DIP Episode 32 - Comprehensive Medicine Shelf Review Session 4

Medicine Keywords C Some MS4

1 Classic presentation of Unstable Angina. Are there ST or troponin elevations in UA? How is UA differentiated from NSTEMI? Treatment of UA. Are fibrinolytics ever indicated? 2 Vitamin deficiencies associated with chronic pancreatitis/some other cause of fat malabsorption. Presentation of these Vitamin deficiencies. Reversing Warfarin toxicity. Genetic disease associated with an increased incidence of skin necrosis with initiation of Warfarin therapy. 3 Watery, extremely foul smelling diarrhea 2 days after returning from a hiking/camping trip. Bug? Diagnostic testing? Pharmacological management? Immunodeficiency disease associated with recurrent infection with this bug? 4 Most common cause of chronic hyperphosphatemia. Treatment strategies in hyperphosphatemia. Electrolytes that spill into the circulation with tumor lysis syndrome/rhabdomyolysis. Refeeding syndrome and phosphate balance. 5 Most common kind of shoulder dislocation. Commonly affected artery/nerve (+ clinical presentation). HY association with a posterior shoulder dislocation. Most common hip dislocation. 6 Cystic fibrosis. Mechanism of inheritance (and genetic mutation, most common). Pathophysiology. Infectious causes of pneumonia by age. Diagnostic testing. Treatment options (by system). Classic newborn presentation. Reproductive problems. Vitamin deficiencies. Classic nasal/rectal findings. Nutrition in cystic fibrosis patients.

7 Severe chest pain at night in a 25 yo F smoker with a history of migraines. Diagnosis? Pathophysiology? Diagnostic testing (provocative)? Treatment? Drugs to avoid? 8 Nasty anal pruritus in a child. Bug? Treatment? 9 65 yo F presents with signs of pancytopenia. Bone marrow biopsy reveals > 20% blasts. Cells are positive for myeloperoxidase. Auer rods are found on biopsy. Diagnosis? Treatment? Potential complication of treatment? 10 Protozoal cause of bloody diarrhea and liver abscesses. Treatment (including specific intraluminal agent in abscesses). What is the bug that increases the risk of cholangiocarcinoma? 11 Causes of hypoxemia with a normal and elevated A-a gradient. Discussion of mechanisms. 12 EKG leads and MI correlations. What should be avoided in a patient with a right sided infarct? Serum markers in an MI. Diagnosing a reinfarction. 13 75 yo M with recurrent infections. CBC is notable for a lymphocyte count of 109k. PE reveals anterior and posterior cervical lymphadenopathy with a blood smear revealing a preponderance of smudge cells. These cells are CD5/19/20/21 +ve. Diagnosis? Preventing tumor lysis syndrome with treatment. 14 Watery diarrhea after consuming undercooked oysters. Bug? Is there a population that could present severely when infected? Treatment strategies. 15 Patient on eclampsia prophylaxis is found by a med student to have ⅖ patellar tendon reflexes. The resident elicited 5/5 reflexes a few hours ago. Diagnosis?

Potential sequelae. Ca balance with this presentation? Protecting the myocardium. Other treatment strategies. Hypomagnesemia and refractory electrolyte replenishment. 16 Cardiogenic vs noncardiogenic pulmonary edema. Treatment of pulmonary edema. Pharmacological improvement of cardiac systolic function. 17 When is a percutaneous coronary intervention indicated for an MI? When should TPA be administered instead? Contraindications to TPA. Treatment of left main stenosis or 3 vessel disease. Acute MI management. 18 Brush border enzyme deficiency in an Asian immigrant that presents with abdominal pain and bloating after consuming cheese. Diagnosis? Pathophysiology? Breath testing. 19 Abdominal discomfort + pancytopenia + bone marrow biopsy revealing a dry tap + cells that stain +ve for Tartrate Resistant Acid Phosphatase + lymphoid cells with fine cytoplasmic projections on histology. Diagnosis? 20 Watery diarrhea and severe vomiting for a 3 day period after consuming fried rice at a Korean restaurant. Bug? 21 Patient with a history of HBV presents with asymmetric neurological deficits + weight loss + severe abdominal pain after meals + ANCA -ve + segmental transmural inflammation detected on renal angiography. Diagnosis? 22 Primary spontaneous pneumothorax (PTX) vs tension PTX. Classic demographic. Common secondary causes. Classic presentation. Auscultation findings (spontaneous vs tension). Management considerations (stable vs unstable, large vs small).

