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ABIM Medicine Boards > MKSAP 4 > Flashcards

MKSAP 4 Flashcards

1
Q

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

(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

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2
Q

Radiation pneumonitis

(a) Timeline
(b) Clinical features
(c) Tx

A

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

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3
Q

What type of extrapyramidal symptoms are the following

a) Sudden muscle contractions
(b) Subjetive restlessness
(c) Repetitive involuntary behavior (ex: lip smacking

A

Extrapyramidal symptoms

(a) Sudden muscle contractions = dystonia/ dystonic reaction
(b) Akathisia = subjective restlessness, pacing
(c) Lip smaking = tardive dyskinesia

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4
Q

Malaria prophylaxis options

A

Atovaquone-proguanil often first line
Second line- doxy

-used over hydroxychloroquine given high resistance

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5
Q

When is daily acyclovir for HSV-1 ppx indicated?

A

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)
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6
Q

Most common bug causing culture negative endocarditis

A

Coxiella burnetti (Q-fever)

-HACEK organisms are actually usually found on cultures now

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7
Q

Q-fever

(a) Mechanism of transmission
(b) Most common clinical course

A

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

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8
Q

Scleroderma renal crisis

(a) Clinical features
(b) Lab abnormalities
(c) Acute management

A

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

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9
Q

Possible cardiac complication of Q-fever

A

Q-fever (coxiella burnetti) can cause culture-negative endocarditis

Endocarditis associated w/ high antiphospholipid titer

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10
Q

38M works on farm, presents w/ fever and conjunctival redness

A

Conjunctival effusion = buzzword for leptospirosis

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11
Q

+blood cultures with which 3 organisms necessitates removal of tunneled catheter line (and not just salvage w/ antimicrobial lock)

A

3 organisms in which long-term catheters must be removed (don’t just try to antibiotic lock them)

  1. pseudomonas
  2. staph aureus b/c makes biofilms
  3. candidemia/fungemia
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12
Q

What blood test to get for any pt diagnosed with medullary thyroid cancer

A

RET germline mutation

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13
Q

57M w/ unilateral pleural effusion, recent negative TST, bulky mediastinal lymphadenopathy on imaging

Effusion exudative with turbid white fluid

(a) Most likely diagnosis

A

Chylothorax- TG > 110, due to thoracic duct obstruction from lymphoadenopathy

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14
Q

Type of double vision seen in myasthenia gravis

A

Fattiguable diplopia- worse at the end of the day, after prolonged periods of staring etc

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15
Q

How to diagnosed myasthenia gravis

(a) Gold standard
(b) Second step

A

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

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16
Q

Once diagnosed with myasthenia gravis what other 2 things should be checked?

A

Need to check for other concomittant issues

  1. TSH given high crossover with autoimmune thyroid issues
  2. CT neck for thymoma (often place where autoantibodies are made)
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17
Q

When is hemodialysis indicated in severe hypercalcemia?

A

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

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18
Q

List 2 benefits of liraglutide over saxagliptin

A

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%)

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19
Q

62M smoker w/ GERD, claudication symptoms on walking, ABIs 1.45 on R, 1.40 on L

Dx?

A

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

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20
Q

Nocardia

(a) Most common site of primary infection
(b) Feared CNS complication

A

Nocardia = gram positive rod, branching, partially acid fast staining

(a) Lungs/inhaled, PNA
(b) CNS/brain parenchymal consolidation

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21
Q

Brain abscess with culture + partially acid-fast GP rods

Dx?

A

Nocardia

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22
Q

Features of disseminated blastomycoses

A

“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

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23
Q

Which 2 endemic mycoses are typical for Mississippi and Ohio River Valley

A

Mississippi/Ohio River valley, midwest

-histo and blasto (not coccidio- thats arizona/Cali/New Mexico)

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24
Q

Aside from diabetes, name 2 other associated endocrinopathies seen in hereditary hemochromatosis

A

Hereditary hemochromatosis causes iron deposition in

  1. pituitary gonadotrophic cells => low TSH/LH, low tesosterone
  2. thyroid follicular cells => hypothyroidism
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25
Q

Spotaneous PTX with surrounding ground in HIV pt w/ LDH > 450

Dx?

