Other IM + Surg Flashcards
1
Q
Why do OCP’s (birth control) cause HTN?
A
Due to estrogen effects
(Exact mechanism is unclear, but know that estrogen is a pro-clotting, blood pressure raising hormone. Progesterone is a smooth muscle relaxant (to keep baby in) and therefore relaxes smooth muscle in vessels-> vasodilation-> lowered BP. Although progesterone may be in OCPs, estrogen is the main ingredient-> o’ all high BP.)
2
Q
What is SIRS criteria? Diagnosis of sepsis vs. severe sepsis vs. septic shock vs. multi-organ dysfunction syndrome?
A
SIRS (systemic inflammatory response syndrome) criteria:
- Temp >38C or <36C
- WBC >12 or <4
- HR >90 (tachycardic)
- RR >20 (tachypenic)
- need 2/4 to be SIRS positive (means infection should be on your ddx)
Sepsis= SIRS positive + there’s a source
Severe sepsis= organ dysfunction (>1 organ), responsive to fluids
Septic shock= organ dysfunction (>1 organ), NOT responsive to fluids (give pressors)
Multi-organ dysfunction syndrome if >2 organs are shot—> death
3
Q
If a patient has hypocalcemia, what do you first have to do to make sure the patient truly has hypocalcemia?
A
Correct the calcium with the albumin
Note that 99% of calcium in the body is bound to albumin (only 1% is free calcium)- so albumin influences calcium levels. Albumin plays the biggest role in hypocalcemia, so make sure to MD Calc it and check if corrected calcium level is still in the hypocalcemic range
*for every change of albumin by 1, calcium changes by 0.8
4
Q
Dialysis indications (AEIOU)?
A
Acidosis (refractory to bicarb)
Electrolytes (hyperkalemia refractory to insulin/ beta blockers/ lasix- meds that normally drive K+ into cells)
Intoxication (aminoglycosides, polyethylene glycol, other nephrotoxic agents)
Overload
Uremia
*uremia presents as nausea/ vomiting, bleeding (disrupts platelet function, mental status changes, pericarditis)
5
Q
Some IV meds that cover MRSA?
A
Vancomycin, Daptomycin, Telavancin
6
Q
Some oral drugs that cover MRSA?
A
Doxycycline, Bactrim (TMP-SMX), Ceftaroline (5th gen cephalosporin), Linezolid
7
Q
What is Light’s criteria?
A
Criteria for determining if fluid in a pleural effusion is transudative or exudative
- Transudative= protein only (due to high hydrostatic pressure like in HF or low oncotic pressure like in nephrotic syndrome or cirrhosis)
- Exudative= “extra shit in it” (like in pneumonia or malignancy where inflammation causes vasculature to become more leaky-> LDH, WBC’s, etc.)
P:S (protein: serum) ratios:
- LDH >0.6 (and 2/3rds the upper limit of normal)
- Protein >0.5
**Dirty USMLE: “PS (P:S), In sex (0.6) you want the D (LDH), up to 5 (0.5) you hope your P (protein)”
If either criteria are true, you got exudative! (Extra shit in it)
8
Q
What should you always check before starting a patient on Ondansetron (Zofran)?
A
Their EKG!
If it’s abnormal, then the side effect of QT prolongation-> Torsades is more likely and that will likely kill your patient!
9
Q
What number must the hemoglobin be under to warrant a blood transfusion?
A
Hb < 7
CAD with symptoms is another indication for a blood transfusion
10
Q
Your patient has A-fib. What 6 things should you order/ find out?
A
- EKG
- Echo (check for mitral stenosis)
- Troponins
- Drug screen (check for amphetamines)
- Get an alcohol hx
- TSH (hyperthyroid can cause a-fib!)
11
Q
Your patient has A-fib. What do you need to get their HR under for them to be appropriately rate controlled?
A
<110 bpm
Rate control usually > rhythm control and you need this rate to be <110 (based on studies)
12
Q
If you cardiovert a patient (for example, to get them out of new-onset A-fib), how do you do it? (There are 2 answers)
A
- Shock their heart back into normal rhythm
OR
- Rhythm control with pharm using Amiodarone (type III anti-arrhythmic)
13
Q
Which carbapenem does NOT cover pseudomonas?
A
Ertapenem
14
Q
What is MRCP?
A
Magnetic resonance cholangiopancreatography (MRCP)
Basically an MRI of the bile ducts and pancreatic ducts (can also show the pancreas, gallbladder, and liver)
15
Q
Why might a patient in septic shock have an anion gap metabolic acidosis?
A
From lactate
Systemic inflammation-> widespread vasodilation-> drop in BP-> inadequate perfusion to organs-> since there’s low oxygen to organs, aerobic cellular respiration gets switched to anaerobic respiration and releases lactic acid as a byproduct (we use elevated lactate in the blood as a measure of organ failure)
16
Q
What is a CTA?
A
CT angiogram
They time when they inject the contrast and take a picture of the vessels then so you can see the blood flow
17
Q
What is the CHADS-VASC score? HAS-BLED?
A
These are MD Calc tools to tell you if you should start your a-fib patient on anticoagulation to prevent stroke
CHADS-VASC—> tells you the patient’s risk for having stroke if you don’t anticoagulate
HAS-BLED—> tells you the patient’s risk for bleeding if you do anticoagulate
*weigh the benefits/ risks and decide what to do from there
18
Q
Treatment for autoimmune hepatitis?
A
Corticosteroids (Prednisone + Azithroprine)
**check the TPMT enzyme prior to giving Azithroprine…this is an enzyme that breaks the drug down. If the enzyme is low, the drug will hang out in the blood longer and will increase bone marrow suppression risk.
19
Q
How can you use T3 and T4 levels to figure out if a hyperthyroid patient is likely to have subactue thyroiditis (viral etiology)?
A
T3/T4 ratio >20 suggests viral etiology (subacute/ DeQuarvains thyroiditis) vs. Graves
- when you’re sick, your T3 (active) levels are higher
- viral would also have a hx of viral illness and textbook definition is painful. Graves would have a positive TSI antibody
20
Q
What happens to cardiac output as HR increases by a lot?
