Internal Medicine Shelf Exam Review - High-Yield Concepts

High-yield vocabulary flashcards detailing diagnostic criteria, presentation clues, pathophysiologic mechanisms, and management protocols for internal medicine shelf preparation based on Annabelle Reichi's lecture notes.

Stable Angina

A clinical diagnosis defined by meeting all three criteria: substernal chest discomfort, provoked by exertion or emotional stress, and relieved by rest or nitroglycerin.

Atypical Angina

Chest discomfort that meets only two of the three criteria for typical stable angina.

Low Pretest Probability of CAD

A clinical state characterized by an asymptomatic patient or a woman aged $< 50$ with atypical angina (two out of three criteria), for which the recommended next step in management is no further testing.

High Pretest Probability of CAD

A clinical state seen in men aged $> 40$ or women aged $> 60$ meeting all three criteria for stable angina, requiring direct catheterization lab referral for coronary angiography without non-invasive stress testing.

Vasospastic Angina

Recurrent episodes of severe chest pain occurring at night that resolve completely within 15 seconds in a young patient without coronary risk factors; managed primarily with calcium channel blockers (CCBs).

Ischemic Colitis (Post-Cardiac Catheterization)

A catheterization complication presenting with sudden left lower quadrant abdominal pain and bloody diarrhea within 3 hours post-procedure; confirmed with contrast-enhanced CT or colonoscopy and managed supportively without vasopressors.

Retroperitoneal Hematoma

A catheterization complication presenting with sudden flank/back pain and hypotension 12 hours post-procedure; diagnosed via contrast CT and treated with supportive care.

Femoral Pseudoaneurysm

A post-catheterization vascular complication marked by a painful, pulsatile groin mass with a systolic bruit and a hypoechoic collection communicating with the femoral artery but not the vein; managed by observation if uncomplicated and $< 3\,\text{cm}$, ultrasound-guided thrombin injection if uncomplicated and $> 3\,\text{cm}$, or open surgical repair if complicated.

Femoral Arteriovenous (AV) Fistula

A post-catheterization vascular lesion featuring a continuous bruit and a palpable thrill in the groin without a discrete mass, involving both the artery and vein; managed with ultrasound-guided compression.

Right Ventricular Myocardial Infarction

An ST-elevation myocardial infarction involving the inferior leads (II, III, aVF) where preload reduction with nitrates is contraindicated and management requires IV fluids.

Papillary Muscle Rupture

A mechanical complication occurring approximately 3 days after an inferior MI, presenting with acute severe pulmonary edema and a new holosystolic murmur at the apex due to severe mitral regurgitation.

Interventricular Septum Rupture

A post-MI mechanical complication occurring approximately 3 days after an infarction, presenting with hemodynamic instability and a new harsh holosystolic murmur heard best at the left sternal border due to an acquired ventricular septal defect.

Ventricular Free Wall Rupture

A catastrophic post-MI complication occurring approximately 5 days after infarction, presenting with sudden severe hypotension, tachycardia, and rapid progression to cardiac arrest secondary to cardiac tamponade.

Left Ventricular Aneurysm

A late post-MI complication presenting weeks to a month after infarction with persistent ST-segment elevations and bulging of the ventricular wall on echocardiogram.

Peri-Infarction Pericarditis

Pericarditis occurring 1 day status post-MI where NSAIDs must be avoided and management relies on acetaminophen with or without high-dose aspirin.

Dressler's Pericarditis

An autoimmune pericarditis developing several weeks after a myocardial infarction, treated with NSAIDs and colchicine.

Uremic Pericarditis

Pericarditis occurring in patients with end-stage renal disease characterized by a pericardial friction rub; managed urgently with hemodialysis.

Constrictive Pericarditis

Fibrocalcific pericardial thickening often caused by tuberculosis in developing nations, presenting with a positive Kussmaul sign and pericardial calcifications; treated with pericardiectomy and diuretics.

Heart Failure with Reduced Ejection Fraction (HFrEF)

Systolic heart failure with an ejection fraction $< 55\%$, characterized by eccentric hypertrophy and volume overload; chronic mortality-reducing therapy consists of an ARNI/ACEi/ARB, beta blocker, mineralocorticoid receptor antagonist, and an SGLT2 inhibitor (ABCS).

