photosensitivity is what causes the rashes
seen in SLE. This is why the nasolabial
folds are typiccally spared in the malar
rash as they are shaded.
- note that this differs from the discoid
rash which looks like a disc
1576. A pt is dx w/ A pt is dx w/ Libman-Sacks endocarditis.

Libman-Sacks What autoimmune disorder should be
endocarditis. What considered?
autoimmune SLE
disorder should be
considered?
[...]
245 of 340
1577. A female pt has A female pt has multiple, 2nd trimester

1581. A pt w/ a history of A pt w/ a history of SLE presents c/o
multiple, 2nd miscarriages. Workup has been unfruitful
trimester so far. She has no PMHx and is otherwise SLE presents c/o severe joint pain. She is dx w/ a lupus
miscarriages. healthy. What autoimmune disorder severe joint pain. flare. Labs also reveal AKI. What test
Workup has been should be considered? She is dx w/ a lupus must be performed before administering
unfruitful so far. She SLE flare. Labs also cyclophosphamide
has no PMHx and is reveal AKI. What Kidney Bx
otherwise healthy. test must be
What autoimmune Healthy woman with repeated 2nd performed before
disorder should be trimester miscarriages of unknown cause? administering
considered? Think lupus. cyclophosphamide
[...] Thought to be 2/2 hypercoagulability in [...]
lupus.
1582. What is the What is the treatment for the joint pain in
1578. A pt has 5/11 criteria A pt has 5/11 criteria for SLE. What is the treatment for the SLE?
for SLE. What is the first step in diagnosis? joint pain in SLE? NSAIDs
first step in ANA testing [...]
diagnosis?
[...]
Remember, ANA is sensitive, but not 1583. A pt is diagnosed A pt is diagnosed with a lupus flare-up.
specific for SLE. A positive ANA does with a lupus flare-up. What is the first line treatment to induce
not confirm the dx, but a negative ANA What is the first line remission while in the acute flare-up?
effectively rules out SLE. treatment to induce High-dose prednisone
remission while in
1579. A pt has 5/11 criteria A pt has 5/11 criteria for SLE. ANA testing the acute flare-up?
for SLE. ANA testing is positive. What is the next step in [...]
is positive. What is diagnosis?
the next step in Anti-dsDNA testing 1584. A pt w/ SLE is dx w/ A pt w/ SLE is dx w/ lupus nephritis. What
diagnosis? lupus nephritis. What is the treatment?
[...] is the treatment? Cyclophosphamide; or mycophenolate
While ANA is sensitive and not specific, [...] mofetil (safer)
anti-dsDNA is specific but not
sensitive for SLE. However, the pt
must have the other criteria as well.
1585. A pt w/ SLE A pt w/ SLE develops lupus cerebritis.

1580. Lupus nephritis and Lupus nephritis and subsequent renal develops lupus What is the treatment?
subsequent renal failure is a major contributor to mortality in cerebritis. What is Cyclophosphamide
failure is a major SLE. What test is imperative in the treatment?
contributor to investigating the severity of lupus [...]
mortality in SLE. nephropathy?
What test is Bx
1586. Which drugs are Which drugs are classically associated
imperative in
classically with Drug-induced lupus?
investigating the
associated with Procainamide, hydralazine, INH,
severity of lupus Performing screening UA's are
Drug-induced lupus? alpha-methyldopa
nephropathy? imperative. If things are off, perform Bx.
[...]
[...] Only a Bx will be able to tell us the
severity of lupus nephropathy (i.e.
nephritis, or glomerulosclerosis, or
glomerular scarring). It also guides
treatment (e.g. scarring is not treatable).
246 of 340
1587. A pt is given A pt is given procainamide and soon

1592. How do anti-dsDNA How do anti-dsDNA antibody levels
procainamide and after develops a malar rash and
soon after develops polyarthralgia. You suspect antibody levels change in an acute lupus flare?
a malar rash and drug-induced SLE. What is the best change in an acute Increase
polyarthralgia. You diagnostic test? lupus flare? In an acute lupus flare, complement
suspect Anti-histone antibodies [...] levels decrease and anti-dsDNA levels
drug-induced SLE. increase. Use this to rule out other
What is the best diagnoses or a flare up itself.
diagnostic test?
[...] 1593. Which new Which new monoclonal anitbody is used
monoclonal anitbody to control the progression of lupus?
1588. Typical SLE and Typical SLE and drug-induced SLE are is used to control the Belimumab
drug-induced SLE similar in many ways. Other than the progression of "Belimumab selectively binds to soluble
are similar in many diagnostic antibody, how does lupus? human B lymphocyte stimulator protein
ways. Other than the drug-induced SLE differ from typical SLE? [...] (BLyS) so that BLyS is unable to bind to
diagnostic antibody, There is no visceral involvement in receptors on B lymphocytes. The binding
how does drug-induced SLE of BLyS to its receptor is essential for the
drug-induced SLE survival of B lymphocytes. Consequently,
differ from typical belimumab reduces B-cell mediated
SLE? Drug-induced SLE will have the skin and immunity and the autoimmune response.
[...] joint manifestations, but the viscera is By the 52nd week of treatment with
left untouched. belimumab, a reduction in CD19+,
CD20+, naive and activated B cells,
plasma cells, plasmacytoid cells, and SLE
1589. What is the most What is the most common B-cell subset can be observed.
common glomerulonephritis seen in lupus Reductions in plasma cells and SLE B-cell
glomerulonephritis nephropathy? subset can be seen by the eighth week
seen in lupus Membranous nephropathy and these levels were maintained to week
nephropathy? 52. Belimumab also reduced levels of IgG
[...] and anti-dsDNA."
(www.drugbank.ca)
1590. A pt is found to have A pt is found to have positive ANA on
positive ANA on incidental finding (don't ask why, lol). She 1594. What is the most What is the most common cause of death
incidental finding denies any symptoms and is otherwise common cause of in young pts with SLE?
(don't ask why, lol). healthy. What is the treatment? death in young pts Infection
She denies any Nothing with SLE?
symptoms and is
[...]
otherwise healthy.
What is the Do not treat asymptomatic ANA positivity.
1595. What is the most What is the most common cause of death
treatment?
[...] common cause of in older pts with SLE?
death in older pts MI
with SLE?
1591. How do complement How do complement levels change in an [...]
levels change in an acute lupus flare?
This is 2/2 the fact that atherosclerosis
acute lupus flare? Decrease
is accelerated in SLE
[...]
In an acute lupus flare, complement

levels decrease and anti-dsDNA levels
increase. Use this to rule out other
diagnoses or a flare up itself.
247 of 340
1596. A pt presents w/ a A pt presents w/ a Hx of thromboses in 1600. Antiphospholipid Antiphospholipid (APL) syndrome is

Hx of thromboses in both arterial and venous circulations. You (APL) syndrome is associated with 2 autoantibodies. Which
both arterial and suspect antiphospholipid antibody (APL) associated with 2 of the two is known to more often cause
venous circulations. syndrome. What is the best initial autoantibodies. spontaneous abortion?
You suspect diagnostic test? Which of the two is Anticardiolipin antibody
antiphospholipid Mixing study (aPTT will not correct and known to more often
antibody (APL) will stay elevated) cause spontaneous
syndrome. What is The mixing study involves mixing the pt's abortion?
the best initial plasma with an equal amount of normal [...]
diagnostic test? plasma and then gauging the change in
[...] aPTT.
1601. Antiphospholipid Antiphospholipid (APL) syndrome is
- if there is a clotting factor deficiency,
(APL) syndrome is associated with 2 autoantibodies. Which
aPTT will normalize
associated with 2 of the two is known to more often elevate
- if there is APL, aPTT will stay elevated
autoantibodies. aPTT?
Which of the two is Lupus anticoagulant
known to more often
1597. What coagulation What coagulation study results are elevate aPTT?
study results are commonly seen in antiphospholid [...] Of course, the naming of lupus
commonly seen in syndrome? anticoagulant is a huge headache.
antiphospholid Increase aPTT w/ normal PT and INR It is an anticoagulant in vitro, but
syndrome? procoagulant in vivo.
[...]
1602. A pt is found to be A pt is found to be positive for an

1598. A pt presents w/ a A pt presents w/ a Hx of thromboses in positive for an antiphospholipid antibody
Hx of thromboses in both arterial and venous circulations. You antiphospholipid (anti-cardiolipin). She is asymptomatic
both arterial and suspect antiphospholipid antibody (APL) antibody and otherwise healthy. What is the
venous circulations. syndrome. What is the most accurate (anti-cardiolipin). treatment?
You suspect diagnostic test? She is asymptomatic Nothing
antiphospholipid Russell Viper Venom test and otherwise
antibody (APL) healthy. What is the
syndrome. What is treatment? Do not treat asymptomatic
the most accurate The RVVT in APL is prolonged. [...] antiphospholipid antibodies
diagnostic test?
[...]
1599. What VDRL test What VDRL test result is associated with
result is associated antiphospholipid (APL) syndrome?
with antiphospholipid False-positive VDRL (w/ a negative
(APL) syndrome? FTA-Abs)
[...] Due to the antibody reacting to the
cardiolipin reagant.
If FTA-Abs testing is positive it's syphilis

bruh...
248 of 340
1603. A pt presents w/ a A pt presents w/ a Hx of thromboses in 1606. A pt presents with a A pt presents with a single, warm, red,
Hx of thromboses in both arterial and venous circulations. You single, warm, red, painful joint. What is always the first step
both arterial and suspect antiphospholipid antibody (APL) painful joint. What in workup?
venous circulations. syndrome. Coagulation studies reveal is always the first Arthrocentesis
You suspect elevated aPTT with normal PT and INR. step in workup? With this type of presentation it's either
antiphospholipid A mixing study fails to correct aPTT. [...] septic arthritis or a crystal deposition
antibody (APL) Russell Viper Venom testing is positive. disease - you never, ever want to miss
syndrome. The pt is dx w/ APL syndrome. What is septic arthritis.
Coagulation studies the treatment? - if the aspirate has a +gram-stain, 90%
reveal elevated Warfarin PMNs and >50k WBCs it's septic;
aPTT with normal APL Syndrome treatment key points: determine management depending on
PT and INR. A gram+ or gram-
mixing study fails to - Thrombosis is the #1 worry in APL - if the aspirate has a -gram-stain and
correct aPTT. syndrome and it is approached like other crystals; determine management
Russell Viper Venom thrombotic diseases. depending on needle morphology and
testing is positive. - aim for a INR of 2-3 birefringence
The pt is dx w/ APL - the duration of treatment is controversial
syndrome. What is --- some sources say lifelong therapy is
the treatment? needed after a single thrombotic event,
[...] others say 6 months
--- it's generally agreed that recurrent
non-gonococcal arthritis. What organism is the msot
thrombotic events warrant lifelong
and gonoccocal common non-gonococcal cause?
therapy
arthritis. What Staphylococcus aureus
organism is the msot
1604. Anticardiolipin Anticardiolipin antibodies are associated common
antibodies are with spontaneous abortions. What is the non-gonococcal
associated with threshold amount of abortions that make a cause?
spontaneous workup for anticardiolipin antibodies [...]
abortions. What is indicated?
the threshold > 2 first trimester events; or > 1 second
amount of abortions trimester event
that make a workup
non-gonococcal arthritis. Which type is typically 2/2
for anticardiolipin
and gonoccocal hematogenous spread only?
antibodies
arthritis. Which type Gonococcal
indicated?
is typically 2/2
[...]
hematogenous
spread only?
1605. What is the What is the treatment to prevent [...]
treatment to prevent recurrence of a spontaneous abortion?
recurrence of a Heparin + aspirin
spontaneous Not warfarin since it is teratogenic.
abortion? Not steroids since they don't help.
[...]
249 of 340
1609. A pt presents w/ a A pt presents w/ a single, warm, red, 1611. A pt presents w/ a A pt presents w/ a swollen, red, painful
single, warm, red, painful joint. You want to rule out septic swollen, red, right knee joint that started last night. He
painful joint. You arthritis so arthrocentesis is performed. painful right knee denies any trauma or IV drug use. He is
want to rule out Arthrocentesis reveals 90% PMNs and > joint that started last otherwise healthy but states that last
septic arthritis so 50k WBCs. Gram-staining of the aspirate night. He denies any week he had urethral discharge with
arthrocentesis is reveals gram-positive organisms. What trauma or IV drug dysuria. Arthrocentesis is performed and
performed. is the next step in management? use. He is otherwise gram-negative organisms are seen.
Arthrocentesis Nafcillin if MSSA; Vanco if MRSA; healthy but states What is the most likely dx?
reveals 90% PMNs Vanco + ceftriaxone if giving empiric tx that last week he Gonococcal arthritis
and > 50k WBCs. until sensitivity returns had urethral
Gram-staining of the Non-gonococcal septic arthritis tx key discharge with
aspirate reveals points: dysuria.
gram-positive - most often it's Staphylococcus aureus Arthrocentesis is
organisms. What is - if a prosthetic joint is involved, consider performed and
the next step in Staphylococcus epidermidis gram-negative
management? - on the test: pick nafcillin unless they organisms are seen.
[...] clearly say it is MRSA; if MRSA pick What is the most
vanco likely dx?
- in real life: tx w/ empiric vanco until [...]
sensitivity returns; switch to nafcillin if
MSSA as vanco is associated w/ poor
1612. A pt presents w/ a A pt presents w/ a swollen, red, painful
outcomes with MSSA
swollen, red, right knee joint that started last night. He
painful right knee denies any trauma or IV drug use. He is
joint that started last otherwise healthy but states that last
night. He denies any week he had urethral discharge with
trauma or IV drug dysuria. Arthrocentesis is performed and
use. He is otherwise gram-negative organisms are seen. He is
1610. A pt presents w/ a A pt presents w/ a warm, red, and healthy but states dx w/ gonococcal arthritis. What is the
warm, red, and painful right knee joint. He had a knee that last week he treatment?
painful right knee replacement last year. Arthrocentesis had urethral Ceftriaxone (+
joint. He had a knee reveals gram-positive organisms. What discharge with azithromycin/doxycycline to co-treat
replacement last Staphylococcus species must be dysuria. for Chlamydia)
year. Arthrocentesis considered in this pt? Arthrocentesis is
reveals S. aureus and S. epidermidis performed and
gram-positive gram-negative
organisms. What organisms are seen.
Staphylococcus While S. aureus is the most common He is dx w/
species must be cause, the prosthetic joint means we have gonococcal arthritis.
considered in this to worry about S. epidermidis as well. What is the
pt? treatment?
[...] [...]
250 of 340
1613. What is the best What is the best diagnostic test for 1616. A pt presents w/ a A pt presents w/ a single, red, warm,
diagnostic test for gonococcal arthritis? single, red, warm, swollen, painful joint. He states that his
gonococcal arthritis? Cx on chocolate agar; or nucleic acid swollen, painful right big toe began hurting after a day of
[...] amplification test (NAAT) joint. He states that eating BBQ and drinking beers for the
his right big toe superbowl. His PMHx is significant for
began hurting after a HTN managed by HCTZ. You suspect
K gonorrhea is weird so bare with me on day of eating BBQ gout. Arthrocentesis reveals an aspirate
this one and drinking beers containing < 50k WBCs without
- choosing culture as the diagnostic test is for the superbowl. organisms and negatively birefringent,
risky as gonorrhea is intracellular and His PMHx is needle-shaped crystals. What is the
requires chocolate agar; if it doesn't significant for HTN most likely dx?
specifically say chocolate agar, think twice managed by HCTZ. Gout
before choosing Cx You suspect gout.
- NAAT is a good choice if Cx on Arthrocentesis
chocolate agar is not an option reveals an aspirate
containing < 50k
WBCs without
1614. Which crystals are Which crystals are associated with gout?
organisms and
associated with Monosodium urate
negatively
gout?
birefringent,
[...]
needle-shaped
crystals. What is the
1615. A pt presents w/ a A pt presents w/ a single, red, warm, most likely dx?
single, red, warm, swollen, painful joint. He states that his [...]
swollen, painful right big toe began hurting after a day of
joint. He states that eating BBQ and drinking beers for the
1617. Which Which crystal-deposition disease is
his right big toe superbowl. His PMHx is significant for
crystal-deposition associated with negatively birefringent
began hurting after a HTN managed by HCTZ. You suspect
disease is crystals?
day of eating BBQ gout. What is the best initial diagnostic
associated with Gout (monosodium urate crystals)
and drinking beers test?
negatively
for the superbowl. Arhtrocentesis (as is the case for all
birefringent
His PMHx is single, red, swollen, painful joints)
crystals?
significant for HTN
[...]
managed by HCTZ.
You suspect gout.
What is the best
initial diagnostic
test? 1618. Which crystal Which crystal deposition disease is
[...] deposition disease is associated with positively birefringent
associated with crystals?
positively Pseudogout (calcium pyrophosphate
birefringent crystals)
crystals?
[...]
251 of 340
1619. Which crystal Which crystal deposition disease is 1624. A pt w/ leukemia is A pt w/ leukemia is begun on
deposition disease is associated with needle-shaped crystals? begun on chemotherapy. You are worried about
associated with Gout (monosodium urate crystals) chemotherapy. You Tumor Lysis Syndrome. How do you
needle-shaped are worried about prophylax against this?
crystals? Tumor Lysis Allopurinol + vigorous hydration
[...] Syndrome. How do Tumour Lysis Syndrome is a cancer
you prophylax syndrome where chemotherapy causes a
against this? bunch of cells to die at once, thereby
[...] releasing a shietload of uric acid, causing
renal failure and impaired urate excretion.
Febuxostat is another xanthine oxidase
1620. Which crystal Which crystal deposition disease is
inhibitor that you can consider.
deposition disease is associated with rhomboid-shaped
Rasburicase is a drug you can consider
associated with crystals?
if uric acid levels are already elevated.
rhomboid-shaped Pseudogout (calcium pyrophosphate
crystals? crystals)
[...]
1625. What is the first line What is the first line treatment for acute
treatment for acute pseudogout?
1621. What is the What is the treatment for acute gout?
pseudogout? NSAIDs
treatment for acute NSAIDs (1st line; c/i in CKD); Steroids
[...]
gout? (2nd line; if pt has CKD or NSAIDs
[...] ineffective); Colchicine (3rd line;
diarrhea is the dose-limiting side
effect) 1626. What is the What is the treatment for pseudogout in
treatment for a pt w/ CKD?
pseudogout in a pt Steroids
w/ CKD? Note that colchicine can be given in CKD
[...] but the dose must be adjusted and toxicity
1622. From the From the recommended treatments of
rises.
recommended acute gout, which is considered the best
treatments of acute therapy?
gout, which is NSAIDs
considered the best 1627. Which sex is more Which sex is more commonl affected by
therapy? commonl affected by rheumatoid arthritis?
[...] Remember, you cannot give in CKD. rheumatoid arthritis? Women
[...]
1623. What is the What is the treatment for chronic gout?

treatment for chronic Allopurinol (1st line; preferred;
gout? consider febuxostat as well); 1628. A 60 y/o female pt A 60 y/o female pt presents c/o of
[...] Probenecid (for under-excretors) presents c/o of symmetrical joint pain in the hands and
If the pt truly is an underexcretor of Uric symmetrical joint knees. Further history reveals that the
Acid (pretty rare), then probenecid is the pain in the hands MCPs, ICPs and DIPs are affected in the
first choice. The question will go out of its and knees. Further hands. Is rheumatoid arthritis on the
way to tell you that the pt is a true history reveals that differential?
under-excretor (i.e. 24 hr urine collection the MCPs, ICPs and No; RA does not affect the DIPs
is low for urate). In that case, choose DIPs are affected in
probenecid. Otherwise, the hands. Is
Allopurinol/febuxostat. rheumatoid arthritis
on the differential?
[...]
252 of 340
1629. A pt presents c/o of A pt presents c/o of morning stiffness in 1632. A 60 y/o female pt A 60 y/o female pt presents c/o of > 60
morning stiffness the hands. You suspect rheumatoid presents c/o of > 60 min of morning hand stiffness that
in the hands. You arthritis. Which cervical spinal levels min of morning improves with use as the day
suspect rheumatoid can be affected in RA? hand stiffness that progresses. Xray of the affected MCP and
arthritis. Which C1 and C2 (and can cause subluxation) improves with use DIP joints of the hands reveal
cervical spinal as the day periarticular osteopenia and bony
levels can be progresses. Xray of erosions. What is the most likely
affected in RA? Remember, RA has a weird tropism for the affected MCP diagnosis?
[...] small joints (but not the DIPs). So if the and DIP joints of Rheumatoid Arthritis
spine is ever involved or checked in a the hands reveal The buzz phrase "periarticular
RA case, remember to check C1 and periarticular osteopenia" is associated with
C2. Otherwise, the spine is left unaffected osteopenia and rheumatoid arthritis.
in RA. bony erosions. What
Hence, if a pt is going to do anything that is the most likely
involves neck hyperextension (i.e. diagnosis?
intubation), an XRay should be [...]
considered.
This is useful in questions that will involve
1633. A pt is Dx w/ A pt is Dx w/ rheumatoid arthritis. What is
"morning stiffness" and "back pain". If it's
rheumatoid arthritis. the first line treatment regimen?
lower back, think ankylosing spondylitis, if
What is the first line Methotrexate + NSAIDs
neck, think of C1 and C2.
treatment regimen? Rheumatoid Arthritis treatment key
[...] points:
1630. What is the What is the "NSHRS3X" mnemonic for the - as soon as the pt is dx'd they should be
"NSHRS3X" diagnostic criteria of rheumatoid arthritis? started on treatment; the regimen should
mnemonic for the (see below) involve both symptom control (w/
diagnostic criteria of NSAIDs) and disease control (w/ MTX)
rheumatoid arthritis? - use NSAIDs (ibuprofen/meloxicam) to
[...] control symptoms
- use DMARDs (1st line is MTX; 2nd line
is hydroxychloroquine) to control disease
1631. What is the best What is the best initial test for rheumatoid
progression; notice the difference vs.
initial test for arthritis?
SLE (MTX 1st line vs.
rheumatoid arthritis? RF testing; or anti-CCP testing
hydroxychloroquine)
[...]
- add biologics for refractory cases, but
remember to screen for TB/fungus before
Basically, if CCP is there, choose it. If not,
doing so
choose RF.
- use steroids for acute flares and wean
RF testing is cheaper but only 70-80%
off once stabilized
sensitive and not specific; in fact, RF is
rather poorly named as it is an
inflammatory mediator for a number of
diseases
Anti-CCP testing is > 80% sensitive and
> 95% specific
253 of 340
1634. A pt is dx w/ A pt is dx w/ rheumatoid arthritis and is 1635. A pt is dx w/ an A pt is dx w/ an acute, life-threatening

rheumatoid arthritis started on ibuprofen + MTX as first line acute, flare of rheumatoid arthritis. What is the
and is started on treatment. She does not improve and her life-threatening flare treatment?
ibuprofen + MTX as symptoms worsen. What can be added to of rheumatoid Corticosteroids
first line treatment. her regimen? arthritis. What is the
She does not Biologic (e.g. etanercept, infliximab, treatment?
improve and her rituximab) [...] In general, steroids ought to be avoided in
symptoms worsen. The biologics should be left for severe RA to avoid long-term side effects, but in
What can be added cases as they cause immunosuppression. an acute flare they are effective.
to her regimen? If you give them, you should screen for Rheumatoid Arthritis treatment key
[...] fungus/TB if they've been in endemic points:
areas as the biologics can cause these to - as soon as the pt is dx'd they should be
flare up. started on treatment; the regimen should
involve both symptom control (w/
Rheumatoid Arthritis treatment key NSAIDs) and disease control (w/ MTX)
points: - use NSAIDs (ibuprofen/meloxicam) to
- as soon as the pt is dx'd they should be control symptoms
started on treatment; the regimen should - use DMARDs (1st line is MTX; 2nd line
involve both symptom control (w/ is hydroxychloroquine) to control disease
NSAIDs) and disease control (w/ MTX) progression; notice the difference vs.
- use NSAIDs (ibuprofen/meloxicam) to SLE (MTX 1st line vs.
control symptoms hydroxychloroquine)
- use DMARDs (1st line is MTX; 2nd line - add biologics for refractory cases, but
is hydroxychloroquine) to control disease remember to screen for TB/fungus before
progression; notice the difference vs. doing so
SLE (MTX 1st line vs. - use steroids for acute flares and wean
hydroxychloroquine) off once stabilized
- add biologics for refractory/severe
cases, but remember to screen for
TB/fungus before doing so
1636. A pt w/ a PMHx of A pt w/ a PMHx of rheumatoid arthritis
- use steroids for acute flares and wean
rheumatoid presents w/ neutropenia and
off once stabilized
arthritis presents w/ splenomegaly. What is the most likely
neutropenia and dx?
splenomegaly. Felty's Syndrome
What is the most
likely dx?
[...] If you see RA + splenomegaly or RA +
neutropenia, think Felty's and look for the
third symptom in the triad
(neutropenia/splenomegaly).
1637. Which sex is more Which sex is more commonly affected by

commonly affected seronegative arthritis?
by seronegative Men
arthritis?
[...]
254 of 340
1638. What is the "PAIR" What is the "PAIR" mnemonic for the 1642. A 30 y/o male pt A 30 y/o male pt presents c/o lower back
mnemonic for the most common seronegative arthritides? presents c/o lower pain and morning stiffness. He states
most common Psoriatic arthritis, Ankylosing back pain and that the pain decreases with activity
seronegative spondylitis, IBD-related arthritis, morning stiffness. and increases with rest. A lateral lumbar
arthritides? Reactive arthritis; (PAIR) He states that the xray reveals "bamboo spine" sign. What
[...] pain decreases is the most likely dx?
with activity and
increases with rest.
1639. Which HLA subtype Which HLA subtype is associated with
A lateral lumbar xray Ankylosing spondylitis
is associated with seronegative spondyloarthropathies?
reveals "bamboo Bamboo spine on XR is characteristic of
seronegative HLA-B27
spine" sign. What is AS as a late finding and is 2/2 the fusion
spondyloarthropathies?
the most likely dx? of vertebral bodies by bridging
[...]
syndesmophytes.
- Note that HLA-B27 does not help in
diagnosis, so don't choose it (arguable
[...]
in AS due to the high association, but
otherwise it's useless).
- Also note that these diseases are
seronegative, so testing for antibodies 1643. A 30 y/o male pt A 30 y/o male pt presents c/o lower back
does not help in diagnosis either. presents c/o lower pain and morning stiffness. He states
- It is the extra-articular manifestations back pain and that the pain decreases with activity
and disease associations that allow morning stiffness. and increases with rest. You suspect
diagnosis of spondyloarthropathies. He states that the ankylosing spondylitis. What is the best
pain decreases initial test?
with activity and Lumbar XR (that also visualizes the SI
1640. Which age group is Which age group is commonly affected by
increases with rest. joint)
commonly affected ankylosing spondylitis?
You suspect
by ankylosing Men 20-39 y/o
ankylosing
spondylitis?
spondylitis. What is
[...]
[...]
1641. A 30 y/o male pt A 30 y/o male pt presents c/o lower back
presents c/o lower pain and morning stiffness. He states
1644. While ankyosing While ankyosing spondylitis is associated
back pain and that the pain decreases with activity
spondylitis is w/ lower back pain, it can affect tendons
morning stiffness. and increases with rest. What is the
associated w/ lower in other areas. Which tendon is known to
He states that the most likely dx?
back pain, it can potentially calcify in AS?
pain decreases Ankylosing spondylitis
affect tendons in Achilles tendon (this is enthesopathy)
with activity and This is a pretty unique feature of AS (back
other areas. Which
increases with rest. pain that improves w/ exercise and
tendon is known to
What is the most worsens w/ rest).
potentially calcify in Remember, AS is due to sacroiliitis, fusion
likely dx?
AS? of the sacral joints and tendon
[...]
[...] calcification.
1645. What is the What is the treatment for ankylosing

treatment for spondylitis?
ankylosing Exercise + NSAIDs initially; escalate to
spondylitis? methotrexate or anti-TNF agents if
[...] refractory to NSAIDs
255 of 340
1646. A pt is dx w/ A pt is dx w/ anyklosing spondylitis and 1649. A pt w/ a hx of A pt w/ a hx of psoriasis presents c/o of

