Rotation Tid Bits

Question 1

Rosacea description and treatment

Answer 1

adult acne -> metrogel (metronidazole) -> can cause rhinophyma (inappropriately attributed to alcoholism)

Question 2

Oxybutinin - MOA and use

Answer 2

muscarinic receptor antagonist -> used for overactive bladder (loss of bladder control, urge incontinence) by reducing detrusor muscle tone.

Question 3

Triamcinolone

Trazadone

Tramadol

Toradol

Answer 3

Triamcinolone - steroid used for redness, itching, swelling of skin… betamethasone is stronger

Trazadone - serotonin antagonist and reuptake inhibitor - used as sleep aid.

Tramadol - opiod analgesic - round the clock treatment

Toradol (ketorolac) - strong NSAID

Question 4

Anastrazole

Trastuzumab

Answer 4

A - aromatase inhibitor used for breast cancer prophylaxis - comes with side effects (bone weakness, BPH, gynecomastia, hypogonadism signs, stroke heart attack inflammation) *remember aromatization is increased in adipose tissue

T - HER2 antagonist “herceptin” - can cause cardiomyopathy

Question 5

what is a good rule of thumb for wound care management?

Answer 5

if its wet dry it

if its dry wet it - diabetic wounds get debridement, vasaline, foam protection

Question 6

stroke work up?

Answer 6

CT -> MRI
HbA1c
Lipids
Tele
Echo w/ bubble study
Carotid U/S
Swallow Study / SLP - PT/OT

Question 7

Plaquenil

Synthroid

Answer 7

P - hydroxychloroquine - treats and prevents malaria, lupus, RA, Porphyria Cutanea Tarda, photodermatidis - macular degeneration possible…accumulates in lysosomes increasing pH decreases proteolysis and immune function

S - levothyroxine

Question 8

whats a clinical sign of spinal stenosis? differentiate from herniated disc…

Answer 8

shopping cart sign = stenosis

herniated disc = dont like leaning forward

Question 9

PreOperative Exam

Answer 9

FAIL IF —

CHF EF 20%
LFTs - bili > 2, PT >16, ammonia >150
Recent weight loss
DKA is absolute contraindication

Question 10

Levoquin

Answer 10

levoflaxacin - flouroquinolone - topoII inhibitor - broad spec - achilles tendon rupture / tendonitis and QTc prolongation

Question 11

Provigil

Flexeril

Gabapentin

Answer 11

P = Modafinil - not clearly understood action - unlike amphetamines - seems to inhibit dopamine reuptake - astronauts and military and narcolepsy …used for narcolepsy, shift work disorder, daytime sleepiness, OSA

F - cyclobenzaprine - muscle relaxant - causes sleepiness, not good to use while driving a car …antagonist at histamine, serotonin, and muscarinic receptors

G - brand name is neurontin - anticonvulsant/analgesic - originally made for epilepsy but also treats neuropathic pain and RLS (diabetic neuropathy, post herpetic neuralgia, central neuropathic pain) ..structurally analogous to GABA … pregabalin is lyrica

Question 12

which increases PO4? vitD or PTH?

Answer 12

VitD

Question 13

decreasing microalbuminuria…

Answer 13

ACEi (renal protective) -> CCB #2

Question 14

first line in edema

Answer 14

Lasix - furosemide - loop diuretic … first line in edema

Question 15

what’s something that can cause BC failure?

Mirena

Skylaa

Copper IUD (Paragaurd)

Nexplanon

Answer 15

birth control failure is caused by antibiotic treatment, grapefruit

M - 5 years - levonorgestrel - amenorrhea

S - 3 years - levonorgestrel - amenorrhea

C - 10 years - no hormones - bleeding spotting pads check bhCG if no splitting

N - bleed alot

Question 16

“cradle cap”

Answer 16

seborrheic dermatitis - skin flaking

vs

seborrheic keratosis - brown coin like age spots

Question 17

Symbicort

Answer 17

budesonide and formoterol - steroid and LABA -> asthma, COPD treatment… cant use LABA alone because it increases mortality by masking disease progression

Question 18

CKD stages
1
2
3A
3B
4
5

Answer 18

based on GFR
1 >90
2 60-89
3A 45-59
3B 30-44
4 15-29
5  <15

Question 19

cockcroft gault eq for estimating Crc

Answer 19

(140-Age)Mass(Kg)0.85(if female) / 72*SerumCr(mg/dL)

Question 20

Centor Score in pharyngitis

Answer 20

estimates risk of strep pharyngitis

Age <14
Tonsils (exudate/swelling)
Cervical Nodes (tender/swelling)
Fever
Lack of Cough**

Question 21

Droperidole

Answer 21

antidopaminergic - antiemetic/antipsychotic - neuroleptic/analgesic

QTc prolongation / torsades de pointes / extrapyramidal side effects

haldol family knocks em out “drop-eridole”

Question 22

ketorolac

Answer 22

NSAID - Toradol is brand name

Question 23

weight gain in pregnancy

Answer 23

1-5 lbs in first trimester

1 lbs per week therafter

Question 24

Requip

Mirapex

Reglan

Zantac

Zofran

Phenergan

Imodium

Answer 24

Requip - Ropinerole - nonergot dopamine agonist - Parkinson’s disease treatment

Mirapex - Pramipexole - nonergot dopamine agonist - Parkinson’s, RLS

Reglan - metoclopramide - D2 receptor antagonist - anti-emetic, gastroparesis, nausea / vomiting, GERD

Zantac - ranitidine - H2 receptor blocker - GERD

Zofran - odansetron - 5HT-3 receptor antagonist - antiemetic

Phenergan - promethazine - first generation anti-histamine - nausea vomiting motion sickness, neuroleptic/ treat insomnia where benzos are contraindicated

Imodium - loperamide - opiod u-receptors but doesn’t cross BBB - anti-diarrheal (causes constipation)

Question 25

Creon Fentanyl Byetta n Victoza Saxenda

Answer 25

Creon - pancrelipase - delayed release pancreatic enzyme capsules for patients with pancreatic insufficiency Fentanyl - opiod pain reliever Byetta / Victoza - exenatide / liraglutide - GLP-1 agonist - stimulates insulin release - used for weight loss and diabetes... injectable drugs (thyroid cancer risk? pancreatitis risk?) Saxenda - liraglutide - but for weight loss

Question 26

Topimax Demadex Lasix Bumex Colace Demerol

Answer 26

Topimax - topiramate "dope a max" - seizure / migraine prophylaxis - complex mechanism of action - sodium channels, calcium channels, GABA-a receptors, CA inhibitions Demadex - Torsemide - loop diuretic - treats fluid retention, works well with Lasix Lasix - Furosemide - loop Bumex - stronger loop diuretic Colace - docusate - stool softener - allows more water to be absorbed by feces - laxative to treat constipation - useful in children with hard feces, Demerol - meperidine - narcotic / opiod pain reliever

Question 27

Diabetic Foot Wounds

Answer 27

debride vasaline, Lubriderm (grease em up) get rid of edema protect feet from trauma

Question 28

simethicone

Answer 28

oral anti-foaming agent used to reduce bloating, discomfort or pain caused by excessive gas...aka Gas-X

Question 29

does albumin help furosemide diurese patients?

Answer 29

its helpful in patients with hypoalbuminemia due to nephrotic syndrome - it is able to increase oncotic pressure and thus GFR leading to increased diuresis.

Question 30

Zosyn Levaquin

Answer 30

Zosyn - piperacillin / tazobactam - penicillin with b-lactamase inhibitor.... similar to ampicillin/sulbactam or amoxacillin/clavulanic acid (augmentin) - good for pseudomonas Levoquin - levofloxacin - fluroquinolone - antibiotic, same class as ciprofloxacin... gram negatives, topo2 inhibitors, tendon rupture.

Question 31

Abilify Zoloft Buspar

Answer 31

Abilify - aripiprazole - one of the most highly grossing US drugs by sales, can cause tardive diskinesia while or after discontinuing drugs and can cause metabolic syndrome Zoloft - sertraline - incidence of diarrhea is higher than with other SSRIs, other SEs include - nausea, trembling, sexual dysfunction and weight gain. Buspar - buspirone - anxiolytic psychotrpoic drug, can cause dizziness, headache, somnolence, premature ejaculation (may be used to counter the effects of SSRIs) binds serotonin and dopamine receptors.

Question 32

Parkinsons vs Schizophrenia ... whos got the dopamine?

Answer 32

Parkinsons - not enough dopamine Schizo - too much dopamine... (antipsychotics can cause extrapyramidal side effects)

Question 33

Requip Symmetrel Senna

Answer 33

Ropinerol - parkinsons - nonergot dopamine agonist- for Parkinson's / RLS...can cause hallucinations (think schizo..) Symmetrel - Amantadine - NMDA receptor antagonist / Influenza M2 Protein inhibitor... parkinson's and parkinson's like syndromes Senna - Senocot - Ex-Lax - tree bark

Question 34

Heparin LMWHs Fondaparinux

Answer 34

Heparin - binds and potentiates antithrombin (AT) to increase inactivation of Xa and prevent the conversion of prothrombin to thrombin - half life 45 mins. Protamine Sulfate Reversible. Monitor PTT for IV drip LMWHs - Lovenox - enoxaparin - same as heparin but a longer lasting effect on factor Xa - less likely to bind to other stuff (plasma proteins, endothelial cells), longer half life 4-5 hrs. Protamine Sulfate Reversible Fondaparinux - direct Xa inhibitor - enhances the activity of AT 300 fold, no direct effect on thrombin. 17-21 hours. Not reversible... can use with HIT

Question 35

Diagnosing neuroleptic malignant syndrome

Answer 35

elevated WBCs and CPK (due to increased muscle activity and rhabdo) S/S - hyperthermia, confusion, diaphoresis, rigidity, autonomic imbalance... (similar to parkinson's crisis) People with Lewy Body Dementia are at risk - careful using neuroleptics in this population. Caused - by dopamine receptor blockade... Tx - Dantrolene to reduce muscle rigidity, bromocriptine (dopamine agonist), Amantidine (dopaminergic and anticholinergic properties), aggressive hydration with diuresis may be required (to resuscitate the kidneys) cyproheptadine for serotonin syndrome

Question 36

Seroquel

Answer 36

Quetiapine - (qwi tia peen) atypical antipsychotic - treats schizo, bipolar, depression, makes em go night night... also used for parkinson's psychosis due to lowextrapyrimidal side effects (often used before clozapine) QTc prolongation, sedation

Question 37

What are some of the things to consider when using steroids ... especially high dose?

Answer 37

blood sugar spikes and the need for insulin... long term you'll need stress doses, weens, and caution for osteoporosis / cushings

Question 38

Wheezes vs Crackles vs. Rales vs. Rhonchi vs. Rubs

Answer 38

"Inspiratory crackles, expiratory wheezes" wheezes rhonchi (coarse wheezes) and rales (crackles) Wheezes - constriction from asthma or bronchitis, obstruction, narrowed airways, diffuse in asthma/bronchospasm, local in tumor or FB (foreign body) Crackles -rales - fluid, pneumonia, sound of the lung popping open from inspiration. Rhonchi - snoring - low pitched gurgling liguid, inflammation, drownings, agonal states Rubs - pleural friction, like crackling of new leather, either of both phases of respiration, ephemeral rubs may accompany pain, may disappear

Question 39

Hospital Discharge Criteria

Answer 39

Completed Courses of IV therapy, No longer in need of diagnostic / therapeutic interventions, Place to discharge to... Medication Reconcilliation, Education for Patient, Discharge Summary given to future providers. Follow Up Care

Question 40

What do you worry about in alcohol withdrawl? what's the time frame in which concern is highest?

Answer 40

delerium tremens - tremors, hallucinations, anxiety, and disorientation - 72 hours - rule out electrolyte abnormalities (K and Mg) and vitamin deficiencies (Thiamine) things to ask the patient... 1. last drink/how often 2. hospital visits 3. seizures

Question 41

Etoh Mechanism of Action

Answer 41

alcohol descreases sensitivity to GABA (cus when you drink you increase GABA so you body responds by gettin rid of it's GABA response).. then when you stop drinking... the activity in your CNS cannot be stopped because you can't respond to natural GABA (excess unregulated tone/excitation)

Question 42

CIWA - Clinical Institude Withdrawl Assessment tool

Answer 42

for seizure precautions, ten item scored scale

Question 43

Banana Bags

Answer 43

thiamine, folic acid, and 3 grams of MgSO4... plus multivitamins... used to replenish nutritional deficiencies or correct chemical imbalances. * Mg deficiency in ICU * Terminal Illness (as Mg can mitigate nerve pain and cramps) * Alcoholics (who benefit from the thiamine, or chronic alche's who benefit from B1 and Mg)

Question 44

Asterixis Disdiadokinesia Tenesmus

Answer 44

A -liver flap, hepatic encephalopathy via ammonia and urea. - caused by diencephalon motor centers being disrupted D - unable to perform repeated actions, cerebellar ataxia or cerebrum, other cerebellar dyfunctions include (ataxia, intention tremor, and dysarthria T - recurrent or continual inclination to evacuate bowels or bladder despite being empty...

Question 45

Lower Back Pain - RED FLAGS

Answer 45

Cauda equina - loss of function of the lumbar plexus -> severe LBP, saddle anesthesia, loss of bowel/bladder, weakness/paraplegia... caused by trauma, spinal stenosis,, inflammation. Loss of bowel/bladder Fever Persistent Neurologic Loss Cancer Unexplained weight loss Nocturnal Pain / Recent Weight Loss

Question 46

Intermittent Neurogenic Claudication

Answer 46

a spinal stenosis sign symptomatic with extension. relieved by flexion (shopping cart sign).

Question 47

Cockkroft-Gault

Answer 47

eCcr = eGFR = 140-Age x Kg x 0.85 (female) / 72-Serumcr Serumcr - higher if: kidney cannot filter or there's lots of muscle

Question 48

Pinguecula vs Pterygium

Answer 48

Pinguecula - yellow deposit of fat, protein or Ca+ near the limbus due to excessive UV light exposure... more common in hispanics Pterygium - mebranous changes and tissue overgrowth that can cross the limbus... "surfer's / farmer's eye" **Complication only if crossing the iris field**

Question 49

CHADS2VASc score is? determines risk for? in what population? HASBLEDD score is? determines risk for? in what population?

Answer 49

Risk of Thrombosis / Stroke ``` CHF HTN Age > 75? (2 points) DM Strokes/TIA? (stroke is worth 2 points) Vascular Dx (PVD, CAD, MI, aortic plaque) Age 65-74 Sex - Female ``` Risk of Bleeding (intracranial bleeds), hospitalization, hemoglobin dz, transfusion in pts. with A.Fib ``` HTN Abnormal renal / liver fnct (2) Stroke Bleeding Labile INRs Elderly (2) Drugs/alcohol *all others worth one point. ```

Question 50

CBI...

Answer 50

continuous bladder irrigation - for potential urethral obstruction such as a blood clot...

Question 51

people with polycythemia vera tend to develop which conditions?

Answer 51

vWF disease - most common coagulopathy - caused by reduced vWF ( a multimeric protein required for platelet adhesion ) often presents with nosebleeds, bruising, bleeding gums, long periods.. increased risk of AML - acute myelogenous leukemia

Question 52

compartment syndrome

Answer 52

increased pressure in a body space, particularly a forearm or leg... often presents with paresthesias. .. pulseless. .. pain. .. paralysis. .. pallor. ..

Question 53

hydralazine

Answer 53

direct arteriolar dilator -> treats hypertension often causes bottoming out.

Question 54

Protonix Aggrenox Plavix

Answer 54

P - pantoprazole- PPI A - aspirin+dipyramidole - Cox Inhibitor + PDE5 inhibitor (blocks prostaglandins required for platelet aggregation) P - clopidogrel - P2Y12 inhibitor - prevents ATP binding and platelet aggregations

Question 55

what are the signs of a hip fracture?

Answer 55

shorter leg, externally rotated

Question 56

what is an oral alternative to vancomycin?

Answer 56

linezolid (Zyvox) - expensive - vanco is for gram (+)

Question 57

how do you reverse coumadin?

Answer 57

vitamin K + FFP..... if starting coumadin bridge with lovenox (enoxaparin)

Question 58

SIRS criteria qSOFA

Answer 58

systemic inflammatory response syndrome - pick two 36>T>38 Tachy >90 Tachy >20 WBCs > qSOFA - Change in Mental Status - Tachypnea >22 - SBP <100

Question 59

Aztreonam

Answer 59

the big guns - UTI, Pseudomonas - synthetic monocyclic beta-lactam

Question 60

Causes of elevated troponins

Answer 60

long standing angina, kidney dz, pneumonia, CHF, DKA .. etc.

Question 61

Epworth Sleepiness Scale

Answer 61

ESS - self administered questionare - asks people about chances of dozing off in certain situations - helps diagnose sleep disorders (sleep apnea and narcolepsy)

Question 62

Alcohol Withdrawal Timeline

Answer 62

alcohol intially enhances GABA but later it suppressed GABA (or decreases sensitivity to GABA)...also suppresses activity of glutamate (excitability)... in response the glutamate system responds by functioning at far higher levels to maintain equilibrium -> increased activity of glutamate and where alcohol acts like GABA... therefore when you pull out the alcohol the inhibitor element of the system is lost -> over excitation 6-12 hours anxiety 12-24 hours hallucinations, seizures 24-48 hours withdrawal seizures become less likely 48-72 hours DTs

Question 63

what is a unique sign of chronic alcohol abuse?

