USMLE step 2 CK 2023 Exam with Complete Solutions

pregnant with active HBV - ANSWER-tx newborn with HBIG and HBV vaccine Beck's triad for tamponade - ANSWER-hypotension, JVD, muffled heart sounds (also pulsus paradoxus). Electrical alternans subarachnoid hemorrhage - ANSWER-increased ADH and BNP --> hyponatremia. Tx - water restriction coccidioidomycosis - ANSWER-SW US, central/south America. Pulm infection - dry cough, weight loss, pleuritic chest pain, erythema multiforme/nodosum, arthralgias histoplasmosis - ANSWER-SE US, mid Atlantic, central US, caves. Acute PNA, but usually asymptomatic. HIV disseminated infection- hilar LAD, pneumonitis, pancytopenia, hepatosplenomegaly, palatal ulcers. tx- IV amphotericin B followed by lifelong itraconazole. Blastomycosis - ANSWER-central US (most in Wisconsin). Often asymptomatic or flu-like Sx. Systemic disease- lytic bone lesions, pulmonary infection, skin lesions. Dx- broad-based budding yeast. Tx- itraconazole, amphotericin B aspergillosis - ANSWER-invasive in IMCD. CXR - cavitary lesions. CT - pulm nodules, halo sign, air crescent sporotrichosis - ANSWER-subcutaneous infection. Gardeners. Travel up lymphatics for nodules on forearms cryptococcus - ANSWER-pulm infection often asymptomatic. Usually meningoencephalitis in HIV with CD4<200 hemochromatosis infections - ANSWER-Listeria monocytogenes, Yersinia enterocolitica, septicemia - Vibrio vulnificus Narcolepsy treatment - ANSWER-methyldphenidate, modafinil, antidepressants (for cataplexy) galactorrhea - ANSWER-test B-HCG, prolactin, TSH septic abortion - ANSWER-cervical/blood cultures, antibiotics, gentle suction currettage Lesch-Nyhan - ANSWER-x-linked recessive, HPRT deficiency, increased uric acid. Sx - self mutilation, dystonia, spacticity, gout. Presents at 6 months. minimal change disease - ANSWER-tx - prednisone, cyclophosphamide for resistant cases/frequent relapse Sturge-Weber - ANSWER-seizures, retardation, trigeminal port-wine stain, hemi neuro findings, tramline intracranial calcifications tuberous sclerosis - ANSWER-seizures, retardation, intracranial calcifications (tubers), ashleaf spots, adenoma sebaceum (red papules on face) osteogenesis imperfecta - ANSWER-autosomal dominant. Type 1 collagen problem. Type 2 most severe with perinatal fractures and often intrauterine death. Blue sclera, fractures, hypotonia, hearing loss, joint hypermobility, dentinogenesis imperfecta polymyalgia rheumatica - ANSWER-neck/shoulder/hip pain/stiffness. >50 years old, high ESR. Tx- low dose prednisone, high dose for temporal arteritis massive blood transfusion - ANSWER-citrate anticoagulant --> chelates Ca and Mg --> low Ca --> paresthesias, hyperactive reflexes nephrotic syndrome - ANSWER-dyslipidemia, accelerated atherosclerosis, hypercoagulable, risk for MI/stroke, higher infxn susceptibility. Can have renal vein thrombosis, usually with membranous GN aortic regurgitation - ANSWER-early diastolic (mild) to holodiastolic (severe) murmur. Bounding pulses. Tx- decrease afterload with DHP Ca-channel blockers, ACEi, NOT beta blockers. mycoplasma PNA - ANSWER-erythema multiforme. No cell wall so not on gram stain candidal vulvovaginitis - ANSWER-pseudohyphae. In IMCD and Abx treated people. Tx- oral fluconazole, topical nystatin nonseminomatous germ cell tumor - ANSWER-large anterior mediastinal mass, young males. High HCG