MKSAP8 Flashcards
What are the two goals of medical therapy in an aortic dissection?
Lower BOTH the HR and the BP to reduce shear stress on aortic wall; esmolol and labetalol are good options (BP <120; HR <65)
What are some drugs that can cause thrombotic microangiopathies (5)?
MOA = endothelial damage; Sunitinib, Bevacizumab (both inhibit VEGF; also cause HTN), mitomycin C, Gemcitabine, mTOR inhibitors (cyclosporine, tacrolimus, etc)
When can you stop cervical cancer screening?
In women >65 with 3 consecutive negative pap smears or 2 consecutive negative smears and a negative HPV
What is the first line tx for claudication due to PAD? First line medical? Contraindication?
Supervised exercise program; Cilostazol (PDE-3 inhib) contraindicated in heart failure
What is the difference in tx for OSA vs. CSA?
OSA = CPAP or BiPAP; CSA = Adaptive servoventilation; risk factors for CSA = afib or CHF
How is abdominal compartment syndrome usually defined?
New organ dysfunction in a patient with abdominal pressure > 20 mmHg (measured by bladder pressure); can have worsening respirations or increased peak pressures if on ventilator
What are the CD4:CD8 ratios in hypersensitivity pneumonitis vs. sarcoidosis?
Low in HP because there are more CD8 cells; High in sarcoid bc it is granulomatous inflammation; though there are recent challenges; The IMPORTANT thing is that the BAL is lymphocytic
What might a CT scan look like in a patient with Acute Hypersensitivity pneumonitis? The BAL?
Ground glass opacities with centrilobular nodules in the upper and middle lobes; Lymphocytic infiltrate on BAL often with low CD4:CD8 whereas sarcoid thought to be more CD4 bc granulomatous
Explain the issues of the A1C in ESRD?
Can be falsely elevated due to carbamylated hgb due to uremia, falsely low due to anemia of CKD; need to really look at fasting sugars and post prandial
The labs in Euthyroid Sick Syndrome look most similar to what?
Central hypothyroidism; there is often low TSH and low T4/T3; so if someone has a high TSH it prob is actually hypothyroidism and NOT euthyroid sick syndrome
What can you say about nonbiologic DMARDs (i.e. MTX and sulfasalazine and NOT TNF-alpha) in the mgmt of Ankylosing Spondylitis?
Not useful for axial dz but can be ok for peripheral arthritis; No matter what though NSAIDs first line then biologic DMARD = TNF-alpha
When can rituximab be used in RA? What labs do you need to check first?
Can be used if no response to MTX or TNF-alpha; check HBV serologies first as can reactivate; if + then entacavir or tenofovir
What is March Hemoglobinuria?
i.e. Runners Hemoglobinuria; a hemolytic anemia due to running can get secondary Fe def due to this
If you think someone has an HSV type infxn why should you still consider DFA or PCR of vesicle?
Can differentiate HSV1, HSV2, and VZV which may be important for IC patients
What are Sjogrens pt at increased risk of? What other condition can cause a keratoconjunctivitis sicca type presentation?
DLBCL and MALT (Marginal zone) lymphomas of glands; GVHD can often present this way
How should a patient with myasthenic crisis be treated?
Emergently in an ICU w/ IVIG or PLEX (most often IVIG, no benefit one way or another); avoid quinolones
How can you diagnose infertility related to pelvic inflammatory disease?
Hysterosalpingogram
How do you Tx MAC in a patient with HIV/AIDS
Clarithromycin + Ethambutol and continuation of HARRT
What should you consider doing in a patient diagnosed with Atypical Ductal Hyperplasia (ADH)?
Consider chemoprophylaxis as often can cause CA; tamoxifen if premenopausal or exemestane (or other AI; letrozole) if post
What are the imaging findings for adrenocortical carcinoma?
Large mass with irregular borders and calcification often with high attenuation (increased Hounsfield units) and a DELAY IN CONTRAST WASHOUT
What is the Tx of adrenocortical carcinoma
Surgical excision if possible and then mitotane
What should be tested for in all patients with metastatic melanoma?
BRAF V600E mutation and then give vemurafenib or dabrafenib if + (both BRAF inhibitors); recall BRAF part of MAPK pathway
Tx of multinodular goiter with compressive sx
Total thyroidectomy
Which HLA markers are associated with Celiac dz?
HLA-DQ2 and HLA-DQ8
What are the effective treatments for idiopathic intracranial HTN?
The only really good medical tx are carbonic anhydrase inhibitors i.e. acetazolamide; Optic nerve fenestration is an operation to relieve intracranial HTN
What FEV1 cutoff is pulmonary rehab indicated for all patients w/ COPD?
Less than 50% and can be considered for some symptomatic or exercise limited patients >50%
What kind of kidney injury do PPIs cause (if you believe it)?
Tubulointerstitial; Chronic tubulointerstitial dz often arises from an acute tublointerstitial insult but can occur subacutely as well
What test would you need in order to diagnose acute HIV?
Nucleic acid amplification test as the antibody may be negative (window period); So a positive antigen/antibody test tells you pt EITHER has p24 antigen or antibody
What is the next best test to order if a patient has a positive HIV test?
