General Internal Medicine

Front 1

Major causes of pancreatitis

Back 1

80% due to alcohol or gallstone
Other causes: hypertriglyceridemia, viral infections, trauma, and medications

Front 2

Viral infections that cause pancreatitis

Back 2

mumps, coxsackie virus

Front 3

Medications that cause pancreatitis

Back 3

steroids, azathioprine

Front 4

Clinical presentation of pancreatitis

Back 4

Abdominal pain radiating to the back
N/V that does not relieve the pain
leukocytosis
elevated amylase/lipase

Front 5

Dz other than pancreatitis that causes increase amylase and lipase

Back 5

Perforated peptic ulcer disease - look for free air on abdominal x-ray and hx of PUD

Front 6

Treatment of acute pancreatitis

Back 6

NPO, NG tube, IV fluids, narcotics (meperidine, NOT morphine)

Front 7

Treatment of chronic pancreatitis

Back 7

Alcohol abstinence
oral pancreatic enzyme replacement
fat-soluble vitamin supplements

Front 8

Grey-Turner's sign

Back 8

a complication of severe pancreatitis
appearance: blue/black flanks
due to hemorrhagic exduate

Front 9

Cullen's sign

Back 9

a complication of severe pancreatitis
appearance: blue/black umbilicus
due to hemorrhagic exduate

Front 10

Complications of pancreatitis

Back 10

pseudocyst (drain surgically if chronic and symptomatic)
abscess/infection (abx and sx abscess drainage)
diabetes (with chronic pancreatitis)

Front 11

When should you start screening for HTN?

Back 11

Every 2 years, starting at the age of 3.

Front 12

Cut-off value for HTN

Back 12

140/90 mmHg

Front 13

Diagnosis of HTN

Back 13

3 separate measurements on 3 separate occasions with BP > 140/90

Front 14

Exceptions of 3 measurement rule for dx HTN

Back 14

1. pregnant woman, when waiting for a return visit could be devastating

2. severe HTN: >210 systolic, >120 diastolic, or end-organ effects

Immediate txt is necessary.

Front 15

First step in management of HTN

Back 15

Lifestyle modifications (low salt, low cholesterol, stop smoking, exercise, weight reduction)

Front 16

Second step in management of HTN

Back 16

Medication

Front 17

Txt of HTN in pregnant pts

Back 17

Hydralazine, labetaol, or alpha-methyldopa

Mg sulfate in pts with preeclampsia

Front 18

HTN urgency/emergency

Back 18

occurs when BP > 200/120 with (emergency) or without (urgency) acute end-organ damage

Front 19

Txt of HTN urgency/emergency

Back 19

Nitropusside, NTG, or beta blocker

Front 20

MCC of secondary HTN in young women

Back 20

1. birth control pills
2. renovascular HTN due to fibrous dysplasia

Front 21

MCC of secondary HTN in young men

Back 21

1. EtOH
2. Exotic conditions (pheochromocytoma, Cushing's, Conn's, polycystic kidney disease)

Front 22

MCC of secondary HTN in elderly with new onset HTN

Back 22

renovascular HTN due to atherosclerosis

Front 23

Most important risk factor for stroke

Back 23

HTN

Front 24

MCC of death in untreated HTN

Back 24

coronary disease

Front 25

Effects of nitroprusside and NTG

Back 25

Nitroprusside dilastes both arteries and veins

NTG dilates only veins

Front 26

Who should you screen for diabetes?

Back 26

Not everyone
only pts with FHx, obese, >45 y.o., or members of at risk ethnicity (Black, American Indian, Hispanic)

Front 27

polydipsia, polyuria, polyphagia, weight loss

Back 27

Classic symptoms of DM

Front 28

Dx of DM

Back 28

1a. Two fasting BS >/= 126
1b. One is enough if pt symptomatic
2. Random BS >/= 200
OR
3. Glc tolerance test (BS >/= 200 2 hrs after 75 gm-glucose load)

Front 29

Goal of DM treatment

Back 29

postprandial BS < 200
FBS < 130

Too strict of control can incr risk of hypoglycemia.

Front 30

C-peptide:insulin ratio less than 1:1 (e.g. 1:2, 1:3)
i.e. low C-peptide

Back 30

Exogenous insulin injection

Front 31

Use of IV contrast in DM pt

Back 31

Avoid bc contrast can precipitate acute renal failure. If necessay, make sure pt is well-hydrated first.

