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General Internal Medicine


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Major causes of pancreatitis
80% due to alcohol or gallstone
Other causes: hypertriglyceridemia, viral infections, trauma, and medications
Viral infections that cause pancreatitis
mumps, coxsackie virus
Medications that cause pancreatitis
steroids, azathioprine
Clinical presentation of pancreatitis
Abdominal pain radiating to the back
N/V that does not relieve the pain
elevated amylase/lipase
Dz other than pancreatitis that causes increase amylase and lipase
Perforated peptic ulcer disease - look for free air on abdominal x-ray and hx of PUD
Treatment of acute pancreatitis
NPO, NG tube, IV fluids, narcotics (meperidine, NOT morphine)
Treatment of chronic pancreatitis
Alcohol abstinence
oral pancreatic enzyme replacement
fat-soluble vitamin supplements
Grey-Turner's sign
a complication of severe pancreatitis
appearance: blue/black flanks
due to hemorrhagic exduate
Cullen's sign
a complication of severe pancreatitis
appearance: blue/black umbilicus
due to hemorrhagic exduate
Complications of pancreatitis
pseudocyst (drain surgically if chronic and symptomatic)
abscess/infection (abx and sx abscess drainage)
diabetes (with chronic pancreatitis)
When should you start screening for HTN?
Every 2 years, starting at the age of 3.
Cut-off value for HTN
140/90 mmHg
Diagnosis of HTN
3 separate measurements on 3 separate occasions with BP > 140/90
Exceptions of 3 measurement rule for dx HTN
1. pregnant woman, when waiting for a return visit could be devastating

2. severe HTN: >210 systolic, >120 diastolic, or end-organ effects

Immediate txt is necessary.
First step in management of HTN
Lifestyle modifications (low salt, low cholesterol, stop smoking, exercise, weight reduction)
Second step in management of HTN
Txt of HTN in pregnant pts
Hydralazine, labetaol, or alpha-methyldopa

Mg sulfate in pts with preeclampsia
HTN urgency/emergency
occurs when BP > 200/120 with (emergency) or without (urgency) acute end-organ damage
Txt of HTN urgency/emergency
Nitropusside, NTG, or beta blocker
MCC of secondary HTN in young women
1. birth control pills
2. renovascular HTN due to fibrous dysplasia
MCC of secondary HTN in young men
1. EtOH
2. Exotic conditions (pheochromocytoma, Cushing's, Conn's, polycystic kidney disease)
MCC of secondary HTN in elderly with new onset HTN
renovascular HTN due to atherosclerosis
Most important risk factor for stroke
MCC of death in untreated HTN
coronary disease
Effects of nitroprusside and NTG
Nitroprusside dilastes both arteries and veins

NTG dilates only veins
Who should you screen for diabetes?
Not everyone
only pts with FHx, obese, >45 y.o., or members of at risk ethnicity (Black, American Indian, Hispanic)
polydipsia, polyuria, polyphagia, weight loss
Classic symptoms of DM
Dx of DM
1a. Two fasting BS >/= 126
1b. One is enough if pt symptomatic
2. Random BS >/= 200
3. Glc tolerance test (BS >/= 200 2 hrs after 75 gm-glucose load)
Goal of DM treatment
postprandial BS < 200
FBS < 130

Too strict of control can incr risk of hypoglycemia.
C-peptide:insulin ratio less than 1:1 (e.g. 1:2, 1:3)
i.e. low C-peptide
Exogenous insulin injection
Use of IV contrast in DM pt
Avoid bc contrast can precipitate acute renal failure. If necessay, make sure pt is well-hydrated first.
1. hyperglycemia
2. hyperketonemia
3. metabolic acidosis
Txt of DKA
IV Fluids, IV regular insulin, electrolyte replacement (K+ and Phos)

Use bicarb only if pH < 7
1. hyperglycemia
2. hyperosmolarity
No hyperketonemia
Nonketotic hyperglycemic hyperosmoar state
Txt of nonketotic hyperglycemic hyperosmolar state
IV fluids, IV insulin, electrolyte replacement
Long term complications of DM
Microvascular (retinopathy, nephropathy, neuropathy)

Macrovascular (CAD, PAD, CVA)

