General IM Knowledge - The Rotation Series

CRAB:

• HyperCalcemia

• Renal dysfunction

• Anemia

• Bone pain

How do you diagnose multiple myeloma?

Gamma-globulin protein spike!

What lab values could point us to Multiple Myeloma?

Lasix!

• Blocks the Na+/K+/2Cl- transporter in the ascending loop of Henle

What is the drug store name for furosemide? What is the MOA?

• Fevers/Chills?

• Chest pain?

• SOB?

• Abdominal pain?

• Nausea and vomiting?

• Pooping? (normal bowel movements)

• Hobbies?

What are good questions to always ask when you see a patient in the hospital?

PIRATES:

• P: Pulmonary/Post-op

• I: Ischemia

• R: Rheumatic

• A: Anemia

• T: Thyroid

• E: Electrolytes/Ethanol

• S: Sepsis

What are the most common causes for AFib?

• Embolic stroke

• Rapid Ventricular Response (RVR) → HR>10

What are the most common complications of AFib?

Left atrial appendage

What is the location that thrombi typically form?

CHAS2VASC score!

• Score > 2 = start anticoagulants

What is the score that we can use to estimate the risk of stroke? At what score are anticoagulation drugs indicated?

• CHF

• HTN

• Age > 65

• DM

• Stroke

• Vascular disease

• Sex category (Female = 1 point)

What does the CHADS2VASC score stand for?

HASBLED score

What score estimates the risk of bleeding with anticoagulation?

• Rate control mediacations: Dilitiazem, verapmil, beta-blockers

• Anticoagulant: Apixiban, Rivaroxaban, Warfin

What medications do we use to treat A-Fib?

TRUE!

• The AFFIRM trial showed that rate control = rhythm control

True or False: Rate control = Rhythm control, how do you know?

The RACE II trial showed that lenient rate control (HR < 110) is better than strict rate control (HR < 80)

The **** trial shwed that *** rate control (HR < ***) is better than *** rate control (HR < ***)

Cardioversion

• SHOCK

How do you treat an afib patient who is hemodynamically unstable?

Tachycardia-mediated cardiomyopathy

If a patient has prolonged afib with RVR leading to CHF, what is this called?

Unstable angina, NSTEMI, and STEMI

What are the 3 different types of acute coronary syndrome?

Unstable angina does not have elevated troponin levels

How can you differentiate unstable angina from NSTEMI & STEMI?

Name the disease from left to right

4 hours

How long does it take before troponin starts to rise after an MI?

Aspirin 325 mg → 81mg daily

What treatment should IMMEDIATELY be given if an MI is suspected?

1. Medical managment

2. Stent (PCI)

3. CABG

What are the 3 types of treatment for MI?

Radiation of pain to the RIGHT arm

What historyu finding is most spefic for acute MI?

the RIGHT arm

Pain radiating to which arm is more specific for an acute MI?

Costochondritis/MSK issue

Chest pain with tenderness to palpation to chest wall is most likely what?

• Substernal Chest pain

• Worse with exertion

• Relieved with rest or nitroglycerin

(3 = typical, 2 = atypical, 0-1 = non-cardiac)

What are the 3 features of typical chest pain?

Demand ischemia!

• Type 2 MI

If a patient has elevated troponins and signs of ischemia but you dont think it’s from a primary ACS what are we thinking?

1. Oxygen supplementation

2. Nicotine cessation (STOP SMOKING!)

What are the only two COPD treatments that reduce mortality?

88% - 92%

What is the goal O2 sat for COPD patients?

Reversal of hypoxic pulmonary vasculature!

• Can cause respiratory failure

Why is giving COPD patients more oxygen bad?

Long Acting Muscarinic Antagonist → Long Acting Beta agonist → Inhaled Corticosteroids

LAMA (Tiotropium) → LABA (Salmeterol) → ICS (albuterol)

*For asthma do the opposite!

What is the typical progression of inhaled treatments?

1. Change in sputum

2. Increasing dyspnea or SOB

What is the criteria defining COPD exacerbation?

