Mehlman: SIRS, Cirrhosis, referred pain 11-14 (2)

Question 1

SIRS - vital to know mehlman table on 2 CK.

Answer 1

.

Question 2

SIRS. mechanism?

Answer 2

• In the setting of stress (i.e., due to trauma, surgery, autoimmune flare, infection), catecholamines and ­
  sympathetic activity might shift the patient’s vitals out of the normal range.

Question 3

SIRS. - The reason knowing SIRS is important is because the patient can have abnormal vitals without having an infection.

Answer 3

.

Question 4

SIRS. criterion?

Answer 4

2 or more of the following:
- Temperature <36C or >38 (<96. 8F or >100.4).
- HR >90.
- RR >20.
- WBCs <4,000 or >12,000.

Question 5

SIRS. sepsis?

Answer 5

• SIRS + source of infection.

Question 6

SIRS. septic shock?

Answer 6

Sepsis + low BP.

Question 7

SIRS.
Sometimes you will see a patient’s vitals slightly out of the normal range in the setting of trauma, surgery, or autoimmune flares, and you have to be able to say, “There’s no infection. That’s just SIRS from sympathetic activation.”

Answer 7

.

Question 8

SIRS. Knowing if a patient is septic is important for management of patients on 2CK, where sometimes antibiotic
regimens are stepped up.

Answer 8

.

Question 9

SIRS. 2CK example.

For example, when treating PID, if the patient is septic –> tx?

Answer 9

intravenous ceftriaxone
and azithromycin is correct on one of the 2CK NBMEs

IM ceftriaxone and oral azithromycin is wrong.
This is because the latter is for most patients who have PID but aren’t septic.

Question 10

SIRS. Ceftriaxone is frequently an answer on 2CK for in-hospital patients who are septic from a variety of
community-acquired conditions, e.g., pneumonia, pyelonephritis, prostatitis.

Answer 10

.

Question 11

SIRS. For instance, communityacquired pneumonia is empirically treated …. (if not septic)

Answer 11

with azithromycin

Question 12

SIRS. For instance, community acquired pneumonia + patient is septic ….. tx?

Answer 12

but if patient is septic, we can go straight to ceftriaxone (have seen this more than once on 2CK NBMEs).

Question 13

SIRS. For hospital-acquired infections in which patients are septic, ……. NBME goes hard-hitting with what abs?

Answer 13

NBME goes hard-hitting with vancomycin
PLUS ceftazidime or cefepime. This regimen covers MRSA and Pseudomonas.

Question 14

Cirrhosis. Small, shrunken, burnt out liver due to chronic disease.

Answer 14

.

Question 15

Cirrhosis. HY causes?

Answer 15

HY causes are alcoholism, HepB/C, Wilson disease, hemochromatosis, NASH, a1-antitrypsin deficiency etc.

Question 16

Cirrhosis. what means ,,burned out”?

Answer 16

“Burned out” means LFTs are normal or low – i.e., there is not transaminitis as with acute hepatitis.

Question 17

Cirrhosis. what regarding synthetic function?

Answer 17

USMLE likes ­incr. PT and decr. clotting factor synthesis in cirrhotic patients

Question 18

Cirrhosis. why occurs hyperammonemia?

Answer 18

Hyperammonemia occurs due to decr. urea cycle activity (normally occurs in liver). This can cause hepatic encephalopathy (confusion) and asterixis (“hepatic flap” of the hands).

Question 19

Cirrhosis. USMLE likes acute exacerbations of hyperammonemia caused by …….?

Answer 19

GI bleeds –> incr. amonia absorption

Question 20

Cirrhosis. Spontaneous bacterial peritonitis (SBP) is ­ HY on 2CK, as discussed before.

Answer 20

.

Question 21

Cirrhosis. Esophageal varices from ­incr. portal pressure that backs up to ……

Answer 21

left gastric vein

Question 22

Cirrhosis. - Caput medusae are visible periumbilical veins (superior epigastric veins).

Answer 22

.

Question 23

Pain. Spleenic laceration?

Answer 23

ULQ pain +/- can refer to left shoulder (Kehr sign).

Question 24

Pain. Diaphragmatic irritation can cause pain going to …….

Answer 24

to left shoulder (asked on NBME); spleen is
wrong answer. The key here is they ask “irritation.”

Question 25

Pain. Gallbladder?

Answer 25

RUQ or epigastric pain +/- can refer to right shoulder

Question 26

Pain. Appendix?

Answer 26

Epigastric pain initially (visceral peritoneal inflammation) that migrates to RLQ (parietal
peritoneal inflammation)