ABIM1 Flashcards
Which nerve: leg flexion at the hip & extension at the knee?
Femoral nerve (gives off saphenous nerve at medial calf)
Foot drop & sensory loss of dorsal foot and lateral shin- Which nerve is injured?
Common peroneal nerve (often at fibular head region)
RF Common Peroneal N Injury
Prolonged immobilization, leg crossing, squatting, leg casting (esp when combined w/ significant weight loss)
Weakness of dorsiflexion and eversion. Dx?
Common peroneal nerve injury(often at fibular head region)
Tx Common peroneal nerve injury?
Removing pressure on nerve, ankle-foot orthosis splint to keep the foot dorsiflexed & PT
***Variable Tx results with little recovery in most cases
Burning pain of the foot and heel, paresthesias/sensory loss in the sole. Which nerve is affected?
Posterior tibial n (Via Tarsal Tunnel Injury)
Plantar flexion, toe flexion and foot inversion. Which nerve?
Tibial N
Radiculopathy at 1) Knee, 2) Dorsal foot 3) heel/lateral calf. Which nerve distribution?
1) L4, 2) L5 3) S1
Etiologies central hypothyroidism.
Mass lesions.
Infiltration (sarcoidosis, hemochromatosis),
Radiation, trauma, pituitary surgery.
Pituitary infarct (sheehan Sx).
Empty Sella Syndrome.
Low free T4, Low TSH. NSIM?
ACTH test to r/o central (secondary) hypothyroidism
Tx Central Hypothyroidism?
Levothyroxine (goal free T4 high normal range)
*First line Tx Fibromyalgia?
TCA (ie amitrypyline)….2nd line: pregabalin, duloxetine, milnacipran.
Tx Fibromyalgia (4)
- TCA (amitryptaline)
- Pregabalin, duloxetine, milnacipran
- combo drug therapy, supervised rehab, pain management, CBT
Milnacipran use?
SNRI for fibromyalgia (2nd line to TCA)
MOA hyperCa in sarcoidosis?
Extrarenal production of 1-hydroxylase leading to excessive conversion of 25-OH vitD to 1,25 DiH vit D (calcitriol). Calcitriol then increases Ca GI absorption as well as bone resorption. (**PTH independent, note: PTH is often low)
PTH level in sarcoidosis?
LOW hyperCa is PTH independent (Extrarenal production of 1-hydroxylase leading to excessive conversion of 25-OH vitD to 1,25 DiH vit D (calcitriol). Calcitriol then increases Ca GI absorption as well as bone resorption.
Tx hyperCa in sarcoidosis?
IVF & low dose GCS. Also decrease sun exposure and dietary Ca. MOA: In sarcoid, Extrarenal production of 1-hydroxylase leads to excessive conversion of 25-OH vitD to 1,25 DiH vit D (calcitriol). Calcitriol then increases Ca GI absorption as well as bone resorption. **GCS decreases calcitriol production
Zolendronate is contraindicated in patients w/ ____
renal failure
Dermatomyositis Tx?
High dose GCS 1mg/kg/day. (**age-appropriate cancer screening). +/- CT chest/abd/pelvis, UA (hematuria), CA125, CA19-9, PSA, EGD
Tx: Polymyalgia rheumatica
low dose GCS
Heliotrope rash, transaminitis, high CK & ESR. NSIM?
high dose GCS & age-appropriate cancer screening). +/- CT chest/abd/pelvis, UA (hematuria), CA125, CA19-9, PSA, EGD
Medication w/ rapid & short term Ca reduction (w/in 4-6h) used with bisphosphonates in severe hyperCa (most commonly assd w/ malig).
Calcitonin
Calcium mimetic drug acts on Ca receptors on parathyroid cells to decrease PTH secretion (ie in hyperCa primary or tertiary hyper parathyroidism)
Cinacalcet (Sensipar)
Medication which decreases Ca d/t excessive bone resorption.
Zolendronate
HyperCa 2/2 lymphoma. Tx?
IVF & low dose GCS (same mech as sarcoidosis)
Tilt table test- Use?
Dx unexplained fainting (not first line as it is 20-80% sensitive.) Reserved for patients w/ atypical presentations, recurrent syncope (after CVS etiology excluded) or necessity of excluding dx for work after single episode
Indications for catheter removal- Clinical (5)
Clinical: Severe Sepsis / Suppurative thrombophlebitis / Endocarditis / Persistent bacteremia sp 72h abx / Hemodynamic instability
Indications for catheter removal- Pathogens (4)
S.aureus /
P. aeurginosa /
Fungi /
Mycobacteria
Which is an indication for abx? A) positive cath tip Cx B) S.aureus C) phlebitis w/o fever D) cath Cx+, periph Cx-
B
also requires removal, as with P.aruginosa, fungi, mycobactera
Why are coag neg staph problematic, in terms of catheter infection?
they form biofims, hard to irradicate. May use salvage tx (100-1000x abx dose in lumen x hours to days- hwr does not work for Pseudomonas)
RF HFpEF
Chronic HTN (concentric hypertrophy), obesity/sedentary (myocardial interstitial fibrosis), CAD/related RF (ie DM)
HFpEF: therapies to reduce hospitalization and ~mortality
MRAs (spironolactone) & SGLT2 inhibitor (dapagliflozin)
Tx HFpEF (5)
MRAs (spironolactone) & SGLT2 inhibitor Loops for vol overload.l antiHTN to reduce afterload Tx exacerbating conditions (CAD, OSA, Afib) exercise training/cardiac rehab
Best medication for HFpEF
1) BB
2) ACE/ARB
3) Spironolactone
3) Spironolactone (*for afterload reduction)
Tx to improve quality of life in HFpEF
exercise training/cardiac rehab
Phosphodiesterase-5 inhibitor role in pulm HTN 2/2 HFpEF
None- only effective in group 2 pulm a HTN
Criteria model for functional constipation
Rome III
First line Tx for slow transit constipation?
- increase dietary fiber/water, increase daily exercise, d/c offending meds (opioids, anticholinergics, CCBs, NSAIDs)
Common medications causing slow transit constipation?
opioids, anticholinergics, CCBs, NSAIDs
Nonpharmalogic methods unsuccessful for slow transit constipation. NSIM?
Prescribe bulking agent (psyllium or methylcellulose). Colonoscopy if alarm features, refractory sx, features of pelvid floor dysfunction
Alarm Sx assd w/ constipation?
Sudden/acute constipation onset, gross/occult bleeds, change in stool caliber, unexplained weight loss
Constipation, recurrent abd pain, distension, intermittent loose stools, passage of mucous. Dx?
Think of IBS-C (Tx colonic secretagogues- lubiprostone, linaclotide)
Colonic secretagogues- lubiprostone, linaclotide. Use?
IBS-C & severe chronic constipation (after other etiologies ruled out)
Tx of IBS-C & severe chronic constipation (after other etiologies ruled out)
Colonic secretagogues- lubiprostone, linaclotide.
Name an osmotic laxative
PEG (risk of vol overload and electrolyte def)
What do you know about sodium-phosphate enemas?
(aka fleet enema). Avoided in elderly d/t risk of hypotension, vol depletion and acute phosphate nephropathy
Which tx is avoided in elderly d/t risk of hypotension, vol depletion and acute phosphate nephropathy?
fleet enemas (sodium phosphate). Tap water enema preferred.
Etiologies Mg deficiency
malnutrition/EtOH abuse (low intake, thiazides/loops (renal loss), malabsorp/D (GI loss), Bartter S, Gilteman S
Features Mg def
Tetany, seizures, gen weakness, atrial/ventricular arrhythmias
Mg def is assd w/ which lab values?
hypoK, hypoCa
Mg def is assd w/ which EKG abn?
Wide QRS (TdP if severe)
Wide QRS is associated w/ which electrolyte def?
Mg
Alcoholic w/ hypoK & hypoCa NOT improved w/ supplementation. NSIM?
check Mg
MOA hypoCa VS hypoK
HypoCa (decreased PTH secretion or PTH resistance- impaired mobilization from bone). HypoK (renal wasting)
Catecholamine effect on potassium?
Lowers concentration d/t shift from extra to intracellular
Primary Hyperaldosteronism: Which one- hypoK/hyperK, met alk/acidosis, hypoNa/hyperNa, hypo/HTN.
HypO-K, hypER-Na, HTN, met-Alk
UGIB, coffee grounds on suction. Hgb threshold for transfusion?
> 7 (** landmark study showed better outcomes than with >9 threshold: fewer complications, fewer re-bleed, decreased morbidity). Note: variceal bleeds may have worsening bleed with Hgb >10. Transfuse >9 IF: hypovol, active bleed, risk of severe anemia complications ie CAD.
INR goal for EGD in setting of UGIB
< 3 (hwr FFP transfusion threshold is INR <1.5 or PLT <50k)
Proteinuric CKD d/t HTN or DM. Which medication can be used for both?
SGLT2 inhibitor ie dapagliflozin
Which meds have a renal protective effect (independent of BP & gluc control)?
ACE/ARB, NHP CCB (diltiazem), SGLT2 inhib
CKD Hgb threshold for EPO.
<10
In which condition does weight loss slow progression of CKD?
Obesity related FSGS
Tx venous lake
Electrosurgery or pulsed dye vascular laser
Biggest concern with venous lake
Cosmetic or periodic bleeding
Severe d w/ peritoneal signs, lacticemia, v high WBC, dilated colon on abd imaging, hypotension. Dx?
Think of fulminant colitis (Cdiff)
Severe d w/ peritoneal signs, lacticemia, v high WBC, dilated colon on abd imaging, hypotension s/p Abx. TREATMENT?
High dose PO vanc AND IV metro. (Fidaxomycin or PO vanc while awaiting results.) Cases refractory to Tx- may consider scope w/ extreme CAUTION (high perf risk)
Tx fulminant colitis
High dose PO vanc AND IV metro
Mucoid/bloody d. Fever. Shigella+. Tx?
Supportive (most recover without abx. May give if immunocompromised or severe illness)
MC presenting Sx of Entamoeba histolytica.
90% asymptomatic (10% bloody d w/in 1-3 weeks)
Long term care facility has pt w/ influenza. Protocol?
Start Tx for everyone w/ oseltamivir/zanamivir. (continue ppx for 14 days or 10 days after onset of first pt, whichever is longer)
When should healthcare workers return to work after the flu?
24h after sx resolution
How long does it take for flu vax to give immunity?
~2wks
Tx for essential tremor if pt has a hx of asthma?
atenolol
Two first line meds for essential tremor?
propanolol or primidone. (propanolol has better adverse effect profile)
Narrow based, shuffling gait. Dx?
Suggests Parkinsonism
Intention tremor which increases in severity as the hand gets closer to the target is characteristic of:
Cerebellar CVA (DDX essential tremor is constant and may increase right at the end of movement)
Ca 12-14. Tx?
IVF, calcitonin, bisphosphonates. No immediate Tx unless symptomatic)
Tx Ca >14?
STAT IVF, calcitonin, bisphosphonates.
MOA IVF treatment for hyperCa?
Promotes urinary Ca excretion. Note: most patients improve w/ IVF as hyperCa makes them volume depleted (vomiting, renal Na/H2O wasting)
When is zolendronic acid not recommended of osteoporosis?
CrCl <35 (however, may be considered for tx of malignancy related hyperCa with Cr eve above >4.5)
When is HD used for hyperCa?
Severe hyperCa in patients w/ severe CHF/renal failure who cannot receive IVF
How long does it take for bisphosphonates to affect Ca levels?
2-4 days
Best MDD medication for pregnant woman?
Sertraline (most studied of the SSRIs, which are first line. Note paroxetine carries a smal risk of cardiac malformations)
Complications of endocarditis:
- cardiac & neuro
CARDIAC: HF, perivalvular abscess, pericarditis, intracardiac fistula.
NEURO: CVA, brain abscess, meningitis
Complications of endocarditis: RENAL, MSK, other
RENAL: infacrt or abscess, GN. MSK: septic arthritis, vertebral OM. Other: mycotic aneurysm, septic emboli- splenic/pulm/soft tissue
Endocarditis, abx started. Patient later becomes febrile w/ acute resp failure & intubated. NSIM?
TEE to r/o valvular insuff due to valve leaf perforation or worsening regurg.
MCC CHF in patients w/ valvular endocarditis?
valvular insuff due to valve leaf perforation or worsening regurg. Order TEE to eval.
Tx methicillin susceptible endocarditis VS MRSA.
Susceptible- cefazolin
MRSA- vanc
Trazodone use for sleep
Not recommended d/t significant adverse effects
Dx for each XR finding:
1) subcortical bone cysts w/ possible bony erosions. 2) chondrocalcinosis
1) gout 2) pseudogout
Rhomboidal & positively birefringent crystals. What do you expect to see on XR: subcortical bone cysts or chondrocalcinosis?
Chondrocalcinosis (pseudogout)
Young patient w/ acute inflamm arthritis of the knee. XR showing chondrocalcinosis. Which other condition do you r/o?
(Dx pseudogout) screen for hemochromatosis w/ iron studies.
RF for pseudogout?
hypothyroidism, hemochromatosis, renal osteodystrophy, hyperPTH or recent parathyroidectomy
Which is NOT an RF for gout:
HTN, hypothyroidism, obesity, EtOH, diuretics
hypothyroidism (hwr it is a RF for pseudogout)
Erythrasma Dx test
coral red under Woods lamp d/t porphyrins produced by Corynebacteria minutissimum HWR may be washed away when baithing giving a false neg result
Tx erythrasma
Limited: Clindamycin 1% or topical antifungal (miconazole) for coexisting fungal infection.
Systemic: PO macrolide (erythra/clinda)
DDX Candida VS erythrasma
Candida: Skin scrapings w/ KOH show budding yeast w/ septal hyphae.
Erythtrasma: Red under Woods lamp
Tx of HSV-induced or recurrent erythema multiforme.
Prophylactic antiviral therapy
Factors associated w/ adverse prognosis in IgA nephropatht
HTN, lower GFR, significant proteinuria
Gross hematuria & proteinuria sp URTI. NSIM?
(Dx IgA nephropathy). NSIM measure degree of proteinuria (renal Bx may be indicated if proteinuria >500mg/day, Cr >1.5 & HTN)
When does IgA nephropathy require renal Bx?
proteinuria >500mg/day, Cr >1.5 & HTN
Cough, SOB, w loss wks>months. Hx birds/hay/hot tub. Findings of pulm fibrosis. Dx?
Subacute/Chronic Hypersensitivity Pneumonitis. (Tx Allergen avoidance, if severe PO GCS)
Cough, SOB, w loss wks>months. Farmer. CT: mid/upper ground glass. BAL w/ lymphocytosis. Dx?
Subacute/Chronic Hypersensitivity Pneumonitis. (Tx Allergen avoidance, if severe PO GCS)
Clubbing, cough, SOB, w loss wks>months. Zoo keeper. CT: mid/upper ground glass. BAL w/ lymphocytosis. Tx?
Allergen avoidance, if severe PO GCS. (Dx Subacute/Chronic Hypersensitivity Pneumonitis)
Features of Hypersensitivity Pneumonitis Exam/Hx.
Hx: Cough, SOB, w loss wks>months. Hx birds/hay/hot tub. **Sx improvement w/ vacation. Exam: Clubbing, features of pulm fib if chronic.
Dx work up in HS Pneymonitis
Inhalation testing.
CT: mid/upper ground glass.
BAL: lymphocytosis.
Bx: non-caseating granulomas in periph lung (gold standard)
GCS-induced osteoporosis. PPx/Tx
PPx: Ca/VitD. Bisphosphonates.
General measures to avoid GCS-induced osteoporosis.
Lowest dose possible. Weight-bearing exercises. Stop smoking/EtOH.
Patient on chronic, high dose GCS cannot tolerate bisphosphonates. Tx?
PTH (teraparatide)
What is high VS mod risk GI toxicity d/t NSAIDs?
High (>2 RF), Mod (1-2 RF).
>65yo, high dose NSAID, Hx PUD, Concurrent ASA, GCS, AC.
Patient on chronic NSAIDs w/ high/mod risk GI tox (>65yo, high dose NSAID, Hx PUD, Concurrent ASA, GCS, AC). Management?
Switch to selective COX2 inhibitor OR give PPI OR give misoprostol
Pt w/ URTI has mild asthma sx despite inhalers. NSIM?
Give GCS (PO 40-60mg x 5-7 days)
Rhinosinusitis & upper airway cough syndrome. Tx?
intranasal flucticasone or budesonide
Intranasal budesonide use
Rhinosinusitis & upper airway cough syndrome
Drugs require concurrent folate supplementation?
Phenytoin
MTX
Pyrimethamine
Trimethoprim
(b/c they are folate antagonists & also inhibit rapidly dividing cells > bone marrow suppression)
Leukovorin- use?
reduced folic acid that bypasses enzyme blocked by phenytoin, MTX, trimethoprim, pyrimethamine
Tx Toxoplasmosis
Pyrimethamine & sulfasalazine (second line: TMP-SMX)
Why is leucovorin given with pyrimethamine?
Pyrimethamine causes bone marrow suppression (leukovorin decreases hematologic complications)
Hpylori Tx
Clarithromycin, PPI, amoxicillin x 10-14 days
Hpylori w/ PNC allergy- Tx?
Clarithromycin, PPI, metronidazole x 10-14 days
Hpylori- high macrolide or metronidazole resistance. Tx?
PPI, bismuth, metronidazole, tetracycline x 10-14 days
For whom is Hpylori testing highly recommended
Persistent sx, MALToma, PUD or resected gastric CA (hwr can be considered for everyone)
For how many weeks do you hold PPI prior to stool Ag/urea breath test?
2 weeks
DDx athletes heart vs HCM
HCM: FHx+, EKG w/ depolarization abn (Q waves), septum >15mm, diastolic function impaired, LV cavity size decreased
IV septum size in athletes heart VS HCM
HCM >15mm
Cardiac sarcoidosis manifestations
Conduction abn: arrhythmias, heart blocks, HF (systolic or diastolic)
Decompensated CHF- which IV infusion can acutely improve hemodynamics and decrease SOB?
Milrinone (BUT- RF of atrial/ventricular arrhythmias, provoking ischemia in CAD, may increase mortality. Not recommended for chronic use)
Milrinone use?
Decompensated CHF- which IV infusion can acutely improve hemodynamics and decrease SOB. (BUT- RF of atrial/ventricular arrhythmias, provoking ischemia in CAD, may increase mortality. Not recommended for chronic use)
Low dose antipsychotics use in dementia?
Avoided- associated w/ increased mortality.
Olanzapine role in anorexia?
If CBT or nutritional rehab is ineffective.
Lisdexamphetamine use?
Binge eating disorder (hwr 1st line: behavioral rx, SSRO, CBT)
Bulimia- most efficacious SSRI?
Fluoxetine
Is fluoxetine useful for bulimia as monotherapy?
NO- must be paired with CBT or nutritional rehab
Sx hyperthyroid, high radioactive iodine uptake of thryoid nodule, low TSH. Tx?
Ablative rx or surgery if: large goiter, coexisting malignancy or concurrent hyperPTH
Role of FNA for hot nodule?
Little/none. Hot nodules are rarely malignant.
Middle aged man w/ idiopathic pancreatitis, sclerosing cholangitis, LAD, bilateral salivary/lacrimal gland enlargement. Dx?
Suspect IgG4 related disorder. (fibrosis/tumor-like swelling of affected organs, unknown etiology). May affect thyroid, interstitial fibrosis, tubulointerstitial nephritis, retroperitoneal fibrosis)
Middle aged man w/ idiopathic pancreatitis, sclerosing cholangitis, LAD, bilateral salivary/lacrimal gland enlargement. Treatment?
Tx: GCS +/- azathioprine, mycopheoate mofetil or rituximab for refractory disease (IgG4 related disorder)
Middle aged man w/ idiopathic pancreatitis, sclerosing cholangitis, LAD, bilateral salivary/lacrimal gland enlargement. Which diagnostic work up do you order?
Eval: peripheral eosinophilia, high IgG4 levels, tissue Bx w/ IgG4+ plasma cells & lymphocytes
ASA-exacerbated resp disease triad (Samters)?
Asthma + ASA use + rhinosinusitis w/ nasal polyps
Asthma + ASA use + rhinosinusitis w/ nasal polyps. Dx?
ASA-exacerbated resp disease triad (Samters)
Patient takes ASA and 1-3hrs later develops asthma exacerbation, rhinorrhea, conjunctival injection & facial flushing. Dx?
ASA-exacerbated resp disease triad (Samters). Tx- avoid NSAIDs, add montelukast/zafirlukast, consider ASA desensitization)
ASA-exacerbated resp disease Tx
avoid NSAIDs, monte/zafirlukast, ASA desensitization
Who should get AAA screening?
men ages 65-75 w/ any smoking hx
Three indications for AAA repair?
> 5.5cm, >0.5cm increase in 6 months, symptomatic
How to initiate uric acid lowering therapy for gout during attack?
Wait until attack has resolved. Use colchicine or NSAIDs to prevent flare during initial titration of allopurinol, febuxostat or probenecid.
Which antiHTN meds are best in setting of gout?
amlodipine (CCBs), losartan. (Otherwise generally avoid ACE/ARBS & BB)
How does EtOH increase risk of gout flare?
Increases uric acid production by conversion of ATP>ADP
Syndrome assd w/ multiple epidermal inclusion cysts and CRC.
Gardner
Sx: flushing, telangiectasia, D/cramps, R valvular lesions (TR) , bronchospasm, niacin def (dermatitis, diarrhea, dementia). Which labs/imaging do you order?
5HIAA 24h urinary excretion. CT/MRI abd/pelvis to localize tumor, OctreoScan, TTE. (Tx: octreotide, surgery for liver mets) Dx CARCINOID
Which condition is associated w/ episodic flushing and secretory D?
Carcinoid (also telangiectasia, D/cramps, R valvular lesions (TR) , bronchospasm, niacin def (dermatitis, diarrhea, dementia)).
Tx of carcinoid (symptomatic & preventative)
Octreotide
Carcinoid: most common locations?
distal small intestine, proximal colon, lungs.
Which location of a carcinoid tumor would cause most pronounced sx: distal small intestine, proximal colon, liver, extraintestinal
Liver and extraintestinal (liver metabolizes GI carcinoid tumor products, hence causing minimal sx.)
Sx: flushing, telangiectasia, D/cramps, R valvular lesions (TR) , bronchospasm, niacin def (dermatitis, diarrhea, dementia). Why is this NOT VIPoma?
VIPoma may cause significant watery D and occasional flushing but is NOT associated w/ telangiectasias or cardiac lesions. (those sx are that of Carcinoid)
R-sided infective endocarditis: most common valve affected?
tricuspid
Cardiac auscultation findings in R-sided infective endocarditis?
nothing (murmurs often absent)
Most common pathogen of R-sided infective endocarditis?
S. aureus
S.aureus bacteriemia & several bilateral cavitating pulm lesions. Suspected hx & dx?
IVDU, R-sided infective endocarditis
Common co-infections in setting of R-sided infective endocarditis?
HIV, HCV, HBV (often IVDU)
Highest risk 2nd gen antipsych meds for AE of metabolic syndrome?
Olanzapine/Zyprexa & clozapine (lower risk- aripiprazole/abilify, ziprasidone)
Patient is started on olanzapine for schizophrenia. What should you monitor?
BMI, fasting glucose/lipids, blood pressure, waist circumference
Brand names of olanzapine & aripiprazole?
zyprexa, abilify
Olanzapine requires routine monitoring of which of the following:
- Liver Enzymes
- Renal funct
- Leukopenia
- A1C/Lipids
- A1C/Lipids (as well as weight gain/BMI). **monitoring at baseline, after 3 months and then annually
2 effects of angiotensin II levels?
Vasoconstriction & fluid retention.
Neprylisin role? What inhibits it?
Degrades BNP, ANP, angiotensin II & bradykinin. Sacubitril inhibits it (leading to less breakdown of these products- BNP & ANP promote arteriolar/vasodilation, hwr elevated angiotensin leads to vasoconstriction & fluid retention)
Risk of cough w/ sacubitril-valsartan (Entresto): ___%
10 % (other RF: hyperK, renal f, dizziness/hypotension) HWR- reduces all cause mortality in CHF patients.
Pt w/ CA develops VTE. Tx choice and duration?
LMWH (DOAC efficacy somewhat similiar), Tx indefinitely
Which cancer mets have greatest risk of cerebral hemorrhage?
melanoma, RCC, thyroid, choroicarcinoma. **If patient with one of these develops DVT, may need to place IVC as they cannot be safely anticoagulated
T/F IVC filter placement reduces PE-related death in patients w/ DVTs.
F. They are LESS effective than AC & also have a higher risk of furture DVTs.
Patient w/ cancer develops DVT. When is an IVC the treatment of choice?
Recent surgery, hx IC hemorrhage, active bleed, high risk CA for IC hemorrhage (mets from RCC, thyroid, melanoma, choriocarcinoma). Otherwise opt for LMWH (or ~DOAC)
MMSE score for dementia is <__
<24 however, cutoff may be increased to 27 for those with higher education.
How do you differentiate age-related decline in cognition or mild cognitive impairment from dementia?
*impairment of daily activities (also MMSE <24 or <27 in higher educated)
Adult AOM, MCC pathogens (3)
*S.pneumo then- H.influenza, M.catarrhalis
First line Abx for adult AOM?
Amoxicillin (eval after 48-72h, if persistent sx give Amoxi-Clav for beta-lactamase producing H.influenza)
Pt given amoxicillin for AOM however c/o no improvement of Sx 48h later. NSIM?
Add Amoxi-Clav for beta-lactamase producing H.influenza.
Pt given amoxicillin for AOM however c/o no improvement of Sx 48h later. Likely pathogen?
beta-lactamase producing H.influenza. Add amoxi-clav
AOM Tx for PNC allergic patients VS beta-lactam allergic abx.
PNC allergic: Cefuroxime, Cefdinir. Beta-Lactam allergy: azithromycin
Falls in elderly: Screening/intervention.
Visual improvement (if cateracts, <20/60 acutity, ample lighting). Postural BP (slow change in position, compression stockings, remove offending meds). Med use (reduce offending meds: neuroleptics, sleep meds, benzos, polypharmacy). Balance/gait (get up and go test, exercise training program), Home hazard eval. +/-
T/F: Cane usage confers a lower risk of falls in elderly.
F. Higher risk and risk of more serious falls/injuries.
Rectovaginal fistula Tx if IBD-related vs non-IBD
non-IBD: surgery. IBD: asx (observation), mild sx (cipro+metro x 6-12 months), mod/severe sx (*infliximab, or ~azathiorpine/6MU, or ~tacrolimus. If ineffective > surgery)
Crohns pt w/ rectovaginal fistula causing mild sx. Tx?
Cipro & metro x 6-12 months.
If mod/severe sx (*infliximab, or ~azathiorpine/6MU, or ~tacrolimus. If ineffective > surgery)
1st line Tx for mod/severe sx from rectovaginal fistula in Crohns/UC?
Infliximab or other TNFa inhibitors (or ~azathiorpine/6MU, or ~tacrolimus. If ineffective > surgery)
Gross hematuria w/ impaired ability to concentrate urine in a young AA male. No other abn findings. How do you confirm the Dx?
electrophoresis to eval for sickle cell trait. (note: rare but increased risk of renal medullary CA)
Renal medullary CA is almost exclusively seen in the setting of:
sickle cell trait
Sickle cell trait poses a risk for which rare CA?
Renal medullary CA (highly malignant, seen almost exclusively in SC trait)
NPPV has strongest evidence for which conditions/situations (4)
COPD exacerbation, cardiogenic pulm edema, post-op resp failure, early extubation
List some contraindications for NPPV use (10)
Impending cardiac/pulm failure, Encephalopathy/GCS <10, GIB, ARDS, inability to clear secretions, unstable cardiac arrhythmia, acidosis <7.10, uncooperative/agitated, upper airway obstruction, recent facial surgery, recent esoph anastomosis
T/F continuous albuterol nebs are indicated over intermittent nebs for severe resp failure.
F. continuous & intermittent have the same efficacy
Goal oxygen saturation vs goal arterial oxygen tension in COPD exacerbation.
O2 Sat: 88-92%, PaO2 60-70 (note- excessive O2 may worsen CO2 retention).
Patient returns from South Asia/Central-South America. Has fever, flu-like sx (myalgia/arthralgia), diffuse maculopapular rash, leukopenia. Tourniquet test+. Dx?
