Random Flashcards
1
Q
Age range for ASCVD risk calculator
A
40-80yo
2
Q
What causes AA Amyloid?
A
Amyloid A circulating systemically
3
Q
What causes AL Amyloid?
A
Plasma cel dyscrasias such as multiple myeloma, smoldering myeloma, and MGUS
4
Q
Equation for serum osmolality
A
(2xNa) + (Gluc/18) + (BUN/2.8)
5
Q
What is an elevated serum osm gap?
A
> 10
6
Q
Differential for AGMA
A
Glycols
Oxoproline aka pyroglutamic acid (APAP)
L- Lactate
D- Lactate
Methanol
Aspirin aka salicylate
Renal
Ketoacidosis
7
Q
Name the 3 RTAs and their urn AG, serum K, and urine pH
A
Type 2 (proximal) RTAa
NEGATIVE urn AG
Decreased K+
Urine pH is variable
Type 1 (hypokalemic distal) RTA
Positive urn AG
Decreased K+
Urine pH >5.5
Type 4 (hyperkalemic distal) RTA
Positive urn AG
Increased K+
Urine pH <5.5
8
Q
What are the 4 features of fanconi syndrome?
A
Fanconi syndrome has glycosuria, phosphaturia, aminoaciduria, hypouricemia
9
Q
How do you treat hypermagnesemia in ESRD/anuric patients while awaiting dialysis?
A
Calcium gluconate
(Mg blocks K+ and Ca2+ channels resulting in weakness/paralysis)
10
Q
How does hypoalbuminemia affect serum calcium?
A
Calcium binds to albumin. Hypoalbuminemia will therefore result in a lower total calcium level. Ionized calcium is required to determine if patient is truly hypo/hypercalcemic
11
Q
Describe calcium homeostasis
A
12
Q
When to screen for T2DM? What interval should you screen?
A
USPSTF: 35-70yo Q3yrs
ADA: 35-70yo Q3yrs
Endocrine society: 40yo
13
Q
What is prediabetes range?
A
A1C 5.7% - 6.4%
14
Q
What tests do you order for T1DM confirmation? Which ones are widely available?
A
- Insulin antibodies
- Glutamic acid decarboxylase antibodies (GAD65)
- Islet antigen antibodies
- Zinc transporter A antibodies
- Tyrosine phosphatases IA-2 and IA-2beta
GAD65 and IA-2 and IA-2beta are widely available
15
Q
Diagnostic criteria for diabetes
A
- Random glucose 200+ and hyperglycemia symptoms
- Fasting plasma glucose 126+
- plasma glucose 200+ in oral glucose test
- A1C 6.5% or greater
16
Q
What is C-peptide? How is it affected in T1DM? Exogenous insulin use?
A
C-peptide is a product cleaved from preproinsulin to create insulin
C-peptide will be low in T1DM
C-peptide will be low in exogenous insulin use
17
Q
What other autoimmune disorders are linked to T1DM?
A
Adrenal deficiency
Celiac
Thyroid disorders
Vitiligo
18
Q
What is the difference between T1DM (1A) and (1B)?
A
1A = autoimmune
1B = idiopathic (no antibodies)
19
Q
Define prediabetes A1C and what should you treat it with?
A
5.7% - 6.4%
Lifestyle modification and Metformin
20
Q
When should pregnant women be screened for diabetes?
A
If risk factors: At initial evaluation and before 15 weeks
All other: between 24-28 weeks
21
Q
ADA recommends oral glucose tolerance test 4-12 weeks postpartum if gestational diabetes occurred to monitor for resolution? True ir false?
A
True
22
Q
What is the target A1C in diabetic patients?
A
7-8%
De-intensifying if easily achieving goal <7%
23
Q
What is first line treatment for HBV? When do you treat?
A
Entecavir or tenofovir
Evidence of cirrhosis, liver failure, immune-active phase (chronic), deactivation phase, and immunosuppressives state
24
Q
Hep B vaccine administration age? How many?
