Mix14

Question 1

Empiric treatment of CAP in outpatient setting:

Answer 1

Macrolide or doxy (if healthy).

Respiratory fluoroquinolone (levo/moxifloxacin), or beta-lactam, + macrolide [if comorbidities present]

Question 2

Empiric treatment of CAP inpatient (non-ICU)

Answer 2

IV resp fluoroquinolone (levo/moxifloxacin)

OR beta lactam + macrolide

Question 3

What is the CURB-65 criteria for hospitalization?

Answer 3

Age > 65, Confusion, Urea > 20mg/dL, Resp >30, BP < 90/60

Question 4

What med is needed for patients with febrile neutropenia?

Answer 4

Need empiric monotherapy with antipseudomonal agents (cefepime, meropenem, and pip-tazo).

** Neutropenia = < 1500 neutrophil/uL
Pt with ANC <1000 are at higher risk for overwhelming bacterial infection (esp due to G(-) like pseudomonas)

Question 5

First line treatment for otitis media:

Answer 5

amoxicillin

Question 6

What kind of kidney damage is caused by HIV?

Answer 6

HIV can cause several types of kidney damage. Most classic type is collapsing focal and segmental glomerulosclerosis. Also known as HIV nephropathy.

Causes heavy proteinuria, azotemia, normal size kidneys, and rapid development of renal failure.

Question 7

Of the following (weight control, DASH diet, decreased Na+ intake, smoking cessation) which has the greatest effect in decreasing blood pressure?

Answer 7

weight control (can have 5-20 decrease in systolic bp per 10 kg loss)

Weight loss&raquo_space; DASH&raquo_space; Exercise&raquo_space; Dietary Na+&raquo_space; Alcohol intake decrease

Question 8

What is a feared complication of autosomal dominant polycystic kidney disease.?

Answer 8

Most feared complication is ICH due to intracranial berry aneurysm rupture.

Major complication of ADPKD:
1. Hepatic cysts - most common extrarenal manifestations of ADPKD,

2. Valvular heart disease (MIV prolapse and aortic regurg).
3. Colonic diverticula.
4. Abdominal wall and inguinal hernia.

Question 9

What is a feared complication of autosomal dominant polycystic kidney disease.?

Answer 9

Most feared complication is ICH due to intracranial berry aneurysm rupture.

Major complication of ADPKD:
1. Hepatic cysts - most common extrarenal manifestations of ADPKD,

2. Valvular heart disease (MIV prolapse and aortic regurg).
3. Colonic diverticula.
4. Abdominal wall and inguinal hernia.

Question 10

What kind of acid base disorder would be expected in a Pt with obstructive sleep apnea and obesity hypoventilation syndrome?

Answer 10

Respiratory acidosis with a compensatory metabolic alkalosis. In an effort to maintain normal pH, kidneys increase bicarb retention and decrease chloride resorption (via bicarb-chloride exchangers in intercalated cells of distal nephron)&raquo_space; compensatory metabolic alkalosis.

** In setting of chronic hypoxia, Pt can develop pulmonary HTN (due to hypoxic vasoconstriction) with eventual cor pulmonale (R HF)&raquo_space; peripheral edema. Systemic HTN is common due to hypoxic triggering of sympathetic nervous system and increased levels of catecholamines.

Question 11

Between dialysis and renal transplant ,which is the best option in terms of better survival and quality of life?

Answer 11

Renal transplant (living related donor > living non related donor > cadaveric donor)

Advantages of renal transplant over dialysis:

• Better survival/quality of life
• Anemia, bone disease, and HTN are better controlled with transplant.
• Return of normal endocrine, sexual, and reproductive functions.
• Improvement with diabetes neuropathy.
• Expected survival rate after transplant is 95% at one year and 88% at five years.

Question 12

A woman comes in with a recent development of blisters on the back of her hands in various stages of healing after working out in a garden for the weekend. She has no prior med h/o except for Hep C infection from remote IV drug use in the past. Hands demonstrate erosions and vesicles on dorsum of both hands. What’s the most likely cause?

