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Internal Medicine Flash Cards > Block 1 > Flashcards

Block 1 Flashcards

1
Q

Recommendations for lung cancer screening

A
  • Annual screening→low-dose CT in adults age 55 - 80 who have a 30-pack-year smoking history and currently smoke or have quit within past 15 years
  • Discontinue Screening→Once a person has not smoked for 15 years or develops a health problem limiting life expectancy or ability/willingness to have curative lung surgery
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2
Q

Best initial test to Dx acromegaly

A

Insulin-like growth factor-1 (IGF-1)→significantly ↑↑ level compared to the average for age-matched equivalents►positive screen

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3
Q

Confirmatory test for acromegaly

A

GH after 100 g of glucose is given orally

  • Positive if GH remains high (>5 ng/mL)
  • Normally a glucose load completely suppress levels of GH
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4
Q

Why don’t you have hyperkalemia and salt loss in secondary adrenal insufficiency caused by pituitary disease?

A

Aldosterone production is mainly dependent on the renin-angiotensin system→not aldosterone deficiency

*Salt wasting, hyperkalemia, and death are associated with aldosterone deficiency

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5
Q

Use of Metyrapone test. How does it work?

A
  • Assess ACTH production
  • Blocks cortisol production→↑ ACTH levels.
  • A failure of ACTH levels to rise→suggests pituitary insufficiency
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6
Q

Most common cause of panhypopituitarism

A

Pituitary adenomas

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7
Q

Best diagnostic study for evaluating and confirming the diagnosis of bladder cancer

A

Cystoscopy

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8
Q

Most specific and sensitive test to evaluate celiac disease

A

IgA anti-tissue transglutaminase (anti-tTG) and antiendomysial antibodies (anti-EMA)►jejunal mucosal damage

*Serum antigliadin antibody no longer used routinely►lower sensitivity and specificity

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9
Q

How do you diagnose celiac disease without small bowel biopsy?

A
  • Positive serology (anti-tTG, anti-EMA) + confirmed dermatitis herpetiformis by Bx
  • Small bowel biopsy is the most accurate test
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10
Q

Most accurate test of celiac disease and its common findings

A

Small bowel biopsy→blunting of distal duodenal and/or proximal jejunal villi, crypt hyperplasia, intraepithelial lymphocytosis

*Always necessary to exclude bowel wall lymphoma

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11
Q

How do you differentiate corticosteroid-induced vs statin-induced myopathy?

A
  • Corticosteroid induced→muscle enzymes normal, EMG normal. Lower extremity weakness and proximal atrophy. No correlation with dosage or duration.
  • Statin-induced→↑↑ CPK ten times upper limit, weakness
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12
Q

Enough findings to diagnose Wilson disease. Most accurate test to Dx.

A
  • Low ceruloplasmin concentration (<20 mg/dL), Keyser-Fleischer rings on slit-lamp examination
  • Liver Biopsy
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13
Q

Clinical hallmark of necrotizing fascitis

A

Rapidly progressive erythema with pain and tenderness significantly out of proportion of physical findings

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14
Q

Most important and definitive treatment of necrotizing fascitis

A

Surgical debridement

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15
Q

Difference of the diffusion capacity of the lung for carbon monoxide between emphysema and chronic bronchitis, and why?

A
  • Low in Emphysema→loss of alveolar capillaries

- Normal in Chronic Bronchitis

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16
Q

How do you differentiate Rotor vs Dubin-Johnson syndrome?

A
  • Dubin-Johnson→lack elevation of urinary coproporphyrins, has darkly pigmented liver
  • Rotor→milder in presentation without black liver, ↑urinary coproporphyrins
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17
Q

When do you evaluate for liver transplantation?

A

Decompensated liver failure

  • Portal hypertension
  • ↓Synthetic function (variceal hemorrhage, ascites, encephalopathy)
  • Liver biopsy→evaluate extent of structural damage to the liver and candidacy for liver transplantation
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18
Q

Most common presentation of glucagonoma

A
  • Glucose intolerance
  • Necrolytic migratory erythema→annular erythematous dermatitis, blistering and erosions
  • Weight loss
  • Normocytic normochromic anemia
  • Diarrhea, thromboembolism
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19
Q

What is the differential diagnosis in a patient with polydipsia and polyuria? Initial steps in management.

A
  • Diabetes insipidus, psychogenic polydipsia, Diabetes mellitus
  • 1st step to evaluate→measure urine osmolarity
  • 2nd step→Water deprivation test
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20
Q

What do you do next when diagnosing megaloblastic anemia by vitamin B12 deficiency?

A

Confirm the etiology before treatment (better route is intramuscular)

*Dietary absence (vegans), pregnancy, malabsorption syndrome, ileal or gastric resection, pernicious anemia

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21
Q

History suggestive of pernicious anemia. How do you confirm the diagnosis?

A
  • History of dyspepsia, autoimmune condition (ex, diabetes type 1), elderly.
  • Low B12 levels→confirm:
  • Serum anti-intrinsic factor antibodies and anti-parietal cell antibodies
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22
Q

In which patients do you perform a head CT scan before lumbar punction when suspect meningitis?

A
  • Papilledema
  • Immunocompromised state
  • New-onset seizure (within one week of presentation)
  • History of CNS disease (mass lesion, stroke, focal infection)
  • Abnormal level of consciousness
  • Focal neurologic deficit
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23
Q

What is the therapy for Heparin-induced Thrombocytopenia (HIT)?

A
  • Discontinuation of Heparin
  • Lepirudin (anticoagulant)

*Continue anticoagulation with non-heparin medication (argatroban, fondaparinux)

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24
Q

Esophagus manometry results in scleroderma. How do you suspect esophageal compromise?