Front 32

1. hyperglycemia
2. hyperketonemia
3. metabolic acidosis

Back 32

DKA

Front 33

Txt of DKA

Back 33

IV Fluids, IV regular insulin, electrolyte replacement (K+ and Phos)

Use bicarb only if pH < 7

Front 34

MCC of DKA

Back 34

infection

Front 35

1. hyperglycemia
2. hyperosmolarity
No hyperketonemia

Back 35

Nonketotic hyperglycemic hyperosmoar state

Front 36

Txt of nonketotic hyperglycemic hyperosmolar state

Back 36

IV fluids, IV insulin, electrolyte replacement

Front 37

Long term complications of DM

Back 37

Microvascular (retinopathy, nephropathy, neuropathy)

Macrovascular (CAD, PAD, CVA)

Immunosuppression (caused by hyperglycemia)

Front 38

Prevention of nephropathy in DM

Back 38

ACEI

Front 39

MCC of nontraumatic amputations in U.S.

Back 39

Diabetes

Front 40

Examples of peripheral neuropathy in DM

Back 40

gastroparesis, Charcot joint
Impotence
CN palsies (usually 3,4,6 - ocular palsies)
orthostatic hypotension, "silent" MI

Front 41

Txt of gastroparesis in DM

Back 41

metoclopromide (antiemetic)

Front 42

Regular vs NPH insulin

Back 42

Regular:
onset = 45 min
peak = 3-4 hrs
duration = 4-8 hrs

NPH
onset = 1-1.5 hrs
peak = 6-8 hrs
duration = 18-20 hrs

Front 43

Somogyi effect and txt

Back 43

Rebound Hyperglycemia
Too much NPH at dinner leads to low 3am BS --> rebound hyperglycemia

Txt by decr dinner NPH

Front 44

Dawn effect and txt

Back 44

Primary Hyperglycemia
Too little NPH at dinner leads to normal/high 4am BS --> hyperglycemia

Txt by incr dinner NPH

Front 45

Use of beta blockers in DM

Back 45

Caution bc it may block s/s of hypoglycemia; weigh risk to benefits

Front 46

Normal cholesterol level

Back 46

< 200 mg/dL

Front 47

Normal triglyceride level

Back 47

< 150 mg/dL

Front 48

xanthelasma, corneal arcus, lipemic-looking serum, obesity

Back 48

s/s of familial hypercholesterolemia

Front 49

risk factors for coronary heart disease

Back 49

Age (men > 45, women > 55)
FHx of premature coronary heart disease
Curent cigarette smoking (>10/day)
HTN
Low HDL (<40)

Front 50

First step in management of hypercholesterol

Back 50

lifestyle modifications (diet, exercise, smoking)

Front 51

Factors that can increase HDL

Back 51

exercise, estrogens, moderate alcohol intake (1-2 per day)

Front 52

First line drug txt for hypercholesterol

Back 52

Niacin
Bile acid-binding resins (Cholestyramine)
HMG-CoA reductase inhibitors (Statins)

Front 53

Smoking increases the risk of what cancers?

Back 53

Lung, oral cavity, esophagus, larynx, pharynx, bladder, kidney, pancreas, and cervix

Front 54

MCC of emphysema in and adult

Back 54

smoking

Front 55

MCC of emphysema in young, nonsmoker

Back 55

alpha 1 antitrypsin deficiency

Front 56

Effects of 2nd hand smoke in child

Back 56

upper respiratory infection, otitis media, asthma

Front 57

Bueger's disease

Back 57

Raynaud's symptoms in young male smoker

Front 58

Effects of smoking on fetus

Back 58

low birth weight, prematurity, spontaneous abortion, sillbirth, infant mortality

Front 59

Birth control pills and smoking?

