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ABIM Medicine Boards > MKSAP 3 > Flashcards

MKSAP 3 Flashcards

1
Q

Tx of eosinophilic esophagitis

A

Swallowed aerosolized glucocorticoid (fluticasone or budesonide)
Ex: 8 week course of swallowed aerosolized fluticasone

Can also try PPI

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2
Q

Clinical manifestations of eosinophilic esophagitis

A

Persistent dysphagia, adult w/ food impaction, GERD refractory to standard treatment

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3
Q

55M w/ UGIB s/p EGD with epi injection and thermal coagulation controlled the bleeding.
h/o CAD, DES 2 yrs ago
ASA held on admission

When to resume ASA?

A

Resume w/in 7 days (don’t need to hold for any period of time)

Secondary prevention- ASA reduces all cause mortality when resumed after recent ulcer bleeding

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4
Q

Differentiate features of dumping syndrome and gastroparesis

A

Dumping syndrome- rapid emptying of stomach contents into SI (ex: after partial gastric resection) prompting vasomotor symptoms- palpitations, diaphoresis, lightheadedness ~30 mins after eating

Vs. gastroparesis (the opposite physiology) when gastric emptying is delayed => nausea/vomiting after eating

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5
Q

Fecal osmotic gap in secretory vs. osmotic diarrhea?

A

Osmotic gap (difference in osms between serum and feces)

Lower in secretory (under 50) b/c GI tract is secreting out electrolytes

While very high (over 100) in osmotic b/c something in GI tract just pulling in water w/o electrlytes

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6
Q

What type of diarrhea persists despite fasting?

A

Secretory diarrhea persists despite fasting

While osmotic will resolve w/ fasting (no osmole in the lumen to attract water)

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7
Q

Why prefer CT w/ contrast over mesenteric angiogram if looking for aortoenteric fistula?

A

Aortoenteric fistula (communication btwn aorta and GI tract, most common at duodenum) typically present w/ brisk bleed that spontaneously resolves, then massive GI hemorrhage

To catch while not actively bleeding do CT, as mesenteric angiogram will only detect bleed over 1 ml/min

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8
Q

UC vs. Crohn’s

Continuous
Transmural
Mouth to anus

A

Ulcerative colitis

  • Continuous from rectum upwards
  • Not transmural, only mucosal
  • Not mouth to anus, starts at anus and goes up but rarely into small intestines

Crohn’s

  • Skip lesions
  • Yes transmural on biopsy
  • Yes mouth to anus
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9
Q

UC vs. Crohn’s

Most commonly involved area
Cobblestone mucosa
Granulomas on histology
Strictures

A

UC- almost 100% involves rectum, while Crohn’s 50% ileum

Cobblestoning of mucosa seen in Crohn’s (skip lesions)

Granulomas in 30% on Crohn’s on biopsy, not seen in UC

Strictures, fistulas, fissures seen in Crohns

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10
Q

Utility of fecal calprotectin to differentiate IBS and IBD

A

Fecal calprotectin is a protein found in neutrophils- associated w/ inflammatory process => more likely + in IBD than IBS

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11
Q

Go to drug class for treatment of

Mild/moderate IBD
Severe IBD flare
Maintain remission of steroid-dependent IBD

A

Pharmacologic therapy:

mild/moderate (mesalanine/sulfasalazine), mesalanine prefered b/c of side effect profile

Severe IBD flare- steroids

Maintaining remission: immunomodulators (thiozodines- azathioprine, mercaptopurine) and biologics (infliximab)

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12
Q

5-aminosalicylates for IBD treatment

(a) Formulation of mesalamine
(b) First line: mesalamine vs. sulfasalazin

A

5-ASA as first line for mild-moderate IBD

(a) Mesalamine- needs to be controlled or extended release b/c very highly absorbed in the duodenum- normal formulation leaves only 20% for ileum and colon
(b) Both 5-ASAs but mesalamine has a better side effect profile

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13
Q

Two drug classes approved to help maintain steroid-free remission in IBD

A

Maintain steroid-free remission in moderate/severe IBD with

Immunomodulators- thiozodines- azathioprine and mercaptopurine)

Biologics- anti-TNFs (infliximab)

