Géri/Allergie/MIGO/Préop/USI Flashcards by Alisa Poullet

25F G1P0 currently at 34 weeks gestation presents to ER with sudden onset pleuritic chest pain and shortness of breath. She denies any unilateral leg, buttock, or back pain. Sinus tachycardia in 130’s and saturations are 89% on room air and 93% on 2L nasal prongs. CXR is unremarkable and labs do not show evidence of pre-eclampsia.
Which of the following is the least appropriate?
a) Start therapeutic LMWH now given high index of suspicion of PE
b) Order d-dimer and if <500 PE ruled out
c) Order CTPA
d) Order V/Q scan
e) Order bilateral leg dopplers
f) Order Troponin, BNP, COVID and flu swabs

B) D dimer helpful in ruling out VTE in low/intermediate pretest probability cases.Highest utility in the first trimester due to increase in d dimer with trimesters.

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64 year old man with no past medical history. Brought in by wife as she has noticed a change in personality. He repeatedly checks that doors are locked and has made inappropriate sexual comments to a family friend. He has been missing appointments and his wife has taken over managing these. He has episodes of irritability and verbal aggression directed at his wife, and a few weeks ago he threw a phone at her. MoCA 22/30, no abnormality on physical exam. What is the most appropriate with respect to management?
A. Start Donepezil
B. Start Memantine
C. Start Trazodone
D. StartRisperidone

The correct answer is C. There is escalating aggression which poses a safety concern for patient’s
wife.Risperidone is another possible option; however there can be paradoxical worsening with anti-psychotics, SSRI or Trazodone generally first line. No role for CI or memantine in FTD

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77M presents with cognitive decline. He has a history of T2DM, PVD, DLP, peripheral neuropathy, and GERD. Medications include ASA, metformin, empagliflozin, rosuvastatin, ramipril, bisoprolol. He feels that he is becoming more forgetful. His husband comments that he is slower to respond in conversation. He previously prepared all family meals but recently finds that he will forget a dish or that items are ready at different times. He gave up driving this past year due to a near miss. His husband has taken over managing finances as he had started to make mistakes. MoCA 22/30. What is the most likely diagnosis?
A. Dementia with Lewy Bodies
B. Alzheimer’s Disease
C. Vascular Dementia
D. Frontotemporaldementia

The correct answer is C. He has significant vascular risk factors
and deficits are predominantly in executive function (poor
planning) and slow processing speed. MRI brain indicated to
evaluate for microangiopathic changes and infarcts

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78F with admitted to hospital after fall and hip fracture.
PMHx: MCI, HTN, insomnia
Home Meds: Amlodipine 2.5mg daily, lorazepam 1 mg po qhs for sleep, vitamin D3 1000u daily
Current Meds: Acetaminophen 1 g TID, amlodipine 2.5mg daily, lorazepam 1 mg po qhs, hydromorphone 0.5 mg PO q4h PRN, Senna 2 tabs BID, enoxaparin 40 mg SC daily, and vitamin D3 1000 IU daily.
On POD2 she becomes disoriented. On exam she is calm but not able to follow a conversation and her responses are disorganized. Physical exam otherwise unremarkable. HR 90, regular, BP 125/58, afebrile, RR 16, SpO2 94% RA. Routine labs and ECG are repeated and unchanged from previous. What is the next best step in management:
A. Discontinue Hydromorphone
B. Start Quetiapine 12.5mg po qhs
C. Insert Foley catheter for presumed urinary retention
D. Decrease lorazepam to 0.75mg po qhs

The correct answer is D. While sudden discontinuation of lorazepam could result in withdrawal and worsen delirium. It is likely contributing to current presentation and taper with close monitoring is indicated.

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80M referred for cognitive assessment. He has a history of T2DM, describes a 2-3 year history of worsening forgetfulness. His partner reports he frequently repeats stories and forgets things he has been told. More recently he has developed word finding difficulty. This year his partner took over managing finances due to missed bill payments. MoCA 22/30. BP 124/68, HR 48, RR 18, SpO2 99%. Neuro exam is normal. What is the next best step in management?
A. Exercise
B. Donepezil 2.5mg daily
C. GinkoBilboa
D. Donepezil 10mg daily

The correct answer is A.
STEM describes mild AD. Patient has bradycardia which requires work-up, donepezil should not be initiated in this context.
Exercise is recommended per CCCDTD. No evidence for ginko bilboa

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89F with past medical history of MCI, HTN, anxiety admitted to hospital after fall and hip fracture. Smokes 1pk/day and drinks a glass or two of wine per night.
Home Meds: Amlodipine 2.5mg daily, lorazepam 2 mg po BID, vitamin D3 1000u daily Current Meds: Acetaminophen 1 g TID, amlodipine 2.5mg daily, hydromorphone 0.5 mg
PO q4h PRN, Senna 2 tabs BID, enoxaparin 40 mg SC daily, and vitamin D3 1000 IU daily.
On POD3 she becomes disoriented, agitated yelling and tries to punch. You suspect delirium. HR 109, regular, BP 125/58, afebrile, RR 16, SpO2 94% RA. She is restless, diaphoretic, confrontational not participating in physical exam. TSH, electrolytes, B12 and ECG all normal. What is the next best step in management:
A. Increase Hydromorphone
B. Insert foley
C. Give Lorazepam
D. Give Quetiapine

The correct answer is C. This patient has a history of high dose chronic
benzodiazepine and possibly significant alcohol history. The most concerning (and
potentially life-threatening cause of delirium is benzo/alcohol withdrawal.

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Homme de 80 ans, égyptien. Présente une endocardite aiguë à SASO. Mentionne une réaction à la PNC lorsqu’il était enfant, mais ne se rappelle pas de la réaction. On veut vraiment le traiter avec la PNC. Quoi faire :
A. Testcutané
B. DosagedesIgE-PNC
C. Désensibilisation
D. TestdeRAST

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90 year old woman with past medical history of depression, HTN, urinary incontinence and falls. Which of the following would you recommend to prevent LTC admission.
A. HighdoseVitaminE
B. CognitiveStimulation/Reminiscenttherapy
C. Hearingassessment
D. Statin

The correct answer is B. In a recent meta-analysis cognitive stimulation/reminiscent therapy,
specialized geriatric care, and multicomponent interventions were shown to decrease LTC
admission in pooled analysis of both inpatient and outpatient studies Gaugler et al. JAGS 2023

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A 22yF woman presents at 26 weeks pregnant and is keen to update her vaccines but requests advice as to what is safe in pregnancy. She reports her last vaccine was a tetanus booster 4 years ago, but otherwise no regular vaccines since age 4. You review her antenatal record and see she is HepB SAg neg, HCV neg, Rubella non-immune. What is false?
a) TdAP is indicated in all pregnant women, irrespective of last booster, ideally between 27-32 weeks
b) Inactivated Influenza and COVID19 mRNA vaccines can be co-administered at the same time in pregnancy
c) HPV and Hepatitis B Vaccine series should be offered postpartum if she was not previously immunized for same
d) MMR should be delayed until done breastfeeding

D – MMR does not need to be delayed while breastfeeding. MMR /live attenuated vaccines should not be given during pregnancy but can be given while breastfeeding. Exception is smallpox (AKA MONKEYPOX) and yellow fever vaccines should not be given while breastfeeding.

