Questions I got wrong on BoardVitals Flashcards
How do you treat a regular, wide QRS tachycardia?
Synchronized cardioversion (with sedation if time permits)
Signs of Digoxin toxicity in the elderly
Anorexia, nausea, confusion
Bradycardia and arrhythmias are also common
In patient’s with acute decompensated heart failure that have previously been prescribed beta-blockers, ACE-I, ASA and antiarrhythmics, which medication should be stopped?
The antiarrythmic should be stopped given increase for mortality.
If beta-blockers were already being prescribed, they should not be stopped. You should not start a new beta-blocker however.
ACE-I are helpful to prevent remodeling and maintain appropriate blood pressure so that should not be stopped.
ASA should be continued in heart failure given concern for PE.
Treatment of new DVT - What is the measuring tool and what medications would you start
Wells Score
Active Cancer Treatment: +1 point
Calf swelling >3cm: +1 point
Swollen unilateral superficial veins: +1 point
Unilateral pitting edema: +1 point
Previous documented DVT: +1 point
Swelling of entire leg: +1 point
Localized tenderness along the deep vein system: + 1 point
Paralysis, paresis, or recent cast immobilization: +1 point
Recent bedridden ?3 days, major surgery: +1 point
Alternative diagnosis at least as likely: -2 pts
Greater than 2 points is considered high risk for DVT
Treat with Low Molecular Weight Heparin (Enoxaparin) or Unfractionated Heparin if GFR <40.
Doxycycline is most commonly used to treat
Tick-borne illnesses and pneumonia
Treatment of Bell’s Palsy
Corticosteroids
If concern for HSV/Varicella associated with Bell’s Palsy, can give antiretrovirals however should give Corticosteroids in addition to the antiretrovirals.
What is a prescription strength medication used in the treatment of motion sickness?
Scopolamine Patch
Should be changed every 3 days
Presentation and biggest risk factor for macular degeneration
Age is the biggest risk for for macular degeneration (over 60).
Presentation includes gradually progressive worsening of central vision, often that is worse at night, causing difficulty with reading and recognizing faces.
Fundoscopic exam reveals drusen (yellowish colored subretinal deposits in the macula)
What is the first line treatment for erectile dysfuction
5-phosphodiesterase inhibitors
Which malignancy is the most common cause of cardiac tamponade?
Lung carcinoma accounts for 40% of malignant pericardial effusions.
Triad of symptoms consistent with rhabdomyolysis and important electrolytes/labs to consider
muscle pain
weakness
dark urine
Should check K, often pt presents with hyperkalemia and elevated CK (5x upper limit of normal)
What qualifies as significant unintentional weight loss that warrants further assessment and evaluation?
5% reduction in 6-12 months
New York Heart Association functional class of heart failure
Class I - diagnosis of heart disease with no symptoms or limitations
Class II - Slight symptoms with exertion but not all the time. No symptoms at rest.
Class III - Marked decrease in ability to perform tasks due to symptoms but no symptoms at rest
Class IV - Symptoms at rest
First line treatment of acute bacterial rhinosinusitis
Amoxicillin Clavulanate (Augmentin)
What medication is commonly associated with esophageal irritation?
Potassium Chloride, tetracyclines and NSAIDs
Indications for surgical repair of a thoracic aortic aneurysm
Surgical repair is indicated for all symptomatic or ruptured thoracic aortic aneurysms.
For asymptomatic patients:
Aneurysm larger than 5.5cm
Aneurysm that grows more than 5mm in one year
What is acute chest syndrome and how is treated?
Acute chest syndrome occurs in sickle cell disease.
It is often precipitated by infection and has lung findings that can present similarly to PNA
Acute chest syndrome is treated with IVF, adequate pain control, blood products to maintain Hgb >10 and empiric antibx
Percent total body surface area
Rule of 9’s
Head and Neck - 9%
Each arm - 9%
Each leg - 18%
Posterior trunk - 18%
Anterior trunk - 18%
Perineum - 1%
Symptoms of acute carbon monoxide poisoning
Dizziness, lightheadedness
LOC
dull headache
Shortness of breath
Nausea, vomiting
What should you do for a patient on mechanical ventilation that begins to become agitated and experiences sudden drop in SaO2?
-Disconnect from ventilator and begin manual ventilation using an AMBU bag.
-If this is unsuccessful, assess for mucous plug causing desaturation and suction the patient
-If no improvement, conduct thorough physical exam and consider ABG, CXR, EKG.
-CT PE should be considered if suspicion for pulmonary embolism
Identify the clinical manifestations of acute reactive arthritis (Reiter’s syndrome)
Arthritis, conjunctivitis and sterile urethritis is suggestive of acute reactive arthritis
Make sure to also rule out disseminated gonoccocal infection
A patient presents with exertional chest pain without SOB and stable VS. EKG shows flat ST segments. What is the diagnosis?
Unstable angina
Treatment of fever of unknown origin
Fever of unknown origin is a temp greater than 101 on at least 2 occasions lasting for at least 3 weeks.
Treatment includes broad diagnostic work up. If no identifiable etiology is found and the patient is hemodynamically stable, it is reasonable to treat with antipyretics and monitor for resolution of fevers
Treatment of acute pericarditis
NSAIDs and colchicine
Glucocorticoids are indicated if the patient is allergic to NSAIDs or is pregnant
What is a Jefferson fracture?
Burst fracture of C1
Centor Criteria for strep pharyngitis
Tonsillar exudates
Anterior lymph nodes are palpable
Fever greater than 101
No cough
Difference in clinical presentation of gastric ulcers and duodenal ulcers
Gastric ulcers:
–have pain 1-3 hours after eating and pain is not relieved by food or antacids.
