Mksap 09-08

Front 1

what to do if diabetes not well controlled on a sulfonylurea (eg glyburide)?

Back 1

add metformin (synergy rather than substitution); sulfonylurea is an insulin secretagogue, and metformin is an insulin sensitizer

Front 2

what to do in diabetic hypoglycemic attack

Back 2

give glucagon followed by carbohydrate intake (esp in Type I diabetics); half-life of glucagon is on the order of minutes

Front 3

what factors affect creatinine CLEARANCE besides serum creatinine?

Back 3

body mass, gender, age; eg lean pt with low body mass can have renal insufficiency with "normal-range" creatinine values like 1.3

Front 4

how can renal insufficiency cause hypoglycemia? (2)

Back 4

1) decreased alanine substrate for gluconeogenesis (==> dec glucose production during fasting); 2) renal insufficiency prolongs circulating insulin action

Front 5

what hormones facilitate enzymes involved in gluconeogenesis?

Back 5

cortisol and thyroid hormone

Front 6

effect of gestational diabetes on risk of developing DM II

Back 6

increased risk

Front 7

drugs vs lifestyle intervention in preventing diabetes in prediabetic pts

Back 7

both helpful, but lifestyle intervention more effective than drugs (metformin, acarbose, glitazones); only lifestyle intervention is recommended

Front 8

fasting glucose level needed to confirm diabetes

Back 8

>126

Front 9

goal BP in diabetics?

Back 9

<135/80

Front 10

antihypertensives to use in diabetics (2)? Benefits of each?

Back 10

thiazides (cardioprotective) + ACEi (nephroprotective)

Front 11

what complication of diabetes tx can masquerade as behavioral problems? How to diagnose?

Back 11

hypoglycemia (often undetected) ==> need more frequent glucose monitoring

Front 12

what to do if DM II not well controlled with sulfonylurea + metformin?

Back 12

add insulin

Front 13

3 ways to diagnose DM

Back 13

1) sx of diabetes + casual plasma glucose > 200; 2) 2-hr plasma glucose > 200 during oral glucose tolerance test; 3) fasting glucose > 126 [**recommended test]; EACH MUST BE CONFIRMED ON SUBSEQUENT DAYS BY ONE OF THE OTHER METHODS

Front 14

use of HbA1c in diagnosis of DM

Back 14

not recommended; use primarily to monitor glycemic control (like fructosamine)

Front 15

fructosamine vs HbA1c

Back 15

both used to monitor glycemic control; HbA1c over 120 days, fructosamine over 3 wks

Front 16

target preprandial glucose values in diabetics type I

Back 16

80-120

Front 17

target bedtime glucose values in diabetics type I

Back 17

100-140

Front 18

tx of acutely symptomatic type II DM

Back 18

insulin (also in type II DM with pregnancy or hyperglycemic emergencies); can maybe discontinue later once glucose toxicity / lipotoxicity reversed

Front 19

how to protect vision in pt with very poor glycemic control and evidence of proliferative retinopathy

Back 19

urgent laser therapy

Front 20

how to manage diabetes in hospitalized pt who is NPO?

Back 20

insulin infusion

Front 21

ability to prove diabetic foot ulcer directly to the bone suggests what?

Back 21

osteomyelitis (90% likelihood)

Front 22

what finding on urinalysis presents with a maltese cross appearance under polarized light?

Back 22

oval fat droplet ==> suggests nephrotic-range proteinuria (eg in diabetic nephropathy)

Front 23

what do hyaline casts suggest?

Back 23

normal, concentrated urine; consist of tubular protieins (Tamm-Horsfall protein) but contain few/no cellular elements; can also be seen in diabetic nephropathy -- correlate with protein content on urinalysis

Front 24

how to treat drug-resistant acinetobacter pulmonary infection?

