MKSAP16 Flashcards
The presence of this antibody increases the risk of lupus glomerulonephritis
Anti-dsDNA
What is the deal with adjuvant radioactive iodine in thyroid CA? What is the TSH goal with thyroid replacement?
In pts s/p total thyroidectomy with high risk dz or intermediate (+LNs >5, ETE, and lymphovascular invasion) want adjuvant radioactive iodine and synthroid with goal TSH <0.1
Pt with recent influenza PNA now with cavitary lesion
MRSA pneumonia
In what setting is the diagnosis of portopulmonary HTN made?
When there is evidence of pulmonary HTN in the presence of portal HTN (still rule out other stuff though like HIV, drugs or connective tissue dz b/c it is WHO 1)
What is the first line tx for symptomatic prolactinomas? What is the difference between a microprolactinoma and a macroprolactinoma?
Dopamine agonists such as cabergoline; Micro <10 mm; macro is >10 mm; can give even if mild compressive sx because DA agonists can shrink the size of the tumor; recall octreotide is for GH secreting tumors (Acromegaly)
What sorts of blood products should be used in treating BMT patients?
Leukoreduced and irradiated
At what frequency of UTIs is low-dose antimicrobial ppx useful?
3 UTIs in 12 months or 2 UTIs in 6 months
How does RLL collapse appear on CXR? Mechanism of hypoxia?
Triangular opacity over the R hemidiaphragm; forms a functional shunt (R–>L intrapulmonary shunt)
Most patients with Class III/IV Lupus Nephritis benefit from combo treatment of what?
Steroids + either MMF or Cyclophosphamide
What is the main treatment of high altitude pulmonary edema? Preventitive tx?
Supplemental O2 (to decrease PVR- pulm vasc resistance), descent and possibly vasodilators (short acting CCB); prevent with nifedipine
What should you do for a pt with MS who is on disease modifying meds that are teratogenic and she wishes to become pregnant?
Can stop the medicine; there is a common misconception that there is an adverse risk when getting pregnant
What is the primary mgmt of dysmenorrhea?
NSAIDS first then OCPs
What can you say about glucose intolerance and peripheral neuropathy in the absence of frank DM?
Glucose intolerance can cause neuropathy too; so even if normal A1C can do a glucose tolerance test
This phenomenon, also seen in Behcet’s disease, may explain why Crohn’s patients can develop peristomal pyoderma gangrenosum
Pathergy; irritation at the site can cause the PG; tx is with topical steroid such as clobetasol
How can STARI and early lyme present? Difference in Tx?
Southern Tick Associated Rash Illness (STARI) and Lyme dz both present with erythema migrans; both can be tx with Doxycycline; only Lyme can get the alternative Amoxicillin/Cefuroxime
What is the initial mgmt of ITP?
Can observe if platelet count >30-40k without evidence of bleeding; if bleeding or if platelet <30 then start PO prednisone
What is the standard of care for an MS relapse? What if refractory?
IV glucocorticoid i.e. methylprednisolone 1 mg/kg (oral glucocorticoids have worse outcome); if refractory then PLEX
How would the presentation of cryptococcal CNS dz differ from toxoplasmosis?
Crypto may be preceded by lung infection since that is usually the first place but crypto more likely to have meningitis type picture that is subacute with high CSF pressures; toxo more likely to have mass lesions though cryptococcomas are possible
What is the acting out of dreams in PD called?
RBD- REM Behavioral Disorder
A young man with solid food dysphagia may have this diagnosis _________
Eosinophilic Esophagitis; endoscopy will reveal trachealization of the esophagus and Bx will show >15 eos/hpf; Tx is with swallowed glucocorticoids
What can you say about the use of aspirin for primary prevention of MI etc. in pt with >10% ASCVD risk?
While it was in the guidelines, the ASPIREE and ASCEND trials showed an actual increase in mortality in patients on this for primary prevention as well as increased bleeding risk
What are the classic signs of a fixed drug eruption?
Painful purple rash that occurs in the same area repeatedly (lips, genitals, and hands are MC)
Both Felty Syndrome and LGL are associated with this HLA marker
HLA-DR4
What test can facilitate the diagnosis of primary CNS lymphoma? Where do they tend to occur?
