Block 2 Flashcards
1
Q
Most accurate test for aortic dissection
A
Angiogram
*Source MTB2
2
Q
Which is the triad of aortoiliac disease?
A
Leriche syndrome→hip, thigh, buttock claudication; impotence; symmetric atrophy of bilateral lower extremities
3
Q
How nitrates relieve ischemic symptoms of angina?
A
Systemic venodilation→↓cardiac preload→↓LV systolic wall stress→↓myocardial oxygen demand
4
Q
New onset hypertension in a young patient with epistaxis, tachycardia and tremor. Which test do you run?
A
Secondary hypertension due cocaine intoxication→urine drug screen
5
Q
Sudden posterior knee and calf pain with “crescent sign” most probably may suggest.
A
Ruptured popliteal Baker cyst
*But rule out deep venous thrombosis as well with ultrasound
6
Q
Clinical presentation of anterior spinal artery syndrome
A
Motor weakness, loss of pain and temperature sensation below the lesion
*Proprioception and vibratory sensation are spared
7
Q
Clinical presentation of Transverse myelitis
A
Rapidly progressive myelopathy:
- Motor weakness→from flaccid to spastic paralysis (UMNS)
- Autonomic dysfunction→bowel/bladder incontinence or retention, sexual dysfunction
- Sensory dysfunction→Pain, paresthesia, numbness with distinct sensory level (Ex, lowest spinal cord level with intact sensation). Proprioception and vibration compromised.
8
Q
Findings on the most useful studies for Transverse myelitis
A
- MRI→Enhancement of =>1 contiguous spinal cord segments, usually in thoracic cord without evidence of compression
- Lumbar puncture→CSF pleocytosis, elevated IgG
9
Q
Description of clinical presentation of cluster headache
A
- Acute onset of unilateral retro-orbital pain (excruciating, sharp, steady)
- Paroxysms onset during sleep, awakening, rapid peak, duration 90 minutes, 8 times daily, 6-8 weeks, remission up to 1 year
- Redness of ipsilateral eye, tearing, nasal congestion, flushing, no visual changes
- Ipsilateral Autonomic manifestations, “Horner Sx like”→ptosis, miosis, anhidrosis
10
Q
Treatment of acute attacks and prophylactic treatment of cluster headache
A
- Acute attacks: 100% Oxygen, subcutaneous sumatriptan
- Prophylactic: Verapamil, Lithium
11
Q
Which test you should order in an adult patient with isolated thrombocytopenia (Immune Thrombocytopenic Purpura)?
A
HIV and Hepatitis C➡most common secondary causes
*Initial presentation HIV up to 5-10%
12
Q
What do you have to monitor closely after initiation of Erythropoietin in a CKD patient, and why?
A
- Blood pressure monitoring
- Up to 30% patients develop new or worsening hypertension 2-8 wks after initiation
*Large doses or rapidly Hb increase, highest risk
13
Q
In addition to the classical triad of Renal cell carcinoma, what other features you may find?
A
- Unintentional weight loss
- Intermittent fever
- Paraneoplastic syndromes (ectopic EPO, hypercalcemia)
14
Q
Clinical presentation of acute diverticulitis
A
- Left lower quadrant pain
- Nausea, vomiting
- Bladder symptoms (urgency, dysuria, frequency) or sterile pyuria (➕leukocyte esterase, ➖nitrites/bacterias)➡bladder irritation from bowel inflammation
- Changes bowel habits (diarrhea, constipation)
15
Q
Chest radiograph findings of pulmonary embolism
A
- Atelectasis (most common)
- Infiltrates
- Pleural effusions
- Westermark’s sign➡peripheral hyperlucency due oligemia
- Hampton’s hump➡peripheral wedge of lung opacity due pulmonary infarction
- Fleischner sign➡enlarged pulmonary artery
16
Q
Pathophysiology of Fanconi anemia
A
Autosomal recessive DNA repair defect, Bone-marrow failure
17
Q
Clinical findings of Fanconi anemia
A
- Short stature
- Hypo or hyper-pigmented macula on trunk
- Genitourinary malformations
- Absence or hypoplastic thumb
- Polydactyly, flat thenar eminence
*Most common cause of congenital aplastic anemia
18
Q
Treatment for Dressler’s syndrome
A
- NSAIDs first line
- Corticosteroids in refractory cases or NSAIDs contraindication
*Avoid anticoagulation to prevent hemorrhagic pericardial effusion
19
Q
Physical examination and laboratory findings suggesting heavy alcohol use
A
Macrocytic anemia, AST:ALT >2:1, parotid gland enlargement
20
Q
Primary prophylaxis to prevent bleeding from esophageal varicose veins
A
- Endoscopic variceal ligation (EVL)➡preferred for larger varicose veins
- Nonselective beta-blocker➡propranolol, nadolol
21
Q
Clinical presentation of HSV retinitis in an HIV positive patient
A
- Acute retinal necrosis syndrome➡starts keratitis and conjunctivitis with eye pain; followed by rapidly progressive visual loss
- Fundoscopy➡widespread, pale, peripheral lesions and central necrosis of the retina.
