Internal Medicine Pearls Flashcards
Loratadine
Claritin
Catapres
Clonidine
What is the mechanism of clonidine
Stimulates alpha 2 adrenergic receptors
Central acting anti hypertensive
What is the most common cause of HTN in a young healthy non smoker?
Fibromuscular dysplasia
What is the most likely cause of HTN in a diabetic obese male with hyperlipemia?
Atherosclerosis
What treatment options are available for widely resistant bacterial infections
Consider using an older antibiotic like colistin that is no longer tested for resistance.
How does sepsis effect lactic acidosis
Sepsis increases the risk of lactic acidosis
How should metformin be adjusted for in patient hospital stay
It should be stopped to prevent lactic acidosis
How should a patient be managed for in patient alcohol detox
Fixed dose step down of Librium (longer hospital stay)
Referral to psych
For younger patients use 10 mg baclofen TID and Ativan PRN
Severity of symptoms is increased over the age of 45
What is the problem with using antipsychotics with anti-arrhythmics
Severe QT prolongation
Sedation with Benzos may be the only option for treating delirium in a patient on a phase III anti arrhythmic.
What is the mechanism of rabeprazole
Inhibits the hydrogen potassium ATPase of gastric parietal cells
Name the 1st generation cephalosporins
Cefazolin
Cephalexin
Name the third generation cephalosporins
Ceftibuten Cefdinir Cefotaximine Ceftriaxone Cefixime
Name the 4th generation cephalosporins
Cefepime
Name the fifth generation cephalosporins
Cetaroline
What is the community service board
Psychiatry evaluation that determines if the patient is unsafe for themself and the need for care. The referral does not require patient consents
What is a cosyntropin stimulation test
Baseline ACTH drawn.
30 minutes after cosyntropin IV injection of 1 µg cosyntropin draw blood for ACTH
60 minutes after 1 µg bolus cosyntropin injection draw blood for ACTH
What labs are a good indicator of gallstones and pancreatitis
AST three times of baseline
What are the common bugs the cause community acquired pneumonia
Typical’s: strep pneumonia H. influenzae
Atypicals: Legionella, chlamydia, Mycoplasma
Special risk factors: alcoholics, aspiration
What are the two treatment options for community acquired pneumonia
- Fluoroquinolone
2. Macrolide plus cephalosporin third-generation
What are the respiratory fluoroquinolones
- Levofloxacin.
2. Avelox.
The patient is taking Lasix how do you check the kidney function
Do not get the FeNa with Lasix you will need to get the FeUria
How’s the CNS Penetration of Zosyn
Poor
What is Todd’s paralysis
Postictal states in which lethargy and confusion can remain for sometime. Maybe accompanied by focal neurologic deficits
Byetta
Exenatide
What is the mechanism of exenatide
Activates the GLP-1 receptor
When will serum urate become supersaturated
6.8
What serum level of urate should be treated to
Always treat below 6.0. If tophi are present treat to below 5.0
What items will induce a gout flair up
-Red meat, Beer, Shellfish, yeast, low dose ASA, Chemo, diuretics, ETOH, nicotine Aid
Are most gout patients over Producers or under excretor’s
90% are Under excretor’s
Less than 800 mg in 24 hours
How is gout managed
Managing flareups (Steroids, NSAIDs, colchicine)
Using urate lowering therapy
What options are available for urate lowering therapy
Uricosurics such as probenecid
Xanthine oxidase inhibitors such as allopurinol, Oxipurinol, or feboxustat
What is incentive spirometery
The program was intensive and involved breathing exercises, incentive spirometry, and education in active breathing and forced expiration techniques. Postoperative pulmonary complication rates for experimental and control groups were 18 and 35 percent, respectively, OR 0.52 [95% CI 0.30-0.92]. Median length of stay was one day shorter for the group receiving inspiratory muscle training.
What are the major causes of post operative fever
The five W’s
- wind (atalectasis)
- water (UTI)
- wound (infection)
- walking (DVT’s)
- Wonder drug
Semethicone
Gas X
What are the major causes of cellulitis
Strep pyogenes (GAS) Staph aureus
What is the difference between erysipelas and cellulitis
Cellulitis is a deeper
Erysipelas is superficial, more demarcated border.
Is erysipelas more often strep or staph infection
More commonly strep. But could be either
Is cellulitis more commonly staph or strep
More commonly staph but could be either.
Staph is often associated with abscesses and a more purulent discharge.
What treatment options are available treatment of cellulitis
Clindamycin
Bactrum plus amoxicillin
Less coverage of gram positive but still effective:
Doxycycline
What is a major complication of clindamycin
C. Diff associated diarrhea
Discuss necrotizing fasciitis
- Rapid progressing.
