Case Files Internal Medicine Flashcards
1
Q
What is temporal arteritis?
A
Also known as giant cell arteritis (GCA), temporal arteritis is a common form of systemic vascular inflammation affecting patients older than 50 years. Medium- and large-sized vessels, especially the superficial temporal artery are affected.
2
Q
The majority of patients presenting with headache have …?
A
Tension headache:
Occipital-frontal headache, constant, “band-like”, relieved with relaxation
Migraine headache:
Unilateral throbbing headache with preceding aura, photophobia and nausea, which is relieved with sleep.
Cluster headache:
Male predominance, precipitated by alcohol, occurs with rhinorrhea and lacrimation
3
Q
What are serious causes of headache?
A
Meningitis Intracranial hemorrhage Brain tumor Temporal arteritis Acute angle closure glaucoma
4
Q
What are clinical features of meningitis?
A
Nuchal rigidity Headache Photophobia Prostration Fever
5
Q
What are clinical features of intracranial hemorrhage?
A
Nuchal rigidity
Headache
Clouded consciousness or seizures
6
Q
What are clinical features of a brain tumor?
A
Prostrating pounding headaches
Nausea, vomiting
Progressively severe new headache that is invariably unilateral
7
Q
What are clinical features of temporal arteritis?
A
Unilateral pounding headache
Onset generally in older patients (>50 years)
Frequently associated with visual changes
8
Q
What are clinical features of acute angle closure glaucoma?
A
Severe eye pain with nausea & vomiting
Red eye
Pupil may be dilated
9
Q
How many percent of patients presenting to an emergency center with severe headache have subarachnoid hemorrhage?
A
4%
10
Q
Which diagnostic procedures are essential in case of a suspected subarachnoid hemorrhage?
A
CT: positive in more than 90% of cases on the first day
Lumbar puncture: if subarachnoid hemorrhage is suspected but CT is negative
11
Q
To which disease is giant cell arteritis closely related?
A
Polymyalgia rheumatica:
An inflammatory condition characterized by bilateral aching and stiffness of neck, torso, shoulders or thighs, with a significantly elevated ESR.
12
Q
What is the most worrisome complication of giant cell arteritis?
A
Permanent or partial loss of vision in one or both eyes (early manifestations in up to 20% of patients)
13
Q
What are the drugs of choice to treat polymyalgia rheumatica and GCA?
A
Corticosteroids
14
Q
What are acute and preventive therapies for migraine?
A
Acute treatment:
NSAID
Diyhydroergotamine
Sumatriptan
Preventive treatment:
Beta-blockers
Antidepressants
15
Q
What are acute treatments for cluster headache?
A
Oxygen
Sumatriptan (subcutaneously administered)
16
Q
What are bisphosphonates and what are they used for?
A
Bisphosphonates (alendronate, risedronate, ibandronate) are synthetic carbon phosphate compounds that build bone mass by binding to pyrophosphatase in bone and by inhibiting osteoclast bone resorption. They are used for the treatment of osteoporosis.
17
Q
What is the definition of osteopenia?
A
A T-score between -1.0 and -2.5 standard deviations (SD) below the mean.
18
Q
What is osteoporosis?
A
A decrease in bone mass leading to increased bone fragility and predisposing to fracture of the hip, vertebrae and long bones, with a defined bone mineral density (BMD) more than 2.5 SD below the mean of young healthy adults.
19
Q
What is the T-score?
A
Bone mineral density comparison against young healthy individuals (in standard deviations from the mean).
20
Q
Name the most important risk factors for osteoporosis (6)!
A
Low peak skeletal density reaches in young adulthood
Genetically low bone density
Increasing age
Loss of steroid hormone production (menopause or hypogonadism)
Smoking
Nutritional deficiencies
21
Q
Who is more affected from osteoporosis: Men or women?
A
Women are more affected than men (14% vs. 3-5%).
22
Q
What is the most common cause of secondary osteoporosis?
A
Glucocorticoid excess (usually iatrogenic)
Patients with rheumatoid arthritis are susceptible to accelerated bone loss with even low doses of glucocorticoids!
23
Q
Why are female athletes sometimes affected by osteoporosis?
A
Gonadal deficiency can cause secondary osteoporosis.
Since female athletes are sometimes amenorrhoic this can cause osteoporosis.
24
Q
Which endocrinopathies can cause osteoporosis?