Answer 12

Porphyria cutanea tarda. Blisters, bullae, scarring, hypopigmentation/hyperpigmentation on sun exposed areas, scarring can appear similar to scleroderma. Assoc with HepC, mild transaminitis, and elevated urine or plasma porphyrin levels.

Porphyria cutanea tarda is due to deficiency of uroporphyrinogen decarboxylase.

Question 13

Secondary hyperparathyroidism can be due to Vit D wasting from steatorrhea (Vit D is fat soluble) and malabsorption. What would the Ca2+, PO4, and PTH levels look like if you have Vit D deficiency?

Answer 13

Ca and PO4 are low, while PTH is high.

Question 14

Regular narrow complex tachy (supraventricular tachycardia). Should you shock or give antiarrhythmics?

Answer 14

Pt with persistent tachyarrhythmia (narrow or wide) with hemodynamic compromise should be managed with immediate synchronized cardioversion.

Causes of SVT: sinus tachy, a-tach, a-flutter, and av node reentrant tachy

Question 15

What are the major vs minor Duke criteria for diagnosing infective endocarditis?

Answer 15

Major:

1. Blood Cx pos for typical microorganisms (S aureus, S viridans, enterococcus).
2. Echo showing valvular degeneration.

Minor:

1. Predisposing cardiac lesion.
2. H/o of IV drug use
3. Embolic phenomena
4. Immunologic phenomena (glomerulonephritis)
5. Pos blood Cx not meeting above criteria.

Definite PE: 2 major OR 1 major + 3 minor.

Possible PE: 1 major + 1 minor, OR 3 minor.

Common clinical manifestations of IE:

• Fever
• Heart murmur
• Petechiae
• Subungal splinter hemorrhages
• Osler nodes, Janeway lesions
• Neurologic phenomena (embolic)
• Splenomegaly
• Roth spots

Question 16

If a patient is found to have consumed a large quantity of an unknown substance and presents with CNS depression, cardiac arrhythmias, hypotension, and anticholinergic signs of hyperthermia, flushing, dilated pupils, urinary retention, and decreased bowel sounds, then what is the most likely Dx?

Answer 16

TCA overdose

Question 17

What type of cancer presents with painless lymphadenopathy and B symptoms (night sweats, fatigue, fever) in the setting of a normal peripheral blood smear and CBC?

Answer 17

Chronic Lymphocytic Leukemia

Question 18

How long after toxic admin of APAP can you offer charcoal (how long will it be effective for)?

Answer 18

Can give charcoal for Pt who consume > 7.5 g APAP less than 4 hrs ago. APAP levels should also be measured at that time.

• IF there is any evidence of liver injury you can give N-acetylcysteine and should monitor for liver injury.

Question 19

Electrical alternans (varying amplitude of QRS complexes) with sinus tachy is pathognomonic for:

Answer 19

Pericardial effusion.

** Pericarditis from recent URI causes ^ pericardial fluid&raquo_space; external compression of cardiac chambers&raquo_space; limits diastolic filling&raquo_space; decreased preload&raquo_space; reduced cardiac output&raquo_space; hypotension and syncope.

Phys exam findings include compensatory sinus tachy, distended neck veins, pulsus paradoxus and muffled heart sounds.

Question 20

What is the MOA behind ACEi slowing progression of diabetic nephropathy?

Answer 20

ACEi reduce BP and directly reduce intraglomerular pressure.

Question 21

If a patient presents with intermittent burning chest pain for last 2 hrs, hypotension, elevated JVP, cold extremities, and clear cardiopulm auscultory exam with ECG changes of sinus rhythm and ST elevation in leads II, III, and aVF, then what would be the Dx and best next treatment step?

Answer 21

Dx = inferior wall STEMI (RV MI)

Rx = bolus infusion to increase RV preload and output.

** Avoid nitrates (venous dilation), diuretics, and opioids because these all decrease preload&raquo_space; profound hypotension and can worsen the MI.

All other standard MI treatments should then be given (except for nitrates and maybe BB)