- Pockets of abscess.
- Be sure to draw lines surrounding the border.
- Ensure frequent short duration follow-up.
- Patient presents with disproportionate pain
What are the causes of necrotizing fasciitis
Clostridium
GAS
Poly microbial including anaerobes
What is Ranson scoring
A score based upon Ranson’s criteria is one of the earliest scoring systems for severity in Acute Pancreatitis.
Ranson’s criteria consist of 11 parameters. Five of the factors are assessed at admission and six are assessed during the next 48 hours
Mortality increases with an increasing score. Using the 11 component score, mortality was 0 to 3 percent when the score was <3,
11 to 15 percent when the score was ≥3,
40 percent when the score was ≥6
What are the components of Ranson scoring
At admission: Age in years > 55 years White blood cell count > 16000 cells/mm3 Blood glucose > 10 mmol/L (> 200 mg/dL) Serum AST > 250 IU/L Serum LDH > 350 IU/L
Within 48 hours:
Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg)
BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L
The criteria for point assignment is that a certain breakpoint be met at anytime during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to non-gallstone pancreatitis.
What is tachy - Brady syndrome
Also known as sick sinus syndrome
an umbrella term for a group of abnormal heart rhythms (arrhythmias) presumably caused by a malfunction of the sinus node, the heart’s primary pacemaker. Bradycardia-tachycardia syndrome is a variant of sick sinus syndrome in which slow arrhythmias and fast arrhythmias alternate.
What are common etiologies to prerenal AKI
Hypovolemia (dehydration)
Decrease contractility
Systemic vasodilation (sepsis)
Renal vasoconstriction (NSAIDs, ACE/ARBs)
How can the determination of prerenal AKI be made?
FE(Na) < 1%
BUN/CR > 20
Uosm > 500
How can the determination of prerenal AKI be made if a patient is on lasics
FE(un) < 35%
FE(un)= [U(un)/P(un)] / [U(cr)/P(cr)]
What is the formula for FE(Na)
FE(Na)= [U(Na)/P(Na)] / [U(cr)/P(cr)]
How does PTH related chronic kidney disease
The greater the target range of PTH equals a more severe stage chronic kidney disease
Stage III as target PTH of 35 to 70
Stage IV has target PTH of 70 to 110
Stage V has target PTH 150 to 300
What are the key ingredients in a lactated ringer
130 mEq of Na ion = 130 mmol/L 109 mEq of Cl ion = 109 mmol/L 28 mEq of lactate = 28 mmol/L 4 mEq of K ion = 4 mmol/L 3 mEq of Ca ion = 1.5 mmol/L
Lactated Ringers has an osmolarity of 273 mOsm/L. The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis.
What are the SIRS criteria
Temp: > 38 °C or < 36
Heart rate: >90/min
RR >20/min or PaCO2 12,000 or 10% bands
What is leukocytosis
Leukocytosis is a white blood cell count (the leukocyte count) above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, and is observed in certain parasitic infections. It may also occur after strenuous exercise, convulsions such as epilepsy, emotional stress, pregnancy and labour, anesthesia, and epinephrine administration
What are the classifications of leukocytosis
There are five principal types of leukocytosis: Neutrophilia (the most common form) Lymphocytosis Monocytosis Eosinophilia Basophilia
What is the band cell
A band cell (also called band neutrophil or stab cell) is a cell undergoing granulopoiesis, derived from a metamyelocyte, and leading to a mature granulocyte.
It is characterized by having a nucleus which is curved, but not lobar.
The term “band cell” implies a granulocytic lineage (neutrophil)
What is tacrolimus indicated
To induce immune suppression for transplants rejection therapy
What is the only fluoroquinolone that has anaerobic coverage
Avelox (moxifloxacin)
What is the normal levels of lactate
0.5 to 2.2
At what level of Lactate should sepsis be a concern
Lactate greater than 4.0 consider septic shock until proven otherwise
What bacterial infections is clindamycin used to treat
Aerobic Gram-positive cocci, including some members of the Staphylococcus and Streptococcus (e.g. pneumococcus) genera, but not enterococci.[13]
Anaerobic, Gram-negative rod-shaped bacteria, including some Bacteroides, Fusobacterium, and Prevotella, although resistance is increasing in Bacteroides fragilis.
Most aerobic Gram-negative bacteria (such as Pseudomonas, Legionella, Haemophilus influenzae and Moraxella) are resistant to clindamycin,[13][14] as are the facultative anaerobic Enterobacteriaceae.[15] A notable exception is Capnocytophaga canimorsus, for which clindamycin is a first-line drug of choice.[16]
What is the function of the AST / ALT ratio
When greater than 2.0, it is more likely to be associated with viral hepatitis, alcoholic hepatitis[4] or hepatocellular carcinoma
When greater than 1.0 but less than 2.0, it is likely to be associated with cirrhosis
It is normally less than 1.0
However, the AST/ALT ratio is less useful in scenarios where the liver enzymes are not elevated, or where multiple conditions co-exist.
