INTERNAL MEDICINE High Yield REVIEW Topics : USMLE STEP 2 CK "For students by students" Quick hit questions first,

answers listed later on. 1) 35 yr female with double vision at the end of the day, dysphagia, nasal voice, upp ext weakness, her sx improve after a nights sleep. Dx? 2) What is MG? 3) Best initial test for MG? 4) What is the specific test for MG? 5) What is the sensitive test for MG? 6) Most accurate test for MG? 7) Tx for MG? If primary tx fails, what to use (initial choice) for MG? 9) If initial tx after primary tx fails, what tx for MG? 10) Tx for acute MG crisis? 11) Surgical tx for post puberty till age 55 yrs for MG pts? 12) 46 yr male w/ rubbery legs for 2 days, loss of reflexes bilaterally and weakness in lower ext. Hx of diarrhea 3 wks ago. Dx? 13) What is Gullian-Barre Syndrome? 14) Pattern of sensory distribution loss w/GBS? 15) When to take GBS pt to ICU? 16) What % of GBS pt have prior hx of infection 1-3 wks ago? 17) Best initial test for GBS? 1 Most accurate test for GBS? 19) Tx for GBS? 20) Acute abortive tx for migraine? If contraindicated, alternative tx? 21) Prophylactic tx for migraine when to start n what tx? 22) Pt w/ severe, infrequent migraine unresponsive to any tx? 23) Initial tx for tension H/A, what if refractory? 24) Prophylactic tx for cluster H/A? 25) Most effective tx for acute cluster H/A, alternative? 26) Central vertigo a)onset b)tinitis,HL c)diplopia,blindness,dysarthria,weakness d)nystagmus 27) Peripheral vertigo a)onset b)tinitis,HL c)diplopia,blindness,dysarthria,weakness d)nystagmus 2 Triad of Menieres disease? 29) Two most common causes of Menieres dis? 30) Peripheral vertigo associated w/ blunt ear trauma, air flight, scuba diving? 31) Symptomatic tx for peripheral vertigo? If severe? ANSWERS: Numbers 1-30:::: :1) Myasthenia Gravis 2) Dis. Of NMJ, presents with weakness and fatigue. Ab to Ach receptors -> dec # of active/functional Ach receptors at postsynaptic membrane 3) Ach receptor Ab 4) Fatigued muscle weakness plus +Ach receptor Ab test 5) Edrophonium (Tensilon) test 6) EMG (decremental dec in muscle fiber content on repetitive nerve stimulation 7) Anticholinesterase (pyridostigmine)

Immunosuppressive tx with glucocorticoids 9) Azathioprine and steroid combo 10) Plasmapheresis and IVIG 11) Thymectomy 12) Gullian-Barre synd (Acute idiopathic polyneuropathy) 13) Acute severe polyradiculopathy w/autoimmune destruction of myelin. Bodys immune system attacks self antigens (molecular mimicry) 14) Pain, tingling dysthesia. Loss of large sensory fibers -> loss of reflexes and proprioception 15) Autoimmune instability (profuse sweating, postural hypotension, labile BP, cardiac dysrhythmia) 16) Approx 75% 17) LP (inc protein, no inc in cell count 48 hrs after sx) 1 EMG (demyelination of peripheral nerves) 19) IVIG or plasmapheresis (equally effective) 20) Sumatriptan PO, IN, SQ (serotonin agonist) contraindicated in CVD. Alternative tx: ergotamine 21) Px for migraine when >3x/mo. Tx: propanolol, timolol, valproic acid & {methylsergide (for 2-6 wks distended over 6mo, SE: valvular & retroperitoneal fibrosis)} 22) Opioid analgesics 23) Relaxation & NSAIDS, if refractory: musc relaxants 24) Predinisone, Li, ergotamine, methylsergide & verapamil 25) 100% oxygen, alternative: sumatriptan 26) Central vertigo a)gradual b)absent c)present d)pure, vertical, does not suppress w/fixation &multidirectional 27) Peripheral vertigo a)usually sudden b)present c)absent d)mixed,horizontal,suppress w/fixation,unidirectional 2 Tinitis, hearing loss, episodic vertigo (1-8 hr) 29) Syphilis & head trauma 30) Perilymphatic fistula 31) Meclizine. If severe: diazepam

32) Medical tx for Menieres dis? If fails? 33) Symptomatic tx for vertigo secondary to labyrinthitis? If severe? 34) Examples of reversible causes of dementia? 35) Examples of irreversible causes of dementia? 36) Early presentation of Picks dis? 37) Presentation of Creutzfeldt-Jakob dis? 3 Binswagner dis? 39) Tx for mild-moderate dementia? Other tx? 40) 32 yr female w/numbness & tingling of R hand began several days ago. Hx of seeing double 3 yrs ago for 2 days. Hyperactive reflexes bilaterally and inc spasticity in lower extremities. Dx?

