MKSAP 4 Flashcards
M w/ weeks of b/l hand pain, headache, HTN x1 week. BP 210/110. Cr 2.8, Plt 130, Hb 10, schistocytes on smear
scan with reticular fibrosis
(a) Most likely dx
(b) First line tx
(a) Scleroderma renal crisis- systemic sceroderma pt w/ acute onset hypertensive urgency and kidney failure due to b/l renal artery stenosis (from deposition of collagen and vascular wall thickening 2/2 scleroderma)
(b) First line tx (most studied) = Captopril- rapid onset, short duration of action ACEi
Radiation pneumonitis
(a) Timeline
(b) Clinical features
(c) Tx
Radiation pneumonitis
(a) Typically 4-12 weeks after radiation
(b) Fever, cough (looks just like regular PNA), often is tx first as regular PNA w/ abx then symptoms refractory
(c) Steroids
What type of extrapyramidal symptoms are the following
a) Sudden muscle contractions
(b) Subjetive restlessness
(c) Repetitive involuntary behavior (ex: lip smacking
Extrapyramidal symptoms
(a) Sudden muscle contractions = dystonia/ dystonic reaction
(b) Akathisia = subjective restlessness, pacing
(c) Lip smaking = tardive dyskinesia
Malaria prophylaxis options
Atovaquone-proguanil often first line
Second line- doxy
-used over hydroxychloroquine given high resistance
When is daily acyclovir for HSV-1 ppx indicated?
Daily acyclovir if
- more than 4 outbreaks per year
- painful outbreaks w/o prodromal features (so can’t start oral acyclovir at signs of prodromal features)
- complications (ex: aseptic meningitis)
Most common bug causing culture negative endocarditis
Coxiella burnetti (Q-fever)
-HACEK organisms are actually usually found on cultures now
Q-fever
(a) Mechanism of transmission
(b) Most common clinical course
Q-fever = zoonotic infection 2/2 coxiella burnetti
(a) Zoonotic- farm animals, manure/straw/dust
(b) Most common clinical course = self-limited febrile illness w/o complications
Scleroderma renal crisis
(a) Clinical features
(b) Lab abnormalities
(c) Acute management
Scleroderma renal crisis
-scleroderma = 2/2 collagen deposition, vessel wall thickening
(a) Acute-onset hpertensive emergency and renal failure in pt w/ signs of systemic scleroderma (skin/joint findings)
(b) Renal failure (Cr elevated), also can have MAHA (so anemia) and thrombocytopenia
(c) Acute mgmt = captopril to resolve to normal BP within 72 hours
Possible cardiac complication of Q-fever
Q-fever (coxiella burnetti) can cause culture-negative endocarditis
Endocarditis associated w/ high antiphospholipid titer
38M works on farm, presents w/ fever and conjunctival redness
Conjunctival effusion = buzzword for leptospirosis
+blood cultures with which 3 organisms necessitates removal of tunneled catheter line (and not just salvage w/ antimicrobial lock)
3 organisms in which long-term catheters must be removed (don’t just try to antibiotic lock them)
- pseudomonas
- staph aureus b/c makes biofilms
- candidemia/fungemia
What blood test to get for any pt diagnosed with medullary thyroid cancer
RET germline mutation
57M w/ unilateral pleural effusion, recent negative TST, bulky mediastinal lymphadenopathy on imaging
Effusion exudative with turbid white fluid
(a) Most likely diagnosis
Chylothorax- TG > 110, due to thoracic duct obstruction from lymphoadenopathy
Type of double vision seen in myasthenia gravis
Fattiguable diplopia- worse at the end of the day, after prolonged periods of staring etc
How to diagnosed myasthenia gravis
(a) Gold standard
(b) Second step
Diagnose myasthenia gravis
(a) First with antibodies- most will be anti-ACHreceptor positive, then a few that are AChR negative will be anti-MUSK positive (muscle receptor tyrosine kinase)
(b) Suspicion still high despite negative antibodies- do EMG for fatigability with repetitive nerve stimulation
Once diagnosed with myasthenia gravis what other 2 things should be checked?
Need to check for other concomittant issues
- TSH given high crossover with autoimmune thyroid issues
- CT neck for thymoma (often place where autoantibodies are made)
When is hemodialysis indicated in severe hypercalcemia?
Only if you can’t flood the patient w/ fluids essentially
ex: already renal failure, CKD/oliguria, heart failure
Otherwise even if Ca super high (15/16) still just use fluids, bisphosphonate, calcitonin
List 2 benefits of liraglutide over saxagliptin
Liraglutide (GLP-1 agonist) promotes weight loss and improves A1C by 1%
While saxagliptin (DPP-4 inhibitors) are weight neutral and modest A1C (0.5%)
62M smoker w/ GERD, claudication symptoms on walking, ABIs 1.45 on R, 1.40 on L
Dx?
