Internal Medicine Flashcards
What does it mean to have diabetes? How is type 1 different from type 2?
Simply, glucose cannot enter cells.
Type 1 - The pancreas doesnt make insulin which is required for glucose to enter cells
Type 2 - The pancreas makes insulin but the insulin receptors on cells are not working properly so glucose can’t get into the cells as easily
How is type 1 and 2 diabetes treated?
Type 1 - The pancreas doesnt make insulin so give them insulin
Type 2 - Lifestyle changes can make the insulin receptors more sensitive to insulin, as can Metformin, etc. If it gets severe, add insulin so that the more insulin the more likely they are to bind to the receptors
What happens if diabetes is left untreated?
The blood glucose is really high because it can’t enter the cells which causes:
- increased risk of CVD (plaque formation)
- retinopathy, glaucoma, cataracts
- neuropathy, especially in feet
- poor wound healing
- nephropathy
- DKA
How can diabetes be diagnosed?
A1C of 6.5%
Random glucose of 11.1 mmol/L
Fasting blood glucose 7 mmol/L
What is diabetic ketoacidosis (DKA)? Is it more likely in type 1 or 2?
- More likely in type 1
- The body isn’t able to use glucose as fuel so it uses fatty acids as a fuel source instead. Burning fatty acids produces ketones which builds up in the blood making the blood more acidic
What are the lab values of DKA?
no numbers, just high/low
- High ketones
- Low insulin
- High glucose
- Anion gap metabolic acidosis (Na - Cl - HCO3 >12)
- May see hypokalemia due to osmotic diuresis (inhibits reabsorption of water and electrolytes)
- Often you will see normal potassium or false hyperkalemia because K+ moves out of cells into the blood (looks like hyperkalemia but is not)
Symptoms/Signs of DKA
- Hypovolemia/dehydration
- Nausea, Vomiting
- Abdominal pain/cramps
- Confusion
- Lethargy
- Deep, rapid breathing - Kussmaul respirations
- Altered LOC
Treatment for DKA
- First give Isotonic IV fluids (they are hypovolemic and dehydrated) - normal saline!
- IV Insulin (unless low K+) followed by SQ
- Potassium (unless high)
When should/shouldn’t you give insulin to a patient with DKA?
If K+ <3.3 DO NOT give insulin until potassium is elevated.
Insulin will cause their potassium to shift from extracellular to intracellular making their hypokalemia even more severe
If K+ 3.3-5.2 give insulin and potassium
If K+ >5.2, give insulin
What is hyperosmolar hyperglycemic syndrome (HHS)? Is it more common in type 1 or type 2 diabetes?
In type 2 DM.
Glucose is not getting into the cells so the body is basically starving. Because insulin is present, it prevents the body from using fatty acids to make ketone bodies so the patient is not acidotic like DKA.
Signs/symptoms of hyperosmolar hyperglycemic syndrome (HHS)?
- High blood glucose
- Fatigue
- Weight loss
- Thirst and frequent urination
- Extreme dehydration (tachycardia, hypotension)
- Confusion
NO abdominal pain like DKA
What makes someone frequently urinate with untreated diabetes?
In diabetes, the kidneys can’t reabsorb all the glucose so you pee out a lot of the glucose. In general, water likes to follow wherever glucose is so water is pulled out of the cells and exits in urine with the glucose
What are the causes of DKA?
- Sepsis (#1)
- Sickness (eg. viral)
- Stress/Surgery
- Stopping insulin
What are the causes of HHS?
- Illness
- Infections
Treatment for HHS
Give normal saline first then IV Insulin
What is the treatment for C diff?
Fidaxomicin 200mg po BID x 10 days
preferred due to lower recurrence rate
Vancomycin 125-500mg po QID x 10 days
-cheaper for the patient
What’s an easy way to tell the axis for an EKG?
Lead 1 and 2 are facing away from each other - they have LEFT each other
Lead 1 and 2 are facing towards each other - they are RIGHT for each other
What is the treatment for heart failure with EF <40% (HFrEF)?
Triple therapy:
ACE inhibitor, beta blocker, mineralocorticoid receptor antagonist
How do you treat a STEMI?
Recatheterization Dual antiplatelet therapy (ASA + plavix) ACEi beta blocker nitrates only if angina persists
Treatment for unstable angina
Nitro spray
dual antiplatelet therapy (ASA + plavix)
unfractionated heparin or lovenox
What is a normal EF?
> 55%
Treatment for ventricular tachycardia
Cardiovert back into sinus rhythm
Implanted cardiac defibrillator (ICD)
Pt goes home on Amiodarone
Why might someone with A fib need anticoagulation? Who would need it?
They are at a higher risk of stroke CHADS need anticoagulants: CHF Hypertension Age 65+ Diabetes Stroke in the past
Signs of decompensated cirrhosis
Acute deterioration of liver function:
jaundice
ascites
hepatic encephalopathy (confusion)
Treatment of acute hepatic encephalopathy
Lactulose
What is portal hypertension?
Increased pressure in the portal (liver) vein. Often caused by liver cirrhosis
A common complication of cirrhosis
Gastroesophageal varices in ~1/2 of cirrhosis patients - screen every 1-2 years
Treatment of gastroesophageal varices
Beta blocker (eg. propranolol) or variceal band ligation
Signs of chronic liver disease
Ascites jaundice peripheral edema spider angiomata caput medusa testicular atrophy
What is spontaneous bacterial peritonitis?
Infection of ascites
What are the causes of ascites?
