Alert Medical Series: Internal Medicine Alert I

Ala Sarraj

Description

This series is a compilation of powerful high yield random notes and comparisons that will guarantee laser-sharp comprehensive and effective knowledge acquisition and high score passing rates in the fields of USMLE (US Medical Licensing Exam), Internal Medicine and Emergency Medicine boards.

Sujets

• Médecine
• Spécialités médicales
• Médecine d'urgence
• Emergency Medicine
• Medical

Informations

• Publié par: Outskirts Press
• Date de parution: 15 octobre 2016
• Nombre de lectures: 0
• EAN13: 9781478769484
• Langue: English

Extrait

The opinions expressed in this manuscript are solely the opinions of the author and do not represent the opinions or thoughts of the publisher. The author has represented and warranted full ownership and/or legal right to publish all the materials in this book.

Alert Medical Series: Internal Medicine Alert I
All Rights Reserved.
Copyright © 2016 Ala Sarraj, MD
v6.0 r2.1

Cover Photo © 2016 thinkstockphotos.com. All rights reserved - used with permission.

This book may not be reproduced, transmitted, or stored in whole or in part by any means, including graphic, electronic, or mechanical without the express written consent of the publisher except in the case of brief quotations embodied in critical articles and reviews.

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ISBN: 978-1-4787-6948-4

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PRINTED IN THE UNITED STATES OF AMERICA
To My Mother
Preface
Alert M edical Series is a compilation of powerful random high yield notes and comparisons that will guarantee comprehensive and effective knowledge base and high score passing rates in the fields of USMLE (US Medical Licensing Exam), INTERNAL MEDICINE and EMERGENCY MEDICINE boards alike.
It reflects years of revision and update that will save medical students, residents and physicians measurable time of test prep and knowledge acquisition.
Alert Medical Series will serve you like multitude of pixels creating very high resolution and sharp picture.
The USMLE series notes (basic and clinical) were put in a random manner mixing basic and clinical notes to simulate real life knowledge building and to reflect the future trend in USMLE testing to combine clinical science and the clinically based basic science.
• PNH (Paroxysmal Nocturnal Hemoglobinuria):
Non-immune hemolysis.
Dark urine in the morning.
Thrombosis: liver (Budd Chiari syndrome), mesenteric vein, CNS site.
• NPH (Normal Pressure Hydrocephalus):
1. Urinary incontinence.
2. Slow movements (bradykinesia).
3. Confusion.
(“ Wet, Wacko, Wobbly “).
• ARDS (adult respiratory distress syndrome) most common causes:
Sepsis.
Gastric content aspiration.
Trauma, burns, overdoses.
• PEEP (positive end expiratory pressure) should not exceed 20 cm H2O.
• Intrinsic PEEP (auto PEEP):
End expiratory intra pulmonary pressure.
Causes: obstruction, aggressive bronchodilation therapy, increased expiration time.
Auto PEEP should be minimized.
• Keep insp. Plateau pressure < 35 cc H2O.
• NIF (neg. insp. Pressure) < - 20 (normal: -100):
Impending respiratory failure.
• AC (assist control): the vent. delivers set tidal volume for all breaths including the patient’s.
SIMV (synch. Intermittent mandatory vent) : the vent delivers set tidal volume to the back up breaths only excluding the patient’s.
• Autoimmune chronic hepatiti s: piecemeal necrosis.
• Serum H. Pylori antibody test:
Used for screening.
Not affected by antacids.
• Urea breath test: most accurate.
30% false negative with antacids.
Antacids should be stopped x 2 wks, and antibiotics should be stopped x 3 wks before testing.
• SV (stroke volume)= cardiac output / heart rate.
= 50 ml.
• Coronary perfusion = diastolic BP – PCAP (pulm. capillary art. pressure): > 50.
• In septic shock: Norepinephrine is of choice.
• Uterine arterial Blood flow is PH dependent, avoid alkalosis (asthma attacks) and hypoxia.
• Avoid using Nipride or ACE inhibitors in pregnancy.
• HELLP syndrome:
Occurs > 20 wk of gestation.
R sided abdominal Pain, N/V.
• Primary sclerosing cholangitis (PSC):
Occurs with IBD(inflammatory Bowel disease).
Negative autoimmune serology.
• Vit C leads to false negative Guaiac stools test.
• Tricyclic antidepressants:
Alpha blocker.
Na channel blocker (Quinidine effect).
Reuptake blockers of Norepinephrine and Serotonin.
Anticholinergic effect.
With hypotension unresponsive to Na bicarb use Epinephrine or Norepinephrine instead of Dopamine.
• Digitalis inhibit Na- K ATPase pump ---> intracellular K depletion, Ca and Na accumulation.
2 nd deg. A-V block type 2: uncommon.
