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 night’s 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)nystagmus27) Peripheral vertigo a)onset b)tinitis,HL c)diplopia,blindness,dysarthria,weakness d)nystagmus2 Triad of Meniere’s disease?29) Two most common causes of Meniere’s 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 Gravis2) Dis. Of NMJ, presents with weakness and fatigue. Ab to Ach receptors -> dec # of active/functional Ach receptors at postsynaptic membrane3) Ach receptor Ab4) Fatigued muscle weakness plus +Ach receptor Ab test5) Edrophonium (Tensilon) test6) EMG (decremental dec in muscle fiber content on repetitive nerve stimulation7) Anticholinesterase (pyridostigmine)Immunosuppressive tx with glucocorticoids

9) Azathioprine and steroid combo10) Plasmapheresis and IVIG11) Thymectomy12) Gullian-Barre synd (Acute idiopathic polyneuropathy)13) Acute severe polyradiculopathy w/autoimmune destruction of myelin. Body’s immune system attacks self antigens (molecular mimicry)14) Pain, tingling dysthesia. Loss of large sensory fibers -> loss of reflexes and proprioception15) 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: ergotamine21) 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 analgesics23) Relaxation & NSAIDS, if refractory: musc relaxants24) Predinisone, Li, ergotamine, methylsergide & verapamil25) 100% oxygen, alternative: sumatriptan26) Central vertigo a)gradual b)absent c)present d)pure, vertical, does not suppress w/fixation &multidirectional27) Peripheral vertigo a)usually sudden b)present c)absent d)mixed,horizontal,suppress w/fixation,unidirectional2 Tinitis, hearing loss, episodic vertigo (1-8 hr)29) Syphilis & head trauma30) Perilymphatic fistula31) Meclizine. If severe: diazepam

32) Medical tx for Meniere’s 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 Pick’s 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 Parkinson’s 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 decompression33) Meclizine. If severe: diazepam34) Hypothyroidism, Vit B12 def, Hep/uremic encephalopathy, CNS vasculitis, Syphilis, Brain abscess, Brain tumor, Meds (anticholinergic), Sleep apnea, Trauma, Subdural hematoma, NPH, Depression35) Progressive multifocal leukoencephalopathy, Alzheimer’s dis, Dementia w/ Lewy bodies, Frontotemporal degeneration (Pick’s dis), Vascular dementia

multiinfarct, Binswanger dis), Creutzfeldt Jakob dis36) Personality changes w/visuospatial sparing37) Dementia & myoclonus (aggressive wks-mo)3 Subcortical white matter (slow)39) Donepezil. Others: anticholinesterase inhibitors (rivastigmine, tacrine); discontinue if no improvement in 3-6 mo40) Multiple sclerosis41) Inflammatory dis of CNS white matter, multifactorial (infections, diet, climatic), focal areas of demyelination42) 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 exacerbation44) Brain MRI45) Brain MRI46) CSF (mild pleocytosis <50 cells, inc IgG oligoclonal band 70-90%pts)47) Disease modifying agents: IFN B1b, IFN B1a, glatiramer acetate4 IFN B1b &mitoxantrone49) Methotrexate, cyclophosphamide, IVIG or azithropine50) No disease modifying tx approved yet51) 3 days of intense IV steroids-> oral steroids (taper over 4 wks) If severe & steroid unresponsive: plasma exchange52) baclofen53) tizandine, diazepam54) oxybutynin55) bethanechol56) amantadine or fluoxetine57) sildenafil acetate5 Neurologic synd from def of neurotransmitter dopamine as consequence of degenerative, vascular or inflammatory changes in basal ganglia59) Supranuclear palsy60) Olivopontocerebellar atrophy61) Shy Dragger synd62) Anticholinergic meds63) Amantadine64) Carbidopa/levodopa65) Sustained rel form of carbidopa/levodopa adding dopamine agonist, selegiline or COMT inhibitors or restriction of protein meal to night66) Selegiline67) Surgery for who cant tolerate or respond adequately to medical tx. Procedures: pallidotomy & thalamotomy68 Electroencephalogram69) 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 propofol70) If Pt has abnormal neurologic exam, presented w/ status epilepticus, has strong family hx of seizures, or has abnormal EEG71) Valproic acid (inc availability of GABA). If not a choice, pick lamotrigine (dec glutamate release)72) Ethosuximide. Valproic acid

73) Carbamazepine & phenytoin. Valproic acid & lamotrigine74) Valproic acid75) Diplopia, dizziness & ataxia76) Gum hyperplasia, lymphadenopathy, hirusitism, rash77) Sedation, ataxia, rash78 Ataxia, tremor, hepatotoxicity, thrombocytopenia, GI irritation, hyponatremia79) 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) Bull’s 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?

