Internal Medicine Clerkship

Question 1

Treatment of Stable Angina

Answer 1

ASA
Beta blockers
Ca Channel blockers
Long acting nitrates
Short acting nitrates
Stress test every patient
-high risk needs angiography
statin

Question 2

3 Most important symptoms of stable angina

Answer 2

Substernal chest pain/pressure (can radiate)
occurs with exertion
Subsides with rest or NG

Question 3

3 factors that differentiate Unstable angina from stable

Answer 3

New onset that is physically limiting
worsening from baseline
at rest

Question 4

NSTEMI difference from unstable angina

Answer 4

increase in biomarkers

Question 5

Treatment of NSTEMI

When to do PCI? Time?

Answer 5

NG
O2
Morphine
Statin
Beta Blocker
ASA
ACEi if hypertensive
Therapeutic Heparin (IV not SQ, since they have a clot already)

Medium or high risk:
300 mg Plavix before cath lab
PCI within 90 minutes, otherwise thrombolytics

Question 6

TIMI score

Score needed to cath? Time frame?

Answer 6

• Age > 65
• 3+ CAD risk factors
• known obstructive CAD (>50% lesion)
• Elevated biomarkers
• ST deviation
• Active chest pain
• ASA in the last 7 days

Intermediate or high risk (3-4 or 5-7) need revascularization within 24-48 hours
If unstable, LV dysfunction, new murmur, or refractory chest pain –> immediate cath

Question 7

Indication for immediate catheterization

Answer 7

• unstable
• LV dysfunction
• new murmur
• refractory chest pain

Question 8

Antiplatelet therapy after stent placement and how long?

Answer 8

bare metal stent - ASA for life, plavix for 1 month

drug eluting stent - ASA for life, plavix for 1 year (takes longer to reepithelialize)

Question 9

Complications post-MI and time frame?

Answer 9

Day 0-1: in stent rethrombosis
Day 3-7: rupture of papillary muscle, VSD, or free wall
Week 2-6: Dressler’s syndrome (autoimmune pericarditis)

Question 10

Factor V Leiden

Answer 10

Most common thrombophilic disorder
Autosomal dominant
resistance to activated protein C

Question 11

DVT prevention in the hospital

Answer 11

Heparin 5000 units SC q 8-12 hours
Enoxaparin (Lovenox) 40 mg SC q24h
- Not in CKD or AKI (excreted by kidneys)
Pneumatic compression devices (stockings are inadequate)

Question 12

Wells Clinical Score (DVT)

What score = what treatment?

Answer 12

Active cancer
Immobilization
surgery within 12 weeks requiring regional or general anesthesia
localized tenderness
entire leg swollen
calf size difference >3 cm
pitting edema confined to symptomatic side
collateral superficial veins
previous documented DVT
alternate diagnosis at least as likely as DVT -2 points

Score:
0 - low (perform D-dimer)
1-2 - moderate or 3+ - high (LE ultrasound)

Question 13

Therapy for DVT

How long?

Answer 13

Enoxaparin (lovenox) 1 mg/kg q12h or 1.5 mg/kg SC q24 h (different dosing from prophylaxis)
IV heparin
transition to warfarin with goal INR 2-3 for 24 hours before stopping Heparin

provoked - 3 months
unprovoked, ongoing risk factor, or repeated - 1 year

Question 14

Wells Criteria (PE)

What score is high risk?

Answer 14

Clinical signs or symptoms of DVT 3
Alternate less likely than PE 3
Heart rate 100 / min 1.5
immobilization/surgery last 4 wks 1.5
previous DVT/PE 1.5
Hemoptysis 1
cancer last 6 months 1

6: high risk

Question 15

Treatment for massive PE

Answer 15

hemodynamically stable:
anticoagulate (hep –> warfarin)
IVC filter
hemodynamically unstable (BP

Question 16

HIT

Treatment

Answer 16

5-10 days after heparin exposure
decrease in Plt > 50%
stop heparin
start direct thrombin inhibitor: Lepirudin or Argatroban
Protamine used for Heparin reversal