–May have nocturnal pain or heartburn
–Pain is midline
Duodenal Ulcers:
–Usually relieved with food and antacids.
–Pain generally 1 inch or farther from the midline
Risk factors for gout
Older age
Male gender
African American
Genetics
Diet - high protein, ETOH
Diuretics
First line treatment of Crohn’s Disease
Enteric-coated PO budesomide
Classic presentation of Crohn’s Disease
Fatigue, prolonged diarrhea with abdominal pain, weight loss, fevers
Achille’s Tendonitis - clinical presentation and treatment
Overuse injury that is thought to be due to poor vascularity 2-6cm proximal to the insertion of the achilles tendon.
It presents as pain, warmth and swelling exacerbated by exercise
On exam, there will be notable thickening of the tendon and difficulty with ROM
Treatment is modification of activity and change in shoes as well as eccentric exercises to stretch and strengthen muscle fibers
How often should a fecal immunochemical testing be done on an average-risk for colorectal cancer patient (no family hx, no concerning findings)
Annually
Every 10 years for the same patient with a standard colonoscopy
When would you order a CT scan for a patient with pancreatitis?
No need for CT scan on a patient with pancreatitis when the patient is stable and the diagnosis is straight forward unless the patient’s condition deteriorates.
Ultrasound could be considered on admission to look for gallbladder disease or gallstones
CT would only be helpful within the first 72 hours to assess for necrotizing pancreatitis and would only be indicated if the patient were becoming significantly worse
What is the most common type of cancer in the US
Skin Cancer
Normal limits of Swan Ganz Catheter:
Central Venous Pressure
Central Venous Pressure: 2-6mmHg - Used to measure right sided filling pressure and measures volume status
If low, then likely hypovolemia
What does the pulmonary artery pressure and wedge pressure on a Swan Ganz catheter measure
Normal wedge pressure 4-12mmHg
Measures left side of the heart filling pressures.
When both are diminished, likely hypovolemia
When both are elevated, likely left sided heart failure or cardiac tamponade
Treatment of rosacia
Metronidazole gel and avoidance of triggers for rosacia including alcohol, the sun, spicy foods
What are the indications for emergent hemodialysis? (What would we be concerned for in a patient that missed hemodialysis?)
Symptomatic uremia (pericarditis, neuropathy, unexplained AMS)
Significant fluid overload
Refractory hyperK
Refractory metabolic acidosis
Compare all labs to baseline as they could be chronically elevated due to CKD
Patients with which immunoglobulin deficiency have a high risk of reaction when receiving blood products?
IgA deficiency
Medicare direct reimbursement for NPs is permitted under which federal law?
Balanced Budget Act of 1997
Gives NPs reimbursement up to 85%
When should we conduct screening for peripheral artery disease per the United States Preventative Services Task Force?
No screening is indicated
PAD can be assessed using the ankle brachial index - systolic blood pressure at the ankle over the systolic blood pressure at the brachial.
Should be 1. Less than 1 is concern for PAD
Clinical presentation of inhalation anthrax and treatment
Presents similar to PNA however can rapidly deteriorate and CXR often shows mediastinal widening consistent with mediastinitis.
Treatment for inhaled anthrax is IV ciprofloxacin and clindamycin
What is Kehr’s Sign?
LUQ or flank pain with referred pain to the left shoulder with splenic trauma
What is the FRAX score and what does it help predict?
FRAX score is the best way to determine future fracture risk/probability
Calculated from her age, sex, body mass index and dichotomized risk factors such as:
–prior fragility fracture
–parental hx of hip fracture
–current tobacco use
–long term oral glucocorticoid use
–rheumatoid arthritis
–high alcohol consumption
Which age groups do women have similar stroke risk to men
Ages 25-34 and over 85 years old
In the ilium, which type of tumor is most common?
Carcinoid
What is a Jone’s fracture
Acute fracture at the proximal diametaphyseal junction near the 5th metatarsal
First line treatment of chronic prostatitis
Fluoroquinolones are first line treatment - levofloxacin thought to be superior to ciprofloxacin due to recent resistance to cipro
Second line agent could be Bactrim
Difference between a MOLST and a Healthcare Proxy form
MOLST (Medical Orders for Life Sustaining Treatments)
—replaced the DNR form
Healthcare Proxy
–Simple document, legally valid which allows the patient to name someone to make health care decisions on the patient’s behalf if they are unable to make or communicate those decisions
What is the recommended daily sodium intake for a patient with hypertension that is attempting to make lifestyle changes?
Less than 1.5g/day of sodium
Treatment of anthrax infection, either aerosolized or cutaneous
Anthrax is a zoonotic infection
Grand majority of infections are cutaneous
Should be treated with doxycycline or ciprofloxacin for 60 days post exposure prophylaxis (PEP)
What is papilledema and what is characteristic physical exam finding
Papilledema refers to swelling of the optic disc caused by increased intracranial pressure.
Classic exam finding is optic disc bulging on fundascopic exam
What is the treatment for hyperhemolysis s/p blood transfusion?
Steroids, rituximab
What are clinical manifestations of acute ASA toxicity?
Tinnitus, vertigo, nausea, vomiting, diarrhea
What cancer would an elevated CA 125 suggest? What cancer would an elevated CA 19-9 suggest?
Elevated CA 125 suggest ovarian cancer
Elevated CA 19-9 suggests pancreatic cancer
Classic clinical presentation in pheochromocytoma and diagnostic testing that would confirm it
Episodes of headaches, diaphoresis and palpitations that are not related to exertion
Diagnostics:
24 hours urine catecholamine test
What does varus force mean?
Pushing away from the midline
Valgus is pushing the joint toward the midline
Why is giving corticosteroids after an MI dangerous?
