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Awesome Review 2021 > General Internal Medicine > Flashcards

General Internal Medicine Flashcards

1
Q

overall prevalence of PAD in pt iwth Age 5-69 with DM.tob/age>70

A

29%

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2
Q

Pt with PAD risk factors and suspect PAD wtd?

A

Ankle brachial index
N- >1
1.3=arterosclerosis

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3
Q

68yo M p.w intermittent claudication of legs - quit smoking 10ya - BP left arm 128/84, BPR R arm 134/82 BP RLE 128.80 - ABI =

A

128/138=0.92

(choose higher UE SBP) LE/UE SBP

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4
Q

If equivocal ABI (0.9->1)

A

Excercise ABI

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5
Q

How to manage PVD

A

modify risk factors (BP, gluc, chol)
Anti plt agens ASA+- palvix
Treat claudication - supervised exc program>cilostazol>pentoxyifylline

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6
Q

Whatd medicatio nused in PAD reduced coronary events regardly of BP effect

A

ACEi

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7
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced overall mortality

A

T

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8
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced vascular mortaility

A

T

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9
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced cornoary events

A

T

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10
Q

DM goals

A

LDL<140/80 with PAD

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11
Q

Pt with sudden onlset pain in foot, discoloration of oot h/o afib - petal and poterior tibila pulses not felt wtd?

A

arteriogram r/o embolic event from afib

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12
Q

Pt wit sudden onset black/blue toes, pulses felt, had cardiac cath earlier and BP elevated wtd?

A

Adequate BP control

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13
Q

Metabolic syndrome

A 
Obestiy waist in males 40" (>35 asian)
35" in femael (31" asian)
TGA
Low HDL 140.85
FBS >100
Tx: Diet, exercise, drugs
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14
Q

Which antilipid medication woudl tx component of metabolic syndrome

A

Fibrate

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15
Q

Obesity leading cause of death in US

A 
BMI
Normal 19-25
overweight >25
Obeste stage I >30
stage II >35
Morbid obesity >40
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16
Q

Complications of obesity

A 
Type II DM
Ca endometrial>breast>postate>colon
ele LDL, TGA dec HDL
inc'd CAD risk, SCD
OA
NASH
OSA
FSG
(NOT OSTEOPOROSIS - protective)
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17
Q

45yo F gaining wight - BMI 31 FBS 105 wtd?

A

reduce caloric intake 500 to 1000 cal/day

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18
Q

Pt BMI 32 on red caloric intake 3 months later with BMI 31 - what med for long term use

A

Orlistat
Lorcaserin
Phentermine topirate

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19
Q

Indications for bariatric surgery

A

BMI>35 with DM/hyperchol or HTN or CHF or OSA

BMI>40 with no other conditions

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20
Q

Bariatric surgery reduces mortality?

A

T

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21
Q

Post gastric bypass surgery - next day with horizontal nystagmus and opthalmoplegia dx?

A

Thiamine deficiency

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22
Q

Post bariatric surgeryc/o wk and dark colored urine, tenderness of back muscles - U dip stick + blood no RBCs dx?

A

Rhabdomyolysis

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23
Q

Post bariatric srugery 3 days later with tachcardia nad tachypnea

A

PE

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24
Q

Post gastic bypass 2 days later with RR 22, HR 120, tmep 100.8 dx?

A

Anastomatic suture /stable leak - gastrograffin study needed

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25
Q

Long term deficit post bariatric surgery

A

Vit D, B12, copper, iron

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26
Q

38yo F BMI 40 bariatric surgery 5ya fo rphysical - Hg 10.5, MCV 105 plt 115, retic 1%

A

check B12/cyanocobalamin

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27
Q

34yo F roux en y surgery 8 monts ago - BMI dropped 40 to 28 - now BMI up to 35 - c/o heartburn

A

dx? Gastrogastic fistula

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28
Q

35yo F post bariatric surgery BMI 40-25 in 6 montsh - no ids - nauseous and bloating wtd?

A

preg test

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29
Q

Waist to hip ratio >0.9 in men >0.85 W risk factor

A

at any rate

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30
Q

Inc’d waist to hip ratio considered CAD risk factor in what grop of patients -

A

older age

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31
Q

Exc a/w

A 
protection against CAD
dec'd LD, TGA inc HDL
improved gluc tol
reduction of weight, BP, stress
red'd mortality from all causes
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32
Q

Pt s/p IWMI d/c’d with AS B blocker, ACEi and statin - what else would dec mortalty

A

exc 1hr day, 5 days / week (not just 3 days 1/2 hr)

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33
Q

Pt p/w fahes or streak of light shows, black dots, wavy curtain - cobwe always movee whereever pt looks - initally with normla visual acuity - fundoscopy with retina appearing folded/elevated wtd?

A

retinal detachment - Urgent opthal eval for laser tx

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34
Q

Pt with afib sudden onlset painless vision loss in one eye - fundscopy CHERRY RED SPOT IN MACULA etio?

A

retinal artery occlusion

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35
Q

60yo with waldenstrom’s macroglobulinemia, HTN or P vera with sudden painless los of vision one eye - fundopscopy with multiple hmorrhages - thunder & clouds dx?

A

retinal vein occlusion

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36
Q

Elderly man with blurry vision in CENTER, peripheral vision spares - fundscopy with yellow spots (druzen dx?

A

Macular degeneration - tx

tx: quit smoking anti oxidant vitamins

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37
Q

Pt going for cataract surgery taking ASA or warfarin or plavix wtd?

A

continue ASA/warfarin

d/c tamsulosin (avoid floppy iris syndrome)

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38
Q

Young woman with blurry vision esp after excercise - regains vision gradually - wtd?

A

T2 MRI r/o Multiple sclerosis

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39
Q

Optic nerve infarction

A

temporal arteritis

tx: steroids

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40
Q

Pt with long standing DM, mild vision, fundscopy -> aneurysms with hemorrhage and exudates

A

non-prolif retinopathy (backgroudn) with macular edema

TIGHTER glucose control

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41
Q

Pt with long standing DM with blurry vision Fundscopy->neovascularization

A

dx: prolif DM retinopathy

tx; lasery therapy - periphera nd night vision decreased but central vision spared

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42
Q

Pt with HgA1c of 7% has laser tx for DM retinopathy no response - wtd?

A

Tighter glucose control

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43
Q

Pt with r eye pain, facial pain, n/v/ h/a blurry vision - R pupil dilated, sluggislhy reactive - ciliary flush hazy cornea with congestion

A

Glaucoma

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44
Q

25yo F dec’d vision in L eye with pain - paraesthesia in feet

A

Optic neuritis

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45
Q

Elderly man with progessive loss of central vision - edge of door hazy

A

macular degeneration

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46
Q

Sudden loss of vision in one eye, fundoscopy Cherry red spot

A

retinal artery occlusion

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47
Q

Sudden oloss of vision in one eye fundoscopy multiple hemorrhages and exudates

A

retinal vein occlusion

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48
Q

New monset shower of floaters with flashes of light and cobweb

A

retinal detachment

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49
Q

Magnifying glass

A

macular degeneration (also anti-oxidant vit’s and quit smoking)

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50
Q

Crystals in retinal artery (Hollenhorst plauques)

A

Cholesterol emboli

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51
Q

Pt with intermittent visual loss - fundscopy with crystals in retinal artery wtd?

A

Carotid duplex US

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52
Q

test to establish infective endocarditis

A

Blood ctx

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53
Q

60yo pt wit difficulty driving at night from glare from oncoming cars - diff reading road signs and fine print - dx?

A

Cataract

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54
Q

Pt with cataract surgery one week ago with eye ache and decreasing vision - otherwise well - afebrile - injected conjunctivea - layer of WBC in anterior chamber slit lamp with intraocular WBC - COTTON WOOL SPOTS - dx?

A

endopthalmitis

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55
Q

Conjunctivitis

A

Viral - adneovirus
Bacterial
Allergic
Tx - cool compression or abx or anti-histamines

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56
Q

Pt pw conjunctivitis with serous d/c - prescripbed abx eye drops - 4th day is worse - dx?

