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common problems Flashcards

1
Q

cutaneous pain

A

localized on skin/surface of body

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2
Q

visceral pain

A

poorly localized (ex: internal organs)

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3
Q

somatic pain

A

non-localized

originates: muscle, bone, nerves, blood vessels, supporting tissue

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4
Q

neuropathic pain

A

freq caused by tumor

involves nerve pathway injury/compression

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5
Q

WHO Ladder of Pain Management: Step 1

A

ASA
APAP
NSAID
+/- adjuvant

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6
Q

WHO Ladder of Pain Management: Step 2

A 
APAP or ASA +codeine
hydrocodone
oxycodone
dihydrocodone
tramadol (not with APAP or ASA)
\+/- adjuvant
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7
Q

WHO Ladder of Pain Management: Step 3

A 
morphine
hydromorphone
methadone
levorphanol
fentanyl
oxycodone
\+/- non-opioid analgesics
\+/- adjuvant
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8
Q

adjuvant analgesics

A

drugs with other indications that may be analgesic in specific circumstances

  • anticonvulsants, antidepressants, local anaesthetic, corticosteroid, etc.
  • can be used at any step in WHO ladder
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9
Q

NSAIDS

A

prostaglandin inhibitors (via COX inhibition)
analgesic / antipyretic / antiplatelet
- used primarily as antiinflammatory agents

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10
Q

older patients + opioids: considerations

A

reduce starting doses by 25 - 50% + monitor freq for AE

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11
Q

What is the single most reliable indicator of existence and intensity of pain?

A

Subjective findings - patient report

WHOSE PAIN IS IT

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12
Q

Normal body temperature

A

37 C

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13
Q

When is it appropriate to start Tylenol given fever?

A

AFTER cultures are drawn.

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14
Q

Neuroleptic Malignant Syndrome

A

r/t SSRI toxicity
//or//
family hx significant for NMS

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15
Q

Malignant Hyperthermia is associated with what drug?

A

succinylcholine

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16
Q

Succs is contraindicated in what situation?

A

HYPERKALEMIA

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17
Q

most common cause of non-infectious fever

A

POST-OP ATELECTASIS

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18
Q

elevated eosinophils are present in what reactions?

A

allergic reactions
drug-induced fever

eiosinophilia implies allergic rxn!

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19
Q

Drug Induced Fever

A 
Slow onset (7 - 10 days)
PCN derivatives most commonly induce
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20
Q

initial treatment for non-infection related post-op fever

A

hydration

increasing lung expansion

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21
Q

infectious etiology of fever is manifested in this lab

A

elevated WBC with L shift (bandemia)

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22
Q

likely etiology of WBC elevation over 30k

A

not due to infection - usually leukemia

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23
Q

treatment of infection-related post-op fever x3

A

supportive fluids + APAP
treat underlying source
gram stain, C&S all invasive lines/catheters

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24
Q

patient presents with 101.5 F lasting over 3 wks. ddx and plan of care?

A

it is FUO, ddx include endocarditis & malignancy

plan is to identify source of fever - no intervention otherwise

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25
Q

most important bit of history to collect regarding a headache

A

chronology - onset; when it started

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26
Q

tension headache: s/s x5

A 
vice-like, squeezing, tight
generalized 
intense around neck & back of head
no focal neuro sx
duration: several hours
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27
Q

Patient is complaining of a headache with a squeezing sensation that is generalized but specially intense around the back of her head. It has lasted for several hours and she has no focal deficits. Top differential?

A

tension headache

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28
Q

tension headache: tx x2

A

OTC analgesics

relaxation

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29
Q

migraine

A

r/t dilation + excessive pulsation of external carotid + branches, follows trigeminal nerve (V)

duration: 2 - 72 hours
types: classic vs common

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30
Q

classic vs common migraine

A

classic with aura

common without aura (literally, most pts have these)

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31
Q

migraine: s/s x6

A
  • unilateralized throbbing occurs episodically, can be dull
  • gradual build up
  • focal neuro deficits: hallucinations, visual changes, aphasia, numbness, tingling, clumsiness
  • n/v, photo & phonophobia
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32
Q

25 yo. F presents to ED with chief complaint unilateral throbbing that started 12 hours ago. Pt describes visual changes and numbness in her right hand following the pathway of the headache. What is primary diagnosis?

A

migraine headache

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33
Q

migraine headache: diagnostics

A
  • baseline studies if new, r/o organic causes
  • CT scan (r/o brain tumor)
  • BMP
  • CBC
  • VDRL (r/o syphilis)
  • ESR
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34
Q

You want to rule out neurosyphilis as the etiology of a migraine; what lab do you order?

A

VDRL

- if positive, presumptive

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35
Q

Pt has 2 - 3 migraines per month. What is indicated for prophylactic therapy?

