PAEA INTERNAL MEDICINE EOR ACTUAL FINALS PAPER
UPDATED QUESTIONS AND ANSWERS GRADED A+
✔✔Paget's disease Dx - ✔✔1. Labs: Markedly increased Alk Phos, normal Ca and
Phosphate.
2. X-rays: Lytic phase: "Blade of grass/Flame shapped" lucency; sclerotic phase:
coarsened trabeculae (increased trabechular markings, denser/expanded bones)
Skull - "cotton-wool appearance"
✔✔Paget's disease Tx - ✔✔Bisphosphonates
-asymptomatic generally doesn't need tx
✔✔Paget's disease Clinical manifestations - ✔✔1. asymptomatic (70-90%) - usually
found with high alk phos on screening
2. Bone pain: MC sx* - stress fractures
3. Soft bones: bowed tibias, kyphosis, frequent fractures with slight trauma
4. Skull involvement: Deafness*, HA
✔✔Thyroid cancer - ✔✔-Roughly 5% of thyroid nodules are malignant
-Most pts with thyroid cancer are euthyroid
-a "Cold nodule" on RAIU is highly suspicous for malignancy
✔✔Thyroid cancer Types - ✔✔Papillary: 80%
Follicular: 10%
Medullary: 10% (assoc with MEN 2)
Anaplastic: <1%
✔✔Papillary thyroid cancer - ✔✔MC type (80%) (most common after radiation
exposure)
MC in young females
least aggressive
local METS common, distant uncommon
excellent prognosis
-tx: total thyroidectomy
✔✔Follicular Thyroid cancer - ✔✔10%, MC in age 40-60
more aggreesive, but excellent prognosis
Distant METS common- lung, neck, brain
tx: total thyroidectomy
,✔✔Medullary Thyroid Cancer - ✔✔10% (assoc with MEN 2), not assoc with radiation
-Much lower cure rat
-Arises from parafollicular cells which secrete calcitonin
-may cause diarrhea and flushing
-Local METS early, distant METS late
-poorer prognosis
-tx: total thyroidectomey
✔✔Anaplastic thyroid cancer - ✔✔Rare <1%
MC in males >65
Local and distant METS; may invade trachea
Poor prognosis*
tx: most are not able to be resected, chemo and radiation
✔✔Pituitary adenoma - ✔✔types:
1. Prolactinoma: MC type. Presents as amenorhea and galactorrhea in women,
impotence in men
2.Somatotropinoma: Growth hormone secreting;
-causes acromegaly/gigantism; as well as DM/glucose intolerance
3.Adrenocorticotropinomas: secrete ACTH
-Manifesst as Cuching's disease and hyperpigmentation
4. TSH secreting adenoma
-presents as thyrotoxicosis
5.FSH/LH secreting adenomas: rare
Tx: trans-sphenoidal surgery
(medical tx for prolactinoma is 1st line - cabergoline or bromocriptine (DA agonists that
inhibit prolactin))
✔✔Diabetes Mellitus Type 1 Hx/PE - ✔✔
✔✔Diabetes Mellitus Type 1 Dx - ✔✔
✔✔Diabetes Mellitus Type 1 Tx - ✔✔
✔✔Diabetes Mellitus Type 2 Hx/Dx - ✔✔A dysfunction in glucose metabolism that is
best characterized as varying degrees of insulin resistance that may lead to β-cell
burnout and insulin dependence.
,✔✔Diabetes Mellitus Type 2 Tx - ✔✔
✔✔ACEi protects the - ✔✔Kidney. That way it's good for DM pt.
Switch to ARBs if pt have cough symptoms.
✔✔Congestive heart failure - ✔✔Acute decompensated heart failure with worsening
baseline sx characterized by pulmonary congestion
✔✔What is systolic dysfunction? - ✔✔Is a ↓ ejection fraction and dilation of the heart. It
is characterized by a ↓ ejection fraction (less than 45%). The strength of ventricular
contraction is attenuated and inadequate for creating an adequate stroke volume,
resulting in inadequate cardiac output. On the left side of the heart, the increased
pressure is transmitted to the pulmonary vasculature, and the resultant hydrostatic
pressure favors extravasation of fluid into the lung parenchyma, causing pulmonary
edema.
✔✔What is diastolic dysfunction? - ✔✔Is the ability of the heart to "relax" and receive
blood. The failure of ventricular relaxation also results in elevated end-diastolic
pressures, and the end result is identical to the case of systolic dysfunction (pulmonary
edema in left heart failure, peripheral edema in right heart failure.)
✔✔What is Myocardial infarction? - ✔✔It happens when blood stops flowing properly to
part of the heart and the heart muscle is injured due to not receiving enough oxygen.