Corticosteroids and some non-ASA NSAIDs can interfere with cardiac wall remodeling and scaring after a MI, which can leave the wall weak and prone to rupture
In cardiac tamponade, what values will you see on a right heart catheter?
High RA pressure
Equalization of the RA pressure, PA pressure and Wedge pressure
What is the most common bacterial cause of PNA?
Streptococcal pneumoniae
What is tumor lysis syndrome and what electrolytes are commonly affected by tumor lysis syndrome?
Tumor lysis syndrome describes massive tumor cell lysis with the release of intracellular material, resulting in an onc emergency.
Often happens with cytoxin iniation
Often presents as severe nausea, vomiting and diarrhea after a few days of initiation of cytoxin
Usually present with hypocalcemia
Seizures characterized by a sudden loss of muscle tone that result in a fall or “drop seizures”
Atonic seizures
What test could be done to confirm the diagnosis of peripheral artery disease?
Ankle brachial index
Treatment of post-herpatic neuralgia after herpes zoster infection
Gabapentin or tricyclic antidepressants
EKG changes in TCA overdose
Prolonged QRS interval
Cardiogenic shock: What is it and what is a sign of decreased perfusion?
Cardiogenic shock is characterized by the failure of the heart to pump effectively resulting in decreased cardiac output and decrease in tissue and organ perfusion.
Symptoms include cool, mottled skin, oliguria, and clouded sensorium
Vitamin C deficiency: What are the symptoms
Scurvy
Malnourished individuals who do not eat enough vegetables.
Hemorrhagic skin lesions that usually appear in a perifollicular pattern on the legs
Also include fatigue, bleeding gums, ecchymosis, petechiae, hyperkeratosis
On a pulmonary function test, what are the classic signs of obstructive disease?
Increased residual volume (volume left over) and total lung capacity
Decreased tidal volume and decreased total capacity
Decreased forced expiratory volume over 1 second
FEV1:FVC is less than 80%
Common electrolyte abnormalities in SIADH and treatment
HypoNa because of diminished urinary output and water retention
Treatment is fluid restriction
Antibiotic of choice for aspiration PNA
Clindamycin
–Good for broad spectrum coverage
When is screening for lung cancer indicated?
Annual lung cancer screening is recommended for all adults between the ages of 55-80 with a 30 pack year history who are current smokers or quit less then 15 years ago.
High resolution pulmonary CT
A deficiency of ____ during the first trimester of pregnancy is associated with neural tube defects.
Folate
The use of Lisinopril during pregnancy can lead to ______.
Organ malformation in the first trimester. Renal malformations or renal failure if taken in the second or third trimester
Should take nifedipine, labetalol, hydralizine
What is the highest risk for factor for developing a lacunar infarct?
Hypertension
Lacunar infarct represents a type of small vessel disease
What is the most common bacteria that could cause a catheter related blood stream infection?
Coagulase negative Staphylococcus such as S. epidermis
What would a typical peripheral blood smear show in a patient with acute lymphocytic leukemia and chronic lymphocytic leukemia
In an acute leukemia, the cells would be immature because they are being sent out so quickly. There would be an increase in blast cells.
In chronic lymphocytic leukemia, the cells are normocytic, meaning that they have completely matured. This suggests that the disease process has been underway for some time.
In both cases, there would be a lymphocyte predominance on peripheral smear to suggest that it is a lymphoid leukemia.
How would one diagnose polycystic kidney disease (PKD)?
renal ultrasound
Normal VBG
pH 7.35 - 7.45
PaO2 >90 75-89 - mild hypoxia <75 severe hypoxia
PaCO2 35 - 45
HCO3 18-24
What is the FiO2?
Fraction of oxygen per each inspiration
Trouble shooting vents: How could you decrease a plateau pressure?
Decrease tidal volume
What is the best diagnostic test for portal and splenic vein thrombosis, as in a patient with chronic pancreatitis?
Visceral angiography
Worsening abd pain could be caused by splenic or portal vein thrombosis in a patient with chronic pancreatitis.
Multiple myeloma: Clinical presentation, labs
Weakness, fatigue, bone pain, recurrent infections, recurrent infections, hypercalcemia sxs (n/v, thirst, loss of appetite)
Labs:
Hypercalemia
Anemia
Bone lesions
Renal Failure
What is the most common adult form of muscular dystrophy?
Myotonic muscular dystrophy
Usually isolates in certain muscles and patients can live for longer.
Duchenne Muscular Dystrophy has much more rapid course and patients often die earlier
What antibiotic would you choose for prophylactic treatment of recurrent UTIs?
Bactrim 40/200mg PO Daily
Macrobid 50-100mg PO Daily
What are the recommendations for women with a risk of osteoporosis as it pertains to D3 and calcium supplementation?
Women over the age of 65 who are community dwelling and at increased risk for falls should have Vit D supplementation.
They concluded however that there is not enough evidence for recommendation of dosages to prevent fractures in post-menopausal women.
They do recommend osteoporosis screening for all women over the age of 65 or younger with increased risk factors using the FRAX score
—Takes into account age, BMI, parental hx of fracture, alcohol and tobacco use
Heart sounds of someone with aortic stenosis
Late systolic murmur heard over the R second intercostal space and radiates to the carotid arteries.
Heart sounds of someone with Aortic regurgitation
Early diastolic murmur/ decrescendo murmur at the third left intercostal space
In a patient with a lacunar stroke, what is an important medication to consider starting to prevent future strokes?
Statin
Lacunar strokes are largely caused by atherosclerotic disease, so starting a statin can help reduce the risk of atherosclerosis.