A
  • ↓Lower esophageal sphincter pressure, ↓esophageal peristalsis
  • Gastroesophageal reflux disease (GERD) and dysphagia
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25
Q

What is motility-type dysphagia? example of a disease with that.

A
  • Difficulty with liquids and solids from the onset of symptoms
  • Diffuse esophageal spasm
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26
Q

Gradual luminal narrowing of the esophagus after many years of gastroesophageal reflux disease (GERD).

A

Peptic esophageal stricture

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27
Q

Which are the two aberrant electrical pathways of the Wolff-Parkinson-White (WPW) syndrome?

A
  • Pre-excitation→involves the node itself►Supraventricular tachycardias (atrial fibrillation or atrial flutter)
  • Electrical pathway→reaches out of the AV node, connects to the bundle of His in the ventricles→early electrical impulse to the ventricles while bundle of His is in refractory period►Ventricular tachycardia
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28
Q

Drugs of choice in acute WPW hemodynamically stable. Which drugs you must avoid?

A
  • Drugs of choice: Procainamide or Amiodarone
  • MUST avoid: Digoxin, calcium channel blockers➡block the normal AV node and force conduction into the abnormal pathway; Beta-blockers.
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29
Q

Gold standard treatment for chronic WPW syndrome.

A

Radiofrequency ablation

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30
Q

Most sensitive test to diagnose pheochromocytoma

A

Plasma free fractionated metanephrines

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31
Q

Risk factors to develop shingles

A
  • Advancing age
  • Immunosupression
  • Trauma to the skin
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32
Q

What is acquired perforating keratosis (Kyrle disease)? and with what condition is related?

A
  • Dome shaped and umbilicated papules with a central keratotic crust on legs or less often trunk, neck, arms or scalp. Early lessions→pustular. Late lessions→resemble prurigo nodularis (central keratotic scale)
  • Chronic renal failure and Diabetes mellitus
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33
Q

How do you differentiate cardiac taponade vs right ventricle failure?

A
  • Pulsus paradoxus►Cardiac taponade, NO in right ventricle failure
  • Both have Beck’s triad►muffled cardiac sounds, hypotension, jugular venous distention
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34
Q

What is Felty syndrome? Treatment.

A
  • Rare complication (<1%) of rheumatoid arthritis:
  • High titer rheumatoid factor
  • Splenomegaly
  • Neutropenia (<1500, <1000→↑risk of clinically significant infection)
  • Gold, MTX (second-line Tx for RA). G-CSF for severe neutropenia or unresponsive to Tx for RA, when splenectomy is contraindicated or not possible
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35
Q

Most likely ECG pattern expected in a pulmonary embolism.

A

Non-specific ST segment T waves abnormalities and sinus tachycardia→70% of PE

*S1 Q3 T3, right axis deviation, Right bundle branch block, atrial fibrillation [right heart strain]→may suggest PE, but absence doesn´t rule out (20% of PE)

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36
Q

Most useful test for diagnosing pericarditis, which finding is more specific?

A

ECG→Diffuse concave ST elevation, PR depression (more specific finding), occasionally flipped T waves

*Echocardiogram→to rule out coexisting pericardial effusion or tamponade, often normal in acute pericarditis alone. Find small amount of fluid is not specific, seen in variety of conditions

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37
Q

Treatment of urinary uric acid stone (radiolucent)

A
  • Hydration
  • NSAIDs (pain killers)
  • Potassium citrate or potassium bicarbonate→alkalinization of urine►uric acid stone dissolve in an alkaline medium

*Add allopurinol if stones don’t resolve with initial treatment

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38
Q

Why you should avoid sodium bicarbonate for a uric acid stone treatment?

A

Extra salt load→volume expansion►hypercalciuria→formation of calcium stones

*Uric acid is a nidus for calcium oxalate stone formation

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39
Q

Findings in a mesenteric angiography of angiodysplasia. Clinical presentation. Treatment.

A
  • Dilated, slow-flowing vein in the colon
  • Lower GI bleeding
  • Endoscopic ablation→ cauterization or laser coagulation (if fails, surgical removement of affected bowel)
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40
Q

Most common cause of lower GI bleeding.

A
  1. Diverticulosis

2. Angiodysplasia

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41
Q

When beta-blocker and ACEIs are more efficient between them to reduce mortality in post-myocardial infarction patients?

A
  • Beta-blockers→post-MI patients with normal ejection fraction (↓ O2 demand and ventricular arrhythmias)
  • ACEI→post-MI in patients with reduced ejection fraction
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42
Q

Most effective method to diagnose dural sinus thrombosis and findings on it.

A

Cerebral venogram→bilateral infarcts along the posterior and anterior frontal lobes and parietal lobes, extending into the white matter (Sagital sinus infarcts)

*Example: Sagital sinus infarcts tend to cross arterial vascular territories and extend into the white matter

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43
Q

Which Beta-blockers you should avoid when treating Heart Failure and why?

A

Pindolol and Acebutolol→have sympathomimetic activity

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44
Q

Which electrolyte disturbance is caused by Bartter syndrome? Look like which pharmacologic effect?

A
  • Reabsorptive defect in thick ascending loop of Henle→Affect K/Na/Cl cotransporter►hypokalemia, metabolic alkalosis, hypercalciuria
  • Chronic loop diuretic use
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45
Q

Treatment for Bartter syndrome

A
  • Spironolactone→antagonizes effect of ↑ aldosterone (↑ by the loss of electrolytes and intravascular volume in Bartter)
  • NSAID→↓ excessive prostaglandins (in Bartter ↑PGE)
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46
Q

Specific findings at physical exam of Graves disease

A
  • Ophtalmopathy-exophthalmos (proptosis)
  • Periorbital edema
  • Pretibial myxedema
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47
Q

How do you identify a pericardial effusion at chest x-ray? Important physical examination finding to suspect it.

