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ABIM prep > AR HY review 2 > Flashcards

AR HY review 2 Flashcards

1
Q

Dysphagia to liquids and solids d/t what?

Dysphagia to solids d/t what?

A

Dysphagia

solids and liquids: motility problem (DES, scleroderma, achalasia)

solids alone: physical obstruction (carcinoma, stricture, ring)

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2
Q

Dysphagia to solids and

  • >50 yo:
  • heartburn
  • intermittent dysphagia (first bite dysphagia)
A

Dysphagia to solids

  • 50 yo: consider cancer (older patients)
  • heart burn: stricture (as complication of chronic GERD; older patients)
  • intermittent (first bite): esophageal ring (younger patients)
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3
Q

Dysphagia to solids and liquids:

  • intermittent with chest pain
  • progressive with heartburn
  • progressive with regurgitation
A

Dysphagia to solids and liquids:

  • intermittent with chest pain: DES
  • progressive with heartburn: scleroderma
  • progressive with regurgitation: achalasia
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4
Q

Oropharyngeal dysphagia: wtd to dx?

A

barium swallow

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5
Q

DES finding on diagnostic studies:

DES rx1 and rx2?

A

barium swallow→corkscrew esophagus

manometric studies→nonperistatic contractions

rx1: PPI
rx2: CCB (diltiazem)

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6
Q

Young patient with dysphagia at first bite, then rest of swallowing is ok. May have some reguritation. dx? rx?

A

Schatzki’s ring (distal esophagus; often younger patients)

rx: pneumatic dilation

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7
Q

Suspect Zenker diverticulum: wtd

Suspect achalsia: wtd

A

Zenker: barium swallow then EGD

achalasia: EGD (r/o cancer) the barium swallow even if EGD is normal and suspicion is high

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8
Q

HIV patient with dysphagia, odynophagia. Rx with systemic fluconazole d/t suspected esophageal candidiasis does not help. next steps?

A

odynophagia in HIV patient not resolve with fluconazole

EGD

  • one large ulcer: CMV
  • multiple small ulcers: HSV (also seen in pill esophagitis)
  • multiple white plaques: resistant candidia→give echinocandins
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9
Q

Pt with chronic GERD, now has progressive dysphagia to solids. dx?

A

peptic stricture d/t chronic GERD

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10
Q

Pt with stroke history has residual deficits. Now has coughing and choking with some regurgitation. best to dx?

A

modified barium swallow→dysphagia d/t stroke

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11
Q

Pt with GERD, treated empirically on PPI, better after 3months. wtd next?

A

discontinue PPI, or continue PPI at lowest effective dose, or switch to H2 blocker to avoid chronic PPI complications.

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12
Q

What test to do before laproscopic funduplication?

A

Manometry to confirm good peristalsis, other wise achalasia will result from the procedure.

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13
Q

Endoscopy for GERD show metaplasia (i.e Barrett esophagus). wtd

A

PPI for life

EGD + bx in 1 year after initial dx and if no dysplasia

EGD q3y to follow up if no dysplasia continues

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14
Q

Endoscopy for GERD or metaplasia is indefinite for dysplasia. wtd?

A

PPI and EGD in 2-6mo

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15
Q

EGD for Barrett’s show dysplasia. wtd?

A

refer bx sample to esophogeal pathologist and if confirmed get endoscopic radio frequency ablation

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16
Q

Pt with hx of forceful emesis, now has severe CP worse with swallowing and breathing. CXR with pleural effusion and subcutaneous emphysema. Pleural fluid amylase increased. dx? wtd?

A

Dx: Boerhaave (esophageal rupture)

Get water-soluble swallow study (Gastrographin)

Get immediate surgical consult this has a high mortality rate

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17
Q

Pt on PPI 8 weeks while in hospital. PPI discontinued abruptly after discharge. Likely consequence

A

New GERD symptoms due to PPI rebound

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18
Q

Types of gastritis

A
  • Atrophic/Chronic (with type A (autoimmune) and type B (H pylori)
  • Erosive: ETOH, NSAIDs, critically ill patient
  • Acute: infectious
  • Eosinophilic: younger patients
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19
Q

Autoimmune chronic/atrophic gastritis features

A

Type A: autoimmune. Often clinically silent

  • In body and fundus usu. Loss of rugae and lots of polyps. Intestinal metaplasia
  • Achlorydia and inc gastrin production.
  • risk of adenocarcinoma.
  • etio: pernicious anemia (B12 deficiency)
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20
Q

Younger patient with dysphagia to solids and iron deficiency anemia. dx? rx?

