Internal Medicine High Yield – Flashcards
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best first test for pt with chest pain?
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EKG
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if 2 mm ST elevation or new LBBB (wide, flat QRS) on EKG?
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STEMI
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EKG findings of an MI
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ST elevation immediately T wave inversion ( 6 hrs to years) Q waves forever
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Anterior wall of the heart is shown by what leads of an EKG?
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V1-V4
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what artery supplies V1-V4 typically?
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LAD
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what artery typically supplies I, aVL, V4-V6?
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circumflex
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what artery typically suplies II, III, and aVF?
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RCA
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what artery typicaly supplies V4 on R-sided EKG/
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RCA
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next best test after EKG?
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cardiac enzymes
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what cardiac enzyme rises first within 2 hrs, second within 24 hours, and third within 24-48 hours?
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myoglobin, CKMB, troponin
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what is the treatment for a patient presenting with MI?
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morphine, oxygen, nitrates, aspirin, b-blocker
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when is a CABG indicated?
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left main disease, 3 vessel disease (2 vessel + DM)
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what medications should be given at discharge?
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aspirin, b-blocker, ACE inhibitor, statin, short acting ntrates, and clopidogrel if stent placed
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what two chemicals can be used for exercise stress testing?
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dobutamine (increases contractility of the heart) and adenosine (maximally dilates coronary arteries and will cause the blood to preferentially go to unclogged arteries)
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most common cause of death post MI?
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arrythmias/V-fib
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a new systollic murmur occurs 5-7 days after MI?
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papillary muscle rupture causing mitral regurg
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pt develops acute severe hypotension following an MI?
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ventricular free wall rupture
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blood gases show a step up in O2 concentration from RA to RV following an MI?
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ventricular septal wall rupture
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there is persistent ST elevation around 1 month later with a systolic murmur after an MI?
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ventricular wall aneruysm
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what are "cannon A-waves?"
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AV dissociaton, seen with 3rd degree HB
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a post MI patient develops pleuritic chest pain with a low grade temp 5-10 weeks later? Tx?
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Dresslers Syndrome NSAIDS/aspirin
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a young healthy patient presents with chest pain that is....worse with inspiration, better with leaning forward with a frictional rub? worse with palpation? vague pain with hx of viral infection and new murmur? occurs at rest, worse at night, few CAD risk factors and transient ST elevation during episodes? how is the last one treated?
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pericarditis costochondriasis myocarditis prinzmetals CCB/nitrates
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what murmur is a systolic ejection murmur, crescendo/decresendo, louder with squatting, softer with valsalva?
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aortic stenosis
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SEM luder with valsalva, softer with squatting or handgrip?
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Hypertrophic cardiomypoathy
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later systolic murmur with click that is louder with valsalva and hand grip, softer with squatting?
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mitral valve prolapse
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Holosystolic murmur that radiates to axilla
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mitral regurg
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rumbling diastolic murmur with opening snap, left atria enlargement, and a fib?
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mitral stenosis
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blowing diastolic murmur with widened pulse pressure and eponym parade
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Aortic Regurg
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if you suspect PE, what is the best first step?
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O2 and heparin...unless contraindicated! then you need an IVC filter immediately!
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what is the best treatment for acute pulmonary edema?
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nitrates, lasix and morphine
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if a young pt presents with symptoms of CHF with prior hx of viral infection?
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consider myocarditis with coxsackie B virus
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most common causes of systolic heart failure? (<55% EF)
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ISCHEMIC, DILATED, viral, ETOH
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best treatment for alcoholic cardiomyopathy?
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STOP THE BOOZE
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most common causes of diastolic heart failure?
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HTN, amyloidosis, hemochromotosis, sarcoidosis, cancer, fibrosis
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what are the 5 drugs can be used to treat CHF?
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ACE Inhibitors B blockers Spironolactone furosemide Digoxin
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what 3 drugs used to treat CHF have been shown to increase survival?
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B blockers, ACE Inhibitors, Spironolactone
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what 2 drugs for CHF prevents remodeling?
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B blockers and ACE inhibitors
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best treatment to prevent hemachromotosis restrictive cardiomyopathy?
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phlebotomy
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Progressive, prolongation of the PR interval followed by a dropped beat on EKG diagnostic for?
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second degree AV block type 1
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Cannon-a waves on physical exam. "regular P-P interval and regular R-R interval"
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third degree AV block
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"varrying PR interval with 3 or more morphologically distinct P waves in the same lead on EKG diagnostic of?
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multifocal atrial tachycardia
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What is the first step if a patient presents with over 1 cm of pleural effusion?
