Cards
In patients with aortic aneurysm, what is the recommended frequency of surveillance imaging?
In those with aortic aneurysms of 3.5-4.4cm, yearly imaging surveillance is recommended. Aortic aneurysms of 4.5-5.4 should have routine echocardiograms every 6 months.
How many days of antibiotics do you need to treat ESBL gram-negative bacteremia?
Treatment duration of ESBL gram-negative bacteremia can be as short as 7 days. There are more literature supporting 7 days being non-inferior to 14 especially in the absence of uncontrolled source of infection and especially when there is clinical improvement already. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial | Clinical Infectious Diseases | Oxford Academic (oup.com)
Name the three Revised Atlanta 2012 Criteria for acute pancreatitis?
1. Typical pain (acute epigastric abdominal pain, radiation to back)
2. Characteristic image findings
3. Lipase > 3x ULN
Name one of the scoring systems that can be used to predict the likelihood of immune thrombotic thrombocytopenia purpura.
Bentley
French
PLASMIC
What is the target blood pressure for patients with aortic aneurysms and what is the medication of choice?
BP <130/80
First line treatments include beta blocker therapy. However, in Marfan patients, losartan can also be considered in addition to beta blockers as both have been associated with decreasing the rate of aneurysmal growth.
All of the following statements about patients with chronic systolic heart failure are true EXCEPT:
A. Plasma epinephrine level is elevated
B. Serum aldosterone level is elevated
C. Cardiac beta-adrenergic receptor density is elevated
D. Serum brain natriuretic peptide level is elevated
E. Tumor necrosis factor-alpha is elevated
Choice C
Neurohormonal pathways implicated by heart failure include (1) sympathetic nervous system activation and increased circulating catecholamines (norepinephrine, epinephrine, etc). Poor renal perfusion activates the renin-angiotensin-aldosterone system (RAAS) which promotes salt retention, free water reabsorption, and ultimately adverse cardiac remodeling. Chronic fluid volume overload is manifested as increased preload and dilation of the cardiac chambers which promotes the natriuretic peptide activity including atrial natriuretic peptide (ANP) and brain “B-type” natriuretic peptide (BNP) which has hemodynamic benefits including vasodilation and natriuresis. Advanced heart failure patients may have activation in inflammatory pathways including tumor necrosis factor – alpha leading to sarcopenia, cardiac cachexia, and frailty. All of the response choices are correct except beta-adrenergic receptor density which is reduced due to the overcirculation of endogenous catecholamines.
In patients with CAP with concern for co-infection with influenza, what is the recommendation regarding initiation of tamiflu?
Co-infection carries a high mortality rate, and thus the recommendation is that Tamiflu given to patients hospitalized for pneumonia who test positive for influenza regardless of the duration of symptoms.
Name two nutritional deficiencies that can arise from autoimmune gastritis.
Iron and B12 deficiency
What two main causes of kidney disease in multiple myeloma?
1. free light chain cast nephropathy
2. hypercalcemia induced kidney injury
Other causes:
immunoglobulin light-chain amyloidosis, cryoglobulinemic glomerulonephritis, proximal tubulopathy
In acute pancreatitis, improvement of which two lab values after 48 hours of fluid hydration are consistent with a better prognosis?
BUN and Hct
An elevated BUN > 20 or HCT > 45 on admission is highly concerning for a more severe pancreatitis. An improvement in SIRS from admission, and a reduction in BUN and/or HCT is associated with better prognosis.
A 60yo M w/ HFrEF (LVEF 10%), CAD s/p multiple PCIs, DM2, HTN p/w worsening SOB, confusion, orthopnea, and poor UOP.
BP 80/40 mm Hg, HR 135 bpm, T 96F
Exam is notable for AMS, JVD +20cm H2O, BL rales, cold extremities and 2+ BL pitting edema in BLE.
Labs notable for BNP 4000, Cr 1.8 (baseline 1.2), AST/ALT 800/1000, LA 4
What is the diagnosis and describe next steps in management and work up.
Patient is in cardiogenic shock and would be best managed in the ICU setting. Patient currently is in Profile C- cold and wet.
Patient would benefit from diuretics, vasopressors and initiation of inotropes. Given the patient is in cardiogenic shock, you would ideally obtain a concomitant left and right heart catheterization to determine the patient’s hemodynamics and evidence of high-grade ischemia.
A 79 yo previously healthy M is hospitalized with pneumonia. Ten days ago, he developed low-grade fever, headache, myalgia, and nonproductive cough. His initial symptoms improved after 7 days, but 3 days ago, he developed a high fever, dyspnea, and a productive cough.
Temperature is 39.2 °C (102.6 °F). Lung examination reveals diffuse rhonchi. Chest radiograph shows new bilateral cavitary infiltrates. Result of a COVID-19 test is negative.
Which of the following is the most likely causative agent?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Klebsiella pneumoniae
D. Mycoplasma pneumoniae
B. Staphylococcus aureus
He presents with recurrent cough and dyspnea after a recent influenza-like illness, and his chest radiograph shows cavitary lesions, which are most consistent with S. aureus infection.
Klebsiella pneumoniae (Option A) is a relatively rare cause of community-acquired pneumonia (CAP) in the United States, most often diagnosed in patients with alcohol use disorder, diabetes mellitus, or severe COPD and is an unlikely cause of secondary pneumonia in this previously healthy patient.
Although S. pneumoniae (Option D) is more common than S. aureus in postinfluenza pneumonia, it does not typically produce the radiographic picture of cavitary lesions.
