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Outpatient Clerkships > Family Med/Internal Med > Flashcards

Family Med/Internal Med Flashcards

1
Q

Common travel meds

A

Atovaquone - proguanil, mefloquine, chloroquine, doxycycline (use one with minimal side effects)

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2
Q

Diagnosis of DM

A

Two sugar measurements: Fasting >125, random >200

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3
Q

Treatment of HTN in diabetic

A

First line medication ALWAYS ACE inhibitor or ARB - protection of kidneys. Contraindication: leg edema or cough

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4
Q

Treatment of HTN in non-diabetic

A

Amlodipine first line or hydroclorothiazide (chlorthalidone) or ACE inhibitor/Arb

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5
Q

Treatment of DM

A

Metformin for 2-3 months, treatment goal <6.5/7 (Depending on source).
If close to goal: add Glipizide
If >8.5: add insulin

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6
Q

Cellulitis

A

Greater than 1cm erythema surrounding wound

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7
Q

Amlodipine

A

Max dose 10mg, side effect: edema

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8
Q

Benazapril

A

Max dose 40mg, side effect cough

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9
Q

Sleep apnea

A

Suspect in short, obese male. Neck circumference: >37cm. Causes R-sided heart failure - LE edema

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10
Q

Insulin recombinate U500s

A

concentrated regular insulin (500 units). Dose of 0.2mL = 100 units. Releases some insulin immediately, some slowly

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11
Q

Treatment of skin infection

A

Keflex (cephalexin) 500mg TID x 5 days

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12
Q

Treatment of UTI

A

Keflex (cephalexin) 500 mg TID x 5 days

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13
Q

Common causes of right-sided heart failure

A

Sleep apnea, pulmonary HTN

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14
Q

CHADS

A 
Congestive Heart Failure
Hypertension
Age >75
Diabetes
Stroke (+2)
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15
Q

Acute renal insufficiency

A

Think: Prerenal (low blood flow), intrinsic renal damage, postrenal (obstruction
Albumin/Creatinine ratio, SPEP

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16
Q

Chronic kidney disease

A

> 3 months of decreased GFR
Stage 3: GFR 30-59
Stage 4: 15-29
Stage 5: <15

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17
Q

Nausea/vomiting in pregnancy

A

B6

Doxylamine 25mg

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18
Q

Using ACE/Arb

A

Diabetic HTN

HTN with microalbumin rate >0.3. Increase dose to treat HTN but NOT to treat microalbumin

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19
Q

Management of diabetes

A

Foot exam annually
Eye exam annually
A1c q6 months for controlled, q3 months for uncontrolled
Lipid panel and urine albumin-to-creatinine ratio annually

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20
Q

Side effect of decreased oxygen

A

Cerebral edema (can cause syncope), long term: polycythemia, cor pulmonale, R-sided heart failure. Use O2 to prevent cor pulmonale.

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21
Q

Causes of neuropathy

A

Diabetes, idiopathic, alcohol use, medications, vasculitis, amyloidosis, connective tissue disease, low B12, toxicity (metals)

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22
Q

Best SSRI for anxiety

A

Zoloft (sertraline)

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23
Q

Best SSRI for depression

A

Fluoxetine (Prozac)

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24
Q

Refractory insomnia

A

Try prazosin, then Paxil, then amitriptyline

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25
Q

Chronic pain tx

A

Can use TCA (nortriptyline)

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26
Q

Treatment after MI

A

Beta blocker, ACE inhibitor , statin, dual-antiplatelet therapy (for at least one year)

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27
Q

Down syndrome screening

A

Pediatric: echocardiogram for congenital heart disease
Childhood hearing screen and always check for recurrent otitis media
Ophthalmic exam annually
Thyroid function annually
Celiac disease monitoring at one year old
CBC for leukemia and iron-deficiency anemia

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28
Q

Treatment of uncontrolled asthma

A 
leukotriene modifier (like montelukast) + inhaled glucocorticoid + LABA (long-acting beta agonist) = triple-controller therapy
-If also have allergies, you can add omalizumab
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29
Q

Dosing prednisone

A

Low dose <10mg for chronic use
High dose >40mg for acute conditions like COPD exacerbation or MI
Medium dose is the in between

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30
Q

Workup for hematuria

A

Urine sample, cytology, CT urogram, cystoscopy

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31
Q

Monitoring DM

A

AIc goal <7%
If unstable, check A1c every three months
If stable, check every six months
Lipid panel and microalbumin annually

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32
Q

Atrial fibrillation treatment

A

Rate control: beta blocker of calcium channel blocker
Anticoagulation (depending on CHADS score)
Rhythm control: only if symptomatic - (Amiodarone)

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33
Q

New onset hyperkalemia cause

A

CHECK MEDS (could be caused by ACE inhibitor (Lisinopril) which decreases RAAS and decreases aldosterone - decreased sodium uptake and decreased potassium excretion. This is renal tubular acidosis type 4

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34
Q

New onset hypokalemia cause

A

Could be from diuretic

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35
Q

Three rules of wound care

A
  1. Take away offending agent (pressure, infection, edema)
  2. Remove dead skin with abrasion
  3. Keep wound moist to maintain healthy granulation tissue with Vaseline, duoderm
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36
Q

5 main types of antibiotics to KNOW!!

A
  1. Cephalexin/Keflex: 1st generation cephalosporin: Skin infection (mostly caused by strep and staph)
  2. Amoxicillin: beta lactam: ear, sinus, throat infections
  3. Sulfamethoxazole-Trimethoprim/bactrim: UTI
  4. Azithromycin: Macrolide: CAP
  5. Ciprofloxacin: Fluoroqunilone: reserved for last resort
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37
Q

Insomnia tx

A

Sleep onset: choose short-acting medication: zaleplon, zolpidem, triazolam, lorazepam, or remelteon
Sleep maintenance: longer-acting medication: zolpidem ER, eszopiclone, temazepam, estazolam, doexpin (low dose), suvorexant

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38
Q

CHF

A

Symptoms: SOB with exertion. When worse - orthopnea and peripheral edema.

