Internal Medicine

what is the critical stenosis?

70%+

what do we see with stable angina?

when is the angina, biomarkers, ST segment changes?

this is when you have angina with exertion, no elevation in biomarkers, and no ST segment changes

what do we see with unstable angina?

when is the angina? biomarkers? ST segment changes?

angina with exertion but may also be present at rest (worse than stable angina), no change in biomarkers, no ST segment changes

what do we see with NSTEMI?

when is the angina? biomarkers? ST segment changes?

angina at rest, increase in biomarkers (troponins), no ST segment changes

what do we see with STEMI?

when is the angina? biomarkers? ST segment changes?

angina at rest, increase in biomarkers (troponins), and ST segment elevations

what are some risk factors for CAD? nonmodifiable and modifiable

non-modifiable

• age, males >45, females >55, family history

modifiable

• HTN, smoking, obesity, dyslipidemia, DM, CKD, vasculopathies

What are the common drugs for inducing pharmacological stress for a cardiac stress test?

dobutamine, adenosine, and dipyridamole

Why do we care/look at the reticulocyte count with suspected anemia?

helps us determine production vs destruction anemia

• production anemia → you see a low reticulocyte index (often microcytic or macrocytic anemias)

• destruction anemia → you see an increased reticulocyte index (often normocytic anemia)

what do we order next if we see microcytic anemia?

look at iron studies (ferritin, Fe, TIBC)

what is the difference in the methylmalonic acid levels with B12 deficient anemia vs folate deficient anemia?

B12 → increased MMA levels

folate → normal MMA levels

what are the microcytic anemias? are they production or destruction anemias? what lab tells us that?

iron deficiency anemia, anemia of chronic disease, thalassemia (minor and major), sideroblastic anemia

they are typically production anemias → so we see a low/inappropriately normal reticulocyte count (normally it would be high to make up for low hemoglobin, but if its a production issue then that’s part of the problem)

what do we expect to see with iron deficiency anemia?

iron, ferritin, TIBC

low iron, low ferritin, high TIBC

what do we expect to see with anemia of chronic disease?

iron, ferritin, and TIBC

low iron, high ferritin, and low TIBC

with the thalassemias, what do we see with FE, ferritin, and TIBC?

all normal

how to treat iron deficiency anemia, anemia of chronic disease, minor thalassemia, major thalassemia?

iron deficiency → give iron (also stool softener bc iron makes you constipated)

chronic disease → no treatment except treat underlying disease

minor thal: no tx

major thal: transfusions

what do we expect with sideroblastic anemia?

iron, ferritin, and TIBC

high iron, other iron studies don’t matter

note: look for the ringed sideroblasts

what are the typical presentation/cause of iron deficiency anemia?

males: colon cancer

females: menometrorrhagia

What anemia is associated with the “tea and toast” diet?

folate deficiency anemia (macrocytic)

What are the 4 common pt presentations for B12 deficiency anemia?

the strict uneducated long-term vegan pt, pernicious anemia, Chron’s disease, or gastric bypass

You treat B12 deficiency anemia by replacing B12, how do you decide the route of administration?

to be able to absorb oral B12 you need an intact stomach and intrinsic factor, so

• IM: pernicious anemia, gastric bypass, Chron’s dz

• PO: vegan (nutritional deficiency)

What do we use Schilling’s test for? How does it work? How do we interpret it?

used to decide do they have impaired absorption of nutritional deficiency of B12 (anemia)

give them IM injection of B12, then give them oral B12; then check their urine, since you gave the IM and saturated their system then all the PO B12 should be urinated out

urine positive for B12 → nutritional issue

urine negative for B12 → impaired absorption

what is this? next step?

pt presents with symptoms of anemia, microcytic, with low ferritin

iron deficiency anemia → endoscopic evaluation

what is this? What is the treatment?

pt has a DVT in her leg and low platelets even though she is on heparin for thromboprophylaxis

heparin induced thrombocytopenia (HIT) → bivalirudin or argatroban (direct thrombin inhibitor)

What is this?

pt presents with 1 year history of intermittent generalized lymphadenopathy; no fever, weight loss, or night sweats, lab studies are all normal

follicular lymphoma (waxing and waning lymphadenopathy)

what is the likely cause of the anemia?

pt presents with anemia, labs show high reticulocyte count and diagnosed with chronic lymphocytic leukemia 6 months ago

autoimmune hemolytic anemia → immune-mediated destruction of RBCs (note that this is destruction anemia because the reticulocyte count is high to try to compensate)