*Might be caused by VZV as well.
22
Q
Clinical presentation of CMV retinitis in HIV positive patient
A
- Painless
- Fundoscopy➡fluffy or granular retinal lesions near retinal vessels and associated hemorrhages
23
Q
What should you think in a patient with Rheumatoid arthritis history and worsening of weakness and painless sensation of 4 extremities after intubation?
A
Worsening subluxation of the atlantoaxial joint➡cord compression➡cervical myelopathy
*Atlantoaxial instability due RA
24
Q
Clinical presentation of cervical myelopathy
A
- Neck pain radiating to occipital region
- Extremity weaknes and numbness
- Usually first➡Gait dysfunction
- UMN signs (legs)➡slowly progressive spastic quadriparesis, hyperreflexia, Babinski sign, Hoffman sign (corticospinal tract lesion)
- LMN signs (arms)➡muscle atrophy, hyporeflexia
- Sensory changes➡⬇proprioception/vibration/pain sensation in hands or feet
- Respiratory dysfunction
25
What is the critical illness polyneuropathy?
Axonal injury of peripheral nerves➡weakness after prolonged stay in ICU (Ex, hyporeflexia)
*Complication of sepsis
26
Which etiology suggests a high anion gap metabolic acidosis with an osmolal gap?
- Poisoning with:
* Acute ethanol (most common)
* Acute Methanol
* Acute Ethylene glycol
27
Classical finding in acute ethylene glycol poisoning
- Rectangular, enveloped-shaped calcium oxalate crystals on urinalysis
* Most commonly antifreeze ingestion
28
Most common complication of acute ethylene glycol poisoning
Acute renal failure
29
Two most common inherited thrombophilia in the caucasian population
1. Factor V Leiden (Activated Protein C resistance)
| 2. Prothrombin mutation (⬆Prothrombin levels)
30
When do you study or test for hereditary thrombophilias?
- Young age (<45) with first time unprovoked DVT/PE
- Recurrent DVT/PE
- Unusual sited of thrombi (cerebral, mesentery, portal veins)
31
Cephalosporin that can cover MRSA
Ceftalorine (fifth generation)
32
Which cephalosporins can cover anaerobes? Side effects of them
- Cefotixin and Cefotetan (Second generation)
| - ⬇Prothrombin➡⬆Risk of bleeding; disulfiram-like effect with alcohol
33
What is the difference between ertapenem and the other carbapenems?
Ertapenem does not cover Pseudomonas
*All carbapenems cover gram-negative bacilli
34
How do you use the fluoroquinolones to treat diverticulitis and GI infections?
- Ciprofloxacin, gemifloxacin, levofloxacin must be combined + metronidazole; they do not cover anaerobes
- Moxifloxacin (exception) can be used alone; cover anaerobes
35
Classic side effects of quinolones
- Bone growth abnormalities in children and pregnant women
| - Tendonitis and Achilles tendon rupture
36
When do you order bacterial antigen detection (Latex Agglutination Tests) in suspected bacterial meningitis?
Patient has received antibiotics prior to lumbar puncture➡culture may be falsely negative
*Delay in LP may happen when head CT is indicated before (Ex, confused patients)
37
Important feature of the CSF in a tuberculous meningitis
Highest protein level
38
When do you suspect Listeria as the etiology of meningitis? How do you treat it?
- Risk factors for Listeria:
* Elderly
* Neonates
* Steroid use
* AIDS or HIV
* Immunocompromised, include alcoholism
* Pregnant
- Add Ampicillin to the Tx➡Listeria is resistant to all cephalosporins
39
Most common neurological deficit from untreated bacterial meningitis
Eighth cranial nerve deficit or deafness
40
Most accurate test for herpes encephalitis
PCR on CSF
41
Best initial test and most accurate test for bloody diarrhea
- Best initial➡Stool lactoferrin
| - Most accurate➡Stool culture
42
Antibiotics that cover anaerobes in oral and GI infections
- Oral: Penicillin (G, VK, ampicillin, amoxicillin), Clindamycin
- Abdominal/GI: Metronidazole, beta-lactam/lactamase inhibitor, carbapenems, 2nd gen cephalosporins
43
Treatment for ESBL-producing organisms resistant to carbapenems
- Ceftolozane/tazobactam
- Ceftazidime/avibactam
- Polymyxin (Risk for acute renal injury)
44
Treatment for encephalitis by aciclovir resistant herpes
Foscarnet
45
During acute hepatitis which test correlates the best with higher mortality?
⬆Prothrombin time➡⬆risk of fulminant hepatic failure and death
46
What is directly correlated with the amount or quantity of active hepatitis B virus replication?
Hepatitis B e-antigen➡present only when there is ⬆DNA polymerase activity
*e-antigen↔PCR DNA (viral load, is more precise)
47
Which indicates that active infection of hepatitis B has resolved?
