Internal Medicine Notes Flashcards
_________ angina occurs when there is clean coronary arteries that produce ischemia due to vasospasm. Treatment is ______
Prinzmetal’s; CCBs
What additional bone finding is associated with primary hyperparathyroidism?
Osteitis fibrosa cystica (“brown tumor”) — from overstimulated osteoclasts creating large bone lesions
Which of the following commonly cause elevated aminotransferases? Select all that apply
A. Carbamazepine B. Gabapentin C. Isoniazid D. Metformin E. Phenytoin F. Statins
A. Carbamazepine
C. Isoniazid
E. Phenytoin
F. Statins
What do you do if a pt on warfarin has a supratherapeutic INR that is <5 and there is no evidence of bleeding?
Hold a dose
Crescendo decrescendo murmur heard best at aortic region
Aortic stenosis
Symptoms of hypercalcemia
Stones (calcium nephrolithiasis)
Bones (fracture, osteopenia)
Abdominal groans (n/v, pain)
Psychic moans (AMS)
Symptoms of aortic stenosis
Angina (especially on exertion)
Syncope
Active CHF
Management of postrenal failure
The goal is to alleviate the obstruction
Insertion of a catheter can relieve obstruction of the distal GU
Stenting, nephrostomy tubes, and rarely open surgery are used for proximal GU system
Ventricular tachycardia is a wide complex and regular tachycardia. Look for “tombstone” pattern. Since it’s ventricular, there are no p waves at all - just QRS complexes. It responds to __________ (newer/better) or _______ (older/cheaper)
Amiodarone; lidocaine
Management based on kidney stone size
<5 mm = hydration and pain control
<7 mm = medical expulsive therapy (CCBs like amlodipine, alpha blockers like terazosin)
<1.5 cm = ureteroscopy for distal stones, lithotripsy for proximal stones
> 1.5 cm = laparoscopic exploration for proximal stones, percutaneous anterograde nephrolithotomy for distal stones
Initial treatment in the ED for asthma exacerbation
O2
Albuterol/ipratropium nebulizers (to reverse bronchoconstriction)
Corticosteroids (to reverse inflammation)
—Repeat peak flow, CO2 retention, O2 sat, and lung assessment after initial intervention
Pleural effusions are diagnosed on chest x-ray and first become apparent with blunting of the costophrenic angles, which requires at least 250 ccs of fluid. If more than that is present, the air-fluid level rises. In that case, a __________ is needed to assess if the fluid is free moving (not loculated) and in sufficient quantity (greater than ______ from chest wall to fluid level) to do a thoracentesis
Recumbent x-ray; 1 cm
[note that CT scan or bedside ultrasound can also assess for loculation]
Heart rhythm characterized by regularly prolonged PR interval. There’s no interval change between beats but each is prolonged. There are no dropped beats
First degree AV block
2 high intensity statins
Atorvastatin 40, 80
Rosuvastatin 20, 40
Why do patients with DKA often present with hyperkalemia?
- The acidosis drives K+ out of cells into the serum
- Insulin deficiency inhibits K+ transport into cells
Even though they appear hyperkalemic, DKA pts are actually K+ deficient. With the diuresis that results from hyperglycemia, K+ is lost in the urine. When insulin is started and K+ is driven back into cells, serum K+ can drop precipitously. As soon as this happens, K+ needs to be added to the IV fluids and monitored closely during course of tx. If serum K+ is <3.3 mEq/L you must replace that BEFORE starting insulin therapy.
In patients that meet the criteria, screening for lung cancer is done with what test?
Annual low dose CT scan of the chest
What will CXR, EKG, and ABG usually show in the setting of PE?
Normal CXR
EKG shows S1Q3T3 = right heart strain
ABG shows hypoxemic respiratory alkalosis
Pericarditis presents as pleuritic chest pain that improves with leaning forward. It will have a multiphasic friction rub. What is the characteristic finding on ECG?
