High Yield Internal Medicine PDF

High Yield Internal Medicine Shelf Exam Review Emma Holliday Ramahi Cardiology  A patient comes in with chest pain… Best 1st test = EKG If 2mm ST elevation or new LBBB (wide, flat QRS) STEMI ST elevation immediately, T wave inversion 6hrs- years, Q waves last forever Anteri...

High Yield Internal Medicine Shelf Exam Review Emma Holliday Ramahi Cardiology  A patient comes in with chest pain… Best 1st test = EKG If 2mm ST elevation or new LBBB (wide, flat QRS) STEMI ST elevation immediately, T wave inversion 6hrs- years, Q waves last forever Anterior LAD V1-V4 Lateral Circumflex I, avL, V4-V6 Inferior RCA II, III and aVF R ventricular RCA V4 on R-sided EKG is 100% specific Emergency reperfusion- go to cath lab or *thrombolytics if no contraindications Right ventricular infarct- Sxs are hypotension, tachycardia, clear lungs, JVD, and NO pulsus paradoxus. DON’T give nitro. Tx w/ vigorous fluid resuscitation.  Next best test = cardiac enzymes If elevated  NSTEMI. Check enzymes q8hrs x 3. Myoglobin Rises 1st Peaks in 2hrs, nl by 24 CKMB Rise 4-8hrs Peaks 24 hrs, nl by 72hs Troponin I Rise 3-5hrs Peaks 24-48hrs, nl by 7-10days Tx w/ morphine, oxygen, nitrates, aspirin/clopidogrel, and b-blocker Do CORONARY ANGIOGRAPHY w/in 48hrs to determine need for intervention. PCI w/ stenting is standard. CABG if: L main dz, 3 vessel dz (2 vessel dz + DM), >70% occlusion, pain despite maximum medical tx, or post-infarction angina Discharge meds = aspirin (+ clopidogrel for 9-12mo if stent placed) B-blocker ACE-inhibitor if CHF or LV-dysfxn Statin Short acting nitrates  If no ST-elevation and normal cardiac enzymes x3… Diagnosis is unstable angina. Work up- – Exercise EKG: avoid b-blockers and CCB before. – Can’t do EKG stress test if old LBBB or baseline ST elevation or on Digoxin. Do Exercise Echo instead. – If pt can’t exercise- do chemical stress test w/ dobutamine or adenosine. – MUGA is nuclear medicine test that shows perfusion of areas of the heart. Avoid caffeine or theophyline before – Positive if chest pain is reproduced, ST depression, or hypotension  on to coronary angiography  Post-MI complications MC cause of death? Arrhythmias. V-fib New systolic murmur 5-7 Papillary muscle rupture days s/p? Acute severe hypotension? Ventricular free wall rupture “step up” in O2 conc from Ventricular septal rupture RA  RV? Persistent ST elevation Ventricular wall aneurysm ~1mo later + systolic MR murmur? AV-dissociation. Either V-fib or 3rd “Cannon A-waves”? degree heart block 5-10wks later pleuritic CP, Dressler’s syndrome. (probably) low grade temp? autoimmune pericarditis. Tx w/ NSAIDs and aspirin. A young, healthy patient comes in with chest pain… If worse w/ inspiration, better w/ leaning forwards, friction rub & diffuse ST elevation  pericarditis If worse w/ palpation  costochondriasis If vague w/ hx of viral infxn and murmur  myocarditis If occurs at rest, worse at night, few CAD risk factors and migraine headaches, w/ transient ST elevation during episodes  Prinzmetal’s angina – Dx w/ ergonovine stim test. Tx w/ CCB or nitrates  EKG Buzzwords “Progressive, prolongation of the PR interval followed by a dropped beat” img.medscape.com/.../889392-890621-3206.jpg Cannon-a waves on physical exam. “regular P-P interval and regular R-R interval” http://www.ispub.com/ispub/ijpn/volume_4_number_1_43/an_unusual_cause_of_seizures_in_a_10_year_old/seizures-fig1.jpg “varrying PR interval with 3 or more morphologically distinct P waves in the same lead”. https://teach.lanecc.edu/brokawt/MAT4.jpg Seen in an old person w/ chronic lung dz in pending