Answer 63

atrophy of the thenar and hypothenar eminence from nutritional deficiency (also consider neuropathy from nutritional deficiency)

Question 64

what does every ACLS patient get? VOMIT

Answer 64

``` vitals O2 monitor IV/IO Transport ```

Question 65

what does every hospital patient get?

Answer 65

IV fluids Diet DVT prophylaxis

Question 66

serum free light chains? oligoclonal bands in CSF?

Answer 66

SFLC - monitors plasma cell dyscrasias - multiple myeloma and primary amyloidosis OCBs - suggests MS

Question 67

side effect of angiotensin receptor blockers?

Answer 67

angioedema

Question 68

what are some important post-operative considerations

Answer 68

Pain Gas/Bowel Movements Infection

Question 69

PVD - arterial vs venous insufficiency

Answer 69

90% caused by atherosclerosis - chronic and progressive Stages 1 - asymptomatic - bruits, aneurysm, physical exam 2 - claudication - limp/pain with motion/exercise 3 - resting pain wakes you up 4 - necrosis/gangrene venous - pain is relieved with elevation, thick skin, significant edema, stasis dermatitis arterial - pain at rest, relieved by motion, thin skin, pulses diminished, little or no edema, hypotrichosis

Question 70

6 "Ps" of PVD

Answer 70

``` pain paresthesia pallor pulses changes poikilothermia paralysis ```

Question 71

Carvidolol use Metoprolol use

Answer 71

carvidolol - BP control metoprolol - HR control

Question 72

what is the utility of tapping a chronic pleural effusion?

Answer 72

nothing a chronic Pleural effusion will simply re-effuse due to the fibrosis and pulling of the lung

Question 73

Jaw Claudication

Answer 73

one of the specific signs of temporal arteritis -> associated syndrome is Polymyalgia Rheumatica

Question 74

what is clobetasol and its use?

Answer 74

clobetasol - glucocorticoid used for eczema and psoriasis

Question 75

what causes a cough only at night?

Answer 75

GERD or Asthma

Question 76

what are the two situations of use for a living will?

Answer 76

terminally ill | persistent veggitative state

Question 77

AM Stiffness PM Stiffness

Answer 77

AM - inflammatory - RA PM - mechanical - OA

Question 78

CCP

Answer 78

cyclic citrullinated peptide - RA - a little bit better rheumatoid factor - not very specifc - never choose this on a test. usually start with inflammatory factors - ESR, CRP

Question 79

seronegative arthopathies

Answer 79

ankylosing spondylitis reiter's syndrome enteropathic arthritis psoriatic arthritis Behcet's disease juvenile idiopathic arthritis

Question 80

anti-synthetase

Answer 80

dermatomyositis - predilection for lung fibrosus (shawl sign, heliotrope rash, gottrons papules) .. often associated with cancer

Question 81

Migraine Rx

Answer 81

propranolol, tryptans, topimax

Question 82

what are the s/s of hypoglycemia spells, when is it important to ask about this?

Answer 82

hungry, dizzy, sweating when they are on diabetic meds.. they get all.. hypoglycemic

Question 83

Side Effect of CCBs

Answer 83

"dipine" amlodipine/nicardipine/nifedipine" decreases HR increases Fluid retention - CCB

Question 84

what can happen after 3 or more years of metformin therapy?

Answer 84

vitamin B12 deficiency, lactice acidosis in renal disease

Question 85

what are the top 3 causes of peripheral neuropathy?

Answer 85

DM, B12 (includes etoh), Thyroid (hypo/er) ...heavy metals... Agent Orange

Question 86

Fosamax Evista Prolia Remeron Cymbalta

Answer 86

F - alendronic acid - prevents/treats osteoporosis, paget's disease of bone - bisphosphonate - can cause osteonecrosis of the jaw. E - Raloxifene - SERM - treats osteoporosis (increased estrogen play)... se- hotflashes, leg cramps, blood clots (dvt,pe), teratogen P - Denosumab - osteoporosis, tx induced bone loss, bone mets, MM, giant cell tumor of bone... joint / muscle pain (binds and inhibits RANKL) R - mirtazapine - NaSSA (noradrenergic, specific serotinergic antidepressant) - depression, anxiolytic, hypnotic, anti-emetic, appetite stimulant - SEs - somnolence, weight gain, dry mouth, constipation C - duloxetine - SNRI - MDD - sexual dysfunction, anorgasmia, sleep disruption.

Question 87

what are normal lung sounds in the apices? ... lower lobes?

Answer 87

apices - bronchovesicular (equal inspiratory / expiratory phase) at 1/2 interspaces anteriorly, bronchial over sternum (longer expiratory phase) lower lobes - vesicular (longer through inspiration, fade through expiration).

Question 88

granuloma annulare

Answer 88

rare - benign, unknown causes, Tx - steroids/UV light - can be confused with tinea corporis ... may be associated with autoimmune conditions or neoplastic disease however loose, treatment if often futile and lasts 2-10 years.

Question 89

what is a side effect of DDP-4 inhibitors?

Answer 89

"exenatide and luraglutide" - joint pain, not as effective as GLP1 analogs "-gliptins" DDP-4 is an enzyme that inactivates GLP1 (a protein that would otherwise go on to stimulate insulin release)

Question 90

Finasteride, Dutasteride Doxazosin, Prazosin, Tamsulosin

Answer 90

F (Propecia)/D (Avodart) - 5-alpha reductase inhibitor - BPH/alopecia - decrease conversion of T to DHT -> decrease in prostate size D, P, T - alpha-1-selective blocking agent - used for HTN and urinary retention associated with benign prostatic hyperplasia

Question 91

Cutera veins Reticular veins Varicose veins Spider Talengiectasias

Answer 91

small blue varicosities medium blue varicosities large blue varicositiesplugged up spider talengiectasias - like a spider, red though, associated with cirrhosis

Question 92

epulis epithelioma cold water osteoma

Answer 92

epulis - enlargement of the gingiva, can be caused by pregnancy epithelioma - hyperplasia of the epithelium osteoma - common in swimmers/divers, little white flecks in the external auditory meatus

Question 93

Aortic Stenosis symptoms

Answer 93

dyspnea syncope with exertion chest pain

Question 94

Types of incontinence - SURF

Answer 94

stress - increased abdominal pressure - d/t weakened pelvic floor m.s ... kegals urge - aka overactive bladder - d/t damage to bladder nerves, nervouse system, muscles - stroke, parkinsons, diabetes, MS ... oxybutinin retention/overflow - bph, weak detrusor tone, tumors / obstruction, constipation ... 5aReductase inhibitors, A1 antagonists functional - can't make it to the bathroom in time - physical problems (arthritis) or dementia

Question 95

Vesicular Bronchial Bronchovesicular Amorphic Asthmatic Cogwheel

Answer 95

V - long inspiratory, bases B - long expiratory, sternum B - equal insp/exp, 1-2 interspaces A - blowing air over a pop bottle like A - long expieratory, wheezes C - pauses

Question 96

Whipered Pectoriloquoy Bronchophony Egophony

Answer 96

W - atelectasis/pneumonia/consolidation (sounds louder) B - increased sound of syllables E - E sounds like A ***Best PE test for consolidation

Question 97

Risk Factors of Osteoporosis

Answer 97

``` Low Peak Bone Mass Old Age - Loss of Osteoclasts Sex Steroid Hormone Loss Atherosclerosis decreased activity/ weight bearing / fall risk ``` Glucocorticoids -> decrease T/E production -> loss of serum Ca and increased PTH Glucocorticoids -> activation of clasts, inhibition of blasts, decreased VEGF

Question 98

Diagnosis of Osteoporosis

Answer 98

FRAX score - fracture risk score - 10 year risk calculator, includes dxa scan... (prior fragility fx, parental hx, tobacco/alchol, steroid use, RA...) DXA - Dual enery x-ray absorptiometry scan and serum vitamin D 0 - -1 at risk -1 -> -2.5 or fragility fx = osteopenia mean and FRAX >3% chance of hip fx, or 20% any fracture > -2.5 = osteoporosis

Question 99

Drugs that cause osteoporosis

Answer 99

steroids heparin antiepileptics

Question 100

``` Alendronate Zolendronic Acid Denosumab Raloxifen Teriperitide ```

Answer 100

A - oral, poor absorption - causes osteonecrosis of Jaw (especially with hx of cancer/radiation) Z - IV if cannot tolerate oral, convenient but hard to reverse...osteonecrosis D - Ab to RANKL, increases susceptibility to infection R - SERM - decreases risk of breast cancer, SE- thrombosis, hot flashes T - PTH, $, subq, adverse effects

Question 101

Lunesta Ambien Sonata

Answer 101

L - eszopiclone A - zolpidem S - zaleplon * non benzo hypnotics - * SE - hang over, falling asleep while driving... somewhat addictive, increased risk of depression?

Question 102

Aricept Namenda Exelon Razadyne

Answer 102

A - donepezil - centrally acting acetylcholinesterase inhibitor, palliative tx of Alzheimer's (increases acetylcholine in cerebral cortex), 70 hour half life, SE - GI upset N - memantine - NMDA receptor blocker -> decreased glutamate toxicity, can cause dissociative anesthesia at supratherapeutic doses (like phencyclidine - PCP)... also acts on a bunch of other receptors. E - rivastigmine -parasympathomimetic / cholinergic - tx Alzheimer's and Parkinson's dementia...can be used in patch form R - galantamine - vascular dementia and Alzheimer's - GI symptoms,

Question 103

Obtunded vs Psychogenic Sleepiness

Answer 103

Obtunded - raise their arm, let it drop, it will hit them in the face; their eye lids will open easily Sleepy - they will not let the arm hit their head; they will not let you open their eyes

Question 104

Compliance vs Elasticity

Answer 104

deltaV/deltaP Elasticity is the force emptying the lung - lost in obstructive lung disease

Question 105

what lab value do you watch to trend DKA?

Answer 105

anion gap... want it closed, order BMP q 3 hours, glucose stick q 1hr, until resolved. insulin drip with fluids fluids fluids... ketone of choice to follow response to Tx...beta-hydroxybutyrate

Question 106

DKA vs HHS/HHNK

Answer 106

DKA - ketoacidosis and hyperglycemia, fruity breath, kussmaul respirations, high anion gap metabolic acidosis *most commonly caused by infection or discontinuation of insulin therapy* S/S - both present with lethargy/obtunded, severe abdominal pain, coma, volume depletion... in acute distress*

Question 107

Kussmaul Respirations vs Cheyne Stokes

Answer 107

Kussmaul - deep compensatory breathing seen in DKA Cheyne Stokes - tachypnea and apnea cycles

Question 108

anion gap equation

Answer 108

Anion Gap = Sodium - (chloride + bicarb) ...usually greater than 20mEq/L if in DKA

Question 109

Mobile vs Motile

Answer 109

mobile - moves moTile - moves by iTself

Question 110

Hyperacusis Presbycusis Presbyopia

Answer 110

H - oversensitivity to a certain range of sounds P - age related hearing loss P - age related vision loss

Question 111

Rapid acting Short acting Intermediate acting Long acting ...insulin

Answer 111

Rapid - Novolog (aspart), Humalog (lispro) Short - Humulin, Novolin (regular insulin) Intermediate - Humulin, Novolin (NPH insulin) Long - Lantus (glargine), Levemir (detemir)

Question 112

Metalozone Dyazide

Answer 112

M - thiazide like diuretic - treats CHF and HTN, can be used with loop diuretics but watch out for dehydration and electrolyte disturbances D - hydrochlorothiazide+triamterene - thiazide diuretic + potassium sparing diuretic ... also prevents Ca release into urine preventing kidney stones

Question 113

which diuretics cause K loss?

Answer 113

loops thiazides osmotic diuresis (uncontrolled diabetes)

Question 114

which diuretics cause K gain?

Answer 114

ACEs ARBs, NSAIDS, COX-2 inhibitors, heparin, tacrolimus (block aldosterone production) spironolactone, eplerenone - aldosterone receptor antagonists (can be combined with loops and thiazides to counter K loss)

Question 115

Small Fiber Neuropathy

Answer 115

damage to small unmyelinated peripheral nerves "C-fibers" skin, peripheral nerves, and organ... these nerves help control autonomic function "polyneuropathy" - usually starting in longer nerves and progressively attack shorter nerves (thus they start in distal extremities) many causes, no cure, sometimes they try IVIG or plasmapheresis.

Question 116

lewy body dementia triad

Answer 116

fluctuating cognition parkinsonism hallucinations - that are nice

Question 117

who would you get a consult from for post stroke driving status?

Answer 117

occupational therapists can help with that.

Question 118

Grading Strength 0-5

Answer 118

``` 0 paralysis 1 visible contraction 2 ROM without Gravity 3 ROM only Gravity 4 decreased strength 5 normal ```

Question 119

Grading Edema 1-4

Answer 119

+1 - Trace - 2 mm rapid return to normal +2 - Mild - 4mm indentation, rebound few seconds +3 - Mod - 6mm indentation, 10-20s +4 - Sev - 8mm indentation, >30s * *also always check peripheral pulses and capillary refill * *note hair loss for determining length of edema

Question 120

Grading Pulses 0-4

Answer 120

``` 0 absent 1 weak 2 normal 3 strong 4 bounding ```

Question 121

Mallampati Score

Answer 121

can be done with or without phonation but advise that this will change the interpretation Class 1 - complete visualization of soft palate Class 2 - uvula dips behind tongue Class 3 - visualize only the base on the uvula Class 4 - no visualization