A
  • Enlarged and globular cardiac silhouette (“water bottle” heart shape)
  • Clear lung fields
  • Inability to palpate the point of maximal apical impulse
  • If large pericardial effusion→cardiac tamponade►Beck’s triad (hypotension, elevated JVP, muffled heart sounds)
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48
Q

Initial evaluation for coarctation of the aorta. Dx confirmation.

A
  1. Simultaneous palpation of the brachial and femoral pulses→assess for brachial-femoral delay
  2. Bilateral upper extremities (supine position) and lower extremities (prone position) blood pressure measurement→evaluate blood pressure differential
    - Dx confirmation→Echocardiogram
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49
Q

Embolism that more commonly occur during vascular procedures such as peripheral angiography or interventions, guidewire or catheter manipulations during cardiac catheterization, intraaortic balloon pump insertion.

A

Cholesterol crystal embolism→disruption of atherosclerotic aortic plaques►systemic atheroembolism

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50
Q

Most common cause of sepsis in sickle cell disease.

A

Streptococcus pneumoniae→despite immunization, is due to non-vaccine serotypes

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51
Q

When do you use acute therapy for hyperkalemia?

A
  • ECG changes
  • K>7 mEq/L (with or without ECG changes)
  • Rapidly rising K due to tissue breakdown
  • Dialysis→renal failure or severe life-threatening hyperkalemia unresponsive to initial therapy
  • Calcium gluconate and insulin with glucose
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52
Q

Which metabolic disturbance can be found on diabetic hyporeninism? why?

A
  • Hyperkalemic metabolic acidosis
  • Damage of the juxtaglomerular apparatus→hyporeninemic hypoaldosteronism►”aldosterone deficiency”→Renal tubular acidosis type IV (hyperkalemic RTA)
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53
Q

Pathophysiologic cause of renal tubular acidosis type IV (hyperkalemic RTA) and its metabolic consequence

A
  • Aldosterone insufficiency→Diabetic hyporeninism, ACEI, ARBs, NSAIDs, heparin, cyclosporine, adrenal insufficiency
  • Aldosterone resistance→K sparing diuretics, obstructive nephropathy, TMP/SMX
  • *Impaired function of the cortical collecting tubule►retention of H and K→hyperkalemic Non-anion gap metabolic acidosis

*Preserved kidney function→at least 20-50 mL/min

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54
Q

Diagnostic gold standard for viral myocarditis. Most frequently the diagnosis is assisted by which study?

A
  • Endomyocardial biopsy (lymphocytic infiltration) aided by viral polymerase (DNA or RNA)
  • Cardiac MRI▶️late enhancement of the epicardium
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55
Q

What is the indication for mineralocorticoid receptor antagonists on heart failure?

A
  • Left ventricular ejection fraction <40% with recent ST-elevation myocardial infarction
  • Symptomatic heart failure
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56
Q

Tumors that cause approximately 75% of all malignant pleural effusions

A

Lung carcinoma, breast carcinoma and lymphoma

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57
Q

Differences between ascending and descending aortic aneurysms in location and etiology

A
  • Ascending aneurysm→60% cases, origin anywhere from aortic valve to the innominate artery, cystic medial necrosis (aging) or connective tissues disorders (Marfan sx or Ehler-danlos sx)
  • Descending aneurysm→40% cases, origin distal to the subclavian artery, atherosclerosis
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58
Q

Chest X-ray findings suggesting thoracic aortic aneurysm

A
  • Widened mediastinal silhouette
  • Increase aortic knob
  • Tracheal deviation
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59
Q

Finding of ECG of acute pericarditis due to renal failure

A
  • Nonspecific T wave abnormalities

* Classic diffuse ST elevations are typically absent due to lack of myocardial inflammation

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60
Q

Difference between the pleural exudate of tuberculous effusion and malignancy etiology

A
  • Tuberculous→usually lymphocytosis>70%

- Malignancy→lymphocytosis is uncommon

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61
Q

Which electrolyte disturbance is associated with increase susceptibility of digoxin toxicity? Why?

A

Hypokalemia (may be associated with excessive diuretic use)→permissive for digoxin binding at K+ binding site on Na+/K+ ATPase

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62
Q

Best initial tests to diagnose pulmonary embolism. Which is most often the best next step or test to do after them?

A
  • Chest x-ray, EKG, Arterial Blood Gas
  • CT Angiogram (Spiral CT Scan)→standard of care to confirm PE

*Angiography is most accurate but 0,5% mortality (rarely done)

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63
Q

If you suspect a pulmonary embolism and the V/Q and spiral CT don’t give a clear diagnosis, what do you do next?

A

Lower Extremity Doppler study

  • Positive→no further test is needed (80% of PEs come from legs and the therapy won’t change)
  • Negative→Withhold Heparin
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64
Q

First choice test to confirm pulmonary embolism in pregnancy

A

V/Q scan

*Completely normal scan excludes a clot

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65
Q

When do you use thrombolytics in a pulmonary embolism?

A
  • Hemodynamically unstable→hypotension (systolic BP<90, tachycardia, etc)
  • Acute right ventricular dysfunction

*There is no specific time limit as in stroke or MI

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66
Q

What is Ludwig angina? Clinical presentation.

A
  • Rapidly progressive cellulitis of the submandibular space→most cases arise from dental infections
  • Rapidly systemic symptoms→fever, chills, malaise
  • Local compressive→mouth pain, drooling, dysphagia, muffled voice, airway compromise
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67
Q

Findings in the physical examination of Ludwig angina

A

Mass effect from edema; tender, indurated submandibular area; elevated floor of the mouth; tongue displaced; crepitus

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68
Q

What is the first step to confirm the diagnosis of peripheral artery disease?