A

amitryptyline (Elavil)

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36
Q

migraine: acute attack mgmt

A
  1. Rest in dark, quiet room
  2. ASA STAT: pain relief
  3. sumatriptan (Imitrex)
    - 6 mg SQ stat, can repeat in 1 hr (3 max per day)
    - 25 mg PO @ HA onset
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37
Q

cluster headache: s/s x8 + typical population

A

middle-aged men
- severe, unilateral, periorbital pain daily x several weeks (wk - mo between attacks)
- usually @ night, wake from sleep
- shorter than 2 hours
- ipsilateral nasal congestion, rhinorrhea, eye redness
exam otherwise normal

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38
Q

cluster headache: mgmt x3

A
  • 100% O2
  • sumatriptan (Imitrex) 6mg SQ - but PO meds usually unsatisfactory
  • ergotamine tartrate (Ergostat) aerosol inhalation
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39
Q

best nutritional serum marker

A

prealbumin

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40
Q

hgb under 12 (M) or 13.5 (F) indicates what? x4

A

lack of iron or protein

poor oxygenation and perfusion

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41
Q

How does 1 unit PRBC affect H/H in general? If 8/24?

A

1 unit PRBC increases H/H 1/3

8/24 + 1 unit PRBC = H/H of 9/27

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42
Q

What is your first consideration for nutritional support?

A

PO supplements to diet

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43
Q

Patient requires nutrition support but GI tract is non-functional. What are 2 other options and when would you use them?

A

CVC: central - anticipated longer than 2 weeks

PICC line: peripheral - shorter

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44
Q

Patient requires nutrition support and GI tract is functional. What 3 options do you have and when would you use them?

A

enterostomal tube: anticipated longer than 6 weeks

nasoduodenal tube: shorter than 6 weeks and aspiration risk

nasogastric tube: shorter than 6 weeks and no aspiration risk

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45
Q

What solution should be used in parenteral feeds via PICC line?

A

less than 10% dextrose

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46
Q

enteral nutritional support: possible complications x7

A

THE PROBLEM IS THE SOLUTION

  • hypernatremia
  • aspiration
  • dehydration
  • vomiting, GI bleed, diarrhea
  • tube obstruction
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47
Q

hypotonic hyponatremia: what & serum osmolality

A

serum osmolality less than 280 mosm/kg

body water excess = dilutes all fluids, causing clinical signs; either renal or extra-renal cause must be determined

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48
Q

hypovolemic hypotonic hyponatremia: causes

A

Renal Salt EXCRETION: kidneys can’t conserve Na!

  • diuretics
  • ACE Inhibitors
  • mineralcorticoid deficiency
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49
Q

hypervolemic hypotonic hyponatremia: treatment

A

WATER RESTRICTION

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50
Q

hypervolemic hypotonic hyponatremia: causes

A
  • edematous states
  • CHF
  • liver disease
  • advanced renal failure
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51
Q

hypovolemic hypotonic hyponatremia: treatment

A

IVF: NS

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52
Q

hypovolemic hypotonic hyponatremia + urine Na gt20: treatment

A

treat the cause

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53
Q

severe hypovolemic hypernatremia: treatment + important consideration

A

IVF: NS then 0.5 NS

* slowly to avoid cerebral edema *

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54
Q

hypervolemic hypernatremia: treatment x3

A

free water
loop diuretic
consider dialysis

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55
Q

hypokalemia: causes

A

losses: GI, excess renal

alkalosis

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56
Q

Heart failure patient who is on chronic diuretic is at risk for what?

A

hypokalemia

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57
Q

hypokalemia: EKG changes x6

A

decreased amplitude
broad T waves
U waves
rhythm abnormalities: PVCs, v tach, v fib

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58
Q

hypokalemia: s/s - general x5 + severe x4

what counts as severe hypokalemia?

A

muscle weakness, fatigue, cramps
constipation, ileus (d/t smooth muscles)

severe (lt 2.5 mEq/L): flaccid paralysis, tetany, hyporeflexia, rhabdo

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59
Q

hypokalemia: treatment x3

A
  • PO replacement if K 2.5+ and normal EKG
  • IV replacement 10 mEq/hr if PO not possible
  • different for severe (40 mEq/L/hr IV)
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60
Q

severe hypokalemia: expected K value + treatment x4

A

K under 2.5

  • IV repletion @ 40 mEq/L/hr
  • K check q3hrs
  • continuous EKG
  • check Mg (deficiency impairs correction)
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61
Q

Your patient has sustained a dog, cat, or human bite, OH NOES. What do you do to reduce the risk of a gnarly infection, bro?!?!

A

high pressure irrigation (NS or LR) with 18-19 G needle

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62
Q

What types of bite wounds should be left open?

A

bite on hands or lower extremities, any wound older than 6 hours (heal by secondary intention)

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63
Q

what prophylactic antibiotics do you use for bites?