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14
Q

What to add to infliximab to increase rate of steroid-free remission in fistulizing Crohn’s

A

Add antibiotics (flagyl, cipro)- improved steroid-free remission in fistulizing Crohns

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15
Q

Long term risk difference in Crohn’s/UC vs. microscopic colitis

A

Crohn’s/UC both carry increased risk of colorectal cancer, while microscopic colitis (dx on biopsy, normal macroscopic appearance on endoscopy) does not carry increased risk of CRC

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16
Q

AED safe in pregnancy

A

Keppra (levetiracetam)

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17
Q

In memory-predominant aging, how to differentiate dementia from mild cognitive impairment

A

Depends on functional status

Impairs daily activities/functional status- can be dementia. While mild cognitive impairment pts may have memory deficiency but able to carry out daily tasks and fully functional

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18
Q

Vent weening: discharge to LTAC of SNF?

A

LTAC for vent weening, IV meds

SNF cannot do vent weening

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19
Q

44M admitted for EtOH withdrawal, GFR 50, best pharmacologic tx to reduce 30-day readmission and ED visits

A

Naltrexone- reduces 30 day readmission and ED visits when Rx to EtOH withdrawal pts on discharge

  • disulfiram (aversion therapy) is second line
  • acamprosate: TID so hard compliance and contraindicated in CKD
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20
Q

For what form of microbial vaginitis is the treatment of sexual partners indicated?

A

Only for trichimoniasis (tx w/ flagyl 2g x1 dose)

Tx of partner not indicated for bacterial vaginitis or candidiasis

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21
Q

Tx of fibromyalgia

First line drug tx
Other drug class options
A

Fibromyalgia

TCAs- often first line to start amitriptyline 10mg qHS

SSRI, SNRI, TCA, gabapentin/pregabalin, anticonvulsants (cyclobenzaprine)

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22
Q

Utility of transillumination in testicular mass

A

Shine light source at base of tesicles- if mass if fluid filled (hydrocele) scrotum will glow, if solid filled (torsed testicle) will not glow

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23
Q

Clinical features of testicular mass/pain associated w/ what diagnosis

Pain relief with testicular elevation
Absent cremasteric reflex
Discrepant exam when standing vs. supine

A

Testicular pain

Pain relief w/ testicular elevation = Prehn sign indicative of epididymitis

Absence of cremasteric reflex indicative of testicular torsion

Hydrocele (vein drainage issue)- exam differs when standing vs. supine

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24
Q

49M smoker s/p Tdap and influenza, what other vaccine indicated?

A

PPSV-23 indicated for smoker/immunocompromised from ages 19-64

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25
Q

70M never vaccinated against pneumonia, order of vaccines?

A

First PCV-13, then one year later PPSC-23

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26
Q

40M smoker, immunocompromised- any pneumonia vaccines?

A

Yes- PPSV 23 indicated for any immuncompromised ages 19-64

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27
Q

Indication for

Ezetimibe
Gemfibrozil

A

Ezetimibe (Zetia)- for high risk ASCVD with LDL not adequately controlled by high-dose statin alone or or LDL persistently > 190
Gemfibrozil (fibrate) for TG over 500 to prevent pancreatitis

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28
Q

Indication for AAA screening

A

All M from 65-75 who ever smoked

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29
Q

A positive likelihood ratio of ____ would increase the pre-test probability of 50% to a post-test probability of 95%

A

+LR of 10 increases disease probability by 45%

Rule of thumb: positive likelihood ratio of 2, 5, and 10 increase disease probability by 15, 20, 45% respectively

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30
Q

A negative likelihood ratio of ____ would decrease the pre-test probability of 50% to post-test probability of 15%

A

-LR of 0.5 reduces disease probability by 15%

Rule of thumb: negative likelihood ratio of 0.5, 0.2, 0.1 reduces disease probability by 15, 30, and 45% respectively.

