MKSAP

Question 1

type 1 and 2 amiodarone induced hyperthyroidism

Answer 1

hyrotoxicosis occurs in patients with underlying multinodular goiter or latent Graves disease and is associated with increased vascularity on color flow Doppler ultrasonography. Type 2 (destructive thyroiditis) usually affects those without thyroid disease and is not associated with increased vascularity on color flow Doppler. Mixed forms can also be seen and making the correct diagnosis can be difficult. The patient’s clinical presentation is most consistent with type 2 amiodarone-induced thyrotoxicosis given the absence of structural thyroid disease (no nodules or goiter), absent thyroid-stimulating hormone (TSH) receptor antibody, and absent parenchymal flow seen on Doppler ultrasound. Moderate- to high-dose prednisone is an effective treatment that can be gradually tapered over 1 to 3 months.

Question 2

Treatment of PAN

Answer 2

Prednisone and cyclophosphamide are agents typically used to treat mild and severe manifestations of idiopathic

Sofosbuvir and ledipasvir are direct-acting antiviral agents used to treat hepatitis C virus (HCV) infection and would be an appropriate choice for mild HCV-related PAN.

Tenofovir, emtricitabine, and raltegravir are used to treat HIV infection. This drug combination would be an appropriate choice for HIV-related PAN,

The most appropriate treatment is entecavir. Hepatitis B virus (HBV)–related polyarteritis nodosa (PAN) is the most likely diagnosis in this patient.

Question 3

prolactinoma treatment

Answer 3

Prolactinomas are treated with dopamine agonists. The two FDA-approved dopamine agonists are bromocriptine and cabergoline.

Question 4

Hep B treatment in pregnancy

Answer 4

Guidelines recommend treatment with lamivudine, telbivudine, or tenofovir for the prevention of vertical transmission in pregnant women who have HBV DNA levels greater than 200,000 IU/mL at 24 to 28 weeks’ gestation.

Question 5

pulmonary stenosis treatment

Answer 5

Balloon valvuloplasty is recommended for symptomatic patients with appropriate valve morphology who have a peak Doppler gradient of greater than 50 mm Hg or a mean gradient greater than 30 mm Hg and favorable valve characteristics for percutaneous intervention.

Question 6

Aortic Regurg surgical criteria

Answer 6

For patients with severe aortic regurgitation, surgical aortic valve replacement is recommended in the presence of symptoms attributable to regurgitation, left ventricular ejection fraction less than 50%, or another indication for cardiac surgery. In addition, surgical aortic valve replacement can be beneficial in asymptomatic patients with significant left ventricular dilatation (end-systolic dimension >50 mm or indexed end-systolic dimension >25 mm/m2). In the absence of these findings, clinical evaluation and surveillance echocardiography every 6 to 12 months is recommended.

Question 7

Side Effects of pantoprazole

Answer 7

Osteoporosis.Other possible PPI-related adverse reactions include vitamin B12 and mineral (calcium and magnesium) malabsorption, as well as increased risk for community-acquired pneumonia, Clostridium difficile infection, and cardiovascular events.

Question 8

role of rifaximin

Answer 8

Lactulose is first-line treatment and should be titrated to produce three stools per day. Rifaximin is added to lactulose for prevention of recurrent episodes after a second episode of hepatic encephalopathy. Due to its expense, it is not a first-line therapy for hepatic encephalopathy.

Question 9

Infliximab in Chron’s

Answer 9

prine. Infliximab is an anti–tumor necrosis factor (TNF)-α antagonist effective in inducing and maintaining remission in moderate to severe Crohn disease. O

Question 10

Colon Cancer guidelines

Answer 10

ccording the American Cancer Society’s Colorectal Cancer Survivorship Care Guidelines published in 2015, a history and physical examination should be performed every 3 to 6 months for the first 2 years, then every 6 months for 5 years. After treatment for stages 1, 2, or 3 colorectal cancer, patients at high risk for recurrence (for example, with poorly differentiated histology, lymphatic or vascular invasions, or positive resection margins) should receive annual abdominal-pelvic and chest CT scans for 5 years after resection. A history and physical examination should also be performed every 3 to 6 months for 5 years. Carcinoembryonic antigen measurement is recommended every 3 to 6 months for the first 2 years, then every 6 months to 5 years if the patient is a potential candidate for further intervention. Follow-up evaluation recommendations from other expert organizations vary.

Question 11

Ranolazine interactions

Answer 11

Ranolazine is primarily metabolized by cytochrome P450 3A4 (CYP3A4); therefore, caution should be exercised when prescribing ranolazine with CYP3A4 inhibitors, which will result in significantly increased plasma levels of ranolazine. Ranolazine should not be used with strong CYP3A4 inhibitors, such as ketoconazole, clarithromycin, and ritonavir. With moderate CYP3A4 inhibitors, including verapamil and diltiazem, the dosage should be decreased by 50% and should not exceed 500 mg twice daily

Question 12

IBS C treatment

Answer 12

Linaclotide,Plecanatide , and . Lubiprostone

Question 13

Adenomas managemnt

Answer 13

Adenomas larger than 5 cm in size have an increased risk for bleeding that can occasionally cause hemodynamic compromise.

