Y2K2MedGrad
09-22-2005, 01:51 PM
1732-1750
1732
Presented with a case of polycythemia rubra vera. What are they at risk of primarily (pick between renal failure OR hemorrhage)? What drug should you use to NORMALIZE that starts with the letter B? KNOW all the causes of this high white blood cell count.
a) Hemorrhage, in addition to thrombocytosis and infection. Treat with busulfan to normalize platlet number. KNOW that in addition to genetic dx., tuberculosis, low Fe count, and CANCER can cause thrombocytosis.
1733
A 27 year old female, pregnant, develops a sudden swelling of the ankle. You treat with (Pick warfarin or heparin) along with bed rest?
Key point…use heparin, warfarin crosses the placenta!
Hy 1734
SO specific, but boards is super SPECIFIC, know all clotting factors' groups
KNOW that as a patient is transfused over and over from blood from a blood bank, the two factors that are labile and can become deficient are Factors V and VIII.
KNOW which clotting factors are linked with the kininogen system.
KNOW which clotting factors are Vit K dependent.
KNOW which are part of the instrinsic pathway, and the one that is the extrinsic.
heparin, warfarin crosses the placenta!
Hy 1735
A 60 year old female has a PE. She is given heparin for 4 days when suddenly she bleeds from her vagina and gets tachycardic, hypotensive, oliguric. CT shows massive retroperitoneal hematoma. What drug starting with the letter (p) should be given?
a) protamine sulfate, which immediately reverses heparin.
Hy 1736
Pt, young, with HIV to AIDS. Boards LOVE HIV… KNOW that splenectomy is common for HIV associated ITP as is cholecystectomy for common acalculous cholescystitis. Also, know that HIV is associated with CMV perforation of the colon. I heard you have to know the functions of HIV env, pol, etc.
Hy 1737
Do you know this?
This is a lovely dovey. Pt with a history of autoimmune diseases has a short hospital stay for an infection. On the third day, there is a sudden onset of fever, hypotension, weakness, hypoglycemia, hyponatremia, hyperkalemia. What is the dx?
a) This is adrenal failure. There were many clues here. Focus on the sudden hypoglycemia and hyperkalemia. Give hydrocortisone, isotonic saline. Can be due to Addison's Dx. (with resultant high ACTH) or meningococcus infection.
Hy 1738
Biggie Biggie, Supersize Me!
KNOW when to give fresh frozen plasma vs. cryoprecipitate vs. packed RBCs vs. GM-CSF. Listen, know that transfusions with fresh frozen plasma are given to replenish clotting factors. Factor VII, repeat Factor VII is part of the Extrinsic pathway and also is the most stable (long half life) clotting factor.
Hy 1739
Common mistake
KNOW that a hemolytic transfusion reaction (What hypersensitivity is this, and is IgG involved?) is associated with fever, chills, pain and HYPOtension and oliguria (not hypertension).
Hy 1740
Personality disorders. Everyone got at least a couple of questions related to them (Cluster A, B, C) etc. You will be given a clinical case about a person and asked if he/she has schizoid, schizotypal, etc. What axis are they reported on. (Axis I, II, III, IV, or V)?
Axis II
What are reported on Axis I and Axis III?
Hy 1741
Another popular case of a Pt with hemolytic transfusion reaction. What disease process is occurring in their kidneys? What are you afraid of that will kill them if not treated fast? What do you give them pharmaco wise?
a) They will suffer from oliguria and hypotension and hemoglobinuria. So give them isotonic saline and HCO3- to prevent Acute Tub. Necrosis (deadly). An osmotic diuretic will also help clear their blood of the lysed RBC membranes.
Hy 1742
KNOW Hypocalcemia is associated with Alkalosis (not acidosis, think of number of protons and charges on albumin). Hypomagnesemia and myocardial compromise are also related. KNOW that calcium is a positive inotropic agent. Pt. case often presented is with the symptoms of hypocalcemia like muscle spasms, etc.
Hy 1743
Know that gastric juice and salvia has relatively LOW Na and HIGH K compared to the small intestines’ secretion.
Hy 1744
Pretend you are asked the MOA of how Kayexlate works to lower K+ levels in serum. How does it work? How does giving HCO3- work to lower K? Does giving Ca-gluconate DIRECTLY lower K+?