A

Ankle-brachial index→<0,9►diagnostic of occlusive PAD with a 90% sensitivity and 95% specificity in symptomatic patients

*Arterial ultrasound of the lower extremities→less sensitive and specific than ABI►localize site and severity of vascular obstruction

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69
Q

How are the potassium deposits in DKA and why?

A

Excess of glucagon→hyperglycemia, ketonemia, osmotic diuresis►net renal loss of K+→depletion of total body K+ stores

*Despite reduction in K+ stores→serum [K+] may be ↑ due to acidemia and ↓insulin activity►redistribution of K+ to the extracellular fluid compartment

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70
Q

Major risks factors for Clostridium difficile infection

A
  • Recent antibiotic use (fluoroquinolones, clindamycin, cephalosporins, penicillins)
  • Advanced age (>65 years)
  • Gastric acid suppression (Ex, PPI)
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71
Q

Gold standard for diagnosis Herpes encephalitis

A

PCR of HSV DNA in CSF

*Highly sensitive and specific. Replacing brain biopsy.

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72
Q

Best initial test in acute exacerbation of asthma

A
  • Peak expiratory flow (PEF)→approximation of the FVC

- Arterial blood gas (ABG)→↑ A-a gradient

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73
Q

Most accurate test for asthma in an asymptomatic patient

A

> 20% decrease in FEV1 with use of methacholine or histamine

*Less likely to find an ↑ in FEV1 using a SABA (albuterol)→false negative

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74
Q

Findings in the pulmonary function testing in asthma

A
  • ↓ FEV1, FVC and FEV1/FVC
  • ↑>12% and 200 mL in FEV1 with albuterol
  • ↓>20% in FEV1 with methacholine or histamine
  • ↑ Diffusion capacity of the lung for Carbon monoxide (DLCO)
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75
Q

When do you use anticholinergics in chronic asthma management?

A

If SABA, LABA and inhaled corticosteroids at maximum doses are not sufficient

*Iptratropium, Tiotropium

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76
Q

Typical presentation in acute asthma exacerbation in arterial blood gas. Which finding suggests the patient is getting worse?

A
  • Hyperventilation→Respiratory alkalosis
  • ↑ work of breathing→respiratory muscle fatigue→inability to maintain adequate ventilation (hyper)►normal pH and PaCO2 (normalized or elevated from respiratory alkalosis)►impending respiratory collapse
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77
Q

Which are the 3 most common causes of chronic cough? What is chronic cough?

A
  • Chronic cough→lasting >8 weeks
  • Upper airway cough syndrome (postnasal drip)
  • Asthma
  • Gastroesophageal reflux disease (GERD)
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78
Q

What is a solitary pulmonary nodule? What is the first step when evaluating it?

A
  • Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, No associated with lymph node enlargement
  • Determine if nodule is low, intermediate or high malignancy risk
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79
Q

Which is the management of high, intermediate and low malignancy risk solitary pulmonary nodule?

A
  • High risk→surgical excision
  • Intermediate risk→FDG-PET, serial CT scans or Bx depending radiographic findings
  • Low risk→serial CT scans
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80
Q

Which disease result in C1 inhibitor deficiency? Which products of the complement cascade are elevated?

A
  • Hereditary angioedema
  • Edema producing factors→C2b, bradykinin
  • C1q levels are normal, ↑in acquired angioedema forms
  • ↓C4 in all forms of angioedema
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81
Q

How do you differentiate hyperthyroidism due to thyroiditis and exogenous thyroid hormone use (factitious thyrotoxicosis)? What do they have in common?

A
  • Common→Radioactive iodine uptake (RAIU) decreased
  • Differentiate:
  • ↑Thyroglobulin→thyroiditis (subacute or silent), iodide exposure
  • ↓Thyroglobulin→Factitious thyrotoxicosis
82
Q

Which electrolyte disturbance can occur due to immobilization and its mechanism?

A
  • Hypercalcemia
  • ↑Osteoclastic bone resorption

*Onset around 4 weeks, patients with chronic renal insufficiency develop it in about 3 days

83
Q

Hallmark of Paget’s disease and underlying breast condition

A
  • Painful, itching, eczematous, and/or ulcerating rash on the nipple that spreads to the areola
  • Adenocarcinoma
84
Q

Where is the most common location of the VIPoma? How do you confirm the diagnosis?

A
  • Pancreatic tail

- VIP level >75 pg/mL

85
Q

Most common electrolytic disturbances in VIPoma syndrome

A
  • VIPoma syndrome (pancreatic cholera)►secretory, watery diarrhea and ↓ gastric acid secretion→hypokalemia and hypo or achlorhydria
86
Q

Mechanisms by which Beta-adrenergic agonists cause hypokalemia

A
  • Stimulate Na-K ATPase pump and the Na-K-2Cl cotransporter→potassium shift into the intracellular space
  • Release of Insulin→promotes intracellular K+ shift
87
Q

Two major exposure associations of Squamous cell carcinoma. How do you call an SCC arising from a burn wound?

A
  • Ultraviolet sun exposure
  • Chronically wounded, scarred, or inflamed skin
  • Marjolin Ulcer

*Within skin overlying a focus of osteomyelitis, radiotherapy scars, venous ulcers

88
Q

First line inpatient non-ICU treatment for community-acquired pneumonia

A
  • Fluoroquinolone: Respiratory→moxifloxacin, levofloxacin

- Beta-lactam + macrolide

89
Q

Best initial and most accurate diagnostic test for COPD?