✔✔sx of CHF - ✔✔Dyspnea on exertion,
othropnea
peripheral edema
rales
JVD
Paroxysmal nocturnal dyspnea
S3 heart sound
✔✔What diagnostic test is used to evaluate HF? - ✔✔1.Echocardiography. Ejection
fractions less than 55%
2.CXR: esp useful for CHF: Kerley B lines, pulmonary effusions/ edema
3. BNP: may identify CHF as cuase for dyspnea
✔✔Systolic Dysfunction Tx - ✔✔ACE inhibitors or angiotensin receptor blockers
(ARBs): ACEi cause cough, then switch to ARBs
Beta blockers: Antiischemic effect, ↓ HR lead to ↓O2 consumption. ↓ mortality in pt.
Spironolactone: Ø effect of aldosterone; SE: gynecomastia, switch to Eplerenone
Diuretics: 1st therapy of CHF w/ ↓ ejection fracture. Use in combo w/ ACEi & ARBS
, Digoxin: Control symptoms of Dyspnea. Do not ↓ mortality.
✔✔Diastolic Dysfunction tx - ✔✔Beta Blockers, CCBs*, and ACEi,
can add diuretics for volume control
CCBs are helpful for Diastolic, but make systolic failure worse!
✔✔CHF tx - ✔✔"LMNOP"
Lasix
Morphine
Nitrates
Oxygen
Positionins
✔✔What is Hypertension? - ✔✔Defined as a systolic BP > 140 mmHg and/or a diastolic
BP > 90 based on three measurements separated in time.
✔✔Diabetic pt or someone with chronic renal disease hypertension is - ✔✔130/80
mmHg
✔✔What is the most common risk factor for the most common cause of death: -
✔✔Myocardial Infarction
✔✔1° (Essential) Hypertension - ✔✔Hypertension with no identifiable cause.
Represents 95% of cases of hypertension.Risk factors include a family history of
hypertension or heart disease, a high-sodium diet, smoking, obesity, race (blacks >
whites), and advanced age.
✔✔1° (Essential) Hypertension History/PE - ✔✔Hypertension is asymptomatic until
complications develop.
■ Patients should be evaluated for end-organ damage to the brain (stroke, dementia),
eye (cotton-wool exudates, hemorrhage), heart (LVH), and kidney (proteinuria, chronic
kidney disease). Renal bruits may signify renal artery stenosis as the cause of
hypertension.
✔✔1° (Essential) Hypertension Dx - ✔✔Conduct cardiovascular, neurologic,
ophthalmologic, and abdominal exams.
■ Obtain a UA, BUN/creatinine, CBC, and electrolytes to assess the extent of end-organ
damage.
✔✔1° (Essential) Hypertension Tx - ✔✔Rule out 2° causes of hypertension, particularly
in younger patients.
■ Begin with lifestyle modifications (e.g., weight loss, smoking cessation, salt reduction).
Weight loss is the single most effective lifestyle modification.
UPDATED QUESTIONS AND ANSWERS GRADED A+
✔✔Paget's disease Dx - ✔✔1. Labs: Markedly increased Alk Phos, normal Ca and
Phosphate.
2. X-rays: Lytic phase: "Blade of grass/Flame shapped" lucency; sclerotic phase:
coarsened trabeculae (increased trabechular markings, denser/expanded bones)
Skull - "cotton-wool appearance"
✔✔Paget's disease Tx - ✔✔Bisphosphonates
-asymptomatic generally doesn't need tx
✔✔Paget's disease Clinical manifestations - ✔✔1. asymptomatic (70-90%) - usually
found with high alk phos on screening
2. Bone pain: MC sx* - stress fractures
3. Soft bones: bowed tibias, kyphosis, frequent fractures with slight trauma
4. Skull involvement: Deafness*, HA
✔✔Thyroid cancer - ✔✔-Roughly 5% of thyroid nodules are malignant
-Most pts with thyroid cancer are euthyroid
-a "Cold nodule" on RAIU is highly suspicous for malignancy
✔✔Thyroid cancer Types - ✔✔Papillary: 80%
Follicular: 10%
Medullary: 10% (assoc with MEN 2)
Anaplastic: <1%
✔✔Papillary thyroid cancer - ✔✔MC type (80%) (most common after radiation
exposure)
MC in young females
least aggressive
local METS common, distant uncommon
excellent prognosis
-tx: total thyroidectomy
✔✔Follicular Thyroid cancer - ✔✔10%, MC in age 40-60
more aggreesive, but excellent prognosis
Distant METS common- lung, neck, brain
tx: total thyroidectomy
,✔✔Medullary Thyroid Cancer - ✔✔10% (assoc with MEN 2), not assoc with radiation
-Much lower cure rat
-Arises from parafollicular cells which secrete calcitonin
-may cause diarrhea and flushing
-Local METS early, distant METS late
-poorer prognosis
-tx: total thyroidectomey
✔✔Anaplastic thyroid cancer - ✔✔Rare <1%
MC in males >65
Local and distant METS; may invade trachea
Poor prognosis*
tx: most are not able to be resected, chemo and radiation
✔✔Pituitary adenoma - ✔✔types:
1. Prolactinoma: MC type. Presents as amenorhea and galactorrhea in women,
impotence in men
2.Somatotropinoma: Growth hormone secreting;
-causes acromegaly/gigantism; as well as DM/glucose intolerance
3.Adrenocorticotropinomas: secrete ACTH
-Manifesst as Cuching's disease and hyperpigmentation
4. TSH secreting adenoma
-presents as thyrotoxicosis
5.FSH/LH secreting adenomas: rare
Tx: trans-sphenoidal surgery
(medical tx for prolactinoma is 1st line - cabergoline or bromocriptine (DA agonists that
inhibit prolactin))
✔✔Diabetes Mellitus Type 1 Hx/PE - ✔✔
✔✔Diabetes Mellitus Type 1 Dx - ✔✔
✔✔Diabetes Mellitus Type 1 Tx - ✔✔
✔✔Diabetes Mellitus Type 2 Hx/Dx - ✔✔A dysfunction in glucose metabolism that is
best characterized as varying degrees of insulin resistance that may lead to β-cell
burnout and insulin dependence.