41) What is Multiple sclerosis? 42) Triggers that exacerbate MS? 43) Most accurate test for MS? 44) Best initial test for MS? 45) Most sensitive test for MS? 46) If MRI is nonconfirmatory but MS suspicion still high, what test? 47) Tx for relapsing-remitting dis of MS? 4 Tx for secondary progressive dis of MS? 49) If cant tolerate IFN B1b, IFN B1a or glatiramer acetate? 50) Tx for primary progressive disease of MS? 51) Tx for acute exacerbation of MS? 52) Tx for MS pt w/ spasticity? 53) Tx for MS pt w/ nocturnal spasticity? 54) Tx for MS pt w/ bladder hyperactivity? 55) Tx for MS pt w/ Urinary retention? 56) Tx for MS pt w/ fatigue? 57) Tx for MS pt w/ erectile dysfunction? 5 What is Parkinsons disease? 59) Parkinsonism + vertical gaze palsy? 60) Parkinsonism + prominent ataxia? 61) Parkinsonism + prominent orthostatic hypotension? 62) Parkinson pt w/ intact functional status (less bradykinesia) < 60 yrs, initial tx? 63) Parkinson pt w/ intact functional status (less bradykinesia)> 60 yrs, initial tx? 64) Parkinson pt w/ compromised function, initial tx? 65) Tx for late complications of carbidopa/levodopa (response fluctuations)? 66) Only drug that can arrest progression of Parkinson dis? 67) Surgical TX for Parkinson pt, when? Procedure? 6 Test of choice for diagnosing epilepsy? 69) Tx of status epilepticus? 70) When are first time seizures treated with long-term anticonvulsants? 71) First line tx for generalized tonic clonic seizure? If not a choice? 72) First line tx for absence seizures? If not a choice? 73) First line tx for partial seizures (complete/partial)? Acceptable alternatives? 74) Tx of choice for myoclonic and atonic seizures? 75) CNS SE of phenytoin? 76) Systemic SE of phenytoin? 77) SE of phenobarbitol? 7 SE of valproic acid? 79) SE of lamotrigine? ANSWERS:::: 32) Low salt diet & diuretic. If fails: surgical decompression 33) Meclizine. If severe: diazepam 34) Hypothyroidism, Vit B12 def, Hep/uremic encephalopathy, CNS vasculitis, Syphilis, Brain abscess, Brain tumor, Meds (anticholinergic), Sleep apnea, Trauma, Subdural hematoma, NPH, Depression 35) Progressive multifocal leukoencephalopathy, Alzheimers dis, Dementia w/

Lewy bodies, Frontotemporal degeneration (Picks dis), Vascular dementia multiinfarct, Binswanger dis), Creutzfeldt Jakob dis 36) Personality changes w/visuospatial sparing 37) Dementia & myoclonus (aggressive wks-mo) 3 Subcortical white matter (slow) 39) Donepezil. Others: anticholinesterase inhibitors (rivastigmine, tacrine); discontinue if no improvement in 3-6 mo 40) Multiple sclerosis 41) Inflammatory dis of CNS white matter, multifactorial (infections, diet, climatic), focal areas of demyelination 42) Infection, trauma, post pregnancy (2- 3 mo after) 43) Brain MRI (inc T2 density, dec T1 density) Gandolinium enhance lesions till 2-6 wks after exacerbation 44) Brain MRI 45) Brain MRI 46) CSF (mild pleocytosis <50 cells, inc IgG oligoclonal band 70-90%pts) 47) Disease modifying agents: IFN B1b, IFN B1a, glatiramer acetate 4 IFN B1b &mitoxantrone 49) Methotrexate, cyclophosphamide, IVIG or azithropine 50) No disease modifying tx approved yet 51) 3 days of intense IV steroids-> oral steroids (taper over 4 wks) If severe & steroid unresponsive: plasma exchange 52) baclofen 53) tizandine, diazepam 54) oxybutynin 55) bethanechol 56) amantadine or fluoxetine 57) sildenafil acetate 5 Neurologic synd from def of neurotransmitter dopamine as consequence of degenerative, vascular or inflammatory changes in basal ganglia 59) Supranuclear palsy 60) Olivopontocerebellar atrophy 61) Shy Dragger synd 62) Anticholinergic meds 63) Amantadine 64) Carbidopa/levodopa 65) Sustained rel form of carbidopa/levodopa adding dopamine agonist, selegiline or COMT inhibitors or restriction of protein meal to night 66) Selegiline 67) Surgery for who cant tolerate or respond adequately to medical tx. Procedures: pallidotomy & thalamotomy 68 Electroencephalogram 69) Secure ABC, tx reversible causes, lorazepam or diazepam (potentiate GABA recept)-> seizure-> phenytoin or fosphenytoin (inhibit Na+ dependent AP)-> seizure -> phenytoin/fosphenytoin -> seizure -> phenobarbitol -> seizure-> phenobarbitol -> seizure -> midazolam or propofol 70) If Pt has abnormal neurologic exam, presented w/ status epilepticus, has strong family hx of seizures, or has abnormal EEG 71) Valproic acid (inc availability of GABA). If not a choice, pick

lamotrigine (dec glutamate release) 72) Ethosuximide. Valproic acid 73) Carbamazepine & phenytoin. Valproic acid & lamotrigine 74) Valproic acid 75) Diplopia, dizziness & ataxia 76) Gum hyperplasia, lymphadenopathy, hirusitism, rash 77) Sedation, ataxia, rash 78 Ataxia, tremor, hepatotoxicity, thrombocytopenia, GI irritation, hyponatremia 79) Diplopia, ataxia, rash, Steven-Johnson syndrome

