Endo/Heme
Cardio/Resp
Rheum/ Nephro
Derm/ID
Neuro/GI
100
JAK2 V617F mutation is most commonly seen with this desease?
PV- Polycythemia vera
100
65 M presented to ER with CP and Back pain for 3 hours with bp of 180/105. CTA showed a descending thoracic aortic aneurysm with a maximal diameter of 6.5 cm and aortic dissection originating just distal to the left subclavian artery and extending to just below the diaphragm; there is no involvement of the renal arteries. What is the treatment of choice?
CT Surgery consult/ Medical Therapy/ Endovascular Repair/Repeat CT in 12 hrs
Medical Therapy- β-blockers are first-line treatment, and sodium nitroprusside can be added if hypertension does not completely respond to β-blocker therapy .
Current guidelines recommend reducing systolic blood pressure to 120 mm Hg or less in the first hour in patients with aortic dissection.
In patients with ascending aortic dissection (type A aortic dissection), intramural aortic hematoma, or descending aortic dissection (type B aortic dissection) with complications, immediate repair is warranted.
Repeat CT angiography at 12 hours is not indicated unless the patient does not stabilize with medical therapy.
100
49 M with pmh of cirrhosis due to NASH with Ascites and HTN. EGD 3 months earlier showed small varices without stigmata, making prophylaxis for esophageal variceal bleeding unnecessary. His medications are lisinopril, Tylenol ( Prn <2gm/day), Metoprolol and Statins. Stopping which medication is appropriate?
Lisinopril
ACE inhibitors and angiotensin receptor blockers impair the compensatory response to cirrhosis-related hypotension and thereby impair the ability to excrete excess sodium and water and may also affect survival.
Medications that decrease kidney perfusion, including NSAIDs, ACE inhibitors such as lisinopril, and angiotensin receptor blockers, should be discontinued because their use often worsens ascites due to portal hypertension.
100
40M with pmh of spelnectomy is hospitalized with a 9-day history of fever, headache, and myalgia. He is a trail runner and Labs are significant for WBC of 1500 , Plt- 40K, Increased ALT/AST and LDH of 1300.
On physical examination-scleral icterus, jaundiced skin, hepatomegaly, and lower extremity petechiae are noted.A blood smear from this patient is most likely to show which of the following abnormalities?
Cytoplasmic morulae in leukocytes/ Intraerythrocytic banana-shaped gametocytes/ Intraerythrocytic tetrad forms/ Intraneutrophilic gram-positive diplococci/ Schistocytes
Intraerythrocytic Tetrad
Asplenia is a major risk factor for fulminant Babesia infection, as is older age, HIV infection, or other immunocompromising conditions.
Clinical manifestations are variable, with most relating to severe hemolytic anemia. Infection can be diagnosed by visualization of intraerythrocytic parasites, which appear as either ring forms or tetrads, with the latter often described as having the Maltese cross appearance shown.
parasitemia (exceeding 10%) is indication for exchange transfusion.
banana-shaped gametocytes are seen only with Plasmodium falciparum malaria
100
College Seizure is another name for this type of Seizures?
JME- In adults, juvenile myoclonic epilepsy (JME) is the most common form of idiopathic generalized epilepsy. JME seizures often are called “college seizures” because of the age of onset (teens or twenties) and associated triggers (sleep deprivation, alcohol use, and stress).
The presence of myoclonic seizures is required for the diagnosis of JME; patients may report dropping items from their hands, commonly a coffee cup or hairbrush.
Most affected patients have GTCS, and approximately 30% of patients have absence seizures. Patients are usually otherwise neurologically healthy and can live relatively normal lives because seizures are often controlled with one or two AEDs.
Lifelong AED therapy is typically required.
200
Characterstics of beingn Adrenal masses on imaging?
Size <4cm
Density <10 HU
Contrast Washout >60% in 10min
Suspicious for Malignancy
opposite of above
200
CRTD is indicated in patients with CHF with QRS > than this number?
150ms
In patients with heart failure who have an ejection fraction less than 35%, continued symptoms despite maximally tolerated medical therapy, and expected survival of at least 1 year, ICD placement is indicated.
