Medical Management Flashcards
What is the murmur of a patient with aortic stenosis
Crescendo-decrescendo systolic murmur
Murmur-Aortic regurgitation
Decrescendo blowing diastolic murmur
Murmur-mitral stenosis
opening snap
Murmur-mitral regurgitation
Holosystolic, blowing murmur
Murmur-mitral valve prolapse
Midsystolic click
Murmur-mitral valve prolapse syndrome
Midsystolic click
Systolic or Diastolic HF have an S3 murmur
Systolic with a dilated left ventricle
Systolic or Diastolic HF have an S4 murmur
Diastolic with left ventricle hypertrophy
Treatment for VTachy
Cardioversion
VTach caused by
Myocardial infarction, cardiomyopathy, electrolyte abnormality, blunt trauma, infections or infiltrative disease
AFib caused by
HTN
Valvular disease
CAD
HF
AFib diagnosed by
Absent P waves
Treatment for Afib and Aflutter in an unstable situation
Cardioversion
Treatment for paroxysmal supra ventricular tachycardia (PSVT)
(4 pts)
Vagal maneuvers,
adenosine,
medical management,
ablation
WPW Syndrome-Etilogy
Accessory pathway between atria and ventricles due to congenital separation during fetal development; risk of sudden cardiac deaths and tachyarrhythmias
Bradycardia etiology?
(7 causes-4 i’s)
Ischemic, infectious, infiltrative, autoimmune, conditioned heart, medication, neurologic
CHADS scoring table
C-CHF
H-HTN-BP consistently above 140/90 mHg
Age>75 yrs
D-DM
S-Prior stroke or transiet ischemic attack or thromboembolism (2 is for 2 points if yes_
Type I Heart Block ECG finding
Increased PR interval
Type IIa Heart Block ECG finding
Increased PR interval until dropped QRS
Type IIb Heart Block ECG finding
Regularly dropped QRS with constant PR interval
Type III Heart Block ECG finding
Complete dissociation of P waves and QRS complexes
Primary HTN
No identifiable cause
2ndary HTN
(6 causes)
Indetifiable cause such as:
Renal artery stenosis
diabetic nephropathy
Thyroid disease
cocaine use
pheochromocytoma
OSA
Diagnosis of HTN
at least 2 elevated BP readings on 2 different occasions
Stage 1: SBP from 140-159, DBP from 90-99
Stage 2: SBP >160, DBP >100
Beta Blocker used for:
Side effects:
MI, CAD, CHF
Bronchospasm, AV node blockade
ACE Inhibitor
Side Effects:
Diabetes, MI, proteinuria, CHF
SIDE EFFECTS: Cough, Renal Failure
Thiazide use
Side Effects
Combination therapy:
Hypokalemia
Difference of HTN Urgency vs Emergency
Urgency, BP >180/120
Emergency, BP >180/120 with evidence of end organ damage
Duke Criteria, definite IE
2 major; 1 major & 3 minor; 5 minor
Duke Criteria, possible IE
1 major & 1 minor; 3 minor
Duke Criteria, major criteria
Positive blood culture, Echo with evidence of endocardial involvement
Bacteria associated with IE
Staph Aureus-IV
Native Valve-Viridans Streptoocci, S aureus, enterocci
Prosthetic Vavle-S epidermidia, S aureus
Culture Negative-HACEK organism
HACEK organism
H-Haemophilus
A-Aggregatibacter
C-Cardiobacterium
E-Eikenella corrodens,
K-Kingella
Candida, Aspergillus
Minor Criteria of Dukes
-Predisposition to IE (IV drug use, indwelling catheter, diabetes)
-Fever
-Vascular phenomena )Janeway lesions, arterial emboli, intracranial hemorrhage, splinter hemorrhage)
-Microbiologic evidence
-Immunologic phenomena (Osler nodes, Roth spots)
Janeway lesions
Janeway lesions are irregular, nontender hemorrhagic macules located on the palms, soles, thenar and hypothenar eminences of the hands,
associated with IE
Splinter hemorrhages
Associated with IE
Abx treatment for native valve IE with Viridans streptococci, Aureus, enterococci
Vanocmycin and gentomycin
METs
Metatbolic equivalent of tasks
METs score
What is RV, TV, ERV, and FRC
What is FEV1, FVC, TLC
Name three types of obstructive lung disease
COPD,
Asthma
Cystic Fibrosis
Name three types of restrictive lung disease
Sarcoidosis,
Interstital lung disease
Collagen Disorder
Extraparenchymal restrictive types of pulmonary disease
Obesity
Scoliosis
Myasthesia Gravis
Diaphragmatic Weakness
Cervical spine injury
Compare FEV1, FVC, FEV1/FVC, lung volume, flow rates between obstructive and restrictive lung disease
True or False, Asthma has a prolonged expiratory phase
True, it does have prolonged expiratory duration with expiratory wheezing
Mild Intermittent Asthma Definition & Treatment
Def: <2 days week with PEF> 80% (PEF = peak expiratory flow)
Treatment: Bronchdilator as needed like albuterol, salmeterol
Mild PersistentAsthma Definition & Treatment
Def: >2 days week, but less than 1 time a day with PEF> 80% (PEF = peak expiratory flow)
Treatment: Low-dose inhaled steroids like Fluticasone, hydrocortisone, prednisolone
Moderate PersistentAsthma Definition & Treatment
Def: daily symptoms with PEF>60% but less than 80% (PEF = peak expiratory flow)
Treatment: Low-dose inhaled steroids like Fluticasone, hydrocortisone, prednisolone & albuterol, salmeterol (beta 2 agonist)
Severe PersistentAsthma Definition & Treatment
Continuous symptoms with PEF < 60%, add oral steroids to everything mentioned above.
