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Where do 90% of AAA (abdominal aortic aneurysm) occur?
What are the seven “P”s of arterial embolism?
- Pistolshot (acute onset)
- Polar (cold)
What is the most likely etiology of superficial thrombophlebitis in the upper extremities?
Cancer (i.e. pancreatic cancer)
Hx: 45 y/o female who just had knee surgery drives with her husband for two days to see her mother in California. What is she most likely at risk for?
DVT (deep vein thrombosis)
If looking at a picture (X-ray) of a tall, thin male with issues…
…start thinking pneumothorax
What is a condition in which there is marked daily weight gain?
What is a growth measurement that acts as a high risk factor for cardiovascular disease?
Waist circumference > 40 inches in men and >35 inches in women.
Know how to read a 12-lead EKG.
Is the hepatojugular reflux indicative of right heart failure?
No, erroneously suggested since all patients will have elevation of the VP with this maneuver. However, it can be exaggerated when right heart failure is present.
When reading an EKG, a “spindle-like” appearance of the EKG rhythm is indicative of what condition?
Torsades de pointes—changing ventricular waveforms that appear as a series of QRS complexes that rotate about the baseline b/w upright deflections & downright deflections
3% of patients presenting with angina and ST-elevation have this type of angina…
“variant” angina pectoris i.e. Prinzmetal’s angina—resting angina associated with ST-segment elevation caused by focal coronary artery spasm; reduced CFR (coronary flow reserve) due to dynamic stenosis of coronary arteries
What are some classic signs of infective endocarditis (IE)?
- Osler’s nodes—purplish/erythematous subcutaneous papules or nodules (2-15 mm) that may appear on the pads of fingers & toes; painful; may be the result of embolic/immunologic phenomena
- Janeway lesions—painless hemorrhagic plaques that may develop on the palms of hands/soles of feet
- Spingter hemorrhages—thin, linear hemorrhages found under the nail beds of the fingers/toes
What is the Duke Clinical Criteria for IE?
- Major criteria
- Positive blood culture
- Typical organism in 2 separate cultures OR persistently positive
- Cultures >12 hours apart
- Endocardium involved
- Positive echo (vegetation, abscess, dehiscence of prosthetic valve) OR
- New valvular regurgitation (change in murmur not significant)
- Minor criteria
- Predisposition—IV drug abuse, cardiac lesion, prosthetic valves
- Fever > 38? C
- Vascular/immunological phenomena
- Positive blood cultures that don’t meet major criteria
- Positive echo that doesn’t meet major criteria
What are the Jones Criteria (1992) for RHD (rheumatic heart disease)?
- Major manifestations (“specs”)
- Sydenham’s chorea
- Erythema marginatum
- Subcutaneous nodules
- Minor manifestations (“peach”)
- Pyrexia (fever)
- ECG changes (long PR)
- CRP or ESR ?
- Hx of previous RF
- MUST have evidence of preceding Group A strep infection
- Diagnosis requires: 2 major criteria OR 1 major & 2 minor criteria
What heart condition literally means someone could “die of a broken heart”?
- Stress/Tako-Tsubo Cardiomyopathy—transient, reversible LV dysfuntion is response to profound psychological/emotional stress
- Middle age women present w/acute STEMI, but have no CAD
- Tx for HF?rapid improvement
What are the main characteristics of Tetrology of Fallot?
- Ventricular septal defect (VSD)
- Dextroposition of the aorta which communicates with the septal defect
- Pulmonic stenosis, small pulmonary trunk, or both
- Hypertrophy of the right ventricle
What are the Vaughn-Williams classifications?
- A drug classification of various types of antiarrhythmic drugs.
- Class I (IA, IB, IC)—Sodium channel blockers
- Class II—Beta blockers
- Class III—Potassium channel blockers
- Class IV—Calcium channel blockers (non-DHP)
What characterizes Sjögren’s syndrome, and what are the treatment and the prognosis?