A
19-59yo
3 dose series 0 month, 1 month, 6 month
25
Define drug resistant epilepsy. What are the steps for management?
Ongoing seizures despite treatment with 2 adequately dosed AEDs
Continuous EEG and MRI (confirms anatomical location with EEG) to determine candidacy for epilepsy surgery (lobectomy)
26
CHADS2VASC points
27
What are the preferred agents to treat tardive dyskinesia? Other agents? Treatment for refractory disease?
Vesicular monoamine transporter 2 inhibitor
-Valbenazine
-Tetrabenazine
-Deutetrabenazine
Can use amantadine, clonazapam
Deep brain stimulation is used for refractory treatment
28
What is the mechanism of tardive dyskinesia?
Extrapyramidal complication of dopamine receptor blockade medications
29
How do you treat insomnia refractory to improved sleep hygiene and CBT?
Short term Doxapin or a non-benzodiazepine (zolpidem)
Avoid trazadone if possible
30
At what EGFR is metformin contraindicated?
EGFR <30
31
How often should A1C be checked when on treatment?
Q3months if not at goal
Q6months if at goal
32
At what A1C should insulin be initiated?
A1C 9% or greater in a symptomatic patient (polydipsia, polyuria)
33
What agent should be used in gestational diabetes?
Insulin
Metformin and sulfonylureas cross the placenta and long term safety data does not exist.
34
Goal blood glucose range while inpatient
140-180
35
How does DKA cause ketosis? How does HHS typical not have ketosis?
Due to insulin insufficiency, lipolysis occurs which results in ketone creation. HHS is characterized by partial insulin deficiency resulting in suppression of lipolysis
36
When should T2DM patients get retinal screening? T1DM?
T2DM: at diagnosis then QYear
T1DM: within 5 years of diagnosis is then qYear
37
When should T2DM patients get kidney screening? T1DM?
T2: at diagnosis then QYear
T1: within 5 years of diagnosis then QYear
38
When should T2DM patients get neuropathy screening? T1DM?
T2: at diagnosis then QYear
T1: within 5 years of diagnosis then QYear
39
When should ASA be initiated for primary prevention in diabetics? Secondary?
Initiate ASCVD 10% or greater ages 40-59yo
All diabetics should be on ASA for secondary prevention
40
When should patients with diabetes be started on a statin?
40-75yo
Moderate dose for all and high dose for those with high ASCVD risk
41
What are the 2 types of diabetic retinopathy
Proliferative, and non-proliferative
42
What are the treatments available to prevent progression of diabetic retinopathy? (2)
Laser photocoagulation
Anti-VEGF
43
What two drugs are FDA approved for diabetic neuropathy?
Pregabalin and duloxetine
44
What is the difference between non-invasive and invasive infectious diarrhea?
Non-invasive typically cause watery diarrhea
Invasive typically causes dysentery (bloody diarrhea)
45
What are the 6 causes of diarrhea
Osmotic
Secretory
Steatorrhea
Inflammatory
Motility
Miscellaneous
46
What are the characteristics of steatorrhea?
Malodorous, greasy stools that float
47
What is a common about osmotic diarrhea and eating?
It’s worse with eating and resolves with fasting
48
What is common about secretory diarrhea and food?
It remains constant with eating and fasting
49
What is the pathophysiology of secretory and osmotic diarrhea?
Osmotic: involves unabsorbed substance that draws water into the lumen
Secretory: results in disordered electrolyte transport resulting in secretion of fluids into the lumen
50
What are some stool studies that can help identify possible causes of chronic diarrhea?
Stool electrolytes
Stool pH
Fat content
Fecal calprotection
RBC/WBC
51
What is the equation for fecal osmotic gap? What do the values mean?
290 - [2x (stool Na + stool K)]
<50= secretory diarrhea
>100= osmotic diarrhea
52
What is fecal elastase used for?
A low fecal elastase indicates impaired pancreatic exocrine function in diarrhea (elastase is a digestive enzyme)
53
What is microscopic colitis? How does it appear on endoscopy? Histology? Management? Symptom management?
