MSKAP3 Flashcards
What should you think if a patient with SLE has a new foot drop? Best test? Tx?
Mononeuritis multiplex (vasculitis of vasa nervorum); EMG/NCS; more aggressive immunosuppression
If doing a R heart cath for suspected pulmonary HTN shows a mean PAP of 30 mmHg and an elevated PCWP what is the probable Dx? Tx?
WHO II Pulmonary HTN i.e. secondary to left heart failure and tx guided towards heart failure
What are D-Dimer levels in liver failure?
Often elevated (FDPs - fibrin degradation products) as they are cleared by the liver so not overly helpful in differentiating DIC from liver dz
What class of drugs are the first line for Type B aortic dissections?
Beta-Blockers i.e. esmolol gtt or labetolol
Patients with Lewy Body dementia have increased sensitivity to which meds?
Neuroleptic meds (already lacking some dopamine)
Small bowel bleeding is best treated with _______
Push enteroscopy; do after negative EGD and Colo or after + pill study
Cortisol replacement therapy should be initiated immediately in persons with confirmed adrenal insufficiency with a serum cortisol level < ____
3
What are some causes of malignant SVC syndrome? (5)
SCLC, NSCLC, Lymphoma, Thymoma, and Germ Cell Tumors
How should a patient with atrial fibrillation with a recent stent placement be treated?
Dual Antiplatelet Therapy (DAPT) and appropriate anticoagulation based on CHADSVASC so warfarin or DOAC + DAPT = triple therapy
Aside from RA what other condition is often RF+ and is often a vasculitic type of event?
Cryoglobulinemia (often w/ low C4, relatively normal C3); here there is a monoclonal protein and +RF w/ low C4 and nl C3
In whom can you see acute progressive disseminated histoplasmosis? Dx? Tx?
AIDS w/ CD4 <200, Heme malignancies who have new fever, weight loss and HSM; Dx w/ histo antigen in urine/blood or bone marrow Bx; Ampho B and long term suppressive Tx
Relative risk is often calculated from what kind of study?
Cohort studies; investigate the outcomes of similar patients w/ different exposures; the standard outcome measurement is relative risk
What is an obstructive pattern on PFT?
FEV1:FVC ration <0.7 and if there is a >12% response to bronchodilator test probably asthma
What progressive neurodegenerative disorder is triggered by repetitive mild head injuries and occurs in military combat victims and athletes in contact sports?
CTE- Chronic Traumatic Encephalopathy
What is the safest option for birth control in women with a history of migraine with aura?
IUD or condoms
Determination of ______ receptor status is indicated in all patients with metastatic gastric and GE junction cancer?
HER2; addition of trastuzumab to cisplatin + 5-FU or to capecitabine (prodrug of 5-FU); good to check if metastatic at Dx or if new metastatic lesions are found after remission
What is the appropriate first step in managing a probable malignant SVC syndrome?
Obtaining a histologic diagnosis
T/F: BOTH antipsychotics and SSRIs cause hyperprolactinemia
False; only antipsychotics have the dopamine blocking activity (DA= PIF; prolactin-inhibing factor)
Why might a patient with staphylococcal impetigo develop a blister at the site?
Exfoliative toxin (same toxin as staphylococcal scalded skin syndrome)
What is Type I Autoimmune Pancreatitis associated with?
IgG4
What are two conditions associated with Roth spots in the eyes?
Endocarditis and Leukemic retinopathy (i.e. CML)
Do you need to have proteinuria to have pre-ecclampsia?
No; If you have new HTN after 20 weeks of pregnancy w/ END-ORGAN damage; that counts too; this includes thrombocytopenia w/ the end organ being BM; concern is for HELLP
What is ambulatory blood pressure monitoring the most useful for?
Detecting Masked Hypertension- especially in patients with evidence of end-organ dysfunction i.e. LVH on EKG or AKI
Why is a right heart catheterization required in patients with probable WHO 1 (pulmonary arterial; primary) pulmonary HTN?