A
  • Best initial: chest x-ray

- Most accurate: Pulmonary Function Test

90
Q

Most appropriate initial step in the management of Hyperkalemia with ECG changes

A

Calcium gluconate

91
Q

Most appropriate next step when suspect clinically amebic liver abscess

A

EIA test - antibodies for Entamoeba histolytica

*The role of microscopic stool examination is limited. Less than 30-40% of patients with amebic liver abscess have concomitant intestinal amebiasis, and 10% of the population is infected with the nonpathogenic strain of E. dispar

92
Q

Most likely causal organism of a macular rash involving abdomen, chest, back, extremities and soles without fever and pruritus

A

Treponema pallidum

93
Q

Why are the thyroid antibodies (antithyroid peroxidase/antithyroglobulin) important to evaluate hypothyroidism?

A

If TSH is less than double the normal and antibodies are positive→replace thyroid hormone

94
Q

Ventricular apical ballooning, history of myocardial infarction after a stressful situation and normal coronary angiography. Disease and its mechanism?

A
  • Tako-Tsubo cardiomyopathy

- Massive catecholamine discharge

95
Q

When do you use Exercise Tolerance Testing to evaluate chest pain?

A

Etiology is not clear and EKG is not diagnostic

96
Q

Why the EKG in an Exercise Tolerance Testing may not be suitable to read and interpret?

A

Baseline EKG abnormality→Left bundle branch block, left ventricular hypertrophy, pacemaker use, effect of digoxin

97
Q

Which antiplatelet drugs are preferred in addition to aspirin in a patient undergoing angioplasty and stenting? and why?

A
  • Prasugrel or Ticagrelor

- Restenosis of stenting is best prevented

98
Q

Medication that offers the best mortality benefit in chronic angina

A

Aspirin and Beta blockers

99
Q

Which other medications can be used instead of ACEI/ARB in systolic dysfunction to decrease mortality? in what situation could you switch them?

A
  • Hydralazine (arterial vasodilator→↓ afterload) and Nitrates (dilate coronary arteries) - Reduce mortality in african-american
  • Hyperkalemia by ACEI or ARB
100
Q

Which are the most common liver metastases?

A

Primary tumors from gastrointestinal tract (colon), lung and breast

101
Q

Most important clues to recognize a Valley Fever. Which is the etiology?

A
  • Valley Fever
    1. Desert Southwest (Ex, Arizona or California)
    2. Symptoms onset 7-14 days after inoculation, subclinical, >50% Community acquired pneumonia (fever, chest pain, dry or productive cough, lobar infiltrate)
    3. Often accompanied: arthralgias, erythema nodosum or erythema multiforme
  • Coccidioides immitis
102
Q

Best first-line treatment for acute multiple sclerosis exacerbation

A
  1. Glucocorticoids

2. Plasmapheresis - MS flares refractory to corticoid therapy

103
Q

Screening indications for Diabetes mellitus

A
  • USPSTF→patients with sustained blood pressure (treated or untreated) >135/80
  • ADA→all patients >45 years,and at any age with risk factors for diabetes
104
Q

Which EKG finding in the context of acute coronary syndrome has the worst prognosis?

A

ST elevation in V2-V4 leads or Anterior Wall Miocardial Infarction

*If untreated - 30 to 40% mortality in 1 year

105
Q

Most important measure in decreasing the risk of restenosis of the coronary artery after PCI

A

Placement of drug-eluting stent (paclitaxel, sirolimus)

106
Q

When do you suspect a perivalvular abscess?

A

Symptoms of infective endocarditis + New conduction abnormalities (ex, 2:1 second-degree atrioventricular block with syncope)

107
Q

Which symptom is more specific when suspecting beta-blocker intoxication?

A
  • Beta-blocker intoxication→bradycardia, atrioventricular block, hypotension (ex, present also in CCB, digoxin, cholinergic intoxication)
    (+) Wheezing more specific
108
Q

In an ST-segment depression acute coronary syndrome, which is the best next step in the management after aspirin is given? Which of them is best in terms of mortality?

A
  • Heparin

- Low molecular weight heparin superior to unfractionated heparin

109
Q

Most accurate test in diagnosing congestive heart failure. In which case do you use it?

A
  • Multiple-gated acquisition scan (MUGA) or nuclear ventriculography
  • Ex: Patient receiving chemotherapy with doxorrubucin
110
Q

Best initial treatment for beta-blocker poisoning. Best next step if there is no improvement after the initial treatment.

A
  • Initial Tx→secure airway, isotonic fluids, atropine

- Next best step→Glucagon (⬆cAMP➡Tx for BB and CCB toxicity) in profound refractory hypotension

111
Q

How can you suspect Hypoparathyroidism induced by low magnesium?

A
  • Low Calcium

- Low Phosphorus (different from other causes of hypoparathyroidism➡High Phosphorus)

112
Q

Mechanism by which hypomagnesemia induce hypocalcemia

A

↓Mg→⬆resistance to PTH and ⬇PTH secretion

113
Q

Causal agent and treatment of Bacillary angiomatosis

A
  • Bartonella

- Oral Erythromycin

114
Q

Most common cause of Glomerulonephritis in adults

A

IgA Nephropathy

115
Q

Earliest findings of macular degeneration. Risk factors.

A
  • Distortion of straight lines (look wavy)→Grid test to screen
  • Driving and reading first activities affected
  • Ophtalmologic exam: drusen deposits in macula
  • Increase age, smoking
116
Q

Which arterial blood gas result would you find in a carbon monoxide poisoning?

A
  • Lactic acidosis→↓ bicarbonate, ↓pH (tissue hypoxia)

- ↑ Carboxyhemoglobin levels

117
Q

Which finding do you expect to find in cell blood count in a patient with chronic carbon monoxide poisoning?

A

Kidney responds to tissue hypoxia→↑EPO→Secondary polycythemia

118
Q

Which sodium disturbance you may find secondary to a pulmonary pathology and why?