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31
Q

Differentiate antigens seen in hep B disease

HBsAg
HBcAg
HBeAg

A

Hep B antigens

Surface antigen indicates active infection present. Once becomes negative, then small lag time to when HBsAb rises and confers immunity

Hep B core antigen- intracellular antigen in infected hepatocytes. Not present in serum but the anti-HbC indicates pt was actually infected (vs. just vaccinated)

Hep B E-antigen is a marker of active replication and infectivity. Often correlates with ALT rise

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32
Q

What do the following indicate in hep B infection?

anti-HBs
anti-HBc
anti-HBe

A

Hep B antibodies

Anti-surface antigen: when cleared infection

Anti-core antigen: s/p active infection (present in pts who cleared infection from active infection not vaccine)

anti-E antigen: Ag against active replication, (not very helpful, more used as antigen)

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33
Q

Vertically transmitted hep B- when to treat?

A

If have chronic hep B (surface Ag persistently + x6 months with HBsAb negative) from vertical transmission- only treat if enter immune-active phase (essentially when ALT elevates above 100)

Most vertical transmissions remain in immune tolerant phase until at least 20-30 yoa, during which tx has shown no benefit. Immune-tolerant = ALT normal, HBsAg+ and HBsAb-, HBeAg+

Converts from immune-tolerant to immune-active (when tx is indicated) when ALT > 100, often correlates with HBV DNA > 20k

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34
Q

Serologic definition of chronic hepatitis B

A

Chronic hepatitis B in about 5% of those exposed- HBsAg+ persistently for >6 months, HBsAb negative

-so surface Ag persistently positive (not cleared)

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35
Q

M with CAD s/p PCI 2 years ago, undergoing colonoscopy with polypectomy- pre-op management of aspirin?

A

Continue ASA straight through- showed better overall mortality for any type of colonoscopy (including polypectomy planned)

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36
Q

Typical clinical presentation of hepatopulmonary syndrome

A

Hepatopulmonary syndrome (due to presence of intrapulmonary vascular dilations)- dyspnea at rest or w/ exertion in pt w/ longstanding liver disease w/ exclusion of other etiologies, also often platypnea (SOB worse when upright vs. supine) and orthodeoxia (desat when sit up)

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37
Q

Diagnostic criteria for hepatopulmonary syndrome

A

PaO2 under 80 or A-a gradient 15 or above with evidence of intrapulmonary shunt on echo w/ agitated saline (bubble study)

Mechanism = intrapulmonary vascular dilations causing intrapulmonary shunting

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38
Q

How to use bubble study to differentiate intracardiac from intrapulmonary shunt

A

Bubble study- use agitated saline into R heart and see when it makes its way to L heart

Within 1 cardiac cycle of entering RA indicative of intracardiac shunt

Within 3-8 cycles “ indicative of intrapulmonary shunt

Within 2ish cycles- indeterminate of shunt location

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39
Q

When is an incidental finding of gallbladder polyp an indication for cholecystectomy

A

If polyp is > 1cm or there are associated stones, given risk of malignancy

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40
Q

When to do cholecystectomy for

Acute cholangitis
Gallstone related pancreatitis

A

For both- cholecystectomy is indicated same hospitalization (prior to discharge)

Doesn’t need to be immediately, but better outcomes if not delayed weeks

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41
Q

Explain physiology of orthodeoxia in hepatopulmonary syndrome

A

Desat when go from supine to upright- proposed physiology is that intrapulmonary vascular dilations (which are disproportionately present at the lung base) are preferentially perfused when sitting up

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42
Q

3 indications for lifelong SBP ppx in cirrhotics

A
  1. Prior episode of SBP
  2. Variceal bleed
  3. Ascites with ascitic protein < 1 (b/c high risk of SBP)
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43
Q

Indication for linaclotide

A

Linaclotide and lubiprostone- both FDA approved for idiopathic constipation and IBD-C

Linaclotide- indirect secretory laxative

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44
Q

Mechanism of lactulose

A

Lactulose- binds NH4 in gut, works as osmotic laxative.

  • Osmotic laxative (pulls water into lumen as accumulates NH4 as active osmole)
  • Reduces serum ammonia level
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45
Q

When is anti-gliadin antibodies superior to anti-tissue glutaminase in dx of Celiac disease?