Back 59

NEVER! - increases risk of blood clots

Front 60

MCC of cirrhosis and esophagel varices

Back 60

alcohol abuse

Front 61

ophthalmoplegia, nystagmus, ataxia, confusion; condition is acute and reversible

Back 61

Wernicke's encephalopathy

Front 62

anterograde amnesia, confabulation; condition is chornic and irreversible

Back 62

Korsakoff's encephalopathy

Front 63

Txt of Wernicke's and Korsakoff's encephalopathy

Back 63

Thiamine replacement

Front 64

Pathophysiology of Wernicke's and Korsakoff's encephalopathy

Back 64

damage to mamillary bodies and thalamic nuclei

Front 65

Stages of alcohol withdrawal

Back 65

1. acute (12-48 hrs after): tremors, sweating, hyperreflexia, seizures
2. alcoholic hallucinosis: A/V hallucinations and illusions without autonomic symptoms
3. delerium tremens (2-4 days after): hallucinations, illusions, confusion, poor sleep, autonomic lability (sweating, incr temp and pulse); fatal

Front 66

Best txt for alcohol abuse

Back 66

Alcoholics Anonymous

Front 67

Mental retardation, microcephaly, microphthalmia, short palpebral fissures, midfacial hypoplasia, cardiac defects

Back 67

Fetal Alcohol Syndrome

Front 68

MCC of aspiration pneumonia in alcoholics

Back 68

Klebsiella (currant-jelly sputum)

Front 69

Alcohol and blood sugar

Back 69

Alcohol causes hypoglycemia

Front 70

First step in management of alochol induced hypoglycemia

Back 70

Thiamine. Glucose may precipitate Wernicke's encephalopathy.

Second step is glucose.

Front 71

Common causes of SIADH

Back 71

small cell lung cancer
head trauma/surgery, meningitis
pulmonary infections
opioids or chlorpropamide

Front 72

Txt of SIADH

Back 72

Water restriction
For refractory cases: demeclocycline (a tetracycline that causes renal diabetes insipidus)

Front 73

K+ and Na+ levels in Addison's dz

Back 73

Hypoaldosteronism -->
hyponatremia + hyperkalemia

Front 74

Txt of hypovolemic hyponatremia

Back 74

Normal saline

Front 75

Txt of euvolemic/hypervolemic hyponatremia

Back 75

Free water restriction
possibly diuretics for hypervolemia

Front 76

Effect of rapid correction of hyponatremia

Back 76

Brain stem damage (central pontine myelinolysis)

Front 77

Effect of hyperglycemia on Na+

Back 77

for glucose > 200:
Na+ decreases by 1.6 for each increase of 100 in glucose

Front 78

MCC of hponatremia in surgical pt

Back 78

excessive fluid administration

Front 79

Oxytocin and Na+

Back 79

Oxytocin has ADH-like effects --> hyponatremia in pregnant women, especilly if exogenously given oxytocin

Front 80

Txt of hypernatremia

Back 80

Water replacement with normal saline initially, then switch to 1/2 normal saline.

Front 81

Pituitary vs nephrogenic DI

Back 81

Pituitary DI repsonds to vasopressin; nephrogenic DI does not

Front 82

Causes of Pituitary DI

Back 82

tumor, trauma, sarcoidosis

Front 83

Causes of Nephrogenic DI

Back 83

meidcations (lithium, demeclocycline, methoxyflurane, amphotericin B)

Front 84

Txt of Nephrogenic DI

Back 84

Thiazide diurectics (paradoxical effect)

Front 85

S/S of hyper- and hyponatremia

Back 85

Similar for both: confusion, mental status changes, hyperreflexia, seizure, coma

Front 86

S/S of hypokalemia

Back 86

*muscular weakness*
both skeletal and smooth muscle
--> ileus, hypotension, respiratory paralysis

Front 87

EKG findings of hypokalemia

Back 87

loss of T wave, presence of U waves, PAC/PVC, tachyarrhythmias

Front 88

Relationship between K+ and pH

Back 88

alkalosis causes hypokalemia
acidosis causes hyperkalemia

Front 89

Relationship between K+ and digitalis effects

Back 89

hypokalemia --> digitalis toxicity

Front 90

Txt of hypokalemia in presence of hypomagnesemia

Back 90

HypoK+ will be difficult to tx unless you also correct hypoMg2+

Front 91

MCC of hyperkalemia lab result in asymptomatic pt with normal EKG

Back 91

hemolysis of the specimen (non-pathologic hyperkalemia)
Repeat the test.