and AFP. seminoma - ANSWER-high HCG but normal AFP thymoma - ANSWER-associated with myasthenia gravis, pemphigus hepatocellular carcinoma - ANSWER-high AFP but normal HCG choriocarcinoma - ANSWER-gestational trophoblastic disease usually in molar pregnancy. Very high HCG C. dif diagnosis - ANSWER-cytotoxin assay of stool Erb-Duchenne palsy - ANSWER-C5, C6. waiter's tip, absent Moro but intact grasp Klumpke's paralysis - ANSWER-C7, C8, T1. hand paralysis, Horner's (ptosis, miosis) dermatitis herpetiformis - ANSWER-papulovesicular, pruritic. Associated with Celiac. Dx - IgA anti-endomysial Ab, anti-gliadin phenelzine - ANSWER-MAOi antidepressant. Avoid tyramine (aged meat/cheese) --> HTN crisis CMV esophagitis - ANSWER-in HIV. Dysphagia, odynophagia, shallow ulcers, intranuclear/cytoplasmic inclusions. Tx- ganciclovir IV HSV esophagitis - ANSWER-in HIV. Small ulcers with volcano-like appearnace. Eosinophilic intranuclear inclusions. Tx- acyclovir candidal esophagitis - ANSWER-most common HIV esophagitis. Tx - oral fluconazole splenic rupture - ANSWER-ex-lap if unstable. CT if stable pseudocyesis - ANSWER-pregnancy conversion disorder prolactin - ANSWER-stimulated by serotonin and TRH, inhibited by dopamine. Hypothyroid --> amenorrhea/galactorrhea adenomyosis - ANSWER-endometrial glands in myometrium. Usually > 40yo, dysmenorrhea, menorrhagia, enlarged symmetric uterus. Must curettage to r/o endometrial carcinoma leiomyoma/fibroids - ANSWER-irregular shaped uterus endometriosis - ANSWER-uterus not enlarged. Dysmenorrhea, dyspareunia, dyschezia. Dx- laparoscopy. Tx- OCPs aminoglycosides - ANSWER-amikacin, gentamicin, tobramicin. ototoxic, nephrotoxic. Gentamicin very ototoxic hydroxychloroquine - ANSWER-DMARD. Treats SLE. SE - retinopathy/corneal damage (need q6month eye exams), GI, hemolysis in G6PD methotrexate SE - ANSWER-DMARD. Inhibits folate metabolism. Macrocytic anemia, GI, hepatotoxic, ILD, alopecia, pancytopenia premature ovarian failure - ANSWER-low estrogen, high FSH > LH, <40yo hyperparathyroidism - ANSWER-hypercalcemia - stones, bones, groans, psyciatric overtones, polydipsia, polyuria. pseudogout. Also sometimes HTN low-grade (without mets) gastric MALT lymphoma - ANSWER-H pylori association. Tx- PPI, clarithromycin, amoxicillin Jarisch-Herxheimer rxn - ANSWER-primary/secondary syphilis treated with penicillin --> spirochetes die --> immune complexes --> looks like syphilis flare-up INH SE - ANSWER-hepatitis, peripheral neuropathy/ataxia (give pyridoxine) fanconi anemia - ANSWER-pancytopenia, congenital anomalies, presents 4-12yo. Autosomal recessive. Skin changes diamond-blackfan - ANSWER-pure red cell aplasia, congenital anomalies. Presents 3 months old. Tx - steroids, possibly transfusion transient erythroblastopenia of childhood - ANSWER-RBC aplasia. Presents 6mo - 5yo psoriatic arthritis - ANSWER-DIP, dactylitis. Tx- NSAID, anti-TNF, methotrexate, NOT steroids RA - ANSWER-MCP, PIP, not DIP. Tx- methotrexate, hydroxychloroquine, TNF inhibitors (infliximab, etanercept) OA - ANSWER-DIP adjustment disorder - ANSWER-within 3 months of event, lasts < 6 months post-event. Tx- cognitive/psychodynamic psychotherapy cushing's - ANSWER-high corticosteroids, central obesity, DM, proximal muscle weakness, psychosis, thin skin, purple striae, osteoporosis, hypokalemic alkalosis, secondary HTN APML - ANSWER-Tx- ATRA