Heart Failure with Preserved Ejection Fraction (HFpEF)

Diastolic heart failure caused by concentric hypertrophy and pressure overload from hypertension or obesity; managed with SGLT2 inhibitors to reduce hospitalizations, alongside loop diuretics and blood pressure control.

Class 1C Antiarrhythmics

Rhythm-control medications (e.g., flecainide, propafenone) that slow atrial depolarization and demonstrate use dependence, posing increased risk of toxicity at higher heart rates.

Class III Antiarrhythmics

Rhythm-control agents (e.g., amiodarone, sotalol, dofetilide) that prolong repolarization and demonstrate reverse use dependence, presenting increased risk of toxicity and QT prolongation during bradycardia.

Atrial Fibrillation Cardioversion Protocol ($> 48\,\text{hours}$)

A management requirement in stable patients with AF lasting $> 48\,\text{hours}$ necessitating either 3 weeks of therapeutic anticoagulation or a transesophageal echocardiogram (TEE) prior to cardioversion to exclude left atrial appendage thrombus.

Wolff-Parkinson-White (WPW) Syndrome

A ventricular pre-excitation syndrome where stable tachyarrhythmias are treated with procainamide or ibutilide, strictly avoiding AV nodal blocking agents that accelerate conduction down the accessory pathway.

Hypertensive Emergency

Severe blood pressure elevation associated with acute end-organ damage, requiring IV agents to reduce blood pressure by a maximum of $25\%$ in the first hour and toward $160/110\,\text{mmHg}$ within 6 hours (with the exception of aortic dissection, where rapid lowering is mandated).

Thoracic Aortic Aneurysm

Aortic dilation above the diaphragm primarily driven by hypertension, bicuspid aortic valve, Marfan syndrome, or tertiary syphilis; diagnosed with CT angiography.

Abdominal Aortic Aneurysm (AAA) Screening

A preventive ultrasound recommendation performed one time for all men aged $65\text{--}75$ who have ever smoked.

Stanford Type B Aortic Dissection

A dissection originating distal to the left subclavian artery (descending aorta), managed medically with rapid blood pressure and heart rate control using IV beta blockers such as labetalol.

Peripheral Arterial Disease (PAD)

Atherosclerotic vascular insufficiency of the extremities diagnosed with an ankle-brachial index $< 0.9$; initial therapy for intermittent claudication is supervised exercise therapy, followed by cilostazol for persistent symptoms.

Acute Limb Ischemia

A sudden vascular emergency characterized by the 6 Ps (pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis); threatened viable limbs require urgent revascularization within $6\,\text{hours}$.

Chronic Venous Insufficiency

A venous disorder characterized by lower extremity dull aches, edema, and warm hyperpigmented skin (stasis dermatitis); mild disease is treated with compression stockings, whereas advanced skin changes require endovenous thermal ablation.

Infective Endocarditis Prophylaxis

Pre-procedure antibiotic administration (typically oral amoxicillin 30 to 60 minutes prior) indicated exclusively for high-risk cardiac conditions (prosthetic heart valves, repaired congenital heart disease with residual defects, prior endocarditis, or heart transplant with valvulopathy) undergoing high-risk dental, respiratory, or infected tissue procedures.

Pervalvular Abscess

An extension of infective endocarditis (most frequently aortic valve endocarditis) into surrounding myocardial tissue, presenting as new-onset conduction abnormalities or AV block on ECG.

Heparin-Induced Thrombocytopenia (HIT) Type 2

An immune-mediated complication developing 5 to 14 days after heparin administration, marked by a $> 50\%$ drop in platelet count, necrotic skin lesions, and high risk of venous/arterial thrombosis; confirmed by serotonin release assay and managed by immediately replacing heparin with direct thrombin inhibitors or fondaparinux.

Ventilator Oxygenation Adjustments

Adjusting oxygen delivery parameters on mechanical ventilation where elevated $PaO_2$ ($> 100\,\text{mmHg}$) prompts decreasing $FiO_2$ to prevent toxicity, while hypoxemia prompts increasing PEEP.

