MSKAP 1 Flashcards
Tx for strep pyogenes necrotizing fasciitis
Group A strep nec fasc tx with combo PCN + clinda (suppresses strep toxic production)
Pathogenesis of acute interstitial nephritis
Immune cell infiltration of kidney interstitium
Describe how tx with estrogen for metastatic prostate cancer can induce hypocalcemia
Bony mets of prosate CA act as calcium sink inducing serum hypocalcemia
Estrogen inhibits bone resorption unmasking the increase in bony Ca uptake by mets
Indication for adrenal vein sampling
Adrenal vein used to lateralize abnormal adrenal hormone secretion
Class I vs. II of pHTN
Class I pHTN = idiopathic
Class II pHTN = PAH 2/2 L heart failure (HFrEF, HFpEF)
Physiologic vs pathologic split in S2
Physiologic (normal) for S2 to split during inspiration (increased preload 2/2 increased intrathoracic pressure)
Paradoxical/pathologic split of S2 is present during expiration- due to delay in LV emptying (A takes even longer to close) due to severe aortic stenosis
-so presence of S2 in inspiration is helpful for ruling OUT severe AS
What is porphyria cutanea tarda?
(a) Main clinical manifestation
Porphyria cutanea tarda = skin manifestations of acquired deficiency in liver enzyme required for heme synthesis
-prompts accumulation of porphyrins that are photosensitive
(a) Photosensitive prophyrins mvoed to skin where the disrupt the epidermal barrier => fragile skin and blisters on sun exposed areas
What is hungry bone syndrome?
(a) Lab abnormalities?
Hungry bone syndrome: no PTH to tell bones to breakdown (aka after parathyroidectomy) so bone acts a sink for calcium, phos, and mag
(a) Low Ca, phos, and mag (all hypo)
Differentiate causes of types of bone pain in elderly:
osteomalacia vs. osteitis fibrosis cystica
Bony pain
-osteomalacia due to vitamin D deficiency (no sunlight or poor gut absorption from diet etc)
vs
-osteitis fibrosis cystica is due to long-standing exposure to very elevated PTH (ex: primary hyperparathyroidism or secondary from kidney disease): bony pain and typical subperiosteal bone resorption pattern on Xrays
Serum coag results in pt w/ vitamin K deficiency
- elevated PT/INR (b/c PT is more sensitive to reduction in factor VII levels and vit K needed to make 1972)
- normal PTT
Describe classification staging of pulmonary fibrosis
Radiographically classified (not by symptoms) b/c correlates w/ % spontaneously resolve w/o treatment
I- hilar lymphadenopathy w/ normal lung parenchyma (> 90%)
II- hilar LN w/ abnormal parenchyma (~50% spontaneously improve w/o tx)
III- no hilar LN but abnormal parenchyma (~20%)
IV- extensive parenchymal changes w/ fibrosis and architectural distortion
Adult M admitted for HF exacerbation found to have central sleep apnea w/ Cheyne-Stokes breathing pattern
First line tx?
First line tx for heart failure related central sleep apnea = optimizing HF therapy (ex: furosemide…)
-degree of central sleep apnea often correlates w/ LV dysfunction
Not CPAP! that would be for OSA, while central sleep apnea is cheyne-stokes w/ ABSENCE of upper airway obstruction
Mechanism of roflumilast vs. theophylline
Both are phosphodiesterase inhibitors, roflumilast (decreases exacerbations) is PDE5 specific
Theophylline is a nonspecific phosphodiesterase inhibitor => bronchodilator
Clinical features that distinguish serotonin syndrome from NMS
Serotonin syndrome- faster onset (hours) and faster resolution (24 hrs). 2/2 overdose of serotonin agents. +fever, hyperreflexia, myoclonus
NMS- more subacute (days/weeks) onst and takes longer to resolve (Days/weeks). 2/2 uptitration of antipsychotics or removal of Parkinsonian (dopaminergic) agent.
+higher fever, hyporeflexia, rigidity
Describe 2 expected lab abnormalities seen in cyanide poisoning
Cyanide poisoning inhibits intracellular oxidative phosphylation => no aerobic respiration
- Lactic acidosis
- Abnormally elevated central venous O2 (b/c O2 not being used in tissues…)
ADA guidelines for normal
(a) fasting BS
(b) 2-hr postprandial BS
(a) 80-130
(b) under 180
Scenario of cyanide poisoning
(a) Mechanism of poisoning
Cyanide poisoning- fire
(a) Inhibits intracellular oxidative phosphorylation => can only do anaerobic metabolism => tissues don’t get ATP => multisystem organ failure
Risk factors for porphyria cutanea tarda
Risk factors for porphyria cutanea tarda (acquired liver enzyme deficiency causing accumulation of porphyrins) EtOH Smoking Hep C HIV
Thought to be 2/2 increased oxidative stress to liver or somehow reduced hepcidin expression (which increases iron absorption)
Type 1 vs. Type 2 autoimmune pancreatitis
AIP
Primary- part of a systemic IgG4-positive disease
vs.
