Teaching (bedside, ward, & sessions) - Weeks 1 & 2 Flashcards
Dr Van Alstine, Dr Chick, + teaching sessions
What are the 7 features of the JVP?
- Biphasic
- Emerges between the two heads of the SCM
- Nonpalpable
- Obliterated by pressure
- Position/height dependent
- Level lowers on inspiration
- Elevated with increased abdo pressure (AJR)
What is the FAILURE mnemonic for heart failure exacerbation?
Forgot meds Arrythmia, Anemia Ischemia, Infection Lifestyle Upregulation of CO Renal failure Embolism
What is an initial approach to falls? (2 categories)
Intrinsic
Extrinsic
What are the 4 main intrinsic causes of falls?
Syncope/Presyncope
Neuro/Psych Impairment
Sensory impairment
Reduced physical capacity
What are the 2 main extrinsic causes of falls?
Drugs
Environment
What are the 3 main causes of syncope?
- Cardiac (CHF, aortic stenosis, arrythmias)
- Orthostatic (volume depletion – can be due to Rx, diarrhea, low intake, hyperglycemia, other)
- Vasovagal / neurocardiogenic (eg with pain, panic, BM or micturition)
What neurological and psych issues can cause falls?
Stroke
Parkinsonism
Cognition
Depression (can have physical manifestations, esp in elderly)
What sensory causes can lead to falls?
- Bad vision (feet blurry when standing)
- Vestibular issues
- Neuropathy (position sense)
How can reduced physical capacity lead to falls?
- Weakness
- Balance & gait abnormaliites
- MSK pain
- Muscle-wasting pro-inflammatory conditions (eg DM, COPD)
How do medications lead to falls?
- Polypharmacy (>4 meds)
- Diuretics (worsen orthostatic hypotension)
- Psychotropic meds
What are the contributing mechanisms to psychotropic meds causing falls?
- can worsen orthostatic hypotension
- can cause parkinsonism
- can impair cognition and alertness
What features of a pt’s environment might contribute to falls?
- Rugs
- Stairs (esp w/o handrails)
- bad lighting
- footwear (eg socks, bare feet too)
What exam findings should be assessed when a pt presents with falls?
- Orthostatic vitals
- Arrythmia/murmurs
- Neuro/motor deficits
- gait, instability
- vision
What are the biggest risk factors for falls?
- Fall in the last year
- Impaired vision
- Impaired gait (weakness, pain)
Why should a pt with new fever be Dx with “fever NYD” and not “fever of unknown origin”?
Fever of unknown origin has a specific definition:
- fever higher than 38.3ºC on several occasions
- lasting for at least three (some use two) weeks
- without an established etiology despite intensive evaluation and diagnostic testing (original definition: Uncertain diagnosis after one week of study in the hospital)
What is the initial workup before Dx of Fever of unknonwn origin?
- History
- Physical examination
- Complete blood count
- Blood cultures
- Routine blood chemistries, including liver enzymes and bilirubin
- If liver tests are abnormal, hepatitis A, B, and C serologies
- Urinalysis (incl microscopic examination & culture)
- CXR
What are the stipulations for blood culture Ix, before Dx Fever of unknown origin?
Three sets drawn from different sites with an interval of at least several hours between each set
In cases in which antibiotics are indicated, all blood cultures should be obtained before administering antibiotics
What three general categories of illness account for the majority of “classic” FUO cases?
- Infections
- Malignancies
- Systemic rheumatic diseases (eg, vasculitis, rheumatoid arthritis)
What is the TRAP mnemonic for Parkinson’s?
Tremor
Rigidity
Akinesia
Postural instability
What are the most common presenting findings of Parkinson’s?
Tremor
Syncope with orthostatic hypotension
More rarely: dementia
What presenting history is common in Parkinson’s from the patient?
Pt often complains of difficultly sleeping (because they can’t turn in bed) and difficulty with knobs and jars
What presenting history is common in Parkinson’s from the patient’s spouse?
Spouse often reports tremor, and notes that pt is very slow
What is more useful in diagnosing Parkinson’s, the history or the exam?
History is not as helpful in Parkinsons: exam more helpful
If a pt feels faint while you are assessing orthostatic vitals, should you support them to keep them standing?