Silent Chest (Asthma)

A critical sign of impending respiratory arrest in severe acute asthma exacerbation where wheezing markedly diminishes despite persistent hypoxemia and hypercapnia, necessitating immediate endotracheal intubation.

Allergic Bronchopulmonary Aspergillosis (ABPA)

A hypersensitivity reaction to Aspergillus in patients with asthma or cystic fibrosis presenting with recurrent pneumonias, brown sputum plugs, and central bronchiectasis; managed with oral prednisone and itraconazole.

COPD Exacerbation Management

Acute medical regimen consisting of antibiotics, bronchodilators, systemic corticosteroids, and titrated oxygen targeting an $SpO_2$ of $88\text{--}92\%$ (ABCOS).

Oxygen-Induced Hypercapnia

A phenomenon in COPD where excessive supplemental oxygen reverses hypoxic pulmonary vasoconstriction, increases physiological dead space, and impairs ventilation, clinically presenting with morning headaches, altered mental status, and asterixis.

Tension Pneumothorax

A life-threatening pleural emergency characterized by hypotension, tracheal deviation away from the affected side, absent breath sounds, and hyperresonance; managed with immediate needle decompression followed by tube thoracostomy.

Pancreatic Pseudocyst

A fluid collection lined by granulation tissue rather than epithelium that arises approximately 4 weeks following acute pancreatitis; managed conservatively unless symptomatic or $> 6\,\text{cm}$, which warrants drainage.

Primary Biliary Cholangitis (PBC)

An autoimmune destruction of intrahepatic bile ducts in middle-aged females characterized by elevated ALP/GGT, positive antimitochondrial antibodies (AMA), and granulomatous duct lesions; treated with ursodeoxycholic acid.

Primary Sclerosing Cholangitis (PSC)

A chronic cholestatic disease associated with ulcerative colitis, characterized by p-ANCA positivity, fibrous periductal 'onion skin' structuring of intra- and extrahepatic bile ducts yielding a 'beads on a string' cholangiogram, and increased cholangiocarcinoma risk.

Choledocholithiasis

The presence of a gallstone within the common bile duct, causing ductal dilation and elevated bilirubin/ALP without systemic signs of infection; diagnosed with ultrasound and managed with endoscopic retrograde cholangiopancreatography (ERCP).

Acute Cholangitis

A life-threatening ascending infection of an obstructed common bile duct presenting with Charcot's triad (fever, jaundice, RUQ pain) or Reynolds' pentad (adding shock and altered mental status); managed with IV fluids, broad-spectrum antibiotics, and emergent ERCP.

Postcholecystectomy Syndrome

Persistent abdominal symptoms or persistent bile acid diarrhea occurring after gallbladder removal; secretory bile acid diarrhea is treated with bile acid sequestrants such as cholestyramine.

Acute Esophageal Variceal Bleeding

Massive upper gastrointestinal hemorrhage from portal hypertension; acute management consists of volume resuscitation, IV octreotide, prophylactic antibiotics, and emergent endoscopic band ligation.

Colovesical Fistula

An abnormal tract connecting the colon to the urinary bladder (often secondary to diverticulitis or Crohn's disease), presenting with pneumaturia, fecaluria, and recurrent mixed-flora UTIs; diagnosed via abdominal CT with oral contrast.

Prerenal Acute Kidney Injury

A functional decrease in renal perfusion (e.g., dehydration, volume depletion) with intact tubular reabsorption, characterized by a $BUN/\text{Creatinine ratio} > 20$, urine sodium $< 20\,\text{mEq/L}$, and high urine osmolality; treated with IV fluid resuscitation.

Diabetic Nephropathy Screening

Annual assessment using the random urine albumin-to-creatinine ratio (UACR); a value $> 30\,\text{mg/g}$ indicates microalbuminuria and mandates starting an ACE inhibitor or ARB.

Acute Interstitial Nephritis (AIN)

An immune-mediated renal inflammation triggered by medications (diuretics, rifampin, antibiotics/PPIs, NSAIDs), presenting with low-grade fever, maculopapular rash, arthralgias, peripheral eosinophilia, and white blood cell casts.