Question 122

Grading Reflexes 0-4

Answer 122

``` 0 absent even with reinforcement 1 present only with reinforcement 2 normal 3 brisk 4 hyperactive/sustained with clonus ```

Question 123

what does a good drug accomplish?

Answer 123

decreased... mortality hospital stay increased... quality of life

Question 124

what vaccine is important for people with heart disease?

Answer 124

flu vaccine

Question 125

angioedema is a side effect of which medication?

Answer 125

acei's arb's

Question 126

why's bactrim bad for old people?

Answer 126

TMP/SMX more senstive to its effects - skin reactions, bone marrow problems, or high potassium... can have supratheraputic blood levels due to loss of renal capacity.

Question 127

what is procalcitonin and why is it clinically significant?

Answer 127

precursor to calcitonin released by the thyroid parafollicular cells -> rises in response to infection especially of bacterial origin, best studied in respiratory conditions like pneumonia

Question 128

at what CRP level would you expect infection?

Answer 128

CRP > 120 likely bacterial

Question 129

Spiriva Atrovent Combivent Dulera Symbicort

Answer 129

S - Tiotropum - anticholinergic A - Ipratropium - anticholinergic **COPD and asthma - less severe anticholinergic SEs than oral...include dry mouth sedation..headache C - Ipratropium with Albuterol D - Mometasone / formoterol - steroid and long acting b-agonist - COPD S - budesonide / formoterol - similar to dulera

Question 130

Acapella

Answer 130

a rehabilitative breathing device for bronchitis and for clearing mucous secretions.

Question 131

how to treat COPD exacerbations?

Answer 131

prednisone 40-50mg q5 days and Abx

Question 132

DDx for inborn disorders of hypercoagulability

Answer 132

factor 5 leiden - resistent to cleavage by protein C which encourages clotting, 6% of white people, rare in others. protein C&S deficieny AT3 deficiency - inactivates thrombin, selective proteinuria in nephrotic syndrome. Antiphospholipid syndrome - placental ischemia and multiple miscarriages is the presenting sign. lupus anticoag, anti-b2-glyocoprotein-1 or anti-cardiolipin hyperhomocysteinemia - increases coagulability increased fibrinogen / d-dimers malignancy CHF / A.Fib Obesity Varicositiy

Question 133

Fentanyl Dilaudid Percocet Lortab Demerol

Answer 133

**In Descending potency** D - hydromorphone - very potent opiod - more potent than morphine F - potent opiod with rapid onset and short duration - 80-100x more potent than morphine, transdermal patch in chronic pain tx - SE: diarrhea, nausea, constipation, dry mouth, somnolence, confusion, asthenia (weakness) P - oxycodone/paracetamol (acetominophen) L - vicodin - hydrocodone/paracetamol (acetominophen) D - meperidine - less potent than morphine oxycodone and hydrocodone (codeine derived - methylated morphine) have similar properties - hydrocodone is more likely to cause constipation and stomach pain hydromorphone (morphine derived)

Question 134

constricted pupils dilated pupils nystagmus

Answer 134

constrition - miosis - opiods / heroin dilation - cocaine, decongestants / meth, weed, hallucinogens nystagmus - PCP, inhalants, depressants

Question 135

whats the difference in presentation of an atypical migraine resulting in focal neurologic defecits and tia/stroke? where does a pure motor stroke occur? where does a pure sensory stroke occur?

Answer 135

onset - migraine comes on slower, stroke is immediate! motor - internal capsule sensory - thalamic

Question 136

what are the steroid dose equivalents? Dexamethdasone > methylprednisone (solumedrol) > prednisone/nisolone > hydrocortisone

Answer 136

H - 20mg P/P - 5mg M - 4mg D - 0.75mg

Question 137

minoxidil

Answer 137

androgen induced hair loss therapy to vertex only originally developed as a vasodilator for hypertension side effects include may initially cause hair loss to area of application, vasodilatory effects, and hypersensitivity to the drug or vector (vehicle - alcohol/propylene glycol)

Question 138

relative polycythemia

Answer 138

a type of secondary polycythemia - > apparent rise in RBCs in blood... with actual cause being reduced blood plasma. Gaisbock syndrome - hypertension in obese men -> reduced plasma volume, especially sedentary lifestyles and high caloric intake.

Question 139

Tagamet Remeron

Answer 139

T - cimetidine - H2 blocker prevents release of HCL in stomach for GERD related ulcers R - mirtazapine - antidepressant / antiemetic

Question 140

chigger bites

Answer 140

remember what these look like - they are the little red bugs that are found in grass and crawl on you almost imperceptibly tx - topical hydrocortisone or benadryl

Question 141

is it peripheral neuropathy?

Answer 141

if it's painful all the time, yes if it's relieved by raising the feet, no, then it's venous insufficiency -> horse chestnut extract

Question 142

herpes infections of the eye...

Answer 142

herpes zoster ophthalmicus - CNV3 distribution - a variant of shingles - herpes simplex keratitis - geographic epithelial defects on florescien stained conjunctiva

Question 143

discoid lupus erythematosis

Answer 143

tends to prefer the face - sores with inflammation

Question 144

Diarrhea DDx in elderly person

Answer 144

Clostridium difficile Abx associated Norwalk / Norovirus

Question 145

Bouchard's nodes Heberden's nodes Trigger finger

Answer 145

B - proximal interphalangial joints - H - distal interphalangial joints - arthritis most commonly osteoarthritis, more common in women T - a type of tenosynovitis where the flexor tendon becomes larger than the flexor retinaculum, tx - steroids x2, then surgical release of the retinaculum

Question 146

where is alk phos found / released?

Answer 146

liver, bone, intestine, placenta if questioning do a fractionated alkphos

Question 147

what Abx for diabetic foot ulcer?

Answer 147

Levoquin - aerobics | Flagyl - anaerobics (don't drink on dis shiz)

Question 148

what disease is associated with dermatitis herpetiformis?

Answer 148

celiac's disease

Question 149

Doxycycline

Answer 149

not for kids for lyme disease, but yes for kids with RMSF works as antibiotic and antiinflammatory

Question 150

who are some people who don't show fevers as well..

Answer 150

Elderly CKD Steroids Tylenol

Question 151

Hypertrichosis Hypotrichosis Hirsuitism Alopecia Areata Greying Hair

Answer 151

Hypertrichosis - excessive hair growth, aka Ambras syndrome - anorexia/bulimia, hypothyroid, drugs (minoxidil, phenytoin, hydrocortisone) Hypotrichosis - may be a sign of hypopituitarism, or drugs that block testosterone Hirsuitism - androgen mediated excess in hair, androgen secreting tumor, cushings, PCOS, late onset CAH, drugs... Alopecia Areata - autoimmune hair loss, may accompany trachyonychia (sand paper nails), or ophiasis (wedge shaped hair loss) ... commoner in children and female.. can happen to anyone at anytime Greying Hair - age related, albinism, vitiligo, pernicious anemia, chloroquire Tx *treatment of hair loss, locks of love, minoxidil...

Question 152

Acanthosis nigricans

Answer 152

ACTH stimulates melanin production as well as melanocyte stimulating hormone... excess androgen (cushings, acromegaly, PCOS) insulin resistance / often obesity related - increased insulin (due to resistance -> increase IGF-1 stimulation of keratinocytes hereditary - FGF variants Malignancy - GI adenocarcinoma, GU cancers of prostate, breast, ovary..increased TGF -> epidermal tissue. **acral acanthotic anomaly -> limited to elbows, knees, knuckles and dorsum of feet -> normal in the abseonce of other findings, ie healthy people.

Question 153

brown skin conditions

Answer 153

hemosiderin deposits from hemochromatosis stasis dermatitis - brown pigmentation from venous insufficiency (gets better with elevation - tx horse chestnut extract) acanthosis nigricans - endocrine, hereditary, benign, malignancy

Question 154

blue skin conditions

Answer 154

Arggria - silver salts - blue gray Ochronosis - alkaptonuria -> black accumulations due to lack of homogentisate oxidase - over pinnae, tip of nose, black extensor tendons of hands Chrysoderma - occasional parenteral administration of gold salts in arthritis tx -> blue/grey skin

Question 155

yellow skin conditions

Answer 155

Jaundice, Icterus, Bilirubinemia Carotenemia - orange skin, mangos, apricots, carrots, green veggies.. or inability to metabolize carotene due to liver failure.. or in myxedema or DM

Question 156

Windkessel

Answer 156

german to english means air chamber but generally taken to mean elastic reservoir

Question 157

ABPI

Answer 157

ankle brachial pressure index > 1.3 - 1.5 is diagnostic of PVD, medial calcific sclerosis, atherosclerosis... et al.

Question 158

Panniculitis

Answer 158

inflammation of subcutaneous adipose tissue - tender skin nodules and systemic signs including weight loss and fatigue.. associated with SLE, A1AT deficiency, scleroderma, pancreatic dz,

Question 159

calciphylaxis

Answer 159

skin necrosis from ca precipitation in tissues

Question 160

low RDW with target cells on blood smear...

Answer 160

little variation due to genetic disease -> thallassemia

Question 161

sideroblasts

Answer 161

nucleated RBCs from the marrow with iron laden mitochondria forming a ring around the nucleus due to an inability to incorporate iron into hemoglobin

Question 162

high homocysteine normal methylmalonic acid (MMA)... high homocysteine and high methylmalonic acid (MMA)...

Answer 162

folate deficiency - macrocytic, may also see hypersegmented neutrophils vitB12 deficiency - macrocytic, may also see neurologic signs

Question 163

direct bilirubin indirect bilirubin

Answer 163

conjugated, made and comes directly from the liver, high in bile duct obstruction if indirect / unconjugated bilirubin is high this suggests increased hemolysis.

Question 164

minute volume

Answer 164

the volume of gas inspired or expired from the lungs per minute... although it sounds like a measure of volume it is actually a measure of flow (v/min)

Question 165

causes of shock included

Answer 165

decreased pre load (hypovolemic) decreased cardiac output (cardiogenic) decreased SVR (septic/anaphylactic/drugs/toxins)

Question 166

dopamine

Answer 166

10ug/kg/min - A1 agonist - vasoconstriction (^ SVR)

Question 167

dobutamine

Answer 167

B1 > B2 primarily inotropic (contractility) and chronotropic (rate) stimulator some level of vasodilation (via B2 stimulation)

Question 168

Plaquenil

Answer 168

P - hydroxy chloroquine - used for malaria, RA, lupus and others - can cause retinal toxicity though but verify both daily dose and lifetime exposure to calculate risk in a patient.

Question 169

Palindromic RA

Answer 169

RA that comes and goes and bops around to different locations...

Question 170

what is a fund and interesting treatment for vestibular dysfunction?

Answer 170

valium otherwise meclizine

Question 171

Estimating TBSA for burns... Degrees of burns - 1st, 2nd, 3rd, 4th

Answer 171

use rule of 9s 1st - epithelial layer 5-10 day heal time 2nd - epidermis, supeficial dermis - blisters, deeper dermis may scar, blisters cilcoprix3rd - epidermis, dermis, subQ fat 4th - epidermis, dermis, subQ fat, mucles/tendons

Question 172

a good topical NSAID for burns or skin pain

Answer 172

Voltaren - diclofenac - also used for AKs, arthritis

Question 173

seborrheic dermatitis chronic actinic dermatitis seborrheic keratosis actinic keratosis lentigo senilis stasis dermatitidis

Answer 173

SD - dry flakey scaley itchey red skin inflammation, found on babies and is called cradle cap - particularly effects areas with sebaceous glands - Tx ketoconazole, ciclopirox, selsun blue CAD - a chronic skin condition where the afflicted's skin gets inflammed with exposure to sunlight. SK - benign nodular pigmented lesions with "stuck on" appearance that originate in keratinocytes AK - aka solar keratosis - precancerous patch of thick scaly or crusty skin -> form squamous cell carcinoma LS - liver spots, solar lentigo - freckles or blemishes in the skin associated with normal aging and exposure to UV light - not actually caused by the liver or liver disease StD - hemosiderin laden hyperpigmentation from increased extravasation and hemolysis due to venous insufficiency

Question 174

Langer Lines

Answer 174

lines of tension for excisions and incisions use 3:1 ratio for excisional biopsy, make single swipe verses multiple little hashes, sew towards yourself

Question 175

empirical pseudomonas treatments

Answer 175

beta-lactam (cefipime, ceftazamine) with an amino glycoside (gentamycin) ciprofloxacin is a good treatment zosyn - piperacillin/tazobactam - especially for critically ill patients

Question 176

Chronic alcohol consumption has what two effects on lab studies

Answer 176

decreased Mg/K bone marrow suppression (pancytopenias)

Question 177

beta1 selective-blockers - MANBABE

Answer 177

metoprolol atenolol nebivolol bisoprolol acebutolol betaxolol esmolol decrease heart rate more than they decrease BP (rate controllers)

Question 178

scopolamine

Answer 178

s - muscarinic antagonist - good for N/V post operatively, also good for drying up secretions in people who are in the active dying process

Question 179

bird fancier's lung vs parrot fever

Answer 179

BFL - a hypersensitivity pneumonitis - caused by bird droppings, lungs become inflammed with granulomatosis - can have ground glass radiography, fibrosis, may have s/s within a few hours of exposure acutely or chronic exposure can lead to fibrotic changes....treated similarly to allergies / asthma - beta-agonists/steroids PF - psitticosis - chlamydiophila psittaci - contracted from infected parots (macaws cockatiels) and from, pidgeons, sparrows, ducks, hens...presents as atypical pneumonia can have low white count early, Horder's "rose" spots, splenomegaly and/or epistaxis - tx doxy/tetracycline

Question 180

what is the blood sugar range you keep people in ICU or higher acuity settings?

Answer 180

keep them higher rather than lower - 140-180s this improves mortality rather than risking hypoglycemic conditions (high blood sugar is bad long term, low blood sugar is bad short term)

Question 181

neutropenic fever

Answer 181

aka febrile neutropenia - single temp > 38.3 or 1 hour > 38 with neutropenia... generally recognized as a complication of chemotherapy where there is supression of the bone marrow. treat with empiric antibiotics, treatment may need to continue for 2 weeks if it's unresolved, no change in fever after 72 hours add antifungal

Question 182

Ranson Criteria GALAW and CHOBBS (48 hrs after admission) - non-gallstone ileus

Answer 182

predicts the severity of pancreatitis - GALAW at admission, CHOBBS within 48 hours ... ``` Glucose >200mg/dL AST > 250 IU/L LDH > 350 IU/L Age > 55 WBCs > 16k ``` ``` Calcium < 8.0 mg /dL Hematocrit fall > 10% PaO2 < 60 mmHg Base Deficit > 4 mEq/L BUN > increased by 1.8 or more after IVFs Sequestration > 6L ```

Question 183

when is it a bad time to use bactrim?

Answer 183

if the patient is on an ACEI, elderly folks

Question 184

dihydroperidine CCBs vs non-dihydroperidine CCBs

Answer 184

DHP - "-dipine" amlodipine - dipin down the blood pressure / reduce systemic vascular resistance - SEs - edema, dizziness/HA/redface, constipation, gingival overgrowth NDHP Phenylalkylamines - verapamil - selective for myocardium used to reduce myocardial O2 demand and reverse coronary vasospasm for angiina Benzothiazepines - Cardizem - diltiazem - intermediary between DHP and NDHP - decreases SVR and reduces reflex tachy Gabapentinoids - gabapentin/pregabalin - epilepsy/neuropathic pain

Question 185

intrathecal route....

Answer 185

directly into CSF

Question 186

what antibiotic is bad to mix with amlodipine?

Answer 186

clarithromycin - leads to severe hypotension

Question 187

Loop Diuretics

Answer 187

furosemide - Lasix - use a K supplement...

Question 188

K sparing diuretics

Answer 188

spironolactone - aldosterone antagonist, anti-androgen - diuretic, treats hypokalemia, secondary hyperaldosteronism (in cirrhosis), conn's syndrome (primary hyperaldosteronism) eplerenone - similar to spironolactone but much more selective for the mineralcorticoid receptor (used mostely for diuresis) amiloride - blocks ENaC in distal tubule, collecting ducts - promotes sodium and water loss and K sparing triamterene - Dyazide (when combined with HCT) - same as amiloride **Careful if using salt replacements as they often contain KCL

Question 189

treating hypertension in pregnancy

Answer 189

1ST LINE - Labetolol 200-2400 mg/day also - methyldopa, nifedipine * thiazides only ok if already on them prior to gettin pregs * ACEs/ARBs - contraindicated d/t teratogenicity

Question 190

what are a few causes for posterior shoulder dislocation

Answer 190

electrocution, epileptic seizure, motorcycle accident

Question 191

malingering Munchausens factitious disorder somatic symptom disorder illness anxiety disorder conversion disorder

Answer 191

M - faking it and they know they're faking it and they know why they're faking it - usually to get out of something M - hospital addiciton syndrome, thick chart syndrome - unclear whether or not these folks know they're doing it or not. F - deliberately producing symptoms to be cared for or treated SSD - have symptoms but they are not real - includes conversion, IAD, body dysmorphia, pain disorder IAD - excessively worrying about getting a disease C - converting emotional stress into physical symptomology, can be discovered when sx dont match any neuromuscular disease

Question 192

spinal muscular atrophy - I (infantile), II (intermediate), III (juvenile), IV (adult onset)

Answer 192

I - werdnig-hoffman dz II - dubowitz dz III - kugelberg-welander dz IV - adult * AR defect in SMN1 gene (most common genetic cause of infant death) necessary for survival in motor neurons, loss of protein causes loss of anterior horn cells with system wide muscle wasting, proximal muscle wasting first * loss of motor without loss of sensory

Question 193

apoplexy

Answer 193

loss of consciousness due to intracranial hemorrhage or stroke

Question 194

anasarca

Answer 194

wide spread soft tissue edema

Question 195

loperamide

Answer 195

weak narcotic with no CNS activity but still has the side effect of slowing the bowels... used for diarrhea

Question 196

Valium Xanax Ativan Versed

Answer 196

V - diazepam - PO/IV Rapid Onset - peaks in 1 hour - 20-50hr t1/2 X - alprazolam - PO Intermediate - peaks in 0.5-1.5hr - 6-20hr t1/2 A - lorazepam - IV Rapid, PO Intermediate - peaks in 1-1.5hr - 10-20hr t1/2 V - midazolam - IV Most Rapid - peaks in 0.5-1 hr - 1-4hr t1/2

Question 197

Lyrica vs Gabapentin

Answer 197

L is the brand name, more expensive and may be habit forming. gabapentin is the generic *a type of CCB

Question 198

N-acetyl-cysteine Guaifenesin

Answer 198

N - tylenol OD / expectorant / thins secretions G - expectorant - unknown MOA but increases volume of secretions and decreases viscosity of secretions - SE N/V/D/C kidney stone ... take with lots of fluids

Question 199

SLE treatments

Answer 199

hydroxychloroquine, methotrexate

Question 200

Mesenteric Ischemia

Answer 200

acute abdominal pain, risk factors for thrombosis (afib, CHF, CKD, MI) 4 mechanisms - blood clot forms somewhere else and travels to mesenteric bowel, clot forms within bowel artery, clot forms in bowel vein, decreased perfusion d/t low pressure or arterial spasm. dx - clinical picture, CT with dilated loops of bowel tx - stenting, anticoags/thrombolytics, intervential radiology/surgery.

Question 201

what is the treatment for hepatic encephalopathy?

Answer 201

lactulose - laxative that also decreases excess ammonia production from gut bacteria + Spironolactone / Lasix (100/40mg starting up to 4x this each)

Question 202

Treatment for aspergillus? Treatment for PCP pneumonia?

Answer 202

steroids bactrim

Question 203

Celebrex parecetamol Florinef Pravachol Sinemet

Answer 203

Celecoxib - selective cox2 inhibitor - useful NSAID that does not increase bleeding risk - anti-pyretic, analgesic, anti-inflammatory reactions. P - tylenol/acetominophen F - fludrocortisone - treats hypotension - corticosteroid with moderate glucocorticoid activity and potent mineralcorticoid activity. (basically an aldosterone analog) P - pravastatin - lowest incidence of aches and pains or side effects... try with coQ10 S - levodopa/carbidopa

Question 204

Premarin

Answer 204

pregnant mare urine - conjugated estrogens - HRT - treats hot flashes in women with hysterectomy as well as burning, itching, and dryness of vaginal areas SE - yeast infections, vaginal spotting/bleeding, painful menses, cramping of the legs

Question 205

Otezla

Answer 205

O - apremilast - PDE4 inhibitor, which inhibits TNFa production from human rheumatoid synovial cells... anti-inflammatory. Psoriatic Arthritis, Plaque Psoriasis, AnkSpondy, Behcets, RA

Question 206

Pathergy

Answer 206

a skin condition where even a small bump or trauma to the skin leads to formation of lesions or ulcers... Behcets and Pyoderma gangrenosum

Question 207

stachybotrys

Answer 207

black mold/toxic black mold - found in places with poor indoor air quality especially water damaged building materials... bleach is recommended to remove the mold.

Question 208

enthesopathy

Answer 208

disorder involving the attachment of tendon or ligament to bone. the site of attachment is known as the entheses. If it is know to be inflammatory it's called enthesitis... similar to continuum distortion.

Question 209

ESR vs CRP

Answer 209

ESR - increases in the presence of inflammation when increased fibrinogen causes RBCs to stick together. Userful for PMR and Temporal Arteritis. signals more of a chronic inflammatory process. CRP - made in liver, binds phosphocholine on dead or dying cells (apoptotic) to activate the complement and immune system (to enhance phagocytosis by macrophages). rises within 2 hours of insult half life is constant at 18 hours.

Question 210

what is one way to reduce side effects of methotrexate?

Answer 210

take folic acid supplements with low dose MTX used for arthridities... high dose MTX is useful for malignancy... 5-27.5 mg / week folic acid with 24 hours after MTX dose

Question 211

Midodrine Florinef Octreotide

Answer 211

M - vassopressor / antihypotensive agent - alpha-1-agonist - does not cross CNS so there are no CNS side effects... Uses - symptomatic orthostatic hypotension... has been used with ostreotide for hepatorenal syndrome. SEs include normal sympathetic responses (dry mouth, flushing, feeling pressure/fullness in the head) F - fludrocortisone - treats hypotension - corticosteroid with moderate glucocorticoid activity and potent mineralcorticoid activity. (basically an aldosterone analog) O - somatostatic mimetic - more potent inhibition of GH, Glucagon and Insulin than natural hormone. Treats gigantism/acromegaly, diarrhea/flushing assoicated with carcinoid syndrome, and diarrhea in people with VIPomas

Question 212

Pseudotumor Cerebri NPH Tonsillar Herniation Central Pontine Myelinolysis

Answer 212

PC - aka idiopathic intracranial hypertension - increased intracranial htn in the absence of clear etiology (papilledema blindness more common in women) NPH - incontinence, ataxia, dementia TH - rapid correction of hypernatremia - water moves from blood to brain (swells) causes cerebral edema, tonsillar herniation, or multiple cerebral hemorrhages... in TH the cerebellar tonsils press through foramen magnum and compress the brain stem. CPM - rapid correction of hyponatremia - water moves from brain to blood (shrivels) correct sodium at a rate of no more than 12-20 mmol/L sodium per day. Damage to the myelin sheath -> acute paralysis, dysphagia, dysarthria

Question 213

Depakote Tegretol Keppra

Answer 213

D - Valproate - anticonvulsant and mood stabilizer - epilepsy, bipolar, migraine prophylaxis - MOA - many different binding sites, GABA/sex steroid receptor binders, PIP3 reduction... SE - NVD, diplopia, thrombocytopenia T - carbamazepine - epilepsy, schizophrenia, neuropathic pain, not effective for abscence seizures or myoclonic seizures... SEs - nausea, drowsiness, aplastic anemia, seizures if you stop taking it suddenly, spina bifida for pregnant women. K - levitiracetam - apilepsy

Question 214

leuko. .. neutro. .. Left shift -

Answer 214

leukocytosis neutrophilia LS - baby WBCs indicate infection vs demargination for example

Question 215

Sicca vs Sjogrens

Answer 215

Sicca - dryness of the exocrine glands particularly the eyes and mouth, it is just a symptom complex. Can be caused by sjogrens, radiation tx to the head, certain medications, HepC/HIV Sjogren's - may affect any organ in the body that secretes moisture, saliva, tears, nasal passages, sinuses, throat, skin, vag

Question 216

what effect does HCT have on uric acid in the urine? Ca in the urine?

Answer 216

decrease both. Thiazides increase uric acid in the serum and Ca in the serum. *acute gout can be caused by a rapid drop in serum Uric acid but not sure how..

Question 217

Ramsey Hunt Syndrome type II - three types exist

Answer 217

reactivation syndrome of herpes zoster in the geniculate ganglion - variable presentation including facial nerve lesion, deafness, vertigo, and pain. Triad - ipsilateral facial paralysis, ear pain, vesicles in auditory canal.

Question 218

ABCDEF of delirium prevention and management in the ICU

Answer 218

A - assess/manage pain B - breathing (ventilator interruption) and awake (sedative interruption) trials (spontaneous) C - choice of sedation and analgesia - use a sedation scale and agree to depth of sedation (RASS scale) +1 restless (to +5) and -1 is drowsy (to -5).... anything -3 and up are ok to proceed with CAM D - Delirium assessment - see next card E - Early mobility and exercise F - family involvement - critical illness of a loved one can be profoundly traumatizing for all involved.

Question 219

steps in the CAM-ICU

Answer 219

confusion assessment method - ICU 1. Acute change or fluctuation of Mental Status? yes move on 2. Inattention - Sqeeze when I say "A" .. SAVEHAART. >2 errors move on 3. Altered LOC - RASS - at or above -3 but not 0? -> Delirium ... if RASS is 0 move to step 4 4. Disorganized Thinking - Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two? Can you use a hammar to pound a nail? Hold up two fingers ask pt to repeat, then ask to do on other hand >1 error = delirium

Question 220

Saphris

Answer 220

S - asenapine - atypical antipsychotic used for tx of schizophrenia and acute mania of bipolar disorder. SE - somnolence, weight gain, appetite, weight gain, dysgeusia (distortion in sense of taste)

Question 221

Who has berry aneurysms? When do you look for HFE gene mutations?

Answer 221

PCOS, ADPKD, NF1, Marfan, Ehlers-Danlos, hereditary hemorrhagic telengiectasians.... don't treat with coumadin HFE - hemachromatosis

Question 222

1 pound of fat forces the heart to pump through how much capillaries? 1 pound of fat takes what weight off the knees?

Answer 222

7 miles of capillaries 4 pounds of weight loss

Question 223

tolerance to opioids includes loss of analgesia but not loss of what other opioid effect?

Answer 223

constipation

Question 224

What are the two general agents used for constipation?

Answer 224

push and mush

Question 225

Push agents?

Answer 225

Senna - tree bark - natural, stimulates myenteric plexus - 8.6mg QHS (bed time) Bisacodyl Metoclopramide - 5HT agonist - good for gastroparesis, prokinetic - can cause dyskinesia tx with benadryl

Question 226

Mush agents?

Answer 226

colace / docusate - ^ water absorption in stool "stool softener" Osmotics - lactulose, sortbitol, mannitol, glycerin, Miralax (PEG), **watch electrolytes Saline Agents - MgOH / MgSulfate (milk of mag) **watch renal failure Bulking Agents - metamucil / fiber **not good if bed bound Lubricants - mineral oil.... really? not really used.

Question 227

Enemas? Naturals?

Answer 227

Enema - saline, soap suds, oil - retain enema 15 minutes Naturals - prunes, dates, figs, raisins, apples, senna

Question 228

Opiod Antagonists? Post-op ileus?

Answer 228

Methylnaltrexone -like narcan for the bowel - subQ every other day for opiod induced constipation Alvimopan - post-op ileus

Question 229

What kind of deficiencies will you see in celiacs? How does celiacs present? What's the diagnosis of celiacs?

Answer 229

Iron deficiency anemia, VitD, vitB12 due to absorption problems presents with weight loss, iron deficiency anemia, thin frail osteoporitic/bone pain, osteomalacia, fatigue, muscle aches, odd constitutional symptoms Dx - gluten challenge followed by elisa (anti-gliadin ab) -> endoscopy might be negative if already on GF diet or if they have a IgA deficiency -> if highly suspicious can do a genetic screen

Question 230

CT Urogram

Answer 230

CT of the kidneys and bladder to detect blood, stones and cancer.. watch for allergies to contrast material

Question 231

verrucous verrucous carcinoma

Answer 231

verricose - wart like verrucous carcinoma - snuff dippers cancer, oral pharyngeal

Question 232

condyloma accuminata condyloma lata

Answer 232

A - HPV - warts L - syphilis warts

Question 233

exanthema

Answer 233

skin rash accompanied by fever

Question 234

Echo virus

Answer 234

enteric cytopathic human orphan - RNA picoviridae - GI tract, exposure causes opportunistic infections - most common cause of aseptic meningitis, Males and children, high mortality if first couple weeks of birth, death by liver failure or myocarditis. Rash that covers face trunk extremities. Dx serum Abs. Ts - fecal oral, overcrowding.

Question 235

Borrelia Babesia Ehrlichia

Answer 235

Borrelia burdorferi - spirochete - lyme disease - erythema migrans - great mimic - doxy unless opportunistic infections, toxic shock like syndrome - doxy Babesia - protozoan - causes malaria like syndrome (irregular fevers, lethargy, pain, malaise) - fatal in 8 days if no spleen - atovaquone and azithromycin -> blood exchange transfusions if severe Ehrlichia - rickettsial - "spotless RMSF" - HME human monocytic ehrlichiosis - (south east and northeasy) vs. HGA (anaplasma phagocytophilum) more common in US and midwest -> fever, NO-rash, leukopenia, thrombocytopenia -> watch for renal failure and myocarditis/pericarditis.

Question 236

Anthrax vs Plague vs Tularemia vs Tuberculous Lymphadenitis

Answer 236

Anthrax - ulcer with black base, pruritic Plague - lymphadenopathy, toxic appearing Tularemia - purple ulcerative lesions that painful not pruritic Tuberculous Lymphadenitis - enlarged nodes often of the cervical chain

Question 237

Methacholine challenge

Answer 237

methacholine (M3) or histamine (H1) are used to invoke broncho constriction in the dx of asthma

Question 238

Leuprolide

Answer 238

GnRH agonist -> interrupts normal pulsatile stimulation of GnRH receptors leading to indirect downregulation -> hypogonadism (drop of T and E) Tx - breast and prostate cancer and precocious puberty

Question 239

Rhus Dermatitis

Answer 239

toxicodendron poisoning - poison ivy, sumac, oak - boils on erythematous base

Question 240

T1 weighted T2 weighted

Answer 240

T1 - high fat tissue (white matter) appear bright, fluid (CSF) appears dark T2 - fluid bright, fat tissue dark

Question 241

Milrinone Afterload Preload

Answer 241

PDE3 inhibitor -> increased cAMP... ionotropic, vasodilatory (decreased afterload) Afterload - the pressure in the aorta and pulmonary artery that must be overcome to eject blood from the heart. Increased by anything that stenoses vasculature. SVR Preload - the stretch placed on the heart just prior to contraction, atrial pressure serves as a surrogate to preload, EDV end diastolic volume is more useful clinically.

Question 242

what lab test can be used to trend sarcoidosis?

Answer 242

ACE

Question 243

diastolic apical rumble and opening snap late systolic murmur with midsystolic click apical blowing holosystolic murmur, radiates to axilla

Answer 243

mitral stenosis MVP MR

Question 244

diastolic rumble, louder with inspiration blowing holosystolic murmur at left sternal border, louder with inspiration

Answer 244

tricuspid stenosis tricuspid regurg

Question 245

blowing early diastolic; austin flint (apical diastolic rumble), mid systolic flow murmur at base midsystolic crescendo-decrescendo at second right interspace, radiates to carotids and apex with S4 due to atrial kick

Answer 245

AR - wide pulse pressure (pulsus bisferiens) AS - peripheral pulses weak and late, systolic thrill second interspace

Question 246

systolic murmur at apex and left sternal border that is poorly transmitted to carotids

Answer 246

HCM - increases with standing and valsalva - if you find a systolic murmur have them valsalva and if it gets worse them HOCM.

Question 247

wide, fixed split S2 paradoxical split S2 physiologic split S2

Answer 247

ASD heard during expiration (not inspiration), occurs in the setting of delayed aortic valve closure (AS, LBBB, HCM) physiologic split - P2 closes late on inspiration due to increased venous return and decreased left output

Question 248

Protein C and S deficiency

Answer 248

proteolyzing Factor 8 and Factor 5 -> preventing activation of X and Prothrombin -> anti-coagulant properties... if lost -> coagulation S/S - PE, DVT, Fetal Loss Tx - warfarin with heparin bridge, bridge necessary because C and S activity drop first (loss of anti-coagulant action - > increased thrombosis risk)

Question 249

Warfarin (WARF- WI-Alumni-Research-Foundation) -arin (coumarin - from tonka beans)

Answer 249

inhibits vitamin k dependent carboxylation of coagulation factors - 2,7,9,10 (pro-coagulant) C, S (anticoagulant) - by inhibiting recycling of vitaminK originally a rat poison, can be augmented by leafy greens (high vitK) takes 3-5 days to work, and 3-5 days to stop working Uses - Afib, heart valves, DVT, PE, Anti-phospholipid Syndrome...***Useful for clotting where there is blood stasis*** agents for arterial clotting are anti-platelet drugs Other Similar agents - dabigatran, rivaroxaban, apixaban - don't need to monitor but cannot be reversed. Target INR - usually 2-3 or 2.5-3.5 in mech heart valves Contraindicated in preggers - 1st trimester fetus can bleed, teratogenicity. Less bad later on. Side Effects - Hemorrhage (especially INR>4.5), Warfarin Necrosis (especially after first starting tx d/t thrombosis d/t early inactivation of anticoagulant protein C), osteoporosis, purple toe syndrome, ***vascular calcification***

Question 250

Purple Toe Syndrome

Answer 250

cholesterol embolism released from atherosclerotic plaque -> livedo reticularis, gangrene, renal failure (atheroembolic renal dz) statins can help

Question 251

livedo reticularis erythema ab igne livedo dermatitis rhinitis medicamentosa

Answer 251

LR - mottled reticulated vascular pattern with lace like purplish discoloration of the skin... d/t swelling of venules owing to obstruction of capillaries and blood clots. EAI - aka livedo reticularis e calore - rash d/t prolonged exposure to heat. LD - embolia cutis medicamentosa, Nicolau syndrome - iatrogenic reaction immediately after drug injection, immediate extreme pain, with overlying skin rapidly becoming erythematous, violaceous, or blanched... eventually leads to necrosis, heals but can by atrophic and scarred. RM - rhinitis caused by overuse/addiction to topical intranasal decongestants (Afrin)

Question 252

D-dimer

Answer 252

acute phase reactant & fibrin degradation product, shows a resolving clot when elevated (not elevated if clot is epithelialized / healed clot) used to diagnose DVT, PE, or DIC.. Wells Score - predicts probablity of DVT / PE

Question 253

gynecomastia ddx

Answer 253

