MKSAP Flashcards
SGLT2 inhibitor assoc with risk of lower extremity amputation
Canagliflozin
Most common toe and mid foot
Top 5 modifiable risk factors for acute MI, in order
HLD Smoking Psychosocial DM HTN
Also: obesity, alcohol, physical activity, diet
What population is cilastazol ( PDE 3 inhibitor for claudication) contraindicated?
LVEF <40%
Because similar MOA to milrinone- increased mortality
What underlying conditions make exercise stress tests indeterminate?
ST segment analysis limited with LBBB, LVH, ventricular pacing, WPW
Can use Sgarbossa criteria to identify MI with LBBB or V pacing
When to screen for other family members for HOCM?
If < 12 yr
If 12 to 18-21
If >21
<12 : only if symptoms, competitive athlete, clinical early LVH, family hx of VTach
12-18/21: every 12-18 mo
> 21: symptoms or every 5 years
Which malignancy is most strongly assoc with pruritus?
Hodgkin lymphoma
Symptoms of DRESS
Drug reactions with eosinophilia and systemic symptoms
Onset 2-6 days after drug
Skin eruption
Hematologic abnormalities (eosinophilia, atypical lymphocytosis
LAD
Organ involvement (elevated liver enzymes, kidney, lungs)
Sweet syndrome signs and treatment
Aka acute febrile neutrophilic dermatosis
Juicy red papules / plaques/ nodules with sharp borders on upper trunk and prox extremities
Fever
Treat with steroids
How does hypoMg cause hypoCa?
Activates G proteins that stimulate Ca-sensing receptors and decrease PTH
HRS diagnostic criteria
Cr increase >1.5 (acute or subacute)
Lack of response to albumin challenge 1 g/kg/day for 2 days
Absence of shock, nephrotoxicity, active sediment, proteinuria >500, US evidence of kidney issues
Alarm features for abd pain
Anemia Dysphagia Odynophagia Weight loss Fam hx of GI cancer Hx PUD / surgery / cancer Mass or LAD
What size gallbladder polyp is indication for cholecystectomy?
Over 1 cm, even if asymptomatic because risk of neoplasia
If less than 1 cm and no stones or symptoms, follow with serial US
Dx for endoscopy showing rings, longitudinal furrows I’m setting of solid food dysphagia
Eosinophilic esophagitis
May also have structures
MOA of lorcaserin (appetite suppressant)
Serotonin 2C agonist
Caution with other serotonin meds
Phentermine- topiramate combo is effective in weight loss. Who is it contraindicated for?
Glaucoma
Phentermine is a sympathomimetic
Risk factors for statin adverse effects
Age >75
CKD
Liver disease
Medication interactions
Use moderate intensity instead
What med prevents progression of dry macular degeneration?
High dose antioxidant vitamins (C, E, beta carotene, Zn, Cu)
Use AREDS (age related eye disease study) formulation instead of beta carotene if increased risk of lung cancer
Treatment for wet macular degeneration
VEGF - inhibits neovascularization
Use antioxidants for dry MD
Who to offer BRCA 1/2 testing
Breast cancer <45 yr
Breast cancer any age plus family hx breast or ovarian
Triple negative diagnosed before age 60
Health maintenance for women who received chest wall radiation between ages 10 and 30
High risk for breast cancer
Annual mammograms AND breast MRIs starting age 30 or 8 years after radiation
Sudden high fever Frontal/ retro orbital headache Myalgias Arthalgias Severe low back pain Rash Thrombocytopenia
Dengue fever signs/symptoms
Rash appears as fever abates
S/s of dengue
Sudden high fever Frontal/ retro orbital headache Myalgias Arthalgias Severe low back pain Rash as fever abates Thrombocytopenia
Difference between dengue and chikungunya
Chik has more severe arthralgias, involving small joints
Also less thrombocytopenia
Both have low back pain, fever, arthralgias
When to give PCV 13 and PPSV 23?
Incl immunocompromised, cochlear implant, CSF leak
PCV 13:
- >65, at least one year if got PPSV23
PPSV23:
- 19-64 if comorbidities
- 65+ one year after PCV13
HIV/ immunocompromised (CKD, asplenia):
- PCV 13 then 8 weeks later PPSV23 then 5yrs later PPSV23
Cochlear implant or CSF leak:
- PCV13 then one year PPSV23
- if already got both, one additional PPSV23
Features of Anaplasma
Co infects with Lyme
Ixodes tick
Fever
Leukopenia
Thrombocytopenia
Increase LFTs
Features of Babesia
Coinfects with Lyme
Ixodes tick
Fever
Hemolysis / jaundice
Splenomegaly
Balkin nephropathy increases risk of what malignancy?