A

whether human bites require antibiotics is controversial, but for both human and animal bites:

3 - 7 days of PO abx with coverage for staph & anaerobes (amoxicillin clavulanate/Augmentin is a good choice)

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64
Q

GOOD CHOICE FOR BITES ABX PROPHYLAXIS

A

amoxicillin clavulanate (Augmentin) PO 3-7 days

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65
Q

Which of these require suturing

a. dog bite
b. puncture wound
c. clean laceration of elderly patients hand
d. abrasion

A

Clean laceration of elderly person’s hand requires suturing

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66
Q

3 most common causes of cellulitis in the outpatient setting?

A

Strep pyogenes (GAS): the usual cause
Staph aureus: less common
Strep etc: rare

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67
Q

3 most common causes of inpatient cellulitis?

A
  • GRAM NEGS (Klebsiella, E Coli, Pseudomonas, Enterobacter)
  • Staph aureus
  • Strep
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68
Q

Patient has sustained a wicked boil that looks super spider bitey. What do you suspect and how do you fix dat ish?!

A

MRSA!!!!

per IDSA: I & D + culture, NO ABX!

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69
Q

CA-MRSA cellulitis: 3 treatment options

A

sulfamethoxazole-trimethoprim (Bactrim)
doxycycline
clindamycin

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70
Q

GAS cellulitis: 3 tx options

A

sulfamethoxazole-trimethoprim (Bactrim) + beta lactam (PCN, amoxicillin, keflex)

doxy/minocycline + beta lactam (PCN, amoxicillin, keflex)

dlindamycin

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71
Q

Which antimicrobial indicated for cellulitis has strep and staph coverage?

A

Clindamycin - but it’s not as effective as a beta lactam plus either Bactrim or doxy or mino

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72
Q

bull’s eye rash is associated with what diease?treatment?

A

aka erythema migrans = Lyme disease

treatment: doxy

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73
Q

Rocky Mountain Spotted Fever treatment

A

doxyyyyy

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74
Q

Most important aspect of assessment of patient with suspected toxicity?

A

HISTORY

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75
Q

activated charcoal: indication & dose

A

use for GI decontamination

1 g/kg (max 50g) q4 hrs PRN
- in combination w Sorbitol (cathartic = poo city!)

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76
Q

ipecac: indications & contraindications

A

barfing up your guts after at home, SOLID ingestion

never use for: corrosives/detergents (esophageal erosion or aspiration pna may result)

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77
Q

APAP toxicity: s/s x4

A
  • early: usually asymptomatic
  • around 24 - 48 hrs: n & v
  • RUQ pain
  • hepatoxicity as manifested by: jaundice, elevated LFTs, prolonged PT, AMS
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78
Q

APAP toxicity: mgmt x3

A
  • emesis if recent
  • GI lavage, activated charcoal (1 gm/kg q4)
  • N-Acetylcysteine (Mucomyst) + loading dose PO PRN
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79
Q

hyperkalemia: mnemonic + causes

A

M A C H I N E

M eds: NSAIDS, ACE-I
A cidosis 
C ellular destruction (trauma, burns)
H ypoaldosteonism
I ncreased intake
Nephron damage (renal failure)
E xcretion impaired
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80
Q

hyperkalemia: mnemonic + s/s

A

M U R D E R

M uscle weakness (flaccid paralysis)
U OP decrease
R esp distress
D iarrhea, decreased heart FOC
E KG changes (peaked T + brady)
R eflexes (hyper or none)
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81
Q

hyperkalemia: general mgmt

A
  • Kayexalate (exchange resins)

- if severe or cardiac toxicity or paralysis, insulin 10U + 1 amp D50

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82
Q

A patient is severely hyperkalemic with flaccid paralysis. What is the expected K level and treatment plan? What does that plan accomplish?

A

severe = 6.5+

insulin 10 U
+ one amp D50
- pushes K back into cell

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83
Q

calcium: 2 major roles, normal total and normal ionized values

A

mediates neuromuscular & cardiac fxn
normal TOTAL: 8.5 - 10.5 mg/dL
normal IONIZED: 4.5 - 5.5 mg/dL

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84
Q

Patient’s albumin levels are abnormal and you want to measure calcium. Which form do you order and why?

A

IONIZED: does not vary with the albumin level

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85
Q

How do acidemia and alkalemia impact serum calcium levels?

A

acidemia INCREASES calcium

alkalemia DECREASES

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86
Q

hypocalcemia: causes x5

A

PANCREATITIS
hypomag, hypoPTH
renal failure
trauma

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87
Q

hypocalcemia: s/s - 3x major + 3x more

A

Calcium calms. Not enough, so wacko.