Secondary- granulocytic lesions without IgG4-positive cells or systemic involvement
Indications for cinacalcet treatment
Cinacalcet increases sensitivity of parathyroid gland receptors to calcium => reducing PTH secretion
Use in secondary parathyroidism 2/2 CKD to reduce hypercalcemia from bone breakdown
Proposed mechanism by which IV Mag reduces admission for acute asthma exacerbation
Bronchial dilation
Differentiate type I vs type II amiodarone induced thyrotoxicosis
(a) How to differentiate on thyroid ultrasound
(b) Differing treatments
Amiodarone induced thyrotoxicosis (hyperthyroidism in s/o amio)
Type I- underlying Graves or hyperplasia, so with big increase of substrate (amio has 2 iodine components per compound) thyroid becomes super hyperactive
(a) increase flow/vascularity on doppler ultrasound
(b) tx w/ methimazole
Type II- no underlying disease, amio can directly cause destructive folliculitis (rupture of follicular cells releases stored thyroid hormone)
(a) No increased vascularity on ultrasound
(b) Steroids as tx
Definition of acute IPF exacerbation
IPF exacerbation: less than 30 days of worsening dyspnea with new diffuse GGOs on top of pre-existing imaging findings (typically bibasilar fibrotic changes w/ extensive honeycombing)
Thyroid cancer
(a) Most common
(b) From parafollicular cells
Thyroid cancer
(a) 85% are papillary, next 10% follicular, 3% medullary
(b) Medullary thyroid cancer- from parafollicular cells, seen in MEN 2A/2B
Dog bite
(a) What bacteria to expect if gets infected
(b) When to give abx
(c) Which abx
Dog bite- (a) expect skin flora and polymicrobial- staph, strep, bacteroides, pasteurella
(b) any immuncompromised state including asplenia, cirrhosis
(c) Augmentin (amox-clavulanate)
Inciting factors of
(a) NMS
(b) Serotonin syndrome
(c) Malignant hyperthermia
Inciting factors
(a) Neuroleptic malignant syndrome: mostly from antipsychotics (haldol, risperidol etc) also antiemetics (reglan)
(b) Serotonin syndrome from 2+ agents that affect release/reuptake of serotonin: ex: SSRI and ecstasy
(c) Malignant hyperthermia due to inhaled anesthetic (halothane, isoflurane) or depolarizing paralytic (succinylcholine)
Pt w/ hypereosinophilic asthma and nasal polyps may want to avoid what class of meds?
Semter’s triad: severe asthma, hyperplastic nasal polyps w/ eosinophilia, aspirin sensitivity
=> avoid COX1 inhibitors = ASA and NSAIDs
2 treatment regimens for LTBI in HIV negative pt
(a) INH daily, self administered, for 9 months
b) INH and rifapentine weekly for 12 weeks (not 24 weeks…), has to be DOT (as w/ all intermittent regimens
Expected adjustment to levothyroxine dose for pt starting tamoxifen or estrogen
Tamoxifen/estrogen increases thyroid binding protein => reduces free circulating thyroid hormone
So increase levothyroxine dose when starting estrogen compound (vs. decrease when start testosterone)
Pt w/ proven scabies s/p 2 doses of permethrin, still w/ itching but no new lesions
Next step in management?
Tx symptoms of itching (benadryl, topical low-dose steroid) but don’t need to do permethrin or oral ivermectin unless new lesions accumuating
Not uncommon to see post-tx persistent itching
What is actigraphy?
Actigraphy = wrist monitor for sleep cycle, duration
-more accurate version of a slepe diary
Pemphigus vulgaris vs. Bullous pemphigoid
a) Nikolsky sign
(b) H&E stain (where is the clefting?
Pemphigous vulgaris: flaccid blisters + mucus membrane involvement
(a) + Nikolsky sign
(b) Suprabasilar clefting (more superficial than in BP)
Bullous pemphigoid: tense blisters, no mucus membrane involvement
(a) Negative Nikolsky
(b) Subepidermal clefting
74 y/oF presents w/ symptomatic hypocalcemia shortly after starting alendronate-
what other hormone should be measured?
Vitamin D- needs to be measured and stores replete before starting any bisphosphonate
Bisphosphonate inhibits osteoclast activity, if there is underlying vit D deficiency (active vitamin D works on bone to regulate serum Ca levels) then at high risk of hypocalcemia
Mainstay of treatment for serotonin syndrome
Treat autonomic instability w/ supportive care and benzos
Essentially overdose of drugs that affect reuptake/release of serotonin (ex: ecstasy, SSRI)
Class II vs. III of pHTN
Class II and III are due to cardiac and pulmonary causes, respectively
class II pHTN = PAH 2/2 elevated L sided pressures (HFrEF, HFpEF)
class III pHTN = PAH 2/2 lung disease or chronic hypoxia (COPD, IPD/ILD)
Pre-op BP management of pheo removal
(a) First line class of drugs
Pre-op management for pheo removal: 10-15 days pre-op start alpha blocker to prevent hypertensive crisis (seen due to catechol surge w/ anesthesia induction or tumor manipulation)
(a) Phenoxybenzamine = alpha receptor blocker
What is erythrasma?
(a) Tx
Erythrasma = bacterial (gram positive) infection of intertriginous area (groin, folds)
(a) Tx- topical clinda/erythromycin
2 indicated tests for pt w/ incidentally found adrenal mass
Incidental adrenal mass: want to r/o pheo and subclinical Cushing’s syndrome
- 24-hr urine free metanephrines to r/o pheo
- 1mg dexamethasone suppression test (normal would be AM serum cortisol <5) to r/o subclinical Cushing’s
Mainstay of treatment for NMS vs. malignant hyperthermia
Treatment:
NMS (from antipsychotic or withdrawal of dopaminergic agent): stop triggering event (hold antipsychotic, reuptitrate withdrawn Parkinson med)
-poor data for dantrolene
-after ~2 weeks can reintroduce antipsychotic at lower dose
Malignant hyperthermia (from inhaled anethetic or succ in genetic susceptible pt)- stop agent, active cooling, dantrolene IV q5-10 minutes
Pemphigus vulgaris vs. Bullous pemphigoid
(a) Type of blister
(b) Location/skin involvement
Pemphigus vulgaris
(a) flacid, painful blister b/c more superficial
(b) involves mucus membranes, especially the mouth
Bullous pemphogoid
(a) tense blisters b/c deeper (subepidermal antibody), often itchy
(b) typical no oral lesions, mucous membrane involvement less likely
CSF studies expected in tuberculosis meningitis
Tb/fungal meningitis:
- clear color
- WBCs elevated but < 500 (not in thousands like bacterial)
- Protein moderately elevated like 45-200 (viral under 200, bacterial over 200)
- glucose normal to low, in Tb typically under 40 (low like bacterial vs. normal in viral)
55 y/oF smoker should get which pneumococcal vaccine?
