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MS3 > Internal Med 7 > Flashcards

Internal Med 7 Flashcards

1
Q

What are the 3 criteria for BBB

A
  1. Wide QRS
  2. Inverted T-waves in precordial leads
  3. No Q-wave in V5 or V6
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2
Q

What leads will you see RBBB?

A

V1 and V2 because RV is anterior

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3
Q

What leads will you see LBBB?

A

V6 because LV is posterior

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4
Q

What will you see in R atrial enlargement

A

Peaked P-waves in Lead 2

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5
Q

What will you see in L atrial enlargement

A
  • Widened or “notched” P-wave in Lead II

- S-shaped of P-wave in lead V1 will have a deepened negative deflection

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6
Q

What do Q waves indicated

A

Sign of old ischemia

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7
Q

What are the types of tachycardia with narrow QRS and regular rhythm

A
  • Sinus tachy
  • Atrial tachy (due to ectopic nodes)
  • AVnRT
  • Atrial flutter
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8
Q

What are the types of tachycardia with narrow QRS and irregular rhythm

A
  • A fib
  • A flutter with variable block
  • Multifocal atrial tachycardia
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9
Q

What are the types of tachycardia with wide QRS and regular rhythm

A
  • V tach

- SVT with aberrancy (BBB)

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10
Q

What are the types of tachycardia with wide QRS and irregular rhythm

A
  • V fib

- SVT with abberancy (BBB)

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11
Q

Describe AVnRT (AV nodal reentrant tachycardia)

A

♣ Electrical current goes from SA to AV node
♣ Then from AV node, some current travels down bundle and some current reenters the AV node and heads backwards toward the atria
♣ This re-entering into the atria occurs around the same time as ventricular depolarization
♣ So will see a QRS immediately followed by/overlapping an inverted P-wave (inverted because signal is going opposite way up the atria)

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12
Q

Describe AVRT (AV reentrant tachycardia)

A

♣ Instead of re-entry circuit going back to the atria, in reenters to the AV septum and then bac to the atria
♣ So the inverted retrograde P-wave will be later on
♣ Thus, AVRT will have a longer PR interval than AVnRT

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13
Q

Indications for dialysis

A

AEIOU

A = acidosis
E = electrolytes
I = intoxication
O = overload
U = uremia
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14
Q

What will you see in volume status in CKD / how do you treat

A

♣ Inability to produce urine = water retention:
• Peripheral edema, heart failure, pulmonary edema, HTN
• Tx = Loop and Thiazide diuretics

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15
Q

What will you see in potassium in CKD

A

Hyperkalemia (inability to excrete)

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16
Q

What will you see in Hgb in CKD / how do you treat

A

♣ Anemia
• Due to decreased erythropoietin production
• Tx = Iron, EPO, transfusions

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17
Q

What will you see in calcium in CKD / how do you treat

A

♣ Secondary hyperparathyroidism
• Due to decreased Vitamin D active form = low absorption of Ca and low secretion of P = hypocalcemia causes increased PTH = increased bone resorption (renal osteodystrophy)
• Tx = give phosphate binders, calcimimetics, and Vitamin D

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18
Q

What is the first step in assessment of hyponatremia

A

o Calculate Serum Osmols = (2 x Na) + (Gluc / 18) + (BUN / 2.8)
♣ Normal (= 280)

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19
Q

What is does normal serum osmols (=280) mean?

A

• Psuedo-hyponatremia

o Caused by fats and proteins

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20
Q

What does elevated serum osmols (>280) mean?

A

• Na is low in order to balance out another component of the equation that is high (e.g. Hyperglycemia or elevated BUN in kidney damage)

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21
Q

How do you correct for Na in the setting of hyperglycemia

A

♣ For every 100 that glucose is above 100, you need to correct the sodium by 1.6
♣ E.g. Pt with glucose of 500, that is four 100s above 100, so correct sodium with (4 x 1.6) = 6.5
• So if measured Na was 130, then corrected sodium is 136.5

22
Q

What are the different types of hypotonic hyponatremia (sOsm < 280)

A
  • Hypervolemic
  • Hypovolemic
  • Euvolemic
23
Q

What do you do for hypervolemic hyponatremia

A

Diurese

24
Q

What do you do for hypovolemic hyponatremia

A

IVF

25
Q

What do you do for euvolemic hyponatremia

A 
o	Use mnemonic RATS
♣	R = Renal tubular acidosis
•	Work up = UA
♣	A = Addison’s
•	Work up = cortisol
♣	T = Thyroid
•	Work up = TSH
♣	S = SIADH
•	Diagnosis of exclusion 
•	Tx = volume restriction, gentle diuresis
26
Q

How do you correct hyponatremia to avoid CPM

A

♣ Correct Na by 0.25 per hour
♣ Only correct 4-6 per day
♣ Only correct more quickly if you need to stop seizures

27
Q

What other lab value affects measured calcium

A

Calcium is usually bound to albumin, so measured calcium is the amount of FREE calcium

Therefore, calcium may be artificially high if albumin is low and artificially low if albumin is high

