COMLEX 3 (DIT, COMBANK, MTB) Flashcards
MC microorganism in exogenous endopthalmitis
Staphylococcus epidermidis (eye infection)
Endophthalmitis is an inflammation of the interior of the eye
Sensitivity equation
TP / TP + FN
screening test positive in pts with a disease
likelihood that a test will detect all people with the disease
SN-OUT - negative test, rules out disease
ifits perfectly sensitive then no false negatives
Specificity equation
TN / TN + FP
probability test will be negative in pts w/o disease
likelihood that people without disease are correctly identified as disease free by a test
SP-in - specificity, positive test rules in disease
Positive Predictive Value (PPV)
TP / TP + FP
probability someone with positive test has disease
Attributable risk calculation
AR = (A/A+B) - (C/C+D)
difference in rates between exposed and unexposed populations
Incidence equation
New cases of dz / Population at risk
Prevalence equation
of people with disease currently / total population
Compares a group of people with a given disease to a group w/o the disease
Case control
Compares a group with a given risk factor or exposure to a group without that risk factor
Cohort
Relative risk calculation
(A/A+B)/(C/C+D)
probability of getting a disease in a group exposed to specific risk factor compared to probability of getting disease in unexposed group
Absolute risk reduction
(C/C+D) - (A/A+B)
Difference in rates of disease between exposed and unexposed populations
Number needed to treat
1/ARR
ARR = (C/C+D) - (A/A+B)
number of pts that have to be treated in order to prevent one negative outcme
Standard error of mean
“sigma / square root of sample size
“
Z-value for CI = 90%
1.645
CI = [(mean - Z(SEM) to (mean + Z(SEM)]
Z-value for CI = 95%
1.96
CI = [(mean - Z(SEM) to (mean + Z(SEM)]
Z-value for CI = 99%
2.57
CI = [(mean - Z(SEM) to (mean + Z(SEM)]
Chest Pain + Pleuritic Pain (changes with respiration) DDx
Pulmonary embolism
Pneumonia
Pleuritis
Pericarditis
Pneumothorax
Ages that make cardiac family hx significant
Female relatives < 65
Male relatives < 55
S3 gallop
“Dilated Left Ventricle
"”Rapid ventricular filling during diastole””
As soon as the mitral valve opens, blood rushes into the ventricle, causing a splash sound transmitted as an S3”
S3 or Ventricular Gallop
- After S2
- Failing left ventricle, increased blood volume in ventricles
- Dilated CHF
- Ken-tuck-y
S4 gallop
Left ventricular hypertrophy
The sound of atrial systole into a stiff or noncompliant ventricle
S4 or Atrial Gallop
- Before S1
- Blood being forced into hypertrophic left ventricle
- Failing left ventricle, restrictive cardiomyopathy.
- Tenn-ess-ee
Mitral regurgitation murmur
Holosystolic
Best initial test for ischemic-like pain
EKG
Most accurate test for ischemic-like pain
Troponin or CK-MB
Which cardiac enzyme will rise first with an MI?
Myoglobin (1-4 hours)
Troponin and CK-MB will rise 3-6 hours after
Most accurate method to evaluate ejection fraction
Nuclear ventriculogram
Medication that reduces mortality in ACS
Aspirin
Medication that inhibits ADP activation and only given if angioplasty is done
Prasugrel (Brilinta)
3 meds that block ADP-mediated activation of platelets
Clopidogrel
Ticagrelor
Prasugrel
_____________ activate plasminogen into plasmin
Thrombolytics
What medication will lower mortality in ACS if the EF is low?
ACE-inhibitors and ARBs
Therapy that ALWAYS lowers mortality in ACS
Aspirin
Thrombolytics
Primary angioplasty
Metoprolol
Statins
Clopidogrel, prasugrel, or ticagrelor
When do you use CCBs in ACS?
Patient has:
- Intolerance to BBs (like asthma)
- Cocaine induced CP
- Coronary vasospasm (prinzmetal’s angina)
When is a pacemaker the answer for acute MI?
1) NEW LBBB
2) Symptomatic bradycardia
3) Bifasicular block
4) 2nd AV block, Mobitz II
5) 3rd degree AV block
Cardiogenic Shock (Diagnostic Test and Treatment)
Diagnostic Test: ECHO, Swan-Ganz catheter
Treatment: ACE-i, urgent revascularization
Valve Rupture (Diagnostic Test and Treatment)
Diagnostic Test: ECHO
Treatment: ACE-i, nitroprusside, intra-aortic balloon pump as bridge to surgery
Septal Rupture (Diagnostic Test and Treatment)
Diagnostic Test: ECHO
Treatment: Ace-i, nitroprusside, and urgent surgery
Myocardial wall rupture (Diagnostic Test and Treatment)
Diagnostic Test: ECHO
Treatment: Pericardiocentesis, urgent cardiac repair
Sinus bradycardia (Diagnostic Test and Treatment)
Diagnostic Test: EKG
Treatment: Atropine, followed by pacemaker if there are still symptoms
Sinus bradycardia can be the result of many things including good physical fitness, medications, and some forms of heart block.
“Sinus” refers to the sinus node, the heart’s natural pacemaker which creates the normal regular heartbeat.
“Bradycardia” means that the heart rate is slower than normal
3rd degree heart block (Diagnostic Test and Treatment)
“Diagnostic Test: EKG, cannon ““a”” waves
Treatment: Atropine and pacemaker EVEN if symptoms resolve”
“Cannon ““a”” waves”
“3rd degree heart block
Cannon A waves, or cannon atrial waves, are waves seen occasionally in the jugular vein of humans with certain cardiac arrhythmias. When the atria and ventricles contract simultaneously, the blood will be pushed against the AV valve, and a very large pressure wave runs up the vein.[1][2] It is associated with heart block, in particular third-degree (complete) heart block
Right ventricular infarction (Diagnostic Test and Treatment)
Diagnostic Test: EKG showing right ventricular leads
Treatment: Fluid loading
Electrolyte abnormality caused by ACE-i or ARBs
Hyperkalemia
With ACE inhibitor use, the production of ATII is decreased, which prevents aldosterone release from the adrenal cortex. This allows the kidney to excrete sodium ions along with obligate water, and retain potassium ions. This decreases blood volume, leading to decreased blood pressure.
Ranolazine
“Anti-angina med added if no other meds control pain
”
Ranolazine is used to treat chronic angina. It may be used concomitantly with β blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE inhibitors, and angiotensin receptor blockers.
Contraindications
Some contraindications for ranolazine are related to its metabolism and are described under Drug Interactions. Additionally, in clinical trials ranolazine slightly increased QT interval in some patients and the FDA label contains a warning for doctors to beware of this effect in their patients. The drug’s effect on the QT interval is increased in the setting of liver dysfunction; thus it is contraindicated in persons with mild to severe liver disease.
Ranolazine prolongs the action potential duration, with corresponding QT interval prolongation on electrocardiography, blocks the INa current, and prevents calcium overload caused by the hyperactive INa current, thus it stabilizes the membrane and reducing excitability.
