PGY-3 Q2 Flashcards
How does calciphylaxis presents and what is illness script?
A single necrotic black eschar with surrounding angulated purpura in a patient with CKD/ESRD and elevated Ca-phosphate product. Pathogenesis is intra-arteriole deposition of Ca-phosphate leading to ischemia and painful tissue necrosis. Tx with HD, non-Ca phosphate binders, na thiosfulfate, bisphosphonates, PTH-ectomy.
What intervention in SBP has a survival benefit?
Administration of 25% albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 in pts in three scenarios:
- Cr>1.0
- T.bili > 4
- BUN>30
When can cervical cancer screening be stopped?
At age 65 if 3 consecutive Pap smears are negative or 2 consecutive negative Pap smears with HPV in last 10 years, most recent one at least in past 5 years
How do pulmonary Langerhans cell histiocytosis (PLCH) compare to pulmonary lymphangioleiomyomatosis (LAM)?
Both are cystic pulmonary diseases that can have an indolent course before diagnosis or marked by spontaneous pneumothoraces. PLCH tends to have thick walled cysts with interstitial thickening and nodularity whereas LAM have thin walled cysts scattered through the parenchyma. PLCH tends to be in young smokers while LAM are in young women of child-bearing age.
How does subacute cutaneous lupus erythematosus present?
Either as annular scaly rash on sun-exposed areas or psoriaform. Can be drug-induced (CCB, HCTZ, terbinafine). ANA and anti-Ro often positive.
When is decompressive surgery indicated in carpal tunnel syndrome?
Motor weakness with atrophy on exam and NCS demonstrating denervation.
What treatment can prevent chronic GVHD in patients undergoing alloHSCT?
Anti-T-lymphocyte immunoglobulin (ATG)
What are the treatment guidelines for hypertension in acute ischemic stroke?
Only if BP > 220/120 or signs of end-organ damage
What is the approach to a constrictive pericarditis?
Need to decide if it is transient or not. The vast majority are not transient. Those that are more likely idiopathic, viral, or postsurgical. Tx is a 2-3 month trial of high dose NSAIDs.
What is the testing approach for Zika?
Before 2 weeks, use RNA PCR of serum and urine.
After 2 weeks, a two step process. First, IgM. It can be positive for other flavi tropical viruses like Dengue, so second confirmatory step needed.
What is first line treatment for early stage SCC of the H&N?
Radiation OR surgery alone.
What is the approach to a patient with a prolactinoma during pregnancy?
Risk stratification needs to occur because high estrogen can cause increase in size. Microadenomas (<10 mm) are less likely than macroadenomas (>10 mm) to experience large size increases. Hence, macroadenoma patients are screened every trimester with visual field testing. MRIs are not used because unnecessary, while PRL levels do not change management as we know they are high.
What is the illness script for erythroderma?
80-90% BSA erythematous inflammation that is a derm emergency. Occur more in men than women, avg age onset 55.
Etiology:
- Psoriasis
- Medications
- Others–GVHD, CTL, pityriasis rubra
What is the illness script for Lofgren syndrome?
A form of sarcoidosis that spontaneously remits. Classic triad of nondestructive periarthritis (enthestitis, tenosynovitis), bilateral hilar adenopathy, and erythema nodosum. Classically involves ankles bilaterally, but knees and elbows can be involved. The triad is 95% specific. If diagnosed, you can use NSAIDS (or colchicine or low-dose steroids) since most remit within 12 months, not requiring high-dose steroids.
What are the features of temporal lobe epilepsy/seizure?
Rising epigastric feeling/discomfort aura accompanied by intense anxiety/fear lasting a few seconds to minute. Then development of brief confusion and stereotyped motions. Often confused for panic disorder.
When do you give a TDaP for a pregnant woman?
27-36 weeks which produces the highest titer load at the right time to allow placental crossing to protect the fetus when birthed.
What is the treatment of fatigue in MS patients?
Modafinil
What is the definition and treatment of unexplained chronic cough?
8 weeks of a chronic cough despite adequate medical work up and trial of medications. Treatment based on 2016 ACCP guidelines says try a 6 month trial of gabapentin with speech therapy. Start at 300 mg and titrate to 900 mg BID.
What is first line therapy for H.pylori and how does macrolide resistance factor in?