Immunosuppression (caused by hyperglycemia)
Prevention of nephropathy in DM
MCC of nontraumatic amputations in U.S.
Examples of peripheral neuropathy in DM
gastroparesis, Charcot joint
CN palsies (usually 3,4,6 - ocular palsies)
orthostatic hypotension, "silent" MI
Txt of gastroparesis in DM
metoclopromide (antiemetic)
Regular vs NPH insulin
onset = 45 min
peak = 3-4 hrs
duration = 4-8 hrs

onset = 1-1.5 hrs
peak = 6-8 hrs
duration = 18-20 hrs
Somogyi effect and txt
Rebound Hyperglycemia
Too much NPH at dinner leads to low 3am BS --> rebound hyperglycemia

Txt by decr dinner NPH
Dawn effect and txt
Primary Hyperglycemia
Too little NPH at dinner leads to normal/high 4am BS --> hyperglycemia

Txt by incr dinner NPH
Use of beta blockers in DM
Caution bc it may block s/s of hypoglycemia; weigh risk to benefits
Normal cholesterol level
< 200 mg/dL
Normal triglyceride level
< 150 mg/dL
xanthelasma, corneal arcus, lipemic-looking serum, obesity
s/s of familial hypercholesterolemia
risk factors for coronary heart disease
Age (men > 45, women > 55)
FHx of premature coronary heart disease
Curent cigarette smoking (>10/day)
Low HDL (<40)
First step in management of hypercholesterol
lifestyle modifications (diet, exercise, smoking)
Factors that can increase HDL
exercise, estrogens, moderate alcohol intake (1-2 per day)
First line drug txt for hypercholesterol
Bile acid-binding resins (Cholestyramine)
HMG-CoA reductase inhibitors (Statins)
Smoking increases the risk of what cancers?
Lung, oral cavity, esophagus, larynx, pharynx, bladder, kidney, pancreas, and cervix
MCC of emphysema in and adult
MCC of emphysema in young, nonsmoker
alpha 1 antitrypsin deficiency
Effects of 2nd hand smoke in child
upper respiratory infection, otitis media, asthma
Bueger's disease
Raynaud's symptoms in young male smoker
Effects of smoking on fetus
low birth weight, prematurity, spontaneous abortion, sillbirth, infant mortality
Birth control pills and smoking?
NEVER! - increases risk of blood clots
MCC of cirrhosis and esophagel varices
alcohol abuse
ophthalmoplegia, nystagmus, ataxia, confusion; condition is acute and reversible
Wernicke's encephalopathy
anterograde amnesia, confabulation; condition is chornic and irreversible
Korsakoff's encephalopathy
Txt of Wernicke's and Korsakoff's encephalopathy
Thiamine replacement
Pathophysiology of Wernicke's and Korsakoff's encephalopathy
damage to mamillary bodies and thalamic nuclei
Stages of alcohol withdrawal
1. acute (12-48 hrs after): tremors, sweating, hyperreflexia, seizures
2. alcoholic hallucinosis: A/V hallucinations and illusions without autonomic symptoms
3. delerium tremens (2-4 days after): hallucinations, illusions, confusion, poor sleep, autonomic lability (sweating, incr temp and pulse); fatal
Best txt for alcohol abuse
Alcoholics Anonymous
Mental retardation, microcephaly, microphthalmia, short palpebral fissures, midfacial hypoplasia, cardiac defects
Fetal Alcohol Syndrome
MCC of aspiration pneumonia in alcoholics
Klebsiella (currant-jelly sputum)
Alcohol and blood sugar
Alcohol causes hypoglycemia
First step in management of alochol induced hypoglycemia
Thiamine. Glucose may precipitate Wernicke's encephalopathy.

