All subjects Flashcards
The most appropriate treatment of medication-related tardive dyskinesia
discontinuation of the causative dopamine blocker agent.
Patient being evaluated for primary hyperparathyroidism in context of hypercalcemia. What is the first non-invasive intervention that should be attempted initially?
Measure Vit D and Vit D repletion if needed.
* There is a high prevalence of concurrent vitamin D deficiency in patients with primary hyperparathyroidism, and low levels of 25-hydroxyvitamin D can stimulate parathyroid hormone secretion in non-adenomatous glands.*
Patient with stiffness and pain in proximal interphalangeal and metacarpophalangeal joints of the fingers, the wrists, and the analogous joints of the feet. She has morning stiffness for over 1 hour in the mornings. Dx?
RA
NSTEMI with stent placement. What is goal-directed medical therapy for this. Normal echo after stent placement.
aspirin, a β-blocker, an ACE inhibitor, and a statin; a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) should be continued for at least 1 year for patients undergoing coronary percutaneous intervention with stent placement.
30yoF presenting with chronic dyspnea and cough. On CT you see diffuse, thin-walled cysts. Dx?
Lymphangioleiomyomatosis is a rare cystic lung disease that occurs sporadically in women of childbearing age or in association with tuberous sclerosis; characteristic findings include diffuse, thin-walled, small cysts on CT.
What kind of labs are seen in exercise-induced hemolysis?
-Hemoglobinuria
-UA shows blood, but no erythrocytes
-May lead to iron -def anemia
(intravascular hemolysis caused by repetitive mechanical trauma like running or marching)
Hallmarks of interstitial nephritis?
Sterile pyuria
Leukocyte casts
(also can see mild subnephrotic proteinuria)
Which EKG abnormality in a patient undergoing a nuclear stress test would make you want to do a chemical rather than an exercise stress test?
Left bundle branch block
could lead to false positive dueto septal perfusion abnormality which can occur in exercise
Which antiepileptic med most likely to cause hyponatremia?
Oxcarbazepine is associated with hyponatremia in 20% to 30% of the patients who take it; although symptoms are generally mild and not clinically significant, severe hyponatremia occurs in 8% to 12% of these patients.
What constitutes a low risk peptic ulcer?
How do you treat it once its found?
Low-risk gastric ulcers are clean-based or have a nonprotuberant pigmented spot; they should be treated with oral proton pump inhibitor therapy, initiation of refeeding within 24 hours, and early hospital discharge.
How does tx for occlusive crisis in sickle cell differ from pregnant to non-pregnant patients?
It does NOT differ
Before replacing calcium, what do you need to replace first?
magnesium
In patients with lung, breast, and GI adenocarcinoma, which complication should you be concerned about if you see new interstitial thickening in the lungs on CT?
Lymphangitic spread og the tumor
Most appropriate management for fatty liver disease?
weight loss?
Which medicine interacts poorly with febuxostat?
Azathioprine
concomitant use of these agents can lead to dangerously high levels of azathioprine.
Patient has whipple procedure for pancreatic cancer. 1 year later foudn to have liver mets. What’s the plan now?
Multiagent systemic chemo
5FU, leucovorin, irinotecan, oxaliplatin
What are the risk factors for a potential DRSP (Drug Resistant Strep Pneumo) pneumonia?
Age >65
Immunosuppression
Alcoholism
Comorbidities: COPD, DM, cancer, CHF, asplenia
Abx in last 3-6 months (fluroquinolone, macrolide, b-lactam)
If patient presents with strep pneumo bacteria after taking beta-lactam for cellultiis 2 months ago, what should you treat her with?
Treatment with respiratory fluoroquinolone (moxifloxacin)
Patient presents with fatigue, joint pain, abdominal pain, petechial/purpural skin lesions, and glomerulonephritis following an upper respiratory tract infection.
Likely dx?
IgA Vasculitis
AKA Henoch Schonlein Purpura
Patient with CKD, hyperparathyroidism. Normal serum levels of Ca, Vit D, and phosphorous. What should be your next step in treating this patient?
Patient with 2ndary hyperparathyroidism from CKD. First step is normalize Ca, Phosphorous, and Vit D. If those are normal then the next step is a Vit D analogue, like Calcitriol.
Calcitriol directly suppresses PTH production by the parathyroid glands, thereby protecting bones from osteitis fibrosa cystica, which can occur as a result of chronic secondary hyperparathyroidism.
Sterile pyuria and leukocyte casts
Interstitial Nephritis
Most common causes of interstitial nephritis
Interstitial nephritis may be associated with autoimmune diseases and infections but is most commonly caused by drugs.
FDA approved medciation tx for bipolar disorder?
Quetiapine or combined Olanzapine-Fluoxetine
NExt step in treatmnet after a stage II or III resection of NSCLC?
Cisplatin based chemo
Patient with marfan syndrome foudn to have aortic root dilation. When should you next screen and if normal how frequent should screening be following that?
In patients with Marfan syndrome and aortic root dilation, surveillance imaging should be performed 6 months after diagnosis and annually thereafter if the aortic size remains stable.
Most important lab test when you are considering TTP dx?
Thrombotic thrombocytopenic purpura is a clinical diagnosis that requires the presence of thrombocytopenia and microangiopathic hemolytic anemia, which is confirmed by schistocytes on the peripheral blood smear.
