General Internal Medicine Flashcards
1
Q
overall prevalence of PAD in pt iwth Age 5-69 with DM.tob/age>70
A
29%
2
Q
Pt with PAD risk factors and suspect PAD wtd?
A
Ankle brachial index
N- >1
1.3=arterosclerosis
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
4
Q
If equivocal ABI (0.9->1)
A
Excercise ABI
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
6
Q
Whatd medicatio nused in PAD reduced coronary events regardly of BP effect
A
ACEi
7
Q
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced overall mortality
A
T
8
Q
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced vascular mortaility
A
T
9
Q
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced cornoary events
A
T
10
Q
DM goals
A
LDL<140/80 with PAD
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
12
Q
Pt wit sudden onset black/blue toes, pulses felt, had cardiac cath earlier and BP elevated wtd?
A
Adequate BP control
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
14
Q
Which antilipid medication woudl tx component of metabolic syndrome
A
Fibrate
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
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)
17
Q
45yo F gaining wight - BMI 31 FBS 105 wtd?
A
reduce caloric intake 500 to 1000 cal/day
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
19
Q
Indications for bariatric surgery
A
BMI>35 with DM/hyperchol or HTN or CHF or OSA
BMI>40 with no other conditions
20
Q
Bariatric surgery reduces mortality?
A
T
21
Q
Post gastric bypass surgery - next day with horizontal nystagmus and opthalmoplegia dx?
A
Thiamine deficiency
22
Q
Post bariatric surgeryc/o wk and dark colored urine, tenderness of back muscles - U dip stick + blood no RBCs dx?
A
Rhabdomyolysis
23
Q
Post bariatric srugery 3 days later with tachcardia nad tachypnea
A
PE
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
25
Long term deficit post bariatric surgery
Vit D, B12, copper, iron
26
38yo F BMI 40 bariatric surgery 5ya fo rphysical - Hg 10.5, MCV 105 plt 115, retic 1%
check B12/cyanocobalamin
27
34yo F roux en y surgery 8 monts ago - BMI dropped 40 to 28 - now BMI up to 35 - c/o heartburn
dx? Gastrogastic fistula
28
35yo F post bariatric surgery BMI 40-25 in 6 montsh - no ids - nauseous and bloating wtd?
preg test
29
Waist to hip ratio >0.9 in men >0.85 W risk factor
at any rate
30
Inc'd waist to hip ratio considered CAD risk factor in what grop of patients -
older age
31
Exc a/w
```
protection against CAD
dec'd LD, TGA inc HDL
improved gluc tol
reduction of weight, BP, stress
red'd mortality from all causes
```
32
Pt s/p IWMI d/c'd with AS B blocker, ACEi and statin - what else would dec mortalty
exc 1hr day, 5 days / week (not just 3 days 1/2 hr)
33
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?
retinal detachment - Urgent opthal eval for laser tx
34
Pt with afib sudden onlset painless vision loss in one eye - fundscopy CHERRY RED SPOT IN MACULA etio?
retinal artery occlusion
35
60yo with waldenstrom's macroglobulinemia, HTN or P vera with sudden painless los of vision one eye - fundopscopy with multiple hmorrhages - thunder & clouds dx?
retinal vein occlusion
36
Elderly man with blurry vision in CENTER, peripheral vision spares - fundscopy with yellow spots (druzen dx?
Macular degeneration - tx
| tx: quit smoking anti oxidant vitamins
37
Pt going for cataract surgery taking ASA or warfarin or plavix wtd?
continue ASA/warfarin
| d/c tamsulosin (avoid floppy iris syndrome)
38
Young woman with blurry vision esp after excercise - regains vision gradually - wtd?
T2 MRI r/o Multiple sclerosis
39
Optic nerve infarction
temporal arteritis
| tx: steroids
40
Pt with long standing DM, mild vision, fundscopy -> aneurysms with hemorrhage and exudates
non-prolif retinopathy (backgroudn) with macular edema
| TIGHTER glucose control
41
Pt with long standing DM with blurry vision Fundscopy->neovascularization
dx: prolif DM retinopathy
| tx; lasery therapy - periphera nd night vision decreased but central vision spared
42
Pt with HgA1c of 7% has laser tx for DM retinopathy no response - wtd?
Tighter glucose control
43
Pt with r eye pain, facial pain, n/v/ h/a blurry vision - R pupil dilated, sluggislhy reactive - ciliary flush hazy cornea with congestion
Glaucoma
44
25yo F dec'd vision in L eye with pain - paraesthesia in feet
Optic neuritis
45
Elderly man with progessive loss of central vision - edge of door hazy
macular degeneration
46
Sudden loss of vision in one eye, fundoscopy Cherry red spot
retinal artery occlusion
47
Sudden oloss of vision in one eye fundoscopy multiple hemorrhages and exudates
retinal vein occlusion
48
New monset shower of floaters with flashes of light and cobweb
retinal detachment
49
Magnifying glass
macular degeneration (also anti-oxidant vit's and quit smoking)
50
Crystals in retinal artery (Hollenhorst plauques)
Cholesterol emboli
51
Pt with intermittent visual loss - fundscopy with crystals in retinal artery wtd?
Carotid duplex US
52
test to establish infective endocarditis
Blood ctx
53
60yo pt wit difficulty driving at night from glare from oncoming cars - diff reading road signs and fine print - dx?
Cataract
54
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?
endopthalmitis
55
Conjunctivitis
Viral - adneovirus
Bacterial
Allergic
Tx - cool compression or abx or anti-histamines
56
Pt pw conjunctivitis with serous d/c - prescripbed abx eye drops - 4th day is worse - dx?
allergy to drops
| tx: d/c drops
57
Red eye with itchiness
allergic conjunctivitis
58
Pt with red eye with graves or RA with dry eyes and gritty sensation
Keratoconjunctivitis sicca
| tx: artificial tears
59
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?
