Internal Medicine Tips Tricks and Techniques Part II Flashcards Preview

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Flashcards in Internal Medicine Tips Tricks and Techniques Part II Deck (186):
1

What are the two major classes of IBD

Ulcerative colitis;
Crohns disease

2

Where is the inflammation in ulcerative colitis

Limited to the colon and the rectum. Inflammation is limited to the mucosal lining.

3

Where is the inflammation in crohns disease

transmural inflammation in any part of the entire GI tract

4

What is the presentation of IBD

diarrhea;
weight loss;
abdominal pain

5

Crohns disease can also present with

fistula formation;
strictures;
abscesses;
bowel obstruction

6

How is IBD diagnosed

Endoscopy is the preferred method.
CT and MRI scans;
Serologic markers

7

What will differentiate crohns disease from UC histopathologically

UC: Chronic mucosal inflammation with crypt abscess and cryptitis;

Crohns: multinucleated giant cells and noncaseating granulomas in CD

8

What are the serologic markers used to distinguish UC from Crohns

CD: Anti-Saccharomyces cerevisiae antibodies;

UC: pANCA (perinuclear antineutrophil cytoplasmic antibodies)

9

How is treatment determined for IBD

Based on the severity of the symptoms

10

How is the severity of disease classified for IBD

Mild;
Moderate;
Severe

11

What defines mild to moderate disease

UC: less than 4 bowel movements with no rectal bleeding or anemia.;

CD: little to no abdominal pain

12

What are the medical treatment options for mild to moderate disease

5-ASA; Antibiotics for CD; Budesonide; Topical therapy (limited to left colon)

13

What are the 5-ASA used

Sulfasalazine; Mesalamine; Olsalazine

14

Name Mesalamine preparations used for IBD

Asacol
Pentasa;
Apriso;
Balsalazide;
Multimatrix delivery system mesalamine

15

What is budesonide

A synthetic corticosteroid with first pass liver metablism that limits systemic toxicity while retaining local efficacy from high affinity glucocorticoid receptors

16

What defines moderate to severe disease

CD: Patients that fail to respond to therapy with mild to moderate disease or those that develop significant weight loss, anemia, fever, abdominal pain or tenderness, and intermittent nauseas and vomiting without bowel obstruction.;

UC: Patients with more than 6 bloody bowel movements a day, fever, mild anemia, and elevated ESR

17

What are the medical treatments used for moderate to severe IBD

Glucocorticoids;
Immunosuppressive agents;
Anti-tumor necrosis factor alpha;
Natalizumab

18

What immunosuppressive agents are used in the treatment of IBD

6-Mercaptopurine;
azathioprine (6-M's S-imidazole precursor);
Methotrexate

19

How does 6-Mercaptopurine work for IBD

causes preferential suppression of T=cell activation and antigen recognition and are useful in maintaining glucocorticoid induced remission in both UC and CD

20

What will help prevent toxicity caused by 6-mercaptopurine

Determination of thiopurine methyltransferase (TPMT) enzyme activity prior to initiation of therapy

21

How does methotrexate work for IBD

effective as a steroid sparing agent in CD but not UC.

22

What are the anti-tumor necrosis factor monoclonal antibodies for IBD

Infliximab;
Adalimumab;
certolizumab pegol

23

What are the adverse effects of using anti-TNFa

reactivation of a latent tuberculosis;
development of antibodies to infliximab and double stranded DNA

24

What is natalizumab

a humanized monoclonal antibody to alpha-4 integrin, a cellular adhesion molecule used for moderate to severe CD refractory to all other approaches including Anti-TNFa antibodies

25

What are the adverse effects of natalizumab

induce reactivation of JC polyoma virus causing progressive multifocal leukoencephalopathy.

26

When is surgery an option for patients with IBD

patients with fistulas;
obstruction;
perforations;
abscesses;
bleeding

27

What are adverse outcomes of surgery for IBD

Short bowel syndrome;
recurrence close to the resected margins is common with CD

28

Surgery for UC

a total colectomy may be curative

29

What defines nephrotic syndrome

Proteinuria >3.5 grams/d;
hypoalbuminemia;
hyperlipidemia
edema

30

What will biopsy show for nephrotic syndrome

will show injury along the filtration barrier;
thickening of the glomerular basement membrane
fusion of the podocyte foot processes

31

What is the general medical treatment for nephrotic syndrome

ACE inhibitors and ARBs to reduce intraglomerular pressure;
Aggressive treatment of hypertension can also slow progression of renal disease