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A 24y G1P1 woman experiences preeclampsia at 36 weeks and her daughter is delivered. She is seen 6 weeks postpartum. She is healthy with normal BP, BMI and has no history of diabetes. She is presently breastfeeding.
In follow-up which is false?
a) She should be counselled that breastfeeding reduces risk of future cardiovascular diseases.
b) In future pregnancies she should take ASA 162mg to prevent preeclampsia from 12-36 weeks.
c) A lipid profile should be drawn at nearest opportunity and statin therapy initiated if intermediate-high risk
d) Moderate intensity Exercise 150 min /week is recommended in pregnancy to prevent risk of preeclampsia

C – drawing lipid profile and starting statin. JAMA 2022 meta analysis of >1million parous women showed reduction in MI, Stroke, CV death in women who breastfed controlling for multivariable. Prior preeclampsia is an indication for ASA. In all women with hypertensive disorders of pregnancy CCS suggests lipid profile be drawn postpartum but frankly we aren’t given a lot of guidance as to what to do with results in a 24 year old – it’s to inform decision making. Certainly you won’t start a statin in a breastfeeding woman.

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A 25F G1P0 currently 35 weeks gestation tests positive for COVID-19. She is unvaccinated and has shortness of breath at rest. She is found to be 89% on room air and CXR shows bilateral lower lobe infiltrates. She is placed on 2L NP and admitted to hospital for further management.
All of the following should be done except:
a) Start DVT prophylaxis
b) Start Dexamethasone and Remdesivir
c) Close monitoring of fetal status using NST and fetal ultrasound
d) Monitor for increased risk of pre-eclampsia and maternal respiratory compromise including need of ICU admission and mechanical ventilation
e) Recommend vaccination 3 months after COVID-19 infection

: B –Avoid Dexamethasone due to its readiness to cross the placenta and cause adverse fetal complications. Use Methylprednisolone or other steroid alternatives for COVID-19 treatment. Remdesivir is no longer recommended in pregnancy (BC Treatment Table)

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A 28F G2P1 at 28 weeks of gestation is found to have severe IUGR with fetal weight of <1st percentile on ultrasound. She is admitted to antenatal floor for monitoring. You are asked to see to assess for possible pre-eclampsia. She has a history of pre-eclampsia at 33 weeks requiring C-section in her first pregnancy.
On review of labs done in first pregnancy, she had an elevated cardiolipin IgM.
Which of the following is most appropriate?
a) Initiate ASA 81-162mg QHS to prevent preeclampsia
b) Initiate enoxaparin 40 mg sc for obstetric acute phospholipid antibody syndrome
c) Initiate Nifedipine XL 30mg if her blood pressure is >140/85
d) Order uric acid as an early marker of preeclampsia
e) She should get Betamethasone IM
f) She should get Magnesium Sulfate

C – initiate Nifedipine if BP>140/85. Aspirin should be started <16 weeks. Prophylactic LMWH started at onset of pregnancy for antiphospholipid syndrome. Betamethasone given if preterm delivery anticipated within next 7 days (not enough information to initiate this). Doesn’t meet criteria for Magnesium Sulfate start.

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A 29F previously healthy G2P1 had an uncomplicated vaginal delivery 30 minutes ago, but is now experiencing significant vaginal bleeding. In addition to ABCs and giving fluids and blood products as necessary, which of the following is false?
a. Assess for uterine atony and retained placental products as cause
b. Post partum hemorrhage is defined as more than 500mL of blood loss post vaginal delivery and 1000mL after C-section
c. Give misoprostol and tranexamic acid now
d. Giving tranexamic acid prophylactically immediately after delivery would have prevented post partum hemorrhage
e. Severe bleeding is treated with intra-uterine balloon or uterine artery embolization

D – prophylactic tranexamic acid. Studies show that TXA given prophylactically immediately after vaginal delivery does not reduce PPH.

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A 30yoF G1P0 currently 30 weeks gestation is referred to you for palpitations. Her cardiac exam is reassuring. You do a 48 hour Holter monitor which shows 10% PVCs and no other arrhythmias.
What would you not recommend at this time?
a. Start Amiodarone for symptomatic PVCs
b. Start Metoprolol for symptomatic PVCs
c. Start Diltiazem for symptomatic PVCs
d. Monitor for symptoms of heart failure
e. Do labs for electrolytes, Calcium profile, and TSH

A – Avoid Amiodarone in pregnancy. In addition to checking metabolic labs you would also get an ECHO and refer to a cardiologist – 10% is a high burden of PVCs even if not pregnant in a young woman.

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A 35F G4P3 currently at 32 weeks gestation presents to hospital with blood pressure of 200/120 and HR 88 with shortness of breath. She has jugular venous distension and bilateral crackles. She has a history of chronic hypertension on Labetalol 200mg TID and Nifedipine XL 30mg BID. She has been on Aspirin 160mg daily since 10 weeks gestation.
Basic labs show Hgb 110, WBC 13, Plt 174, ALT 56, Cr 142, urinalysis 3+ protein
Which of the following is least appropriate?
a) Give Nifedipine 10mg IR and increase Nifedipine XL to 60mg BID with repeat BP
b) Give Hydralazine 10mg IV and start Methyldopa 500mg TID
c) Betamethasone 12mg IM stat
d) MgSO4 4g IV bolus then infusion at 2g/hr
e) CXR to assess for evidence of pulmonary edema / dyspnea workup
f) OB to urgently perform fetal ultrasound for growth and placental dopplers

D)
This is too much Mg : would want to know her urine output and possibly repeat Cr before giving that bolus. High risk toxicity if already on pulm edema.

Usual Dose: 4g IV loading bolus then 1g/hr x 24h Q30min vitals; Q1h monitor: U/O, reflexes Caution if oliguric renal failure à Mg Toxicityi

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A 38 week pregnant woman G1P0 presents with shortness of breath worsening for the past 2 weeks. She recently travelled from North Bay to Toronto for a “babymoon” (3.5 hour car ride). No infectious symptoms. She is scheduled for a C-section at 39 weeks for breech baby, EFW is >97%le.
BMI 43, BP 110/70, HR 110, SpO2 100% RA. ECG is normal. Pulmonary exam is normal. There are non tender varicose veins on the left calf, no leg edema or pain.
Labs: Hgb 96, Cr 42, WBC 11, Plt 382, D-Dimer 912 What is the best next test or intervention?
a) CTPAtoruleoutPE
b) Bilateral leg dopplers to rule out DVT
c) Ferrous fumarate 300 mg po daily
d) Iron Sucrose 300 mg IV
e) Urgent spirometry

D – Iron Sucrose. Using the YEARS algorithm, you have ruled out PE (0 clinical criteria and D-dimer <1000). Leg dopplers are not recommended unless there are signs of DVT. Thankfully North Bay is quite close to Toronto – just north enough to be perfect, consider relocating to practice here when done, and I have yet to have a patient develop a DVT from drivingthere;) Sheisduein1weekandhighriskofmajorhemorrhage(Csection,anemia,?macrosomicinfant)soshould have urgent IV iron replacement for symptomatic anemia.

