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Internal Medicine

87 important questions on Internal Medicine

Treatment of dermatitis herpetiformis

Gluten-free diet and dapsone

Treatment of cyanide toxicity

Hydroxocobalamin, sodium thiosulfate, or nitrites

Estrogen and thyroid hormone

Estrogen increases the levels of thyroxine-binding globulin, decreasing the levels of free T4. As a result, higher levothyroxine doses may be needed in hypothyroid patients who are pregnant or on oral estrogen replacement therapy.

Treatment of trigeminal neuralgia

Carbamazepine: Risk of aplastic anemia with prolonged use, so routine CBCs should be done
Surgical gangliolysis or suboccipital craniectomy are second line

Features of aspirin exacerbated respiratory disease

Asthma, chronic rhinosinusitis with nasal polyposis, bronchospasm or nasal congestion following the ingestion of aspirin or NSAIDs

Interstitial cystitis presentation

Bladder pain with filling, relief with voiding
Increased frequency and urgency
Dyspareunia

Interstitial cystitis diagnosis and treatment

Diagnosis: Bladder pain with no other attributable cause for at least 6 weeks and normal U/A
Treatment: Behavioral modification, amitriptyline

Niacin side effects

Flushing and pruritus due to prostaglandins

Pulsus parvus et tardus

Decreased pulse amplitude and delayed peak
Seen in aortic stenosis

What murmur develops in aortic dissection?

Early decrescendo diastolic murmur due to aortic regurgitation

Common side effect of calcium channel blockers

Peripheral edema

Symptoms and management of TCA overdose

Anticholinergic (eg. dilated pupils, ileus, hyperthermia)
ABCs
Sodium bicarbonate improves systolic BP, narrows the QRS complex, and decreases the incidence of ventricular arrhythmias

Eye complication in neurofibromatosis type 1

Optic glioma

When can you give live vaccines to patients with HIV?

MMR and VZV can be given to those with CD4>200
All other live vaccines (BCG, anthrax, oral typhoid, oral polio, and yellow fever) are contraindicated

How is immune clearance determined in chronic HBV?

Serial ALT and HBeAg every 3-6 months
ALT should be normal and HBeAg should be negative

What needs to be done before starting treatment for HCV?

Liver biopsy to assess likelihood of response to treatment, stage of disease, rule out other concomitant liver diseases, and guide treatment decisions

Adult Still's disease

Inflammatory disorder characterized by recurrent high fevers, rash, and arthritis

Side effects of cyclosporine

Nephrotoxicity
Hypertension: Treat with calcium channel blocker
Neurotoxicity
Glucose intolerance
Infection
Malignancy
Gingival hypertrophy
Hirsutism
GI manifestations

MOA and side effects of azathioprine

Purine synthesis inhibitor
Dose-related diarrhea, leukopenia, and hepatotoxicity

MOA and side effects of mycophenolate

Inhibitor of IMPDH involved in purine synthesis
Bone marrow suppression

When is Mohs surgery used in the treatment of BCC?

BCC on the face or other delicate areas

What is a complication of entamoeba histolytica infection?

Amebic liver abscess: Generally a single cyst in the right lobe
Treat with metronidazole

What is a sensitive laboratory indicator of orthostatic hypotension?

BUN/creatinine ratio >20 indicating prerenal azotemia

Which cancers are associated with pernicious anemia?

Intestinal-type gastric cancer and gastric carcinoid tumors due to atrophic gastritis

Lab findings in G6PD deficiency

Hemolysis
Bite cells with Heinz bodies (precipitation of denatured hemoglobin)
Negative Coombs test
Low G6PD activity level, but may be normal during attack (wait 3 months to retest)

Risk factors for focal segmental glomerulosclerosis

African American
HIV
Heroin use
Obesity

Side effects of erythropoietin therapy

Hypertension
Headache
Flu-like syndrome
Red cell aplasia

Clinical presentation of Pancoast tumor

Shoulder pain
Horner's syndrome
C8-T2 neurological involvement: Weakness or atrophy of intrinsic hand muscles and pain and paresthesias of 4th and 5th digits, medial arm, and forearm
Supraclavicular lymph node enlargement
Weight loss

Variceal hemorrhage prophylaxis

Non-selective beta-blocker: Propranolol or nadolol

What bacteria typically causes malignant otitis externa?

Pseudomona

Treatment of malignant otitis externa

IV ciprofloxacin

Clinical features of VIPoma

Watery diarrhea
Flushing
Achlorhydria due to decreased gastric acid secretion
Hypokalemia, hypercalcemia, hyperglycemia

Progressive multifocal leukoencephalopathy

Opportunistic infection seen in immunocompromised patients due to JC virus
Causes focal neurological deficits
Diagnose with MRI showing multiple demyelinating, non-enhancing lesions
No treatment

What test can be used to diagnose lactose intolerance?

Hydrogen breath test

What are common viruses that cause viral arthritis?

