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Study Notes Internal Medicine

Study Notes Internal Medicine



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Study Notes Internal Medicine
Study Notes Internal Medicine

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Study Notes – Internal MedicineJames Lamberg28Jul2010DO NOT DISTRIBUTE - 1 -
: Cecil Essentials of Medicine, Hospital Medicine Secrets, First Aid for Medical Clerkship
Introductory Guide
: Primer to the Internal Medicine Clerkship 2nd Edition by Picchioni
--------------------------------------------------------------------------------------------------------------------------------------------Common Problems in Internal Medicine
Cardiovascular: Acute Coronary Syndromes, Congestive Heart Failure, Valvular Heart Disease, Atrial Fibrillationand Anticoagulation, HypertensionEndocrine: Diabetes Mellitus, Hypothyroidism, Hyperthyroidism, Osteoporosis, Disorders of Calcium MetabolismHematology: Anemia, CoagulopathiesGastro: Hepatitis, Peptic Ulcer Disease, Gastroesophageal Reflux Disease, Diarrhea and ConstipationOncology: Hematological Malignancy, General Care of the Cancer Patient, Management of Pain Nephrology: Electrolyte Disturbances, Acid-Base Disorders, Acute and Chronic Renal FailureRheumatology: Rheumatoid Arthritis, Osteoarthritis, Monoarthritides, PolyarthritidesPulmonary: DVT and Pulmonary Embolism, Chronic Bronchitis and Asthma, EmphysemaInfectious: Fever of Unknown Origin, Acquired Immune Deficiency Syndrome, Pneumonia, Urinary TractInfection, Cellulitis, Subacute Bacterial EndocarditisAllergy: Urticaria Neurology: Cerebrovascular Disease, Headache, Dementia and ComaDermatology: Dermatological Manifestations of Chronic Medical Disease
 NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine
Kaplan Videos (2001) – Board Studying Thoughts from Dr. Conrad Fischer, MD
* For USMLE Step 2 (and any exam for that matter), think from the point of view of the question writer. Questionsyou can expect include “Which of the following is the most likely diagnosis?” seem commonly in Internal Medicinesections, where physicians ponder over the diagnosis for hours. Diagnosis questions account for about 20-30%,more in Internal Medicine, less on Surgery. “Which of the following is the best initial diagnostic test?” or “Whatwould you do first to confirm your diagnosis?” Also, “What is the best diagnostic test” or “What is the mostaccurate diagnostic test?” Treatment questions follow “Which of the following is the best initial therapy?” Alwaysask “What is the next best step in the management of this patient?”* What is the problem? Pay attention to the question. If the question asks what is the best initial diagnostic test andyou pick the best test (most accurate), you missed the question. If the question asks what is the best initial therapyand you choose the best therapy (most effective), you missed the question.* But you think to yourself, no no no I don’t do this. I won’t make this mistake. But, you do make this mistake because everybody makes this mistake. Examination results show this time and time again.* Answer questions based on what the question-writer is saying, now what you think they mean.* You’re sitting there looking up at that board exam and all you see is a huge exam. You feel scared and all you canthink about is how big that exam is. But, if you could find a way to look past the exam and see good and beauty.You could connect with the goodness and beauty that is beyond the exam, which you can’t do right now because allyou see is a giant exam. But, if you can connect with the knowledge, the data that you need for the exam andconnect it with the beauty and good, great things will happen.* First, the exam will seem much smaller and lighter in the palm of your hands (from William Blake). Second, youwill be able to remember the knowledge longer and help someone later on with it, and that is a great good. Third,you will get a better grade anyway and get what you want. If doing well on the exam is your highest aspiration, itwill become so painful. Fourth, your trip/voyage/journey will be filled with much more joy. This idea is theanalgesic for your studying.
How To Succeed In Clerkship – First Aid For The Medicine Clerkship (Stead, Stead, & Kaufman)
 Be On Time
: Team rounds usually begin between 7am and 8am. Give yourself at least 10 minutes per patient for  pre-rounding to learn about events that occurred overnight or lab/imaging results.
 Dress In A Professional Manner 
: Regardless of what the attending wears. A short white coat should be worn over your professional dress clothes unless it is discouraged (e.g. pediatrics).