Acute Tubular Necrosis (ATN)

Intrinsic renal tubular injury caused by ischemia or nephrotoxins, characterized by muddy brown granular casts, high urine sodium, and a $BUN/\text{Creatinine ratio} < 15$.

Renal Vein Thrombosis

A thrombotic occlusion of renal venous outflow seen in nephrotic syndrome (particularly membranous nephropathy) due to urinary loss of antithrombin III, presenting with flank pain, hematuria, and elevated LDH; treated with anticoagulation (warfarin).

Hyperkalemic Emergency Management

Treatment protocol for serum potassium $> 6.5\,\text{mEq/L}$ or with ECG changes, requiring immediate IV calcium gluconate for cardiac membrane stabilization, followed by IV insulin with dextrose to shift potassium intracellularly.

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

A genetic condition presenting in adults with palpable bilateral flank masses, hypertension, liver cysts, increased hemoglobin (secondary to excess EPO), and an association with intracranial berry aneurysms and mitral valve prolapse.

Uncomplicated Cystitis

A lower urinary tract infection occurring in healthy non-pregnant females, managed empirically with nitrofurantoin for 5 days, TMP-SMX for 3 days, or a single dose of fosfomycin.

Asymptomatic Bacteriuria

The presence of positive urine cultures without urinary symptoms; screening and treatment are strictly reserved for pregnant women, patients undergoing urologic procedures, or recipients $< 3\,\text{months}$ status-post renal transplantation.

Nephrolithiasis Size-Based Management

Therapeutic strategy where stones $< 10\,\text{mm}$ are managed conservatively with hydration and alpha-1 blockers; proximal stones $> 10\,\text{mm}$ undergo extracorporeal shock wave lithotripsy (ESWL); distal stones $> 10\,\text{mm}$ undergo ureterorenoscopy; and stones $> 20\,\text{mm}$ require percutaneous nephrolithotomy.

HIV Post-Exposure Prophylaxis (PEP)

An immediate occupational safety measure consisting of a 3-drug antiretroviral regimen initiated empirically as soon as possible and continued for 4 weeks following high-risk exposure.

Mycobacterium avium Complex (MAC) Prophylaxis

Primary antibiotic prophylaxis with azithromycin or clarithromycin plus ethambutol indicated in HIV patients whose CD4 count drops below $50/\mu\text{L}$.

Pneumocystis jirovecii Pneumonia (PCP) Prophylaxis

Primary preventive antimicrobial therapy with daily trimethoprim-sulfamethoxazole (TMP-SMX) indicated in HIV patients with a CD4 count $< 200/\mu\text{L}$.

Bacillary Angiomatosis

A vascular infection caused by Bartonella henselae in advanced HIV, presenting with friable, exophytic, red-purple skin nodules and liver involvement showing neutrophilic infiltrates on Warthin-Starry stain; treated with oral erythromycin or doxycycline.

Toxoplasma Encephalitis

An opportunistic parasitic reactivation in HIV patients with CD4 counts $< 100/\mu\text{L}$, presenting with multiple ring-enhancing brain lesions with edema; managed empirically with pyrimethamine, sulfadiazine, and leucovorin.

Primary CNS Lymphoma

An EBV-associated intracranial malignancy in HIV patients with CD4 counts $< 50/\mu\text{L}$, presenting with a solitary, periventricular, ring-enhancing mass with surrounding edema; treated with high-dose methotrexate.

CURB-65 Criteria

A risk-stratification score for community-acquired pneumonia (Confusion, Urea $> 20\,\text{mg/dL}$, Respiratory rate $\ge 30/\text{min}$, Blood pressure $< 90/60\,\text{mmHg}$, Age $\ge 65$); a score of 2 mandates inpatient ward admission, while $3\text{--}5$ warrants ICU admission.

Hospital-Acquired Pneumonia (HAP)

Pneumonia developing $\ge 48\,\text{hours}$ after hospital admission, requiring broad empiric coverage against MRSA and Pseudomonas aeruginosa with vancomycin plus cefepime or piperacillin-tazobactam.

Active Tuberculosis (RIPE) Regimen

Standard quadruple therapy for active TB comprising rifampin, isoniazid, pyrazinamide, and ethambutol for 2 months, followed by rifampin and isoniazid for an additional 4 months (totaling 6 months).