To confirm the hemodynamics and to determine if there is a response to vasodilator infusion because it guides further tx; in confirming the hemodynamic expect to see mean PAP of >25 mmHg and normal PCWP
What is the cornerstone of tx for Autoimmune pancreatitis?
Glucocorticoids
Prior use of what type of chemo predisposes to an increased risk for developing arthralgias on aromatase inhibitors?
Taxanes (Paclitaxel/Docetaxel)
How may the presentation of autoimmune pancreatitis differ from that of regular ethanol/GB pancreatitis?
It often has extrapancreatic organ involvement such as sclerosing cholangitis; need glucocorticoids; assoc w/ IgG4
What is the DLCO in asthma?
Normal as the alveolar-capillary surface area is preserved and so diffusing capacity is normal
How do isopropyl, ethanol, and ethylene glycol differ in terms of lab values?
All 3 can cause encephalopathy; methanol and ethylene glycol will cause an anion gap metabolic acidosis and isopropyl will not, ALL increase the osmolar gap
What is Perioral Dermatitis? In whom do you see it?
discrete papules and pustules w/o comedones on an erythematous base around the mouth; often seen as eruptions after the initiation of topical or inhaled corticosteroids
A QTc greater than > _____ increases the risk for Torsades de Pointes
500 ms
When is an ACTH stimulation test useful?
For borderline cases of adrenal insufficiency; suspect if pt is hyponatremic and hyperkalemic
What is the difference between a “Bone Infarct” and “Avascular Necrosis”?
Bone Infarct: lesions occuring at the metaphysis and diaphysis; AVN occurs at epiphysis
If you check for cryoglobulins and they are present you should then screen for what dz?
Hepatitis C infection; probably already ordered this when thinking of cryoglobulins though
What is the treatment of a boil (simple furuncle) in an immunocompetent patient?
Incision and Drainage without antibiotics; if IC, systemic sx, or nonresponsive then: linezolid, TMP-SMX, Clindamycin, or Doxycycline
What are some non-malignant causes of SVC syndrome? (2)
Thrombosis i.e. from CVC or fibrosing mediastinitis
What is the best test for diagnosing HSV lesion?
DFA or PCR
What is the next step in any patient with a possible implanted cardiac device infection with or without fever?
Two sets of blood cultures; most commonly S. aureus or coagulase negative staph
A patient with a vasculitic picture who has ear infarctions probably has what?
Mixed cryoglobulinemia; This is often associated with LOW C4 but relatively preserved C3; you should check serum cryoglobulin levels; often RF+
Patients with enteric hyperoxaluria may benefit from what drugs?
Bile salts i.e. cholestyramine to decrease absorption in the intestines; i.e. Crohns pt w/ calcium oxalate stone should get
What is the most appropriate VTE ppx for patients undergoing cancer surgery especially if abdominal?
Enoxaparin (LMWH) for up to 28 days s/p surgery (cancer is prothrombotic and the prolonged immobility of surgery increases risk)
How do you calculate the plasma osmolality?
(2 x Sodium) + (glucose/18) + (BUN/2.8)
What kind of fluid is known to exacerbate hypophosphatemia and why?
Dextrose containing fluids as they stimulate insulin release which then lowers the phosphate; hypophosphatemia can lead to respiratory failure (poor diaphragmatic fxn) and rhabdomyolysis
What is the preferred initial diagnostic test for a pregnant patient with probable PE?
LE US; if + then no need for CT-PE
Explain difference in utilization of metal biliary stents and plastic stents?
Metal Biliary stents often used for palliation in malignant strictures; Plastic stents more useful if temporary in setting of a “dominant stricture” as they can be removed at a later date
Why might looking at factor V, VII, and VIII be useful in patients with suspected coagulopathy of liver disease?
Patients with coagulopathy of liver disease have elevated PT (extrinsic pathway) and elevated PTT (intrinsic pathway); factor VII is low (extrinsic, elevated PT), factor V is low (common; elevated PT and PTT); and factor VIII is often normal as it is produced in the vascular endothelium AND you need a functioning liver to adequately clear factor VIII
Mononeuritis multiplex is highly specific for what type of condition? Most common nerve affected?
