General internal medicine (memo from NEJM knowledge plus and MKSAP)

＜general medicine＞

・management of patient with general weakness, slow gait, recent fall

prescribe vitamin D without obtaining level

・dumping syndrome

avoid refined carbohydrate

・zoster vaccine

live vaccine

・linezolid toxicity

type B lactic acidosis

・bisphosphonate to patient with CKD

contraindication to patient with GFR<30

・diagnosis of patient with one week history of sore throat, fever, neck pain, sign of pharyngitis, no cervical lymphadenopathy, CXR show multiple densities

septic thrombosis of the jugular vein (Lemierre syndrome)

・medical Tx for urinary incontinence  

anti-cholinergic (tolterodine)

・isolated elevation of ALP with normal γGTP in asymptomatic elderly person

bone scintigraphy for suspected Paget disease

・management of patient with opioid-induced delirium

switch to different opioid

・interval of blood pressure screening for healthy person

every 2 years for person older than 18 yo, with blood pressure < 120/80

 ・preoperative test for young healthy female

only pregnancy test

・sleep-maintenance insomnia

temazepam

・management of patient with cancer-related pain which is persistent throughout the day

sustained-release morphine

・thrombophilia work-up for patient with recent DVT on enoxaparin and warfarin

factor V Leiden and prothrombin gene-mutation

(acute thrombosis reduce protein S, protein C, antitrhombin III, heparin reduce antithrombin III, warfarin reduce protein S, protein C)

・management of patient with functional incontinence due to limited mobility or significant cognitive impairment

prompt voiding (periodically ask and remind patient to go to toilet)

・phenoxybenzamine 

alfa blocker

・management of patient with GERD-related cough whose cough and heart burn don't change 2 weeks after patient started omeprazole

continue omeprazole for 8 to 12 weeks

・antiemetic Tx for patient receiving chemotherapy 

ondansetron, dexamathasone, fosaprepitant (neurokinin-1 inhibitor)

・medication causing low testosterone level (erectile dysfunction, decreased energy)

opioid, high-dose corticosteroid, hormonal therapy 

・management of 28 yo female with breast mass, 1.5cm, mobile, tender, without nipple discharge or overlying skin change

ultrasonography (aspirate if cyst, biopsy if solid)

・most successful long-term and safe weight loss strategy

consistent reduction of caloric intake by 500-1000kcal/day

・cirrhotic patient with Child-Pugh C who undergo preoperative evaluation for elective total hip replacement

avoid elective surgery (mortality 80% with Child-Pugh C)

・next diagnostic step for patient with 6 months chronic non-productive cough, without apparent sign or cause, negative CXR, PFT, methachollin challenge test

sputum testing for eosinophil (for nonasthmatic eosinophilic bronchitis)

・first-line treatment of stress urinary incontinence

pelvic floor muscle training

・management of temporomandibular joint disorder

jaw relaxation, heat and therapeutic exercise

・DDx of patient with chronic pelvic pain with unexplained urinary symptoms

interstitial cystitis (no pyuria)

・management of patient with neuropathic pain secondary to DM who doesn't respond to NSAIDs, gabapentin, oxycodone-acetaminophen

sustained-release morphine

・management of perioperative warfarin for patient with atrial fibrillation with CHADS2 score of 5 and TIA 2 months ago

discontinue warfarin 5 days prior to surgery with enoxaparin bridge until the morning of surgery 

・first-line medication for elderly patient with chronic non-cancer pain

acetaminophen (325mg)

・indication of rapid antigen detecting test for patient suspected with streptococcal pharyngitis

all patients (Centor criteria 1-4)

・management of patient with prolonged interval since the previous dose of multiple-dose vaccine

series should be resumed rather than restarted from the beginning

・DDx from pityriasis rosea (pink, scaly, christmas-tree pattern)

syphilis

<orthopedic surgery>

・initial management of carpal tunnerl syndrome

wrist splinting

・difficulty with arm abduction and positive drop-arm test

rorator cuff tear

・most common cause of knee pain in younger than 45 yo, worse with prolonged sitting and with walking up and down stairs

patellofemoral pain syndrome

・maneuver eliciting lateral epicondylitis

resisted wrist extension with elbow fully extended 

・indication of x-ray for ankle injury 

unable to bear weight or bony tenderness to palpation 

・pain along anteromedial aspect of proximal tibia distal to the joint line of knee, in the setting of overuse

pes anserine bursitis

・burning pain on the plantar surface in the space between third and fourth toes, in the setting of wearing high heels

morton neuroma

・management of acute back pain with positive straight leg raise test, diminished ankle refelx without motor or sensory deficit

analgesics and mobilization as tolerated (no imaging study)

・Dx of patient with burning sensation on the lateral aspect of thigh with sensory deficit

melargia paresthetica (entrapment of lateral femoral cutaneous nerve beneath inguinal ligament)

・management of patient with plantar fasciitis refractory to initial Tx with NSAIDs

arch support

・management of osteoarthritis of trapeziometacarpal joint (pain at base of thumb)

wrist splint with thumb post

・hip pain in young athlete with femoroacetabular dysplasia

labrum tear

・management of symptomatic popliteal cyst

glucocorticoid injection 

・diagnosis of knee osteoarthritis

weight-bearing x-ray

<dermatology>

・Tx for psoriasis and psoriatic arthritis 

TNF-alfa blocking agents

・V-shaped rash on upper chest 

dermatomyositis

・molluscum contagiosum in adults

possible sign of HIV progression

・ecthyma gangrenosum (purpuric patch with ulceration)

pseudomonas aeruginosa bacteremia

・actinic keratoses

5-fluorouracil cream

・most common identifiable cause of erythema nodosum

streptococcal infection 

・dyshidrotic eczema (pruritic vesicular eruption, due to repeated water exposure or sweating)

potent topical glucocorticoid (triamcinolone ointment)