Diastolic: Can’t fill

  • Commonly due to HTN (causes stiff ventricle) and afib (causes loss of atrial kick). Can also be due to hypertrophic cardiomyopathy or infiltrative diseases (amyloidosis or sarcoidosis)
  • Treat with diuretic and rate control

Systolic: can’t pump

  • Commonly due to MI (malfunctioning ventricle wall). Can also be caused by HTN, aortic stenosis, mitral regurg
  • Treat with ACE inhibitor, diuretic, and rate control
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39
Q

Chronic dry cough differential

A
  1. Allergic rhinitis is most common. Tx: flonase, possibly antihistamines
  2. ACE inhibitor therapy
  3. GERD: can present with heartburn. Tx: PPI
  4. Cystic fibrosis: more likely in younger population
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40
Q

Claudication differential

A

Causes: neurogenic or peripheral vascular disease

Neurogenic: Can be from radiculopathy or spinal stenosis/myelopathy

  • Radiculopathy: nerve compressed where it leaves cord. Surgery is last case scenario, commonly L4-5
  • Myelopathy: spinal cord compression, usually from spinal stenosis. Surgery is warranted because it may cause paralysis

Vascular: Increases with walking but relieves when standing and immediately when sitting down

Neurogenic: Increases with walking but does not resolve with standing and takes a few minutes to resolve when sitting. Relieved when leaning over shopping cart!

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41
Q

Vertigo differential

A

Central process (brain stem) or vestibular (more common)
Vestibular can be:
1.Meniere’s disease: triad of vertigo, hearing loss, tinnitus
2. eustachian tube dysfunction: signs of allergic rhinitis or recurrent ear infections - will have NEGATIVE Dix hallpike maneuver. Sxs for longer periods of time
3. BPPV: otolith in the ear, sxs only last for a few seconds, ROTATIONAL nystagmus with dix hallpike

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42
Q

Chronic kidney disease differential

A

Common causes:

  1. Diabetes: usually has microalbuminemia and large kidneys
  2. Hypertenion: usually NO microalbuminemia and small kidneys
  3. Other things

Workup: renal ultrasound to rule out obstruction, microalbumin

Treatment: maintain blood sugars and blood pressures
AVOID NSAIDS

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43
Q

Acute kidney injury

A

Causes: prerenal, intrinsic, post-renal
-prerenal: decreased blood volume, CHF, liver disease, ACE inhibitor, NSAIDs
-intrinsic: nephritic syndromes, nephrotic syndromes, acute interstitial nephritis, acute tubular necrosis
-post-renal: obstruction
Workup: per protocol. Obtain SPEP and UPEP if workup otherwise normal

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44
Q

Symptoms of cervical spinal stenosis

A

Ataxia and lower extremity weakness - affecting dorsal column

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45
Q

Management of gout

A

Allopurinol if >3-4 flares in one year. No need to titrate based off of uric acid levels, titrate more based on flares.
If big joint - treat with allopurinol sooner.
If tophi - treat more aggressively.

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46
Q

Common inherited causes of hypercoagulability

A 
Factor V Leiden mutation
Prothrombin gene mutation
Protein S deficiency
Protein C deficiency
Antithrombin deficiency
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47
Q

Angioedema

A

Swelling of soft tissue, usually face but can be extremities or genitals
Caused by mast cell degranulation (urticaria, pruritis, hypotension, anaphylaxis), histamine release (urticaria but no respiratory or circulatory symptoms), or bradykinin (ONLY swelling)
Workup: CBC, CMP, ESR, CRP, C4

-Hereditary angioedema (C1 inhibitor deficiency)
ACE inhibitors
Specific trigger

Treatment depends on severity and cause. Triggered angioedema can be treated with epinephrine, glucocorticoids, and antihistamines

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48
Q

Early identification of sepsis

A

QSOFA standard:

  • RR >22
  • Change in mentation
  • Systolic blood pressure <100
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49
Q

Bilirubin level for scleral icterus

A

2.5-3 minimum

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50
Q

Choledocholithiasis

A

Biliary obstruction from a stone
Elevated AST, ALT, but cholestatic picture with elevated bilirubin, GGT, and alk phos greater than AST/ALT
-Elevated direct bili indicates obstruction (can have obstruction even with normal alk phos)
US can show dilation or stone
In patients with prior cholecystectomy, US that show dilation can be normal or sign of stone.
Continue with MRCP (dye and imaging of duct) or ERCP (scope, can remove stone at time of scope)

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51
Q

Charcot’s triad

A

RUQ pain, fever, jaundice - symptoms of acute cholangitis

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52
Q

Reynolds’ pentad

A

RUQ pain, fever, jaundice, hypotension, altered mental status

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53
Q

Antibiotics used for GI infections

A

Ampicillin (covers gram positive - enterococcus), gentamycin (covers gram negative enterics), and metronidazole (covers anaerobes)

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54
Q

Piperacillin-tazobactam (Zosyn)

A

Antibiotic that mostly covers everything (gram positives, gram negatives, and anaerobes)

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55
Q

Congestive heart failure

A

<40% EF: Systolic heart failure
40-50% EF: CHF with borderline ejection fraction
>50% EF: Diastolic heart failure

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56
Q

Acute exacerbation of CHF

A

Causes: MI, infection, food change, under-medicated, atrial fibrillation, renal failure, hypertensive crisis, drugs, anything else that shocks the body

Dosing of Lasix: at least twice the dose of home dose. An IV dose is 2x as much as oral dose

Goal for discharge: 1-1.5L removed, best measured by daily weight changes but can also be monitored by input/output

Management of HFREF:
-Drugs to treat symptoms: diuretics, beta blockers (not during acute exacerbation), ACE inhibitors, ARBs, ARNI, hydralazine plus nitrate, digoxin, and aldosterone antagonists

-Prolongation of patient survival: beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and aldosterone antagonists.

