Final Review

Question 1

S/sx’s:

Dyspnea, anxiety, pleuritic chest pain, cough, hemoptysis. Low pulse ox and arterial gasses

Answer 1

Pulmonary Embolism:

Question 2

S/sx’s:

Sx onset is usually gradual over minutes and chest pain is the mc sx. Sensation of tightness, squeezing, pressure.

Answer 2

Myocardial Infarction:

Question 3

S/sx’s:

Crackles (rales), Chest pain but with fever, cough, and dyspnea

Answer 3

Pneumonia:

Question 4

S/sx’s:

Discomfort induced by exertion and relieved with rest or nitroglycerin.

Answer 4

Angina Pectoris:

Question 5

S/sx’s:
Sx’s occur with the same degree of exertion and resolves with the same decree of rest and same dosage and strength of nitroglycerine.

Answer 5

Stable Angina:

Question 6

S/sx’s:
Angina that occurs with more frequent occurrence of angina episodes, longer lived ones, or more easily proved not relieved by nitroglycerine

Answer 6

Unstable Angina:

Question 7

S/sx’s:

Angina at rest not relieved by Nitroglycerine

Answer 7

Prientz Metal/ Atypical:

Question 8

S/sx’s:
Pressure/squeezing quality, pain similar to prior mi or angina, radiation to neck, shoulders, jaw or left arm, associated dyspnea and could have nausea and sweating.

Answer 8

Acute Coronary Syndrome:

Question 9

S/sx’s:

Inc. heart rate, rapid breathing and displacement of windpipe away from affected side

Answer 9

Pneumothorax:

Question 10

S/sx’s:

Unequal pulses, radiating pain to the back, new onset murmur

Answer 10

Aortic Dissection:

Question 11

S/sx’s:
Cardiac Tamponade:
“Beck’s triad”

Answer 11

Becks Triad= Low BP, JVD, Decreased Heart Sounds

Question 12

S/sx’s:
Pain radiating to the mid back, hoarse voice and left due to left recurrent laryngeal nerve being stretched *Matching of where pain goes

Answer 12

Aortic Aneurysm:

Question 13

Beck’s triad

Answer 13

Low BP, JVD, Decreased Heart Sounds

Question 14

Wells DVT score:

Answer 14

1. Active cancer (treatment within last 6 months or palliative): +1
2. Calf swelling ≥ 3cm compared to asymptomatic calf (measured 10cm below tibial tuberosity): +1
3. Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1
4. Unilateral pitting edema (in symptomatic leg): +1
5. Previous documented DVT: +1
6. Swelling of entire leg: +1
7. Localized tenderness along deep venous system: +1
8. Paralysis, paresis or recent cast immobilization of lower extremities: +1
9. Recently bedridden ≥ 3days, or major surgery requiring regional or general anesthetic in
   the past 12 weeks: +1
10. Alternative diagnosis at least as likely as a diagnosis of DVT: -2

Question 15

Wells PE score:

Answer 15

Clinically suspected DVT: +3
Alternative diagnosis is less likely than PE: +3
Tachycardia (HR > 100): +1.5
Immobilization (≥ 3d)/surgery in previous four weeks: +1.5
History of DVT or PE: +1.5
Hemoptysis: +1
Malignancy (with treatment within 6 months) or palliative treatment: +1
(possible score -2 to +9)

Question 16

Wells PE score:

Traditional interpretation

Answer 16

Score of > 6.0 = High probability of PE (probability 59% based on pooled data)
Score of 2.0 to 6.0 = Moderate probability of PE (probability 29% based on pooled data])
Score of

Question 17

Wells PE score:

Alternative interpretation

Answer 17

Score > 4 means that a PE is likely. Consider diagnostic imaging.
Score 4 or less means that a PE is unlikely. Consider D-dimer testing.

Question 18

Know the different stages used in assessing the severity of an asthmatic attack.

Answer 18

1. Mild asthma - Adequate air exchange, mild dyspnea, diffuse wheezes. FEV1 50 to 80% of normal.
2. Moderate asthma - Respiratory distress at rest, hyperpnoea, marked wheezes, and air exchange is normal to decreased. FEV1 is 50% of normal or less.
3. Severe - Marked respiratory distress, marked wheezes or absent breath sounds, check for pulsus paradoxus - drop of systolic blood pressure >10 mm. with inspiration. SCM retraction is commonly noted. FEV1 is 25% to 11% of normal.
4. Respiratory failure - Severe respiratory distress, lethargy, confusion, prominent pulsus paradoxus, SCM retraction. FEV1 is generally 10% of normal or less.

Question 19

Review the presentations of different causes of GI bleeding.

Answer 19

• Approximately 50% of upper GI bleeds are due to peptic ulcer disease.
• Esophagitis and erosive disease of the esophagus causing bleeding are the next most common causes.
• About 75% of patients presenting to the emergency room with GI bleeding have an upper source.
• Patients with upper GI bleed due to peptic ulcer disease often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon colored stool if the hemorrhage is severe).
  
