Internal Medicine Step Iii

Front 1

Compelling indications to start HTN trmt in PreHTN pts.

Back 1

DM
CKD
HF
prior MI
prior stroke

Front 2

Life style modifications to lower HTN?

Back 2

weight loss
exercise
smoking cessation
low salt/cholesterol intake
decrease EtOH intake

Front 3

Avoid B blockers in pts with?

Back 3

Asthma
COPD
Heart block
sick sinus syndrome

Front 4

What is sick sinus syndrome?

Back 4

damage to SA node conduction tract, causing symps of bradycardia: syncope, SOB, dizziness

Front 5

Anti-HTN meds for pregnancy?

Back 5

hydralazine
B-blockers
alpha methyldopa
Mg sulfate (lowers BP in pre-ecclampsia)

Front 6

Causes of Secodary HTN?

Back 6

OCP
Renovascular (fibromuscular dysplasia, athersclerosis)
Excessive EtOH
Pheo
PCKD
Cushing dz
Conn syn (aldosterone)
Coarctation
- all occur new b/t ages 30-55, hard to control w/ meds

Front 7

HTN emergency

Back 7

= end organ failure
- trt with Nitroprusside, nitroglycerin, or labetalol

Front 8

HTN epidemiology - 4 fun facts?

Back 8

- every 20/10 mmHg inc over 115/75 carries a doubling of CVD
- CAD MC cause of death if HTN untreated
- control of HTN lowers stroke, MI, CHF, RF, Ao dissec, renal
- if normal @ 55, still 90% chance of developing HTN

Front 9

DM health maintenance issues? (5)

Back 9

- ACE inhib to prevent RF
- opthamology yearly
- foot exam for neuropathy
- BG monitoring, A1C
- trt risks for HTN, athero aggresively

Front 10

C peptide level with insulin

Back 10

- if high after hypogly episode, think insulinoma
- if low, think factitious disorder

Front 11

DKA

Back 11

-hyperglycemia
-metabolic acidosis
-hyperketonemia
-ketonuria
-trt with IVF, insulin, K+,Phos
-r/o infection

Front 12

NHH (nonketotic hyperglycemic hyperosmolality)

Back 12

-in Type II DM
-trt w/ IVFs, IV insulin, electrolytes
-no ketones because insulin is present, preventing lipolysis

Front 13

Longterm complications of DM?

Back 13

-Atherosclerosis
-Retinopathy
-Nephropathy
-Neuropathy (Charcot jts, silent MI, gastroparesis, impotence)
-infections

Front 14

Somogyi effect vs. dawn phenomenon

Back 14

-Somogyi=3 a.m. glucose is 40, causing inc in glucose release by 7 a.m; decrease p.m. NPH dose
-dawn=3 a.m. BG is 160; still have normal GH & cortisol a.m. surge; trt is inc in p.m. NPH

Front 15

How do you measure LDL?

Back 15

LDL = total cholesterol - HDL - (TGs/5)
**not valid is TG is >500

Front 16

5 risk factors for CHD?

Back 16

-Age
-Smoking
-HTN
-FH of premature CHD
-low HDL

Front 17

Drugs for managing cholesterol?

Back 17

-niacin
-bile-acid binding resins
-statins
-fibrin

Front 18

Cancers associated with smoking

Back 18

lung 90%
oral 90%
esophagus 80%
larynx 50%
pharynx
bladder
kidney 30%
pancreas 25%
cervix
vulva
penis
anus

Front 19

smoking in pregnancy

Back 19

low birth weight
prematurity
spontaneous abortion
stillbirth
infant mortality

Front 20

Beuger disease

Back 20

-painful red fingers/cold toes in a heavy smoker
-thromboangiitis obliterans
-inflam and thrombosis of medium arts & veins

