Clin Med Review Flashcards
Which of the following is a significant predictor of death in nursing homes? A. Chlamydia B. Unintentional weight loss C. Asparin use D. A only
B. unintentional wt loss
A 75 year old FTT pt is depressed and not gaining weight. What would be your 1st choice of medication?
Remeron
What is the difference between HFrEF and HRpEF?
HFrEF has a LV Ejection fraction of <50%
Which two medications improve m/m in pts with HFrEF
ACEI, Beta Blocker
Which Beta blockers improve M&M in pts w/ HFrEF? (3)
(carbetolol (coreg), metoprolol succinate, bisproprolol))
What is a recommended medication for pts with a LVEF <40%, who can’t tolerate ACEI or ARBs?
Hydralazine & Nitrates
Elequis Reversal Agent
Andexxa
What are the symptoms associated with upper motor deficiencies in als?
spasticity, slow rapid alternating movements, hyperreflexia, stiffness
Which medication prolongs ALS life expectancy by a couple months? A. Rilutek (riluzole) B. Levodopa C. Lamotrigine D. Gabapentin
A. Rilutek
What is pseudo bulbar-affect in als?
Inappropriate emotional responses, happens as disease progresses
Define CHADS2
At which score should you anticoagulate?
CHF, HTN, Age >75, DM, Previous stroke/TIA (2 points) - over 2 anticoagulate
Which drug is best for rhythm control in a-fib
Amiodarone
What is the classic triad of parkinsons?
Pill Rolling Tremor
Bradykinesia
Cogwheel rigidity
Which tremor is improved with moderate alcohol consumption?
Benign Essential Tremor
What is the treatment for Benign Essential Tremor?
Propranolol
What is the most effective drug in treating symptomatic Parkinson’s patients?
Sinemet
Name the four classifications of a-fib and how long each lasts.
Paroxysmal (within 7 days)
Persistent (>7 days)
Longstanding persistent (>12 months)
Permanent (given up on trying to correct)
Name 4 potential side effects you would want to warn your parkinsons patient about before starting anticholinergics.
Dilated pupils (sight impact) Dry mouth Confusion Hyperthermia Urinary retention Flushed skin Tachycardia Constipation (absent bowl sounds)
What hormones are secreted by the posterior pituitary?
Oxytocin
Vasopressin
What ABI value is diagnostic of PAD?
<0.9
What is the treatment of choice for viral URI?
Supportive care
What are the 3 p’s of acute limb ischemia?
Pulseness, pain, pallor, pain, paresthesia, perishingly cold
What is the most common pituitary secreting hormone?
Prolactin
List two ways viral URI differs from bacterial?
Timeframe, maxillary pain, tooth pain, second sickening
What is the underlying cause of varicose veins?
Decreased vein compliance
In Alzheimer’s dementia what are the 2 common pathological feature?
Beta amyloid, hyperphosphorylated tau
aka plaques and tangles
What is the first line tx for Alzheimer’s dementia?
Aricept
Which dementia is characterized by hallucinations?
Lewy Body
What is the first line maintenance therapy for Vasospastic Angina?
CCBs
What is an EKG findings in Prinzmetal Angina?
NL or ST elevation during episode
Name 2/4 statin benefit groups
- ASCVD
- high dose statin - Pts with LDL-C ≥190mg/dl
- high dose statin - Pt 40-75 with DM and LDL-C 70-189 mg/dl
- moderate statin - Pt 40-75 w/ risk ≥7.5% and LDL-C 70-189 mg/dl
- moderate statin
What test is used to monitor pts on statins?
Fasting lipid panel
What’s the first line alternative medication to use on patients who do not tolerate statins?
Ezetimibe
ACA stroke Sx
cerebral-leg
UMN- Spastic paralysis
MCA Stroke Sx
cerebral- arm, hands, and head
Homonymous hemianopsia
UMN- Spastic paralysis
LCA Stroke Sx
Vision issues
Lacunar Infarction Sx
Posterior Limb of Internal Capsule (hemiparesis, ataxia), Basal Ganglia,
Thalamus (sensory deficit),
Pons (Dysarthria/CLUMSY HAND)
- Lacumar are usually pure motor or pure sensory
- -often assoc. w/Chronic HTN
Cerebellar Stroke
dizziness, nausea difficulty standing
Wells Criteria PE (7)
- Clinical findings of DVT (leg swelling, pn w/palp)
- Other Dx less likely than PE
- HR >100
- Immobilizatoion or surg in past 4 wks
- Prev. DVT/PE
- Hemoptysis
- Malignancy
Scores- PE likely vs PE unlikely
> 4 -likely
< (or equal to) 4- unlikely
Epidural Hematoma Vessel & finding
cross cranial sutures?
