Pearls from ACP July 2019

1. Psoriasis may be exacerbated by streptococcal infection, skin injury (sunburn or drug reaction) or HIV disease.

2. Think of the 5 P’s for the diagnosis of lichen planus - pruritic, purple, polygonal, planar, papules.

3. Porphyria cutanea tarda is associated with heavy alcohol consumption, hepatitis C, and iron overload (especially hepatitis C- 70% of PCT patients have hep C) Clinical features include facial hirsutism, milia, erosions, scars and tense bullae (frequently on hands).

4. Pemphigus vulgaris often involves the mouth (50%). Diagnosed by immunofluorescent studies of perilesional skin. High fatality rate if not treated.

5. Erythema nodosum: Think Inflammatory bowel disease, sarcoid, strep infection , or drugs (OCP most common)

6. Erythema Multiforme: “Target lesions” : Think HSV, drugs (PCN, Sulfa and Phenytoin most common), or Mycoplasma. For patients with recurrent erythema multiforme, a trial of acyclovir therapy is appropriate

7. Acanthosis nigricans is most often seen in association with obesity and diabetes with insulin resistance. It is occasionally seen associated with malignancy (60% gastric).

8. In a younger patient with severe seborrheic dermatitis think HIV, an older person with severe Seb Derm think Parkinson’s disease

9. Treat herpes zoster with 7 days of Valacyclovir or famciclovir. Acyclovir, although much less expensive, must be given 5 times a day to be effective which makes it much harder to use (and a less attractive option). Tricyclic antidepressants and gabapentin are the best options for post herpetic neuralgia treatment. Remember to avoid Tricyclics in men with BPH and patients with CAD.

10. Tinea versicolor occurs on the chest/back/lower neck/ upper arms. It is hypopigmented when exposed to sun. Treatment is 400 mg of ketoconazole orally X1 (no ppi’s as acid stomach needed), and then work up a sweat. Also can use selenium containing shampoos

11. Patients with alcoholic hepatitis usually have AST levels less than 300 with trivial elevations of ALT with an AST/ALT ratio usually >3.

12. AST/ALT ratio almost always under 1 in viral hepatitis, until cirrhosis occurs

13. The initial diagnostic test for hepatitis C is measurement of anti-HCV, if positive, check a HCV RNA to determine the presence of active infection

14. Interferon alfa should not be used in patients with active autoimmune disorders, severe cytopenias, decompensated cirrhosis or major depression

15. Hemochromatosis and alcohol liver disease share several overlapping features – hepatomegaly, glucose intolerance, testicular atrophy and cardiomyopathy.

16. Nonalcoholic steatohepatitis can mimic alcoholic hepatitis. It usually occurs in middle-aged women with obesity, diabetes and hypertension. Clinical features are hepatomegaly and elevated transaminases (usually AST > ALT).

17. Causes of marked transaminase elevation (with transaminases > 2000): Drugs (Acetominophen ) most common, Viral hepatitis(A and B), Ischemia. Toxin (mushrooms)

18. Statins are safe to give to people with liver disease, NSAIDS are not

19. Autoimmune hepatitis usually occurs in women and serologically these patients have antinuclear and anti-smooth muscle antibodies as well as hyperglobulinemia.

20. Wilson’s disease is a rare autosomal recessive disorder. Clinical features include hepatitis (both fulminant and chronic), neurologic symptoms, hemolytic anemia and Kayser – Fleischer rings around the iris.

21. Several drugs can cause prominent drug induced cholestasis – chlorpromazine, gold, chlorpropamide, oral contraceptive pills, erythromycin and amoxicillin/clavulanate.

22. PSC usually occurs in middle age males with a history of ulcerative colitis. Past colectomy does not protect the patient from developing this.

23. In patients with acute CBD obstruction due to gallstones, ALT/AST rise almost immediately, and can climb over 1000

24. Sclerotherapy is effective in controlling acute variceal bleeding (75-90%). Serious complications limit its usefulness. Variceal band ligation is as effective but with less complications. B-blockers are effective for prophylaxis of variceal bleeding

25. Spontaneous bacterial peritonitis is usually caused by gram negative rods and should be treated with a five day course of a 3rd generation cephalosporin. Give albumin if Cr >1, Bili >4

26. Do not give B blockers to liver patients with refractory ascites

27. Crohn disease most commonly involves the terminal ileum and cecal region (45%).

28. Extra intestinal manifestations include uveitis, spondyloarthropathy, erythema nodosum and pyoderma gangrenosum

29. Bacterial overgrowth in the small bowel can cause malabsorptive diarrhea. Risk factors for bacterial overgrowth are scleroderma, diabetes, high dose PPI’s, postoperative (Billroth 2), radiation enteropathy

30. Whipple’s disease (etiologic agent Tropheryma whipplei ) can cause malabsorptive diarrhea in addition to many other features including: arthritis, fever, lymphadenopathy, clubbing, CNS involvement and uveitis.

31. Celiac sprue is associated with dermatitis herpetiformis, increased risk for small bowel lymphoma, selective IgA deficiency and occasionally is the cause of isolated ALT elevation

32. Osmotic diarrheas have high stool osmolol gaps (>125), secretry diarrheas have low osmolol gaps (<50)

33. Serologic tests for IgA endomysial antibody and IgA tissue trans glutamine antibody can help in the diagnosis of celiac sprue. Patients who are on a gluten free diet at the time of testing may have false negative results

34. Chronic watery diarrhea in a middle age woman without weight loss or pain think microscopic (collaginous) colitis. Bismuth or budesonide are used for microscopic colitis.

