ICM 5 Study Notes
In ICM 5, we learn to apply everything we’ve learned in basic sciences to real life clinical situations, to evaluate possible diagnosis, what labs to order, and how to follow up.
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- Respiratory rate (Adult) — 12 – 20 breaths/min
- Heart Rate (Adult) — 60 – 80 bpm
- BP — 120/80
- T — 98.6 F
- BMI — 18.5 – 24.9 normal. 25 – 29.9 overweight. >30 obese. <18.4 underweight.
COMPLETE BLOOD COUNT
- RBC — Females: 3.5 – 5.5 million/mm3. Males: 4.3-5.9 million/mm3.
- WBC – 4500 – 11,000/mm3
- Hb — Females: 12 -16g/dL. Males: 13.5 – 17.5 g/dL.
- Hct — Females: 36 – 46%. Males: 41 – 53%.
- MCV — 80 – 100 um3
- MCH — 25.4 – 34.6 pg/cell
- MCHC — 31 – 36%
- Platelet — 150,000 – 400,000/mm3
- Reticulocyte count – 0.5 – 1.5%
- Segmented Neutrophils – 54 – 62%
- Band Neutrophils – 3 – 5%
- Eosinophils — 1 – 3%
- Lymphocytes — 25 – 33%
- Monocytes — 3 – 7%
- Na – 135 – 147 meq/L
- K — 3.5 – 5.0 meq/L
- Cl — 95 – 105 meq/L
- Bicarbonate – 22 – 28 meq/L
- BUN – 7 – 18 mg/dl
- Creatinine — 0.6 – 1.2 mg/dL
- Glucose — Fasting: 70 – 110 mg/dL. 2-hr Postprandial: <120
- Calcium — 8.4 – 10.2 mmol/L
LIVER FUNCTION TEST
- Aspartate Aminotransferase (AST) – 8 – 20 U/L
- Alanine Aminotransferase (ALT) – 8 – 20 U/L
- Lactate Dehydrogenase (LDH) — 45 – 90 U/L
- Bilirubin Total/Direct — 0.1 – 1 / 0.0 – 0.3 mg/dL
- Alkaline Phosphatase (ALP) – 20 – 70 U/L
AMYLASE AND LIPASE TEST
- Amylase – 25 – 125 U/L
- Lipase – <95 U/L
- Prothrombin Time (PT) — 11 – 15 seconds
- Triglyceride — 35 – 160 mg/dL
Q: Patient comes in with abdominal pain. What 10 things should be on your differential diagnosis?
A: Gastroenteritis, Appendicitis, Biliary Colic, Cholecystitis, Pancreatitis, Diverticulitis, Small bowel obstruction, Perforated peptic ulcer, Mesenteric ischemia, Ruptured abdominal aortic aneurysm.
Q: What are the three types of abdominal pain?
A: Visceral, Somatoparietal, adn Referred abdominal pain.
Q: What type of abdominal pain feels dull and poorly localized and the pain does not get relieved by changing position?
A: Visceral pain.
Q: What type of pain develops when there is peritoneal wall irritation, like from inflammed viscera?
A: Somatoparietal pain.
Q: What type of pain is more localized and sharper and can be relieved from certain positions (and hence the patient will remain motionless in the position that feels better)?
A: Somatoparietal pain.
Q: What type of pain is the result of the convergence of vesceral afferent and somatic neurons from different locations?
A: Referred pain.
Q: If patient has mild to moderate generalized abdominal pain that gets worse over days, along with nausea, fever, diarrhea, or vomiting unrelated to meals, AND RESOLVES SPONTANEOUSLY, what could it be?
Q: What is the most common cause of gastroenteritis?
Q: What is guarding a sign of?
A: Guarding (which is when patients tense their abdominal muscles to “guard” their inflammed organs when the doctor presses on the abdomen during physcial exam) is a sign that the abdominal organs are inflammed.
Q: What is rebound tenderness a sign of?
A: Rebound tenderness (which is when the patient feels pain during REMOVAL of pressure from the abdomen during physical exam) is a sign that the peritoneum (abdominal walls, vs the organs) are inflammed.
Q: If a person has lower blood pressure when they stand up, what do you think of?
