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Internal Medicine > JH IM Board Review - SOS I > Flashcards

JH IM Board Review - SOS I Flashcards

1
Q

Insensible losses:

A

500-1000ml/day lost through skin and respiratory tract.

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2
Q

Increases in plasma osmolality as small as …% can release ADH:

A

1%.

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3
Q

How great hypovolemia causes ADH release?

A

10% or greater.

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4
Q

What else causes incr. in ADH?

A
  1. Pain.
  2. Nausea.
  3. Dx: antidepressants, antipsychotics, nsaids, opioids, barbs.
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5
Q

Hyponatremia can occur with what total body Na?

A
  1. Low.
  2. Normal.
  3. High.

==> Hyponatremia requires the presence of too much water relative to the quantity of total body Na.

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6
Q

Asymptomatic hyponatremia is …?

A

Isosmolar.

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7
Q

Hypoosmolar hyponatremia causes symptoms by …?

A

SWELLING of the cns.

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8
Q

Hyperosmolar hyponatremia causes symptoms by …?

A

DEHYDRATION of the cns.

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9
Q

Hyponatremia 125-135 - Symptoms:

A
  1. Anorexia.
  2. Apathy.
  3. Restlessness.
  4. Nausea.
  5. Lethargy.
  6. Muscle cramps.
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10
Q

Hyponatremia 120-125 - Symptoms:

A
  1. Agitation.
  2. Disorientation.
  3. Headache.
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11
Q

Hyponatremia <120 - Symptoms:

A
  1. Seizures.
  2. Coma.
  3. Areflexia.
  4. Cheyne-Stokes.
  5. Incontinence.
  6. Death.
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12
Q

Rare causes of SIADH:

A
  1. HIV.
  2. Prolactinoma.
  3. Waldenstorm.
  4. Shy-Drager.
  5. Delirium tremens.
  6. Exercise-induced (eg marathon).
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13
Q

Hyponatremia - Deal with severe CNS symptoms:

A
  1. Raise Na concentration with 3% saline until symptoms abate.
  2. 4-6mmol/L increase in Na concentration should suffice.
  3. 100mL bolus of 3% saline infused over 10min. Can be repeated twice if necessary.
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14
Q

Mild to moderate symptoms - Hyponatremia - Manage:

A

Raise Na concentration with 3% saline at 1 mL/kg/h.

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15
Q

Effect of 1L of infused solution on Na concentration can be estimated by:

A

ΔNa = (Na (infused) - Na (serum))/(TBW +1).

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16
Q

Classic outpatient presentation of HYPERnatremia:

A

Elderly nursing home resident with underlying infection.

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17
Q

Hypernatremia - Patients may experience:

A
  1. Restlessness.
  2. Irritability.
  3. Lethargy.
  4. Muscle twitching.
  5. Hyperreflexia.
  6. Spasticity.
  7. Intracranial hemorrhage.
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18
Q

DI in pregnancy:

A

Placental production of vasopressinase.

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19
Q

Free water deficit equation:

A

FWD = TBW x [(Serum sodium concentration/140) - 1].

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20
Q

Hypokalemia - <2.5 and <2?

A

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.

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21
Q

Hypokalemia and osmotic demyelination syndrome?

A

Hypokalemia may increase the risk of osmotic demyelination syndrome when correcting hyponatremia.

==> If neurologically stable, correct hypokalemia before correcting hyponatremia.

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22
Q

Classic example of intracellular shifting is …?

A

Hypokalemic periodic paralysis.

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23
Q

What should be addressed before K repletion in hypokalemia?

A

Hypomagnesemia and hypocalcemia.

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24
Q

Degrees of hyperkalemia:

A

MILD ==> 5.5-6 ==> USUALLY asymptomatic.

> 6.5 ==> PROGRESSIVE weakness, muscle aches, areflexia, paresthesias, ECG changes.

> 7 ==> Paralysis, respiratory failure, life-threatening arrhythmias.

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25
Q

Familial pseudohyperkalemia:

A

AD.

K EFFLUX occurs as blood COOLS.

K concentration normalizes with rewarding of blood sample.

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26
Q

Classic example of EXTRACELLULAR SHIFTING is …?

A

HYPERKALEMIC PERIODIC PARALYSIS.

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27
Q

GORDON SYNDROME:

A

Hyperkalemia associated with hypertension and metabolic acidosis ==>

PSEUDOhypoaldosteronism type II.