``` Liver Disease (estrogen release) Spironolactone (blocks androgen receptors) ```

Question 254

Dissociative Fugue

Answer 254

reversible amnesia for personal identity - memories, personality, and other identifying characters - usually short lived (hours to days but can last months or longer) - usually involved unplanned traveling or wandering, sometimes accompanied by a new identity. after fugue memories return, though the event and the precipitating factor (the acute stressor) usually are forgotten.. typically accompanies dementia, delirium, dissociative identity disorder, or psychotropic meds typically a retroactive diagnosis (after people "return" from fugue state)

Question 255

Achalasia Diffuse Esophageal Spasm Web Schatsky Ring Chagas Dz Zenker's Diverticulum Plummer Vinson Syndrome Pseudoachalasia

Answer 255

Achalasia - bird's beak, dysphagia to solids and liquids Diffuse Eso Spasm- corkscrew or nut cracker esophagram, can be caused by scleroderma Web - small membrane of tissue in semi circle distribution that obstructs esophagus Schatsky Ring - narrowing of the lower esophagus that can cause dysphagia Chagas - T-cruzi, reduviid kissing beetle - south america to tx - mega heart, mega colon, mega esophagus (atonic esophageal body with non-relaxing LES) - dx serologic - tx nifurtimox & benznidazole Zenker's - pharyngeal diverticulum, just above the cricopharyngeal m. false diverticulum. Halitosis, cough, regurgitation Plummer Vinson - dysphagia, iron deficiency anemia, esophageal webs - postmenopausal women - increased risk of SqCC of the esophagus..tx with correcting anemia, improve dysphagia, remove obstruction Pseudoachalasia - Gastroesophageal junction obstruction or tumor (rapidly progressive, younger patients, profound weight loss)

Question 256

Triple-A-syndrome

Answer 256

Adrenal Insufficiency Alacrima Achalasia AR genetic dz, with rare family history...

Question 257

which way is the shunt in VSD?

Answer 257

right to left... (LV to RV to Pulmonary to LA to LV) -> LVH if you hear a carotid bruit rule out radiating AS before concluding that you have carotid obstruction and ordering carotid duplex

Question 258

hyperpigmentation of the legs with hypotrichosis? hypotrichosis with weak reflexes?

Answer 258

stasis dermatitidis -> hemosiderin from blood cell extravasation, lysis and macrophage uptake... hypothyroidism

Question 259

Hypererythema

Answer 259

blanching, temperature, atrophy, ulceration - think nutritional (VitC - remember collagen) (Zn - necessary cofactor - especially if desquamating) check tongue for lingual papillae atrophy, loss of taste, wound healing delay

Question 260

when should you avoid inducing vomitting?

Answer 260

oily solvents because they can cause aspiration pneumonitis...

Question 261

port wine stain in trigeminal distribution is associated with what condition?

Answer 261

Sturge Weber Syndrome - intracranial calcifications, port wine stain, Glaucoma, Seizures, MR

Question 262

Neulasta

Answer 262

N- Pegfilgastrim - stimulates WBCs in neutropenia

Question 263

Bebulin

Answer 263

better than FFP because its got better QC (manufactured vs pooled plasma) but it's spendy HepC was discovered in transfusions, used to be called non-A/B Hepatitis

Question 264

MAT

Answer 264

multifocal atrial tachycardia - type of SVT - 3 or more Pwaves with variable morphology and varying P-R intervals + tachycardia + narrow QRS - associated with COPD exacerbations, common in smokers, wandering pacemaker WAP ... narrow QRS are visible as well. **acute MI, COPD, mg/k deficiency, digitalis, hypoxia, theophylline toxicity.

Question 265

what are you thinking if you see a Ca+ of 12 or more?

Answer 265

Hypercalcemia of malignancy until proven otherwise... start by looking at PTHrP then look for cancer

Question 266

Eosinophilic Urine is suggestive of what renal condition? how do you stain them eosinophils?

