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USMLE Step 2 CK > Internal Medicine > Flashcards

Internal Medicine Flashcards

1
Q

DDX for WBC casts?

A

Pyelonephritis Acute intersitial nephritis

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2
Q

DDx for muddy brown casts?

A

Acute tubular necrosis

Can be caused by ischemic AKI or nephrotoxic AKI (antibiotics, radiocontrast agents, NSAIDs, poisons, myoglobinuria, hemoglobinuria, chemotherapy, AL in MM)

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3
Q

Metabolic derangements in AKI

A

Hyperkalemia Anion gap metabolic acidosis Hypocalcemia Hyponatremia Hyperphosphatemia Hyperuricemia

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4
Q

Metabolic derangements in CKD

A

Hyperkalemia Hypermagnesemia Hyperphosphatemia Metabolic acidosis Hypocalcemia

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5
Q

Side effects of ACEI

A

ACEI dilate afferent arteriole Hyperkalemia

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6
Q

Absolute indications for dialysis

A

Acidosis Electrolyte abnormalities Intoxications Overload, hypervolemic Uremia based on clinical presentation (e.g. AMS, pericarditis)

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7
Q

Minimal change disease

A

Most common in children

May present as nephrotic syndrome

A/w lymphomas

Microscopy: no changes on light microscopy, foot process fusion

Tx: 4-8 weeks of steroids

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8
Q

Focal segmental glomerulosclerosis (FSGS)

A

Nephrotic

More common in Blacks

Microscopy: focal segmental sclerosis, foot process fusion

A/w HIV, heroin use, sickle cell disease

Does not respond well to steroids

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9
Q

Membranous glomerulonephritis

A

Nephrotic

Microscopy: thick glomerular basement membrane

A/w: Hep B, Hep C, SLE

Does not respond well to steroids

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10
Q

Post-infectious glomerulonephritis

A

Nephritis 10-21 days following URI

Low C3 complement

Elevated anti-streptolysin O and/or anti-DNAse B

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11
Q

IgA nephropathy

A

Nephritis 5 days following URI

Normal complements

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12
Q

Prostate cancer

A

Risk factors include age, African American race, high-fat diet, FHx, exposure to herbicides and pesticides Mostly adenocarcinoma, starts at periphery Mostly asymptomatic but can cause obstruction in late phase Likes to metastasize to bone (pelvis, vertebral bodies, long bones in the legs) Indications for transrectal ultrasound: PSA > 4.1, abnormal DRE Tx: radiation + androgen deprivation OR prostatectomy OR orchiectomy, antiandrogens, leuprolide, GnRH antagonists

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13
Q

Treatment of CAD

A

Risk factor modification (HTN, DM, HLD control, etc.) Aspirin (reduces risk of MI) Nitrates Beta-blockers (reduces frequency of coronary events) + coronary angiography to assess for PCI (if moderate) + consider CABG (if severe)

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14
Q

Treatment of hypertrophic cardiomyopathy

A

Beta-blockers

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15
Q

Treatment of CHF

A

ACEI + loop or thiazide diuretic Beta-blockers Spironolactone/Eplerenone

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16
Q

Treatment post-stent placement

A

Dual platelet therapy (aspirin + clopidogrel) 1 month for BMS 12 months for DES

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17
Q

Treatment for aortic dissection

A

IV beta-blocker to SBP 100-120 If SBP still > 120, add sodium nitroprusside

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18
Q

Treatment for cocaine-induced chest pain

A

IV benzodiazepines Aspirin, nitroglycerin, CCB Beta-blockers contraindicated

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19
Q

Arrhythmia most specific for digitalis toxicity

A

Atrial tachycardia with AV block

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20
Q

Finds for aortic stenosis

A

Fatigue, lightheadeness with exertion, presyncope Midsystolic murmur over RUSB Diminished and delayed carotid pulse Soft and single S2

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21
Q

Tx for sinus bradycardia

A

IV atropine

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22
Q

Metabolic derangments in intravascular hemolysis

A

Hemoglobinemia
Hemoglobinuria
Elevated lactate dehydrogenase
Decreased haptoglobin (excess hemoglobin exceeds binding capacity)

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23
Q

Primary biliary cholangitis

A

S&S: pruritus, fatigue, jaudice, eyelid xanthelasma, portal HTN, osteopenia
Labs: antimitochondrial antibody, elevated Alk Phos
Tx: ursodeoxycholic acid, liver transplant for advanced disease