respiratory failure www.emedu.org/ecg/images/wpw_3a.jpg “Three or more consecutive beats w/ QRS 120bpm” www.emedu.org/ecg/images/wpw_3a.jpg “Short PR interval followed by QRS >120ms with a slurred initial deflection representing early ventricular activation via the bundle of Kent”. “Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm” “prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline” In a pt w/ low Mg and low K. Li or TCA OD  “Regular rhythm w/ a rate btwn 150-220bpm.” Sudden onset of palpitations/dizziness. www.ambulancetechnicianstudy.co.uk/images/SVT.gif www.emedu.org/ecg/images/k_5.jpg Renal failure patient/crush injury/burn victim w/ “peaked T-waves, widened QRS, short QT and prolonged PR.” img.medscape.com/pi/emed/ckb/emergency_medici.. “Alternate beat variation in direction, amplitude and duration of the QRS complex” in a patient w/ pulsus paradoxus, hypotension, distant heart sounds, JVD “Undulating baseline, no p- waves appreciated, irregular R-R interval” in a hyperthyroid pt, old www.ambulancetechnicianstudy.co.uk/images/SVT.gif pt w/ SOB/dizziness/palpitations w/ CHF or valve dz  Murmur Buzzwords SEM cresc/decresc, louder w/ Aortic Stenosis squatting, softer w/ valsalva. + parvus et tardus SEM louder w/ valsalva, softer HOCM w/ squatting or handgrip. Late systolic murmur w/ click Mitral Valve Prolapse louder w/ valsalva and handgrip, softer w/ squatting Holosystolic murmur radiates Mitral Regurgitation to axilla w/ LAE  More Murmurs Holosystolic murmur w/ late VSD diastolic rumble in kiddos Continuous machine like PDA murmur- Wide fixed and split S2- ASD Rumbling diastolic murmur Mitral Stenosis with an opening snap, LAE and A-fib Blowing diastolic murmur with Aortic Regurgitation widened pulse pressure and eponym parade.  A patient comes in with shortness of breath… cardiac or pulmonary? If you suspect PE (history of cancer, surgery or lots of butt sitting)  heparin! Check O2 sats  give O2 if 1cm on lat decu  thoracentesis! – If transudative, likely CHF, nephrotic, cirrhotic If low pleural glucose? Rheumatoid Arthritis If high lymphocytes? Tuburculosis If bloody? Malignant or Pulmonary Embolus – If exudative, likely parapneumonic, cancer, etc. – If complicated (+ gram or cx, pH < 7.2, glc < 60): Insert chest tube for drainage. – Light’s Criteria  transudative if: LDH < 200 LDH eff/serum < 0.6 Protein eff/serum < 0.5 ncbi.nlm.nih.gov  Pulmonary Embolism High risk after surgery, long car ride, hyper coagulable state (cancer, nephrotic) – Sxs = pleuritic chest pain, hemoptysis, tachypnea Decr pO2, tachycardia. download.imaging.consult.com/... /gr1-midi.jpg – Random signs = right heart strain on EKG, sinus tach, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2. – If suspected, give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard. – Tx w/ heparin warfarin overlap. Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. Surgical thrombectomy if life threatening. IVC filter if contraindications to chronic coagulation.  ARDS Pathophys: inflammation  impaired www.ispub.com/.../ards3_thumbnail.gif gas xchange, inflam mediator release, hypoxemia Causes: – Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis. Diagnosis: 1.) PaO2/FiO2 < 200 (5mm for AIDS, immune suppressed – If + PPD  do CXR. – If +CXR  do acid fast stain of sputum. – If CXR negative, or +CXR & 3 negative sputums  – If positive  tx w/ 4 drug RIPE Regimen for 6mo (12 for meningitis and 9 if pregnant) *Chemoprophylaxis (INH for 9mo) for kiddos 10% A young patient with thrush, Zoster, or Kaposi sarcoma  When to start Tx/Post exposure Prophylaxis Start HAART when CD4 < 350 or viral load >55,000 (except preggos get tx >1,000 copies) – GI, leukopenia, macrocytic anemia Zidovudine- – Pancreatitis, peripheral neuropathy Didanosine- – HS rash, fever, n/v, muscle aches, SOB in 1st 6wks. D/C and never use again! Abacavir- – Nephrolithiasis and hyperbilirubinemia Indinavir- – Sleepy, confused, psycho Efavirenz- Post-exposure prophylaxis- – If stuck w/ known HIV pt  AZT, lamivudine and nelfinavir for 4wks  HIV+ patient with DOE, dry cough, fever, chest pain Think PCP. CD4 prob 35 Prophylaxis? Start st when CD4 is 200 for >6mo nd 1 - Trim-sulfa 2 - Dapsone 3rd- Atovaquone 4th- Aerosolized pentamidine (causes pancreatitis!)  HIV+ patient with diarrhea CMV- ( 5.4 analgesics HypoK, Kidney stones Replete K Distal SLE, Sjogrens, sickle Problem? Cannot excrete H+ Oral bicarb cell, hepatitis Type II *Fanconi’s syndrome HypoK, Osteomalacia Replete K Myeloma, amyloid, Problem? Cannot reabsorb Proximal Mild diuretic vitD def, HCO3. Bicarb won’t help autoimmune dz Type IV >50% caused by HyperK diabetes! HyperCl Hyperrenin Addisons, sickle cell, High urine [Na] even w/ salt Fludrocortisone Hypoaldo any cause of aldo restriction def. *Fanconi’s anemia = hereditary or acquired prox tubule dysfxn where there is defective transport of glc, AA, Na, K, PO4, uric acid and bicarb.  Acute Renal Failure >25% or 0.5 rise in creatinine over baseline. Work up- – BUN/Cr ratio  if >20/1 = prerenal – Check urine Na and Cr  if FENA < 1% = prerenal – If pt on diuretic measure FENurea  is 50K Septic arthritis 30 yr old who “travels a lot Gonococcal. Cx may be negative. Look for work” also for tenosynovitis and arm pustules. Tx w/ ceftriaxone. 70 yr old nun Staph aureus. Tx w/ nafcillin or vanco. WBCs 5-50K Inflammatory. If no crystals, think RA, ank spon, SLE, Reiter’s Needle shaped, negatively Gout. Monosodium Urate. birefringent crystals. Acute TX? Indomethacin + colchicine (steroids if kidneys suck). Chronic TX? Probenecid if undersecreter. Allopurinol if overproduc. Rhomboid shaped, positively Pseudogout. Calcium pyrophosphate. birefringent crystals. WBCs 200-5K OA, hypertrophic osteoarthropathy, trauma WBCs 10mm) Order of hormones lost in #1 FSH and LH #2 GR #3 TSH #4 ACTH hypopituitarism? Polyuria, polydipsia, hyperNa, DI- lack of ADH (or non-fxnal) hyperOsm, dilute urine. Do water deprivation test to tell if crazy – Central- urine Osm still ↓ s/p water depriv. Urine Osm ↑ w/ ddAVP – Nephrogenic- Urine Osm still ↓ s/p ddAVP. Tx w/ HCTZ/amiloride. See low TSH, high free T3/T4. Next best step? I123 RAIU scan. If ↑ = Graves. If ↓ = factitious or thyroiditis – Tx? 1st = propranolol + PTU/MTZ. I131 ablation or surgery (preggos & kiddos) – Tx of thyroid storm? PTU + Iodine (Lugol’s sol’n) + propranolol.  Work up of a Thyroid Nodule 1st step? Check TSH If low? Do RAIU to find the “hot nodule”. Excise or radioactive I131 If normal? FNA If benign? Leave it alone. If malignant? Surgically excise and check pathology If indeterminate? Re-biopsy or check RAIU If cold? Surgically excise and check pathology – Papillary MC type, spreads via lymph, psammoma bodies – Follicular Spreads via blood, must surgically excise whole thyroid! – Medullary Assoc w/ MENII (look for pheo, hyperCa). Amyloid/calci – Anaplastic 80% mortality in 1st year. – Thyroid Lymphoma Hashimoto’s predisposes to it.  Adrenal Issues Osteoporosis, central fat, DM, hirsutism Suspect Cushing’s. – Best screening tests? 1mg ON dexa suppression test or 24hr urine cortisol If abnormal? Diagnoses Cushing’s Syndrome – Next best test? 8mg ON dexa suppression test Suppression to 126 x 2, 2hr OGTT > 200, random glc > Diagnosis of Diabetes? 