CC3 Internal Medicine

Written Exam Review

August 30 2024
DISCLAIMER…

• This is merely a REVIEW

• Most of your learning will be from the WARDS
• If you can’t think of the answer…think back to what you did
in the REAL world setting with your patients
• You know more than you think!!
Outline

• Hour 1: Order writing and MCQs

• Break
• Hour 2: Cardiology, Respirology, Hematology
• Break
• Hour 3: Nephrology, Endocrinology, Rheumatology, GI, Neurology

• Self study: OSCE stations

https://docs.google.com/presentation/d/1pr9RRzvMBHQa3_E4hV
bj4i2DD4YwhGRP/edit?usp=sharing&ouid=1167247081832795103
51&rtpof=true&sd=true
Order writing ADC DAVIIID

• ADC DAVIIID
• Admit to
• Diagnosis
• Consults (including allied health)
• Diet
• Activity
• Vitals + nursing
• Investigations
• IVs
• Isolation
• Drugs:
• To treat the cause of the presentation
• The 5 P’s pain, puke, pus, prophylaxis, precedent
• HELD medications
Order writing

• ADC DAVIIID
• Re-read after and make sure you have considered causes of
event, consequences and management
• Don’t sweat too much over drug doses-knowing which drugs
are indicated is most important
• Give an indication for PRN meds (e.g. for pain, dyspnea)
Order writing

• Err on the side of caution

• Order frequent vitals, blood work
• Don’t forget to isolate patients for infectious diseases
• Contact- diarrhea
• Droplet- pneumonia
• Negative pressure- TB
• Consider allied health consultation (PT/OT/SW/dietician)
• This is not like the real world, so you will need to order
things usually done for you by the ER physicians
Case 1

• 72 year old man presents with a CHF exacerbation

• Write orders…
CHF Orders

• Admit to Team A under Dr. X

• Diagnosis: Congestive heart failure
• Consults: Cardiology
• Diet: Healthy heart diet, restrict to < 1200 mL/day, low sodium (<2
g/day)
• Activity: as tolerated
• Vitals: Q4h, maintain O2 sat > 92%, +/- telemetry, call MD if SBP <
100 or > 180, HR < 50 or > 100
• IV/nursing instructions: IV to saline lock, I&Os Q12h, daily weights
CHF Orders

• Investigations
• Chest X-ray - PA and lateral
• CBC, Na, K, Cl, HCO3, creatinine, INR, aPTT, AST, ALT, ALP, bili, troponin Q8H
x3, Ca/Mg/PO4, albumin, BNP, TSH
• Daily electrolytes, creatinine
• ECG (12 lead)
• 2D echocardiogram - TTE
• Drugs
• Lasix 60 mg IV x1 now, then MD to reassess daily
• Nitroglycerin 0.4mg/hr transdermal - apply now, reapply daily at 1000h and
remove at 2200h. Hold if sBP<100
• Morphine 1-2 mg IV Q2H PRN for dyspnea. Hold if sBP <100
• MD to assess for initiation of ACEi and beta blocker in 24-48 hours
• Home medications
• Dietician consultation, heart failure pathway
Case 2

• 65 year old man presents with 72 hour history of

lightheadedness, presyncope, and dyspnea. He reports 2
episodes of dark tarry stools and has been vomiting blood.
He has a significant history of alcohol use. Initial SBP 100.
Hemoglobin 65 g/L.
• Write admission orders
Upper GI Bleed

• Admit to Step-up unit under Team A (Dr. X)

• Diagnosis: Upper GI Bleed
• Consults: Gastroenterology
• Diet: NPO - for possible OGD tomorrow
• Activity: as tolerated, not to leave ward
• Vitals: Q2H - call MD if HR>100, sBP<100. Keep
SaO2>92%
• IVs and nursing instructions
• Two large bore IVs (16 gauge)
• Bolus normal saline x1 litre over 20 minutes, then MD to
reassess
UGIB

• Investigations
• CBC, lytes, creatinine, INR, aPTT, AST, ALT, ALP, bilirubin, albumin, glucose,
lactate, BUN
• Group and screen
• CBC Q6H, Daily lytes, creatinine, INR, aPTT
• ECG – ?demand ischemia, ?arrhythmia from electrolyte abnormality
• Drugs
• Pantoloc 80mg IV x1, then 8 mg/hr IV
• (Octreotide 50 mcg IV x1, then 50mcg/hr IV) - only if they give you a story
suggestive of liver disease for treatment of variceal bleed
• Ceftriaxone 1g IV q24h (if known/suspected cirrhosis-related ascites) for 7 days
• GI consultation for OGD
• 1 unit pRBCs transfused over 2 hours
• CIWA
• Thiamine 500 mg IV daily x 3 days
Case 3

• 80 year old woman from home presents with fever and

productive cough. She requires admission for community
acquired pneumonia (CAP). Initial SBP 80.
• Write orders…
Community acquired pneumonia

• Admit To: Step-Up unit under Team A Medicine (Dr. Jogova)

• Diagnosis: Community Acquired Pneumonia
• Diet: As tolerated
• Activity: As tolerated
• Vitals: Q2H - call MD if HR>100, sBP<100. Keep SaO2>92% (88-92% if
COPD)
• IVs and nursing instructions
• Droplet precautions
• Bolus normal saline x1 litre over 30 minutes, then MD to reassess
CAP
• Investigations
• Blood cultures x2 now, sputum cultures
• CBC, lytes, creatinine, INR, aPTT, lactate, liver enzymes, ?NP/MT swab
• Daily CBC, lytes, creatinine
• CXR