CML - ANSWER-leukocytosis, anemia, increased granulocytic forms (PMNs, bands), leuk alk phosh low (high in leukemoid reaction). Philadelphia chromosome, t(9:22), BCR-ABL gene. Tx- tyrosine kinase inhibitors (imatinib). Usually > 50yo McCune-Albright - ANSWER-3 P's - precocious puberty, pigmentation (café-au-lait), polyostotic fibrous dysplasia. Associated with other endocrine d/o's - hyperthyroid, prolactinoma, growth hormone, cushing's von Recklinghausen/NF1 - ANSWER-autosomal dominant. café-au-lait, axillary/genital freckling, Lisch nodules, neurofibromas, bony lesions, tumors. NF2 - ANSWER-autosomal dominant. brain tumors, bilateral acoustic neuromas, other tumors. Peutz-Jeghers - ANSWER-autosomal dominant. GI polyposis, mucocutaneous pigmentation, precocious puberty Wiskott-Aldrich - ANSWER-x-linked recessive. Eczema, thrombocytopenia, hypogammaglobulinemia. Infections with encapsulated bacteria. Low platelet production, small platelets TCA toxicity - ANSWER-hyperthermia, seizures, hypoTN, anticholinergic Sx, long QRS (indicates severity of overdose), V-arrythmias. Tx- sodium bicarb slipped capital femoral epiphysis - ANSWER-risk factors: obesity, hypothyroid, growth hormone deficiency/supplementation. tx- surgical pinning. Dx- lateral hip xray hydatidiform mole - ANSWER-triad - large uterus, hyperemesis, HCG > 100,000. dx - pelvic u/s snowstorm alcoholic hepatitis - ANSWER-AST:ALT > 2 autoimmune hepatitis - ANSWER-ANA, anti-smooth muscle Ab Tet spells - ANSWER-tx- knee chest position, morphine, IVF bolus Grave's - ANSWER-chronic Sx. Tx- radioactive iodine, propylthiouracil if pregnant (possible SE of agranulocytosis), propranolol for symptoms Dejerine-Roussy/thalamic stroke - ANSWER-VPL nucleus. Hemianesthesia, athetosis, dysesthesia hypervitaminosis D - ANSWER-hyperCa- stones, bones, groans, psych overtones. Polyuria, polydipsia hemochromatosis - ANSWER-autosomal recessive. bronze DM, hepatomegaly, arthropathy, restrictive heart failure, cardiac conduction problems, hypogonadism, HCC. Dx- iron studies, liver bx to confirm MS - ANSWER-Can have bilateral trigeminal neuralgia. Dx - MRI (cerebral/cerebellar plaques) - periventricular, corpus callosum, deep white matter, basal ganglia parvovirus b19 - ANSWER-kids - slapped cheeks, erythema infectiosum, fifth disease. Adults - viral arthritis, 2 months sx, MCP/PIP/wrists/ankles joints, normal ESR, dx- Anti-B19 IgM liver malignancy - ANSWER-mets (GI, lung, breast, melanoma) 20x more likely than HCC fibromuscular dysplasia - ANSWER-HTN in children/young adults, HA, CVA bruit. "string of beads" on angiogram. Tx- percutaneous angioplasty with stent conn's syndrome - ANSWER-aldosterone adenoma or bilateral adrenal hyperplasia. Presents in older patients - low K, HTN crohn's - ANSWER-non-caseating granuloma, transmural, skip lesions, cobblestoning, creeping fat, fistulas, fissures, mouth-to-anus, spares rectum, often terminal ileum UC - ANSWER-always rectum, only colon, rarely terminal ileum, crypt abscesses, bloody diarrhea. Risk of colon cancer (screen with annual colonoscopies starting 8 yrs after dx) UC extraintestinal Sx - ANSWER-HLA-B27, P-ANCA. PSC, uveitis, arthritis, spondyloarthropathy, erythema nodosum, pyoderma gangrenosum UC toxic megacolon - ANSWER-emergency tx- IVF, Abx, bowel rest, IV steroids, maybe surgery. Worry about perforation. HSV - ANSWER-tzanck