ABIM Flashcards
Immediate angiography for UA or NSTEMI
HD unstable HF Recurrent rest angina despite therapy New or worse MR murmur Sustained VT
UA/NSTEMI treatment
TIMI 0-2 low risk, 3-7 high risk (early cath)
Asa, BB, ntg, heparin, statin, plavix
Ddx of ST elevation
STEMI, pericarditis, LV aneurysm, Takotsubo, vasospasm, myocarditis, acute stroke, early repolarization
STEMI treatment
Asa, BB, P2Y12 (1 year), heparin, ACE (lifelong if HF), ntg, statin
PCI - 90 min in hospital, 2 hrs transfer (from door)
Lytics if no PCI within 2 hrs - failure if HD unstable
Emergent CABG if thrombotic PCI failure or mechanical complications
Spiro 3-14 days later - if EF <40 and HF or DM
Post-MI therapy
Asa, plavix 1 year post DES, statin, BB, ACE if DM, htn, CKD, or HF, spiro if EF <40 and HF or DM
F/u echo in 40 days (3 months if PCI or CABG), ICD if EF <35 in class 2 or 3 or <30 in class 1
Types of stress test
EKG - no in LBBB, dig, LVH, prev PCI, ST depression at baseline
Echo or spect
Dobutamine or nuc - can’t exercise, paced ventricular rhythm
Treatment of stable angina
BB
CCB if BB contraindicated (HR, AV block, asthma)
Nitrates - need washout period of 8-12 hrs to prevent tachyphylaxis
Ranolazine if still symptomatic
Asa, ACE if htn, HF, DM, or CKD, statin
PCI if still symptomatic with max medical therapy
Contraindicated in HF
Dilt and verapamil
NSAIDs
Thiazolidinediones
Don’t start BB in decompensated HF, ok to continue
DCM ddx
Myocarditis (supportive care)
EtOH (standard HF)
Drugs - cocaine, meth (standard HF, no unopposed alpha (use labetalol))
Giant cell myocarditis (immunosuppressant, transplant)
Hemochromatosis
Peripartum (ACE, ARB, spiro are teratogens) (warfarin if EF <35) (don’t get pregnant again)
Takotsubo (supportive care)
Tachycardia induced (fix arrhythmia)
Murmur maneuvers in HCM
Louder with valsalva and squatting (increased preload)
Migraine treatment
No orals in severe NV
Triptans contraindicated in CAD, stroke, brainstem aura, hemiplegic migraine
Use acute therapy 3 days per week max
Avoid OCPs in migraine bc risk of stroke
No butalbital or opioids
Prophylaxis if no response to therapy, >10 days/month, disabling >4 days/month, using meds >8 days/month — amitryptiline, metoprolol, propranolol, timolol, topiramate, valproate, venlafaxine
Trigeminal cephalgias
Cluster headache (15-120 min several times a day for weeks)- triptan or O2, prevent w verapamil
Chronic paroxysmal hemicrania (5+ times a day 2-30 min)- indomethacin
SUNCT (1-600 seconds hundreds of times per day) - no treatment
Hemicrania continua - indomethacin
Red flags for secondary headache
Thunderclap Physical exam abnormal Neuro symptoms for more than an hour New headache in older than 50 Cancer, immunosuppression, pregnancy Level of consciousness Triggered by exertion, sex, valsalva
MRI
CT if suspect ICH
ESR CRP if suspect giant cell arteritis
LP for suspected meningitis or increased ICP
AED side effects
Carbamazepine - hepatic clearance, osteoporosis, HL, hyponatremia, pancytopenia
Valproate - weight gain, HL, PCOS, teratogen, hepatotoxic
Topiramate, zonisamide - kidney stones, teratogen
All - hypersensitivity, SJS, suicidal ideation, many inactivate OCPs
Stroke treatment
tPA within 3 hours if no bleeding or BP 185/110
Tylenol for fever
NS
Asa if no lytics
DVT prophylaxis after 48 hrs
Antihypertensives in first 48 hrs only if BP 220/120 (185/110 w lytics) or aortic dissection or end organ damage
