PAEA INTERNAL MEDICINE EOR EXAMS SCRIPT UPDATED
QUESTIONS AND ANSWERS GRADED A+
✔✔Clinical manifestations of acute cholecystitis - ✔✔1.. Biliary colic
2. Fever, N/V, and palpable gallbladder* (33%)
positive Murphy's sign
positive boas sign*
jaundice not common
✔✔Dx of acute cholecystitis - ✔✔1. US: initial test of choice: thickenned gallbladder
(>3mm), distended gallbladder, sludge gallstones, pericholcystic fluid, and positive
sonographic murpheys sign
2. Labs: increased WBCs (leukocytosis with keft shift), increased bilirubin, increased
ALP and LFTs
3. HIDA scan: Gold standard!
✔✔management of acute cholecystitis - ✔✔1. conservative: npo, ivf, abx (3rd gen
cephalosporin and metronidazole)
2. cholecystectomy if that doesnt work (usually within 72 hrs)
Meperidine is preferred pain management
✔✔Cholangitis - ✔✔biliary tract infection secondary to obstruction by gallstone
Charcots triad: Jaundice, RUQ pain, fever
Raynauds pentad: added AMS change and hypotension
✔✔Celiac disease - ✔✔Autoimmune intestinal reaction to alpha gliadin in gluten,
leading to loss of villi & absorptive area
-causes B12, folate, and iron deficiency
✔✔Celiac disease Presentation - ✔✔Clinical presentation
a. Diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension
are common.
b. Infants and children may present with failure to thrive.
c. Older patients may present with iron deficiency, coagulopathy, and hypocalcemia.
✔✔Celiac disease Dx - ✔✔Small bowel biopsy
✔✔Irritable bowel syndrome - ✔✔Chronic functional idiopathic disorder with NO organic
cause.
Hallmark: Abd pain associted with altered defecation/bowel habits (diarrhea,
constipation, or altering between the two.
✔✔Irritable bowel syndrome dx - ✔✔Abd pain or discomfort with 2 of 3 features for at
least 12 weeks (not necessarily consecutive)
,-Relief with defecation**
-onset associated with change in stool frequency
-onset associated with change in stool formation
✔✔Irritable bowel syndrome tx - ✔✔Lifestyle changes: smoking cessation, eat low
fat/unprocessed foods
-if diarrhea: anticholinergics or antidiarrheals
-if constipation: bulking laxitives
✔✔Common Thyroid abnormalities table - ✔✔
✔✔Diabetes insipidus - ✔✔ADH deficiency (central DI) or insensitivity to ADH
(nephrogenic)
-causes the kidneys to be unable to concentrate urine, so production of large amounts
of dilute urine
✔✔Diabetes insipidus management - ✔✔1. Central DI: desmopression/DDAVP, or
carbemazepine
2. Nephrogenic DI: Na/protein restricion, and hydrochlorothiazide or indomethocin
3. If symptomatic: hypotonic fluid
✔✔Addison's disease - ✔✔Primary Adrenal Insufficiency
-Chronic cortisol deficiency, also lacks aldosterone
-MC caused by bilateral adrenal destruction from autoimmune disease.