Under what circumstances would a capsule endoscopy be first line for dx of Gi bleeding?
Capsule endoscopy has become the first-line test in evaluating the small bowel in patients with obscure gastrointestinal bleeding after a negative upper endoscopy and colonoscopy.
Obscure gastrointestinal bleeding refers to recurrent or persistent bleeding
In what circumstances would a technetium scan or angiography be appropriate for diagnosing a GI bleed?
Angiography and technetium-labeled nuclear scans are used in patients with active bleeding (melena or hematochezia) who are transfusion dependent and hospitalized.
Man with AIDS, now found to have positive blood cx for Mycobacterium Avium Complex. What is next step in treatment?
Treatment with clarithromycin, ethambutol, and rifabutin is recommended for disseminated Mycobacterium avium complex infection in patients with HIV/AIDS whose CD4 cell counts are less than 50/µL
A 68-year-old woman is evaluated 1 month after having an ischemic stroke of the left thalamus. She now has only residual right-sided anesthesia. The patient has hypertension and dyslipidemia, both well controlled by medication, and had been taking a daily aspirin before the stroke. Medications are lisinopril, chlorthalidone, aspirin, and rosuvastatin.
What treatment is most appropriate at this time?
Dipyridamole should be added to this patient’s medication regimen. She had a small subcortical infarction despite taking daily aspirin before the stroke. The combination of aspirin and dipyridamole has been shown to be superior to aspirin alone in reducing the risk of recurrent stroke.
What therapy for Crohn’s Disease is considered safe in pregnancy?
TNF-inhibitors
Patient found to have <12mm unruptured aneurysm. What are the next steps in treatment?
Patients with unruptured intracranial aneurysms should be counseled to stop smoking because of the increased risk of aneurysmal rupture. Also keep their blood pressure under control.
Patient with symptomatic PVC’s, beta blocker therapy not fixing it. Echo now showing signs of heart failure. NExt step in treatment?
Cardiac ablation therapy
Mainstay of treatment for ARDS?
The mainstay of management for acute respiratory distress syndrome is a lung-protective ventilator strategy, with low tidal volume (6 mL/kg of ideal body weight) and low plateau pressure (<30 cm H2O), even if this results in hypercapnia.
What should be the tidal volume for a patient with ards?
What should the plateau pressure be?
Tidal volume: 6ml/kg (ideal body weight)
Plateau pressure: <30 cm H2O
Patient with multiple myeloma and 3 months of back pain. XR negative for lytic lesions. Next step to manage?
Get a CT or MRI to eval for lytic lesions
Patient presenting for concern for acute leukoemia, in particular APL.
A peripheral blood smear shows 80% immature blasts with prominent Auer rods phenotypically consistent with promyelocytes.
Next steps???
Immediate next step is to start ATRA (all-trans-retonic acid), DO NOT wait for confirmation testing.
Immediate administration of all-trans retinoic acid is important in preventing early mortality in suspected acute promyelocytic leukemia.
What causes infertility in cystic fibrosis?
Loss of vas deferens in males
Dietary Restrictions in hemochromatosis?
Why?
Avoid raw and undercooked seafood
Vibrio vulnificus infection is associated with ingestion of raw seafood, especially oysters, and the risk of sepsis and death is increased in persons with hereditary hemochromatosis.
Muscle cramps 2/2 corticospinal tract damage from ultiple sclerosis. How to treat?
Baclofen
48yoF w/ migraines not controlled by NSAIDS. An MRI of the brain shows several punctate hyperintensities in the bilateral subcortical white matter.
Next steps?
Just treat migraine with triptans
White matter signal abnormalities are typically seen on MRIs of patients with migraine, particularly in the posterior circulation and particularly in women; these lesions are benign and unrelated to neurologic examination abnormalities or cognitive anomalies
When should you treat someone with essential thrombocytosis?
PLT > 1,000,000
Age > 60yo
Hx of thrombosis
If it is decided to treat someone with essential thrombocytosis, how should you treat it?
Low-dose aspirin and hydroxyurea
What are the key features of patellofemoral pain syndrome?
Patellofemoral pain syndrome is characterized by anterior knee pain that is slow in onset and typically made worse with running, climbing stairs, and prolonged sitting.
Exam: Pain is reproduced by applying direct pressure to the left patella
Patient with diffuse lymphadenopathy. LN biopsy showing DC20+ and cyclin D1 overexpression.
Dx?
Prognosis?
Mantle cell lymphoma is a rare form of non-Hodgkin lymphoma characterized by extranodal involvement and overexpression of cyclin D1, and it is associated with a poor prognosis.
What is the general presentation for a patient with bilateral adrenal hemorrhage?
Patients with bilateral adrenal hemorrhage typically present with clinical features of acute cortisol and aldosterone deficiency, including gastrointestinal disturbance, lethargy, weakness, hypotension, shock, hypoglycemia, and electrolyte imbalances, such as hyponatremia and hyperkalemia.
Risk factors for adrenal hemorrhage?
Risk factors for adrenal hemorrhage include anticoagulant therapy (and may occur with treatment levels within the therapeutic range), the postoperative state, abnormalities of hemostasis (such as heparin-induced thrombocytopenia or antiphospholipid antibody syndrome), and sepsis.
Patient really needs NSAIDs for back pain, but had an ulcer in the past. Tx plan?