smear, multinucleated giant cells, herpetic whitlow amyloidosis - ANSWER-hx of RA, multiple myeloma. Nephrotic syndrome, large kidneys, hepatomegaly, amyloid deposits, apple-green birefringence with congo red, amyloid fibrils on EM. RPGN - ANSWER-crescent formation anti-GBM disease/Goodpasture's - ANSWER-Nephritic + lung. renal biopsy- linear IG deposits. Young males. Type 4 collagen. Tx immediately with plasmapheresis immune complex GN - ANSWER-SLE, poststrep, endocarditis. Granular deposits on immunofluorescence MEN type 1 - ANSWER-Pituitary, pancreatic, parathyroid tumors. hypercalcemia, peptic ulcers (if pancreatic tumor is Z-E gastrinoma). Autosomal dominant, menin gene MEN type 2a - ANSWER-Medullary thyroid cancer, Pheo, Parathyroid hyperplasia. Autosomal dominant, RET gene. Almost all develop medullary thyroid cancer --> prophylactic thyroidectomy MEN type 2b - ANSWER-Medullary thyroid cancer, Pheo, mucosal neuromas, Marfanoid habitus. Autosomal dominant, RET gene hyponatremia - ANSWER-seizures, AMS vitiligo - ANSWER-autoimmune dz, associated with other autoimmune diseases endocarditis - ANSWER-S. viridans - SBE, associated with valve disease, S. aureus (IV drugs - can cause cavitating lung emboli), S. epidermidis (prosthetic valve), S. bovis (colon Ca), enterococcus ototoxic meds - ANSWER-aminoglycosides, loop diuretics (high doses or in renal failure), high aspirin use, chemotherapy lysosomal storage - type 1 - Gaucher - ANSWER-most common, low acid B-glucosidase, Ashkenazi. Presents in adolescence, fatigue, anemia, thrombocytopenia, bruises, bone pain, fractures (Erlenmeyer flask deformity of distal femur), wrinkled paper cells in marrow lysosomal storage - Niemann-Pick - ANSWER-low sphingomyelinase. Fatal in infancy, FTT, hepatosplenomegaly, neurodegenerative, cherry-red macula lysosomal storage - GM1 gangliosidosis - ANSWER-low B-galactosidase. Presents in newborn/infants, hepatosplenomegaly, skeletal abnormalities. lysosomal storage - GM2 gangliosidosis/Tay-Sachs - ANSWER-Low hexosaminidase, high GM2 gangliosides in CNS. Presents early with retinal cherry-red spot, neuro Sx, hepatosplenomegaly lysosomal storage - Farber - ANSWER-low ceramidase, high ceramide in joints. Bone pain and swelling Neuroleptic malignant syndrome - ANSWER-within 2 weeks of neuroleptic. Confusion, fever, diaphoresis, lead pipe rigidity, autonomic instability. Tx- dantrolene, bromocriptine, amantadine neuroleptic dystonia - ANSWER-tx- anticholinergic (benztropine) or antihistamine (diphenhydramine) neuroleptic parkinsonism - ANSWER-onset 4days - 4months. Tx- benztropine neuroleptic akathisia - ANSWER-onset anytime. Tx- propranolol lithium toxicity - ANSWER-tremors, ataxia, AMS, N/V, hypotension. Tx- may need dialysis. lithium SE - ANSWER-nephrotoxic (DI), hypothyroid, teratogen (Ebstein's anomaly - right heart defect) measles - ANSWER-3 C's, Koplik, rash (starts face --> body). Rare complication - subacute sclerosing panencephalitis. Paramyxovirus. Aka rubeola roseola - ANSWER-HHV6, sixth disease, exanthema subitum. High fever, defervescence, rash rubella - ANSWER-togavirus. Aka german measles, 3-day measles. Rash with LAD (posterior cervical/occipital), slight fever, polyarthralgia ARDS - ANSWER-similar picture as cardiogenic pulmonary edema. Differentiate with PCWP < 18. tx- PEEP to counter low compliance, FiO2 < 60% ideally