No: even if you’re able to, brain is hypoperfusing
If you do this you can cause GTC in pt!
Why should you not send nursing to do your orthostatic vitals?
Most imp thing is the HR, and nursing generally just takes BP
What fevers are typically higher, infectious or malignant?
Infectious: malignant fevers usually low grade
What is seen on orthostatic vitals in parkinson’s pt?
Pulse stays the same
Parkinsons has central dysautonomia: unable to generate tachycardia
Pulse jump makes parkinson’s less likely.
What are the features of a parkinsonian tremor?
- resting
- pill-rolling: at wrist, large amplitude, low frequency
- consciously suppressible
Describe the gait of a pt with parkinsons
festinating
stooped
shuffling
hesitation at lines on the floor, doors
How is the glabellar tap test done?
Tap on the glabella, reaching from behind the head (so pt can’t see hand)
Tap 10x
Pt stops blinking after <7 taps: negative
Pt continues to blink for 10 or more taps: positive
Rhyme off a basic list of things to ask about on ROS
headache CP SOB abdo pain N/V/D urinating, BM any other aches, pains, or changes
DDx for lytic lesions
Thyroid Lung, Breast Renal cell Ca, Adrenal Prostate Melanoma
(Star of David mnemonic: one in each area on the “body” that it makes. Alternately, think of “paired” organs)
What is the first categorization in the approach to anemia?
Microcytic (MCV <80)
Normocytic (MCV 80-100)
Macrocytic (MCV >100)
What are common causes of microcytic anemia with low or normal reticulocyte count?
- Iron deficiency (late)
- Anemia of chronic disease/inflammation
- Sideroblastic anemias
- Copper deficiency; zinc poisoning
What are common causes of microcytic anemia with elevated reticulocyte count?
Thalassemia
Hemolysis, particularly with RBC fragmentation
What are common causes of normocytic anemia with low or normal reticulocyte count?
- Bleeding (acute)
- Iron deficiency (early)
- Anemia of chronic disease/inflammation
- Bone marrow suppression (cancer, aplastic anemia, infection)
- Chronic renal insufficiency
- Hypothyroidism
- Hypopituitarism
- Excess alcohol
What are common causes of normocytic anemia with elevated reticulocyte count?
Bleeding (with bone marrow recovery)
Hemolysis
Bone marrow recovery (eg, after infection, vitamin B12 or folate replacement, and/or iron replacement)
What are common causes of macrocytic anemia with low or normal reticulocyte count?
Vitamin B12 or folate deficiency Excess alcohol Myelodysplastic syndrome Liver disease Hypothyroidism HIV infection Medications that interfere with nuclear maturation (hydroxyurea, methotrexate, some chemotherapy agents)
What are common causes of microcytic anemia with elevated reticulocyte count?
Hemolysis
Bone marrow recovery (eg, after infection, vitamin B12 or folate replacement, and/or iron replacement)
Why is hemolysis usually associated with some degree of macrocytosis?
Reticulocytes are larger than mature RBCs
What should you order for a pt with suspected hemolytic anemia?
Hemolytic workup:
LDH, haptoglobin, bilirubin
and usually: reticulocyte count
What should you do if someone reports K > 5.7 ?
Stat ECG
What clinical exam test has a high LR for obstructive lung disease?
FET > 9s
Test: Auscultate larynx and time from beginning to end of expiration
What three things can cause a line along a lung fissure on CXR?
Fibrosis
Fluid
Atelectasis
If we’re being picking about terms, what is “silhouetting” on CXR?
Loss of silhouette
What is a white out on CXR?
Completely opacified hemithorax
What lung finding can you not technically report on on auscultation of the lungs, and what should you say instead?
Air entry: say “breath sounds” instead.
Name three physical exam findings for volume overload.
Edema
JVP
Crackles (lungs)
What is post-intensive care syndrome?
No formal definition; generally, changes in function after intensive care in one of the following domains:
- Cognitive function
- Psychiatric function
- Physical function
What is refeeding syndrome?
condition caused by rapid reinitiation of normal nutrition in a chronically malnourished patient (e.g., patients with anorexia nervosa, chronic alcohol overuse)
What is the pathophys of refeeding syndrome
- shift from a catabolic to an anabolic state
- massive release of insulin
Causes severe electrolyte imbalances and fluid retention.