Diffuse ST elevation with PR segment depression
Causes of obstruction in postrenal failure
Stones and cancer can cause obstruction throughout, but are most often in the ureters
BPH, Neurogenic bladder, and kinked catheters most often affect the distal GU system
Best test for dx of kidney stones
Non-contrast CT
[use US in pregnancy]
Granulomatous disease (sarcoid, TB) can turn on _________ independently of kidneys, which increases calcium and turns off PTH, resulting in phosphate being unable to be renally excreted. Use _______ to treat the underlying disease
Vitamin D
Steroids
Treatment for pericarditis
NSAIDs + Colchicine
Define CVA permissive HTN
> 220 systolic and/or >120 diastolic
Adjustment of risk factors for acute coronary syndrome relating to LDL includes statin therapy with LDL goal of ______ and HDL goal of ______
<70; >40
How do you definitively diagnose ARDS vs. CHF?
Measure capillary-wedge pressures via Swan-Ganz cath
In ARDS, this will show a decreased or normal wedge (no backup of fluid) and an increased or normal LV function (not heart failure)
There are 2 types of effusions - transudates and exudates. What is a transudate and what are some potential causes?
Transudate = a lot of fluid, and not much else. Usually bilateral
Caused by an intravascular pathology; either an increased hydrostatic pressure (CHF) or decreased oncotic pressure (nephrotic syndrome or cirrhosis)
Management of HTN and proteinuria in CKD
Use either ACE-I or ARB (don’t combine) with BP goal of <130/<80
2 drug options for pharmacologic stress test
Dobutamine
Adenosine
Myoglobin nephritis will present with blood in the urine but no RBCs, how do you tx?
NaHCO3
IVF
Causes of mitral regurg
Chordae tendinae rupture
Infective endocarditis
Direct trauma
How do you manage a pt with non-valvular atrial fibrillation present for >48 hours?
Place pt on warfarin or NOAC for 4 weeks (no LMWH bridge needed). After 4 weeks, TEE is done. If no clot is found, cardioversion is done and pt remains on anticoagulation for another 4 weeks
[Major difference from valvular afib is that you can choose NOAC or warfarin, and you do NOT need to bridge with LMWH]
Radioopaque vs. radiolucent stones
Radioopaque = calcium oxalate, magnesium/ammonium/phosphate (struvite)
Radiolucent = uric acid, cysteine
Management of diabetes in CKD
Similar to general diabetic management — A1c goal is still <7
Don’t use metformin
What are the stages of chronic kidney disease?
Stage I = GFR >90
Stage II = mild, GFR 60-89
Stage III = moderate, GFR 30-59
Stage IV = severe, GFR 15-29
Stage V = renal failure/ESRD, GFR <15, dialysis required for survival
Confirmatory test for valvular disease when a murmur is heard on cardiac auscultation
Echocardiogram
Screening for lung cancer is done with annual low dose CT of the chest. What are the criteria for those who require screening?
30 pack year history
Quit less than 15 years ago
Age between 55-80 years old
Treatment for mitral stenosis
Preload reduction
For severe disease, balloon valvotomy or valve replacement
If there is afib, anticoagulate and cardiovert once lesion is identified
Staging method for lung cancer
PET CT
List complications of CKD
Anemia Secondary hyperparathyroidism Osteoporosis Volume overload Metabolic acidosis
A pt with RBC casts on urinalysis is indicative of glomerulonephritis. There are many diseases that can cause this and the way to tell them apart is with biopsy - something that is not often done. Learning the typical history should help you tell them apart. What becomes important is to rule out nephrotic syndrome with a UA spot test or 24-hr urine. What are you looking for?
> 3.5 g/24 hr urine
Edema
Hyperlipidemia
Best test for dx of coronary artery disease
Catheterization
[assesses severity of stenosis AND helps r/o Prinzmetal angina]
DVTs form in the deep veins, typically the ______ or _______ veins. Since there aren’t valves in deep veins, a piece of clot can travel up to the IVC and into the lungs where it gets stuck in a small vessel.
Popliteal; femoral
What criteria are used to characterize thoracentesis fluid?
Light’s criteria — compares serum protein and serum LDH to pleural protein and pleural LDH
Note that definitive diagnosis of pleural fluid also depends on WBC, RBC, pH, and glucose levels
Levels of _____, _____, and ____ are non-diagnostic for sarcoid but can be used to track therapy
ACE, Calcium, Vit D
Chronic NYHA classes I-IV
I = no patient limitations, no symptoms
II = slight limitations, pt is comfortable at rest and walking
III = moderate limitations, pt is comfortable at rest only
IV = totally limited, pt is bed-bound and has symptoms at rest
The only thing that causes metabolic alkalosis is high aldosterone. The decision becomes whether the person is volume responsive. This is done in one of two ways: using the hx to say pt is volume down and give fluids then recheck bicarb, OR by checking the urine chloride.