A

Hypotonic Euvolemic Hyponatremia

  • Pulmonary pathology (Pneumocystis pneumonia, Ex)→ SIADH
  • Infusion of normal saline - worsen hyponatremia
119
Q

What potassium level do you expect in a hyperglycemic crisis (DKA or HHS)? Why?

A
  • Normal or slightly elevated serum potassium
  • Insulin deficiency→put K+ out of cells
  • Osmotic diuresis→excessive urinary K+ loss

*Total body potassium deficit (3-5 mg/kg)

120
Q

Which is the implication of a total body potassium loss in a Hyperglycemic Hyperosmolar State?

A

Insulin therapy→abruptly decrease K+ - severe hypokalemia

*K+ reposition during initial insulin therapy

121
Q

Colonoscopy recommendations for colon cancer screening in inflammatory bowel disease

A
  • 8-10 years after diagnosis (12-15 years if only left colon)
  • Repeat every 1-3 years
122
Q

Colonoscopy recommendation for colon cancer screening in lynch syndrome (HNPCC)

A
  • Age 20-25 years

- Repeat every 1-2 years

123
Q

Colonoscopy recommendations for colon cancer screening in classic familial adenomatous polyposis

A
  • Age 10-12 years

- Repeat anually

124
Q

Colonoscopy recommendations for colon cancer screening family history of adenomatous polyps or CRC

A
  • Age 40 or 10 years before the age of diagnosis of the relative
  • Repeat every 5 years
125
Q

Kartagener syndrome screening test

A

Decreased nasal nitric oxide

126
Q

Most common cause of endocarditis in a patient with associated nosocomial urinary tract infection

A

Enterocci species, Ex Enterococcus faecalis

*Recent instrumentation can yield the bacteremia

127
Q

Which germs that cause endocarditis or bacteremia are associated with colon pathology? What test you should perform?

A
  • Clostridium septicum>Streptococcus bovis
  • Perform colonoscopy➡rule out colon cancer

*Tumor cells undergo anaerobic glycolysis➡adequate environment for C. septicum spores germination; damage colonic mucosa➡bacteria translocation into bloodstream

128
Q

How do you treat endocarditis secondary to staphylococcus aureus on a protestic valve?

A

Oxacilin, Nafcilin or Cefazolin + Rifampin for 6 weeks

129
Q

Strongest indication of surgery in acute endocarditis

A

Acute valve rupture and congestive heart failure

130
Q

Most common bacteria causing endocarditis when culture is negative

A
  • Coxiella

- Bartonella

131
Q

Pathognomonic sign of syphilis

A

Epitrochlear lymphadenopathy→2-handed “sailor’s handshake”

132
Q

When do you consider an adequate or successful treatment of syphilis?

A

4-fold decrease in serologic titers at 6-12 months

133
Q

What is the endemic typhus? Clinical presentation.

A

Louse-borne rickettsial infection→abrupt onset of fever, severe headache, malaise and centrifugally-spreading macular or maculopapular rash (sparing palms and soles)

134
Q

How is the rash of the Rocky Mountain spotted fever?

A

Maculopapular rash that spreads centripetally toward the trunk. Includes palms and soles. Petechial over time.

135
Q

Treatment of tertiary syphilis

A

Intravenous Penicillin for 10-14 days

*Desensitize if penicillin allergy

136
Q

What must you do with a pregnant woman with syphilis or a patient with neurosyphilis to treat them?

A

Penicillin desensitization

137
Q

What is the long-term outcome of nonalcoholic fatty liver disease (NAFLD)?

A
  • Hepatic Fibrosis 40%

- Cirrhosis 10-15%

138
Q

Since hepatic steatosis is similar between NAFLD and alcoholic liver diseases, how can you differentiate both?

A
  • NAFLD→AST/ALT ratio <1
  • Alcoholic liver disease→AST/ALT ratio 2:1

*Off course ask for severe alcohol exposition

139
Q

Extrarenal complications of autosomal dominant polycystic kidney disease. What is the most common?

A
  1. Hepatic cyst
  2. Intracranial berry aneurysm (5-15%)
  3. Valvular heart disease (most often mitral valve prolapse and mitral regurgitation)
  4. Colonic diverticula
  5. Abdominal wall and inguinal hernia
140
Q

Treatment for anticholinergic toxicity

A

Physostigmine►cholinesterase inhibitor

141
Q

Most common sources of exposure for cyanide intoxication

A
  • Dermal: partial immersion in liquid cyanide or cyanide solutions or contact with molten cyanide salts
  • Inhalational: Hydrogen cyanide, product of combustion from nitrogen-containing synthetic polymers (foam, cotton, paint, silk, etc)►Faster onset of symptoms
  • Intestinal: ingestion of amygdalin (cyanogenic glucoside in apricot seeds), cyanide directly
142
Q

Which empiric treatment should be done in unconscious victims of smoke inhalation?

A

Cyanide toxicity→Hydroxicobalamin►forms Cyanocobalamin; Sodium thiosulfate or Nitrites►induce methemoglobinemia

*Prevent cardiorespiratory arrest and permanent neurologic disability

143
Q

Two major products of combustion in closed spaces

A

Hydrogen cyanide (HCN) and Carbon monoxide (CO)

144
Q

Best initial management of altered mental status of unclear etiology (suspecting intoxication)

A
  • Opiate antagonist→Naloxone (give immediately, opiate overdose is fatal)
  • Dextrose
145
Q

Keys on clinical presentation to diagnose aspirin overdose

A
  • Tinnitus and hyperventilation
  • Respiratory alcalosis
  • Metabolic acidosis with ↑ Lactate
146
Q

Best initial test when suspect tricyclic antidepressant toxicity and why?