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28
Q

Duodenal ulcers may penetrate …

A

POSTERIOR to the pancreas ==> ELEVATIONS IN AMYLASE AND LIPASE.

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29
Q

H2 blockers — Time to work?

A

Relatively quickly (30min).

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30
Q

PPIs — Time to work?

A

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.

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31
Q

PPIs can interfere with the absorption of other drugs:

A

Ketoconazole

Ampicillin

Iron

Digoxin

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32
Q

Emerging data document potential side effects a/w the use of PPIs:

A
  1. Decreased bone mineral density.
  2. Increased community-acquired infection.
  3. C.diff infection.
  4. Hypomagnesemia.
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33
Q

PPI use with clopidogrel:

A

Omeprazole and esomeprazole have greater effect on CYP2C19-mediated conversion of clopidogrel to its active metabolite ==> Diminishing platelet effect.

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34
Q

Enteric-coated aspirin has a rate of complications …

A

SIMILAR to non-enteric-coated preparations.

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35
Q

Urea breath test vs Stool H.pylori antigen test:

A

95% se and sp ==> UREA BREATH TEST.

93% se and sp ==> STOOL ANTIGEN.

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36
Q

In pts with penicillin ALLERGY — Tx of H.pylori:

A

PPI — Bismuth — Tetracycline — Metronidazole.

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37
Q

Rescue regimens for H.pylori tx:

A

Levofloxacin or RIFABUTIN.

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38
Q

Sequential Tx for H.pylori:

A

DAY 1–5 ==> PPI 2x a day + Amoxicillin 1g twice a day.

DAY 6-10 ==> PPI 2x a day + Clarithromycin + TINIDAZOLE.

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39
Q

Z-E syndrome — Diarrhea due to …

A

HIGH VOLUMES OF GASTRIC ACID PRODUCED.

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40
Q

Secretin test for Z-E:

A

IV SECRETIN results in paradoxic increase in serum gastrin in pts with Z-E, but not in other conditions.

85% se.

41
Q

Octreotide scintigraphy scan:

A

Bind to somatostatin type 2 receptors on GASTRINOMAS.

Se 71-75% and sp 86-100%.

42
Q

If the pt is presenting with massive bleeding and significant blood transfusion requirements and hemodynamic instability, then …

A

ANGIOGRAPHY can lead to both diagnosis and treatment.

43
Q

If UGIB is suspected, may wish to start …

A

IV PPI EMPIRICALLY ==> Reduce the rate of rebleeding and need for surgery in pts with bleeding ulcers.

44
Q

Watermelon stomach:

A

Vascular ectasia of the gastric antrum ==> GAVE.

==> ELDERLY WOMEN WITH CHRONIC LIVER DISEASE OR SCLERODERMA.

==> Usually as Fe-def ==> Tx with iron supplements.

45
Q

Vascular malformations — Tx with:

A
  1. Iron supplements.

2. ESTROGEN.

46
Q

Mild cases of diverticulitis may NOT …

A

REQUIRE ABX.

47
Q

The amount of hemorrhage needed for positive angiography is a rate of blood loss of …

A

1mL/min of bleeding in the setting of hemodynamic instability.

48
Q

Common missed lesions in the UGIT:

A
  1. Cameron erosions in large hiatal hernia.
  2. FUNDIC varices.
  3. PUD.
  4. Angioectasia.
  5. Dieulafoy.
  6. GAVE.
49
Q

Common causes of small bowel bleeding depending on age:

A

<40 ==> Small bowel tumor — Meckel — Dieulafoy — Crohn.

> 40 ==> Vascular lesion — NSAID-induced enteropathy.

50
Q

PPI and increased risk of cancer:

A

NO increased risk of tumors (carcinoid or gastrinoma) with long-term use.

51
Q

Pancreas divisum is present in …-…% of the general population.

A

5-10%.

52
Q

Annular pancreas can be seen with other congenital abnormalities:

A
  1. Intestinal malrotation.
  2. Meckel.
  3. Down.
  4. TEF.
  5. Imperforate anus.
  6. Cardiac abnormalities.
53
Q

Drug-induced pancreatitis usually occurs within the …

A

1mo of drug administration.

54
Q

The levels of pancreatic enzymes do or do not correlate w/ disease severity?

A

Do not.

55
Q

Hemosuccus pancreaticus:

A

Massive GI bleeding caused by pseudoaneurysm of the SPLENIC ARTERY.