anyklosing started on NSAIDs. He is escalated to psoriasis presents joint pain. He states that he feels it in his
spondylitis and methotrexate but his symptoms are still c/o of joint pain. He hands and has noticed pitting of the
started on NSAIDs. severe. What drug can be used to further states that he feels it nails. Further examination reveals that his
He is escalated to escalate treatment? in his hands and DIPs and PIPs are symmetically
methotrexate but his Anti-TNF agents (e.g. etanercept, has noticed pitting affected and that he has silvery, scaly
symptoms are still infliximab, adalimumab) of the nails. Further plaques at his elbows and knees. You
severe. What drug examination reveals suspect psoriatic arthritis. What is the
can be used to that his DIPs and treatment?
further escalate PIPs are Methotrexate (as there is skin
treatment? symmetically involvement)
[...] affected and that he
has silvery, scaly
plaques at his Psoriatic Arthritis treatment key points:
1647. What is the What is the treatment for reactive arthritis
elbows and knees. - use NSAIDs for mild disease or if there
treatment for (or Reiter's syndrome)?
You suspect is no/mild cutaneous involvement
reactive arthritis (or NSAIDs (for arthritis); doxycycline or
psoriatic arthritis. - use methotrexate for severe disease or
Reiter's syndrome)? azithromycin (for Chlamydia); IM
What is the if there is significant cutaneous
[...] ceftriaxone (to co-treat for gonorrhea)
treatment? involvement
[...] - use anti-TNF agents if it is refractory to
MTX
Remember, reactive arthritis is 2/2
- do not use steroids as they can
non-gonococcal urethritis/STD. So we
precipitate a flare of psoriasis
tx the arthritis as expected and the cause
as expected. Remember to co-treat for
gonorrhea in any chlamydia infection (and 1650. A pt is dx w/ A pt is dx w/ psoriatic arthritis with
vice versa). psoriatic arthritis with significant cutaneous involvement.
significant cutaneous Methotrexate is started but fails to be
involvement. effective. What can be considered
Methotrexate is instead?
started but fails to be Anti-TNF agents (not steroids as they
effective. What can can precipitate psoriasis flare)
be considered Psoriatic Arthritis treatment key points:
1648. A pt w/ a hx of A pt w/ a hx of psoriasis presents c/o of
instead? - use NSAIDs for mild disease or if there
psoriasis presents joint pain. He states that he feels it in his
[...] is no/mild cutaneous involvement
c/o of joint pain. He hands and has noticed pitting of the
- use methotrexate for severe disease or
states that he feels it nails. Further examination reveals
if there is significant cutaneous
in his hands and sausage digits and that his DIPs and
involvement
has noticed pitting PIPs are symmetically affected and that
- use anti-TNF agents if it is refractory to
of the nails. Further he has silvery, scaly plaques at his
MTX
examination reveals elbows and knees. What is the most likely
sausage digits and dx?
that his DIPs and Psoriatic arthritis
PIPs are The nail pitting can look like someone
symmetically drilled a hole with a pin (or just like pitting 1651. Both ankylosing Both ankylosing spondylitis (AS) and
affected and that he nails). spondylitis (AS) and enteropathic arthritis are associated with
has silvery, scaly Sausage fingers are 2/2 enthesopathy. enteropathic arthritis IBD. Which of the two will not improve
plaques at his are associated with after the IBD is treated?
elbows and knees. IBD. Which of the AS
What is the most two will not
likely dx? improve after the
[...] IBD is treated? AS = does not improve w/ IBD treatment
[...] EA = will resolve w/ IBD treatment
256 of 340
1654. What is the CREST What is the CREST mnemonic for the
1652. A pt w/ a history of A pt w/ a history of ulcerative colitis mnemonic for the presentation of CREST syndrome (limited
ulcerative colitis presents c/o of joint pain. History reveals presentation of scleroderma)?
presents c/o of joint a symmetric, bilateral, non-deforming CREST syndrome (see below)
pain. History reveals arthritis affecting the fingers and lower (limited
a symmetric, back. What is the most likely dx? scleroderma)?
bilateral, Enteropathic Arthritis [...] CREST key points:
non-deforming Look for a "history of diarrhea" instead to - most of the presentation of scleroderma
arthritis affecting suspect IBD. can be remembered easily when you
the fingers and Note that AS is also associated w/ IBD realise that the disease involves
lower back. What is but will not involve anything but the lower wide-spread collagen deposition that
the most likely dx? back and will not resolve w/ treatment of also replaces smooth muscle
[...] the IBD (EA will fully resolve). - Calcinosis
- Raynaud's phenomenon
- Esophagus; can involve esophageal
1653. Systemic Systemic Scleroderma can be described dysmotility and/or GERD
Scleroderma can be as CREST syndrome (Limited - Sclerodactyly; leads to tights skin at the
described as CREST Scleroderma) with visceral involvement. hands and face
syndrome (Limited What involvement is seen that sets - Telangiectasias; can cause GI bleed
Scleroderma) with systemic scleroderma apart? and iron deficiency anaemia
visceral Cardiac (restrictive cardiomyopathy,
involvement. What heart block); renal (renovascular
involvement is seen hypertension); lung (interstitial lung
that sets systemic disease, pHTN) 1655. What is the best What is the best diagnostic test for both
scleroderma apart? These are all 2/2 the main pathological diagnostic test for Systemic and Limited Scleroderma
[...] feature of this disease: wide-spread both Systemic and (CREST)?
collagen deposition and replacement of Limited Scleroderma Autoantibodies; although the dx are
smooth muscle. (CREST)? both clinical
Collagen deposition at the renal arterioles [...]
prevents dilation and constriction, thereby
creating a pre-renal cause of HTN by Systemic scleroderma = Anti-Scl70 =
activating the RAAS. Anti-topoisomerase = only positive in
30% (still the most specific test)
CREST syndrome = anti-centromere =
only positive in 50% (still the most specific
test)
1656. There is no There is no treatment for both

treatment for both scleroderma or CREST syndrome, but we
scleroderma or can control symptoms. What is given to
CREST syndrome, treat the raynaud's phenomenon?
but we can control CCBs
symptoms. What is
given to treat the
raynaud's
phenomenon?
[...]
257 of 340
1657. There is no There is no treatment for both 1660. Pulmonary Pulmonary hypertension can manifest
treatment for both scleroderma or CREST syndrome, but we hypertension can after a number of things. Which
scleroderma or can control symptoms or progression. manifest after a connective tissue disorder is associated
CREST syndrome, What DMARD has been shown to slow number of things. w/ pHTN?
but we can control disease in CREST syndrome? Which connective Scleroderma (both systemic and
symptoms or tissue disorder is limited)
progression. What associated w/
DMARD has been MTX pHTN?
shown to slow [...] CREST is associated with Pulmonary
disease in CREST Artery Hypertension on its own (causing
syndrome? pHTN); but there is no other lung
disease and no other visceral
involvement; the lungs themeselves are
[...] normal
Systemic Scleroderma is associated w/
ILD, which can cause pHTN.
scleroderma or can control symptoms. What is given to 1661. A pt presents c/o of A pt presents c/o of dry eyes, dry mouth
CREST syndrome, treat the renovascular hypertension seen dry eyes, dry and some facial swelling. Physical exam
but we can control in systemic scleroderma? mouth and some reveals keratoconjunctivitis,
symptoms. What is ACE-I facial swelling. xerostomia and bilateral parotid
given to treat the Physical exam enlargement. You suspect Sjogren's
renovascular reveals syndrome. What is the best initial
hypertension seen in No matter how high the creatinine gets in keratoconjunctivitis, diagnostic test?
systemic this case, treat the HTN w/ ACE-I (as it is xerostomia and Anti-SS-A-(Ro) and anti-SS-B-(La)
scleroderma? renovascular). bilateral parotid testing (best initial blood test);
[...] Collagen deposition at the renal arterioles enlargement. You Schirmer tear production test (best
prevents dilation and constriction, thereby suspect Sjogren's overall initial test)
creating a pre-renal cause of HTN by syndrome. What is Sjogren's Syndrome Dx key points:
activating the RAAS. the best initial - often a part of another autoimmune dz
diagnostic test? (esp SLE), but can be solo; Dx clinical but
[...] needs confirmation
- best initial blood test is SS-A-Ro and
SS-B-La testing
scleroderma or can control symptoms. What is given to
- best initial overall test is the Schirmer
CREST syndrome, treat the interstitial lung disease seen in
tear production test with a fliter paper on
but we can control systemic scleroderma?
the eye
symptoms. What is Cyclophosphamide
- most accurate test is a lip or parotid
given to treat the
Bx looking for the lymphocytic infiltration
interstitial lung
- Rose bengal staining reveals an
disease seen in Cyclophosphamide improves the dyspnea
abnormal corneal epithelium if
systemic and PFTs.
performed
scleroderma?
[...]
258 of 340
1662. A pt is dx w/ sjogren A pt is dx w/ sjogren syndrome. What is 1666. While not a great While not a great cause of debility,
syndrome. What is the treatment? cause of debility, osteoarthritis can affect the hands. Which
the treatment? None; manage symptoms (artificial osteoarthritis can hand joints are primarily affected?
[...] tears and saliva); f/u testing for affect the hands. DIPs (moreso than PIPs and MCPs)
lymphoma (manifests in 10%) Which hand joints
Fluoride treatments can help w/ dental are primarily
caries. affected? Contrast this w/ RA that does not affect
[...] the DIPs.
1663. A pt presents A pt presents complaining of difficulty

complaining of getting out of chairs, muscle pain and 1667. A pt presents A pt presents complaining of < 15 min of
difficulty getting rashes. Physical exam reveals proximal complaining of < 15 joint stiffness. Which type of arthritis is the
out of chairs, muscle weakness with intact distal min of joint stiffness. most likely dx?
muscle pain and muscle strength. You also find a purple Which type of Osteoarthritis
rashes. Physical rash around the eyes with periorbital arthritis is the most
exam reveals edema and scaly lesions distributed likely dx?
proximal muscle symmetrically over the wrists, elbows [...] RA has stiffness of longer duration (>
weakness with and knees. What is the most likely dx? 30-60 min)
intact distal muscle Myositis
strength. You also Remember, the myositides all present
1668. A pt is dx w/ A pt is dx w/ osteoarthritis. At which joint
find a purple rash similarly, but have different underlying
osteoarthritis. At will Heberden nodes be found?
around the eyes pathology. Definitive diagnosis requires
which joint will DIPs
with periorbital Bx.
Heberden nodes be
edema and scaly - Heliotrope rash = purple rash around
found?
lesions distributed the eyes w/ periorbital edema
[...] "B before H"
symmetrically over - Gottron's papules are pathognomonic
- Bouchard nodes = PIP
the wrists, elbows of myositis and are scaly areas around
- Heberden nodes = DIP
and knees. What is the major joints
the most likely dx? - note that an EMG is done to rule out
[...] nerve cause of pain or if there is a 1669. A pt is dx w/ A pt is dx w/ osteoarthritis. At which joint
conduction issue osteoarthritis. At will Bouchard nodes be found?
which joint will PIPs
Bouchard nodes be
1664. A pt is dx w/ A pt is dx w/ dermatomyositis after a
found?
dermatomyositis biopsy. What is the treatment?
[...] "B before H"
after a biopsy. What High-dose steroids; look for occult
- Bouchard nodes = PIP
is the treatment? malignancy
- Heberden nodes = DIP
[...]
Myositis can be a manifestation of 1670. What is the most What is the most accurate test for
paraneoplastic syndrome. accurate test for osteoarthritis?
osteoarthritis? XR of the affected joint(s)
[...]
Osteoarthritis dx key points:

1665. What is the most What is the most common cause of joint
- typically clinical
common cause of pain?
- the absence of inflammation, normal
joint pain? Osteoarthritis
labs and clinical picture is often enough
[...]
to dx OA
- XR will typically show joint space
narrowing, osteophytes, dense
subchondral bone, and/or bone cysts.
259 of 340
1671. What is the best What is the best initial analgesic therapy 1674. What is the best What is the best initial therapy of acute,
initial analgesic for osteoarthritis? initial therapy of painful gout?
therapy for Acetaminophen acute, painful gout? NSAIDs
osteoarthritis? [...]
[...]
Osteoarthritis treatment key points: They are superior to colchicine as best
- weight loss and moderate exercise initial therapy.
should always be implimented
- acetaminophen is the 1st line analgesic
1675. Steroids are given in Steroids are given in acute gout if there is
due to side effects
acute gout if there is no response to NSAIDs or if NSAIDs are
- NSAIDs are the 2nd line analgesic; be
no response to c/i. When are steroids given orally in
sure to be minfdul of side effects, esp. GI
NSAIDs or if NSAIDs gout?
bleed
are c/i. When are PO steroids for multiple joints; Injected
- capsaicin cream can help
steroids given orally steroids for single joint (injected into
- intraarticular steroids if all other
in gout? the joint)
medical therapy is ineffective
[...]
- hyaluronan injections into the joint can
help; glucosamine and chondroitin sulfate
are no more effective than placebo 1676. A pt is diagnosed A pt is diagnosed with chronic gout and
- joint replacement if severe with chronic gout started on colchicine to prophylax against
and started on future attacks. What are the notable side
colchicine to effects of colchicine?
prophylax against Dose-limited diarrhea; neutropenia
accurate diagnostic for gout?
future attacks. What
test for gout? Arthrocentesis + needle study
are the notable side
[...]
effects of colchicine?
[...]
i.e. tap the joint and look at the crystals for
negative birefringence
Remember, when it comes to synovial 1677. A pt w/ chronic A pt w/ chronic gout is diagnosed w/
fluid, glucose, protein and other gout is diagnosed w/ hypertension. Which antihypertensive
measured elements are not helpful in hypertension. drug is the best choice to control BP in
diagnosis Which gout?
antihypertensive Losartan
drug is the best
1673. A pt is thought to be A pt is thought to be in an acute gout
choice to control BP
in an acute gout attack. Your cheeky medical student think
in gout? Losartan (an ARB) lowers uric acid
attack. Your cheeky it would be helpful to measure uric acid
[...] levels as well as its effect on BP.
medical student levels. Why is this not the best idea?
think it would be Uric acid is normal in 25% of acute
helpful to measure gout attacks 1678. Which joints are Which joints are typically affected in
uric acid levels. Why typically affected in pseudogout (calcium-pyrophosphate
is this not the best pseudogout deposition disease; CPPD)?
idea? And it sort of makes sense.. a lot of the (calcium-pyrophosphateLarge joints (knee, wrist)
[...] uric acid is depositing in the joint, so deposition disease;
circulating levels may not necessarily be CPPD)?
elevated. [...] This is a good differentiator vs. other
diseases:
- Gout most commonly affects the big toe
(but can affect others)
- OA/DJD affects the small joints in the
hands (DIPs and PIPs, which are not
affected in CPPD)
260 of 340
1683. What is the best What is the best initial therapy for disk
1679. A pt is dx w/ A pt is dx w/ pseudogout and given initial therapy for herniation?
pseudogout and NSAIDs. NSAIDs are ineffective. What is disk herniation? NSAIDs + ordinary activity as tolerated
given NSAIDs. the 2nd line treatment for acute [...]
NSAIDs are pseudogout?
ineffective. What is Steroids Disk herniation treatment key points:
the 2nd line - NSAIDs + continuation of ordinary
treatment for acute activity is the best initial management
pseudogout? Typically given intraarticular (i.e. and superior to bed rest (srsly, just don't
[...] triamcinolone) via injection. choose bed rest when it comes to back
pain)
1680. What organism is What organism is the most common - yoga is just as effective and often used
the most common cause of an epidural spinal abscess? as a more regimented treatment
cause of an epidural Staphylococcus aureus - steroid injection into the epidural space
spinal abscess? can achieves rapid benefit for refractory
[...] cases
- surgery is rarely needed and typically
only enters the situation if FNDs develop
1681. Which physical Which physical exam technique is very
exam technique is sensitive for disk herniation?
very sensitive for Straight-leg raise 1684. A pt presents w/ s/s A pt presents w/ s/s of cord
disk herniation? of cord compression. No imaging has been
[...] compression. No ordered. What is the most appropriate first
- SLR is 95% sensitive for disk imaging has been step in management of this pt after
herniation, but only 50% specific ordered. What is the completion of the H&P?
- hence if SLR is negative, herniation most appropriate Dexamethasone
can be ruled out first step in
- SLR involves raising the knee > 60 management of this
degrees and positive test result involves pt after completion of While imaging will be necessary to
shooting pain into the buttock and below the H&P? accurately dx this pt's supposed cord
the knee [...] compression, giving steroids is fast
and can prevent permanent paralysis.
1682. What is the most What is the most accurate test for cord
accurate test for compression? 1685. A pt presents w/ A pt presents w/ back pain. What type of
cord compression? MRI back pain. What type sign/symptom must be present for
[...] of sign/symptom imaging of the back to be indicated?
must be present for Focal neurological deficits
Plain XR first. Then MRI. imaging of the back
to be indicated?
[...] The point here is to remember to only
order back imaging if there are focal
neurological deficits.
- simple lumbosacral pain does not
warrant imaging
261 of 340
1686. What is the first line What is the first line treatment for spinal 1689. A pt presents c/o of A pt presents c/o of hand pain that is
treatment for spinal stenosis? hand pain that is worse at night. Physical exam reveals
stenosis? Weight loss + pain meds worse at night. that the pain affects the palm, thumb,
[...] Physical exam index finger, and radial half of the right
reveals that the pain finger on the right side. Thenar
Lumbar Stenosis Tx key points: affects the palm, eminence atrophy is also seen. Tinel
- weight loss and analgesics are first thumb, index and phalen sign are both positive. You
line finger, and radial suspect carpal tunnel syndrome. What is
- epidural steroids injections improve half of the right the most accurate test for carpal tunnel
25-50% of cases finger on the right syndrome?
- physical therapy and bicycling/swimming side. Thenar EMG (or other nerve conduction study)
are helpful eminence atrophy
- surgical correction is typically needed in is also seen. Tinel
75% of cases and involves dilation of the and phalen sign are Do not pick MRI of the wrist!
spinal canal both positive. You
suspect carpal
tunnel syndrome.
1687. A 35 y/o female pt A 35 y/o female pt presents c/o chronic
What is the most
presents c/o chronic muscle pain. Physical exam reveals
accurate test for
muscle pain. tenderness with trigger points at the
carpal tunnel
Physical exam trapezius, medial fat pad of the knee, and
syndrome?
reveals tenderness lateral epicondyle. What is the most likely
[...]
with trigger points dx?
at the trapezius, Fibromyalgia
medial fat pad of the 1690. A pt suspected of A pt suspected of having carpal tunnel
knee, and lateral having carpal tunnel syndrome has a positive tinel sign on
epicondyle. What is syndrome has a physical exam. What is tinel sign?
the most likely dx? positive tinel sign Reproduction of pain/tingling with
[...] on physical exam. tapping/percussion of the median
What is tinel sign? nerve
[...]
1688. A pt presents c/o of A pt presents c/o of hand pain that is
hand pain that is worse at night. Physical exam reveals
Tinel sign: reproduction of the pain and
worse at night. that the pain affects the palm, thumb,
tingling with tapping or percussion of
Physical exam index finger, and radial half of the right
the median nerve
reveals that the pain finger on the right side. Thenar
Phalen sign: reproduction of symptoms
affects the palm, eminence atrophy is also seen. Tinel
with flexion of the wrists to 90 degrees
thumb, index and phalen sign are both positive. What
finger, and radial is the most likely dx?
half of the right Carpal Tunnel Syndrome 1691. A pt suspected of A pt suspected of having carpal tunnel
finger on the right having carpal tunnel syndrome has a positive phalen sign on
side. Thenar syndrome has a physical exam. What is phalen sign?
eminence atrophy positive phalen sign Reproduction of pain/tingling w/
is also seen. Tinel on physical exam. flexion of the wrists to 90 degrees
and phalen sign are What is phalen Tinel sign: reproduction of the pain and
both positive. What sign? tingling with tapping or percussion of
is the most likely dx? [...] the median nerve
[...] Phalen sign: reproduction of symptoms
with flexion of the wrists to 90 degrees
262 of 340
1692. What is the best What is the best initial therapy for carpal 1695. What is the most What is the most accurate test for a
initial therapy for tunnel syndrome? accurate test for a rotator cuff injury?
carpal tunnel NSAIDs + wrist splint (immobilize the rotator cuff injury? MRI
syndrome? hand in a position that relieves [...]
[...] pressure)
1696. What is the first line What is the first line therapy for a rotator
therapy for a rotator cuff injury?
Pts should also avoid manual activity.
cuff injury? NSAIDs + rest + PT/OT
Steroid injections help if splint + NSAIDs
[...]
do not
Surgery can be curative and typically
If ineffective, steroid injections can help
involves decompression by cutting open
w/ pain.
the flexor retinaculum
If unresponsive to anything, surgery may
help.
1693. [...] is a MSK Dupuytren contracture is a MSK If the tear is complete, surgery is first
disorder that disorder that invovles hyperplasia of the line.
invovles palmar fascia leading to nodule formation
hyperplasia of the and contracture of the 4th+5th digits,
1697. What is the therapy What is the therapy for patellofemoral
palmar fascia thereby causing the inability to extend
for patellofemoral syndrome?
leading to nodule fingers.
syndrome? PT + strength training w/ cycling
formation and
[...]
contracture of the
4th+5th digits, - a/w alcoholism and cirrhosis
Patellofemoral syndrome key points:
thereby causing the - loss of extension is more of a cosmetic
- knee pain 2/2 trauma, meniscal tear, or
inability to extend issue than it is functional
imbalance of quadriceps muscle strength;
fingers. - triamcinolone (steroid), lidocaine, or
pain is often worse when walking up/down
collagenase injections may help
stairs or sitting for too long
- surgery is done when function becomes
- exam is often positive for crepitus, joint
impaired and involves release of the
locking, and/or instability
fascia
- XRay is normal
- Tx is PT + strength training (to correct
1694. What is the therapy What is the therapy for Dupuytren any imbalance) + pain control; knee
for Dupuytren Contracture? braces don't help much and there is
Contracture? Triamcinolone injections; or lidocaine nothing to fix surgically
[...] injections; or collagenase injections
Dupuytren contracture is a MSK disorder
1698. What ocular What ocular symptoms are commonly
that invovles hyperplasia of the palmar
symptoms are seen in rheumatoid arthritis?
fascia leading to nodule formation and
commonly seen in Episcleritis
contracture of the 4th+5th digits,
rheumatoid arthritis?
thereby causing the inability to extend
[...]
figners.
- a/w alcoholism and cirrhosis
- loss of extension is more of a cosmetic
issue than it is functional
- triamcinolone (steroid), lidocaine, or
collagenase injections may help;
collagenase is more helpful earlier
- surgery is done when function becomes
impaired and involves release of the
fascia
263 of 340
1699. Joint deformity can Joint deformity can be a common feature 1705. What is the most What is the most accurate test for
be a common in rhematological disease. Which disorder accurate test for myositis?
feature in commonly involves boutonniere (left) and myositis? Muscle bx
rhematological swan neck (right) deformities? [...]
disease. Which Rheumatoid arthritis
disorder commonly
1706. Which autoantibody Which autoantibody associated w/
involves
associated w/ myositis is also associated w/ lung
boutonniere (left)
myositis is also fibrosis?
and swan neck
associated w/ lung Anti-Jo
(right) deformities?
fibrosis?
[...]
[...]
1700. A pt w/ rheumatoid A pt w/ rheumatoid arthritis presents w/

1707. A female pt presents A female pt presents w/ rampant dental
arthritis presents w/ pneumoconiosis and lung nodules.
w/ rampant dental caries and dyspareunia. Which
pneumoconiosis What is the dx?
caries and autoimmune disorder is the likely cause?
and lung nodules. Caplan syndrome
dyspareunia. Which Sjogren Syndrome
What is the dx?
autoimmune Just a reminder that SS can cause both.
[...]
disorder is the likely
cause? Dental caries 2/2 lack of saliva
1701. What is the most What is the most common cause of death [...] Dyspareunia 2/2 lack of vaginal secretions
common cause of in rheumatoid arthritis?
death in rheumatoid CAD
1708. What is the most What is the most dangerous complication
arthritis?
dangerous of Sjogren Syndrome?
[...]
complication of Lymphoma
Sjogren Syndrome?
1702. A pt is dx w/ SLE A pt is dx w/ SLE and started on [...]
and started on hydroxychloroquine. What notable
hydroxychloroquine. toxicity should be kept in mind?
1709. What is the best What is the best initial test for Sjogren
What notable toxicity Retinal toxicity (do dilated eye exams
initial test for Sjogren Syndrome?
should be kept in to gauge)
Syndrome? Schirmer test (tear production test)
mind?
[...]
[...]
Involves placing filter paper against the

1703. Juvenile rheumatoid Juvenile rheumatoid arthritis (JRA) is eye and seeing the amount of tears
arthritis (JRA) is difficult to diagnose. What is the most produced by the amount of wetness on
difficult to diagnose. important feature of the disease that sets the filter paper (yeah... i'll just get the
What is the most it apart? blood test)
important feature of High, spiking fever (> 104 F) in a young Best initial blood test is the
the disease that sets person w/ a rash and no clear autoantibodies (SS-A-Ro and SS-B-La)
it apart? identified fever etiology
[...] - no clear diagnostic test for JRA
1710. Which cholinergic Which cholinergic agent can be used to
- Tx typically involves ASA/NSAIDs;
agent can be used to stimulate saliva production in sjogren
escalate to steroids if no response;
stimulate saliva syndrome?
escalate to anti-TNF agents if refractory
production in sjogren Pilocarpine
syndrome?
1704. What is the best What is the best initial test for myositis? [...]
initial test for CPK + aldolase
myositis?
[...]
264 of 340
1711. The seronegative The seronegative spondyloarthropathies 1716. What is the best What is the best initial therapy for
spondyloarthropathies involve enthesopathy. What is initial therapy for psoriatic arthritis?
involve enthesopathy? psoriatic arthritis? NSAIDs
enthesopathy. Inflammation where tendons and [...] Psoriatic Arthritis treatment key points:
What is ligaments attach to bone - use NSAIDs for mild disease or if there
enthesopathy? is no/mild cutaneous involvement
[...] - use methotrexate for severe disease or
if there is significant cutaneous
involvement
1712. What ocular What ocular pathology is associated w/
- use anti-TNF agents if it is refractory to
pathology is seronegative spondyloarthropathies?
MTX
associated w/ Uveitis
seronegative
spondyloarthropathies?
[...]
accurate test for osteoporosis?
1713. Which seronegative Which seronegative spondyloarthropathy
osteoporosis? DEXA scan (< 2.5)
spondyloarthropathy involves flattening of the normal lumbar
[...]
involves flattening curvature and decreased chest
of the normal expansion?
Remember, the DEXA scan involves
lumbar curvature Ankylosing spondylitis
bone density T-scores and compares
and decreased
the pt's T-score to that of a young, healthy
chest expansion?
woman/adolescent. The score is
[...]
represented as the # of standard
deviations below normal.
1714. What is the most What is the most accurate test for - osteopenia is between -1 to -2.5
accurate test for ankylosing spondylitis? - osteoporosis is < -2.5
ankylosing MRI
spondylitis?
1718. Bisphosphonates Bisphosphonates are part of the first line
[...]
are part of the first therapy for osteoporosis. What are the
Can detect abnormalities long before
line therapy for notable possible complications of the
XRays become abnormal.
osteoporosis. What drug?
are the notable Osteonecrosis of the jaw; Pill-induced
1715. What is the best What is the best initial test for psoriatic possible esophagitis
initial test for arthritis? complications of the
psoriatic arthritis? XRay of the joint which will show drug?
[...] "pencil in a cup" deformity [...]
1719. A pt is diagnosed w/ A pt is diagnosed w/ osteoporosis. What

osteoporosis. What drug can be used to decrease the risk of
drug can be used to vertebral fractures?
decrease the risk of Nasal calcitonin
vertebral fractures?
[...]
265 of 340
1720. Certain arthropathies Certain arthropathies can increase the 1725. What is the best What is the best initial test for
can increase the risk risk of septic arthritis by damaging initial test for osteomyelitis??
of septic arthritis by synovial lining. Which disorder poses the osteomyelitis?? XR
damaging synovial greatest risk? [...]
lining. Which Rheumatoid Arthritis
disorder poses the If the XR is negative, do an MRI, if MRI is
greatest risk? c/i, do a bone scan.
[...] The greatest overall risk is with a XR will reveal periosteal elevation.
prosthetic joint. But as far as disease
goes, it's RA > OA.
1726. A pt is thought to A pt is thought to have osteomyelitis but
Remember, the synovial lining has no
have osteomyelitis the XR is normal. What is the most
basement membrane and hence bacteria
but the XR is normal. appropriate next step in management?
and drugs can easily find their way
What is the most MRI; or bone scan if the MRI is c/i (e.g.
across, esp. hematogenously (i.e.
appropriate next pacemaker)
bacteremia).
step in MRI is just as sensitive as a bone scan
management? and reveals abnormalities 48 hrs after
1721. What is the best What is the best initial and most accurate [...] onset with much higher specificity.
initial and most test for septic arthritis?
accurate test for Arthrocentesis
septic arthritis?
1727. A pt is diagnosed w/ A pt is diagnosed w/ osteomyelitis and
[...]
osteomyelitis and started on therapy. What is the role of
started on therapy. testing for ESR?
1722. A pt has a prosthetic A pt has a prosthetic knee joint. It gets What is the role of To follow treatment response
knee joint. It gets infected. What is the treatment? testing for ESR?
infected. What is the Remove the joint, then 6-8 wks of Abx, [...]
treatment? then replace the joint
[...]
1728. A pt is diagnosed w/ A pt is diagnosed w/ osteomyelitis and
osteomyelitis and given ciprofloxacin. What is the only type
1723. A young pt presents A young pt presents c/o of given ciprofloxacin. of organism that warrants the use of
c/o of polyarthralgia. Physical exam reveals a What is the only type fluoroquinolones in osteomyelitis?
polyarthralgia. petechial rash and tenosynovitis. You of organism that GNR (gram-negative rod/bacillus)
Physical exam suspect gonococcal arthritis. What is the warrants the use of
reveals a petechial best diagnostic test? fluoroquinolones in
rash and Find the STD (i.e. multiple cultures osteomyelitis?
tenosynovitis. You from high-risk sites such as the [...]
suspect gonococcal pharynx, rectum, urethra, cervix)
arthritis. What is the
1729. Fluoroquinolones Fluoroquinolones are c/i in pregnancy and
are c/i in pregnancy children as they interfere with bone
[...] Note, if there are recurrent gonococcal
and children as they growth. What other notable MSK side
infections, make sure you test for
interfere with bone effect of fluoroquinolones should be
Complement Factor deficiency.
growth. What other considered in everyone else?
notable MSK side Achilles tendon rupture
1724. What is the most What is the most accurate test for effect of
accurate test for osteomyelitis? fluoroquinolones
osteomyelitis? Bone bx should be 2/2 interfering w/ chondrocyte growth
[...] considered in
everyone else?
[...]
266 of 340
1730. Anaemia affects Anaemia affects different people in 1734. A pt is found to have A pt is found to have microcytic anaemia
different people in different ways. What can we use to microcytic anaemia and you decide to order an iron panel to
different ways. What assess the severity of anaemia? and you decide to workup the issue. If you had to choose 1
can we use to Symptoms order an iron panel individual test from the iron panel to
assess the severity to workup the issue. workup microcytic anaemia, what would it
of anaemia? If you had to choose be?
[...] It is the symptoms (not measured Hgb) 1 individual test from Ferritin
that conveys the severity and it all comes the iron panel to
down to oxygen delivery (O2 delivery = workup microcytic
Hgb * %sat * CO). Think of it this way: anaemia, what On the test, if you have to choose, pick
- an elderly male pt w/ COPD (decreased would it be? ferritin.
%sat), MI, and CHF (decreased CO) on a [...] In real life, get the whole iron panel.
beta-blocker (decreased CO) may not be
able to tolerate a drop in Hgb by maybe
1735. A pt is found to have A pt is found to have macrocytic anaemia.
even 1 g/dL
macrocytic anaemia. What finding on peripheral blood smear
- a young athlete may be able to tolerate a
What finding on highly indicative of megaloblastosis
large drop in Hgb as he/she can
peripheral blood should be looked for prior to B12/folate
compensate by increasing CO
smear highly testing?
indicative of Polysegmented neutrophils
1731. In general, at which In general, at which Hgb level will megaloblastosis
Hgb level will conjunctival pallour be seen? should be looked for
conjunctival pallour < 8 g/dL (at the anterior rim of the prior to B12/folate i.e. PBS (looking for polysegmented
be seen? conjunctivae) testing? neutrophils) is the best initial test for
[...] [...] macrocytic anaemia
- also note that B12/folate testing is a
waste if megaloblastosis is not present;
there are non-megaloblastic causes of
macrocytic anaemia
- remember, "macrocytic" = large cells;
1732. Anaemia is typically Anaemia is typically separated into micro-,
"megaloblastic" = impaired nuclear
separated into macro-, or normocytic types. Which types
development; they are not synonymous
micro-, macro-, or are generally seen as production
normocytic types. anaemia(s)?
Which types are Micro and Macro 1736. The workup of all The workup of all types of anaemia begins
generally seen as types of anaemia with a CBC w/ a focus on MCV. What is
production begins with a CBC the best initial test for macrocytic
anaemia(s)? In general, w/ a focus on MCV. anaemia (MCV > 100)?
[...] micro + macro = production anaemia What is the best Peripheral blood smear
normo = consumption anaemia initial test for Remember, "macrocytic" (large cells)
macrocytic does not mean "megaloblastic"
anaemia (MCV > (impaired nuclear development).
1733. Anaemia is typically Anaemia is typically separated into micro-,
100)? In real life, you would get a PBS +
separated into macro-, or normocytic types. Which types
[...] B12/folate testing together, but if asked,
micro-, macro-, or are generally seen as consumption
the smear always comes first.
normocytic types. anaemia(s)?
Which types are Normocytic
generally seen as
consumption
anaemia(s)? In general,
[...] micro + macro = production anaemia
normo = consumption anaemia
267 of 340
1737. Both Vitamin B12 Both Vitamin B12 and folate deficiencies 1740. After a peripheral After a peripheral smear reveals
and folate can cause macrocytic, megaloblastic smear reveals megaloblastic anaemia in a pt, you pursue
deficiencies can anaemia and present the same way megaloblastic vitamin B12 and folate testing. The test is
cause macrocytic, except for 1 distinct feature. What is it? anaemia in a pt, you equivocal. What is the next step in
megaloblastic Vit B12 deficiency has neuro s/s pursue vitamin B12 workup?
anaemia and and folate testing. Methyl-malonic acid testing
present the same The test is Megaloblastic anaemia workup key
way except for 1 equivocal. What is points:
distinct feature. the next step in - if MCV > 100, get a PBS to test for
What is it? workup? megaloblastic anaemia
[...] [...] - if PBS reveals megaloblastosis, check
B12/folate
- if equivocal, check methylmalonic acid
1738. What type of foods What type of foods are known for their
--- if MMA is normal, it is a folate
are known for their high folate content?
deficiency
high folate content? Leafy green vegetables
--- if MMS is elevated, it is a Vit B12
[...]
deficiency
There is no storage form of folate in the