LDL goal in a patient with CAD and Diabetes
LDL goal at least < 70
MC adverse effect of statin medications is _____ ________
Liver toxicity
LFTs should be routinely checked
Melanoma suspicion AND most appropriate NEXT step in management
“Excisional biopsy
“
Shingle/Herpes zoster AND most appropriate management
“1.) 7-day course of anti-viral drug within 72 hours
- Acyclovir, Valcyclovir, or Famciclovir
- ) Analgesics
- ) Herpes zoster vaccine (Recommended in ages > 60)
“
Pruritic, purple, polygonal papules
“Lichen planus
tx: topical corticosteroids
“
Scabies tx
“Topical permethrin or Oral ivermectin
“
Mongolian spot AND most appropriate next step in management
“Reassurance
“
Stevens-Johnson syndrome / Toxic epidermal necrolysis TX
“1.) Admit to ICU or burn unit
- ) Stop offending drug
- ) Wound care
- ) Supportive treatment (fluids, electrolytes, pain control)
- ) Monitor for bacterial superinfection
“
Vancomycin-induced RED MAN’s syndrome TX/management
“1.) Stop vancomycin infusion
- ) Give benadryl + ranitidine
- ) Restart infusion @ slower rate
“
What conditions are associated with erythema nodosum?
“1.) Streptococcus pharyngitis
- ) Sarcoidosis
- ) TB
- ) Fungal infections
- Coccidiomycosis
- Histoplasmosis
- Blastomycosis - ) Inflammatory bowel disease
- ) Pregnancy/OCP use
- ) Idiopathic
“
Post-infectious oral erosions and target lesions
Erythema multiforme
Stasis dermatitis tx
“1.) Leg elevation
- ) Compression stockings
- ) Treat underlying cause
“
Developmental mile-stones at 9 months of age
“Expected to begin to say ““dada/mama””
Understand the meaning of ““no””
Crawl
Pull to a stand
Use a 3-finger pincer grasp
Wave ““bye-bye””
Play pat-a-cake”
First line treatment for hyperosmolar coma
Fluid resuscitation with isotonic saline
6-day old male w/fever, irritability, and an erythematous rash around the mouth. One day later, the rash generalizes and flaccid blisters appear. The upper layer of the skin begins to slough off, especially when gentle lateral pressure is applied to skin. Dx, Organism, and Treatment:
Staphylococcus scalded skin syndrome
S. aureus
- ) IV Anti-staph abx
- Nafcillin/oxacillin - ) Supportive Care
- Emollients
- IV Fluids
- Correct electrolytes
Staphylococcus scalded skin syndrome (characteristics)
“Flaccid blisters
+ Nikolsky
No mucous membranes
Tx: Nafcillin/oxacillin
“
What are the treatment options for actinic keratosis?
“1.) Cryotherapy
2.) Curettage
- ) Topical:
- 5-fluorouracil
- Imiquimod
- Ingenol mebutate
4.) Photodynamic therapy
“
Pemphigus vulgaris vs. Bullous pemphigoid
Pemphigus vulgaris:
+ Nikolsky
+ oral involvement
Systemic corticosteroids
+/- immunosuppression
Bullous pemphigoid
Tense blisters
Rare oral involvement
Topical corticosteroids
+/- immunosuppression
Pemphigus vulgaris tx
“Flaccid blisters (+ Nikolsky)
Oral involvement
Treatment:
Systemic glucocorticoids
- Prednisone
- Prednisolone
+/- Immunosuppression
Azathioprine
Mycophenalate
“
Bullous pemphigoid tx
“Tense, sub-epidermal blisters
(-) Nikolsky
Oral involvement rare (10-30%)
Treatment:
Topical corticosteroids
- Clobetasol
+/- Immunosuppression
Azathioprine
Mycophenalate
“
Hep C + skin blisters in the sun (Dx and Tx)
Dx: Porphyria cutanea tarda
Treatment:
Avoid triggers (alcohol, estrogen, poly-hydrocarbons)
Phlebotomy (removing excess iron)
Chloroquine
“Herald patch + ““christmas tree pattern”” rash”
“Pityriasis rosea
Tx:
Reassurance
Topical Corticosteroids
IF SEVERE: acyclovir
“
What should be done prior to initiating isotretinoin therapy in a teenage girl?
- ) Counseling and education
- ) Pregnancy test x2 (and tests throughout)
- ) 2 forms of birth control
- ) Labs (Lipids, LFTs, CBC, preg)
Nodular basal cell carcinoma classic description
“Papular
Pearly
Translucent
Telangiectasia
Painless/raised
“
Lice tx
“1.) Permethrin cream (MC)
- ) Malathion
- ) Benzyl alcohol
- ) Spinosad
- ) Ivermectin
- ) Lindane (last resort/neurotoxic)
“
A 2-year old boy is brought to the office by his mother because of a 1-year history of dry skin despite frequent application of moisturizing lotion. She says that he constantly scratches skin. Physical examination shows erythematous patches and scaling on the: face, neck, and ANTECUBITAL/POPLITEAL fosse What is the most likely diagnosis? This patient is as increased risk for what condition later in life?
“Atopic dermatitis / eczema
ASTHMA
“
What is the classic description of a cutaneous squamous cell carcinoma lesion?
“Head/neck (MC location)
Plaque/papule/nodule
Ulceration
Crusting
Hyperkeratosis
““Non-healing ulcer””
“
WPW syndrome and digoxin
AVOIDED
Initial slurring of the QRS is called the _____ wave and is associated with ___ syndrome
Delta wave
WPW
What is a delta wave on EKG associated with?
“WPW syndrome
“
WPW syndrome tx
“Carotid massage
Procainamide
Valsava manneuver
Cardioversion if unstable
“
DEXA scan up to -1
normal range
DEXA scan -1 to -2.5
Osteopenia
DEXA scan < -2.5
Osteoporosis
When should a DEXA scan be ordered as preventative screening?
Hx of cigarette smoking
Chronic glucocorticoid therapy
BW less than 127 lbs
Previous fractures
Excessive alcohol intake
DEXA scanning should be performed in women:
> 65 as screening OR
in post-menopausal women < 65 with risk factors
Acute Pulmonary Edema tx
“Oxygen
Furosemide
Nitrates
Morphine
“
Carvedilol MOA
Beta 1, Beta 2, and Alpha 1 antagonist
Thus it is:
Anti-arrhythmic
Anti-ischemic
Anti-hypertensive
Milrinone and Inamrinone MOA
Phosphodiesterase inhibitors
Increase contractility
Decrease afterload
Vasodilators
(similar effect that dobutamine has)
Dopamine MOA
Alpha-1 agonist
Vasoconstriction
Increases afterload
Increases contractility
Hypoxia in CHF causes respiratory __________
Alkalosis
Further management in CHF/pulmonary edema when furosemide, oxygen, nitrates, and morphine are given and the patient is still SOB
Dobutamine
Inamrinone
Milrinone
Acute Pulmonary Edema + Ventricular Tachycardia. Next step?
Synchronized cardioversion
What is Nesiritide?