MAJOR: trousseau, chvostek, QT prolongation

convulsions, hyper DTRs, muscle/abd cramps

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88
Q

hypocalcemia: mgmt x5

A

ACUTE: IV calcium gluconate
CHRONIC: PO supplements: Vit D, Ca, aluminum hydroxide
BOTH: blood pH - check for alkalosis

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89
Q

hypercalcemia: causes

A

hyperthyroidism, hyperPTH, Vitamin D intoxication, prolonged immobilization

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90
Q

hypercalcemia: s/s x9

A

Calcium calms. Too calm!

fatigue, muscle weakness
depression, anorexia
nausea, vomiting, constipation
severe: coma, death

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91
Q

What lab value of hypercalcemia is considered a medical emergency? Treatment plan?

A

over 12 mg/dL

- IV NS + loop diuretic

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92
Q

hypercalcemia: mgmt x3

A

calcitonin (if impaired cardiovascular or renal function)
dialysis
severe: IV NS with loop diuretics

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93
Q

respiratory acidosis: s/s x5

A

AMS (somnolence, confusion, coma)
MYOCLONUS + asterixis
↑ ICP (d/t ↑CBF = ↑ CSF pressure)

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94
Q

respiratory acidosis: mgmt x3 + rationale behind each

A
  • if no obvious cause: naloxone (Narcan) 0.04 - 2mg IVP
  • intubation (improve ventilation)
  • ↑ RR on vent (blow off CO2)
95
Q

respiratory alkalosis: values + cause

A

greater than pH 7.45
less than pCO2 35

r/t hyperventilation: blowing off CO2

96
Q

respiratory alkalosis: s/s x4 - what are clinical symptoms related to?

A

sx r/t ↓ CBF

  • light-headedness
  • paresthesia, tingling in hands/feet
  • anxiety
  • tetany if severe
97
Q

respiratory alkalosis: mgmt x4

A

PRIMARILY: TREAT UNDERLYING CAUSE! (Rarely life threatening. Is usually d/t a stimulus that must be removed.)

  • acute hyperventilation syndrome: breathe into paper bag
  • ↓ vent RR
  • sedation
98
Q

metabolic acidosis: hallmark lab values x2

A

↓ HCO3

evaluate anion gap

99
Q

anion gap: normal, equation, meaning

A

NORMAL: 12 +/- 5 (7-17)

( Na + K ) - ( HCO3 + Cl )

seen in metabolic acidosis
higher gap = higher acuity

100
Q

increased anion gap: causes mnemonic

A 
M ethanol  
U remia  
D KA / AKA  **
P ropylene glycol  
I  ron / INH  
L actic acidosis  **
E thylene glycol  
S alicylates
101
Q

normal anion gap: causes x4

A
  • diarrhea (losing HCO3/base)
  • ileostomy
  • renal tubular acidosis
  • DKA recovery
102
Q

metabolic acidosis: mgmt x3

A

TREAT UNDERLYING CAUSE!
fluids
HCO3 (if significant hyperkalemia, NOT for DKA or hypoxia)

103
Q

metabolic alkalosis: causes x4

A

the following are saline-responsive (volume contraction is the most common problem):

  • ng suction, vomiting
  • diuretics
  • post-hypercapnia alkalosis
104
Q

metabolic alkalosis: mgmt x4

A

saline-responsive (volume contraction is the most common problem):

  • correct volume deficit with NaCl + KCl
  • d/c diuretics
  • if volume replacement contraindicated, acetazolamide (Diamox) 250 - 500mg IV q4 - 6hrs
  • if GI loss (n/v), H2 blockers
105
Q

first degree burn

A

NO BLISTERS
dry, red, painful
extent: epidermis only

106
Q

second degree burn

A

aka partial thickness
BLISTERS!
moist, painless
extent: beyond epidermis

107
Q

third degree burn

A

aka full thickness burn
dry, leathery, black or pearly waxy
extent: epidermis, dermis, underlying tissue (fat, muscle, bone)

108
Q

burn mgmt: fluid requirements x4

A

~ 4 mL/kg x TBSA - first 24 hrs TOTAL (Parkland formula)

  • half of this amount given during first 8 hrs
  • remaining amount given during next 16 hours
  • crystalloid NOT colloid

UNDER-RESUSCITATION IS A PROBLEM FYI

109
Q

This is a major problem seen in burn care.

A

under-resuscitation/lack of fluids

110
Q

When does fluid resuscitation begin for burn patients?

A

at the time of injury, not when they arrive at a facility

111
Q

major acid-base and electrolyte complications associated with burn injuries x3

A
  • metabolic acidosis: during early resuscitation phase
  • hyperkalemia: first 24 - 48 hrs
  • hypokalemia: after fluid resus/diuresis, approx 3 days post-burn
112
Q

You should monitor a burn patient for hyperkalemia during what time period?

A

first 24 - 48 hrs after burn

113
Q

You should monitor a burn patient for hypokalemia during what time period?

