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Internal Flashcards

0
Q

Differential for new CXR infiltrate in HIV positive patient

A

PCP, kaposi, lymphoma, CMV, TB, cryptococcosis, hemophilius, cryptococcus, mycoplasma, chlamydia

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1
Q

Well’s criteria

A
  1. Signs and symptoms of DVT (3)
  2. PE is most likely diagnosis or equally likely (3)
  3. HR> 100 (1.5)
  4. Immobilization 3 days, or surgery in last 4 wks (1.5)
  5. Previous hx of PE/DVT (1.5)
  6. Hemoptysis (1)
  7. Malignancy (tx 6months) or palliative (1)
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2
Q

Precipitants of DKA

A
  1. Recent surgery
  2. recent trauma
  3. Pregnancy
  4. MI
  5. Infection
  6. Non-compliance or wrong insulin dose
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3
Q

History for Diabetic Control

A

Last dose of insulin taken? missed doses? usual sugars?
Symptoms: polyuria, polydipsia
Diet, exercise
Drugs, Alcohol, Smoking
Complications: retinopathy, neuropathy, nephropathy, infections

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4
Q

Investigations in DKA

A

ABG, lytes, glucose, serum ketones
Lytes to monitor: Na, Ca+2, PO4, K, Cr, Urea
pH, HCO3
Septic work up: CBC, blood cultures, urinalysis, CXR
ECG if K is elevated

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5
Q

Management of DKA

A
  1. IV fluids: 1L NS x 2-3 hours until HR and BP normalize
    then 500cc/hr x2 hours
    then 250 cc/hr x2 hours
  2. Insulin: 10 Units IV push, then 2U/hr drip
  3. Monitor glucose and lytes Q2H
  4. When glucose=15, then switch to maintenance fluids , begin diet and regular insulin regimen
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6
Q

Causes of Heart Block

A

Cardio: inferior MI, coronary spasm, cardiac tumor, congenital
Medications: digitalis overdose, TCA overdose, beta-blockers, calcium channel blockers
Infectious: viral rheumatic fever, lyme disease
Other: sarcoid, amyloid

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7
Q

Lung Nodule History

A

ID: name, age
Symptoms
-Respiratory symp: cough, sputum, SOB, dyspnea, hemoptysis, wheeze, orthopnea, PND, chest wall pain
-Infectious: history of pneumonia, TB
-Malignant: weight loss, fatigue, night sweats, anorexia, night pain, anorexia

Environment: living conditions, hobbies, pets (cats? birds?), contact with hazardous materials (asbestos)
Habits: smoking, alcohol
Travel

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8
Q

Ddx Lung nodule

A
  1. Neoplasm (malignant tends to be >3cm)
  2. Benign (tends to be <3cm)
  3. Infectious: TB, histoplasmosis, coccidiomycosis
    4 Other: granuloma (from old pneumonia, TB, sarcoid, histoplasmosis), vascular, congenital cyst, round pneumonia, located effusion
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9
Q

Investigations for solitary lung nodule

A
  1. CXR: compare to old CXR- look for change, calcifications (associated with benign lesions)
  2. CT chest, needle guided biopsy
  3. Sputum for cytology and acid-fast staining
  4. TB skin test
  5. Bronchoscopy
  6. Biopsy or lobectomy
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10
Q

Management Algorithm for Lung Nodule on CXR

A
  • Repeat CXR q3-6 months x2 years
    If any changes
  • CT Chest
  • if no dx- consider bronchoscopy or transthoracic needle aspiration
  • if no dx- consider biopsy
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11
Q

History for transfusion reaction

A
  • what is the indication for transfusion?
  • when did reaction start since starting transfusion?
  • how much of blood has been received?
  • how was blood checked?
  • PMHx, reason for admission, meds, allergies?
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12
Q