Back 24

potent carbepenems (imipenem, meropenem) or some of the aminoglycosides (eg amikacin and tobramycin) active in vitro, but aminoglycosides have poor lung penetration (amiNO O2); cephalosporines, quinolines usu ineffective;

Front 25

persistent fever despite successful tx of nosocomial infection

Back 25

drug fever (allergic basis, but can lack other signs of allergy; rash and Eos are rare)

Front 26

common sources of candidal bacteremia

Back 26

GI tract, central venous catheter (==> seen in surgical ICUs bc of GI surgical prcedures, parenteral nutrition via CV catheter, ARF requiring hemodialysis, and use of broad spectrum antibiotics)

Front 27

tx for candidal bacteremia

Back 27

systemic fluconazole

Front 28

what needs to be done for pts with resolving staph aureus bacteremia before discharge?

Back 28

TEE! Risk of endocarditis as high as 25%; followed by 4wks of IV abx if endocarditis seen, 2wks if not seen

Front 29

what is the risk of antimotility agents for diarrhea in pts with severe inflammatory conditions

Back 29

increased risk of toxic megacolon

Front 30

what dz a/w extensive seborrheic dermatitis refractory to corticosteroid tx?

Back 30

HIV

Front 31

in which pts do you see cryoptococcal meningitis?

Back 31

only in pts with untreated HIV, pts with HIV who cannot tolerate or do not benefit from antiretroviral tx, and pts with undiagnosed HIV

Front 32

what causes high mortality with cryptococcal meningitis?

Back 32

increased intracranial pressure (ICP proportional to mortality); need to normalize pressure, either by therapeutic LP or VP shunt

Front 33

when to biopsy suspected toxoplasmic encephalitis?

Back 33

only if not responsive to initial tx

Front 34

location of lesions typical of toxoplasmic encephalitis

Back 34

deep in cerebral hemispheres, often basal ganglia

Front 35

CMV vs Toxo encephalitis

Back 35

no mass lesion in CMV

Front 36

how to prevent vertical xmission of HIV?

Back 36

antiretroviral tx during pregnancy (zidovudine monotherapy in 2nd trimester)

Front 37

renal findings in HIV nephropathy

Back 37

nephrotic-range proteinuria, azotemia, and normal-sized kidneys (focal segmental glomerulosclerosis)

Front 38

what is immune reconstitution syndrome? What do you do about it?

Back 38

occurs following effective control of HIV by antiretroviral therapy -- see transient paradoxical worsening of underlying infections, such as TB, MAC, and CMV; tx: continue HAART, can add NSAID to control fever/pain

Front 39

when does HIV lipodystrophy occur?

Back 39

fat redistribution usu a/w HAART, but can also occur without antiretroviral tx; esp a/w protease inhibitors;

Front 40

what is seen in HIV lipodystrophy?

Back 40

lipoatrophy of extremities and face, fat accumulation in abdomen, breasts, and neck

Front 41

which anti-TB drug contraindicated with HIV tx?

Back 41

Rifampin (known to interfere with many protease inhibitors); rifabutin can be substituted

Front 42

adjunctive tx for hypoxemic pneumocystic pneumonia

Back 42

add corticosteroids to TMP-SMX

Front 43

what is pentamidine

Back 43

antimicrobial used for prevention and tx of PCP; also has some anti-protazoal activity

Front 44

primary CNS lymphoma in immunocompetent vs HIV pts

Back 44

in HIV, often manifest with central necrosis + ring-enhancing lesions (can be confused for toxo)

Front 45

EBV and CNS lymphomas

Back 45

nearly all primary CNS lymphomas in HIV pts a/w EBV; rarely in immunocompetent pts

Front 46

tx of CNS lymphoma in HIV

Back 46

methotrexate and brain radiation, but rarely succesfull; usu die within 6 mos

Front 47

criteria for SIRS

Back 47

>=2 of the following: 1) T > 100.4 or < 96.8; 2) HR > 90; 3) RR > 20 or Pco2 < 32; WBC > 12000 or < 4000 w 10% bands

Front 48

criteria for sepsis

Back 48

SIRS with documented infection

Front 49

criteria for severe sepsis

Back 49

sepsis + organ dysfunction/hypoperfusion/hypotension

Front 50

criteria for septic shock

Back 50

severe sepsis with sepsis-induced hypotension despite adequate fluid resuscitation

Front 51

tx of sensitive strpe viridans endocarditis of normal valves

Back 51

4wks x PCN or ceftriaxone; OR 2wks if combined with gent

Front 52

stages of chickenpox lesions

Back 52

macular, papular, vesicular, pustular; rapid progression thru stages, and several stages of development seen in a given area

Front 53

most common location of molluscum contagiosum

Back 53

face, anogenital areas

Front 54

widened mediastinum a/w what bug?

