MKSAP 3 Flashcards
Tx of eosinophilic esophagitis
Swallowed aerosolized glucocorticoid (fluticasone or budesonide)
Ex: 8 week course of swallowed aerosolized fluticasone
Can also try PPI
Clinical manifestations of eosinophilic esophagitis
Persistent dysphagia, adult w/ food impaction, GERD refractory to standard treatment
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?
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
Differentiate features of dumping syndrome and gastroparesis
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
Fecal osmotic gap in secretory vs. osmotic diarrhea?
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
What type of diarrhea persists despite fasting?
Secretory diarrhea persists despite fasting
While osmotic will resolve w/ fasting (no osmole in the lumen to attract water)
Why prefer CT w/ contrast over mesenteric angiogram if looking for aortoenteric fistula?
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
UC vs. Crohn’s
Continuous
Transmural
Mouth to anus
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
UC vs. Crohn’s
Most commonly involved area
Cobblestone mucosa
Granulomas on histology
Strictures
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
Utility of fecal calprotectin to differentiate IBS and IBD
Fecal calprotectin is a protein found in neutrophils- associated w/ inflammatory process => more likely + in IBD than IBS
Go to drug class for treatment of
Mild/moderate IBD
Severe IBD flare
Maintain remission of steroid-dependent IBD
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)
5-aminosalicylates for IBD treatment
(a) Formulation of mesalamine
(b) First line: mesalamine vs. sulfasalazin
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
Two drug classes approved to help maintain steroid-free remission in IBD
Maintain steroid-free remission in moderate/severe IBD with
Immunomodulators- thiozodines- azathioprine and mercaptopurine)
Biologics- anti-TNFs (infliximab)
What to add to infliximab to increase rate of steroid-free remission in fistulizing Crohn’s
Add antibiotics (flagyl, cipro)- improved steroid-free remission in fistulizing Crohns
Long term risk difference in Crohn’s/UC vs. microscopic colitis
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
AED safe in pregnancy
Keppra (levetiracetam)
In memory-predominant aging, how to differentiate dementia from mild cognitive impairment
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
Vent weening: discharge to LTAC of SNF?
LTAC for vent weening, IV meds
SNF cannot do vent weening
44M admitted for EtOH withdrawal, GFR 50, best pharmacologic tx to reduce 30-day readmission and ED visits
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
For what form of microbial vaginitis is the treatment of sexual partners indicated?
Only for trichimoniasis (tx w/ flagyl 2g x1 dose)
Tx of partner not indicated for bacterial vaginitis or candidiasis
Tx of fibromyalgia
First line drug tx Other drug class options
Fibromyalgia
TCAs- often first line to start amitriptyline 10mg qHS
SSRI, SNRI, TCA, gabapentin/pregabalin, anticonvulsants (cyclobenzaprine)
Utility of transillumination in testicular mass
Shine light source at base of tesicles- if mass if fluid filled (hydrocele) scrotum will glow, if solid filled (torsed testicle) will not glow
Clinical features of testicular mass/pain associated w/ what diagnosis
Pain relief with testicular elevation
Absent cremasteric reflex
Discrepant exam when standing vs. supine
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
49M smoker s/p Tdap and influenza, what other vaccine indicated?
PPSV-23 indicated for smoker/immunocompromised from ages 19-64
70M never vaccinated against pneumonia, order of vaccines?
First PCV-13, then one year later PPSC-23
40M smoker, immunocompromised- any pneumonia vaccines?
Yes- PPSV 23 indicated for any immuncompromised ages 19-64
Indication for
Ezetimibe
Gemfibrozil
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
Indication for AAA screening
All M from 65-75 who ever smoked
A positive likelihood ratio of ____ would increase the pre-test probability of 50% to a post-test probability of 95%
+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
A negative likelihood ratio of ____ would decrease the pre-test probability of 50% to post-test probability of 15%
-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.
Differentiate antigens seen in hep B disease
HBsAg
HBcAg
HBeAg
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
What do the following indicate in hep B infection?
anti-HBs
anti-HBc
anti-HBe
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)
Vertically transmitted hep B- when to treat?
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
Serologic definition of chronic hepatitis B
Chronic hepatitis B in about 5% of those exposed- HBsAg+ persistently for >6 months, HBsAb negative
-so surface Ag persistently positive (not cleared)
M with CAD s/p PCI 2 years ago, undergoing colonoscopy with polypectomy- pre-op management of aspirin?