Suspect Dengue. (more severe sx: abd pain/V, ascites/pleural eff, mucosal bleed, hepatomegaly >2cm, increased HCT w/ rapidly dropping PLT). May lead to severe liver failure, resp distress & bleeding.
Patient returns from South Asia/Central-South America. Has fever, flu-like sx (myalgia/arthralgia), diffuse maculopapular rash, leukopenia. Tourniquet test+. *Which sx are they at risk of developing with progression to severe disease?
Suspect Dengue. (more severe sx: abd pain/V, ascites/pleural eff, mucosal bleed, hepatomegaly >2cm, increased HCT w/ rapidly dropping PLT). May lead to severe liver failure, resp distress & bleeding.
Returns from Mexico- fever, myalgias, retro-orbital HA, epistaxis. Dx?
Suspect Dengue. (more severe sx: abd pain/V, ascites/pleural eff, mucosal bleed, hepatomegaly >2cm, increased HCT w/ rapidly dropping PLT). May lead to severe liver failure, resp distress & bleeding.
Returns from Brazil- fever, myalgias, retro-orbital HA, epistaxis. What do you expect to see on labs?
Leukopenia, thrombocytopenia, elevated HCT. Confirm Dx w/ serology. Tx supportive.
Dengue fever- Tx?
supportive
Farmer w/ fever, myalgias, HA, N/V/D, conjunctival suffusion (redness w/o exudates), cough/SOB, proteinuria/electrolyte abn. Dx?
Think Leptospirosis. Other Sx: HSM, LAD, Jaundice if severe (Weil)
RF for leptospirosis apart from freshwater swimming.
Pet dogs/rodents, farmers, vets. Higher incidence closer to equator
Pregnant woman w/ Hgb 10.6 in 2nd trimester. MCV, ferritin/TIBC/iron & periph smear wnl. Tx?
Observation. Normal w/u & in range of physiologic preg changes. Goal Hgb 1st trim >11, 2nd trim >10.5, 3rd trim >11
Goal Hgb in pregnancy by trimester?
1st trim >11, 2nd trim >10.5, 3rd trim >11
Pregnant woman w/ Hgb 10.6 in 2nd trimester. MCV elevated, ferritin/TIBC/iron wnl, periph smear w/ spherocytosis. Which dx test do you order to help confirm Dx?
Direct antiglobulin (Coombs), LDH, haptoglobin. Dx: AIHA, as seen in 10% SLE patients during preg.
How soon does physiologic anemia of pregnancy resolve post-partum?
6-8wks
Long extremities, scoliosis, early diastolic murmur at the 2nd R ICS. Dx?
Suggestive of Marfan (AD disorder of skeleton, eyes/lens dislocation & heart/AR)
MCCOD in Marfans?
aortic dissection (35-40%), then CHF
Marfans: Most common cardiac abn?
aortic root dilation (60-80% adults). MCCOD aortic dissection (35-40%), then CHF. Always screen w/ TTE at diagnosis & recommend surgical repair if aortic root >50mm.
Marfan suspected. Pt feels well. How do you confirm Dx & NSIM?
fibrillin-1 gene mutation, TTE: aortic root dilation, FHx, ectopia lentis. (note: order TTE at Dx & then interval follow up screenings)
Fibrillin-1 gene mutation. Dx?
Marfans
Which is NOT a dx work up for Marfans: fibrillin-1 gene mutation, TTE: aortic root dilation, skin bx, FHx, ectopia lentis.
skin bx (but may be used for eval of Ehlers Danlos)
Fair complexion, marfanoid body habitus, developmental delays, hypercoag. Dx?
Homocystinuria (AR disorder). Confirm w/ homocysteine, methionine in the plasma or urine. +/- genetic testing looking for changes in both copies of the CBS gene to confirm their diagnosis. Note: most states screen at birth.
Which is not a manifestation of 47, XXY? Hypogonadism, gynecomastia, cardiac defects, learning disability/behavioural problem
cardiac defects
Wide-based gait, cognitive dysfunction, urinary incontinence, UMN signs in legs. Dx?
NPH (may be assd w/ depression d/t compression of frontal lobe)
NPH suspected. How do you confirm the dx?
MRI w/ enlarged ventricles out of proportion to brain atrophy. LP tap 30-50cc w/ marked gait improvement (Miller Fisher test+)
Wide-based gait, cognitive dysfunction, urinary incontinence (late), UMN signs in legs. Treatment??
ventriculoperitoneal shunting (clinical improvement in 60%)
SAR or meningitis leading to impaired CSF absorption. Which Sx do you expect?
Secondary NPH (Wide-based gait, cognitive dysfunction, urinary incontinence, UMN signs in legs.)
Wide-based gait “feet fixed to floor”, depression & UMN signs in legs. Dx?
NPH (note: urinary incontinence/urgency occurs late). Depression 2/2 compression of frontal lobe.
Elderly pt reports “feet fixed to floor” & unstable gait. You stand behind the pt and pull shoulders backward. They take several steps to regain stability. Babinski+. Dx?
Eval for NPH w/ MRI enlarged ventricles out of proportion to brain atrophy., LP tap w/ marked gait improvement (Miller Fisher test+). (note: urinary incontinence/urgency occurs late). Tx: ventriculoperitoneal shunting
NPH: What do you expect for reflexes/LMN signs in the legs?
Brisk/increased.
Ventriculoperitoneal shunting for NPH: efficacy/% clinical improvement?
Clinical improvement in 60%
Which hematologic malignancy is the MCC of leptomeningeal carcimatosis?
AML (Leptomeningeal CA: Acute onset of CN palsies, focal weakness, HA/N/V, diplopia, absent reflexes)
Pt w/ AML develops acute onset of CN palsies, focal weakness, HA/N/V, diplopia, absent reflexes. Dx?
Eval for Leptomeningeal CA
HA, papilledema, LP w/ high OP >250. Dx?
Idiopathic IC HTN
UTI in preg. Tx asymptomatic bacteruria VS mild/mod pyelo.
ASx: Amoxi-Clav, Fosfomycin, Cephalexin, (may use nitro or bactrim AFTER 1st trim). Mild/Mod pyelo: Inpatient IV *Ceftriaxone/Cefepime, Aztreonam, Ampi/Genta (if v severe/immunocompromised: zocyn or carbapenem)
Which is NOT a tx for asymptomatic bacteruria in pregnancy: Ceftriaxone, Cephalexin, Fosfomycin, Amoxi-Clav, Ampi-Genta?
Ceftriaxone and Ampi/Genta are used for mild/mod pyelonephritis in pregnancy.
Which is NOT recommended for 2nd trimester ASx bacteriuria? Ceftriaxone, Cephalexin, Fosfomycin, Amoxi-Clav, TMP/SMX, nitrofurantoin?
Ceftriaxone agent of choice for mild/mod pyelonephritis in pregnancy. (note: TMP/SMX and nitrofurantoin are avoided only in 1st trimester)
When are bactrim and nitrofurantoin avoided for cystitis/bacteruria in pregnancy?
Only 1st trimester
Abx choice for severe pyelo (urinary retention, immunocompromised) in preg?
zocyn or carbapenem
Complications of pyelonephritis in pregnancy.
ARDS, pulm edema, preterm labor, low birth weight
When to give TMP-SMX ppx in HIV? (3 criteria)
CD4 <200 OR oropharyngeal candidiasis OR Hx PCP (alternatives: Dapsone, atovaquone, pentamidine)
Pt w/ sulfa allergy & CD4 count 150. What do you use for PCP ppx?
Dapsone, atovaquone, pentamidine (as per allergy to TMP-SMX)
CD4 >200, however physician gives PCP ppx w/ TMP-SMX. Why?
Criteria for PCP ppx: CD4 <200 OR oropharyngeal candidiasis OR Hx PCP
PPx T.gondii is indicated for CD4 < ___ & positive IgG ab.
CD4 <100 (alternative meds: dapsone/pyrimethamine/leucovorin OR atovaquone/pyrimethamine/leukovorin)
Which medication prophylaxes against T.gondii & PCP?
TMP-SMX (threshold to give is CD4 <200 for PCP & <100 for T.gondii)
PPx w/ ________for Histoplasma capsulatum if endemic area and CD4 <___.
itraconazole, CD4 <150.
Pt w/ HIV & no prior VZV infection, comes into contact w/ person w/ shingles. NSIM?
VariZIG or IVIG w/in 4 days
VariZIG use?
VZV Ig as PEP for immunocompromised populations ie HIV
Patient w/ HIV has last two CD4 counts over 3 months improve to 300. Asks whether they can discontinue bactrim.
Yes. Criteria for PCP ppx: CD4 <200 OR oropharyngeal candidiasis OR Hx PCP. Once CD4 improves >200, may discontinue.
MAC ppx in HIV?
Not recommended. (previously azithromycin if CD4 <50, hwr risk of MAC is v low when on HAART)
Indication for EtOH septal ablation in HCM?
Severe LVOT obstruction & HF sx refractory to medical tx
Indication for implantable ICD in HCM?
LV wall >3cm, FHx sudden cardiac death, hx sustained ventricular arrhythmia.
Indication for negative inotropes (BB, non-DHP CCBs) in HCM?
LVOT obstruction or sx HF (**note: AVOID ACEi, diuretics & DHP CCBs like amlodipine/nifedinpine per risk of decreasing afterload and increasing LVOT obstruction)
Which meds to AVOID in HCM?
AVOID ACEi, diuretics & DHP CCBs like amlodipine/nifedinpine per risk of decreasing afterload and increasing LVOT obstruction. (If symptomatic, give non-DHP CCB or BB)
ASx teen w/ known HCM and no FHx sudden death or hx sustained arrhythmia. Tx?
Instruct to avoid all competitive sports or high intensity physical activity
Febrile neutropenia <7d, clinically stable w/o significant sx, tolerates PO. Tx?
Cipro & amoxi-clav.
Febrile neutropenia: High risk, profound, >7d, AMS, hemodynamic instability, organ involv (oral mucositis, GI Sx, hypoxia, hepatitis). Tx?
IV zocyn, cefepime, meropenem (antipseudomonal beta-lactam monotherapy). IF line sepsis, skin infection or hemodynamic instability, PNA, severe sepsis, BCx for GP organism ADD vanc. IF persistent >4-7 days or evidence of fungal infection, add caspofungin
Febrile neutropenia <7d, clinically stable w/o significant sx, PO intolerance. Tx?
IV zocyn, cefepime, meropenem (antipseudomonal beta-lactam monotherapy). IF line sepsis, skin infection or hemodynamic instability, PNA, severe sepsis, BCx for GP organism ADD vanc. IF persistent >4-7 days or evidence of fungal infection, add caspofungin
When to add vanc for febrile neutropenia?
suspected septic line, skin infection or hemodynamic instability, PNA, severe sepsis, BCx for GP organism
Febrile neutropenia persists after 7 days of zocyn. NSIM?
Start caspofungin (or antifungal). If suspected septic line, skin infection or hemodynamic instability, add vanc.
When to add antifungal to febrile neutropenia?
persistent despite zocyn/vanc >4-7 days OR evidence of fungal infection OR chemo for AML OR recent hematopoietic stem cell transplant
Hip/buttock pain w/ activity, abruptly resolves w/ rest. Suspected Dx?
Aortoiliac PAD- also: diminished femoral pulse +/- bruit, muscle atrophy & slow wound healing in legs.
Calf pain w/ exertion, promptly alleviated w/ rest. PAD suspected- Which arteries are affected if calf pain is upper 2/3 of calf VS lower 1/3?
upper 2/3 (superficial femoral a), lower 1/3 (popliteal)
Hip/buttock pain w/ activity, abruptly resolves w/ rest. Why is it unlikely OA/DJD?
Abrupt resolution
Which movement aggravates hip OA/DJD?
passive flexion
Myalgia DDX
viral inf, polymyositis/dermatomyositis, hypothyroid, fibromyalgia, statins
ED, buttock pain, decreased femoral pulse. Dx?
(Leriche Syndrome) Think aortoilliac PAD
Thigh pain. If 2/2 PAD, which pulses would be diminished? Which arteries involved?
decreased distal pulses (but normal in groin). Likely aortoilliac or common femoral arteries.
Pt w/ BPH & CHF exacerbation has worsening nocturia (but no polyuria during the day). NSIM?
Increase diuretics. CHF may worsen nocturia per Na retention during the day, which gets released into urine at night d/t better renal filtration w/ recumbency)
Indication for antipsychotics in setting of eldery delirium?
Short term if patient poses risk to self/others. Preferred agents (haldol, olanzapine, risepridone, quetiapine)
Name some etiologies of SNHL
Presbyacusis, Menieres D, barotrauma, acoustic neuroma, CVS ischemia, vestibular schwannoma, viral cochleatitis
Acute unilateral SNHL- NSIM. & prognosis?
MRI & audiometry to r/o serious etiology (ie vestibular schwanoma). Note: most acute SNHL is benign and resolves 3-4 months. If work up is inconclusive, some specialists recommend high dose PO GCS and antivirals
Pt w/ allergic rhinitis or viral URTI presents w/ HL accompanied by pain or cracking/popping sounds & middle ear effusion. NSIM/Dx?
Decongestants or antihistamines (Dx Eustachian tube dysfunction related to rhinitis/URTI)
SGLT2 inhibitor (ie Dapagliflozin) AE**
GU (vulvovaginal candidiasis, UTI, rare Fourniers G), Osmotic (vol depletion, hypoTN, pre-renal AKI), metabolic (euglycemic DKA), ortho (low trauma fracture, foot ulcers > increased amputation risk)
Benefits of SGLT inhibitors
Slows DM RF (lowers glom pressures), decreases BP, modest weight loss. (MOA: decreases renal reabsorp of glucose)
Fludrocortisone use?
synthetic mineralocorticoid agonist occasionally used for orthostatic hypotension.
T/F AE of BB is MDD.
F. Previously reported hwr no longer supported.
Elderly M who denies MDD/SI hwr hx suggests high risk & possible SI. NSIM?
Psych hospitalization during which MDD tx can be safely initiated.
DM > ESRD. Tx to increase QoL & survival?
Renal transplant (living donor preferred but deceased donor also provides benefit). Note: 5y survival upon initiating HD is 33% (MCCOD CVS). 5yr survival w/ transplant is 66-77%.
DM > ESRD. If placed on HD, what is the MCCOD?
> 50% patients on HD die of CVS event. Note: 5y survival upon initiating HD is 33%. 5yr survival w/ transplant is 66-77%.
Do you start HD at onset of uremic sx or when GFR <10?
Who knows. Debatable. Note: 5y survival upon initiating HD is 33%.
Tx vertebral compression fracture.
Analgesics, 2nd line: Calcitonin may alleviate pain refractory to NSAIDs/Tylenol/opioids, avoid bed rest (causes additional loss of bone density), PT for core strengthening, vertebroplasty in select patients
2nd prevention of vertebral fracture?
bisphosphonates for osteoporosis, exercise
Vertebral compression fracture- indication for MRI/CT?
significant neuro findings.
Psioriatic nail involvement: Tx involving 1-2 digits VS widespread involvement?
1-2 digits: topical GCS & vitD (ie calcitriol)
>2 digits: systemic TNFa or MTX
(note: nail involvement indicates increased risk of psoriatic arthritis)
Etiologies of clubbing?
intrathoracic neoplasms, intrathoracic suppurative d (bronchiectasis, lung abscess), fibrotic lung disease, cyanotic congen heart failure
Nails: brittle, dystrophic, leukonychia, longitudinal striations, increased risk of onychomycosis. Which dx?
chronic viral hepatitis
Acquired coarctation of the aorta- etiology?
Takayasu (rare)
Which findings do you suspect in aortic coarctation on EKG, CXR, TTE?
EKG: LVH.
CXR: rib notching of 3rd-8th ribs, “3 sign” d/t aortic indentation.
TTE: confirmation of defect
Pt c/o HA, epistaxis. EKG: LVH. CXR: rib notching of 3rd-8th ribs, “3 sign”. What is the treatment?
(aortic coarctation) Tx Balloon angioplasty, surgery.
L interscapular systolic or continuous murmur. Assd Dx?
Aortic coarctation, EKG: LVH. CXR: rib notching of 3rd-8th ribs, “3 sign” d/t aortic indentation. TTE: confirmation of defect. Tx Balloon angioplasty, surgery.
Aortic coarctation. Most common assd defect?
*bicuspid AV. (others: PDA, VSD, AS above or below defect)
Which conditions are assd w/ the following:
Ebstein anomaly of TV? ASD? Pulm stenosis?
WPW (Ebstein anomaly of TV), Downs (ASD), ToF (pulm stenosis)
Main clinical features of aortic coarctation?
BP higher in arms than legs. Upper body HTN > HA, epistaxis. Brachiofemoral pulse delay. Claudication & underdeveloped legs.
MOA of elderly delirium w/ urinary retention.
increased bladder tension stimulates sympathetic catecholamine release > delirium.
Bladder volume > ___mL suggests urinary retention.
> 300
Fatigue, pruritus, nausea, hand arthragia. Labs: high bili, transaminitis, IgG, ANA+, LMK1+, HCV ab+ otherwise liver viral panel neg. Dx?
Suspect AI hepatitis. Check anti-smooth muscle abs. Bx: piecemeal necrosis. **note: often false positive HCV ab (rule out w/ neg HCV RNA). Tx: GCS +/- AZA or 6MU. Liver transplant for ALF or decompensated cirrhosis.
anti-smooth muscle abs+. Tx?
(AI hepatitis) Tx: GCS +/- AZA or 6MU. Liver transplant for ALF or decompensated cirrhosis.
When is liver transplant indicated for AI hepatitis?
ALF or decompensated cirrhosis.
LC-1 ab & LKM1 Ab are assd w:
AI hepatitis (Liver cyotosol ab & liver/kidney microsomal ab)
Demographic most affected by AI hepatitis?
40-50yo F
How does a1 antitrypsin present in the first couple of decades vs later on?
First 2 decades: chronic hepatitis, cirrhosis, HCC +/- derm/panniculitis. Then pulm sx (early onset emphysema)
Derm finding assd w/ a1 antitrypsin def?
Panniculitis (inflamm of subQ fat, looks like PAN)
Dx studies to confirm granulomatosis w/ polyangitis?
C-ANCA, anti-proteinase3 Abs. Tissue bx: vasculitus
40yo w/ IDA, osteoporosis, arthritis, transaminitis, neuro sx, infertility. Dx?
Atypical celiac
TCA OD. EKG showing wide complex tachycardia (or QRS >100ms). NSIM?
STAT IV sodium bicarb (administered up to pH of 7.45- 7.55 or until QRS stabilizes)
Cyproheptadine use?
5HT antagonist used in 5HT syndrome
Flumazenil carries the risk of:
lowering seizure threshold when used to tx benzo OD
Med overdose. Sx: hypotension, resp depression, tachycardia, seizures, coma. EKG w/ QRS >100. NSIM?
STAT IV sodium bicarb (administered up to pH of 7.45- 7.55 or until QRS stabilizes). Likely TCA OD.
Pituitary incidentaloma <10mm. ASx. NSIM?
Check prolactin only (if other sx, targeted hormone testing). If it was >10mm, check for all hormone overproduction- if present, surgery (except prolactinoma!)
When is surgery indicated for management of a pituitary incidentaloma?
If >10mm AND overproduction of any pituitary hormones excluding PRL … Also if continues to enlarge.
Pituitary incidentaloma prevalence?
In 10% of patients undergoing MRI brain for unrelated reasons
Large gallstones on imaging, w/o sx. NSIM?
Nothing. If biliary colic sx develop: pain management, elective cholecystectomy or UDCA in poor surgical candidates/patients refusing surgery.
Gallstones on imaging w/ atypical Sx. NSIM?
eval for other causes, trial of UDCA- cholecystectomy if sx improve.
Typical biliary colic sx w/o gallstones on imaging.
Cholecystokinin-stimulated cholescintigraphy to eval functional gallbladder disorder. Cholecystectomy in patients w/ low gallbladder ejection.
RF for gallstones other than female, fatty, fourty, fertile.
hemolytic anemia, pregnancy, OCPs, hyperTG
Typical biliary colic sx?
RUQ pain radiating to R shoulder after fatty meals
Ursodeoxycholic acid efficacy?
most effective in patients with small, cholesterol-rich stones, requires prolonged tx and failure rate is high. Can be
Modality for stones in the cystic duct, common bile duct and ampulla.
HIDA (MR cholangiography can also see stones in the hepatic/biliary ducts, as well as common bile duct stones, malignant duct obstructions and obliterative diseases.
Nocturnal cardiac arrhythmias in OSA?
bradycardia, asystole, afib, non-sustained VT
CVS effects of OSA (4)
HTN/Difficult to control HTN, pulm HTN, CAD, HF, arrhythmias
RFs for esophageal CA: SCC VS adenocarcinoma
SCC: smoking/EtOH. Adenocarcinoma: obesity, cigarette smoking, GERD/Barretts
DIP joint involvement: RA or gout?
Gout
Clinical picture suggestive of gout with possible tophi hwr uric acid is normal. NSIM?
Start allopurinol (with short course of colchicine during initiation). For those who do not tolerate allopurinol, they may use Febuxostat (more expensive, requires LFT monitoring). Uric acid levels may be wnl and should not be used to confirm tophaceous gout.
Etanercept use?
severe RA, psoriatic arthritis, ankylosing spondylitis, chronic plaque psoriasis
Prednisone: role in gout
Tx of polyarticular attacks in patients who cannot tolerate/have contraindications to NSAIDs & colchicine
Most specific ab for SLE?
antiSmith
SLE labs
most spec (antiSmith, anti-dsDNA), most sen (ANA), LOW complement, leukopenia, thrombocytopenia, hemolytic anemia. Also possible elevated Cr & proteinuria.
Young F w/ painless, non-exudative ulcer in throat. Regional non-tender LAD, otherwise no Sx. Which test do you order.
RPR, Treponema pallidum enzume immunoassay (cheaper)
Opioid withdrawal Tx?
Opioid agonist: methadone or buprenorphine. Non-opioid: clonidine or adjunctive medications (antiemetic, antidiarr, benzos)
When is opioid withdrawal life-threatening?
If withdrawal patient is given opioid antagonist (ie narcan)
How soon after opioid cessation can withdrawal sx occur?
1-2 days. Gerenrally 3x half-lives sp discontinuation. Sx peak at 3 days but may persist up to 10. (note: tolerance develops >3wks of reg use)
Kyphosis or scoliosis with > ___ angle curvature above vertebral level __ cause greatest risk for restrictive alveolar vent, microatelectasis, V/Q mismatch.
65 degrees, T10. Tx (adults) NPPV at night & pulm rehab.
Respiratory consequences of significant kyphosis or scoliosis >65 deg.
Reduced alveolar vent, microatelectasis, V/Q mismatch. This causes restrictive defect > low tidal vol > increased RR/ work of breathing.
Which stroke has maximal sx at onset: embolic, thrombotic or hemorrhagic?
embolic
CVA: contralat somatosensory/motor weakness *face/arm/leg. Congugate eye deviation towards the side of infarct, contralat homonymous hemianopia, hemineglect (non-dominant hemisphere) or aphasia (dominant hemisphere). Which vessel is affected?
MCA
Patient is right handed and has a R MCA CVA. Do you expect aphasia or hemineglect.
hemineglect as the L brain is the dominant brain in this patient.
Small vessel lipohyalinosis typically causes ____ infarcts.
lacunar (occlusion of single penetrating branch of a larger artery). Often limited motor/focal neuro deficits.
Which shows improved survival in CA patients for VTE ppx: warfarin VS LMWH?
Neither. Hwr LMWH is the preferred agent. (also must take cost, delivery route, cost/copay & renal function into consideration)
Dx test for gastroparesis (2)
Exclude obstruction (EGD +/- CT/MR enterography). Assess motility (nuclear gastric emtying study)
Tx gastroparesis for refractory sx
Gastric electrical stim +/- jejunal feeding tube.
1st line Tx gastroparesis
Freq small meals (low fat, soluble fiber), Promotility meds (metoclopramide, erythromycin)
GI infection (N/V/D) then sx of early satiety, epigastric pain, bloating, weight loss. Dx?
Gastroparesis may occur after a viral GI infection (Norwalk, Rota)
Scintigraphic gastric emptying study is positive for gastroparesis if >__% retention at 2 hours, >__% retention at 4h
> 605 at 2 hours, >10% at 4 hours
High RF for gestational DM (5)
obesity PLUS: hx gestational DM, prior macrocrosomic infant, FHx, PCOS, >40yo
When do you screen in 1st VS 3rd trimester for gestational DM?
1st: high risk patient (obesity PLUS: hx gestational DM, prior macrocrosomic infant, FHx, PCOS, >40yo)
3rd: everyone else
How do you screen for DM postpartum in pt who had gestational DM?
screen 6-12 months postpartum with 2hr GTT (then every 1-3 years afterwards)
Unprotected sex: rectal pain, tenesmus, purulent discharge +/- some bleeding. Dx: condition/pathogen?
STD proctitis- purulence suggests gonorr (MCC) /chlamydia. (Dx: anoscopy/sigmoidoscopy w/ mucosal bx. Discharge cx: gram stain, Tsank, Cx/HSV, PCR/Chlamydia. Test RPR, HIV)
MCC STD for anal receiving proctitis?
Gonorrhea
Unprotected sex: rectal pain, tenesmus, purulent discharge +/- some bleeding. Work up?
Dx: anoscopy/sigmoidoscopy w/ mucosal bx. Discharge cx: gram stain, Tsank, Cx/HSV, PCR/Chlamydia. Test RPR, HIV
List some causes of discordant bone density results: Focal INCREASE in bone density.
Osteophytes (OA), osteoblastic mets, compression fracture, Paget
List some causes of discordant bone density results: focal DECREASE in bone density
osteolytic lesions, fibrous dysplasia
Which conditions do you think of when bone density: hip>spine? spine>hip?
hip>spine- hyperPTH,
spine>hip- GCS
Which NON-SKELETAL factors can cause discordant bone density results?
calcium tablets in stomach or aortic calcification
DXA shows T score +0.2 spine & -2.7 at hip. NSIM?
START bisphosphonates (use lowest screening density for osteoporosis)
What do you expect to see on imaging & labs w/ Pagets?
focal increased bone density and elevated alkP
BMT patient requires which RBC infusion:
1) irradiated
2) leukoreduced
3) washed
1) irradiated (also if acquired/congenital cellular immunodeficiency or if donor is 1st or 2nd degree relative)
AIDS patient requires which RBC infusion:
1) irradiated
2) leukoreduced
3) washed
2) Leukoreduced (per risk of CMV seronegative/at risk). Also for potential transplant patients, chronically transfused patients, previous febrile non-hemolytic transfusion)
How do you prevent febrile non-hemolytic reaction w/ RBC infusion:
1) irradiated
2) leukoreduced
3) washed
2) Leukoreduced (per risk of CMV seronegative/at risk, AIDS). Also for potential transplant patients, chronically transfused patients, previous febrile non-hemolytic transfusion) ** note CMV can be passed on because it resides in leukocytes
IgA def- Which RBC infusion:
1) irradiated
2) leukoreduced
3) washed
3) Washed (also for complement dependent AIHA or Hx persistent hives despite antiH pre-Tx: ) **Washes off residual plasma
Hx persistent hives despite antiH pre-Tx: Which RBC transfusion: RBC infusion: 1) irradiated 2) leukoreduced 3) washed
3) washed, (also for complement dependent AIHA, IgA def) **Washes off residual plasma
donor is 1st or 2nd degree relative- Which RBC transfusion:
1) irradiated
2) leukoreduced
3) washed
1) irradiated (removes all lymphocytic components)
Patients at risk of transfusion ass-d graft vs host disease: which RBC transfusion?
1) irradiated
2) leukoreduced
3) washed
1) irradiated (removes all lymphocytic components), also if donor is 1st or 2nd degree relative.
Dx of skin bx:
1) net-like intracellular IgG against desmosomes
2) linear IgG against hemidesmosomes along BM
1) Pemphigus (intraepidermal cleavage)
2) Pemphigoid (subepidermal cleavage)
Abs against desmogleins 1 & 3. Dx?
Pemphigus vulgaris- confirm w/ skin bx: net-like intracellular IgG against desmosomes, intraepidermal cleavage
Clear pemphigus vulgaris clinical picture. NSIM?
Skin Bx to confirm prior to tx.
Pemphigus vulgaris- confirm w/ skin bx: net-like intracellular IgG against desmosomes, intraepidermal cleavage.
Pemphigus vulgaris Tx?
Lifelong (must confirm before Tx): PO GCS, immunosup agents (rituximab, azathioprine, mycophenoate mofetil)
Which sudden severe derm conditions are signs of potential HIV?