Kayexlate works in the GI tract to exchange Na for K. The bicarb raises serum pH and thus pushes the K intracellularly lowering serum K levels. KNOW you also give insulin to treat the high serum K. And you give calcium gluconate to treat the bad effects of high K on the heart but IT does NOT lower K serum levels directly.
Hy 1745
KNOW that the so important cytotoxic T cell is associated with WHICH protein? (Pick between CD7, CD4, CD1, MHC II, MHC I)? This concept was on a recent boards.
a) MHC I. Easy but tricky. If I asked for the link to a CD8 T cell, MHC I is very straightforward. But if asked a little differently, you can get confused, so please don't...
Hy 1746
Four days after an acute subdural hematoma, a 44 year old man becomes tired with with flapping at the wrists and gait problems (What symptom is this?). After the hematoma, he is normotensive. Labs show Na=110, K=3.5, Cl=82, HCO3- =24. Serum osmolality is 250. Urine sodium=45, Urine osmolality=500. (Hint: Urine is concentrated!) What disease does he have? What is the pathophys? If you gave him hypertonic saline, what is the major risk (hint: involves heart)?
He has SIADH. He cannot dilute the urine. As Dr. Goljan, my idol said, he is reabsorbing all his “free” water, so you get DILUTIONAL hyponatremia and thus you see the ASTERIXIS. But total body sodium stores are normal. Here, you need to know you must restrict water below what he is able to excrete. Recall that hypertonic saline can be dangerous because it can shift water to the extracellular space and cause pulmonary EDEMA. Big Board concept here.
With a serum Na of 110, the patient is at risk for seizure. The treatment is 3% saline even we know that he might be at risk for pulmonary edema and pontine myolinosis. Fluid restriction is a good idea too.
Hey Tommy
I'm confused........ why is your hint 'unine is dilute' ...... isn't it concentrated?>
Oops, already corrected.
Thanks for catching me. YES, with so much ADH around, he is sort of "drinking" back up all his free water, diluting his serum sodium (which is what I meant to say), so his urine is HYPERtonic.
Hy 1747
A 25-year-old obese woman with bipolar disorder complains that her recent struggles with her weight and eating have caused her to feel depressed. She states that she has increased difficulty sleeping, anxious and agitated, and has thoughts of suicide. She often finds herself fidgety and unable to sit still. Her family tells her that she is increasingly irritable. Her current medications include lithium carbonate and zolpidem. Which of the following is more consistent with a diagnosis of major depressive disorder than bipolar depression in this patient during this episode? (Pick one: Insomnia, thoughts of suicide, psychomotor agitation)
Psychomotor agitation. The other two choices are connected more with bipolar illness.
Hy 1748
A 35-year-old woman, increasing weakness, shortness of breath. A complete blood count shows a megaloblastic anemia. Her vitamin B12 level is low. She is also found to have hypothyroidism and diabetes and type A gastritis. Which of the following is associated with this illness? (Pick: Antral involvement, Helicobacter pylori infection, (NSAIDs), Parietal cell antibody)
a) ans is Parietal cell antibody. KNOW that Type A gastritis is immunologically mediated and is associated with an elevated level of parietal cell antibody. Thus, acid secretion is reduced. Type B gastritis is more commonly associated with Helicobacter pylori infection. Chronic NSAID use will lead to type B gastritis as well, involving the antrum of the stomach.
Hy 1749
This is a cherry.
A 6-month-old male, oliguria after surgery. Has generalized edema. His blood pressure is 94/48 mm Hg, pulse is 140/min, and respirations are 20/min. His B.U.N. is 50 mg/dL, and serum creatinine is 1.5 mg/dL (Hint: do a BUN/Cr ratio, is it over or under 15?). Initial urinalysis shows a specific gravity of 1.02 and 2+ protein. Microscopic examination of the urine sample reveals 1 WBC per high-power field (HPF), 20 RBCs per HPF, and 5 granular casts per HPF. His fractional excretion of sodium is 3.5% (high). What dx does he have?