80) Presentation of occlusion of anterior cerebral artery? 81) Presentation of occlusion of middle cerebral artery? If dominant hemisphere is involved? If non-dominant hemisphere is involved? 82) Presentation of posterior cerebral artery? Involvement of penetrating branches/CN III palsy? 83) Presentation of occlusion of basilar artery branches? Involvement of post inferior cerebellar artery? 84) Presentation of occlusion of major cerebellar artery? 85) Initial test of choice for cerebrovascular disease? 86) Most sensitive test to detect blood in brain? 87) Most accurate test for detecting cerebral ischemia? 88 Diagnostic workup for pt w/acute ischemic stroke? 89) Tx for pt who present w/in 3 hrs of onset of stroke? 90) When is heparin given in acute ischemic stroke? 91) First line tx for secondary prevention of ischemic stroke? 92) If aspirin allergic or continue to have recurrent CVA on aspirin alone? 93) When to recommend carotid endarterectomy? 94) Most common site of spinal cord compression? 95) Dx test of choice for SC compression? When contraindicated? 96) Plain X-ray abn in what % of SCC? 97) Tx of choice for herniated disc, epidural abscess, hematoma? 98 Tx of SCC? 99) Px of SCC depends on what factor? 100) E.g., of communicating syringomyelia? 101) E.g., of non-communicating syringomyelia? 102) Most common site of syringomyelia? 103) Pattern of subacute combined degeneration (B12 related) 104) Pattern of ant spinal art infarction? 105) Overall 5 yr survival for small cell CA of lung? 106) Overall 5 yr survival for non-small cell CA of lung? 107) Smoking hx of 40 pack/yr increases lung CA risk how many times compared to normal non-smoker individual? 108) Asbestos exposure increases bronchiogenic CA risk by how many times? 109) Centrally located lung CA types? 110) Peripherally located lung CA types? 111) Which lung CA type is associated w/ pleural effusion (w/increase hylauronidase) Dx? 112) Most common sx of lung CA at time of dx?

113) What % of squamous cell CA dx is made by sputum cytology? 114) Best dx procedure for centrally located lung CA? 115) Best dx procedure for peripherally located lung CA? 116) Bulls eye lesion? 117) What % of lung tumors w/ malignant effusion is unresectable? 118) Sx that suggest unresectable lesion of lung CA? 119) Tx of choice for resectable small cell lung CA? 120) Tx of choice for resectable non-small cell lung CA? 121) Tx of effusion associated w/lung CA? 122) Px after surgical resection of squamous cell lung CA? If large cell CA & adenoCA? Ans 80) Contralateral weakness & sensory loss in legs > upp ext. Urinary incontinence, confusion, beh disturbances 81) Contralateral hemiplegia, hemisensory loss, homonymous hemianopia w/ eyes towards cortical lesion. Dominant: aphasia. Nondominant: preserved speech, comprehension w/ confusion & apraxia w/ spatial & constructional deficit 82) Contralateral HH, visual hallucinations, agnosia. Weber synd (w/contralat hemiplegia), Benedikt synd (contralat ataxia or athetosis) 83) Locked in synd (paramedian br) quadrapresis w/ intact vertical eye movement. Wallenberg synd (ipsilat facial sensory loss, contralat body sensory loss, vertigo, ataxia, dysarthria, dysphagia, Horner synd) 84) Vertigo, Vomiting, nystagmus, ipsilat limb ataxia 85) Non contrast head CT 86) Non contrast head CT 87) Diffusion weighted MRI 88 Echo, carotid duplex, 24 hr holter, inherited coagulability 89) Tissue plasminogen activator (tPA) 90) Inc risk of recurrent stroke (A fib, basilar art thrombosis, stroke in evolution) 91) Aspirin 92) Add dipyridamole or clopidrogel 93) When occlusion >70% of arterial lumen & lesion is symptomatic 94) Thoracic cord (70%)level as spinal cord is narrowest at this point 95) MRI of spine. If contraindicated: CT myelogram 96) 84-94% 97) Surgical decompression 98 High dose dexamethasone immediately. For radiosensitive tumors: RT. For others: surgical decompression 99) Functional status at time of presentation (80% who are initially able to ambulate -> retain function later) 100) Arnold Chiari 101) Spinal cord trauma 102) Cervical cord level 103) Distal paresthesia & weakness of ext followed by spastic paresis & ataxia. Combined def of vibration & proprioception w/ pyramidal signs (plantar extension & hyperreflexia) 104) Acute onset of flaccid paralysis->evolves into spastic paresis over

days-wks. Loss of pain & temp (w/ sparing of vibration & position sense as post column is supplied by post spinal art) 105) 5% 106) 8% 107) 60-70x 108) 75x 109) squamous cell CA & small cell CA of lung 110) large cell CA & adeno CA of lung 111) AdenoCA of lung. Often req thoracotomy w/pleural biopsy 112) Cough (74%) Wt loss (68%) 113) 80% 114) Bronchoscopy (90%) helps in staging 115) Needle aspiration biopsy (40-50%) 116) Granuloma 117) 90% 118) Wt loss >10%, bone pain or other extrathoracic mets, CNS sx (tx: RT or chemo), sup vena cava synd, hoarseness, contralat mediastinal adenopathy, split-lung test tidal vol <800ml, classification of MI w/in 3 mo, tumor invasion of trachea, esophagus, pericardium or chest wall 119) Chemo VP16 (etoposide & platinum) 120) Chemo & RT or CAP (cyclophosphamide, adriamycin, platinum) 121) Sclerose w/ tetracycline 122) For squamous lung CA: 30-35%. For large cell & adeno cell lung CA: 25%