Blastomycosis

A dimorphic fungal infection endemic to the Great Lakes and Ohio/Mississippi River valleys (e.g., Wisconsin), presenting with pulmonary symptoms, verrucous ulcerative skin lesions, and osteolytic bone lesions; treated with itraconazole or amphotericin B.

Rocky Mountain Spotted Fever (RMSF)

A tick-borne rickettsial infection presenting with high fever, severe headache, hyponatremia, thrombocytopenia, and a centripetally spreading macular rash starting on the wrists and ankles; treated with immediate oral/IV doxycycline.

Ehrlichiosis (Spotless RMSF)

A tick-borne zoonosis prevalent in the south-central states (e.g., Arkansas) causing fever, leukopenia, thrombocytopenia, elevated transaminases, and intracytoplasmic morulae in monocytes without a rash; treated with empiric doxycycline.

Disseminated Gonococcal Infection

A systemic sexually transmitted infection characterized by the triad of migratory polyarthralgia, tenosynovitis, and painless pustular or vesiculopustular skin lesions; diagnosed with nucleic acid amplification testing (NAAT) and treated with IV ceftriaxone.

Entamoeba histolytica Liver Abscess

A protozoal infection following travel to endemic areas (e.g., Mexico) presenting with bloody diarrhea, right upper quadrant pain, and a smooth subcapsular liver abscess showing ingested red blood cells within trophozoites; treated with metronidazole followed by paromomycin.

Lacunar Stroke of the Posterior Limb of the Internal Capsule

An ischemic small-vessel stroke caused by lipohyalinosis of the lenticulostriate arteries secondary to chronic hypertension, resulting in pure motor hemiparesis affecting the contralateral face, arm, and leg.

Cerebral Amyloid Angiopathy (CAA)

A cause of spontaneous lobar intracerebral hemorrhage in non-hypertensive elderly adults ($> 75$ years old) caused by amyloid-beta deposition in cerebral cortical vessels.

Subarachnoid Hemorrhage (SAH) Complications

Major post-rupture intracranial complications where rebleeding is the leading cause of death within the first 24 hours, and cerebral vasospasm occurs days later (prevented with enteral nimodipine).

Conus Medullaris Syndrome

A distal spinal cord lesion presenting with sudden, symmetric lower extremity weakness, mixed upper and lower motor neuron signs, perianal numbness, and early-onset bowel and bladder incontinence.

Cauda Equina Syndrome

Compression of the lumbosacral nerve roots causing progressive, asymmetric lower-extremity flaccid weakness, hyporeflexia, saddle anesthesia, and late-onset urinary retention.

Idiopathic Intracranial Hypertension

Elevated intracranial pressure in obese young females presenting with daily headaches, pulsatile tinnitus, transient visual obscurations, and papilledema with an opening pressure $> 200\,\text{mm H}_2\text{O}$; treated with weight reduction and acetazolamide.

Guillain-Barré Syndrome (GBS)

An acute post-infectious polyradiculoneuropathy featuring symmetric ascending weakness, hyporeflexia, and albuminocytologic dissociation on CSF analysis; monitored closely with serial spirometry and managed with IVIG or plasmapheresis.

Progressive Multifocal Leukoencephalopathy (PML)

A severe demyelinating CNS disease caused by JC virus reactivation, seen as an adverse complication of natalizumab (an alpha-4 integrin antagonist) in patients with multiple sclerosis.

Central Retinal Artery Occlusion (CRAO)

Acute painless monocular visual loss with fundoscopic findings of a pale retina and a cherry-red spot at the fovea; treated acutely with ocular massage and carbogen therapy.

Central Retinal Vein Occlusion (CRVO)

Acute painless monocular visual loss showing severe retinal hemorrhages ('blood and thunder' appearance), dilated tortuous veins, and optic disc swelling; managed with anti-VEGF injections and photocoagulation.

Acute Angle-Closure Glaucoma

An ocular emergency marked by severe ocular pain, headache, nausea, halos around lights, and a fixed mid-dilated pupil; treated with immediate IV acetazolamide and IV mannitol, strictly avoiding epinephrine.