Transitional cell carcinoma
Treat Uric acid stones
Hydration for UOP > 2 liters per day
Urine alkalinization with Kcitrate or Kbicarb (increased urate solubility)
Xanthine oxidase inhibitor If refractory
Treatment for calcium renal stones
Thiazides and K citrate, maybe pyridoxine if primary hyperoxaluria
Increase proximal sodium reabsorption and passive Ca reabsorption
Citrate binds Ca in tubule preventing precipitation with oxalate. Kcitrate decreases uptake of citrate from tubules
Treatment of choice for resistant HTN with CKD
Use loop over thiazide with CKD4 or worse
Thiazides lose potency
Treatment for struvite stones
Remove them when confirmed - hard to treat
Urine acidification decreases risk of formation
How can bowel resection cause kidney stones?
How to treat it?
Excess fatty acids bind Ca - Ca Not available to bind oxalate - increased oxalate absorption (enteric hyperoxaluria)
Treat with adequate Ca intake, hydration, and cholestyramine to bind oxalate
Pyridoxine only works for primary hyperoxaluria not enteric (improves glyoxylate metabolism)
Confusion
Aphasia
Ataxia
High anion gap
D lactic acidosis
Occurs in short bowel syndrome
Management for ischemic stroke on aspirin mono therapy
Add dipyridimole
Clopidogrel DAPT increases mortality without benefit
Personality change, psychosis, and seizures over weeks. What type of encephalitis?
Antibody mediated like paraneoplastic antibody syndrome
Assoc with SCLC, breast, thymoma, germ cell, Hodgkin
Can also be primary autoimmune like anti-LG1
Course of HHV1 encephalitis
Cognitive problems, psych disturbance, bitemporal seizures
Progresses acutely over days
What is water restriction test for and how does it work?
Evaluate for DI (absence or resistance to ADH)
May not have hypernatremia if access to water
Restricting water will increase plasma osmolality But urine osm doesn’t increase with DI
Management for Barrett esophagus with low grade dysplasia
Confirm with two pathologists
Endoscopic ablation or yearly endoscopic surveillance
Supplement for MS treatment, superior to disease modifying therapy along
Vitamin D
Best imaging to detect insulinoma
Endoscopic ultrasound
Often too small for CT or abdominal US
Clinical manifestations of eosinophilic granulomatosis with polyangiitis
Churg Strauss
Autoimmune small vessel vasculitis
Peripheral eosinophilia
Asthma
Purpura on hands and legs
Neuropathies (sensory or motor)
Allergic bronchopulmonary aspergillosis
Population?
Clinical picture?
Treatment?
Commonly in ppl with atopic asthma or CF
Severe asthma Cough with production of mucous plugs Fever/fatigue CXR normal or infiltrates Peripheral eosinophilia
Treat with steroids and maybe anticoagulation
Diagnose PCOS
2 of 3:
- oligo ovulation
- evidence of hyperandrogenism
- polycystic morphology in ovaries on US
Which antiplatelet agent if giving tPA for STEMI (no cath lab available)?
Clopidogrel
Ticagrelor isn’t well studied
Treatment for cancer of rectum vs other parts of colon
Can irradiate rectum because it’s retroperitoneal and stationary
Timing of colonoscopy screens after colorectal cancer
1 year, 3 years then every 5 yrs if those are normal
For kidney transplants, is it better to get HLA incompatible or stay on dialysis and wait for compatible ?
Survival benefit to get earlier incompatible kidney than to wait
Claudication symptoms with ABI between 0.91 and 0.99. What next?
Get exercise ABI if borderline resting results
Exercise ABI significant if <0.90 and decreases 20% from resting
Get CT angiography for surgical planning only after official diagnosis
White atrophic patches with itching around vagina. Diagnose and treat.
Lichen sclerosis
Treat with topical high potency steroids
1st line medication for ALS
Riluzole
Increases survival by 3 mo
Also edaravone is FDA approved
Goal transferrin sats and ferritin level for CKD?
Transferrin >30%
Ferritin >500
Sulfonylurea plus DPP4 inhibitor. What to think about?
Hypoglycemia
Decrease sulfonylurea (glipizide) when adding a DPP4 (gliptins)
Imaging to diagnose MS?