Endarterectomy after 2 weeks if stenosis ipsilateral >70
Statin, aspirin, dipyridamole, warfarin for cardioembolic
SAH treatment
CSF if CT normal but high suspicion
Clip or coil within 48-72 hrs
Keep BP under 140
Nimodipine for 21 days
ICH treatment
Surgery or angiography
Mannitol, barbiturate coma, hyperventilation for ICP
Nicardipine, labetalol to keep SBP 140-160
Reverse warfarin
No ntg or nipride bc they can increase ICP
No platelets or steroids
Parkinson disease ddx
Multiple system atrophy - ataxia and orthostatic hypotension, MRI showing necrosis of putamen, cerebellar atrophy
Supranuclear palsy - unexplained backward falls, inability to move eyes vertically
Lewy body dementia - dementia, hallucinations
Medication induced Parkinsonism - antiemetics, antipsychotics, reserpine, lithium, methyldopa
Myelopathy ddx
MS - oligoclonal bands
Neuromyelitis optica - NMO-IgG, MS wo brain lesions
Idiopathic transverse myelitis - after viral infection
B12 deficiency - check MMA and homocysteine, sensory
Copper deficiency - after bariatric surgery or taking lots of zinc
Spinal cord infarct - acute flaccid paralysis
Compressive
Myasthenic crisis
Triggered by infection, surgery, meds - aminoglycosides, quinolones, magnesium, BBs, CCBs
Treat w plasmapheresis or IVIg. No pyridostigmine alone bc it increases secretions
Regular myasthenia treated w pyridostigmine, thymectomy if thymoma
Drugs that cause TTP
Plavix, gemcitabine
Skin biopsy
Lesion for histology, perilesional for DIF
Milaria
Heat rash
Can be in fever
Amyopathic dermatomyositis
Heliotrope sign, gottrons papules, shawl sign
No muscle enzymes or decreased strength
Bullous pemphigoid
Urticarial plaques and tense bullae trunk upper legs
Treatment for impetigo
Mupirocin
Drug induced SLE
Adalimumab Hydralazine Procainamide isoniazid Minocycline Annular scaly patches
HCTZ causes subacute cutaneous lupus
Erythema multiforme
HSV mycoplasma pneumoniae
Tricolored targetoid papules
Actinic purpura
Age related capillary fragility
Epidermal inclusion cyst
Excise
Tinea treatment
Imidazole
Localized scleroderma
Skin hardening without systemic disease
Poison ivy
Prednisone taper
Lentigo maligna
On the face
Pyoderma gangrenosum treatment
Prednisone
Erythema nodosum next steps
CXR to look for sarcoidosis
Can be triggered by hormones
Pitted keratolysis
Small pits punctate erosions on sweaty feet, bacterial, topics antibiotics
Treatment of venous stasis ulcers
Compression
Dermatitis herpetiformis treatment
Dapsone and gluten free diet
Erythroderma
Psoriasis can flare to this w glucocorticoids
Inverse psoriasis
Itchy plaques in axillae intergluteal pannus etc
Heart transplant rejection
Biopsy
Heart failure, complete heart block
To decide what kind of AAA repair
Cta a/p to see if other vessels involved
Effusive constrictive pericarditis
Ibuprofen and colchicine
Intermittent claudication
Supervised exercise
Stable heart failure follow up labs
Electrolytes and kidney function
Papillary fibroelastoma
Independently mobile cardiac tumor stalk to left sided valvular endocardium, associated w embolization
Isolated anterior thigh numbness
Meralgia paresthetica - lateral femoral cutaneous nerve
Relieve pressure
Bell palsy
Prednisone within 72 hours
No antivirals
No imaging needed
Mononeuritis multiplex
Vasculitis, lymphoma, amyloid, sarcoidosis, Lyme, hiv, leprosy, diabetes
GBS
Areflexic
