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

JH IM Board Review - SOS II Flashcards

1
Q

The 4 idiopathic interstitial pneumonias:

A
  1. IPF.
  2. DIP.
  3. AIP.
  4. NSIP.
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2
Q

Is complete recovery possible for DIP, AIP, NSIP?

A

YES.

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3
Q

2 new drugs for IPF:

A
  1. Pirfenidone.

2. Nintedanib.

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4
Q

AIP is commonly referred to as …

A

Hamman-Rich syndrome.

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5
Q

2 interesting lung manifestations of SLE:

A
  1. Alveolar hemorrhage (+/- APS).

2. Shrinking lung syndrome (!) — Restrictive lung disease in the absence of parenchymal disease.

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6
Q

RA lung involvement is more common in men or women?

A

Men (3:1).

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7
Q

Sx of RA lung disease precede joint disease in …% of cases.

A

20%.

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8
Q

3 interesting manifestations of RA lung disease:

A
  1. Rheumatoid — necrobiotic — nodules. (Keep in mind Caplan syndrome)
  2. Constrictive bronchiolitis (or bronchiolitis obliterans).
  3. Cricoarytenoid arthritis (!) — Pain, hoarseness, dyspnea, stridor, obstruction. (25% of RA)
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9
Q

What is the antisynthetase syndrome (keep in mind polymyositis/dm)?

A
  1. Subclinical myositis.
  2. ILD.
  3. Raynaud’s.
  4. Mechanic’s hands.
  5. Symmetric polyarthritis of small joints.
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10
Q

2 forms of Wegener:

A

CLASSIC ==> UPPER + LOWER RT + KIDNEYS.

LIMITED ==> ISOLATED RT involvement — Up to 40% may be ANCA(-).

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11
Q

The 6 eosinophilic lung diseases:

A
  1. Acute eosinophilic pneumonia.
  2. Chronic eosinophilic pneumonia.
  3. Hypereosinophilic syndrome.
  4. ABPA.
  5. Churg-Strauss.
  6. Eosinophilic granuloma.
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12
Q

Dx of acute/chronic eosinophilic pneumonia requires …

A

BAL or lung tissue bx showing eosinophils.

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13
Q

Both acute and chronic eosinophilic pneumonia are responsive to …

A

STEROIDS.

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14
Q

What defines the hypereosinophilic syndrome:

A
  1. Defined as more than 1500 eosinophils/mm3 in peripheral blood for 6mo.
  2. Primary targets include ==> Heart, CNS, peripheral nervous system, skin.

==> The lung is LESS commonly involved.

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15
Q

Churg-Strauss may be unmasked after …

A

Tapering steroids in an asthmatic.

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16
Q

Eosinophilic granuloma presents almost exclusively in …

A

Smoking adults.

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17
Q

Eosinophilic granuloma tx:

A

SMOKING CESSATION.

STEROIDS INEFFECTIVE.

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18
Q

Eosinophilic granuloma may be a/w which 2 entities?

A
  1. Bone cysts.

2. DI.

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19
Q

Tx of idiopathic BOOP:

A

STEROIDS for >6mo.

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20
Q

Obliterative bronchiolitis (NOT BOOP) is or is not responsive to steroids?

A

IS NOT.

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21
Q

Mesothelioma risk is or is not affected by smoking?

A

IS NOT.

Lung Ca is

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22
Q

What has been seen in pts with FIBROCYSTIC sarco?

A

MYCETOMAS.

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23
Q

What is the uveoparotid fever in sarco pts?

A

Heerfordt-Waldenstrom syndrome:

==> Bil lacrimal/parotid duct enlargement + FEVER + Anterior uveitis.

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24
Q

What is the Lofgren syndrome?

A

ERYTHEMA NODOSUM +

HILAR ADENOPATHY +

ARTHRALGIAS +

FEVER.

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25
Q

Lofgren course?

A

SPONTANEOUS REMISSION IS COMMON.

