common problems Flashcards
cutaneous pain
localized on skin/surface of body
visceral pain
poorly localized (ex: internal organs)
somatic pain
non-localized
originates: muscle, bone, nerves, blood vessels, supporting tissue
neuropathic pain
freq caused by tumor
involves nerve pathway injury/compression
WHO Ladder of Pain Management: Step 1
ASA
APAP
NSAID
+/- adjuvant
WHO Ladder of Pain Management: Step 2
APAP or ASA +codeine hydrocodone oxycodone dihydrocodone tramadol (not with APAP or ASA) \+/- adjuvant
WHO Ladder of Pain Management: Step 3
morphine hydromorphone methadone levorphanol fentanyl oxycodone \+/- non-opioid analgesics \+/- adjuvant
adjuvant analgesics
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
NSAIDS
prostaglandin inhibitors (via COX inhibition)
analgesic / antipyretic / antiplatelet
- used primarily as antiinflammatory agents
older patients + opioids: considerations
reduce starting doses by 25 - 50% + monitor freq for AE
What is the single most reliable indicator of existence and intensity of pain?
Subjective findings - patient report
WHOSE PAIN IS IT
Normal body temperature
37 C
When is it appropriate to start Tylenol given fever?
AFTER cultures are drawn.
Neuroleptic Malignant Syndrome
r/t SSRI toxicity
//or//
family hx significant for NMS
Malignant Hyperthermia is associated with what drug?
succinylcholine
Succs is contraindicated in what situation?
HYPERKALEMIA
most common cause of non-infectious fever
POST-OP ATELECTASIS
elevated eosinophils are present in what reactions?
allergic reactions
drug-induced fever
eiosinophilia implies allergic rxn!
Drug Induced Fever
Slow onset (7 - 10 days) PCN derivatives most commonly induce
initial treatment for non-infection related post-op fever
hydration
increasing lung expansion
infectious etiology of fever is manifested in this lab
elevated WBC with L shift (bandemia)
likely etiology of WBC elevation over 30k
not due to infection - usually leukemia
treatment of infection-related post-op fever x3
supportive fluids + APAP
treat underlying source
gram stain, C&S all invasive lines/catheters
patient presents with 101.5 F lasting over 3 wks. ddx and plan of care?
it is FUO, ddx include endocarditis & malignancy
plan is to identify source of fever - no intervention otherwise
most important bit of history to collect regarding a headache
chronology - onset; when it started
tension headache: s/s x5
vice-like, squeezing, tight generalized intense around neck & back of head no focal neuro sx duration: several hours
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?
tension headache
tension headache: tx x2
OTC analgesics
relaxation
migraine
r/t dilation + excessive pulsation of external carotid + branches, follows trigeminal nerve (V)
duration: 2 - 72 hours
types: classic vs common
classic vs common migraine
classic with aura
common without aura (literally, most pts have these)
migraine: s/s x6
- unilateralized throbbing occurs episodically, can be dull
- gradual build up
- focal neuro deficits: hallucinations, visual changes, aphasia, numbness, tingling, clumsiness
- n/v, photo & phonophobia
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?
migraine headache
migraine headache: diagnostics
- baseline studies if new, r/o organic causes
- CT scan (r/o brain tumor)
- BMP
- CBC
- VDRL (r/o syphilis)
- ESR
You want to rule out neurosyphilis as the etiology of a migraine; what lab do you order?
VDRL
- if positive, presumptive
Pt has 2 - 3 migraines per month. What is indicated for prophylactic therapy?
amitryptyline (Elavil)
migraine: acute attack mgmt
- Rest in dark, quiet room
- ASA STAT: pain relief
- sumatriptan (Imitrex)
- 6 mg SQ stat, can repeat in 1 hr (3 max per day)
- 25 mg PO @ HA onset
cluster headache: s/s x8 + typical population
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
cluster headache: mgmt x3
- 100% O2
- sumatriptan (Imitrex) 6mg SQ - but PO meds usually unsatisfactory
- ergotamine tartrate (Ergostat) aerosol inhalation
best nutritional serum marker
prealbumin
hgb under 12 (M) or 13.5 (F) indicates what? x4
lack of iron or protein
poor oxygenation and perfusion
How does 1 unit PRBC affect H/H in general? If 8/24?
1 unit PRBC increases H/H 1/3
8/24 + 1 unit PRBC = H/H of 9/27
What is your first consideration for nutritional support?