A

In pts w/ IgA deficiency anti-gliaden IgG is helpful

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46
Q

Dx:

Endoscopy shows diffuse dilation of main pancreatic duct and mucin extruding from ampulla during endoscopic visualization

A

Dx: IPMN = intrapapillary mucinous neoplasm
Finding of mucin from ampulla and enlarged main pancreatic duct

Tx- surgical removal

47
Q

Endoscopic findings of esosinophilic esophagitis

A

Rings (almost trachea-appearing) and furrows

48
Q

Nonspecific febrile illness in traveler to tropical area w/ conjunctival suffusion should raise suspicion for what?

A

Conjunctival suffusion (redness of eye) good distinguishing feature for leptospirosis.

Leptospirosis = zoonotic (from animal droppings/contaminated water) w/ biphasic clinical features
-conjunctival suffusion helpful to differentiate from malaria, dengue, Chikungunya

49
Q

22F at 25 weeks gestation with refractory pruritis, AST/ALT 30/55 w/ elevated bile acids

Dx
Tx

A

Dx- Cholestasis of pregnancy- possibly 2/2 estrogen-induced cholestasis

Tx- Ursodeoxycholic acid

50
Q

Screening colonoscopy for 52M reveals 3 tubular adenomas- 5mm, 8mm, and 3mm in size

When to repeat surveillance colonoscopy?

A

3 years (not 5!)

Indication for repeat colo in 3 years

  • 3 or more any adenomas
  • any adenoma larger than 1 cm
  • any adenoma with high grade dysplasia or villous features
51
Q

33F on OCPs incidentally found to have hepatic adenoma- next steps?

A

D/c OCPs- hepatic adenomas thought to be estrogen sensitive (so higher risk w/ OCPs and anabolic steroids)

Most adenomas regress when OCPs discontinued, good thing since have malignant potential

Require q6month ultrasound f/u for at least 3 years

52
Q

Liver abscess on RU ultrasound and positive E. Histolytica IgG- tx?

A

Tx is antibiotics- NOT drainage of liver abscess (best for pyogenic abscess)

Abx tx = flagyl + luminal agent (paromycin) to get ride of intraluminal cysts

53
Q

Decompensated cirrhotic with 3cm liver mass c/w HCC on imaging

Best tx?

A 
Early HCC (1 mass under 5cm, 3 single masses all under 3cm, no vascular invasion/nodes/mets): 
-if poor surgical candidates (Child-Pughes B/C): liver transplant preferred over surgical resection

-only if good surgical candidate is surgical resection preferred

Given decompensated cirrhosis: early HCC has better survival w/ transplant than surgical resection

54
Q

21F w/ bloody/mucus BM 3x/day over past 6 weeks
No fevers/chills/N/V/weight loss
Colonoscopy- continuous, symmetric rectal and sigmoid inflammation

Best tx?

A

Dx = moderate ulcerative colitis

  • involves rectum and continuously moves upwards
  • moderate b/c 3x/day w/ blood, not severe b/c no systemic features

Best tx for moderate UC = both oral and topical (enemas) 5-ASA compound = mesalamine oral and enema

55
Q

30M hospitalized for UC flare with 6 bloody BMs daily- best VTE ppx?

A

SQH- IBD pts are at high risk for VTE

Use pharmacologic ppx over SCDs unless actively hemorrhaging

56
Q

38M, father w/ colon cancer diagnosed at 52 yo- when should he undergo first screening colo?

A

40 yoa

For first-degree FHx- either 40 yoa or 10 years before index case- whichever is first

57
Q

First line pharmacologic tx for active hep B

A

Tenofovir or entecavir (nucleos(t)ide analogues) are first line for acute hep B

58
Q

Lynch syndrome

2 associated cancers
When to start cancer screening

A

Lynch syndrome

Colon cancer and endometrial cancre
Start colon CA screening at age 20-25 with q1-2 year colonoscopies

59
Q

Indication for Shingrex vaccine

A

Shingrex vaccine (2 vaccine-series, 0 months then 2-6 months) indicated for all adults over age 50

Even if immunocompromised, guidelines are for age 50 and above

60
Q

Use of glucose hydrogen breath test

A

Glucose hydrogen breath test used as diagnostic tool for SIBO (small intestine bacterial overgrowth)

Early peak in breath hydrogen/methane due to faster metabolism by more prolific small bowel bacteria

61
Q

Why is screening endoscopy indicated in pts w/ pernicious anemia?