Beta 2 agonists for asthma treatmetn
relaxation of bronchial muscle due to increase in cAMP formation
Corticosteroids role in asthma treatment
Suppresses inflammatory response and decreases mucosal edema like Fluticasone, hydrocortisone, prednisolone
What is Montelukast
a leukotriene modifier used for asthma treatmetn which is an antagonist that decreases bronchoconstriction
What is Zileuton
A leukotriene formation inhibitor that treats asthma
What is ipratropium bromide used for
It blocks cholinergic constriction causing bronchodilation
Asthma vs COPD
Asthma is reversible, COPD is not reversible, both are obstructive lung diseases
Chronic bronchitis def
Chronic productive cough for 3 months in 2 consecutive years…blue bloater
What’s a pink puffer”
Refers to emphysema which is enlargement of airways and wall destruction distal to bronchioles, “pursed lip breathing
COPD its with arterial blood gas analysis will show
Hypercarbia
hHypoxemia
What deficiency can be associated with emphysema patients?
Alpha 1 antitrypsin deficiency
FEV1 can determine severity of COPD, true or false
True, it is on stages based on FEV which determine treatment
What is ARDS?
Acute respiratory distress syndrome associated with bilateral lung infiltrates?
What causes ARDS?
(6 pts)
Pneumonia
Aspiration
Trauma
Acute pancreatitis
inhalation injury,
Reperfusion injury
ARDS is diagnosid by a ration of PaO2 to FiO2 that is less than _____?
200
PE symptoms? ( 6 pts)
-Dyspnea,
-hemoptysis,
-fever,
-cough,
-tachypnea,
-tachycardia
V/Q scan in treatment PE
Ventilation without perfusion suggests PE
What anticoagulant treats PE
Heparin bridge to Coumadin to maintain iNR of 2-3 for at leasts 3-6 months
What is the modified wells criteria
Something that determines the likelihood of PE and if greater than 4, someone likely has PE?
What are the criteria for modified wells criteria? (7 pts)
signs/symptoms of DVT
-PE is primary diagnosis
-HR >100 bpm
-immbilized for at least 3 days or surgery in previous 4 weeks
-previous diagnosed PE or DVT
-Malignancy with treatment
-Hemoptysis
-DVT
What determines acute renal failure?
Increase in serums creatinine >0.3 mg/dL over baseline
-Urine output less than 0.5 cc/kg/hr for more than 6-12 hrs
Prerenal causes of renal failure?
( 3 pts)
volume depletion, severe liver disease, severe CHF
Treatment: Fluids
REnal causes of renal failure?
(4 pts)
Tubular injury, acute tubular necrosis, interstitial disease, globular disorder
Remove underlying agent and treat cause
Postrenal causes of renal failure
(3 pts)
Urinary tract obstruction with a fractional excretion of sodium <1%, oliguria (little urine), anuria (no urine)
Treatment: Remove obstruciton
Need for emergent dialysis
AEIOU
A-Acidosis
E-Electrolyte abnormality
I-Ingestion
O-Overload
U-Uremia
Chronic renal fialure
Permanent loss of renal function for at least 3 months caused by
HTN
DM
renal artery stenosis,
Polycystid kidney disease
What predicts progression of chronic renal failure
Protienuria
Complications of CRF
(6 pts)
PHAARD
-Pericarditis due to fluid overload
-Hyperkalemia
-Anemia
-Acidosis
-Renal osteodystorphy due to phosphate issues
-Dialysis infections
T/F, leukocyte esterase and nitrites and protein in abundance are found in abnormal urine
True, possible urine infection
Glucose absent in abnormal urine?
False, it is present due to renal fialure
What is primary nephrotic syndrome?
direct damage to glomeruli causing massive proteinuira
What symptoms are associated with nephrotic disease
(4 pts)
nePHHrotIc
-Peripheral edema,
-hypoalbuminemia,
-hyperlipidemia,
-increased proteinuria
Membranous nephropathy
Thickneing of capillary loops with sub epithelial deposits
It is a nephrotic disease meaning damage to glomeruli
Goodpasture syndrome
Linear IgG deposition along globular basement membrane
It is a nephrotic disease meaning damage to glomeruli
What is focal segmental glomerulosclerosis
Glomerulcsclerosis causing proteinuria
It is a nephrotic disease meaning damage to glomeruli
What is minimal change disease
It is epithelial foot process loss
It is a nephrotic disease meaning damage to glomeruli
Nephrotic syndrome is a group of symptoms that include protein in the urine, low blood protein levels in the blood, high cholesterol levels, high triglyceride levels, and swelling.
What is secondary nerphrotic syndrome
Damage of glomeruli secondary to systemic disease.
What is a kimmelstiel-Wilson lesion
It is a lesion associated with nephrotic syndrome and diabetes mellitus
What two pathologies have positive Congo red stains?
Multiple Myeloma & Amyloidosis
What is nephritic disease?
