Internal Medicine: Case Files Flashcards
For individuals from areas of low drug-resistance, What is the usual therapy for TB?
2 month course of INH, Rifampin, and Pyrazinamide (Watching patients take the medication should be instituted in all patients in this phase), followed by 4 month course of INH and rifampin. Pyridoxine is frequently added to avoid peripheral neuropathy caused by INH.
Treatment failure is defined as positive cultures after 3 months or positive AFB stains after 5 months and should be treated by adding two more drugs.
What are the most common causes of bloody pleural effusion (in the absence of trauma)?
- Malignancy: Associated with subacute symptoms
- Pulmonary embolism with infarction: associated with acute onset dyspnea and pleuritic chest pain
- Tuberculosis
What is the treatment for an acute painful episode in a sickle cell patient?
- Hydration
- Narcotic analgesia
- Adequate oxygenation
- Search for underlying infection
At what point is carotid endarterectomy superior to medical therapy in stroke prevention (provided the surgical risk is
In symptomatic patients with severe stenosis >70%
Elevated serum levels of LDH and indirect bilirubin or decreased serum levels of haptoglobin are consistent with what?
Hemolysis
What is the most common cause of pleural effusion and how does it present?
Congestive heart failure which is associated with bilateral symmetric transudative effusions
Treatment of choice is diuresis
When do you start prophylaxis against Mycobacterium avium-intracellulare (MAC) complex in a HIV positive patient and what do you give?
Clarithromycin or Azithromycin when CD4 count < 50 cells/mm3
What is the treatment for latent TB?
INH for 9 months
What is the principal imaging modality to diagnose suspected pulmonary embolism?
Chest CT with IV contrast
Patients in whom a CT with radiocontrast cannot be obtained or is contraindicated, a V/Q scan remains a useful tool
What are some poor prognostic signs of acute pancreatitis?
- BUN rises 5 mg/dL after 48hrs despite IV hydration
- Elevated serum glucose
- Hematocrit drop of at least 10%
Notably, the amylase level does not correlate to the severity of the disease
What is the treatment of choice for endocarditis due to one of the HACEK oragnisms?
Ceftriaxone
What is the treatment for viral or inflammatory pericarditis?
Nonsteroidal anti-inflammatory drugs or corticosteroids for refractory cases
What is the BUN:Creatinine ratio in prerenal failure?
>20
When is PPD considered positive in a person without any risk factors?
Induration >15mm after 48-72 hours
What is the treatment for prerenal and postrenal failures?
Prerenal: Volume replacement
Postrenal: Relief of obstruction
What is the drug of choice for treating Osteoarthritis?
Acetaminophen
What are the most common bacteria implicated in catheter-associated infections?
Staph Aureus and coagulase-negative Staph
What is the treatment for neurosyphilis or tertiary syphilis?
IV penicillin for 10-14 days
What is the treatment for euvolemic patients with hyponatremia?
Fluid restriction
Patients with severe symptoms such as coma or seizures, should be treated with hypertonic (3%) saline
What are the 3 most common causes of cough in an immunocompetent nonsmoker who is not taking ACE inhibitors?
- Postnasal drip
- Asthma
- GERD
Unconjugated hyperbilirubinemia is usually caused by what?
Hemolysis or Gilbert Syndrome
When is PPD considered positive in patients with HIV, close contacts of patients with TB, or patients with CXR findings consistent with TB?
Induration of 5mm or more after 48-72 hours
What is the appearance of the ventricles and brain in a patient with normal pressure hydrocephalus?
Enlarged brain ventricles without brain atrophy
Hemorrhagic cerebrospinal fluid with evidence of temporal lobe involvement by imaging or EEG suggests what?
Herpes simplex virus encephalitis
Acyclovir is the tx of choice
In what normal conditions or disease states can RPR and VDRL tests for syphilis be falsely positive?
- Pregnancy
- SLE
Microhemagglutination assay for Treponema pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS) test should be performed for confirmation of syphilis, but once positive, they usually stay positive for life.