• Drugs
• Ceftriaxone 1 g IV now, then Q24H (after cultures drawn)
• Azithromycin 500 mg IV x1 now, then Q24H (po)
• – ?Antiviral and levofloxacin 750 mg PO daily would be reasonable
• Acetaminophen 325 - 650 mg PO Q4H PRN for T>38.3 (If T>38.3, please call
MD).
• Ventolin 2 puffs q4h prn, atrovent 2 puffs q4h prn
• Prednisone if COPD exacerbation 50 mg daily x 5 days

• PT for chest physio, RT to assist with O2 delivery

Case 4

Admit a 50F with AKI in context of recent nephrotoxic medication

exposure.
AKI

• Admit To: General Internal Medicine Dr. Badkidney

• Diagnosis: Acute kidney injury
• Consults: +/- nephrology
• Diet: Nephro diet Low K, Low Phos
• Activity: As tolerated
• Vitals + nursing: Q4H, post-void residual bladder scan. Foley
catheter and page MD if urine output <0.5cc/kg/hr
• Isolation: Routine precautions
• IVs:
• Bolus? Saline lock IV?
AKI Continued

◼ Investigations:
▪ CBC, lytes, creatinine, extended lytes, albumin daily x 3
▪ Urinalysis, urine microscopy and ACR
▪ Renal ultrasound with dopplers rule out hydronephrosis.
◼ Drugs:
▪ HOLD nephrotoxic drug
▪ Heparin 5000 units BID for DVT prophylaxis (depending on severity of renal
injury)
▪ If previously on NSAIDs, ACE/ARB, etc. must be held
▪ Careful to dose adjust or hold: anticoagulants and anti-hyperglycemic
medications
Case 5

Admit a 70M with acute diarrhea after recent episode of antibiotics for
dental infection.
Diarrhea

• Admit To: GIM Dr. Difficile

• Diagnosis: Acute Diarrhea
• Diet: Regular as tolerated
• Activity: Activity as tolerated
• Vitals + nursing: Q4H, Stool charting
• Isolation: Contact precautions
• IVs:
• Bolus 1L Ringer’s Lactate IV over 2hrs (if volume depleted or AKI)
Diarrhea continued…

• Investigations
• CBC, lytes, creatinine, extended lytes, lactate, liver enzymes, albumin
• Blood cultures
• C diff toxin assay, stool cultures, ova and parasites
• Drugs
• Home meds (HOLD anything that could worsen hypotension or AKI)
• Tylenol 500mg q6h prn pain/fever
• Enoxaparin 40mg subcut daily
 Questions!

• An 84-year-old woman presents to the ED complaining of persistent left-

sided, dull chest pressure at rest. It is accompanied by nausea, diaphoresis
and SOB. It is typical, though worse than her angina pain which she has had
for three years. Over the past few weeks, she has reports to have needed
her nitroglycerin more frequently.

• PMH: HTN, hypercholesterolemia and DM2 (managed by diet) and

hypothyroidism. She does not drink alcohol or smoke.

• O/E: HR 90, regular and BP 100/50. Her lungs are clear to the bases
bilaterally. Precordial examination reveals an S4. The rest of her
examination is normal. Initial laboratory work reveals a normal CBC and
lytes and a troponin of 640 (high sensitivity)
Interpret ECG
What is the next best step?

A. Oxygen
B. Metoprolol
C. Percutaneous coronary intervention
D. Nitrospray
E. Amiodarone
Question 2

Which of the following is not an indication for dialysis?

A. Refractory acidosis
B. Uremic pericarditis
C. Volume overload refractory to diuresis
D. Hyperphosphatemia
E. Hyperkalemia
Question 3

88 year-old active smoker with known severe COPD (FEV1/FVC = 0.4).

Last admitted to GIM 2 months ago with an infectious acute COPD
exacerbation. She presents to the ED with a 3 day history of
productive cough, increased sputum and SOBOE.

On examination, she appears to be in respiratory distress. Her O2 sat

is 82 on RA. RR 30 BP 150/80 and heart rate 92. Her chest exam
reveals diffuse wheeze and prolonged expiration.
Interpret the X-ray
Question 3

All would be appropriate considerations for treatment except:

A. Prednisone 50 mg PO x 5 days
B. Levofloxacin 750 mg PO x 7 days
C. Ventolin 2 puffs q4h standing
D. Consider BiPAP
E. Lasix 60 mg IV x1 now and then daily
Question 4

Name the following abnormality

Question 4

Clubbing can be seen in all of the following except:

A. Bronchiectasis
B. Cirrhosis
C. Endocarditis
D. COPD
E. Inflammatory Bowel Disease
 Causes of Clubbing

• Idiopathic or secondary
• Secondary:
• Resp: Lung CA, CF, ILD, Sarcoid
• Cardiac: Cyanotic congenital heart disease, endocarditis
• GI: UC, Crohn’s, PBC, liver cirrhosis, HPS
• Cancer
Question 5

What is the abnormality on blood film:

Question 5

All of the following are likely to be associated with the disease

associated with the blood film except:
A. Hypocalcemia
B. Renal failure
C. Amyloidosis
D. Lytic lesions
E. Anemia
 Question 6

What’s the
diagnosis?
Question 6 cont…

The antibiotic regimen that makes most sense for the 70 M who
presents with a fever of 39.2 C and the previous CXR.
A. Ciprofloxacin 500 mg PO BID
B. Piperacillin/tazobactam 4.5 g IV q8h
C. Cefepime 2 g IV daily
D. Azithromycin 500 mg IV daily
E. Levofloxacin 750 mg IV daily
Question 7

A 45 F presents with acute R leg swelling and lower extremity U/S

show an occlusive DVT in the R common femoral vein.
The best treatment option is:
A. Enoxaparin (LMWH) 1.5 mg/kg SC daily, transitioning to warfarin
B. Rivaroxaban 15 mg PO BID (DOAC)
C. Apixaban 10 mg PO BID (DOAC)
D. All of the above are reasonable
Question 8

What’s the diagnosis?