Inflammation of the inner lining of colon
Normal endoscopy
Inflammation on pathology
Tx:
1st line: Budesonide
2nd line: Mesalamine, prednisone, or bismuth subsalicylate
Sxs Tx:
Loperamide
54
What are the celiac labs?
Total IgA
IgA tissue transglutaminase Ab
If IgA deficiency obtain:
Anti-deamidated gliadin peptide IgG Ab
Or
Tissue transglutaminase IgG Ab
55
What HLAs are associated with celiac? Can these confirm celiac disease?
HLA-DQ2 and HLA-DQ8
Genetic testing cannot confirm celiac disease BUT it can rule it out
56
Can serologic labs confirm celiac disease?
While it can highly suggest disease, endoscopy with biopsy from duodenum is needed to confirm diagnosis
57
What is a PESI score?
Pulmonary embolism severity index
58
What are differentiating features between early repolarization and pericarditis?
59
What is first line treatment for essential tremor (3 drugs)? what is second line (One drug)? 3rd?
1st: propranolol, primidone, topiromate
2nd: clonazapam
3rd: deep brain stimulation or thalmotomy
60
How do you test for H pylori? Treatment? Confirming eradication?
Urea breath test or fecal antigen or biopsy
PPI, bismuth, tetracycline, flagyl
Urea breath test or fecal antigen or biopsy (only biopsy if needed)
61
Besides the obvious cessation of gluten, what medication can treat dermatitis herpataformis?
Dapsone but check for G6DP deficiency before starting
62
What symptoms does small intestinal bacterial overgrowth cause? What causes SIBO? How to diagnose it? Treatment?
Abdominal pain, bloating, farts, diarrhea, steatorrhea
Impaired motility, strictures, diverticula, and more that slows food transit allowing for more “food” for bacteria
Glucose breath test
(lactulose breath test has lower sensitivity)
Rifaxamin
63
What is short bowel syndrome? Management?
Loss of functional small bowel (resection, crohns, trauma, etc)
Adequate nutrition, antimotility agents
64
What are the 3 types of inflammatory bowel diseases?
Crohns, ulcerative colitis, and microscopic colitis
65
Tobacco is protective in which inflammatory bowel disease? Increases risk?
Protective in UC
Increases risk in Crohns
66
How does sarcoidosis cause hypercalcemia?
It increases the activity of 1-alpha-hydroxylase thereby increasing levels of 1,25 Vitamin D
67
Can patients with ulcerative colitis get toxic megacolon?
Yes
68
What are the 2 most common dermatologic manifestations of inflammatory bowel disease?
Erythema nodosum and pyoderma grangrenosum
69
What are possible inflammatory bowel disease antibodies?
1. saccharomyces cerevisiae antibodies 2. perinuclear antineutrophil cytoplasmic antibodies
70
What are the 4 categories of drugs used to treat inflammatory bowel disease?
5-aminosalicylates
glucocorticoids
immunomodulators
biologics
71
Define IBS-C and IBS-D
IBS-C: IBS with constipation
IBS-D: IBS with diarrhea
72
What are the diagnostic criteria for IBS?
Recurrent abdominal pain at least 1 day a week for 3 months along with at least two of the following:
1. defecation-related pain
2. change in stool frequency
3. change in stool consistency
73
IBS management
Adding fiber to diet
FODMAPs reduction diet
74
How to diagnose acute/chronic mesenteric ischemia?
Mesenteric angiography
75
Treatment of acute mesenteric ischemia
Fluid resuscitation
Pain management
Antibiotics
Stenting +/- Surgery (necrotic bowel? Pneumatosis?)
76
Treatment of chronic mesenteric ischemia
Stenting or surgical revascularization
77
What are common sites for colonic ischemia? What could you find on CT? What is the test to confirm diagnosis?
Watershed areas such as splenic flexure and rectosigmoid junction
Bowel wall thickening and pericolonic fat stranding around watershed areas
Colonoscopy with biopsy
78
Should patients with RIGHT sided colonic ischemia get vascular imaging? Left?