A

Pernicious anemia (autoimmune atrophic gastritis) can cause hypergastrinemia (gastrin released to promote gastric acid secretion)

Hypergastrinemia can promote gastric carcinoid

=> screen autoimmune atrophic gastritis pts w/ upper endoscopy and gastric biopsy for gastric adenocarcinoma and gastric carcinoid

62
Q

Tx of microscopic colitis (60F w/ persistent watery diarrhea, visually no abnormality on endoscopy but lymphocytic infiltrate on biopsy)

A

Microscopic colitis tx
First- stop any possible offending agent (NSAID, SSRI)
Second- antidiarrheal agents- lopiramide or bismoth

Lastly- oral budesonide (steroid) for immunosuppression. Budesonide (over prednisone) b/c has high first-pass metabolism

63
Q

26F new onset jaundice, psychomotor slowing, Hb 10.2. Bili 6.4/2.6

Wilsons vs. hemochromatosis?

A

Wilsons- presents earlier (HH typically after age 40 and even later in women due to iron loss thru menstruation)

Wilsons- copper accumulation in CNS => neurologic manifestations

Wilsons’s acute hepatitis- release of copper from liver cells also induces hemolytic anemia

-Young age, presence of hemolytic anemia makes Wilsons more likely

64
Q

Tx of giardia

A

Metronidazole or other azole

65
Q

Differentiate endoscopic treatment of Barrets esophagus based on degree of dysplasia on biopsy

A

Barrets esophagus

No dysplasia- continue regular screening w/ endoscopy q3-5 years

Indeterminant- optimize antisecretory meds (ex: increase PPI from daily to BID) then repeat endoscopy in 3-6 months. If still present repeat in 1 year

Low grade dysplasia confirmed- ablate

High grade dysplasia confirmed- ablate

Cancer- esophagectomy

66
Q

Most common cause of drug-associated enteropathy

(a) Mimics what clinical entity

A

Olmesartan- mimics sprue (celiac) induced enteropathy: same microscopic findings of villous atrophy
Olmesartan most common, other ARBs also possible

Celiac disease

67
Q

When can diverticulitis be treated with oral (as opposed to IV) antibiotics?

A

Uncomplicated diverticulitis can be treated w/ oral meds- aka no abscess or fistula, no HDUS or e/o peritonitis

68
Q

68M w/ planned CABG- best way to prevent surgical site infection

A

Staph aureus nasal test 2 weeks before surgery and decolonize if needed

69
Q

General description of IRIS after starting tx for HIV

A

Inflammatory response characterized by paradoxical worsening of preexisting infection following initiation of ART (anti-retroviral therapy) due to improved immune function

Ex: AIDs pt, 5 weeks after starting ART develops persistent cough/fever. CXR shows RML infiltrate and b/l hilar lymphadenopathy- likely reconstitution of Tb- start RIPE

70
Q

Distinguishing clinical characteristic of West Nile encephalitis

A

Limb weakness

Characteristic limb weakness/flaccid paralysis in West Nile

71
Q

M w/ fever and indwelling foley c/b recurrent UTIs. UCx shows E. Coli sensitive to zosyn/cefepime/meropenem and confirms ESBL producing organism

Best tx?

A

FIrst line for ESBL producing organisms is carbapenems => switch to mero even tho sensitivities profile says zosyn is ok

72
Q

Management of subarachnoid hemorrhage- 3 main things

A

-most are due to aneurysmal rupture
Prevent rebleed, prevent complications (mainly vasospasm)

Prevent rebleed of aneurysm

  • surgical excision of rupture aneurysm (surgical excision or endovascular clipping) indicted ASAP (preferably w/in first 24 hrs) given high rate of rebleed w/o excision in first 48 hrs
  • Tight BP control < SBP 140, MAP < 110

Prevent complications- nimodipine! Reduces mortality (likely by reducing risk of vasospasm)
-Other CCB not as effective, use nimodipine

73
Q

First line pharmacologic agent for subarachnoid hemorrhage

A

Nimodipine- CCB, high lipophilicity so more effect on cerebral arterials than peripheral arterials

