Simple Cases Internal Medicine

Front 1

Categories of Back Pain (7)

Back 1

1. Mechanical (arthritis, spinal stenosis, muscular, disk disease)
2. Inflammatory spondyloarthropathies associated with inflammatory bowel disease, psoriasis, reactive spondylitis (following certain infections), and ankylosing spondylitis.
3. Active infections (such as epidural abscess, usually via hematogenous spread from another infection site)
4. Fracture (osteoporotic or traumatic)
5. Neoplastic (from bony metastasis of another primary cancer, or from a primary bone tumor)
6. Referred (often from abdominopelvic sources)
7. Functional (often associated with psychiatric diagnoses)

Front 2

Back Pain cancer types (mets) and quality

Back 2

prostate, lung, breast, thyroid
focal pain - worse when pt is reclining/sleeping

Front 3

Risks for AAA

Back 3

Male, HTN, smokers, >55yo

Front 4

Duration of backpain classification

Back 4

acute <6 weeks
subacute 6-12 weeks
chronic >12 weeks

Front 5

Reiters Reactive Arthritis

Back 5

Involves: eye, urinary system, hands/feet
appear 1-3wks post infection
Eye = uveitis/conjunctivitis and is generally an early finding
Possibly precursor to other joint diseases

Front 6

Triamterene + HCTZ

Back 6

Diuretic (water pill) - used for HTN and edema in patients that are important to avoid low K levels. (K sparing)

Front 7

No fever suggests?

Back 7

less likely to be an infectious etiology

Front 8

Radicular pain

Back 8

This referes to pain that radiates like in sciatica where it goes down the leg.

Front 9

Exam in leg w/ pain

Back 9

Look for symetry to r/o radicular pain at hip level

MOTOR
L3-4: inversion of the foot
L4-5: big toe dorsiflexion
L5-S1: foot eversion

SENSORY
L4: sensory changes around the medial malleolus
L5: sensory changes around the third metatarsal
S1: sensory changes around the lateral heel

DTR
L3-4: decreased patellar reflex
L5-S1: decreased medial hamstring change
S1-S2: decreased Achilles reflex
S2-S4: decreased anal wink

Front 10

Alternative to straight leg raise

Back 10

Seated leg raise is a confirmatory test for straight leg raise. Used to weed out the functional leg pain.

Front 11

Prognosis of mechanical low back pain

Back 11

90% of mechanical low back pain and 50% of acute back pain with sciatica resolve within a one-month period without specific treatment
-Acetaminophen or NSAIDs may help though muscle relaxants & narcotics are without efficacy
- Spinal manipulation may help
- Heat & Ice help in acute stage
- PT is recommended at 1mo from onset

Front 12

Indication surgery in back pain

Back 12

1. instability of vertabrae from trauma
2. tumor causing neurologic compromise
3. cauda equina syndrome

Front 13

Causes of spinal stenosis

Back 13

Can progress to cause spinal stenosis:
1. Spondylosis (degenerative spine changes),
2. facet arthropathy,
3. bulging disks, and
4. hypertrophy of the ligamentum flavum,

Front 14

Chest pain differential

Back 14

Cardiovascular
-Ischemic (ACS) vs non ischemic

Chest wall
- MSK
- Skin (herpes)

GI
- esophageal
- pancreatobiliary
- Peptic ulcer disease

Pulmonary
- vasulature
- parenchyma
- airways (bronchospasm)
- pleurisy

Mediastinal Dz
- inflammation
- tumor
- air present

Psych (Anx/dep/panic/munchausen)

Front 15

Chest Pain Ddx in cardiovascular realm (2-4)

Back 15

Ischemic
- Hyperadrenergic (cocaine, amphetamine, pheochromocytoma )
- Prinztmetals (atypical variant angina)
- Stable/Unstable angina
- Acute MI