Front 21

Cancers associated with EtOH

Back 21

oral
larynx
pharynx
esophagus
liver

Front 22

Stages of EtOH withdrawal

Back 22

-12 to 24 hrs tremors, sweating, hyperreflexia, seizures
-24 to 48 hrs alcoholic hallucinosis
-2 to 4 days DTs; hallucinations, illusions, confusion, poor sleep, fever

Front 23

Signs/symptoms of cirrhosis/chronic liver dz

Back 23

varices/hemorrhoids
spider angiomas
palmar erythema
caput medusae
ascites
gynecomastia/testic. atrophy
asterixis
anemia
spontaneous bacterial peritonitis

Front 24

Dz's associated with EtOH

Back 24

gastritis
Mallory Weiss tears
pancreatitis (acute & chronic)
dilated cardiomyop.
hepatitis
cerebellar degen./ataxia
rhabdomyolysis

Front 25

Fetal alcohol syndrome

Back 25

MR
microcephaly
microphthalamia
midfacial hypoplasia
cardiac defects

Front 26

How to treat alcoholics with IVFs

Back 26

Give thiamine first
then fluid with glucose
- prevents Wernicke enceph.

Front 27

Chronic thiamine deficiency

Back 27

-alcoholic develops Korsakoff syn
-can't form new memories/makes up stories
-chronic/irreversible

Front 28

TIPS

Back 28

-transjugular intrahepatic portosystemic shunt
-trts portal htn by shunting flow from portal v. to hepatic v.

Front 29

hepatorenal syndrome

Back 29

-rapid kidney func. decline in cirrhotic pts
-due to change in blood flow to kidneys
-AMS, jaundice, oliguria, ascites
-Type I is rapid, II is slow

Front 30

Pickwickian syndrome

Back 30

-hypoventilation in obesity
-trt with CPAP
-sleep apnea, somnolence during day, high CO2, low O2 sat due to shallow breathing

Front 31

MC hypercoagulable conditions

Back 31

surgery (ortho, abd, pelvic)
neoplasm
trauma
immobile
pregnancy/PCPs
lupus anticoag/antiphospho
factor V Leyden
def in ATII, prot C or S

Front 32

Studies to eval for PE?

Back 32

-CTA
-Vent-Perf scan if can't use IV contrast
-cath pulm angiogram (invasive)

Front 33

How does warfarin work?

Back 33

-inhibs epoxide reductase in liver, preventing gamma-carboxylation of Vit. K coags
-followed by PT (ext. pathway)
-effects reversed by Vit. K

Front 34

Uremia

Back 34

-renal azotemia (inc BUN & Cr)
-parenchymal damage to kidneys
-ATN, CRF
-BUN:Cr ratio <15

Front 35

ASA overdose and treatment?

Back 35

-causes primary metab. alkalosis and primary resp. acidosis = near normal pH
-alkalinize the urine to inc excretion
-use bicarb

Front 36

What does high O2 in COPDers do?

Back 36

-decreases resp drive
-will see inc in CO2, dec in pH
-turn down O2 support

Front 37

Acid base in a sleep apnea pt?

Back 37

-has high pH, high bicarb, normal CO2
-pt has chronic metab compensation for his CO2 retention at night

Front 38

Symptoms of hypoNa?

Back 38

lethargy
MS changes
seizures
cramps
disorientation
coma

Front 39

SIADH

Back 39

-caused by head trauma, surgery, meningitis, SCC of lung, pulm infections, painful states, opioids
-hypoNa
-restrict H2O intake
-Demecclcycline: induces DI, counteracting ADH

Front 40

Initial stroke steps?

Back 40

-initiate stroke team/pager
-get emergent CT of brain
-12 EKG
-full neuro exam

Front 41

Asystole/PEA steps?

