PGY-2 Spring

Question 1

How do you diagnose and confirm Zika? What’s the caveat?

Answer 1

IgM, which can be positive for 4 months or more. Confirm with PCR. IgG positivity is cross reactive with other flaviviruses (like dengue), so caution with interpretation.

Question 2

How do you diagnose gestational HTN? When is treatment warranted and the goal?

Answer 2

Persistent HTN after 20 weeks without preceding HTN and lasting no longer than 12 weeks after delivery. Additionally no proteinuria. Treat at 160/105 to no lower than 120/80.

Question 3

When do you refer IPF patients for transplant? What about medical therapies?

Answer 3

If they are high risk for respiratory failure and likely have high survival with txp. This includes patients on supplemental O2 but with progressive worsening of PFTs. Medical therapies are very limited. Since IPF is fibrosis without inflammation, steroids not shown to help. TK inhibitors have been approved but do not affect QOL.

Question 4

What is considered high intensity statin?

Answer 4

Atorva 40, rosuva 20, simva 80 (but this increases CK)

Question 5

When should LE DVT anticoagulation be withheld?

Answer 5

Low risk DVT (no cancer or previous DVT) below the knee without proximal extension.

Question 6

Next step in mgmt after dx of pheo?

Answer 6

Institute alpha blockade (phenoxybenzamine, prazosin, doxazosin). Alpha blockade for at least 1-2 weeks prior to surgery is necessary.

Question 7

What is second line treatment for gout control? What is the major contraindication and why?

Answer 7

Febuxostat is a XO inhibitor that can be used if allopurinol doesn’t work. Azathioprine is a hard contraindication because it’s a purine analogue degraded by XO and hence, can accumulate.

Question 8

What is the approach for acute pyelonephritis?

Answer 8

First, can they be treated as an outpatient (tolerating PO, hemodynamically stable, likely good adherence)? Secondly, is the local fluoroquinolone resistance > 10%? If so, treat first with one time IV CTX. If not, no need to pre-treat, proceed with fluoroquinolone (cipro 1g x 7 days or levo 750 mg x 5 days).

Question 9

What is the approach to dysphagia?

Answer 9

Where is it? Oropharyngeal or esophageal? If oropharyngeal modified barium swallow (aka videofluoroscopy) is the best initial test. If esophageal, then upper endoscopy to detect intraluminal structural defects. If ruled out, then barium swallow and/or manometry.

Question 10

What is porphyria cutanea tarda?

Answer 10

Presents as skin fragility with small transient blisters in sun-exposed areas. It is associated with liver disease.

Question 11

What is a major side-effect of oxcarbazapine and how often does it occur?

Answer 11

~20% develop hyponatremia that is mild but a small percent of these patients have severe hyponatremia. It often improves with dose reduction and free water restriction.

Question 12

What are the indications for albumin in SBP?

Answer 12

1. Cr > 1.0
2. T.bili > 4
3. BUN > 30

Give 1.5 g/kg of 25% on day 1, then 1 g/kg on day 3.

Question 13

What are the key facts about small cell lung carcinoma? How does it contrast to NSCLC?

Answer 13

15% of all lung cancers, exclusively smokers. Most commonly presents with hoarseness, dyspnea, chest pain, hemoptysis with a CXR showing hilar mass and bulky lymphadenopathy. Tends to be very aggressive but chemo-responsive. Can also present with Lambert-Eaton syndrome and thus increasing weakness with use.

In contrast, 80% of all lung cancers are NSCLC with about half of them being adenocarcinoma and a quarter of them squamous cell.