Severe sudden psoriasis, seb derm or molluscum contagiosum (or if facial involvement)
Age for pemphigus vulgaris VS pemphigoid
Pemphigus 40-60, Pemphigoid >60
Tx mollusum contagiousum
(if desired) cryo, curettage, cantharidin, podophyllotoxin
Macular or papular rash involving palms/soles
Secondary syphilis
Multiple lesions w/ central umbilication & cough. Dx?
Disseminated Cryptococcosis
Acute chest syndrome: Management mild VS mod/severe?
Mild: simple transfusion.
Mod/Severe: exchange transfusion. Goal Hgb >10
Goal Hgb for transfusion in acute chest syndrome?
> 10
20yo w/ Hx acute chest syndrome and SCD presents in good health. Not on meds. Recs?
Start hydroxyurea
IVF type for sickle cell crisis?
1/2 NS or 1/2 D5W
Sickle crisis: Management to prevent acute chest syndrome?
Incentive spirometry (also once developed, low threshold for abx for PNA, must include atypical coverage)
OA flare in pt w/ CKD & hx PUD. Tx?
Tylenol (avoid NAIDs per CKD & per PUD)
Nursing home patient w/ fever, bradycardia, confusion, diarrhea, unresponsive to beta lactam and aminoglycosides. Labs w/ transaminitis, thrombocytopenia hematuria/proteinuria, hypoNa. Which test yields Dx?
Legionella urinary Ag & BAL/sputum Cx. (Tx levofloxacin or azithromycin )
Apart from hypoNa, what is seen on Legionella labs?
transaminitis, thrombocytopenia hematuria/proteinuria, sputum gram show neutrophilia w/o organism, Legionella urinary Ag+
Legionella Tx?
levofloxacin or azithromycin (beta lactam and aminoglycosides ineffective)
Unilateral neck/head pain, transient vision loss, ipsilateral HORNER syndrome, signs of cerebral ischemia. Dx?
Suspect carotid artery dissection
MOA Horners and carotid artery dissection?
Post-gang sympathetic fibers run on the outside of the ICA to supply the head, compressed during dissection
Tx carotid artery dissection
AC, anti-PLT, endovasc or surgical repair. Thrombolysis if <4.5hr of sx
Etiology of carotid artery dissection
trauma or spontaneous
Thunderclap HA, Horner, loss of sensation on face and contralateral body, nystagmus, dysarthria. Dx?
Vertebral artery dissection (Horners per ipsilateral dorsolat medulla)
ICD placement indications: primary VS secondary prevention * (2 each)
Primary: EF <30 & Hx MI (40 days s/p MI & 3 months sp revasc) OR EF <35 w/ NYHA class II/III Secondary: hx VF or unstable VT w/o reversible causes. Hx sustained VT w/ underlying cardiomyopathy
Scarring genital ulcers- Dx?
think Behcets
List assd findings/conditions in Behcets:
Eyes, Skin
Eyes: uveitis, retinal vasculitis.
Skin: EN, superficial thrombophlebitis, papulopustular lesions, acneiform nodules. (also DVT superficial/deep, non-deforming arthritis, GI ulcers, pulm a aneurysm)
MOA Behcets
Vasculitis (hwr renal & PNS spared). (Tx: colchicine, GCS, immunosuppressive agents)
Which organ system is spared in Behcets? Skin, Renal, GI, Eyes
Renal
Tx Behcets
colchicine, GCS, immunosuppressive agents
Paroxysmal fever, peritonitis, pleuritis, pericarditis. Dx?
Mediterranean fever
Pathergy test+, genital ulcer/scarring, Hx DVT. Tx?
colchicine, GCS, immunosuppressive agents
Dx: Behcets
Normal Ag metabolic acidosis- how to DDX in a patient with diarrhea VS RTA
Urinary Ag (neg: diarrhea, laxative abuse), (pos: RTA, carbonic anhydrase inhibotor)
NAGMA: occurs d/t renal or GI loss of ____
bicarb (DDX w/ urinary AG- neg: diarrhea/laxatives, pos: renal)
Which sx is presbycusis assd w/?
bilateral tinnitus, vertigo, disequillibrium
How to examine presbyacusis?
Whisper test, Rinne-Weber test, audiogram (Tx hearing aids, if refractory then consider cochlear implant)
Patient admitted for CHF develops tinnitus. Cause?
Likely IV loops. Others: NSAIDs, aminoglycosides, platinum chemo
Unilat conductive HL, no other sx, otherwise normal exam. Dx?
Consider otosclerosis
Alcoholic w/ petechiae/echymoses, impaired wound healing, arthralgias and gingival hypertrophy. Labs w/ anemia, PLT wnl. Dx?
Vit C def (impairment of collagen production)
Tx Vit C def
PO/IV Vit C (improvement in days/weeks)
Sx of Vit C tox
abd pain, D
antiHTN med to cause gingeval hypertrophy
CCB
Met alkalosis: Test to determine etiology?
urine chloride (LOW: vomiting, diuretic overuse, HIGH/hypovol: Bartter & Giltemans, HIGH/hypervol: Excess mineralocorticoids
Met Alk. Urine Cl is <20. Tx?
IVF (cause: vom or diuretic use, hwr if diuretic use w/in few hours the chloride can still be high_
How to determine whether metabolic alkalosis with be saline responsive?
Urine chloride <20 is responsive (etiology vomiting or diuretic overuse)
Which pressor decreases the need for other vassopressors?
Vasopressin (but it does not improve mortality in septic shock)
Target PCWP in septic shock?
12-14
Vasopressor for tachyarrythmias?
phenylephrine
CHF pt in ICU w/ bradycardia who needs inotropic support. Tx?
Dobutamine may be added
In Tx of DKA- Which K level do you stop insulin? Which K level do you stop IV K supplementation?
HOLD insulin if K 3.3, STOP supplementation at K 5.3
Criteria to bridge insulin to SC during DKA Tx.
Patient can eat, gluc <200, no AG, HCO3 >15
pH level to start HCO3 supplement during DKA?
pH<6.9
Phos level to consider supplementation during DKA Tx?
Ph <1.0 OR if cardiac dysfunction or resp depression
How much K supplement given w/ each L during DKA?
20-30mEq
Duration of SSRI taper?
2-4wks
RF for pustular psoriasis
Hx plaque psoriasis, pregnancy, infection, withdrawal of GCS (PO or high-potency topical)
Several small sterile pustules on hands/feet which may become confluent “lakes of pus”, fever, malaise, arthralgia. Tx?
(Dx: pustular psoriasis) Tx: long term systemic retinoids ie acitretin, and/or immunosuppressive agents (cylosporine, MTX, infliximab)
Acitretin use
psoriasis
Mitral stenosis & hx L atrial thrombus. AC of choice?
Warfarin w/ INR goal 2.5 (also if MS + hx embolus OR MS + L atrial thrombus)
Which valvular conditions still require warfarin?
mitral stenosis, hx MV repair, prosthetic heart valve
CKD patient w/ high suspicion of aortic dissection, Diagnostic work up?
TEE (also preferred w/ suspicion of aortic dissection in patient w/ contrast allergy), otherwise first line is CTA
patient contrast allergy w/ high suspicion of aortic dissection, Diagnostic work up?
TEE (also for renal failure patients) Otherwise CTA
Dx test for Schatzki rings?
barium esophagram (endoscopy will not visualize unless esophagus is widely dilated)
Tx Schatzki rings
dilation & acid suppression. High recurrence rate
Schatzki rings are assd w/ IDA & _____
celiac
Imaging study for uric acid stones?
US or CT (not seen on XR)
Tx uric acid stones
Potassium citrate alkalizes urine to 6-6.5 (allopurinol for refractory sx)
For which stones is HCTZ used?
hypercalciuric (decreases Ca excretion)
Poor dentition & mitral valve issue w/ arthralgias, anemia, leukocytosis, high ESR, decreased complement & high RF. Splenomegaly+. Dx?
Infective endocarditis (obtain BCx & TTE/TEE). Can obtain imaging of the spine for vertebral myelitis or abdomen for splenic infarcts.
ANCA- which conditions?
GPA and microscopic polyangitis
Painless mild thyromegaly w/ v low TSH, v high T4. NSIM?
RAIU to DDx Graves (high uptake) vs painless thyroiditis (low/np uptake)
Labs for painless thyroiditis?
high antiTPO & thyroglobulin. v high T4, v low TSH (variant of Hashimotos, transient hyperthyroid state)
Tx & prognosis painless thyroiditis
symptomatic (ie BB, NSAID) followed by hypothyroid sx then recovery, 20% develop permanent HYPOthyroidism (Hashimotos)
Work-place exposure to pulm irritant > asthma like sx. Diagnostic test and prognosis
(Dx: reactive airway dysfunction syndrome) PFT w/ ~airflow obstruction and methacholine challenge+. (note; initial sx onset may show chemical pneumonitis on CT). Usually resolves w/in 2 years. Tx inhaled GCS/bronchodilators
High AlkP/bili/IgM. Cholangiogram/MRCP/ERCP: multifocal bile duct stricturing/dilation “beaded appearance”. Dx?
PSC (also periductal onion skinning fibrosis on bx)
PBS suspected. Other than confirming w/ imaging/Bx, NSIM?
Colonoscopy r/o IBD.
Tx PSC
liver transplant (cyclosporine does not slow disease progression)
PSC: Which CA is pt at risk for?
CRC & cholangiocarcinoma. (should undergo annual colonoscopy if also IBD+ or q5y if not)
PBC VS PBS Tx:
PBC: ursodeoxycholic acid, PSC: liver transplant
Periductal onion skin fibrosis. Dx?
PSC (assd w/ UC, high risk CRC, Tx: liver transplant)
Colonoscopy screening intervals for PSC assd w/ UC vs not assd w/ UC
Assd w/ UC: annual, NOT assd w/ UC: q5y
Dyspepsia w/o GERD Sx, no alarm features. 62yo+. NSIM
EGD (if >60, if no then Hpylo)
65yo w/ GERD, no alarm features. NSIM?
PPI trial (if dyspepsia only, EGD)
Dyspepsia description
postprandial fullness, early satiety, epigastric pain
59yo M w/ dyspepsia w/o GERD sx, no red flag sx. NSIM?
PPI trial
New onset HTN: which labs do you order?
CBC, BMP, UA, lipids, A1C TSH (also ECG)
low dose CT screening indications
50-80yo w/ >20 pack smoking hx or quit under 15y ago
US screening for thyroid malignancy indications?
Hx childhood radiation, MEN2
HTN crisis, flash pulm edema & afib after anesthesia induction, NSIM?
Screen pheocromocytoma w/ urine/plasma metanephrines (cathecolamine surge may be unmasked by pregnancy, anesthesia induction or extreme exercise)
How is pheochromocytoma most commonly diagnosed?
incidentally or cathecolamine surge may be unmasked by pregnancy, anesthesia induction or extreme exercise
Tx pheochromocytoma
surgical resection/adrenalectomy (not always effective ***requires initial pre-op alpha blockade phenoxybenzamine, then BB)
How can pheochromocytoma diagnosed incidentally w/o sx?
it may be clinically silent but unmasked by pregnancy, anesthesia induction or extreme exercise
Achalasia is a RF for which CA?
Esophageal SCC
Top 3 RF (conditions) for esophageal CA
- achalasia (16%)
- GERD (5-7%)
- atrophic gastritis (2%)
Top 3 RF (conditions) for gastric CA
- atrophic gastritis (3-18%)
- Hpylo (6%)
- Gastric surgery, pernicious anemia, gastric ulcers (1-3%)
Biggest GI condition RF for CRC?
IBD
Dysphagia to solids/liquids, difficulty belching, w.loss, heartburn. Dx?
Achalasia
Crycopharyngeal dysfunction may cause:
Zenkers diverticulum
High bleed risk procedure planned for pt on warfarin. How do you manage AC preop?
STOP warfarin, wait until INR <1.5, then proceed. Resume AC 24-48h later.
Which patients should undergo LMWH bridge to unfractioned heparin prior to a procedure?
Very high risk conditions (Mechanical MV, VTE w/in 3 months, protein C def (severe thrombophilia), AF w/ TIA/CVA w/in 3 months, AF w/ RHD
Mechanical MV planning to undergo knee replacement- AC recs?
LMWH bridge to unfractioned heparin (very high risk condition)
VTE w/in 3 months, planning to undergo knee replacement- AC recs?
LMWH bridge to unfractioned heparin (very high risk condition)
HyperCa, PTH wnl. NSIM?
24hr urine collection to DDx FHH (low Ca excretion) & primary PTH (high Ca excretion)
HyperCa, PTH wnl, 24hr urine: low Ca excretion. Dx?
FHH
Painless hematuria w/ clots in 65yo ex-smoker. NSIM?
Cystoscopy to r/o bladder CA
MCC hyperCa in patient w/ nephrolithiasis?
hyperPTH
Work up for nephrolithiasis?
non-contrast CT, BMP, UA, stone analysis
60yo w/ fatigue, weight loss, anemia, elevated Cr, hyperCa. NSIM?
SPEP or UPEP (monoclonal protein), UA w/ protein:quantitative protein analysis discordance (BMB to confirm MM, plasma cells >10)
UA protein 1+, protein/Cr ratio 2.5. NSIM?
Work up for MM. UA protein 1+ suggests 30-100mg/dL proteinuria hwr protein:Cr ratio 2.5 suggests 2.5g/dL proteinuria (suggesting light chain excretion or protein other than albumin)
MOA of renal failure in MM
Filtered light chains are directly toxic to renal tubular epithelial cells & may combine w/ TammHorsfall proteins to form casts. Also significant hyperCa, hyperuricemia, hyperviscosity, renal plasma cell infiltration
40yo w/ fatigue & SOB, found to have afib w/ RVR. TTE: dilated/hypokinetic LV w/ EF 25%, central jet of moderate MR. Tx?
Dx: Tachycardia induced cardiomyopathy. Tx: rate control (often significant recovery over few months)
MV w/ central jet, signifies…?
secondary MR due to mitral annulus dilation
Dry eyes, dry mouth, dry vag. What are some extraglandular features you would suspect?
Reynauds, cutaneous vasculitis, distal RTA, nephrogenic DI arthralgia, ILD, NHL. (Sjogrens)
Cancer assd w/ Sjogrens?
NHL
3 tests for Sjogrens Dx
anti-Ro/SSA, anti-La/AAB. Salivary gland Bx: focal lymphocytic sialodenitis. Schrimer test: decreased lacrimation.
Preschool teacher, fever, sore throat, oral/palmoplantar lesions. Dx?
Coxackie (hand-foot-mouth)
Diagnostic criteria for Sjogrens is oral/apthous ulcers >3x/yr & 2 of the following:
- Pathergy test
- Skin lesions (acneiform)
- Eye lesions
- Recurrent genital lesions
DDX oral ulcers in SLE VS Sjogrens
SLE (painless, Sjogrens (painful)
Proximal muscle weakness/pain & neuropathy. V high CK, Bx: cytoplasmic vacuolization. Dx?
Colchicine tx neuromyopathy (often CKD patients using colchicine for gout ppx)
Myalgia +/- weakness. Bx: myonecrosis w/o vasculitis/inflammation. CK likely wnl. Dx?
Statin myopathy
DM w/ painless, watery D that can occur at night and may be assd w/ fecal incontinence. Also bloating/flatulence. Colonoscopy/small bowel Bx wnl. Dx?
autonomic neuropathy >bowel hypomotlity, increased fluid secretion & anorectal dysfunction. **SIBO may contribute (assd w/ lactose intolerance, D: carb breath test, Tx: abx/rifaxamin)
SIBO Dx & Tx?
carb breath test & rifaximin
Tx of DM diarrhea in absence of SIBO
loperamide
SIBO complications
malabsorption if severe (steatorrhea, vitamin malabsorp)
Preg patient w/ mild HTN, proteinuria, fatigue and daytime somnolence. NSIM?
Overnight polysomnography (r/o OSA). Physiologic changes of preg: weight gain, nasopharyngeal mucosal edema, upward displacement of diaphragm.
OSA complications/links in preg patients?
gestational DM & HTN, preeclampsia
Tx preg HTN
labetalol, hydralazine (2nd line CCB- diltiazem, verapamil, nifedipine)
Anemia during preg- Hgb threshold in 1st, 2nd, 3rd trimesters
1st: <11, 2nd: <10.5, 3rd: <11
Preg patient w/ prominent JVP, NSIM?
Nothing. Prominent= physiologic in preg. Elevated is concerning.
Vaccines always recommended in pregnancy
Influenza, Tdap (regardless of prior vax, preferably in 3rd trimester, also for those who plan to be in close contact with the infant)
Which vaccine should NOT be given in pregnancy: HBV, HAV, PCV, Hinf., meningococcal, VZV
VZV (howecer varicella zoster Ig may be given as ppx PRN exposure)
Pt Hx IVDU presents with black fingers x 5 days. Labs with low complement, high RF. Dx & Tx?
Mixed cryoglobulinemia (NSIM test for HCV), if HCV Tx the virus
Livedo reticularis, cyanosis, gangrene sp angiography. Dx?
Think cholesterol embolization syndrome
Patient is diagnosed w/ mixed cryglobulinemia. NSIM?
test for HCV (90% of patients will be positive, Tx HCV should improve sx)
First asthma, rhinitis, atopic derm. THEN periph eosinophilia, lung eosinophilia THEN polyangitis. Dx?
Churg-Strauss syndrome
Tx single brain met VS multiple brain mets
resection, radiation
New onset HA w/ focal neuro deficitis, imaging suggesting brain mets. Tx?
IV GCS (ie dexamethasone 6mg Q6h)
PPx anticonvulsants w/ one week taper are recommended for (3)
Bleeding in the IC tumor, craniotomy for tumor resection, significant mass effect/edema in vicinity of the cortex
low carb diet: adverse effects?
More GI side effects (bloating, diarrhea, constipation), lower exercise tolerance, HA
Which diet produces rapid weight loss?
low carb (likely assd w/ mobilization of glycogen stores and fluid loss)
T/F low fat diets are recommended over low carb diets for sustained weight loss
F (they both have equal success & reduce CVS risk equally, hwr mediterranean is better)
When to choose an external VS implantable loop recorder
External: if event occurs >1x per month. Implantable: if event is months apart (Holer is only 24-48h)
Numbness & tingling upper lateral thigh. Cause & Tx?
(meralgia paresthetica) Cause: DM, preg, tight clothes, obesity > compression of lat fem nerve. Tx: weight loss, loose clothes, reassurance, +/- gabapentin
Recent immigration, fever, arthralgia, migratory arthritis, subcut nodules, high ESR. Tx?
PNC (Dx: RF)
Dx tests for Strep throat?
Throat Cx (neg in 75% pts w/ RF), rapid strep Ag, high antistreptolysin O Abs
Tx hepatorenal syndrome (3 meds)
Midodrine, Octreotide, Albumin. norepi in ICU. Definitive: liver transplant
Cirrhosis, worsening renal studies/oliguria, bland UA, FeNa <1%, no response to IVF. NSIM?
Midodrine, Octreotide, Albumin. norepi in ICU. Definitive: liver transplant ( Hepatorenal S)
Triggers hepatorenal syndrome
Infection (SBP) or GIB
Patient w/ hx seizures presents w/ fever, rash, LAD, eosinophilia, transaminitis. NSIM?
(Dx anticonvulsant hypersensitivity syndrome.) Tx: remove offending agent, supportive care, GCS
rash, horizontal nystagmus, ataxia, slurred speech, lethargy, hypertrichosis, gingeval hyperplasia: All are AE of which medication?
Phenytoin
Which is a dose-DEPENDENT adverse effect of phenytoin? hypertrichosis, rash, gingival hyperplasia, folic acid def, osteomalacia/vitD def, anticonvulsant HS syndrome
rash (rest are dose-independent)
IV phenytoin infusion may cause which AE?
hypotension & bradyarrythmia
Eosinophilia w/in 2 months of starting anticonvulsant. NSIM?
(Dx anticonvulsant hypersensitivity syndrome.) Tx: remove offending agent, supportive care, GCS
Seizure pt w/ facial swelling, pharyngitis, fever, LAD, rash, nephritis, hepatitis. NSIM?
(Dx anticonvulsant hypersensitivity syndrome.) Tx: remove offending agent, supportive care, GCS
Which is NOT a high risk procedure?
TURP, laminectomy, renal bx, ICD placement, endoscopy w/ FNA
ICD placement
Patient on warfarin planning to undergo renal bx. AC recs?
peri-op bridge to LMWH or heparin
Patient on warfarin planning to undergo ICD placement, AC recs?
c/w warfarin, low risk procedure
How long do the following stay positive after syphilis infection?
1) T pallidum particle agglutination
2) RPR
3) FTA-Abs
1) for life 2) months 3) for life
RPR remains mildly positive 6 months after Tx. NSIM?
repeat RPR in 6 months
T/F You should measure uric acid in acute gout
TRUE (though often normal in attacks, monitoring needed for goal <6 in recurrent gout & high level is more suggestive than crystals in joint fluid)
Colchicine dose for acute gout attack
0.6 BID or TID (note: try NSAIDs first). Note: use for 6 months after attack subsides,
T/F Allopurinol should be HELD during an acute gout attack
FALSE- changes in allopurinol dose can worsen or precipitate an attack. Wait 3-4wks after attack to change dose (keep increasing until uric acid <6. (For attack- add NSAIDs, and if ineffective- add colchicine)
First line Tx for acute gout
NSAIDs (if ineffective add colchicine. If already on allopurinol- DO NOT discontinue it…may change dose 3-4wks after attack)
When is febuxostat used?
Patient cant tolerate allopurinol or has mild/mod CKD
Criteria for outpatient DOAC in tx of DVT
VSS, Low bleed risk, normal renal function, reliable social enviro for administration
Tx of high bleed risk DVT?
unfractionated heparin (rapid cessation of action, admission and initiation)
When to Tx subclinical hypothyroidism?
TSH >10
TSH upper normal, T4 wnl. TPO+. Tx?
START levothyroxine (if TPO neg, monitor)
Ovulatory dysfunction in pt w/ high TSH and normal T4. NSIM?
START levothyroxine for subclinical hypothyroidism
Ovulatory dysfunction in pt w/ high TSH and normal T4. Synthroid started, no improvement. NSIM?
START clomiphine (E receptor blocker in hypothalamus)
AC agents appropriate in setting of ESRD?
Warfarin or apixaban
Heparin antidote?
Protamine sulphate
Warfarin antidote?
PCC (prothrombin complex concentrate)
Aspirin antidote?
DDAVP (desmopressin) & PLTs
Oral thrombin inhibitor (Dabigatran) antidote?
PCC (prothrombin complex concentrate)
Clinically asx patient with no medical problems found to have PLT 12. NSIM?
Repeat PLT in heparinized tube, if normalized, Dx: pseudothrombophilia 2/2 EDTA induced PLT clumping (0.1% of pop)
55yo M sp revasc & stent placement develops gastroenteritis 2 weeks later with subsequent CP, EKG 2mm ST elevations in multiple leads. Dx?
Consider non-adherence to DAPT > stent thrombosis (DAPT should be used 6-12m after stent placement_
Time frame for papillary muscle rupture sp MI.
3-5 days
MCC stent thrombosis?
Non-adherence to DAPT
Few days after MI pt develops pleuritic CP & diffuse ST elevations on EKG. Dx?
Peri-infarction pericarditis
Cryptococcal meningoencephalitis is diagnosed in HIV pt. Initial Tx?
Amphotericin B w/ flucytosine (2 weeks), THEN fluconazole 800mg (up to 8wks) THEN fluconazole (200mg up to a year)
Tx of Cryptococcal meningoencephalitis other than antifungals?
Serial LPs (daily) to reduce ICP <200 or by 50%
Which Tx manages high ICP in Cryptococcal meningoencephalitis? Serial LP VS acetazolamide VS mannitol
serial LP (others hwr effective to reduce ICP in other senarios)
Pt w/ Cryptococcal meningoencephalitis found to be HIV+. Tx?
Amphotericin B w/ flucytosine x2wks then fluconazole taper. AVOID HIV Tx during Crypto infection onset per risk of immune reconstitution syndrome- wait 2-10wks after antifungal tx
Frequent epistaxis, AVMs in pulm/cerebral/hepatic vasc, GI telangiectasia/GIB/IDA. Dx?
Osler Weber Rendu AKA Hereditary hemorrhagic tenalgiectasia.
Hereditary hemorrhagic tenalgiectasia: what is the risk of pulm AVMs?
cerebral abscess or embolic stroke
1-5mm flat blue/grey/brown spots that resemble freckles on lips, buccal mucosa, hands. feet. Assn?
GI polyps (Peutz Jeghers)
angiofibromas on face, shagreen patch on trunk, hypopigmented macules. Assn?
Tuberous sclerosus (also ashleaf spots
A week after starting new med > palpable purpura, hematuria, bowel angina, GIB. Dx?
Hypersensitivity vasculitis
Hip surgery planned but pt has severe Hashimotos thyroiditis- What is the concern?
Possible co-existing adrenal insufficiency
Genetic syndrome assd w/ Aortic dissection?
Marfan
> 20mmHg BP deficit btwn both arms. Dx?
Aortic dissection (this finding is in 66% of patients)
Tx aortic dissection (other than surgical repair)
IV BB (esmolol, labetalol, propanolol), sodium nitroprusside if SBP >120 (give after BB to prevent reflex sympathetic stim), morphine. Avoid AC & hydralazine
Severe common bile duct obstruction or cholangitis. NSIM?
ERCP w/ sphincterotomy w/in 24h
Moderate gallstone pancreatitis w/o CBD obstruction, no improvement in 72h. NSIM?
Consider endoscopic US/MRCP/ERCP
Fever, abd pain, jaundice. CBD dilation, high lipase. Dx?
Gallstone pancreatitis
Acute pancreatitis, Air bubbles in pancreas on CT. NSIM?
CT-guided percutaneous aspiration to r/o infected pancreatic necrosis
Tx triglyceride induced pancreatitis
TG >500: insulin infusion,
TG >1000 or severe pancreatitis (hypOCa, lacticemia): therapeutic plasma exchange. ALSO IVF
TG >1000 or severe pancreatitis. Plasma exchange unavailable. Tx?
insulin infusion as second line (w/ gluc in <200)
All indicate SEVERE pancreatitis EXCEPT - lactic acidosis, AKI, hyperCa
HyperCa (*HypOCa indicates severe panc
Serum lipase concerning for acute panc: >___
> 300 (3x upper limit)
Which is NOT a RF for acute panc? EtOH, obesity, DM, smoking or pregnancy
smoking
70yo F w/ severe R shoulder pain. Arthrocentesis is v hemorrghagic, WBD 10k, 80% PMN. Dx?
Milwaukee shoulder (aggressive joint destruction of the GH/rotator cuff, basic calcium phosphate crystals present hwr labs dont routinely have special stains for dx, so dx is clinical)
rhomboid shaped Ca pyrophosphate crystals. Dx?>
pseudogout
Elderly F w/ dizziness, N/V, dysarthria, diplopia. anti-Yo, anti-Hu- anti-Ri. Dx?
paraneoplastic cerebellar degeneration (assd w/ lung, gyn, br CA, may precede CA dx for years, hence work up for occult malig required)
anti-Yo, anti-Hu- anti-Ri. What are they?
Paraneoplastic antibodies (ie. used to confirm paraneoplastic cerebellar degeneration)
Dementia, glove/stocking numbness, gait abn. Dx?
B12 def
CRC w/ liver mets: When do you perform the following -
1) Chemo then hemicolectomy and liver mets rescection
2) hemicolectomy w/ liver mets resection, chemo after
1) chemo first IF >70% liver w/ portal involvement.
2) if <70% liver & NO portal involvement
CRC w/ liver mets. >70% liver w/ portal involvement. Do you do chemo BEFORE or AFTER surgery?
BEFORE (if <70% liver & NO portal involvement, you do it after)
Lat hip pain over outer thigh worsened w/ climbing stairs/getting out of car or lying on affected side. May radiate to knee or buttock. TREATMENT?
(Dx trochanteric bursitis) FIRST: avoid repetative bending or laying on affected side, reduced weight bearing, NSAIDS. If ineffective: GCS bursa injection.
Hip OA/DJD. Pain is in groin OR lateral hip? Discomfort w/ adduction OR abduction?
groin, abduction
S/P chemo pt develops AKI, oliguria, severe hypOCa & hyERphos, hyperK. Calcium phosphate stones in renal tubules. NSIM?
urgent HD, IVF +/- loops (Dx tumor lysis syndrome: all contents spill out of cells, K/Ph.)