Second step is glucose.
Common causes of SIADH
small cell lung cancer
head trauma/surgery, meningitis
pulmonary infections
opioids or chlorpropamide
Txt of SIADH
Water restriction
For refractory cases: demeclocycline (a tetracycline that causes renal diabetes insipidus)
K+ and Na+ levels in Addison's dz
Hypoaldosteronism -->
hyponatremia + hyperkalemia
Txt of hypovolemic hyponatremia
Normal saline
Txt of euvolemic/hypervolemic hyponatremia
Free water restriction
possibly diuretics for hypervolemia
Effect of rapid correction of hyponatremia
Brain stem damage (central pontine myelinolysis)
Effect of hyperglycemia on Na+
for glucose > 200:
Na+ decreases by 1.6 for each increase of 100 in glucose
MCC of hponatremia in surgical pt
excessive fluid administration
Oxytocin and Na+
Oxytocin has ADH-like effects --> hyponatremia in pregnant women, especilly if exogenously given oxytocin
Txt of hypernatremia
Water replacement with normal saline initially, then switch to 1/2 normal saline.
Pituitary vs nephrogenic DI
Pituitary DI repsonds to vasopressin; nephrogenic DI does not
Causes of Pituitary DI
tumor, trauma, sarcoidosis
Causes of Nephrogenic DI
meidcations (lithium, demeclocycline, methoxyflurane, amphotericin B)
Txt of Nephrogenic DI
Thiazide diurectics (paradoxical effect)
S/S of hyper- and hyponatremia
Similar for both: confusion, mental status changes, hyperreflexia, seizure, coma
S/S of hypokalemia
*muscular weakness*
both skeletal and smooth muscle
--> ileus, hypotension, respiratory paralysis
EKG findings of hypokalemia
loss of T wave, presence of U waves, PAC/PVC, tachyarrhythmias
Relationship between K+ and pH
alkalosis causes hypokalemia
acidosis causes hyperkalemia
Relationship between K+ and digitalis effects
hypokalemia --> digitalis toxicity
Txt of hypokalemia in presence of hypomagnesemia
HypoK+ will be difficult to tx unless you also correct hypoMg2+
MCC of hyperkalemia lab result in asymptomatic pt with normal EKG
hemolysis of the specimen (non-pathologic hyperkalemia)
Repeat the test.
S/S of hyperkalemia
*EKG changes*
muscle weakness and paralysis
EKG changes of hyperkalemia
(in order of incr K+)
1. peaked T waves
2. widening of QRS
3. incr PR interval
4. loss of P waves
5. sine wave
6. Asystole and V-fib
Common causes of pathologic hyperkalemia
*Renal failure*
Severe tissue destruction
Adrenal insufficiency
Medications (K+ sparing diuretics, beta blockers, NSAID, ACEI)
Txt of hyperkalemia with cardiac toxicity
1. calcium gluconate (will not correct K+, but is cardioprotective)
2. sodium bicarbonate (causes alkalosis)
3. glucose and insulin (insulin shifts K+ into cells)
4. If refractory: dialysis
Sign of hypocalcemia
Neurologic: tetany
Chovstek's sign
Sign of hypocalcemia - tapping on the facial nerve causes the facial muscles to twitch
Trousseau's sign
Sign of hypocalcemia - applying a tourniquet or blood pressure cuff around the arm causes hand muscle (carpopedal) spasms
EKG sign of hypocalcemia
increased QT interval
MCC of hypocalcemia
*non-pathologic: hypoalbuminemia*
*pathologic: hypomagnesemia*
Others: DiGeorge's syndrome, renal failure, hypoparathyroidism, Vit D deficiency, pseudohypoparathyroidism, acute pancreatitis, loop diuretics
Ricket's vs osteomalacia
Skeletal effects of Vit D deficiency in children (rickets) and adults (osteomalacia)
pH and calcium
Alkalosis may cause symptoms of hypocalcemia due to effects of ionized fraction of calcium.
Phosphorus and Calcium
Phosphorus and calcium levels are usually in opposite directions
Symptoms of Hypercalcemia
Bones, stones, abdomenal groans, psychiatric overtones, thrones, hypertones
EKG sign of hypercalcemia
shortened QT interval
MCC of hypercalcemia in hospitalized pts
Other common causes of hypercalcemia:
HyperPTH, Vit A or D intoxication, Sarcoidosis, Thiazide diuretics, immobilization
Txt of hypercalcemia
loop diuretic
phosphorus administration
calcitoni, disphosphonates, prednisone
Most common pt to present with Hypomagnesemia
S/S of hypomagnesemia
similar to hypocalcemia
MCC of hypermagnesemia
Renal failure

