Psych

-OCD Treatment → SSRI or Clomipramine?

• Obsessive-Compulsive Anxiety Disorder - According to the DSM-IV, OCD is characterized by the

presence of persistent, intrusive thoughts that lead to the performance of compulsive acts in
order to allay inherent anxieties. Individuals suffering from this disorder often perform multiple
time-wasting rituals and recognize the absurdity of their behavior but feel unable to stop. They
suffer from significant functional impairment. They are ego-dystonic.

• This disorder results from altered levels of serotonin, a neurotransmitter that regulates mood,
aggression, and impulsivity. The treatment of choice for OCD is a selective serotonin reuptake
inhibitor (SSRI), such as paroxetine & TCAs like Clomipramine.

-Guy having schizophrenia in the past and now has depression, whats the dx? Schizoaffective (delusions
or hallucinations for >2wks in absence of mood symptoms)

• Schizoaffective disorder is defined as the presence of symptoms of schizophrenia along with

mood symptoms (major depression. bipolar disorder. or a mixed episode). To make the
diagnosis, there should be at least two weeks when psychotic symptoms are present without
any mood symptoms.

Lady loses vision in one eye, and had motor symptoms in the past → demylination of CNS
-Women had MS, then says she had episode previous but wasn’t having episode right now. Whats the
treatment? Interferon beta
• Multiple Sclerosis - In patients with multiple sclerosis (MS), CSF examination shows normal
pressure, normal total cell count and normal total protein concentration. The predominant
cell type is T lymphocytes. Although the total protein concentration is normal,
immunoglobulin levels are high relative to other protein components. The predominant
immunoglobulin type is lgG although lgM and lgA are also increased. The lgG index measures
the increase in immunoglobulin G level relative to other proteins and is elevated in 90% of
patients with MS. Oligoclonal bands are present in 85 - 90% of cases of MS.

• Suspect multiple sclerosis in a young female with bilateral trigeminal neuralgia.

• Relapsing-Remitting form of multiple sclerosis (MS) is characterized by well-defined acute
episodes with no significant disease progression between the episodes. Several well-designed
clinical trials have proven that interieron-beta decreases the frequency of relapse and reduces
disability in patients with the relapsing-remitting form of MS.

• Acute exacerbations of multiple sclerosis are generally treated with IV steroids. Steroids are
the most widely used drugs in the treatment of acute exacerbations because these can hasten
the recovery of such patients. High-dose intravenous steroids (i.e ..methylprednisone) is used
when patients present with disabling symptoms. Mild sensory symptoms generally do not
require steroids. Long-term steroid therapy provides no benefit, and does not prevent future
relapses. To reduce the frequency of acute exacerbations, interferon,plasmapheresis,
cyclophosphamide, intravenous immunoglobulins and glatiramer acetate may be used.

Huntington disease described → lesion in caudate nucleus

• Huntington's Disease - It is an autosomal dominant neurodegenerative disorder. Patients

usually present in their forties or fifties with chorea and/or behavioral disturbance. Chorea is
characterized by sudden, jerky and irregular movements of the extremities. Impaired
judgment,Executivefunction, awareness and attention occur at an early stage. Memory
impairment is a late finding. Depression irritability and social withdrawal are also
common. Atrophy of the caudate nucleus is a characteristic feature and is seen on
neuroimaging as enlargement of lateral ventricles

-Someone on typical antipsychotic now having painful tonic contractions → Benztropine

• Dystonia can occur between 4 hours and 4 days after receiving an antipsychotic medication. It is
characterized by muscle spasms or stiffness, tongue protrusion or twisting, opisthotonus, and
oculogyric crisis. Antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine)
provide relief.

-Old lady and mini-mental 28/30 and can recall 3/5 things → normal aging
-Old lady alzheimers type symptoms → alzheimers
-Old lady active in the community, mini-mental 25/30 → normal aging

• Alzheimer's disease is a progressive dementia. Its associated risk factors are: age, female
gender, positive family history, head trauma, and Down's syndrome. The typical first
symptoms are subtlememory loss, language difficulties and apraxia, followed by
impaired judgment and personality changes.

