Case Files Internal Medcine

Question 1

The Equation for Cardiac Index

Average cardiac Index as a percentage of CO. Actual Number?

Answer 1

CI = CO/BSA

In the average-sized adult, the cardiac index is about 60% of the cardiac output, and the
normal range is 2.4–4 L/min/m2.

Question 2

Goals of Submaximal exercise stress testing in a patient that has had recent MI. Patient population, signs on exam?

Answer 2

generally performed in stable
patients before hospital discharge to detect residual ischemia and ventricular ectopy
and to provide a guideline for exercise in the early recovery period

Question 3

Post- Stemi patients Post-STEMI patients with LV dysfunction
(LV ejection fraction = ? ) are at increased risk of?

How can this be prevented?

Answer 3

sudden cardiac death from
ventricular arrhythmias

placement of an implantable cardioverter-
defibrillator (ICD).

Question 4

New York heart association Classification of Heart Failure

Class I, II, III, IV?

Answer 4

Class I: No limitation during ordinary physical activity

Class II: Slight limitation of physical activity. Develops fatigue or dyspnea with moderate exertion

Class III: Marked limitation of physical activity. Even light activity produces symptoms

Class IV: Symptoms at rest. Any activity causes worsening

Question 5

Patient that get the most benefit from the addition of spirolactone to there Heart Failure treatment regimens?

Which CHF patient can benefit for the use of Bi-ventricular pacing

Answer 5

patients with NYHA class III or IV heart
failure with persistent symptoms

Patients with depressed ejection fraction (EF) and advanced
symptoms often have a widened QRS >120 ms indicating dyssynchronous ventricular
contraction

Question 6

Definition of Severe aortic stenosis? Valve? gradients?

Answer 6

Severe aortic stenosis often has valve areas less than 1 cm2 (normal 3-4 cm2) and
mean pressure gradients more than 40 mm Hg.

Question 7

what are the two most prognostic factor for failure to convert from Afib?

Answer 7

left atrial dilation (atrial diameter

>4.5 cm predicts failure of cardioversion) and duration of AF.

Question 8

What is done with patient that have been in Afib for the more than 24 hours and need to be cardioverted.

What about people with lower risk? Anticoagultion in this people

Answer 8

patients should receive 3 to 4 weeks of
warfarin therapy prior to and after cardioversion to reduce the risk of thromboembolic event

low-risk patients can undergo transesophageal echocardiography
to exclude the presence of an atrial appendage thrombus prior to cardioversion.
Postcardioversion anticoagulation is still required for 4 weeks,

Question 9

Definiton in the CHADS2 score

Drug that can be used in chemical cardioversion in WPW

Drugs that should be avoided?

Answer 9

(CHF, Hypertension, Age ≥ 75, Diabetes, Stroke or
transient ischemic attack history)

Procanimide

Av Nodal blocking agents like CCB or BB

Question 10

Definition of Functional Dyspepsia

Answer 10

Symptoms as described for dyspepsia,

persisting for at least 12 weeks but without evidence of ulcer on endoscopy

Question 11

Classic Presentation of Duodenal ulcers Timing? Length of Symptom?

Why must gastric Ulcer undergo endoscopy?

Answer 11

typically produced after the stomach is
emptied but food-stimulated acid production still persists, typically 2 to 5 hours after
a meal. They may awaken patients at night, when circadian rhythms increase acid
production. The pain is typically relieved within minutes by neutralization of acid
by food or antacids

Five percent to 10% of gastric ulcers are malignant

Question 12

What population of patient must be immediate worked up with endoscopy for the r/o of Gastric Cancer

Alarm Symptoms? Heme? UGI? LGI?

What is done with patients that have failed to response to empiric therapy?