PO supplements to diet
Patient requires nutrition support but GI tract is non-functional. What are 2 other options and when would you use them?
CVC: central - anticipated longer than 2 weeks
PICC line: peripheral - shorter
Patient requires nutrition support and GI tract is functional. What 3 options do you have and when would you use them?
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
What solution should be used in parenteral feeds via PICC line?
less than 10% dextrose
enteral nutritional support: possible complications x7
THE PROBLEM IS THE SOLUTION
- hypernatremia
- aspiration
- dehydration
- vomiting, GI bleed, diarrhea
- tube obstruction
hypotonic hyponatremia: what & serum osmolality
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
hypovolemic hypotonic hyponatremia: causes
Renal Salt EXCRETION: kidneys can’t conserve Na!
- diuretics
- ACE Inhibitors
- mineralcorticoid deficiency
hypervolemic hypotonic hyponatremia: treatment
WATER RESTRICTION
hypervolemic hypotonic hyponatremia: causes
- edematous states
- CHF
- liver disease
- advanced renal failure
hypovolemic hypotonic hyponatremia: treatment
IVF: NS
hypovolemic hypotonic hyponatremia + urine Na gt20: treatment
treat the cause
severe hypovolemic hypernatremia: treatment + important consideration
IVF: NS then 0.5 NS
* slowly to avoid cerebral edema *
hypervolemic hypernatremia: treatment x3
free water
loop diuretic
consider dialysis
hypokalemia: causes
losses: GI, excess renal
alkalosis
Heart failure patient who is on chronic diuretic is at risk for what?
hypokalemia
hypokalemia: EKG changes x6
decreased amplitude
broad T waves
U waves
rhythm abnormalities: PVCs, v tach, v fib
hypokalemia: s/s - general x5 + severe x4
what counts as severe hypokalemia?
muscle weakness, fatigue, cramps
constipation, ileus (d/t smooth muscles)
severe (lt 2.5 mEq/L): flaccid paralysis, tetany, hyporeflexia, rhabdo
hypokalemia: treatment x3
- 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)
severe hypokalemia: expected K value + treatment x4
K under 2.5
- IV repletion @ 40 mEq/L/hr
- K check q3hrs
- continuous EKG
- check Mg (deficiency impairs correction)
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?!?!
high pressure irrigation (NS or LR) with 18-19 G needle
What types of bite wounds should be left open?
bite on hands or lower extremities, any wound older than 6 hours (heal by secondary intention)
what prophylactic antibiotics do you use for bites?
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)
GOOD CHOICE FOR BITES ABX PROPHYLAXIS
amoxicillin clavulanate (Augmentin) PO 3-7 days
Which of these require suturing
a. dog bite
b. puncture wound
c. clean laceration of elderly patients hand
d. abrasion
Clean laceration of elderly person’s hand requires suturing
3 most common causes of cellulitis in the outpatient setting?
Strep pyogenes (GAS): the usual cause
Staph aureus: less common
Strep etc: rare
3 most common causes of inpatient cellulitis?
- GRAM NEGS (Klebsiella, E Coli, Pseudomonas, Enterobacter)
- Staph aureus
- Strep
Patient has sustained a wicked boil that looks super spider bitey. What do you suspect and how do you fix dat ish?!
MRSA!!!!
per IDSA: I & D + culture, NO ABX!
CA-MRSA cellulitis: 3 treatment options
sulfamethoxazole-trimethoprim (Bactrim)
doxycycline
clindamycin
GAS cellulitis: 3 tx options
sulfamethoxazole-trimethoprim (Bactrim) + beta lactam (PCN, amoxicillin, keflex)
doxy/minocycline + beta lactam (PCN, amoxicillin, keflex)
dlindamycin
Which antimicrobial indicated for cellulitis has strep and staph coverage?
Clindamycin - but it’s not as effective as a beta lactam plus either Bactrim or doxy or mino
bull’s eye rash is associated with what diease?treatment?
aka erythema migrans = Lyme disease
treatment: doxy
Rocky Mountain Spotted Fever treatment
doxyyyyy
Most important aspect of assessment of patient with suspected toxicity?
