MKSAP15 Flashcards
1
Q
What can you say about white blood cell counts in septic arthritis of prosthetic joints?
A
Often times it is much lower than native joint and some say the cutoff leukocyte count should be as low as 1100 to call it septic arthritis
2
Q
What is the most appropriate tx for pt with arthritis, conjunctivitis, urethritis and PCR + for C. trachomatis?
A
Azithromycin + NSAID (i.e. indomethacin); pustular skin lesions, if present = Keratoderma blenorrhagicum
3
Q
Most appropriate test for a pt with a non-diminishing varicocele L sided
A
CT abdomen
4
Q
What should be started while culture findings are pending in patients with suspected septic arthritis?
A
Empiric Vancomycin and CTX
5
Q
What are Lofgren’s syndrome and Heerfordt’s syndrome?
A
Both are acute forms of sarcoidosis; Lofgren = ankle arthritis, erythema nodosum, and hilar LAD; Heerfordt’s = uveoparotid fever and CN VII palsy
6
Q
What are some common manifestations of dermatomyositis aside from rash and muscle weakness? When do these tend to be present?
A
Arthritis and ILD (usually NSIP) and these are usually when there is an anti-synthetase syndrome (Ab against aminoacyl t-RNAs, Anti-Jo-1)
7
Q
What is the first line tx for Raynaud phenomenon in pt with limited cutaneous systemic sclerosis
A
Amlodipine or nifedipine
8
Q
This finding on a BAL specimen would clinch a diagnosis of Coccidiodes
A
Spherule
9
Q
What is the most appropriate tx for idiopathic cutaneous small vessel vasculitis?
A
Prednisone
10
Q
The cancer with which acanthosis nigricans is most associated is ______
A
Gastric CA
11
Q
What are the crystals in Milwaukee Shoulder Syndrome made of?
A
Calcium Hydroxyapatite
12
Q
Most likely diagnosis in a young smoker with occlusive arterial dz with limb loss
A
Thromboangiitis obliterans; Buergers disease
13
Q
Preferred mgmt of pseudogout involving a single joint
A
Intraarticular glucocorticoid injection
14
Q
What is the cause of meralgia parasthetica?
A
Entrapment of the lateral femoral cutaneous nerve at the inguinal ligament
15
Q
Where is a Codman Triangle seen?
A
This is the periosteal reaction, “sunburst” pattern of osteosarcoma
16
Q
SCC found in a cervical LN is __________ until proven otherwise; next steps?
A
Head and Neck CA; CT and “Triple Endoscopy” with laryngoscopy, endoscopy, and bronchoscopy
17
Q
In a patient on steroids, when should you consider PCP ppx?
A
If on 20 mg or more of prednisone for more than 3 weeks; Tx is with one SS pill daily or a DS pill 3x weekly; same for AIDS
18
Q
How can you use complement levels to help differentiate cryoglobulinemia from HSP?
A
Complement levels are often normal in HSP because IgA does not fix complement; cryoglobulinemia often has low complement levels and can be associated with HCV; also less likely to have abdominal pain seen in HSP bc cryo does not affect abdomen as much
19
Q
A patient with a hx of oligoarticular juvenile idiopathic arthritis should be screened for what joint condition as an adult
A
TMJ arthritis
20
Q
What is the most sensitive test for inflammatory sacroiliitis in a patient with Crohn dz
A
MRI of the sacroiliac joints
21
Q
What tumor and tumor marker is associated with cryptorchidism?
A
Seminoma; B-HCG
22
Q
What workup should be done for a pregnant patient with SLE with Anti-Ro antibodies?
A
Fetal cardiac US bc baby can have congenital heart block
23
Q
What is the most appropriate test for a woman with an inflammed breast that has not responded to PO abx?
A
Biopsy as it is likely inflammatory breast CA
24
Q
Explain the relationship between cyclosporine and gout
A
Cyclosporine commonly causes hyperuricemia and it also inhibits hepatic metabolism of colchicine
25
Cryoglobulins are immunoglobulins that precipitate out of serum at temps \< \_\_\_\_\_\_. The infection MC assoc with Type II "Mixed" cryoglobulinemia is \_\_\_\_\_\_
37 C; HCV
26
The development of acute sarcoidosis with uveoparotid fever and CN VII palsy is \_\_\_\_\_\_
Heerfordts syndrome
27
What has fixed splitting of S2, a mitral regurgitation murmur and L axis deviation
Ostium primum ASD (MR due to mitral valve cleft)
28
A cutaneous nodule with a bruise-like appearance in a patient with previous hx of radiation to the area is suspicious for \_\_\_\_\_\_\_\_\_
Radiation-Associated Angiosarcoma
29
What disorder of the shoulder is associated with a large shoulder effusion, destructive arthritis, and calcium hydroxyapatite crystals?
