Internal Medicine Shelf Exam

Define polycythemia vera.

Malignant clonal proliferation of hematopoietic stem cells leading to excessive erythrocyte production; increase in RBC mass occurs independent of erythropoietin

What are 5 clinical symptoms of polycythemia vera?

Sx due to hyperviscosity; thrombotic phenomena; bleeding; hepatosplenomegaly; hypertension

Describe the hyperviscosity symptoms which may be present w/ polycythemia vera.

Headache; dizziness; weakness; pruritis; visual impairment; dyspnea

Name the 3 major criteria which must be present in order to dx polycythemia vera.

Elevated RBC mass (men > 36 L/kg, women > 32 L/kg); arterial oxygen saturation > 92%; splenomegaly

What are 4 minor diagnostic criteria of polycythemia vera?

Thrombocytosis (platelet count > 400 x 10⁹/L); leukocytosis > 12 x 10⁹/L; leukocyte alkaline phosphatase > 100 (w/ no fever or infection); serum vitamin B₁₂ > 900 pg/mL

What procedure confirms a dx of polycythemia vera?

Bone marrow biopsy

Name 2 treatment modalities for polycythemia vera.

Repeated phlebotomy to lower hematocrit; myelosuppression w/ hydroxyurea or recombinant interferon alpha (rIFN-α)

What is the first step in therapy for a suspected acute ST-segment elevation MI?

Administer aspirin and a beta-blocker, and assess whether the patient is a candidate for rapid reperfusion of the myocardium (e.g., treatment w/ thrombolytics or percutaneous coronary intervention)

Describe acute coronary syndrome.

Spectrum of acute cardiac ischemia ranging from unstable angina to acute MI, usually precipitated by thrombus formation in a coronary artery w/ atherosclerotic plaque

Name 3 types of thrombolytics used to treat ACS.

Tissue plasminogen activator (tPA); streptokinase; reteplase (rPA)

Critical coronary artery stenosis > _____ produces stable angina symptoms.

70%

Differentiate between portions of the myocardium affected by STEMIs and NSTEMIs.

STEMIs: transmural; NSTEMI: subendocardial

What EKG leads correspond to the RCA?

II, III, aVF; inferior surface of the heart

What EKG leads correspond to the LAD?

V₂, V₃, V₄; anterior surface of the heart

Name 4 EKG leads that correspond to the left circumflex artery.

I, aVL, V₅, V₆; lateral surface of the heart

Name 2 specific cardiac enzymes and their elevation window following an MI.

Cardiac-specific troponin I (cTnI): rises 6 hours after infarct and remains elevated for 7-10 days; cardiac specific troponin T (cTnT): rises 6 hours after infarct and remains elevated for 10-14 days

What are 3 features of an acute MI?

Chest pain persisting for > 30 minutes; typical EKG findings; elevated cardiac enzyme levels

Name 3 clinical features of aortic dissection.

Unequal pulses or BPs in the arms; new murmur of aortic insufficiency; widened mediastinum

Name 4 criteria for thrombolytic therapy in the setting of an acute MI.

Clinical complaints are consistent w/ ischemic-type chest pain; ST-segment elevation more than 1mm in at least 2 anatomically contiguous leads; there are no contraindications to thrombolytic therapy; patient is < 75 years of age

What are 2 common causes of mortality in acute MI?

Myocardial pump failure (resulting in cardiogenic shock); ventricular arrhythmia (VT or VF)

What is accelerated idioventricular rhythm?

Wide-complex escape rhythm between 60-100 bpm that frequently accompanies reperfusion of the myocardium but causes no hemodynamic compromise

What medication is used to treat sinus bradycardia following acute MI?

Atropine

What are 3 criteria used to define cardiogenic shock?

Hypotension w/ systolic arterial pressure < 80 mm Hg; markedly reduced cardiac index < 1.8 L/min/m²; elevated LV filling pressure (measured indirectly w/ a pulmonary capillary wedge pressure > 18 mm Hg)

What is the hallmark of treatment for pts w/ right ventricular infarction?

Volume replacement w/ saline or colloid solution to maintain adequate preload

What is the triad of Dressler syndrome?

Pericarditis; pleuritis; fever

Pts w/ established CAD should have an LDL cholesterol level < _____.

70 mg/dL

What 2 tests may be used to dx reinfarction in a patient w/ a recent MI?

New ECG findings; rapidly rising cardiac markers such as serum myoglobin or CK-MB

What are 3 symptoms of aortic valvular stenosis?

Late systolic murmur radiating to the carotid; paradoxical splitting of S₂; diminished carotid upstroke

What are the 3 major treatment goals for pts w/ CHF?

Relief of sx; preventing disease progression; reduction in mortality risk

(T/F) Digoxin provides survival benefit for pts w/ CHF.