Is a ALT or AST a better indicator of inflammation
ALT is a more specific indicator of liver inflammation than AST, as AST may be elevated also in diseases affecting other organs, such as myocardial infarction, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, musculoskeletal diseases, and trauma
What is the clinical significance of an elevated ALT
Significantly elevated levels of ALT(SGPT) often suggest the existence of other medical problems such as viral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy.
For this reason, ALT is commonly used as a way of screening for liver problems. Elevated ALT may also be caused by dietary choline deficiency. However, elevated levels of ALT do not automatically mean that medical problems exist.
Fluctuation of ALT levels is normal over the course of the day, and ALT levels can also increase in response to strenuous physical exercise
What pathologies will cause an increase and ALK PHOS
The normal range is 20 to 140 IU/L.
High ALP levels can show that the bile ducts are blocked.
Levels are significantly higher in children and pregnant women.
Also, elevated ALP indicates that there could be active bone formation occurring as ALP is a byproduct of osteoblast activity (such as the case in Paget’s disease of bone).
Levels are also elevated in people with untreated Celiac Disease.
Lowered levels of ALP are less common than elevated levels.
What are the pathologies that will cause hyperbillirubinemia?
- Mild rises in bilirubin may be caused by:
- Hemolysis or increased breakdown of red blood cells
- Gilbert’s syndrome – a genetic disorder of bilirubin metabolism that can result in mild jaundice, found in about 5% of the population
- Rotor syndrome: non-itching jaundice, with rise of bilirubin in the patient’s serum, mainly of the conjugated type. - Moderate rise in bilirubin may be caused by:
- Pharmaceutical drugs (especially antipsychotic, some sex hormones, and a wide range of other drugs)
- Sulfonamides are contraindicated in infants less than 2 months old (exception when used with pyrimethamine in treating toxoplasmosis) as they increase unconjugated bilirubin leading to kernicterus.[14]
- Hepatitis (levels may be moderate or high)
- Chemotherapy
- Biliary stricture (benign or malignant) - Very high levels of bilirubin may be caused by:
- Neonatal hyperbilirubinaemia, where the newborn’s liver is not able to properly process the bilirubin causing jaundice
- Unusually large bile duct obstruction, e.g. stone in common bile duct, tumour obstructing common bile duct etc.
- Severe liver failure with cirrhosis (e.g. primary biliary cirrhosis)
- Crigler–Najjar syndrome
- Dubin–Johnson syndrome
- Choledocholithiasis (chronic or acute).
How can volume depletion be determined
- urine Na concentration remains below 15 meq/L
2. Elevated specific gravity
What is S1Q3T3
EKG interpretation that shows an S wave in I a Q wave and inverted T wave in lead III. It is the classical sign of a PE
What is the wells score
Calculation used to determine the risk of Pulmonary embolism. Criteria include:
- Symptoms of DVT (3)
- No alternative dx (3)
- tachycardia > 100 (1.5)
- immobilizations or surgery (within 4 weeks) (1.5)
- Hx of DVT (1.5)
- hemoptysis (1)
- malignancy (1)
Score greater than 6 is high probability
Score less than 2 is low probability.
Colace
docusate sodium
What is the mechanism of docusate sodium
stool softner.
Facilitates mixture of stool fat and water
Senna soft
Sennosides
What is the mechanism of sennosides
increases peristalsis (Stimulant laxative)
What are the 3 mechanism in which T-bili can be elevated
increased production (hemolysis), intrahepatic causes (toxins, injury, gilberts), posthepatic causes (obstruction/gall stones)
What are the major risk factors for NASH (non alcoholic steatohepatitis)
obesity
DM
hyperlipidemia
macule
A flat, generally less than 0.5 cm in diameter area of skin or mucous membranes with different color than surrounding tissue. Color may be tan, brown, blue, red, or hypopigmented; macules may have nonpalpable, fine scale.
patch
A flat, generally greater than 0.5cm in diameter area of skin or mucous membrane with different color than surrounding tissue. Color may be tan, brown, blue, red or hypopigmented; patches may have nonpalpable, fine scale.