123) Define sleep apnea? 124) Tx for obstructive sleep apnea? 125) Tx for central sleep apnea? 126) Dx of sleep apnea? 127) ABGs in ARDS? 128) Swan Ganz catheter findings in ARDS? 129) Tx for ARDS? 130) Mortality rates for ARDS? 131) Most common cause of thrombophilia? 132) Pts at inc risk for post op venous thromboembolism? 133) EKG changes of pulmonary embolism? 134) First test when PE is suspected? 135) Gold stand to dx PE? 136) Gold stand to dx DVT? 137) Pts w/ PE who dont req angiogram for dx? 138) Tx for PE? 139) Tx for PE pts who r hemodynamically unstable? If contraindicated? 140) Tx for hemodynamically stable PE pt w/contraindication to anticoagulation or recurrent PE on anticoagulant? 141) Tx for pregnant pt w/PE or DVT? 142) Epidemiology of silicosis? 143) Epidemiology of asbestosis? 144) Epidemiology of coal miners lung? 145) PFT pattern of pneumoconiosis? 146) Most common CA associated w/ asbestosis? 147) Dx of asbestosis?

148) Main difference b/w asbestosis & acute silicosis? 149) How to evaluate silicosis associated w/TB? 150) CXR findings of asbestosis? 151) CXR findings of silicosis? 152) CXR findings of coal miners lung (CWP)? 153) Associated immunolgoical abn in CWP? 154) What is Caplan synd? 155) What is Lofgren synd? 156) What is Heerfordt-Waldenstrom synd? 157) Lab findings of sarcoidosis? 158) Definitive dx of sarcoidosis? 159) Px of sarcoidosis? 160) In which sarcoidosis pt, steroids r mandatory for tx? 161) 57 yr male w/exercise intolerance over 5 mos. No significant past hx. Over past wk, he gets dyspnea on walking across room. Never smoked. RR 20, JVD 9 cm, coarse crackles, clubbing, trace pedal edema (both legs), CXR: diffuse reticular disease. Dx? Tx? 162) Etiology of bronchiectasis (permanent dilation of small-med bronchi)? 163) Best non-invasive test for bronchiectasis? 164) Tx for bronchiectasis? 165) When are IV antibiotics (aminoglycosides, ceftazidime, or quinolones) used in bronchiectasis? 166) When is surgical tx considered in bronciectasis? 167) What % of smokers develops COPD? 168) What % of COPD pts are smokers? 169) Dx test of choice for COPD? 170) First line tx for COPD? 171) Second line tx for COPD? 172) 2 modalities that decease mortality in COPD pt? 173) COPD + cor pulmonale will benefit from home O2 tx? 174) When are antibiotics used in COPD? 175) First line tx for acute exacerbation of COPD? 176) Best predictor of survival in COPD? 177) When is dyspnea at rest noted? 178) When is dyspnea on exercise noted? 179) Vaccine for COPD pt? 180) Which B agonist used for nocturnal & exercise induced asthma? 181) Asthmatic pt w/HD in whom B agonist & theophylline may be dangerous so what tx? 182) Tx of choice for spontaneous atelectasis? 183) What 3 criteria have to be present for transudative effusion? 184) How to proceed in low risk pt w/ pulmonary nodule? 185) How to proceed in high-risk pt w/ pulmonary nodule? 186) How to maintain O2 content (O2 to vital organs) in critically ill pt? 187) Formula for alveolar-arterial gradient (useful in assessment of oxygenation)? 188) 60 yr male w/chronic bronchitis develop persist diarrhea, what acid base disorder? 189) Markedly obese 24 yr male, what acid base disorder?

190) 14 yr female w/ severe asthmatic attack, what acid base disorder? 191) 56 yr female w/ chronic bronchitis is started on diuretic tx for peripheral edema resulting in 3kg wt loss, what acid base disorder? Ans 123) Cessation of airflow >10 sec at least 10-15x/hr during sleep. Day time somnolence 124) Wt loss & CPAP (as floppy airway but adequate ventilation) 125) Acetazolamide, progesterone & supplemental O2 126) Polysomnography 127) Dec PaO2, N or inc PaCo2 128) N C.O. & capillary wedge press, inc pulm art press 129) Tx underlying dis, PEEP & permissive hypercapnea 130) 70% 131) Factor V leiden 132) >40 yrs w/hx of DVT or prior PE, pts w/ extensive pelvic or abd surg for malignant dis or maj orthopedic surg of lower limbs 133) S1 Q3 T3 (R axis deviation, deep S in lead 1, Q waves in lead 3, inverted T waves in lead 3) w/nonspecific RV strain pattern, sinus tachycardia 134) V/Q scan 135) Angiogram 136) Venogram 137) Pts w/ high probability V/Q scan & high or intermediate clinical suspicion for PE should be treated. Any pt w/ abn V/Q scan and +DVT by US should also be treated. 138) Continuous heparin (5 days) to prolong PTT to 1.5-2x N, Long term warfarin (on day 1 to inc PT 1.3-1.5x N; baseline for 6 mo) 139) Thrombolytic tx (tPA). If contraind: embolectomy 140) Interrupt IVC Greenfield filter 141) LMWH for 6 mo 142) Workers in mining, quarrying, tunneling, glass & pottery making, sand blasting 143) Asbestos exposure in mining, milling, foundry work, shipyard, asbestos application to pipes, brake linings, insulation and boilers 144) Coal dust exposure (amount), high rank (hardness of coal), high silica content of inhaled dust 145) Restrictive w/dec DLCO, hypoxemia w/inc PAO2-PaO2 gradient 146) Bronchiogenic CA (adeno or squamous cell) 147) Lung biopsy: barbell shaped asbestos fiber 148) In acute silicosis: lung failure in months 149) Yearly PPD (if >10mm: INH pox for 9 mo) 150) Diffuse or local pleural thickenings, pleural plaques & calcifications at diaphragm, pleural effusion common at lower lung fields 151) Nodules (1-10mm) seen thru out lungs (prominent in upp lobes), Rare egg shell calcifications, progressive dis (densities >10mm) in large masses 152) Small round densities in parenchyma (upp half of lung), progressive