EBV PCR from the CSF; usually only if very immunosuppressed i.e. CD4 <50 and often periventricular and only one lesion whereas Toxo often multiple but not always
This is a common cause of hypogonadotrophic hypogonadism and azoospermia?
Klinefelter Syndrome (XXY)
What underlies humoral hypercalcemia of malignancy?
PTHrP as in breast CA and SCC of the lung
What infection are solid organ transplant pts at increased risk of within 6 months of an episode of acute rejection?
PCP because acute rejection requires intensification of their immunosuppression (affects cell-mediated immunity); of note things like aspergillosis are more common when someone is neutropenic
If a lung nodule is stable for _____ amount of time, then no further monitoring is needed
24 months
In whom is omalizumab useful?
Moderate to severe asthma with Sx inadequately controlled with inhaled glucocorticoid and LABA, evidence of allergies to pereniall aeroallergens, and IgE leves between 30-700
What should be on the DDx for a pt with Wegeners who is being treated with cyclophosphamide who develops bloody urine?
Would always be concerned about a pauci-immune glomerulonephritis due to the Wegeners but could also be bladder CA due to Cyclo
What is the malignancy most commonly associated with generalized pruritis, often without a primary rash?
Hodgkin Lymphoma; consider obtaining a CXR in these pts to evaluate
What is the basic approach to treating MDS?
Based on risk stratification some can be observed (based on IPI), azacitidine (and other HMAs) for high risk dz and short life expectancy; allo-HSCT for high risk dz and longer life expectancy
Immediate administration of this is indicated to prevent early mortality in suspected APML? Translocation?
ATRA; t(15;17)
What are 6 indications for AICD in HOCM?
Massive Myocardial Hypertrophy (>30 mm), Previous Cardiac Arrest, Blunted BP response or HoTN during exercise, Unexplained Syncope, NSVT, and FMHx of sudden cardiac death
When a pt has panhypopit such as after pituitary surgery, how do you make adjustments in hydrocortisone dosing?
Based on sx such as orthostasis, weight loss, N/V, light headedness as the ACTH and cortisol levels will be low so you cannot base off that
Where are target cells commonly seen?
In thalassemias, i.e. imbalance of globin chain synthesis with impaired production of hemoglobin and intramedullary hemolysis
In whom does primary thyroid lymphoma MC occur? Typical presentation?
In elderly women with underlying Hashimoto (due to the chronic inflammation); often presents as an enlarging goiter rapidly, night sweats, and weight loss; tx is chemo often do not need thyroidectomy
This disorder (sometimes associated with malignancy) often has “juicy” well demarcated borders
Sweet Syndrome
What GI disorder is identified in 9% of patients with otherwise unexplained elevations in transaminases?
Celiac Dz; LFTs may improve with the treatment of the Celiac
What disease will have trachealization of the esophagus on endoscopy? Tx?
Eosinophilic Esophagitis then a bx would show >15 eos/hpf; tx is with swallowed aerosolized glucocorticoids
What is NODAT?
New-Onset DM After Transplant; implicated meds are s/p solid organ xplant due to steroids and tacro
What is associated with Anti-phospholipase-2-Receptor antibodies (Anti-PLA2R)?
Primary Membranous Glomerulonephritis; PLA2R is located on podocyte membrane so antibody against it causes nephrotic syndrome by causing podocyte damage
A painful purple rash that occurs in the same area repeatedly may be a ____
Fixed Drug Eruption
What should be considered in patients with parkonsonianism, cerebellar ataxia, and early postural instability?
Multiple System Atrophy; the Shy-Drager subtype has significant autonomic instability
What is a major difference (usually) of stasis dermatitis and cellulitis?
Cellulitis often has leukocytosis and fever, possibly LAD; Stasis dermatitis often has overlying scale/serum crust and more often bilateral
What is the basic management of microscopic colitis (lymphocytic or collagenous)?
Withdrawal of any known offending med, antimotility agent; if worse then can do bismuth and budesonide
This occurs when there is cutaneous involvement of Gottron papule, shawl sign, and lilac lids but negative Bx and EMG evidence of myositis
Amyopathic Dermatomyositis
Lymphangitic spread in the lungs of a cancer is best identified by what modality?