Non-Ischemic
- Pericarditis
- Aortic dissection
- Valvular heart dz
- arrhythmia

Front 16

Chest Pain Ddx in gastrointestinal realm (3)

Back 16

1. Esophageal
- GERD
- esophagitis
- esophageal dysmotility

2. PancreoBiliary
- atypical cholangitis
- atypical cholecystitis
- pancreatitis

3. PUD

Front 17

Chest Pain Ddx in pulmonary realm (4-2)

Back 17

1. Vasculature
- PE
- Cor pulmonale/pulmonary HTN
2. Parenchyma
- PNA
- pleural effusion
3. Airways (bronchospasm)
- asthma
- COPD
4. Pleura
- plurisy
- spon. pneumo

Front 18

What to do if suspect ACS ?

Back 18

- Aspirin unless contraindicated
- serial ECG
- Cardiac troponins q6-12H (detectable for 24H post myocyte death biut takes 4-6H after insult)
- Nitroglycerin (ONLY if CURRENTLY having CP)
- +/- o2 supplementation

Front 19

Chest pain Ddx menominc

Back 19

-- CHEST PAIN --
Cocaine/Costochondritis
Hyperventialtion/Herpes Zoster
Esophagitis/Esophageal spasm
Stenosis of aorta
Trauma
Pulmonary embolism
Pericarditis/Pancreatitis
Angina/Aortic dissection/Aortic aneurysm
Infarction (myocardial)
Neuropsychiatric dz

Front 20

Suspected ACS history points

Back 20

Pain timing and location
-atypical presentation MC in women, elderly, DM

Associated symptoms
- nausea, diaphoresis, SOB

Risk Factors
- Smoking, HTN, HLD, DM, FHx, vascular dz

Front 21

Suspected ACS PE points

Back 21

VS (HR and BP)
Cardiac Exam (murmur, S3, S4)

Front 22

PNA - PE and HPI

Back 22

fever, crackles, decreased breath sounds, cough

Front 23

How to construct a summary statement

Back 23

A summary statement should:

1. Be a concise statement that accurately highlights the most pertinent features in a case without omitting any significant points:
• Epidemiology (age, gender, risk factors)
• Key clinical findings (symptoms, signs, data)

2. Transform specific details into medical terms (example: "tachycardia" rather than "heart rate of 150").

3. Use qualifying adjectives to describe key findings better:
• Diagnostic considerations: diffuse vs focal; monoarticular vs polyarticular
• Severity: mild vs severe
• Temporal pattern: acute vs chronic


Ultimately, a good summary statement should provide the basis for developing an appropriate differential diagnosis.

Front 24

What are the componets of this summary statement?

Susan Johnston is a 60-year-old obese woman with a past history of hypertension and dyslipidemia and a family history of cardiac disease who presents with a three month history of intermittent burning anterior chest pain associated with SOB, but only variably associated with exertion. Other than hypertension, her physical exam is unremarkable.

Back 24

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 60-year-old obese woman with history of hypertension and dyslipidemia and family history of cardiac disease.

Key clinical findings about the present illness using qualifying adjectives and transformative language:

burning chest pain
three months of intermittent symptoms
association with SOB
variable association with exertion
physical exam unremarkable other than hypertension

Top DDx = GERD/ANGINA

Front 25

Aortic Dissection - PE and HPI

Back 25

tearing/radiating to the back, risks = HTN/smoking/over age 60

Front 26

Pericarditis - PE and HPI

Back 26

worse on inspiration, positional alleviation (foward), non exertional, ECG=diffuse concave upward ST seg. + depressed PR seg.

Front 27

Pulmonary Embolism

Back 27

Pain= sharp + pleuritic, Common presentation is CP + SOB, ECG = 70% abnormal (S1Q3T3 -or- RBBB -or- T wave inversion)

Front 28

Classical Angina

Back 28

retrosternal CP onset w/ exertion and relieved by rest or nitroglycerin

Front 29

Stable angina vs unsatble angina vs Acute MI

Back 29

Acute MI - rupture of plaque that occludes with myocyte necrosis (onset is once and immediate onset)

Stable vs. Unstable Angina
Angina occurs when myocardial oxygen demand exceeds supply. When angina is thought to be present it is important to further characterize it as stable angina vs. unstable angina since these two syndromes are managed very differently.