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A 40F G2P1 with BMI of 35 is currently 28 weeks gestation. Her screening 1-hour 50G OGCT is 13. Her blood pressure is 120/70 and she feels well.
Which of the following statements is not recommended in management of pregnant patients with diabetes?
a) Start measuring glucose fasting and 2 hour post meals
b) Start NPH qhs to target fasting glucose <5.3
c) Start Glyburide to target 2hr post-prandial glucose <6.7
d) Measure Fasting Glucose, A1C and lipid profile
e) Stop insulin and all oral hypoglycemics immediately postpartum

D – measure lipids. Lipid profile is generally NOT measured in pregnancy due to physiologic
increase in lipids during pregnancy makes the values meaningless in terms of treatment targets.

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A 42 year old G3P3 with type 2 diabetes is planning a pregnancy. Her HbA1c is 7% on Metformin, Sitagliptin and Semaglutide. She is also on Atorvastatin and Perindopril. Her blood pressure is 125/75, Cr 85 with ACR of 35.
Which of the following statements is false?
a) Continue Metformin and discontinue Sitagliptin and Semaglutide
b) Continue Perindopril until positive pregnancy test
c) Continue Atorvastatin until positive pregnancy test
d) Target BP <130/80 during pregnancy
e) She is at increased risk of pre-eclampsia and will require ASA 162mg f) She may require insulin during pregnancy

C – continue atorvastatin until positive pregnancy test. Should stop statins 3 months pre-pregnancy or while attempting to conceive due to uncertainty regarding teratogenic effects or miscarriage risk, in this scenario for 1o prevention so can stop.

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A 45F G1P0 undergoing IVF just discovered she is pregnant. She has a history of type 2 diabetes on Metformin, Sitagliptin, Gliclazide, and Semaglutide weekly injections. Her BMI is 40 and blood pressure is 132/85. Last HbA1c is 7.5%.
Which of the following statements is false in management of pregnant patients with diabetes?
a) HbA1c should ideally be 6.5% pre-conception
b) DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors are contraindicated
in pregnancy and breastfeeding
c) Metformin and Gliclazide may be continued in pregnancy
d) She will likely be started on insulin in pregnancy
e) She should be started on Aspirin 162mg daily and continued until 36 weeks

c) Gliclazide is not recommended in
pregnancy, while Glyburide may be
used as third line in pregnancy if patient
declines insulin and metformin l

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A 45F G3P1A2 seen in the ER for acute shortness of breath and chest pain. CTPA confirms PE. She has a two miscarriages at 8 weeks gestation and a pregnancy delivered at 30 weeks due to pre-eclampsia.
You do antiphospholipid testing and she is positive for lupus anticoagulant and anti- cardiolipin, negative for beta-2 glycoprotein.
You recommend the following except:
a. She has antiphospholipid syndrome and should be on lifelong Warfarin
b. Her INR target should be 2.5-3.5
c. She is at increased risk of recurrent miscarriage, pre-eclampsia and thrombosis in pregnancy
d. During future pregnancies, she should be switched to therapeutic LMWH
e. For future pregnancies, she should also be on low dose ASA

C – INR 2.5-3.5. INR target for antiphospholipid syndrome is 2-3.

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A 62yF is scheduled for thyroidectomy for symptomatic goitre. She reports she had a mild heart attack 3 years ago after death of her husband– had angiography and was advised angio/coronary arteries normal, no stenting required.
Meds: ASA 81mg daily, Bisoprolol 5 mg daily, Simvastatin 10 mg daily.
What do you advise with regards to her antiplatelet management prior to surgery?
a) Continue ASA perioperatively
b) Hold ASA 7 days preop, resume when surgeon says safe postop
c) Hold ASA 72h preop, resume POD #2
d) Hold ASA 72h preop, resume POD #1

Pick B - Thyroidectomy for goitre is high risk bleeding (airway compromise if patient gets postop hematoma).
Without compelling indication for ASA, although CCS says to hold ASA “at least 3 days preop” your surgeon will probably appreciate
pt being completely off ASA!

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A 63yF is scheduled for an elective TKA for severe Rt knee Osteoarthritis in 6 days. She has a history of stable CAD following NSTEMI and PCI with 1 stent in 2018. She reports she is short of breath when she walks up the stairs but this has been present for over one year as she has significant weight gain due to lack of exercise with painful knee arthritis.
BP 110/68, BMI 37, HR 58. CV Exam unremarkable.
Meds: Clopidogrel 75 mg daily, Rosuvastatin 10mg daily, Bisoprolol 5mg daily, Lisinopril 10 mg daily, celecoxib 100 mg po BID, acetaminophen 1 g po TID.
ECG: Sinus Brady, old inferior Q’s.
Labs: Hgb 109, Cr 83, A1C 6.3% , NT pro BNP 120 mg/L
With regards to preventing myocardial injury after surgery, what is the best recommendation at this time?
a) Advise anesthesiologist to target MAP >80 intraoperatively
b) Advise anesthesiologist to deliver FiO2 >= 80% intraoperatively
c) Advise anesthesiologist to keep temperature 37oC intraoperatively
d) Delay surgery
e) Continue bisoprolol perioperatively

PICK D - This patient has significant symptomatic anemia and is scheduled for surgery with high risk of major bleeding (>1L average blood loss). At this time safest to delay surgery to optimize Hgb – major anemia puts pt at high risk of “type 2” supply/demand mismatch MINS or even ACS ALSO - clopidogrel on board, ideally for anesthesia to give spinal want held 7 days There are RCTs whichshow(a)and(b)andcdon’treduceMINS. Bisoprololcanbecontinuedperioperativelythough“atthistime”youdon’twantto greenlight elective surgery in a cardiac patient who is not optimized.