A
Hyperparathyroidism:
Increased calcium mobilization from the bone
Hyperthyroidism:
Accelerated bone loss
25
Why do patients with celiac sprue often develop osteoporosis?
Due to the malnutrition or nutritional deficiencies resulting from celiac sprue.
26
Which medications are known for inducing osteoporosis?
Cyclosporine
Antiepileptics
GnRH inhibitors
Heparin
27
Which kind of physical activity influences bone density?
Weight-bearing activity
28
What are the stages of bone growth?
Modeling
Remodeling
29
Who is currently recommended to undergo bone mineral density (BMD) screening?
Women > 65 years
Patients with (unusual) fractures before age 65
30
What is the appropriate test to measure bone mineral density?
Dual-energy x-ray absorptiometry (DEXA scan)
31
What is the Z-score?
Bone mineral density comparison against individuals of the same age (in standard deviations from the mean).
32
What is better in predicting fracture risk: T-score or Z-score?
T-score
33
How does the risk for fractures increases with decreasing bone mineral density?
Every 1 standard deviation doubles the risk for fracture.
34
Which laboratory evaluations should routinely be considered in patients with osteoporosis (3)?
Serum level of calcium
Serum level of phosphorus
Serum level of alkaline phosphatase
35
Define osteomalacia!
Osteomalacia is defective mineralization of bone matrix with accumulation of unmineralized osteoid.
36
What are the two most important causes of osteomalacia?
Vitamin D deficiency
Phosphate deficiency
37
What are the typical symptoms of osteomalacia?
Diffuse bone pain and tenderness
Proximal muscle weakness
Laboratory abnormalities (elevated alkaline phosphatase, low to normal calcium levels)
38
Define Paget disease!
Paget disease is a disorder characterized by disorganized bone remodeling with a high alkaline phosphatase level causing weakened and enlarged bones with skeletal deformities.
39
What is the correct treatment of osteoporosis?
Adequate calcium intake:
1000 – 1200 mg/d for premenopausal women and adult men
1500mg + 400 – 800 IU of vitamin D
Estrogen replacement
Bisphosphonates
40
In which individuals can bisphosphonates only be used with caution?
In individuals with gastric reflux disease, since bisphosphonates can lead to severe esophagitis.
41
How do you instruct a patient to take bisphosphonates?
Bisphosphonates should be taken on an empty stomach, with a large quantity of water and the patient should remain in the upright position for at least 30 minutes.
42
Besides esophagitis, what are other serious side effects of bisphosphonates?
Osteonecrosis of the jaw
Paradoxical bone fragility (often causing atypical subtrochanteric femur fractures)
43
Besides medication and supplements, what kind of sports do you recommend patients with osteoporosis to practice?
Weight-bearing physical activity decreases bone loss and improves coordination and muscle strength.
44
Considering the environment of patients with osteoporosis, what steps should be taken?
Ensuring that patients see adequately
Ensuring that patients use a cane or walker if needed
Removal of rugs
Use of railings in the shower or bath
Use of hip protectors
45
In patients with so-called "pathologic fractures" which diagnoses must be ruled out before diagnosing osteoporosis?
Paget disease
Osteomalacia
Malignant disease
46
To what extent is the risk of fracture reduced by the use of bisphosphonates in patients with osteoporosis?
30 – 50%
47
What diagnostic workup is necessary before assigning a diagnosis of Alzheimer dementia?
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)
Chemistry panel
Thyroid-stimulating hormone (TSH) level
Venereal Disease Research Laboratory (VDRL)
Human immunodeficiency virus (HIV) assay
Serum vitamine B12 and folate levels
Chest radiograph
Electrocardiogram
Computed tomography (CT) or Magnetic resonance imaging (MRI) of the head
48
What is the correct definition of dementia?
1) Impairment of memory and at least one other cognitive function (e.g. language, visuospatial orientation, judgment)
2) Without alteration in consciousness
3) With a decline from previous level of ability
4) With disturbance of daily functioning and independent living
49
Give a short description of Alzheimer disease (AD)!
AD is the leading cause of dementia, accounting for half of the cases involving elderly individuals. Anatomically it presents with diffuse cortical and hippocampal atrophy leading to ventricular enlargement. The pathologic changes include neurofibrially tangles and deposition of abnormal amyloid in the brain.
50
Give a short description of Multi-infarct dementia!
Multi-infarct dementia occurs in the setting of cerebrovascular disease after multiple cerebral infarctions (large or small).
51
What are the 3 important questions a clinician must ask when evaluating a patient with dementia?