It is inflammatory disorder in the glomeruli
Glomerulonephritis
RBCs in urine with or without cellular casts and proteinuria
What symptoms are associated with inflammatory disorder in the glomeruli (nephritic diseases)
(4 pts)
-HTN,
-edema,
-oliguria,
-hematuria
Immune complex glomerulonephritis
3 conditions and assoicated renal pathology
Subacute bacterial endocarditis-leads to present glomerulonephritis
Post-streptococcal-Subepithelial hums
Membranoproliferative glomerulonephritis-subendothelial deposits
Decreased complement levels is associated with what kind of nephritic disease?
Immune complex glomerulonephritis
What is Pauci immune glomerulonephritis
It is glomerulonephritis associated normal complement levels
IgA nephropathy?
IgA deposits in mesangium
Wegners granulomatosis pathology
Necrotizing crescent disease
Churg-Struss syndrome
Necrotizing crescent disease
Discuss differences of nephritic versus nephritic disease in terms of:
-Protein
-Urinalysis
-BP
-GFR
Nephritic Disease- Inflammatory of the glomeruli
Nephrotic Disease-Damage to glomeruli causing massive proteinuria
In evaluating pH and PaCO2, how do you tell if it s metabolic or respiratory disorder?
Metabolic disorders - pH and PaCO2 change in the same direction
Respiratory Disorders-pH and PaCo2 change in opporsite directions
Discuss the differences of metabolic acidosis, alkalosis in terms of PaCO2 and bicarbonate.
How do you determine the anion gap?
AG: Na- (CL+HCO2) < 12
If aG <12, acidosis is due to…
loss of bicarbonate (i.e. diarrhea)
If AG>12, acidosis is due to increase of
nonvolatile acid (lactic acidosis.
Metabolic acidosis etiology is best determined by th emneumonic MUDPILES
M-Methanol ingestion
U-Uremia
D-Diabetic Ketoacidosis
P-Paraldehyde Ingestion (antiseizur medicine)
I-Isoniazid Ingestion (drug for tB)
L-Lactic Acidosis
E-Ethylene glycol ingestion (antifreeze)
S-Saliacylate ingestion (aspirin)
Remember AG>12 in these situations
Symptoms of Metabolic acidosis
Hyperventilation (compensatory_
-Decreaed tissue perfusion
-Decreased CO
-Altered mental status
-Arrhythmias
-Hyperkalemia
How do you manage metabolic acidosis
Treatment of underlying issue.
Sodium bicarbonate
What is metabolic alkalosis
Increased blood pH with increased bicarbonate
What are the etiologies of Metabolic alkalosis
1-Extracellular fluid expansion-like adrenal disorders causing increased mineralocorticoid secretion; increased reabsorption of bicarbonate and sodium and secretion of chloride
2-Extracellular fluid contraction-Vomiting, nasogastric suction causing hydrochloric acid and bicarbonate loss, excessive use of diuretics
What are the signs/symptoms of metabolic alkalosis
Hypokalemia,
elevated bicarbonate,
elevated pH,
Hypoventilation,
arrhythmia,
decrease in cerebral blood flow
Metabolic alkalosis, treated with?
Volume and K replacement
REspiratory acidosis diagnosis
Decreased blood pH with arterial PaCO2 > 40
What causes respiratory acidosis?
-COPD
-Brainstem injury
-Respiratory muscle fatigue
-Drug overdose causing hypoventilation
What are signs of respiratory acidosis?
Confusion
headaches
Fatigue
CNS
How to treat respiratory acidosis
Consider mechanical ventilation with severe acidosis, deteriorating mental status, and impending respiratory failure.
What is respiratory alkalosis
Alveolar hyperventilations with increased blood pH and a decrease in PaCO2 ( breathing quickly into a bag to help it)
What are the causes of respiratory alkalosis
-Anxiety
-Sepsis
-Pregnancy
-Liver Disease
-Pulmonary embolism
-Asthma
What are the symptoms of respiratory alkalosis?
-Decreased cerebral blood flow
-Lightheadedness
-Anxiety
-Perioral Numbness
-Arrhythmias
How to treat respiratory alkalosis
Breathe into paper bag, rebreathe CO2 and decrease the pH
What are symptoms of hyponatermia
Lethargy, seizures, nausea/vomiting, confusion
Hyponatremia can be caused by SIADH which stands for?
Syndrome of inappropriate antidiuretic hormone secreiton
What happens if you rapidly improve sodium levels?
It can lead to demyelinating encephalopathy
Treatment of hyponatremia
Depends what kind of volume status and neurologic symptoms are present.
-You can calculate the sodium deficit
-Hypovolemia-Isotonic saline
-Euvolemia-Diuresis, and infusion of hypotonic saline in symptomatic patients,
-Hypervolemia-Diuretics with addition of hypertonic saline only in symptomatic patients.
What are symptoms of hypernatermia
-Lethargy
-Weakness
-Irritability
-Seizure
-Polyuria
Treatment of hypernatermia
-Treat diabetes insepitius, replace isotonic fluid
Hypokalemia? better or worse than hyperkalemia
Hypokelimia is better tolerated than hyperkalemia
Symptoms of hypokalemia
-Muscle weakness but usually less than 2.5
-Abnormal ECT
-Prominent U waves and QT prolongation
How to treat hypokalemia
Potassium replacement and magnesium replacement
Symptoms of Hyperkalemia
-Poorly tolerated, especially when level is above 5.5, a patient with chronic renal disease may normally have an elevated potassium level
Symptoms of Hyperkalemia
-ECG changes
-Peaked T waves, and PR interval lengthening, disappearance of p waves and QRS prolongation, final-ventricular asystole
-Respiratory failure
-Nausea/vomiting
-Muscle weakness
How to treat hyperkalemia
Shift potassium intracellular with insulin and desctorse
-Diuretics
-ECG changes.
