internal medicine pearls
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. What would you like to do?
What commonly exacerbates psoriasis?
- Strep infection
- skin injury (e.g. (sun)burn, drug rxn)
What are common presentations of lichen planus?
- 5 P's:
What condition is associated with heavy alcohol consumption, hepatitis C, and iron overload?
porphyria cutanea tarda
What are clinical features of porphyria cutanea tarda?
- facial hirsutism
- tense bullae (especially on hands)
- heavy alcohol consumption
- hepatitis C
- iron overload
What is the primary presentation of pemphigus vulgaris?
- mouth ulcers/lesions
- high fatality rate if not treated
If a patient presents with chronic mouth ulcers/lesions, what test would diagnose pemphigus vulgaris?
immunofluorescent studies of perilesional skin
What conditions are associated with ertyhema nodosum?
- inflammatory bowel disease (esp. Crohn's)
- strep infection
- drugs (esp OCP)
What are some adverse clinical conditions associated with OCP use?
- erythema nodosum
- (+ smoking or factor V mutation) DVT, VTE
If a patient develops DVT/VTE soon after starting OCP, what condition should be investigated?
factor V leiden mutation (i.e. APC resistance)
What conditions are associated with this skin lesion?
- skin lesions = erythema multiforme
- associated with:
- drugs (esp. PCN, sulfa, phenytoin)
What conditions are associated with this skin finding?
- skin finding = acanthosis nigricans
- associated with:
- insulin resistance
- occasionally malignancy (60% gastric)
What LFT changes do you expect with alcoholic hepatitis?
- AST levels <300
- trivial ALT elevation
- AST/ALT ratio >3
What are some common features to hemochromatosis and alcohol liver disease?
- glucose intolerance
- testicular atrophy
What are clinical features of nonalcoholic steatohepatitis?
- elevated transaminases (usually AST>>ALT)
- esp. middle-aged women with obesity, diabetes, and HTN
What are common causes of acute liver failure?
- #1: drugs (esp. acetaminophen)
- viral hepatitis
Who is usually affected by autoimmune hepatitis? What tests will confirm diagnosis?
- usually women
- antinuclear antibodies
- anti-smooth muscle antibodies
What are key clinical features of Wilson's disease?
- rare autosomal recessive
- hepatitis (fulminant, chronic)
- neurologic symptoms
- hemolytic anemia
- Kayser-Fleischer rings around iris
What drugs are associated with cholestasis?
What condition is associated with ulcerative colitis, whether or not they underwent colectomy?
primary sclerosing cholangitis
What is the initial therapy for acute variceal bleeding?
- sclerotherapy: successful 75-90%, serious complications
- variceal band ligation: as effective as sclerotherapy with fewer complications
If a patient has EGD confirmed varicosities, what medication should they be put on?
What is the initial therapy for most spontaneous bacterial peritonitis?
- 5d course of 3rd generation cephalosporin
- (usually caused by gram neg. rod bacteria)
What GI regions are commonly affected by Crohn's disease?
- terminal ileum
- cecal region
What are common extraintestinal manifestations of Crohn's disease?
- erythema nodosum
- pyoderma gangrenosum
A patient presents with malabsorptive diarrhea. What conditions would make you suspect small bowel bacterial overgrowth?
- high dose PPI's
- postoperative (Billroth 2)
- radiation enteropathy
A patient presents with malabsorptive diarrhea. What conditions would make you suspect Whipple's disease (i.e. Tropheryma whipplei infection)?
- clubbing CNS involvement
What clinical conditions are associated with celiac sprue?
- dermatitis herpetiformis
- small bowel lymphoma
- selective IgA deficiency
- (isolated ALT elevation)
What blood tests are used to confirm celiac sprue?
- IgA endomysial antibody
- IgA tissue trans glutamine antibody
A middle aged woman presents with chronic watery diarrhea. She denies recent weight loss or abdominal pain. What condition do you suspect? How would you treat her?
