MKSAP Flashcards
(107 cards)
1
Q
What is the most likely diagnosis upon finding of a positive FABER test (hip Flexion, ABduction, External Rotation)?
A
Sacroiliitis (spondyloarrhropathies or isolated MSK condition)
2
Q
What’s the most likely diagnosis for anterior hip pain, often localized to the groin with positive FADIR (Flexion, ADduction, and Internal Rotation)?
A
Acetabular labrum tear. Common in young athletes.
3
Q
What are the 2 best treatment options for tobacco addiction on inpatient (including with acute coronary syndromes)?
A
Varenicline
Or
Combined long (patch) and short (gums/inhaler) acting nicotine.
4
Q
What’s the 2 best 2nd line treatments for DM after metformin in patients with high ASCVD risk (obesity, hypertension, HLD)?
A
GLP1 (glutides)
Or
SGLT2 (flozins)
5
Q
What endocrine dysfunction can be caused by chronic opioid use?
A
Inhibition of GnRH, leading to decreased FSH, LH, Testosterone and INCREASED PROLACTIN levels, with unremarkable MRI. Treatment is Testosterone replenishment.
6
Q
What classes of drugs should be used for type 2 DM with ASCVD risks or kidney disease?
A
SGLT2
Or
GLP1
7
Q
Which medications should be prescribed to any patient after an Acute Coronary Syndrome without stent placement?
A
DAPT (aspirin + clopi/ticag) for 1 year
ACE-I or ARB
BetaBlocker.
If diabetic, include SGLT2 or GLP1
8
Q
In a patient with hypothyroidism and hyperprolactinemia, what should we do?
A
Always treat hypothyroidism first. It can cause high TRH that will increase prolactin levels. After treating the thyroid recheck prolactin levels. If still elevated perform MRI.
9
Q
What’s the treatment for Pure Red Cell Aplasia (ex. Due to parvovirus)?
A
IVIG
10
Q
What type of anemia could benefit from Steroid treatment?
A
Hemolytic anemia
11
Q
Where is the appropriate location for a patient with thyroid storm?
A
ICU
12
Q
How to treat thyroid storm in order of most important meds?
1
2
3
4
A
1- IV Beta blockers (esmolol)
2- Propylthiouracil (then we later transition to methimazole when stable)
3- IV high dose glucocorticoids (inhibit conversion to T3 from T4)
4- Potassium iodide (can only be given 1 h after PTU, to avoid thyroid uptake of iodine and worsening condition)
13
Q
Does anticoagulant or antiplatelet therapy change the management of hematuria?
What’s the normal workup?
A
No.
1- Rule out vigorous exercise, vira illness, menstruation…
2- if inciting factor is stopped, repeat UA after resolution.
3- if no factors (AC is not a factor), proceed with US bladder kidney and ureters.
4- if US negative, proceed with CT non Contrast (look for stones).
5- if imaging negative, proceed with cystoscopy.
14
Q
Is urine cytology a good test?
A
No. It has a very low sensitivity, so it’s usually not recommended
15
Q
Stage 0-2 breast cancer.
What are the imaging exams necessary?
A
None.
Other than US and mammogram with core biopsy, no need to look for mets since very low chances of having them, unless symptoms are present elsewhere or labs show elevated alk phos.
16
Q
What characterizes stage 3 cancer?
A
Presence of metastasis to local lymphnodes.
17
Q
What lab test is of upmost importance for staging of large B cell lymphomas?
A
LDH
18
Q
What is the presumptive diagnosis for Cancer of Unknown Primary in case of abdominal carcinomatosis in MEN?
What about WOMEN?
A
Men = GI
Women = Ovarian
19
Q
What’s the treatment for stage 3 cervical cancer? Chemo/Radiation or Surgery?
A
Patients with stage III cervical cancer have extension to the pelvic sidewall, lower third of the vagina, or pelvic adenopathy, are at higher risk for locoregional and distant recurrence, and are treated with concurrent chemoradiation. (Chemo with cisplatin)
Surgery is only performed in stage 1-2.
20
Q
What’s the treatment for Immunotherapy-induced diarrhea/colitis?