Acute Renal Failure, likely ATN. Note the increase in blood urea nitrogen and serum creatinine and the decrease in urine output. REMEMBER that prerenal causes include hypovolemia secondary to severe dehydration, hemorrhage, and hypotension secondary to shock. Renal causes include acute tubular necrosis (ATN), parenchymal disorders (e.g., glomerulonephritis), and vascular disorders (e.g., renal artery thrombosis or renal vein thrombosis). Postrenal causes include ureteral or urethral obstruction. A fractional excretion of sodium greater than 2% is consistent with renal causes of ARF. Got it?
Hi Tommy,
I have read that if it is a prerenal failure the diagnosis can usually be made by looking at the BUN: Creatinine ratio of more than 20:1 and the fractional excretion of Na less than 1%
Now in tha above case if you say it is most likely a ATN then shouldn't the creatinine level go up as to make the BUN:Creatine less than 20:1 or 15:1 , the fractional excretion of NA is right since it more than 1% Please do explain! Thankyou,
Sanya.
Thanks, here is my explanation.
Yes, a BUN/Cr over 15 usually means pre renal which is what I did say. But I also related it to renal causes too. I should have been more specific. Basically, PRErenal BUN/Cr shoots up when there is volume depletion, and ATN usually occurs after an acute ischemic or toxic event, and it has a well-defined sequence of events. The initiation phase is characterized by an acute decrease in GFR to very low levels, with a relatively rapid increase in serum creatinine and blood urea nitrogen (BUN) concentrations (since the GFR decreases very fast). Polycystic kidney disease, Congestive Heart Failure, Sepsis, DIC, drugs like an ACE inhibitor, basically stuff like that lowers volume. I read though that the BUN can skyrocket much faster than the Creatinine, so those were the values I chose based on the Boards concepts told to me.
Thanks,
Tommy
Hy 1750
A 60-year-old man, rapidly progressive memory loss, jerking movements of the upper and lower extremities. Neurologic examination = severe cognitive deficits and memory dysfunction w/ no significant inflammatory infiltration. CSF analysis is NORMAL. What’s this Board favorite dx? Pick: (Alzheimer dementia, Creutzfeldt-Jakob disease,Glioma, Pseudotumor cerebri)
a) Creutzfeldt-Jakob disease (CJD) is the most important of the prion-related spongiform encephalopathies. It manifests with a rapidly progressive dementing picture, which is further distinguished by myoclonic jerking movements.
1732
Presented with a case of polycythemia rubra vera. What are they at risk of primarily (pick between renal failure OR hemorrhage)? What drug should you use to NORMALIZE that starts with the letter B? KNOW all the causes of this high white blood cell count.
a) Hemorrhage, in addition to thrombocytosis and infection. Treat with busulfan to normalize platlet number. KNOW that in addition to genetic dx., tuberculosis, low Fe count, and CANCER can cause thrombocytosis.
1733
A 27 year old female, pregnant, develops a sudden swelling of the ankle. You treat with (Pick warfarin or heparin) along with bed rest?
Key point…use heparin, warfarin crosses the placenta!
Hy 1734
SO specific, but boards is super SPECIFIC, know all clotting factors' groups
KNOW that as a patient is transfused over and over from blood from a blood bank, the two factors that are labile and can become deficient are Factors V and VIII.
KNOW which clotting factors are linked with the kininogen system.
KNOW which clotting factors are Vit K dependent.
KNOW which are part of the instrinsic pathway, and the one that is the extrinsic.
heparin, warfarin crosses the placenta!
Hy 1735
A 60 year old female has a PE. She is given heparin for 4 days when suddenly she bleeds from her vagina and gets tachycardic, hypotensive, oliguric. CT shows massive retroperitoneal hematoma. What drug starting with the letter (p) should be given?
a) protamine sulfate, which immediately reverses heparin.
Hy 1736
Pt, young, with HIV to AIDS. Boards LOVE HIV… KNOW that splenectomy is common for HIV associated ITP as is cholecystectomy for common acalculous cholescystitis. Also, know that HIV is associated with CMV perforation of the colon. I heard you have to know the functions of HIV env, pol, etc.
Hy 1737
Do you know this?
This is a lovely dovey. Pt with a history of autoimmune diseases has a short hospital stay for an infection. On the third day, there is a sudden onset of fever, hypotension, weakness, hypoglycemia, hyponatremia, hyperkalemia. What is the dx?
a) This is adrenal failure. There were many clues here. Focus on the sudden hypoglycemia and hyperkalemia. Give hydrocortisone, isotonic saline. Can be due to Addison's Dx. (with resultant high ACTH) or meningococcus infection.
