MKSAP Flashcards
Best initial antibiotic for an adult with acute otitis media.
Amoxicillin.
Class of drugs is used to treat generalized anxiety disorder.
(Especially if insomnia is the chief complaint).
Selective serotonin reuptake inhibitors. SSRIs.
Don’t use benzodiazepines.
If the triglycerides are between 200 mg/dl - 500 mg/dl then should they be started on lipid lowering drugs?
The first step into determine what their non- HDL cholesterol is:
Total cholesterol - (minus) HDL cholesterol = non-HDL cholesterol.
Goal for non-HDL cholesterol is = Goal LDL + (plus) 30 mg/dl.
Treatment should also be considered for people with a personal or family history of coronary artery disease regardless of non-HDL cholesterol.
Empiric treatment for chronic cough. (defined as more than 8 weeks).
First generation antihistamine/decongestant combination.
Most effective drug for smoking cessation.
And
Most effective smoking cessation therapy.
Verenicline.
(Chantix).
Contra-indicated in patients with history of major depression and suicidal ideation as the drug is associated with new-onset of these symptoms or exacerbation of these symptoms.
Most effective therapy is high dose nicotine patch in combination with another anti-smoking therapy e.g, nicotine replacement gum or spray.
Manage recurrent falls in an elderly patient.
Measure 25-hydroxy-vitamin D level.
Vitamin D supplementation reduces falls and fractures by about 20% in the elderly.
Treatment of chronic prostatitis/chronic pelvic pain syndrome.
Alpha-blockers.
e.g. terazosin, tamsulosin.
Treatment for musculoskeletal neck pain.
NSAIDS and physical therapy.
Symptoms of scleritis.
Deep, boring eye pain.
Erythema localized to sclera (no normal white sclera visible between blood vessels) that looks like raised erythematous lesions.
Watering and tearing of eye.
Decreased visual acuity.
When to give herpes zoster vaccination.
Indicated in all patients over 60 years of age regardless of chicken pox history.
Symptoms and initial step in management of olecranon bursitis.
Pain on flexion of elbow.
Aspiration of olecranon bursa.
Oral lesion associated with smokeless tobacco use.
And
Oral lesion associated with HIV.
Leukoplakia.
And
Oral hairy leukoplakia.
Causes of dizziness in geriatric patients.
Multifactorial - deficits in multiple sensory systems and medication side effects.
Treatment is by physical therapy.
Treatment of advanced carpal tunnel syndrome.
Surgery - Carpal tunnel release.
Features of rotator cuff tendinitis.
Overuse injury, subacromial tenderness, and impingement.
Features of bicipital tendinitis.
Overuse injury, bicipital groove tenderness, anterior shoulder pain with resisted forearm supination or elbow flexion.
Preventing pressure ulcers.
Specialized foam mattresses and overlays.
Acute painless visual loss, pale fundus, cherry red spot on fovea.
Central retinal artery occlusion.
Screening for hearing loss in the elderly.
Whispered voice test or hand held audioscopy. Do it even if the patient denies having hearing problems.
Ottawa ankle rules - for ankle pain/sprain.
No imaging unless there is tenderness along the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or the inability to bear weight.
Treatment of urge incontinence.
Oxybutynin or tolterodine.
Prevent attacks of allergic rhinitis.
Intranasal cromolyn sodium.
Root-cause analysis.
Used by performance improvement team to investigate the multiple factors associated with patient care errors.
Panic disorder treatment.
Cognitive-behavior therapy plus SSRI.
Management of abnormal uterine bleeding in perimenopausal woman.
Rule out endometrial hyperplasia or cancer with endometrial biopsy.
Systemic side effects of ophthalmic timolol.
Bronchospasm, bradycardia, lethargy, decreased libido and erectile dysfunction.
Test to order when evaluating benign prostatic hyperplasia.
Urinalysis.
Key points to ascertain in medical decision making.
Whether the patient understands the risks and benefits and why the patient is making the choices that he is making.
Therapy and duration for drug eluting stents.
Dual therapy with aspirin and clopidogrel uninterrupted for at least 12 months.
Prevent medication (opiate) related falls.
Standardized protocols for management of opiate medications - dosage and strength.
Manage ocular trauma.
Emergency ophthalmology consult and shield (metal or paper cup) for affected eye.
How to reduce surgical risk in ESRD patient.
Schedule dialysis one day before surgery.
Patient with depression and suicidal ideation willing to make a ‘no harm contract’.
Urgent referral to psychiatric facility/mental health referral. (Even if they contract for safety). If they contract for safety than a psychiatrist is okay. If not then hospitalization is appropriate.
Treat grief response.
Patient’s that meet criteria for major depression for two consecutive weeks, eight or more weeks after their loved ones’ death are candidates for pharmacological therapy.
Yellow deposits on retina. Diagnosis?
Early age-related macular degeneration. Patients should be counseled to quit smoking.
Difference between binge-eating disorder and bulemia nervosa.
Bulemia: Binge-eating two or more times a week for three months with purging or compensatory behavior.
Binge-eating disorder: Binge eating two or more times a week for six months with feelings of disgust or guilt but no purging or compensatory behavior.
LDL goal for patients with zero or one cardiovascular risk factor.
Less than 160 mg/dl.
Increased glare and impaired blue-yellow color vision. Diagnosis?