HISTORY
activated charcoal: indication & dose
use for GI decontamination
1 g/kg (max 50g) q4 hrs PRN
- in combination w Sorbitol (cathartic = poo city!)
ipecac: indications & contraindications
barfing up your guts after at home, SOLID ingestion
never use for: corrosives/detergents (esophageal erosion or aspiration pna may result)
APAP toxicity: s/s x4
- early: usually asymptomatic
- around 24 - 48 hrs: n & v
- RUQ pain
- hepatoxicity as manifested by: jaundice, elevated LFTs, prolonged PT, AMS
APAP toxicity: mgmt x3
- emesis if recent
- GI lavage, activated charcoal (1 gm/kg q4)
- N-Acetylcysteine (Mucomyst) + loading dose PO PRN
hyperkalemia: mnemonic + causes
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
hyperkalemia: mnemonic + s/s
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)
hyperkalemia: general mgmt
- Kayexalate (exchange resins)
- if severe or cardiac toxicity or paralysis, insulin 10U + 1 amp D50
A patient is severely hyperkalemic with flaccid paralysis. What is the expected K level and treatment plan? What does that plan accomplish?
severe = 6.5+
insulin 10 U
+ one amp D50
- pushes K back into cell
calcium: 2 major roles, normal total and normal ionized values
mediates neuromuscular & cardiac fxn
normal TOTAL: 8.5 - 10.5 mg/dL
normal IONIZED: 4.5 - 5.5 mg/dL
Patient’s albumin levels are abnormal and you want to measure calcium. Which form do you order and why?
IONIZED: does not vary with the albumin level
How do acidemia and alkalemia impact serum calcium levels?
acidemia INCREASES calcium
alkalemia DECREASES
hypocalcemia: causes x5
PANCREATITIS
hypomag, hypoPTH
renal failure
trauma
hypocalcemia: s/s - 3x major + 3x more
Calcium calms. Not enough, so wacko.
MAJOR: trousseau, chvostek, QT prolongation
convulsions, hyper DTRs, muscle/abd cramps
hypocalcemia: mgmt x5
ACUTE: IV calcium gluconate
CHRONIC: PO supplements: Vit D, Ca, aluminum hydroxide
BOTH: blood pH - check for alkalosis
hypercalcemia: causes
hyperthyroidism, hyperPTH, Vitamin D intoxication, prolonged immobilization
hypercalcemia: s/s x9
Calcium calms. Too calm!
fatigue, muscle weakness
depression, anorexia
nausea, vomiting, constipation
severe: coma, death
What lab value of hypercalcemia is considered a medical emergency? Treatment plan?
over 12 mg/dL
- IV NS + loop diuretic
hypercalcemia: mgmt x3
calcitonin (if impaired cardiovascular or renal function)
dialysis
severe: IV NS with loop diuretics
respiratory acidosis: s/s x5
AMS (somnolence, confusion, coma)
MYOCLONUS + asterixis
↑ ICP (d/t ↑CBF = ↑ CSF pressure)
respiratory acidosis: mgmt x3 + rationale behind each
- if no obvious cause: naloxone (Narcan) 0.04 - 2mg IVP
- intubation (improve ventilation)
- ↑ RR on vent (blow off CO2)
respiratory alkalosis: values + cause
greater than pH 7.45
less than pCO2 35
r/t hyperventilation: blowing off CO2
respiratory alkalosis: s/s x4 - what are clinical symptoms related to?
sx r/t ↓ CBF
- light-headedness
- paresthesia, tingling in hands/feet
- anxiety
- tetany if severe
respiratory alkalosis: mgmt x4
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
metabolic acidosis: hallmark lab values x2
↓ HCO3
evaluate anion gap
anion gap: normal, equation, meaning
NORMAL: 12 +/- 5 (7-17)
( Na + K ) - ( HCO3 + Cl )
seen in metabolic acidosis
higher gap = higher acuity
increased anion gap: causes mnemonic
M ethanol U remia D KA / AKA ** P ropylene glycol I ron / INH L actic acidosis ** E thylene glycol S alicylates
normal anion gap: causes x4
- diarrhea (losing HCO3/base)
- ileostomy
- renal tubular acidosis
- DKA recovery
metabolic acidosis: mgmt x3
TREAT UNDERLYING CAUSE!
fluids
HCO3 (if significant hyperkalemia, NOT for DKA or hypoxia)
metabolic alkalosis: causes x4
the following are saline-responsive (volume contraction is the most common problem):
- ng suction, vomiting
- diuretics
- post-hypercapnia alkalosis
metabolic alkalosis: mgmt x4
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
first degree burn
NO BLISTERS
dry, red, painful
extent: epidermis only
second degree burn
aka partial thickness
BLISTERS!
