Immunology + ENT + Endocrine +

Question 1

The allergen most frequently associated with asthma is

Answer 1

house dust mites

Question 2

the most common adverse reaction that occurs within 1-6 hours of transfusion.

Answer 2

febrile nonhemolytic transfusion reaction

• When red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate.
• During blood storage, these leukocytes release cytokines, which when transfused can cause transient fevers, chills, and malaise without hemolysis.
• Management includes stopping the transfusion to exclude other serious reactions, administering antipyretics, and using leukoreduced blood products for future transfusions.
• Leukoreduction involves reducing the number of transfused leukocytes through filtering or other methods such as saline washing, freezing and deglycerolizing, or buffy coat removal.

Question 3

Recurrent bacterial infections in an adult patient may indicate

Answer 3

humoral immunity defect.

- Quantitative measurement of serum immunoglobulin levels helps to establish the diagnosis

Question 4

Alpha-1-antitrypsin deficiency is an inherited disorder that leads to emphysema and liver damage.
Does it increase risk of recurrent infxn?

Answer 4

no

Question 5

suppurative otitis media (also called acute otitis media or bacterial otitis media)

Answer 5

• group A Streptococcus.
• no pain with pinna manipulation
• Exposure to cigarette smoke is an important risk factor for acute otitis media

Question 6

Bacterial otitis externa:

Answer 6

infection of the outer auditory canal

• Pseudomonas aeruginosa
• Pain with manipulation of pinna

Question 7

Pneumococcal polysaccharide vaccine (PPSV) 23 vs 13 valent pneumococcal conjugate vaccine

Answer 7

Pneumococcal polysaccharide vaccine (PPSV) 23 is recommended for children at high risk for invasive pneumococcal disease (eg, those with sickle cell anemia, cardiac disease, cochlear implants, asplenia) but is not recommended for immunocompetent children.

• Patients age <2, PPSV 23 does not elicit an effective immune response (due to inability to mount a T-cell independent immune response), so the 13-valent pneumococcal conjugate vaccine would be recommended

Question 8

Benign paroxysmal positional vertigo (BPPV)

vs Menieres disease

Answer 8

BPPV: is characterized by typical acute vertigo attacks that are provoked by a change in position;

Meniere’s disease.: A classic triad of periodic vertigo, unilateral hearing loss and tinnitus

• Unlike Meniere’s disease, BPPV is NOT accompanied by hearing loss

Question 9

presbycusis:
- what is it?
- Does it affect high or low freq?
- characteristic sign?

Answer 9

sensorineural hearing impairment in elderly individuals.

• Usually, the disease is gradually progressive, and initially affects the high-frequency range of hearing.
• The decreased ability to discriminate speech is especially obvious in a noisy, distracting environment.

Question 10

squamous cell carcinoma of the glottis:

• T1a designates
• T1
• T2

Treatment?

Answer 10

• T1a designates a lesion confined to one vocal cord.
• Radiation is the primary nonsurgical treatment for early stage glottic tumors:
• T1 (confined to vocal cords) and some T2 (tumor extending to the supraglottis or subglottis with impaired vocal cord mobility) lesions.
• Radiotherapy may yield a more favorable voice outcome.
• Laser excision with a CO2 laser is also effective in curing early stage glottic cancer

Question 11

Sudden hearing loss should be evaluated to determine if it is conductive or sensorineural.
- Sudden sensorineural hearing loss should be evaluated urgently by otolaryngology with ________

Answer 11

a formal audiogram,
MRI,
and corticosteroid therapy.

Question 12

Normal hearing tests: Weber:

Rinne:

Answer 12

Weber: Midline, no lateralization

Rinne: AC>BC

Question 13

Sensorineural hearing loss:

Conductive hearing loss:

Answer 13

Sensorineural hearing loss:

• Weber: lateralizes to unaffected ear, away from affected ear
• Rinne: AC>BC

Conductive hearing loss:

• Weber: Lateralizes to affected ear
• Rinne: BC>AC in affected ear

Question 14

Acute mastoiditis

Answer 14

a bacterial infection of the mastoid air cells, is a complication of acute otitis media.
- Patients typically present with fever, protrusion of the auricle, and postauricular erythema, swelling, and tenderness.

Question 15

Kartagener syndrome

Answer 15

is an autosomal recessive disorder consisting of situs inversus, chronic sinusitis, and airway disease leading to bronchiectasis.
- It is a subgroup of a congenital mucociliary disorder known as primary ciliary dyskinesia.