Tumor lysis syndrome s/p chemo. Uricemia, hypoCa, hyperPhos. Why are the following NOT advised? Allopurinol? Ca supplement? Phosphate binders?
Allopurinol: does not affect existing uric acid. Ca supplement: may worsen Calcium phos stones in renal tubules. Phos binders: work slowly. (Tx; HD & IVF)
Schizo pt w/ 40C, confusion, muscle rigidity, autonomic instability. Tx?
STOP antipsychs, supportive care (IVF, cooling, ICU). IF REFRACTORY: dantroline or bromocriptine. (Dx: NMS)
Tx NMS
STOP antipsychs, supportive care (IVF, cooling, electrolye supp, BP control, ICU). CONSIDER ONLY IF REFRACTORY: dantroline or bromocriptine.
acute dystonic rxns in schizo & parkinsonism. Tx?
benztropine
Tx serotonin syndrome?
Cyproheptadine
Tx restless leg syndrome if mild VS moderate
Supplement iron if ferritin <75.
Mild: carbi-levodopa PRN
Freq/daily: gabapentin, pregabalin
***Pramipexole or ropinerole are NOT preferred per paradoxical worsening of sx in some patients
Which is NOT a tx for restless leg syndrome?
1) Iron
2) Levo-Carbidoipa
3) Gabapentin
4) Pramipexole
5) Lyrica
4) pramipexole
RF for restless leg syndrome (7)
Iron def, Uremia, Pregnancy, DM, MS, Parkinsons, SSRI, anti-psych, antiemetics
When should LN Bx be performed? (3)
1) node >4wks…
2) findings suggestive of CA…
3) generalized LAD w/o explaination (neg HIV, TB, RPR, ANA, HBsAg, heterophile abs)
Patient w/ Generalized LAD & B symptoms. CBC & CXR wnl. NSIM?
HIV, TB, RPR, ANA, HBsAg, heterophile abs. If inconclusive- excisional LN Bx.
young healthy M comes in c/o swollen, non-tender LN x 5 weeks. NSIM?
Bx (Bx all LN >4wks)
Which LN have the highest diagnostic yield: Cervical, Supraclav, Axillary, Inguinal
Supraclav, THEN cervical, axillary, inguinal
Painless scrotal swelling in 30yo M. NSIM?
Testicular US (DDx cystic from hypoechoic), r/o hydrocele or epididymitis…. then CT abd/pelvis to eveal retroprit LNs, serum markers: AFP, bhCG, LDH
Painless scrotal swelling in 30yo M. Elevated bhCG & AFP. Seminoma or non-seminoma?
NON-seminoma (seminomas do not have elevated AFP) . Confirm w/ radical inguinal orchiectomy.
Onychomycosis: Test to confirm Dx?
KOH prep of nail scrapings (to DDX from 45% other causes: eczema, psoriasis, lichen planus). MAY GIVE PO terbinafine before work up and diagnostic testing if failed.
When to perform nail bx?
When SCC is suspected or Dx is uncertain
Scleroderma pt w/ watery d, weight loss, abd pain/bloating. Dx?
SIBO, Tx Abx (rifaximin, cipro, doxy)
Which Abx is NOT used for SIBO? Rifaximin, Cipro, Metro, Doxy
Metro (note: 45% develop recurrent sx & required repeat/prolonged tx)
GCS effect on SIBO
worsens sx
Elderly, CAD, DM, HTN OA/DJD w/ mild unilateral leg edema, Homans+, post fossa fullness (non-pulsatile). Dx?
Popliteal cyst dissection. (note the swelling decreases w/ flexion 45deg “Fouchers sign”)
Symptomatic bakers cyst, recurrent. NSIM?
GCS +/- arthrocentesis
DDX popliteal cyst dissection/rupture VS DVT
DVT: palpable cord. Bakers cyst: post knee effusion/fullness
Hx renal transplant, w/ hematuria/leukouria, cellular casts, cytology: atypical cells w/ nuclear inclusions. Dx?
polyoma virus: BK or JC (difficult to dx, may need renal bx x 2, appears like CMV, immunohistochemistry tests against BK/JC virus, occurs ~1yr s/p transplant)
Intranuclear inclusions in transplant pt. Which conditions?
BK, JC, CMV
Which hand joints are most affected by psoriatic arthritis?
DIP (can be poly/oligoarthritis, mutilating/destriuctive)
Arthritis w/ sausage digits, onycholysis, swelling of hands/feet w/ pitting, pencil in cup joint destruction, sacroiliitis/spondylis. Dx?
Psoriatic arthritis (may precede skin sx in 30%)
Hypertrophic osteoarthropathy manifests as:
digital clubbin (assd w/ lung CA)
Travelers D- Tx?
Cipro (or other quinolone) ** If traveling to SE Asia- azithromycin: d/t FQ resistant Campylobacter
Prophylactic med for travelers d in pt traveling to Indonesia.
Azithromycin (d/t FQ resistant Campylobacter, for patients traveling outside SE Asia, use FQ/cipro)
Tx travelers D for patients going to SE Asia VS not SE Asia
SE Asia- Azithromycin, NOT SE Asia- Cipro
Recent infection, abrupt onset painful erythematous lesions, Fever >38F, neutrophilic leucocytosis, no sign of vasculitis. Tx?
GCS (topical or systemic), Dx: Sweet Syndrome AKA acute febrile neutrophilic dermatosis
Describe Sweet Syndrome
AKA acute febrile neutrophilic dermatosis,. Recent infection, abrupt onset painful erythematous lesions, Fever >38F, neutrophilic leucocytosis, no sign of vasculitis. Affects preg, IBD, heme CA, GCSF use.
100F, leukocytosis, abd pain. CT abd: sigmoid wall thickening & increased density pericolic fat. Dx?
Diverticulitis (Tx: PO abx if uncomplicated w/o significant comorbs)
100F, leukocytosis, abd pain. CT abd: sigmoid wall thickening & increased density pericolic fat. TREATMENT uncomplicated VS complicated?
Uncomplicated: PO Cipro/Metro OR amoxi/clav.
Complicated: IV zocyn OR ceftriaxone/metro OR cipro/metro
Acute diverticulitis Abx for complicated vs non-complicated illness?
Uncomplicated (75%): PO Cipro/Metro OR amoxi/clav.
Complicated: IV zocyn OR ceftriaxone/metro OR cipro/metro
Planning to get tattoo, which vaccines do you recommend?
HBV, Tdap
Most common infections from tattoos?
S.aureus, Mycobacterium chelonae, Pseudomonas
Complications of tattooing
HS rxn, keloid, delayed hS rxn, HBV, HCV, infection (S.aureus, Pseudomonas, Mycobacterium chelonae)
Fever, weight loss, HA, jaw/arm claudication. Likely dx?
Large cell arteritis (Takayasu or GCA)
Pt w/ hx valve has fatigue, dark urine and change in murmur, anemia, LDH++. Dx?
Hemolytic anemia 2/2 prosthetic valves. Smear also shows schistocytes.
30yo F w/ recurrent abd pain, constipation, dark urine & hypoNa. Dx?
Acute Intermittent Porphyria (d/t enzyme deficiency hepatic PBG deaminase)
Acute Intermittent Porphyria triggers?
starvation, stress, infection, EtOH, sulfonamides, low carb diet
30yo F w/ recurrent abd pain, constipation, dark urine & hypoNa. Dx test & Tx?
elevated urine porphobilinogen. Tx: glucose loading, IV hemin, avoid triggers (starvation, stress, infection, EtOH, sulfonamides, low carb diet)
Physical exam for PID
vaginal discharge & tenderness (uterine, cervical, adnexal)
Tx: Acute Intermittent Porphyria
Tx: glucose loading, IV hemin, avoid triggers (starvation, stress, infection, EtOH, sulfonamides, low carb diet)
SLE dermatitis: Tx in mild VS mod VS severe d
MILD: topical GCS, sunscreen
MOD: hydroxychloroquine/chloroquine, low PO GCS
SEVERE: MTX, isotretinoin, Aza, cyclophosphamide, cyclosporine
Moderate SLE dermatitis.
hydroxychloroquine/chloroquine, low PO GCS (MILD: topical GCS, sunscreen
SEVERE: (immunosuppressants/retinoids) MTX, isotretinoin, Aza, cyclophosphamide, cyclosporine)
GCA is diagnosed. What should be screened?
Osteoporosis (d/t GCS tx), annual CXR for thoracic aortic aneurysm screen
GCA- cardiac risk?
aortic aneurysm or dissection.
Anemia type in GCA
normocytic normochromic (also assd w/ reactive thrombocytosis
Tx tinea versicolor
topical ketoconazole OR terbinafine OR selenium sulfide (if failed or widespread, PO ketoconazole, itraconazole, fluconazole)
Tinea versicolor suspected, how to confirm Dx?
KOH/skin scraping “spaghetti & meatballs” (curved hyphae & round yeasts)
locations affected: vitiligo VS tinea versicolor?
Vitiligo: surrounding skin orifices & sun exposed areas. Tinea: areas of many sebaceous glands.
Yersinia pestis suspected. Which Abx for Tx and PEP?
Tx: Streptomycin OR Doxycycline (/other tetracyclines). PEP: Doxy
Contact w/ person infected w/ bubonic plague. PEP?
Doxycycline
Flea bite>pustule/eschar, SW USA, sudden fever/chills/HA, painful LAD. Possible > PNA, meningitis. Dx?
Plague (Yersinia pestis), Dx w/ BCx, fluid Cx, serologic titers. Tx: Streptomycin OR Doxycycline (/other tetracyclines). PEP: Doxy
SW USA, dry cough, PNA, +/- skin lesions. Pathogen?
Coccidioides
Rabbit contact. Ulceroglandular disease. Dx?
Tularemia
**MVP when is repair indicated?
Symptomatic (EF 30+) OR possibly case-to-case EF<30.
MVP, EF >60, ASx. Do you recommend repair?
Only if becomes symptomatic of EF 30-60% OR pulm a pressure >50 OR new onset afib OR LV end syst diameter >40….. If no sx w/ EF >60, monitor w/ TTE q6-12 months.
T/F Dental abx ppx is recommended for MVP.
FALSE: only for high risk: prosthetic heart valve or hx endocarditis
HIGH or LOW: Pleural effusion in RA.
1) pH
2) glucose
3) LDH
v low, v low, v high (DDX empyema which has a cell count >50k, neutrophilic predominance while RA is cell count <5k, lymphocytic)
Unilateral pleural effusion: yellow-green, v low pH, v low gluc, v high LDH, cell count <5k, lymphocytic. Etiology?
RA ( (DDX empyema: purulent, cell count >50k, neutrophilic predominance)
LKM1 or LC1 Abs+. Dx?
AI hepatitis (Liver-kidney microsomal-1 Ab, Liver-cytosol-1 Ab)
Liver bx: piecemeal necrosis. Dx?
AI hepatitis
Tx AI hepatitis
GCS (+/- azathioprine or 6MU to lower GCS doses)
Tx AI hepatitis IF LFT >10x norm or >5x norm w/ ____
hyperglobulinemia (IgG)
When is transplant recommended for AI hepatitis?
development of cirrhosis (note: GCS +/- azathioprine or 6MU lead to 90% improvement w/ sustained remission in 10-40%)
Anti-mitochondrial abs+. Dx?
PBC
Eye: Sensation foreign body, watery discharge, grey branched corneal opacity, trauma hx. Dx?
Viral infectious keratitis (if bacterial: mucopurulent discharge, white corneal opacity). Emergent referral.
Eye: Sensation foreign body, mucopurulent discharge, white corneal opacity, Hx trauma. Dx?
Bacterial infectious keratitis (if viral: watery discharge, grey branched corneal opacity). Emergent referral.
Eye: photophobia, watery discharge, mitotic pupil, red ring around iris. Dx? Anterior uveitis, hyphema, hypopyon, irititis, keratitis, episcleritis
Anterior uveitis (irititis). Emergency
Eye: RBC layer in anterior chamber. Dx? Anterior uveitis, hyphema, hypopyon, irititis, infectious keratitis, episcleritis
Hyphema. Emergency
Eye: WBC layer in anterior chamber. Dx? Anterior uveitis, hyphema, hypopyon, irititis, infectious keratitis, episcleritis
Hypopyon. Emergency
Acute eye pain, fixed dilated pupil, HA, N/V. What is patient at high risk of?
Permanent blindness 2/2 optic n atrophy w/o acute intervention (Dx Acute closure glaucoma)
CVA w/ subsequent coughing/choking, nasal regurg, prolonged swallowing. NSIM?
modified barium swallow to w/u oropharyngeal dysphagia (prompt dx recommended as high risk of asp PNA: high mortality rates)
TSH 6-10, T4 lower norm. When to start Tx?
<70yo OR >70 w/ convincing bothersome sx.
80yo w/ TSH 7-10, T4 lower norm. Some fatigue, constipation. Tx?
Monitor Thyroid labs & only tx if TSH >10 OR convincing/ botehrsome sx. **Synthroid carries risk in elderly (afib, osteoporosis)
When to consider ablation for symptomatic paroxysmal afib?
When Tx w/ 1+ class I OR III anti-arrhythmic has failed
EGD w/ gastric ulcer & Hpylo+. Indications for repeat Bx?
Ulcer bx was inadequate OR high risk fo malig (Asia, Central America, FHx gastric CA, >2cm, Hpylori+, no recent NSAID use, 50yo+)
Stomach ulcer: CA assn?
40% gastric malig & gastric MALT lymphoma.
Multiple recurrent gastric ulcers & diarrhea. DX?
suspect gastrinoma
When is a repeat EGD performed after Tx of Hpylori?
If in presence of gastric ulcer & high risk (Asia, Central America, FHx gastric CA, >2cm, Hpylori+, no recent NSAID use, 50yo+)
Constipation, crampy umbilical pain assd w/ vomiting, no radiation to the back. NSIM?
upright AXR to r/o SBO (multiple air-fluid levels w/ distended small bowel loops)
AXR: multiple air-fluid levels w/ distended small bowel loops. Dx?
SBO (air in rectum rules out complete obstruction)
SBO pt managed w/ NPO, IVF, electrolyte supplement, serial abd exam, strict monitor NG and UOP, hwr pt develops worsening pain. NSIM?
CT w/ gastrografin to eval/Tx strangulation (note: gastrografin draws water into lumen decreasing wall edema, stimulates peristalsis & leads to improved bowel function.)
SBO managed conservatively, hwr sx worsen, CT w/ gastrografin administered, no contrast is seen in bowel w/in 24h. NSIM?
Indicates need for surgery (contrast cannot bipass SBO)
SBO managed conservatively, hwr sx worsen, CT w/ gastrografin administered, no contrast is seen in bowel w/in 24h. NSIM?
C/w management. Contrast in bowel w/in 4-24h is good predictor of SBO resolution.
Non-pancreatic causes of lipase elevation?
SBO/ileus, DKA, renal insuff
Anthracycline induced leukemia- interval btwn exposure to disease?
5-10y s/p chemo (MDS >AML)
Which is NOT a paraneoplastic syndrome of breast CA: cerebellar degeneration, scleroderma, SLE, nephritic syndrome, leukemoid reaction
Nephritic Syndrome (hwr development of NephrOtic syndrome is)
**Indication for biventricular pacemaker.
EF <35% & QRS >150 (optional for QRS 120-150)
EF <35% & QRS >150 . Tx?
**Indication for biventricular pacemaker.
Explain TR murmur in ILD.
ILD >pulm HTN > R side HF w/ TR
Worsening SOB, JVD+, mild hepatomegaly, TR murmur, bibasilar crackles, digital clubbing, CXR w/ prominent interstitial markings. NSIM?
hrCT to r/o ILD (ILD >pulm HTN > R side HF w/ TR)
Parkinsons is Dx. How would you treat mild-mod disease <65yo VS >65yo
<65yo: dopamine agonists (bromocriptine, pramipexole, ropinerole), >65yo: Carbi-Levodopa (note: Carbi-Levo is more effective hwr dopamine agonists have fewer motor fluctucations)
Trihexyphenidyl use?
Parkinsons (anticholonergic adjunt/monoTx for Tx resting tremor in mild disease <65yo)
Tremor worsens w/ action: Parkinsons OR Essential?
Essential (Parkinsons worsens w/ rest)
Symmetric, high frequency tremor: Parkinsons OR Essential?
Essential
Afib RVR x 3 days despite increasing metoprolol. Cardioversion planned. What must be r/o before procedure?
L atrial appendage thrombus (which may develop w/ afib >48h), via TEE. **If unable to r/o, must be medically optimized & receive >3wks AC prior to cardioversion
60yo w/ postprandial reflux, vomiting, succussion splash.. Which dx test do you order?
First r/o gastric outlet obstruction w/ EGD, THEN confirm w/ gastric emptying scintigraphy
Tx chronic prostatitis
6-8wks of cipro (note: Tx failure is common, complications: epididymitis, prostatic abscess, bacteremia)
IV ___ is an antidote for BB or CCB toxicity
IV glucagon
Indication for digoxin-specific antibody fragments (Fab)
End organ dysfunction 2/2 hypoperfusion. K >5..5. Life threatening arrhythmia ( advanced conduction block w/ junctional rhythm)
Why are the following not Tx for digoxin toxicity: HD, amiodarone, glucagon
HD: digoxin is too large, amiodarone: competes w/ digoxin for renal excretion * worsens tox, glucagon: antidote for BB & CCB tox
Pt has GI, visual sx, hyperK. Digoxin tox suspected. NSIM & Tx hyperK?
digoxin-specific antibody fragments (Fab), DO NOT administer Ca gluconate or insulin w/ Fab as Fab will rapidly lower K on its own)
HFrEF meds which IMPROVE MORTALITY?
entresto, spironolactone, BB (esp w/ hx MI), SGLT2 inhibitor
Pt w/ HFrEF cannot tolerate ACE/ARBs. Which medication MAY improve sx and mortality in their place?
Isosorbide dinitrate & hydralazine
T/F restricting salt intake may worsen HFrEF
T (restriction may enhance RAAS activity)
Earliest, most sensitive suggestive sign of cardiac tamponade on TTE?
R atrium collapse during diastole (lowest pressures of the heart chambers)
Which is more SPECIFIC for cardiac tamponade: LV collapse during diastole OR RA collapse during diastole
LV collapse (note: RA collapse is most SENSITIVE per lowest chamber pressures)
RV dilation & free wall hypokinesia sparing the apex. Dx?
acute PE (McConnel sign)
Severe tearing CP, hypotension, EKG showing electrical alterans. NSIM?
STAT TTE to confirm type A aortic dissection (then surgery immedjet). Type A aortic dissections can extend into the pericardial space and cause hemopericardium, cardiac tamponade & shock
Anasarca, elevated JVP, pulsus paradoxus, Kussmails sign, pericardial knock. Dx?
Constrictive pericarditis
increase in JVP during inspiration. Dx?
Kussmauls sign for constrictive pericarditis
Easy fatigability of arm work outs, dizziness, vertigo. Dx?
Subclavian steel syndrome (Subclavian artery stenosis ?flow reversal in ipsilateral vertebral artery)
SVC syndrome Dx: gold standard VS best initial test?
GOLD: bilateral upper extremity venography. BEST INITIAL: CTA (shows extent of venous blockage, collaterals* possible compressive factor)
Shoulder pain, hand muscle weakness/atrophy, miosis, ptosis anhidrosis. Dx?
Usually pancoast tumor invading the brachial plexus
ESRD pt w/ NSTEMI, Tx?
ASA, clopidogrel, heparin, BB (Note: statin unclear benefit, enoxaparin is contraindicated in ESRD per decreased renal clearance and high risk of bleed)
SVC syndrome in pt w/ ICD., MOA?
AICD can induce thrombosis and occlusion around the leads. (RF: number of leads, endothelial damage during insertion, prothrombotic state, infections. Can occur 1-15 months after insertion)
Severe hyperK. Which medication do you give FIRST?
STAT Ca gluconate (stabilizes cardiac membrane). THEN insulin/glucose, albuterol, bicarb, loop/thiazide. May consider HD if severe/refractory.
EKG: PR prolongation, atrial asystole, QRS widening w/ progression to sine wave. Which electrolyte abn?
hyperK (late changes indicating subsequent asystole)
Patient is concerned that starting statin for his HLD will worsen his glycemic control. What do you tell him?
Very small likelihood, also CVS benefit outweighs AE
Which factors increase risk of rhabdo in patients taking statins?
statin +amlodipine, statin + fibrate, presence of hypOthyroid or renal f.
Indications for low dose CT screening.
50-80 w/ >20 pack hx, quit with in the last 15y or currently smoke. Note: if 20 pack Hx but quit >15y ago, discontinue screen.
34yo w/ FX MI in mother age 59yo. Which screening do you perform?
Lipids (per premature hx CAD , women <60, men <50)
AAA screening indications
Men 65-75 with ANY smoking hx. One time US
DXA screen recs
women <65 w/ RF or >65
HIV screen recs
15-65 or w/ RF
ABI < ___ is indication for revasc.
<0.5
PAD: pharmacologic tx
ASA (or plavix), cilostasol for those who dont yet meet revasc criteria (inhibits platelet aggregation and increases maximal & pain free walking distances). Note: pentoxyphilline is second like w/ limited/inconsistent benefit in improving walking capacity
PAD revasc indications (3)
Fail medical therapy, ABI <0.5 OR severe symptoms
PCI for STEMI w/in ___hrs sx onset AND w/in ___hrs of first medical contact to PCI placement
12h, 1.5h (unless if presenting to a non-PCI-capable facility, then its 2h)
Elder w/ >20mmHg decrease in BP after meals. Tx?
smaller/frequent meals, low carb, increase salt and water, compression stockings, avoid EtOH. Last resort: octreotide (increases splanchnic vasc resistance, but SC admin and $$)
Prognosis Takotsubo cardiomyopathy.
Tx: supportive w/ recovery of LV function w/in 8-12wks. (MOA: excessive catecholamine release per stress, microcirc dysfunction & multivessel coronary spasm)
High ABI >1.3 assn?
increase in all cause CVS mortality (elevated ABI suggests calcified vessels ie in ESRD, DM)
Normal ABI level
0.9-1.3 (if increased, may indicate calcified/uncompressible vessels 2/2 DM or ESRD. Suggests increase in all cause CVS mortality )
You suspect statin myopathy because of myalgia after adding verapamil. Which labs do you order?
CK, vitD (def), TFT (hyper/hypo), BMP (hypoK),
T/F Patient w/ prosthetic valve and hx endocarditis needs abx ppx prior to c-section
FALSE- considered low risk (as well as ERCP, EGD, colonoscopy…)
PPX for high risk patients undergoing high risk procedures. Which abx?
Clindamycin or amoxicillin
MI > revasc w/ PCI. Now EF of 25%. When do you implant ICD?
Maybe you dont. Reassess in 3 months after medical therapy. (if there was no revasc, reassess after 40 days)
Which med does NOT have antiproteinuric effects? Amlodipine/ Verapamil/ ACEi/ ARB/ Diltiazem
Amlodipine
CHF patient w/ afib RVR- what is a good agent?
digoxin
Antiarrythmics of choice in otherwise healthy young patient w/ sporadic symptomatic paroxysmal afib?
Fleicanide & propafenone
Indication for surgery for infective endocarditis?
> 1cm lesion, lesion causing acute HF, or emboli in setting of abx use
Infective endocarditis: Which is an indication for cardiac valve surgery?
1) AV involvement
2) embolus to brain
3) high grade valvular regurg
4) signs of acute HF
5) vegetation 0.9cm
4) signs of acute HF (also: >1cm lesion, lesion causing acute HF, or emboli in setting of abx use, new heart block)
T/F ischemic stroke is a relative contraindication to fibrinolytic therapy
Relative if >3 months ago, absolute if <3 months
T/F hemorrhagic CVA 10y ago is an absolute contraindication to fibrinolytic therapy
TRUE, lifetime absolute contraindication
Fibrinolytics must be given w/in ___hrs
12 (hwr most effective if given within the hour)
Cardiogenic shock 2/2 acute MI. NSIM? Vasopressor OR dobutamine OR PCI OR intra-aortic pump insertion
PCI (only thing that improves mortality)
NSTEMI w/ troponemia resolves w/ meds. What should be done prior to d/c?
med optimization & cath w/in 24h
**When is INR 2-3 recommended VS 2.5-3.5
2-3: AV replacement with NO RFs (afib, LVSD, hx VTE, hyper coag state). 2.5-3.5: MV replacement, AV replacement w/ RF or AV w/ old gen valve
**When do you give ASA in addition to warfarin for valve replacements?
when there is severe concomitant CAD
Which does not require INR goal of 2.5-3.5? MV replacement, AV replacement w/ RF or AV w/ old gen valve, AV replacement w/ no RF
AV replacement w/ no RF
33yo M w/ HCM on BB & FHx sudden death presents sp episode of syncope. NSIM?
ICD placement (other indications- Hx cardiac arrest, hypotension w/ exercise, >3cm septal wall thickness, non-sustained VT on holter, FHx sudden death, syncope)
Normal Mean RA pressure?
4
Normal cardiac index
2.8-4.2
Normal Mean PCWP
9
Normal SVR
1150
***Normal values for the following: Mean RA pressure? Cardiac index? PCWP? SVR?
Mean RA p: 4….
Cardiac index: 2.8-4.3….
PCWP: 9….
SVR: 1150
Late peaking 3/6 systolic murmur w/ paradoxical splitting of S2 at RUSB?
severe aortic stenosis
When to consider cardiac cath prior to non-cardiac surgery?
unstable angina or recent MI
Which is NOT a part of RCRI risk assessment:
- IHD
- CHF
- Hx CVA
- DM on insulin
- Cr >1.5
Cr >1.5 (a risk predictor is Cr >2)
Knee replacement planned (intermediate risk), RCRI <1. NSIM?
It able to perform >4 METS, Proceed with surgery
Pt planned for elective surgery. RCRI >1 & not able to perform 4 METS. NSIM?
Further cardiac work up (TTE, stress test)
CP, pericardial friction rub, diffuse STE. Dx?
Pericarditis (DDX Myopericarditis: same symptoms PLUS one of the following- elevated CKMB, trops, new depressed LV function on TTE, MRI showing myocarditis)
Tx pericarditis:
NSAIDS (indomethacin. aspirin, ibuprofen), colchicine (improve sx and decrease recurrence) **AVOID GCS (higher rate of recurrence, indicated +/- IVIg if initial episode doesnt respond to coclchicine/NSAIDs)
WPW on EKG. NSIM?
Risk stratification for SCD: non-invasive tests (exercise testing, procainamide challenge) or EPS. If intermittent loss of preexcitation during faster heart rates= low risk, manage conservatively.
WPW pt undergoes risk stratification for SCD: non-invasive tests (exercise testing, procainamide challenge) or EPS. Intermittent loss of preexcitation during faster heart rates: Tx?
Conservative (low risk)
Loud S1 followed by opening snap and middiastolic murmur w/ presystolic accentuation. Murmur?
MS
Crescendo-decrescendo systolic murmur at the RUSB in young patient. Dx?
Likely AS 2/2 bicuspid valve
Peripartum cardiomyopathy- timeline?
> 36wks gestation- 5 months post gestation
Harsh holosystolic murmur at mid L sternal border. Dx?
VSD
Which electrolyte derangements cause prolonged QT?
HYPO- Ca, Mg, K
Tx for all patients w/ long QT?
BB (propanolol, nadolol) to decrease the risk of symptomatic arrhythmia & sudden cardiac death. Ensure supplementation on Mg, K, Ca PRN. ICD recommended for hx syncope, recurrent tachy despite BB, hx cardiac arrest
Threshold for QT prolongation in men VS women
men: >450
women: >470
ICD indications for pts w/ long QT syndrome?
if hx syncope, recurrent tachy despite BB, hx cardiac arrest
Which is an INDICATION for percutaneous mitral balloon valvotomy?
1) Severe MS w/ Sx
2) Mod/Severe MR
3) Complex valve anatomy
4) Extensive valve calcification
5) L arterial thrombus
1) Severe MS w/ Sx (or w/ pulm a systolic pressure >50) **the rest are contraindications
Which is are CONTRANDICATIONS for percutaneous mitral balloon valvotomy?
1) Severe MS w/ Sx
2) Mod/Severe MR
3) Complex valve anatomy
4) Extensive valve calcification
5) L arterial thrombus
All except 1
Patients w/ MS & non-complex valve anatomy. Best Tx?