・symmetric target-shaped lesions on palms

erythema multiforme, associated with herpes simplex infection 

・bedbug bite

steroid cream (triamcinolone acetonide cream) 

・venous stasis ulcer

unna boot compression 

・allergic contact dermatitis on face

hydrocortisone valerate (lower potency)

・treatment for impetigo

topical mupirocin

・ulcerative skin disease associatd with inflammatory bowel disease

pyoderma gangrenosum

・management of atypical urticaria, lasting for more than 24 hours, not pruritic

skin biopsy (to evaluate urticarial vasculitis)

・acne medication which is contraindicated during pregnancy

tazarotene

・pigmentation extending onto the proximal nail fold

subungual melanoma

・management of suspected toxic epidermal necrolysis

skin biopsy to confirm diagnosis and supportive care (systemic corticosteroid is controversial)

・DDx of red plaque on lip that is covered with scale, crust

squamous cell carcinoma

・crateriform pitted lesion on the sole of feet

pitted keratolysis

・flesh-colored smooth bump on face that occur by shaving

verruca plane (HPV)

・management of miliaria

cooling

(small papulovesicle associated with itching, caused by blockage and rupture of eccrine sweat duct, occur when skin is hot and occluded)

・slow-growing type of melanoma commonly seen on face of older fair-skinned patient

lentigo maligna

・pruritic blister on chest, abdomen, lower extremities, draining clear yellow fluid and crusting over before healing

bullous pemphigoid

・pruritic eruption that topical corticosteroid temporarily reduce inflammation, but recur after discontinuation

tinea corporis

・red papules on the chest, topped by vesicle or scale, waxing and waning, exacerbated by heat and sweating

Grover disease (achantholytic dermatosis)

・ulcer on the feet under metatarsal heads in DM patient

neuropathic ulcer

・management of intensly itchy small papulovesicle on scalp, elbow, knee, skin biopsy shows deposition of granular IgA

gluten-free diet for dermatitis herpetiformis associated with celiac disease

・Tx for seborrheic dermatitis (itchy, scaly rash in eyebrow, nose, ear)

ketoconazole cream

・acne that is widespread or that is inflammatory and refractory to topical medication 

doxycycline

<ophthalmology>

・corneal abrasion from fingernail

fluoroquinolone eyedrop (covering pseudomonas)

・Sx of uveitis

photophobia, eye pain, decreased vision

・bacterial VS viral conjunctivitis

viral conjunctivitis lacks morning gluing

・bothered by glare from oncoming headlights when driving

cataracts

・pseudodendrite

herpse zoster

・uveitis and lacrimal gland enlargement

sarcoidosis

・management of viral conjunctivitis

cool compression 

・central retinal artery occlusion vs central retinal vein occlusion 

CRAO: cherry red spot

CRVO: flame-shaped retinal hemorrhage, cotton-whool spots

・foreign body sensation and vascular growth over conjunctiva

pterygium

<OBGYN>

・reversible, highly effective contraception

levonorgestrel intrauterine device, etonogestrel implant

・medroxyprogesterone acetate IM injection every 3 months

not for long-term use, risk for osteoporosis

・prophylaxis Tx after sexual assault

azithromycin, ceftriaxone, HIV prophylaxis, HBV vaccine, metronidazole, levonorgestrel 

・inhaled glucocorticoid Tx for pregnant female with mild persistent asthma

budesonide

・uncomplicated mastitis

continue breast feeding and dicloxacillin (staphylococcal coverage)

・Tx for postpartum endometritis

clindamycin and gentamicin

・management of Graves disease during pregnancy

propylthiouracil in 1st tremester and methimazole in 2nd and 3rd tremester

・opioid addiction during pregnancy 

methadone / buprenorphine

・persistent lack of desire for sexual activity

hypoactive sexual desire disorder

・management of female who is planning to attempt conception, found to have HbA1c 7.5

metformin (class B, switch to insulin during pregnancy)

・next step for patient with heavy menstrual bleeding secondary to fibroid which is scheduled for surgery in 2 weeks

oral medroxyprogesterone acetate

・management of hot flush in patient with h/o cardiovascular disease or VTE

venlafaxine (serotonin norepinephrine reuptake inhibitor)

・first-line treatment of dysmenorrhea

NSAIDs

・recommended contraception for 38 yo female without PMH, smoking a pack daily 

progesterone contraceptive

(women older than 35 yo smoking more than 15 cigarettes daily shoud not be prescribed estrogen-containing preparations)

<otolaryngology>

・central cause of vertigo

direction-changing nystagmus, severe trunchal instability, negative head-thrust test

・Dix-Hallpike maneuver to BPPV

vertical-torsional nystagmus toward affected side

・Tx for acute otitis extema

almost always due to bacterial infection -> topical ABX covering pseudomonas and staphylococcus

・Tx for vestibular neuritis

meclizine and hydration 

・Tx for nasal polyposis

intranasal glucocorticoid

・idiopathic sudden sensorineural  hearing loss

high-dose prednisone

・cerumen impaction 

cerumenolytics (hydrogen peroxide, carbamino peroxide, mineral oil)

・whistling or swishing sound in ear, faster and louder when exercise

pulsatile tinnitus -> evaluate for bruit for possible vascular anomaly

・Tx for rhinosinusitis

anti-histamine (chlorpheniramine)