A

dx: Plummer Vinson: webs (causing dysphagia) and IDA
rx: treat IDA and webs go away

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21
Q

H pylori atrophic/chronic gastritis features

A

H pylori atrophic/chronic gastritis. initial symptoms on infection then usually clinically silent

  • location: antrum/cardia usually
  • incr gastrin → incr acid → ulcers in 15%
  • may also cause atrophic gastritis (decr acid) if infection is in gastric body (less common)
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22
Q

Erosive gastritis features

A

Erosive gastritis: often asx but can have dyspepsia and UGIB

  • alcoholics, NSAIDs, critically ill patients (vent, shock, sepsis, burns, surgery)
  • usu no inflammation but does have hemorrhage and erosions. GIB is usually minor.
    *
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23
Q

MCCs of PUD (3)

A
  • NSAIDs
  • H pylori
  • Zollinger Ellison syndrome
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24
Q

Intermittent dysphagia: two causes

A
  1. DES (solids and liquids; often pain with swallowing more than difficulty swallowing)
  2. Schatzki ring (solids)
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25
Q

Screening for Barrett esophagus in who?

A

>50y men with chronic GERD. If not there, then no need for further follow up studies

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26
Q

Pt with giant ulcers (>2cm), ulcers refractory to nl treatment, frequent recurring ulcers, multiple ulcers (esp if distal to duodenal bulb) or ulcers with hypercalcemia? wtd

A

Suspect Zollinger-Ellison; get gastrin level

gastrin (and thus acid) hyper-secreting tumors

diarrhea is a common symptom with ulcers

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27
Q

Things that cause gastrin hyper-scretion

A
  • Z-E syndrome
  • PPI
  • Atrophic gastritis
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28
Q

Tests to get if suspect Z-E syndrome?

A
  • Gastrin (after stopping PPI)
  • Serum calcium (r/o MEN syndrome)
  • PTH (r/o MEN syndrome)
  • Prolactin (r/o MEN syndrome)
  • LH, FSH, GH
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29
Q

Pt suspected of or with PUD on PPI or GIB should undergo what test for H pylori?

A

urea breath or stool Ag

hold PPI (2 weeks) and abx (4 weeks) before testing

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30
Q

triple therapy Rx for PUD d/t H pylori

A

PAC: PPI, amoxicillin, clarithromycin

PMC: PPI, metronidazole, clarithromycin

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31
Q

quad therapy Rx for PUD d/t H pylori

A

Lead mountain: PB MT

PPI, bismuth, metronidazole, tetracycline

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32
Q

Rx for MALT?

A

triple or quad therapy for underlying PUD d/t H pylori

MALT is a type of NHLymphoma, usu presents with complicated GERD (wt loss, bleeding, anorexia, dyspepsia, etc)

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33
Q

wtd if EGD finds gastric ulcer?

A

get Bx!

Bx not usually needed for duodenal ulcers

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34
Q

Pt with active GIB, HR 120, BP 87/66, hgb 9.7. wtd?

A

Transfuse. pt is hypotensive and actively bleeding. Transfuse if hgb < 10 in this scenario

35
Q

Hospitalized patient with EGD: ulcer < 2cm clean base, no bleeding. wtd?

A

PPI and discharge to home (or d/g to floors)

36
Q

Hospitalized patient with EGD: bleeding ulcer, s/p APC or electrocautery. wtd?

A

monitor 72 hr on PPI before discharge

37
Q

Pt with hx long or violent retching now with coffee ground emesis. Pt is known alcoholic or bulemic. Has epigastric pain or pain back pain. wtd?

A

EGD to r/o Mallory-Weiss (partial thickness) tear in esophagus

(Boerhaave pt will be HD unstable and have subq emphysema)

38
Q

Possible side fx of PPI

A
  • B12 def
  • diarrhea (microscopic colitis)
  • AIN
  • C diff incr risk
  • HAP incr risk
  • osteoporosis (if chronic use)
  • hypomagnesemia
39
Q

Pt with suspected/new dx of cirrhosis. wtd?

A

get EGD to screen for varices

40
Q

Pt with cirrhosis and ascites comes with variceal bleed. Tap reveals 150 WBCs and 40% PMNs wtd?

A

Variceal bleed: wtd?

  • octreotide and band varices
  • Start CTX prohpylactically even if no SBP (WBC 250 or greater). This has mortality benefit
41
Q

47y M comes with coffee ground emesis. He drinks 2 glasses of wine/day. VSS, afebrile. Endoscopy shows no ulcer but does have gastric varices. wtd? dx?

A

wtd: CT abdomen
dx: splenic vein thrombosis

(causes gastric not esoph varices)

42
Q

Pt with hx of gastric bypass or has motility issues. B12 deficiency, fatty stools, abd pain, diarrhea. Breath test abnormal dx? rx?

