MKSAP19

Question 1

What is an S3? What conditions would it be present in?

Answer 1

Low frequency, early diastolic sound. Best heard at the cardiac apex. Heard in heart failure with reduced ejection fraction or volume overload states

Question 2

Patient with blood pressure of 200/110 and in acute heart failure exacerbation. What is IV medication of choice, in addition to lasix, to help with blood pressure? What medication class should be avoided in these cases?

Answer 2

IV nitroglycerin

Avoid beta blockers in decompensated heart failure

Question 3

Who should get hepatitis b vaccine?

Answer 3

Anyone aged 15-59 or older than 60 who are at increased risk of hepatitis b, such as diabetics (exposed to needles), HIV, chronic liver disease, incarceration, travel to endemic areas, IV drug usage, sexual exposure

Question 4

Which live vaccine is contraindicated in HIV, regardless of CD4 count?

Answer 4

Live influenza vaccine

Question 5

Patient with autoimmune hepatitis, started on immunosuppressive therapy. How long would you be on therapy before making decision to taper?

Answer 5

Must be on therapy for 2-3 years prior to tapering because of high rate of relapse.

Question 6

Patient presents with exertional dyspnea. Physical exam reveals fixed splitting of S2, a parasternal impulse at the left sternal border.

Most likely diagnosis?

Answer 6

Atrial septal defect

Question 7

Patient who is an agricultural worker presents with progressive worsening of kidney disease after undergoing treatment for cellulitis with antibiotics. UA with no casts or leukocytes. Most likely diagnosis?

Answer 7

Chronic interstitial nephritis

Question 8

Patient with aortic stenosis on physical exam. Echo shows severe stenosis, but hemodynamic eval on echo shows more moderate. When there is a discrepancy between the clinical evaluation and the echocardiogram, what’s best next test to further evaluate?

Answer 8

Cardiac catheterization

Question 9

Pregnant patient at 16w develops gingival bleeding. Platelets noted to be at 60K. Most likely diagnosis? What if at 32w and platelets at 100K?

Answer 9

Immune thrombocytopenic purpura

Gestational thrombocytopenia

Question 10

Patient with fatigue, abdominal pain and weight loss over past month. The patient has intensely tanned skin and hyperpigmented buccal mucosa and palmar creases. Labs significant for hyponatremia, hyperkalemia, low morning cortisol, high ACTH level. Most likely diagnosis and treatment step?

Answer 10

Primary adrenal insufficiency

Hydrocortisone and fludricortisone

Question 11

Recs for those taking vitamin E, fish oil, beta carotene?

Answer 11

In patients taking anticoagulants, vitamin E and fish oil increase the risk for bleeding; β-carotene increases the risk for lung cancer in cigarette smokers

Question 12

HSV type that’s associated with viral meningitis?

Answer 12

HSV type 2

Question 13

How big of a rise would you expect with transfusion of 1 unit of platelets?

Answer 13

One unit of platelets should raise the platelet count by around 20,000 to 30,000/μL

Question 14

Patient comes in with concerns for bacterial meningitis. Platelets are at 38K. What should be done first prior to LP?

Answer 14

Platelets up to above 50K

Question 15

Patient that comes in with microangiopathic hemolytic anemia, thrombocytopenia and purpura. Most likely diagnosis and treatment?

Answer 15

thrombotic thrombocytopenic purpura

Plasma exchange, prednisone and rituximab

Question 16

Patient who comes in with syncope, ekg shows dropped beat with no change in PR interval. Diagnosis and most appropriate management?

Answer 16

Mobitz type 2 AV block

Pacemaker placement

Question 17

Is warfarin teratogenic?
In patient with mitral valve prostheses, on warfarin 4mg daily, what is safest anticoagulation option in 1st trimester is? What if they were on 6mg daily?

Answer 17

Yes

Warfarin if dose is less than 5mg per day in all three trimesters

If greater than 5mg, then would recommend IV unfractionated heparin in first trimester, followed by warfarin in 2nd and 3rd

Question 18

Wanting to start patient on thyroid replacement therapy for hypothyroidism. Normal starting dose is based on weight. What is the conversion for dose?

What if they were older and had history of heart disease?

Answer 18

1.6ug/KG/day

25ug-50ug per day due to cardiotropic effects of thyroid hormone

Question 19

In patient with alcoholic hepatitis with Maddrey discrimination function score greater than 32, what’s the most appropriate management? How long do you stay on this?