Answer 266

acute interstitial nephritis - infection or allergic reaction to analgesic or antibiotics (hypersensitivity) - 71-92% of cases are medication reactions - (PCN, Cephalexin, NSAIDs, Fluoroquinolones, Diuretics, Allopurinol, Phenytoin)...corticosteroids don't help, extra fluids, remove offending agent Hansel's stain - eosinophils

Question 267

Acamprosate (Campral) and Clonidine for which medical condition? Antabuse

Answer 267

alcohol withdrawal - acamprosate is a gaba agonist - clonidine is a central andrenergolytic Antibuse - Disulfiram - unpleasant reaction when drinking but causing buildup of..inhibits acetaldehyde dehydrogenase -> build up of acetaldehyde

Question 268

ESBL bugs

Answer 268

Extended Spectrum Beta Lactamase bugs - - - > beta lactamases that hydrolyze extended spectrum cephalosporins... cefotaxime, ceftriaxone, ceftazidime, aztreonam

Question 269

Pulmonary Edema

Answer 269

cardiogenic - Mitral Regurgitation, LV failure - or non-cardiogenic - injury to lung parenchyma - (hypertensive crisis, upper airway obstruction -> negative pressure edema, neurogenic - seizures, head trauma, strangulations, electrocutions)

Question 270

what do you use for UTI with sulfa allergy?

Answer 270

Trim-Sulfa out of the question (the mainstay) Macrobid - Nitrofurantoin - not effective for kidney infections though - also used for pregnant women - works by damaging bacterial DNA, drug activated by bacteria better than eukaryotic cells.

Question 271

Kerley Lines

Answer 271

interstitial pulmonary edema, suggestive of CHF or pulmonary fibrosis, heavy metal deposition in interstitium, carcinomatosis of the lung.. fibrosis or hemosiderin from recurrent pulmonary edema A Lines - longer unbranching, diagonally from hila - distention of anastomotic channels b/t peirpheral and central lymphatics of the lungs (only seen with B and C lines) B Lines - short parallel lines at lung periphery, interlobular septa, usually less than 1cm, peripheral in contact with pleura, more frequently at lung base C Lines - least commonly seen, short fine lines throughout lungs, reticular appearance

Question 272

stable vs unstable angina

Answer 272

stable - known about, predictable, consistent unstable - unknown, new onset, or change from previous condition... may make you think stemi/nstemi

Question 273

when do you prescribe a blood transfusion? what are the two determinants of O2 delivery?

Answer 273

when the Hb is less than 7 Hb and CO

Question 274

Oligoclonal Bands

Answer 274

high prevelance in Multiple Sclerosis, usually multiple bands... if single band consider plasma cell lymphoma... many other conditions can give oligoclonal bands.

Question 275

Transverse Myelitis

Answer 275

starts off with motor, sensory and/or autonomic dysfunction due to inflammation of the myelin tissue of the CNS. Presents especially with urinary retention. Idiopathic is most common, disease associated is less common but worse prognosis. Related to a spectrum of demyelinating autoimmune diseases including MS, neuromyelitis optica, acute disseminated encephalomyelitis. Dx - Suspect Myelopathy? r/o Compression (MRI), Confirm Inflammatory vs non-inflammatory (MRI with gadolinium, oligoclonal bands in CSF) Tx - with high dose steroids, plasma exchange, and cyclophosphamide.. other chronic immunomodulators can be used for high recurrance.

Question 276

erythema nodosum ddx

Answer 276

inflammation of fat underneath the skin - caused by... Infection - steptococcal infection, TB, Mycoplasma, Histoplasma, yersinia, EBV, coccidiodes immitus, cat scratch disease Autoimmune - Inflammatory bowel disease, Behcet's disease, Sarcoidosis. Pregnancy Meds - sulfonamides, penicillins, oral contraceptives, bromides, HepB vaccination. Cancer - non-hodgkins, carcinoid, pancreatic cancer

Question 277

Cat Scratch Disease

Answer 277

Bartonella henselae - found in children following a bit or scratch from a cat. Tender swollen lymph nodes, near site of inoculation... lots of constitutional s/s (HA, fever, aches, chills, myalgias, arthralgias, malaise, anorexia). rarely has serious sequela - meningoencephalitis, encephalopathy, seizures or endocarditis (endocarditis has a high mortality) -> bacilliary angiomatosis es. HIV pts. Dx - PCR, Tx - clear infection normally, but some immunocomprimised need abx

Question 278

Activated Clotting Time - ACT

Answer 278

a quick test that can be used to detect the time required to clot a sample of blood after addition of factor XII. It's a relative scale and requires a baseline value for a point of comparison due to inconsistency of activators being used. normal means blood has no heparin or all the heparin has been inhibited by protamine sulfate used to monitor unfractionated herparin may be affected by - warfarin, gp2b3a inhibitors (abciximab), aprotonin, severe thrombocytopenia (

Question 279

Intubation Mnemonic - SOAPIER

Answer 279

Suction O2 Airway - OPA, NPA, ET Tube Pharmacy - etomidate, proprfol (short acting), fentanyl, versed, ketamine, recuronium/pancuronium, succinylcholine IV- fluids for bolus if needed, vasopressors if needed Emergency plan - adjunct (laryngeal airway mask) Rescue plan - anesthesia

Question 280

Confirming intubation

Answer 280

X-ray Breath Sounds/ PaO2 Capnography

Question 281

what are the three cardinal features of delirium? each day of delirium has what effect on ICU mortality? always ask what about a patients medication list?

Answer 281

Delrium - acute onset, inattention, disorganized thinking each day of delirium increases risk of mortality by 10% always ask what can be discontinued

Question 282

what is the presentation of acute adrenal insufficiency? what is the conversion for decadron to hydrocortisone? what is the advantage of decadron?

Answer 282

hypoglycemia, hypotension, hypoNa, hyperK 0.75 D - 20 H the advantage is that decadron doesn't interfere with cortisol assays, so you can still assess the endogenous cortisol levels.

Question 283

P/F ratio

Answer 283

PaO2/FiO2 ratio - helps determine ARDS - a low P/F ratio indicates a lower arterial oxygen content derived from inhaled oxygen -> its a lung problem Mild 200-300 Moderate 101-200 Severe

Question 284

if you have blood drip down the esophagus or swallowed this is a very powerful what?

Answer 284

emetic, blood stongly stimulates emesis (powerful emetic)

Question 285

5 risk factors "I's" of DKA...

Answer 285

``` Iatrogenic Infection Inflammation Infarction Intoxication ```

Question 286

acidosis falsely elevates??? alkalosis falsely depresses??

Answer 286

acidosis elevates - K alkalosis depresses -K, Ca

Question 287

BiPAP - what, who CPAP - what, who when are these measures contraindicated?

Answer 287

BiPAP bilevel positive airway pressure - O2 in, CO2 out - both phases - COPD exacerbations, drying, no good for pneumonias CPAP continous positive airway pressure - O2 in only, symptomatic / decompensated CHF. **CIs - bleeding, vomiting or unable to remove mask in case of vomiting, restrained, must be awake alert, spontaneous.

Question 288

what's on your differential for lung edema?

Answer 288

blood, pus, or fluid... nothing else, figure it out.

Question 289

anion gap equation and meaning of high, normal and low

Answer 289

Na - (Cl+HCO3) 3-10 is normal High - anion gap suggests elevated acid anions (negative charge) like lactate, acetoacetate, b-hydroxybutyrate, acetone Normal - hyperchloremic, metabolic acidosis (vomitting, RTA 1n2, hypoaldosteronism) Low - hypoalbuminemia (albumin is negatively charged) leads to increase in Cl and HCO3 **Anion Gap drops 2.4 meq/L for each 1 g/dL Albumin loss**

Question 290

anion gap corrections: calcium and albumin

Answer 290

add 0.8 for each 1g/dL Ca less than 8.5 add 2.5 for each 1g/dL Albumin less than 4

Question 291

Winter's formula and purpose...

Answer 291

used to determine respiratory compensation or compromise in metabolic acidosis PCO2measured ...=?... 1.5 x HCO3 + 8 (+/- 2) (calculated) if measured is higher than calculated -> there is also a primary respiratory acidosis if measured is lower than calculated -> there is also a primary respiratory alkalosis **There exists equations to check respiratory status in metabolic alkalosis to be memorized some other time**

Question 292

Base Excess

Answer 292

Metabolic alkalosis(excess bicarb) compensation from respiratory acidosis, loss of HCl (vomiting), renal overproduction of bicarb (cushing's contraction alkalosis)

Question 293

Base Defecit

Answer 293

metabolic acidosis, excretion of bicarb or neutralization of bicarb by excess organic acids (DKA, lactic acidosis, CKD-prevention of H+ secretion, HCO3 production), Diarrhea (loss of bicarb)

Question 294

how do you dose Insulin?

Answer 294

0. 1 U/kg/hr IV and Bolus | 0. 1 U/kg/hr

Question 295

when you have neuropathy what is the time frame you might expect that to resolve?

Answer 295

if it's a compressive injury -> waiting for remyelination (a few days to a few weeks) if it's an axonal injury -> long term (these puppies grow 0.5 - 0.9 mm/day

Question 296

Miralgia paraesthetica

Answer 296

numbness or pain in the outer thigh not caused by injury to the thigh but rather by lateral femoral cutaneous nerve injury... weight gain -> pressure near belt line, waistbands, and tight pants..

Question 297

what is an example of a high troponin?

Answer 297

3 / 4

Question 298

Bumex what is a side effect of baclofen? Contraindication of propofol? Acyclovir?

Answer 298

Bumex - bumetanide - loop diuretic - same class as furosemide, torsemide, ethacrynic acid. strong diuretic Side effect of baclofen Contraindication of propofol - hypotension Acyclovir - kidney crystals

Question 299

heparin vs LMWH

Answer 299

heparin upregulates AT to inhibit Xa and Thrombin, reversible LMWH upregulates AT to inhibit Xa only

Question 300

Anti-factor Xa activity "Hep-X-a"

Answer 300

LMWH heparins are managed via HepXa rather than PTT (like hep) or PT (like warf) or ACT (faster than ptt) patient plasma added to a sample with known amount of Xa and an excess AT... any LWMH present in the patients sample will inactivate factor Xa. Substrate for Xa is then added and a colorimetric or spectrophotometric or fluroscopic emission is read.

Question 301

Serum Phosphorus - normal levels, when high, when low ... think

Answer 301

2.4-4.1 mg/dL High - DKA, Hypoparathyroid, Kidney Failure, Liver Disease, hypervitaminosis D, dietary Low - Alcoholism, HyperCa, Hyperparathyroidism, dietary / poor nutrition, hypovitaminosis D (rickets/osteomalacia)

Question 302

hypophosphatemia induced acute rhabdomyolysis hypophosphatemia induced by vitamin D deficiency... hypophosphatemic rickets...

Answer 302

occurs in drunks Vit D deficiency -> decreased Ca absorption -> loss of blood Ca -> increased PTH (secondary hyperparathyroidism) aka x-linked hypophosphatemia/ x-linked vitamin D resistant rickets - short stature, genu varum, PHEX gene, - tx with phosphate replacement

Question 303

Central Venous Pressure (CVP)

Answer 303

Central Venous Pressure - pressure of vena cava near the right atrium - influenced by intravascular volume, venous return, venous tone, intrathoracic pressure, right heart function and myocardial compliance... TRENDS ARE MORE IMPORTANT THAN ISOLATED READINGS... these are obtained through the central line normal - 5-10 cmH2O

Question 304

Cardiac Index

Answer 304

CI = CO/BSA (body surface area) *relates heart performace to the size of the individual* Normal - 2.6 - 4.2 L/min/m2 less than 2.2 the patient may be in cardio genic shock

Question 305

Lactate

Answer 305

marker for cellular hypoxia - half life of 20 minutes so useful for response to treatment - if lactate drops within 6 hours survival is increased but if it above 4.0 mmol/L is associated with 27% mortality whereas 2.5-4.0 is associated with 7% mortality less than 2.5 is associated with 5% mortality tourniquet for over 2 mins can skew results negatively

Question 306

Causes of Ascites

Answer 306

Portal hypertension - d/t cirrhosis, alcoholic hepatitis, liver failure, budd chiari, heart failure, constrictive pericarditis, hemodialysis associated (nephrogenic). Hypoalbuminemia - nephrotic syndrome, protein losing enteropathy, malnutrition. Peritoneal Disease - malignancy, infectious peritonitis, eosinophilic gastroenteritis, peritoneal dialysis, multicystic mesothelioma. Others - chylous ascites, pancreatic ascites, myxedema, hemoperitoneum.

Question 307

``` Normal Values - Urinalysis Spec.G pH - alkali vs acidic stones Protein Albumin When does glucose spill? When do you see Ketones? Nitrites Bilirubin Leukocyte Esterase Squamous cells ```

Answer 307

Spec G - 1.003 - 1.030 pH - 4.6 - 8.0 - alkali (ca-Oxa, ca-Po4, struvite/mgNh4po4) acid (uric acid/ cystine) Protein - 0 - 20 mg/dL Albumin - 0 - 23 mg/L (serum - 3.5 - 5.5 g/dL) Glucose - spills at 180 mg/dL Ketones - DKA, starvation, extreme exercise, vomitting, pregnancy Nitrites - specific for certain UTI but not sensitive to all bugs - ecoli, klebsiella, proteus, enterobacter, citrobacter, pseudomonas.... but not staph / strep / haemophilus.... negative nitrites do not rule out UTI but a positive rules it in. Bilirubin - only conjugated bili can be sent to the urine (soluble)... unconjugates as urobilinogen Leukocyte Esterase - pyuria - indicates UTI (sterile pyuria is pyuria with bugs that don't normally grow on std UA..chlomydia, mycobacterium, TB, ureaplasma) Squamous Cells - contamination

Question 308

``` Normal Values - ECG P-wave PR - interval QRS complex ST T-wave QT - interval ```

Answer 308

P - 1.5 -3.0 box duration x 0.5 - 2.5 boxes high, Upright in leads I, II, aVF PR - 3 - 5 box duation (short in WPW, Pompes, Duchennes, HCM) QRS - 3 squares (wide with R/LBBB, centricular rhythm, hyperk) ST - elevated = infarct, depressed = ischemia T - tall (MI, hyperK, LBBB), small/flat (ischemia, hyperventillation/anxiety, LVH, digoxin, pericarditis, PE) QT - interval - 0.42 (QTc) - long (MI, myocarditis, hypoCa, hypoT, SAH, amiodarone, sotalol

Question 309

ECG pnemonic

Answer 309

``` Rate Rhythm Axis RWP Intervals Chamber Size Injury/Ischemia ```

Question 310

LBBB vs RBBB

Answer 310

LBBB - (williaM) QRS makes M in V6, Lead 1, aVL, V5 RBBB - (Marrow) QRS makes M in V1, RSrsR in Lead 1

Question 311

LVH vs RVH

Answer 311

LVH - S in V3 + R in aVL (>24mm) RVH - RAD > +110, R in V1 > 7mm, S in V1

Question 312

LAE vs RAE

Answer 312

atrial enlargement LAE - sine wave (P wave) in V1, Notched P wave in II, III RAE - tall peaked P-wave in II, III, AVF, positive Deflection of the p-wave in V1 or V2

Question 313

what should you check before giving ACE and ARBs or NSAIDS?

Answer 313

creatinine

Question 314

what are three things you check first in acute altered mental status

Answer 314

check BG (sugar) Give Narcan Give Thiamine

Question 315

what labs do you get in hyponatremia?

Answer 315

urine osmolality, urine sodium, serum osmolality, BMP, cortisol, TSH

Question 316

what values are optimized when you're ready to extubate? what's the RSBI?

Answer 316

HighVt (tidal volume), low RR (respiratory rate) RSBI - rapid shallow breathing index - frequency (RR) / Vt (Tidal Volume) - **a high frequency and low Vt indicate poor tolerance to independent breathing (a high RSB) 105 is the maximum acceptable level. **a low RSBI indicates preparedness to ween

Question 317

what's are some ways you can check volume status?

Answer 317

blood pressure change with passive leg raise while supine, skin turgor, (bp vs pulse), mentation, cap refill, urine output, mucus membranes

Question 318

how do you calculate the necessary free water to give in HyperNa?

Answer 318

look up the free water deficiency equation and give that.

Question 319

how do you approach a new patient that is making your head spin???

Answer 319

KISS (keep it simple stupid) ABCs (airway breathing circulation) Go through your Systems

Question 320

what do you do if you are having trouble obtaining a peripheral stick for labs?

Answer 320

go through the femoral - doesn't matter if you get artery or vein... 20g Needle, 20-50CC syringe, Pass em off...

Question 321

what is a side effect of hypothermia therapy in arrest patients?

Answer 321

lactic acidosis

Question 322

what kind of drugs linger in the elderly esp with decreased renal function?