 Act In A Pleasant Manner 
: The medical rotation is often difficult, stressful, and tiring. Smooth out your experience by being nice to be around. Smile a lot and learn everyone’s name. Don’t be afraid to ask how your resident’sweekend was. If you do not under- stand or disagree with a treatment plan or diagnosis, do not “challenge.” In-stead, say “I’m sorry, I don’t quite understand, could you please explain…” Show kindness and compassion towardyour patients. Never participate in callous talk about patients.
Study Notes – Internal MedicineJames Lamberg28Jul2010DO NOT DISTRIBUTE - 2 -
Take Responsibility
: Know everything there is to know about your patients: their history, test results, details abouttheir medical problem, and prognosis. Keep your intern or resident informed of new developments that they mightnot be aware of, and ask them for any updates you might not be aware of. Assist the team in developing a plan;speak to radiology, consultants, and family. Never give bad news to patients or family members without theassistance of your supervising resident or attending.
 Respect Patient’s Rights
1) All patients have the right to have their personal medical information kept private. This means do not discuss the patient’s information with family members without that patient’s consent, and do not discuss any patient inhallways, elevators, or cafeterias.2) All patients have the right to refuse treatment. This means they can refuse treatment by a specific individual (you,the medical student) or of a specific type (no nasogastric tube). Patients can even refuse life- saving treatment. Theonly exceptions to this rule are if the patient is deemed to not have the capacity to make decisions or understandsituations, in which case a health care proxy should be sought, or if the patient is suicidal or homicidal.3) All patients should be informed of the right to seek advanced directives on admission. Often, this is done by theadmissions staff, in a booklet. If your patient is chronically ill or has a life-threatening illness, address the subject of advanced directives with the assistance of your attending.
More Tips
: Volunteer, be a team player, be honest, and keep patient information handy.
 Present In An Organized Manner 
: “This is a [age]-year-old [gender] with a history of [major history such as HTN,DM, coronary artery disease, CA, etc.] who presented on [date] with [major symptoms, such as cough, fever, andchills] and was found to have [working diagnosis]. [Tests done] showed [results]. Yesterday, the patient [stateimportant changes, new plan, new tests, new medications]. This morning the patient feels [state the patient’s words],and the physical exam is significant for [state major findings]. Plan is [state plan].”
 Presenting A Chest Radiograph (CXR)
1) Technique: Rotation, anteroposterior (AP) or posteroanterior (PA), penetration, inspiratory effort.2) Bony structures: Look for rib, clavicle, scapula, and sternum fractures.3) Airway: Look for tracheal deviation, pneumothorax, and pneumomediastinum.4) Pleural space: Look for fluid collections, which can represent hemothorax, chylothorax, and pleural effusion.5) Lung parenchyma: Look for infiltrates and consolidations: These can represent pneumonia, pulmonarycontusions, hematoma, or aspiration. The location of an infiltrate can provide a clue to the location of pneumonia:* Obscured right (R) costophrenic angle = Right lower lobe* Obscured left (L) costophrenic angle = Left lower lobe* Obscured R heart border = Right middle lobe* Obscured L heart border = Left upper lobe6) Mediastinum: Look at size of mediastinum—a widened one (> 8 cm) goes with aortic dissection. Look for enlarged cardiac silhouette (> 1⁄2 thoracic width at base of heart), which may represent congestive heart failure(CHF), cardiomyopathy, or pericardial effusion.7) Diaphragm: Look for free air under the right hemidiaphragm (suggests perforation). Look for stomach, bowel, or nasogastric tube (NGT) above diaphragm (suggests diaphragmatic rupture).8) Tubes and lines:* Identify all tubes and lines.* An endotracheal tube should be 2cm above the carina. Common mistake is right bronchus intubation.* A chest tube (and proximal hole) should be in the pleural space (not in the lung parenchyma).* An NGT should be in the stomach and uncoiled.* The tip of a central venous catheter should be in the superior vena cava (not in the right atrium).* The tip of a Swan–Ganz catheter should be in the pulmonary artery.* The tip of a transvenous pacemaker should be in the right atrium.
