Internal Medicine Flashcards
DDX for WBC casts?
Pyelonephritis Acute intersitial nephritis
DDx for muddy brown casts?
Acute tubular necrosis
Can be caused by ischemic AKI or nephrotoxic AKI (antibiotics, radiocontrast agents, NSAIDs, poisons, myoglobinuria, hemoglobinuria, chemotherapy, AL in MM)
Metabolic derangements in AKI
Hyperkalemia Anion gap metabolic acidosis Hypocalcemia Hyponatremia Hyperphosphatemia Hyperuricemia
Metabolic derangements in CKD
Hyperkalemia Hypermagnesemia Hyperphosphatemia Metabolic acidosis Hypocalcemia
Side effects of ACEI
ACEI dilate afferent arteriole Hyperkalemia
Absolute indications for dialysis
Acidosis Electrolyte abnormalities Intoxications Overload, hypervolemic Uremia based on clinical presentation (e.g. AMS, pericarditis)
Minimal change disease
Most common in children
May present as nephrotic syndrome
A/w lymphomas
Microscopy: no changes on light microscopy, foot process fusion
Tx: 4-8 weeks of steroids
Focal segmental glomerulosclerosis (FSGS)
Nephrotic
More common in Blacks
Microscopy: focal segmental sclerosis, foot process fusion
A/w HIV, heroin use, sickle cell disease
Does not respond well to steroids
Membranous glomerulonephritis
Nephrotic
Microscopy: thick glomerular basement membrane
A/w: Hep B, Hep C, SLE
Does not respond well to steroids
Post-infectious glomerulonephritis
Nephritis 10-21 days following URI
Low C3 complement
Elevated anti-streptolysin O and/or anti-DNAse B
IgA nephropathy
Nephritis 5 days following URI
Normal complements
Prostate cancer
Risk factors include age, African American race, high-fat diet, FHx, exposure to herbicides and pesticides Mostly adenocarcinoma, starts at periphery Mostly asymptomatic but can cause obstruction in late phase Likes to metastasize to bone (pelvis, vertebral bodies, long bones in the legs) Indications for transrectal ultrasound: PSA > 4.1, abnormal DRE Tx: radiation + androgen deprivation OR prostatectomy OR orchiectomy, antiandrogens, leuprolide, GnRH antagonists
Treatment of CAD
Risk factor modification (HTN, DM, HLD control, etc.) Aspirin (reduces risk of MI) Nitrates Beta-blockers (reduces frequency of coronary events) + coronary angiography to assess for PCI (if moderate) + consider CABG (if severe)
Treatment of hypertrophic cardiomyopathy
Beta-blockers
Treatment of CHF
ACEI + loop or thiazide diuretic Beta-blockers Spironolactone/Eplerenone
Treatment post-stent placement
Dual platelet therapy (aspirin + clopidogrel) 1 month for BMS 12 months for DES
Treatment for aortic dissection
IV beta-blocker to SBP 100-120 If SBP still > 120, add sodium nitroprusside
Treatment for cocaine-induced chest pain
IV benzodiazepines Aspirin, nitroglycerin, CCB Beta-blockers contraindicated
Arrhythmia most specific for digitalis toxicity
Atrial tachycardia with AV block
Finds for aortic stenosis
Fatigue, lightheadeness with exertion, presyncope Midsystolic murmur over RUSB Diminished and delayed carotid pulse Soft and single S2
Tx for sinus bradycardia
IV atropine