(densities from 1cm to entire lobe) 153) Inc levels of IgA, IgG, C3, ANA, Rf 154) Rheumatoid nodules in lung periphery in pt w/RA & coexisting pneumoconiosis (usually CWP) 155) Sarcoid synd: Erythema nodosum, arthritis, hilar adenopathy 156) F, parotid enlargement, uveitis & facial palsy 157) Hypercalcemia or hypercalciuria (inc circulation of vit D produced by macrophages), nonspecific inc in ACE (60%), abn in LFT (30%) w/90% symptomatic pt, skin anergy, PFT N or restrictive, uveitis & conjunctivitis (>25%) 158) Biopsy of suspected tissue (non-caseating granuloma) 159) 80% w/lung inv: stable or resolve spontaneously, 20% have progressive dis w/end organ compromise 160) Involvement of CNS, uveitis & hypercalcemia 161) Idiopathic pulmonary fibrosis. Seen in 5th decade, CT: ground glass app. PFT: restrictive. Tx: steroid +/- azathioprine. Px: response to steroids 162) Secondary to repeated pneumonic processes as TB, fungal, lung abscess, and pneumonia (focal bronchiectasis) or when defense mech of lungs are compromised as CF and immotile cilia synd (diffuse b) 163) High resolution chest CT 164) Bronchodilators, chest phys tx, postural drainage, rotating antibiotics (amox, TMP-SMX, amox, amox/clavulanic acid when sputum prod inc or mild sx) 165) If significant sx or pneumonia 166) Localized bronchiectasis w/adequate PFT or massive hemoptysis 167) 10-15% 168) 80-90% 169) PFT (dec FEV1/FVC & FEF 25-75%, inc RV & TLC, DLCO dec in emphysema & N in chronic bronchitis) 170) Anticholinergic (ipratropium bromide; atrovent) 171) B2 agonist (albuterol, terbutaline, metaproterenol) 172) Home O2 tx & smoking cessation 173) PaO2 < 59mmHg 174) Empirically for acute exacerbation of COPD: cover H inf & pneumococcus 175) Systemic steroids (slowly taper w/in 2 wks) 176) Check FEV1 after bronchiodilator (If inc FEV1: better survival, If faster rate of decline of FEV1: worse px) 177) FEV1 < 25% predicted 178) FEV1 < 50% 179) Pneumococcus/5 yr, Influenza/yr 180) Salmeterol (12hr) 181) Anticholinergic (ipratropium bromide: takes 90 min to bronchodilate, has medium potency) 182) Bronchoscopy w/subsequent removal of mucous plugs 183) LDH effusion<200, LDH E/S<0.6, Protein E/S<0.5 184) <35 yr non-smoker w/calcified nodule (follow w/ CXR/3mo for 2 yr. Stop follow up if after 2 yr, there is no growth

185) >50 yr w/smoking hx & nodule->likely bronchiogenic CA so best dx procedure is open lung biopsy & removal of nodule at the same time 186) Keep Hb & C.O. near normal 187) PAO2 PaO2 gradient= 150-1.25 x PCo2-PaO2 (In N young individual its 5-15 mmHg; increases w/hypoxemia except hypoventilation & increase altitude) 188) Combined chronic resp acidosis & metab acidosis 189) Chronic hypercapnia (chronic resp acidosis or metab acidosis) superimposed on acute resp acidosis 190) Acute resp acidosis 191) Chronic resp acidosis superimposed on metabolic alkalosis