A

allergy to drops

tx: d/c drops

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57
Q

Red eye with itchiness

A

allergic conjunctivitis

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58
Q

Pt with red eye with graves or RA with dry eyes and gritty sensation

A

Keratoconjunctivitis sicca

tx: artificial tears

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59
Q

Red eye with pain and photophobia, constricted irregular pupil - ciliary flush normal cornea and normal intraocular pressure - slit lamp - WBC in aquous humor or on corneal epithelium - consensual eye reflex with pain dx?

A 
Iridocylitis (Anterior uveitis)
Emergent referal to opthalmologist
intensive topical steroid to reduce inflammation
cycloplegics to prevent synechiae
tx underlying dz
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60
Q

Pt with red eyes and foreign body sensation with pain - corneal exam with DENDRITIC ULCER - branchign - fluorescin stain +

A

HSV I keratitis

Tx: topical triflurodine (no acyclovir)

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61
Q

Pt intubated on mechanic vent wit one eye redness - cornea white

A

Pseduomonas keratitis
Tx: topical antipseduomonal
IV anti-pseudomonals

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62
Q

Pt with contact lense develops conjunctivitis

A

Pseudomonas keratitis

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63
Q

Glaucoma

A

inc’d intraocular pressure- progressive visual loss 2/2 optic nerve damage
Complication - gradual loss of peripheral vision

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64
Q

Open ange glaucoma

A

gradual loss of peripheral vision
Cup to dis ratio >50%
Inc’d incidence in AA’s

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65
Q

45yo F pw/ R eye pain and temporal headache - exam with conjunctival inection in R eye and vision 20/200 - pupil mid-dilated, fixed, non-reacitve wtD?

A

urgent referral to opthalmologist - before tx - give PIOLCARPINE drops

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66
Q

22yo p/w ER with teary eyes - hit in eye with paintball - exam with mid conjunctival injection pupillary refelx normla vision normal Slit exam with linear abnormality wtd?

A

No therapy f/u PRN

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67
Q

Pt p/w teary eye - pupillary refle normal wood lamp after fluorescin patttern of parallel lines of vertical abrasion - vision normal wtd?

A

every eyelid and remove foreign body

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68
Q

High velocity and insdustrial injury with hyphema (blood in anterior chamber

A

urgent referral to ophthalmologist

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69
Q

Pt witih conjunctiviti - exam layers of WBC in anterior chamber

A

refer to ophthalmoligst
Hypopyon - lyering of white cells in anterior chamber
Coudl be ophthalmitis or keratitis - urgent referral needed

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70
Q

Pt with cough - exam with redness in conjunctiva - wtd?

A

nothing - subconjunctival hemorrhage resolves spontaneously in 1-2 weeks

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71
Q

Pt with diplopia of a few days duration with h/a - on exam lookign stright left is inward and right eye is also slightly inward - dx of b/l lateral rectus palsy made - dx?

A

cavernous sinus thrombosis

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72
Q

Cellulits of periorbital area with warth swelling around eye wtd?

A

CT/MRI - orbital cellulitis-> cavernous sinus thrombosis

tx: IV anti-biotics

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73
Q

Pustule on lid margin

A

Stye

tx: warm compess - may need surgery

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74
Q

Vascular structure in conjunctiva - can spread to cornea and impair vision

A

dx: pterygum
Tx: surgery

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75
Q

Inflammed eyelid

A

blephritis

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76
Q

small nodule under tarsus

A

Chalazion
etio obstruction of meibomian gland -
Tx: warm compress - surgery may be needed

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77
Q

AIDS pt with blurry vision - fundsocpy with cheese, ketchup appearance

A

Dx: CMV retinitis
tx: gancyclovir

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78
Q

How to manage otitis media

A

Amoxicillin

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79
Q

Pt with recurrent chronic ear infection p/w d/c and MASS out of tympanic membrane - hearing loss on that side - dx?

A

Cholesteatoma

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80
Q

Pt with c/o hearin gloss - esp in crowded area - wtd?

A

2 feet whisper test

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81
Q

If 2 feet whisper test abn - tuning fork at mastoid with no response - tunign for at forehead no response dx?

A

b/l presbycusosis

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82
Q

30yo F with gradual hearing loss - whisper test abn, can hear better with tuning fork at mastoid process than near ear - keeping tunign for at forehead with better hearing in both ears - dx?

A

b/l otosclerosis
(abn growth of bone in middle ear - conductive hearing loss)
fixation of stapes bone
Tx - surgery

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83
Q

Pt with hearing loss in R ear - webber’s test localizes to R ear - exam with obstruction of typanic membrane by cerumen wtd?

A

Webber test - tuning fork on forhead
Normal = hearing same both ears
If defective ear hears sound louder - CONDUCTIVE hearing loss
If normal ear hears sound better than SENSONEURAL hearing loss
RHINE test - first tuning for on mastoid bone - when can’t hear that tuning for in front of canal - normal(or sensoneural) if Air conduction (AC) louder than bone conduction (BC)
If BC>AC then conductive hearing loss

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84
Q

Pt pw c/o discarhge from R ear - exam with pain on pulling ear up and out - d/c and debri in ext auditory canal and partial obsstruction of typmapinc membrane dx?

A

Swimmer’s ear

Tx: poymyxin drops

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85
Q

Pt with otitis externa in DM - red ear

A

malignant otitis externa

cover with 2 anti-pseddoonal abx - ceftazidime and amikacin/tobramycin

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86
Q

Pt going for surgery - pt has LBBB and asx wtd?

A

clear for surgery

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87
Q

Pt with severe PVDz going for vasc surgery or aneursym repair - wtd prior to OR

A

thallium or dob stress

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88
Q

Pt for elective surgery - multiple PVCs asx no evidence of ischemia

A

Clear for surgery

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89
Q

70 HTN OA going fo rhip replacement

A

Clear for surgery

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90
Q

Pt with colon CA going for colon surgery father MI 49 wtd?

A

Clear for surgery

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91
Q

Pt with CABG 7ya with occasion CP on exertion schedule for urgent AAA 7.5cm in AM - abd tenderness and pulsatile mass wtd?

A

Emergency surgery - high risk - clear fo rsurgery

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92
Q

After MI when should elective surgeries be done?

A

6 months

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93
Q

Pt with stable angina going for surgery wtd?

A

c/w angina meds pre and post surgery

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94
Q

Pt post op after CABG in CCU with confusion, disoriented, doesn’t follow commands inattentive pulling ET tube HR 100 wtd?

A

haldol

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95
Q

What med can cause delirium in elderly during post op period?

A

Meperidine (demerol)

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96
Q

Pt in recovery room and BP 160/104 not known HTN

A

morphine sulfate for adequate analgesia (pain causing htn)

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97
Q

Pt with severe abd pain - xray with air under diaphragm - c/s for learance - while doing consult pt vomints and becomees bradycardic - EKG HR 48, some non-conducted p-waves and 1mm ST dep

A

Inc’d vagal tone from vomiting - clear for surgery

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98
Q

What has been shown to decrease risk of perioperative complications?

A

Lugn exapansion interventios (incentive spirometry, deep breathing, CPAP)

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99
Q

What is recognied as risk factor post non cardiac surgery

A

inc’d tropoinin T levels < 72hrs after surgery

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100
Q

40yo F s/w PNA - next mornign see’s “little green ppl
Or 40yo M a/w GIB see’s “spiders on ceiling” exam afebrile HR 84 bp OK - Mild tremulousness - fhx etoh abuse - thiamine give dx?

A

etoh hallucinations

DT with inc HR/BP

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101
Q

Pt had urgent surgery yesterday today oriented x 2, temp 101, HR 105 mild tremor dx?

A

etoh withdrawal

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102
Q

Pt with anxiet, tremors confusion HR 104, BP 150/92 deslusional and seizure

A

Delirum tremons -

Tx Diazepam, lreazepam phenobarb - propofol

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103
Q

54yo chornic alcoholic to ER with confusion ataxia nystagmus diplopia

A

Wernickes encephalopathy

Tx FIRST thiamine then glucose

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104
Q

Chornic alcoholic with anterograde and partial retrograde amneis - confabulatory speech

A

Korsakoff psychosis - poor prognosis

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105
Q

Pt with SOB, tach and bounding pulse - CXR cadriomegaly

A

thiamine def - high output cardiac failure (beri beri)

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106
Q

Pt with h/o etoh in hosptial - gets thiamine, glucose and is fed wel - 5 days later uscular weaknes - sob - CPK inc’d Hg dec reti ct inc’d

A

Refeeding syndrome - hypophosphatemia

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107
Q

Chornic etoh wit muscle sapsms - serum ca low, K low wtd?