✔✔Addison's disease manifestations - ✔✔Low Cortisol and High ACTH
-hyperpigmentation d/t increased ACTH
-low cortisol causes: weakness, fatigue, non specific GI sx
Decreased aldosterone causes:
-hyponatremia
-hyperkalemia
-non anion gap Metabolic acidosis
✔✔Addison's disease dx - ✔✔1. high dose ACTH (Cosyntropin) Stimulation Test:
screens for adrenal insufficiency
-little to no increase in cortisol levels
-Bloos or urine cortisol measured before and after IM injection of ACTH
✔✔Addison's disease management - ✔✔Hormone replacement. Glucocorticoids +
Mineralocorticoids
1. synthetic glucocorticoid: hydrocortisone 1st line
2. synthetic mineralocorticoid: Fludrocortisone
✔✔Pheochromocytoma - ✔✔Catecholamine-secreting tumors that arise from
enterochromaffin cells of the adrenal
,Rare
90% benogn
✔✔Pheochromocytoma clincical manifestations - ✔✔1. HTN
2. "PHE" = Palpitations, Headaches, Excessive sweating
✔✔Pheochromocytoma dx - ✔✔1. increased 24hr catecholamines including metabolites
(metanephrine and vanillylmandelic acid)
2. MRI or CT to visualize tumor
✔✔Pheochromocytoma tx - ✔✔Complete adrenalectomy
-preoperative a-blockade: phenoxybenzamine or phentolamine
✔✔Cushings syndrome vs cushings disease - ✔✔Syndrome = signs and sx related to
cortisol excess
Disease = Cushing's syndrome caused specifically by Pituitary increased ACTH
secretion
✔✔Cushing's disease manifestations - ✔✔sx secondary to excess cortisol and
glucocarticoids
1. Redistribution of fat: central obesity, "Moon facies", Buffalo hump
2. Catabolism of protein: wasting of extremities
3. HTN: weight gain, osteoporosis, hypokalemia*, acanthosis nigricans, mental
depression, mania, psychosis
✔✔Cushing's disease etiologies - ✔✔1. Taking corticosteroids (MC)
2. Cushing's disease - benign ACTH-secreting pituitary adenoma
3. ectopic ACTH secreting Pituitary adenoma
4. Adrenal tumor
✔✔Cushing's disease diagnosis - ✔✔Screening tests:
1. low- dose Dexamethasone suppression test:
Give 1 mg dexamethasone at 11 pm
At 8 am draw serum cortisol level
No suppression = cushings syndrome
2. increased 24 hr urinary free cortisol levels: if eleveated = Cushing's syndrome
3. INcreased salivary cortisol levels
✔✔Cushing's syndrome management - ✔✔1.Cushing's disease:
transsphenoidalsurgery
2. Ectopic tumor: removal of tumor, ketoconazle in innoperative (decreased cortisol
production)
, 3. iatrogenic steroid therapy: gradually withdrawal from steroids
✔✔Hypoparathyroidism - ✔✔Rare: either low PTH or insensitivity to its action
MC etiologies are:
1. accidental damage or removal of parathyroid during neck/thyroid surgery
2. autoimmune destruction of thyroid gland
✔✔Hypoparathyroidism Manifestation - ✔✔Signs of hypocalcemia:
carpopedal spasms, Trousseau and Chvostek sign, perioral paresthesia, increased
DTRs
✔✔Hyperparathyroidism dx and tx - ✔✔1. Triad of hypocalcemia, decreased PTH, and
increased Phosphate
Tx: supplementation of calcium and Vit D
✔✔Acromegaly - ✔✔Pituitary tumore causing increased growth hormone secretion
tx: transsphenoidal resection of pituitary
✔✔Hypocalcemia Hx/PE - ✔✔-Muscle cramps, finger parasthesias
-tetany: chvostek's sign - facial spasm with tapping; trousseau sign: inflation of BP cuff
causes carpal spasm; increased DTRs
-Cardio: arrhythmias - prolonged QT
Skin: dry
GI: diarrhea, abd pain/cramps
✔✔Hypocalcemia Dx - ✔✔Serum Ca levels below 8.5 mg/dl
✔✔Hypocalcemia Tx - ✔✔Mild: PO calcium + Vit D
Severe: IV calcium gluconate
✔✔Hypocalcemia Etiology - ✔✔-hypoparathyroidism
-chronic renal dz (MC if PTH normal)
-Vit D deficiency
-hypomagnesemia
✔✔Hypercalcemia Hx/PE/Dx/Tx - ✔✔-Most are asymptomatic
-stones: kidney stones
-bones: painful bones, fractures
-abdominal groans: ileus, constipation*
-psychiatric moans: weakness, fatigue decresed DTRs, depression or psychosis
✔✔Hypercalcemia causes - ✔✔-90% due to primary hyperparathyroidism or malignancy
QUESTIONS AND ANSWERS GRADED A+
✔✔Clinical manifestations of acute cholecystitis - ✔✔1.. Biliary colic
2. Fever, N/V, and palpable gallbladder* (33%)
positive Murphy's sign
positive boas sign*
jaundice not common
✔✔Dx of acute cholecystitis - ✔✔1. US: initial test of choice: thickenned gallbladder
(>3mm), distended gallbladder, sludge gallstones, pericholcystic fluid, and positive