Treatment of choice for mild ulcerative colitis
5-Aminosalycilic acid enema
Risk factors for secondary restless leg syndrome
Diabetes, hypothyroidism, iron deficiency, venous insuffiency, lumbosacral radiculopathy, spinal stenosis, hypoglycemia
Treatment of acute bacterial sinusitis
Amoxicillin is the first line
Could also consider Azithromycin or clarithromycin
Phenylephrine may be beneficial for symptom relief
What is an adverse reaction to phenytoin that is pushed too fast
Purple glove syndrome
Fosphenytoin does not have this risk and therefore is often preferred.
CHA2DS2-VASc Score: What does it stand for and when would you use it
CHF - 1pt
Hypertension - 1pt
Age >75 - 2pt
Diabetes - 1pt
Stroke - 2pt
Vascular Disease - 1pt
Age 65-74 - 1pt
Sex - Female - 1pt
Used to determine if pt should be anticoagulated
If they score more than 1 on this, they should be considered with treatment with a DOAC
Which vasopressor is associated with hypokalemia and lactic acidosis
Epinephrine
Most common bacteria associated with UTI
E. Coli
An epidural hematoma is caused by bleeding from ______
the middle meningeal artery.
Hypercalcemia: Causes, normal range, Physical manifestations
Usually caused by hyperparathyroid
Hypercalcemia: Ca of >10.5 or ionized calcium >5.3
Sxs:
Shorted QT interval
Muscle weakness
Delayed deep tendon reflexes
Vomiting
Constipation
Stupor
What bacteria most often causes toxic shock syndrome in a patient that is menstruating and using tampons.
Staph aureus
Strep pyogenes can also cause toxic shock syndrome however it is usually associated with a skin or soft tissue rash
What is the first line therapy for immune thrombocytopenia?
Prednisone 1mg/kg/day
What is the most common cause of a new seizure disorder in patients over 60
Vascular disease
What is the target A1c for patients >65 years old?
<8.0 - helps prevent episodes of hypoglycemia and falls
What is the treatment for vitiligo
Topical corticosteroids
What are the CD4 cutoffs for prophylactic treatment of pneumocystis jiroveci pneumonia and what is the treatment
Bactrim for CD4 count of less than 200.
Pulmonary function tests in restrictive pulmonary disease
Decreased Forced Vital Capacity (FVC) and decreased total lung capacity
Both FEV1 and FVC are reduced so the FEV1:FVC would be normal
In order to wean a patient off of a ventilator, what should the spontaneous rapid shallow breathing index be?
<105
Medication of choice in a patient with symptomatic a-fib (presyncope, palpitations) with hx of MI and LVEF 20%.
Amiodarone
Best treatment for patients with mixed urge and stress urinary incontinence
Behavioral Therapies
Treatment of CAP
Inpatient treatment:
Fluoroquinolone or Macrolide (Azithromycin) and a third generation cephalosporin (Ceftriaxone)
Outpatient treatment:
Azithromycin
Treatment of HAP
Need broad spectrum and MRSA coverage
Vanc and Cefepime
What are some lifestyle modifications that could help reduce the risk of nephrolithiasis?
Decreased sodium intake and increase fluid water intake
What is the treatment for a patient with a DVT and a malignancy
LMWH - Enoxaparin daily
The pt is at risk for thrombosis from the DVT and bleed from the tumor, therefore only LMWH
What is the best prognostic indicator for patients with COPD
FEV1
Clinical presentation and initial treatment of ankylosing spondylitis
Back pain that has a slow onset and is a dull, aching pain
Heel pain that originates from the Achilles tendon and plantar fascia
Uveitis
Treatment is with NSAIDS
What to do when you have a wide complex tachycardia and the patient is awake and stable other than tachycardia
Amiodarone
Synchronized cardioversion could be considered if the patient was unstable
What test do you use to diagnose an Achilles tendon tear
Thompson test
Sarcoidosis: Clinical presentation
Rash on lower extremities
Erythema nodosum on the upper extremities
Also can present with hilar adenopathy, fatigue, arthralgias
Usually symptoms resolve with time
What is the only treatment modality noted to decrease mortality in patients with COPD
Oxygen therapy
EKG changes in Wolf Parkinson White Syndrome
slow, slurred uprise of the Q wave, wide QRS complex, short PR interval, T wave abnormalities, ST abnormalities
Treatment of quadriceps tendonitis
In the acute phase, treatment is rest, ice and NSAIDs
Cryotherapy can help lower tissue metabolism and help reduce secondary hypoxic injury
Electrolytes that usually are deficit during DKA
Bicarb
What is the most appropriate method of determining the severity of a splenic injury
CT with contrast
How long should patients undergo anticoagulation before cardioversion in patients with atrial fibrillation that has lasted longer than 48 hours
3 weeks
For patients that went into a-fib within the last 48 hours who have a CHA2DSVASc score of >1, should start on DOAC immediately.
What is the most common cause of euvolemic hyponatremia
SIADH
What is the first line vasopressor in septic shock
Norepinephrine
What is the most common extra-renal complication of polycystic kidney disease?
Colonic diverticular disease with an increased risk of perforation
What is the first line treatment of dementia
Cholinesterase inhibitors
–Donepezil
-Galantamine
-Rivastigmine
-Tacrine
Memantine is an NMDA receptor antagonist and is used as an adjunct with a cholinesterase inhibitor in moderate-severe dementia
What is the confirmatory test needed to diagnose sarcoidosis?
Tissue biopsy
What are absolute contraindications to receive fibrinolytic therapy during a STEMI
Prior intracranial hemorrhage
Structural cerebral vascular lesion or neoplasm
Ischemic stroke within the last 3 months
Suspected aortic dissection
Active bleeding
Significant closed head or facial trauma in the last 3 months
Intracranial or intraspinal surgery within the last 2 months
Which toxic alcohol is associated with optic disc changes and intoxication when ingested?