,✔✔Diabetes Mellitus Type 2 Tx - ✔✔
✔✔ACEi protects the - ✔✔Kidney. That way it's good for DM pt.
Switch to ARBs if pt have cough symptoms.
✔✔Congestive heart failure - ✔✔Acute decompensated heart failure with worsening
baseline sx characterized by pulmonary congestion
✔✔What is systolic dysfunction? - ✔✔Is a ↓ ejection fraction and dilation of the heart. It
is characterized by a ↓ ejection fraction (less than 45%). The strength of ventricular
contraction is attenuated and inadequate for creating an adequate stroke volume,
resulting in inadequate cardiac output. On the left side of the heart, the increased
pressure is transmitted to the pulmonary vasculature, and the resultant hydrostatic
pressure favors extravasation of fluid into the lung parenchyma, causing pulmonary
edema.
✔✔What is diastolic dysfunction? - ✔✔Is the ability of the heart to "relax" and receive
blood. The failure of ventricular relaxation also results in elevated end-diastolic
pressures, and the end result is identical to the case of systolic dysfunction (pulmonary
edema in left heart failure, peripheral edema in right heart failure.)
✔✔What is Myocardial infarction? - ✔✔It happens when blood stops flowing properly to
part of the heart and the heart muscle is injured due to not receiving enough oxygen.
✔✔sx of CHF - ✔✔Dyspnea on exertion,
othropnea
peripheral edema
rales
JVD
Paroxysmal nocturnal dyspnea
S3 heart sound
✔✔What diagnostic test is used to evaluate HF? - ✔✔1.Echocardiography. Ejection
fractions less than 55%
2.CXR: esp useful for CHF: Kerley B lines, pulmonary effusions/ edema
3. BNP: may identify CHF as cuase for dyspnea
✔✔Systolic Dysfunction Tx - ✔✔ACE inhibitors or angiotensin receptor blockers
(ARBs): ACEi cause cough, then switch to ARBs
Beta blockers: Antiischemic effect, ↓ HR lead to ↓O2 consumption. ↓ mortality in pt.
Spironolactone: Ø effect of aldosterone; SE: gynecomastia, switch to Eplerenone
Diuretics: 1st therapy of CHF w/ ↓ ejection fracture. Use in combo w/ ACEi & ARBS
, Digoxin: Control symptoms of Dyspnea. Do not ↓ mortality.
✔✔Diastolic Dysfunction tx - ✔✔Beta Blockers, CCBs*, and ACEi,
can add diuretics for volume control
CCBs are helpful for Diastolic, but make systolic failure worse!
✔✔CHF tx - ✔✔"LMNOP"
Lasix
Morphine
Nitrates
Oxygen
Positionins
✔✔What is Hypertension? - ✔✔Defined as a systolic BP > 140 mmHg and/or a diastolic
BP > 90 based on three measurements separated in time.
✔✔Diabetic pt or someone with chronic renal disease hypertension is - ✔✔130/80
mmHg
✔✔What is the most common risk factor for the most common cause of death: -
✔✔Myocardial Infarction
✔✔1° (Essential) Hypertension - ✔✔Hypertension with no identifiable cause.
Represents 95% of cases of hypertension.Risk factors include a family history of
hypertension or heart disease, a high-sodium diet, smoking, obesity, race (blacks >
whites), and advanced age.
✔✔1° (Essential) Hypertension History/PE - ✔✔Hypertension is asymptomatic until
complications develop.
■ Patients should be evaluated for end-organ damage to the brain (stroke, dementia),
eye (cotton-wool exudates, hemorrhage), heart (LVH), and kidney (proteinuria, chronic
kidney disease). Renal bruits may signify renal artery stenosis as the cause of
hypertension.
✔✔1° (Essential) Hypertension Dx - ✔✔Conduct cardiovascular, neurologic,
ophthalmologic, and abdominal exams.
■ Obtain a UA, BUN/creatinine, CBC, and electrolytes to assess the extent of end-organ
damage.
✔✔1° (Essential) Hypertension Tx - ✔✔Rule out 2° causes of hypertension, particularly
in younger patients.
■ Begin with lifestyle modifications (e.g., weight loss, smoking cessation, salt reduction).
Weight loss is the single most effective lifestyle modification.