35. Diarrhea due to pancreatic insufficiency has a greater amount of stool fat than other malabsorptive diarrheas and normal small bowel absorption tests (D- Xylose and Hydrogen breath tests)

36. A trial of cholestyramine is appropriate for patients with post cholecystectomy diarrhea

37. Think fecal impaction in elderly patients with small volume watery diarrhea and fecal incontinence.

38. Acute pancreatitis is caused by alcohol consumption or gallstones 60% of the time.

39. Colitis from campylobacter and occasionally amebiasis can mimic the symptoms and appearance of ulcerative colitis.

40. Pseudocysts develop in 20% of patients with severe acute pancreatitis. Pseudocysts larger than 6 cm are at risk for perforation, infection and hemorrhage. Surgical drainage should be performed if they do not resolve.

41. In evaluating suspected chronic pancreatitis, the initial diagnostic test should be plain abdominal x-ray. Presence of diffuse calcifications in the pancreas is diagnostic (~40%). The most sensitive imaging test is ERCP.

42. Helicobacter Pylori present in 80-95% of duodenal ulcers and 60-90% of gastric ulcers

43. Patients with ALS present with asymmetric weakness with a bulbar or limb presentation. No sensory, visual or bowel or bladder abnormalities

44. Lambert-Eaton syndrome involves progressive progressive proximal weakness and diminished DTR’s that improve with repetitive movement (MG usually worsens with repetitive movement). Lambert-Eaton syndrome is caused by antibodies to voltage-gated calcium channels. More than 50% have an underlying malignancy (small cell cancer most common)

45. Campylobacter infection can trigger Guillain-Barre Syndrome

46. Patient with a DVT plus stroke think patent Foramen Ovale

47. Aspirin plus clopidogrel offers no benefit over aspirin alone for stroke prevention, but does increase bleeding risk

48. Aspirin plus clopidogrel offers no benefit over aspirin alone for stroke prevention, but does increase bleeding risk

49. Carotid endarterectomy recommended for symptomatic patients with > 70% stenosis, asymptomatic patients with > 80% stenosis who have a low surgical risk and an otherwise good 5 year survival

50. Carotid endarterectomy should be done as soon as possible after a TIA (If the patient is an appropriate candidate

51. Statins decrease stroke risk about 20-30%

52. Essential tremor is usually a bilateral postural tremor, worse with activity- may improve with alcohol. Treat with primidone or propranolol.

53. 90% of patients with recurrent “sinus headaches” actually have migraine, treat with triptans.

54. The presence of hypokalemia in a hypertensive patient who is not on diuretics makes the likelihood of a secondary cause much greater. Alcoholism, hyperaldosteronism and renal artery stenosis all can lead to hypokalemia.

55. The physical finding of orthostatic hypotension in a hypertensive patient is seen in patients with pheochromocytoma. Think of the H’s for symptoms of pheochromocytoma- Hypertensive, Hyperhydrosis, Hyperglycemia, Headache, Hypotension (orthostatic)

56. Evaluate patients with spontaneous hypokalemia and hypertension for hyperaldosteronism.

57. Patients with nephrotic syndrome are at increased risk for infections due to urinary loss of IgG and complement. They are also at risk for thrombosis due to urinary loss of anti-thrombin III and an increase in coagulation factors.

58. Features of renal vein thrombosis include flank pain, hematuria and enlarged kidney by U/S.

59. Minimal change disease is more common in children but when seen in adults it is associated with atopy/allergy, NSAID use, or with Hodgkin’s disease.

60. IgA nephropathy is the most common cause of nephritis syndrome worldwide. This usually presents as micro/macroscopic hematuria often within 48 hours of a URI.

61. Separating strep glomerulonephritis from IgA nephropathy by history: IgA nephropathy often has current episodes of hematuria following URI, whereas post strep is not usually recurrent

62. Time course for IgA hematuria is 2-3 days post URI, for post strep, 2-4 weeks

63. Goodpasture’s disease usually presents in patients with a typical epidemiology – young male smokers with a history of hydrocarbon exposure. Hemoptysis often follows a URI, usually diffuse infiltrates on Xray

64. Do not give Gadolinium to patients with CKD because of the risk of nephrogenic fibrosing dermopathy.

65. Atheroembolic renal disease occurs after angiography, aortic surgery and can occur after institution of anticoagulation. Clinical features include livedo reticularis, purple toes and progressive renal dysfunction. Peripheral eosinophilia is far more common than eosinophiluria.

66. ARF with thrombocytopenia- think microscopic angiopathy (look for hemolysis, schistocytes)

67. Which patients with thrombotic microangiopathy do you definitely plasmapherese? TTP, antiphospholipid antibody syndrome, complement disorders

68. Drug induced acute interstitial nephritis is most commonly due to B-lactams (especially penicillins) and NSAIDS. Dilantin and allopurinol also important causes.

69. Clues to renal failure due to ethylene glycol include oxalate crystals in the urine and a marked anion gap acidosis with an osmolar gap.

70. MCV elevation in non anemic patients is most likely due to alcohol

71. Reflux esophagitis should be considered in patients with refractory asthma.

72. GERD induced laryngitis requires higher dose of PPI’s (often BID dosing), longer courses

73. Barium x-ray in patients with achalasia shows bird beak distal esophagus with dilated esophageal body.

74. Key clues of Zenker’s diverticulum are cervical dysphagia, halitosis and aspiration pneumonia.

75. Intermittent non-progressive solid dysphagia is suggestive of a Schatzki’s Ring.

76. Pill induced esophagitis is most commonly caused by: Tetracycline/doxycycline followed by KCL, NSAIDS, iron, clindamycin or Alendronate.