28
Q

How do you treat hypercalcemia

A

Bisphosphonates and IVF for dilution

Can also give calcitonin

29
Q

What are the effects of aldosterone in the collecting duct

A

Increases activity of the Na/K exchanges, causing retention of Na and excretion of K

30
Q

What is likely the issue if you are repleting K and the lab values are not responding appropriately

A

Likely due to low Mg

31
Q

Causes of hypokalemia

A

o GI = vomiting or diarrhea
o Renal = Hyperaldosteronism, diuretics (thiazides, and loops)
♣ Barter’s presents how loops diuretics would
♣ Gittelmans’ presents how thiazides would
Also insulin, beta-agonists, alkalosis, cell creation/proliferation

32
Q

Tx for HYPERkalemia

A 
o	C = Calcium
o	***B = beta AGONIST 
o	I = insulin
o	G = glucose
o	K = Kayexalate
o	D = diuresis / dialysis
33
Q

What is the gold standard imaging for kidney stones

A

*Non con CT

Can use US of pregnant

34
Q

Describe tx of kidney stones based on size

A

• <5mm
o IVF and pain meds to help stone pass

• 5mm – 3 cm
o Lithotripsy to break stone up
o Can also use CCB or BB to help expel stones that are barely over 5mm

• >3cm
o Surgery

• If patient is septic
o Nephrostomy tube for proximal tube
o Stent for distal tube

35
Q

What can you do to prevent calcium kidney stones

A

♣ Prevent with Hydrochlorothiazide – prevents calcium in the urine by enhancing calcium resorption

36
Q

Causes of struvite stones

A

AKA ammonium magnesium phosphate stones

Causes by Urease (+) bacteria (proteus, klebsiella, staph, pseudomonas)

37
Q

Tx of struvite stones

A

Abx

38
Q

Which are the radiolucent kidney stones (not seen on XR)

A
  • Uric acid stones

- Cystine stones

39
Q

Which are the radioopaque stones (seen in XR)

A
  • Calcium

- Struvite

40
Q

What other disorders are associated with autosomal dominant polycystic kidney disease

And which one of these associated diseases is the most deadly

A

♣ Associated with cysts in the liver, cysts in the pancreas, berry aneurysms, mitral valve prolapse

Must be screened for berry aneurysms because they can cause death

41
Q

What is the next step in assessing metabolic alkalosis

A

Want to see if pt is volume responsive aka low/high urine chloride

42
Q

What does it mean if a pt has metabolic alkalosis with low urine chloride

A

o This means that you are volume down and will respond to fluids
♣ Recall: If you are volume down, the body will respond by reabsorbing water which is done by reabsorbing Na+
♣ Na+ is reabsorbed with Cl-, so if you are reabsorbing NaCl, then Cl will be low in the urine

43
Q

Causes of volume responsive metabolic alkalosis

A

♣ Vomiting/nasogastric aspiration
♣ Diuretics
♣ Dehydration

44
Q

Causes of volume non-responsive metabolic alkalosis

A
  • Not hypertensive = Barter and Gitelman syndrome

- Hypertensive = excessive mineralocorticoid activity (renal artery stenosis, primary hyperaldo, Cushing’s)

45
Q

Causes of anion gap metabolic acidosis

A

MUDPILES

M = methanol
U = uremia (renal failure)
D = DKA
P = propylene glycol
I = Isoniazid/Iron
L = lactic acidosis
E = ethylene glycol
S = salicylates
46
Q

Causes of non-anion gap metabolic acidosis

A

• Losing excessive HCO3-

o Diarrhea, Renal tubular acidosis, Spironolactone, Acetazolamide

47
Q

How do you determine if a respiratory acidosis/alkalosis is acute or chronic

A

• For every change in 10 of pCO2:
o The pH will change by:
♣ 0.08 if it is acute
♣ 0.04 if it is chronic

48
Q

How do you determine if there is a coexisting metabolic disorder on top of a respiratory acidosis

A

• For every change in 10 of pCO2:
o The Bicarb will change by:
♣ 1 if acute
♣ 3 if chronic

  • If given bicarb is greater than expected, you have a coexisting metabolic alkalosis
  • If given bicarb is less than expected, you have a coexisting metabolic acidosis
49
Q

How do you determine if there is a coexisting metabolic disorder on top of a respiratory alkalosis

A

• For every change in 10 of pCO2:
o The Bicarb will change by:
♣ 2 if acute
♣ 4 if chronic

  • If given bicarb is greater than expected, you have a coexisting metabolic alkalosis
  • If given bicarb is less than expected, you have a coexisting metabolic acidosis
50
Q

How do you determine if there is a coexisting respiratory disorder on top of metabolic acidosis

A

♣ Winters formula = Determines the predicted respiratory compensation for metabolic acidosis
• Predicted pCO2 = 1.5(HCO3-) + 8 +/- 2
o If measured pCO2 > predicted pCO2 – concomitant respiratory acidosis
o If measure pCO2 < predicted pCO2 – concomitant respiratory alkalosis

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