A
Stop immunotherapy and start Budesonide if mild diarrhea and Methylprednisolone if moderate or severe diarrhea (low BP, dehydration…)
21
Q
What’s the most likely diagnosis when you see a “sausage-shaped pancreas”
A
Autoimmune Hepatitis (ill defined borders with generalized enlargement of the pancreas)
22
Q
What pancreatic disease should you think when the patient is positive for IgG4?
What’s the treatment?
A
Autoimmune pancreatitis.
Treatment with prednisone for 2-3 months with taper
23
Q
Which sex is more prone to having primary biliary cholangitis (former cirrhosis)?
What’s the marker for that?
A
Females.
Markers are increase =/> 1.5x All phos and + antimitochondrial Ab.
24
Q
What’s the classic person with primary sclerosis cholangitis?
What’s the marker?
A
Male with IBD (85% of cases).
Marker is elevation of Alk phos and positive ASMA (anti smooth muscle ab)
25
What characterizes each phase of HBV chronic infections:
Immune tolerant, immune control, immune active and reactivation?
Immune tolerant: acquired through vertical transmission. In this phase, HBeAg is positive, anti-HBeAg is negative, ALT level is normal, but HBV DNA level exceeds 1 million U/mL. Treatment is NOT recommended in this phase.
Immune control: normal serum alanine aminotransferase (ALT) measurement, indicating absence of liver inflammation; positive results for hepatitis B core (HBc) antigen IgG antibody, indicating previous infection; hepatitis B e antigen (HBeAg)–negative and anti-HBe–positive serology, indicating lack of viral replication and infectivity; and HBV DNA level less than 2000 U/mL, indicating immune control of viral replication and infection. Does NOT require treatment.
Immune active: evidence of liver inflammation (elevated ALT level) and uncontrolled infection (HBV DNA >2000 U/mL). HBeAg may be positive or negative in this phase. Depending on other factors, treatment may be indicated.
Reactivation: loss of HBV immune control. It is recognized by a rising HBV DNA level compared with baseline or seroconversion of hepatitis B surface antigen (HBsAg) from negative to positive in patients who were previously HBsAg negative and anti-HBc positive. Reactivation may be the result of immunosuppression with immune modulators, cytotoxic chemotherapy, and drugs that deplete B lymphocytes, such as rituximab. Prophylactic treatment is typically recommended for select patients in the immune control phase who are at risk for reactivation.
26
At what size does a hepatic abscess require needle drainage on top of Abx treatment?
Greater than 3cm
27
What’s the treatment for alcoholic hepatitis? How the Maddrey score will change management?
For maddrey 32 or higher (or in case of hepatic encephalopathy) steroids are the choice.
Abx should only be given (adjunct) in case of infection.
28
What’s the first line treatment for vaginal dryness and atrophy in postmenopausal women?
Topical lubricants/moisturizers.
Only after failing this treatment, we can offer topical steroids.
29
How to treat hydradenitis suppurativa?
1- Topical Clindamycin + bleach bathe + Chlorhexidine washes for decolonization.
2- if no response, Oral Clinda + Rifampin
3- if severe disease (scarring, many episodes, multiple lesions), start Adalimumab
30
Who should receive stress dose steroids on day of surgery?
Patients on high doses of glucocorticoids for extended periods (equivalent of >20 mg/d prednisone for >3 weeks) are at high risk for AI and should receive stress dosing when undergoing intermediate- to high-risk surgery.
31
Which antiarrhythmics are contraindicated in patients with ischemic heart disease (even post treatment)?
Class Ic
- Flecainide
- Propafenone
32
When should we treat subclinical hyperthyroidism?
If TSH < 0.1 and one of the following:
- symptomatic
- cardiac risk factors (risk of arrhythmia)
- heart disease
- osteoporosis (risk for fractures)
- postmenopausal women not in estrogen therapy or biphosphonates (risk for fractures).
33
Which ratio is indicative of pulmonary arterial hypertension? Checked by spirometry*
FVC/DLCO ratio >1.6
- usually falls in DLCO too big when compared to falls in FVC. A DLCO <60% predicted should point to that direction. Also a fall in 20% within a year in the DLCO.
34
What’s the follow up for resolved gestational diabetes?
Check fasting glucose level or 2h, 75g OGTT between 6-12 weeks postpartum and then A1c every 1-3 years for life.