77. Severe GERD in a younger woman, think about the possibility of Bulemia

78. Parvovirus B19 infection in adults can cause rheumatoid arthritis like syndrome with polyarthritis. Transient aplastic crisis occurs in patients with chronic hemolytic anemias (especially sickle cell disease). Patients with immunosuppression (especially HIV) can develop chronic anemia.

79. Treatment with immunoglobulin is used for chronic anemia due to parvovirus in immunocompromised patients.

80. The major reservoirs for rabies in the United States are bats, skunks, raccoons, foxes and coyotes.

81. Think of Hantavirus infection in patients with fevers, myalgias, noncardiac pulmonary edema, increased hematocrit, and leukocytes.

82. Babesiosis is most commonly seen in the Northeastern U.S. (for board purposes think Martha’s Vineyard) but has been described elsewhere. Disease is more severe in splenectomized patients.

83. Ehrlichiosis is a rickettsial infection most common in South Central and South Atlantic states. Clinical features include fevers, headache, myalgias but rarely (<20%) rash. “Rocky mountain spotless fever.” As with all rickettsial infections expect to see thrombocytopenia, lymphopenia and increased LFT’s.

84. The classic finding of Lyme disease is erythema migrans, a rash that occurs 7-10 days after the tick bite (occurs in 60-80% of patients). It is an erythematous, annular lesion, usually with central clearing and is large - over 5 cm (average 15 cm).

85. Think Lyme disease when you see bilateral 7th nerve palsies (sarcoid is another disease that can do this).

86. Third generation cephalosporins are particularly effective and indicated for treatment of meningitis (except cefoperazone), gonorrhea (ceftriaxone/cefixime) and nosocomial infections.

87. Third generation cephalosporins do not cover enterococcus.

88. Appropriate therapy for a cat or dog bite: Amoxicillin + Clavulanate . PCN allergic = Clindamycin + fluoroquinolone

89. “Red man” syndrome is a side effect of infusion of vancomycin at too fast a rate. It consists of itching and rash on the face, neck and trunk. It is due to histamine release

90. Patients with recurrent erythema multiforme should be evaluated for HSV infection. Consider a trial of acyclovir.

91. Cellulitis with bullae in a patient with liver disease think Vibrio vulnificus.

92. Turtle and reptile exposure is linked to Salmonella infections

93. Patients with hereditary angioedema present with recurrent episodes of swelling usually beginning in childhood and frequently after trauma. Episodes of abdominal pain due to edema are common. These patients do not have urticaria. A good screening test for this is C4 levels which are always low.

94. Acquired C1 esterase deficiency is seen in patients with B-cell proliferative disorders, connective tissue disorders and monoclonal gammopathies.

95. Pseudoxanthoma elasticum causes “chicken skin” around neck, axilla. Angioid streaks on funduscopic exam. Clinical features include recurrent GI bleeding.

96. Thyroid hormone can be bound by iron, calcium, cholestyramine, antacids and sucralfate. Estrogen increases TBG, and hypothyroid women may need increased doses of T4

97. TMP/Sulfa decreases Warfarin’s binding leading to overanticoagulation.

98. Natural products which interact with warfarin generally begin with the letter G (ginko, ginger, glucosamine/Chondroitin and garlic increase the bleeding risk, ginseng can decrease anticoagulation).

99. Remember drugs that can cause hyperkalemia – ACE inhibitors, ARB’s, TMP/Sulfa, K+ sparing diuretics and NSAIDS.

100. The risk of rhabdomyolysis with statin drugs increases greatly when the drug is combined with erythromycin or cyclosporin. Combination with gemfibrozil can also increase the risk (risk is highest if patient is on steroids). Risk is 10X higher for gemfibrozil over fenofibrate

101. Quinolones can cause tendon rupture and CNS symptoms including confusion and hallucinations (usually seen in the elderly). QT prolongation is most severe with moxifloxacin . Risk of tendon rupture highest if patient is elderly and on steroids

102. Drug causes of acidosis include metformin (gap) only in patients with low GFR’s (<30) and topiramate (nongap).

103. Patients with acute HIV infection share many symptoms with mononucleosis. Differences between the illnesses: rash common with acute HIV (70%), oral ulcers occur with acute HIV (30%), diarrhea with acute HIV (30%).

104. Bacillary angiomatosis is due to Bartonella sp usually acquired from cats. Treat with erythromycin/azithromycin.

105. An HIV-infected patient with oral candidiasis complaining of dysphagia should be treated empirically for esophageal candidiasis (fluconazole). The positive predictive value of these symptoms is ~ 100%.

106. USPSTF recommends HIV screening for everyone between ages 15-65

107. Patients with HIV who develop a spontaneous pneumothorax probably have an infection with pneumoocystis (95% chance).

108. Clinical features of tuberculosis in patients with HIV differ by CD4 count. In patients with CD4 counts >300 typical symptoms occur (cough, sputum, fever, upper lobe infiltrates, cavities). When the CD4 count is <200 atypical TB presentations predominate (hilar adenopathy, no sputum, lower lobe infiltrates, extrapulmonary disease).