A

PCP- LDH > 450 is rather specific for PCP

-5% of PCP cases have spontaneous PTX

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26
Q

Anti-glutamic acid decarboxylase- dx?

A

Anti-GAD = LADA (latent autoimmune diabetes of adulthood)

Adults 30-50, type 1 diabetes so need insulin sooner, not obese typically

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27
Q

When to use high vs. low potency topical steroids for psoriasis

A

Psoriasis:
Low potency for face or intertriginous regions with high risk for skin atrophy
High potency for mild/moderate skin findings

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28
Q

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

(a) Jarish-Herxheimer reaction 2/2 spirochete release/death

(b) Symptomatic mgmt, tylenol/NSAID

29
Q

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

(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

30
Q

When to give antibiotics after I&D of abscess

A

If abscess > 2cm, or significant surrounding erythema c/f cellulitis

31
Q

When is PPI indicated for pt requiring DAPT

A 
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
32
Q

85M prior depression tx with TCA, now recurrent severe depression: 15 lb weight loss, hears voices and has thoughts of suicide

First line tx?

A

ECT- first line for severe depression w/ psychotic features especially w/ life-threatening features (SI, unwilling to eat)
- especially efficacious in elderly

33
Q

Which alzheimer medication can cause sinus bradycardia?

A

Donepazil = cholinesterase inhibitor => more ACh around = affects SA node
can cause symptomatic bradycardia

34
Q

Features of latent autoimmune diabetes of adulthood

(a) Age of onset
(b) Response to oral meds
(c) BMI
(d) Serologies

A

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

35
Q

In DKA when to

(a) Remove K from fluids
(b) Hold insulin gtt
(c) Start D5

A

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

36
Q

57M smoker w/ R thigh pain/fatigue w/ walking and ulcer at R toe. ABI 1.0 on R

Next diagnostic step?

A

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

37
Q

Differentiate acid/base disorder in vomiting vs. diarrhea

A

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

38
Q

Triad in fat embolism

A

Fat embolism after long bone fracture: typically 24-72 hrs after initial insult

  1. SOB/ resp distress- often GGOs on CT chest w/ perfusion defect on V/Q scan
  2. petechial rash
  3. neurologic abnormality- seizures, confusion, focal deficit
39
Q

What CBC abnormality to expect in lead poisoning

A

Lead poisoning => anemia due to inhibition of heme synthesis
Basophilic stippling on peripheral smear due to denatured RNA in RBCs

40
Q

Ways to reduce risk of fat embolism after long bone fracture

A
  • immediate immbolization (have them not walk)

- urgent surgical evaluation (don’t delay surgical repair

41
Q

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?

A

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)
42
Q

60M from Rhode Island p/w fever, severe muscle aches, Hb 7.8, Plt 80, Tbili 3.1

(a) Dx
(b) Diagnostic test

A

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

43
Q

Utility of FRAX score

A

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

44
Q

3 days after MI pt w/ pericardial chest pain and stable trops

Best tx

A

Post-MI pericarditis

Tx with increased dose of ASA (650mg-1g daily)

NOT NSAIDs- that can worsen myocardial scar

45
Q

Describe change in flow volume loop due to vocal cord dysfunction

A

Vocal cord dysfunction = abnormal abduction (opening) during inspiration => variable extrathoracic obstruction

Flattening/plateau of inspiratory curve on flow volume loop, normal expiratory loop

46
Q

66M smoker w/ COPD requiring increased use of albuterol PRN
no exacerbations, no hospitalizations, but increasing DOE

Next med to add?