Stable angina pectoris is a predictable pattern of chest discomfort that usually occurs with exertion or extreme emotion. It is relieved by rest or nitroglycerin in less than 5-10 minutes.

Unstable angina is a more serious condition characterized by chest pain that occurs at rest or with increasingly less exertion. New onset angina (within 4-6 weeks) and angina that has worsening severity, frequency or duration is also c

Front 30

Treatment in suspected unstable angina

Back 30

Sublingual then IV nitro - unless hypotenive

Beta blocker decrease hearts work unless hypotenive

Front 31

Leads for anterior wall MI

Back 31

ST segment elevation V1-V4 compared to PR segment

Front 32

What is TIMI Score (Thrombolysis In Myocardial Infarction)

Back 32

Used to determine medical tx vs. early intervention

Higher score = Higher rates of events in the next 14 days (all cause mortality, new/recurrent MI. severe recurrent ischemia requiring revascularization)

1 point if YES 0 if NO (Max is 7pts)
-------------------------------
Age ≥65 years
Presence of at least three risk factors for coronary heart disease (CHD)
Prior coronary stenosis of ≥50 percent
Presence of ST segment deviation on admission ECG
At least two anginal episodes in prior 24 hours
Elevated serum cardiac biomarkers
Use of aspirin in prior seven days

Front 33

TIMI Score percentages of events next 2weeks

Back 33

Score of 0/1 – 4.7 percent
Score of 2 – 8.3 percent
Score of 3 – 13.2 percent
Score of 4 – 19.9 percent
Score of 5 – 26.2 percent
Score of 6/7 – 40.9 percent

Front 34

Leads for Inferior MI

Back 34

ST segment elevation 2, 3, aVF compared to PR segment

Front 35

Leads for lateral wall MI

Back 35

ST segment elevation in 1, aVL, V5, V6 compared to PR segment

Front 36

Leads for septal wall MI

Back 36

ST segment elevation in V1, V2 compared to PR segment

Front 37

CP and STEMI -or- new LBBB on ECG warrants what?

Back 37

Dx coronary angiography

goal of angioplasty within 90 minutes (time is myocardium)

Front 38

Fibrinolytic -vs- Angioplasty

Back 38

Angioplasty is preferred if expert operator within a certain time frame. However fibrinoloytic may be best given time frame of onset and time to availability for angioplasty.

Front 39

Contraindications to Fibrinolytic tx

Back 39

Major are: bleeding or hemorrhagic stroke

- Strong suspicion of dissection of the aorta
Pericardial effusion
- Active gastrointestinal or other internal bleeding
- Brain tumor, arteriovenous malformation, or aneurysm
- Ischemic stroke in preceding 6 months (a verified transient ischemic attack (TIA) is an exception)
- Previous intracerebral hemorrhage or subarachnoid hemorrhage
- Intracranial procedure or recent head trauma
- Severe known bleeding disorder: coagulation abnormality, thrombocytopenia, etc.

Front 40

GP IIb/IIIa inhibitor

Back 40

abciximab or eptifibatide - improve oputcomes in STEMI patients despite their increase risk of bleeding

Front 41

What are the complications of acute MI

Back 41

Complications of acute myocardial infarction include:
-arrhythmias (bradyarrhythmias and tachyarrhythmias)
-reduced ventricular function
-cardiogenic shock (hypotension)
-papillary muscle dysfunction with acute valvular dysfunction
-ventricular free wall rupture
-recurrent thrombosis

Front 42

ACS what meds should they be on when discharged?