Metabolic derangments in intravascular hemolysis
Hemoglobinemia
Hemoglobinuria
Elevated lactate dehydrogenase
Decreased haptoglobin (excess hemoglobin exceeds binding capacity)
Primary biliary cholangitis
S&S: pruritus, fatigue, jaudice, eyelid xanthelasma, portal HTN, osteopenia
Labs: antimitochondrial antibody, elevated Alk Phos
Tx: ursodeoxycholic acid, liver transplant for advanced disease
Wernicke encephalopathy
Thiamine deficiency due to alcoholism, malnutrition
S&S: encephalopathy, oculomotor dysfunction, postural and gait ataxia
Tx: IV thiamine followed by glucose infusion
Indications for hospitalization for CAP
Confusion
Urea > 20
Respirations ≥ 30
SBP < 90, DBP < 60
Age ≥ 65
Treatment of diverticulitis
Uncomplicated: outpatient bowel rest, oral antibiotics, observation
Complicated (abscess): IV antibiotics if < 3 cm, CT-guided percutaneous drainage if > 3 cm, surgical drainage and debridement if no improvement in 5 days
Cellulitis vs. erysipelas
Cellulitis: S. pyogenes or MSSA infection of deep dermis and subcutaneous fat with flat edges with poor demarcations, indolent
Erysipelas: S. pyogenes infection of superficial dermis and lymphatics with raised, sharply demarcated edges, rapid spread and onset
Bounding pulses, fixed splitting of S2, pulsus paradoxus, pulsus parvus and pulsus tardus
Bounding pulses: AR
Fixed splitting of S2: ASD
Pulsus paradoxus (systemic arterial pressure falls > 10 mmHg during inspiration): cardiac tamponade
Pulsus parvus and pulsus tardus (decreased amplitude and delayed upstroke): AS
Diagnosis and management of carbon monoxide poisoning
Dx: ABG (carboxyhemoglobin level), ECG, cardiac enzymes if ischemia or CAD
Tx: high-flow 100% oxygen, intubation/hyperbaric oxygen therapy (if severe)
Treatment elevated homocystine
Pyroxidine, folate, B12 (if deficiency documented) as these are co-factors in homocysteine metabolism
Treatment for PCP
AIDS-defining illness when CD4 count < 200
First line: TMP-SMX
Second line: pentamidine, atovaquone, TMP + dapsone, clindamycin + primaquine
Adjunctive corticosteroids if PaO2 Copyright 70 mmHg or A-a gradient > 35 mmHg
Diagnosis and management of heparin-induce thrombocytopenia
S&S: heparin exposure > 5 days + platelet reduction > 50% from baseline, arterial or venous thrombosis, necrotic skin lesions at heparin injection sites, anaphylactoid reaction
Dx: if suspected, STOP ALL HEPARIN PRODUCTS then do serotonin release assay
Tx: start direct thrombin inhibitor (e.g. argatroban) or fondaparinux (can switch to warfarin once platelets > 150,000)
Next best step of management for chest pain
ECG
> 2 mm ST elevations or new LBBB concerning for STEMI → cath lab or thrombolytics if cath lab unavailable in reasonable amount of time
Leads I and aVL
Lateral MI –> left circumflex
Leads V1-V4
Anterior MI –> left anterior descending
Leads V1-V4, V5-V6, I, aVL
Anterolateral MI –> left main
Leads II, III, aVF
Inferior MI –> posterior descending (85% branches from right coronary)
Causes of dilated cardiomyopathy?