Ascending
Campylobacter
Elevated CSF protein w normal cell count
Plex or ivig
No steroids
CIDP
Proximal neuropathy over months
Prednisone, plex, IVIG
Steroid myopathy
Normal CK
Proximal weakness
Normal EMG
Lipophilic statins
Atorva simva lova
Statin myopathy more likely
Primary CNS lymphoma
Supratentorial, visual symptoms, immunocompromised
Ocular involvement
Biopsy
Radiation and chemo, start haart, no surgery
Meningioma
Enhancing dural tail
Resection, no chemo
Brain mets
Lung, breast, melanoma
Steroids, radiation
Methotrexate and cytarabine for leptomeningeal mets
Brain death
Coma, apnea, absence of brain stem reflexes
Can’t be brain death with respiratory drive or posturing
RA
RF, CCP Periarticular osteopenia, symmetric joint space narrowing Cervical spine subluxation Bronchiolitis obliterans Mononeuritis multiplex Cricoarytenoid involvement Caplan syndrome HF ILD Felty syndrome
Treatment of RA
Steroids for symptoms
Methotrexate for erosive disease
Screen for osteoporosis
Methotrexate and leflunomide are teratogens
Erosive Inflammatory OA
Pain and swelling of PIP and DIP joints
ESR and CRP normal
DISH
OA
Ossification along anterolateral aspect of vertebral bodies
No disk space narrowing or syndesmophytes
Complications: dysphasia, fractures, spinal stenosis, myelopathy
Hypertrophic osteomyopathy
Clubbing
New periosteal bone formation
Psoriatic arthritis
Check for HIV
Nsaids
Methotrexate - doesn’t prevent progression
TNF blockers
Cutaneous T cell lymphoma treatment
Photophoresis
Reactive arthritis
Arthritis, conjunctivitis, urethritis in 1/3
Enthesopathy
Sacroiliitis
Keratoderma blennorrhagicum (psoriasis on palms and soles)
Circinate balanitis
HIV, chlamydia, stool studies
Self limited within 6 months
Ankylosing spondylitis
Worse at night, better with activity or heat
AI, uveitis, aortic aneurysm, EP problem
Cervical fracture with minor accident
NSAIDs Glucocorticoid injections TNF for axial Methotrexate for peripheral Calcium and D
SLE criteria
4 of:
ANA Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Kidney disease Neuro disease Heme disease Immunologic disease
Neonatal lupus
Mothers have SSA or SSB
Heart block
Lupus testing
ANA
Anti smith
Ds DNA correlates with disease activity
Low complements in flares
Anti Histone in drug induced lupus
Therapy for SLE
Hydroxychloroquine for arthritis.
Topical glucocorticoids for rash
Life threatening disease cytoxan and MMF
Bisphosphonates for osteopenia
Hydroxychloroquine monitoring
Annual eye exam
SLE safe in pregnancy meds
Prednisone, hydroxychloroquine
Diffuse cutaneous systemic sclerosis
Proximal to elbows and knees
ANA, SCL-70
ILD
Scleroderma renal crisis
Limited cutaneous systemic sclerosis
Distal to elbows and knees
ANA, anti centromere
PH
CREST syndrome
Systemic sclerosis test
Nail fold capillary destruction, dilated capillary loops
Has to have raynaud phenomenon to be SSc
Treatment for systemic sclerosis
Raynaud - no smoking, amlodipine, felodipine, nifedipine, sildenafil, nitro paste
GI dysmotility - PPI, metoclopramide
Scleroderma renal crisis - ACE inhibitor
Bacterial overgrowth - antibiotics
Alveolitis - MMF or cyclophosphamide
No steroids; they cause scleroderma renal crisis
MCTD
SLE, SSc, and/or polymyositis with anti U1 RNP antibodies
Mortality related to PH
Fibromyalgia evaluation
CBC, BMP, TSH, ESR, CRP - normal
Don’t order ANA, RF, CCP
Fibromyalgia treatment