What electrolyte imbalances are seen in refeeding syndrome?
hypophosphatemia
hypokalemia
hypomagnesemia
What are the clinical features of refeeding syndrome?
edema
cardiac arrhythmias
seizures
ataxia
How is refeeding syndrome managed/prevented?
- monitor lytes closely
- replete lytes if needed
- reintroduce normal nutrition slowly
What are the 5 things that you should think about for a pt that has extreme leukocytosis? (WBC in 20s)
- C. diff
- infection (septic)
- Acute myeloid leukemia
- leukemoid reaction (to high high stress)
- steroids (diagnosis of exclusion)
What is the mechanism of leukocytosis in steroid use?
Demarginalization of WBC from endothelium
What is POTS?
Postural orthostatic tachycardia syndrome. Hallmark is exaggerated heart rate increase in response to postural change.
Increase in resting HR by ≥30 within 10 minutes of moving from a supine to an upright position
What is the gender ratio in POTS?
F:M is 5:1
What physical exam findings are helpful in assessing for volume depletion?
Key: Orthostatic vitals Dry mucous membrane, tongue furrow Axillary moistness (feel with glove on hand)
What physical exam findings are not helpful in assessing volume depletion?
Sunken eyes, cap refill, skin turgour (helpful in peds, not adults), JVP (“JVP is flat” doesn’t mean depletion)
If your pt has normocytic anemia + elevated Ca++, what should you think of?
Multiple myeloma
What does SBAR stand for?
Situation
Background
Assessment
Recommendation (/request)
Use when you call a consultant.
What is the MASCC score?
Risk index for patients with neutropenic fever
Looks at
- symptom severity
- comorbidities (hypotension, COPD, malignancy, dehydration)
- inpt vs outpt
- age
What is Lofgren’s syndrome?
Sarcoid arthopathy
Triad of hilar adenopathy, acute arthritis, and erythema nodosum; sometimes fever
What is erythema nodosum?
delayed-type hypersensitivity reaction that most often presents as erythematous, tender, palpable nodules on the shins
If you have a pt with HF on a beta blocker who develops an exacerbation, what should you do?
Hold the beta blocker: acute HF is a contraindication
What is a standard drink? (serving of alcohol)
14g ethanol
1.5oz shot, half glass of wine, bottle of beer
What criteria qualify as “risky drinking”?
> 2 a day for men
1 a day for women
every day
4 in one day
What EtOH threshold puts pt at increased risk for alcoholic hepatitis?
1.5 drinks / day for 20y
vast majority won’t get, but, increased risk
What EtOH threshold puts pt at increased risk for alcoholic cirrhosis?
2 drinks / day for 30y
vast majority won’t get, but, increased risk
What liver chemistry values should make you think of alcoholic hepatitis?
AST:ALT > 2
Which labs assess actual liver function?
INR, PTT albumin bilirubin platelets glucose (monitor for hypoglycemia)
Why is glucose a measure of liver failure?
- depletion of hepatic glycogen stores
- impaired gluconeogenesis
Why monitor glucose in pt with liver failure?
Hypoglycemia occurs in more than 40 percent of the patients with acute liver failure; associated with increased mortality
(Consider adjusting DM Rx)
What should you think when a pt has prolonged INR and PTT, and a fever?
DIC sepsis
What should you do if you’re suspecting liver failure vs DIC?
Liver doesn’t make vWF or factor 8; if factor 8 is normal, it’s liver (not DIC)
What is the DDx for liver failure?
- Toxins (EtOH, acetaminophen)
- Obesity (DM, NASH)
- Obstruction (stone, CA)
- Viral
- Autoimmune
- Budd Chiari, portal vein thrombosis
- Hereditary (Hemochromotosis, Wilson’s)
- Shock liver / ischemic liver
What is the treatment for liver failure?
Supportive!
Fluids, gravol
CIWA if applicable
If severe, consider prednisolone
What is the Maddrey score?
Used to score prognosis in alcoholic hepatitis
Uses PT and bilirubin
What is the MELD score?
Stratifies severity of end-stage liver disease. Used for transplant planning.
What should you monitor daily in pt being treated for liver failure?
Daily extended lytes: monitoring for refeeding syndrome
What is the “thousands club” and what’s in it?