A

EKG➡look for cardiac toxicity

  • Widening of the QRS complex➡⬆risk ventricular arrhythmia
  • Prolongs QT→Torsade de Pointes
147
Q

Severe symptoms of carbon monoxide poisoning and most appropriate treatment

A
  • Severity: CNS symptoms, Cardiac symptoms, Metabolic acidosis
  • Treatment: Hyperbaric oxygen

*No severe treat with 100% Oxygen

148
Q

Best initial and most effective therapy for Methemoglobinemia

A
  • Best initial: 100% Oxygen

- Most Effective: Methylene blue (↓ half-life)

149
Q

Treatment for Lead poisoning

A
  • Oral: Succimer

- Parenteral: Ethylenediaminetetraacetic acid (EDTA) and dimercaprol (BAL)

150
Q

Most accurate test and best initial test for Lead poisoning

A
  • Most accurate: Lead level

- Best initial: Level of free erythrocyte protoporphyrin

151
Q

Describe the clinical presentation and lesions of pityriasis rosea

A
  • Viral prodrome: headache, malaise, fever.
  • Lesions: First herald patch→erythematous annular lesion, scaly around edge. In 1 week→clusters of small, scaly, erythematous oval lesions on the trunk in “Christmas tree” pattern (back). Mild pruritus.
152
Q

Best initial test and their results when suspect idiopathic intracranial hypertension

A
  • MRI→Normal or empty sella (70%)
  • MRV→Normal
  • Lumbar puncture→Opening pressure >250 mmH2O
153
Q

Risk factors for splenic infarction

A
  • Hypercoagulable disorder
  • Source of embolic disease (atrial fibrillation)
  • Myeloproliferative neoplasm
  • Hemoglobinopathy (sickle cell disease)
154
Q

Most probable diagnosis in a patient with chest/back pain, fever, vomiting and pleural effusion. Most common etiologies.

A

Esophageal perforation or rupture

  • Effort rupture (ex, self-induced vomiting, Boerhaave syndrome)
  • Instrumentation (ex, endoscopy), trauma
  • Esophagitis (infection, pills, caustic)
155
Q

Best diagnostic test for esophageal perforation and expected finding

A

Esophagography or CT scan with water-soluble contrast (no barium, it is inflammatory)→Leak from perforation

156
Q

Diagnosis of Hepatitis C Virus chronic infection

A
  • Hepatitis C virus antibody→Positive serology

- HCV PCR→confirmatory molecular test (Do this because HCV may clear in up to half of patients)

157
Q

What is “Lone Atrial Fibrilation”? Treatment.

A
  • Paroxysmal, persistent or permanent AF + No evidence of cardiopulmonary or structural heart disease
  • Usually <60 years, CHA2DS2VASc=0→No treatment needed
158
Q

Most common cause of megaloblastic anemia in chronic alcoholics

A

Folate deficiency

*Alcohol impair enterohepatic cycle and absorption of folate, may develop anemia in 5-10 wks (body stores are limited)

159
Q

Which types of acid-base disorder may cause acute kidney injury and why?

A
  • Non-anion gap metabolic acidosis⇦impaired acid excretion, ammonia generation or bicarbonate reabsorption
  • Anion gap metabolic acidosis⇦retention of unmeasured uremic toxins
160
Q

COPD patient with acute-on-chronic respiratory acidosis

A

Hypoventilation→CO2 narcosis

161
Q

Typical MRI/CT finding of high-grade (ex, IV grade) astrocytoma (glioblastoma)

A

Butterfly appearance with central necrosis, heterogenous serpiginous contrast enhancement

162
Q

Diseases associated with erythema nodosum

A
  • Streptococcal infection
  • Sarcoidosis
  • Tuberculosis
  • Endemic fungal disease (Histoplasmosis)
  • Inflammatory Bowel Disease
  • Behcet Disease
163
Q

Therapy for hemodynamically stable atrial fibrillation with rapid ventricular response

A

Beta blockers, Calcium channel blockers (Diltiazem), Digoxin

164
Q

How do you identify by auscultation the tricuspid valve compromised by infective endocarditis? Why?

A
  • Tricuspid valve endocarditis (Regurgitation)→⇧holosystolic murmur with inspiration (differentiates right sided murmurs from all others)→Carvallo’s sign
  • ↑Venous blood flow on inspiration→↑stroke volume of right ventricle in systole→↑blood from right ventricle to the right atrium
165
Q

Measure of aortic valve area on echocardiogram to cause left ventricular hypertrophy and symptoms of angina

A

Aortic valve area<1cm2→severe stenosis

166
Q

Measure of aortic valve area to diagnose aortic stenosis

A

Valve area<3cm2

167
Q

When do you suspect Renovascular Hypertension?

A

Patients with resistant hypertension and:

  • Diffuse atherosclerosis
  • Asymmetric kidney size
  • Recurrent flash pulmonary edema
  • ↑Creatinine >30% from baseline after initiate ACEI or ARB’s
  • Continuous abdominal bruit (high specificity)
168
Q

Auscultations findings of severe mitral regurgitation

A
  • Blowing and high-pitched holosystolic murmur at the apex
  • S3 gallop→sudden cessation of blood flow into dilated LV during filling phase of diastole

*Absence of S3 helps rule out severe chronic MR

169
Q

Effect of brussels sprouts, broccoli and green tea on warfarin

A

↓Effect→↑Thrombosis risk NO bleeding risk

170
Q

Effect of acetaminophen on warfarin

A

↑Effect→↑Bleeding risk

171
Q

Signs and symptoms of malignant hyperthermia

A
  • Hypercarbia (↑cell metabolism)→Tachypnea
  • Sinus tachycardia
  • Masseter/generalized muscle rigidity
  • Myoglobinuria (rhabdomyolysis)
  • Hyperthermia→later manifestation, not usually present initially
172
Q