35
What’s the difference between a 30 day cardiac monitor and a loop recorder?
The 30 day cardiac monitor is triggered by the patient whenever he feels the symptoms, so it’s a good method for mildly symptomatic patients who can press a button when having symptoms.
The implantable loop recorder is running all the time and is meant for people who might be at risk of severe symptoms that would not let them press a button (such as syncope). It is more expensive and more invasive.
36
What’s the higher risk in a male patient that wants to undergo estrogen treatment for feminilization?
What can we do to reduce the risk?
What may be a contraindication for initiation of estrogens?
Venous thromboembolism.
We should aim at subphysiologic levels (estradiol level 100-200pg/mL), not 360-730pg/mL as seen in women.
- Might be contraindicated if personal or family history of VTE. Also, smoking cessation should be highly enforced.
37
Which score should be used for calculating probability of PE?
PERC score (PE Rule-out Criteria).
A score of Zero means no further testing is needed.
This score reduced to 0.3% chance of missing a PE and decreased d dimer testing in 22%.
38
What medication should be used for patients with High risk for tumor lysis syndrome?
What about for Intermediate risk?
High: Rasburicase
Intermediate: Allopurinol
39
What’s the most likely diagnosis for unilateral eye pain with movement + visual deficit + afferent pupillary defect?
Optic neuritis
40
What is needed for the diagnosis of Androgen deficiency?
Two separate 8am serum total testosterone levels below 300
41
What’s the treatment for anal cancer? Surgery? Chemo? Radiation? Combos?
Usually Radiation + chemo (mitomycin + capecitabine or 5FU).
42
What is the usual treatment for neuroendocrine tumors that are low grade, well differentiated and asymptomatic?
Watchful waiting with follow ups q3 months.
43
In the setting of acute stroke, including hemorrhagic, what should be the VTE prophylaxis?
First 24h = Pneumatic compression.
>24h = if no evidence of hematoma expansion -> start heparin or enoxaparin.
44
How long after a stroke or TIA can we perform Elective procedures?
After 6-9 months. And the risk for recurring stroke is still higher than in persons without previous stroke hx.
45
What are the cutoffs for MELD score and prediction for normal, intermediate and high risk for surgery?
Meld score:
<10 = normal surgical risk (as non cirrhotic)
11-19 = intermediate risk (discuss possible complications with patient and see what’s in his best interest)
>20 = only perform surgery for life threatening conditions.
46
What is the treatment for nephrogenic diabetes insipidus (like lithium)?
Amiloride
47
When to switch Vancomycin to Daptomycin in a patient with right soded endocarditis due to MRSA?
When MIC for Vancomycin is > 2 or close to 2 and clinical response to Vanco is poor. Otherwise, keep Vanco to a goal with an area under the curve.
48
Patient with suspected cervical radiculopathy.
What are the red flag symptoms that would indicate an XRAY? What about MRI?
If no red flags, what’s the best treatment option?
Xray = helpful if bone abnormalities are suspected, such as fractures, metastatic disease, osteomyelitis, diskitis.
MRI = helpful in myelopathy, cancer or infection. Or if conservative measures fail.
Red flags usually: trauma, fever, chills, immunosuppression, myelopathy.
Conservative tx: analgesics, range of motion exercises, PT. Usually improve sx in 6-8weeks.
49
What characterizes a chylothorax labwise?
What are the most common causes? Traumatic and not?
Pleural fluid triglycerides > 110, usually with lymphocytic predominance.
MCC = traumatic. surgery (esophageal or mediastinal).
MCC of non traumatic = malignancy. Might also be from lymphatic disorders.
50
Hepatocellular carcinoma: how to treat? What does treatment choice depend on?
Depends on presence of hepatic dysfunction/portal hypertension.
In patients very well compensated, no portal HTN and no signs/lab/sympt of liver dysfunction, the treatment should be Surgical Resection of the region of the cancer, because these patients would tolerate it well.
In case of positive portal htn and liver dysfunction, treatment should be aimed at transplant, because if kept with same liver, they will not respond adequately.
Embolization/Radioablation can be a therapy in case patient os not a candidate for resection or transplant.
51
After positive ccp and RF, do we need any further testing for diagnosis of RA?
We should do a hand x ray to look for early radiographic findings that can indicate need of biologic DMARDS earlier on.
