general internal medicine Flashcards

Question

What is the difference between a myleoproliferative and a myleodysplastic disorder?

Answer 1

Myeloproliferative--\> cell accumulation--\> PRV, CML, ET, MF Myelodysplastic-\>abnormal bone marrow cell growth Both disorders have risk of conversion to acute myeloid leukemia

Answer 2

Dress is Drug Reaction with Eosinophillia and Systemic Symptoms It is caused by starting a drug most commonly 1) antiepileptics 2) sulfonamides (5- ASA, vancomycin, daptomycin) There is a latency period between starting the drug and seeing symptoms DRESS is associated with reactivation of herpes virus When to suspect DRESS — The diagnosis of DRESS is suspected in a patient receiving a drug treatment who presents with the following signs and symptoms: ●Skin eruption (morbilliform or diffuse, confluent, and infiltrated) (picture 1A) ●Fever (38 to 40°C [100.4 to 104°F]) ●Facial edema ●Enlarged lymph nodes Treatment of DRESS is 1) stop the drug 2) steroids 3) Treat the organ

Answer 3

Posterior reversible encephalopic syndrome -- also called-- Reversible posterior leukoencephalopic syndrome Caused by loss of autoregulation in the brain, associated with hypertension the clinical syndrome of reversible posterior leukoencephalopathy syndrome

Answer 4

(CONS)Coagulase negative staph (epidermidis, saprophyticus) Corynebacteria propionbacteria acnes

Answer 5

Strep Viridans HCEK Neisseria Anaerobes (Peptostreptococcus, veillonella, fusobacterium, actinomyces, prevotella)

Answer 6

CURB 65 Confusion Urea\> 7 Respiratory rate \> 30 Blood pressure --\> systolic \< 90. diastolic \< 60 65 ( Age) 0-1 --\> outpatient 2- inpatient 3-5- ICU

Answer 7

bradyarrhythmia ( - sinus bradycarida - sick sinus syndrome - SA block - AV block - junctionl escape - ventricular escape tachyarrhythmia (\>100) 1) constant RR interval 2) irregular RR

Answer 8

Serum calcium normal range is 2.2-2.6 mmol/L -serum calcium is divided into 3 parts **_a)albumin bound 40%_** -0.2mmol drop for every 10 drop in albumin **Corrected calcium= serum Ca + (0.2 (40-albumin (g/L)))** **_b)ionized 45%_** (free in serum) the fact that this is the largest proportion makes it a good serogate of total calcium **_c) bound to inorganic anions 15%_** Ionized calcium normal range is 1.15-1.35 mmol/L - ionized calicum is the most important because it is the free calcium - ionized calcium is affected by a) basic pH (acute and chronic respiratory alkalosis) b) PTH decreases binding of Ca to albumin= increases ionized fraction c) hyperphosphatemia --\>increased phosphate binds Ca and decreases ionized Ca

Answer 9

Pericarditis can present with chest pain that radiates Physical exam findings include a a) high JVP with positive abdomiojugular reflex b) pulsus paradoxis ECG findings include a)widespread STE and PR depression that progress through four phases Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first two weeks) Stage 2 – normalization of ST changes; generalized T wave flattening (1 to 3 weeks) Stage 3– Flattened T waves become inverted (3 to several weeks) Stage 4 – ECG returns to normal (several weeks onwards) **Tx of idiopathic pericarditis** ASA 650 qid **Admit to hospital if** 1) tamponade 2) immunocompromised 3) fever and leukocytosis 4) failure to respond to NSAID therapy Treatment of pericarditis

Answer 10

\< 30= congenital bicuspid valve 30-70= rheumatic heart disease congenital stenosis \>70= calcification

Answer 11

FMD is a non-inflammatory, non-atherosclerotic disorder that leads to arterial stenosis, occlusion, aneuyrsm and dissection - it can affect one or more body system - there is often no acute phase reaction like in vasculitis - It is often associated with hypertension Clinical manifestations are broad and include - ischemia related to stenosis - spontaneous dissection - rupture of aneurysms - embolization of intravascular thrombi Differential diagnosis for fibromusclar dysplasia - atherosclerosis (usually presents with risk factors) - vasculitis (usually has acute phase reactants)

