Internal Medicine Notes Flashcards
_________ angina occurs when there is clean coronary arteries that produce ischemia due to vasospasm. Treatment is ______
Prinzmetal’s; CCBs
What additional bone finding is associated with primary hyperparathyroidism?
Osteitis fibrosa cystica (“brown tumor”) — from overstimulated osteoclasts creating large bone lesions
Which of the following commonly cause elevated aminotransferases? Select all that apply
A. Carbamazepine B. Gabapentin C. Isoniazid D. Metformin E. Phenytoin F. Statins
A. Carbamazepine
C. Isoniazid
E. Phenytoin
F. Statins
What do you do if a pt on warfarin has a supratherapeutic INR that is <5 and there is no evidence of bleeding?
Hold a dose
Crescendo decrescendo murmur heard best at aortic region
Aortic stenosis
Symptoms of hypercalcemia
Stones (calcium nephrolithiasis)
Bones (fracture, osteopenia)
Abdominal groans (n/v, pain)
Psychic moans (AMS)
Symptoms of aortic stenosis
Angina (especially on exertion)
Syncope
Active CHF
Management of postrenal failure
The goal is to alleviate the obstruction
Insertion of a catheter can relieve obstruction of the distal GU
Stenting, nephrostomy tubes, and rarely open surgery are used for proximal GU system
Ventricular tachycardia is a wide complex and regular tachycardia. Look for “tombstone” pattern. Since it’s ventricular, there are no p waves at all - just QRS complexes. It responds to __________ (newer/better) or _______ (older/cheaper)
Amiodarone; lidocaine
Management based on kidney stone size
<5 mm = hydration and pain control
<7 mm = medical expulsive therapy (CCBs like amlodipine, alpha blockers like terazosin)
<1.5 cm = ureteroscopy for distal stones, lithotripsy for proximal stones
> 1.5 cm = laparoscopic exploration for proximal stones, percutaneous anterograde nephrolithotomy for distal stones
Initial treatment in the ED for asthma exacerbation
O2
Albuterol/ipratropium nebulizers (to reverse bronchoconstriction)
Corticosteroids (to reverse inflammation)
—Repeat peak flow, CO2 retention, O2 sat, and lung assessment after initial intervention
Pleural effusions are diagnosed on chest x-ray and first become apparent with blunting of the costophrenic angles, which requires at least 250 ccs of fluid. If more than that is present, the air-fluid level rises. In that case, a __________ is needed to assess if the fluid is free moving (not loculated) and in sufficient quantity (greater than ______ from chest wall to fluid level) to do a thoracentesis
Recumbent x-ray; 1 cm
[note that CT scan or bedside ultrasound can also assess for loculation]
Heart rhythm characterized by regularly prolonged PR interval. There’s no interval change between beats but each is prolonged. There are no dropped beats
First degree AV block
2 high intensity statins
Atorvastatin 40, 80
Rosuvastatin 20, 40
Why do patients with DKA often present with hyperkalemia?
- The acidosis drives K+ out of cells into the serum
- Insulin deficiency inhibits K+ transport into cells
Even though they appear hyperkalemic, DKA pts are actually K+ deficient. With the diuresis that results from hyperglycemia, K+ is lost in the urine. When insulin is started and K+ is driven back into cells, serum K+ can drop precipitously. As soon as this happens, K+ needs to be added to the IV fluids and monitored closely during course of tx. If serum K+ is <3.3 mEq/L you must replace that BEFORE starting insulin therapy.
In patients that meet the criteria, screening for lung cancer is done with what test?
Annual low dose CT scan of the chest
What will CXR, EKG, and ABG usually show in the setting of PE?
Normal CXR
EKG shows S1Q3T3 = right heart strain
ABG shows hypoxemic respiratory alkalosis
Pericarditis presents as pleuritic chest pain that improves with leaning forward. It will have a multiphasic friction rub. What is the characteristic finding on ECG?
Diffuse ST elevation with PR segment depression
Causes of obstruction in postrenal failure
Stones and cancer can cause obstruction throughout, but are most often in the ureters
BPH, Neurogenic bladder, and kinked catheters most often affect the distal GU system
Best test for dx of kidney stones
Non-contrast CT
[use US in pregnancy]
Granulomatous disease (sarcoid, TB) can turn on _________ independently of kidneys, which increases calcium and turns off PTH, resulting in phosphate being unable to be renally excreted. Use _______ to treat the underlying disease
Vitamin D
Steroids
Treatment for pericarditis
NSAIDs + Colchicine
Define CVA permissive HTN
> 220 systolic and/or >120 diastolic
Adjustment of risk factors for acute coronary syndrome relating to LDL includes statin therapy with LDL goal of ______ and HDL goal of ______
<70; >40
How do you definitively diagnose ARDS vs. CHF?
Measure capillary-wedge pressures via Swan-Ganz cath
In ARDS, this will show a decreased or normal wedge (no backup of fluid) and an increased or normal LV function (not heart failure)
There are 2 types of effusions - transudates and exudates. What is a transudate and what are some potential causes?
Transudate = a lot of fluid, and not much else. Usually bilateral
Caused by an intravascular pathology; either an increased hydrostatic pressure (CHF) or decreased oncotic pressure (nephrotic syndrome or cirrhosis)
Management of HTN and proteinuria in CKD
Use either ACE-I or ARB (don’t combine) with BP goal of <130/<80
2 drug options for pharmacologic stress test
Dobutamine
Adenosine
Myoglobin nephritis will present with blood in the urine but no RBCs, how do you tx?
NaHCO3
IVF
Causes of mitral regurg
Chordae tendinae rupture
Infective endocarditis
Direct trauma
How do you manage a pt with non-valvular atrial fibrillation present for >48 hours?
Place pt on warfarin or NOAC for 4 weeks (no LMWH bridge needed). After 4 weeks, TEE is done. If no clot is found, cardioversion is done and pt remains on anticoagulation for another 4 weeks
[Major difference from valvular afib is that you can choose NOAC or warfarin, and you do NOT need to bridge with LMWH]
Radioopaque vs. radiolucent stones
Radioopaque = calcium oxalate, magnesium/ammonium/phosphate (struvite)
Radiolucent = uric acid, cysteine
Management of diabetes in CKD
Similar to general diabetic management — A1c goal is still <7
Don’t use metformin
What are the stages of chronic kidney disease?
Stage I = GFR >90
Stage II = mild, GFR 60-89
Stage III = moderate, GFR 30-59
Stage IV = severe, GFR 15-29
Stage V = renal failure/ESRD, GFR <15, dialysis required for survival
Confirmatory test for valvular disease when a murmur is heard on cardiac auscultation
Echocardiogram
Screening for lung cancer is done with annual low dose CT of the chest. What are the criteria for those who require screening?