200 + sxs (polyuria, polydipsia, blurred vision) Nausea, vomiting, abdominal pain, Kussmaul respirations, coma w/ BGL = 400? DKA – Dx? Ketones in blood (&urine), AGMA, hyperkalemia – Tx? High volume NS + insulin bolus & drip. Add K once peeing. Add glc 60% if arm. R ACA stroke Confusion, behavioral disturbance. L hemiplegia + R ptosis & eye deviated to the right R Webber’s and down. Falling to the L + R ptosis & eye deviated to the right R Benedikt’s and down. L hemisensory loss + Horners + R facial sensory loss.R Wallenburg (PICA) Vertigo, vomiting, nystagmus and clumsiness with Major R cerebellar the right arm. arteries Total paralysis except for vertical eye movements. Paramedial branches of the basilar artery.  Seizures Medical causes include hypoglycemia, hyponatremia, hypocalcemia, structural (tumor, bleed, stroke), infection, ETOH or benzo w/drawal. Status Epilepticus. – Tx? Lorazepam + LD of phenytoin. Then phenobarbitol. Then anesthesia. Partial seizures begin focally. (Arm twitch, de-ja-vu, burning rubber smell). – They are simple if no LOC and complex if LOC (may have lip smacking). Both can generalize. – Tx? 1st line = carbamazepine or phenytoin. Then valproate or lamotrigine Generalized seizures begin from both hemispheres @ once. – Either grand mal or absence (5-10sec unresponsiveness in kiddos), myoclonic, atonic. Tx absence w/ ethosuximide – Tx? 1st line = valproic acid, then lamotrigine, carbamezepine, phenytoin  EEG Buzzwords 3 Hz spike-and- Absence Seizure. Tx w/ ethosuxamide wave. Triphasic bursts Creutzfeldt Jakob. Dementia + myoclonus Diffuse Delirium. Contrast w/ psychosis that has no background EEG changes slowing. Hypsarrhythmia Infantile spasms. Tx w/ ACTH. Most are associated w/ mental retardation.  New Onset Severe Headache Things to consider: “Worse headache of my life” Subarachnoid hemorrhage. Noncon CT 1st! + Fever and Nuchal rigidity Meningitis. Abx then CT then LP. Deep pain that wakes them up Consider brain tumor. Most important at night. Worse w/ coughing or prognostic factor is grade (degree of anaplasia). bending forward. Unilateral pounding headache Temporal arteritis. Check ESR, then w/ changes in vision and jaw give steroids, then do temporal artery biopsy. Can lead to blindness. claudication. Fat lady on minocycline or who Pseudotumor cerebri. Also assoc w/ takes isotreintoin w/ abducens OCPs. Normal CT, elevated pressure on LP. Tx w/ weight loss, then nerve palsy/diplopia. acetazolamide, then shunt or optic nerve sheath fenestration.  Neuro reasons to go to the hospital… Diarrhea 3wks ago, now Guillain-Barre. areflexia and ascending CSF shows albumino-cytologic dissociation paralysis. – Most likely bug? Campylobacter, HHV, CMV, EBV – Best tx? IVIG or plasmapheresis. Monitor VC for intubation req. Nasal voice, ptosis, dysphagia, Myasthenia Gravis. 1st test is Ach-ab. Most respiratory acidosis. accurate is EMG, decrease in muscle fiber contraction. – Acute tx? IVIG or plasmapheresis. Monitor VC for intubation req. – Chronic tx? Pyridostigmine, GCs/azathioprine, thymectomy (1000 means stone) & lipase. Best imaging is CT scan. Tx w/ NG, NPO, IV. Observe. – Prognosis- worse if old, WBC>16K, Glc>200, LDH>350, AST>250… drop in HCT, decr calcium, acidosis, hypox – Complications- pseudocyst (no cells!), hemorrhage, abscess, ARDs Chronic Pancreatitis- – Chronic MEG pain, DM, malabsorption (steatorrhea) – Can cause splenic vein thrombosis Adenocarcinoma- – Usually don’t have sxs until advanced. If in head of pancreas  Courvoisier’s sign (large, nontender GB, itching and jaundice). Trousseau’s sign = migratory thrombophlebitis. – Dx w/ EUS and FNA biopsy – Tx w/ Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.  