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A 72y M is referred for preop assessment. The surgeon wonders if they can stop clopidogrel prior to upcoming elective laparoscopic cholecystectomy for symptomatic gallstones.
PMH: Lacunar stroke 2 years ago. HTN, Dyslipidemia, ex-smoker. No history of cardiac disease or Afib. Osteoarthritis. Last known LVEF 65%.
Meds: Clopidogrel 75mg daily, Indapamide 2.5mg daily, Simvastatin 40 mg daily, vitamin D, Ibuprofen PRN arthritis.
On exam: Alert, oriented. Using his iPhone he shows you his BP and HR trend for past 2 years which he tracks meticulously. BP 128/72, HR 68. Cardiac exam normal.
ECG shows normal sinus rhythm with ECG LVH.
With regards to his pre-operative management, which is the next best recommendation?
a) Measure NT-pro BNP
b) Order post-operative ECG and Troponin
c) Order exercise stress test
d) Advise to hold clopidogrel 5 days preoperatively

Advise to hold clopidogrel 5 days pre op

This is a low risk OUTPATIENT surgery so no BNP

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A 76yF is seen prior to elective hip arthroplasty. She had a previous inferior STEMI w TNK and RCA stent in 2018. She is on clopidogrel, ramipril, rosuvastatin, nitro PRN. She is a non-smoker. She gets short of breath on exertion, stable for the past 1 year. She undergoes a stress test which shows 1mm ST depression in II, III, AVF. What do you recommend with regards to her perioperative management:
a) No further testing or changes
b) Rivaroxaban 2.5mg po bid for perioperative vascular optimization
c) Referral to cardiology for PCI prior to surgery
d) Start and titrate beta-blocker, proceed to OR
e) Hold clopidogrel 5 days prior to surgery

Pick D - STABLE CAD. The bigger question is why did she get a preop stress test with stable symptoms? Rivaroxaban 2.5 BID per COMPASS trial not indicated to start periop Stable CAD no role for PCI. Clopidogrel needs to be held, 7 days for spinal, change to ASA 81mg How long to wait for OR? Depends on clinical scenario. If patient is booked for surgery tomorrow you really don’t have time to start – but if OR in a couple weeks can start today eg bisoprolol 2.5 daily , reassess in a week …

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A middle aged woman with history of mechanical bileaflet AVR for bicuspid aortic stenosis is scheduled for a hysterectomy for a large fibroid uterus. She presented with post menopausal bleeding. She is otherwise healthy. Wt: 60 kg eGFR 100, ECG = sinus with LVH Meds: Warfarin, Vitamin D, Multivitamin How do you advise her with regards to pre-operative warfarin management? a) Stop warfarin 5 days preop, take enoxaparin 60 mg sc Days -3, -2, -1 preop. INR day - 1. b) Stop warfarin 5 days preop, INR morning of surgery, if >1.5, vitamin k 2mg po x 1 c) Stop warfarin 5 days preop, take enoxaparin 30 mg sc Days – 3, -2, -1, INR on day of surgery d) Stop warfarin 5 days preop, INR day before surgery, if >1.5, vitamin k 1mg po x 1

Pick D - High risk of bleeding (because she presented with bleeding) and has a bileaflet AVR but no other thrombosis risk factors so bridging is NOT recommended here. Ideally have INR check day before surgery to avoid delays day of surgery, vitamin K 1-2 mg po if over 1.5 is suggested by thrombosis Canada

A middle-aged female presents with a 6 month history of urticaria. She has never had any episodes of swelling. The urticaria resolve within 12hr, with no residual bruising or scarring. She reports that she has been eating out at restaurants more recently. She is otherwise well. Initial bloodwork is normal including a CBC, creatinine and liver profile. What is the most likely cause of this patient’s symptoms? 1. Chronic Idiopathic Urticaria 2. Food allergy 3. C1 esterase deficiency 4. Autoimmune Disease

1. Chronic idiopathic urticaria

A young man presents with occasional angioedema of his lips and hands. Which of the following features make it least consistent with C1 esterase deficiency? 1. Occasional GI symptoms 2. Triggered by dental procedure 3. Presence of urticaria 4. Laryngeal involvement

Presence of urticaria

ACE inhibitors and breast feeding ?

Safe (enalapril, quinapril, captopril)

ACHEi are indicated in those dementias EXCEPT ? - Alzheimer - Vascular - Dementia with Lewy bodies - Parkinson dementia - Gronto temporal dementia

Fronto temporal dementia no role for ChEI Trazodone, SSRIs for behavious only

Amines qui diminue la pulmonary capillary wedge pressure ?

Epinephrine Milrinone Dobutamine

An 87 year old female resident in a nursing home with a diagnosis of severe dementia has been reported to yell and curse at staff around bathing. She is argumentative with other residents throughout the day. She has gone without bathing weeks at a time because staff are unwilling to approach her. When asked months of the year backwards, she consistently completes December to April then gives up. What is the best next step in her management? a. Quetapine 12.5mg PO PRN prior to bathing b. Tylenol 1g PO TID c. Risperidone 0.125mg PO BID d. Routine bloodwork including CBC, lytes, creatinine, LFT, TSH, B12 and head imaging

The correct answer is B. Adequate pain control reduces BPSD. This patient’s aggression is stable, which is more suggestive of BPSD than delirium.

Beer’s criteria inappropriate medications in geratric patient ?

Warfarin, rivaroxaban, anticholinergics (amitryptiline, dimenhydrinate, hydroxyzine, paroxetine) Drug-drug interactions : warfarin + SSRIs / Li + ARB/ACEi Baclofen as renal clearance

ChEIs side effects?

BRADYCARDIA so avoid if conduction defects/syncope GI intolerance Urinary incontinence Wild or vivid dreams

Clinical findings associated with poor neurological outcome in ACR?

Absence of pupillary reflex to light at 72h or more LR + 4 Presence of status myoclononus during first 72h LR +5 Absence of the N20 sonatosensory evoked potential cortical wave 24-72h after cardiac arrest or after rewarming LR +16.1 Also : reduced grey white matter differentiation on CT and large diffusion restriction on MRI have poor outcome

Clinical presentation of TCA overdose ?

Anticholinergic toxicity RED as a beet DRY as a bone : urinary retention MAD : sedation, confusion, hallucination BLIND : mydrasis non responsive HOT hyperthermic Seizures

Comment différencier intox alcool isopropylique et intox methanol/ethylene glycol ?

ABSENCE d’un ANION GAP a 4-6h post ingestion : isopropyl ROH ROH isopropylique : - cause PAS d’AG augmente - Toxicite retinienne (methanol) - IRA (ethylene flycol)

Compliance VCI et necessite de bolus ?

Intubated, fully ventilated : distenbility > 15-20% likely to fluid responsive Spontaneoulsy breathing not intubated IVC < 2cm and respiratory variation > 50% : likely fluid responsive

COVID 19 in pregnancy management ?

- Should have 3rd trimester growth ultrasound following infection as risk of growth restriction - Hypertensive disorders including severe preeclampsia higher following infection IF ADMITTED - < 22w or >34 w : methyprednisolone x 10d - 22-34w : dexamethasone x 2d (replace betamethasone for lung maturation) then methylprednisolone x 8d - Post partum : dex x 10d Consnider paxlovid and tocilizumab

Criteres de dialyse pour intox lithium ?

- Arrhymias - Seizures or severely abN mental status - Serum lithium levels > 5 - Serum lithium levels > 4 with a Cr > 176

Criteria for ARDS ?