32

What bleeding disorders are often accompanied by nephrotic syndrome

hypercoaguable state and can predispose pt to thromboembolic events

33

Name the primary glomerular nephropathies

Minimal Change Disease;
Focal Segmental Glomerularsclerosis;
Membranous Nephropathy;
Membranoproliferative

34

What age groups are most commonly affect by MCD

children;
second peak seen 50-60

35

How will MCD present

sudden onset proteinuria with hypertension and edema;
Renal insufficiency is unusual

36

What are associated conditions of MCD

Hodgkins and solid tumors

37

How is MCD diagnosed

LM: Normal glomeruli;
Electron: shows effacement of the foot processes as the only abnormality

38

What is the treatment for MCD

oral prednisone for 1mg/kg/d for 8-16 weeks until remission.
Then tapered over the next 3 months

39

How will Focal Segmental Glomerulosclerosis present

nephrotic syndrome;
HTN;
Renal insufficiency

40

What are the associated conditions of Focal Segmental Glomerulosclerosis

Obesity;
HIV;
IV Drug use

41

How is FSGS diagnosed

Immunofluorescense shows staining for C3 and IgM in areas of sclerosis representing areas of trapped immune deposits

42

How is the prognosis for FSGS determined

the degree of interstitial fibrosis and tubular atrophy

43

What can be used to treat nephrotic syndromes if they are refractory to oral prednisone

cyclosporine;
cyclophosphamide

44

How will membranous Nephropathy present

nephrotic syndrome or heavy proteinuria while renal function is often normal

45

How is disease progression for Nephropathy

1/3 remit spontaneous;
1/3 ESRD;
1/3 intermediate course

46

What are the associated conditions with membranous nephropathy

SLE;
Viral hepatitis;
syphilis;
solid organ malignancy

47

How is membranous nephropathy diagnosed

kidney biopsy shows;
LM: thickening of the basement membrane;
Silver stain: "spikes"

48

Who receives treatment for membranous nephropathy

patients at higher risk for progression (reduced GFR, age >50, and HTN, and males);
Severe nephrotic syndrome (proteinuria >10g/d)

49

What is the primary cause of Membranoproliferative Glomerularnephropathy

Hepatitis C and frequently in association with cryoglobinemia

50

How is Membranoproliferative GN diagnosed

LM: mesangial proliferation and hypercellularity with lobularization of the glomerular tuft;
Silver stain: mesangial interpositioning appearance gives a double contour or "tram tracking appearance"

51

What are the compliment levels for Membranoproliferative GN

usually low

52

What is the treatment for membranoproliferative GN

treatment has not been shown to improve disease free survival, steroids may stabilize the disease in children.;
If renal function is rapidly declining in the presence of cyroglobulins, plasmapheresis may help stabilize the disease.

53

Name the hepatotropic viruses

HAV;
HBV;
HCV;
HDV;
HEV

54

What is the classification of HAV

RNA virus that belongs to the Picornavirus family

55

What is the most common cause of viral hepatitis world wide

HAV

56

How is HAV spread

fecal-oral route

57

What is the period of infectivity for HAV

2 weeks before symptoms through 2-3 weeks after symptoms

58

What are high risk conditions for HAV

anything to do with developing countries

59

How is the diagnosis made for HAV

detection of IgM anti-HAV antibodies

60

How is the recovery and immunity phase determined for HAV

detection of IgG anti-HAV antibody

61

What is the clinical presentation for HAV

All are common but non specific:
Malaise;
fatigue;
pruritus;
headache;
abdominal pain;
myalgias;
arthralgias;
nausea;
vomiting;
anorexia;
fever

62

What is the treatment for HAV

no specific treatment, only supportive therapy

63

What can be used for preexposure prophylaxis

the HAV vaccine containing the single HAV antigen

64

What can be used for post exposure prophylaxis

Ig

65

What is the prognosis of HAV

almost all will resolve in 4-8 weeks

66

What is the classification of HBV

DNA virus that belongs to the hepadnavirus family

67

What phenotypes of HBV have been found in the US

All phenotypes; The most prevalent being A, B and C

68

What is the leading cause of HCC world wide

HBV attributes 60-80% of all cases

69

What percentage of liver transplants is due to HBV

5-10%

70

What causes liver damage following HBV

immune mediated

71

What are the modes of transportation for HBV

Parenteral or percutaneous routes; Sexual contact; Vertical transmission (mother to infant)

72

What is the incubation period after an HBV infection

30-160 days

73

What are the clinical phases of HBV

Acute hepatitis B;

Chronic Hepatitis B
- Immune tolerant
- Immune Active
- Carrier state with low replication
- Chronic HBeAg negative;