Management of HFPEP: Treat underlying cause

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57
Q

Side effect of ACE/Arb

A

Hyperkalemia. Always order chemistry panel one week after starting an ACE or Arb to assess for hyperkalemia. ESPECIALLY if patient is on a diuretic which further increases risk of hyperkalemia

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58
Q

Difference between metoprolol tartrate and metoprolol succinate

A

Tartrate: short-acting - usually dosed as BID

Succinate: long-acting - usually dosed as once a day. Recommended for tx of heart failure

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59
Q

Difference in treatment for HFREF vs HFPEP

A

HFREF: Ace inhibitor, beta blocker, diuretic, aldosterone antagonist (if adequate renal function and without hyperkalemia), ICD for refractory heart failure

HFPEF: diuresis, BP control, prevention of tachycardia. NO BENEFIT to: ACE inhibitor, spironolactone is questionable

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60
Q

Lactated ringers

A

Hydrates, provides electrolytes, diureses, and reduces acidity

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61
Q

Definition of shock

A

Hypotension and organ damage

Hypotensive shock: excessive bleeding, dehydration

Cardiogenic shock: Anything cardiac related

Distributive shock: anaphylaxis, PE

Septic shock: sepsis

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62
Q

Atrial fibrillation

A

Common causes:

  • Mitral stenosis
  • Hypertension
  • Cardiomyopathies

Treat for:

  • to avoid thromboembolic issues (stroke, arterial emboli) - treat those at high risk (CHADs score >2)
  • Other complications are due to tachycardia (RVR)

Treatment for rate:

  • Beta blockers and calcium channel blockers act on the AV node so they affect heart rate but will also decrease BP
  • Digoxin completely blocks the AV node to decrease HR
  • Amiodarone stabilizes the heart - decreases HR and rhythm
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63
Q

Thrombocytopenia

A

Causes: decreased production, increased use (consumption in the body), or sequestration by the spleen

The patient can still have surgery with 50 count.
<10 is when we worry about intracranial hemorrhage

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64
Q

HIT

A

Herparin-induced thrombocytopenia - a risk of using heparin.
4T score can calculate pre-test probability for someone developing HIT

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65
Q

PERC score

A

Used to determine those at a LOW risk of PE and includes the following:

  • Age <50 years
  • Heart rate <100 beats/minute
  • Oxyhemoglobin saturation ≥95 percent
  • No hemoptysis
  • No estrogen use
  • No prior DVT or PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior four weeks
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66
Q

Wells criteria

A

Used to determine someone who is at high risk for PE (>4) and includes the following:

  • Clinical symptoms of DVT (leg swelling, pain with palpation) -3 pts
  • Other diagnosis less likely than pulmonary embolism -3.0 pts
  • Heart rate >100 -1.5 pts
  • Immobilization (≥3 days) or surgery in the previous four weeks 1.5 pts
  • Previous DVT/PE 1.5 pts
  • Hemoptysis 1.0 pts
  • Malignancy 1.0 pts
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67
Q

Fractionated sodium

A

Anything less than 2% indicates pre-renal cause.
Calculated by serum Na and Creatinine and urine Na and Creatinine

Use fractionated urea if patient is on Lasix (if low, they are not putting out much)

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68
Q

Hypocalcemia correction

A

Hypocalcemia needs to be corrected with albumin.
Normal albumin is 4.
For every 1 point drop in albumin, you add 0.8 to the calcium score

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69
Q

Non-anion gap metabolic acidosis

A
  • Increased acid generation (lactic acidosis, ketoacidosis)
  • Loss of bicarbonate (diarrhea)
  • Diminished renal acid excretion (RTA)
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70
Q

“Flash” pulmonary edema

A
  • dramatic form of ADHF, caused by an acute increase in left ventricular diastolic pressure from any of the following:
  • myocardial ischemia
  • acute severe mitral regurgitation
  • hypertensive crisis
  • acute aortic regurgitation
  • stress-induced cardiomyopathy
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71
Q

Fluoroquinolones

A

Covers gram + and gram -

Worry about QT prolongation and tendon ruptures

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72
Q

Cephalosporins

A

Covers some gram + and gram - and pseudomonas

-can cross-react with penicillins

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73
Q

Macrolides

A

gram +, atypicals

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74
Q

Carbapenems

A

Broad spectrum

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75
Q

Astronium

A

gram - only, no cross reaction with penicillins

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76
Q

Amiodarone dosing

A

600mg daily for one week, 400mg daily for two weeks, then 200mg daily after for maintenance

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77
Q

Disseminated intravascular coagulation

A

Elevated D-dimer, thrombocytopenia, and increased coagulation studies

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78
Q

Workup of anemia

A

First obtain peripheral blood smear, then reticulocyte count.
-Retic count tells if bone marrow is intact. If it is low, then bone marrow is NOT intact. If it is high, bone marrow is intact but the body is using RBC somewhere else

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79
Q

Ventricular tachycardia

A

Causes:

  • Electrolyte abnormalities (HYPERkalemia, HYPOcalcemia, HYPOmagnesia)
  • A fib with bundle branch block
  • Coronary artery disease with ischemia due to poor perfusion
  • Medications (digoxin)
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80
Q

Paroxysmal ventricular contraction

A

Don’t treat!

If symptomatic, you can treat with beta blocker

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81
Q

TSH in elderly

A

Normal is higher because it adjusts upward with age

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82
Q

D-dimer with elderly

A

Normal is higher because it adjusts upward with age

-Add 0 to your age and that’s what d-dimer should be

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83
Q

How to interpret ECG

A
  1. Rate: multiple bottom by 6 or count boxes (300, then 150, then 100, then 75, then 60)
  2. Rhythm: Is it regular or no? Is there a p wave for every QRS?
  3. Axis: Find isoelectric node and then perpendicular to that (use II for +/-)
  4. Intervals: PR: <1 big box, QRS: <3 little boxes
  5. Waves: Look at p wave in v1. If inverted, dipolar, or M - indicates left atrial enlargement. If TALL skinny M(“peaked” called por pulmonale), then right atrial enlargement
  6. ST segments: Are there elevations or depressions?
  7. Bundle branch blocks:
    - RBBB: Look at V1 and V6: V1 will have bunny ears, V6 will have big R and big S
    - LBBB: V1 is W and V6 is M
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84
Q

Hemoglobin level at which we transfuse

A

7 but it is also case-based

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85
Q

Why use nitro drip over SL?