Answer 12

patients older than 45 years who present with new-onset dyspepsia should generally
undergo endoscopy.

weight
loss, recurrent vomiting, dysphagia, evidence of GI bleeding, or iron-deficiency anemia)

They should have endoscopy

Question 13

Standard triple therapy for H. Pylori

Answer 13

combination antibiotic regimen for
14 days and acid suppression with a proton-pump inhibitor or H2-blocker. Several
different regimens are used, such as omeprazole plus clarithromycin, plus metronidazole
or amoxicillin

Question 14

What can be done with a patient that has no alarms symptoms, has a PMH of ulcers, and has new onset dyspepsia.

What is the first step to the dx of zollinger ellison syndrome? Labs?

Answer 14

antibiotic treatment may be considered, but
a follow-up visit is recommended within 4 to 8 weeks. If symptoms persist or alarm
features develop, then prompt upper endoscopy is indicated

syndrome, the first step
is to measure a fasting gastrin level, which may be markedly elevated (>1000 pg/mL),
and then try to localize the tumor with an imaging study

Question 15

Causes of Hypovolemic Hyponatremia with a UNa >20

Renal? Medication? Neuro? Endo?

Answer 15

Renal losses
Diuretic excess
Mineral corticoid deficiency
Salt-losing deficiency
Bicarbonaturia with
renal tubal acidosis and
metabolic alkalosis
Ketonuria
Osmotic diuresis
Cerebral salt wasting
syndrome

Question 16

Causes of Hypovolemic Hyponatremia with a UNa

Answer 16

Extrarenal losses
Vomiting, Diarrhea, Third spacing of fluids
Burns
Pancreatitis
Trauma

Question 17

Causes of Euvolemic Hyponatremia
Endo? Medication? Endo/Renal?

What will be the urine sodium level in most cases?

Answer 17

Glucocorticoid deficiency
Hypothyroidism
Stress
Drugs
Syndrome of inappropriate
antidiuretic hormone
secretion

It will be greater than 20 as the patient have a mild natereis

Question 18

Cause of Hypervolemic Hyponatriema when UNA > 20?

Less than 20

Answer 18

Acute or chronic
renal failure

Nephrotic syndrome
Cirrhosis
Cardiac failure

Question 19

Treatment for Hypovolemic Hyponatriema

Workup for Euvolemic Hyponatermia? Urine studies? interpretation?

Answer 19

correction of the volume status, usually replacement with isotonic (0.9%) saline.

urine osmolality
should be maximally dilute, 150-200 mOsm/kg).

Question 20

Lab finding in SIADH? Urine and BMP

treatment?

What if there are severe Neurological symptoms

How can this treatment be changed if there is concern for volume overload?

Answer 20

urine that is not maximally dilute (osmolality >150-200 mOsm/L), urine sodium more than 20 mmol/L; BUN and low uric acid levels

Water Restriction.

correction of the sodium level with hypertonic saline.

When there is concern that the saline infusion might cause volume
overload, the infusion can be administered with a loop diuretic such as furosemide.

Question 21

What is the maximal rate that longstanding hyponatermia can be corrected?

Answer 21

serum sodium concentration should correct no faster than 0.5-1 mEq/h.

Question 22

CLINICAL MANIFESTATION OF AORTIC DISSECTION

Cause of Horner’s Syndrome

MI?

Hemopericardium, pericardial tamponade?

Aortic regurgitation

Bowel ischemia, hematuria?

Hemiplegia?

Answer 22

Compression of the superior cervical ganglion

Compression of the superior cervical ganglion

MI: Occlusion of coronary artery ostia

Hemopericardium: Thoracic dissection with retrograde flow into the
pericardium

Aortic regurgitation: Thoracic dissection involving the aortic root

Dissection involving the mesenteric arteries or renal
arteries

Hemiplegia: Carotid artery involvement

Question 23

What is the CD4 count in a normal immunocompetent adult

How long can the latent period of HIV last, on average

How is LDH useful in the dx of PCP

Answer 23

Normal CD4 levels in adults range from 600 to
1500 cells/mm3.