Resolution

74

What defines immune tolerant phase of HBV

high rates of viral replication, yet normal liver enzymes and low levels of inflammation and fibrosis

75

What define immune active phase of HBV

Characterized by elevated liver enzymes as a consequence of a vigorous immune response

76

What defines Carrier state with low replication phase of HBV

low or undetectable levels of HBV DNA levels

77

what defines the chronic HBeAg negative phase of HBV

patients harbor HBV variants with mutations that prevent the production of or have low expression of HBeAg

78

What labs will indicate acute hepatitis

abnormal:
AST;
ALT;
ALP;
total bilirubin

79

What are the HBV antigens detected in the serum

HBsAg;
HBeAg

80

What is the most accurate viral marker for HBV replication

HBV DNA

81

What genotypes of HBV have the highest response to IFN therapy

genotypes A and B

82

Is liver biopsy beneficial for HBV

yes.
It can determine the grade (degree of inflammation) and stage (fibrosis)

83

What are the medications used for HBV

Seven Agents in three main groups;
1. Interferon based therapy;
a. IFN-a;
b. pIFN;

2. Nucleoside analogs;
a. lamivudine;
b. entecavir;
c. telbivudine;

3. Nucleotide analogs;
a. adefovir;
b. tenofovir

84

What are the first line treatment options for HBV

IFN-a;
pIFN;
Entecavir;
Tenofovir

85

What drug groups are anti-viral resistance associated with for HBV

nucleoside and nucleotide analogs

86

What is the classification of HCV

RNA virus that belongs to the flavivirus family

87

What is the prevalence of HCV in the US

1.8%;
Genotype 1 makes up 70%;
Genotype 2 and 3 make up 20%

88

What is the prophylactic treatment for HCV

does not exist

89

What is the incubation period for HCV

15-150 days

90

What are the symptoms of HCV

All are common but non specific:
Malaise;
fatigue;
pruritus;
headache;
abdominal pain;
myalgias;
arthralgias;
nausea;
vomiting;
anorexia;
fever;

Fatigue is the most common. All may be subclinical until late when the symptoms are associated with advanced liver disease

91

How long may it take before labs will show anti-HCV

up to 8 weeks post infection

92

Does the anti-HCV antibody imply immunity

NOPE

93

What are the medications for HCV

IFN;
Ribavarin

94

With regards to HCV, what is RVR

rapid viral response;
HCV RNA negative at 4 weeks of treatment

95

With regards to HCV, what is EVR

Early viral response;
HCV RNA negative at 12 weeks of treatment

96

With regards to HCV, what is cEVR

no RVR, but HCV RNA negative at 12 weeks of treatment

97

With regards to HCV, what is pEVR

no RVR,
detectable HCV RNA but >2log10 drop at 12 weeks of treatment

98

With regards to HCV, what is Slow responder

>2log10 drop at 12 weeks of treatment and HCV RNA negative at 24 weeks

99

With regards to HCV, what is partial responder

>2log10 drop at 12 weeks of treatment and HCV RNA positive at 24 weeks

100

With regards to HCV, what is relapse

HCV RnA negative at end of treatment but HCV RNA positive after treatment cessation

101

With regards to HCV, what is SVR

Sustained viral response; absence of HCV RNA 6 months post viral treatment

102

What is the prognosis of HCV

40% will have spontaneous remission while 60% will have chronic infection

103

What percentage of HCV pt's develop HCC

1-2%

104

What is HDV classification

considered a subviral particle resembling plant pathogens;
Circular RNA genome

105

What is required for HDV infection and replication

HBV

106

What is the transmission of HDV

similar to HBV

107

What is a coninfection of HDV

simultaneous infection of HBV and HDV

108

What is a superinfection of HDV

HDV infection of a patient already infected with HBV

109

What is the treatment of choice for HDV

IFN-a

110

What is the classification for HEV

RNA virus that belongs to the hepeviridae family

111

What is the transmission of HEV

Fecal oral route

112

What is the fatality of HEV

high fatality rate in pregnant women in the second and third trimester

113

What is the treatment of HEV

supportive

114

What are the typical presentation of GERD

Esophageal symptoms;
Chest pain;
Extraesaphogeal symptoms

115

What are the esophageal symptoms associated with GERD

Heartburn and regurgitation

116

What are the extraesophageal symptoms of GERD

Cough;
Laryngitis;
Asthma;
Dental erosions

117

What other diseases should be considered in a differential of GERD

Eosinophilic esophagitis
-Infectious esophagitis
- Candida esophagitis
- HSV esophagitis
- CMV Esophagitis;

