Internal Medicine Videos & books

2022-03-26 18:49:29 48) A 24-year-old male medical student is admitted to the hospital for the evaluation of a 3-month history of bloody stools. The patient has approximately six blood stained or blood streaked stools per day, associated with relatively little, if any, pain. He has not had any weight loss, and he has been able to attend classes without interruption. He denies any fecal incontinence. He has no prior medical history. Review of systems is remarkable only for occasional fevers and the fact that the patient quit smoking approximately 8 months ago. A colonoscopy is performed and reveals a granular, friable colonic mucosal surface with loss of normal vascular pattern from the anal verge to the hepatic flexure of the colon. Biopsies reveal prominent neutrophils in the epithelium and cryptitis with focal crypt abscesses, and no dysplasia. The patient is diagnosed with ulcerative colitis.
Which of the following is the best initial treatment for this patient? Open / Comment

2022-03-22 11:33:01 The patient has chronic diarrhea superimposed on a long history of loose stools, steatorrhea, and significant weight loss. While these features could be seen in several diseases, the presence of the pruritic vesiculopapular lesions on his extensor surfaces makes the diagnosis highly likely to be celiac sprue, with its frequently accompanying skin manifestation dermatitis herpetiformis. Crohn’s disease is not usually associated with steatorrhea, and ulcerative colitis is often associated with bloody stools. Chronic pancreatitis and Whipple disease could cause a similar clinical picture but would not have the associated skin findings. A small bowel biopsy would confirm histopathologic features consistent with celiac sprue, such as villous atrophy and crypt hyperplasia. A small bowel biopsy could also diagnose or rule out Whipple disease by looking for the pathognomonic PAS (periodic acid-Schiff) positive organism Tropheryma whippelii. Colonic biopsies would be unhelpful in celiac sprue. A fecal fat quantification would likely confirm and assess the degree of steatorrhea, but would offer little other diagnostic information. A small bowel x-ray is too nonspecific to confirm the diagnosis and an abdominal CT scan would likely be normal unless the patient had developed a complication of advanced sprue, such as intestinal lymphoma. Patients with celiac sprue are at increased risk for malignancies of the small bowel with adenocarcinoma and lymphoma being the two most commonly encountered. Patients with celiac sprue are not at greatly increased risk of the other malignancies listed. Limited data suggest that strict adherence to a glutenfree diet may decrease the incidence of malignancy in these patients. Open / Comment

2022-03-21 11:32:31 47) A 42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea… Open / Comment

2022-03-21 11:31:23 47) A 42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well.
Which of the following is the most likely diagnosis for this patient? Open / Comment

2022-03-14 07:16:01 Septic shock results from inflammatory effects secondary to infection that ultimately leads to hemodynamic decompensation. The treatment encompasses three primary goals. The initial priority is to maintain a reasonable mean arterial pressure and cardiac output to keep the patient alive. Then the nidus of infection must be treated and the pathogenic sequence leading to septic shock should be interrupted. While these latter goals are being pursued, adequate organ system perfusion and function must be maintained, guided by cardiovascular monitoring. Large fluid deficits exist in patients with septic shock. Up to 6–10 L of crystalloid solutions or 2–4 L of colloid solutions may be required for initial resuscitation in the first 24 hours. Volume repletion in patients with septic shock produces significant improvement in cardiac function and systemic oxygen delivery, thereby enhancing tissue perfusion and reversing anaerobic metabolism. Cardiac index will usually improve by 25–40% during fluid resuscitation. In approximately 50% of septic patients who initially present with hypotension, fluids alone will reverse hypotension and restore hemodynamic stability. Fluid resuscitation with isotonic crystalloids, such as normal saline or lactated Ringers solution, should be the initial therapy in shock. When fluid resuscitation fails to maintain adequate arterial pressure and organ perfusion, vasopressor therapy should be initiated. In this patient, the initial therapy should be fluid resuscitation. If fluid resuscitation fails, then vasopressor therapy should be initiated with dopamine. If this alone fails, then adding another vasopressor/inotropic agent, such as norepinephrine, may be warranted. Although patients with septic shock should receive broad antibiotic coverage after being pan-cultured, this should not precede fluid resuscitation. As this patient is able to breathe independently while maintaining good O2 saturation, intubation may be held off for now. If the patient starts to deteriorate (increased respiratory rate, low O2 saturation, poor excursion, hypercapnia, hypoxia), intubation could be considered. Open / Comment

2022-03-13 07:15:47 46) A 72-year-old male with type II diabetes, hypertension, and a history of recurrent pneumonia is admitted to the Medical intensive care unit (ICU) with a diagnosis of septic shock. His vital signs are: BP 80/60 mmHg, RR 24 breaths per minute, pulse 120… Open / Comment

2022-03-13 07:14:23 46) A 72-year-old male with type II diabetes, hypertension, and a history of recurrent pneumonia is admitted to the Medical intensive care unit (ICU) with a diagnosis of septic shock. His vital signs are: BP 80/60 mmHg, RR 24 breaths per minute, pulse 120 beats per minute (bpm), temp. 102.4°F, O2 saturation 99% on room air. Of the choices listed below, what would be your initial management? Open / Comment

2022-03-05 13:05:46 When acetaminophen is taken in normal doses, it is conjugated in the liver to harmless glucuronide and sulfate metabolites. These metabolic pathways become easily overwhelmed in the setting of a large overdose, however. If this occurs, the cytochrome P450 system directs conversion of the excess acetaminophen to a compound called NAPQI, which is conjugated with glutathione to form a nontoxic mercapturate metabolite. Once glutathione stores are exhausted in the liver, however, the excess NAPQI combines with proteins within hepatic cells causing hepatic cell death. Taurine is a mercaptan-containing amino acid involved in bile acid biochemistry. Citrulline aids in the detoxification and elimination of ammonia. Ornithine plays an important role in the urea cycle. (Katzung, 2004, p. 36) N-acetylcysteine should be administered as promptly as possible for treatment of acetaminophen overdose. It works by helping restore hepatic glutathione stores and by providing sulfhydryl groups that bind toxic metabolites. N-acetylcysteine is administered orally in the form of an initial loading dose (140 mg/kg) followed by 17 doses (70 mg/kg each) given every 4 hours. In addition to this oral therapy, the Food and Drug Administration (FDA) approved 21-hour and 48-hour long intravenous treatment regimens in 2004. Left untreated, acetaminophen overdose carries a significant risk for hepatic failure and subsequent death depending on the amount of acetaminophen ingested, the presence of any preexisting liver disease, and interactions with any other medications that induce cytochrome P450 enzyme activity. Naloxone, flumazenil, and physostigmine are given as antidotes for toxicity related to opioid analgesics, benzodiazepines,
and muscarinic receptor blockers, respectively. (Harrison’s Internal Medicine online, Chap. 286 “Toxic and Drug-induced Hepatitis”; Katzung, 2004, pp. 36, 521) Poor prognosis is associated with elevated serum lactate levels (above 3.5 mmol/L), acidemia (arterial pH less than 7.3), renal failure, and coagulopathy. The Rumack-Matthew nomogram provides a means of determining whether an individual falls into the possible-, probable-, or high-risk categories for developing hepatotoxicity based on serum acetaminophen levels and the number of hours since ingestion. Therapy with N-acetylcysteine is most effective if begun within 8 hours of the toxic ingestion but still has proven benefit if started within 24 hours. Open / Comment

2022-03-02 17:30:19 Quiz '@doctorusmle'
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10 questions · 1 min Open / Comment

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