PGY-3 Q1

Question 1

What are the indications for urate lowering therapy in gout? What does the ACR guidelines say about this?

Answer 1

1. ) CKD II
2. ) 2+ attacks per year
3. ) One or more tophi
4. ) Uric acid nephrolithiasis

ACR says allopurinol can be escalated to target serum urate<6 if not tophi present or <5 if tophi present. Gradual escalation is okay even in CKD. If intolerant/allergies then use febuxostat.

Question 2

How do you interpret PSA after prostatectomy for prostate cancer and how does that influence management?

Answer 2

PSA > 0.2 right after surgery suggests distant metastasis and warrants androgen deprivation therapy as prostate cancer is initially hormone-dependent for growth.

After 2 years, this is more likely local recurrence and salvage radiotherapy is recommended.

Question 3

First line management of RA?

Answer 3

Nonbiologic DMARD monotherapy first (MTX), then combo therapy reasonable plaquenil-sulfasalazine, then biologics (etanercept) regardless of stage, with rituximab for moderate severe refractory RA

Question 4

What is the illness script for granulomatosis with polyangiitis (GPA), an ANCA-associated vasculitis?

Answer 4

Acute onset, fever, polyarthralgias, nephritic syndrome, and diffuse alveolar hemorrhage with personal/family history of AI phenomena, such as Raynaud’s. Upper airway involvement is classic. Labs reveal elevated inflammatory markers, normal C3/C4, +C-ANCA/ antiproteinase-3 antibodies, kidney biopsy showing pauci-immune glomerulonephritis. Treat with IV steroids and rituximab or cyclophosphamide, and consider plasmapheresis in extreme cases.

Question 5

p-ANCA is associated with?

Answer 5

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss), microscopic polyangiitis, and RPGN.

Question 6

How do you treat ankylosing spondylitis?

Answer 6

First NSAID trial failure of at least 2 different drugs in a month or incomplete response to 2 drugs in 2 months. If failure, then TNFa inhibitor like etanercept, infliximab, or adalimumab.

Question 7

In a young female patient with a single ring-enhancing lesion on brain MRI and neurologic symptoms what is the next step and why?

Answer 7

MRI of the thoracic and lumbar spine in order to establish “dissemination in space” for the diagnosis of MS as the single lesion suggests demyelination

Question 8

What is the management of mitral stenosis in pregnant women?

Answer 8

Regardless of symptoms, pregnancy is a class I indication for intervention (likely valvuloplasty) in severe stenosis, defined as MVA<1.5cm2 or PAP>50 mmHg.

Question 9

What is your illness script for reactive arthritis?

Answer 9

Subacute development of oligoarticular lower extremity dactylitis/spondyloarthritis and rash called keratoderma blennorrhagicum which is a hyperkeratotic nodular rash with brown-yellow vesicles. It can look similar to pustular psoriasis. Typically occurs 3-6 weeks after GI/GU infection. Common culprits are chlamydia, shigella, campylobacter.

Question 10

What are first line treatments to SVT and limitations?

Answer 10

Adenosine, modified Valsalva, carotid massage. Standard valsalva only successful <20%. Modified valsalva involves recumbent position with SLR following valsalva and with OR 3.7 compared to standard. Carotid massage has downsides like dislodging plaque. Hence, contraindications include advanced age, h/o CVA/TIA in past 3 months, or presence of carotid bruit.

Question 11

What are the features, lab testing, and treatment of warm autoimmune hemolytic anemia?

Answer 11

• Hemolysis: LDH, bili, increased retic
• Direct antiglobulin test positive (DAT) aka Coomb’s IgG+
• -> spherocytosis as pieces bitten off after IgG binding and passing through spleen
• Associated with autoimmune or lymphoproliferative disorders
• Treat with prednisone. Rituximab and splenectomy are second line

Question 12

What are the clinical and ECG features of ASD?

Answer 12

Fixed splitting of S2, midsystolic flow murmur and diastolic rumble from increased flow due to L>R shunt, RV heave, RAD, incomplete RBBB

Question 13

How is chronic migraine defined and what are the only two evi-based tx?

Answer 13

15 migraines per month x 3 months. Also notable for increasing mild headache in between episodes. Only 2 EBM tx are topiramate and botulinum.

Question 14

What is the illness script for primary open angle glaucoma?

Answer 14

Gradual PAINLESS loss of bilateral peripheral vision. Exam findings include increased cup:disc ratio, vertical extension of the central cup, disc hemorrhages, increased IOP. Treat with BB eye drops and prostaglandins

Question 15

What is the first dx step in Budd-Chiari?