Question 8 cont…

Best treatment options is…

A. Amiodarone
B. Metoprolol
C. Adenosine
D. Vagal maneuvers
E. All of the above
Question 9

A 70 M presents with cellulitis. You decide to send him home with PO

Keflex. Routine ECG (asymptomatic) prior to discharge shows and
normal troponin:
Question 9 cont…

The next best step is…

A. ASA
B. IV heparin
C. Metoprolol
D. Percutaneous coronary intervention
E. Discharge home
Question 10

A 40M presents to the local emergency department with a one day

history of fever, confusion and lethargy. Physical exam shows T39.8 BP
110/80 HR 110 RR 26 and Sa02 98% RA. There is evidence of
petechiae on his lower extremities. No meningismus.

• His CBC shows: Hb 90 Plts 30 WBC 11 Electrolytes are normal, Cr 130

Question 10 cont..

What is the abnormality…

Question 10 cont…

The next step in management is…

A. Begin pip/tazo and vancomycin STAT
B. Anticoagulate with IV heparin
C. Transfuse 2 U PRBCs
D. Transfuse 4 pools of adult platelets
E. Consult hematology and consideration of plasma exchange
CARDIOLOGY
ECGs
What to identify on an ECG
1. Clinical context
2. Heart rhythm
○ Regular = same distance between R waves
3. Heart rate
○ 300 / n of large boxes between R waves
4. Cardiac axis
○ Normal = both lead I and II upright
○ RAD = Reaching
○ LAD = Leaving
5. Evaluate each wave & interval
○ P wave before every QRS → sinus rhythm
○ ST elevation and depression in territories → signs
of ischemia
○ QT prolongation → >440ms in women and
>460ms in men

Challenge yourself - how would you treat the following ECGs?

26 year old man has ECG done pre-op ACL repair

Normal sinus rhythm

ST elevations
DDx:
● Acute myocardial infarction
● Pericarditis
● Benign early repolarization
● Left bundle branch block
● Left ventricular hypertrophy
● Ventricular aneurysm
● Brugada syndrome
● Ventricular paced rhythm
40 year old woman with goitre, palpitations and ophthalmopathy

Sinus tachycardia =
think secondary cause
● Pain
● Exercise
● PE
● Hyperthyroid
● Sepsis/fever
● Anemia
● Volume deplete
● EtOH withdrawal
● Stimulants
● Salbutamol
48 year old man presents to the ED with acute chest pain

Anteroseptal STEMI
ECG signs of ischemia
● ST segment elevation
● ST depression
● T wave inversion or flattening
● Dynamic
● Reciprocal territories
80 year old woman presenting with palpitations

Atrial fibrillation
- No P waves
- Irregular irregular rhythm
57 year old man on a beta blocker for hypertension

2nd degree, Mobitz I AV block

AV Block
● 2nd degree, Mobitz II = dropped beats with
constant PR interval
● First degree = prolonged PR

● 3rd degree = complete dissociation between P

● 2nd degree, Mobitz I (Wenckebach) = waves and QRS complexes
progressive long PR then dropped QRS

Benign - often due to AV nodal blockers Ominous - usually structural heart

disease, needs pacemaker
70 year old man in clinic with ischemic cardiomyopathy

Left bundle branch block

(with atrial fibrillation)
- Broad QRS
- WiLLiaM
60 year old woman with poorly controlled COPD in clinic

Right bundle branch block

- Broad QRS
- MaRRoW
75 year old man presenting with dyspnea and CHF

Atrial flutter
- “Sawtooth” baseline
- 2:1 block = 150 bpm
28 year old woman in ED with abdominal pain

WPW pre-excitation
- Short PR
- Delta wave
32 year old man presents with recurrent palpitations

Supraventricular tachycardia =
bad terminology…
AVNRT is more specific
- Narrow complex
tachycardia
- Regular rhythm
- Retrograde P waves

Other SVT is AVRT, but you

won’t be expected to
differentiate the two
70 year old man with CAD presenting with palpitations

Monomorphic VT
- Broad QRS of same
morphology
- Tachycardia
How would you
treat these
tachycardic
patients if they had
a pulse?

If they had no
pulse?
42 year old man with schizophrenia presents with vomiting

Torsades de Pointes =
polymorphic VT
- Broad QRS tachy
- “Twisting” morphology
- Caused by long QT
- Congenital
- HypoK
- HypoMg
- Drugs Ex:
Antipsychotics,
methadone,
fluoroquinolones
67 year old man presenting with acute chest pain

Ventricular fibrillation
- Chaotic, irregular
- No discernible ECG
features
Heart Failure with reduced ejection fraction
(HF-REF)
• 89M with prior MI presents with SOB, orthopnea, PND
• JVP 5 cm, bilateral pitting edema
• 160/90, 87% RA, HR 100, RR 26

• What tests do you need?

