Usmle Step 2: Heme Onc Qbank

Front 1

Schilling test: explain test and how it differentiates different types of Vit B12 deficiency

Back 1

Differentiates pernicious anemia, dietary deficiency, and malabsorption as causes of Vit B12 deficiency and megaloblastic anemia.

In dietary deficiency, oral radiolabeled Vit B12 is absorbed in the gut and excreted by kidneys in nl amounts

Front 2

Management of acute stroke from sickle cell anemia?

Back 2

Use exchange transfusion (won't fix initial stroke, but may decrease chances of additional stroke)

- continue HU to decrease percentage of sickle cells by increasing the proportion of Hgb F

Front 3

Iron study results for iron deficiency

Back 3

Low serum iron
Low ferritin
Elevated TIBC
Low transferrin saturation (iron/TBC)

Front 4

Increased ferritin in anemia of chronic disease. Why?

Back 4

Ferritin often elevated because it is an acute phase reactant that is elevated in many inflammatory conditions

Front 5

Osler-Weber-Rendu syndrome

Back 5

hereditary telangiectasia, autosomal dominant

characterized by
1) diffuse telangiectasias
2) recurrent epistaxis
3) widespread AVMs

AVMs in the lungs can shunt blood from right to left side of the heart, causing chronic hypoxemia and reactive polycythemia

Front 6

Warfarin: what substances increase/decrease anticoagulation

Back 6

Warfarin = vit K antagonist

Decreased efficacy: vitamin K foods (dark green veggies)

Increased efficacy (more bleeding): alcohol, vit E, garlic, gingko biloba, ginseng, St. John's wort, several antibiotics

Front 7

competitive athlete with steroid use will have what lab finding and clinical finding?

Back 7

Elevated Hct --> androgens, autologous blood transfusions, or EPO abuse

Clinical: gynecomastia, decreased testicular size, hepatotoxicity

Front 8

First line txs for RA

Back 8

MTX, hydroxychloroquine, TNF inhibitors (eg infliximab, etanercept)

Front 9

Pt with h/o cancer or fever who presents with back pain + neurologic sx. First tx?

Back 9

Compression of thecal sac should be suspected!

Use MRI to confirm dx

start glucocorticoid tx (dexamethasone)!!!! (answer to question) while awaiting test results in order to decrease risk of permanent neuro damage (reduce swelling to attempt to preserve neurologic function)

Front 10

What neurologic sx make you think of compression of thecal sac?

Back 10

imbalance, mild weakness, and weak rectal sphincter tone

Front 11

Name the two ways that pernicious anemia leads to vitamin B12 deficiency

Back 11

1) anti-intrinsic factor antibodies
2) pts develop chronic atrophic gastritis with decreased production of intrinsic factor by gastric parietal cells --> increases risk of intestinal-type gastric cancer and gastric carcinoid tumors by 2-3x

Front 12

When should UC patients have colonoscopies?

Back 12

Guidelines state that patients should begin colonoscopy surveillance 8 yrs after dx, possibly longer if only left colon involved.

Once surveillance program started, colonoscopy should be repeated every 1-2 yrs to assess for development of colonic dysplasia.

Front 13

Most common manifestation of hemophilia? Treatment?

Back 13

Hemarthrosis (almost diagnostic!) treated with replacement of missing coag factor

Other sites of bleeding include: skeletal muscle, mucous membranes of head and neck (eg epistaxis), and GI/GU systems.

Front 14

Platelet dysfunction/thrombocytopenia causes what kinds of physical exam findings?

Back 14

Petechiae and small ecchymoses

Front 15

Infectious mono sx?

Back 15

extreme fatigue, malaise, sore throat, fever, and generalized maculopapular rash

Remember that heterophile antibodies, while very sensitive and specific, may be negative early in the illness.

Front 16

Multiple myeloma classic tetrad:

Back 16

calcium (hypercalcemia), renal impairment, anemia, and bones (bone pain, lytic lesions, fractures

Why are people with MM at increased risk for infection?

