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PGY-3 Q2 Flashcards

1
Q

How does calciphylaxis presents and what is illness script?

A

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.

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2
Q

What intervention in SBP has a survival benefit?

A

Administration of 25% albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 in pts in three scenarios:

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

When can cervical cancer screening be stopped?

A

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

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4
Q

How do pulmonary Langerhans cell histiocytosis (PLCH) compare to pulmonary lymphangioleiomyomatosis (LAM)?

A

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.

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5
Q

How does subacute cutaneous lupus erythematosus present?

A

Either as annular scaly rash on sun-exposed areas or psoriaform. Can be drug-induced (CCB, HCTZ, terbinafine). ANA and anti-Ro often positive.

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6
Q

When is decompressive surgery indicated in carpal tunnel syndrome?

A

Motor weakness with atrophy on exam and NCS demonstrating denervation.

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7
Q

What treatment can prevent chronic GVHD in patients undergoing alloHSCT?

A

Anti-T-lymphocyte immunoglobulin (ATG)

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8
Q

What are the treatment guidelines for hypertension in acute ischemic stroke?

A

Only if BP > 220/120 or signs of end-organ damage

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9
Q

What is the approach to a constrictive pericarditis?

A

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.

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10
Q

What is the testing approach for Zika?

A

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.

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11
Q

What is first line treatment for early stage SCC of the H&N?

A

Radiation OR surgery alone.

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12
Q

What is the approach to a patient with a prolactinoma during pregnancy?

A

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.

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13
Q

What is the illness script for erythroderma?

A

80-90% BSA erythematous inflammation that is a derm emergency. Occur more in men than women, avg age onset 55.

Etiology:

  1. Psoriasis
  2. Medications
  3. Others–GVHD, CTL, pityriasis rubra
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14
Q

What is the illness script for Lofgren syndrome?

A

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.

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15
Q

What are the features of temporal lobe epilepsy/seizure?

A

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.

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16
Q

When do you give a TDaP for a pregnant woman?

A

27-36 weeks which produces the highest titer load at the right time to allow placental crossing to protect the fetus when birthed.

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17
Q

What is the treatment of fatigue in MS patients?

A

Modafinil

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18
Q

What is the definition and treatment of unexplained chronic cough?

A

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.

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19
Q

What is first line therapy for H.pylori and how does macrolide resistance factor in?

A

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.

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20
Q

What prenatal counseling is necessary in SLE patients?

A

Attempt conception once disease quiescent for 6 months. Note that anti-Ro/La confers 2-5x increased risk (2%) of congenital heart block.

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21
Q

What is the illness script for subarachnoid hemorrhage?

A

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.

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22
Q

What are the distinguishing features of basal cell carcinoma vs squamous cell carcinoma vs melanoma?

A

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.

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23
Q

What is the approach to treating UC?

A

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.

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24
Q

When should you start screening for DM in asymptomatic patients?