HRCT
What drug is indicated in all patients who have had an aneurysmal subarachnoid hemorrhage?
Oral nimodipine x21 days
What disorder presents with small pits in the skin and hyperhidrosis? Tx?
Pitted Keratolysis; tx is with clindamycin topical
In a patient with breast CA who has developed peripheral interstitial abnormality identified on CT likely has ___________
Lymphangitic spread of cancer
What are some secondary causes of membranous glomerulonephritis?
Solid organ cancers (minimal change = Hodgkin), infections such as HBV and HCV (note HCV more often MPGN; HBV often PAN which causes renal artery aneurysms but not GN), and NSAIDS
What is the appropriate mgmt of a complicated parapneumonic effusion?
Should be suspected in all patients who do not respond to appropriate abx; place a small bore chest tube (<14 French)
What drug is often used in glomerulonephritis due to ANCA or SLE?
Often times cyclophosphamide is used upfront; in ANCA vasculitides rituximab can also be used
What noninflammatory condition is defined by the presence of “flowing osteophytes” involving the anterolateral aspect of the spine at 4-5 contiguous vertebrae?
Diffuse Idiopathic Skeletal Hyperostosis (DISH); this is different than ankylosing spondylitis in that it occurs in older ppl and is non-inflammatory
How is otosclerosis different from presbycusis?
Otosclerosis is a loss of low pitched sounds (conductive hearing loss) due to abnormal hardening of bones in middle ear tx is with amplification or stapedectomy with prosthetic stapes; presbycusis affects high pitched sounds and is a dz of elderly
What are the GOLD stage I-IV based on? ABCD groups?
Stages by FEV1; ABCD group by symptoms
In whom is lung transplantation used? Lung volume reduction surgery?
FEV1 <20%, DLCO <20% and HOMOGENOUS distribution of emphysema; Lung volume reduction surgery in pt with upper lobe emphysema and low post-rehab exercise capacity
What is an important diagnostic test in patients suspected of having VAP?
Should undergo deep respiratory sampling with BAL to identify the organism
Under what circumstance is a CSF study for EBV by PCR most likely to be helpful?
In an immunosuppressed pt with a lesion concerning for primary CNS lymphoma; EBV is a driver tumor virus
What is STARI and what is the treatment?
Southern Tick Associated Rash Illness; Doxycycline. Note that doxycycline is good for both early Lyme and STARI but amoxicillin and cefuroxime are only good for Lyme
What studies are important to perform in a patient who presents with optic neuritis?
MRI of brain to evaluate for lesions consistent with a diagnosis of MS; of note the presence of oligoclonal bands in CSF is NOT part of any MS diagnostic criteria
Mgmt of AAA <5.5 cm in men or <5.0 cm in women
Conservatively with abdominal US q6-12 months
A woman 65 or older with a FRAX > ______ should be screened for osteoporosis
>9.5% and if >20% should be treated as osteoporosis
In what patients with HSP are steroids used?
In patients with severe symptoms of Henoch Schonlein purpura especially if involving multiple systems; of note more severe in adults than kids; Deposition of IgA in skin confirms dz
What is the scientific name for bedbugs? How can you recognize?
Cimex lectularius; often painless and itchy lesions in a linear pattern
What is the first line tx of central sleep apnea in patients on opiates?
Reduction in opiate dosage (normally it is ASV)
Best test for mild hyperthyroidism that is thought to be likely due to a toxic adenoma?
Radioactive Iodine Uptake scan; presence of hot nodule obviates need for Bx
What drug is approved for fatigue in multiple sclerosis?
Modafanil and Armodafanil; can also be used in refractory pts with OSA as well as in Narcolepsy
What is the treatment of peristomal pyoderma gangrenosum? Theorized mechanism?
Topical steroid such as clobetasol; can be due to pathergy
This is an overlap syndrome that includes features of SLE, systemic sclerosis and/or polymyositis __________. Assoc with this antibody ____________
Mixed Connective Tissue Disease; Anti-U1-RNP
How would bronchiolitis obliterans organizing pneumonia differ from lymphangitic spread of cancer to the lungs?
BOOP tends to show up more as a consolidation (it can be assoc with CA); lymphangitic spread tends to show up as a peripheral interstitial abnormality
What disorder can have sx of chest tightness and dyspnea with lack of improvement with asthma tx and a monophasic wheeze and stridor?
