Internal Medicine SHELF Review 2

Cardiology 2

100

Two murmurs louder with valsalva.

What are mitral valve prolapse and HOKM?

200

Medications that decrease mortality with CHF

What is Beta blocker, spirolactone, ACEI? Bonus: ICD!

300

Way to confirm AV shunt.

What is Saline Contrast Study aka Bubble contrast TTE. shaken saline into veins, normally absorbed by lungs. If shows up in left heart = shunt.

400

Varying PR interval with 3 or more morphologically distinct P waves in the same lead. Seen in an old person w/ chronic lung disease in pending respiratory failure

What is Multifocal Atrial Tachycardia?

500

Five causes of high output cardiac failure

What are AVM (secondary to trauma or underlying disorder which shows increased hemoglobin, increased oxygen content Thyrotoxicosis secondary to sympathetic overload

GI

100

35 y/o male with no PMHx presents with epigastric pain and no alarm features get this workup.

In patients aged 55 yr or younger with no alarm features, the clinician may consider two approximately equivalent management options: (i) test and treat for H. pylori using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4–8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (≥10%), whereas the empirical PPI strategy is preferable in low prevalence situations.

200

67 y/o presents with repeated episodes of regurgitating undigested food after meals for several months. Describes a sensation of food getting stuck in his throat and vague gurgling sensation when swallowing and gets this study.

What is Barium Swallow…diagnosis of Zenker’s Diverticulum

300

Two days after surgery for a torn ACL, a 24 y/o male develops jaundice but otherwise asymptomatic. Bilirubin 3.5 mg/dL with Direct 0.2mg/dL

What is Gilbert’s disease? vs rotor syndrome and dubin Johnson syndrome Gilbert syndrome Super Common: 5-10% of the population has it. Decreased activity of UGT1A1 (30% of normal): conjugates bilirubin with glucuronic acid Autosomal recessive syndrome Unconjugated hyperbilirubinemia No clinical consequence (other than anxiety that occurs when your skin turns yellow Crigler-Najjar syndrome Type I CN is a super rare, autosomal recessive disorder in which patients have no UGT1A1 activity fatal in the neonatal period w/o liver transplant. unconjugated bilirubin producing severe jaundice and icterus Type II CN is an autosomal dominant disorder in which patients have some UGT1A1 activity Nonfatal but really really yellow skin. Dubin-Johnson syndrome Autosomal recessive disorder Conjugated bilirubin with defect in secretion of bilirubin glucuronides (already conjugated!) across the canalicular membrane ( Liver darkly pigmented because of coarse granules within the hepatocyte cytoplasm. Most patients are asymptomatic Rotor syndrome Autosomal recessive disorder with conjugated bilirubin The exact molecular defect is unknown – most patients are asymptomatic (other than some jaundice).

400

4 alarm features for epigastric pain that would require an EGD.

Dyspeptic patients more than 45-55 yr old, or those with alarm features (bleeding, anemia, early satiety, unexplained weight loss (>10% body weight), progressive dysphagia, odynophagia, persistent vomiting, a family history of gastrointestinal cancer, previous esophagogastric malignancy, previous documented peptic ulcer, lymphadenopathy, or an abdominal mass) should undergo prompt endoscopy to rule out peptic ulcer disease, esophagogastric malignancy, and other rare upper gastrointestinal tract disease.

500

Antibiotic combinations are used to eradicate H. pylori infection.

What is t/m one week.....eradicate hpylori infection, allow ulcer to heal ppi+clarithromycin+amoxicillin(triple therapy) Allergic to pencillin=ppi+clarithromycin+metronidazole Resistant=triple therapy+bismuth(quadraple therapy) Resistant to clarithromycin=instead of clarithromycin ,levofloxacin can be tried

Endocrine

100

Type of thyroid cancer is unable to be diagnosed by FNA

What is follicular carcinoma because the only way to diagnosis cancer is to see if the cancer is extending beyond the capsule so it’s impossible to see with an FNA biopsy. BONUS: When is it appropriate to send a pt with a newly diagnosed thyroid nodule to get a radionuclear thyroid scan? A: When the TSH value is low because it might mean it’s a Hot nodule which is never malignant and no FNA is necessary

200

37 y/o female with no PMHx present with BP 155/108 x3 visits and asymptomatic. Pts labs show Na+ 143 mEq/L and K+ 3.1 mEq/L

What is Conn Syndrome or Hyperaldosteronism Bonus Question: discuss some other causes of secondary HTN with AFP handout

300

A 45 y/o female with a hypercalcemia, high PTH level and a low urinary calcium level.

What is Familial hypocalciuric hypercalcemia. The patient is missing the calcium sensing receptor on the parathyroid gland which causes hypercalcemia with increased PTH levels. In the kidney’s, the receptor mediates negative feedback relating to calcium reabsorption from the tubular system (reabsorption should decrease if there is a high blood calcium level). First line treatment for hypercalcemia: Normal saline and fluids are almost always the first line treatment. Note that furosemide, bisphosphonates and calcitonin can be used if levels are extremely elevated

400

A 18 y/o DM1 patient with a recent history of the flu presents with nausea and vomiting, polyuria and severe RLQ pain. The pt is mildly confused and disoriented. The patient’s lab show hyponatremia, hypokalemia and glucose around 310. The physician asks for these two lab values should be ordered in order to assess the severity of the current condition.