A
It decreases
Increased HR (tachy)-> less time for the heart to fill-> decreased CO
21
Q
If a-fib is NEW <48 hrs or patient is unstable (vitals are concerning- regardless of how long a-fib has been present) how do you treat?
A
Cardiovert (shock or give Amiodarone to correct the rhythm and attempt to get the person completely out of a-fib)
*note that the patient may come in and you diagnose a-fib for the first time ever, but if you aren’t certain when their symptoms started (not sure if onset was <48 hrs ago), do not cardiovert! This is dangerous bc if a-fib has been going on quite a while, clots may have formed in the LA appendage due to the arrhythmia and if you mess with the heart’s rhythm, you could cause that clot to be thrown-> stroke.
*so then what do you do?
Anticoagulate them for 3 weeks (make sure there are no clots)-> THEN cardiovert
OR do a TTE (transesophageal echo- invasive but takes a great pic of the LA to ensure no clots)-> THEN you can cardiovert same day
22
Q
You just diagnosed a patient with a-fib, but they’ve had symptoms >48 hrs. How are you going to treat it?
A
Anticoagulate them for 3 weeks (make sure there are no clots that can be thrown and cause a stroke when you cardiovert)-> THEN cardiovert (with shock or Amiodarone)
OR
Do a TEE (transesophageal echo- invasive but takes a great pic of the LA to ensure no clots)-> THEN you can cardiovert same day
**Reason why you can’t jump straight to cardioversion if a-fib has been going on a while: dangerous bc clots may have formed in the LA appendage due to the arrhythmia and if you mess with the heart’s rhythm when cardioverting, you could cause that clot to be thrown-> stroke.
23
Q
Some patients are chronically in a-fib (cardioversion was not indicated or did not work and they keep coming back to a-fib). How do you manage these patients?
A
Rate-control
-use Diltiazem, Verapamil, or a beta-blocker (Metoprolol) to keep the HR <110
Also, anticoagulate if indicated to prevent stroke! (calculate CHADS-VASC score to know their stroke risk if you don’t anticoagulate and the HAS-BLED score to know their bleeding risk if you do anticoagulate to weigh pros/ cons)
*a-fib patients are at increased risk for stroke bc the heart is beating funny-> allows clot formation, especially in the LA appendage-> these clots can be thrown and lodge into cerebral vasculature causing a stroke
24
Q
Patient with angina symptoms is having chest pain. What can you give the patient for pain management?
A
Nitrates
*Remember, angina pain is due to narrowed coronary vessels (stenosis >70%). The heart is being starved of blood (low supply to match high demand). Nitrates cause venodilation-> dec preload (less ‘milking’ of blood to heart)-> less blood that the heart has to pump (lowers demand to meet lowered supply).
25
TTE vs TEE?
```
TTE= TransTracheal Echocardiogram (the ‘normal echo’ just like an ultrasound of the heart)
TEE= TransEsophageal Echocardiogram (invasive- they go down the esophagus to get a really clear picture of the LA)
```
26
If procalcitonin is low (<0.25) in your pneumonia patient, what does that suggest?
It is more likely to be VIRAL as opposed to bacteria (consider discontinuing antibiotics if clinical judgment supports this also)
27
How good is the influenza swab test?
Not so good—can often be a false negative (test says no flu, but patient really has the flu)
28
What is the one and only fluoroquinolone that covers anaerobes?
Moxifloxacin
29
A patient had stroke symptoms but now they are resolved. CT of the head is negative. What additional test do you need to do and why?
MRI
If MRI is also negative-> it was a TIA (stenosis through cerebral vessels affected an area of the brain temporarily, but no areas were permanently damaged)
If MRI is positive-> it was a stroke (doesn’t matter that the symptoms left)!
30
When is surgery indicated for a patient with a cerebellar hematoma (hemorrhagic stroke)?
If the patient meets one of the following criteria:
1. Hemorrhage is >3cm
2. Patient is neurologically deteriorating
3. Brainstem is compressed
4. Hydrocephalus (due to ventricular compression)
* Whenever you have a hemorrhagic stroke patient, consult neurosurgery for evaluation right away!
* *Surgery reduces mortality in patients who meet the criteria, but does not improve functionality.
31
A end-stage renal disease patient missed dialysis and had a hemorrhagic stroke a couple days later. How might missing dialysis be related?
Missed dialysis-> excess fluid retention-> HTN-> excess pressure in small vessels of brain causes vascular leakage-> hemorrhage in brain
32
What is ESRD?
End-Stage Renal Disease
33
What are the “4 H’s” to reduce ICP (intracranial pressure) (such as in a patient who had a hemorrhagic stroke and has elevated ICP)?
What diuretic could be given to reduce ICP?
1. Hypertonic saline
2. Hyperventilation
3. Head/ bed elevation
4. HTN treatment
Mannitol (osmotic diuretic) can also be used to reduce ICP
* *MORE DETAILS:
* Hypertonic saline- draws water out of intracerebral space (or use Mannitol to do this)
* Hyperventilation (if patient is intubated)- blow off more CO2-> high CO2-> increases cerebral blood flow and reduces cerebral pressure
* HTN treatment (often with Nitroprusside)- goal is to decrease gradually to <140/80 bc high BP increases ICP and can cause further bleeding. That said, don’t decrease BP too fast/ too much or you can cause hypotension-> inadequate blood flow to brain-> worsened neurological deficits.
34
What is dysarthria?
Slurred speech
35
Why might a patient with a history of a PE have an IVC filter?
To prevent future PE’s from occurring—often placed if the patient is not a good candidate for lifelong anticoagulation therapy
36
Why might you give a patient with hemorrhagic stroke Keppra (Levetriracetam) in the ED?