192) Best initial screening test for renal artery stenosis? 193) Best noninvasive method to confirm renal art stenosis? 194) Best invasive method to confirm renal art stenosis? 195) Best initial tx for renal art stenosis? 196) Dx of primary hyperaldosternosim (Conn synd)? 197) Tx for Conn synd? 198) Tx for simple kidney cysts? 199) Dx of RTA type I (distal)? 200) Tx for RTA type I (distal)? 201) Dx of RTA type II (proximal)? 202) Tx for RTA type II (proximal)? 203) Dx of RTA type IV (hyporenin/hypoaldosteronism)? 204) Tx for RTA type IV? 205) EKG in hyperkalemia? 206) Tx of hyperkalemia? 207) What is Bartter synd? 208) EKG findings of hypokalemia? 209) Tx of hypokalemia? 210) Tx for hypernatremia? For CDI? For NDI? 211) Dx of hyponatremia? 212) Tx of hyponatremia? Mild (approx 120-130)? Moderate (approx 110120)? Severe (<110 w/sx)? Chronic? 213) Tx of anemia in ESRD? 214) Tx of osteodystrophy (secondary hyperparathyroidism) in ESRD? 215) General tx of ESRD? 216) Indications of dialysis in ESRD? 217) Helpful in dx of post infectious GN? 218) Tx for Goodpasture synd? 219) Which nephritic synd is associated w/ Hep C? 220) Tx for Hemolytic Uremic Synd? 221) Tx for TTP? 222) TX for cryoglobulins IgM & IgG deposits? 223) Tx for HSP? 224) Tx for Wegners granulomatosis? 225) Dx of analgesic nephropathies? 226) Tx of choice for TSS? 227) Dx of blastomycosis? 228) Tx for blastomycosis? Severe? Mild? 229) Best dx test for toxoplasmosis? 230) Best initial test for CNS toxo lesion in AIDS pt?

231) Dx of RMSF? Tx? 232) When to start triple tx for HIV pt? 233) When to give AIDS pt prophylaxis for PCP? What? When to discontinue? 234) When to give MAI px to AIDS pt? What? How to dx MAI in HIV pt? Tx? 235) Prophylaxis for toxo in AIDS? 236) Tx for cryptococcus in AIDS? 237) Best dx test /specific dx for myocarditis? 238) Ultimate dx for gas gangrene? 239) Tx of gas gangrene? 240) Initial dx test for brain abscess? 241) Most accurate test for brain abscess? 242) Most common cause of encephalitis? 243) Most specific & sensitive test for HSV encephalitis? 244) What type of meningitits in pt w/hx of neurosurgery? 245) Best initial test for meningitis? 246) DIC associated w/ which leukemia type? 247) Tx for DIC? 248) Tx for hemophilia A? 249) Most common cause of congenital disorder of hemostasis? 250) Dx of vWD? 251) Tx for vWD? 252) Dx of ITP? 253) Tx of ITP? 254) Virus/bacteria associated w/ Non Hodgkin lymphoma? 255) % Location of cervical/supraclavicular nodes in NHL? 256) Initial dx for NHL & HL? 257) Tx for stage I A & II A of HL & NHL? 258) Tx for stages IB, IIB, III & IV of NHL? 259) Tx of relapses of NHL? 260) % Location to cervical/supraclavicular nodes in HL? 261) Tx for stages IB, IIB, III & IV of HL? 262) Which HL has good prognosis? 263) Dx of CML? 264) Tx of CML? 265) Confirmatory dx of acute leukemia? 266) Differentiation b/w different types of acute leukemia? 267) Tx of acute leukemia? 268) Common causes of death in PNH? 269) Defect in PNH? 270) Dx of PNH? 271) TX of PNH? 272) Defect in hereditary spherocytosis? 273) Dx of heredietary spherocytosis? 274) Tx of heredietary spherocytosis? 275) Specific dx for autoimmune, cold-agglutinin & drug induced hemolytic anemia? 276) Staging for HL & NHL? 277) Etiology of MGUS? 278) Dx of MGUS? 279) Sx of hyperviscosity synd associated w/MM? 280) Confirmatory dx for MM? 281) Tx for MM? Young pt? Old pt? 282) Staging & survival for CLL? 283) Dx of CLL? 284) TX of CLL?

285) Dx of aplastic anemia? 286) Tx of aplastic anemia? 287) Genetic association of CML? Ans: 192) Abd US & captopril renogram 193) Captopril renogram 194) Arteriogram 195) PC transluminal angioplasty 196) Inc aldosterone in urine & blood 197) If adenoma: surgical resection; If hyperplasia: spironolactone 198) If smooth walled w/ no debri in cyst: no further dx or tx; If cysts w/ irregular walls or debri inside cyst: aspirate (R/O malignancy) 199) Acid load test; give NH4Cl (should lower urine pH secondary to inc H+) but in type I, pH remains high. Serum HCO3-=10 200) PO HCO3- as HCO3- reabsorption still works. K+ replacement 201) Pts unable to absorb IV HCO3- load & have basic urine in presence of academia 202) K+ replacement, thiazide diuretics, very large amounts of HCO3203) High urine Na+ w/ PO salt restriction 204) Fludrocortisone 205) Peaked T waves, wide QRS, short QT or prolonged PR interval 206) CaCl, NaHCO3-, Glucose & insulin, diuretic, B agonist, Kayexalate (w/sorbitol), dialysis 207) Primary inability to reabsorb NaCl from loop of Henle-> High renin, high aldosterone, N BP 208) U wave, T wave flattening 209) Correct underlying dis, IV K+ max 10-20 mEq/hr, K+ PO 200-400 mg/point of K+ decrease gut regulates absorption, half N or NS 210) Isotonic IV fluids. For CDI: correct dis, give ADH. For NDI: correct dis, diuretics or NSAIDS 211) Urine Osmolality > Serum Osmolality w/U Na+>40 212) Mild: fluid restriction <1000ml/d; Mod: loop diuretic & NS; Severe: hypertonic saline; Chronic: Li & demeclocycline 213) Erythropoietin & transfusions 214) Vit D, phosphate binders (Amphojel), Ca rep 215) Restrict protein, K, PO4, Mg & give Vit D, CaCo3, DDAVP (for bleeding) 216) Hyperkalemia, acidosis, fluid OL, pericarditis, encephalopathy 217) After pharyngitis or strep skin infect-> smoky urine (hematuria, proteinuria) w/HTN & edema. Inc ASLO, AHT (antihyaluronidase) & dec C3 218) Plasmapheresis (remove circulating Ab) combined w/ steroids & cyclophosphamide 219) Membranoproliferative (immune deposits & dec complement) 220) None as self-limited. Sometimes steroids 221) Plasmapheresis & steroids 222) Plasma exchange 223) Non-specific tx. For refractory cases: steroids 224) Cytotoxics & steroids