To be diagnosed with Systemic Lupus Erythematosus, a patient must have 4 of what 11 criteria?
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis
- Serositis
- Renal disease
- Neurologic manifestations
- Hematologic cytopenias
- Immunologic abnormalities
- Positive Antinuclear antibody (ANA)
What should the rate of sodium correction not exceed in order to avoid central pontine myelinolysis?
0.5 to 1 mEq/hr
What is the initial treatment for immune thrombocytopenic purpura?
Corticosteroids
Severe disease can be treated with IV immunoglobulin and chronic refractory cases are treated with splenectomy.
Acute onset dyspnea or hypoxemia with a normal chest x-ray should be considered what until proven otherwise?
A pulmonary embolism
What is the drug of choice for Polymyalgia Rheumatica and Temporal Arteritis?
Corticosteroids
- Polymyalgia Rheumatica: Prednisone 10-20mg
- Temporal Arteritis: Prednisone 40-60mg
What are the indications for urgent dialysis?
AEIOU
- Acid-base problems (severe acidosis or alkalosis)
- Electrolyte problems (hyperkalemia)
- Intoxications
- Overload, fluid
- Uremic symptoms
Because of the risk of fatal cardiac arrhythmias, severe hyperkalemia is considered an emergency best treated medically and not with dialysis
What is the treatment for rhabdomyolysis?
Aggressive administration of IV normal saline to prevent renal failure
What is the medical approach to Alzheimer disease?
Cholinesterase inhibitors such as Donepezil or Rivastigmine
In a patient with adrenal insufficiency, is hyperpigmentation a sign of primary, secondary, or tertiary etiology?
Primary
Hyperpigmentation occurs as a result of increased melanocyte-stimulating factor, a byproduct of ACTH, and occurs in primary adrenal insufficiency. Secondary causes of adrenal insufficiency result in low ACTH levels and thus do not cause the “tanned” appearance
What is the prophylaxis of choice in patients at high risk of endocarditis?
Amoxicillin
What is the target blood pressure of a patient being treated for hypertension?
< 135/85 mmHg unless the patient has diabetes or renal disease, in which case the target is < 130/80 mmHg
What is the medical approach to multi-infarct dementia?
Address atherosclerotic risk factors and identify/treat thrombus
What is the difference between the onset of action of DMARDs and TNF antagonists?
TNF antagonists take effect within weeks whereas DMARDs take several months
What is the medical approach to Multiple Sclerosis?
Recombinant interferon and corticosteroids
What is the approach to Normal-pressure Hydrocephalus?
Ventricular shunting process
Pulsus paradoxus (drop in systolic BP >10mm Hg upon inspiration) is suggestive of what?
Cardiac tamponade
This is the most important physical sign to look for in tamponade, although it is not specific for tamponade it is fairly sensitive for hemodynamically significant tamponade in almost all cases
Early reperfusion with Percutaneous coronary intervention or thrombolytics reduces mortality and preserves ventricular function in which patients suffering from an acute MI?
Those who have ST-segment elevation, no contraindications, and receive treatment within the first 6-12 hours
Patients benefit maximally from thrombolytics when they are administered within 1 to 3 hours after the onset of chest pain, and the relative benefits decline with time. Because systemic coagulopathy may develop with time, the major risk of thrombolytics is bleeding, which can be potentially disastrous, for example, intracranial hemorrhage. The risk of hemorrhage is relatively constant, so the risk begins to outweigh the benefit by 12 hours, at which time most infarctions are completed, that is, the at-risk myocardium is dead
What is the definitive treatment for Graves Disease?
Radioactive iodine
For patients with chronic hypoxemia, what treatment has the most significant impact on mortality?
Supplemental oxygen
What is the most important step in the diagnosis of endocarditis?
Serial blood cultures
Acutely ill patients should have three blood cultures obtained over a 2-3 hour period prior to initiating antibiotics. In subacute disease, three blood cultures over a 24 hour period maximize the diagnostic yield
What test is done to rule out a PE in a patient with a low probability of having PE?