PPSV23 has a much broader base for pts under 65: includes immunosuppression but also many chronic diseases (DM, heart, liver, kidney) and smokers
PCV13 only for under age 65 in immunocompromised (asplenia)
Mechanism of bosentan in pHTN
Bosentan = endothelin receptor antagonist
-endothelin found on vascular smooth muscle and bronchioles, when activated causes vasoconstriction
Key lab abnormality in granulomatous disease that leads to hypercalcemia
Elevated 1,25-OH vit D b/c macrophages in the granuloma activate 25-OH to 1,25-OH in a PTH-independent manner (while kidneys will listen to PTH)
So high serum 1,25-OH vit D will stimulate Ca2+ and phos absorption (from gut and bone) => hypercalcemia
(ex: so in pt w/ CXR c/f sarcoid, measure 1,25-OH D instead of PTHrP to determine mechanism of hypercalcemia)
Mechanism of action of micafungin
Micafungin inhibits 1-3-beta-D-glucan synthase, an essential polysaccharide for candida cell wall
decreased glucan content causes osmotic instability and cellular lysis
=> micafungin is first-line tx for candidemia/invasive candidiasis
Main pharmacologic agent for treating acute hep B
Acute hepatitis B- typically will self-resolve, only ~1% progress to liver failure and 5% progress to chronic hepB
Tx first line = nucleot(s)ide analogs tenofovir and entecavir
Phenoxybenzamine
(a) Mechanism
(b) Main indication in pheo pre-surgical management
Phenoxybenzamine
(a) Alpha receptor blocker- causes peripheral venodilation (opposite of pressors)
(b) Alpha blockade to prevent hypertensive crisis peri-op for pheo removal
- huge catechol surge during anesthesia induction and tumor manipulation: uptitrate alpha blockade to goal systolic under 130 pre-op
First line tx for actinic keratosis
Topical 5-FU
5-FU inhibits rapidly replication cells
Pathogenesis of how amyloidosis causes proteinuria
Amyloidosis = plasma cell dyscrasia where light chain (kappa and lambda) are deposited in end organs causing damage
27F w/ Graves started on methimazole 3 months ago p/w fever, sore throat, pain w/ swallowing
In addition to supportive care what else is required?
Need to rule out methimazole-induced agranulocytosis
Methimazole can cause bone marrow suppression => get CBC to calculate ANC
Diagnostic criteria for CTEPH
CTEPH diagnosis:
(1) pHTN (R sided pressures) over 25 mmHg w/o elevated L-sided pressures
+
(2) imaging findings of chronic thromboembolism
pulmonary arterial webbing, luminal irregularities/narrowing
Indications for tacrolimus
(a) Topical
(b) Systemic
Tacrolimus = non-steroid immunomodulator, works as calcineurin inhibitor to inhibit T-cell activation
(a) Topically used as second line agent for atopic dermatitis
(b) Systemically used in post-transplant patients (ex: prevention of G vs host disease)
Also in fistulating Crohns, refractory rheumatoid arthritis
Mechanism of hypothryoidism in late stages of subacute thyroiditis
Subacute thyroiditis- painful destruction of thyroid follicular cells => release stored thyroid hormone
2-6 weeks of hyperthyroid, followed by 6-12 weeks of hypothyroid after thyroid hormone stores are deplete
-may require transient levothyroxine
When to increase levothyroxine dose for hypothyroid pregnant F
Immediately once pregnancy confirmed
T4 requirements increase by 40-50% from TSH/HCG rather quickly, so don’t want until 3rd trimester
Differentiate amyopathic dermatomyosis and dermatomyositis
Dermatomyositis = autoimmune against skin and proximal muscles
“a-myopathic” (without muscle) has the cutaneous findings (Gottrons papules, shawl sign, heliotrope rash) with normal strength and normal muscle enzymes
What is dermatomyositis?
Dermatomyositis = autoimmune against skin and proximal muscle
- muscle weakness, elevated CK
- skin: Gottron’s papules (lichenoid patches on knucles), shawl sign, heliotrope rash (on eyelides)
Etiologies of cavernous sinus thrombosis
Clot in intracranial vein
- acquired hemophilia (OCPs, pregnancy, malignancy)
- inherited hemophilia (genetic)
- HEENT infection (S. Aureus)
Why measure alk phos prior to starting bisphosphonate after radiographic dx of Paget’s disease
B/c alk phos can be normal, indicating quiescent or burnt out phase of disease- during which bisphosphonates aren’t indicated/won’t help
Risk factors for vitamin K deficiency in hospitalized pts
- poor PO intake
- antibiotics (since most of vitK made from saprophytic bacteria in the colon)
- pancreatic dysfunction (fat-soluble vitamin)
74F w/ osteoporosis on alendronate x5 yrs
recent BMD: t-score -2.2 L-spine, -2.4 femoral neck
Next step in management?
Next step after 5 years of alendronate therapy in pt w/ non-severe osteoporosis (T score greater than -3.5) is to stop alendronate
-FLEX trial showed not much benefit of continuing alendronate for 10 vs. 5 yrs
Class II vs. IV of pHTN
Class II pHTN = PAH 2/2 L heart failure (HFrEF, HFpEF)
Class IV = PAH 2/2 pulmonary artery obstruction (ex: CTEPH)
vs. class III = PAH 2/2 lung disease or chronic hypoxia
Antibodies in Graves vs. Hashimotos
Graves (hyperthryoid): anti-thyrotropin receptor Abs
Hashimotos (autoimmune hypothyroid): anti-TPO (thyroid peroxidase) antibodies
Antimicrobial regimen of choice for
(a) cryptococcal meningitis
(b) candidema
(a) liposomal amphotericin B + flucytosine
(b) micafungin
Lab value findings of gestational thyrotoxicosis
HCG and TSH have the same alpha-subunit so some cross over => see elevated T4, with resultant suppressed TSH
High T4, low TSH
Downfall (limitation) of meningococcal vaccine
Vaccine doesn’t cover serogroup B which causes 40% of meningococcal meningitis
Higher risk of hypoglycemia: metformin vs. glyburide
Glyburide (sulfonylurea, stimulates insulin secretion from pancreas regardless of serum glucose) carries relatively high risk of hypoglycemia
Other sulfonylureas = glipize, glimepiride
Clinical presentation (onset of menses) that distinguishes Turner’s syndrome from primary ovarian insufficiency
Turner’s syndrome (X,0) presents in late teens w/ primary amenorrhea
Primary ovarian insufficiency- presents in 30/40s w/ secondary amenorrhea (pts stop getting their period, despite FSH levels elevated)
For treatment of myxedema coma which hormone should be given first?