  • The anatomic cut-off for upper GI bleeding is the ligament of Treitz & pharynx.
• Patients may also present with complications of anemia, including fatigue, chest pain, syncope and shortness of breath.

Question 20

Metabolic:
S/sx’s & Cancer-
Hypercalcemia of malignancy

Answer 20

All cancers, esp. lung, breast, and prostate as well as multiple myeloma

Fatigue, anorexia, nausea, vomiting, constipation, mental decline, renal failure, coma, myalgia, headache, altered mental status

Question 21

Metabolic:
S/sx’s & Cancer-
Syndrome of inappropriate antidiuretic hormone

Answer 21

Bronchogenic carcinoma

Anorexia, nausea, vomiting, constipation, muscle weakness, myalgia, polyuria, polydipsia, seizures, coma

Question 22

Metabolic:
S/sx’s & Cancer-
Tumor lysis syndrome

Answer 22

Hematologic malignancies, cancers with rapidly growing tumors,

Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, acidosis, acute renal failure particularly acute leukemias and high-grade lymphomas

Question 23

Hematologic:
S/sx’s & Cancer-
Febrile neutropenia

Answer 23

Chemotherapy-associated bacterial or fungal infections

Temp. greater than 101º F (38.3º C), absolute neutrophil Hematologic count less than 500 per mm3

Question 24

Hematologic:
S/sx’s & Cancer-
Hyperviscosity syndrome

Answer 24

Waldenström’s macroglobulinemia, multiple myeloma, leukemia

Spontaneous bleeding, hemorrhagic retinal veins, neurologic defects,

Question 25

Structural:
S/sx’s & Cancer-
Epidural spinal cord compression

Answer 25

Breast, lung, renal, and prostate cancers and myeloma

New back pain that worsens when lying down, late paraplegia, late incontinence, and loss of sensory function

Question 26

Structural:
S/sx’s & Cancer-
Malignant pericardial effusion

Answer 26

Metastatic lung and breast cancer, melanoma, leukemia, lymphoma,

Dyspnea, fatigue, distended neck veins, distant heart sounds, tachycardia, orthopnea, narrow pulse pressure, pulsus paradoxus,

Question 27

Structural:
S/sx’s & Cancer-
Superior vena cava syndrome

Answer 27

Lung cancer, metastatic mediastinal tumors, lymphoma, indwelling venous catheters

Edema, discoloration of head, neck or upper extremity swelling or discoloration; development of collateral venous circulation

Question 28

Shocks:

fluid is lost from the circulatory system.

Answer 28

Hypovolemic –

Question 29

Shocks:

heart fails to pump enough blood, heart is injured or damaged, CAD, CHF, VF.

Answer 29

Cardiogenic –

Question 30

Shocks:

blood vessels dilate or constrict causing blood to pool away from vital areas.

Answer 30

Peripheral vascular –

Question 31

Hemorrhages: class 1-4

Answer 31

Class I – up to 15%
Class II – 15% - 30%
Class III – 30% - 40%
Class IV – over 40%

Question 32

Samter’s triad

Answer 32

asthma, aspirin and NSAID sensitivity, and nasal / ethmoidal polyps.

Question 33

Compare and contrast ischemic stroke and hemorrhagic stroke.

Ischemic=> A clot blocks blood flow to an area the brain.

Hemorrhagic=> Bleeding occurs inside or around brain tissue.

Answer 33

• Nausea, vomiting, headache and change in the level of consciousness are symptoms that are more common in hemorrhagic strokes.
• Morbidity is more severe and mortality rates are higher for hemorrhagic stroke
• Morbidity is more severe and mortality rates are higher for hemorrhagic stroke
• 80% of strokes are ischemic.
• The 30 day mortality rate for hemorrhagic stroke ranges from 40 to 80%.
• Approximately 50% of all stroke deaths occur within the first 48 hours.
• Ischemic stroke can be reduced by using aspirin or related compounds which inhibit platelets from aggregating and forming obstructive clots.
• However this same treatment intervention may increase the likelihood and effects of hemorrhagic stroke.

Question 34

Review signs and symptoms of meningitis..

The classic triad Dx

Answer 34

The classic triad Dx=> nuchal rigidity, sudden high fever, and altered mental status.

Young children often exhibit only nonspecific symptoms such as irritability, drowsiness, or lack of appetite.

In adults, the most common symptom of meningitis is a severe headache, occurring in almost 90% of cases of bacterial meningitis, followed by nuchal rigidity (the inability to flex the neck forward passively due to increased neck muscle tone and stiffness).