Answer 322

benzodiazepine sedatives, anti-histamines, morphine, anti-cholinergics (especially take care in renal failure with these)

Question 323

Framingham Criteria for Heart Failure

Answer 323

``` MAJOR PND (paroxysmal nocturnal dyspnea) Orthopnea JVD Rales S3 Cardiomegaly Pulmonary Edema ``` Minor - leg edema, nocturnal cough, dyspnea on exertion, hepatomegaly, pleural effusion, tachycardia, weight loss. **Dx requires 2 major, or 1 major + 2 minor

Question 324

Barbeau Test

Answer 324

allens test with pulse oximetry

Question 325

Classification of HF I-IV Stages of HF A-D

Answer 325

I - heart disease no s/s with activity II - heart disease slight limitation of activity III - heart disease marked limitation of activity, not at rest IV - heart disease s/s at rest A - high risk but without structural changes or s/s B - structural changes w/o s/s of HF C - structural changes with prior or current s/s of HF D - refractory HF requiring specialized interventions

Question 326

Myopathies

Answer 326

dilated, restrictive (idiopathic, hemachromatosis, sarcoidosis, amyloidosis), hypertrophic, arrythmogenic RV cardiomyopathy, alcoholic cardiomyopathy, viral myocarditis, amyloidosis, tacotsubo - disease of the heart muscle itself

Question 327

Periorbital Purpura

Answer 327

PoP - pathognomonic for AL amyloid cardiomyopathy... (also may see peripheral neuropathy)

Question 328

cirrhosis, diabetes, hyperpigmented skin... xanthelasma

Answer 328

triad - late stage hemochromatosis x - fatty deposition above the eyes... usually suggestive of hypercholesterolemia...

Question 329

Initial Tests in HF

Answer 329

ECG - prior MI, LVH, loss of R in V2-5 (infiltrative process), heart block, persistent tachy like afib w/ RVR (cardiomyopathy) ECHO, Stress Test / Angiogram CBC - anemia / infection CMP - Ca, Mg, Bun, Cr, HypoNa (if severe HF), BNPs - heart congestion LFTs - hepatic congestion Thyroid Studies - either hypoT or hyperT can exacerbate or cause HF

Question 330

HFpEF pathophysiology

Answer 330

aka Diastolic HF - determined by myocardial relaxation (active - requires metabolic energy), compliance/distensibility of LV (passive) ... increased LV pressure -> pulmonary congestion, dyspnea, edema **when in diastole - the LV, LA and PulmVein form a common chamber and diastolic LV pressure is synonymous with PCWP (3-12mmHg = normal, 12-25 elevated, >25mmHg -> pulmonary edema)**

Question 331

Side Bar - Causes of Bradycardia

Answer 331

``` hypothermia vagal tone (vagal stim / drugs) hypothyroidism beta-blockade intracranial HTN obstructive jaundice / uremia SA node disease ```

Question 332

Side Bar - Causes of Tachycardia

Answer 332

``` pain adrenergic stimulations thyrotoxicosis hypovolemia vagolytic drugs (atropine) anemia / pregnancy vasodilator drugs (many hypotensive agents) fever myocarditis ```

Question 333

HFrEF pathophysiology

Answer 333

ventricular dysfunction, aortic insufficiency, myocarditis => loss of EF => loss of CO => increased sympathetic activity and salt/fluid retention => reestablishement of CO with a side of extra fluid

Question 334

Lactate - why, normals, etc.

Answer 334

lactate is a marker for cellular hypoxia, half life of 20 minutes, get serial lactates. 4.0 mmol/L is associated with 27% mortality vs. 7% for (2.5-4.0 mmol/L) other things cause lactic acidosis- seizures, drug - epinephrine, metformin, hypothermia, liver failure, low CO ...

Question 335

Precedex

Answer 335

Dexmedetomidine - sedative used in ICU and anesthesia - like clonidine it's an alpha-2 agonist - similarly effective as midazolam **sedative, sympatholytic, anxiolytic - reduces need for sedatives that depress the respiratory system**

Question 336

EEG findings: Spike and wave 8-13Hz unremitting, unresponsive to stimulation 11-14Hz paroxysmal on delta background 2-2.5Hz sinusoidal bilateral synchronic waveforms appearing in bursts 3Hz spike and dome high volatage (300-1500uV) repetitive, polyphasic, sharp and slow wave complexes of 0.5 - 2 second duration that recur q4-15s Hypsarrhythmia continuous periodic stereotypic 200-400 ms sharp waves at intervals of 0.5 - 1.0s

Answer 336

seizure Alpha-coma Spindle-coma - must distinguish from normal alpha rhythm in locked in state and from various intoxications Intermitted Rhythmic Delta Activity - IRDA - metabolic, toxic, hypoxic, intracranial disease... absence seizure - can be diagnosed with hyperventiallation Subacute Sclerosing Panencephalitis - inflammatory disease of children caused by chronic infection by the measles virus. Infantile spasm - associated with MR Crutzfeld Jacob Disease - prion disease

Question 337

Acute Respiratory Failure - types... and other terms to differentiate from

Answer 337

ARF - inadequate gas exchange... Type 1 hypoxemia without hypercapnia Type 2 hypoxic hypercapnic ``` ARDS - acute respiratory distress Acute Bilateral infiltrates cannot be cardiac or fluid overload (no CHF) PaO2/FiO2 ratio ```

Question 338

ARF - Type 1 causes ARF - Type 2 causes

Answer 338

1 - low ambient O2, VQ mismatch (PE), alveolar hypoventillation (decreased minute volume), diffusion problem from parenchymal dz (pneumo, ARDs), shunt RtoL 2 - airway resistance (COPD, asthma, suffocation), reduction in breathing effort (drugs, brainstem lesions, obesity), decrease in lung surface area (chronic bronchitis), neuromuscular dz (GBS, motor neuron dz - ALS), deformation (kyphoscoliosis, ankylosing spondylitis, flail chest, preggers)

Question 339

Anti-platelet therapy after coronary stent placement: DAPT

Answer 339

DAPT - dual antiplatelet therapy (aspirin and P2Y12 inhibitor - clopidogrel) works better because more aggressive anti-platelet tx is necessary as blood forms clots on metal... tx until the stent is covered in neointimal endothelializatoin *75-100 mg aspiring, 75 mg -grel -> 12 months and up to 18 months if handling tx well (for stable CAD) patients with risk of bleeding can be treated for shorter period of time., BMS can be treated slower, DES should be treated longer.

Question 340

Pulmonary Artery Wedge Pressure (PAWP) Central Venous Pressure (CVP)

Answer 340

PAWP - aka PWP aka PCWP - 6-12mmHg - measured by PA catheter to pulmonary artery branch (right heart) - indirect measure of left atrial pressure - used to dx pulm edema, LVHF, mitral stenosis... CVP - 3-8mmHg - pressure in thoracic vena cava near the right atrium - surrogate for preload - used to monitor hemodynamics but may not be the best index

Question 341

Three histopathologic patterns of Diffuse Alveolar Hemorrhage (DAH)

Answer 341

DAH - bleeding into the alveolar spaces of the lungs due to disruption of the alveolar-capillary basement membrane 1. Capillaritis - neutrophilic infiltration of the alveolar septum -> fibrinoid necrosis / blood spilling..systemic vasculitides, rheumatic dz, drugs, other 2. Bland Hemorrhage - hemorrhage into the alveolar spaces without destruction of alveolar structures - CT disease, drugs, other 3. Diffuse Alveolar Damage - edema of alveolar septums and formation of hyaline membranes - DAD leads to ARDS...INFECTION, rheumatic dz, drugs/toxins, other ....4. miscellaneous DX - progressively hemorrhagic effluent on BAL - hemosiderin laden macrophages - Prussian blue

Question 342

Light's Criteria - transudative vs exudative effusion

Answer 342

transudative - imbalances of hydrostatic pressures in the chest (CHF, nephrosis) limited number of diagnostic possibilities exudative - diagnostically challenging - infection, malignancy, immune, lymphatics, non-infectious inflammation, iatrogenic LIGHTS Pleural Protein / Serum Protein > 0.5 Pleural LDH / Serum LDH > 0.6 Pleural LDH greater than 2/3rds the upper limit of normal serum LDH

Question 343

most common causes of pulmonary renal syndrome

Answer 343

autoimmune - granulomatosis with polyangiitis (wegeners), goodpastures syndrome, lupus, microscopic polyangiitis

Question 344

bactrim

Answer 344

TMP-SMX - UTI, MRSA, traveler's diarrhea, RTI, cholera

Question 345

when do you use prophylactic post operative antibiotics?

Answer 345

only for cardio and neuro operations, pre-op antibiotics are still legit!

Question 346

what is the number one contraindication to tube feeds? what is it called when you use minimal tube feeds? when would you avoid iron replacement?

Answer 346

hypotension due to blood redistribution to digestive system trickle or trophic feeds chronically infected patients

Question 347

what age group is most likely to have a seizure? what kind of seizure are they most likely to have? what kind of seizure does the age group least likely to have seizures have?

Answer 347

infants and elderly due to rapid growth or deterioration of the CNS non-generalized due to under-developed corpus callosum middle aged most likely to have generalized seizure

Question 348

5 indications for dialysis - FUUTH, AEIOU

Answer 348

``` FUUTH Fluid Overloaded - not amenable to tx... Uremia - oliguric / non-oliguric Uremic Pericarditis Toxicity / Drug OD HyperK / electrolyte imbalance ``` ``` Acidosis Electrolytes (K) Ingestions / Toxicity Overload fluid Uremia ```

Question 349

Lactate vs LDH

Answer 349

Lactate is indicative of anoxia, hypoperfusion, important marker of sepsis LDH - marker of cell lysis

Question 350

hepatorenal syndrome

Answer 350

portal hypertension via cirrhosis -> splanchnic vasodilation (liver mediated cytokines) -> decreased effective circulatory volume -> RAAS -> renal vasoconstriction

Question 351

when you give fluids what happens to serum lab studies?

Answer 351

they all go down, like Hb, WBCs, etc.. dilutional

Question 352

MIBG CT scan

Answer 352

metaiodobenzylguanidine scan - radiolabeled molecule similar to norepinephrine ... used as the Gold Standard in diagnosis of Pheo

Question 353

what is a rarely taught aspect of DKA? when would you see envelope shaped crystals and osmolar gap?

Answer 353

it can cause an osmolar gap (of course it causes anion gap...) PEG overdose (Miralax) vs... antifreeze which is Ethylene Glycol

Question 354

``` Osmolar Gap Anion Gap Winter's Formula Delta Gap Urine Anion Gap Albumin Correction ```

Answer 354

Osmolar Gap - 2Na + Glu/18 + BUN/2.8 ... >10 is a big deal Anion Gap - Na - Cl - HCO3 Winter's Formula - PCO2 = 1.5xHCO3 + 8 +/- 2 Delta Gap - Change in AG (vs expected...12) + Bicarb vs. 24 (normal bicarb) Urine Anion Gap - Na + K - Cl ... + is RTA (kidney unable to excrete acid)...- is diarrhea (acidic urine from high NH4Cl) 4 - measured albumin = Albumin Defecit x 2.5 = corrected or expected anion gap

Question 355

how are chloride and bicarb related?

Answer 355

if you increase chloride (as in during NS fluid resuscitation) you will decrease bicarb (metabolic acidosis)

Question 356

cirrhotic ascites and pregnancy will both show what physiologic adjustment?

Answer 356

displaced lungs -> compensated respiratory alkalosis increased progesterone (metabolized in the liver) -> alters the brain's respiratory center to stimulate breathing

Question 357

neutrophilia DDX

Answer 357

demargination - caused by infection, prednisone, cortisol, and adrenaline malignancy -> CML appendicits/ splenectomy **Left Shift - lots of premature leukocytes/neutrophils -> leukemoid reaction - is severe neutrophilia with strong left shift

Question 358

procalcitonin

Answer 358

procalcitonin -> produced by parafollicular cells of the thyroid and by neuroendocrine cells of the lungs and intestines.... rise in response to infection of bacterial origins respiratory infections?!

Question 359

what is that replacement dose of prednisone for adrenal insufficiency? what else should you consider in adrenal insufficiency?

Answer 359

7.5mg/day more in the AM hydrocortisone takes 30mins to work, T1/2 is 90mins, consider mineral corticoid replacement as well

Question 360

triggers for chronic adrenal insufficiency signs and symptoms of adrenal insufficiency what if 1* AI?

Answer 360

fluid loss diarrhea, Lupus -> infection S/S - GI complaints, NVD hyperK, hypoNa hyperCl, hypoBicarb hypoglycemia ...others...mild hyperCa, acidosis, eosinophilia 1* AI = hyperpigmentation (due to increased ACTH)

Question 361

thallium scan

Answer 361

radiolabeled myocardial perfusion imaging

Question 362

neutropenic fever

Answer 362

commonly recognized complication of chemotherapy.. treat with empirical antibiotics, add antifungals if persistent

Question 363

SIRS Ordering Bundle

Answer 363

fluid resuscitation check lactates, ESR/CRP send blood cultures and other sample cultures source of infection

Question 364

what is adequate rate of fluid resuscitation in hypotension?

Answer 364

hypotension despite fluid resuscitation (30ml/kg) if septic shock place a central line and start pressors

Question 365

signs and symptoms of ... Tamponade AS AR

Answer 365

Tamponade - Beck's Triad - hypotension, JVD, distant/muffled heart sounds... also pulsus paradoxus (auscultate first, palpate the radial pulse later). AS - syncope/presyncope, dyspnea (especially exertional), angina, systolic murmur AR - wide pulse pressure, bounding pulse, De Musset's sign (bobbing head), diastolic murmur

Question 366

recommendations for surgery of aortic stenosis... define severe and the 3 patients who for sure get surgery.

Answer 366

severe AS - Aortic Jet Velocity >4.0m/s , Mean Transvalvular Gradient >40mmHg... (AVA aortic valve area not required but often coexistent... area less than 4 cm?

Question 367

Absolute Neutrophil Count Equation and Definitions

Answer 367

Eq = (%PMNS + %Bands) * WBCs

Question 368

3 mechanisms of neutropenia

Answer 368

1. decreased production 2. margination (demargination is caused by epinephrine/exercise) 3. destruction - drug / AI dz

Question 369

in what order is an ABG reported by RTs?

Answer 369

pH - PCO2 - O2 - HCO3

Question 370

what are the three main blood proteins?

Answer 370

1. albumin 2. immunoglobulins 3. fibrinogen

Question 371

what acid base status makes pressors work less effectively?

Answer 371

acidemia

Question 372

what is phytonadione?

Answer 372

vitamine K

Question 373

what are the diagnostic criteria for ARDS

Answer 373

P/F ratio, bilateral infiltrates, meets clinical picture

Question 374

what are the diagnostic criteria for ARF

Answer 374

A-a gradient 760 -47 * FiO2 - CO2/0.8 (compared to measured A-a)

Question 375

chronic compensation of respiratory acidosis will have an increased basal bicarb...a chronic elevation of PaCO2 will result in a chronic elevation of Bicarb (what is the ratio acutely, and chronically)

Answer 375

increase PCO2 by 10 -> -> -> increase HCO3 by 1 acutely increase HCO3 by 4 chronically

Question 376

what is the mnemonic for Anion Gap Metabolic Acidosis - MUDPILES what is the mnemonic for Non-Gap Metabolic Acidosis - DURHAM

Answer 376

``` Methanol Uremia DKA, AKA Paraldehyde / Phenformin Iron/ INH Lactic Acidosis Ethylene Glycol - envelope chrystals Salicylates ``` ``` Diarrhea Ureteral diversion RTA - renal tubular acidosis Hyperaldosteronism Acetazolamide (CA inhibitor) Meds - isoniazid, aces/arbs ```

Question 377

what are the three clincial measures used to determine need for mechanical ventilation in someone with neuromuscular comprimise?

Answer 377

40/30/20 rule MEF - max expiratory force 40 mmH2O NIF - neg inspiratory force -30mmH2O VC - 20ml/kg, or under 1L anything lower than these absolute values is in need of intubation....

Question 378

compliance elasticity

Answer 378

c - delatV / deltaP - ability of the lungs to expand e - ability of the lungs to collapse

Question 379

Abdominal Compartment Syndrome

Answer 379

Peritoneal / Retroperitoneal - edema, free fluid, blood - accumulates to levels beyond the compliance of the abdominal wall... >12 mmHg (intraabdominal hypertesion) for adults >20 mmHg -> organ failure may set in ... highly fatal situation (young healthy or athletic peeps may handle this well) causes include - SIRS (capillary permeability>leakage), fluid therapy from volume rescusitation, trauma/aortic rupture, pancreatitis, ileus / obstruction, masses, ascites treatment - free up the abdominal cavity - Bogota Bag (sterile bag sewn into the abdomen)

Question 380

female athlete triad

Answer 380

osteopenia/porosis, decreased coloric intake, amenorrhea

Question 381

Things that increase the effect of warfarin (cyp450 inhibitors, vitamin K influence)

Answer 381

``` Acetominophen, NSAIDs Antibiotics/fungals Amio Cimetidine, Omeprazole Cranberry Juice, Ginko Bilboa, Vitamin E Thyroid Hormone SSRIs (fluoxetine) ``` can cause bleeding in warfarin use

Question 382

Things that decrease the effect of warfarin (cyp450 inducers, vitamin K sources)

Answer 382

``` Carbamazepine Ginseng Green Veggies Oral Contraceptives Phenobarbital Rifampin St Johns Wort ``` cause thrombosis on warfarin

Question 383

cohort vs case-control

Answer 383

case-control - "already have the disease" - comparing risk factors in two populations, one with disease, one without disease cohort - "has the risk factor" comparing incidence of disease in two populations, one with risk, one without the risk factor (can be retrospective or prospective)

Question 384

Marjolin's Ulcer Cushings Ulcer Curlings Ulcer

Answer 384

SCC that results from chronic burn wound Cushings - elevated ICP related gastric ulcer Curlings - burn related gastric ulcer

Question 385

NAGMA mnemonic ABCD

Answer 385

Addisons, Acetazolamide Bicarb loss - Renal (RTA), GI loss (diarrhea) Chloride excess - NS rescus Drugs - diarrhea, diuretics, acetazolamide

Question 386

Causes of hyponatremia - Hypervolemic, Normovolemic, Hypovolemic

Answer 386

HyperV HypoNa - CHF, Cirrhosis, Nephrotic Syndrome Normovolemic HypoNa - SIADH (cxr for Lung cancer), Addisons, HypoT HypoV HypoNa - Diarrhea, Vomitting, Free Water correct with NS at 12 mEq/day

Question 387

low platelets with clotting... maybe post op? isolated decrease in platelets with bleeding? normal platelets with increased bleeding time and PTT?