Hypoxemia PaO2/FiO2 < 100 if severe, 101-200 if moderate Hypoxemia SpO2/FiO2 < 315 with SpO2 < 97%

David Homme de 25 ans en choc avec ARDS. Intubé aux USI. Sous perf de levo 0.4mcg/kg/min. TA 120/65. Hématocrite à 0,31 et Hb 95. ScvO2 à 53% et lactates 3.2. IET avec AI 12, PEEP 10, FiO2 70%, VC 450cc. Gaz pH: 7,46/30/80/25. (reponse pneumo dada) Quoi faire? A) Culot HB B) Débuter perfusion dobutamine C) Augmenter la perfusion de levophed D) Débuter perfusion de vasopressine

B) Perf dobutamine ScVO2 N 60-80% Composé PaO2, Hb, débit cardiaque et ici PaO2 et Hb sont OK

Décrivent un patient avec myopathie des soins. Lequel de ces éléments n’est pas associé à ceci? a) ventilation mécanique b) corticothérapie c) Usage de curare prolongée d) Alitement prolongé

Usage de curare prolongé

ECG in TCA overose ?

- QRS > 100 - Tall R in AVR - Deep slurred S in 1 and aVL - R/S ratio > 0.7 AVR - Type 1 Brugada (RBBB, downslope ST depression V1-V3)

Eclampsia : delivery safe if PLT ? Platelet targets in ITP ?

PLT > 75 ITP : Vaginal delivery >30, C-section >50, neuraxial anesthesia >70-80 treat ITP if PLT < 30, clinically bleeding or < 50 near delivery

EKG and lithium overdose ?

T wave flattening in the precordial leads, QT prolongation, brady, unmask Brugada

F avec pneumonie LIG, sepsis avec TA 85/36. Post 4L de volume, TA toujours 90/35, mais reste avec TVC à l'angle de Louis, pas de surcharge. À l'écho, VG hyperdynamique et VD pas surchargé, pas d'ép péricardique. VCI 1cm avec variation >50% à l'inspiration. TX? A) Pentasharp B) Dopamine C)Lévo D)Soluté de LR

C) Choc refractaire au volume meme wsi encore vide : debuter la levo precocement ameliore la mortalite

Femme de 28 ans qui consulte pour de l’urticaire migratoire depuis 6 semaines. Aucun antécédent personnel ni familial pertinent et ne prend pas de médicament. Aucun angioedème. Ses lésions ne sont pas douloureuses et ne laissent aucune séquelle cutanée. Les bilans biochimiques sont normaux. Quel est le diagnostic le plus probable? A. Urticaire idiopathique B. Angioedème héréditaire C. Vasculite urticarienne D. Urticaire allergique

Femme de 32 ans, admise pour sepsis. Antécédent de réaction allergique suite à l’administration de PNC IV lors d’une appendicectomie il y a 2 ans. Test cutané qui confirme allergie à la PNC et amoxicilline. Quel choix d’antibiotique est le plus sécuritaire? A. Meropenem B. Piptazo C. Aztreonam D. Ceftriaxone

Aztreonam

Femme de 45 ans qui consulte pour une éruption maculopapuleuse érythémateuse qui est très prurigineuse. On note une anaphylaxie aux abeilles nouvelle depuis l'âge adulte. Elle se plaint également de bouffées de chaleur et de douleurs abdominales récurrentes. À l'examen physique, lorsque vous grattez les plaques, elles deviennent très surélevées, rouges et prurigineuses. Ses SV sont normaux. Quel test pourra appuyer le diagnostic? A. 5-HIAA B. Tryptase C. Métanéphrinesurinaires D. InhibiteurC1q

Tryptase Mastocytose systemique, Signe de Darier est suggestif Anaphylaxie, att cutanee, sx GI, hepatosplenomegalie, ADP…

Femme de 50 ans connue pour une allergie à la pénicilline. Elle développe une cellulite du membre inférieur pour laquelle elle reçoit de l'ancef. Quelque temps plus tard, elle développe un urticaire avec des vomissements. SV stables, examen physique cardio pulmonaire normal. Votre traitement? A. Epinephrine B. Prednisone C. Benadryl D. Gravol

Femme de 65 ans connu MPOC (VEMS 65%). A cessé de fumer depuis 3 mois. Pas autres ATCD médicaux. Vous la voyez en préop d'une hystérectomie par laparoscopie. Tous ces éléments augmentent son risque de complications pulmonaires post-op sauf un, lequel? 1. Hystérectomie par laparoscopie 2. Âge de plus de 60 ans 3. MPOC 4. Albumine moins de 30

Hysterectomie par laparo LOW RISK procedures : hip surgery, gyno/uro procedures Albumine < 35 augmente le risque

Femme de 73 ans, connue HTA sous hydrochlorothiazide. Consulte pour un angioedème de la langue sans urticaire. Elle a eu un épisode similaire il y a 3 mois. Quelle est la cause la plus probable? A. Idiopathique B. DéficitC1inhibiteur C. SecondaireàHCTZ D. Désolée,jenemesouviensplus

Femme âgée qui vit en CHSLD. Hx de chutes répétées. Sa fille est inquiète que sa mère soit victime de maltraitance au CHSLD. Qu'est-ce qui est le plus en faveur de maltraitance? 1-Fracture humérus D 2-Fracture col fémoral compactée 3-Fracture arc zygomatique 4-multiple ecchymoses d'âge différentes.

Fracture arc zygomatique

First line for depression in a geriatric patient ?

Sertraline, duloxetine Second line is citalopran or escialopram Monitor for hyponatremia in first 2w

Gestational diabetes, capillary glucose target ?

Fasting < 5.3 1H post prandial < 7.8 Post prandial < 6.7 HbA1c < 6.5 Insuline NPH is first line

HbA1C visé pregrossesse ?

HbA1c < 7 ideally < 6.5

Homme de 50 ans avec FA, DB type 2 et HTA. Il attend une chirurgie élective pour exérèse de lipome et le chirurgien préfère un INR normal pour la procédure, car à risque de saignement, Que faire avec son anti coagulation? A) Cesser Coumadin 48h preop et donner vitamine K le jour SOP. B) Cesser Coumadin 5 jrs et preop et redebuter PO immédiat doses usuelles avec HBPM thérapeutique. C) Cesser Coumadin 5 jrs preop et redebuter PO immédiat doses usuelles D) Cesser Coumadin 48h preop et donner Beriplex jour SOP.

C) Cesser coumadin 5j pre op et redebuter PO immediat doses usuelles

Homme sans abri admis pour altération de l'état de conscience. À l'examen, dilatation fixe des pupilles. Quelle est la cause la plus probable? a) Hypoglycémie sévère b)Hémorragie pontique c) Atropine d) cocaine

Hypoglycemie severe

How long does it take for IV iron to take effect if you give it pre op?

Takes minimum 3-4 days for any effect

How long should you delay surgery after POBA ?

Min 14 days

How long should you stop clopi/tica/prasugrel ?