YES as it is commonly an occlusive process
No as it is typically non-occlusive disease
79
When can you remove thrombosed hemorrhoids?
Thrombosed external hemorrhoids are best treated with surgical excision within the first 4 days of symptom onset
80
What are some causes of fecal incontinence?
1. Decreased sphincter tone
2. Decreased sphincter sensation
3. Increased fecal loading (high stool volume)
4. Diarrhea
5. Hemorrhoids
6. Medications
Think about how to work these up!
81
Physical exam signs of appendicitis
McBurney (RLQ)
Rovsing (right lower quadrant pain with left lower quadrant palpation)
82
What does crohns colonoscopy and histology show?
Colonoscopy results show patchy distribution of mucosal inflammatory changes with “skip areas” of normal intervening mucosa
biopsy results for involved mucosa show features of chronicity (distorted and branching colonic crypts, similar to UC).
83
What does UC colonoscopy and histology show?
Patients with ulcerative colitis have distorted and branching colonic crypts on biopsy, but the distribution of inflammation begins in the rectum and progresses up the colon in a continuous and symmetric pattern, without skip areas.
84
How do you treat myxedema coma?
Check serum cortisol and replete if needed (random <18?) prior to starting levothyroxine
85
What are the 5 types of urinary incontinence?
Stress
Urgency
Overflow
Functional
Mixed
86
Define stress incontinence. Treatment?
Incontinence associated with increased intra-abdominal pressure, such as sneezing, laughing, or coughing
Pelvic floor therapy, decreased EtOH and caffeine, tobacco cessation
Topical estrogen, pessiaries
87
Define urge incontinence. Treatment?
Incontinence due to detrusor overactivity associated with urge to void preceding or accompanied by leakage of urine
Timed voiding, decreased EtOH and caffeine, tobacco cessation
Mirabegron, antocholinergics, topical estrogen
88
Define overflow incontinence. Treatment?
Incontinence due to incomplete bladder emptying, leading to continuous urine leakage or dribbling, weak urinary stream, urinary hesitancy, increased frequency, and nocturia
Double voiding, decreased EtOH and caffeine, tobacco cessation
Tamsulosin, finasteride
89
Define functional incontinence. Treatment?
Incontinence due to physical inability to toilet in a timely manner
Timed voiding, decreased EtOH and caffeine, tobacco cessation
No pharmacological medications
90
Define mixed urinary incontinence. Treatment?
Incontinence due to a combination of increased intra-abdominal pressure and detrusor hyperactivity
Pelvic floor therapy, timed voiding, decreased EtOH and caffeine, tobacco cessation
91
When should women get breast cancer screening?
50-75yo Q2years
92
What is the preferred treatment for mild C diff? Severe? Treatment for fulminant c diff?
Fidaxomicin or Vanco
Fidaxomicin or Vanco (WBC >15)
PO Vanc and IV flagyl (hypotension, ileus, shock, or toxic megacolon)
93
What are the criteria for pre-eclampsia?
New onset HTN with proteinuria (≥300 mg/24 h or a urine protein-creatinine ratio ≥300 mg/g) after 20 weeks of pregnancy.
Can be diagnosed without proteinuria if HTN is accompanied by other end-organ damage (thrombocytopenia, kidney dysfunction, liver dysfunction, pulmonary edema, cerebral or visual symptoms).
94
How do you treat mild/moderate CO poisoning? Severe (define)?
15L non-rebreather for CO
Hyperbaric oxygen chamber
(any of the following: coma/loss of consciousness, neurologic deficits, cardiac or other end-organ ischemia, severe metabolic acidosis, or a CO level of 25% or greater (15% or greater in pregnant patients)
95
What is defined at treated depression in remission?
PHQ9 less than 5
96
Where does primary TB occur? Reactivation?
Primary: lower/middle lobe
Reactivation: upper lobes
97
Differential for intrarenal AKI (Mack’s diagram)
98
What does a M spike of electrophoresis indicate?
monoclonal spike suggests a plasma cell dyscrasia or monoclonal gammopathies
99
What labs should be obtained when working up a monoclonal spike?