Alcohol abuse Wet beriberi Coxsackie A and B virus myocarditis Chronic cocaine use Chagas disease Doxorubicin toxicity Hemochromatosis Peripartum cardiomyopathy
Unilateral headaches, jaw claudication, blindness (if untreated)
Temporal (giant cell) arteritis Labs: elevated ESR and CRP Dx: temporal artery biopsy shows granulomas, intimal thickening, elastic lamina fragmentation, multinucleated giant cells Tx: corticosteroids Cx: polymyalgia rheumatica, IL-6 related to severity of disease
Weak upper extremity pulses, arrowing of aortic arch and proximal great vessels
Takayasu arteritis Tx: corticosteroids
Hepatitis B, hypertension, transmural inflammatory and fibrinoid necrosis of arterial wall, “string of pearls” on arteriogram
Polyarteritis nodosa Tx: cyclophosphamide, corticosteroids
Fevers, conjunctivitis, cervical lymphadenopathy, strawberry tongue, rash on palms and soles
Kawasaki disease Tx: aspirin, IV immunoglobulins Complications: coronary artery aneurysm
Smoking, claudication,gangrene, autoamputation, Raynauds
Buerger disease (thromboangiitis obliterans) Tx: smoking cessation
c-ANCA (PR3-ANCA), involvement of nasopharynx, lungs, kidneys
Granulomatosis with polyangiitis (Wegners) Tx: cyclophosphamide, corticosteroids
p-ANCA (MPO-ANCA), invovlement of lungs, kidneys
Microscopic polyarteritis No nasopharyngeal involvement and no granulomas distinguishes from Wegners
p-ANCA (MPO-ANCA), asthma, palpable purpura, GI complaints, increased IgE
Churg Strauss (eosinophilic granulomatosis with polyagiitis) Granulomas with eosinophils
Indications for CABG over stent
Left main disese or 3-vessel disease (or 2-vessel disease + DM)
> 70% occlussion
Pain despite maximal medial treatment
Post-infarction angina
Medical management post-MI
Aspirin (+ clopidogrel if stent for 9-12 months)
Beta-blocker
ACEI (if CHF or LV dysfunction)
Statin
Nitrates for pain
Exercise stress test
Indicated for patients with intermediate pre-test probability of cardiac ischemia
Avoid beta-blockers, CCB
Need to do echo stress test if old LBBB, baseline ST elevation, or digoxin
If pt cannot exercise, chemical stress test with dobutamine or adenosine
Positive if –> ST depressions, chest pain, hypotension –> coronary angiography
Treatment of WPW
Procainamide
Avoid beta-blockers, digoxin, CCB (anything that slows AV conduction)
Treatment of SVT
First line: carotid massage, face in ice water (for children)
Second line: adenosine
Cardiac tamponade
Clinical indicators: hypotension, distant heart sounds, JVD, pulsus paradoxus, electrical alternans
Tx: pericardiocentesi
Crescendo-decrescendo systolic ejection murmur, louder with squatting, softer with valsalva + parvus et tardus
Aortic stenosis
Tx: valve replacement
Systolic ejection murmur, louder with valsalva, softer with squatting/handgrip
Hypertrophic obstructive cardiomyopathy
Late systolic murmur with click, louder with valsalva and handgrip, softer with squatting
Mitral valve prolapse
Holostystolic murmur, radiates to the axilla
Mitral regurgitation
Rumbling diastolic murmur with an opening snap, left atrial elargement and afib
Mitral stenosis
Blowing diastolic murmur with widened pulse pressure, waterhammer pulse
Aortic regurgitation
Most specific arrhythmia associated with digitalis toxicity
Atrial tachycardia with AV block
Treatment for long QT syndrome
Beta-blockers and pacemaker
Indication for antithrombotic therapy in afib
> 4 on CHA2DS2-VASc
C = CHF (1 point)
H = HTN (1 point)
A = age > 75 (2 points)
D = DM (1 point)
S2 = stroke/TIA/thromboembolism (2 points)
V = vascular disease (1 point)
A = age 65-74 (1 point)
Sc = sex (female = 1 point)
Most likely location following aspiration?
Right mainstem bronchus wider and more vertical than the left While upright –> lower portion of right inferior lobe While supine –> superior portion of right inferior lobe or posterior segments of the right upper lobe
What factors shift the oxygen-hemoglobin curve to the right?
Right shift = reduced affinity = more oxygen is offloaded at a given pO2 ↑ in Cl-, H+, CO2, 2,3-BPG, temperature, altitude, and exercise
What factors shift the oxygen-hemoglobin curve to the left?
Left shift = greater affinity = less oxygen is offloaded at a given pO2 ↓ in Cl-, H+, CO2, 2,3-BPG, and temperature
Methemeglobinemia
Oxidized hemoglobin (with Fe3+) has reduced affinity for oxygen and increased affinity for cyanide S&S: cyanosis and chocolate-colored blood Tx: methylene blue
Cyanide poisoning
Nitrites to oxidize hemoglobin to methemeglobin which binds CN Thiosulfate to bind this cyanide, forming thiocyanate, which is renally excreted
Lobes of the lungs affected by pneumoconioses
Asbestosis –> lung bases
Silica and coal –> upper lobes
Light’s criteria?