Myxedema coma treatment: give IV hydrocort thennnn give IV levothyroxine
-if give thyroid hormone first may precipitate adrenal crisis due to augmented cortisol metabolism
50 y/oF s/p total thyroidectomy
takes calcium citrate for supplementation
serum Ca wnl
what else needs to be monitored?
Urine calcium excretion needs to be monitored in chronic hypo-PTH states
- b/c hypercalciuria will limit calcium supplementation therapy
- risks of high urine calcium = kidney stones and reduced GFR
- can consider adding thiazide (reduce urine Ca excretion) if hypercalciuria is limiting serum Ca levels from normalizing
Contrast the clinical presentation of Tb meningitis and cryptococcal meningitis
Tb- more subacute (2-4 weeks) onset of symptoms
Cryptococcal neoformans- inhaled pathogen so typically accompanied by respiratory symptoms/PNA
Interpret UA w/ trace protein but UACR of 2500 mg/g
Proteinuria without albumineuria- another protein in the urine = typical meyloma light chains!
Difference in Fleischner society guidelines for pure ground-glass vs. partially solid pulmonary nodule
GGOs progress slower (average doubling time of partially solid nodules is 3-5 years)
Pure GGO: repeat in 12 months, then q2 years for 5 years
Partially solid: repeat in 6 months, then q1 year for 5 years
What finding on routine bloodwork monitoring for pt on long course of daptomycin would prompt discontinuation
Weekly Cr and CPK given risk of myositis
Stop dapto if
CK 10x ULN and asymptomatic
Pt symptomatic with CPK 5x ULN
Characteristics of CVID (common variable immunodeficiency)
(a) Why relevant to make diagnosis
CVID- heterogenous genetic deficiency in IgG/IgA => increased risk sinopulmonary and GI infectious
-recurrent sinusitis, otitis media, diarrhea
Key is that they benefit from IVIG
BP goals in hypertensive emergency
ex] Pt 230/140 w/ AMS and Cr bump, by when should BP be <160, normalized?
HTN emergency:
- first hour drop BP by no more than 25%
- first 6 hrs SBP under 160
- cautiously bring down to normal (under 120) within 24-48 hrs
HIV prophylaxis via CD4 count
Prophylaxis by CD4 count
- under 200: bactrim for PCP
- under 100: bactrim for toxo
- under 50 and NOT starting HAART (pt noncompliance, some other delay): azithro for MAC
Viral vs. Tb meningitis on CSF studies
WBC: higher in Tb (500s) than viral (under 300s, lymphocyte predominance)
Glucose: lower in Tb (10-40) in viral (normal)
Protein: moderately elevated in Tb (100-500), low in viral
Distinguishing feature of subacute thyroiditis
Subacute thyroiditis in the painful one
While Graves and multinodular goiter will not be painful
Side effect profile of topical diclofenac
Increase in localized skin rash
not lipodystrophy, localized hypopigmentation, or eye/mucus membrane irritation
Mechanism of cheyne-stokes breathing
Cyclic breathing of apnea, gradually up to tachypnea (high RR and high TV) then gradually back down to apnea
Mechanism thought to be delay in central chemoreceptor detection of PaCO2 (arterial CO2) and therefore changes in ventilation
-associated w/ prolonged lung to brain transit time (heart failure)
Which type of vitamin D level to check before undergoing parathyroidectomy for primary hyperparathyroidism
Test 25-OH vit D before parathyroidectomy to reduce post-op risk of hungry bone syndrome
PTH stimulates conversion of 25-OH vit D to 1,25-OH vit D so measuring active 1,25-OH D will falsely reassure you that vit D stores are adequate
Serologic testing that can help diagnose an anterior mediastinal mass
Terrible Ts = pneumonic for anterior mediastinal mass = teratoma (germ cell tumor), thymoma, thymic tumor (lymphoma)
germ cell tumor: AFP, beta-hCG
thymoma: ACH-receptor antibody (for myasthenia gravis)
lymphoma: LDH
When should IV flagyl be added to PO vanc for tx of initial C. Diff infection?
When initial case is fulminant = c/b ileus, toxic megacolon, or hypotension/shock
-also consider PR vanc b/c ileus-limiting colonic transit of oral meds
What drug can iatrogenically cause cyanide poisoning?
Nitroprusside at high doses in drip form used for HTN emergency can cause cyanide toxicity- watch out for metabolic acidosis and AMS
Mechanism of anti-PD-L1 monoclonal antibodies
Blocks PD-L1 (ligand) from binding to its receptor => preventing cancer from silencing cellular immunity
(PD-L1 on tumor cell binding to PD-1 on T-cell inhibits the immune response by not activating the T-cell)
How smoking changes birth control advice
In smokers (>15 cigs/day) over 35 yoa estrogen containing contraception is relatively contraindicated 2/2 higher risk of VTE =>
opt for progesterone-only IUD (copper IUD) vs. progesterone only pill (mini pill)
Contrast buzzword CT chest findings of
a) RB-ILD (respiratory bronchiolitis ILD
(b) Pulmonary langerhan cell histiocyosis
(c) Desquamative IP
Buzzword CT chest findings of smoking-associated ILDs
(a) RB-ILD = centrilobular GGOs/micronodules
(b) Pulmonary langerhan cell histiocytosis = thin-walled cysts
(c) Desquamative interstitial pneumonitis = diffuse GGOs (less centrilobular predominant to RB-ILD) w/ lower-lobe predilection
Why are baseline TFTs (then q3-4 month monitoring of TFTs) required for pts on amiodarone?