Celecoxib and omeprazole BID
MS drug which is contraindicated in acute kidney failure?
Dalfampridine
Patient with post-inflammatory pigmentation from facial acne. Standard of care treatment?
topical retinoid
Patient with low output heart failure has been diuresed for a while now, now appears to have normal filling pressure on right heart cath. Heart failure signs and sx still present. NExt step?
Nitroprusside
In patients with low-output heart failure, nitroprusside can reduce afterload and increase cardiac output; nitroprusside should be used only in the setting of invasive cardiac monitoring.
All SLE patients who can tolerate it should be taking…..?
Hydroxychloroquine
You suspect ethylene glycol toxicity in a patient what are the mainstays of treatment? List 4
1) Fomepizole
2) IV hydration
3) Hemodialysis to clear alcohol and toxic metabolites
4) If pH < 7.3, give IV Na-bicarb
WOman with roux en y gastric bypass. Now has sx of chronic nonbloody diarrhea since her bariatric surgery. She also has had generalized fatigue, dry skin, dry and itchy eyes, and increased difficulty seeing road signs at night while driving. What is the vitamin deficiency?
Vit A deficiency
fat soluble vitamin
What results from factora 8 deficiency?
Hemophilia A
Viral infection common to first few months after kidney transplant?
Cytomegalovirus is a common complication of transplantation, especially in the first few months after transplantation when immunosuppression is typically highest, and patients who have just finished prophylaxis against cytomegalovirus are at risk for reactivation.
Explain platypnea-orthodeoxia syndrome:
positional symptoms of cyanosis and dyspnea that generally occur when the patient is sitting and resolve in the supine position. Right-to-left shunting across an atrial septal defect or patent foramen ovale may rarely cause cyanosis and dyspnea owing to deformation of the atrial septum and redirection of shunt flow that result from increased right atrial pressure in the upright position.
How might a myocardial infarction subsequently cause platypnea-orthodeoxia syndrome?
Inferior and right ventricular myocardial infarction can cause associated right heart enlargement and dysfunction. The right heart enlargement causes annular dilatation and tricuspid regurgitation. The foramen ovale stretches and becomes patent.
The preferential cyanosis is caused by the hemodynamic alterations and preferential transfer of right atrial blood across the patent foramen in the upright position
How to treat overcorrection of sodium in patient with chronic hyponatremia?
Desmopressin (to halt corrective diuresis)
5% Dextrose (to lower Na a little)
Standard testing eval for patient with encephalitis?
Brain MRI, EEG, LP
Signs and sx of encephalitis?
obtundation, fever, elevated cerebrospinal fluid [CSF] leukocyte count
What are the risk factors for sudden cardiac death which would cause you to send a patient for an implanted cardioverter-defibrillator?
Any run of non-sustained Vtach on EKG Fam Hx of sudden cardiac death Cardiac wall thickness >30mm Previous cardiac arrest due to ventricular arrythmia Hypotension in exercise Unexplained syncope
Triad of gait abnormalities, cognitive impairment, and urinary disturbance, especially when neuroimaging studies show enlarged ventricles out of proportion to cortical atrophy.
Dx and treatment?
Large-volume lumbar puncture should be performed before placement of a ventriculoperitoneal shunt in patients with normal pressure hydrocephalus.
Wart-like growths on penis. Name?
Condylomata acuminata
Patient on warfarin with supratherpetuic INR. No active bleeding. What is the INR threshold that will cause you to give Vit K?
INR > 9
In patients with breast cancer who develop findings suspicious for mets, what is the next steps? Why?
Patients with a history of early breast cancer who develop findings suspicious for metastatic breast cancer should undergo biopsy of one of the suspected metastatic sites to confirm the diagnosis and to assess hormone receptor and HER2 status, as these may differ from the original cancer.
Patient with pheochromocytoma. Other diagnoses most likely to develop as well?
Medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism occur in patients with multiple endocrine neoplasia type 2A (MEN2A).
Patient recently diagnosed with metastatic gastric cancer. Before selecting a systemic chemotherapy regimen, which genetic test run on the tumor biopsy specimen would be most helpful for choosing a regimen?
Determination of HER2 tumor status is indicated for patients with newly diagnosed metastatic gastric cancer, as the anti-HER2 monoclonal antibody trastuzumab, when added to a systemic chemotherapy regimen, is beneficial in treating patients whose tumors overexpress HER2.
Which meds to use in HCM?
Negative inotropic agents, such as β-receptor antagonists, calcium channel blockers, and disopyramide, are the cornerstone of medical therapy in these patients.
Which BP meds to avoid in HCM?
Lisinopril and Thiazides
treatment for patient with prolactinoma?
Cabergoline - a dopamine agonist
First step in tx of patient with new cord compression from newly discovered multiple myeloma?
High dose IV steroids
Later consider radiation or Neurosurgery
Diagnose inclusion body myositis:
Inclusion body myositis has an insidious onset, with muscle weakness that may be diffuse and involve both the distal and proximal muscles. Skin spared.
Diagnose Amyotrophic Lateral Sclerosis:
Amyotrophic lateral sclerosis is characterized by progressive dysfunction of both upper motoneuron and lower motoneuron pathways in one or more areas of the body. Common upper motoneuron features are spasticity, hyperreflexia, and pathologic reflexes, including extensor plantar responses. Typical lower motoneuron features are muscle weakness, atrophy, fasciculations, and cramps. These findings are not present in the patient.