Cataracts.
Treatment of acute non-specific lower back pain.
Acetominophen.
Complications of gastric bypass surgery.
Stomal stenosis, marginal ulcers or erosions can result in persistent nausea and vomiting. Do an upper endoscopy.
Active young women with anterior knee pain worse when going down steps.
Patellofemoral syndrome.
Treatment of bacterial vaginosis.
Metronidazole. No need to treat partner.
Pink, pearly nodules with telangiectases and sometimes flecks of melanin pigment.
Basal cell carcinoma.
Erythematous, excoriated papules, sometimes with punctum, along clothing lines in the setting of outdoor activity - caused by?
Chigger bites.
Affect of smoking on cutaneous lupus erythamatosus.
Smoking interferes with the anti-malarial drugs used to treat it thus making the cutaneous lesions worse.
Large, irregular lesion with uneven pigmentation. Diagnosis?
Lentigo Maligna (malignant melanoma in situ). Do a broad, shallow shave biopsy.
Diagnosis of uticarial vasculitis.
Uticarial plaques are fixed in position for more than 24 hours and commonly heal with bruising. Diagnosis is confirmed with a biopsy of the skin.
Diagnositic test of choice for non-healing or atypical appearing ulcers.
Skin biopsy.
Pustular erythrodermic flare in the setting of history of psoriasis.
Can happen days to weeks after treatment with systemic steroids.
Neurogenic pruritus.
Subacute, severe, generalized pruritus with secondary erosions in the absence of a primary dermatological lesion.
Rapidly growing, non-tender, firm nodules with depressed keratotic centers.
Keratoacanthoma.
Ocular cicatricial pemphigoid - first step?
Accurate diagnosis with biopsy.
Treatment of pyoderma gangrenosum.
Systemic corticosteroids.
Treatment of gram negative folliculitis as a complication of Acne vulgaris.
Isotretinoin.
Florinated topical corticosteroid (triamcinolone) use on facial skin.
Perioral dermatitis - no treatment.
Gold standard for diagnosis in allergic contact dermatitis.
Epicutaneous patch testing.
How do you take pressure off a neuropathic ulcer.
Contact casting.
Recurrent erythema multiforme.
Herpes simplex virus (90%).
Fever with onset of erythematous macules and plaques that progress to epidermal necrosis and sloughing.
Steven-Johnson syndrome.
Proximal white subungal onychomychosis. Underlying disease?
HIV
Treatment of mixed cryoglobulinemia in the setting of HCV infection.
Treat underlying infection with pegylated interferon alfa and ribavirin.
Persistent, scaling, eczematous, or ulcerated lesion involving the areola/nipple.
Paget’s disease of the breast.
Indications for bi-ventricular pacemaker defibrillator.
NYHA class III or IV heart failure.
QRS greater than 120 msec.
Ejection fraction less than or equal to 35%.
Cardiopulmonary symptoms in patients with less than severe mitral regurgitation.
Indicative of some other disease process e.g. pulmomary, coronary artery disease or physical de-conditioning.
Heart failure symptoms, decreased exercise tolerance, conduction defects, syncope or cardiac arrest in heart transplant patients is indicative of…
Coronary artery disease.
Indications for low dose spironolactone in heart failure patients.
Mortality benefit of 35% in patients continuing to have class III or class IV heart failure symptoms despite beta-blockers and ACE inhibitors. Not indicated for class I or class II heart failure symptoms.
Indications for an ICD (implantable cardioverter-defibrillator).
Reduces risk of sudden death in people with NYHA class II or III heart failure symptoms and an ejection fraction of 35% or less (in either ischemic or non-ischemic cardiomyopathy).
Echocardiogram shows echogenic, globular, mobile mass attached to the atrial septum. What is it and what’s the treatment?
Atrial myxoma. Treatment is cardiac surgery for resection of the mass.
Type of cardiomyopathy caused by iron over load and treatment.
Restrictive cardiomyopathy. Treat the underlying cause i.e. phlebotomy, and if not tolerated then iron chelation.
Treatment of medically refractory angina.
External enhanced counterpulsation (EECP) and spinal cord stimulation.
Treatment of recurrent atrial flutter.
Radioactive ablation. Flecainide is contraindicated as a single agent as it can lead to ventricular fibrillation.
Management of decompensated mitral stenosis in a pregnant woman.
Maximum medical management first with beta-blockers, diuretics and heparin/lovenox.
Treatment of recurrent pericarditis.
Colchicine.
Titration of dose of beta-blocker in coronary artery disease.
Beta-blocker should be titrated to acheive a resting heart rate of 55 - 60 beats/min; or 75% of the heart rate that produces angina with exertion.
Hemoglobin levels in Eisenmenger syndrome.
Usually between 18 - 20 mg/dl as it is a cyanotic heart disease. Relative anemia is treated with low dose iron; if less than 10 mg/dl (bleeding/surgery) then may need transfusion.
Pain on prolonged standing, better on sitting; ankle reflexes decreased, sometimes knee reflexes too…
Spinal canal stenosis.
Treatment of syncope in heart failure with low EF on medication.
ICD placement. No need to document arrhythmias if suspicion is high enough.
Management of idiopathic pericardial effusion persisting for more than three months.
Pericardiocentesis.
