INTERNAL MEDICINE REVIEW

1. INTERNAL MEDICINE REVIEW DEBORAH DAVID-ONA, MD Clinical Associate Professor Department of Medicine UPCM

2. Vaccines for Routine Use

3. Special Considerations in Vaccination

4. Sepsis and Septic Shock

5. Empiric Antimicrobial Treatment

6. Clinical Manifestations of Infective Endocarditis

7. Predictors of MDR-TB • History of treatment of TB • Treatment failure after 2 courses of the standardized regimen • Patients with cavitary and bilateral lesions on CXR • TB patients with HIV infection or AIDS

8. Steroids in Extrapulmonary TB • Miliary TB • TB pericarditis • TB Meningitis

9. Which of the following infections are associated with Streptoccocus pyogenes? • Impetigo contagiosa • Bullous impetigo ( Staph aureus) • Hot Tub Folliculitis (Pseudomonas) • None of the above Others: Erysipelas, Cellulitis associated with lymphangitis and fever

10. Common Viral Respiratory Infections • Common Cold • Rhinovirus, Coronaviruses, Adenovirus • Influenza • Influenza A and B • Croup and LRTI in children • Parainfluenza viruses • Pneumonia and Bronchiolitis in children • RSV

11. Typhoid Fever • The WBC count is normal despite high fever. • Blood cultures are positive in 90% of cases during the first week of infection. • Bone marrow cultures are 90% positive despite antibiotic treatment. • Stool cultures that are negative during the first week can become positive during the 3rd week of infection. • Culture of duodenal secretions can be positive despite a negative bone marrow culture.

12. Dengue Fever • All four types of dengue viruses have Aedes aegypti as their principal vector and all cause a similar clinical syndrome. • In Dengue fever, a macular rash is seen on the first day accompanied by adenopathy, palatal vesicles and scleral injection. • Near the time of defervescence, a maculopapular rash is seen spreading centrifugally • Macrophage- monocyte infection is central to the pathogenesis of dengue fever.

13. STD • A 21yo sexually active woman with fever, pleuritic pain of the RUQ and lower abdominal pain. • Pelvic examination reveals mucopurulent cervicitis and tenderness after production of cervical motion. The RUQ, uterine fundus and adnexae are slightly tender. • Lab exam revealed a high WBC count and elevated ESR, rest of the lab exams including liver function tests are normal. • Etiologic Agent: Neisseria Gonorrhea

14. Leptospirosis • Vasculitis is responsible for most of the manifestations of the disease. • Severe hepatocellular necrosis is NOT a feature of leptospirosis. • More than 90% of symptomatic patients have the anicteric form of the disease WITH or without meningitis. • In the leptospiremic phase, the most common finding is fever with conjunctival suffusion.

15. Malaria Diseases which confer protection against death in malaria? • Sickle cell disease • Thalassemias • G6PD deficiency

16. PTB in Pregnancy • Sputum smear + and or TB culture +, with/without CXR evidence of PTB • HIV negative, Immunocompetent • HER for at least 9 months or at least 6 months beyond sputum conversion whichever is longer

17. Large Bounding Pulse (Hyperkinetic Pulse) • Seen in cases where there is increase LV stroke volume, wide pulse pressure and decrease in PVR • Examples: complete heart block, anemia, exercise, fever, PDA, peripheral AV fistula, MR, VSD, AR

18. Jugular Venous Pressure (JVP) “a “ wave • Produced by venous distention due to right ATRIAL contraction • It is the dominant wave in the JVP, particularly during INSPIRATION. • Large a waves- TS, PS, pulmo HPN, complete heart block • Absent a wave- AF

19. Heart Murmurs • Most Murmurs decrease in length and intensity during valsalva maneuver and standing and increased with squatting and passive leg raising • Systolic murmur of HCM and MVP- INCREASE in length and intensity during valsalva maneuver and standing and decreased with squatting and passive leg raising

20. Ventricular Tachycardia • a. Procainamide • b. Bretylium tosylate • c. Epinephrine • d. Lidocaine

21. Heart Failure • increased secretion of aldosterone • Decreased effective arterial volume • increased level of plasma renin • sympathetic nervous system mediated renal vasoconstriction

22. Role of Aspirin in Acute Coronary Syndromes Aspirin has been shown to reduce the risk of myocardial infarction in all of the following groups: • patients with chronic stable angina • patients who have survived myocardial infarction • patients experiencing unstable angina • patients who had unstable angina