Hy 1738
Biggie Biggie, Supersize Me!
KNOW when to give fresh frozen plasma vs. cryoprecipitate vs. packed RBCs vs. GM-CSF. Listen, know that transfusions with fresh frozen plasma are given to replenish clotting factors. Factor VII, repeat Factor VII is part of the Extrinsic pathway and also is the most stable (long half life) clotting factor.
Hy 1739
Common mistake
KNOW that a hemolytic transfusion reaction (What hypersensitivity is this, and is IgG involved?) is associated with fever, chills, pain and HYPOtension and oliguria (not hypertension).
Hy 1740
Personality disorders. Everyone got at least a couple of questions related to them (Cluster A, B, C) etc. You will be given a clinical case about a person and asked if he/she has schizoid, schizotypal, etc. What axis are they reported on. (Axis I, II, III, IV, or V)?
Axis II
What are reported on Axis I and Axis III?
Hy 1741
Another popular case of a Pt with hemolytic transfusion reaction. What disease process is occurring in their kidneys? What are you afraid of that will kill them if not treated fast? What do you give them pharmaco wise?
a) They will suffer from oliguria and hypotension and hemoglobinuria. So give them isotonic saline and HCO3- to prevent Acute Tub. Necrosis (deadly). An osmotic diuretic will also help clear their blood of the lysed RBC membranes.
Hy 1742
KNOW Hypocalcemia is associated with Alkalosis (not acidosis, think of number of protons and charges on albumin). Hypomagnesemia and myocardial compromise are also related. KNOW that calcium is a positive inotropic agent. Pt. case often presented is with the symptoms of hypocalcemia like muscle spasms, etc.
Hy 1743
Know that gastric juice and salvia has relatively LOW Na and HIGH K compared to the small intestines’ secretion.
Hy 1744
Pretend you are asked the MOA of how Kayexlate works to lower K+ levels in serum. How does it work? How does giving HCO3- work to lower K? Does giving Ca-gluconate DIRECTLY lower K+?
Kayexlate works in the GI tract to exchange Na for K. The bicarb raises serum pH and thus pushes the K intracellularly lowering serum K levels. KNOW you also give insulin to treat the high serum K. And you give calcium gluconate to treat the bad effects of high K on the heart but IT does NOT lower K serum levels directly.
Hy 1745
KNOW that the so important cytotoxic T cell is associated with WHICH protein? (Pick between CD7, CD4, CD1, MHC II, MHC I)? This concept was on a recent boards.
a) MHC I. Easy but tricky. If I asked for the link to a CD8 T cell, MHC I is very straightforward. But if asked a little differently, you can get confused, so please don't...
Hy 1746
Four days after an acute subdural hematoma, a 44 year old man becomes tired with with flapping at the wrists and gait problems (What symptom is this?). After the hematoma, he is normotensive. Labs show Na=110, K=3.5, Cl=82, HCO3- =24. Serum osmolality is 250. Urine sodium=45, Urine osmolality=500. (Hint: Urine is concentrated!) What disease does he have? What is the pathophys? If you gave him hypertonic saline, what is the major risk (hint: involves heart)?
He has SIADH. He cannot dilute the urine. As Dr. Goljan, my idol said, he is reabsorbing all his “free” water, so you get DILUTIONAL hyponatremia and thus you see the ASTERIXIS. But total body sodium stores are normal. Here, you need to know you must restrict water below what he is able to excrete. Recall that hypertonic saline can be dangerous because it can shift water to the extracellular space and cause pulmonary EDEMA. Big Board concept here.
With a serum Na of 110, the patient is at risk for seizure. The treatment is 3% saline even we know that he might be at risk for pulmonary edema and pontine myolinosis. Fluid restriction is a good idea too.
Hey Tommy
I'm confused........ why is your hint 'unine is dilute' ...... isn't it concentrated?>
Oops, already corrected.
Thanks for catching me. YES, with so much ADH around, he is sort of "drinking" back up all his free water, diluting his serum sodium (which is what I meant to say), so his urine is HYPERtonic.