A

Nitro drip is less likely to cause hypotension.

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86
Q

Most common SE of nitro?

A

Headache from vasodilation of the brain

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87
Q

Treatment of NSTEMI

A

Needs to have full anticoagulation until cath
ASA + clopidigrel
Statin (stabilize plaque)
Nitro for chest pain (drip less likely to cause hypotension)
Ace inhibitor
Beta blocker

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88
Q

Level of magnesium that we try to maintain for cardiac stability

A

2

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89
Q

Level of potassium that we try to maintain for cardiac stability

A

4

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90
Q

When to use a straight cath

A

Urinary retention with bladder scan showing PVR >300mL. If unsuccessful, then use catheter

91
Q

Score for major bleeding risk

A 
HAS-BLED
hypertension
Renal disease
Liver disease
Stroke history
Prior major bleeding or predisposition
Labile INR
AGE >65
Medication that predisposes to bleeding
Alcohol use
92
Q

Normal BP for age >65

A

150 systolic

93
Q

Causes for acute encephalopathy

A

Infection (meningitis, encephalitis, sepsis)
Autoimmune encephalopathy
Trauma
Seizure (epileptic encephalopathy, post-ictal)
Toxins (drugs, heavy metal, CO)
Metabolic disturbances (uremia, increase in ammonia, glucose, lactic acid, electrolytes)
HTN (renal disease or heart disease)
Hypoxia encephalopathy (nearly drowning, prolonged resuscitation, vascular)
Hemorrhage (traumatic, spontaneous)
Malignancy (primary brain, metastatic)
Increased intracranial pressure/hydrocephalus

94
Q

Blood glucose goals

A

Fasting and before meals: 80-130
1-2 hours post-meal: <180
Before bed: 100-130

Can be higher for patients having other chronic illnessss

95
Q

Duration of abx for community acquired pneumonia

A

5 days

96
Q

Treatment of CAP in hospital

A

Azithromycin 500mg loading dose followed by 250mg for five days total
Rocephin

97
Q

How long does warfarin take to work?

A

48 hours
So you have to bridge with lovenox!
Bridging also prevents pro-thrombotic state during initiation of warfarin

98
Q

Lab findings in DIC

A

All levels up besides fibrinogen.

Factor 8 is made in endothelium so it will be normal in liver injury but low in DIC

99
Q

Treatment of CAP

A

Augmentin!

100
Q

Rhabdomyolysis

A

Elevated CK, blood(myoglobin) in urine, elevated AST/ALT
-Usually presents with hyperkalemia and hyperphosphatemia
Worry about kidney injury: myoglobin is toxic to tubules and also forms casts
Treatment is to flush out the kidneys
Treatment for hyperkalemia are fluids, diuresis, and potassium binders (Kayexalate)

101
Q

Central pontine myolysis

A

Occurs from overcorrecting sodium too rapidly

Symptoms: new neurological deficits, altered mental status

102
Q

Causes of DKA

A

Infection, ischemia, insulin, intoxication

103
Q

Insulin

A

Long-acting: Lantus (glargine), detimir, NPH
Short-acting: Lispro (Novolog), Novelin (regular insulin)

Dosing in hospital:
0.5units/kg insulin for the total day. Divide 50/50 between long and short acting

104
Q

Prokinetic agents

A

Erythromycin, metoclopramide

105
Q

Severe aortic stenosis

A

40: pressure gradient across valve
4: velocity across valve
0. 8/1: diameter of valve

106
Q

Gram negative antibiotic coverage

A 
Piperacillin-tazobactam
3rd generation cephalosporin
Impipenem
Fluoroquinolones (Cipro, levofloxacin)
Aminoglycosides (Gentamicin)
Bactrim
Aztreonam
107
Q

Gram positive antibiotic coverage

A 
ampicillin
piperacillin
early generation cephalosporins
fluoroquinolones
vancomycin
108
Q

Anaerobic coverage

A

metronidazole
clindamycin
Zosyn (pip-tazo)
Unasyn (amp-sulbactam)

109
Q

Hypertensive urgency cutoff

A

220/120

110
Q

Hypertensive emergency treatment protocol

A

25% reduction MAP in 2-6 hours with drip

Then switch to orals

111
Q

HTN med for heart failure/CAD

A

Beta blocker, ACE inhibitor

112
Q

HTN med for stroke

A

ACE and thiazide

113
Q

HTN med for CKD

A

ACE/Arb except for not stage four

114
Q

HTN med for diabetes

A

ACE/Arb especially If microalbuminuria

115
Q

dihydropyridine CCB side effects

A

felodipine, amlodipine

peripheral edema

116
Q

ACEs/Arbs

A

Increase in creatinine
Increase in K+
Only ACE cause dry cough and angioedema through bradykinin

117
Q

Thiazides

A

HCTZ and chlorthalidone
Decrease K+
Decrease urinary calcium to treat kidney stones

118
Q

Beta blockers

A

Heart failure with reduced EF and CAD

SE: Decreased HR

119
Q

Aldosterone antagonist

A

Spironolactone and expleronone
Increase in K+
Gynecomastia

Uses: CHF class 3 or primary hyperaldosteronism

120
Q

Combo dilators

A 
Hydralazine (arterial dilator) can cause reflect tachycardia and drug-induced lupus
Isosorbide Dinitrate (venous dilator): should not be used with other nitrates or PDE5

Together: Bidell used in CHF

121
Q

Alpha antagonists

A

Terazosin, doxazosin
Used for BPH
SE: orthostatic hypotension

122
Q

Meds not to use for HTN

A

Clonidine - reflect hypertension

Non-dihydropyridine CCB such as verapamil and diltiazem - used for rate control for afib.