A: Think about orthostatic hypotension, like due to hypovolemia or dehydration.
Q: If a person has vague periumbilical pain that gets worse over 6-10 hours to a more localized pain in the right lower quadrant, along with fever, what do you think of?
Q: If a person with appendicitis has involuntary guarding and rebound pain, what do you think of?
A: These suggest perforation.
Q: What’s the difference between biliary colic and cholecystitis?
A: They are both obstruction of the cystic duct by calculi (gall stones), but biliary colic is an intermittent obstruction that can move around whereas a cholecystitis is a persistent obstruction that is truly stuck there. Biliary colic can lead to cholecystitis.
Q: If a person has a dull pain on the right upper quadrant that lasts for 6-8 hours after eating a fatty meal, but goes away, BUT COMES BACK AND GOES AWAY FOR THE NEXT FEW DAYS OR WEEKS, what is it?
A: Biliary colic. But if it lasts longer than 6-8 hours, it is probably cholecystitis
Q: Where does the pain in cholecystitis often radiate to?
A: It starts in the right upper quadrant or epigastric area, and can radiate to the right scapular region.
Q: If a person has vague epigastric pain that becomes localized, unrelenting over hours and days and radiates to the back, and have fever and vomiting, what can they have?
Q: What does it mean when a person has periumbilical or flank ecchymoses along with their epigastric pain that radiates to the back?
A: periumbilical ecchymoses (Cullen’s sign) or flank ecchymoses (Grey-Turner’s sign) are signs of intra-abdominal bleeding into the pancreatic bed (retroperitoneal hemorrhage). By this point, the patient has a high risk of death.
Q: If an elderly patient has a vague lower-mid-abdominal pain that progresses over hours or days to the left lower quadrant, and have tenderness, guarding, and possibly palpable mass, what could they have?
Q: If a patient has abdominal pain or cramps and has a history or abdominal surgery or appendectomy, what should you think of?
A: Small bowel obstruction, as a result of intra-abdominal adhesions from the surgery.
Q: What do people with bowel obstructions sometimes vomit?
A: fecal-like or bile-like vomit
Q: If a person has severe epigastric pain and has involuntary guarding, rebound tenderness, with hypotension and tachycardia, what do you think of?
A: First, the hypotension and tachycardia may suggest hypovolemia, like from loss of blood. The rebound tenderness suggest peritonitis, like from gastric or intestinal contents spilling out of perforated peptic ulcer.
Q: Where do perforated peptic ulcers most commonly occur?
A: Proximal duodenum.
Q: If a person has vague epigastric or periumbilical pain that worsens with meals and the patient also has circulation problems, cardiac arrythmias, peripheral vascular disease, or ischemia, what could it be?
A: Mesenteric ischemia, due to decreased intestinal blood circulation. Sometimes you can also see GI bleeding, like blood in feces.
Q: If a person has acute mid-abdominal pain that feels like “tearing” and has hypotension, tachycardia, low pulse, or skin mottling, what could it be?
A: The “tearing” pain is typical of abdominal aortic rupture. The hypotension, tachycardia, low pulse, and skin mottling further shows the patient is losing a lot of blood volume from the rupture.
Q: What are some non-abdominal causes of abdominal pain that you should also consider in your differential diagnosis?
Cardiac: Myocardial ischemia, myocarditis, endocarditis
Thoracic: Esophagitis, Esophageal spasm, Esophageal rupture, Pneumonia, Pneumothorax, Pulmonary Embolism
Hematologic: Sickle Cell Anemia, Acute Leukemia
Infections: Herpes, Osteomyelitis
Neurologic: Radiculitis, Tabes dorsalis
Miscellaneous: Muscular contusion, Porphyria, Psychiatric
Q: Whenever you see hypotension and tachycardia, what test should you order?
A: You think of hypovolemia, like that due to blood loss, and therefore you should order a complete blood count (CBC).
Q: What 8 things do you count in a Complete Blood Count (and don’t say “blood”)?