225) Sterile pyuria, hematuria, flank pain, mild proteinuria, hx (need 1g/d for 1-3 yrs) 226) Naficillin/oxacillin, restoration of hypovolemic shock, removal of toxin 227) Isolation of fungus in sputum, pus, biopsy 228) Severe: prolonged amphotericin (8-12 wks); mild: itraconazole/ketoconazole (6-12 mo) 229) Visualize parasite in tissue & fluid (serology is the most common method used) 230) Contrast Head CT or MRI, pt is given 10-14 days of tx, then rescan, if lesion shrinks->dx confirmed 231) Specific serology: biopsy of skin lesion. Doxycycline 232) CD4<350 or (on PCR-RNA) VL>55,000 233) CD4<200. TMP-SMZ (most effective), dapsone, atovaquone, aerolized pentamidine (breakthrough). Discontinue when antiretrovirals raise CD4>200 >6mo 234) CD4<50. Px: Azithromycin PO 1/wk or clarithromycin bid (rifabutin is an alternative) Dx: blood culture, bone marrow, liver, and other body tiss or fluids culture. Tx: clarithromycin & ethambutol 235) CD4<100. TMP/SMZ, dapsone/pyrimethamine 236) Amphotericin IV at least 10-14 days followed by fluconazole (life long) 237) Endomyocardial biopsy 238) Direct visualization (usually at surgery) of pale, dead muscle w/brownish, sweet smelling discharge 239) High dose pnc (24 million/d) or clindamycine (if pnc allergic), surgical debridment or amputation, hyperbaric oxygen 240) Head CT w/contrast 241) MRI 242) HSV 243) PCR for HSV has 98% sensitivity & >95% specificity 244) Staph aureus 245) Head CT 246) Promyelocytic leukemia (M3) 247) FFP & sometimes platelets, correct underlying dis 248) Desmopressin (DDAVP) pre-op for mild pts. Factor 8 for severe pts. 249) VWD 250) Abn Ristocetin platelet agg test, low vW factor (aka factor VIII), inc BT, maybe inc PTT 251) Pre-op DDAVP for mild pts, VWF replacement for severe cases 252) Superficial bleeding, thrombocytopenia, N spleen, Antiplatelet Ab (high sensitivity w/poor specificity), Bone marrow filled w/ megakaryocytes, N peripheral smear & creatinine (R/O HUS, TTP, DIC) 253) Initially prednisone (mostly). IF platelet<10,000-20,000 recur even w/ rep steroid course-> splenectomy. If platelet <10,000 & life threatening bleed-> IVIG or Rhogam initially. If no response to IVIG or steroids in life

threatening condition-> platelet transfusion (very rare) 254) HIV, EBV, HTLV-1, H. pylori 255) Only 10-20% 256) Excisional lymph node biopsy 257) Radiation 258) Combination chemo; Initial CHOP (cyclophosphamide, hydroxyadriamycin, oncovin (vincristine), prednisone) 259) Autologous bone marrow transplant 260) 80-90% 261) Combination chemo ABVD (adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine) 262) Lymphocyte predominant HL 263) Inc WBC (predominantly neutrophils), blasts absent or <5%, dec LAP, basophilia, association w/ polycythemia vera, inc B12 264) If <60 yrs w/ suitable donor->bone marrow transp (as 25%/yr convert to acute leukemia); If w/o donor-> IFA initially, if fails-> hydroxyurea (dec # of cells); specific tx: Gleevec (tyrosine kinase inhibitor) 265) Bone marrow biopsy: >30% blasts 266) Monoclonal Ab 267) Initially chemo-> 99.9% remission-> consolidate -> transplant; Initial chemo for AML: cytosine arabinoside & daunorubicin or idarubicin; Initial chemo for ALL: Daunorubicin, vincristine, prednisone & asparginase; Promyelocytic leukemia: Add Vit A derivative (ATRA); CNS px for ALL: intrathecal methotrexate 268) Thrombosis of hep veins (Budd Chiari) 269) RBC memb defect in PIG-A 270) Specific: Sugar water test, Ham test, decrease DAF (decay accelerating factor) 271) If severe blood loss: Fe rep; If severe for unclear reasons: steroids; For thrombosis: anticoagulation 272) AD loss of spectrin (splenomegaly, jaundice, anemia) 273) Sensitive: Osmotic fragility test, Inc MCHC, -ve Coombs test 274) Chronic folate rep; If more severe anemia: splenomegaly 275) Coombs test (smear will show spherocytosis) 276) Stage I: 1 lymphatic gp; Stage II: 2 lymphatic gp on same side of diaphragm; Stage III: lymphatic gp on both sides of diaphragm or inv of any extra lymphatic gp contiguous to primary nodal site; Stage IV: widespread dis w/ different extralymphatic sites as bone marrow or liver 277) Unknown cause. 1% of population>50 yrs & in 3% of those >70yrs 278) Inc monoclonal spike of SPEP (lower than MM), N creatinine, Ca, Hb, inc total protein, no lytic lesion, bone marrow: <5% plasma cells) 279) Blurry vision, confusion, mucosal bleeding 280) Bone marrow biopsy: >10% plasma cell 281) Pre-op chemo VAD (vincristine, adriamycin, dexamethasone). Young pts: autologous bone marrow transp; Older pts: melphalan & prednisone

