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OMS III > Internal Medicine > Flashcards

Internal Medicine Flashcards

1
Q

Principles of answering infectious disease questions

A
  1. The radiologic test is never the most accurate test.
  2. Risk factors for an infection are not as important as the individual presentation.
  3. Beta-lactam antibiotics have greater efficacy than other classes
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2
Q

Penicillin

A 
Viridans group Strep
Strep Pyogenes
oral anaerobes
Syphilis
Leptospira
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3
Q

Ampicillin and Amoxicillin

A

same as penicillin
E. coli
Lyme disease
Gram neg bacilli

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4
Q

Most accurate test for an infectious disease?

A

Culture

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5
Q

Bacteria covered by Amox

A

HELPS

H Flu
E coli
listeria
proteus
salmonella
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6
Q

What conditions is Amox the best initial therapy for?

A

otitis media

dental infection and endocarditis prophylaxis

lyme disease limitd to rash joint or 7th cranial nerve involvement

UTI in pregnant women

Listeria

enterococcal infections

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7
Q

Penicillinase-resistant penicillins (PRPs)

A

oxacillin, cloxacillin,dicloxacillin, and nafcillin

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8
Q

PRPs treat

A

Skin infections: cellulitis, impetigo, erysipelas

Endocarditis, meningitis, bacteremia from staphylococci

osteomyelitis and septic arthritis when bacteria is susceptible

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9
Q

Methicillin

A

Never the right answer it causes renal failure from allergic interstitial nephritis

really meaning oxacillin sensitive or resistant

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10
Q

Piperacillin, ticarcillin, azolcillin, mezolcillin

A

cover gram negative bacillin (ecoli and proteus) from large enterobaceriaciae group and pseudomonads

best initial therapy for:
cholecystitis and ascending cholangitis
pyelonephritis
bacteremia
hospital acquired and ventilator associated pneumonia
neutropenia and fever

always use with beta lactam inhibitor

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11
Q

Medications that cover MRSA

A 
vancomycin
daptomycin
ceftaroline
linezolid
tedizolid
dalbavancin
telavancin
tigecycline
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12
Q

the amount of cross reaction with penicillins and cephalosporins is

A
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13
Q

All cephalosporins will cover

A

group a b and c strep

viridans strep

e coli

klebsiella

proteus mirabilis

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14
Q

is the case describes a rash to penicillin

A

answer cephalosporins

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15
Q

if the case describes anaphylaxis

A

answer a non-beta-lactam antibiotic

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16
Q

First Generation Cephalosporins

A

Cefazolin, cephalexin, cephradrine, cefadroxyl

staph: methicillin sensitive=oxacillin sensitive=cephalosporin sensitive

streptococci (except enterococci)

some gram neg bacillus like e coli but not pseudomonas

osteomyelitis, septic arthritis, endocarditis, cellulitis

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17
Q

Second Generation Cephalosporins

A

cefotetan, cefoxitin, cefaclor, cefprozil, cefuroxime, loracarbef

same coverage as first generation but add anaerobes and more gram neg bacilli

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18
Q

listeria mrsa and enterococcus are resistant to all forms of

A

cephalosporins

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19
Q

of the cephalsporins only cefotetan and cefoxitin cover

A

anaerobes

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20
Q

Best initial therapy for pid combined with doxycycline

A

cefotetan and cefoxitin

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21
Q

cefotetan and cefoxitin warning

A

increase the risk of bleeding and give a disulfiramlike rxn with alcohol

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22
Q

cefuroxime, loracarbef, cefprozil, and cefaclor

A

respiratory infections such as bronchitis, otitis media, and sinusitis

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23
Q

Third Genertation Cephalosporins

A

Ceftriaxone, cefotaxime, ceftazidime

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24
Q

Ceftriaxone uses

A

first line for pneumococcus, including partially insensitive organisms

meningitis

cap w/macrolides

gonorrhea

lyme involving the heart or brain

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25
Q

Avoid ceftriaxone in neonates because of

A

impaired bilirubin metabolism

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26
Q

Ceftazidime has

A

pseudomonal coverage

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27
Q

Fourth Generation Cephalosporin

A

Cefepime

better staph coverage than 3rd gen

neutropenia and fever

ventilator associated pneumonia

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28
Q

Cefotaxime

A

superior to ceftriaxone in neonates

spontaneous bacterial peritonitis

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29
Q

Fifth Generation Cephalosporin

A

Ceftaroline

Gram neg bacilli and MRSA, not pseudomonas

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30
Q

Ceftaroline is the first Cephalosporin to cover

A

MRSA

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31
Q

Adverse effects of cephalosporins

A

cefoxitin and cefotetan deplete prothrombin and increase risk of bleeding

inadequate biliary metabolism with ceftriaxone

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32
Q

Carbapenems

A

Imipenem, meropenem, ertapenem, doripenem

cover gram neg bacilli (a lot that are resistant), anaerobes, streptococci, staphylococci

neutropenia and fever

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33
Q

ertapenem

A

does not cover pseudomonas like other carbapenems

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34
Q

aztreonam

A

monobactam

exclusively gram negative bacilli

no cross rxn with penicillin

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35
Q

Morganella and Citrobacter are gram neg bacilli so what group of abs would work

A

carbapenems

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36
Q

tedizolid dalbavancin and ortivancin are exclusively for:

A

gram pos cocci and mrsa, found in skin and soft tissue infections

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37
Q

Fluroquinolone drugs

A

Cipro, gemifloxaxin, levofloxaxin, and moxifloxacin

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38
Q

Fluoroquinolone uses

A

best for cap, and penicillin resistant pneumococcus

gram neg bacilli and pseudomonads

ciprofloxacin for cystitis and pyelonephritis

GI infections

moxifloxacin can be used as a single agent for diverticulitis

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39
Q

Cipro and gemifloxacin and levofloxacin muct be combined with what when treating diverticulitis

A

metronidazole bc the don’t cover anaerobes except for moxifloxacin

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40
Q

Quinolones ae

A

bone growth abnormalities in children and pregnant women

tendonitis and Achilles tendon rupture

gatifloxacin removed bc of glucose abnomalities

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41
Q

Aminoglycosides

A

Gentamicin tobramycin amikacin

game neg bacilli (bowel, urin and bactermia)

synergistic with beta lactam abs for enterococci and staphylococci

no effect against anaerobes bc they need o2

nephrotoxic and ototoxic

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42
Q

Acute coronary Syndromes occur when

A

a thrombus forms at the site of rupture of an atherosclerotic plaque and acutely occludes a coronary artery

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43
Q

acute mi is diagnosed based on the presence of at least 3 of the three criteria:

A

typical symptoms, ecg findings, and cardiac enzymes

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44
Q

early reperfusion with pci or thrombolytics reduces mortality and preserves ventricular function in pts who have

A

st segment elevation, no ci, and receive treatment within the first 6 to 12 hours