• Alzheimer's disease is the most common cause of dementia in the United States. Early signs
include visuospatial deficits (getting lost in one's own neighborhood), problems with
anterograde memory formation (old memories tend to be preserved), personality and
 behavioral changes (apathy, agitation) and apraxia (difficulty using a comb),Hallucinations,
changes in alertness, gait impairment and urinary incontinence may occur late in the disease.
The diagnosis is madeclinically by assessing the mini-mental status exam (MMSE),
neuropsychological testing and the following clinical criteria.

• Two or more areas of cognitive deficits
• Progressively worsening memory and other cognitive function
• No disturbance of consciousness
• Onset between 40 and 90 years
• Absence of other systemic or neurologic disorder causing progressive cognitive defects
• Normal aging can be differentiated from Alzheimer they can perform normal daily function like
cooking and cleaning. The patient comes to the doctor complaining he or she is forgetting
things, but on the other side Alzheimer patient are not aware of their problem.

IM

1. -Anorexia what would FSH levels be? Decreased àHypothalamic-pituitary axis dysfunction
resulting in anovulation, amenorrhea and estrogen deficiency
(make sure to check the concept)
-Anorexic purging what happens with the levels of K+, HCO+, etc → K+ decrease, HCO3+ increase
-Little kid yellow crusted lesions around mouth (picture) → Tx muciprocin
-20 y/o female who was hypoglycemic and C-Peptide was low → factitious disorder
-Lactose deficiency → hydrogen breath test
-Pt comes in complains of losing weight, watery diarrhea w/ no blood what test next? D-Xylose
-Kid bleeding in the knees w/ PTT elevated, uncle had bleeding disorder → Factor 8 deficiency (given in
roman numerals)

-Fragile X → X linked dominant Fragile

X syndrome is typically due to an expansion
of the CGG triplet repeat within the Fragile X mental retardation 1 (FMR1)
gene on the X chromosome.
-EKG shows delta wave → Wolf Parkinson white

-EKG shows SVT → SVT

-EKG shows electrical alternans → cardiac tamponade beats to beats variation in QRS amplitudes.
-Drug abuser has murmur third left intercostal early decrescendo diastolic murmur → AR
-Mechanism behind TOF squatting making kid go from blue to pink → increased systemic vascular
resistance
▪ increasing SVR via compression of the femoral arteries
▪ improves bloodflow across the VSD
allows blood to enter pulmonary circulation
-Talks about aortic stenosis murmur, asks about physio of the murmur?

-Guy gets angina, has ST depression. Whats the physio? Decreased supply, increased demand
-Guy with TIA has less than 50% occlusion of carotid what do you do for long term treatment? Aspirin
-Right ventricular infarct, lungs not involved what do you do? Don’t put Nitro (makes it worse) give IV
fluids to increase the preload to the right ventricle.
-Girl got stabbed in her chest heart sounds decreased, blood pressure down, JVD distended → cardiac
tamponadeà Pericardiocentisis

-Heart sounds decreased, blood pressure down, JVD distended → Symmetric pericardial fluid

-Wrestler got something on skin (describe ringworm) → tinea corpis à Trichophyton rubrum is the
most frequent culprit à The lesions are pruritic, erythematous, scaly, and have a red ring with
central clearing. Exposure to infected animals, people, and public places are major risk factors.
-Show picture of kids hand (scabies picture) → Scabies
- Old guy with scaly ulcerated on forehead → squamous cell carcinoma
-Person goes out and in the son, family history of basal cell, what would be most protective? SPF vs
Protective clothingà however, there is evidence that SPF protects against non-melanoma skin
cancers such as squamous cell carcinoma.
-Black kid comes in with hypopigmented rash after they went to the beach (sun exposure) → Tinea
versicolor
-Carpal tunnel question what to do? Splinting
-Contractions of palm → fibrosis of the palmar something
-Guy who works with pile driver, has pain in the hand? → Carpal tunnel

Peds
-Kids parents used to smoke or still are smokers, he has asthma and has a lot of asthmas, whats the
biggest risk factor → Smoking
-4 month old w/ symptoms of meningitis show picture of gram + diplococci (google picture of strep
pneumo it was same pic) what is the bug? Strep pneumo
-Describes VZV rash on abdomen what is treatment → IV or oral acyclovir?