A

dx: SIBO
rx: rifaxamin 1st line. otherwise cipro or augmentin

43
Q

Pt with severe pancreatitis, high LFTs and bili, dilated CBD. On IV abx in the MICU. wtd?

A

ERCP to remove stone, cholecystecomy before discharge

44
Q

75y F s/p R hip replacment initially recovering well. POD 6 new RUQ pain, anorexia, fever 103, LFTs and bili mildly elevated. US show thick GB wall. HIDA with nonvisualization of GB, but CBD patent and normal size. dx? rx?

A

dx: acalculous cystitis
rx: cholecystostomy (needle drainage; not cholecystectomy)

45
Q

Pt with hx of UC now with jaundice and/or high alkaline phos. wtd?

A

MRCP/ERCP to rule out PSC, get brush biopsy to r/o cholangiocarcinoma if onion skin fibrosis is seen

46
Q

Pt with RUQ colicky pain (or may be asx) and RUQ or CT abdomen shows 1.1 cm GB polyp. wtd?

A

cholecystectomy for GB polyps > 1cm

47
Q

wWPt with vitiligo or some other AI disease come with epigastric pain and jaundice. LFTs and AlkP mildly elevated. US show large pancreas with sausage shaped mass with beaded appearance. IgG4 elevated. CBD dilated but pancreatic duct is constricted. dx?

A

autoimmune pancreatitis

48
Q

what lab is a poor prognostic predictor in acute pancreatitis?

A

BUN > 19

49
Q

Pt w incidental finding of calcification of GB. wtd?

A

surgery

50
Q

Asx pancreatic cyst found incidentally on CT scan. Worrisome features and wtd?

A

worrisome: solid component, >3cm, duct >10cm, thickening of cyst
wtd: if two or more worrisome features: EUS and FNA

51
Q

Pancreatic cyst size that likely not to resolve on its own?

A

Drain if 4cm or more

52
Q

Extra-intestinal manifistations mc in UC or Crohns?

what are they?

A

MC in UC

E. nodosum, arthritis, pyoderma gangrenosum, PSC, ankylosing spondylitis

53
Q

IBD more a/w higher risk of cancer?

IBD more a/w RLQ mass on PE?

IBD more a/w with abdominal pain than diarrhea?

IBD more a/w deep ulcers and fistulas?

A

higher risk of cancer: UC

RLQ mass: Crohn’s

higher risk of pain: UC

fistulas and deep ulcers: Crohn’s

54
Q

Best screening test for IBD

A

fecal calprotectin

55
Q

Pt. with ileal-anal anastomosis pouch. 1 y later has increased diarrhea with blood and low grade fever. Stool is c/s negative. Endoscopy reveals ulcers in pouch. dx? rx?

A

dx: pouchitis
rx: metronidazole

56
Q

MCC of TNF-a?

A

MCC of TNF-a?

PNA

may also cause reactivation of TB, histo, hepatitis

57
Q

Pt with UC 4 years now. Presents with jaundice and fever. AlkP, bili and liver enzymes are elevated. wtd?

A

UC pt with bili or jaundice:

get ERCP/MRCP to r/o PSC on any UC patient with high bili

58
Q

IBD a/w B12 def?

IBD gets better with smoking?

IBD a/w calcium oxalate stones?

IBD a/w granulomas?

A

a/w B12 def: Crohn’s (d/t ileal involvement)

better w smoking: UC

a/w Ca++ ox stones: Crohn’s

a/w granulomas: Crohn’s

59
Q

Pt with bloody diarrhea, had hamburgers at a park 2d ago (or unpasteurized milk). Platelets low. dx? rx?

A

dx: E coli O157:H7
rx: NO antibiotics–increases risk of HUS

to culture: add sorbitol to McConkey agar

60
Q

Food poisoning a/w vomiting predominantly

A

Food poisoning a/w vomiting predominantly

B cereus, Norovirus,

can also be Staph but this co-occurs with diarrhea

61
Q

Edlerly pt fever, diarrhea, AMS after eating soft cheeses. dx? rx?

A

Listeria

Ampicillin

62
Q

Toxins

a/w perioral parethesia and reversal of hot and cold

a/w flushing and urticaria

a/w weakness and ascending paralysis

A

Toxins

a/w hot/cold reversal: Ciguatoxin (large reef fish)

a/w urticaria: Scromboid poisoning

a/w ascending paralysis: tetrodotoxin (puffer fish)

63
Q

How to treat traveler’s diarrhea?