Duoneb

• Ipratropium-albuterol (Short-acting muscarinic antagonist, and short-acting beta-agonist)

What is the nebulized treatment we often give in the hospital?

Steroid, azithromycin

What medications do you give for COPD exacerbation?

5 day

• per the REDUCE trial

How long should we give steroids for COPD exacerbation?

Decreases inflammation

Why is azithromycin useful for COPD exacerbations?

• O2 sat < 88%

  or

• PaO2 < 55

What are the indications to start O2 in COPD?

IMPENDING RESPIRATORY FAILURE!!

• You may need to intubate

*They literally have such low airflow we cant hear it anymore

An asthma/COPD patient start to look worse, but their wheezing goes away and PCO2 rises to 40 (normal)… what is going on?

BIPAP!

(Not CPAP → cpap only gives oxygen and does not ventilate)

What is a non-invasive ventilation you can use before intubation?

FEV1/FVC < 0.7

FEV1/FVC ratio that defines obstructive lung disease = ?

• Hepatic encephalopathy

• Ascities

• SBP

• Variceal bleed

• Hepatorenal syndrome

What are the complications of cirrhosis?

Decompensated cirrhosis!

If a patient presents with a complication to cirrhosis, what is this called?

• Non-adherance to meds

• Infection

• Bleed

• Hypokalemia

• Overdiuresis

What are the triggers for decompensated cirrhosis?

• Lactulose (titrated to 2-3 bowel movements/day

• Rifaximin if refractory

How do you treat hepatic encephalopathy?

• 1 = sleep disturbance

• 2-3 = confusion with asterixis

• 4 = coma

What are the stages of hepatic encephalopathy?

1. Spironolactone + Furosemide in 5:2 ratio

2. Large volume paracentesis if needed

How do you treat ascities?

Spontaneous bacterial peritonitis

Any cirrhotic patient with ascites and fever needs to be ruled out for what condition?

1. Diagnostic

2. Therapeutic

What are the two types of paracentesis?

PMNs > 250

What is the criteria for diagnosing SBP in ascites fluid?

SAAG > 1.1 - Portal hypertension!!

• Serum Ascites Albumin Gradient

How can you tell if ascites fluid is from portal hypertension or another etiology?

• Octreotide

• Ceftriaxone

• PPI

• 2 large bore IVs

• Consult GI for banding of varices

When the patient is stable you can use beta blockers for prophylaxis!

What is the treatment for variceal bleed?

TIPS!

What is the procedure that can reduce risk of variceal bleed by decreasing portal pressure?

Worsened hepatic enecephalopathy!

• The liver is not processing the ammoniu

What is the expected complication of TIPS?

FALSE!

• It is more of a marker of damage/inflammation NOT function

True or false: AST/ALT a marker of liver function

• PT/INR

• Bilirubin

• Albumin

• Platelets

What are the actual measures of liver function?

MELD - Na

• If >15 start thinking about transplant

What score is used to determine the degree of cirrhosis and need for transplant?

1. Hepatocellular → Elevated AST ALT, with minimal ALP/Bilirubin elevation

2. Cholestatic → Significantly elevated ALP bilirubin, but minimal AST/ALT elevation

What are the two patterns of liver injury

VAID

• Viral hepatitis

• Autoimmune hepatitis

• Ischemic (shock liver)

• Drug-induced

What condition can cause AST/ALT in the thousands?

Anti-smooth muscle Ab (ASMA)

What is the antibody for autoimmune hepatitis?

Anti-mitochondrial Ab (AMA)

What is the antibody for primary biliary cholangitis?

• Encephalopathy

• INR > 5

*If they meet the criteria consider a transplant

What is the criteria for acute liver failure?

• Systolic (HRrEF) → Eccentric

• HFmrEF

• Diastolic (HFpEF) → Concentric

What are the different classifications of CHF?

• HFrEF → <40%

• HFmrEF → 40%-50%

• HFpEF → > 50%

What are the ejection fraction cut offs for CHF?