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24
Q

Wernicke encephalopathy

A

Thiamine deficiency due to alcoholism, malnutrition
S&S: encephalopathy, oculomotor dysfunction, postural and gait ataxia
Tx: IV thiamine followed by glucose infusion

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25
Q

Indications for hospitalization for CAP

A

Confusion
Urea > 20
Respirations ≥ 30
SBP < 90, DBP < 60
Age ≥ 65

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26
Q

Treatment of diverticulitis

A

Uncomplicated: outpatient bowel rest, oral antibiotics, observation
Complicated (abscess): IV antibiotics if < 3 cm, CT-guided percutaneous drainage if > 3 cm, surgical drainage and debridement if no improvement in 5 days

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27
Q

Cellulitis vs. erysipelas

A

Cellulitis: S. pyogenes or MSSA infection of deep dermis and subcutaneous fat with flat edges with poor demarcations, indolent
Erysipelas: S. pyogenes infection of superficial dermis and lymphatics with raised, sharply demarcated edges, rapid spread and onset

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28
Q

Bounding pulses, fixed splitting of S2, pulsus paradoxus, pulsus parvus and pulsus tardus

A

Bounding pulses: AR
Fixed splitting of S2: ASD
Pulsus paradoxus (systemic arterial pressure falls > 10 mmHg during inspiration): cardiac tamponade
Pulsus parvus and pulsus tardus (decreased amplitude and delayed upstroke): AS

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29
Q

Diagnosis and management of carbon monoxide poisoning

A

Dx: ABG (carboxyhemoglobin level), ECG, cardiac enzymes if ischemia or CAD
Tx: high-flow 100% oxygen, intubation/hyperbaric oxygen therapy (if severe)

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30
Q

Treatment elevated homocystine

A

Pyroxidine, folate, B12 (if deficiency documented) as these are co-factors in homocysteine metabolism

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31
Q

Treatment for PCP

A

AIDS-defining illness when CD4 count < 200

First line: TMP-SMX

Second line: pentamidine, atovaquone, TMP + dapsone, clindamycin + primaquine

Adjunctive corticosteroids if PaO2 Copyright 70 mmHg or A-a gradient > 35 mmHg

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32
Q

Diagnosis and management of heparin-induce thrombocytopenia

A

S&S: heparin exposure > 5 days + platelet reduction > 50% from baseline, arterial or venous thrombosis, necrotic skin lesions at heparin injection sites, anaphylactoid reaction

Dx: if suspected, STOP ALL HEPARIN PRODUCTS then do serotonin release assay

Tx: start direct thrombin inhibitor (e.g. argatroban) or fondaparinux (can switch to warfarin once platelets > 150,000)

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33
Q

Next best step of management for chest pain

A

ECG

> 2 mm ST elevations or new LBBB concerning for STEMI → cath lab or thrombolytics if cath lab unavailable in reasonable amount of time

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34
Q
A
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35
Q

Leads I and aVL

A

Lateral MI –> left circumflex

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36
Q

Leads V1-V4

A

Anterior MI –> left anterior descending

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37
Q

Leads V1-V4, V5-V6, I, aVL

A

Anterolateral MI –> left main

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38
Q

Leads II, III, aVF

A

Inferior MI –> posterior descending (85% branches from right coronary)

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39
Q

Causes of dilated cardiomyopathy?

A

Alcohol abuse Wet beriberi Coxsackie A and B virus myocarditis Chronic cocaine use Chagas disease Doxorubicin toxicity Hemochromatosis Peripartum cardiomyopathy

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40
Q

Unilateral headaches, jaw claudication, blindness (if untreated)

A

Temporal (giant cell) arteritis Labs: elevated ESR and CRP Dx: temporal artery biopsy shows granulomas, intimal thickening, elastic lamina fragmentation, multinucleated giant cells Tx: corticosteroids Cx: polymyalgia rheumatica, IL-6 related to severity of disease

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41
Q

Weak upper extremity pulses, arrowing of aortic arch and proximal great vessels

A

Takayasu arteritis Tx: corticosteroids

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42
Q

Hepatitis B, hypertension, transmural inflammatory and fibrinoid necrosis of arterial wall, “string of pearls” on arteriogram

A

Polyarteritis nodosa Tx: cyclophosphamide, corticosteroids

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43
Q

Fevers, conjunctivitis, cervical lymphadenopathy, strawberry tongue, rash on palms and soles

A

Kawasaki disease Tx: aspirin, IV immunoglobulins Complications: coronary artery aneurysm

