Case Files Internal Medcine Flashcards
The Equation for Cardiac Index
Average cardiac Index as a percentage of CO. Actual Number?
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.
Goals of Submaximal exercise stress testing in a patient that has had recent MI. Patient population, signs on exam?
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
Post- Stemi patients Post-STEMI patients with LV dysfunction
(LV ejection fraction = ? ) are at increased risk of?
How can this be prevented?
sudden cardiac death from
ventricular arrhythmias
placement of an implantable cardioverter-
defibrillator (ICD).
New York heart association Classification of Heart Failure
Class I, II, III, IV?
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
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
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
Definition of Severe aortic stenosis? Valve? gradients?
Severe aortic stenosis often has valve areas less than 1 cm2 (normal 3-4 cm2) and
mean pressure gradients more than 40 mm Hg.
what are the two most prognostic factor for failure to convert from Afib?
left atrial dilation (atrial diameter
>4.5 cm predicts failure of cardioversion) and duration of AF.
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
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,
Definiton in the CHADS2 score
Drug that can be used in chemical cardioversion in WPW
Drugs that should be avoided?
(CHF, Hypertension, Age ≥ 75, Diabetes, Stroke or
transient ischemic attack history)
Procanimide
Av Nodal blocking agents like CCB or BB
Definition of Functional Dyspepsia
Symptoms as described for dyspepsia,
persisting for at least 12 weeks but without evidence of ulcer on endoscopy
Classic Presentation of Duodenal ulcers Timing? Length of Symptom?
Why must gastric Ulcer undergo endoscopy?
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
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?
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
Standard triple therapy for H. Pylori
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
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?
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
Causes of Hypovolemic Hyponatremia with a UNa >20
Renal? Medication? Neuro? Endo?
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
Causes of Hypovolemic Hyponatremia with a UNa
Extrarenal losses Vomiting, Diarrhea, Third spacing of fluids Burns Pancreatitis Trauma
Causes of Euvolemic Hyponatremia
Endo? Medication? Endo/Renal?
What will be the urine sodium level in most cases?
Glucocorticoid deficiency Hypothyroidism Stress Drugs Syndrome of inappropriate antidiuretic hormone secretion
It will be greater than 20 as the patient have a mild natereis
Cause of Hypervolemic Hyponatriema when UNA > 20?
Less than 20
Acute or chronic
renal failure
Nephrotic syndrome
Cirrhosis
Cardiac failure
Treatment for Hypovolemic Hyponatriema
Workup for Euvolemic Hyponatermia? Urine studies? interpretation?
correction of the volume status, usually replacement with isotonic (0.9%) saline.
urine osmolality
should be maximally dilute, 150-200 mOsm/kg).
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?
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.
What is the maximal rate that longstanding hyponatermia can be corrected?
serum sodium concentration should correct no faster than 0.5-1 mEq/h.
CLINICAL MANIFESTATION OF AORTIC DISSECTION
Cause of Horner’s Syndrome
MI?
Hemopericardium, pericardial tamponade?
Aortic regurgitation
Bowel ischemia, hematuria?
Hemiplegia?
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
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
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
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
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
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
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
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?
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
How can crytoccal mengitis in a HIV patient be confirmed?
What are the findings on CSF?
Tx?
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
CMV tends to effect patient with AIDS at what CD4 count?
Presenting symptoms? General? Neuro? GI? Endo?
TX?
Treatment for MAC in the Context of AIDS?
Clarithromycin, ethambutol, and
rifabutin is required for weeks in an attempt to clear the bacteremia.
When is toxoplasma for AIDS patients needed? and what is the drug used
MAC?
Components of HAART therapy
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
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
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,
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
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.
for patient that will have there pheochromocytoma removed, must hey be premedicated with and why?
What family Gene mutations are associated with pheochromocytoma?
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
Definition of Primary Amenorrhea? Secondary?
OLIGOMENORRHEA?
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.
If Sheehan Syndrome if suspected in a patient was test would be diagnostic?