Ans80) Contralateral weakness & sensory loss in legs > upp ext. Urinary incontinence, confusion, beh disturbances81) Contralateral hemiplegia, hemisensory loss, homonymous hemianopia w/ eyes towards cortical lesion. Dominant: aphasia. Nondominant: preserved speech, comprehension w/ confusion & apraxia w/ spatial & constructional deficit82) 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 ataxia85) Non contrast head CT86) Non contrast head CT87) Diffusion weighted MRI88 Echo, carotid duplex, 24 hr holter, inherited coagulability89) Tissue plasminogen activator (tPA)90) Inc risk of recurrent stroke (A fib, basilar art thrombosis, stroke in evolution)91) Aspirin92) Add dipyridamole or clopidrogel93) When occlusion >70% of arterial lumen & lesion is symptomatic94) Thoracic cord (70%)level as spinal cord is narrowest at this point95) MRI of spine. If contraindicated: CT myelogram96) 84-94%97) Surgical decompression98 High dose dexamethasone immediately. For radiosensitive tumors: RT. For others: surgical decompression99) Functional status at time of presentation (80% who are initially able to ambulate -> retain function later)100) Arnold Chiari101) Spinal cord trauma102) Cervical cord level103) 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) 75x109) squamous cell CA & small cell CA of lung110) large cell CA & adeno CA of lung111) AdenoCA of lung. Often req thoracotomy w/pleural biopsy112) Cough (74%) Wt loss (68%)113) 80%114) Bronchoscopy (90%) helps in staging115) Needle aspiration biopsy (40-50%)116) Granuloma117) 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 wall119) Chemo VP16 (etoposide & platinum)120) Chemo & RT or CAP (cyclophosphamide, adriamycin, platinum)121) Sclerose w/ tetracycline122) 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 don’t 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 miner’s 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 miner’s 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?

Ans123) Cessation of airflow >10 sec at least 10-15x/hr during sleep. Day time

somnolence124) Wt loss & CPAP (as floppy airway but adequate ventilation)125) Acetazolamide, progesterone & supplemental O2126) Polysomnography127) Dec PaO2, N or inc PaCo2128) N C.O. & capillary wedge press, inc pulm art press129) Tx underlying dis, PEEP & permissive hypercapnea130) 70%131) Factor V leiden132) >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 limbs133) 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 tachycardia134) V/Q scan135) Angiogram136) Venogram137) 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: embolectomy140) Interrupt IVC Greenfield filter141) LMWH for 6 mo142) Workers in mining, quarrying, tunneling, glass & pottery making, sand blasting143) Asbestos exposure in mining, milling, foundry work, shipyard, asbestos application to pipes, brake linings, insulation and boilers144) Coal dust exposure (amount), high rank (hardness of coal), high silica content of inhaled dust145) Restrictive w/dec DLCO, hypoxemia w/inc PAO2-PaO2 gradient146) Bronchiogenic CA (adeno or squamous cell)147) Lung biopsy: barbell shaped asbestos fiber148) In acute silicosis: lung failure in months149) 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 fields151) Nodules (1-10mm) seen thru out lungs (prominent in upp lobes), Rare egg shell calcifications, progressive dis (densities >10mm) in large masses152) Small round densities in parenchyma (upp half of lung), progressive (densities from 1cm to entire lobe)153) Inc levels of IgA, IgG, C3, ANA, Rf154) Rheumatoid nodules in lung periphery in pt w/RA & coexisting pneumoconiosis (usually CWP)155) Sarcoid synd: Erythema nodosum, arthritis, hilar adenopathy156) F, parotid enlargement, uveitis & facial palsy157) 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 compromise160) Involvement of CNS, uveitis & hypercalcemia161) Idiopathic pulmonary fibrosis. Seen in 5th decade, CT: ground glass app. PFT: restrictive. Tx: steroid +/- azathioprine. Px: response to steroids162) 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 CT164) 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 pneumonia166) Localized bronchiectasis w/adequate PFT or massive hemoptysis167) 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 cessation173) PaO2 < 59mmHg174) Empirically for acute exacerbation of COPD: cover H inf & pneumococcus175) 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% predicted178) FEV1 < 50%179) Pneumococcus/5 yr, Influenza/yr180) Salmeterol (12hr)181) Anticholinergic (ipratropium bromide: takes 90 min to bronchodilate, has medium potency)182) Bronchoscopy w/subsequent removal of mucous plugs183) LDH effusion<200, LDH E/S<0.6, Protein E/S<0.5184) <35 yr non-smoker w/calcified nodule (follow w/ CXR/3mo for 2 yr. Stop follow up if after 2 yr, there is no growth185) >50 yr w/smoking hx & nodule->likely bronchiogenic CA so best dx procedure is open lung biopsy & removal of nodule at the same time186) Keep Hb & C.O. near normal187) 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 acidosis189) Chronic hypercapnia (chronic resp acidosis or metab acidosis) superimposed on acute resp acidosis