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45
Q

secondary prevention after mi is to prevent recurrent cardiac events and death

A

smoking cessation, aspirin and clopidogrel, beta blockers, ace inhibitors, and statins

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46
Q

after mi

A

pci can be done to recue ischemia and angina symptoms. bypass surgery may be indicated for pts with multivessel stenosis and impaired systolic function to reduce symptoms and prolong survival

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47
Q

anterior leads

A

v2-v4

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48
Q

lateral leads

A

I, aVL, v5, and v6

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49
Q

inferior leads

A

II, III, and avf

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50
Q

Posterior MI

A

R waves in v1 and v2

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51
Q

STEMI is characterized by

A

ischemic discomfort along with st segment elevation on ecg

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52
Q

unstable angina and NSTEMI

A

will not have st elevation but nstemi is diagnosed by positive cardiac biomarkers

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53
Q

Doxycycline uses

A

Chlamydia

lyme disease limited to rash, joint, or 7th cranial nerve palsy

rickettsia

MRSA of skin and soft tissue (cellulitis)

primary and secondary syphilis in those allergic to penicillin

borrelia, ehrlichia, and mycoplasma

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54
Q

Doxycycline adverse effects

A

adverse effects: tooth discoloration (children), fanconi syndrome (type II RTA proximal), photosensitivity, esophagitis/ulcer

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55
Q

Nitrofurantoin has one indication

A

cystitis, especially in pregnant women

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56
Q

Trimethoprim/Sulfamethoxazole

A

Cystitis

pneumocystis pneumonia treatment and prophylaxis

MRSA of skin and soft tissue (cellulitis)

besides rash it causes hemolysis with g6pd deficiency and bone marrow suppression because it is a folate antagonist

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57
Q

Beta lactam/beta lactamase combinations

A

amoxicillin/clavulanate

ticarcillin/clavulanate

ampicillin/sulbactam

piperacillin/tazobactam

beta lactamase adds coverage against sensitive staphylococci to these agent. they cover anaerobes and are a first choice for mouth and GI abscess.

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58
Q

MRSA drugs

A

telavancin

dalbavancin

tedizolid

oritavancin

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59
Q

Gram positive cocci: staph and strep

treatments

A

Oxacillin, cloxacillin, dicloxacillin, nafcillin

first generation cephalosporins: cefazolin and cephalexin

fluoroquinolones

macrolides (azithromycin, clarithromycin,erythromycin) are third line agents bc they have less efficacy than oxacillin or cephalosporins. erythromycin is also more toxic

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60
Q

Oxacillin (methicillin)-resistant Staph is best treated by

A

vancomycin

linezolid: reversible bone marrow toxicity
daptomycin: elevated cpk

tigecycline

ceftaroline

telavancin

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61
Q

Minor MRSA infections of the skin are treated with:

A

tmp/smx

clindamycin

doxycycline

linezolid

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62
Q

Oral anaerobes above the diaphragm

A

penicillin (G, VK, ampicillin, amoxicillin)

clindamycin

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63
Q

Abdominal/GI anaerobes

A

Metronidazole

beta-lactam/lactamase combinations

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64
Q

Piperacillin and carbapenems and 2nd generation cephalosporins also cover

A

anaerobes

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65
Q

gram negative bacilli

A

E coli, klebsiella, proteus, pseudomonas, enterobacter, citrobacter

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66
Q

gram negative bacilli treatment

A

quinolones

aminoglycosides

carbapenems

piperacillin, ticarcillin

aztreonam

cephalosporins

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67
Q

all cns infections may present with fever, ha, nausea, and vomiting and all of them can lead to

A

seizures

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68
Q

stiff neck, photophobia, meningismus

A

meningitis

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69
Q

confusion

A

encephalitis

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70
Q

focal neurological findings

A

abscess

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71
Q

Meningitis

definition and etiology

A

infection covering the meninges

strep pneumo (60%)
group b strep (14%) 
h flu (7%)
n meningitis (15%)
listeria (2%)

staph with neurosurgery

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72
Q

Meningitis

presentation

A

fever, ha, neck stiffness, photophobia

if confusion occurs you cannot answer what is the ostlikely diagnosis w/o a ct and lumbar puncture

cryptococcal meningitis may be present for several weeks

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73
Q

Meningitis

Aids with

A

croptococcus

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74
Q

Meningitis

camper/hiker, rash shaped like a target, joint pain, facial palsy, rick remembered in 20%

A

lyme disease

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75
Q

Meningitis

camper/hiker, rash moves from arms/legs to trunk, tick remembered in 60%

A

rocky mountain spotted fever (rickettsia)

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76
Q

Meningitits

pulmonary tb in 85%

A

tb

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77
Q

Meningitis with viral etiology presentation

A

none

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78
Q

meningitis

adolescent, petechial rash

A

neisseria

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79
Q

Best initial and most accurate diagnostic test for meningits

A

lp

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80
Q

Meningitis LP results

Bacterial

A

1000s neutros

protein elvated

glucose decreased

stain 50-70%
culture90%

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81
Q

Meningitis LP results

Cryptococcus, lyme, rickettsia

A

10-100s lymphocytes

possibly elevated protein

possibly dereased glucose

stain and culture are neg

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82
Q

Meningitis LP results

Tuberculosis

A

10-100s lymphocytes

markedly elevated protein

glucose may be low

stain and culture are neg

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83
Q

Meningitis LP results

viral

A

10-100s lymphocytes

protein is usually normal

glucose is usually normal

stain and culture are neg

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84
Q

when is a head ct the bets initial test in meningitis?

A

whenever there is possibility of a space occupying lesion

papilledema
seizures
focal neurological abnormalities
confusion interfering with neuro examination

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85
Q

if there is a ci to immediate lp

A

giving abs is the best initial step in management

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86
Q

you cannot do an accurate neuro exam if the pt is severely

A

confused

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87
Q

better to treat and decrease the accuracy of a test than to risk

A

permanent brain damage

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88
Q

Latex agglutination tests

A

if ag detection is positive they are extremely specific. if they are negative they could still have the infection

sensitivity is 50-90%

indicated when the pt has received antibiotics prior to the lp and the culture may be falsely negative

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89
Q

Most accurate diagnostic test

TB

A

acid fast stain and culture on 3 hig volume lumbar punctures

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90
Q

Most accurate diagnostic test

lyme and rickettsia

A

specific serologic testing, ELISA, western blot, PCR

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91
Q

Most accurate diagnostic test

Cryptococcus

A

india ink is 60-70% sensitive

ag is more than 95% sensitive and specific

culture of fungus is 100% specific

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92
Q

Most accurate diagnostic test

Viral

A

Dx of exclusion

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93
Q

Best initial treatment for bacterial meningitis is:

A

ceftriaxone vancomycin and steroids

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94
Q

Base your initial meningitis treatment on?