Basics of diagnosing Paroxysmal Nocturnal Hemoglobinuria
Findings diagnostic of paroxysmal nocturnal hemoglobinuria include hemolytic anemia, hypocellular bone marrow, and lack of CD55 and CD59.
What testing should be done to identify chronic thromboembolic pulmonary hypertension (CTEPH)?
VQ scan
How to treat AIN?
Stop offending agent (if drug related)
MOnitor creatininine
Steroids controversial, only use if patient is not responding
Topical steroid that can be used on skin thin, like eyelids?
hydrocortisone valerate
which supplement is vitally important in management of Multiple Sclerosis?
Vitamin D
How to treat inpatient with PID?
Cefoxitin and IV Doxycycline
OUtside the hospital, use IV dose of ceftriaxone and then 14-day course of doxycycline
Diet lifestyle changes to reduce gout flares
- Low-fat dairy products have been shown to decrease the risk of gout flares both through uricosuric and anti-inflammatory properties.
- reduce intake of high-fructose beverages such as soft drinks because they are associated with gout flares due to metabolic pathways utilized in the metabolism of fructose, which lead to increased uric acid generation.
- Obesity is also a risk factor for gout
How to best manage hypothyroidism in pregnancy?
- Maternal thyroid hormone production typically increases by 30% to 50% during pregnancy
- The replacement dose usually needs to be increased to provide adequate thyroxine (T4) for the neurologic development of the fetus
What are the COPD Gold ABCD categorized?
Group A: 0-1 exacerbations in 1 year. mMRC 0-1. CAT < 10.
Group B: 0-1 exac in 1 year. mMRC 2 or +, CAT 10 or +.
Group C: 2+ exac in 1 year. mMRC 0-1, CAT <10.
Group D: 2+ exac in 1 year. mMRC 2 or +, CAT 10 or +.
Therapy for A, B, C, and D Gold categories of COPD?
Group A: short acting inhaled bronchodilator PRN
Group B: short-acting inhaled bronchodilator PRN and a long-acting bronchodilator
(Alternative: Combination LAMA/LABA)
Group C: Inhaled glucocorticoid plus a LABA or monotherapy with a LAMA.
(Alternative: LAMA plus inhaled glucocorticoid or LABA, or a phosphodiesterase-4 inhibitor and a long-acting bronchodilator)
Group D: short-acting bronchodilator as needed and inhaled glucocorticoid and a LABA and/or a LAMA, and pulmonary rehabilitation.
(Alternative triple combinations of two long-acting bronchodilators and an inhaled glucocorticoid; an inhaled glucocorticoid plus a LABA and PDE-4 inhibitor; or double combinations of two long-acting bronchodilators, or a LAMA and PDE-4 inhibitor)
Features of small cell lung cancer?
- Typically presents on imaging as a large hilar mass with bulky mediastinal lymphadenopathy.
- Signs and symptoms of cough, hemoptysis, chest pain, hoarseness, and dyspnea
- May present with various paraneoplastic syndromes
- Because of their rapid growth rate, these tumors are rarely found incidentally
- SCLC tends to be more aggressive than non–small cell lung cancer (NSCLC); it is usually already disseminated at presentation but is usually more sensitive to chemotherapy and radiation therapy initially. Often chemo started during initial hospitalization
The triad of hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit in a patient with systemic lupus erythematosus. Dx?
The triad of hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit is highly predictive of underlying diffuse alveolar hemorrhage associated with systemic lupus erythematosus.
Patient has with foot rash:
presents as a pruritic serpiginous, red plaque that migrates at a rate of a few millimeters to centimeters per day
Dx?
Tx?
Dx: Cutaneous Larva Migrans
Tx: Ivermectin or Albendazole
Explain the stratgey for treatment of Burkitt Lymphoma?
Patients with Burkitt lymphoma always warrant aggressive and immediate therapy with combination chemotherapy (R-hyper-CVAD) and aggressive intravenous hydration, urine alkalinization, and administration of allopurinol or rasburicase.
R-Hyper-CVAD is Rutuximab, hyperfractionated Cyclophosphamide, Vincristine, Doxorubicin (anthra), and Dexamethasone
Clarithromycine, Amoxicillin, and PPI can be used to treat what kind of tumor?
Because of their association with Helicobacter pylori infection, gastric mucosa-associated lymphoid tissue lymphomas can often be induced into complete and durable remission with the combination of antimicrobial agents and a proton pump inhibitor such as amoxicillin, clarithromycin, and omeprazole without the need for additional chemotherapy.
What medication can be used to treat infection from bioterrorism anthrax?
Ciprofoxacin
Or Levfloxacin, Moxifloxacin, Doxycycline
When to screen inflammatory bowel disease patients for colon cancer? How frequently after initial screening?
Patients with long-standing colitis associated with inflammatory bowel disease are at increased risk for colon cancer and should undergo surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years of disease.
Explain type 4 renal tubular acidosis
Patients with type 4 (hyperkalemic distal) renal tubular acidosis typically present with hyperkalemia, a normal anion gap metabolic acidosis, and impaired urine acidification, but with the ability to maintain the urine pH to <5.5.
