High yield internal medicine uworld note A+ Latest updated high rated
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High yield internal medicine uworld note
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High Yield Internal Medicine Uworld Note
High yield internal medicine uworld note A+ Latest updated high rated
Neurology
2671: In apparent unprovoked first seizure pt should have imaging done ASAP to check for masses/bleeds that
may have caused the seizure. This patient also fell while seizing, making CT w/out a great choice for initi...
Neurology
2671: In apparent unprovoked first seizure pt should have imaging done ASAP to check for masses/bleeds that
may have caused the seizure. This patient also fell while seizing, making CT w/out a great choice for initial
imaging because they might have a traumatic bleed
● CT w/out contrast is the imaging of choice in emergent situations
● MRI is imaging of choice for non-emergent situations
● EEG is useful, but more pressing matters may need to be addressed. This may be done later if assessing
the patient for a possible seizure disorder
3630: C.Jejuni is the most common precipitant of Guillian-Barre Syndrome. Often it’s manifested by bloody
diarrhea prior to the ascending weakness. Apparently people with lymphoma/SLE get it more often. Other
ways of getting it could be:
● Less common infection: Herpes virus, Mycoplasma spp, H.Flu
● Recent HIV infection or immunization
2316: Lumbar spinal stenosis presents classically as low back pain, worse with standing/walking uphill (causes
greater compression) and better with sitting/walking downhill (opens up spine). Typically caused by
degenerative joint disease (DJD) resulting in disc herniation/osteophyte impingement on the spinal cord.
● Neurologic exam may be normal (straight leg raise only positive in 10% of pts) but there can be signs of
nerve compression in lower extremities (numbness/tingling/etc)
● Best next step 🡪 MRI of the spine to look for degenerative changes in spine
3726: Cerebellar hemorrhage is a type of intracranial hemorrhage presenting as: Headache (occipital/radiates
to shoulder); facial weakness/gaze palsy/nystagmus; neck stiffness (blood in the 4th ventricle causing
irritation); gait ataxia; N/V
● Classically there is no hemiparesis
● Often comes on as progressive for minutes – hours (as opposed to immediate)
● Best next step 🡪 non-contrast head CT to visualize bleed
● Tx 🡪 emergent surgical decompression
3446: Workup of Multiple Sclerosis (MS) includes the following:
● T2 weighted MRI: check for hyper/hypodense lesions due to white matter demyelination
(periventricular regions/corpus callosum, optic nerves, brainstem, spinal cord)
● LP: check for IgG oligoclonal bands, often with normal opening pressure/CSF
3631: Atrophy of the caudate nucleus is a classic sign on imaging for Huntington’s disease
4130: Shy-Drager Syndrome (multiple systems atrophy) is a Parkinson+ syndrome consisting of:
● Parkinsonism (tremor, gait disturbance, etc.)
● Autonomic dysfunction (orthostatic hypotension, abnormal lacrimation/sweating, bladder/bowel
dysfunction, etc.)
● Widespread neurologic signs
● Parkinsons drugs are not effective here (as is the case with most Park+ syndromes)
● Tx 🡪 expand intravascular blood volume to keep BP up as orthostatic hypotension is a problem
(salt-supplementation, fludrocortisone, a-adrenetgic agonists, etc.)