Pleural effusion is exudative if:
PF/serum protein > 0.5
PF/serum LDH > 0.6
PF LDH > 2/3 upper limit of normal (about 200)
Exudative processes (inflammation that causes increased permeability): parapneumonic, lung adenocarcinoma (high hyaluronidase)
Transudative processes (imbalance between hydrostatic and oncotic pressures): RA (low glucose 2/2 leukocytosis), TB (high lymphocytes), malignant or pulmonary embolus (bloody) → treat underlying disease
Locations of primary lung cancers
Adenocarcinoma, bronchioalveolar, large cell –> peripheral Squamous cell, Small cells –> central
Adenocarcinoma
Most common lung cancer in nonsmokers and overall Found in periphery
Bronchioloalveolar subtype looks like pneumonia on CXR –> good prognosis
Squamous cell carcinoma
Most common lung cancer in male smokers
Centrally located as hilar mass from the bronchus
a/w cavitation, cigarettes, hypercalcemia (from PTHrP)
Keratin pearls and intercellular bridges on histology
Small cell (oat cell) carcinoma
Centrally located
Undifferentiated neuroendocrine cells –> very aggressive May produce ACTH, ADH, antibodies against presynaptic calcium channels (Lambert-Eaton)
Inoperable, must treat with chemotherapy
Large cell carcinoma
Found in periphery
Highly anaplastic undifferentiated tumor –> mets
Less responsive to chemotherapy, removed surgically
Pleomorphic giant cells on histology
a/w gynecomastia and glactorrhea
CXR shows peripheral cavitation
Bronchial carcinoid tumor
Nests of neuroendocrine cells (chromogranin A +)
Excellent prognosis, metastasis rare
Symptoms due to mass effect or carcinoid syndrome (5-HT –> flushing, diarrhea, wheezing)
Common sites of primary lung cancer metastasis?
Adrenal glands, brain, bone, liver
The terrible T’s of a mediastinal mass
Teratoma Thymoma Thyroid cancer Terrible lymphoma
Hamartoma of the lung
Benign lesion Typicallly a solitary lung nodule (“coin lesion”) with “popcorn” calcifications Often contains islands of mature hyaline cartilage, fat, smooth muscle, and clefts lines by respiratory epithelium
Smoking-related vs. A1AT deficiency emphysema
Smoking-related emphysema: centriacinar in the upper lobes
A1AT deficiency emphysema: panacinar in the lower lobes
Which pneumoconicosis is associated with increased risk of TB?
Silicosis
Silica particles internalized into macrophages disrupt phagolysosomes and cause release of the particles and viable mycobacteria limiting the immune system’s ability to combat TB infection
a/w eggshell calcifications
Chronic rejection of a lung vs. kidney transplant
Kidney –> inflammation of vasculature Lung –> inflammation of small bronchioles (bronchiolitis obliterans)
Causes of deviated trachea
Tension pneumothorax –> trachea deviates away from the collapsed lung Collapsed lung due to bronchial obstruction –> trachea deviates towards the affected side
Diagnostic criteria and management of ARDS
Dx: PaO2/FiO2 < 200, bilateral alveolar infiltrates on CXR, PCWP < 18
Tx: mechanical ventilation with PEEP
Treatment for COPD
First line: ipratropium, tiotropium
Second line: beta agonists
Third line: theophylline
Indications to start oxygen in COPD
PaO2 < 55 or SpO2 < 88%
Best prognostic indicator for COPD
FEV1
Interventions shown to improve mortality from COPD
Smoking cessation
Continuous oxygen therapy > 18 hours/day (is PaO2 < 55 or SpO2 < 88%)
Sarcoidosis
Hilar lymphadenopathy, increased ACE, hypercalcemia, erythema nodosum
Refer to ophthalmology 2/2 uveitis conjunctivitis
Dx: biopsy
Tx: steroids
COPD + new-onset clubbing
Occult malignancy of the lung –> get CXR
Diagnosis and treatment of asthma
Dx: obstructive process on spirometry (decreased FEV1/FVC) with reversibility after SABA (> 12% improvement)
Tx:
<= 2x/week + normal PFT → albuterol prn
More frequent symptoms + normal PFT → albuterol + inhaled corticosteroids
More frequent symptoms + FEV1 60-80% → albuterol + inhaled corticosteroids + LABA
Daily symptoms + FEV1 60% → albuterol + inhaled corticosteroids + LABA + montelukast or oral steroids
Complications of inflammatory bowel disease?