Imaging modality contraindicated if pacemaker or ICd present.
MRI.
Treatment of Dressler syndrome.
High dose aspirin.
Treatment of choice for pulmonary stenosis.
Pulmonary balloon valvuloplasty.
Intervention of choice in unstable angina and high pretest probability of coronary artery disease.
Coronary angiography.
Cardiac clearance in aortic stenosis.
Asymptomatic patients - proceed with surgery. Symptomatic patients - prophylatic aortic valve replacement.
Next step after echocardiogram to evaluate congenital cardiac disease in adults following surgery during childhood.
If cause of symptoms is not apparent on the echocardiogram then a cardiac MRI needs to be done.
Evaluation of frequent symptoms (palpitations) in patients with known diagnosis of paroxysmal atrial fibrillation.
If symptoms happen multiple times a day then 24-hour amubulatory monitoring can be done to see if the symptoms correlate with atrial fibrillation or with rapid ventricular response. This will help in tailoring therapy.
What should be used instead of beta-blockers in acute coronary syndrome if their are contraindications to beta-blockers?
Calcium channel blockers.
Syncope during activity and family history of early sudden death,
Congenital long QT syndrome.
Indications for endomyocardial biopsy.
- New onset heart failure (< 2 weeks) with hemodynamic compromise.
- New-onset heart failure (2 weeks to 3 months) with dilated left ventricle, new ventricular arrhythmias, Mobitz type II 2nd degree, or 3rd degree heart block, or failure to response to usual care in 1 - 2 weeks,
Indications of aortic valve replacement surgery in aortic regurgitation.
- Symptomatic patients.
- Asymptomatic patients with bicuspid aortic valve and severe aortic regurgitation when the left ventricular end systolic diameter reaches 55 mm or the LVEF is less than 60%.
- Equivocal symptoms - exercise induced increase in pulmonary systolic pressure more than 60 mmHg (or 25 mmHg over baseline) during treadmill stress echocardiography.
Progressive dyspnea and pulmonary hypertension.
Evaluate with VQ scan to rule out chronic thromboembolic disease.
Pregnancy and pulmonary artery hypertension.
Pregnancy is contraindicated in severe pulmonary artery hypertension even if the patient is asymptomatic. Estimated maternal mortality risk 30% - 50%. If unplanned pregnancy occurs then termination is recommended.
Pregnancy and anticoagulation in mechanical prothesthetic valves.
Warfarin use throughout pregnancy until near term provides the lowest risk for maternal complications/death in women with mechanical heart valves. Teratogenic risk less than 10% in first trimester if dose less than 5 mg/day. Low molecular weight heparin is very difficult to dose by weight during pregnancy.
Factors influencing BNP levels.
BNP levels are usually lower in obese people, even in the setting of acute heart failure, They can be higher in elderly, females, in renal failure, even if there is no volume overload.
Management of patient with cardiac sarcoidosis and syncope secondary to frequent PVCs and ventricular tachycardia episodes.
Placement of implantable cardiac defibrillator because these patients are risk of sudden cardiac death.
Treatment of reversible heart block secondary to Lyme disease (Lyme carditis).
Intravenous ceftriaxone.
Treatment of infrapoliteal symptomatic peripheral vascular disease.
Supervised exercise program.
This can provide substantial symptomatic relief.
Hydralazine versus spironolactone in heart failure.
Hydralazine is added to the standard therapy of beta-blockers, ACEIs and diuretics in black patients.
Spironolactone is indicated in heart failure class III or IV in addition to standard therapy. Reduces mortality by 30%. Make sure potassium is not over 5 meq/L.
Indications for Milrinone.
Short term treatment of cardiogenic shock.
It is a phosphodiesterase inhibitor and positive ionotropic agent.
Treatment of sick sinus syndrome with bradycardia and dizziness.
Pacemaker placement.
(Even if the bradycardia is a drug side effect if the patient still needs the drug e.g. rate control in atrial fibrillation.
Imaging studies that can diagnose aortic dissection.
- Transesophageal echocardiogram.
- Contrast-enhanced CT chest/abd.
- Thoracic magnetic resonance angiography.
Pregnancy risk in repaired Tetralogy of Fallot.
Chance of offspring being born with congenital heart disease is about 50%.
Nonpharmacological treatment of atrial fibrillation with rapid ventricular response.
Atrioventricular nodal (junctional) ablation with pacemaker placement.
Common complication of repair of Tetralogy of Fallot.
Pulmonary and tricuspid valve regurgitation.
Management of patient with sedentary lifestyle, and severe asymptomatic mitral regurgitation.
An exercise stress echocardiography will need to be performed as the patient’s exercise tolerance cannot be gauged by history as she has a sedentary lifestyle.
Exercise associated increase in pulmonary pressures of 25 mmHg over baseline should prompt surgical intervention.
Treatment of decompensated heart failure with volume overload and decreased cardiac output.
Intravenous inotropic agent e.g. dobutamine.
How to manage patient with prosthetic aortic valve and no history of thromboembolism on warfarin before elective surgery.
Stop warfarin 3 - 5 days before surgery. There is no need to use a heparin bridge in low risk patients.
Treatment of persistent asthma.
Defined as asthma attacks on 2 or more days a week or 2 more nights a month and is treated with inhaled corticosteroids with albuterol as needed.