What does it mean if it’s low (<10) vs. high (>10)?
Low (<10) = pt is salt-sensitive, or volume responsive, and giving them fluids will help their condition
High (>10) = not volume responsive. If pt is hypertensive, consider diseases of too much aldosterone (renal artery stenosis, Conn’s syndrome). If the pt is NOT hypertensive, consider genetic syndromes like Bartter and Gitelman
If hypokalemic, oral replacement is preferred. If IV must be used, the rate must be less than _______ if by peripheral IV, or less than ______ if by central line
<10 mEq/hr; <20 mEq/hr
______ is an alternative to statins that decreases fatty acid release and decreases LDL synthesis. It may cause flushing, which can be treated by aspirin prophylaxis
Niacin
Intrarenal disease is quite difficult to diagnose, and definitive diagnosis can be made with biopsy — however this is rarely the right answer. Instead, use of the clinical history and urinalysis can often provide the diagnosis. What finding on UA is particularly helpful in differentiating between the 3 types of intrarenal disease?
Casts
Pt presents with glomerulonephritis and history of asthma and hematuria
What type of glomerulonephritis?
Churg-strauss
When someone presents to the ED with acute or refractory symptoms of asthma they need to be treated and stratified. Evaluation requires what 3 components?
Peak expiratory flow rate (PEFR)
Physical exam
ABGs
[A CXR isn’t needed but may be used to r/o other causes of dyspnea]
Pharmacologic therapy options for inpatient DVT prophylaxis
Unfractionated heparin 5000 units subQ q8hrs
LMWH options: enoxaparin 40 mg subQ daily, Dalteparin 5000 units subQ daily
Fondaparinux daily injection
Whenever a cardiac stress test is positive, the next step is ________
Catheterization
Pattern of breathing characterized by oscillations between apnea and tachypnea seen in patients with stroke, TBI, brain tumor, CHF, or actively dying
Cheynes-Stokes breathing
Pattern of very deep respirations with a normal rate; this is a compensatory mechanism that allows patients who have metabolic acidosis (such as DKA) to blow off additional CO2
Kussmaul breathing
What is the best test for diagnosing PE?
CT angiogram
What are the criteria required to start chronic home O2 in a COPD pt?
pO2 <55 on ABG or SpO2 <88% on pulse ox at rest, activity, or exercise
[goal is to titrate SpO2 >88-92%]
Causes of high anion gap metabolic acidosis
Methanol Uremia DKA Propylene glycol Iron and INH Lactic acidosis Ethylene glycol Salicylates
Typical treatment for sarcoid includes _____ and ______
Methotrexate; cyclophosphamide
Steroids may be used for associated uveitis, bells palsy, and erythema nodosum
Pt presents with glomerulonephritis and history of hemoptysis, hematuria, and positive anti-GM antibodies
What type of glomerulonephritis?
Goodpasture
Vertebrobasilar insufficiency may result in syncope. What test is used to diagnose?
CT angiogram
Hyperosmolar hyperglycemic state is a condition characterized by very elevated blood glucose, usually over 600, as well as increased serum osmolarity (usually above 300) and no ketones present; usually develops in pts with chronic hyperglycemia and an inciting event such as infection or other acute illness.
If this condition were accompanied by severe mental status changes, it would be termed ___________
Nonketotic hyperosmolar coma
[aka hyperosmolar hyperglycemic nonketotic coma]
Symptoms of mitral regurg
Atrial stretch — possible afib
Pulmonary congestion (possible CHF)
Decreased forward flow —> cardiogenic shock
When evaluating chest pain, it is important to r/o the most severe disease (STEMI) first with a 12-lead ECG, looking for ST-segment elevations or a new _______.
STEMI tx is emergent cath. If negative, r/o NSTEMI with _________. NSTEMI goes to urgent cath. If both STEMI and NSTEMI testing are normal, determine whether chest pain is coronary in nature at all using ___________
LBBB
Biomarkers (Troponin-I); Stress test
SVT is an aberrant reentry that bypasses the SA node and will be distinguished from a sinus tachycardia by a resting HR >150 with the loss of P waves. What is the pharmacologic tx?