sonographic murpheys sign
2. Labs: increased WBCs (leukocytosis with keft shift), increased bilirubin, increased
ALP and LFTs
3. HIDA scan: Gold standard!
✔✔management of acute cholecystitis - ✔✔1. conservative: npo, ivf, abx (3rd gen
cephalosporin and metronidazole)
2. cholecystectomy if that doesnt work (usually within 72 hrs)
Meperidine is preferred pain management
✔✔Cholangitis - ✔✔biliary tract infection secondary to obstruction by gallstone
Charcots triad: Jaundice, RUQ pain, fever
Raynauds pentad: added AMS change and hypotension
✔✔Celiac disease - ✔✔Autoimmune intestinal reaction to alpha gliadin in gluten,
leading to loss of villi & absorptive area
-causes B12, folate, and iron deficiency
✔✔Celiac disease Presentation - ✔✔Clinical presentation
a. Diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension
are common.
b. Infants and children may present with failure to thrive.
c. Older patients may present with iron deficiency, coagulopathy, and hypocalcemia.
✔✔Celiac disease Dx - ✔✔Small bowel biopsy
✔✔Irritable bowel syndrome - ✔✔Chronic functional idiopathic disorder with NO organic
cause.
Hallmark: Abd pain associted with altered defecation/bowel habits (diarrhea,
constipation, or altering between the two.
✔✔Irritable bowel syndrome dx - ✔✔Abd pain or discomfort with 2 of 3 features for at
least 12 weeks (not necessarily consecutive)
,-Relief with defecation**
-onset associated with change in stool frequency
-onset associated with change in stool formation
✔✔Irritable bowel syndrome tx - ✔✔Lifestyle changes: smoking cessation, eat low
fat/unprocessed foods
-if diarrhea: anticholinergics or antidiarrheals
-if constipation: bulking laxitives
✔✔Common Thyroid abnormalities table - ✔✔
✔✔Diabetes insipidus - ✔✔ADH deficiency (central DI) or insensitivity to ADH
(nephrogenic)
-causes the kidneys to be unable to concentrate urine, so production of large amounts
of dilute urine
✔✔Diabetes insipidus management - ✔✔1. Central DI: desmopression/DDAVP, or
carbemazepine
2. Nephrogenic DI: Na/protein restricion, and hydrochlorothiazide or indomethocin
3. If symptomatic: hypotonic fluid
✔✔Addison's disease - ✔✔Primary Adrenal Insufficiency
-Chronic cortisol deficiency, also lacks aldosterone
-MC caused by bilateral adrenal destruction from autoimmune disease.