Continue ASA straight through- showed better overall mortality for any type of colonoscopy (including polypectomy planned)
Typical clinical presentation of hepatopulmonary syndrome
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)
Diagnostic criteria for hepatopulmonary syndrome
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
How to use bubble study to differentiate intracardiac from intrapulmonary shunt
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
When is an incidental finding of gallbladder polyp an indication for cholecystectomy
If polyp is > 1cm or there are associated stones, given risk of malignancy
When to do cholecystectomy for
Acute cholangitis
Gallstone related pancreatitis
For both- cholecystectomy is indicated same hospitalization (prior to discharge)
Doesn’t need to be immediately, but better outcomes if not delayed weeks
Explain physiology of orthodeoxia in hepatopulmonary syndrome
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
3 indications for lifelong SBP ppx in cirrhotics
- Prior episode of SBP
- Variceal bleed
- Ascites with ascitic protein < 1 (b/c high risk of SBP)
Indication for linaclotide
Linaclotide and lubiprostone- both FDA approved for idiopathic constipation and IBD-C
Linaclotide- indirect secretory laxative
Mechanism of lactulose
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
When is anti-gliadin antibodies superior to anti-tissue glutaminase in dx of Celiac disease?
In pts w/ IgA deficiency anti-gliaden IgG is helpful
Dx:
Endoscopy shows diffuse dilation of main pancreatic duct and mucin extruding from ampulla during endoscopic visualization
Dx: IPMN = intrapapillary mucinous neoplasm
Finding of mucin from ampulla and enlarged main pancreatic duct
Tx- surgical removal
Endoscopic findings of esosinophilic esophagitis
Rings (almost trachea-appearing) and furrows
Nonspecific febrile illness in traveler to tropical area w/ conjunctival suffusion should raise suspicion for what?
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
22F at 25 weeks gestation with refractory pruritis, AST/ALT 30/55 w/ elevated bile acids
Dx
Tx
Dx- Cholestasis of pregnancy- possibly 2/2 estrogen-induced cholestasis
Tx- Ursodeoxycholic acid
Screening colonoscopy for 52M reveals 3 tubular adenomas- 5mm, 8mm, and 3mm in size
When to repeat surveillance colonoscopy?
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
33F on OCPs incidentally found to have hepatic adenoma- next steps?
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
Liver abscess on RU ultrasound and positive E. Histolytica IgG- tx?
Tx is antibiotics- NOT drainage of liver abscess (best for pyogenic abscess)
Abx tx = flagyl + luminal agent (paromycin) to get ride of intraluminal cysts
Decompensated cirrhotic with 3cm liver mass c/w HCC on imaging
Best tx?
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
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?
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
30M hospitalized for UC flare with 6 bloody BMs daily- best VTE ppx?
SQH- IBD pts are at high risk for VTE
Use pharmacologic ppx over SCDs unless actively hemorrhaging
38M, father w/ colon cancer diagnosed at 52 yo- when should he undergo first screening colo?
40 yoa
For first-degree FHx- either 40 yoa or 10 years before index case- whichever is first
First line pharmacologic tx for active hep B
Tenofovir or entecavir (nucleos(t)ide analogues) are first line for acute hep B
Lynch syndrome
2 associated cancers
When to start cancer screening
Lynch syndrome
Colon cancer and endometrial cancre
Start colon CA screening at age 20-25 with q1-2 year colonoscopies
Indication for Shingrex vaccine
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
Use of glucose hydrogen breath test
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
Why is screening endoscopy indicated in pts w/ pernicious anemia?
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
Tx of microscopic colitis (60F w/ persistent watery diarrhea, visually no abnormality on endoscopy but lymphocytic infiltrate on biopsy)
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
26F new onset jaundice, psychomotor slowing, Hb 10.2. Bili 6.4/2.6
Wilsons vs. hemochromatosis?
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
Tx of giardia
Metronidazole or other azole
Differentiate endoscopic treatment of Barrets esophagus based on degree of dysplasia on biopsy
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
Most common cause of drug-associated enteropathy
(a) Mimics what clinical entity
Olmesartan- mimics sprue (celiac) induced enteropathy: same microscopic findings of villous atrophy
Olmesartan most common, other ARBs also possible
Celiac disease
When can diverticulitis be treated with oral (as opposed to IV) antibiotics?
Uncomplicated diverticulitis can be treated w/ oral meds- aka no abscess or fistula, no HDUS or e/o peritonitis
68M w/ planned CABG- best way to prevent surgical site infection
Staph aureus nasal test 2 weeks before surgery and decolonize if needed
General description of IRIS after starting tx for HIV
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
Distinguishing clinical characteristic of West Nile encephalitis
Limb weakness
Characteristic limb weakness/flaccid paralysis in West Nile
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?
FIrst line for ESBL producing organisms is carbapenems => switch to mero even tho sensitivities profile says zosyn is ok
Management of subarachnoid hemorrhage- 3 main things
-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
First line pharmacologic agent for subarachnoid hemorrhage
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
Biggest side effect that limits use of pramipexole
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)
Lab data that distinguishes Lyme disease from Babesiosis
Babesiosis- characteristic hemolytic anemia
Best anticoagulaion choice for mechanical aortic valve replacement
All mechanical and prosthetic valves- BOTH warfarin and aspirin
Not just warfarin alone! Adding aspirin reduces mortality likely from vascular causes
F p/w recurrent R maxillary pain lasting several seconds, triggered by washing face or chewing.