Vasculitis; it is due to inflammation of the vasa nervorum which is a small vessel; Peroneal nerve - new foot drop in pt w/ SLE
When is it safe to add a beta blocker to new HFrEF?
After the patient is euvolemic
What is the most common immunodeficiency and what is the treatment?
Selective IgA deficiency; clinical observation w/ prn antibiotics for the recurrent sinopulmonary infections
T/F: cholestasis in primary sclerosing cholangitis (i.e. conjugated/direct hyperbilirubinemia) is always assoicated with a dominant stricture
False- that may be the answer but there isn’t always one to stent and there is some evidence that cholestasis may be independent of a dominant stricture though that is certainly a possibility
What is the first step in evaluating hyperprolactinemia?
Check a TSH
In whom are pharmacologic vasodilators such as dypyridamole, adenosine, and regadenoson contraindicated in for cardiac stress testing?
Patients with any active wheezing; caution in patients with COPD (w/o wheezing)
What do you do first in suspected Giant Cell Arteritis- steroids or biopsy?
Prednisone 60 mg daily; histopathology is still readable 1-2 weeks after starting steroids
If both TSH and prolactin are high what should you do?
Treat the hypothyroidism first and the prolactin may normalize
How can you treat arthralgias associated with aromatase inhibitor therapy aside from stopping the drug?
NSAIDs and Duloxetine can help
What kinds of behavioral symptoms are seen in CTE (Chronic Traumatic Encephalopathy)?
Depression and disinhibition in a patient w/ hx of multiple concussions and subconcussions
Why is IVIG not useful in selective IgA deficiency?
Because IgA is produced and secreted locally at the GI mucosa so IV formulation not useful; only useful in CVID, X-linked hypogammaglobulinemia, and CLL-associated hypogamma
What is the approach to a patient with history of breast CA who develops arthralgias from aromatase inhibitor therapy?
Can switch to another AI but if the arthralgias continue then can try tamoxifen (Raloxifene also an option but not as effective as tamoxifen but w/ least side effects)
What are two serious clinical outcomes associated with hypophosphatemia?
Respiratory failure secondary to impaired diaphragmatic function and rhabdomyolysis
What is mononeuritis multiplex? What types of conditions is it associated with?
Abnormal findings in the territory of two or more nerves in separate parts of the body; highly specific for vasculitic conditions due to inflammation of vasa nervorum
What do you do if a pregnant patient has acute cholecystitis?
Can safely perform a laparoscopic cholecystectomy esp. if in 2nd trimester
What are the two main types of IUDs?
Levonorgestrel containing (hormone containing) or hormone free (copper); Levonorgestrel containing ones lead to significant diminution of menstrual bleeding
What is Inverse Psoriasis?
Psoriasis that forms predominately at the skin folds
What is oncogenic osteomalacia?
Bone pain w/ hypophosphatemia and low 1,25 hydroxy vitamin D with a normal 25-hydroxyvitamin D; often due to benign mesenchymal tumors from overexpression of FGF-23 which causes decreased phosphate resorption @the tubules and impairs calcitriol synthesis.
How can you differentiate coagulopathy of liver dz from vitamin K deficiency?
Coagulopathy of liver disease will have low factor V (common pathway); Vitamin K def. will have a normal factor V level as it is not a vitamin K dependent factor
What is Acne Keloidalis Nuchae?
Firm, skin colored lesions centered on hair follicles on the back of the neck in black ppl
Where do adrenal insufficient patients typically have discoloration? Why?
Extensor surfaces and buccal mucosa due to increase production of MSH which is made from POMC
What is a cohort study? What is the standard outcome measurement?
Study that investigates the outcomes of similar patients with different exposures; relative risk
What transporter is responsible for refractory hypokalemia due to hypomagnesemia?
ROMK; Mg inhibits K secretion through ROMK; low Mg levels disinhibit this and lead to more K secretion