Question 16

suspect this in patients with fatigue, weight loss, myalgias, increased pigmentation, and decreased axillary and pubic hair.

Answer 16

Chronic adrenal insufficiency

Question 17

CAH (#1 cause primary adrenal insufficiency/Addison’s disease)

• classic triad
• dx?

Answer 17

• Hyponatremia, hyperkalemia, and hyperchloremic metabolic acidosis!!
• Diagnosis is confirmed with low morning plasma cortisol and elevated adrenocorticotropic hormone [ACTH] (often performed with an ACTH stimulation test). Low THen High

Question 18

Urgent or emergent surgeries can usually be done on patients with hypothyroidism as long as ______

Answer 18

there are no symptoms of myxedema coma or other findings to suggest severe hypothyroidism.

• Treatment with levothyroxine can increase myocardial oxygen demand resulting in myocardial infarction, angina, or cardiac dysrhythmias.
• Levothyroxine generally needs to be started slowly and gradually in patients with cardiac disease, which might prolong the wait for badly needed CABG.
• Therefore, it is probably best to do the surgery now despite her hypothyroid state, even though it might slightly increase her risk for perioperative adverse events.

Question 19

Levothyroxine be empirically increased by approximately _____% at the time the pregnancy is first detected
- why?

Answer 19

30% (eg, 2 additional levothyroxine doses weekly) at the time the pregnancy is first detected

• B-hCG binds TSH receptor -> stim T3 and T4, suppress TSH
• Estrogen increases Thyroxine-binding globulin (TBG) -> higher T3 and T4 -> suppress TSH

Question 20

non-parathyroid hormone (PTH)-dependent hypercalcemia is d/t ____

Secondary hyperparathyroidism is a compensatory rise in PTH d/t

Answer 20

humoral hypercalcemia of malignancy (HHM), which is due to secretion of PTH-related protein

due to hypocalcemia and is most commonly seen patients with chronic kidney disease (eg, diabetic nephropathy)

Question 21

T2DM: When insulin therapy is necessary, _____ is typically added first and is safe to use with other antidiabetic agents.
- Both NPH and long-acting insulin analogs (eg, detemir, glargine, degludec) are effective in lowering A1c in patients with T2DM. However, ____ is associated with a higher risk of hypoglycemia compared with long acting insulin analogs.

Answer 21

basal insulin (ie, insulin that is intended to work continuously throughout the day)

NPH

Question 22

Hyperglycemic hyperosmolar nonketotic state is characterized by
______
- Initial management includes _____

Answer 22

severe hyperglycemia,
acute mental status changes,
and absence of ketoacidosis.

Initial management includes intravenous fluids and continuous insulin infusion.
- Stabilized patients can transition to subcutaneous insulin with a basal-bolus regimen

Question 23

Pheochromocytoma: adequate preoperative control of blood pressure for ____ days with an ____ blocker, and intravascular fluid volume repletion with liberal fluid and salt.
- ____blockers are given only to patients with adequate and complete ___ blockade.

Answer 23

10-14 days with an alpha blocker,

Intraoperative complications are much higher with inadequate preoperative alpha blockade and intravascular fluid deficiency.

• Beta blockers are given only to patients with adequate and complete alpha blockade.
• Beta-blocking agents started before alpha blockade can lead to paradoxical increase in blood pressure.
• Intra- and postoperative hypotension usually responds well to normal saline bolus.
• Pressors may be required in patients who do not respond to intravenous fluids.
  Other complications include hypertensive crisis, hypoglycemia, and cardiac tachyarrhythmias.

Question 24

2-step approach is involved in screening for GDM:

• The first step is ______,
• A blood glucose level >140 mg/dL is an indication for the second step, a _____

Answer 24

• First step is a glucose challenge test (GCT), a screening test that consists of a blood glucose level measured an hour after administration of a 50-g glucose load.
• A blood glucose level >140 mg/dL is an indication for the second step, a 3-hour glucose tolerance test (GTT).
• The GTT is a diagnostic test that consists of a fasting blood glucose and blood glucose levels measured 1, 2, and 3 hours after a 100-g glucose load. - GDM is diagnosed when >2 of the GTT values are elevated

Question 25

Patients with GDM monitor fasting and either 1- or 2-hour postprandial blood glucose levels. Target glucose levels are: Fasting _____ 1-hour postprandial ____ or 2-hour postprandial ____

