ABIM

High vs low risk stress test results

1. High risk: greater degree of ST depression, inability to reach 5 METs, slow HR recovery (HR drop <12 BPM in the first 1 min after exercise)

2. Low risk: trial medical therapy only

New HTN workup

Basic bloodwork

UA, UACr

Baseline EKG- r/o LVH and silent MI

Only need sleep study if specific sxs

Mycoplasma genitalium

New STI

Diagnosed with NAAT- first void urine or swab

Tx: doxy 100 mg BID for 7 days then Moxifloxacin QD for additional 7 days

Can also use Azithromycin 1g x1 then 500 mg QD for 3 days instead of Moxifloxacin

Also need to tx partners

Tension headache

Mild

No associated sxs

Tx: Ellavil, Venalfaxine, Remeron

Hemicrania Continua

Unilateral side-locked

Ipsilateral autonomic features

Pull test

Pull back on shoulders

If patient falls back> positive test

Sensitive predictor of falls in Parkinson’s patients

Syncope workup

EKG in everyone even vasovagal

Varices workup

Need EGD every 3 years if initial testing negative and patient is now no longer a drinker

Indications for SVC stent

Confusion, hypoxia, compressive sxs, etc

Otherwise get tissue dx first

Coreg vs Lopressor

Coreg causes more hypotension

What blood type to use in emergency situation?

Uncross matched O, Rh negative

Diabetes screening criteria

Normal patients- age 35

If BMI >25 or BMI > 23 in Asians can screen earlier + 1 risk factor:

• first degree relative with DM

• high risk ethnicity (black)

• Hx CVD

• Inactivity

• HTN

• HDL <35 ± trigs >250

• PCOS

• Conditions associated with insulin resistance- NAFLD, obesity, etc

Can consider if hx pancreatitis or HIV

Screen every 3 years if initial test is negative

Pre-diabetics screen every year

Gestational diabetes hx: screen every 1-3 years B

Brugada syndrome

RBBB

2 mm ST elevation in precordial leads

Crypto meningitis

CD4 <100

Leukocytes <50, increased protein, normal to low glucose, high opening pressure

What do you biopsy if concerned for metastatic lung cancer?

Metastatic site- can help confirm diagnosis and stage

If you biopsy the lung will only confirm diagnosis but not stage

Indication for CPAP in COPD

pCO2 >52

Indication for lung volume reduction surgery in COPD

Primarily upper lobe disease

Exercise limitation despite pulmonary rehab

FEV1 and DLCO at least 20% of predicted

Indication for Roflumilast in COPD

Severe COPD with FEV1 <50

Sxs of chronic bronchitis- cough, sputum, etc

Diagnosis of gonorrhea

Need both NAAT of urine and rectal swab in gay men who engage in high risk behaviors

Tx for poorly differentiated carcinoma in the midline

Platinum based germ cell regimen

Tx for adenocarcinoma of unknown primary below the diaphragm

5FU GI regimen

Pneumonic plague

Yersenia pestis

Fever, blood tinged sputum, SOB, headache

Gram negative coccobacilli

Bipolar staining- safety pin shaped

Tx: fluoroquinolones, gentamicin, streptomycin

When do you need to correct PT/INR in liver disease?

High risk procedures

Actively bleeding

Do not need to adjust in low risk procedures like paracentesis

Barter Syndrome

AR

Impaired NaCl reabsorption

Looks like loop diuretic: hypokalemia, metabolic alkalosis, hypercalciuria, volume depletion

Gordon Syndrome

AD

Retention of sodium

HTN, volume expansivo, hyperkalemia, metabolic acidosis

Liddle syndrome

AD

Mineralocorticoid excess

Severe HTN, hypokalemia, metabolic alkalosis

Gittleman syndrome

AR

Tubular defect

Acts like thiazide: hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalciuria

How to treat high risk AML after induction chemo?

stem cell transplant

Barrett’s screening indications

GERD for 5+ years and 3 or more of the following features:

• Male

• Tobacco use

• 50 + years old

• White

• Obesity

• hx in first degree relative

AAA screening

65-75 year old with smoking hx

1x abdominal US

Lung cancer screening

50-80 years

20 pack year smoking history

current smoker or quit within last 15 years

Low dose CT lung

What medication do you use for patients with mismatch repair protein deficiency?