Middle meningeal a
lens shaped collection of blood,
does NOT cross cranial sutures
Subdural Hematoma Vessels & findings
cross cranial sutures?
tear of bridging veins
acceleraing/decelerating injuries
Crescent shaped collection of blood
Which vertigo-causing condition usually presents after a URI?
Labyrinthitis
Which form of nystagmus is the most concerning and why?
Vertical,
CNS issue
What anticoagulant do you prescribe for a patient with a mechanical valve?
Warfarin
Which lab do we continuously monitor for a patient on warfarin and what should the value be?
NL INR 2-3
Mechanical Heart Valve 2.5-3.5
How would you treat a patient with Afib before a scheduled cardioversion?
Anticoags 1mo before AND after cardioversion
Which test for Myasthenia Gravis will improve its symptoms?
Ice Pack Test
What can be used to differentiate between MG and botulism in terms of symptoms (not including the pattern of paralysis, ie descending paralysis)?
Fatigeability
What are the categories for CHADS2 and what does a value of 2+ signify?
CHF, HTN, Age > or = 75 yo, DM, Stroke (2 pts)
2+ pts = Anticoagulation indicated
1st test to order if growth hormone excess is suspected
IGF-1
Most common cause of acromegaly
Benign pituitary adenoma
Manifestations of Acromegaly (
- enlargement (hands, feet, jaw, internal organs)
- HTN
- DM2
- CHF
- cardiomegaly
- MAcroglossa
- deep voice
- OSA
- Spinal stenosis
- arthralgias
- wt gain
- hypogonadism
- decreased libido/ED
- irregular menses
- temporal hemianopsia
- HA
- thick skin
- hyperhydrosis
- acne/skin tags
- colon polyps
The gold standard lab test for confirming acromegaly
1hr glucose tolerance test
Should inhibit GH secretion in NL ppl
functions of GH (4)
- ↑ Ca2+ retention
- ↑ Muscle mass
- Stim growth of internal organs
- lipolysis
- homeostasis
- pancreatic islet cell function
- ↑ protein synthesis
- ↓ liver uptake of glucose
What is the middle layer of the adrenal cortex and what does it secrete?
Fasiculada
Glucocorticoids (cortisol)
Name the 3 areas you expect to see affected by tumors in MEN1
- Parathyroid
- Anterior pituitary
- Pancreas
Classic triad of pheochromocytoma
HA
Sweating
Tachycardia
Name BOTH initial tests you could order if you suspect pheochromocytoma
- 24hr urine metanephrines/catecholamines
2. plasma fractionated metanephrines
If a patient has bilateral adrenal hyperplasia causing hyperaldosteronism or surgery isn’t an option, what is the first line medication?
Spirnolactone (Aldactone)
Main lab abnormality you expect to see in a patient with hypoaldosteronism
Hyperkalemia
Name 3 main end points or functions of aldosterone
- ↑ Na+ & H2O RESORPTION in kidneys
- ↑ plasma volume (BP)
- ↑ H+ SECRETION
- ↑ K+ SECRETION
What is the other name for an adrenal adenoma that causes hyperaldosteronism?
Conn’s syndrome
Name 3 classic clinical findings you’d expect to see in a patient with hyperaldosteronism
- Difficult to control HTN
- Hypokalemia
- Hypernatremia
- metabolic alkalosis
If a patient has a high plasma aldosterone concentration and a high plasma renin activity, what type of hyperaldosteronism do they likely have?
SECONDARY HYPERALDOSTERONISM
(if the KIDNEY’S SECRETION OF RENIN IS STIMULATING HYPERALDOSTERONISM, then BOTH aldosterone and renin would be ↑)
(remember renin can be stimulated by things like CHF, cirrhosis, volume depletion, etc)
Which is the main hormone that is underproduced in Adrenal insufficiency?
Cortisol
may also see ↓ aldosterone and DHEA
What is the basic pathophysiology of tertiary adrenal insufficiency?
There is a lack of CRH from the hypothalamus.
If a patient with adrenal insufficiency gets sick, what do you need to treat them with?
Stress dose (↑ steroids) because cortisol secretion normally ↑ with stress/injury/illness
Name 2 features that you expect to see in primary but not secondary or tertiary adrenal insufficiency
- Hyperpigmentation
- Hyperkalemia
- dehydration
- GI sx
What medications are you going to maintain a patient with primary Adrenal Insufficiency on on a daily basis?