• What is the mechanism of his heart failure?
Heart Failure with reduced ejection fraction
(HF-REF) – management
• Acute Rx =– reduce preload, reduce afterload
• Two pronged – reduce preload, reduce afterload
• ‘LMNOP’ not a great mnenomic, but…
• Lasix, morphine (rarely), nitro (if hypertensive), oxygen, position
• BiPAP an option

• Look for precipitant:

• Ischemia, arrhythmia, infections, diet, change in meds/compliance,
endocrine

• Meds with survival benefit = ABS

• ACE inhibitors (or ARB), beta blocker, Spironolactone
• SGLT-2 inhibitors and ARNIs (Entresto – STOP ACEi/ARB)
Heart Failure with reduced ejection fraction
(HF-REF) – Chronic
• Principles of Management
1. Lifestyle
• Low-salt diet
• Exercise
2. Manage Vascular RFs / Etiology
• DM, Lipids
• CAD
Coronary Artery Disease
Chronic/Stable Angina treatment STEMI, NSTEMI, USA
• For survival: • Treatment
• ASA • Dual Antiplatelet Therapy

• Risk factor modification

• ASA + Clopidogrel, Ticagrelor, Prasugrel

• Hypertension: Use ACE-i

• Anticoagulant
• Heparin (if STEMI), LMWH,
• Diabetes control Fondaparinux
• Dyslipidemia control: Use statin • If STEMI, Revascularization
• Diet/Exercise • PCI preferred
• Mortality benefit: Beta blocker, • If >120 minutes before first medical
contact to balloon choose fibrinolysis
ACE-i, statin
• If NSTEMI/USA:
• Use TIMI score to decide early (<48h) vs
• For symptoms: late (>48h) revascularization approach

• BB first line • Low risk “risk stratify” with exercise

stress test or MIBI
• Other options: CCB, Nitrates
• Consider CABG:
• Left main disease, T2DM and
multivessel CAD, 3 vessel disease
Atrial Fibrillation

• Rate control
• Rhythm control
• When to anticoagulate?
Atrial Fibrillation

• Rate control – target <110bpm

• Rhythm control
• When to anticoagulation?
• Options: DOAC, warfarin
Murmurs

• AS

• MR

• TR
Murmurs

• AS – crescendo-decrescendo, late peaking, radiation to clavicles.

Assess for apical radial delay, pulsus parvus et tardus, accentuated
apex

• MR – holosystolic, radiation to the axilla, lateral displacement of the

apex beat

• TR – systolic, LLSB, CV waves, can have pulsatile liver

Extra heart sounds

• S3
• Ventricular gallop
• Early in diastole
• Best heard with bell
• Rapid filling phase of ventricle
• Causes
• Heart failure (high atrial pressure)
• Regurgitations/Shunts – MR, VSD
Extra heart sounds

• S4
• Filling of stiff ventricle
• Late diastole, with atrial kick
• Cannot get with AF
• Causes
• Hypertension!
• HCM
• AS
• Anything causing LVH
I. Physical Exam Findings In…

CARDIAC TAMPONADE AORTIC DISSECTION

• Muffled heart sounds • Blood pressure difference
• Elevated JVP • Pulse deficit
• Pulsus Paradoxus • Diastolic murmur
• Tachycardia • (sudden-onset searing chest
• Hypotension pain)
RESPIROLOGY
CXR
Approach to CXR
• There are many approaches – use the one that you are most
comfortable with
• The most important thing is to have a consistent approach that becomes
routine for you
• Review technique, quality, and patient info (good way to stall…)
• “Outside-in” or “inside-out”
• ABCDEFGH
• Airway, bones, cardiac, diaphragm, effusions, lung fields, great vessels,
hila/mediastinum
• SYSTEMATIC APPROACH
• Quality Control, Lines & Hardware, Heart & Mediastinum, Lungs and
Diaphragm, Pleura, Bones, Soft Tissues
• CHECKPOINTS: Apices, Aorta, Hila, Retrocardiac Regions
Cough and abdominal pain in IBD patient

Free air
CHF
Cough, fever, hemoptysis, 4 days post-op from hip surgery.

Pulmonary
infarct
(Hampton’s
hump)
Lingular pneumonia
RML pneumonia
DDX Airspace Disease

• Fluid (cardiogenic vs. non-cardiogenic/ARDS)

• Pus (pneumonia)
• Blood (alveolar hemorrhage)
• Cells (bronchoalveolar carcinoma, lymphoma)
• Protein (pulmonary alveolar proteinosis)
Diffuse interstitial
DDx Interstitial Patterns

Reticular Nodular

• CHF • Cancer
• IPF / ILD • Pneumoconiosis
• Infectious (viral / atypical • Sarcoidosis
pneumonias) • Miliary TB
• Lymphangitic carcinomatosis • Fungal
• Medications (Bleomycin,
Nitrofurantoin)
Bilat hilar
LAD
Miliary TB
Lung mets
Cavitary lung
lesions
Tension
pneumothorax
COPD

• COPD
• Characterized by irreversible airflow obstruction (PFTs FEV1/FVC<0.7 or below
lower limit of normal)
• 3 things improve survival in COPD
• Quit smoking
• 24 hours O2 (if hypoxic at rest)
• Pulmonary rehabilitation
COPD Exacerbation

• Cardinal symptoms (Winnipeg Criteria)