moist, painless
extent: beyond epidermis
third degree burn
aka full thickness burn
dry, leathery, black or pearly waxy
extent: epidermis, dermis, underlying tissue (fat, muscle, bone)
burn mgmt: fluid requirements x4
~ 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
This is a major problem seen in burn care.
under-resuscitation/lack of fluids
When does fluid resuscitation begin for burn patients?
at the time of injury, not when they arrive at a facility
major acid-base and electrolyte complications associated with burn injuries x3
- metabolic acidosis: during early resuscitation phase
- hyperkalemia: first 24 - 48 hrs
- hypokalemia: after fluid resus/diuresis, approx 3 days post-burn
You should monitor a burn patient for hyperkalemia during what time period?
first 24 - 48 hrs after burn
You should monitor a burn patient for hypokalemia during what time period?
3 days post-burn (it’s related to fluid volume resuscitation and diuresis)
What is an indication for prophylactic intubation in a burn patient?
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
- Per ABA: when do you refer a patient to a burn center? *
x 6
- 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
salicylate intoxication: s/s x11
TINNITUS *elevated LFTs* dizziness, HA n/v, dehydration hyperthermia apnea, cyanosis, metabolic acidosis
salicylate intoxication: mgmt
- emesis if recent
- GI lavage, activated charcoal (1 gm/kg q4)
- severe acidosis: IV sodium bicarb
organophosphate (insecticide) poisoning: s/s x9
EXCESSIVE SALIVATION * blurred vision, miosis * bradycardia AMS, HA N/V/D
organophosphate poisoning: drug of choice for
atropine - addresses bradycardia & secretion management
antidepressant toxicity: causative agents
amytriptyline (Elavil)
fluoxetine (Prozac)
bupropion (Wellbutrin)
imipramine, nortriptyline
antidepressant toxicity: s/s x9
confusion, hallucinations, blurred vision hypotension, tachycardia, dysrhythmias urinary retention hypothermia seizures
antidepressant toxicity: mgmt x8
- 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
seizure prophylaxis in anti-depressant toxicity?
diazepam (Valium) IV
Your patient has overdosed on Lexapro and you suspect Serotonin Syndrome. What is your treatment plan?
dantrolene sodium (Dantrium)
clonazepam (Klonopin): for rigors
cooling blankets: temp control
4 drugs that cause narcotic toxicity?
morphine
codeine
heroin
opium
narcotic toxicity: s/s x5
respiratory depression
miOsis
hypothermia
AMS, coma
miosis vs mydriasis in which toxicities
miosis: codeine, heroin, morphine
- think relaxation, euphoria
mydriasis: cocaine, extasy
- think amped up
contraindication in narcotic toxicity management
emetics
narcotic toxicity: mgmt x3
naloxone (Narcan) 0.04 - 2 mg IVP
butorphanol (Stadol)
GI lavage/activated charcoal
benzo OD: s/s x4
respiratory depression
AMS, coma
hyporeflexia
THINK RELAXED & EUPHORIC
benzo OD: mgmt
- HD & respiratory support
- flumazenil (Romazicon) IV
- GI lavage, activated charcoal
You suspect your patient is rejection their freshly transplanted appendix. What is your first order?
biopsy of transplanted organ
Standard anti-rejection induction agents
calcineurin inhibitor + antimetabolite + steroid
i.e.,
tacrolimus (Prograft) or Cyclosporine \+ azathioprine (Imuran) or mycophenolate mofetil (Cellcept) \+ prednisone
What steroid is administered as part of an anti-rejection drug regimen for transplant prophylaxis?
prednisone
Herpes Zoster: pathophysiology
aka shingles!
acute vesicular eruptions due to infection with varicella zoster virus - can be life-threatening in immunocompromised adults
Herpes Zoster: s/s x3
- pain along dermatome distribution (usually trunk)
- grouped vesicle eruption of erythema and exudate along dermatome
- regional lymphadenopathy
Herpes Zoster: mgmt x4
- acyclovir, famciclovir, or valacyclovir
- ophthalmology referral if ocular involvement
- gabapentin (Neurontin) for post-herpatic neuralgia
- zostavax if 50+ (uh isn’t this prevention)
When is Zostavax appropriate?