Question 14

GLP-1 receptor agonists.(liraglutide and exenatide) side effects

Answer 14

GLP-1 receptor agonists.

Question 15

. Tenofovir or entecavir is first-line treatment for immune-active HBV infection because of low rates of resistance. T

Answer 15

n. Tenofovir or entecavir is first-line treatment for immune-active HBV infection because of low rates of resistance. T

Question 16

hepatorenal syndrome

Answer 16

Two types of hepatorenal syndrome have been recognized. Type 1 is characterized by acute kidney dysfunction and is usually triggered by a precipitating event such as spontaneous bacterial peritonitis, other infections, gastrointestinal hemorrhage, or a major surgical procedure. Type 2 is more common and is characterized by more slowly progressive kidney failure in patients with refractory ascites.

Type 1 hepatorenal syndrome is characterized by a rise in serum creatinine of at least 0.3 mg/dL (26 μmol/L) and/or ≥50% from baseline within 48 hours with a bland urinalysis and normal findings on renal ultrasonography. It is also supported by a lack of improvement in kidney function after withdrawal of diuretics and two days of volume expansion with intravenous albumin. Often patients with hepatorenal syndrome also have low urine sodium, low fractional excretion of sodium, and oliguria. In addition, patients should have no evidence of shock, no current or recent use of nephrotoxic drugs, and no evidence of renal parenchymal disease (proteinuria less than 0.5 g/day, no microhematuria, and normal renal ultrasound). The main treatment of hepatorenal syndrome is the removal of drugs that may reduce kidney perfusion and volume expansion. Ultimately, hepatorenal syndrome is a condition for which the only cure is liver transplantation.

Question 17

Criteria for Parathyroidectomy

Answer 17

alcium level ≥1 mg/dL (0.25 mmol/L) above upper limit of normal; creatinine clearance <60 mL/min, 24-hour urine calcium >400 mg/day (>10 mmol/day), or increased stone risk by biochemical stone risk analysis; presence of nephrolithiasis or nephrocalcinosis by radiograph, ultrasound, or CT; T-score (on DEXA scan) of less than or equal to −2.5 at any site or evidence of vertebral fracture; and age younger than 50 years.

Question 18

Cardiac transplantion criteria

Answer 18

ardiac transplantation remains the gold standard therapy for patients with end-stage heart failure. Indications for cardiac transplantation in these patients include age younger than 65 to 70 years, no medical contraindications (diabetes with end-organ complications, malignancies within 5 years, kidney dysfunction, other chronic illnesses that will decrease survival), and good social support and adherence. Heart transplant is contraindicated in this patient.

Question 19

mitral valve surgerical indications

Answer 19

. Surgical treatment with repair of the mitral valve is indicated for chronic severe primary mitral regurgitation in (1) symptomatic patients with left ventricular ejection fraction greater than 30%, (2) asymptomatic patients with left ventricular dysfunction (left ventricular ejection fraction of 30%-60% and/or left ventricular end-systolic diameter ≥40 mm), and (3) patients undergoing another cardiac surgical procedure. Mitral valve repair should also be considered in asymptomatic patients with chronic severe primary mitral regurgitation who have new-onset atrial fibrillation or pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg).

Question 20

Metabolic Alkalosis

Answer 20

For those who have a high urine chloride (>15 mEq/L [15 mmol/L]) with elevated blood pressure and hypokalemia and do not appear to be overtly volume overloaded, a mineralocorticoid excess disorder must be considered (saline-resistant metabolic alkalosis). Examples include Cushing syndrome and primary aldosteronism. N

Saline-responsive metabolic alkalosis typically presents with hypovolemia and a low urine chloride of <15 mEq/L (15 mmol/L); the most common causes are vomiting, nasogastric suction, and diuretic use.

Question 21

CKD anemia

Answer 21

Improving Global Outcomes (KDIGO) recommendations suggest maintaining transferrin saturation levels of >30% and serum ferritin levels of >500 ng/mL (500 µg/L).

Question 22

HTN guidelines

Answer 22

, the American College of Physicians and American Academy of Family Physicians recommend that antihypertensive drugs be initiated in patients ≥60 years old if blood pressure is >150/90 mm Hg, with a goal of reducing systolic blood pressure to <150 mm Hg; the American College of Cardiology/American Heart Association recommends a systolic blood pressure target of <130 mm Hg in patients ≥65 years old.

Question 23

White coat HTN guidelines

Answer 23

According to the American College of Cardiology/American Heart Association blood pressure guideline, in adults with untreated systolic blood pressure >130 mm Hg but <160 mm Hg or diastolic blood pressure >80 mm Hg but <100 mm Hg, it is reasonable to screen for white coat hypertension using either ABPM (the gold standard) or home blood pressure monitoring.

Question 24

Kidney Failure prediction

Answer 24

The kidney failure risk equation uses four variables (age, sex, estimated glomerular filtration rate, and albuminuria) to predict 2-year and 5-year risk of end-stage kidney disease in patients with stages G3 to G5 chronic kidney disease.