____________ is a synthetic version of atrial natriuretic peptide that is used for acute pulmonary edema as part of preload reduction
Pulmonary edema is associated with decrease in _______ ______ due to pump failure, which results in backup of blood into the left atrium causing ___________ wedge pressure
Cardiac Output
Increased
Wedge pressure =
Left Atrial Pressure
BB’s with evidence of lowering mortality in CHF
Metoprolol
Carvedilol
Bisoprolol
In CHF when ACE inhibitors and ARBs cannot be used
Hydralazine + Nitrates
ANY PATIENT originally presenting with pulmonary edema should get ______________
Spironolactone
SA nodal inhibitor used in systolic CHF when BB’s can’t be used
Ivabradine
Decreased mortality in CHF with these 3 drugs (drug/classes)
ACE/ARB
Beta blocker
Spironolactone
Systolic dysfunction drugs
ACE/ARB
Metoprolol, carvedilol, Bisoprolol
Spironolactone or eplerenone
Diuretics
Digoxin
Hydralazine/nitrates
Diastolic dysfunction drugs
Metoprolol, carvedilol, bisoprolol
Diuretic
______________________________ are indicated in dilated cardiomyopathy with an EF below 35%
Implantable cardioverter/defibrillator
Severe CHF with EF < 35% and wide QRS ( > 120 msec)
Biventricular pacemaker
“SOB, ““worse with exertion/exercise””, and young female”
Mitral valve prolapse
“SOB, ““worse with exertion/exercise””, and healthy, young athlete”
Hypertrophic obstructive cardiomyopathy
“SOB, ““worse with exertion/exercise””, and immigrant and/or pregnant”
Mitral stenosis
“SOB, ““worse with exertion/exercise””, and turner’s syndrome and/or coarctation of aorta”
Bicuspid aortic valve
“SOB, ““worse with exertion/exercise””, and palpitations w/atypical chest pain (no CP with exertion)”
Mitral valve prolapse
If a murmur INCREASES in intensity with EXHALATION think _______ side of heart
LEFT
If a murmur INCREASES with INHALATION think _______ side of heart
RIGHT
AS, AR, MS, MR, and VSD ALL _________ with increased venous return to heart (squat or leg raise)
INCREASE
They will DECREASE with decreased venous return to heart (stand or valsalva)
Which are the only two murmurs that DECREASE with increased venous return to heart (squat or leg raise)
MVP and HOCM
They will INCREASE with decreased venous return to heart (stand or valsalva)
Handgrip WORSENS which murmurs?
AR, MR, VSD
Amyl nitrate as a vasodilator ____________ AR and MR
improves
Amyl nitrate _____________ the murmurs of MVP, HOCM, and AS
worsens
Handgrip SOFTENS which murmurs?
MVP, HOCM, AS
BEST INITIAL test for valvular heart disease
ECHOCARDIOGRAM
Most accurate test for valvular heart disease
LEFT heart cath
“If ““handgrip”” makes a murmur worse, then use…”
ACE inhibitors (most effective medical therapy)
Regurgitant lesions tx
Vasodilator therapy
- ACE
- ARB
- Nifedipine
Stenotic lesions are best treated with
Anatomic repair
”"”Valsava”” improves murmur = _____________ indicated”
Diuretics
Older patient with chest pain and hx of HTN Has a murmur: DECREASES with standing, valsalva, and handgrip INCREASES with leg-raising, squatting, and amyl nitrate
“Aortic stenosis
“
Mild, moderate, and severe disease in AS based on pressure gradient across the valve (criteria)
30 mm Hg: mild
30-70 mm Hg: moderate
> 70 mm Hg: severe
Best INITIAL treatment for AS vs. treatment of choice
Diuretics (initial) Valve replacement (treatment of choice)
Aortic regurgitation DDx
“Hypertension
Rheumatic heart disease
Endocarditis
Cystic medial necrosis
Rarer:
Marfan’s
Ankylosing spondylitis
Syphilis
Reactive arthritis
“
”"”Diastolic decrescendo murmur heard best at Left sternal border”” Increases in intensity with leg raising, squatting, and handgrip”
Aortic Regurgitation
Quincke pulse
“Aortic regurgitation
Arterial or capillary pulsations in fingernails
“
Corrigan’s pulse
“Aortic regurgitation
High bounding pulses (AKA water-hammer pulse)
“
Musset’s sign
Aortic regurgitation
Head bobbing up and down with each pulse
Duroziez’s sign
Aortic regurgitation
Murmur heard over the femoral artery
Hill sign
Aortic regurgitation
Blood pressure gradient much higher in lower extremities
Aortic regurgitation TESTING
Best initial: TTE
More accurate: TEE
Most accurate: Left heart cath
ADD in: EKG and CXR showing LVH
Aortic regurgitation
“Best initial therapy: ACE/ARBs and Nifedipine
ADD in Loop diuretic for CCS
“
AR treatment with EF < 55% OR Left ventricular end systolic diameter > 55mm
SURGERY, even if asymptomatic
Abscess tx
Warm compresses
Incision & Drainage
Abx:
- Clindamycin
- TMP-SMX
Antibiotics for abscess tx
Clindamycin & TMP-SMX
Impetigo tx (antibiotics)
“Topical Antibiotics
- Mupurocin
- Retapamulin
IF SEVERE: oral dicloxacillin or cephalexin
“
“Superficial infection, w/papules that progress to vesicles and pustules, and finally ““honey-colored crusts”””
“Impetigo
“
MC organism for Impetigo
S. aureus
MC organism for Erysipelas
Strep pyogenes
Microorganisms in Cellulitis
S. aureus
S. pyogenes
OTHERS
Depth of infection in erysipelas
Upper dermis
Depth of infection in cellulitis
Deeper dermis and sub Q fat
“Skin infection w/spreading warmth, edema, redness AND ““INDISTINCT borders”””
Cellulitus
Skin infection w/painful, red, raised lesions AND a clearly demarcated border
“Erysipelas
“
Erysipelas tx
Oral penicillin or amoxicillin
IF SEVERE: IV ceftriaxone or cefazolin
Cellulitis tx
Oral dicloxacillin or cephalexin
IF SEVERE: IV cefazolin or clindamycin
Cellulitis borders are _______________ (key word)
“Indistinct
“
What is the appropriate management of a necrotizing soft tissue infection?
Surgical debridement
IV broad spectrum abx
Supportive care (IV fluids and vasopressors)
IV broad spectrum abx for necrotizing soft tissue infection
Carbapenem or Beta-lactam/Beta-lactamase inhibitor (ex: zosyn)
Clindamycin
MRSA coverage (vancomycin)
What lab should you monitor when putting patients on terbinafine, itraconazole, or griseofulvin?
LFTs, these agents are hepatotoxic
Patient appears toxic w/fever, crepitus, and pain out of proportion to exam w/skin infection
“Necrotizing soft tissue infection
“
Tinea unguium tx
“Oral antifungals
- Terbinafine
- Itraconazole
- Griseofulvin
“
Tinea pedis tx
“Topical antifungals
- Terbinafine
- Naftifine
- Clotrimazole
“
Tinea corporis tx
“Topical antifungals
- Terbinafine
- Naftifine
- Clotrimazole
“
Tinea capitis tx
“Oral antifungals
- Terbinafine
- Itraconazole
- Griseofulvin
“
Potentially how long could a patient need anti-fungal treatment for dermatophyte infection?