Methanol
What is the earliest marker for diabetic neuropathy?
Microalbumin
It can be measured in an early morning urine albumin concentration
If elevated, should consider strict glycemic control and HTN treatment to avoid peripheral diabetic neuropathy
What medication is used to treat von Willebrand Disease
DDAVP - Desmopressin
Treatment for H. Pylori
Diagnosed via urea breath test
Treated with two antibx and a PPI
Metronidazole and Clarithromycin
Metronidazole and Amoxicillin
Amoxicillin and Clarithromycin
What is the immediate treatment of a meniscus tear
Conservative management (rest, ice, NSAIDs)
What type of thyroid disorder has a goiter
Hyperthyroidism
Myxedema coma: How does it start, what are the symptoms, treatment
Usually occurs in a patient that has poorly treated hypothyroidism that is under physiologic stress (infection)
Presents with:
hypothermia
hypotension
bradycardia
hyponatremia
hypoglycemia
hypoxia
Usually has very high TSH, very low FT4
Treatment is with levothyroxine 400mcg IV, followed by levothyroxine 100mcg IV daily
Lab results suggestive of SIADH
Serum hyponatremia
Normal serum osm
Elevated urine sodium
Elevated urine osm
Elevated urine Spec Grav
Very concentrated urine
What is a third line treatment of severe asthma if supplemental O2, nebulized albuterol, and corticosteroids have not worked?
IV Magnesium
Causes smooth muscle relaxation
What is the gold standard for diagnosing interstitial lung disease?
High resolution CT chest
What is the role of an ACE-I in regards to preload/afterload?
ACE-I reduce afterload and therefore decrease the work of the heart
Also they decrease the remodeling of the heart due to CHF
What is Brown-Sequard Syndrome?
Brown-Sequard (hemi cord) syndrome involves the dorsal column and the spinothalamic tract unilaterally producing weakness, loss of vibration and proprioception ipsilateral to the site of injury and loss of pain and temperature on the opposite side
Treatment of hepatorenal syndrome
Albumin, midodrine, octreotide
They synergistically act to increase circulating volume and improve renal perfusion by reversing sustained renal vasoconstriction
What is an advanced directive
It is a document that outlines the patient’s wishes and names a healthcare proxy
It can be overturned at any time by legal next of kin or the patient
What is a complication of hypertensive crisis?
Intracerebral hemorrhage or subarachnoid hemorrhage or thrombus.
Horner’s Syndrome: Causes, symptoms, diagnostics
Carotid dissection
Miosis, Ptosis, anhydrosis
Need to obtain MRA head and neck
Signs of digitalis toxicity and drugs that can cause it
Bradycardia, PVCs, left bundle branch block
Diltiazem can potentiate the effects of digitalis
What is the Somogyi effect?
When you give too much insulin in the evening (usually an intermediate acting agent such as NPH) and therefore causing hypoglycemia at night time, which leads to a cascade of glucose production resulting in hyperglycemia in the AM.
The treatment is to stop NPH in the evening.
Make sure to continue basal insulin
Treatment of tricyclic antidepressive OD
Sodium bicarbonate
Beta blockers are the cornerstone for management of what disease
CHF
Great at controlling the heart rate
Only provide a modest decrease in BP
What does digoxin do to BP and HR
Increase contractility and decrease HR
Does not do much to BP
What is the use for Dobutamine
Dobutamine is an IV inotropic medication indicated to support cardiac function and cardiac output.
Has Beta 1 and Beta 2 effects and causes mild vasodilation
Especially useful in afterload reduction in heart failure patients that cannot tolerate vasodilator therapy
In a patient with an ischemic stroke that is hypertensive to 190/110, what the is the first medication given?
Labetalol
Need to get the BP below 185/110 in order to give tPA
Pheochromocytoma: What is it, symptoms, diagnostics, treatment
Tumor forms (usually in the adrenal glands) that secretes catecholamines (epinephrine, norepinephrine) inappropriately
Patients will present with attacks of headaches, tremors, diaphoresis, palpitations, chest pain
Will become hypertensive and tachycardic
TSH will be normal
24 hour urine collection for metanephrines (catecholamine metabolites) should be collected
Treat patient symptomatically but will ultimately need to have tumor resected
Treatment of a patient with heparin-induced thrombocytopenia who is currently being prescribed heparin
Stop heparin immediately and start on alternative anticoagulant (not warfarin)
If warfarin was being given, should give Vitamin K to return INR to normal until thrombocytopenia resolves
What is a cardiac index that is associated with cardiogenic shock?
Cardiac index of <1.7
SJS vs TEN
SJS covers less than 10% of total surface body area and involves purpuric rash with blisters and bulae involving oral, optic and genital mucosa.
TEN involves greater than 30% of total surface body area
10-30% is known at SJS/TEN
What is the antibiotic choice to treat PNA caused by Legionella?
Macrolides - Azithromycin
Cor Pulmonale
Common in patients with COPD. Right sided heart failure caused by pulmonary disease and pulmonary artery HTN
In pre-renal AKI, what would we expect to see in a UA and in a fractional excretion of sodium test?
Hyaline casts in the UA
FENa <1%
What is the antibiotic treatment choice to treat H. Pylori
Metronidazole, Clarithromycin and PPI
Amoxicillin, Clarithromycin and PPI
Metronidazole and Amoxicillin and PPI
Which vitamin deficiency can cause night blindness and Bitot’s spots?
Vitamin A deficiency
Treatment for uremic pericarditis
Dialysis
NSAIDs have not proven to be helpful in uremic pericarditis
What are contraindications to the use of calcium channel blockers?
bradycardia
any degree heart block
CHF
First line treatment of cluster headaches
100% O2 by nonrebreather
Sumatriptan
What the symbol for a healthy male on a genogram?