Clopi and tica 5-7 days Prasugrel 10 days If not = no neuraxial anesthesia

Indication for troponin and ECG post op ?

If emergent or semi urgent : if > 65y or 18-64 with significant CV disease If elective : if > 65y, RCRI ≥ 1, 45-64y with significant CV disease : NT pro BNP do it if ≥ 300 mg/L

Intoxication aiguë au lithium. Arrive à l'urgence 2h post ingestion d'une quantité inconnue. Patient clairement intoxiqué mais protège ces voies respiratoires. Pas de symptôme sévère, diurèse et fonction rénale normale. Lithémie à 3.7. Hydratation IV débutée (NS à 125 cc/h), prochaine étape? 1- Hémodialyse d'urgence 2- Charbon activé 3- Recontrôler lithémie dans 1 heure 4- Furosémide

3) recontroler lithémie Presentation : sx GI, T wave flattening, QT prolongation, brady, unmask Brugada, CNS late findings Lithium NOT absorbed by activated charcoal, whole bowel irrigation possible < 6h ingestion DIALYSE : arrhythmie, atteinte CNS, lithium > 5 ou > 4 avec creat > 176

Jeune femme avec ATCD maladie psychiatrique et tentative suicidaire qui se présente en état d'ébriété et vision embrouillée. SV stable hormis légère tachycardie FC 105 régulière. FSC, Creat, É+ N. pH 7.17, pCO2 basse, BIC 10. lactate 3.4. (on nous donnait l’osmolarité sérique, on devait calculer le gap qui était clairement augmenté). Après avoir donné du fomepizole et débuté un rx de support, quelle sera votre prochaine étape: 1. Perf ethanol 2. Perf bicarbonate 3. Lavage gastrique 4. Dialyse

Dialyse car vision embrouille = critere HD meme si pH 7.17 Prise en charge d’intox alcools toxiques: - Fomepizol ou ethanol - Perf de bic pour viser un pH 7,35 car pH acide permet aux metabolites toxiques de mieux penetrer dans les tissus - Dialyse si 1 critère : dysfonction d’organe, pH ≤ 7.15, acidose metab persistant, high AG metabolic acidosis…

Labs in salicylate toxicity ?

Respiratory alkalosis Anion gap metabolic acidosis If concurrent respiratory acidosis : acute lung injury, CNS depression, mixed overdose

Labs in TCA overdose ?

TCA serum levels not helpful and beware of false positives Respiratory acidosis from decrease LOC ECG very helpful : QRS > 100 (associated with seizures and arrhytmia), tall R in aVR, deep slurred S in 1 and aVL, type 1 brugada (RBBB, downslope ST depression V1-V3), R/S ratio > 0.7

MAP target in septic chock ?

TAM > 65 After initial rescucitation, 60-65 could be considered for elderly patients with ongoing vasodilatation : trend toward possible mortality benefict with permissive hypoension if >65 and chronic HTN

Minimum core temperature before completin DNC assesment ?

Must be ≥ 36 degrees

Mortality benefit giving hydrocortisone in septic chock ?

No mortality benefit Vasopressor sparing agent

Patient de 75 ans vu en pré-op de fracture de hanche. Il est connu pour de l'angine stable CCS classe II, sous AAS et diltiazem à la maison. Les signes vitaux sont normaux, l'examen physique est sans particularité. Un ECG est fourni, qui démontre essentiellement des ondes Q dans le territoire inférieur. Quelle est votre conduite par rapport à la chirurgie? A- OK pour chirurgie, cesser AAS. B- Référer le patient pour une coronarographie urgente. C- Modifier le diltiazem pour du metoprolol avant la chirurgie. D- Débuter nitroglycérine en patch avant la chirurgie.

Ok pour chx, cesser AAS

Patient qui reçoit de l’infliximab et qui développe une réaction avec prurit et rash. Comment gérez-vous la situation? A. Reprendre à débit faible B. Hydrocortisone/benadryl et reprendre une fois le rash passé C. Hydrocortisone/benadryl et reprendre au même débit D. Hydrocortisone/benadryl et ne pas reprendre infliximab

A) Grand majorité des réactions ne sont pas des anaphylaxies Selon severite : donner hydrocortisone/benadryl si nodere a severe

Post op orthopedic VTE prophylaxis after THA or TKA ?

NOT for hip fx surgery DOACS : apix 2.5 BID, dabigatran 220 OD, rivaroxabam 10 OD x 5 then ASA

Prise en charge d’intox alcoool isopropylique ?

Soins de support uniquement Perf de 10%

Prise en charge si embolie veineuse gazeuse ?

Decubitus lateral gauche : place la chambre de chasse du VD dans un angle qui diminue les chances d’embolisation + FiO2 max car permet d’accelerer la vitesse a laquelle l’air se résorbe

Présentation intox alcool isopropylique ?

Dépresseur SNC : AEC / désinhibition / haleine d’acétone ? hypoglycémie FAUSSE elevation de la creat rapportée par interférence de laboratoire avec l’acétone Trouvé dans les désinfectants, hand sanitizer, anti freeze, solvent, rubbing alcohol.

Pt post-arrêt cardiaque, voulons faire neuropronostication, quel serait le plus indicatif d’un pronostique neuro sombre: a) Réponse de décérébration au stimulus douloureux à 72h b) EEG montrant pattern dont le nom m’échappe (pas absence d’activité alpha) c) Absence de gag reflex d) Présence de la protéine S-100B dans le LCR

C) Mais vielle question. Pourrait indiquer atteinte des paires craniennes par herniation.

Quel beta bloqueur preferre en CMP peri partum ? Metoprolol ou labetalol ?

Metoprolol preferred over labetalol as cardio selective Avoid atenolol Lasix, nitrates, digoxin, hydralazine also part of management

RCRi score ?

High risk surgery (intraperitoneal, intrathoracic, supra inguinal vascular) Ischemic heart disease CHF history History of stroke or TIA Db on insuline Pre op creat > 177 Risk of infarct/arrest/death 30d post op 0 4% 1 6% 2 10% 3+ 15%

Salicylate intox treatment ?

- Activated charcoal within 2 hours or can consider whole bowel irrigation - ALKALINIZE the urine and blood target pH 7.4-7.5 with IV bicarb correct hypoK before alkalinization - DIALYSIS if O2, AKI, change mental status,anything severe… and salicylate levels > 7.2

Selon les critères de Beers, tous les rx suivant devraient être évités sauf un lequel ? 1) glyburide 2) polyethylene glycol 3) alprazolam 4) diphenhydramine

polyethylene glycol

Syndrome neuroleptique malin et syndrome serotoninergique: comment les differencier ?

Serotonin syndrome : - MYOCLONUS, HYPERreflexia, bilat babinski - Onset within 24h NEUROLEPTIC - NO clonus and HYPOreflexive - Onset days to weeks

TCA overdose treatment ?