Test of choice for acute exacerbation of idiopathic pulmonary fibrosis.
Bronchoscopy with a bronchoalveolar lavage to rule out opportunistic infections.
Define GOLD stage II COPD and treat it.
Defined as a postbronchodilator FEV1/FVC ratio of less than 70% and an FEV1 of less than 80% but more than 50%. Treatment is with long acting beta-2 agonists with albuterol as needed. Long acting anticholinergics can also be used.
Follow-up for 3 mm lung nodule found on chest CT.
If low risk for lung cancer then nodules less then 4 mm then no follow-up. If the patient is high risk then a follow-up CT is done at 12 months.
Generalized, flaccid weakness, with unexplained difficulty weaning from ventilator.
Intensive care unit acquired weakness.
Imaging to diagnose pulmonary embolism in a patient with a creatinine of 2 mg/dl.
Ventilation/perfusion scan.
Asthma like symptoms that do not respond to conventional asthma therapy.
Patient may have vocal cord dysfunction and needs a laryngoscopy.
Diagnosis of dermatomyositis with lung disease resembling idiopathic interstitial lung disease.
Electromyography and muscle biopsy.
Lymphocytic predominate pleural effusion, with high protein and LDH.
Likely a tuberculous pleural effusion.
Treatment of pulmonary embolism after delivery of baby.
Even if you suspect an amniotic fluid embolus you will still anti-coagulate the patient since you cannot differentiate and thrombus from an amniotic fluid embolus.
Subcutaneous unfractionated heparin, low molecular weight heparin or fondaparinux can be used.
Treatment and prevention of high altitude pulmonary edema.
Nifedipine.
Myasthenia gravis and mass of chest CT.
Thymoma. Thymomas are associated with paraneoplastic syndromes like myasthenia gravis.
Episodic chest discomfort and cough after upper respiratory tract infections with normal spirometry. Next step?
Suspect asthma if there are episodic symptoms and the patient is well with normal spirometry inbetween episodes. Methacholine challenge testing is performed.
Next step in management of 1.5 cm lung nodule that is non-enhancing (Hounsfield units < 15) on dynamic CT contrast study.
Non-enhancing lesions are likely to be benign so 3 month follow-up CT chest is appropriate.
Next step in patient failing extubation because of hypoxemic respiratory failure and what not to do.
Reintubate the patient.
Non-invasive positive-pressure ventilation is potentially harmful in these patients.
Japanese patient who recently started smoking, who has hypoxemic respiratory failure after 1 - 2 weeks of fever and systemic symptoms.
Acute eosinophilic pneumonia.
A COPD patient on home oxygen wants to take a flight. Next step?
Hypoxia inhalation test to predict in-flight pO2 and development of cardiac events related to low oxygen levels.
Severe anterior chest pain during therapeutic thoracocentesis.
Diagnostic of unexpandable lung with development of significant negative intrapleural pressure. Treatment is by insertion of a thoracentesis needle or catheter to allow air entry and relieve pressure. An indwelling pleural catheter will allow for drainage which can be discontinued when chest pain develops.
Selection criteria for augmentation with alpha-1 antitrypsin intravenous augmentation therapy.
Most effective in patients with FEV1 35 - 60% of predicted and FEV1/FVC ratio of 30 - 65%.
- Age at least 18 years.
- Non-smoker or ex-smoker.
- Likely adherence to protocol.
- High risk phenotype (protease inhibitor Z). .
- Plasme alpha-1 antitrypsin levels below 50 - 80 mg/dl.
- Airflow obstruction with spirometry.
Improve survival in patients with severe sepsis and APACHE score of 25 or greater.
Activated protein C.
Platelets below 30,000 are a relative contraindication.
Mortality benefit not shown if APACHE score less than 25 or only one organ system involved.
Routes of epinephrine in anaphylaxis/anaphylactic shock.
Epinephrine can be given subcutaneously, intramuscularly or intravenously; depending on severity of symptoms.
Diagnosis in young woman with spontaneous pneumothorax and cystic changes seen on high resolution CT scan.
Lymphangioleiomyomatosis.
Management of pulmonary involvement in systemic sclerosis.
Minimal lung involvement (less than 20%) just requires periodic lung function testing and high resolution CT scans. Severe, but not moderate involvement may benefit from cyclophosphamide. FVC less than 70% of predicted is predictive of response to therapy.
If there is a lung nodule and a malignant appearing lymph node which one would you biopsy.
The lymph node because that would establish the stage as well, whereas biopsying the lung nodule would only establish the diagnosis and not the stage.
Management of complex parapneumonic pleural effusions with septations.
Initially try pleural fluid drainage with a chest tube or catheter, and then a trial of thrombolysis for the septations. If there is no response then a surgical consultation for VATS is warranted.
Caloric requirements of patients in the ICU.
Critically ill patients typically require 25 - 30 nonprotein kcal/kg/day and 1 - 1.5 protein kcal/kg/day.
Severely malnourished patients require 30 nonprotein kcal/kg/day and 1.5 protein kcal/kg/day.
In patients with hypoxemia and ARDS which ventilator setting should be changed?
The PEEP should be increased to recruit the collapsed and flooded alveoli.
Rewarming techniques in hypothermia.
Mild hypothermia: 93 - 97 F - passive and active rewarming techniques.
