All subjects Flashcards
The most appropriate treatment of medication-related tardive dyskinesia
discontinuation of the causative dopamine blocker agent.
Patient being evaluated for primary hyperparathyroidism in context of hypercalcemia. What is the first non-invasive intervention that should be attempted initially?
Measure Vit D and Vit D repletion if needed.
* There is a high prevalence of concurrent vitamin D deficiency in patients with primary hyperparathyroidism, and low levels of 25-hydroxyvitamin D can stimulate parathyroid hormone secretion in non-adenomatous glands.*
Patient with stiffness and pain in proximal interphalangeal and metacarpophalangeal joints of the fingers, the wrists, and the analogous joints of the feet. She has morning stiffness for over 1 hour in the mornings. Dx?
RA
NSTEMI with stent placement. What is goal-directed medical therapy for this. Normal echo after stent placement.
aspirin, a β-blocker, an ACE inhibitor, and a statin; a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) should be continued for at least 1 year for patients undergoing coronary percutaneous intervention with stent placement.
30yoF presenting with chronic dyspnea and cough. On CT you see diffuse, thin-walled cysts. Dx?
Lymphangioleiomyomatosis is a rare cystic lung disease that occurs sporadically in women of childbearing age or in association with tuberous sclerosis; characteristic findings include diffuse, thin-walled, small cysts on CT.
What kind of labs are seen in exercise-induced hemolysis?
-Hemoglobinuria
-UA shows blood, but no erythrocytes
-May lead to iron -def anemia
(intravascular hemolysis caused by repetitive mechanical trauma like running or marching)
Hallmarks of interstitial nephritis?
Sterile pyuria
Leukocyte casts
(also can see mild subnephrotic proteinuria)
Which EKG abnormality in a patient undergoing a nuclear stress test would make you want to do a chemical rather than an exercise stress test?
Left bundle branch block
could lead to false positive dueto septal perfusion abnormality which can occur in exercise
Which antiepileptic med most likely to cause hyponatremia?
Oxcarbazepine is associated with hyponatremia in 20% to 30% of the patients who take it; although symptoms are generally mild and not clinically significant, severe hyponatremia occurs in 8% to 12% of these patients.
What constitutes a low risk peptic ulcer?
How do you treat it once its found?
Low-risk gastric ulcers are clean-based or have a nonprotuberant pigmented spot; they should be treated with oral proton pump inhibitor therapy, initiation of refeeding within 24 hours, and early hospital discharge.
How does tx for occlusive crisis in sickle cell differ from pregnant to non-pregnant patients?
It does NOT differ
Before replacing calcium, what do you need to replace first?
magnesium
In patients with lung, breast, and GI adenocarcinoma, which complication should you be concerned about if you see new interstitial thickening in the lungs on CT?
Lymphangitic spread og the tumor
Most appropriate management for fatty liver disease?
weight loss?
Which medicine interacts poorly with febuxostat?
Azathioprine
concomitant use of these agents can lead to dangerously high levels of azathioprine.
Patient has whipple procedure for pancreatic cancer. 1 year later foudn to have liver mets. What’s the plan now?
Multiagent systemic chemo
5FU, leucovorin, irinotecan, oxaliplatin
What are the risk factors for a potential DRSP (Drug Resistant Strep Pneumo) pneumonia?
Age >65
Immunosuppression
Alcoholism
Comorbidities: COPD, DM, cancer, CHF, asplenia
Abx in last 3-6 months (fluroquinolone, macrolide, b-lactam)
If patient presents with strep pneumo bacteria after taking beta-lactam for cellultiis 2 months ago, what should you treat her with?
Treatment with respiratory fluoroquinolone (moxifloxacin)
Patient presents with fatigue, joint pain, abdominal pain, petechial/purpural skin lesions, and glomerulonephritis following an upper respiratory tract infection.
Likely dx?
IgA Vasculitis
AKA Henoch Schonlein Purpura
Patient with CKD, hyperparathyroidism. Normal serum levels of Ca, Vit D, and phosphorous. What should be your next step in treating this patient?