D-Dimer ELISA
Conjugated hyperbilirubinemia with elevated alk phos is usually caused by what?
Biliary obstruction
Patient presents with pleuritic chest pain, a pericardial friction rub, and ECG findings of diffuse ST-segment elevation and PR-segment depression. What is the diagnosis?
Acute Pericarditis
When is a permanent cardiac pacemaker indicated?
- Symptomatic bradyarrhythmias (sick sinus syndrome)
- Mobitz II atrioventricular block
- Third degree heart block
What are the two most common causes of restrictive cardiomyopathy and what is the therapy?
- Causes: Amyloidosis or radiation therapy
- Treatment: No effective therapy
What is the treatment of choice for endocarditis due to Methicillin susceptible Staph aureus?
Nafcillin
Often used in combination with Gentamicin initially for synergy, to help resolve bacteremia
What is a positive Kussmaul sign and what condition is it likely to be seen in?
An increase in neck veins with inspiration is seen in constrictive pericarditis
Ordinarily the JVP falls with inspiration due to reduced pressure in the expanding thoracic cavity and the increased volume afforded to right ventricular expansion during diastole. Kussmaul’s sign suggests impaired filling of the right ventricle due to either fluid in the pericardial space or a poorly compliant myocardium or pericardium. This impaired filling causes the increased blood flow to back up into the venous system, causing the jugular vein distension (JVD) and is seen clinically in the external jugular veins becoming more readily visible.
What is the first agent that should be used after oxygen and nitroglycerin to decrease mortality in the face of an acute coronary event?
Aspirin
What test is necessary to differentiate between ischemic and hemorrhagic stroke?
Noncontrast computed tomography (CT)
What are the treatment guidlines for moderate persistent (daily symptoms and >1 night with symptoms per week)?
Daily medications
- Low-to-medium dose inhaled steroids
- Long acting B2-agonist
Quick relief medications
- Short-acting inhaled B2-agonist as needed
- Oral steroids may be required
What is the difference in presentation of biliary obstruction due to gall stones and biliary obstruction due to stricture or neoplasm?
Gallstones are painful but strictures and neoplasms are often painless
Albuminuria must be in excess of what in order for it to be detected with urine dipstick?
> 300 mg/d
At this point the patient is said to have overt nephropathy
In a hypervolemic patient, what is the treatment for hyponatremia?
Diuretics to reduce excess salt and water
What are the stages of lyme disease?
- Early localized stage: Occurs within the first month of the tick bite and presents with classic erythema migrans and possibly viral-like symptoms of fatigue, headaches, myalgias, and arthralgias
- Early disseminated stage: Occurs days to months after the initial tick bite and may present with additional skin lesions similar to the primary skin lesion, systemic symptoms of headache, mild neck stiffness, malaise, fatigue, fever, and commonly migratory musculoskeletal pain without joint inflammation. This stage may also include cardiac (heart block, myocarditis or pericarditis) or neurological (nerve palsies, meningitis, encephalitis) manifestations
- Late or persistent infection: Occurs months to years after the initial infection and commonly presents with generalized musculoskeletal pain and a migratory polyarthritis that may mimic juvenile rheumatoid arthritis
Abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis is indicative of what?
Pancreatic pseudocyst
Phlegmon (walled-off inflammatory mass without bacterial infection), pancreatic necrosis, and abscess should also be considered
Spontaneous hemorrhage may occur in a patient when platelet counts fall below what level?
10,000/mm3
When is elective repair recommended for abdominal aortic aneurysms
When they are > 5.5cm in size
What are the two causes of euvolemic hyponatremia?
- Increased free water intake (IE Polydipsia) that has overwhelmed the kidney’s capacity for excretion. Urine will by maximally dilute (osmolality < 100 mOsm/kg)
- Water excretion is impaired (IE hypothyroidism, adrenal insufficiency, or SIADH). Urine will not be maximally dilute (osmolality >150-200 mOsm/kg)
What is the treatment of choice for endocarditis due to streptococcus species?
