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