Explain type 1 Renal tubular acidosis
Type 1 (hypokalemic distal) RTA results from a defect in urine acidification in the distal tubule with impaired excretion of hydrogen ions and a normal anion gap metabolic acidosis. this tubular defect also results in potassium wasting and hypokalemia
Explain type 2 renal tubular acidosis
Type 2 (proximal) RTA involves a defect in regenerating bicarbonate in the proximal tubule and is characterized by hypokalemia, glycosuria (in the setting of normal plasma glucose), low-molecular-weight proteinuria, and renal phosphate wasting
Which types of polyps require 3 year follow-up colonoscopy screening?
For patients with large (≥10 mm) or dysplastic sessile serrated polyps or traditional serrated adenomas, the recommended postpolypectomy surveillance colonoscopy interval is 3 years
Normal schedule for Hep B vaccination?
What if someone gets a dose too late?
1, 2, 6 month schedule
If a dose is done too late (off schedule) then just pick it back up (DO NOT need to redo the series)
When to resplace an aortic valve in a n asymptomatic patient?
When aortic stenosis is severe
When is surgery to repair or replace the ascending aorta in adults with a bicuspid aortic valve recommended?
when the ascending aorta diameter is greater than or equal to 5.5 cm or progressive dilatation occurs at a rate of 0.5 cm per year or greater.
How to identify de Quervain (subacute granulomatous) thyroiditis?
low radioactive iodine uptake (RAIU) and painful thyroid on examination in context of thyrotoxicosis
What medicine would be the most appropraite to give a patient with thyrotoxicosis 2/2 subacute granulomatous (de quervain) thyroiditis?
Metoprolol
Blocking further release of thyroid hormones with a thionamide (either methimazole or propylthiouracil) is ineffective because the thyroid has already released preformed thyroid hormone into the bloodstream and is currently not producing or secreting additional thyroxine.
With Tuberculin skin test, for which set of patients is a 5mm or larger induration considered a positive test?
tuberculin skin test (TST) reaction of 5-mm or larger induration is interpreted as positive in patients who are immunosuppressed, including those who are taking tumor necrosis factor α inhibitors or the equivalent of at least 15 mg/d of prednisone for 1 month or longer.
Or patients with HIV infection, organ transplants, and fibrotic changes on chest radiograph consistent with old tuberculosis, and recent contacts of a person with active tuberculosis
Which chemo drugs have been linked to Thrombotic Microangiopathy?
Chemotherapeutic agents known to be associated with TMA include mitomycin C, gemcitabine, tyrosine kinase inhibitors, mammalian target of rapamycin (mTOR) inhibitors (sirolimus, everolimus), and anti-vascular endothelial growth factor (VEGF) inhibitors
Classic Features of thrombotic microangiopathy?
microangiopathic hemolytic anemia, a low platelet count, and kidney dysfunction.
Lab test for dx of Granulomatosis with Polyangiitis (wegener’s)?
Anti-Pr3
antiproteinase 3 antibodies are sufficient to establish a diagnosis of granulomatosis with polyangiitis in patients with classic upper airway manifestations, pulmonary infiltrates/nodules, and urinary abnormalities consistent with glomerulonephritis.
What should you recommend to prevent progression of moderate age-related macular degeneration?
High-dose antioxidant vitamins are indicated to prevent the progression of moderate dry age-related macular degeneration (AMD) to advanced AMD.
54yo F with an episode of pancreatitis 1 year ago. Presents with renal failure, pyuria, enlarged kidneys. Dx?
IgG4-related disease is characterized by infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4 levels.
Patient with focal pancreatic enlargement with a featureless rim and a nondilated pancreatic duct, increased serum IgG4 level, and extrapancreatic organ involvement (sclerosing cholangitis or IgG4-associated cholangitis). Dx?
This patient has evidence of type 1 autoimmune pancreatitis. Almost all patients (>90%) enter clinical remission in response to glucocorticoids, but relapse is common.
First line for status epilepticus
1st and 2nd meds given:
Lorazepam
Then Phenytoin
Diagnosis:
Severe pancytopenia and hypocellular bone marrow after BMbx
Aplastic anemia
A 56-year-old man diagnosed with gout 4 months ago based on recurrent episodes of podagra and a serum urate level of 7.2 mg/dL (0.42 mmol/L). Colchicine and allopurinol were initiated at that time and have been maintained at their initial doses. History is also significant for chronic kidney disease and hypertension, for which he takes losartan.
Current laboratory studies reveal a serum urate level of 6.4 mg/dL (0.38 mmol/L) and a serum creatinine level of 2.1 mg/dL (185.6 µmol/L).
Next steps?
According to the 2012 American College of Rheumatology gout guidelines, gradual dose escalation of allopurinol, with monitoring for side effects, is a safe approach for patients (even those with chronic kidney disease) with gout who have not reached a target serum urate level of less than 6.0 mg/dL (0.35 mmol/L).
So INCREASE allopurinol
Age at which a medication needs to be added to cover listeria meningitis when empirically covering for meningitis?
What medication?
In patients over 50 or those with immune compromise
Add Ampicillin to empirically cover listeria
I Patient with asthma and 6 weeks pregnant is on inhaled glucocorticoids, β2-agonists, and montelukast.
Given pregnancy how should you adjust asthma regimen?
All these meds are safe in pregnancy
How often should you do surveillance EGD’s in patient with Barrett’s Esophagus and no dysplasia?
In patients with Barrett esophagus and no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years.