Back 42

Aspirin (A) therapy should be started promptly in all patients with a suspected acute coronary syndrome and should be continued indefinitely.
- Administer aspirin, 160 to 325 mg, immediately upon presentation with suspected acute coronary syndrome (ACS) and continue daily aspirin at a dose of 75 to 325 mg/day.

Clopidogrel (B) should be continued for a year after stent placement in addition to aspirin to prevent stent thrombosis.

β-adrenoceptor blockers (C) should be started early in all patients with suspected ACS unless there are significant contraindications.
- Begin with oral β-blockers within a few days of the event, if not begun acutely, and continue them indefinitely. Goal heart rate is <70 and blood pressure <130/80.

HMG CoA reductase inhibitors (statins) (D) should be started while in the hospital in patients with ACS with a target LDL of <100.

Sublingual nitroglycerin (F) should be sent home with patients post-admission.

ACEi - only if clinical HF or anterior

Front 43

GERD - PE and HPI

Back 43

Pain is "burning", not a/w exertion, but a/w obesity

Front 44

Define Typical Angina

Back 44

The Three Criteria for Typical Angina
Substernal chest discomfort with a characteristic duration and features
Exertional in nature
Relief with rest or nitroglycerin

Front 45

Define Atypical Angina

Back 45

Atypical Angina
Patients who have diabetes, women, and the elderly are more likely to present with atypical features. Occasionally they will present with only weakness or shortness of breath on exertion. Those symptom are considered "anginal equivalents".

Front 46

Value of an ECG

Back 46

With an electrocardiogram, you can:
1. rule out an ST elevation MI,
2. look for evidence of prior infarction (pathologic Q waves)
3. occasionally, make other diagnoses such as pericarditis.

Front 47

Met X Criteria from ATP3 study

Back 47

Front 48

What is seen in a positive stress test (heart)? What would be the next step?

Back 48

An example is on ECG =

2mm downsloping ST segments in leads II, III, aVF, V2, V3, V4 and V5

Next step = Cornoary angiogram to determine candidacy for per-cutaneous interventions

Front 49

Rx treatment for angina ?

Back 49

- Beta blockers (A) decrease myocardial oxygen consumption by slowing heart rate and decreasing blood pressure, and thus reduce angina.

- Calcium channel blockers (B) dilate coronary arteries and increase coronary blood flow while also decreasing myocardial oxygen consumption.

- Nitrates (D) dilate systemic and coronary arteries and venodilatory effects also decrease cardiac work.

Front 50

Side effects of HCTZ

Back 50

dehydration, hyponatremia, hypokalemia, renal dysfunction, increases serum uric acid which may precipitate gouty attack

Front 51

Side effects of ACEi (Lisinopril)

Back 51

cough, renal dysfunction, angioedema, hyperkalemia

Front 52

Side effects of Statins

Back 52

myositis, myalgias, hepatitis (requires initial measurement of transaminases and an initial creatinine phosphokinase (CPK) level. Additional CPK levels are indicated with symptoms of muscle soreness.)

Front 53

Signifigance of Fever temperature and if present?

Back 53

Fever is an important part of the history in a patient with cough because it makes an infectious cause more likely. The severity of fever (e.g., 100.4 vs. 104.0) is not specific and therefore does not help distinguish between different causes of inflammation. Fever is both detrimental and beneficial. It leads to increased metabolism, which can cause dehydration, promote inflammation, and inhibit function of proteins at very high temperatures. The primary potential benefit of fever is to decrease bacterial reproduction and growth, because most bacteria function best in a limited temperature range. Patients are unable to accurately assess their temperature based on touch.

Front 54

What is Pleurisy and PE findings ?

Back 54

If the chest pain is due to a pulmonary process, then you can be certain that the pleura are involved and inflamed (because the pulmonary parenchyma is insensate). Such a condition is called pleurisy and the chest pain is worse with deep inspiration or coughing, which is most commonly unilateral.

