JH IM Board Review - SOS I Flashcards
Insensible losses:
500-1000ml/day lost through skin and respiratory tract.
Increases in plasma osmolality as small as …% can release ADH:
1%.
How great hypovolemia causes ADH release?
10% or greater.
What else causes incr. in ADH?
- Pain.
- Nausea.
- Dx: antidepressants, antipsychotics, nsaids, opioids, barbs.
Hyponatremia can occur with what total body Na?
- Low.
- Normal.
- High.
==> Hyponatremia requires the presence of too much water relative to the quantity of total body Na.
Asymptomatic hyponatremia is …?
Isosmolar.
Hypoosmolar hyponatremia causes symptoms by …?
SWELLING of the cns.
Hyperosmolar hyponatremia causes symptoms by …?
DEHYDRATION of the cns.
Hyponatremia 125-135 - Symptoms:
- Anorexia.
- Apathy.
- Restlessness.
- Nausea.
- Lethargy.
- Muscle cramps.
Hyponatremia 120-125 - Symptoms:
- Agitation.
- Disorientation.
- Headache.
Hyponatremia <120 - Symptoms:
- Seizures.
- Coma.
- Areflexia.
- Cheyne-Stokes.
- Incontinence.
- Death.
Rare causes of SIADH:
- HIV.
- Prolactinoma.
- Waldenstorm.
- Shy-Drager.
- Delirium tremens.
- Exercise-induced (eg marathon).
Hyponatremia - Deal with severe CNS symptoms:
- Raise Na concentration with 3% saline until symptoms abate.
- 4-6mmol/L increase in Na concentration should suffice.
- 100mL bolus of 3% saline infused over 10min. Can be repeated twice if necessary.
Mild to moderate symptoms - Hyponatremia - Manage:
Raise Na concentration with 3% saline at 1 mL/kg/h.
Effect of 1L of infused solution on Na concentration can be estimated by:
ΔNa = (Na (infused) - Na (serum))/(TBW +1).
Classic outpatient presentation of HYPERnatremia:
Elderly nursing home resident with underlying infection.
Hypernatremia - Patients may experience:
- Restlessness.
- Irritability.
- Lethargy.
- Muscle twitching.
- Hyperreflexia.
- Spasticity.
- Intracranial hemorrhage.
DI in pregnancy:
Placental production of vasopressinase.
Free water deficit equation:
FWD = TBW x [(Serum sodium concentration/140) - 1].
Hypokalemia - <2.5 and <2?
May result in fatigue progressing to muscle weakness and arrhythmia, followed by tetany or rhabdomyolysis at K less than 2.5, and then paralysis when less than 2.
Hypokalemia and osmotic demyelination syndrome?
Hypokalemia may increase the risk of osmotic demyelination syndrome when correcting hyponatremia.
==> If neurologically stable, correct hypokalemia before correcting hyponatremia.
Classic example of intracellular shifting is …?
Hypokalemic periodic paralysis.
What should be addressed before K repletion in hypokalemia?
Hypomagnesemia and hypocalcemia.
Degrees of hyperkalemia:
MILD ==> 5.5-6 ==> USUALLY asymptomatic.
> 6.5 ==> PROGRESSIVE weakness, muscle aches, areflexia, paresthesias, ECG changes.
> 7 ==> Paralysis, respiratory failure, life-threatening arrhythmias.
Familial pseudohyperkalemia:
AD.
K EFFLUX occurs as blood COOLS.
K concentration normalizes with rewarding of blood sample.
Classic example of EXTRACELLULAR SHIFTING is …?
HYPERKALEMIC PERIODIC PARALYSIS.
GORDON SYNDROME:
Hyperkalemia associated with hypertension and metabolic acidosis ==>
PSEUDOhypoaldosteronism type II.
Duodenal ulcers may penetrate …
POSTERIOR to the pancreas ==> ELEVATIONS IN AMYLASE AND LIPASE.
H2 blockers — Time to work?
Relatively quickly (30min).
PPIs — Time to work?
Most effective when given BEFORE MEALS (before breakfast if once daily and before breakfast and before dinner if twice daily).
TAKES 3 DAYS TO BLOCK 90% OF PUMPS.
PPIs can interfere with the absorption of other drugs:
Ketoconazole
Ampicillin
Iron
Digoxin
Emerging data document potential side effects a/w the use of PPIs:
- Decreased bone mineral density.
- Increased community-acquired infection.
- C.diff infection.
- Hypomagnesemia.
PPI use with clopidogrel:
Omeprazole and esomeprazole have greater effect on CYP2C19-mediated conversion of clopidogrel to its active metabolite ==> Diminishing platelet effect.
Enteric-coated aspirin has a rate of complications …
SIMILAR to non-enteric-coated preparations.
Urea breath test vs Stool H.pylori antigen test:
95% se and sp ==> UREA BREATH TEST.
93% se and sp ==> STOOL ANTIGEN.
In pts with penicillin ALLERGY — Tx of H.pylori:
PPI — Bismuth — Tetracycline — Metronidazole.
Rescue regimens for H.pylori tx:
Levofloxacin or RIFABUTIN.
