Internal Medicine Flashcards
1
Q
DDX for WBC casts?
A
Pyelonephritis Acute intersitial nephritis
2
Q
DDx for muddy brown casts?
A
Acute tubular necrosis
Can be caused by ischemic AKI or nephrotoxic AKI (antibiotics, radiocontrast agents, NSAIDs, poisons, myoglobinuria, hemoglobinuria, chemotherapy, AL in MM)
3
Q
Metabolic derangements in AKI
A
Hyperkalemia Anion gap metabolic acidosis Hypocalcemia Hyponatremia Hyperphosphatemia Hyperuricemia
4
Q
Metabolic derangements in CKD
A
Hyperkalemia Hypermagnesemia Hyperphosphatemia Metabolic acidosis Hypocalcemia
5
Q
Side effects of ACEI
A
ACEI dilate afferent arteriole Hyperkalemia
6
Q
Absolute indications for dialysis
A
Acidosis Electrolyte abnormalities Intoxications Overload, hypervolemic Uremia based on clinical presentation (e.g. AMS, pericarditis)
7
Q
Minimal change disease
A
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
8
Q
Focal segmental glomerulosclerosis (FSGS)
A
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
9
Q
Membranous glomerulonephritis
A
Nephrotic
Microscopy: thick glomerular basement membrane
A/w: Hep B, Hep C, SLE
Does not respond well to steroids
10
Q
Post-infectious glomerulonephritis
A
Nephritis 10-21 days following URI
Low C3 complement
Elevated anti-streptolysin O and/or anti-DNAse B
11
Q
IgA nephropathy
A
Nephritis 5 days following URI
Normal complements
12
Q
Prostate cancer
A
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
13
Q
Treatment of CAD
A
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)
14
Q
Treatment of hypertrophic cardiomyopathy
A
Beta-blockers
15
Q
Treatment of CHF
A
ACEI + loop or thiazide diuretic Beta-blockers Spironolactone/Eplerenone
16
Q
Treatment post-stent placement
A
Dual platelet therapy (aspirin + clopidogrel) 1 month for BMS 12 months for DES
17
Q
Treatment for aortic dissection
A
IV beta-blocker to SBP 100-120 If SBP still > 120, add sodium nitroprusside
18
Q
Treatment for cocaine-induced chest pain
A
IV benzodiazepines Aspirin, nitroglycerin, CCB Beta-blockers contraindicated
19
Q
Arrhythmia most specific for digitalis toxicity
A
Atrial tachycardia with AV block
20
Q
Finds for aortic stenosis
A
Fatigue, lightheadeness with exertion, presyncope Midsystolic murmur over RUSB Diminished and delayed carotid pulse Soft and single S2
21
Q
Tx for sinus bradycardia
A
IV atropine
22
Q
Metabolic derangments in intravascular hemolysis
A
Hemoglobinemia
Hemoglobinuria
Elevated lactate dehydrogenase
Decreased haptoglobin (excess hemoglobin exceeds binding capacity)
23
Q
Primary biliary cholangitis
A
S&S: pruritus, fatigue, jaudice, eyelid xanthelasma, portal HTN, osteopenia
Labs: antimitochondrial antibody, elevated Alk Phos
Tx: ursodeoxycholic acid, liver transplant for advanced disease
24
Q
Wernicke encephalopathy
A
Thiamine deficiency due to alcoholism, malnutrition
S&S: encephalopathy, oculomotor dysfunction, postural and gait ataxia
Tx: IV thiamine followed by glucose infusion
25
Indications for hospitalization for CAP
Confusion
Urea \> 20
Respirations ≥ 30
SBP \< 90, DBP \< 60
Age ≥ 65
26
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
27
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
28
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
29
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)
30
Treatment elevated homocystine
Pyroxidine, folate, B12 (if deficiency documented) as these are co-factors in homocysteine metabolism
31
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
32
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)
33
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
34
35
Leads I and aVL
Lateral MI --\> left circumflex
36
Leads V1-V4
Anterior MI --\> left anterior descending
37
Leads V1-V4, V5-V6, I, aVL
Anterolateral MI --\> left main
38
Leads II, III, aVF
Inferior MI --\> posterior descending (85% branches from right coronary)
39
Causes of dilated cardiomyopathy?