Which has bloody diarrhea…chron’s or ulcerative colitis?
Ulcerative colitis
Which has patchy transmural inflammation….Chron’s or ulcerative colitis?
Chron’s disease
Which has continuous mucosal inflammation….Chron’s or ulcerative colitis?
Ulcerative colitis
Which is associated with uveitis, erythema nodosum and ankylosing spondylitis…chron’s or ulcerative colitis
Ulcerative colitis
Where does ulcerative colitis occur?
colon to th erectum
Where does Chron’ disease occur?
anywhere in the GI but propensity to the illeum
Ulcerative colitis…increased malignancy risk or decrease
Increased
Diagnosis, Transmission and Treatment of Hep A/B/C
Hepatitis B serology
T/F: GERD is associated with adenocarcinoma and Barrett esophagus
True
ESLD: Etiology
Chronic hepatocellular injury leads to fibrosis of liver
Symptoms of ESLD:
Fatigue,
anorexia,
impotence,
mElena,
spider nevi,
gynecomastia,
jaundice,
testicular atrophy,
coarse hand tremor,
caput Medusa,
spider telangiectasia,
Complications of ESLD
-Esophageal varices
-Ascites
_increase in bleeding risk
-Portal HTN
-Hepatic encephalopahty
Child-Turcotte Pugh score
-Associated with ESLD and the following factors
-Ascites
-Encephalopahty
-Albumin
-Prothrombin Time
-Bilirubin
Which type of anemia is associated with iron deficiency?
Microcytic
Which type of anemia is associated with renal deficiency?
Normocytic
Which type of anemia is associated withB12/Folate deficiency?
Macrocytic
What symptoms are associated with microcytic, normocytic, and microcytic anemias
Sickle Cell disease is caused by what
A homozygous defect in gene for beta-globulin that produces hemoglobin S
What diagnoses sickle cell disease
Target cells, sickle cells, Howell Jolly bodies, Hemoglobin S on smear
How do you treat sickle cell disease?
Folate
Hydroxyurea
Agressive Hydration
Analgesia
Oxygen
Transfuse for major surgery 9-10 g hemoglobin
What acute complications are associated with sickle cell disease?
Stroke
Splenic infarc
Osteomyelitis
FActor 8 deficiency symptoms and treatment?
Spontaneous bleeding, treat with desmopressin or factor replacement
FActor 9 deficiency symptoms and treatmetn?
Spontaneous bleeding, prolonged PTT, treat with factor replacement
vWF deficiency (von Willebrand disease) symptoms and treatments?
Symptoms: Petechiae, mucosal bleeding, epistaxis, factor 8 activity with vwF deficiency
Treatment: Desmopressin, aminocaproic acid and factor 8 replacement
What is immune thrombocytopenia purpura
Normal spleen with petechiae and mucosal bleeding due to immune destruction of platelets
Treat with platelet transfusion if platelet drop below 25,000-30,000
DIC
Disseminated Intravascular Coagulation-A coagulopahty associated with serious illness
What is thrombocytopenia?
aThrombocytopenia is a condition that occurs when the platelet count in your blood is too low.
What is desmopressin?
Desmopressin is used to treat central cranial diabetes insipidus. It is a clotting promoter and diuretic
DIC leads to symptoms of
thrombocytopenia and excessing bleeding or clotting
Diagnosis of DIC is discovered with
Decreased fibrinogen, platelets, increased PT/partial thromboplastin time (PTT), d-dimertest, schistocytes present
Treatment of DIC:
treat underlying cause; platelets and cryprecipaite for bleeding, low-dose heparin for clotting
What is the INR goal for patients with mechanical heart valves
3 to 4
Factor V Leiden (Venous or Arterial thrombosis?
Venous
Protein C/S deficiency and Heparin-INdcued Thrombocytopenia…arterial or venous thrombosis?
Arterial and Venous
Lab and REversiblity for warfarin
INR and FFP and Vitamin K reverse it
Heparin-Lab and REversiblity
Lab-PTT and platelet count
Reversability-Protamine
Low molecular weigh heparin-Lab and REversiblity
Lab-Antifacotr Xa
Reversibility-No
Fondaparinum Lab and REversiblity
Lab-None
Reversibility: No
Diabigatran Lab and REversiblity
Lab-None
Reversability-None
Diabetes Mellitus Daignosis
Complications of DM Type I versus DM Type II
Complications: Diabetic Ketoacidosis for Type I DM
Complications of Type II DM: Hyperosmolar nonketontic coma
Name complications of diabetes (7)
-Retinopathy
-Neuropathy
-Nephropathy
-Infections
-MI
-CVD
-Stroke
Is glargine long acting or short acting insulin?
It is long acting (24 hrs
Is lispro long acting or short acting insulin?
It is short acting (3-4 hrs)
What is the mechanism of metformin?
It decreases insulin resistance and glucose production?
What is the mechanism of sulfonylurea?