PD1 inhibitors

Tx for menstruation related seizures (catamenial seizures)

Diamox

Crohn’s tx

TNF (Infliximab) + Azathioprine

Have to do both

Aortic aneurysm repair indications

>5.5 cm

rapid expansion >0.3 cm/2 years or >0.5 cm/year

If bicuspid valve/valve disease then repair if > 4.5 cm

HLD treatment guidelines

All patients with DM regardless of risk: statin

>10% ASCVD: statin

Adrenal mass testing

All patients: low dose dexamethasone suppression test

If HTN and hypokalemia: renin/aldo (r/o hyperaldosteronism)

If mass density >10 HU on CT: metanephrines (r/o pheo)

If signs of hyper-androgenism (deep voice, increased libido, hirsutism, etc): testosterone, DHEA, etc

Thyroid nodule testing

If pure cystic: no testing

Cystic/solid nodule: FNA only if > 2 cm

If isoechoic and hyper echoic components: FNA if > 1.5 cm

Hypoechoic solid: FNA if > 1 cm

If solid, hypo echoic, partially cystic with solid: FNA if > 1 cm

Severe OSA

> 30 apnea events per hour

Medical tx for limb ischemia after surgery

Can use Xarelto instead of ASA

Coumadin in pregnancy

Can continue if daily dose is <5 mg

Can switch to LMWH but will increase risk of valve thrombosis

Goal INR is still the same

At time of delivery needs to change to LMWH

Angina tx

Max dose nitrates: needs 8-12 hours per day nitrate free to prevent tolerance

Can add Ranexa instead but have to watch QTC

Babesiosis

Hemolytic anemia, thrombocytopenia, AKI, ARDS, etc

Tx: Atovaquone + Azithromycin for 10 days

Stage 1 HTN

130-139/80-89

Start 1 medication at time of dx

Stage 2 HTN

>140/90

Start 2 meds at time of dx

Signs of successful thrombolytic therapy in STEMI

Resolution of sxs

Improvement in ST elevation by > 50%

Can do coronary angiography within 24 hours to see if they still need PCI

Microscopic colitis

Caused by anti-diarrheals (Immodium)

Tx with Budesonide

Synthroid dosing

Under 65 yrs

• 1.5 micro g/kg/day

Over 65 yrs

• Start at 25-50 micro g/day and increase until at goal

• Overcorrection can cause arrhythmias and angina in this age group

Lyme disease prevention indications

Tick was backlogged

Present within 72 hours of exposure to tick

Tick attached at least 36 hours

Occurred in Lyme endemic area

Ppx: Doxy 200 mg PO x1

Myocardial ischemia on exercise EKG

ST elevation or depression > 1 mm occurring 80 ms after J point

How do you monitor Paget’s after tx?

Alk phos

Screening indications for infertility

After 1 year unprotected intercourse in women under 35

6 months unprotected intercourse in women 36-39

Under 6 months unprotected intercourse in women > 40

Associations with ITP

H pylori

Hep B/C

HIV

Gene associated with hypersensitivity to carbamezapine

HLA B15:02

> 5 mm positive TB skin test

HIV

Close contacts of known TB positive person

Signs of old TB on CXR

Immunosuppressed or transplant patient

> 10 mm positive TB skin test

Coming from high prevalence county within the last 5 years

Substance use

Recent residence in prison, nursing home, hospital, etc.

< 90% ideal body weight

Healthcare workers

> 15 mm positive TB skin test

Everyone else

Tx of atrial myxoma

Remove mass

Zoster vaccine

> 50 years or 19-49 years and immunocompromised

HIV regardless of age

2 doses 2-6 months apart

Pneumonia vaccine

> 50 years or 19-49 years if immunocompromised (smoking included)

15+23 together done 1 year apart

20 or 21 alone

Pyroglutamic acid overdose

Excessive tylenol in the setting of malnutrition

Causes HAGMA without osmolar gap

Tx for smoking related lung disease

Steroids

Ninedanib

TK inhibitor and anti-fibrotic agent

Used for idiopathic pulmonary fibrosis and systemic sclerosis lung disease

Wellen Syndrome

Presents with CP

Deep inverted T waves in V2-V3

Trops ±

Indicative of high grade proximal LAD stenosis

Tx of primary insomnia

CBT

How to diagnosis cirrhosis

Transient elastography

Can’t use in setting of active inflammation or will give false positives

Indication for screening for bicuspid aortic valve

first degree relative with known disease

Contraindication for Pletal

HFrEF

Timeline for stopping anticoagulation prior to surgery

Eliquis- 24 hours

Dabigatran- 2-4 days

Coumadin -5 days

Indication for TIPs

Refractory ascites or pulmonary effusions related to cirrhosis

Can cause worsening encephalopathy- relative contraindication

Goal INR in mechanical valves

2.5-3

Closer to 3 if high risk of thromboembolism, mitral valve, older model of aortic valve