190) Acute resp acidosis191) 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 110-120)? 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 Wegner’s 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 renogram193) Captopril renogram194) Arteriogram195) PC transluminal angioplasty

196) Inc aldosterone in urine & blood197) If adenoma: surgical resection; If hyperplasia: spironolactone198) 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-=10200) PO HCO3- as HCO3- reabsorption still works. K+ replacement201) Pts unable to absorb IV HCO3- load & have basic urine in presence of academia202) K+ replacement, thiazide diuretics, very large amounts of HCO3-203) High urine Na+ w/ PO salt restriction204) Fludrocortisone205) Peaked T waves, wide QRS, short QT or prolonged PR interval206) CaCl, NaHCO3-, Glucose & insulin, diuretic, B agonist, Kayexalate (w/sorbitol), dialysis207) Primary inability to reabsorb NaCl from loop of Henle-> High renin, high aldosterone, N BP208) U wave, T wave flattening209) 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 NS210) Isotonic IV fluids. For CDI: correct dis, give ADH. For NDI: correct dis, diuretics or NSAIDS211) Urine Osmolality > Serum Osmolality w/U Na+>40212) Mild: fluid restriction <1000ml/d; Mod: loop diuretic & NS; Severe: hypertonic saline; Chronic: Li & demeclocycline213) Erythropoietin & transfusions214) Vit D, phosphate binders (Amphojel), Ca rep215) Restrict protein, K, PO4, Mg & give Vit D, CaCo3, DDAVP (for bleeding)216) Hyperkalemia, acidosis, fluid OL, pericarditis, encephalopathy217) After pharyngitis or strep skin infect-> smoky urine (hematuria, proteinuria) w/HTN & edema. Inc ASLO, AHT (antihyaluronidase) & dec C3218) Plasmapheresis (remove circulating Ab) combined w/ steroids & cyclophosphamide219) Membranoproliferative (immune deposits & dec complement)220) None as self-limited. Sometimes steroids221) Plasmapheresis & steroids222) Plasma exchange223) Non-specific tx. For refractory cases: steroids224) Cytotoxics & steroids225) Sterile pyuria, hematuria, flank pain, mild proteinuria, hx (need 1g/d for 1-3 yrs)226) Naficillin/oxacillin, restoration of hypovolemic shock, removal of toxin227) Isolation of fungus in sputum, pus, biopsy228) 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 re-scan, if

