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1
Q

SGLT2 inhibitor assoc with risk of lower extremity amputation

A

Canagliflozin

Most common toe and mid foot

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2
Q

Top 5 modifiable risk factors for acute MI, in order

A 
HLD
Smoking
Psychosocial
DM
HTN

Also: obesity, alcohol, physical activity, diet

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3
Q

What population is cilastazol ( PDE 3 inhibitor for claudication) contraindicated?

A

LVEF <40%

Because similar MOA to milrinone- increased mortality

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4
Q

What underlying conditions make exercise stress tests indeterminate?

A

ST segment analysis limited with LBBB, LVH, ventricular pacing, WPW

Can use Sgarbossa criteria to identify MI with LBBB or V pacing

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5
Q

When to screen for other family members for HOCM?

If < 12 yr

If 12 to 18-21

If >21

A

<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

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6
Q

Which malignancy is most strongly assoc with pruritus?

A

Hodgkin lymphoma

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7
Q

Symptoms of DRESS

A

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)

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8
Q

Sweet syndrome signs and treatment

A

Aka acute febrile neutrophilic dermatosis

Juicy red papules / plaques/ nodules with sharp borders on upper trunk and prox extremities

Fever

Treat with steroids

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9
Q

How does hypoMg cause hypoCa?

A

Activates G proteins that stimulate Ca-sensing receptors and decrease PTH

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10
Q

HRS diagnostic criteria

A

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

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11
Q

Alarm features for abd pain

A 
Anemia
Dysphagia
Odynophagia
Weight loss
Fam hx of GI cancer
Hx PUD / surgery / cancer
Mass or LAD
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12
Q

What size gallbladder polyp is indication for cholecystectomy?

A

Over 1 cm, even if asymptomatic because risk of neoplasia

If less than 1 cm and no stones or symptoms, follow with serial US

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13
Q

Dx for endoscopy showing rings, longitudinal furrows I’m setting of solid food dysphagia

A

Eosinophilic esophagitis

May also have structures

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14
Q

MOA of lorcaserin (appetite suppressant)

A

Serotonin 2C agonist

Caution with other serotonin meds

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15
Q

Phentermine- topiramate combo is effective in weight loss. Who is it contraindicated for?

A

Glaucoma

Phentermine is a sympathomimetic

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16
Q

Risk factors for statin adverse effects

A

Age >75
CKD
Liver disease
Medication interactions

Use moderate intensity instead

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17
Q

What med prevents progression of dry macular degeneration?

A

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

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18
Q

Treatment for wet macular degeneration

A

VEGF - inhibits neovascularization

Use antioxidants for dry MD

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19
Q

Who to offer BRCA 1/2 testing

A

Breast cancer <45 yr

Breast cancer any age plus family hx breast or ovarian

Triple negative diagnosed before age 60

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20
Q

Health maintenance for women who received chest wall radiation between ages 10 and 30

A

High risk for breast cancer

Annual mammograms AND breast MRIs starting age 30 or 8 years after radiation

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21
Q 
Sudden high fever
Frontal/ retro orbital headache
Myalgias
Arthalgias
Severe low back pain
Rash
Thrombocytopenia
A

Dengue fever signs/symptoms

Rash appears as fever abates

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22
Q

S/s of dengue

A 
Sudden high fever
Frontal/ retro orbital headache
Myalgias
Arthalgias
Severe low back pain
Rash as fever abates
Thrombocytopenia
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23
Q

Difference between dengue and chikungunya

A

Chik has more severe arthralgias, involving small joints
Also less thrombocytopenia

Both have low back pain, fever, arthralgias

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24
Q

When to give PCV 13 and PPSV 23?