56
Q

2 conditions (w/o pancreatitis) that may lead to elevated amylase and lipase?

A
  1. Renal failure.

2. DKA.

57
Q

Abx in pancreatitis?

A

In severe necrotizing pancreatitis.

==> Imipenem/meropenem.

58
Q

Cholecystectomy for pts with gallstone pancreatitis after recovery?

A

Yes.

59
Q

Are pancreatic duct stents useful in reducing the risk of post-ERCP pancreatitis?

A

YES.

60
Q

Hereditary pancreatitis — 3 genes:

A
  1. PRSS1 ==> AD mutation in the serine protease 1 gene — Acute/Chronic pancreatitis w/ prominent PANCREATOLITHIASIS.
  2. SPINK1 ==> Acute/Chronic pancreatitis caused by mutations in the serine protease inhibitor Kazal type 1 gene.
  3. CFTR.
61
Q

Most definitive test for diagnosing steatorrhea (pancreatic and non pancreatic):

A

72h fecal fat collection.

==> >7g/24h while on high-fat diet = abnormal.

62
Q

Pancreatic steatorrhea does not occur until the pancreatic lipase output decreases to < …-…% of normal.

A

5-10%

63
Q

IPMNs — Which ones should be considered for surgical resection?

A
  1. Large cysts.
  2. Cysts w/ a solid component.
  3. Dilation of the pancreatic duct.
  4. Symptomatic cysts.
64
Q

Variceal bleeding in pancreatic cancer?

A

From compression of the portal system.

65
Q

Chemotherapy for pancreatic cancer (2):

A
  1. Gemcitabine.

2. 5-FU.

66
Q

Mirizzi syndrome is when …

A

A CYSTIC duct stone erodes into or compresses the adjacent COMMON bile duct.

67
Q

Bouveret syndrome:

A

Bowel obstruction caused by large stones that ERODE into the duodenum from an inflamed gallbladder.

68
Q

Post-cholecystectomy syndrome:

A

Abdominal discomfort + Pain + Nausea persisting or presenting post-cholecystectomy.

+ abnl liver enzymes

+ abnl lipase/amylase (occasionally).

69
Q

MCCs of postcholecystectomy syndrome:

A
  1. Papillary stenosis.
  2. Retained bile duct stone.
  3. Consequences of the intraoperative bile duct injury (Strictures, bile leak).
  4. Biliary dyskinesia (sphincter of Oddi dysfunction).
70
Q

Most causes of postcholecystectomy syndrome can be corrected …

A

Endoscopically during ERCP.

71
Q

RFs for cholangiocarcinoma:

A
  1. PSC (15% lifetime risk).
  2. Clonorchis, opisthorchis, Ascaris, other parasites.
  3. Thorotrast.
  4. Choledochal cysts.
  5. ORIENTAL CHOLANGIOHEPATITIS — Brown pigment intrahepatic biliary stones develop as a result of chronic inflammation from chronic bacterial infection.
  6. Multiple biliary papillomatosis (!).
  7. HNPCC.
  8. Age + males.
72
Q

Disorders that may mimic asthma (4):

A
  1. CHF.
  2. MS.
  3. Upper airway obstruction (eg laryngeal tumors, subglottic stenosis, Wegener granulomatosis).
  4. Paradoxical vocal cord dysfunction (more common in women and health care workers).
73
Q

Causes of refractory asthma (6):

A
  1. Chronic allergen exposure.
  2. Beta-blockers (timolol for glaucoma).
  3. Aspirin-containing drugs.
  4. Mucocutaneous fungal infections.
  5. ABPA.
  6. Churg-Strauss vasculitis.
74
Q

Indications for hospitalization in asthma (5):

A
  1. Peak flow <40% of baseline after 4-6h of Tx.
  2. Persistent hypoxemia.
  3. Hypercapnia.
  4. Altered sensorium.
  5. Hx of previous near-fatal asthma attacks.
75
Q

Survival is lower in pts with higher BODE index based on:

A
  1. Low BMI.
  2. Severe Obstructive ventilatory defect.
  3. Severe Dyspnea.
  4. Poor Exercise tolerance on 6-min walk test.
76
Q

RFs for development of COPD in smokers:

A
  1. Airway reactivity.
  2. FHx of COPD.
  3. Childhood lung disease.
  4. Occupational dust exposures (eg silica, cotton dust, grain dust).
77
Q

The 2 indications for long-term O2 therapy in COPD:

A
  1. PaO2 <55mmHg — SaO2 <89% in usual health.