body, hence we can become deficient in
3-6 weeks. 1741. Which cause of Which cause of megaloblastic anaemia is
However, many foods are reinforced w/ megaloblastic associated with an elevated level of
folate nowadays, so it's typically seen w/ anaemia is methylmalonic acid?
malnutrition (esp. alcoholism) associated with an Vitamin B12 deficiency
- I've had a few questions that mentioned elevated level of Megaloblastic anaemia workup key
the pt eating a "bread and water" diet; methylmalonic points:
look out for that acid? - if MCV > 100, get a PBS to test for
[...] megaloblastic anaemia
- if PBS reveals megaloblastosis, check
1739. What is the biggest What is the biggest risk factor for Folate
B12/folate
risk factor for Folate deficiency?
- if b12/folate is equivocal, check
deficiency? Alcoholism
methylmalonic acid
[...] There is no storage form of folate in the
--- if MMA is normal, it is a folate
body, hence we can become deficient in
deficiency
3-6 weeks.
--- if MMS is elevated, it is a Vit B12
However, many foods are reinforced w/
deficiency
folate nowadays, so it's typically seen w/
malnutrition (esp. alcoholism)
- I've had a few questions that mentioned
the pt eating a "bread and water" diet;
look out for that
268 of 340
1742. What type of foods What type of foods are considered 1745. The Schilling test is The Schilling test is a test that used to be
are considered common sources of Vitamin B12? a test that used to be used in B12 deficiency, but is now rarely
common sources of Animal products used in B12 used. When do we use it nowadays?
Vitamin B12? Vitamin B12 deficiency key points: deficiency, but is When etiology is uncertain
[...] now rarely used.
- absorption requires an intact When do we use it
gastric/ileum mucosa (and intrinsic nowadays?
factor from parietal cells). [...]
- roughly 3-10 years worth of storage is
kept in the body, hence a deficiency is
1746. A pt is diagnosed A pt is diagnosed with macrocytic,
typically seen in strict vegans or
with macrocytic, megaloblastic anaemia 2/2 pernicious
pernicious anaemia (autoimmune IgA
megaloblastic anaemia. What is the treatment for the
vs. parietal cells/intrinsic factor)
anaemia 2/2 resultant vitamin B12 deficiency?
- in fact, absorption compromise (e.g.
pernicious IM vitamin B12
pernicious anaemia or impaired terminal
anaemia. What is
ileum in crohn's or s/p surgery) is more
the treatment for the
common than nutritional deficiency
resultant vitamin B12 B12 deficiency tx key points:
deficiency? - tx is easy, give vitamin b12
1743. If left untreated, If left untreated, vitamin B12 deficiency [...] - the route of administration however
vitamin B12 can cause subacute combined depends
deficiency can cause degeneration w/ irreversible neuro - if pernicious anaemia, Crohn's
subacute symptoms. Which spinal tract is affected disease, or bypass surgery is present,
combined in SCD? give the b12 IM as the pts do not have
degeneration w/ Dorsal column-medial lemniscus intrinsic factor or have an impaired
irreversible neuro Results in a loss of proprioception and 2 ileum
symptoms. Which point touch discrimination. - if the deficiency is not 2/2 an absorption
spinal tract is Peripheral neuropathy is the most issue, give PO b12
affected in SCD? common symptom.
[...]
1747. A pt is diagnosed A pt is diagnosed with macrocytic,

with macrocytic, megaloblastic anaemia 2/2 vitamin B12
megaloblastic deficiency. His PMHx is positive for
1744. Subacute combined Subacute combined degeneration is a anaemia 2/2 vitamin Crohn's disease. What is the treatment
degeneration is a spinal cord pathology that presents B12 deficiency. His for the vitamin B12 deficiency?
spinal cord following vitamin B12 deficiency. What is PMHx is positive for IM vitamin B12
pathology that the most common neurological symptom Crohn's disease.
presents following seen? What is the
vitamin B12 Peripheral neuropathy treatment for the B12 deficiency tx key points:
deficiency. What is vitamin B12 - tx is easy, give vitamin b12
the most common deficiency? - the route of administration however
neurological [...] depends
symptom seen? - if pernicious anaemia, Crohn's
[...] disease, or bypass surgery is present,
give the b12 IM as the pts do not have
intrinsic factor or have an impaired
ileum
- if the deficiency is not 2/2 an absorption
issue, give PO b12
269 of 340
1753. Iron deficiency Iron deficiency anaemia can result from

1748. What autoantibodies What autoantibodies are seen in anaemia can result blood loss. What type of bleeding is
are seen in pernicious anaemia? from blood loss. typically involved?
pernicious anaemia? Anti-intrinsic factor; anti-parietal cell What type of Slow, chronic bleed (e.g. GI bleeds or
[...] bleeding is typically gynecological bleeding)
involved? The idea here is that when the body starts
[...] to lose blood, it will begin to use iron
1749. A pt is diagnosed w/ A pt is diagnosed w/ macrocytic anaemia. stores to replace lost hemoglobin. With a
macrocytic anaemia. A peripheral smear rules out chronic, slow bleed, iron consumption by
A peripheral smear megaloblastic anaemia. What is the most the marrow eventually overtakes iron
rules out common cause of nonmegaloblastic, absorption, thereby causing anaemia.
megaloblastic macrocytic anaemia?
anaemia. What is Liver disease (typically cirrhosis)
the most common
cause of
nonmegaloblastic,
macrocytic 1754. A 60 y/o male pt is A 60 y/o male pt is diagnosed w/ iron
anaemia? diagnosed w/ iron deficiency anaemia. What follow up
[...] deficiency anaemia. imaging test should be done?
What follow up Colonoscopy (to look for GI source of
1750. A pt is found to have A pt is found to have microcytic anaemia imaging test should bleeding/cancer)
microcytic anaemia after his MCV is found to be < 80. What is be done?
after his MCV is the most appropriate next step in workup [...]
found to be < 80. regardless of etiology?
What is the most Iron studies
appropriate next Remember, if you have to choose 1
step in workup particular test, choose ferritin. Otherwise 1755. What is the most What is the most accurate test to
regardless of get the complete panel. accurate test to diagnose iron deficiency anaemia?
etiology? diagnose iron BM Bx (looking for stainable iron)
[...] deficiency anaemia?
[...]
1751. What is the most What is the most common form of
common form of microcytic anaemia?
microcytic anaemia? Iron Deficiency Anaemia
[...] 1756. A pt is found to have A pt is found to have microcytic anaemia,
microcytic anaemia, so an iron panel is ordered. What single
so an iron panel is study in the iron panel is the most
ordered. What single sensitive for iron deficiency anaemia?
study in the iron Ferritin
1752. What is the normal What is the normal daily requirement of panel is the most On the iron panel, ferritin is the most
daily requirement of iron? sensitive for iron sensitive.
iron? 1 mg/day deficiency anaemia? - if ferritin is low, it is IDA. Period.
[...] [...]
With a max of 3 mg/day
270 of 340
1757. A pt is dx w/ iron A pt is dx w/ iron deficiency anaemia. 1760. Thalassemia results Thalassemia results from defects in either
deficiency anaemia. What is the treatment? from defects in either the alpha or beta globin genes. How many
What is the Stop/control the bleed if present; then the alpha or beta alpha and beta genes are there?
treatment? replace iron globin genes. How 4 alpha; 2 beta
[...] many alpha and beta Thalassemia key points:
genes are there? - there are 4 alpha and 2 beta genes
IDA tx key points: [...] - if < 50% of genes are defective, you are
- give the iron 2-6 weeks to correct the asymptomatic; this is hence only feasible
anaemia in alpha-thalassemia
- give the iron 2-6 months to correct - if 50% of genes are defective, you have
body iron stores minor thalassemia
- if > 50% of genes are defective, you
have major/severe thalassemia
- if all 4 alpha genes are defective, you
are dead from Hydrops Fetalis
1758. A pt is found to have A pt is found to have microcytic anaemia,
- both thalassemias involve normal iron
microcytic anaemia, so an iron panel is ordered. Iron studies
studies
so an iron panel is reveal increased ferritin, decreased
- both thalassemias are dx via
ordered. Iron studies TIBC, and decreased iron. What is the
hemoglobin electrophoresis
reveal increased dx?
- if the thalassemia is minor, do nothing
ferritin, decreased Anaemia of chronic disease
- if the thalassemia is major, transfuse
TIBC, and In AICD, the body tries to "disconnect"
and give deferoxamine to prevent iron
decreased iron. iron extraction from the body's iron stores.
overload
What is the dx? This works well in the acute setting to
[...] keep iron away from bacteria, but
chronically it sets the stage for anaemia.
Also remember that ferritin is a positive
acute phase reactant and will increase in
inflammatory states. 1761. A pt is found to have A pt is found to have microcytic anaemia
microcytic anaemia and is suspected to have thalassemia.
and is suspected to An iron panel is ordered. What results are
have thalassemia. expect if suspicions are correct?
An iron panel is Normal iron study
ordered. What
1759. A pt is dx w/ A pt is dx w/ anaemia of chronic
results are expect if
anaemia of chronic disease/inflammation. What is the
suspicions are Remember, thalassemia involves
disease/inflammation. treatment?
correct? defects in globin, not heme.
What is the Treat underlying inflammatory disease;
[...]
treatment? give EPO to support the use of iron
[...] stores
1762. Both types of Both types of thalassemia (and their

thalassemia (and subtypes) involve normal iron studies.
their subtypes) How then do we definitively diagnose
involve normal iron thalassemia?
studies. How then do Hemoglobin electrophoresis
we definitively
diagnose
thalassemia?
[...]
271 of 340
1763. It is much simpler to It is much simpler to think of thalassemias 1765. What is the only What is the only microcytic anaemia w/
think of thalassemias as minor or major. What is the treatment microcytic anaemia elevated iron?
as minor or major. for any minor thalassemia? w/ elevated iron? Sideroblastic anaemia
What is the Nothing [...] Sideroblastic anaemia results from the
treatment for any Thalassemia key points: inability of iron to be incorporated into
minor thalassemia? - there are 4 alpha and 2 beta genes heme.
[...] - if < 50% of genes are defective, you are
asymptomatic; this is hence only feasible
in alpha-thalassemia
- if 50% of genes are defective, you have
minor thalassemia
- if > 50% of genes are defective, you
1766. A pt is found to have A pt is found to have microcytic anaemia,
have major/severe thalassemia
microcytic anaemia, so an iron study is ordered. Iron study
- if all 4 alpha genes are defective, you
so an iron study is reveals normal ferritin, normal TIBC and
are dead from Hydrops Fetalis
ordered. Iron study elevated iron. What is the most likely dx?
- both thalassemias involve normal iron
reveals normal Sideroblastic anaemia
studies
ferritin, normal
- both thalassemias are dx via
TIBC and elevated
hemoglobin electrophoresis
iron. What is the
- if the thalassemia is minor, do nothing
most likely dx?
- if the thalassemia is major, transfuse
[...]
and give deferoxamine to prevent iron
overload
accurate diagnostic for sideroblastic anaemia?
test for sideroblastic BM Bx (will show ringed sideroblasts)
anaemia?
[...]
1764. It is much simpler to It is much simpler to think of thalassemias
think of thalassemias as minor or major. What is the treatment
as minor or major. for any major thalassemia?
What is the Transfusion + deferoxamine PO
treatment for any 1768. Sideroblastic Sideroblastic anaemia typically has both
major thalassemia? anaemia typically reversible and irreversible causes. Which
[...] Remember, thalassemia pts do not has both reversible causes are typically reversible?
need iron. They just need proper Hgb. and irreversible (see below)
Since every bag of blood has a year's causes. Which
supply of iron (325 mg), deferoxamine causes are typically
must be given for iron chelation to reversible? Siderblastic anaemia causes key points:
prevent hemosiderosis. [...] - can be reversible or irreversible
- reversible includes lead poisoning,
EtOH, low copper and isoniazid
- irreversible includes cancer, MDS, and
vitamin b6 metabolism defects
- as a result, treatment depends on the
cause
272 of 340
1769. What is the What is the treatment for sideroblastic

1773. What type of What type of hemoglobin is seen in sickle
treatment for anaemia?
sideroblastic Tx depends on the cause hemoglobin is seen cell disease?
anaemia? in sickle cell HbSS
[...] disease?
Sideroblastic anaemia tx key point: [...]
- remember, sideroblastic anaemia has HbS is in sickle cell trait
both reversible and irreversible causes
- reversible includes lead poisoning, 1774. Sickle cell disease Sickle cell disease involves chronic pain
EtOH, low copper and isoniazid involves chronic pain 2/2 vasoocclusive crisis. What is
- irreversible includes cancer, MDS, and 2/2 vasoocclusive vasoocclusive crisis?
vitamin b6 metabolism defects crisis. What is Infarction of tissue 2/2 microvascular
- tx of a reversible cause typically vasoocclusive crisis? occlusion 2/2 HbSS sickling
involves removal of the agent or [...]
correction (i.e. stopping the drug,
chelating the lead, giving copper, etc.) Vasoocclusive crisis in sickle cell key
points:
- the basis of chronic pain or acute pain
attacks in sickle cell is microvascular
1770. Normocytic anaemia Normocytic anaemia manifest typically 2/2 occlusion
manifest typically 2/2 acute blood loss or hemolysis. What lab - the vasoocclusive crises that happen
acute blood loss or tests aid in investigating the presence of cause infarction, which hurts
hemolysis. What lab hemolysis after a CBC (w/ MCV) has - acute chest crisis is akin to MI or
tests aid in been completed? ARDS
investigating the Haptoglobin (decreased); Bilirubin - acute brain crisis is akin to CVA
presence of (increased); LDH (increased); - priapism can also result 2/2 occlusion
hemolysis after a Reticulocyte count; PBS and is considered severe
CBC (w/ MCV) has - splenic autoinfarction typically occurs
been completed? and increases the risk for infection by
[...] encapsulated organisms
- aseptic necrosis of the femur/hip can
occur and requires DEXA scanning
1771. How do haptoglobin How do haptoglobin levels change in
levels change in hemolytic anaemia?
hemolytic anaemia? Decreased
[...]
Remember, haptoglobin binds to released

hemoglobin to transport it to the liver. We
measure free haptoglobin, hence the
levels decrease as it is used up.
1772. How do bilirubin How do bilirubin levels change in

levels change in hemolytic anaemia?
hemolytic anaemia? Increased
[...] Hemolysis leads to overwhelming of the
conjugation system and can result in
indirect/nonconjugated
hyperbilirubinemia and possible
jaundice, icterus and pruritus.
273 of 340
1775. Sickle cell disease Sickle cell disease involves anaemia as a 1778. Splenic Splenic autoinfarction is a common
involves anaemia as result of sickled RBCs. What happens to autoinfarction is a feature of sickle cell disease. What annual
a result of sickled the sickled RBCs that then causes common feature of vaccines are typically given to these pts?
RBCs. What anaemia? sickle cell disease. PCV, meningococcus,
happens to the Hemolysis What annual Haemophilus,HBV
sickled RBCs that Anaemia in SCD ket points: vaccines are
then causes - the chronic anaemia is 2/2 hemolysis typically given to
anaemia? which is 2/2 sickling which is 2/2 these pts?
[...] oxidative/metabolic stress [...]
- typically the anaemia is normocytic with
sufficient reticulocytosis
1779. Avascular necrosis Avascular necrosis is a possible
- if reticulocyte count is low, consider
is a possible complication of sickle cell disease. What
acute aplastic crisis or folate
complication of diagnostic test can we use to screen for
deficiency (SCD pts are on daily folate +
sickle cell disease. this?
iron)
What diagnostic test DEXA scan
can we use to
screen for this?
[...]
1776. A pt with sickle cell A pt with sickle cell disease comes in for
disease comes in a checkup. Labs reveals that reticulocyte
for a checkup. Labs count is low. What should be considered
1780. Sickle cell disease Sickle cell disease involves an increased
reveals that as a cause of this?
involves an risk of infection with many organisms.
reticulocyte count Acute aplastic crisis (w/ parvovirus
increased risk of What cause of osteomyelitis has an
is low. What should B19); Folate deficiency
infection with many increased risk in SCD?
be considered as a
organisms. What Salmonella (but remember that
cause of this?
cause of Staphylococcus aureus is still the
[...] SCD pts are on daily folate + iron
osteomyelitis has an most common cause overall)
increased risk in
SCD?
[...]
1777. Splenic Splenic autoinfarction is a common
autoinfarction is a feature of sickle cell disease. With what
common feature of type of organism do infections become a
sickle cell disease. higher risk?
With what type of Encapsulated bacteria
organism do
infections become a
higher risk? Don't forget the need for annual vaccines
[...] (PCV, meningococcus, Haemophilus,
HBV)
274 of 340
1781. Sickle cell disease Sickle cell disease treatment involves 1783. Sickle cell disease Sickle cell disease treatment involves
treatment involves many drugs/therapies that target different treatment involves many drugs/therapies that target different
many aspects of the disease. What drug is used many aspects of the disease. What therapy is
drugs/therapies that to increase the levels of fetal hemoglobin drugs/therapies that used to manage acute vasoocclusive
target different (HbF)? target different crisis like acute chest crisis or priapism?
aspects of the Hydroxyurea aspects of the Exchange transfusion + deferoxamine
disease. What drug disease. What (to chelate excess iron from
is used to increase therapy is used to transfusion and prevent iron overload)
the levels of fetal SCD Tx key points: manage acute
hemoglobin (HbF)? - avoid sickling by avoiding triggers vasoocclusive crisis
[...] and staying hydrated like acute chest SCD Tx key points:
- use hydroxyurea to increase [HbF] crisis or priapism? - avoid sickling by avoiding triggers
(a2y2) and decrease [HbSS] [...] and staying hydrated
- use penicillins for infection ppx - use hydroxyurea to increase [HbF]
- use folate and iron supplements to (a2y2) and decrease [HbSS]
counteract the anaemia - use penicillins for infection ppx
- use vaccines annually to cover - use folate and iron supplements to
increased infection risk counteract the anaemia
- use IVF, O2 and analgesics to control - use vaccines annually to cover
vasoocclusive pain crisis increased infection risk
- use exchange transfusion if there is a - use IVF, O2 and analgesics to control
severe acute crisis such as acute vasoocclusive pain crisis
chest/brain or priapism - use exchange transfusion if there is a
severe acute crisis such as acute
chest/brain or priapism
1782. Sickle cell disease Sickle cell disease treatment involves

treatment involves many drugs/therapies that target different
many aspects of the disease. What therapy is
drugs/therapies that used to mitigate the anaemia involved?
target different Folate + iron supplements
aspects of the
disease. What
therapy is used to SCD Tx key points:
mitigate the anaemia - avoid sickling by avoiding triggers
involved? and staying hydrated
[...] - use hydroxyurea to increase [HbF]
(a2y2) and decrease [HbSS]
- use penicillins for infection ppx
- use folate and iron supplements to
counteract the anaemia
- use vaccines annually to cover
increased infection risk
- use IVF, O2 and analgesics to control
vasoocclusive pain crisis
- use exchange transfusion if there is a
severe acute crisis such as acute
chest/brain or priapism
275 of 340
1784. Sickle cell disease Sickle cell disease treatment involves 1787. Sickle cell trait Sickle cell trait almost never involves
treatment involves many drugs/therapies that target different almost never sickling of RBCs (vs. sickle cell disease),
many aspects of the disease. What therapy is involves sickling of however it can still happen. In which
drugs/therapies that used to manage vasoocclusive pain RBCs (vs. sickle cell specific vessel is this sickling typically
target different crisis? disease), however it known to happen?
aspects of the IVF + O2 + analgesia can still happen. In Renal vein (thereby giving increased
disease. What which specific vessel risk for renal vein thrombosis)
therapy is used to is this sickling
manage SCD Tx key points: typically known to
vasoocclusive pain - avoid sickling by avoiding triggers happen?
crisis? and staying hydrated [...]
[...] - use hydroxyurea to increase [HbF]
(a2y2) and decrease [HbSS]
1788. What is the genetic What is the genetic inheritance of G6PD
- use penicillins for infection ppx
inheritance of G6PD deficiency?
- use folate and iron supplements to
deficiency? XLR
counteract the anaemia
[...]
- use vaccines annually to cover
increased infection risk
- use IVF, O2 and analgesics to control
vasoocclusive pain crisis
- use exchange transfusion if there is a
severe acute crisis such as acute 1789. Which demographic Which demographic is known to have an
chest/brain or priapism is known to have an increased incidence of G6PD deficiency?
increased incidence Mediterranean
of G6PD deficiency?
[...]
And since it is X-linked recessive,
1785. What is the best What is the best initial test for sickle cell
mediterranean men.
initial test for sickle disesae?
cell disesae? Peripheral blood smear
[...]
1790. Hemolysis in G6PD Hemolysis in G6PD deficiency is due to

deficiency is due to oxidative stress and can result 2/2
oxidative stress drugs, infection, DKA, or certain foods.
and can result 2/2 Which drugs are typically associated with
1786. What is the most What is the most accurate test for sickle
drugs, infection, exacerbating a G6PD deficiency?
accurate test for cell disease?
DKA, or certain Dapsone; primaquine; TMP-SMX;
sickle cell disease? Hemoglobin electrophoresis
foods. Which drugs nitrofurantoin
[...]
are typically Atovaquone is a good alternative in
associated with G6PD deficiency.
This test is the only way we can get a
exacerbating a
definitive diagnosis of sickle cell disease
G6PD deficiency?
vs. carrier state.
[...]
276 of 340
1791. Hemolysis in G6PD Hemolysis in G6PD deficiency is due to 1794. What is the What is the treatment for G6PD
deficiency is due to oxidative stress and can result 2/2 treatment for G6PD deficiency?
oxidative stress drugs, infection, DKA, or certain foods. deficiency? Avoid triggers
and can result 2/2 Which foods are typically associated with [...]
drugs, infection, exacerbating a G6PD deficiency?
DKA, or certain Fava beans
foods. Which foods
are typically
associated with
1795. What is the best What is the best initial test for hereditary
exacerbating a
initial test for spherocytosis?
G6PD deficiency?
hereditary PBS (looking for spherocytes); this is
[...]
spherocytosis? not diagnostic, but can rule out
[...]
1792. What is the best What is the best initial test for G6PD
initial test for G6PD deficiency? Note that this test alone is not enough
deficiency? PBS to look for bite cells and heinz for diagnosis. Spherocytes are not
[...] bodies pathognomonic for HS and diagnosis
Heinz bodies need a special methylene must be confirmed via osmotic fragility
blue stain. testing.
1796. What is the What is the treatment for hereditary

treatment for spherocytosis?
1793. A pt presents with A pt presents with signs of hemolysis. He hereditary Folate; Splenectomy if needed (will
signs of hemolysis. states that his symptoms began after spherocytosis? stop hemolytic anaemia, but will not
He states that his eating fava beans yesterday. You [...] correct spherocytes)
symptoms began suspect G6PD deficiency. Your cheeky
after eating fava medical student remembers that G6PD
beans yesterday. testing is the most accurate test. Why is Instability of the RBC membrane causes
You suspect G6PD this the wrong test to order at this time? hemolysis, especially in the sinusoids of
deficiency. Your G6PD levels during an attack are the spleen. Remember, it is the biconcave
cheeky medical artificially normal disc shape of normal RBCs that lets them
student remembers G6PD during an attack is NORMAL: get through tight spaces. Splenectomy
that G6PD testing is - this is because all of the cells that lacked will stop the anaemia, but should only
the most accurate G6PD are already dead, bruh (i.e. the be considered if anaemia is really
test. Why is this the older cells) severe (as splenectomy has it's own
wrong test to order - newer cells will have G6PD (despite problems).
at this time? being deficient); however, during an
[...] attack, because all of the bad cells are
hemolyzed and hence not part of the test,
measured g6pd levels will be artificially
1797. Autoimmune Autoimmune hemolytic anaemia can exist
normal
hemolytic anaemia in 2 types. What are they?
can exist in 2 types. Warm + cold
What are they?
[...]
277 of 340
1798. Autoimmune Autoimmune hemolytic anaemia can exist 1803. What is the etiology What is the etiology of paroxysmal
hemolytic anaemia in 2 types. Which type is associated with of paroxysmal nocturnal hematuria?
can exist in 2 types. IgM? nocturnal Mutation in PIG-A gene, resulting in a
Which type is Cold hematuria? lack of GPI anchor in RBC membranes,
associated with IgM? Cold = IgM = a/w Mycoplasma and Mono [...] resulting in complement fixation on
[...] - i.e. both Mycoplasma and mono can RBCs, resulting in hemolysis via the
precipitate the production of IgM against MAC
RBCs in cold temperatures PIG-A = phosphatidylinositol class A gene
GPI anchor = decay accelerating factor
= CD55 and CD59

hemolytic anaemia in 2 types. Which type is associated with
can exist in 2 types. IgG?
Which type is Warm 1804. A pt presents c/o of A pt presents c/o of dark urine in the
associated with IgG? "Everyone perfers warm eggs. I also like dark urine in the mornings and abdominal pain. You
[...] warm IgGs." mornings and suspect paroxysmal nocturnal
abdominal pain. hemoglobinuria. What is the best
You suspect diagnostic test?
paroxysmal Flow cytometry (will show decreased
hemolytic anaemia in 2 types. Which type is associated with
nocturnal CD55 and CD59)
can exist in 2 types. mycoplasma and mono (EBV)?
hemoglobinuria.
Which type is Cold
What is the best
associated with
diagnostic test?
mycoplasma and
[...]
mono (EBV)? Cold = IgM = a/w Mycoplasma and Mono
[...] - i.e. both Mycoplasma and mono can
precipitate the production of IgM against
RBCs in cold temperatures
1801. What is the best What is the best initial test for both warm
initial test for both and cold autoimmune hemolytic anaemia?
warm and cold Coomb's testing
autoimmune
hemolytic anaemia?
[...]
1802. What is the best What is the best overall test for cold
overall test for cold autoimmune hemolytic anaemia?
autoimmune Cold agglutining titer testing
hemolytic anaemia?
[...]
278 of 340
1805. What is the What is the treatment for paroxysmal 1806. In regards to In regards to leukemia, what is the
treatment for nocturnal hemoglobinuria? leukemia, what is the different between acute and chronic?
paroxysmal Eculizumab different between Acute = undifferentiated/immature +
nocturnal "A genetic mutation in PNH patients leads acute and chronic? aggressive; Chronic =
hemoglobinuria? to the generation of populations of [...] differentiated/mature + indolent
[...] abnormal RBCs (known as PNH cells)
that are deficient in terminal complement
inhibitors (CD-59), rendering PNH RBCs Acute vs. Chronic leukemia breakdown:
sensitive to persistent terminal - acute involves undifferentiated cells
complement-mediated destruction. The and is typically more aggressive
destruction and loss of these PNH cells --- hence, AML/ALL pts are typically very
(intravascular hemolysis) results in low sick (with fever, night sweats, bleeding,
RBC counts (anemia) and also fatigue, infection) 2/2 the expansion of useless,
difficulty in functioning, pain, dark urine, immature cells causing pancytopenia
shortness of breath, and blood clots. --- best initial test is PBS looking for
Eculizumab, the active ingredient in blasts
Soliris, is a monoclonal antibody that - chronic involves differentiated cells
binds to the complement protein C5 and is indolent
specifically and with high affinity, thereby --- CML/CLL are typically found on routine
inhibiting its cleavage to C5a and C5b and screening (or a test for something else)
subsequent generation of the terminal --- best initial test after the PBS is the
complement complex C5b-9. Soliris differential
inhibits terminal complement mediated
intravascular hemolysis in PNH patients
1807. AML can arise de AML can arise de novo after exposure to
and therefore the destruction of PNH
novo after exposure radiation, chemo or certain substances.
erythrocytes that lack complement
to radiation, chemo Which substance has been linked to
protection with CD-59."
or certain AML?
(www.drugbank.ca)
substances. Which Benzene
substance has been
linked to AML?
[...]
1808. A pt presents c/o A pt presents c/o fever, bone pain,

fever, bone pain, petechiae, and epistaxis. CBC reveals
petechiae, and pancytopenia. You suspect acute
epistaxis. CBC leukemia. What is the best initial
reveals diagnostic test?
pancytopenia. You PBS (looking for blasts)
suspect acute Best initial test for all acute leukemia is
leukemia. What is PBS
the best initial
diagnostic test?
[...]
279 of 340
1809. What is the best What is the best initial test for all acute 1812. A pt is thought to A pt is thought to have AML after a PBS
initial test for all leukemias? have AML after a reveals immature blasts. What other
acute leukemias? PBS (looking for blasts) PBS reveals tests should be ordered to confirm the dx
[...] immature blasts. and get a definitive dx?
What other tests Flow cytometry; BM Bx for definitive
CBC can help but it doesn't tell the whole should be ordered to dx
picture. confirm the dx and
get a definitive dx?
[...] Flow cytometry should be done to
1810. What is the best What is the best initial test for all chronic
confirm that it is a monoclonal
initial test for all leukemias (after a peripheral smear has
expansion and will reveal which CD
chronic leukemias ruled out acute leukemia)?
subtypes are involved
(after a peripheral Differential
BM Bx is needed for definitive Dx and
smear has ruled out With chronic leukemia, the cells look
requires > 20% blasts; if > 20% blasts
acute leukemia)? normal on PBS. So getting a differential
are not seen, then it is not AML/ALL (at
[...] is key in understanding what type of
least not yet)
expansion is happening. Get a BM Bx to
confirm.
1813. What is the most What is the most accurate test for all
1811. Acute leukemia often Acute leukemia often presents with fever,
accurate test for all types of acute leukemias?
presents with fever, bleeding, bruising, petechiae, fever,
types of acute Flow cytometry; or BM Bx (showing >
bleeding, bruising, pallour/anaemia, and/or infection.
leukemias? 20% blasts)
petechiae, fever, Why?
[...]
pallour/anaemia, (see below)
and/or infection.
I'm getting different answers from diff
Why?
sources for this one.
[...] It all comes down to 1 thing: AML/ALL
Flow cytometry should be done to
involves expansion of immature,
confirm that it is a monoclonal
useless cells that crowd out other cell
expansion and will reveal which CD
lines in the BM.
subtypes are involved
- bleeding (or signs of bleeding issues
BM Bx is needed for definitive Dx and
like bruising, petechiae, epistaxis, etc.) is
requires > 20% blasts; if > 20% blasts
2/2 affected platelet formation
are not seen, then it is not AML/ALL (at
- anaemia is 2/2 affected RBC formation
least not yet)
- fever and infections are 2/2 there being
many useless WBCs, or WBCs with poor
function
- bone pain occurs as the expansion is
typically aggressive 1814. Which acute Which acute leukemia is associated with
leukemia is myeloperoxidase?
associated with AML
myeloperoxidase?
[...]
280 of 340
1815. What is the What is the treatment for all forms of AML 1819. What is the What is the treatment for all forms of ALL?
treatment for all (except AML-M3)? treatment for all Chemotherapy; don't forget CNS ppx
forms of AML Chemotherapy (idarubicin + Ara-C) forms of ALL? w/ intrathecal ARA-C
(except AML-M3)? [...]
[...]
1816. A pt is thought to A pt is thought to have acute leukemia, so 1820. The CNS can be a The CNS can be a sheltered region for
have acute a PBS is ordered. PBS reveals immature sheltered region for ALL to hide while therapy for systemic
leukemia, so a PBS blasts with Auer rods. What is the most ALL to hide while blood/marrow cancer is occurring. What
is ordered. PBS likely dx? therapy for systemic drug(s) should be given prophylactically to
reveals immature AML-M3 (acute promyelocytic blood/marrow cancer protect the CNS?
blasts with Auer leukemia) is occurring. What Intrathecal ARA-C; or MTX
rods. What is the Remember, AML-M3 can induce DIC drug(s) should be
most likely dx? following release of Auer rods and is given
[...] treated w/ ATRA prophylactically to
protect the CNS?
[...]
1821. Which form of Which form of chronic leukemia is