For seizure prevention
* Hemorrhagic stroke patients have a 15% chance of having a seizure (bleeding irritates the brain), so can do this prophylaxis
* *Note that some docs do this ASAP while others don’t do it at all (may not be enough evidence at this point that this measure has benefits > risks)
37
1st line treatment in an acute Gout attack? (Be specific)
Indomethacin (NSAID)
* can also give glucocorticoids or colchicine in an acute attack
* *Allopurinol is for chronic management only! (After a patient has had 2 gout attacks and they resolve, give this as prophylaxis)
38
If a patient has chronic gout and you find by urine testing that they are an under-excreter, what drug can you give for management?
Probenecid
| Decreases tubular reabsorption of uric acid-> so you will pee out more uric acid
39
Is a gout attack in a large joint like the knee more likely to be gout or pseudo-gout?
Psuedo-gout
Gout typically presents in the red toe. It is painful and red (looks similar to cellulitis, but isolated to the big toe). Psuedo-gout is more likely to affect large joints, but that doesn’t mean it’s not gout (could be either).
40
A patient is on Eliquis (ApiXaBAN) anticoagulant for past PE (last time taken was in the morning). The patient just had an ischemic stroke. Can you give TPA?
No!
TPA is contraindicated if anticoagulants (ex: Eliquis) were given <24 hrs ago...can make them bleed into the brain
**It is ok to give TPA if the patient is on Warfarin therapy and INR <1.7 (lower INR= more clotting, higher INR= less clotting/ more bleeding risk)
41
It is ok to give TPA if the patient is on Warfarin therapy and INR is at what level?
INR <1.7
(lower INR= more clotting/ less bleeding risk, so TPA is safe at this level)
**remember the goal with Warfarin is to keep INR 2-3 (higher INR= less clotting), so for a patient to be on Warfarin and INR<1.7 they probably didn’t take it recently
42
What imaging routinely ordered in stroke work-up will tell you whether the stroke occurred from carotid artery occlusion?
CTA head/ neck
| CT angiogram of the head and NECK looking at blood flow through the vessels
43
What EKG change can occur in hypOcalcemia?
QT prolongation (monitor the EKG to prevent progression into Torsades- a fatal arrhythmia!)
*calcium is physically needed to contract the heart. Low calcium= drawn out systole (QT= entire length of systole including depol and depol of the ventricles)
44
Your patient is hypOcalcemic. What other ion do you need to make sure is not depleted?
Magnesium
In the thick ascending loop of Henle, Mg and Ca2+ are reabsorbed together...so you can’t hold onto calcium if you are Mg depleted! You can give calcium/ calcitriol all day, but you gotta replete Mg too.
45
If brain MRI of a stroke patient shows no penumbra, should you consider thrombectomy for the patient?
No
No penumbra= no salvageable brain tissue (the whole region affected by the stroke is dead and cannot recover), so thrombectomy would not help
46
In a stroke, what is a Penumbra?
The region around the dead tissue from the stroke
-this area has reduced blood flow (local hypoxia) from the stroke, but it is not dead yet. You can save this tissue (by TPA or thrombectomy interventions) before it dies.
47
Why is TPA contraindicated if glucose <50?
Hypoglycemia can cause focal neurologic deficits and present like an ischemic stroke (even though it’s not)
You don’t want to subject a patient to the risk of intracranial hemorrhage from TPA if all they needed was dextrose (glc)
48
4 core measures for CAD (coronary artery disease)?
1. Beta-blocker
2. ACE inhibitor
3. Aspirin
4. Statin
(All CAD patients get these 4 things)
49
What 4 outpatient antibiotics cover MRSA?
“B C D L”
1. Bactrim
2. Clindamycin
3. Doxycycline
4. Linezolid (expensive)
50
Most common cause of anal cancer?
HPV
| Often seen in gay men who have anal sex
51
Anal cancer Mets to what lymph nodes? Recal cancer?
Anal cancer—> inguinal LN
Rectal cancer—> internal iliac LN
52
When do you start screening for colon cancer with colonoscopy?
At age 50
Earlier if family history of colon cancer—start them 10 years before the family member was diagnosed (ex: if dad got colon CA at age 50, start screening the kids at age 40)
53
Charcot’s triad and Reynold’s pentad for ascending cholangitis?
```
Charcot’s triad:
1. RUQ pain
2. Jaundice
3. Fever
Reynold’s pentad:
4. Hypotension
5. Altered mental status (from becoming septic)
```
*Watch asc cholangitis patients carefully! They can become septic super fast due to the close proximity to the liver, which has a huge blood supply and can cause an infection to spread all over.
54
Number one cause of headache in kids?
Eye strain from poor vision (get them checked for glasses)
55
In blunt abdominal trauma, do you get a CT?
NO, not enough time!
| Do a FAST exam with ultrasound to search for fluid—then get to surgery to remove the internal bleeding.
56
EKG: what 2 leads do you check to see if the rhythm is sinus or not?
Leads II and aVR
57
EKG: what 2 leads do you check to see if the axis is normal or deviated?
Leads I and aVF
| Normal= the P waves of both are going UP
58
Poor R-wave progression in anterior leads or Q waves in other leads indicates what?
Previous MI
59
In “holiday heart” (CHF exacerbation after salty meals), the patient is fluid overloaded, despite taking Lasix/ furosemide (loop diuretic). Why?
The excess salt-> fluid overload causes the gut to swell too.
Swollen gut-> can’t absorb Lasix-> Lasix cannot do its job.
*Must give these patients IV Lasix (also replete K+ since loop diuretics can cause hypOkalemia)
60
What are 2 simple things a patient can do to help their bowels get moving in an SBO to improve their condition?
1. Move around (helps the gut wake up and get moving too)
| 2. Chew gum (activates the GI tract w/o anything actually going down and getting backed up more)
61
What psych condition does Hydroxyzine work for?
Anxiety
It is an anti-histamine (crosses BBB-> central effects) and can treat anxiety/ calm a patient down
*better alternative to benzos!
62
What’s a seroma?
A pocket of clear serous fluid that sometimes develops in the body after surgery
63
Best SSRI for kids?