Malignant Otitis Externa

An invasive osteomyelitis of the external ear canal skull base caused by Pseudomonas aeruginosa in elderly diabetic patients, presenting with ear discharge, severe pain, granulation tissue, and potential cranial nerve palsies; treated with IV ciprofloxacin.

Meniere's Disease

An inner ear condition caused by endolymphatic hydrops, presenting with recurrent episodes of vertigo lasting 20 minutes to 12 hours, unilateral sensorineural hearing loss, and tinnitus; managed with dietary sodium restriction.

Nelson Syndrome

Rapid growth of an ACTH-secreting pituitary microadenoma following bilateral adrenalectomy for Cushing disease, presenting with hyperpigmentation, severe headaches, visual field defects, and markedly elevated ACTH; managed with pituitary surgery.

DKA/HHS Potassium Protocol

A fluid and electrolyte management rule in diabetic crises where serum potassium $< 3.3\,\text{mEq/L}$ requires holding insulin and administering IV potassium alone to prevent fatal arrhythmias; levels between $3.3\text{--}5.2\,\text{mEq/L}$ allow concurrent insulin and potassium; and levels $> 5.2\,\text{mEq/L}$ permit insulin administration alone.

Paroxysmal Nocturnal Hemoglobinuria (PNH)

An acquired hematopoietic stem cell mutation causing complement-mediated hemolytic anemia, dark morning urine, and a propensity toward venous thrombosis (such as hepatic vein thrombosis/Budd-Chiari syndrome).

Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

The most common transfusion reaction, developing 1 to 6 hours after transfusion due to accumulated donor leukocyte cytokines, causing fever and chills with stable vitals; prevented with leukoreduction.

Transfusion-Related Acute Lung Injury (TRALI)

A transfusion reaction occurring within 6 hours, characterized by acute hypoxemia, fever, hypotension, and non-cardiogenic pulmonary edema mediated by donor anti-leukocyte antibodies.

Papillary Thyroid Carcinoma

The most common thyroid malignancy associated with prior ionizing radiation exposure, featuring Orphan Annie eye nuclei and psammoma bodies on histology; managed with total thyroidectomy.

Courvoisier Sign

A palpable, non-tender, distended gallbladder accompanied by painless jaundice, highly suggestive of adenocarcinoma of the head of the pancreas.

Polycythemia Vera

A myeloproliferative neoplasm driven by a JAK2 mutation resulting in erythrocytosis, low serum erythropoietin, facial plethora, and aquagenic pruritus; treated with therapeutic phlebotomy.

Chronic Lymphocytic Leukemia (CLL)

An indolent B-cell leukemia in older adults presenting with generalized painless lymphadenopathy, profound lymphocytosis, and smudge cells on peripheral blood smear; diagnosed via flow cytometry.

Hodgkin Lymphoma Hypercalcemia

Elevated serum calcium in Hodgkin lymphoma resulting from Reed-Sternberg cytokine release that stimulates macrophages expressing 1-alpha-hydroxylase to convert vitamin D into calcitriol.

Waldenström Macroglobulinemia

A plasma cell dyscrasia characterized by an IgM monoclonal spike, hyperviscosity symptoms (headache, vision changes), hepatosplenomegaly, and $> 10\%$ clonal lymphoplasmacytic B cells on bone marrow biopsy.

Lumbar Spinal Stenosis

Degenerative narrowing of the spinal canal causing neurogenic claudication (bilateral leg pain and paresthesias that worsen with upright extension and improve with spinal flexion, such as pushing a shopping cart).

Spinal Cord Compression

An oncologic emergency presenting with severe back pain, progressive motor weakness, and new urinary or fecal retention; managed with immediate high-dose IV glucocorticoids followed by emergent MRI of the spine.

Breslow Thickness

The depth of melanoma invasion measured from the granular layer of the epidermis, representing the single most important prognostic indicator.

Basal Cell Carcinoma

The most common cutaneous malignancy, presenting as a pearly translucent papule with telangiectasias and rolled borders, characterized histologically by palisading nuclei and linked to PTCH1 loss-of-function mutations activating Sonic Hedgehog.