Papule
Discrete, solid, elevated bodies, usually less than 0.5cm in diameter. Papules are further classified by shape, size, color and surface characteristics.
plaques
Discrete, solid, elevated bodies, broader than they are thick, measuring more than 0.5cm in diameter. Plaques may be further classified by shape, size, color and surface characteristics.
nodules
Dermal or subdermal lesions that are firm, well-defined, and usually greater than 0.5cm in diameter. Cysts are fluid-filled nodules. Large nodules are called tumors.
pustules
Circumscribed elevations that contain pus. Pustules are usually less than 0.5cm in diameter.
vesicles
Fluid-filled cavities that are less than 0.5cm in diameter. Vesicles may be filled with fluid that is clear, serous, hemorrhagic or purulent.
bullae
Fluid-filled blisters greater than 0.5cm in diameter. Bullae can be filled with fluid that is clear, serous, hemorrhagic or purulent.
What is Inducible clinicamycin resistance
MRSA can develop resistance rapidly to single antibiotic treatment
How long should septic arthritis be treated
Four weeks IV antibiotics
How long should a septic bursitis be treated
Three weeks oral antibiotics
How does treatment of staph aureus cellulitis differ from strep cellulitis
Staff aureus requires two weeks IV vancomycin because staph aureus can seed other areas
The patient presents with coma, what are the medical treatments to counteract the coma.
Glucose (diabetes)
Thiamine (wernickes)
Flumazenil (Benzos)
Narcan (opiod antagonist)
What is the mechanism of benzonate
Anesthetizes respiratory passage, lung and pleural stretch receptors, reducing cough reflex
What are delirium tremens
Delirium tremens (DT) is defined by hallucinations, disorientation, tachycardia, hypertension, fever, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol. In the absence of complications, symptoms of DT can persist for up to seven days
How is the level of alcohol withdrawal determined
CIWA-Ar Score
Clinical Institute withdrawal assessment scale for alcohol revised
Less than 8 none to minimal withdrawal
8 to 15 mild
16 to 20 moderate
greater than 20 severe
What is a modified madrey’s discriminate function
predict prognosis in alcoholic hepatitis
(4.6 x (PT test - control))+ S.Bilirubin in mg/dl
Prospective studies have shown that, it is useful in predicting short term prognosis especially mortality within 30 days. A value more than 32 implies poor outcome with one month mortality ranging between 35% to 45%.
How is obesity hyperventilation syndrome different from obstructive sleep apnea
Obesity hypoventilation syndrome is a form of sleep disordered breathing. Two subtypes are recognized, depending on the nature of disordered breathing detected on further investigations.
The first is OHS in the context of obstructive sleep apnea; this is confirmed by the occurrence of 5 or more episodes of apnea, hypopnea or respiratory-related arousals per hour (high apnea-hypopnea index) during sleep.
The second is OHS primarily due to “sleep hypoventilation syndrome”; this requires a rise of CO2 levels by 10 mmHg (1.3 kPa) after sleep compared to awake measurements and overnight drops in oxygen levels without simultaneous apnea or hypopnea.[1][3] Overall, 90% of all people with OHS fall into the first category, and 10% in the second.[2]
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Discuss GGT
Blood test results for GGT suggest that the normal value for men is 15-85 IU/L, whereas for women it is 5-55 IU/L.[9]
Elevated serum GGT activity can be found in diseases of the liver, biliary system, and pancreas. In this respect, it is similar to alkaline phosphatase (ALP) in detecting disease of the biliary tract. Indeed, the two markers correlate well, though there is conflicting data about whether GGT has better sensitivity.[10][11] In general, ALP is still the first test for biliary disease.
The main value of GGT over ALP is in verifying that ALP elevations are, in fact, due to biliary disease; ALP can also be increased in certain bone diseases, but GGT is not.[11] More recently, slightly elevated serum GGT has also been found to correlate with cardiovascular diseases and is under active investigation as a cardiovascular risk marker. GGT in fact accumulates in atherosclerotic plaques,[12] suggesting a potential role in pathogenesis of cardiovascular diseases,[13] and circulates in blood in the form of distinct protein aggregates,[14] some of which appear to be related to specific pathologies such as metabolic syndrome, alcohol addiction and chronic liver disease. High body mass index is associated with type 2 diabetes only in persons with high serum GGT.[15]
GGT is elevated by large quantities of alcohol ingestion. Determination of total serum GGT activity is however not specific to alcohol intoxication,[16] and the measurement of selected serum forms of the enzyme offer more specific information.[14] Isolated elevation or disproportionate elevation compared to other liver enzymes (such as ALP or ALT) may indicate alcohol abuse or alcoholic liver disease.[17] It may indicate excess alcohol consumption up to 3 or 4 weeks prior to the test. The mechanism for this elevation is unclear. Alcohol may increase GGT production by inducing hepatic microsomal production, or it may cause the leakage of GGT from hepatocytes.[18]
Numerous drugs can raise GGT levels, including barbiturates and phenytoin.[19] GGT elevation has also been occasionally reported following NSAIDs, St. John’s wort, and aspirin. Elevated levels of GGT may also be due to congestive heart failure.[20]
Will alkaline phosphatase be elevated with alcoholic liver disease
No
How is magnesium effect with alcoholics
Alcoholics tend to waste total body stores magnesium
How is the spleen related to platelets
Splenomegaly will cause thrombocytopenia
What is traubes space
Traube’s (semilunar) space is an anatomic region of some clinical importance. It is a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin.