23. Hypertensive Emergency • A 63 year old woman with past history of hypertension, with possible encephalopathy • BP: 240/160 HR: 110, RR: 20 • Bibasilar rales • Management: administer IV nicardipine

24. Thrombolysis • Promote plasminogen to plasmin  lyses fibrin thrombi • Benefit is seen 1-6 hours after onset of infarction especially if with chest pain and ST segment elevation • Absolute Contraindications: • History of CV bleed at any time • Non hemorrhagic stroke of CV event within the past year • Marked hypertension SBP>180, DBP> 110 • Suspicion of aortic dissection • Active internal bleeding

25. Atrial Fibrillation • 52/M with significant COPD • Dyspnea and palpitations for the past hour. • Diffuse expiratory wheezing and an irregular heart rate . • ECG demonstrates rapid atrial fibrillation at HR of 170 Digoxin, Verapamil, Cardioversion

26. Atherosclerosis Pathophysiology • the fatty streak is the initial lesion of atherosclerosis • adhesion molecules such as VCAM-1 are expressed by endothelial cells as they act as receptors for circulating lymphocytes and monocytes. • cellular hallmarks of the lesions that may lead to myocardial infarction include large necrotic lipid cores, thin fibrous caps, and large numbers of macrophages • the clinical benefit of lipid lowering therapy with HMG coreductase inhibitors DOES NOT appear to stem from a significant decrease in the extent of coronary stenosis.

27. Switch therapy Criteria • Less cough and resolution of respiratory distress • Afebrile for 24 hours • Etiology is not a high risk (virulent/resistant) strain • No unstable co morbid condition or life threatening complication • No obvious reason for continued hospitalization

28. Prevention of Pneumonia • Vaccination with pneumococcal vaccine is recommended to any of the ff high risk patients: • Age > 65 yrs • Persons with increased risk of pneumococcal disease or its complication due to chronic illness such as cardiovascular disease, COPD, DM, Alcoholism and CLD • Patients with functional or anatomic asplenia • Persons living in environments in which the risk for invasive disease is high, eg nursing homes and chronic care facilities • Immunocompromised persons

29. S/Sx Fever, cough and dyspnea HR= 125 RR>35 BP: 80/60 Anti pseudomonal beta-lactams +/- aminoglycoside or Ciprofloxacin + Erythromycin IV Management of High Risk CAP c c

30. Transudative When systemic factors influence formation and absorption of pleural fluid LV failure, pulmonary embolism, cirrhosis Exudative Local Factors Pleural fluid protein/serum protein >0.5 Pleural fluid LDH/serum LDH>0.6 Pleural fluid LDH > 2/3 upper limit for serum Pleural Effusion

31. Lung Volume Measurements • Total lung capacity (TLC)- volume of gas contained in the lungs after maximum inspiration • Residual Volume (RV)- volume of gas remaining in the lungs at the end of maximal expiration • Vital capacity -TLC minus RV • FEV1 is the volume of gas exhaled during the first second of expiration • FVC- total volume exhaled

32. Asthma • Hypoxia is a finding in acute exacerbations and frank ventilatory failure in 10-15% of patients only • The presence of a normal pCO2 is associated with quite severe levels of obstruction. • Cyanosis is a LATE sign in patients with asthma. • The END of an asthmatic episode is frequently marked by a cough that produces mucus with Curschmann’s spirals. • The sine qua non for the symptoms of asthma is the triad of DYSPNEA, cough and wheezing.

33. INCITING STIMULI IN ASTHMA • Allergic asthma is dependent on an IgE response controlled by T AND B lymphocytes and activated by the interaction of antigen with mast cell bound IgE molecules. • Allergic asthma is frequently seasonal and most observed in children and young adults. • Drug induced asthma should be recognized immediately as is it associated with great morbidity. • Respiratory infections are the most common of the stimuli that evoke exacerbations of asthma. • Inhalation of warm air produces a more severe attack of asthma than cold air.

34. PNEUMOTHORAX • Primary spontaneous pneumothorax occurs in the ABsence of underlying lung disease. • Primary spontaneous pneumothorax occur almost exclusively in smokers. • Secondary spontaneous pneumothorax should be treated with tube thoracostomy and instillation of a sclerosing agent • Traumatic pneumothorax occurs exclusively in patients with penetrating AND non-penetrating chest injuries.

