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)