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44
Q

Smoking, claudication,gangrene, autoamputation, Raynauds

A

Buerger disease (thromboangiitis obliterans) Tx: smoking cessation

45
Q

c-ANCA (PR3-ANCA), involvement of nasopharynx, lungs, kidneys

A

Granulomatosis with polyangiitis (Wegners) Tx: cyclophosphamide, corticosteroids

46
Q

p-ANCA (MPO-ANCA), invovlement of lungs, kidneys

A

Microscopic polyarteritis No nasopharyngeal involvement and no granulomas distinguishes from Wegners

47
Q

p-ANCA (MPO-ANCA), asthma, palpable purpura, GI complaints, increased IgE

A

Churg Strauss (eosinophilic granulomatosis with polyagiitis) Granulomas with eosinophils

48
Q

Indications for CABG over stent

A

Left main disese or 3-vessel disease (or 2-vessel disease + DM)

> 70% occlussion

Pain despite maximal medial treatment

Post-infarction angina

49
Q

Medical management post-MI

A

Aspirin (+ clopidogrel if stent for 9-12 months)

Beta-blocker

ACEI (if CHF or LV dysfunction)

Statin

Nitrates for pain

50
Q

Exercise stress test

A

Indicated for patients with intermediate pre-test probability of cardiac ischemia

Avoid beta-blockers, CCB

Need to do echo stress test if old LBBB, baseline ST elevation, or digoxin

If pt cannot exercise, chemical stress test with dobutamine or adenosine

Positive if –> ST depressions, chest pain, hypotension –> coronary angiography

51
Q

Treatment of WPW

A

Procainamide

Avoid beta-blockers, digoxin, CCB (anything that slows AV conduction)

52
Q

Treatment of SVT

A

First line: carotid massage, face in ice water (for children)

Second line: adenosine

53
Q

Cardiac tamponade

A

Clinical indicators: hypotension, distant heart sounds, JVD, pulsus paradoxus, electrical alternans

Tx: pericardiocentesi

54
Q

Crescendo-decrescendo systolic ejection murmur, louder with squatting, softer with valsalva + parvus et tardus

A

Aortic stenosis

Tx: valve replacement

55
Q

Systolic ejection murmur, louder with valsalva, softer with squatting/handgrip

A

Hypertrophic obstructive cardiomyopathy

56
Q

Late systolic murmur with click, louder with valsalva and handgrip, softer with squatting

A

Mitral valve prolapse

57
Q

Holostystolic murmur, radiates to the axilla

A

Mitral regurgitation

58
Q

Rumbling diastolic murmur with an opening snap, left atrial elargement and afib

A

Mitral stenosis

59
Q

Blowing diastolic murmur with widened pulse pressure, waterhammer pulse

A

Aortic regurgitation

60
Q

Most specific arrhythmia associated with digitalis toxicity

A

Atrial tachycardia with AV block

61
Q

Treatment for long QT syndrome

A

Beta-blockers and pacemaker

62
Q

Indication for antithrombotic therapy in afib

A

> 4 on CHA2DS2-VASc

C = CHF (1 point)

H = HTN (1 point)

A = age > 75 (2 points)

D = DM (1 point)

S2 = stroke/TIA/thromboembolism (2 points)

V = vascular disease (1 point)

A = age 65-74 (1 point)

Sc = sex (female = 1 point)

63
Q

Most likely location following aspiration?

A

Right mainstem bronchus wider and more vertical than the left While upright –> lower portion of right inferior lobe While supine –> superior portion of right inferior lobe or posterior segments of the right upper lobe

64
Q

What factors shift the oxygen-hemoglobin curve to the right?

A

Right shift = reduced affinity = more oxygen is offloaded at a given pO2 ↑ in Cl-, H+, CO2, 2,3-BPG, temperature, altitude, and exercise

65
Q

What factors shift the oxygen-hemoglobin curve to the left?

A

Left shift = greater affinity = less oxygen is offloaded at a given pO2 ↓ in Cl-, H+, CO2, 2,3-BPG, and temperature

66
Q

Methemeglobinemia

A

Oxidized hemoglobin (with Fe3+) has reduced affinity for oxygen and increased affinity for cyanide S&S: cyanosis and chocolate-colored blood Tx: methylene blue

67
Q

Cyanide poisoning

A

Nitrites to oxidize hemoglobin to methemeglobin which binds CN Thiosulfate to bind this cyanide, forming thiocyanate, which is renally excreted

68
Q

Lobes of the lungs affected by pneumoconioses

A

Asbestosis –> lung bases

Silica and coal –> upper lobes

69
Q

Light’s criteria?