123
Q

CAD spectrum definitions

A

Asymptomatic CAD:
-No pain, <50% occlusion

Stable angina:

  • Pain with exertion, relieved with rest
  • No heart damage so no biomarkers
  • No ST changes
  • 70% occlusion

Unstable angina:

  • Pain with rest
  • No heart damage so no biomarkers or ST changes
  • 90% occlusion

NSTEMI

  • Pain with rest
  • Heart damage so elevated biomarkers
  • No ST changes
  • 90% occlusion

STEMI

  • -Pain with rest
  • Heart damage so elevated biomarkers
  • ST elevation
  • 100% occlusion
  • Supply ischemia - NO supply of O2 so heart will die if not intervened

Stable angina, unstable angina, NSTEMI are demand ischemia - not total occlusion. If you decrease heart work load, you can get more O2 to heart and decrease sxs

Unstable angina, NSTEMI, and STEMI require hospitalization

124
Q

Diamond classification of CAD

A

Substernal
Worse with exertion
Improved with nitro

3/3=typical
2/3=atypical
1/3

125
Q

CAD Risk factors

A 
Hypertension
Diabetes
Smoking
Hyperlipidemia
Obesity

Male >45
Female >55
Family history

126
Q

Chest pain workup

A

ECG
If ST elevations - go straight to cath
If no ST elevations - obtain Troponin (peak first and last longer)
If elevated, go to cath urgently but not emergently

Then, is this coronary ischemia? Answer with stress test. If positive - go to cath electively.

127
Q

Treatment for ACS

A

Morphine
Oxygen
Nitrates
Aspirin

BB
ACE-inhibitor
Statin
Heparin
Clopidogrel

Nitrates for someone with continued angina after initial episode.
If they get stent - you give clopidogrel

90 minutes to get cath
60 minutes to get TPA

128
Q

Workup for CHF

A

BNP (may falsely elevate in ESRD)
Echo - systolic or diastolic
Left heart cath to determine if there is ischemia

129
Q

Treatment of CHF by class

A

Class 1: No limitations
Class 2: No symptoms with ADLs
Class 3: Symptoms with ADLs
Class 4: Symptoms at rest

All get BB and ACE inhibitor
Class 2 and worse get diuretic
Class 3 and worse get isosorbide dinitrate or spironolactone
Class 4 near death, get inotrope like dobutamine

If EF <35% and NOT class 4, the patient gets AICD

If ischemic, get ASA and statin

Everyone: smoking cessation and fluid <2L/day, NaCl <2g/day

130
Q

CHF exacerbation workup

A

CXR, BNP, ECG, Troponin

131
Q

Treatment for CHF exacerbation

A 
Lasix
Morphine
Nitrates
Oxygen
Position
132
Q

Who HAS to be on a statin

A
  1. Vascular disease
  2. REALLY high LDL
  3. LDL 70-189 with age 40-75 and DM
  4. LDL 70-189, with age 40-75 and calculated risk (HTN, smoking, obesity, age, family history)
133
Q

Statin strength and dose

A

High intensity: Atorvastatin 40, 80 or rosuvastatin 20, 40

Moderate: same as above but lower dose

Even lower are the others

134
Q

Before you start statin

A

Obtain Lipids, A1c, CK, and LFTs for baseline

Lipids annually
A1c only if diabetic
Only recheck CK if myalgias
Only recheck LFTs if hepatitis

135
Q

Cholesterol meds

A

Statin, lowers LDL, myositis and hepatitis
Fibrates lower total but increase HDL, myositis and hepatitis
Ezetimibe and bile resins, lower LDL, diarrhea
Niacin, lower LDL but raise HDL, flushing (prophylax with ASA)

136
Q

Diagnosis of GERD

A

PPI and lifestyle modifications for six weeks

If no improvement, get ECG and biopsy

Patients with alarm symptoms (N/V, anemia, weight loss) go straight to EGD

137
Q

Tx of GERD

A

Just GERD: PPI

Metaplasia to columnar epithelium: (barrett’s), increase PPI

Dysplasia (precancer): PPI and local ablasion - radiofrequency ablasion, laser, or cryo

Adenocarcinoma - stage and resect

Meta and dys requires surveillance EGDs

138
Q

Ulcerative colitis versus Crohn’s

A

UC:

  • 20-30 year-old
  • Continuous lesions, only in the colon
  • Biopsy: superficial with crypt abscesses
  • Sxs: bloody diarrhea
  • Cancer: Increased risk of colon cancer. Screening colonoscopy at year 8, then yearly
  • Extra-intestinal: primary sclerosing cholangitis, and PNCA
  • Surgery: Colectomy is curative

Crohn’s disease:
-20-30 and 50-75
-Skip lesions, entire GI tract
-Biopsy: transmural, non-caseating granulomas
-Sxs: Watery diarrhea, multiple bowel movements per day and water loss
-No associatiation with colorectal cancer
-Extra-intestinal: Fistulas, If affecting the terminal ileum: B12 and fat issues. If affecting the duodenum: Irone deficiency and osteopenia
Surgery: Reserved for complications (fistulotomy, drain abscesses)

139
Q

Treatment of IBD

A

Mild: 5-ASA compounds (Mesalamine) good for UC more than Crohn’s

Moderate: Immunemodulators such as 6MP, azathrioprine, methotrexate, good for BOTH

Severe: Crohn’s: TNF inhibitors (infliximab)
UC: surgical resection

With flare up:

  • Rule out infection (C diff)
  • Treat with prednisone
  • Treat with antibiotics (cipro and metronidazole)
140
Q

Chronic diarrhea causes

A

Diarrhea >4weeks (not infectious)