```
Iridocylitis (Anterior uveitis)
Emergent referal to opthalmologist
intensive topical steroid to reduce inflammation
cycloplegics to prevent synechiae
tx underlying dz
```
60
Pt with red eyes and foreign body sensation with pain - corneal exam with DENDRITIC ULCER - branchign - fluorescin stain +
HSV I keratitis
| Tx: topical triflurodine (no acyclovir)
61
Pt intubated on mechanic vent wit one eye redness - cornea white
Pseduomonas keratitis
Tx: topical antipseduomonal
IV anti-pseudomonals
62
Pt with contact lense develops conjunctivitis
Pseudomonas keratitis
63
Glaucoma
inc'd intraocular pressure- progressive visual loss 2/2 optic nerve damage
Complication - gradual loss of peripheral vision
64
Open ange glaucoma
gradual loss of peripheral vision
Cup to dis ratio >50%
Inc'd incidence in AA's
65
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?
urgent referral to opthalmologist - before tx - give PIOLCARPINE drops
66
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?
No therapy f/u PRN
67
Pt p/w teary eye - pupillary refle normal wood lamp after fluorescin patttern of parallel lines of vertical abrasion - vision normal wtd?
every eyelid and remove foreign body
68
High velocity and insdustrial injury with hyphema (blood in anterior chamber
urgent referral to ophthalmologist
69
Pt witih conjunctiviti - exam layers of WBC in anterior chamber
refer to ophthalmoligst
Hypopyon - lyering of white cells in anterior chamber
Coudl be ophthalmitis or keratitis - urgent referral needed
70
Pt with cough - exam with redness in conjunctiva - wtd?
nothing - subconjunctival hemorrhage resolves spontaneously in 1-2 weeks
71
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?
cavernous sinus thrombosis
72
Cellulits of periorbital area with warth swelling around eye wtd?
CT/MRI - orbital cellulitis-> cavernous sinus thrombosis
| tx: IV anti-biotics
73
Pustule on lid margin
Stye
| tx: warm compess - may need surgery
74
Vascular structure in conjunctiva - can spread to cornea and impair vision
dx: pterygum
Tx: surgery
75
Inflammed eyelid
blephritis
76
small nodule under tarsus
Chalazion
etio obstruction of meibomian gland -
Tx: warm compress - surgery may be needed
77
AIDS pt with blurry vision - fundsocpy with cheese, ketchup appearance
Dx: CMV retinitis
tx: gancyclovir
78
How to manage otitis media
Amoxicillin
79
Pt with recurrent chronic ear infection p/w d/c and MASS out of tympanic membrane - hearing loss on that side - dx?
Cholesteatoma
80
Pt with c/o hearin gloss - esp in crowded area - wtd?
2 feet whisper test
81
If 2 feet whisper test abn - tuning fork at mastoid with no response - tunign for at forehead no response dx?
b/l presbycusosis
82
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?
b/l otosclerosis
(abn growth of bone in middle ear - conductive hearing loss)
fixation of stapes bone
Tx - surgery
83
Pt with hearing loss in R ear - webber's test localizes to R ear - exam with obstruction of typanic membrane by cerumen wtd?
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
84
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?
Swimmer's ear
| Tx: poymyxin drops
85
Pt with otitis externa in DM - red ear
malignant otitis externa
| cover with 2 anti-pseddoonal abx - ceftazidime and amikacin/tobramycin
86
Pt going for surgery - pt has LBBB and asx wtd?
clear for surgery
87
Pt with severe PVDz going for vasc surgery or aneursym repair - wtd prior to OR
thallium or dob stress
88
Pt for elective surgery - multiple PVCs asx no evidence of ischemia
Clear for surgery
89
70 HTN OA going fo rhip replacement
Clear for surgery
90
Pt with colon CA going for colon surgery father MI 49 wtd?
Clear for surgery
91
Pt with CABG 7ya with occasion CP on exertion schedule for urgent AAA 7.5cm in AM - abd tenderness and pulsatile mass wtd?
Emergency surgery - high risk - clear fo rsurgery
92
After MI when should elective surgeries be done?
6 months
93
Pt with stable angina going for surgery wtd?
c/w angina meds pre and post surgery
94
Pt post op after CABG in CCU with confusion, disoriented, doesn't follow commands inattentive pulling ET tube HR 100 wtd?
haldol
95
What med can cause delirium in elderly during post op period?
Meperidine (demerol)
96
Pt in recovery room and BP 160/104 not known HTN
morphine sulfate for adequate analgesia (pain causing htn)
97
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
Inc'd vagal tone from vomiting - clear for surgery
98
What has been shown to decrease risk of perioperative complications?
Lugn exapansion interventios (incentive spirometry, deep breathing, CPAP)
99
What is recognied as risk factor post non cardiac surgery
inc'd tropoinin T levels < 72hrs after surgery
100
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?
etoh hallucinations
| DT with inc HR/BP
101
Pt had urgent surgery yesterday today oriented x 2, temp 101, HR 105 mild tremor dx?
etoh withdrawal
102
Pt with anxiet, tremors confusion HR 104, BP 150/92 deslusional and seizure
Delirum tremons -
| Tx Diazepam, lreazepam phenobarb - propofol
103
54yo chornic alcoholic to ER with confusion ataxia nystagmus diplopia
Wernickes encephalopathy
| Tx FIRST thiamine then glucose
104
Chornic alcoholic with anterograde and partial retrograde amneis - confabulatory speech
Korsakoff psychosis - poor prognosis
105
Pt with SOB, tach and bounding pulse - CXR cadriomegaly
thiamine def - high output cardiac failure (beri beri)
106
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
Refeeding syndrome - hypophosphatemia
107
Chornic etoh wit muscle sapsms - serum ca low, K low wtd?