A: 1. Total Red Blood Cell
2. Hemoglobin (Hb),
4. Mean Corpuscular Volume (MCV, average volume of RBC),
5. Mean Corpuscular Hemoglobin (MCH, amount of Hb per RBC),
6. Mean Corpuscular Hemoglobin Concentration (MCHC, conc of Hb per RBC)
7. Red Blood Cell Distribution Width (RDW)
8. Total White Blood Cell
Q: What five additional things do you count in a Complete Blood Count with Differential?
A: It’s all 8 items in the CBC plus:
Q: Whenever you suspect gastroenteritis, what tests should you order?
A: 1. CBC with Differential
2. Electrolytes test
3. Renal function test.
Q: What would the CBC with differential show in gastroenteritis?
A: The CBC+D will show a left shift (increase in immature leukocytes in blood, indicating infection).
Q: What would the electrolytes test show in gastroenteritis?
A: The Electrolytes test will show hypokalemia if there is volume lost (because aldosterone cause Na and water to be reabsorbed and K to be excreted in the kidneys).
Q: What would the renal function test show in gastroenteritis?
A: The Renal Function Test will show prerenal azotemia (azotemia = increase in nitrogen waste in blood due to renal insufficiency). Prerenal azotemia is caused by decrease in blood flow to kidney (like due to hypovolemia), causing hypoperfusion of kidney, causing it to fail. Renal azotemia is caused by some sort of inherent kidney disease. Postrenal azotemia is caused by a blockage of urine flow away from and after the kidneys.
Q: Whenever you suspect Appendicitis, what tests should you order? What do you see?
A: 1. CT Scan — shows inflamed appendix.
2. CBC+D — shows leukocytosis w/ left shift.
3. Chemistry panel — shows acidosis, multiple electrolyte disorders, and renal dysfunction.
4. Urinalysis — to see if there is any possible urinary tract problems.
Q: Whenever you suspect Biliary Colic, what tests should you order? What do you see?
A: Ultrasound is all you really need — shows gallstones. Lab tests are typically unremarkable.
Q: If you suspect Acute Cholecystitis, what would you find during physical examination?
A: If you palpate the right subcostal region (where the liver and gall bladder are), the patient will stop breathing because it hurts. This is a positive Murphy’s Sign.
Q: Whenever you suspect Acute Cholecystitis, what tests should you order? What do you see?
A: 1. Ultrasound — you’ll see gallstones
2. If you don’t see anything with Ultrasound, you can do Cholescintigraphy — nuclear imaging of gall bladder — If you have cholecystitis, you’ll see that the gall bladder fails to take up the radioactive contrast media.
3. Liver Function Tests (LFT) — you’ll see transaminase (AST/ALT), alkaline phosphatase, and bilirubin are elevated (because bile duct is obstructed, they can’t be excreted and therefore collect in the blood)
4. CBC+Differential — you’ll see left shift
Q: What are the two most common causes of pancreatitis?
A: Gallstones (usually causes acute pancreatitis) and Alcohol (usually causes chronic pancreatitis)
Q: Whenever you suspect Pancreatitis, what tests should you order? What do you see?
A: 1. Amylase/Lipase Test (most important for pancreatitis diagnosis) — elevated amylase and lipase in serum (when pancreatic cell is damage, the enzymes leak into the blood).
2. Liver Function Tests — mild elevation — like in cholecystitis, suggests bile duct blockage.
3. CBC+Differential — if Pancreatitis due to gallstone, you see left shift
4. CT — if Pancreatitis due to gallstone, you see it. Plus, it’s a great tool to rull out other abdominal pathologies as well as staging the pancreatitis, and to see if you have necrosis or abscesses anywhere.
Q: Whenever you suspect Diverticulitis, what tests should you order? What do you see?
A: 1. CBC+D — left shift, leukocytosis
2. CT — see the mass
Q: What would you discover during physical exam of small bowel obstruction?
A: You’ll hear high-pitched bowel sounds separated by quietness.
Q: Whenever you suspect Small Bowel Obstruction, what tests should you order? What do you see?
A: 1. X-ray of abdomen — see air-fluid levels and obstruction site.
2. CBC+D — mild leukocytosis.
3. Electrolyte panel and renal function test if there is lots of vomiting.
Q: Whenever you suspect Perforated Peptic Ulcer, what tests should you order? What do you see?