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26
Q

What should be given to skin sarco lesions?

A

Chroloquine or pentoxyfylline — NOT STEROIDS.

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27
Q

What is the best clinical predictor for sarco liver involvement?

A

ALP.

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28
Q

Factor V leiden homozygotes or heterozygotes have increased risk?

A

Homozygotes.

Heterozygotes have NO INCREASED RISK.

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29
Q

CT venography use in the dx of DVT:

A

Se and sp comparable to US, so NOT routinely recommended.

==> Useful if INJURED or CASTED leg because US cannot be performed in this scenario.

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30
Q

PE - Hypoxemia:

A

VARIABLE because it is an EPIPHENOMENON OF THROMBUS ==>

Atelectasis, edema, interatrial shunting, low-mixed venous tension.

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31
Q

PE/DVT duration of therapy:

A

3 mo after reversible major RFs ==> Provoked VTE.

3 mo to indefinite ==> First unprovoked VTE. Can continue indefinitely if pt agrees + no significant bleeding risk.

FOREVER for first PE/DVT w/ active cancer OR 2nd unprovoked DVT/PE.

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32
Q

Hypopnea means …

A

A 50% or greater decrease in airflow

OR

<50% decrease in airflow a/w at least 4% drop in SaO2.

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33
Q

Apnea-Hypopnea index (AHI) is the total number of …

A

Apneas + Hypopneas per hour of sleep.

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34
Q

Normal Apnea-Hypopnea index (AHI) is …

A

5 or fewer per hour.

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35
Q

Upper airway resistance syndrome (UARS) means …

A
  1. Repeated arousals 2o to increased upper airway resistance (“crescendo snoring”).
  2. AHI is normal.
  3. No significant O2 desat episodes.
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36
Q

Obesity-hypoventilation syndrome is also known as …

A

Pickwickian syndrome.

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37
Q

Clinical conditions a/w CENTRAL sleep apnea:

A
  1. Stroke.
  2. Stable METHADONE maintenance tx (!).
  3. MSA.
  4. Autonomic dysfunction.
  5. MG.
  6. Neuromuscular diseases.
  7. Bulbar poliomyelitis.
  8. Encephalitis.
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38
Q

Dx of an apnea syndrome is made by an …

A

Overnight POLYSOMNOGRAM (PSG) sleep study.

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39
Q

If AHI is >5 episodes per hour, sleep study is …

A

Positive for sleep apnea.

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40
Q

OSA vs CENTRAL SA is determined by presence vs absence of …

A

CHEST/ABDOMINAL WALL EFFORTS.

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41
Q

Mild — Moderate — Severe APNEA means …

A

MILD ==> 6-15 events.

MODERATE ==> 16-30 events.

SEVERE ==> More than 30 events.

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42
Q

What is the ration of benign — malignant solitary pulmonary nodules?

A

60 BENIGN — 40 MALIGNANT.

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43
Q

SPN doubling time of 25 to 450 days suggests a benign or a malignant process?

A

A MALIGNANT.

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44
Q

SPN doubling time of LESS THAN 25 days or MORE THAN 450 days suggests a benign or a malignant process?

A

A BENIGN.

45
Q

SPN doubling time refers to what parameter of the nodule?

A

To the VOLUME ==> MEANING THAT DOUBLING IS 28% INCREASE IN DIAMETER.

46
Q

Calcification patterns in solitary pulmonary nodules:

4 benign patterns:

A
  1. Central (“target”).
  2. Diffuse.
  3. Popcorn.
  4. Laminar (concentric).
47
Q

Calcification patterns in solitary pulmonary nodules:

2 malignant patterns:

A
  1. Eccentric.

2. Stippled.

48
Q

If the SPN has doubling time 25-450 and the pt’s cardio status permits surgery, then …

A

Thoracotomy with resection is indicated.

49
Q

SPN <1cm, stable for 2y, are most likely …

A

Benign and DO NOT require F/U.