No AgHBs found
48
Which is the best indication of treatment for chronic hepatitis B?
- e-antigen or DNA polymerase (PCR DNA hepatitis B)➡strongest indicator of acute viral replication➡Degree of infectivity
* e-antigen (qualitative)↔PCR DNA (quantitative, viral load, is more precise)
49
Best test to determine response to therapy or failure in therapy for chronic hepatitis B or hepatitis C
PCR DNA hepatitis B and PCR RNA hepatitis C
50
Most common method of transmission of hepatitis B
Perinatal transmission
* e-antigen ➕➡90% children infected at birth
* e-antigen ➖➡10% children infected
51
Best treatment for Hepatitis C genotype 1, and for any genotype
- Ledipasvir + Sofosbuvir for genotype 1
| - Velpatasvir for all genotypes
52
Goals of chronic hepatitis treatment
- ⬇DNA polymerase to undetectable levels
| - Convert patients from e-antigen to antibody e-antigen
53
Indications to treat hepatitis C
- ⬆PCR-RNA viral load
| - Fibrosis on biopsy (even for hepatitis B)
54
Sensitive and specific tests for syphilis study on CSF
- FTA-ABS nearly 100% sensitive in CSF
| - VDRL and PCR specific
55
Which test may be useful to diagnose both chlamydia and Neisseria gonorrhoeae?
Nucleic acid amplification test (NAAT)
*Gram stain only detects gonorrhea, with chlamydia infection only see PMNs
56
What is late secondary syphilis or latent infection?
- Asymptomatic stage with ➕ serology
- After chancre and rash of primary and secondary syphilis have resolved
*End or beyond the first year of infection
57
Treatment of latent or late secondary syphilis
Benzathine Penicillin IM weekly for 3 weeks
58
Treatment of primary and secondary syphilis
- One dose IM Benzathine Penicillin
| - Oral Doxycycline or Tetracycline for 14 days, for penicillin allergy
59
Treatment of HACEK group of organisms causing endocarditis
Ceftriaxone
60
Indications for prophylaxis for endocarditis
- Significant cardiac defect:
* Prosthetic valve
* Previous endocarditis
* Cardiac transplant recipient with valvulopathy
* Unrepaired cyanotic heart disease
- Risk of bacteremia:
* Dental work with blood
* Respiratory tract surgery that produces bacteremia
61
Best initial empiric therapy for endocarditis
Vancomycin + Gentamicin
62
Risk factors for endocarditis
- Prosthetic valve ⬆⬆Risk
- Regurgitant and stenotic lesions
- Dental procedures
- Surgery of mouth and respiratory tract + severe valvular disorder (prosthetic valve, cyanotic heart disease)
63
Most common joint, neurological and cardiac manifestations of untreated Lyme disease
- Joint➡Knee arthritis
- Neurological➡7th cranial nerve or Bell palsy (classically bilateral)
- Cardiac➡Transient AV block
64
Treatment for Lyme disease when rash, joint compromised or 7th cranial nerve palsy
- Doxycycline
| - Amoxicillin or Cefuroxime
65
Treatment for Lyme disease when cardiac or neurologic manifestations other than 7th CN palsy
Intravenous Ceftriaxone
66
Prophylaxis indications for Lyme disease when tick bite and no symptoms
Single-dose of doxycycline within 72 hours of tick bite:
- Ixodes scapularis clearly identified
- Tick attachment >24 hours
- Engorged nymph-stage tick
- Endemic area
*Tick bite + no symptoms generally do not need prophylaxis; treat if rash shows up
67
What must you test before start abacavir in an HIV patient? and why?
HLA B5701 mutation➡⬆risk of life-threatening skin reactions (Steven-Johnson syndrome)
68
Most important adverse effects of Tenofovir
- Renal Tubular Acidosis (RTA)
- Bone demineralization
*Disoproxil version ⬆risk, alafenamide version is absorbed by CD4➡⬇plasma levels➡⬇adverse effects
69
Treatment for baby from an HIV positive mother
Zidovudine intrapartum (to the pregnant woman) and for 6 wks (to the baby)➡prevent transmission
70
Antiretroviral to be avoided during pregnancy
Efavirenz
71
Indication for Pre-exposure prophylaxis (PrEP) for HIV and what drugs do you give?
- High risk sexual and needle-stick practices with potentially HIV-infected contacts
- Emtricitabine-Tenofovir before exposure and one month after the last exposure
72
Best initial and definitive treatment for Mucormycosis
- Best initial: Amphotericin B
- Surgical emergency➡resect necrotic areas
*Follow up Tx➡Posaconazole or Isavuconazole
73
Treatment for invasive Aspergillosis
Voriconazole, Isavuconazole, Caspofungin
* DO NOT use Amphotericin B (is inferior)
74
Tests for invasive Aspergillosis
- Serum Galactomannan assay
- B-D-glucan level
- PCR
*2 of those ➕➡>95% specificity
75
Treatment for Plasmodium falciparum
Mefloquine or Atovaquone/proguanil
76
Treatment for Plasmodium non-falciparum
- Chloroquine
| - Primaquine (vivax and ovale only)➡eradicate the hypnozoites in the liver
77
What you should rule out first before start Primaquine?