prevention of Herpes Zoster in 50+
actinic keratoses what + describe + treatment
- 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
Squamous Cell Carcinoma what + describe + treatment
- arise from actinic keratoses, develop over months (3-7% mets)
- firm, irregular papule or nodule
- keratotic, scaly bleeding
tx with bx & surgical excision (Mohs)
Seborrheic Keratoses what + describe + tx
BENIGN
non-painful lesions 3 - 20 mm diameter
beige/brown plaques
“stuck on” appearance
tx: liquid nitrogen or none
malignant skin cancers x3
Squamous Cell Carcinoma
Basal Cell Carcinoma
Malignant Melanoma
benign skin growths x2
Actinic Keratoses
Seborrheic Keratoses
Basal Cell Carcinoma: what + describe + tx
MALIGNANT! most common skin cancer
waxy, pearly lesion
slow growing (1 - 2cm)
telangiectatic vessels (spider veins)
tx: shave/punch bx + surgical excisino
Patient has spider veins, what cancer might you want to rule out?
basal cell carcinoma
aka telangiectatic vessels
What is the most common skin cancer?
basal cell carcinoma
What skin cancer has the highest mortality rate?
MALIGNANT MELANOMA
What malignant skin cancer can mets to any organ?
MALIGNANT MELANOMA
brain death criteria
No functional cranial nerves.
end-of-life care: 2 drugs used & indication
morphine: respiratory distress
scopolamine: secretion reduction
What is the antidote for CO poisoning?
100% oxygen
What is an anti-convulsant that accelerates acetaminophen toxicity?
phenytoin (Dilantin)
What are 2 hallmark signs of aminoglycoside toxicity?
ototoxicity
nephrotoxicity
What is the most common pathogen in surgical site infection?
Staphylococcus
What is the most common cause of third degree (full thickness) burns?
electrical
What is a common complication associated with circumferential burns?
compartment syndrome
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?
surgical consult STAT to salvage limbs
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
c. Basal cell carcinoma is commonly found on the HEAD and NECK not abdomen and trunk
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
b. Shingles pain can last for months after the acute exacerbation
Most common bite seen in the ED?
human
Individuals most at risk for development of melanoma?
fair skinned
blue eye
red hair
freckles
Most common cause of fever?
infection
most common causes of FUO?
endocarditis
malignancy
surgical procedure with highest incidence of wound infection
colon resection
initial management of post-operative atelectasis
improve ventilation
IVF
CXR and blood cultures
best pain medication for chronic cancer pain
fentanyl patch (sustained release!)
rapid onset
short half life
allows patient to be lucid
post-surgical pain management alternative to morphine
ketorolac (Toradol)
most common sites of acute compartment syndrome
forearm
leg
how long to see healing response on pressure ulcer that is clean and well vascularized
2 days
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
B. surgical gastrostomy PEG tube
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. weakness and edema
anti-emetic that blocks serotonin 5HTC and can cause EPSE used for delayed gastric emptying
metoclopramide (Reglan)
most helpful tests in determining nutrition status
prealbumin
albumin
calcium
what acid-base imbalance causes urinary potassium excretion
metabolic alkalosis
fluid used in correction of hypernatremia
D5W (free water)
indication for sodium bicarbonate IV administration in hyperkalemia
stabilize myocardial membrane and counteract myocardial effects of hyperkalemia
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
C. seizures and cardiac arrythmias
CATS go numb Convulsions Arrythmias Tetany Seizures Numb
most common cause of hyponatremia in the hospitalized patient
SIADH
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
d. HTN and migraine should be treated with a beta blocker
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. Beta blockers should not be used in patients with asthma due to ARF bronchospasm
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
C. low potassium diet is recommended with renal failure patients
diet recommended for renal failure patients
low potassium
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
d. PO vancomycin is best for C. diff. Metronidazole (Flagyl) is also used.
drugs used to treat c diff
vancomycin
metrondiazole (flagyl)
most common valvular heart disease in adults
aortic stenosis
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. ACE Inhibitors and diuretics for mitral regurgitation and LV dysfunction - reduce afterload
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
Early ambulation
acute vs chronic pain
less than or more than 6 mo
- acute: caused by tissue damage
- chronic: continual or episodic, usually needs combo therapy
What oral temperature is considered fever? What interventions x3?
38.6 C / 101.5F
order cultures
anti-pyretics (Tylenol)
treat underlying cause
Rectal temperature considered fever?