12 weeks
Terbinafine, Itraconazole, & Griseofulvin in treating tinea capitis/unguium
Oral antifungals
“Warts with ““stuck-on”” appearance”
“Seborrheic keratosis
“
Seborrheic keratosis tx
“Curettage AFTER cryosurgery
“
Podophyllin, Trichloroacetic acid, or 5-fluorouracil
Topical agents for condyloma acuminata
19-year-old woman w/fever, hypotension, AMS, rash w/history of being on menstrual cycle recently
Toxic Shock Syndrome
Toxic Shock Syndrome tx
“1.) Remove source of infection (tampon)
- ) Supportive care (IV fluids/pressors)
- ) Abx: Clindamycin and Vancomycin
“
What are the treatment options for condyloma acuminata?
- ) Topical agents
- ) Immune modulators
- ) Surgical removal
Condyloma acuminata tx (immune modulators)
Imiquimod
IFN-alpha
Condyloma acuminata tx
“1.) Topical agents (podophyllin, acid, 5-fu)
- ) Immune modulators (Imiquimod, IFN-a)
- ) Cryosurgery
- ) Laser therapy
- ) Surgical excision
“
+ Nikolsky sign ddx
“Stevens-Johnson syndrome
Toxic epidermal necrolysis
SSSS
Pemphigus vulgaris
“
Psoariasis tx
“1.) Emollients
- ) Topical corticosteroids
- ) Topical calcineurin inhibitors
- ) Topical retinoids
- ) Topical vitamin D
- ) Phototherapy
- ) Biologic agents
“
Biologic agents in severe Psoariasis tx
Methotrexate
Cyclosporine
Adalimumab
Etanercept
Infliximab
Topical corticosteroids in Psoariasis tx
Hydrocortisone
Betamethasone
Clobetasol
Topical calcineurin inhibitor in Psoariasis tx
Tacrolimus
Seborrheic dermatitis tx
“1.) Anti-fungal shampoo
- Selenium sulfide
- Ketoconazole
- ) Topical corticosteroid
- ) Topical anti-fungal
“
Patients with severe injuries such as burns, short bowel syndrome, or those receiving TPN are at risk for _________ deficiency
Chromium
Chromium deficiency + Diabetes
Increased insulin requirements, supplementation with chromium can improve glucose tolerance
Patient with fragile-abnormal hair, depigmented skin, ataxia, neuropathy, cognitive defects, edema, and osteoporosis + microcytic anemia / neutropenia
Copper deficiency
Patient with microcytic anemia that gets worse with iron supplementation
Copper deficiency
Perioral/perianal rash + diarrhea + hair loss
Zinc deficiency
Skeletal muscle dysfunction, cardiomyopathy, mood disorders, impaired immunity, macrocytosis, and white nail beds
Selenium deficiency
Patient with suspected BPH and urinary retention. What do you need to evaluate next?
Renal function and r/o infection and hematuria with BMP and urinalysis
BPH + renal insufficiency (elevate Cr). Next step?
Renal ultrasound to evaluate for bladder outlet obstruction or hydronephrosis
What is the ACLS protocol for ventricular fibrillation?
“Shock FIRST then CPR immediately
“
What is the ACLS protocol for pulseless electrical activity or asystole?
“CPR FIRST, Drugs, Evaluate and treat H’s and T’s
“
H’s of PEA/aystole
Hypovolemia
Hypoxemia
H+ (acidosis)
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
T’s of PEA/aystole
Tamponade
Tension pneumothorax
Thrombosis (MI or PE)
Trauma
Toxins or Tablets
Hypovelmia and PEA/aystole tx
Volume resucitation
Hypoxemia and PEA/aystole tx
Intubation, oxygen, chest tube
H+ (acidosis) and PEA/aystole tx
Bicarbonate
Hyperkalemia and PEA/aystole tx
Calcium chloride/gluconate
Bicarbonate
Insulin and glucose
Hypokalemia and PEA/aystole tx
Potassium chloride
Hypoglycemia and PEA/asytole tx
D50
Hypothermia and PEA/aystole tx
Warm
Tamponade and PEA/aystole tx
Pericardiocentesis
Tension pneumothorax and PEA/aystole tx
Needle decompression
Chest tube
Thrombosis (MI) and PEA/aystole tx
Cardiac cath
Thrombolytics
Thrombosis (PE) and PEA/aystole tx
Thrombolysis
Thrombectomy
Trauma patient with high-riding prostate OR blood at urethral meatus
Suspect urethral injury
- Do a retrograde cystourethrogram BEFORE foley
What study is used to diagnose injury to urethra or bladder following trauma?
Retrograde cystourethrogram
What type of IV nutrition is recommended for a patient with acute alcohol withdrawal?
Potassium
Magnesium
Phosphate
Thiamine
Glucose
Acute alcohol withdrawal tx
IV Fluids
IV nutrition
Benzodiazepines
Propofol (if severe)
Respiratory support
Benzo’s for acute alcohol withdrawal
Diazepam
Lorazepam
Chlordiazepoxide
What are the indications for emergent hemodialysis in acute renal failure?
”
“
What empiric antibiotic prophylaxis is used for cat and dog bites?
”
“
What empiric antibiotic treatment is used for an INFECTED cat or dog bite?
”
“
What is the treatment for carbon monoxide poisoning?
”
“
What is the treatment for acquired methemoglobinemia?
”
“
What substances are known to cause malignant hyperthermia?
”
“
What is the initial, standard treatment for malignant hyperthermia?
”
“
When do you need to cool a patient with malignant hyperthermia?
Temp above 39 celsius or 102.2 F
Malignant hyperthermia AND hyperkalemia tx
Calcium chloride
Bicarbonate
Furosemide
Insulin and glucose
Difference between heat EXHAUSTION and heat STROKE
Exhaustion: Temp 101-104 F and no CNS dysfunction
Stroke: Temp > 104 F w/CNS dysfunction
Patient comes in with suspected heat-related injury and has temperature above 104 F with CNS dysfunction?
Heat stroke
Patient comes in with suspected heat-related injury and has temperature between 101-104 F without CNS dysfunction? (may also mention difficulty with exercise)
Heat exhaustion
Td should be given to every adult every _________________
10 years
Tdap booster is recommended ONCE in place of the Td between ages ______________ years
19-64
Nontetanus-prone wound (LE, clean, minor) + 3 or more prior tetanus shots. When is a Td indicated?
Td if it’s been more than 10 years since last dose
Tetanus-prone wound (dirt, contamination, puncture, crush injury) + 3 or more prior tetanus shots. When is a Td indicated?
Td if it’s been more than 5 years since last dose
Patient is uncertain of last dose or if they have had the complete series (3). When do you give Td in nontetanus and tetanus prone wounds?
Td to complete series
DT if <7 years
When do you give tetanus immune globulin and how much?
When a patient is uncertain of vaccination history and has a tetanus-prone wound
250 units IM
PAINLESS, progressive obstructive jaundice
Pancreatic cancer
Atropine administration and EYES
“Fixed and dilated pupils (mydriatic) with no response to light stimulation or accommodation
“
-TROPs (possible adverse effects)
Confusion
Constipation
Urinary retention
Fever
Flushing
Tachycardia
Blurry vision
Mydriasis
MC cause of mitral stenosis
Rheumatic fever
Why are pregnant patients at risk for mitral stenosis?