G6PD deficiency
78
Treatment for severe malaria
- Artemisinins (Artemether, Artesunate)
| - IV Quinine➡⬇Efficacy, ⬆QT prolongation toxicity
79
Prophylaxis for malaria
Patients traveling to endemic regions➡atovaquone-proguanil or mefloquine at least 2 weeks before travel and for 4 weeks after returning
*Avoid Mefloquine in seizure, psychiatric, and
cardiac conduction disorders
80
Treatment for Babesiosis
Azithromycin + Atovaquone
81
Which infectious diseases may show morulae in WBCs? What is the morulae in WBCs?
- Ehrlichiosis (Monocytic) and Anaplasmosis (Granulocytic)
| - Obligate intracellular parasites➡form microcolonies in the cytoplasm of WBCs
82
Best clinical clues that may suggest Legionnaires' diseases?
- Atypical community-acquired pneumonia
- CSN features➡confusion
- Gastrointestinal features➡abdominal pain, diarrhea, mild hepatitis
- Hotel and cruise ships
- Relative bradycardia (despite ⬆fever)
- Hyponatremia
83
Best initial test for Legionnaires' disease?
Urine antigen testing
*Best overall➡Culture
84
Treatment for cryptococcal meningitis
IV Amphotericin B + Flucytosine for 2 wks, then fluconazole for 8 wks
85
Which vaccines are contraindicated in HIV patients?
Live vaccines (MMR, VZ) are contraindicated If CD4<200
*If CD4>200 there are no contraindications
86
Main side effects of Isoniazid, what you should do to avoid one of them?
- Drug-induced hepatitis
| - Peripheral neuropathy➡Vitamin B6 (Pyridoxine) to prevent
87
Diagnosis of Allergic Bronchopulmonary Aspergillosis
- Previous history most commonly of Asthma or Cystic Fibrosis
- Pulmonary infiltrates on CXR, eosinophilia, ➕skin aspergillus antigen test, antibodies to aspergillus on blood, ⬆IgE levels
88
Life-threatening complication of untreated retropharyngeal abscess and treatment
- Acute necrotizing mediastinitis
| - Urgent surgical drainage to prevent spread to the posterior mediastinum➡lethal pleural and pericardial effusions
89
Treatment to reverse Warfarin toxicity bleeding
Prothrombin complex concentrate➡Vitamin K dependent coagulation factors (II, VII, IX, X, Protein C and S)
* Room temperature
* No transmit disease
* No excess volume
90
Most common adverse effect of statins
1. Liver inflammation
| 2. Myopathy
91
Most common cause of blindness in the US in the elderly and its treatment
- Macular Degeneration [Dry (80%)>Wet]
- Dry: No treatment
- Wet: VEGF Inhibitors➡Bevacizumab, Ranibizumab
92
Frequent history clues in orbital cellulitis that you should look for
- Ocular trauma or surgery
| - Sinusitis
93
Best initial therapy for HIV
Two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) + one integrase inhibitor
94
Treatment for Histoplasmosis chronic cavitary lesions
Itraconazole for >1 year
95
Treatment for Histoplasmosis severe acute pulmonary disease or disseminated disease
Liposomal amphotericin B or amphotericin B for 14 days followed by itraconazole for 1 year or longer
96
How is the geographic distribution of the most common systemic fungal infections in the United States?
- Histoplasmosis➡ Ohio and Mississippi river valleys
- Coccidioidomycosis➡ southwestern
- Blastomycosis➡central and southeastern, particularly the Mississippi and Ohio river valleys
97
Clues on history and laboratory findings in disseminated infection of Mycobacterium Avium Complex
- AIDS patients with a CD4+ < 50/mm3
- Fever, weakness, and weight loss, night sweats, diarrhea
- Anemia, hypoalbuminemia, ↑alkaline phosphatase, ↑LDH
98
Treatment and prophylaxis for MAC disseminated infection
- Tx: Clarithromycin + ethambutol, and consider HAART if drug-naïve; Rifabutin is second line. Continue for > 12 months and until CD4+ is > 100/mm3 for > 6 months
- Prophy: Azithromycin for those with a CD4+ < 50/mm3 or AIDS-defining opportunistic infection
99
Which complications of infectious mononucleosis are indicated to treat with corticosteroids?