Parvovirus, hepatitis, HIV, mumps, rubella

What is an epidermal inclusion cyst?

Benign nodule that produces keratin. It is a dome-shaped, firm, and freely movable nodule with a central punctum. May produce a cheesy discharge. Often due to trauma or comedones.

What is a dermatofibroma?

Benign fibroblast proliferation that is a firm, hyperpigmented nodule. Shows dimple sign (central dimpling when pinched).

What is erythema multiforme?

Target rash that occurs after a herpes simplex infection

What are the hallmark ECG findings of ventricular aneurysm?

Persistent ST-segment elevation after recent MI and deep Q waves in the same leads

Which complication of hep C can cause glomerulonephritis?

Cryoglobulinemia: Antibodies in the blood that precipitate in the cold. Can be a complication of hep C, MM, leukemia, mycoplasma pneumonia, primary macroglobulinemia, RA, or SLE. Symptoms include fatigue, SOB, GN, joint and muscle pain, purpura, Raynaud's, and skin ulcers. Diagnose by demonstrating on labs the presence of cryoglobulins in the blood along with typical signs and symptoms.

What is the ideal FiO2 ventilator setting to prevent O2 toxicity?

Below 50-60%

How does cirrhosis affect thyroid hormone?

Decreased production of thyroxine-binding globulin results in a decrease of total T3 and T4, but free T3 and T4 levels remain unchanged

Manifestations of primary hyperparathyroidism

Hypercalcemia, kidney stones, confusion, depression, psychosis, hypertension, arrhythmias, ventricular hypertrophy

Cluster headache treatment

Sumatriptam and O2
Verapamil for prophylaxis

Migraine headache treatment

NSAIDs, acetaminophen, dihydroergotamine (5-HT1 agonist), or sumatriptan (more selective 5-HT1 agonist)
Prophylaxis: Amitriptyline or propranolol, NSAIDs and estrogen supplementation for menstrual migraines
If treatments do not work, most likely not a migraine

4 major diagnoses of sore throat

Viral infection, tonsillitis, strep throat, and mononucleosis

What are the lab findings in Paget disease of bone?

Normal calcium and phosphate levels
Elevated alkaline phosphatase and urinary markers of bone degradation (hydroxyproline, deoxypyridinoline, N-telopeptide, and C-telopeptide)

Differential of lower back pain

Degenerative disc disease (osteoarthritis)
Spondylolisthesis
Lumbar disc herniation
Spinal stenosis
Musculoligamentous strain
Vertebral compression fracture
Neoplasm
Infection (discitis, osteomyelitis)
Non-musculoskeletal causes: Aortic dissection, pancreatitis, prostatitis, nephrolithiasis, endometriosis, ectopic pregnancy, PID

Clinical manifestations of Cushing syndrome

Central obesity, hirsutism, moon facies, buffalo hump, abdominal striae, acne, easy bruising
HTN
Diabetes
Hypogonadism
Proximal muscle wasting
Osteoporosis, aseptic necrosis of femoral head
Depression, mania
Infection

What is required in all patients with new onset lupus nephritis?

Renal biopsy determines class and treatment and is used to monitor progression

What are the lab findings of tumor lysis syndrome?

Elevated uric acid, phosphate, and potassium

What medications are used to prevent gout?

Allopurinol or probenecid

What drugs are used to treat an acute gout attack?

Colchicine, NSAIDs, or steroids

What is Behcet's syndrome?

An autoimmune vasculitis manifested by recurrent oral and genital ulcerations, arthritis, uveitis, meningoencephalitis, fever, and weight loss
Diagnosed with biopsy
Treated with steroids

What is Buerger's disease?

AKA thromboangiitis obliterans
Inflammation of small and medium-sized vessels due to smoking that results in claudication and can lead to gangrene

What is hypersensitivity vasculitis?

A small-vessel vasculitis that is a reaction to a drug (penicillin, sulfa), infection, or other stimulus. Clinical features include constitutional symptoms and skin lesions (palpable purpura, macules, or vesicles). Treat with steroids.

What is amaurosis fugax?

Painless vision loss from cholesterol emboli
Assessed with duplex ultrasound of the neck to identify plaques at carotid bifurcation

Treatment of bacterial meningitis

Age 2-50: Vancomycin + ceftriaxone for N meningitidis and S pneumoniae
Age >50: Vancomycin + ampicillin + ceftriaxone for added coverage of listeria
Neurosurgery/shunt or penetrating trauma to skull: Vancomycin + cefepime for GNRs and staph
Immunocompromised: Vancomycin + ampicillin + cefepime for N meningitidis, pneumococcus, listeria, and GNRs
Always add dexamethasone

What is the pathogenesis of hydatid cysts?

Infection of the tapeworm, echinococcus, from contact with dogs

Diagnosis and treatment of hydatid cyst

Diagnosis: CT shows eggshell calcification of a hepatic cyst
Tx: Surgical resection + albendazole

What type of monoarthropathy is a complication of hyperparathyroidism?

