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USMLE Step 2 - Internal Medicine Flashcards

USMLE Step 2 - Internal Medicine (113 cards)

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0
Q

How is hypertension diagnosed?

A

> 140 sys or >90 dia

x3 separate measurements

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1
Q

When should screening for hypertension be done?

A

Start at 3 years old

Every 2 years thereafter

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2
Q

What is Stage 2 hypertension?

A

> 160 sys or >100 dia

Add 2nd agent

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3
Q

What is severe hypertension?

A

> 210 sys or >120 dia or end-organ effects

Immediate Rx

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4
Q

What is first line pharmaceutical treatment for hypertension?

A

Thiazides

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5
Q

What is prehypertension?

A

> 120 sys or >80 dia

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6
Q

What are the compelling indications for treatment of prehypertension?

A

Diabetes

Chronic Kidney Disease

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7
Q

What is the goal BP in the treatment of prehypertension?

A

<130/80

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8
Q

What is the workup for hypertension?

A

Urinalysis
BMP
EKG
H&H

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9
Q

What is the first line treatment of hypertension?

A

Weight reduction
Exercise
Alcohol & Smoking cessation
- attempt for 3 to 4 months before medication

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10
Q

What are the five first-line agents in the treatment of hypertension?

A 
Thiazides
ACE inhibitors
Beta-blockers
ARBs
Ca-Channel blockers
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11
Q

What are the three antihypertensive agents used during pregnancy?

A

Hydralazine
Labetolol
Alpha-methyldopa

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12
Q

What lowers the blood pressure in pre-eclampsia?

A

Magnesium-sulfate

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13
Q

What is hypertensive emergency vs. urgency?

A 
Both >200/120
Emergency occurs with end-organ damage:
Acute left ventricular failure
Unstable angina / Myocardial Infarction
Encephalopathy
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14
Q

What are the signs and symptoms of encephalopathy?

A 
Headache
Altered mental status
Vomiting
Blurred vision
Dizziness
Papilledema
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15
Q

What is the treatment of hypertensive emergency?

A

Nitroprusside
Nitroglycerin
Beta-blocker (Labatelol)

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16
Q

What are the cariovascular effects of…
Nitroprusside
Nitroglycerin
Hydralazine, A1-antagonist, Ca-chnl blkrs

A 
Dilates arteries and veins (both)
Dilates veins (reduces preload)
Dilates arteries (reduces afterload)
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17
Q

What risks are lowered in lowering blood pressure?

A 
Stroke (HTN most important risk factor)
Heart disease
Myocardial infarction
Renal Failure
Atherosclerosis
Dissecting Aortic Aneurysm
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18
Q

What is the most common cause of death in the untreated hypertensive patient?

A

Coronary disease

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19
Q

Indications for use of ACE inhibitors

A

Heart failure
Diabetes
Acute coronary syndrome or unstable angina
Acute or prior myocardial infarction
High risk of coronary artery disease or stroke
Chronic kidney disease

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20
Q

Contraindications for ACE inhibitors

A 
Pregnancy (fetal cardiac defects)
Renovascular hypertension (renal failure)
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21
Q

Indications for use of Aldosterone receptor blockers (eg spironolactone, eplerenone)

A

Heart failure

Prior myocardial infarction

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22
Q

Contraindications for use of Aldosterone receptor blockers

A

Hypoerkalemia

Pregnancy

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23
Q

Indications for use of ARBs (eg losartan, irbesartan)