Answer 387

HIT - heparin induced thrombycytopenia - treat with synthetic heparin (lepuridin or argatroban) ITP - idiopathic thrombyocytopenic purpura vWF dz

Question 388

Parkland formula

Answer 388

used to determine volume given in burn patietn within first 24 hours - first half given in 8 hours second half given in 16 hours. 4 x wt(kg) x (%TBSA * 100)

Question 389

Paraneoplastic lung cancer syndromes Small Cell vs Squamous Cell Ca

Answer 389

Squamous Cell = PTHrP (low PTH, High Ca, low PO4) Small Cell = "SCL" superior sulcus syndrome (ptosis, miosis, facial edema), SIADH (euvolemic hypoNa), Carcinoid, Lambert Eaton (ptosis improves with upward gaze, Abs to Ca channels),

Question 390

Ataxia vs Apraxia Paresis vs Paralysis

Answer 390

Ataxia - incoordinated muscle movements Apraxia - inability to conduct complicated tasks, disordered motor planning Paresis - weakness of voluntary movement Paralysis - complete loss of voluntary movement

Question 391

Admit Orders - ADC VAN DISMAL

Answer 391

Admit to - who? Diagnosis - listed in order of priority Condition - good fair poor guarded critical Vitals - frequency etc Activity - ad lib, bed rest, up to chair, ambulate Nursing - InOs, drains, wounds ``` Diet - soft, puree, mech soft, liquids IV fluids Studies Medications - drugs Allergies Labs / Imaging ```

Question 392

when do you do a FENa

Answer 392

fractional excretion of sodium is done when you have... Acute Kidney Injury (^Cr by 0.3) Oliguria/Anuria No Diarrhea

Question 393

GI cocktail

Answer 393

antacid, lidocaine, anticholinergic (maalox and lidocaine) used for dyspepsia

Question 394

hypervolemic hyponatremia

Answer 394

cirrhosis, cardiosis, nephrosis | loss of protein, loss of pump/LHF, loss of ability to retain solutes

Question 395

euvolemic hyponatremia

Answer 395

SIADH Pseudohyponatremia - Adrenal Insufficiency Drugs

Question 396

hypovolemic hyponatremia

Answer 396

vomitting, diarrhea, diuretics, Addison's disease

Question 397

CRP when do use and why ... how about pro-calcitonin... sed rate??

Answer 397

CRP - use it to see if there is an infection / inflammation ... cheap proCalcitonin - useful for respiratory infections only. sed rate -> auto immune

Question 398

contraction alkalosis

Answer 398

when you diurese someone they lose volume and the kidney holds bicarb so you get increased bicarb in the blood.

Question 399

what do you use for determining when to order D-Dimer for DVT/PE?

Answer 399

PERC score (PE Rule-out Criteria) WELLS criteria (probability scoring for DVT and PE)

Question 400

Inferior MI Anterior / Septal Lateral

Answer 400

Inferior - Lead 2,3, AFV Anterior Septal - V1 - V4 Lateral - V1, V5, V6

Question 401

Alvarado Score - MANTRELS

Answer 401

``` Migrating abdominal pain to iliac fossa Anorexia Nausea/vomiting Tenderness of right lower quadrand Rebound pain Elevated Temperature Leukocytosis / 10K with Left Shift ```

Question 402

four types of shock

Answer 402

Distributive - sepsis/SIRS, pancreatitis, neurogenic, anaphylactic, toxin mediated, endocrine (addison's crisis). Cardiogenic - MI, arrhythmia, mechanical (valve rupture) Hypovolemic - hemorrhage, vomitting/diarrhea (fluid loss) Obstructive - pulmonary vascular related (PE, tension pneumothorax, pericardial tamponade)

Question 403

Hyperthryriod symptoms Hypothyroid symptoms

Answer 403

heat intolerance, sweating, hunger, tachycardia, sweating, irritability, mood swings, insomnia, wt loss, tremor cold intolerance, dry thinning skin, fatigue, wt gain, hair thinning or loss, brittle nails, sluggish heart rate ** often low symptomology in the elderly

Question 404

Osmolality vs Tonicity

Answer 404

Osmolality - includes all osmoles like ethanol urea glucose salt tonicity - includes just effective osmoles... things that don't cross the PM

Question 405

Aplastic Anemia Myelodysplastic syndrome

Answer 405

AA - hypo-cellular marrow - tends to occur in younger patients. MDS - hyper-cellular marrow - abnormal maturation of cells

Question 406

Congenital Adrenal Hyperplasia mnemonic - 21, 17, 11

Answer 406

A / T 21 - X - Up 17 - Up - X 11 - Up - Up

Question 407

Diagnostic Criteria for Pancreatitis - need 2/3

Answer 407

1. Characteristic Abdominal Pain 2. Lipase > 3x upper limit of normal 3. Imaging findings on U/S, CT suggestive of pancreatitis

Question 408

Diagnostic / Resolution Criteria for DKA

Answer 408

1. AG > 12 2. pH <7.3 3. Bicarb <15-18 serum and urine ketones are used to rule out not rule in DKA

Question 409

Correction of Na in DKA

Answer 409

add 1.6[(BG-100)/100] to measured sodium example Na 118 BG 1060 118 + 1.6*(9.6) = 133.6

Question 410

Types of NSTEMI

Answer 410

**NSTEMI - signs and symptoms of ischemia with elevated troponins but no ST elevation or Q waves 1 - spontaneous - intraluminal coronary thrombosis from any number of causes (plaque rupture, ulceration, fissure, dissection) 2 - ischemic imbalance - d/t embolism, anemia, arrhythmia, vasospasm, respiratory failure 3 - death before biomarkers are available - cardiac death before troponin elevations (takes up to 12 hours for troponins to rise) 4 - Intrastent Thrombosis 4A - During PCI 4B - Stent Thrombosis related 5 - CABG related

Question 411

Pre-operative Visit

Answer 411

Heart/Lungs/Anesthesia Hx Able to carry 2 grocery bags up 2 flights of stairs How many blocks walking w/o dyspnea *Women - LMP/Pregnant/Hb

Question 412

Aortic Stenosis and normal valve area

Answer 412

normal are is 4cm^2 symptoms usually arise at 2cm^2 (syncope, CP, SOB)

Question 413

Dosing levothyroxine for hypothyroidism

Answer 413

1.7 mcg/kg to start, recheck TSH in 1-2 months, levothyroxine half life long, should take in AM 1 hr before breakfast

Question 414

Diffuse ST Elevation

Answer 414

pericarditis - chest pain alleviated by leaning forward

Question 415

Levamisole

Answer 415

pesticide used as cutting agent used in cocaine that can cause cutaneous chemical vasculitis

Question 416

which is more liver specific ALT or AST?

Answer 416

ALT more liver specific, AST double the ALT means alcohol

Question 417

CAP - Bugs n Drugs HCAP - definition - Bugs n Drugs VAP - Bugs n Drugs Aspiration - Bugs n Drugs Atypicals - Bugs n Drugs

Answer 417

CAP - SPneumo, Hflu, MCatarrhalis - FQ (levoquin), Moxifloxacin HCAP - 48 hours of the last 3 mos in LTACH, SNF, NH, Prison - #1 SPneumo - MRSA (Vanc, Bactrim, Linezolid, Clinda) & Pseudomonas (zosyn, levoquin, cefipime, genta, meropenem) VAP - same bugs n drugs as HCAP Aspiration - anaerobes - above diaphragm (clinda) below diaphragm (metronidazole) Atypicals - chlamydia, legionella, mycoplasma - levoquin, moxiflox, or(augmentin/amoxicillin/ceftriaxone + macrolide)

Question 418

MRSA Tx Pseudomonas Tx Anaerobes Tx Atypicals Tx

Answer 418

MRSA - vanc, tmp/smx, linezolid, clinda Pseudomonas - zosyn, levoquin, cefipime, genta, mero Anaerobes - above diaphragm (clinda) below diaphragm (metronidazole) Atypicals - levoquin, moxiflox, or (augmentin/amoxicillin/ceftriaxone + macrolide)

Question 419

PRES vs RCVS

Answer 419

PRES - posterior reversible encephalopathy syndrome - MRI diagnosis - AMS, Sz, HTN, Hallucinations RCVS - reversible cerebral vasoconstriction syndrome - CTA Head - intermittent cerebral vasoconstriction with thunderclap HA, focal neuro signs - treatment is nimodipine

Question 420

Pyoderma Gangrenosum

Answer 420

PG - necrotic deep tissue ulcerations sometimes associated with IBD

Question 421

CURB-65 Score

Answer 421

``` Confusion Uremia (>20) Respirations (>30) BP <90/>160 65 - years or older ``` * 2pts hospital * 4pts ICU

Question 422

SAAG ratio for Ascites

Answer 422

SAAG = (Serum Albumin - Ascites Albumin) > 1.1 = increased hepatic pressures - Cirrhosis, CHF, RHF, Budd Chiari <1.1 = Nephrotic Syndrome, peritoneal carcinomatosis, TB, pancreatitis, infection

Question 423

What are the components of PFTs

Answer 423

Spirometry - exhalation test - FEV1/FVC <70% = obstructed - then do bronchodilator (if improves by 12% and 200cc then BD responsive) FEV1 is compared to expected for severity of obstructive lung disease Lung Volumes - < 80% Restricted < 80-120% (normal) >120% Hyper-inflated Diffusion - DLCO < 80% (fibrosis, bronchiectasis, emphysema, amio, PAH) >120% (PV, AVM, Hyperdiffusion) *The values are compared to sex, age, race, height, not weight

Question 424

What level is an adequate fluid resuscitation?

Answer 424

should give fluids of 30cc/kg/hr

Question 425

Non-TB Mycobacterial Infections

Answer 425

NTM - MAC, M. Kansasii, M. Abscessus - treat with Macrolides (atypicals)

Question 426

2 Lung responses to local hypoxemia

Answer 426

1. Shunting to different parts of the lung | 2. Vasoconstriction (at the level of the arteriole decreases transit time through the capillary)

Question 427

Portal Hypertensive Gastropathy

Answer 427

PHG - usually asx, diagnosed by endoscopy for other reasons, suspect in cirrhotics with UGIB (upper GI bleed) - prophylax with beta-blockers, octreotide for acute bleed, TIPS for refractor bleeding

Question 428

what is the change in FiO2 with each 1L O2?

Answer 428

1L O2 = 4% increase in FiO2, generally speaking

Question 429

Small Cell Lung cancer sequel SQuamous cell lung cancer sequel

Answer 429

Siadh Cushings Lambert Eaton Syndrome PR SQ -Parathryroid Related Peptide

Question 430

Light's Criteria

Answer 430

Exudative pleural effusions Pleural / Serum Protein > 0.5 Pleural / Serum Albumin > 0.6 Pleural LDH > 2/3 ULN Serum LDH (200-300)

Question 431

What are exudative vs transudative effusions?

Answer 431

Exudative - inflammation/vascular permeability - malignancy, infection, trauma, AI, lupus, RA Transudative - increased hydrostatic pressure, decreased oncotic pressure (HF, Cirrhosis, Nephrotic syndrome)

Question 432

CHF, Cirrhosis, and Nephrotic Syndrome cause?

Answer 432

Transudative effusions with low lights criteria Hypervolemic Hyponatremia Ascites with high SAAG

Question 433

Normal Values for K, PO4, Mg?

Answer 433

K ~ 4 PO4 ~3 Mg ~ 2

Question 434

What are the diagnostic/staging criteria for asthma and COPD?

Answer 434

asthma - GINA criteria copd - GOLDs criteria

Question 435

What is controlled in A/C ventilation? What is controlled in P/S ventilation? What is controlled in NIPP ventilation?

Answer 435

A/C - TV, RR, Peep, FiO2 P/S - "weening" - FiO2, Peep, Pressure Support NPPV - non-invasive positive pressure ventilation - pressure support only e.g. BiPAP, CPAP, AVAPs

Question 436

Gold's Criteria for COPD

Answer 436

1. FEV1/FVC < 0.7 of expected (based on age, height, sex) 2. FEV1 (>80% mild, 50-80% moderate, 30-50% severe, <30% very severe) 3. Hospitalized x 1, Exacerbations x 2 4. CAT/mMRC symptom surveys

Question 437

COPD Treatment

Answer 437

GOLD 1/2 A = SABA or SAMA prn GOLD 1/2 B = LABA or LAMA GOLD 3/4 C = ICS + LABA or LAMA GOLD 3/4 D = ICS + LABA and/or LAMA *Anyone hospitalized or 2 exacerbations in 1 year gets ICS*

Question 438

GINA Criteria for Asthma

Answer 438

"Global Initiative for Asthma ``` Step 1 - intermittent - SABA prn ...Persistent Step 2 - Low Dose ICS Step 3 - Low Dose ICS + LABA Step 4 - Med Dose ICS + LABA Step 5 - High Dose ICS + LABA Step 6 - ICS and Oral + LABA ``` *Attempt to ween ICS after some time

Question 439

DIC Score

Answer 439

Platelets < 50K (2pts) Fibrin Degradation Products Increased - (3pts) PT > 6 (2pts) Fibrinogen < 1g/dL (1pt)

Question 440

LRINEC Score

Answer 440

for NecFasc - Laboratory Risk Indicator for Nec Fasciitis ``` CRP > 150 (4pts) WBCs > 25K (2 pts) Hb < 11 (2pts) Na < 135 (2pts) Cr > 1.6 (2pts) Glucose > 180 (1pt) ``` **Doesn't sound very specific, but definitely sensitive maybe??**

Question 441

1st rule of Medicine? | 2nd rule of Medicine?

Answer 441

1 - do no harm | 2 - get the right diagnosis

Question 442

Asthma Severity Sx

Answer 442

Intermittent - sx/inhaler use < 2days/week, < 2 night coughs/month Mild - sx/inhaler use > 2D/wk but not daily, 3-4x night coughs/month Moderate - sx daily/inhaler daily, nighttime sx but not every night Severe - sx/inhaler daily/several times, nighttime sx 7 days a week

Question 443

Berlin Criteria for ARDs - TROP

Answer 443

Timing - onset < 7 days Respiratory failure non-cardiogenic Opacities on CXR - fluffy bilateral, no other explanation P/F Ratio - < 300 (mild) < 200 (mod) < 100 (severe)

Question 444

McConnell's Sign

Answer 444

echocardiographic finding of apical contraction w/ hypokinesis of the ventricles as a sign of pulmonary embolism

Question 445

Duke Criteria for Endocarditis - Major

Answer 445

1. ECHO with vegetation, dehiscence, abscess 2. Persistently positive blood cultures for suspicious organisms 3. New valvular regurgitant murmur 4. Coxiella burnetii infection

Question 446

Duke Criteria for Endocarditis - Minor

Answer 446

``` predisposing heart condition fever septic emboli glomerulonephritis clinical - oslers nodes, janeway lesions, roth spots positive blood cultures ```

Question 447

Jones Criteria for Rheumatic Heart Disease

Answer 447

``` Joints - polyarthritis O - Carditis Nodules - subcutaneous Erythema Marginatum, ESR Sydenham Chorea ``` *Rheumatic Heart Disease - inflammatory disease of joints heart skin and nervous system following GAS infection (strep throat)

Question 448

Framingham Criteria for Left Heart Failure - major ... minor

Answer 448

Major PND - paroxysmal nocturnal dyspnea / orthopnea Rales/Crackles Radiographic (cardiomegaly/pulmonary edema) JVD / HJR S3 gallop Minor - dyspnea on exertion, LE edema, nocturnal cough, pleural effusion

Question 449

Three patterns of progressive fluid accumulation in the lungs.

Answer 449

1. Cephalizaiton - increased vascular markings superiorly 2. Lateralization - kerly B lines 3. Alveolarization - fluffy bilateraly opacities

Question 450

Abx Coverage - Cefipime, Fluoroquinolone, Vanco, Clindamycin, Carbapenems

Answer 450

Cefipime - pseudomonas, strep FQ - pseudomonas, strep, legionella Vanco - MRSA Clinda - anaerobes Carbapenems - ESBLs

Question 451

Where do the following lung sounds come from? what can you ask the patient to do if uncertain about clinical findings?

Answer 451

1. Rhonchi (large airways), Wheezes (bronchioles), Rales (alveolar) * you can have them cough to clear secretions

Question 452

Anaphylaxis - defined and treatment

Answer 452

1. must involve 2 body systems 2. 125mg methylprednisolone, 50mg Benadryl, 20mg famotidine...epinephrine if respiratory involvement (0.01 mg/kg...0.3-0.5 ml) may repeat q 10 mins, 1000 mcg/ml (1:1000)

Question 453

Phlegmasia Alba and Phlegmasia Cerulea Dolens

Answer 453

PA / PCD - complication of extensive DVT whereby there is critical limb ischemia. albans is more common in pregnant women. LDS - champagne legs - skin changes of the legs that occurs in venous insuffiency

Question 454

Pulmonary Embolism Classification - Massive, Submassive, Low Risk

Answer 454

Massive - hemodynamic instability Submassive - RV strain, elevated biomarkers, but stable Low Risk - normal BP, negative markers

Question 455

Pleurodesis Thoracentesis

Answer 455

Pleurodesis - chemical affixation of visceral and parietal pleuras Thora - tapping pleural effusion

Question 456

Hypoxemia Hypoxia

Answer 456

Hypoxemia - low SaO2 and PaO2 (low blood oxygen) - has 5 main causes (low FiO2-altitude, Hypoventilation-OHS, Increased V/Q Deadspace-PE, Decreased V/Q Shunt-ARDs, Diffusion-ILD) Hypoxia - poor oxygen delivery (tissues are not getting enough blood) - Lactic Acid, Poor EF/CO, low Hb)

Question 457

Alveolar Gas Equation

Answer 457

PaO2 = FiO2 x 713 - PaCO2/0.8 **Also youtube Alveolar Air Equation and evaluate at different FiO2s**

Question 458

What are features of a benign pulmonary nodule?