109. PPD induration of 5mm is considered positive in a patient with HIV

110. Antiretroviral therapy should be started early in the course of HIV if the patient is committed to taking the regimens. Patient compliance is the single most important issue in starting therapy.

111. Important disease associations with HIV are EBV = Oral hairy leukoplakia, JC virus= PML, HHV 8= Kaposi’s Sarcoma, and Bartonella sp= Bacillary angiomatosis

112. Abacavir can cause a life threatening hypersensitivity syndrome on rechallenge. Abacavir allergy is associated with the presence of HLA-B*57:01

113. In patients with low CD4 counts (< 100) recently started on antiretroviral therapy who develop fever and lymphadenopathy the cause is usually MAC infection.

114. D4T, DDI, and DDC can all cause peripheral neuropathy and pancreatitis.

115. Indinavir and atazanavir can cause unconjugated hyperbilirubinemia

116. Tenofovir can cause renal insufficiency

117. The following vaccines are contraindicated in HIV patients: Live attenuated influenza vaccine, Varicella vaccine (Zostavax) if CD4 count is <200, Smallpox vaccine, live oral polio vaccine, Measles vaccine if CD4 <200, yellow fever vaccine, Typhoid Ty21a. Shingrex is ok for patients with HIV , regardless of CD4 count

118. Pseudomonas aeruginosa is an important cause of community-acquired pneumonia in patients with HIV with CD4 counts <100.

119. Lactic acidosis can occur with nucleoside reverse transcriptase inhibitors. Most will have hepatomegaly and abnormal LFT’s as well. D4T the most associated

120. Risk factors for disseminated candidal infection include - hyperalimentation, central venous catheters, diabetes, broad-spectrum antibiotics and steroid therapy.

121. Clinical features of disseminated candidiasis - fever, endophthalmitis, and pulmonary infiltrates. Hepatosplenic candidiasis most common in transplant of leukemic patients - fever, abdominal pain, hepatosplenomegaly, increases alkaline phosphate.

122. Risk factors for invasive aspergillosis - prolonged granulocytopenia, corticosteroid therapy, and cytotoxic chemotherapy. Interestingly not common in AIDS patients.

123. Rhinocerebral mucormycosis usually seen in patients with diabetic ketoacidosis or leukemics. High mortality rate due to complication of cavernous sinus thrombosis and cerebral infarction.

124. Coccidiomycosis - Two presentations to know 1) symptomatic pulmonary infection “valley fever” - flu like illness, hilar adenopathy or effusion on x-ray, mild eosinophilia. May have rash and erythema nodosum; 2) disseminated disease - more common in Filipino’s/Asians/Blacks and patients with AIDS. Lesions can occur in bone, skin, meninges, and joints.

125. Leishmaniasis - epidemiology especially Latin America, Mediterranean littoral, middle east. Cutaneous and visceral disease. Key features of visceral disease - hepatosplenomegaly, generalized lymphadenopathy, pancytopenia, fever, cachexia (resembles lymphoma).

126. In patients with virulent E. histolytica infections almost all have a positive serology. In a patient with a liver abscess and suspected E. histolytica serology usually needed to confirm diagnosis.

127. Trichinosis - Clinical features - severe muscle pain, periorbital and facial edema, subconjunctival and splinter hemorrhages, eosinophilia.

128. Women with simple cystitis should not have a urine culture done.

129. First line therapy for cystitis are nitrofurantoin , trimethoprim sulfa or Fosfomycin (rarely ever used)- NOT quinolones

130. E. Coli is developing increasing resistance to TMP/Sulfa (often >20%) and quinolones

131. Key features of disseminated gonococcal infection include tenosynovitis, asymmetric arthritis and a few skin lesions on hands, feet, and wrist ankles.

132. Increased susceptibility to gonococcal and meningococcal bacteremia may be due to homozygous deficiency to complement components C5, C6, C7 or C8. Screen patients for these defects with a total hemolytic complement (CH50).

133. The most common cause for genital ulcers in the U.S. is HSV2

134. Chancroid causes painful genital ulcers with irregular borders. Endemic areas include SE Asia and Africa.

135. High risk surgeries include emergency surgery, aortic and peripheral vascular and prolonged surgeries with lots of blood loss.

136. Major clinical predictors for cardiac death or MI with surgery are unstable coronary syndromes, decompensated CHF, significant arrhythmias and severe valvular disease.

137. Patients with step 2 asthma should be on a low dose inhaled steroid and prn short acting B agonist (Know the asthma guidelines, lots of questions on this)

138. Pearls about secondary rhinitis – conditions that cause nasal congestion – hypothyroidism, pregnancy, Wegener’s granulomatosis, and medication induced (topical nasal decongestant over use, ACE inhibitors, alpha blockers).

139. Patients with moderate persistent asthma (daily symptoms) should be on inhaled steroids (moderate to high dose).

140. When a patient has intraoperative anaphylaxis suspect latex allergy, preoperative antibiotics, induction agents (especially thiopental), opiates.

141. ACE inhibitors have two important hypersensitivity reactions, a) cough (20-30%) which may occur up to a year after starting med. It is associated with bronchial hyperactivity to methacholine; b) angioedema – (.1 - .2%) involves face especially the lips, and tongue which can lead to fatal airway obstructions.

142. Aztreonam does not have cross reactivity in regards to allergic reactions with beta lactams with the possible exception of Ceftazidime, which shares an identical side chain.

143. Aspirin sensitivity occurs in 8-19% of adult asthma patients. The classic triad of aspirin allergy is a) asthma; b) nasal polyps; c) sinusitis.