It is known as glburide and stimulates insulin release
What is the mechanisms of meglitinide (repaglindide)
Stimulates pancreas to release insulin
What is the mechanism of pioglitazone
Decreases insulin resistance peripherally
What is the goal of treatment for Diabetes
BP < 130/85
LDL- , 100, total glycerides <150, HDL >40
Smoking cessation
HbA1c < 7
What is good control for DM
HbA1c between 7-8.5 is good
Fasting glucose <130
Peak postpranidal glucose <180
What is diabetic ketoacidosis
It is an insulin deficiency and glucagon excess that causes severe hyperglycemia and ketogenesis. Severe hyperglycemia causes an osmotic diuresis leading to dehydration and volume depletion.
What are symptoms of DKA
-Abdominal pain
Nausea
Vomiting
Kussmaul respirations
Ketone breath
Anion gap metabolic acidosis
Marked dehydration
Tachycardia
Polydipsia
Polyuria
Weakness
Altered Consciousness
What is a diagnosis of DKA?
Serum glucose >250, metabolic acidosis pH >7.3 and serum bicarbonate < 15, increased anion gap, ketonuria, ketonemia, hyperkalemia, and hyponatremia
What is the treatment of DKA
IV insuline at 0.1 units/kg
-drip at 0.1 units/kg/hr
-Normal saline replacement
-Decrease insulin once AG has closed and acidosis has resolved
-Monitor K
Add dextrose to IV lfuids when glucose is below 250
-Monitor Na, K, and Mg levels
Hypohtyroid diagnosis
Elevated TSH and decreased T4
What are the symptoms of hypothyroidism?
fatigue,
-weight gain
-cold intolerance
-depression
What are the symptoms of hyperthyroidism
-Palpitations
-Heat intolerance
-Sweating
-Anxiety
Graves disease hyper or hypothyroidism?
It is hyperthyroidism and comes iwht a toxic nodule and goiter
A fib and thyroid storm are associated with hyperthyroidism
Explain Adrenal Disorders
Symptoms of Weakness, postural hypotension, salt craving
Labs of Low NA, increased K, volume depletion, low glucose, elevated Ca, AM cortisol
Adrenal insufficiency
Check ACTH
-Low ACTH-2ndary insufficiency due to steroids or pituitary tumors, treatment: glucocorticoid replacement
High ACTH: Primary insufficiency due to malignancy, infections, drugs or autoimmune disease
Treatment: Minearlcorticoid and glucocorticoid.
What is an adrenal crisis?
Shock, nausea, vomiting, confusion, fever,, can be fatal
What is Addison’s disease?
Primary renal insufficiency.
-Etiology: Autoimmune adrenalitis, malignancy, infection.
-Symptoms: Hyperpigmenation of the oral mucosa, dehydration, hypotension, fatigue, anorexia, nausea, vomiting, diarrhea, abdominal pain, salt craving, hyponatremia, hyperkalemia
Treatment: mineralocorticoid and glucocorticoids
What is cushing’s syndrome?
It is caused by exogenous steroids, pituitary adenoma, ectopic ACTH, adrenal hyperplasia.
Symptoms of Cushing’s syndrome
-Moon facies
-Buffalo hump,
HTN
-Truncal obesity
-Depression
Striae
-Diabetes
-Osteopenia
-Hypokalemia
-Metabolic acidosis
When do you have to conduct a dexamethasone suppression test or 24 hr urine free cortisol level?
For Cushing syndrome
How many hormones released by pituitary gland? (6)
-ACTH
TSH
-LH/FSH
-GH
-Prolactin
- A 22 y/o patient is s/p MVA. C/C pain right shoulder, SOB, and positive Hamman’s sign. What is the diagnosis?
“mediastinal crunch” produced by the heart beating against air-filled tissues. Associated with pneumomediastinum
- Which NIDDM med gives rise to lactic acidosis
Metformin. It can also cause the GI tract to become upset.
- Blood Brain Barrier – what determines what enters?
a. Freely crosses: high lipid solubility and CO2, non ionized
- Beta-2 transferrin is what?
a. Beta-2-transferrin is a carbohydrate free glycoprotein produced by neuraminidase activity in the brain which is uniquely found in the cerebrospinal fluid (CSF) and perilymph.
. Vancomycin (Red Man Syndrome). The cause of this is what?
28
a. Histamine release
Red man syndrome is an infusion-related reaction peculiar to vancomycin. It typically consists of pruritus, an erythematous rash that involves the face, neck, and upper torso. Intravenous dose of vancomycin should be administered over at least a 60 min interval to minimize the infusion-related adverse effects Discontinuation of the vancomycin infusion and administration of diphenhydramine can abort most of the reactions. Slow intravenous administration of vancomycin should minimize the risk of infusion-related adverse effects.
- Pansystolic murmur is what type of murmur?
a. TR, MR, VSD - Pansystolic (Holosystolic) murmurs often occur with regurgitant flow across the atrioventricular valves
- A patient on 5 Fluorouracil for beast cancer. What should the doctor be worried about?
a. Drug has myelosuppressive effects which can increase rise of infection and bleeding tendency by causing low WBC and platelets counts
- Patient with leukemia. Why is there so much bleeding?
a. Decreased amount of megakaroctes which is the progenitor cell for platelets
- What medications do you give to treat PSVT?
a. Adenosine – first line choice ACLS
- What changes in respiratory function are found in the pregnant patient?