8 to 10 years

patients with an LDH level less than 220 IU/L are very unlikely
to have PCP

Question 24

Which patient quality for the use of predinsone for the tx PCP? Resp and Labs?

what can be used for abx therapy if the patient is allergic to sulfa medication in PCP

Answer 24

Patients with arterial PO2 less than 70 mm Hg or
A-a gradient less than 35 mm Hg

Patients who are allergic to sulfa can be treated with alternative regimens,
including pentamidine or clindamycin with primaquine

Question 25

Why is TB infection less likely to lead to hypoxia compared to other lung infections What other species of Bacteria can lead to a presentation similar to TB in HIV patients

Answer 25

TB involves both the alveoli and the pulmonary circulation, patients with TB rarely are hypoxic with minimal infiltrate ( no V/Q mismatch) M kansasii can cause pulmonary disease and radiographic findings identical to those of M tuberculosis

Question 26

What other disease must be considered in an HIV patient that has a mass lesion or if the lesions do not regress after 2 weeks of empiric toxoplasmosis therapy with sulfadiazine with pyrimethamine ? How is the dx confirmed? DNA test?

Answer 26

CNS lymphoma With stereotactic brain biopsy; or with Epstein-Barr virus DNA is a useful strategy because it is present in more than 90% of patients with CNS lymphoma

Question 27

How can crytoccal mengitis in a HIV patient be confirmed? What are the findings on CSF? Tx?

Answer 27

cryptococcal infection by a serum cryptococcal antigen or perform a lumbar puncture normal white blood cell [WBC] count), but the patient often presents with elevated intracranial pressures Induction with intravenous amphotericin B plus flucytosine, then chronic suppression with oral fluconazole

Question 28

CMV tends to effect patient with AIDS at what CD4 count? Presenting symptoms? General? Neuro? GI? Endo? TX?

Question 29

Treatment for MAC in the Context of AIDS?

Answer 29

Clarithromycin, ethambutol, and | rifabutin is required for weeks in an attempt to clear the bacteremia.

Question 30

When is toxoplasma for AIDS patients needed? and what is the drug used MAC? Components of HAART therapy

Answer 30

100 cells/mm3; toxoplasmosis can be prevented with daily dosing of TMP-SMX. If CD4 levels are less than 50 cells/ mm3, MAC prophylaxis consists of clarithromycin 500 mg twice daily or azithromycin 1200 mg weekly. At Least three drugs often consisting of two nucleoside reverse transcriptase inhibitors, along with either a nonnucleoside reverse transcriptase inhibitor or a protease inhibitor

Question 31

Examples of End organ damage in the context of HTN emergency include... Range were the brain is capable of autoregulating is cerebral blood flow. Events on a cellular level in the brain vasculature that occur when a patient is hypertensive, and exceded the brain ability to autoregulate Clincial Manifestations

Answer 31

hypertensive encephalopathy, myocardial ischemia or infarction associated with markedly elevated blood pressure, aortic dissection, stroke, declining renal function with proteinuria, and pulmonary edema secondary to acute left ventricular failure. Between 60 and 120 mmHg there is cerebrovascular endothelial dysfunction and increased permeability of the blood-brain barrier, leading to vasogenic edema and the formation of micro-hemorrhages. Patients then manifest symptoms of hypertensive encephalopathy, such as lethargy, confusion, headaches,

Question 32

How long does it take for the administration of Sodium Nitroprusside before the efffect of Cyanide toxicity set it. If a suspected Pheocytocytoma is not located at the adrenal medulla, what test can be used to located the neoplasm

Answer 32

However, its metabolite may accumulate, resulting in cyanide or thiocyanate toxicity when it is given for more than 2 to 3 days. scintigraphic localization with 123I-metaiodobenzylguanidine (123I-MIBG) or an octreotide (somatostatin-analogue) scan is indicated, because this radioisotope is preferentially taken up in catecholamine-producing tumors.

Question 33

for patient that will have there pheochromocytoma removed, must hey be premedicated with and why? What family Gene mutations are associated with pheochromocytoma?