Need dissemination in space and time
If only one lesion on MR brain , need to get MR spine too (cervical and thoracic)
LP with oligoclonal bands not necessary to diagnose if imaging confirms
How to diagnose Zika
PCR of blood and urine
ELISA has cross reactivity with dengue and yellow fever
Should also suspect dengue and chikungunya
When to place chest tube for parapneumonic effusion?
pH <7.20 with suspected infection
Or presence of pus or positive gram stain/culture
First line management for cryptogenic stroke and PFO?
Aspirin
Closure of PFO not proven unless recurrent stroke on warfarin, thrombus trapped, or shunting
Treatment for Crohn’s disease in pregnancy?
Anti-TNF agents
Certolizumab is preferred over infliximab and adalimumab because it’s pegylated which limits placental transfer
Who to screen for DM if asymptomatic?
Age 40-70 if overweight or obese, every 3 years
Expected compensation for metabolic acidosis?
Acute:
pCO2 is 1.5 x bicarb + 8
Chronic:
pCO2 is bicarb + 15
OR pCO2 is last two digits of pH
Expected compensation for metabolic alkalosis?
1 increase in bicarb = 0.7 increase in CO2
Expected compensation for respiratory acidosis?
Acute:
10 increase in CO2 = 1 increase in bicarb
Chronic:
10 increase in CO2 = 3.5 increase in bicarb
Expected compensation for respiratory alkalosis?
Acute:
10 decrease in CO2 = 2 decrease in bicarb
Chronic:
10 decrease in CO2 = 4-5 decrease in bicarb
What is delta delta ratio and what does it mean?
Use to determine if mixed or simple AGMA
Ratio of change in AG to change in bicarb
<0.8 means concurrent non AGMA
0.8-2.0 is pure AGMA
> 2 means concurrent metabolic alkalosis
What pretest to get before starting treatment for HepC?
Test for prior HepB
HepC antivirals can reactivate; keep monitoring if evidence of past
Diagnose bulla in setting of alcoholic liver disease?
Porphyria cutanea tarda
Assoc with extensive alcohol use, hemochromatosis, HepC infection
Fragile easily ruptured vesicles on sun exposed areas, darkened skin, hypertrichosis
Risk factors for progression from acute to chronic pancreatitis?
Male, alcohol, tobacco
Not hyperTG or pseudo cysts
Management of PMR?
Low dose prednisone (15 mg) plus methotrexate if high risk for relapse (ESR>40, peripheral arthritis, women, can’t tolerate steroids)
Treatment for SCD with frequent vaso-occlusive crises despite optimal medical therapy?
Stem cell transplant
Best with young age
Treatment for actinic keratoses?
Cryosurgical destruction if <10-15 lesions
If more, use topical fluorouracil
What to screen for in patients with polymyositis/dermatomyositis?
ILD
Strong association with presence of antiJo1
What agent to prevent GVHD in recent stem cell transplant?
Anti-T lymphocyte immune globulin
GVHD is T cell mediated
First line for active seizures
Ativan, phenytoin, fosphenytoin (prodrug, works faster than phenytoin)
Keppra is not abortive
Treatment for psoriatic arthritis that has failed conventional DMARDs and TNFalpha inhibitors?
Secukinumab (anti IL17A) if no axial disease
What to work up if iron deficiency is resistant to supplements?
Malabsorption: celiac, achlorhydria, H pylori
Pt in 2nd trimester of preg has gallstone pancreatitis. What next?
Take it out,safest in 2nd trimester.
Worse to wait until after delivery. Bile acid dissolution is expensive, frequent dosing, close follow up
With liver failure, what happens to factors 5, 7, 8?
All factors low except for 8, which is high
Factor 8 is synthesized by all endothelial cells, not just hepatic. Also is cleared by the liver.
How to tell between liver disease and vit K deficiency from clotting factors?
5 isn’t vit K dependent so will be normal with deficiency
5 will be low with liver disease
Work up for fasting hypoglycemic episodes in non-diabetic
72 hour fast with hypoglycemic studies
beta hydroxybutyrate is suppressed by endogenous and exogenous insulin
If hypoglycemia <5 hours after meal, do mixed meal testing to assess metabolic response to glucose
Degludec vs glargine in type 1 diabetes
Degludec preferred
Glargine more likely to cause hypoglycemia
MOA of febuxostat
What are some drug interactions?
