Internal

Question 0

Differential for new CXR infiltrate in HIV positive patient

Answer 0

PCP, kaposi, lymphoma, CMV, TB, cryptococcosis, hemophilius, cryptococcus, mycoplasma, chlamydia

Question 1

Well’s criteria

Answer 1

1. Signs and symptoms of DVT (3)
2. PE is most likely diagnosis or equally likely (3)
3. HR> 100 (1.5)
4. Immobilization 3 days, or surgery in last 4 wks (1.5)
5. Previous hx of PE/DVT (1.5)
6. Hemoptysis (1)
7. Malignancy (tx 6months) or palliative (1)

Question 2

Precipitants of DKA

Answer 2

1. Recent surgery
2. recent trauma
3. Pregnancy
4. MI
5. Infection
6. Non-compliance or wrong insulin dose

Question 3

History for Diabetic Control

Answer 3

Last dose of insulin taken? missed doses? usual sugars?
Symptoms: polyuria, polydipsia
Diet, exercise
Drugs, Alcohol, Smoking
Complications: retinopathy, neuropathy, nephropathy, infections

Question 4

Investigations in DKA

Answer 4

ABG, lytes, glucose, serum ketones
Lytes to monitor: Na, Ca+2, PO4, K, Cr, Urea
pH, HCO3
Septic work up: CBC, blood cultures, urinalysis, CXR
ECG if K is elevated

Question 5

Management of DKA

Answer 5

1. IV fluids: 1L NS x 2-3 hours until HR and BP normalize
   then 500cc/hr x2 hours
   then 250 cc/hr x2 hours
2. Insulin: 10 Units IV push, then 2U/hr drip
3. Monitor glucose and lytes Q2H
4. When glucose=15, then switch to maintenance fluids , begin diet and regular insulin regimen

Question 6

Causes of Heart Block

Answer 6

Cardio: inferior MI, coronary spasm, cardiac tumor, congenital
Medications: digitalis overdose, TCA overdose, beta-blockers, calcium channel blockers
Infectious: viral rheumatic fever, lyme disease
Other: sarcoid, amyloid

Question 7

Lung Nodule History

Answer 7

ID: name, age
Symptoms
-Respiratory symp: cough, sputum, SOB, dyspnea, hemoptysis, wheeze, orthopnea, PND, chest wall pain
-Infectious: history of pneumonia, TB
-Malignant: weight loss, fatigue, night sweats, anorexia, night pain, anorexia

Environment: living conditions, hobbies, pets (cats? birds?), contact with hazardous materials (asbestos)
Habits: smoking, alcohol
Travel

Question 8

Ddx Lung nodule

Answer 8

1. Neoplasm (malignant tends to be >3cm)
2. Benign (tends to be <3cm)
3. Infectious: TB, histoplasmosis, coccidiomycosis
   4 Other: granuloma (from old pneumonia, TB, sarcoid, histoplasmosis), vascular, congenital cyst, round pneumonia, located effusion

Question 9

Investigations for solitary lung nodule

Answer 9

1. CXR: compare to old CXR- look for change, calcifications (associated with benign lesions)
2. CT chest, needle guided biopsy
3. Sputum for cytology and acid-fast staining
4. TB skin test
5. Bronchoscopy
6. Biopsy or lobectomy

Question 10

Management Algorithm for Lung Nodule on CXR

Answer 10

• Repeat CXR q3-6 months x2 years
  If any changes
• CT Chest
• if no dx- consider bronchoscopy or transthoracic needle aspiration
• if no dx- consider biopsy

Question 11

History for transfusion reaction

Answer 11

• what is the indication for transfusion?
• when did reaction start since starting transfusion?
• how much of blood has been received?
• how was blood checked?
• PMHx, reason for admission, meds, allergies?

Question 12

Symptoms of transfusion reaction

Answer 12

Resp: respiratory distress, wheezing, tachypnea, chest pain
Anaphylactic: urticaria, rash, resp distress, N/V, diarrhea
Constitutional: chills, fever, feeling of impending doom
MSK: muscle pain, neck pain

Question 13

Types of transfusion reaction

Answer 13

• Febrile non-hemolytic transfusion reaction
• allergic
• anaphylactic
• acute hemolytic transfusion reaction
• citrate toxicity/hypocalcemia
• hyperkalemia
• circulatory overload
• dilutional coagulopathy
• delayed transfusion reaction
• iron overload- with repeated transfusions over time
• graft vs host disease (4-30 days later), usually in immunocompromised, prevent by using irradiated blood

Question 14

History for SBO (obstipation, nausea, vomiting, colicky abdo pain)

Answer 14

• appetite, last meal, last bowel movement, passing gas
• PSHx
• PMHx, meds, allergies

Question 15

History for hip pain and fever

Answer 15

• Trauma?
• Skin lesions?
• arthritis?
• PSHx: previous joint surgery
• Hx of steroid use, corticosteroid joint injection
• Hx of STD
• PMHx, allergies, meds, DM?
• Habits: smoking, alcohol, IV drug use

Question 16

Diagnosis of septic hip

Answer 16

Joint synovial fluid aspiration 
Blood culture (positive 50%) 
CBC, CRP, ESR

Question 18

History for Dysphagia

Answer 18

1. Liquids/solids or both?

Question 19

History for shortness of breath and hemoptysis

Answer 19

• age
• onset, duration
• previous episode?
• MI symptoms: chest pain, tightness, heaviness, pain in jaw, L arm, palpitations, heaviness/tightness
• Resp: cough, sputum, wheeze, hx of immobilization, leg pain, prev hx of DVT, PE
• GI symptoms: reflux, hx of peptic ulcer, hx of gastritis

Basic info:

• pmhx:
• meds? med compliance?
• allergies:

Question 20

CXR signs of CHF, pulmonary edema

Answer 20

1. enlarged heart
2. upper lobe vascular redistribution
3. Kerley B lines
4. interstitial infiltrates
5. pleural effusions

Question 21

History for microscopic hematuria

Answer 21

Basic info: PMHx, PSHx, meds, allergies, occupation

• hx of trauma
• pain? pain with urination?
• incontinence, frequency, urgency, difficulty voiding
• UTI: fever, nausea, vomiting
• cancer symptoms: weight loss, back pain

Question 22

Ddx for microscopic hematuria

Answer 22

UTI
Nephrolithiasis
Hydronephrosis 
Protatitis 
Prostate cancer 
BPH 
Renal cell carcinoma
bladder cancer

Question 23

Investigations for microscopic hematuria

Answer 23

PSA
U/S renal, bladder, prostate
cystoscopy
IVP

Question 24

History for patient with inability to urinate and dribbling

Answer 24

• onset of symptoms, previous episodes
• associated urinary symptoms: suprapubic pain, pain on urination, blood in urine, difficulty maintaing stream
• neuro symptoms: constipation, perineal numbness, leg weakness
• cancer symptoms: weight loss, fatigue, night sweats
• new meds?
• ROS
• basic info: PMHx, PSHx, FMHx, ROS hx of cancer BPH

Question 25

Investigations for urinary hesitancy, dribbling

Answer 25

``` UA, urine microscopy Urine culture PSA Renal/pelvic ultrasound Cystoscopy ```

Question 26

Needle Stick Injury | -history

Answer 26

severity of exposure - needle gauge - depth of penetration - did needle contain blood from a pt - was blood injected - is hiv and hepatitis status of pt known? - is pt high risk pt? (e.g. multiple partners, IV drug user, immigration from endemic area) - immunization status for hep B

Question 27

Odds of transmission from needle stick injury for - HIV - HepB - Antigen Hep B - Antibody Hep C

Answer 27

- HIV: 0.3% - Hep B: 40% - Antigen Hep B: 10% - Antibody Hep C: 5%

Question 28

Statistics for - HIV - Hep B - Hep C

Answer 28

- HIV: much longer life expectancy due to improved anti-retroviral therapy - Hep B: 1% will have fulminant hepatic necrosis, which is fatal in 60% of cases. 5% will remain in carrier status with 25-40% of cirrhosis, and 2-5%/year of HCC - Hep C: >50% of chronic liver disease, same risk of cirrhosis, and HCC as Hep B

Question 29

Interventions for needle stick injury

Answer 29

- baseline testing: HIV, Hep B, Hep C - repeat in 6 months - HIV prophylaxis if pt is high risk - immunization for HepB

Question 30

Mammography screening

Answer 30

- yearly mammography after age 50 - starting at age 40 if family history of breast cancer - starting at 5-10 years before youngest family member's presentation, if there are 2 first degree relatives with breast cancer (parents, sibs, children)

Question 31

Breast exam

Answer 31

1. inspection: size, symmetry, masses, skin retraction, erythema, dimpling, nipple retraction,ulceration, peau d'orange 2. palpation of - nodes: axillary, infraclavicular, supraclavicular - breast- light/deep palpation or masses, all 4 quadrants

Question 32

History for elevated creatinine

Answer 32

- urinary symptoms: suprapubic pain, renal pain, groin pain, pain with urination, blood in urine, frequency, urgency, colour of urine diff initiating or maintaining urinary stream - neuro symptoms: saddle anesthesia, loss of bowel control - infectious symptoms: fever, chills, nausea, fatigue - cancer symptoms: night sweats, weight loss, fatigue - ROS - hx of UTI, STD, TB, radiation, hypertension, diabetes, kidney stones - Basic info: PMHx, PSHx, meds, allergies, smoking, alcohol, drugs, FMHx

Question 33

Ddx for chronic renal failure

Answer 33

Pre-renal: hypovolemia, poor cardiac output, renal vascular disease, NSAID, liver failure Renal: -vascular: malignant hypertensoin, cholesterol emboli, HUS/TTP -tubulo-interstitial: acute tubular necrosis, -glomerular- contrast, myoglobinuria, acute glomerulonephritis, DIC, pyelo, myeloma Post renal obstruction: tumor, stone, BPH, stricture, autonomic dysfunction

Question 34

Investigations for chronic renal failure

Answer 34

``` CBC, lytes (PO4, Ca, Mg) urea, creat UA, microscopy, culture INR/PTT, AST, ALT, ALP, GGT, CK, Trops AXR Abdo US Post-void cath ```

Question 35

History for 60 yo M, slipped and fell 6 days ago, with hemoptysis

Answer 35

Basic info: PMHx, PSHx, meds, allergies, anticoagulation? - mobilization since accident? - shortness of breath? chest pain? pleuritic pain? pain in legs - neuro symptoms?

Question 36

Physical exam for PE

Answer 36

Cardio: Heart sounds, murmurs, rate, rhythm, pulses Resp: trachea midline, air entry, wheezes, crackles, pleuritic pain MSK: inspect for redness, swelling/size, deformity, palpation for warmth, calf tenderness, Homan's sign, (pain with dorsiflexion of foot)

Question 37

Investigations for PE

Answer 37

``` ABG, D-dimer ECG- S1Q3T3 CXR- hamptons hump, westermark sign, dilatation of proximal PA Doppler ultrasound of legs VQ scan/Spiral CT ```

Question 38

Treatment for PE

Answer 38

Anticoagulation - Heparin (80 U/kg) then infuse at (18U/kg/hr) - measure PTT Q6H (adjust so that PTT 70-90, about 2.5-3x baseline) - start coumadin- INR 2-3, continue coumadin for 3 months