A 27-year-old woman at 30 weeks’ gestation is evaluated during a routine examination. She is gravida 2, para 1, and delivered her first child vaginally without complications 20 months ago. During her first pregnancy, she received the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine.
Next step for vaccines? td vs tdap?
Pregnant women should receive a single dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine between 27 and 36 weeks’ gestation during each pregnancy, regardless of when they last received either the tetanus and diphtheria (Td) or Tdap vaccine.
How can you tell the difference between chronic hypertension, gestational HTN, and pre-eclampsia?
Before 20th week, its all just chronic HTN
After 20th week, no eclampsia features is gestational
After 20th wk, end-organ damage such as proteinuria, kidney dysfunction, thrombocytopenia, abnormal liver chemistry tests, pulmonary edema, and cerebral or visual symptoms.
Asymptomatic patient with recent homeless shelter roommate has active tb. CXR normal. TST is 7mm. What should you do with this person?
TST reaction of 5-mm or larger induration is interpreted as positive in patients who have recently been in contact with a person with active tuberculosis. A TST reaction of 10-mm or larger induration is interpreted as positive in patients who use injection drugs, are recent arrivals from countries with a high prevalence of tuberculosis, or reside in homeless shelters. Treatment for LTBI with isoniazid for 9 months is recommended
Which blood pressure medications are beneficial for HTN as well as preventing gout?
The angiotensin receptor blocker losartan and calcium channel blockers lower serum urate and may be useful to treat patients in whom hypertension and gout are both clinical concerns.
1st line tx for H. Pylori?
two 2nd line treatments?
1st: Clarithromycin, AMoxicillin, PPI (10 days)
2nd: Levofloxacin, Amoxicillin, PPI (10 days)
or Bismuth, Metronidazole, Tetracycline, PPI (10 days)
First line treatment for localized impetigo infection?
Mupirocin ointment
Indications for parathyroidectomy in asymptomatic patients with primary hyperparathyroidism?
CKD, nephrolithiasis, serum calcium level 1 mg above upper limit of normal, DEXA T-score of −2.5 or worse
Patients with these indications are considered to have the highest potential benefit from surgery.
Skin biopsy shows malignant melanoma, superficial spreading type, and measuring 1.4 mm in thickness, with invasion into the reticular dermis but not into the subcutaneous tissue. No lymphovascular invasion. What are the two most important next steps?
A 2-cm excision margin is appropriate for melanomas that are 1 mm thick or deeper.
Sentinel lymph node biopsy is recommended for patients with melanomas of 1- to 4-mm thickness to provide accurate staging, as metastasis to regional lymph nodes is the most important prognostic factor in patients with early-stage melanoma.
How should you evaluate a palpable breast mass?
Does eval change according to age?
A palpable breast mass always requires further evaluation with either mammography or ultrasonography; ultrasonography is a more sensitive test in women younger than 35 years.
What testing is used to diagnose adrenal insufficiency. Explain some of the nuances please.
So first test is morning cortisol.
Less than 3 and you know its adrenal insuff
4-12 And you’re not sure
13 or more and it’s a no
If it’s between 4 and 12, then you need to order an ACTH stim test
Remember! Do NOT hold therapy for adrenal insuffienc while waiting for labs
How to treat adrenal insufficiency
Treatment of primary adrenal failure requires both glucocorticoid and mineralocorticoid replacement. Hydrocortisone or another long-acting agent with primarily glucocorticoid activity should be given along with a mineralocorticoid agent such as fludrocortisone.
Patient with newly metastatic melanoma. What mutation should the tumor be tested for?
all patients with metastatic melanoma should have their tumor tested for the presence of driver V600 BRAF mutation to determine whether treatment with a BRAF inhibitor is a therapeutic option.
How to treat spinal cord mass causing cord compression? When mass is myleoma or plasmcytoma?
Use radiation, these cancers are exquisitely sensitive to radiation tx
How to treat patient presenting with cervicitis?
Ceftriaxone and azithro
It is important to differentiate cervicitis from vaginitis because the treatments differ. Cervicitis, characterized by an inflamed and friable cervix, is typically caused by gonorrhea and chlamydia. Vaginitis refers to inflammation of the vagina and is caused by infections such as candidiasis and trichomoniasis or by noninfectious conditions such as atrophic vaginitis or vaginal irritation.
Patietn diagnosed with papillary thyroid cancer by FNA. What is next diagnostic step before surgery?
US of cervical lymph nodes to check for mets
best antipsychotic in Alzheimer pt with delirium, posing threat to self or others?
Quetiapine
Pathways for treatment in newly diagnosed metastatic non-small-cell lung cancer:
1) EGFR mutation
2) EML4/ALK
3) ROS1
4) no mutation
1) EGFR mutation: use Erlotinib
2) EML4/ALK: Crizotinib and ceritinib
3) ROS1: Crizotinib and ceritinib
4) No mutation: Pembrolizumab
Classic triple therapy for H Pylori?
Which drug should be switched out due to resistance in an area or previous treatment with drugs of same class?
Clarithromycin, PPI, Amoxicillin
In areas of resistance or previous macrolide use ->
Change Clarithromycin to Levofloxacin (or other combo)
How to treat hepatitis C in patient with ESRD and who was resistant to initial tx for Hep C?
he combination of grazoprevir and elbasvir is an FDA-approved treatment for hepatitis C virus genotype 1 infection in patients with stage 4 or 5 chronic kidney disease.