・Dx of patient with h/o allergic rhinitis who has intractable nasal congestion and rhinorrhea on oxymetazoline

rhinitis medicamentosa

(continued use of vasoconstictor (oxymetazoline) cause withdrawal congestion)

・erythematous patches with white hyperkeratotic rim on the tongue

georgraphic tongue (benign migratory glossitis)

・unilateral ulcerative tonsillar lesion with cervical lymphadenopathy

squamous cell carcinoma until proven otherwise

<psychiatry>

・medication for prevention of alcohol dependence relapse in patient with cirrhosis

acamprosate

・initial treatment for alcohol-use disorder

naltrexone

・dementia with visual hallucination 

dementia with Lewy bodies

・bulimia nervosa

Na in urine elevated when diuretic abuse, and decreased when self-induced vomiting

・first choice for panic disorder

SSRI

・major depressive disorder with sexual dysfunction

bupropion

・monotherapy for bipolar depression

quetiapine

・psychosis, purpuric skin lesion, neutropenia

intravenous cocaine use 

・indication for depression screening

all adults

Cardiology (memo from NEJM knowledge plus and MKSAP)

・dual antiplatelet Tx for STEMI

    avoid prasugrel for patient with h/o stroke, >75 yo, body weight < 60kg

・Tx for HTN in HFpEF patient

ARB (candesartan) reduce hospitalization in patient with HFpEF

・first-line monotherapy for hypertensive african-american patient

thiazide or CCB

・indication of echocardiography for patient with heart murmur

3/6 or louder SM or any diastolic or continuous murmur

・management of NSTEMI with high TIMI score (5-7)

anticoagulation (TIMI 3-7) and glycoprotein IIb/IIIa (eptifibatide) in addition to ASA, clopidogrel, BB, nitrate, statin

・complete heart block secondary to Lyme disease

    reversible

・management of recurrent pericarditis

colchicine and aspirin

・management of perioperative (total hip replacement) anticoagulation for patient with mechanical aortic valve on warfarin

discontinue warfarin 3 days prior to surgery and restart on evening of surgery (no heparin bridge if no risk factor: afib, LVEF<30, hypercoagulable state, h/o thromboembolic event)

・intermittent claudication and borderline ABI

    -> ABI after exercise increase sensitivity 

・management of patient with suspected peripheral artery disease whose ABI is above 1.4

great toe pressure measurement

・diagnosis of type A aortic dissection 

transesophageal echocardiography

・cocaine-induced chest pain

   NTG + benzodiazepine

・widespread deeply inverted T waves

   sign of severe brain injury

・new onset of widened QRS and QT interval secondary to TCA overdose

    sodium bicarbonate

・patient with ACS managed with non-invasive fashion

    LMWH has better outcome than unfractionated heparin

・indication for surgical intervention to aortic aneurysm

   diameter > 5.5 cm or expand 0.5 cm/year

・indication for aortic valve replacement for AS

    symptomatic or LVEF <50%

・initial management of congenital long-QT syndrome

    beta blocker

・patient with severely depressed systolic function and fluid overload who responds poorly to IV diuretics or has worsening renal function

   -> inotropic agent (milrinone)

・narrow-complex tachycardia in patient with h/o heart transplant

   low dose of adenosine (3mg)

・atrial tachycardia with atrioventricular 2:1 block 

    digoxin toxicity

・ST-segment elevation more prominent in aVR than V1

　obstruction of left main coronary artery

・patient with mechanical valves on warfarin

    addition of low-dose ASA reduce the risk of thromboembolism

・ABX for endocarditis prophylaxis prior to dental procedure 

   amoxicillin 2 gram po once 1 hour prior to procedure

・6 months of intermittent fever, orthopnea, progressive SOB, chest pain

    cardiac myxoma

・management of asymptomatic myxoma

surgical removal (risk for systemic embolic event)

・late cardiac complication of Hodgkin disease treatment

coronary artery disease, (valve disorder, restrictive cardiomyopathy, diastolic dysfunction)

・fixed splitting of the S2

ASD

・management of patient with pacemaker whose corner is eroding through skin without sign of systemic infection

extraction of pacemaker and leads

・management of severe pulmonary valve stenosis with peak gradient of 70

percutaneous pulmonary balloon valvuloplasty

・diagnosis of patient who has newly developed holosystolic murmur at left sternal border associated with palpable thrill 3 days after myocardial infarction

postinfarction VSD

・cardiovascular risk scoring system preferable for young female

Raynolds risk score (Framingham risk score underestimate risk of young female)

・cannon a wave

atrial contraction against closed tricuspid valve -> AV dissociation 

・management of patient with ACS who is contraindicated to beta blocker

diltiazem

・clopidogrel Tx for patient with unstable angina or NSTEMI who is treated medically without stent placement

clopidogrel for at least 1 month, ideally up to 1 year

・management of patient with chronic stable angina who remains symptomatic despite optimal dose of beta blocker, cacium channel blocker and long-actign nitrate

ranolazine

・management of patient with ICD placement and pacemaker dependence who is about to undergo surgery

turn off shock therapy and change to asynchronous mode (ventricular pacing continue regardless of any native electrical activity)

・time window of thrombolytic Tx for STEMI

within 12 hours

・follow up aortic coarctation repair

MRI or CT for aort (to evaluate recurrent coarctation and aneurysm)