30 pack year history
Quit less than 15 years ago
Age between 55-80 years old
Treatment for mitral stenosis
Preload reduction
For severe disease, balloon valvotomy or valve replacement
If there is afib, anticoagulate and cardiovert once lesion is identified
Staging method for lung cancer
PET CT
List complications of CKD
Anemia Secondary hyperparathyroidism Osteoporosis Volume overload Metabolic acidosis
A pt with RBC casts on urinalysis is indicative of glomerulonephritis. There are many diseases that can cause this and the way to tell them apart is with biopsy - something that is not often done. Learning the typical history should help you tell them apart. What becomes important is to rule out nephrotic syndrome with a UA spot test or 24-hr urine. What are you looking for?
> 3.5 g/24 hr urine
Edema
Hyperlipidemia
Best test for dx of coronary artery disease
Catheterization
[assesses severity of stenosis AND helps r/o Prinzmetal angina]
DVTs form in the deep veins, typically the ______ or _______ veins. Since there aren’t valves in deep veins, a piece of clot can travel up to the IVC and into the lungs where it gets stuck in a small vessel.
Popliteal; femoral
What criteria are used to characterize thoracentesis fluid?
Light’s criteria — compares serum protein and serum LDH to pleural protein and pleural LDH
Note that definitive diagnosis of pleural fluid also depends on WBC, RBC, pH, and glucose levels
Levels of _____, _____, and ____ are non-diagnostic for sarcoid but can be used to track therapy
ACE, Calcium, Vit D
Chronic NYHA classes I-IV
I = no patient limitations, no symptoms
II = slight limitations, pt is comfortable at rest and walking
III = moderate limitations, pt is comfortable at rest only
IV = totally limited, pt is bed-bound and has symptoms at rest
The only thing that causes metabolic alkalosis is high aldosterone. The decision becomes whether the person is volume responsive. This is done in one of two ways: using the hx to say pt is volume down and give fluids then recheck bicarb, OR by checking the urine chloride.
What does it mean if it’s low (<10) vs. high (>10)?
Low (<10) = pt is salt-sensitive, or volume responsive, and giving them fluids will help their condition
High (>10) = not volume responsive. If pt is hypertensive, consider diseases of too much aldosterone (renal artery stenosis, Conn’s syndrome). If the pt is NOT hypertensive, consider genetic syndromes like Bartter and Gitelman
If hypokalemic, oral replacement is preferred. If IV must be used, the rate must be less than _______ if by peripheral IV, or less than ______ if by central line
<10 mEq/hr; <20 mEq/hr
______ is an alternative to statins that decreases fatty acid release and decreases LDL synthesis. It may cause flushing, which can be treated by aspirin prophylaxis
Niacin
Intrarenal disease is quite difficult to diagnose, and definitive diagnosis can be made with biopsy — however this is rarely the right answer. Instead, use of the clinical history and urinalysis can often provide the diagnosis. What finding on UA is particularly helpful in differentiating between the 3 types of intrarenal disease?
Casts
Pt presents with glomerulonephritis and history of asthma and hematuria
What type of glomerulonephritis?
Churg-strauss
When someone presents to the ED with acute or refractory symptoms of asthma they need to be treated and stratified. Evaluation requires what 3 components?
Peak expiratory flow rate (PEFR)
Physical exam
ABGs
[A CXR isn’t needed but may be used to r/o other causes of dyspnea]
Pharmacologic therapy options for inpatient DVT prophylaxis
Unfractionated heparin 5000 units subQ q8hrs
LMWH options: enoxaparin 40 mg subQ daily, Dalteparin 5000 units subQ daily
Fondaparinux daily injection
Whenever a cardiac stress test is positive, the next step is ________
Catheterization
Pattern of breathing characterized by oscillations between apnea and tachypnea seen in patients with stroke, TBI, brain tumor, CHF, or actively dying
Cheynes-Stokes breathing
Pattern of very deep respirations with a normal rate; this is a compensatory mechanism that allows patients who have metabolic acidosis (such as DKA) to blow off additional CO2
Kussmaul breathing
What is the best test for diagnosing PE?
CT angiogram
What are the criteria required to start chronic home O2 in a COPD pt?
pO2 <55 on ABG or SpO2 <88% on pulse ox at rest, activity, or exercise
[goal is to titrate SpO2 >88-92%]
Causes of high anion gap metabolic acidosis
Methanol Uremia DKA Propylene glycol Iron and INH Lactic acidosis Ethylene glycol Salicylates
Typical treatment for sarcoid includes _____ and ______
Methotrexate; cyclophosphamide
Steroids may be used for associated uveitis, bells palsy, and erythema nodosum
Pt presents with glomerulonephritis and history of hemoptysis, hematuria, and positive anti-GM antibodies
What type of glomerulonephritis?
Goodpasture
Vertebrobasilar insufficiency may result in syncope. What test is used to diagnose?
CT angiogram
Hyperosmolar hyperglycemic state is a condition characterized by very elevated blood glucose, usually over 600, as well as increased serum osmolarity (usually above 300) and no ketones present; usually develops in pts with chronic hyperglycemia and an inciting event such as infection or other acute illness.
If this condition were accompanied by severe mental status changes, it would be termed ___________
Nonketotic hyperosmolar coma
[aka hyperosmolar hyperglycemic nonketotic coma]
Symptoms of mitral regurg
Atrial stretch — possible afib
Pulmonary congestion (possible CHF)
Decreased forward flow —> cardiogenic shock
When evaluating chest pain, it is important to r/o the most severe disease (STEMI) first with a 12-lead ECG, looking for ST-segment elevations or a new _______.
STEMI tx is emergent cath. If negative, r/o NSTEMI with _________. NSTEMI goes to urgent cath. If both STEMI and NSTEMI testing are normal, determine whether chest pain is coronary in nature at all using ___________
LBBB
Biomarkers (Troponin-I); Stress test
SVT is an aberrant reentry that bypasses the SA node and will be distinguished from a sinus tachycardia by a resting HR >150 with the loss of P waves. What is the pharmacologic tx?
Adenosine
_______ _______ is the most common cause of acute kidney injury in the outpatient setting and should correct quickly with fluid
Prerenal azotemia
Sinus bradycardia is simply a slow normal sinus rhythm that responds to ______ until it gets really bad, then only pacing helps
Atropine
Anti-anginal antihypertensive agents that cause peripheral edema; they are not useful in heart failure with reduced EF
Dihydropyridine calcium channel blockers
Restrictive lung disease resulting from exposure to rock dust (quarries, blasting) and sand blasting; unique CXR findings of upper lobe nodules. There’s no tx but pts should be screened annually for TB
Silicosis
What do you do if a pt on warfarin has a supratherapeutic INR and there is evidence of bleeding?