These changes are periarticular osteopenia, joint space narrowing and bony erosions.
52
What is the hemoglobin goal for patients with sickle cell SS preoperatively?
10g/ml
53
Should we prescribe PPI to patients with diagnosed Mallory-Weiss tears?
No. PPI are not indicated for mallory weiss and should be discontinued given possible side effects (as in general population).
54
For how long should we continue VTE prophylaxis with enoxaparin for ptients with cancer in the postsurgical period?
4 weeks
55
What is the XRAY finding that helps to diagnose adhesive capsulitis?
NONE. Adhesive capsulitis should have a normal shoulder XRAY
56
What size of colonic tubular adenoma would warrant 3yr follow up instead of 10yr?
If >1cm.
Or if more than 5 <1cm
Or if villous/tubulovillous pathology
57
When to start spironolactone for PCOS?
If hirsutism/acne still present After 6 months of oral hormonal contraceptive therapy.
58
In patients with peripheral artery disease, what is the most appropriate therapy to be added to aspirin?
Very low dose rivaroxaban 2.5mg BID
59
When should we perform EGD and within how many hours in a patient with acute UGIB?
ALWAYS. Within 24h of hospital admission.
60
Hat conditions seen on EGD are indicative of doing 3 days of high dose PPI, followed by oral PPI 40mg day for 2 weeks following therapeutic EGD?
Apparent blood vessel (bleeding or not), active bleeding and/or active oozing.
61
What’s the treatment for hot tub folliculitis?
Observation. It can last up to 7-10 days.
We give ciprofloxacin if symptoms not improving after that period or if lesions too numerous or patients with severe illness.
62
What test should we use in order to check for a patient’s responsiveness to steroids in the context of asthma?
FeNO (fractional excretion of nitric oxide).
Values >50ppb are consistent with eosinophilic airway inflammation, which should respond to steroids.
Values <25ppb are negative for eosinophilic inflammation and are likely to NOT to respond to steroids.
Values between 25-50ppb need cautious interpretation.
63
When to stop antibiotic therapy in febrile neutropenia?
Once patient is afebrile and symptoms are better, check these criteria:
After a full course of antibiotics OR after neutropenia resolves with >500 neutrophils. Whatever is LONGER.
*Some guidelines say it’s ok to discontinue after 48-72h of afebrile patient regardless of neutropenia.
64
When to start antifungals (Voriconazole) for febrile neutropenia?
After 4 days of antibiotics without resolution of fevers AND expected neutropenia for extra 7 days.
65
What’s the treatment for patients with intolerable PVCs (premat. Vent. Contr)?
Beta blocker. Preferred propranolol (also anxiolytic)
66
Which drugs should we start after a TIA (transient ischemic attack)?
Clopidogrel for 21 days
Aspirin indefinitely
67
In patients with hyperthyroidism after amiodarone use, what test should we order?
Thyroid US with doppler to check for Graves disease.
Type 1 amiodarone-induced thyrotoxicosis (AIT) (hyperthyroidism) occurs in patients with Graves disease or thyroid nodules;
type 2 AIT (destructive thyroiditis) occurs in patients without underlying thyroid disease.
Thyroid ultrasonography with Doppler studies can help distinguish type 1 amiodarone-induced thyrotoxicosis (increased vascularity) from type 2 (decreased vascularity).
Treatment:
Type 1 AIT: This form of iodine-induced hyperthyroidism (Jod-Basedow phenomenon) is typically treated with methimazole.
Type 2 AIT (destructive thyroiditis) is more common and occurs in patients without underlying thyroid disease. Type 2 AIT is usually self-limiting but sometimes requires treatment with glucocorticoids.
68
If you have a patient with heart failure symptoms, hypertrophic walls but LOW VOLTAGE EKG (instead of a high amplitude as would be expected), what should you think of?
Infiltrative cardiac disease leading to HF. Like amyloidosis
69
What test do you do if you suspect your patient has infiltrative cardiomyopathy?
MRI with Gadolinium
70
What is Felty Syndrome?
Rheumatoid Arthritis complicated by neutropenia and splenomegaly.
71
What is the classical triad for Fat Embolism Syndrome?
Petechial rash
Respiratory insufficiency
Altered mental status
72
What are the 4 stages of pulmonary sarcoidosis?