・biventricular pacing

QRS > 120

・complication of previous radiation to thorax

aortic regurgitation,  ・・・

・ejection click that diminish in intensity during inspiration 

pulmonary valve stenosis

・evaluation of newly diagnosed left ventricular systolic dysfunction 

coronary angiography 

・management of limb ischemia with dense anesthesia, severe motor impairment, lack of doppler vascular signal 

prompt amputation (consistent with nonviable limb)

・DDx of patient with newly developed heart failure 5 years after heart transplant

cardiac allograft vasoculopathy

・ST change in myocarditis and pericarditis

myocarditis: nonspecific ST-T change (ST elevation, TWI)

pericarditis: concave ST elevation 

・management of patient with cyanotic congenital heart disease who present with dyspnea on exertion, Hb 15, Hct 52, ferritin 10, transferrin saturation 13%

iron therapy

(normal Hb and Hct are 18-20 and 60-65% for cyanotic heart disease patient)

・management of severe MR

mitral valve repair or replacement?

・management of patient with STEMI brought to the facility without cardiac cath lab and the other facility with cardiac cath is in 1.5 hour drive

thromolytic Tx if not contraindicated (door-to-balloon time should be 90 minutes or less)

Pulmonary and Critical care medicine (memo from NEJM knowledge plus and MKSAP)

・Tx for idiopathic pulmonary arterial hypertension

 require long-term anticoagulation 

・management of acute pulmonary embolism in patient with h/o HIT

argatroban (parenteral direct thrombin inhibitor) or others

・duration of ABX for ventilator-associated pneumonia caused by Pseudomonas aeruginosa

   15 days

・management of patient with provoked DVT on warfarin for 6 months, who was found to have residual nonocclusive thrombus by US

discontinue warfarin

(follow-up US not necessary, residual thrombi are present  in 60% at 6 months, 30% at 2 years, using D-dimer to gauge the duration of anticoagulation is not appropriate for provoked DVT)

・management of patient with repeated exacerbation of asthma who present with respiratory distress, inspiratory and expiratory wheezing heard predominantly in central lung fields, no improvement with repeated bronchodilator nebs and systemic corticosteroid IV

laryngoscopy (for possible misdiagnosis, evaluate vocal cord dysfunction)

・first-line treatment of central sleep apnea secondary to heart failure

medical opitimaztion of cardica function (diuresis,　)

・managment of patient with h/o unprovoked pulmonary embolism and elevation of follow-up D-dimer after 3 months duration of anticoagulation

restart anticoagulation for indefinite period

・next step for patient with significant smoking history who presents with cough, weight loss, CXR and CT show right upper lobe mass and moderate amount of right pleural effusion, diagnostic thoracentesis negative for cytology

repeat thoracentesis and pleural effusion cytology

(sensitivity of pleural effusion cytology: 60% for initial sampling, additional 27% on second sampling, and 5% on third sampling)

・one of the risk factors of pulmonary artery hypertension

symptomatic hemoglobinopathy (thalassemia, sickle cell disease) 

・benign pattern of calcification in lung nodule

central (granuloma), popcorn, lamellar (concentric ring), diffuse

・plateau pressure in ARDS management 

less than 30, TV initially set at 6ml/kg of ideal body weight, sebsequently reduced by 1ml/kg if necessary to maintain plateau pressure < 30

・diagnostic test for chronic thromboembolic pulmonary hypertension 

ventilation / perfusion scan

・first line treatment of hemodynamically unstable massive pulmonary embolism

intravenous tPA (catheter-based thrombus removal not first-line, catheter-directed thrombolysis: no data of improved outcome so far)

・military veteran deployed to Iraq during Operation Iraq Freedam p/w dyspnea, centrilobular nodules and airway thickening in CT   

   constrictive bronchiolitis

・common cause of COPD in nonsmoker from developing countries

    biomass fuel exposure (wood, crop, residues, and animal dung)

・most well-described cause of occupational asthma

   diisocyanate

・most common extrapulmonary site of disseminated nocardiosis

   central nervous system (-> focal sign)

・two most common cause of secondary pneumothorax

   pneumocystis jirovecii infection and COPD

・second major cause of lung cancer

   residential radon 

・ABX for UTI causing interstitial lung disease

   nitrofurantoin

・Tx of amiodarone-induced lung toxicity 

   discontinuation and prednisone

・diagnosis of tuberculosis pleural effusion 

    pleural biopsy

・test of pleural effusion when tuberculosis is suspected

adenosine deaminase (>70: highly specific, < 40: almost exclude)

(acid-fast stain positive only 5% in non-HIV, TB culture positive in 24%)

・prevention of high altitude pulmonary edema 

   nifedipine

・patient from New Mexico p/w flu-like symptom, pulmonary edema, peripheral immunoblast, cardiac collapse 

   aerosolized rodent excreta (hantavirus)

・primary ciliary dyskinesia:

   involvement of upper and lower respiratory tract,  infertility

・treatment of patient who found unconscious, Cre 1.9, severe AG acidosis, osmolal gap 109, negative ETOH and toxic screen, envelope-shaped crystal in urine

IV fomepizole and hemodialysis for ethylene glycol toxication 

・initial step of evaluation for patient with excessive daytime sleepiness and no obvious sign of sleep disorder

sleep diary

・pulmonary nodule less than 4mm

no further evaluation if no risk, follow up CT in 12 months if risk factor

・upper lobe predominance diffuse infiltrate witn normal or minimally abnormal pulmonary function test

sarcoidosis 

・management of 9mm ground-glass nodule in lung, followed by CT, no change in the past 2 years

follow up in 1 year (ground-glass nodule requires more than 2 years follow up, for possible slow-growing adenocarcinoma in situ) 