A

3 days post-burn (it’s related to fluid volume resuscitation and diuresis)

114
Q

What is an indication for prophylactic intubation in a burn patient?

A

to prevent laryngeal edema, which may develop after: burns to the face (singed nares/eyebrows, dark soot/mucous in mouth/nares)

always intubate patients with this presentation

115
Q
  • Per ABA: when do you refer a patient to a burn center? *

x 6

A
  • partial thickness burn greater than 10% TBSA
  • involvement of face, hands, feet, genitalia, perineum, major joints
  • third degree burns, any age
  • electrical, chemical, inhalation burns
  • comorbs that complicate mgmt
  • pts who require special social, emotional, rehab intervention
116
Q

salicylate intoxication: s/s x11

A 
TINNITUS
*elevated LFTs*
dizziness, HA
n/v, dehydration
hyperthermia
apnea, cyanosis, metabolic acidosis
117
Q

salicylate intoxication: mgmt

A
  • emesis if recent
  • GI lavage, activated charcoal (1 gm/kg q4)
  • severe acidosis: IV sodium bicarb
118
Q

organophosphate (insecticide) poisoning: s/s x9

A 
EXCESSIVE SALIVATION
* blurred vision, miosis
* bradycardia
AMS, HA
N/V/D
119
Q

organophosphate poisoning: drug of choice for

A

atropine - addresses bradycardia & secretion management

120
Q

antidepressant toxicity: causative agents

A

amytriptyline (Elavil)
fluoxetine (Prozac)
bupropion (Wellbutrin)
imipramine, nortriptyline

121
Q

antidepressant toxicity: s/s x9

A 
confusion, hallucinations, blurred vision
hypotension, tachycardia, dysrhythmias
urinary retention
hypothermia
seizures
122
Q

antidepressant toxicity: mgmt x8

A
  • ICU: if CNS or cardiac toxicity evident
  • GI lavage, activated charcoal
  • IV sodium bicarb (maintain pH, counter cardiac dysrhythmia)
  • IV benzo diazepam (Valium): seizure control
    if Serotonin Syndrome:
  • dantrolene sodium (Dantrium):
  • clonazepam (Klonopin): Serotoni rigor
  • cooling blankets
123
Q

seizure prophylaxis in anti-depressant toxicity?

A

diazepam (Valium) IV

124
Q

Your patient has overdosed on Lexapro and you suspect Serotonin Syndrome. What is your treatment plan?

A

dantrolene sodium (Dantrium)
clonazepam (Klonopin): for rigors
cooling blankets: temp control

125
Q

4 drugs that cause narcotic toxicity?

A

morphine
codeine
heroin
opium

126
Q

narcotic toxicity: s/s x5

A

respiratory depression
miOsis
hypothermia
AMS, coma

127
Q

miosis vs mydriasis in which toxicities

A

miosis: codeine, heroin, morphine
- think relaxation, euphoria

mydriasis: cocaine, extasy
- think amped up

128
Q

contraindication in narcotic toxicity management

A

emetics

129
Q

narcotic toxicity: mgmt x3

A

naloxone (Narcan) 0.04 - 2 mg IVP
butorphanol (Stadol)
GI lavage/activated charcoal

130
Q

benzo OD: s/s x4

A

respiratory depression
AMS, coma
hyporeflexia

THINK RELAXED & EUPHORIC

131
Q

benzo OD: mgmt

A
  • HD & respiratory support
  • flumazenil (Romazicon) IV
  • GI lavage, activated charcoal
132
Q

You suspect your patient is rejection their freshly transplanted appendix. What is your first order?

A

biopsy of transplanted organ

133
Q

Standard anti-rejection induction agents

A

calcineurin inhibitor + antimetabolite + steroid

i.e.,

tacrolimus (Prograft) or Cyclosporine
\+ 
azathioprine (Imuran) or mycophenolate mofetil (Cellcept) 
\+ 
prednisone
134
Q

What steroid is administered as part of an anti-rejection drug regimen for transplant prophylaxis?

A

prednisone

135
Q

Herpes Zoster: pathophysiology

A

aka shingles!

acute vesicular eruptions due to infection with varicella zoster virus - can be life-threatening in immunocompromised adults

136
Q

Herpes Zoster: s/s x3

A
  • pain along dermatome distribution (usually trunk)
  • grouped vesicle eruption of erythema and exudate along dermatome
  • regional lymphadenopathy
137
Q

Herpes Zoster: mgmt x4

A
  • acyclovir, famciclovir, or valacyclovir
  • ophthalmology referral if ocular involvement
  • gabapentin (Neurontin) for post-herpatic neuralgia
  • zostavax if 50+ (uh isn’t this prevention)
138
Q

When is Zostavax appropriate?