FFP
Vitamin K
Symptoms of hyperkalemia
Areflexia
Flaccid paralysis
Paresthesia
ECG changes — PR prolonged, widened QRS, peaked T waves
4 categories of patients who should be on a statin
- Vascular disease — MI, CVA, PVD, carotid stenosis
- LDL >190
- LDL 70-189 + age 40-75 + diabetes
- LDL 70-189 + age 40-75 + risk factors
[risk factors include diabetes, smoking, HTN, dyslipidemia, age >55 for women, age >45 for men]
Tx for new onset atrial fibrillation <48 hours, or atrial fibrillation in unstable pt
Cardioversion
Guidelines for initiating diabetes therapy in the following cases:
A1c <9%
A1c >9%
A1c >10% or severe sxs
A1c <9% = metformin monotherapy
A1c >9% = dual therapy (metformin + additional agent)
A1c >10% or severe sxs = combo injectable therapy (basal insulin + mealtime insulin or GLP-1 receptor agonist)
DVTs form in the deep veins, typically the popliteal or femoral veins. Since there aren’t valves in deep veins, a piece of clot can travel up to the IVC and into the lungs where it gets stuck in a small vessel. What are the 2 primary consequences?
- Because blood is unable to get to the alveoli, there’s limitation of gas exchange
- Because there’s less piping to pump blood through, there’s an increase in pulmonary vascular resistance, creating right heart strain
LMNOP mnemonic for tx of CHF exacerbation
Lasix Morphine Nitrates O2 Position
For exercise induced asthma with known triggers, the IgE/Histamine stabilizers ______or ______ can be used immediately before known exposure but with limited use
Nedocromil; cromolyn sulfate
A pulmonary nodule is found on CT scan and on comparison of old films, you find that it has not changed in 2 years. What is the next step?
No change in 2 years means it is stable — no further follow up required
Acute tubular necrosis is caused by either ischemic damage or toxin exposure. The tubules necrose, die, and slough off producing muddy brown casts. The pt will go through what 3 phases?
Prodrome — creatinine rises but urine output remains the same
Oliguric — creatinine rises but urine output plummets (caution fluid overload)
Polyuric — pt pees a lot
What are some causes of restrictive cardiomyopathy?
Sarcoid Amyloid Hemochromatosis Cancer Fibrosis
What are the Well’s criteria used in evaluation of DVT/PE?
PE most likely dx, s/s DVT = 3 points each HR > 100 = 1.5 points Immobilization = 1.5 points Surgery w/i 4 weeks = 1.5 points Hemoptysis = 1 point Malignancy = 1 point Hx of DVT or PE = 1.5 points
Wells Score for V/Q scan interpretation
Score <2 = small probability
Score 2-6 = moderate probability
Score >6 = high probability
Modified Well’s — do I do a CT scan?
Score of 4 or less = don’t do it
Score >4 = Do it
Decrescendo murmur heard best at aortic valve
Aortic insufficiency
Hypertrophic cardiomyopathy is a ______ ______ inherited mutation of myocyte sarcomeres, causing an asymmetric hypertrophy of the septal wall which occludes the aortic outlet — thus it presents similar to aortic stenosis except that its heard at the apex and improves with increased preload.
Autosomal dominant
Central lung lesion caused by smoking; typically metastasized by the time it is dx. Requires CT scan to see, and EBUS with bx will confirm. Can produce ADH causing SIADH or ACTH causing Cushings, also may cause lambert eaton
Small cell carcinoma
Carcinoid is a rare neuroendocrine tumor that may occur in the small intestine or lung. It produces serotonin, which degrades to 5-HIAA and gets secreted into the urine. What are clinical features?
Because the serotonin originates in the lung, it will cause a left-sided valve fibrosis along with flushing, wheezing, and diarrhea typical of the intestinal carcinoid
Since the serotonin is degraded by the liver, the right side of the heart is spared.
What do you do if you find that pts INR is subtherapeutic on warfarin?
Put back on heparin and bridge until therapeutic
[a bridge must be a minimum of 5 days and as long as it takes to get therapeutic]
Acute interstitial nephritis is essentially an allergic reaction with invasion of white cells. Drugs, infections, and deposition disease can cause it. The urine will present with immune cells: WBCs, white cell casts (pyelonephritis), or eosinophils. How do you manage this?
Removal of offending agent is critical — that means either treat the infection or stop the drug
[Steroids are often ineffective]
Recurrent pleural effusions may be treated with ______ - a chemical or surgical elimination of the pleural space
Pleurodesis
The Diamond classification identifies pt’s risk of coronary artery disease based on symptoms. What are the 3 components?
- Substernal chest pain
- Worse with exertion
- Better with Nitroglycerin
[3/3 is called typical, 2/3 is called atypical, 0-1 is called non-anginal. The more positives, the higher the likelihood that the chest pain is anginal]
Pt presents with glomerulonephritis and history of recent viral illness
What type of glomerulonephritis?
IgA nephropathy
_______ failure is caused by obstruction to outflow. Obstruction results in hydroureter or hydronephrosis. While CT can be used to dx obstruction, _______ is the preferred test.
Postrenal; ultrasound
Drug that may be used as antihypertensive because the physician is also treating BPH, but really what the drug is causing is an orthostatic hypotension
Alpha antagonists
What are the symptoms that may accompany mitral stenosis?
Blood backs up in the lungs and you get pulmonary edema = CHF/SOB symptoms
Atrial stretch results in possible atrial fibrillation
[Mitral stenosis represents an obstruction to flow across the mitral valve during diastole, so forward flow is impeded]
Adjustment of risk factors for acute coronary syndrome relating to DM includes tight glucose control to near normal values _________ or HbA1c _______ with oral medications or insulin
80-120; <7%
Winter’s formula for expected CO2 for bicarb
Expected CO2 = (bicarb x 1.5) + 8 +/- 2
There are several biopsy methods for intrapulmonary lesions without evidence of spread. Bronchoscopy with EBUS is used to biopsy proximal lesions. ___________ is chosen when the lesion is peripheral. __________ can be used to sample lesions not accessible by the above options.
Still other methods exist. Thoracentesis revealing malignant cells indicates stage ____ disease. And lesions that are clearly malignant can be dx with resection
Percutaneous CT guided biopsy; Video Assisted Thorascopic Surgery
Stage IV metastatic
Treatment for PE is basd on severity of disease. If there’s a massive embolism that has compromised cardiac function (hypotension), it’s imperative to start emergent ___________
Intra-arterial tPA
What causes secondary hyperparathyroidism in CKD and how is it managed?