・management of patient with OSA who doesn't tolerate CPAP due to nasal congestion

add heated humidification to CPAP circuit

・explanation to patient who is concerned about radiation of CT scan of chest

5-7 mSv

comparable to the amount of radiation a person receives from ambient solar radiation over 1 year

・diagnosis of childbearing-age female without smoking history who has dyspnea on exertion, dry cough, hyperinflation in CXR, diffuse, thin-walled, small cyst in CT

lymphangioleiomyomatosis

・Dx of coal miner with productive cough, dyspnea on exertion 

obstructive lung disease

・assessment of risk of respiratory failure for patient with exacerbation of myasthenia gravis

serial vital capacity and maximum negative inspiratory force

・next step for patient who present with cough, hemoptysis, weight loss, sputum cytology positive for squamous cell carcinoma, CXR and CT show mass in right lower lobe, PET-CT show mass in R lung and increased activity in mediastinal lymph nodes

mediastinal lymph node sampling

・management of agitation for patient with neuroleptic malignant syndrome

benzodiazepine (lorazepam)

・management of patient who present with fever, polyarthralgia, erythema nodosum, CXR show bilateral hilar lymphadenopathy

observation :  more than 80% of patient with sarcoidosis who present with Lofgren syndrome have spontaneous resolution

Nephrology (memo from NEJM knowledge plus and MKSAP)

・statin for CKD 

no benefit for dialysis patient, but reduce all-cause of mortality in patient with CKD not on dialysis

・management of patient with acute myeloid leukemia on chemotherapy, on normal saline IV at 200ml/hr and rasburicase for tumor lysis syndrome prophylaxis, urine output of 50cc/hr, Cre 1.0, K 5.2, phos 5.7, uric acid 7.1

increase IV hydration to help promote excretion of K, phos, uric acid (250cc/hr)

・estimate of GFR

modification of diet in renal disease (MDRD) equation underestimate GFR
chronic kidney disease epidemiology collaboration (CKD-EPI) equation more accurate

・diagnostic test for former battery factory worker with CKD, glycosuria, proteinuria

chelation mobilization testing

(for lead nephrotoxicity, lead blood level would be normal due to former exposure)

・management of blood access for patient with stage 4 CKD who develop osteomyelitis requiring 4 weeks IV ABX 

through peripheral line,  not PICC line for potential hemodialysis in future

・management of recurrent nephrolithiasis with calcium-containing kidney stone and hypercalciuria

thiazide diuretic

・management of IV fluid for patient on HCTZ who present with altered mental status secondary to hyponatremia of 110, that came up to 121, 10 hours after initiation of 3% saline

discontinue 3% saline and start 5% dextrose to adjust Na around 114 to 116 in the first 24 hours

・evaluation of hypokalemic metabolic alkalosis

urine chloride (↑: diuretic, Gitelman, Batter, ↓: vomiting, volume depletion)

・acanthocyte in urine

glomerular hematuria, suggesting glomerulonephritis

・DDx of effacement of podocyte foot process in electron microscopy

minimal change glomerulopathy:  normal light and immunofluorescence microscopy

menbranous glomerulopathy:  glomerular membrane thickening, IgG, C3 deposit

・management of patient with bipolar disorder who develops lithium-associated nephrotoxicity, but still requires to continue lithium

amiloride

・diagnosis of patient with h/o psoriasis using certain cream who develop confusion, slight AG metabolic acidosis, respiratory alkalosis

salicylate toxicity

・Tx of salicylate toxicity

sodium bicarbonate infusion

(HD indicated for level>80, AMS, pulmonary edema, advanced kidney disease)

 ・Tx of low risk of membranous glomerulopathy with nephrotic syndrome

ACEI (no glucocorticoid)

untreated 2/3 of MG undergo spontaneous complete or partial remission 

high risk of progression to CKD: male, > 50 yo, HTN, elevated Cre, secondary glomerulosclerosis, tubulointerstitial change on biopsy

・Dx of patient from Romania who has CKD, no proteinuria, no obvious cause of CKD

Balkan nephropathy

・initial managment of polyoma BK virus associated nephropathy in kidney transplant recipient

decrease immunosuppression 

・DDx of patient with AKI following partial colectomy for perforated diverticulitis, requiring 15L of IV hydration to maintain BP

abdominal compartment syndrome

・management of pregnant patient with h/o borderline HTN and family history of preeclampsia

low-dose aspirin (reduce risk of preeclampsia for patient with risk factor)

・management of severe ANCA positive vasculitis presenting as rapidly progressive glomerulonephritis

plasmapheresis, cyclophosphamide, glucocorticoid

・management of patient with CKD who develop dyspnea on exertion, no chest pain, no JVD, trace leg edema

refer to ED, for possible ACS, ACS in CKD patient may have atypical Sx 

・management of CKD wiht low calcium, high normal phosphorus, elevated parathyroid hormone, low 25-hydroxyvitamin D

try inactive form of vitamin D (cholecalciferol (vit D3), ergocalciferol (vit D2)) before beginning active form of vitmain D (calcitriol, alfacalcidol, doxercalciferol) that are expensive

・Dx of 17 weeks pregnant female with BP 140/90, Cre 1.7, 1+ protein in urinalysis

CKD and HTN (not preeclampsia)

blood pressure typically decreases early in the first trimester, creatinine typically falls during pregnancy due to expansion of plasma volume

・negative eosinophil in urine in the setting of acute interstitial nephritis

not uncommon (eosinophil in urine: low sensitivity and specificity)

Gastroenterology (memo from NEJM knowledge plus and MKSAP)