Milwaukee Shoulder syndrome
30
What is also usually given to women who have brest conserving therapy for breast CA?
Adjuvant RT; if ER/PR positive then also add hormone therapy x10 years (tamoxifen if premenopasual, AI if not)
31
80% of patients with PSC also have this disease
Ulcerative Colitis so if PSC is dx'd they need to be screened for UC but the opposite is not true
32
Patients with HHV-8 seropositivity undergoing a solid organ transplantation have a high risk of \_\_\_\_\_\_
Kaposi Sarcoma (due to immunosuppression)
33
The presence of earlobe infarctions in a cocaine user should prompt you to think of \_\_\_\_\_\_\_\_
Cocaine-induced vasculitis due to levamisole (a veterinary antihelminthic agent); often strongly ANCA positive with BOTH anti-PR3 and anti-MPO
34
What is the best step in mgmt of a young woman with acute monoarticular arthritis that appears septic but whose gram stain is negative and there are no crystals?
Aside from empiric abx would check Nucleic Acid Amplification test for Gonorrhea (cervical or throat); can also test for Chlamydia to differentiate from reactive arthritis
35
The 3 markers of APS are \_\_\_\_\_\_\_\_\_\_\_\_. What is an ulcerating skin rash seen in APS?
Anti-cardiolipin, Anti-Beta-2-glycoprotein, and Lupus anticoagulant (check 2x, 12 w apart); Occlusive vasculopathy (would not expect nodules as seen in PAN)
36
The triad of erythema nodosum, arthritis (often ankles), and hilar adenopathy is \_\_\_\_\_\_\_\_\_
Lofgren's syndrome a form of acute sarcoid (don?t forget that acute sarcoid can have a fever)
37
In a pt with GCA the symptom most likely to portend blindness is \_\_\_\_\_\_\_\_
Amaurosis fugax
38
What can you say about vasoreactivity testing in patients with WHO 1 pulmonary HTN associated with a CTD (eg. SS w/ anti-centromere)?
While it is a WHO 1 group so you should do a vasoreactivity test to look for drop in MPAP or in pulmonary vascular resistance, there is a low likelihood of having a positive test in CTD related
39
Most appropriate test for a post-menopausal woman treated with tamoxifen who has irregular vaginal bleeding
Endometrial biopsy; in general post-meno women with irregular bleeding shoud get bx
40
Pain related to spondylolysis is worse in what position? What structure is affected?
Extension; pars interarticularis
41
Most important component of mgmt of hypercalcemia of malignancy
Aggressive IV hydration followed by an IV bisphosphonate
42
Granulomas in the skin and lungs without another explanation suggests this dx \_\_\_\_\_\_\_\_\_\_
Sarcoidosis
43
What often precedes the vasculitic phase of EGPA by several months to years? Greatest mortality in EGPA supposedly from \_\_\_\_\_\_
Asthma, allergic rhinitis and atopic symptoms almost always precede the vasculitic phase; cardiac involvment
44
Most likely dx in a pt with persistent fevers, organomegaly, arthritis, elevated transaminases, and a highly elevated ferritin level
Adult Onset Still Disease (Yamaguchi criteria); often with evanescent salmon colored rash
45
What are the ceruloplasmin levels and urinary copper levels in Wilson Dz?
Low ceruloplasmin and high urinary copper
46
Dyspnea and decreased exercise tolerance in systemic sclerosis is likely due to one of 2 things how would you differentiate? Abs assoc?
Pulmonary HTN (WHO 1, get vasoreactivity test) and this is more common with Anti-Centromere; or ILD usually NSIP pattern more with Anti-Scl70/Topoisomerase 1
47
Most likely cause of cutaneous vasculitis in pt who uses cocaine
Levamisole (a veterinary antihelminthic agent) often positive for BOTH anti-MPO and anti-PR3 and commonly causes earlobe infarctions
48
The general leukocyte cutoff at which a joint is considered likely to be septic is \_\_\_\_\_\_\_\_; notable exception?
Around 50,000; however, if it is a prosthetic joint the cutoff can be lower
49
How is EGPA different from a Hypereosinophilic Syndrome?