Bottom or top of intercostal space? 23 Emphysema. Risk factors (centriacinar vs panacinar). Pathophysiology. Diagnostic testing. Findings on imaging and PFT testing. Differentiating emphysema from chronic bronchitis. GOLD staging. Treatment by GOLD staging criteria. Key difference b/w asthma and emphysema management. Improving survival. Cor Pulmonale. 24 PFT findings in pneumoconiosis. Asbestosis (histological finding, lung lobes affected, most common lung malignancy, classic XR/thoracentesis presentation of mesothelioma). Caplan syndrome. Pneumoconiosis and increased TB risk. 25 Interstitial infiltrates on CXR + Sputum sample revealing broad based budding yeasts on histology + hemoptysis/productive cough/shortness of breath + Indiana resident + Gray skin lesions. Diagnosis? Treatment? 26-Drugs and Bugs Hospitalized patient with fever and diarrhea. Endocarditis in a patient with prosthetic valves. Fever in an ICU patient with a long history of alcohol abuse. Common causes of drug fever. Drugs that cover MRSA and Pseudomonas. Classic LP/imaging findings in HSV encephalitis. 27-Drugs Antibiotic coverage of Neisserial infection (+ co-treatment). Coverage of most abdominal infections. Simple UTI management. Pyelonephritis treatment. Community acquired pneumonia. RMSF. Syphilis management. Flu coverage. Commonly tested antibiotic side effects. 28 HIV Pharmacology (MOA and common side effects).

Watery diarrhea, meningitis, difficulty swallowing, skin lesions, ring enhancing lesions on MRI (single vs multiple), white non-scrapable oral lesions in an AIDS patient. Treatment of these different disorders. Prophylactic strategies in HIV infection and CD4 thresholds. 29 CML. Pathophysiology (including genetics). Diagnostic testing. Classic CBC findings. Signs and symptoms. Classic patient demographics. Treatment strategies (pharmacology). Differentiating b/w CML and a leukemoid reaction. 30 Next best step in the management of a neutropenic fever. Quick discussion and test worthy considerations with anti-cancer pharmacology. Management of cancer related cachexia. 31 Classic NBME causes of high output heart failure (bone, hematologic). Differential diagnosis of eosinophilia (super HY for the shelf). 32 HIV+ patient with the acute onset of shortness of breath, productive cough, and high fevers. CD4 count is 150. CXR shows a lobar consolidation. What is the most likely offending organism? 33 HIV complications (and associated bugs). Retinitis. Esophagitis. Meningitis. Diarrhea. Bacillary angiomatosis. Ataxia + motor deficits (+ associated MS drug). Histoplasmosis and Coccidioidomycosis prophylaxis. 34 Metabolic acidosis. Causes of a high and a normal anion gap acidosis. Equations for the serum and urine anion gap. Differentiating between diarrhea and RT As as causes of a normal anion gap. RT As (all types and serum findings). Winters Formula.

35 Common causes of a metabolic alkalosis (drugs, diseases, volume depletion). Conn syndrome. 36 Smoker OR Egyptian with history of chronic schistosomiasis OR patient with a history of nephrotic syndrome well controlled with cyclophosphamide presenting with hematuria. Diagnosis? Diagnostic testing? Treatment strategies. HY causes of hemorrhagic cystitis. 37 Indications for dialysis. Complications of uremia. First use syndrome. Amyloidosis in patients on chronic dialysis (involved protein). Abdominal pain, distension, and high fevers in a patient that undergoes regular peritoneal dialysis. 38 Flank pain + CVA tenderness + High fevers + Urgency/Frequency/Dysuria. Diagnosis? Diagnostic testing? What will you find on urinalysis? Treatment options (specific pharmacology, these are HY). Who should get outpatient treatment vs IV antibiotics. Common bugs. 39 Quick overview of renal physiology (and transporter diseases). Quick overview of renal endocrinology. Quick overview, MOA, and commonly tested side effects with the diuretics (including elyte anomalies). HY off-target diuretic uses. Bartter’s, Gitelman’s, and Liddle’s syndromes. 40 FSGS. Classic demographic. Collapsing variant. Electron microscopy findings. Treatment strategies. 41-HY Renal Disorders/RPGN Goodpasture’s syndrome. Post Strep glomerulonephritis. Lupus nephritis. IgA nephropathy. Henoch Schonlein purpura. Granulomatosis with polyangiitis (Wegener’s). EGPA (Churg Strauss). Microscopic polyangiitis.

Discussion of HY associations/presentation. Immunofluorescence patterns. 42 Beck’s triad of cardiac tamponade. Hemodynamic parameters in cardiac tamponade. Treatment strategies. 43 Very basic AVNRT overview (pathophysiology). Basic management strategies. Management of an unstable AVNRT patient (recurring theme). Basic AVRT overview (+WPW, classic EKG finding, treatment). Differentiating b/w orthodromic and antidromic AVRT on EKG. Treatment differences b/w ortho/antidromic AVRT. WPW