1817. What is the What is the treatment for AML-M3? chronic leukemia is associated with the Philadelphia
treatment for ATRA (all-trans retinoic acid; aka associated with the chromosome (t9;22)?
AML-M3? tretinoin; vit A derivative) Philadelphia CML
[...] chromosome Remember, the philadelphia chromosome
(t9;22)? results in overactivity of a tyrosine kinase.
Works by inducing development of [...]
blasts
Remember, all other forms of AML are
treated w/ chemotherapy
1822. What finding on a What finding on a differential is indicative

differential is of CML?
indicative of CML? > 90% PMNs
1818. Which form of acute Which form of acute leukemia is [...]
leukemia is associated with CALLA and TdT
associated with proteins? Remember, CML involves neutrophils
CALLA and TdT ALL and CLL involves lymphocytes.
proteins? AML = myeloperoxidase = makes sense
[...] w/ AML being myeloid
ALL = cALLa + TdT = makes sense w/
ALL being lymphocytic
1823. A pt is dx w/ CML A pt is dx w/ CML after a differential
after a differential revealed > 90% PMNs. What tests should
revealed > 90% be ordered to confirm the dx?
PMNs. What tests BM Bx (looking for bcr-abl)
should be ordered to
confirm the dx?
[...]
281 of 340
1824. What is the What is the treatment for CML? 1827. Which type of Which type of lymphoma is more
treatment for CML? Imatinib lymphoma is more commonly associated with B-symptoms?
[...] commonly Hodgkin's
associated with
Remember, CML is 2/2 philadelphia B-symptoms?
chromosome, a translocation that results [...]
in an overactive tyrosine kinase. Imanitib
is a direct tyrosine-kinase inhibitor.
Imatinib also delays the blast crisis.
1828. A pt presents c/o a A pt presents c/o a growing, nontender
However, eventually CML will become
growing, nontender lymph node. You suspect lymphoma.
resistant and progresses to AML, at which
lymph node. You What is the best initial test for
point pts ultimately begin to succumb.
suspect lymphoma. lymphoma?
What is the best Excisional biopsy
initial test for Do not get an FNA. An excisional bx is
lymphoma? needed to see lymph node architecture
1825. Which type of Which type of leukemia is associated with [...] and to detect reed-sternberg cells.
leukemia is smudge cells?
associated with CLL
smudge cells? They are an artifact finding on peripheral
1829. A pt suspected of A pt suspected of having lymphoma
[...] smear 2/2 rupture of fragile lymphocytes
having lymphoma undergoes an excisional biopsy of a
during slide preparation.
undergoes an nontender lymph node which reveals
excisional biopsy of reed-sternberg cells. What is the
a nontender lymph diagnosis?
node which reveals Hodgkin's Lymphoma
reed-sternberg Reed–Sternberg cells are large and are
1826. What is the average What is the average survival after being cells. What is the either multinucleated or have a bilobed
survival after being diagnosed w/ CLL? diagnosis? nucleus with prominent eosinophilic
diagnosed w/ CLL? 10 years [...] inclusion-like nucleoli (thus resembling an
[...] "owl's eye" appearance). Reed–Sternberg
cells are CD30 and CD15 positive, usually
The point here is that CLL is sometimes negative for CD20 and CD45. The
compared to prostate cancer in that presence of these cells is necessary in
people die with it, not from it. The typical the diagnosis of Hodgkin's lymphoma –
age of dx is around 65-70. the absence of Reed–Sternberg cells has
In general: very high negative predictive value.
- if the pt is > 65 and there is no donor,
watch and wait until they become
symptomatic
- - if the pt is < 65 and there is a donor,
perform stem cell transplant
- if the pt is younger (50s or below), start
chemo with
rituximab/fludarabine/cyclophosphamide
before pursuing stem cell transplantation
282 of 340
1830. What is the next step What is the next step in management of 1833. A pt w/ lymphoma A pt w/ lymphoma comes in c/o of
in management of lymphoma after a pt has been diagnosed comes in c/o of painful lymph nodes whenever he
lymphoma after a pt (any type)? painful lymph drinks EtOH. What type of lymphoma
has been diagnosed Staging nodes whenever he does he likely have?
(any type)? Staging lymphoma key points: drinks EtOH. What Hodgkin's Lymphoma
[...] - 1. CXR type of lymphoma
- 2. CT of the abdomen/pelvis/chest or does he likely have?
PET scan [...]
- 3. BM Bx to rule out BM involvement;
only do if 1 and 2 are negative
- anything greater than or equal to
1834. The treatment of The treatment of lymphoma depends on
stage IIb gets chemo
lymphoma depends the stage of the disease. What is the
on the stage of the treatment for any lymphoma in stage IIA
disease. What is the or less?
treatment for any Local radiation
lymphoma in stage
1831. Staging of Staging of lymphoma is an integral part of IIA or less?
lymphoma is an management. What tests are often used [...]
integral part of for staging?
management. What CXR first; then CT/PET scan; if both
tests are often used negative do a BM Bx to exclude
for staging? marrow involvement
[...] Staging lymphoma key points:
on the stage of the treatment for Hodgkin's lymphoma in
- 1. CXR
disease. What is the stage IIB or higher?
- 2. CT of the abdomen/pelvis/chest or
treatment for Chemotherapy w/ ABVD or BEACOPP
PET scan
Hodgkin's (formerly MOPP)
- 3. BM Bx to rule out BM involvement;
lymphoma in stage
only do if 1 and 2 are negative
IIB or higher?
- anything greater than or equal to
[...]
stage IIb gets chemo

on the stage of the treatment for non-Hodgkin's lymphoma
disease. What is the in stage IIB or higher?
1832. A pt w/ lymphoma A pt w/ lymphoma begins to develop
treatment for Chemotherapy w/ CHOP-R
begins to develop cyclical fevers that come and go
non-Hodgkin's
cyclical fevers that randomly over weeks. What type of
lymphoma in stage
come and go lymphoma does he likely have?
IIB or higher?
randomly over Hodgkin's (these are Pel-Epstein
[...]
weeks. What type of fevers)
lymphoma does he
likely have? 1837. Which type of Which type of lymphoma involves
[...] lymphoma involves contiguous (i.e. anatomical) spread?
contiguous (i.e. Hodgkin's
anatomical) spread?
[...]
283 of 340
1838. Which type of Which type of lymphoma involves 1844. Cyclophosphamide Cyclophosphamide is a commonly used
lymphoma involves hematogenous spread? is a commonly used chemotherapy agent. What is its notable
hematogenous Non-hodgkin's chemotherapy side effect?
spread? agent. What is its Hemorrhagic cystitis
[...] notable side effect?
[...]
1845. A pt presents c/o A pt presents c/o bone pain, renal

1839. Which type of Which type of non-hodgkin's lymphoma is bone pain, renal failure, and fatigue. Labs reveals
non-hodgkin's associated with a "starry-sky" failure, and fatigue. hypercalcemia and an elevated protein
lymphoma is appearance on Bx? Labs reveals gap. Which plasma cell disorder is the
associated with a Burkitt's Lymphoma hypercalcemia and most likely dx?
"starry-sky" an elevated protein Multiple Myeloma
appearance on Bx? gap. Which plasma MM typically presents in the elderly with
[...] Honestly, i never saw the "starry sky" that cell disorder is the "CRAB":
people mention, but it's a pretty big most likely dx? - hyperCalcemia (2/2 lytic bone lesions
association so... [...] and increased bone turnover via
osteoclast activating factor)
- Renal failure (2/2 immunoglobulin and
1840. Cisplatin is a Cisplatin is a commonly used
Bence-Jones protein deposition at the
commonly used chemotherapy agent. What are it's notable
kidneys)
chemotherapy side effect?
- Anaemia (2/2 crowding out of the bone
agent. What are it's Ototoxicity; nephrotoxicity
marrow)
notable side effect?
- Bone pain (2/2 lytic bone lesions 2/2
[...]
osteoclast activating factor)
1841. Bleomycin is a Bleomycin is a commonly used

commonly used chemotherapy agent. What is its notable
chemotherapy side effect?
agent. What is its Pulmonary fibrosis
1846. What is the best What is the best initial test for multiple
notable side effect?
initial test for multiple myeloma?
[...]
myeloma? SPEP (looking for the monoclonal
[...] M-spike) or UPEP (looking for
1842. Adriamycin/doxorubicin Adriamycin/doxorubicin is a commonly bence-jones proteinuria)
is a commonly used used chemotherapy agent. What is its
chemotherapy notable side effect?
agent. What is its Cardiotoxicity (can cause dilated Remember, the M-spike just means that
notable side effect? cardiomyopathy) there is a lot of that same type of protein,
[...] not that it is IgM. In fact, it is typically IgA
(60-70%) or IgG (20%) that is found in
MM or MGUS. IgM is seen in
1843. Vincristine and Vincristine and vinblastine are commonly Waldenstrom's.
vinblastine are used chemotherapy agents. What are
commonly used their notable side effects?
chemotherapy Peripheral neuropathy
agents. What are
their notable side
effects?
[...]
284 of 340
1847. While the SPEP or While the SPEP or UPEP is the best initial 1850. Hypercalcemia and Hypercalcemia and pathological,
UPEP is the best test for multiple myeloma, they do not pathological, non-traumatic fractures are a feature of
initial test for multiple confirm diagnosis. What is the best overall non-traumatic multiple myeloma. Why?
myeloma, they do test for multiple myeloma? fractures are a They are 2/2 increased osteoclast
not confirm BM Bx (which must show > 10% feature of multiple activating factor (OAF) activity
diagnosis. What is plasma cells to be MM) myeloma. Why?
the best overall test [...]
for multiple Plasma cells secrete osteoclast
myeloma? activating factor (OAF), and this is
[...] increased in multiple myeloma. This
results in increased bone turnover and
hypercalcemia. The bone turnover
1848. An elevated protein An elevated protein gap can be seen in a
becomes rampant to the point where
gap can be seen in a number of situations, but it is constantly
there are lytic bone lesions and
number of situations, elevated in multiple myeloma. Why?
pathological, non-traumatic fractures.
but it is constantly (see below)
Pts will complain of bone pain.
elevated in multiple
myeloma. Why?
[...] MM involves plasma cell expansion. 1851. Recurrent infection Recurrent infection can be a feature of
Plasma cells make antibodies. However, can be a feature of multiple myeloma. Why?
in MM, the antibodies are made against a multiple myeloma. There is an overwhelming number of
phantom antigen and are hence useless. Why? useless antibodies
In MM, the plasma cells also produce and [...]
secrete incomplete immunoglobulins
known as Bence-jones proteins. MM involves the secretion of useless,
Together all of this increases the protein monoclonal immunoglobulins against a
gap. This process also causes other phantom antigen. This in turn means that
issues such as recurrent infection and there are fewer circulating antibodies that
renal failure. actually work. Also, amino acids shuttled
However, it is prudent to mention that an into making the useless antibodies are
elevated protein gap does not always essentially taken away from normal
mean MM. It is very nonspecific and will antibody production. Lastly, because MM
be elevated whenever antibodies are typically involves crowding out of the bone
being made in the body (i.e. any viral or marrow, overall immune system strength
bacterial infection or inflammatory state) is lower.
1849. Renal failure is a Renal failure is a featur of multiple 1852. A pt is diagnosed w/ A pt is diagnosed w/ multiple myeloma.
featur of multiple myeloma. Why? multiple myeloma. What imaging should be performed if not
myeloma. Why? It is 2/2 immunoglobulin and What imaging should done already?
[...] Bence-Jones protein deposition in the be performed if not Full body XR skeletal survey looking
kidneys done already? for lytic bone lesions/pathological
[...] fractures
The bone lesions in MM are exclusively
lytic.
We cannot use nuclear bone scan as
there is no blastic activity. The bone
only picks up the nuclear isotope used in
the scan if there is blastic activity.
285 of 340
1853. What is the What is the treatment for multiple 1858. What is the best What is the best overall test for MGUS?
treatment for myeloma in a > 70 y/o pt with no overall test for BM Bx (must show < 10%
multiple myeloma in transplant donor? MGUS? plasmacytosis to be MGUS)
a > 70 y/o pt with Chemotherapy; supportive measures [...] MGUS can be thought of as early MM that
no transplant does not meet full diagnostic criteria (no
donor? lytic bone lesions, no renal failure, no
[...] hypercalcemia, no bence-jones
proteinuria). The protein gap is much
lower or normal in MGUS.
With these patients, rule out myeloma
1854. What is the What is the treatment for multiple
with a Bx (< 10% plasmacytosis on BM
treatment for myeloma in a < 70 y/o pt with no
Bx is MGUS) and follow for conversion
multiple myeloma in transplant donor?
to MM.
a < 70 y/o pt with Chemotherapy; supportive tx
no transplant
donor?
[...]
1859. What is the therapy What is the therapy for MGUS?

for MGUS? None; monitor and check for
1855. What is the What is the treatment for multiple
[...] conversion to multiple myeloma (1-2%
treatment for myeloma?
yearly conversion rate)
multiple myeloma? Stem cell transplant if < 70 y/o with a
[...] donor; chemotherapy + supportive tx if
no donor or > 70 y/o
MGUS can be thought of as early MM that
does not meet full diagnostic criteria (no
lytic bone lesions, no renal failure, no
hypercalcemia, no bence-jones
proteinuria). The protein gap is much
lower or normal in MGUS.
1856. Which isotype of Which isotype of immunoglobulins is most With these patients, rule out myeloma
immunoglobulins is commonly involved in multiple myeloma? with a Bx (< 10% plasmacytosis on BM
most commonly IgG (60-70%) and IgA (20%); this is the Bx is MGUS) and follow for conversion
involved in multiple same for MGUS to MM.
myeloma?
[...]
It is not IgM. The M in M-spike stands for
1860. The protein gap is a The protein gap is a measure of serum
monoclonal.
measure of serum proteins that can help in the dx of multiple
IgM is involved in waldenstrom's.
proteins that can myeloma and MGUS. How does the
help in the dx of protein gap in MGUS differ?
1857. What is the best What is the best initial diagnostic test for multiple myeloma It is typically lower
initial diagnostic test MGUS? and MGUS. How
for MGUS? SPEP (will be + just like in MM) does the protein gap
[...] Note that UPEP is negative in MGUS. in MGUS differ? MGUS involves fewer plasma cells.
MGUS can be thought of as early MM that [...] Note that the quantity of
does not meet full diagnostic criteria. With immunoglobulins in the M-spike of
these patients, rule out myeloma with a MGUS is the main correlate of risk for
Bx (< 10% plasmacytosis on Bx is MGUS to become MM (more MGUS =
MGUS) and follow for conversion to higher chance of MM).
MM.
286 of 340
1861. Which plasma cell Which plasma cell disorder is associated 1866. It is sometimes best It is sometimes best to approach bleeding
disorder is with hyperviscosity syndrome and to approach bleeding by asking whether or not a bleed is due to
associated with peripheral neuropathy? by asking whether or defective primary (platelet) or
hyperviscosity Waldenstrom's Macroglobulinemia not a bleed is due to secondary (factor) hemostasis. What is
syndrome and defective primary the difference between the two?
peripheral (platelet) or (see below)
neuropathy? secondary (factor)
[...] hemostasis. What Platelet vs. Factor bleeding key points:
is the difference - it is important to understand that
between the two? hemostasis involves 2 phases: primary
[...] and secondary
initial test for Waldenstrom's macroglobulinemia?
- primary hemostasis involves vWF and
Waldenstrom's SPEP; or UPEP
platelets and consists of platelet
macroglobulinemia?
adhesion and then aggregation resulting
[...]
in a platelet plug
--- platelet bleeding is typically
1863. What is the best What is the best overall test for superficial/mucosal (e.g. epistaxis,
overall test for Waldenstrom's macroglobulinemia? gingival bleeding, menorrhagia)
Waldenstrom's BM Bx (looking for lymphocytosis; not - secondary hemostasis involves
macroglobulinemia? plasma cells) clotting factors and consists of the
[...] clotting cascade, resulting in a fibrin plug
--- factor bleeding is typically deep
and/or prolonged (e.g. hematoma,
hemarthrosis, prolonged bleeding)
initial therapy for Waldenstrom's Macroglobulinemia?
Waldenstrom's Plasmapheresis
Macroglobulinemia?
[...] 1867. A pt has a A pt has a superficial/mucosal bleed. You
Plasmapheresis will remove IgM and superficial/mucosal suspect platelet bleeding. What is the best
decrease blood viscosity. bleed. You suspect initial test?
Long term therapy involves platelet bleeding. Platelet count
chemotherapy (with rituximab or What is the best If platelet count is normal, consider a
prednisone cyclophosphamide). initial test? defect in platelet function and the
[...] associated differentials
If platelet count is low, get a PBS,
consider BM Bx and run through the DDx
common cause of thrombophilia?
thrombophilia? Factor V leiden 1868. A pt has deep A pt has deep bleeding. You suspect that
[...] bleeding. You it is factor bleeding. What is the best initial
suspect that it is test?
factor bleeding. Coagulation studies (i.e. PT, PTT, INR)
What is the best
initial test?
[...] Also consider ordering factor levels to
further help narrow the differential.
287 of 340
1869. What is the best What is the best initial test for von 1873. What is the most What is the most common cause of
initial test for von willebrand's disease? common cause of platelet type bleeding?
willebrand's Platelet count (as this would involve platelet type von willebrand's disease
disease? platelet bleeding) bleeding?
[...] [...]
If a pt has platelet type bleeding and
platelet count is normal, think vWD.
1870. What is the best What is the best overall test for von
overall test for von willebrand's disease?
willebrand's vWF assay
disease? 1874. Glanzmann's Glanzmann's Thrombasthenia is a
[...] Thrombasthenia is a disorder that involves platelet type
disorder that bleeding. What is the defect involved?
involves platelet type Deficiency of GpIIb/IIIa (thereby
bleeding. What is the causing defective platelet aggregation)
defect involved?
[...]
Glanzmann's Thrombasthenia = defect in
1871. Platelet type Platelet type bleeding (superficial) is the
GpIIb/IIIa
bleeding (superficial) main type of bleeding seen in von
Bernard-Soulier Syndrome = defect in
is the main type of Willebrand's disease, however it may
GpIb
bleeding seen in von also involve factor type bleeding (deep).
Willebrand's Why?
disease, however it vWF binds to, carries, and stabilizes 1875. Bernard-Soulier Bernard-Soulier Syndrome is a bleeding
may also involve Factor VIII Syndrome is a disorder that involves platelet type
factor type bleeding bleeding disorder bleeding. What defect is involved in this
(deep). Why? that involves platelet disease?
[...] Hence, a pt w/ vWD may also exhibit type bleeding. What Deficiency of GpIb (thereby causing
factor type bleeding with increased defect is involved in defective platelet adhesion)
PTT this disease?
[...]
Glanzmann's Thrombasthenia = defect in
GpIIb/IIIa
Bernard-Soulier Syndrome = defect in
GpIb
1872. What is the What is the treatment for von willbrand's

treatment for von disease? 1876. What is the genetic What is the genetic inheritance of
willbrand's disease? Desmopressin (increases vWF levels) inheritance of Hemophilia (both A and B)?
[...] Hemophilia (both A XLR
and B)?
[...]
288 of 340
1877. A young boy A young boy presents w/ hemarthrosis 1881. What peripheral What peripheral blood smear finding is
presents w/ and easy bruising. You suspect blood smear finding associated w/ DIC?
hemarthrosis and hemophilia. What is the best initial test? is associated w/ Schistocytes
easy bruising. You PT/PTT/INR (typically there is DIC?
suspect hemophilia. increased PTT with normal PT); or [...]
What is the best mixing study (correction is seen) Schistocytes are a byproduct of
initial test? microangiopathic hemolysis as RBCs
[...] are sheared as they cross the fibrin clots
formed in DIC.
1878. A young boy A young boy presents w/ hemarthrosis

presents w/ and easy bruising. You suspect 1882. DIC and TTP can DIC and TTP can both present in similar
hemarthrosis and hemophilia. What is the most accurate both present in ways (fever + renal failure + neuro sxs all
easy bruising. You diagnostic test? similar ways (fever + 2/2 thrombosis), but they differ when it
suspect hemophilia. Factor VIII or IX assay renal failure + neuro comes to labs. What are the major
What is the most sxs all 2/2 differences in lab findings?
accurate diagnostic thrombosis), but they DIC will have decreased fibrinogen and
test? differ when it comes increased PT/PTT; in TTP these
[...] to labs. What are the measures are all normal
major differences in
lab findings?
1879. A young boy A young boy presents w/ hemarthrosis
[...]
presents w/ and easy bruising. Coagulation studies
hemarthrosis and reveal increased PTT and normal PT.
easy bruising. Mixing studies are corrected. You 1883. What is the What is the treatment for DIC?
Coagulation studies suspect hemophilia. What other bleeding treatment for DIC? Fix underlying cause; replace what is
reveal increased disorder must be ruled out? [...] lost (i.e. pRBCs, cryo, FFP, platelets;
PTT and normal PT. von Willebrand's Disease (remember, see below)
Mixing studies are vWF carries factor VIII)
corrected. You
suspect hemophilia.
What other bleeding
disorder must be
ruled out?
1884. The widespread The widespread formation of clots is a
[...]
formation of clots is feature of both TTP and DIC. What defect
a feature of both is involved in TTP?
1880. Factor type bleeding Factor type bleeding disorders can be TTP and DIC. What ADAMSTS-13 deficiency
disorders can be acquired instead of pre-existing. What is defect is involved in A deficiency in ADAMSTS-13 results in
acquired instead of the treatment for acquired factor TTP? the failure to cleave vWF multimers
pre-existing. What is deficiency? [...] (which consume platelets).
the treatment for Vitamin K Note that the clots in TTP are hyaline
acquired factor With acquired deficiency, vitamin K will clots and hence do not consume
deficiency? be given at some point. If there is no factors.
[...] improvement, it's likely liver disease. If
there is improvement, it may have just
been a Vitamin K deficiency.
289 of 340
1885. What type of clots What type of clots are made in TTP? 1889. What is the What is the diagnostic test for ITP?
are made in TTP? Hyaline clots diagnostic test for None; it is a diagnosis of exclusion
[...] ITP? once everything else has been ruled
[...] out
This is huuuuge for understanding TTP
vs. DIC.
TTP = hyaline clots = only platelets are
consumed = normal PT, PTT, and
fibrinogen in TTP
DIC = fibrin clots = platelets and
1890. What is the What is the treatment for ITP?
factors both consumed = hence the
treatment for ITP? (see below)
typical DIC lab results
[...]
1886. What peripheral What peripheral blood smear finding is ITP treatment key points:
blood smear finding seen in TTP? - if mild or plt count < 30,000, give
is seen in TTP? Schistocytes steroids
[...] - if severe (i.e. GI bleed or CNS) or plt
count < 10,000, give IVIG
Remember, schistocytes are just a - if recurrent or the pt becomes steroid
byproduct of RBC shearing/hemolysis. It dependent, perform splenectomy
is not a specific finding. - if refractory to steroids/splenectomy,
consider rituximab or a
thrombopoietin-receptor agonist (e.g.
1887. What is the What is the treatment for TTP?
romiplostim or eltrombopag)
treatment for TTP? Plasma exchange or tranfusion
[...]
i.e. either take out the antibodies and give

back lots of ADAMTS-13 or give 1891. How soon after How soon after starting heparin does
ADAMTS-13 only starting heparin does heparin-induced thrombocytopenia
heparin-induced typically manifest?
thrombocytopenia 5-10
typically manifest?
[...]
1888. The treatment of The treatment of TTP involves either
TTP involves either plasma exchange or tranfusion. Why
plasma exchange or should you never give platelets in TTP? 1892. What is the What is the diagnostic test for heparin
tranfusion. Why It will worsen the MAHA and clotting diagnostic test for induced thrombocytopenia?
should you never heparin induced HIT Panel (i.e. ELISA for platelet factor
give platelets in thrombocytopenia? 4 (PF4) antibodies or serotonin release
TTP? Remember, the clots in TTP are hyaline [...] assay
[...] clots that only consume platelets. Even
though there is thrombocytopenia, do not
give platelets
290 of 340
1893. What is the What is the treatment for heparin induced 1898. How do hepcidin How do hepcidin levels change in
treatment for heparin thrombocytopenia? levels change in anaemia of chronic disease?
induced Stop all heparin-containing products anaemia of chronic Decrease
thrombocytopenia? (this includes LMWH); switch to a disease?
[...] direct thrombin inhibitor (e.g. [...]
argatroban or lepirudin) Hepcidin is a protein that regulates iron
Remember to eventually switch the pt to absorption.
warfarin for a few months.
accurate test for sideroblastic anaemia?
1894. Which type of Which type of anaemia can be sideroblastic Prussian blue staining (looking for
anaemia can be differentiated by a peripheral blood anaemia? ringed sideroblasts)
differentiated by a smear? [...]
peripheral blood Macrocytic anaemia
smear?
[...]
Basically... don't choose a smear to
accurate test for thalassemia?
workup microcytic anaemia. They are all
thalassemia? Hemoglobin electrophoresis
hypochromic and all etiologies can yield
[...]
target cells.
Thalassemia is the microcytic anaemia
For alpha thalassemia it's genetic
most commonly associated w/ target cells.
studies.
1895. A pt has anaemia. At A pt has anaemia. At which point should

1901. A pt is diagnosed w/ A pt is diagnosed w/ Vitamin B12
which point should you consider transfusion as therapy?
Vitamin B12 deficiency and started on replacement
you consider If the pt is symptomatic; or if the pt has
deficiency and Vitamin B12. What is the notable
transfusion as a low Hct and is elderly or has heart
started on complication of vitamin b12 replacement?
therapy? disease
replacement Vitamin Hypokalemia
[...]
B12. What is the
notable complication
of vitamin b12 The hypokalemia results from extremely
replacement? rapid cell production at the bone
[...] marrow. No other condition involving the
1896. A pt is given 1 unit of A pt is given 1 unit of packed RBCs. By generation of cells rapidly causes
packed RBCs. By how many points do you expect their hypokalemia.
how many points do hematocrit to rise?
you expect their 3 points
1902. Pancreatic Pancreatic insufficiency can cause vitamin
hematocrit to rise?
insufficiency can b12 deficiency. How?
[...]
cause vitamin b12 Pancreatic enzymes are needed to
1 unit pRBCs should yield a 3 point
deficiency. How? remove vitamin b12 from the R-protein
increase in Hct and 1 g/dL increase in
[...] so it can be bound by intrinsic factor
Hgb
1903. Which infection is Which infection is associated w/ morulae