A

Age 40-70 or BMI>30

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25
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.
26
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.
27
What are the classic complement deficiencies?
C2-C4 which are associated with rheum.
28
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.
29
When should bariatric surgery for obesity be considered?
BMI 40 or greater. If BMI 35+, should have comorbid condition.
30
What polyp features warrant surveillance in 3 years?
1. Adenoma 10 mm+ 2. 3-10 Adenomas 3. Adenoma with villous component 4. High-grade dysplasia
31
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
32
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
33
What are the indications for lung txp?
1. Hx of AECOPD with acute hypercapnia of pCO2 50+ 2. PHT, cor pulmonale, or both despite oxygen 3. FEV1<20% pred with DLCO<20% pred
34
What lab do you need to monitor for IFNb therapy in MS?
AST due to risk of AIH
35
What screening do patients w/ MS on natalizumab need?
JC virus due to risk of PML.
36
What should you check before starting COCs?
Pregnancy if more than 1 week since period
37
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.
38
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.
39
What is the illness script for trichomoniasis?
Vulvar itching, dyspareunia, pale yellow or grey frothy discharge, and can sometimes have postcoital bleeding (basically vulvovaginitis and urethritis). Diagnosis can be made with high pH and trich on micro but these have low sens/spec. Increasingly NAAT is used. Treat with 2g x 1 of MNZ. Remember to treat partners.
40
When is combination therapy is the initial recommendation for HTN?
When BP is >20/10 goal BP
41
How do you manage cirrhosis at MELD=>15?
15-18 or bili>4 a TIPS would be contraindicated. Refer for txp.
42
Bone-limited or bone-predominant metastatic prostate cancer is treated with?
Radium-223
43
What is the approached to unprovoked DVT/PE?
First assess bleeding risk. If low/moderate treat indefinitely. If high bleeding risk, treat for 3 months. Transient RFs in DVT/PE can be treated short term.
44
What are the immunization recs for HIV patients?
All should get hep B vax if not immune already. Hep A vax if they have additional RF like MSM or another liver disease. Prevnar-13 should be given and pneumovax-23 8 weeks later.
45
What is the treatment and evidence for first line in ALS?
Riluzole has been shown to extend survival by 3 months.
46
Why is clotrimazole used for tinea rather than nystatin?
Nystatin only active against candida.
47
How do you manage supratherapeutic INR?
INR 3-5 then hold warfarin once and reduce maintenance dose. If 5-9 and no bleeding then hold 1-2 doses and recheck INR in 48h. If >9 and no bleeding, give PO vitK. If >9 and bleeding give IV vitK. If catastrophic bleeding then give K-centra.
48
What do you do if fasting plasma glucose is elevated but A1C normal?
Repeat fPG to confirm diagnosis of possible DM
49
What is the illness script for discoid lupus?
Chronic cutaneous lupus, lacking systemic signs. Also has elevated ANA titers. Tx with topical steroids and calcineurin inhibitors first and then hydroxchloroquine.
50
What findings prompt concern for lymphangitic carcinomatosis? What other findings prompt concern for metastatic spread of carcinoma in the lungs in general?
Peripheral interstitial abnormality or solitary nodule in a pt with history of adenocarcinoma (commonly lung, breast, GI tract) as well as hilar lymphadenopathy. Multiple, peripheral, or subpleural nodules can all be signs of mets.
51
What is the illness script for radiation pneumonitis?
About 6 weeks after radiation exposure involving parts of the lung in the radiation field. Typical findings include hazy GGOs. Tend to go away in 6 months, otherwise can develop into into well-demarcated fibrosis with traction bronchiectasis.
52
What is the illness script for BV?
Non-inflammatory condition so no vaginitis symptoms but there is a malodorous discharge that is due to alterations of vaginal flora. The pH is elevated, clue cells are present, and whiff test is positive. Treat with MNZ.
53
What is the illness script for enteric hyperoxaluria?
Pt with history of small bowel resection leading to malabsoportion of free fatty acids. This leads to excess calcium oxalate reabsorption in the colon. This then leads to oxaluria and recurrent nephrolithiasis. Treat with low oxalate diet. If refractory, give bile acid binder like cholestyramine.
54
What is the first step of management in amyloidosis?
Amyloid typing is absolutely necessary because it guides management. AL (light-chain) requires chemo or autoHSCT. AA is secondary and often involves anti-inflammatories and treating underlying condition. Hereditary amyloid is usually supportive and commonly implicated in cardiac amyloid.
55
What are the CURB-65 criteria?
