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Transitions > Aquifer Material > Flashcards

Aquifer Material Flashcards

1
Q

Acute management of unstable angina

A
  • Pharmacology: Heparin, Aspirin, Beta-blocker, Statin, Sublingual nitroglycerin
  • Intervention: Non-emergent PCI
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2
Q

“GI cocktail”

A

Refers to a combination of antacid, viscous lidocaine, and an anticholinergic.

Used for suspected GERD in the hospital setting.

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3
Q

GP IIb/IIIa Inhibitors in Angioplasty for STEMI

A

In patients undergoing angioplasty, a GP IIb/IIIa inhibitor such as abciximab or eptifibatide inhibits platelet aggregation and may prevent platelet adhesion to the vessel wall.

While these medications increase the risk of bleeding (especially when used in combination with fibrinolytics) and can cause thrombocytopenia within 24 hours of initiation, they improve outcomes in patients with STEMI.

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4
Q

Complications of an MI

A
  • Chronically:
    • Bradyarrhythmia/heart block
    • Ventricular arrhythmia
    • Reduce ventricular function
    • Cardiogenic shock
    • Recurrent thrombosis
      • 2-7 day window:
    • Papillary muscle rupture
    • Ventricular free wall rupture
    • Pericarditis
  • ~Months later:
    • Dressler’s syndrome
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5
Q

Standard post-MI discharge drug regimen

A
  • ACE inhibitor
  • Beta-blocker
  • Aspirin and clopidogrel (dual antiplatelet therapy)
  • Statin
  • Sublingual nitroglycerin PRN
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6
Q

Why dual antiplatelet therapy for one year after MI?

A

It has been shown to prevent stent thrombosis, specifically. After the one year, discontinuing is not associated with increased risk of thrombosis.

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7
Q

In what context are ACE inhibitors usually recommended for post-MI hypertension treatment?

A

New left ventricular systolic dysfunction

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8
Q

Guidelines for afib rate control

A
  • HR <80 BPM is reasonable for symptomatic atrial fibrillation management.
  • HR <110 BPM is reasonable if asymptomatic and LVEF is preserved.
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9
Q

Anticoagulation recommendation for patients with afib AND valvular heart disease

A

Warfarin is the choice over heparin, titrated to an INR between 2 and 3

Otherwise, refer to CHADS-VASc system

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10
Q

Anticoagulation recommendations for patients with afib in the absence of valvular heart disease

A

If 0, then no need for anticoagulation

If 1, then aspirin for sure, consider DOAC.

If 2 or more, then DOAC or warfarin

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11
Q

Cheynes-Stokes respirations

A
  • aka “periodic breathing”
  • Oscillation between apnea and tachypnea
  • Stroke, traumatic brain injury, brain tumors, congestive heart failure, or actively dying
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12
Q

Potassium in DKA

A

Patients with DKA are often hyperkalemic, but potassium deficient!

The hyperkalemia is because the osmolarity forces potassium out of cells, and without intact insulin signaling it is not being siphoned back in.

However, they can’t stop peeing! So they quickly lose all of that potassium, becoming net potassium deficient. So, when you do treat with insulin, the potassium will start going back into cells and the patient will become hypokalemic.

For this reason, potassium must be added to fluids when treating DKA with fluid and insulin. If potassium drops below 3.3, begin IV potassium replacement immediately and delay the insulin treatment until potassium concentration is restored to a normal value ​

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13
Q

When is it safe to stop an insulin drip on someone being treated for DKA?

A

When:

  1. The anion gap is back to normal
  2. The patient has received long-acting subcutaneous insulin
  3. The patient can tolerate food PO
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14
Q

Standard tests for a patient newly diagnosed with type II DM

A
  • HbA1c
  • Fasting lipids
  • Urine albumin/creatinine ratio
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15
Q

Abdominal pain that worsens with movement suggests. . .