Answer 25

Fasting <95 mg/dL 1-hour postprandial <140 mg/dL or 2-hour postprandial <120 mg/dL

Question 26

Stress hyperglycemia is a potential complication of _______ - It is associated with increased morbidity risk and is caused by high circulating stress hormones (eg, cortisol, catecholamines). - transiently elevated blood glucose levels in the context of severe illness in patients without known diabetes mellitus

Answer 26

severe illness (eg, sepsis) - hyperglycemia and ketoacidosis in the setting of sepsis with fever, hypotension, dehydration, and tachycardia

Question 27

Screening for diabetic retinopathy is indicated beginning: Screening for diabetic nephropathy is indicated beginning:

Answer 27

Retinopathy: - 3-5 years after the original diagnosis in patients with type 1 diabetes - at the time of diagnosis in those with type 2. Nephropathy: - 5 years after the original diagnosis in patients with type 1 diabetes - at the time of diagnosis in those with type 2.

Question 28

__________ are the preferred medication for treating hypertension in patients with diabetes or have evidence of nephropathy

Answer 28

ACE inhibitors

Question 29

Current guidelines from the American College of Cardiology/American Heart Association recommend ________ for all patients age 40-75 with diabetes (type 1 or type 2) who have a baseline LDL level >70 mg/dL.

Answer 29

statin therapy

Question 30

_____ is the first-line treatment for sulfonylurea poisoning. - can cause transient hyperglycemia that may elicit an even higher level of insulin secretion and subsequent rebound hypoglycemia

Answer 30

Dextrose Octreotide is a somatostatin analogue that decreases insulin secretion and should be considered in patients with a large sulfonylurea overdose

Question 31

Hyperthyroidism in pregnancy:

Answer 31

- Propylthiouracil is preferred in the first trimester (due to the teratogenic effects of methimazole) - Methimazole is preferred in the second and third trimesters (due to the hepatotoxicity of propylthiouracil).

Question 32

Normal fasting blood sugar range is ______ - Any individual with a blood sugar level less than ___ mg/dL is suspected to be hypoglycemic. - The most important cause of hypoglycemia in type 1 diabetes mellitus is ______

Answer 32

70 to 100 mg/dL. < 60 mismatch between insulin dose and insulin requirement.

Question 33

3 thyroid-related syndromes associated with amiodarone use:

Answer 33

1. Amiodarone decreases the peripheral conversion of T4 to T3. May result in higher T4, lower T3, and normal or mildly elevated TSH (<20 mU/L). - The thyroid test abnormalities are most prominent in the first 13 months after starting amiodarone and may become less apparent afterward. These patients are clinically euthyroid. 2. The high iodine content in amiodarone inhibits thyroid hormone synthesis, leading to primary hypothyroidism (Wolff-Chaikoff effect). 3. Amiodarone can also induce thyrotoxicosis (amiodarone-induced thyrotoxicosis [AIT]) due to either increased thyroid hormone synthesis (AIT type 1) or destructive thyroiditis (AIT type 2). In both AIT subtypes, TSH will be low. - These abnormalities then improve over the subsequent 3-6 months. Patients are usually clinically euthyroid, and no treatment is necessary.

Question 34

- Pts with GDM may have had undiagnosed preexisting T2D. For this reason, patients with gestational diabetes are screened for _____ postpartum with fasting blood glucoses and at ______ postpartum with a 2-hour oral glucose tolerance test

Answer 34

24-72 hours postpartum with fasting blood glucoses and at | 6-12 weeks postpartum with a 2-hour oral glucose tolerance test

Question 35

antithyroid drugs (ATDs): - Methimazole or PTU is usually preferred due to the risk of hepatotoxicity?

Answer 35

Methimazole - although propylthiouracil is recommended in the first trimester of pregnancy due to the teratogenic effects of methimazole - total T3 and free T4 levels should be used to assess efficacy of ATD therapy, especially early in the treatment course. (TSH may remain suppressed for several months after initiation of therapy)

Question 36

Pseudohypoparathyroidism, caused by end-organ resistance to parathyroid hormone (PTH), causes chronic:

Answer 36

- hypocalcemia - hyperphosphatemia, - elevated PTH. Elevated PTH distinguishes pseudohypoparathyroidism from true hypoparathyroidism, which also causes hypocalcemia and hyperphosphatemia but is due to impaired PTH production

Question 37

Bicarbonate should not be added to the IV fluids as it has not been shown to be beneficial. - In addition, bicarbonate administration can cause ________

Answer 37

hypokalemia, cerebral edema, and metabolic alkalosis

Question 38

painful/tender goiter is often preceded by an URI and is thought to be due to a postviral inflammatory process. - caused by what? - Tx?