What are Venous pH or serum bicarbonate levels

500

55 y/o pt with no significant PMHx/medication present with 5 months of weight loss, fatigue, persistent N/V, and polyuria. The pt has also noted her skin to be darker even though she has not increased her time in the sun. He gets this test.

What is ACTH test (also called the cosyntropin test). This patient is suffering from adrenal insufficiency. The next step is to determine whether it is primary or secondary…primary is a problem with the actual adrenal glands (Addison disease usually due idiopathic or autoimmune reaction.) Secondary causes are usually caused by iatrogenic long term steroid therapy. In addition, pituitary adenoma or microadenoma; a hypothalamic tumor (surgical removal of a pituitary tumor can also suppress production of ACTH and lead to adrenal deficiency); and Sheehan's syndrome

Nephrology

100

physical exam findings and EKG change associated with hypocalcemia

What is numbness, Chvostek or Troussaeu, prolonged QT interval

200

14 y/o male with no PMHx but had a runny nose, sore throat & cough present 1-2 days ago present with painless hematuria.

What is Berger's disease (IgA nephropathy) because of the time frame which differentiates it from Post strep which is 1-2 weeks post infection.

300

Two major categories of ATN

What are Acute tubular necrosis (ATN) is the death of tubular cells. *CAUSES: 1.ISCHEMIC: Hypotension (low blood pressure) Surgery (e.g., open heart surgery, repair of abdominal aortic aneurysm) Obstetric (birth-related) complications Obstructive jaundice (yellow-tinged skin caused by blocked flow of bile Prolonged prerenal state Sepsis (infection in the blood or tissues) 2.NEPHROTOXIC: Aminoglycosides (antibacterial antibiotics such as streptomycin and gentamicin) Amphotericin B (antibiotic used to treat some forms of meningitis and systemic fungal infections) Cisplatin (anticancer agent used to treat late-stage ovarian and testicular cancers) Radioisotopic contrast media (agent used in certain imaging studies) *Most common cause of ARF. *ATN does not rapidly improve following the administration of large-volume intravenous fluid. ******Urine analysis: Broad, dirty brown granular casts are typically found in ischemic or nephrotoxic ATN

400

UA for a pt suffering from Acute interstitial nephritis (AIN)

What is eosinophils—specialized white blood cells that are seen in allergic reactions. *Acute interstitial nephritis (AIN) is rapidly developing inflammation of the spaces between the tubules and may include inflammation of the tubules. *CAUSES: ascending infection, VUR(ACUTE) Drug induced NSAID induced,Urate myopathy, Chr.lead poisioning, Multiple myeloma-Bence Jones proteinuria(tubular casts ith foreign body giant cell reaction),Nephrocalcinosis,primary amyloidosis. ****Urine analysis: often reveals eosinophils—specialized white blood cells that are seen in allergic reactions.

500

A 35 y/o pt with PMHx of uncontrolled asthma present with painless hematuria and acute elevated BUN/Cr. The pt's lab show she is p-ANCA (+) and has eosinophilia.

What is Churg Strauss. Best test is lung bx. Tx w/ cyclophosphamide

Rheumatology

100

A chronic RA patient develops splenomegaly and one other symptoms to complete Felty’s triad.

What is Neutropenia…think the spleen is eating all the neutrophils. spleen is palpable secondary to Felty = feeling the spleen

200

45 y/o female is recently diagnosed with dermatomyositis and wants to know to what the next step in management after her disease is controlled with a short course of steroid.

What is an abdominal and pelvic CT scan secondary to the increased risk of underlying GI/Pelvic organ cancer

300

classic symptoms associated with psoriatic, ankylosing spondylosis, and Reiter’s

What are dactylitis (sausage fingers) for reiters, severe nail involvement and obvious skin lesion with silver plaques for Psoriatic, and enthesis for AS PAIR…Psoriatic, ankylosing spondylosis, Inflammatory Bowel, Reactive arthritis (includes Reiter’s).

400

One lab test to differentiate polymyositis and polymyalgia rheumatica what test would you order?

What is CK enzyme though anti Jo-1 antibody (60%) could also be correct

500

A 32 y/o female G2P1 presents to the ER with a placental abruption. The patient needs an immediate transfusion and after following all the correct protocols receives 3 units of pRBC. The patient immediately develops rigors, fever, flank pain, tachycardia, dyspnea, hypotension.

What is ACUTE HAEMOLYTIC REACTION Note: Contrast with SEPTIC REACTION / BACTERIAL CONTAMINATION Fever, chills, rigor, nausea, vomiting, hypotension The flank pain, unexplained bleeding, oliguria, haemoglobinuria, haemoglobinaemia are vital clues to the DIC type picture. In contrast: A 32 y/o female G2P1 with a hx of celiac disease presents to the ER with a placental abruption. The patient needs an immediate transfusion and after following all the correct protocols receives 3 units of pRBC. The patient immediately develops flushing, wheezing, hypotension. What is SEVERE ALLERGIC REACTION / ANAPHYLAXIS secondary to IgA deficiency (celiac disease) was a hint…the patient has anti- IgA antibodies Note: contrast this with TRALI – Transfusion Related Acute Lung Injury Dyspnea, tachypnea, respiratory failure, noncardiogenic pulmonary edema, chills, fever Incidence 1 in 5,000-190,000 Additional Clinical Actions: •Administer supplemental oxygen and employ ventilation support as necessary CAUTION – this may become a medical emergency •Support blood pressure and maintain airway.