Patient with 2ndary hyperparathyroidism from CKD. First step is normalize Ca, Phosphorous, and Vit D. If those are normal then the next step is a Vit D analogue, like Calcitriol.
Calcitriol directly suppresses PTH production by the parathyroid glands, thereby protecting bones from osteitis fibrosa cystica, which can occur as a result of chronic secondary hyperparathyroidism.
Sterile pyuria and leukocyte casts
Interstitial Nephritis
Most common causes of interstitial nephritis
Interstitial nephritis may be associated with autoimmune diseases and infections but is most commonly caused by drugs.
FDA approved medciation tx for bipolar disorder?
Quetiapine or combined Olanzapine-Fluoxetine
NExt step in treatmnet after a stage II or III resection of NSCLC?
Cisplatin based chemo
Patient with marfan syndrome foudn to have aortic root dilation. When should you next screen and if normal how frequent should screening be following that?
In patients with Marfan syndrome and aortic root dilation, surveillance imaging should be performed 6 months after diagnosis and annually thereafter if the aortic size remains stable.
Most important lab test when you are considering TTP dx?
Thrombotic thrombocytopenic purpura is a clinical diagnosis that requires the presence of thrombocytopenia and microangiopathic hemolytic anemia, which is confirmed by schistocytes on the peripheral blood smear.
Under what circumstances would a capsule endoscopy be first line for dx of Gi bleeding?
Capsule endoscopy has become the first-line test in evaluating the small bowel in patients with obscure gastrointestinal bleeding after a negative upper endoscopy and colonoscopy.
Obscure gastrointestinal bleeding refers to recurrent or persistent bleeding
In what circumstances would a technetium scan or angiography be appropriate for diagnosing a GI bleed?
Angiography and technetium-labeled nuclear scans are used in patients with active bleeding (melena or hematochezia) who are transfusion dependent and hospitalized.
Man with AIDS, now found to have positive blood cx for Mycobacterium Avium Complex. What is next step in treatment?
Treatment with clarithromycin, ethambutol, and rifabutin is recommended for disseminated Mycobacterium avium complex infection in patients with HIV/AIDS whose CD4 cell counts are less than 50/µL
A 68-year-old woman is evaluated 1 month after having an ischemic stroke of the left thalamus. She now has only residual right-sided anesthesia. The patient has hypertension and dyslipidemia, both well controlled by medication, and had been taking a daily aspirin before the stroke. Medications are lisinopril, chlorthalidone, aspirin, and rosuvastatin.
What treatment is most appropriate at this time?
Dipyridamole should be added to this patient’s medication regimen. She had a small subcortical infarction despite taking daily aspirin before the stroke. The combination of aspirin and dipyridamole has been shown to be superior to aspirin alone in reducing the risk of recurrent stroke.
What therapy for Crohn’s Disease is considered safe in pregnancy?
TNF-inhibitors
Patient found to have <12mm unruptured aneurysm. What are the next steps in treatment?
Patients with unruptured intracranial aneurysms should be counseled to stop smoking because of the increased risk of aneurysmal rupture. Also keep their blood pressure under control.
Patient with symptomatic PVC’s, beta blocker therapy not fixing it. Echo now showing signs of heart failure. NExt step in treatment?
Cardiac ablation therapy
Mainstay of treatment for ARDS?
The mainstay of management for acute respiratory distress syndrome is a lung-protective ventilator strategy, with low tidal volume (6 mL/kg of ideal body weight) and low plateau pressure (<30 cm H2O), even if this results in hypercapnia.
What should be the tidal volume for a patient with ards?
What should the plateau pressure be?
Tidal volume: 6ml/kg (ideal body weight)
Plateau pressure: <30 cm H2O
Patient with multiple myeloma and 3 months of back pain. XR negative for lytic lesions. Next step to manage?
Get a CT or MRI to eval for lytic lesions
Patient presenting for concern for acute leukoemia, in particular APL.
A peripheral blood smear shows 80% immature blasts with prominent Auer rods phenotypically consistent with promyelocytes.
Next steps???