2. PaO2 <60mmHg — SaO2 <90% w/ evidence of cor pulmonale or neurocognitive impairment.

78
Q

Lung transplantation candidates:

A
  1. FEV1 <20% predicted.
  2. Age <60-65y.
  3. Sufficient social support.
79
Q

Lung volume reduction surgery (LVRS):

A
  1. Procedure removes 20-30% of lung volume.

2. Best results in pts w/ upper lung zone emphysema and poor exercise capacity after rehab.

80
Q

Bullectomy:

A

For single bulla occupying 1/3 of a hemithorax.

==> Best results w/ normal compressed lung and normal DLco.

81
Q

Lymphangioleiomyomatosis target group:

A

Affects only fertile women.

82
Q

Unusual causes of obstructive lung disease:

A
  1. Ig deficiency with bronchiectasis — IgA, IgG2, IgG4.
  2. Immotile cilia syndromes — Kartagener w/ situs inversus.
  3. Yellow nails syndrome w/ bronchiectasis — Pleural effusions, lymphedema, yellow nails.
  4. Sarcoidosis w/ upper or lower airway involvement.
  5. Eosinophilic granuloma.
  6. Sjogren syndrome.
  7. HIV w/ premature emphysema.
83
Q

7 Potential indications for spirometry:

A
  1. Dx of obstructive lung disease.
  2. Evaluation of severity of lung disease.
  3. Screen high-risk individuals (eg smokers).
  4. Preoperative assessment.
  5. Evaluation of disability/impairment.
  6. Monitoring of treatment.
  7. Assess toxic effects of exposure or drug toxicity.
84
Q

Vocal cord dysfunction (VCD) — Presents as …

A

ASTHMA — but w/o hyperinflation on chest radiograph.

85
Q

Vocal cord dysfunction is unresponsive to …

A

Steroids.

86
Q

VCD is more common in men or women?

A

Women.

87
Q

VCD — Definitive dx is made by …

A

Laryngoscopy during an acute attack.

88
Q

Bronchoprovocation test is defined by achieving a …% or greater decrease in FEV1 w/ dose of 16 to 25mg/mL methacholine or less.

A

20%.

89
Q

…% of COPD pts have positive methacholine challenge test.

A

50%.

90
Q

Methacholine test is useful for ruling in or ruling out asthma?

A

Ruling out.

91
Q

7 causes of normal or increased DLCO:

A
  1. Asthma.
  2. Polycythemia.
  3. Obesity.
  4. L ==> R shunt.
  5. Supine position.
  6. Postexercise.
  7. Pulmonary hemorrhage.
92
Q

6 causes of decreased DLCO:

A
  1. Emphysema.
  2. Anemia.
  3. ILD.
  4. Pneumonectomy.
  5. Pulmonary HTN.
  6. Pulmonary embolism.
93
Q

Obesity typically does what to FRC, TLC, VC?

A

FRC ==> Disproportionate reduction in end-expiratory lung volume.

TLC, VC ==> Small reductions.

94
Q

Chest radiology — Nodule and mass?

A

Nodule = <4cm.

Mass = >4cm.

Lesions >3cm ==> 75% probability of being malignant.

95
Q

Anterior mediastinal terrible Ts:

A
  1. Teratoma.
  2. Thymoma.
  3. Thymolipoma.
  4. Thymic carcinoma/carcinoid.
  5. Thymic cyst.
  6. Thoracic thyroid.
  7. Terrible lymphoma.
96
Q

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):

A
  1. Sarco.
  2. Eosinophilic granuloma.
  3. Ankylosing spondylitis (!).
  4. CF.
  5. Hypersensitivity pneumonitis.
  6. Old TB or Histo.
  7. Pneumoconiosis (eg silicosis).
97
Q

UNILATERAL UPPER lobe infiltrates:

A
  1. TB — Histo — Coccidio — Klebsiella.

2. 1o lung neo.

98
Q

Right-sided effusion suggests:

A
  1. CHF.
  2. Hepatic hydrothorax.
  3. Meigs.
99
Q

Left-sided effusion suggests:

A
  1. Aortic dissection.
  2. Boerhaave syndrome.
  3. Pancreatitis.
  4. Splenic rupture/infarction.

Internal Medicine (107 decks)

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