Confusion, urea > 20, RR>30, BP<90/60, or older than 65. 1 or less can be considered for discharge from ED.
56
What is the illness script for multiple system atrophy? Shy-Drager?
Parkinsonian symptoms + cerebellar ataxia + multiple falls from postural instability. Above + autonomic dysfunction.
57
What cancers are patients with dermatomyositis especially at risk for?
Adenocarcinoma of the lung, GI tract, ovary, cervix, bladder. Strongly consider ovarian if ascites present.
58
What is scleroderma renal crisis?
Acute deterioration in renal function with subsequent HTN. It results from scleroderma involvement of afferent arteriole leading to glomerular ischemia. UA is usually bland. Tx with ACEi.
59
What is the arthropathy of hemochromatosis?
2nd and 3rd MCP joint narrowing that mimics OA. Can also involve the knees. Think of hemochromatosis in somebody with arthopathy but abnormal liver labs.
60
What is the role of dexamethasone in working up Cushing's syndrome?
It suppresses ACTH and can localize if it is primary hypercortisolism or secondary cortisolism. If due to ACTH secretion 8 mg test is done. If unresponsive, it is ectopic. If responsive, then its from a microadenoma of the pituitary.
61
What are the three categories of positivity for TB skin tests and what is the next step?
5 mm is positive for immunosuppressed (TNFa inhibitor or prednisone 15 mg + for 30+ days), HIV, organ transplant, recent contact with active TB patient 10 mm for IVDU and recent travelers from endemic areas 15 mm is usual. If no symptoms get a CXR. If no sign of active TB, then INH + B6 for 9 months.
62
Who gets screened for osteoporosis?
65 and up, or 65 and under with FRAX 10-yr osteoporotic fx risk of 9.3%+
63
What is the illness script for babesiosis?
Fatigue, fevers, chills, general malaise with mild hepatitis and hemolytic anemia in a patient with possible Ixodes tick exposure. Incubation can be up to 9 weeks so pt cannot always recall a tick bite. Often seen in northeastern US. Diagnose with PCR and thin smear which shows Maltese cross. Stratify based on severity of labs and symptoms. Asymptomatic patients should be rechecked in 3 months for clearance. Mild cases treat with atovaquone and azithro. More severe cases treat with clinda and quinine.
64
What is the breast cancer screening guideline for women who received chest radiation?
Annual mammogram and MRI
65
When transitioning to warfarin for VTE, what do you do to LMWH?
Keep LMWH for at least 5 days and discontinue after warfarin therapeutic for 24 hours.
66
What are the echo parameters that classify AS? How should asymptomatic patients be treated?
Mild AS: mean grad 0-25 mmHg, AVA>1.5 Moderate AS: mean grad 25-40 mmHg, AVA 1.0-1.5 Severe AS: mean grad >40 mmHg, AVA<1.0 Any depressed EF = severe, decompensated Asymptomatic pts should undergo repeat TTE every 6-12 mo. If EF<50% and meeting severe AS criteria they should undergo SAVR/TAVR.
67
What is seborrheic keratosis?
Brown/dark oval lesions in older adults that are benign but can be confused for melanoma, which should have more irregular borders. They have a waxy or scaly stuck on appearance. Both can be itchy and occasionally bleed. If in doubt, biopsy.
68
What is the definition of preeclampsia? Severe preeclampsia? Treatment?
Preeclampsia = new onset HTN after 20 weeks with proteinuria of (300 mg/24h or p:c of 300mg:g) Severe = severe range BPs (160/110), end-organ damage (liver dysfunction, thrombocytopenia, elevated Cr) Without severe feature, induction of labor at 37 weeks; otherwise induce at 34.
69
How and why does increased breast density affect cancer risk and subsequent screening?
Heterogeneously dense breast impart have 1.2 increased RR while extremely dense breasts have 2.1 increased RR. Increased density is therefore a major risk factor although it does not alter screening guidelines. What it does do is change what modality you use which should be digital mammography because traditional method is less sensitive for small lesions.
70
What is the illness script for acute lymphoblastic leukemia?
S/S of BM failure, splenomegaly. 25% LYMPHOblasts on flow. FISH will show t(9;22) aka Philadelphia chromosome in 25% of most adults but 50% in older adults, which is a poor prognostic sign. Ph+ B-ALL is treated with dexamethasone and dasatinib. Standard regimen is hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone).
71
What is the illness script for basal cell carcinoma and how does it contrast to squamous cell carcinoma?
BCC tends to present as a slow growing pearly papule in sun-exposed area with telangiectasia. SCC has a scaly appearance and grows faster.
72
What is the illness script for atheroembolic showering?
New AKI within 14 days of PCI with inflammatory UA with eosinophiluria and peripheral eosinophilia. Also can have livedo reticularis, scotoma, or blue toe syndrome.
73
How do you approach management of pancreatic mass and obstructive jaundice?