Cirrhosis (85% of ascites) Malignancy TB Nephrotic syndrome Right sided heart failure Pancreatic duct disruption
Calculation for determining if ascites is due to portal hypertension
serum albumin - ascites albumin >1.1 = portal hypertension
Treatment of ascites
loop diuretic (eg. lasix) spironolactone 2 grams/day sodium restriction diet
What is hepatorenal syndrome?
Decline in renal function due to cirrhosis because of decreased blood flow to the kidneys
What are the causes of decompensated heart failure?
Ischemia Arrhythmia Nonadherence to meds High sodium diet Infections HTN NSAIDs Renal failure pulmonary embolism anemia
What is the most frequent comorbidity of primary sclerosis cholangitis?
Ulcerative Colitis - In 80%
What liver enzymes are usually elevated for cholangitis?
ALP, Bili, GGT cholangitis
What liver enzymes are usually elevated for hepatitis?
AST, ALT
Causes of liver disease
Hepatitis - Autoimmune, A, B, C Primary biliary cholangitis Primary sclerosing cholangitis Hemochromatosis Wilson's disease Alpha-1 antitrypsin deficiency Malignancy NAFLD Alcohol Drugs
What is hemochromatosis?
Hemochromatosis isa disorder in which the body can build up too much iron in the skin, heart, liver, pancreas, pituitary gland, and joints. Too much iron is toxic to the body and over time the high levels of iron can damage tissues and organs
What is Primary biliary cholangitis and
Primary sclerosing cholangitis?
Diseases that result in the blockage of the bile duct causing bile to back up into the liver and damage it
What is Wilson disease?
Wilson disease isa rare genetic disorder characterized by excess copper stored in various body tissues, particularly the liver, brain, and corneas of the eyes
What is Alpha-1 antitrypsin deficiency?
Alpha-1 antitrypsin deficiency is aninheriteddisease that causes an increased risk of havingCOPD,liver disease and vasculitis
What is NAFLD?
Nonalcoholic fatty liver disease isa condition in which excess fat builds up in your liver not related to alcohol use.
What is NASH?
Non-alcoholic steatohepatitis isan advanced form of NAFLD which can result in cirrhosis and liver failure
What should you give to patients staying immobile for a long period of time?
Lovenox - to prevent a clot
What factors are included in the Wells score for DVT?
active cancer paralysis bedridden for 3 days or surgery within 4 weeks previous DVT tenderness pitting edema asymmetric calves large visible veins
What factors are included in the Wells score for pulmonary embolism?
Previous PE or DVT Immobilization or surgery in past 4 weeks cancer hemoptysis tachycardia clinical signs of DVT
What blood test can you order for DVT/PE specifically?
D-dimer
Besides lowering the K+, what do you need to do if a patient is hyperkalemic?
EKG and give calcium gluconate
How can you lower potassium?
- Dextrose (D50) followed by insulin
- K+ binder like kayexalate
- diuretic
- bicarb
- salbutamol (8 puffs)
- dialysis if all else fails
What could hyperkalemia show on EKG?
peaked T waves
wide QRS
What are the criteria for dialysis?
Acidosis Electrolyte imbalance Intoxication Overload Uremia
AEIOU
What are the causes of delirium?
Drugs - intoxication, alcohol withdrawal, anticholinergics
Infections
Metabolic - hypoglycemia, electrolyte abnormalities, liver or renal failure
Environmental - restraints, change in environment
Structural - stroke, hemorrhage, ischemia, brain tumor
What is cardiogenic shock?
- Shock due to MI, cardiac tamponade, acute mitral regurg, etc.
- exremities are often cold
What is distributive shock?
- Septic, anaphylaxic or spinal shock
- extremities are warm
What is hypovolemic shock?
- Low intravascular volume due to blood loss, diarrhea, emesis or poor oral intake
- extremities are cold
Causes of upper GI bleed
- Peptic ulcer disease (due to NSAIDs or H Pylori)
- Gastritis
- Esophagitis
- Variceal bleeding (due to cirrhosis)
- Mallory Weiss tear
Treatment of H pylori
Triple therapy - PPI, amoxicillin, clarithromycin
Type of arrhythmia with wide vs narrow QRS
Wide - Ventricular tachycardia
Narrow - Atrial fibrillation
Does low CO2 represent respiratory/metabolic, acidosis/alkalosis?
respiratory alkalosis
respiratory because it involves CO2
*When you hyperventilate you lose CO2 making you more basic and fainting
Does high CO2 represent respiratory/metabolic, acidosis/alkalosis?
respiratory acidosis
respiratory because CO2 is involved
Does low HCO3 represent respiratory/metabolic, acidosis/alkalosis?
metabolic acidosis
Does high HCO3 represent respiratory/metabolic, acidosis/alkalosis?
metabolic alkalosis
What is pulmonary hypertension?
Increased pressure in the pulmonary artery (artery leading from the heart to the lungs)
What are some causes of pulmonary hypertension?
Heart failure
COPD
PE
Cirrhosis
2 main types of COPD
Chronic bronchitis and emphysema
What is chronic bronchitis? What are the symptoms?
A type of COPD Clinical diagnosis: daily productive cough for 3 months or more for 2 consecutive years Overweight and cyanotic Leg edema Crackles, wheezing Blue bloater
What is emphysema ? What are the symptoms?
A type of COPD
Permanent enlargement and destruction of alveoli
Thin, dyspnea, quiet chest
Pink puffer
Signs of a COPD exacerbation
Increased cough
Increased sputum production
Dyspnea
What is cor pulmonale?
Right ventricle of the heart enlargement caused by pulmonary hypertension. Often leads to right sided heart failure