- Keratoconjunctivitis sicca (dry eye syndrome)
- Dryness of mucous membranes
- Telangiectases or purpuric spots on the face (tiny little bruises)
- Bilateral parotid enlargement
- Seen most often in menopausal/post-menopausal women
- Often associated with:
- Rheumatoid arthritis
- Raynaud phenomenon
- Dental caries
- Treatment—symptomatic and supportive
- Artificial tears applied frequently
- Sipping water frequently or sugar-free gum or hard candy
- Good oral hygiene
- Prognosis—usually benign disease, consistent with a normal life span
- Increased incidence of lymphoma in patients with more severe symptoms
- What is a Kayser-Fleischer ring?
- A golden or greenish copper ring around the cornea (abnormal corneal deposit). Often occurs in Wilson’s disease, in which there is an excess of copper in the body.
What do Horner Syndrome and Argyll Robertson pupils have in common?
- They are both conditions with abnormal papillary reflexes.
- Horner Syndrome
- Ptosis, miosis, and anhidrosis on the side of a sympathetic palsy
- The affected pupil is slow to dilate in dim light
- Argyll Robertson pupils
- Miosis, irregular shape, and a loss of the direct & consensual papillary reflex to light
- Normal papillary constriction to a near vision effort (accommodation)
- Seen in nuerosyphilis
How would you identify non-proliferative diabetic retinopathy (NPDR) in a patient?
Use an Amsler grid to help distinguish diabetic macular edema that causes blurring, darkening, distorted images, etc.
What bacterial pathogens normally cause acute otitis media (AOM)?
- Present in ½ to ¾ by culture or DNA tests
- Strep. pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Strep. pyogenes
- Others (S. aureus, P. aeruginosa)
What is the most common viral cause of AOM?
RSV—always go with rhinovirus if an option on MC question.
What are the Weber and Rinne tests?
- Using a 512 cps tuning fork is best
- Weber test—performed by placing the vibrating tuning fork on the midline of the head. Ask the patient if the sound is heard equally in both ears or better in one ear.
- Interpretation: lateralization to the involved ear w/ conductive hearing loss & lateralization to better ear w/sensorineural hearing loss
- Rinne test—performed by placing a vibrating tuning fork on the mastoid process. The time to decay should be noted & then the tuning fork is held 1-2 cm from the ear, & time to disappear noted. Air conduction should be twice the time of bone conduction.
- Interpretation: exhibits bone conduction longer than air conduction in the affected ear w/conductive hearing loss
What is a Koplik spot?
A white lesion (like salt ‘spot’) in the soft palate of the mouth that is pathognomic for acute measles.
What is a common sign of viral croup on the X-ray in 40% of patients?
“Steeple sign” or “pencil point sign.”
Which respiratory condition is characterized by a decrease in sputum that is rust/purulent?
- Pneumococcal pneumonia
- Streptococcus pneumoniae—Gram positive diplococci encapsulated in polysaccharide=virulence
- S/S: sudden malaise, severe chills, fever, cough, watery sputum, limited breath sounds, fine crackles
- Pleuritic pain—sharp with respiratory movement
- Elderly may only present w/decreased appetite or decrease in mental status
- Prevention with immunization
What is the therapeutic plasma concentration of methylxanthines (i.e. theophylline)—a long-term control med in persistent asthma?
- Approximately 5-15 mg/L
- Signs and symptoms of toxicity
- Severe HA
- Nausea & vomiting
- Clearance is age dependent, with 1- to 9- year-olds having the highest systemic clearance
Know how to differentiate type of lung dx—obstructive, restrictive or mixed based on PFT.
What is Kuzmal’s breathing?
Characteristic rapid, deep, labored breathing pattern of patient in diabetic ketoacidosis (DKA) or other metabolic respiratory problem; they need to get rid of CO2.
What is a qualitative alteration in voice transmission that results in an ‘e’ sounding like an ‘a’ upon auscultation?