Fluoxetine
64
80% of suicidal thoughts in kids these days are due to what?
Being bullied
65
What drug class do we use to treat Bipolar kids?
Antipsychotics
*Lithium is the go-to for adults, but not in kids. It is harsh on the kidneys.
66
How can you tell a Lupis (SLE) butterfly rash apart from Rosacea?
SLE—> spares the nasolabial folds
Rosacea—> involves the nasolabial folds
67
1st line drug for Onchomycosis (fungal infection of the nails)?
Terbinafine
68
What is plantar fasciitis?
Inflammation of the plantar fascia (ligament/ band of tissue that connects the heel bone to the toes) from arch overuse
*rolling a tennis ball underneath the foot arch can help loosen up the plantar fascia, making it less likely to be irritated
69
What is ventricular bigeminy?
Alternating normal sinus rhythm and premature ventricular complexes
*if you count up the normal sinus beats= bradycardia. So the heart’s back-up pacemakers kick in with extra beats right after (premature ventricular complexes) to contract the heart more
70
What do these terms mean?
1. Neoadjuvant
2. Adjuvant
1. Neoadjuvant—before surgery (or procedure)
| 2. Adjuvant—after surgery (or procedure)
71
What is diastasis recti?
A false hernia
Just a separation of the large abdominal (rectus abdominus) muscles
(*can look similar to a hernia when lying down-> sitting up)
72
What’s an incisional hernia?
You got a surgery—> not you got a hernia where they left you with an incision (bowel is protruding out at the incision site)
73
If a mamogram states “dense breasts,” what do you need to do?
Follow up with additional testing (U/S)
*This means the patient’s extra breast tissue makes the mammography report difficult for the radiology to read
74
If a woman has red, black, or brown nipple discharge, is it okay to leave it alone?
No- work it up!
75
1 in how many women get breast cancer?
1 in 8 women (about 12%)
76
Best test for diagnosing appendicitis?
CT scan
In kids and pregnant women (don’t want to expose to radiation)—> use ultrasound or MRI (U/S is preferred bc it is faster, though MRI is more specific. Both CT and MRI are ~95% specific for appendicitis, while U/S is ~85% specific.)
77
If a patient has distinct appendicitis symptoms and then they go away, what is your concern?
Ruptured appendicitis
- it can wall off (you could see the walled off infection on CT)
- get them to surgery ASAP
78
What is Impella?
A “propeller” catheter device that is temporary placed in the LV to assist the heart in beating during cardiogenic shock
79
What types of SBO are there?
1. Mechanical/ obstructive (this can be incomplete or complete)
- due to adhesions (most common)
- OR due to a tumor/ colon cancer
2. Functional ileus
- post-op ileus (gut is ‘frozen’/ paralyzed from the surgery/ trauma)
80
After a cholecystectomy, we send off the freed gallbladder to pathology. Why?
To check for gallbladder cancer
*rare, but nasty. If you happen to catch it, do additional work-up and get chemo for your patient (Mets early on to liver and bone, etc.)
81
How many valves of Houston do we have in the gut?
3 (these are transverse folds in the rectal wall)
82
Why should you and everyone (esp following colorectal surgery) take a Sitz bath?
1. Warm water relaxes muscles, including the anal sphincter
2. Warm water causes vasodilation, which promotes blood flow to the area for healing
3. The water cleanses the area
83
What classification tool do we use for acute diverticulitis?
Hinchey classification
Stage 1–> uncomplicated
2–> small abscess (*note: only drain if >4 cm, otherwise try to manage medically with gram negative + anaerobic coverage)
3–> peritonitis w/ pus
4–> peritonitis w/ feces
84
What is a normal urine output in 1 hour?
30 cc’s/ hr
| 1 cc (cubic centimeter)= 1 mL
85
How many times can you drain a breast abscess before surgery is indicated?
3-6 times
86
For the most part, stop anticoagulants how many days prior to surgery?
5-7 days before surgery
87
What’s the difference between “normal vitals” and “stable vitals”?
Normal vitals- means they are in within the normal range
Stable vitals- means they are not fluctuating day to day, but are keeping consistent (*for example, a patient can be hypotensive but stable if it is normal for them to run a low BP)
88
Why is mesh often placed in hernia repairs?
It prevents reoccurrence of the hernia!
89
What symptoms are red flags for ascending cholangitis? What’s the name of the triad and pentad?
Charcot’s triad:
1. RUQ pain
2. Jaundice (elevated bili)
3. Fever (elevated WBCs)
Reynold’s pentad:
4. Hypotension
5. Altered mental status
* having ascending cholangitis involves jaundice, meaning the stone is lodged in the common hepatic/ common bile duct causing infection behind the blocked tube- NOT the cystic duct
* *you cannot rule out ascending cholangitis if WBC is normal (takes time for body to mount response to infection, plus some people don’t mount as strong as a WBC response)
* **if they got the pentad, they are septic. These patients can go into septic shock and die fast, within 8 hrs (due to close location to liver w/ rich blood supply), so act fast!
90
Where is the gallstone in choledocholithiasis?
Lodged in the main biliary tract -this includes the common hepatic duct and common bile duct (*the common hepatic duct changes names to the common bile duct once it meets up with the cystic duct)
**note that when you have choledocolithiasis far down the common bile duct, also obstructing the exit of the main pancreatic duct, we call it “gallstone pancreatitis”
91
If a patient has RUQ pain and jaundice (high bili), but no fever or elevation in WBC count (2 of the 3 Charcoat’s triad criteria), can you rule out ascending cholangitis?
No, you cannot rule out ascending cholangitis if afebrile and WBC is normal
Why not? It takes time for body to mount response to infection, plus some people don’t mount as strong as a WBC response so WBC will appear normal!
92
How can radiation (from past cancer treatment) cause SBO?
Radiation kills cells by free radicals and causes scar tissue in the bowel, making it harder and more likely to get kinked/ obstructed-> SBO
93
Patient has RUQ pain, high ALT, AST, alk phos, and lipase, what is the most likely diagnosis and what is the step-by-step course of action?