Still peripheral arterial disease even though ABI not low
normal is 0.5 to 1.3 actually, so elevated is b/c of calcified/stiff vessels that are non-compressible in advanced PAD
Nocardia
(a) Most common site of primary infection
(b) Feared CNS complication
Nocardia = gram positive rod, branching, partially acid fast staining
(a) Lungs/inhaled, PNA
(b) CNS/brain parenchymal consolidation
Brain abscess with culture + partially acid-fast GP rods
Dx?
Nocardia
Features of disseminated blastomycoses
“Blasts, bones, balls, and skin”
Blastomycosis:
Bones- osteomyelitis in 1/4 of pts w/ disseminated disease, often w/ soft tissue swelling or draining sinus tract adjacent to focus of osteo
Balls- prostatitis, epidiymoorchitis
Skin- verrucous lesions w/ irregular borders, microabscesses, subcutaneous nodules
Which 2 endemic mycoses are typical for Mississippi and Ohio River Valley
Mississippi/Ohio River valley, midwest
-histo and blasto (not coccidio- thats arizona/Cali/New Mexico)
Aside from diabetes, name 2 other associated endocrinopathies seen in hereditary hemochromatosis
Hereditary hemochromatosis causes iron deposition in
- pituitary gonadotrophic cells => low TSH/LH, low tesosterone
- thyroid follicular cells => hypothyroidism
Spotaneous PTX with surrounding ground in HIV pt w/ LDH > 450
Dx?
PCP- LDH > 450 is rather specific for PCP
-5% of PCP cases have spontaneous PTX
Anti-glutamic acid decarboxylase- dx?
Anti-GAD = LADA (latent autoimmune diabetes of adulthood)
Adults 30-50, type 1 diabetes so need insulin sooner, not obese typically
When to use high vs. low potency topical steroids for psoriasis
Psoriasis:
Low potency for face or intertriginous regions with high risk for skin atrophy
High potency for mild/moderate skin findings
24M HIV negative, s/p IM PCN 1 day ago for rash presumed to be secondary syphilis
Returns w/ fevers, chills, progressed rash
(a) Dx
(b) Mgmt
(a) Jarish-Herxheimer reaction 2/2 spirochete release/death
(b) Symptomatic mgmt, tylenol/NSAID
29F w/ complicated vaginal delivery 1 yr ago, presenting w/ fatigue and hair loss x months
BP 90/60, sparse axillary/public hair
TSH and free T4 low, thyroxine (T4) wnl
(a) Next diagnostic step
(b) Dx?
(a) Cosyntropin sim test- basically r/o adrenal insufficiency
(b) Likely pituitary apoplexy from Sheehans => low TSH released => low thyroid hormones
But need to r/o AI first b/c if give thyroid hormone and there’s adrenal insufficiency, can precipitate adrenal crisis
When to give antibiotics after I&D of abscess
If abscess > 2cm, or significant surrounding erythema c/f cellulitis
When is PPI indicated for pt requiring DAPT
High risk pts on DAPT requiring PPI for GI bleed ppx - prior GI bleed - prior PUD - active H. pylori in adult over 65 years old
85M prior depression tx with TCA, now recurrent severe depression: 15 lb weight loss, hears voices and has thoughts of suicide
First line tx?
ECT- first line for severe depression w/ psychotic features especially w/ life-threatening features (SI, unwilling to eat)
- especially efficacious in elderly
Which alzheimer medication can cause sinus bradycardia?
Donepazil = cholinesterase inhibitor => more ACh around = affects SA node
can cause symptomatic bradycardia
Features of latent autoimmune diabetes of adulthood
(a) Age of onset
(b) Response to oral meds
(c) BMI
(d) Serologies
LADA
(a) Age 30-50 yoa
(b) Typically dont respond to oral meds and require insulin earlier b/c its a form of type I (no islet cells left)
(c) BMI low, typically not obese like in type 2
(d) Anti-GAD antibody
In DKA when to
(a) Remove K from fluids
(b) Hold insulin gtt
(c) Start D5
DKA
(a) Add K to fluids unless K is over 5.3
(b) Hold insulin for K under 3.3
(c) Start D5 when FS under 200
57M smoker w/ R thigh pain/fatigue w/ walking and ulcer at R toe. ABI 1.0 on R
Next diagnostic step?
