In a pt with hx of breast CA with findings of a new metastasis what is the next best step
Biopsy to confirm and to assess receptor status as it may have changed from the original tumor; particularly Her2 (a tyrosine kinase; trastuzumab induces rapid removal of Her2 from cell surface)
How do you manage non-typhoidal Salmonella gastroenteritis in healthy patients?
You should withold antibiotics as it may prolong viral shedding
Explain pseudohypokalemia and pseudohyperkalemia in leukemias
Pseudohypokalemia can be due to increased uptake of K by the tumor cells in the test tube; pseudohyperkalemia can be due to lysis of the tumor cells in the test tube; both are relative diagnoses of exclusion
What provides a more realistic estimate of risk: absolute risk reduction or relative risk reduction?
Absolute Risk Reduction (i.e. the classic example is that if relative risk is 50% that sounds like a lot but if the risk in population is 1 in 1000 the absolute risk is now 1.5 in 1000)
How is the heart disease of SLE different from that of systemic sclerosis?
SLE is associated with accelerated coronary artery disease which could lead to ischemic CMO; systemic sclerosis is associated with microvascular cardiomyopathy due to small vessel vasospasm; of note, systemic sclerosis could also cause pulmonary HTN and lead to R heart failure indirectly
When should you use cyclosporine eye drops in Sjogren syndrome?
After failing artificial tears and maybe punctal plugs
What sorts of diseases lead to Microvascular Cardiomyopathy typified by patchy myocardial fibrosis?
Diseases such as systemic sclerosis as they can lead to coronary vasospasm with microvascular disease and therefore patchy myocardial fibrosis
What effect on morbidity and mortality does revascularization (cardiac cath) have on patients with stable angina who are medically refractory?
None but improves sx
What is the term used to describe dry eyes in Sjogren's?
What is a punctal plug?
They are placed in the tear ducts of patients with dry eyes to keep moisture on the eye itself
What effect does aldosterone have on the DCT?
Increased sodium and K exchange (i.e. hypokalemia with hypernatremia; aldosterone antagonists cause hyperkalemia)
What is the best step for a patient with what appears to be early ovarian CA on imaging?
Surgery as there is survival benefit following intact removal of an adnexal mass
What is the most common psoriatic nail finding?
Subungual Hyperkeratosis (not nail pitting, though that is more specific probs)
What direct cardiac pathology may a patient with systemic sclerosis experience that leads to heart failure?
Microvascular Cardiomyopathy- can have systemic sclerosis-induced vasospasm with microvascular dz and patchy myocardial fibrosis
How is vaginitis different from cervicitis?
Cervicitis often has friable cervix whereas vaginitis does not; cervicitis often STD and tx w/ CTX and azithro whereas vaginitis often fungal or trichomoniasis
What is Triage Cueing?
A type of bias in which a patient gets managed based on where they are triaged (probably bc you have a mental heuristic for how to manage floor vs. ICU vs. heme onc vs. GI)
What has the greatest influence on prognosis in a patient with DLBCL?
The r-IPI score
What autoimmune disease is typified by inflammation of exocrine glands?
Sjogren Syndrome (i.e. salivary, lacrimal, and pancreas)
After giving tPA for a stroke where should the person go? What is the BP goal? How long should anticoagulation and antiplatelet agents be held for?
To an ICU, BP goal is <180/105, and antiplatelets and anticoagulation should be held for 24 hours (don't place NGT, A-lines, or Foleys for first 24h unless critically needed)
If a newly diagnosed person w/ EF of 35% should you place an ICD?
No, would first need to optimize their heart failure meds and reassess; then, if on maximal therapy with EF <35% and NYHA II-III sx would have Class I indication
Differentiate use of SAVR vs. TAVR
SAVR is indicated in all pt with symptomatic severe AS who are low surgical risk; TAVR is indicated mainly for pt with intermediate risk
What is the preferred way to replace a bicuspid aortic valve, SAVR or TAVR?
SAVR; used to say that TAVR had no role but now that is coming into question
What is the major clinical difference between vestibular neuronitis and labyrinthitis?
In labyrinthitis the patient will also have hearing loss because the cochlea is affected as well
What asthma meds are safe in pregnancy?
Inhaled glucocorticoids, albuterol, and montelukast (leukotriene inhibitor)
Why is the diagnosis of ovarian CA usually best made by exploratory surgery rather than bx?
Because, for early ovarian CA, there is a survival benefit following intact removal of an adnexal mass
What drugs are used for IBS-C after failure of standard laxative therapy?
Linaclotide and Lubiprostone
What sort of diagnostic workup needs to be included in a patient with newly diagnosed heart failure
Ischemic workup either stress test (exercise or pharm if normal QRS; perfusion if LBBB or QRS morphology weird) vs. Cardiac catheterization
When is a CRT-D indicated in the mgmt of heart failure?
If a patient has severe conduction system disease with QRS >150 ms
What are the Centor Criteria?
Fever, Absence of Cough, Tonsillar exudates, and tender anterior cervical LAD (rapid strep if 2-3); If 4 then just treat
How do you treat cervicitis?
CTX 250 mg IM x1, azithromycin 1g x1; often caused by C. trachomatis or N. gonorrhea; friable cervix differentiates from vaginitis
What is a Halo Nevus and why does it look that way?
Benign melanocytic nevus with area of depigmentation around it which indicates regression of the nevus
What medications have been shown to alter the progression of aortic stenosis?
What are the management options for dry eyes in Sjogren's syndrome?
Can start with artificial tears, then punctal plugs, then cyclosporine eye drops (Restasis)
How long after giving TPA should you wait to place NGT, Foley, or A-lines?
At least 24 hours
What has a class I indication in pt w/ HFrEF w/ EF <35% and NYHA II-III sx while on maximal therapy?
ICD (if QRS >150 ms then would include a CRT-D)
What is the preferred drug for campylobacter jejuni gastroenteritis?
Azithromycin (recall, Campy can be assoc. with small bowel MALT lymphoma)
How do you treat vitamin K antagonist toxicity w/ INR >9 in a patient who has no bleeding?
Hold the medicine and give vitamin K
What is the management of Infection-Related Glomerulonephritis? Proposed pathophys?
Treating the underlying infection; it is an immune complex disease often assoc. with non-streptococcal infections; suspect if nephritic urine sediment in an azotemic patient who has an active infection
What type of metastatic breast lesion cannot be assessed for Her2 status when biopsied?
What sorts of labs might you see in a patient with hypokalemia associated with vomiting?
Metabolic alkalosis, increased urine potassium excretion, and decreased urine chloride excretion; this is bc vomiting leads to increased loss of hydrogen chloride; hypovolemia activates RAAS and leads to inccrease in H/Na exchange and increased bicarb resorption in the PCT
What is concern for OSA in the post-op setting?
Post-operative hypoxia or frank respiratory failure
Differentiate urine chloride in vomiting vs. Barter syndrome?
In vomiting, urine chloride is low because of the GI losses that leads to increased chloride reabsorption; in Bartter syndrome, urine chloride is high
In a patient who no longer has parathyroid function after surgery what are the serum and urine calcium goals for supplementation?
Serum calcium goals is 8-8.5; urine calcium goal is <300 mg/24h
Why does immune complex deposition lead to glomerulonephritis?
Because immune complexes can activate complement (IgG and IgM i.e. GM is a classic car; activate classic complement cascade) which leads to calling in of inflammatory cells
If you need an anti-epileptic drug in pregnancy what is the best one to go with?