- Airway compromise caused by tonsillar enlargement
- Severe thrombocytopenia
- Severe autoimmune hemolytic anemia
100
Complications of Infective endocarditis
- Embolic strokes
- Metastatic infection (most common cause of splenic abscess)
- Heart failure (valvular insufficiency)
- Glomerulonephritis
101
Infective endocarditis most common microorganism based on valve status
* Prosthetic valve➡Streptococcus viridans➡mitral valve (mitral regurgitation)>aortic valve (non-IV drug users, dental procedures)
* Normal valve➡Staphylococcus aureus➡tricuspid valve>mitral valve>aortic valve (IV drug users)
102
Best initial test and most accurate test for achalasia
- Best initial: Barium esophagram➡"Bird's beak sign"
- Most accurate: Manometry➡Failure lower esophageal sphincter to relax (⬇Esophageal peristalsis, ⬆Lower esophageal sphincter tone)
103
Treatments options for achalasia
1. Pneumatic dilation (perforation risk <3%)
2. Myotomy (more effective but more dangerous)
3. Botulinum toxin (effect wear off in 3-6 mo, reinjections)
104
Clinical presentation of esophageal spasm. Which are the two forms of them?
- Sudden onset of severe chest pain not related to exertion, can be precipitated by drinking cold liquids
- Diffuse esophageal spasm (DES) and Nutcracker esophagus
*Both forms clinically indistinguishable. Hard to differentiate at the beginning with coronary disease. EKG and stress test normal
105
Most accurate test for Diffuse esophageal spasm (DES) and Nutcracker esophagus
Manometry➡Different pattern of abnormal contraction
106
Treatment for esophageal spastic disorders
Calcium channel blockers and nitrates (similar Prinzmetal angina)
*PPIs can improve some cases
107
Important history clue and best initial test for eosinophilic esophagitis
- Asthma and allergic diseases
| - Endoscopy➡Multiple concentric rings
108
Most accurate test for eosinophilic esophagitis
Biopsy➡Eosinophilic infiltration of esophageal mucosa
109
Best initial and most effective therapy for eosinophilic esophagitis
- PPIs and eliminate allergenic food
| - Swallow steroid inhalers (topical effect of steroids)
110
Difference between Schatzki ring and Plummer-Vinson syndrome esophageal lesions
- Schatzki ring➡from acid reflux, associated with hiatal hernia. Scarring or tightening (also called peptic stricture) of the distal esophagus.
- Plummer-Vinson syndrome➡associated with iron deficiency anemia, rarely transforms into squamous cell cancer. More proximal.
111
Treatment of Schatzki ring and Plummer-Vinson syndrome esophageal lesions
- Schatzki ring➡pneumatic dilation in an endoscopic procedure
- Plummer-Vinson syndrome➡ iron replacement at first▶may lead to resolution of the lesion
112
Best diagnostic test for Zenker diverticulum
Barium studies
*Do not answer nasogastric tube placement or upper endoscopy➡dangerous, may cause perforation
113
Finding on the most accurate test for the scleroderma esophagus compromised
Manometry➡inability to close the lower esophageal sphincter▶⬇LES pressure
114
Most common cause of epigastric pain
Non-ulcer dyspepsia
115
Treatment for cannabinoid hyperemesis syndrome
- Hot shower or bath
| - Antiemetics (ondansetron) or benzodiazepines (lorazepam)
116
Most common cause of peptic ulcer disease
1. Helicobacter pylori
| 2. NSAIDs
117
Treatment for GERD for whose do not respond to the medical management
- Nissen fundoplication➡wrapping the stomach around the lower esophageal sphincter
- Endocinch➡suture around the LES
- Local heat or radiation of LES➡scarring
*About 5% of GERD patients do not respond to medical therapies
118
Indication for stress ulcer prophylaxis
- Mechanical ventilation
- Burns
- Head trauma
- Sepsis with coagulopathy
119
Most common cause of upper GI bleeding
Peptic ulcer disease
120
Clinical presentation of gastritis
- Bleeding without pain➡“coffee-ground” emesis, large hematemesis, melena, Heme (guaiac) positive stool
- Severe, erosive gastritis➡epigastric pain
- Nausea, vomiting
- Asymptomatic
121
What you must always rule out in a patient with a gastric ulcer?
Gastric cancer is present in 4% of those with GU but in none of those with DU
122
Best next step when you suspect persistent helicobacter pylori infection with a duodenal ulcer and gastric ulcer
- DU: Think antibiotic resistance➡urea breath testing, stool antigen detection, or a repeat endoscopy for biopsy➡if ➕➡switching to metronidazole + tetracycline + PPIs + bismuth
- GU: repeat endoscopy to exclude cancer
123
What is Non-ulcer dyspepsia?
Epigastric pain with a normal endoscopy
124
Clues on clinical presentation that makes you suspect gastrinoma
Peptic ulcer disease symptoms + diarrhea (acid inactivates lipase)
125
How are the ulcers from gastrinoma?
- Large (>1–2 cm)
- Recurrent after Helicobacter eradication
- Distal in the duodenum
- Multiple
126
How do you confirm gastrinoma (Zollinger-Ellison syndrome)?
Any of them:
- ⬆Gastrin off antisecretory therapy (PPIs or H2 blockers) with high gastric acidity
- ⬆Gastrin despite a high gastric acid output
- Persistent ⬆Gastrin despite injecting secretin
127
What is the most accurate test to identify metastases from gastrinoma?