The Rome IV criteria define functional dyspepsia as the presence of one or more of the following symptoms: bothersome postprandial fullness, early satiation, epigastric pain, or epigastric burning, without evidence of structural disease that is likely to explain the symptoms.
In patients with myelodysplastic syndrome and symptomatic anemia with a del5q on cytogenetics, what medication is beneficial?
Lenalidomide
A 68 yo F is admitted to the hospital due to sepsis of unknown etiology and empirically started on vancomycin and cefepime. Blood cultures are later found to have 4/4 bottles growing MSSA.
What is the most optimal change in antibiotic regimen for this patient?
A. discontinue cefepime and continue vancomycin
B. discontinue vancomycin and continue cefepime
C. discontinue both vancomycin and cefepime, and start cefazolin
D. Discontinue vancomycin and cefepime, and start penicillin G
C. discontinue both vancomycin and cefepime, and start cefazolin
Antistaphylococcal beta-lactams (eg, cefazolin, nafcillin, oxacillin) are the treatment of choice for MSSA infections (answers A and B are incorrect). Although vancomycin does provide coverage of MSSA, antistaphylococcal beta-lactams are considered superior to vancomycin, and is associated with significantly lower treatment failure, shorter time to bacteremia clearance, and most importantly, lower mortality. Most staphylococci (∼85%) are resistant to penicillin. Because current methods for detecting penicillin susceptibility have questionable reliability, penicillin should not be used to treat S. aureus (answer D is incorrect).
Between these two heart failure profiles, which one has higher risk?
Patient 1: age 60yo, NYHA 3, ischemic HF, BP 100/60, LVEF 20%, meds: lisinopril, metoprolol, spironolactone, bumetanide 2mg BID, ICD present, serum Na 125, Hgb 12
Patient 2: age 60yo, NYHA 3, ischemic HF, BP 130/70, LVEF 10%, meds: lisinopril, metoprolol, spironolactone, furosemide 20mg BID, ICD present, serum Na 130, Hgb 13
Patient 1
These two patients are directly compared in the Seattle Heart Failure Model. Patient 1 has an estimated 1-year mortality risk of 19% with an expected life expectancy of 3.8 years. Patient 2 has an estimated 1-year mortality risk of 7.9% with an expected life expectancy of 7.3 years, which is much better than Patient 1 despite having a lower ejection fraction. High risk features of Patient 1 include: lower systemic blood pressure, higher baseline diuretic requirement, lower hemoglobin, and hyponatremia.
70 yo male is admitted for 10 days of fever and cough with worsening SOB.
BP 70/50; Pulse 130; oxygen saturation 70% on RA.
Chest xray with RML/RLL consolidations
Admitted to MICU and intubated. Started on levophed 10mcg/min.
He has no prior h/o pneumonia or recent hospitalizations.
What is the appropriate antimicrobial therapy?
A. Ceftriaxone and azithromycin
B. Levofloxacin
C. Vancomycin and zosyn
D. Vancomycin, ceftriaxone, and azithromycin
A. Ceftriaxone and azithromycin
The 2019 IDSA Practice Guidelines for community acquired pneumonia states that even in a patient admitted with severe pneumonia, empiric MRSA or pseudomonal coverage should only be instituted for a history of prior respiratory cultures with these organisms or a history of recent IV antibiotic use (within 90 days). Patients without these risk factors should be treated with a b-lactam and macrolide.
Name three treatment options for achalasia.
Medications: nitrates, anticholinergics, CCB
Botox injections
Balloon dilation or surgical myotomy
Name 3 therapies that can be used in immune TTP.
Plasma exchange
High-dose steroids
Rituximab
Caplacizumab
In MRSA prosthetic valve endocarditis, in addition to vancomycin, which two antimicrobial agents can be added to enhance efficacy of therapy?
Gentamicin and rifampin
Gentamicin dosed for synergy should be added for the first 2 weeks. Rifampin should be added for the entire course of therapy to help with sterilization of prosthetic material.
What is the role of pulmonary artery catheterization in congestive heart failure AND name the trial that supports this argument.
Pulmonary artery catheterization is NOT performed routinely in management of acute decompensated heart failure given no improved outcomes (no difference in days alive out of the hospital or mortality) as demonstrated in the ESCAPE trial.
In a patient with endocarditis, name 4 clinical or echocardiographic features that suggest the need for surgery.
Perivalvular abscess
Valvular dysfunction including aortic or mitral insufficiency
Valve perforation
Mitral leaflet vegetations > 1cm
Increase in vegetation size despite appriopriate antimicrobial therapy
Heart failure unresponsive to medical therapy
Embolic event during the first two weeks of antibiotic therapy
Name three etiologies of dysphagia and whether it is a structural obstruction, functional issue, or type of esophagitis.
Structural obstruction: esophageal webs, rings, stenosis, malignancy
Functional issue: nutcracker esophagus, diffuse esophageal spasms
Esophagitis: infectious esophagitis (candidiasis, herpes simplex, CMV), EOE, GERD
In high risk myelodysplastic syndrome, what is the only chance for cure?
AND
If a patient is deemed too high risk, what alternative treatment option is available?
Allogeneic stem cell transplantation offers the only cure to high risk MDS.
If risks involved in stem cell transplantation outweigh the benefits, patient can be treated with azacitidine.
Name 5 tests to confirm diagnosis of multiple myeloma.
M protein quantification w/ SPEP, UPEP, serum free light chain testing
Bone marrow biopsy - evaluate plasma cell burden / cytogenetics
CBC, serum Cr, Ca
Whole body, lose dose CT or PET-CT or whole-body MRI to detect lytic bone lesions