A

cell count

gram stain is good if positive howevere the false neg rate is almost 50%

protein and glucose levels are too nonspecific to allow for a treatment decision

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95
Q

thousands of neutrophils on csf=

A

ceftriaxone, vancomycin and steroids. add ampicillin if immunocompromised for listeria

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96
Q

steroids have only been proven to lower mortality in what type of meningitis and why do we give them initially

A

strep pneumonia

bc we wont know cultures for a few days

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97
Q

Listeria treatment

A

resistant to cephalosporins but sensitive to penicillins

must add ampicillin to ceftriaxone and vancomycin if these risk factors are present:
eldery
neonates
steroid use
aids or hiv
immunocompromised, including alcoholism
pregnant

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98
Q

Neisseria Menignitidis: additional management

A

resp isolation

rifampin Cipro or ceftriaxone to close contacts to decrease nasopharyngeal carriage (household contacts kissing or sharing cigarettes or eating utensils, work and school does not count, healthcare workers only count if they intubated the pt or performed suction or came in contact with resp droplets

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99
Q

what is almost always the wrong answer on step 2

A

consultation

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100
Q

what is the most common neurological deficit of untreated bacterial meningitis?

A

eight cranial nerve deficit or deafness

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101
Q

encephalitis

A

look for the acute onset of fever and confusion. herpes simplex is by fare the most common cause. must do a head ct first bc of the confusion

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102
Q

most accurate test of herpes encephalitis?

A

PCR of CSF

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103
Q

initial test on a genital ulcerative lesion

A

tzanck, viral culture is most accurate

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104
Q

herpes encephalitis treatment

A

acyclovir is the best initial therapy, fam and vala are not IV drugs

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105
Q

what is used for acycylovir resistant herpes

A

foscarnet

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106
Q

Renal toxicity in herpes encephalitis

A

Foscarnet>Acyclovir

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107
Q

Otitis Media

A

redness immobility bulging and a decreased light reflex o the tympanic membrane, pain is common, decreased hearing and fever can also occur

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108
Q

most sensitive physical finding for otitis media

A

immobility, full mobility will exclude otitis media

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109
Q

what is always the wrong answer for otitis

A

radiology

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110
Q

diagnostic test for otitis media

A

tympanocentesis for a sample of gluid for culture is the most accurate diagnostic test. choose tympanocentesis if there ar emutliple recurrences or if there is no response to multiple abs

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111
Q

treatment for otitis media

A

amox is best initial, if no response or recently treated with amox go with:

augmentin
azithromycin, clarithromycin
cefuroxime,loracarbef
levfofloxacin, gemifloxacin, moxifloxacin

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112
Q

quinolones are relatively ci in

A

children

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113
Q

culture of nasal discharge is always the wrong answer for

A

sinusitis

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114
Q

use of sinus biopsy, aspirate, or endoscopy

A

only needed if:

infection frequently recurs
there is no response to diff empiric therapies

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115
Q

first line therapy for otitis and sinusitis

A

augmentin

doxycycline

Bactrim

decongestant is used in all cases to promote sinus drainage

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116
Q

erythromycin had poor coverage for? in sinusitis

A

strep pneumo

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117
Q

linezolid does not cover? in sinusitis

A

haemophilus, but excellent in resistant gram pos organisms

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118
Q

Pharyngitis presents with

A

pain on swallowing

enlarged lymph node in the neck

exudate in the pharynx

fever

no cough or hoarseness

> 90% If all these are present

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119
Q

pharyngitis diagnostic tests

A

initial test is the rapid strep test - group a beta hemolytic trep, neg cannot exclude disease.

small vesicles or ulcers: HSV or hepangina
membranous exudates: diphtheria, Vincent angina, or EBV

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120
Q

Pharyngitis treatment

A

penicillin or amox is best initial

if allergic to above then cephaliexin if the rxn is only a rash if anaphylaxis use clindamycin or a mcarolide

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121
Q

erythromycin has ae like

A

nausea vomiting and diarrhea

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122
Q

Influenza presents with

A

athralgias/myalgias

cough

fever

ha and sore throat

nausea vomiting or diarrhea especially in kids

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123
Q

Most appropriate next step in the flue

A

if w/in 48 hours then perform a naopharyngeal swab or wash in order to rapidly detect the ag associated with influenza

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124
Q

influenza treatment

A

less than 48 hours since symptoms: oseltamivir, zanamivir. neuraminidase inhibitor shorten the duration of symptoms. treat both a and b

greater than 48 hours: symptomatic treatment only, analgesics, rest, antipyretics, hydration

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125
Q

oseltamivir and zanamivir do not treat complications of influenza like

A

pneumonia

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126
Q

Infectious Diarrhea

Blood and WBC in stool

A

salmonella - poultry
campylobacter - most common cause, assoc with gbs
ecoli o157:h7 - hemolytic uremic syndrome
shigella - 2nd most common hus
vibrio parahaemolyticus - shellfish and cruise ships
vibrio vulnificus - shellfish, history or liver disease, skin lesions
Yersinia - high affinity for iron, hemochromatosis, blood transfusions
cdiff - white and red cells in stool

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127
Q

best test for infectious diarrhea blood and wbcs in stool

A

initial test is blood and fecal leukocytes

lactoferrin is a better answer than leukocytes if it is there

most accurate is stool culture

mos

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128
Q

Infectious Diarrhea

no blood or wbcs in stool

A

viral
giardia - camping/hiking and unfiltered fresh water
cryptosporidiosis - aids with less than 100 cd4 cells, detect with modified acid fast stain
bacillus cereus - vomiting
staphylococcus - vomiting

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129
Q

Infectious diarrhea

Scombroid

A

most rapid onset

wheezing flushing and rash

treat with antihistamine

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130
Q

Indectious diarrhea treatment

A

Mild - oral fluid replacement

severe - fluid replacement and oral antibiotics such as cipro

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131
Q

what is the most accurate in determining the etiology of infectious diarrhea?

A

blood in the stool (invasive like salmonella shigella Yersinia or ecoli) other things are what food was eaten, bowel frequency, and smell are useless

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132
Q

Severe infectious diarrhea means

A 
hypotension
tachycardia
fever
abdominal pain
bloody diarrhea
metabolic acidosis
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133
Q

Giardia treatment

A

metronidazole, tinidazole

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134
Q

cryptosporidiosis treatment

A

treat underlying AIDS, nitazoxanide

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135
Q

Viral diarrhea treatment

A

fluid support as needed

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136
Q

B cereus and staphylococci diarrhea treatment

A

fluid support prn

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137
Q

Acute hepatitis definition/etiology

A

infection or inflammation of the liver

most cases for hep a or b

hep c rarely causes acute infection

hep d only exists in people with hep b

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138
Q

hep e

A

worse in pregnancy esp east Asians

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139
Q

hep from sex, blood and perinatal (parenteral):

A

b c d

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140
Q

hep from food and water:

A

a and e

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141
Q

hepatitis presentation

A

jaundice

fever, weight loss, fatigue

dark urine

hepatosplenomegaly

nausea, vomiting and abdominal pain

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142
Q

acute hepatitis diagnostic tests

A

increased direct bilirubin

increase alt to ast

increased alk phos

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143
Q

aplastic anemia is a rare complication of

A

acute hepatitis

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144
Q

elevated pt

A

fulminant hepatic failure and death

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145
Q

best initial diagnostic test for acute viral hep

A

igm for acute

igg for resolution

hep c activity is with pcr for rna level

hep b and c pcr levels are firt thing to chang as an indication of improvement with treatment and they rise if treatment fails

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146
Q

acute or chronic hep b infection tests

A

surface ag - pos
e ag - pos
core ab - positive igm or igg

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147
Q

resolved, old, or past hep b infection tests

A

core ab - pos igg

surface ab - pos

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148
Q

hep b vaccination tests

A

surface ab - pos

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149
Q

hep b window period test

A

core ab - pos igm then igg

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150
Q

what becomes abnormal first after acquiring hep b infection?