Large increase in plasma volume
(more volume with same valve diameter means more pressure, backflow, and symptoms)
Diastolic rumble after an opening snap + increase in intensity with leg-raising, squatting, or expiration
Mitral Stenosis
Best initial diagnostic test for mitral stenosis
TTE (best initial)
TEE (more accurate)
Most accurate test for mitral stenosis
Left heart catheterization
”"”straightening of the left heart border and elevation of the left mainstream bronchus”” on chest x-ray”
Mitral stenosis
Best initial therapy for mitral stenosis
Diuretics
Most effective therapy for mitral stenosis
Balloon valvuloplasty
SPECIAL features of mitral stenosis
Dysphagia: LA pressing on esophagus
Hoarseness: pressure on recurrent laryngeal nerve
Atrial fibrillation: leading to stroke
Causes of mitral regurgitation
Hypertension
Ischemic heart disease
Conditions leading to dilated heart
MC symptoms of mitral regurgitation
Dyspnea on exertion
___ gallop is associated with fluid overload states, such as congestive heart failure or mitral regurgitation
S3
S3 gallop DDx
CHF or Mitral regurgitation
Holosystolic murmur, best heard at apex, radiates to axilla, and increased with leg-raising, squatting, and handgrip
Mitral regurgitation
Holosystolic murmur, best heard at apex, DECREASES with standing, valsalva, and amyl nitrate
Mitral regurgitation
Best initial diagnostic test for mitral regurgitation
TTE (best initial)
TEE (more accurate)
Best initial therapy for mitral regurgitation
ACE-i
ARBs
Nifedipine
Patient with mitral regurgitation and EF drops below 60% OR LV volume > 40mm
SURGERY repair or replacement
Holosystolic murmur at the lower left sternal border, SOB, and worsens with exhalation, squatting and leg raise
VSD
Best initial diagnostic test for VSD
ECHO
More precise test to determine degree of left-to-right shunting in VSD
Cath
Fixed splitting of S2
ASD
When is repair indicated in ASD?
When the shunt ratio exceeds 1.5 to 1
Wide splitting of S2, P2 delayed
RBBB
Pulmonic stenosis
Right ventricular hypertrophy
Pulmonary hypertension
Paradoxical splitting of S2, A2 delated
LBBB
Aortic stenosis
Left ventricular hypertrophy
Hypertension
Best initial test for dilated cardiomyopathy
ECHO
Most accurate method for determining ejection fraction in dilated cardiomyopathy
MUGA or nuclear ventriculography
MC causes of dilated cardiomyopathy
Ischemia
Alcohol
Adriamycin
Radiation
Chaga’s disease
Treatment for ALL forms off dilated cardiomyopathy
ACE-i
ARBs
Beta blockers
Spironolactone
Spironolactone and eplerenone, mineralocorticoid or aldosterone antagonists are given in dilated cardiomyopathy to…
Decrease the work of the heart; they are NOT given for their diuretic effect
What do you give a patient with dilated cardiomyopathy if the heart rate is > 70 after the use of beta blockers
Ivabradine, a Na+ channel blockers
S4 gallop is a sign of…
Left ventricular hypertrophy and decreased compliance or stiffness of the ventricle
SOB on exertion and S4 gallop
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy EF
Normal!
Mainstay of therapy in hypertrophic cardiomyopathy
Beta blockers AND diuretics
Causes of Restrictive cardiomyopathy
History of:
- Sarcoidosis
- Amyloidosis
- Hemochromatosis
- Cancer
- Myocardial fibrosis
- Glycogen storage diseases
Kussmaul’s sign
an increase in jugular venous pressure on inhalation
SOB is the main presenting complaint in ALL FORMS of…
Cardiomyopathy
SOB + Kussmaul’s sign
Restrictive cardiomyopathy
“Low voltage EKG, ““speckled pattern”” on ECHO, and SOB”
Amyloid Restrictive cardiomyopathy
Mainstay of diagnosis in Restrictive cardiomyopathy
ECHO
Single most accurate diagnostic test of the etiology of Restrictive cardiomyopathy
Endomyocardial biopsy
Best treatment for Restrictive cardiomyopathy
Diuretics and correcting underlying cause
(sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis, glycogen storage disease, etc)
Rare, sudden systolic dysfunction brought on by extreme emotions
Takotsubo Cardiomyopathy
Post-menopausal woman with sudden psychological stress, presents like an acute MI, normal coronary arteries
Takotsubo Cardiomyopathy
Takotsubo Cardiomyopathy treatment
ACE-i, Beta-blockers, and Diuretics
_____________ adds efficacy to NSAIDs and prevents recurrent episodes in pericardial disease
Colchicine
Pleuritic CP that is positional, sharp, and brief with a friction rub on physical exam
Pericardial disease
Best initial test for pericarditis
EKG
- ST segment elevation everywhere
- PR segment depression in lead II (not always present)
PR segment depression in lead II
“Pericarditis
“
Causes of pericarditis
MC: Cancer
Others: infection, collagen vascular disease, or trauma
Best initial therapy in pericarditis
NSAID:
- Indomethacin
- Naproxen
- Aspirin
- Ibuprofen
NSAID + Colchicine
Persistent symptoms in pericarditis after NSAID + colchicine therapy
Oral prednisone
SOB + Hypotension + Jugular venous distension
Pericardial tamponade
Unique features of tamponade (physical exam and EKG)
Pulsus paradoxus + Electrical alternans
Electrical alternans
“Alterations of the axis of the QRS complex on EKG
“
Pulsus paradoxus
“Decrease in BP > 10 mm Hg on inhalation
“
Most accurate diagnostic test in cardiac tamponade
“ECHO: ““diastolic collapse of the right atrium and right ventricle”””
EKG findings of cardiac tamponade
Low voltage and electrical alternans
”"”Equalization”” of all pressures in heart during diastole on right heart catheterization”
Cardiac tamponade
Best initial therapy for cardiac tamponade
Pericardiocentesis
Most effective long-term therapy in cardiac tamponade
Pericardial window placement
MOST DANGEROUS therapy in cardiac tamponade
Diuretics
SOB + chronic right heart failure + positional, pleuritic pain
Constrictive pericarditis
Signs of chronic RIGHT heart failure
Edema, JVD, Hepatosplenomegaly, Ascites
Pericardial knock
EXTRA diastolic sound from the heart hitting a calcified, thickened pericardium
Calcification surrounding the heart on CXR, low voltage on EKG, and thickened pericardium on CT/MRI
Constrictive pericarditis
Best initial therapy for constrictive pericarditis
Diuretics
Most effective therapy for constrictive pericarditis
Surgical removal of the pericardium (pericardial stripping)
Abdominal aortic aneurysms are repaired when they are bigger than ____ cm
5
“CP radiating to the back between the scapula, described as ““ripping””, and a difference in BP between right and left arms”
Aortic dissection
Best initial test for aortic dissection
CXR showing widened mediastinum
Most accurate test for aortic dissection
CT angiography
Aortic dissection management
- ) Order beta blockers, EKG, and CXR
- ) Next: CT, TEE, or MRA (all equally accurate)
- ) Add nitroprusside to control BP