A

prevention of Herpes Zoster in 50+

139
Q

actinic keratoses what + describe + treatment

A
  • PREMALIGNANT: 1/1000 progress to squamous cell carcinoma
  • asymptomatic, can be tender
  • rough, small-patches on sun-exposed skin
  • flesh, pink, or hyperpigmented

tx w liquid nitrogen

140
Q

Squamous Cell Carcinoma what + describe + treatment

A
  • arise from actinic keratoses, develop over months (3-7% mets)
  • firm, irregular papule or nodule
  • keratotic, scaly bleeding

tx with bx & surgical excision (Mohs)

141
Q

Seborrheic Keratoses what + describe + tx

A

BENIGN
non-painful lesions 3 - 20 mm diameter
beige/brown plaques
“stuck on” appearance

tx: liquid nitrogen or none

142
Q

malignant skin cancers x3

A

Squamous Cell Carcinoma
Basal Cell Carcinoma
Malignant Melanoma

143
Q

benign skin growths x2

A

Actinic Keratoses

Seborrheic Keratoses

144
Q

Basal Cell Carcinoma: what + describe + tx

A

MALIGNANT! most common skin cancer
waxy, pearly lesion
slow growing (1 - 2cm)
telangiectatic vessels (spider veins)

tx: shave/punch bx + surgical excisino

145
Q

Patient has spider veins, what cancer might you want to rule out?

A

basal cell carcinoma

aka telangiectatic vessels

146
Q

What is the most common skin cancer?

A

basal cell carcinoma

147
Q

What skin cancer has the highest mortality rate?

A

MALIGNANT MELANOMA

148
Q

What malignant skin cancer can mets to any organ?

A

MALIGNANT MELANOMA

149
Q

brain death criteria

A

No functional cranial nerves.

150
Q

end-of-life care: 2 drugs used & indication

A

morphine: respiratory distress
scopolamine: secretion reduction

151
Q

What is the antidote for CO poisoning?

A

100% oxygen

152
Q

What is an anti-convulsant that accelerates acetaminophen toxicity?

A

phenytoin (Dilantin)

153
Q

What are 2 hallmark signs of aminoglycoside toxicity?

A

ototoxicity

nephrotoxicity

154
Q

What is the most common pathogen in surgical site infection?

A

Staphylococcus

155
Q

What is the most common cause of third degree (full thickness) burns?

A

electrical

156
Q

What is a common complication associated with circumferential burns?

A

compartment syndrome

157
Q

Your patient who has sustained circumferential, full thickness burns on his lower extremities has now developed what you suspect to be compartment syndrome. What is your immediate plan of care?

A

surgical consult STAT to salvage limbs

158
Q

All of the following statements concerning basal cell carcinoma are true except:

a. it is the most common cutaneous malignancy
b. it is associated with chronic sun exposure
c. it is most commonly found on the abdomen and trunk
d. it may be difficult to differentiate from malignant melanoma

A

c. Basal cell carcinoma is commonly found on the HEAD and NECK not abdomen and trunk

159
Q

The clinical presentation of shingles includes all of the following EXCEPT:

a. unilateral vesicular eruption
b. pain during the eruption only
c. vesicular eruption in a dermatomal distrbuition
d. potential involvement of the cranial nerves

A

b. Shingles pain can last for months after the acute exacerbation

160
Q

Most common bite seen in the ED?

A

human

161
Q

Individuals most at risk for development of melanoma?

A

fair skinned
blue eye
red hair
freckles

162
Q

Most common cause of fever?

A

infection

163
Q

most common causes of FUO?

A

endocarditis

malignancy

164
Q

surgical procedure with highest incidence of wound infection

A

colon resection

165
Q

initial management of post-operative atelectasis

A

improve ventilation
IVF
CXR and blood cultures

166
Q

best pain medication for chronic cancer pain

A

fentanyl patch (sustained release!)
rapid onset
short half life
allows patient to be lucid

167
Q

post-surgical pain management alternative to morphine

A

ketorolac (Toradol)

168
Q

most common sites of acute compartment syndrome

A

forearm

leg

169
Q

how long to see healing response on pressure ulcer that is clean and well vascularized

A

2 days

170
Q

70 M 2 weeks s/p CVA and sustained pharyngeal paralysis. He is unable to eat food without aspiration. What is the most appropriate method to provide nutrition to this patient?

a. TPN
b. surgical gastrostomy
c. NGT
d. PPN

A

B. surgical gastrostomy PEG tube

171
Q

Symptoms of protein malnutrition include:

a. weakness and edema
b. fever and chills
c. skin rashes and hair loss
d. muscle wasting and hair loss

A

a. weakness and edema

172
Q

anti-emetic that blocks serotonin 5HTC and can cause EPSE used for delayed gastric emptying

A

metoclopramide (Reglan)

173
Q

most helpful tests in determining nutrition status

A

prealbumin
albumin
calcium

174
Q

what acid-base imbalance causes urinary potassium excretion

A

metabolic alkalosis

175
Q

fluid used in correction of hypernatremia

A

D5W (free water)