- Egophony—a qualitative alteration of voice transmission is noted over consolidation and along the upper margin of pleural effusion.
- The sound is a nasal twang or goat bleating.
A patient presents with a sore throat, malaise, is very tired, and has swollen cervical lymph nodes. The CBC shows atypical (reactive) lymphocytes. What is the most likely dx?
A positive “Tzanck” prep is supportive evidence for the diagnosis of what viral condition?
- HSV (herpes simplex virus).
- Tzanck prep—scraping the HSV lesion & then examining the slide under a microscope to find intranuclear inclusion bodies & multinucleated giant cells
What does a heterophil antibody test help determine?
- The presence of infectious mononucleosis. Heterophil ab test & “Monospot” test become positive w/in 4 weeks of onset.
- Very specific, but not very sensitive early in course of disease
Subacute sclerosing panencephalitis (SSPE) is a potential complication in which major vaccine preventable viral infection?
- Measles (rubeola; “red” or “hard” measles).
- SSPE—rare late CNS complication (5-15 years post infection); virus acts as a “slow virus” (similar to prions) to cause degenerative CNS changes
What is a systemic viral infection pathogen that is carried by rodents?
- Hantaviruses—rodent borne bunyavirus infections come from aerosols of rodent urine & feces
- Two major clinical syndromes:
- Hemorrhagic fever
- Hantavirus pulmonary syndrome
- ARDS-like clinical picture
- Associated with shock
- ~450 cases in the US in the last 10 yrs
What exotoxins of Staphylococcus aureus lead to food poisoning by ingestion with rapid onset (more rapid that other causes of food poisoning)?
Enterotoxins (A to E, G to I)—superantigens.
What fungal infection looks like spaghetti & meatballs under the microscope?
Tinea Versicolor (uneven tanning on the trunk).
Pay attention when a question specifically states where a patient is from.
- Example: Mr. C.J., a patient from Kansas City, has presented with an undifferentiated fever, non- productive cough, dyspnea, and malaise. What is the most likely diagnosis?
- Histoplasmosis (endemic in Ohio & Mississippi River valleys and in Indianapolis, Kansas City, Houston).
If a beaver poops upstream, what infection is patient Hiker likely to get after he takes a drink from the stream further down?
The infectious disease sign of creamy white roundworms passed in the stool is indicative of…
- Ascaris lumbricoides.
- Epidemiology/prevalence—Asia (75%), Africa (10%), Latin America (10%)
- Human feces contaminated fruits & veggies
- Fomites—flies can deposit eggs on food
- Symptoms: intense lower abdominal pain for days
- Signs: roundworms passed in stool
- Size: 6-10 inches
- Color: creamy white
- Bowel obstruction
- Management: mebendazole, albendazole, pyrantel pamoate
What parasite enters unbroken skin in infested water?
- Schistosomiasis, bilharzia.
- Vectors: fluke, intermediary freshwater snail
- Parasite enters unbroken skin in infested water
- Acute illness (Katayama fever), fever, malaise, abdominal pain, diarrhea
- Weight loss, arthralgias, cough
- Severe neurologic sequelae (rare)
- Microscopic exam of stool & urine eggs
- Praziquantel 40-60 mg/kg for 1 dose
What are some common metabolic disorders associated with HIV (and with the ART—antiretroviral therapy—used to treat HIV)?
A particular concern is the mitochondrial disorders in which cells revert to anaerobic metabolism and generate lactic acidosis. 50% die when this disorder is present.
- Occurs in Thailand, Indonesia region
- Characteristic ST segment elevation w/dip
- More prone to VT & death in 20-30 yr old individuals
Pretibial myxedema, or dermopathy, is characteristic of which endocrine disorder?
- Hypothyroidism (also seen here, but the only myxedema seen in hyperthroidism)
- Hyperthyroidism (also known as Graves’ disease)
What are some signs & symptoms of congenital hypothyroidism (bold=more common)?