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thoracentesis
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Thickened peritracheal stripe and splayed carina bifurcation"
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mediastinal lymphadenopathy/atrial hypertrophy
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cavity containing an air-fluid level on CXR?
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abscess
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what are the three criteria for a pleural effusion to be transudative?
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LDH < 200 LDH effusion/serum < .6 protein effusion / protein serum < .5
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3 most common causes of a transudative pleural effusion?
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CHF, nephrotic, cirrhotic
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if the effusion is transudative wth low pleural glucose?
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RA
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if the effusion is transudative with lymphocytes?
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TB
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if the effusion is transudative with blood?
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malignancy or PE
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pt presents with pleuritic chest pain, hemopytysis, tachypnea, decreased PO2 and tachycardia after surgery. most likely Dx?
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PE
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best first step in PE tx?
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heparin unless contraindicated
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gold standard for PE dx?
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pulmonary angiography
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if pt cannot be placed on blood thinners, what is the best alternative to prevent PE?
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IVC filter
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pt develops sudden desaturation in ICU, CXR shows bilateral alveolar infiltrates, and PCWP is < 18 (normal); most likely dx?
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ARDS
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tx of ARDS?
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mechanical ventilation with PEEP
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FEV1/FVC ratio, TLC, and RV in obstructive disease ? (asthma, COPD, ephysema)
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decreased, increased, increased
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FEV1/FVC ratio, TLC, and RV in restrictive disease? (interstitial lung disease)
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normal, decreased, decreased
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in what obstructive conditions will the DLCO be reduced?
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emphysema 2/2 alveolar destruction
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in what restrictive condition with the DLCO be reduced?
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interstital lung disease due to fibrosis and thickening
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1st line treatment for COPD? 2nd line?
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ipratropium; beta agonists
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a change in sputum with increasing dyspnea in a pt with COPD are signs of what?
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exacerbation
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what 4 things are needed to treat a COPD exacerbation?
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supplemental O2 to 90%, ipratropium and allbuterol nebulizer, corticosteroids, and antibiotics
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what is the best prognostic indicator in COPD?
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stop smoking and continuous O2 therapy
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what two methods have been shown to increase survival in COPD?
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the only respiratory drive these people have is their hypoxia; taking it away may blunt their respiratory drive
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A patient with COPD comes in with new clubbing. what is the dx? next best step?
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hypertrophic osteoarthropathy CXR because it is likely due to lung malignancy
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an asthmatic has symptoms twice a week with normal PFTs. tx?
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allbuterol only
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an asthmatic has symptoms 4x a week, night cough 2 a month and PFTs are normal. tx?
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albuterol and inhaled corticosteroids
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an asthmatic has symptoms daily, with a night cough 2x a week and FEV1 at 60-80%. tx?
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albuterol, inhaled corticosteroids and long acting beta agonist (salmeterol)
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an asthmatic has symptoms daily, night cough 4x a week and FEV1 is less than 60%?
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albuterol, inhaled CS, salmeterol, and oral steroids /montelukast
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best treatment for an asthma exacerbation?
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inhaled albuterol and PO/IV steroids
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in an asthma exacerbation, what PCO2 level indicates impending respiratory failure?
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increased PCO2; initially the PCO2 will be low due to hyperventilation. As the attack gets worse, the airway is worse and worse and the PCO2 will rise ==> intubate
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what is a compication that asthmatics can have regarding a fungus?
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allergic bronchopulmonary aspergillus
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a patient presents with interstitial lung disease and 1 cm nodules in upper lobes with eggshell calcifications. dx?
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silicosis
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pt presents with interstital lung disease and reticulonodular process in loer lobes with pleural plaques. dx?
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asbestosis
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most common cancer in asbestosis?
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bronchogenic carcinoma, NOT MESOTHELIOMA
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pt presents with interstitial lung disease and patchy lower lobe infiltrates with thermophilic actinomyces. dx?
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hypersensitivity pneumonitis (farmers lung)
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pt presents with interstital lung disease with hilar lymphadenopathy, increased ACE and erythema nodosum. dx?
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sarcodosis
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why do sarcoidosis pts have hypercalcemia/?
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increase in macrophages that synthesize Vit D
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what is the most common systemic complication of sarcoidosis (think ophto)
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uveitis
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how is sarcoidosis diagnosed/treated?
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biopsy; steroids
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a pulmonary nodule is found on CXR. best first step?
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look for an old CXR
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if popcorn calcifications are seen on CXR, most likely dx?
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benign harmartma
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if concentric calcification on CXR, most likely dx?