Secondary hyperparathyroidism is a product of phosphate retention (elevated phosphorus stimulates PTH) and vitamin D deficiency that leads to low calcium (which also stimulates PTH)
Thus, phosphate binders such as sevelamer and calcimimetics such as cinacalcet are used to decrease this risk
In a patient with prerenal azotemia, you are looking for a urine sodium <10, FENa <1%, and a BUN/Cr ratio >20. However, if the patient is on a diuretic, you should look at ______ instead of sodium
Urea
How do you calculate anion gap vs. urine anion gap?
Anion gap = Na - Cl - Bicarb
Urine anion gap = Na + K - Cl
When is it safe to stop the insulin drip in a pt with DKA?
When the pt can take food by mouth
After the pt has had a dose of long-acting subQ insulin
After the pt has had 2 successive panels showing normal anion gap
For thrombolysis in tx of acute treatment of coronary syndrome, either administration of _____ (within 12 hrs of onset) or _______ is done only when catheterization is not available AND pt is in an acute disease (STEMI)
tPA, heparin
Pt presents with glomerulonephritis and history of sinus, lung, and kidney issues in the setting of positive ANCA testing
What type of glomerulonephritis?
Wegners
Condition producing lung noncaseating granulomas secondary to pigeon feathers, organic dust, or actinomyces
Hypersensitivity pneumonitis
First-line antimicrobial regimens for use in acute uncomplicated cystitis
TMP-SMX 160/800 mg q12h for 3 days
Nitrofurantoin 100 mg q12h for 5 days
Fosfomycin 3 g single dose
Holosystolic murmur radiating to axilla, heard best at cardiac apex
Mitral regurg
Chronic kidney disease is defined as reduced ______ for greater than __________
GFR (GFR <60 mL/hr or creatinine ~2)
3 months
Normal rhythm with constantly prolonging PR interval with each beat, until a QRS complex is finally dropped. The signal comes from the atria so there is a narrow QRS. Responds to atropine
Second degree AV block type I
Antihypertensive class that can cause hyperkalemia and gynecomastia
Aldosterone antagonists (spironolactone, eplerenone)
[these are used as primary meds in pts with hyperaldosteronism and CHF, but as added options in pts already on other antihypertensives. Eplerenone more likely to cause gynecomastia]
ED rescue therapy for refractory asthma symptoms
Racemic epinephrine nebulizers
Subcutaneous epinephrine
IV magnesium
3 criteria that mean a heart murmur needs no further investigation
If it is graded as <3/6, systolic, and asymptomatic — it needs no further investigation
[Any diastolic, symptomatic, or >3 grade murmur needs a workup]
Baseline values of what labs are needed prior to starting a statin?
Lipids
A1c
Creatine kinase
LFTs
[after that lipids are tested annually. CK and LFTs are not checked routinely — assess only if they present with symptoms of myositis or hepatitis]
Meds to use in hypertensive pts with diabetes with microalbuminuria
ACE-I
Beck’s triad of pericardial tamponade
JVD
Hypotension
Distant heart sounds
[also clear lungs and pulsus paradoxus >10 mmHg]
Heart rhythm without atrial activity, only the ventricles are contracting. It looks like a third degree AV block, but there are no p waves. Pacing is the only option
Idioventricular rhythm
There are 2 main goals while treating CHF — to reduce fluid (preload) and reduce afterload. To reduce fluid, it’s important to restrict salt intake to _______ and reduce fluid intake to _______.
Once the pt is a NYHA class II, keep the fluid off by adding ________ to treatment regimen. At class III, _________ __________ is added
<2g/day; <2L water/day
Diuretics (furosemide); isosorbide dinitrate
5 options for moderate intensity statins
Atorvastatin 10, 20
Rosuvastatin 5, 10
Simvastatin 20, 40
Pravastatin 40, 80
Lovastatin 40
When asthma exacerbation patients come to the ED, a peak flow is performed. If there’s no improvement after 3 hours of continuous nebulizer treatment, they go ________. If 100% improvement, they go _______. Anywhere in between gets admitted to the hospital for further management, meaning albuterol/ipratropium every ____ hours with ongoing oral or IV steroids.
To the ICU; home; 4
Iatrogenic causes for restrictive lung disease pattern on PFTs include _______ and _______
Bleomycin; amiodarone
What lifestyle modifications are given to pts with HTN?
Diet — <2.4g NaCl daily; DASH diet, K+ supplementation, EtOH limit 2 for man or 1 for woman
Exercise — 30 minutes daily, with goal of 2 hours per week
Weight — BMI over 25 needs to lose weight
Once diagnosis of asthma is established, it is important to determine severity as this drives treatment choices. What are the indicators of severity?
Frequency of daytime symptoms
Nocturnal symptoms
Severity of PFTs
Urine sodium, FENa, and BUN/Cr ratio characteristic of intrarenal injury
Urine sodium >20
FENa >1%
BUN/Cr <10
T/F: the only time an IVC filter is the right answer is when there’s a DVT, the next PE will kill them, AND there’s a contraindication to anticoagulation
True
After more than ________ minutes of cardiac arrest in a pulseless electrical activity or asystole, the recommendation is to discontinue resuscitation
20-25 minutes
[after this length of time the chances of return of spontaneous circulation and neurologic function are negligible]
The etiology of DVT/PE is virchows triad — what is the triad?
Venous stasis
Hypercoagulable state
Endothelial damage
If you diagnose a pleural effusion that is loculated, a _________ is required.
Parapneumonic effusions that are loculated may form a rind, called _________. This requires ________ with decortication.
Thoracostomy
Empyema; thoracostomy
Calculation of blood pressure
BP = CO x SVR
[CO = HR x SV]
Why should clonidine be avoided in the treatment of HTN? How can this effect be avoided?
It causes rebound HTN; avoid by using transdermal patch instead of TID dosing
[still a last resort option for HTN]
What lab and PE findings should you look for in a pt with hypocalcemia?
Check for decreased albumin (caused by poor nutrition, cirrhosis, or nephrosis) — adjustment for albumin will usually reveal normal calcium
Check for perioral tingling and signs of tetany (Chvostek’s and Trousseau’s)
What do you do if a pt on warfarin has a supratherapeutic INR that is >9 and there is no evidence of bleeding?
Hold a dose, give vitamin K, and lower their overall dose
Define bronchitis
Productive cough for more than 3 months in 2 consecutive years
How would you manage a patient with atrial fibrillation with RVR present >48 hrs who also presents with CHF exacerbation?