Dulness to percussion is significant for splenomegaly
What is the difference in mechanism concerning vancomycin and oxicillin
Oxacillin is bacteriocidal vancomycin is bacteriostatic
What significance is a positive D-test for Clindamyosin
Positive D test indicates an inducible resistance
discuss how to determine basil and sliding scale insulin
Factor .3 is used for Insulin sensitive
factor .4 Is used for moderate patients
factor .5 for insulin resistant patients
Multiply the factor times the body weight in kilograms
Set 50% for basal insulin 50% for sliding scale Insulin. Have a sliding scale insulin broke up for each of the three meals.
Divide the daily caloric intake by the factor determines from body weight in kilograms To determine the sliding scale range
Once insulin total is greater than 200 change to a higher potency
What are Dercum’s
Also known as adiposis Dolorosa
Rare disease that consists of painful lipomas
What are McGreers criteria for UTI
Includes only symptomatic urinary tract infections
No Indwelling Catheter
Must have three of the following:
fever >= 100.4°F/ > 38°C or chills
new or increased burning on urination, frequency or urgency
new flank or suprapubic pain or tenderness
new change in character of urine
worsening of mental or functional status
With Indwelling Catheter
Must have two of the following:
fever >= 100.4°F/ > 38°C or chills
new flank or suprapubic pain or tenderness
change in character of urine
worsening of mental or functional status
How is opiates withdrawal scored
COWS
Subjective score based off withdrawal symptoms including gooseflesh and pinpoint pupils along with trimmers sweats and arthralgias
Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal
What is significant with a lactate of 4.0
One third of patients will die within one month
How is a upper G.I. bleed scored
Glasgow-Blatchford Bleeding Score (GBS)
Name the top 4 severe upper G.I. bleed
- Esophageal varices
- Borheaves
- Peptic ulcer bleeds.
- gastritis
What are the common causes of lower G.I.
Diverticulosis
Hemorrhoids
Malignancy
Colitis
Mesenteric ischemia, VTE
What is gave syndrome
Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the antrum, or the last part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.
What is Dieulafoy’s lesion
medical condition characterized by a large tortuous arteriole in the stomach wall that erodes and bleeds. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. However, unlike most other aneurysms these are thought to be developmental malformations rather than degenerative changes.
The lesion will cease bleeding with the volume depletion
What is the generic treatment for an upper G.I. bleed
Use protonic for 24 hours with IV drip followed by oral
Two large bore IVs
Typing cross prepare for transfusion.
What is the ratio of a blood transfusion
4 units of blood
2 FFP
1 platelets
How is octreotide used for varices
It decreases the pressure to the varices
Mucomyst
Acetylcysteine
What are the three major liver function patterns
Hepatocellular
Cholestatic
Isolated hyperbillirubinemia
Outside of the liver what can cause a significant bump in AST
Acute MI
What are the causes of hepatocellular patterns
Viral Toxins Fatty Liver Auto Immune Hereditary
What is a cholestatic liver pattern
Increase in ALK PHOS
What are the causes of cholestatic pattern
Obstruction (us dilation)
- Gall stones
- Pancreatic cancer
Dilated
- Sclerosing
- PBC
What antibodies are associated with auto immune hepatitis
Anti smooth
What antibodies are associated with auto immune cholangitis
Anti mitochondria
What is the first blood cell line that is increased after chemo
Monocytes
What is the most specific EKG pattern for a pulmonary embolism
Inverted T waves on leads V1-V4
What is S1Q3T3
Indicates right heart strain.
Suspicious of cor pulmonale
What is polyglandular autoimmune disease
Autoimmune polyendocrine syndrome type 1 (APECED or Whitaker’s syndrome)
Autoimmune polyendocrine syndrome type 2 (Schmidt’s syndrome)
The most serious but rarest form is the X-linked polyendocrinopathy, immunodeficiency and diarrhea-syndrome, also called XLAAD (X-linked autoimmunity and allergic dysregulation) or IPEX (immune dysfunction, polyendocrinopathy, and enteropathy, X-linked). This is due to mutation of the FOXP3 gene on the X chromosome.[3] Most patients develop diabetes and diarrhea as neonates and many die due to autoimmune activity against many organs. Boys are affected, while girls are carriers and might suffer mild disease.