No opioids or NSAIDs
Exercise and CBT
Pregabalin, duloxetine, milnacipran
Gout testing
Monosodium urate crystals and urate tophi
Negatively birefringent
Synovial fluid WBC 2000-75000; >50000 should raise concern for septic joint
Gout flare treatment
NSAIDs, colchicine, steroids
Recurrent gout treatment
ACR says aim for urate <6 if tophi, <5 wo tophi
Allopurinol - start w few month course of colchicine or NSAID to prevent gout flare
Avoid allopurinol in Asians w HLA B27
Febuxostat if CKD
If nothing else works, pegloticase
Allopurinol and HCTZ
Hypersensitivity syndrome
Dermatitis, fever, eosinophilia, hepatic necrosis, nephritis
Gout and azathioprine
Allopurinol and febuxostat raise levels; don’t use them
CPPD
Positively birefringent rhomboid shapes crystals
Linear calcification of meniscus
Screen for hemochromatosis, hypomagnesemia, hyperparathyroidism, hypothyroidism
Disseminated gonorrhea
Migratory polyarthritis, fever, vesicles
Ceftriaxone for GC and doxy for chlamydia
Polyarteritis nodosa kidney disease
Does not involve the glomerulus - no blood, casts, or protein
Htn, mononeuritis multiplex, livedo reticularis, purpura
Check HBV, biopsy (skin or testicle), mesenteric and renal angiography
Prednisone, cytoxan
Giant cell arteritis
Fever, headache, jaw claudication
Blindness, aortic dissection and aneurysm
Diagnose with ESR and temporal artery biopsy
Treat with high dose steroids, tocilizumab, aspirin
EGPA
Asthma, eosinophilia, IgE, hemoptysis
P ANCA/ MPO
Treat w prednisone, cytoxan for multi organ failure
Takayasu arteritis
Fever, malaise, weight loss, arthralgia Arm and leg claudication Pulse deficits Bruits Asymmetric BP
Aortography
Prednisone
Relapsing polychondritis
Red hot painful ears
Strider caused by tracheal collapse
Saddle nose deformity
Cartilage biopsy
NSAIDs, colchicine, dapsone for mild
Steroids for severe
Familial Mediterranean fever
Recurrent fever and serositis, arthritis, rashes
ESR CRP
Serum amyloid AA
Proteinuria
Genetic testing
Colchicine
Adult onset Still disease
Daily fever, myalgia, proteinuria, serositis, evanescent pink rash, arthritis
Ferritin >2500
Steroids
Mtx, TNF inhibitor, anakinra
Complex regional pain syndrome
Abnormal bone metabolism and osteoporosis
Follows injury, surgery, MI, or stroke
Hair loss, movement disorder, swelling, autonomic dysfunction
Physical therapy, steroids, bisphosphonates even if no osteoporosis
Primary adrenal insufficiency
Low aldo, hyperpigmentation
Autoimmune adrenalitis - hydrocortisone and fludrocortisone Bilateral adrenal hemorrhage TB Addison disease Neisseria HIV Histo Mets
Primary adrenal insufficiency testing
Morning serum cortisol low, diagnosed <3. Normal >15
If borderline, cosyntropin stim test
ACTH to see primary vs secondary
Stress dose steroids if they are sick
Secondary adrenal insufficiency
ACTH deficiency
Pituitary apoplexy
Steroids
Long term opioid use - long acting
Adrenal crisis
Shock, fever, abdominal pain, tachycardia
Usually primary because that causes hypotension
Hypercortisolism testing
24 hour urine, nighttime salivary cortisol
Low dose suppression test - 1 mg dex doesn’t suppress
ACTH low - Cushing syndrome - CT MRI adrenals
ACTH high - high dose suppression test - 8 mg
If suppresses, pituitary. If not, ectopic production (small cell lung cancer)
Pheochromocytoma treatment
Phenoxybenzamine
No contrast - can cause crisis. Make sure treated before imaging.