Penicillin G
While awaiting pericardiocentesis, immediate supportive care of a patient with cardiac tamponade should include what?
Intravenous fluids
Patients with cardiac tamponade are preload dependent and any decrease in preload could lead to hypotension
What is the treatment regimen for H. Pylori infection?
14-day course of a proton-pump inhibitor in high doses (eg. Lansoprazole 30mg twice daily or omeprazole 20mg twice daily) along with antibiotic therapy, usually clarithromycin and amoxicillin
What are the treatment guidlines for mild persistent asthma (>2 days of symptoms per week, only 1 time per day, and >2 nights with symptoms per month)?
Daily medication
- Low dose inhaled steroids (preferred) or Cromolyn
- Leukotriene modifier
Quick relief medication
- Short acting inhaled B2-agonist as needed
- Oral steroids may be required
What does a serum ascites albumin gradient >1.1 g/dL suggest?
Portal hypertension (eg cirrhosis)
How does the DLCO differentiate between asthma and emphysema?
DLCO is decreased in emphysema and high in asthma
Nongonococcal septic arthritis usually affects large weight-bearing joints and is most often caused by what organism?
Staphylococcus aureus
What is the treatment for early localized Lymes disease?
Oral Doxycycline or Amoxicillin
What is the FENa in prerenal failure?
Prerenal failure with a FENa >1% may be seen with diuretic medications which interfere with sodium reabsorption and are often used in CHF and nephrotic syndrome
What differentiates common migraine headache from classic migraine headache?
The classic type has a preceding aura, whereas the common type does not.
Patients with diabetes should have their urine screened for what?
Microalbuminuria (albumin excretion of 30-300 mg/d)
Patient presents with visceral pain that localizes later to the left lower quadrant and is associated with fever, nausea, vomiting, and constipation. Labs reveal leukocytosis. What is the likely diagnosis?
Diverticulitis
Pain in the right lower quadrant wouldnt exclude this diagnosis because ascending colon or cecal diverticulitis can occur
What is the treatment of choice for endocarditis due to MRSA?
Vancomycin
Therapy for endocarditis in an IV drug user is directed against Staph aureus
Conjugated hyperbilirubinemia with elevated AST and ALT is usually caused by what?
Hepatocellular disease
Stepwise decline in cognitive function is typical for what?
multi-infarct dementia
What does a Delta wave on ECG indicate?
Wolff-Parkinson-White Syndrome
WPW syndrome: An accessory pathway provides an alternate route for electrical communication between the atria and ventricles, leading to preexcitation, that is, early ventricular depolarization that begins prior to normal AV nodal conduction
What is one of the most commonly used medications for treating hypertensive emergencies because of its nearly instantaneous onset of action and because it is easily titrated for a smooth reduction in blood pressure?
Sodium Nitroprusside
Its metabolite may accumulate, resulting in cyanide or thiocyanate toxicity when it is given for more than 2 to 3 days.
What can be done to drive potassium intracellularly in a hyperkalemic patient?
- Insulin + 50% glucose solution: Insulin drives potassium into cells, lowering levels within 30 minutes. The 50% glucose solution is to protect against hypoglycemia secondary to insulin administration.
- Beta-agonists: IE. Albuterol by nebulizer
- Sodium Bicarbonate: In the presence of a severe metabolic acidosis, administration of intravenous sodium bicarbonate also promotes intracellular diffusion of potassium, albeit less effectively
All three methods are transient because total body potassium balance is unchanged and the potassium eventually leaks back out of the cells
When is PPD considered positive in people with risk factors such as healthcare workers and patients with immunocompromise for reasons other than HIV?
Induration >10mm after 48-72 hours
In a hypovolemic patient, what is the treatment for hyponatremia?
Correction of the volume status, usually by replacement with isotonic (0.9%) normal saline
Spontaneous bacterial peritonitis is characterized by what ascitic fluid findings
- >250 polymorphonuclear cells/mm3
- Positive Monomicrobial culture
In patients with impaired systolic function and moderate to severe symptoms, What drugs have been shown to reduce mortality?