FIRST give magnesium then K/Ca+
108
Pt underoes surgery - post op seizure tachy, consfused tachypnic
etoh withdrawal
109
Lifetiem incidence etoh abuse and drug abuse
20%
110
etoh abuse screening
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
111
Etoh abuse
Problems - failures to fulfil work/school oblig, use in hazardous situation, legal proglems with etoh use - constineud use despote social problems
112
etoh dependence
keeps drinking - work/social school oblsigations sacrified - tolerance - needs more and more
desire to cut down but continues
withdrawal sx if stops
113
Pt p/w routine checkup - depressed - inc'd MCV, inc'd GGT - what wil establish chronic eetoh abuse
inc'd carboydrate free transferrin
114
Etoh abuser on sidewalk to ER pain in legs no back pain exam wk fo foot and dec'd ankle jerk - dx?
etoh neuropathy
115
MCC death etoh abusers
heart disease
116
All true about alcoholism
inc'd malignancy incidence
inc'd MVA
inc'd suicides and drug OD
inc'd STDs
117
Best drug to tx etoh addiction in addition to support goups?
Naltrexone
118
Pt with normal FBS - white/gray spots on conjunctiva dx?
Vit A deficiency
119
Pt taking multiple vitamins p/w dizziness, hza, abd pain n/v elev LFTs Ca 10.7, xerosis of skin dx?
Vit A toxicity
120
Pt with nausea labs Ca 11, fundsocpy blurring of disk margin - pt takes multiple vitamins dx?
Vit A toxcity
121
Pt lives on tea and toast diet pw bleeding gums - perifollicular hemorrhage and non-healing ulcer - coages, plts' normal dx?
Vit C deficiency - scurvy
122
PP+ pt on INH pw pin pricks and tingling on legs - low MCV
Vit B6 def - inc'd homocystine
123
Pt taking multiple vitamins with HEADACHES - fundoscopy papilledema
Pseduotumor cerebri
| etio? Vit A intoxication
124
50yo chronic etoh with sensory ataxia with romberg +, deemntia dec'd proprioception, spasticity optic neuropathy but normal pin pricke
Dx: subacute degen of cord 2/2 vit B12 def
| elev MMA
125
Pt takes multiple vitamins p/w nausea, anorexia fatigue sever constip - MM dry Ca 11.3, pho 5.2 dx?
Vit D intoxication
126
Pt with dementia diarrhea dermatitis
Pellagra (niacin) deficiency
127
Diarrhea and LINEAR VERTICAL LINES on nails
Arsenic posoning
128
Pt wit hlong ICU stay on TPN with ALOPIECIA, hyeprkeratotoic rash, anemia, LOSS OF TASTE
Zinc deficincy
129
Post surgery NPO on IVF with inc'd PT etio?
Factor VII def
130
Pt post surgery in ICU with nausea is given phenothiazine - next day horizontal nystagmus ophthalmoplegia dx?
Wernicke's encephalopathy
131
Cheilosis, glossitis, dermatitis
Vitamin B2 def (riboflavin)
132
Iodine
goiter or hypothyroid
133
Bleeding diathesis
Vit K def
134
Cardiomyopathy, CHF
Selenium
hypophophatemia
Thiamine
135
Anxiety d/o
```
Panic d/o
GADisorder
Phobias
Obsessive compulsive disorder
Post Traumatic disorder
```
136
Discrete period of intnese fear and anxiety, womatic sx SOB palpitations, trembiling diaphoresis ches tpain discormfort - click+MVP
Panic d/o
137
Percieved difficult to escape situation
Agoraphobia
TCA/SSR
benzo - short term
138
Excessive anxiety ou tof proportion of fear to impact of fear event
Gen anxiety d/o
Tx: buspirone
cognitive behav therapy
139
40yo F with complaints of CP, palptiatons diaphoresis and numbness while watching movie/concer - happened couple times before EKG normal wtd?
start benzos and re-eval in 2 weeks
| tx: SSRI
140
Pt with feeling of vibration sense inside body - has CP, palptiations, SOB - exam mid systolic click - dx?
Panic attack
| Tx: Paroxetine
141
Persistent distressing thought -> obsession
| Repetive response to the persistent thought -> compulsion
Dx. Obesessive Compulsive disorder
| Tx: Fluoxetine, Fluvoxamine, Clomipramine (TCA), behavior modification
142
Fear of public speaking with sweating and trembling
Phoic situation
tx: B Blocker
TCA
143
Vietname vet - saw friends die - pw nightmares, avoidance of remnder of even, flashbacks intrusive memories
Dx: PTSD
tx: Psychotx, SSRI
144
Young woman witih multiple complaints multiple organ systems >8 - exam NO macthcing physical findings to sx
Dx: Somatization d/o
tx: - PCP, psychiatrist - monthly appt with PCP for reassurance and dec of utilz of health care resources
145
Pt with alteration or loss of physical fxn wihtout pathologic basis - pt is unawar - not concoiously producing sx -
dx: conversion d/o
Tx: usually responds to suggestive therapeutic modality
146
Young woman of high socioeconomic status related to health care field with h/o emtional trauma p/w deliberate production of signs and sx
dx: Factitious d/o
147
A man of low socioeconomic status with deliberte production of signs and symptoms pathologic lying and wandering
Munchausen's
148
Intentional prodxn of signs and sx for SECONDARY gains. Such as avoiding military duty or court case etc
malingering
149
Physical findings dont' match multiple complaints
Somatization
150
Doctor shopping and high utilization of health care
Somatization
151
Needs PCP q1month appts
Somatization
152
Weakness one side of body but w/u normal with MRI
Conversion d/o
153
Young white femail nurse deliberate prodxn of sign's and sx
Facticious d/o
154
Factious d/o with pathologic lying and wandering
Muchausen
155
Exaggerated sx compared to physical exam - pending court case or military service
Malingering
156
Depression
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
157
Depression
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)
158
Mcc suicide in US
major depression
159
Depression
anti antidperessant
160
Enuresis
Imipramine (TCA)
161
Panic d/o
Alprazolam SSRI
162
Obsessive-compulsive d/o
Fluoxetine
Clomipramine
Fluvoxamine
163
Chronic pain+- depression
Amitriptyline
164
Smoking cessation
nicotine replacement->bupropion->vareniciline
165
Insompnia
Amitrptyline, trazadone
166
Overdowse with low lethal potentila
citalopram (SSRI)
167
45yo M pw depression - stated on fluoxetine and starts to feel better in 3 weeks how long to continue
4-9 months
168
83yo F awake, doesn't respond to stimuli x few months - refelxes/power intact dx?