CBC with differential
Chemistries (creatinine, calcium, and albumin levels)
β2-microglobulin
SPEP/UPEP
serum and urine immunofixation (FLC)
serum FLC tests
Quantitative immunoglobulins.
100
What imaging modalities are used to detect lyric bone lesions?
PET and MRI
101
Criteria for MGUS
MGUS is characterized by an M protein level less than 3 g/dL (or less than 500 mg/24 h of urinary monoclonal FLCs), clonal plasma cells comprising less than 10% of the bone marrow cellularity, and the absence of related signs and symptoms of end-organ damage
102
What type of 5-ASA should be used in UC proctitis? Left sided colonic disease?
5-ASA suppository
5-ASA enema
103
When is multimatrix budesonide used in UC?
mild to moderate ulcerative colitis unresponsive to 5-ASAs and in moderate to severe disease.
104
When are immunomodulators used in UC? How fast are they?
Used to maintain remission. Takes 3-4 months to work so needs steroid taper while waiting to work.
Azathioprine and 6-mercaptopurine
105
Is methotrexate used in UC? Crohns?
Used in crohns
NOT used in UC
106
What 2 tests should be ordered before starting TNF agents in IBD?
TB and Hep B
107
Since 5-ASAs are not good to treat crohns, What 5-ASA derivative is used?
Sulfasalazine
108
What steroid is used to treat ileocolonic crohns?
Budesonide
109
What immunomodulators are commonly used to treat crohns?
Methotrexate, azathioprine, 6-MP
110
What eye drop antibiotic should be used in bacterial conjunctivitis who don’t wear contacts? Do wear contacts?
Trimethoprim-polymixin or erythromycin
Ofloxacin
111
What eye drops should be used for allergic conjunctivitis?
Antihistamines
112
Guidelines for lung cancer screening?
Ages 50-80, quit less than 15yrs ago, 20+ pack history
Can choose to stop if negative CT scans and 15years out from smoking
113
What are the two cel types in the thyroid? What do they produce?
Follicular cells: T 3/4
Parafollicular (c) cells: calcitonin
114
Where is T4 predominantly converted into T3?
Liver and kidney
115
How to work up a thyroid nodule?
FNAB: fine needle aspiration biopsy
116
Causes for diffuse goiter?
Grave’s
Hashimoto’s
Riedel (IgG4) thyroiditis
Iodine insufficiency/deficiency
117
What vitamin can falsely affect thyroid function?
Biotin
(Falsely Low TSH, falsely high T 3/4)
118
What is the difference between thyrotoxicosis and hyperthyroidism?
Thyrotoxicosis describes high levels of circulating thyroid hormones (T4 and T3) from any cause.
Hyperthyroidism is thyrotoxicosis caused by excessive endogenous thyroid hormone production.
119
How do you diagnose Graves?
- Low TSH, high T3/4
- Diffuse radioactive iodine uptake
- Presence of thyroid stimulating globulin (TSI) or thyrotropin receptor antibodies (TRAb)
120
A patient with signs if thyrotoxicosis gets a RAIU shown below. What are the two possible causes?
- Destructive thyroiditis (hypothyroidism will follow)
- Exogenous thyroid hormone ingestion
121
When is thyroid scintigraphy contraindicated?
Pregnancy and lactation
122
Name 10 causes of thyrotoxicosis
Graves
Toxic multinodular goiter
Toxic adenoma
Thyroiditis
Medication induced
HCG-mediated
Strums ovarii
Follicular thyroid cancer mets
Thyrotrope adenoma (TSH secreting tumor)
123
Normal QTc
<450
124
First-line treatment of cluster headache? Maintenance therapy?
Subcutaneous Sumatriptan and O2
Verapamil and galcanezumab
125
How should levothyroxine be dosed in general patients? Cardiac patients?
Weight based
Start small and ramp up as it can cause imbalances in myocardial oxygen demand
126
A patient with an EF <50% has an echo that shows low-flow, low-gradient severe aortic stenosis. What test do you order to confirm?