- ACE inhibitors
- Beta-blockers such as Carvedilol, metoprolol, or bisoprolol
Hydralazine with nitrites have been shown to reduce mortality in patients that cannot tolerate ACE inhibitors
What is the initial treatment for DKA?
IV normal saline for volume replenishment, followed by free water in the form of a glucose solution.
Glucose levels fall more quickly that ketones resolve. Continuous insulin therapy is necessary for resolution of the ketoacidosis and can be coadministered with a glucose infusion until the anion gap is resolved
What is the treatment for Early disseminated or late Lyme disease?
Intravenous cephalosporins
COPD is associated with what finding on pulmonary exam?
Expiratory wheezing
What are the 3 definitive treatments for hyperkalemia?
- Loop diuretics
- Sodium polystyrene sulfonate (Kayexalate): A cationic exchange resin that lowers potassium by exchanging sodium for potassium in the colon
- Emergency dialysis
What is the target therapeutic INR in warfarin therapy and when initiating warfarin therapy, what is the protocol to avoid a hypercoagulable state?
INR of 2.5 and warfarin therapy should begin with heparin, LMWH, or fondaparinux for at least 5 days while overlapping with warfarin until the INR has been therapeutic for 2 consecutive days.
How do you correct serum total calcium for changes in albumin levels?
Add 0.8 mg/dL to the serum total calcium for every 1g/dL of albumin that is below 4g/dL
What is the initial treatment for suspected bacterial meningitis?
High-dose 3rd generation cephalosporin given concurrently with Vancomycin
Patients who have undergone neurosurgical procedures or who have been subject to skull trauma are at risk for what?
Staphylococcal meningitis
What is the drug class of choice in alcohol withdrawal?
Benzodiazepines delivered in an upward titration followed by a downward tapering over the course of 48-72 hours
What is the target INR for Warfarin?
INR of 2 to 3
What two drugs increase Hemoglobin F and thus reduce the frequency of pain crises and other complications of Sickle cell disease?
- Hydroxyurea
- Decitabine
What is the appearance of the ventricles and brain in a patient with Alzheimer disease?
Enlarged cerebral ventricles and brain atrophy
What are some extra-intestinal manifestations of crohns disease and ulcerative colitis?
- Uveitis
- Erythema nodosum
- Pyoderma gangrenosum
- Arthritis
- Primary sclerosing cholangitis
Bone mineral density must meet what criteria for a diagnosis of osteoporosis?
T = -2.5 SD
The patient’s bone density must be 2.5 standard deviations below the mean bone density for age and sex matched population
What should be done immediately for a patient with hyperkalemia following an urgent ECG showing the classic peaked or “tented” T-waves?
IV Calcium should be administered
immediately
Although calcium will not lower the serum potassium level, the calcium will oppose the membrane effects of the high potassium concentration on the heart, allowing time for other methods to lower the potassium level
When is an MRI indicated in a workup for low back pain?
MRI should be reserved for those patients for whom surgery is being considered, because it is not required to make most diagnoses
What are the Light criteria for pleural fluid to be labeled an exudate?
Fluid must meet at least one of the following criteria:
- Pleural fluid protein/serum protein ratio >0.5
- Pleural fluid LDH/Serum LDH ratio >0.6
- Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH
Which symptom of Graves disease can progress even after treatment of thyrotoxicosis?
Opthalmopathy
Opthalmopathy is characterized by inflammation of extraocular muscles, orbital fat, and connective tissue, resulting in proptosis (exopthalmos), sometimes with impairment of eye muscle function (diplopia), and periorbital edema
Hypotonic hyponatremia always occurs due to what?
Water gain (that is, restriction or impairment of free water excretion
The normal kidney capacity to excrete free water is approximately 18-20 Liters/day, so it is clear that it is very difficult to overwhelm this capacity solely through excessive water intake. Therefore, when hyponatremia develops, the kidney is usually holding on to free water, either pathologically, as in SIADH, or physiologically, as an attempt to maintain effective circulating volume when patients are significantly volume depleted.