lesion shrinks->dx confirmed231) Specific serology: biopsy of skin lesion. Doxycycline232) CD4<350 or (on PCR-RNA) VL>55,000233) CD4<200. TMP-SMZ (most effective), dapsone, atovaquone, aerolized pentamidine (breakthrough). Discontinue when antiretrovirals raise CD4>200 >6mo234) 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 & ethambutol235) CD4<100. TMP/SMZ, dapsone/pyrimethamine236) Amphotericin IV at least 10-14 days followed by fluconazole (life long)237) Endomyocardial biopsy238) Direct visualization (usually at surgery) of pale, dead muscle w/brownish, sweet smelling discharge239) High dose pnc (24 million/d) or clindamycine (if pnc allergic), surgical debridment or amputation, hyperbaric oxygen240) Head CT w/contrast241) MRI242) HSV243) PCR for HSV has 98% sensitivity & >95% specificity244) Staph aureus245) Head CT246) Promyelocytic leukemia (M3)247) FFP & sometimes platelets, correct underlying dis248) Desmopressin (DDAVP) pre-op for mild pts. Factor 8 for severe pts.249) VWD250) Abn Ristocetin platelet agg test, low vW factor (aka factor VIII), inc BT, maybe inc PTT251) Pre-op DDAVP for mild pts, VWF replacement for severe cases252) 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. pylori255) Only 10-20%256) Excisional lymph node biopsy257) Radiation258) Combination chemo; Initial CHOP (cyclophosphamide, hydroxy-adriamycin, oncovin (vincristine), prednisone)259) Autologous bone marrow transplant260) 80-90%261) Combination chemo ABVD (adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine)262) Lymphocyte predominant HL263) Inc WBC (predominantly neutrophils), blasts absent or <5%, dec LAP,

basophilia, association w/ polycythemia vera, inc B12264) 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% blasts266) Monoclonal Ab267) 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 methotrexate268) Thrombosis of hep veins (Budd Chiari)269) RBC memb defect in PIG-A270) 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: anticoagulation272) AD loss of spectrin (splenomegaly, jaundice, anemia)273) Sensitive: Osmotic fragility test, Inc MCHC, -ve Coombs test274) Chronic folate rep; If more severe anemia: splenomegaly275) 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 liver277) Unknown cause. 1% of population>50 yrs & in 3% of those >70yrs278) 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 bleeding280) Bone marrow biopsy: >10% plasma cell281) Pre-op chemo VAD (vincristine, adriamycin, dexamethasone). Young pts: autologous bone marrow transp; Older pts: melphalan & prednisone282) Stage 0: lymphocytosis; Stage I: lymphadenopathy; Stage II: splenomegaly; Stage III: anemia; Stage IV: thrombocytopenia283) Inc WBC (80-90% lymphocytes), CD19, smudge cells284) None for stage 0-II if asx; If stage I-II w/sx: chemo; Initial tx: chlorambucil w/prednisone; if don’t work: fludarabine285) CBC: pancytopenia; confirm w/bone marrow biopsy: hypoplastic fat filled w/no abn cells286) When pt<50yr & healthy: allogenic bone marrow transp (cure 80-90%); 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 HIVB. contact the appropriate government health agency and report your findingsC. promise him that as his doctor you will respect his privacy and maintain confidentialityD. promise him that you will keep the results confidential if he agrees to use condoms with his wifeE. try to persuade him to voluntarily discuss the issue with his wifeThe 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 half y/o boy presents with fever, irritability, and erythema of the hands and feet for the past week. His mother has been giving him aspirin to reduce his temperature. P/E on admission showed a T=39.7 C (103.4 F), bilateral conjunctival injection, an enlarged right-sided cervical lymph 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. corticosteroidsB. ibuprofenC. intravenous gammaglobulinD. oxacillinE. penicillin VThe 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. What’s the most appropriate management at this time?A. draw blood cultures and await resultsB. draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapyC. draw blood, urine, and sputum cultures and await resultsD. obtain an urgent abdominal CT scanE. start ampicillin, gentamicin, and metronidazole therapyThe 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 tumorb) Hypoxemia in utero and possibly during deliveryc) Cerebral trauma during deliveryd) Vitamin B6 dependencye) None of the above*** In the diagnostic work-up, you may obtain the following tests or procedures, EXCEPT:a) CT scan of the headb) Lumbar puncture for examination and culture of spinal fluidc) Electroencephalographyd) Serology for toxoplasmosise) Blood levels of sugar and calciumanswers are B & DHypoxemia 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.