Answer 458

Pt Age < 35 Stable Over 2 years Central Calcification <8mm *No followup recommended

Question 459

Tuberculosis - Dx, Tx, Vaccine

Answer 459

Dx - three AFB smears and cultures, with Nucleic Acid Analysis (NAA), culture being the gold std. - Smear and NAA + = dx - Culture + = dx Tx HIV Negative - RIPE 2 months, RI 4 additional months (b6 with Isoniazide) HIV Positive - RIPE 2 months, RI 4 months w/B6 - Rifampin interacts with ART so check it...+ get those peeps on ART Vax - BCG - bacilli Calmette-Guerin vaccine - variable efficacy multifactorial, generally not recommended in US

Question 460

Hair eating disorder

Answer 460

trichobezoar - eating own hair trichophagia - eating own hair Rupunzels Syndrome

Question 461

Jugular Venous Pressure Waves - a,x,c,X,v,y

Answer 461

a - atrial kick x - S1 c - tricuspid X - atrial diastole v - ventricular contraction y - atrial emptying

Question 462

JVP wave findings - Steep Y descent - Abscent Y descent - Giant V waves

Answer 462

steep y-descent - constrictive pericarditis absent y descent - tamponade giant V waves - severe tricuspid regurg

Question 463

3 stages of Fluid Overload on CXR

Answer 463

Cephalization - increased vascular marking superiorly Lateralization - kerleys lines, interstitial opacities / infiltrates (of the interlobular septa) Effusions and Patchy Alveolar Infiltrates

Question 464

Tessalon Pearls

Answer 464

Benzonatate - non-narcotic oral cough suppressant, antitussive last 6-8 hours - local anesthetic similar to procaine or tetracaine

Question 465

Fecal Calprotectin

Answer 465

elevated levels indicate the infiltration of neutrophils into the gastrointestinal mucosa which occurs during inflammation particularly during IBD -necrotizing enterocolitis, cystic fibrosis, colorectal cancer, celiac dz, UC

Question 466

Corrected Ca equation for albumin...

Answer 466

Corrected Ca = Serum Ca + 0.8 (4 - Serum Albumin)

Question 467

Midodrine vs Clonidine

Answer 467

Midodrine - a1 agonist - anti-hypotensive - "pressor" - can cause supine hypertension Clonidine - a2 agonist - anti-hypertensive - good for HTN and etoh w/d

Question 468

MRSA Treatment - IV vs PO

Answer 468

IV - Vancomycin PO - Clinda, doxy, Bactrim, minocycline, linezolid

Question 469

What is Macrobid and a contraindication?

Answer 469

Macrobid = nitrofurantoin - check renal function also it makes people nauseated.

Question 470

What is one way to increase potency of topical steroids?

Answer 470

apply cream them wrap the dressing

Question 471

Central Sleep Apnea

Answer 471

>65yrs, M>F, RF - HF, AF, Cerebrovascular Dz dx with PSG can be primary or secondary DDx - OSA, PLMS (fmly RLS), Rotating Night Shift Workers, Narcolepsy, Resp Dz

Question 472

What are two complications of high altitude exposure?

Answer 472

HAPE and HACE - both can be treated by return to a lower altitude and steroids HAPE - HA Pulm Edema - occurs when hypoxic pulmonary vasoconstriction becomes generalized leading to pulmonary hypertension and increase vascular permeability leads to alveolar edema HACE - HA Cerebral Edema - occurs d/t cerebral vasodilation, pts will die within two days (even greater than 24hrs) without therapy Acetazolamide can prophylax both

Question 473

JNC-8 BP Guidelines

Answer 473

<150/80 for >60 years <140/80 for <60 years or >60 w/DM or CKD

Question 474

AKI definition? In pt BS Goals?

Answer 474

^Cr >0.3 in <24hrs In pt BS Goals - 120 - 180

Question 475

Microscopic Colitis

Answer 475

Watery diarrhea in a 65 year old (w>m) RFs - NSAIDS, Tobacco... associated with celiac and AI thryroiditis DX - biopsy TX - bismuth, budesonide, mesalamine, cholestyramine, PO prednisone...

Question 476

Wallenberg's Syndrome Ondine's Curse

Answer 476

WS - Lateral Medullary Infarct - ipsilateral vestibular and cerebellar sx w/ bulbar symptoms... OC - apnea at the onset of sleep

Question 477

Normal Serum Osmolality

Answer 477

275 - 295 (solute concentration)

Question 478

What is the first delineation in SVT? What are examples of each category?

Answer 478

Irregular - A.Fib, MAT (3+ p-wave morphologies and irregular...wandering pacemaker is the normo-cadic version of this SVT) Regular - Sinus, AVNRT, AVRT Orthodromic (ventricles to accessory) AVRT Antidromic (accessory to ventricles)

Question 479

IV vs PO Diuretics?

Answer 479

1 IV = 2 PO (IV stronger) 40 Lasix = 1 Bumex

Question 480

What are the three meds for heart failure - BAS?

Answer 480

Beta blockers - Coreg (carvedilol) Metoprolol, Besoprolol Ace Inhibitors Spironolactone

Question 481

What are the antbiotics used as first line in ESBL resistant microorganisms?

Answer 481

Carbapenems - 1st go to Zosyn Fluoroquinolone - if sensitive Polymicin B - old drug Nitrofurantoin (Macrobid) - no CKD, no elderly

Question 482

what lab do you get if you have a concern for DIC? what is the treatment?

Answer 482

fibrinogen - if low then DIC is ruled in... cryoprecipitate because it has fibrinogen..

Question 483

SIRS ? QSOFA ?

Answer 483

SIRS - T, WBC, RR, HR QSOFA - RR, BP, AMS

Question 484

Altered Mental Status in ED best first thoughts?

Answer 484

Blood Glucose Narcan ABG EKG

Question 485

Define Neutropenic Fever and 1st antibiotic?

Answer 485

ANC < 500 with fever cefipime + vanco if concern for MRSA, vanco can cause redman syndrome...

Question 486

what should you never give a patient who is on methadone?

Answer 486

Zofran they can both cause QT elongation

Question 487

what does the deep sulcus sign suggest on CXR?

Answer 487

pneumothorax

Question 488

4 D's of Posterior Stroke...

Answer 488

dysarthria dissiness double vision disequilibrium

Question 489

Subclavian Steal Syndrome

Answer 489

Subclavian Steal - stenosis of the subclavian results in collateral circulation via the vertobrobasilar system which causes posterior cerebral symptoms.

Question 490

Long Acting Insulin Short Actin Insulin

Answer 490

Lantus - Glargine; Levemir - Determir Novolog/Humalog

Question 491

Loftgren Syndrome

Answer 491

Triad for Sarcoid 1. Hilar Fullness 2. Joint Pain - particularly ankles 3. Erythema Nodosum

Question 492

Wilsons Syndrome

Answer 492

Neuropsychiatric + Choreaform Movements + Cirrhosis + keyser Fleischer rings...

Question 493

Essential Tremor vs Parkinson's Tremor

Answer 493

Essential is non-distracctable Parkinsons is able to distract like if they hold something it stops.

Question 494

TTP mnemonic HIT mnemonic

Answer 494

TTP - FATRN - Fever, Anemia, Thrombocytopenia, Renal, Neurologic HIT - 4Ts - Thrombocytopenia, Time 5-10 days, Thrombosis, T-things to cause it.

Question 495

pentamidine robaxin

Answer 495

pentamidine - antimicrobial used to treat PCP pneumonia robaxin - methocarbamol - unknown mech of action but used to treat muscle spasm

Question 496

FeNa intepretation

Answer 496

< 1% - PRE-RENAL - (renal vasoconstriction, HRS, NSAIDs) > 2% - ATN

Question 497

CAD Risk Factors

Answer 497

``` HTN Smoker Low HDL DM FamHx of Premature CAD (Male < 55, Female <65 - first degree) ```

Question 498

TIMI Risk Calculation - AAABCCS

Answer 498

stratifies risk of ischemic events and death in people with UA/NSTEMI; 1 pt each ``` AGE >65 Aspirin in last 7 days Angina x 2 in 24hrs Biomarkers elevated CAD Known (>50% stenosis) CAD Risk factors x 3 ST Changes > 0.5mm in contiguous leads ```

Question 499

Eosinophilic Granulomatosis with Polyangiitis Granulomatosis with Polyangiitis Anti-glomerular Basement Membrane Antibody disease

Answer 499

Churg Strauss - RF + Blood Eosinophilia +/- Palpable Rash Wegener's - RF + Upper Lung sx + Lowe Lung Sx Goodpasture Syndrome - Anti basement membrane Abs to Kidney's Lungs

Question 500

Phlegmon

Answer 500

inflammation of the connective tissue just underneath the skin

Question 501

Complicated vs Uncomplicated UTI - definition and tx duration Complicated vs Uncomplicated Bacteremia

Answer 501

Complicated UTI - Male, Sx > 7 days, Anatomic/Mechanic Implements Uncomplicated UTI - 3-4 days Complicated Bacteremia - 2-4 weeks IV abx - prosthetic valve, septic mets/seeding, endocarditis, still + after 72 hours abx Uncomplicated Bacteremia - 2 weeks IV abx

Question 502

Stages of HF Classification of HF

Answer 502

Stages (1-4) - asx > slight limitation > marked limitation > sx at rest Classification (A-D) - at risk > structural dx no sx > structural with sx > refractory HF with specialized interventions

Question 503

Light's Criteria

Answer 503

Exudative if Protein (Pleural v Serum) > 0.5 Albumin (Pleural v Serum) > 0.6 Pleural LDH > 2/3 ULN

Question 504

Transudative Effusions Exudative Effusions

Answer 504

T - CHF, Cirrhosis, Nephrotic Syndrome, Peritoneal Dialysis E - infection, malignancy, PE, CABG, CT Dz, Inflammatory Dz

Question 505

Post Op Fever

Answer 505

"five W's" ``` wind - atelectasis - POD 1-2 water - UTI - POD3-5 walking - DVTs - POD4-6 wound - infection - POD5-7 wonder drugs - POD7+ - iatrogenic ```

Question 506

Indications for Dialysis - AEIOU

Answer 506

``` Acidemia Electrolytes - K Ingestions Overload - volume Uremia ```

Question 507

WHO PAH Classification

Answer 507

``` 1 - Idiopathic 2 - Left Heart Disease 3 - Lung Disease 4 - CTEPH 5 - miscellaneous ```

Question 508

Phosphate Binders in CKD

Answer 508

people with ESRD have problems getting rid of PO4 ips facto get rid of it... 1. Ca Containing - CaCO3, CaAcetate 2. Non-Ca Containing - Sevelamer (polycationic), Lanthanum (rare earth metal)

Question 509

Framingham Criteria Duke Criteria Jones Criteria

Answer 509

Framingham - heart failure Duke - infective endocarditis Jones - rheumatic heart disease

Question 510

Mesenteric Ischemia (acute and chronic)

Answer 510

Mesenteric Ischemia - acute - severe pain d/t embolization... chronic - pain with meals, food avoidance, nutritional deficiency, anorexia **ischemic colitis... same shit**

Question 511

MELD score MILAN criteria Child-Pugh score

Answer 511

MELD - model for end stage liver disease - uses bili, Cr, and INR MILAN - one lesion < 5cm, 3 lesions < 3cm, no extrahepatic manifestations, no vascular invasion Child-Pugh - assess prognosis of cirrhosis - bili, albumin, PT, ascites, hepatic encephalopathy

Question 512

LBBB vs RBBB direction of ventricular depolarization in V1

Answer 512

wide QRS LBBB - negative in V1 RBBB - positive in V1

Question 513

Free Water Deficit Eq.

Answer 513

FWD = Total Body Water(0.5 * Weight in Kg) * (SerumNa - 140) /140 TBW = 50% in males and 40% in females * wt

Question 514

V/Q should be about 1 Low V/Q vs High V/Q

Answer 514

Low V/Q = poor ventilation = shunt (blood keeps pumpin but not hitting any O2) = alveolar fluid, edema, pneumonia High V/Q = poor perfusion = dead spacing (alveoli are full of air that isn't moving around) = PE

Question 515

Normal Synovial Fluid - WBCs, Crystals, Glucose, Stain/Culture

Answer 515

Normal - < 200 WBCs Inflammatory - > 2000 WBCs (positively birefringent for pseudogout, negatively birefringent for gout, low glucose for RA) Septic - > 50,000 WBCs, low glucose, positive gram / culture

Question 516

cavernous sinus thrombosis

Answer 516

blood clot in the cavernous sinuses of the head -> usually caused by URI => sx of vision loss, chemosis (swelling of conjunctiva), exophthalmos, headache, CN palsies.

Question 517

Brain on Fire - what is the type of patient and what is the next step in work up...

Answer 517

Anti-NMDA R Antibody Syndrome - patient is usually a middle aged young woman and its usually associated antibody cross reactivity due to ovarian teratoma* Tx - Prednisone, IVIG, plasmaphoresis, estuximab

Question 518

Eosinophilic Pneumonitis

Answer 518

idiopathic vs eosinophilic granulomatosis with polyangiitis *can be idiopathic or triggered by meds, drugs, chemicals, parasitic (Lofflers syndrome), Dx - blood eosinophils, biopsy eos, lavage eos Tx - steroids

Question 519

Gerstmann Syndrome

Answer 519

destruction of the inferior parietal lobe 1. Agraphia 2. Acalcula 3. Finger agnosia 4. L/R disorientation

Question 520

Causes of Thrombocytopenia

Answer 520

HIT, TTP, ITP, Liver disease (portal stasis and splenomegaly), etoh

Question 521

HIT T-score

Answer 521

occur in 5-10 days of heparin therapy or less with prior episodes of HIT... suspect when platelets drop to 1/2 baseline Timing (5-10 days) Thrombocytopenis (<1/2 baseline or < 50K) Thrombosis without explanation The other causes - Depakote, sepsis resolves in 10-14 days *Serotonin functional assay (HIT assay) - > measures platelet activity... HIT antibodies

Question 522

Alternatives to heparin for DVT

Answer 522

Factor 10 inhibitors - Rivaroxaban (eliquis), Apixaban Direct Thrombin Inhibitors - bivalirudin LMWH - lovenox - enoxaparin - RENALLY DOSE (GFR<30) - better in cancer 1mg/kg BID

Question 523

DVT

Answer 523

Provoked - smoking, surgery, flights, OCPs, 6mos - 1 yr anticoagulation Unprovoked - intrinsic - lifetime AC

Question 524

How to treat PE?

Answer 524

Heparin Drip - loading dose of 5000U followed by drip to target PTT of 60 - 90. Check PTT Q6hrs

Question 525

NOACs - novel oral anti-coagulants - examples and contraindications

Answer 525

Pradaxa (dabigatran), Eliquis (apixaban), Xarelto (rivaroxaban) CIs 1. any heart valve issues 2. ESRD / Hemodialysis 3. Pregnancy 4. BMI > 40 5. Cancer 6. Spinal Epidural Abscess **These NOACs cause more GI bleeds but Fewer Intracranial bleeds than coumadin

Question 526

IV VitK Precautions

Answer 526

can cause anaphylaxis -> give 30-60 mins give FFP if actively bleeding

Question 527

What must you check to ensure appropriate replacement of K?

Answer 527

Magnesium, it blocks secretion of K in the kidney making replacement of K more efficacious.

Question 528

Brugada Syndrome

Answer 528

AD - genetic defect of Na Channels - Asian males ... susceptible to arrhythmia and sudden cardiac death ECG with pseudo-RBBB and ST elevations in V1-V3 Work up with echo stress test -> genetic testing if symptomatic, ICD is definitive tx

Question 529

Polychromasia

Answer 529

increased immature blood cells

Question 530

Hematologic Abnormalities in Cirrhosis

Answer 530

Most prominently Thrombocytopenia and Leukopenia often pancytopenia 1. Cirrhosis -> low hepatic Tpo (which is mostly produced by kidney) 2. Portal HTN -> splenic and splanchnic sequestration and intravascular hemolysis 3. Bone Marrow -> alcohol is a direct marrow toxin / viral suppression by hepB/C 4. Losses -> blood loss from GI bleeds due to portal hypertensive varicosity.

Question 531

stages of cirrhosis -> compensated vs decompensated

Answer 531

``` compensated ... 1 - no varices no ascites 2 - varices no ascites ... decompensated ... 3 - varices +/- ascites 4 - bleeding +/- ascites ```

Question 532

Clinical Course of Decompensated Cirrhosis

Answer 532

Portal Hypertension - variceal hemorrhage, ascites -> SBP, HRS Liver Insufficiency - Encephalopathy, Jaundice

Question 533

Hepatorenal Syndrome

Answer 533

a cirrhotic liver is unable to process splanchnic vasoactive substances like NO2 and prostaglandins and as a result these compounds get released systemically leading to decreased effective circulating volume and subsequent pre-renal AKI. Type 1 - rapidly declining renal function Type 2 - associated with ascites that does not respond to diuresis

Question 534

What is a common cause of thrombocytosis?

Answer 534

reactive thrombocytosis - inflammatory states cause the spleen to release thrombocytes that are otherwise sequestered.

Question 535

Na Correction in Hyperglycemia

Answer 535

add 1.6 Na / 100 mg Glucose over 100

Question 536

Jarisch Herxheimer Reaction

Answer 536

release of antigenic microbial molecules due to cell lysis following antibiotic therapy. First described in syphilis but also seen in other infections.

Question 537

SNAP - for actinomyces and nocardia

Answer 537

Sulfas -> nocardia Penicillin -> actinomyces

Question 538

What should ESRD on HD patients be on?

Answer 538

Ca/VitD and Phosphate Binders (pull PO4 out of the gut and prevent from entering circulation)