Orthodromic vs Antidromic AVRT

Prolonged QT Interval

Torsade de Pointes

44 Causes of a prolonged QT interval (drugs, electrolytes). Torsade de pointes. TdP treatment. Quick antiarrhythmic review. 45 Cardiovascular parameter changes with physiologic manipulation (arrow questions on NBM Es). Examples to consider-> Milrinone administration, NE administration, Hydralazine administration, Nitrate administration. Re-review of murmur physiology. 46 Recent knife wound to the arm + PE revealing a warm, pulsating, palpable arm mass + Echocardiography revealing an EF of 75%. Diagnosis? 47 Japanese female with abdominal pain + > 10 mm Hg difference in systolic B Ps in the arms + 6 mo history of low grade fevers + CBC revealing marked elevations in ESR and CRP. Diagnosis? 48 Pericardial knock on auscultation + JVP increase with inspiration + Reduced EDV on echocardiography. Diagnosis? Key NBME distinguishing feature from cardiac tamponade. 49 Most common cause of death after an MI. Ventricular free wall rupture. Interventricular septal rupture. Papillary muscle rupture. Peri-infarction pericarditis. Dressler’s syndrome. Post-MI medications. 50 Colon cancer screening guidelines (age, modalities). First degree relative diagnosed with colon cancer at 52. Multiple colon polyps in a 22 yo. Colon polyps (+ bone and soft tissue tumors, + brain tumors). Commonly implicated gene mutation. Early colon cancer arising from normal mucosa. Peutz Jeghers Syndrome. 51 Brief overview of GI pharmacology (primarily GERD treatment and H. Pylori therapy).

MO As and unique side effects. 52 35 yo F with a 15 year history of OCP use presenting with RUQ pain. US reveals a well circumscribed hepatic mass. 53 60 yo M presents with a 7 week history of bilateral knee pain and chronic diarrhea. Endoscopy with biopsy of the intestinal mucosa reveals PAS+ macrophages and villous atrophy. A PE is notable a murmur that was not present at the last visit. Diagnosis? Bug? 54 60 yo M presents with a long history of halitosis and difficulty swallowing. A palpable mass is felt in the neck with swallowing. Diagnosis? Diagnostic testing? Treatment? Difficulty swallowing + chest pain radiating to the jaw relieved with nitrates. Diagnosis? Diagnostic testing? Treatment? 55 47 yo F with a history of “relentless DM” presents with a 1 week history of a necrotic, erythematous skin lesion. Diagnosis? Endocrine “syndrome” association. Treatment. 56 Diabetic gastroparesis. Pathophysiology. Treatment strategies. Severe abdominal pain and distension in a 60 yo M septic patient. There is no obstructing lesion identified on abdominal CT. 57 Elevated creatinine and oliguria in a patient with a history of ESLD. Diagnosis? Possible pathophysiology? Associated urine labs? Distinguishing this presentation from prerenal azotemia. Treatment. Hypoxia with standing/walking that improves with recumbency in a patient with a history of ESLD. Diagnosis? 58 Cruise ship gastroenteritis.

Diarrhea with the following associations (AIDS patient, 2 hrs after eating potato salad, daycare, oyster consumer, consuming fried rice, pork consumption, bloody diarrhea from eggs and poultry, common cause of bloody diarrhea in the US). 59 AST/ALT ratios in alcoholic liver disease. Most sensitive serum marker for ROH liver disease. Common hepatotoxic medications (VSTAA, 5). 60 MEN1 syndrome. MEN1 syndrome + jejunal ulcers + unrelenting GERD. Diagnosis? Diagnostic testing? Treatment (pharmacology, 2 options). 61-Miscellaneous Topics Associated autoantibodies in Type 1 and 2 autoimmune hepatitis. UC vs Crohn’s. Hemochromatosis. Complications of cirrhosis/hepatic encephalopathy. GERD management. Pancreatic cancer diagnosis/mgt. Budd Chiari syndrome. Acetaminophen OD.

Beck's Triad: Hypotension, Muffled heart sounds, and elevated Jugular Venous Distention (JVD).

Vitamin deficiencies include fat-soluble vitamins (A, D, E, K) and potentially B12.

Associated injury to the axillary nerve and often involves greater tuberosity fracture; suspicion for radial/ulnar nerve damage is also high.

Diminished patellar tendon reflexes (hyporeflexia), as magnesium is necessary for proper neuromuscular function.

Mucocutaneous pigmentation (dark spots) around the mouth, lips, and buccal mucosa, along with an increased risk of GI/colorectal polyps and cancers.

V/Q mismatching (e.g., atelectasis or pneumonia).

High chloride concentration in sweat; obstructive pattern on PF Ts, often with low FEV1/FVC ratio.

Vibrio parahaemolyticus.

Mutations in the CFTR gene (Cystic Fibrosis Transmembrane Conductance Regulator).

Post-streptococcal glomerulonephritis.

Increased delivery of Na+ to the distal tubule enhances K+ secretion via increased activity of the Na+/K+-AT Pase pump.

Acute leukemia (e.g., AML), aplastic anemia, or myelodysplastic syndrome (MDS).

Emphysema typically shows hyperinflation/flattened diaphragms; Chronic bronchitis often presents with a more pronounced cough/mucus production history.

High chloride concentration in sweat; obstructive pattern on PF Ts, often with low FEV1/FVC ratio.

Vibrio parahaemolyticus.

Mutations in the CFTR gene (Cystic Fibrosis Transmembrane Conductance Regulator).

Post-streptococcal glomerulonephritis.

Increased delivery of Na+ to the distal tubule enhances K+ secretion via increased activity of the Na+/K+-AT Pase pump.

Acute leukemia (e.g., AML), aplastic anemia, or myelodysplastic syndrome (MDS).

Emphysema typically shows hyperinflation/flattened diaphragms; Chronic bronchitis often presents with a more pronounced cough/mucus production history.