- microscopic (collaginous) colitis
- tx: bismuth
A patient presents with malabsorptive diarrhea. What findings would make you suspect pancreatic insufficiency?
- greater amount of stool fat
- normal small bowel absorption tests (D-xylose, Hydrogen breath tests)
What are the most common causes of acute pancreatitis?
- 60% of causes =
- alcohol consumption
What 2 types of infectious colitis are known to mimic ulcerative colitis?
What is the occurrence rate of pseudocysts with acute pancreatitis? When would you surgically drain them and why?
- occurrence rate = 20% of severe pancreatitis
- drain cysts >6cm
- risk of perforation, infection, hemorrhage
- also drain if pseudocysts do no resolve
What is the preferred imaging test to diagnose chronic pancreatitis?
- diffuse calcifications
- most sensitive test = ERCP
How do patients with ALS initially present?
- asymmetric weakness
- bulbar or limb presentation
What heart finding is associated with a patient who presents with stroke with a hx of DVT?
patent foramen ovale
H. pylori is associated more with duodenal or gastric ulcers?
- duodenal ulcers (80-95%)
- gastric ulcers (60-90%)
Should clopidogrel be used with aspirin for stroke prevention?
- no: aspirin + clopidogrel does not decrease stroke risk
- (it does increase bleeding risk)
Which patients should receive carotid endarterectomy?
- symptomatic patients with >70% stenosis
- asymptomatic patients with >80% stenosis
- should be done ASAP post-TIA
- + low surgical risk and good 5yr survival
Do statins reduce stroke risk?
yes: reduce stroke risk by 20-30%
What are common causes of hypokalemia?
- renal artery stenosis
What condition would you suspect in a patient with hypertension and orthostatic hypotension?
What symptoms are associated with pheochromocytoma?
- think H's:
- hypotension (orthostatic)
What condition would you suspect in a patient with hypertension and hypokalemia?
(renal artery stenosis, alcoholism)
Why are nephrotic patients at increased risk for infections? What other conditions are they at risk for?
- urinary loss of IgG and complement
- also at risk for thrombosis: urinary loss of anti-thrombin III, increase in coagulation factors
What are prominent clinical features of renal vein thrombosis?
- flank pain
- enlarged kidney (ultrasound)
What conditions are associated with adult onset minimal change disease?
- NSAID use
- Hodgkin's disease
What condition is associated with young male smokers with a history of hydrocarbon exposure?
What is the most common cause of nephritis worldwide? How does this condition present?
- IgA nephropathy:
- micro/macroscopic hematuria
- usually presents <48hrs post-URI
What imaging tests should be avoided in patients with chronic renal insufficiency? Why?
- gadolinium-contrast imaging (some MRI's):
- risk of nephrogenic fibrosing dermopathy
What are clinical findings with atheroembolic renal disease?
- livedo reticularis
- purple toes
- progressive renal dysfunction
- eosinophilia: peripheral >> urinary
What procedures carry a risk of developing atheroembolic renal disease?
- aortic surgery
- initiation of anticoagulation
What condition would you investigate in a patient who presents with acute renal failure and thrombocytopenia?
- microscopic angiopathy:
Which patients with thrombotic microangiopathy do you definitely plasmaphorese?
- antiphospholipid antibody syndrome
- complement disorders
What commonly causes acute interstitial nephritis?
- beta lactams (esp. PCN)
A patient presents with ARF. What findings would make you suspect ethylene glycol toxication?
- oxalate crystals in urine
- anion gap acidosis
- osmolar gap
What are the clinical features of SLE?
- "SOAP BRAIN MD":
- Serositis (lung or heart)
- Oral ulcers
- Blood (Coombs+ hemolytic anemia, leukopenia)
- Renal (casts or proteinuria)
- Immune abnml. (FP, VDRL, anti-DNA, anti-sm)
- Neurologic abnml. (seizures, psychosis)
- Malar rash
- Discoid rash
(+/- alopecia, Raynaud's)
What drugs are associated with lupus-like syndromes?
What would you like to do?
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