-inhibits calcium entering in slow Ca channels => reduces vascular smooth muscle and myocardial depolarization

74
Q

Biggest side effect that limits use of pramipexole

A

Pramipexole = dopamine agonist used in Parkinsons to limit exposure to levodopa (dopamine precursor that all pts will eventually require)

Dopaminergic agents carry risk of medication-induced psychosis

  • hallucinations (ex: distressing seeing small animals, unfamiliar faces)
  • impulse control disorder (gambling, hypersexuality)
75
Q

Lab data that distinguishes Lyme disease from Babesiosis

A

Babesiosis- characteristic hemolytic anemia

76
Q

Best anticoagulaion choice for mechanical aortic valve replacement

A

All mechanical and prosthetic valves- BOTH warfarin and aspirin

Not just warfarin alone! Adding aspirin reduces mortality likely from vascular causes

77
Q

F p/w recurrent R maxillary pain lasting several seconds, triggered by washing face or chewing.

Dx
First line tx

A

Dx- Trigeminal neuralgia

Tx- Carbamazepine

78
Q

81F had DES placed 1 month ago, h/o PUD and wants to stop DAPT ASAP

When can she stop plavix?

A

Depends on indication for stent-

Placed for ACS- continue plavix x12 months

Not placed for ACS (ex: disabling angina)- plavix x6 months (so 5 more months then can stop)

79
Q

Why are elderly classically at higher risk for spontaneous subdural hematoma?

A

Brain volume loss leads to stretching out of bridging veins- venous rupture => slow bleed of venous blood above subarachnoid and below dural space

Crescent shaped on imaging b/c crosses suture lines (suture lines are dura adhering to calvarium)

80
Q

Why are elderly classically at higher risk for spontaneous subdural hematoma?

A

Brain volume loss leads to stretching out of bridging veins- venous rupture => slow bleed of venous blood above subarachnoid and below dural space

Crescent shaped on imaging b/c crosses suture lines (suture lines are dura adhering to calvarium)

81
Q

Indications for AAA repair

A

AAA repair indicated in

  • diameter is 5.5cm or bigger
  • rapid enlarging: increasing by 0.5cm or more in a year
  • symptomatic: back/abdominal pain
82
Q

When to suspect Libman-Sacks endocarditis (nonbacterial thrombotic endocarditis)

A

See vegetations on TTE (typical mitral or aortic) without signs of systemic infection in a patient at high risk for clot (ex: malignancy, SLE)

83
Q

Tuberculin skin test induration cutoff for healthcare worker

A

10mm (not 5 which is for immunocompromised)

84
Q

On exam how to differentiate ostium primum from ostium secundum ASD

A

Ostium primum (hole at bottom of atrial septum, affects mitral valve) vs. ostium secundum (way more common, hole in middle of atrial septum)

Both will have signs of R sided overload, but ostium primum affects mitral valve =>MR murmur can show difference on exam

85
Q

Most common type of ASD

A

Atrial septal defect

  • most common = ostium secundum- in the middle of the atrial septum
  • second most common- ostium primum = at bottom of atrial septum so involves mitral valve => have signs of MR (ex: MR murmur on exam)
  • uncommon: coronary sinus and sinus venosis ASD
86
Q

Screening during routine health maintenance visit shows:

Reactive HIV-½ Ag/Ab combination immunoassay

Negative HIV-½ Ab differentiation immunoassay

No RNA on NAAT

Dx?

A

False positive- can tell the patient she does NOT have HIV

  • initial immunoassay tests for HIV-1 and 2 antibody and the p24 antigen. But can be false positive especially if no antibodies and no DNA
  • higher likelihood of false positive given screening (otherwise low risk population with low pre-test probability)
87
Q

39M p/w 2weeks of malaise and fever, lives in Ohio River Valley. Febrile, BP 90/50. CXR unremarkable, moderate hepatosplenomegaly, pancytopenia

Dx
Tx

A

Ohio and Mississippi River Valleys = buzzword for histoplasmosis (blasto NE, coccidio Cali and SW, histio inbetween)

Dx- histoplasmosis
Tx- disseminated so start w/ amphotericin B, then after induction can switch to fluconazole or itraconazole- but need to do ampho first