Digoxin or amiodarone
In heart failure exacerbations, central acting calcium channel blockers are contraindicated because they drop the EF
There are several steps in tx of hyperkalemia. Phase I is to stabilize the myocardium with IV ______ and _______.
Phase II is to decrease serum K by sequestering it in cells, done with _____ and _______, or with ________.
Phase III is to actually decrease total body K with either ______ or more commonly with _______
Calcium; gluconate
Insulin; glucose; bicarbonate
Diuretics; kayexalate
Restrictive lung disease that takes >30 years after exposure to manifest. Characteristic CXR shows pleural plaques and may be associated with adenocarcinoma or mesothelioma
Asbestosis
Alkaline urine secondary to frequent UTI with urea-splitting bacteria like proteus predisposes to what type of kidney stone?
Magnesium ammonium phosphate (struvite)
Central lung lesion caused by smoking; classic warning signs are hemoptysis and weight loss without fever. Diagnosed by EBUS with biopsy. Cancer may produce PTH-rp causing hypercalcemia
Squamous cell carcinoma
Antihypertensive class that are indicated in heart failure with reduced EF and in pts with CAD
Beta blocker
Abx regimen for pyelonephritis
Ciprofloxacin 500 mg PO q12h for 7 days
Ceftriaxone 1 g IV as single dose, followed by TMP-SMX 160/800 mg PO q12h for 14 days
MONA-BASH mnemonic for tx of acute coronary syndrome
Morphine
Oxygen
Nitrates
Aspirin
Beta-blocker
ACE-inhibitor
Statin
Heparin
Define hypertensive urgency vs emergency
Urgency means >180 systolic or >120 diastolic
Emergency means above values with evidence of end-organ damage (elevated troponins, altered mental status, SOB, chest pain) — this pt gets put on a drip and goes to ICU, then gets oral meds
T/F: initiating or increasing a beta blocker is contraindicated in acute CHF exacerbation
True — beta blockers acutely decrease ejection fraction, so initiating them is contraindicated in an exacerbation. If a patient is already on a beta blocker, it is safe to continue it
Light’s criteria for the thoracentesis findings indicate what type of effusion?:
LDH >2/3 upper limit normal (~200)
Total pleural protein/Total serum protein = >0.5
Pleural LDH/Serum LDH = >0.6
Exudate
Urine sodium, FENa, and BUN/Cr ratio characteristic of prerenal azotemia
Urine sodium <10
FENa <1 %
BUN/Cr >20
Define impaired fasting glucose vs. impaired glucose tolerance vs. prediabetes
Impaired fasting glucose = fasting BG 100-125
Impaired glucose tolerance = 2 hr post-prandial glucose 140-199
Prediabetes = HgbA1c 5.7-6.4%
Heart rhythm with normal PR interval but simply drops QRS complexes randomly. The signal comes from the atria so the complexes are narrow. This is the most severe a rhythm can be before atropine no longer works
Second degree AV block type II
A small PE doesn’t cause right heart strain or significantly impact gas exchange, yet even the smallest PE can cause dyspnea — why??
Small emboli can cause profound dyspnea through platelet-derived mediators leading to lung-wide inflammation
This allows fluid to leak out around the alveoli causing a fluid barrier to diffusion of oxygen, but not carbon dioxide. Thus, as respiratory rate increases, CO2 is blown off while O2 can’t get in
Meds to use in hypertensive pts who have CKD
ACE-I or ARB
EXCEPT if it’s stage IV
The decision to start dialysis is NOT based on creatinine, but on the severity of the condition and the presence of one of the AEIOU mnemonic — what does this stand for?
Acidosis Electrolytes (Na/K) Ingestion (toxins) Overload (CHF, edema) Uremia (pericarditis)
Condition caused by abnormal calcium sensing receptor. There’s an elevated serum calcium and PTH, bu the body is just maintaining its “normal”. Pts are asymptomatic and require no treatment. There is a risk of stenotic aortic disease as they age
Familial hypocalciuric hypercalcemia
Steroid options for COPD exacerbation
Methylprednisone (solumedrol) IV 125 mg
Prednisone 40 mg PO
Condition characterized by very elevated blood glucose, usually over 600, as well as increased serum osmolarity (usually above 300) and no ketones present; usually develops in pts with chronic hyperglycemia and an inciting event such as infection or other acute illness
Hyperosmolar hyperglycemic state
Pt presents with glomerulonephritis and history of recent viral illness AND systemic vasculitis
What type of glomerulonephritis?
Henoch-Schonlein
Sodium correction should occur no faster than _________ unless severe.
If corrected too quickly, it may result in ________________
0.25mmol/hr
Osmotic demyelination syndrome (aka central pontine myelinolysis, which is a spastic quadruplegia)
First line therapy for hypercalcemia is ________. _______ is added to increase naturesis and calcium excretion, but only after volume status is corrected.
If more aggressive therapy is needed (i.e., severe sxs), start ______ and ______
IV fluids; furosemide
Calcitonin; bisphosphonates
Management of DKA involves continuous IV insulin and IV normal saline. Monitor blood work closely, especially potassium and anion gap. The insulin dose is frequently adjusted according to finger sticks. If the blood glucose starts to drop while the anion gap remains greater than 12, IV fluids are switched to __________. Insulin is continued despite low blood sugars to treat insulin deficiency.
D5 normal saline
What are the 2 mechanisms by which malignancy can cause hypercalcemia?
- Metastasis to bone —> bone destruction, releasing Ca and P
- Production of PTH-rp, turning cancer into a primary hyperparathyroidism but with a low blood PTH (special tests are required to measure PTH-rp)
What test confirms suspicions of vasovagal (neurocardiogenic) syncope?
Tilt table test (will reproduce symptoms)
Antihypertensive that causes venodilation and thus should not be given to pts on nitrates or PDE-5 inhibitors
Isosorbide dinitrate
[ISMN is an antianginal, ISDN is used in CHF]
Dose of ipratropium and albuterol used in COPD as first line therapy
Ipratropium 0.5mg neb q4
Albuterol 2.5mg neb q4
What antibiotics are primary offenders when it comes to acute interstitial nephritis?
TMP-SMX
PCN
Cephalosporins
Triple therapy for h.pylori
PPI, Amoxicillin, Clarithromycin x14 days
[quad therapy is PPI, bismuth, metronidazole, and tetracycline x14 days, utilized if pt is likely to be resistant to macrolides]
Formula for acute vs. chronic respiratory acid/base disturbance
7.4 + (dimes x 0.08) = pH if acute
24 - (dimes x 2) = expected bicarb if acute
7.4 + (dimes x 0.04) = pH if chronic
24 - (dimes x 4) = expected bicarb if chronic
[dimes means every “dime” change in CO2 beyond 40]
Treatment for aortic stenosis
Preload reduction
Valve replacement is required sooner rather than later
Valve replacement results in ostia being lost, prompting a CABG, regardless of CAD status
Coal Miner’s lung is a restrictive lung disease caused by exposure to coal. It is associated with ______ ______, so a pt with restrictive lung pattern and a bilateral symmetrical arthralgia should be worked up for rheumatoid arthritis with a rheumatoid factor or ________ antibody
Caplan syndrome; anti-CCP
Treatment for mitral valve prolapse
Increase preload
What do you need to monitor for when you put pts on heparin in the hospital?