Answer 38

Subacute (de Quervain, subacute granulomatous) thyroiditis: - Thyrotoxicosis is caused by release of stored thyroid hormone due to follicular injury. - Other possible findings include leukocytosis, mild anemia, and mild elevation of liver enzymes ``` - Tx: NSAID to relieve pain; glucocorticoids can be used in severe or refractory cases. Beta blocker (eg, propranolol, atenolol) to minimize the hyperadrenergic symptoms of thyrotoxicosis ```

Question 39

The initial management of diabetic ketoacidosis consists of

Answer 39

intravenous (IV) insulin, aggressive fluid support, and potassium supplementation. - If serum glucose falls to <200 mg/dL but the patient still has an elevated anion gap, the rate of insulin infusion should be halved and dextrose added to the IV fluids to prevent hypoglycemia. anion gap (serum Na – [serum Cl + serum bicarbonate]) is (normally 7-13 mEq/L),

Question 40

Patients with diabetic ketoacidosis (DKA) can be transitioned from IV insulin to subcutaneous (SQ) insulin once

Answer 40

the ketoacidosis has resolved, provided they are reliably able to eat. - glucose <200 mg/dL along with 2 of the following: - serum anion gap <12 mEq/L, - serum bicarbonate >15 mEq/L, and - venous pH >7.30.

Question 41

Low dose dexamethasone test is used to diagnose _____

Answer 41

Cushing's Disease - Secondary HTN - Obesity - Muscle weakness - Hyperpigmentation - Bruising - Cushingoid features

Question 42

_______ is characterized by pituitary enlargement, hyperpigmentation, and visual field defect following bilateral adrenalectomy. How do you treat it?

Answer 42

Nelson's syndrome Usually, these pituitary tumors are rapidly growing and can be treated with surgery and/or local radiation.

Question 43

Failure to thrive (FTT) is defined by weight below the___ percentile or down-trending weight percentiles crossing _____ major percentiles

Answer 43

5th % 2 or more (eg, 50th, 25th, 10th)

Question 44

familial hypocalciuric hypercalcemia (FHH) - What is it d/t? - How do you treat asymp pts?

Answer 44

Decreased sensitivity to calcium. No need to treat asymptomatic hypercalcemia - Normally, high-normal calcium levels suppress PTH secretion, but in FHH, higher calcium concentrations are required to suppress PTH release. - Concurrently, the defective CaSR causes increased reabsorption of calcium in renal tubules.

Question 45

______ is due to niacin deficiency, and is characterized by dementia, diarrhea, dermatitis, stomatitis and cheilosis.

Answer 45

Pellagra

Question 46

"necrolytic migratory erythema" is the characteristic rash of ______

Answer 46

glucagonoma - rare pancreatic tumor associated with mild diabetes and a classic skin rash. - Most are malignant and have metastasis, mainly in the liver, at the time of diagnosis

Question 47

Asymptomatic subclinical hypothyroidism does not require treatment. Treatment is warranted in the presence of: (4 things)

Answer 47

1. antithyroid antibodies 2. an abnormal lipid profile 3. symptoms of hypothyroidism 4. ovulatory and menstrual dysfunction

Question 48

These are all symptoms of what? - weight loss, eosinophilia, low sodium levels, hyperkalemia, mild anion gap acidosis, prerenal azotemia, and low blood glucose levels

Answer 48

adrenal failure | - cosyntropin stimulation test is indicated.

Question 49

- euglycemic diabetic ketoacidosis (euDKA), a recognized complication of which diabetic med?

Answer 49

sodium-glucose cotransporter-2 (SGLT2) inhibitor (eg, canagliflozin): - lower blood glucose by reducing reabsorption of glucose in the kidney, which leads to a low insulin-to-glucagon ratio because high blood glucose levels are the primary stimulus for insulin release

Question 50

Eval of Hypoglycemia will show which test result? - Exogenous insulin: _____ - Oral Hypoglycemic agents: ______

Answer 50

Exogenous insulin: C-peptide is LOW Oral Hypoglycemic agents: hypoglycemic drug assay is POSITIVE

Question 51

Most thyroid hormone in the circulation is bound to ______.

Answer 51

plasma proteins, primarily thyroxine-binding globulin (TBG)

Question 52

How does estrogen affect thyroid levels?