Secretory: high volume, just water

  • Osmolar gap: normal
  • Fecal WBC: none
  • Fecal RBC: none
  • Mucous: none
  • Changes NPO: none
  • Nocturnal sxs: yes
  • Fecal fat: none

Osmotic/Malabsorption: something that can’t be absorbed so water leaves cells into lumen

  • Osmolar gap: elevated
  • Fecal WBC: none
  • Fecal RBC: none
  • Mucous: none
  • Changes NPO: yes
  • Nocturnal sxs: none
  • Fecal fat: + fat

Inflammatory

  • Osmolar gap
  • Fecal WBC: +
  • Fecal RBC: +
  • Mucous: +
  • Changes NPO
  • Nocturnal sxs
  • Fecal

stool osmolar gap: measured osm (290) - 2*(Na+K)

  • If number high, there isn’t a lot of other stuff, then #<50 = secretory
  • If number is low, there is more osmals, >100 = osmotic diarrhea

Usual suspects:

  • Laxative
  • Medications
  • Lactose intolerance
  • C diff
  • Celiac sprue
141
Q

Workup for chronic diarrhea

A

Fecal RBC, fecal WBC, stool osmol, fecal fat

Secretory: hormones, EGD with biopsy, C. diff

Inflammatory: colonoscopy

Osmotic: H&P, EGD and biopsy, dz-specific

142
Q

VIPoma

A

Tumor that secretes VIP (tells intestines to go) = chronic diarrhea
Dx: VIP level
Tx: resection

143
Q

Zollinger-Ellison syndrome

A

Gastrinoma which stimulates parietal cells to acid release which causes virulent PUD and diarrhea

Dx: Gastrin level
-If <250, you have ruled out
-If >1600, you have ruled in
-If in between, you get secretin stimulation test
If postitive, localize with somatostatin receptor sonography (SRS)

Tx: resection

144
Q

Carcinoid syndrome

A

Tumor that secretes serotonin
Causes R sided heart fibrosis, flushing, and diarrhea
Dx: 5HIAA in urine, CT scan to stage
Tx: resection

145
Q

PFT finding of obstructive lung disease

A

FEV1/FVC that is reduced

-asthma or COPD

146
Q

Treatment of asthma exacerbation

A

Oxygen to keep above 90%
Nebulizers (albuterol and ipratropium)
Assess peak expiratory flow rate

Go home: if peak expiratory flow rate is >70% - treat with inhalers and prednisone

Go to ICU if increased O2 demand, rising CO2, decreased lung sounds or PEFR of <50% - treat with ventilator, IV methylprednisolone, contin. nebulizers
-If patient still not better, can treat with racemic epi, subQ epi, and magnesium

Go to floor: Nebulizers that transition to inhalers and IV steroids that transition to oral. Eventually get spaced out

147
Q

COPD pathophysiology

A

Loss of surface area of alveoli
-CO2 retention (no O2 exchange) so no hypoxemia
Increase AP diameter and prolonged expiration, breathing through pursed lips
=PINK puffers

148
Q

Bronchitis pathophysiology

A

Inflammation of the airways
Decreased O2 = cyanosis
Decreased O2 in the lungs causes vasoconstriction which can cause pulmonary HTN and heart failure and edema
=BLUE BLOATERS

149
Q

Treatment of COPD

A 
SABA
Then SABA + LAMA (piotropium)
Then SABA + LAMA + LABA (do not need ICS to prescribe LABA)
Then SABA + LAMA+LABA+ICS
LAMA+LABA+ICS + PDE4 inhibitors
Then all above + oral steroids

Corticosteroids (ICS, PO, IV)
Oxygen (spO2<88% or PaO2 <55 with goal of spO2 88-92%)
Prevention: vaccines (flu, pneumococcal), smoking cessation
Dilators (short acting, long acting, orals)
E-
Rehab

150
Q

Treatment of asthma

A 
SABA
SABA+ICS
SABA+ICS+LABA
SABA+higher dose ICS+LABA
then all above +Oral steroids

Must have ICS before you prescribe LABA

151
Q

Treatment of COPD exacerbation

A

Order CXR, ABG, and ECG
Tx: abx (doxycycline, azithromycin)
Bronchodilators (albuterol, ipratropium) q30minutes
Steroids: PO - prednisone, IV=methylprednisolone

152
Q

Screening for colon cancer

A

Age >50
Colonscopy q10
sigmoidoscopy q5 with FOBT q3
FOBT or FIT q1

153
Q

Screening for lung cancer

A

Age 55-80
30pyear history
quit <15 years ago

Low dose CT scan

154
Q

AAA screening

A

Men
>65
Smoking history
With one-time ultrasound of abd (but CT works)

155
Q

Osteoporosis screennig

A

Women
>65
DEXA scan
Treat with bisphophonates (Vitamin D and calcium should be PROPHYLACTIC)

156
Q

Hep C screening

A 
Baby boomer (1945-1965)
Hep C antibody
157
Q

HIV screening

A

Everyone once and those with risks, with ELISA

158
Q

Hypertension screening

A

Everyone, every visit

Best way is ambulatory monitoring

159
Q

Diabetes screening

A

Those with HTN

A1c

160
Q

Hyperlipidemia screening

A

Men >35 or >20 with CAD risk factor
Women >45 or >20 with CAD risk factor
Lipid panel

161
Q

Depression screening

A

PHQ-9

162
Q

Mobility screening

A

Get up and go

163
Q

Abx for community acquired PNA

A

Hospital: ceftriaxone and azithromycin
Home: Oral version of azithromycin
Moxi = IV or PO (always wrong on test)

164
Q

Abx for hospital acquired pneumonia

A

Covering for MRSA and pseudomonas

Hospital: Vanc and pip/tazo

165
Q

Abx for meningitis

A

ceftriaxone, vancomycin, +/-steroids, +/- ampicillin

166
Q

Abx for UTI

A 
Amoxicillin - pregnant
Nitrofurantoin - woman
Bactrim - no renal failure
Ceftriaxone - hospitalized pyelo
Cipro - ambulatory pyelo
167
Q