Symptoms of transfusion reaction

A

Resp: respiratory distress, wheezing, tachypnea, chest pain
Anaphylactic: urticaria, rash, resp distress, N/V, diarrhea
Constitutional: chills, fever, feeling of impending doom
MSK: muscle pain, neck pain

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13
Q

Types of transfusion reaction

A
  • Febrile non-hemolytic transfusion reaction
  • allergic
  • anaphylactic
  • acute hemolytic transfusion reaction
  • citrate toxicity/hypocalcemia
  • hyperkalemia
  • circulatory overload
  • dilutional coagulopathy
  • delayed transfusion reaction
  • iron overload- with repeated transfusions over time
  • graft vs host disease (4-30 days later), usually in immunocompromised, prevent by using irradiated blood
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14
Q

History for SBO (obstipation, nausea, vomiting, colicky abdo pain)

A
  • appetite, last meal, last bowel movement, passing gas
  • PSHx
  • PMHx, meds, allergies
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15
Q

History for hip pain and fever

A
  • Trauma?
  • Skin lesions?
  • arthritis?
  • PSHx: previous joint surgery
  • Hx of steroid use, corticosteroid joint injection
  • Hx of STD
  • PMHx, allergies, meds, DM?
  • Habits: smoking, alcohol, IV drug use
16
Q

Diagnosis of septic hip

A 
Joint synovial fluid aspiration 
Blood culture (positive 50%) 
CBC, CRP, ESR
18
Q

History for Dysphagia

A
  1. Liquids/solids or both?
19
Q

History for shortness of breath and hemoptysis

A
  • age
  • onset, duration
  • previous episode?
  • MI symptoms: chest pain, tightness, heaviness, pain in jaw, L arm, palpitations, heaviness/tightness
  • Resp: cough, sputum, wheeze, hx of immobilization, leg pain, prev hx of DVT, PE
  • GI symptoms: reflux, hx of peptic ulcer, hx of gastritis

Basic info:

  • pmhx:
  • meds? med compliance?
  • allergies:
20
Q

CXR signs of CHF, pulmonary edema

A
  1. enlarged heart
  2. upper lobe vascular redistribution
  3. Kerley B lines
  4. interstitial infiltrates
  5. pleural effusions
21
Q

History for microscopic hematuria

A

Basic info: PMHx, PSHx, meds, allergies, occupation

  • hx of trauma
  • pain? pain with urination?
  • incontinence, frequency, urgency, difficulty voiding
  • UTI: fever, nausea, vomiting
  • cancer symptoms: weight loss, back pain
22
Q

Ddx for microscopic hematuria

A 
UTI
Nephrolithiasis
Hydronephrosis 
Protatitis 
Prostate cancer 
BPH 
Renal cell carcinoma
bladder cancer
23
Q

Investigations for microscopic hematuria

A

PSA
U/S renal, bladder, prostate
cystoscopy
IVP

24
Q

History for patient with inability to urinate and dribbling

A
  • onset of symptoms, previous episodes
  • associated urinary symptoms: suprapubic pain, pain on urination, blood in urine, difficulty maintaing stream
  • neuro symptoms: constipation, perineal numbness, leg weakness
  • cancer symptoms: weight loss, fatigue, night sweats
  • new meds?
  • ROS
  • basic info: PMHx, PSHx, FMHx, ROS hx of cancer BPH
25
Q

Investigations for urinary hesitancy, dribbling

A 
UA, urine microscopy
Urine culture
PSA
Renal/pelvic ultrasound
Cystoscopy
26
Q

Needle Stick Injury

-history

A

severity of exposure

  • needle gauge
  • depth of penetration
  • did needle contain blood from a pt
  • was blood injected
  • is hiv and hepatitis status of pt known?
  • is pt high risk pt? (e.g. multiple partners, IV drug user, immigration from endemic area)
  • immunization status for hep B
27
Q

Odds of transmission from needle stick injury for

  • HIV
  • HepB
  • Antigen Hep B
  • Antibody Hep C
A
  • HIV: 0.3%
  • Hep B: 40%
  • Antigen Hep B: 10%
  • Antibody Hep C: 5%
28
Q