Most pts will remain euthyroid, but others can become both hypo or hyperthyroid
Hypothyroid due to direct follicular cell damage
Hyperthyroid = amiodarone-induced thyrotoxicosis
Explain utility of vasoreactivity testing with nitrous oxide during R. heart cath during eval for pHTN
pHTN evaluation: R heart cath NO vasoreactivity to see if CCB is indicated
if + vasoreactivity: start diltiazem (cheaper, fewer side effects)
If negative vasoreactivity: need to think more advanced therapies: endothelin receptor blocker like bosentan
Mechanism of action of echinocandins
Echinocandins = micafungin, caspofungin- inhibits production of beta-glucan which is key to fungal cell walls. Unstable fungal cell walls => osmotic instability => cell lysis
Main indication and mechanism of diamox
Diamox = acetazolamide = carbonic anhydrase inhibitor
Main indication- diuretic in edematous pt w/ metabolic alkalosis (high HCO3) to cause excretion of bicarb to restore acid/base balance
ex] pt w/ hypercapnic chronic lung disease when lasix causing metabolic alkalosis, then respiratory compensation (2/2 hypoventilation) causes rise in pH that exacerbates hypoxemia => prevents weening from mechanical ventilation
Tx of dermatitis herpetiform
Dermatitis herpetiform highly associated w/ celiac disease. Immediate tx use dapsone to relieve itch, then maintain gluten free diet to prevent recurrence
PT vs. PTT in what factors they measure
(a) Which impacted more by vitamin K deficiency
PT/INR measures extrinsic pathway (VII –> X)
PTT measures intrinsic pathway (12 11 9 8 –> X)
Then from X –> 5 –>2 (thrombin) –> fibrin
(a) Extrinsic (PT/INR) more likely to be elevated in vit K deficiency b/c more sensitive to reduction in factor VII (only other factor it relies on)
Indicated screening for Marfanoid female prior to pregnancy
TTE for aortic root diameter- ensure under 4cm and stable x6 months before advising pregnancy given high risk of pregnany-related aortic dissection and rupture
34F p/w secondary amenorrhea, found to have elevated prolactin levels
TFTs, Cr, LFTs wnl
MRI brain w/ 7mm pituitary microadenoma
Next step in mgmt?
Prolactinoma w/o other pituitary abnormalities (TSH wnl, kidneys fine)- tx with dopamine agonists
Dopamine agonists = carbegoline, bromocriptine
28F w/ neisseria meningitis, sister w/ h/o neisseria meningitis, suspected underlying diagnosis
Terminal complement deficiency of MAC (membrane attack complex) protein using C5-C9
high risk for niesseria infections
What percent of BSA involvement w/ psoriasis is typically treated with topicals only (not systemic tx)
When under 10% of skin involved- can consider using just topicals
Once over 10% involved: systemic therapies such as phototherapy, methotrexate, cyclosporin
Location of laceration where sutures preferred to skin glue
Suture preferred over joint or tendon- b/c tensile forces of area will make glue ineffective
ex: on finger, knee, elbow use sutures even if smaller than 2 inches
Treatment options for CTEPH
First line is to consider surgical thrombectomy to prevent irreversible remodeling
If not a good surgical candidate or clot not resectable: lifetime warfarin (not DOAC b/c not studied)
What are the smoking associated ILDs?
Smoking associated ILDs: RB-ILD (respiratory bronchiolar ILD), Pulmonary langerhan cell histiocyosis, DIP (desquamative IP)
Euthyroid sick syndrome/nonthyroidal illness lab values (TSH, T3/4)
Critically ill patients often have non-clinically relevant reductions in T3/4 and TSH (would expect to be high)
Not relevant unless see symptoms, otherwise just repeat once out of critical illness
ex: dude with large MI and incidentally pan-low TFTs: repeat later on
What type of lung cancer is pembrolizumab first line agent for?
Pembrolizumab = anti-PD-L1 mAb
-first line agent (over platinum based chemo) for metastatic NSCLC (ex: lung adenocarcinoma) with > 50% PD-L1 tumor cell positivity, and negative for EGFR or ALK/ROS1 translocation
Stains
(a) India ink
(b) Congo red
(a) India ink stain = crypto
(b) Apple-green birefringence of congo red = amyloidosis
How to distinguish empyema from parapneumonic effusion with pleural studies
Both can have pH under 7.2, very exudative
Empyema- appearance is frank pus, positive gram stain
Parapneumonic effusion- appearance serosang, negative gram stain
When does hungry bone syndrome happen?
Hungry bone syndrome: after parathyroidectomy (b/c PTH stimulates bone resoprtion/turnover that causes net efflux of Ca from bone)
Acute drop in PTH (needed to release Ca from bone) => acute drop in serum calcium
Illness script (clinical presentation/risk factors) for subacute thyroiditis
Subacute thyroiditis- few weeks after viral URI, get symptoms of hyperthryoidism and painful neck fullness
b/c destructive thyroiditis (follicular cells destroyed => release stored hormone), followed by period of hypothyroidism where stored hormone is depleted
Mechanism by which risperdone can cause hyperprolactinemia
Risperdone: inhibits dopamine
Dopamine reduces prolactin secretion (negative feedback from pituitary)
Differentiate use of methimazole and radioactive iodine
Methimazole for reversible causes (acute thyrotoxicosis, type I amiodarone induced hyperthyroid due to high iodine load, short term before surgery or radioactive iodoine, if pt can’t get radioactive iodine
-b/c in multinodular goiter or toxic adenoma: unlikely to regress so tx would be lifelong, so look to radioactive iodine for more permanent fix
Radioactive iodine triggers follicular cell death- use in multinodular goiter and toxic adenoma
Indications for steroids in infectious meningitis
- S. pneumo or suspected bacterial when organism not yet known (given before abx)
- tuberculous meningitis
If no evidence of mass effect of excess hormone secretion- when should repeat MRI be performed for incidentally-found pituitary macro/microadenomas?