282) Stage 0: lymphocytosis; Stage I: lymphadenopathy; Stage II: splenomegaly; Stage III: anemia; Stage IV: thrombocytopenia 283) Inc WBC (80-90% lymphocytes), CD19, smudge cells 284) None for stage 0-II if asx; If stage I-II w/sx: chemo; Initial tx: chlorambucil w/prednisone; if dont work: fludarabine 285) CBC: pancytopenia; confirm w/bone marrow biopsy: hypoplastic fat filled w/no abn cells 286) When pt<50yr & healthy: allogenic bone marrow transp (cure 8090%); if not possible: immunosuppresion (remission in 60-70% w/ anti thymocte globulin, cyclosporine & prednisone) 287) Philadelphia chromosome 9-22 (more specific)

A 71.3 y/o married man has been diagnosed to be HIV positive. He comes in to the office to discuss the results and begs you not to tell his wife, who is also your patient. He says that hearing what he has been in involved in "will destroy her." You remind him that HIV may also "kill her." The most appropriate first step is to: A. contact his wife anonymously and tell her that she has been exposed to HIV B. contact the appropriate government health agency and report your findings C. promise him that as his doctor you will respect his privacy and maintain confidentiality D. promise him that you will keep the results confidential if he agrees to use condoms with his wife E. try to persuade him to voluntarily discuss the issue with his wife The correct answer is E. Physicians must violate confidentiality and warn third persons about the danger of HIV infection if the patient is unwilling to inform the person himself. Before informing third parties, the physician should try to do everything possible to persuade the patient to voluntarily discuss the issue with their partner. If the physician believes that an individual may really be saved from a deadly infection, confidentiality should be violated. A 3 and a of the hands aspirin to reduce F), bilateral lymph half y/o boy presents with fever, irritability, and erythema and feet for the past week. His mother has been giving him his temperature. P/E on admission showed a T=39.7 C (103.4 conjunctival injection, an enlarged right-sided cervical

node (1.8-cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. IV fluids were started, the aspirin therapy was continued. Laboratory studies show ESR= 28mm/h Plt= 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The most appropriate therapy at this time is: A. corticosteroids B. ibuprofen C. intravenous gammaglobulin D. oxacillin E. penicillin V The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement. 41 y/o woman with a Hx of similar attacks of epigastric abdominal pain in the past was admitted to the hospital with a Dx of gallstone pancreatitis. She was NPO and IV fluid started. On the evening of admission day, the patient is noted to have T=103.3 F. Her BP & HR are within normal range. Her abdomen is diffusely tender to palpation with guarding. Whats the most appropriate management at this time? A. draw blood cultures and await results B. draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy C. draw blood, urine, and sputum cultures and await results D. obtain an urgent abdominal CT scan E. start ampicillin, gentamicin, and metronidazole therapy The correct answer is B. The most appropriate management at this time is to draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy. Intravenous antibiotics are only indicated if there is evidence of pancreatic necrosis or if the patient develops a fever after the diagnosis of pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis. The

appropriate sequence of events is to draw blood cultures prior to initiating therapy in order to maximize chances of detecting an organism. A 24.6 hour old male infant is noted to have some peculiar jerking movements of the right foot and arm. His axillary temperature an hour before was 36.2"C. The physical examination reveals no unusual findings except that he appears small and premature. His birth weight was 2,550 g. The mother's and infant' s history show that he was the second of twins born after 37 weeks' gestation, presented in transverse position and his heart rate had dropped to 80 per minute 10 minutes prior to birth, with documented fetal hypoxia. He had an Apgar score of 3 at 1 minute and 7 at 5 minutes. The mother had nausea and vomiting during pregnancy for which she was given vitamin B6. She had mild preeclampsia at delivery. *** Which is the most likely diagnosis? a) Brain tumor b) Hypoxemia in utero and possibly during delivery c) Cerebral trauma during delivery d) Vitamin B6 dependency e) None of the above *** In the diagnostic work-up, you may obtain the following tests or procedures, EXCEPT: a) CT scan of the head b) Lumbar puncture for examination and culture of spinal fluid c) Electroencephalography d) Serology for toxoplasmosis e) Blood levels of sugar and calcium answers are B & D Hypoxemia is the leading cause of seizures considering the history of drop in fetal heart rate and low Apgar score at 1 minute. Hypoglycemia, hypocalcemia, vitamin B6 dependency, and meningitis are possible causes of seizures but unlikely and should be ruled out. Some cerebral anomaly is possible. Incidence of congenital malformations is higher in twins than , in singletons, and central nervous system malformations lead all others in frequency. Brain tumors at this age are rare and usually present with recurrent vomiting and not with seizures.