Minute ventilation increased 50%
Alveolar ventilation increased 70%
Tidal Volume increased 50%
Oxygen consumption increased 20%
Respiratory rate increased 15 %
Dead space no change
Vital capacity no change
Lung compliance no change
Closing volume no change or decreased
Total compliance decreased 30%
Airway Resistance decreased 36%
Expiratory Reserve vol. decreased 20%
Total lung capacity decreased 0-5%
Functional residual capacity decreased 20%
- Albuterol given to a patient and an improvement in FEV1 is noted. What type of disease does this patient have?
a. Reversible obstructivelug disease
- What labs are associated with a patient diagnoses with Paget’s disease?
a. Normal Ca2+, normal PO4, and elevated alkaline phosphatase
- Bleeding time is increased, PTT increased. What coaguloathy is present?
a. von Willdebrands
- Removal of the parathyroid glands leads to what lab changes?
a. Ca2+ down and PO4 up
- What are the signs of a massive P.E.?
- Massive P.E. – syncope, cardiovascular collapse
- Signs/ Symptoms: Tachycardia (most common sign), SOB, tachypnea, hypotension, chest pain, fever, tender lower extremity, loud pulmonary component of S2, hempoptosis with pulmonary infarct
- Virchow’s triade: endothelial cell trauma, stasis and hypercoagulable state
- EKG changes: S wave in I, Q in III, inverted T III
- Homan’s Sign: calf pain with dorsiflexion of foot
- A patient with ESRD preparing for anesthesia, which labs to check?
a. Potassium – hyperkalemia leading to cardiac issues
- EKG strip after starting an IV – rhythm appeared to be regular and roughly 100 beats per minute – next step
a. Titrate midazolam to effect - (Patient anxious getting IV with basic tachycardia and no arrhythmia on EKG)
What symptoms show up in hypopituitarism?
Depends on hormone deficiency, GH, LH/FSH, TSH, ACTH, antidiuretic hormone
What is the etiology of hyperpitutarism?
Adenoma, prolactinoma
Symptoms of hyperpituitarism?
Headache, vision changes, additional symptoms specific released from pituitary gland
Hypercalcemia Symptoms
Moans (stupor, depression, psychosis)
Groans (nausea, vomting, constipation)
Stones (Kidney stones, nephrogenic diabetes insipidus)
Bones (arthritis fractures
Other symptoms include Weakness, hypertonia, bradycardia.
Etiology of hypercalcemia,
Malignancy (parathyroid hormone-related protein)
Local osteolysis
Granulomatous disorders
Paget disease
Treatment of hypercalcemia
Saline infusion for urinary excretion.
-Consider diuretics to inhibit calcium reabsorption and bisophosphonates or calcitonin when hypercalceimia is secondary to malignancy
-Glucocorticoids may be used to treat hypercalcemia in patients with multiple myeloma
Hypocalcemia Symptoms
-Neuromuscular excitability (seizures, tetany)
-Chvostek sign (ipsilateral twitching of the facial muscles occurs)
-Trousseau sign (when a carpopedal spasm of the hand and wrist occurs )
-Prolonged QT interval
Sarcoidosis and what does a lip biopsy show
Autoimmune disease causing noncaseating granulomas
Lip Biopsy shows minor salivary glands with noncaseating granulomas with normal-appearing mucosal tissue
Treatment: systemic steroids
Rheumatoid Arthritis Diagnosis
Increased erythrocyte sedimentation rate and C-reactive protein,
Can be associated with serositis, ocular disease, amyloidosis, atherosclerosis.
Rheumatoid arthritis includes 6 diagnoses from either…
Joint involvement, serology, acute phase reactants (CRP and ESR), with a duration greater than 6 weeks.
In which classification of arthritis does movement improve pain?
Rheumatoid arthritis
Differences between rheumatoid arthritis and osteoarthritis
Diagnosis of Lupus and symptoms
Symptoms: Arthralgias, malar rash (photosensitive), oral ulcers, pancytopenia, serositis
Diagnosis: Anti-double standard DNA (anti-dsDNA), antinuclear antibody (ANA testing, anti-Smith antibodies, antiphospholipid antibodies.
Myasthenia Gravis Definition
Autoimmune disorder with auto-antibodies to acetylcholine receptor
Treatment of Myasthenia Gravis
Physostigmine (anti cholinesterase inhibitor)
Scleroderma definition and symptoms
Collagen overproduction
Associated with GERD, Raynaud’s disease and skin tightening.
Progressive systemic Sclerosis
Disorder of connective tissue with thickening of dermal collagen bundles and fibrosis and vascular abnormalities in internal organs with symptoms of vasomotor disturbance (HTN), fibrosis, skin atrophy, muscle atrophy, internal organ dysfunction
Sjrogren Syndrome Definition
Systemic autoimmune disease in which immune system attacks exocrine glands
Sjrogren’s Syndrome Diagnosis
ANA, RF, anti-SSA/B autoantibodies
Lip Biopsy
Eye exam, Schrimer test
Sialography
Allergies…IgE
Type I, anaphylaxis
Allergies Type 2
Antibodiy mediated cytotoxic reactions, penicillin-induced hemolytic anemia,
Type 4 Allergies
Delayed hypersensitivity activating T cells-poison ivy dermatitis
Wegener Granulomatosis
Symptoms
Diagnosis
Pathology
Treatment
Churg-Strauss Angiitis
Symptoms
Diagnosis
Pathology
Treatment
Microscopic Polyangiitis
Symptoms
Diagnosis
Pathology
Treatment
Giant Cell Arteritis
Symptoms
Diagnosis
Pathology
Treatment
Takayasu Arteritis
Symptoms
Diagnosis
Pathology
Treatment
Polyarteritis Nodosa
Symptoms
Diagnosis
Pathology
Treatment
Bechet’s Disease
Symptoms
Diagnosis
Pathology
Treatment
Which serology test is associated with Wegner granulmatosis?