A

Heart failure
Diabetes
Chronic kidney disease

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24
Contraindications for use of ARBs
``` Pregnancy Renovascular Hypertension (renal failure) ```
25
Indications for use of Beta-blockers
Stable angina Acute coronary syndrome or unsatble angina Acute or prior myocardial infarction High risk of coronary artery disease Atrial tachycardia or fibrillation Thyrotoxicosis, Essential tremor, Migraines
26
Contraindications for use of Beta-blockers
``` Asthma Chronic obstructive pulmonary disease heart block Sick sinus syndrome *blocks signs of hypoglycemia *causes hypercholesterolemia ```
27
Indications for use of Calcium channel blockers
Raynaud's syndrome | Atrial tachyarrhythmias
28
Contraindications for use of Calcium channel blockers
Heart block Sick sinus syndrome Congestive heart failure Pregnancy
29
Indications for use of Thiazides
Heart failure Diabetes High risk of coronary artery disease or stroke Osteoporosis
30
Contraindications for use of Thiazides
Gout Electrolyte disturbances (eg hyponatremia) Pregnancy
31
What are the clues to possibilty of secondary hypertension?
Onset before 30 yrs old or after age 55
32
What are the possible causes of secondary hypertension in a woman?
In a young woman, most common cause is OCP Next, renovascular HTN from fibrous dysplasia Look for renal bruit
33
What are the possible causes of secondary hypertension in a man?
``` Excessive alcohol intake Pheochromocytoma Cushing's syndrome Conn's Syndrome Polycystic Kidney Disease ```
34
What are the possible causes of secondary hypertension in the elderly?
Renovascular HTN due to atherosclerosis | ACE inhibs precipitate renal failure
35
Signs and symptoms of pheochromocytoma?
``` Urinary catecholamines (vanillylmandelic acid, metanephrine) Intermittent severe HTN Dizziness Diaphoresis ```
36
Signs and symptoms of Polycystic Kidney Disease?
Flank mass Family history Elevated BUN and creatinine
37
Signs and symptoms of Cushing's syndrome?
Dexamethasone suppression test | 24-hr urine cortisol level
38
Signs and symptoms of renovascular hypertension?
MR/CT angiogram Ultrasound ACE inhib nuclear scan Bruit on exam - angioplasty and stenting
39
Signs and symptoms of Conn's syndrome?
High aldosterone | Low renin
40
Signs and symptoms of coarctation of the aorta?
``` Upper extremity HTN only Unequal pulses Radiofemoral delay Associated with Turner's syndrome Rib notching on xray ```
41
Diabetes screening
Generally not recommended, except Obesity Family History Black, American indian, Latin American
42
Signs and symptoms of diabetes
Polyuria Polydypsia Polyphagia Weight loss
43
Diagnosis of diabetes
Fasting (overnight) plasma glucose of 126 mg/dL | Random glucose of 200 mg/dL
44
Differences between DM1 and DM2 - age at onset - body habitus - DKA - hyperosmolar state - endogenous insulin
``` <30yo - >30yo Thin - Obese Yes - No No - Yes Low - High ```
45
Differences between DM1 and DM2 - twin concurrence - HLA association - response to oral hypoglycemics - antibodies to insulin - Islet cell pathology
``` <50% - >50% Yes - No No - Yes Yes - No Yes - No Insulitis (loss of beta cells) - Normal # (+amyloid) ```
46
Treatment of DKA
``` Fluids iv Insulin Potassium Phosphorous Do not use bicarb unless pH <7 Find cause - often infection ```
47
Treatment of Nonketotic Hyperglycemic Hyperosmolar state
Fluids iv Insulin Electrolytes mortality is high
48
Complications of diabetes
Atherosclerosis (CAD, PVD, MI, Stroke) Retinopathy (Screen annually, rx-lasr photocoag) Nephropathy - ACE inhibs prevent, 30% of ESRD Neuropathy, Infections, Foot disease
49
Sequellae of peripheral neuropathy in diabetes
``` Gastroparesis (early satiety, nausea) rx-metoclopromide Charcot's joints Impotence Cranial nerve palsies (esp III, IV, VI - ocular) Orthostatic hypotension Silent myocardial infarctions ```
50
Treatment of T2DM
Diet, exercise, wgt loss - cures 90%!!! Sulfonylurea (glimepiride, glipizide, glyburide) Metformin Thiazolidinedione
51
Insulin preparations | - onset, peak, duration
``` Aspart <.25 1-3 3-5 before meals Lispro <.5 .5-2.5 3-5 before meals Regular .5-1 2-4 5-8 inpatient NPH 2-3 4-12 12-24 standard regimen Lente 2-3 4-12 12-24 standard regimen Ultralente 6-10 8-16 18-26 basal Glargine 1.5-4 none 24+ basal ```
52
Insulin dosing
0.5 to 1.0 U/kg per day Initial requirements are less because of redisual endogenous insulin Type 2 inpatients require more b/c of resistance