If a pt presents with stent thrombosis, where they have had a recent coronary artery stent (metal or drug-eluting) and now they present with STEMI, what is the most common cause of this complication?

noncompliance with dual antiplatelet therapy

what is the underlying cause of warfarin-induced skin necrosis?

protein C deficiency

If a pt is given a RBC transfusion and a few minutes after it begins starts to have SOB, decreased temp, tachycardia, and low pulse ox, what is this? what is the next step in management?

anaphylactic transfusion reaction → IM epinephrine (note that the low pulse ox means you should give oxygen, but the answer isn’t intubation, you can use a non-rebreather)

what is this? what is the next step in diagnosis?

pt presents with LUQ pain and CT shown

splenic infarct → check the antinuclear antibody assay (splenic infarct is associated with lupus)

If a pt presents with idiopathic thrombocytopenia purpura what is the next step in management? (you see decreased platelet count with no real cause)

test for HIV and hep C

What is this? what is the underlying cause of the symptoms?

pt presents with RUQ pain, hemoglobin is 9.9, MCV is 90, splenomegaly, and peripheral blood smear is shown

hereditary spherocytosis → pigmented gallstones (causing his RUQ pain)

What is this? what do we expect to see on chest xray?

pt presents with fever, weight loss, fatigue, pruritis, and lymphadenopathy

Hodgkin lymphoma → anterior mediastinal mass

what is the next step?

pt has a recently diagnosed DVT that has failed to resolve with warfarin

replace warfarin with a factor Xa inhibitor (rivaroxaban, apixaban, etc)

What is a drug that we should think of if we see leukocytosis? (known to cause medication induced leukocytosis)

systemic glucocorticoids (methylprednisolone, prednisolone)

besides secondary malignancy, what are pts with Hodgkin lymphoma at greatest risk for developing?

cardiovascular disease

what is this? what do we expect with potassium, phosphate, calcium, and uric acid?

pt presents with acute myelogenous leukemia and starts chemotherapy, she develops palpitations, muscle cramps and nausea

tumor lysis syndrome (causes electrolyte abnormalities) → high potassium, high phosphate, low calcium, and high uric acid (hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia)

What is this? treatment?

pt is a young woman with anemia, heavy menstrual bleeding, prolonged bleeding time and pTT, normal platelets

von Willebrand disease → desmopressin

what is the management of HIT?

d/c heparin and start a direct thrombin inhibitor (like argatroban)

what do we suspect? what is the diagnostic test?

pt presents with recurrent infections, nontender lymphadenopathy, severe leukocytosis (very high) and hepatosplenomegaly

chronic lymphocytic leukemia → flow cytometry of the peripheral blood

what is this?

pt presents with pallor, scleral icterus, high reticulocyte count, high total bilirubin, high lactate dehydrogenase, and peripheral blood smear shows multiple spherocytes and direct Coombs test is positive

autoimmune hemolytic anemia

If a pt has anemia and we see LDH is elevated, bilirubin is elevated, and haptoglobin is low what do we suspect?

hemolytic anemia (hemolysis of some kind)

What do we suspect if we have anemia and bite cells and heinz bodies are seen in peripheral blood smear?

G6PD deficiency

How do we treat pts with sickle cell disease?

hydroxyurea (makes fetal hemoglobin)

for the acute pain setting: add IV fluids, oxygen supplementation, and pain control

If a pt has sickle cell and we transfuse them they can get iron overload. how do we treat this?

deferoxamine

What is this?

african american male that takes dapsone, TMP-SMX, or nitrofurantoin and gets hemolysis

G6PD deficiency (normocytic anemia)

also fava bean presentation

what is this? explain briefly

pt presents with hemolysis and spherocytes and has issues with spectrin, ankrin, or pallidin

hereditary spherocytosis (they are shaped like spheres, can’t fit through the spleen, so the spleen thinks they are bad and destroyes them)

what is the treatment for hereditary spherocytosis?

splenectomy (stops the hemolysis, doesn’t stop the spherocytosis)

If you see a positive coombs test what do we think? types?

autoimmune hemolytic anemia

types: cold (IgM → cold milk) warm (IgG → gooey cookies)

What is the diagnostic test for paroxysmal noctunal hemoglobinuria?

flow cytometry (CD55-)