- Florinef + Hydrocortisone/prednisone
can also add DHEA
Where is Cushing’s disease localized?
the anterior pituitary
oversecretes ACTH
Name 4 common clinical manifestations of Cushing’s Syndrome
- buffalo hump
- moon facies
- striae
- central obesity
- skin atrophy
- fungal infections
- acanthosis nigricans
- hirsuitism
- increased CV dz
- psych manifestations
- increased infections
- proximal muscle wasting
What is the treatment of choice in Cushing’s disease?
Transsphenidal resection
Most common cause of an ectopic ACTH-producing tumor?
Small cell lung cancer
Name the 3 first-line tests that can show increased cortisol
- Low dose dexamethasone suppression text
- late night cortisol level
- 24hr urinary free cortisol excretion
eczema (atopic dermatitis), allergic rhinitis, asthma
Atopic Triad
asthma, nasal polyps, and NSAID sensitivity
Samster’s triad
New asthma prevention
SABA + ICS- just know this one.
Copious, foul-smelling sputum
“tram tracks”-mucous lining airways, atelectasis
Gold standard: CT chest
Bronchiectasis
Inhaled corticosteroids and bronchodilators
Bronchiectasis
Measured FVC / Predicted FVC
If < 80% of predictive →
Restrictive lung dz
Most common cause of interstitial lung disease
idiopathic interstitial PNA
Lungs (90%) & lymph nodes are most common
*Bilateral Hilar Adenopathy (diagnostic)
Prednisone 20-40mg QD x 4-6wks
Sarcoidosis
> 25 mmHg at rest or
30 mmHg with exertion
- Idiopathic –majority of cases
Definitive Dx:
Swan-Ganz Catheter
Anticoagulation
Digoxin
Pulm HTN
Often a few days after a URI
Sudden onset of sharp, localized pn that is worse w/coughing, deep breathing, & mvmt
Pleurisy
The most common reason for a healthcare provider visit
90% viral (Rhinoviruses 30%- 35%
Influenza and adenovirus-30%)
Tx:
APAP/NSAIDs
URI
- Anchor on LAMA & LABA
2. Anchor on corticosteroids (ICS)
- COPD
2. Asthma
Measured FEV1 / Measured FVC
If <70% →
Obstructive process
Hyper or hypopigmented patches Dx: KOH: Spaghetti & meatballs under microscope** Tx: topical antifungal
Tinea Versicolor
- AKA adjustment insomnia or acute insomnia
Sx <3 months
In response to an identifiable stressor - Sx ≥3x/wk & persist ≥3mo
- short term insomnia
2. chronic insomnia
Tx Longterm Insomnia
CBT-I 1st line
Loss of orexin-A & orexin-B
Type 1: with cataplexy
Type 2: without cataplexy
Epworth Sleepiness Scale usually >15
Narcolepsy
If Hx suggests, Dx by
Polysomnogram
Narcolepsy
narcolepsy 1st line Tx
Modafinil (Provigil)
Most common sleep-related breathing disorder
Sleep apnea
Dx 1st line for Sleep apnea
in-laboratory polysomnography
≥ 15 obstructive resp events/hr of sleep,
or
≥ 5 obstructive resp events/ hour of sleep in pt w/ ≥ 1 of the following:
1. Sleepiness, nonrestorative sleep, fatigue, or insomnia symptoms
2. Waking up with breath holding, gasping, or choking
3. Habitual snoring, breathing interruptions, or both noted by bed partner/observer
4. HTN, mood disorder, cognitive dysfunction, CAD, CVA, CHF, AF, or DM2
Sleep apnea Dx
sleep apnea Tx
Weight loss
Continuous positive airway pressure (CPAP)
1 cause of hepatic cellular carcinoma
HEP B
Prevnar 13
pneumococcal
the MOST contagious of all infectious diseases
Measles (2 doses)
3 C’s of measles
Cough, Coryza, Conjunctivits
HPV Bad strains
16 & 18
TDaP booster dose
Q10y
Hep B 3 doses DTaP 4 doses Hib 3 - 4 doses* Polio 3 doses Prevnar 4 doses MMR 1 dose Varicella 1 dose
Vaccines by age 7
2 newborn prophylaxis Tx
Erythromycin ointment- important!
Vit K
*The greater the degree of prematurity the higher the risk of complications
rule of thumb
Systemic illness due to bacteria in the bloodstream-typically w/in 1st 72hrs
most likely-Hyperthermia, Tachycardia, Respiratory Distress
Neonate Sepsis
How to calculate neonate birth wt
(Birth Weight - Current Weight)/ Birth Weight
- Have more RBC’s (delayed cord clamping)
- Liver is immature
- Body can’t clear it (no bacterial capacity to conjugate bilirubin
why babies get jaundice
If it is _______ bilirubinemia- call hepatology! NOT GOOD!