Somatostatin receptor scintigraphy (nuclear octreotide scan) + endoscopic ultrasound
(Always do first CT and MRI)
*Gastrinoma is associated with a massive increase in the number of somatostatin receptors in the abdomen
128
Best initial treatment for diabetic gastroparesis
Dietary modifications➡Blenderize foods, Restore fluids, Correct potassium and glucose levels
*Not always have to confirm diagnose to start treatment
129
Most accurate test to confirm diabetic gastroparesis
Nuclear gastric emptying study➡Bolus of food tagged with technetium▶delay in the emptying of food
130
Best initial test for diabetic gastroparesis
Upper endoscopy or abdominal CT scan➡ excludes luminal gastric mass or abdominal mass compressing the stomach
131
Which treatments can you give if the best initial therapy for diabetic gastroparesis fails?
1. Metoclopramide➡⬆gastrointestinal motility (Do not use permanently: Dystonia and hyperprolactinemia)
2. Erythromycin + antiemetics➡⬆gastrointestinal motility
3. Gastric electrical stimulation (gastric pacemaker)
132
Most common cause of lower GI bleeding
Diverticulosis
133
What is the most important next step in the management of GI bleeding?
Fluid replacement with high volumes (normal saline or Ringer lactate)
134
Initial medical treatment for esophageal and gastric varices
Octreotide (somatostatin)➡⬇portal pressure
135
Best initial therapy for clostridium difficile colitis. Next best step if there is NO RESPONSE and if there is RECURRENCE.
- Oral Vancomycin
- NO RESPONSE➡Fidaxomicin
- RECURRENCE (there was resolution)➡tapered dose of vancomycin (another course) or fidaxomicin
136
What is fulminant clostridium difficile infection? Treatment.
- ⬆WBC, Metabolic acidosis, ⬆lactate, ⬆creatinine
| - Vancomycin and metronidazole
137
Most accurate test for chronic pancreatitis
Secretin stimulation testing
138
Sensible and specific finding on imaging in chronic pancreatitis
- Abdominal x-ray➡calcification of the pancreas
| - Abdominal CT scan➡pancreatic calcification (80% to 90% sensitive)
139
Hemoglobin electrophoresis pattern of Beta-thalassemia major
- HbA2 ⬆⬆ (2 alpha + 2 delta)
- HbF ⬆⬆ (2 alpha + 2 gamma)
* Mutation in both beta-globin genes
* HbS absent, HbA absent
140
Treatment of Beta-thalassemia major
Transfusion-dependent➡⬆Risk of iron overload➡Iron chelation therapy▶avoid damage on liver, kidneys, endocrine glands
141
Most sensitive predictor of anastomotic leak after bariatric surgery (Roux-en-Y gastric bypass). What other manifestations you may find?
- HR>120/min most sensitive predictor
| - Fever, abdominal pain, tachypnea
142
Why do patients with fat malabsorption (Ex, Chron disease, small intestinal disease) have a high risk of nephrolithiasis?
Hyperoxaluria
- Normally Calcium binds Oxalate in gut➡❌Oxalate absorption
- Fat malabsorption➡Calcium is bound by fat➡Oxalate is absorbed; ❌absorb bile salts➡⬇bile salts reabsorption in small intestine➡⬆⬆bile salts damage colonic mucosa➡⬆Oxalate absorption
143
Findings on laryngoscopy of laryngeal squamous cell carcinoma in a patient with hoarseness
Fungating, irregular white/red mass on vocal cord with/without blood crusting (ulcer)
144
How do you expect to find the urinary sodium, fractional excretion of sodium, urine sediment, urine WBC and BUN/creatinine ratio in a patient with sepsis?
- Renal hypoperfusion➡activation of RAAS➡⬆Na reabsorption➡⬇Urinary sodium (<20mEq/mL), ⬇Fractional excretion of Na (<1%)
- No intrinsic kidney damage➡urine sediment bland (acellular, no WBC or RBC)
- Urea follows reabsorption of Na and water➡⬆BUN/creatinine ratio >20:1
145
How are the urinary sodium, urine osmolality and urine sediment in acute tubular necrosis?
- ❌reabsorption of Na by the injured tubules➡⬆Urinary Na (>20mEq/mL)
- ⬇Urine Osmolality (300-350)
- Muddy brown granular urinary casts
- BUN/creatinine ratio 10-15:1
- FENa>2%
*Contrast-induced ATN may have ⬇Urinary Na (<20mEq/mL)
146
Urine sodium and urine sediment on glomerulonephritis
- RBC casts, mild ⬆WBC, hematuria
- ⬇Urine Na (<20mEq/mL)
*Hypertension
147
Which conditions may present with very high urinary sodium levels?
- Syndrome of inappropriate antidiuretic hormone (SIADH)
| - Diuretics
148
When do you suspect carcinoid syndrome?