Incl immunocompromised, cochlear implant, CSF leak

A

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
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25
Features of Anaplasma
Co infects with Lyme Ixodes tick Fever Leukopenia Thrombocytopenia Increase LFTs
26
Features of Babesia
Coinfects with Lyme Ixodes tick Fever Hemolysis / jaundice Splenomegaly
27
Balkin nephropathy increases risk of what malignancy?
Transitional cell carcinoma
28
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
29
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
30
Treatment of choice for resistant HTN with CKD
Use loop over thiazide with CKD4 or worse Thiazides lose potency
31
Treatment for struvite stones
Remove them when confirmed - hard to treat Urine acidification decreases risk of formation
32
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)
33
Confusion Aphasia Ataxia High anion gap
D lactic acidosis Occurs in short bowel syndrome
34
Management for ischemic stroke on aspirin mono therapy
Add dipyridimole Clopidogrel DAPT increases mortality without benefit
35
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
36
Course of HHV1 encephalitis
Cognitive problems, psych disturbance, bitemporal seizures | Progresses acutely over days
37
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
38
Management for Barrett esophagus with low grade dysplasia
Confirm with two pathologists Endoscopic ablation or yearly endoscopic surveillance
39
Supplement for MS treatment, superior to disease modifying therapy along
Vitamin D
40
Best imaging to detect insulinoma
Endoscopic ultrasound Often too small for CT or abdominal US
41
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)
42
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
43
Diagnose PCOS
2 of 3: - oligo ovulation - evidence of hyperandrogenism - polycystic morphology in ovaries on US
44
Which antiplatelet agent if giving tPA for STEMI (no cath lab available)?
Clopidogrel Ticagrelor isn’t well studied
45
Treatment for cancer of rectum vs other parts of colon
Can irradiate rectum because it’s retroperitoneal and stationary
46
Timing of colonoscopy screens after colorectal cancer
1 year, 3 years then every 5 yrs if those are normal
47
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
48
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
49
White atrophic patches with itching around vagina. Diagnose and treat.
Lichen sclerosis | Treat with topical high potency steroids
50
1st line medication for ALS
Riluzole Increases survival by 3 mo Also edaravone is FDA approved
51
Goal transferrin sats and ferritin level for CKD?
Transferrin >30% | Ferritin >500
52
Sulfonylurea plus DPP4 inhibitor. What to think about?
Hypoglycemia Decrease sulfonylurea (glipizide) when adding a DPP4 (gliptins)
53
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
54
How to diagnose Zika
PCR of blood and urine ELISA has cross reactivity with dengue and yellow fever Should also suspect dengue and chikungunya
55
When to place chest tube for parapneumonic effusion?
pH <7.20 with suspected infection Or presence of pus or positive gram stain/culture
56
First line management for cryptogenic stroke and PFO?
Aspirin Closure of PFO not proven unless recurrent stroke on warfarin, thrombus trapped, or shunting
57
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
58
Who to screen for DM if asymptomatic?
Age 40-70 if overweight or obese, every 3 years
59
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
60
Expected compensation for metabolic alkalosis?
1 increase in bicarb = 0.7 increase in CO2
61
Expected compensation for respiratory acidosis?
Acute: 10 increase in CO2 = 1 increase in bicarb Chronic: 10 increase in CO2 = 3.5 increase in bicarb
62
Expected compensation for respiratory alkalosis?
Acute: 10 decrease in CO2 = 2 decrease in bicarb Chronic: 10 decrease in CO2 = 4-5 decrease in bicarb
63
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
64
What pretest to get before starting treatment for HepC?
Test for prior HepB HepC antivirals can reactivate; keep monitoring if evidence of past
65
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
66
Risk factors for progression from acute to chronic pancreatitis?
Male, alcohol, tobacco Not hyperTG or pseudo cysts
67
Management of PMR?
Low dose prednisone (15 mg) plus methotrexate if high risk for relapse (ESR>40, peripheral arthritis, women, can’t tolerate steroids)
68
Treatment for SCD with frequent vaso-occlusive crises despite optimal medical therapy?
Stem cell transplant | Best with young age
69
Treatment for actinic keratoses?
Cryosurgical destruction if <10-15 lesions If more, use topical fluorouracil
70
What to screen for in patients with polymyositis/dermatomyositis?
ILD Strong association with presence of antiJo1
71
What agent to prevent GVHD in recent stem cell transplant?
Anti-T lymphocyte immune globulin GVHD is T cell mediated
72
First line for active seizures
Ativan, phenytoin, fosphenytoin (prodrug, works faster than phenytoin) Keppra is not abortive
73
Treatment for psoriatic arthritis that has failed conventional DMARDs and TNFalpha inhibitors?
Secukinumab (anti IL17A) if no axial disease
74
What to work up if iron deficiency is resistant to supplements?
Malabsorption: celiac, achlorhydria, H pylori
75
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
76
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.
77
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
78
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
79
Degludec vs glargine in type 1 diabetes
Degludec preferred Glargine more likely to cause hypoglycemia
80
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
81
What to work up if iron deficiency is resistant to supplements?
Malabsorption: celiac, achlorhydria, H pylori
82
Treatment for unexplained chronic cough
Gabapentin - reassess at 6 months
83
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
84
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
85
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
86
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
87
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
88
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
89
When is TIPS contraindicated?
MELD over 15 or 18 Bili over 4 Existing HE
90
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
91
Most common cause of reduced EF in heart transplant after one year
Allograft vasculopathy (evaluate with LHC)
92
How to diagnose gastroparesis
>10% retention on gastric emptying at 4 hours
93
How to give flu vaccine to solid organ transplant
Inactivated vaccine, two doses five weeks apart Live vaccine is contraindicated
94
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
95
When to use epo for CKD?
CKD 3-5 for Hgb less than 9.5
96
Things that can cause refractoriness to platelet transfusion
Nonimmune: sepsis, fever, DIC, splenomegaly, meds Immune
97
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
98
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
99
Dosing schedule for zoledronic acid for bone metastases
Every 3 mo is just as effective as monthly Alendronate is too low potency
100
What’s the risk of sub clinical hyperthyroidism?
Hip and other fractures | Esp with TSH <0.1
101
Increased risk of what with cyclophosphamide
Bladder cancer Lower risk with IV administration
102
What supplement lowers the risk of nonmelanoma cancer in high risk patient?
Vitamin B3 - nicotinamide High risk is two or more prior cancers
103
When to refer to nephrologist for transplant evaluation
GFR <20
104
When not to treat Shigella with cipro
When MIC >/= 0.12 General rule is sensitive when MIC < 1.0
105
Therapy for MG without thymoma
Thymectomy has significant clinical benefits
106
MEN 1
Parathyroid, pancreatic, pituitary tumors DIAMOND
107
MEN 2A
Medullary thyroid, pheochromocytoma, parathyroid SQUARE
108
MEN 2B
Medullary thyroid, pheo, neuromas (mucosal) Marfanoid TRIANGLE
109
Measures to prevent surgical site infection
Perioperative hyperoxia (80% fio2 during surgery and 2-6 hr after) and 24 h abx pox
110
When to use coronary artery calcium scoring?
To define CVD risk with moderate risk ASCVD 5-7.5%
111
Relative contraindications for cholinesterase inhibitors (donepezil)
``` Sick sinus LBBB Uncontrolled asthma Close angle glaucoma Ulcers ```

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