Sequential Tx for H.pylori:
DAY 1–5 ==> PPI 2x a day + Amoxicillin 1g twice a day.
DAY 6-10 ==> PPI 2x a day + Clarithromycin + TINIDAZOLE.
Z-E syndrome — Diarrhea due to …
HIGH VOLUMES OF GASTRIC ACID PRODUCED.
Secretin test for Z-E:
IV SECRETIN results in paradoxic increase in serum gastrin in pts with Z-E, but not in other conditions.
85% se.
Octreotide scintigraphy scan:
Bind to somatostatin type 2 receptors on GASTRINOMAS.
Se 71-75% and sp 86-100%.
If the pt is presenting with massive bleeding and significant blood transfusion requirements and hemodynamic instability, then …
ANGIOGRAPHY can lead to both diagnosis and treatment.
If UGIB is suspected, may wish to start …
IV PPI EMPIRICALLY ==> Reduce the rate of rebleeding and need for surgery in pts with bleeding ulcers.
Watermelon stomach:
Vascular ectasia of the gastric antrum ==> GAVE.
==> ELDERLY WOMEN WITH CHRONIC LIVER DISEASE OR SCLERODERMA.
==> Usually as Fe-def ==> Tx with iron supplements.
Vascular malformations — Tx with:
- Iron supplements.
2. ESTROGEN.
Mild cases of diverticulitis may NOT …
REQUIRE ABX.
The amount of hemorrhage needed for positive angiography is a rate of blood loss of …
1mL/min of bleeding in the setting of hemodynamic instability.
Common missed lesions in the UGIT:
- Cameron erosions in large hiatal hernia.
- FUNDIC varices.
- PUD.
- Angioectasia.
- Dieulafoy.
- GAVE.
Common causes of small bowel bleeding depending on age:
<40 ==> Small bowel tumor — Meckel — Dieulafoy — Crohn.
> 40 ==> Vascular lesion — NSAID-induced enteropathy.
PPI and increased risk of cancer:
NO increased risk of tumors (carcinoid or gastrinoma) with long-term use.
Pancreas divisum is present in …-…% of the general population.
5-10%.
Annular pancreas can be seen with other congenital abnormalities:
- Intestinal malrotation.
- Meckel.
- Down.
- TEF.
- Imperforate anus.
- Cardiac abnormalities.
Drug-induced pancreatitis usually occurs within the …
1mo of drug administration.
The levels of pancreatic enzymes do or do not correlate w/ disease severity?
Do not.
Hemosuccus pancreaticus:
Massive GI bleeding caused by pseudoaneurysm of the SPLENIC ARTERY.
2 conditions (w/o pancreatitis) that may lead to elevated amylase and lipase?
- Renal failure.
2. DKA.
Abx in pancreatitis?
In severe necrotizing pancreatitis.
==> Imipenem/meropenem.
Cholecystectomy for pts with gallstone pancreatitis after recovery?
Yes.
Are pancreatic duct stents useful in reducing the risk of post-ERCP pancreatitis?
YES.
Hereditary pancreatitis — 3 genes:
- PRSS1 ==> AD mutation in the serine protease 1 gene — Acute/Chronic pancreatitis w/ prominent PANCREATOLITHIASIS.
- SPINK1 ==> Acute/Chronic pancreatitis caused by mutations in the serine protease inhibitor Kazal type 1 gene.
- CFTR.
Most definitive test for diagnosing steatorrhea (pancreatic and non pancreatic):
72h fecal fat collection.
==> >7g/24h while on high-fat diet = abnormal.
Pancreatic steatorrhea does not occur until the pancreatic lipase output decreases to < …-…% of normal.
5-10%
IPMNs — Which ones should be considered for surgical resection?
- Large cysts.
- Cysts w/ a solid component.
- Dilation of the pancreatic duct.
- Symptomatic cysts.
Variceal bleeding in pancreatic cancer?
From compression of the portal system.
Chemotherapy for pancreatic cancer (2):
- Gemcitabine.
2. 5-FU.
Mirizzi syndrome is when …
A CYSTIC duct stone erodes into or compresses the adjacent COMMON bile duct.
Bouveret syndrome:
Bowel obstruction caused by large stones that ERODE into the duodenum from an inflamed gallbladder.
Post-cholecystectomy syndrome:
Abdominal discomfort + Pain + Nausea persisting or presenting post-cholecystectomy.
+ abnl liver enzymes
+ abnl lipase/amylase (occasionally).
MCCs of postcholecystectomy syndrome:
- Papillary stenosis.
- Retained bile duct stone.
- Consequences of the intraoperative bile duct injury (Strictures, bile leak).
- Biliary dyskinesia (sphincter of Oddi dysfunction).
Most causes of postcholecystectomy syndrome can be corrected …
Endoscopically during ERCP.
RFs for cholangiocarcinoma:
- PSC (15% lifetime risk).
- Clonorchis, opisthorchis, Ascaris, other parasites.
- Thorotrast.
- Choledochal cysts.
- ORIENTAL CHOLANGIOHEPATITIS — Brown pigment intrahepatic biliary stones develop as a result of chronic inflammation from chronic bacterial infection.