On appearance on chest radiograph:
-stage I, bilateral hilar lymphadenopathy;
-stage II, bilateral hilar lymphadenopathy with pulmonary infiltrates;
-stage III, parenchymal infiltrates alone; and
-stage IV, pulmonary fibrosis with parenchymal distortion or bullae.
73
What are the clinical contexts of pulmonary sarcoidosis that do not require biopsy for diagnosis?
Diagnosis of pulmonary sarcoidosis, with a few exceptions, typically requires bronchoscopic biopsy, with tissue obtained from a lymph node or from the pulmonary parenchyma.
The diagnosis is made by the finding of noncaseating granulomas with exclusion of potential mimicking infections (mycobacteria, fungi), exclusion of other systemic granulomatous diseases, and involvement of more than one organ system.
The absence of respiratory and constitutional symptoms makes infectious and malignant causes unlikely.
- Clinical presentations of sarcoidosis that do not require a biopsy include:
- asymptomatic stage I pulmonary sarcoidosis (absence of fevers, malaise, or night sweats to suggest a malignancy);
- Löfgren syndrome (bilateral hilar lymphadenopathy, migratory polyarthralgia, erythema nodosum, and fever);
- Heerfordt syndrome (anterior uveitis, parotiditis, fever, and facial nerve palsy).
74
What to do with elevations of INR on warfarin?
In patients taking warfarin with a supratherapeutic INR less than 10 and no signs of bleeding, warfarin should be withheld until the INR returns to the therapeutic range.
For INR elevation greater than 10 without bleeding, vitamin K is recommended in addition to withholding warfarin;
if the INR is elevated and life-threatening bleeding is present, then warfarin is withheld, and vitamin K and a prothrombin complex concentrate should be administered.
75
In patients with Afib and CAD s/p Stent placement a few months ago, with high bleeding risk (hx of GI bleed for example), what can we do to the triple therapy (AC, ASA, AntiP2Y12)?
Discontinue Aspirin and keep only DOAC/Warfarin (AC) and Clopido/Prasugrel/Ticagrelor (P2y12)
76
Patient with multiple sclerosis, presents with symptoms of infection and a fever. Also neurologic symptoms. What to do? What’s likely happening?
Uhthoff phenomenon.
chronic neurologic symptoms become more prominent in patients with MS when they have elevated body temperature. (Fever, hot weather, exertion…)
Always check for infections first and treat it. The neurologic findings should resolve after resolution of fevers.
77
At what age do we need to check hormones for eval of amenorrhea in women when thinking of menopause?
Only check labs if <40yr. After that, menopause is a clinical diagnosis.
78
Who should take hep b vaccines?
all adults aged 19 through 59 years as well as for patients aged 60 years or older who are at increased risk for hepatitis B virus infection. Medical conditions and/or situations that confer increased risk include chronic liver disease, HIV infection, sexual exposure, current or recent injection drug use, percutaneous or mucosal exposure to blood (including patients with diabetes), incarceration, and travel to countries with hepatitis B endemicity.
79
At what level of bicarb do we start bicarb replacement with bicitra or whatever drug in patients with CKD?
22
80
Test of choice for ectopic pregnancy AFTER bhcg is ordered and noted to be positive:
Transvaginal US.
NOT CT scan. CT indicated for appendicitis.
81
What’s the best test to eval primary hyperaldosteronism in a patient taking ACE or ARBs?
Plasma renin levels.
Because if they are taking ACE/ARB, the angiotensin should be blocked and renin should be increased. In case renin is low, the only explanation is that Aldo is primarily being elevated causing a reduction in renin levels by negative feedback
82
What’s the best test to identify RENAL potassium loss Vs other etiologies for hypokalemia?
24-hour urine potassium.
however, this test is often impractical. The preferred alternative is a “spot urine potassium-creatinine ratio”. A value lower than 13 mEq/g identifies hypokalemia secondary to lack of intake, transcellular shifts, or gastrointestinal losses.
83
What is the treatment for insomnia?
Cognitive behavioral therapy.
In case of fail or if patient refuses it, then next best options are:
- Doxepin
- Zolpidem, Zaleplon, Eszopiclone (nonBDZ BDZ receptor agonists)
84
What’s the goal INR for warfarin on patient s/p mechanical valve?