1897. A pt is given 1 unit of A pt is given 1 unit of packed RBCs. By
associated w/ inside neutrophils on a PBS?
packed RBCs. By how much should their hemoglobin rise?
morulae inside Ehrlichia
how much should 1 g/dL
neutrophils on a
their hemoglobin 1 unit pRBCs should yield a 3 point
PBS?
rise? increase in Hct and 1 g/dL increase in
[...]
[...] Hgb
291 of 340
1904. A pt w/ known sickle A pt w/ known sickle cell disease is 1909. Peripheral blood Peripheral blood smear in warm/IgG
cell disease is admitted with an acute pain crisis. His smear in warm/IgG autoimmune hemolytic anaemia can
admitted with an hematocrit on admission is 34% and it autoimmune involve microspherocytes. Why do they
acute pain crisis. His drops to 22% by hospital day 3. What is hemolytic anaemia form?
hematocrit on the best initial test for parvovirus B19 can involve Autoantibody binding to RBC
admission is 34% aplastic crisis? microspherocytes. membranes takes away surface area
and it drops to 22% Reticulocyte count Why do they form? needed to maintain a biconcave disc
by hospital day 3. [...] shape
What is the best
initial test for Most accurate test is parvovirus B19
parvovirus B19 PCR. Hence, spherocytes are not specific for
aplastic crisis? BM Bx can reveal giant pronormoblasts. hereditary spherocytosis. They will
[...] Best initial therapy is IVIG typically form in any situation where RBCs
have trouble maintaining their surface
area or membrane integrity.
initial therapy for parvovirus b19 aplastic crisis?
parvovirus b19 IVIG 1910. What is the best What is the best initial therapy for warm
aplastic crisis? initial therapy for autoimmune hemolytic anaemia?
[...] warm autoimmune Glucocorticoids (e.g. prednisone)
hemolytic anaemia?
[...]
accurate test for hereditary spherocytosis?
hereditary Osmotic fragility test 1911. What is the What is the recommended treatment for
spherocytosis? recommended recurrent warm autoimmune hemolytic
[...] treatment for anaemia?
Cells are placed in a slightly hypotonic recurrent warm Splenectomy
solution which causes just enough cell autoimmune
swelling to cause hemolysis. hemolytic anaemia?
[...] In AIHA, hemolysis occurs in the
spleen or liver, not intravascular. This
1907. How does MCHC How does MCHC change in hereditary
is why no fragmented cells are seen on
change in hereditary spherocytosis?
PBS in AIHA.
spherocytosis? Increased
[...]
1912. What is the What is the treatment for warm
treatment for warm autoimmune hemolytic anaemia that is
autoimmune refractory to splenectomy?
hemolytic anaemia Rituximab (or AZT, or
accurate diagnostic for warm/IgG autoimmune hemolytic
that is refractory to cyclophosphamide, or cyclosporine)
test for warm/IgG anaemia?
splenectomy?
autoimmune Coombs test
[...]
hemolytic
Why perform splenectomy in AIHA?
anaemia?
- In AIHA, hemolysis occurs in the
[...]
spleen or liver, not intravascular. This
is why no fragmented cells are seen on
PBS in AIHA.
292 of 340
1913. Which plasma cell Which plasma cell disorder is associated 1918. What is the most What is the most common cause of death
disorder is with cold autoimmune hemolytic common cause of in paroxysmal nocturnal hemoglobinuria?
associated with cold anaemia? death in paroxysmal Thrombosis
autoimmune Waldenstrom's macroglobulinemia nocturnal
hemolytic hemoglobinuria?
anaemia? [...] Thrombosis in PNH most commonly
[...] Cold AIHA involves IgM. occurs at the mesenteric and hepatic
Waldenstrom's also involves IgM. veins.
1914. What is the most What is the most accurate test for cold 1919. What is the curative What is the curative therapy for
accurate test for autoimmune hemolytic anaemia? therapy for paroxysmal nocturnal hemoglobinuria?
cold autoimmune Cold agglutinin titer test paroxysmal Bone marrow transplant
hemolytic anaemia? nocturnal
[...] hemoglobinuria?
[...]
1915. What is the What is the treatment for cold

treatment for cold autoimmune hemolytic anaemia? 1920. What is the best What is the best initial therapy for
autoimmune Stay warm; Rituximab; plasmapheresis initial therapy for paroxysmal nocturnal hemoglobinuria?
hemolytic anaemia? when needed; immunosuppression to paroxysmal Prednisone (mechanism unknown;
[...] stop antibody production nocturnal targets hemolysis only)
hemoglobinuria?
[...]
Notice the difference here vs. warm AIHA: Also consider starting eculizumab initially
- steroids do not work in CAIHA as well. It is a complement inhibitor and
- splenectomy does not work in CAIHA targets both hemolysis and thrombosis.
1916. What is the most What is the most common oxidative stress 1921. What is the most What is the most accurate test for
common oxidative seen in G6PD deficiency? accurate test for aplastic anaemia (i.e. pancytopenia of
stress seen in G6PD Infection aplastic anaemia unknown cause)?
deficiency? (i.e. pancytopenia of Bone marrow Bx
[...] unknown cause)?
[...]
1917. TTP involves a TTP involves a deficiency of

deficiency of ADAMSTS-13. Which other hematological 1922. What protein is often What protein is often mutated in
ADAMSTS-13. disorder involves decreased mutated in Polycythemia vera?
Which other ADAMSTS-13 activity, but 2/2 an Polycythemia vera? JAK2 kinase (also involved in other
hematological infectious cause? [...] myeloproliferative disorders)
disorder involves Hemolytic-Uremic Syndrome (HUS)
decreased
ADAMSTS-13 Remember, P. vera involves expansion
activity, but 2/2 an The Shiga-toxin from Escherichia coli of all 3 cell lines, it's just that RBC
infectious cause? O157:H7 binds to and inactivates expansion is the most prominent and
[...] ADAMSTS-13 (hence vWF action typically occurs in the setting of low EPO
becomes uncontrolled, and platelet levels.
activation occurs)
- knowing this, many of the same
principles of TTP apply to HUS, especially
the big one: do not give platelets in
HUS/TTP as they will worsen the disease
293 of 340
1923. Pruritis after a warm Pruritis after a warm shower is often a 1928. What is the What is the treatment for myelofibrosis?
shower is often a sign of potential polycythemia vera. Why treatment for (see below)
sign of potential does this manifest? myelofibrosis?
polycythemia vera. Histamine release 2/2 expansion of [...]
Why does this basophils Thalidomide and lenalidomide are
manifest? tumour necrosis factor inhibitors that can
[...] increase bone marrow production
Ruxolitinib is a JAK2 kinase inhibitor and
suppresses disease progression
accurate test for polycythemia vera?
polycythemia vera? JAK2 kinase mutation detection (seen 1929. What is the most What is the most accurate test for all
[...] in 95% of cases) accurate test for all acute leukemias?
acute leukemias? Flow cytometry
[...]
1925. What is the What is the indication for treatment in
indication for essential thrombocytosis?
treatment in > 60 y/o with thromboses; or platelet 1930. Treatment of acute Treatment of acute leukemia aims to
essential count > 1.5 million leukemia aims to induce remission. What do we use to
thrombocytosis? induce remission. gauge the next step in management after
[...] What do we use to remission has been achieved?
Best initial therapy is hydroxyurea gauge the next step Prognosis
Treat erythromelalgia with aspirin in management after
remission has been
achieved? Prognosis and acute leukemia
[...] management key points:
initial therapy for essential thrombocytosis?
- the best indicator of prognosis is
essential Hydroxyurea; use aspirin for
cytogenetics
thrombocytosis? erythromelalgia
- good prognosis = good cytogenetics =
[...]
less chance of relapse = continue
chemotherapy
Treatment indications are > 60 y/o with
- poor prognosis = bad cytogenetics =
thromboses or platelet count > 1.5
high change of relapse = immediate
million
bone marrow transplant
- in AML-M3 remember to add ATRA
1927. Myelofibrosis Myelofibrosis involves pancytopenia and a - in ALL remember to add intrathecal
involves bone marrow with extensive fibrosis. chemotherapy (e.g. MTX)
pancytopenia and a Which organs are made to help with blood
bone marrow with production in this disease?
extensive fibrosis. Spleen + liver
Which organs are
made to help with
blood production in Hence there is hepatosplenomegaly.
this disease?
[...]
294 of 340
1931. Prognosis is used to Prognosis is used to determine the next 1935. What PBS finding is What PBS finding is classically associated
determine the next step in management of acute leukemia classically w/ myelodysplastic syndrome?
step in management after remission has been achieved. What associated w/ Pelger-Huet cells
of acute leukemia test is the best indicator of prognosis? myelodysplastic
after remission has Cytogenetics syndrome?
been achieved. Prognosis and acute leukemia [...]
What test is the best management key points:
indicator of - the best indicator of prognosis is
1936. What lab/biopsy What lab/biopsy finding aids in
prognosis? cytogenetics
finding aids in determining the severity of
[...] - good prognosis = good cytogenetics =
determining the myelodysplastic syndrome?
less chance of relapse = continue
severity of The % of blasts
chemotherapy
myelodysplastic
- poor prognosis = bad cytogenetics =
syndrome?
high change of relapse = immediate
[...]
bone marrow transplant
- in AML-M3 remember to add ATRA
- in ALL remember to add intrathecal 1937. What drug has been What drug has been shown to yield an
chemotherapy (e.g. MTX) shown to yield an excellent response in myelodysplastic
excellent response syndrome with chromosome 5q
in myelodysplastic deletion?
1932. What is the msot What is the msot accurate diagnostic test
syndrome with Lenalidomide
accurate diagnostic for CML?
chromosome 5q
test for CML? BCR-ABL testing (via PCR or FISH)
deletion?
[...]
[...]
Remember, CML involves the

Philadelphia chromosome in 95% of 1938. What is the What is the treatment for myelodysplastic
cases and involves a t(9:22) treatment for syndrome?
translocation creating BCR-ABL myelodysplastic
syndrome?
[...]
1933. Which Which myeloproliferative disorder has the
myeloproliferative highest risk of transforming into AML/ALL
disorder has the after a blast crisis? 1939. Which type of Which type of chronic leukemia involves
highest risk of CML chronic leukemia PCP prophylaxis?
transforming into involves PCP CLL
AML/ALL after a prophylaxis?
blast crisis? When untreated, this happens in 20% of [...]
[...] cases.
1940. What is the What is the treatment for stage 0-2 CLL?
1934. Which chromosomal Which chromosomal deletion is treatment for stage Nothing
deletion is characteristic of myelodysplastic 0-2 CLL? CLL staging:
characteristic of syndrome? [...]
myelodysplastic 5q deletion Stage 0 = leukocytosis only
syndrome? Stage I = + lymphadenopathy
[...] Stage II = + hepatomegaly or +
5q deletion invovles better prognosis vs. splenomegaly or +
not having 5q deletion hepatosplenomegaly
Stage III = + anaemia
Stage IV = + thrombocytopaenia
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1941. What is the What is the treatment for stage 3-4 CLL? 1946. What PBS findings What PBS findings are seen in multiple
treatment for stage Fludarabine, cyclophosphamide and are seen in multiple myeloma?
3-4 CLL? rituximab myeloma? Rouleaux formation; the "hof"
[...] [...]
Use alemtuzumab if fludarabine fails. Rouleaux is 2/2 IgG paraproteins

CLL staging: stickings to RBCs, causing them to
adhere to each other in a stack or roll.
Stage 0 = leukocytosis only The Hof is the area of lightness/lucency
Stage I = + lymphadenopathy near the nucleus in plasma cells.
Stage II = + hepatomegaly or +
splenomegaly or +
1947. Which plasma cell Which plasma cell disorder is associated
hepatosplenomegaly
disorder is w/ engorged blood vessels in the eye?
Stage III = + anaemia
associated w/ Waldenstrom's
Stage IV = + thrombocytopaenia
engorged blood
vessels in the eye?
1942. What is the best What is the best initial test for hair cell [...]
initial test for hair cell leukemia?
leukemia? PBS (showing hairy cells)
1948. What is the genetic What is the genetic inheritance of von
[...]
inheritance of von Willebrand's disease?
Willebrand's AD
Most accurate is flow cytometry for
disease?
CD11c
[...]
1943. What is the most What is the most accurate test for hairy
1949. What is the therapy What is the therapy for clotting factor XII
accurate test for cell leukemia?
for clotting factor XII deficiency?
hairy cell leukemia? Flow cytometry for CD11c
deficiency? None
[...]
[...]
Best initial test is PBS looking for hairy

While there is elevated aPTT, there is
cells
typically no bleeding and no therapy is
needed.
1944. What is the What is the treatment for hairy cell
treatment for hairy leukemia?
cell leukemia? Cladribine; or pentostatin
initial test for antiphospholipid syndrome?
[...]
antiphospholipid Mixing study (aPTT will not correct)
syndrome?
1945. A patient has A patient has hodgkin's disease. What [...]
hodgkin's disease. test must be done prior to starting the pt Most accurate test is the russell viper
What test must be on adriamycin/doxorubicin to determine venom test.
done prior to starting dosing?
the pt on MUGA or nuclear ventriculogram
adriamycin/doxorubicin
to determine
dosing? You cannot use adriamycin if EF <
[...] 50%.
Remember, adriamycin/doxorubicin can
cause dilated cardiomyopathy.
296 of 340
1951. In general, what is In general, what is the heirarchy/order of 1954. In which situations is In which situations is estrogen and
the heirarchy/order leukemias when they are matched up to estrogen and progesterone receptor testing indicated in
of leukemias when the most common age of presentation progesterone breast cancer?
they are matched up (from youngest to oldest)? receptor testing All; ER and PR testing is routine for all
to the most common ALL --> AML --> CML --> CLL indicated in breast patients
age of presentation This is a generalization, but has been cancer?
(from youngest to super helpful for me in practice questions [...]
oldest)? in narrowing the differential. If positive, pursue hormonal therapy.
[...]
It's a "myeloid sandwich"
1955. What is the preferred What is the preferred surgical treatment
Use the 7's and add 20 years as you
surgical treatment for breast cancer?
move up the ladder:
for breast cancer? Lumpectomy + local radiation
- ALL ~ 7 y/o
[...]
- AML ~ 27
- CML ~ 47
Lumpectomy + radiation is equal in
- CLL ~ 77
efficacy to modified radical mastectomy
and is much less deforming.
1952. What is the best What is the best initial test for breast - the local radiation part of this is massive;
initial test for breast cancer? it is indispensible in preventing
cancer? Biopsy (FNA) recurrences at the breast
[...] Best initial test is FNA - if radiation is c/i, so is lumpectomy
-- false positive rate is < 2%, but since the - radical mastectomy is always the wrong
sample is small, false negative rate is answer
10% and you cannot test for
ER/PR/HER2-neu
1956. Hormonal therapy is Hormonal therapy is commonly used in
Core needle biopsy can also be done. It
commonly used in breast cancer when indicated. What are
takes a larger sample of breast tissue,
breast cancer when the notable side effects of tamoxifen?
but is more deforming.
indicated. What are Endometrical cancer; clotting
the notable side
Most accurate is open biopsy as it allows
effects of
for frozen section and immediate
tamoxifen? Tamoxifen is better for post-menopausal
resection of cancer + sentinal LN biopsy
[...] pts.
1953. Mammography is the Mammography is the most commonly

1957. Hormonal therapy is Hormonal therapy is commonly used in
most commonly used imaging technique when screening
commonly used in breast cancer when indicated. What is the
used imaging for or working up breast cancer. In which
breast cancer when notable side effect of aromatase
technique when situations is a PET scan appropriate?
indicated. What is inhibitors?
screening for or To determine the contents of a lymph
the notable side Osteoporosis
working up breast node not easily accessible w/ biopsy
effect of aromatase
cancer. In which
inhibitors?
situations is a PET
[...] e.g. anastrozol, letrozole, exemestane
scan appropriate? Cancer (i.e. mets to a lymph node) will
Aromatase inhibitors are better in
[...] yield increased uptake on PET scan.
premenopausal women.
If you are asked "which will most likely
benefit the patient", pick aromatase
inhibitors
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1958. Adjuvant Adjuvant chemotherapy is often added on 1963. Hormonal therapy in Hormonal therapy in breast cancer
chemotherapy is to breast cancer therapy to further lower breast cancer prevents recurrences. Is that also true in
often added on to mortality. In which cases should adjuvant prevents prostate cancer?
breast cancer chemotherapy be used? recurrences. Is that No, they only shrink lesions that are
therapy to further If the lesions are > 1 cm; if there are also true in prostate already present
lower mortality. In positive axillary lymph nodes cancer?
which cases should [...]
adjuvant Flutamide, GNRH agonists, ketoconazole,
chemotherapy be and orchiectomy all help control the size
used? and progression of metastasis only.
[...]
1964. A pt specifically A pt specifically requests to get his PSA

1959. What is the best What is the best initial test for prostate requests to get his levels checked. Results come back
initial test for cancer? PSA levels checked. elevated. What is the most appropriate
prostate cancer? Biopsy Results come back next step?
[...] elevated. What is DRE
It is also the most accurate next step?
[...] Get that glove and lube out, brah.
accurate test for prostate cancer? 1965. A pt specifically A pt specifically requests to get his PSA
prostate cancer? Biopsy (also the best initial) requests to get his levels checked. Results come back
[...] PSA levels checked. elevated. A DRE reveals a palpable
Results come back prostate mass. What is the most
elevated. A DRE appropriate next step?
1961. It is unclear if It is unclear if surgery (prostatectomy) or
reveals a palpable Biopsy
surgery radiation is better for prostate cancer.
prostate mass.
(prostatectomy) or What are the notable complications of
What is the most
radiation is better for prostatectomy?
appropriate next
prostate cancer. Urinary incontinence; Erectile
step?
What are the notable dysfunction
[...]
complications of
prostatectomy?
[...] Note that radiation does not cause ED, 1966. A pt specifically A pt specifically requests to get his PSA
but does cause diarrhea. requests to get his levels checked. Results come back
PSA levels checked. elevated. A DRE is normal. What is the
Results come back most appropriate next step?
1962. How is the Gleason How is the Gleason grading related to the
elevated. A DRE is Transrectal ultrasound
grading related to treatment of prostate cancer?
normal. What is the Geez, these guys really go through hell if
the treatment of If Gleason grading is high, it suggests
most appropriate they ask for a PSA...
prostate cancer? a greater benefit of surgical removal
next step?
[...]
[...]
If Gleason is high, cut it out before mets.

1967. What is the preferred What is the preferred screening test for
screening test for ovarian cancer?
ovarian cancer? There is none, brah
[...]
CA-125 is used only for following

treatment response.
298 of 340
1968. What is the only What is the only major cancer in which 1974. A pt receives a pap A pt receives a pap smear. It reveals
major cancer in removing large amounts of locally smear. It reveals ASCUS. What is the most appropriate
which removing metastatic disease will benefit the pt? ASCUS. What is the next step?
large amounts of Ovarian cancer most appropriate Perform HPV testing or repeat pap in 1
locally metastatic next step? year
disease will benefit [...]
the pt? Hence we surgically remove all visible
[...] tumours and pelvic organs (+
1975. A pt receives a pap A pt receives a pap smear. It reveals
chemotherapy).
smear. It reveals ASCUS. You opt to test for HPV DNA
ASCUS. You opt to instead of repeat the pap in 1 year. HPV
1969. Which type of Which type of testicular cancer is test for HPV DNA testing is positive. What is the most
testicular cancer is associated w/ alpha-fetoprotein? instead of repeat the appropriate next step?
associated w/ Non-seminomomatous pap in 1 year. HPV Colposcopy
alpha-fetoprotein? testing is positive.
[...] What is the most
appropriate next
step?
1970. Which type of Which type of testicular cancer is
[...]
testicular cancer is sensitive to both chemotherapy and
sensitive to both radiation?
chemotherapy and Seminoma 1976. Prolactinoma in Prolactinoma in females typically
radiation? females typically manifests as a microadenoma without
[...] manifests as a any visual deficits (bitemporal
Non-seminomatous cancer is only microadenoma hemianopsia), whereas the opposite is
sensitive to chemotherapy without any visual true in males. Why is this the case?
deficits (bitemporal (see below)
hemianopsia), -Prolactinoma in females often presents
1971. What is the What is the treatment for testicular
whereas the as a microadenoma without visual
treatment for cancer?
opposite is true in deficits as females tends to notice
testicular cancer? Orchiectomy; then radiation for local
males. Why is this galactorrhea and amenorrhea early in
[...] disease and chemotherapy for
the case? the tumour's development; as a result, the
widespread disease
[...] tumour is not allowed to grow prior to
workup
- Prolactinoma in males is then pretty
May depend on the type of cancer
logical; men don't lactate or menstruate,
(seminoma vs. nonseminomatous)
hence there is nothing to tip them off;
gynecomastia can be a late finding; hence
1972. What is the What is the treatment for advanced the tumour can grow
treatment for cervical cancer?
advanced cervical Hysterectomy
cancer?
[...]
1973. What age group is What age group is able to receive HPV
able to receive HPV vaccination?
vaccination? 11-26 y/o
[...]
299 of 340
1977. A pt presents w/ A pt presents w/ galactorrhea and 1980. What is the best What is the best initial test for
galactorrhea and amenorrhea. You suspcet initial test for acromegaly?
amenorrhea. You hyperprolactinemia. What is the best initial acromegaly? ILGF-1 (Somatomedin) level
suspcet diagnostic test? [...]
hyperprolactinemia. TSH (+ look at their med list); then
What is the best order prolactin levels + pregnancy test Measuring a GH level is not reliable
initial diagnostic When you suspect hyperprolactinemia because GH secretion is pulsatile.
test? you must rule out other causes such as Somatomedin (ILGF-1) is the middle-man
[...] medications (antipsychotics) and hormone through with GH elicits its
hypothyroidism (increased TRH from the effects. GH can also cause
hypothalamus in hypothyroidism gluconeogenesis, making it seem like the
stimulates prolactin release). pt has glucose intolerance. Luckily for us,
this allows us to use the glucose
suppression test (most accurate test) to
diagnose acromegaly.
1978. What is the What is the treatment for prolactinoma?

treatment for Dopamine agonists (bromocriptine;
prolactinoma? cabergoline)
[...] Cabergoline is preferred as it is better
tolerated. 1981. What is the most What is the most accurate test for
Transphenoidal surgery is considered accurate test for acromegaly?
when the pt desires pregnancy, if there acromegaly? Glucose Suppression Test (if positive,
are visual deficits, or if medical therapy [...] get the MRI to confirm)
fails.
- After giving glucose, if GH levels

decrease, the test is negative as there is
suppression
1979. Acromegaly in Acromegaly in children results in
- After giving glucose, if GH levels do not
children results in gigantism, whereas in adults it causes
decrease (i.e. do not change), the test is
gigantism, whereas visceral organ enlargement in addition
positive for acromegaly as there is a
in adults it causes to growth of non-long bones. What is the
failure to suppress
visceral organ most common cause of death in
- If positive, get an MRI to confirm
enlargement in acromegaly in adults?
addition to growth of Cardiomyopathy and diastolic heart
non-long bones. failure 2/2 cardiomegaly
What is the most
common cause of 1982. A pt is suspected to A pt is suspected to have acromegaly.
death in acromegaly have acromegaly. ILGF-1 levels are elevated. The glucose
in adults? ILGF-1 levels are suppression test fails to suppress GH
[...] elevated. The levels and is positive. What is themost
glucose appropriate next step in workup?
suppression test MRI
fails to suppress GH
levels and is
positive. What is
themost appropriate
next step in workup?
[...]
300 of 340
1983. What is the What is the treatment for acromegaly? 1987. What is often the What is often the first sign of Sheehan's
treatment for Surgery (with medications as adjuncts) first sign of Syndrome?
acromegaly? Sheehan's Inability to lactate just after delivery
[...] Syndrome?
Treatment of acromegaly key points: [...]
- Surgery is the definitive therapy and is
done via transphenoidal approach
1988. What is apoplexy? What is apoplexy?
- Octreotide (Somatostatin) can be used
[...] (see below)
as an adjunct as it inhibits GH release
Apoplexy is an acute, life-threaning form
- Pegvisomant can be used as an
of panhypopituitarism that results 2/2 a
adjunct as it is a GH receptor antagonist
pituitary tumour that has outgrown its
and blocks IGF-1 release from the liver
blood supply. This is why people may cut
- Radiation is only considered in pts
out pituitary tumours.
where surgery and medication fail
1989. What is empty sella What is empty sella syndrome?

syndrome? A benign anatomical/developmental
1984. Which anterior Which anterior pituitary disorder can be
[...] variant where the pituitary gland does
pituitary disorder can associated with carpal tunnel
not sit in the sella turcica
be associated with syndrome?
No treatment needed.
carpal tunnel Acromegaly
It's typically an incidental finding.
syndrome?
[...]
1990. What is the only What is the only calcium channel blocker
calcium channel that can raise prolactin levels?
blocker that can Verapamil
1985. What is the best What is the best initial test for chronic
raise prolactin
initial test for panhypopituitarism?
levels?
chronic Insulin Stimulation test; (if positive,
[...]
panhypopituitarism? confirm with MRI)
[...] Insulin stimulation test is the opposite of
the glucose suppression test used to 1991. What electrolyte What electrolyte imbalance is seen in
diagnose acromegaly. Giving insulin imbalance is seen in SIADH?
causes hypoglycaemia which normally SIADH? Hyponatremia
causes an increase in GH. If GH fails to [...]
rise then the test is positive.
Why do we care about GH here? GH
(along with LH/FSH) is typically scarificed 1992. What is the best What is the best initial test for SIADH?
first in chronic panhypopituitarism. initial test for Serum osmolality and/or Urine
SIADH? osmolality
[...]
1986. What is the What is the treatment for chronic 1993. What is the most What is the most accurate test for
treatment for chronic panhypopituitarism? accurate test for SIADH?
panhypopituitarism? Repacement hormones SIADH? ADH level
[...] [...]
301 of 340
1994. Which thyroid Which thyroid disorder can cause SIADH? 1998. A pt is thought to A pt is thought to have diabetes insipidus.
disorder can cause Hypothyroidism have diabetes What is the best diagnostic test?
SIADH? insipidus. What is Water deprivation test (with ADH
[...] the best diagnostic stimulation)
In high doses, TSH can stimulate ADH test? - If at the start of water deprivation there is
release. [...] a sudden correction via endogenous ADH
(black arrow), it's likely psychogenic
polydipsia; tell the pt to stop drinking so
1995. How does urinary Na How does urinary Na change in SIADH?
much water and consider psych consult
change in SIADH? Increase
- If at the black arrow there is no
[...]
correction, we got DI, but which one?
- At some point after, administer
In SIADH there is a lot of retained water.
desmopressin. If it corrects, it's central
As an effort to excrete some of this extra
DI; if it does not correct, it's
water, the kidneys excrete extra Na. This
nephrogenic DI
compounds the hyponatremia that SIADH
itself causes.
1996. Both diabetes Both diabetes mellitus and diabetes

1999. What is the What is the treatment for central diabetes
mellitus and insipidus present w/ poluydipsia and
treatment for central insipidus?
diabetes insipidus polyuria. How does the urine differ in
diabetes insipidus? IVF + electrolye correction;
present w/ these conditions?
[...] Desmopressin
poluydipsia and DM involves hypertonic urine; DI
polyuria. How does involves hypotonic urine
the urine differ in DM urine is hypertonic because it is full
these conditions? of glucose that drags water into the urine
[...] with it. 2000. What is the What is the treatment for nephrogenic
DI urine is hypotonic because the treatment for diabetes insipidus?
kidneys are unable to retain water. nephrogenic IVF + electrolyte correction; gentle
Remember, regardless if its central or diabetes insipidus? diuresis; fix underlying cause if
nephrogenic: no ADH action will result [...] possible
in water loss. Hence, Uosm is low and NDI can respond to HCTZ and amiloride.
Sosm is high (opposite of SIADH) Hypokalemia and hypercalcemia (both
are able to inhibit ADH action at the
kidneys) are examples of reversible
underlying causes.
1997. A pt is suspected of A pt is suspected of having either
having either diabetes insipidus or diabetes mellitus.
diabetes insipidus or What is the best initial test?
diabetes mellitus. UA 2001. What electrolyte What electrolyte imbalance is seen in
What is the best Rule out diabetes mellitus by making sure imbalance is seen in diabetes insipidus?
initial test? there is no glucose in the urine. diabetes insipidus? Hypernatremia
[...] [...]
2002. What psychiatric What psychiatric drug is a classical cause

drug is a classical of nephrogenic diabetes insipidus?
cause of Lithium
nephrogenic
diabetes insipidus?
[...]
302 of 340
2003. What is the best What is the best initial test for all thyroid 2009. What is the most What is the most common cause of
initial test for all disorders? common cause of hyperthyroidism?
thyroid disorders? TSH hyperthyroidism? Graves
[...] [...]
In hypothyroidism, TSH will be high.