A

Pleural effusion is exudative if:

PF/serum protein > 0.5

PF/serum LDH > 0.6

PF LDH > 2/3 upper limit of normal (about 200)

Exudative processes (inflammation that causes increased permeability): parapneumonic, lung adenocarcinoma (high hyaluronidase)

Transudative processes (imbalance between hydrostatic and oncotic pressures): RA (low glucose 2/2 leukocytosis), TB (high lymphocytes), malignant or pulmonary embolus (bloody) → treat underlying disease

70
Q

Locations of primary lung cancers

A

Adenocarcinoma, bronchioalveolar, large cell –> peripheral Squamous cell, Small cells –> central

71
Q

Adenocarcinoma

A

Most common lung cancer in nonsmokers and overall Found in periphery

Bronchioloalveolar subtype looks like pneumonia on CXR –> good prognosis

72
Q

Squamous cell carcinoma

A

Most common lung cancer in male smokers

Centrally located as hilar mass from the bronchus

a/w cavitation, cigarettes, hypercalcemia (from PTHrP)

Keratin pearls and intercellular bridges on histology

73
Q

Small cell (oat cell) carcinoma

A

Centrally located

Undifferentiated neuroendocrine cells –> very aggressive May produce ACTH, ADH, antibodies against presynaptic calcium channels (Lambert-Eaton)

Inoperable, must treat with chemotherapy

74
Q

Large cell carcinoma

A

Found in periphery

Highly anaplastic undifferentiated tumor –> mets

Less responsive to chemotherapy, removed surgically

Pleomorphic giant cells on histology

a/w gynecomastia and glactorrhea

CXR shows peripheral cavitation

75
Q

Bronchial carcinoid tumor

A

Nests of neuroendocrine cells (chromogranin A +)

Excellent prognosis, metastasis rare

Symptoms due to mass effect or carcinoid syndrome (5-HT –> flushing, diarrhea, wheezing)

76
Q

Common sites of primary lung cancer metastasis?

A

Adrenal glands, brain, bone, liver

77
Q

The terrible T’s of a mediastinal mass

A

Teratoma Thymoma Thyroid cancer Terrible lymphoma

78
Q

Hamartoma of the lung

A

Benign lesion Typicallly a solitary lung nodule (“coin lesion”) with “popcorn” calcifications Often contains islands of mature hyaline cartilage, fat, smooth muscle, and clefts lines by respiratory epithelium

79
Q

Smoking-related vs. A1AT deficiency emphysema

A

Smoking-related emphysema: centriacinar in the upper lobes

A1AT deficiency emphysema: panacinar in the lower lobes

80
Q

Which pneumoconicosis is associated with increased risk of TB?

A

Silicosis

Silica particles internalized into macrophages disrupt phagolysosomes and cause release of the particles and viable mycobacteria limiting the immune system’s ability to combat TB infection

a/w eggshell calcifications

81
Q

Chronic rejection of a lung vs. kidney transplant

A

Kidney –> inflammation of vasculature Lung –> inflammation of small bronchioles (bronchiolitis obliterans)

82
Q

Causes of deviated trachea

A

Tension pneumothorax –> trachea deviates away from the collapsed lung Collapsed lung due to bronchial obstruction –> trachea deviates towards the affected side

83
Q

Diagnostic criteria and management of ARDS

A

Dx: PaO2/FiO2 < 200, bilateral alveolar infiltrates on CXR, PCWP < 18

Tx: mechanical ventilation with PEEP

84
Q

Treatment for COPD

A

First line: ipratropium, tiotropium

Second line: beta agonists

Third line: theophylline

85
Q

Indications to start oxygen in COPD

A

PaO2 < 55 or SpO2 < 88%

86
Q

Best prognostic indicator for COPD

A

FEV1

87
Q

Interventions shown to improve mortality from COPD

A

Smoking cessation

Continuous oxygen therapy > 18 hours/day (is PaO2 < 55 or SpO2 < 88%)

88
Q

Sarcoidosis

A

Hilar lymphadenopathy, increased ACE, hypercalcemia, erythema nodosum

Refer to ophthalmology 2/2 uveitis conjunctivitis

Dx: biopsy

Tx: steroids

89
Q

COPD + new-onset clubbing

A

Occult malignancy of the lung –> get CXR

90
Q

Diagnosis and treatment of asthma

A

Dx: obstructive process on spirometry (decreased FEV1/FVC) with reversibility after SABA (> 12% improvement)

Tx:

<= 2x/week + normal PFT → albuterol prn

More frequent symptoms + normal PFT → albuterol + inhaled corticosteroids

More frequent symptoms + FEV1 60-80% → albuterol + inhaled corticosteroids + LABA

Daily symptoms + FEV1 60% → albuterol + inhaled corticosteroids + LABA + montelukast or oral steroids

91
Q

Complications of inflammatory bowel disease?