Statistics for

  • HIV
  • Hep B
  • Hep C
A
  • HIV: much longer life expectancy due to improved anti-retroviral therapy
  • Hep B: 1% will have fulminant hepatic necrosis, which is fatal in 60% of cases. 5% will remain in carrier status with 25-40% of cirrhosis, and 2-5%/year of HCC
  • Hep C: >50% of chronic liver disease, same risk of cirrhosis, and HCC as Hep B
29
Q

Interventions for needle stick injury

A
  • baseline testing: HIV, Hep B, Hep C
  • repeat in 6 months
  • HIV prophylaxis if pt is high risk
  • immunization for HepB
30
Q

Mammography screening

A
  • yearly mammography after age 50
  • starting at age 40 if family history of breast cancer
  • starting at 5-10 years before youngest family member’s presentation, if there are 2 first degree relatives with breast cancer (parents, sibs, children)
31
Q

Breast exam

A
  1. inspection: size, symmetry, masses, skin retraction, erythema, dimpling, nipple retraction,ulceration, peau d’orange
  2. palpation of
    - nodes: axillary, infraclavicular, supraclavicular
    - breast- light/deep palpation or masses, all 4 quadrants
32
Q

History for elevated creatinine

A
  • urinary symptoms: suprapubic pain, renal pain, groin pain, pain with urination, blood in urine, frequency, urgency, colour of urine diff initiating or maintaining urinary stream
  • neuro symptoms: saddle anesthesia, loss of bowel control
  • infectious symptoms: fever, chills, nausea, fatigue
  • cancer symptoms: night sweats, weight loss, fatigue
  • ROS
  • hx of UTI, STD, TB, radiation, hypertension, diabetes, kidney stones
  • Basic info: PMHx, PSHx, meds, allergies, smoking, alcohol, drugs, FMHx
33
Q

Ddx for chronic renal failure

A

Pre-renal: hypovolemia, poor cardiac output, renal vascular disease, NSAID, liver failure
Renal:
-vascular: malignant hypertensoin, cholesterol emboli, HUS/TTP
-tubulo-interstitial: acute tubular necrosis,
-glomerular- contrast, myoglobinuria, acute glomerulonephritis, DIC, pyelo, myeloma
Post renal obstruction: tumor, stone, BPH, stricture, autonomic dysfunction

34
Q

Investigations for chronic renal failure

A 
CBC, lytes (PO4, Ca, Mg) urea, creat 
UA, microscopy, culture
INR/PTT, AST, ALT, ALP, GGT, CK, Trops
AXR
Abdo US
Post-void cath
35
Q

History for 60 yo M, slipped and fell 6 days ago, with hemoptysis

A

Basic info: PMHx, PSHx, meds, allergies, anticoagulation?

  • mobilization since accident?
  • shortness of breath? chest pain? pleuritic pain? pain in legs
  • neuro symptoms?
36
Q

Physical exam for PE

A

Cardio: Heart sounds, murmurs, rate, rhythm, pulses
Resp: trachea midline, air entry, wheezes, crackles, pleuritic pain
MSK: inspect for redness, swelling/size, deformity, palpation for warmth, calf tenderness, Homan’s sign, (pain with dorsiflexion of foot)

37
Q

Investigations for PE

A 
ABG, D-dimer
ECG- S1Q3T3 
CXR- hamptons hump, westermark sign, dilatation of proximal PA 
Doppler ultrasound of legs 
VQ scan/Spiral CT
38
Q

Treatment for PE

A

Anticoagulation

  • Heparin (80 U/kg) then infuse at (18U/kg/hr)
  • measure PTT Q6H (adjust so that PTT 70-90, about 2.5-3x baseline)
  • start coumadin- INR 2-3, continue coumadin for 3 months

LMCC (8 decks)

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