Answer 15

Check for a JAK2 activating mutation since half of all cases are positive for a mutation.

Question 16

What is and what are the indications for pegloticase?

Answer 16

Synthetic IV uricase for bothersome persistent tophi or recurrent gout flares despite PO urate-lowering therapy. Stop febuxostat.

Question 17

What is the management of varicella exposure in non-immune immunocompromised individuals?

Answer 17

Give varicella immunoglobulin.

Question 18

What is ddx for worsening Cr in a pt with MRSA IE?

Answer 18

Infection-related glomerulonephritis, vancomycin-induced nephropathy, AIN, septic emboli

Question 19

How does toxo present in AIDS? What other things are on the differential?

Answer 19

Usually CD4<100, with FOCAL deficits, +/- fever/seizures, and MULTIPLE ring-enhancing lesions. IgG often positive and since it is re-activation IgM will be negative.

Crypto: depressed mental status rather than FND and no imaging findings, dx confirmed with serum/CSF antigen
CNS lymphoma: usually CD4<50, single lesion, EBV+
PML: multiple lesions, white-matter involvement, typically non-inflammatory

Question 20

What are the features of G6PD deficiency?

Answer 20

X-linked disorder more commonly in men where exposure to oxidative stressors leads to hemolysis. Because BM will retic in hemolytic episodes measuring G6PD levels will be inaccurate since they are concentrated in the retics. Typical triggers include infection, bactrim, nitrofurantoin. Smear shows bite cells.

Question 21

What are the features of hereditary spherocytosis?

Answer 21

Consider in patients with personal or family history of anemia, jaundice, splenomegaly, or gallstones. DAT (Coombs) test is negative. Dx with fragility test in which cells are put in hypotonic saline over 24h and they burst much faster than normal RBCs. Smear shows spherocytes.

Question 22

What alteration to oxygen status can prevent surgical site infections?

Answer 22

Hyperoxia with 80% FiO2 for 2-6 hours post-op

Question 23

What features suggest a central vertigo?

Answer 23

Prolonged vertigo of acute onset, spontaneous nystagmus, ataxia, immediate nystagmus with Dix-Hallpike

Question 24

What are the features of Paget’s disease?

Answer 24

On XR, there are focal areas of overgrowth from accelerated remodeling. Bones look coarsened. Common sites include, skull, long bones, spine, pelvis. It’s a combination of osteoblastic and osteolytic processes. Treat with antiresorptive meds if painful or hypercalcemic. Commonly, elevated alk phos.

Question 25

What is standard postop surveillance for colon cancer?

Answer 25

Exam and CEA every 3-6 months
CT C/A/P every 3-5 years
Colonoscopy 1 year after resection and then every 3-5 years

Question 26

What is the treatment for ILD due to diffuse cutaneous systemic sclerosis?

Answer 26

Cyclophosphamide

Question 27

What is the approach to treating pulmonary arterial hypertension?

Answer 27

Test for vasoreactivity with inhaled NO.
If vasoreactive, start with CCB like nifedipine.
If not, then use phosphodiesterase inhibitors like sildenafil and tadalafil or endothelin receptor antagonists like ambrisentan.

Question 28

What is the differential for a pulmonary-renal syndrome?

Answer 28

Small vessel (ANCA) vasculitis, anti-GBM antibody (Goodpasture) syndrome, cryoglobulinemia vasculitis, IgA vasculitis, SLE.

Question 29

What are the features of anti-GBM antibody syndrome?

Answer 29

Pulmonary-renal syndrome. Anti-GBM antibodies attack type IV collagen leading to DAH and crescentic glomerulonephritis. On IF, linear deposits on the GBM rather than electron dense deposits of other etiologies. Treat with cyclophosphamide, steroids, plasmapheresis.

Question 30

What are the key features and epidemiology of microscopic polyangiitis?

Answer 30

Most common cause of pulmonary-renal syndrome. Other distinguishing features are vasculitic lesions like palpable purpura and ANCA+.

Question 31

Who to consider for screening for Barrett’s esophagus and what follow up is warranted?

Answer 31

Chronic reflux in men older than 50 for more than 5 years and specific risk factors: nocturnal reflux, tobacco use, hiatal hernia, elevated BMI, intra-abdominal fat. If Barrett’s and no dysplasia, screen every 3-5 years. If dysplastic, low-grade should be scoped again in 6-12 months. If high-grade, either scope sooner or ablate endoscopically or esophagectomy.