Front 55

Significance of hemoptysis ?

Back 55

Hemoptysis is a non-specific finding of cough. It is important to determine whether a patient has massive or life-threatening hemoptysis, which is defined as greater than 100 mL over a 24-hour period. Patients often do not estimate the amount of their hemoptysis accurately, so it is difficult to make this determination by history alone.

Front 56

What are chills and rigors and physiology?

Back 56

Chills are non-specific and can occur in any inflammatory state that leads to cytokine release. Certain cytokines cause the hypothalamus to change the body's temperature set point to a higher level. To achieve this new set point, peripheral blood vessels vasoconstrict, and this can give the patient a sense of being cold. The body also may try to increase the temperature set point by having the muscles contract (shivering) and the patient may feel this as rigors

Front 57

Significance of wheezing ?

Back 57

Wheezing may suggest reactive airways disease, such as chronic obstructive pulmonary disease (COPD), but it is non-specific. If an infection causes bronchiolitis or significant mucus production, wheezing can occur even in patients without a history of asthma or COPD

Front 58

Lung Exam Key Points

Back 58

Lungs (C)
Careful percussion and auscultation of the lungs is critical to assess for the presence of dullness, increased or decreased breath sounds, crackles, rhonchi, or other abnormal sounds. It is important to remember to listen over the right middle lobe, which will be missed if your exam is done on the posterior thorax only. The right middle lobe is an anterior and lateral structure so the best place to listen to it is lower portion of the right anterior thorax.

Front 59

Orhtostatic Hypotension Defintiion and etiology ?

Back 59

Orthostatic hypotension
Although expert definitions of orthostatic hypotension vary, any of the following indicate an inability to compensate for postural changes:

- fall in systolic blood pressure of >20 mm Hg with standing
- increase in pulse of >30 beats/min with standing
- inability to stand long enough for vital signs because of dizziness

Causes of orthostatic hypotension can include medications, hypovolemia, cardiac insufficiency, and diabetic neuropathy.

Front 60

What is egophony ?

Back 60

Egophony (assess for consolidation)
Ask the patient say "eeeee" for about 3-5 seconds. Auscultate the lungs and listen for a change in the character of the sound from that of "E" to "A."

Front 61

Difference between Vesicular and Bronchial Breath sounds ?

Back 61

Vesicular breath sounds
Normal breath sounds in the lung, characterized by a long inspiratory phase followed by a short expiratory phase.

Bronchial breath sounds
Compared to vesicular breath sounds, bronchial breath sounds have a louder, shorter inspiratory phase and louder, prolonged expiratory phase. This is a normal finding when heard over the trachea. However, when bronchial breath sounds are heard in a location other than the trachea, it is suggestive of pulmonary consolidation (C) (meaning the alveoli are full of something other than air such as pus, water, or blood).

Front 62

What to do if suspect decreased lung sounds?

Back 62

decreased breath sounds, percuss out the lungs. Dullness to percussion in an area of decreased breath sounds suggests pleural effusion (A), whereas hyperresonance suggests pneumothorax (B).

Front 63

Writing a summary statement example.

Back 63

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 71 year-old man with history of tobacco use
2. Key clinical findings about the present illness using qualifying adjectives and transformative language:
fever with chills
productive cough
dyspnea
hemoptysis
right pleuritic chest pain
hypoxia
orthostasis
tachycardia
borderline hypothermia
evidence of RLL consolidation.

Example is:
Mr. Groszek is a 71 year-old man with a history of tobacco use who presents with a two-day history of fever with chills, productive cough, dyspnea, hemoptysis, and right pleuritic chest pain. His vital signs reveal hypoxia, orthostasis, tachycardia, and borderline hypothermia, and there is evidence of RLL consolidation on lung exam.

Front 64

What do you see in acute aspiration pneumonitis ?