Moderate hypothermia: 86 - 93 F - active external rewarming by rewarming the trucal areas first.
Severe hypothermia: less than 86 F - active internal rewarming techniques.
Depressed consciousness and hypoventilation in a patient who has been receiving pain medications.
Think of opiod overdose and treat with intravenous naloxone.
Pulmonary hypertension and chronic progressive dyspnea in a patient with no parenchymal lung disease (or out of proportion disease).
Think of chronic thomboembolism; and go for a V/Q scan before doing a pulmonary catheterization.
Patient with fever who stopped taking her antiParkinsonian medications.
Neuroleptic malignant syndrome.
Causes:
1. Taking neuroleptic drugs.
2. Abrupt withdrawal of antiparkinsonian medications.
Treatment of idiopathic pulmonary fibrosis.
Lung transplant is the only therapy that improves survival.
Reduction of post-operative risk of pulmonary complications in COPD patients who smoke.
Incentive spirometry.
If patient quits smoking two months before surgery then there is a decrease in pulmonary complications.
Moderate COPD with rising pCO2 and use of accessory muscles.
Initiate non-invasive positive pressure ventilation early. It can prevent the need for intubation.
Definitive therapy for chronic thromboembolic pulmonary hypertension.
Pulmonary thromboendarterectomy.
Common cause of difficulty weaning from ventilator.
Excessive ventilation.
Treatment for patient with homogenous emphysema with FEV1 less than 20% of predicted and DLCO less than 20%.
Lung transplantation.
They have a median survival of 3 years. Lung transplant improves quality of life but not survival.
Treatment of severe pulmonary arterial hypertension.
Intravenous epoprostenol.
Evaluate lung nodules 1 - 2 cm in size.
Transthoracic needle aspiration of nodule will have a higher yield than bronchoscopy for nodules of this size.
Interstitial lung disease in the context of significant past or current smoking.
Respiratory bronchiolitis interstitial lung disease.
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
Main influenza vaccine used in US.
Trivalent killed virus.
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
Main influenza vaccine used.
Trivalent killed virus.
Propofol infusion syndrome.
Primarily occurs in patients with acute neurological or inflammatory conditions complicated by severe sepsis or infection who are receiving catecholamines or corticosteroids in addition to propofol. Symptoms include heart failure, rhabdomyolysis, severe metabolic acidosis and renal failure associated with hyperkalemia.
Role of limiting exposure of allergens in asthma patients.
Limiting allergens as a main intervention in asthma is not very effective. It might be effective in allergic patients who also have difficult-to-control asthma,
How would you monitor the respiratory status of a patient with neuromuscular weakness.
Measuring serial vital capacity.
Patients with vital capacity under 15 - 20 ml/kg, who are unable to generate more than 30 cm H2O of negative inspiratory force, or those with declining values are at high risk of ventilatory failure requiring invasive mechanical ventilation.
Treatment of Helicobacter pylori after initial proton-pump inhibitor based triple therapy has failed to eradicate the infection.
Bismuth based quadruple therapy with a proton-pump inhibitor, bismuth subsalicylate, metronidazole and tetracycline.
The initial failure is most likely secondary to non-compliance or resistance to clarithromycin.
Colorectal cancer screening in a patient with ulcerative colitis.
Colorectal cancer screening should be initiated 8 years after onset of disease (risk 1 - 2% per year after 8 years). Screening is done with colonoscopy 8 years after onset of disease and follow-up colonoscopy every 1 - 2 years thereafter.
If someone has MALT (Mucosa-associated lymphoid tissue) then what should you test for?
Helicobacter pylori.
First line treatment for diffuse esophageal spasm.
Proton-pump inhibitor.
It is usually caused by GERD so a trial of PPIs is recommended first.
In obscure GI bleeding - if the EGD and colonoscopy have previously been normal, what is the next step?
Repeat EGD.
This identifies the source in a significant number of patients.
Alcoholic patient with chronic diarrhea, normal pancreatic enzymes, and fat in his stool. What is the diagnosis and treatment?
Chronic pancreatitis and pancreatic insufficiency.
Pancreatic enzyme replacement (even if the serum levels are normal).
Alcoholic patient with chronic diarrhea, normal pancreatic enzymes, and fat in his stool. What is the diagnosis and treatment?
Chronic pancreatitis.
Pancreatic enzyme replacement (even if the serum levels are normal).
Treatment of achalasia in the elderly or people with multiple co-morbidities.
Botulinum toxin injection is the treatment of choice in patients who are not candidates for surgical or endoscopic treatment.
Treatment of achalasia in the elderly or people with multiple co-morbidities.
Botulinum toxin injection is the treatment of choice in patients who are not candidates for surgical or endoscopic treatment.
Criteria of irritable bowel syndrome and initial management.
Recurrent abdominal pain or discomfort.
Marked change in bowel habits for at least 6 months.
Symptoms experienced at least 3 days a month for 3 months.
Two or more of the following:
1. Pain relieved by bowel movement.
2. Onset of pain related to change in frequency of stool.
3. Onset of pain related to change in appearance of stool.
Symptomatic treatment.
Treatment for eosinophilic esophagitis.
Topical (swalllowed) liquid corticosteroids.
How to proceed if you have a patient who might have Hereditary Nonpolyposis Colorectal Cancer in his family.