A blank, open square
What is a common presenting problem in patients with multiple myeloma
bone pain, usually of the lumbar spine
Pathologic fractures are also common
What are common symptoms of multiple myeloma
bone pain
renal failure
anemia
hypercalcemia
Diagnostic tests for Multiple Myeloma
Serum and urine assessment for monoclonal proteins
What does a positive Squeeze Test indicated in a patient with a suspected ankle injury?
Syndesmotic injury
“High ankle sprain”
Maisonneuve Fracture
Ankle injury that results in a fracture of the proximal fibula from rotation of the body around a planted foot
Clinical manifestations of polycystic ovarian syndrome
Irregular periods
hyperandrogenism
Ultrasound that shows cysts
Testosterone will be elevated
LSH is greater than FH
High DHEA-S level
Shock types and their Cardiac output, right atrial pressure, capillary wedge pressure and systemic vascular resistance
Septic Shock: High cardiac output, low right atrial pressure, low capillary wedge pressure and low systemic vascular resistance
Hypovolemic shock: Low cardiac output and high systemic vascular resistance
Cardiogenic shock: Low cardiac output, high right atrial pressure, high capillary wedge pressure and high systemic vascular resistance
Anaphylactic shock: Low cardiac output, low wedge pressure, low systemic vascular resistance
Treatment for idiopathic thrombocytopenia
If platelet count is between 30,000 and 50,000, prednisone is the first course of action.
If the patient is to have a surgical procedure, would consider IV gamma globulin
What are PO options to treat MRSA skin infection
Bactrim or Clindamycin
What cranial nerve is implicated in Bells Palsy
Cranial nerve 7, the facial nerve
What are three antihypertensives that are considered safe during pregnancy
Methyldopa, Labetalol, Nifedipine
What causes splitting of S2 in a heart murmur?
Aortic stenosis
This is often caused by prior strep pharyngitis as a child
Ig___ deficiency is associated with celiac disease
IgA
What is the most common cause of acute tubular necrosis?
Ischemic injury
Nephrotoxins (like Gentamicin) are the second most common cause
What is the reversal agent for serotonin syndrome?
Cyproheptadine
Kernig’s Sign is an indication of what?
Meningitis
What are the clinical features of mycoplasma pneumonia
Sounds viral
Non-productive cough
Not very high fevers
CXR that shows bilateral interstitial infiltrates
What type of nutrition should be started in a patient with sepsis that is intubated
Enteral feedings (G-tube or NGT)
What are the rules surrounding the Medicare Care Choices Model?
Allows current Medicare members to receive hospice care along with the their current Medicare benefits.
Eligibility requires:
-Patient must live in a traditional home (not a nursing home)
-Have Medicare A&B for the last 12 months
-Have a terminal diagnosis (specifically COPD, advanced cancer, Heart Failure, HIV/AIDS)
What is the recommended treatment for unrelieved break through cancer pain
Sustained release Fentanyl patches
What would be a treatment for metastatic bone cancer pain?
Bisphosphonates
Causes a decrease in bone mets and pain relief in the bones
Define the stages of pressure ulcers
Stage 1: Intact skin with erythema that does not blanch: Color changes do not include purple or maroon discoloration - just red
Stage 2: Partial thickness loss of skin with exposed dermis; wound bed is viable, pink or red, moist; adipose tissue is not visible
Stage 3: Full thickness skin loss - adipose tissue is visible in the ulcer and granulation tissue and rolled wound edges are present. Slough or eschar might be present - IF SLOUGH OR ESCHAR IS PRESENT THEN IT IS UNSTAGEABLE
Stage 4: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer - undermining and tunneling often present
What are some considerations to help manage a pressure ulcer
Monitor for hypoalbuminemia to make sure that albumin is between 3.5-5.0
Wound care specialist consult
Dressing
—If it is weeping - hydrocolloid dressing
What are negative outcomes of pressure ulcers
Because the pressure ulcer is usually at the coccix, concern for stool in the ulcer
-this can lead to osteomyelitis
-Can spread and move on to sepsis
Normal body temp in Celsius
37C
Fever is considered 37.7C
Common causes of fevers
Infection
Autoimmune disease (SLE, arteritis)
CNS disease (cerebral hemorrhage, brain tumor, MS) - thermoregulation problem
Malignant neoplastic disease (primary and liver mets of cancer)
Hematologic disease (lymphoma, leukemia)
CV disease (MI, phlebitis, PE)
GI Disease (inflammatory bowel disease, alcoholic hepatitis)
Endocrine (hyperthyroidism, pheochromocytoma)
Neuroleptic malignant syndrome
What is an absolute contraindication for the use of succinylcholine?
Hyperkalemia
What are the normal ranges of albumin and what happens if it is too low?
Normal albumin range is 3.5-5.0
Less than 2.7 - you will start to see edema
Complications of enteral nutritional support
Enteral feedings - through the GI tract (G-tube)
Have to do with the solution itself and the gut’s inability to handle it
Aspiration
Diarrhea
Emesis
GI Bleed
Mechanical obstruction
Hypernatremia
Dehydration
Refeeding syndrome
—-hypophos, hypokalemia, hypomag, hypocalcemia, thiamine deficiency
Complications of parenteral nutritional support
Feeding through the vasculature
–If less then 2 weeks needed, can use peripheral vein but otherwise will need central line
The complications occur due to the mode of delivery
Pneumothorax
Hemothorax
Arterial laceration
Air emboli
Catheter thrombosis
Catheter sepsis
Hyperglycemia
Hyperosmolar Hyperglycemic state
Antibiotic treatment for animal bites
Human and animal bites: Should cover for staph and anaerobes
—-Amoxicillin Clavulanate (Augmentin)
Should treat for 3-7 days depending on the bite
What does an acute rejection of an organ transplant look like and what should your initial action be?