Answer 19

Prednisolone

28 days. If not responding in 7 days, should discontinue

Question 20

Patient with epigastric pain that is more severe with eating, progressively worsening. Trial of PPI has been ineffective. Upper endoscopy is normal. Abdominal exam is normal. PPI is discontinued. Diagnosis and next step in treatment?

Answer 20

Functional dyspepsia

Trial of tricyclic antidepressant
Nortriptyline

Question 21

Patient with binge eating disorder, started in CBT and citalopram with improvement in symptoms but not complete resolution. What can be added in adjunct to help with this?

Answer 21

Lisdexamfetamine

Question 22

Patient with CKD4 who presents for routine follow up. Hg 10.1, Cr 3.3, K 4.2, Bicarb 19.

Most appropriate treatment?

Answer 22

Sodium bicarbonate supplementation
If serum bicarb is less than 22, should start

Question 23

Tremor that worsens with action but disappears at rest?
Often affects bilateral hands and arms, head and voice

Answer 23

Essential tremor

Question 24

Patient with progressive SOB and dry cough for 7 months. Physical exam reveals Velcro-like crackles at bilateral lung base and clubbing. Most likely diagnosis? Most appropriate treatment?

Answer 24

Idiopathic pulmonary fibrosis

Antifibrotic therapy, pirfenidone

Question 25

Patient with year long worsening dementia. MRI brain shows no hippocampus involvement, and diffuse confluence white matter hyperintensities. Most likely diagnosis?
What if there was hippocampal involvement?

Answer 25

Vascular cognitive impairment

Alzheimer disease

Question 26

Patients who has family history of colon cancer, who presents with new found ovarian cancer. What genetic testing should be done?

Answer 26

BRCA and Lynch syndrome mutations

Question 27

45 year old woman being worked up for elevated alk phos. She has mild pruritus. No liver disease or other LFT abnormalities. Most likely diagnosis? Next best lab test to obtain to confirm diagnosis?

Answer 27

Primary biliary cholangitis

Antimitochondrial antibody

Question 28

Which test would help predict responsiveness to inhaled glucocorticoids in a patient that has asthma?

Answer 28

Fractional exhaled nitric oxide

Question 29

What imaging modality should be used when working up a breast mass in women aged 30 or more? What if less than 30?

Answer 29

Mammography

Ultrasound

Question 30

Patient with acute bacterial conjunctivitis. They do not wear contacts. What is best pharmacological treatment option? What if they do wear contacts?

Answer 30

Trimethoprim - polymyxin ophthalmic solution

Ofloxacin ophthalmic solution

Question 31

Female Patient with signs of hyperandrogenism who has DHEAS level greater than 700. Most appropriate diagnostics test.

Answer 31

CT abdomen

Question 32

Opioid of choice for an admitted patient with history of ESRD on HD?

Answer 32

Hydromorphone

Question 33

Recommended treatment for guillan barre syndrome?

Answer 33

Plasma exchange or IVIG

Question 34

Patient of African descent who has nephrotic range proteinuria. Most likely diagnosis?

Answer 34

Focal segmental glomerulosclerosis

Question 35

In a patient with newly diagnosed atrial fibrillation, what should always be considered with regards to appropriate treatment/management?

Answer 35

Rhythm control, such as ablation or anti-arrhythmic drugs

Question 36

Patient with COPD who quit smoking, takes his appropriate meds, good inhaler technique, and participates in pulm rehab. He continues to have diminished quality of life. Chest imaging shows predominantly upper lobe emphysema. FEV1 and DLCO are greater than 20% of predicted. What’s the most appropriate treatment?

Answer 36

Lung lobe reduction surgery

Question 37

Hearing loss associated with ear pain and discharge?

Answer 37

Conductive hearing loss

Question 38

Hearing loss associated with tinnitus and vertigo?

Answer 38

Sensorineural hearing loss

Question 39

AKI with UA that shows muddy brown casts. Most likely diagnosis?

Answer 39

Acute tubular necrosis

Question 40

Patent ductus arteriosus is found in 40y/o who is asymptomatic

Echo has moderate left atrial and ventricular enlargement.

Most appropriate management?

Answer 40

PDA device closure

Question 41

Patient with giant cell arteritis who responds well to steroids but has bad side effects from it. Apart from prednisone taper, what is best additional therapy?

Answer 41

Tocilizumab

Question 42

Vasculitis that affects large vessels, most commonly the aorta?

Answer 42

Takayasu arteritis

Question 43

Hepatic adenoma found in men is managed how? In women?

Answer 43

Surgical resection

If on OCPs, stop them and follow up imaging 6 months later

If >5cm worrisome and should be taken out