Post op fluids, might need pressors
Long term monitor for mets
Men 2A
Pheo, medullary thyroid cancer, pituitary adenoma
Prolactinoma treatment
Cabergoline or bromocriptine - dopamine agonist. Shrinks it
Surgery if it fails
Hypothyroidism and prolactin
TSH can elevate prolactin mildly
Other causes : risperdone,
Bartter syndrome
High urine cl na ca
Like loop diuretic effect
CKD and chronic metabolic acidosis
Give bicarb if bicarb <22
Minimal change disease treatment
Prednisone
Ace, diuretics, statin
IgA nephropathy treatment
ACE inhibitor
Multiple myeloma diagnosis
Aki, anemia, hypercalcemia, bone pain, nagma
Antihypertensive regimen adjustment
Add another agent instead of increasing dose once at 50% max dose
Ethylene glycol toxicity treatment
Fomipazole, fluid, dialysis
Membranous glomerulonephropathy management
Eval for secondary causes - cancer screening, hepatitis, syphilis, lupus
Prior to immunosuppression
Balkan endemic nephropathy
Aristolochic acid
Tubulointerstitial
Associated w upper urinary tract urothelial cancer
Cystoscopy
DI diagnosis and treatment
High sodium w low urine osm
Try desmopressin, if it doesn’t work it’s nephrogenic - HCTZ
Hypoaldosteronism sources causing hyperK
Heparin, RAAS inhibition, type 4 RTA, primary adrenal disease
Pyroglutamic acidosis
Chronic acetaminophen if chronically ill, CKD, poor nutrition, vegetarian
Mental status changes, agma
Previously treated GPA with hematuria
Cystoscopy to look for bladder cancer - both GPA and cytoxan increase risk
Hematuria workup
Cystoscopy to look for bladder cancer in age >35
Acute hyponatremia treatment
3% saline
Sarcoidosis renal involvement
Nephrocalcinosis, hypercalcemia, hypercalcuria
Interstitial nephritis w granulomas
Hyperlipidemia in CKD treatment
Statin
Though triglycerides are primary problem
Assess high creatinine in patients with high muscle mass
Cystatin C - produced by all cells, not just muscle cells, so it’s clearance may be better indicator
Kidney stone prevention
If hypercalcuria, add a thiazide
Membranous GN antibody
Anti PLA2
Treatment of renal artery stenosis
Atherosclerosis treatment including ACE, check to see that cr doesn’t increase >25%
Type 1 RTA
Distal tubule
Can’t acidify urine
HypoK
Nagma
Positive urine anion gap
FSGS associations
Premature birth
Solitary kidney
Obesity
Black
Fabry disease
X linked Lisosomal storage disorder Burning hands and feet Nephritis Angiokeratomas Corneal and lens opacities Heart infiltration Neuro involvement
Struvite stone treatment
Remove stones - Nidus for infection
Adynamic bone disease
ESRD
Normal pth and vitamin d
CKD anemia treatment
Supplemental iron with goal of tsat >30 and ferritin >500
Epo if normal iron stores
Calcineurin inhibitor aki and hyperkalemia treatment
Thiazide diuretic
Hypermagnesemia treatment
Calcium
Topamax kidney stone
Calcium phosphate
Cisplatin renal toxicity
Tubular injury
Fanconi syndrome
Hypomagnesemia
Polyuria
Liraglutide
Diabetes and weight loss
Autoimmune adrenalitis testing
21 hydroxylase antibodies
Prolactin and antipsychotics
If prolactin is <50, probably medication side effect
But if >200, get pituitary mri
Pager disease of bone
After diagnosis with X-ray
Need alk phos. If normal, disease is burnt out and needs no treatment
Antiresorptive drug hypocalcemia
Caused by low vitamin D
Monitoring labs chronic hypoparathyroidism
24 hr urine calcium
If over 300, have to decrease calcium and vitamin D replacement
Thiazide diuretics decrease calcium excretion, can be used to meet calcium goals
False negative metanephrines
Norepinephrine uptake meds
Like amitryptiline
Metformin GFR
> 45
Toxic adenoma treatment
Radioactive iodine or surgery
Parathyroidectomy indications
Ca >1 over ULN, gfr <60, urine ca >400, kidney stones, T score
Hypoglycemic unawareness
Decrease all insulin doses
Methimazole side effect
Agranulocytosis, comes with sore throat and fever
Myxedema coma treatment
Hydrocortisone before thyroid hormones
Amiodarone induced thyrotoxicosis treatment
Prednisone taper
Methimazole if just hyperthyroidism without destruction
Stop amio
Osteomalacia
Low vit d Low ca Low phos High PTH High ALP
Colonoscopy and aspirin
No need to discontinue
Hyperplastic polyps
Repeat colonoscopy in 10 years