Hint 16

1) Decrease in functional antibodies
2) Leukopenia that develops as bone marrow is filled with malignant plasma cells

Front 17

Setting in which pernicious anemia commonly presents in younger patients?

Back 17

Autoimmune conditions (eg vitiligo, autoimmune thyroid dz)

Front 18

Distinguish Lynch syndrome I and II

Back 18

I: hereditary site specific colon cancer

II: cancer family syndrome - associated with high risk of extracolonic tumors, the most common of which is endometrial carcinoma, which develops in up to 43% of females in affected families.

Front 19

Polycythemia vera: explain etiology and sx

How to dx?

Back 19

def: myeloproliferative disorder due to EPO-independent overproduction of RBCs

Sx: hyperviscosity (dizziness, H/A), pruritis especially after shower (mast cell degranulation and prostaglandin release), and splenomegaly

Dx: JAK2 mutation (>95%) and low EPO levels

lab values may include elevated Hgb/Hct, platelets, and WBC --> risk of thrombosis (elevated platelets) and bleeding (impaired platelet function)

Front 20

G6PD deficiency - epidemiology, cause, blood smear results

Back 20

X-linked disorder commonly seen in African american men

characterized by episodic hemolysis in response to oxidant drugs, infections, or fava beans

Heinz bodies characteristically seen on peripheral blood smear

Front 21

U/S shows high likelihood of testicular tumor. What is the next best step in management?

Back 21

Radical Orchiectomy!

Front 22

HIT predisposes a person to what?

Back 22

highly thrombogenic and pts must be monitored closely for ARTERIAL AND VENOUS CLOTS

Front 23

CML:

Back 23

characterized by leukocytosis, anemia, and increased number of mature granulocytic forms, such as segmented neutrophils and band forms on peripheral blood filmm.

exam of bone marrow bx: hypercellularity with prominent granulocytic hyperplasia. Leukocyte alkphos score is low.

Front 24

MGUS vs multiple myeloma: how to differentiate

Back 24

MGUS differentiated by lack of renal insufficiency, hypercalcemia, anemia, and lytic bone lesions

Although MGUS is asymptomati, there is a 1% per year risk of progression to MM

Front 25

pt gets a DT, treated with agent, then complains of right arm pain on day 3. PTT prolonged. what is the agent?

Back 25

unfractionated heparin

thrombocytopenia and hypercoagulation within days of initiating anticoagulant therapy are most likely caused by unfractionated heparin. HIT often associated with abnl intravascular thrombosis.

parenteral enoxaparin and other LMWHs may be used in place of unfractionated heparin in the treatment of DVT. However, enoxaparin does not prolong the aPTT.

Front 26

distinguishing CML from leukemoid reaction

Back 26

indistinguishable on peripheral blood film

Leuk alk phos (LAP) test plays a role! usually DECREASED in CML and INCREASED in leukemoid reaction

HOWEVEVER, in CML it may be increased in the presence of subsequent secondary infections. For this reason, the presence of the Philadelphia chromosome should be determined in suspicious cases since this is diagnostic of CML.

Front 27

splenectomy stuff

Back 27

studies have shown that the risk for sepsis is present up to 30years and probably longer after splenectomy.

current recommendations state that patients should receive anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks before the operation, and daily oral PCN ppx for three to five years following splenectomy.

Front 28

common causes of folic acid deficiency

high yield

Back 28

nutritional due to poor diet and/or alcoholism

also DRUGS! these drugs can impair the absorption of folic acid (phenytoin) or antagonize its physiologic effects (MTX, TMP)

Front 29

clotting disorder in a young person with elevated PTT

Back 29

lupus anticoagulant, or APLS

elevated PTT cause?

Hint 29

it is an IgM or IgG immunoglobulin that prolongs the PTT by binding the phospholipids used in the assay. Thus, it is strictly a LABORATORY ARTIFACT and does not actually promote bleeding.

