internal medicine high yield review topics -...

Dr.G.Bhanu Prakash – www.mbbsinchina.us www.gims-org.com

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INTERNAL MEDICINE High Yield REVIEW Topics

"For students by Global Institute Of Medical

Sciences"

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)nystagmus

27) Peripheral vertigo a)onset b)tinitis,HL

c)diplopia,blindness,dysarthria,weakness

d)nystagmus

2 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 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.



Body’s 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 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 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, Alzheimer’s dis,

Dementia w/

Lewy bodies, Frontotemporal degeneration

(Pick’s 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) 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?

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 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?

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 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 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 HCO3-



203) 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 re-scan, 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, hydroxy-adriamycin,

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 don’t 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 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

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 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. 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. What’s 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.

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