50
Q

Role of percutaneous transthoracic needle aspiration (usually under CT guidance) in the dx of SPN?

A
  1. Most useful for peripheral lesions.

2. Higher dx yield than bronchoscopic bx — 80-95% (even in lesions less than 2cm).

51
Q

Clinically significant hemoptysis is rarely from the pulmonary circulation, because it’s …

A

A low-pressure system + Hypoxic pulmonary vasoconstriction diverts blood flow away from diseased portions of the lung.

52
Q

Massive hemoptysis means …

A

> 600mL in 24h.

53
Q

Pseudohemoptysis means …

A

S.marascens pneumonia.

54
Q

Invasive procedure of choice for NON massive hemoptysis?

A

Fiberoptic bronchoscopy.

55
Q

What physical finding is a reliable indicator of elevated PA pressure?

A

A prominent pulmonic component of the S2.

56
Q

Tx of PHTN — Positive response to acute admin of NO:

…-…% are responders (drop 10mm to <40mmHg) and should be tx w/ …

A

5-10%.

Should be tx w/ ORAL CCB.

57
Q

NON responders have an increased risk of … w/ CCBs and should receive …

A

DEATH.

They should receive OTHER Tx.

58
Q

Long-term anticoag in PHTN?

A

INDICATED FOR ALL ==> prevent intravascular thrombosis in the pulmonary circulation as well as deep venous thrombosis.

59
Q

Epoprostenol and bosentan are frequently used for 2o PHTN caused by …

A

SCLERODERMA.

60
Q

2 pathophysiologic causes of acute respiratory failure:

A
  1. Failure of oxygenation.

2. Failure of ventilation.

61
Q

The 8 mechanisms of pleural fluid accumulation:

A
  1. Increased hydrostatic pressure of vasculature ==> CHF.
  2. Decreased oncotic pressure of vasculature ==> Nephrotic syndrome.
  3. Decreased pleural pressure ==> Atelectasis.
  4. Obstruction of lymphatic drainage ==> Malignancy.
  5. Increased capillary permeability ==> Parapneumonic effusion.
  6. Rupture of thoracic duct ==> Chylothorax.
  7. Increased fluid in peritoneal cavity ==> Hepatic hydrothorax.
  8. Iatrogenic ==> Placement of central line into pleural space.
62
Q

MCC of massive pleural effusions that cause complete opacification of one hemithorax?

A

Malignancy.

63
Q

Rheumatoid pleurisy — Classic presentation is …

A

An older man w/ subcutaneous rheumatoid nodules and a unilateral pleural effusion.

==> Frequently mimics a complicated parapneumonic effusion — W/ high LDH (>1000 U/L) + low glu (<40), and low pH (<7.2).

64
Q

Lupus pleuritis may be seen in …

A

Drug-induced lupus 2o to procainamide or isoniazid among others.

65
Q

Site of interruption of the thoracic duct determines …

A

Side of pleural effusion (chylothorax).

RIGHT if below the T4.

LEFT if above T4.

66
Q

Consider SUBPULMONIC effusions if one …

A

HEMIdiaphragm appears elevated and apex of diaphragm is LATERALLY DISPLACED.

67
Q

Sensitivity of single thoracentesis sample for diagnosing malignancy is …

A

60%.

3 sequential thoracenteses increase SE to 80%.

68
Q

Pseudochylothorax means …

A

Milky fluid but not a true chylothorax.

==> Usually seen in long-standing effusions.

  1. Old TB.
  2. Rheumatoid pleurisy.
  3. Nephrotic syndrome.
69
Q

Tx of chylothorax:

A
  1. Chest tube + bed rest + enteral feeding w/ medium-chain TGs — absorbed to circulation via portal vein, avoiding thoracic duct.
  2. Occasionally ==> Thoracic duct ligation or placement of pleuroperitoneal shunt needed.
70
Q

Tx of pneumothorax:

A

Administer 100% O2 and observe pt if pneumothorax is small (<15% of hemithorax).