A

FIRST give magnesium then K/Ca+

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108
Q

Pt underoes surgery - post op seizure tachy, consfused tachypnic

A

etoh withdrawal

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109
Q

Lifetiem incidence etoh abuse and drug abuse

A

20%

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110
Q

etoh abuse screening

A

Cage, AUDIT, 4 drinks on one occsion in men (3 in F)
C - cutting donw
A - annoyed
G - guilty
E eye opener?
Addressing etoh - SBIRT - screeing brief intervetion referral fo rtx

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111
Q

Etoh abuse

A

Problems - failures to fulfil work/school oblig, use in hazardous situation, legal proglems with etoh use - constineud use despote social problems

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112
Q

etoh dependence

A

keeps drinking - work/social school oblsigations sacrified - tolerance - needs more and more
desire to cut down but continues
withdrawal sx if stops

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113
Q

Pt p/w routine checkup - depressed - inc’d MCV, inc’d GGT - what wil establish chronic eetoh abuse

A

inc’d carboydrate free transferrin

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114
Q

Etoh abuser on sidewalk to ER pain in legs no back pain exam wk fo foot and dec’d ankle jerk - dx?

A

etoh neuropathy

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115
Q

MCC death etoh abusers

A

heart disease

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116
Q

All true about alcoholism

A

inc’d malignancy incidence
inc’d MVA
inc’d suicides and drug OD
inc’d STDs

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117
Q

Best drug to tx etoh addiction in addition to support goups?

A

Naltrexone

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118
Q

Pt with normal FBS - white/gray spots on conjunctiva dx?

A

Vit A deficiency

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119
Q

Pt taking multiple vitamins p/w dizziness, hza, abd pain n/v elev LFTs Ca 10.7, xerosis of skin dx?

A

Vit A toxicity

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120
Q

Pt with nausea labs Ca 11, fundsocpy blurring of disk margin - pt takes multiple vitamins dx?

A

Vit A toxcity

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121
Q

Pt lives on tea and toast diet pw bleeding gums - perifollicular hemorrhage and non-healing ulcer - coages, plts’ normal dx?

A

Vit C deficiency - scurvy

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122
Q

PP+ pt on INH pw pin pricks and tingling on legs - low MCV

A

Vit B6 def - inc’d homocystine

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123
Q

Pt taking multiple vitamins with HEADACHES - fundoscopy papilledema

A

Pseduotumor cerebri

etio? Vit A intoxication

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124
Q

50yo chronic etoh with sensory ataxia with romberg +, deemntia dec’d proprioception, spasticity optic neuropathy but normal pin pricke

A

Dx: subacute degen of cord 2/2 vit B12 def

elev MMA

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125
Q

Pt takes multiple vitamins p/w nausea, anorexia fatigue sever constip - MM dry Ca 11.3, pho 5.2 dx?

A

Vit D intoxication

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126
Q

Pt with dementia diarrhea dermatitis

A

Pellagra (niacin) deficiency

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127
Q

Diarrhea and LINEAR VERTICAL LINES on nails

A

Arsenic posoning

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128
Q

Pt wit hlong ICU stay on TPN with ALOPIECIA, hyeprkeratotoic rash, anemia, LOSS OF TASTE

A

Zinc deficincy

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129
Q

Post surgery NPO on IVF with inc’d PT etio?

A

Factor VII def

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130
Q

Pt post surgery in ICU with nausea is given phenothiazine - next day horizontal nystagmus ophthalmoplegia dx?

A

Wernicke’s encephalopathy

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131
Q

Cheilosis, glossitis, dermatitis

A

Vitamin B2 def (riboflavin)

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132
Q

Iodine

A

goiter or hypothyroid

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133
Q

Bleeding diathesis

A

Vit K def

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134
Q

Cardiomyopathy, CHF

A

Selenium
hypophophatemia
Thiamine

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135
Q

Anxiety d/o

A 
Panic d/o
GADisorder
Phobias
Obsessive compulsive disorder
Post Traumatic disorder
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136
Q

Discrete period of intnese fear and anxiety, womatic sx SOB palpitations, trembiling diaphoresis ches tpain discormfort - click+MVP

A

Panic d/o

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137
Q

Percieved difficult to escape situation

A

Agoraphobia
TCA/SSR
benzo - short term

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138
Q

Excessive anxiety ou tof proportion of fear to impact of fear event

A

Gen anxiety d/o
Tx: buspirone
cognitive behav therapy

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139
Q

40yo F with complaints of CP, palptiatons diaphoresis and numbness while watching movie/concer - happened couple times before EKG normal wtd?

A

start benzos and re-eval in 2 weeks

tx: SSRI

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140
Q

Pt with feeling of vibration sense inside body - has CP, palptiations, SOB - exam mid systolic click - dx?

A

Panic attack

Tx: Paroxetine

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141
Q

Persistent distressing thought -> obsession

Repetive response to the persistent thought -> compulsion

A

Dx. Obesessive Compulsive disorder

Tx: Fluoxetine, Fluvoxamine, Clomipramine (TCA), behavior modification

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142
Q

Fear of public speaking with sweating and trembling

A

Phoic situation
tx: B Blocker
TCA

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143
Q

Vietname vet - saw friends die - pw nightmares, avoidance of remnder of even, flashbacks intrusive memories

A

Dx: PTSD
tx: Psychotx, SSRI

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144
Q

Young woman witih multiple complaints multiple organ systems >8 - exam NO macthcing physical findings to sx

A

Dx: Somatization d/o
tx: - PCP, psychiatrist - monthly appt with PCP for reassurance and dec of utilz of health care resources

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145
Q

Pt with alteration or loss of physical fxn wihtout pathologic basis - pt is unawar - not concoiously producing sx -

A

dx: conversion d/o
Tx: usually responds to suggestive therapeutic modality

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146
Q

Young woman of high socioeconomic status related to health care field with h/o emtional trauma p/w deliberate production of signs and sx

A

dx: Factitious d/o

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147
Q

A man of low socioeconomic status with deliberte production of signs and symptoms pathologic lying and wandering

A

Munchausen’s

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148
Q

Intentional prodxn of signs and sx for SECONDARY gains. Such as avoiding military duty or court case etc

A

malingering

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149
Q

Physical findings dont’ match multiple complaints

A

Somatization

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150
Q

Doctor shopping and high utilization of health care

A

Somatization

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151
Q

Needs PCP q1month appts

A

Somatization

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152
Q

Weakness one side of body but w/u normal with MRI

A

Conversion d/o

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153
Q

Young white femail nurse deliberate prodxn of sign’s and sx

A

Facticious d/o

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154
Q

Factious d/o with pathologic lying and wandering

A

Muchausen

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155
Q

Exaggerated sx compared to physical exam - pending court case or military service

A

Malingering

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156
Q

Depression

A

depressed mood
loss of interest in pleasurable activities
wt loss/gain
Insomnia or hypersomnia
Fatigue
Diminshed ability to concentrate
Sx >2 weeks=depression
If sx after death in family and sx < 2 months - bereavement
> 2 years - dysthymic
If abv sx with delusions/hallucinations - depression with psychotic features

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157
Q

Depression

A

MCC suidcide
Tx with any antidepressant - 4-9mo
HOw soon see response - 2-6 weeks
When to switch if no response - 6-8wks
Recurrent > 2 episodes of depression - 2 or more years
When stopping drug - taper it
Psychotx - Cognifitive tx - Thought->emtion-behavior
Interpersonal tx
Don’t go from SSRI-> bupriopion (ok other way around)

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158
Q

Mcc suicide in US

A

major depression

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159
Q

Depression

A

anti antidperessant

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160
Q

Enuresis

A

Imipramine (TCA)

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161
Q

Panic d/o

A

Alprazolam SSRI

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162
Q

Obsessive-compulsive d/o

A

Fluoxetine
Clomipramine
Fluvoxamine

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163
Q

Chronic pain+- depression

A

Amitriptyline

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164
Q

Smoking cessation

A

nicotine replacement->bupropion->vareniciline

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165
Q

Insompnia

A

Amitrptyline, trazadone

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166
Q

Overdowse with low lethal potentila

A

citalopram (SSRI)

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167
Q

45yo M pw depression - stated on fluoxetine and starts to feel better in 3 weeks how long to continue

A

4-9 months

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168
Q

83yo F awake, doesn’t respond to stimuli x few months - refelxes/power intact dx?