A

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)

47
Q

Schistocytes vs. spherocytes

A

Schistocytes = thrombotic microangiopathy (TTP or HUS) or MAHA

Speropcytes in hereditary spherocytosis and AIHA

48
Q

Erythema multiforme

(a) description of rash
(b) Most common etiologies

A

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

49
Q

Symptomatic AFib refractory to many oral antiarrthymics- transcatheter ablation vs. MAZE

A

Transcatheter ablation first

MAZE is an open procedure, so only if another indication exists for open heart surgery

50
Q

Pulmonary manifestations of ANCA vasculitis

a) granulomatous polyangiitis (anti-PR3, c-ANCA
vs.
(b) microscopic polyangiitis (anti-MPO, p-ANCA)

A

ANCA vasculitis

(a) GPA, anti-PR3, c-ANCA: pulmonary nodules
(b) MPA, anti-MPO, p-ANCA: pulmonary hemorrhage due to pulmonary cappilarities

51
Q

Joint symptoms of parvovirus B19 vs. acute rheumatic fever

A

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)

52
Q

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

A

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

53
Q

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?

A

Testosterone therapy contraindicated in

  • untreated OSA
  • polycythemia (can increase Hct b/c stimulates EPO)
  • PSA over 4
54
Q

65F p/w LLL PNA, BCx grow Strep pneumo

Duration of abx?

A

7 days- bacteremia doesn’t mean 14 days, only infective endocarditis requires 2 weeks

55
Q

27M s/p splenectomy after MVA has a fever x1 day, has augmentin in his medicine cabinet

Next step?

A

Take the abx and come to the office

-splenectomy and fever: aggressive abx

56
Q

27F at 25 weeks gestation dx with gestational diabetes- goal FS and when to start insulin

A

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

57
Q

Differentiate clinical manifestations of granulomatous with polyangiitis vs. microscopic polyangiitis

Renal
Pulmonary
ENT

A

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

58
Q

Emergency mechanism of copper-containing IUD vs. levonorgesterol

A

Emergency contraception: two most efficacious are copper-IUD and plan B (levonorgesterol)

Plan B (levonorgesterol) delays ovulation

Copper-IUD prevents fertilization

59
Q

73M smoker with COPD, Zenker diverticulum p/w PNA, CXR with RLL cavitary lesion with air-fluid level

Next step in management

A

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

60
Q

Which antibody goes with which ANCA vasculitis

Anti-MPO vs. Anti-PR3

A

ANCA vasculitis

anti-MPO = p-ANCA = MPA

anti-PR3 = c-ANA = GPA

61
Q

CURB-65

A

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

62
Q

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

A

rat exposure, big bubae, bubonic plague! = yersinia pesis (gram negative bacilli)

Tx = doxy
-also prophylaxis w/ doxy for others exposed

63
Q

Exposure to what animals increase risk for

(a) Francisella tularensis
(b) Pasteurella multocida
(c) Yersinia pestis

A

Zoonotic stuff

(a) Francisella tularenesis = tulaeremia from bunnies
(b) Pasteurella multocida = from domesticated animals, cats or dogs
(c) Yersinia pestis = bubonic plague from rats

64
Q

Hydroxyzine vs. loratadine for chronic urticaria

A

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)
65
Q

Transvalvular velocity and mean gradient in mild vs. severe aortic stenosis

A

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
66
Q

2 etiologies of bacteremia that require colo as further workup

A
  1. strep bovis
  2. 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)

67
Q

Indication for repeat screening colonoscopy in 5 years vs. 10 years

A

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

68
Q

Differentiate bugs associated w/ watery vs. inflammatory predominant diarrhea

A

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

69
Q

Differentiate symptoms of foodborne disease from campylobacter jejuni and norovirus

A

Campylobacter- inflammatory diarrhea predominant (many BMS per day, small volume)

vs.

Norovirus- vomiting predominant 2/2 preformed toxins

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