200
Tenderness to palpation and slight swelling over the proximal medial tibia about 6 cm below the anteromedial joint margin of the left knee in a 45 yr old man for one month duration. The pain is aggravated by ascending stairs and rising from a seated position. What is the likely diagnosis?
Pes anserine bursitis is an inflammatory condition affecting the bursa at the insertion of the conjoined medial knee tendons into the anteromedial proximal tibia and should be considered when there is localized pain inferomedial to the knee joint.
The diagnosis of pes anserine bursitis is clinical, based on a history of increased medial knee pain worsened with climbing or descending stairs or rising from a seated position.
200
This type of psoriatic lesions erupt suddenly on the trunk often after a group A streptococcal infection?
Guttate psoriasis-0.5- to 2-cm red plaques
inverse psoriasis (red, thin plaques with variable amount of scale in the axillae, under the breasts or pannus, intergluteal cleft, and perineum)- Can be confused with Tinea given the location of lesions but lacks the scaly border seen with Tinea.
200
44 F with pmh of Small bowel resection secondary to MVA brought to Er with c/c of ataxia, confusion, and slurred speech occurring for several days. Labs shows anion gap metabolic acidosis. What is the diagnosis?
D-lactic acidosis is characterized by an increased anion gap metabolic acidosis in patients with short-bowel syndrome from small-bowel resection or jejunoileal bypass.
D-lactate may accumulate when excess carbohydrates reach the colon and are metabolized to D-lactate by bacteria. Therefore, it is sometimes manifested after a large carbohydrate load.
Pyroglutamic acidosis also manifests as mental status changes in the context of an increased anion gap. This acidosis occurs in patients chronically receiving therapeutic doses of acetaminophen.
Diagnosis can be confirmed by measuring urine levels of pyroglutamic acid.
300
Testosterone supplements should be stopped if Hematocrit is above this percentage level?
54%
Polycythemia is a common adverse effect of testosterone (and anabolic steroid) supplementation, and evaluating the hematocrit level at initiation, 3 to 6 months after testosterone initiation, and annually thereafter is recommended by Endocrine Society guidelines.
Secondary polycythemia can cause symptoms, such as headaches and elevated blood pressure, and increase the risk of thromboembolism.
300
isometric or competitive exercise is discouraged in patients with VSD when their pulmonary pressure is greater than what percentage of SBP?
50%
VSD closure is not indicated for patients with a small left-to-right shunt and no chamber enlargement or valve disease, but periodic clinical evaluation and imaging are recommended.
Large VSDs with shunt reversal (right-to-left shunting) and PH (Eisenmenger syndrome) should not be closed because this causes clinical deterioration owing to reduced cardiac output.
300
Correcting this metabolic disorder in CKD can slow down the progression of CKD?
Metabolic Acidosis
(KDIGO) guidelines recommend treatment of metabolic acidosis with alkali therapy in patients with chronic kidney disease when the serum bicarbonate is chronically <22 mEq/L (22 mmol/L).
Untreated metabolic acidosis can lead to muscle loss and bone loss.
Large observational studies have shown a strong association between lower serum bicarbonate levels and both increased progression of CKD and mortality.
300
25 M presented 4 days ago with a cold sore on his lower lip. This was followed by the development of painful sores throughout his mouth. The next day he developed a rash on his hands, arms, legs, and face, and eventually on his palms and soles. Diagnosis?
Erythema multiforme -features the development of characteristic tricolored targetoid plaques .
Erythema multiforme major is the term used to describe EM with severe mucosal involvement (and may have associated systemic symptoms, such as fever and arthralgias). Erythema multiforme minor refers to EM without (or with only mild) mucosal disease (and without associated systemic symptoms).
The disorder is most commonly induced by infection, with herpes simplex virus being the most frequent precipitator. The clinical course of EM is usually self-limited, resolving within weeks without significant sequelae.
Both SJS and EM may present with mucosal erosions and atypical target lesions on the skin . A helpful clinical finding is that the atypical target lesions of SJS tend to be macular, rather than the papular lesions associated with EM . Unlike EM, medication is the most frequent cause of SJS.