Iatrogenic (e.g. in txt of preeclampsia in pregnancy)
Txt of hypermagnesemia
Stop Mg sulfate (if taking)
supportive txt
IV hydration
Most common pts that develop hypophosphatemia
DKA and alcoholics
S/S of hypophosphatemia
neuromuscular dysfunction (encephalopathy, weakness)
rhabdomyolysis (esp in alcoholics)
anemia with WBC and platelet dysfunction
Most common pts that develop hyperphosphatemia
Pts with renal failure
Txt of hyperphosphatemia
Phosphate restriction
phosphate-binding resins (calcium carbonate)
Maintenence fluid in NPO pts and pediatric pts
NPO pts: D5 1/2 NS
peds pts: D5 1/4 or 1/3 NS
MCC of deficiency of Vitamins A, D, E, and K
Most common vitamin deficiency in alcoholic
MCC of Vit B12 deficiency
Pernicious Anemia
Vitamin deficiency seen after ileum resection
Vit B12
Vitamin deficiency seen in Diphyllobothrium latum infection
Vit B12
Vitamin deficiency in pts taking isonizid
Vit B6 (pyridoxine)
Vitamin deficiency in pts taking anticonvulsants, e.g. phenytoin
Craniotabes, rachitic rosary, delayed fontonelle closure, bossing of the skull, kyphoscoliosis, bowlegs, knock-knees
Physical findings of Rickets
Vitamin giving to all newborns as prophylaxis against hemorrhagic dz
Vit K
Vit K is required for synthesis of which clotting factors?
Factors II, VII, IX, X, protein C, and protein S
Nightblindness, scaly rash, xerophthalmia (dry eyes)
Vit A deficiency
Pseudotumor cerebri, bone thickening, teratogenicity
Vit A toxicity
Rickets, osteomalacia, hypocalcemia
Vit D deficiency
Hyercalcemia, nausea and vomitting, renal effects
Vit D toxicity
Anemia, peripheral neuopathy, ataxia
Vit E deficiency
Necrotizing enterocolitis in infants
Vit E toxicity
Hemorrhage, prolonged PT
Vit K deficiency
Hemolysis, kernicterus
Vit K toxicity
Wet beriberi (high-out put cardiac failure), dry beriberi (peripheral neuropathy), Wernicke and Korsakoff syndrome
Thiamine (B1) deficiency
cheilosis, angular stomatitis, dermatitis
Vit B2 (riboflavin) deficiency
Pellagra (Dementia, Dermatitis, Diarrhea), stomatitis
Niacin (B3) deficiency
Peripheral neuropathy, cheilosis, stomatitis, convulsions in infants, microcytic anemia, seborrheic dermatitis
Pyridoxine (B6) deficiency
Peripheral neuropathy
Pyridoxine (B6) toxicity
Megaloblastic anemia, neurologic symptoms
Cobalamin (B12) deficiency
Megaloblastic anemia without neurologic symptoms
Folic acid deficiency
Hemorrhages, bleeding gums, loose teeth, gigivitis, poor wound healing, hyperkeratotic hair follicles, bone pain
Vit C deficiency (Scurvy)
Microcytic anemia, koilonychia (spoon-shaped fingernails)
Iron deficiency
Iron toxicity
goiter, cretinism, hypothyroidism
Iodine deficiency
Iodine toxicity
Dental caries
Fluorine deficiency
Fluorosis with mottling of teeth and bone exostoses
Fluorine toxicity
Hypogeusia (decreased taste), rash, slow wound healing
Zine deficiency
Menke's disease (X-linked, kinky hair, mental retardation)
Copper defiency
Cause of Wilson's disease
Copper toxicity
Cardiomyopathy and muscle pain
Selenium deficiency
loss of hair and nails
Selenium toxicity
"Manganese madness" in minors of ore
Maganese toxicity
Impaired glucose tolerance
Chromium deficiency
Four clinical types of shock
First step in management of shock of any cause
IV fluids
High CO
High SVO2
Septic (early) shock
Low CO
High SVR
Low SVO2
Hypovolemic (or late septic) shock
Low CO
High SVR
Low SVO2
Cardiogenic shock
Low CO
Low SVO2
Neurogenic shock
Virchow's triad
Endothelial damage
Hypercoagulable state
Woman of reproductive age using tampons in place too long
Toxic shock syndrome(Staph aureus)
What is considered a positive family history of premature coronary heart disease?
Definite MI or sudden death in:
first-degree male relative <55 y.o. OR
first-degree female relative <65 y.o.

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