2010. What RAIU scan What RAIU scan finding is seen in
In hyperthyroidism, TSH will be low.
finding is seen in Grave's Disease?
Grave's Disease? Diffuse uptake
2004. What is the most What is the most common cause of [...] Graves disease involves diffuse
common cause of hypothyroidism? enlargement of the thyroid (i.e. the
hypothyroidism? Iatrogenic entire thyroid is hyperfunctional)
[...]
i.e. from ablation or surgery

2011. A pt is found to have A pt is found to have Graves disease.
Graves disease. What drug can be used to control their
2005. What is the most What is the most common non-iatrogenic What drug can be symptoms?
common cause of hypothyroidism? used to control their Propanolol
non-iatrogenic cause Hashimoto's thyroiditis symptoms? Grave's Disease tx key points:
of hypothyroidism? [...] - propanolol is used to control sxs
[...] - PTU or methimazole is used to treat the
elevated T4/T3; PTU is safe in pregnancy;
do not start these drugs if radioablation is
2006. Which antibodies are Which antibodies are associated with
planned
associated with hashimoto's thyroiditis?
- Radioactive iodine ablation or surgery
hashimoto's Antithyroid peroxidase and
is definitive therapy, but will cause
thyroiditis? antithyroglobulin
hypothyroidism, so start the pt on
[...]
synthroid
- if needed, steroids or radiation can be
They are 90% specific to Hashimoto's.
used to treat ophthalmology if needed
2007. What is the What is the treatment for hypothyroidism?

treatment for Levothyroxine
hypothyroidism?
[...]
2008. A pt w/ A pt w/ hypothyroidism presents w/

hypothyroidism hypothermia, hypotension and coma.
presents w/ You suspect myxedema coma. What is
hypothermia, the treatment?
hypotension and Warmed IVF + warming blankets + IV
coma. You suspect T4
myxedema coma.
What is the
treatment? Consider giving IV T3 straight up as
[...] peripheral conversion of T4 to T3 may be
impaired.
303 of 340
2012. A pt is found to have A pt is found to have Graves disease. 2014. What is the What is the treatment for Grave
Graves disease. What drug can be used to lower thyroid treatment for Grave ophthalmopathy?
What drug can be hormone levels? ophthalmopathy? Steroids; or radiation
used to lower thyroid PTU (safe in pregnancy); or [...]
hormone levels? methimazole
[...] This is typically only considered if the
ophthalmopathy worsens despite
Grave's Disease tx key points: adequate treatment.
- propanolol is used to control sxs Steroids are the best initial, radiation is
- PTU or methimazole is used to treat the considered if steroids don't work.
elevated T4/T3; PTU is safe in pregnancy; Severe cases may require
do not start these drugs if radioablation is decompressive surgery
planned
- Radioactive iodine ablation or surgery
2015. Thyroiditis and Thyroiditis and Graves disease can
is definitive therapy, but will cause
Graves disease can present with the same thyroid panel. What
hypothyroidism, so start the pt on
present with the tests help differentiate the two?
synthroid
same thyroid panel. RAIU (will be cold and inactive in
- if needed, steroids or radiation can be
What tests help thyroiditis); ESR/CRP (elevated in
used to treat ophthalmology if needed
differentiate the two? Hashimoto's thyroiditis)
[...]
2013. A pt is dx w/ Graves A pt is dx w/ Graves disease. What 2

disease. What 2 therapies offer definitive treatment?
therapies offer Radioiodine ablation; or surgery
definitive treatment?
2016. Which type of Which type of thyroiditis is commonly
[...]
thyroiditis is associated with being painful?
However, this typically makes pts
commonly De Quervian
hypothyroid, so start them on Levo.
associated with
2 major points about radioiodine tx with
being painful?
Graves (the most common tx for
[...]
hyperthyoidism in the US):
- 1. Graves pts are most likely to develop
hypothyroidism with this tx (as the whole 2017. A pt is suspected to A pt is suspected to have
thyroid is hyperfunctional) have hyperthyroidism. After physical exam you
- 2. This form of tx is most likely to result hyperthyroidism. suspect a toxic multinodular goiter. What
in worsened ophthalmopathy, and you After physical exam imaging test is able to reveal and localize
can pre-treat with glucocorticoids. you suspect a toxic the nodule?
multinodular goiter. RAIU scan
What imaging test is - very rarely are these "hot" nodules
able to reveal and cancerous.
localize the nodule? - because the rest of the thyroid senses
[...] the increase in T4, only the nodule is
revealed on RAIU scan (the rest of the
thyroid is cold)
304 of 340
2018. A pt presents w/ A pt presents w/ signs of hyperthyroidism. 2021. Iodide can be used Iodide can be used as a temporizing
signs of After H&P you suspect exogenous use as a temporizing measure in thyroid storm to decrease T4
hyperthyroidism. of levothyroxine. What test can be used measure in thyroid levels. How does this work?
After H&P you to rule out struma ovarii? storm to decrease The thyroid will either pickup iodide or
suspect exogenous Sestamibi scan T4 levels. How does make thyroid hormone; it prefers
use of Struma ovarii is a teratoma that secretes this work? iodide
levothyroxine. T4. [...]
What test can be RAIU scan in both cases will be normal
used to rule out with no uptake. However, the thyroid storm must be
struma ovarii? fixed to prevent Iodide Escape.
[...] Iodide Escape is when the administered
iodide is then used to make T4, thereby
making the thyroid storm worse.
2019. A pt presents w/ A pt presents w/ signs of hyperthyroidism.
signs of In the ER, the pt suddenly develops fever,
hyperthyroidism. In delirium and hypotension. Physical 2022. Iodide can be used Iodide can be used as a temporizing
the ER, the pt exam reveals tachycardia. You suspect as a temporizing measure in thyroid storm, but we must be
suddenly develops thyroid storm. What is the first step in measure in thyroid wary of Iodide Escape. What is iodide
fever, delirium and management? storm, but we must escape?
hypotension. Supportive measures (IVF + cooling be wary of Iodide When the administered iodide is then
Physical exam blankets) Escape. What is used to make T4, thereby making the
reveals tachycardia. iodide escape? thyroid storm worse.
You suspect thyroid [...]
storm. What is the
first step in
2023. You discover a You discover a thyroid nodule on a pt
management?
thyroid nodule on a during physical exam. What is the best
[...]
pt during physical initial test?
exam. What is the U/S (or jump to FNA in certain cases)
2020. A pt presents w/ A pt presents w/ signs of hyperthyroidism. best initial test? In general, it's prudent to do an U/S first to
signs of In the ER, the pt suddenly develops fever, [...] get a better idea of the nodule and to
hyperthyroidism. In delirium and hypotension. Physical identify good sites for biopsy. The U/S is
the ER, the pt exam reveals tachycardia. You suspect helpful for the FNA, not the dx
suddenly develops thyroid storm. Supportive measures (IVF - The things on the U/S that tell you
fever, delirium and + cooling blankets) are started. What is should proceed with FNA are >1cm or
hypotension. the most appropriate next step in "Ultrasound findings consistent with
Physical exam management? malignancy."
reveals tachycardia. Propanolol + PTU/methimazole +
You suspect thyroid steroids
storm. Supportive The hypotension/shock seen in thyroid
measures (IVF + storm is 2/2 tachycardia. The tachycardia
cooling blankets) are gets so severe that diastolic filling is
2024. A RAIU scan is A RAIU scan is typically used in thyroid
started. What is the impaired, resulting in hypotension.
typically used in disorders. What is the difference between
most appropriate
thyroid disorders. hot and cold nodules?
next step in
What is the (see below)
management?
difference between Hot nodules are hyperfunctioning and
[...]
hot and cold are less likely to be cancerous (e.g.
nodules? benign toxic adenoma)
[...] Cold nodules are the opposite.
305 of 340
2025. A pt has a A pt has a suspicious thyroid nodule. 2030. Which thyroid cancer Which thyroid cancer is associated with
suspicious thyroid What is the best overall test? is associated with orphan-annie nuclei and psammoma
nodule. What is the FNA Bx orphan-annie bodies on biopsy?
best overall test? nuclei and Papillary Ca
[...] psammoma bodies
on biopsy?
[...]
2026. Both TSH and RAIU Both TSH and RAIU scan are used in the 2031. Which thyroid cancer Which thyroid cancer requires excisional
scan are used in the workup of a thyroid nodule. When is TSH requires excisional bx for diagnosis?
workup of a thyroid the best initial test? bx for diagnosis? Follicular Ca
nodule. When is For a low risk nodule suspected of [...] Remember, you cannot Dx follicular ca
TSH the best initial being hyperfunctioning accurately on FNA because the entire
test? 1. If you can feel a nodule, and the TSH is follicle needs to be visualised. If there is
[...] low, you have a hyperfunctioning nodule, invasion through the capsule, it's cancer.
then do a RAIU, and ablate If not, it may be follicular adenoma.
2. If you can feel a nodule, and the TSH is
normal, you might have cancer, get an
ultrasound THEN a biopsy
2032. Which thyroid cancer Which thyroid cancer produces
3. If you happen to get an imaging study
produces calcitonin?
for something else and find a nodule, get
calcitonin? Medullary Ca (cancer of C-cells)
an ultrasound THEN a biopsy
[...] The calcitonin then results in
4. If your biopsy isn't good, biopsy again
hypocalcemia.
Medullar Ca is also a part of MEN2a and
MEN2b.
2027. In the workup of a In the workup of a thyroid nodule, it is

thyroid nodule, it is important to try and categorize the nodule
2033. Which thyroid cancer Which thyroid cancer is known to grow
important to try and as low or high risk depending on the
is known to grow quickly and invade local tissue/structures?
categorize the history. What key points in the history
quickly and invade Anaplastic
nodule as low or indicate high risk?
local
high risk depending Hx of thyroid cancer; Hx of neck
tissue/structures?
on the history. What radiation; age > 70 y/o
[...]
key points in the
history indicate high
risk? 2034. What genetic defect What genetic defect is seen in MEN1
[...] is seen in MEN1 syndrome?
syndrome? Autosomal dominant mutation in MEN1
[...]
2028. What is the most What is the most common thyroid cancer?
common thyroid Papillary Ca
cancer?
[...] 2035. MEN1 syndrome can MEN1 syndrome can be remembered by
be remembered by the "3 Ps". What are they?
the "3 Ps". What are Pituitary adenoma (any); Parathyroid
2029. Which thyroid cancer Which thyroid cancer has the best
they? adenoma; Pancreatic adenoma
has the best prognosis?
[...] Notice how all of the P's are hard P's and
prognosis? Papillary Ca
not soft as in Pheochromocytoma.
[...]
Pancreatic lesions are typically
zollinger-ellison or insulinoma
306 of 340
2036. What genetic defect What genetic defect is seen in MEN2 2040. What is the best What is the best initial test for Cushing's
is seen in MEN2 syndromes (both A and B)? initial test for Syndrome/Disease?
syndromes (both A Mutation in the RET oncogene Cushing's 24 hr urine cortisol; or low dose
and B)? Syndrome/Disease? overnight dexamethasone suppression
[...] [...] test
24 hr urine cortisol is the right answer,
but if it is not an option choose the low
2037. What is the only What is the only cause of hyperthyroidism
dose DST.
cause of that involves eye and skin abnormalities?
Workup of Cushing's
hyperthyroidism that Graves disease
Syndrome/Disease key points:
involves eye and
- Your first tests work to determine the
skin abnormalities?
presence of hypercortisolism
[...]
--- 24 hr urine cortisol is more specific
--- low dose DST is positive if morning
2038. How large must a How large must a thyroid nodule be for cortisol is high; normally, the DST should
thyroid nodule be for biopsy to be indicated? lower morning cortisol
biopsy to be > 1 cm - Your following tests work to determing
indicated? the cause of hypercortisolism
[...] --- ACTH testing is the best here; low
Euthyroid nodules should be Bx as well. means its an adrenal source; high means
pituitary or ectopic
2039. What is the most What is the most common cause of --- if ACTH is high, follow up with a high
common cause of Cushing's Syndrome? dose DST
Cushing's Iatrogenic
Syndrome?
[...]
disease/syndrome. A test confirms hypercortisolism. What is
24 hr urine cortisol the most appropriate next step in workup?
test confirms ACTH testing
hypercortisolism. Workup of Cushing's
What is the most Syndrome/Disease key points:
appropriate next - Your first tests work to determine the
step in workup? presence of hypercortisolism
[...] --- 24 hr urine cortisol is more specific
--- low dose DST is positive if morning
cortisol is high; normally, the DST should
lower morning cortisol
- Your following tests work to determing
the cause of hypercortisolism
--- ACTH testing is the best here; low
means its an adrenal source; high means
pituitary or ectopic
--- if ACTH is high, follow up with a high
dose DST
307 of 340

2045. What is the What is the difference between primary
disease/syndrome. A test confirms hypercortisolism. Follow difference between and secondary hyperaldosteronism?
24 hr urine cortisol up ACTH testing is high. What is the primary and Primary = Conn's Syndrome = adrenal
test confirms most appropriate next step in workup? secondary tumour/adenoma; Secondary is, well,
hypercortisolism. High-dose DST hyperaldosteronism? secondary to something else lol
Follow up ACTH Workup of Cushing's [...] Secondary causes include renovascular
testing is high. What Syndrome/Disease key points: disease, CHF, cirrhosis, nephrotic
is the most - Your first tests work to determine the syndrome and the hyperaldosteronism is
appropriate next presence of hypercortisolism dependent on renin and decreased
step in workup? --- 24 hr urine cortisol is more specific renocasular flow.
[...] --- low dose DST is positive if morning
cortisol is high; normally, the DST should
lower morning cortisol
- Your following tests work to determing 2046. A pt presents w/ A pt presents w/ HTN and hypokalemia.
the cause of hypercortisolism HTN and What adrenal disorder should be
--- ACTH testing is the best here; low hypokalemia. What considered?
means its an adrenal source; high means adrenal disorder Hyperaldosteronism
pituitary or ectopic should be
--- if ACTH is high, follow up with a high considered?
dose DST [...]

disease/syndrome. A test confirms hypercortisolism. Follow
24 hr urine cortisol up ACTH testing is high. As a follow up to
test confirms that, high dose DST yields no
hypercortisolism. suppression. What is the diagnosis?
Follow up ACTH Cushing's Syndrome 2/2
testing is high. As a paraneoplastic syndrome (get CT to
follow up to that, confirm)
high dose DST
yields no
suppression. What Typically 2/2 lung or pancreatic cancer
is the diagnosis?
[...]
2044. What is the "low What is the "low THen high" rule in the
THen high" rule in workup of Cushing's disease/syndrome?
the workup of (see below)
Cushing's “Low THen High” rule:
disease/syndrome? - LOW dose (1 mg) IV dexamethasone:
[...] should suppress ACTH, and hence
supress cortisol; if the cortisol remains
elevated, then they have Cushing’s
Syndrome
- next step is to check ACTH (ACTHen)
- then do HIGH dose dexamethasone if
ACTH is high (i.e. no adrenal tumour)
308 of 340
2047. What is the best What is the best initial test for 2048. A pt w/ HTN and A pt w/ HTN and hypokalemia is
initial test for hyperaldosteronism? hypokalemia is suspected to have hyperaldosteronism.
hyperaldosteronism? Aldosterone:renin (> 20) + aldosterone suspected to have Aldosterone:renin ratio is high (> 20),
[...] + renin (taken at 8 AM; be sure to d/c hyperaldosteronism. with decreased renin. Follow-up salt
any antihypertensives) Aldosterone:renin suppression test is positive
ratio is high (> 20), (aldosterone does not decrease after
with decreased 200g Na load). What is the most likely
Workup of Hyperaldosteronism key renin. Follow-up salt Dx?
points: suppression test is Primary hyperaldosteronism (Conn
- it's similar to the workup for Cushing's: positive syndrome) 2/2 adrenal
first determine whether or not there really (aldosterone does tumour/hyperplasia (order CT/MRI to
is an excess of aldosterone not decrease after confirm and adrenal vein sampling to
(aldosterone:renin ratio); then determine 200g Na load). What localize)
the cause (i.e. is it renin dependent?) is the most likely Workup of Hyperaldosteronism key
- First determine the presence of Dx? points:
hyperaldosteronism: [...] - it's similar to the workup for Cushing's:
--- aldosterone:renin ratio is the best first determine whether or not there really
initial test; be sure to d/c is an excess of aldosterone
antihypertensives as ACE-I, CCBs, and (aldosterone:renin ratio); then determine
diuretics can confound the test the cause (i.e. is it renin dependent?)
--- elevated renin rules out Conn' - First determine the presence of
Syndrome, and points towards a hyperaldosteronism:
secondary cause --- aldosterone:renin ratio is the best
- if Conn syndrome (primary) is initial test; be sure to d/c
suspected, order salt suppression test antihypertensives as ACE-I, CCBs, and
(200 g Na load should normally decrease diuretics can confound the test
aldosterone levels); follow up with CT/MRI --- elevated renin rules out Conn'
to localize the lesion if positive Syndrome, and points towards a
- remember to do adrenal vein sampling secondary cause
to localize the lesion to a side and look for - if Conn syndrome (primary) is
an "incidentaloma" suspected, order salt suppression test
an "incidentaloma"
309 of 340
2049. A pt w/ HTN and A pt w/ HTN and hypokalemia is 2051. The workup of The workup of primary
hypokalemia is suspected to have hyperaldosteronism. primary hyperaldosteronism (Conn syndrome)
suspected to have Aldosterone:renin ratio is low (< 10), hyperaldosteronism often involves Adrenal Vein Sampling
hyperaldosteronism. with increased renin. What is the most (Conn syndrome) prior to pursuing therapy. Why?
Aldosterone:renin likely Dx? often involves (see below)
ratio is low (< 10), Secondary hyperaldosteronism Adrenal Vein
with increased (consider angiogram for renovascular Sampling prior to
renin. What is the disease) pursuing therapy. About 50% of pts with
most likely Dx? Why? Hyperaldosteronism have an
[...] [...] “Incidentaloma” on the contralateral
Workup of Hyperaldosteronism key adrenal gland; this makes the ipsilateral
points: adrenal gland hyperplastic (causing
- it's similar to the workup for Cushing's: hyperaldosteronism); hence, DO
first determine whether or not there really SAMPLING to see which side is actually
is an excess of aldosterone secreting the aldosterone
(aldosterone:renin ratio); then determine
the cause (i.e. is it renin dependent?)
- First determine the presence of
initial test for pheochromocytoma?
hyperaldosteronism:
pheochromocytoma? 24 hr urinary metanephrines; or urinary
--- aldosterone:renin ratio is the best
[...] VMA; or plasma free metanephrines
initial test; be sure to d/c
Getting confilicting answers from diff
antihypertensives as ACE-I, CCBs, and
sources, but they all agree that:
diuretics can confound the test
- 24 hr urinary metanephrines is the
--- elevated renin rules out Conn'
most sensitive
Syndrome, and points towards a
- urinary VMA (vanillylmandelic acid) is
secondary cause
cheaper, but less sensitive
- if Conn syndrome (primary) is
- plasma free metanephrines is
suspected, order salt suppression test
easiest/quickest and is a good initial
screen before you confirm with 24 hr
urinary metanephrines
an "incidentaloma"
2053. A pt is suspected of A pt is suspected of having

having pheochromocytoma. Plasma free
pheochromocytoma. metanephrine testing is normal and the
Plasma free disease is confirmed via 24 hr urinary
2050. What is the What is the treatment for primary
metanephrine metanephrines. What is the most
treatment for primary hyperaldosteronism (Conn syndrome)?
testing is normal and appropriate next step in workup?
hyperaldosteronism Resection
the disease is CT/MRI
(Conn syndrome)?
confirmed via 24 hr
[...]
urinary
metanephrines.
What is the most
appropriate next
step in workup?
[...]
310 of 340
2054. A pt is suspected of A pt is suspected of having 2057. What is the best What is the best initial test for suspected
having pheochromocytoma. Plasma free initial test for hypocortisolism (Addison's)?
pheochromocytoma. metanephrine testing is elevated and the suspected 3 AM cortisol measurement (< 3 ug is
Plasma free disease is confirmed via 24 hr urinary hypocortisolism diagnostic; > 18 ug rules out the
metanephrine metanephrines. CT/MRI is negative. (Addison's)? disease)
testing is elevated What is the most appropriate next step in [...] Addison's workup key points:
and the disease is workup? - best initial test is 3 AM cortisol
confirmed via 24 hr MIBG scintillography measurement; (< 3 ug is diagnostic; > 18
urinary ug rules out the disease)
metanephrines. - most specific test is the Cosyntropin
CT/MRI is negative. (ACTH) stimulation test
What is the most --- the CST involves giving exogenous
appropriate next ACTH
step in workup? --- if cortisol increases, it is secondary
[...] hypocortisolism and you only need to
replace cortisol
--- if cortisol does not change, then it is
2055. A pt is dx with A pt is dx with pheochromocytoma. Why
primary hypocortisolism and you need
pheochromocytoma. is it a bad idea to biopsy the lesion?
to replace cortisol and aldosterone
Why is it a bad idea Biposy can trigger a catecholamine
to biopsy the lesion? surge, killing the pt
[...]
2056. A pt is dx w/ A pt is dx w/ pheochromocytoma and is

2058. A pt presents w/ A pt presents w/ hypotension,
pheochromocytoma being boarded for surgical resection.
hypotension, hyperkalemia and nausea/vomiting.
and is being What drugs must be given prior to the
hyperkalemia and You suspect Addison's disease. Initial 3
boarded for procedure and in what order?
nausea/vomiting. AM cortisol levels are low (< 3 ug). What
surgical resection. (see below)
You suspect is the most appropriate next step in
What drugs must be
Addison's disease. workup?
given prior to the
Initial 3 AM cortisol Cosyntropin stimulation test (we've
procedure and in Pheochromocytoma treatment key
levels are low (< 3 diagnosed Addison's, now we need to
what order? points:
ug). What is the see if it is primary or secondary)
[...] - 1. Give alpha-blockers first
most appropriate
(phenoxybenzamine) to prevent
unopposed alpha-adrenergic action when
[...] Addison's workup key points:
you give the follow-up beta-blockade
- best initial test is 3 AM cortisol
- 2. Give beta-blockers second to
measurement; (< 3 ug is diagnostic; > 18
stabilize HR/BP and complete the
ug rules out the disease)
adrenergic blockade
- most specific test is the Cosyntropin
- 3. Resection STAT
(ACTH) stimulation test
--- the CST involves giving exogenous
ACTH
--- if cortisol increases, it is secondary
hypocortisolism and you only need to
replace cortisol
--- if cortisol does not change, then it is
primary hypocortisolism and you need
to replace cortisol and aldosterone
311 of 340
2062. Which form of Which form of adrenal insufficiency

2059. A pt presents w/ A pt presents w/ hypotension, adrenal insufficiency involves hyperpigmentation?
hypotension, hyperkalemia and nausea/vomiting. involves Primary
hyperkalemia and You suspect Addison's disease. Initial 3 hyperpigmentation?
nausea/vomiting. AM cortisol levels are low (< 3 ug). Follow [...]
You suspect up cosyntropin stimulation test yields an Remember, in primary insufficiency it is
Addison's disease. increase in cortisol. What is the most the adrenal glands that fail. As a result,
Initial 3 AM cortisol likely dx? ACTH production is increased and
levels are low (< 3 Secondary adrenal insufficiency (2/2 hyperpigmentation results as a
ug). Follow up no/low ACTH; consider MRI to look at byproduct (from byproducts).
cosyntropin the pituitary)
stimulation test
yields an increase
in cortisol. What is Replace cortisol only via prednisone.
the most likely dx?
common cause of adrenal insufficiency in the USA?
[...]
adrenal insufficiency Autoimmune adrenalitis
in the USA?
2060. A pt presents w/ A pt presents w/ hypotension, [...]
hypotension, hyperkalemia and nausea/vomiting.
hyperkalemia and You suspect Addison's disease. Initial 3
nausea/vomiting. AM cortisol levels are low (< 3 ug). Follow
common cause of adrenal insufficiency worldwide?
You suspect up cosyntropin stimulation test yields no
adrenal insufficiency TB
Addison's disease. change in cortisol. What is the most
worldwide?
Initial 3 AM cortisol likely dx?
[...]
levels are low (< 3 Primary adrenal insufficiency (2/2
ug). Follow up adrenal failure) Don't forget about
cosyntropin Waterhouse-Friderichsen Syndrome
stimulation test (adrenal insufficiency 2/2 adrenal
yields no change in Replace both cortisol AND aldosterone hemorrhage in sepsis).
cortisol. What is the with prednisone and fludrocortisone
most likely dx? respectively. 2065. What therapies are What therapies are considered the "three
[...] considered the prongs" of DKA management?
"three prongs" of K, IVF, Insulin
DKA management?
2061. A pt is diagnosed w/ [...]
A pt is diagnosed w/ primary adrenal
- Potassium (K) is given before insulin,
primary adrenal insufficiency. What is the treatment?
as insulin shifts K into cells and the large
insufficiency. What Prednisone + fludrocortisone
volume of IVF increases urine output and
is the treatment?
K wasting
[...]
- IVF are given in large volume (LR =
In primary adrenal failure, both cortisol
NS); if glucose lowers, but the anion gap
AND aldosterone are typically deficient.
doesn't close, switch to a D5 containing
Replace both.
solution
- Insulin is given IV until the anion gap
closes; once the anion gap is closed,
switch to SQ insulin and start food
(remember, in DKA the body thinks its
starving and activates starvation ketosis,
which creates an anion gap)
312 of 340
2066. Diabetes mellitus Diabetes mellitus involves an accelerated 2070. What is the best What is the best initial pharmacotherapy
involves an atherosclerosis/microvascular disease. initial for diabetes mellitus?
accelerated How does HgbA1C influence this? pharmacotherapy for Metformin (pioglitazone if cannot
atherosclerosis/microvascular
(see below) diabetes mellitus? tolerate)
disease. How does [...]
HgbA1C influence
this? RBC surface proteins get glycosylated by Non-insulin Pharmacotherapy in
[...] serum glucose; this eliminates the Diabetes key points:
negative charge of these proteins and - start with metformin
also makes them larger. HbA1C is a - start with a thiazoledinedione if
surrogate measure of how bad the metformin not tolerated
glycosylation is; normal is <5.5%. - add glyburide to either of the first drugs
As these heavily glycosylated RBCs tavel if more coverage is needed
through capillaries, the blood flow is - switch glyburide for a
impaired; ischemia and atherosclerosis thiazoledinedione if hypoglycaemia is an
are both accelerated as a result issue
- from here, any additional coverage (i.e.
with DPP-4 inhibitors and GLP-1
2067. What is the What is the diagnostic criteria for diabetes
analogues) is added on a case by case
diagnostic criteria for mellitus using fasting blood glucose?
basis
diabetes mellitus 2 measurements > 125 (this is the best
using fasting blood way of diagnosing DM)
glucose?
[...]
2071. What is the major What is the major contraindication for

2068. What is the HgbA1C What is the HgbA1C goal in diabetics?
contraindication for metformin?
goal in diabetics? < 7% (average bGlc of 100-150)
metformin? Renal failure (or sometimes CHF)
[...]
[...]
Why not 6% like normal people?

With renal dysfunction, Metformin can
- When people attempted to get people to
accumulate and cause metabolic
6%, there were far too many episodes of
(lactic) acidosis.
hypoglycemia and people were dying.
Yes, diabetes causes severe
microvascular complications, but the
hypoglycemia kills pts right there and
then.
2069. Which class of Which class of diabetic medication is

diabetic medication known to decrease HbA1C levels the
is known to most?
decrease HbA1C Insulins
levels the most?
[...]
313 of 340
2072. A pt is diagnosed w/ A pt is diagnosed w/ diabetes and started 2073. A pt is diagnosed w/ A pt is diagnosed w/ diabetes and started
diabetes and started on metformin as initial pharmacotherapy. diabetes and started on metformin as initial pharmacotherapy.
on metformin as A follow-up checkup reveals the need for on metformin as A follow-up checkup reveals the need for
initial increased coverage. In general, what is initial increased coverage so glyburide is
pharmacotherapy. A the best drug to be added to the regimen? pharmacotherapy. A added. The pt then begins have
follow-up checkup Glyburide follow-up checkup hypoglycemic episodes. In general, how
reveals the need for Non-insulin Pharmacotherapy in reveals the need for should the drug regimen be altered?
increased coverage. Diabetes key points: increased coverage Switch glyburide for a
In general, what is - start with metformin so glyburide is thiazoledinedione
the best drug to be - start with a thiazoledinedione if added. The pt then
added to the metformin not tolerated begins have
regimen? - add glyburide to either of the first drugs hypoglycemic Non-insulin Pharmacotherapy in
[...] if more coverage is needed episodes. In Diabetes key points:
- switch glyburide for a general, how should - start with metformin
thiazoledinedione if hypoglycaemia is an the drug regimen be - start with a thiazoledinedione if
issue altered? metformin not tolerated
- from here, any additional coverage (i.e. [...] - add glyburide to either of the first drugs
with DPP-4 inhibitors and GLP-1 if more coverage is needed
analogues) is added on a case by case - switch glyburide for a
basis thiazoledinedione if hypoglycaemia is an
issue
- from here, any additional coverage (i.e.
with DPP-4 inhibitors and GLP-1
analogues) is added on a case by case
basis
314 of 340
2074. What is the route of What is the route of administration for all
2076. What is the formula What is the formula used to calculate a
administration for all insulin therapies in the day-to-day
insulin therapies in management of diabetes? used to calculate a patient's total daily requirement of
the day-to-day SubQ (important to remember to patient's total daily insulin (in units) in the management of
management of educate your pts on proepr use) requirement of diabetes mellitus?
diabetes? Insulin therapy in DM tidbits: insulin (in units) in 0.5 units per 1 kg body weight
[...] - the L drugs (Lantus, Levemir) are Long the management of
acting and equivocaL diabetes mellitus?
- LOGarithmic math is harder than [...] Note that the total daily req. of units is
drawing a LINe; the drugs follow suit: split differently in different insulin
humalog and novalog are used in more regimens:
complex ways (e.g. given qAc) - in basal-bolus, it is a 50/50 split
- NPH is the rapid-acting component between basal dose and total bolus
found in the -log combination insulins (postprandial) doses
- regular insulin is medium-acting - in "idiot insulin" (i.e. combination
- LisPRO is for the pros. Use it only if insulin) it is a 66/33 split between AM and
you're really good at managing your PM doses respectively
diabetes. And just like a pro, it is fast - in sliding scales each dose varies
(acting). depending on bGlc, so the equation does
- NPH is Not Particularly Hard. Give this not apply
to the patient who is not particularly handy
with a glucose diary. 2077. While basal-bolus While basal-bolus insulin is considered
insulin is considered the best regimen to manage diabetes,
the best regimen to there are others used that are not optimal.
manage diabetes, Which regimen is often used in pts that
there are others are unable to maintain a basal-bolus
2075. What insulin regimen What insulin regimen is considered the used that are not regimen?
is considered the best for the day-to-day management of optimal. Which Combination insulin regimen (or "idiot
best for the diabetes? regimen is often insulin", which is easier to remember)
day-to-day Basal-Bolus used in pts that are "Idiot Insulin" key points:
management of Normally, insulin exists at a baseline unable to maintain a - typically used in pts that cannot inject
diabetes? level and insulin spikes occur after a basal-bolus themeselves 4x a day, are afraid of
[...] meal. regimen? needles, or are poor at measuring bGlc
Basal-Bolus regimens are considered the [...] - involves giving the same amount of
best because they emulate the natural medium acting insulin regardless of
trend of insulin levels the best; it does not bGlc and hence has poor basal
chase glucose measures (like in coverage and poor post-prandial
sliding-scale) and allows for prophylactic coverage
insulin use in preparation of future meals; - the pro is that the regimen only
this ultimately results in good glucose involves 2 daily doses (vs. much more
control. in basal-bolus)
In basal bolus it is important to remember - does not offer optimal glucose control
that blood sugar measurements are and target A1C is typically not met;
affected by the prior insulin dose however, this is better than your patient
(hence, if AM glucose measurement is dying from DKA/HHNKC
high, increase the nigttime dose; if
lunchtime Glc is high, increase the
breakfast dose).
315 of 340
2078. What is considered What is considered the worst regimen for 2079. It is generally agreed It is generally agreed that sliding scale
the worst regimen managing diabetes mellitus? that sliding scale insulin is the worst regimen to manage
for managing Sliding Scale insulin is the worst diabetes mellitus. When is sliding scale
diabetes mellitus? Why is Sliding Scale considered the regimen to manage actually useful?
[...] worst regimen? diabetes mellitus. When it is added on top of an existing
- firstly, no basal insulin is given When is sliding scale regimen as needed
- secondly, the insulin that is given is actually useful?
given reactively (vs. proactively); this [...]
means that you are always behind and Why is Sliding Scale considered the
chasing bGlc measurements worst regimen?
- this sets the stage for huge upward and - firstly, no basal insulin is given
downwards swings in bGlc which can - secondly, the insulin that is given is
obviously be dangerous given reactively (vs. proactively); this
Is Sliding Scale ever useful then? means that you are always behind and
- Yes. Sliding scale insulin is useful chasing bGlc measurements
when added on top of an existing - this sets the stage for huge upward and
regimen. downwards swings in bGlc which can
- Let's say you have a very compliant and obviously be dangerous
controlled type 2 diabetic patient on a Is Sliding Scale ever useful?
basal-bolus regimen. It's his birthday - Yes. Sliding scale insulin is useful
weekend and he would like to enjoy cake when added on top of an existing
and birthday meals with his family and regimen.
friends. Instead of drastically altering his - Let's say you have a very compliant and
basal-bolus regimen to prepare for this, controlled type 2 diabetic patient on a
get him on a sliding scal ON TOP of the basal-bolus regimen. It's his birthday
basal-bolus regimen which will allow him weekend and he would like to enjoy cake
to inject insulin as needed depending on and birthday meals with his family and
how his birthday weekend goes. friends. Instead of drastically altering his
(generalized example that helps me basal-bolus regimen to prepare for this,
understand the concept; don't shoot me get him on a sliding scale ON TOP of the
pls) basal-bolus regimen which will allow him
to inject insulin as needed depending on
how his birthday weekend goes.
(generalized example that helps me
understand the concept; don't shoot me
pls)
316 of 340
2080. Part of the challenge Part of the challenge of establishing a 2083. Retinopathy is a Retinopathy is a possible serious
of establishing a good insulin regimen in diabetes mellitus possible serious complication of diabetes mellitus. How
good insulin regimen is ensuring that the nighttime dose of complication of often should retinal exams be performed?
in diabetes mellitus insulin is optimal. What is the Somogyi diabetes mellitus. q1year
is ensuring that the effect seen in some patients? How often should
nighttime dose of Rebound hyperglycemia in the AM 2/2 retinal exams be
insulin is optimal. too much nighttime insulin performed?
What is the Too much insulin at night results in [...]
Somogyi effect hypoglycemia. As a response (while
seen in some you're sleeping), the body kicks up
2084. What is the best way What is the best way to screen for
patients? gluconeogenesis to correct the problem.
to screen for diabetic diabetic nephropathy and how often
[...] However, the nighttime insulin soon
nephropathy and should it be performed?
wears off, leaving the newly made
how often should it Urinary microalbumin testing every 1
glucose in circulation. As a result,
be performed? year
morning glucose is high.
[...]
2081. Part of the challenge Part of the challenge of establishing a