1) What is the most likely diagnosis?
2) Is any treatable or reversible condition contributing to the patient's cognitive decline?
3) What interventions are available to preserve the patient's level of function and relieve the burden to the caregivers?
52
Which two conditions are important to consider in making a differential diagnosis of dementia and how do they present?
Delirium:
- Acute or subactue onset of confusion
- Fluctuating level of consciousness
Depression ("Pseudodementia"):
- Prominent mood disturbance along with
cognitive impairment
- Medical history
- Improvement with antidepressive medication
53
How do multi-infarct dementia and Alzheimer disease differ in their clinical presentation?
Alzheimer disease present with a slowls progressive decline in memory and cognitive function.
Multi-infarct dementia presents with a sudden, stepwise decline in functioning. However, Binswanger disease (diffuse subcortical white matter changes) may also present with insidious decline.
54
Which are the 4 most important causes of dementia?
Alzheimer disease
Vascular dementia
Parkinson dementia
Dementia due to longstanding alcoholism
55
What are less common causes of dementia? (7)
Wernicke encephalopathy (vitamin B1 deficiency)
Dementia due to pernicious anemia (vitamin B12 deficiency)
Dementia due to hypothyroidism
HIV dementia
Neurosyphilis
Huntington disease
Normal pressure hydrocephalus
56
What are the typical symptoms of normal pressure hydrocephalus and why is it important to consider this condition in a patient with dementia?
Normal pressure hydrocephalus is a potentially reversible form of dementia in which the cerebral ventricles slowly enlarge as a result of disturbances to cerebral spinal fluid resorption.
The classic triad of symptoms is:
- Dementia
- Gait disturbance
- Urinary or bowel incontinence
57
Describe clinical features and treatment of Alzheimer disease!
Slowly progressive decline in cognitive and behavioral ability.
```
Treatment:
Cholinesterase inhibitors:
Donezepil
Rivastigmine
Galantamine
```
NMDA-receptor antagonist (for more advanced dementia):
Memantine
58
Describe clinical features and treatment of normal-pressure hydrocephalus!
Dementia, gait disturbance, incontinence.
Treatment:
Ventricular shunting
59
Describe clinical features and treatment of multi-infarct dementia!
Focial deficits with stepwise loss function.
Treatment:
Adress atheroslerotic risk factors. Identifiy and treat risk of thromboembolic events.
60
Describe clinical features and treatment of frontotemporal dementia (e.g. Pick disease)
Behavioral and language deficits with spared memory.
Treatment:
Supportive care. No treatment to slow progression or improve symptoms.
61
Creutzfeld-Jakob disease (CJD)
Rapidly progressive mental deterioration and myoclonus. Death in <1 year of onset.
Treatment:
Supportive care. No effective treatment.
62
How prevalent is dementia?
Approximately 5% of people older than 65 years and 20% older than 80 years have some form of dementia.
63
Define "nephrotic syndrome"!
Urine protein excretion more than 3.5 g over 24 hours, serum hypoalbuminemia (<3g/dL), hyperlipidema, and edema.
64
What is the normal amount of protein excreted by the kidneys and excludes proteins from urine?
The normal amount of protein excreted per day is less than 150mg.
Proteins are excluded from the urine by the glomerular filter both by their large size and their net negative charge.
65
What is edema that affects the whole body called?
Anasarca
66
What are the most common causes of nephrotic syndrome in adults?
One third of adults with nephrotic syndrome have a systemic disease that involves the kidneys, such as diabetes or lupus.
The rest have a primary renal disease with one of four pathologic lesions:
- Minimal change disease
- Membranous nephropathy
- Focal segmental glomerulosclerosis
- Membranoproliferative glomerulonephritis
67
Which blood tests should be ordered to diagnose a systemic cause of nephrotic syndrome?
Serum glucose & glycosylated hemoglobin:
Diabetes
```
Antinuclear antibody (ANA):
Lupus erythematosus
```
Serum- and urine protein electrophoresis:
Multiple myeloma
Amyloidosis
Viral serologies:
HIB
Viral hepatitis
68
Which invasive diagnostic procedure is usually performed in adult patients with nephrotic syndrome?
Renal biopsy
69
What are the main points of action in treatment of nephrotic syndrome?
Treatment of the underlying disease (!)
Management of edema
Attempts to limit the progression of the renal disease
70
How do you manage edema in patients with nephrotic syndrome?