Back 54

bacillus anthracis

Front 55

abx used for empiric tx of community acquired pneumonia

Back 55

ceftriaxone + azythromycin

Front 56

suspected cause of neutropenic fever without resolution with adequate antiacterial regimen

Back 56

fungal! (eg candida, aspergillus) ==> start amphotericin B

Front 57

lyme dz vs RMSF

Back 57

lyme dz usu doesn’t cause septic findings

Front 58

areas a/w yellow fever

Back 58

africa, south america, panama (NOT asia)

Front 59

tx of pt with central venous port and neutropenic fever

Back 59

IV antibiotics (eg cephalosporins), if resolving, continue IV abx (no need to pull port); can't do PO meds b/c port puts pt in "high risk" category

Front 60

tx of neutropenic fever

Back 60

broad empiric antibiotic coverage, ideally bactericidal, through alternate ports of any indwelling IV lines; ideally tailored to pt, but generally cefepime or carbepenem recommended, with aminoglycoside if critically ill

Front 61

what to do if neutropenic fever persists >5-7d after administration of broad empiric abx?

Back 61

add antifungal

Front 62

when to stop abx in neutropenic fever?

Back 62

if source known, std duration; if unknown, stop if ANC > 500 and pt afebrile (~7-14d)

Front 63

what does the physiologic murmur of pregnancy sound like?

Back 63

early peaking systolic ejection murmur (pulmonary outflow murmur) a/w S3 and displaced PMI

Front 64

difference in ausculatation between flow murmur and murmur from left ventricular outflow obstruction

Back 64

flow murmur peaks in 1st 1/2 of systole

Front 65

which murmurs decrease with valsalva?

Back 65

aortic and pulmonic stenoses, mitral and tricuspid regurg

Front 66

appropriate frequency of pap smears in patient with low risk for cervical cancer (long-term, monogomous relationship, many normal pap smears, etc.)

Back 66

every 3 yrs; annually if high risk

Front 67

frequency of tetanus boosters

Back 67

every 10 yrs after pediatric series

Front 68

what vaccines needed for day care center staff / long-term care facilities?

Back 68

hep A and B

Front 69

what lab testing required before low risk procedures (dental extraction, lymph node biopsy, herniorrhapy) to avoid bleeding?

Back 69

none, as long as history and family history are negative

Front 70

what lab work prior to moderate- or high-risk procedures?

Back 70

PT, APTT, platelet count; NOT bleeding time (no predictive value)

Front 71

mgmt of person recently exposed to TB

Back 71

PPD, followed by repeat PPD in 3 months (takes weeks to seroconvert)

Front 72

cervical cancer screening in pts who have had hysterectomy for benign disease

Back 72

no need for routine pelvic exam / pap smear (no proven benefit for detection of cancer)

Front 73

modifiable risk factor for head and neck cancer

Back 73

alcohol abuse

Front 74

use of pap smears to detect uterine cancer

Back 74

pap smears do NOT reduce mortality from uterine cancer; they DO lower incidence of cervical cancer and its mortality

Front 75

risks of post-menopausal hormone replacement therapy (HRT)

Back 75

increased relative risk of coronary heart disease and breast cancer

Front 76

raloxifene as tx for hot flushes

Back 76

no good! Raloxifene can INCREASE hot flushes

Front 77

when to use estrogen tx for hot flushes?

Back 77

if low risk of breast cancer and cardiovascular dz (and ?absence of uterus?)

Front 78

best screening strategy for ovarian cancer

Back 78

annual rectovaginal pelvic exams

Front 79

impact of PSA screening on prostate cancer detection and mortality

Back 79

markedly increased detection with unclear impact on overall mortality

Front 80

digital rectal exam vs PSA as screening tool for PrCa

Back 80

DRE less sensitive than PSA, but can pick up tumors missed by PSA

Front 81

at what age to pts with hereditary genetic cancer syndromes get cancer?