T cell subsets as they may have full on AIDS (i.e. CD4 <200)
What is the best tx for bone-only breast CA metastases?
Aromatase inhibitors i.e. if patient has been free of dz for a while and gets bone mets start an AI (exemestane) and if they are resistant to that add everolimus (mTOR inhib); chemo with paclitaxel may be used instead if pt is hormone neg or has impending visceral crisis
Name a non-SLE vasculitis that often causes fevers, abdominal pain, and peripheral mononeuropathies (mononeuritis multiplex)
Polyarteritis Nodosa (assoc with HBV)
What are the steps if a patient has low ACTH but high cortisol? High ACTH and high cortisol?
This is ACTH independent so scan adrenals; if ACTH high then MRI pituitary or petrosal venous sampling OR consider ectopic ACTH production
A diagnosis of cushing requires how many screening tests?
- These include 24 hour urinary free cortisol, low dose dexamethasone suppression test, and midnight salivary cortisol
What is the first line tx for sympathomimetic overdose syndromes (i.e. cocaine, meth, bath salts)
Benzos are first line drugs; other supportive care includes intubation, evaporative cooling/cooling blankets, and consideration that they may develop rhabdo
Drug of choice in anticholinergic toxicity and “nerve agent” bioterrorism
Physostigmine
What disease should be on the DDx for patients with weird sensory sx and weakness that extends beyond 8 weeks of the onset?
CIDP - Chronic Inflammatory Demyelinating Polyneuropathy; diff from Guillian Barre or AIDP in the length of sx whereas AIDP hits its nadir within 4 weeks
What is the major difference between AIDP and CIDP?
Length of sx. AIDP will max out by 4 weeks; CIDP takes up to 8 weeks
What test can suggest presence of tuberculous effusion? Confirmatory?
ADA level (less than 40 rules it out; high NPV) and a pleural biopsy is required to confirm; suspect in pt w/ lymphocytic predominant pleural effusion
T/F a positive sputum culture will show Mycobacteria in patients with suspected tuberculous effusions
False (kind of); it will only show it if there is also pulmonary parenchymal disease; a patient with a possible tuberculous effusion should have ADA level checked and pleural bx and should not be considered ruled out only on the basis of negative sputum Cx
What disorder will have differential cyanosis on physical exam i.e. cyanosis and clubbing in lower body but not upper
Patent Ductus Arteriosus (PDA) with Eisenmenger physiology
What is the difference between D-lactic acidosis and Type B lactic acidosis?
D-lactic acidosis occurs in patients w/ SIBO etc. as the bacteria produce the D enantiomer of lactate; Type B lactic acidosis is still the regular L-Lactate picked up on lab tests but occurs due to inability to clear lactate as opposed to excess production
What should you do in a patient with hyperalbuminemia or MM with HYPOcalcemia?
Order ionized calcium as these situations may have more protein binding to albumin
How do you treat a sickle cell pain crisis in pregnant patients?
Same as for a normal pt i.e. fluids, narcotics, etc; if worsening or signs of fetal distress then would transfuse
Why should you perform a radical inguinal orchiectomy in patients with metastatic testicular cancers?
Because there is a blood-gonadal barrier that can prevent chemo from getting into the testis
What renal issue is HIV assoc with?
Collapsing Variant of FSGS
How should you manage a pt who undergoes a RUQ US and findings of a 2 cm polyp are found?
Cholecystectomy even if asymptomatic; any polyp >1 cm needs to come out bc can be cholangio; otherwise can be followed unless pt has PSC
What is the purpose of ambulatory pH testing in pt w/ GERD?
Can be done if atypical sx of GERD to see if that is the cause or if ongoing sx while on PPI to see if there is adequate acid suppression; if not can do Nissen
What is the concern for a patient with prolactinoma who gets pregnant?
They can grow in response to estrogen and so need to carefully monitor for changes in vision; additionally can get Sheehan syndrome after delivery
Vesicles on tip of nose suggestive of VZV is known as __________. Who to call?
Hutchinson Sign; Ophtho
In whom are air filters in IV lines important?
Patients with Eisenmengers or any R->L shunt because they can get a paradoxical air embolism to the brain
What two populations are the most likely to get ABPA?
Asthma and Cystic Fibrosis
What should be tested for in patients with FIXED Livedo reticularis (i.e. that remains despite changes in position or temp changes)
Antiphospholipid antibodies esp. if sx of thrombosis or multiple pregnancy loss
What is the best mgmt for an advanced Parkinson pt who benefits from anti-parkinsonian meds but has bad side effects?
Deep Brain stimulator to subthalamic nucleus; most approp first steps when DA agents work but wear off are to increase dose of carbidopa/levodopa and then to ADD entacapone
What are sporadic fundic gland polyps assoc with?
Usually with PPI and require no tx; if FAP then assoc with APC gene mutation and can harbor dysplasia
What should you do if you suspect hypothyroidism but pt has low or normal TSH?
Check T4 because it may be central hypothyroidism and not primary