Answer 12

Smoking Hypertension Dyslipidemia Elevated homocysteine

Answer 13

Pre hypertension= 120-139/ 80-89 Stage 1 hypertension= 140-159/ 90-99 Stage 2 hypertension= 160/100

Answer 14

Hypertensive encephalopathy is a form of end organ damage found in extreme hypertension. **Hypertensive encephalopathy is a diagnosis of exclusion** The symptoms of hypertensive encephalopathy are - severely elevated blood pressures - confusion - increased ICP - +/- seizures

Answer 15

**MEN 1 = "The 3 P's"** - parathyroid gland - anterior pituitary - entero-pancreatic endocrine cells MEN 2a - parathyroid gland - medulary thyroid cancer - pheochromocytoma MEN 2b - mucosal neuromas - medulary thyroid cancer - pheochromocytoma

Answer 16

Pheochromocytoma is a neuroendocrine tumor of the medulla of the adrenal glands -Commonly found in MEN II and VHL Pheochromocytomas are best diagnosed using 24 hour urine collection for metanephrines, and unconjugated or free catecholamines Radiographic testing with 123- I metaiodobenzylguandine or octreotide scan is indicated 90% of pheochromocytoma's are the in adrenal glands Definitive treatment of choice for pheochromocytoma's is surgical resection The medical treatment of a pheochromocytoma is alpha and beta blockade- first establish alpha and then beta.

Answer 17

Observe -in general hypertension should not be acutely decreased in an individual suspected of having a stroke because of the concern for cerbral hypoperfusion and worsening brain ishcemia

Answer 18

SAAG= Serum albumin- ascites fluid albumin SAAG tells you the likely underlying etiology of an ascites collection if \> 1.1 g/dl= portal hypertension - etiologies a) cirrhosis b) bud chiari c) CHF d) constrictive pericarditis if\< 1.1 g/dl= nonportal hypertension etiologies a) peritoneal carcinomatosis b) tuberculosis peritonitis c) bowel obstruction or infarction d) serositis e) nephrotic syndrome

Answer 19

**On Admission** Age \> 55 years WBC \> 16,000 Serum glucose \> 10 mmol/L on admission AST\> 250 LDH\> 350 **48 Hours Into Admission** Hct drop\> 10% from admission BUN increase \> 1.79 mmol/L from admission Ca \< 2 mmol/L within first 48 hours Arterial pO2 \< 60 mmHg within 48 hours Base deficit (24- HCO3) \> 4 within 48 hours Fluid needs \> 6L within 48 hours **Scoring** **-each criteria = 1 point** **1 to 3= mild pancreatitis** **\>4 = increased mortality rate 15-100%**

Answer 20

colon with diameter \> 6cm on imaging usually acompanied by fever, leukocytosis, tachycardia, and evidence of serious toxicity such as hypotension or altered mental state

Answer 21

**S**erositis- pleuritis or pericarditis **O**ral ulcers- **A**NA **P**hotosensitivity **B**lood- hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia **R**enal- nephritic/ nephrotic or mixed picture **A**rthritis-symmetric, non-erosive **I**mmune **N**eurlogic- seizures or psychosis **M**alar rash **D**iscoid rash

Answer 22

Gout is caused by uric acid crystals (needle shaped and negatively birefringent) Pseudogout is caused by calcium pyrophosphate dihydrate crystals (blue, rhomboid, positively birefringent)

Answer 23

The combination of - ra - splenomegally - leukopenia - lymphadenopathy - thrombocytopenia

Answer 24

b12 deficiency is defined by macrocyclic anemia with methylmalonic acid and homocysteine being high. Folate just has high homocysteine

Answer 25

-absolute neutrophil count \<500 cells/mm cubed Or -ANC \<1000 with w predicted decrease to less than 500 cells/mm(cubed)

Answer 26

Major: - sustained bacteremia by an organism known to cause endocarditis ( or 1 bacterial culture with + serology for Coxiella) - endocardial involvment documented by either a positive echo or new valvular regurgitation minor - predisposing condition - fever - vascular phenomenon --\> septic arterial or pulmonary emoli, mycotic aneurysms, ICH, janeway lesions, splinter hemorrhages - immune phenomenon--\> + RF, GN, Oslers nodes, roth spots + BCx not meeting major criteria Definitive= 2 major, 1 major + 3 minor or 5 minor Possible= 1 major+ 1 minor, or 3 minor