・how long patient with upper GI bleed and high-risk lesion on upper endoscopy need to be observed in hospital after successful procedure

72 hours (high-risk peptic ulcer: active bleeding, visible vessel)

・management of opiod-induced constipation refractory to standard laxative

methylnaltrexone

・management of recurrent obscure GI bleeding with negative upper endoscopy and colonoscopy

repeat upper endoscopy +/- colonoscopy

(capsule endoscopy and single-balloon endoscopy are reserved for patient with negative for repeated endoscopy and colonoscopy)

・management of obscure GI bleeding requiring 1 unit transfusion every 3 days, negative upper endoscopy and colonoscopy 2 times, negative capsule endoscopy

nuclear scintigraphy 

(nuclear scintigraphy requiring bleeding rate 0.1-0.5 ml/min to detect, angiography reguiring bleeding rate > 1 ml/min)

・screening for hereditary nonpolyposis colorectal cancer

colonoscopy initiated by age of 20 to 25 or 10 years prior to the earlest age colorectal cancer diagnosis in the family

・colon cancer screening for ulcerative colitis

every 1-2 years, beginning 8-10 years after diagnosis

・colon cancer screening for patient with positive family hitory (father at 54 yo)

every 5 years, initiating at age of 40 

(first degree with CRC < 60 yo: initiate at 40 yo or 10 years younger than age at diagnosis)

・postpolypectomy surveillance (1.5cm villous adenoma, low-grade dysplasia and 6mm tubular adenoma, low-grade dysplasia)

colonoscopy in 3 years

(high risk adenoma: > 3 adenomas, > 1cm, villous morphology, high-grade dysplasia)

・management of patient with bright red blood per rectum with syncopal episode, BP 88/58, HR 123, Hb 7.3, nasogastric tube aspirate negative

upper endoscopy first, then colonoscopy if negative

(bright red blood per rectum associated with ongoing brisk bleeding from upper source, nasogastric tube placement miss up to 15% of active bleeding)

・follow up resolution of uncomplicated acute diverticulitis

colonoscopy to rule out other disorders that mimic diverticulitis, such as cancer or Crohn disease

・Tx for moderately to severely active Crohn disease

anti-TNF agent (infliximab)

・follow up patient with h/o familial adenomatous polyposis syndrome after total colectomy

periodic upper endoscopy to screen ampullary adenocarcinoma

・prevention of esophageal variceal rebleeding 

beta blocker and serial band ligation every 3-4 weeks (PPI no role in secondary prevention of esophageal variceal bleeding)

・management of type 1 gastric carcinoid tumor with size of 1cm after removal 

follow up endoscopy in 6 months (rarely metastasis occur, 5 years-survival 95%)

・management of traveler's diarrhea without alarm symptoms (fever, hematochezia)

supportive care

・management of patient with severe diarrhea after massive small-bowel resection for acute mesenteric ischemia

PPI

(surge of gastric acid in the postoperative period -> inactivate pancreatic lipase -> diarrhea)  

・two most common complication of Meckel's diverticulum

GI bleeding (acid secreted by heterotopic gastric mucosa) and small-bowel obstruction (intussusception)

・Tx for constipation-predominant irritabl bowel syndrome refractory to fiber and standard laxatives

lubiprostone

・imaging study for suspected insulinoma if contrast CT negative

endoscopic ultrasound

・diagnosis of patient with diarrhea, bloating, weight loss, vit B12 deficiency with elevated folate

small intestinal bacterial overgrowth

・management of immune-tolerant hepatitis B (positive HBsAg, HBeAg, high HBV-DNA,  normal ALT)

monitor ALT every 3-6 months

(as long as pt maintain normal ALT, low risk for progression of liver disease, once ALT elevated -> biopsy -> initiate Tx )

・management of patient who present with hematemesis, hemodynamically unstable even after 2L of IV normal saline and 2 units of transfusion

continue IV hydration and transfusion (upper endoscopy after hemodynamic stability achieved)

・indication for liver biopsy in hereditary hemochromatosis

> 40 yo, ferritin > 1000

・diagnosis of patient with passive movement of undigested stomach contents into the mouth without retching, then spit or reswallow

Rumination syndrome

・management of cirrhotic patient with large esophageal varices (>5mm)

non-selective beta blocker or endoscopic ligation 

・diagnostic study for acute acalculous cholecystitis

US has better sensitivity than CT

・management of eosinophilic esophagitis

PPI 6 weeks first to exclude GERD

(EE can occur secondary to GERD, no criteria to distinguish EE from GERD)

・first-line therapy of achalasia

laparoscopic myotomy

・unexplained iron deficiency anemia in patient with Down syndrome with negative result of upper endoscopy, colonoscopy and serum tissue transglutaminase IgA Ab

repeat upper endoscopy with small bowel biopsy

(celiac disease, sensitivity of serum tissue transglutaminase IgA Ab significantly varies among lab)

・if bowel preparation is poor for screening colonoscopy

repeat colonoscopy before planning long-term surveillance program

Rheumatology (memo from NEJM knowledge plus and MKSAP)

・DDx of patient with rheumatoid arthritis on methotrexate and etanercept who develop fever, arthralgia, pleuritic chest pain, nonblanching purpuric rash, pancytopenia, proteinuria

drug-induced lupus erythematosus (TNF alfa inhibitor)

・management of patient with h/o gout who develop acute knee arthritis, joint fluid shows WBC 110,000, positive for crystal, gram stain negative

empiric ABX for possible concomitant infection until Cx come back negative if WBC in joint fluid > 50,000