✔✔Addison's disease manifestations - ✔✔Low Cortisol and High ACTH
-hyperpigmentation d/t increased ACTH
-low cortisol causes: weakness, fatigue, non specific GI sx
Decreased aldosterone causes:
-hyponatremia
-hyperkalemia
-non anion gap Metabolic acidosis
✔✔Addison's disease dx - ✔✔1. high dose ACTH (Cosyntropin) Stimulation Test:
screens for adrenal insufficiency
-little to no increase in cortisol levels
-Bloos or urine cortisol measured before and after IM injection of ACTH
✔✔Addison's disease management - ✔✔Hormone replacement. Glucocorticoids +
Mineralocorticoids
1. synthetic glucocorticoid: hydrocortisone 1st line
2. synthetic mineralocorticoid: Fludrocortisone
✔✔Pheochromocytoma - ✔✔Catecholamine-secreting tumors that arise from
enterochromaffin cells of the adrenal
,Rare
90% benogn
✔✔Pheochromocytoma clincical manifestations - ✔✔1. HTN
2. "PHE" = Palpitations, Headaches, Excessive sweating
✔✔Pheochromocytoma dx - ✔✔1. increased 24hr catecholamines including metabolites
(metanephrine and vanillylmandelic acid)
2. MRI or CT to visualize tumor
✔✔Pheochromocytoma tx - ✔✔Complete adrenalectomy
-preoperative a-blockade: phenoxybenzamine or phentolamine
✔✔Cushings syndrome vs cushings disease - ✔✔Syndrome = signs and sx related to
cortisol excess
Disease = Cushing's syndrome caused specifically by Pituitary increased ACTH
secretion
✔✔Cushing's disease manifestations - ✔✔sx secondary to excess cortisol and
glucocarticoids
1. Redistribution of fat: central obesity, "Moon facies", Buffalo hump
2. Catabolism of protein: wasting of extremities
3. HTN: weight gain, osteoporosis, hypokalemia*, acanthosis nigricans, mental
depression, mania, psychosis
✔✔Cushing's disease etiologies - ✔✔1. Taking corticosteroids (MC)
2. Cushing's disease - benign ACTH-secreting pituitary adenoma
3. ectopic ACTH secreting Pituitary adenoma
4. Adrenal tumor
✔✔Cushing's disease diagnosis - ✔✔Screening tests:
1. low- dose Dexamethasone suppression test:
Give 1 mg dexamethasone at 11 pm
At 8 am draw serum cortisol level
No suppression = cushings syndrome
2. increased 24 hr urinary free cortisol levels: if eleveated = Cushing's syndrome
3. INcreased salivary cortisol levels
✔✔Cushing's syndrome management - ✔✔1.Cushing's disease:
transsphenoidalsurgery
2. Ectopic tumor: removal of tumor, ketoconazle in innoperative (decreased cortisol
production)
, 3. iatrogenic steroid therapy: gradually withdrawal from steroids
✔✔Hypoparathyroidism - ✔✔Rare: either low PTH or insensitivity to its action
MC etiologies are:
1. accidental damage or removal of parathyroid during neck/thyroid surgery
2. autoimmune destruction of thyroid gland
✔✔Hypoparathyroidism Manifestation - ✔✔Signs of hypocalcemia:
carpopedal spasms, Trousseau and Chvostek sign, perioral paresthesia, increased
DTRs
✔✔Hyperparathyroidism dx and tx - ✔✔1. Triad of hypocalcemia, decreased PTH, and
increased Phosphate
Tx: supplementation of calcium and Vit D
✔✔Acromegaly - ✔✔Pituitary tumore causing increased growth hormone secretion
tx: transsphenoidal resection of pituitary
✔✔Hypocalcemia Hx/PE - ✔✔-Muscle cramps, finger parasthesias
-tetany: chvostek's sign - facial spasm with tapping; trousseau sign: inflation of BP cuff
causes carpal spasm; increased DTRs
-Cardio: arrhythmias - prolonged QT
Skin: dry
GI: diarrhea, abd pain/cramps
✔✔Hypocalcemia Dx - ✔✔Serum Ca levels below 8.5 mg/dl
✔✔Hypocalcemia Tx - ✔✔Mild: PO calcium + Vit D
Severe: IV calcium gluconate
✔✔Hypocalcemia Etiology - ✔✔-hypoparathyroidism
-chronic renal dz (MC if PTH normal)
-Vit D deficiency
-hypomagnesemia
✔✔Hypercalcemia Hx/PE/Dx/Tx - ✔✔-Most are asymptomatic
-stones: kidney stones
-bones: painful bones, fractures
-abdominal groans: ileus, constipation*
-psychiatric moans: weakness, fatigue decresed DTRs, depression or psychosis
✔✔Hypercalcemia causes - ✔✔-90% due to primary hyperparathyroidism or malignancy