Question 35

Toxic syndromes due to drug use or overdose:

Dry skin and dry mucous membranes, dry skin, hyperthermia, thirst, constipation, tachycardia, urinary retention, delirium, mydriasis**

Answer 35

Anticholinergic drugs
(i.e. Benadryl)

• *A common mnemonic for the main features of anticholinergic syndrome is: Hot as a hare (hyperthermia), blind as a bat (dilated pupils), dry as a bone (dry skin), red as a beet (vasodilation) and mad as a hatter (deliurm/hallucinations/agitation) and the bowel and bladder lose their tone while the heart goes on alone (ileus, urinary retention and tachycardia).

Question 36

Toxic syndromes due to drug use or overdose:

(SLUDGE)
Salivation, lacrimation, increased urination, increased defecation, diarrhea, emesis, bradycardia, confusion, miosis

Answer 36

Cholinergic drugs

i.e. Organophosphate poisoning

Question 37

Toxic syndromes due to drug use or overdose:

Miosis, depressed level of consciousness, respiratory depression, hypotension, hypothermia, hyporeflexia

Answer 37

Narcotics

(i.e. Oxycontin)

Question 38

Toxic syndromes due to drug use or overdose:

Depressed level of consciousness, respiratory depression, hypotension, hypothermia, hyporeflexia

Answer 38

Sedatives/hypnotics

(i.e. Ambien)

Question 39

Toxic syndromes due to drug use or overdose:

Tachycardia, hypertension, mydriasis, diaphoresis, seizures

Answer 39

Sympathomimetic

(i.e. Cocaine)

Question 40

Antidotes and interventions:

Acetaminophen

Answer 40

N-acetyl cysteine (NAC)

Question 41

Antidotes and interventions:

Amphetamines, cocaine

Answer 41

Benzodiazepines

Question 42

Antidotes and interventions:

Aspirin

Answer 42

alkalinization of urine with IV sodium bicarb, hemodialysis

Question 43

Antidotes and interventions:

Benzodiazepines

Answer 43

Flumazenil

Question 44

Antidotes and interventions:

Beta-blockers

Answer 44

Glucagon, IV calcium, ventricular pacing

Question 45

Antidotes and interventions:

Calcium channel blockers

Answer 45

Glucagon, IV calcium, ventricular pacing

Question 46

Antidotes and interventions:

Carbon monoxide

Answer 46

100% oxygen, hyperbaric oxygen

Question 47

Antidotes and interventions:
Ethylene glycol (anti-freeze)

Answer 47

Ethanol, hemodialysis

Question 48

Antidotes and interventions:

Warfarin (Coumadin)

Answer 48

Vitamin K

Question 49

Antidotes and interventions:

Heparin

Answer 49

Protamine sulfate

Question 50

Antidotes and interventions:

Insulin, oral hypoglycemic agents

Answer 50

Glucagon, IV glucose (D5W)

Question 51

Antidotes and interventions:

Narcotics

Answer 51

Naloxone*

*Naloxone should not be confused with Naltrexone. Naloxone is used in emergency cases of opioid overdose whereas Naltrexone (full strength dosing) is used primarily in the management of alcohol dependence and opioid dependence. Using Naloxone in place of Naltrexone can cause acute opioid withdrawal symptoms. Conversely, using Naltrexone in place of Naloxone in an overdose situation can lead to insufficient opioid antagonism and fail to reverse the overdose.

Question 52

Antidotes and interventions:

Organophosphates (cholinergic)

Answer 52

Atropine

Question 53

Glasgow-Blatchford bleeding score (GBS) is a screening tool to assess the likelihood that a patient with an acute upper gastrointestinal bleeding (UGIB) will need to have urgent medical intervention such as a blood transfusion or endoscopic examination.

Answer 53

Blood Urea
Hemoglobin (g/L) for men
Hemoglobin (g/L) for women
Systolic blood pressure (mm Hg)
Pulse
Melena
Syncope
Hepatic
cardiac failure

Question 54

Glasgow-Blatchford bleeding scoring (GBS)

Answer 54

Scores of 6 points or more on the Glasgow-Blatchford scoring system are associated with a greater than 50% risk of signifigant bleeding that requires urgent/ emergent intervention.

1. A G-B score can be zero if all of the following findings are present:
2. Hemoglobin level: >12.9 g/dL (men) or >11.9 g/dL (women)
3. Systolic blood pressure: >109mm Hg, Pulse:

Question 55

Rockall scoring system:

This system attempts to identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding.

Answer 55

The scoring system uses clinical criteria (increasing age, co-morbidity, shock) as well as endoscopic finding (diagnosis, signs of acute bleeding).

ABCDE - Age, Blood pressure fall (shock), Co-morbidity, Diagnosis and Evidence of bleeding.

Question 56

Advantages of the GBS over the Rockall score:

Answer 56

Assesses the risk of mortality in patients with UGIB, include a lack of subjective variables such as the severity of systemic diseases and the lack of a need for upper endoscopy to complete the score, a feature unique to the GBS.

Question 57

(STEMI)

Answer 57

MI=> ST elevation