144. A normal P02 does not rule out pulmonary embolism. A normal PC02 and a normal A-a gradient make PE unlikely.

145. A normal perfusion scan (V/Q scan with normal perfusion) make PE extremely unlikely (~1%)

146. D Dimer testing is useful in patients with low or intermediate clinical probability of PE. The negative predictive value of a normal D dimer is very good if the pretest probability is low

147. CT angiography has a good sensitivity and specificity for diagnosis of PE. Also has a good negative predictive value. Especially good in patients who have known lung disease (COPD/Hx lung surgery)

148. The negative predictive value of a normal D dimer level is close to 100% when combined with a nondiagnostic V/Q scan or a normal lower extremity ultrasound in a patient with a low clinical probability of PE.

149. Indications for inferior vena cava barrier (Greenfield filter): 1) patient with PE or DVT and anticoagulation is contraindicated or 2) patient has suffered recurrent DVT/PE despite appropriate anticoagulation or 3) massive life threatening PE.

150. Patients with tamponade have equalization of diastolic pressures.

151. PA catheters are rarely indicated- usually the wrong choice on the boards

152. Ventilator management for ARDS- low tidal volumes and prone positioning (16 hrs/day)

153. Do not do tight glucose control in the ICU as it increases mortality

154. Legionella - clinical features abrupt onset of high fever, myalgias, headache - initially non productive cough with purulent/sometimes bloody sputum developing later. Hyponatremia, leukocytosis common. Diagnosis - urinary antigen or DFA of sputum/throat swab.

155. Psittacosis is spread from parrots, parakeets, lorries, pigeons and turkeys

156. Mycoplasma pneumonia may be associated with hemolytic anemia, erythema multiforme , bullous myringitis

157. Increased TLC indicates hyperinflation, increased RV indicates air trapping

158. Neuromuscular disease on PFTs: Restrictive pattern on spirometry and lung volumes with normal DLCO and reduced maximum inspiratory and expiratory pressures

159. Chronic eosinophilic pneumonia usually has bilateral peripheral infiltrates.

160. Do not prescribe 80 mg dose of simvastatin as a new prescription- recognize the amiodarone/verapamil/diltiazem/grapefruit juice interactions

161. Do not give niacin (recent FDA recommendation)

162. Think of sleep apnea as a common cause of secondary hypertension

163. For resistant hypertension, give spironolactone. If patient has CKD thiazide diuretics don't work well, but loop diuretics are effective

164. Clinical features of 1o adrenal insufficiency: weakness/fatigue, weight loss, anorexia, hyperpigmentation, hypotension and GI symptoms. Abnormal labs: hyponatremia (88%), hyperkalemia (64%), eosinophilia, hypoglycemia and hypercalcemia.

165. Differences in clinical presentation between 2o and 1o adrenal insufficiency: hyperpigmentation absent, hyperkalemia not present, hypoglycemia is more prominent (due to coexistent growth hormone deficiency).

166. Diagnosis of adrenal insufficiency: acute insufficiency suspected: During stress cortisol should be > 20, if less adrenal insufficiency likely. Chronic: synthetic ACTH given (Cortrosyn) with blood samples for cortisol at 0, 30, 60 minutes.

167. Hyporeninemic hypoaldosteronism most commonly seen with diabetes. Typical features are hyperkalemia and hyperchloremic metabolic acidosis (type IV RTA).

168. Cushing’s disease - pituitary over secretion of ACTH. Clinical features - facial plethora, striae, easy bruisability, weakness, osteopenia (80%), glucose intolerance, centralized obesity (85%), neuropsychiatric effects (85%).

169. Diagnosis of Cushing’s syndrome: 24 hour urinary free cortisol has lower false positive rate than overnight dexamethasone suppression test. If an equivocal 24-hour urinary free cortisol or overnight dexamethasone suppression test, then perform standard low - dose dexamethasone suppression test.

170. Differentiating adrenal versus pituitary Cushing’s: standard high dose dexamethasone suppression test will suppress patients with pituitary Cushing’s to 50% of pre-test values. Adrenal tumors fail to suppress.

171. Clinical importance of hyperlipidemia - Primary prevention - In men without known CAD lipid lowering with HMG - C0A reductase inhibitor caused a 30% decrease in coronary events over 5 years. Secondary prevention - Scandinavian simvastatin survival study showed decrease in coronary events and mortality in hyperlipidemic patients with CAD. Lipid lowering with statins has shown decreased morbidity and mortality in patients with CAD and “normal” cholesterol.

172. Secondary causes of hyperlipidemia to be aware of include diabetes (increased triglycerides), hypothyroidism (increased triglycerides and LDL), drugs (Thiazides/B blockers), and nephrotic syndrome.

173. Liraglutide and SGLT2 inhibitors reduce CV mortality

174. Toxicities of SGLT2 inhibitors include ketoacidosis, increased amputation risk, and fournier's gangrene

175. Oral sulfonylureas, especially glyburide (longer ½ life , renally excreted) can cause severe hypoglycemia, with stroke like presentations in the elderly. The hypoglycemia can last for several days. Giving a sulfonylurea will be the wrong answer on the boards

176. Causes for a rising TSH in hypothyroid patients previously well managed on levothyroxine: Addition of iron, calcium, or a PPI (all effect absorption). Estrogen increases binding with albumin, cholestyramine and sucralfate bind the levothyroxine and decrease absorption. Always consider that the patient has developed celiac disease- decreases levothyroxine absorption and is more common in patients with hypothyroidism

177. In elderly patients with subclinical hyperthyroidism, is is appropriate to follow with serial thyroid testing if the TSH is between .1 and .4

178. Causes of Vitamin K deficiency - malabsorption, malnutrition, anticoagulants, cephalosporins (cefoperazone, cefotetan).