==> Increases rate of reabsorption of air from pleural space 4x.

***Larger (>15% hemithorax) pneumothoraces require removal of air, either with catheter (works best w/ young pts) or w/ chest tube (required for most pts).

71
Q

2 pathophysiologic mechanisms of acute respiratory failure:

A
  1. Failure of oxygenation.

2. Failure of ventilation.

72
Q

Cyanosis occurs only after deoxyhemoglobin level is > …g/dL which corresponds to an SaO2 at approx …%.

A

> 5.

67%.

73
Q

Pulse oximeter may be UNRELIABLE in the following situations:

A
  1. On the steep portion of the oxyhemoglobin dissociation curve (ie at SaO2 <90%).
  2. Pts w/ carboxyhemoglobin or methemoglobin (may overestimate oxyhemoglobin).
  3. Decreased peripheral perfusion (eg shock).
  4. Pts w/ pigmented skin or nail polish.
74
Q

Criteria for use of NON invasive ventilation:

A
  1. COPD exacerbation ==> Hypercapnic resp failure (pH 7.25-7.35, RR 20-30), able to manage secretions.

CIs ==> Shock — Not able to tolerate mask — GCS <8.

  1. Resp failure in immunosuppressed w/ bil infiltrates (BMT, HIV, Post-chemo).

CIs ==> Shock — Not able to tolerate mask — GCS <8.

75
Q

Acute resp failure — Supplemental O2 target ==> SaO2 >…% or PaO2 >… mmHg.

A

88%.

55mmHg.

76
Q

Complications of mechanical ventilation:

A
  1. Auto-positive pressure (PEEP) (dynamic hyperinflation) ==> Air trapping due to inadequate emptying during expiration (eg asthma, COPD).
  2. Volutrauma or barotrauma ==> PTX, pneumomediastinum, DAD.
  3. VAP.
  4. Endotracheal tube complications ==> Subglottal stenosis, vocal cord dysfunction, TEF, sinusitis.
77
Q

The Berlin definition of ARDS requires the following:

A
  1. Onset within 7 days following insult OR progressively worsening symptoms over past 7 days.
  2. Diffuse bil infiltrates consistent with pulm edema on CXR or chest CT.
  3. Resp failure cannot be caused by heart failure or volume overload.
78
Q

Severity of ARDS is based on …

A

PaO2/FiO2

while on CPAP 5cm H2O or greater

OR

end-expiratory pressure of 5cm H2O or greater.

79
Q

Mild — Moderate — Severe ARDS:

A
  1. Mild ==> PaO2/FiO2 ==> 200-300.
  2. Moderate ==> PaO2/FiO2 ==> 100-200.
  3. Severe ==> PaO2/FiO2 ==> Less than 100.
80
Q

Prevention of ARDS — Mention some measures:

A
  1. Early ABX + resuscitation for severe sepsis.
  2. Use of lower Vt.
  3. Conservative blood product use.
  4. Early CPAP in hematologic malignancy(!) pts w/ signs of resp failure decreases incidence of ARDS.
81
Q

What is now the MCC of sepsis?

A

GRAM (+) organisms.

Followed closely by gram (-).

82
Q

Abx in sepsis:

A

Should be infused within 1h in pts w/ hypotension caused by sepsis (door-to-infusion time <1h).

83
Q

Sepsis — In pts w/o adrenal suppression at baseline, steroids are of use?

A

NO EFFECT ON MORTALITY!

84
Q

Activated charcoal blocks absorption of most drugs — EXCEPTIONS?

A
  1. Alkali.
  2. Li.
  3. Iron.
  4. Insecticides.
85
Q

Gastric lavage role?

A

Of UNPROVEN efficacy — may be useful if recent ingestion (<1h).

86
Q

Amount of insensible H2O losses through skin and respiratory tract:

A

500-1000mL.

87
Q

Order of correction of electrolytes:

A

Mg > Ca > K > Na.