YOung woman with abnromal menstrual bleeding every 10-14 days. Negative pregnancy. Most likely cause and tx?
Luteal phase problem
try oral contraceptives
If bleeding was at normal menstrual intervals then you would consider fibroids
You suspect a patient has cryoglobulinemia
(joint aches, palpable purpura, no signs of renal/pulm involvement). What lab should you always order?
Hepatitis C
How to treat DIC?
Fresh frozen plasma, cryoprecipitate (and sometimes platelets)
Tx for TTP?
Plasma exchange
echo findings in hypertrophic cardiomopathy?
asymmetric septal thickening
tx for symptomatic HCM?
beta-blockers
What medicion for BP in patient with scleroderma renal crisis?
Captopril IV, then titrate!
Which type of cancer can cause SIADH, lambert eaton myasthentic syndrome, and ACTH secretion?
small cell lung cancer
leads for inferior MI?
II, III, AVF
Anterior MI leads?
v3, v4
Anterolateral MI leads?
I, AvL, v3, v4, v5, v6
Order of events for patient with very suspicious presentation for meningitis?
Order blood cx Order IV dexamethasone Order Abx Get LP (CT scan only necessary if high concern for space-occupying lesion)
How to eval hot thyroid nodule in elderly patient?
Get radioactive iodine uptake test
treatment for advanced stage prostate cancer?
androgen depreivation: via LHRH agonist like leuprolide
AND
Androgen receptor antagonist: like flutamide or bicalutamide
At what renal threshold is metformin contraindicated?
eGFR of < 30
Components of dermatomyositis?
photsensitive, pruritic rash,
proximal muscle weakness
classic heliotropic rash
gottron papules
agent used to reverse overdose with tricyclic antidepressant?
Sodium bicarb
Hormonal lab findings in Klinefelter’s?
High FSH and LH
+ Small testes
Day 5 after STEMI, patient has new systolic murmur and is acute short of breath. Cause?
Ruptured papillary muscle
post-herpetic neuralgia first line tx?
gabapentin and pregabalin
What blood malignancy can occur more often in patients with Sjogren’s syndrome?
Non-hodgkin lymphoma
large percentage of patients with polyarteritis nodosa have which infectious disesae?
Hep B
Whenever a pituitary adenoma is found, what labs need to be checked?
IGF-1 (measure growth hormone)
Dexamethasone suppression test
PRL (serum prolactin)
runner has pain at the anteromedial knee. Worse with clibming stairs. Dx?
Pes anserine bursitis
transplant med that increase risk of gout?
cyclosporine
what is antihistone used to test?
Drug-induced lupus
Appropriate vent settign for asthma patient?
low respiratory rate, high flow, low tidal volume
most common ovarian cancer type?
Epithelial cell carcinoma
Patient on warfarin for afib - gets a stent placed for MI. What is next step in medical mangement?
Add clopidogrel and continue warfarin
treatment for patient with mild histoplasmosis, less than 4 weeks of symptoms?
no tx
treatment for mild histoplasmosis >4 weeks of sx?
treatment for severe or disseminated histoplasmosis?
- itraconazole
- Amphotericin B
40 year old patient with a few weeks of headache presents with a very high BP. Also notable orthostasis. What should you check?
Check for pheochromocytoma
Measure 24 hour urine metanephrines or plasma metanephrines
CML treatment initial?
Hydroxyurea to lower WBC count
Tyrosine Kinase Inhibitor (like Imatinib)
What is the diagnosis? Patient has spinal compression fracture, hypercalcemia, hypokalemia, hypophosphatemia, hypourisemia, elevated creatinine, and anemia.
Fanconi syndrome
What causes hereditary angioedema?
low levels of C1 inhibitor
middle-aged white male with diarrhea, fat malabsorption, weight loss, CND involvement, and recurrent bouts of inflammatory arthritis. Diagnosis?
Whipple disease
treatment for tetanus in patient with recent wound and now having sx of lockjaw:
tetanus toxoid, tetanus immunoglobulin, metronidazole
other issue assoicated with PCKD?
aneurysms
50yo with panctyopenia, bone marrow with hypercellularity adn 45% blasts. Blasts positive for myeloperoxidase. dx?
AML.
Myeloperoxidase is marker in AML
Patient with HIV, CD4 <50. Has developed a wasting syndrome with fevers, lymphadenopathy, weight loss, night sweat, diarrhea, and splenomegaly.
Dx?
Test needed for dx?
Mycobacterium Avium-intracellulare Infection
Get an acid fast blood culture (AFB)
treatment for HIV patient who has developed CMV retinitis?
Ganciclovir
side effects of cisplatin:
nephrotox
ototox
nausea/emesis
SE asia prophylaxis drug?
Atovaquone/Proguanil
To avoid malaria
Types of cells seen and bone marrow findings in MDS?
Hypercellular marrow
Pseudo-Pelger-Huet cells
Pancytopenia and hypocellular bone marrow. Dx?
Aplastic Anemia
why annual TTE for patient with CREST?
screening for pulmonary HTN
AIDS, low CD4, palatal ulcer, ohio river valley. Dx?
Histoplasmosis
Hereditary angioedema involved malfunction of what protein?
c1 esterase inhibitor
Describe post-exposure prophylaxis for healthcare worker who has blood contact with HIV?