179. Most common hereditary cause of unexplained venous thrombosis (20-60%) is APC (activated protein C) resistance (factor V mutation). This is especially common in women who develop clotting on OCP’s.

180. Antiphospholipid antibody syndrome acquired with SLE, some drugs, HIV disease or idiopathic. Venous or arterial clotting can occur as well as recurrent fetal loss. Pearl - PTT will be elevated in most patients and does not correct with a 1:1 mix.

181. A bone marrow exam is not indicated as part of the initial evaluation of suspected ITP. Obtain a complete CBC with smear eval, HIV test, ANA, TFT’s, basic metabolic panel, H. Pylori.

182. Recommendations for treatment of breast cancer premenopausal women - tumors > 1 cm with or without lymph node positive receive chemotherapy +/- Tamoxifen if (ER +)

183. Postmenopausal women - tumors  1 cm with or without lymph nodes + and ER + receive Tamoxifen, if ER or Her-2+ receive chemotherapy.

184. Risk for developing lung cancer: smoking, asbestos (asbestos + smoking increase risk > 50 times)

185. Small cell lung cancer - treatment

- limited stage disease = chemo + radiation

- advanced disease = chemo

186. Checkpoint inhibitors Immune mediated- serious toxicity should be treated with stopping drug and giving corticosteroids

187. Younger patients with tonsillar/pharyngeal cancer likely to have HPV as etiology

188. Lung cancer + hypercalcemia likely squamous cell (NOT small cell)

189. Colorectal cancer treatment:

Stage A + stage B surgical resection

Stage C (lymph nodes positive): resection + 5 FU + leucovorin x 6 months.

Metastatic: 5Fu + leucovorin or oral capecitabine (better tolerated than 5Fu/leucovorin)

190. 5 year survival for anal cancer is best with chemotherapy followed by radiation therapy

191. Staging of testicular cancers should include: alpha - fetoprotein, beta HCG, Chest x-ray, CT of abdomen and pelvis.

192. Treatment of testicular cancer

Localized to testis  orchiectomy and retroperitoneal LND

Bulky lymph node involvement or mets  Cisplatinum based combination chemotherapy.

193. Risk factors for ovarian cancer: genetic, asbestos, talc, fertility agents.

194. Symptoms of ovarian cancer (usually advanced disease): abdominal pain (57%), abdominal distention (51%), vaginal bleeding (25%).

195. Carcinoma unknown primary workup: review of path specimen and evaluate for treatable/curable malignancies (breast, germ cell tumors, prostate cancer).

196. Paraneoplastic erythrocytosis seen with hypernephroma, hepatoma, cerebellar hemangioblastoma.

197. Glomerulonephritis seen with carcinomas (colon/lung), minimal change disease - Hodgkin’s disease.

198. CLL associations/complications : Autoimmune hemolytic anemia, ITP, Infections (especially pneumonia with pneumococcus)

199. Only treat CLL if severe “B” symptoms, obstructing nodes, severe anemia or thrombocytopenia

200. CML look for Philadelphia chromosome (t(9;22) in the marrow or RT-PCR Bcr-Abl mRNA in the blood

201. Gleevec ( imatinib mysylate) inhibits Bcr-Abl tyrosine kinase activity. It can help control disease but does not cure it.

202. AML look for Auer rods

203. Myeloma pearls for boards: Rouleaux formation on the peripheral smear with RBC’s, low anion gap, diffuse osteoporosis, lytic lesions on plain xrays with a normal bone scan.

204. Hodgkin’s disease pearls for the boards: eosinophilia, bone pain after drinking alcohol, minimal change disease, pruritus

205. Sweets syndrome (acute febrile neutrophilic dermatosis) can be associated with acute nonlymphocytic leukemia (most common).

206. Necrolytic migratory thrombophlebitis is seen with glucagonoma.

207. Cancers that cause fever: hepatoma, hypernephroma and lymphoma.

208. Adults can refuse care on a religious basis

209. Order of decision making Durable power of attorney > Spouse > Parents > Children > Sibs

210. HIPPA: Use and disclosure of patients medical information is allowed for treatment purpose

211. Confidentiality is not absolute. If patient has a reportable disease or has threatened someone, that information must be shared.

212. In aortic stenosis severe obstruction = valve area < 1 cm2. Mortality is > 50% if symptomatic and untreated.

213. Treatment options for severe mitral stenosis (symptomatic with valve area  1.0 cm2) a) surgical commissurotomy; b) catheter balloon mitral commissurotomy or c) mitral valve replacement.

214. The clinical sign with the worst prognosis for patients with aortic stenosis is congestive heart failure

215. An important clinical trigger for symptoms with hypertrophic cardiomyopathy is volume depletion

216. Clinical features of aortic insufficiency include wide pulse pressure, head nodding, bounding peripheral pulses, capillary pulsation (Quincke’s pulse), and early high pitched diastolic murmur

217. Recommendations for valve replacement in patients with AI: NYHA class 3 or 4 symptoms and EF > 50 or NYHA class 2 symptoms EF >50 but with LV dilation or CHA functional class 2 or greater angina or Asymptomatic or symptomatic patients with mild to moderate LV dysfunction at rest

218. Clinical features of mitral stenosis: loud first heart sound, opening snap, rumbling diastolic murmur, presystolic murmur (absent if patient in a fib), and frequent atrial fibrillation.