88
Q

5 indications for DIALYSIS:

A
  1. Severe metabolic acidosis.
  2. Electrolyte disturbances.
  3. Intoxications.
  4. Volume overload.
  5. Uremia.
89
Q

Important point about FeNa:

A

Can be >1% w/ prerenal AKI in pts w/ preexisting chronic kidney disease because of impaired ability to reabsorb Na.

Can be <1% w/ glomerulonephritis, iodinated contrast admin, and rhabdomyolysis.

90
Q

Infections that may lead to INTERSTITIAL NEPHRITIS:

A
  1. Staph/strep.
  2. Brucella.
  3. HIV.
  4. CMV.
  5. HANTAVIRUS.
  6. TB.
  7. Schistosoma.
  8. Toxoplasma.
91
Q

Eosinophilia/eosinophiluria are or are not sensitive for interstitial nephritis dx?

A

ARE NOT ==> Their absence should not exclude dx.

92
Q

Interstitial nephritis dx gold standard:

A

Biopsy.

93
Q

Contrast-induced nephropathy — Cr peaks within … and usually returns to baseline within … .

A

Peak 7 days.

Baseline 10 days.

94
Q

Pigment nephropathy — Mechanism:

A

Heme pigment (ferrihemate) of myoglobin — hemoglobin.

==> causes VASOCONSTRICTION ==> Ischemia.

95
Q

Keep in mind that obstruction of renal tubules is caused by myoglobin or hemoglobin casts?

A

MYOGLOBIN casts.

Hemoglobin is TOO LARGE to be substantially filtered at glomerulus into tubules.

96
Q

3 important lab findings in cholesterol atheroembolic disease:

A
  1. Eosinophilia.
  2. Eosinophiluria.
  3. Hypocomplementemia.
97
Q

Postrenal AKI — Paradoxical polyuria?

A

PARTIAL OBSTRUCTION ==> Transmitted to the distal renal tubules impaired water reabsorption ==> INCREASE URINE OUTPUT.

98
Q

Nuclear medicine furosemide renogram (!):

A

Can provide functional status of the kidneys and avoid risk of IV contrast.

99
Q

Renal vein thrombosis is MC with which type of glomerular disease?

A

Membranous glomerulonephropathy.

100
Q

MCD — The formation of edema is characteristically …

A

RAPID.

IN ONE DAY.

101
Q

2o causes of MCD:

A
  1. HL.
  2. Thymoma.
  3. NSAIDs.
  4. Bee stings.
  5. Li.
102
Q

HIV-associated nephropathy (HIVAN) presents w/ a …

A

COLLAPSING FSGS.

103
Q

Besides HIVAN, collapsing FSGS may be seen in …

A

NON-HIV-infected pts — Parvo, pamidronate.

104
Q

DM 1 vs DM 2 importance of retinopathy regarding NEPHROPATHY?

A

DM 1 + Nephropathy ==> 95% RETINOPATHY.

DM 2 + Nephropathy ==> 50-75% RETINOPATHY.

105
Q

Keep in mind that all DM pts w/ proteinuria should be evaluated for …

A

Other systemic diseases — HBV, HCV, SLE, monoclonal gammopathy.

AS UP TO 20% have a NON diabetic cause of proteinuria.

106
Q

4 cases in which you should consider renal biopsy in DM:

A
  1. Presence of proteinuria w/ <10y DM duration.
  2. Presence of significant hematuria or RBC casts on urinalysis.
  3. Absence of retinopathy in DM 1 and possibly DM 2.
  4. ANY evidence of systemic disease.
107
Q

Post-infectious GN following STAPH infection is increasingly …

A

Being recognized — Particularly in DIABETICS.

108
Q

Diseases that may present with rapidly progressive renal failure:

A
  1. GN.
  2. CH emboli syndrome (transient hypocomplementemia in 25%).
  3. HUS, TTP, MHTN, APS.
  4. Scleroderma renal crisis.
  5. Myeloma cast nephropathy.

Internal Medicine (107 decks)

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