4 week of 3 drug regimen
emtricitabine, rategravir, tenofovir
egg shell calcifications, dx?
silicosis
40-60yo, upper and lower motor neuron sx, normal sensation.
Dx?
Lou Gehrigs
What do you do for a woman diagnosed with atypical ductal hyperplasia?
Try Tamoxifen ppx for 5 years to prevent progression to invasive breast cancer
seborrheic dermatitis tx?
ketoconazole cream
Anti-smith?
SLE
Anti-topoisomerase antibodies (Anti-SCL-70)?
diffuse systemic scelrosos
anti-centromere antiodies?
limited systemic sclerosis
Anti-histone antibodies?
Drug-induced lupus
anti-mitochrondral antibody?
primary biliary cholangitis
what can be done to reduce recurrence of calcium oxalate kidney stones?
reduce animal protein in diet
citrate supplements
thiazide diuretics
medication for obstruction HCM?
beta blockers
common medicine frequenlt causing hyperkalemia?
bactrim
Small vessel vasculitiies like GPA, microscopic polyangiitis, and eosinophilic granulomatosis with angiitis show what on biposy?
pauci-immune crescenteric glomerulonephritis
Why is it a bad idea to mix clarithromycin with statins/fibrates?
high risk of rhabdo
ACE and renal artery stenosis?
Often exagerate response in Bp lowering
Patient with hx of congential retinoblastoma. Risk of what type of cancer in future?
osteosarcoma
treatment of drug-induced TTP?
no plasmapheresis!
Instead remove offending agent and supportive care
lupus nephritis treatment?
steroids and mycophenolate mofetil for induction
common cause of burr cells?
liver disease
New HIV. How to treat new patient?
Regardless of viral load or CD4, first check resistance. If sensitive then start: Tenofovir, emtricitabine, and integrase inhibitor
Which common med can lead to b12 deficiency?
PPI’s due to poor absorption
Most common cardiac problem stemming from lyme disease?
AV conduction problems
unilateral headache, constricted pupil, cholesterol emboli on fundoscopic exam. Dx?
Internal carotid artery dissection
First degree relative with CRC diagnosed before age 60. What are screening guidelines for their family members?
Begin 10 years younger than their dx. Screen with colonoscopy every 5 years
Common abx that can raise levels of theophylline?
Cirpofloxacin, erythromycine
also cimetedine, propanolol
Patient with sickle cell who develops sudden severe anemia and low reticulocyte count. Problem?
Parvovirus b19 infection
Most sensitive and specific tests for ankylosing spndylitis?
Sensitive: HLA-B27
Specific: MRI of hips
Difference in presentation of most MI papillary muscle rupture and free wall rupture?
Ventricular free wall rupture: chest pain, shock, new systolic murmur \that is loud and has a thrill
Papillary muscle: new systolic murmur, but murmur is quieter and doesn’t have a thrill
medication to stabilize mast cells?
cromolyn
Which 2nd degree heart block requires pacer?
2nd degree type 2, with the long fixed PR and dropped beats
Repeat colonscopy timeline:
- hyperplastic polyps
- 1-2 small (<1cm adenomas)
- 3-10 adenomas
- villous adenoma
- Adenoma >1cm
- 10+ adenomas
- Adenoma large enough to be reomced piecemeal
- hyperplastic - 10 years
- 1-2 small adenomas - 5 years
- 3-10 adenomas - 3 years
- villous adenoma - 3 years
- Adenoma >1cm - 3 years
- 10+ adenomas - <3 years
- Adenoma large enough to be removed piecemeal 2-6 months
Components of qSOFA score for sepsis?
RR >22
Altered mental status
systolic BP <100
Explain which types of adenomas on colonoscopy warrant a repeat colonoscopy in 3 years?
- Adenoma 10mm or larger
- Three to ten adenomas
- Adenoma with a villous component (tubulovillous, villous)
- Adenoma with high grade dysplasia
Patient with 25mm polyp found on screening colonoscopy, when should they get their next colonoscopy?
in 3-6 months
larger than 20mm or removed piecemeal should wait 3-6 months
On screening colonoscopy patient is found to have 2 tubular adenomas, one is 9mm and then other is 6mm - both removed. When should next colonoscopy be done?
5 years
patients with 1-2 tubular adenomas are considered low risk and should have repeat in 5 years
Once a patient has a dx of Lynch syndrome, what does their cancer screening look like?
- Colonoscopy every 1-2 years
- Annual US of urinary tract
- Women should get annual transvaginal US w/ endometrial bx
- Upper endoscopy every 2-3 years w/ antrum bx
- Regular UA’s
What should be tested for in a patient with incidentally discovered adrenaloma on imaging?
- Low dose dexamethasone suppression test (eval for subclinical cushing syndrome)
- 24 hr urine metanephines/catecholamines or plasma free metanephines (eval for pheochromocytoma)
- If hypertensive: check plasma aldosterone to plasma renin ratio (eval for hyperaldosteronism)
What pulmonary condition is associated with dermatomyositis?
interstitial lung disease
Imaging that can help risk stratification for patients with hypertrophic cardiomyopathy?
cardiac MR
Options for treatment of pyoderma gangrenosum?
prednisolone and cyclosporine are equally efficacious treatments for pyoderma gangrenosum; therefore, the choice of treatment should be based on the side-effect profiles or patient preference.