219. Hypertrophic cardiomyopathy high risk features: personal history of syncope, fit of sudden death, septum > 30 mm, age < 30.

220. Appropriate treatment of PSVT in patient with WPW - vagal maneuvers/adenosine or verapamil.

221. Appropriate treatment of atrial fibrillation in patient with WPW: unstable - cardioversion, stable – procainamide

222. Rate control in patients with atrial fibrillation is best achieved with calcium channel blockers (Diltiazem or Verapamil) or B blockers. Digoxin does not control rate well in exercising patient.

223. Must anticoagulate for three weeks prior to cardioversion in prolonged atrial fibrillation (> 72 hours) or AF of uncertain duration.

224. Torsade de Pointe - arrhythmia due to QT prolongation often due to type I antiarrhythmic drugs . Other causes - hypokalemia, hypomagnesemia

225. Critical aortic stenosis and critical mitral stenosis are contraindications to elective surgery. Valve replacement should occur prior to any elective surgery.

226. Atrial tachycardia with 2:1 block is digoxin toxicity until proven otherwise

227. Treatment of AV nodal reentrant tachycardia- carotid massage, if ineffective give adenosine

228. When you see a narrow complex tachycardia at 140-160 think atrial flutter with 2:1 block

229. 3rd degree heart block is slow and regular without dropped QRS's, Mobitz 1 and II are irregular

230. The following are extreme risks for complications during non-cardiac surgery: MI within 3 months, uncontrolled CHF, significant mitral or aortic stenosis.

231. Pearls on pregnancy and heart disease: If signs of MI think of coronary artery dissection. Drugs to avoid in pregnancy – Coumadin and ACEI.

232. Results of ETT that suggest high probability of severe 3 vessel disease or left main disease: a) duration of exercise < 6 min.; b) exercise induced hypotension or failure to increase SBP to > 120 mm Hg; c) ST depression > 2 mm at less than 6 METS and present in > 5 leads; d) exercise induced ST elevation; e) symptomatic exercise induced ventricular arrhythmia.

233. Add an imaging modality to the ETT if:

a) Widespread ST depression  1 mm on resting ECG

or

b) ST changes due to digoxin, LBBB, LVH or WPW

234. When to refer for angiography: LVEF <35%, high risk ETT score, multiple large ischemic zones on stress imaging, successful resuscitation from sudden cardiac death, sustained VT, significant angina despite medical therapy

235. CABG improves prognosis compared to medical therapy in patients with chronic stable angina with:

1) Left main coronary artery stenosis  50%

or

2) Three vessel CAD and LV dysfunction

236. Drugs with proven survival benefit in the treatment of systolic heart failure are ACE inhibitors, B-blockers, sacubitril/valsartan, and spironolactone

237. Drugs with proven survival benefit in patients with history of MI are statins, ASA, B blockers and ACEI

238. Pearls on presentation of atrial septal defect: often presents between ages 20 – 40, symptoms: exercise intolerance, atrial arrhythmias. Exam: fixed split S2 , on ECG: RAD.

239. Best management of AF? For survival, no obligation to Cardiovert. If patients do not tolerate AF clinically, conversion is reasonable.

240. Consider evaluating for sleep apnea in patients with new onset atrial fibrillation

241. The HLA B27 associated spondyloarthropathies are ankylosing spondylitis, Reiter’s syndrome.

242. Key clinical features of ankylosing spondylitis are back stiffness, sacroiliac pain and iritis (25%). Rarer manifestations include aortic insufficiency (10%), upper lobe pulmonary fibrosis.

243. Spinal complications on ankylosing spondylitis: fractures due to an immobile spine, cauda equina syndrome, and spinal stenosis.

244. Radiographic features of ankylosing spondylitis include sacroiliitis, “bamboo” spine and vertebral squaring.

245. Psoriatic arthritis can cause an asymmetric oligoarthritis, sometimes causing swelling of the whole digit, causing a sausage digit.

246. Arthritis mutilans can occur with psoriatic arthritis, usually in patients with severe psoriasis. Digits can be destroyed.

247. Radiographic features of psoriatic arthritis include marginal erosions causing a “pencil in cup” deformity at the interphalangeal joints.

248. Reactive arthritis (Reiter’s syndrome) may occur after dysentery or following chlamydial or other forms of NGU.

249. Think of Reactive arthritis ( Reiter’s syndrome) in young adults with seronegative asymmetric arthritis (also think of disseminated gonococcal infection in this group).

250. Clinical features of Reactive arthritis (Reiter’s syndrome) include: peripheral arthritis affecting the lower extremities, swelling of the Achilles tendon, conjunctivitis/uveitis, urethritis, prostatitis, and two important skin lesions - keratoderma blennorrhagica (rash on soles/palms) and circinate balanitis (rash on penis).

251. Risk factors for gout include medications (diuretics, niacin), alcohol use, exposure to lead, family history of gout. Gout is also very common in Filipino’s and Samoan’s.

252. Most initial attacks of gout are monoarticular (85-90%) with 50% involving the first MTP joint.

253. Urate gout attacks can be precipitated by trauma or surgery. Severe attacks of gout can be accompanied by fever.

254. Most cases of calcium pyrophosphate deposition disease are idiopathic. Occasionally it can be associated with systemic disease, hyperparathyroidism and hemochromatosis are the two most important of these.