Russel viper venom test used :)

Front 30

most important prognostic consideration in tx of pts with breast CA.

Back 30

TNM staging.

Front 31

perivascular connective tissue atrophy

Back 31

senile purpura usually presents with ecchymoses in elderly patients in areas exposed to repeated minor trauma (extensor surfaces of the hands and forearms). due to age-related loss of elastic fibers in perivascular connective tissue. Thus, minor abrasions that would merely stretch the skin in younger pts can rupture superficial blood vessels in the elderly. Incidence and severity also increased in those on anticoagulation, NSAIDs, corticosteroids,

Senile purpura is not dangerous and requires no further evluation.

Front 32

glucagonoma

Back 32

suspect in pts with mild DM or hyperglycemia with necrotic migratory erythema, diarrhea, anemia, and weight loss.

Glucagon > 500 pg/mL usually confirms the dx

2645

Front 33

most common type of lung CA

Back 33

adenocarcinoma is the most common in both smokers and nonsmokers.

accounts for most of the primary lung CA in nonsmokers.

usually located peripherally nad may present as a solitary nodule, with or without sx.

Front 34

poor prognosticator in CLL

Back 34

thrombocytopenia

Front 35

Bernard-Soulier syndrome

Back 35

autosomal recessive d/t absent platelet glycoprotein ib-IX-V, which acts as a receptor for VWF.

pts usually have MILD thrombocytopenia, circulating "giant" platelets, severe plt dysfunction, and bleeding out of proportion to the degree of thrombocytopenia

Front 36

drugs of choice when treating and preventing chemo-induced N/V

Back 36

serotonin antagonists that block 5HT3 receptors (ondansetron)

Front 37

treating hypercalcemia of malignancy

Back 37

bisphosphonates (zoledronic acid, pamidronate) initial drug of choice

asymptomatic or mild hyperCa does not require urgent or aggressive therapy.

sympomatic moderate or severe hyperCa is usually treated with a combo of saline, calcitonin, and bisphosphonate

Front 38

idiopathic thrombocytopenia purpura

Back 38

usually diagnosed after excluding other possible causes of thrombocytopenia

pts should be tested for hepC and HIV as thrombocytopenia may be the initial presentation of HIV infxn

Front 39

TTP

Back 39

look at 4339!!

requires emergent treatment with plasmapharesis

rates of recovery are high if therapy is given promptly.

Front 40

Hypercalcemia and intractable ulceration

Back 40

suggests hyperparathyroidism and possible Zollinger-Ellison syndrome

part of MEN syndromes

Front 41

acute hemolytic transfusion reaction

Back 41

life-threatening reaction from transfusion of mismatched blood! (ABO mismatch)

rapid development of fever, flank pain, hemolysis, oliguric renal failure, and DIC within an hour of transfusion

febrile nonhemolytic transfusion reactions are the most common adverse reaction to transfusion and p/w fever and chills within 1-6hr of transfusion

Front 42

mgmt of metastatic brain CA

Back 42

solitary brain metastasis: surgical resection followed by whole brain radiation

multiple brain metastases: palliative whole brain radiation

Front 43

trousseau's syndrome

Back 43

hypercoagulability disorder presenting with recurrent and migratory superficial thrombophlebitis at unusual sites (eg arm, chest area). It is usually a/w an occult visceral malignancy such as pancreatic (most common), stomach, lung, or prostate CA

Front 44

paradoxical pro-coagulant effects of warfarin

Back 44

during the first few days it is given, it can have a paradoxically pro-coagulant effect in susceptible pts by inhibiting protein C!!! production

affected pts may p/w skin necrosis 2/2 thrombos formation

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Front 45

treatment of SIADH

Back 45

initial treatment of choice is fluid restriction

svere or symptomatic or resistant hyponatremia from SIADH requires administration of hypertonic saline

demeclocycline rarely necessary!