Percutaneous mitral balloon valvotomy. (note this is CONTRAINDICATED w/ MR as it can initially worsen the condition).
When is valve REPLACEMENT indicated for tx of MS?
If contraindications to Percutaneous mitral balloon valvotomy (Mod/Severe MR, Complex valve anatomy, Extensive valve calcification, L arterial thrombus)
Episodes of angina pectoris occurring at rest w/ transient STE, absence of high grade coronary artery stenosis. Dx?
Prinsmetals angina (per coronary artery vasospasm)
How to manage nitrate tolerance?
adjust schedule to allow for drug free intervals
Elective surgery planned. Pt underwent DES placement 2 months ago. When can you perform the sugery?
after 6 months total DAPT therapy (then you may HOLD plavix 3-7 days pre-op and c/w ASA)
Pt on DAPT after DES placement a year ago. Elective surgery planned. What do you recommend for AC?
HOLD plavix 3-7 days pre-op and c/w ASA
MVP- risk of CVS morbidity/mortality?
For most, equal to gen pop. The following mark an increased risk: moderate/severe MR, EF <50%, LA >40mm, flail mitral leaflet, >50yo.
Risks of MVP w/ moderate/severe MR, EF <50%, LA >40mm, flail mitral leaflet, >50yo?
arrhythmia, embolic CVA, infective endocarditis, decompensated HF, SCD
Elderly pt presents w/ SOB. EKG shows atrial rate >100, irreg R-R, >3 distinct P wave morphologies. Tx?
Dx: multifocal atrial tachycardia likely 2/2 COPD, Tx: COPD (GCS, bronchodil)
EKG shows atrial rate >100, irreg R-R, >3 distinct P wave morphologies. What is the CAUSE of this presentation?
Likey COPD, hypoMg, hypoK, catecholamine surge (sepsis), PE, PNA
Coarctation: Associated conditions (cardiac, genetic)
Turners, Bicuspid aortic valve, aortic dissection/rupture, IC aneurysms
HA, epistaxis, HTN, BP greater in arms than legs, continuous cardiac murmur. Dx?
Coarctation
MC cardiac pathology assd w/ coarctation of the aorta?
20-30% have bicuspid aortic valve
MOA CCB adverse effect of leg edema?
peripheral arterial vasodilation (seen in ~10%)
Tx of CCB adverse effect of leg edema
ACEi can reduce CCB-induced peripheral edema (no response to loops)
Biggest lifestyle effect on improving HTN?
DASH diet 11mmHg (also 6mmHg decrease per 10kg weight loss).
Top 3 lifestyle factors to reduce HTN?
** DASH **Na <2.3g/day aerobic exercise **EtOH reduction*weight loss
1) DASH, 2) W.loss, 3) exercise
Describe DASH diet
High in fruits/veg, low fat dairy, legume protein, LOW in processed meats, total fat & sweets
DASH diet provides greatest benefit in which demographic?
Elderly, women, black, metabolic syndrome
Effect of giving prophylactic perioperative BB: hypotension, CVA, mortality
POISE trial showed INCREASED hypotension, CVA, mortality (only indicated for patients with specific indications)
Best antiarrythmic for afib in CHF?
Amiodarone, dofetilide
Best antiarrythmic for afib in LVH?
amiodarone or dronedarone
Sotalol is used for afib in & hx ____
CAD (w/o HF)
T/F Antiarrythmics for afib decrease the rate of CHF progression
FALSE (hwr rate control has shown a decreased risk of progression to LV systolic dysfunction)
40yo w/ mid-diastolic murmur, DOE, hemoptysis, light-headedness, fever, weight loss, Reynauds & TIA. Dx?
TTE to r/o cardiac myxoma. Tx: prompt surgical resection (not constitutional sx are from overproduction of IL6)
Dysphagia, hoarseness, SOB, CHF. Decrescendo blowing diastolic murmur heard best at the left lower sternal border. Dx?
Large aortic aneurysm compressing local structures (esophagus, recurrent laryngeal nerve, phrenic n) CHF can be from chronic AR.
Fatigue, DOE, R-heart failure, flushing, secretory D, bronchospasm, hypOtension, Dx?
Carcinoid S
Which is NOT a hypercoag state?
Factor V Leiden, Prothrombin gene mutation, Factor IX deficiency, Protein C def, Protein S def, antithrombin III deficiency
Factor IX deficiency (hemophilia)
Ca 11, PTH wnl. Dx?
Primary/Tertiary hyperPTH OR Familial hypocalciuric hypercalemia, lithium
Ca 11, PTH wnl. Which MEDICATION can be causing this?
lithium
Ca 11, PTH wnl: Which can be a cause:
**Vit D tox ** Drug induced ** Milk Alkali ** Familial hypocalciuric hypercalcemia ** Vit A tox ** Granulomatous D
Familial hypocalciuric hypercalcemia (rare) OR primary/tertiary hyperpTH OR lithium (note: in all other listed conditions PTH should be suppressed)
Patient starts thiazide and develops Ca 11.5, NSIM?
Order PTH level as thiazides should only mildly increase Ca while suppressing PTH. If PTH is normal or elevated, work up for hyperparathyroidism
High Ca, AKI, met alk in patient with GERD. Dx?
Consider Milk Alkali Syndrome (taking excessive Ca carbonate)
Tx Milk Alkali S?
IVF +/- Ca supplement, stop excessive Ca
Which medications other than GCS may cause osteoporosis in men?
Leuprolide (androgen antagonists), anti-convulsants, synthroid w> high T4
50yo male has fracture after fall from standing height. Which RF led to this presentation?
Possibly hyperthyroid, andogen antagonists, GCS, anticonvulsants, EtOH/smoking, gastrectomy, celiac, IBD
Tx osteoporosis in renal failure?
Denosumab
Tx osteoporosis for pts intolerant to bisphosphonates w/ normal renal function?
Teriparatide (recombinant PTH analog)
Denosumab is used to Tx osteoporosis w/ renal failure. Which adverse effects do you watch out for?
skin reactions, infections and hypocalcemia
Elderly M w/ fatigue x several months presents to ED w/ bradycardia, hypoventillation, diastolic HTN, hypothermia, AMS, non-pitting edema face/hands/tongue. Labs: hypoNa, hypoglyc. Tx?
Myxedema coma: synthroid (T4) & T3, add GCS for possible concomitant adrenal insufficiency
Name 5 presenting factors for myxedema coma other than AMS
Bradycardia, hypothermia, diastolic hypOTN, hypoventillation, hypoNa, hypoglyc, swelling of face/hands/tongue (Tx w/ T4, T3 & GCS for possible concomitant adrenal insuff)
33yo F presents w/ infertility, acne/hirsutism. 8mm hypopituitary mass seen on MRI. What is the patients risk of untreated condition?
osteoporosis (rapid bone loss, per low estrogen), mass effect symptoms
40yo F w/ amenorrhea, infertility, acne/hirsutism, HA. NSIM?
MRI brain r/o pituitary adenoma, likely prolactinoma (Tx dopamine agonist, ie cabergoline)
40yo M w/ hypogonadism, ED, gynecomastia and HA. Dx?
Consider prolactinoma
Prolactinomas require Tx if symptomatic or >__mm
> 10mm
High unopposed E can cause which CA?
endometrial
Patients treated w/ high dose cabergoline (Parkinsons) may develop _____ and be monitored every 2 years
valvular disease, monitor with TTE
Which infiltrative disease is a RF for listeria, vibrio, yersinia?
hemochromatosis
Secondary hypogonadism in patient w/ hemochromatosis can be reversed if:
patient starts phlebotomy <40
What would you expect for the levels of the following in Klinefelters? T, LH, FSH
low T, high FSH, high LH
Which is a SECONDARY cause of hypogonadism? Klinefelters, cryptorchidism, ketoconazole, hemochromatosis, orchitis, testicular trauma, CKD
hemochromatosis
What does primary VS secondary hypogonadism mean?
primary (testicular), secondary (pituitary/hypothalamic)
Is cirrhosis a primary or secondary cause of hypogonadism?
combined. Note: primary (testicular), secondary (pituitary/hypothalamic
Thyroid nodule on thyroid US. TSH level is low. NSIM?
Radioactive iodine scintigraphy, if HOT- Tx hyperthyroidism. If COLD consider FNA.
Thyroid nodule on thyroid US. TSH level is normal. NSIM?
Consider FNA based on nodule size and US findings (microcalcifications, increased vascularity, hypoechoic, elongated shape, irreg margins, >1cm). (same goes for HIGH TSH)
Thyroid nodule on thyroid US. TSH level is HIGH. NSIM?
Consider FNA based on nodule size and US findings. (same goes for normal TSH, if LOW- Radioactive iodine scintigraphy)
Which is NOT a high risk feature of a thyroid nodule? microcalcifications, increased vascularity, hyperechoic, elongated shape, irreg margins, >1cm
hyperechoic
Thyroid nodule found incidentally on routine exam- which factors would prompt an FNA?
FHx CA, >1.5cm, Hx radiation in childhood, rapid growth, cervical LAD
Which is a HIGH risk feature of a thyroid nodule? hyperechoic, microcalcifications, spongiform, cystic, >8mm
microcalcifications (also increased vascularity, hyperechoic, elongated shape, irreg margins, >1cm)
Serum calcitonin is elevated in which thyroid CA?
medullary (screen MEN2)
Adrenal incidentaloma on imaging. Borderline hyperNa & borderline hypoK. NSIM?
Order either: Overnight dexamethasone suppression test, Urine catecholamines/metanephrines, aldosterone: renin ratio
Which 3 tests can you order to work up adrenal adenoma?
Order either: Overnight dexamethasone suppression test, Urine catecholamines/metanephrines, aldosterone: renin ratio
Pt w/ adrenal mass & HTN. Starts thiazide and rapidly develops hypOkalemia. Dx?
Possible primary hyperaldosteronism (hypokalemia is rapidly provoked w/ diuretics)
38yo w/ adrenal incidentaloma & HTN. Which conditions do you consider?
Cushings, primary hyperaldosteronism, pheochromocytoma
Pt develops hypothyroidism after pregnancy. What do you consider?
Sheehan syndrome
Low T4, low TSH. Small pituitary mass. You suspect central hypothyroidism. Which test do you order prior to synthroid tx?
ACTH stim test (synthroid can accelerate
Thyroperoxidase Ab+, Dx?
Hashimotos AKA chronic lymphocytic thyroiditis
Hypothyroid pt on OCP w/ TSH 2.2, T4 1.6, c/o persistent fatigue, weight gain, hair loss, dry skin. NSIM?
Eval for other etiologies. (chemically euthyroid, increasing synthroid may cause HTN/osteoporosis. OCPs stimulate SBH hwr normal TSH indicates this has been accounted for)
3 things to check w/ dx medullary thyroid CA?
1) metastatic disease 2) identify co-existing tumors 3) possible germline RET mutations
Hyperparathyroid, enteropancreatic tumor, pituitary tumor. Dx?
MEN1
Medullary thyroid CA, phenochromocytoma, parathyroid neoplasia. Dx?
MEN 2A
Medullary thyroid CA, pheochromocytoma, mucosal/intestinal neuromas. Dx?
MEN 2B (or Marfanoid habitus)
Marfanoid habitus is assd w/ which MEN syndrome?
MEN 2B
Medullary thyroid CA- when is pre-op imaging of the neck/chest/abd indicated?
serum calcitonin >400 or when local LNs are present.
Medullary thyroid CA+. Serum calcitonin >400. Thyroidectomy planned. What is required beforehand?
pre-op imaging of the neck/chest/abd
RET mutation is positive in patient w/ medullary thyroid CA. What does this signify?
poor prognosis. First degree relatives should be screened.
What tests 3 screening tests for Cushings?
TWO of the following: low-dose overnight dexamethasone suppression test OR late night salivary cortisol OR 24h urine free cortisol
Which two are NOT initial screening tests for Cushings? **AM Cortisol **vernight dexamethasone suppression test **night salivary cortisol **ACTH level ***late night salivary cortisol
ACTH level (DDx primary VS secondary but not an initial screen) & AM cortisol (not helpful w/o ACTH suppression)
Which screening test for Cushings should be avoided in women on OCPs d/t risk of false positive? **low-dose overnight dexamethasone suppression test ** late night salivary cortisol *** 24h urine free cortisol
low-dose overnight dexamethasone suppression test (OCP increases cortisol binding globulin)
TSH normal/high, F4 high, NSIM?
MRI pituitary
TSH low, T4 high, signs of NO signs of Graves. NSIM?
RAIU scan
TSH low, T4 high, signs of NO signs of Graves. RAIU w/ high/nodular uptake. Dx?
Toxic adenoma or multinodular goiter. (eval w/ US)
TSH low, T4 high, signs of NO signs of Graves. RAIU w/ low uptake. NSIM?
Measure thyroglobulin. If low: Dx exogenous hormone. If HIGH: thyroiditis, iodine exposure, extraglandular production
TSH low, T4 high, signs of NO signs of Graves. RAIU w/ low uptake. Thyroglobulin low. Dx?
exogenous hormone admin
TSH low, T4 high, signs of NO signs of Graves. RAIU w/ low uptake. Thyroglobulin high. Dx?
thyroiditis, iodine exposure, extraglandular production
TSH low, T4 high. HypERthyroid Sx. Small thyroid, thyroglobulin is LOW. Dx?
Suspect exogenous hormone admin
When is thyroglobulin useful?
If TSH low, T4 high, hypERthyroid sx- you can use it to eval for exogenous administration
T/F Elevated TSH is suggests higher likelihood of malignancy.
T
T/F Nuclear medicine technicians are at higher risk of malignancy.
F
Which age group is at higher risk for malignancy? <30, 30-60, >60
30-60
Pt on synthroid starts phenytoin/carbamazepine for seizures. Do you expect them to develop hypO or hypERthyroid symptoms?
hypO (seizure meds increase thyroid hormone metabolism)
Pt on synthroid starts estrogen (or SERM) Tx. Do you expect them to develop hypO or hypERthyroid symptoms?
hypO (those meds cause increased TBG & in turn decreased circulating free T4)
Pt on synthroid starts androgen (or GCS) Tx. Do you expect them to develop hypO or hypERthyroid symptoms?
hypER (those meds cause decreased TBG & in turn increased circulating free T4)
Which agents DECREASE synthroid absorption?
bile-acid binding agents (cholestyramine) iron, Ca, PPI, sucralfate
Elderly pt w/ weight loss, insomnia, afib, SOB, constipation. What should you screen?
For hypERthyroidism per new onset afib. (note: elderly can present w/ paradoxical constipation & SOB of unknown mechanism)
Excess thyroid admin assd w/ hypo or hyper Ca?
hyperCa (per increased bone resorption)
Excess thyroid admin assd w/ increased or decreased PTH?
Decreased (per feedback of hyperCa d/t bone resoprtion)
MOA hyperCa in hyperthyroidism?
Increased osteoclast activity/bone resorption
RA sounding Hx but anti-CCP & RA abs neg. Dx?
Probably RA “sero-negative” (also order CRP, ESR, hepatitis panel, parvovirus & XR)
HSP suspected. NSIM?
Bx (skin kidney): small vessel involvement w/ PMN/monocyte infiltration
Long term risk of HSP?
ESRD in 10-30% at 15y f/u)
Lithium level requiring HD?
> 4 OR >2.5 w/ AMS/seizure or inability to excrete lithium (CKD or decompensated HF)
Bipolar pt w/ sluggishness, confusion, agitation, neuromuscular excitability, course tremors. DX?
Suspect lithium poisoning (acute on chronic). Note: acute tox- N/V/D, later neuro sx
Awake/ASx pt s/p suicide attempt w/ lithium 2h ago. NSIM?
PEG whole bowel irrigation- may replace need for HD
Elderly pt reporting worsening in distance vision. “myopic shift” which may indicate-
early nuclear cataract formation (myopic shift often occurs before opacification becomes evident, hence may have recent normal retinal exam)
Cataracts: List 3 RF other than age.
Chronic sun exposure, DM, GCS
Blurry vision, flashing lights black spots in elderly pt. MCC?
Prolf DM retinopathy
Slow progressive vision loss, impaired reading difficulty, distortion of vision or scotoma. MCC?
AMD (DDX- DM retinopathy: Blurry vision, flashing lights black spots)
Painless loss of peripheral vision.
open-angle glaucoma (2/2 increased IOP)
What kind of acid/base disorder do loops cause?
met alk which should trigger respiratory compensation w/ CO2 being blown off- if CO2 is elevated it indicates resp acidosis 2/2 another condition
Tx tarsal tunnel syndrome
NSAIDs, shoe modification, GCS injections or last resort: decompressive surgery
Stomatitis w/ MTX use. Tx?
folic acid supplementation (1g/day increased to 5g/day based on sx)
Which tests/studies should be ordered prior to starting MTX?
CXR & hepatitis panel. (monitoring includes: LFTs, albumin, CBC & Cr)
What should be monitored on MTX?
LFTs, albumin, CBC & Cr (also prior to starting the med a hepatitis panel & CXR should be ordered)
Life-threatening complications of MTX?
hepatocyte damage, pulm damage, myelosuppression & nephrotoxicity (monitor: LFTs, albumin, CBC & Cr)
Stomatits is assd w/ which RA med?
MTX
What level urine Na do you expect in pre-renal injury?
<20 mEq/dL
Trimethoprim & cimetidine effect on creatinine?
increased serum Cr w/o decrease in GFT (per competing w/ creatining for tubular secretion)
Pt w/ CKD has increased bleeding. PLT wnl & INR wnl. Explaination?
PLT dysfunction. Rising urea > increased nitric oxide > decreased PLT adhesion/aggregation/activation
Connection btwn uremia & increased bleeds.
Rising urea > increased nitric oxide > decreased PLT adhesion/aggregation/activation
CKD pt w/ high BUN, susceptible to bleeds. Planning to undergo surgery. Tx?
Desmopressin DDAVP *stimulates vWF x 4-24h (note: PLT dysfunction MOA in CKD- Rising urea > increased nitric oxide > decreased PLT adhesion/aggregation/activation)
Prognosis of urinary incontinence sp radical prostatectomy?
Occurs in 50%, most likely to dramatically DECREASE to 10% 2y post surgery. Tx: kegal exercises/biofeedback
What type of incontinence does tolterodine Tx?
Urge (ie. 2/2 BPH)
Average life span for artificial joints ie hip replacement
10-15y
RA patient w/ severe joint disfigurement but low inflammatory markers. Tx?
Ortho referral (likely mechanical stress from joint destuction). Surgery indicated if intractable pain, severe functional disability or impending tendon rupture.
SLE pt develops proteinuria, elevated Cr w/ urinary sediment. NSIM?
Renal bx to determine type of SLE renal nephritis subtime (MCC: diffuse)
Which SLE labs have been implicated in the pathogenesis of lupus nephritis?
dsDNA (although not always present in serum)
SLE pt w/ hip pain on abduction & internal rotation. No erythema, swelling or tenderness. ESR/CRP/WBC wnl. Dx?
Eval for avasc necrosis (MRI most sensitive, XR w/ crescent sign in advanced d)
SLE pt w/ hip pain on abduction & internal rotation. XR w/ crescent sign. NSIM?
MRI to r/o avasc necrosis. (ESR/CRP/WBC wnl)
Indium 111 use?
It is a WBC scan useful in localizing abscess/ infection
Crescent sign on hip XR. Dx?
pathomnemonic for avasc necrosis
hyperK 8 w/o EKG changes. NSIM?
arterial K (no tourniqet/shaking, stored on ice, prompt analysis)
EKG w/ increased PR, prolonged QT, widened QRS. Dx?
hyperK (also peaked T)
Patient undergoing chemo develops high uric acid, phosphorus, Cr. Dx?
Tumor lysis syndrome, Tx aggressive IVF
PseudohyperK, MOA
in setting of v elevated WBC >50k or PLT >600. Occurs dt mechanical stress causing fragile cell lysis during blood draw, w/ extravasation of cell contents
Amyloidosis w/u
MPEP/SPEP, confirm w/ tissue bx (Congo Red)
Nephrotic range proteinuria, hepatomegaly, low cardiac voltage. Dx?
Consider amyloidosis
Leukoclastic vasculitis w/ IgA immune complexes in affected organs. Abd pain, GN, arthritis & derm findings. Dx?
HSP (w/ palpable purpura)
RA medication w/ following AE: stomatitis, megaloblastic anemia, GI sx, macular rash
MTX (hence, monitior: CBC, LFTs, albumin, Cr)
AE of MTX
stomatitis, megaloblastic anemia, GI sx, macular rash
Pt on MTX develops stomatitis. What could have prevented this?
Folate supplementation
Name a few meds that can increase serum Cr but not affect GFR
trimethoprim, cimetidine, flucytosine, ketone bodies
Interstitial nephritis findings on UA
WBC++, granular casts (rash, fever, eosinophilia, eosinophiluria)
SLE pt w/ membranous nephritis develops worsened renal function & hematuria. NSIM?
renal bx (repeat bx in SLE nephritis w/ worsening/changing sx, as transformation of LN subtypes may occur)
Hydroxychloroquine is used for MILD or SEVERE lupus nephritis?
MILD (+/- GCS)
Avasc necrosis- which motions cause pain?
Weight-bearing, internal rotation
Significant proteinuria, hematuria, dysmorphic RBC and possibly RBC casts on UA. Dx?
IgA nephropathy
Calcium oxalate stones are most likely seen in which patients?
Malabsorptive conditions: Crohns, small bowel resection/bariatric surgery, CF. (MOA: Ca binds to FA, which causes GI reabsorbtion of oxalate, causing increased renal oxalate excretion)
MOA Calcium oxalate stones in malabsorptive disorders?
Malabsorp > more Ca binds to FA, which causes GI reabsorbtion of oxalate, causing increased renal oxalate excretion. Also causes lower citrate excretion (note: citrate supplement treats these stones)
Tx Calcium oxalate stones
Citrate supplementation & low oxalate diet
D, Abd pain. Hgb 7.5, neg Coombs, schistocytes+, severe thromboctopenia, AKI. LDH, bili++. Dx?
HUS (EHEC)
Triad of HUS?
D > microangiopathic hemolytic anemia (neg Coombs, schistocytes), thrombocytopenia, AKI
Diarrhea > anemia w/ schistocytes, AKI. Dx?
Consider HUS (EHEC)
Non-spec lower back/flank/abd pain w/ AKI, ureteral obstruction w/o dilation, ~IVC obstruction w/ edema/DVT. Dx?
Retroperitoneal fibrosis (Tx: GCS, relieving the obstruction & Tx underlying cause)
Tx abd compartment sx
surgical decompression
AKI in presence of massive ascites. NSIM?
measure hydrostatic pressure w/in the bladder (this correlates w/ intra-abd pressure). AKI likely 2/2 decreased renal blood flow and elevated venous pressure. Tx surgical decompression. V high mortality rate
RF for abd compartment syndrome
Rapid volume expansion ie post-op, massive ascites, severe bowel distension, fluid resuscitation in shock, liver transplant, trauma/burn patients
HA, V, red eye, corneal opacity. Dx?
acute angle closure glaucoma. (Tx: timolol, pilocarpine, IV acetazolamide)
Tx acute angle closure glaucoma
Tx: timolol, pilocarpine, IV acetazolamide
MS pt w/ pain w/ eye movement. Dx?
optic neuritis Dx: contrast MRI, Tx: IV methylprednisone
Optic neuritis suspected in MS patient. Which test do you order?
Dx: contrast MRI, (Tx: IV methylprednisone)
Tx optic neuritis
IV methylprednisone
Mucopurulent eye exudate/pain, eye-lid swelling, conjunctival injection, epithelial ulceration on fluorescein stain. TREATMENT?
broad spectrum abx drops ie FQ, avoid GCS in acute phase (Dx: keratitis) **MCC contact lens infectious complications. May present w/ hypopyon
Foreign body sensation, Hx trauma or HSV. Dx?
Corneal ulcer
Which lab marker indicates poor prognosis for RA?
anti-CCP Abs (also high RF, CRP/ESR)
Bacterial conjunctivitis Tx in contact lens wearer VS non-wearer?
contacts: FQ (cipro), no contacts: erythro/azithromycin or polymyxin-TMP drops
Freq allergic conjunctivitis. In addition to antihistamine/decongestant drops, which drops do you recommend?
mast cell stabilizer drops (cromolyn) or NSAIDs ketorolac
Opthalmic cyclosporine use?
Sjogrens
Acute onset testicular pain, profound testicular swelling. NSIM?
US for suspected testicular torsion (Cremasteric reflex absent) Tx: surgery
Fever, urinary frequency/urgency, induration/swelling of teste, pyuria/bacteruria. Dx?
Order UCx to work up epididymitis (note UA may be normal w/o urinary sx). Tx elevation, NSAIDs, abx, close follow up
Severe pain from anterior abdoment to scrotum/penis, crepitus/bullae. NSIM?
STAT surgical eval, CT/MRI (Fourniers)
Which men are at highest risk of chlamydia/gonorrhea?
men who have anal sex
MCC viral orchitis, other than mumps?
rubella, parvovirus
25yo F completes first marathon and has N/V/HA & seizure at finish line. Likely cause?
hyponatremia (too much water w/o electrolyes, Na loss via sweating). Unlike the collapsed athlete who may be hypernatremic from not drinking enough water.
When is a diuretic advised prior to contrast imaging?
If patient is fluid overloaded, a diuretic may improve renal perf prior to contrast admin
Interventions to reduce contrast-induced nephropathy?
IVF (or lasix in event of hypervol), lowest possible contrast dose, avoid NSAIDs
Patient has work up of tumor and two days later- develops FeNa <1, muddy brown/granular casts. Dx?
Contrast induced nephropathy
Anti-topoisomerase Ab AKA
anti-Scl-70 ab (systemic sclerosis)
Anti-topoisomerase Ab Dx?
Systemic sclerosis
anti-RNA polymerase II. Dx?
Systemic sclerosis
Anti-mitochondrial Ab. Dx?
PBC
Anti-synthase Ab. Dx?
myositis ( & anti-Jo)
Scleroderma w/ oliguria, thrombocytopenia & MAHA. Dx?
scleroderma renal crisis
Physician invests in a radiology center. Are they prohibited to send their patients there?
No BUT the investment should be disclosed to the patient
New onset floaters, flashing lights, spotty/periph loss of vision. Dx?
retinal detachment (RF: myopia, >50, prolif DM retinopathy)
New onset floaters, flashing lights, spotty. When should patient see retinal specialist STAT?
if vision loss is present (warrants prompt surgical correction). Otherwise elective apt.
Amaurosis fugax & marked vision loss w/o pain. What do you expect on fundoscopy?
Pale fundus w/ cherry red macula (CRAO)
Is CRAO painful?
NO
Gradual vision loss w/ drusen on fundoscopy. Dx?
Dry macular degen (if wet: acute, w/ hemorrhage)
Dry VS wet macular degen (fundoscopy findings and duration of sx onset)
DRY: gradual vision loss w/ drusen. WET: acute, w/ hemorrhage
Match the stone to the shape: (Ca oxalate) **rhomboid **coffin lid ** hexagonal yellow/green **large branched caliculi
envelope
Match the stone to the shape: (uric acid) **rhomboid **coffin lid ** hexagonal yellow/green **large branched caliculi
rhomboid
Match the stone to the shape: (struvite) **rhomboid **coffin lid ** hexagonal yellow/green **large branched caliculi
coffin (staghorn)
Match the stone to the shape: (cysteine) **rhomboid **coffin lid ** hexagonal yellow/green **large branched caliculi
hexagonal yellow/green AND large branched calicili
RF for calcium oxalate stones
malabsorptive d, hyperPTH, distal RTA
Rare AR disease w/ multiple kidney stones (hexagonal), c/b UTI & loss of kidney function. Dx?
Cystinuria (Tx alkalization of urine- (K citrate/bicarb)
Tx cystinuria
Alkalizing urine w/ K-citrate or bicarb, hydration
Most commonly passed shape crystal: **rhomboid **coffin lid ** hexagonal yellow/green **large branched caliculi
envelope (Calcium containing)
Na 160. Euvolemic. Tx?
free water (if hypovol/symptomatic NS til euvolemic then D5W, if hypovol w/o sx give D5W)
Na 160, hypovol & symptomatic. Tx?
NS til euvolemic then D5W (if hypovol w/o sx give D5W)
Na 160, hypovol & NOT symptomatic. Tx?