Answer 52

- Estrogen stimulates hepatic synthesis of TBG (what thyroid hormone binds to) - Hypothyroid patients with elevated estrogen levels (eg, pregnancy, oral contraceptive use) require a higher dose of levothyroxine to saturate the increased number of binding sites.

Question 53

Name these 2 disorders with these associated characteristics - thyroid peroxidase antibody - variants of chronic lymphocytic (Hashimoto) thyroiditis

Answer 53

postpartum thyroiditis (PT) + silent thyroiditis PT and silent thyroiditis have a low RAI

Question 54

Graves disease has a (high/low) RAIU

Answer 54

high Postpartum thyroiditis and silent thyroiditis have a low RAI

Question 55

Elevated prolactin levels suppress which hormones, leading to symptoms of hypogonadism including hot flashes, vaginal dryness, and potentially osteoporosis if left untreated.?

Answer 55

``` gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and estradiol, ```

Question 56

Euthyroid sick syndrome (ESS) encompasses a variety of alterations in thyroid physiology, the most common of which is termed _________

Answer 56

"low T3 syndrome" - thought to be primarily the result of decreased conversion of T4 to T3. - normal TSH and T

Question 57

Fluid retention can occur in ___% of patients on thiazolidinediones, most of them likely have underlying heart failure ( S3 on physical exam)

Answer 57

5% PPAR-y receptors are present in the collecting tubule of the nephron, and stimulation by pioglitazone results in increased sodium reabsorption.

Question 58

Normal gonadotrophs secrete LH and FSH (which are dimeric hormones consisting of a common ___ subunit and a different ___, but the dysfunctional cells in most gonadotroph adenomas secrete primarily just the ____ subunit

Answer 58

common a-subunit diff b-subunit common a-subunit

Question 59

- The clinical symptoms of a-subunit gonadotroph overproduction are usually minimal ("nonfunctioning" adenoma), and the diagnosis is not apparent until the adenoma is large enough to cause headaches or visual disturbances due to mass effect. Preferred therapy for most nonfunctioning pituitary adenomas is _____

Answer 59

trans-sphenoidal surgery

Question 60

central precocious puberty (CPP) is due to _____

Answer 60

early maturation of the hypothalamic-pituitary-gonadal axis - This causes the typical pubertal sequence, starting with breast or testicular development, to occur early. - Can be idiopathic or d/t (CNS) tumors, among others.

Question 61

peripheral precocity is due to _______

Answer 61

excess sex hormone (eg, androgen) production from the gonads, adrenal glands, or an exogenous source. - acne and early pubic (and axillary) hair development. - Unlike patients with classic CAH (complete 21-hydroxylase deficiency), those with nonclassic CAH have no salt-wasting and are not identified by newborn screen.

Question 62

Subclinical hyperthyroidism is defined as low TSH with normal thyroid hormone concentrations. - Transient fluctuations in thyroid markers can be seen (particularly with acute illness), but patients who have persistently suppressed TSH levels warrant further evaluation. But what do for pts with . . . - mildly suppressed TSH levels (0.1-0.5 µU/mL) - Pts w/ Severe TSH suppression or increased risk for complications due to age (>65) or comorbid conditions (eg, heart disease, osteoporosis)

Answer 62

- They often experience spontaneous remission and can usually be monitored with periodic thyroid function tests. - treat with antithyroid medication or radioactive iodine.

Question 63

Is methimazole or PTU usually preferred?

Answer 63

Methimazole is usually preferred due to the risk of hepatotoxicity with propylthiouracil

Question 64

Serum ____levels are used to assess thyroid function during treatment with antithyroid drugs.

Answer 64

total T3 and free T4 TSH may remain suppressed for several months following initiation of therapy and does not reliably reflect thyroid functional status.

Question 65

Subclinical Hypothyroidism: For asymptomatic patients with mild elevations in TSH, an elevated __________ INCREASES the likelihood of progression to overt hypothyroidism and can identify patients who are likely to benefit from treatment

Answer 65

antithyroid peroxidase antibody titer

Question 66

Exogenous thyrotoxicosis can result from the intake of over-the-counter thyroid supplements or an excessive dosing of prescription thyroid medication. - The activity of the thyroid gland is suppressed, with (decreased/increased) radioactive iodine uptake AND serum thyroglobulin levels?

Answer 66

decreased | radioactive iodine uptake AND serum thyroglobulin levels