- Prolonged hyperbilirubinemia
- Poor feeding
- Hoarse cry
- Umbilical hernia
- Respiratory distress
- Large fontanelle
- Delayed skeletal maturation
What are four predominant characteristics of hyperparathyroidism?
- Painful bones (myopathy, weakness, osteoporosis, pseudogout, bone pain)
- Psychic moans (confusion, obtundation, psychosis, lassitude, depression, coma)
- Renal stones (nephrolithiasis, renal insufficiency, polyuria, decreased urine-concentrating ability, nocturia, nephrocalcinosis)
- Abdominal groans (pancreatitis, constipation, anorexia, N/V, ulcers)
Genetic condition seen in children who are overweight/obese
What is the female athlete triad?
- Disordered eating, amenorrhea, osteoporosis
- Gymnasts, figure skating, ballet, diving (modeling & professional cheerleading) require lean figures
- Distance runners, swimmers, & cross-country skiers require large NRG intake
Surgery pimp question: Who can describe Morrison’s pouch?
The potential space b/w Glisson’s capsule of liver and Gerota’s fascia surrounding the kidney.
Surgery pimp question: Who can describe Douglas’ pouch?
An extension of peritoneal cavity b/w rectum and back wall of uterus (or bladder in male); “posterior cul-de-sac”
What areas are most sensitive for detection of free intraperitoneal fluid with FAST scan?
Morrison’s & Douglas’ pouches.
Understand etiology, disease process, clinical features, diagnostic tests, and treatments for anterior & posterior disorders: hyperprolactinoma, Cushing’s disease, acromegaly, gigantism, hypopituitary, hyperpituitary, isoprecocious puberty, SIADH, diabetes insipidus
Describe the histology of the anterior pituitary.
- acidophilic cells
- somatotrophs—produce GH
- mammotrophs—produce prolactin (also secreted by lactotrophs)
- corticotrophs—produce the precursor pro-opiomelanocortin
- from which ACTH, MSH, endorphins, & lipotropin are derived
- thyrotrophs—produce TSH
- gonadotrophs—produce LH & FSH
- chromophobes—comprise metabolically quiescent cells as well as “null” cells that don’t secrete hormone
What is the cause of 80% of cases of ADH excess (syndrome of inappropriate ADH—SIADH)?
- Small cell bronchogenic carcinoma (typically paraneoplastic).
- Other 20% caused by pulmonary infections; CNS lesions such as hemorrhage, thrombosis, & infections
What is Sheehan’s syndrome?
- (Also known as postpartum pituitary necrosis)
- Infarction of hypertrophic pituitary due to obstetric hemorrhage or shock. The pituitary is susceptible to decreases in BP related to problems during delivery.
- Can also occur with DIC, sickle cell anemia, cavernous sinus thrombosis, and other vascular disorders.
- Sx may be acute or require years to develop after the initial damage
- Breast atrophy, amenorrhea, can not breastfeed
Cushing’s dz and Addison’s dz always on PANCE.
What are the 5 “S” ‘ s of management for acute adrenocortical insufficiency?
- Salt replacement
- Sugar replacement
- Steroid replacement
- Support physiologic functioning
- Search for underlying cause (eg. Infection)
Which malignancy is the ectopic source of Cushing’s syndrome (hypercortisolism) in 15% of cases?
Small cell carcinoma of the lung.
What is the most common cause of Cushing’s syndrome?
What is the cause of Cushing’s disease?
Central cause—pituitary adenoma.
What are the various types of adrenal causes of Cushing’s syndrome?
- Adrenal adenoma
- Adrenal hyperplasia
- Adrenal malignancy (15%)
PA students also know Wermer’s syndrome as the PPP syndrome. What is another name for this syndrome and for what does PPP stand?
- MEN 1 (Multiple endocrine neoplasia).