A: 1. X-ray– see perforation
2. CBC+D — leukocytosis, left shift
3. Electrolyte panel (chem test) — metabolic acidosis
Avoid endoscopy since you suspect perforation.
Q: Whenever you suspect Mesenteric Ischemia, what tests should you order? What do you see?
A: 1. Selective Mesenteric Angiography — #1 diagnostic tool for mesenteric ischemia. You see the ischemia.
2. CBC+D — leukocytosis, left shift
3. Electrolyte panel (chem test) — metabolic acidosis, elevated lactic acid
Q: Whenever you suspect Ruptured Abdominal Aortic Aneurysm, what tests should you order? What do you see?
A: First of all, you’ll see the patient in hemodynamic shock. Mortality is already high and you gotta act fast. But you could do tests:
1. Ultrasound or CT — see the rupture
2. electrolyte panel (chem test) — lactic acidosis, since you don’t have enough blood to carry oxygen to the tissue (lack of tissue perfusion).
ACUTE GI BLEEDING
Q: What defines the border between upper and lower GI bleeding?
A: Ligament of Treitz
Q: What’s the most common cause of upper GI bleeding?
A: Bleeding peptic ulcers. They have a mortality rate of 6-10%.
Q: What’s the most common cause of upper GI bleeding?
A: Bleeding peptic ulcers. They have a mortality rate of 6-10%.
Q: What is it when you vomit red or “coffee ground” blood?
Q: Where is the GI bleeding in hematemesis?
A: Upper GI only
Q: Where is the GI bleeding in melena?
A: Upper GI to right colon
Q: Where is the GI bleeding in Hematochezia?
A: Usually lower GI, but but in some cases it could also be upper GI, like if your peptic ulcer suddenly bleeds a lot and really fast.
Q: What is black stool?
Q: What is red stool?
Q: Patient comes in with acute UPPER GI bleeding. What should be on your differential diagnosis?
A: Peptic ulcer, Esophageal varices, Gastric erosion, Erosive esophagitis, Mallory-Weiss tear, NSAID. Less commonly, it could also be Dieulafoy’s lesion, Aortoenteric fistula, Malignancy, Vascular lesion.
Q: Patient comes in with acute LOWER GI bleeding. What should be on your differential diagnosis?
A: Diverticulosis, Angiodysplasia, Malignancy/Polyp, Hemorrhoids/Anorectal fissures. Less commonly, it could also be postpolypectomy, Aortocolic fistula, NSAID-induced colitis, Vasculitis.
Q: A patient comes in with sharp, gnawing epigastric pain that starts hours after eating and gets woken up at night because of it?
A: Peptic ulcer
Q: When can you ever have hematochezia with bleeding peptic ulcer?
A: When the ulcer bleeds rapidly and massively.
Q: Where is an ulcer that is relieved by food?
A: Duodenal ulcer
Q: Where is an ulcer that is worsened by food?
A: Gastric ulcer
Q: What are risk factors for peptic ulcer?
A: H. pylori, NSAID use, stress
Q: Where on the esophagus is the most common site of esophageal varices?
A: distal 5 cm of esophagus
Q: How does chronic alcohol use lead to esophageal varices?
A: Alcoholic liver disease –> cirrhosis –> portosystemic shunting of blood –> esophageal varices (where the anastomosis between portal and systemic circulations is)
Q: What are the most common causes of esophageal varices?
A: portal hypertension, cirrhosis, alcoholic liver disease, chronic active heptatitis (which causes cirrhosis)
Q: If a person suddenly has throws up bright red blood or clots, and it is PAINLESS, and (have signs of chronic liver disease), what do you think of?
A: Esophageal varices
Q: For any type of GI bleeding, what should you be worried about?
A: Hypovolemia, shock, death, hemodynamic instability.
Q: If a person has a history of heartburn and comes in with hematemesis, what do you think of?
A: Erosive Esophagitis, from chronic Gastric reflux
Q: If a patient is a heavy alcohol user and comes in coughing or vomiting up blood, what do you think of?
A: Mallory-Weiss tear (longitudinal laceration at Gastroesophageal junction.