A

surface ab

151
Q

what most directly correlates with the amount of virus or quantity of hep b replication?

A

e ag, correlates with dna polymerase, these pts will most likely need antiviral medications in chronic disease also if e ag is present

152
Q

when do you know that a pt is no longer going to pass hep b?

A

surface ag is present

153
Q

Viral load testing in hepatitis

A

b and c you track the level of viral particles, pcr is used for this, measure response to therapy also

154
Q

what is the best indicator that a pregnant woman will transmit infection to her child?

A

e ag

qualitative test

dna polymerase is a quantitative test

90% of children with mother e ag pos will be infected at birth

155
Q

what is the most common transmission of hep b worldwide?

A

perinatal

156
Q

hepatitis b viral load is more precise than

A

e ag

157
Q

hep a and e resolve

A

spontaneously, takes a few weeks and almost always benign

158
Q

hep b becomes chronic in?

A

10%, treatment doesn’t change this

159
Q

acute hep c treatment

A

interferon, ribavirin and wither boceprivir or telaprevir

this decrease the likelihood of developing a chronic infection

160
Q

only acute hep c get

A

medical therapy

161
Q

sofosbuvir and ribavirin alone can be oral therapy for

A

hep c for genotypes 2 and 3

162
Q

chronicity for hep bi is defined as

A

persistence of surface ag for more than 6 months

163
Q

chronic hep b treatment

A

if positive for e ag with elevated level of dna polymerase, use one of the following: entecavir, adefovir, lamivudine, telbivudine, interferon, or tenofovir

interferon is injection and has the most adverse effects so it is no the best first choice

164
Q

adverse effects of interferon

A

arthralgia/myalgia

leukopenia and thrombocytopenia

depression and flu like symptoms

165
Q

goal of chronic hep therapy is

A

reduce dna polymerase to undetectable levels

convert hose pts with e ag to having antihepatitis e ab

166
Q

hep c genotype 1 treat with

A

ledipasvir and sofosbuvir

167
Q

role of liver biopsy in hep

A

presence of fibrosis with b or c - treat right away

if there is active viral replication, fibrosis will progress to cirrhosis

cirrhosis is not reversible

168
Q

alt levels are not a good indication of the activity of

A

chronic hep, you can have significant infection with normal transaminase levels

169
Q

ribavirin causes

A

anemia

170
Q

treatment of chronic hep c

A

treat if pcrrna viral load is elevated

genotype 1 is treated with ledipasvir and sofosbuvir orally for 12 weeks

other genotypes are treated with sofosbuvir and ribavirin orally

interferon is used in treatment failure

telaprevir and boceprevir are less effective and should never be the first choice

if there is fibrosis on biopsy treatment is urgent

the goal of therapy is to cahive an undetectable viral load

171
Q

key points of hep c treatment

A

acute hep c I streated

hep ci si the only form of acute hep to be treated

everyone born between 45 and 65 is tested for hep c regardless of risk factors

cure rates are exceeding 90%

hopefully prevent the need for liver transplant

172
Q

interferon is rarely used as first line in

A

hep

173
Q

hep c can be effectively cured in the majority of cases, be concerned with the following

A

do not test base only on risk factors (needle use)

anyone with a high pcr rna viral load needs treatment

genotype predicts the response to therapy

viral load assesses the effect of therapy. viral load answers the question has there been an effect

liver bipsy determines how much damage there has been to the liver. if you are going to treat anyone bc the viral load is high there is very little point in doing a liver biopsy.

174
Q

Urethritis

A

what is the mostly likely diagnosis? if urethral discharge

urethritis and cystitis give dysuria with urinary frequency and burning but cystitis does not give urethral discharge

175
Q

urethritis diagnostic tests

A

best initial test is a swab for gram stain

urin testing for nucleic acid amplification can detect gonorrhea and chlamydia

increased wbcs

intracellular gram neg diplococci is sufficient for Neisseria gonorrhea to initiate treatment

most accurate test is a urethral culture, dna probe, or nucleic acid amplification test (NAAT) for chlamydia and gonorrhea.

other causes can be mycoplasma genitalium and ureaplasma

176
Q

urethritis treament

A

use a combination of one drug for gonorrhea and one for chlamydia

quinolones are not the best initial therapy bc of resistance

177
Q

cefixime can no longer be used for

A

gonorrhea

178
Q

Cervicitis

A

cervical discharge and an inflamed strawberry cervix

swab for nucleic acid amplification

treatment is ceftriaxone and azithromycin as a single dose, doxy is efficacious as azithromycin but harder to use

179
Q

PID presents with

A 
lower abdominal tenderness
lower abdominal pain
fever
cervical motion tenderness
leukocytosis

first step if these are present is to exclude pregnancy

180
Q

pid diagnostic tests

A

cervical swab for culture, dna probe, or nucleic acid amplification

clarify need to treat the partner for an std and make treatment more precise

181
Q

cervical testing is not the most accurate test in

A

pid

182
Q

laparoscopy in pid

A

most accurate test

needed rarely, only if dx is unclear and symptoms persists or recur despite treatment

183
Q

pid treatment

A

treat with combo for chlamydia and gonorrhea

inpatient - cefoxitin, or cefotetan combined with doxycycyline

outpatient - ceftriaxone and doxycycline (possibly with metronidazole)

pts with anaphylaxis to penicillin - levofloxacin and metronidazole as outpatient or clindamycin gentamicin and doxycycline as inpatient

184
Q

it is often impossible to determine the specific diagnosis of genital ulcers by physical examination alone, but if this issue appear on step it means the question must

A

provide sufficient clues or evidence to give you the answer

185
Q

all ulcerative genial disease can have

A

inguinal adenopathy

186
Q

painless genital ulcer

A

syphilis

187
Q

painful genital ulcer

A

chancroid (haemophilus ducreyi)

188
Q

inguinal lymph nodes tender and suppurating

A

lymphogranuloma venereum

189
Q

genital vesicles prior to ulcer and painful

A

herpes simplex

190
Q

syphilis diagnostic tests

A

dark field

vdrl or rpr (75% sensitive in primary syphilis)

fta or mhatp (confirmatory)