Question 25

Membranous Nephropathy Treatment

Answer 25

The recommended strategy is to treat patients with primary membranous Glomerulopathy conservatively with renin-angiotensin system blockers, cholesterol-lowering medications (if cholesterol is above goal), and diuretics (for edema).

Question 26

HTN Guidelines

Answer 26

According to the ACC/AHA BP guideline, the use of antihypertensive medications is recommended for secondary prevention of recurrent coronary events in patients with clinical coronary vascular disease and an average systolic BP of ≥130 mm Hg or an average diastolic BP of ≥80 mm Hg.

Question 27

Adverse drug reactions

Answer 27

Cisplatin-induced acute kidney injury is characterized by polyuria, tubular injury, hypomagnesemia, and proximal renal tubular acidosis with Fanconi syndrome.

Bevacizumab and gemcitabine can cause hypertension and AKI due to thrombotic microangiopathy, which manifests as thrombocytopenia with hemolytic anemia, elevated lactate dehydrogenase, decreased haptoglobin, and schistocytes on peripheral smear.

Paclitaxel has been associated with subacute diffuse interstitial lung disease and peripheral neuropathy.

Question 28

Hypermagnesium treatment

Answer 28

Management of hypermagnesemia includes discontinuation of magnesium-containing medications, administration of saline diuresis to enhance magnesium excretion, and administration of intravenous calcium to treat severe symptoms.

Question 29

Statins in CKD

Answer 29

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend treatment of dyslipidemia with a statin in patients aged ≥50 years with an estimated glomerular filtration rate <60 mL/min/1.73 m2, but not treated with chronic dialysis or kidney transplantation.

Question 30

Calcineurin inhibitor( (tacrolimus or cyclosporine)

Answer 30

Calcineurin inhibitor–induced hypertension and hyperkalemia share the same phenotype as Gordon syndrome (familial hyperkalemic hypertension), which is due to a dysregulation of the WNK kinases in the distal convoluted tubule. Thiazide and thiazide-like diuretics such as chlorthalidone address the underlying mechanism of calcineurin inhibitor–induced hypertension and hyperkalemia by inhibiting the sodium chloride cotransporter.

Question 31

Delaying dialysis

Answer 31

Thus, this study demonstrated that with careful clinical management, dialysis may be delayed until either the GFR drops below 7.0 mL/min/1.73 m2 or more traditional clinical indicators (such as uremic symptoms or metabolic abnormalities) for the initiation of dialysis are present.

Question 32

Pregnancy with transplant

Answer 32

In kidney transplant recipients who are planning pregnancy, mycophenolate mofetil, sirolimus, and everolimus must be discontinued 3 to 6 months prior to conception and replaced with azathioprine, which is generally safer and well tolerated in pregnancy.

Question 33

Serum Osmolality

Answer 33

Serum Osmolality (mOsm/kg H2O) = (2 × Serum Sodium [mEq/L]) + Plasma Glucose (mg/dL)/18 + Blood Urea Nitrogen (mg/dL)/2.8

Question 34

head and neck cancer treatment

Answer 34

However, because of long-term experience with cisplatin and the significantly higher cost of cetuximab, cisplatin is preferred unless there is a contraindication to use of this agent. For this patient, who has chronic kidney disease with a baseline creatinine level of 1.8, cisplatin is clearly contraindicated and, therefore, cetuximab combined with radiotherapy is the most appropriate treatment.

Question 35

VITAMIN K REVERSAL

Answer 35

For patients with an INR of 4.5 to 10 and with no evidence of bleeding, routine use of vitamin K is not recommended. For patients with an INR greater than 10 and with no evidence of bleeding, oral vitamin K is recommended. For patients with major bleeding, such as this patient with an intracerebral hemorrhage, rapid reversal of anticoagulation is recommended with four-factor PCC rather than fresh frozen plasma (FFP). These patients are also likely to benefit from the addition of vitamin K by slow intravenous injection rather than using coagulation factors alone.

Question 36

daracizumab

Answer 36

darucizumab is a monoclonal antibody approved for reversal of the anticoagulant effects of dabigatran. I

Question 37

An autoimmune condition termed anti–N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis

Answer 37

Ovarian teratoma–

Question 38

anti-Ri and anti–glutamic acid decarboxylase antibodies

Answer 38

breast adenocarcinoma

Question 39

these syndromes include anti-Hu, anti-LGI1 (voltage-gated potassium channel), and anti-CRMP5 antibodies but not the anti-NMDAR antibody.

Answer 39

Small cell lung cancer

Question 40

EGFR mutations

Answer 40

erlotinib

Question 41

ALK translocations and ROS1 mutations

Answer 41

crizotinib

Question 42

Treatment of tardive dyskinesia

Answer 42

Pharmacologic treatment of tardive dyskinesia is often unsatisfactory, but options include clonazepam, tetrabenazine, valbenazine, anticholinergic agents, and clozapine.

Question 43

parkinson psychosis

Answer 43

Pimavanserin, a nondopaminergic atypical antipsychotic agent and selective serotonin 5-hydroxytryptamine receptor 2A inverse agonist, is the only FDA-approved medication for Parkinson psychosis.