2.5-3.5
85
What to do after thyroid US and FNA show the following patterns for a nodule:
1 - high suspicion
2 - low-intermediate suspicion
3 - very low suspicion
1 - repeat US and maybe FNA again in 6-12 mo
2 - repeat US in 12-24mo and think of FNA
3 - repeat US >24mo and take it from there
86
Big diference between SLE and Rosacea:
Rosacea does NOT spare the nasolabial folds and is likely to have pustular lesions.
87
What is Lupus pernio?
Lesions that occur in people with sarcoidosis. Firm and purple, not photosensitive and do not appear on chest or arms
88
What is Subacute cutaneous lupus erythematosus?
Annular and polycyclic photosensitive plaques on back, chest and extremities or psoriasiform scaly plaques that is usually unrelated to lupus. Majority are drug induced and improve upon discontinuation.
89
How much does 1 PLT unit increase the PLT count after transfusion?
20-30k
90
How long after exposure to hep A virus should a patient receive post exposure prophylaxis?
Within 2 weeks from exposure.
Vaccination is the choice for healthy adults.
Vaccination + HAV immune globulin can be considered for >40yo or people with risk factors for immunosuppression.
91
What is rosacea?
Chronic inflammation of pilosebaceous units with increased vascular reactivity. More common in white (great britain), 60 decade of life.
May be
- papulopustular
- erythrotelangiectatic
- phymatous (rhinophyma).
Triggered by stress, alcohol, sunlight, heat.
Includes nasolabial folds.
92
What’s the treatment of Rosacea?
metronidazole cream
93
How to determine discharge to SNF with subacute rehab Vs inpatient acute rehab?
If patient is able to tolerate >3h of rehab, 5x week, they should go to ACUTE REHAB INPATIENT. If they can’t, should go to SNF for subacute rehab for a slower paced rehab (up to 100 days)
94
Can I perform adenosine myocardial perfusion imaging on a patient with asthma?
No. Contraindicated for reactive airway diseases
95
Can I use PPI on patients with CKD or AKI?
H2 blockers are better. PPIs may contribute to development and progression of CKD, AIN, AKI.
96
What is Brugada pattern? What about Brugada syndrome?
Pattern = EKG with ST segment abnormalities (concave or linear downsloping) in V1-V3 with or without RBBB.
Syndrome is the pattern + ventricular fibrillation or arrhythmogenic syncope or cardiac arrest.
97
What’s the best treatment for chronic ulcers?
Compression therapy (socks)
Make sure to use bandaging with some sort of emollient (none has been proven superior to another).
98
Which ABI value would contraindicate use of compression therapy for ulcers?
<0.5
99
What’s the initial step after diagnosing Membranous Nephropathy?
Investigating for secondary forms if the disease (age appropriate cancer screening, hepatitis serologies, lupus, drugs)
100
How to reverse these agents?
1- Dabigatran
2- DOACs
1- Idarucizumab or Hemodialysis if monoclonal ab is not available.
2- Andexanet Alfa or 4 factor prothrombin complex concentrate. Since these are very powerful, they can cause thrombotic events, so if patient stable, may try to just hold these agents and see if reversal is really needed
101
What are echinocandins (caspofungin) good for?
Candidemia and invasive candidiasis
102
What’s the treatment for cryptococcus?
Flucytosine and Amphotericin B for initia regimen, then may switch to Fluconazole
103
What are the cutoffs for initiation of alendronate after FRAX score?
FRAX 20 and 3
20% major osteoporotic fx
3% hip fx
104
What is the first line treatment for relapsed multiple sclerosis (worsened symptoms with new cerebral lesion)?
High dose steroids.
Methylprednisolone 1g/day for 3-5days
105
What’s the treatment for suspected Bacterial Meningitis >50yo?
All four agents:
-Vanco + Ceftriaxone (s. Pneumoniae)
-Ampicillin (Listeria)
-Dexamethasone given on 1st dose .
106
What’s the new name for CREST syndrome?
Limited Cutaneous Systemic Sclerosis
107
In patients with RPGN (rapidly progressive glomerulonephritis), what is the most common cause? Meaning, which test should we order first?
ANCA first
then anti GBM