Heparin-induced thrombocytopenia (HIT)
This usually occurs within 7 days on first exposure and 3 days on repeat.
How do you manage heparin-induced thrombocytopenia?
Draw a HIT panel, stop the heparin, and give argatroban
Treatment option to consider in the case of NYHA class I, II, or III in which EF is <35%
AICD placement
Causes of euvolemic hyponatremia
RATS
Renal tubular acidosis — assess with UA
Addison’s disease — assess with cortisol
Thyroid disease — assess with TSH
SIADH — dx of exclusion; tx with volume restriction and gentle diuresis. Refractory cases can be treated with demeclocycline
Symptoms of aortic insufficiency
If chronic — dilated heart failure
If acute — cardiogenic shock
What class of medication is added to CHF treatment regimen when they reach class IV NYHA classification?
Inotropes like Dobutamine
Code blue revolves around 2 minutes of CPR followed by rhythm check and possible shock. How does associated pharmacotherapy differ in Vtach/Vfib vs. PEA/asystole?
Vtach/Vfib — start with epi —> amiodarone —> epi —> amiodarone
PEA/asystole — epi —> nothing —> epi —> nothing
Beta blockers that work for both heart failure and CAD
Metoprolol
Carvedilol
Nobifolol??
T/F: Do not use an ARB after a pt has an angioedema reaction to an ACE-inhibitor
False — you can use an ARB if pt has bad reaction to ACE-I
Antibiotic therapy for diverticulitis
Initial therapy with metronidazole plus a fluoroquinolone (ciprofloxacin) is indicated
Other reasonable combo of a 3rd gen cephalosporin (like ceftriaxone) plus metronidazole (anaerobic coverage) or single-agent therapy with ertapenem, moxifloxacin, or cefoxitin
For oral tx: metronidazole plus a fluoroquinolone, metronidazole plus TMP-SMX, or moxifloxacin alone may be used
3 options for low-intensity statins
Simvastatin 5, 10
Pravastatin 10, 20
Lovastatin 20
Autoimmune disorder causing restrictive lung disease resulting in exertional dyspnea that may be associated with erythema nodosum, uveitis, and bell’s palsy. Characteristic chest x ray shows bilateral hilar lymphadenopathy and definitive diagnosis requires biopsy of lung tissue showing noncaseating granulomas
Sarcoid
Antihypertensive class that cause decreased potassium and decreased urinary calcium (tx kidney stones) but don’t work in pts with CKD with GFR <30
Thiazides
What is hypertonic hyponatremia?
While the measured sodium is low, the measured osmoles are elevated
This is usually a product of glucose, BUN, or sugar alcohols — basically other stuff in the blood that accounts for osmotic activity.
For every 100 mg/dL of glucose above 100, adjust for the Na by 1.6. If the corrected sodium is normal, correct the osmotic component alone
Light’s criteria for the thoracentesis findings indicate what type of effusion?:
LDH <2/3 upper limit of normal (~200)
Total pleural protein/Total serum protein = <0.5
Pleural LDH/Serum LDH = <0.6
Transudate
What causes secondary hyperparathyroidism?
Renal failure
In early renal failure, vit D isn’t made. This produces hypocalcemia that causes increased PTH and parathyroid gland hypertrophy
For non-gap acidosis, check a urine anion gap (Na + K - Cl). If elevated, the answer is ________________. If not, the answer is _________.
Renal tubular acidosis; diarrhea
The most common presenting symptom of hypertrophic cardiomyopathy is SOB, but it can also present with angina or sudden death in athletes. What are the 2 primary treatments?
Avoiding dehydration (avoid exercise)
Beta blockers — to allow increase in ventricular filling which pushes septum out of the way of the aortic outlet
2 drugs that pt should be on if they’re hypertensive and have had a stroke
ACE inhibitor
Thiazide diuretic
Symptoms of ______ ventricular failure include orthopnea, crackles, rales, dyspnea on exertion, S3 heart sound, and paroxysmal nocturnal dyspnea
Left
What is the utility of the D-dimer in evaluating for PE?
A D-dimer is only useful if the pre-test suspicion is low and you’re ruling out PE with a normal D-dimer
[any inflammation can raise the D-dimer; a positive D-dimer does NOT mean PE]
Treatment progression for asthma
- SABA
- SABA + ICS
- SABA + ICS + LABA
- SABA + increase ICS + LABA
- SABA + increase ICS + LABA + oral steroids
[Consider leukotriene antagonists equivalent to inhaled corticosteroids, they can be used interchangeably but shouldnot be used together]
2 tests that should be used when first attempting to diagnose CHF
BNP — useful to say whether pt is volume overloaded or not
2D echocardiogram — distinguishes between systolic failure (EF <55%) and diastolic failure (preserved EF)
Why are there strict criteria for home O2 therapy in pts with COPD?
Because of the risk of eliminating hypoxic drive
Define Elevated BP vs. Stage I vs. stage II HTN
Elevated BP means <130 systolic and <80 diastolic — main tx is lifestyle mods, come back in 6 months
Stage I means <140 systolic and <90 diastolic — main tx is lifestyle mods, add medication if other comorbid conditions that are risk factors for CAD (>10% calculated risk), come back in 3 months to check if lifestyle mods worked, or 1 month if meds were started
Stage II means >140 systolic and >90 diastolic — requires 2 meds or more, return in 1 month
When is thrombectomy utilized in tx of PE?
Thrombectomy is used to manage chronic thromboembolic pulmonary hypertension, it is not used in acute management
When a pt needs to be on a high-intensity statin, start a moderate-intensity and increase the dose to high-intensity. However, if there is _____ disease or ______ disease, start at and stay on a moderate-intensity statin
Liver; renal
The only thing that causes metabolic alkalosis is high _________. The decision becomes whether the person is volume responsive. This is done in one of two ways: using the hx to say pt is volume down and give fluids then recheck bicarb, OR by checking the ______ ______
Aldosterone; urine chloride
3 effects of PTH
- Activates osteoclasts to clear bone —> increased Ca and P
- Directly reabsorbs Ca and excretes P in the kidney
- Indirectly absorbs Ca and P from the gut via vitamin D
You discover a pulmonary nodule on CT and find that it has changed in the last 2 years, indicating that it is unstable — what is the next step?