Refer for genetic counseling. Initial genetic testing should be under the guidance of a genetic counselor and the initial sample should be taken from a relative affected with cancer.
CT scan of abdomen: well-circumscribed lesion in liver with and an enhancing central scar.
Treatment?
Focal nodular hyperplasia.
This is benign and just requires observation.
Treatment of acute, recurrent bleeding from H. pylori infected peptic ulcer that does not respond to endoscopic treatment.
Surgical treatment.
Imaging modalities of staging of gastric adenocarcinoma.
After diagnosis by EGD, initial staging is done by CT imaging, followed by pre-operative PET scan if the lesions on the CT scan are indeterminate.
Symptoms of achalasia with mass at the distal esophagus - management.
Psuedoachalasia.
Endoscopic ultrasonography of the esophagus with needle biopsy to evaluate the mass.
How do you diagnose pancreatic cancer if a mass is not seen on CT scan.
Endoscopic ultrasonography.
Delayed gastric emptying after infectious gastroenteritis.
Post-viral gastroparesis.
Next step in evaluation of obscure GI bleeding after the patient has had two negative EGDs and a negative colonoscopy.
Wireless capsule endoscopy.
Management of fundic gland polyps.
No follow-up needed.
No malignant potential.
If the liver function tests are abnormal after a liver transplantation in a Hepatitis C patient, what is the next step?
Liver biopsy to differentiate between recurrent hepatitis C infection and rejection.
Colon cancer screening in patients with a family history of colon cancer or adenomas.
Screening should be started at age 40 or at an age 10 years younger than the youngest affected family member, whichever comes first. Screening is done by colonoscopy 3 - 5 years.
How long can patients with acute hepatitis C remain seronegative? And what should you test for?
They can remain seronegative up to 8 weeks.
Check HCV RNA.
Evaluation of younger patient with hematochezia and low risk for colon cancer.
Flexible sigmoidoscopy.
What is the most sensitive test for chronic pancreatitis?
Endoscopic reterograde cholangiopancreatography (ERCP).
Management of high grade dysplasia detected at screening colonoscopy in ulcerative colitis patients.
Total proctocolectomy.
Biopsy specimen from esophageal ulcer in immuno-suppressed patient shows intense inflammatory infiltrates with granulation tissue associated with occlusion body cells. Diagnosis?
Cytomegalovirus esophagitis.
What is the next step in evaluating a patient with a clinical diagnosis of pancreatitis?
Abdominal ultrasound to rule out gallstones.
Management of patients with abnormal liver enzymes and abnormal transferrin saturation.
Screen for hereditary hemochromatosis - mutations of the HFE gene.
Treatment with phlebotomy, or chelation if patient cannot tolerate phlebotomy (anemic).
Management and screening of a patient after resection of colon cancer.
Initial colonoscopy (pre- or post-operative) and then colonoscopy at 1 year, 3 years and 5 years.
CEA every 3 months post-operatively for 3 years.
CT scan at 1 year for 3 years.
History and physical exams every 3 - 6 months for 3 years and then every 6 months for the next 2 years.
Patient who just had bariatric surgery presenting with sudden shortness of breath, tachycardia and tachypnea.
Suspect pulmonary embolism.
Infrequent early complication of bariatric surgery, but accounts for 50% of the deaths in these patients.
Treatment of a single focus hepatocellular carcinoma in a patient with decreased liver reserve (cirrhosis - decompensated or with complications).
Evaluation for a liver biopsy.
Persistently elevated liver enzymes in patients with metabolic disease should get…
Liver biopsy.
To distinguish between non-alcoholic steatohepatitis and steatosis.
Persistently elevated liver enzymes in patients with metabolic disease should get…
Liver biopsy.
To distinguish between non-alcoholic steatohepatitis and steatosis.
Persistently elevated liver enzymes in patients with metabolic disease should get…
Liver biopsy.
To distinguish between non-alcoholic steatohepatitis and steatosis.
Left lower quadrant abdominal pain, fever, and elevated leukocyte count.
Diagnosis and best imaging modality?
Diverticulitis.
CT Abd/Pelvis.
What kind of murmurs in asymptomatic patients needs a trans-thoracic echocardiogram?
- Systolic murmurs grade 3/4 or higher in intensity.
- Diastolic murmurs.
- Continuous murmurs.
- Holosystolic murmurs.
- Late systolic murmurs.
- Murmurs associated with ejection clicks.
- Murmurs that radiate to neck or back.
Asymptomatic patient with non-radiating, systolic, 2/6 intensity murmur. Does he/she need an echocardiogram?
No.
What has the greatest effect on reducing mortality in coronary artery disease patients?
Smoking cessation.
Chest pain in cancer survivor with previous radiation therapy. Suspect?
Premature coronary artery disease.
Treatment of a type A (proximal) aortic intramural hematoma.
Emergency cardiothoracic surgery.
Treatment of a type B (descending aortic) intramural hematoma.
Intravenous beta-blockade followed by intravenous sodium nitroprusside to control blood pressure.
Pulmonary edema and low ejection fraction. Think of…
Congestive heart failure and give intravenous furosamide.
Fixed splitting of the S2, systolic pulmonary flow murmur, right ventricular or parasternal impulse and right sided cardiac chamber enlargement noted on chest radiograph.