A

. . . focal parietal peritoneal pain

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16
Q

Non-megaloblatsic causes of macrocytosis

A
  • Alcohol use disorder
  • Liver disease
  • Hypothyroidism
  • Hydroxyurea
  • Myelodysplasia
  • Reticulocytosis
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17
Q

When to consult an abdominal surgeon for explorative surgery in the setting of acute abdomen

A
  • Cholecystitis
  • Small bowel obstruction
  • Perforation of an abdominal organ
  • Complicated pancreatitis
    • ie, impacted gall stone, pancreatic abscess, large or symptomatic pseudocyst, necrotic pancreatitis
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18
Q

Management of acute pancreatitis

A
  • Isotonic IV fluids, pain control, and a soft, low fat diet as tolerated (if there is no vomiting and no ileus).
  • Formerly patients with mild pancreatitis were kept NPO for several days until symptoms resolved however more recent trials have shown that a PO diet is safe.
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19
Q

Imaging in acute pancreatitis

A
  1. RUQ ultrasound (to rule in/out gallstones)
    • Here you are looking for gallstones or CBD dilation
  2. ERCP once RUQ ultrasound shows CBD dilation
  3. CT ONLY WHEN there is suspicion of pseudocyst
    • Not generally used in the acute setting
20
Q

Criteria for antibiotics in acute pancreatitis

A

Antibiotic use in pancreatitis has been studied in controlled clinical trials but remains controversial.

With increasing severity of illness, organ dysfunction, and worsening pancreatic necrosis, some studies have shown benefit with prophylactic antibiotic therapy, and some have not.

Empiric (not prophylactic) antibiotic therapy should definitely be used in patients who appear to have infection complicating a severe pancreatitis course, such as infected pseudocyst or pancreatic abscess complicating extensive pancreatic necrosis.

21
Q

ERCP vs MRCP

A

MRCP is a noninvasive imaging test to detect obstruction of the biliary tree and pancreatic duct. It is slightly less sensitive than ERCP, but much less risky for patients since it is not invasive. It does not have the ability to be therapeutic.

ERCP directly cannulates the Ampulla of Vater and injects radio-opaque dye into the duct to outline an obstruction. Instruments can then be passed through the ampulla to allow for biopsy or dilation and release of gall stones.

Drainage of an obstructed bile duct with ERCP provides rapid relief of symptoms and improved outcomes in obstructive forms of pancreatitis, but carries a risk of complications including bleeding, perforated bowel, worsening pancreatitis, or even death. If this test was performed in a patient who clearly had non-obstructive pancreatitis that was already improving, the risk definitely outweighs the benefit.

22
Q

Lorazepam vs diazepam for alcohol withdrawal

A

Diazepam is the treatment of choice, BUT, it can only be given orally, which is often a problem when dealing with nausea/vomiting/psychological changes of alcohol withdrawal.

Lorazepam may be given intravenously, and so it is often used over diazepam in these situations.

23
Q

What is going on in this patient?

A

Angular cheilitis

An inflammatory lesion at the labial commissure, or corner of the mouth, which often occurs bilaterally. The condition manifests as deep cracks or splits and can be associated with malnutrition or deficiencies of iron or vitamin B12.

24
Q

What is going on in this patient?

A

A combination of atrophic glossitis and angular cheilitis

This is susipcious for folate or B12 deficiency. This individual may have megaloblastic anemia.

25
Q

A vegetarian with megaloblastic anemia is much more likely to have a ___ deficiency than a ___ deficiency.

A

A vegetarian with megaloblastic anemia is much more likely to have a B12 deficiency than a folate deficiency.

Fruits and vegetables are FULL of folate! It is the carnivores that are more at risk for folate problems.

26
Q

Reticulocyte production index

A

In healthy individuals, the reticulocyte index is 1-2. If the reticulocyte index is <2, there is decreased red cell production. An RPI > 2 with anemia indicates hemolysis leading to compensatory reticulocytosis.

The reticulocyte maturation time is based on the patient’s hematocrit. The maturation time corrects for the longer lifespan of prematurely released reticulocytes in the blood.

Maturation time is 1.0 if the patient’s hematocrit is > 35, 1.5 if the hematocrit is 25-34, 2.0 if the hematocrit is 20-25, and 2.5 if the hematocrit is < 20.

27
Q

Burr cells

A

Aka echinocytes

Red blood cells with multiple small projections with blunt edges symmetrically distributed across their surface as seen at 1:00 in the smear. Burr cells can be an artifact, but can also be seen in patients with uremia, alkalosis and bile acid abnormalities. Burr cells should not be confused with spur cells (acanthocytes) which have multiple thorn-like, irregularly spaced projections. They are seen in liver disease and certain neuromuscular disorders.