autoimmune hemolytic anemia - ANSWER-pallor, jaundice, splenomegaly, high indirect bili, high reticulocytes, high LDH, normal haptoglobin, extravascular hemolysis. Positive spherocytes, osmotic fragility test, Direct Coomb's hereditary spherocytosis - ANSWER-extravascular hemolysis, autosomal dominant, positive osmotic fragility, NEGATIVE direct Coomb's. Risk of cholelithiasis/cholecystitis, Parvovirus aplastic crisis. Give folate supplementation. paroxysmal nocturnal hemoglobinuria - ANSWER-intravascular hemolysis, low haptoglobin, venous thrombosis, anemia. Abnormal GP1 anchor --> CD55/59 can't bind to prevent destruction. Dx- sugar water test G6PD deficiency - ANSWER-x-linked recessive. Heinz bodies, bite cells. G6PD activity often normal during acute hemolysis. Med precipitants- sulfa drugs, antimalarials, nitrofurantoin. turner's - ANSWER-45XO, coarctation, bicuspid aortic valve, ovarian dysgenesis, low estrogen, high FSH, amenorrhea, horseshoe kidney. Dx- karyotype congenital rubella - ANSWER-via placenta. triad- sensorineural deafness, cataract, heart defects (PDA, ASD). Microcephaly/gnathia, retarded, IUGR, hepatosplenomegaly, thrombocytopenia, blueberry muffin spots. congenital CMV - ANSWER-most common. Hydrocephalus, cerebral calcifications, chorioretinits, microcephaly, microphthalmia, blueberry muffin spots congenital toxo - ANSWER-hydrocephalus, cerebral calcifications, chorioretinitis, retarded congenital syphilis - ANSWER-hepatosplenomegaly, ulcers, jaundice, anemia, rhinorrhea. Xray- metaphyseal dystrophy, periostitis congenital HSV - ANSWER-most infections acquired during birth, so no congenital anomalies. Encephalitis, chorioretinitis, disseminated disease. Lambert-Eaton - ANSWER-presynaptic membrane damage (voltage gated Ca channels), hyporeflexia, strength increases with repetition. Associated with small cell carcinoma of lung Myasthenia Gravis - ANSWER-postsynaptic membrane damage. Facial/ocular muscle weakness worse with repetition. Chest CT to screen for thymoma. Dx- edrophonium. Tx- pyridostigmine paraneoplastic myelopathy - ANSWER-spinal cord damage. Para/quadriplegia, sensory deficits, urinary incontinence/retention dermatomyositis - ANSWER-rash and proximal muscle weakness. Can be paraneoplastic syndrome. Reflexes normal and sensory intact. Dx- high CK, EMG asthma tx - ANSWER-short bronchodilator, low-dose inhaled steroid, long bronchodilator, high-dose inhaled steroid, oral steroid, leukotriene inhibitor sickle cell anemia, hip complication - ANSWER-avascular necrosis systemic sclerosis - ANSWER-CREST. Pulmonary disease - most commonly interstitial fibrosis. ANA, anti-topoisomerase-I Ab. olanzapine - ANSWER-any atypical antipsychotic has most common SE - weight gain. SE- DM, HLD, orthostatic hypotension. Screen glucose and lipids before starting. CO poisoning - ANSWER-carboxyhemoglobinemia. Polycythemia, nausea, dizziness, HA mild preeclampsia - ANSWER-BP>140/90, proteinuria>0.3g/day. Severe- BP>160/110, proteinuria>5g, oliguria, high LFTs, thrombocytopenia, pulmonary edema. >20wks gestation (<20wks is chronic HTN or hydatiform mole) Marfan's - ANSWER-autosomal dominant. Fibrillin-1 gene adult-onset still's disease - ANSWER-Arthralgias, rash, fever. High ferritin, LAD membranous nephropathy - ANSWER-nephrotic, HBV, HCV, malaria, syphilis hepatorenal syndrome - ANSWER-ARF 2/2 cirrhosis. Oliguria, high