Ostium secondum atrial septal defect.
What can high sensitivity C-reactive protein be useful for?
Reclassifying patients with an intermediate cardiovascular risk as either high or low risk.
Symptomatic bicuspid aortic valve and dilated aortic root. Treatment?
Aortic valve replacement and if aortic diameter is more than 45 mm then ascending aortic graft placement (aortic root surgery).
Dronedarone - effect on kidney.
May reduce creatinine clearance. However, does not reduce glomerular filteration rate or kidney function.
What do you give patients with high risk NSTEMIs in addition to heparin for anticoagulation?
Glycoprotein IIb/IIIa inhibitors.
What is the best anti-arrhythmic drug for atrial fibrillation in the setting of heart failure and structural heart disease?
Amiodarone.
What does the door to balloon need to be for primary percutaneous intervention?
90 minutes or less.
If the transfer time is 90 min - that’s too long.
How do you give mechanical hemodynamic support in cardiogenic shock.
Placement of an intra-aortic balloon pump. This will reduce afterload and increase cardiac output.
When do you need mechanical hemodynamic support in cardiogenic shock?
When cardiogenic shock does not improve with inotropic agents.
Management of patient with aortic mechanical valve without additional risk factors on warfarin who needs a surgery.
Discontinue warfarin 48 - 72 hours before the surgery and resume after the surgery as soon as hemostasis allows.
Preferred treatment of pulmonary valve stenosis.
Pulmonary balloon valvuloplasty.
The Reynold’s risk score versus the Framingham risk assessment system.
The Reynolds risk score is a sex-specific cardiovascular risk assessment system that is more sensitive in predicting risk in women compared with the Framingham risk assessment system.
Treatment of wide-complex tachycardia with a history of coronary artery disease or cardiomyopathy.
Ventricular tachycardia.
Treat with amiodarone.
Diagnosis?
Patient has clubbing, cyanosis, right ventricular hypertrophy and decreased pulmonary vascularity on chest radiograph.
Eisenmenger syndrome.
After ablation for atrial fibrillation what should be done about the anticoagulation?
All patients should continue warfarin for 2 - 3 months. After this the anti-coagulation is based on the CHADS2 score; as if the ablation never happened.
Treatment of patient with repaired Tetralogy of Fallot who developed pulmonary valve regurgitation, which leads to right heart enlargement, tricuspid valve regurgitation and atrial fibrillation.
Pulmonary valve replacement.
Tricuspid valve repair.
And a maze procedure.
Treatment of unstable angina in patients with contraindications to beta-blockers.
Diltiazem.
First line therapy.
Which supraventricular tachycardias does adenosine terminate?
- AV nodal re-entrant tachycardia.
2. AV reciprocating tachycardia.
Management of patient with chronic, severe mitral regurgitation and normal left ventricular systolic function, with new-onset atrial fibrillation.
Mitral valve repair surgery.
How long do you keep a patient on clopidogrel if they have unstable angina or an NSTEMI treated medically with no stent placed after cardiac catheterization?
For at least 1 month and ideally for 1 year.
Patient with chronic stable angina is symptomatic on optimal doses of beta-blockers, calcium channel blockers and nitrates. Next step?
Ranolazine.
What do you do with an ICD during surgery?
Turn off the shock therapy because the electrocautery will cause it to go off.
- Packemaker dependent people: turn of shock function and change pacing function to asynchronous mode.
- Non-pacemaker dependent people: Putting a magnet over the ICD will disable the shock feature.
STEMI with single vessel disease. Treatment?
Primary percutaneous coronary intervention.
What EKG change can haloperidol produce?
Prolonged QT increasing the risk for Torsades de pointes.
How do you assess for recurrent coarctation or aneurysm in patients with a repaired aortic coarctation?
CT or MRI of the heart.
When should patients admitted to the hospital for heart failure follow-up after discharge.
Physician appointment one week after discharge.
When would you not image someone with abdominal aortic aneurysm?
Not a surgical candidate because of multiple co-morbidities.
New-onset heart failure in patients with angina; or new-onset left ventricular dysfunction in the setting of a condition that may predispose to silent ischemia. Next step?
Coronary Angiography.
What vascular complications can occur after percutaneous coronary intervention and what study would you do?
Pseudoaneurysm or arteriovenous fistula.
Duplex ultrasonography would differentiate between the two.
Management of a limb that has severe motor impairment, dense anesthesia and lack of Doppler vascular signals.
Acutely ischemic non-viable limb.
Needs prompt amputation.
How do you monitor an infrequent arrhythmia?
Implantable loop recorder.
What are the indications of aortic value replacement in patients with severe aortic stenosis?
- Symptomatic.
- LVEF less than 50%.
- Exercise results in hypotension or symptoms.
- Rapid progression of stenosis.
- Very severe stenosis (mean gradient > 60 mmHg)
Findings on echocardiography: Restrictive ventricular diastolic filling, severely dilated atria, and small- to normal-sized ventricular cavities. Diagnosis?
Restrictive cardiomyopathy.
What is myopericarditis?
Acute pericarditis occurring together with myocardial injury unrelated to myocardial infarction that may lead to heart failure.
What stressor should be used in patients with severe reactive airway disease who require pharmalogical stressing?
Dobutamine.
What study can be used to confirm cardiac involvement in sarcoidosis?