Back 64

Typically occurs in patients who are debilitated, have neuromuscular problems affecting swallowing, or with altered mental status including excessive alcohol use.
Patients often have concomitant periodontal disease and more indolent symptoms of a putrid cough, fever, and dyspnea evolving over days to weeks.

Front 65

Lung Cancer Presentation ?

Back 65

Lung cancer can obstruct the diameter of a bronchus leading to a post-obstructive pneumonia, thus both diagnoses can sometimes co-exist. Lung cancer alone would not cause symptoms of infection and pulmonary findings of consolidation.
Hemoptysis is associated with pulmonary malignancy, but it is neither sensitive nor specific for this diagnosis

Front 66

What is the role of CBC in PNA ? SIRS criteria.

Back 66

CBC (A) has limited utility in terms of the diagnosis of pneumonia. Patients with pneumonia usually have an elevated white blood cell count with a neutrophil predominance and a left shift (i.e., increased percentage of bands), but the absence of these do not rule out pneumonia. The CBC can be helpful in assessing the severity of pneumonia because a WBC <4.0 cells x103/μL (<4.0 cells x109/L) or >12.0 cells x103/μL (>12.0 cells x109/L) is a criterion for the systemic inflammatory response syndrome (SIRS). SIRS suggests the patient has a very severe infection.

Front 67

Tests to order in suspected PNA?

Back 67

CBC, Gram stain & sputum cx, blood cx, CXR

Front 68

When to order a ABG ?

Back 68

The two situations where an ABG can be useful are:
(1) when a clinician is on the fence about intubating a patient, and
(2) when there is a concern the patient is retaining excess carbon dioxide.

Front 69

How do you know if CXR is of good quality ?

Back 69

RIP
Rotation - Measure the distance of each clavicle from the spinous processes at that level. If they are equidistant, the patient is not rotated.
Inspiration - A good inspiratory effort is present if you can count nine posterior ribs within the lung fields before you reach the diaphragm.
Penetration - The ability to visualize the intervertebral spaces within the heart boundaries. If the intervetebral space has a similar density to the vertebrae themselves, then the film is underpenetrated and all the shadows will appear denser than they actually are.

Front 70

Healthcare associated PNA compared to CAP.

Back 70

Risk factors for healthcare-associated pneumonia
- Hospitalization for two days or more in the preceding 90 days (A)
- Home infusion therapy (including antibiotics) (B & D)
- Chronic dialysis within 30 days (C)
- Home wound care (D)
- Residence in a nursing home or extended care facility (E & G)
- Family member with multidrug-resistant pathogen

Front 71

CURB 65 Score

Back 71

Prognostic score for PNA severity that can be used to aid in the decision of whether or not to hospitalize patients with community-acquired pnuemonia.

CURB-65 stands for:
Confusion
blood Urea nitrogen (>19 mg/dL)
Respiratory rate (>30 breaths per minute)
Blood pressure (systolic <90 or diastolic <60 mmHg)
age (65 or older)

Front 72

Characteristics of TB ?

Back 72

Tuberculosis is unlikely because it rarely presents acutely and the location of the infiltrate is usually in the upper lobes

Front 73

What types of PNA are highly contagious ?

Back 73

Influenzae and TB types but NOT bacterial

Front 74

Common complications of PNA ?

Back 74

Bacteremia, Sepsis, Pleural Effusion

Front 75

When to order CT in a PNA patient ?

Back 75

The chances for an alternate diagnosis (e.g., pulmonary embolism, malignancy) are low, based on the initial history and physical exam findings.

If after 72 hours, he does not seem better or is getting worse, a chest CT could be reasonable to assess for complications such as cavitary disease or smaller pleural effusions not visualized on chest x-ray.

Front 76

Does pneumovax decrease PNA rates ?

Back 76

pneumococcal vaccine (Pneumovax) has not shown any reduction in the risk of developing community-acquired pneumonia, but it can reduce the risk of invasive disease; including bacteremia, meningitis, or infection of other sterile sites.