No mass effect on MRI and no excess hormone secretion (cortisol, prolactin, IGF-1 for growth hormone)
Microadneoma (under 1cm): repeat MRI in 12 months
Macroadenoma (1cm and above): repeat MRI in 6 months for growth
Name for these skin findings:
(a) Lichenoid patches on knuckles
(b) Eyelid rash
(c) Rash on upper back and posterior neck
Skin findings
(a) Gottrons papules seen in dermatomyositis
(b) Eyelid rash = heliotrope rash
(c) Shawl sign
Elderly M p/w jaundice found to have ‘sausage-shaped- pancreas w/ biopsy > 10 IgG4 positive cells/hpf
‘Sausage-shaped’ pancreas pathognomonic for autoimmune pancreatitis (imaging finding of homogeneous hypodense swelling)
Tx = steroids!
Not ERCP w/ stent b/c > 90% pts respond to steroids
Differentiate mechanism of heparin and lovenox
Both work in clotting cascade
- heparin = mostly anti-factor IIa (thrombin) which is a protease => inhibits conversion of fibrinogen –> fibrin
- lovenox mostly antifactor Xa, low degree of antifactor IIa
Describe dermatitis herpetiform appearance
subepidermal autoimmune disease
Diffuse verrrrry pruritic tiny tense vesicles that don’t remain intact => presents as excoriations w/ rare intact vesicles that are profoundly pruritic
Use of KOH prep vs. wood lamp for diagnosing dermatologic conditions?
KOH prep diagnostic for fungal/hyphae (candida)
Wood lamp helps diagnose vitiligo, erythrasma (bacterial infection in intertrigenous areas), porphyria cutanea tarda
Explain why hydrocort, but NOT fludrocort, is required as replacement after unilateral adrenalectomy for cortisol-producing adrenal adenoma
Hydrocort responds to ACH/ACTH axis (that will take a while to amp up after cortisol-producing tumor removed)
While mineralocorticoid (aldo) is not depending on HPA axis (yay RAAS system) contralateral adrenal gland can compensate
After ~1 yr can expect HPA axis to recover and can try downtitrating hydrocort
Appropriate screening tests for pt w/ stage I pulmonary fibrosis
Screen for extrapulmonary manifestations
- cardiac w/ EKG
- hypercalcemia
- eye exam
Enlarged thyroid noticed on exam, ultrasound shows a nodule, scintigraphy shows one highly-uptaking nodule.
(a) most likely dx
(b) 1st line tx
(a) Toxic adenoma
(b) 131 iodine: beta-radiation triggers follicular cell death
not methimazole b/c adenoma likely not to go into remission, so would require lifelong methimazole therapy
Differentiate the two types of serologic testing for syphilis
Treponemal- lifetime positive after infection, EIA (enzyme immunoassay) and FTA (fluorescent treponemal antibody). More specific b/c testing specific Ab against treponemal Ag
qualitative (reactive, nonreactive)
Nontreponemal = RPR, VDRL, cheaper, higher rate false positive, but correlates w/ disease activity and can be used to track treatment response
nonspecific, quantitative (titer of how much dilution required to detect Ab)
When dexamethasone is indicated in altitude sickness
Dex indicated in high altitude cerebral edema- through unclear mechanism altitude sickness can lead to reversible vasogenic brainedema
ex] person rapidly ascends mountain, becomes confused and irritable- start dex
Etiologies of secondary polyarteritis nodosum
Polyarteritis nodosum (systemic, necrotizing, non-ANCA associated, medium vessel vasculitis) is often idiopathic or
Secondary from HBV or HCV
Mechanism of teriparatide
(a) Indications
Teriparatide = recombinant PTH- give to very high osteoporosis risk pts, acts to activate osteoblasts and increase GI calcium reabsorption
(a) Postmenopausal F w/ high osteoporosis risk (prior fracture), pts on long-term steroids w/ bone screening t-score under -3.0 or prior fracture
What is the risk of actinic keratosis?
Risk of squamous cell carcinoma: 1-5% risk lifetime transformation
Not high risk of transformation, but >50% of squamous cell CA of skin come from AK precursors
52 y/oM w/ lab test confirmed primary hyperaldosteronism. CT showed 0.8 R adrenal mass
Next step in mgmt?
Next step = adrenal vein sampling, want to confirm/lateralize aldo-secreting side (b/c 25% of the time it’ll just be a nonfunctioning tumor and you missed b/l adrenal hyperplasia if you hastily proceed to surgery w/o adrenal vein sampling)
Tx for incidental finding of +nontreponemal test for syphilis
+RPR or VDRL (marker of active infection) incidentally found (unknown duration of infection) gets 3 weekly doses of IM benzathine PCN
vs. known duration (primary, secondary, early latent) requires single dose benzathine PCN
57 y/oM p/w fragile skin and blisters on dorsal knuckles x2 yrs. Active smoker and drinker, works as a roofer so lots of time outside
Dx of skin lesions?