HES often has cardiac involvement, eosinophilic PNA (\>25% eos on BAL, photographic neg of CHF) but EGPA often has hx of pre-existing asthma and atopy and can have neuropathy and often + ANCA (anti-MPO/ p-ANCA)
50
This is the most likely dx in a young adult with a destructive bony lesion of the knee with a sunburst pattern on XR
Osteosarcoma; CT chest next to look for ; the periosteal reaction is called the "Codman Triangle"
51
This is the tumor marker for yolk sac tumors
Alpha-fetoprotein (AFP)
52
Which part of the cerebral circulation is the most commonly affected by Giant Cell Arteritis?
Vertebrobasilar circulation (but also get involvement of ophthalmic artery which is an anterior circulation artery)
53
How is the sinus sx different in GPA vs. EGPA
GPA (anti-PR3/ C-ANCA) often has vasculitic destruction and bleeding whereas the sinus involvment in EGPA is more atopic so things like nasal polyps and allergic rhinitis
54
What is the most likely Dx in an afebrile pt who presents with erythema and tenderness of the breast one month into the course of adjuvant RT for breast CA
Radiation-Induced Dermatitis
55
What labs should be checked in a man with predominant osteoblastic mets and adenocarcinoma of unknown primary
PSA as it is likely prostate CA
56
Violaceous lesions on the the face are _________ and pathognomonic for \_\_\_\_\_\_\_\_\_
Lupus pernia; sarcoidosis
57
What type of glomerulonephritis is commonly associated with cryoglobulinemic vasculitis?
Membranoproliferative GN (recall: this is mixed cryo, type 2. polyclonal and monoclonal)
58
Best mgmt of recurrent ganglion cyst on dorsal aspect of wrist with pain
Surgical Excision
59
Chronic blood loss in scleroderma may be due to \_\_\_\_\_\_\_\_
GAVE as it is actually a manifestation of the vascular pathology (i.e. Telangiectasias)
60
How can oral ulcerations and GI sx in a pt on MTX for DMARD tx for RA be managed?
First line would be folate supplementation but if truly cannot tolerate then may need to switch drugs
61
Membranoproliferative Glomerulonephritis is commonly associated with this vasculitis
Cryoglobulinemic (Type 2 Mixed Cryoglobulinemia) often RF positive, assoc with HCV
62
What is the best mgmt in suspected "preradiographic" axial spondyloarthritis
Would want to start NSAIDs and PT and continue to monitor for radiographic changes
63
What would be the best test to order for a patient with systemic sclerosis, anti-Scl70 who has shortness of breath?
HRCT as they probably have ILD (often NSIP pattern); if anti-centromere more likely pulmonary HTN
64
What is the most common pattern of ILD for ILD associated with a connective tissue disease? Exception?
Most CTDs have an NSIP pattern though they can have any that is the most common; RA on the other hand commonly causes a UIP pattern
65
This is a common knee syndrome in athletes who complain of lateral knee pain that radiates to the thigh
Iliotibial band syndrome; often in runners on uneven terrain; + Noble test pain when extending knee from 90-\>30 degrees with pressure on lateral condyle
66
A patient with RA being treated with infliximab who develops malar rash, serositis, and oral ulcers should raise suspicion for \_\_\_\_\_\_\_\_\_\_\_
Drug induced lupus; check Anti-Histone (positive in \>90% of cases)
67
A person with APS who develops multiple thrombotic events in multiple organs despite AC likely has what?
Catastrophic APS- when person develops a TMA with APS; tx is AC and steroids along with either PLEX or IVIG
68
What rheumatologic condition can Anti-TNF-A inhibitors potentially CAUSE
Drug-Induced Lupus (Anti-Histone); whereas DI-SLE usuallly does NOT cause nephritis, the SLE induced by TNFs can
69
What needs to be checked for pt with gout of Thai or Han descent prior to starting allopurinol and why
HLA-B5801 allele as there is an increased risk for severe allergic rxn in these pts
70
What is the most appropriate tx for a single brain met in NSCLC?
Stereotactic radiosurgery \> resection; WBRT if multiple; IT chemo more for lymphomatous meningitis and leptomeningeal carcinomatosis
71
Combination of malar rash, serositis, and arthralgia in a patient who just started taking chlorpromazine; tx?
Drug-induced Lupus (Anti-Histone); withdrawal of drug and if severe then steroid; also assoc: procainamide, hydralazine, minocycline, and TNF-A, as well as methyldopa
72
How are the pulmonary-renal syndromes of SLE and anti-GBM different from ANCA vasculitis
SLE and anti-GBM would not affect upper airways and sinsuses; also ANCA vasculitis causes a pauci-immune GN whereas SLE would cause immune deposits (Type III hypersens) and GBM only affects lungs and kidneys and causes linear staining)
73
What is Caplan Syndrome?