depression
169
Terminally ill pt with lung CA depressed, loss of appetite - loss of interest in life wtd?
Methyphenidate - elevates mood w/in days and can be used with other anti-depressants which take weeks
170
Drug-drug interactions
MAOI
171
HTN crisis
MAOI (Phenelizine, selegilen)
172
Orhostatic hypotension
TCA (imipramine, clomipramine, amitrypyline, nortriptyline)
173
Antichol s/e (dil pupil, tachy, dry secrtions)
TCA
174
sexual dysfxn
SSRI (fluoxetine, citalopram, sertraline
175
Least sexual dysfxn
Bupropion
176
Avoid in anemia
SSRI/Buproprion
177
Avoid in Bulimia
Bupropion
178
Tx Bulimia
SSRI
179
62yo M HTN depression tx'd with BB and fluoxetine - alwso vitamins pw dec'd erections aunable to have orgasm for few moths wtd?
PDEi
180
SSRI s/e
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
Pt started on SSRI with cloudy urine dx?
retrograde ejaculation
182
Electroconvulsive therapy for...
```
Refractor depression
Psychotic fts
Suicidality
Catatonic stupor
S/E - acute confusion, sz
long term - impaired memory
Relative contraindic - recent MI, aneurysm, CHF, COPD
```
183
Stop bupropion in
Mania state
184
Biplar d/o
```
Manic depressive - lamotrigine
Manid/hypomanic
euphoria
inflated self esteem grandiosity
decreased need for sleep
tx: lithium, valproic acid/atypical antipsychotic
```
185
22yo started on fluoxetine for depression now starts playing music all night wtd?
d/c SSRI, start lithium or olanzapine
186
S/E lithium
```
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
Antipsychotic agents
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
Pt on paroxetine and olanzapine for major depression develops increasing blood sugears etio?
Olanzapine
189
Side effects of typical agents
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
Pt with hallucinations, smaking lips, says he takes nerve pills not sure what d/o - dx?
Schizophrenia
191
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?
Phenothiazine that she used to take 6mo ago - paranoid schizophrenia
192
Pt with schizophrenia develops parkinson's dz - develops psychosis - refuses blood tets because of needle sticks
Quetiapine
193
Pt with parkinson's dz, dementia, BPH and glaucoma becomes agitated and confused - best anti-psychotic
Quetiapine
194
Hyperthermia with mental status changes, tremor and autonomic instability (inc'd HR, dec BP, n/v/d) and hyperreflexia
```
Serotonin syndrome (SSRI+MAOI, SSRI+linezolid)
D/C med and start benzo o
```
195
Hyperthermia with mental status change, autonomic dysxn with LEAD PIP RIDIGIDY and rhabdomylysis
Neurolptic malignant syndrome - phenotiazine +- haldol
| Tx: bromocryptine or dantrolene
196
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
Neuroleptic malginant syndorme (inhalation anestetics
| tx: rapid cooling/dantrolene
197
Pt with hyperthermia, delirium HTN, tachcardia and diaphresis dx?
sympathomemetic crisi (amphetamine+cocaine, rx diet pills
198
Hyperthermia with mental status changes, tachycardia, dec'd bowel movements and urinary retention
antichoinergic delirium (antihistamine/TCAs)
199
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?
Drug induced
200
Pt with depression - takes ambien fo rinsomnia - on exam amnesia and confused
D/C ambien
201
70yo M wife died couple years ago - loss of appetite, weight last 6 months - hearing voices or seeing thigns on wall dx?
Depression with psycotic features
202
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?
Complicated grief
203
Borderline perosnality d/o
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
Best management for pt with borderline personality d.o
Behavioral psychotherapy
205
Anorexia
appetite
206
Bulimia
```
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
Young woman with new onset UGIB at party - Na 136, K2.7 Cl 80, bicarb 35, BMI 24 dx?
Bulemia (GIB from vomiting)
208
How to treat Bulimia
psychotherapy
| Fluoxetine
209
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?
```
TCA
Methadone (check QT interval)
```
210
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?
glucagon - inc contractility of myocardium
| epinephrine gtt
211
Pt took OD of CCB - BP 80 systolic - HR 42/min started on IVF bolus and atropine what else to give pt -
CaCl - counteract peripheral vasodil effects of CCB
212
Pt pw inc'd SECRETION, drooling, profuse sweating, n/v/SOB, tremors, fasciulations - exam pupils consdtricted HR< 50 what is poisoning
```
organophosphorus
dx test - RBC Acetylchoinesterase level
tx: remove contaminated clothing
activated charcoal
IV atropine
IV pralidoxime (muscularic rct - blocks rcts)
```
213
Pt and family feel tired, fatigued and somnolent - pt goes out and shovels the snow and feels better dx?