• (a) increased sputum production
• (b) increased dyspnea
• (c) change in sputum colour (increased purulence)
• Oxygen (titrate 88-92%)
• Consider BiPAP for respiratory acidosis or respiratory distress
• Short acting bronchodilators standing and prn
• ipratropium (anticholinergic)
• salbutamol (beta agonist)
• Corticosteroids – 50 mg PO daily x 5 days
• +/- antibiotics (3/3 or ⅔ with one being increased purulence
Winnipeg Criteria)
Chronic COPD management

Treatment is based primarily on SYMPTOMS & frequency of

exacerbations (not FEV1)
High risk AECOPD is 2+ exacerbations in last year, or 1+ requiring
Chronic COPD management

• A typical regimen for a patient with moderately severe disease =

‘triple therapy’
• Spiriva (tiotropium)= LAMA
• Advair (salmeterol +fluticasone) = LABA + ICS
• PRN short-acting bronchodilators (SABA)

• All patients should have annual flu vaccine and pneumovax

• All patients should have attempt at smoking cessation

Asthma
• Diagnosed with reversible
airflow limitation
• post bronchodilator
improvement if FEV1 >12%
and 200cc or positive
provocative testing with
methacholine challenge

• Chronic treatment (step

up therapy)
1. ICS-LABA PRN
2. ICS-LABA regular (can increase
dose if worsening control)
3. Add-on therapy – tiotropium,
montelukast, biologics
Asthma exacerbation

• Acute exacerbation treatment

• Bronchodilators:
• Salbutamol (beta-agonist) and ipratropium (anti-muscarinic) +
• Systemic steroids (methylpred or prednisone)
• +/- magnesium sulfate IV if severe
Pleural effusions
• Light’s criteria: Exudative if
• LDH > 0.6 serum
• LDH > 2/3 ULN
• Protein > 0.5 serum
• Empyema
• Purulent, gram stain or culture positive or pH <7
• Common organisms include strep pneumo, anaerobes, atypicals, staph aureus
• Treat with Pip-tazo
• Required definitive management with chest tube (consult thoracics!)
PFT
Principles

1. Flow-Volume Loop (Morphology)

2. Spirometry (Flows)
3. Lung Volumes
4. Diffusing Capacity
Flow-Volume Loop Morphology
Flow-Volume Loop Morphology

Restrictive
Case 1

FVC 51%
FEV1 34% 🡪 57%
FEV1/FVC 0.60

TLC 94%

DLCO 96%

Asthma/RAD
Case 2

FVC 65%
FEV1 55%
FEV1/FVC 0.75

TLC 60%

DLCO 55%

Restrictive lung disease/ILD

HEMATOLOGY
A. Anemia

MICROCYTIC MACROCYTIC
• Thalassemia • Megaloblastic:
• Anemia of Chronic Disease • B12
• Folate & drugs (methotrexate)
• Iron Deficiency
▪ Any man or post-menopausal • Non-megaloblastic:
woman with iron deficiency • Hypothyroidism
anemia needs a colonoscopy to • Liver Disease
rule out occult CA
▪ Ferritin is your test of choice,
• Drugs
but technical gold standard for • EtOH
Fe-deficiency anemia- BM • Myelodysplastic Syndrome
biopsy
▪ TIBC ELEVATED in IDA
• Lead Poisoning
• Sideroblastic Anemia
A. Anemia

NORMOCYTIC
• Anemia of Chronic Disease
• Iron deficiency anemia
• Hemolytic Anemias
• Intrinsic: Membrane (Hereditary Spherocytosis), Globin (Sickle Cell), Enzyme
(G6PD)
• Extrinsic: Immune (AIHA), Sequestration (Splenomegaly), MAHA
A. Anemia

• What tests to order when you suspect hemolytic anemia?

• Blood Film
• Haptoglobin
• LDH
• Reticulocytes
• Indirect Bilirubin
• Direct Antiglobulin Test (Coombs Test)
Thrombocytosis

• Primary:
• e.g. Essential thrombocytosis (myeloproliferative disorder), familial
thrombocytosis
• Secondary/reactive (most common!): to anything!
• Infection, surgical stress, malignancy, iron deficiency/bleeding, inflammation, thrombosis
Thrombocytopenia

• Decreased production vs Destruction vs Sequestration

• Key diagnoses:
• TTP/DIC/HUS – Schistocytes (RBC fragments) on blood film
• DIC = ABNORMAL COAGS (prolonged PT/PTT)
• ITP – normal film, except lack of platelets, generally responsive to steroids/IVIG
(no hemolytic markers)
• Splenomegaly

• ALWAYS get a blood film, especially if concurrent anemia!!!

Leukocytosis

• Lymphocytosis
• Viral illness vs. CLL
• Clue to CLL – massive lymphocytosis (can be >100), smudge cells,
lymphadenopathy

• Neutrophilia
• Acute stress reaction
• corticosteroid use (demargination)
• CML (and other MPNs)
Heme malignancies
Smudge cell CLL
Blast with Auer rods
Schistocytes and thrombocytopenia
Sickle cells
Rouleux
Myeloproliferative neoplasms (MPN)

• Too many cells of one myeloid cell line!