RA and coal workers pneumoconiosis
74
What is Felty Syndrome? What hematologic malignancy is on the same spectrum?
RA, neutropenia, and splenomegaly; assoc with T cell LGL (but not NK cell LGL)
75
What type of bladder CA is associated with exposure to aromatic amine dyes (B-napthylene)
Transitional Cell CA
76
What is the most appropriate test to confirm a dx of HCC (i.e. seen on screening US)
Dyanamic Contrast-Enhanced MRI (or CT- 4 phase detector CT); often there is intense arterial enhancement with delayed washout in the venous phase; specific imaging findings can obviate need for Bx
77
Which type of cryoglobulins are "mixed" and are monoclonal and polyclonal and associated with HCV?
Type II "mixed" cryoglobulinemia
78
ANCA (p-ANCA/anti-MPO) tends to be positive in \_\_\_\_\_\_% of EGPA patients
Only 30-40% so need to go on clinical suspicion etc as well
79
The combination of uveitis and a junctional rhythm should make one consider \_\_\_\_\_\_; tx?
Cardiac sarcodosis; steroids are the mainstay
80
What diuretics can increase serum uric acid levels? Which can decrease?
Thiazides and Loops can increase; losartan can have uricosuric effects but unclear if it actually reduces gout flares
81
This cytokine tends to be elevated in Castleman's Disease
IL-6
82
A patient with new onset RA is likely to have arthritis at which joints? Which joint can help differentiate RA from other diagnoses such as OA and psoriatic arthritis?
Mainly PIP, MCP and flexor tendons; the DIP is more commonly affected by OA, gout, and psoriatic arthritis
83
What cause of septic arthritis will classically have a negative gram stain?
N. gonorrhea (gonococcal arthritis in disemminated gonoccocemia); why the dx requires clinical suspicion and the WBC count
84
What severe pulmonary disorder can occur with EGFR inhibitors such as afatinib and gefitinib
Interstitial Lung Dz
85
Recurrent episodes of inflammation involving ears, nose, respiratory tract and polyarthritis is characteristic of \_\_\_\_\_\_\_\_\_\_\_
Relapsing polychondritis
86
How would the presentation of IgG4 related cholangitis differ from PSC?
PSC would mostly just affect the liver whereas IgG4 disease would likely also affect the pancreas and possibly cause retroperitoneal fibrosis as well
87
What is the appropriate mgmt of surgically excised LCIS
Should continue with annual diagnostic mammography as well as chemoprevention with tamoxifen (almost always ER+); tends to recur in ipsilateral or contralateral breast
88
What are the 3 types of cryoglobulinemia?
Type I = MONOCLONAL immunoglobulins often d/t malignancy such as Waldenstroms and cause hyperviscosity syndrome; Type II = Mixed bc both polyclonal and monoclonal and most likely to cause vasculitis, HCV assoc; Type III is polyclonal and MC in CTDs and chronic infxn such as chronic osteo
89
What is the most likely organism to cause acute olecranon bursitis?
MSSA
90
Which type of cryoglobulins are monoclonal and most often seen in Waldenstroms where they can cause hyperviscosity and vasculitis?
Type I = monoclonal i.e. see ear infarctions etc in WM
91
Absent or diminished pulses in a young woman with arm pain and elevated inflammatory markers
Takayasu arteritis
92
What is the most appropriate agent to prevent recurrence of mild to moderate mucocutaneous Behcet dz
Colchicine
93
Why is it important to start IV abx right away if you suspect septic arthritis?
Because it can be rapidly destructive to the joing and bc the person could develop sepsis etc.
94
In patients with SLE the most common cause of symptomatic cardiac disease is \_\_\_\_\_\_\_\_\_
Pericardial effusions or pericarditis; however, they also have increased risk of accelerated coronary dz
95
A unilateral, warm, swollen, and erythematous foot in a DM pt who is afebrile with a normal ESR is likely \_\_\_\_\_\_\_\_\_
Diabetic Neuropathic Arthropathy (often with pes planus) aka Charcot Foot
96
Testing for what infection is important in Type II cryoglobulinemia?