Immediate next step is to start ATRA (all-trans-retonic acid), DO NOT wait for confirmation testing.
Immediate administration of all-trans retinoic acid is important in preventing early mortality in suspected acute promyelocytic leukemia.
What causes infertility in cystic fibrosis?
Loss of vas deferens in males
Dietary Restrictions in hemochromatosis?
Why?
Avoid raw and undercooked seafood
Vibrio vulnificus infection is associated with ingestion of raw seafood, especially oysters, and the risk of sepsis and death is increased in persons with hereditary hemochromatosis.
Muscle cramps 2/2 corticospinal tract damage from ultiple sclerosis. How to treat?
Baclofen
48yoF w/ migraines not controlled by NSAIDS. An MRI of the brain shows several punctate hyperintensities in the bilateral subcortical white matter.
Next steps?
Just treat migraine with triptans
White matter signal abnormalities are typically seen on MRIs of patients with migraine, particularly in the posterior circulation and particularly in women; these lesions are benign and unrelated to neurologic examination abnormalities or cognitive anomalies
When should you treat someone with essential thrombocytosis?
PLT > 1,000,000
Age > 60yo
Hx of thrombosis
If it is decided to treat someone with essential thrombocytosis, how should you treat it?
Low-dose aspirin and hydroxyurea
What are the key features of patellofemoral pain syndrome?
Patellofemoral pain syndrome is characterized by anterior knee pain that is slow in onset and typically made worse with running, climbing stairs, and prolonged sitting.
Exam: Pain is reproduced by applying direct pressure to the left patella
Patient with diffuse lymphadenopathy. LN biopsy showing DC20+ and cyclin D1 overexpression.
Dx?
Prognosis?
Mantle cell lymphoma is a rare form of non-Hodgkin lymphoma characterized by extranodal involvement and overexpression of cyclin D1, and it is associated with a poor prognosis.
What is the general presentation for a patient with bilateral adrenal hemorrhage?
Patients with bilateral adrenal hemorrhage typically present with clinical features of acute cortisol and aldosterone deficiency, including gastrointestinal disturbance, lethargy, weakness, hypotension, shock, hypoglycemia, and electrolyte imbalances, such as hyponatremia and hyperkalemia.
Risk factors for adrenal hemorrhage?
Risk factors for adrenal hemorrhage include anticoagulant therapy (and may occur with treatment levels within the therapeutic range), the postoperative state, abnormalities of hemostasis (such as heparin-induced thrombocytopenia or antiphospholipid antibody syndrome), and sepsis.
Patient really needs NSAIDs for back pain, but had an ulcer in the past. Tx plan?
Celecoxib and omeprazole BID
MS drug which is contraindicated in acute kidney failure?
Dalfampridine
Patient with post-inflammatory pigmentation from facial acne. Standard of care treatment?
topical retinoid
Patient with low output heart failure has been diuresed for a while now, now appears to have normal filling pressure on right heart cath. Heart failure signs and sx still present. NExt step?
Nitroprusside
In patients with low-output heart failure, nitroprusside can reduce afterload and increase cardiac output; nitroprusside should be used only in the setting of invasive cardiac monitoring.
All SLE patients who can tolerate it should be taking…..?
Hydroxychloroquine
You suspect ethylene glycol toxicity in a patient what are the mainstays of treatment? List 4
1) Fomepizole
2) IV hydration
3) Hemodialysis to clear alcohol and toxic metabolites
4) If pH < 7.3, give IV Na-bicarb
WOman with roux en y gastric bypass. Now has sx of chronic nonbloody diarrhea since her bariatric surgery. She also has had generalized fatigue, dry skin, dry and itchy eyes, and increased difficulty seeing road signs at night while driving. What is the vitamin deficiency?
Vit A deficiency
fat soluble vitamin
What results from factora 8 deficiency?
Hemophilia A
Viral infection common to first few months after kidney transplant?
Cytomegalovirus is a common complication of transplantation, especially in the first few months after transplantation when immunosuppression is typically highest, and patients who have just finished prophylaxis against cytomegalovirus are at risk for reactivation.