creatinine. Short life expectancy without liver transplant. constrictive pericarditis - ANSWER-increased JVP, ascites, Kussmaul sign (JVD on inspiration), edema, x/y descents, pericardial knock (after S2). Causes- idiopathic, viral, TB, XRT, surgery cocaine vasospasm - ANSWER-tx- Ca-channel blocker or alpha-blocker phentolamine, NOT beta blocker. Myocardial ischemia tx- BZDs, nitrates, aspirin. cellulitis - ANSWER-GAS, S.aureus. Oral dicloxacillin for mild. IV nafcillin/cefazolin for systemic signs Wegener's granulomatosis - ANSWER-Dx- C-anca and tissue biopsy. Triad- small/medium vessel vasculitis (purpura, ulcers), upper/lower airway granuloma inflammation (with nasopharynx destruction), GN, presents around 40yo. Tx- cyclophosphamide, steroids DM sinus infection - ANSWER-Mucormycosis, Rhizopus. Bloody nasal discharge, proptosis, necrotic turbinates, extend into orbit and brain, death A-fib tx - ANSWER-cardiovert if unstable or stable and < 48 hours onset. If > 48 hours- rate control, anticoag, cardiovert in 4 weeks if symptomatic Absence seizure tx - ANSWER-ethosuximide, valproate partial seizure tx - ANSWER-phenytoin H. pylori tx - ANSWER-amoxicillin, clarithromycin, PPI Calcium levels - ANSWER-high in immobilization (tx with bisphosphanates), low in ARF due to rhabdo, low in low albumin (asymptomatic because ionized calcium normal). Alkalosis --> more calcium binds to albumin --> low ionized calcium --> hypocalcemia symptoms nocturnal enuresis - ANSWER->5yo. Tx- alarms, desmopressin, imipramine HSV keratitis - ANSWER-corneal blindness. Corneal vesicles, dendritic ulcers. Tx- topical/oral antivirals herpes zoster ophthalmicus - ANSWER-in elderly. Vesicular rash CN V1, conjunctivitis, corneal ulcers CMV retinitis - ANSWER-HIV CD4<50. yellow-white retinal patches, retinal hemorrhages. Tx- ganciclovir, foscarnet fungal keratitis - ANSWER-multiple stromal abscesses Pseudomonas aeruginosa tx - ANSWER-cefepime, pip-tazo, aztreonam, ciprofloxacin, imipenem, aminoglycosides lithium DI - ANSWER-damages renal tubules. Tx- amiloride (prevents further lithium accumulation), IVF NS if hypotensive, hypotonic fluids if normotensive steroids for fetal lung maturity - ANSWER-used in period between 24 to 34 weeks gestation Familial adenomatous polyposis (FAP) - ANSWER-adenomatous polyposis coli gene (APC). Autosomal dominant. 100% risk of cancer - tx with proctocolectomy clubfoot - ANSWER-immediate tx- stretching, manipulation, serial casting. Surgery if conservative management not successful pulmonary contusion - ANSWER-severe blunt chest trauma (MVA). Dyspnea, chest pain, hypoxemia worse with IVF, patchy alveolar infiltrates. myocardial contusion - ANSWER-often asymptomatic. Sx- arrythmia, chest pain, heart failure. High PCWP fat embolism - ANSWER-12-72 hours after long bone fractures. Respiratory distress, AMS, petechiae. Tx- respiratory support Schizo dx durations - ANSWER-<1month- brief psychotic disorder. 