HCV; Type II = mixed so see both polyclonal and monoclonal and often RF positivity; important to find the HCV bc tx of HCV helps tx the dz
97
Explain how the renal involvment of PAN would be different from HSP
Both are vasculitides that can cause abdominal pain; HSP is IgA nephropathy and has normal compliment levels; PAN does not cause glomerulonephritis bc it is a medium vessel vasculitis but can cause renal artery aneursyms and renal dysfxn
98
Best mgmt of enlarged lymph nodes in pt with Sjogren?
Excisonal bx as there is increased risk of DLBCL and marginal zone lymphoma
99
Which types of cryoglobulins are polyclonal and often associated with CTDs and chronic infections?
Type III cryoglobulins
100
This is the name of the criteria used to dx Adult Onset Still disease
Yamaguchi criteria
101
Homonymous hemianopsia indicates a lesion __________ whereas bitemporal hemianopsia indicates one \_\_\_\_\_\_\_\_\_
Homonymous hemianopsia or quadrantanopsia is due to occipital lobe infarction whereas bitemporal hemianopsia is due to optic chiasm lesion
102
This vasculitis is often ANCA positive and positive for BOTH anti-PR3 and anti-MPO
Cocaine-induced vasculitis due to levamisole (a veterinary antihelminthic agent); often causes earlobe infarctions (cryoglobulinemia does this too)
103
How are initial attacs vs. recurrent attacks of gout different?
Tend to be monoarticular at first but later on can become polyarticular and involve the upper extremities
104
Best additional workup of pt with sx of Raynaud phenomenon but no other signs or symptoms of systemic dz?
No additional workup; could tx with CCBs if ya want (if concern for other sx could do Anti-Scl70/topoisomerase 1 for Systemic Sclerosis; Anti-Centromere for LcSC)
105
How does Wilson disease tend to present in young patients? Old patients?
Young people can have acute liver failure and it can induce a hemolytic anemia; older patients tend to have more chronic liver dz and parkinsonian sx
106
This is the most appropriate tx to relieve sx of diarrhea and flushing associated with carcinoid syndrome while also controlling tumor growth
Octreotide
107
What is Catastrophic Antiphospholipid Syndrome? What is the mainstay of tx?
When a pt with APS develops a thrombotic microangiopathy; Tx is with anticoagulation AND glucocorticoids and EITHER PLEX or IVIG; the presentation is often multiple thrombotic events in multiple organs despite AC
108
Tx of choice for advanced or inoperable GIST
Imatinib (C-Kit is the activating mutation here)
109
What antibodies are associated with paraneoplastic sensory neuropathy and encephalomyelitis
Anti-Hu (often SCLC)
110
What are some cancers that people with Von-Hippel Lindau are at risk for?
RCC (clear cell), pheochromocytoma, and CNS hemangioblastoma
111
What is the common histopathologic pattern of ILD associated with Sjogren syndrome?
While most CTDs cause NSIP; Sjogren tends to cause LIP
112
MC AE of bevacizumab
Hemorrhage (i.e. pulmonary hemorrhage) but also nephrotic syndrome and elevated BP, poor wound healing
113
This zoonotic disease can cause bloody "lakes" in the liver known as hepatis peliosis
Bartonella henselae
114
Differentiate the arthritis of RA vs. SLE
RA is erosive and commonly affects MCPs, PIPs; SLE causes Jaccoud arthropathy which is nonerosive and causes reversible deformities
115
Patients receiving ADT for prostate CA should be monitored for this endocrine side effect?
Osteopenia; get DEXA at Dx
116
What is the difference between Lofgren's syndrome and Loffler's syndrome? Loeffler endocarditis?
Lofgren's is a form of acute sarcoidosis with erythema nodosum, hilar LAD, and arthritis; Loffler syndrome is a pulmonary infiltration of eosinophils in response to a parasite; Loeffler endocarditis is a restrictive CMO with infiltration of eosinophils (aka eosinophilic myocarditis)
117
How should lupus nephritis be treated?
With steroids and one of the 2 first line immunosuppresants = either MMF or Cyclophosphamide
118
What kind of gout is precipitated by lead toxicity?
Saturnine gout
119
What is the maximum dose of MTX for RA? What do you do if pt is still symptomatic on this dose?
25 mg qWeekly (often with folate supplement); ADD a TNF-alpha inhibitor (watch for drug induced lupus)
120
How is the presentation of HSP different from PAN?
Both are small vessel vasculitides; HSP often follows a URI whereas PAN often has association with HBV; both can affect the abdomen though PAN prob has lots of aneurysms; additionally the skin lesions in PAN are often livedo reticularis or racemosa and there are DEEP CUTANEOUS ULCERS OR NODULES that are not seen in HSP