Front 92

S/S of hyperkalemia

Back 92

*EKG changes*
muscle weakness and paralysis

Front 93

EKG changes of hyperkalemia

Back 93

(in order of incr K+)
1. peaked T waves
2. widening of QRS
3. incr PR interval
4. loss of P waves
5. sine wave
6. Asystole and V-fib

Front 94

Common causes of pathologic hyperkalemia

Back 94

*Renal failure*
Severe tissue destruction
Hypoaldosteronism
Adrenal insufficiency
Medications (K+ sparing diuretics, beta blockers, NSAID, ACEI)

Front 95

Txt of hyperkalemia with cardiac toxicity

Back 95

Steps:
1. calcium gluconate (will not correct K+, but is cardioprotective)
2. sodium bicarbonate (causes alkalosis)
3. glucose and insulin (insulin shifts K+ into cells)
4. If refractory: dialysis

Front 96

Sign of hypocalcemia

Back 96

Neurologic: tetany

Front 97

Chovstek's sign

Back 97

Sign of hypocalcemia - tapping on the facial nerve causes the facial muscles to twitch

Front 98

Trousseau's sign

Back 98

Sign of hypocalcemia - applying a tourniquet or blood pressure cuff around the arm causes hand muscle (carpopedal) spasms

Front 99

EKG sign of hypocalcemia

Back 99

increased QT interval

Front 100

MCC of hypocalcemia

Back 100

*non-pathologic: hypoalbuminemia*
*pathologic: hypomagnesemia*
Others: DiGeorge's syndrome, renal failure, hypoparathyroidism, Vit D deficiency, pseudohypoparathyroidism, acute pancreatitis, loop diuretics

Front 101

Ricket's vs osteomalacia

Back 101

Skeletal effects of Vit D deficiency in children (rickets) and adults (osteomalacia)

Front 102

pH and calcium

Back 102

Alkalosis may cause symptoms of hypocalcemia due to effects of ionized fraction of calcium.

Front 103

Phosphorus and Calcium

Back 103

Phosphorus and calcium levels are usually in opposite directions

Front 104

Symptoms of Hypercalcemia

Back 104

Bones, stones, abdomenal groans, psychiatric overtones, thrones, hypertones

Front 105

EKG sign of hypercalcemia

Back 105

shortened QT interval

Front 106

MCC of hypercalcemia in hospitalized pts

Back 106

Malignancy
Other common causes of hypercalcemia:
HyperPTH, Vit A or D intoxication, Sarcoidosis, Thiazide diuretics, immobilization

Front 107

Txt of hypercalcemia

Back 107

Fluids
loop diuretic
phosphorus administration
calcitoni, disphosphonates, prednisone

Front 108

Most common pt to present with Hypomagnesemia

Back 108

alcoholics

Front 109

S/S of hypomagnesemia

Back 109

similar to hypocalcemia

Front 110

MCC of hypermagnesemia

Back 110

Renal failure

Iatrogenic (e.g. in txt of preeclampsia in pregnancy)

Front 111

Txt of hypermagnesemia

Back 111

Stop Mg sulfate (if taking)
supportive txt
IV hydration
furosemide
dialysis

Front 112

Most common pts that develop hypophosphatemia

Back 112

DKA and alcoholics

Front 113

S/S of hypophosphatemia

Back 113

neuromuscular dysfunction (encephalopathy, weakness)
rhabdomyolysis (esp in alcoholics)
anemia with WBC and platelet dysfunction

Front 114

Most common pts that develop hyperphosphatemia

Back 114

Pts with renal failure

Front 115

Txt of hyperphosphatemia

Back 115

Phosphate restriction
dialysis
phosphate-binding resins (calcium carbonate)

Front 116

Maintenence fluid in NPO pts and pediatric pts

Back 116

NPO pts: D5 1/2 NS
peds pts: D5 1/4 or 1/3 NS

Front 117

MCC of deficiency of Vitamins A, D, E, and K

Back 117

Malabsorption

Front 118

Most common vitamin deficiency in alcoholic

Back 118

Thiamine
Folate
Magnesium

Front 119

MCC of Vit B12 deficiency

Back 119

Pernicious Anemia

Front 120

Vitamin deficiency seen after ileum resection

Back 120

Vit B12

Front 121

Vitamin deficiency seen in Diphyllobothrium latum infection

Back 121

Vit B12

Front 122

Vitamin deficiency in pts taking isonizid

Back 122

Vit B6 (pyridoxine)

Front 123

Vitamin deficiency in pts taking anticonvulsants, e.g. phenytoin

Back 123

Folate

Front 124

Craniotabes, rachitic rosary, delayed fontonelle closure, bossing of the skull, kyphoscoliosis, bowlegs, knock-knees

Back 124

Physical findings of Rickets

Front 125

Vitamin giving to all newborns as prophylaxis against hemorrhagic dz

Back 125

Vit K

Front 126

Vit K is required for synthesis of which clotting factors?