Answer 33

Alpha-adrenergic blocking agents, such as phenoxybenzamine, an irreversible, long-acting agent, started a week prior to surgery help to prevent hypertensive exacerbations, which are especially worrisome during surgery. II (MEN II) or the VHL gene for von Hippel- Lindau syndrome

Question 34

Definition of Primary Amenorrhea? Secondary? OLIGOMENORRHEA?

Answer 34

Absence of menarche by the age of 16 years regardless of the presence or absence of secondary sex characteristics. Secondary—Absence of menstruation for 3 or more months in women with normal past menses. Menses occurring at infrequent intervals of more than 40 days or fewer than nine menses per year.

Question 35

If Sheehan Syndrome if suspected in a patient was test would be diagnostic? CV signs in hypothyroidism?, Signs in the hands? Neuro GI?

Answer 35

magnetic resonance imaging (MRI) enlarged heart, nonmechanical intestinal obstruction (ileus), and a delayed relaxation phase of their deep tendon reflexes

Question 36

Interpretation and Utility of the free thyroxine index (FTI)?

Answer 36

The FTI is calculated from measurements of total T4 and the T3 resin uptake test. When there is excess thyroid-binding globulin (TBG), as in pregnancy or oral contraceptive use, T4 levels will be high (as a consequence of the large amount of carrier protein), but T3 uptake will be low (value varies inversely with amount of TBG present). Conversely, when there is a low level of TBG, as in a hypoproteinemic patient with nephrotic syndrome, the T4 level will necessarily also be low (not much carrier protein), but the T3 uptake will be high. If both total T4 and T3 uptake are low, the FTI is low, and the patient is hypothyroid.

Question 37

Definition of Subclinical Hypothyroidism how many of these patient will have true hypothyroidsim in five years? Half life of levothyroxine Dosing? in old people/ cardiac disease

Answer 37

TSH level is mildly elevated (4-10 mU/L), but the free T4 or FTI is within the normal range. 50% 6-7 days 1.6 μg/kg, or typically 100 to 150 μg/ 25 to 50 μg/d, in old people or people with cardiac disease.

Question 38

Definition of Chronic Hepatitis What percent of people with Hep C will develop chronic hepatitis in 10 years Serum-ascites albumin gradient = ?

Answer 38

Evidence of hepatic inflammation and necrosis for at least 6 months. 70-80 percent Serum-ascites albumin gradient = serum albumin − ascitic albumin

Question 39

DIFFERENTIAL DIAGNOSIS OF ASCITES BASED ON SAAG Definition of a high gradiant and ddx GI? CV?

Answer 39

High gradient >1.1 g/dL = Portal HTN ``` Cirrhosis • Portal vein thrombosis • Budd-Chiari syndrome • Congestive heart failure • Constrictive pericarditis ```

Question 40

DIFFERENTIAL DIAGNOSIS OF ASCITES BASED ON SAAG Definition of a low gradient and ddx ID? GI? CV? Rhem? Renal?

Answer 40

Low gradient

Question 41

RANSON CRITERIA Initial?

Answer 41

``` Initial • Age >55 years • WBC >16,000/mm3 • Serum glucose >200 • Serum lactate dehydrogenase (LDH) >350 IU/L • AST >250 IU/L ```

Question 42

RANSON CRITERIA 48 hours?

Answer 42

``` Within 48 hours of admission • Hematocrit drop >10 points • Blood urea nitrogen (BUN) rise >5 mg/dL after intravenous hydration • Arterial Po2 4 mEq/L • Estimated fluid sequestration of >6 L ```

Question 43

Drugs that can cause pancreatitis?

Answer 43

the antiretroviral didanosine [DDI], pentamidine, thiazides, furosemide, sulfonamides, azathioprine, L-asparaginase

Question 44

Phelgmon definition? Risk associated with the presence of the phelgmon? time course of the development of pancreatic abscess? Warning signs?