- Decontamination : activated charcoal if < 1-2h unless CI (decreased LOC, gut perforation, bowel obstr) - NS or Na bicarb bolus if hypotensive SODIUM BICARB indication - QRS > 100 - Ventricular arrhytmia - Hypotension Goal pH 7.5-7.55

TCA tx of arryhtmias ?

Wide complex ventricular tachy or QRS> 100 : - Na bicarb 1-2 mEq/kg IV : if QRS narrows start infusion at 250ml/h - If fails : mg sulfate - If fails : lidocaine bolus then perf - If fail and unstable : lipid emulsion DO NOT use phenytoin or physostigmine as will worsen cardiac instability

Test le plus spécifique et test le plus sensible pour dysfonction executive ?

Specifique : horloge Sensible : MoCA

Tests cutanés/pinprick utiles pour dx allergie IgE médié immédiate ou retardé ?

Tests cutanés sont utilisés pour évaluer la présence d’allergie immédiate Pinprick prends 30min à 1h et permet d’éliminer une allergie immédiate a la penicilline

Trouvaille NORMALE pour l’âge a l’examen physique chez une femme de 85 ans ? 1) Diminution des MEO 2) Diminution de l’amplitude de mouv aux epaules 3) Absence de reflexe achilleen 4) Augmentation du tonus musculaire dans les bras 5) Diminution de la force de flexion des hanches

Absence de reflexe achilleen

Très longue vignette. En résumé, jeune patiente dams la vingtaine qui vient de déménager dans un appartement au sous-sol. Le lendemain matin, on la retrouve plus confuse, céphalée, étourdie, présence de vertige. Saturation 87%. Reste des signes vitaux normaux. Labo de bases normaux On fournit un gaz artériel : pH N, Pa02: 112 SatO2: 60 HCO3 N On lui donne de l'oxygène mais quoi faire de plus ? a) CT scan cérébral b) Administrer du bleu de méthylène c) Administrer du dextrose d) Débuter de la norépinéphrine

B) Ici intox methemoglobinémie : empêche la liaison entre Hb et O2 donc PaO2 haute mais SpO2/SaO2 basse = tx bleu methylene Alors que intox carbon monoxide : prends la place de l’O2 sur Hb mais indistinguable par la sat pulsée : PaO2 haute, SpO2 haute + AGMA et lactates hauts. Cherry red skin / lips. Tx : 100% FiO2 +/- chambre hyperbare

Tx of Mg toxicity in context of eclampsia ?

Calcium gluconate, dialysis Monitor toxicity clinically with decreased reflexes and decreased urine output NOT serum Mg levels

Un fermier est amené à l’urgence par sa femme pour AEC. Il a passé la journée sur sa ferme à ranger le fumier, avec des pigeons tout autour, et a épandre des pesticides sur ses terres. Ils ont pris 3h pour se rendre à l’hôpital. Il a les pupilles à 1 mm bilatéralement, peu réactives à la lumière. Il commence à baver. Ses signes vitaux sont FC 80, TA 104/75, Sat 89% AA, afébrile. En plus du traitement de support, quel médicament allez-vous donner à ce patient? 1. Flumazenil 2. Atropine 3. Physostigmine 4. Épinéphrine

2) Atropine Intox organophosphate trouvé dans insecticides Muscarinic effect : MIOSIS, bronchospasm, bradycaria, nronchorrhea, emesis, salivation, diaphoresis, diarrhea Tx: 100% FiO2, IET, atropine

Un homme de 35 ans est retrouvé dans la rue et admis au soins intensifs pour AEC. Signe vitaux : pouls à 102, TA : 118/78, Ventimask a 50%, crépitants bilatéraux et GCS à 11. Plusieurs labos fournies :TO : 10 (fournie) ASA, tylénol, cétones, éthanol : Négatif Bilan qui montraient une acidoses à trou anionique augmenté (à calculer) mais avec un ratio delta- delta à 1. Quoi faire avec le patient IMMÉDIATEMENT? A-consult Néphrologie pour hémodialyse d’urgence B- attendre le reste des bilans toxico en continuant les traitements de C- support intubation et ventilation mécanique D- Fomepizole IV

A) HD Pas besoin de fomepizole car OG N donc tout est deja metabolise

Un homme de 65 ans subit une angioplastie coronarienne avec pose d'un tuteur non medicamenté pour un STEMI. Il est mis sous double thérapie anti plaquettaire avec AAS et Clopidogrel. Une semaine plus tard, vous l'évaluez en prévision d'une hémi-colectomie droite prévue une semaine plus tard pour un néo du côlon. Les chirurgiens ne veulent absolument pas retarder l'intervention. Qu'allez-vous faire par rapport à ses antiplaquettaires? a) Poursuivre AAS et Clopidogrel b) Cesser AAS et poursuivre Clopidogrel c) Cesser Clopidogrel maintenant et poursuivre AAS d) Cesser les deux antiplaquettaires

Cesser clopi et poursuivre AAS

Un patient est admis avec un choc d'origine inconnu. Il est admis aux soins intensifs et un Swan est installé. Une perfusion d'un médicament est débuté afin de maintenir sa pression artérielle. Voici ses paramètres HD après avoir débuté la perfusion: Augmentation de la TA FC DC Diminution de la PAP Augmentation de la RVS Quelle est le médicament qui a été utilisé? 1) Phényléphrine 2) Vasopressine 3) Épinéphrine 4) Dobutamine

Epinephrine Vasopresseur et phenyl sont des vasopresseurs purs donc diminue HR / DC Dobutamine diminue la SVR

Une femme de 70 ans est amenée par sa famille, qui croit qu'elle s'est intoxiquée avec des antidépresseurs tricycliques et de l'ASA non-enrobée. Signes vitaux et examen physique normaux. Qu'est-ce qui augmenterait votre suspicion d'une intoxication à ces médicaments? 1. Oedème pulmonaire à la radiographie 2. Acidose métabolique et respiratoire 3. Raccourcissement du QT à l'ECG 4. Trou osmolaire augmenté

2. Acidose metab et respiratoire Intox ASA : acidose metabolique avec high anion gap et N osmol gap + alcalose respi, si acidose respi surajouté considérer : acute lung injury, CNS depression, mixed overdose Intox tricycline : AEC avec hypoV et acidose respi secondaire Tricyclines AUGMENTE le QT Pulmonary edema in LATE ASA toxicity

Vous voyez en consultation un patient avec antécédent d'angio oedème à la pénicilline. Vous voulez prescrire de la pénicilline. Quel est le meilleur test? A. BAT (basophil activation test) B. IgE spécifique pénicilline C. Re-challenge D. Pinprick

D) Pinprick

What is a abnormal CoHB level ?

> 10 % abdnormal Smokers can have levels 5-10 %

What is a MMSE or MoCA abnormal test ?

MMSE ≤ 23 for dementia MoCA ≤ 26 for MCI/dementia

What is ethylene glycol vs methamol clinical presentation ?