Explain platypnea-orthodeoxia syndrome:
positional symptoms of cyanosis and dyspnea that generally occur when the patient is sitting and resolve in the supine position. Right-to-left shunting across an atrial septal defect or patent foramen ovale may rarely cause cyanosis and dyspnea owing to deformation of the atrial septum and redirection of shunt flow that result from increased right atrial pressure in the upright position.
How might a myocardial infarction subsequently cause platypnea-orthodeoxia syndrome?
Inferior and right ventricular myocardial infarction can cause associated right heart enlargement and dysfunction. The right heart enlargement causes annular dilatation and tricuspid regurgitation. The foramen ovale stretches and becomes patent.
The preferential cyanosis is caused by the hemodynamic alterations and preferential transfer of right atrial blood across the patent foramen in the upright position
How to treat overcorrection of sodium in patient with chronic hyponatremia?
Desmopressin (to halt corrective diuresis)
5% Dextrose (to lower Na a little)
Standard testing eval for patient with encephalitis?
Brain MRI, EEG, LP
Signs and sx of encephalitis?
obtundation, fever, elevated cerebrospinal fluid [CSF] leukocyte count
What are the risk factors for sudden cardiac death which would cause you to send a patient for an implanted cardioverter-defibrillator?
Any run of non-sustained Vtach on EKG Fam Hx of sudden cardiac death Cardiac wall thickness >30mm Previous cardiac arrest due to ventricular arrythmia Hypotension in exercise Unexplained syncope
Triad of gait abnormalities, cognitive impairment, and urinary disturbance, especially when neuroimaging studies show enlarged ventricles out of proportion to cortical atrophy.
Dx and treatment?
Large-volume lumbar puncture should be performed before placement of a ventriculoperitoneal shunt in patients with normal pressure hydrocephalus.
Wart-like growths on penis. Name?
Condylomata acuminata
Patient on warfarin with supratherpetuic INR. No active bleeding. What is the INR threshold that will cause you to give Vit K?
INR > 9
In patients with breast cancer who develop findings suspicious for mets, what is the next steps? Why?
Patients with a history of early breast cancer who develop findings suspicious for metastatic breast cancer should undergo biopsy of one of the suspected metastatic sites to confirm the diagnosis and to assess hormone receptor and HER2 status, as these may differ from the original cancer.
Patient with pheochromocytoma. Other diagnoses most likely to develop as well?
Medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism occur in patients with multiple endocrine neoplasia type 2A (MEN2A).
Patient recently diagnosed with metastatic gastric cancer. Before selecting a systemic chemotherapy regimen, which genetic test run on the tumor biopsy specimen would be most helpful for choosing a regimen?
Determination of HER2 tumor status is indicated for patients with newly diagnosed metastatic gastric cancer, as the anti-HER2 monoclonal antibody trastuzumab, when added to a systemic chemotherapy regimen, is beneficial in treating patients whose tumors overexpress HER2.
Which meds to use in HCM?
Negative inotropic agents, such as β-receptor antagonists, calcium channel blockers, and disopyramide, are the cornerstone of medical therapy in these patients.
Which BP meds to avoid in HCM?
Lisinopril and Thiazides
treatment for patient with prolactinoma?
Cabergoline - a dopamine agonist
First step in tx of patient with new cord compression from newly discovered multiple myeloma?
High dose IV steroids
Later consider radiation or Neurosurgery
Diagnose inclusion body myositis:
Inclusion body myositis has an insidious onset, with muscle weakness that may be diffuse and involve both the distal and proximal muscles. Skin spared.
Diagnose Amyotrophic Lateral Sclerosis:
Amyotrophic lateral sclerosis is characterized by progressive dysfunction of both upper motoneuron and lower motoneuron pathways in one or more areas of the body. Common upper motoneuron features are spasticity, hyperreflexia, and pathologic reflexes, including extensor plantar responses. Typical lower motoneuron features are muscle weakness, atrophy, fasciculations, and cramps. These findings are not present in the patient.