4513: Brain abscesses classically present as a triad of headache, focal neurologic signs, fever (20%) although
some may not even have fever (50%). Ring-enhancing lesions are highly specific on MRI/CT. Typically infection
is due to:
● Direct spread from head/neck infection (50% sinusitis) – Viridians group step (S. intermedius, mutans,
mitis, oralis) or anaerobic bacteria (prevotella, peptostreptococcus, bacteriodes)
● Hematogenous spread (25% lung inf./endocarditis) – Staph aureus
● Rarely direct inoculation may occur – Staph aureus
, ● Best next step 🡪 MRI/CT with contrast to see ring-enhancing lesions
● Tx 🡪 4-8 weeks of antibiotics (decide via culture/like source) with drainage if possible
4691: Spinal Cord compression typically presents as: gradual worsening of severe lower back pain, worse when
lying down/at night, with lower extremity weakness/sensory signs
● If more advanced, UMN signs (Babinski, exaggerated reflexes) in the lower extremities, loss of sphincter
tone, paraplegia, and sensory loss can occur
● Best next step 🡪 MRI of the spine/IV glucocorticoids
● Tx 🡪 aimed at underlying cause (this case was metastatic cancer, so we’d treat that)
2938: Wilson’s disease is autosomal recessive disease with abnormal copper absorption in the gut
● Presentation in kids 🡪 liver disease of unknown etiology
● Presentation in young adults 🡪 neuropsychiatric disease (Parkinsonism, depression, catatonia) with
liver disease
● Best next step 🡪 ceruloplasmin levels (<20 diagnostic), urine copper levels, slit-lamp eye examination
(look for Kayser-Fleischer rings)
12028: Myasthenia Gravis exacerbation may be precipitated surgery, infections, and medications
(aminoglycosides/B-blockers are classic). The ice pack test is supportive for MG by improving muscle weakness
(often ptosis) by decreasing ACh breakdown from the cold temperature
● +Ice pack test should prompt confirmatory ACh antibody testing
4378: Seizures may be precipitated by strong emotions, sleep deprivation, alcohol withdrawal, or flashing
lights with a delayed return to baseline. Syncope may occur with upright positioning, strong emotions, heat,
and crowded spaces with an immediate return to baseline
2634: If a patient has signs of Myasthenia Gravis (weakness with repetitive use, often of small muscles):
● Dx 🡪 Bedside testing (ice pack/Tensilon testing) and confirmatory Ach Antibody testing
● Next best step 🡪 chest imaging as MG is often due to thymoma (thymus makes the antibodies)
● Removal of the thymus can greatly improve MG symptoms
2673: When evaluating facial hemi-weakness, the distribution can tell you where the lesion is:
● Above the pons (central lesion): forehead is spared, pt can raise the eyebrow; this is due to
contralateral connections in the CNS that will link up with the LMNs of the forehead
● Below the pons (tu palsy): whole hemi-face is affected, eyebrow cannot be raised; typically, recovery
will occur within 3 weeks and total recover in 6 months
3724: Syringomyelia typically presents with a cape-like distribution of sensory loss (pain/temp sensation;
spinothalamic tract) and is associated with Arnold-Chiari malformation I (caudal displacement of the
cerebellum into the foramen magnum)
4376: Acute Angle-closure glaucoma: sudden narrowing/closure of the anterior angle chamber, stopping the
flow of aqueous humor and increasing intraocular pressure.
● Presentation: acute onset of orbitofrontal headache, N/V, severe eye pain with injection, poorly
reactive, dilated pupil, excessive lacrimation, poor visual acuity.
● Permanent vision loss may occur from damage due to increased intraocular pressure
4072: When assessing brain metastases, the clinical picture will direct therapy:
● Surgical resection followed by radiation/radiosurgery 🡪 single mass, good performance status, mass is
accessible for surgery
● Whole brain radiation or supportive therapy 🡪 multiple masses, poor performance status, mass in not
accessible for surgery
● Note that brachytherapy is implantation of a radioactive device next to the tumor to limit radiation
exposure to the other organs
3919: Dexamethasone depression testing may be helpful in assessing depression causing pseudodementia.
This is a weird, and often useless test for this reason; but the clinical picture for pseudo vs genuine dementia
can be difficult, so this MAY be helpful in delineating that line
,3738: Anterior lobe lesions may result in weakness of the contralateral body and Broca’s (expressive) aphasia
(Broca’s area is present in the posterior frontal lobe). Temporal lobe lesions will cause Wernicke’s (receptive),
anomic, or conduction aphasias.
3300: Anterior Cord Syndrome: often due to burst fracture of the vertebrae (vertebrae is burst open, typically
due to high energy impact) with total loss of motor function and bilateral loss of pain/temperature sense
below the lesion. Proprioception is intact.
2289: Tick paralysis is classically an ascending paralysis with predominance to one side (left weaker than right
but weakness present in both). Typically occurs within hours-days (faster the guillian-barre)
● Occurs due to release of neurotoxin from an attached tick; pt may have history of hiking and NO
prodromal illness. Tick must be attached about a week before symptoms onset. Metriculous search for
a tick is the next best step. Removal of tick / supportive care will often result in recovery. Typically
autonomic function/sensory function/CSF are normal
● Guillian barre can have a similar history but onset of symptoms will be bilateral and over the course of
days to week. Autonomic function/sensory function may be messed up! CSF may show high protein. Tx
is IVIG or plasmapheresis to remove the autoantibody causing disease.