False

In CHF pts who cannot tolerate ACE inhibition (or in black pts in whom ACE inhibitors appear to confer less benefit, the use of _____ has been shown to decrease mortality.

Hydralazine /w nitrates

What is the most common valvular abnormality in adults?

Aortic stenosis

Aortic stenosis in pts younger than 30 yrs is usually caused by _____.

Congenital bicuspid valve

What is the most common cause of aortic stenosis in pts 30-70 years of age?

Congenital stenosis; acquired rheumatic heart disease

In pts older than 70, the most common cause of aortic stenosis is _____.

Degenerative calcific stenosis

What are 3 physical findings a/w aortic stenosis?

Narrow pulse pressure; harsh late-peaking systolic murmur heard best at the right second intercostal space w/ radiation to the carotid arteries; delayed slow-rising carotid upstroke (pulsus parvus et tardus)

What are 2 characteristics of the EKG a/w atrial fibrillation?

Absence of discrete P waves; irregularly irregular ventricular response

Name the 2 most common causes of atrial fibrillation.

Hypertension; coronary atherosclerosis

Describe the "I SMART CHAP" mnemonic for causes of atrial fibrillation.

Inflammatory disease; surgery; medications (theophylline, caffeine, digoxin); atherosclerotic coronary artery disease; rheumatic heart disease; thyrotoxicosis; congenital heart disease (ASD, Ebstein anomaly); hypertensive heart disease; alcohol consumption; pulmonary disease

What 3 medications can be used for ventricular rate control in a hemodynamically stable pt w/ atrial fibrillation?

Beta-blockers; calcium channel blockers; digoxin

The risk of intra-atrial thrombus formation increases if atrial fibrillation occurs for > _____.

48 hours

(T/F) Pts w/ atrial fibrillation occuring > 48 hrs can be directly cardioverted.

False; pts should receive 3-4 weeks of warfarin therapy prior to and after cardioversion to reduce the risk of thromboembolic phenomenon

What are 3 pharmacologic cardioverting agents?

Procainamide; amiodarone; sotalol

What are 2 prognostic factors for successful atrial fibrillation cardioversion?

Left atrial dilation (> 4.5 cm predicts failure); duration of AF

What is lone AF?

AF that develops in pts younger than 60 years w/o evidence of structural heart disease, hypertension, or other factors for stroke

What are 3 physical signs of mitral stenosis?

Loud S₁; opening snap following S₂; low-pitched diastolic rumble

(T/F) Digoxin, verapamil, and other AV nodal-blocking agents can, paradoxically, increase the ventricular rate and should be avoided in Wolff-Parkinson-White pts w/ AF.

True

What 2 medications may be used in hemodynamically stable pts w/ WPW in order to convert to sinus rhythm?

Procainamide; ibutilide

What is metabolic syndrome X?

Any combination of hypercholesterolemia, hypertriglyceridemia, impaired glucose tolerance, diabetes, hyperuricemia, or HTN; key underlying factor is insulin resistance (due to obesity)

What 4 characteristics are indicative of a positive stress test?

S-T segment depression; chest pain; hypotension; significant arrhythmia

Pts w/ positive stress ECG should undergo _____.

Cardiac catheterization

Name 3 agents used in pharmacologic stress testing. Describe their mechanisms of action.

Adenosine, dipyramidole: cause generalized coronary vasodilation; dobutamine: increases myocardial oxygen demand

What are 4 side effects of nitrates?

Headache; orthostatic hypotension; tolerance; syncope

Name 4 medications used to treat stable angina pectoris.

Aspirin; beta-blockers; nitrates; calcium channel blockers

At what level of BMI should drug therapy for weight loss be considered?

Greater than 30 or greater than 27 w/ comorbidities

For what type of patient is gastric bypass surgery recommended?

Patients with class III obesity, defined as those with a BMI of ≥40 who cannot maintain weight loss with exercise and diet with or without drug therapy and who have obesity-related comorbid conditions

What test has been shown to be highly sensitive and specific for diagnosing occupational asthma?

Serial peak expiratory flow rate measurement

A grade 2/6 diastolic murmur that is heard loudest at the second left intercostal space is typical of _____.

Aortic regurgitation

What medication is a common cause of hyponatremia in the outpatient setting?

Hydrochlorothiazide

Name 2 characteristics of chronic myeloid leukemia.

Elevated leukocyte count; increased numbers of granulocytic cells in all phases of development on the peripheral blood smear

What testing is indicated for patients with Pap smear results showing atypical squamous cells of undetermined significance?

HPV testing

Name 4 physical findings in severe aortic stenosis.

Small and late carotid pulsations; late peaking systolic murmur; absence or splitting of the S₂; sustained apical impulse

What degree of cutaneous involvement differentiates diffuse from limited systemic sclerosis?