- ) ICU transfer + surgical consult
Most effective therapy for aortic dissection
Surgical correction
AAA screening guidelines
U/S in men 65-75 years old who are current or former smokers
Pain + Pallor + Pulseless =
Arterial occlusion
Acute loss of pulse, cold extremity, and pain with history of AS or a-fib
Acute arterial embolus
Best initial test in PAD
Ankle-brachial index (ABI)
Normal ABI
Equal to or greater than 0.9
Greater than 10% difference in BP when comparing legs
Obstruction is present
Most accurate test in PAD
Angiography
Best initial therapy in PAD
Aspirin
BP control w/ACE-inhibitor
Exercise as tolerated
Cilostazol
Lipid control w/statins (LDL < 100 is goal)
Vorapaxar
Vorapaxar
Anti-platelet drug given in PAD w/aspirin or clopidogrel
Palpations and an irregular pulse in a person with a history of HTN, ischemia, or cardiomyopathy
A-fib
A-fib patients who are hemodynamically STABLE should undergo _______ monitoring outpatient
Holter
Other tests to order once A-fib is found on EKG
ECHO
Thyroid function testing (T4 and TSH)
Electrolytes (K+, mag, and Ca++)
Troponin or CK-MB levels
Unstable a-fib patient (systolic < 90, confusion related to hemodynamic instability, CP, or CHF) and management
Immediate synchronized cardioversion
Stable a-fib patient and HR > 100-110
Slow ventricular HR with beta blockers, CCBs, or digoxin
CHADS-VASc
C: CHF
H: HTN
A: Age > 75
D: Diabetes
S: Stroke or TIA
V: vascular disease
A: Age between 65-74
S: sex (female)
Score of 0-1 on CHADS-VASc
Aspirin therapy
Score of 2 or more on CHADS-VASc
Control rate and anticoagulate
(Warfarin, Apixaban, Dabigatran, Edoxaban, or Rivaroxaban)
Factor Xa inhibitors
Rivaroxaban
Apixaban
Edoxaban
NOAC thrombin inhibitor
Dabigatran
Severe bleeding with warfarin use
Reverse with FFP
Severe bleeding with dabigatran
Reverse with Idacrucizumab
Severe bleeding with Xa inhibitors
Reverse with Andexanet
Benefits of NOACs (novel oral anticoagulants)
- ) Prevent more strokes than warfarin
- ) Cause less intracranial bleeding than warfarin
- ) Decrease mortality MORE than warfarin
- ) Treat DVT and PE
The main indication for warfarin is a patient with atrial fibrillation who have…
Metallic heart valves
Common BB used in ischemic heart disease + a-fib or a-flutter
Metoprolol
Migraines + a-fib or a-flutter tx
Metoprolol and/or diltiazem
Graves disease + a-fib or a-flutter tx
Metoprolol
Pheochromocytoma + a-fib or a-flutter tx
Metoprolol
Asthma + a-fib or a-flutter tx
CCB: Diltiazem
Borderline hypotension in a patient with a-fib or a-flutter tx
Digoxin
Patient with COPD/emphysema + atrial arrhythmia (polymorphic P waves, tachycardia)
Multifocal atrial tachycardia (MAT)
Multifocal atrial tachycardia EKG finding
“Polymorphic P waves (different atrial foci for the QRS complexes)
“
Irregular, chaotic rhythm on EKG showing polymorphic P waves in a patient with history of COPD/emphysema
Multifocal atrial tachycardia (MAT)
Multifocal Atrial Tachycardia tx
- ) OXYGEN first
- ) Diltiazem second
- ) NEVER beta blockers
Best initial management for UNSTABLE patients in SVT
Synchronized cardioversion
Best initial management for STABLE patients in SVT
Vagal maneuvers
NEXT best step in management of a stable patient in SVT when vagal maneuvers do not work
IV Adenosine
Best long-term management of a patient with recurrent SVT
Radio frequency catheter ablation
SVT that can alternate with Ventricular tachycardia
Wolff-Parkinson-White Syndrome
”"”worsening of SVT AFTER the use of CCB or digoxin”””
WPW syndrome
Delta wave on EKG
“WPW syndrome
“
Most accurate test in WPW
Electrophysiologic studies
WPW syndrome treatment
Procainamide
Best initial therapy IF the patient is described as being in SVT or VT from WPW
Procainamide
Best long-term therapy in WPW syndrome
Radio frequency catheter ablation
If an EKG does not detect VT, then _______________________ should be ordered
Telemetry monitoring
The most accurate diagnostic test for ventricular tachycardia
Electrophysiologic studies
Hemodynamically stable patients in VT treatment
Amiodarone, Lidocaine, Procainamide, Magnesium
Unstable patients in VT treatment
Synchronized cardioversion
Treatment of V-fib
ALWAYS unsynchronized cardioversion
Initial Syncope workup
Cardiac/neuro examination
EKG
Chemistries (glucose)
Oximeter
CBC
Cardiac enzymes
Make sure to order these tests for syncope
EKG
Cardiac Enzymes
ECHO
Head CT
A physician refuses to administer abx to a patient with a viral infection because of the high risk of dangerous side effects. Identify core ethical principle.
Non-maleficence (do no harm)
A physician allows a cancer patient to choose between two acceptable and equally effective treatment plans. Identify core ethical principle.
Patient autonomy
Paternalism definition
Opposite of patient autonomy; the attending physician chooses best treatment
A competent patient refuses therapy for a life-threatening condition. Identify core ethical principle.
Patient autonomy
A working-class patient with end-stage liver disease is given higher priority for a liver transplant than an internationally-renowned actor whose liver disease is less advanced. Identify core ethical principle.
Justice, all patients must be treated fairly
Patient does not want blood products, has signed consent, and understands risk. During procedure a large artery was injured and the patient will die w/o transfusion. How is this patient handled in the OR under anesthesia?
No blood products given due to patient’s living will
Under what circumstances may a physician share a patient’s confidential information?
“Danger/harm to self/others
Child/elder abuse
Reportable diseases
Patient grants permission
Those involved in direct care
“
Suspicion of elder abuse. Next step?
- ) Report
- ) Speak to patient w/o caregiver
A physician orders an invasive test for the wrong patient. What is the most appropriate ethical response?
Inform patient of mistake; always communicate mistakes to maintain patient trust
A patient tells the physician that he/she finds the physician attractive and wants to start dating. What is the most appropriate ethical response?
- ) Maintain professionalism
- ) + Chaperone during encounters
An elderly woman is found to have inoperable lung cancer, and her family asks the physician to tell the patient the biopsy is negative. What is the most appropriate ethical response?
- ) DO NOT lie
- ) Ask patient if they want to know results
- ) Ask family for motives
You suspect another physician of practicing under the influence of alcohol. What is the most appropriate ethical response?
Notify physician’s superior
Who should determine patient’s capacity in making decisions?
Attending physician
Who should determine patient’s COMPETENCY in making decisions?