• RBC – PRV
• WBC – CML
• BCR-ABL aka 9:22 translocation aka Philadelphia Xme
• PLT – ET
• Fibroblasts - Myelofibrosis clues
• Clues for Myelofibrosis = pancytopenia, tear drop cells
Acute leukemia

• Either AML v. ALL

• AML more common in our patient population, and may have auer rods
• Clinical features:
• B symptoms
• Blasts
• Need > 20% in peripheral blood or bone marrow for diagnosis
• APML (Auer rods) is a special scenario (tx with ATRA)
• Complications:
• Pancytopenia / Infection
• Leukostasis
• Tumour lysis syndrome (high K, high uric acid, low Ca)
• DIC

• High WBC >100

• AML = Acute = 20% blasts in the peripheral blood or bone marrow
• CML hallmark = Basophils are up + blasts are low %
Multiple myeloma

• Diagnostic features (CRAB + biomarkers)

• Hypercalcemia
• Renal failure
• Anemia (usually normocytic)
• Lytic bone lesions (also plasmacytoma)
• Suspect MM in elderly with anemia and renal failure

• Hypercalcemia management:
• Fluids, Fluids, Fluids
• IV bisphosphonate
• Consider steroids, calcitonin
 MM Spectrum of Disease

Monoglonal Gammopathy Smoldering Myeloma Multiple Myeloma

of Undetermined Significance
(MGUS) 1. Clonal BMPC (>=10%) or
biopsy-proven plasmacytoma
1. M protein < 30 g/L 1. M protein > 30 g/L or PLUS
2. Clonal BMPC < 10% Clonal BMPC 10-60% 2. Presence of CRAB (1+)
3. No CRAB 2. No CRAB OR
3. >=60% BM clonal plasma cells
1% annual risk of progression 10% annual risk of FLC ratio >100
to myeloma (incidence 5%) progression to myeloma MRI with >1 focal lesion

CRAB: end-organ damage

Hypercalcemia (Ca > 2.75), renal failure (Cr > 176), anemia (Hb < 100), bone lesions
(lytic lesions or osteopenia or pathologic fractures)
Febrile Neutropenia

• Commonly seen in patient undergoing chemotherapy

• Treatment:
• Broad spectrum antibiotics
• No evidence for giving G-CSF (Filgrastim) once Feb Neut develops (sometimes
given with intensive chemotherapy to prevent)
NEPHROLOGY
Approach to Acid Base Questions

• 1. Acidemia or Alkalemia
• 2. Primary metabolic vs Primary respiratory
• 3. Acute or Chronic? Appropriate compensation?

• Always always → Calculate an AG

 Compensations

Primary Metabolic Disturbance Primary Respiratory Disturbance

ΔpCO2 ΔHCO3
ΔHCO3 ΔpCO2
Acidosis (A) 10 1
Acidosis 1 1

Alkalosis 1 0.7 Acidosis (C) 10 3

Alkalosis (A) 10 2

Alkalosis (C) 10 5
Metabolic Acidosis

Non-AGMA AGMA

1. Renal Tubular Acidosis 1. Ketoacidosis

2. Early Renal Failure 2. Uremia (CKD)
3. Diarrhea 3. Lactate
4. Normal Saline 4. Toxins (MeOH, ASA, Ethylene
(hyperchloremic metbaolic Glycol)
acidosis)
Osmolar Gap

• Causes of increased osmolar gap

Ethanol
Methanol
Isopropyl Alcohol
Salicylates
Mannitol
Ethylene Glycol
How do you calculate?
Osmolar gap

- Osmolar gap: measured – calculated

- Normal <10
- Calculated = 2xNa +urea +glucose (can add EtOH)
Case 1

85M with metastatic lung cancer to bone. Constipated, difficult to

awaken.
• pH 7.25
• pCO2 50
• pO2 60
• HCO3 25

• Acute respiratory acidosis. Compensated.

Rise in 10 of pco2
• Rise in 1 of bicarb
• (if chronic, would be 3)
Case 2

35M with Type I DM, fever x 2 days and stopped eating.

• pH 7.25
• pCO2 28
• pO2 95
• HCO3 15

• Primary metabolic acidosis with secondary respiratory alkalosis

• Drop in 9 of bicarb
• Drop in 12 of pco2 – there is also a respiratory alkalosis
Case 3

50F with asthma presents with 24 hours SOB, productive cough, fever.
Hypotensive. CXR LLL CAP.
• pH 7.55
• pCO2 30
• pO2 63
• HCO3 17

Primary respiratory alkalosis with concomitant metabolic acidosis

Pco2 drop by 10
Hco3 drop by 7 (should be 2 if acute, 5 if chronic)
Case 4

18F ate raw chicken. Diarrhea for 3 days with no oral intake. Na 140 Cl
110 K 2.9 HCO3 13. Cr 120 (baseline normal).
• pH 7.35
• pCO2 27
• pO2 95
• HCO3 11

Primary AGMA (starvation) with superimposed non-anion gap

metabolic acidosis (diarrhea).
Case 4

18F ate raw chicken. Diarrhea for 3 days with no oral intake. Na 140 Cl
110 K 2.9 HCO3 11. Cr 120 (baseline normal).
• pH 7.35 AG 17
• pCO2 27 Appropriate resp
comp.
• pO2 95 dAG (5) < dHCO3 (13)
• HCO3 11

Primary AGMA (starvation) with superimposed non-anion gap

metabolic acidosis (diarrhea).
Delta delta

(AG-12)/(24-HCO3)
Delta ratio:
1-2 – pure AGMA
> 2 – elevated bicarb suggests metabolic acidosis
< 0.4 – NAGMA
< 0.4 to 1-2 – high anion gap metabolic acidosis and NAGMA
Hyperkalemia

• Case 1
• K = 5.6. Normal EKG.
• What do you do?
• Case 2
• K = 5.7. EKG – peaked T waves.
• What do you do?
• Case 3
• K = 8.0. EKG – normal.
• What do you do?
EKG Findings