Gallstone pancreatitis (stone lodged in CBD far down “choledocolithiasis”, but also obstructing the main pancreatic duct exit point—> elevated lipase)
1. Do RUQ U/S
2. MRCP to prove it
3. ERCP to remove the stone blocking the CBD
4. Wait hours for the pancreas to ‘cool down’ bc inflammation complicates surgery
5. Do a cholecystectomy (**this patient has gallstones and although gallstones are asymptomatic 80% of the time, if a patient has symptoms from gallstones once, they are likely to have them again...better to remove the gallbladder while they’re in the hospital vs. waiting for pancreatitis again which has complication in of itself)
94
ERCP carries a small risk of what? (What’s the side effect/ risk to the procedure)
5% risk of pancreatitis secondary to the procedure
95
What do you do for a patient with a ruptured appendix, confirmed with CT?
1. Surgery (appendectomy and lysis of adhesions/ abdominal washout)
2. Advance diet as tolerated (can discharge once they can handle a normal diet)
3. 3-5 days of IV antibiotics (like Zosyn)
*note: these patients often develop post-op ileus
96
AAA vs aortic dissection
| -Which is more likely to present with HTN?
Aortic dissection
* Aortic dissection- more likely in really old people, HTN
* AAA- in younger people, usually presents with hypotension, can present with bilateral flank pain
97
If you suspect kidney stone, what imaging do you order?
CT without contrast (contrast would obscure the image of the calcified stone)
98
Patient comes in with severe unilateral flank pain and has a history of recurring kidney stones (nephrolithiasis). What imaging do you order?
Ultrasound the kidneys to check for hydronephrosis suggestive of a large stone (you probably can’t see the stone if you directly U/S the ureters)
If hydronephrosis suggestive of a large stone—> follow-up with CT without contrast to take a better look
Otherwise, no CT needed- the clinical picture and knowing the patient has recurrent stones is enough! Spare them the CT radiation exposure
99
What is the systematic way to read a CXR?
“ABCDE”
1. Airway (look if trachea is midline, no shifts)
2 Bones (look at clavicle moving down to ribs, no fractures)
3. Cardio (look at heart- if >half the size of chest wall that is cardiomegaly)
4. Diaphragm (if flattened w/ blunting of costodiaphragmatic recess that is consistent with COPD, for example)
4. Everything else
100
What position are patients with COPD exacerbation often in?
Tripod position (“tripoding”)
-sitting up, leaning forward, arms opened up with hands against knees or other object to help them breathe
101
If a COPD exacerbation patient comes in and you do NOT hear wheezing, are you concerned?
Yes, more so! Decreased breath sounds period= not a lot of air moving through lungs
102
CPAP vs. BiPAP?
```
CPAP= continuous positive airway pressure
BiPAP= bi-level positive airway pressure
```
- both are continuous
- difference is CPAP gives equal inspiratory and expiratory pressure support (used in sleep apnea, patients that just need some help propping open airways) vs. BiPAP gives inspiratory > expiratory pressure support (used in acute respiratory distress patients)
103
What’s a typical pressure support on a BiPAP?
10-12 range
Pressure support= IPAP- EPAP (the difference in the inspiratory pressure support you are giving vs the expiratory pressure support you are giving)
*remember, BiPAP gives inspiratory pressure support > expiratory pressure support, for people who need a lot of help breathing (acute respiratory distress, like COPD exacerbation)
104
Causes of COPD exacerbation?
70% due to respiratory infection (bacterial or viral)
*if PNA, listen for crackles and look for consolidation on CXR
30% due to environmental pollution (something in the air), PE, or unknown etiology (lots of things can cause COPD exacerbation!)
(*this is from UpToDate)
105
What are some things you want to do to manage a COPD exacerbation patient coming into the ED?
- Oxygen support (BiPAP)
- Bronchodilators
- Steroids
- Antibiotics (evidence to suggest that treating a COPD exacerbation like CAP improves outcomes)
106
If you suspect PE, what MedCalc tools can you use to guide your work-up plan?
1. Calculate WELLS score for PE
2. If <4 = low risk—> you can then calculate PERC score to try to rule it out (If you can’t rule it out do a CTA. If you rule it out but still have suspicious, do a D-dimer to rule out.)
2. If >4 = high risk—> do a CTA
107
Why is it important to clarify if a patient is coughing or vomiting up blood?
Coughing up blood (hemoptysis)—> from the lungs
Vomiting up blood (hematemesis)—> from the GI tract
108
If an alcoholic has esophageal hemorrhage, how would they present to the ED?
Vomiting up a ton of blood, blood all over the floor (this is deadly if not treaded promptly!)
*vs. a little blood in vomit of an alcoholic would suggest esophageal varices that are just oozing blood
109
What are the 2 long-acting Benzos (including trade names)?
1. Diazapam (Valium)
| 2. Chlordiazepoxide (Librium)
110
Why might you give Mg to an asthma patient?
Magnesium sulfate= bronchodilator (helps open up the airways)
111
COPD vs. CHF exacerbation
| -Which is more likely to present with HTN?
```
CHF exacerbation
(Pumping problem-> kidneys read low BP-> ramp up RAAS-> arteries clamp down/ vasoconstrict-> increase BP)
```
112
95% of CAH (congenital adrenal hyperplasia) cases are due to what enzyme deficiency?
21-OH
| *17-OH and 11-OH are extremely rare
113
What symptoms would you expect in a 21-OH deficient CAH (congenital adrenal hyperplasia) kid? How would you manage this disease?
Lack of aldosterone and cortisol-> hypOnatremia (low Na+), hyperkalemia (high K+), low blood sugar
Adrenal crisis-> lethargy, poor feeding, vomiting, dehydration, virilization
More shunting to sex hormone production-> virilization/ ambiguous genitalia
Management: NS bolus, daily steroids (hydrocortisone), high salt diet
114
What is post-stroke recrudescence?