Answer 44

solid mass of inflamed pancreas, often with patchy areas of necrosis extensive areas of pancreatic necrosis develop within a phlegmon. Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis

Question 45

Time course for the resolution of Pseudocyst

Answer 45

resolve spontaneously within 6 weeks, especially | if they are smaller than 6 cm.

Question 46

Steroid taper in the treatement of IBD (moderate to severe) Treatment for Toxic megacolon Supportive, Medications? Definitive.

Answer 46

6 to 8 weeks Therapy is designed to reduce the chance of perforation and includes IV fluids, nasogastric tube placed to suction, and placing the patient NPO (nothing by mouth). Additionally, IV antibiotics are given in anticipation of possible perforation, and IV steroids are given to reduce inflammation. Surgery

Question 47

Medications that are capable of causing Tubulointerstitial nephritis? Infections?

Answer 47

Medications (cephalosporins, methicillin, rifampin) | Infection (pyelonephritis, HIV)

Question 48

Common causes are acute pericarditis? Idiopatic?, ID? CV? Autoimmune? Metabolic? Trauma? Cx?

Answer 48

Idiopathic pericarditis: specific diagnosis unidentified, presumably either viral or autoimmune and requires no specific management Infectious: viral, bacterial, tuberculous, parasitic Vasculitis: autoimmune diseases, postradiation therapy Hypersensitivity/immunologic reactions, eg, Dressler syndrome Diseases of contiguous structures, eg, during transmural myocardial infarction Metabolic disease, eg, uremia, Gaucher disease Trauma: penetrating or nonpenetrating chest injury Neoplasms: usually thoracic malignancies such as breast, lung, or lymphoma

Question 49

Components of pericaridal friction rub? Treatment for symptomatic idiopathic pericarditis? if they have refractory symptoms? length of symptoms?

Answer 49

presystolic (correlating with atrial systole), systolic, and diastolic. The large majority of rubs are triphasic (all three components) or biphasic, having a systolic and either an early or late diastolic component aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as indomethacin, for relief of chest pain. Colchicine or corticosteroids may be used for refractory symptoms symptoms typically resolve within days to 2 to 3 weeks.

Question 50

change in the EKG that are presents in Percariditis but not MI Vice Versa?

Answer 50

PR-segment depression Loss of R-wave amplitude and development of Q waves, ST-segment depression inferiorly with anterior ischemia.

Question 51

Diagnostic Criteria for SLE ``` Derm? Light? Mucosal? CT? Serositis? Renal Neuro? Hemo? Immune Markers? ```

Answer 51

Malar rash: fixed erythema, flat or raised over the malar area, that tends to spare nasolabial folds Discoid rash: erythematous raised patches with adherent keratotic scaling and follicular plugging Photosensitivity: skin rash as a result of exposure to sunlight Oral or vaginal ulcers: usually painless Arthritis: nonerosive, involving two or more peripheral joints with tenderness, swelling, and effusion Serositis: usually pleuritis or pericarditis Renal involvement: persistent proteinuria or cellular casts Neurologic disorder: seizure or psychosis Hematologic disorder: hemolytic anemia or leukopenia (

Question 52

Treatment of Renal Disease in Lupus?

Answer 52

high-dose corticosteroids or cyclophosphamide

Question 53

SEROLOGIC MARKERS OF GLOMERULONEPHRITIS ``` Complement Levels? ANCAs? ANA? Antibasement membrane Antibody levels? ASO? Blood Cultures Cryoglobulins Hepatitis Serologies? ```