191
Q

chancroid diagnostic tests

A

stain and culture on specialized media

192
Q

lymphogranuloma venereum diagnostic tests

A

complement fixation titers in blood

nucleic acid amplification testing on swab

193
Q

herpes simplex diagnostic tests

A

tzanck prep is the best intiatl test

viral culture is the most accurate test

194
Q

syphilis treatment

A

single dose of I’m benzathine penicillin

doxycycline if penicillin allergy

195
Q

chancroid treatment

A

azithromycin single dose

196
Q

lymphogranuloma venereum treatment

A

doxycyline

197
Q

herpes simplex

A

acyclovier valaylovir famciclovir

foscarnet for acyclovir resistant herpes

198
Q

If dark field is positive for spirochetes…

A

not further syphilis testing is needed

199
Q

serology is worthless with herpes bc

A

it cannot distinguish between a current infection and a past oral infection

200
Q

primary syphilis presentation

A

painless genital ulcer with heaped up indurated edges (it becomes painful if is becomes secondarily infected with bacteria)

painless adenopathy

201
Q

secondary syphilis presentation

A

rash (palms and soles)

alopecia areata

mucous patches

condyloma lata

202
Q

Tertiary syphilis presentation

A

neurosyphilis
meningovascular (stroke from vasculitis)
tabes dorsalis (loss of position and vibratory sense, incontinence, cranial nerve)
general paresis (memory and personality changes)
Argyll Robertson pupil ( reacts to accommodation but not light)

aortitis (aortic regurg or aneurysm)

gummas (skin and bone lesions)

203
Q

syphilis chancres heal spontaneously even w/out treatment

A

penicillin prevents later stages

204
Q

sensitivity of vdrl or rpr in syphilis

A

primary - 75-85%

secondary - 99%

tertiary - 95%

205
Q

sensitivity of fta-abs in syphilis

A

primary - 95%

secondary - 100%

tertiary - 98%

206
Q

a negative fta means

A

not neurosyphilis

207
Q

if vdrl and rpr are negative it means what for neurosyphilis?

A

nothing, it has not been ruled out yet

208
Q

vdrl and rpr titer levels

A

reliable when greater than 1:8

lower tier is more often falsely positive

high titer (greater than 1:32) are rarely false positive

209
Q

false positive vdrl/rpr

A 
infection
older age
ijection drug use and aids
malaria
antiphospholipid syndrome
endocarditis
210
Q

syphilis treatment

A

primary and secondary syphilis - single I’m injection of penicillin. oral doxy if allergic

tertiary - iv penicillin. desensitive to penicillin if allergic

211
Q

jarish-herxheimer rxn

A

fever and worse symptoms after syphilis treatment

give aspirin and antipyretics, it will pass

212
Q

syphilis, desensitization is the answer for

A

allergies and pregnant women

213
Q

Genital warts (condyloma Acuminata)

A

papillomavirus

diagnosed with visual appearance (wrong answer is biopsy serology stain smear or culture)

remove with cryotherapy liquid nitrogen, surgery laser or melting with podphyllin or trichloroacetic acid

imiiquimod is a locally immunostimulant that leads to sloughing off of the lesion. (also works for keratosis and basal cell cancer) it does not burn or damage the skin

214
Q

Pediculosis (crabs)

A

found on hair bearing areas (askilla and pubis)

itching

sivislbe on surgace

permethrin, lindane is equal in efficacy but more toxic

215
Q

scabies

A

web spaces between fingers and toes or at elbows or genitalia

nipples or near genitals

burrows visible but smaller than crabs

scrape and magnify

permethrin

widespread disease is crusted or hepyrkeratototic and responds to ivermectin, severe disease needs repeat dosing

216
Q

Anatomic defects that lead to UTI

A

Stones
strictures
tumor or prostate hypertrophy
diabetes

any form of obstruction like a foley catherter or foreign body

neurogenic bladder is an obstruction

217
Q

UTI presentation

A

all utis can present with dysuria (frequency, urgency, burning) and a fever

218
Q

UTI urinalysis

A

increased WBC

e coli is the most common

219
Q

quinolones are best initial therapy for

A

pyelonephritis

220
Q

urinary frequency

A

multiple episodes of micturition

221
Q

polyuria

A

increase in the volume of urine

222
Q

Cystitis presentation

A

dysuria

suprapubic pain/discomfort

mild or no fever

223
Q

men with utis have what more often then women

A

anatomic abnormalities

224
Q

Best initial test for uti

A

urinalysis with more than 10 wbc

225
Q

most accurate test for uti

A

urine culture

226
Q

cystitis treatment

A

nitro (3 days worth if uncomplicated and 7 if anatomic abnormality) or fosfomycin

bactrim is local resistance is low

Cipro - don’t use routinely so you don’t get resistance

cefixime

227
Q

all beta lactams are considered safe with

A

pregnancy

228
Q

when do you do a urine culture or imaging with uti

A

frequent episodes or failure to respond to therapy

229
Q

what is first for pyelonephritis treatement

A

ceftriaxone

230
Q

Pyelonephritis presentation

A

flank or costovertebral angle tenderness

high fever

occasionally with abdominal pain from an inflamed kidney

wbcs on ua

ct or sonogram are done to determine anatomic abnormality

231
Q

pyelonephritis treatment

A

ceftriaxone or ertapenem

ampicillin and gentamicin until culture results are known

ciprogloxacin (po for outpt)

232
Q

any drugs for what are good for pyelo

A

gram neg bacilli

233
Q

acute prostatitis

A

dysuria

perineal pain

tender prostate on exam

diagnostic yield of urin culture is increased with prostate massage

treat like pyelo

Cipro or bactrim for 6-8 weeks for chronic

234
Q

prostatitis is usually caused by

A

ecoli

235
Q

diff between cystitis and prostatitis treatment

A

still use Bactrim Cipro and other fluoros but with cystitis in a man you treat for 7 days and prostatitis treat for 2-6 weeks

236
Q

perinephric abscess

A

pyelo that doesn’t resolve with therapy

fever after 5-7 days of pyelo therapy

do imaging

drainage and collection of fluid is must

culture fluid

237
Q

Endocarditis

A

infection of the valve heart leading to a fever and a murmur. diagnosed with vegetations seen on echo and positive blood cultures

238
Q

endocarditis etiology

A

rare on normal heart valves unless injection drug user

risk is proportional to damaged of valve

regurg and stenosis increase risk

prosthetic valves have the highest risk

staph aureus on normal valves and iv drugs

dental procedures althought he risk is small

239
Q

endocarditis presentation

A 
fever
new murmur or change in murmur
splinter hemorrhages
janeway lesions (flat and painless)
osler nodes (raised and painful)
roth spots in the eyes
brain (mycotic aneurysm)
kidney (hematuria, glomerulonephritis)
conjunctival petechiae
splenomegaly
septic emboli to the lungs
240
Q

endocarditis diagnostic tests

A

best initial test is:

blood culture (95-99% sensitive)

transthoracid echo (60% sensitive but 95-100% specific)

transesophageal echo (95% sensitive and specific)

ekg rarely shows and av block if there is dissection of the conduction system (less than 5-10%) sensitive