When a patient with hx of stroke has an infection (ex: UTI)/ stressor and they present like they had another stroke (but they really didn’t)
*it is due to worsening/ reemergence of neurological deficits after a stroke, not fully understood
115
What’s the door-to-balloon time for STEMI and NSTEMI (time you need to get them to cath from the time they walked through your hospital doors)?
STEMI- 90 minutes
| NSTEMI- 24 hrs
116
Why is it important to allow for permissive HTN (let the BP get high) for a patient who just had an ischemic stroke?
If BP were to drop low, there would be decreased blood flow to the brain…and it’s already decreased from the stenotic vessels that were stroked out, so you can complete a stroke!!
*allow for HTN for 24-72 hrs and GRADUALLY decrease the BP again (bc of course, HTN overtime is a risk factor for plaque formation and strokes so have to get it down—but slowly until enough time has passed to where you know lowering blood to the brain won’t complete a stroke that’s cooking)
117
What is the Glasgow Come Scale (GCS) on MDCalc for?
Assessment of level of consciousness of a patient (based on eye response, verbal response, and motor response)
GCS less than 8= intubate! (But don’t rely on this scale alone- consider full clinical picture to assess whether or not patient can maintain airway or if intubation is needed)
118
What is FiO2 for a patient breathing room air? For a patient on 1L of oxygen nasal cannula?
FiO2= 21 room air (room air is made up of 21% oxygen)
FiO2 on 1 L oxygen nasal cannula= 25 (YOU ADD 4% FOR EVERY 1L OF OXYGEN GIVEN)
119
How do you calculate MAP (mean arterial pressure)?
MAP= 2/3(diastolic BP) + 1/3(systolic BP)
*if pressors are needed (as in septic shock), the goal is to keep MAP >65 (less than 70 is considered hypotensive)
120
How do opioids and osteoporosis relate?
Chronic opioid abuse—> increased risk for osteoporosis
121
1st, 2nd, and 3rd line treatment for ACUTE gout attack?
1. NSAIDs (Indomethacin)
2. Colchicine
3. Steroid injections
*you have to worry about GI bleeds with NSAIDs. You have to worry about diarrhea and neutropenia with colchicine.
122
What are the 3 categories of C-diff?
1. Non-severe
2. Severe
3. Fulminant (*patient is unstable, may present with abdominal dissension due to toxic megacolon)
*give oral Vanco (or Findaxamicin) to treat C-diff (Metronidazole/ Flagyl isn’t as good, though we tag it on in fulminant c-diff)
123
How long do you give oral Vanco if:
(1) this is the 1st time presenting with C-diff
(2) this is a reoccurance of C-diff?
1st time—> 10 days of oral Vanco
Reoccurance—> pulse taper regimen with 3 months of oral Vanco, but you taper down on the dose (this extended time period is to prevent germination of any spores)
*if they get 3 episodes of C-diff, at that point we consider fecal transplant
124
What symptoms can differentiate preseptal (periorbital) cellulitis vs. orbital cellulitis?
Orbital cellulitis will present with pain on extra-ocular eye movements, proptosis (forward displacement of eye), maybe visual changes (like diplopia)
-this infection involves orbital contents (fat + EO muscles) and is an emergency! Failure to treat—> blindness and/or death (ascension of infection to CNS/ brain)
*Note that both preseptal (periorbital) cellulitis and orbital cellulitis will have edema and pain around the eyes (orbital may be a deeper pain). Both may or may not be associated with fever and WBC count.
125
What bugs do you have to cover when giving antibiotics to treat preseptal (periorbital) cellulitis, a soft tissue infection?
Most commonly caused by Staph (often MRSA), but strep pneumo and anaerobes are also culprits so cover for these bugs
Treatment of choice is: Bactrim, Clindamycin, or Doxy (broad-spectrum, incl MRSA coverage) + Amoxicillin, Augmentin, Cefpodoximine, or Cefdinir (anaerobic coverage)
**my patient with this was given Doxy + Augmentin
126
Treatment for orbital cellulitis?
Vancomycin + Ceftriaxone
127
Do we worry about cirrhosis patients bleeding or clotting more?
We don’t know- could be both (cirrhosis causes all sorts of coagulopathies)
*remember the liver makes both coag factors and anti-coag proteins C and S...so if the liver is not working, both coagulation and anti-coagulation will be affected
128
If a patient who underwent bariatric surgery has a fib requiring long-term anti-coagulation, can you give aspirin?
NO. ASA (and all NSAIDs) shouldn’t be used in patients who had bariatric surgery since they block GI protective prostaglandins and the stomach can’t handle it since it’s now so small
*would have to use NOAC’s or Warfarin
129
Why would you keep a patient NPO prior to a TEE (trans esophageal echo)?
To avoid aspiration while putting the camera down the throat/ into the esophagus (low risk, but we want to minimize chances of complications)
130
Do you have to have ST segment depression in NSTEMI?
NO!
NSTEMI= non-ST segment elevation! It’s an MI of the subendocardium (not transmural) so no ST elevation, but having ST depression is just one subtype. May have ST depression, T-wave changes, or no EKG changes at all.
131
For MI, go to cath within what time frame. For NSTEMI go to cath within what time frame?
MI—> 90 minutes
NSTEMI—> 48 hrs (12 hrs if high-risk)
132
If you give a MI patient nitrates and their BP starts dropping dangerously low thereafter, what does this mean? What do you do about it?
They probably had a RCA (right-sided heart) infarct (STEMI or NSTEMI)
The right heart is preload dependent, so if blood is occluded here and you give a nitrate on top of this, BP will get too low.
Stop the nitrate and give IV fluids (add back preload)!
133
If you suspect brain abscess (imaging showing a single brain ring-enhancing lesion, usually in the temporal lobe if due to an ear infection that spread), what empiric treatment do you give?
Vanco + Ceftriaxone (Rocephin) + Metronidazole (Flagyl)
| Covering MRSA, gram +/-, and anaerobes since many abscesses can be oropharyngeal in origin
134
What antibiotics do you give empirically for bacterial meningitis? Viral meningitis?