Pseudogout due to calcium pyrophosphate deposition
Synovial fluid shows rhomboid-shaped, positively birefringent crystals

Indications for urgent dialysis

AEIOU:
-Acidosis refractory to medical treatment
-Electrolyte abnormalities: Hyperkalemia with ventricular arrhythmias or refractory to medical treatment
-Ingestion: Toxic alcohols, salicylate, lithium, sodium valproate, carbamazepine
-Overload refractory to diuretics
-Uremia: Encephalopathy, pericarditis, or bleeding

Diagnostic criteria for antiphospholipid antibody syndrome

1) Vascular thrombosis or pregnancy morbidity (fetal losses or premature birth related to eclampsia)
2) Consistent lab findings (lupus anticoagulant, anticardiolipin antibody, or anti-b2GP1 antibody)

Lab findings and treatment of antiphospholipid antibody syndrome

Labs: Lupus anticoagulant, anticaridolipin antibody, prolonged PTT or PT (laboratory artifact that does not correlate with increased bleeding) that is not corrected by adding normal plasma
Tx: Anticoagulation with INR goal of 2.5-3.5

Causes of thyrotoxicosis with with reduced radioactive iodine uptake

Subacute lymphocytic thyroiditis (painless)
Subacute granulomatous thyroiditis (painful)
Levothyroxine overdose
Iodine-induced thyrotoxicosis
Struma ovarii (ovarian teratoma that produces thyroid hormone)

Clinical manifestations of neuroleptic malignant syndrome

Fever, confusion, muscle rigidity, diaphoresis, and elevated CK

Treatment of neuroleptic malignant syndrome

Dantrolene (muscle relaxant)
Bromocriptine (dopamine agonist)
Amantadine (antiviral with dopaminergic properties)

Treatment of essential tremors

Propranolol

What supplement should be given to all patients with sickle cell disease?

Folic acid due to increased RBC turnover

Which commonly prescribed drugs are ototoxic?

Aminoglycosides, chemotherapeutic agents, aspirin, and loop diuretics

Treatment of peripheral artery disease

Aspirin, statin, smoking cessation, exercise program

What is a complication of dermatomyositis?

Malignancy, most commonly ovarian, lung, pancreatic, stomach, colorectal, or non-Hodgkin lymphoma

Symptoms of adrenal insufficiency

Weight loss, weakness, anorexia, nausea, abdominal pain, hypoglycemia
Primary only: Hyperpigmentation, hypotension, hyperkalemia

What can cause vision loss depending on head position?

Papilledema

How does nitroglycerin relieve anginal pain?

Dilation of capacitance vessels (veins) results in decreased preload and decreased oxygen requirement of the heart. It also dilates arteries, decreasing afterload, but this does not contribute to pain relief.

Which heart sound is heart during an acute MI?

What are secondary causes of restless leg syndrome?

Iron deficiency anemia
Uremia
DM
MS
Parkinson disease
Pregnancy
Drugs (antidepressants, metoclopramide)

Treatment of restless leg syndrome

Leg massage, heating pad, exercise, avoid sleep deprivation, supplement iron for ferritin <75, dopamine agonist (pramipexole), alpha-2-delta calcium channel ligand (gabapentin)

Diagnosis of ankylosing spondylitis

Young patient with progressive low back pain for >3 months
Morning stiffness lasting >30 mins
Tenderness over sacroiliac joints
X-ray of sacroiliac joints showing joint fusion or bamboo spine

Major side effect of hydroxychloroquine

Retinopathy, eye exams every 6 months necessary

What medication is used to treat hairy cell leukemia?

Cladribine, a purine analog

Clinical manifestation of CMV colitis

Opportunistic infection
Chronic bloody diarrhea, abdominal pain, mucosal erosions, colonic ulcerations, biopsy shows large cells with eosinophilic intranuclear and basophilic intracytoplasmic inclusions (owl eye)

How is afib treated in WPW?

Hemodynamically unstable patients: Electrical cardioversion
Stable patients: Rhythm control with procainamide or ibutilide

When is statin therapy indicated?

-Clinically significant atherosclerotic disease
-LDL >190
-Age 40-75 with diabetes
-10-year CVD risk >7.5%

Conditions associated with afib

Cardiac: HTN, CAD, valvular heart disease, CHF, cardiomyopthy, post-cardiac surgery
Pulmonary: OSA, PE, COPD, acute hypoxia
Obesity
Hyperthyroidism
DM
Alcohol abuse
Drugs: Amphetamines, cocaine, theophylline

Clinical features and complications of cocaine use

Sympathetic hyperactivity--tachycardia, hypertension, dilated pupils
Chest pain due to coronary vasoconstriction
Psychomotor agitation
Seizures
MI
Aortic dissection
Intracranial hemorrhage

Treatment of cocaine toxicity

Supplemental O2 and IV benzodiazepine
Aspirin
Nitrates or calcium channel blocker for chest pain

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STEP 2

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