High enough suspicion for PAD but ABIs not diagnostic- do exercise ABI
Reduction in ABI for 20% is diagnostic for exercise-induced claudication
-wouldn’t go straight to CTA without diagnosis b/c that’s a lot of contrast exposure for surgical planning
Differentiate acid/base disorder in vomiting vs. diarrhea
Acid/base disorder
Vomiting- getting rid of HCl => metabolic alkalosis
Diarrhea => metabolic acidosis b/c loss of organic acid anions (acetate, proprionate) and some HCO3 in stool
Triad in fat embolism
Fat embolism after long bone fracture: typically 24-72 hrs after initial insult
- SOB/ resp distress- often GGOs on CT chest w/ perfusion defect on V/Q scan
- petechial rash
- neurologic abnormality- seizures, confusion, focal deficit
What CBC abnormality to expect in lead poisoning
Lead poisoning => anemia due to inhibition of heme synthesis
Basophilic stippling on peripheral smear due to denatured RNA in RBCs
Ways to reduce risk of fat embolism after long bone fracture
- immediate immbolization (have them not walk)
- urgent surgical evaluation (don’t delay surgical repair
35 y/oM from Turkey p/w painful oral lesions, anterior uveitis, skin lesions on face
refuses lab work b/c gets skin bump and infections w/ blood draws
Dx?
Not all Bechets have painful genital lesions too! Dx = Behcets
- optho and dermatologic manifestations common
- pathergy test = bump to needle in skin (hence why refusing lab work)
60M from Rhode Island p/w fever, severe muscle aches, Hb 7.8, Plt 80, Tbili 3.1
(a) Dx
(b) Diagnostic test
Acute febrile illness w/ hemolytic anemia and thrombocytopenia w/ tick exposure = babesia
(a) Dx = babesiosis
(b) Dx test = peripheral smear for intra-RBCs inclusions called maltese cross
Utility of FRAX score
FRAX score = predicts 10 year fracture risk in pts over 50 with osteopenia (t-score between -1 and -2.5) and not on tx for osteoporosis
Uses bone mineral density
3 days after MI pt w/ pericardial chest pain and stable trops
Best tx
Post-MI pericarditis
Tx with increased dose of ASA (650mg-1g daily)
NOT NSAIDs- that can worsen myocardial scar
Describe change in flow volume loop due to vocal cord dysfunction
Vocal cord dysfunction = abnormal abduction (opening) during inspiration => variable extrathoracic obstruction
Flattening/plateau of inspiratory curve on flow volume loop, normal expiratory loop
66M smoker w/ COPD requiring increased use of albuterol PRN
no exacerbations, no hospitalizations, but increasing DOE
Next med to add?
Gold class B (low risk b/c no exacerbations or hospitalizations, but +symptoms): next step after PRN SABA is LAMA (tiotropium)
Add LAMA
-Not ICS/LABA: would add that for prior exacerbations or hospitalizations (class C or D)
Schistocytes vs. spherocytes
Schistocytes = thrombotic microangiopathy (TTP or HUS) or MAHA
Speropcytes in hereditary spherocytosis and AIHA
Erythema multiforme
(a) description of rash
(b) Most common etiologies
Erythema multiform = (a) targetoid lesions w/ central redness surrounded by pallor
(b) 90% infections, most common HSV also common mycoplasma
10% due to drug toxicity
Symptomatic AFib refractory to many oral antiarrthymics- transcatheter ablation vs. MAZE
Transcatheter ablation first
MAZE is an open procedure, so only if another indication exists for open heart surgery
Pulmonary manifestations of ANCA vasculitis
a) granulomatous polyangiitis (anti-PR3, c-ANCA
vs.
(b) microscopic polyangiitis (anti-MPO, p-ANCA)
ANCA vasculitis
(a) GPA, anti-PR3, c-ANCA: pulmonary nodules
(b) MPA, anti-MPO, p-ANCA: pulmonary hemorrhage due to pulmonary cappilarities
Joint symptoms of parvovirus B19 vs. acute rheumatic fever
Parvovirus B19- acute symmetrical arthralgias typically of hands/wrists that can mimic RA
vs.
Acute rheumatic fever (JONES criteria) with migratory arthritis of large joints (knees, ankles, elbows)
34 y/oF p/w acute R-sided weakness and dysphonia- exam w/ R hemiparesis and mild expressive aphasia.
Hb 12, Plt 55k, PTT 54, INR wnl
CT w/o bleed
(a) Dx to consider
(b) Next mgmt step
Young adult F w/ no other risk factors w/ acute ischemic stroke- need to (a) consider APLS (antiphospholipid syndrome)
APLS lab abnormalities- prolonged PTT and 25% will have thrombocytopenia
(b) Ischemic stroke- give ASA to prevent another within 48 hrs
70M seeking testosterone replacement therapy- Hct 54%, TC 240, PSA 3.5, BMI 30, neck circumference 20
Why is supplementary testosterone a bad idea for him?
Testosterone therapy contraindicated in
- untreated OSA
- polycythemia (can increase Hct b/c stimulates EPO)
- PSA over 4
65F p/w LLL PNA, BCx grow Strep pneumo
Duration of abx?