Conjugated
Caput succedaneum-
cone head
crosses suture line
Cephalohematoma
Does not cross the suture line
Ortolani & Barlow tests
(try to dislocate hip)
Bilirubin-induced neurologic dysfunction
-crosses BBB and causes neuro issues.
BIND
Ethical Decision Making Matrix
- Non maleficence- medical knowledge,
- justice- context (legal, financial, cultural, social)
- Beneficence- quality of life
- autonomy- pt preference
rule of 7s
pediatric capacitance to understand.
children lack the capacity to make medical decisions
=breakdown childhood ranges every 7yrs.
0-7y, 7-14y, 14-21y
Can 15yo pt decide to withold life-saving measures? NO
ethical principle that minors are capable of participating at some level in decision-making related to their care.
Assent
Best Interest Standard
Parents are obligated to make decisions that best maximize the well-being of their children
Rests on value judgments
Harm Principle
Parents cannot make decisions that will harm their children
Pediatric Ethic principles
Most common cause of intermittent stridor in infants
Laryngomalacia
gold standard Tx for FB upper airway
Bronchoscopy
Viral croup Laryngotracheobronchitis Epiglottitis Supraglotittis Bacterial tracheitis
Croup syndromes
Most common: Parainfluenza
Steeple Sign
croup
Medical emergency
Haemophilus influenzae
Cherry- red and swollen epiglottis
Thumb Sign
epiglottitis
Most common pediatric airway emergency requiring PICU admission
Subglottic narrowing
Copious purulent tracheal secretions and membranes
Bacterial Tracheitis
Most common serious acute respiratory illness in infants & young children
Most common organism:
RSV
Bronchiolitis
Acute onset**
1-2d fever, rhinorrhea, cough, then…
Tachypnea
Expiratory Wheezing
Will see with a preceding illness
Bronchiolitis
Suxygen
Maintain hydration
Albuterol and racemic epi should NOT be used
Bronchiolitis Tx
70% cases of bronchiolitis
40% cases of pneumonia
RSV
Complications Otitis media: most common Typical onset 3-4 days after onset Pneumonia ***** Coinfection with Staph aureus (the PNA causes death)
Influenza
Oseltamivir (Tamiflu®) A & B
DO NOT GIVE AMANTIDINE & RIMANTIDINE
-Flu is resistant
Flu Tx
Annual vaccination is best way to prevent influenza!***
Best way to prevent flu
which flu vaccine?
not for use in pts:
prengnacy
cochlear implant
immunocompromised
Nasal spray, (live attenuated)
Highly communicable
Organism:
Bordetella pertussis
Severe bronchitis
50% of children <12mo are hospitalized
Pertussis
Stages of Pertussis
Cataharral: 7-10d coryza, irritating cough Paroxysmal: 1-6wks Vomiting coughing "whoop" cough on inspiration Convalescent: 7-10d
the single greatest cause of death in otherwise healthy children***
>2 million children die
Lung exam Crackles ↓ breath sounds (bronchophony, tactile fremitus) Consolidation Wheezing Viral and atypical
First 2 years of life, up to 80% viral
Pneumonia
15% of newborns with CF present with:
____ _____
Diagnostic of CF
Meconium Ileus
15-month-old male present with inspiratory stridor audible without a stethoscope and RR of 40 bpm. There are moderate intercostal retractions, and no cyanosis. After one course of racemic epinephrine, which is the next best management plan?
A. Cool mist room humidification (not recomm)
B. Dexamethasone IM, one dose
C. Aerosolized ribavirin
D. Chest physical therapy
B. Dexamethasone IM, one dose
A 10-month-old presents for evaluation of noisy breathing and barking cough that gets worse at night. There is a one week history of rhinorrhea, low-grade fever, and cough. The cough has progressively worsened over the past 3 days. On exam: RR 50bpm, T 100.6, inspiratory stridor, barking cough. Remainder of exam unremarkable. What is the most likely diagnosis? A. Croup B. Epiglottitis C. Foreign Body in trachea D. Pneumonia
A. Croup
A 4-month-old infant presents with acute onset of tachypnea, cough, rhinorrhea, expiratory wheezing. Which is the most likely cause? A. Influenza B. Adenovirus (looks like kawasaki) C. Streptococcus pneumoniae D. Bronchiolitis
D. Bronchiolitis
Most common EKG finding for PE is ____
Can also see ______
NSR
S1Q3T3
QT longer than _____sec (_____sec always long)
2.5 large boxes long
longer than 0.47sec
Q waves >2mm
pathological Q waves
EKG: LVH, deep Q waves without h/o prior heart disease, large inverted T Waves
Present all the time
HOCM