Abx for cellulitis

A

Vancomycin in hospital because assume MRSA

Can use Clinda or Bactrim

168
Q

Community acquired pneumonia organisms

A 
Strep pneumo
Moraxella
H flu (COPD, smoke)
Klebsiella (EtOH)
Staph aureus (post-viral)
Legionella (immunosuppressed)

Treat with ceftriaxone and axithromycin OR moxifloxacin

169
Q

Hospital acquired pneumonia organisms

A

Within 90 days of exposure to hospital or after 48 hours of being in hospital

Pseudomonas
MRSA

Tx: Vanco and pip/tazo

170
Q

Treatment of lung abscess

A

Ceftriaxone and clindamycin

171
Q

PCP

A

HIV AIDS CD4 ct <200
Sputum silver stain
Tx: Bactrim +/- steroids (hypoxemic or low PaO2)

172
Q

When to admit for PNA

A

CURB 65 or PSI

173
Q

What makes cystitis complicated?

A

Pyelonephritis
Penis
Plastic (foley catheter)
Procedure

174
Q

Treatment of different types of cystitis

A

Uncomplicated - 3 days
Complicated - 7 days
Pyelonephritis - 10 days
Perinephric abscess - 14 days

175
Q

Urethritis

A 
STD: Gonorrhea, chlaymdia
Presents with discharge
Dx: GC/Chl swab or urine
Tx: ceftriaxone x1 IM + azithromycin x 1PO or doxy x7 days
Screen for HIV
176
Q

Asymptomatic bacteriuria

A

Gram negative rods and GBS
Screened in pregnant and those undergoing urologic procedure
Pregnancy: treat with amoxicillin.
Repeat screen for test of cure

177
Q

Treatment of pyelo

A

IV: ceftriaxone
PO: Cipro

Patient with pyelo that does not improve - worry about perinephric abscess (CT or US).
Tx: continue abx for 14 days and I&D

178
Q

Treatment of cellulitis

A

Strep: cephalexin (Keflex)
Staph: Bactrim, clindamycin

TOXIC
Strep: Pip/tazo, amp/clavulonate
Staph: Vanc, linezolid, Clinday

179
Q

Osteomyelitis

A

Caused by hematogenous spread or direct wound inoculation
Pt usually has wound where you can probe the bone or recurrent cellulitis
Dx: 1st XR. If negative, MRI. Best test is bone biopsy
Tx: debridement, 4-6wks of abx

180
Q

Gas gangene

A

C. perfringes
Pt: penetrating wound contaminated with crepitus
Dx: 1st XR that shows gas
Tx: debridement, penicillin + clinda

181
Q

Necrotizing fasciitis

A

Strep and staph
Pt presents with cellulitis, super sick, rapidly spreading or abx doesn’t help, pain out of proportion or crepitus
Blue-gray discoloration
Dx: XR that shows gas
Tx: surgical debridement, ceftriaxone, clinda, amp

182
Q

Most common bug to cause osteomyelitis

A

staph aureus

If sickle cell - salmonella
If penetrating wound - pseudomonas
If diabetic foot - polymicrobial (cover for pseudomonas)
If oyster/cirrhotic, think vibrio fulmificus
If gardening - sporothrix

183
Q

AAA

A

Caused by atherosclerosis
usually asymptomatic finding on imaging for another reason (may be tender mass with back pain)
Tx: >3.5 requires yearly screening
>4.5 requires screening q6 months
>5.5cm OR >0.5cm growth in 6 months requires surgery

184
Q

Aortic dissection

A

Caused by HTN
Tearing chest pain that radiates to the back
Asymmetric BP between arms
Widened mediastinum on CXR
Dx: CT angiogram is best. TEE is equivalent to MRI if can’t do angiogram

Type A: right next to heart. Needs operation. May need aortic valve replacement.
Type B: past arch. Medically with IV beta blockers

185
Q

Anterior shoulder dislocation

A

Any trauma
Abduction, external rotation
Axillary nerve might be affected causing deloid paresthesias
Relocate and sling

186
Q

Posterior shoulder dislocation

A

significant trauma
Abduction, internal rotation
Relocate and sling

187
Q

Colles’ fracture

A

Older lady
Osteoporosis
Breaking fall with outstretched wrist
Broken radius and ulna, dorsally displaced\

188
Q

Monteggia fracture

A

Blocking upward from downward blow.

Item strikes ulna, breaking ulna and displacing radius

189
Q

Galezzia

A

Downward block from upward blow

Item strikes radius, breaking radius and displacing ulna

190
Q

Scaphoid fracture

A

Fall on outstretched hand
Pain at anatomic snuffbox
XR normal on day 1
Cast anyway due to vascular compromise

191
Q

Boxer’s fracture

A

Punch against wall

4th and 5th digits break

192
Q

Hip fracture

A

A lot of trauma or old lady with osteoporosis
Shortened and externally rotated
If there is fracture of femoral head - need to do prosthesis

193
Q

EtOH intoxication

A

Alcoholic beverages
No anion gap
Osmolar gap
Supportive

194
Q

Isopropyl alcohol

A

Rubbing alcohol
No anion gap
Osmolar gap
Supportive

195
Q

Ethylene glycol

A

Anti-freeze (causes renal failure)
Anion gap
Osmolar gap
Prevent breakdown to toxic metabolites with fonepizole or EtOH

196
Q

Methanol

A

“Moonshine” can lead to blindness
Anion gap
Osmolar gap
Prevent breakdown to toxic metabolites with fonepizole or EtOH

197
Q

Acetaminophen toxicity

A

AST, ALT >1000
Dx: Acetaminophen level 4 hours and 16 hours after ingestion
Tx: N-acetylcystine

198
Q

Salicylate toxicity

A

Aspirin
Early: tinnitus, n/v, vertigo, respiratory alkalosis
Late: AG acidosis, obtunded in coma, hyperpyrexia
Dx: Salicylate level
Tx: Alkalinization of urine and diuresis