A

depression

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169
Q

Terminally ill pt with lung CA depressed, loss of appetite - loss of interest in life wtd?

A

Methyphenidate - elevates mood w/in days and can be used with other anti-depressants which take weeks

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170
Q

Drug-drug interactions

A

MAOI

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171
Q

HTN crisis

A

MAOI (Phenelizine, selegilen)

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172
Q

Orhostatic hypotension

A

TCA (imipramine, clomipramine, amitrypyline, nortriptyline)

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173
Q

Antichol s/e (dil pupil, tachy, dry secrtions)

A

TCA

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174
Q

sexual dysfxn

A

SSRI (fluoxetine, citalopram, sertraline

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175
Q

Least sexual dysfxn

A

Bupropion

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176
Q

Avoid in anemia

A

SSRI/Buproprion

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177
Q

Avoid in Bulimia

178
Q

Tx Bulimia

179
Q

62yo M HTN depression tx’d with BB and fluoxetine - alwso vitamins pw dec’d erections aunable to have orgasm for few moths wtd?

180
Q

SSRI s/e

A

1-4 wks - Suicidal ideation - d/c or consider other drug
2-6 weeks - restlessness/akastheisia - switch drug or add benzodiazipine
2-4 wks angry outbursts/lack of sleep, silliness gigling (in bipolar d/o - change to lithium or mood stabilizer

181
Q

Pt started on SSRI with cloudy urine dx?

A

retrograde ejaculation

182
Q

Electroconvulsive therapy for…

A 
Refractor depression
Psychotic fts
Suicidality
Catatonic stupor
S/E - acute confusion, sz
long term - impaired memory
Relative contraindic - recent MI, aneurysm, CHF, COPD
183
Q

Stop bupropion in

A

Mania state

184
Q

Biplar d/o

A 
Manic depressive - lamotrigine
Manid/hypomanic
euphoria
inflated self esteem grandiosity
decreased need for sleep
tx: lithium, valproic acid/atypical antipsychotic
185
Q

22yo started on fluoxetine for depression now starts playing music all night wtd?

A

d/c SSRI, start lithium or olanzapine

186
Q

S/E lithium

A 
Diabetes insipidus - impaired renal concetration
hypothyroid
hyperCa
Hand tremors
Toxicty 1.5-2
N/V
slurred speech
nstagmus
ataxia
>2.5
Fasciculations
Delirium
Coma/death
187
Q

Antipsychotic agents

A

Typical
Phenothiazine - chlroopromazine, fluphenazine, thioridazine
Non-phenothiazine - haldol, loxapine
Atypicals
Cloazapine, (most efficacious, agranulocytosis)
Olanzapine - inc’d blood sugar, inc weight
quetiapine - well tolerated
Risperidone - use in elderly

188
Q

Pt on paroxetine and olanzapine for major depression develops increasing blood sugears etio?

A

Olanzapine

189
Q

Side effects of typical agents

A

Acute dystonic rxn - tx diphenyl hydramine/benztropine
Akastheisa - motor restless, wantering - tx - dec or d/c drug
Tardive dyskinesisa - smaking lips/tonue
Neuroleptic malignant syndrome - cool down, dantroline
prolonged QT interval

190
Q

Pt with hallucinations, smaking lips, says he takes nerve pills not sure what d/o - dx?

A

Schizophrenia

191
Q

Pt has not been taking her meds - moves in with her son 6 months later says daughter in law trying to kill her - on exam smaks lip and tongue - etio?

A

Phenothiazine that she used to take 6mo ago - paranoid schizophrenia

192
Q

Pt with schizophrenia develops parkinson’s dz - develops psychosis - refuses blood tets because of needle sticks

A

Quetiapine

193
Q

Pt with parkinson’s dz, dementia, BPH and glaucoma becomes agitated and confused - best anti-psychotic

A

Quetiapine

194
Q

Hyperthermia with mental status changes, tremor and autonomic instability (inc’d HR, dec BP, n/v/d) and hyperreflexia

A 
Serotonin syndrome (SSRI+MAOI, SSRI+linezolid)
D/C med and start benzo o
195
Q

Hyperthermia with mental status change, autonomic dysxn with LEAD PIP RIDIGIDY and rhabdomylysis

A

Neurolptic malignant syndrome - phenotiazine +- haldol

Tx: bromocryptine or dantrolene

196
Q

Hyperthermia with sustained muscle contraction, HTN, diff ventillating patient with sudden inc in end tial CO21 - CPK inc’d fhx of sudden death or fever on table during anesthesia

A

Neuroleptic malginant syndorme (inhalation anestetics

tx: rapid cooling/dantrolene

197
Q

Pt with hyperthermia, delirium HTN, tachcardia and diaphresis dx?

A

sympathomemetic crisi (amphetamine+cocaine, rx diet pills

198
Q

Hyperthermia with mental status changes, tachycardia, dec’d bowel movements and urinary retention

A

antichoinergic delirium (antihistamine/TCAs)

199
Q

69yo F husband passed away 2 years ago now lives along several meds including ambien 10g daily - appears confused and period of not routable CT head neg - likely cause?

A

Drug induced

200
Q

Pt with depression - takes ambien fo rinsomnia - on exam amnesia and confused

A

D/C ambien

201
Q

70yo M wife died couple years ago - loss of appetite, weight last 6 months - hearing voices or seeing thigns on wall dx?

A

Depression with psycotic features

202
Q

70yo wife a couple yrs ago - loss of appetite/weight loss for last 6 months - pt says he sees her when he closes his eyes and frequnetly wakes up - does not indulge any pelasurable acitviiteis dx?

A

Complicated grief

203
Q

Borderline perosnality d/o

A

instability in self image, mood state, interperonsl relationship impulse control
social history many stormy relatinship
awknowldeges chornic anger control issue
marked swings in mmod thru day
at one moment frien or parted viewed as trusted then curel or betraying

204
Q

Best management for pt with borderline personality d.o

A

Behavioral psychotherapy

205
Q

Anorexia

206
Q

Bulimia

A 
not < 15% of ideal body weight
eat and purge - vomiting -> laxatives
called on knuckles, submandibular LN+
Parotid enlargement, loss of inner dental enamel
esophagitis
low Cl low K and metabolic alkalosis
Urine Cl very low
207
Q

Young woman with new onset UGIB at party - Na 136, K2.7 Cl 80, bicarb 35, BMI 24 dx?

A

Bulemia (GIB from vomiting)

208
Q

How to treat Bulimia

A

psychotherapy

Fluoxetine

209
Q

38yo woman on various antidepresants and analgestics for pain, consumes several extra pills of one of her meds, on arrival to the ER she is awake, soon after gets hypotensive, tachy and then seizure - tele shows widened QRS, ABG respiratory acidosis pt took what?

A 
TCA
Methadone (check QT interval)
210
Q

50yo brought with overdose of hypertension and angina meds - took 30 pills metoprolol BP 70 HR 35bpm with AV blcok - atropien and IVF not much change wtd?

A

glucagon - inc contractility of myocardium

epinephrine gtt

211
Q

Pt took OD of CCB - BP 80 systolic - HR 42/min started on IVF bolus and atropine what else to give pt -

A

CaCl - counteract peripheral vasodil effects of CCB

212
Q

Pt pw inc’d SECRETION, drooling, profuse sweating, n/v/SOB, tremors, fasciulations - exam pupils consdtricted HR< 50 what is poisoning

A 
organophosphorus
dx test - RBC Acetylchoinesterase level
tx: remove contaminated clothing
activated charcoal
IV atropine
IV pralidoxime (muscularic rct - blocks rcts)
213
Q

Pt and family feel tired, fatigued and somnolent - pt goes out and shovels the snow and feels better dx?