Adenosine
_______ _______ is the most common cause of acute kidney injury in the outpatient setting and should correct quickly with fluid
Prerenal azotemia
Sinus bradycardia is simply a slow normal sinus rhythm that responds to ______ until it gets really bad, then only pacing helps
Atropine
Anti-anginal antihypertensive agents that cause peripheral edema; they are not useful in heart failure with reduced EF
Dihydropyridine calcium channel blockers
Restrictive lung disease resulting from exposure to rock dust (quarries, blasting) and sand blasting; unique CXR findings of upper lobe nodules. There’s no tx but pts should be screened annually for TB
Silicosis
What do you do if a pt on warfarin has a supratherapeutic INR and there is evidence of bleeding?
FFP
Vitamin K
Symptoms of hyperkalemia
Areflexia
Flaccid paralysis
Paresthesia
ECG changes — PR prolonged, widened QRS, peaked T waves
4 categories of patients who should be on a statin
- Vascular disease — MI, CVA, PVD, carotid stenosis
- LDL >190
- LDL 70-189 + age 40-75 + diabetes
- LDL 70-189 + age 40-75 + risk factors
[risk factors include diabetes, smoking, HTN, dyslipidemia, age >55 for women, age >45 for men]
Tx for new onset atrial fibrillation <48 hours, or atrial fibrillation in unstable pt
Cardioversion
Guidelines for initiating diabetes therapy in the following cases:
A1c <9%
A1c >9%
A1c >10% or severe sxs
A1c <9% = metformin monotherapy
A1c >9% = dual therapy (metformin + additional agent)
A1c >10% or severe sxs = combo injectable therapy (basal insulin + mealtime insulin or GLP-1 receptor agonist)
DVTs form in the deep veins, typically the popliteal or femoral veins. Since there aren’t valves in deep veins, a piece of clot can travel up to the IVC and into the lungs where it gets stuck in a small vessel. What are the 2 primary consequences?
- Because blood is unable to get to the alveoli, there’s limitation of gas exchange
- Because there’s less piping to pump blood through, there’s an increase in pulmonary vascular resistance, creating right heart strain
LMNOP mnemonic for tx of CHF exacerbation
Lasix Morphine Nitrates O2 Position
For exercise induced asthma with known triggers, the IgE/Histamine stabilizers ______or ______ can be used immediately before known exposure but with limited use
Nedocromil; cromolyn sulfate
A pulmonary nodule is found on CT scan and on comparison of old films, you find that it has not changed in 2 years. What is the next step?
No change in 2 years means it is stable — no further follow up required
Acute tubular necrosis is caused by either ischemic damage or toxin exposure. The tubules necrose, die, and slough off producing muddy brown casts. The pt will go through what 3 phases?
Prodrome — creatinine rises but urine output remains the same
Oliguric — creatinine rises but urine output plummets (caution fluid overload)
Polyuric — pt pees a lot
What are some causes of restrictive cardiomyopathy?
Sarcoid Amyloid Hemochromatosis Cancer Fibrosis
What are the Well’s criteria used in evaluation of DVT/PE?
PE most likely dx, s/s DVT = 3 points each HR > 100 = 1.5 points Immobilization = 1.5 points Surgery w/i 4 weeks = 1.5 points Hemoptysis = 1 point Malignancy = 1 point Hx of DVT or PE = 1.5 points
Wells Score for V/Q scan interpretation
Score <2 = small probability
Score 2-6 = moderate probability
Score >6 = high probability
Modified Well’s — do I do a CT scan?
Score of 4 or less = don’t do it
Score >4 = Do it
Decrescendo murmur heard best at aortic valve
Aortic insufficiency
Hypertrophic cardiomyopathy is a ______ ______ inherited mutation of myocyte sarcomeres, causing an asymmetric hypertrophy of the septal wall which occludes the aortic outlet — thus it presents similar to aortic stenosis except that its heard at the apex and improves with increased preload.