3461: Carbamazepine is the treatment of choice for Trigeminal Neuralgia (80%); note that it can cause aplastic
anemia and CBCs must be monitored on this drug; if this drug does not work, then surgical decompression of
the trigeminal nerve (CN V) may be warranted.
3715: Early symptoms in carbi/levodopa treatment are hallucinations/dizziness/headache/agitation. After
5-10 years of treatment, dyskinesias and tardive dyskinesia are more likely to come up.
4702: always choose non-contrast CT over contrast CT when evaluating a stroke initially. The contrast can be
confused for blood and obstruct the clinical evaluation.
3727: When treating myasthenic crisis (worsening weakness/difficulty breathing and swallowing) intubation
for declining respiratory status is immediately done and plasmapheresis/IVIG/corticosteroids is done after
patient is stable to minimize symptoms. AChE drugs (typically used to treat) are held to minimize secretions as
these can further worsen respiratory status.
4394: HCTZ is a K+ wasting diuretic and pts may suffer from hypokalemia on it (always supplement K+ when
pt are on HCTZ). Signs of hypokalemia are as follows:
● Minor: cramps, weakness, fatigue
● Major: flaccid paralysis, rhabdomyolysis, hyporeflexia, tetany, heart abnormalities (premature
ventricular beats, broad T-waves, U-waves, and ST depression) with fatal arrhythmias can all occur!
● Tx: potassium repletion
4372: Pt with spinal cord compression (low back pain, parasthesias in leg, butthole working poorly) in the
setting of an infection should be examined for epidural abcess.
● Best next step 🡪 MRI of spine with gadolinium contrast, blood culture, inflammatory markers
● Tx: immediate Abx (typically staph aureus) and surgical consult for de-compression/drainage/culture
, 4443: Corticosteroid-induced myopathy may be confusing as it can be in the presence of inflammatory
disorders that can cause muscle weakness/pain. Classically it presents in a patient taking chronic
corticosteroids, with proximal muscle weakness, no pain/tenderness, normal ESR/CK, and more involvement
of the lower extremities
● Occurs weeks-months of starting high-dose corticosteroid treatment; presents with the classic “can’t
climb stairs, comb hair, etc.”
● Tx: taper/discontinuation of corticosteroids yields recovery in the following months
3809: Remember! Pts with myasthenia gravis may have an exacerbation with infection and drug treatments
(floroquinolones [-floxacin], aminoglycosides, beta-blockers, or macrolides)
● Classically it’s generalized weakness and difficulty breathing after an infection treated with antibiotics!
● Tx (if respiratory status decline) 🡪 ICU monitoring with intubation
4022: Remember that ACA stroke will produce contralateral weakness/loss of sensation with lower>upper
extremity weakness. This is due to the homunculus distribution of the motor cortex perfused by the ACA. It
may even feature urinary incontinence.
3327: Remember that infection of the periorbital region/face can move into the cavernous sinus
(ophthalmic/facial venous system is valveless) and cause thrombosis. This may result in nerve palsies and
intracranial hypertension. This is beyond a normal cellulitis as nerve symptoms would not be present if it was
just a superficial cellulitis.
3691: Exertional heat stroke is best managed with ice bath immersion (although cold water shower can work),
fluids/electrolyte repletion, management of any end-organ damage. Temperatures can skyrocket above 104F,
which results in symptom presentation.
3637: Idiopathic intracranial hypertension (pseudotumor cerebri) is best managed with:
● acetazolamide (inhibits choroid plexus carbonic anhydrase 🡪 decreases CSF production). Lasix
(furosemide, etc.) may be added in pts that continue to have symptoms.
● Optic nerve sheath decompression may be used in patients refractory to medical treatment (stop
damage to eye nerves and blindness).
● Corticosteroids/LPs may be used as bridging therapy until definitive treatment is initiated
● Mannitol is not used in treatment; it require in-patient monitoring and only used for severe
intracranial hypertension (pt is obtunded)
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