1-6months- schizophreniform. >6months- schizophrenia dysthymic disorder duration - ANSWER->2 years Metastatic brain tumors - ANSWER-most common intracranial tumor. Commonly from non-small cell lung cancer. Solitary- resect + whole brain XRT. Multiple- whole brain XRT primary syphilis dx - ANSWER-serologic tests often false negative. Dx with spirochetes on darkfield microscopy cluster HA - ANSWER-unilateral retroorbital pain, tearing, rhinorrhea, ipsilateral Horner's syndrome. Tx- 100% O2 and SQ sumatriptan acutely, prophylaxis with verapamil, lithium, ertogamine graft versus host disease - ANSWER-donor T cell activation. Maculopapular rash, heme-positive diarrhea, high LFTs chronic granulomatous disease - ANSWER-infections with catalase-positive S. aureus, Aspergillus, Serratia, Burkholderia, Klebsiella. Dx- nitroblue tetrazolium test. Tx- daily bactrim, gamma-interferon 3x a week shoulder dislocations - ANSWER-anterior- most common, arm held abducted/externally rotated. Posterior- after seizure, arm held adducted/internally rotated. polycythemia vera - ANSWER-high hct, leukocytosis, thrombocytosis, high leukocyte alk phos, normal O2 sat, low epo level, no epo in urine. Pruritus after bathing, splenomegaly, HTN. Tx- phlebotomy to keep HCT<45 Hep E - ANSWER-RNA virus. Sx similar to Hep A. fecal contaminated water transmission. No chronic illness. High risk of fulminant disease in pregnant women, esp 3rd trimester. tinea versicolor - ANSWER-malassezia furfur. Pale macules that don't tan, don't look scaly but scale on scraping. KOH prep - spaghetti and meatballs. Tx- selenium sulfide lotion, ketoconazole shampoo. severe hyponatremia (including SIADH) - ANSWER-tx- 3% saline, no more than 1meq/hr to avoid central pontine myelinosis. Water restriction for mild hyponatremia Stevens Johnson/TEN - ANSWER-<10% body = SJ, >30% = TEN. Common meds- sulfa drugs, barbiturates, phenytoin, NSAIDs. Pneumocystis PNA - ANSWER-dx- sputum induction with hypertonic saline (low sensitivity), BAL if sputum non-diagnostic (high sensitivity). Tx- IV bactrim, +steroids if PaO2<70 lichen sclerosus - ANSWER-postmenopausal women. Tx- potent topical steroids. Clinical dx, but requires regular surveillance to biopsy if vulvar SCC is suspected. valve implicated in endocarditis - ANSWER-usually mitral regurgitation trastuzumab - ANSWER-used to treat HER2 positive breast cancer. Can be cardiotoxic, especially if baseline EF is low, so screen with echocardiogram Hodgkin's after XRT and chemo - ANSWER-3% chance of secondary cancer within 20 years of treatment. Usually lung or breast cancer. vesicoureteral reflux - ANSWER-frequent UTIs leading to renal scarring and ESRD. Dx- VCUG or radionuclide cystogram (done in any child with UTI between 2m-2yo) Leydig cell tumor - ANSWER-high testosterone, high estrogen, suppressed LH/FSH. Gynecomastia in adults, precocious puberty in kids. severe symptomatic hypercalcemia tx - ANSWER-IV NS, hemodialysis as a last resort. Bisphosphanates for hypercalcemia due to malignancy. Ovarian cancer - ANSWER-CA125 and pelvic US for diagnosis. Screening maybe in BRCA positive women. cerebellar tumors - ANSWER-medulloblastoma-vermis, astrocytoma/abscess-hemispheres nocardiosis - ANSWER-filamentous, aerobic, gram positive rod, partially acid fast. Found in soil. PNA/disseminated in IMCD. Tx-bactrim aortic dissection - ANSWER-beta-blockers to lower BP. Surgery in type A, only medical tx in type B spinal cord injury - ANSWER-tx with high dose steroids ASAP necrotizing fasciitis - ANSWER-GAS, S.aureus, mixed aerobic/anaerobic. Tx- debridement, empiric Abx (amp/sulbactam + clindamycin) central cord syndrome - ANSWER-commonly in hyperextension injuries in elderly with cervical spondylosis. Weakness in UE > LE, possibly loss of local pain/temperature