Relieve the jaundice with stent. If imaging shows that it is confined without lymph node involvement, it is resectable. Do not try to go after bx with EUS or perc approach because negative samples do not significantly lower your pretest odds. Do not measure a CA 19-9 which is useless for initial diagnosis. Proceed to surgical resection.
74
In patients with weekly fluctuations in INR but with unchanged diet what can help stabilize dosing?
Supplemental low dose vitamin K
75
What mutation should you test for in NSCLC adenocarcinoma and why?
EGFR mutations because tyrosine kinase inhibitors can be used in treatment (ie erlotinib).
76
What are the Milan criteria?
For HCC if there are 3 lesions they need to be = 3 cm or 1 = 5 cm in order to meet criteria which automatically goes to txp listing. HCC can be dx'ed on triple phase--arterial enhancement and venous washout.
77
What are the vaccine guidelines for COPD?
Annual flu shot, inactivated if 50+. Should get PPSV-23 if between 19-65. PCV-13 at age 65 if PPSV-23 given greater than 1 year ago.
78
What is the treatment for uric acid nephrolithiasis?
Urine alkalization
79
How do you calculate ABI and at what point can you not interpret it?
Posterior tibialis/dorsalis pedis systolic pressure are needed and compared to brachial pressure. ABI>1.40 uninterpretable. Get toe-brachial index.
80
What is the illness script for Waldenstrom's macroglobulinemia?
Night sweats, weight loss, fevers, symptomatic anemia, splenomegaly, and LAD in an older person. Marrow shows at least 10% plasma cell infiltrate. It is essentially a low-grade mature B-cell NHL. Tx with rituximab and chemo.
81
What is the management of mitral stenosis?
No longer in criteria but usually mean gradient over 5-10 mmHg and MV area < 1.5 cm2 indicates severe mitral stenosis. If no MR and pt symptomatic, then percutaneous balloon mitral valvuloplasty is indicated.
82
When do you pull the trigger on treating ITP?
When plt <30-40. Otherwise check in one week because only about 15% will develop severe thrombocytopenia to warrant tx.
83
What is the approach to renal cell carcinoma?
If negative margins on resection and not metastasized, then observation only.
84
How do we stage and treat mycosis fungoides?
Early stage is limited to skin so treat with topical glucocorticoids. Can add retinoids or do psoralen with UV light (PUVA). Advanced stage (sezary, organ involvement) may need photopheresis or external beam therapy or CHOP.
85
What is the approach to stage III breast cancer?
Surgical resection, chemoXRT, then 5 years of anti-estrogen treatment and at least 2 with AI.
86
What is first line treatment in recurrent breast cancer limited to bone mets after a long period of remission?
Anastrazole
87
How do we stage and treat mycosis fungoides?
Early stage is limited to skin so treat with topical glucocorticoids. Can add retinoids or do psoralen with UV light (PUVA). Advanced stage may need photopheresis or external beam therapy or CHOP.
88
What is the management of a thyroid nodule?
Ultrasound and functional studies. If >1cm needs FNA. If 2 benign FNAs can follow clinically.
89
What is the illness script for anti-GBM disease?
AKA Goodpasture's disease, presents rapidly as a pulmonary-renal syndrome. DDx includes small-vessel ANCA vasculitis (microscopic polyangiitis), less likely cryoglobulinemic vasculitis, SLE, or IgA vasculitis. Pathogenesis is antibody to type IV collagen leading to proliferative inflammation at renal and pulmonary basement membranes. Path shows crescentic glomerulonephritis with IF lighting up the GBM. Tx: cyclophosphamide, steroids, daily plasmapheresis to remove anti-GBM.
90
What is the approach to diagnosing neurosyphilis?
First, check for positive RPR and confirmatory anti-treponemal serologic test. Second, obtain CSF and if VDRL positive then tx with IV PCN.
91
What is your approach to hyponatremia?
Ensure that it is true hypo-osmotic hyponatremia by checking serum osm (roughly 2*serum Na). Then check Uosm. If >100 then turn to the urine Na. < 20 is inadequate arterial volume causes. >40 is AI, thyroid, HCTZ, SIADH. Everything in between is ambiguous so try a small fluid challenge.
92
What should be done prior to starting testosterone in hypogonadism?
Determine if pt wants to have children because exogenous testosterone can cause oligospermia.
93
What adjunct is appropriate in GOLD class D patients with recurrent COPD exacerbations?
Romiflulast which reduces inflammation and has a very small effect on FEV1 although it is not a bronchodilator.
94
Refractory vitamin D deficiency should prompt what other work up?
Celiac disease which may be mild
95
What is DISH?
Diffuse idiopathic skeletal hyperostotis is a noninflammatory condition defined by anterolateral thoracic vertebral osteophytes without loss of intervertebral spaces in 4 contiguous vertebrae.
96
What is age-corrected D-dimer formula
D-dimer threshold = 0.01 x age

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