• 30 deg. Cent. = 85 deg. F
35 deg. Cent. = 95 deg. F.
• Neuroleptic malignant syndrome: Rigidity.
Serotonin syndrome: shivering, quivering.
• Neuroleptic malignant syndrome:
Dopamine depletion.
Dopamine blocking agents.
Withdrawal from dopaminergic agonists.
Tx: Bromocriptine, Dantrolene.
Avoid anticholinergics.
• Malignant hyperthermia:
Disorder of muscle Ca utilization. (use of Succinylcholine can be a factor).
Tx: Dantrolene 3 mg/ kg q 10 min x3.
Procainamide.
• Sympathomimetic crisis:
Cocaine.
Amphetamine.
Theophylline.
• Mannitol: can be used in rhabdomyolysis--->
Diuresis.
Renal vasodilation.
Hydroxyl radical scavenger.
• Risk factors of stress ulcers:
Mechanical ventilation.
Coagulopathy.
Burns.
Trauma including closed head injury.
• Aspiri n: not effective in prophylaxis against DVT.
• Celiac sprue:
IgA anti endomysial antibody test and
IgG anti Gliadin antibody test are both positive.
• Drug apparent volume of distribution =
Dose/ initial plasma level (immediately after administration) or peak plasma concentration.
• Time required to reach steady state = 3 - 5 halftimes.
• Drug distribution depends on:
Lipid solubility.
Protein binding.
Blood flow.
• Nonionized (unchanged) drug fraction is most lipid soluble ---> tubular reabsorption.
• Only the unbound fraction of the drug is filtered to the tubules.
• In order to be eliminated (urine, bile or feces) the drug must be converted to water soluble in the liver.
• Sulfonylurias, Prandin: stimulate insulin secretion.
Metformin, Actos, Avandia : increase muscle sensitivity to insulin.
• DM type 2:
Midnight long acting insulin(NPH) + Metformin
Is a good starting regimen.
• In DKA, PH > 7.30, plasma osmolality < 320
Treat in the ED then send home.
• In hypoglycemia check serum insulin level and C. Peptide:
If levels increased, endogenous: insulinomas.
If levels decreased, exogenous: sulfonylurias.
• Non atherogenic lipoproteins:
Chylomicrons, VLDL.
• Non alcoholic steatohepatitis (fatty liver):
Increased blood glucose.
Steatosis on US liver.
Abnormal LFTs.
• TIPS (Transjugular Intra Hepatic Portosystemic shunt):
Used for recurrent cirrhotic hydrothorax.
Refractory ascites.
• LDL carries 75% of total plasma cholesterol.
• Increased VLDL / chylomicrons: hyper triglyceridemia.
• In insulin deficient patients: VLDL/ chylomicrons clearance is defective.
Use insulin as part of treatment regimen.
• Pituitary apoplexy: headache, fever, stiff neck.
Hypoadrenalism.
CT or MRI brain: hemorrhagic mass in sella.
Check cortisol level.
Treatment: steroids.
• Normal ACTH, TSH don’t rule out central causes except prolactin random level can be used to diagnose hyperprolactinemia.
• You can document the menopause state by measuring FSH level at the end of 7 day pill free interval before changing to HRT (hormone replacement therapy).
• The hypothalamic – pituitary- adrenal axis:
Check am cortisol (except in pregnancy: falsely high): > 18 ug / dL.
Or check cortisol level post Cosyntropin stimulated test.
• The hypothalamic- pituitary- thyroid axis:
Check free T4 index, not TSH (normal in central hypothyroidism).
• The gonadal axis:
In males check serum testosterone level, if low check LH/ FSH(used for primary failures only).
• Growth hormone < 2.5-5 ng/ ml during stimulation test(insulin induced hypoglycemia) is diagnostic of deficiency.
• In central hypothyroidism (secondary):
Check free T4 or free T4 index, not TSH to monitor therapy.
• Diabetes insipidus (DI):
High plasma osmolality > 280.
High volume dilute urine .
Positive response to vasopressin (increased urine osmolality > 50%).
In nephrogenic DI: no response.
• Microadenomas < 1 cm in diameter.
• The best screening for:
Prolactinomas: two random serum prolactin.
Acromegaly: ser. Insulin like growth factor IGF1.
Cushing’s syndrome: 24 hr urine free cortisol.
• Prolactinoma symptoms:
Hypogonadism.
Galactorrhrea.
Headache, hirsutism, acne.
• Prolactin level increases in:
Pregnancy, primary hypothyroidism, renal failure, cirrhosis.
Tx: Bromocriptine (in pregnancy), Cabergoline.
• Acromegaly: risk of colon polyps, recommend colonoscopy.
Growth hormone level not suppressible with glucose.
Tx: Bromocriptine, Octreotide, radiation or surgery.
• Screening for pituitary lesions:
Prolactin level, IGF1, urine free cortisol, free T4 index.
• Subclinical hypothyroidism:
Elevated TSH.
Normal T3 or T4 level.
• T4 half life: 7 days.
Check TSH only after 6 weeks of starting therapy.
• Amiodarone: 35% of its weight is Iodine.
• Lithium decreases the release of thyroid hormone leading to hypothyroidism.
• Thyroid cold nodules: 90% benign.
Most cystic lesions are benign
Microfollicular pattern on biopsy warrants surgical removal.