・Tx for chronic reactive arthritis

sulfasalazine, usually self-limited, 25% develep chronic persistent arthritis

・initial Tx for gout attack prophylaxis

urate-lowering agent (allopurinol) + colchicine

・first-line treatment of uncomplicated dermatomyositis

high-dose corticosteroid

・diagnosis of ankylosing spondylitis

MRI of sacroiliac joint

・medical Tx for patient with fibromyalgia not tolerate pregabalin

serotonin and norepinephrine reuptake inhibitor (duloxetine, milnacipran)

・shoulder pain, large noninflammatory joint effusion, subsequent to trauma, periarticular  diffuse calcification 

basic calcium phosphate diposition disease (Milwaukee shoulder)

・diagnostic test for patient with uveitis, erythema nodosum, oligoarthritis

CXR to evaluate hilar lymphadenopathy, sarcoidosis, known as Lofgren syndrome (diagnosis without tissue biopsy)

・Tx for musculoskeletal feature of systemic sclerosis

methotrexate

・heliotrope and Gottron's papules with normal CPK

amyopathic dermatomyositis

・patient with rheumatoid arthritis refractory to methotorexate

add TNF alfa inhibitor

・rheumatoid arthritis

diagnosed with > 10 synovitis more than 6 weeks even if RF/anti-CCP Ab/ESR/CRP all negative (20% RA negative with RF and anti-CCP Ab)

・erosive hand osteoarthritis

involve proximal and distal interphalangeal joints that are associated with erythema, swelling, and severe pain, ESR mildly elevated

・management of active SLE disease with proteinuria

kidney biopsy, followed by aggresive Tx

・osteoarthritis-like arthritis in atypical joints

calcium pyrophosphate arthropathy (calcium diposition)

・osteoarthritis-like arthritis in metacarpophalangeal joints, wrist, hip

hemochromatosis

・Tx for rheumatoid arthritis during pregnancy

discontinue DMARDs (methotrexate), 75% spontaneous remission, if persistent -> prednisone, hydroxychloroquine, sulfasalazine

・diagnosis of patient with 3 months h/o rash worsened by sun exposure and fatigue, no other symptoms, ANA negative, anti-Ro/SSA Ab positive

subacute cutaneous lupus erythematosus

・pain management of osteoarthritis refractory to medications and physical therapy

try tramadol

・mangement of patient with acute gout polyarthritis with CKD

prednisone 0.5mg/kg of ideal body weight

・suspected giant cell arteritis with negative temporal artery biopsy

contralateral temporal artery biopsy

・anti-U1-ribonucleoprotein (RNP) antibody

mixed connective tissue disease

・cutaneous sclerosis that involves only skin without other systematic symptoms

morphea

・adverse effect of tocilizumab for RA

hyperlipidemia

・diagnostic test for patient with pulmonary nodular infiltrate, boggy nasal turbinate, positive p-ANCA

lung nodule biopsy, instead of nasal sinus mucosa biopsy, which infrequently yield sufficient tissue to evaluate

・follow-up management of stable patient with rheumatoid arthritis diagnosed 1 year ago when x-ray showed early sign of erosion 

repeat hand and wrist x-ray

・evaluation of patient with thickened ears, saddle nose deformity, polyarthritis

pulmonary function test to evaluate large upper airway involvement in suspected relapsing polychondritis

 ・cutaneous palpable papura, low complement, Sjogren syndrome

Type 1 cryoglobuminemic vasculitis 

・neck and low back pain with limited mobility throughout spine in obese male h/o DM

diffuse idiopathic skeletal hyperostosis

・elbow pain due to repetitive movement

lateral epicondylitis

・Tx for urticarial vasculitis

hydroxychloroquine

・lateral hip pain, tenderness to palpation on bursa

trochanteric bursitis

・lateral hip pain, tenderness to palpation along the band down to knee, young athlete

iliotibial band syndrome

・woody induration in extremities, no Raynaud phenomenon

eosinophilic fasciitis (scleroderma spectrum disoder, spare fingers, even normal pheripheral eosinophil count)

・diagnostic test for patient with DM, who present with 5 month h/o knee pain, frequently scraping knee in the soil while working, warm and swollen knee, T 38.0, WBC 11000, joint aspiration: WBC 6500, negative crystal and gram stain, negative bacterial Cx, RF, ANA, Lyme titer, TB skin test

synovial biopsy (fungal arthritis: Sporothrix schenckii)

 ・diagnosis of patient with thrombocytopenia, livedo reticularis, valvular disease, microangiopathic kidney insufficiency, pregnancy loss

antiphospholipid syndrome

Hematology and Oncology (memo from NEJM knowledge plus and MKSAP)

・target platelet count in the setting of intracranial hemorrhage

100,000,  transfusion as needed

・management of superior vena cava syndrome secondary to small cell lung cancer

chemotherapy

・diagnosis of polycythemia vera

elevated Hb, JAK2 mutation, no secondary cause of erythrocytosis

・diagnosis of patient without bleeding history who has normal PT and elevated aPTT failing to fully correct on mixing study

acquired hemophilia (acquired antibody to factor VIII)

・Tx for acquired homophilia (acquired factor VIII inhibitor)

recombinant activated factor VIIa (bypass the need for factor VIII)

・hemophilia

A: factor VIII deficiency, B: factor IX deficiency

normal PT, elevated aPTT, fully corrected by mixing study

・breast cancer screening for 29 yo female with PMH of lymphoma status post mantle radiation

mammography and MRI yearly 

・Tx indication for primary myelofibrosis

high risk feature:  > 65 yo, fever, night sweat, weight loss > 10%,  Hb < 10, WBC > 25000, circulating blast > 1%