D5W (if symptomatic, give NS until euvol, then D5W)
At which rate should you lower Na in hyperNa?
no more than 0.5 mEq/hr (no more than 12 mEq/24hr)
What is the max Na you should lower in 24h?
no more than 12 mEq/24hr (no more than 0.5 mEq/hr). If too rapid > cerebral edema.
Consequence of correcting sodium too quickly?
cerebral edema.
Medications that cause optic neuritis
ethambutol, linezolid, sildanefil
Adverse effects: linezolid
optic neuropathy, peripheral neuropathy, bone marrow suppression (if >4wks, monitor CBC weekly)
Assessment tool for qualifying adverse post-op outcomes in elderly?
Eval fraility
Linezolid use
VRE, MRSA, GP bacteria
Ciliary flush (erythematous ring around iris) & hypopyon in AIDS pt. Possible pathogens?
CMV, syphilis, toxoplasma
Tx: Acute uveitis assd w/ autoimmune conditions.
topical GCS
30yo M w/ significant proteinuria on evening spot protein, and then no proteinuria on AM spot protein. TREATMENT?
None. (Dx orthostatic proteinuria). Often resolves in adulthood, no progression to CKD.
Heat stroke- Tx?
evaporative cooling (if young patient, ice bath immersion may be considered). Avoid Tylenol/Aspirin/Dantrolene.
What may be the presenting sign of renal vein thrombosis and which patients are at risk?
PE/DVT. RF: membranous nephropathy.
Complications of nephrOtic syndrome?
protein malnutrition, hypovol, AKI, renal DVT/PE, pneumococcal infection, prox tubular dysfunction > vit D def
Patient w/ membranous GN drops dead. COD?
possible PE/DVT (10-30% w/ nephrOtic syndrome) **MCC: memnranous nephropathy: 60% will develop renal thromboembolism (ASx but high risk of DVT)
STE II III aVF. Where is the STEMI?
RCA > inferior wall (RHF w/ JVD, hypOtn)
Pressure like CP, STEMI w/ JVD+, hypotension. Which vessel & part of the heart is affected?
RCA, inferior. (leads II III aVF)
Flash pulmonary edema, hypoxia, severe hypOtn, JVD+. Dx?
bilateral RAS
Massive proteinuria, lipiduria, hyperlipidemia, edema. Dx?
nephrotic syndrome (MCD, FSGN, membranous, amyloidosis, DM)
Young man w/ varicocele & small testis. Tx?
Gonadal vein ligation (note: Tx in elderly who do not desire more children is scrotal support & NSAIDs)
Which side is varicocele usually on?
LEFT (L gonadal v enters renal v at a right angle, which may be compressed by SMA & aorta > valve incompetence, retrograde flow & venous dilation)
R-sided varicocele. Tx?
Consider RCC compressing vena cava or thrombus. (Varicocele most commonly affects L d/t the way it enters the renal v at a right angle) Note: R gonandal vein empties straight into vena cava)
2wks S/P coronary arteriography for angina, pt develops livedo reticulitis & dusky looking toes. UA: WBC+, RBC+, eos+, mild proteinuria. Dx?
Renal atheroembolic disease (s/p arteriography, angioplasty, surg).
2wks S/P CABG pt develops livedo reticulitis. UA: WBC+, RBC+, eos+, mild proteinuria. Dx
Renal atheroembolic disease (s/p arteriography, angioplasty, surg). Also commonly cyanotic/gangrenous toes w/ intact pulses.
Renal atheroembolic disease sp arteriography. What do you expect on UA?
RBC+, WBC+, eos+, mild proteinuria
Mild uncomplicated BPH suspected. Tx?
Behavioral (start meds if mod/severe sx, last resport TURP)
BPH sx, UA showing hematuria. NSIM?
Cystoscopy. Eval for bladder CA.
Mild uncomplicated BPH suspected. Which labs for w/u?
UA (hematuria-bladder CA), BMP (obstructive renal injury), BPH
BPH patient on chronic finasteride/tamsulosin develops obstructive uropathy/hydronephrosis. Tx?
Consider TURP (trans-urethral resection of the prostate)
RF for pseudogout.
Hypothyroidism, hemochromatosis, renal osteodystrophy, hyperPTH (or recent thyroidectomy)
Most commonly affected joint(s) in pseudogout?
*KNEE, also wrist/ankle
Needle shaped negatively birefringent, WBC 2-100k. Dx?
Gout
XR showing subcortical bone cysts w/ bony erosions. Which type of arthritis?
Gouty arthritis (pseudogout shows chondrocalcinosis)
XR w/ chondrocalcinosis: Is this gout or pseudogout?
Pseudogout (gouty: XR showing subcortical bone cysts w/ bony erosions)
Severe hyperPTH w/ bone pain and salt and pepper appearance of the skull. Dx?
Osteitis fibrosa cystica. (Also- Subperiosteal bone resorp in middle phalanges, tapering of distal clavicles, brown tumors in long bones)
Salt & pepper skull appearance, subperiosteal bone resorp in middle phalanges, tapering of distal clavicles, brown tumors in long bones. What do you expect in the labs?
Severe hyper PTH (Dx: osteitis fibrosa cystica)
Septic arthritis has >__k WBC
> 100k
Tx butterfly rash (SLE)
Sun avoidance, topical GCS (if persistent- antimalarials)
Common infection causing erythema multiforme?
HSV
Patient w/ prostate CA resection is on leuprolide. Which ppx do you recommend?
Ca & vitD supplements to prevent osteoporosis per androgen deprivation therapy
List some causes of acquired hypogonadism in men.
Cirrhosis, HIV, CKD, mumps, local radiation, surgical orchiectomy, leuprolide (androgen deprivation)
Which men should be screened for osteoporosis?
On chronic GCS, androgen deprivation or those w/ low trauma fractures
How to DDx primary vs secondary Reynauds.
Nail bed capillaroscopy (fine coiling in primary/normal VS disorganized coils w/ microhemorrhaging)
Tx of patient w/ Reynauds with digital ulceration
CCB & Aspirin
Which is assd w/ Secondary Reynauds:
1) women <30
2) neg ANA/ESR
3) digital ulcers
4) normal nail fold capillary exam
3) digital ulcers (the rest are primary)
Which is assd w/ PRIMARY Reynauds:
1) men, >40
2) tissue injury/digital ulcers
3) abnormal nail fold capillary exam
4) neg ANA/ESR
4) neg ANA/ESR
> 45yo w/ sudden HTN, HLD, proteinuria, normal GFR, leg swelling after an URI. Dx?
MCD, Bx to confirm (effacement of podocyte foot processes, normal glom, no immune deposits). Note: not all pts have HTN, some pt also have AKI
MCC allergic interstitial nephritis (meds)
NSAIDs (also PNC or other abx)
2ks sp URTI, pt develops edema, hematuria, leukocyturia & HTN. Dx?
PSGN
Tx MCD
GCS
HD patient w/ elevated PTH & Ph, First line Tx?
(Dx secondary hyperparathyoidism) DIET (phos restriction <900mg/day). If still elevated add sevelamer or lanthanum. If PTH & Ca is still high, add cacimimetic (cincalcet) * only for HD patients
HD patient w/ elevated PTH, despite dietary interventions and phosphate binder. Phos <5.5, Ca <9.5. NSIM?
Add vitamin D or synthetic analog
Benefit of cinacalcet in uncontrolled secondary hyperPTH (ie ESRD pts)
Reduces need for parathyroidectomy and decreases fracture risk (MOA- increases sensitivity of parathyroid gland Ca-sensing receptors)
Calcimimetics should be avoided in secondary hyperPTH if which lab is low?
hypoCa (as their (MOA- increases sensitivity of parathyroid gland Ca-sensing receptors, and reduces secretion of pTH_
25yo M w/ hip/back pain, shoulder pain & unilateral eye pain/photophobia/blurry vision. Dx?
Consider Ankylosing spondylitis. (PE: limited chest expansion, limited lumbar spine motion in sagittal/frontal, enesthisis ahiclles/plantar fascia/ +/- fever/chills, fatigue, weight loss)
Tx pulm impairment in ankylosing spondylitis
pulm rehab, NPPV
30yo M w/ increased arm span, aortic root dilation, ectopia lentis, MVP or PTX. Dx?
Marfans
Drop arm tests helps w/ Dx of which condition?
Supraspinatus (unable to lower arm from a fully abducted position to a smooth controlled manner)
> 50, bilateral shoulder/hip pain w/ morning stiffness, fever, malaise, weight loss. Decreased ROM shoulder, neck, hips. High ESR/CRP. Normocytic anemia. Dx?
Polymyalgia rheumatica (~20% may have normal studies). Tx. GCS
Felty Syndrome:
RA, neutropenia, splenomegaly. ***seen in patients w/ RA >10y
Dx tests Felty Syndrome:
anti-CCP & RF. ESR >85. periph smear/BMB to r/o other causes of neutropenia (Tx MTX/DMARDs, G-CSF can be used w/ patient who have life-threatening infections
Pt w/ IBD w/ abrupt erythematous plaques w/ pseudoblistering plaques of the face, neck, chest, extrem. Preceded by flu-like sx & WBC. Dx?
Sweets (also assc w/ malignancy)
AIN common cause (meds)
Abx, NSAIDs, PPIs (meds account for >75% cases. Also: SLE, sjogrens, Sarcoidosis)
AIDS pt develops AKI, arthralgia, malaise. UA: WBC, WBC casts, mild RBC/proteinuria, peripheral eosinophilia. Dx?
Consider AIN (infections: legionella, TB, CMV)
Normal get up and go test <___s
<15s
A rise in Cr ~__% from baseline should not warrant discontinuing ACE/ARB for DM nephropathy.
30-35%
NSAID contraindications: PUD, AKI/CKD & ____
HF (Na retention, edema)
Step Tx gout.
1) NSAIDs 2) If intolerance to NSAID: colchicine 3) if intolerance to NSAID & colchicine: GCS injections (if 1-2 joints)
CKD patient w/ gout flare in knee. Tx?
GCS injection (d/t contraindication to NSAID & colchicine)
AE colchicine
D, abd cramps, neuromyopathy
Which is NOT a Tx for acute gout? ** NSAID ** febuxostat ** GCS INJ ** GCS PO *** colchicine
febuxostat
Why is colchicine not a first line agent for acute gout in CKD?
decreased renal clearance can cause significant neuropathy
Major AE of hydroxychloroquine?
retinopathy
Which DMARD has the following AE effects? Infection, demyelination, CHF, CA
TNF inhibitors
Previous smoker has signs of clubbing. NSIM?
CXR (eval for non- small cell lung CA, per possible hypertrophic osteoarthropathy
Which is NOT known for AE: hepatoxicity & cytopenia? ** infliximab ** MTX ** leflunomide **sulfasalazine
infliximab (Infection, demyelination, CHF, CA )
Smoking, clubbing, periosteal inflammation. Dx?
non- small cell lung CA. (Dx hypertrophic osteoarthropathy)
Previous smoker has signs of clubbing. NSIM?
CXR (eval for non- small cell lung CA, per possible hypertrophic osteoarthropathy
MCC hypertrophic osteoarthropathy
intrathoracic CA (non- small cell lung CA)
Knee pain. Arthrocentesis: WBC 200-2000, PMNs 25%. Dx?
non-inflammatory OA (note in normal fluid WBC <200)
Knee pain. WBC 2k-100k, PMN >50%. Dx?
Inflammatory (crystals, RA)
Knee pain. 50k-150k, PMN >80%. Dx?
Septic joint
Knee pain. On aspiration- 120k WBC. Dx?
Septic joint (inflammatory arthropathies <100k)
Chondrocalcinosis (calcium deposits in the cartilage on AR) is suggestive of:
pseudogout (calcium pyrophosphate dihydrate)
OA WBC level on arthrocentesis is < ___
<2000
Elderly w/ RA develops slowly progressive spastic quadriparesis, hyperreflexia, Babinski. Dx?
Consider RA cervical myelopathy
Long term RA develops increased reflexes and muscle weakness. NSIM?
MRI to eval for cervical myelopathy (Tx surgery for spinal stabilization if sx are severe.
30yo in ED for asthma exacerbation which resolves with Tx. Which meds do you discharge her with?
GCS x 5-10 days **AND step up asthma Tx x 2-4 weeks.
Which is NOT a cause of pulsatile tinnitus:
- dural AVF ***
- paraganglioma ***
- inner ear muscle ** spasms **
- TMJ ***
- eustachian tube dysfunction
TMJ
Non-pulsatile tinnitus do NOT include:
- paraganglioma
- TMJ
- ototoxic meds
- presbycusis
- otosclerosis
- vestibular schwannoma
- paraganglioma
Elderly w/ constant tinnitus. NSIM?
audiometry testing
Acute sinusitis w/ diplopia. NSIM?
CT
Sinusitis w/ persistent sx despite abx. NSIM?
CT
Sinusitis Tx (first line)
Amoxi-Clav (for PNC allergy- FQ: levo/moxifloxacin)
When to Tx sinusitis w/ abx?
Sx >10 days OR fever >102 OR purulent nasal discharge/facial pain OR worsening sx >5 days after initially improving viral infection
Tx bactrerial sinusitis in PNC allergic patient
FQ- levo/moxifloxacin
Elderly M is diagnosed w/ REM behavior disorder after acting out his dreams. Which condition is he at risk of developing?
Parkinsons or dementia w/ Lewy Bodies. Tx: melatonin
Pt diagnosed w/ REM behavior disorder after acting out his dreams. First line Tx?
1st line: melatonin. 2nd line: low dose clonazepam
Pt <40yo dx w/ REM behavior disorder after acting out his dreams. Most commonly associated meds?
SSRI, TCA, venlafaxine
Weakly GP rod shaped bacteria: ulceration, pyoderma, cellulitis, nodules, subcut abscess. Pathogen?
Nocardia
Severe immunocompromise. Fever, skin lesions, PNA +/- cavitations. BCx grow mold (fungemia). Dx?
Fusarium moniliforme (2nd MC pathogenic mold)
Which patients are at risk of Fusarium moniliforme infection?
Severe immunocompromise. Fever, skin lesions, pulm d. BCx grow mold. Skin Bx+. Tx: amphotericin B +/- voriconazole
T/F Aspergillus fumigatus is diagnosed w/ BCx.
FALSE: it does not usually appear on BCx
RF for vibrio vulnificus
Cirrhosis, hemochromatosis, DM, CKD, hepatitis ***these patients should AVOID eating or handling raw shellfish
Other than pts w/ anaphylaxis/HS to shellfish, who should AVOID eating/handling them?
Cirrhosis, hemochromatosis, DM, CKD, hepatitis (high risk of infection) Sx: wound infection, sepsis without defined infection source, gastroenteritis w/ bullous lesions
Sx: wound infection, sepsis without defined infection source, gastroenteritis w/ bullous lesions. BCx w/ curved GN rods. Dx?
Vibrio vulnificus
Rapid onset of N/V w/in 2-6h ingestion. What did the patient eat?
fried rice (B cereus)
Tx Strep pharyngitis?
PNC or amox
Fever, ant cervical LAD, tonsillar exudates, no cough. NSIM?
Rapid strep test (Those 4 sx make up the centor criteria, if all 4 are present you may Tx empirically)
Fever, ant cervical LAD, tonsillar exudates, no cough. TREATMENT?
PNC or amox (if PNC allergy **cephalexin, cefadroxil or macrolide)
Tx strep throat for PNC allergic patient?
cephalexin or macrolides (erythromycin, azith/clariromycin)
Weakness in arms/legs, pain in neck w/ radiculopathy, paresthesias in arms, urinary urgency/frequency/retention. Spastic gait, reduced vibratory/pain sensation & UMN signs in legs. TREATMENT?
(Dx Cervical spondylotic myelopathy) Tx: Conservative w/ cervical immobilization. Surgical decompression if failed conservative tx, severe myelopathy/ progressive deficits or acute deterioration w/ cord compression)
ALS: Lower extremities have LMN or UMN signs?
LMN (note cervical spondylotic myelopathy has UMN signs in legs, hwr LMN signs in arms)
Weakness in arms/legs, pain in neck w/ radiculopathy, paresthesias in arms, urinary urgency/frequency/retention. Spastic gait, reduced vibratory/pain sensation & UMN signs in legs. Dx?
Cervical spondylotic myelopathy (2/2 disc herniation, osteophytes, hypertrophy of the posterior longitudinal ligament»_space;> spinal stenosis, cord compression or ischemia)
Weakness in arms/legs, pain in neck w/ radiculopathy, paresthesias in arms, urinary urgency/frequency/retention. Spastic gait, reduced vibratory/pain sensation & UMN signs in legs. TREATMENT?
(Dx Cervical spondylotic myelopathy) Tx: Conservative w/ cervical immobilization. Surgical decompression if failed conservative tx, severe myelopathy/ progressive deficits or acute deterioration w/ cord compression)
DDX: ALS vs Cervical spondylotic myelopathy
EMG (denervation in ALS)
GBS: hypER or hypOreflexia?
hypO
Gait issue, urinary sx, cognitive issues. Dx?
NPH
Transverse myelitis- Dx work up?
Spinal MRI & CSF. (young population)
Cervical spondylotic myelopathy- does it present w/ UMN or LMN signs?
Both. (LMN in arms, UMN in legs)
How long can a peripheral catheter (ie femoral line) stay in w/ sterile VS non-sterile technique?
sterile 48-72h. non-sterile: 24-48h
Which has a HIGHER rate of infection: IJ vs SC central line?
IJ
Recommendation to reduce central line infection?
daily chlorhexidine bath, use of abx-impregnanted cath, fewer ports, sterile handling, NO ppx abx, NO routine replacement,
Exam DDX for foot drop etiology.
Common peroneal injury (weakness in foot dorsiflexion, foot eversion & toe extension). L5 radiculopathy (“” PLUS: weakness with *inversion & leg abduction, may be assd w/ radiculopathy)
Foot drop w/ weakness in foot dorsiflexion, foot eversion & toe extension, as well as weakness with foot *inversion & leg abduction. Etiology?
L5 radiculopathy
MG- first initial test?
AChR Ab (if neg > muscle specific tyrosine kinase receptor AB, if still neg > EMG). If +, start Pyridostigmine, check TSH & CT r/o thymoma
High clinical suspicion for MG. AChR Ab NEG. NSIM?
muscle specific tyrosine kinase receptor AB, if still neg > EMG/NCT to confirm fatiguability
MG suspected. AChR Ab+. NSIM?
start Tx, check TSH & CT r/o thymoma
First line tx for MG?
Pyridostigmine (For crisis: GCS PLUS plasmapheresis or IVIg. Other second line agents: GCS, azathioprine, mycophenoate mofetil, cyclosporine)
MG Crisis Tx?
GCS PLUS plasmapheresis or IVIg.
Positive muscle specific tyrosine kinase receptor AB (MuSK), Dx?
MG (note: first test is AChR Ab, hwr if negative get MuSK)
DDX MG vs Horners?
MG has pupillary response
DDX MG vs Bells.
Extraocular & palate involvement in MG
CN3 palsy: pupil sparing vs pupil non-sparing etiologies?
SPARING: microvascular ischemia ie DM (ptosis, down/out, normal size/reactive pupil). NON-SPARING: aneurysm/tumor (Early- dilated pupil w/ loss of accommo. Later- Ptosis & opthalmoplegia (down/out) Dx & etiology)
Early- dilated pupil w/ loss of accommo. Later- Ptosis & opthalmoplegia ( down/out) Dx & etiology?
CN3 palsy 2/2 aneurysms or mass effect/tumor. (DDX: if it was normal size and reactive, then down/out think DM opthalmoplegia)
Early- dilated pupil w/ loss of accommo. Later- Ptosis & opthalmoplegia (down/out). NSIM?
MRA or CTA IMMEDJET!! CN3 palsy 2/2 aneurysms.
When to get an MRA/CTA for CN palsy w/ pupil sparing?
If no vasc RF or sx fail to improve in 6-12wks)
Neisseria meningitis PEP indications?
> 8h contact (plane, household contacts, child care workers) or direct resp/oral contact (kissing, mouth-mouth resuscitation, intubation/vent management). Tx: rifampin, cipro or ceftriaxone.
PEP for close contact of Neisseria meningitis?
rifampin, cipro or ceftriaxone. ***required even if hx vaccine (Indications: >8h contact, plane, household contacts, child care workers OR direct resp/oral contact: kissing, mouth-mouth resuscitation, intubation/vent management)
Who does NOT need Neisseria meningitis PEP?
>8h contact, plane, household contacts, child care workers, performer of LP, kissing, mouth-mouth resuscitation, intubation/vent management
performer of LP
Which is NOT first line PEP for Neisseria meningitidis? doxycycline, rifampin, cipro, ceftriaxone.
Doxy
Tenosynovitis, dermatitis, migratory arthralgias. Dx?
Disseminated gonococcal infection (or can just present w/ purulent monoarthritis)
Purulent monoarthritis. Work up?
N.gonorrhea in urine, cervical/urethral swab. **Cx blood/synovial fluid is less sensitive (note: may present as purulent monoarthritis OR tenosynovitis, dermatitis, migratory arthralgias)
MC joints affected w/ dissem gonococcal infection?
knees, wrists, ankles
Tenosynovitis, dermatitis, migratory arthralgias. Which is LEAST sensitive for Dx? Urine NAAT, urethral/cervical swab, pharyngeal swab, rectal swab, synovial fluid
synovial fluid (may have 50k WBC but commonly <10k. Note: BCx more likely to be positive in classic triad but may be neg.
Recurrent disseminated gonocorrhea. What should you eval for?
complement deficiencies
Tx disseminated gonorrhea
Ceftriaxone IM (may switch to PO cefixime when sx improve). Tx: 7-14 days or longer if septic arthritis. **also Tx for possible Chlamydia w/ azithro/doxy (and test for HIV & syphilis)
Tx chlamydia
azithro (1g then 500mg x 2), doxy (x 7 d)
AMS, autonomic dysreg (diaphoresis, HTN, tachy, hyperthermia, V/D), neuromuscular hyperactivity (ie hyperreflexia, tremor, rigidity). TREATMENT?
benzo, supportive (5HT syndrome) **if supportive measures fail: cyproheptadine
Tx 5HT syndrome
benzo, supportive. **if supportive measures fail: cyproheptadine. If fever >41.1 sedate/paralyze/intubate
AMS, autonomic dysreg (diaphoresis, HTN, tachy, hyperthermia, V/D), neuromuscular hyperactivity (ie hyperreflexia, tremor, rigidity). Tx?
benzo, supportive (5HT syndrome) **if supportive measures fail: cyproheptadine
Which abx can cause 5HT syndrome?
linezolid
Features of 5HT syndrome?
AMS, autonomic dysreg (diaphoresis, HTN, tachy, hyperthermia, V/D), neuromuscular hyperactivity.
Patient w/ 5HT syndrome & fever 41.2F. NSIM?
If fever >41.1 sedate/paralyze/intubate. Benzos, supportive.
AMS, autonomic dysreg (diaphoresis, HTN, tachy, hyperthermia, V/D), neuromuscular hyperactivity (ie hyperreflexia, tremor, rigidity). How to confirm DX?
Clinical/Hx- 5HT syndrome (if unclear, may order CT to eval for IC bleed/mass)
Cyproheptadine use?
If benzo/supportive measures fail for 5HT syndrome
RF for CMV eye disease?
Most commonly in HIV
Tubulointerstitial nephritis & ureteric stenosis in transplant pt. Pathogen?
BK virus
Time frame in which transplant may develop HSV (since transplant)
first few months *same goes for CMV)
Which transplant drug causes the following AE: Acute nephro-tox, HTN, neuro-tox & glucose intolerance.
tacrolimus
Pathogen which may cause the following in an immunosuppressed pt: LAD, HSM, pneumonitis, myocarditis, brain abscess, chorioretinitis
Toxoplasma
Tx of CMV in transplant patient.
decrease immunosuppressants & give gancivclovir for more severe disease
Drug-induced Parkinsonism. Tx?
Switch antipsych (better agents: quetiapine & clozapine)
CMV Tx
Ganciclovir (valganciclovir for non-severe disease)
Which atypical antipsych and other med can commonly cause drug-induced Parkinsonism?
risperidone, metoclopramide
Pramipexole use?
Parkinsons d
Anti-psychs w/ low risk of Parkinsonism?
quetiapine & clozapine
Post-herpetic neuralgia Tx?
First line: TCA (hwr if elderly- lyrica or gabapentin) **note: post-herpetic neuralgia dx is given w/ sx >4 months- if less: acute/subacute neuritis which is managed w/ Tylenol, NSAIDs, ~opioids
Trigeminal neuralgia Tx
Carbamazepine
Tx of dermatome-neuralgia for the following: Occurring w/in 4 months of infection VS >4 months.
<4 months: acute/subacute neuritis which is managed w/ Tylenol, NSAIDs, ~opioids. >4 months: post-herpetic neuralgia managed w/ TCA (or if elderly gabapentin/lyriga)
25yo F w/ monocular vision loss, eye pain w/ movement, “washed out” color vision & afferent pupillary defect. Dx?
Likely MS optic neuritis (immune related demyelination). Dx MRI brain/orbit, Tx IV GCS
25yo F w/ monocular vision loss, eye pain w/ movement, “washed out” color vision & afferent pupillary defect. NSIM?
Dx MRI brain/orbit, Tx IV GCS (MS optic neuritis ) ***note: may be isolated presentation hwr 20% risk of conversion to MS
HA improved when sitting, tinnitus & visual loss (horizontal diplopia) in obese F. NSIM?
LP check for opening pressure >200, r/o IIH. Fundoscopy w/ papilledema. MRI to r/o other causes- hydrocephalus, venous sinus thrombosis, mets.
Positional HA & visual loss in obese F. NSIM?
LP check for opening pressure, r/o IIH. papilledema on fundoscopy.
40yo M w/ anosmia, excessive daytime somnolence, constipation, mood sx & REM behavior disorder. Prognosis?
Signs of early Parkinsons
REM behavior disorder may be signs for developing which conditions in the future?
Lewy body dementia or Parkinsons
Opening pressure in IIH > ___mmH2O
200
Tx IIH
Acetazolamide & weight loss (may need addition of loops, surgery as last resort)
Biggest risk of untreated IIH
blindness per optic nerve injury
Horizontal diplopia and HA in obese F. Dx work up?
IIH: LP check for opening pressure >200, r/o IIH. Fundoscopy w/ papilledema. MRI to r/o other causes- hydrocephalus, venous sinus thrombosis, mets
Tinnitus w/ ear fullness, progressive SNHL & vertigo. Dx?
Mennieres (endolymphatic hydrops)
Endolymphatic hydrops AKA
Mennieres
Gradual painless vision loss. Tonometry w/ elevated IOP. Increased disc to cup ratio. Dx?
Likely open angle glaucoma
HA worsened when laying flat. Dx?
IIH
T/F papilledema on fundoscopy suggest open angle glaucoma
FALSE (hwr may be seen in closed angle glaucoma d/t high intraoccular pressures)
Back pain followed by progressive spastic lower extremity paresis, decrease tendon reflexes (early, then increased late), worse at night & an epidural mass w/ spinal cord edema. Dx?
Neoplastic epidural spinal cord compression. Tx IV GCS. Spinal surgery & radiation increases the likelihood pt will regain normal ambulation.
Metastatic prostate CA Tx?
Leuprolide (if resistent, may give chemo), bisphosphonates to tx bone pain & prevent pathologic fractures
Prostate CA w/ ack pain followed by progressive spastic lower extremity paresis, decrease tendon reflexes (early, then increased late), worse at night & an epidural mass w/ spinal cord edema. NSIM?
STAT surg, heme/onc consul. STAT MRI spine. STAT IV GCS
GBS Tx?
Plasma exchange or IVIg (GCS NOT EFFECTIVE)
Other than B.cereus, Which other two pathogens commonly cause vomiting predominant foodborne illness?
S.aureus, Norwalk
GBS findings on CSF or MRI spine?
CSF: elevated protein only (takes one week to develop). MRI: normal or enhancement of anterior nerve roots/cauda equina
Which is NOT a presenting sx of GBS? back pain** absent reflexes **dysarthria **sluggish pupils ** autonomic dysfunc (palpitations, diaphoresis, dyspnea)
They are all presenting signs
Which does NOT present w/ watery D? Enterobacter, C.perfingens, Enteric viruses, Cryptosporidium, Intestinal tapeworms
Enterobacter (inflammatory)
Foodborne illness > fever, arthralgias.
Brucellosis.
Foodborne illness > cellulitus, bullae, sepsis
Vibrio vulnificus
Foodborne illness > descending paralysis
Botulism
Which inflammatory D is NOT self limited? Salmonella, Campy, Shiga-toxin producing Ecoli, Shigella, Enterobacter, Vibro parahemolyticus, Yersinia.