176
Q

indication for sodium bicarbonate IV administration in hyperkalemia

A

stabilize myocardial membrane and counteract myocardial effects of hyperkalemia

177
Q

Which of the following symptoms may be seen in a patient with hypomagnesemia?

a. muscle weakness and paralysis
b. nystagmus and paralysis
c. seizures and cardiac arrythmias
d. excessive thirst and confusion

A

C. seizures and cardiac arrythmias

CATS go numb
Convulsions
Arrythmias
Tetany
Seizures
Numb
178
Q

most common cause of hyponatremia in the hospitalized patient

A

SIADH

179
Q

30 yo. F with PMH of migraines and new onset HTN should be treated with:

a. enalapril (Vasotec)
b. amitriptyline (Elavil)
c. ASA
d. metoprolol

A

d. HTN and migraine should be treated with a beta blocker

180
Q

40 yo. F with asthma develops HTN. Which of the following should be avoided in this patient?

a. metoprolol (Lopressor)
b. enalapril (Vasotec)
c. diltiazem (Cardizem)
d. furosemide (Lasix)

A

a. Beta blockers should not be used in patients with asthma due to ARF bronchospasm

181
Q

65 yo. M with ESRD is on hemodialysis. Which of the following diets should be recommended?

a. low sodium
b. high protein
c. low potassium
d. restricted calories

A

C. low potassium diet is recommended with renal failure patients

182
Q

diet recommended for renal failure patients

A

low potassium

183
Q

80 yo. F is hospitalized for PNA and treated with IV abx. On day 2 the patient develops diarrhea and tests positive for C. diff. What is the best treatment?

a. gentamicin
b. clindamycin
c. doxycycline
d. vancomycin

A

d. PO vancomycin is best for C. diff. Metronidazole (Flagyl) is also used.

184
Q

drugs used to treat c diff

A

vancomycin

metrondiazole (flagyl)

185
Q

most common valvular heart disease in adults

A

aortic stenosis

186
Q

The medical management of mitral regurgitation and LV dysfunction includes:

a. ACE Inhibitors and diuretics
b. CCB and BB
c. Diuretics and BB
d. Alpha blockers and diuretics

A

a. ACE Inhibitors and diuretics for mitral regurgitation and LV dysfunction - reduce afterload

187
Q

Which of the following ppx measures should be implemented to prevent DVT in a 70 yo. patient s/p abdominal surgery?

a. IV heparin 2 hrs. post op
b. Preoperative ASA use
c. early ambulation
d. Compression wrapping of the lower extremities

A

Early ambulation

188
Q

acute vs chronic pain

A

less than or more than 6 mo

  • acute: caused by tissue damage
  • chronic: continual or episodic, usually needs combo therapy
189
Q

What oral temperature is considered fever? What interventions x3?

A

38.6 C / 101.5F
order cultures
anti-pyretics (Tylenol)
treat underlying cause

190
Q

Rectal temperature considered fever?

A

+99.5F

191
Q

priority intervention for NMS or malignant hyperthermia

A

likely r/t drugs (NMS: SSRI or MH: succinylcholine)

IVF to flush out agent

192
Q

infectious causes of post-op fever

A

incision, point of entry for any catheter (IV), urinary tract, lungs, sinusitis (ng tubes), abscess

193
Q

protein malnutrition: labs x2

A

albumin & prealbumin (early indicator)

194
Q

What albumin value indicates protein malnutrition? At what value can edema be expected? Normal range?

A
  • less than 3.5 g/dL
  • less than 2.7 g/dL
  • 3.5 - 5 g/dL
195
Q

3.5 - 5 is the normal range for which 3 lab values?

A

albumin
K
phos

196
Q

normal range for K?

A

3.5 - 5

197
Q

normal range for phos?

A

3.5 - 5

198
Q

hypotonic hyponatremia

A

,serum osmolality lt280

FVE

199
Q

most common electrolyte imbalance

A

hyponatremia

200
Q

hyponatremia: 3 evaluation steps

A
  • urine Na (normal 10 - 20)
  • serum osmolality (normal 2x Na)
  • clinical status
201
Q

urine Na normal

A

10 - 20

202
Q

serum osmolality normal

A

285 - 295 mosm/kg

203
Q

what can urine Na distinguish?

A
  • urine Na 20+ mEq/L suggests RENAL problem (salt wasting)

- urine Na under 10 mEq/L suggests EXTRARENAL fluid loss (kidneys retaining Na to compensate)

204
Q

parenteral nutritional support: possible complications x8

A

THE PROBLEM IS THE MODE OF DELIVERY

  • pneumo or hemo -thorax
  • arterial laceration
  • air emboli (major complication of CVC line placement)
  • catheter related sepsis or thrombosis
  • HHNK, hyperglycemia
205
Q

what is the general difference between complications of enteral and parenteral nutrition?