Autosomal dominant
Central lung lesion caused by smoking; typically metastasized by the time it is dx. Requires CT scan to see, and EBUS with bx will confirm. Can produce ADH causing SIADH or ACTH causing Cushings, also may cause lambert eaton
Small cell carcinoma
Carcinoid is a rare neuroendocrine tumor that may occur in the small intestine or lung. It produces serotonin, which degrades to 5-HIAA and gets secreted into the urine. What are clinical features?
Because the serotonin originates in the lung, it will cause a left-sided valve fibrosis along with flushing, wheezing, and diarrhea typical of the intestinal carcinoid
Since the serotonin is degraded by the liver, the right side of the heart is spared.
What do you do if you find that pts INR is subtherapeutic on warfarin?
Put back on heparin and bridge until therapeutic
[a bridge must be a minimum of 5 days and as long as it takes to get therapeutic]
Acute interstitial nephritis is essentially an allergic reaction with invasion of white cells. Drugs, infections, and deposition disease can cause it. The urine will present with immune cells: WBCs, white cell casts (pyelonephritis), or eosinophils. How do you manage this?
Removal of offending agent is critical — that means either treat the infection or stop the drug
[Steroids are often ineffective]
Recurrent pleural effusions may be treated with ______ - a chemical or surgical elimination of the pleural space
Pleurodesis
The Diamond classification identifies pt’s risk of coronary artery disease based on symptoms. What are the 3 components?
- Substernal chest pain
- Worse with exertion
- Better with Nitroglycerin
[3/3 is called typical, 2/3 is called atypical, 0-1 is called non-anginal. The more positives, the higher the likelihood that the chest pain is anginal]
Pt presents with glomerulonephritis and history of recent viral illness
What type of glomerulonephritis?
IgA nephropathy
_______ failure is caused by obstruction to outflow. Obstruction results in hydroureter or hydronephrosis. While CT can be used to dx obstruction, _______ is the preferred test.
Postrenal; ultrasound
Drug that may be used as antihypertensive because the physician is also treating BPH, but really what the drug is causing is an orthostatic hypotension
Alpha antagonists
What are the symptoms that may accompany mitral stenosis?
Blood backs up in the lungs and you get pulmonary edema = CHF/SOB symptoms
Atrial stretch results in possible atrial fibrillation
[Mitral stenosis represents an obstruction to flow across the mitral valve during diastole, so forward flow is impeded]
Adjustment of risk factors for acute coronary syndrome relating to DM includes tight glucose control to near normal values _________ or HbA1c _______ with oral medications or insulin
80-120; <7%
Winter’s formula for expected CO2 for bicarb
Expected CO2 = (bicarb x 1.5) + 8 +/- 2
There are several biopsy methods for intrapulmonary lesions without evidence of spread. Bronchoscopy with EBUS is used to biopsy proximal lesions. ___________ is chosen when the lesion is peripheral. __________ can be used to sample lesions not accessible by the above options.
Still other methods exist. Thoracentesis revealing malignant cells indicates stage ____ disease. And lesions that are clearly malignant can be dx with resection
Percutaneous CT guided biopsy; Video Assisted Thorascopic Surgery
Stage IV metastatic
Treatment for PE is basd on severity of disease. If there’s a massive embolism that has compromised cardiac function (hypotension), it’s imperative to start emergent ___________
Intra-arterial tPA
What causes secondary hyperparathyroidism in CKD and how is it managed?
Secondary hyperparathyroidism is a product of phosphate retention (elevated phosphorus stimulates PTH) and vitamin D deficiency that leads to low calcium (which also stimulates PTH)
Thus, phosphate binders such as sevelamer and calcimimetics such as cinacalcet are used to decrease this risk
In a patient with prerenal azotemia, you are looking for a urine sodium <10, FENa <1%, and a BUN/Cr ratio >20. However, if the patient is on a diuretic, you should look at ______ instead of sodium
Urea
How do you calculate anion gap vs. urine anion gap?
Anion gap = Na - Cl - Bicarb
Urine anion gap = Na + K - Cl
When is it safe to stop the insulin drip in a pt with DKA?
When the pt can take food by mouth
After the pt has had a dose of long-acting subQ insulin
After the pt has had 2 successive panels showing normal anion gap
For thrombolysis in tx of acute treatment of coronary syndrome, either administration of _____ (within 12 hrs of onset) or _______ is done only when catheterization is not available AND pt is in an acute disease (STEMI)
tPA, heparin