Q: If a patient does not have a history of NSAID or alcohol use, but has recurrent, painless, and massive hematemesis, what can you think of?
A: Dieulafoy’s lesion, although this is not very common. It happens when an aberrant submucosal arteriole bleeds from mucosal erosion.
Q: If a patient has large, painless hematochezia that stops spontaneously, and has a history of bloating or constipation, what do you think of?
A: Diverticulosis, which is when the diverticulum (sac-like protrusion in colon) herniates and ruptures the vasa recta.
Q: What are the risk factors for diverticulosis?
A: lack of dietary fiber, aspirin/NSAID use, advanced age (most happen in elderly), constipation.
Q: Why is bleeding from angiodysplasia less massive than bleeding from diverticulosis?
A: Because angiodysplasia has venous bleeding rather than arteriole bleeding found in diverticulosis.
Q: If a patient has moderate hematochezia or melena and have a history of aortic stenosis (hear 2nd Right intercostal space ejection in physical exam), what do you think of?
Q: What is mucosal inflammation in response to acute injury in the colon, like due to infection, ischemia, or inflammation?
Q: If a patient has hematochezia with rectal pain that is worse with bowel movements, straining, or sitting, what do you think of?
A: Hemorrhoids. Red blood on toilet paper.
Q: If a patient has a history of anemia, and comes in with recurrent low-grade hematochezia or melena, what do you think of?
A: Malignancy or polyps.
Q: A colon malignancy with melena is located where on the colon?
A: Right colon.
Q: A colon malignancy with hematochezia and bowel obstructions are where on the colon?
A: Left colon.
Q: How much blood do you need to lose before you have orthostatic hypotension?
A: 500 mL
Q: How much percent of you blood volume do you have to lose before you have shock?
Q: If a patient has GI bleeding, what is the hands-down first thing you should do?
A: STABILIZE THEIR FLUIDS AND ELECTROLYTES by immediately giving them two large-bore catheters or central venous line for intravenous access. Then, give them fluid replacement (or blood transfusion, depending on the need) and correct any electrolyte disturbances.
Q: What level of measurement do you use to monitor and assess the severity of the bleeding?
A: Hemoglobin level, but the initial hemoglobin level with RAPID blood loss is not accurate since it takes 8 hours for blood to equilibrate.
Q: If you can’t seem to stabilize the patient hemodynamically, what do you do next?
A: Do Esophagogastroduodenoscopy (EGD), regardless if the person has hematemesis, melena, or hematochezia.
Q: If after doing EGD, you can’t find anything and the patient has hematochezia, then what do you do?
A: Do a colonoscopy.
Q: If colonoscopy is negative, what do you do?
A: Do an enteroscopy to look at upper portions of small intestines.
Q: If after doing EGD, you can’t find anything and the patient has hematemesis, then what do you do?
A: Do an enteroscopy, to look at the upper parts of the small intestines.
Q: In outpatient settings, what is the most common cause of chest pain?
A: Musculoskeletal problems
Q: In the emergency room, what is the most common cause of cheest pain?
A: Coronary Artery Disease (about half of patients)
Q: When a patient comes in with chest pain at the emergency room, what five cardiac differential diagnoses should you think of?
A: Ischemic Heart Disease, Acute Pericarditis, Aortic Dissection, Aortic Stenosis, Cocaine-Induced
Q: What musculoskeletal differential diagnoses are there for chest pain?
A: Costochondritis, Fibromyalgia
Q: What gastrointestinal differential diagnoses are there for chest pain?
A: GERD, Esophageal spasm, Dysmotility, Cholecystitis, Peptic Ulcer Disease, Pancreatitis
Q: What psychosomatic differential diagnoses are there for chest pain?
A: Panic attack, Anxiety, Depression
Q: What pulmonary differential diagnoses are there for chest pain?
A: Pulmonary embolism, Pneumonia, Pneumothorax
Q: If a patient comes in with pressure or heaviness in the retrosternal area, and the pain radiates to the jaw, shoulders, and back, and lasts for 10 to 30 minutes, often after exertion, and the patient has tachycardia and elevated blood pressure, what could it be?