241
Q

fever + murmur =

A

endocarditis

242
Q

clostridium septicum and strep bovis endocarditis

A

think colonoscopy

243
Q

Establishing a diagnosis of culture negative endocarditis

A

oscillating vegetation on echo

minor criteria:
fever>100.3 or 38
risk such as injection drug use or prosthetic valve
signs of embolic phenomena

244
Q

endocarditis treatment

initial empiric therapy

A

best initial empiric therapy is vanco and gentamicin

245
Q

Endocarditis treatment

viridans strep

A

ceftriaxone for 4 weeks

246
Q

Endocarditis treatment

staph aureus (sensitive)

A

oxacillin nafcillin or cefazolin

247
Q

Endocarditis treatment

fungal

A

amphotericin and valve replacement

248
Q

Endocarditis treatment

staph epi or resistant staph

A

vanco

249
Q

Endocarditis treatment

enterococci

A

ampicillin and gentamicin

250
Q

endocarditis treatment of resistant organisms

A

add an aminoglycoside and extend duration of treatment

251
Q

when do you do surgery with endocarditis

A

chf from ruptured valve

prosthetic valves

fungal endocarditis

abscess

av block

recurrent emboli while on antibiotics

252
Q

add what for prosthetic valve endocarditis with staph

A

rifampin

253
Q

the single stongetst indication for surgery with endocarditis is

A

acute valve rupture and chf

254
Q

treatment of culture negative endocarditis

A

coxiella is most common cause and bartonella

hacek
h aphrphilus
h parainfluenzae
actinobacillus
cardiobacterium
eikenella
kingella

use ceftriaxone for hacek

255
Q

what do you need in order to receive endocarditis prophylaxis

A 
significant heart defect
   prosthetic valve
   previous endocarditis
   cardiac transplant recipient with valvulopathy
   unrepaired cyanotic heart disease

and

risk of bacteremia
dental work with blood
respiratory tract surgery that produces bacteremia

use amox unless allergic use clindamycin azithromycin or clarithromycin

256
Q

procedures or conditions that do no need endocarditis prophylaxis

A

mvp even with a murmur

mitral regurg and stenosis

aortic regurg and stenosis

hocm

asd

257
Q

Lyme disease

definition

A

arthropod borne disease from spirochete borrelia burgdorferi

fever and rash

untreated you get joint pain cardiac disease or neurological disease

258
Q

lyme disease etiology

A

ixodes scapularis (deer tick)

20% of pts recall the tick bite

been hiking or camping

tick must be on for 24 hours to transmit organism

northeast

259
Q

lyme disease rash

A

85-90% of pts

5-14 days after bite

fever

round lesion with pale area in middle (buls eye)

erythema migrans

260
Q

lyme diseas joint pain

A

most common long tem manifestation

60% w/o treatment

few joints are affected (oligoarthritis)

joint fluid will have 25000 wbc

261
Q

lyme disease neuro

A

10-15% of pts

menignits encephalitis or cn palsy

262
Q

lyme disease cardiac

A

4-10% of pts

damage to any part of the myocardium or pericardium such as the myocarditis or ventricular arrhythmia

263
Q

what joint is most commonly affected in lyme disease

A

knee

264
Q

what is the most common neuro manifestation of lyme

A

7th nerve or bells palsy

265
Q

what is the most common cardiac symptom of lyme

A

transient av block

266
Q

lyme diagnostic tests

A

if rash is typical you are done

serology is essential if any of the other symptoms are present,do igm igg elisa western blot and pcr testing

267
Q

lyme treatment

asymptomatic tick bite

A

no routine treatment, but a single dose of doxy is indicated withing 72 hours of bite when:

ixodes scapularis is clearly the tick
attached for longer than 24-48 hours
engorged nymph-stage tick
endemic area

268
Q

lyme treatment

rash

A

doxycycline

amox or cefuroxime

269
Q

lyme treatment

joint or bells palsy

A

doxy

amox or cefuroxime

270
Q

lyme treatment

cardiac and other neuro besides bells palsy

A

iv ceftriaxone

271
Q

HIV/AIDS

definition

A

retrovirus that infects the cd4 t helper cell

cd4 drops at a rate of 50-100 if untreated

5-10 years to deplete cd4 cell and before you get any clinical manifestation

272
Q

HIV/AIDS

etiology

A 
transmitted through
   injection drug use with contaminated needles
   sex, men who have sex with men
   perinatal
   needle stick or blood sharp injury
   transfusion (rare since 1985)

kissing does not transmit it

273
Q

HIV/AIDS

vaginal transmission

A

1 in 3 to 10000 for insertive intercourse

1 in 1000 for receptive intercourse

274
Q

HIV/AIDS

oral sex

A

1 in 1000 for receptive fellatio with ejaculation

unclear for insertive fellatio or cunnilinjus

275
Q

HIV/AIDS

needle stick injury

A

1:3000

276
Q

HIV/AIDS

anal sex

A

1:1000 for receptive anal intercourse

277
Q

HIV/AIDS

mother to chld

A

25-30% perinatal transmission w/o meds

278
Q

HIV/AIDS

presentation

A

infection occurs with progound immunosuppression when cd4 count frops below 50/ul

pcp occurs at 200/ul or below or under 14%

when cd4 is above 200 few infection occur

279
Q

HIV/AIDS

infection with hiv that occur with higher frequency but cd4 above 200

A 
shingles
herpes simplex
tb
oral and vaginal candidiasis
bacterial pneumonia
Kaposi sarcoma
280
Q

HIV/AIDS

diagnostic tests

A

elisa is the best initial test

confirmed with western blot

infants are diagnosed with pcr or viral culture

elisa is unreliabele in infants bc they havce maternal hiv abs for up to 6 months after delivery

281
Q

HIV/AIDS

viral load testing

A

pcr-rna level

measures response to therapy

detect treatment failure

diagnose hiv in babies

if viral load is undetectable (below 50/ul) then cd4 will rise and life expectancy is the same as uninfected person

282
Q

HIV/AIDS

viral resistance testing (genotyping)

A

performed prior to initiating antiretroviral meds so you don’t take a med that your virus is resistant to

also do if there is treatment failure

if treamtner failure select 3 drugs from 2 classes the virus is susceptible to

283
Q

HIV/AIDS

treatment failure first manifests with

A

a rising pcr rna load

284
Q

HIV/AIDS

treatement

A

initiated when:

cd4 drops below 500

or

viral load is very high (greater than 100,000/ul

or

opportunistic infection occurs

antiretroviral meds are ok even if cd4 is greater than 500

285
Q

the strongest indication for antitretroviral med is

A

a cd4 below 500

286
Q

HIV/AIDS

best initial drug choice

A

the best initial drug combo is emtricitabine, tenofovir, and efavirenz, combine in a single once a day pill called atripla