Salt restriction
Diuretics
Dietary protein restricition
71
What is a common complication of protein wasting in patients with nephrotic syndrome?
Hypercoagulability:
Due to decreased levels of antithrombin III, protein C and protein S
Increased infection risk:
Due to hypogamma-globulinema
Iron deficiency:
Due to hypotransferrinema
Vitamin D deficiency:
Due to loss of vitamin-D-binding-protein
72
How can diabetic nephropathy be detected at an early stage?
The earliest stages of nephropathy can be detected as microalbuminema (urine albumin excretion between 30 and 300 mg per day).
This can also be measured in a random urine simple by the ratio of albumin/creatinine.
73
What is the typical progression of diabetic nephropathy like?
Microalbuminuria - Macroalbuminuria - overt nephropathy.
No symptoms - hypertension, edema - nephrotic syndrome - end stage renal disease.
Initially elevated GFR, followed by decline over time.
74
Nephropathy and proteinuria are also associated with much higher risk of disease in which organ system?
Cardiovascular system
75
Which intervention can prevent progression of renal disease in patients with diabetes?
Tight glycemic control (HbA1c < 6.5)
Strict blood pressure control (less than 130/80mmHg in patients with diabetes and even less than 125/75mmHg in patents with proteinuria greater than 1g per day).
Angiotension inhibition:
ACE inhibitors
Angiotension receptor blockers
Additionally (to reduce cardiovascular risk):
Smoking cessation
Reduction of hypercholesterolemia (LDL<70mg/dL)
76
What is the most common presentation of gout?
Podagra = inflammation at the metatarsal-phalangeal joint at the base of the big toe
77
Give a short definition of gout!
A disturbance of uric-acid metabolism occurring mainly in men, characterized by hyperuricema and the deposition of monosodium urate crystals in the joints, as well as in connective tissues.
78
Define "pseudogout"!
Arthritis caused by deposition of calcium pyrophosphate dihydrate crystals.
79
Which disease is the primary concern in any acute monoarthritis and why?
The primary concern in any monarthritis is infectious arthritis because it may lead to joint destruction and resultant severe morbidity.
Acute monoarthritis = medical emergency!
80
Which diagnostic workup should be performed in a patient with acute monoarthritis?
Medical history
Physical examination
Synovial fluid analysis (!)
Radiograph
(Synovial biopsy)
81
Why can the location of joint involvement be helpful?
The location of joint involvement can help in suspecting the right diagnosis
Gout:
- First MTP joint ("podagra")
- Ankle
- Midfoot
- Knee
Pseudogout:
- Large joints
- Wrist
- MTP joint
Gonococcal arthritis:
- Migratory arthralgias & tenosynovitis (wrist
and hands)
- PLUS: pustular skin lesions
- finally: monoarthritis or oligoarthritis
Non-gonococcal septic arthritis:
- large weigh-bearing joints like knee or hip
82
How can a physical examination help in differentiating arthritis from inflammatory conditions adjacent to the joint (e.g. cellulitis, bursitis)?
True arthritis is characterized by swelling and redness around the joint and painful limitation of active and passive motion in all planes.
Joint movement that is not limited by passive motion suggests a soft tissue disorder such as bursitis.
83
Which diagnostic technique is necessary in case a diagnostic arthrocentesis does not reveal the cause of arthritis?
Synovial biopsy
Usually performed to rule out tuberculosis or hemochromatosis as underlying pathologies.
84
Which technique allows examination of crystals in joint fluid?
Polarizing light microscopy.
Monosodium urate crystals (cause of gout) are needle-shaped, typically intracellular within a polymorphonuclear cell and are negatively birefringent, appearing yellow.
Calcium pyrophosphate dihydrate crystals (cause of pseudo gout) appear short and rhomboid and are weakly positively birefringent, appearing blue.
85
What do chondrocalcinosis or linear calcium deposition in the joint cartilage suggest?
Pseudogout
86
What therapy is indicated in case of septic arthritis and when is it usually initiated?
Antibiotic therapy:
Empirical, until gram stain and culture reveal information.
Drainage of purulent joint fluid by repeated percutaneous aspiration
87
What are the four stages of gout?
Stage 1: Asymptomatic hyperuricemia.
Stage 2: Acute gouty arthritis.
Stage 3: Intercritical gout, asymptomatic, 60–70% will have another attic within 1–2 years.
Stage 4: Chronic tophaceous gout; after 10 or more years of acute intermittent gout; intercritical periods are no longer asymptomatic (chronic swelling and discomfort at affected joints, worsens over time).