Indication for treatment of pneumothorax

> 2 cm despite sxs

Use “small bore” tubes (lower number= lower bore) 10F

Indication for parathryoidectomy in primary hyperparathyroidism

Under 50 years

Ca 1 mg/dL > ULN

GFR <60, urine Ca >250 in women or > 300 in men

Kidney stones

T score -2.5 anywhere

Vertebral fractures

What does cryo replace?

Fibrinogen

What does FFP replace?

Factors

What part of DAPT do you stop for surgery?

Can only do 6 months after stent placement. Prior to that need to delay any non-urgent surgeries

Stop Plavix, keep ASA

Gold A COPD

<1 exacerbations with no hospitalizations

<10 CAT (cough, SOB, limited activity, etc)

0-1 mMRC (SOB with what level of activity)

Tx: SABA or LABA only

Gold B COPD

<1 exacerbations with no hospitalizations

>10 CAT (cough, SOB, limited activity, etc)

>2 mMRC (SOB with what level of activity)

Tx: LAMA + LABA

Gold E COPD

> 2 exacerbations or 1+ hospitalizations per year

any CAT (cough, SOB, limited activity, etc)

any mMRC (SOB with what level of activity)

Tx: LAMA + LABA or LAMA + LABA + ICS

Scrotal mass indications for tx

If > 2 cm and symptomatic. If not just watch (probably a cystocele)

What needs to be screened for after a stroke if memory loss is starting to develop?

OSA

Positive low dose dexamethasone suppression test

AM cortisol that does not suppress to 1.8 microgram/dL or less

Sign that there is exogenous cortisol production

What unusual genetic testing needs to be done on upper GI (esophageal) cancers?

HER2

What is actinography

Non-invasive wrist monitoring of rest cycles over 1-2 weeks

Can be used in patients with sleep complaints in place of a sleep diary and low risk for OSA

Immune mediated necrotizing myositis

Anti-3-hydroxy-3-methylglutaryl coenzyme reductase Ab

Inclusion Body Myositis

Proximal and distal weakness- symmetric

finger and forearm flexor weakness

anti-5 nucleotides cytosolic 1A Ab

Bx: endomysial inflammation, rimmed vacuoles, protein aggregates 15-18 nm filaments

Tx for dyspnea in hospice patients

first -fans

second- morphine

Indication for imaging in diabetic ulcers

> 2 cm

Deep

Signs of infection- erythema, warmth, drainage, etc

HELLP vs preeclampsia

HELLP will always have signs of hemolysis- elevated bilirubin, schistocytes, etc

Duffy-null neutropenia

Isolated mild asymptomatic neutropenia (ANC >1000 usually)

Protective against malaria so prevalent in patients of Middle Eastern/African descent

If ANC <500 more likely to be something else

Can just watch

Calcium pyrophosphate crystals

Rhomboid crystals

Positive birefringent

Gout crystals

Needle shaped

Negative birefringent

How to diagnose obstruction in HOCM?

Stress test

Scabies dx

Mineral oil prep of skin scrapings

Can see the mite

Typhoid fever

Fever, headache, arthralgia, abdominal pain, non-bloody diarrhea

Blanching, salmon colored macules

From contaminated food/water- fecal oral

Tx: Rocephin (can’t use fluoroquinolones due to resistance especially if contracted in Southern Asia)

Spontaneous bacterial peritonitis

PMN >250

Progressive supra nuclear palsy

Rapidly progressive Parkinson’s

Facial dystonia, dysarthria, dysphagia

Decreased ability to look up/down

Midbrain atrophy

Posterior Cortical Atrophy

Balint Syndrome:

Inability to perceive more than 1 object at a time

Difficulty reaching for objects

Difficulty voluntarily moving the eyes horizontally

Parito-occiptal atrophy

Tx: OT and acetylcholinesterase inhibitors

What do you need to test for if a patient under 60 years has shingles?

HIV

Ecthyma

Superficial ulcer shaped ulcers with crusting

Impetigo variant