88
Q

Differentiate locations of the 3 systemic mycoses

A

Systemic mycoses = fungal infections that typically cause pneumonia but can also wreak systemic havoc

Locations

  • NE = blastomycosis
  • Ohio and Mississippi River valley = histoplasmosis
  • California/Arizona/SW = coccidio (valley fever)
89
Q

Indication for ivabradine

A

Ivabradine (inhibits I-funny channel of SA node)

Indicated for HFrEF < 25 with HR > 70 despite max tolerated beta-blocker: add to beta-blocker (not replace)

-associated w/ reduction in hospitalizations for HF

90
Q

Indication to add rifampin to vanc or ceftaz for staph infection

A

Only in s/o retained hardware

Ex: osteo of retained bone screws

Not all staph bacteremia or endocarditis, only with hardware

91
Q

Cryptosporidium

Clinical features
Risk factor
Way to diagnose

A

Cryptosporidium = enteric protozoa that causes secretory diarrhea w/ systemic features (fever, nausea)

Large volume watery diarrhea, abdominal cramping
Swimming pool diarrhea b/c cryptosporidium oocytes are resistant to chlorine
Dx- see oocytes in modified acid-fast stain or stool antigen PCR test

92
Q

45M w/ HTN and FHx of early MI found to have bicuspid aortic valve on TTE. LVEF 50%, enlarged ascending aorta

Next step in mgmt?

A

Given high association of bicuspid valve with aortopathies (dissection, aneurysm, coarctation): CTA of aorta is indicated for any newly diagnosed bicuspid valve

Given high risk nature of aortopathies => CTA of aorta

93
Q

Use of single-photon emission CT in ACS algorithm

A

SIngle-photon emission CT = nuclear stress test. Compare myocardial perfusion at rest and after stressor (treadmill, adenosine, dobutamine, dipyridamole)

-use cardiac specific radiopharmaceutical tracer

See if area of hypoperfusion induced by exercise, also can tell viability (if perfused at rest than potentially save-able)

94
Q

Expected urine sodium in

(a) ATN
(b) HRS
(c) AIN

A

Urine sodium

(a) ATN- elevated urine Na (tubules necrosed and can’t reabsorb Na)
(b) HRS- low urine Na, mimics prerenal
(c) AIN- elevated urine Na

95
Q

75M with AFib on warfarin has hematemesis- EGD with duodenal ulcer w/ actively bleeding vessel s/p endoscopic hemostasis.
When to resume warfarin?

A

Once hemostasis achieved, resume AC within 24 hrs, often same day

-no need to wait even tho active vessel visualized and high risk of bleed

96
Q

38F p/w epigastric discomfort, weight loss, early satiety, FHx x2 of stomach cancer

(a) Genetic test
(b) Associated breast cancer

A

(a) CDH1 gene (E-cadherin gene) mutation associated w/ 70% lifetime risk of gastric cancer
= hereditary diffuse gastric cancer
-if found to have this mutation, recommended to have prophylactic gastrectomy

(b) lobular breast cancer

97
Q

What is MRI elastrography of the liver used to evaluate?

A

Evaluates degree of cirrhosis- so can use this special liver MRI in chronic cirrhosis (ex: PBC) to stage fibrosis

98
Q

Is liver biopsy required to diagnose PBC?

A

Nope- adequate diagnosis made if alk phos > 1.5(ULN) and have positive antibody
90% have +anti-mitochondrial Ab
10% with neg anti-mitochondrial: can test for more specific antibodyes sp100 and gp210

(so if suspicion for PBC is high enough and anti-mitochondrial is negative, test for sp100 and gp210)

99
Q

61F w/ chronic hep C p/w joint pain, rash on shins/legs, and weakness

(a) Most likely dx
(b) Tx

A

(a) Mixed cryoglobulinemia 2/2 hep C = vasculitis from cryoglubulins (type of Ig) in serum. Classic triad is weakness, arthralgias, and palpable purpura
(b) Antivirals for hep C (many combos)