・factor V Leiden

itself is not indicated for life-long anticoagulation (risk: 5-fold for initial VTE, 1.5-fold for recurrent VTE)

・elevation in both homocysteine and methylmalonic acid

vit B12 deficiency (only homocysteine elevated in folate deficiency)

・diagnosis of symptomatic multiple myeloma

require organ damage (kidney dysfunction, hypercalcemia, anemia or bone disease)-> Tx

asymptomatic MM -> observation 

・Dx of recurrent bacterial infection with vitiligo and pernicious anemia

common variable immunodeficiency 

・above what percent of clonal plasma cell on bone marrow biopsy to diagnose multiple myeloma

10%

・follow-up patient with stage IIIC ovarian cancer status post chemotherapy

CA125 every 4 months

・management of non-small cell lung cancer with pleural effesion 

chemotherapy (no radiation)

・Tx for persistent hypoxia in acute chest syndrome due to sickle cell disease

transfusion 

 ・symptoms of sickle cell trait

hematuria due to renal papillary necrosis

(chest pain, SOB, joint pain: not increase frequency in sickle cell trait)

・pregnant female with h/o idiopathic venous thromboembolism

require antepartum and postpartum heparin prophylaxis

・mild anemia, microcytosis, target cell, normal hemoglobin electrophoresis

alfa thalassemia trait

・Tx for acute lymphoblastic leukemia

induction chemotherapy

・gestational thrombocytopenia

benign clinical course, usually no intervention

・Tx for secondary iron overload

iron chelation (deferasirox)

・hemolytic episode after using trimethoprim-sulfamethoxazole

glucose-6-phosphate dehydrogenase deficiency 

・diagnosis of paroxysmal nocturnal hemoglobinuria

flow cytometric analysis for CD55 and CD59

・cause of pure red cell aplasia

large granular lymphocytosis, parvo B19, thymoma, myelodyplasia

・acute kidney injury in multiple myeloma

vulnerable to NSAIDs and intravenous contrast dye

・hydroxyurea for sickle cell anemia

cause macrocytosis

・rapid reversal of warfarin

vitamin K iv and prothrombin complex concentrate

・incidentally found several pulmonary nodules 2-4 mm with smoking history

follow up CT in 12 months (< 4mm with risk factor -> f/u 12mo)

・Gleason score in prostate cancer

6: lowest score of cancer,  8-10: poorly differentiated

・breast cancer Tx

tamoxifen to hormone receptor positive, increase risk of VTE -> ovarian ablation if h/o VTE

aromatase inhibitor to hormone receptor positive cancer in postmenopausal pt

trastuzumab to HER2 positive

・management of lobular carcinoma in situ in premenopausal female after excisional biopsy

tamoxifen (LCIS nealy always estrogen receptor positive)

・adverse effect of bevacizumab

HTN, bleeding, thrombose, intestinal perforation

・multiple lymphadenopathy, splenomegaly, bone marrow show cyclin D1 and t(11:14) translocation

Mantle cell lymphoma

・management of cancer of unknown primary site with axillay lymphadenopathy, negative mammography and MRI

mastectomy with axillary lymph dissection (treat as stage II breast cacner)

 ・management of prostate cancer with Gleason score of 8 and PSA of 22

androgen deprivation therapy and radiation (for high risk group: Gleason: 8-10, PSA > 20, sugery not indicated)

・management of asymptomatic well-differentiated metastatic carcinoid tumor

observation, f/u CT in 3-4 months

・empiric Tx for cancer of unknown primary site, retroperitoneal node Bx reveal pooly differentiated carcinoma in young man

cisplatin-based chemotherapy 

・next step for incidentally found kidney mass by non-contrast CT

ultrasound to evaluate whether the mass is cyst or solid

・initial mangement of SVC syndrome

mediastinoscopy and biopsy (Tx differ based on histology)

・management of well-differentiated invasive ductal cancer, mass: 2cm, no palpable lymphadenopathy

lumpectomy, sentinel lymph node biopsy, radiation

・Tx of anal cancer

radiation Tx with chemotherapy for stage I,II,III (potentially cured without surgery)

・testicular mass with elevated beta-hCG and AFP

nonseminoma germ cell tumor

(elevated AFP rule out seminoma, beta-hCG elevated in both seminoma and nonseminoma)

・management of recurrent diffuse large B-cell lymphoma

high-dose chemotherapy and autologous hematopoietic stem cell transplantation

 ・management of hot flush secondary to tamoxifen Tx for breast cancer patient

venlafaxine (SNRI)

・management for patient who present with seizure secondary to isolated brain metastasis from melanoma

surgical resection for symptomatic relief

 ・next step following surgery for high-risk, early stage bladder cancer

intravesicular BCG (bacillus Callmette-Guerin) immunotherapy

・management of tumor lysis syndrome

aggressive hydartion and diuresis, (hemodialysis), rasburicase, allopurinol

・management of oligometastatic colorectal cancer isolated to liver

partial hepatectomy

・management of bone metastasis likely from recurrent breast cancer

bone biopsy (assess hormone receptor and others to guide Tx)

・postoperative surveillance colorectal cancer

physical exam, CEA every 3-6 months, colonoscopy 1 year after, then every 3-5 years, chest/abdomen/pelvic CT annually for 3 years

・stage I rectal cancer (cancer penetrate into, but not fully through rectal wall with no lymph node metastases)

surgery (no chemotherapy after surgery)