CV signs in hypothyroidism?, Signs in the hands? Neuro GI?
magnetic resonance imaging
(MRI)
enlarged heart, nonmechanical intestinal obstruction
(ileus), and a delayed relaxation phase of their deep tendon reflexes
Interpretation and Utility of the free thyroxine index (FTI)?
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.
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
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.
Definition of Chronic Hepatitis
What percent of people with Hep C will develop chronic hepatitis in 10 years
Serum-ascites albumin gradient = ?
Evidence of hepatic inflammation and necrosis for at
least 6 months.
70-80 percent
Serum-ascites albumin gradient = serum albumin − ascitic albumin
DIFFERENTIAL DIAGNOSIS OF ASCITES BASED ON SAAG
Definition of a high gradiant and ddx GI? CV?
High gradient >1.1 g/dL = Portal HTN
Cirrhosis • Portal vein thrombosis • Budd-Chiari syndrome • Congestive heart failure • Constrictive pericarditis
DIFFERENTIAL DIAGNOSIS OF ASCITES BASED ON SAAG
Definition of a low gradient and ddx ID? GI? CV? Rhem? Renal?
Low gradient
RANSON CRITERIA Initial?
Initial • Age >55 years • WBC >16,000/mm3 • Serum glucose >200 • Serum lactate dehydrogenase (LDH) >350 IU/L • AST >250 IU/L
RANSON CRITERIA 48 hours?
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
Drugs that can cause pancreatitis?
the antiretroviral didanosine [DDI], pentamidine, thiazides, furosemide, sulfonamides,
azathioprine, L-asparaginase
Phelgmon definition?
Risk associated with the presence of the phelgmon?
time course of the development of pancreatic abscess? Warning signs?
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
Time course for the resolution of Pseudocyst
resolve spontaneously within 6 weeks, especially
if they are smaller than 6 cm.
Steroid taper in the treatement of IBD (moderate to severe)
Treatment for Toxic megacolon Supportive, Medications? Definitive.
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
Medications that are capable of causing Tubulointerstitial nephritis? Infections?
Medications (cephalosporins, methicillin, rifampin)
Infection (pyelonephritis, HIV)
Common causes are acute pericarditis? Idiopatic?, ID? CV? Autoimmune? Metabolic? Trauma? Cx?
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
Components of pericaridal friction rub?
Treatment for symptomatic idiopathic pericarditis? if they have refractory symptoms?
length of symptoms?
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.
change in the EKG that are presents in Percariditis but not MI
Vice Versa?
PR-segment depression
Loss of R-wave amplitude and development
of Q waves, ST-segment depression inferiorly
with anterior ischemia.
Diagnostic Criteria for SLE
Derm? Light? Mucosal? CT? Serositis? Renal Neuro? Hemo? Immune Markers?
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 (
Treatment of Renal Disease in Lupus?
high-dose corticosteroids or cyclophosphamide
SEROLOGIC MARKERS OF GLOMERULONEPHRITIS
Complement Levels? ANCAs? ANA? Antibasement membrane Antibody levels? ASO? Blood Cultures Cryoglobulins Hepatitis Serologies?
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
Difference between IgA nephropathy and PSGN in presentation
Complement levels?
Biospy
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.
Treatment for ANCA induced GN?
Antibody mediated GN?
poststreptococcal GN?
IgA nephropathy?
steroids and cyclophosphamide
Plasmapheresis
Antihypertensives and edema control for several weeks?
ACE inhibitors, fish oils, and steroids have all been used.
labs for working up the ddx for new onset nephrotic syndrome.
Other Causes? Meds? Ingestion? Genes
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.
Fluid and electrolyte management in Nephrotic Syndrome. Meds? Diet?
Defs, in the context of nephrotic syndrome
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
Definition of microalbuminuria
Overt nephropathy?
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
How does asymptomatic hyperuricemia relate to the presentation of Gout
Symptoms and presentation of Acute gouty arthritis
Timing, location, General ROS? Length of time?
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.
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
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
What should the uric acid levels be lower to in intercritical gout.
When is surgery indicated for Gout
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