Bacterial—> Vanco + Ceftriaxone (broad-spectrum) + Ampcillin (Listeria)
Viral—> Acyclovir (HSV)
135
What are the 3 important fluoroquinolones to know?
1. Ciprofloxacin
2. Levofloxacin (Levaquin)
3. Moxifloxacin
*Cipro and Levaquin cover Psuedomonas. Moxifloxacin covers anaerobes. All cover gram (-) and gram (+) bugs.
136
What happens in Takotsubo cardiomyopathy (aka stress CM or “broken heart syndrome”)?
The apex/ tip of the heart is not contracting properly (hypokinesis) due to vasospasm of tiny arterioles
- caused by stress (though the exact pathophysiology is not well understood)
- presents like an MI
137
Is ejection fraction low in Takotsubo cardiomyopathy (aka stress CM or “broken heart syndrome”)?
Not necessarily
-can have it with a lowered EF or with a normal EF
138
Where is the ureteropelvic junction?
Where the ureters meet up with the kidneys
139
How will a nephrostomy tube help a patient with complicated UTI w/ right hydronephrosis?
It will drain the fluid in the kidney/ hydronephrosis
140
Patient on Apaxiban (Eliquis) and Carvedilol for a-fib is getting ready to have an invasive procedure done for something else. Can we keep the patient on their meds for a-fib at this time?
No—hold the Eliquis (long-acting anticoagulant) for the procedure due to bleeding risk
* you want to wait 2 days for it to get out of the system, though this really depends on the procedure you’re doing, the doctor who’s doing it, and how stable the patient is (if they are not doing too well, screw the bleeding risk, you gotta get the procedure done)
* if the patient really needs anticoagulation, once you DC the Eliquis you can bridge to heparin and keep them on a hep drip (short-acting, only has to be stopped 4 hrs, not days, before a procedure)
141
A patient was just given IV fluids. Now they have a low Hb (anemia) and low platelets. Should you do an anemia work-up?
Nope
If Hb AND platelets drop following IV fluid administration, this is most likely dilutional
(Dehydrated—> Hb will appear high
Fluids—> Hb will appear low)
142
Retrosternal vs. substernal?
They are the same thing
| Pain behind the sternum/ breastbone
143
Why use spirometers? In who?
To prevent atelectasis (alveolar collapse)
In PNA patients (hurts to breathe, so they otherwise take shallow breaths) and bed bound patients to help them open up their lungs
144
Can you get hypOnatremia from pneumonia?
Yes
145
When do you have to worry about correcting hypOnatremia too fast? When do you not have to worry about this?
Worry about correcting low Na+ too fast when the patient has chronic hypOnatremia (brain has adapted to the current state, so changing this can cause central pontine syndrome)
Don’t worry about correcting low Na+ too fast when it’s Acute (<48 hrs) or if the patient is having a seizure (that takes priority- you need to get the patient out of the danger zone)
146
In chronic hypOnatremia (going on >48 hrs or unknown), at what rate do you correct Na?
Rate of 6-8 mEq/ day (0.5 mEq/ hr)
*check it q6 hrs
147
What’s a normal Na level? What’s considered hypOnatremia?
Normal Na= 140
HypOnatremia= <135
* mild: 130-134
* mod: 120-129
* severe: <120
* ICU: <115
148
Normal saline (NS) is more salty than we are, so it can be helpful in correcting hypOnatremia. Why is it not always a good idea to give in hypOnatremia?
Depends on the cause—if hypOnatremia is due to fluid overload (CHF, renal failure) diluting the [Na+], giving more fluid would make the problem worse (give a loop diuretic). If it’s due to SIADH (too much water retention), again giving more fluid would make the problem worse (give a vaptan).
149
What are the 2 high-yield electrolyte corrections to remember?
1. If hyperglycemia (high glc)—> correct for sodium (Na+)
- beyond glucose of 100, for every add’l 100, add 1.6 to the Na+ level
2. If hypoalbuminuria (low albumin)—> correct for calcium (Ca2+)
- measured total Ca+ 0.8 (4- albumin)
150
What’s the risk of significant complication (arrhythmia, heart attack, stroke) during a cardiac cath procedure?
<1%
151
You have a cirrhosis patient with lots of ascites fluid, >25mL requiring drainage. Why should you only get out ~4mL at a time?
Their heart is used to their fluid overloaded baseline. If you suddenly get rid of all the excess fluid at once, you can induce MI.
Heart pumps faster to try to compensate for huge drop in BP all the sudden—> tachyarrhythmia—> MI
152
What is HFpEF and HFrEF?
HFpEF= Heart Failure w/ preserved Ejection Fraction (diastolic dysfunction/ filling problem...less blood in= less blood out, so heart has low CO, but FRACTION is maintained)
HFrEF= Heart Failure w/ reduced Ejection Fraction (systolic dysfunction/ pumping problem)
153
Can you be fluid overloaded in HFpEF (diastolic dysfunction)?
Yes!
Filling problem means less blood is pumping forward, so more blood will back up
154
Mycoplasma IgM comes back negative. Mycoplasma IgG comes back positive. Does the patient have atypical Mycoplasma pneumonia?
No
They were previously exposed (IgG). If they currently had it, IgM (1st antibody to show up) would be positive.
155
What is Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)?
Autoimmune condition in which the immune system attacks myelin of peripheral nerves (PNS)
*In my Neuro case patient, she had 2 episodes of Gillian Barre- after Polio vaccine and after flu vaccine. The cause was underlying CIDP and the vaccines happened to be triggers for her since it mounts an immune response (having a virus, for example, could be another trigger but was not in her case)
156
How long do we usually continue CPR in a code blue?
20 minutes
*longer if the family says too (and often we go longer when the patient is young...but after 20 min, their chances of making it are almost nothing)
157
Use IV drugs for hypertensive urgency?
NO!