A: Ischemic Heart Disease. If the pain lasts for just a few seconds, it usually is not of cardiac origin.
Q: If a patient comes in with chest pain that is worsened by coughing or deep inspiration, and is relieved when he sits up and leans forward, and has pleural rubs and tachycardia, and often has a history of viral infection, what could it be?
A: Acute Pericarditis
Q: If a patient comes in with a sharp chest pain, radiating to the back or abdomen, and has hypertention and over a 20 mmHg blood pressure difference in each arm, what could it be?
A: Aortic Dissection
Q: If a patient comes in with chest pain and has a crescendo-decrescendo systolic murmur at the second right intercostal space, what could it be?
A: Aortic Stenosis
Q: If a patient comes in with chest pain that is worse after lying down, eating fatty meals, alcohol, or using NSAIDs, what could it be?
Q: If a patient comes in with chest pain and has fever, productive cough, wheezing, egophony, and tactile fremitus, what could it be?
A: Pneumonia. Egophony shows lung consolidation and fibrosis. More tactile fremitus means consolidation/fibrosis. No tactile fremitus means an “empty” lung like due to pneumothorax or pleural effusion (liquid in pleural space).
Q: If a patient comes in with sudden-onset chest pain and unexplained acute dyspnea (or tachypnea), and when you percuss the lungs and it is hyperresonant, what could it be?
Q: If a patient has no tactile fremitus, but dull sound upon percussion, what could it be?
A: Pleural effusion
Q: If a patient has no tactile fremitus, but hyperresonant sound upon percussion, what could it be?
Q: If a patient comes in with chest pain that developed gradually, that is worsened by moving the trunk, deep breathing, or arm movement, that is painful upon chest palpation is most likely what?
Q: If a patient comes in with chest pain that occurs at specific trigger points on the upper chest is likely to have what?
Q: What labs would you order if you suspect any sort of cardiac involvement in the chest pain?
A: ECG, Chest X-ray, Troponin test (r/o MI), TTE (transthoracic echocardiogram, aka “cardiac ultrasound”).
Q: If the chest pain patient’s labs show up an increase in Troponin serum markers, what does it suggest?
A: Myocardial injury. Abnormal ECG further supports evidence of MI.
Q: How long after an MI does Troponin show up in the serum?
A: 3-12 hours
Q: How long after myocardial necrosis does troponin show up in the serum
A: 7-11 days
Q: If you suspect someone has an aortic dissection, what tests could you order?
A: Chest X-ray (see widened midiastinum), ECG (should show up normal or w/ LVH, but rules out other causes like MI, pericarditis), CT, Transesophageal echocardiogram, angiography of aortic root, MRI.
Q: What would ECG look like in angina?
A: ST depression, T-wave abnormalities
Q: What would ECG look like in MI?
A: ST elevation
Q: What would ECG look like in pericarditis?
A: Diffuse ST elevations
Q: What would ECG look like in Aortic Dissection?
A: often normal, but can see evidence of LVH
Q: What would ECG look like in pneumonia?
Q: What tests do you use to diagnose pulmonary embolism?
A: Spiral CT (Helical CT), Ventilation-Perfusion Scan (V/Q Scan)
Q: What test is the first choice for diagnosing pulmonary embolism?
A: Spiral CT!!
Q: Is d-dimer test diagnostic for pulmonary embolism?
A: No! It is not specific for pulmonary embolism, because hospitalized patients, those with malignancies and recent surgeries or are pregnant may also have elevated d-dimer levels.
Q: If a patient comes in with chest pain, tachycardia, tachypnea, as well as a right ventricular heave, what would you suspect?
A: Pulmonary embolism. The right ventricular heave is due to right ventricular hypertrophy due to the blockage in the lungs.
Q: How long does it take for a cough to be considered “chronic”?
A: over 2 months
Q: How short does it take for a cough to be considered “acute”?
A: less than 3 weeks. Everything else in between 3 weeks and 2 months are “subacute.”
Q: What are the most common differential diagnosis of acute cough?
A: Acute bronchitis, Acute sinusitis, COPD, Asthma exacerbation, Allergic rhinitis, Whooping cough (Pertussis).
Q: What are the most common differential diagnoses of chronic cough?