Intermittent diarrhea + episodic flushing (85%) + cutaneous telangiectasias + bronchoespasm (wheezing) + cardiac abnormalities (right heart HF, tricuspid regurgitation)
149
Best initial diagnostic test for carcinoid syndrome
Urinary 5-hydroxyindolacetic acid (5-HIAA)
*Degradation product of Serotonin
150
Treatment for carcinoid syndrome
Octreotide
151
Serologic testing to differentiate Crohn disease from Ulcerative colitis
- CD➡ANCA➖, Anti-Saccharomyces cerevisiae antibody (ASCA)➕
| - UC➡ANCA➕, ASCA➖
152
Which procedure you must avoid in a patient with diverticulitis and why?
Colonoscopy➡infection weakens the colonic wall➡risk of perforation
153
Best test for diverticulitis
CT scan
154
Worst prognosis marker in acute pancreatitis
Low calcium
155
When you must rule out infection in pancreatitis? How do you do it?
- Severe necrosis➡>30% necrosis on CT or MRI
| - Needle biopsy➡only way to confirm infection
156
Best initial test for spontaneous bacterial peritonitis
Ascitic fluid study➡cell count >250 neutrophils
157
Which symptom is very important to ask for when suspect hepatopulmonary syndrome?
Orthodeoxia➡hypoxia upon sitting upright
158
Most accurate blood test for primary biliary cholangitis
Antimitochondrial antibody
159
From the patient history, how you may distinguish primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC)?
80% of PSC occurs in association with IBD
160
Which test may help you distinguish PBC and PSC?
- PBC➡antimitochondrial antibody and liver biopsy (most accurate)
- PSC➡MRCP or ERCP▶beading, narrowing, strictures in biliary system (most accurate). Bx is not essential for Dx. (ONLY cause of cirrhosis for which Bx is the not most the accurate)
161
Most likely diagnosis in a nonsmoker young patient with liver disease + emphysema (COPD). Treatment.
- Alpha 1-antitrypsin deficiency
| - Replace enzyme
162
Findings in the iron studies profile on hemochromatosis
⬆serum Iron, ⬆Ferritin, ⬇Iron binding capacity
*Best initial test for hemochromatosis
163
Besides the liver biopsy, which studies are enough to confirm hemochromatosis?
MRI➡⬆iron deposition in the liver
➕
Hemochromatosis gene (HFE; mutation C282y) testing
164
Hemochromatosis treatment
Phlebotomy
165
How is the clinical presentation of Wilson disease in other organs than the liver compromise?
- CNS➡Psychosis, tremor, dysarthria, ataxia, seizures
- RBCs➡Coombs negative hemolytic anemia
- Kidneys➡Renal tubular acidosis, nephrolithiasis
166
Best initial test and most accurate test for Wilson disease
- Best initial➡Slit-lamp examination▶Kayser-Fleischer rings
- Most accurate➡abnormally ⬆copper excretion into urine after giving penicillamine
* ⬇Ceruplasmin is NOT the most accurate
* Liver Bx is sensitive and specific
167
Key findings on imaging and serum when suspect autoimmune pancreatitis
- CT scan➡enlarged, "sausage-shaped" pancreas
- ⬆serum IgG4 (IgG4-related pancreatitis), ➕ANA and rheumatoid factor
*Associated with Sjögren syndrome, autoimmune thyroiditis, interstitial nephritis, sclerosing cholangitis
168
Treatment options for Wilson disease
- Penicillamine➡chelate copper, removes it from body
- Zinc➡❌intestinal copper absorption
- Trientine➡copper-chelating
*Penicillamine cannot be used with allergy to penicillin➡zinc or trientine.
169
How do you assess for severe exocrine pancreas insufficiency? For which diagnosis is it useful?
- ⬇Fecal elastase
- ⬇serum Trypsinogen
- Chronic pancreatitis
170
Which findings on feces you may find high on inflammatory bowel disease?
⬆️Calprotectin or Lactoferrin
| ⬆️Fecal leukocytes
171
In a patient with liver disease, which is the indication to receive prophylaxis for SBP?
Cirrhosis with ascites + variceal bleeding
172
Classic clinical presentation of pellagra and its cause
- Niacin deficiency
- Clinical presentation, "3 Ds":
* Dermatitis - sun-exposed areas, rough, hyperpigmented, scaly
* Diarrhea - watery, loss appetite, nausea, abd pain
* Dementia - memory loss, affective symptoms (depression), psychosis
173
Why you may have niacin deficiency? Which is the disease?
Pellagra
- Diet based on corn products (developing countries)
- Impaired nutritional intake (developed countries; alcoholics, chronic illness)
- Carcinoid syndrome➡⬇tryptophan
- Hartnup disease➡❌tryptophan absorption
- Prolonged Isoniazid therapy➡❌tryptophan metabolism
174
Potential complications of infectious mononucleosis
- Splenic rupture
- Acute airway obstruction
- Autoimmune hemolytic anemia and thrombocytopenia
175
How do you differentiate central vs nephrogenic diabetes insipidus?