CO poisoning - call EMS and gt whole family out of house
214
Firefighter brought after fighting fire - ABG 94% on 40% venti - soot in nares pt intubated - what FIO2 required -
100%
215
Heroin addict or pt on morphine or codeine develops URI with profuse lacrimation, sweating rhinorreha, yawing restlessness and diarrhea
Dx: opiate withdrawal
Tx: methadone
216
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
Meth/speed (methamphetamine
217
24 yo pt back from party agitated - has seizure - +diaphoresis elev tmep/HR/BP - hyperreflexia
MDMA (ecstasy)
218
24yo pt agitated after party not following commnads - diaphoresis, elev bp, temp, hr hyperreflexia Na 124
MDMA (ecstasy)
219
Fever
MDMA and meth
220
HTN
MDMA and meth
221
tachy
MDMA and meth
222
Hyponatremia
MDMA
223
agitated, psychotic but alert
meth/speed
224
agitated mental status change
MDMA
225
Skin pickering
Meth
226
Oral musocsa burns
meth
227
mydriasis
meth and MDMA
228
hyperreflexia
MDMA and meth
229
serotonergic and SIADH
MDMA
230
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?
taper benzo d/c morphine
231
80yo F h/o depression tx'd with imipramine and haldol now a/w delirium neck ridgidty, spasiticty - elev BP/HR - NMS
tx: dantrolene
232
Most CC admission to hospital in elderly
CHF
233
Delirium
```
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
72yo F episodes of inattentiveness and cnosulion esp at night - takes enalapril and diphenyhydramine - etio?
diphenylhydramine
| tx: d/c drug
235
T/F delirium in hospital related to inc'd mortality
T
236
T/F delirium in hospital related to inc'd dementia
T
237
T/F delirium in hospital related to inc'd institutaionalization
T
238
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?
Lorazepam withdrawal
239
Best tx for insomnia?
sleep hydene (no caffine, tempo in bedroom, avoid naps, bed for sex and sleep - fixed bedtime and wakup time)
240
Best med to initiate sleep
ambien,
241
Dementia
```
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
Dementia
```
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
Ways to decrease falls
d/c psychotropic/targeted reduction in meds
Muscle strengthinging / balance exc - tai chi
improved lighting
decrease hazards (rugs)
extra support in toilet/shower
244
Best test to predict mobility and falls
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
elderly pt with freq falls - what deficiency?
Vit D (check 25,0H vit D level)
246
85yo F in NH trips and falls - uses cane occasionally - wtd?
Physical therapy
247
Pt in NH fell and suffered NON-dispaced fem fx of neck of femur wtd?
surgery and 3 parallel pins
248
Elderly pt fell and sustained displaced fx of femoral neck, wtd?
arthroplasty
249
Pt with displaced fx of neck of femur - meta analysis has shown which procedure had better hip outcomes?
total hip arthroplasty (femur+ball + socket)
| better than hemiarthropalsty (femur + ball only
250
Intertrochanteric fx ->
hip comporession screws
251
T/F elderly pt with acute compression vertebral fx - no advantage of verebroplasty over rehab and analgesia
T
| If no response to conservative tx - then vertebroplasty
252
elderly pt with hip fx - s/p ORIF - confused and agitated in evenings (sundowning) wtd?
atypical antipsychotics (SSRI takes too long)
253
Pt with dementia - can swallow bu teats only half meals - sometimes food in side of mouth wtd?
Aid with feedings
254
lower rate of feeding tubes in NH refulects what?
values of resident autonomy
255
IN advanced dementia pt who is not eating PEG has shown what?
NO change in nutritional status
256
82yo h/o freq falls - BP 140/90 what to d/c ASA or diphenyhydramine?
diphenylhydramine
257
Drugs that cause depression
```
BB
etoh
steroids
psychotropics
Parkinson's
CVA
```
258
Urge incontince
Detrusor overactivity
Tx: bladder training excercise
Anticholinergic (TCA) - oxybutyn, ditropan, detrol
259
Stress incontinence (coughing make pee)
Decreased sphincter tone
tx: Kegel excercises - strengthen pelvic muscles
Estrogen cream
Surgery
260
PSA
>18 - finasteride + alpha blocker
| <18 - alpha blocker only
261
Overflow incontinence
```
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
T/F Incontinence is normal part of aging
F
263
MCC incontinence
```
Urge Incontinence
Detrusor muscle overactivity
Tx: bladder training excercise
Anticholinergic, oxybutyn, TCA
Surgery
```
264
Detrusor overactivity
Urge incontinence
265
Decreased sphincter tone
```
Stress incontinence
Decreased sphincter tone
Tx: behavior change
kegel excercise
Surgery (sling)
```
266
Side effect of anticholinergic
```
Detrusor underactivity
overflow incontinence
s/e of some meds
passing urine involuntarily without urge to go
tx: benechol
surgery
catheterization
```
267
Post void normla
urge and stress incontinence
268
Post void residual >100mL
urethral obstruction and detrusor underactivity (overflow incontinence)
269
Bladder trianing better than TCA (imipramine)
Urge incontinence
270
Urodynamic studies
urethral obstruction, detrusor underactivity (overflow incontinence)
271
Response to prazaosin or finasteride
Urethral obstruction
272
Responds to B adrenergics (bethanechol)
Detrusor underactivity - overflow incontinence
273
Timed bathroom visits and diapers
Urge incontinence
274
Oxyburtynin, tolterodine
Urge incontinence
275
78yo F CVA with independent ADLs including toileting aw PNA - pt confused restraints applied - diazepham for sleep - now INCONTINENT of urine
Functional incontinence
276
67yo F DM urge to urinate every 30-60 min - leaks urine in dres - started wearing diaphers
urge incontinence
277
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
Overflow incontinence
278
80yo M in NH dx with depression and started on desipramine (TCA) 2 weeks later pt smells of urine
dx: overflow incontinence
| Chagne TCA to other class
279
67yo F no DM hasurine leadage - has to use bathroom with inc'ing freq including gtting up at night - no dysuria or fever wtd?