Judge
What is required to determine if a patient has decision-making capacity?
“1.) Patient is 18+
- ) Understands and is informed
- ) Decision stable over time
- ) Can communicate appropriately
- ) Decision not influenced by psychiatric disorders
“
When is parental consent not required?
“Emergency, Pregnancy, Alcohol-related, STI’s, contraception
“
MC underlying cause of TIA
Atrial fibrillation
Patient has bruit on exam. Next first step?
Carotid u/s
Young patient with hyponatremia and hyperkalemia. Next step?
Order blood glucose. Looking for evidence of DKA
Staphylococcus epidermidis is coagulase ___________
Negative
MC organism that infects a hydrocephalus shunt
Staph epidermidis (coagulase negative)
”"”NOLIP”” what mnemonic is this for?”
Treatment of acute pulmonary edema (CHF exacerbation)
Nitrates, oxygen, loop diuretic, inotropic drug, and position change (legs down)
Acute pulmonary edema tx
”"”NOLIP””
N: Nitrates
O: Oxygen
L: Loop diuretic
I: Inotropic drug (dobutamine)
P: Position change (legs down)”
What findings on cardiac catheterization would be indication for CABG?
1.) Left main coronary artery stenosis > 50%
or
2.) Severe 3-vessel coronary artery stenosis
What precautions should be taken prior to cardioversion to prevent an embolic event in a patient with stable atrial fibrillation?
a-fib > 48 hours: TEE
Thrombus found in atria in a patient with a-fib. Next step?
Anti-coagulate for 3 weeks then cardioversion
Patient in acute a-fib for < 48 hours and unstable. Next step?
Cardioversion w/o the need for TEE. Then +/- anti-coagulation
Bounding pulses, diastolic decrescendo murmur heard at left sternal border, ECHO w/early mitral valve closure and reverse blood flow across the aortic valve. Most likely diagnosis?
Aortic regurgitation
What two classes of medication would be most likely to improve the symptoms of AR?
Ace-inhibitors and CCBs
+ Troponin and EKG changes in V2-V5 (precordial leads)
Anterior wall MI
+ Troponin and EKG changes in lead I and aVL
Lateral wall MI
+ Troponin and EKG changes in lead II, III< and aVF
Inferior wall MI
What is the most useful test in determining acute pericarditis?
EKG
- diffuse ST elevations
- PR depression
Vasculitis of the kidney, upper airway, and lungs
Granulomatosis with polyangiitis (Wegener’s)
Vasculitis of the kidney, GI tract, but spares the lungs
Polyarteritis nodosa
Palpable purpura on the legs, associated with IgA nephropathy
Henoch-schönlein purpura
Vasculitis in a young asthmatic
Eosinophilic granulomatosis w/polyangitis (Churg-strauss)
Vasculitis in a young male smoker
Thrombosis obliterans (Buerger’s disease)
Wegener’s granulomatosis
“Vasculitis of the kidney, upper airway, and lungs
“
Polyarteritis nodosa
“Vasculitis of the kidney and GI tract, but spares the lungs
“
Arteritis that spares the lungs and is associated with hep B
Polyarteritis nodosa
2-year old Asian girl with strawberry tongue and desquamation of hands/feet
Kawasaki disease
Eosinophilic granulmatosis w/polyangitis (Churg-strauss)
“Vasculitis in a young asthmatic
“
20-year old Asian woman with weak pulses in the upper extremities
Takayasu arteritis (aka pulseless disease)
Elderly woman with unilateral headache and jaw claudication
Giant cell arteritis (aka Temporal arteritis)
Vasculitis associated with Hepatitis B
Polyarteritis nodosa (remember: usually spares the lungs)
Vasculitis associated with perforation of the nasal septum
Granulomatosis with polyangiitis (Wegener’s)
Vasculitis associated with polymyalgia rheumatica
Giant cell arteritis (aka Temporal arteritis)
What medications are indicated to reduce mortality in patients with CHF?
Beta-blocker (Biso-, Carve-, or ER Meto-)
Ace-i/ARB
Aldosterone Antagonist (Spiro- or Eplerenone)
Stanford A-type aortic dissection
“Any involvement of the ascending aorta
- Tx: surgery
“
Standford B-type aortic dissection
“Confined to descending aorta
- Tx: medical management (usually)
“
Swanz-Ganz pulmonary artery catheter reveals: decreased CO, increased SVR, and increased PCWP
Cardiogenic shock
Swanz-Ganz pulmonary artery catheter reveals: increased CO, decreased SVR, and normal PCWP
Septic shock
Septic shock treatment
IV Fluids and Norepinephrine
Cardiogenic shock treatment
Dobutamine or Dopamine
Medical management of aortic dissection (confined to ascending aorta)
- ) Transfer to ICU
- ) BETA-BLOCKERs
- ) Surgical consult
Administering a beta-blocker in a patient with a murmur from hypertrophic cardiomyopathy with _________ the intensity of the murmur
DECREASE (beta blockers increase pre-load)
Episodic frank hematuria that starts within a day of an upper respiratory tract infection
IgA nephropathy
Frank hematuria which starts and resolves within days of an upper respiratory or GI infection with PERSISTENT microscopic hematuria
IgA nephropathy
Oliguria, edema, HTN, and smokey-brown urine within 2 weeks of a group A beta-hemolytic strep infection
Post-infectious glomerulonephritis
Low serum C3, increased ASO titer, and lumpy-bumpy immuno-fluorescence
Post-infectious glomerulonephritis
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. What NYHA class is this?
Class III (Moderate)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. What NYHA class is this?
Class II (Mild)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. What NYHA class is this?
Class IV (Severe)
Telavancin is a _________ derivative with similar efficacy
Vancomycin
IV abx for MSSA
Oxacillin/nafcillin or cefazolin
Oral abx for MSSA
Dicloxacillin or cephalexin
Severe MRSA abx
Vancomycin
Linezolid
Daptomycin
Ceftaroline
Tigecyline
Telavancin
Minor MRSA abx
TMP/SMX
Clindamycin
Doxycycline
Adverse effect of linezolid
Thrombocytopenia
and
Interferes with MAO inhibitors
Abx that interferes with MAO inhibitors
Linezolid
Abx used for severe MRSA infection that can cause thrombocytopenia
Linezolid
Adverse effects of daptomycin
Myopathy and rising CPK
If the organism is sensitive, _________, _________, or _________ is superior to vancomycin
Oxacillin
Nafcillin
Cefazolin
3 antibiotics specific for streptococcus
Penicillin
Ampicillin
Amoxicillin
Telavancin, dalbavancin, and oritavancin MOA
Bactericidal lipolysaccharides
Inhibit bacterial cell wall synthesis
Bind to D-Ala-D-Ala terminus of Pg cell wall
Ceftaroline MOA
Inhibit cell wall growth by binding to penicillin-binding protein
Linezolid MOA
Inhibits protein synthesis
TMP-SMX MOA
Folate antagonist
Gram-negative bacilli (list of microorganisms)
E. coli
Enterobacter
Citrobacter
Morganella
Pseudomonas
Serratia
Quinolone for pneumonia
Gemifloxacin
Cefepime and Ceftazadine (drug class and coverage)
Cephalosporins for gram-negative bacilli
Piperacillin and Ticarcillin (drug class and coverage)
Penicillins for gram-negative bacilli
Aztreonam (drug class and coverage)
Monobactam for gram-negative bacilli
Quinolones for gram-negative bacilli
Ciprofloxacin
Levofloxacin
Moxifloxacin
Gemifloxacin
Gentamicin, Tobramycin, and Amikacin (drug class and coverage)
Aminoglycosides for gram-negative bacilli
Carbapenems for gram-negative bacilli
Imipenem
Meropenem
Ertapenem
Doripenem
__________ is the only carbapenem that DOES NOT cover pseudomonas
Ertapenem
Pipercillin and Ticarcillin coverage
Gram-negative bacilli
Streptococci
Anaerobes
3 excellent pneumococcal drugs
Levofloxacin
Gemifloxacin
Moxifloxacin
_________________ work synergistically with other agents to treat staph and enterococcus
Aminoglycosides
- Gentamicin
- Tobramycin
- Amikacin
Excellent anti-anaerobic medications that also cover streptococci and MSSA
Carbapenems
- Imipenem
- Meropenem
- Ertapenem
- Doripenem
______________ covers MRSA and is broadly active against gram-negative bacilli. It is weaker than other anti-MRSA drugs
Tigecycline
Why is polymyxin/colistin used last in multi-drug resistant gram negative rods?