Back 41

1- ABC and call for AED
2- 30 compressions/2 breaths
3- EPI 1 mg IV q3-5min
**give vasopressin 40U at 2nd dose instead, then resume epi
4- Atropine 1 mg IV q3-5, max 3 mg

Front 42

H's and T's?
(6 & 5)

Back 42

Hypovolemia
Hypoxia
Hypothermia
Hypoglycemia
Hypo/Hyperkalemia
Hydrogen (acidosis)
Toxins
Tamponade
Tension PTX
Thrombosis
Trauma

Front 43

VT/VF steps?

Back 43

1- ABC and crash cart
2- BLS
3- Biphasic shock @ 120-200J
4- EPI 1mg q3-5
**may use vasopress 40U once
5- 5 CPR cycles
6- shock
7- Amiodarone 300mg once
8- Consider Mg 1-2g for torsades

Front 44

Nine indications for hemodialysis?

Back 44

- serum K > 5.5
- BUN > 80-90
- acute fluid overload
- persistent metabolic acidosis
-removal of toxins
-uremia (pericarditis, encephalopathy, anorexia)
-hyperPO4 with hyperCa
-platelet dysfunc. w/ bleeding

Front 45

List the signs of ARF?

Back 45

-decreased UOP (<20ml/hr) with inc. BUN
-discoloration of urine
-FENa >2 is pre or post renal
-too high/too low urine osmolality

Front 46

Five types of ARF?

Back 46

-prerenal
-parenchymal
-postrenal
-oliguric
-nonoliguric

Front 47

Causes of ARF?

Back 47

-any disregulation effective glomeruli perfusion
-hypoTN (aff constrict)
-NSAIDS (inhibs vasodilatation)
-G- sepsis (dec PVresistence)
-stenosis, thrombosis
-outflow obstruction
-ischemia/nephritis/toxins
-IV contrast (w/in 48 hrs)
-trauma (myoglob/hemogb)

Front 48

treatment of ARF?

Back 48

-adequate hydreation
-mucomyst (pre-emptively)
-insulin + glucose, aerosolized B2 agonist, Ca carbonate to correct hyperK
-fleet Phospho-Soda for hyperPO4 to prevent rhabdo
-hemodialysis if all fails

Front 49

Clostridium colitis details

Back 49

-commonly occurs after Abx trmt (clindamycin, cephalasporins, fluoroquin's are more common)
-severe diarrhea, pain, leukocytosis
-toxins A and B
-high false neg = do multiple tests
-DIC, hypoTN, BD, lactate inc

Front 50

How to treat C. diff?

Back 50

-oral or IV Flagyl
-oral Vancomycin
-colectomy if pt is septic/progressively worsening (toxic megacolon)

Front 51

Describe relationship b/t CRP and prealbumin?

Back 51

-CRP is acute phase reactant that inc. in sepsis, injury, inflam.
-prealbumin is a constitutive prot made by liver
-in times of stress, liver dec production of constitutive prots
-if CRP is high, pre-alb might be falsely low= =don't use prealb for nutritional gauge until CRP=0

Front 52

How do you calculate Ideal Body Weight for a female?

Back 52

IBW=45kg + 2.3kg for each inch over 5 ft

IBW=100lbs + 5lbs for each in. over 5 ft

Front 53

Calculation for IBW in males?

Back 53

IBW=50kg + 2.3kg for each in.>5ft

IBW=106lbs + 6lbs for each in. > 5ft

Front 54

What components make up parenteral support?

Back 54

-lipids
-dextrose
-amino acids
-vitamins
-minerals

Pt generally needs 25kcal/kg/day and 1.5g protein/kg/day

Front 55

Difference between SIADH and DI?

Back 55

-SIADH causes hyponatremia
-DI causer hyperNa

Front 56

Treatment of DI?

Back 56

-Vasopressin to dx pituitary vs. nephrogenic
-thiazide diuretic decreases urine formation

Front 57

Traits of hypokalemia?

Back 57

-muscle weakness, fatigue
-adynamic ileus
-too little = vent failure
-beware of after insulin trmt to DKA; give K+ prophylactically

Front 58

Traits of hyperkalemia?