2085. A pt has diabetic A pt has diabetic nephropathy. What drug
of establishing a good insulin regimen in diabetes mellitus
nephropathy. What class can be used to improve this
good insulin regimen is ensuring that the nighttime dose of
drug class can be condition?
in diabetes mellitus insulin is optimal. What is the dawn
used to improve this ACE-I or ARB
is ensuring that the phenomenon seen in some patients?
condition?
nighttime dose of Morning hyperglycemia 2/2 too little
[...]
insulin is optimal. nighttime insulin
Start when microalbuminuria is
What is the dawn Too little insulin at night is not enough to
detected.
phenomenon seen overcome counterregulatory hormones
Both have been proven to decrease the
in some patients? that typically dominate the sleep hours,
rate of progression of nephropathy by
[...] thereby resulting in morning
decreasing intraglomerular
hyperglycemia. Adjust the nighttime
hypertension and mitigating damage to
dose accordingly.
the kidneys.
2086. A pt has diabetic A pt has diabetic nephropathy. What is

2082. Both the Somogyi Both the Somogyi effect and dawn
nephropathy. What the pharmacotherapy?
effect and dawn phenomenon result in morning
is the Gabapentin; pregabalin
phenomenon result hyperglycemia, and necessitate
pharmacotherapy?
in morning adjustments to the dose of nighttime
[...]
hyperglycemia, and insulin (however, in different ways). How
necessitate can we distinguish between the two?
adjustments to the Measuring early morning bGlc (i.e. 2087. Diabetic neuropathy Diabetic neuropathy is a common
dose of nighttime around 3 AM) is a common complication of diabetes mellitus. How
insulin (however, in complication of often should it be tested for?
different ways). How diabetes mellitus. q1year via monofilament
can we distinguish If 3 AM bGlc is high, it is the dawn How often should it Just think of Dr. D in 3rd year and you will
between the two? phenomenon and you need to increase be tested for? never forget this, brah.
[...] nighttime (qHs) insulin. [...]
If 3 AM bGlc is low, it is the Somogyi
effect and you need to decrease
nighttime (qHs) insulin.
317 of 340
2088. What is the best What is the best measure of the severity 2093. What is the criteria What is the criteria for the duration of
measure of the of DKA? for the duration of acute diarrhea?
severity of DKA? Serum bicarbonate (i.e. the anion gap) acute diarrhea? < 2 weeks
[...] [...] Diarrhea duration key points:
- < 2 weeks is considered acute; it
Not bGlc. typically infectious and self-limiting
If serum bicarb is very low (very high - 2-4 weeks is considered subacute; can
anion gap), the pt is at risk of death. be infectious or other causes
- > 4 weeks is considered chronic; it is
typically due to a chronic underlying
2089. What is the BP goal What is the BP goal in diabetes mellitus?
condition
in diabetes mellitus? < 140/90
[...]
Due to the increased risk of MI, CVA, 2094. What cause of What cause of enterotoxic
CHF and accelerated atherosclerosis.. enterotoxic (non-invasive) diarrhea is associated w/
Also remember that DM is considered a (non-invasive) camping and drinking fresh water
CAD equivalent in lipid control. Diabetics diarrhea is sources?
have an LDL goal of < 100 via statins associated w/ Giardia lamblia
camping and
drinking fresh water
2090. What is the What is the treatment for gastroparesis
sources?
treatment for 2/2 diabetes mellitus?
[...]
gastroparesis 2/2 Metoclopromide (+ erythromycin)
diabetes mellitus?
[...] 2095. What cause of What cause of invasive diarrhea is
Prokinetic agents invasive diarrhea is associated w/ rats?
associated w/ rats? Yersinia
[...]
2091. Diabetic retinopathy Diabetic retinopathy can be proliferative
can be proliferative or nonproliferative. What is the
or nonproliferative. treatment for nonproliferative
What is the retinopathy?
treatment for Tighter glucose control
nonproliferative 2096. What cause of What cause of enterotoxic
retinopathy? enterotoxic (non-invasive) diarrhea is associated w/
[...] Laser photocoagulation only has a role (non-invasive) chinese food/buffets (i.e. reheated rice)?
in proliferative. diarrhea is Bacillus cereus
associated w/
chinese food/buffets
2092. Diabetic retinopathy Diabetic retinopathy can be proliferative
(i.e. reheated rice)?
can be proliferative or nonproliferative. What is the
[...]
or nonproliferative. treatment for proliferative retinopathy?
What is the Laser photocoagulation
treatment for 2097. What cause of What cause of enterotoxic
proliferative enterotoxic (non-invasive) diarrhea is associated w/
retinopathy? Markedly slows the progression to (non-invasive) picnics and proteinaceous foods?
[...] blindness. Which is dope because vision diarrhea is Staphylococcus aureus
is awesome. associated w/
picnics and
proteinaceous
foods?
[...]
318 of 340
2098. What cause of What cause of enterotoxic 2102. What is the best What is the best initial treatment for
enterotoxic (non-invasive) diarrhea is associated w/ initial treatment for Clostridium difficile diarrhea?
(non-invasive) traveling (esp. to central america)? Clostridium difficile PO MTZ
diarrhea is Enterotoxic Escherichia coli (aka diarrhea? C. diff treatment key points:
associated w/ Montezuma's revenge) [...] - if uncomplicated give PO MTZ
traveling (esp. to - if severe give PO Vanco + IV MTZ
central america)? - if refractory give fidaxomycin
[...] - if still refractory consider fecal
transplant
2099. What is the most What is the most common cause of 2103. Clostridium difficile Clostridium difficile diarrhea can be
common cause of bloody diarrhea? diarrhea can be uncomplicated (i.e. just smelly, watery
bloody diarrhea? Campylobacter uncomplicated (i.e. diarrhea) or severe. What is seen in the
[...] just smelly, watery severe form?
diarrhea) or severe. Fever; leukocytosis; megacolon;
What is seen in the elevated BUN/Cr
severe form?
[...]
The treatment is different and involves PO
2100. Acute infectious Acute infectious diarrhea can be
Vanco + IV MTZ.
diarrhea can be separated into invasive and
The vancomycin does not cross the
separated into enterotoxic/non-invasive. What are the
blood-gut barrier, thereby staying in the
invasive and features of invasive diarrhea?
gut lumen and attacking the C diff. MTZ
enterotoxic/non-invasive.
Bloody stool; fever; abdominal pain;
can cross the blood-gut barrier, and is
What are the leukocytosis; fecal WBCs
given IV to attack C diff on 2 fronts.
features of invasive
diarrhea?
[...] If the diarrhea seems invasive (i.e. 2104. A pt presents w/ A pt presents w/ bloody diarrhea,
positive fecal WBCs/RBCs/lactoferrin), bloody diarrhea, elevated BUN/Cr and acute anaemia. A
follow up with stool Cx and colonoscopy elevated BUN/Cr PBS reveals MAHA. You suspect
+ Bx. and acute anaemia. hemolytic uremic syndrome. What is
Do not give Loperamide in an invasive A PBS reveals the best initial test?
diarrhea as it will worsen the diarrhea. MAHA. You suspect Shiga-like toxin assay (or the PBS if it's
hemolytic uremic not done yet)
syndrome. What is
[...]
2101. What is the best test What is the best test for Clostiridium
for Clostiridium difficile diarrhea?
difficile diarrhea? NAAT (not the toxin; not colonoscopy) 2105. What is the What is the treatment for hemoyltic
[...] Remember, you only treat if C diff testing treatment for uremia syndrome?
is positive AND there is watery hemoyltic uremia Supportive care; dialysis; plasma
diarrhea. syndrome? exchange
[...]
319 of 340
2106. What is the most What is the most common cause of acute 2111. In the blood, calcium In the blood, calcium travels mostly as
common cause of diarrhea? travels mostly as bound-calcium (bound to albumin). A
acute diarrhea? Viral gastroenteritis bound-calcium small proportion is left free as ionized
[...] This is important to realise. First thing to (bound to albumin). calcium. How do we adjust our total Ca
do is ask whether or not the diarrhea/case A small proportion is measurement for changes in albumin
seems like viral gastroenteritis. If yes, you left free as ionized level?
don't do much. If there are alarm calcium. How do we For 1 g change in Albumin, correct Ca
symptoms, continue on with workup. adjust our total Ca by 0.8 in the opposite direction
Everything else in diarrhea is easy. The measurement for
big point is to be able to discern who does changes in albumin
and doesn't get a full workup. level?
Alarm sxs include: [...]
- fever > 104 F
- severe dehydration
2112. A pt has elevated Ca A pt has elevated Ca on routine outpatient
- bloody (and/or pus) diarrhea
on routine outpatient labwork. He is asymptomatic. What is the
- recent hospitalization or Abx use
labwork. He is most appropriate next step?
asymptomatic. What Re-check Ca levels
2107. What is the What is the treatment for viral is the most If he is asymptomatic, simply recheck.
treatment for viral gastroenteritis? appropriate next
gastroenteritis? Rehydration (PO preferred, IV if not step?
[...] possible) and loperamide [...]
2108. What is the effect of What is the effect of PTH at the bones?
PTH at the bones? Increased osteoclast activity, thereby 2113. What are the What are the classical symptoms of
[...] resulting in increased Ca and PO4 classical symptoms hypercalcemia?
of hypercalcemia? Stones, bones, groans, moans
[...] Stones = calcium nephrolithiasis
Bones = fracture, osteopenia
Groans = abdominal pain, nausea,
2109. What is the effect of What is the effect of PTH at the kidneys?
vomiting
PTH at the kidneys? Increased Ca reabsorption; Increased
Moans = AMS (but typically only in severe
[...] PO4 excretion
cases w/ a Ca of 13-15)
With PTH it's important to remember the
general rule: "The kidneys always win".
That is to say, that if there are functioning
kidneys AND PTH, the kidney will win and
PO4 levels will typically fall due to
excretion. This is big in diagnosing
calcium disorders.
2110. What is the effect of What is the effect of PTH at the GI tract?
PTH at the GI tract? Absorption of C and PO4 via Vitamin D
[...]
320 of 340
2114. A pt has A pt has symptomatic hypercalcemia. 2115. A pt is found to have A pt is found to have hypercalcemia. XR
symptomatic What is the treatment? hypercalcemia. XR reveals fibrosa cystica (brown tumour).
hypercalcemia. What IVF + bisphosphonates reveals fibrosa Labs reveals elevated PTH, elevated Ca
is the treatment? The more deranged their labs (further cystica (brown and decreased PO4. What is the most
[...] from normal), the more you should tumour). Labs likely dx?
consider IV therapy. Do the vice versa reveals elevated Hyperparathyroidism
for PO. PTH, elevated Ca Hyperparathyroidism dx key points:
Therapy revolves around heavy IVF and and decreased - can be primary, secondary, or tertiary
early bisphosphonates. PO4. What is the - primary involves a single autonomous
Furosemide or other loop diuretics can most likely dx? gland
be considered only after the pt has been [...] - secondary is 2/2 early CKD and an
loaded with fluid (loop diuretics cause inability to produce Vit D, hence an
calciuria). Giving loop diuretics too early appropriate increase in PTH is seen w/
can result in severe dehydration and hyperplastic glands
exacerbation of the hypercalcemia. - tertiary is 2/2 higher stage CKD where
Calcitonin IV is used in very severe there are now multiple autonomous
cases; it has rapid onset and rapid glands
elimination. - first you should diagnose hyperPTH as a
whole; labs will reveal elevated PTH,
elevated Ca, and decreased PO4
- next, differentiate between the three
types via sestamibi scan which will
reveal the glands that are involved (if 1, its
primary, if multiple, use the history)
- fibrosa cystica aka brown tumours
are a unique feature of hyperPTH and are
large bone lesions 2/2 overstimulated
osteoclasts
321 of 340
2116. Hyperparathyroidism Hyperparathyroidism can be primary, 2118. A pt w/ sarcoidosis A pt w/ sarcoidosis is found to have
can be primary, secondary, or tertiary. After labs have is found to have hypercalcemia. Labs reveal elevated
secondary, or reveals hyperPTH, how can we hypercalcemia. Ca, elevated PO4, and decreased PTH.
tertiary. After labs distinguish between the different types? Labs reveal What is the most likely cause of the
have reveals Sestamibi scan elevated Ca, hypercalcemia?
hyperPTH, how can elevated PO4, and Hypervitaminosis D 2/2 sarcoidosis
we distinguish decreased PTH. (i.e. granulomas)
between the different Hyperparathyroidism dx key points: What is the most Hypervitaminosis D key points:
types? - can be primary, secondary, or tertiary likely cause of the - while it's possible that someone just
[...] - primary involves a single autonomous hypercalcemia? takes too much Vitamin D (hehe), it's
gland [...] likely not going to be in the vignett cause
- secondary is 2/2 early CKD and an NBME ain't nice; hence, look for
inability to produce Vit D, hence an granulomatous dz (TB, sarcoid)
appropriate increase in PTH is seen w/ - the labs looks just like hypercalcemia of
hyperplastic glands malignancy, so if needed, order a
- tertiary is 2/2 higher stage CKD where 1,25-Vitamin D level to confirm; but if you
there are now multiple autonomous can use the history to discern, do that first
glands
- first you should diagnose hyperPTH as a
whole; labs will reveal elevated PTH,
elevated Ca, and decreased PO4
- next, differentiate between the three
2119. Hypercalcemia of Hypercalcemia of malignancy and
types via sestamibi scan which will
malignancy and hypervitaminosis D 2/2 granulomatous
reveal the glands that are involved (if 1, its
hypervitaminosis D disease both present with similar calcium
primary, if multiple, use the history)
2/2 granulomatous lab panels (increased Ca, increased PO4,
- fibrosa cystica aka brown tumours
disease both present decreased PTH). What lab test can be
are a unique feature of hyperPTH and are
with similar calcium ordered to discern between the two?
large bone lesions 2/2 overstimulated
lab panels 1,25-Vitamin D levels (to confirm
osteoclasts
(increased Ca, hypervitaminosis); or PTH-rp levels (to
increased PO4, confirm paraneoplastic syndrome)
decreased PTH).
What lab test can be
ordered to discern If you're asked this, use the history to
between the two? discern which one you need (i.e. history
2117. What is the What is the treatment for [...] suggestive of sarcoid/TB vs. a lung mass)
treatment for hyperparathyroidism?
hyperparathyroidism? Resection (watch for post-op
[...] hypocalcemia)
Watch for post-operative hypocalcemia
(i.e. hungry bone syndrome)
322 of 340
2120. An elderly pt that An elderly pt that has bedridden for 2124. A pt has perioral A pt has perioral tingling and Chvostek
has bedridden for years 2/2 debility develops tingling and sign. Labs reveal hypocalcemia.
years 2/2 debility hypercalcemia. Labs reveal increased Chvostek sign. Albumin levels are checked and true
develops Ca, increased PO4, and decreased Labs reveal hypocalcemia is confirmed. What is the
hypercalcemia. PTH. PMHx is only positive for trauma hypocalcemia. most appropriate next step in
Labs reveal causing debility and the pt is other wise Albumin levels are management?
increased Ca, healthy. What is the most likely cause for checked and true Treat (PO Ca + Vit D if nonemergent;
increased PO4, and the hypercalcemia? hypocalcemia is use IV Ca if emergent)
decreased PTH. Hypercalcemia of immobilization confirmed. What is
PMHx is only the most appropriate
positive for trauma next step in
causing debility and Just know this exists... management?
the pt is other wise [...]
healthy. What is the
most likely cause for
2125. What is the What is the treatment for hypocalcemia?
the hypercalcemia?
treatment for PO Ca + Vitamin D if nonemergent; use
[...]
hypocalcemia? IV Ca if emergent/severe
[...] The more deranged their labs (further
2121. A pt presents w/ A pt presents w/ hypercalemia. His FHx is from normal), the more you should
hypercalemia. His positive for calcium disorders. Labs consider IV therapy. Do the vice versa
FHx is positive for reveals elevated Ca (11-12) with normal for PO.
calcium disorders. PTH and PO4. Urinary Ca is decreased.
Labs reveals What is the most likely dx?
elevated Ca (11-12) Familial Hypocalciuric Hypercalcemia
with normal PTH (FHH)
common cause of hypoparathyroidism?
and PO4. Urinary
hypoparathyroidism? Iatrogenic (i.e. post-op from
Ca is decreased.
[...] thyroidectomy or parathyroidectomy)
What is the most
It can be autoimmune (very rare).
likely dx?
When it is s/p parathyroidectomy, it is a
[...]
normal physiological response as the
remaining, previously atrophied glands
2122. What are the What are the classical symptoms of need time to regain normal function.
classical symptoms hypocalcemia? When it is s/p thyroidectomy, it is the
of hypocalcemia? Perioral tingling; Chvostek sign; surgeon's error.
[...] Trousseau sign; tetany
2123. A pt has perioral A pt has perioral tingling and Chvostek 2127. A pt is found to have A pt is found to have hypocalcemia. Labs
tingling and sign. Labs reveal hypocalcemia. What is hypocalcemia. Labs reveal decreased Ca, decreased PTH.
Chvostek sign. the most appropriate next step in workup? reveal decreased What is the most likely dx?
Labs reveal Check albumin (to see what corrected Ca, decreased PTH. Hypoparathyroidism
hypocalcemia. Ca is) What is the most Note that PO4 is irrelevant in this case
What is the most likely dx? as the low PTH action means that it is
appropriate next [...] neither absorbed or excreted as a result
step in workup? of PTH.
[...]
323 of 340
2128. A pt is found to have A pt is found to have hypocalcemia. Labs 2133. What is the What is the treatment for iatrogenic
hypocalcemia. Labs reveal decreased Ca, decreased PO4, treatment for hypoparathyroidism?
reveal decreased and increased PTH. What is the most iatrogenic IV Calcium
Ca, decreased PO4, likely dx? hypoparathyroidism?
and increased PTH. Pseudohypoparathyroidism [...]
What is the most Remember, this is a poorly named When it is s/p parathyroidectomy, it is a
likely dx? disease and actually involves PTH normal physiological response as the
[...] insensitivity. remaining, previously atrophied glands
need time to regain normal function.
When it is s/p thyroidectomy, it is the
surgeon's error.
2129. A pt is found to have A pt is found to have osteopenia with a
Typically these pts need IV calcium as
osteopenia with a DEXA scan score of -2.0. You suspect
their hypocalcemia appears quickly
DEXA scan score of vitamin D deficiency. What lab test should
post-operatively and is symptomatic.
-2.0. You suspect be ordered to confirm?
vitamin D deficiency. 25-Vit D
What lab test should 2134. Vitamin D exists in Vitamin D exists in many forms. What
be ordered to many forms. What forms are referred to as Vitamin D2 and
confirm? forms are referred to Vitamin D3 respectively?
[...] as Vitamin D2 and D2 = 25-vitD; D3 = 1,25-vitD
Vitamin D3
respectively?
2130. What is the What is the treatment for vitamin D
[...] Order 25-vitD testing in vit D deficiency
treatment for vitamin deficiency?
Order 1,25-vitD testing in
D deficiency? High-dose PO vit D2 (+
granulomatous disease
[...] bisphosphonates if severe osteopenic)
(hypervitaminosis D)
2135. What symptoms are What symptoms are characteristic of

characteristic of severe hypo- or hypernatremia?
2131. Hypocalcemia is a Hypocalcemia is a part of the Ranson
severe hypo- or Coma; seizures
part of the Ranson criteria in pancreatitis. How can
hypernatremia?
criteria in hypocalcemia manifect in pancreatitis?
[...]
pancreatitis. How Sequestration
can hypocalcemia This is not a true calcium disorder but a
manifect in byproduct of the inflammation.
pancreatitis?
[...] 2136. What symptoms are What symptoms are characteristic of
characteristic of moderate hypo- or hypernatremia?
moderate hypo- or Non specific sxs such as nausea,
2132. Chronic kidney Chronic kidney disease involves an
hypernatremia? vomiting, AMS, headache
disease involves an inability to form 1,25-Vit D, even in early
[...]
inability to form stages. What is the treatment for this in
1,25-Vit D, even in CKD?
early stages. What is Ca + Vit D3
the treatment for this - add cinacalcet is a calcimimetic that
in CKD? works to decrease PTH levels while they
[...] are being replaced
- add sevelamer to mitigate the
hyperphosphatemia
324 of 340
2137. What is the What is the treatment for mild

2142. What is the equation What is the equation to determine serum
treatment for mild hypernatremia?
hypernatremia? PO water to determine serum osmolality?
[...] osmolality?
[...]
PO > IV replacement (if PO is feasible
and appropriate) 2143. A pt has A pt has hyponatremia. Serum osmolality
hyponatremia. is found to be high. What is the
Serum osmolality is diagnosis?
found to be high. Hypertonic hyponatremia
2138. What is the What is the treatment for severe What is the Make sure to correct Na for glucose
treatment for severe hypernatremia? diagnosis? (adjust Na by 1.6 for every 100 mg/dL
hypernatremia? IV D5W (or 1/2 NS) [...] Glc above 100)
[...] In severe hypernatremia, the pt needs
hypotonic solution.
2144. A diabetic pt is A diabetic pt is diagnosed w/ hypertonic

diagnosed w/ hyponatremia. How must be adjust
2139. What is the What is the treatment for moderate hypertonic measured Na for Glucose?
treatment for hyponatremia? hyponatremia. How Adjust Na by 1.6 for every 100 mg/dL
moderate IV NS must be adjust Glc above 100
hyponatremia? measured Na for
[...] Glucose?
[...] e.g. if bGlc is 300 and uncorrected Na is
130, corrected sodium is 130 + (2*1.6) =
133.2
Note that if the corrected Na is normal,
2140. Osmotic Osmotic Demyelination Syndrome
only fix the osmotic compound in
Demyelination (formerly Central Pontine Myelinolysis) is
question.
Syndrome (formerly a possible complication of rapid sodium
Central Pontine correction. How fast should sodium be
Myelinolysis) is a corrected to mitigate this risk?
possible No faster than 0.25 mmol/hr (unless
complication of rapid severe)
sodium correction.
How fast should
sodium be corrected
to mitigate this risk?
[...]
2141. A pt is found to have A pt is found to have hyponatremia.

hyponatremia. Serum osmolality is measured and found
Serum osmolality is to be normal. What is the diagnosis?
measured and found Isotonic Hyponatremia (aka
to be normal. What pseudohyponatremia)
is the diagnosis?
[...]
No need to do anything.
325 of 340
2145. A pt has A pt has hyponatremia. Serum osmolality 2148. A pt has A pt has hyponatremia. Serum osmolality
hyponatremia. is measured and found to be low. What is hyponatremia. is measured and found to be low. Further
Serum osmolality is the most appropriate next step in work Serum osmolality is history and physical makes you suspect
measured and found up? measured and found euvolemic hyponatremia. What 4
to be low. What is Assess volume status and clinical to be low. Further differentials in the "RATS" mnemonic
the most appropriate picture history and physical should be considered?
next step in work makes you suspect RTA; Addison's; Thyroid disease;
up? euvolemic SIADH
[...] Hypotonic hyponatremia is considered hyponatremia.
true hyponatremia and is separated into What 4 differentials
euvolemic, hypovolemic, and in the "RATS" Continue workup with the appropriate
hypervolemic types. To determine which, mnemonic should be tests for each:
assess volume status and the history. considered? - for RTA get a UA
- in hypervolemia look for JVD, edema, [...] - for Addison's measure cortisol
CHF, anasarca, etc - for thyroid measure TSH
- in hypovolemia look for dry mucous - for SIADH begin volume restriction
membranes, burns, fever, tachypnea, and gentle diuresis
hypotension, sepsis
2149. What is the What is the treatment for hypervolemic

2146. A pt has A pt has hyponatremia. Serum osmolality treatment for hyponatremia?
hyponatremia. is measured and found to be low. hypervolemic Diuresis
Serum osmolality is Physical exam reveals dry mucous hyponatremia?
measured and found membranes. What is the diagnosis? [...]
to be low. Physical Hypovolemic hyponatremia (correct
exam reveals dry with IVF)
mucous
membranes. What
2150. What type of fluids What type of fluids are typically used in
is the diagnosis?
are typically used in volume resuscitation?
[...]
volume NS or LR (as a bolus)
resuscitation?
2147. A pt has A pt has hyponatremia. Serum osmolality [...]
hyponatremia. is measured and found to be low.
Serum osmolality is Physical exam reveals JVD and edema.
2151. What type of fluids What type of fluids are typically used to
measured and found What is the diagnosis?
are typically used to replace free water?
to be low. Physical Hypervolemic hyponatremia (correct
replace free water? Hypotonic solutions such as PO free
exam reveals JVD with diuresis)
[...] water, D5W, (and technically 1/2 NS)
and edema. What is
the diagnosis?
[...]
326 of 340
2152. What is the criteria What is the criteria for the duration of
2156. A pt has chronic A pt has chronic diarrhea and you decide
for the duration of chronic diarrhea?
chronic diarrhea? > 4 weeks diarrhea and you that a workup is indicated. Stool osmolar
[...] Diarrhea duration key points: decide that a workup gap comes back elevated (> 50). Fecal
- < 2 weeks is considered acute; it is indicated. Stool fats are positive, but WBCs and RBCs
typically infectious and self-limiting osmolar gap comes are both negative. The diarrhea
- 2-4 weeks is considered subacute; can back elevated (> improves following making the pt NPO.
be infectious or other causes 50). Fecal fats are What subtype of diarrhea is most likely
- > 4 weeks is considered chronic; it is positive, but WBCs present in this pt?
typically due to a chronic underlying and RBCs are both Osmotic diarrhea
condition negative. The Osmotic diarrhea is 2/2 something in the
diarrhea improves lumen forcing water back into the lumen.
following making the This this typically seen in malabsorption.
2153. Chronic diarrhea is Chronic diarrhea is typically caused by a
pt NPO. What
typically caused by a chronic underlying condition. What 3
subtype of diarrhea
chronic underlying subtypes of diarrhea are typically chronic
is most likely present
condition. What 3 in nature?
in this pt?
subtypes of diarrhea Secretory; osmotic; inflammatory
[...]
are typically chronic
in nature?
2157. A pt presents w/ A pt presents w/ chronic diarrhea and you
[...]
chronic diarrhea and perform a workup. Fecal WBCs and RBCs
you perform a are positive. Mucous is positive. What
2154. Chronic diarrhea is Chronic diarrhea is typically either workup. Fecal WBCs subtype of diarrhea is typically involved?
typically either secretory, osmotic, or inflammatory. What and RBCs are Inflammatory diarrhea
secretory, osmotic, lab test(s) can be used to differentiate positive. Mucous is
or inflammatory. between the 3 in workup? positive. What
What lab test(s) can Stool osmolar gap; fecal fat; fecal subtype of diarrhea
be used to WBCs; FOBT is typically involved?
differentiate between
[...]
the 3 in workup?
[...]
2158. A pt is diagnosed A pt is diagnosed with chronic
with chronic inflammatory diarrhea. What is the best
2155. A pt has chronic A pt has chronic diarrhea and you decide inflammatory initial test in determining the definitive
diarrhea and you that a workup is indicated. Stool osmolar diarrhea. What is the diagnosis?
decide that a workup gap comes back normal. Fecal fats, best initial test in Colonoscopy (+ Bx)
is indicated. Stool WBCs and RBCs are all negative. There determining the
osmolar gap comes are no changes in diarrhea following definitive diagnosis?
back normal. Fecal making the pt NPO. What subtype of
[...]
fats, WBCs and diarrhea is most likely present in this pt?
RBCs are all Secretory diarrhea
2159. What is the best What is the best initial test for a
negative. There are
no changes in initial test for a gastrinoma?
diarrhea following Remember, secretory diarrhea involves gastrinoma? Gastrin level; then secretin challenge;
making the pt NPO. transformation of what is normally an [...] then localize the tumour via
What subtype of absorptive gut into a secretory gut via somatostatin receptor scintillography
diarrhea is most toxins or secretagogues. Hence consider or CT
likely present in this VIPoma, gastrinoma, carcinoid and C
pt? diff. Also considewr enterotoxic infectious
[...] diarrhea that has persisted.
327 of 340
2160. What is the best What is the best initial test for a VIPoma? 2166. What is the best What is the best overall test for celiac
initial test for a Serum VIP (if high, it is diagnostic; no overall test for celiac disease?
VIPoma? other test is needed) disease? EGD w/ Bx (to look for atrophic,
[...] [...] blunted villi)
2161. What is the best What is the best initial test for carcinoid
This is in fact how we confirm the dx.
initial test for tumour?
carcinoid tumour? Urinary 5-HIAA
[...]
2162. What subtype of What subtype of diarrhea is seen in a