Diffuse: skin thickening proximal to the elbows and knees; limited: skin thickening distal to the elbows and knees

What is Grey-Turner's sign?

Ecchymosis of the flanks; suggests pancreatic hemorrhage due to pancreatic necrosis, which is a very rare presentation of acute pancreatitis.

What antibiotic provides effective empiric therapy for patients with possible disseminated gonococcal infection?

Ceftriaxone

What is the most common cause of diarrhea in travelers to developing countries?

Enterotoxigenic Escherichia coli

What type of asthma should be considered in pts w/ asthma and nasal polyps?

Aspirin-sensitive

What type of lung cancer has the lowest association w/ smoking?

Adenocarcinoma

What 2 types of lung cancers occur centrally? Peripherally?

Central: squamous cell, small cell; peripheral: adenocarcinoma, large cell

Name 2 nerves which can be affected by local invasion of lung cancer.

Phrenic nerve; recurrent laryngeal nerve

What 3 paraneoplastic syndromes are a/w small cell carcinoma?

SIADH; ectopic ACTH secretion; Eaton-Lambert syndrome

Describe 3 characteristics of Eaton-Lambert syndrome.

Proximal muscle weakness/fatigability; diminished deep tendon reflexes; paresthesias

Name 5 common anterior mediastinal masses.

Thyroid; teratogenic tumors; thymoma; lymphoma

What are 5 masses a/w the middle mediastinum?

Lung cancer; lymphoma; aneurysms; cysts; Morgagni hernia

Name 5 masses a/w the posterior mediastinum.

Neurogenic tumors; esophageal masses; enteric cysts; aneurysms; Bochdalek's hernia

Describe the pathophysiology of transudative effusions.

Either elevated capillary pressure in visceral or parenteral pleura, or decreased plasma oncotic pressure

What are Light's criteria for differentiation of exudative effusions?

Pleural protein / serum protein > 0.5; pleural LDH / serum LDH > 0.6; LDH > 2/3 upper limit of normal serum LDH

(T/F) Pulmonary embolism can result in either a transudative or exudative effusion.

True

What 2 types of pleural effusions are a/w pH < 7.2?

Parapneumonic effusion; empyema

What 3 conditions are a/w elevated pleural fluid amylase?

Esophageal rupture; pancreatitis; malignancy

Do not perform thoracentesis if pleural effusion is < _____ thick on lateral decubitus CXR.

10 mm

What are the "4 C's" of pleural effusion testing?

Chemistry (glucose, protein); cytology; cell count (CBC w/ differential); culture

What are the 2 classifications of acute respiratory failure?

Hypoxemic; hypercarbic (respiratory)

What are the 2 major pathophysiologic mechanisms of hypoxemic respiratory failure?

V/Q mismatch; intrapulmonary shunting

Differentiate between V/Q mismatch and intrapulmonary shunting based on response to supplemental oxygen.

V/Q mismatch: responsive to supplemental oxygen; intrapulmonary shunting: not responsive to supplemental oxygen

What disease is a/w livedo reticularis?

Atheroembolic acute renal failure

Patients w/ inflammatory bowel disease have an increased risk of developing what liver-related disorder?

Primary sclerosing cholangitis

What is the first-line therapy for scabies?

Permethrin 5%, topically

What is the cause of hyperphosphatemia in chronic kidney disease?

Low glomerular filtration rate

Describe the HELLP mnemonic.

Microangiopathic Hemolytic anemia; Elevated Liver enzymes; Low Platelets

What medication is preferred for the treatment of chronic myeloid leukemia?

Imatinib mesylate

Patients with pancolitis for 10 or more years should undergo colonoscopy with biopsies every _____ for cancer surveillance.

1 - 2 years

Pts w/ spontaneous bacterial peritonitis should be given what 2 medications?

Cefotaxime; albumin

What is Winter's formula?

P_CO2 = 1.5 x [HCO₃^-] + 8 ± 2; if expected P_CO2= actual P_CO2, then respiratory compensation is appropriate

What is the pentad of thrombotic thrombocytopenic purpura (TTP)?

Fever; neurologic abnormalities; thrombocytopenia; renal insufficiency; microangiopathic hemolytic anemia

What diabetic medication should be withheld in patients w/ renal insufficiency who are to undergo a radiographic procedure using intravenous contrast?

Metformin

2 of what 3 criteria are required for the diagnosis of polycystic ovarian syndrome (PCOS)?

Ultrasound evidence of polycystic ovaries; ovulatory dysfunction; laboratory or clinical evidence of hyperandrogenism

What triple therapy is used to treat H. pylori infection?

Proton pump inhibitor; clarithromycin; amoxicillin or metronidazole

Name 3 cardiac conditions a/w ST segment elevation on EKG.