Ethylene glycol - Decreased LOC - Frank hematuria, flank pain, oliguria - HypoCA : risk of PROLONGED QTc - CN palsies - Tetany Methanol - Decreased LOC - Retinal injury leading to blindness - Afferant pupillary defect, mydriasis, retinal sheen…

What is the tx of carbon monoxide poisoning vs cyanide poisoning ?

Carbon monoxide : 100% FiO2 +/- hyperbaric O2 Cyanide : hydrocobalamin, otherwise nitrites, sodium thiosulfate

What is the tx of toxic alcohols intoxication?

- BIC for pH 7.35 : avoid acidemia as allows toxic metabolites to penetrate end organ tissue - FOMEPIZOLE to block degradation of the alcohol into its toxic metabolites indicated if pH < 7.3 or bic < 20 or OG > 10 or urine oxalate crystals - Also folic acid for methanol - Also thiamine and pyridoxine for ethylene glycole - HD: – Indications for HD - any 1 of... • End organ dysfunction (eg. Coma, Seizure, Visual defects, Renal failure) • pH≤7.15 • Persistent metabolic acidosis • High AG metabolic acidosis • Very high level of parent alcohol

What’s the difference between MMSE and MoCA ?

MMSE doesn’t test executive function MMSE for limited education pts, MoCA for highly educated pt

When is risperidone approved for BPSD in dementia ?

ONLY if ALL three conditions met : - pure AD - non pharm rx ineffective - risk to self/others or distressing psychotic sx Antipyschotic black box warning : Increased stroke risk 2x and death 1.6 x

When should you give antenatal corticosteroids in context of eclampsia ?

Bethamethasone 12mg IM x 2 for fetus < 35wks if delivery anticipated within next 7 days

Which of these intoxications will give AGMA ? - Methemoglobimemia - Carbon monoxide - Cyanide toxicity

Carbon monoxide : AGMA and lactic acidosis Cyanide toxicity : AGMA and severe lactic acidosis

Which patient on warfarin needs bridging?

– Mechanical MVR or older AVR (ball- cage, tilting) – DVT, PE or Arterial TE <3 mos – Chronic AFIB, CHADS 5-6 – Rheumatic mitral stenosis – Prior thrombosis when warfarin held – Severe thrombophilia (APLA, Protein C, S, ATIII deficiency)

Which tx have a mortality benefit in ARDS ? In COVID ?

In ARDS : High PEEP in moderate-severe ARDS Prone positioning if P/F < 150, duration > 12h per day In COVID : Dexamethasone x 10days if requiring O2 lower mortality and need for mechanical ventilation Remdesivir if on low flo O2 Tocilizumab PAXLOVID NOT RECOMMENDED

Which vasopresors decrease peripheral resistance?

Milrinone Dobutamine Dopamine at low doses

YEARS algorithm in pregnancy to R/O PE ?

3 criteria of YEARS + d dimer : - signs or sx of DVT - hemoptysis yes/no - PE felt to be most likely dx by MRP 3 negative clinical criteria + d dimer < 1000 : PE ruled out 1 or more clinical criteria + d dimer < 500 : PE ruled out

You are asked to assess a 72yF prior to arthroscopic shoulder surgery for rotator cuff injury. She has history of Hypertension and atrial fibrillation. She reports she is feeling well and walks 4km daily with her dog. Meds: apixaban 5mg bid, chlorthalidone 50 mg daily, metoprolol 50mg BID. On exam: BP 152/78, HR irreg 78 bpm. In RUSB you hear a Late peaking SEM with soft S2, radiation to carotid. ECHO: Aortic stenosis with AVA 0.89 cm2, mean gradient 45 mmHg, peak flow 3.5 m/s, LVEF 60. What do you recommend at this time? a) Hold apixaban 72h preop, resume POD #1 b) Dobutamine stress echo c) Delay surgery and refer to cardiology d) Increase metoprolol to 75mg po BID, Hold apixaban 48h preop, resume POD#1

Pick C - This patient meets some ECHO criteria for severe Aortic stenosis (mean gradient >40 mmHg). Although asymptomatic, we know patients with severe AS have 10-30% risk of postop complications so on your safety exam it is best to get blessing of cardiologist before proceeding. (DSE not required to risk stratify if meets 1 criteria for severe AS already – go straight to cardio referral!)

You see an obese pregnant 26yF for gestational diabetes. You detect a thyroid nodule on your exam. Ultrasound reveals a 1.6 cm hypoechoic left thyroid nodule without calcifications. No adenopathy or family history of thyroid cancer. EXAM: BP 110/70, HR 90, wt 110 kg. Meds: ASA 162mg HS for preeclampsia prevention, metformin 1 g BID, prenatal vitamins, ferrous sulphate 300 mg daily FNA reveals a focus of follicular thyroid cancer. ENT recommends a hemithyroidectomy. She is now 35 weeks GA. Which of the following would you recommend? a) HOLD ASA for 72 h prior to surgery b) Postop Pharmacologic DVT prophylaxis with dalteparin 5000 u sc BID to start POD#1 c) Delay surgery until postpartum. d) Consult OB for recommendations regarding intraoperative fetal monitoring

Pick C. This woman is 35 weeks pregnant. Due to anatomic changes in pregnancy head and neck surgery at this time is VERY DANGEROUS.

Diagnosis of pre eclampsia ?

- HTN (140/90 x 2 or 160/110 x 1) PLUS ONE of the 3 criterias - Proterinuria new or worsening (>2= on dipstick, RPC > 30mg/mmol, RAC > 8mg/mmol or > 300mg of protein on 24h urine) - Another adverse conditions (maternal sx, lab abN, fetal complications) - One or more complications

Sx of magnesium toxicity and tx ?

low BP and bradycardia, decreased reflexes, decreased urine output, low GCS Tx : stop Mg, calcium gluconate, dialysis

Can you give warfarin or DOAC in pregnant or breastfeeding women ? Which ACO in case of HIT ?

Warfarin CI in pregnancy, OK for breastfeeding NOACs not recommended in pregnant or breastfeeding women HIT : danaparoid 1st line then fondaparinux (as cross placenta)

Difference between HELLP and AFLP ?

HELLP > 20w with AST/ALT 1000s and high unconjugated bili due to HEMOLYSIS ask for abdo US to r/o hepatic hemorrhage/infarct/rupture AFLP T3 late with AST/ALT 500 and high CONJUGATED bili Polydipsia and polyuria, ascites

IBD in pregnancy : what to do with MTX, 5 ASA, AZA, anti TNF ?

STOP MTX X 3 months pre conception CONTINUE 5 ASA, AZA, anti TNF

ATB safe and not safe in pregnancy ?

SAFE: macrolides (azithro), PNC/B lactam, carbapenem, iNH, nitrofurantoin (but avoid after 36w) FOSFOMYCIN OK AVOID: fluoroquinolones, tetra, septra NO CIPRO NO DOXY NSAIDS generally avoid and stop if > 32w for PDA non closure