287
Q

usmle step 2 ck does not test

A

dosing

288
Q

changes in cd4 lag behind and are slower to occur than

A

changes in viral load testing

289
Q

treating everyone no matter how high the cd4 is

A

acceptable

290
Q

HIV/AIDS

alternate drug regimens

A

if emtricitabine/tenofivir/efavirenz cannot be used bc of resistance alternate regimesn are based on a combo or 3 drugs from at least 2 diff classes

the first choices are either atazanavir, darunavir, or raltegravir combined with emtricitabine/tenofovir.

abacavir is dangerous with hla b5701 mutation

ritonavir is used with other protease inhibitors to boos their levels

elvitagravir is an integrase inhibitor used with cobicistat which inhibits its metabolism

291
Q

ritonavir in a small dose

A

is used to boost darunivir or atazanavir levels

292
Q

nucleoside and nucleotide reverse transcriptase inhibitors (rtis)

A 
zidovudine
didanosine
stavudine
lamivudine
emtricitabine
abacavir
tenofovir
293
Q

non nucleoside rtis

A

efavirenz
etravirine
nevirapine
rilpivirine

294
Q

protease inhibitors

A

-avirs

295
Q

HIV/AIDS

addtl classes or second line agents

A

used for theose with drug resistance to multiple classes or first line agents

entry inhibitors - enfuvirtide and maraviroc

integrase inhibitors - raltegravir, dolutegravit and elvitegravir with cobicistat

296
Q

cobicistat inhibits

A

elvitegravir metabolism which boosts its levels

297
Q

HIV/AIDS

postexposure prophylaxis

A

all significant needle stick injuries and sexual exposures are given 4 weeks of therapy with combination therapy, choice of therapy is the same as the initial choice of antiretroviral med

exposure to urine and stool are not indicated for prophylaxis unless blood is in them

bites are indicated as needle stick and sex above

298
Q

is postexposure prophylaxis indicated in a needle stick injury if the pts hiv status is unknown?

A

no

299
Q

Zidovudine AE

A

anemia

300
Q

stavudine and didanosine ae

A

peripheral neuropathy and pancreatitis

301
Q

abacavir (if hlab5701) ae

A

hypersensitivity, stevens Johnson rxn

302
Q

protease inhibitors ae

A

hyperlipidemia, hyperglycemia

303
Q

indinavir ae

A

nephrolithiasis

304
Q

tenofovir ae

A

renal insufficiency

305
Q

HIV/AIDS

prevention of perinatal transmission

A

continue if pt is on effective treatment

if not on meds treat with same indications as if not pregnant

do not use efavirenz switch it to protease inhibitors they are ok to use

give no matter what cd4 levels are

baby receives zidovudine during deliver (interpartum) and for 6 weeks after to prevent transmission

306
Q

Cesarean deliver for hiv positive mothers

A

prevents transmission of virus if load is high

if viral load is over 1000/ul do c section

intrapartum antiretrovirals with zidovudine are routinely given to every pregnant hiv positive pt

307
Q

fully controlled hiv (viral load undetectable) give what percentage of transmission

A

less than 1%

308
Q

anaphylaxis definition

A

worst from of allergic condition or acute event

synonymous with term: immediate hypersensitivity

must be presensitized to ag

ige binds to mast cells leading to the release of their granules (histamine prostaglandins and leukotrienes)

anaphylactoid rxns are not ige related but are clinically identical and are treated the same way, they are not presensitized though

resp and hemodynamic problems

309
Q

anaphylaxis etiology

A

the same causes of any allergic event

insect bite and stings

medications: penicillin phenytoin lamotrigine quinidine rifampin and sulf

foods

310
Q

anaphylaxis is identified by what

A

severity not the cause of the reaction

311
Q

latex is a very important cause of anaphylaxis in who

A

healthcare

312
Q

anayphylaxis presentation

A

rash (hives)

hypotension and tachycardia

Resp: sob wheeze swelling of lips tongue or face and stridor

can also have itching, constriction of airways, dyspnea, nausea, vomiting, diarrhea, dizziness or fainting

313
Q

urticarial is considered part of anaphylaxis and not just an

A

allergy

314
Q

anaphylaxis treatment

A

best initial therapy is:

epinephrine

antihistamines such as diphyenhydramine (h1blocker) and ranitidine (h2blocker)

glucocorticoids such as methylprednisolone or hydrocortisone

emergent airway protection if needed: intubation or cricothyroidotomy

315
Q

there is no specific test to define

A

anaphylaxis

316
Q

angioedema definition

A

sudden swelling of the face, tongue, eyes, or airway

this can be from deficiency of c1 esterase inhibitor

there is a characteristic association with the onset with minor physical trauma

often is idiopathic

317
Q

look for ace inhibitor when pt has

A

angioedema

318
Q

angioedema presentation

A

hereditary is characterized by sudden facial swelling and stridor with the absence of pruritus and urticarial. hereditary does not respond to glucocorticoids

319
Q

angioedema diagnostic tests

A

best initial test is for dereased levels of c2 and c4 in the complement pathway as well as deficiency of c1esterase inhibitor

320
Q

ecallantide is specific therapy for

A

angioedema

321
Q

angioedema treatment

A

for acute therapy use ffp or ecallantide

for long-term management use androgens: danazol and stanazol

ensure airway protection first; can be a rapidly evolving process

322
Q

urticaria

A

for of allergic reaction that causes sudden swelling of the superficial layers of the skin

can be caused by:
   insects
   medication
   pressure
   cold
   vibration
323
Q

urticaria treatment

A

antihistamines: hydroxyzine, diphenhydramine, fexofenadine, loratidine, or cetirizine: ranitidine

leukotriene receptor antagonists: montelukast or zafirlukast

324
Q

allergic rhinitis

etiology

A

seasonal allergies like hay fever are common. this is an igedependent triggering of mast cells

325
Q

allergic rhinitis

presentation

A

recurrent episodes of:

watery eyes, sneezing, itchy nose, itchy eyes

inflamed boggy nasal mucosa

pale or violaceous turbinates

nasal polyps

326
Q

allergic rhinitis diagnostic tests

A

most often a clinical dx with recurrent episodes

skin testing and blood testing for reactions to ags may be sueful to identify a etiology

allergen specific ige levels may be elevated

nasal smear may show large number of eos

327
Q

allergic rhinitis

treatment

A

prevention with avoidance of precipitating allergen
close windows and don’t use ac to avoid pollen
get rid of animals to which the pt is allergic
cover mattresses and pillows
use air purifiers and dust filters

intranasal corticosteroid sprays

antihistamines: loratidine clemastine fexofenadine and bormpheniramine

intranasal anticholinergic medications: ipratropium

desensitization to allergens that cannot be avoided

328
Q

common variable immunodeficiency

etiology

A

b cells are present in normal numbers but they do not make effective amounts of ig there is a decrease in all subtypes: igg igm and iga