Dx
First line tx
Dx- Trigeminal neuralgia
Tx- Carbamazepine
81F had DES placed 1 month ago, h/o PUD and wants to stop DAPT ASAP
When can she stop plavix?
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)
Why are elderly classically at higher risk for spontaneous subdural hematoma?
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)
Why are elderly classically at higher risk for spontaneous subdural hematoma?
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)
Indications for AAA repair
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
When to suspect Libman-Sacks endocarditis (nonbacterial thrombotic endocarditis)
See vegetations on TTE (typical mitral or aortic) without signs of systemic infection in a patient at high risk for clot (ex: malignancy, SLE)
Tuberculin skin test induration cutoff for healthcare worker
10mm (not 5 which is for immunocompromised)
On exam how to differentiate ostium primum from ostium secundum ASD
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
Most common type of ASD
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
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?
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)
39M p/w 2weeks of malaise and fever, lives in Ohio River Valley. Febrile, BP 90/50. CXR unremarkable, moderate hepatosplenomegaly, pancytopenia
Dx
Tx
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
Differentiate locations of the 3 systemic mycoses
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)
Indication for ivabradine
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
Indication to add rifampin to vanc or ceftaz for staph infection
Only in s/o retained hardware
Ex: osteo of retained bone screws
Not all staph bacteremia or endocarditis, only with hardware
Cryptosporidium
Clinical features
Risk factor
Way to diagnose
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
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?
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
Use of single-photon emission CT in ACS algorithm
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)
Expected urine sodium in
(a) ATN
(b) HRS
(c) AIN
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
75M with AFib on warfarin has hematemesis- EGD with duodenal ulcer w/ actively bleeding vessel s/p endoscopic hemostasis.
When to resume warfarin?
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
38F p/w epigastric discomfort, weight loss, early satiety, FHx x2 of stomach cancer
(a) Genetic test
(b) Associated breast cancer
(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
What is MRI elastrography of the liver used to evaluate?
Evaluates degree of cirrhosis- so can use this special liver MRI in chronic cirrhosis (ex: PBC) to stage fibrosis
Is liver biopsy required to diagnose PBC?
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)
61F w/ chronic hep C p/w joint pain, rash on shins/legs, and weakness
(a) Most likely dx
(b) Tx
(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)
Distinguish restrictive cardiomyopathy from constrictive pericarditis
Both will have high JVP, elevated R sided pressures
Restrictive (ex: amyloid): myocardium involved, see elevated BNP
Constrictive pericarditis- pericardial calcium, constraint is extracardial
Common side effect of ticagrelor
Brilinta/ticagrelor (P2Y12 inhibitor) main side effect = dyspnea
Up to 15% experience self-limited SOB
How to differentiate causes of nephrotic syndrome in adults: FSGS vs. Membranous Glomerulopathy
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
Name 3 most common causes of nephrotic syndrome in adults
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
Most common cause of nephritic syndrome in adults
First line treatment
Nephritic syndrome in adults- IgA nephritis
First line tx- ACEi or ARB to reduce proteinuria and therefore slow progression of disease
Characteristic imaging findings of hypersensitivity pneumonitis
CT chest- GGO that migrate (move over time) upper and middle lobe predominant
Aside from CT chest and clinical picture, diagnostic tests to confirm hypersensitivity pneumonitis
Confirm HP diagnosis with
- BAL with lymphocytes
- Lung biopsy with non-organized granulomas
Aside from malaria, other FDA approved indications for hydroxychloroquine
Hydroxychloroquine = antimalarial drug also used for
- SLE, especially dermatologic manifestations of discoid lupus
- acute and chronic rheumatoid arthritis in adults
63M w/ DES 1 yr ago on DAPT, pending CABG
What to do with antiplatelets pre-op?
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
36F w/ Hashimotos, TSH and T4 wnl but T3 is low- what to do with levothyroxine dose?
In primary hypothyroidism- titrate levothyroxine dose to TSH (not T3)
So continue current levothyroxine dose (don’t need to uptitrate for low T3)
When to use IV flagyl for C. Diff
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
HCW intubated patient with neisseria meningitis- what medications to use for post-exposure prophylaxis
Exposure to respiratory secretions or close contacts (roomate etc) of neisseria meningitis- need post-exposure prophylaxis with
Rifampin, cipro, CTX
62F w/ 2 weeks of palpitations, found to be in AFib w/ RVR refractory to days of uptitration of beta-blockade
Next step?
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)
Next best agent for dermatologic manifestations of lupus not responsive to topical steroids and sun avoidance
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