28
Q

Codocytes

A

aka target cells

Red blood cells with a central color spot in the area of pallor (thereby resembling a target). Target cells can be seen in thalassemia and liver disease.

29
Q

Spur cells

A

aka acanthocytes

Red blood cells with multiple thorn-like, irregularly spaced projections. They are seen in cirrhotic liver disease and certain neuromuscular disorders.

30
Q

Rouleaux

A

Stacks of red cell pancakes

They are seen when there is hyperfibrinogenemia or hypergammaglobulinemia (such as in multiple myeloma).

31
Q

Which is a better way to sample for fecal occult blood: a digital rectal exam, or sending the patient home/to the bathroom with a kit?

A

Let the patient do it themselves!

Not only are rectal exams uncomfortable for both parties, you may produce trauma that elicits blood and leads to a false-positive. For this reason, the evidence-based protocol is to let the patient sample it themself.

32
Q

What is the most common cause of B12 deficiency?

A

Pernicious anemia

Although, it tends to be in older individuals, it also tends to occur early in females of African descent.

If someone presents with new B12 deficiency and a history of autoimmune disease, you should be very suspicious of pernicious anemia.

33
Q

Blood tests for pernicious anemia

A
  • Anti-parietal cell antibodies (sensitive, nonspecific)
  • Anti-intrinsic factor antibodies (specific, nonsensitive)
34
Q

How can you treat pernicious anemia?

A

Two ways:

  • Intramuscular B12
  • High-dose oral B12

As it turns out, the terminal ileum has a small intrinsic-factor-independent absorptive capacity for B12 (about 1% of the total oral dose), so just increasing the oral dose is often sufficient. This way you save the patient from having to get regular intramuscular injections.

35
Q

Why shouldn’t you take iron pills with tea?

A

Tannins decrease iron absorption

Vitamin C, on the other hand, increases it! So substitute orange juice instead.

36
Q

What medications should you avoid taking with iron pills?

A

Levothyroxine and many oral antibiotics

Wait 4 hours after taking iron pills before taking these medications.

37
Q

Vaccine recommendations for HIV-infected patients with CD4 count below 200

A
  • All should receive Hep A and Hep B
  • All should receive influenza annually
  • All should receive streptococcal polysaccharide vaccines (see guidelines attached)
  • The varicella, zoster, intranasal influenza, and measles, mumps, and rubella (MMR) vaccines are all contraindicated in HIV-infected persons with a CD4+ cell count < 200 cells/μL because they are live vaccines.
38
Q

Recommendations for Pap Tests in Females with HIV

A

Every female who is diagnosed with HIV needs a Papanicolaou (Pap) test at the time of diagnosis and another one six to twelve months after. If these are normal, then Pap tests should be obtained annually.

If the results of three consecutive Pap smears are normal, the screening interval can be increased to every 3 years.

39
Q

Two most common causes of fever of unknown origin

A

Malignancies and non-infectious diseases

40
Q

When to start worrying about crypto__ oragnisms in HIV patients

A

When CD4 count falls below 100

Cryptococci and cryptosporidium are the two to worry about.

41
Q

Three major categories of AIDS-related lymphomas

A
42
Q

Adverse effects of antiretrovirals

A
43
Q

Baseline Studies to Obtain Prior to ART Initiation

A
44
Q

Prophylaxis against opportunistic infections for AIDS patients

A
45
Q

Deciding whether or not to admit a patient with pneumonia

A

CURB-65 score

  • Confusion
  • Blood Urea Nitrogen (>19)
  • Respiratory Rate > 30
  • Blood pressure (systolic < 90 or diastolic < 60)
  • Age (65 or older)
46
Q

Which pneumonia patients are highly contagious and therefore should be placed in respiratory isolation?

A

Not really those who walk in with a bacterial pneumonia, but viral pneumonias like influenza and tuberculous pneumonia are highly contagious.

47
Q

Benefits of the pneumococal vaccine

A

The pneumococcal vaccine has not shown any reduction in the risk of developing community-acquired pneumonia, but it can reduce the risk of invasive disease, including bacteremia, meningitis, or infection of other sterile sites.

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