ANCA
Which serology test is associated with just lupus and sjrogren syndrome
Anti SSA, Anti SSB
Cardiogenic
Neurogenic
Vasovagal
Orthostatic
Causes of Syncope
Static Epilepitus
Continous seizure activity > 30 min or recurrent seizures without rturn of consciousness
-Treatment: Check airway, breathing, circulation, consider thiamine, glucose, bentos, phenytoin
Seizure
abnormal discharge of cortical neurons
CVA
Acute onset focal neurologic changes secondary to blood flow disruption to the brain.
Ischemic Stroke
Emboli from internal carotid artery or heart causing blood vessel blockage
Ischemic stroke-contrast or no contrast for scan
No contrast
Hemorrhagic Stroke
Associated with headache and loss of consciousness with HTN being primary cause
Intracranial bleeding-Epidural Hematoma
Vessels
Symptoms
Diagnosis
Treatment
Intracranial bleeding-Subdural Hematoma
Vessels
Symptoms
Diagnosis
Treatment
Intracranial bleeding-Subarachnoid Hematoma
Vessels
Symptoms
Diagnosis
Treatment
Neurolepic Malignant Syndrome
Etiology: Decreased levels of dopamine activity secondary to dopamine receptor blockade.
Symptoms: Increased body temp, altered consciousness, diaphroesis, rigid muscles, autonomic imbalance.
What drug is used for muscle ridigidty in Neuroleptic Malignant Syndrome?
Dantrolene
Serotonin Syndrome
Excess of serotonergic active in the CNS and peripheral serotonin recpetroms from therapeutic drug use, recreational drug use, or drug interactions.
Symptoms of Serotonin Syndrome ( 13)
-Headache
-Agitation
-Confusion
-Shivering
-Sweating
-Hyperthermia
-HTN
-Tachycardia
-Nausea
-Vomiting
-Hyper-reflexia
-Tremors
-Muscle Twitching
Differences between Serotonin Syndrome & Neuroleptic Malignant Syndrome
Is alcohol a stimulant or depressant?
Depressant
What does alcohol do?
Enhances gamma-aminobutyric acid inhibitory tone and inhibits excitatory amino acid activity.
Abrupt removal of alcohol results in overactivty o fth eCNS
When does delirium tremens occur?
Usually 36 hrs after the last drink
Delirium tremens occurs with what symptoms
HTN
Tachycardia
Agitation
Hyperthemia
Symptoms monitored for alcohol withdrawl
Nausea/vomiting
-Anxiety
-Visual distrubance
-Paroxysmal Sweats
-Tactile disturbance
-Orientation
-Auditory disturbance
-Headache
-Agitation
-Tremors
Treatment for alcohol withdrawl/dilirum tremns
-Hydrations
-Correct eletrolyte imbalance
-Thiamine, 100 mg IV daily for 3 days, then orally daily
-Folic acid
-Benzodiazepines (long acting benzos are preferred)-clonazepam
Parkin’s Disease: Symptoms & Treatment
-Resting tremor, bradykinesia, cogwheel rigidity, postural instability, symptoms begin asymmetrically
Treatment: Anticholinergics, levodopa/carbidopa, doapmine agonists, anticholinergics
Huntington Disease
Progressive autosomal dominant disease (cytosine-adenine guanine expansion in DNA)
Pathology of Huntington Disease
Atrophy of the caudate nucleus with symptoms of chorea, dementia, psychiatric symptoms
Alzeheimer’s Disease
Unkown etiology; however theory of low acetylcholine being involved
Alzheimer Disease Symptoms:
Mild forgetfulness with poor concentration and changes in personality that worsen in later stages to paranoid delusions, hallucinations and need for assitance
Alzheimer’s Disease
Avoid anticholinergics, donepezil is first line agent.
Lewy body dementia
Loss of cholinergic neurons and death of dopaminergic neurons
Symptoms of Lewy body dementia
Variation in cognition and attention; recurrent hallucinations and Parkinson-like motor symptoms
Treatment for Lewy body Dementia
Donepezil for cognition and levodopa for motor symptoms; otherwise palliation
Shock
Pathophysiologic state associated with decreased tissue perfusion and hypoxia.