Triple therapy with amoxicillin, clarithromycin, and PPI is first line. Quadruple therapy where MNZ and bismuth replace clarithro is indicated when macrolide resistance is high. Think patients coming from areas where resistance is endemic due to availability of OTC azithromycin.
What prenatal counseling is necessary in SLE patients?
Attempt conception once disease quiescent for 6 months. Note that anti-Ro/La confers 2-5x increased risk (2%) of congenital heart block.
What is the illness script for subarachnoid hemorrhage?
Sudden-onset thunderclap headache. CTh rules out SAH in the first 6 hours, after which LP needed to detect xanthochromia as by that point CSF dilutes the blood leading to FPs.
What are the distinguishing features of basal cell carcinoma vs squamous cell carcinoma vs melanoma?
BCC is the most common and has a translucent, pearly appearance. SCC has a hyperkeratotic pink nodular appearance and can be crusty. Melanomas tend to be dark black/brown plaques.
What is the approach to treating UC?
Try mesalamine and 5-ASA for mild-moderate disease. As severity picks up start on steroids. Wean down and switch to immunosuppressants like 6-MP and azathioprine. Strongly consider infliximab which has strong RCT evidence. Key though is to check thiopurine methyltransferase which inactivates byproducts of 6-MP and azathioprine. If low, then high risk of toxicity.
When should you start screening for DM in asymptomatic patients?
Age 40-70 or BMI>30
How are colon cancer patients surveillanced after treatment?
Depends on the stage. Those that were limited to the colon undergo more frequent colonoscopy. Advanced stage gets CEA annually and CT A/P for 5 years with physical every 3-6 months. They get colonoscopy at 12 months.
What are the key facts of late complement deficiency?
Late complement deficiency includes C5-C9 which confer bactericidal activity. Patients are at risk for recurrent meningococcal and gonococcal infections. Among patients with a recurrent infection the risk of having a late complement deficiency increases by 30%. Among those with a diagnosis, 60% have a recurrent meningococcal infection and 45% have a recurrent gonococcal infection.
What are the classic complement deficiencies?
C2-C4 which are associated with rheum.
What is the illness script for polyarteritis nodosum?
Most common medium-sized vasculitis and tends to affect renal and mesenteric arteries. It presents with fever, abdominal pain (chronic or acute mesenteric ischemic pain), weight loss, neurologic findings that do no localize (mononeuritis multiplex), and skin findings (purpura, livedo reticularis, painful subQ nodules). It is associated with HBV infection. When kidney’s are involved urine sediment is benign and biopsy would show arterial involvement.
When should bariatric surgery for obesity be considered?
BMI 40 or greater. If BMI 35+, should have comorbid condition.
What polyp features warrant surveillance in 3 years?
- Adenoma 10 mm+
- 3-10 Adenomas
- Adenoma with villous component
- High-grade dysplasia
What are the two types of pharm stress test and their contraindications?
Vasodilators: regadenason, dipyramidole, and adenosine. Contraindicated in bronchospasm and hypotension.
Inotropic: Dobutamine. Contraindicated in people with history of VT
How do Chikungunya and Dengue compare in presentation?
Both present with high-fevers after travel to areas with mosquitoes. Dengue is marked by retro-orbital pain, headache, maculopapular rash, severe back pain, and myalgias. It can also have lymphomcytosis with thrombocytopenia. Chikungunya has a less severe thrombocytopenia and more likely to have arthritis
What are the indications for lung txp?
- Hx of AECOPD with acute hypercapnia of pCO2 50+
- PHT, cor pulmonale, or both despite oxygen
- FEV1<20% pred with DLCO<20% pred
What lab do you need to monitor for IFNb therapy in MS?
AST due to risk of AIH
What screening do patients w/ MS on natalizumab need?
JC virus due to risk of PML.
What should you check before starting COCs?
Pregnancy if more than 1 week since period
Aside from IDA, what is on the differential for microcytic anemia?
Thalassemias, which are differentiated by hgb electrophoresis. a-thal has normal EP. B-thal has slightly increased HbA2. RDW tends to be normal in thal.
What is the approach to adrenal incidentaloma?
Check for pheo and Cushing’s with plasma metanephrines and dexamethasone suppression. The reason this is standard even when symptoms not present is that 10-15% are clinically present. If HTN present, then primary hyperaldo should also be checked.