53
Somogyi Effect vs Dawn Phenomenon
High night-time insulin leads to low overnight glucose. Then stress hormone release increases morning glucose. Decrease insulin. High morning glucose from GH secretion without overnight hypoglycemia. Increase insulin.
54
Monitoring of diabetes compliance
Hemoglobin A1c - 3 month avg, target 7% | C peptide is present with endogenous insulin
55
Insulin for patients undergoing surgery
1/3 to 1/2 usual dose because of NPO status | monitor intraoperatively - use D5 & regular insulin
56
Side effect of Chlorpropamide
SIADH
57
Treatment of diabetes and heart disease
Beta-blockers prevent physical manifestations of hypoglycemia (tachycardia, diaphoresis) Benefits outweigh risks however
58
Cholesterol screening
Fasting lipid profile Start at age 20 years Every 5 years More aggressive for family history and obesity
59
Lipoprotein analyis
Total - HDL - Trigly/5 = LDL
60
Secondary causes of hypercholesterolemia
``` Diabetes Hypothyroid Uremia Obstructive liver disease Alcohol (incrs trigly) ```
61
Medications that cause hypercholesterolemia
OCPs Glucocorticoids Thiazides Beta-blockers
62
LDL levels and intervention | - no risk factors
<160 none, goal 160-190 diet, +/- medication >190 medication, +diet
63
LDL levels and intervention | - 2 or more CHD risk factors
<100 none, goal 100-129 diet, +/- medication >130 medication, +diet Age, FH, Smoking, HTN, Low HDL
64
Coronary Heart Disease risk factors
Age - men=45yrs, women=55yrs (premat menop) FH - first degree premat CHD, men55/women65 Current smoker >10 per day HTN - 140/90 or on anti-HTN meds Low HDL - <40mg/dL HDL > 60 is protective and negates one risk fac DM is risk factor, not included b/c also CADequiv
65
LDL levels and intervention | - known CAD or equivalent
<100 none, goal >100 medication, +diet DM, PAD, CAD, AAA
66
LDL levels and intervention | - very high risk
<70 none, goal 70-100 diet, +/- medication >100 medication, +diet CAD with MI or poorly controlled risks
67
LDL levels and medical intervention summary
No risk factors >190 (160) 2 risk factors >130 (100) CAD (DM,PAD,AAA) >100 High risk >100 (70)
68
Epidemiology of Atherosclerosis
Involved in... Half of all deaths in U.S. Third of all deaths ages 35-65 Most important cause of disability&hospitalization
69
Other factors related to Coronary Heart disease
NOT independent risk factors: Obesity, stress, physical activity, type a personality Hypertriglyceridemia alone is not a risk but when associated with hyperXOL causes more CHD than hyperXOL alone.
70
Treatment of Hypercholesterolemia
Exercise and diet | - decrease calories,cholesterol,fats, alcohol and smoking
71
Modifying factors of HDL
Increased by exercise, estrogens, mod alcohol | Decreased by smoking, androgens, progesterone, hypertriglycerides
72
First line medications fo Hypercholesterolemia
Niacin - poorly tolerated but effective, raises HDL Bile acid-binding agents (cholesteramine, colesevelam) HMG CoA-reductase inhibitors - Statins - effective, expensive, liver & muscle damage Block cholesterol absorption (ezetimibe)
73
What cancers have an increased risk in smokers?
``` Lung Oral cavity, Esophagus, Larynx, Pharynx Bladder, Kidney Stomach, Pancreas Cervix, vulva, penis, anus ```
74
Wernicke's Syndrome
``` Acute and reversible Thiamine (B1) Def Opthalmoplegia Nystagmus Ataxia Confusion ```
75
Korsakoff Syndrome
Chronic and irreversible Thiamine (B1) Def Amnesia (anterograde) Confabulation
76
Pathophysiology of Thiamine deficiency
Damage to mamillary bodies and thalamic nuclei
77
Specific dysmorphisms of Fetal Alcohol Syndrome
``` Epicanthal folds Short palpebral fissures Flattened filtrum thin upper lip "Railroadtrack" ears Upturned nose Flat nasal bridge ```
78
General recognition of Fetal Alcohol Syndrome
``` Mental retardation Microcephaly Micropthalmia Short papebral fissure Midfacial hypoplasia Cardiac defects ```
79
Fetal Alcohol Syndrome
Most common preventable cause of mental retardation
80
Bacteria of aspiration pneumonia in alcoholics
``` Klebsiella (currant-jelly sputum) Anaerobes E. coli Strep Staph ```
81
Treatments for alcoholism
AA Disulfiram Naltrexone
82
Stigmata of chronic liver disease in alcoholics
varices, hemorrhoids, caput medusae, jaundice, ascites, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, encephalopathy, asterixis, prolonged PT, hyperbilirubinemia, spontaneous bacterial peritonitis, hypoalbuminemia, anemia
83