The decision is now whether to follow with serial CT scans for 2 years until it becomes stable, or biopsy right now
Factors that increase risk are size >2 cm, spiculated surface, >30 pack year smoking history, and age >70
[reassuring features are size <8mm, smooth calcified surface, no smoking history, and age <45]
How do you manage a pt with valvular atrial fibrillation present for >48 hours, and why can’t you cardiovert them right away?
Place pt on warfarin with LMWH bridge for 4 weeks, after 4 weeks, TEE is done. If no clot is found, cardioversion is done and pt remains on warfarin for another 4 weeks [NOTE: in valvular afib you MUST choose warfarin over NOAC]
If you cardiovert them right away you run the risk of throwing an embolism —> stroke
Restrictive lung disease that is the result of exposure to heavy metal (gold, nickel, silver). Pts have typical course of insidious hypoxia. CXR shows ground glass opacities. There’s no tx but to remove exposure
Pneumoconiosis
3 classic presenting symptoms of lung cancer
Fever
Hemoptysis
Weight loss
2 classes of antihypertensives that cause an increase in creatinine (20% is ok), and can cause an increase in potassium
ACE-I and ARBs
[adverse effects = cough, angioedema]
CT angiogram is the best test for diagnosing PE. A _____ can be used if there’s CKD or AKI, but only if there are clear lungs. If all else fails, since a DVT is treated the same as PE, a _______ can be used to diagnose DVT as a proxy if no test is available for PE
V/Q scan; ultrasound
Anemia in CKD is caused by decreased EPO. The goal hemoglobin is 11-12. Anemia in CKD is usually normocytic and seen in late stage disease. Use _____ and ______ to sustain blood counts. Transfusions with dialysis can also be done
EPO and iron supplementation
What causes anemia in CKD?
Decreased EPO
______ and _______ are alternatives to statins that block absorption of either cholesterol or bile acids. This leads to osmotic diarrhea as a side effect
Bile acid binding resins; Ezetimibe
Pharmacologic tx — Patients presenting with angina need _____ first and foremost. ______ can be given to alleviate pain, but must be avoided in right-sided infarcts (II, III, aVF). __________ reduce myocardial work and prevent ventricular arrhythmias (the thing that kills pts in the first 24 hrs).
________ have long term benefits. ______ are the mainstay of therapy for cholesterol. If certain it’s acute coronary syndrome, therapeutic heparin and ______ load should be used as well.
Aspirin; nitrates; beta-blockers
ACE-inhibitors; statins; clopidogrel
T/F: small cell carcinomas should be resected
False - they are exquistely sensitive to chemo
Indications for angioplasty (PCI) vs. CABG during catheterization
1,2 vessel disease = angioplasty/PCI
Left mainstem disease, 3+ vessel disease = CABG
Symptoms of _____ ventricular failure include hepatosplenomegaly, JVD, peripheral edema, dyspnea on exertion, and increased JVP
Right
Diagnostic test of choice for pericardial effusion
Echocardiogram
Condition characterized by noncardiogenic pulmonary edema resulting from increased permeability of capillaries permitting the transudation of fluid from capillaries into the interstitium; looks and feels like CHF but cardiovascular function is intact
ARDS
_________ acute kidney injury is the result of decreased perfusion - whether it be from decreased cardiac output, 3rd spacing of fluid, or decreased vessel diameter. In this case, the kidneys think they are dehydrated and thus hold onto salt and urine.
Prerenal
If someone cannot take a statin, second line option is _________. They have the same side effect profile, but are also really good at getting the LDL down and the HDL up
Fibrates
What are the 3 types of intrarenal disease and what type of casts are they associated with?
Tubules (acute tubular necrosis) = muddy brown casts
Interstitium (acute interstitial nephritis) = WBC casts
Glomerulus (glomerulonephritis) = RBC casts
Congestive heart failure with preserved ejection fraction
Diastolic heart failure
Antihypertensive that can cause reflex tachycardia and drug induced lupus. This is however the agent of choice in pts with CKD stage 5
Hydralazine
T/F: the first step in treatment of pleural effusion in the setting of CHF is thoracentesis
False — diurese only! You may proceed with thoracentesis if it fails to resolve with diuresis
Pt presents with glomerulonephritis and history of positive ANA and antibodies to dsDNA
What type of glomerulonephritis?
Lupus glomerulonephritis
What named criteria are used to decide what type of test to do and how to treat DVT/PE?
Well’s criteria
What do you do if a patient has pre-existing renal damage, or is at increased risk, and they NEED contrast for an imaging procedure?
Give vigorous hydration, prophylactic N-Acetyl-Cysteine, and stop ACE-I/ARBs and diuretics prior to contrast
Dx and tx of primary hyperparathyroidism
High calcium, low phosphate
Use a radionucleotide scan to identify which parathyroid gland is autonomous/hypertrophied, then resect. Monitor for hypocalcemia after surgery
Clopidogrel duration guidelines for drug eluting stent, bare metal stent, and angioplasty alone
Drug eluting stent = Clopidogrel x12 months
Bare metal stent = Clopidogrel x1 month
Angioplasty alone = No Clopidogrel
Pleural effusions are diagnosed on chest x-ray and first become apparent with blunting of the costophrenic angles, which requires at least _______ of fluid
250 ccs
4 types of etiology of pericardial disease
Infection — viral (coxsackie), bacterial (strep/staph), TB, fungal
Autoimmune — lupus, rheumatoid, scleroderma, procainamide, hydralazine, uremia
Trauma — blunt, penetrating
Cancers — lung, breast, esophagus, lymphoma
Lung cancer in people who don’t smoke, typically occuring in periphery of lung and is stuck to pleura causing it to pucker. Occurs either spontaneously or with remote hx of asbestos exposure
Adenocarcinoma
During a stress test, you can evaluate for changes using ECG, echo, or nuclear testing. What does each of these look for?
ECG — ST segment changes (T wave inversion or ST elevation)
Echo — dyskinesia (aka akinesis) that is present on stress test but absent at rest (this is at-risk tissue but not dead tissue)
Nuclear — demonstrate perfusion with Thallium. Normal perfusion at rest but compromised with stress identifies salvageable tissue
What do you do if a pt on warfarin has a supratherapeutic INR that is between 5-9 and there is no evidence of bleeding?
Hold a dose, give vitamin K
Causes of hypokalemia
GI losses — diarrhea, vomiting, laxatives
Renal losses — hyperaldo states, loop diuretics, thiazides
If you decide to do rate control in a pt with atrial fibrillation, anticoagulation may still be needed. This is decided using what criteria?
