Internal Med 4

Question 1

Outpatient treatment of CAP

Answer 1

• In healthy = Macrolide or Doxycycline

- Comorbidities = Fluoroquinolones or beta-lactam + macrolide
beta-lactams don’t work against atypicals

Question 2

Inpatient treatment of CAP in non-ICU patients

Answer 2

• Fluoroquinolone (Levo = lung)

- Beta-lactam + Macrolide

Question 3

Inpatient tx of CAP in ICU patient

Answer 3

• Beta-lactam + macrolide

- Beta-lactam + fluoroquinolone

Question 4

What will you see on histology of UC vs. Crohns

Answer 4

UC = Crypt abscess with neutrophils

Crohns = noncaseating granulomas

Question 5

What will you see on gross imaging of UC vs. Crohns

Answer 5

UC = loss of haustra “lead pipe”

Crohns = Strictures, “string sign”

Question 6

Which is associated with increased risk of colorectal cancer, UC or Crohns

Answer 6

UC

Question 7

Where would you expect pain and which one has blood diarrhea, UC or Crohn’s

Answer 7

UC = LLQ pain (colorectal), bloody

Crohns = RLQ pain (ileum), non-bloody

Question 8

When and with what, should you treat an HIV+ patient with TB skin test

Answer 8

• If area of induration >5 mm at 48-72 hours you need to rule out active TB via CXR and sx review
• If no manifestation of active TB, treat for latent TB with 9 months of Isoniazid (+Pyridoxine to prevent peripheral neuropathy)

Question 9

Tx of toxic megacolon

Answer 9

IVF, broad-spectrum abx, bowel rest

IV corticosteroids used in IBD-induced toxic megacolon

Question 10

What is tumor lysis syndrome

Answer 10

♣ Patients with aggressive hematologic malignancies who begin cytotoxic chemotherapy
♣ Large-scale cell death increases vascular concentrations of intracellular products, resulting in potentially life-threatening electrolyte and metabolic abnormalities

Question 11

Describe electrolyte abnormalities in tumor lysis syndrome (K, Na, Phos, Uric acid)

Answer 11

• Hyperkalemia and Hyperphosphatemia (intracellular ions are liberated)
• Hypocalcemia (phosphate binds and precipitates calcium)
• Hyperuricemia (nucleic acids are released and metabolized into uric acid)

Question 12

What are the two main organs that need to be monitored in tumor lysis syndrome

Answer 12

♣ Kidney - Acute kidney injury (due to uric acod/calcium phosphorus)
♣ Heart - Cardiac arrhythmias (due to hyperkalemia)

Question 13

Treatment of tumor lysis syndrome

Answer 13

♣ Continious telemetry

♣ Aggressive electrolyte monitoring/treatment

Question 14

Prophylaxis of tumor lysis syndrome

Answer 14

♣ IV fluids (to flush kidneys)

♣ Allopurinol (to metabolize uric acid)

Question 15

Describe steps of immediate treatment of pt with an acute STEMI

Answer 15

♣ Oxygen in patients with saturation <90% or other features of hypoxia
♣ Relief of ischemic pain (Nitroglycerine)
♣ Assesssment of hemodynamic state and correction of abnormalities
♣ Initiaion of reperfusion therapy with primary percutaneous coronary intervention (PCI aka stent placement) or fibrinolysis
♣ Antithrombotic therapy to prevent rethrombosis or acute stent thrombosis
♣ Beta blocker therapy to prevent reccurent ischemia and life-threatening ventricular arrhythrmias

Question 16

What will be done in-hospital in a patient who just had an acute STEMI, in order to improve long-term prognosis

Answer 16

♣ Antiplatelet therapy to reduce risk of recurrent coronary artery thrombosis or, with PCI, coronary artery stent thrombosis
♣ ACEi therapy to prevent remodeling of the left ventricle
♣ Statin therapy
♣ Anticoagulation in the presence of left ventricular thrombus or chronic atrial fibrillation to prevent embolization