Answer 27

- uncontrollable infection (positive cultures after 7 days, no appropriate antimicrobial therapy, ) - local suppurative complications - most cases of prosthetic valve endocarditis - intractible congestive heart failure caused by valvular dysfunction

Answer 28

A colonoscopy because a signifiicant number of patients with strep bovis endocarditis have colon cancer or a premalignant polyp which seed the valve

Answer 29

latent- asymptomatic infection primary- development of critical illness immediately after infection with M tuberculosis reactivation tuberculosis- illness that occurs after latent TB becomes activated

Answer 30

primary pulmonary TB usually affects the middle and lower lung zones reactivation TB usually affects apical and posterior segments of upper lobes

Answer 31

More than 100-600ml of blood loss that is coughed up within a 24 hour period

Answer 32

SVC syndrome--\> compression of SVC causing swelling of upper extremeties and formation of new collateral veins Horner syndrome--\> combination of symptoms of miosis (pupils don't dilate ), ipsilateral anhydrosis, and ptosis (eyelid drop) Both Horners syndrome and SVC sydnrome are warning signs of cancer development

Answer 33

Non Small Cell (75%) - 3 major subgroups a) squamous cell b) adenocarcinoma c) large cell Small cell (25%) - more aggressive - neuroendocrine in origin

Answer 34

Stage I- \< 3 cm with no nodal or metastatic involvement Stage II-\< 3cm with nodal involvement but no metastatic involvement \*\*\*\*stage IIb- nodes or invasion of chest wall but no distant metastasis Stage III \> 3 cm and invading chest wall ( a vs b is what it is invading) Stage IV- distant metastasis

Answer 35

Solitary pulmonary nodule is \< 30mm \> 30mm is mass The risk of malignancy increases with increasing size of the nodule * Nodules * Nodules 5 to 9 mm: 2 to 6 percent * Nodules 8 to 20 mm: 18 percent * Nodules \>20 mm: \>50 percent

Answer 36

**Common Bacterial -**S.Pneumo, Moraxella Catarrhalis, Haemophilus Influenza **Viral**- influenza, adenovirus

Answer 37

SMART COP S- systolic blood pressure \<90 M- multilobular infiltrates on CXR A- albumin \< 35 g/L R- RR\> 30 T- Tachycardia ( HR\> 125) C- Confusion O- O2 sat \< 90% P- pH \< 7.35

Answer 38

Staph Aureus Tuberculosis gram negative organism--\> klebsiella

Answer 39

An akle radiographic series is only required if there is any pain in **malleolar zone and any of these findings** bone tenderness at posterior tip of (1)lateral or (2) medial malleolus and 6 cm superior 3)innability to weight bear immediately afterwards or in the emergency department A foot radiographic series is required only if for **midfoot** pain and any of these findings 1) pain at base of 5th metatarsal 2) pain at navicular 3) innability to weight bear immediately afterwards or in the emergency departmen

Answer 40

knee X-ray is required only for acute injury patterns with one or more of the following: - age 55 yrs or older - tenderness at head of fibula - isolated tenderness of patella - inabilty to flex to 90 degrees - inability to weight bear immediately and in the emergency room ( 4 steps)

Answer 41

CT head is only required for minor head injury patients with any one of the these findings: **High risk** - GCS \< 15 at 2 hours after injury - suspected open or depressed skull fracture - Any sign of basal skull fracture ( hemotympanum, racoon eyes, CSF otorrhea/ rhinorrhea, Battles sign) \>2 episodes of vomiting Age \> 65 **Medium Risk** Amnesia before impact \>/= 30 minutes Dangerous mechanism (pedestrian vs vehicle, ejection from motor vehicle, fall from \> 1 meter or 5 stairs RULE DOES NOT APPLY TO - non trauma - GCS \< 13 Age \< 16 - Coumadin or bleeding disorder - Obvious open skull fracture