Dobutamine stress test
127
What is roflumilast? When to start it?
PDE4 inhibitor used for sever COPD with frequent exacerbations
128
Equation for positive likelihood ratio? Negative likelihood ratio? Sensitivity? Specificity? Positive predictive value? Negative predictive value?
POS LR: sensitivity / (1-spec)
NEG LR: (1-sens)/specificity
129
What are the 3 initial tests you can use for Cushing diagnosis? How many need to be abnormal?
1. 24hr urine free cortisol
2. 1mg dexamethasone suppression
3. Late-night salivary cortisol
2 of 3
130
If one of the 3 initial Cushing tests is positive, what test do you order next?
ACTH level
Initial tests:
1. 24hr urine free cortisol
2. 1mg dexamethasone suppression
3. Late-night salivary cortisol
131
In Cushing syndrome, if ACTH is suppressed, what does that mean? What do you do?
ACTH independent process
Should get a CT or MRI of adrenal glands and look for a mass or find another possible hormone producing lesion
132
What is the treatment for benign and malignant cortisol-secreting tumors? What does the patient require following treatment?
Surgical resection
Needs glucocorticoid treatment to allow for the other adrenal gland to recover from prolonged ACTH suppression
133
Symptoms of Cushing (7 possible)?
HTN
Diabetes
Osteoporosis
Proximal muscle weakness
Supraclavicular fat pad
Facial plethora
Striae
134
What test is used to diagnose primary hyperaldosteronism?
PAC/PRA >20 and PAC >15
PAC: plasma aldo concentration
PRA: plasma renin activity
135
To confirm the diagnosis of hyperaldosteronism, what imaging should be done? Procedure?
Adrenal CT
Adrenal vein sampling
136
What is the treatment for hyperaldosteronism?
spironolactone (eplerenone can be used but spironolactone is preferred)
Surgery can be considered if unilateral
137
What is the classic pheochromocytoma symptom triad?
Headache, palpitations, and diaphoresis
138
What are the two tests for diagnosing pheochromocytoma/paraganglioma?
Plasma and urine metanephrines
139
What is the definitive treatment for a pheochromocytoma/paraganglioma?
Surgical resection
140
What diseases are associated with MEN1? MEN2?
MEN1:
-pituitary adenoma
-parathyroid adenoma
-pancreatic tumors
MEN2:
-parathyroid adenoma
-pheochromocytoma
-medullary thyroid carcinoma
141
What is a concerning hounsfield unit for an adrenal incitentaloma? What needs to be done?
10+ HU
Test for cushings and pheochromocytoma
142
Addison disease is an autoimmune process that destroys what cortical layers of the adrenal gland?
All of them!
143
How does Addisons disease cause hyperpigmentation?
ACTH stimulates melanocytes
144
What morning cortisol level requires ACTH stimulation testing? What if stimulation test is low?
3-15 microgram/dl
Obtain serum ACTH to determine if primary or secondary insufficiency
145
What antibodies are associated with autoimmune Addison?
21-hydroxylase antibodies
146
What is the treatment of Addisons?
Steroid and fludrocortisone
147
What is the common bug for acute prostatitis in ages <35? 35 and older? Treatment?
<35: gonorrhoeae or chlamydia; Doxycycline and one dose of ceftriaxone
35+: E. coli; Bactrim or fuoroquinolone
148
When treating autoimmune hepatitis, how long do you treat before trying to wean/stop medications?
At least 2 years and you should biopsy before discontinuation to determine risk of relapse
149
How often should women with IBD on immunosuppressants get PAP screening?
Yearly
150
When should screening for prostate cancer occur?
55-70
151
What are 3 tests used to diagnose gastroparesis?
Gastric scintigraphy
Wireless motility capsule
Breath testing
152
What organ disease should you avoid morphine?
Renal disease and morphine is Renault excreted
153
What is a medication used for IBS-D?
Rifaxamin
154
What is a medication used for IBS-C when not responding to conservative measurements?
Linaclotide