- The syndrome typically involves the pituitary, parathyroid, and pancreas glands.
- Thymus, adrenal, carcinoid tumors (less common).
What is the triad associated with MEN 2A?
- Medullary thyroid carcinoma (MTC)
- Pheochromocytoma (about 50%)
- Hyperparathyroidism—caused by parathyroid gland hyperplasia (about 20%)
What are the characteristic findings in MEN 2B (also known as MEN type 3)?
- Medullary thyroid tumor
- Associated abnormalities—mucosal neuromas (leads to enlarged, thick lips), medullated corneal nerve fibers, & marfanoid habitus
To what side does the tongue protrude during a stroke?
Towards the affected side (i.e. tongue protrudes towards right in a stroke that occurs in right hemisphere).
What condition should come to mind immediately if a patient states he/she is having “the worst headache of my life”?
SAH (subarachnoid hemorrhage).
List the specialized tactile receptors in the skin & deeper structures and their basic functions
- Free nerve endings—detect touch & pressure; found in skin, cornea, & many others
- Meissner’s corpuscles—an elongated encapsulated nerve ending present in non-hairy parts of the skin; abundant in fingertips, lips, & other areas w/highly developed sense of touch (ex. Genitalia)
- Merkel’s disks—dome-shaped receptors found in non-hairy & hairy skin that allow for continuous determination of touch against skin
- Pacinian corpuscles—detect tissue vibration; located immediately beneath skin & deep in fascial tissues
- Hair follicle end-organs—afferent unmyelinated fibers entwined around most of the length of the hair follicle that detect movement on the surface of the body & adapt rapidly
- Ruffini’s end-organs—multi-branched encapsulated endings that signal continuous states of deformation such as heavy & continuous touch & pressure; occur in skin & deeper structures, including joint capsules
Name the three types of thermal receptors & their temperature ranges.
- Cold receptors
- <34oC (93oF)
- Warmth receptors
- >34oC (93oF)
- Pain receptors
- <5oC (41OF)
- >45oC (113oF)
What is another name for trigeminal neuralgia?
- Tic douloureux—a disorder of the 5th cranial nerve (trigeminal)
- Usually maxillary or mandibular divisions
- To what does the term watershed zone refer?
- Critical perfusion failure distal to a stenosis in the brain—serves as warning sign & danger zone in stroke prevention & tx.
What condition is caused by pressure on the anterior superior iliac spine that compresses the lateral femoral cutaneous nerve of the thigh & in whom is it most common?
- Meralgia paresthetica (also known as Bernhardt-Roth syndrome)
- Most common in…
- Pregnant women (36 weeks)
- 350 lbs people
- Recovering from trauma/surgery to thigh
What is the difference between myasthenia gravis and Eaton-Lambert syndrome during a repetitive motion exam (like squeezing their hand)?
- Stronger response over time—Eaton-Lambert syndrome
- Weaker response over time—myasthenia gravis
Random from Dr. White: Use IV clindamycin as treatment for dog bite in person with splenectomy.
What are the most common bone cancers in children and young adults?
- Ewing’s sarcoma
What is the most common bone cancer in adults (age >40)?
What is the most common bone caner?
What is the most common form of benign tumor in the skeletal system?
What is the most common primary malignant bone tumor?
- Possibly multiple myeloma (if considering hematogenous origin)
- Should check with current EBM sources to be sure
What is the second most common type of primary bone tumor in children and adolescents?
What is the second most common form of malignant bone tumor?
Sites that commonly metastasize to the bone…
Prostate, breast, lung (also kidney & thyroid)
What are the first and second most common bone disorders?
Osteoporosis & Paget’s disease
Bone pain that occurs more frequently at night makes you think of…
What are the common deformities of the hands in RA and where are they located?