Cause of malignant hyperthermia

A

Autosomal dominant or sporadic skeletal muscle receptor disorder→excessive calcium release→sustained muscle contraction

*Triggered by volatile anesthetics, succinylcholine, excessive heat

173
Q

Neuropsychiatric manifestations of Wilson disease

A
  • Psychiatric→Depression, personality changes, psychosis, mania, anxiety
  • Neurologic→parkinsonism, dysarthria, choreoathetosis, ataxia
174
Q

Risk factors of Multiple Sclerosis

A
  • Female, caucasian, HLA-DRB1
  • Location: USA, Europe, cold climate
  • Low Vitamin D levels
  • Smoking
  • EBV
175
Q

Most common cause of mitral and aortic stenosis

A
  • Mitral stenosis→rheumatic fever (most common immigrants in USA)
  • Aortic stenosis→congenital bicuspid valve or calcification by aging
176
Q

Treatment of mitral and aortic stenosis

A
  • Mitral stenosis→dilation through balloon valvuloplasty with catheter
  • Valve replacement when ballon cannot be done or fails
  • Aortic stenosis→surgical replacement
177
Q

Unique features of mitral stenosis clinical presentation

A

Dysphagia, Hoarseness, Atrial fibrilation (stroke) [Big LA], Hemoptisis

178
Q

Etiology of Mitral Regurgitation

A
  • Any reason that dilated the heart
  • Hypertension
  • Endocarditis
  • MI with papillary muscle rupture
179
Q

First line of treatment of regurgitant lesions (mitral and aortic regurgitation)

A

Vasodilators: ACEIs or ARBs or nifedipine→delay the progression

180
Q

Valve replacement indication for mitral regurgitation

A

When heart starts to dilate→LVESD>40mm or EF<60% *Operatively or with catheter placing a clip or sutures

181
Q

Most common presentation of mitral valve prolapse

A

Atypical chest pain, palpitations and panic attack

182
Q

Heart compensatory mechanisms of the asymptomatic phase of chronic volume overload (AR, MR, Ischemic disease, dilated cardiomyopathy)

A

Eccentric hypertrophy→↑Left ventricle compliance (have additional LV volume) and ↑Left ventricle contractility (sustain stroke volume)

183
Q

Most common cause of sick sinus syndrome

A

Age-related degeneration of the cardiac conduction system→fibrosis of the sinus node

184
Q

ECG findings of sick sinus syndrome

A
  • Sinus bradycardia
  • Sinus pauses (delayed P waves)
  • Sinoatrial nodal exit block (dropped P waves)
185
Q

Clinical presentation of sick sinus syndrome

A
  • Bradycardia→fatigue, dyspnea, dizziness, syncope
  • Palpitations:
    +Bradycardia-tachycardia syndrome→bradycardia alternating with supraventricular tachycardia
    +Atrial arrhythmias (ex, atrial fibrillation)
186
Q

Most common arrhythmia on hyperthyroidism and its treatment

A
  • Thyroid hormone ↑beta-adrenergic receptor expression ↑sympathetic activity→Atrial fibrillation (5-15%)
  • Beta-blockers (propranolol, atenolol)→continue until hyperthyroidism is well treated
187
Q

Pathologic causes of sinus bradycardia

A

Sick sinus syndrome, myocardial ischemia, obstructive sleep apnea, hypothyroidism, ↑intracranial pressure, medications (b-blockers, CCB excess)

188
Q

Best initial therapy for hypertrophic obstructive cardiomyopathy and ordinary hypertrophic cardiomyopathy

A

Beta-blockers

*Strong negative inotropic drugs are useful - Verapamil, Disopyramide

189
Q

Contraindicated medications in HOCM

A

Diuretics, ACEIs do not help (may worsen symptoms), digoxin, hydralazine

*Diuretics may help in ordinary hypertrophic cardiomyopathy symptoms

190
Q

Distinctive feature of chronic constrictive pericarditis

A

Chronic pericarditis→fibrosis and calcification of pericardium►Calcification on x-ray (Best initial test)

191
Q

Presumed etiology of idiopathic pericarditis

A

Coxsackie B virus

192
Q

Treatment of idiopathic pericarditis

A

NSAID and colchicine

193
Q

What is the Kussmaul sign and when it is most likely associated?

A
  • ↑JVD on inhalation (normally neck veins go down on inspiration)
  • Constrictive pericarditis
194
Q

Most appropriate study for pericardial tamponade

A

Echocardiogram→right atrial and ventricular diastolic collapse

195
Q

EKG findings on pericadial tamponade

A

Electrical alternans→different heights of QRS complexes between beats

196
Q

Best initial test for aortic dissection

A

Chest x-ray→widening of the mediastinum

*Source MTB2

197
Q

Screening test and indication for aortic aneurysm

A

Men who ever smoked >65 years with ultrasound

198
Q

What is peripartum cardiomyopathy? In which stage during pregnancy is most commonly developed?

A
  • LV dysfunction secondary to antibodies against the myocardium in a pregnant woman
  • After delivery in most cases
199
Q

Best initial test for hemodynamically stable and unstable patients in those who suspect aortic dissection

A
  • Stable→CT angiography, MRA if contrast is contraindicated
  • Unstable→Transesophageal echocardiogram

*Source First aid 2CK

200
Q

Differences between the treatment of the type A and B aortic dissection

A
  • Type A (ascending)→proximal to left subclavian artery (may involve descending aorta)►all patients should have surgery
  • Type B (descending)→distal to left subclavian artery (no involve ascending aorta)►BP, heart rate control; surgery if leakage, rupture, or compromised organs

Internal Medicine Flash Cards (3 decks)

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