Dx = porphyria cutanea tarda
-acquired deficiency in liver enzyme used in heme synthesis (risk factors: etOH, smoking, hep C, HIV). W/ this deficiency porphyrins build up- transported to skin and cause photosensitive epidermal junction breakdown => skin fragility and blisters in sun exposed areas
Management of loculated empyema not completely drained by chest tube placement
(MIST-1 and MIST-2 trials)
Loculated empyema not fully drained by chest tube:
MIST-2 trial: tPA-DNase BID x3 days reduced opacity on imaging, LOS in hospital, and need for surgery (VATS)
while MIST-1: streptokinase had no benefit over intrapleural saline
So: use tPA:DNase
Mechanism of cinacalcet
Cinacalcet- works on parathyroid cells to increase sensitivity to calcium => reducing secretion of PTH
Used in primary hyperparathyroidism if there is a contraindication to surgery, or more commonly in secondary hyperparathyroidism (in CKD) to protect bones
Why add clinda in nec fasc 2/2 strep pyogenes when GAS is sensitive to PCN alone?
Clinda suppresses production of strep toxin- to in theory decrease risk of toxic shock syndrome (50% risk with GAS nec fasc)
Maneuvers that increase HOCM murmur
Decreased preload (venous return) => decreased LV size => worsened obstruction
So squatting or Valsalva both increase intensity of HOCM murmur 2/2 reduced preload
Most common etiologies
Drugs, drugs, drugs (NSAIDs, methicillin abx, bactrim, PPIs)
Then autoimmune diseases (SLE, Sjogrens)
Then infection
Histopath way to differentiate respiratory bronchiolitis ILD from hypersensiivity pneumonitis
Both RB-ILD and HP can be associated w/ smoking and can have centrilobular GGOs
Histiopath difference:
- RB-ILD = tan/yellow-pigmented macrophages in bronchiolar lumen
- HP = noncaseating granulomas on path
Thyroid cancer associated with childhood head/neck radiation
Papillary thyroid cancer associated w/ head/neck radiation, also papillary thyroid is by far the most common thyroid cancer (85%)
10% follicular
3% medullary
Tx for incidental finding of +nontreponemal test for syphilis
+RPR or VDRL (marker of active infection) incidentally found (unknown duration of infection) gets 3 weekly doses of IM benzathine PCN
vs. known duration (primary, secondary, early latent) requires single dose benzathine PCN
Name of the SGLUT2 inhibitors
Empagliflozin, dapagliflozin, canagliflozin
Clinical features of PPI-induced tubulointerstial nephritis
Chronic (month-long) decline in CrCl with nonspecific symptoms (malaise, polyuria, anorexia).
Chronic tubulointerstitial disease results from chronic exposure to drugs that cause AIN
Main treatments for chrnoic Cheyne-stoke breathing
- Optimize heart failure regimen
- CPAP during sleep
- Supplemental O2
Dermatologic manifestation of celiac disease
Dermatitis herpetiform (diffuse, tense vesicles that often break and are super itchy) associated w/ celiac disease (vs. erythema nodosum in IBD)
Bug implicated in
(a) Nec fasc w/ presence of gas in soft tissue on imaging
(b) Nec fasc w/o gas
(a) Polymicrobial w/ Clostridium species
b) Group A strep (strep pyogenes), staph aureus (MRSA, MSSA
Mechanism of acetazolamide for altitude sickness
Acetazolamide = carbonic anhydrase inhibitor
- inhibition of renal carbonic anhydrase slows hydration of CO2 (into HCO3) in proximal tubule to reduce reabsorption of bicarbonate => bicarbonate diuresis => metabolic acidosis
- disinhibits central chemoreceptors (by decreasing CO2 –> HCO3, lowers pH in the brain) to stimualte central ventilatory drive) to stimulate ventilation to improve oxygenation
Most common cause of Addison’s disease in the US?
Addison’s = primary adrenal insufficiency
MC cause in the US is autoimmune 2/2 21-hydroxylase antibodies
ex] 33 y/oM p/w lab-proven adrenal insufficiency: next test is to test for 21-hydroxylase antibodies (not biopsy adrenals or anything crazy)
Type of UV phototherapy used for diffuse psoriasis
Limited UVB phototherapy
- gives a higher wavelength than that absorbable by DNA => doesn’t increase risk of cancer
- UVA light typically reserved for tx of cutaneous lymphoma b/c increases risk of melanoma and non-melanomatous skin cancers
Main clinical features of polyarteritis nodosum
Vasculitis of medium-sized arteries (idiopathic, HBV, HCV):
- systemic features are most common (fever, malaise, weight loss)
- neuropathy, arthritis
- cutaneous: livedo reticularis, purpura
- renal disease
- GI symptoms
Utility of cosyntropin stimulation test
Cosyntropin (ACTH) stim test is used in cortisol/adrenal insufficiency to see if primary, secondary, or tertiary
Can be helpful when AM serum cortisol or ACTH levels are on the border and you want to localize the issue
Mechanism of ivabradine in heart failure
(a) Main indication
Ivabradine = slows down If (funny currents) to slow heart rate from sinus node
(a) Reduce hospitalizations in HFrEF <35% in sinus rhythm > 70 bpm and already on max beta-blocker
What 3 alterations to look for in NSCLC
Non-small cell lung cancer (adenocarcinoma, squamous cell, large cell)
Test for EGFR and ALK/ROS1 mutations, and PD-L1 expression
65 y/o post-menopausal F develops coarsening of facial, body, chest hair, deeper voice, and cliteromegaly over 6 months
serum T 89 (H but not HHH)
DHEAS 890 (HHH)
Next diagnostic step?
Next step = abdominal CT for adrenal androgen secreting mass, also will see ovarian mass
NOT a pelvic ultrasound (ovarian mass, since ovaries and adrenals make androgens in F) b/c with such an elevated DHEA more likely adrenal than ovarian
Clinical manifestations of type 1 autoimmune pancreatitis
Type 1 (IgG4-related) AIP: usually obstructive jaundice
Associated salivary gland symptoms, RP fibrosis
Mechanism by which severe hypomagnesemia due to platinum based therapies can cause hypocalcemia
Platinum based chemos remarkably impair renal handling of mangesium
Hypomag causes reversible parathyroid hypofunction- so PTH is not secreted
On labs see hypocalcemia with low-PTH (when would expect PTH to be high to compensate)
Most common pituitary abnormality seen when empty sella found on imaging
Empty sella can be increased CSF or smaller pituitary, not pathognomonic. Most common pituitary abnormality is hyperprolactinemia 2/2 low dopamine
-want to also screen for cortisol deficiency and hypothyroidism
56 y/oM on stable levothyroxine dose, starts supplemental testosterone
Expected adjustment to levothyroxine dose?