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What is the time period that is being examined when a creatinine measurement is taken
Previous 24 hours
Discuss contrast induced nephropathy
Typically occurs 2-5 days
Mucomyst to reduce inflammation
Increase fluids (125/hour)
Dialysis as necessary
What are the three most common bugs with CF
Pseudomonas Cepacia
Staph Aureus
Pseudomonas Aeriginosa
What is the correction factor for Na with elevated glucose
For every 100 over 100 multiply by 1.6 and add to Na.
476 glucose with Na 130
3.76x1.6=6
Corrected Na = 136
What is the general rule for fluid resuscitation
Volume: Hourly Rate
– Divide daily maintenance by 24 or use “4:2:1 rule”
Patient’s Weight Range
Hourly maintenance fluid rate
if 10 kg or less—Pt. needs 4 mL/hr. for each kg
if 11-20 kg—Pt. needs 40 mL/hr. PLUS 2 mL/hr. for each kg over 10 (or 3mL/kg)
if more than 20 kg—Pt. needs 60 mL/hr. PLUS 1 mL/hr. for each kg over 20 (or 2mL/kg)
What is the difference between hypervolemia and dehydration?
Dehydration is loss of free water and is always associated with hypernatremia
How quickly should lactate be corrected
It should be normalized in 4 hours. Always treat to 2.0
Precedex
Dexmedetomidine
What is the mechanism of Dexmedetomidine
Produces centrally mediated sympatholytic, sedative and analgesic effects
Used for sedation
What is the child Pugh scoring
is used to assess the prognosis of chronic liver disease, mainly cirrhosis. Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation.
Points Cla. 1 yr. 2 yr
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%
Keppra
Levetiracetam
When is Levetiracetam indicated
Seizures
Should you go pressors through a peripheral line
No! Possibility of limb ischemia and loss of limb
Levophed
Norepinephrine
What is the problem of using dopamine as a pressor
Dopamine is very pro arrhythmic
Use levophed instead
How do you rule out cardiogenic shock
Echocardiogram
Should you give positive inotropes or chronotropes with diastolic heart failure
No. You will further exacerbate the problem
What is the mechanism of cyclosporine
Anti-IL2
What is boaz sign
Right shoulder pain associated with gall bladder disease
What are the baseline BNP levels that carry an 84% specificity
< 50 yo is BNP of 450
50-75 is BNP of 900
>75 is BNP of 1800
What are the MDR risk factors
90 days prior abx use 2 days of hospital stay in previous 90 days Chemotherapy Dialysis Long term care facility
What is the tx for outpatient CAP
Macrolide
Doxycycline
What is the tx for failed outpatient or in patient CAP
Levoquin
What is the to for ICU CAP
Ceftriaxone
Azithromycin
Or
Fluoroquinolone
What is the tx HCAP MDR
Vancomycin
Zosyn
What penacillins have pseudomonas coverage
- All carbapenims except ertapenim
- Tobramycin & Gentamycin
- Levofloxacin & ciprofloxacin
- Aztreonam
Bentyl
Dicyclomine
What is the mechanism and indications for dicyclomine
Anticholinergic and relaxes smooth muscle.
Indicated for IBS
What are Wellington wave on an EKG
Biphasic T waves in V1-V4
Indicates impending proximal LAD occlusion. Emergent cath necessary to prevent STEMI
What is used for DVT’S prophylaxis
- Activity
- Mechanical (SCD’s)
- Medical (heparin or lovenox)
When should you use heparin instead of lovenox
STEMI
Allergies
Heparin has a shorter half life (1.5 hrs) and is easily reversible with protamine.
Lovenox half life is 12 hours
What is an IJ line.
Internal jugular line (central venous line)
What is Hoffman sign
tingling sensation triggered by a mechanical stimulus in the distal part of an injured nerve. This sensation radiates peripherally, from the point where it is triggered to the cutaneous distribution of the nerve. The tingling response can be compared with that produced by a weak electric current, as in transcutaneous electrical nerve stimulation (TENS). This unpleasant sensation is not a severe pain and does not persist
What are muehrcke’s lines
changes in the fingernail that may be a sign of an underlying medical disorder or condition. Muehrcke’s lines are white lines (leukonychia) that extend all the way across the nail and lie parallel to the lunula (half moon). In contrast to Beau’s lines, they are not grooved. The lines are actually in the vascular nail bed underneath the nail plate, and as such, they do not move with nail growth. Meuhrcke’s lines disappear when pressure is placed over the nail, blanching the underlying nail bed.