Categories of Shock
Cardiogenic, Hypovolemic, Distributive
Stages of Shock-Initial
No signs of shock but cells starting to use anaerogic metabolism
Stages of shock-Compensatory
Reversible-Yes
Compensatory mechanisms try to reverse the symptoms of shock (eg hyperventilation to correct acidosis)
Stages of Shock-Progressive
Rerversible-No
Compensatory mechanisms cannot correct shock symptoms, leading to worsening acidosis and decreased organ perfusion
Stages of Shock-Refractory
Reversible-No
Organ failure and death
Treatment for shock
Agressive IV fluid (2 Liters), except for cardiogenic shock
Shock - Class I
Blood Loss < 15%, Pulse - Normal, Blood Pressure- Normal, Respiratory Rate - Normal, Urine output- Normal, Orientation- Normal
Treatment- minmal
Shock Class II
Blood Loss
Pulse
Blood Pressure
Respiratory Rate
Urine Output
Orientation
Treatment
Shock Class III
Blood Loss
Pulse
Blood Pressure
Respiratory Rate
Urine Output
Orientation
Treatment
Blood Loss-30-40%
Pulse-Increased, >120
Blood Pressure-Decreased
Respiratory Rate-Marked tachypnea
Urine Output-20 cc/hr
Orientation-Confused
Treatment-Agressive fluids and packed RBCs
Shock Class IV
Blood Loss
Pulse
Blood Pressure
Respiratory Rate
Urine Output
Orientation
Treatment
Blood Loss->40%
Pulse-Increased, >140, non palpable
Blood Pressure-Marked Decreased
Respiratory Rate-Marked tachypnea
Urine Output-Negligible
Orientation-Comatos
Treatment-Agressive therapy
Fever Etiology - 5 Ws
Wind (pneumonia)
Water (Urinary tract infection)
Walking (DVT/PE)
Wound (surgical site infection)
Wonder drugs (drug fever)
When to give fluids?
Fever
Drains
Gastrointestinal Losses
Burns
Crystalloid the gold standard for volume replacement?
Yes, it is
Signs of postoperative fluid overload
-Pitting Edema
-HTN
-Lung crackles
-shortness of breath
-Increased jugular vein distention
Atrial Fibrillation- 1st step
-Systemic illness,
-Pulmonary embolus
-Acute MI
-Thyroid Disease
A fib EKG finding
Wavy EKG with loss of P waves
Treatments of Afib include
Beta blockers
Calcium channel blocckers
Cardioversion
Anticoagulation
Acute myocardial infarction diagnosis on an ECG
-ST elevations
-T wave Changes
-Q waves for acute MI diagnosis
Chest Pain Work UP
Postopeartive Respiratory Therapy for Asthma
-Supplemental oxygen
Short-acting beta agonist
Systemic steroids
-IV magneium sulfate
Postoperative respiratory therapy for PE
-Supplemental oxygen
-Heparin therapy
Postoperative Respiratory Therapy for Guillan-Barre syndrome
Supplemental oxygen
Mechanical ventilation
Plasmapheresis or IV immunoglobulin syndrome
Pneumonia post-operative workup
Culture sputum
Unasyn or Zosyn
Treatment for post-operative status epileptics
Patients with long term/chronic steroid use include:
-People taking a daily dose of 20 mg or more of prednisone
-More than 3 weeks of steroid treatment
-An accute cortisol deficiency secondary to surgical stress with in a patient with adrenal insufficnecy
5 conditions that require abs prophylaxis prior to procedures
-Prosthetic cardiac valve
-Prosthetic material for cardiac valve repair
-Hx of IE
-Congenital heart disease
-Unrepaired cyanotic CHG within 6 months of repair
-Repaired CHD with residual disease
- cardiac transplant patients who have developed valvulpathy
Are dialysis patients, joint replacement patients, or solid organ transplant patients required to receive prophylaxis.
Nope, only if recommended by their doctor.
- Temporal arteritis. Patient with jaw clicking, photophobia, and intense HA. Biopsy temporal artery shows arteritis. What is the best treatment?
a. Methylprednisolone: high doses of corticosteroids may be given at 1-2 mg/kg/d until the disease activity is suppressed adequately
- 5 yo w/ URI develops buccal cellulites w/ blue hue, what is cause?
a. H. influenza
- Why is a cranial bone graft for midface reconstruction used in place of an AICBG?
a. Less resorption
- Cat scratch disease. What organism responsible?
a. Gram negative rods, Bartonella henselae
- Patient with impacted supernumerary teeth and multiple osteoma?
a. Gardner syndrome - sebaceous cysts, osteomas, desmoids tumors, gastrointestinal polyps, multiple teeth,
- Chest x ray. Pt s/p MVA, c/c SOB, hypotension and trachea deviation. CXR shows right tension pneumothorax. How would you manage?
a. Needle decompression
- In a tension pneumothorax
1. The patient is hypotensive with acute respiratory distress
2. The trachea may be shifted away from the affected side
3. Neck veins may be engorged
- Chest x-ray with description of trauma and pulmonary findings of tachypnea, increased resonance, absence of breath sounds?
a. Pneumothorax
- Child sustained kicked in the face and the traumatized tissue turned blue hue. What is oraganism?
a. H. influenza
- Mechanism of action of cyclosporine?
a. Inhibits the production of interleukin IL-2 by helper T-cells thereby blocking T cell activation and proliferation
- Tinel’s sign is due to what?
a. Tingling or electric sensations in a nerve upon percussion – Distal tingling to percussion
- Glossopharyngeal neuralgia
- Glossopharyngeal neuralgia (GN) is described as sharp, jabbing, electric, or shock like pain located deep in the throat on one side. Generally located near the tonsil although the pain may extend deep into the ear. It is usually triggered by swallowing or chewing. Treatment: carbamazepine (Tegretol®) and gabapentin (Neurontin®)
- How is glossopharyngeal neuralgia distinguished from trigeminal neuralgia?
- Distinguished from trigeminal neuralgia based on the pain’s location or results of a specific test. Touch the back of the throat with a cotton-tipped applicator. If an attack results, apply a local anesthetic to the back of the throat and repeats the test. If the anesthetic prevents an attack, the diagnosis is glossopharyngeal neuralgia.