A

enteral: the problem is the SOLUTION
parenteral: the problem is the DELIVERY

206
Q

isotonic hyponatremia: what & lab value

A

PSEUDOhyponatremia is a lab artifact

  • occurs w extreme hld or hyperprot
  • body water normal, asymptomatic
  • tx r/t fat

serum osm 284 - 295 mosm/kg

207
Q

hypovolemic hypotonic hyponatremia + urine Na lt 10 mEq/L: causes

A

DEHYDRATION

diarrhea, vomiting (more dehydration!)

208
Q

hypertonic hyponatremia: serum osm & causes x2

A

serum osm over 290 mosm/kg

- hyperglycemia & HHNK

209
Q

hypotonic hyponatremia: in general, 3 types/overarching cause

A

hypovolemic, urine Na under 10: dehydration
hypovolemic, urine Na 20+: kidneys can’t conserve salt
hypervolemic, “traditional”: edema-related

210
Q

hyponatremia: general mgmt x5

A
  • tx based on cause, treat underlying condition (esp urine Na 20+)
  • hypovolemic: NS IVF
  • hypervolemic: fluid restriction
  • symptomatic: NS + loop
  • CNS symptoms: 3%NS + loop
211
Q
  • Patient is hyponatremic and symptomatic. Treatment plan?
A

NS IVF + loop diuretic

212
Q
  • Patient is hyponatremic and CNS symptoms are manifesting. Treatment plan?
A

3%NS + loop diuretic

213
Q

hypernatremia is usually d/t what?

A

hyperosmolality results from excess water loss; excess sodium intake is rare

214
Q

euvolemic hypernatremia: treatment

A

free water (D5W)

215
Q

Why do you order Mg level if patient is being treated for hypokalemia?

A

Mg deficiency can impair K repletion.

216
Q

How does calcium relate to albumin?

A

IONIZED does not vary with albumin.

TOTAL is 50% bound to albumin

217
Q

Your patient is hypoalbuminemic due to malnutrition with a normal calcium level. What do you suspect?

A

Actually hypercalcemia. Total calcium is 50% bound to albumin.

218
Q

respiratory acidosis: values & cause

A

less than: pH 7.35
greater than: pCO2 45

cause: decreased alveolar ventilation

219
Q

respiratory acidosis vs alkalosis presentation

A

acidosis: deathly ill
alkalosis: distress

220
Q

Why should you avoid rapid correction of respiratory alkalosis?

A

Rapid correction may result in metabolic acidosis, “due to the renal compensatory drop in serum bicarbonate.”

221
Q

FUN FAX - C Diff + Vomiting = acid-base imbalances?

A

C Diff: acidosis because you’re blowing out the bicarb

Vom: alkalosis because you up chucked the acid

222
Q

metabolic alkalosis & respiratory acidosis

A

metabolic usually ↑↑ HCO3 - pCO2 rarely exceeds 55

if pCO2 is 55+ superimposed respiratory acidosis likely

223
Q

emergent burn mgmt x3

A
  • submerge in clean water ASAP then wrap in clean, wet towel (STERILE NS/towels) & take to hospital
  • no ice, lotion, toothpaste, lard, butter, products
  • VERY IMPORTANT: maintain normal temp (37-37.5)
224
Q

burn: pain mgmt most commonly used

A

IV fentanyl or morphine

225
Q

How do you care for a tar burn injury?

A

use a petroleum based product to remove burning tar

226
Q

what is silver sulfadiazine used for in burn care even though this is based on very little evidence that I wrote all about in my spring research paper

A

topical antibacterial/antifungal for 2nd and 3rd degree burns

227
Q

gastric lavage is bad but boards wants you to know what?

A

lavage until clear with 28 - 38F/ng tube for ingestions older than 30 minutes

228
Q

with each 0.1 drop in pH, how much does K+ increase?

A

0.7

229
Q

organophosphate poisoning: mgmt x3

A
  • wash skin thoroughly
  • activated charcoal if ingested insecticide
  • atropine
230
Q

benzo OD: reversal agent

A

flumazenil (Romazicon) IV

231
Q
  • acute organ rejection: s/s + initial intervention *
A
  • immediate failure of tx organ
  • flu-like symptoms (prodrome)
  • immediate biopsy of transplanted organ!
232
Q

how do anti-rejection induction agents used as transplant rejection prophylaxis work?

A

they significantly lower and nearly abolish circulating lymphoid cells that are critical to rejection response

233
Q

What is the ABCDEE method for malignant melanoma?

A 
A symmetrical
B order irregularity
C olor change
D iameter over 6mm
E levation
E nlargement

2+ more = 97% chance of malignant melanoma

234
Q

Treatment for topical salicylate toxicity?

A

wash with warm tap water

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