- Multiple biliary papillomatosis (!).
- HNPCC.
- Age + males.
Disorders that may mimic asthma (4):
- CHF.
- MS.
- Upper airway obstruction (eg laryngeal tumors, subglottic stenosis, Wegener granulomatosis).
- Paradoxical vocal cord dysfunction (more common in women and health care workers).
Causes of refractory asthma (6):
- Chronic allergen exposure.
- Beta-blockers (timolol for glaucoma).
- Aspirin-containing drugs.
- Mucocutaneous fungal infections.
- ABPA.
- Churg-Strauss vasculitis.
Indications for hospitalization in asthma (5):
- Peak flow <40% of baseline after 4-6h of Tx.
- Persistent hypoxemia.
- Hypercapnia.
- Altered sensorium.
- Hx of previous near-fatal asthma attacks.
Survival is lower in pts with higher BODE index based on:
- Low BMI.
- Severe Obstructive ventilatory defect.
- Severe Dyspnea.
- Poor Exercise tolerance on 6-min walk test.
RFs for development of COPD in smokers:
- Airway reactivity.
- FHx of COPD.
- Childhood lung disease.
- Occupational dust exposures (eg silica, cotton dust, grain dust).
The 2 indications for long-term O2 therapy in COPD:
- PaO2 <55mmHg — SaO2 <89% in usual health.
2. PaO2 <60mmHg — SaO2 <90% w/ evidence of cor pulmonale or neurocognitive impairment.
Lung transplantation candidates:
- FEV1 <20% predicted.
- Age <60-65y.
- Sufficient social support.
Lung volume reduction surgery (LVRS):
- Procedure removes 20-30% of lung volume.
2. Best results in pts w/ upper lung zone emphysema and poor exercise capacity after rehab.
Bullectomy:
For single bulla occupying 1/3 of a hemithorax.
==> Best results w/ normal compressed lung and normal DLco.
Lymphangioleiomyomatosis target group:
Affects only fertile women.
Unusual causes of obstructive lung disease:
- Ig deficiency with bronchiectasis — IgA, IgG2, IgG4.
- Immotile cilia syndromes — Kartagener w/ situs inversus.
- Yellow nails syndrome w/ bronchiectasis — Pleural effusions, lymphedema, yellow nails.
- Sarcoidosis w/ upper or lower airway involvement.
- Eosinophilic granuloma.
- Sjogren syndrome.
- HIV w/ premature emphysema.
7 Potential indications for spirometry:
- Dx of obstructive lung disease.
- Evaluation of severity of lung disease.
- Screen high-risk individuals (eg smokers).
- Preoperative assessment.
- Evaluation of disability/impairment.
- Monitoring of treatment.
- Assess toxic effects of exposure or drug toxicity.
Vocal cord dysfunction (VCD) — Presents as …
ASTHMA — but w/o hyperinflation on chest radiograph.
Vocal cord dysfunction is unresponsive to …
Steroids.
VCD is more common in men or women?
Women.
VCD — Definitive dx is made by …
Laryngoscopy during an acute attack.
Bronchoprovocation test is defined by achieving a …% or greater decrease in FEV1 w/ dose of 16 to 25mg/mL methacholine or less.
20%.
…% of COPD pts have positive methacholine challenge test.
50%.
Methacholine test is useful for ruling in or ruling out asthma?
Ruling out.
7 causes of normal or increased DLCO:
- Asthma.
- Polycythemia.
- Obesity.
- L ==> R shunt.
- Supine position.
- Postexercise.
- Pulmonary hemorrhage.
6 causes of decreased DLCO:
- Emphysema.
- Anemia.
- ILD.
- Pneumonectomy.
- Pulmonary HTN.
- Pulmonary embolism.
Obesity typically does what to FRC, TLC, VC?
FRC ==> Disproportionate reduction in end-expiratory lung volume.
TLC, VC ==> Small reductions.
Chest radiology — Nodule and mass?
Nodule = <4cm.
Mass = >4cm.
Lesions >3cm ==> 75% probability of being malignant.
Anterior mediastinal terrible Ts:
- Teratoma.
- Thymoma.
- Thymolipoma.
- Thymic carcinoma/carcinoid.
- Thymic cyst.
- Thoracic thyroid.
- Terrible lymphoma.
The DDx of upper lobe infiltrates is generally small and depends on the clinical Hx and whether the abnl is bil or unilateral.
Diffuse BILATERAL UPPER lobe infiltrates (7):
- Sarco.
- Eosinophilic granuloma.
- Ankylosing spondylitis (!).
- CF.
- Hypersensitivity pneumonitis.
- Old TB or Histo.
- Pneumoconiosis (eg silicosis).
UNILATERAL UPPER lobe infiltrates:
- TB — Histo — Coccidio — Klebsiella.
2. 1o lung neo.
Right-sided effusion suggests:
- CHF.
- Hepatic hydrothorax.
- Meigs.
Left-sided effusion suggests:
- Aortic dissection.
- Boerhaave syndrome.
- Pancreatitis.
- Splenic rupture/infarction.