7 days- bacteremia doesn’t mean 14 days, only infective endocarditis requires 2 weeks
27M s/p splenectomy after MVA has a fever x1 day, has augmentin in his medicine cabinet
Next step?
Take the abx and come to the office
-splenectomy and fever: aggressive abx
27F at 25 weeks gestation dx with gestational diabetes- goal FS and when to start insulin
Can have one week of dietary modification, but then if fasting FS above 95 need to start insulin- way tighter control b/c of associated adverse fetal outcomes
fasting FS under 95
1 hr postprandial under 140
2 hr postprandial under 120
Differentiate clinical manifestations of granulomatous with polyangiitis vs. microscopic polyangiitis
Renal
Pulmonary
ENT
Both will have pauci-immune glomerulonephritis
GPA = c-ANCA = anti-PR3
more ENT symptoms
Pulmonary nodules
MPA = p-ANCA = anti-MPO
pulmonary hemorrhage b/c of pulmonary capillarities
Emergency mechanism of copper-containing IUD vs. levonorgesterol
Emergency contraception: two most efficacious are copper-IUD and plan B (levonorgesterol)
Plan B (levonorgesterol) delays ovulation
Copper-IUD prevents fertilization
73M smoker with COPD, Zenker diverticulum p/w PNA, CXR with RLL cavitary lesion with air-fluid level
Next step in management
Pulmonary abscess- next step = IV unasyn
Not surgical- lung abscesses typically respond to abx and don’t require surgery
Not Bronch w/ washes- typically polymicrobial and are walled off so bronch w/ washes have low yield
Which antibody goes with which ANCA vasculitis
Anti-MPO vs. Anti-PR3
ANCA vasculitis
anti-MPO = p-ANCA = MPA
anti-PR3 = c-ANA = GPA
CURB-65
CURB-65 = triaging tool for PNA,
One point for each
- Confusion
- Urea over 20
- RR over 30
- BP under 90/60
- Age over 65
Zero points = outpt tx
1-2 points = intermediate, consider inpatient
3-4 points = high risk, def admit, consider ICU
19 y/oM from Arizona found dead rat in his apartment, 2 days after p/w fevers/chills and enlarged non-fluctuant nodules in axilla and groin
Dx
rat exposure, big bubae, bubonic plague! = yersinia pesis (gram negative bacilli)
Tx = doxy
-also prophylaxis w/ doxy for others exposed
Exposure to what animals increase risk for
(a) Francisella tularensis
(b) Pasteurella multocida
(c) Yersinia pestis
Zoonotic stuff
(a) Francisella tularenesis = tulaeremia from bunnies
(b) Pasteurella multocida = from domesticated animals, cats or dogs
(c) Yersinia pestis = bubonic plague from rats
Hydroxyzine vs. loratadine for chronic urticaria
Both histamine blockers
Hydroxyzine = first generation so sedating
Loratidine = second generation, non-sedating Loratidine = drug of choice for chronic urticaria (symptoms for more than 6 weeks)
Transvalvular velocity and mean gradient in mild vs. severe aortic stenosis
Transvalvular velocity higher (over 4 m/s) in severe than in mild (2-2.9 m/s)
-need higher velocity to bust thru the stenosis
Mean gradient higher in severe (over 40) than mild (under 20)
-higher pressure gradient against more stenosis
Severe AS
- high transvalvular velocity
- high gradient
2 etiologies of bacteremia that require colo as further workup
- strep bovis
- clostridium septicum (not perfinges)
Ex: 71M p/w gas gangrene, blood Cx + clostridium septicum- get colo to rule out GI source b/c clostridium septicum typically originates in GI tract and is associated w/ GI pathology (colon CA)
Indication for repeat screening colonoscopy in 5 years vs. 10 years
10 years if only found small hyperplastic polyps
5 years if found 1 or 2 small tubular adenomas (b/c tubular adenomas are considered neoplastic vs. hyperplastic polyps are non-neoplastic)
EX: 54 y/oM w/ 2 6mm sessile polyps, path w/ tubular adenomas w/ low-grade dysplasia => repeat in 5 years
Differentiate bugs associated w/ watery vs. inflammatory predominant diarrhea
Watery diarrhea (ex: 3-4x/day, large volume) associated w/ intestinal toxin release: Clostridium, ETEC, cryptosporidium
Inflammatory diarrhea (ex: frequent, small volume): salmonella, shigella, campylobacter, vibrio
Differentiate symptoms of foodborne disease from campylobacter jejuni and norovirus
Campylobacter- inflammatory diarrhea predominant (many BMS per day, small volume)
vs.
Norovirus- vomiting predominant 2/2 preformed toxins