Alcohol abuse Wet beriberi Coxsackie A and B virus myocarditis Chronic cocaine use Chagas disease Doxorubicin toxicity Hemochromatosis Peripartum cardiomyopathy
40
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
41
Weak upper extremity pulses, arrowing of aortic arch and proximal great vessels
Takayasu arteritis Tx: corticosteroids
42
Hepatitis B, hypertension, transmural inflammatory and fibrinoid necrosis of arterial wall, "string of pearls" on arteriogram
Polyarteritis nodosa Tx: cyclophosphamide, corticosteroids
43
Fevers, conjunctivitis, cervical lymphadenopathy, strawberry tongue, rash on palms and soles
Kawasaki disease Tx: aspirin, IV immunoglobulins Complications: coronary artery aneurysm
44
Smoking, claudication,gangrene, autoamputation, Raynauds
Buerger disease (thromboangiitis obliterans) Tx: smoking cessation
45
c-ANCA (PR3-ANCA), involvement of nasopharynx, lungs, kidneys
Granulomatosis with polyangiitis (Wegners) Tx: cyclophosphamide, corticosteroids
46
p-ANCA (MPO-ANCA), invovlement of lungs, kidneys
Microscopic polyarteritis No nasopharyngeal involvement and no granulomas distinguishes from Wegners
47
p-ANCA (MPO-ANCA), asthma, palpable purpura, GI complaints, increased IgE
Churg Strauss (eosinophilic granulomatosis with polyagiitis) Granulomas with eosinophils
48
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
49
Medical management post-MI
Aspirin (+ clopidogrel if stent for 9-12 months)
Beta-blocker
ACEI (if CHF or LV dysfunction)
Statin
Nitrates for pain
50
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
51
Treatment of WPW
Procainamide
Avoid beta-blockers, digoxin, CCB (anything that slows AV conduction)
52
Treatment of SVT
First line: carotid massage, face in ice water (for children)
Second line: adenosine
53
Cardiac tamponade
Clinical indicators: hypotension, distant heart sounds, JVD, pulsus paradoxus, electrical alternans
Tx: pericardiocentesi
54
Crescendo-decrescendo systolic ejection murmur, louder with squatting, softer with valsalva + parvus et tardus
Aortic stenosis
Tx: valve replacement
55
Systolic ejection murmur, louder with valsalva, softer with squatting/handgrip
Hypertrophic obstructive cardiomyopathy
56
Late systolic murmur with click, louder with valsalva and handgrip, softer with squatting
Mitral valve prolapse
57
Holostystolic murmur, radiates to the axilla
Mitral regurgitation
58
Rumbling diastolic murmur with an opening snap, left atrial elargement and afib
Mitral stenosis
59
Blowing diastolic murmur with widened pulse pressure, waterhammer pulse
Aortic regurgitation
60
Most specific arrhythmia associated with digitalis toxicity
Atrial tachycardia with AV block
61
Treatment for long QT syndrome
Beta-blockers and pacemaker
62
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)
63
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
64
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
65
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
66
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
67
Cyanide poisoning
Nitrites to oxidize hemoglobin to methemeglobin which binds CN Thiosulfate to bind this cyanide, forming thiocyanate, which is renally excreted
68
Lobes of the lungs affected by pneumoconioses
Asbestosis --\> lung bases
Silica and coal --\> upper lobes
69
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
70
Locations of primary lung cancers
Adenocarcinoma, bronchioalveolar, large cell --\> peripheral Squamous cell, Small cells --\> central
71
Adenocarcinoma
Most common lung cancer in nonsmokers and overall Found in periphery
Bronchioloalveolar subtype looks like pneumonia on CXR --\> good prognosis
72
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
73
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
74
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
75
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)
76
Common sites of primary lung cancer metastasis?
Adrenal glands, brain, bone, liver
77
The terrible T's of a mediastinal mass
Teratoma Thymoma Thyroid cancer Terrible lymphoma
78
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
79
Smoking-related vs. A1AT deficiency emphysema
Smoking-related emphysema: centriacinar in the upper lobes
A1AT deficiency emphysema: panacinar in the lower lobes
80
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
81
Chronic rejection of a lung vs. kidney transplant
Kidney --\> inflammation of vasculature Lung --\> inflammation of small bronchioles (bronchiolitis obliterans)
82
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
83
Diagnostic criteria and management of ARDS
Dx: PaO2/FiO2 \< 200, bilateral alveolar infiltrates on CXR, PCWP \< 18
Tx: mechanical ventilation with PEEP
84
Treatment for COPD
First line: ipratropium, tiotropium
Second line: beta agonists
Third line: theophylline
85
Indications to start oxygen in COPD
PaO2 \< 55 or SpO2 \< 88%
86
Best prognostic indicator for COPD
FEV1
87
Interventions shown to improve mortality from COPD
Smoking cessation
Continuous oxygen therapy \> 18 hours/day (is PaO2 \< 55 or SpO2 \< 88%)
88
Sarcoidosis
Hilar lymphadenopathy, increased ACE, hypercalcemia, erythema nodosum
Refer to ophthalmology 2/2 uveitis conjunctivitis
Dx: biopsy
Tx: steroids
89
COPD + new-onset clubbing
Occult malignancy of the lung --\> get CXR
90
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
91
Complications of inflammatory bowel disease?
Toxic megacolon → surgery
Pyoderma gangrenosum → NO antibiotics
Erythema nodosum (painful nodules on anterior tibia)
92
Which IBD is a/w increased risk of primary sclerosing cholangitis?
Ulcerative colitis
PSC confers and increased risk for cholangiocarcinoma
93
How do you treat ulcers, abcesses, or fistulas associated with Crohn's disease?
Metronidazole
94
Treatment for IBD
ASA, sulfasalazine to maintain remission
Corticosteroids to induce remission
Azathioprine, 6MP, and methotrexate for severe disease
95
ALT \> AST and in the 1000s
Viral hepatitis
96
AST and ALT in the 1000s after surgery or hemorrhage
Ishemic hepatitis (shock liver)
97
Antimitochondrial antibodies
Primary biliary cirrhosis
Steroids not effective
98
ANA + antismooth muscle antibodies
Autoimmune hepatitis
Tx: steroids
99
Cholestatic pattern of liver enzymes?
Think obstruction → RUQ ultrasound → if equivocal, do abdominal CT (painless jaundice in elderly = pancreatic CA) → if equivocal, do ERCP
100
Prophylaxis for people exposed to bacterial meningitis?
Rifampin
101
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
102
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
103
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
104
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
105
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
106
Diarrhea + solitary cyst in the right lobe of the liver (anchovy paste)
Entamoeba hystolytica
Tx: metronidazole + intraluminal antibacterial (e.g. paromomycin)
107
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
108
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