Basics of diagnosing Paroxysmal Nocturnal Hemoglobinuria
Findings diagnostic of paroxysmal nocturnal hemoglobinuria include hemolytic anemia, hypocellular bone marrow, and lack of CD55 and CD59.
What testing should be done to identify chronic thromboembolic pulmonary hypertension (CTEPH)?
VQ scan
How to treat AIN?
Stop offending agent (if drug related)
MOnitor creatininine
Steroids controversial, only use if patient is not responding
Topical steroid that can be used on skin thin, like eyelids?
hydrocortisone valerate
which supplement is vitally important in management of Multiple Sclerosis?
Vitamin D
How to treat inpatient with PID?
Cefoxitin and IV Doxycycline
OUtside the hospital, use IV dose of ceftriaxone and then 14-day course of doxycycline
Diet lifestyle changes to reduce gout flares
- Low-fat dairy products have been shown to decrease the risk of gout flares both through uricosuric and anti-inflammatory properties.
- reduce intake of high-fructose beverages such as soft drinks because they are associated with gout flares due to metabolic pathways utilized in the metabolism of fructose, which lead to increased uric acid generation.
- Obesity is also a risk factor for gout
How to best manage hypothyroidism in pregnancy?
- Maternal thyroid hormone production typically increases by 30% to 50% during pregnancy
- The replacement dose usually needs to be increased to provide adequate thyroxine (T4) for the neurologic development of the fetus
What are the COPD Gold ABCD categorized?
Group A: 0-1 exacerbations in 1 year. mMRC 0-1. CAT < 10.
Group B: 0-1 exac in 1 year. mMRC 2 or +, CAT 10 or +.
Group C: 2+ exac in 1 year. mMRC 0-1, CAT <10.
Group D: 2+ exac in 1 year. mMRC 2 or +, CAT 10 or +.
Therapy for A, B, C, and D Gold categories of COPD?
Group A: short acting inhaled bronchodilator PRN
Group B: short-acting inhaled bronchodilator PRN and a long-acting bronchodilator
(Alternative: Combination LAMA/LABA)
Group C: Inhaled glucocorticoid plus a LABA or monotherapy with a LAMA.
(Alternative: LAMA plus inhaled glucocorticoid or LABA, or a phosphodiesterase-4 inhibitor and a long-acting bronchodilator)
Group D: short-acting bronchodilator as needed and inhaled glucocorticoid and a LABA and/or a LAMA, and pulmonary rehabilitation.
(Alternative triple combinations of two long-acting bronchodilators and an inhaled glucocorticoid; an inhaled glucocorticoid plus a LABA and PDE-4 inhibitor; or double combinations of two long-acting bronchodilators, or a LAMA and PDE-4 inhibitor)
Features of small cell lung cancer?
- Typically presents on imaging as a large hilar mass with bulky mediastinal lymphadenopathy.
- Signs and symptoms of cough, hemoptysis, chest pain, hoarseness, and dyspnea
- May present with various paraneoplastic syndromes
- Because of their rapid growth rate, these tumors are rarely found incidentally
- SCLC tends to be more aggressive than non–small cell lung cancer (NSCLC); it is usually already disseminated at presentation but is usually more sensitive to chemotherapy and radiation therapy initially. Often chemo started during initial hospitalization
The triad of hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit in a patient with systemic lupus erythematosus. Dx?
The triad of hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit is highly predictive of underlying diffuse alveolar hemorrhage associated with systemic lupus erythematosus.
Patient has with foot rash:
presents as a pruritic serpiginous, red plaque that migrates at a rate of a few millimeters to centimeters per day
Dx?
Tx?
Dx: Cutaneous Larva Migrans
Tx: Ivermectin or Albendazole
Explain the stratgey for treatment of Burkitt Lymphoma?
Patients with Burkitt lymphoma always warrant aggressive and immediate therapy with combination chemotherapy (R-hyper-CVAD) and aggressive intravenous hydration, urine alkalinization, and administration of allopurinol or rasburicase.
R-Hyper-CVAD is Rutuximab, hyperfractionated Cyclophosphamide, Vincristine, Doxorubicin (anthra), and Dexamethasone