Acute pericarditis; STEMI; variant angina

For what 2 criteria is chest tube drainage recommended?

Presence of pus or gram-positive fluid; fluid pH < 7.0

Why is the use of β-blockers contraindicated in the treatment of cocaine-induced myocardial ischemia?

May result in unopposed α-receptor stimulation, further increasing vascular tone and worsening the cardiovascular effects

How can levels of methylmalonic acid and homocysteine be used to distinguish vitamin B₁₂ deficiency from folate deficiency?

Vitamin B₁₂ deficiency: elevated methylmalonic acid and homocysteine concentrations; folate deficiency: elevated homocysteine concentration only

In a patient w/ ascites, how can the serum-albumin ascites gradient be used to determine a cause?

SAAG > 1.1: cirrhosis, Budd-Chiari syndrome, right-sided heart failure; SAAG < 1.1: tuberculosis, nephrotic syndrome, malignancy

Differentiate between the causes of ascites based on the ascitic fluid protein level.

Protein > 2.5 g/dL: malignancy, tuberculosis, right-sided heart failure, Budd-Chiari syndrome; protein < 2.5 g/dL: cirrhosis, nephrotic syndrome

What is the auscultory feature of mitral valve prolapse?

Midsystolic click followed by a late systolic murmur

What are 3 cardiac findings common in pregnancy?

Systolic murmur; S₃ gallop; mild peripheral edema

Define impaired glucose tolerance based on fasting and 2-hour glucose measurements.

Fasting glucose 100 - 125 mg/dL; 2-hour glucose 140 - 199 mg/dL

(T/F) Digoxin and spironolactone are not indicated in pts w/ asymptomatic systolic heart failure.

True

What 2 classes of medications are recommended in all pts w/ systolic heart failure?

ACE-I; β-blocker

Name 3 characteristics of monoclonal gammopathy of undetermined significance (MGUS).

Presence of serum monoclonal γ-globulin w/o the clinical features of multiple myeloma; paraprotein level < 3.5 g/dL; <10% plasmacytosis in bone marrow

What is the most common cause of knee pain in pts < 45 years of age?

Patellofemoral pain syndrome

What is the definitive treatment for pts w/ fulminant hepatic failure?

Liver transplant

Define fulminant liver failure.

Clinical syndrome of severe acute liver failure and encephalopathy in a patient w/o pre-existing liver disease

What are 6 "alarm symptoms" in pts w/ abdominal pain?

Hematochezia; weight loss; family history of colon cancer; fever; anemia; chronic severe diarrhea

Anti–tumor necrosis factor-α therapy increases the risk for what condition?

Reactivation tuberculosis

What pathogen is responsible for the majority of cases of septic arthritis in pts w/ pre-existing rheumatoid arthritis?

Staphylococcus aureus

What is the target blood pressure for pts w/ diabetes mellitus or renal failure?

Less that 130/80 mmHg

What is the cornerstone in preserving renal function in pts w/ diabetic nephropathy?

Aggressive blood pressure control

Small cell lung cancer responds best to what 2 modalities of treatment?

Chemotherapy; whole-brain radiation therapy

What is the recommended hemoglobin A_1c level for pts w/ diabetes mellitus?

Less than 7.0%

Describe 3 characteristics of pts w/ "locked-in" syndrome.

Quadriplegia; paralysis of horizontal eye movements and bulbar muscles; can communicate only by moving their eyes vertically or blinking

Name 2 vasodilators that may be used to treat heart failure in pregnancy.

Hydralazine; nitrates

What is a common cause of mixed anion gap metabolic acidosis and respiratory alkalosis?

Salicylate toxicity

In what pt population is metformin contraindicated?

Pts with renal insufficiency, defined as a serum creatinine concentration > 1.6 mg/dL in men and > 1.5 mg/dL in women

How is PSA level related to probability of having prostate cancer?

4 - 10 ng/mL: 25% have prostate cancer; > 10 ng/mL: 50% have prostate cancer

Name 4 classic symptoms for pheochromocytoma.

Headache; hypertension; diaphoresis; palpitations

What are the 2 most common mutations predisposing to venous thromboembolisms in the Caucasian population?

Factor V Leiden; prothrombin 20210A

What is the most sensitive physical examination finding excluding the diagnosis of severe aortic stenosis?

Physiologically split S₂ heart sound

What drug is used as adjuvant therapy in polycythemia vera pts older than 70?

Hydroxyurea

The presence of what 2 characteristics is diagnostic of Wilson's disease?

Keyser-Fleischer rings; serum ceruloplasmin concentration < 20 mg/dL

Describe heparin-induced thrombocytopenia (type II).

Immune complex-mediated disorder that manifests as thrombosis and decreased platelet count (30,000 - 50,000) approx. 5 - 10 days after heparin therapy is initiated

Internal Medicine Shelf Exam

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