• Ischemic → HTN, Smoking, obesity, DM, MI

• Non-Ischemic → Drug use, viral cardiomyopathies

What are the two broad categories of causes of systolic HF?

• Beta blockers

• ACE inhibitors

• Spironolactone

SGLT2 inhibitors, ICDs (implantable cardiac defibrilators), CRT (cardiac resynchronization therapies), and Bidil in African American populations

What treatments decrease mortality in SYSTOLIC HF?

NONE! → Treat the underlying condition

• The mcc is HTN

What treatments decrease mortality in diastolic HF?

JVD!

• In practice look at the IVC on POCUS

What physical exam maneuver has the highest sensitivity for volume overload? What about in clinical practice?

BNP!

What is the test with the highest sensitivity for CHF exacerbation?

BNP < 100

• Meaning they are probably not volume overloaded enough

What is the BNP cut-off that can rule out CHF?

because adipocytes degrade BNP

What is the reason BNP may be falsely low in obese patients?

• K > 4

• Mg > 2

*For every 10mEq given, raises their serum K by 0.1, and for every 1 g of Mg goes up by 0.1

What is the goal K and Mg in patients who are being diuresed?

2-2.5x home does

• Per DOSE trial

How much Lasix should you give for CHF exacerbation?

6 hours!

• LaSIX

How long does Lasix last?

Furosemide!

• A sulfonamide loop diuretic that blocks the Na-K- 2Cl- channel

What is the common name for Lasix? What is the MOA?

140-180 mg/dL

• Per the NICE-SUGAR trial

*Helps to prevent any hypoglycemic events from occuring

What is the goal glucose range for hospitalized diabetic patients?

Typically NONE except insulin

What outpatient diabetes medication should you continue while inpatient?

Lactic Acidosis!

What are people worried about when using metformin in patients with renal impairment?

• Fear of hypoglycemia if patients develop AKI

• Pancreas issues (GLP-1, DDP-4 → cause insulin secretion)

• Euglycemic DKA

• HF (-glitazones)

Why do we hold most outpatient ORAL diabetic medications on admission?

SGLT2 Inhibitors

What is a diabetic medication that has mortality benefit in HFrEF?

• <7%

  • <8% in elderly

What is the goal A1c in most adults?

ACCORD trial!

What landmark trial showed that strict A1C goal <6% was not better than lenient <7-8%?

No!

• It reduces microvascular complications

Does good control of blood glucose reduce macrovascular complications?

Fluids, insulin, and K+

What is the treatment for DKA?

• Urine: Ketones

• Serum: Beta-hydroxybutyrate

What can you find in urine and serum that can help diagnose DKA?

Anion gap!!

• We want to close it and make it <12

What value do you trend while treating a patient with DKA?

Duke criteria!

What criteria do we use to diagnose endocarditis?

They are “stickier” than gram negative!

• I.e. staph aureus or strep need repeat blood cultures

Why do we have to keep repeating blood cultures for gram positive organisms?

Heart rate!

What is the first vital sign to change in acute GI bleed?

Two large-bore IVs!

All patients with GI bleed need two what?

18-gauge or larger

• Smaller number is bigger (i.e. 16,14,…)

What size defines a large bore IV?

Usually no!

• It’s too long, therefore there is a lot of resistance

Can you give rapid fluid resuscitation through a central line?

Ligament of Treitz!

What is the cut-off point for upper and lower GI bleed?

• Melena

• Hematemesis

• Coffee-ground emesis

What are presenting symptoms of upper GI bleed?

Hematochezia

What are the presenting symptoms of lower GI bleed?

The passage of dark tarry stools containing blood

Define Melena

The passage of fresh bright red blood in the stool

Define Hematochezia

• DiverticulOSIS bleeds

• Diverituclitis hurts

Does diverticulosis or diverticulitis bleed?

• Colonoscopy with banding

• CT angiogram with IR embolization

What are two treatment approaches to active lower GI bleed?

HGB > 7 g/dL

• Per TRICC trial

What is the transfusion goal for hemoglobin?