A

Toxic megacolon → surgery

Pyoderma gangrenosum → NO antibiotics

Erythema nodosum (painful nodules on anterior tibia)

92
Q

Which IBD is a/w increased risk of primary sclerosing cholangitis?

A

Ulcerative colitis

PSC confers and increased risk for cholangiocarcinoma

93
Q

How do you treat ulcers, abcesses, or fistulas associated with Crohn’s disease?

A

Metronidazole

94
Q

Treatment for IBD

A

ASA, sulfasalazine to maintain remission

Corticosteroids to induce remission

Azathioprine, 6MP, and methotrexate for severe disease

95
Q

ALT > AST and in the 1000s

A

Viral hepatitis

96
Q

AST and ALT in the 1000s after surgery or hemorrhage

A

Ishemic hepatitis (shock liver)

97
Q

Antimitochondrial antibodies

A

Primary biliary cirrhosis

Steroids not effective

98
Q

ANA + antismooth muscle antibodies

A

Autoimmune hepatitis

Tx: steroids

99
Q

Cholestatic pattern of liver enzymes?

A

Think obstruction → RUQ ultrasound → if equivocal, do abdominal CT (painless jaundice in elderly = pancreatic CA) → if equivocal, do ERCP

100
Q

Prophylaxis for people exposed to bacterial meningitis?

A

Rifampin

101
Q

Treatment of meningitis

A

Empiric treatment (+ steroid if you think bacterial), exam/CT to access for ICP, LP (+ gram stain, > 1000 WBCs diagnostic)

N. meningititis, H. flu, S. pneumo → ceftriaxone, vancomycin

Listeria → ampicillin

Staph (brain surgery) → vancomycin

TB → RIPE + steroids

Lyme → ceftriazone

102
Q

Diagnosis of TB

A

PPD (+ if > 15 mm or > 10 mm if prison, healthcare, DM, ETOH, chronically ill, > 5 mm if AIDS/immunosuppressed)

If PPD+ → CXR

If CXR+ → acid fast stain of sputum → treat with RIPE for 6 months (12 if meningitis, 9 if pregnant)

If CXR- → need 3 negative sputums to rule out TB

103
Q

Side effects of RIPE drugs

A

Rifampin: turns body fluids orange/red, induces CYP450

INH: peripheral neuropahty and sideroblastic anemia (prevent by giving B6), hepatitis with mild bump in LFTs

Pyrazinamide: benign hyperuricemia

Ethambutol: optic neuritis, other color vision abnormalities

104
Q

Definition of and management of neutropenic fever

A

Neutropenic fever = absolute neutrophil count (ANC) < 1500 (severe if < 500)

Increased risk of mucositis and translocation of bacteria into bloodstream (NEVER DO A DRE)

Treat empirically with anti-pseudomonal beta-lactam (cefepime, meropenem, piperaciilin-tazobactam) then blood and urine cultures

105
Q

Hepatitis B postexposure prophylaxis

A

If completed Hep B vaccine series + documented response → no prophylaxis

If did not complete Hep B vaccine series/unvaccinated → test source patient blood → if HBsAg and no anti-HBsAg → hepatitis B immunoglobulin + initiate vaccine series → viral serology

106
Q

Diarrhea + solitary cyst in the right lobe of the liver (anchovy paste)

A

Entamoeba hystolytica

Tx: metronidazole + intraluminal antibacterial (e.g. paromomycin)

107
Q

Filamentous, branching bacteria

A

Nocardia: gram +, aerobic, partially acid-fast, tx with TMP-SMX

Actinomyces: gram +, anaerobic, not acid fast, sulfure granules, tx with penicillin G

108
Q

Acid-base disturbances in saicylate toxicity

A

ASA overdose causes respiratory alkalosis (early) and anion-gap metabolic acidosis (late) which together give nearl-normal pH, low pCO2, and low HCO3

USMLE Step 2 CK (7 decks)

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