+99.5F
priority intervention for NMS or malignant hyperthermia
likely r/t drugs (NMS: SSRI or MH: succinylcholine)
IVF to flush out agent
infectious causes of post-op fever
incision, point of entry for any catheter (IV), urinary tract, lungs, sinusitis (ng tubes), abscess
protein malnutrition: labs x2
albumin & prealbumin (early indicator)
What albumin value indicates protein malnutrition? At what value can edema be expected? Normal range?
- less than 3.5 g/dL
- less than 2.7 g/dL
- 3.5 - 5 g/dL
3.5 - 5 is the normal range for which 3 lab values?
albumin
K
phos
normal range for K?
3.5 - 5
normal range for phos?
3.5 - 5
hypotonic hyponatremia
,serum osmolality lt280
FVE
most common electrolyte imbalance
hyponatremia
hyponatremia: 3 evaluation steps
- urine Na (normal 10 - 20)
- serum osmolality (normal 2x Na)
- clinical status
urine Na normal
10 - 20
serum osmolality normal
285 - 295 mosm/kg
what can urine Na distinguish?
- 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)
parenteral nutritional support: possible complications x8
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
what is the general difference between complications of enteral and parenteral nutrition?
enteral: the problem is the SOLUTION
parenteral: the problem is the DELIVERY
isotonic hyponatremia: what & lab value
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
hypovolemic hypotonic hyponatremia + urine Na lt 10 mEq/L: causes
DEHYDRATION
diarrhea, vomiting (more dehydration!)
hypertonic hyponatremia: serum osm & causes x2
serum osm over 290 mosm/kg
- hyperglycemia & HHNK
hypotonic hyponatremia: in general, 3 types/overarching cause
hypovolemic, urine Na under 10: dehydration
hypovolemic, urine Na 20+: kidneys can’t conserve salt
hypervolemic, “traditional”: edema-related
hyponatremia: general mgmt x5
- 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
- Patient is hyponatremic and symptomatic. Treatment plan?
NS IVF + loop diuretic
- Patient is hyponatremic and CNS symptoms are manifesting. Treatment plan?
3%NS + loop diuretic
hypernatremia is usually d/t what?
hyperosmolality results from excess water loss; excess sodium intake is rare
euvolemic hypernatremia: treatment
free water (D5W)
Why do you order Mg level if patient is being treated for hypokalemia?
Mg deficiency can impair K repletion.
How does calcium relate to albumin?
IONIZED does not vary with albumin.
TOTAL is 50% bound to albumin
Your patient is hypoalbuminemic due to malnutrition with a normal calcium level. What do you suspect?
Actually hypercalcemia. Total calcium is 50% bound to albumin.
respiratory acidosis: values & cause
less than: pH 7.35
greater than: pCO2 45
cause: decreased alveolar ventilation
respiratory acidosis vs alkalosis presentation
acidosis: deathly ill
alkalosis: distress
Why should you avoid rapid correction of respiratory alkalosis?
Rapid correction may result in metabolic acidosis, “due to the renal compensatory drop in serum bicarbonate.”
FUN FAX - C Diff + Vomiting = acid-base imbalances?
C Diff: acidosis because you’re blowing out the bicarb
Vom: alkalosis because you up chucked the acid
metabolic alkalosis & respiratory acidosis
metabolic usually ↑↑ HCO3 - pCO2 rarely exceeds 55
if pCO2 is 55+ superimposed respiratory acidosis likely
emergent burn mgmt x3
- 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)
burn: pain mgmt most commonly used
IV fentanyl or morphine
How do you care for a tar burn injury?
use a petroleum based product to remove burning tar
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
topical antibacterial/antifungal for 2nd and 3rd degree burns
gastric lavage is bad but boards wants you to know what?
lavage until clear with 28 - 38F/ng tube for ingestions older than 30 minutes
with each 0.1 drop in pH, how much does K+ increase?
0.7
organophosphate poisoning: mgmt x3
- wash skin thoroughly
- activated charcoal if ingested insecticide
- atropine
benzo OD: reversal agent
flumazenil (Romazicon) IV
- acute organ rejection: s/s + initial intervention *
- immediate failure of tx organ
- flu-like symptoms (prodrome)
- immediate biopsy of transplanted organ!
how do anti-rejection induction agents used as transplant rejection prophylaxis work?
they significantly lower and nearly abolish circulating lymphoid cells that are critical to rejection response
What is the ABCDEE method for malignant melanoma?
A symmetrical B order irregularity C olor change D iameter over 6mm E levation E nlargement
2+ more = 97% chance of malignant melanoma
Treatment for topical salicylate toxicity?
wash with warm tap water