Immediate failure of that organ
Flu like syndrome (fever, chills, malaise)
Should immediately biopsy the transplanted organ
Most effective anti-rejection regimen for transplant patients
Three different immunosuppressants from three different classes
Corticosteroid: Methylprednisolone or prednisone
Antimetabolite: Azathioprine, Cellcept, cyclophsphamide (Cytoxan)
Calcineurin inhibitor: Tacrolimus, cyclosporine
You must have had what disease in order to get Shingles
Chicken pox
Herpes Zoster is an acute vesicular eruption due to infection with varicella-zoster virus
Management of herpes zoster
Cover the vesicles while they are oozing
Treatment:
Acyclovir
Famciclovir
Valacyclovir
If suspected ocular involvement, contact ophthalmology immediately
What medications are given for post-herpatic neuralgia?
Gabapentin
Pregabalin
At what age is the shingles vaccine indicated?
All adults >50 years old, regardless of previous shingles vaccine
What are the two types of migraines?
Classic - Migraine with aura
Common - Migraine without aura
Which cranial nerve is most implicated in migraine headaches?
Trigeminal nerve
Treatment of cluster headaches
Inhalation of 100% O2
Sumatriptan SQ
Ergotamine tartrate aerosol inhalation may also be effective
What is the difference between an advanced directive and a living will
Advanced directive:
Written statement of a patient’s intent regarding medical treatment
Living will:
Written compilation of statements in document format that specifies which life-prolonging measures one does and does not want to be taken if he/she becomes incapacitated
-In the US, most states recognize living wills as long as they are specific enough
-Often lists someone as the durable power of attorney if they should not be able to make decisions for themselves.
—This is the person that will be charged with making decisions if the patient is incapacitated
—-Same as a proxy
-Power of attorney must be in writing before it can be accepted
What are the 6 mandated reporting diseases
Gonorrhea
Chlamydia
Syphilis
HIV
Tb
COVID-19
What are the requirements for hospice
Need to have a terminal illness with a prognosis of 6 months or less.
Need to be CMO - no antibxs
What are the types of Medicare and what is covered under each?
Medicare A:
Covers inpatient/hospitalization, SNF, home health services and/or hospice associated with the inpatient event: Most people qualify at 65 years old
Medicare B:
Covers physician services (NPs), outpatient hospital services, lab and diagnostic procedures, medical equipment and some home health services
-Supplemental coverage that requires pts to pay a premium
-NPs are reimbursed 85% of what a physician would make
-Medicare pays 80%, the patient is required to pay 20%
Medicare C:
Medicare A+B - now known as Medicare Advantage
-If pts are entitled to A and enrolled in B, they can pick all services through one provider organization under Part C
Medicare D: Limited prescription drug coverage
-Monthly premeium required
-Co-pay on each prescription is required
Medicaid: What is covered and who gets medicaid?
Federally supported, state administered program for low-income families and individuals
Benefits vary from state to state
Medicaid payments are made after other insurance or third party payments have been made
In terms of quality improvement, define:
Structures
Processes of Care
Outcomes
Structures: Inputs into care such as resources, equipment or numbers and qualifications of staff
Processes of Care: Include assessments, planning, performing treatments and managing complications
Outcomes: Include complications, adverse events, short term results of treatment and long-term results of patient health and functioning
What are the 6 key competencies that are supported by the Quality and Safety Education for Nurses initiative?
PETS IQ
Patient-centered care
Evidence-based practice
Teamwork and collaboration
Safety
Informatics
Quality Improvement
What is a root cause analysis
A tool for identifying prevention strategies to ensure safety
A process that is part of the effort to build a culture of safety and move beyond the culture of blame
What is a cross sectional study?
A type of observational study that examines a population with a very similar attribute but differs in one specific variable (such as age); designed to find relationships between variables at a specific point in time or “surveys”
What is a cohort study?
A type of nonexperimental or observational study
Retrospective or prospective
Compares a particular outcomes (such as lung cancer) in groups of individuals who are alike in many ways but differ by a certain characteristic (i.e. female nurses who smoke compared with those who do not smoke)
What is a longitudinal study?
A study that involves taking multiple measures of a group/population over an extended period of time to find relationships between variables
What is a quasi-experimental study?
Research that involves manipulation of variables but lacks a comparison group or randomization
What is a qualitative study?
Includes case studies, open-ended questions, field studies, participant observation and ethnographic studies where observations and interview techniques are used to explore phenomena through detailed descriptions of people, events, situations or observed behavior
What is the difference between a type 1 and type 2 error
Type 1 error: False Positive - incorrectly rejecting the true null hypothesis
Type 2 error: False Negative - failing to reject a null hypothesis which is false
How many percentage points fall within each standard deviation from the mean?
68% fall within one standard deviation
95% fall within two standard deviations
What is the difference between sensitivity and specificity
Sensitivity: Positive
True Positives: The degree to which those who have a disease screen/test positive
Specificity: Negative
True negatives: The degree to which those who do not have a disease screen/test negative
As far as herbal remedies go, if it starts with a G it increased the risk for…..
bleeding.
St. John’s Wort: Hazards and Precations/Interactions
Increases risk of blood clotting
Should not be taken with ASA
Many drug interactions (SSRI - serotonin syndrome, decrease oral contraceptive efficacy, digoxin)
Can cause HIV medications not to work
May increase the potency of narcotics
Why do people take St. John’s Wort?