255. The most common presenting symptoms of patients with SLE are joint complaints (56%) and skin problems (20%). Almost all patients (90%) will have joint involvement during the course of the disease.

256. The use of ANA for diagnosis of SLE is very dependent on the clinical pretest probability of disease. A positive ANA in a patient with several clinical features suggesting SLE, example: (photosensitivity, arthritis and pleuritic pain) is a powerful diagnostic tool making the diagnosis of SLE very likely. If the patient has only arthralgias as a symptom and has a positive ANA it is still very unlikely for the patient to have SLE even with the positive ANA.

257. A positive anti-DS DNA test is specific for SLE, but not too sensitive (only 50-60% of lupus patients have a positive anti-DS DNA).

258. Anti-Sm antibody is highly specific for lupus but very insensitive (20-30%).

259. Anti-CCP antibody is often positive early in RA before RF becomes positive.

260. Subacute cutaneous lupus is associated with annular lesions with scale. Patients usually have anti-Ro antibody.

261. Patients with lupus with CNS involvement often have antineuronal antibodies and anti-ribosomal P.

262. Drug induced lupus - antihistone antibody present in > 90% of patients. Most common drugs procainamide and hydralazine.

263. Patients with discoid lupus do not have involvement of other organs.

264. Rheumatoid factor are IgM antibodies reactive with IgG. It is neither sensitive nor specific for RA. High titers of RF in RA patients is associated with vasculitis and a worse prognosis.

265. Anti CCP antibody is very specific for RA, often turning positive before RF

266. Felty’s syndrome is the combination of neutropenia, splenomegaly, rheumatoid factor and longstanding RA.

267. Caplan’s syndrome is the presence of multiple pulmonary nodules in a patient with RA. Pleural effusions in patients with RA are associated with low glucose levels in pleural fluid.

268. Henoch-Schonlein purpura usually occurs in the Spring, often after an URI. Clinical features: palpable purpura, arthritis and abdominal pain.

269. Cryoglobulinemia (especially type II mixed) is strongly associated with hepatitis C. Clinical features - glomerulonephritis, vascular infarcts, palpable purpura (especially on legs).

270. Polyarteritis nodosa is associated with hepatitis B (antigen positive) in about 20% of patients. Common clinical features: renal failure, livedo reticularis, mononeuritis multiplex, palpable purpura. This is a systemic disease and may involve CNS, GI tract and heart.

271. Granulomatosis with Polyangiitis (Wegener’s granulomatosis) - consider in patients with sinus disease, pulmonary infiltrates (especially if nodular), and renal involvement. This can cause saddle nose deformity as well. c-ANCA is sensitive and specific (99%) for this disease.

272. Giant cell arteritis occurs in older individuals usually with northern European background. Many patients also have PMR. Typical features are - headache, weight loss and jaw claudication.

273. Anti-SSA (anti-Ro) is associated with neonatal lupus, Sjogren’s syndrome and subacute cutaneous lupus.

274. Anticentromere antibody is seen in 80-90% of patients with CREST syndrome.

275. The following drugs should absolutely be avoided during pregnancy: Isotretinoin (Accutane), ACE inhibitors, Benzodiazepines, Quinolones, Estrogens, Tetracycline and Coumadin.

276. Asymptomatic bacteriuria of pregnancy should be treated. Increase of risk of pyelonephritis 20-30 times compared to non pregnant patients. Amoxicillin and cephalosporins are preferred agents.

277. Treat hypertensions during pregnancy at DBP > 100 or if patient has diabetes or renal disease DBP > 90. Safe drugs – methyldopa, hydralazine, labetalol.

278. Adults should receive Tetanus booster every 10 years or at least a booster at age 50 or after Pneumococcal 23 and 13 vaccines recommended for adults age 65 or greater. Annual influenza vaccine recommended for those > 65 years old, health care workers. Shingles vaccine should be given at age 60

279. Give Tdap to those who need a tetnus booster

280. You can stop obtaining pap smears in women > 65 who have had repeatedly normal paps previously, and in any woman who has had a hysterectomy for benign disease.

281. Asplenic individuals should receive pneumococcal, H. influenza B + Meningococcal vaccines.

282. Current recommendations for colon cancer screening are in adults > 50 annual fecal occult blood test with flex sig every 3-5 years, OR colonoscopy (if you do colonoscopy, do not do fecal occult blood testing)

283. Panic disorder is frequently misdiagnosed on presentation (70% of patients have seen 10 or more physicians). The most effective treatment are SSRI’s.

284. Many diseases are associated with depression including: Panic disorder, stroke, hypothyroidism, fibromyalgia, CFS, coronary artery disease and chronic steroid use.

285. Patients with atypical depression tend to have hypersomnia, weight gain and lots of physical symptoms

286. Major side effects of SSRI’s include sexual side effects (delayed orgasm), and insomnia.

1. Weight gain is a common side effect of most antidepressants. It does not occur with bupropion (Wellbutrin) and Veralafaxine (Effexor). The SSRI most associated with weight gain is Paroxetine.

2. The newer antipsychotics ( Olanzapine, Risperidone and Clozapine can cause increased insulin insensitivity and trigger DM

287. Bulimia occurs primarily in young women (ages 15-25). Clinical features include: Amenorrhea, parotid hypertrophy, reflux esophagitis, dental problems, Mallory-Weiss tears and Metabolic alkalosis

288.