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old granuloma
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if a pt is <40, < 4 cm, well circumscribed nodule on CXR; best tx?
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CXR or CT scans every 2 months to check for growth
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if a pt is a smoker/old, has > 3cm nodule with eccentric calcification on CXR. best first step? tx?
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biopsy and removal
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a pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. most common cancer in non-smokers? location? mets to? effusion studies show?
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adenocarcinoma; peripheral; liver, bone, brain, adrenals exudative with high hyaluronidase
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a patient with kidney stones, constipation, malise, low PTH has a central lung mass. most likely dx? why the low PTH
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squamous cell carcinoma paraneoplastic syndrome 2/2 secertion of PTH-rP, causing low PO4 and high Ca
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a pt presents with shoulder pain, ptosis, constricted pupil and facial edema with weight loss, cough, dysnea and hemoptysis. most likely dx?
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superior sulcus syndrome from small cell carcinoma
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patient with weight loss, dysnpea, hemoptysis presents with ptosis better after 1 minute of upward gaze. dx?
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lambert eaton syndrome 2/2 small cell carcinoma; caused by anti-bodies to pre-synaptic Ca channels
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an old smoker presents with sodium of 125, moist mucous membranes and no JVD but with hemopytsis, cough and dyspnea dx?
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SIADH ffrom small cell carcnioma fluid restriction and 3% saline if Na < 112
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CXR shows peripheral caviatation and CT showing distant mets in a pt with hemopytsis, dyspnea, and cough. Dx?
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Large cell Carcinoma
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what inflammatory bowel disease can mimic appendicits and involves the terminal ileum?
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Crohn's disease
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what mineral deficiency can you get with Crohn's diseasE?
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Fe
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what inflammatory bowel disease has an increased risk for primary sclerosing cholangitis?
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UC
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primary sclerosing cholangitis has an increased risk for what cancer?
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cholangiocarcinoma
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what inflammatory bowel disease typically affects the rectum?
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ulcerative colitis; ileal backwash can occur BUT IT IS RARE
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which inflammatory bowel disease has common fisutale formation? tx?
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Crohns; metronidazole
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which inflammatory bowel disease has granulomas on biopsy?
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Crohns
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what inflammatory bowel disease involves transmural inflammation?
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Crohns
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what inflammatory bowel disease is cured by colectomy?
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UC
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what inflammatory bowel disease has a higher risk of colon cancer?
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UC
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what inflammatory bowel disease is associated with P-ANCA?
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UC
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what is the best treatment for maintaining remission of IBD?
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ASA and sulfasalzine
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what is the best treatment to induce remission in IBD?
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corticosteroids
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if a pt develops an ulcer or fistuale in Crohn's, what is the best tx?
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metronidazole
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if AST > ALT (2x higher or more) + high GGT, what type of hepatitis is most likely occuring?
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DRUGS/ALCOHOL
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if the ALT>AST and in the 1000s, what type of hepatitis is occuring?
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viral
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if the AST and ALT are in the 1000s after surgery or hemorrhage, what has occureD?
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ischemic hepatitis ("shock liver"
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an elevated direct bilirubin indicates what type of process in the liver?
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obstructive
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f a patient has an elevated direct bilirubin, what are the three diagnoses on the top of the differnetial?
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obstruction due to stone/cancer Rotor's syndrome Dubin Johnson's syndrome
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if a patient has elevated indirect bilirubin, what are the two most common diagnoses?
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hemolysis, gilbert's
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if a patient has elevated alk phos with elevated GGT, what is most likely occuring? if this is occuring in the presence of IBD, what different diagnosis should be considered?
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bile duct obstruction primary sclerosing cholangitis
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if a patient has elevated alk phos with normal GGT and normal Ca with hearing loss but no elevated bilirubin, what diagnosis should be considered? tx?
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Paget's. Bisphosphonates
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what disease does the presence of antimitochondiral antibody indicate? best treatment?
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primary biliary cirrhosis; ursacholic acid?
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a patient is ANA positive with antismooth muscle antibodies. what is the most likely diagnosis? tx?
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autoimmune hepatitis; steroids
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a patient has high iron, low ferritin and low TIBC. what is the most likely diagnosis? what are the three most common systemic signs of this disease?
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hemochromotosis; hepatitis, DM, and golden skin
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if a patient has low ceruloplasmin levels with high urinary copper, what is the most likely diagnosis?
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Wilson's disease; hepatitis, psychiatric symptoms due to lenticular deposits in the basal ganglia and corneal deposits (kaiser-fleisher rings)
