Clin Med Review Flashcards by Cat Johnson

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

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A 75 year old FTT pt is depressed and not gaining weight. What would be your 1st choice of medication?

Remeron

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What is the difference between HFrEF and HRpEF?

HFrEF has a LV Ejection fraction of <50%

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Which two medications improve m/m in pts with HFrEF

ACEI, Beta Blocker

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Which Beta blockers improve M&M in pts w/ HFrEF? (3)

(carbetolol (coreg), metoprolol succinate, bisproprolol))

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What is a recommended medication for pts with a LVEF <40%, who can’t tolerate ACEI or ARBs?

Hydralazine & Nitrates

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Elequis Reversal Agent

Andexxa

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What are the symptoms associated with upper motor deficiencies in als?

spasticity, slow rapid alternating movements, hyperreflexia, stiffness

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Which medication prolongs ALS life expectancy by a couple months?
A. Rilutek (riluzole)
B. Levodopa 
C. Lamotrigine 
D. Gabapentin

A. Rilutek

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What is pseudo bulbar-affect in als?

Inappropriate emotional responses, happens as disease progresses

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Define CHADS2

At which score should you anticoagulate?

CHF, HTN, Age >75, DM, Previous stroke/TIA (2 points) - over 2 anticoagulate

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Which drug is best for rhythm control in a-fib

Amiodarone

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What is the classic triad of parkinsons?

Pill Rolling Tremor
Bradykinesia
Cogwheel rigidity

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Which tremor is improved with moderate alcohol consumption?

Benign Essential Tremor

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What is the treatment for Benign Essential Tremor?

Propranolol

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What is the most effective drug in treating symptomatic Parkinson’s patients?

Sinemet

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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)

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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)

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What hormones are secreted by the posterior pituitary?

Oxytocin

Vasopressin

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What ABI value is diagnostic of PAD?

<0.9

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What is the treatment of choice for viral URI?

Supportive care

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What are the 3 p’s of acute limb ischemia?

Pulseness, pain, pallor, pain, paresthesia, perishingly cold

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What is the most common pituitary secreting hormone?

Prolactin

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List two ways viral URI differs from bacterial?

Timeframe, maxillary pain, tooth pain, second sickening

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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

1. ASCVD - high dose statin 2. Pts with LDL-C ≥190mg/dl - high dose statin 3. Pt 40-75 with DM and LDL-C 70-189 mg/dl - moderate statin 4. 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)

1. Clinical findings of DVT (leg swelling, pn w/palp) 2. Other Dx less likely than PE 3. HR >100 4. Immobilizatoion or surg in past 4 wks 5. Prev. DVT/PE 6. Hemoptysis 7. 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 (

1. enlargement (hands, feet, jaw, internal organs) 2. HTN 3. DM2 4. CHF 5. cardiomegaly 6. MAcroglossa 7. deep voice 8. OSA 9. Spinal stenosis 10. arthralgias 11. wt gain 12. hypogonadism 13. decreased libido/ED 14. irregular menses 15. temporal hemianopsia 16. HA 17. thick skin 18. hyperhydrosis 19. acne/skin tags 20. 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)

1. ↑ Ca2+ retention 2. ↑ Muscle mass 3. Stim growth of internal organs 4. lipolysis 5. homeostasis 6. pancreatic islet cell function 7. ↑ protein synthesis 8. ↓ 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

1. Parathyroid 2. Anterior pituitary 3. Pancreas

Classic triad of pheochromocytoma

HA Sweating Tachycardia

Name BOTH initial tests you could order if you suspect pheochromocytoma

1. 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

1. ↑ Na+ & H2O RESORPTION in kidneys 2. ↑ plasma volume (BP) 3. ↑ H+ SECRETION 4. ↑ 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

1. Difficult to control HTN 2. Hypokalemia 3. Hypernatremia 4. 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

1. Hyperpigmentation 2. Hyperkalemia 3. dehydration 4. GI sx

What medications are you going to maintain a patient with primary Adrenal Insufficiency on on a daily basis?

1. 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

1. buffalo hump 2. moon facies 3. striae 4. central obesity 5. skin atrophy 6. fungal infections 7. acanthosis nigricans 8. hirsuitism 9. increased CV dz 10. psych manifestations 11. increased infections 12. 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

1. Low dose dexamethasone suppression text 2. late night cortisol level 3. 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 1. 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

1. Anchor on LAMA & LABA | 2. Anchor on corticosteroids (ICS)

1. 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

1. AKA adjustment insomnia or acute insomnia Sx <3 months In response to an identifiable stressor 2. Sx ≥3x/wk & persist ≥3mo

1. 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

1. Have more RBC's (delayed cord clamping) 2. Liver is immature 3. 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

1. Non maleficence- medical knowledge, 2. justice- context (legal, financial, cultural, social) 3. Beneficence- quality of life 4. 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