-Baby with clunking of the hip? → Ultrasound of hip

-Kid comes with leukemia but parents believe in herbal treatment and decided not to go on with
treatment? Court order and treat he kid
-HIV guy having sex with other guy in the ass and had picture of asshole with wart → HPV
-Two gay guys, one positive for HIV and gonorrhea, do penile swab on HIV negative guy and gonorrhea
negative, what do you do? Waiting for culture vs treat with ceftriaxone + doxy, treat w/ doxy

-Vignette about caves → histoplasma

-Kenyan lady comes to new England area now has malaise fever fatigue → malaria
-Stroke pt of Left MCA causing right side hemiparesis + right side vision loss and eye deviated to left side,
with aphasia → Left MCA stroke

OBGYN

-She got tubes tied, what is a complication? Ectopic pregnancy

-Described placentia previa, and what is a complication? → Placenta accrete
-Lady is pregnant and baby having late decels →change the maternal position
-Pregnant lady delivers, and has post partum fever, has lochia? Is it e. coli/staph aureus?
-Bleeding after delivery what happened? Uterine Atony
-52 y/o comes to clinic, had hysterectomy in passed, on hormone replacement, negative pap smears in
past, what screening would you recommend? Dexa
-IV drug abuser first baby was premature, she has abused cocaine in the past but hasn’t taken in the
past 12 months, has not done anything bad since pregnant with current baby? Preterm baby

-Smooth uterus that was equal on both sides? Adenomyosis

-Lady with elevated CA-125 what is most likely risk? Ovarian cancer
-Mom is pregnant with twins what do you tell mother, what is most likely risk for babies? Growth
restriction for twice
-Couple came in and wanted to have a girl, what do you tell them? Tell them you cant decide to have a
girl
-Pregnant lady w/ diabetes → switch her to insulin

Need to Organize From Here on:

1) Sleep latency study was an answer

2. xray of intussusception - what is complication - ischemic bowel

• Intussusception – It is the telescoping of one bowel segment into another. Intussusception is the
most common cause of intestinal obstruction in children age 6-36 months. The ileocolic junction
is most frequently involved, with invagination of the ileum into the colon. Most children (-75%)
have no identifiable lead point. Preceding viral infections (eg. gastroenteritis) are thought to
play a role in inflaming intestinal lymphatic tissue ( eg. Peyer patches), which can subsequently
serve as a lead point for intussusception. Meckel's diverticulum, followed by polyps and
hematomas (Henoch-Schonlein purpura), are the most commonly identified triggers in the
remaining 25%.

• Classically, the telescoping is intermittent, resulting in periodic pain associated with drawing the
legs up toward the abdomen. Emesis may follow episodes of abdominal pain. It is initially
nonbilious but becomes bilious as the obstruction persists. Ongoing obstruction can
compromise circulation causing mucosal ischemia, occult bleeding and, if untreated, grossly
bloody "currant jelly" stools. Occasionally, the intussusception is palpable as a tubular
"sausage-shaped" mass.

• Ultrasound is the method of choice in detecting intussusception and has a sensitivity and
specificity of 100% if performed by an experienced sonographer during the period of pain. The
positive finding of the "target sign" should prompt immediate enema reduction. Air or water-
soluble contrast is instilled through the rectum and the pressure from these mediums
successfully reduces most obstructions. Air enemas are preferred because they are typically
faster, cleaner, and safer than contrast.

3. SCD - gallstones & gallbladder wall thickening - what caused stones - i put
pigmented calculi

4. kid swims, wrestles; does bunch of other activities - theres ringworm pic - what
caused it - answer choices listed all his activities mentioned in vignette - i put wrestling

5. girl’s got a lump, mobile, small, she’s 27ish - come back in 6 months
6. kid with small testes, tall - u know its klienfeilters’ - they asked about genetic level - i
put the one with the X chromosome (i think it said bisomy X)

7. Adhesions was answer- such a straight forward vignette

8. SVT EKG - ans was SVT

9. pericarditis - ekg showed diffuse ST elevations

10. NPH pathophys - dec absorption

11. something about fetus death at 12-14 weeks? asked, other than checking BHCG,
what else to do - i put TVU bc nothing else made sense to me

12. 2 vit def q’s - super easy peasy: mines was: Niacin def (pellagra s/s)
13. pt placed on a total parenteral nutrition over the next several days, developed a rash
on face and complains of patchy hair loss. - zinc def