What are some clinical findings of the hands that are associated with cirrhosis
Asterixis Hoffmann sign Hypothenar Muehrcke's lines Clubbing
Phenergan
Promethazine
Endocort EC
Budesonide
What is the most common cause of death In a patient with cirrhosis
Bleeding and infection due to decreased protein production
What is the mechanism of rifaximin
Reduces ureas producing bacterial flora
Is albumin beneficial for cirrhosis
No clear benefit currently defined
What is prophylactic tx of gastroesophogeal varicies.
Non selective Beta blockers. Not preventative. Will decrease mortality.
Nadolol or propranolol
Goal of treatment is decrease of 25%
What is SBP
Spontaneous bacterial Peritonitis
What is the tx for SBP
Cefotaximine 2 gms IV Q 8 hrs x 5 days
If no encephalopathy or ARF can use PO Ofloxacin.
Major bugs include klebsiela, enterics, and E. coli
What causes decompensated cirrhosis
Constipation Infection Increased alcohol intake Medication Bleeding from esophageal varicies
What is hepatopulmonary syndrome
Triad of
- Liver disease
- Impaired oxygenation
- Intrapulmonary vascular abnormalities (referred to as intrapulmonary vascular dilations - IPVD’s)
PiO2 < 80
AA gradient > 15
What is decompensated cirrhosis
1 of the four
- Ascites
- SBP
- Worsening
- Hepatic encephalopathy
What is a tips procedure
Transjugular intrahepatic portosystemic shunt or transjugular intrahepatic portosystemic stent shunting (commonly abbreviated as TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding (esophageal varices) or the buildup of fluid within the abdomen (ascites)
What is platypnea
refers to shortness of breath (dyspnea) that is relieved when lying down,[3] and worsens when sitting or standing up. It is the opposite of orthopnea. The word is derived from the Greek platus (= flat) and pnoia (=breath).
What must be considered if more than 5 L is pulled from a patient with ascites
Oncotic pressure is very low, add albumin replacement otherwise you may induce a hepatorenal syndrome. Death will occur in 1-2 weeks.
What are the seronegative arthritis
IBD associated
Ankylosing
Psoriatic
Reactive
What is 96 % specific test for RA
Anti-CCP
What is a CAT test
COPD Assessment Test
Subjective patient completed survey grading the patients severity of COPD
What is a good mnemonic to follow for keeping ROS organized.
RICHMAN
Respiratory Infection Cardiovascular Heme/onc Metabolites Ailamentary Neurological Skin
What can be used to reduce immunogenicity of patients taking biologics
Methotrexate in addition to biologics grossly reduces immunogenicity responses against the biologics
What is the mechanism of plaquanil
Plaquanil prevents the lysosomes ability to modify pH and thus limits protein production and therefore modifies the immune system
What is the mechanism of etanercept
Binds and inhibits soluble TNF a
How is RA diagnosed
- Points on arthritis
- ESR / CRP
- CCP / RF
- Present greater than 6 weeks
Discuss the basic potency of the statins
Crestor is 2 times as potent as Lipitor
Lipitor is 2 times as potent as zocor
Zocor is 2 times as potent as prevastatin
What is the dosing regimen of Tylenol
1-2 tabs 325 mg PO Q 4-6 hrs PRN
Max is 1 gram/4 hours or 4 gram/ day
What is the dosing regimen of Motrin
Take 1-2 200 mg tabs PO Q 4-6 PRN
Max dose is 2400/ day
What is acapella breathing treatment
Acappella is a handheld device that combines the resistive features of a positive expiratory pressure (PEP) device with oscillations. The physiologic rationale is that by exhaling against resistance we slow down our expiratory phase of breathing.. This slower exhalation against resistance or positive pressure generates a back pressure which in turn splints or stents open the more peripheral airways and moves the equal pressure or choke point more central and so lessens airway collapse distally. This prolonged exhalation time also allows for collateral ventilation to occur. So, that with the assist of the pores of Kohn, canals of Lambert and channels of Martin, mucus can be mobilized from the distal or peripheral airways to the larger more central airways and thereby enhances secretion clearance. However, the patient or individual must be able to generate adequate air flow to use this device.
Uroxatrol
Alfuzosin
What is the mechanism of alfuzosin
Selectively antagonizes lower urinary tract Alpha-1-adrenergic receptors, relaxing smooth muscle and improving urine outflow.
What bugs are associated with HCAP
MRSA.
Pseudomonas.