A: Postnasal drip, GERD, Asthma, Medications (specifically ACE inhibitors)
Q: What is the first step in diagnosing asthma?
Q: If the spirometry test shows obstruction at the baseline, what do you do?
A: administer bronchodilator. If symptoms improve after using bronchodilators, then it confirms asthma
Q: If the spirometry test shows normal baseline, what do you do?
A: do methacholine challenge test. If it comes out negative, then asthma is ruled out. If it comes out positive (symptoms worsen), then asthma is diagnosed.
Q: What test do you do if you suspect ACE inhibitors as the cause of the cough?
A: give methacholine challenge test. It tests positive (symptoms worsen) then it is diagnostic.
Q: If a patient comes in with frequent nasal discharge and feel like there’s liquid dripping back behind the throat as well as a cobblestone appearance on the nasal mucosa during physical exam, what could it be?
A: Postnasal drip
Q: If a patient comes in with wheezing or normal lung exam upon physical exam but has history of wheezing, nighttime or seasonal cough, and dyspnea, what could it be?
Q: What are the most common causes of dyspnea?
A: Asthma, COPD, Interstitial Lung Disease, and Cardiomyopathy.
Q: A patient comes in with gradual progressive dyspnea, dry cough, and pleuritic chest pain and has a history of exposure to inhaled agents. What could it be?
A: Interstitial lung disease, which can be caused by a whole bunch of things, like silicosis, asbestosis, or rheumatoid arthritis.
Q: A patient comes in with dyspnea with fevers, chills, inspiratory rales, wheezes, chest pain, and cough. What do you think of?
Q: A patient comes in with dyspnea, non-productive cough, chest pain, and decreased tactile fremitus, dull percussion sounds over chest… what could it be?
A: Pleural effusion
Q: What does the pulse oximeter measure?
A: oxygen saturation of hemoglobin.
Q: What test do you order to evaluate asthma and COPD?
A: Pulmonary Function Tests (PFTs)
Q: What FEV1/FVC ratio indicates obstructive lung disease?
A: less than 70%, or an amount less than what is normal for the patient.
Q: You see a patient who purses his lips when he breathes, has a barrel chest (increased AP diameter), and sits by leaning forward and weight supported by palms… what could he have?
Q: Why does pursed-lip breathing help in COPD?
A: When you purse your lips and breathe out, you create more pressure inside your mouth, opening up the collapsed airways in your lungs.
Q: What does Pulmonary Function Test measure?
A: Functional Residual Capacity (FRC), Forced Vital capacity (FVC), Forced Expiratory Volume in 1 second (FEV1), Forced Expiratory Volume in 2 seconds (FEV2), Total Lung Capacity (TLC), Residual Volume (RV), etc.
Q: What is the treatment for COPD?
A: Smoking cessation, Long-term O2 therapy (LTOT), bronchodilators (i.e. beta 2 agonists like albuterol or salmeterol or anticholinergics like iptratropium), inhaled corticosteroids.
Q: What is the last-resort drug for COPD?
A: Methylxanthine drugs (i.e. Theophylline)
Q: If a patient is diagnosed with COPD at a young age (younger than 45 years old), what should you suspect?
A: A1AT deficiency. So therefore you test for A1AT.
Q: What vaccines should you give COPD patients?
A: You want to prevent respiratory illnesses or pneumonia and so you give vaccines for influenza virus and strep pneumo.
Q: How do you give oxygen?
A: Either through face mask (which is better for ppl who need higher flow of oxygen), or nasal cannula (which is more portable, but delivers oxygen inefficiently)
Q: What causes clubbing of fingers (thickening of flesh under fingernails)?
A: It indicates low oxygen levels in the blood. Therefore you find it in lung cancer (mainly large-cell lung cancer), interstitial lung disease, tuberculosis, lung abscess, bronchiectasis, cystic fibrosis, mesothelioma, chronic hypoxia, Crohn’s Disease, Primary Biliary Cirrhosis, Ulcerative Colitis, and a whole bunch of other stuff.
Q: Is Clubbing of fingers associated with COPD?
A: It is NOT associated with COPD (although it doesn’t mean you can’t see it in COPD patients)
Q: What’s the first thing to take notice when someone comes in with edema?