Shiga-toxin producing Ecoli (EHEC)- 10-15% > HUS
MCC non-inflammatory D (2)
Clostridium perfringens, ETEC
Broca aphasia is classic sx of CVA in _____ artery
MCA
CVA w/ pure motor hemiparesis: Localization?
1) posterior limb internal capsule
2) posterior thalamus
3) basis pontis (pons)
1) posterior limb internal capsule (also may include ataxis hemiparesis)
CVA w/ ataxic hemiparesis: Localization?
1) posterior limb internal capsule
2) posterior thalamus
3) basis pontis (pons)
1) posterior limb internal capsule (may also include pure motor hemiparesis)
CVA w/ pure sensory sx: Localization?
1) posterior limb internal capsule
2) posterior thalamus
3) basis pontis (pons)
2) posterior thalamus (no motor deficits)
CVA w/ dysarthria & clumsy hand: Localization?
1) posterior limb internal capsule
2) posterior thalamus
3) basis pontis (pons)
3) basis pontis (pons)
aquaphorin-4 Abs. Dx?
Neuromyelitis optica (previously thought to be part of MS but since discovery of aquaphotin-4 Abs, now considered distinct)
Prophylactic meds for HSV?
Valacyclovir QD (best studied), May use acyclovir if cost is an issue
Pt suspected to have HSV first time. NSIM?
Serologic testing if never previously obtained. Partner susceptibility testing for HSV1/HSV2. Tx valacyclovir QD (or acyclovir)
T/F Condom use helps prevent F > M HSV transmission.
FALSE (somewhat effective in M > F transmission however)
T/F condom use recommended to prevent HSV transmission M>F during active outbreak.
FALSE- effective somewhat, hwr abstinence recommended for active outbreak
RF for cellulitis
Immunosupp (DM, HIV, chronic GCS), dry skin, chronic inflamm (eczema, radiation), chronic wounds (pressure ulcer, venous ulcer), tinea pedis, venous insuff, CKD, HF, post surg lymphedema, obesity.
Medical indications for HAV vaccine?
chronic liver d, clotting factor deficiency, exposure (outbreak or infected close contact) *** if exposure, PEP: HAV vax or Ig, hwr vax is more avail and easier to admin.
Lifestyle indications for HAV vaccine?
MSM, illicit drugs, travel to endemic country, lab work w/ HAV, close contact w/ international adoptee
Syphilis Tx
1(primary/secondary/early latent) VS 2(late latent/tertiary) VS 3***neurosyphilis.
1- PNC IM x 1 (or doxy x 14), 2- PNC IM x3/qWk (or doxy x 28d), 3- PNC IV 10-14d (or ceftriaxone IV x 14d)
Syphilis w/ painless chancre. Tx?
PNC IM x 1 (or doxy x 14)
Syphilis w/ diffuse rash. Tx?
PNC IM x 1 (or doxy x 14)
Syphilis w/ CV or gummata. Tx?
PNC IM x3/qWk (or doxy x 28d)
Syphilis- ASx w/ unknown duration. Tx?
PNC IM x3/qWk (or doxy x 28d) as it is managed as late latent since we dont know if duration <1y
AE of sildanefil (other than priapism or hypotension)
Ocular: blue discoloration of vision (as a PDE-5 inhibitor it interacts w/ PDE-6 which is required for cones/rods in retina), non-arteritic anterior ischemic neuropathy. Other: flushing, HA, HL
Blue discoloration of vision is an possible adverse effect of which medication in high doses?
sildanefil
Pt w/ mild cognitive impairment (MMSE 20-25) inquiring about how to prevent progression to dementia.
Moderate intensity exercise and cognitively stimulating activities/social engagement. (NO evidence that memantine, vir E or other supplements prevent dementia, hwr vit E may slow progression once disease is established)
T/F memantine can slow progression to developing dementia in patients w/ mild cognitive impairment (MMSE 20-25).
FALSE. Moderate intensity exercise and cognitively stimulating activities/social engagement. (NO evidence that memantine, vir E or other supplements prevent dementia, hwr vit E may slow progression once disease is established)
Which type of dementia: insidious short term memory loss, language deficits/spatial disorientation, later- personality changes.
Alzheimer
Which type of dementia: Apathy, disinhibition, compulsive behavior.
Frontotemporal (atrophy on neuroimaging)
Which type of dementia: REM behavior disorder, fluctuating cognition
Dementia w/ Lewy bodies (also hallucinations/parkinsonism)
Sx: REM behavior disorder, fluctuating cognition, Parkinsonism, hallucinations. Tx Lewy Body Dementia
AChE inhibitors for cognitive impairment, melatonin for REM, carbi-levodopa for Parkinsonism. Consider v low dose second gen antipsych for functionally impairing hallucinations/delusions.
Tx Lewy Body Dementia
AChE inhibitors for cognitive impairment, melatonin for REM, carbi-levodopa for Parkinsonism. Consider v low dose second gen antipsych for functionally impairing hallucinations/delusions.
30yo w/ multiple ovoid shaped peri-ventricular white matter lesions on brain MRI w/ gadolimium. Dx?
MS
Acute onset of vision loss, halos around lights, HA, severe eye pain, N/V. TREATMENT?
STAT optho consult: Topical Pilocarpine or timolol to lower IOP, w/ IV acetazolamide. If ineffective - anterior chamber paracentesis.
Eye pain, central scotoma, color vision loss & loss of vistal acuity in 40yo F. Tx?
IV methylprednisone (for optic neuritis, r/o MS)
Fever/chills, myalgia, diffuse rash s/p Tx syphilis. TREATMENT?
Supportive- IVF, acetaminophen, NSAIDs. Self limiting w/in 48h (Jarisch Herxheimer rxn)
Fever/chills & myalgia s/p Tx leptospirosis. TREATMENT?
Supportive- IVF, acetaminophen, NSAIDs. Self limiting w/in 48h (Jarisch Herxheimer rxn s/p spirochete Tx)
When is doxycycline used for syphilis?
If severe PNC allergy
Pt managed w/ tPA for acute CVA. What is the following AC plan.
Obtain CT in 24h to ensure no IC hemorrhage, then start low dose LMWH and ASA
T/F ALS can have sensory deficits
TRUE in 1/3 of patients. (also has both UMN (hyperreflexia/Babinski) and LMN signs (atrophy/hyporeflexia)
Other than GI infection, what else is assd w/ GBS?
HIV, vaccinations
Progressive muscle weakness, distal sensory loss, absent reflexes developing >8wks. Periph nerve EMG showing peripheral demyelination. Dx?
Chronic inflammatory demyelinating polyradiculopathy (DDX MS: which affects CNS ie brain/spinal cord)
Pt on valproic acid develops encephalopathy. Which test do you order?
ammonia level (valproic acid induced hyperammonemic encephalopathy). Tx lactulose, L-carnitine and drug d/c
Tx valproic acid induced hyperammonemic encephalopathy?
lactulose, L-carnitine and d/c valproic acid
RF for developing lactic acidosis 2/2 metformin?
CKD, liver disease or acute OD. Sx: GI sx then AMS, SOB, hypOtn. HAGMA on labs.
DM pt on metrformin w/ CKD develops GI sx then AMS, SOB, hypOtn. HAGMA on labs. Dx?
Lactic acidosis
Tx migraines in pregnancy.
Hydration, massage, Ice packs. Tylenol +/- metoclopramide for nausea. If refractory NSAIDs may be considered in 2nd trimester only, ~~~triptants (risk of ureteroplacental vasoconstriction, increased uterotonic activity, premie, low birth weight)
Metoclopramide use > dystonia. Tx?
stop drug. Anti-cholinergics. Benztropine or trihexphenidyl or benadryl
Hx CVA w/ worsening Sx in setting of UTI. INR wnl. NSIM?
Likely exacerbation of prior neuro deficits 2/2 infection. Diffusion weighted MRI brain if unclear
1st line for listeria in immunocompromised patient?
ampicillin
1st line Tx of frequent restless leg syndrome if ferritin wnl.
alpha2 delta Ca channel ligands (gabapentin, pregabailin). If mild/infrequent may use carbo/levo PRN. Otherwise leg massage, warm/cold compress, sleep hygiene, reg exercise, limit EtOH/caffeine. (note: D agonists- pramipexole/ropinerole NOT preferred ***paradoxical sx w/ long term use)
1st line Tx of frequent restless leg syndrome if ferritin wnl.
alpha2 delta Ca channel ligands (gabapentin, pregabailin). Otherwise leg massage, warm/cold compress, sleep hygiene, reg exercise. (note: D agonists- pramipexole/ropinerole NOT preferred)
Tx restless leg syndrome for mild/intermittent VS severe/frequent sx.
Mild/infrequent- carbo/levo PRN. Frequent/severe- alpha2 delta Ca channel ligands (gabapentin, pregabailin).
RF for RLS
CKD, IDA, uremia, DM, MS, Parkinsons, Meds (anti-depressants, anti-psych, anti-emetics)
Non-pharmologic Tx RLS:
leg massage, warm/cold compress, sleep hygiene, reg exercise, limit EtOH/caffeine.
MAC Tx
Combo: rifampin, clarithro, ethambutol (RICLET)
MAC- which patients are at risk?
Pulm d (CF, antitrypsin def). SpCx x 2 needed for dx. If first Cx is positive and 2nd is neg > BAL.
1st SpCx is positive, 2nd is negative. NSIM?
BAL (note: 2 positive Cx are needed for Dx)
cANCA
Wegeners
Ipsilateral CN III palsy, contralat lower face weakness, hemiplegoa. Where is the stroke?
1) Midbrain **
2) Lateral medulla *
3) Medial medulla
4) Cerebellar ***
1) Midbrain (CN III oculomotor, CN IV abducens)
Ipsilateral CN III palsy, contralat lower face weakness, hemiplegoa. Where is the stroke?
1) Midbrain **
2) Lateral medulla *
3) Medial medulla
4) Cerebellar ***
1) Midbrain
Ipsilateral TONGUE weakness, contralat hemiplegia, decreased positional sense. Where is the stroke?
1) Midbrain **
2) Lateral medulla *
3) Medial medulla
4) Cerebellar ***
3) Medial medulla***
Ipsilateral TONGUE weakness, contralat hemiplegia, decreased positional sense. Where is the stroke?
1) Midbrain **
2) Lateral medulla *
3) Medial medulla
4) Cerebellar ***
3) Medial medulla***
Nystagmus, ataxia, N/V. Where is the stroke?
1) Midbrain **
2) Lateral medulla *
3) Medial medulla
4) Cerebellar ***
4) Cerebellar
CVA affecting the trigeminal, abducens, facial & vestibulochochlear. Location?
1) Midbrain **
2) Medulla
3) Pons
4) Cerebellar **
3) Pons
CVA in posterior limb of internal capsule Sx
(aka lacunar stroke) Contralateral hemiparesiss, sensory loss occasional weakness,
Where region is affected by lacunar CVA
posterior limb of internal capsule
RF for severe babesiosis?
s/p splenectomy > CHF, ARDS, DIC
Pt w/ blood smear showing maltese crosses develops ARDS, DIC. What do expect in their Hx?
s/p splenectomy (At risk for Babesiosis, which causes severe disease in these patients: CHF, ARDS, DIC)
Tx for meningiococcal meningitis & PEP for close contacts
Tx: Ceftriaxone, Close contacts: rifampin, cipro, ceftriaxone. (note: precautions= DROPLET)
Type of precautions for or meningiococcal meningitis?
DROPLET if w/in 6ft, for 24h after starting abx (PPx for close contacts: rifampin, cipro, ceftriaxone.
25yo w/ severe myalgias, followed by petechial hemorrhagic rash, fever, meningeal signs. Tx?
(Dx Meningococcal meningitis.) Tx: Ceftriaxone, Close contacts: rifampin, cipro, ceftriaxone. (note: precautions= DROPLET)
Return from Central America. High fever, severe polyarthralgia, HA, conjunctivitis, myalgia, maculopapular rash. Labs: low WBC, PLT, high LFTs). Tx?
Supportive for Chukungunya fever (often chronic arthralgia, may be managed w/ MTX)
Rodent exposure. Cardio/pulm sx, hemorrhagic fever, AKI w/in 2-3 wks rodent exposure. Dx?
Hantavirus
Antipsychotics cause increased risk for which infection in elderly pts?
CAP, unknown mech (also increased mortality)
Tick should be attached >__h to be concerning
36h (or if it was engorged) Note: risk of Lyme occurs s/p 48-72h attachment.
Connecticuit lactating pt w/ attached ixodes tick x 3 days. NSIM?
Observe & rapid Tx if erythema migrans appears. Note: lactation/pregnancy is a contraindication to doxycycline 200mg x 1 which is given otherwise)
ASx Connecticuit M w/ attached, engorged ixodes tick x 3 days. NSIM?
doxycycline 200mg x 1
Patient presents w/ erythema migrans after tick bite. NSIM?
Tx Lyme (do not need serology). Doxycycline, Cefuroxime, Amoxicillin.
How long after infection does it take for IgM for Lyme to appear in the blood?
2-6wks (check w/ ELISA > Western Blot)
Multiple lesions at the junction of the white and grey matter. Dx?
non-seminomatous germ cell lesions
Hispanic 40yo M w/ chronic HA has seizure. CT shows 5-20 cysts w/ enhancement/edema > calcified granulomas. Tx?
(Dx Cystericosis) Tx: Albendazole or GCS. Note: Pt may be ASx for 3-5yrs prior to sx onset.
MS relapse VS pseudorelapse.
RELAPSE: New lesions or sx 2/2 inflammatory demyelination. PSEUDORELAPSE: worsening prior sx, no new lesions. 2/2 decreased conduction over previously damaged axons
Tx MS relapse VS pseudorelapse.
Relapse (New lesions or sx): high dose GCS, consider changing/adding DMARDs. Pseudorelapse (worsening old sx, no new lesions) Tx triggers- ie abx for infections and modify behavior: avoid heat.
Cluster HA Acute Tx?
100% O2 6-16L x 15 min. Or subcutaneous sumatriptan VS zolmitriptan nasal spray
Cluster HA PPX
Verapamil (best), Lithium, Topiramate
Best PPX Cluster HA vs Migraine.
CLUSTER: Verapamil (also topiramate, lithium)
MIGRAINE: Topiramate, Divalproex Na, TCA, Propanolol
PPX Migraines
Topiramate, TCA, Propanolol, Divalproex Na
Other than asthmatics, which patients should avoid propanolol for migrain ppx?
> 60yo, smokers
MCC periph neuropathy?
DM, EtOH
Work up for peripheral neuropathy?
glucose, B12, TSH, ANA, RPR, A1C, ESR, CBC, SPEP
Sensory ataxia, Romberg+, laciating pain & Argyll Robertson pupil. Dx?
Syphilis
25yo w/ unprovoked partial seizure. Tx?
Obtain MRI/EEG for first time seizure for risk stratification. If abnormal, indicates high risk of recurrence, warranting antiepileptics.
Acute Bells Palsy is likely 2/2 :
HSV reactivation. Tx: GCS +/- valacyclovir
Bells Palsy DDx:
HIV, Lyme, sarcoid, tumor, cholesteatoma, Sjogrens.
Tx acute Bells Palsy
Tx: GCS +/- valacyclovir
How sensitive is the rapid influenza test?
65% sensitive.
Specific indications for oselamivir/zanamivir?
w/in 48h flu symptoms OR ANYTIME w/ RF (<2, >65, COPD, CKD, CVS/neuro disorders, DM, HIV, immunosupp, preg, <19 on long term ASA, morbid obesity, native)
LV apical aneurysm is pathomnemonic for:
Chagas (Trypansoma cruzi late disease)
Phases of Trypansoma cruzi?
- viral prodrome, 2. ASx w/ serologic/parasitic evidence, 3. LV apical aneurysm
Erythrasma pathogen?
Corynebacterium minutissimum (GP bacteria)
Tx Enterobius vermicularis?
albendazole
Gas gangrene diagnosed 2/2 Clostridium septicum. NSIM?
Colonoscopy (strong correlation to CRC, also IBD/diverticulitis)
Non-typhoidal Salmonella, Which test should the pt undergo?
HIV (per correlation)
Candidemia warrants which additional work up?
Opthalmoscopic eval
Sudden cardiac arrest >patient unresponsive- how to preserve neuro function?
Cooling protocol 32-36F x 24-48h. (Cooling blankets, cold saline infusion)
Tx essential tremor
propanolol or primidone
Primidone use?
essential tremor (or propanolol)
TBI sx: duration & management
most improve w/in 3 months. If not, consider comprehensive neuropsych testing to help w/ long term management & rehab.
RF for immune reconstitution syndrome in HIV
v high VL or v low CD4.
Tx Immune reconstitution syndrome in HIV
c/w HAART hwr if life threatening sx- may stop HAART & start GCS
Preg woman discovers she has HIV. What are the indications for type of delivery?
VL >1000 c/s & add zivudine to HAART. If <1000 vaginal
Can HIV women breastfeed?
They should avoid breastfeeding & us formula in developed countries. (hwr in developing countries they may c/w HAART & breastfeed.
Preg woman discovers she has HIV. Drug resistance is sent. NSIM?
START HAART immedjet
Hiker w/ D, steatorrhea, fatigue, malaise, abd cramps, flatus/bloating. Significant weight loss. NSIM?
Stool microscopy (>90% sensitive if 3x samples). If not detected, EGD w/ duodenal bx or colonoscopy and very sensitive.
Hiker w/ D, steatorrhea, fatigue, malaise, abd cramps, flatus/bloating. Significant weight loss. NSIM?
Stool microscopy (>90% sensitive if 3x samples). If not detected, EGD w/ duodenal bx or colonoscopy and very sensitive.
Hiker w/ D, steatorrhea, fatigue, malaise, abd cramps, flatus/bloating. Significant weight loss. Stool microscopy neg for Giardia. NSIM?
Ensure 3 stool samples as sensitivity >90%. If not detected, EGD w/ duodenal bx or colonoscopy and very sensitive for Giardia but may also rule our other conditions
Tx crusted scabies
PO ivermectin & topical keratinolytic agent 20% urea w/ permethrin
HIV pt w/ crusted scabies. Dx work up?
skin scrapings >dermatoscopy. Tx PO ivermectin & topical keratinolytic agent 20% urea w/ permethrin
AAM goes to mountains and develops acute LUQ pain (sharp, constant & worse w/ inspiration), L shoulder pain. CXR w/ blunting of L costophrenic angle. Dx?
Sickle trait > splenic infarct in hypoxic conditions. Order Hgb electrophoresis. Tx: supportive.
Complications of Sickle Trait?
RENAL: hematuria, UTIs, renal medullary CA.
THROMBOSIS: splenic infarct, VTE, priapism
MCC acute liver failure in the US
Acetaminophen. >12g w/in 24h. Tx: NAC
Tx acute liver failure
NAC
Presentation of acute HCV infection
slowly progressive & LFTs rarely >10x norm
EtOH effect when consumed during acute hepatic failure 2/2 Tylenol
Protective (competes w/ Tylenol for P450 enzymes)
Alcoholic w/ back pain develops N/V, lethargy, RUQ pain, oliguria, jaundice & bleed. Dx?
Consider acute liver failure 2/2 Acetaminophen toxicity. Tx: NAC
You suspect IBS-D. Work up?
Stool Cx, Celiac, 24h stool collection, colonoscopy w/ flex sig/bx
When do you order a 24h stool collection?
Eval fecal fat
Patient w/ GERD, dysphagia, early satiety, CP & abd pain alleviated by BM, hwr incomplete evacuation. Dx?
Consider IBS (may present w/ non-spec sx: “GERD, dysphagia, early satiety, CP”
Tx IBS-C VS IBS-D
C- Lubiprostone. D- rifaximin
Common preceding occurance prior to guttate psoriasis
S.pyogenes infection ie pharyngitis/cellulitis (2-3 wks prior)
How to calculate stool osmotic gap?
290 mOsm/kg − 2 × (stool Na + stool K).
RESULTS: <50: secretory, >125 osmotic
How to calculate stool osmotic gap?
290 mOsm/kg − 2 × (stool Na + stool K).
RESULTS: <50: secretory, >125 osmotic
30yo F w/ high education level, high stress, low BMI presenting w/ D. NSIM?
Order stool osm/electrolytes to calculate osmotic gap. 290 mOsm/kg − 2 × (stool Na + stool K).
If gap <75 consider- saline laxatives, senna, bisacodyl. If >75 measure fecal fat, r/o ingestion of lactulose, sorbitol, mineral oil, MgSO4, PEG
30yo F w/ high education level, high stress, low BMI presenting w/ D. NSIM?
Order stool osm/electrolytes to calculate osmotic gap. 290 mOsm/kg − 2 × (stool Na + stool K).
RESULTS: <50: secretory, >125 osmotic
What does stool osmolality of <250 or >400 mean?
<250: water added to sample. >400 urine added to stool (measure Cr & urea)
Melanosis coli+, Dx?
chronic laxative abuse
Indurated yellowish plaques w/ central atrophy on shins. Dx?
Necrobiosis lipoidica in DM.
Timeframe for warfarin-induced skin necrosis
within few days of starting warfarin per transient hypercoag state
ESRD pt w/ extremely painful SC nodules that can be violaceous/purpuric and plaquelike > necrotic ulcer. Dx?
Calciphylaxis (also in transplant pt)
Elderly smoker w/ PAD, weight loss & dull postprandial epigastric pain after the first hour of eating. NSIM?
Consider CTA/MRA or duplex US to r/o chronic mesenteric ischemia. (Gold standard is angiography but nin-invasive imaging is preferred initially)
Tx chronic mesenteric ischemia
percutaneous transluminal angioplasty +/- stent OR surgical reconstruction
Labs in chronic VS acute ischemia.
CHRONIC: wnl. ACUTE: high WBC, lactate, amylase, phos. (met acidosis)
Tx acute mesenteric ischemia
resuscitate, broad spect abx, NGT for decompression, surgery if bowel perf
Dx test for mesenteric ischemia: Best initial VS gold standard
Initial: *CTA (or MRA), Golden: mesenteric angiography
Which is NOT a RF for ACUTE mesenteric ischemia? Afib, CHF, Hypercoag, Smoking, Atherosclerosis, Advanced Age
Smoking (hwr big RF for chronic mesenteric ischemia)
These RF are for ACUTE or CHRONIC mesenteric ischemia, 1) smoking, 2) afib, 3) CHF
1) Chronic, 2) Acute, 3) Acute
50yo F w/ fatigue, arthritis, darker skin & generalized pruritus (worse at night). TREATMENT?
Ursodeoxycholic acid to prolong time btwn needing surgery for advanced cirrhosis (Dx labs: AMA+, high AlkP/ GGT & marked lipidemia > xanthelasma/xanthoma)
Features of PBC?
Young/middle aged woman, fatigue, arthritis, darker skin (abnormal melanin deposition) & generalized pruritus (worse at night).
40yo F w/ fatigue, RA has HLD, elevated AlkP & GGT on labs. NSIM?
Order AMA (highly spec for PBC)
Abx for acute cholecystitis
zocyn OR ceftriaxone+metro
Tx acute cholecystitis
IVF, bowel rest, analgesics, consider abx if septic (zocyn OR ceftriaxone+metro). Early lap cholecystectomy if stable.
Elderly pt w/ acute cholecystitis managed w/ IVF, bowel rest, analgesics, abx. Presentations/lab worsen. NSIM?
Consider percutenaous cholecystotomy (as unstable for early lap cholecystectomy)
Tx milaria
“heat rash” sweat reduction w/ cool baths, compresses and loose light clothing
Most common deficiencies in celiac other than iron.
Calcium, vitD, folic acid, thiamine
Celiac is diagnosed. Which imaging & vaccine do you recommend?
DXA (per high risk ostepenia/osteoporosis despite normal vitD levels) & pneumococcal (per possible assd hypOsplenism)
30yo w/ periph neuropathy, HA, depression, IDA, skin rash. NSIM?
Consider Celiac. Order tissue transglutaminase IgA (tIgA), endomysial IgA, and reticulin IgA. EGD w/ Duodenal Bx for Dx.
Complications of PBC?
malabsorption ADEK, HCC, osteoporosis/malacia (often normal vitD, likely per accumulation of substances that inhibit bone turnover **still supplement vitD/Ca & monitor w/ DXA)
Is the following assc w/ HCV or HBV? 1) Cryoglobulinemia, 2) PAN
1) HCV, 2) HBV
Is the following assc w/ HCV or HBV? 1) Cryoglobulinemia, 2) PAN
1) HCV, 2) PAN
Why are PBC patients NOT at risk of CAD despite marked hyperlipidemia?
Likely v high HDL, only mild elevation in LDL/VLDL
Most common liver diseases (6)
EtOH, HBV/HCV, NAFLD, drug-induced, hemochromatosis (other nonhepatic causes: muscle d, thyroid d, celiac, adrenal insuff OR rare: AI hepatitis, Wilsons, a1-antitrypsin
NADLD Tx?
Initial: weight loss & EtOH avoidance
Which of the following are ELEVATED in PHYSIOLOGIC pregnancy: Hgb, WBC, PLT, DDimer, LFTs, bili, AlkP, ESR
WBC, DDimer, ESR (E & PR stimulate acute phase reactants) AlkP (formed by placenta),
Which are NOT elevated in physiologic pregnancy? WBC, DDimer, LFTs, bili, AlkP, ESR
PLT, LFT, bili, AlkP. Abnormality should raise suspicion for hepatobiliary disease.
Preg w/ high LFTs & generalized priritus on hands/soles. TREATMENT?
Ursodeoxycholic acid (intrahepatic cholestasis of pregnancy)
Preg w/ vom, transaminitis. Which GI condition would warrant early preg?
acute fatty liver of pregnancy
Preg w/ hemolysis & low PLT. Management?
Early delivery (HELLP)
Pt w/ high risk oozing/clotted ulcer. Intrahosp management VS meds on discharge.
HOSP: IV PP, clear diet x 2 days, endoscopic hemostasis, 3 day hospitalization. DISCHARGE: PPI PO BID x 2 weeks then daily
Pt w/ high risk oozing/clotted ulcer. Intrahosp management VS meds on discharge.
HOSP: IV PP, clear diet x 2 days, endoscopic hemostasis. DISCHARGE: PPI PO BID x 2 weeks then daily
Tx eosinophilic esophagitis? (3)
elim diet, PPI, topical GCS (budesonide, flucticasone)
25yo M w/ asthma/atopy develops acute dysphagia, heartburn, regurg and food impaction. Dx TEST?
EGD showing longitudinal furrows, concentric rings, white papule/exudates: eosinophilic microabscesses, w/ bx (eosinophils >15), exclude other Dx. (Dx: eosinophilic esophagitis). Other Sx: GERD refractory to PPI/H2blockers, intermittent solid food dysphagia.
EGD findings for eosinophilic esophagitis
longitudinal furrows, concentric rings, white papule/exudates: eosinophilic microabscesses, w/ bx (eosinophils >15),
Tx mild-mod plaque psoriasis
High dose topical GCS BID up to 4 wks (fluocinonide, betamethasone)
Tx mild-mod plaque psoriasis
High dose topical GCS BID up to 4 wks (fluocinonide, betamethasone)
Lichen simplex chronicus is often related to which condition?
anxiety (aka neurodermatitis)
Topical tazarotene, retinoids, tar, calcitriol, calcineurin inhibitors may be used to Tx which condition?
Psoriasis (in addition to high dose GCS *mainstay: fluocinonide, betamethasone)
Tx pityriasis rosea
Self limiting. Symptomatic Dx: topical GCS or PO antihistamines. Phototherapy for severe cases. Reassurance.
DDX Pityriasis VS guttate psoriasis
GUTTATE: thicker w/ prominent scale, no herald patch. After strep infection (not viral inf)
Elderly pt w/ easy bruising limited to forearms and hands. Dx?
Senile solar purpura w/w blood vessel fragility after years of sun damage
Frequency of thyroid monitoring in hyperthyroid pregnant patient?
Q4wks, maintain mild hyperthyroid state. Thyrotropic receptor Abs are typically measured in Graves at 18-22wks gestation to predict the risk of fetal thyrotoxicosis
Patient w/ mild hyperthyroidism 2/2 Graves becomes pregnant. Tx?
monitor (do not Tx unless mod/severe, if so 1st trim PTU then 2nd/3rd switch to methimazole) PTU may cause severe hepatoxicity
How can you predict the risk of fetal thyrotoxicosis in a hyperthyroid preg patient?