14. home birth of baby - what needs to be supplemented – vitamin D or vitamin K

15. chick with graves - what is inc - abs to TSH

16. specificity Q - know definition - concept q not actual calculation

17. man with prostate enlargement can’t pee - obstruction incontinence

18. HIV pt CD4 around 450 - what to give em - only thing made sense was
pneumococcal vaccine (influenza wasn’t there)

19. vomiting person - what lab values would u see - hypochloremic hypokalemic met
alkalosis

20. something with DiGeorge sydrome and the heart i can’t remember

21. ARDS pathophys - know it

22. MAT EKG - a/w copd; a/w smoking

23. hella depressed dude; none of the depression drugs work; wife died; he’s so sad all
the time - what to do - i put ECT sessions

24. SIADH was answer hyponatremia concentrated urine

25. pre renal - contrast & hypovolemia

26. described chick with gullian barre - URTI

27. SSC on face - wide excision w/ 1 mm

28. rocky mountain spotted fever was the dx

29. osteomyelitis in kid - s.aureus

30. pyelonephritis was an answer i picked can’t remember case

31. prep lady with gauze packing smelled bad - s.aureus

32. G6PD q

33. Few Pysch q’s: MDD, schizophrenia, pathophys of nuerotransmitters

34. LOTS and LOTS and LOTS of management – next best test – next step in
management questions legit more than half my blocks were these types of q’s

35. Dude with blood dz, sister had blood dz milder form – answer options factor 8, 9,
vWF, etc

36. serotonin syndrome

37. quiet a few RISK FACTOR q’s – like what’s the most important risk factor – or the
worst prognosis risk factor – hated those q’s

38. Pt with irreg irreg rhythm – rheumatic heart dz. Don’t pick infective endocarditis –
trick question

39. Acute angle closure glaucoma in pt that went to eye dr and got bad reaction to drops
put in

40. Woman who had previous transverse c-section, what is risk - Uterine rupture

41. Car accident, tension ptx, tamponade, what treat 1st? Chest tube for ptx first!

42. TOF kid crouches for relief? What's the mechanism? Increase systemic vascular
resistance

43. MEN syndrome dx -what other stuff will you see type of question

44. 12 year old guy with testicular torsion, take for immediate surgery

45. guy post-surgery where is iron absorption question

46. lots of OBGYN q’s on complciations

47. lots of PEDS q’s on immunodef, rashes, growth q’s

Lab values showing high eosinophils-interstitial nephritis

Pic of port wine stain- complication is seizure
Pt on TMP-SMX and has abnormal heme/onc nimbers. Due to G6PD defi
Pt has jelly like diarrhea. Asks what's the next best step-- I put barium enema
Child complains of wrist pain and joint pains. Juvenile arthritis
Otitis externa- due to pseudomonas
Young girl is sexually active. Asked for what test to do. Gono and chlamydia
Asked what protects against osteoporosis. Estrogen
Pic of bone raise on a child: osteosarcoma
Had a lot of questions where SSRIs is the answer to depression
I had a question on number to treat. Skipped that shit. Maybe if I knew, I would've passed lol
Pt has schizo and now has rigidity and dystonia. Answer is benztropine
Tx of MALT. Treat H. Pylori
I had like 5 Uti questions. Asked what's the most common cause in different situations like young female on
honeymoon. Know all the causes
Know your incontinences
Pt with klinfelters- answer is aneuploidy
Fragile x. Example of trinuc repeat CGG triple repeat.
Know the stupid causes of curtain falling over the eyes. Amorex fugo
Thx for s. Pneumo. I put macrolide
A woman with painful mensus had a 4 mm stripe and it described fibroids scenario. I put leiomyomata uteri
A woman with vaginal dryness I put lichen sclerosis.
Showed a very ugly vagina. think it's lichen planus or something

lady itching down there; pic of vulva; dx? —> lichen sclerosis

marfans dude; what kind of heart prob? —> aortic root dilation or something

boy hitting puberty; has a right breast mass; what to do —> reassure that its normal

whats abnormal in baby w/ omphalocele —>AFP

Friedreich ataxia: expansion of GAA triple repeat in the FXN gene.