A: See if its localized over portion of body or generalized. See if it is pitting or non-pitting. Find out onset and duration.
Q: When you see a patient with edema, what are the first differential diagnoses you should think of?
A: CHF, Cirrhosis, Renal insufficiency, and Medication. Find out if the patient has any of these and get a complete list of medications the patient is taking.
Q: What are the cardiac causes of generalized edema?
A: Heart failure (right-sided), Primary pulmonary hypertension (caused by hypertrophy of arteriole smooth muscle walls and fibrosis), constrictive pericarditis
Q: What kind of edema would you also often find in cardiac edema?
A: Pulmonary edema, especially from left-sided heart failure.
Q: What are the hepatic causes of generalized edema?
A: Cirrhosis with portal hypertension
Q: What are the renal causes of generalized edema?
A: End-stage renal failure, nephrotic syndrome.
Q: What do you expect from labs with renal edema?
A: elevated serum creatinine and urea nitrogen levels. Hyperkalemia, Hyperphosphatemia, Hypocalcemia, metabolic acidosis.
Q: What are the medicinal causes of generalized edema?
A: Calcium channel blockers (i.e. nifedipine, amlodipine), Hormones (corticosteroids, testosterone, estrogen), and NSAIDs (becasue inhibit prostaglandins), anything that increases sodium retention.
Q: What are the nutritional causes of generalized edema?
A: Hypoalbuminemia (like from either not eating enough protein, or not being able to adbsorb/digest protein like in chronic pancreatitis, or nephrotic syndrome). Check serum albumin!!
Q: What are the endocrine causes of generalized edema?
A: Myxedema from hypothyroidism
Q: How does congestive heart failure lead to generalized edema?
A: Heart doesn’t pump enough –> decrease in effective blood volume –> activation of renin-angiotensin –> Na/Water retention –> increased hydrostatic pressure in capillaries –> water goes to extracellular space –> edema
Q: How does cardiac edema present?
A: lower extremities, SYMMETRICAL, pitting.
Q: How does cirrhosis lead to generalized edema?
A: cirrhosis –> hepatic venous outflow obstructed –> decreased venous return means decreased effective blood volume –> activation of renin-angiotensin –> Na/Water retention –> increased hydrostatic pressure in capillaries –> water goes to extracellular space –> edema
Q: What are the causes of localized edema?
A: Obstruction in venous or lymphatic circulation, inflammation (causes increased capillary permeability).
Q: What does localized edema look like?
Q: What does generalized edema look like?
Q: What are the obstructive causes of localized edema?
A: deep venous thrombosis, thrombophlebitis (phlebitis caused by thrombus), lymphadenopathy (inflammation of lymph nodes) or masses that inhibit venous return (like from neoplasm), lymphatic obstruction (congenital or primary), filariasis.
Q: What are the inflammatory causes of localized edema?
A: burns, cellulitis, angioedema, infection, tissue injury that causes capillary permeability.
Q: What lab tests do you do for edema?
A: Serum creatinine (check for renal insufficiency), Albumin (like from urinalysis, check for nephrotic syndrome), Liver function test (check for cirrhosis). Also stop any vasodilating drugs they are taking to rule out these as causes.
Q: If a patient comes in with asymmetric, non-pitting edema and has lower extremity pain and erythema, what do you think of?
A: Deep vein thrombosis.
Q: How do you detect deep vein thrombosis?
Q: How do you detect pelvic lymphadenopathy or other mass you suspect is causing the edema?
A: contrast-enhanced CT scan
NAUSEA AND VOMITING
Q: If nausea and vomiting accompanies constipation, what do you think of?
A: Colon obstruction
Q: If nausea and vomiting accompanies a missed period, what do you think of?
A: Early pregnancy
Q: If nausea and vomiting accompanies diarrhea, what do you think of?
Q: What are the common GI causes of acute-onset nausea and vomiting?
A: obstruction, gastroenteritis, inflammatory condition
Q: What are the common non-GI causes of acute-onset nausea and vomiting?
A: Toxins/medications, meningitis, CNS hemorrhage, myocardial infarction