early morning urinalysis - u/a r/o UTI
280
65yo M sx BPH - BP 90/65 tx?
tamusulosin (better with low BP) alpha blocker
281
65yo M BPH BP 140/85
terazosin (ok if BP ok - lowers BP) alpha blocker
282
BPH + hematuria
finasteride
283
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
d/c diphenyhydramine (overflow incontinence)
284
Pressure ulcer
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
Drugs to avoid in pregnancy
```
Valproic acid
ACEi
Cipro
Methimazole (1st trim only avoid)
Radio Iodine
Anti histamines
Warfarin 5mg or more (nasal hypoplasia)
Nitroprusside
Aminoglycosides
Doxy/Tetra
```
286
Drugs safe in pregnancy
```
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
Preg Pt with asx bacturia
Treat (ampicillin / nitrofurantoin NOT bactrim or cipro)
288
Preg pt with detnal caries and ache - abx?
Augmentin
289
Pt with post partum fver and chills
r/o post partum endometritis
| etio GBStresp - MCC mortality a/w preg in US
290
Will immune globulin prevent rubella?
No
291
Preg woman exposed to...
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
Can preg pt get Hep B vaccine
yes
293
What vaccines contraindicated in pregnancy
```
Live vaccines
MMR
Varicella
Oral Polio
Fever
```
294
Can lactating woman receive vaccines?
yes
295
Pt visits 3rd world country comes back with jaundice - hep A/B neg wtd?
Hep E serology 20% mortality
296
Can HIV mother breast feed?
NO
297
Can you treat LTBI/PPD in preg woman?
yest
298
Can you tx MTB during preg?
Yes
299
When can 60yo get herpes vaccine
When on steroids and methotrexate
300
22yo RA pt on ethanercept - can she get HPV?
yes
301
Which vaccine for 65yo pt - ?
Polysaccharid ePPSV23
302
Which vacc for 65yo
PPSV23 x1
303
40yo with DM, HIV, CRF or asplenia wtd?
PPSV23
304
45yo with DM, HIV CRF or aspelenia got PPSV23 at age 40 - wtd?
PPSV23 dose now
305
65yo Pt with DM, HIV, CRF asplenia PPSV at 40,45
give now
306
40yo DM tx for DKA d/cd wit PCV 13 wtd?
PPSV23 x 1 8 weeks later
307
40yo DM tx'd for DKA d/c'd with PPSV23 wtd?
PPSV23 at least 1y later
308
Pt allergy to eggs wtd?
Flu shot ok
309
Pt with anaphylactic rxn to eggs -
non-egg flu vaccine
310
Vaccine for joining college
Tdap
311
Pt with laceration - had tetanus shot last year wtd?
Tdap
312
Preg pt had TD booster last year wtd?
Tdap
313
preg pt20 wkks had tetanus shot last year wtd?
Tday now
314
60yo M Tdap vacc pw swollen arem 50% begger than other arm witih soreless - ROM normal wtd?
reassuance
315
>60 ptwith h/o shingles wants to prvent shignles in future
- HZV vaccine even if had before
316
Best pt to get IVIG
open woudn fx at gym, TdT 12 yr ago
317
Whic pt NO VZV vacc
pt with CLL/lymphoma
318
65yo pt comes in for shingle vaccine and also wants pneumococcal vaccine wtd?
Shingles and pneumococcal vacc 4 wks apart
319
The following ok in pregnancy
electrical DVVC for unstable rhythm, procainamide, dioxin, for MS with CHF, verapamil
320
Pt wit MS
>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
Pt with MS and afib - how to tx?
Digoxin and BB, A/C
322
Preg Pt with MD =started on BB - now has SOB inc'd JVD - lasix given wtd?
mitral valvuloplasty
323
Pt with ASD wants to get pregnant wtd?
If shunt < 2:1 - then can get pregnant
| If shunt >2:1 - surgery first
324
Contraindications to pregnancy
```
Pulm HTN
Eisenmenger's
Marfan's syndorme with dilated aortic root
Dilated CM with CHF
Sev AS
```
325
Whic of the following is LEAST tolerated during preg
VSD with central cyanosis
326
Can HOCM and MVP patients get pregnant?
yes
327
10 days post partum pt come wit fatigue and SOB JVD+, echo dilated CM with EF 30% - dx?