What is the next step in working up patient with an initial fasting glucose above 126 mg/dL but a repeat level below 126 mg/dL?
Oral glucose tolerance test
When is surgical thyroidectomy indicated in the treatment of Graves disease?
Indicated when obstructive symptoms are present or for women during pregancy
Upper airway (usually extrathoracic) obstruction is associated with what finding on pulmonary exam?
Inspiratory stridor
Syncope that occurs during or after exertion is likely caused by what?
Cardiac outflow obstruction such as aortic stenosis
What is the medical approach to intracranial tumor?
Corticosteroids to reduce intracranial pressure and treat the lesion
When does Delirium Tremens usually occur in a patient with alcohol withdrawal?
2-4 days after the cessation of drinking
Sudden resolution usually occurs several days later
What is the treatment for meningitis due to Listeria infection?
Ampicillin
What are the treatment guidlines for severe persistent asthma (daily symptoms and frequent symptoms at night)?
Daily medications
- high dose dose inhaled steroids
- Long acting B2-agonist
- Oral steroids if needed
Quick relief medications
- Short-acting inhaled B2-agonist as needed
- Oral steroids may be required
What is the treatment for early disseminated (Stage 2) and late (stage 3) lyme disease?
IV Cephalosporins
What is the classic triad of symptoms for normal pressure hydrocephalus?
- Dementia
- Incontinence
- Gait disturbance
When treating a patient in DKA, what can result from overly rapid correction of hyperglycemia or possibly from rapid administration of hypotonic fluid?
Cerebral edema
What is the recommended interval for cholesterol screening in the population of healthy young adults
Every 5 years
What is the treatment for uremic pericarditis?
Urgent dialysis
What can be given to a RA patient who is refractory to TNF antagonists and DMARDs?
Immunosuppressive agents
- Azathioprine
- Leflunomide
- Cyclosporine
- Cyclophosphamide
Equally as effective as DMARDs but considerably more toxic
What is the treatment for early syphilis?
A single intramuscular injection of penicillin
What is the treatment for late latent syphilis?
3 weekly intramuscular injections of penicillin
What are the 3 physical exam findings known as the Beck’s triad that describe acute cardiac tamponade?
- Hypotension
- Elevated JVP
- Small quiet heart
What is the first treatment that should be administered for a diabetic patient with microalbuminuria?
ACE inhibitor
Patients with diabetic nephropathy and proteinuria are at very high risk for CV disease, so aggressive risk factor reduction, such as use of statins, is important
What is the medical therapy for aortic dissection?
IV beta-blockers such as metoprolol or labetalol
Type A aortic dissections require emergency surgical repair. Type B aortic dissections can be managed medically
What is the treatment for early localized (stage 1) lyme disease?
Oral Doxycycline or Amoxicillin
What is the next step in assessing a “cold” nodule on radionuclide scan of the thyroid?
Fine-needle aspiration
Most “cold” thyroid nodules are not malignant, but must be examined to evaluate the need for surgical resection
What is the treatment of choice in a patient with atrial fibrillation in the setting of Wolff-Parkinson-White syndrome?
- Direct current cardioversion
- Procainamide or Ibutilide
AV nodal-blocking agents can, paradoxically, increase the ventricular rate
What is the most common cause of syncope in healthy young people?
Vasovagal syncopy
It often has a precipitating event, prodromal symptoms, and an excellent prognosis
What is the standard treatment regimen for diverticulitis?
Triple therapy
- Ampicillin
- Aminoglycoside
- Metronidazole
What are the 3 TNF antagonists used in the treament of RA if traditional DMARDS fail?
- Etanercept
- Infliximab
- Adalimumab
Which DMARD is often used as the first drug of choice in treating RA because of rapid onset of action and higher tolerability leading to greater patient compliance?
Methotrexate