300
35 F is evaluated for a 3-year history of headaches that occur twice weekly and last 8 to 12 hours when not treated early. The pain is bilateral, frontotemporal, vice-like, and aggravated by physical activity. Approximately half of the episodes have become severe and are associated with combined photophobia and phonophobia. She has had no associated nausea, vomiting, or visual or neurologic symptoms and reports no cranial autonomic features. PE is normal. Headache is relieved by NSAIDS. What is the diagnosis?
Migraine or Tension Type Headache or Medication overuse headache.
Migraine
Migraine without aura is the most prevalent migraine subtype .
Moderate to severe pain is the most sensitive feature, and worsening by routine physical activity is the most specific element among the pain criteria.
Hemiplegic aura comprises any aura involving motor weakness. Brainstem aura is defined by the presence of two of the following brainstem symptoms: dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, or decreased level of consciousness.
Both hemiplegic and brainstem auras are listed as contraindications for triptan use.
Given an associated increased risk of stroke, estrogen-containing oral contraceptives should be avoided in women with migraine aura of all subtypes.
Tension type Headache-Episodes may last from 30 minutes to 1 week. The pain of TTH typically is not severe or aggravated by routine physical activity. Photophobia or phonophobia may be present, but not both,
400
65M is evaluated for an asymptomatic elevation of serum protein. Medical history and PE is unremarkable, and he takes no medications. CBC and Renal panel is normal. Serum protein electrophoresis and immunofixation show an IgA spike of 3.5 g/dL. Skeletal survey findings are negative.
Which of the following is the most appropriate next test?
Bone scan / CT of the chest, abdomen, and pelvis/
Whole body MRI / No further testing
Whole body MRI -gold standard
The International Myeloma Working Group recommends that all patients with smoldering multiple myeloma undergo whole body MRI to assess for lytic lesions (or spine and pelvic MRI if whole body MRI is not available )
Smoldering multiple myeloma (MM) is characterized by a serum M protein level of 3 g/dL or greater (or ≥500 mg/24 hr of urinary monoclonal free light chains) or bone marrow plasma clonal cells of 10% or greater and no evidence of myeloma-related signs or symptoms requiring therapy.
This monoclonal (M) protein can be a complete immunoglobulin, with a heavy chain (IgG, IgA, IgD, or IgM) complexed with a light chain (κ or λ), or free light chains (FLCs) without a heavy chain component.
400
VSD closure is indicated when Qp/ Qs ratio is greater than ?
2
VSD closure is indicated when the Qp:Qs ratio is 2.0 or greater with evidence of left ventricular volume overload or a history of endocarditis.
400
32 F admitted with rt-sided pleuritic CP & SOB that began 2 days ago. 3 weeks ago, she began to experience fever once a day, pharyngitis, intermittent rash on the trunk and proximal extremities that occurs with the fever, severe joint pain, and myalgia. She gave birth 10 weeks ago to a healthy female infant. Exam reveals enlarged cervical lymph nodes, hepatomegaly, and splenomegaly . A pleural friction rub is heard. What is the diagnosis? (BIG SICK)
AOSD
Adult-onset Still disease is characterized by spiking fever, an evanescent salmon-colored rash on the trunk and extremities that occurs in conjunction with fever, arthritis, lymphadenopathy, and leukocytosis; an extremely high serum ferritin level is characteristic.
AOSD may also be seen during pregnancy or in the postpartum period.
400
Vancomycin should not be used in the treatment of MRSA bacteremia when the vancomycin MIC is greater than ?
2 µg/mL
When MIC is above 2 then switch to Daptomycin.
400
This class of HTN medication reduces the risk of ischemic and hemorrhagic stroke regardless of blood pressure levels?
ACEI / CCB / B-blockers
ACEI or ARB
500
35 F is seen in follow-up to discuss the findings of an abdominal/pelvic CT scan which showed an incidental 1.8-cm rt adrenal mass with a density of 18 Hounsfield units (indeterminate for adrenal adenoma). On physical examination, vital signs and the remainder of the examination are unremarkable. Laboratory studies show normal serum electrolytes.