CHADS2 score
CHF = 1 point HTN = 1 point Age >75 = 1 point DM = 1 point Stroke = 2 points
If your score is 0 = ASA alone
If your score is 1 = ASA or anticoagulation
If your score is 2+ = anticoagulation with warfarin (INR 2-3) or NOAC
[NOTE: in valvular afib you MUST choose warfarin over NOAC]
A patient presents with cardiogenic shock as a product of bradycardia from toxic ingestion of a beta blocker. Treatment options in a stable patient include ______, which is the antidote to beta blockers.
________ and ______ can be used as an infusion to increase the heart rate. ________ can be used in the meantime to temporize the heart rate while an infusion is started.
In an unstable patient, the only option is _________
Glucagon
Epinephrine; dopamine; atropine
Transcutaneous pacing
Management of prerenal acute kidney injury
IV fluids if dehydrated
Diuresis if volume overloaded
There are several biopsy methods for intrapulmonary lesions without evidence of spread. The _______ with _______ is used to biopsy proximal lesions.
Bronchoscopy; Endobronchial ultrasound (EBUS)
[Rigid bronchoscopy alone allows us to sample lesions that are intraluminal in large airways, while EBUS allows more accurate sampling of LNs ormasses outside the lumen (in chest/lung)]
Opening snap followed by decrescendo murmur in diastole
Mitral stenosis
[the earlier the snap, the worse the stenosis]
What is tertiary hyperparathyroidism?
In ongoing renal failure, eventually parathyroid glands become autonomous — just like primary hyperparathyroidism
Look for autonomous parathyroid glands in the presence of existing renal disease. Resection is required, but there is no increased risk of cancer
4 ways to dx diabetes
- Fasting BG >126 on two occasions
- Random BG >200 accompanied by polyuria, polydipsia, or unexplained weight loss
- BG >200 two hours after 75g glucose load on two occasions
- Hemoglobin A1c 6.5% or greater
When treating CHF, afterload reduction is achieved with what medications?
ACE-inhibitors or ARBs
When class III or greater, add Spironolactone or Hydralazine
Before a treatment plan for lung cancer is made, ________ are required to assess if pt can tolerate surgery
PFTs
Torsade is a form of wide complex tachycardia. What are 2 pharmacologic tx options?
Magnesium
Amiodarone
Heart rhythm with total AV node dissociation. The p waves march out and the QRS complexes march out regularly, but are completely independent of each other. Because the impulse comes from the ventricles, it is a wide QRS complex rhythm
Third degree AV block
Management of acute tubular necrosis
Supportive care
Treatment for PE is basd on severity of disease. In most cases there are 2 treatment goals. One is to shut off platelet mediators using _____, which is the mainstay of therapy. The second goal is to prevent recurrence with ________
Heparin; warfarin
[to put a pt on warfarin they need a heparin to warfarin bridge. Target INR is 2-3. Novel oral anticoagulants like rivaroxaban or apixaban are acceptable alternatives but are dosed BID and can’t be reversed]
Pt presents with glomerulonephritis and history of pharyngitis or impetigo
What type of glomerulonephritis?
Post-streptococcal glomerulonephritis
[check ASO titer]
If pericarditis is left untreated, it can lead to fibrosis and resulting constrictive pericarditis. It causes no trouble with contractility, but filling is impaired. As the heart expands into too-small-a-space, a pericardial knock is heard. Diagnosis is made with _________. Treatment is _______
Echocardiogram; pericardiectomy
Acid base disturbance seen in pnemonia
Respiratory acidosis
Anti-histidyl-tRNA synthetase (anti-Jo1) antibodies are seen in _______
Dermatomyositis
7 criteria included in TIMI Risk Score for unstable angina/NSTEMI
Age 65+ 3+ CAD risk factors Known CAD (stenosis >50%) ASA use in past 7 days Severe angina (>2 episodes in 24 hrs) EKG ST changes >0.5mm Positive cardiac marker
[CAD risk factors include HTN, high cholesterol, DM, family hx of CAD, or current smoker]
Purpose is to calculate percentage risk of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization
Duke criteria is used in pts with suspected infective endocarditis
Pathologic criteria include microorganisms identified in vegetation, or pathologic lesion confirmed by histologic exam showing active endocarditis — if either is positive, the diagnosis is definite.
There are 2 major criteria and 5 minor criteria. A definitive diagnosis requires 2 major criteria OR 5 minor criteria OR 1 major + 3 minor criteria.
What are the major and minor criteria?
Major criteria:
Blood cultures positive for endocarditis x2
Evidence of endocardial involvement (echocardiogram, abscess, new valvular regurg, new partial dehiscence of prosthetic valve)
Minor criteria: Predisposing heart condition or injection drug use Fever Vascular phenomena Immunologic phenomena Microbiological evidence
[vascular phenomena are major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, and Janeway lesions. Immunologic phenomena include glomerulonephritis, osler nodes, roth’s spots, and rheumatoid factor. Microbiologic evidence includes positive blood culture but does not meet a major criterion as noted above or serologic evidence of active infection with organism not consistent with IE]
Components of Child Pugh score to assess severity of liver disease
Total bilirubin Albumin INR Ascites Encephalopathy
Diagnosis of C.diff
C.diff NAAT
Tx for recurrent C.diff
Fidaxomicin
Tx of severe C.diff (toxic megacolon, overt sepsis/shock, renal failure)
IV metronidazole + oral vancomycin
Spontaneous bacterial peritonitis dx requires 250+ neutrophils in paracentesis fluid. What is the treatment?
Ceftriaxone
[Fluoroquinolones if pen allergy]
If a paracentesis reveals 250+ neutrophils and a polymicrobial source of infection, the dx is secondary bacterial peritonitis. In this case, it’s necessary to add ________ to ceftriaxone to cover anaerobes.
If a pt does not have SBP but the total protein is <1.0, they get _____ prophylaxis
Metronidazole
Fluoroquinolone
Varices are a complication of cirrhosis. Use a _______ as an outpatient. If they bleed, they must be banded. Also give ______ and ______
Beta blocker (nadolol; propranolol); ceftriaxone; octreotide
HCC is screened for q6 months in pts with cirrhosis. A _______ is sufficient for diagnosis, no biopsy is needed
Triple phase CT scan
Hepatorenal syndrome is fatal. Treat a patient with renal failure and cirrhosis by holding the diuretics, giving ______ and then _______
Albumin; octreotide
Treatment options for diverticulitis
Ampicillin-gentamicin and metronidazole
Ciprofloxacin and metronidazole
Pip/tazo