Toxic megacolon → surgery
Pyoderma gangrenosum → NO antibiotics
Erythema nodosum (painful nodules on anterior tibia)
Which IBD is a/w increased risk of primary sclerosing cholangitis?
Ulcerative colitis
PSC confers and increased risk for cholangiocarcinoma
How do you treat ulcers, abcesses, or fistulas associated with Crohn’s disease?
Metronidazole
Treatment for IBD
ASA, sulfasalazine to maintain remission
Corticosteroids to induce remission
Azathioprine, 6MP, and methotrexate for severe disease
ALT > AST and in the 1000s
Viral hepatitis
AST and ALT in the 1000s after surgery or hemorrhage
Ishemic hepatitis (shock liver)
Antimitochondrial antibodies
Primary biliary cirrhosis
Steroids not effective
ANA + antismooth muscle antibodies
Autoimmune hepatitis
Tx: steroids
Cholestatic pattern of liver enzymes?
Think obstruction → RUQ ultrasound → if equivocal, do abdominal CT (painless jaundice in elderly = pancreatic CA) → if equivocal, do ERCP
Prophylaxis for people exposed to bacterial meningitis?
Rifampin
Treatment of meningitis
Empiric treatment (+ steroid if you think bacterial), exam/CT to access for ICP, LP (+ gram stain, > 1000 WBCs diagnostic)
N. meningititis, H. flu, S. pneumo → ceftriaxone, vancomycin
Listeria → ampicillin
Staph (brain surgery) → vancomycin
TB → RIPE + steroids
Lyme → ceftriazone
Diagnosis of TB
PPD (+ if > 15 mm or > 10 mm if prison, healthcare, DM, ETOH, chronically ill, > 5 mm if AIDS/immunosuppressed)
If PPD+ → CXR
If CXR+ → acid fast stain of sputum → treat with RIPE for 6 months (12 if meningitis, 9 if pregnant)
If CXR- → need 3 negative sputums to rule out TB
Side effects of RIPE drugs
Rifampin: turns body fluids orange/red, induces CYP450
INH: peripheral neuropahty and sideroblastic anemia (prevent by giving B6), hepatitis with mild bump in LFTs
Pyrazinamide: benign hyperuricemia
Ethambutol: optic neuritis, other color vision abnormalities
Definition of and management of neutropenic fever
Neutropenic fever = absolute neutrophil count (ANC) < 1500 (severe if < 500)
Increased risk of mucositis and translocation of bacteria into bloodstream (NEVER DO A DRE)
Treat empirically with anti-pseudomonal beta-lactam (cefepime, meropenem, piperaciilin-tazobactam) then blood and urine cultures
Hepatitis B postexposure prophylaxis
If completed Hep B vaccine series + documented response → no prophylaxis
If did not complete Hep B vaccine series/unvaccinated → test source patient blood → if HBsAg and no anti-HBsAg → hepatitis B immunoglobulin + initiate vaccine series → viral serology
Diarrhea + solitary cyst in the right lobe of the liver (anchovy paste)
Entamoeba hystolytica
Tx: metronidazole + intraluminal antibacterial (e.g. paromomycin)
Filamentous, branching bacteria
Nocardia: gram +, aerobic, partially acid-fast, tx with TMP-SMX
Actinomyces: gram +, anaerobic, not acid fast, sulfure granules, tx with penicillin G
Acid-base disturbances in saicylate toxicity
ASA overdose causes respiratory alkalosis (early) and anion-gap metabolic acidosis (late) which together give nearl-normal pH, low pCO2, and low HCO3