Depression and anxiety
What is Ginko Biloba used for
Memory and concentration
Improves sxs of Alzheimer’s Disease, intermittent claudication and glaucoma
Top 5 causes of death
CAD
Cancer
Unintentional injury
Lower respiratory disease (asthma, COPD)
CVA
What cancer in women is responsible for the highest mortality
Lung cancer
Leading GYN associated cancer
Ovarian - no screening exam available
Highest incidence of cancer other than skin cancer in women
Breast Cancer
What cancer in men is responsible for the highest mortality
Lung Cancer
Other than skin cancer, what is the 2nd most common cancer in men
Prostate Cancer
Who should get the pneumococcal vaccine?
Ages 65 and older
Those 19-64 who smoke or have asthma
People with lung, heart or kidney disease
Those with weakened immune systems
Those living in a nursing home or long term care facility
Who gets the mumps vaccine
If born before 1957: should get one dose unless immunity because of previous mumps infection
If born after 1957: should get 2 doses of the vaccine
Meningococcal vaccine: When is it recommended and how often
Recommended for ages 2-55. Should get booster x1 if high risk (military, dorm livers) usually at age 11-15
How often should a female have a pap smear done? Breast self exam?
Pap: 3 years
Breast exam: Starting at age 21, every 3 years, annually after age 40
How often should a woman get a mammogram
From ages 45-54, annually
After age 55, every 2 years
Continue as long as the pt is expected to live 10+ years
How often should a man get a prostate exam
For men with a family hx of prostate cancer, should get a prostate exam and PSA checked annually starting at age 40.
For men without a family hx of prostate cancer, should get a prostate exam and PSA annually starting at age 50
How often should one get a colonoscopy and when should they start?
Should start ages 45-75
Should get annual stool based testing
Colonoscopy every 10 years
Who should be considered for prophylactic antibiotics before a dental procedure?
Those with:
Prosthetic cardiac material
Hx of endocarditis
Hx of congenital cardiac illness
Hx of cardiac transplant
In a patient with hypocalcemia s/p thyroidectomy (hypoparathyroidism), what medication should be started if the patient is demonstrating sxs of hypocalcemia
Should administer calcium gluconate immediately
Then the patient should be started on calictriol to help with the absorption of calcium
If a patient is cardioverted for A-fib, how long before and after cardioversion should the patient be treated with anticoagulants?
3 weeks prior to cardioversion and 4 weeks after
What are the triad of features of Marfan’s Syndrome?
Long, thin extremities, often associated with other skeletal changes
Reduced vision due to dislocation of the lenses (ectopia lentis)
Aortic aneurysm that starts at the base of the aorta
Other skeletal deformities include chest deformities, scoliosis, kyphosis, and pes planus
What is the pathophysiology behind migraines
Vasodilation and excessive pulsation of the branches of the carotid arteries
What are electrolyte abnormalities found in acute pancreatitis
Hyperglycemia
Hypocalcemia
Elevated LFTs
In terms of capacity and compliance, how do the lungs change in the elderly?
Total lung capacity remains the same throughout old age
Residual volume increases
Vital capacity decreases
Functional residual capacity increases
What is a typical lab finding associated with isotonic hyponatremia?
HLD
What are two herbal remedies to alleviate premenstrual discomfort for women
Black Cohosh and Evening Primrose
With regards to potassium, would we suspect potassium to be high or low in alkalotic states? Acidotic states?
Hypokalcemia is associated with alkalosis
Hyperkalcemia is associated with acidosis
Sodium is not associated with acid-base abnormalities
How often should women receive a physical exam in their 20s
Every 5-6 years
How often are clinical breast exams recommended inpatients in their 20s
Every 3 years
What is the leading cause of death among patients 40-59 years old
Coronary artery disease
What bowel sounds would be expected in patients with a small bowel obstruction?
Partial bowel obstruction?
In a partial small bowel obstruction, the pt will complain of abd distention but not constipation, rather watery stool
—High pitched, tinkling bowel sounds will be presents
In complete small bowel obstruction, there will be constipation
—Hypoactive bowel sounds or absent bowel sounds
Describe Kernig’s Sign
Maneuver used to diagnose meningitis
Patient will lay supine with knees and hips flexed at 90 degrees
If straightening the knee, while the hip is flexed at 90 degrees causes increase headache or neck pain, this is a positive Kernig’s Sign and suggests meningitis
A patient presents with a murmur that is low pitched, mid-diastolic and has an apical crescendo rumble. The murmur would most likely occur during which heart sound? What type of murmur is this?
This is mitral stenosis
It would occur during S1
How do you calculate creatinine clearance
[(140-age) x weight in kg]/ 72xCr = Creatinine clearance
Multiple by 0.85 for women
What medication would give to a patient that has a NSAID induced peptic ulcer but needs to continue to take NSAIDs
Misoprostol
What test would you use in order to differentiate between instrisic renal failure and post renal failure
Urine Sediment would show granular white casts in intrinsic renal failure. In postrenal, it would be normal.
BUN/Cr and FENa would differentiate prerenal from intrinsic
What test could you perform to help make the diagnosis of DIC?
Elevated fibrin degradation product is a typical finding of DIC
Fibrinogen levels would be normal
PT and PTT would be elevated
D-Dimer would be elevated
What is a symptom of Acetaminophen poisoning?
RUQ pain
Delirium
What is the drug of choice for organophosphate toxicity that is absorbed through the skin
Atropine
Activated charcoal would be used if he were to have ingested in orally
How often should a Pap Smear with HPV co-test be conducted in a woman between the ages of 20-39
Every 5 years
A Pap smear with cytology should be done every 3 years
First line treatment for acetaminophen intoxication?
What about if the patient has AMS?
First line treatment should include emesis or gastric lavage
If AMS, gastric lavage is recommended
N-acetylcysteine is indicated at 140mg/kg
What can cause both cardiogenic and obstructive shock
Cardiac tamponade