A

CO poisoning - call EMS and gt whole family out of house

214
Q

Firefighter brought after fighting fire - ABG 94% on 40% venti - soot in nares pt intubated - what FIO2 required -

215
Q

Heroin addict or pt on morphine or codeine develops URI with profuse lacrimation, sweating rhinorreha, yawing restlessness and diarrhea

A

Dx: opiate withdrawal
Tx: methadone

216
Q

24yo pt back from party agitated, talking fast but fluent - acting paranoid, diarphoretic, HR and BP up, low grade temp burn on oral mucosa, poor dentition, picking skin hyperreflexia exoriations on skin

A

Meth/speed (methamphetamine

217
Q

24 yo pt back from party agitated - has seizure - +diaphoresis elev tmep/HR/BP - hyperreflexia

A

MDMA (ecstasy)

218
Q

24yo pt agitated after party not following commnads - diaphoresis, elev bp, temp, hr hyperreflexia Na 124

A

MDMA (ecstasy)

219
Q

Fever

A

MDMA and meth

220
Q

HTN

A

MDMA and meth

221
Q

tachy

A

MDMA and meth

222
Q

Hyponatremia

223
Q

agitated, psychotic but alert

A

meth/speed

224
Q

agitated mental status change

225
Q

Skin pickering

226
Q

Oral musocsa burns

227
Q

mydriasis

A

meth and MDMA

228
Q

hyperreflexia

A

MDMA and meth

229
Q

serotonergic and SIADH

230
Q

Your pt is receiving morphine sulfate and benzos for leg pain from an injury - agrees not to abuse drugs - urine tox 3 mo later - benzos, opiates, cocaine, marijuana + wtd?

A

taper benzo d/c morphine

231
Q

80yo F h/o depression tx’d with imipramine and haldol now a/w delirium neck ridgidty, spasiticty - elev BP/HR - NMS

A

tx: dantrolene

232
Q

Most CC admission to hospital in elderly

233
Q

Delirium

A 
Flucuating course of inattention and altered conciousness
Etio - s/e poly pharmacy
meperidine, morphine
Fever, met abn, elect distrubance
hypoxia,
Med/surg pt >65
etoh withd
antichol/anti histamines
antidepressants
alzhiemers meds
sedatiems (ambine)
Tx: correct underlying cuase
234
Q

72yo F episodes of inattentiveness and cnosulion esp at night - takes enalapril and diphenyhydramine - etio?

A

diphenylhydramine

tx: d/c drug

235
Q

T/F delirium in hospital related to inc’d mortality

236
Q

T/F delirium in hospital related to inc’d dementia

237
Q

T/F delirium in hospital related to inc’d institutaionalization

238
Q

Pt post hip surgery 2 days later, awake till 2am andconfused - prior to surgery on enalapril MVI, lipitor, lorezepam - post surgery meds for BP and HLD restarted etio of confusion?

A

Lorazepam withdrawal

239
Q

Best tx for insomnia?

A

sleep hydene (no caffine, tempo in bedroom, avoid naps, bed for sex and sleep - fixed bedtime and wakup time)

240
Q

Best med to initiate sleep

241
Q

Dementia

A 
progressive deterioration in cognitive fxn, impaired memory judgement abstract thinking
Dx:
r/o treatable causes
Drugs
Vit B12 def
hypothyroid
NPH
havey metal poisoning (lead)
Infections (syphilis, whipples, lyme's, meningitis
Deg dz
alheimer's
dementia with lewy body (see crazy things like lions/monkeys)
parkinson's
Picks (disruptive behavior)
242
Q

Dementia

A 
dx:
assessing cognifitve status
MMSE - Score >23/30 normal
other screening tests
Clock drawing test
Making change test
Fxn assessment - basic ADLs
eating bathing dressing
Instrumental ADL
complex activities to maintian household - shippping, driving managming finances
243
Q

Ways to decrease falls

A

d/c psychotropic/targeted reduction in meds
Muscle strengthinging / balance exc - tai chi
improved lighting
decrease hazards (rugs)
extra support in toilet/shower

244
Q

Best test to predict mobility and falls

A

Timed get up and go test - arise from chair, walk 10 feet turn around and site in chair
>14 sec high riks for fall
Major predictor for fracture with fall
osteoporosis

245
Q

elderly pt with freq falls - what deficiency?

A

Vit D (check 25,0H vit D level)

246
Q

85yo F in NH trips and falls - uses cane occasionally - wtd?

A

Physical therapy

247
Q

Pt in NH fell and suffered NON-dispaced fem fx of neck of femur wtd?

A

surgery and 3 parallel pins

248
Q

Elderly pt fell and sustained displaced fx of femoral neck, wtd?

A

arthroplasty

249
Q

Pt with displaced fx of neck of femur - meta analysis has shown which procedure had better hip outcomes?

A

total hip arthroplasty (femur+ball + socket)

better than hemiarthropalsty (femur + ball only

250
Q

Intertrochanteric fx ->

A

hip comporession screws

251
Q

T/F elderly pt with acute compression vertebral fx - no advantage of verebroplasty over rehab and analgesia

A

T

If no response to conservative tx - then vertebroplasty

252
Q

elderly pt with hip fx - s/p ORIF - confused and agitated in evenings (sundowning) wtd?

A

atypical antipsychotics (SSRI takes too long)

253
Q

Pt with dementia - can swallow bu teats only half meals - sometimes food in side of mouth wtd?

A

Aid with feedings

254
Q

lower rate of feeding tubes in NH refulects what?

A

values of resident autonomy

255
Q

IN advanced dementia pt who is not eating PEG has shown what?

A

NO change in nutritional status

256
Q

82yo h/o freq falls - BP 140/90 what to d/c ASA or diphenyhydramine?

A

diphenylhydramine

257
Q

Drugs that cause depression

A 
BB
etoh
steroids
psychotropics
Parkinson's
CVA
258
Q

Urge incontince

A

Detrusor overactivity
Tx: bladder training excercise
Anticholinergic (TCA) - oxybutyn, ditropan, detrol

259
Q

Stress incontinence (coughing make pee)

A

Decreased sphincter tone
tx: Kegel excercises - strengthen pelvic muscles
Estrogen cream
Surgery

260
Q

PSA

A

> 18 - finasteride + alpha blocker

<18 - alpha blocker only

261
Q

Overflow incontinence

A 
Urethral obstruction
prostate hyper plasia
Detrusor underactivity
DM neuropathy, MD
Drugs: anticholingerics
Tx: alpha bloccers (terazosin (better with HTN), tamsulosin (causes floppy iris syndrome if taken during cataract surgery)
Cholinergic bethanechol
262
Q

T/F Incontinence is normal part of aging

263
Q

MCC incontinence

A 
Urge Incontinence
Detrusor muscle overactivity
Tx: bladder training excercise
Anticholinergic, oxybutyn, TCA
Surgery
264
Q

Detrusor overactivity

A

Urge incontinence

265
Q

Decreased sphincter tone

A 
Stress incontinence
Decreased sphincter tone
Tx: behavior change
kegel excercise
Surgery (sling)
266
Q

Side effect of anticholinergic

A 
Detrusor underactivity
overflow incontinence
s/e of some meds
passing urine involuntarily without urge to go
tx: benechol
surgery
catheterization
267
Q

Post void normla

A

urge and stress incontinence

268
Q

Post void residual >100mL

A

urethral obstruction and detrusor underactivity (overflow incontinence)

269
Q

Bladder trianing better than TCA (imipramine)

A

Urge incontinence

270
Q

Urodynamic studies

A

urethral obstruction, detrusor underactivity (overflow incontinence)

271
Q

Response to prazaosin or finasteride

A

Urethral obstruction

272
Q

Responds to B adrenergics (bethanechol)

A

Detrusor underactivity - overflow incontinence

273
Q

Timed bathroom visits and diapers

A

Urge incontinence

274
Q

Oxyburtynin, tolterodine

A

Urge incontinence

275
Q

78yo F CVA with independent ADLs including toileting aw PNA - pt confused restraints applied - diazepham for sleep - now INCONTINENT of urine

A

Functional incontinence

276
Q

67yo F DM urge to urinate every 30-60 min - leaks urine in dres - started wearing diaphers

A

urge incontinence

277
Q

94yo F in NH back after hip surery takign tylenol and codeine - MS intact - upset that is leaking urine and smells - never had this before

A

Overflow incontinence

278
Q

80yo M in NH dx with depression and started on desipramine (TCA) 2 weeks later pt smells of urine

A

dx: overflow incontinence

Chagne TCA to other class

279
Q

67yo F no DM hasurine leadage - has to use bathroom with inc’ing freq including gtting up at night - no dysuria or fever wtd?