optic neuritis - ANSWER-often in MS. Sx- central scotoma, afferent pupillary defect, abnormal colors, descreased visual acuity, pain on eye movement, swollen optic disc esophageal varices - ANSWER-screening endoscopy in any newly diagnosed cirrhosis. Prophylactic tx- beta blockers indications for peds hernia repair - ANSWER-persists to 3yo, over 2cm diameter, symptomatic, strangulation, enlargement after 1yo. trigeminal neuralgia tx - ANSWER-carbamazepine (SE: aplastic anemia - requires routine CBCs) febrile neutropenia - ANSWER-definition- T>38, ANC<500. Admit patient, blood cultures, empiric Abx (cefepime or ceftazidime) Peds myocarditis - ANSWER-usually viral (enterovirus most common). PNA symptoms plus heart failure, dilated cardiomyopathy, mitral regurg, hepatomegaly from congestion, arrhythmias. ciprofloxacin in peds - ANSWER-cartilage destruction, growth retardation severe CF pneumonia - ANSWER-P. aeruginosa. Tx- aminoglycoside + anti-pseudomonal (piperacillin, cefepime, ceftazidime) Trendelenburg sign (hip drop) - ANSWER-gluteus medius/minimus - superior gluteal nerve PKU - ANSWER-autosomal recessive. Fair skin, blue eyes, musty body/urine odor, eczema. High plasma phenylalanine, urine Guthrie test postpartum endometritis - ANSWER-polymicrobial, treat with clindamycin + gentamicin acute otitis media - ANSWER-most common organisms (same for acute sinusitis)- S.pneumo, then non-typeable H.flu, then Moraxella. Tx- amoxicillin rosacea - ANSWER-30 to 60yo. Erythema/telangiectasias on cheeks, nose, chin. Flushing with hot drinks, heat, emotion. wernicke's encephalopathy - ANSWER-thiamine deficiency. Triad- encephalopathy, oculomotor problems, ataxia wilson's disease/hepatolenticular degeneration - ANSWER-autosomal recessive. Abnormal copper deposition. Presents in children as liver disease. Presents in young adults as neuropsychiatric symptoms with abnormal LFTs. Dx- low serum ceruloplasmin, high urinary copper, Kayser-Fleischer rings. Tx- copper chelators (d-penicillamine, trientine), oral zinc, liver transplant alcoholic dilated cardiomyopathy - ANSWER-thrombocytopenia, macrocytic anemia, elevated transaminases. Sobriety in early disease can reverse disease. fibromyalgia - ANSWER-may be due to fatigue from low stage 4 sleep. Tx- amitriptyline, cyclobenzaprine (sleep aids), SSRI if also depressed hypercarbia - ANSWER-confusion, somnolence, seizures, coma porphyria cutanea tarda - ANSWER-painless blisters (on dorsum of hands), hyperpigmentation. Associated with Hep C, ethanol, OCPs. Dx- elevated urinary porphyrins Paget's disease of bone - ANSWER-elderly patients. isolated high alk phos (hypercalcemia if immobilized). Bone pain, big head, HA, deafness, fractures. Dense expanded bone on xray (chaotic mosaic bone). Tx- bisphosphanates if symptomatic. Risk of osteosarcoma. Swinging toddler by arms - ANSWER-nursemaid elbow. Subluxation of head of radius at elbow. Child holds arm in pronation. Closed reduction- supinate forearm, flex elbow. SLE tx - ANSWER-if kidneys involved, do bx to determine type of nephritis. Tx includes methotrexate, cyclophosphamide, steroids eclampsia/severe preeclampsia - ANSWER-admit to hospital, lower BP with hydralazine/labetalol, seizure prophylaxis with magnesium, deliver baby. Mag toxicity- hyporeflexia is first sign, then respiratory depression. d/c mag and give calcium gluconate.