Renal toxicity
“What drug should be used in ““failed therapy for ventilator-associated pneumonia””?”
Polymyxin/colistin
Beta-lactam antibiotics (4 classes)
Penicillin
Cephalosporins
Carbapenem
Monobactam
Beta-lactam abx MOA
All inhibit cell wall by binding the penicillin-binding protein
4 classes:
- Penicillin
- Cephalosporins
- Carbapenem
- Monobactam
Beta-lactamase inhibitors (4 drugs)
Clavulanate
Sulbactam
Tazobactam
Avibactam
2 combined antibiotics that cover anaerobes
Piperacillin-tazobactam
Ticarcillin-clavulanate
Imipenem adverse effect
Seizures
Daptomycin adverse effect
Myopathy
Linezolid adverse effect
Low platelets
________________ is the best medication for abdominal anaerobes
Metronidazole
Carbapenems, piperacillin, and ticarcillin are equal in efficacy for abdominal anaerobes compared to _____________________
Metronidazole
The only 2 cephalosporins that cover anaerobes
Cefoxitin
Cefotetan
______________ is the best drug for anaerobic strep
Clindamycin
3 agents for herpes simplex or varicella zoster
Acyclovir
Valacyclovir
Famciclovir
________________ is the best long-term therapy for CMV retinitis
Valganciclovir
3 agents for CMV
Valganciclovir
Ganciclovir
Foscarnet
Foscarnet adverse effect
Renal toxicity
Valganciclovir and ganciclovir adverse effect
Neutropenia and bone marrow suppression
Oral agents for Hep C
Sofosbuvir-ledipasvir
Elbasvir-grazoprevir
Daclatasvir-sofosbuvir
Ombitasvir-paritaprevir-dasabuvir
Sofosbuvir
_______________ when combined with sofosbuvir will cover all genotypes of hepatitis C
Velpatasvir
Neuraminidase inhibitors for influenza A and B
Oseltamivir, zanamivir, and peramivir
””“-mivir”” drug class”
Neuraminidase inhibitors
Ribavirin adverse effect
Anemia
Ribavirin + Interferon treats
Hepatitis C (only used when other treatments have failed)
Respiratory syncytial virus treatment
Ribavirin
Chronic Hepatitis B treatment
Lamivudine
Interferon
Adefovir
Tenofovir
Entecavir
Telbivudine
Sofosbuvir and Dasabuvir MOA
RNA polymerase inhibitors
- Treat Hep C
Paritaprevir, simeprevir, daclatasvir, and ombitasvir MOA
Protease inhibitors that prevent viral maturation by inhibiting protein synthesis
- Treat Hep C
Candidemia treatment
Fluconazole
Caspofungin
ALL -azoles possible adverse effect
Liver toxicity (at high dose)
Candida treatment
Fluconazole
Cryptococcus treatment
Fluconazole
BEST agent against Aspergillus
Voriconazole
Voriconazole adverse effect
Visual disturbance
Mucormycosis treatment
Posaconazole
Echinocandins (3 of them)
Caspofungin
Micafungin
Anidulafungin
””“-fungin”” class”
Echinocandins
Excellent treatment for neutropenic patients
“Echinocandins
““-fungins”””
______________ have NO significant human toxicity because they affect/inhibit the 1,3 gluten synthesis step, which does not exist in humans
Echinocandins
- Caspofungin
- Micafungin
- Anidulafungin
Efinaconazole and tavaborole
Topical anti-fungal agents against onychomycosis
What class of antifungals inhibit conversion of lanosterol to ergosterol?
Azoles
Powerhouse drug effective against ALL Candida, Cryptococcus, and Aspergillus
Amphotericin
Aspergillus treatment superior to amphotericin
Voriconazole, isavuconazole, and caspofungin
_______________ is superior to amphotericin in neutropenic fever
Caspofungin
Amphotericin adverse effects
Renal toxicity (increased creatinine)
Hypokalemia
Metabolic acidosis from distal RTA
Fever, shakes, and chills
When renal toxicity is described in a patient needing amphotericin… next step?
”"”Switch to liposomal amphotericin”””
Osteomyelitis best initial test
Plain x-ray
Best 2nd test for osteomyelitis
MRI (if clinical suspicion + X-ray is negative)
Most accurate test for osteomyelitis
Bone biopsy and culture
What is the earliest finding of osteomyelitis on x-ray?
Periosteal elevation
What is the next best step in determining the diagnosis of osteomyelitis when the x-ray is normal
MRI
How do you follow response to treatment in osteomyelitis?
Sedimentation rate
MC cause of osteomyelitis (microorganism)
Staphylococcus
Osteomyelitis abx treatment if the organism is sensitive
Oxacillin or nafcillin IV for 4-6 weeks
MRSA Osteomyelitis tx
Vancomycin
Dalbavancin
Oritavancin
Linezolid
Ceftaroline
Daptomycin
Gram negative bacilli in osteomyelitis
Salmonella and Pseudomonas
Itching and drainage from the external auditory canal with history of swimming or foreign objects
Otitis Externa
Otitis Externa tx
Topical antibiotics (ofloxacin, ciprofloxacin, or polymyxin/neomycin)
+ Topical hydrocortisone to decrease swelling/itching
+ Acetic acid and water solution to reacidify the ear
Osteomyelitis of the skill from Pseudomonas in a patient with diabetes
Malignant Otitis Externa
Malignant Otitis Externa best initial test
CT or MRI
Most accurate test for Malignant Otitis Externa
Biopsy
Malignant Otitis Externa tx
Surgical debridement and Antibiotics active against pseudomonas
Ciprofloxacin
Piperacillin
Cefepime
Carbapenem
Aztreonam
Quinolone antibiotics MOA
Inhibit DNA gyrase
Immobility of the tympanic membrane
Otitis Media