199
Q

Carbon monoxide toxicity

A 
Smoke inhalation with HA, n/v, delirium
Affinity for hemoglobin greater than O2. O2 delivery is compromised
Pulse ox = 100%
Dx: ABG for carboxy hemoglobin
Tx: 100% FiO2 and possibly hyperbarics
200
Q

Cyanide toxicity

A

Nitroprusside, smoke inhalation
Super sick, cherry red skin or cherry red blood
Dx: clinically
Tx: thiosulfate

201
Q

Organophosphate toxicity

A 
Weapons of terror
Pesticides
Myasthenia gravis medications
Block Ach-esterase
Salivation
Lacrimation
Urination
Defication
GI upset
Emesis
Dx: clinical
Tx: Atropine and pralidoxime
202
Q

Symptoms of bipolar disorder

A 
E + 3 of following
>1 week
Distractibility
Insomnia
Grandiosity
Flight of ideas
Agitation/activities
Sexual exploits
Talkative
Elevated mood
Racing thoughts
203
Q

Treatment of anorexia

A

Anti-psychotic (and CBT) unless associated with OCD, MDD in which case you’d treat with SSRI or SNRI

204
Q

Treatment of bulemia

A

SSRI/SNRI (and CBT)

NEVER buproprion

205
Q

Symptoms of depression

A 
>2 weeks
Need 5 of following:
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor retardation
Suicide
206
Q

Screening for substance use disorder

A

Cut down
Anger
Guilty
Eye opener

For adolescents:
Car
Relax
Alone
Friendships
Forget
Trouble
207
Q

Stages of change

A 
Pre-contemplative - denial
Contemplative - acceptance
Preparation - first steps
Action -actual behavior change
Maintenance - sustain behavior change
208
Q

Difference between nightmares and night terrors

A

Nightmares: dreams gone bad. REM so no tone, easy to wake up and remember
Any age
No treatment

Night terrors: Non-REM,
active behaviors while asleep
Tone, doesn’t remember
Child - will outgrow

209
Q

Insomnia

A

Trouble falling asleep or sleep <6 hours per night

Tx: Sleep hygiene
If not helpful, then:
Diphenhydramine
Trazodone
Quetiapine
Zolpidem - last resort
210
Q

Protocol for anti-depressants

A

Use one med at one dose for six weeks before making adjustments
Treat at least six months at effective dose
Give at least six weeks for washout before starting next med

Combo of therapy and meds are best!

211
Q

SSRIs

A

Escitalopram
Fluoxetine
Paroxetine
Sertraline

SE: sexual dsyfunction
decreased libido
prolonged ejaculation

212
Q

SNRIs

A

Desvenlafaxine
Duloxetine

Cleaner but more expensive

213
Q

Atypical antidepressants

A

Buproprion

Smoking cessation without weight gian
Do not use in bulemia because decreased seizure threshold

214
Q

Serotonin modulators

A

Mirtazapine - sleep aid and appetite stimulant

Trazodone - sleep aid (can cause priapism)

215
Q

Tricyclic antidepressants

A

Triptylines, imipramine and doxepin

Treat enuresis
Mostly used in neuropathic pain

SE: convulsions, cardiac toxicity, and coma

216
Q

MAOIs

A

Selegeline
Phenylzine

Causes hypertensive emergency especially when eating wine or cheese (increase in tyramine)

217
Q

Typical antipsychotics

A

Work by inhibiting D2 receptors
Block D2 in mesolimbic: decreased POS symptoms
Block D2 in nigrostriatal: EPS
Block D2 in tubuloinfundibular: gynecomastia, galactorrhea, ammenorrhea
Acetylcholine SE: dry mouth, urinary retention

Haloperidol, fluphinezine, chloridiazine, chlorpromazine

218
Q

Atypical antipsychotics

A 
D2 antagonism and Serotonin antagonism
Quetiapine - sleepy
Olanzapine - weight gain, DM
Risperidone - EPS
Aripiprazole
Ziprasidone 
Clozapine - BEST but last resort 2/2 agranulocytosis

QT prolongation and EPS

219
Q

Development of female puberty

A

Breasts 8
Axillary hair 9
Growth 10
Menarch 11

220
Q

Causes of precocious puberty

A

Tumor that secretes FSH/LH in anterior pituitary
Ovarian cyst (granulosa-theca that secretes estrogen or sertoli-lydig that secretes testosterone)
Congenital adrenal hyperplasia or tumor that secretes DHEA or testosterone

221
Q

Workup for precocious puberty

A

Bone age. If 2 year younger than age then:
GnRH stim test. (Leuprolide)
If it stimulates LH then axis is working and it is central process. Follow with MRI. If tumor - resect. If no tumor, then it is constitutional. (Treat with continuous leuprolide to delay puberty so growth is not stunting)
If stim does NOT change LH, then there is peripheral lesion - US of abdomen (adrenals), US of ovaries, test for DHEAS and testosterone, 17OH progesterone to look for CAH.
CAH (treat with steroids)
Tumor (resect)

222
Q

Delayed puberty workup

A

No secondary sex characteristics by 13 or no bleeding by 15
Get bone age and FSH/LH
If FSH/LH are increased: hypergonadotropic - usually due to karyotype
If FSH/LH are not elevated: hypogonadotropic (prolactin, TSH, urine pregnancy, CBC, LFT, EFR, MRI to rule out lesion)
If everything is negative, this is constitutional delay. Just wait - no need for growth hormone!

223
Q

Workup for infertility

A

Male first
Mucous smoosh test. If abnormal, treat with estrogen or artificial insemination
Then check if she’s ovulation with basal temp, blood progesterone, endo biopsy, or OTC urine LH. If anovulatory - treat with clomiphine
If normal, then do hysterosalpingogram to assess for structural abnormalities.
if normal, do laparoscope to look for endometriosis (tx with laser ablation, OCP, estrogen)

Outpatient Clerkships (4 decks)

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