A

early morning urinalysis - u/a r/o UTI

280
Q

65yo M sx BPH - BP 90/65 tx?

A

tamusulosin (better with low BP) alpha blocker

281
Q

65yo M BPH BP 140/85

A

terazosin (ok if BP ok - lowers BP) alpha blocker

282
Q

BPH + hematuria

A

finasteride

283
Q

Pt wakes up every morning with strong urge to urinate - by the time goes to bathroom - she is incontinent - she does not take any meds except DIPHENYHYDRAMINE for sleep

A

d/c diphenyhydramine (overflow incontinence)

284
Q

Pressure ulcer

A

Stage 1 - skin intact, non-blanchable rednes
tx: positioning and support
Stage 2 - shallow ulcer red pink with wound bed
Tx: occlusive or semipermeable dressing tha tmaintains moist wound environment
Stage III - full thickness tissue loss - SQ fat may be visible but no visible bone, tendon, muscle
Tx: debridement and Abx as needed
Stage IV - Full thickness tissue loss with exposed bone tendon or muscle
Tx: debridement and abx as needed

285
Q

Drugs to avoid in pregnancy

A 
Valproic acid
ACEi
Cipro
Methimazole (1st trim only avoid)
Radio Iodine 
Anti histamines
Warfarin 5mg or more (nasal hypoplasia)
Nitroprusside
Aminoglycosides
Doxy/Tetra
286
Q

Drugs safe in pregnancy

A 
Carbamazepine (se neutropenia, SIADH)
Mg Sulfate
Latetolol
Furosemide
alpha methyl dopa
Hydralazine
Nitrofurantoin
Amox
Ampicillin
PTU 
Hydroxazine
Chlorpheniramine
Heparin
Clnidine, BB
CCB
Procainamide
Gentamycin
B lactams
287
Q

Preg Pt with asx bacturia

A

Treat (ampicillin / nitrofurantoin NOT bactrim or cipro)

288
Q

Preg pt with detnal caries and ache - abx?

289
Q

Pt with post partum fver and chills

A

r/o post partum endometritis

etio GBStresp - MCC mortality a/w preg in US

290
Q

Will immune globulin prevent rubella?

291
Q

Preg woman exposed to…

A

Hep A -> immune globulin
Hep B -> Bep B immune globulin
Measles Immune glboulin w/in 1 wk
Varicella - varicella immune globulin wi.in 10 days

292
Q

Can preg pt get Hep B vaccine

293
Q

What vaccines contraindicated in pregnancy

A 
Live vaccines
MMR
Varicella
Oral Polio
Fever
294
Q

Can lactating woman receive vaccines?

295
Q

Pt visits 3rd world country comes back with jaundice - hep A/B neg wtd?

A

Hep E serology 20% mortality

296
Q

Can HIV mother breast feed?

297
Q

Can you treat LTBI/PPD in preg woman?

298
Q

Can you tx MTB during preg?

299
Q

When can 60yo get herpes vaccine

A

When on steroids and methotrexate

300
Q

22yo RA pt on ethanercept - can she get HPV?

301
Q

Which vaccine for 65yo pt - ?

A

Polysaccharid ePPSV23

302
Q

Which vacc for 65yo

303
Q

40yo with DM, HIV, CRF or asplenia wtd?

304
Q

45yo with DM, HIV CRF or aspelenia got PPSV23 at age 40 - wtd?

A

PPSV23 dose now

305
Q

65yo Pt with DM, HIV, CRF asplenia PPSV at 40,45

306
Q

40yo DM tx for DKA d/cd wit PCV 13 wtd?

A

PPSV23 x 1 8 weeks later

307
Q

40yo DM tx’d for DKA d/c’d with PPSV23 wtd?

A

PPSV23 at least 1y later

308
Q

Pt allergy to eggs wtd?

A

Flu shot ok

309
Q

Pt with anaphylactic rxn to eggs -

A

non-egg flu vaccine

310
Q

Vaccine for joining college

311
Q

Pt with laceration - had tetanus shot last year wtd?

312
Q

Preg pt had TD booster last year wtd?

313
Q

preg pt20 wkks had tetanus shot last year wtd?

314
Q

60yo M Tdap vacc pw swollen arem 50% begger than other arm witih soreless - ROM normal wtd?

A

reassuance

315
Q

> 60 ptwith h/o shingles wants to prvent shignles in future

A
  • HZV vaccine even if had before
316
Q

Best pt to get IVIG

A

open woudn fx at gym, TdT 12 yr ago

317
Q

Whic pt NO VZV vacc

A

pt with CLL/lymphoma

318
Q

65yo pt comes in for shingle vaccine and also wants pneumococcal vaccine wtd?

A

Shingles and pneumococcal vacc 4 wks apart

319
Q

The following ok in pregnancy

A

electrical DVVC for unstable rhythm, procainamide, dioxin, for MS with CHF, verapamil

320
Q

Pt wit MS

A

> 1.5 sq cm - mild no tx
1-1.5 sq c - mod BB/dep on sx - need to inc diastolic filling time
<1 sq cm - severe - baloon valvulopasty

321
Q

Pt with MS and afib - how to tx?

A

Digoxin and BB, A/C

322
Q

Preg Pt with MD =started on BB - now has SOB inc’d JVD - lasix given wtd?

A

mitral valvuloplasty

323
Q

Pt with ASD wants to get pregnant wtd?

A

If shunt < 2:1 - then can get pregnant

If shunt >2:1 - surgery first

324
Q

Contraindications to pregnancy

A 
Pulm HTN
Eisenmenger's
Marfan's syndorme with dilated aortic root
Dilated CM with CHF
Sev AS
325
Q

Whic of the following is LEAST tolerated during preg

A

VSD with central cyanosis

326
Q

Can HOCM and MVP patients get pregnant?

327
Q

10 days post partum pt come wit fatigue and SOB JVD+, echo dilated CM with EF 30% - dx?

A

post partum CM - occurls mainly in 3rd trim or post partum

If normalized - pt can get pregnant again but chance for PPCM inc’d

328
Q

Otherwise normal preg woman 14th week routine prenatal visit has S3+ and II/VI systolic murmur

A

Normal fxn heart sound and murmur due to normal vol overload of pregnancy

329
Q

Pt with HTN and preg what can yo uuse

A

Labetolol, alpha methyl dopa, hydralazine

CANNOT use ACEi, nitroprusside

330
Q

33wk preg - BP 160/104, plt 90, PT/PTT 15/40, urine proteinuria, BUN/Cr eelv

A

DIC 2/2 pre-eclampsia

Tx: Deliver baby

331
Q

Causes of DIC in preg

A 
Dead fetus
Abruptio placentae
Amniotic fludi embolism
AFLP (acute fatty liver of pregnancy - inc'd d bili, NH3)
Pre-eclampsia
332
Q

Pre-eclampsia with seizure=

A

Eclampsia

Tx for seizure - MgSO4

333
Q

What anti-Sz med can’t use during preg

334
Q

Pt lactating post partum with prolactin >200

A

Dx: prolactinoma - check MRI
tx: bromocryptine

335
Q

Best tx for Thyrotoxicosis (graves dz) during PREGANCY

A

PTU
NO Methimazole 1st trimester
NO Radioiodine

336
Q

T?F Thyroxine requirement inc’s during pregnancy and gets back to normal postpartum

337
Q

T/F MCC amenorrhea is pregnancy

338
Q

T/F Insulin requirements inc’s by about 50% during pregnancy - needs tight control otherwise increased fetal loss and fetal malformations

339
Q

Pregnant woman with DM on oral meds wtd?

A

D/C oral meds start multiple insulin injections for tight glycemic control

340
Q

DM pt wants to conveive wtd?

A

screen for etinopathy tx if prsent before conception - otherwise tough to treat retinopathy during pregnancy

341
Q

In non-DM F when to screen for gestational DM?

A

24-28 weeks

342
Q

Do people with gestational DM have higher risk of DM in future?

A

Yes - 50% with DM at 5-10 years

343
Q

Pt in labor with IDA - MC seen in pt’s with….

A

No pre-natal care

344
Q

Pt with SLE gets pregnant ESR dec’d wtd?

A

Stop all drugs and monitor for spontaneous remission

345
Q

Pt had recent exacerbation of SLE (pregnant) wtd?