- Boutonniere deformity—thumb (flexion of PIP w/hyperextension of DIP)
- Swan-neck deformity—fingers (subluxation of MCP, hyperextension of PIP & partial flexion of DIP)
Which laboratory test for SLE is highly specific with a sensitivity of 70% and with levels correlating with disease activity, particularly SLE nephritis?
Which laboratory test for SLE can also be tested for as the causative agent in women with multiple miscarriages?
What is the characteristic radiographic appearance of the digits in psoriatic arthritis (PA)?
“Pencil-in-cup”—whittling of proximal phalanx and expanded base of distal phalanx
What is the classic triad of Reiter’s syndrome?
- Non-gonococcal urethritis & genital ulceration
Characteristic, possibly pathognomonic, cutaneous features of dermatomyositis include…
- Heliotrope rash (lilac-colored) to face
- A violaceous-to-dusky erythematous rash with or w/o edema in a symmetrical distribution involving periorbital skin
- Sometimes, this sign is subtle & may involve only a mild discoloration along the eyelid margin
- Rarely observed in other disorders; its presence is highly suggestive of dermatomyositis
- Gottron papules
- Found over bony prominences
- Slightly elevated violaceous papules & plaques
- A slight scale and, occasionally, a thick psoriatic scale may be present
What is the acronym for OA (osteoarthritis) characteristic radiography findings?
- Loss of joint space
- Subchondral sclerosis
- Subchondral cysts
What are the 3 rules for treating intra-articular (IA) fractures?
- Perfect reduction
- Stable fixation
- Early ROM (range of motion)
How is lithium excreted from the body?
What is pseudohyponatremia and when does it usually occur?
- Definition: rare situations where serum Na+ is low but ECF osmolality and tonicity are normal
- Severe hypertriglyceridemia (>1000)
- Severe hyperproteinema (multiple myeloma)
What metabolic condition is characterized by tall, peaked T waves on the EKG (more severe stages also exhibit widening of the QRS complex)?
When dealing with electrolyte disorders, which electrolyte(s) will NOT correct without correction of a Mg2+ deficiency?
K+ and Ca2+.
A 30-year old former basketball player presents to the ER with “tearing” chest pain. What is the most likely diagnosis?
Dissecting aortic aneurysm.
pH is determined by the HCO3 : H2CO3 ratio, with a ratio of ________ driving a pH of 7.40 (perfect pH).
A child presents with a diffuse, punctuate, macular rash that begins on the trunk & spreads to the arms and legs with a mild febrile state (<100) as well as postauricular, sub-occipital, and cervical lymph node adenopathy. What is your diagnosis?
Rubella ( German measles).
What is another name for Hutchinson’s freckle or malignant melanoma in situ?
- Lentigo maligna—a slowly progressive (= 20 yrs) preneoplastic disorder of melanocytes
- occurs on sun-exposed areas, especially the face
- a pigmented macule with a well-defined border & growing 5 cm or larger
- if untreated, a true malignant melanoma often develops
- tx’d w/excision
- careful monitoring for conversion to melanoma = important
What should be at the top of your DDx for a woman with painful bleeding during pregnancy?
What condition is colloquially known as “bag of worms”?
A family goes on a picnic one Sunday afternoon, yet that night everyone is sick and vomiting. What is the most likely etiology of the food poisoning at the picnic?
What is the enterohepatic circulation?
The circulation of bile out of the liver, into the small intestine, and absorbed back into hepatic portal circulation (see diagram in Porth for more detail).
What is the only clotting factor mutation that leads to excess clotting rather than bleeding (like most other clotting factor deficiencies/mutations)?
Mutated Factor V (Factor V Leiden) because this clotting factor is not inactivated by protein C, one of the body’s natural anticoagulants.
Name some examples of cells in the RES (reticular endothelial system) and their respective locations.
- Alveolar macrophages—lungs
- Kupffer cells—liver
- Apparently this system is now known also as the Macrophage System or the Mononuclear Phagocyte System (MPS)
Which hematologic disorder leads to hemolysis after eating fava beans?