100
Q

Distinguish restrictive cardiomyopathy from constrictive pericarditis

A

Both will have high JVP, elevated R sided pressures

Restrictive (ex: amyloid): myocardium involved, see elevated BNP

Constrictive pericarditis- pericardial calcium, constraint is extracardial

101
Q

Common side effect of ticagrelor

A

Brilinta/ticagrelor (P2Y12 inhibitor) main side effect = dyspnea

Up to 15% experience self-limited SOB

102
Q

How to differentiate causes of nephrotic syndrome in adults: FSGS vs. Membranous Glomerulopathy

A

Both membranous glomerulopathy and FSGS- nephrotic syndrome (edema, proteinuria). Need biopsy to differentiate

FSGS- more sudden onset. Glomeruli affected are focal (<50% involved) and segmental (only a portion of the glomeruli is involved)

Memberanous glomerulopathy- immune complex penetrate into glomerular basement membrane making spikes between immune deposits

103
Q

Name 3 most common causes of nephrotic syndrome in adults

A

Nephrotic syndrome in adults

Two most common: membranous glomerulopathy (immune complexes in subepithelial spaces creating spikes) and focal (< 50% of glomeruli) segmental (only portion but not entire glomeruli affected) glomerulosclerosis = FSGS

3rd- minimal change disease- normal on biopsy, abnormal under electron microscopy

104
Q

Most common cause of nephritic syndrome in adults

First line treatment

A

Nephritic syndrome in adults- IgA nephritis

First line tx- ACEi or ARB to reduce proteinuria and therefore slow progression of disease

105
Q

Characteristic imaging findings of hypersensitivity pneumonitis

A

CT chest- GGO that migrate (move over time) upper and middle lobe predominant

106
Q

Aside from CT chest and clinical picture, diagnostic tests to confirm hypersensitivity pneumonitis

A

Confirm HP diagnosis with

  • BAL with lymphocytes
  • Lung biopsy with non-organized granulomas
107
Q

Aside from malaria, other FDA approved indications for hydroxychloroquine

A

Hydroxychloroquine = antimalarial drug also used for

  • SLE, especially dermatologic manifestations of discoid lupus
  • acute and chronic rheumatoid arthritis in adults
108
Q

63M w/ DES 1 yr ago on DAPT, pending CABG

What to do with antiplatelets pre-op?

A

Pre-op DAPT for stent 1 year ago

  • Continue aspirin b/c reduces post-op risk of in-graft stenosis
  • Hold P2Y12 inhibitor (plavix) 5-7 days prior to surgery if >6-12 months (minimum time for DAPT after DES) to reduce risk of bleeding

So continue ASA and hold plavix 5 days prior to CABG

109
Q

36F w/ Hashimotos, TSH and T4 wnl but T3 is low- what to do with levothyroxine dose?

A

In primary hypothyroidism- titrate levothyroxine dose to TSH (not T3)

So continue current levothyroxine dose (don’t need to uptitrate for low T3)

110
Q

When to use IV flagyl for C. Diff

A

IV flagyl for C. Diff only in fulminant C. Diff, not just in recurrence (even if multiple recurrences)

Fulminant- hypotension, shock, megacolon, ileus

For recurrence use fidaxomicin and prolonged course w/ taper of PO vanc

111
Q

HCW intubated patient with neisseria meningitis- what medications to use for post-exposure prophylaxis

A

Exposure to respiratory secretions or close contacts (roomate etc) of neisseria meningitis- need post-exposure prophylaxis with

Rifampin, cipro, CTX

112
Q

62F w/ 2 weeks of palpitations, found to be in AFib w/ RVR refractory to days of uptitration of beta-blockade

Next step?

A

Since 2 weeks of symptoms- need to r/o LA clot prior to cardioversion (either chemical or mechanical)

=> next step is TEE to r/o LA/LAA clot, then can cardiovert either synchronized or chemically (amio, flecainide, sotolol)

113
Q

Next best agent for dermatologic manifestations of lupus not responsive to topical steroids and sun avoidance

A

Moderate dermatologic manifestations of SLE

  • 1st line agent: topical steroids and sun avoidance
  • 2nd line: antimalarial (hydroxycloroquine, chloroquine)
  • 3rd line would be immunosuppressants (MTX)

So go to hydroxychloroquine before MTX

ABIM Medicine Boards (5 decks)

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