Vocal Cord Dysfunction (flattening of inspiratory limb)
What can you say about the use of bicarbonate in the treatment of DKA?
No benefit if the pH is >6.9 and a 2011 systematic review noted that bicarb can worsen ketonemia
A STOP-BANG score of > __________ suggests increased risk of OSA
5
What is the preferred initial diagnostic test to evaluate for ILD?
HRCT as the pattern seen on CT correlates well with pathology (so transbronchial Bx often not helpful, would need surgical lung bx)
What antibodies is primary membranous glomerulonephritis associated with? What malignancy can it be due to?
Anti-phospholipase2-Receptor (Anti-PLA2R); possibly due to solid organ CA–phospholipase A2-Receptor is located on the podocyte surface so the antibody causes nephrotic syndrome
What is the MOA of teriflunomide?
This is the active metabolite of leflunomide and inhibits pyrimidine synthesis which therefore interferes with interaction between T cells and APCs
How should FSGS in obese patients be treated?
Should be on an ACE inhibitor but since FSGS can be secondary to obesity, should lose weight which can decrease the proteinuria
What is Cough Variant Asthma?
A type where the primary symptoms are nonproductive cough especially in a patient with hx of allergies
What biomarkers define severe C. diff (may be out of date)
WBC >15k and sCr >1.5x baseline
In what population should asymptomatic bacteriuria be treated in? Tx?
Pregnant women as there is high risk for pyelo given the physiologic hydronephrosis; amoxicillin or nitrofurantoin but nitrofurantoin is class B
What test can help clarify the diagnosis of asthma in a patient with sx but normal spirometry?
Methacholine challenge
What is the MOA of fingolimod?
A sphingosine-1-receptor modulator that restricts activated lymphocytes to LNs (preg category C)
When should you perform a brain MRI in Bell Palsy?
If there is incomplete recovery after 3 months (hyperacusis and impaired taste are suggestive of peripheral nerve)
What disease can present with multiple thunderclap headaches that recur over several days to weeks? Tx?
Reversible Cerebral Vasoconstriction Syndrome; kind of like the Prinzmetal angina of the brain and angiography will show multiple areas of vasoconstriction; BP control is tx
Abrupt onset of abdominal pain, emesis, and forceful bowel evacuation with severe hypotension and an unremarkable abdominal exam is consistent with ________
Acute mesenteric ischemia especially if associated with atrial fibrillation
When is mechanical stone removal indicated for patients with kidney stones?
If the stone is >10 mm or smaller stones with refractory pain, AKI, or urosepsis
Trigeminal neuralgia is often sporadic but may complicate this disease _____
Multiple Sclerosis; of note should get MRI in Tic patients because can be due to mass lesion at the CP angle
What is the best treatment of frequent, forceful closure of the eyes?
i.e. Blepharospasm (tx with Botulinum toxin injection)
What is essential treatment of patients with Takotsubo cardiomyopathy?
Beta Blockers and ACE inhibitors (essentially GDMT)
What are some general AEDs to be used in the setting of generalized seizures?
Topiramate, Lamotrigine, Levetiracem, Valproate, and Zonisamide; ones that are more for partial seizures are Carbamazepine, gabapentin, and phenytoin
How do you manage allopurinol and febuxostat in patients on azathioprine?
Allpurinol requires dose-adjustment and febuxostat is contraindicated; can get dangerously high levels of azathioprine as it is metabolized by xanthine oxidase
What should be corrected prior to starting IV insulin for DKA?
Hypokalemia; the IVF is important and one should correct the hypokalemia then start the insulin; should start giving KCl if K <5.2 but ok to give insulin unless the K is <3.3 then you need to replete first then start the insulin
Explain how peak and plateau pressures would differ between Auto-PEEP and tube obstruction
Both are high in Auto-PEEP; however, in tube obstruction pressure is only high when there is flow so only peak pressure is high; plateau pressure is measured when there is no flow
What is undifferentiated connective tissue disease?
NOT an overlap syndrome (as in mixed connective tissue dz) but rather a series of nonspecific clinical features of Raynaud and Arthralgia with nonspecific autoantibodies such as ANA