Vasopressin stimulation test
- Central➡⬇urine volume, ⬆urine osmolality
- Nephrogenic➡no effect on urine volume or osmolality
176
Treatment for hyperprolactinemia
- Dopamine agonists: Cabergoline>Bromocriptine
- Transsphenoidal surgery when not responding to medications
- Radiation (rarely needed)
- Asymptomatic does not need treatment
177
What is the Kallman syndrome and which is the etiology?
Defective migration of neurons and failure of olfactory bulbs to develop➡⬇GnRH➡⬇FSH, LH, testosterone▶hyposmia/anosmia, Infertility, 50% Renal agenesis
*Failure to complete puberty; a form of hypogonadotropic hypogonadism
178
Best initial test for GH deficiency
Injecting GHRH➡normal response is ⬆GH
179
Treatment options for acromegaly
- Surgery: transsphenoidal resection (responds in 70% of cases)
- Medications:
* Cabergoline: Dopamine agonist➡❌GH release
* Octreotide or lanreotide: Somatostatin agonist➡❌GH release
* Pegvisomant: GH receptor antagonist➡❌IGF release from the liver
- Radiotherapy: for no response to surgery or medications
180
What is Euthyroid sick syndrome?
⬇T3,⬆reverse T3 (rT3), ⬇T4, TSH does not rise
*Clinically euthyroid patients with nonthyroidal systemic illness have low serum levels of thyroid hormones
181
Most common cause of hypercalcemia
Primary hyperparathyroidism and cancer 90% of cases
182
First-line treatment for acute hypercalcemia
- Saline hydration at high volume
| - Bisphosphonate: Pamidronate, zoledronic acid (take several days to work)
183
Treatment for acute hypercalcemia when the first option does not work
Calcitonin➡❌Osteoclasts, onset of action is very rapid
184
What treatment you should add to treat hypercalcemia from sarcoidosis or any granulomatous disease?
Prednisone
185
Causes of primary hyperparathyroidism
- Solitary adenoma (80%-85%)
- Hyperplasia of all 4 glands (15%-20%)
- Parathyroid malignancy (1%)
186
Possible clinical presentation of primary hyperparathyroidism
- Asymptomatic
- Acute severe hypercalcemia
- Slower o chronic presentation➡Osteoporosis; Nephrolithiasis and renal insufficiency; muscle weakness, anorexia, nausea, vomiting, abdominal pain; Peptic ulcer disease (calcium ⬆gastrin)
187
Standard of care for primary hyperparathyroidism and which are the indications?
Surgical removal of involved parathyroid glands
* Bone disease (Ex, Osteoporosis)
* Renal involvement, including stones
* Age <50 yrs
* Calcium consistently 1 point above normal
188
Most common cause of hypocalcemia. Other causes.
- Primary hypoparathyroidism prior neck surgery (Ex, thyroidectomy)
- Other causes:
* Hypomagnesemia➡Mg is needed to release PTH
* Renal failure➡kidney 25 OH-D▶1,25 OH-D
* Vitamin D deficiency➡inadequate sunlight exposure or insufficient intake; Rickets and Osteomalacia
* Genetic disorders
* Fat malabsorption
* Hypoalbuminemia (no symptoms because free Ca is normal)
189
Treatment for primary hyperparathyroidism when the first line of management is not possible
Cinacalcet➡❌release of PTH
190
Most accurate test for Paget disease of bone. Best initial test.
- Radionuclide (technetium) bone scan
- Best initial: Plain film x-rays (lytic and sclerotic lesions, depending on disease stage)
*⬆Alkaline phosphatase and normal GGTP, Bilirrubin aid in diagnosis
191
Best initial test for hypercortisolism. What other options to rule out it?
- 24-hour urine cortisol (also more specific)
| - 1 mg dexamethasone suppression test (sensitive, might be false positive)➡normally suppress morning cortisol level
192
Best initial test to determine the cause (source) or location of hypercortisolism
ACTH level
193
Treatment options for endogenous hypercortisolism when surgically removing the source (pituitary, adrenal or cancer) is not possible
- Pasireotide: somatostatin analog➡❌levels and activity of ACTH (for ACTH dependent Cushing sx)
- Mifepristone: ❌cortisol receptors throughout the body
- Mitotane: ❌steroidogenesis, also cytotoxic to adrenal tissue (for adrenal cancer cannot be fully resected or metastatic disease can’t be identified)
194
Most specific test of adrenal function (mainly for hypoadrenalism)
Cosyntropin test: measure cortisol before and after administration➡normally ⬆cortisol after give it
195
Most common classic presentation of primary hyperaldosteronism
High blood pressure + Hypokalemia
196
Best initial test for primary hyperaldosteronism
Ratio of plasma aldosterone to plasma renin >20:1
197
Most accurate test to confirm unilateral adrenal adenoma
Sample of venous blood draining the adrenal➡⬆Aldosterone
198
Most common cause of primary hyperaldosteronism
1. Solitary adenoma
| 2. Bilateral hyperplasia
199
Treatment for bilateral adrenal hyperplasia in primary hyperaldosteronism
Eplerenone or Spironolactone