Back 58

-tall T waves, prolonged QRS and PR, loss of P
-sine wave: loss of ST segment
-caused by RF, NSAIDS, ACE inhibs, hypoaldosteronism, adrenal insuff.

Front 59

How to treat hyperK+ with EKG changes?

Back 59

1. Calcium gluconate
2. NaHCO3 -> shifts K+ back into cells (via alkalosis)
3. IV glucose and Insulin
4. Dialysis if emergent w/ RF

Front 60

Signs of hypocalcemia?

Back 60

-Chvostek's sign
-depression, dementia, convulsion
-Trousseau sign: hand spasm after arm BP cuff inflation
-

Front 61

Causes of hypoCa2+?

Back 61

-DiGeorge syn
-post thyroid/parathyroidectomy
-Vit D deficiency
-acute pancreatitis (Ranson's criteria)
-psuedohypoparathyr: high PTH, but resistance
-hypoalbuminemia: loss of prot-bound fraction

Front 62

Ranson's criteria at admission?

"GA LAW"

Back 62

-age > 55
-WBC > 16000
-LDH > 350
-AST > 250
-glucose > 200

Front 63

Ranson's criteria at 48 hours?

"CHOBBS"

Back 63

-Calcium < 8
-Hematocrit fall > 10%
-Oxygen <PO2 60%
-BUN inc > 5
-BD > 4
**score > 3 is pancreatitis
**score 7-8 is 100% mortality
-Sequestration of fluid

Front 64

Traits of hypercalcemia?

Back 64

-bones, moans, groans, and psychiatric overtones
-hyperPTH, sarcoidosis, malignancy, Hypervitaminosis of A or D, thiazides

Front 65

Treatment options for hyperCa2+?

Back 65

-Lasix
-oral Phos
-calcitonin
-diphosphonates
-prednisone in malignancy

Front 66

Degrees of hypovolemia?

Back 66

I = 750cc or 15% loss
II = 1500cc or 30% loss
III = 2000cc or 40% loss
IV = >2000cc or >40% loss

Front 67

What is the "sepsis 3"?

Back 67

hypoTN
documented infection
organ dysfunction

Front 68

What is the treatment options for sepsis?

Back 68

-Volume resus
-Abx trmt
-Drainage of collections/abscess
-Pressors
-Zygris; active Prot C

Front 69

Neurogenic shock parameters

Back 69

-low CO
-low PCWP
-low SVR
-low SvO2

Front 70

Hypovolemic shock parameters

*and late septic shock

Back 70

-low CO
-low PCWP
-high SVR
-low SvO2

Front 71

Cardiogenic shock parameters

Back 71

-low CO
-high PCWP
-high SVR
-low SvO2

Front 72

Septic shock parameters
**early

Back 72

-high CO
-low PCWP
-low SVR
-high SvO2

Front 73

Anaphylaxis

Back 73

-peanuts, shellfish, beestings, PCNs, sulfa drugs
-admin EPI and IVFs, O2
-beware of laryngeal edema--> intubate

Front 74

Geriatrics

Back 74

-presbyopia, presbyacusis
-dec immunity
-inc fat mass, dec muscle

Front 75

Common causes of dementia

Back 75

- Alzheimer's (neurofib tangles)
-multiple cerebral infarcts
-HIV
-Pick disease
-pseudodementia (due to depression)

Front 76

Correcting calcium if hypoalbuminemia -- formula

Back 76

Serum calcium + 0.8(4 -Serum Albumin)

Front 77

How do you calculate Pt's H2O deficit?

Back 77

(Na+/140 - 1) X 0.6(body weight)

Front 78

Correcting Hypernatremia

Back 78

-dec. no faster than 0.5-1 mEq/L/hr, or 12 mEq/L/24hr
-Change in Na= Infusate Na - serum Na/ weight kg X 0.6