Hy 1747
A 25-year-old obese woman with bipolar disorder complains that her recent struggles with her weight and eating have caused her to feel depressed. She states that she has increased difficulty sleeping, anxious and agitated, and has thoughts of suicide. She often finds herself fidgety and unable to sit still. Her family tells her that she is increasingly irritable. Her current medications include lithium carbonate and zolpidem. Which of the following is more consistent with a diagnosis of major depressive disorder than bipolar depression in this patient during this episode? (Pick one: Insomnia, thoughts of suicide, psychomotor agitation)
Psychomotor agitation. The other two choices are connected more with bipolar illness.
Hy 1748
A 35-year-old woman, increasing weakness, shortness of breath. A complete blood count shows a megaloblastic anemia. Her vitamin B12 level is low. She is also found to have hypothyroidism and diabetes and type A gastritis. Which of the following is associated with this illness? (Pick: Antral involvement, Helicobacter pylori infection, (NSAIDs), Parietal cell antibody)
a) ans is Parietal cell antibody. KNOW that Type A gastritis is immunologically mediated and is associated with an elevated level of parietal cell antibody. Thus, acid secretion is reduced. Type B gastritis is more commonly associated with Helicobacter pylori infection. Chronic NSAID use will lead to type B gastritis as well, involving the antrum of the stomach.
Hy 1749
This is a cherry.
A 6-month-old male, oliguria after surgery. Has generalized edema. His blood pressure is 94/48 mm Hg, pulse is 140/min, and respirations are 20/min. His B.U.N. is 50 mg/dL, and serum creatinine is 1.5 mg/dL (Hint: do a BUN/Cr ratio, is it over or under 15?). Initial urinalysis shows a specific gravity of 1.02 and 2+ protein. Microscopic examination of the urine sample reveals 1 WBC per high-power field (HPF), 20 RBCs per HPF, and 5 granular casts per HPF. His fractional excretion of sodium is 3.5% (high). What dx does he have?
Acute Renal Failure, likely ATN. Note the increase in blood urea nitrogen and serum creatinine and the decrease in urine output. REMEMBER that prerenal causes include hypovolemia secondary to severe dehydration, hemorrhage, and hypotension secondary to shock. Renal causes include acute tubular necrosis (ATN), parenchymal disorders (e.g., glomerulonephritis), and vascular disorders (e.g., renal artery thrombosis or renal vein thrombosis). Postrenal causes include ureteral or urethral obstruction. A fractional excretion of sodium greater than 2% is consistent with renal causes of ARF. Got it?
Hi Tommy,
I have read that if it is a prerenal failure the diagnosis can usually be made by looking at the BUN: Creatinine ratio of more than 20:1 and the fractional excretion of Na less than 1%
Now in tha above case if you say it is most likely a ATN then shouldn't the creatinine level go up as to make the BUN:Creatine less than 20:1 or 15:1 , the fractional excretion of NA is right since it more than 1% Please do explain! Thankyou,
Sanya.
Thanks, here is my explanation.
Yes, a BUN/Cr over 15 usually means pre renal which is what I did say. But I also related it to renal causes too. I should have been more specific. Basically, PRErenal BUN/Cr shoots up when there is volume depletion, and ATN usually occurs after an acute ischemic or toxic event, and it has a well-defined sequence of events. The initiation phase is characterized by an acute decrease in GFR to very low levels, with a relatively rapid increase in serum creatinine and blood urea nitrogen (BUN) concentrations (since the GFR decreases very fast). Polycystic kidney disease, Congestive Heart Failure, Sepsis, DIC, drugs like an ACE inhibitor, basically stuff like that lowers volume. I read though that the BUN can skyrocket much faster than the Creatinine, so those were the values I chose based on the Boards concepts told to me.
Thanks,
Tommy
Hy 1750
A 60-year-old man, rapidly progressive memory loss, jerking movements of the upper and lower extremities. Neurologic examination = severe cognitive deficits and memory dysfunction w/ no significant inflammatory infiltration. CSF analysis is NORMAL. What’s this Board favorite dx? Pick: (Alzheimer dementia, Creutzfeldt-Jakob disease,Glioma, Pseudotumor cerebri)
a) Creutzfeldt-Jakob disease (CJD) is the most important of the prion-related spongiform encephalopathies. It manifests with a rapidly progressive dementing picture, which is further distinguished by myoclonic jerking movements.