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
Otherwise normal preg woman 14th week routine prenatal visit has S3+ and II/VI systolic murmur
Normal fxn heart sound and murmur due to normal vol overload of pregnancy
329
Pt with HTN and preg what can yo uuse
Labetolol, alpha methyl dopa, hydralazine
| CANNOT use ACEi, nitroprusside
330
33wk preg - BP 160/104, plt 90, PT/PTT 15/40, urine proteinuria, BUN/Cr eelv
DIC 2/2 pre-eclampsia
| Tx: Deliver baby
331
Causes of DIC in preg
```
Dead fetus
Abruptio placentae
Amniotic fludi embolism
AFLP (acute fatty liver of pregnancy - inc'd d bili, NH3)
Pre-eclampsia
```
332
Pre-eclampsia with seizure=
Eclampsia
| Tx for seizure - MgSO4
333
What anti-Sz med can't use during preg
VPA
334
Pt lactating post partum with prolactin >200
Dx: prolactinoma - check MRI
tx: bromocryptine
335
Best tx for Thyrotoxicosis (graves dz) during PREGANCY
PTU
NO Methimazole 1st trimester
NO Radioiodine
336
T?F Thyroxine requirement inc's during pregnancy and gets back to normal postpartum
T
337
T/F MCC amenorrhea is pregnancy
T
338
T/F Insulin requirements inc's by about 50% during pregnancy - needs tight control otherwise increased fetal loss and fetal malformations
T
339
Pregnant woman with DM on oral meds wtd?
D/C oral meds start multiple insulin injections for tight glycemic control
340
DM pt wants to conveive wtd?
screen for etinopathy tx if prsent before conception - otherwise tough to treat retinopathy during pregnancy
341
In non-DM F when to screen for gestational DM?
24-28 weeks
342
Do people with gestational DM have higher risk of DM in future?
Yes - 50% with DM at 5-10 years
343
Pt in labor with IDA - MC seen in pt's with....
No pre-natal care
344
Pt with SLE gets pregnant ESR dec'd wtd?
Stop all drugs and monitor for spontaneous remission
345
Pt had recent exacerbation of SLE (pregnant) wtd?
continue steroids
346
Pt c/o itching what drugs can you use?
hydroxyzine
| Chlorpheniramine
347
Preg woman wants to fly from NY to LA - what is optimal time if she has to fly
2nd trimester
348
These pregnant woman cna't fly
h/o pre-eclampsia
History of DM, HTN, anemia
h/o premature delivery
H/o incompetent cervix
349
T/F Young women with pulm HTN should avoid pregnancy with progesterone ONLY meds - NOT estrogen containing meds
T
350
Pt on ocp going for elective surgery
STOP 1 month prior
351
T/F Pregnant more prone to DVT/PE
T
352
T/F Preg woman can use steroids
T
353
Intrahepatic cholestasis of pregnancy
```
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
22yo Pt 34 wk preg wit pruritis, ast/alt normal, alk phos mily elevated wtd?
Reassurance - pruritis gravidarum (mild intrahepatic cholestasis of pregnancy
355
Acute Fatty liver of pregnancy
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
40yo with dysxn uterine bleed
tx: Medroxyprogestine acetate 10-21 days
357
16yo asks for OCP wtd?
give it
358
Pt wants to know tiem of start of OCP - last mentrual period 1 week ago when to start?
NOW
359
Pt with dysmenorrhea, dysparenurnia - pelvic exam with enlarged ovaries and palpable bands on ligaments, no pelvic motion tenderness wtd?
Laparoscopy - r/o endometriosis (endometrial tissue in other places)
360
Pt wants post coital contraception wtd?
Start Levengestrel within 72hr
| Physiology - inhibit ovulation and impalntation and delayed onset of next menstrual period
361
Pt missed OCP x 3 days and no sexual activity during that period wtd?
Take only most recently missed pill and another method of contraception x 1 week
362
OCP complications
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
When NOT to use OCP
```
h/o DVT
Pregnancy
CAD
HTN
migrain h/a
breast CA
smoker >35
chronic hepatitis
```
364
OCP failure
St John's wart
Rifampin
Toclizumab
365
Pt on oral contraceptive for long time brought to ER with shock BP 80/60 - suspect ruptured liver adenoma
Tx: surgery
Dx: CT scan
366
pt wit hcrampy abd pain and vaginal spotting - last period 1 month ago preg test + - dx test?
US r/o ectopic pregnancy
367
Effect of HRT on fibroids
May inc size but NO INCREASE in malignancy
368
26 on OCP for past 2 months - c/o mid cycle spotting wtd?
continue OCP
369
19yo on OCP c/o moderate to severe mid-cycle bleeding fo rpast 2 months no fhx endometrial CA wtd?
D/C OCP and use intrauterine device (also can use higher dose estrogen continaing pill - stabilizes endometrium)
370
Young woman exc 1hr / day BMI 23 mentstrual cycle 24-28 days - been having trouble conceiving wtd?
Ovulation kit to check basal body temp for ovulation
371
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?
Hyperstimulation syndrome
372
Middle aged woman with pelvic pressure sensation, constipation, sensation of incomplete evacuation - colonscopy with ehmmorhoids - 3 grown childrne dx?
Rectocele
373
Never events in health care settings
```
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
Time out before surgery to confirm
Correct pt
Correct side
Correct site
Type of procedure
375
Insurance
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
Advanced directive
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
Can a surrogate withdraw alllifesuport including nutritional support in an incapacitated pt?
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
Living will
More focused advanced directive in which pt refuses life support in terminal condition - do not need lawyer to make
379
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?
follow living will
380
Fiduciary relationship btween physician and pt is base on which 4 things?
Justice
Autonomy - right of individual to self determination
Non-maleficence - do no harm
Benefecience - take action in best interest of patient
381
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?
listen to proxy
382
Pt brought in by family no living will - pt terminally ill and family wnats DNR wtd?
Determine patient wishes
383
Can a physician give telephone order to nurse for DNR
No - need to write adn document circumstances
384
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?