Thyrotropic receptor Abs are typically measured in Graves at 18-22wks gestation to predict the risk of fetal thyrotoxicosis
Vitiligo is diagnosed. What should you screen for?
AI thyroid disease and DMT1
Tx vitiligo
topical GCS (may use topical calcineurin inhibitors or UV light)
Tx dermatitis herpetiformis
Dapsone & gluten free diet
Tired patient presents w/ rash. Bx: PMNs, papillary microabscesses, suberpidermal vesicles. Direct immunofluoresence shows granular IgA deposits in the dermal papillae. Dx?
dermatitis herpetiformis (eval for Celiac w/ IgA **transglutaminase Abs & IgA endomysial Abs)
Tired patient presents w/ rash. Bx: PMNs, papillary microabscesses, suberpidermal vesicles. Direct immunofluoresence shows granular IgA deposits in the dermal papillae. Dx?
dermatitis herpetiformis (eval for Celiac w/ IgA **transglutaminase Abs & IgA endomysial Abs)
Patient develops skin tags in 2nd trimester of pregnancy and requests removal, NSIM?
Inform her they will likely regress on their own after pregnancy
25yo M w/ psychosis, liver d & Parkinsonism. NSIM?
slit lamp exam, serum & urine copper levels, decreased serum ceruloplasmin. Tx: penicillamine
25yo M w/ psychosis, liver d & Parkinsonism. TREATMENT?
penicillamine (may prevent many of the permanent sequelae)
25yo M w/ psychosis, liver d & Parkinsonism. Dx TESTS?
serum & urine copper levels, decreased serum ceruloplasmin, slit lamp exam
Which heme, renal and rheum complications can occur in Wilsons?
Hemolytic anemia, Fanconi S, recurrent nephrolithiasis, premature arthropathy & chondrocalcinosis
Elevated TSH despite escalating T4 doses. Cause?
Bile acid sequesterants, antacids/PPIs, malabsorption syndrome (ie celiac)
Which is better for Celiac Dx: IgA anti-tissue transglutaminase Abs & IgA endomysial Abs
IgA anti-tissue transglutaminase Ab
Colonoscopy screening onset/interval in UC?
Start 8-10y after Dx, q1-2yrs
FHx mother w/ CRC age 62. At which age should the patient start screening?
Age 40, then repeat every 10 years (if mothers Dx <60yo, then q5y)
FHx mother w/ CRC age 58. At which age should the patient start screening?
Age 40, then repeat every 5 years (if mothers Dx >60yo, then q10y)
FHx mother w/ high grade dysplasia polyp age 58. At which age should the patient start screening?
Age 40, then repeat every 5 years (if mothers Dx >60yo, then q10y) ***Screening intervals are the same as for FHx CRC
*** Alternatives to Colonoscopy q10yrs for CRC screen.
FIT or gFOBT annually, FIT-DNA Q1-3yrs, CT colonography Q5yrs, Flex sig Q5yrs or Q10yrs with annual fit)
Intertrigo dx work up & Tx
Dx clinical but may confirm w/ KOH. Tx: topical antifungals (miconazole, nystatin, terbinafine). May add hydrocortisone ointment if significant pruritis, burning, pain.
Severe intertrigo in multiple areas failing topican antifungals. TREATMENT?
PO antiungals (fluconazole, itraconazole)
MC symptom of splenic vein thrombosis?
Variceal hemorrhage ?dull epigastric pain (on EGD: gastric varices w/o esophageal varices). Tx splenectomy
Splenic vein thrombosis diagnosed after seeing isolated gastric varices. RISK FACTORS and Tx?
Chronic pancreatitis, Splenectomy if recurrent variceal hemorrhage
Alopecia areata: Prognosis & Tx?
Often resolve w/in 1 year hwr often recur. Tx: IL steroids (topical if refuse IL, may consider minoxidil as second line)
Alopecia w/ hair thinning at the base. Which type of alopecia?
areata
Tx NAFLD
Weight loss (gradual as rapid may worsen), consider bariatric surgery if BMI >35
Which AST/ALT ratio suggests NAFLD pt w/ metabolic syndrome?
<1
Delated relaxation of deep tendon reflexes may suggest which condition?
hypothyroidism
Prognosis of NAFLD?
hepatic fibrosis > cirrhosis
50yo white man w/ GERD gets EGD: shows columnar lined esophagus, esophageal bx w/ intestinal metaplastia but NO dysplasia. TX & f/u EGD?
PPI, EGD in 3-5y
50yo white man w/ GERD gets EGD: shows columnar lined esophagus, esophageal bx w/ intestinal metaplastia & LOW GRADE DYSPLASIA. TX & f/u EGD?
PPI, EGD in 6-12 months or endoscopic eradication
50yo white man w/ chronic GERD gets EGD: shows columnar lined esophagus, esophageal bx w/ intestinal metaplastia & HIGH GRADE DYSPLASIA. TX?
endoscopic eradication
T/F Hpylori places patients at higher risk for Barrett esophagus
FALSE, no association
Lactose intolerance exam finding?
increased borborygmi
What do you expect on the stool exam in lactose intolerance?
high osmotic gap >125 & low pH <6
Lactose def Tx?
avoid lactose, enzyme replacement & **supplement vitD & Ca
Prognosis of secondary lactose intolerance after a viral infection?
often resolves in a few months (regeneration of terminal villi)
Lichen planus possible triggers?
HCV, ACEi, BB
Lichen planus Tx?
high potency topical GCS
How to diagnose lichen planus.
Clinically, if uncertain- punch Bx
Patient w/ anal fissure which does not respond to 8wks optimal tx. NSIM?
Colonoscopy r/o Crohns
What are some ATYPICAL features of anal fissues?
anterior or lateral, multiple, painless, very deep, recurrent. (if respond to 8wks optimal tx, consider Colonoscopy r/o Crohns)
Tx anal fissures
topical vasodilators (NTG, nifedipine) stool softners, increased fiber
Stool Cdiff- is it sensitive or specific
very sensitive and specific
Which abx are known to have the adverse effect of D?
clindamycin, cephalosporins, amoxi-clav
Severe or prolonged D. Which studies do you order?
Fecal: WBC, O/P, Cx, Cdiff
Tx of dyspepsia w/ GERD sx VS without
GERD: PPI trail. NO GERD: Hpylo if <60 (if neg, PPI trial) & EGD if >60
Dyspepsia w/o GERD in 61yo. NSIM?
EGD (if <60, do Hpylori first)
Tx GERD in pregnancy
Diet > antacids > sucralfate > H2block > PPI > EGD if complications (ie hemorrhage) ***Avoid alka seltzer as it contains aspirin -fetal tox)
Glycemic goals in pregnancy: Fasting, 2h postprandial, 4h postprandial
Fasting <95, 2h: <140, 4h <120 (Tx w/ insulin- if refusing: glyburide or metformin)
Preg pt w/ fasting gluc 120, NSIM?
Try dietary interventions x 1 week, if not at goal (Fasting <95, 2h: <140, 4h <120) start INSULIN (note: glargine is not safe but detimir is)
Tx infective necrotizing pancreatitis
Metro/Cipro or Meropenem, Imipenem. (CT-guided FNA is done to eval septic VS sterile necrosis/ to direct therapy) Note: sterile necrosis warrants supportive care.
Acute cholangitis w/ gallstone pancreatitis. Tx?
ERCP w/in 24h
Elevated AlkP & normal GGT. Dx?
2/2 bone path
RUQ pain, Elevated AlkP, AMA neg w/ abnormal liver parenchema. NSIM?
Liver Bx
After Tx for PNA pt develops high LFTs, bili, v high AlkP. US wnl. NSIM?
Likely drug-induced cholestasis, remove abx and anticipate improvement.
Transaminitis >1000. Dx?
Consider Tylenol OD, AI hepatitis, ischemic injury or ~HBV (not HCV)
DDX rosacea VS SLE
rosacea has papules * pustules. SLE has scaling over cheeks and bridge of nose
Afib develops sudden severe periumbilical w/ pain out of proportion to exam. High WBC & amylase, lacticemia. NSIM?
CTA
Use of neosporin on abrasion > erythematous, indurated priritic plaque > edema, drainage, vesicles/bullae. VSS, afebrile. Dx?
Severe contact derm
Discoid lupus suspected but ANA neg. Dx?
Likely discoid lupus (ANA often neg & SLE only assd in 25%)
Tx discoid lupus
topical GCS or calcineurin inhibitor (tacrolimus)
Lifetime occurrence of androgenic hair loss in women ___%
50
Tx androgenic hair loss in M vs W?
W: topical minoxidil
M: topical minoxidil or finasteride
UC Tx mild/mod VS severe disease
Mild/mod: 5ASA (mesalamine). Severe (azathioprine, 6MU, anti-TNF)
Watery non-bloody D, abd pain, fatigue, weight loss, arthralgia,. Colonoscopic Bx: lymphocytic infiltration of lamina propria. TREATMENT?
(Microscopic collitis). Anti-diarrheals & budesonide
Colonoscopic Bx w/ thickened subepithelial collagenous band. TREATMENT?
(Microscopic collitis). Anti-diarrheals & budesonide. Note: the other subtype shows high levels of of intrepithelial lymphocytes & focal cryptitis.
Colonoscopic Bx w/ high levels of of intrepithelial lymphocytes & focal cryptitis. TREATMENT?
(Microscopic collitis). Anti-diarrheals & budesonide. Note the other type shows thickened subepithelial collagenous band.
Mesalamine enema use?
L-sided UC
First line Tx onychomycosis (with duration)
PO terbinafine (fingernail 6wks, toenail 12wks). 2nd line itraconazole BID x 4wks (toenail only), Note: likely to recur & only 50% effective Tx.**Obtain LFTs as both meds can cause liver tox.
How to establish onychomycosis Dx?
KOH prep.
Onychomycosis suspected but KOH neg. NSIM?
Obtain Cx of nail clipping hwr note that it takes 6wks to grow
Hypothyroid pt gets pregnant. NSIM?
Increase levo by 30% (then monitor TSH every month & adjust synthroid)
Which is NOT a physiologic change in preg:
1) bHCG stim of TSH receptors **
2) increased TBG **
3) decreased T3 & T4 ***
4) feedback suppression of TSH
3) decreased T3 & T4 (it is INCREASED in preg)
Tx SAD vs GAD vs performance subtype
SAD/GAD: SSRI/SNRI/CBT. Benzos if no response and no hx substance abuse. GAD: may also use buspirone. Performance subtype: BB or benzo
Longstanding pattern of odd, magical thinking and eccentric behavior. Dx?
Schizotypal disorder
ADAMS13 activity <10% Dx?
TTP (ADAMS13 is a vWF cleaving protein) TTP > large vWF multimers > stimulate PLT aggreg >thrombi in multiple organs
TTP or HUS: 1) renal involvement 2) neuro sx
1) renal- HUS
2) neuro- TTP
TTP suspected. Tx?
plasma exchange (confirm w/ ADAMS13 level <10, hwr not required). If refractory: consider GCS, rituximab or cyclosporine
Thrombocytopenia, MAHA, AKI, fever, CNS involv. Dx & Tx?
TTP, plasma exchange
PTT, PT & INR in TTP VS DIC
much more prolonged in DIC, may be normal in ITP
normal PTT
25-35s
MAHA, low fibrinogen, high DDimer, elevated PT/PTT/INR, schistocytes. Dx?
DIC
DDX DIC vs TTP
TTP has normal coags
55yo w/ fatigue, abd pain, anorexia. Splenomegaly. Hgb 10.5, WBC 40k, PLT 500k. BMB hypercellular. Dx & Tx?
CML. Tyrosine kinase inhibitor imatinib (CML, translocation ch 9 & 22- Philadelphia, BCR-ABL1 fusion gene or mRNA). Depending on response and comorbs, may be candidate for BMT
Low blasts, BMB w/ hypergranular promyelocytes. Dx & Tx?
APML, Tx: All-trans retinoic acid w/ antrhacycline based chemo
Fludrabine-based chemo is for which of the following: AML, APML, CML, CLL, MM, MDS
CLL
Lenalidomide is a Tx for which of the following: AML, APML, CML, CLL, MM, MDS
MM, MDS
> 40C, AMS, generalized muscle rigidity, diaphoresis, autonom instab after stopping Parkinsons meds. DIAGNOSIS?
NMS. Check CK/Cr for assd rhabdo/AKI
> 40C, AMS, generalized muscle rigidity, diaphoresis, autonom instab after stopping Parkinsons meds. TREATMENT?
(NMS). Resume Parkinsons meds, cooling, IVF. Dantrolene & bromocriptine if failure to respond to above. Note: 10-20% mortality rate
Pt is intubated & subsequently spikes temp 103F. Dx?
Malignant hyperthermia, Tx Dantrolene.
Malignant hyperthermia- typical hx & Tx?
Use of succinylcholine & halogenated anesthetics > high fever 2/2 gene mutation. Tx: dantrolene
What is the On/Off phenomenon in Parkinsons?
Pts on long term Carbi/Levo dopa who get intermittent Parkinson Sx despite Tx
Which is assd w/ hyperreflexia and muoclonus: NMS or 5HT syndrome?
5HT syndrome (NMS is lead pipe rigidity). Serotonin syndrome also has lower fever and often N/V/D
Precipitating factors for NMS?
Antipsychs, antiemetics (promethazine, metoclopramide), infection, surgery, withdrawal of Parkinsonian meds
Schizophrenic develops lead-pipe rigidity, diaphoresis, autonomic instab. Labs w/ high WBC & CK. Tx?
(NMS) Stop antipsychotic, cooling, IVF. Dantrolene & bromocriptine if failure to respond to above. Note: 10-20% mortality rate.
Bipolar pt develops ataxia, coarse tremor, GI sx, AMS. NSIM?
Check lithium level
NMS is assd w/ high D or low D?
low D (ie antipsychotic use, or withdrawal of Parkinson meds)
Management of non-responder to 8wks of SSRI VS partial responder.
NON: switch to another med. PARTIAL: augment (add anther med)
Patient has partial response to lexapro. Which medications can you augment with?
second-gen antipsyc, antidepressant w/ another MOA, occasionally lithium or triiodothyronine
2nd-gen antipsych which is helpful in augmenting antidepressant therapy?
aripiprazole (abilify)
Phenelzine & Selegline are which kinds of drugs?
MAOi
Transfusion-assd-GVHD. What are the two biggest RF?
Immunocompromised (ie blood CA) or partial HLA match to donor (family member). To prevent this: irradiate the cells to inactivate donor lymphocytes). HIV *NOT at risk.
HL patient undergoes transfusion. 2wks later: fever, gen maculopapular rash, RUQ pain, transaminitis, profuse diarrhea, pancytopenia. Dx?
Transfusion-assd-GVHD. To prevent this: IRRADIATE the cells to inactivate donor lymphocytes. !!90% mortality. HIV not at risk.
Blood transfusion received from family donor. 2wks later: fever, gen maculopapular rash, RUQ pain, transaminitis, profuse diarrhea, pancytopenia. WHAT COULD HAVE PREVENTED THIS?
Irradiating cells. Transfusion-assd-GVHD. RF: Immunocompromised (ie blood CA) or partial HLA match to donor (family member). !!90% mortality. HIV not at risk.
Splenectomy patient: when should they receive meningiococcal vax?
at splenectomy and then 5 years
Pt undergoes splenectomy. Which vaccines/schedules are indicated.
At time of splenectomy: PCV13 then in 2 wks give PPSV23. Another PPSV23 in 5 years. MENINGIOCOCCAL 2 doses given 8wks apart then q5yrs. H.influenza single dose.
Minutes after transfusion: fever/chills, hypotension, acute hemolytic anemia, renal insuff. Dx?
ABO incompatibility
Transfusion prep for patients w/ IgA def or recurrent/severe transfusion rxns?
Washing (removes residual plasma)
vWF deficient patient to undergo surgery. NSIM?
obtain vWF activity level. For more extensive surgeries or severe disease: use VWF concentrate pre-op. For mild disease/small procedure use desmopressin.
Laparoscopic cholecystectomy is planned in F w/ mild VWD. Which Tx do you give pre-op?
For mild disease/small procedure use desmopressin. Obtain vWF activity level. For more extensive surgeries or severe disease: use VWF concentrate pre-op.
First line Tx GVHD
GCS (if acute: add cyclosporine & MTX)
Nephrogenic systemic fibrosis/dermatopathy. Cause?
AKI/CKD patient exposed to gadolimium
Renal transplant 1y ago. Develops sleroderma-like rash, transaminitis, dry oral mucosa and eyes, esoph web/strictures, fasciitis/joint strictures. Dx?
Chronic GVHD (Tx: topical GCS, may require additional cyclosporine/tacrolimus)
Pt c/o pain s/p cholecystectomy. Which discharge analgesics/supply do you prescribe?
3-5 day supply of hydrocodone/acetaminophen (Vicodin) or oxycodone (Percocet)
Smear shows: BITE CELL. What other than G6PD can cause this?
a-thalassemia, G6PD def
Smear shows: SCHISTOCYTE. DDX (4)?
DIC, TTP/HUS, traumatic hemolysis. (aka helmet cell)
Smear shows: SPHEROCYTE. What other than hereditary spherocytosis can cause this?
AI hemolysis, snake bite, G6PD deg, MAHA
Which conditions assd w/ TARGET CELLS?
thalassemia, HbC disease, post-splenectomy, obstructive liver d
TEARDROP CELLS- assd conditions?
myelofibrosis, major thalassemia (ie extramedullary hematopoiesis)
BASOPHILLIC STIPLING- assd conditions? (4)
Lead/heavy metal poisoning, EtOH, thallasemias, IDA
HOWELL-JOLLY BODIES- assd conditions?
asplenia or splenic hypofunct (SCD)
B sx, anemia, thrombocytopenia, painless LAD, HSM. Periph smear w/ >5000 mature small B lyphocytes & flow cytometry w/ monoclonal B characteristics CD19, CD20, CD23. Dx?
CLL
CLL pt w/ positive direct Coombs & spherocytes. DIAGNOSIS & Tx?
AIHA (common complication of CLL). Tx: GCS, if refractory- splenectomy. pRBC transfusion PRN.
Calcitonin main use?
Pagets
Bone mets+. Which medication is given in setting of GFR <35 VS >35?
<35 denosumab. >35 IV bisphosphonate (zolendrnate or pamidronate) **not PO bisphosphonates per poor bioavailability (hwr it is cheaper and has more analgesic properties). Note hypoCa & vitD def must be corrected prior to starting therapy.
Which bisphosphonate would you NOT use for bone mets: alendronate, zolendronate, pamidronate?
alendronate (per poor PO bioavail). Use IV bisphosphonate for mets.
Osteonecrosis of the jaw assn?
AE of bisphosphonates
Pt admits to feeling lonely. NSIM?
refer to social servies, senior center activities, volunteer work. **it is an independent predictor of functional decline and death
AA amyloidosis can be a paraneoplastic syndrome in which CA?
RCC (rare)
Mechanism of hyperCa in RCC?
bone mets, high PTHrP, high prostaglandins
CT shows suspicious mass in kidney. NSIM?
nephrectomy (note: bx can be done for patients who are poor surgical candidates)
How are 80% of RCC discovered?
Incidentally
Asian M w/ sterile pyuria & gross hematuria. Dx?
Consider renal tuberculosis (common in Asia)
HyperCa, erythrocytosis, weight loss. Dx?
RCC
DDX binge eating disorder VS bulimia
Binge eating has no compensatory behaviors and no excessive worrying about weight and body shape
Lisdexamphetamine use?
(Vyvanse) ADHD or compulsive eating disorder
Best SSRI for bulemia?
fluoxetine (prozac)
Risk of IV over PO vit K?
IV has higher risk of anaphylaxis
How to manage supratherapeutic INR in warfarin pt?
If no significant bleed: hold warfarin & give PO vit K. If significant bleed: hold warfarin & admin IV vitK 10mg with PCC
Pt w/ afib (on warfarin) develops GIB, INR supratherapeutic. NSIM?
hold warfarin & admin IV vitK 10mg with PCC (if INR was supratherapeutic w/o bleed, give PO vitK)
Loss of autobiographical memory suggests _____ amnesia
dissociative
55yo F w/ hx migraines presents w/ impairment of anterograde memory, disorientation to place/time, but everything else is preserved. Dx?
Transient global aphasia (often 1-10h), unclear pathophysiology. R/o other conditions: toxic/metabolic encephalopathy, CVA/TIA, seizure
Good antidepressant choice for pts w/ DM neuropathy, fibromyalgia, chronic back pain & OA.
Duloxetine (SNRI) analgesic properties
Pt w/ chronic lower back pain is diagnosed w/ MDD. Which med do you prescribe?
Duloxetine (SNRI) has analgesic properties
Pt w/ fibromyalgia is diagnosed w/ MDD. Which med do you prescribe?
Duloxetine (SNRI) has analgesic properties
Cold agglutinin AIHA may be seen in which condition: Mono, PNC, SLE, M.pneumoniae
Mono, M.pneumonia
Complications of warm VS cold agglutinin AIHA?
WARM- VTE, lymphoprolif d. COLD- ischemia/periph gangrene. lymphoprolif d
Tx WARM agglutinin AIHA (ie in SLE, CLLm viral inf, PNC).
GCS, splenectomy for refractory d. (RF for VTE, lymphoprolif d)
Tx COLD agglutinin AIHA
avoid cold, rituximab +/- fludarabine
SLE pt presents w/ signs of anemia. Labs: low Hgb, low haptoglobin, high direct bili & LDH. Smear w/ spherocytosis. TX?
(Dx: warm agglutinin AIHA) Tx: GCS, splenectomy for refractory d. (RF for VTE, lymphoprolif d)
Which do you seen in MAHA- schistocytes or spherocytosis?
schistocytes (note: sphertocytosis in in AIHA)
Acute febrile neutrophilic dermatosis, assd w/ hematologic CA, erythematous plaques. Dx?
Sweets
RCC on chemo develops blisters/hyperkeratosis, paresthesias/pain in hands and feet. Dx?
Hand foot skin reaction 2/2 tyrosine kinase inhibitor. Tx supportive: emollients, GCS, pain control.
Primary cause of polycythemia. (2)
PV (JAK2 mutation) or EPO receptor mutations. Note: primary causes have low EPO
High EPO excludes which condition? OSA, RCC, PV, high altitude, androgen supplementation
PV. Primary causes of polycythemia have low EPO
JAK2 mutation
PV, essential thrombocytosis, primary myelofibrosis
AKI after chemo initiation. Labs: HIGH Ph, K, uric acid. LOW Ca. Dx?
Consider tumor lysis syndrome causing acute nephrocalcinosis. PPX IVF, rasburicase or xanthine oxidase inhibitor
Rasburicase use
PPx for tumor lysis syndrome causing acute nephrocalcinosis.
AKI after chemo initiation. Labs: HIGH Ph, K, uric acid. LOW Ca. How could this have been prevented?
tumor lysis syndrome causing acute nephrocalcinosis. PPX aggressive IVF, rasburicase x 5-7 days or xanthine oxidase inhibitor
AKI after chemo initiation. Labs: HIGH Ph, K, uric acid. LOW Ca. MOA of renal injury?
(tumor lysis syndrome causing acute nephrocalcinosis.) high phos binds Ca and deposits in renal tubules >obstruction & cellular injury OR severe hyperuricemia can cause urate stone formation
How does cyclophosphamide urotoxicity manifest?
hemorrhagic cystitis or bladder CA
Which type of lab abnormalities do you expect in tumor lysis syndrome?
HIGH Ph, K, uric acid. LOW Ca.
Basophilic leukocytosis. Assn?
acute or chronic leukemia (also HSM, periph eosinophilia)
ABL1 (chrom9) & BCR (chrom22)= abnormal chromosome 22 BCR-ABL1. Dx?
CML (Philadelphia chromosome) Dx: M, fatigue, HSM, periph eosinophilia/basophilia.
Elderly M w/ fatigue, HSM, periph eosinophilia, basophilia. Which test do you order to confirm the Dx?
chromosome 22 BCR-ABL1. Dx: CML
Which mutation is found in essential thrombocytosis & primary myelofibrosis?
JAK2 (also in PV)
Patient with no actual sx, who is preoccupied about having undiagnosed condition. Dx?
Illness Anxiety Disorder
Tx breast Ca w/ nodal involvement, ER PR & HER2 negative.
Chemo > Rad
Triple negative Breast CA. Prognosis?
Poor. ER PR & HER2 negative indicate a more aggressive clinical course w/ freq relapse & higher mets
Eosin-5-maleimide binding (on flow cyto) or acidified glycerol lysis test+. Dx?
Hereditary spherocytosis (can order direct agglutinin to r/o AIHA)
Which liver disease can be diagnosed w/ SPEP?
a-1-antitrypsin
Classic MM picture w/ neg SPEP. NSIM?
UPEP w/ immunofixation or serum free light chain assay to identify monoclonal light chains.
Acute chest syndrome: indication for exchange transfusion?
SaO2 <85% & >2 lobes. (otherwise RBC transfusions for moderate disease). Also IVF, O2, analgesia, broad spect Abx
Somatic symptom disorder: Management?
Reg follow-up, CBT/SSRI.
40yo M on SSRI has improved MDD but troubling sexual dysfunction. NSIM?
Consider adjunctive therapy w/ sildanefil or bupropion. May decrease SSRI hwr close monitoring for MDD worsening. R/o out other issues.
40yo M on SSRI has minimally improved MDD & troubling sexual dysfunction. NSIM?
May switch to bupropion (or mirtazepine/Remeron but there is assd weight gain)
CXR suggests pancoast tumor. NSIM?
Core needle bx
PLT drop to ~100k in first two days sp heparin use. Dx?
HIT1 (not concerning).
% drop in PLT sp heparin use to prompt concern for HIT2.
> 30%, esp if >50% from baseline. Timeframe 5-10 days later (or <1 day if prior exposure). New thrombosis or skin necrosis.
HIT2 Tx.
Stop all heparins. Start agatroban
What lab should be monitored w/ use of testosterone?
Hgb/HCT (if >16.5, HCT >54%, reduce dose or d/c. Risk of CVS/VTE events.
anti-glutamic decarboxylase abs- Dx?
DMT1
Is thrombocytosis assd w/ IDA OR thalassemia.
IDA
Most common long term AE of external beam radiation for prostate CA?
Sexual dysfunction, increases in frequency with time & with androgen deprivation tx. Can be avoided by reduced radiation involving the penile structures. Tx: viagra
Which adverse effects of external beam radiation for prostate CA do NOT resolve in a few weeks: GI (incontinence, strictures, ulceration), Urinary (frequency, dysuria), Sexual dysfunct
Sexual dysfunction, increases in frequency with time & with androgen deprivation tx. Can be avoided by reduced radiation involving the penile structures. Tx: viagra
Which screening should pt undergo at dx of ITP?
HIV & HCV
Pt has bilateral cervical/axillary LN enlargement. No other Sx. CD15 & CD30+. NSIM?
(Dx: Hodgekin). IMMEDIATE fertility specialist referral prior to initiating chemo. Unless advanced, then tx right away.
Tx of SCLC w/ mets vs w/o mets.
METS+: platinum based chemo, NO-METS: chemo/rad
SCLC location and RF
central/hilar mass, heavy smokers (v aggressive CA)
NSCLC suspected. NSIM?
molecular profiling to determine Tx. If early stage, obtain PFTs and schedule lobectomy
Which lung CA is very responsive to chemo?
SCLC
ITP PLT goal
> 30k (if below, give GCS & IVIG, if still <30k splenectomy or rituximab if still <30k give thrombopoiesis stimulating agent)
When to Tx ITP
PLT <30k give GCS & IVIG, if still <30k splenectomy or rituximab if still <30k give thrombopoiesis stimulating agent
When to obtain BMB for ITP?
age >60 to r/o MDS
LOW iron, HIGH TIBC, LOW ferritin Dx?
IDA
LOW iron, LOW TIBC, iron-laden macrophages on BMB. Dx?
ACD
BMB shows iron-laden macrophages but decreased erythrocyte precursors. Dx?
ACD (likely d/t increased cytokine release (IL6, TNF) or increased hepcidin (acute phase reactant that inhibits iron transport to the intestine & iron release from macrophages)
Increased hepcidin is proposed etiology for which anemia?
ACD likely d/t increased cytokine release (IL6, TNF) or increased hepcidin (acute phase reactant that inhibits iron transport to the intestine & iron release from macrophages
Tx ACD
Tx underlying disease. If symptomatic, may give iron/EPO to bring levels to 12g/dL