Cardiac magnetic resonance imaging.
What is the initial test of choice when there is a moderate or high pretest probability of endocarditis?
Transesophageal Echocardiography.
Pleuritic chest pain, regional concave downward ST-segment elevation, regional or global left ventricular dysfunction but no obstructive coronary artery disease in the distribution of dysfunctional myocardium, and elevated cardiac biomarkers.
Myopericarditis.
How do you detect right to left intracardiac shunts on echocardiography?
An agitated saline contrast study.
What stress test is used in patients who are able to exercise but have baseline electrocardiographic abnormalities?
An exercise nuclear stress test.
If the ankle-brachial index is 1.4 or more; how will you establish the diagnosis of peripheral artery disease?.
Cannot be interpreted. Indicates non-compressible vessels.
Measure great toe systolic pressure to establish diagnosis.
Management of patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia who experienced a syncopal event.
Placement of an implantable cardioverter-defibrillator.
Which calcium channel blockers may precipitate heart failure due to their negative inotropic effects in patients with a history of systolic heart failure?
Diltiazem.
Nifedipine.
Verapamil.
What calcium channel blockers can be given in systolic heart failure patients to control blood pressure?
Amlodipine.
Felodipine.
In a patient with peptic ulcers and arthritis, what is important to look for?
Review medication list to make sure the patient is not using too many NSAIDS.
Liver mass that is:
- A hyperechoic lesion on ultrasonography.
- Peripheral arterial enhancement on contrast enhanced CT scan with no central scar.
- Hyperintensity on both T1- and T2-weighted images.
Hepatic adenoma.
Liver biopsy specimen shows sheets of hepatocytes with no bile ducts or Kupffer cells.
(CT shows peripheral arterial enhancement with no central scar).
Hepatic adenoma.
Liver biopsy shows sheets of hepatocytes with bile ducts and Kupffer cells.
(CTs shows peripheral arterial enhancement with a central scar).
Focal nodular hyperplasia.
Treatment of patient with Barrett esophagus and high-grade dysplasia.
Esophagectomy.
Treatment of gastric adenomatous polyps.
Endoscopic polypectomy (regardless of degree of dysplasia since they all have malignant potential).
A patient has a significant portion of his distal ilium and proximal colon resected.
What kind of diarrhea will he have and what is the treatment?
Secretory diarrhea because the bile salts will not be absorbed.
Treatment is with Cholesytramine.
Multiple patients affected within 2 - 5 days of being at the same event. The have abrupt onset of fever, headache, malaise, chest pain, sore throat, abdominal pain, myalgia, and a dry non-productive cough. Chest radiography shows consolidation.
Pneumonic tularemia.
Suspect bioterrorism
Patient with history of transplant, presents with non-productive cough, decreased oxygen saturation and bilateral pulmonary infiltrates on chest radiography.
Diagnosis?
Pneumocystis jirovecii pneumonia.
AIDS patients with multiple, nonenhancing lesions in the white matter on MRI with no mass effect.
Progressive multifocal leukoencephalopathy (demyelinating disease).
Mild diabetic foot infections in patients without a history of chronic nonhealing ulcers or prior antibiotic use…
Which organisms would you direct antibiotic therapy against?
Aerobic gram positive cocci.
Skin and subcutaneous infections with chronic, purulent drainage, lack of convincing pathogen on routine culture, and association with implanted prosthetic devices.
Organisms?
Mycobacterium abscessus.
Treatment of Herpes simplex encephalitis.
Intravenous acyclovir for 14 - 21 days. If repeat PCR testing is negative at the end of treatment that is a better prognosis. If positive then acyclovir should be continued.
If Mycobacterium avium complex grows out of a culture after a patient has already been treated (and clinically improved) for community-aquired pneumonia then what will you do?
Not treat it.
Can be contaminants or colonizers of sputum culture.
How do you treat Pseudallescheria boydii and Scedosporium apiospermum?
Sensitive to triazoles.
Resistant to Amphotericin B.
How do you treat Pseudallescheria boydii and Scedosporium apiospermum?
Sensitive to triazoles.
Resistant to Amphotericin B.
Box-shaped gram-positive bacilli causing pneumonia and how to treat it?
Inhalation anthrax.
Initial therapy includes a fluoroquinolone or doxycycline plus one or two additional agents (for example, penicillin, erythromycin, vancomycin, rifampin, or clindamycin.)
Which antiretroviral agent is contra-indicated in pregnancy?
Efavirenz.
Pregnancy risk Category D.
What is the empiric treatment for a cerebrospinal fluid shunt infection?
Vancomycin with either Ceftazidime, Cefepime or Meropenem.
A patient has altered mental status, parkinsonism, tremors, myoclonus and poliomyelitis-like flaccid paralysis.
What’s the diagnosis?
West Nile encephalitis.
What is the treatment of a penicillin allergic non-pregnant patient who has syphilis?
Doxycycline.
Drug of choice for pulmonary aspergillosis in immunosuppressed patients.
Voriconazole.
Standard outpatient management of non-pregnant women with pyelonephritis.
Oral floroquinolone.
Treatment of non-gonococcal urethritis.
Oral Azithromycin.
What do you do if an otherwise healthy person has been exposed to someone with chicken pox?
Serologic testing for varicella virus antibodies.