“No IV for high BP”
ONLY use IV HTN medications (like IV beta-blockers, hydrazine is not a great choice) when the patient is in HTN EMERGENCY
*also remember that just being in the hospital can elevate your BP, so don’t throw BP meds too fast at your patient. Recheck BP and do it right.
158
Treatment for status epilepticus (seizure >30min or many seizures with inadequate time to recover in between)?
Benzos (like Lorazepam (Ativan)) + Phenytoin (if seizures continue after benzos)
*also Levetiracetam (Keppra) to prevent seizure reoccurrence
159
Definition of resistant HTN? Refractory HTN?
Resistant HTN- high BP despite use of 3 HTN meds of different classes, one of which is a diuretic
Refractory HTN- high BP despite use of 5 HTN meds of different classes, one of which is a mineralcorticoid receptor antagonist (like Spironolactone)
160
Patient fits the picture of CHF (lower extremity edema, pulmonary congestion, high BNP from ventricular stretching). This patient has a high alk phos. What might explain this lab value?
Also consistent with heart failure
Less forward pumping of blood (from either diastolic or systolic HF)-> more backing up of blood-> hepatobiliary congestion (backs up to liver/ biliary system)
161
Treatment for HFpEF?
Diuretics and BP control
-This is diastolic HF, there is a preserved ejection fraction. Typical HF meds (ACE inhibitors, beta blockers) have not shown to reduce mortality in these HF patients. This type of treatment is for patients with systolic HF, reduced ejection fraction to prevent further remodeling of the heart.
162
Do you need to provide anaerobic coverage (Metronidazole/ Flagyl or Clindamycin) for aspiration PNA?
No
Under the new PNA guidelines you treat it like CAP (for example, use Ceftriaxone + Azithro or a respiratory fluoroquinolone for broad-spectrum and atypical coverage)
163
How do you calculate how much maintenance fluids to give a patient?
4-2-1 rule
Ex: 60 kg patient
4 (10 kg) + 2 (10 kg) + 1 (40 kg)=
40 + 20 + 40= 100 mL/min of fluid
* You multiply 4 times the first 10kg’s, 2 by the next 10kg’s, and add in all the rest of the kg’s of the patient’s body weight
* *Can also do this on MD Calc: “maintenance fluids” and make sure it’s in kg (not lbs—unless you have the patient’s weight in lbs)
164
Crystalloid vs. colloid solutions?
Crystalloid- NS (normal saline), LR (lactated ringers), D5W
Colloid- blood, albumin
165
Besides cancer, pneumonia, infectious processes, what is another weird cause of an EXUDATIVE pleural effusion?
Aggressive diuresis
-this can make the pleural effusion appear exudative (not just transudative)
166
When do we treat asymptomatic UTI’s (3 cases)?
1. During pregnancy
2. If urinary procedure
3. *Kidney transplant
167
Medications used for Essential Thrombocytosis (ET) (myeloproliferative disorder where you have too many platelets)?
HydroxyUrea and Anagrelide
168
Patient has pneumonia and hypOnatremia. What is the hypOnatremia likely due to and what is the treatment for it?
HypOnatremia likely due to SIADH 2/2 PNA (secondary to pneumonia)
```
Fluid restriction (no IV fluids and limit their drinking to ~1.5L/ day)
If that isn’t enough-> salt tablets, Vaptans
```
169
If you are restricting fluids (ex: patient has hypOnatremia from fluid overload), how much water are you going to allow them to drink per day?
About 1.5 L/day
170
How many days of antibiotics do you treat...
1. CAP (community-acquired PNA)?
2. HAP (hospital-acquired PNA)?
3. Aspiration PNA?
CAP—> 5 days
HAP—> 7 days
Aspiration PNA—> 7-10 days
171
When is magnesium used in an asthma exacerbation?
Last resort, other treatments failed
*Mg is a bronchodilator
172
When should you give probiotics?
Within 24 hrs of starting a patient on IV antibiotics
* there is evidence that this reduces infection (like C diff) from restoring good bacteria that the antibiotics kill off
* more of a question mark as to whether probiotics help at all in outpatient situations, but at least telling your patients on antibiotics to eat yogurt never hurts
173
COPD exacerbation: better to go with high-dose (80 mg) or low-dose (40 mg) corticosteroids? IV or oral?
Low-dose oral is preferred in mild-moderate COPD exacerbation!
-40 mg PO Prednisone
* no benefit in a higher dose
* no benefit in IV methylprednisolone (SoluMedrol) unless you don’t want patient to have oral meds because they can’t tolerate oral, you are worried about them aspirating, etc.
174
Name 8 antibiotics that cover MRSA (B, 2 C’s, 3 D’s, V, and L).
1. Bactrim (PO, IV)
2. Clindamycin (PO, IV)
3. Ceftaroline (IV)
4. Doxycycline (PO, IV)
5. Daptomycin (IV)
6. Delafloxacin (IV)
7. Vancomycin (PO, IV)
8. Linezolid (IV)
175
How do you diagnose orthostatic hypotension (how much does BP have to drop upon standing)?
Drop in systolic BP >20 or diastolic BP >10 when laying-> sitting or sitting-> standing
176
For every kg of weight you lose (roughly 2 pounds), you can get your BP down by how many point?
1 point systolic, 1 point diastolic
*This can make a big difference for a heavyset hypertensive patient...losing 20 lbs, for example, may be enough to get off one BP med
177
Treatment duration (w/ anticoagulation) for provoked vs. unprovoked DVT?
Provoked (brought on by recent surgery, immobility, etc.)- treat 30 days
Unprovoked- treat 3 months
*if recurrent DVT, life-long anticoagulation
178
Let’s say your patient has a Mg of 1.7. You want to replete it to 2. How many grams of Mg do you give?
3 grams
The conversion is: 1 g Mg changes serum Mg by 0.1 (you want to add 0.3 to get from 1.7->2, so give 3 g of Mg)
179
Treat C diff with oral Vanco how many days?
10
180
Pain can lead to release of what hormone, causing a hyponatremic picture?
ADH