Back 126

Factors II, VII, IX, X, protein C, and protein S

Front 127

Nightblindness, scaly rash, xerophthalmia (dry eyes)

Back 127

Vit A deficiency

Front 128

Pseudotumor cerebri, bone thickening, teratogenicity

Back 128

Vit A toxicity

Front 129

Rickets, osteomalacia, hypocalcemia

Back 129

Vit D deficiency

Front 130

Hyercalcemia, nausea and vomitting, renal effects

Back 130

Vit D toxicity

Front 131

Anemia, peripheral neuopathy, ataxia

Back 131

Vit E deficiency

Front 132

Necrotizing enterocolitis in infants

Back 132

Vit E toxicity

Front 133

Hemorrhage, prolonged PT

Back 133

Vit K deficiency

Front 134

Hemolysis, kernicterus

Back 134

Vit K toxicity

Front 135

Wet beriberi (high-out put cardiac failure), dry beriberi (peripheral neuropathy), Wernicke and Korsakoff syndrome

Back 135

Thiamine (B1) deficiency

Front 136

cheilosis, angular stomatitis, dermatitis

Back 136

Vit B2 (riboflavin) deficiency

Front 137

Pellagra (Dementia, Dermatitis, Diarrhea), stomatitis

Back 137

Niacin (B3) deficiency

Front 138

Peripheral neuropathy, cheilosis, stomatitis, convulsions in infants, microcytic anemia, seborrheic dermatitis

Back 138

Pyridoxine (B6) deficiency

Front 139

Peripheral neuropathy

Back 139

Pyridoxine (B6) toxicity

Front 140

Megaloblastic anemia, neurologic symptoms

Back 140

Cobalamin (B12) deficiency

Front 141

Megaloblastic anemia without neurologic symptoms

Back 141

Folic acid deficiency

Front 142

Hemorrhages, bleeding gums, loose teeth, gigivitis, poor wound healing, hyperkeratotic hair follicles, bone pain

Back 142

Vit C deficiency (Scurvy)

Front 143

Microcytic anemia, koilonychia (spoon-shaped fingernails)

Back 143

Iron deficiency

Front 144

Hemochromatosis

Back 144

Iron toxicity

Front 145

goiter, cretinism, hypothyroidism

Back 145

Iodine deficiency

Front 146

myxedema

Back 146

Iodine toxicity

Front 147

Dental caries

Back 147

Fluorine deficiency

Front 148

Fluorosis with mottling of teeth and bone exostoses

Back 148

Fluorine toxicity

Front 149

Hypogeusia (decreased taste), rash, slow wound healing

Back 149

Zine deficiency

Front 150

Menke's disease (X-linked, kinky hair, mental retardation)

Back 150

Copper defiency

Front 151

Cause of Wilson's disease

Back 151

Copper toxicity

Front 152

Cardiomyopathy and muscle pain

Back 152

Selenium deficiency

Front 153

loss of hair and nails

Back 153

Selenium toxicity

Front 154

"Manganese madness" in minors of ore

Back 154

Maganese toxicity

Front 155

Impaired glucose tolerance

Back 155

Chromium deficiency

Front 156

Four clinical types of shock

Back 156

Hypovolemic
Cardiogenic
Septic
Neurogenic

Front 157

First step in management of shock of any cause

Back 157

IV fluids

Front 158

High CO
Low PCWP
Low SVR
High SVO2

Back 158

Septic (early) shock

Front 159

Low CO
Low PCWP
High SVR
Low SVO2

Back 159

Hypovolemic (or late septic) shock

Front 160

Low CO
High PCWP
High SVR
Low SVO2

Back 160

Cardiogenic shock

Front 161

Low CO
Low PCWP
Low SVR
Low SVO2

Back 161

Neurogenic shock

Front 162

Virchow's triad

Back 162

Endothelial damage
Stasis
Hypercoagulable state

Front 163

Woman of reproductive age using tampons in place too long

Back 163

Toxic shock syndrome(Staph aureus)

Front 164

What is considered a positive family history of premature coronary heart disease?

Back 164

Definite MI or sudden death in:
first-degree male relative <55 y.o. OR
first-degree female relative <65 y.o.