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)

Infectious disease (memo from NEJM knowledge plus and MKSAP)

・ABX for extensively drug-resistant pseudomonal infection (resistant to fluoroquinolone, carbapenem, aminoglycoside)

intravenous colistin (polymyxin E)

・first recurrance of mild to moderate C.difficile colitis

metronidazole for 14 days

・Tx for tuberculous pericarditis

4-drug antituberculous Tx + prednisone

・positive result of PPD

> 15mm: normal populatoin, 　> 10mm: IV drug abuse, etc, 　> 5mm: HIV, etc

・flu-like symptoms, pulmonary symptms, pancytopenia, in Ohio

histoplasmosis

・GNR bacteremia associated with tunneled central venous catheter 

removal of catheter and 7-14 days of ABX

・management of suspected brain abscess (> 2.5cm in imaging study)

CT-guided aspiration

・beta-lactam ABX covering MRSA

ceftraroline

・Dx of patient with acute symmetric polyarthritis and faint maculopapular rash on chest and extremities associated with recent flu-like symptom

parvovirus B19 (classic slapped cheek appearance usually not occur in adults)

・self-limited shigellosis confirmed by microbiologic diagnosis

still require 3 day of ciprofloxacin

・fever, chills, asymmetric flaccid paralysis

West Nile virus myeltiis

・diarrhea associated with uncooked poultry

campylobacter jejuni 

・coinfection with Lyme disease, causing hemolysis 

 Babesia microti

・management of mild histoplasmosis

observation without ABX

・cough, fever, erythema nodosum in Arizona

coccidiodomycosis

・Dx and Tx for broad-based budding yeast from hyperkaratonic skin lesion

blastomycosis /  itraconazole

・Tx for clinically stable patient with bacteremic pneumococcal pneumonia susceptible to penicillin 

7 days course of oral amoxicillin

・recurrent cystitis treated with trimethoprim-sulfamethoxazole 5 months ago

nitrofurantoin

・flu-like symptoms, widened mediastinum in patient exposed to crop dusting

bacillus anthracis

・infection after transplantation

CMV infection during middle period (the first few months)

・first choice for immunocompromised patients with invasive pulmonary aspergillosis

voriconazole

・invasive group A β hemolytic streptococcal (streptococcus pyogenes) infection (necrotizing fasciitis, toxic shock syndrome)

require contact precaution (not only standard precaution)

・ABX for cat-scratch fever

azithromycin

・choice of statin for HIV patients on ART

no simvastatin 

・Tx for syphilis

primary / secondary / early latent: IM benzathin penicillin G x 1

tertiary / late latent: IM benzathin penicillin G x 3 weekly

neurosyphilis: IV aquaous crystalline penicillin G x 10 days

・fever, productive cough, gram negative bipolar-staining bacilli, in New mexico

Yersinia pestis (Plague)

・Sx of typhoid fever (Salmonella enterica)

constipation followed by diarrhea, salmon-colored rash, relative bradycardia, splenomegaly, hyponatremia

・recurrent erysipelas rash and fever

FMF

・shaving of hair prior to surgery 

risk factor for surgical site infection (not protective factor)