329
Q

common variable immunodeficiency

presentation

A

cvid presents with recurrent sinopulmonary infections in adults with an equal gender distribution. there are frequent episodes of bronchitis pneumonia sinusitis and otitis media

other manifestations are:
giardiasis
sprulike intestinal malabsorption
increase in autoimmune diseass such as pernicious anemia and seronegative rheumatic disease

330
Q

common variable immunodeficiency give a marked increase in the risk of

A

lymphoma

331
Q

Cvid basics

A

low b cell output

normal t cells

332
Q

x linked agammaglobulinemia (brutons) basics

A

low b cells

normal t cells

young males

333
Q

scid basics

A

low b cells and t cells

analogous to hiv

334
Q

iga deficiency basics

A

atopic disorders

anaphylaxis

335
Q

hyper ige syndrome basics

A

skin infections (staph)

336
Q

wiskott-aldrich syndrome basics

A

normal t and b cells

low platelets

eczema

337
Q

lymph nodes with purulent material basics

A 
infections, combined with:
   staphylococcus
   burkholderia
   nocardia
   aspergillus
338
Q

Coronary Artery Disease

definition

A

Coronary Artery Disease can be used interchangeably with atherosclerotic heart diease or ischemic heart disease

all of these terms imply insufficient pergusion of the coronoary arteries from an abnormal narrowing of the vessels, leading to insufficient oxygen delivery to the myocardial tissue

339
Q

by the time a woman is 55-60 the protective effect of menstruation and naturally occurring estrogen have worn off and the rate of what will be the same in men and women

A

cad

340
Q

menstruating women virtually never have?

A

MI

341
Q

estrogen does not improve cad but can improve?

A

ldl

342
Q

the worst risk factor for cad is?

A

diabetes

343
Q

the most common risk factor for cad is?

A

hypertension

344
Q

risk factor for coronary artery disease

A

dm

tobacco

htn

hyperlipidemia

family hx of premature cad

age above 45 in men and 55 in women

345
Q

how many people in country suffer from htn?

A

20% or 60 million

half of them don’t know they have htn

346
Q

family hx and cad

A

this does not covey a risk for the pt if cad developed in elderly relatives or if the realtives were grandparens cousins or aunts and uncles

first degree relatives are sibling and parents

only first degree relatives matter and it must also be premature

347
Q

premature cad is defined as being in a family member who is:

A

male under 55

female under 65

348
Q

hyperlipidemia and cad

A

marked ldl elevation is by far the most dangerous portion of a lipid progile for a pt

a low hdl is also associated with a porr long term prognosis

elevatd tri levels are potentially dangerous but not as porr of an outcome as ldl, treating tris doesn’t really show benefit

obesity, especially abdominal girth is associated with increased cardiac mortality

much of the danger of obesity is from its associations with hyperlipidemia diabetes and htn

349
Q

less reliable but probably risk factors for cad

A

physical inactivity

excess alcohol ingestion

insufficient fruits and veggies

emotional stress

elevated cardiac ct scan calcium scores

positron emission tomography (PET) scanning

increased physical activity and exercise reliably lower all-cause mortality but physical inactivity is not as severe a risk for cad as diabetes and htn

calcium scores on a ct scan of the heart are still considered experimental. it is not clear what to do differently with this information in addition to standard risk factors

350
Q

tako-tsubo cardiomyopathy

A

acute myocardial damage most often occurring in postmenopausal women immediately following an overwhelming, emotionally stressful event. (divorce financial issue earthquake lightning strike and hypoglycemia)

this lead to ballooning and left ventricular dyskinesis. as with ischemic disease manage with bblockers and acei, revascularization will not help bc arteries are fine

351
Q

unreliable risk factors for cad

A

homocysteine levels

chlamydia infection

elevated c reactive protein

these levels have not been proven to be reliable and are the wrong answer

352
Q

the most common wrong answer on cad risk factor questions

A

usually family hx: mistaking cad in elderly relative, even if they are the pts parents but their age is above the guidelines don’t choose it

353
Q

correcting what risk factor for cad results in the most immediate benefit for the pt

A

smoking cessation results in the greatest immediate improvement in pt outcomes for cad

withing 1 year of stopping smoking the risk of cad decreases by 50% withing 2 years of stopping smoking the risk is reduced by 90%

354
Q

what is the most likely dx

chest pain

A

ischemic pain is described as:
dull or sore
squeezing or pressure like

qualities of pain that go against ischemia are:
sharp knife or poinlike
lasts for a few seconds

355
Q

ischemic pain is not

A

tender

positional

pleuritic

356
Q

the most common cause of chest pain that is not ischemic in nature is

A

gi disorders

357
Q

for every 100 people presenting to the ed with chest pain how many have an mi and how many do not have any cardiac disease

A

10%

50%

358
Q

stable angina lasts

A

> 2 min but

359
Q

ACS lasts

A

> 10 to 30 min

360
Q

provoking factors or ischemic chest pain

A

physical activity, cold, emotional stress

361
Q

associated symptoms of ischemic chest pain

A

sob

nausea

diaphoresis

dizziness

lightheadedness

fatigue

362
Q

quality of ischemic chest pain

A

Squeezing tightness heaviness pressure burning aching

not sharp pins stabbing knifelike

363
Q

location of ischemic chest pain

A

substernal

364
Q

alleviating factors of ischemic chest pain

A

rest

365
Q

ischemic chest pain radiation

A

neck lower jaw and teeth arms and shoulders

366
Q

Causes of chest pain

chest wall tenderess

A

most likely dx - costochondritis

most accurate test - pe

367
Q

Causes of chest pain

radiation to back, unequal blood pressure between arms

A

most likely dx - aortic dissection

most accurate test - chest cray with widened mediastinum, chest ct, mri, or tee confirms the disease

368
Q

Causes of chest pain

pain worse with lying flat, better when sitting up, young (

A

most likely dx - pericarditis

most accurate test - ekg with st elevation everywhere, pr depression

369
Q

Causes of chest pain

epigastric discomfort, pain better when eating

A

most likely dx - duodenal ulcer disease

most accurate test - endoscopy

370
Q

Causes of chest pain

bad taste, cough, hoarseness

A

most likely dx - gerd

most accurate test - response to ppis, aluminum hydroxide, and magnesium hydroxide, viscous lidocaine

371
Q

Causes of chest pain

cough, sputum, hemoptysis

A

most likely dx - pneumonia

most accurate test - chest xray

372
Q

Causes of chest pain

sudden-onset sob, tachycardia, hypoxia

A

most likely dx - pe

most accurate test - spiral ct or v/q scan

373
Q

Causes of chest pain

sharp pleuritic pain tracheal deviation

A

most likely dx - pneumothorax

most accurate test - chest x ray

OMS III (21 decks)

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