Testosterone reduces thyroxine-binding globulin => more free circulating thyroid hormone
So expect to require decrease in levothryoxine dose (or possibly hyperthyroid symptoms if don’t adjust dose) when starting testosterone supplementation
Fomepizole
(a) Mechanism of action
(b) Indication
Fomepizole = methanol/ethanol poisoning antidote
(a) Competitive inhibitor of alcohol dehydrogenase to reduce metabolism of methanol and ethanol into toxic metabolites
(b) Methanol/ethanol toxicity
30 y/oF p/w tender red nodules on shins- next step/tests?
Erythema nodosum (form of panniculitis) often associated w/ hormones, infection, or inflammatory disorders
hormones including OCPs, pregnancy, hormone replacement => if F of child-bearing age presents w/ unexplained erythema nodosum order pregnancy test
First line tx for candida bacteremia
Echinocandin (micafungin, caspofungin). Then after induction if improved (and sensitivities have returned) can switch to oral azole (fluconazole)
Mepolizumab vs. omalizumab for severe asthma
Mepolizumab: anti-IL-5 (pro-eosinophilic cytokine), so for use in pts w/ elevated eos (over 150-300)
Omalizumab: monoclonal antibody against IgE (so for elevated IgE 30-700)
Both reduce exacerbations and ED visits in respective populations (elevated eos vs. elevated IgE variants)
Side effects of overusing topical steroids
Overusing topical steroids
- thinning of the skin
- straie = hypopigmented linear striations
- easy bruising
What class of pHTN is caused by CTEPH?
chronic thromboembolic pulmonary HTN is class IV = pHTN due to pulmonary artery obstruction
What is cheyne-stokes breathing?
Cyclic breathing: apnea followed by gradual increase in frequency to tachypnea, then gradually back down to apnea
Utility of pimecrolimus cream
Pimecrolimus (similar to tacrolimus) is a calcineurin inhibitor (inhibits T-cell activation) that reduces immune activation (non-steroid immunomodulator/suppressant)
Used as second line topical therapy for eczema (atopic dermatitis)
GFR cutoff for starting metformin
Metformin- safe to start at GFR 45 or above
contraindicated below 30
30-45: gray zone, some start at half dose then closely monitor, some won’t start but will continue it pt already on it
HLA-B27 implications
Positive antigen on leukocytes associated w/ increased risk of certain autoimmune diseases (ankylosing spondylitis and reactive arthritis)
Benefit of diclofenac over ibuprofen
Topical => less systemic absorption => safer GI side effect profile
Electrolyte abnormalities in hyperaldo
Aldosterone- binds to mineralocorticoid receptor in kidney to increase NaCl channels in distal tubule => Na/water reabsorption and K secretion
Hypernatremia
Hypokalemia
How does amiodarone cause
(a) Hypothyroid
(b) Hyperthyroid
Amiodarone- compound itself contains tons of iodine (precursor of thyroid hormone)
(a) Hypothyroidism by causing direct damage to follicular cells
- more commonly found in iodine-rich nations (develops nations)
(b) Hyperthyroid- amiodarone induced thyrotoxicosis
type I = in pts w/ indolent Graves/hyperplasia more substrate => more production
- tx w/ methimazole
type II = destructive thyroiditis (rupture of follicular cells => release of stored hormone)
- tx w/ steroids
Ideal empiric coverage for suspected nec fasc
(Vanc or linezolid) + (imipenem or meropenem)
Cover for mixed aerobic and anaerobic, also MRSA
-clostridium, group A strep, staph
58F p/w symptoms of Cushings, is on estradiol for post-menopausal hot flashes
Best test for diagnosing Cushings
24-hr urine free cortisol
Serum cortisol measurements will be inaccurate. Estrogen increases cortisol binding proteins => elevate total serum cortisol while free cortisol remains normal
Describe metoprolol use in pts w/ pheochromocytoma
Beta-blockers contraindicated until adequate alpha blockade in ensured
b/c unopposed alpha can precipitate hypertensive crisis
Clinical features of cavernous sinus thrombosis
Cerebral venous blood unable to be drained so increased ICP/cerebral edema
- symptoms: headache (most common), then focal neurologic deficits), signs of increased ICP
- CN III, IV, VI involved => opthalmoplegia (pain w/ EOM)
Indication for exhaled nitrous oxide test
Exhaled NO helps detected severe obstruction when other tests can’t be used- ex: testing for asthma in children or intellectually disabled adults
Potential use as objective tracker of obstruction in asthma
Differentiate tx for cyanide and carbon monoxide poisoning
Cyanide- inhibits oxidative phosphorylation => only anerobic respiraton can happen
- tx w/ hydroxocobalamin which binds intracellular cyanide forming excretable metabolite
vs. CO which binds w/ high affinity to Hb reducing carrying capacity of O2
- tx w/ 100% FiO2 and hyperbaric oxygen (if carboxyhemoglobin is over 25%) to reduce half life of carboxyhemoglobin and displace it from Hb
MSK indications for duloxetine
Duloxetine = SNRI and weak dopamine reuptake inhibitor
-Fibromyalgia
-Diffuse OA pain: specifically chronic lower back and knee pain
(so for diffuse severe OA refractory to NSAIDs, use duloxetine not topical capsaicin)
Rash associated w/ celiac disease
Dermatitis herpetiform: knees, elbows, buttocks
very pruritic
can be vesicular