Chemical esophagits

118

How is the diagnosis made for GERD

Endoscopy;
Ambulatory pH;
Esophogeal manometry

119

What is the purpose for endoscopy when diagnosing GERD

to avoid misdiagnosis of alternate causes of esophageal symptoms

120

What are some warning symptoms of GERD

dysphagia;
odynophagia;
early satiety;
weight loss;
bleeding

121

What is the treatment for GERD

Antacids;
H-2 receptor antagonists;
PPI's

122

What is the most effective treatment for GERD

PPI's

123

What are the adverse effects of PPI's

bone demineralization; enteric infections; CAP;
reduced circulating levels of B-12

124

What are some acid suppressive agents

Cimetidine;
Rantidine;
Famotidine;
Nizatidine;
Omeprazole;
Esomeprazole;
Lansoprazole;
Dexlansoprazole;
Pantoprazole

125

When is surgery indicated for GERD

Fundoplication is indicated for patients who have a continuous increase in medical dosage

126

Are there any lifestyle risk modifications for GERD

Yes, but they are unlikely to completely resolve symptoms. Recommendation is for lifestyle modifications in addition to Medical therapy.

127

What are the lifestyle modifications for GERD

Elevation of the head in bed;
no food 2-3 hours before sleep;
Avoiding trigger foods;
Smoking cessation

128

What is Peptic Ulcer Disease

mucosal breaks in the stomach and duodenum when corrosive effects of acid and pepsin overwhelm mucosal defense mechanisms

129

What is responsible for 50% of PUD

H. Pylori, a spiral gram negative urease-producing bacillus

130

Can chronic NSAID and aspirin users develop PUD

yes, about 15-25% will develop PUD

131

What are the main causes of PUD

H. Pylori;
NSAIDs;
Gastrinoma

132

Does cigarette smoking effect risk of PUD

doubles the risk

133

How is PUD diagnosed

Endoscopy (gold standard);
Barium studies;
Serum H. pylori antibody testing;
Stool H. Pylori antigen testing;
Rapid Urease assay;
carbon-labeled urea breath test

134

What is the most accurate non invasive test for diagnosis of PUD

Carbon labeled breath test

135

What is the medical treatment for PUD

Acid suppression:
PPI;
H2 Receptor Antagonist;
Triple therapy;
Sucralfate;
Antacids (symptomatic relief)

136

What are adverse effects with Cimetidine therapy for PUD

impairs metabolism of many drugs including
warfarin anticoagulants,
theophylline, and
phenytoin

137

What medical treatment protocol is used for treatment of H. Pylori induced PUD

TRIPLE THERAPY;
Two antibiotics and a PPI;

Patients previously exposed to a macrolide antibiotic should be treated with a regimen that does not include clarithromycin

138

When is GI bleeding more commonly associated with PUD

when the ulcer is are close to the pyloric channel

139

What is Zollinger Ellison syndrome

a gastin secreting, non-B islet cell tumor of the pancreas or duodenum. MEN-I associate in 25%

140

When is pancreatitis associated with PUD

results when there is penetration in to the pancreas, most commonly seen with ulcers in the posterior wall of the duodenal bulb.

141

How often are duodenal ulcers malignant

almost never.

142

What is Rheumatoid Arthritis

a systemic disease of unknown etiology that is characterized by symmetric inflammatory polyarthritis, extra-articular manifestations, and serum RF

143

What is the clinical criteria for diagnosis of RA

4 out of 7 of the following (the first 4 present for 6 weeks)
Morning stiffness >60 minutes;
Arthritis of three or more joint areas;
Arthritis of hand joints;
Symmetric arthritis;
Rheumatoid nodules;
Serum RF;
X-ray changes (erosions or decalcifications)

144

Rheumatoid nodules are most commonly present where

on extensor surfaces

145

What is more specific than Rheumatoid Factor for diagnosis of Rheumatoid arthritis

Anti-CCP (cyclic citrullinated peptide)

146

What is the treatment for RA

DMARD's (disease modifying anti rheumatic drugs)

147

What is the initial treatment for moderate to severe RA

Methotrexate

148

What is the initial treatment for mild RA

Hydroxycholorquine or Sulfasalazine

149

What is Methotrexate

a purine inhibitor and folic acid antagonist

150

What are the treatment options for RA if the initial treatment fails

leflunomide; TNF blocker; Abatacept

151

When is rituximab indicated as a treatment option for RA

Approved for patients who have failed TNF therapy

152

What is rituximab

a monoclonal antibody directed against the B-cell surgace molecule CD20

153

What is abatacept

a fusion protein comprising the CTLA4 molecule and the Fc portion of IgG1. It blocks selective costimulation of T-cells