A

continue steroids

346
Q

Pt c/o itching what drugs can you use?

A

hydroxyzine

Chlorpheniramine

347
Q

Preg woman wants to fly from NY to LA - what is optimal time if she has to fly

A

2nd trimester

348
Q

These pregnant woman cna’t fly

A

h/o pre-eclampsia
History of DM, HTN, anemia
h/o premature delivery
H/o incompetent cervix

349
Q

T/F Young women with pulm HTN should avoid pregnancy with progesterone ONLY meds - NOT estrogen containing meds

350
Q

Pt on ocp going for elective surgery

A

STOP 1 month prior

351
Q

T/F Pregnant more prone to DVT/PE

352
Q

T/F Preg woman can use steroids

353
Q

Intrahepatic cholestasis of pregnancy

A 
Cholestasis - inc'd serum bile acids->pruritis
AST/ALT in but < 200
Alk phos elevated
PT normal, Plt normal 
No DIC
tx:
Cholestyramine
Urodeoxycholate
Early delivery at sign of fetal distress
354
Q

22yo Pt 34 wk preg wit pruritis, ast/alt normal, alk phos mily elevated wtd?

A

Reassurance - pruritis gravidarum (mild intrahepatic cholestasis of pregnancy

355
Q

Acute Fatty liver of pregnancy

A

Carnitine def or choline def or Tetracycline use
p/w malaise, h/a nause, poor appet and abd pain
mod elev of AST/ALD>150, ammonia elev, bili elev
can be a/w pre-eclampsia and DIC
Liver bx - microvesicular fatt change
Tx:
Resloves rapidly after delivery of baby

356
Q

40yo with dysxn uterine bleed

A

tx: Medroxyprogestine acetate 10-21 days

357
Q

16yo asks for OCP wtd?

358
Q

Pt wants to know tiem of start of OCP - last mentrual period 1 week ago when to start?

359
Q

Pt with dysmenorrhea, dysparenurnia - pelvic exam with enlarged ovaries and palpable bands on ligaments, no pelvic motion tenderness wtd?

A

Laparoscopy - r/o endometriosis (endometrial tissue in other places)

360
Q

Pt wants post coital contraception wtd?

A

Start Levengestrel within 72hr

Physiology - inhibit ovulation and impalntation and delayed onset of next menstrual period

361
Q

Pt missed OCP x 3 days and no sexual activity during that period wtd?

A

Take only most recently missed pill and another method of contraception x 1 week

362
Q

OCP complications

A

HTN (in’d renin)
DVT, stroke, PE
Peliosis hepatits (rupture of cyst, shock CT surgery)
Budd chiari syndrome (hepatic vein throbosis) - abd pain, ascites, pedal edema
Elevates theophylline level and causes toxicity
Euthyroid thyroxenemia
Mood swings
erythema nodosum
PCT
Melasma

363
Q

When NOT to use OCP

A 
h/o DVT
Pregnancy
CAD
HTN
migrain h/a
breast CA
smoker >35
chronic hepatitis
364
Q

OCP failure

A

St John’s wart
Rifampin
Toclizumab

365
Q

Pt on oral contraceptive for long time brought to ER with shock BP 80/60 - suspect ruptured liver adenoma

A

Tx: surgery
Dx: CT scan

366
Q

pt wit hcrampy abd pain and vaginal spotting - last period 1 month ago preg test + - dx test?

A

US r/o ectopic pregnancy

367
Q

Effect of HRT on fibroids

A

May inc size but NO INCREASE in malignancy

368
Q

26 on OCP for past 2 months - c/o mid cycle spotting wtd?

A

continue OCP

369
Q

19yo on OCP c/o moderate to severe mid-cycle bleeding fo rpast 2 months no fhx endometrial CA wtd?

A

D/C OCP and use intrauterine device (also can use higher dose estrogen continaing pill - stabilizes endometrium)

370
Q

Young woman exc 1hr / day BMI 23 mentstrual cycle 24-28 days - been having trouble conceiving wtd?

A

Ovulation kit to check basal body temp for ovulation

371
Q

Young woman trying to conceive for several years getting infertility tx p/w SOB and abd distenstion with pain - US reveals ascites and enlarged ovaries with inc’d number of ovarian folliclees serum Na 148 Hg 16 dx?

A

Hyperstimulation syndrome

372
Q

Middle aged woman with pelvic pressure sensation, constipation, sensation of incomplete evacuation - colonscopy with ehmmorhoids - 3 grown childrne dx?

373
Q

Never events in health care settings

A 
Decub III/IV
Vasc catheter associated infxn
Catheter ass UTI
DVT/PE in hospital
HAPNA
ABO incompatibility
Pt fall
Disability or death from hypoglycemia
374
Q

Time out before surgery to confirm

A

Correct pt
Correct side
Correct site
Type of procedure

375
Q

Insurance

A

Medicare Part A - hospital , NH, HHealth, hospice services
Medicare Part B - physicians, NP, SW, psycholgist, lab tests, therapists, durable medical equipment
Medicare Part D - some of Rx med cost
Medicare Part C - benefits under Micare part ABD thru medicare advantage plans (managed care)
Medigap - supp insurance to cover part A/B dedeutable and co-insurance and prev care and other heatlh related goods/services
Medicaid - joint fed/state programe give supp insurance to people of all ages who have low income and limited savings

376
Q

Advanced directive

A

Means for Pt to state what tx they accept or refuse if they lose decision makes capacit
Can also have proxy/surrogate who makes decisions for them if they cannot
Surrogate/proxy - person autorized to make decision for incapacitated person - usually next of kin

377
Q

Can a surrogate withdraw alllifesuport including nutritional support in an incapacitated pt?

A

Yes
If pt awake/alert oriented - HCproxy NO ROLE IN DECISIONS
If pt awake/alert orients - FAMILY HAS NO ROLE IN DECISION MAKING or consent fo rprocedures
DEcisions made by pt while awake oreinted stand if pt becomes unresponsive

378
Q

Living will

A

More focused advanced directive in which pt refuses life support in terminal condition - do not need lawyer to make

379
Q

Pt brough in barel concious and confused - has terminal condition - Living will states pt doesn’t want tube or resusitation - family insists on doing everything and threatens to sue if not intubated and resuscated - wtd?

A

follow living will

380
Q

Fiduciary relationship btween physician and pt is base on which 4 things?

A

Justice
Autonomy - right of individual to self determination
Non-maleficence - do no harm
Benefecience - take action in best interest of patient

381
Q

Pt brought in unconscious with terminal condition - pt family wants everythign done - proxy says pt didn’t want to be intubated and resusitated and wants to make pt DNR wtd?

A

listen to proxy

382
Q

Pt brought in by family no living will - pt terminally ill and family wnats DNR wtd?

A

Determine patient wishes

383
Q

Can a physician give telephone order to nurse for DNR

A

No - need to write adn document circumstances

384
Q

30yo Pt comes in and says sister has chronic reanl failure - sister parents and nephorlogist wants him to donate kdney - he doesn’t want to go thru surgery - wtd?

A

Reassure that you will be his advocate and represent his interests

385
Q

Husband wishes to discuss something perosnal and important about wife who is a patient

A

Listen to husband and decide whether to keep secret or not - keeping pt best interest in mind - if pt has spyhillis tell DOH

386
Q

Pt with PNA and pleural effusion - pt has that if he is going to be vent dependent - do not intubate

A

intubate and place chest tube (likely reversible)

387
Q

T/F terminally ill patient palliative care along with standard care decreases mortality

388
Q

When woudl you insert ICD in pt with severe HF

A

Life expectancy >1yr

389
Q

70yo M to ER with AWMI and shock - living will suggests if condition irreversible - not to be resuscitated - you do PTCA whic is unsuccessful and pt intubated - becomes hypotensive echo EF 25% - UOP 125cc - wtd?

A

withdraw all life support

390
Q

Pt with severe dementia and DNR in hospice care - develops PNA what is comfort care?

A

oxygen tx (not abx)

391
Q

Pt with end stage lung CA and SOB/pain - on O2 4l wtd?

392
Q

Terminall ill cancer pt with coarse rales wtd?

A

Glycopyrrolate (robinol)

393
Q

Pt with chronic COPD told you in office doesnt want to be intubated or resuscitated - now in ER with severe COPD exacerbation - as you see him in ER he reminds you - few minutes later lethargic and severly hypercapnic on ABG - no living will wtd?