Answer 53

Complement levels (C3, C4): low in complement-mediated GN (SLE, MPGN, infective endocarditis, poststreptococcal/postinfectious GN, cryoglobulin-induced GN) Antineutrophil cytoplasmic antibody levels (p-ANCA and c-ANCA): c-ANCA positive in Wegener, p-ANCA positive in microscopic polyangiitis and Churg–Strauss ANA: positive in SLE (anti-dsDNA, anti-Smith) Antiglomerular basement membrane (anti-GBM) antibody levels: positive in anti-GBM GN and Goodpasture ASO titers: elevated in poststreptococcal GN Blood cultures: positive in infective endocarditis Cryoglobulin titers: positive in cryoglobulin-induced GN Hepatitis serologies: hepatitis C and hepatitis B associated with cryo-induced GN

Question 54

Difference between IgA nephropathy and PSGN in presentation Complement levels? Biospy

Answer 54

In poststreptococcal GN (PSGN), the glomerulonephritis typically does not set in until several weeks after the initial infection. In contrast, IgA nephropathy may present with pharyngitis and glomerulonephritis at the same time. In addition, PSGN classically presents with hypocomplementemia, and if the patient undergoes a renal biopsy there is evidence of an immune complex-mediated process. In contrast, IgA nephropathy has normal complement levels and negative ASO titer (IgA levels may be elevated in about a third of patients, but this is nonspecific) and the renal biopsy will show mesangial IgA.

Question 55

Treatment for ANCA induced GN? Antibody mediated GN? poststreptococcal GN? IgA nephropathy?

Answer 55

steroids and cyclophosphamide Plasmapheresis Antihypertensives and edema control for several weeks? ACE inhibitors, fish oils, and steroids have all been used.

Question 56

labs for working up the ddx for new onset nephrotic syndrome. Other Causes? Meds? Ingestion? Genes

Answer 56

include serum glucose and glycosylated hemoglobin levels to evaluate for diabetes, antinuclear antibody (ANA) to screen for systemic lupus erythematosus, serum and urine protein electrophoresis to look for multiple myeloma or amyloidosis, and viral serologies, because HIV and viral hepatitis can cause nephrosis. medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), heavy metals such as mercury, and hereditary renal conditions.

Question 57

Fluid and electrolyte management in Nephrotic Syndrome. Meds? Diet? Defs, in the context of nephrotic syndrome

Answer 57

medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), heavy metals such as mercury, and hereditary renal conditions. protein restriction usually is recommended. It is thought that high-protein intake only causes heavier proteinuria hypogammaglobulinemia with increased infection risk (especially pneumococcal infection), iron deficiency anemia caused by hypotransferrinemia, and vitamin D deficiency because of loss of vitamin D–binding protein

Question 58

Definition of microalbuminuria Overt nephropathy?

Answer 58

urine albumin excretion between 30 and 300 mg/d. When albuminuria exceeds 300 mg/d, it is detectable on ordinary urine dipsticks (macroalbuminuria), and the patient is said to have overt nephropathy. After the development of

Question 59

How does asymptomatic hyperuricemia relate to the presentation of Gout Symptoms and presentation of Acute gouty arthritis Timing, location, General ROS? Length of time?

Answer 59

The majority of patients with hyperuricemia never develop any symptoms, but the higher the uric acid level and the longer the duration of hyperuricemia, the greater the likelihood of the patient developing gouty arthritis. occurring at night, in the first MTP joint, ankle, or knee, with rapid development of joint swelling and erythema and sometimes associated with systemic symptoms such as fever and chills. Attacks may last hours or up to 2 weeks.

Question 60

Definition of intercritical gout. When will the people have another attack Sign effects of Colchcine Class of patient in which NSAIDs and colchicine may be contraindicated? Alternative therapy

Answer 60

the period between acute attacks were the patient is completely asymptomatic. However, 60% to 70% of patients will have another acute attack within 1 to 2 years. nausea and diarrhea Individuals affected by acute joint pain with renal insufficiency intraarticular glucocorticoid injection or oral steroid therapy

Question 61

What should the uric acid levels be lower to in intercritical gout. When is surgery indicated for Gout

Answer 61

6.0 mg/dl Surgery may be indicated if the mass effect of tophi causes nerve compression, joint deformity, or chronic skin ulceration with resultant infection