2167. What is the What is the treatment for celiac disease?
diarrhea is seen in a gastrinoma?
treatment for celiac Avoid gluten (will take 3-4 months for
gastrinoma? Secretory
disease? antibodies to diminish)
[...]
[...]
2163. What suybtype of What suybtype of diarrhea is seen with a In those first 3-4 months, symptoms will
diarrhea is seen with VIPoma? taper.
a VIPoma? Secretory
[...]
2164. What subtype of What subtype of diarrhea is seen with a

diarrhea is seen with carcinoid tumour?
a carcinoid tumour? Secretory 2168. What is the etiology What is the etiology of whipple's disease?
[...] of whipple's Tropheryma whipplei
disease?
2165. The stool osmotic The stool osmotic gap is an important [...]
gap is an important measurement that aids in the workup of
measurement that diarrhea thought to be either secretory or
aids in the workup of osmotic. How is this calculated?
diarrhea thought to Stool Osmotic Gap = measured stool 2169. What is the best What is the best initial test for Whipple's
be either secretory osm - calculated stool osm initial test for Disease?
or osmotic. How is Whipple's Disease? EGD w/ Bx (will reveal PAS positive
this calculated? [...] macrophages or organisms on EM)
[...] Measured stool osm is usually given, if Note that you can order Blood/CSF PCR
not, assume it is 290. for the organism as well.
Calculated stool osm is determined by
2*(Nastool + Kstool)
Hence, if measured stool osm is given to
be 280, Nastool is 25 and Kstool is 25, the
stool osmotic gap is: 280 - 2(25+25) =
2170. Which malabsorptive Which malabsorptive disorder is
280-100 = 180.
disorder is associated with PAS positive
< 50 = secretory diarrhea
associated with PAS macrophages on Bx?
> 50-100 = osmotic diarrhea
positive Whipple's Disease
macrophages on
Bx?
[...]
328 of 340
2171. What is the What is the treatment for Whipple's 2176. A pt w/ osmotic A pt w/ osmotic diarrhea is suspected of
treatment for Disease? diarrhea is having pancreatic insufficiency. Which
Whipple's Disease? Long term abx (pick either Bactrim DS suspected of having diagnostic test can be used?
[...] or doxycycline) pancreatic D-xylose (although this is now just
insufficiency. Which being replaced w/ empiric enzyme
diagnostic test can replacement)
be used?
[...]
disorder is associated with bacteria begin seen on
associated with EM of a Bx?
bacteria begin seen Whipple's
on EM of a Bx? 2177. A pt is found to have A pt is found to have chronic osmotic
[...] chronic osmotic diarrhea, so a malabsorptive disorder is
Basically if you have a malabsorptive diarrhea, so a thought to be the cause. What is the best
question and they're showing a Bx under malabsorptive initial test to gauge for malabsorption?
electron microscopy: think whipples disorder is thought to Fecal fat
be the cause. What Fecal fat test for malabsorption:
is the best initial test - first give 100g fat/day
to gauge for - then collect 72 hrs stool (72 hrs after
disorder is associated with blunted villi at the
malabsorption? starting the test)
associated with mucosa in a biopsy?
[...] - then measure fecal fat
blunted villi at the Celiac (can also be seen in tropical
- if measured fecal fat is > 14g/24hrs
mucosa in a sprue)
there is malabsorption
biopsy?
- if measured fecal fat is < 14g/24hrs
[...]
there is no malabsorption
2174. A Carribean farmer A Carribean farmer presents w/ what you

presents w/ what suspect is celiac disease. Antibody testing
you suspect is celiac is negative, but an EGD with Bx reveals
disease. Antibody blunted, atrophic villi. You re-test for
testing is negative, antibodies and they are still negative.
but an EGD with Bx What is the most likely dx?
reveals blunted, Tropical sprue
atrophic villi. You
re-test for antibodies
and they are still
negative. What is the
most likely dx?
[...]
2175. What is the best What is the best diagnostic test for lactase
diagnostic test for deficiency?
lactase deficiency? None; dx clinically with cessation of
[...] s/s after enzyme replacement or
avoidance of dairy
329 of 340
2178. A pt is found to have A pt is found to have chronic osmotic 2181. A pt undergoes A pt undergoes routine, asymptomatic
chronic osmotic diarrhea, so a malabsorptive disorder is routine, screening for colon cancer via
diarrhea, so a thought to be the cause. A fecal fat test asymptomatic colonoscopy. Colonoscopy does not
malabsorptive reveals > 14g fecal fat/24 hrs, thereby screening for colon reveal polyps. When should screening
disorder is thought to confirming malabsorption. What is the cancer via resume?
be the cause. A fecal most appropriate next step? colonoscopy. q10yrs
fat test reveals > 14g D-Xylose testing (+ CT scan) Colonoscopy does
fecal fat/24 hrs, not reveal polyps.
thereby confirming When should
malabsorption. What The idea here is that now that screening resume?
is the most malabsorption is confirmed, we should [...]
appropriate next rule out (or in) pancreatic insufficiency
step? before getting an EGD and Bx (i.e.
2182. A pt undergoes A pt undergoes routine, asymptomatic
[...] invasive test).
routine, screening for colon cancer via
D-Xylose test key points:
asymptomatic colonoscopy. Colonoscopy reveals
- this tests whether or not the GI mucosa
screening for colon polyps that are noninvasive. They are
has integrity and hence is able to absorb
cancer via resected. When should screening
the xylose
colonoscopy. resume?
- xylose does not require enzymes to
Colonoscopy q1-3yrs
be absorbed
reveals polyps that
- after administration, urine is checked to
are noninvasive.
gauge absorption
They are resected.
- if D-xylose is absorbed, pancreatic
When should
insufficiency is the cause, as
screening resume?
absorption confirms that the mucosa is
[...]
intact (hence the malabsorptive disorders
are all ruled out)
2183. A pt undergoes A pt undergoes routine, asymptomatic
routine, screening for colon cancer via
2179. At what age should At what age should routine colon cancer
asymptomatic colonoscopy. Colonoscopy reveals
routine colon cancer screening take place?
screening for colon polyps that are not cancerous. They are
screening take 50
cancer via resected. When should screening
place?
colonoscopy. resume?
[...]
Colonoscopy q3-5yrs
reveals polyps that
are not cancerous.
They are resected.
2180. The apple core sign The apple core sign on barium enema is When should
on barium enema is associated with colon cancer. What stage screening resume?
associated with does the cancer have to be for this sign to [...]
colon cancer. What be present?
stage does the Stage III (at least)
cancer have to be
for this sign to be
present? This is why barium enema is no longer
[...] used to screen.
330 of 340
2184. A pt undergoes A pt undergoes routine, asymptomatic 2189. Hereditary Hereditary Nonpolyposis Colon Cancer
routine, screening for colon cancer via Nonpolyposis Colon (HNPCC; Lynch syndrome) is a genetic
asymptomatic colonoscopy. Colonoscopy reveals Cancer (HNPCC; cancer syndrome involving defects in
screening for colon polyps that are invasive. What is the Lynch syndrome) is DNA mismatch repair. Which cancers are
cancer via most appropriate next step? a genetic cancer seen in Lynch syndrome?
colonoscopy. Staging (via CT) syndrome involving Colon; endometrial; ovarian
Colonoscopy defects in DNA In Lynch syndrome look out for the Meryl
reveals polyps that mismatch repair. Lynch CEO as they may have Colon,
are invasive. What Which cancers are Endometrial, and Ovarian cancer.
is the most seen in Lynch
appropriate next syndrome?
step? [...]
[...]
2190. Which genetic Which genetic cancer syndrome involves

2185. What stage of colon What stage of colon cancer involves cancer syndrome brain and colon cancers?
cancer involves extracolonic involvement? involves brain and Turcot syndrome
extracolonic Stage III and above colon cancers?
involvement? [...]
[...]
2186. What is the What is the treatment for noncancerous

treatment for colonic polyps? 2191. Which cancer Which cancer syndrome involves jaw and
noncancerous Polypectomy syndrome involves colon cancers?
colonic polyps? jaw and colon Gardner syndrome
[...] cancers?
[...]
2187. What is the What is the treatment for stage I and II

treatment for stage I colon cancer? 2192. Which cancer Which cancer syndrome is associated
and II colon cancer? Colectomy or colon resection syndrome is with small intestine tumours, colonic
[...] associated with hamartomas and hyperpigmented spots
small intestine on the buccal mucosa?
tumours, colonic Peutz-Jeghers Syndrome
hamartomas and The hyperpigmented spots are a
hyperpigmented giveaway. Look for that in relevant
spots on the questions.
2188. What is the What is the treatment for stage III or IV
buccal mucosa?
treatment for stage colon cancer?
[...]
III or IV colon Chemotherapy (with FOLFOX) +
cancer? bevacizumab
[...]
2193. Which inflammatory Which inflammatory bowel disorder is
Bevacizumab is a VEGF inhibitor. bowel disorder is associated with superficial inflammation of
associated with the mucosa only at the colon only?
superficial UC
inflammation of the
mucosa only at the
colon only?
[...]
331 of 340
2194. Which IBD is Which IBD is associated with ashkenazi 2198. Which monoclonal Which monoclonal antibody can be used
associated with jews? antibody can be to help severe cases of ulcerative colitis?
ashkenazi jews? Both UC and CD used to help severe Infliximab
[...] cases of ulcerative
colitis?
[...] Ulcerative Colitis tx key points:
- for mild disease, being with
2195. Which IBD is Which IBD is associated with primary
mesalamine or sulfasalazine and
associated with sclerosing cholangitis and p-ANCA?
continue them as maintenance therapy;
primary sclerosing UC
they prevent flares
cholangitis and
- for flares, use steroids
p-ANCA?
- for moderate severity flares, use PO
[...]
steroids and then transition to DMARDS
(e.g. AZT) when you taper off steroids;
2196. What is the best What is the best diagnostic test for return to maintenance therapy after the
diagnostic test for ulcerative colitis? flare ends
ulcerative colitis? Colonoscopy + Bx - for severe flares, use IV steroids and
[...] Remember, UC involves the colon only, then transition to infliximab or
so you cannot get an EGD. cyclosporine or resection to kill the flare
On biopsy, look for contiguous - for UC, colon resection is curative
inflammation limited to the mucosa
and colon only and the presence of
2199. Ulcerative colitis Ulcerative colitis involves an increased
crypt abscesses. There is also an
involves an risk of cancer as there is longstanding
absence of granulomas.
increased risk of inflammation. As such, colonoscopy
cancer as there is screening is important. When should it
longstanding begin?
2197. What is the What is the treatment for mild ulcerative inflammation. As Start 8 yrs after diagnosis and
treatment for mild colitis? such, colonoscopy continue with q1y screening
ulcerative colitis? 5-ASA compounds such as screening is
[...] mesalamine or sulfasalazine important. When
should it begin?
[...]
Ulcerative Colitis tx key points:
- for mild disease, being with
2200. Which IBD is Which IBD is associated with transmural
mesalamine or sulfasalazine and
associated with inflammation that can occur anywhere in
continue them as maintenance therapy;
transmural the GI tract?
they prevent flares
inflammation that CD
- for flares, use steroids
can occur anywhere
- for moderate severity flares, use PO
in the GI tract?
steroids and then transition to DMARDS
[...]
(e.g. AZT) when you taper off steroids;
return to maintenance therapy after the
flare ends 2201. Which IBD is Which IBD is associated with bloody
- for severe flares, use IV steroids and associated with diarrhea?
then transition to infliximab or bloody diarrhea? UC
cyclosporine or resection to kill the flare [...]
- for UC, colon resection is curative
332 of 340
2202. Which IBD is Which IBD is associated with non-bloody, 2206. Treatment of Crohn's Treatment of Crohn's Disease can be
associated with watery diarrhea? Disease can be complex. In general, what do we use as
non-bloody, watery CD complex. In general, maintenance therapy in mild CD?
diarrhea? what do we use as DMARDS (e.g. MTX, AZT)
[...] maintenance therapy
in mild CD?
[...]
diagnostic test for Crohn's Disease?
Crohn's Disease? Biopsy (look for transmural 2207. What is the What is the treatment for cirrhosis?
[...] inflammation with noncaseating treatment for Only transplant is curative
granulomas) cirrhosis?
Crohn's Disease dx key points: [...]
- CD is trickier than UC because the
lesions can be anywhere in the GI tract
2208. What is the best What is the best initial test for cirrhosis?
(mouth to rectum)
initial test for RUQ U/S
- hence, the modality of testing depends
cirrhosis?
- if lesions are apparent in the colon, pick
[...]
colonoscopy
- if lesions are not apparent in the colon,
consider pillcam endoscopy to localize 2209. What is the best What is the best overall test for cirrhosis?
where the inflammation may be found overall test for Biopsy
- on biopsy, looks for transmural cirrhosis?
inflammation with noncaseating [...]
granulomas
2210. Cirrhosis involves an Cirrhosis involves an increased risk of
increased risk of developing hepatocellular carcinoma.
2204. Which IBD is Which IBD is associated with the developing What is the HCC screening protocol in pts
associated with the formation of fistulae? hepatocellular w/ cirrhosis?
formation of fistulae? CD carcinoma. What is AFP + RUQ U/S q6mo
[...] the HCC screening
protocol in pts w/
This is because the inflammation seen in cirrhosis?
CD is transmural. As a result, it can [...]
extend into adjacent structures and
facilitate the formation of a fistula. Most 2211. What is the best What is the best initial test to detect
commonly it is a perirectal abscess. initial test to detect ascites?
ascites? U/S looking for the fluid
2205. Which IBD is Which IBD is associated with a [...]
associated with a cobblestoning appearance of the mucosa
cobblestoning on gross specimen?
appearance of the CD 2212. What is the best What is the best overall test to look for
mucosa on gross overall test to look ascites?
specimen? for ascites? Paracentesis
[...] [...]
333 of 340
2213. Paracentesis and Paracentesis and analysis of the aspirate 2216. What is the What is the diagnostic test for
analysis of the is almost always involved in the workup diagnostic test for spontaneous bacterial peritonitis?
aspirate is almost and management of ascites. What clinical spontaneous Paracentesis w/ gram stain and Cx (>
always involved in score obtained from the aspirated fluid bacterial peritonitis? 250 PMNs is diagnostic)
the workup and aids in determining the cause of ascites? [...]
management of SAAG score
ascites. What clinical The SAAG score and ascites key points:
score obtained from - SAAG = serum albumin - ascites
the aspirated fluid albumin
aids in determining - if SAAG > 1.1, the cause is portal HTN
2217. What is the What is the treatment for spontaneous
the cause of and you should consider cirrhosis, R
treatment for bacterial peritonitis?
ascites? heart failure, or Budd-Chiari as the
spontaneous FQ; or 3rd gen cephalosporin
[...] etiology
bacterial peritonitis?
- if SAAG < 1.1, the cause is non-portal
[...]
HTN and you should consider TB or
Ppx with a FQ
cancer as the etiology
Typically involves GNR (70%; E. coli and
Klebsiella) and GPC (30%; Strep
pneumo)
2214. What is the What is the treatment for ascites?
treatment for (see below)
2218. Both spontaneous Both spontaneous and secondary
ascites? Ascites management key points:
and secondary bacterial peritonitis are possible
[...] - in general, you should correct the
bacterial peritonitis complications of ascites. How are they
underlying disease
are possible told apart in the workup?
- therapeutic paracentesis can help in
complications of > 250 PMNs with polymicrobial Cx
all cases if needed
ascites. How are
- in everyone, you should limit Na intake
they told apart in the
to max 2g/day and limit H2O intake to
workup?
max 2L/day
[...]
- in cirrhosis, you should also add
diuretics (furosemide and
spironolactone) 2219. What is the What is the treatment for secondary
- TIPS can be considered, but is typically treatment for bacterial peritonitis?
only done in refractory cases w/ varices; secondary bacterial FQ or 3rd gen cephalosporin + MTZ;
TIPS has an increased risk of hepatic peritonitis? ExLap
encephalopathy (post-procedure) [...]
Remember, secondary BP is 2/2 bowel

perforation and involves polymicrobial
2215. What is the What is the treatment for ascites 2/2
infection. We must add MTZ to
treatment for ascites cirrhosis?
cephalosporin to cover anaerobes.
2/2 cirrhosis? (see below)
[...]
Ascites 2/2 cirrhosis tx key points:

- limit Na intake max 2g/day
- limit H2O intake max 2L/day
- diuresis with spironolactone and
furosemide
- therapeutic paracentesis if needed
334 of 340
2220. Spontaneous/secondarySpontaneous/secondary bacterial 2224. What type of GI What type of GI bleed is associated with
bacterial peritonitis peritonitis are possible fatal complications bleed is associated hematemesis?
are possible fatal of ascites. What is the criteria for with hematemesis? UGIB
complications of prophylaxis? [...]
ascites. What is the Any Hx of SBP; total protein < 1.0 in
criteria for the tapped fluid
prophylaxis?
[...]
Prophylax with fluoroquinolones.
2221. What imaging test is What imaging test is able to diagnose 2225. What type of GI What type of GI bleed is associated w/
able to diagnose hepatocellular carcinoma? bleed is associated melena?
hepatocellular Triple phase CT w/ melena? Typically UGIB; possible LGIB
carcinoma? [...]
[...]
Do not need biopsy, but then again, Remember, only hematemesis is
nothing beats the biopsy. specific to one type of GIB (UGIB).
While melena is more often indicative of
UGIB, it can be LGIB as well (imagine a
2222. Hepatopulmonary Hepatopulmonary syndrome is a possible
jejunal or ileal bleeding source).
syndrome is a complication of cirrhosis that is classically
While Hematochezia is more often
possible characterized by platypnea (the vice
indicative of LGIB, it can be due to a very
complication of versa of orthopnea; SOB while erect).
bad UGIB as well.
cirrhosis that is What is the diagnostic test for
classically hepatopulmonary syndrome?
characterized by 2D Echo w/ bubble study (will reveal
platypnea (the vice bubbles in 3-6 beats)
versa of orthopnea;
SOB while erect).
What is the
diagnostic test for
hepatopulmonary
syndrome?
[...]
2223. What anatomical What anatomical structure is used as the

structure is used as boundary between the "upper" and
the boundary "lower" GI tracts?
between the "upper" Ligament of Treitz (used to discern
and "lower" GI UGIB and LGIB)
tracts?
[...]
335 of 340
2226. Stabilization should Stabilization should always be the first 2227. A pt presents w/ GI A pt presents w/ GI bleed. You stabilize
always be the first step in management of a pt w/ a GI bleed. bleed. You stabilize the pt and your chief resident is
step in management What is involved in stabilization? the pt and your chief impressed when he arrives. He asks you
of a pt w/ a GI bleed. In general: 2 large bore IVs, IVFs, IV resident is what we should do next. What is the most
What is involved in PPIs, CBC, Type + cross, PT/PTT; (see impressed when he appropriate next step in management?
stabilization? below) arrives. He asks you NG lavage; then EGD regardless of
[...] what we should do what the NG yields
next. What is the
Stabilization in GI Bleed key points: most appropriate
- always done first next step in NG Tube and GI bleed key points:
- involves both supportive and management? - 30% of UGIB will have a negative NG
prophylactic measures: [...] lavage, making it a pretty bad diagnostic
--- obtain 2 peripheral, large bore IV test; for this reason you will still order an
access points EGD regardless of what the NG shows
--- start IVF - so then, if the NG even worth doing?
--- start IV PPIs; PPIs in this setting helps - on the test, yes
the stomach/esophagus heal (by - on the wards, yes
increasing pH) if the bleeding source is --- the NG tube in real life is not just
gastric/esophageal; if it isn't, the PPIs do diagnostic, it is prognostic
not cause any harm, so it is better to give --- if the NG lavage is positive and the
it empirically at the start bleed clears with NG alone, the EGD can
--- order a CBC to monitor changes wait (since the GI dudes hate coming in
--- order a blood type and cross to anyway for some reason lol); likewise, if
prepare for tranfusions; if severe enough, the bleed is ongoing, intervention needs
go ahead and order blood to happen sooner
--- order coags (PT/PTT) - at the end of the day, still place the NG
--- if mesenteric ischemia is suspected, tube, but know that the EGD will be done
get an EKG regardless and will always be the next
--- if the pt is a known cirrhotic, start IV step
octreotide (to target variceal bleeding)
and IV ceftriaxone/FQ (to ppx against
SBP)
2228. What is the best What is the best diagnostic test for an
diagnostic test for an upper gi bleed?
upper gi bleed? EGD
[...]
Esophagogastroduodenoscopy.....
SCHWAAAA
336 of 340
2229. A pt is found to have A pt is found to have a GI bleed. The pt is 2232. A pt w/ cirrhosis A pt w/ cirrhosis presents w/
a GI bleed. The pt is stabilized and the appropriate presents w/ hematemesis. EGD reveals esophageal
stabilized and the medications/infusions/labs are performed. hematemesis. EGD varices. What is the treatment?
appropriate EGD rules out UGIB. What is the next reveals esophageal (see below)
medications/infusions/labs
step in workup? varices. What is the
are performed. EGD Assess bleeding rate treatment?
rules out UGIB. [...] Varices tx key points:
What is the next step - varices can be approached in steps
in workup? Once EGD has ruled out UGIB (effectively - first give IV octreotide (to reduce portal
[...] ruling in LGIB), we need to assess the system pressures) and IV ceftriaxone/FQ
severity of the bleeding before deciding (to ppx against SBP) before EGD
what to do next: - an EGD should be done emergently and
- if the bleed is > 2 cc/min (1 unit pRBCs can involve banding or cautery
q4h), the bleed is brisk; order - you can bridge to TIPS via balloon
arteriogram and treat w/ embolization tamponade of the varices
- if the bleed is < 0.5 cc/min (1 unit - definitive therapy is liver transplant;
pRBCs q1d), the bleed is slow; order you can bridge to transplant via a TIPS
colonoscopy procedure
- if the bleed is slow and in the small - propanolol low dose (10 mg tid) can be
intestine, order a tagged RBC scan or given to shrink varices and decrease the
pill-cam endoscopy risk of bleeding
diagnostic test for Mallory-Weiss Tears?
Mallory-Weiss EGD
2230. A pt is found to have A pt is found to have a GI bleed. The pt is Tears? Few things to remember with
a GI bleed. The pt is stabilized and the appropriate [...] Mallory-Weiss:
stabilized and the medications/infusions/labs are performed. - typically seen s/p binge drinking that
appropriate EGD rules out UGIB. The bleeding rate is induces vomiting; hence not really seen in
medications/infusions/labs
brisk and found to be > 2 cc/min. What is alcoholics or bulimics (that's boerhaave's)
are performed. EGD the next step in workup? - the tears are only mucosal and
rules out UGIB. The Arteriogram (w/ self-limiting
bleeding rate is brisk embolization/cauterization)
and found to be > 2
cc/min. What is the
[...]
2231. What is the best What is the best initial test for esophageal
initial test for varices?
esophageal varices? EGD (also best overall)
[...]
337 of 340
2234. What is the best What is the best initial test for 2237. A pt w/ AFib and A pt w/ AFib and CAD presents c/o of
initial test for Boerhaave's Syndrome? CAD presents c/o of abdominal pain. Physical exam reveals a
Boerhaave's Gastrografin swallow abdominal pain. tender abdomen exhibiting paid that is
Syndrome? Boerhaave's key points: Physical exam out of proportion to the exam. You
[...] - involves transmural tears and is hence reveals a tender suspect mesenteric ischemia. What is the
seen in the "full time vomiters" such as abdomen exhibiting best test?
alcoholics and bulimic pts paid that is out of CT angiogram
- typically pts are very sick w/ fever, proportion to the If you wait for a bloody bowel movement,
mediastinitis, esophageal crepitus, exam. You suspect the bowel is already dead.
leukocytosis, etc. mesenteric If you do a colonoscopy, what are you
- best initial test is the gastrografin ischemia. What is gonna see? You'll only see dead bowel, if
swallow; remember, this involves a literal the best test? it's already dead.
hole in the esophagus; so if present, the [...] CT angiogram localizes the lesion.
swallow will leave; gastrografin is water Tx w/ resection or revascularization.
soluble and less irritating to the
mediastinum and hence should be done
first before barium; if positive, the
2238. Both mesenteric Both mesenteric ischemia and ischemic
diagnosis is made
ischemia and colitis can present similarly (painful,
- if gastrografin is negative, follow up with
ischemic colitis can bloody bowel movement in acute;
barium swallow
present similarly post-prandial abdominal pain in chronic).
- if still negative, follow up with EGD
(painful, bloody What is the difference in their pathology?
- Tx is to assess the underlying disease
bowel movement in (see below)
and repair the tear surgically
acute; post-prandial Mesenteric Ischemia vs. Ischemic
abdominal pain in Colitis key points:
2235. What is the best What is the best diagnostic test for a chronic). What is the - Mesenteric Ischemia can be called the
diagnostic test for a Dieulafoy's Lesion? difference in their "CAD of the gut" and is typically 2/2
Dieulafoy's Lesion? EGD pathology? atherosclerosis
[...] [...] - Ischemic colitis is typically 2/2
hypotension and involves watershed
areas
- both are treated similarly with resection
2236. What is the What is the treatment for a Dieulafoy's
of the ischemic/necrotic segments
treatment for a lesion?
Dieulafoy's lesion? Resection
[...]
initial therapy for anaphylaxis?
anaphylaxis? Epi + H1 blocker + H2 blocker +
[...] glucocorticoids; intubation or
cricothyroidotomy if needed
2240. What compliment What compliment protein deficiency can

protein deficiency cause angioedema?
can cause C1 esterase inhibitor deficiency
angioedema?
[...]
338 of 340
2241. What is the best What is the best initial test for 2247. What is the What is the treatment for Severe
initial test for angioedema? treatment for Severe Combined Immunodeficiency (SCID)?
angioedema? C2 and C4 compliment levels; C1 Combined BMT; Abx as indicated for infections
[...] esterase inhibitor levels Immunodeficiency
(SCID)?
[...] SCIDs is a combined immunodeficiency,
2242. What is the acute What is the acute therapy for
so both B and T cells are affected.
therapy for angioedema?
Remember:
angioedema? Airway protection first; then FFP or
- low B cells results in sinopulmonary
[...] ecallantide
infections
Remember, hereditary angioedema
- low T cells results in increased viral
does not respond to glucocorticoids.
and opportunistics
2248. What primary What primary immunodeficiency is

immunodeficiency is associated w/ anaphylaxis when receiving
diagnostic test for Common Variable Immunodeficiency
associated w/ blood transfusions?
Common Variable (CVID)?
anaphylaxis when IgA deficiency
Immunodeficiency Immunoglobulin levels
receiving blood
(CVID)? CVID involves normal number of B cells
transfusions?
[...] w/ normal lymphoid tissue but there is a
[...] The transfused blood had IgA, which
decreased output from B cells.
causes anaphylaxis.
This decrease in immunoglobulin levels
These pt's should receive IgA deficient
results in recurrent sinopulmonary
blood.
infections
2249. What is the What is the treatment for IgA deficiency?

treatment for IgA Supportive only (i.e. treat infections as
2244. What is the What is the treatment for Common
deficiency? they arise)
treatment for Variable Immunodeficiency (CVID)?
[...]
Common Variable Regular IVIG transfusion; abx as
Immunodeficiency indicated for infections
Giving IVIG in IgA deficiency is not helpful
(CVID)?
as the amount of IgA in the therapeutic
[...]
producct is not significant enough to have
therapeutic effect.
2245. [...] is a primary X-linked (Bruton's) On top of that, the IgA in IVIG may be
immunodeficiency Agammaglobulinemia is a primary enough to cause anaphylaxis in the IgA
seen in male immunodeficiency seen in male children deficient pt.
children and and involves an absence of tonsils,
involves an absence adenoids, lymph nodes and possible
2250. What primary What primary immunodeficiency is
of tonsils, even spleen.
immunodeficiency is associated with reccurent skin infections
adenoids, lymph Tx is long term IVIG
associated with with Staphylococcus?
nodes and possible
reccurent skin Hyper IgE syndrome
even spleen.
infections with
Staphylococcus?
2246. What is the What is the treatment for X-linked [...]
treatment for (Bruton's) Agammaglobulinemia?
X-linked (Bruton's) Long-term IVIG
Agammaglobulinemia?
[...]
339 of 340
2251. Which primary Which primary immunodeficiency is 2257. What is the best What is the best initial test for ovarian
immunodeficiency is associated with thrombocytopenia and initial test for ovarian cancer?
associated with eczema? cancer? U/S or CT
thrombocytopenia Wiskott-Aldrich Syndrome [...]
and eczema?
[...] Most accurate is biopsy
Tx w/ BMT
2252. What is the What is the treatment for Wiskott-Aldrich

treatment for Syndrome?
Wiskott-Aldrich BMT
Syndrome?
[...]
diagnostic test for Chronic Granulomatous Disease?
Chronic Nitroblue Tetrazolium testing (will
Granulomatous detect the decrease in respiratory
Disease? burst)
[...]
Remember, CGD involves a deficiency in

NADPH oxidase, the enzyme that makes
superoxide.
2254. Which primary Which primary immunodeficiency is

immunodeficiency is associated with lymph nodes that have
associated with purulent material leaking out?
lymph nodes that Chronic Granulomatous Disease (CGD)
have purulent Apthuous ulcers and inflammation of
material leaking the nares are also common.
out?
[...]
2255. What is the What is the treatment for mild bullous

treatment for mild pemphigoid?
bullous pemphigoid? Dapsone + nicotinamide
[...]
2256. From the From the recommended treatment of

recommended acute gout, which drug is the best for
treatment of acute prophylaxis?
gout, which drug is Colchicine
the best for
prophylaxis?
[...] Remember that diarrhea is the
dose-limiting side effect.
340 of 340

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Anki Glossary: Brosencephalon's Internal Medicine (2257 cards) Generated on 2017-10-08

15. A pt presents c/o A pt presents c/o chest pain w/

27. What is the treatment What is the treatment for polycythemia

30. How does How does reticulocyte count typically

33. What is the treatment What is the treatment for urticaria?

49. A 60 y/o, A 60 y/o, posmenopausal, female pt is

56. What is the treatment What is the treatment for moderate

60. A pt is diagnosed w/ A pt is diagnosed w/ secondary adrenal

61. How do IgE levels How do IgE levels change in atopic

69. Paroxysmal nocturnal Paroxysmal nocturnal hemoglobinuria

74. Which HAART drug Which HAART drug is routinely given

75. If a pt is suspected to If a pt is suspected to have meningitis, but

78. A pt presents with A pt presents with fever, cough, night

88. Which area of the Which area of the skin is affected in

XRay is not useful as there is no correlation

96. What is the genetic What is the genetic inheritance of sickle

100. A pt presents c/o of A pt presents c/o of an evolving rash. He

104. Septic arthritis is Septic arthritis is typically split into

Other options include milnacipran (SNRI)

121. A pt presents w/ A pt presents w/ hypercalcemia. She is

Do not give both together (hemorrhage

Some studies have shown an association

150. Which class of drugs Which class of drugs can be used as

174. [...] is a neurological Postherpetic neuralgia is a neurological

194. Which specific type Which specific type of seizure involves

193. Which specific type Which specific type of seizure involves

199. Which antiepileptic is Which antiepileptic is preferred in tic

e.g. succinylcholine + midazolam +

202. When is an EEG When is an EEG indicated in the workup of

Seen in 50% of cases

226. What is required for What is required for the Dx of

228. What is the treatment What is the treatment that reverses

230. What is the treatment What is the treatment for hydrocephalus

Contrast is not used when looking for

233. What percentage of What percentage of subarachnoid

247. Which diagnostic Which diagnostic procedure is essential in

255. Which Which neurocutaneous disorder involves

257. Which Which neurocutaneous disorder commonly

269. [...] is a neurological Cogwheel rigidity is a neurological finding

271. What is What is micrographia?

288. [...] is a cause of Lewy Body Dementia is a cause of

284. Tyramine-containing Tyramine-containing foods can precipitate

311. Which drug is Which drug is preferred in the treatment of

310. Which drug is Which drug is preffered for the treatment of

315. A pt w/ multiple A pt w/ multiple sclerosis develops

318. Which diagnostic test Which diagnostic test confirms ALS?

The Dx is typically clinical. EMG confirms.

332. What is the treatment What is the treatment for

340. A pt presents A pt presents complaining of bilateral foot

344. Facial/Bell palsy can Facial/Bell palsy can sometimes involves

EMG will show decreased amplitude w/

383. Which test is able to Which test is able to offer definitive

384. Which organic cause Which organic cause of dementia is

386. Which organic cause Which organic cause of dementia is

389. How do the brain CT How do the brain CT findings in

Typical CP must involve the following:

413. Which type of Which type of myocardial infarction is

414. A pt presents to the A pt presents to the ER w/ chest pain.

Achieve with statins

Achieve with ACE-I and beta-blockers

433. What is the What is the MONA-BASH mnemonic for

439. What is the most What is the most common cause of

FHx and CAD risk:

Brosencephalon's Internal Medicine

Brosencephalon's Internal Medicine