 Presenting A Chest Radiograph (Mnemonic Method)
Mnemonic: RRR, RIP, ABCDEFGH* Right: patient, procedure, date* Rotation: spinous processes are to line up vertically, equal space between clavicles* Inspiration: should show 8 ribs* Penetration: spinous processes should just be visible through the vertebrae* Airway: carina and tracheal deviation* Bones: look at clavicles, vertebrae, scapula, and ribs for fractures
Study Notes – Internal MedicineJames Lamberg28Jul2010DO NOT DISTRIBUTE - 3 -* Cardiac silhouette: > 1/2 total chest width could be CHF, determine if edges are clear * Diaphragm: elevated or depressed, right should be higher, no air under diaphragm* Effusions: check borders and edges for fluid levels, hemothorax, atelectasis, pneumothorax* Fields: infiltrates, masses, objects, size (large in emphysema, small in chronic bronchitis)* Gadgets: ET tubes, central lines, chest tubes, pacemakers, ECG monitors, mention this after RRR RIP in ICU* Hilum: any masses or disturbances
 Presenting An Electrocardiogram (ECG)
1) Rate: The rate is [number of] beats per minute (bpm):* The ECG paper is scored so that one big box is 0.20 seconds. These big boxes consist of five little boxes, each of which is 0.04 seconds.* A quick way to calculate rate when the rhythm is regular is the mantra: 300, 150, 100, 75, 60, 50 (= 300 / # large boxes), which is measured as the number of large boxes between two QRS complexes. Therefore, a distance of onelarge box between two adjacent QRS complexes would be a rate of 300, while a distance of five large boxes between two adjacent QRS complexes would be a rate of 60.* For irregular rhythms, count the number of complexes that occur in a 6-second interval (30 large boxes) andmultiply by 10 to get a rate in bpm.2) Rhythm: The rhythm is [sinus]/[atrial fibrillation]/[atrial flutter] or other:* If p waves are present in all leads and upright in leads I and aVF, then the rhythm is sinus. Lack of p wavessuggests a disorganized atrial rhythm, a junctional rhythm, or a ventricular rhythm. A ventricular rhythm (V Fib or V Tach) is an unstable one (could spell imminent death), and you should be getting ready for advanced cardiac lifesupport (ACLS).* Normal sinus rhythm is usually a regular narrow-complex rhythm with each QRS complex preceded by a p wave.3) Axis: The axis is [normal]/[deviated to the right]/[deviated to the left]:* If I and aVF are both upright or positive, then the axis is normal.* If I is upright and aVF is upside down, then there is left axis deviation (LAD).* If I is upside down and aVF is upright, then there is right axis deviation (RAD).* If I and aVF are both upside down or negative, then there is extreme RAD.4) Intervals: The [PR]/[QRS] intervals are [normal]/[shortened]/[widened]:* Normal PR interval = 0.12 to 0.20 seconds:* Short PR is associated with Wolff–Parkinson–White syndrome (WPW).* WPW syndrome is characterized by a “delta” wave, or slurred up-stroke of QRS complex.* Long PR interval is associated with heart block of which there are three types:* First-degree block: PR interval > 0.20 seconds (one big box)* Second-degree (Mobitz type I or Wenckebach) block: PR interval lengthens progressively until a QRS is dropped.* Second-degree (Mobitz type II) block: PR interval is constant, but one QRS is dropped at a fixed interval.* Third-degree heart block: Complete AV dissociation Normal QRS interval
0.12 seconds:* Prolonged QRS is seen when the beat is initiated in the ventricle rather than the sinoatrial node, when there is a bundle branch block, and when the heart is artificially paced with longer QRS intervals. Prolonged QRS is alsonoted in tricyclic overdose and Wolfe–Parkinson–White syndrome.5) Wave morphology:A. Ventricular hypertrophy: There [is/is no] [left/right] [ventricular/atrial] hypertrophy:* There are multiple criteria for determining right (RVH) and left ventricular hypertrophy (LVH).Clues for LVH:* RI>15mm, RI,II or aVF >20mm, RaVL>11mm, RV5 or RV6 >26mm, RI +SIII >25mm, R+S in Vlead>45mm,SV1 +RV5 or RV6 >35mmClues for RVH:* RV1>7mm, SV1<2mm, R/S ratio inV1 >1, RAD of 110deg or moreB. Atrial hypertrophy:* Right atrial hypertrophy: tall or peaked p waves in limb or precordial leads* Left atrial hypertrophy: broad or notched p waves in limb leadsC. Ischemic changes: There [are/are no] S-T wave [depressions/elevations] or [flattened/inverted] T waves. Presenceof Q wave indicates an old infarct.D. Bundle branch block: There [is/is no] [left/right] bundle branch block. Clues:* Presence of RSR’ wave in leads V1-V3 with ST depression and T wave inversion goes with RBBB.* Presence of notched R wave in leads I, aVL, and V4-V6 goes with LBBB.

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