Xanthine oxidase inhibitor
It’s an alternative first line urate lowering drug
Don’t use with drugs metabolized by it: azathioprine or 6-mercatopurine
What to work up if iron deficiency is resistant to supplements?
Malabsorption: celiac, achlorhydria, H pylori
Treatment for unexplained chronic cough
Gabapentin - reassess at 6 months
Obesity with proteinuria, normal serum albumin, and no edema - diagnosis and treatment?
Secondary FSGS, from glomerular hypertrophy (enlarged glomeruli with mild foot process effacement
Lose weight and start ACEi or ARB
When to use anastrazole vs tamoxifen for ER/PR+ DCIS
After lumpectomy and radiation:
Use anastrozole for post menopausal women
- Has longer cancer free intervals and less VTEs
Polymyositis with new fatigue and dyspnea - what to do next?
Rule out ACS
Poly/dermatomyositis have 4x increase of ischemic events
can have ILD too but more chronic onset
Treatment for acromegaly
If evidence of mass effect (optic chiasm/vision changes), do transsphenoidal surgery
If no mass effect or contraindications to surgery, give somatostatin analogues (octreotide) to inhibit GH
When to take drug holiday for osteoporosis
If taking for 3-5 years with no disease progression AND minimal risk factors for fractures
Continue if high risk
What to use if bisphosphonate therapy fails to prevent progression with osteoporosis
Teriparatide (it’s also first line if T<3.0)
Denosumab, a RANK ligand inhibitor, if high risk and intolerant of bisphos
When is TIPS contraindicated?
MELD over 15 or 18
Bili over 4
Existing HE
Treatment for Sjogren keratoconjunctivitis if artificial tears doesn’t help
Topical cyclosporine
If that doesn’t work, topical glucocorticoids pulse therapy (can cause high IOP)
Hydroxychloroquine is reserved for systemic/extraglandular disease or failure of all topicals
Most common cause of reduced EF in heart transplant after one year
Allograft vasculopathy (evaluate with LHC)
How to diagnose gastroparesis
> 10% retention on gastric emptying at 4 hours
How to give flu vaccine to solid organ transplant
Inactivated vaccine, two doses five weeks apart
Live vaccine is contraindicated
How to treat hepatic adenomas assoc with OCPs
Resect if >5 cm or beta catenin nuclear reactivity positive or hemorrhage
OCP is reversible cause - if <5 cm surveillance CTs every 6-12 mo
When to use epo for CKD?
CKD 3-5 for Hgb less than 9.5
Things that can cause refractoriness to platelet transfusion
Nonimmune: sepsis, fever, DIC, splenomegaly, meds
Immune
When to transfuse HLA matched platelets?
For alloimmunized patients
When platelet counts are refractory to transfusion (measured 10-60 min after) and not due to sepsis , fever, splenomeg, DIC
Washed platelets are for severe allergic reactions or IgA deficiency
What level of coronary stenosis and fractional flow reserve (FFR) do we revascularize, if asymptomatic and no ischemia on MIBI?
Stenosis 50-70% and FFR <0.80
Normal is 1.0
Dosing schedule for zoledronic acid for bone metastases
Every 3 mo is just as effective as monthly
Alendronate is too low potency
What’s the risk of sub clinical hyperthyroidism?
Hip and other fractures
Esp with TSH <0.1
Increased risk of what with cyclophosphamide
Bladder cancer
Lower risk with IV administration
What supplement lowers the risk of nonmelanoma cancer in high risk patient?
Vitamin B3 - nicotinamide
High risk is two or more prior cancers
When to refer to nephrologist for transplant evaluation
GFR <20
When not to treat Shigella with cipro
When MIC >/= 0.12
General rule is sensitive when MIC < 1.0
Therapy for MG without thymoma
Thymectomy has significant clinical benefits
MEN 1
Parathyroid, pancreatic, pituitary tumors
DIAMOND
MEN 2A
Medullary thyroid, pheochromocytoma, parathyroid
SQUARE
MEN 2B
Medullary thyroid, pheo, neuromas (mucosal)
Marfanoid
TRIANGLE
Measures to prevent surgical site infection
Perioperative hyperoxia (80% fio2 during surgery and 2-6 hr after) and 24 h abx pox
When to use coronary artery calcium scoring?
To define CVD risk with moderate risk ASCVD 5-7.5%
Relative contraindications for cholinesterase inhibitors (donepezil)
Sick sinus LBBB Uncontrolled asthma Close angle glaucoma Ulcers