A

Traveler’s diarrhea: watery, usu no fever

rx: hydration, abx to shorten disease: Ciprofloxacin or azithromycin

64
Q

Travel to developing country, now months later with bloody diarrhea. Colonoscopy shows flask-shaped ulcers. dx? rx?

A

Dysentery with flask shaped ulcers

dx: amoebic colitis (E histolytica); get stool sample look for ova and cysts
rx: metronidazole

may also cause abscess in liver that usu do not need drainage

65
Q

Diarrhea, fever, elevated wbc, hx abx use. what to r/o?

A

C diff! any diarrhea with high WBC, rule it out

66
Q

Rx for C diff

1st infection

2nd, and 3rd, ocurrence

A

1st PO vanc

2nd PO vanc with long taper

3rd: fecal trxp

67
Q

Pt with hx C diff now comes with bp 90/60, HR 116, WBC 12000, temp 101, lacate 6, tender distended abdomen. dx? rx?

A

toxic megacolon

po and rectal vanc, flagyl, surgical transplant

68
Q

Pt with arthritis 2 years. Comes with abd pain, diarrhea. Stools are oily or watery, and he has weight loss and changes in skin pigmentation. Small bowel bx shows foamy macrophages and is PAS+. dx? rx?

A

Whipple disease (Tropheryma whipplei (any arthritis with diarrhea-consider this)

rx: CTX 2wk, + bactrim 1 year

69
Q

Pt with hx atrophic gastritis and pernicious anemia; abd pain chronic diarrhea, wt loss, B12 190 (nl) and folic acid is 18 (high)

wtd? dx? rx?

A

wtd: hydrogen or xylose breath test
dx: SIBO
rx: rifaxamin

70
Q

Any patient with oil stools/steatorrhea. What is the basic problem?

A

malabsorption

71
Q

52y F uses PPI and has watery diarrhea mostly in the day but some at night. No blood, fever, or wt loss. Extensive infectious and inflammatory w/u is negative TTg is neg. wtd? dx? rx?

A

wtd: flex sig with bx; inflammation in lamina propria
dx: microscopic colitis (NSAIDs, PPI, SSRI, DM)
rx: d/c offending agent →bismuth

72
Q

60 y M fever, high wbc, abd pain in LLQ. wtd? dx? test to avoid? rx?

A

wtd: CT with IV and oral contrast
dx: likely diverticulitis

test to avoid: colonoscopy or barium enema until 4 weeks s/p resolution

rx: CLD → cipro, flagyl if severe

73
Q

Pt with diverticulitis and 2 cm abscess. wtd?

A

Abx: cipro, flagyl. Drain abscess if >4 cm in size

74
Q

65y M with hx server AS comes with recurrent GIB. wtd? dx? rx?

A

AS with GIB

wtd: colonocopy: will see AVMs
dx: Heyde syndrome
rx: TAVR

75
Q

55y F with intermittent sharp severe abd pain for 1 year. US and CT is normal. Basic infectious w/u is nl. Pain is elicited on straight leg raise. dx?

A

dx: functional abdominal wall pain. No further imaging or labs is warranted.

76
Q

Hep A vaccine

series

for who

A

Hep A vaccine

series: 3 doses six months apart each
for: Hep C, MSM, travel to endemic area, chronic liver dz

77
Q

Acute Hep B infection (pos HBV Ag; pos HBV eAg) with symptoms (jaundice), labs (ALT 100, bili 6) high viral load (850k). wtd?

A

supportive care, no specific Rx for acute infection. 90% will clear it on their own, even if there is high viral load and significant labs

78
Q

HBV serology

acute infection:

carrier/chronic state:

vaccinated, never had dz

A

HBV serology

acute infection: HBsAg, HBeAg, HBcIgM

carrier/chronic state: HBsAb, HBVcIgG

vaccinated: HBsAb

79
Q

Nurse previously vaccinated against HBV. Now with needle stick. wtd?

A

Get antiHBsAb titer

>10 U/L = reassure

<10 U/L = booster shot

80
Q

Time limit between the two shots in HBV vacciation course?

A

no time limit

81
Q

When to treat chronic HBV?

what to treat with?

A

when: ALT or AST > 2x ULN or any cirrhosis or any immunosuppression
what: 1st line: tenofovir and entecavir

what 2nd line: lamivudine or PEG alpha interferon

decompensated cirrhosis: gets liver trxp

82
Q

Pregnant woman with HBV. wtd?

A

Tenofovir for mom, and HBV vax for new born

83
Q

If treating HBV with PEG alpha interferon. What to look out for?

A

PEG alpha interferon

  • this rx is NOT for cirrhotics
  • monitor TSH
  • many side fx: bone marrow suppression, psychiatric, AI dz, etc.

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