Question 17

What are the 4 classes of drugs recommended as initial treatment for HTN

Answer 17

• Thiazide diuretics
• ACEi
• ARBs
• CCBs

Question 18

Describe characteristics of small cell carcinoma of lung + tx

Answer 18

♣ “S” = smokers, central, secreting

Tx = radiation

Question 19

What might small cell cancer of the lung produce

Answer 19

• ADH = SIADH
• ACTH = Cushing’s
• Antibodies against pre-synaptic Ca2+ channels = Lambert-Eaton

Question 20

Describe characteristics of squamous cell carcinoma of lung + tx

Answer 20

• “S” = smokers, central, secreting
• Often presents as a hilar mass

Tx = surgery

Question 21

What might squamous cell carcinoma of the lung produe?

Answer 21

• May produced PTH = hypercalcemia

Question 22

Describe characteristics of adenocarcinoma of lung + tx

Answer 22

• Non-smokers and female smokers
• Located in lung periphery may present with pain because it affects the pleura

Tx = surgery

Question 23

Where does carcinoid tumor occur

Answer 23

♣ Well-differentiated neuroendocrine cells
• Chromogranin A positive
♣ Location:
• Lung = Classically presents as a polyp-like mass in the bronchus
• GI tract = only causes carcinoid syndrome if metastasis to liver

Question 24

Complication of carcinoid tumor

Answer 24

♣	Rarely causes carcinoid syndrome (BFDR)
•	Bronchospasm and wheezing
•	Flushing
•	Diarrhea 
•	R-sided heart lesions

Question 25

Describe transudative pleural effusion + causes

Answer 25

• Low protein content o THINK: Transudate is more transparent • Due to increased hydrostatic pressure (e.g. CHF or fluid overload) or decreased oncotic pressure (e.g. cirrhosis, nephrotic syndrome)

Question 26

Describe exudative pleural effusion + causes

Answer 26

• High protein content, cloudy o Pleural fluid will have High LDH and low glucose (due to high metabolic activity of leukocytes and bacteria within the fluid) • Due to pleural and lung inflammation resulting in increased capillary and pleural membrane permeability (e.g. malignancy, pneumonia, TB, trauma, connective tissue disease) • Must be drained due to risk of infection

Question 27

What is Light's criteria

Answer 27

♣ If at least one of the following 3 criteria is true, the fluid is an exudate • Pleural fluid protein/serum protein ratio > 0.5 • Pleural fluid LDH/serum LDH ratio > 0.6 • Pleural fluid LDH > 2/3 the upper limit of laboratory’s normal serum LDH

Question 28

When should you NOT tap a pleural effusion

Answer 28

* CHF = You can do just observation instead if the patient has CHF because the likelihood it is transudative from CHF is so high * If pleural effusino <1 cm you can watch and wait * If loculated, you need to do a thoracostomy (chest tube) or thoracotomy (surgery) Other than these exceptions, you should tap any new pleural effusion

Question 29

Describe EKG findings of PE

Answer 29

• S1Q3T3 o Large S waves in lead I o Q waves in lead III o Inverted T waves in lead III

Question 30

What will you see in PE for: - pH - pCO2 - pO2

Answer 30

``` pH = high pCO2 = low pO2 = low ``` Hypoxia will cause hyperventilation, blowing of CO2 = hypoxemic, hypocarbic respiratory alkalosis

Question 31

Describe transporters located in thick ascending limp of loop of Henle

Answer 31

Impermeable to water - this is the diluting segment that only re-absorbs ions but no water Contains Na+/K+/2Cl- cotransporter (NKCC) - all 3 are reabsorbed. Makes interstitium of kidney salty

Question 32

Describe MOA and effects of Furosemide

Answer 32

o blocks NKCC on apical membrane of thick ascending limb ♣ Will reduce reabsorption of NaCl, and water will follow – diuresis ♣ Without electrolyte reabsorption in the ascending limb, the interstitium will not be hypertonic and there will be less reabsorption of H2O in the descending limb – diuresis

Question 33

What are the effects of loop diuretics on Ca2+ and Mg2+

Answer 33

♣ Normally, K+ will come into the cell via NKCC, but then will diffuse back into the lumen, giving the lumen a slightly positive charge, causing other cations such as Magnesium and Calcium to leave the tubule and enter the interstitium down their electric gradient • Blocking of NKCC will decrease electric gradient, therefore decreasing the reabsorption of Ca2+ and Mg2+ - AKA adverse effect = hypocalcemia and hypomagnesemia

Question 34

What are the effects of Loop diuretics on Potassium

Answer 34

