Mix3

Question 1

If a patient presents with hypovolemic hypernatremia, at what rate should you correct serum Na+?

Answer 1

Serum sodium should be corrected by 0.5 mEq/dL/hr without exceeding 12 mEq/dL/24hr

Question 2

What is the treatment protocol for a Pt with CMV infection post solid organ transplant?

Answer 2

Discontinue antimetabolite immunosuppression (mycophenolate) and start antiviral therapy. IV ganciclovir for severe sx, and oral valganciclovir for minimal signs/symptoms.

** Dx is confirmed by CMV DNA via PCR of blood.

Question 3

Why do you get pyridoxine (B6) deficiency with isoniazid use?

Answer 3

INH binds active form of pyridoxine&raquo_space; increased renal excretion. This is a problem for people who are malnourished/pregnant/comorbid conditions. Pyridoxine serves as cofactor in neurotransmitter synthesis&raquo_space; presentation of neurologic symptoms, esp numbness and tingling in “stocking glove” distribution.

Treat high risk of pyridoxine def with B6 supplement while on INH.

Question 4

What relative changes would you expect to see in serum Ca, PTH, and PO4 in the case of secondary hyperparathyroidism?

Answer 4

Secondary Hyperparathyroidism is typically due to renal failure/CKD. In CKD you have decreased 1,25 hydroxyvitamin D (calcitriol) and PO4 retention. PO4 binds with circulating Ca2+ and interferes with renal production of 1,25 hydroxyvitamin D (calcitriol). Decreased calcitriol&raquo_space; decreased intestinal Ca2+ absorption and ^ PTH release by directly stimulating the parathyroid glands.

Question 5

What’s the MOA of DM induced neuropathy?

Answer 5

Microvascular injury, demyelination, oxidative stress, and deposition of glycosylation end products. Can cause axonopathy of small (positive sx - pain, paresthesia) and large (negative sx - numb, proprioception loss) nerve fibers.

Question 6

What tests would you perform to confirm a Dx of patellofemoral syndrome?

Answer 6

Patellofemoral compression test - pos(+) if pain is elicited by extending the knee and compressing the patella.

Can also try to reproduce the pain with squatting.

• Typically presents in young women with chronic anterior knee pain that’s worse when climbing stairs.

Question 7

Why do you get increased Hb in cases of obstructive sleep apnea?

Answer 7

In OSA you have reduced blood oxygen levels. Kidney responds to low blood oxygen levels by increasing EPO&raquo_space; stimulates BM to differentiate RBC.

Question 8

What’s the preferred initial medical therapy for a Pt with primary hyperaldosteronism?

Answer 8

Spironolactone/aldosterone antagonist.

** Eplerenone is a selective mineralocorticoid antagonist with low affinity for progesterone or androgen receptors. It has fewer endocrine side effects.

Question 9

What type of structural changes of the heart would you see in a massive PE?

Answer 9

Pt with massive PE typically present with low arterial perfusion (hypotension/syncope), acute dyspnea, pleuritic chest pain, and tachycardia. The thrombus&raquo_space; abrupt increase in pulmonary vascular resistance&raquo_space; increased RV pressure&raquo_space; RV hypokinesis, dilation, and hypotension.

** Note.. ^ RV pressure&raquo_space; ^ RV wall tension&raquo_space; increased myocardial O2 demand&raquo_space; decreased coronary artery perfusion&raquo_space; supply/demand mismatch&raquo_space; decreased coronary perfusion&raquo_space; RV ischemia and eventual hemodynamic collapse.

Question 10

What’s the standard treatment for psuedogout?

Answer 10

Intra-articular glucocorticoids, NSAIDS, and colchicine

Question 11

How long post-MI would you expect to see a papillary muscle rupture develop?

Answer 11

Acute or 3-5 days post MI. Occurs due to thrombus in the RCA. Presents as severe mitral regurg with flail leaflet. Findings of severe pulmonary edema and new holosystolic murmur.

Question 12

Why should you give glucocorticoids while administering radioactive iodine to treat ophthalmic disorders of Grave’s disease?

Answer 12

Graves ophthalmopathy presents as proptosis, swelling of periorbital tissue, and involvement of extraocular muscles (dilplopia, discomfort with movement). This is due to effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocyte.

Admin of RAI can increase titers of TRAB so that’s why you should co-administer with glucocorticoids.

Question 13

What’s the most common type of cancer causing SVC syndrome?

Answer 13

SVC syndrome is typically caused by lung cancer (SCLC) or non-Hodgkin’s lymphoma. Presents as dyspnea, venous congestion, and swelling of head anr arms due to impaired venous return from the head, neck, and arms to the heart.

Dx = CXR then follow up chest CT with histology for tumor type.

Question 14

What is a common adverse effect with prolonged use of hydroxychloroquine in treating active SLE?

Answer 14

Look out for retinal toxicity progressing to irreversible vision loss. Typically occurs 5-6 years after use.

Question 15

The triad of primary hyperparathyroidism, pituitary tumor, and GI/pancreatic endocrine tumor (e.g. gastrinomas) are characteristic of this disease:

Answer 15

MEN 1 - pituitary adenoma, parathyroid adenoma, pancreatic endocrine tumor.

Question 16

How often should you check peripheral blood counts when treating a patient with long term methotrexate?

Answer 16

Every 3 months. Methotrexate is a disease modifying anti-rheumatic drug and works by inhibiting dihydrofolate reductase&raquo_space; decreased cellular utilization of folic acid&raquo_space; macrocytic anemia. Methotrexate can also cause pancytopenia.

Other side effects of methotrexate use include: nausea, stomatitis, rash, hepatotoxicity, interstitial lung disease, alopecia, and fever.

Question 17

What drug would you use to treat pregnant women with a recent Lyme infection?

Answer 17

NOT Doxy (causes skeletal abnormalities).

Use Amoxicillin PO.

Question 18

Characterize the pathophys of ankylosing spondylitis:

Answer 18

Immune mediated destruction of articular cartilage of the spine and the ligamentous insertions. Sacroiliac and apophyseal joints are predominantly affected.

Question 19

What disease would you suspect in a patient with acute pneumonia (cough, SOB, leukocytosis, R lower lobe infiltrate), recurrent pneumonia, sinusitis, and bloody diarrhea?

Answer 19

CVID - Common variable immunodeficiency. Due to impaired B cell differentiation and hypogammaglobulinemia. Characterized by recurrent respiratory and GI infections. Can also have increased risk of autoimmune (hemolytic anemia, RA, pernicious anemia), IBD, and non-Hodgkin lymphoma.

Should perform quantitative measurement of serum immunoglobulin to confirm Dx.

Question 20

What method of imaging would you use to screen for AAA and what population would you screen?

Answer 20

Screen guys 65-75 with a H/o of cigarette smoke. One time Abdominal U/S is the preferred method.

Question 21

What antibiotic options would you use for a Pt with productive cough and foul smelling sputum?

Answer 21

This is aspiration pneumonia (anaerobic coverage needed). Clinda is great. Metro with amoxicillin, amoxicillin-clavulanate, or a carbapenem.

Question 22

When would you use ipratropium bromide in management of asthma?

Answer 22

Generally you don’t. Ipratropium = short acting anticholinergic with a slower onset of action and achieves less bronchodilation than short acting beta 2 agonist (albuterol). Ipratropium does play a role in COPD management though.