Most common vitamin deficiencies in alcoholics
Folate Magnesium Thiamine
84
Important component in treatment of alcoholic
Alcohol precipitates hypoglycemia. But administer Thiamine before glucose othoerwise may precipitate Wernicke's
85
Treatment of esophageal varices
Bleeding - iv fluids, blood, endoscopy - sclerotherapy, cauterization, banding, vasopressin TIPS (transjugular intrahepatic portosystemic shunt) Portacaval shunting is now rare
86
Acid-Base disorders on ABG
``` pH CO2 HCO3 Met Acid low low low Resp Acid low high high Met Alk high high high Met Acid high low low ```
87
Causes of respiratory acidosis
COPD, asthma, chest wall problems (paralysis, pain), sleep apnea, drugs (opioids, benzos, barbs, alcohol, resp depress)
88
Causes of respiratory alkalosis
Anxiety or hyperventilation, aspirin or salicylate od
89
Causes of metabolic alkalosis
diuretics (except CAI), vomiting, volume contraction, antacid abuse or milk-alkali syndrome, hyperaldosterone
90
Causes of metabolic acidosis
Ethanol, DKA, uremia, lactic acidosis (sepsis, shock) methanol or ethylene glycol, aspirin or salicylate, diarrhea, CAI
91
Signs and symptoms of Hyponatremia
``` Lethargy Mental status changes Anorexia Seizures Cramps ```
92
Causes of Hyponatremia in hypovolemia
``` Dehydration Diuretics DKA Addison's disease Hypoaldosteronism ```
93
Causes of Hyponatremia in euvolemia
SIADH Psychogenic polydipsia Oxytocin use
94
Causes of Hyponatremia in hypervolemia
``` CHF Nephrotic syndrome Cirrhosis Toxemia Renal failure ```
95
Causes and treatment of SIADH
Head trauma, surgery, meningitis, small-cell cancer, painful states, pulmonary infections, opioids, chlorpropramide Water restriction Demeclocycline (causes renal DI) if refractory
96
Classic finding with Addison's and Hypoaldosteronism in Hyponatremia
Elevated potassium
97
Na correction in hyperglycemia
Na decreases 1.6 per 100 glucose above 200
98
Signs and symptoms of Hypernatremia
Hyperreflexia Altered mental status Seizures Coma
99
Causes of Hypernatremia
``` Dehydration Diuretics DI Diarrhea Renal disease (isothenuria from SC trait) Iatragenic ```
100
Mimics DI by impairing renal concentrating mechanism
Hypokalemia and Hypercalcemia
101
Treatment of Hypernatremia
Normal saline - pts typically dehydrated 1/2 normal - once hemodynamically stable D5W - should NOT be used
102
Pituitary vs. Nephrogenic DI
Pit - responds to Vassopressin Nephrogenic - Thiazides (paradoxical) Nephro - caused by lithium, demeclocycline, methoflurane, amphotericin
103
Signs and symptoms of Hypokalemia
``` Muscle weakness (smooth-ileus,hypotension) EKG - loss of T waves presence of U waves PVCs, PACs tachyarrhythmias ```
104
Causes of Hypokalemia | Treatment
Changes in pH alter K distriution Alkolosis causes hypokalemia H leaves cells to correct H, K enters Do not replace potassium too quickly, <20/h Hypomagnesemia makes correction difficult, treat hypomag first
105
Signs and symptoms of Hyperkalemia
``` Weakness, paralysis EKG - with increasing K tall, peaked T waves widened QRS prolonged PR interval loss of P waves sine waves Vfib, asystole ```
106
General cause of Hyperkalemia | Treatment
Changes in pH alter K distriution Acidosis causes hyperkalemia Give bicarbonate for severe Hyperkalemia
107
Specific causes of hyperkalemia
Renal failure Severe tissue destruction Hypoaldosteronism (hyporenin/aldoster in DM) Adrenal Insufficiency Medications - K-sparing diuretics, B-blockers, NSAIDS, ACE inhibs
108
Treatment of Hyperkalemia
``` Decreased intake Kaxolate (Na-polysterene resin) Calcium gluconate is cardioprotective NaBicarb Glucose with insulin (forces K inside cells) Dialysis for renal failure ```
109
Signs and symptoms of Hypocalcemia
``` Neurologic tetany (chvostek's-face, trousseau-carpopedal) depression, encephalopathy, dementia seizures laryngospasm EKG - QT prolongation ```
110
Specific causes of Hypocalcemia
DiGeorge's - tetany after birth, athymic Renal failure - altered vitamin D metab Hypoparathyroid - watch post thyroidectomy Vitamin D deficiency Psuedohypoparathyroid - short fingers and stature, MR, nml PTH, end-organ unresp to PTH Acute pancreatitis
111
General treatment of hypocalcemia
Hypomagnesemia makes correction difficult, treat hypomag first Alkalosis can cause hypocalcemic symptoms. treat pH Phosphorous and calcium levels change in opposite direction
112
Signs and symptoms of Hypercalcemia
...

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