154

What are the TNF inhibitors used in RA

Etanercept;
infliximab;
Adalimumab

155

What is leflunomide

A pyrimidine inhibitor that has been approved for the treatment of RA

156

What is the interleukin inhibitor that is available for RA

Anakinra

157

What is the mechanism for Anakinra

Recombinant IL-1 receptor antagonist that block the proinflammatory and immunomodulatory actions of IL-1

158

Can NSAIDs be used for treatment in RA

yes, but as an adjunct to DMARDs

159

What is the use of steroids for RA

provides symptomatic relief in conjunction with DMARDs

160

What are some associated complications of RA

Sjogrens disease;
Felty syndrome;
irreversible joint damage with in first 3 years of Dx

161

What is felty syndrome

Triad of RA, splenomegaly, granulocytosis

162

Osteoarthritis is also known as ...

Degenerative joint disease

163

What is osteoarthritis

deterioration of articular cartilage with subsequent formation of reactive new bone at the articular surface

164

Who is prone to Osteoarthritis

Predominately the elderly but can occur at any age especially with joint trauma or congenital malformation

165

What is initial treatment option for osteoarthritis

Acetaminophen because most patients are elderly and often have decreased renal function

166

What is second line for treatment of Osteoarthritis

NSAIDs or selective cox2 inhibitor

167

Can steroids be used for the treatment of osteoarthritis

Intra-articular glucorrticoid injections are often beneficial but should not used more often than every 3-6 months.;

Systemic steroids should be avoided

168

Can anything be used to help with cartilage regeneration

Glucosamine sulfate;
Chondroitin sulfate

169

What is an alternative analgesic agent for osteoarthritis

Tramadol

170

What is the mechanism of tramadol

Mu opiod aganist

171

How is synvisc used for the treatment of osteoarthritis

Synthetic and naturally occurring hyaluronic acid derivative administered intra-articularly. Reduce pain and improve mobility in select patients

172

What options are available for severe pain and deformity

Surgery: Total hip or knee replacement relieves pain and increases function in select patients;
Laminectomy reserved for patients with severe disease with intractable pain or neurologic complications

173

What is SLE

Systemic Lupus Erythematosus; a multisystem disease of unknown etiology that primarily affects women of childbearing age.
Women:Men 9:1

174

What is required to diagnose SLE

4 or More of the 11 criteria (DOPAMIN RASH):
Discoid Rash;
Oral Ulcers;
Photosensitivity
ANA + antibodies (Smith or Double DNA);
Malar Rash;
Immunologic Diseases;
Neurological (seizures and psychosis);
Renal Dysfunction (proteinuria);
Arthralgias;
Serositis;
Hematologic disorders

175

What comorbidities are associated with SLE

accelerated coronary and peripheral vascular disease

176

What are the medical treatments for SLE

NSAIDS;
Hydroxychloroquine;
Glucocorticoid therapy;
Immunosuppressive therapy

177

What role does NSAIDs have for SLE

controlling arthritis, arthralgias, fever, mild serotosis

178

What caution is with NSAID use and SLE

Hepatic and renal toxicities appear to be increased in SLE

179

When is glucocorticoid therapy indicated in SLE

Life threatening manifestations of SLE;
Debilitating manifestions of SLE

180

What is the dosage and tapering of glucocorticoid therapy for SLE

Prednisone 1-2mg/kg; after disease is controlled, begin to tapered slowly.;
Reduce no more than 10% every 7-10 days.

181

When is immusupressive therapy indicated for SLE

Life threatening manifestations of SLE;
inability to reduce corticosteroid therapy or severe corticosteroid side effects

182

What are immunosuppressive treatment options for SLE

Cyclophosphamide;
Azathiprine and mycophenolate mofetil are used for steroid sparing agents;
Rituximab

183

How is the outcome of renal transplants of pts with SLE

the same as other patients with different chronic renal disease

184

What is drug induced lupus

Sudden onset;
Male:female is 1:1;
Primarily a MSK manifestation;
+ANA and +Anti-Histone antibodies;
-DS DNA and Anti-SM

185

What is the treatment for drug induced lupus

Remove the drug and relief is noticed in a few weeks

186

What drugs are associated with drug induced lupus

Procainamide;
Hydralazine;
minocycline;
diliazem;
Penicillamine;
INH;
quinidine;
methyldopa;
ANTI-TNF;
IFN-a