Reassure that you will be his advocate and represent his interests
385
Husband wishes to discuss something perosnal and important about wife who is a patient
Listen to husband and decide whether to keep secret or not - keeping pt best interest in mind - if pt has spyhillis tell DOH
386
Pt with PNA and pleural effusion - pt has that if he is going to be vent dependent - do not intubate
intubate and place chest tube (likely reversible)
387
T/F terminally ill patient palliative care along with standard care decreases mortality
T
388
When woudl you insert ICD in pt with severe HF
Life expectancy >1yr
389
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?
withdraw all life support
390
Pt with severe dementia and DNR in hospice care - develops PNA what is comfort care?
oxygen tx (not abx)
391
Pt with end stage lung CA and SOB/pain - on O2 4l wtd?
morphine
392
Terminall ill cancer pt with coarse rales wtd?
Glycopyrrolate (robinol)
393
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?
DO NOT INTUBATE
394
Pt with COPD exacerbation - living will states DNR but in ER he tells you to intubate wtd?
Yes intubate - follow pt wishes
395
Elderly pt with ESRD refuses HD in will - could months later - in ER comatosed - son wants HD wtd?
No HD
396
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?
Do HD
397
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
Refer to ethics committee
398
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....
Only if relieves sx
399
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
tell son you will take consent from mother and proceed accordingly
400
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?
Talk to patient
401
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?
Initial proceddings to declare her incompetent
402
45yo GIB and hypotensive - refuses blood tx - wtd?
respect patient wishes - give IVF and EPO
403
80yo Vietnamese man dx colon CA - family tells not to give dx to father wtd?
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
35yo F with MS and poor prognostic factors requests physician assisted suicide wtd?
Respond with empathy, compassioni and assess if she is getting adquate palliative care
405
95yo pt noted in NH to have mass in L breast - refuses and w/u or tx - wtd depends on...
her ability to understand disease and consequences
406
Pt brain dead - can pt organs be donated wihtout his prior approval if proxy gives permission
Yes
407
Can you stop tx if pt brain dead?
tes
408
Is EEG required to confirm brain death?
```
No
3 signs
Coma
absense of brianstem reflexes
Apnea
Respiratory drive and motor posturing signs are incompatible with brain death
```
409
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
You are required to report actions
410
25yo Fhx familial adenomatous polyps refered for colonoscopy but HMO refusing to pay wtd?
Call medical director and discuss case
411
60yo recurren trectal bleeds hemorrhoids neg pt says can't afford further testing wtd?
advise colonoscopy
412
Covering for your partner and pt comes to you to get premarital certificate signed - labs reveal RPR + and FTA neg wtd?
Sign certificate
413
Medical Hold
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
Pt with attempted suicide brought to ER and refuses tx wtd?
Treat - pt in patholgical mental state whic may be treatable
415
Nurse became + hep BeAg - request not to tell supervisor wtd?
inform infxn control team
416
Pt dx with meningiococcal menigitis wants to sign out AMA
hold against will for public welfare
417
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?
Psych c/s
418
45yo Pt with PNA and bctx g neg rods - on 3rd day pt wants to sign out AMA wtd?
Tell pt there is improper transition to outpt care
419
Pt with AWMI, mentally competent, refuses admission - situation explained in detail about consequences pt understands but still refuses admission wtd?
gave nitrates, BB, ASA, ACEi and arrnage for home visitn nurse
420
Pt of yours keeps calling 10 times fo rone rx - demands to be seen right away and wants clarification on simple things wtd?
Define limits of physician patient relationship
421
Pt referred for medical clearance for cataract surgery by opthalmologist hx reveals that he reads a lot and falls asleep while reading
Report physician to ethics commitee
422
You find your physician colleague with unethical behav or chemically impaired wtd?
refer to ethics commitee
423
Pharmaceutical company invites you to exotic location for free wtd?
Don't go
424
Pt bought plane ticket and wants to cancel it - wants note tha the was ill and couldn't travel to get his refund back
don't write the excuse letter
425
For whic is parental counsent required?
```
tetanus shot
No consent for:
treat STD in 16yo
abortion on 15yo
OCP 14yo
17yo tx for substance abuse
```
426
35yo F with multiple injuries to arms and legs nods in agreement to husband's history - you suspect domestic abuse wtd?
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
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?
Domestic abuse counceling
428
What is NOT a HIPPA violation
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
T/F Periodic health evaluation shown improved rate of screening for
Colon CA and HTN
430
Following pt education improved outcomes
Tobacco, firearm, etoh, physical activity, self skin exam, STD
NOT self breast exam
Quit smoking - better chance with recurrent trying
431
Most likley reason to quit smoking is
intention to quit
432
Pt with COPD 2/2 smoking comes fir visit - you discuss quitting smoking - pt says he would like to quit wtd?
set a quit date and f/u in 2 weeks wtd next?
| necotine replacement
433
Pt wants help quitting nicotine patch/losange failed?
buproprion
434
If pt has h/o sz d/o and needs help quitting
NO buproprion
use varencicline
Monitor pt for behavior changes
435
Chronic smoker doesn't want to quit wtd?
Address barriers to quitting
436
In discussion with your pt about quitting smoking what other information would help motivate pt to quit
Quitting smoking is the only way to prevent rate of lung fxn decline (not steroids, albuterol or tiotropium)
437
Leading cause of mortality for 10-24yo
MVA>homocide>suicide
438
Leading cause of prevatable premature death in US
Smoking
439
All true
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
Drowning victim out of water 70 deg F - wtd - ?
CPR
441
Elderly homeless man brought on cold day with bradycardia dec'd reflexes dilated pupils - J waves on EKG what does he have?
Hypothermia
| Tx: passive rewarming with blankets
442
28yo F runs marathonand collapses - on exam confused hypotensive tachy, fused, dry skin - temp 41deg C dx?
heat stroke
tx: tx to hosptial
evaporative cooling - sponge with ice packs/sprink water wtih fans
complication - rhabdomyolysis.