ESBL
Actinobacter
What is used to tx HCAP
- Anti-Psuedomonal or cephalosporins or carbapinems
- Fluoroquinolone or macrolide
- Vancomycin
What is an acute measure of nutrition
Pre albumin
What is a long term measure of nutrition
Albumin
What is an acute measure of inflammation
CRP
What measurement is used for a longer more chronic perspective of inflammation
ESR
What effect does a PPI have on gastric emptying
Delays gastric emptying
What dose of steroids can induce glucocorticoid suppression
Greater than 20 g QD for more than 2 weeks has high risk
5 g QD can be used chronically with low risk
What steroid has little mineralcorticoid activity and can cross the placenta and CNS
Dexamethasone
What is the general steroid potency
Hydrocortisone 1 x
Prednisone 4 x
Solumedrol 5 x
Dexamethasone 20x
What role does adiponectin have with insulin
Makes cells sensitive to insulin
What effect does sulfa drugs have on creatinine clearance
Sulfa drugs compete for clearance and can increase Creatinine
Samsca
Tolvaptan
What are the indications for tolvaptan
Hyponatremia Hypervolemic
Hyponatremia Euvolemic
What is the mechanism of tolvaptan
Electively antagonizes vasopressin V2 receptors increasing free water secretion
What are the criteria determining admission or discharge for patients with a hx of syncope
Boston criteria
San Francisco criteria
Rose Criteria
What defines the San Francisco rule
“CHESS” mnemonic
- C - History of congestive heart failure
- H - Hematocrit < 30%
- E - Abnormal ECG
- S - Shortness of breath
- S - Triage systolic blood pressure < 90
How is the severity of Pneumonia scored
Port score
Curb-65
What causes post influenza pneumonia
Staph Aureus
When is steroids indicated for meningitis
Strep meningitis
What does LDH measure or reflect
Tissue breakdown releases LDH, and therefore LDH can be measured as a surrogate for tissue breakdown, e.g. hemolysis. Other disorders indicated by elevated LDH include cancer, meningitis, encephalitis, acute pancreatitis, and HIV.
What is lemierre’s syndrome?
Thrombophlebitis (Anerobic infection) of the internal jugular
What is Peutz-Jeghers syndrome
mucocutaneous melanin deposits (small black or brown dark spots) involving lips (> 95%), buccal mucosa (83%), nose, fingers, toes, and genitalia in Peutz-Jeghers syndrome
What is the mechanism of steroids
Inhibits NF-kB
What are the 5 p’s associated with compartment syndrome
Pain Palor Poikylothermia Parathesia Pulseless
What is stills disease
Juvenile idiopathic arthritis
What is TTKG
The transtubular potassium gradient (TTKG) is an index reflecting the conservation of potassium in the cortical collecting ducts of the kidneys. TTKG is considered to reflect mainly aldosterone bioactivity with regard to its kaliuretic response.
TTKG is clinically useful in diagnosis for patients suffering from hyper or hypokalemia in determining renal or non-renal cause of the condition. Expected responses are for hyperkalemia or potassium ingestion to result in excretion of potassium and a TTKG to increase (e.g. >10) and for conditions of hypokalemia, for potassium to be retained and the TTKG to decrease (e.g. <2).
Advil
Ibuprofen
Aleve
Naproxen sodium
What items on an EKG are suspicious of an MI or ACS
Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions
The physician should consider patient characteristics and risk factors to help determine initial risk.
What is tietze syndrome
Similar to costochondritis except that there is swelling in the effected joints.
A clinical diagnosis in the absence of other cardiopulmonary findings
Define pericarditis
triad of
- pleuritic chest pain,
- pericardial friction rub, and
- diffuse electrocardiographic ST-T wave changes.
ECG usually demonstrates diffuse ST segment elevation and PR interval depression without T wave inversion.
Acute pericarditis should be considered in patients presenting with new-onset chest pain that increases with inspiration or when reclining, and is lessened by leaning forward
What findings are suggestive of pneumonia
Common symptoms include fever, chills, productive cough, and pleuritic chest pain.
Fever, egophony heard during auscultation of the lungs, and dullness to percussion of the posterior thorax are suggestive of pneumonia
What is required for diagnosis of hereditary hemochromatosis
Diagnosis requires confirmation of increased serum ferritin levels and transferrin saturation, with or without symptoms.
What are the symptoms of hereditary hemochromatosis
symptoms may include weakness, lethargy, arthralgias, and impotence.
Later manifestations include arthralgias, osteoporosis, cirrhosis, hepatocellular cancer, cardiomyopathy, dysrhythmia, diabetes mellitus, and hypogonadism
What gene is associated with hereditary hemochromatosis
HFE gene mutation of C282Y
Protonix
Pantoprazole
What is a Stryker needle
Needle used to evaluate for compartment syndrome
Plaquanil
Hydroxychloroquin