Back 81

<60y

Front 82

prophy for malaria in subsaharan africa

Back 82

mefloquine, doxycycline, or atovaquone/proguanil; NOT chloroquine -- resistance rampant; quinine used for tx, not prophy

Front 83

what to do for pt with positive PPD and history of positive PPDs?

Back 83

chemoprophylaxis (unless cannot be tolerated, eg chronic liver dz); std chemoppx is isoniazid 300mg x 9mo

Front 84

what endocarditis ppx to use in pts undergoing dental procedures and allergic to PCN?

Back 84

clindamycin (1 dose 1hr before procedure)

Front 85

what to do if needle stick with HBV?

Back 85

check vaccination status (ie endogenous antibody response); have 72 days to start ppx, so if vax status negative, begin IVIg and vaccination

Front 86

common lesions on hands/feet of teenagers

Back 86

verruca vulgaris (common warts),

Front 87

tx of common warts

Back 87

usu resolve spontaneously; can use topical salicylic acid if painful. Cryotherapy also possible, but can cause painful neurlagia on digits

Front 88

what is imiquimod and what is it used for?

Back 88

topical immunotherapy used for genital warts

Front 89

tx for actinic keratosis

Back 89

topical 5-FU, cryotherapy

Front 90

tx of chickenpox

Back 90

high dose oral acyclovir within 24 hrs of rash; after 24 hrs, acyclovir not helpful -- can give antihistamines to control itching

Front 91

tx for shingles (herpes zoster)

Back 91

ORAL acyclovir, +/- corticosteroids (accelerate healing and improve quality of life, but don’t decrease post-herpetic neuralgia)

Front 92

when to use IV acyclovir?

Back 92

to tx herpes zoster in an immunocompromised host

Front 93

role of corticosteroids in preventing post-herpetic neuralgia?

Back 93

refuted

Front 94

features of Sweet's syndrome (4)

Back 94

1) fever; 2) leukocytosis; 3) acute, tender, red plaques; 4) papillary dermal infiltrate of neutrophils

Front 95

red, pruritic papules and plaques, lesions last <24 hrs each

Back 95

urticaria

Front 96

urticaria vs other red pruritic papules and plaques

Back 96

urticarial lesions last < 24h

Front 97

where does cutaneous candidiasis occur?

Back 97

warm, moist skin areas

Front 98

in whom does cutaneous candidiasis occur?

Back 98

pts with altered local immunity, eg increased moisture at site of infection, diabetes, or altered systemic immunity

Front 99

cutaneous psoriasis vs candidasis

Back 99

both can occur in intertriginous areas (skin folds) and appear bright red with pustules; PSORIASIS has more distinct borders, pustules are distributed throughout lesion rather than just periphery, and also apperas on the trunk with heavy silver-white scale

Front 100

characteristic features of tinea corporis

Back 100

peripheral expanding lesion with central clearing --> annular

Front 101

distinguishing characteristic of tinea versicolor

Back 101

fine, powderly scale when lesions are lightly scraped

Front 102

where is tinea cruris found?

Back 102

groin, pubic region, and inner thighs; often a/w tinea pedis, so also see lesions on feet

Front 103

where does seborrheic dermatitis occur?

Back 103

oily areas (scalp, central face, upper mid chest)

Front 104

what is an aphthous ulcer?

Back 104

"canker sore" -- painful, small, shallow, white-based lesion with yellow border surrounded by a red areola

Front 105

rosacea vs SLE

Back 105

rosacea does not spare the nasolabial folds, has more prominent acne-like pustules, is unrelated to sun exposure, and does not have other systemic sx such as arthritis

Front 106

what causes all types of psoriasis to improve?

Back 106

sunlight

Front 107

herpes simplex lesions in immunocompromised patient

Back 107

vesicles quickly break down, leaving large, painful ULCERS and erosions that do not heal

Front 108

tx for severe cystic and pustular acne

Back 108

oral antibiotics, followed by oral isotretinoin if abx fail

Front 109

where does eczema commonly occur?

Back 109

skin flexures (elbows, neck, wrists, ankles, sides of neck)