Hyperkalemia Hypokalemia

1. Peaked T waves 1. ST depression

2. Prolonged PR 2. PR prolongation
3. Flattened P wave 3. U waves
4. Widened QRS
5. Sine Wave
 Hyperkalemia = C BIG K Drop
1. Protect the heart:
• Calcium Gluconate 1 g IV
2. Shift:
• 1 AMP D50W
• Insulin 10 units Humulin R IV / SC
• NaHCO3 1 AMP IV push
• Ventolin 8 puffs
3. Excrete:
• Lasix
• Lactulose/PEG
• Dialysis (last resort)
 Acute Kidney Injury
• Definition
• Increase by >26.5 in last 48hrs
• Increase by >1.5x baseline in last 7 days
• Urine volume <0.5cc/kg/hr x 6hours
Indications for dialysis

•AEIOU
• Acidosis
• Electrolytes: Hyperkalemia, hypercalcemia
• Ingestions/Toxins: Lithium, ASA, ethylene glycol,
methanol
• Overload: volume (refractory to lasix)
• Uremia with complications: pericarditis,
encephalopathy
Acute Kidney Injury
Glomerulonephritis
Acute Kidney Injury

NEPHRITIC NEPHROTIC
(“proliferative”) (“non-proliferative”)
RBC Casts Oval Fat Bodies
Dysmorphic RBCs
heme granular casts seen in ATN
RBC cast seen in GN
WBC cast (notice cytoplasm of WBC) seen in AIN or pyelo
Oval fat body seen in nephrotic syndrome
Hyaline casts – normal (Tamm-Horsfall protein)
Chronic kidney disease (CKD)
ISSUE Target Manageme
• Definition: kidney damage > 3 nt
Acidosis HCO3 > 22 Oral NaHOC3
months with or without
decrease GFR, or GFR<60 Anemia Hb > 100, ferritin
>500, Tsat> 30
Iron replacement,
EPO
ml/min/1.73m2
• Most common causes of CKD Hyperkalemia K<5 Low potassium
diet, diuretics, NO
in North America: NSAIDS

• Diabetes
Hyperphosphate Normal Range Low PO4 diet,
• HTN mia PO4 binders
(calcium
• Chronic glomerulonephritis carbonate)
• Others: PCKD, reflux/obstructive Hypocalcemia Normal Range Calcitriol
nephropathy Tertiary 3-9 ULN Calcitriol (if PO4
Hyperparathyroidi not high),
sm cinacalcet ->
parathyroidectom
y
Hypertension Diuretics/ACE/
target < 130/80 ARB
CKD

• Investigations:
• Urinalysis, 24-hr urine for protein, GFR, UPEP
• Serology: ANA, C3, C4, Hep B/C serology, ANCA, cryo, SPEP
• Abdo U/S
• Small kidneys (<9cm) diagnostic of CKD (except diabetes, amyloid/myeloma,
PCKD, hydronephrosis)
• Biopsy
• For unexplained ARF, new nephrotic syndrome, lupus nephritis, progressive
disease
Hyponatremia

◼ First question: Acute vs. chronic?

▪ If acute (<48 hours), reversal can be much quicker

◼ Second question: Are they symptomatic?

▪ Worrisome symptoms = Severely decreased LOC or seizures
▪ Treatment = 3% saline

◼ Third question: What is their volume status and urine studies?

Correct 6/24hr period to avoid

risk of osmotic demyelination
Hyponatremia
ENDOCRINOLOGY
Thyroid disorders

• Hyperthyroid (TSH low, T4 high)

• Think Graves, toxic multinodular goitre, toxic adenoma
• Hyperthyroid phase of acute thyroiditis
• Radioactive iodine uptake tells you Dx
• High uptake = Graves or TMNG
• No uptake = acute thyroiditis

• Hypothyroid (TSH high, T4 low)

• Hashimoto’s thyroiditis
T2DM
T2DM
DKA

• Look for precipitant: ischemia, infection, hypovolemia, meds, etc.

• Tenants of therapy
• Fluids, insulin infusion (0.1 – 0.15 U/kg bolus followed by 0.1 U/kg/hour –
Humulin R IV)
• Monitor AG, potassium, phosphate, blood glucose
• We care most about the gap and potassium
• People die of hypokalemia – need to add potassium to fluid
Adrenal insufficiency

• Presentation usually includes lethargy, abdominal discomfort,

hypotension and/or shock
• Look for classic bloodwork abnormalities including hyponatremia and
hyperkalemia
• Diagnosis: Screen with AM cortisol → confirm with ACTH stim test if low
• Key is to identify and treat with stress dose steroids hydrocortisone 50
mg IV q8h (need mineralocorticoid and glucocorticoid activity)
Osteoporosis

• Definition
• BMD T-score < -2.5
• (NB. Osteopenia between -1.0 and -2.5)
• Risk Factors
• Age
• Weight < 60 kg
• Hypogonadism
• Drugs (steroids, aromatase inhibitors, androgen-deprivation therapy, AEDs, thyroxine)
• Endocrine (hyperPTH, Cushing’s, Addison’s, hyperT4)
• Chronic Disease (renal, malabsorption, liver, rheum.)
• Screening = DEXA
• All >65yo or younger with risk factors
• Treatment = bisphosphonates (or other such as: denosumab, SERM,
teriparatide)
• Usually calcium and vitamin D for all
INFECTIOUS DISEASES