``` o Hypokalemia (potassium wasting) ♣ Sodium that is inhibited from being reabsorbed will be taken to the collecting duct where it is reabsorbed by Na+/K+ ATPase, causing increased potassium excretion ```

Question 35

Describe the transporters that Thiazide diuretics work on in the distal convoluted tubule

Answer 35

• Inhibits NaCl cotransporter in apical membrane of distal tubule (so NaCl stays in lumen instead of being reabsorbed into cell)

Question 36

Describe effects of Thiazides on calcium

Answer 36

Hypercalcemia - Thiazides block NaCl cotransporters = decreased intracellular Na+ will stimulate the Na+/Ca2+ exchanger at basolateral membrane (between cell and interstitium), causing sodium to be brought into the cell and calcium to be pushed out into the interstitial space (increased reabsorption of Ca2+)

Question 37

Why do Thiazide diuretics work to treat Nephrogenic Diabetes insipidus

Answer 37

* Hypovolemia-induced increase in sodium and water reabsorption in more proximal segments of the nephron * Now you don’t have to rely on terminal ducts for reabsorption – this is where ADH works

Question 38

What are the effects of thiazide on: - Glucose - Lipids - Uric acid - Potassium

Answer 38

- Hyperglycemia - Hyperlipidemia - Hyperuricemia - Hypokalemia

Question 39

Describe the transporters that potassium-sparing diuretics work on in the collecting duct

Answer 39

♣ Na+ (ENaC) channels – reabsorbs Na+ across the luminal membrane • Na+ reabsorption creates a negative luminal potential that facilitates K+ excretion via K+ channel Diuretics block the Na+ ENaC channel so that sodium cannot be reabsorbed. Positive luminal potential of Na+ prevents K+ from being secreted

Question 40

What are names of potassium-sparing diuretics

Answer 40

Amiloride, Triamterene, Eplerenone, Spironolactone

Question 41

What is the role of Aldosterone in collecting duct

Answer 41

Aldosterone is produced by adrenal cortex in response to RAAS, and increases activity of ENaC and K+ channels - increases reabsorption of Na+ and excretion of K+

Question 42

How does Amiloride and Triamterene work?

Answer 42

• Blocks the Na+ ENaC channels on the apical membrane so that sodium cannot be reabsorbed

Question 43

How does Eplerenone work?

Answer 43

• Directly antagonizes the mineralocorticoid receptor (so it can no longer increase the activity of ENaC, K+ channels, and Na+/K+ ATPase)

Question 44

How does Spironolactone work?

Answer 44

• Directly antagonized the mineralocorticoid receptor

Question 45

Describe stepwise treatment of COPD

Answer 45

* Short acting beta agonist (SABA) * Long acting muscarinic antagonist (Tiotropium) * Long acting beta agonist (LABA) * Inhaled corticosteroids * Phosphodiesterase 4 inhibitors * Oral steroids

Question 46

How do you treat acute COPD exacerbation

Answer 46

- Oxygen - Inhaled bronchodilators (Albuterol, Ipratropium) - Systemic glucocorticoids (PO Prednisone or IV Methylprednisolone) - Antibiotics if > 2 cardinal symptoms (increased dyspnea, cough, or sputum production) - Oseltamivir if evidence of influenza - NPPV if ventilator failure - Tracheal intubation if NPPV failed or contraindicated