35. COPD • Proven risk factors: cigarette and tobacco smoking • Smoking cessation and oxygen influence the natural course of COPD

36. Community Acquired Pneumonia • CXR which is NOT 100% sensitive is a standard for diagnosis of CAP • All HOSPITALIZED patients with CAP require 2 sets of blood culture before initiation of antibiotic therapy • >25 WBCs and <10 squamous epithelial cells per LOW power field makes a sputum specimen suitable for culture • When Legionella spp is isolated in culture, it is always considered a pathogen.

37. 65/M with cramping LLQ pain. PE showed low grade fever, midabdominal distention and LLQ tenderness. CBC showed: leukocytosis with shift to the left. Incidence: M>F Left colon>right colon Features: fever, LLQ pain, signs of peritoneal irritation Labs: increase PMNs and WBC Treatment: Bowel rest, IV fluids, Antibiotics, Surgery if with complications Acute Diverticulitis

38. 60/M with diffusely painful abdomen. No BM or flatus for the past 3 days. Plain abdominal upright x-ray reveals marked distention of bowel loops, air fluid levels and absence of rectal gas. Complete obstruction- absence of gas in rectum Treatment: NGT, fluid and electrolyte balance Surgery Antibiotics only with strangulation Intestinal Obstruction

39. Acute Appendicitis • The diagnosis can be established, when tenderness is elicited. • Flexing the right hip and abdominal guarding in appendicitis is due to PARIETAL peritoneal involvement. • A (+) psoas sign is an early sign of RARE diagnostic value. • Urinary frequency and dysuria may occur if the appendix lies adjacent to the urinary bladder.

40. Acute Appendicitis • Laboratory examination will not establish the diagnosis because diagnosis is based on clinical grounds. • Plain abdominal film is rarely of value • The absence of leukocytosis DOES not rule out appendicitis.

41. Upper GI Bleeding • About half of cases are due to peptic ulcer disease- 35-62% • Majority of cases of obscure GI bleeding are from the small intestines. (Vascular ectasias and tumors) • Hemorrhagic erosive gastropathy rarely present as massive bleeding, lesions are mucosal only

42. Hepatitis B • Persistence of HBeAg in the serum beyond the first 3 months of acute infection may be predictive of the development of chronic infection. • During the gap or window period, only anti-Hbc IgM is detectable in serum. • Anti-HBc of the IgM class predominates during the first 6 months after acute infection.

43. Hepatitis B Transmission • The likelihood of perinatal transmission of HBV correlates with the presence of HBeAg. • The saliva of hepatitis B patients is NOT infectious. • Most of the hepatitis transmitted by blood transmission is caused by HBC • Sexually promiscuous persons have high rates of HBV infection.

44. Chronic Hepatitis Features that increase risk for chronic hepatitis: • Presence of bridging or multilobular hepatic necrosis on liver biopsy • Persistence of hepatomegaly • Lack of complete resolution of anorexia, weight loss and fatigue.

45. Portal Circulatory Obstruction • Pre-Sinusoidal • schistosomiasis • Sinusoidal • cirrhosis • Post-sinusoidal • Budd-Chiari, Inferior Venal caval obstruction

46. Hepatic Encephalopathy

47. Hepatic Encephalopathy Management • Lactulose should be given for acute encephalopathy 30-80 ml every hour until diarrhea occurs. • Neomycin used to decrease ammonia production in the gut may reach sufficient concentrations in the bloodstream to cause renal toxicity. • Metronidazole and Neomycin have comparable benefits.

48. 35/M with nausea and vomiting,middepigastric pain with radiation to the back after eating a large meal. PE shows low grade fever, epigastric tenderness and decreased bowel sounds. An abdominal film shows localized dilatation of the upper duodenum Laboratory: serum lipase Management: Bowel rest Fluid and electrolyte replacement Surgical debridement (necrosectomy) should be undertaken in the presence of infected necrosis Anticholinergic drugs have no proven benefit. Acute Pancreatitis

49. Allergic Rhinitis Which of the following medications for allergic rhinitis is associated with rebound rhinitis? • Oximetazoline • Fexofenadine • Cromolyn sodium • Fluticasone • Mometasone

50. Toxic Epidermal Necrolysis • also known as Lyell's syndrome, is a life-threatening dermatological condition that is frequently induced by a reaction to medications. • It is characterized by the detachment of the epidermis from the dermis all over the body. • Diagnosis: skin lesion covers > 30% of the body surface area