Answer 42

BMI \> 25 Signs of insulin resistance including (hypetension, low HDL, High TG) First degree relatives with diabetes History of gestational diabetes Being a member of a high risk ethnic group (African American, Hispanics, American indian, Asian americans, Pacific islanders)

Answer 43

Uneven or unilateral pleural effusions Evidence of infection (such as productive cough, fever, pleurisy) Normal cardial silhouette (no heart failure) Alarming sign (weight loss, hemoptysis, hypoxia) Need to evaluate lung parenhyma

Answer 44

Empyema Positive gram stain of fluid Prescence of loculations pH \< 7.10 Glucose \< 40 g/dl LDH \> 1000 U/L If chest tube is placed, it is done until drainage rate has decreased to 50 ml/d It must be followed up with imaging

Answer 45

need 3 of the 5 1) Age at onset \> 50 2) new headache 3) Temporal artery abnormality (redness or decreased pulsatility not due to athersclerosis) 4) elevated ESR 5) Abnormal temporal artery biopsy ( mononuclear or granulomatous cell infiltration)

Answer 46

Hypertensive crisis is generally defined as blood pressure \> 180/120 It is important to identify the following features if they are present 1) focal neurological signs and symptoms due to an ischemic or hemmorrhagic stroke 2) flame hemorrhages, exudates ( cotton wool spots), or papilledema when direct fundoscopy is performed 3) nausea and vomiting ( sign of raised ICP) 4) signs of aortic disection--\> BP both arms looking for \> 20mm Hg difference, pain radiating to the back 5) Dyspnea and crackles secondary to pulmonary edema 6) Signs of eclampsia in pregnant patients Important testing includes 1) ECG 2) Chest x-ray 3) urinalysis 4) serum electrolytes and creatinine 5) cardiac enzymes 6) CT or MR head 7) CT/ MT/ echo of heart ( optional)

Answer 47

Pulsus alternans is a physical finding of alternating strong and weak pulses that is almost always indicative of left ventricular systolic impairment and carries a poor prognosis

Answer 48

Exudates: increased permeability of pleural capillaries or lymphatic dysfunction--\> infections (parapneumonic effusion, empyema), malignancy, imflammatory, intra-abdominal (sub-phrenic abscess, ......... ( basically, if it is not transudative, then it is exudative) Transudates: increased hydrostatic pressure, decreased colloid osmotic pressure--\> LVHF, cirrhosis ( low oncotic pressure), nephrotic syndrome, pulmonary embolism, peritoneal dialysis, hypothyroidism, CF, urinothorax If any of the criteria are met, then the pleural effusion is an exudate Protein- pleural/ serum = Exudate \> 0.5 LDH- pleural/serum= \> 0.6 Pleural LDH= \> 2/3 upper limit of normal

Answer 49

pH \< 7.2 LDH \> 1/2 serum glucose\< 2.2 positive gram stain COMPLICATED EFFUSIONS MUST BE DRAINED AND GIVEN ANTIBIOTICS AND TREATED AS EMPYEMA

Answer 50

Management: -always resect functioning tumors - non-functioning tumors \> 4cm resect - non-functioning tumors \< 4cm, reimage in 6-12 months, and resect if enlarging by \> 1cm size \> 6cm is the best indicator of primary adrenal carcinoma

Answer 51

**Absolute contraindications** **for both copper and progesterone** known or suspected pregnancy undiagnosed genital tract bleeding acute or chronic PID lifetsyle risk for STI's **Absolute contraindications for copper IUD's** known allergy to copper wilsons disease **relative contraindications to copper and progesterone** valvular heart disease presence of prosthetics past history of PID or ectopic pregnancy abnormalities of uterine cavity, intracavity fibroids cervical stenosis immunosuppressed individuals **relative contraindications to copper IUD** severe dysmenorrhea or menorrhagia

Answer 52

**Absolute** active bleeding severe bleeding diathesis or platelet count \< 20 intracranial bleeding neurosurgery or occular surgery within 10 days **Relative Contraindications** mild-moderate bleeding diathesis or thrombocytopenia brain metastasis recent major trauma major abdominal surgery within the last 2 days GI or GU bleeding within 14 days endocarditis severe hypertension recent stroke

general internal medicine Flashcards

(79 cards)