Which of the following is the most appropriate test to perform next?
24-Hour urine free cortisol measurement
24-Hour urine total metanephrine
Plasma aldosterone-plasma renin ratio (ARR) measurement
Serum dehydroepiandrosterone sulfate (DHEAS) measurement
24-Hour urine total metanephrine
Even though this patient does not have hypertension, she should be screened for pheochromocytoma, as these tumors may exist in the absence of typical symptoms or hypertension. Approximately 50% of pheochromocytomas are now first discovered as an incidental adrenal mass. An alternative screening test for pheochromocytoma is measuring the fractionated free plasma metanephrine level. This test has a false-positive rate of approximately 11%, and, therefore, may be considered more useful when suspicion for pheochromocytoma is high.
The 24-hour urine free cortisol test is not sensitive enough to diagnose subclinical autonomous cortisol secretion from an adrenal mass. The 24-hour urine free cortisol levels are usually within the normal range in subclinical Cushing syndrome.
Only patients with an incidental adrenal mass and hypertension require screening for primary aldosteronism.
Measurement of dehydroepiandrosterone sulfate (DHEAS) is not indicated in this patient, as she did not show signs of hyperandrogenism
500
complicated parapneumonic effusion is defined as an effusion associated with a pneumonia that has a pH less than ? and glucose less than ? mg/dL.
ph <7.2 and Glu < 60
Complicated Parapneumonic effusion-However, because bacteria may be cleared rapidly from the pleural space, the Gram stain is typically negative and cultures are usually sterile. require thoracostomy drainage in addition to antibiotics.
An empyema is defined as a bacterial infection of the pleural space that results in frank pus on visual inspection of the pleural fluid or a positive Gram stain. A positive pleural fluid culture is not required for diagnosis as cultures are less sensitive than Gram stain in the detection of bacteria.management of empyema includes early thoracic surgical consultation because thoracoscopic or open debridement and drainage is often required to successfully manage this condition.
500
Safe drug to use in RA during pregnancy?
HCQ
Lefulonomide
MTX
HCQ
500
40M is hospitalized with a 9-day history of fever, headache, and myalgia. He is a trail runner and Labs are significant for WBC of 1500 , Plt- 40K, Increased ALT/AST .
Empiric doxycycline therapy is initiated and within 48 hours, the leukocyte and platelet counts normalize. Serologic tests for Rickettsia rickettsii and Ehrlichia chaffeensis obtained on admission have negative results. Diagnosis?
Heartland virus infection/Human monocytic ehrlichiosis/Infectious mononucleosis/Rocky Mountain spotted fever
HME- The negative serologic results for E. chaffeensis do not disprove the diagnosis and should not prompt early discontinuation of doxycycline.
The sensitivity of antibody testing is low in the first week of illness; seroconversion typically occurs within 2 to 4 weeks of symptom onset, and acute and convalescent titers are useful for retrospective confirmation of infection.
During the acute illness, buffy-coat staining (to reveal the presence of morulae, which are basophilic inclusion bodies in the cytoplasm of monocytes representing clusters of bacteria [shown]) or polymerase chain reaction of whole blood specimens may allow an early diagnosis.
Morulae, basophilic inclusion bodies composed of clusters of bacteria, can be seen in the cytoplasm of monocytes and neutrophils of patients with ehrlichiosis and anaplasmacytosis, respectively.
Babesiosis- presents similarly but in addition has hemolytic anemia.
500
Any patient who does not achieve seizure freedom for at least 1 year after treatment with two adequately dosed, appropriately chosen AEDs is considered to have medically intractable (drug-resistant) epilepsy and should be referred to an epilepsy center to both confirm the diagnosis and evaluate the patient for surgical candidacy, starting with this test?
Video EEG monitoring.
Video EEG is the first step in determining candidacy for surgery by confirming that the seizures seen on video EEG match the location of abnormal findings on MRI.
In appropriately chosen surgical candidates, especially those with temporal lobe epilepsy due to mesial temporal sclerosis, resection can lead to seizure freedom in 60% to 70% of patients.