A

DO NOT INTUBATE

394
Q

Pt with COPD exacerbation - living will states DNR but in ER he tells you to intubate wtd?

A

Yes intubate - follow pt wishes

395
Q

Elderly pt with ESRD refuses HD in will - could months later - in ER comatosed - son wants HD wtd?

396
Q

Elderly pt refusing HD in living will - brought to ER - son says recently father told him he wanted HD - pt now confused and lethargic wtd?

397
Q

Elderly pt dx with breast cancer - maeks advanced directive to be DNR - son moves in with her - he lost job recently 0 couple months later pt condition deteriorates and pt more SOB - son says she told him she now doens’t wnat DNR - wnats you to intubate

A

Refer to ethics committee

398
Q

Pt wants comfort measures only has durable power of attorney to son - doesn’t want to prlong life and wants only comfort measures if incompacitated - now has severe dementia - PNA and SOB - son wants abx - you will consider startin abx if….

A

Only if relieves sx

399
Q

Pt with hemiplegia after stroke 2ya - durable power of attorney to son - she takes place in activities at assisted living - excellent cognifitve fxn - she wants colonoscopy - son agrees bu twant to be there but is concerned mother may ot take explaation of findings in right way

A

tell son you will take consent from mother and proceed accordingly

400
Q

Pt with metastatic colon CA on wheelchair adn trach - communicates in writing - daugther durable power of attonry - refuses enrollment in an experimental clinical trial - wtd?

A

Talk to patient

401
Q

Your 74yo cantankerous and reclusive neighbor who lives along calls you to take a look at her - fatigued and uanble to get aroun - no tspoken with daughte rin 15 years - doesn’t want you to call her - BP ok, HR ok, orthostatic - S3, pedal edema refuses admission to hospital wtd?

A

Initial proceddings to declare her incompetent

402
Q

45yo GIB and hypotensive - refuses blood tx - wtd?

A

respect patient wishes - give IVF and EPO

403
Q

80yo Vietnamese man dx colon CA - family tells not to give dx to father wtd?

A

Tell pt he is very sick and ask him who wants to make decisions for him
If pt says family then comply
If pt wants t o know and make decision for self then comply

404
Q

35yo F with MS and poor prognostic factors requests physician assisted suicide wtd?

A

Respond with empathy, compassioni and assess if she is getting adquate palliative care

405
Q

95yo pt noted in NH to have mass in L breast - refuses and w/u or tx - wtd depends on…

A

her ability to understand disease and consequences

406
Q

Pt brain dead - can pt organs be donated wihtout his prior approval if proxy gives permission

407
Q

Can you stop tx if pt brain dead?

408
Q

Is EEG required to confirm brain death?

A 
No
3 signs
Coma
absense of brianstem reflexes
Apnea
Respiratory drive and motor posturing signs are incompatible with brain death
409
Q

You observe nurse entering airborn isolation room without mask several times and point it out - next time observe touchign pt with contact whtout gloves what to tell nurse

A

You are required to report actions

410
Q

25yo Fhx familial adenomatous polyps refered for colonoscopy but HMO refusing to pay wtd?

A

Call medical director and discuss case

411
Q

60yo recurren trectal bleeds hemorrhoids neg pt says can’t afford further testing wtd?

A

advise colonoscopy

412
Q

Covering for your partner and pt comes to you to get premarital certificate signed - labs reveal RPR + and FTA neg wtd?

A

Sign certificate

413
Q

Medical Hold

A

if pt unable to express preference you CAN perform lifesaving procedure if alter is death or severe disablity - pt with certain psych condition and suicide attempts should be treated despite their wishes
In transient drug induced deliruim/confusion get psych c/s to determine capacity

414
Q

Pt with attempted suicide brought to ER and refuses tx wtd?

A

Treat - pt in patholgical mental state whic may be treatable

415
Q

Nurse became + hep BeAg - request not to tell supervisor wtd?

A

inform infxn control team

416
Q

Pt dx with meningiococcal menigitis wants to sign out AMA

A

hold against will for public welfare

417
Q

Pt h/o indolent NHL told therapy not needed - aware that is slow growing tumor - stops eating and drinking cuz odoesnt want to diet a slow death started on setraline 2 weeks later no response - say she is only depressed about his illness wtd?

418
Q

45yo Pt with PNA and bctx g neg rods - on 3rd day pt wants to sign out AMA wtd?

A

Tell pt there is improper transition to outpt care

419
Q

Pt with AWMI, mentally competent, refuses admission - situation explained in detail about consequences pt understands but still refuses admission wtd?

A

gave nitrates, BB, ASA, ACEi and arrnage for home visitn nurse

420
Q

Pt of yours keeps calling 10 times fo rone rx - demands to be seen right away and wants clarification on simple things wtd?

A

Define limits of physician patient relationship

421
Q

Pt referred for medical clearance for cataract surgery by opthalmologist hx reveals that he reads a lot and falls asleep while reading

A

Report physician to ethics commitee

422
Q

You find your physician colleague with unethical behav or chemically impaired wtd?

A

refer to ethics commitee

423
Q

Pharmaceutical company invites you to exotic location for free wtd?

A

Don’t go

424
Q

Pt bought plane ticket and wants to cancel it - wants note tha the was ill and couldn’t travel to get his refund back

A

don’t write the excuse letter

425
Q

For whic is parental counsent required?

A 
tetanus shot
No consent for:
treat STD in 16yo
abortion on 15yo
OCP 14yo
17yo tx for substance abuse
426
Q

35yo F with multiple injuries to arms and legs nods in agreement to husband’s history - you suspect domestic abuse wtd?

A

As husband to step out sdie and interview pt
If injuries non-lifetreatening - don’t call police - discuss with pt - encourage her to seek help and give her hotline number

427
Q

Pt with bruises on inner arms - tells you she fell - exam reveals bruises on inner arms both old and new - has 2 children 5 and 2yo - recent dental work done wtd?

A

Domestic abuse counceling

428
Q

What is NOT a HIPPA violation

A

Pt asks for referral to a specialist and later calls for records to be sent to specialit without written consent (ok)
NOT OK to discuss rare case with your colleague so he may benefit

429
Q

T/F Periodic health evaluation shown improved rate of screening for

A

Colon CA and HTN

430
Q

Following pt education improved outcomes

A

Tobacco, firearm, etoh, physical activity, self skin exam, STD
NOT self breast exam
Quit smoking - better chance with recurrent trying

431
Q

Most likley reason to quit smoking is

A

intention to quit

432
Q

Pt with COPD 2/2 smoking comes fir visit - you discuss quitting smoking - pt says he would like to quit wtd?

A

set a quit date and f/u in 2 weeks wtd next?

necotine replacement

433
Q

Pt wants help quitting nicotine patch/losange failed?

A

buproprion

434
Q

If pt has h/o sz d/o and needs help quitting

A

NO buproprion
use varencicline
Monitor pt for behavior changes

435
Q

Chronic smoker doesn’t want to quit wtd?

A

Address barriers to quitting

436
Q

In discussion with your pt about quitting smoking what other information would help motivate pt to quit

A

Quitting smoking is the only way to prevent rate of lung fxn decline (not steroids, albuterol or tiotropium)

437
Q

Leading cause of mortality for 10-24yo

A

MVA>homocide>suicide

438
Q

Leading cause of prevatable premature death in US

439
Q

All true

A

injury from firearm at home > injury from intruder
seat belts dec mortality >50%
Front airbags de mortality a lot
child <13yo should be in back seat
helmets for bikes and motocycles reduced morbid and mortality
Fencing of pooland lifevest on boat reduce mortality

440
Q

Drowning victim out of water 70 deg F - wtd - ?

441
Q

Elderly homeless man brought on cold day with bradycardia dec’d reflexes dilated pupils - J waves on EKG what does he have?

A

Hypothermia

Tx: passive rewarming with blankets

442
Q

28yo F runs marathonand collapses - on exam confused hypotensive tachy, fused, dry skin - temp 41deg C dx?

A

heat stroke
tx: tx to hosptial
evaporative cooling - sponge with ice packs/sprink water wtih fans
complication - rhabdomyolysis.

Awesome Review 2021 (14 decks)

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