A patient comes in with diarrhea… If hypotensive, tachycardic. Give NS first! Vial is #1 cause  rota in daycare kids, Norwalk on cruise ships Check fecal leukocytes  tells invasion. Stool cx is best test If bloody diarrhea  consider EHEC, shigella, vibrio parahaemolyticus, salmonella, entamoeba histolytica If hx of picnic  B. ceres, staph food poisoning. 1-6hrs If hx of abx use  check stool for c. diff toxin antigen If foul smelling, bulky, malnourished  consider Sprue, chronic pancreatitis, Whipple’s dz, CF if young person. If accompanied by flushing, tachycardia/ hypotension  consider carcinoid syndrome (metastatic). – *Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) Dementia, Dermatitis, Diarrhea. Oncology Extra Slides  A patient presents w/ fatigue, petechiae, infection bone pain and HSM… If >20% blasts? Defines Acute Leukemia on Biopsy CALLA or TdT? ALL. Most common cancer in kids. Auer Rods, AML. More common in adults. RF = rads myeloperoxidase, exposure, Down’s, myeloprolif. *M3 has Auer Rods and causes DIC upon tx. esterase? Hairy Cell Leukemia. See enlarged Tartate resistant acid spleen but no adenopathy. phosphatase, Hairy Cells have numerous ↓monos & CD11 and Tx w/ cladribine 5-7day single course cytoplasmic projections on smear. CD22+? Danorub, vincris, pred. Add intrathecal MTX for CNS Tx of ALL? recurrence. BM transplant after 1st remission. Tx of AML? Danorub + araC. If *M3  give all trans retinoic acid CML- 9:22 transloc  tyrosine kinase CLL A patient presents w/ Asymptomatic elevation fatigue, night sweats, in WBCs found on routine fever, splenomegaly and exam – 80% lymphs. elevated WBCs w/ low LAP and basophilia? www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi... If Lymphadenopathy Stage 0 or 1 need no tx- 12 yrs img.medscape.com/.../197800-199425-29.jpg till death If Splenomegaly Tx w/ imantinib (Gleevec), inhibits Stage 2 tx w/ fludrabine tyrosine kinase. 2nd line is bone If Anemia marrow transplant. Cx = blast crisis. If Thrombocytopenia Stage 3 or 4 tx w/ steroids  Enlarged, painless, rubbery Think Lymphoma lymph nodes Drenching night sweats, “B-symptoms” = poor prognosis along w/ fevers & 10% weight loss. >40, ↑ESR and LDH, large mediastinal LND Best initial test? Excisional lymph node biopsy Next best test? Staging Chest/Abdominal CT or MRI. If still unsure, staging laparotomy is done. Bone marrow bx (esp for NHL Orderly, centripetal spread Hodgkin’s Lymphoma + Reed Sternberg cells? Type w/ best prognosis? Lymphocyte predominant More likely to involve Non-hodgkin’s Lymphoma extranodal sites? (spleen, BM) I = 1 node group, II = 2 groups, same side of diaphragm, Staging? III = both sides of diaphragm, extension into organ. IV = BM or liver Treatment? I/II get rads III/IV get ABVD chemo  Other hematologic randoms… Bone pain, “punched out Multiple Myeloma lesions” on *x-ray*, hyper Ca – Best 1st test- Serum protein elecrophoresis- IgG monoclonal spike – Confirmatory test- Bone marrow bx showing >10% plasma cells. – Tx- If young, BM transplant. If old, melphalan + prednisone. Hydration and Dizziness, HA, hearing/vision lasix then bisphosphonate for hyperCa problems and monoclonal Waldenstrom Macroglobulinemia IgM M-spike. No sxs, immunoglobulin MGUS spike found on routine exam Older pt w/ generalized Polycythemia Vera pruritis and flushing after hot bath. Hct of 60%. – Best 1st test- Check epo, make sure it isn’t secondary. (PSG, carboxy-Hb) – Tx- Scheduled phlebotomy. Hydroxyurea can prevent thromboses