◼antimicrobialstewardship.com
Empiric Antimicrobials For…
Amoxicillin (young & healthy)
CAP Amoxiclav (comorbidities)
Typicals: S.pneumo, H.flu, M. Cattarhalis
Atypicals: Mycoplasma, legionella and Ceftriaxone + Azithro (inpatient)
chlamydophila Respiratory FQ (2nd line)

HAP Ceftriaxone
GNs, anaerobes
Pip-Tazo

UTI Septra, Amoxicillin, Cipro

(Uncomplicated) Ceftriaxone (Ampicillin)
UTI (Complicated)
K. pneumoniae, E. coli, Enterococcus, P.
mirabilis, S. saprophyticus
Ceftriaxone + Vancomycin
Bacterial +/- Ampicillin +
Meningitis Dexamethasone
S.Pneumo, N. Meningitidis, H. Influ;
Listeria if >50yo, immunocompromised,
Acyclovir
pregnant

Herpes
Empiric Antimicrobials For…
PJP Pneumonia High-dose Septra
Prednisone

Pulmonary Isoniazid, Rifampin,

Tuberculosis Ethambutol,
Pyrazinamide
Clostridium difficile Vancomycin PO +/- IV
flagyl
Prognostic: age, elevated WBC,
Diabetic Foot hypoalbuminemia, AKI, fever
Infection Pip-Tazo
polymicrobial requiring coverage of
gram+ve, gram-ve and anaerobes

Cellulitis
streptococcus or staphylococcus
(MSSA/MRSA)
Keflex (PO), Cefazolin
Vancomycin
Endocarditis

• Physical exam findings

• New Murmurs
• Portal of entry (track marks, dentition, lines)
• Splinter hemorrhages, osler’s nodes,
janeway lesions, roth spots
• Organisms: Staph aureus, Group A strep,
enterococcus,
• Investigations: Routine blood work,
blood cultures, echo, ECG
RHEUMATOLOGY
 Rheumatology

Seropositive Seronegative
Symmetric Usually assymetric (PsA usually assymetric, can be
Small (PIP, MCP) and medium joints (wrist, knee,symmetric)
ankle, elbow) Usually larger joints (exception PsA – DIP and
No axial/pelvic (except C-spine in RA) dactylitis PsA)
No ethnesitis Axial involvement
Extraarticular: nodules, vasculitis, Sicca, Ethesitis
Physical Exam Findings In…

TEMPORAL ARTERITIS RHEUMATOID ARTHRITIS

• Increased temporal artery • Symmetrical small joint
pulsation polyarthritis
• Palpable temporal artery • Spares the DIPs
• Scalp tenderness • Deformities (Swan-Neck,
• Trismus Boutonniere, Mallet Finger)
• Vision loss • Rheumatoid Nodules
 Rheumatologic Markers
ESR GCA, PMR (ESR > 50)
cANCA GPA
pANCA Churg-Strauss
HLA-B27 Seronegative Disease
Anti-Histone Ab Drug-Induced Lupus
Anti-Centromere Ab Scleroderma (CREST)
Anti-CCP RA
Anti-Ro/La Sjogrens
Anti-RNP MCTD
Anti-Smith SLE
Septic arthritis
Gout

▪ Crystal arthritis (ddx = CPPD, i.e. pseudogout)

▪ Negatively birefringent needle shaped crystals under polarized light (CPPD is
positively birefringent rhomboid)
▪ Acute tx: intra-articular steroids, colchicine, NSAIDs, systemic steroids
▪ Chronic tx: allopurinol to lower serum UA level & prevent flares (Indications:
tophi, >2 attack/year, CKD stage II or greater, prior urolithiasis)
▪ Gout flare often precipitated by diuretics (i.e. after aggressive diuresis in the
setting of CHF) – hold the Lasix and don’t use NSAIDs in this context!
Vasculitis

GCA: Jaw claudication,

temporal tenderness.
Can be vision
threatening. Pulse
steroids and temporal
artery biopsy.
GASTROENTEROLOGY
 Transaminases >1000s
- DILI (esp Tylenol)
- Viral hepatitis (A/B/E)
- Ischemia (shock liver, Budd-Chiari)
- Autoimmune hepatitis
- Pregnancy (HELLP, AFLP)

Mild transaminitis ~10-100s

- NAFLD
- Alcohol (AST>ALT)
- DILI
- Hemochromatosis
- A1AT deficiency
Principles of cirrhosis management

• Treat underlying cause of liver disease,

can sometimes reverse
cirrhosis/fibrosis
• Alcohol cessation
• Treatment of HBV, HCV
• Weight loss in NASH
• Monitor/treat decompensated
complications
• Varices (caused by portal HTN)
• Ascites
• Spontaneous bacterial peritonitis
• Encephalopathy
• Surveillance for HCC
• US abdomen Q6mo
• Consideration for transplant
• If MELD>15 with refractory
complications
NEUROLOGY
Status Epilepticus

• Definition?
• > 5 mins or > 1 seizure in a 5 min period (not the previous definition of 30
mins)
• Either continuous seizure activity OR repeat seizure without resolution to
baseline
• Complications
• Rhabdomyolysis
• Lactic acidosis
• Neuronal death
Status Epilepticus

• Management
1. AIRWAY / BREATHING / CIRCULATION
• Intubation – call ICU
• IV Access
2. REVERSIBLE CAUSES?
• Lytes
• Glucose
• Withdrawal
3. Anti-Seizure Medications
• IV Lorazepam 2 mg – 2 mg – 2 mg
• Phenytoin 20 mg/kg @ 50 cc/hr (1.0-1.5 g IV)
• Midazolam / Propofol / General Anesthesia