88
What are the appropriate therapeutic steps in patients with asymptomatic hyperuricemia?
No specific treatment.
Lowering the urate level does not necessarily prevent the development of gout, and most of these patients will never develop any symptoms.
89
Describe a therapeutic approach for a patient with acute gouty arthritis!
NSAIDs: Indomethacin
Oral colchicine
Intraarticular glucocorticoid injection or oral steroid therapy
90
What are the appropriate therapeutic steps during intercritical gout and how are they approached?
Preventing further attacks by lowering uric acid levels to less than 6,0 mg/dl.
Dietary restriction: avoiding organ-rich foods, alcohol, thiazide diuretics
Medication:
Probenecid: increases uric acid excretion by the kidney
Allopurinol: diminishes uric acid production
Febuxostat: does not require lowering of dose in patients with renal insufficiency
91
What is the appropriate therapy for acute pseudogout?
Same as in gout:
NSAID
Colchicine
Intraarticular glucocorticoid injection or oral steroid therapy
92
How can one prevent pseudogout?
There is no effective therapy for preventing CPPD crystal formation or deposition. Prophylaxis with colchicine may be helpful in patients with chronic recurrent attacks.
93
Give typical causes of chronic cough in smokers vs. non-smokers!
Smokers: COPD, bronchogenic carcinoma
| Non-smokers with normal chest radiograph: GERD, postnasal drip, ACE-inhibitors, asthma
94
What are the physiological functions of cough (2)?
1) Protection against aspiration
| 2) Clearance of secretions into more proximal airways to be expectorated from the tracheobronchial tree
95
Name appropriate medications for treatment of asthma bronchiale!
Reliefers:
Short-acting inhaled Beta-2-Agonists
```
Controllers:
Inhaled steroids
Oral steroids
Colony
Leukotriene modifiers
Nedocromil
Theophylline
```
96
Name possible causes of acute hypercalcemia (3)!
Hyperparathyroidism 1°
MEN Syndromes
Malignancy
97
Name possible causes of chronic hypercalcemia (10)!
Hyperparathyroidism 1°, 2° or 3°
MEN Syndromes
```
Granulomatous disease (Sarcoidosis, Tuberculosis)
Familial hypocalciuric hypercalcemia
Milk-alkali syndrome
Medications (lithium, thiazides)
Immobilization
Vit D or Vit A intoxication
Adrenal insufficiency
Hyperthyroidism
```
98
Name the symptoms of hyperparathyroidism!
"Stones, Moans, Groans, Bones and Psychiatric Overtones"
99
Name the classic triad of multiple myeloma symptoms!
Bone pain (lytic lesion)
Anemia
Renal insufficiency
100
Which medications can be used to treat hypercalcemia(4)?
Loop diuretics
Bisphosphonates
Calcitonin
Glucocorticoids
101
How should a foot ulcer be initially evaluated? (Hint: PEDIS)
```
Perfusion
Extent (area size)
Depth
Infection
Sensation
```
102
How should the diagnosis of infection of an open wound be made?
Because all open wounds are colonized, the diagnosis of infection should be based on the combination of culture results and clinical assessment.
103
What are the most common pathogens involved in diabetic foot infections?
Staph. aureus
| Beta-hemolytic Streptococcus
104
Define diabetic neuropathy!
Motor neuropathy, sensory neuropathy or autonomic neuropathy related to diabetes.
105
What is Charcot neuroarthropathy?
A noninfective bone and joint destruction that occurs in a well-perfused, insensate foot.
Assumed cause: repetitive trauma to an insensate portion of the foot.
Clinical presentation: Soft tissue swelling, soft tissue erythema, increased skin temperature.
106
How can foot ulcers be classified according to their location?
Neuropathic foot ulcers are located over weight-bearing portions of the foot and are associated with normal arterial examination.
Vasculogenic ulcers are located at the tips of the toes wehre perfusion is most limited.
107
Which pathologic conditions are summarized under the term "diabetic foot"?
```
Diabetic neuropathy
Ischemic vascular disease
Charcot neuroathropathy
Skin ulceration
Soft tissue infection
Osteomyelitis
```
108
How high is the risk of foot ulcer development in a diabetic individual?
25%
109
Welche Untersuchung ist zum Nachweis einer akuten Osteomyelitis bei blander Röntgen-Untersuchung hilfreich?
Radionuklid-Scan