Causes of acute hepatitis that can cause AST and ALT in the 1000s
Tylenol OD Budd Chiari Autoimmune Shock liver Stones Wilson's Rarely, viral
What is Budd-Chiari syndrome?
Obstruction of hepatic venous outflow
Originates anywhere from the small hepatic veins inside the liver to the inferior vena cava and right atrium.
What causes Budd-Chiari syndrome?
Most commonly due to a thrombotic occlusion secondary to a chronic myeloproliferative neoplasm (e.g., polycythemia vera), but may be caused by other conditions associated with hypercoagulable states.
The obstruction of blood flow causes congestion of the liver with subsequent liver cell damage.
How does Budd-Chiari syndrome present?
hepatomegaly, ascites, and abdominal discomfort.
Can progress to liver failure
What should you do if you have suspected EtOH-related liver failure and AST & ALT in the 1000s?
Look for another cause
EtOH not in the 1000s club
What can cause hepatic encephalopathy?
Two most common:
EtOH
Discontinuation of lactulose
Others:
SBP
Portal vein thrombosis
Electrolyte disturbances, esp hypokalemia
Rx: esp benzos
GI bleed
Large volume paracentesis, esp if dehydrated
If a person has hepatic encephalopathy, what is the most likely treatment?
Give lactulose
How should lactulose be dosed?
Titrate to 2-3 BM per day
To make it easier, usually scheduled till target BM, then hold
What other neurologic finding is common in hepatic encephalopathy?
Myoclonic jerks
(eg might have when eating: bringing food to mouth, & hand/arm jerks)
Think of as increased tone: the opposite of asterixis (which is inability to maintain tone)
What is the treatment for portal vein thrombosis?
RV with hematology: conundrum of person with liver that’s not making coag factors, who needs anti-coagulation
If treating, dalteparin
What should be done post-paracentesis when you remove 5L of fluid or more?
Give back albumin.
For each L over 5L, give 1unit of 25% albumin
What technology is standard of care in paracentesis?
Ultrasound
Can do without if you don’t have it and it’s necessary, but if you have it and don’t use it you are liable if eg bowel perforation
What is SBP?
Spontaneous bacterial peritonitis
What should you do if you drain a large volume of ascites and it returns 2d later?
Consult liver transplant team
What is TIPS?
Transjugular intrahepatic portosystemic shunt
- Shunts from portal vein to hepatic vein
- Indicated in refractory ascites, among other cases (eg to prevent varices)
What are the indications for TIPS?
- Bleeding related to portal hypertension (usually from varices)
- Refractory ascites
- hepatorenal syndrome
- Budd Chiari
- hepatic hydrothorax
What are the absolute contraindications for TIPS?
CHF Severe tricuspid regurg Severe pulmonary HTN Multiple hepatic cysts Active systemic infection or sepsis Biliary obstruction
Practical knowledge: how should you present a pt at multi-D rounds?
So & so admitted with ______. Active issues are _____. (eg resp status, not specific tests/plan; remember rounds are more for allied health than for us)
eg if mobility is main issue, ask PT. If behaviour, ask nursing how pt was overnight. If complex, will talk to multiple people.
As a clerk how can you beef up your assessment and plan?
- DDx
- Instructions/plan eg “keep ____ above ____” )
- [allied health team] to see
- “if ____ continues to rise, ____”
Shows what you know and are thinking of; can also show want you’ve ruled out.
What prophylaxis is indicated in pt with SBP?
Because SBP recurs within a year in up to 70% of patients, prophylactic antibiotics are indicated.
Quinolones are most widely used. eg cipro, or (eg, norfloxacin 400 mg orally once/day)
What lab should you order for a pt with muscle weakness?
CK
What are the two main categories of hypercalcemia?
PTH-related
non-PTH-related
Which mnemonic captures the symptoms of hypercalcemia?
Stones, bones, abdominal moans, psychiatric overtones
What are the standard medications for advanced liver disease?
spironolactone
lactulose
furosemide
pantoloc
What can prolong QT interval?
Meds! (if you have a pt with long QT, check if their meds prolong it!)
Hypokalemia
Hypomagnesemia
What are the renal-related Sx/manifestations of hypercalcemia?
Nephrolithiasis
Nephrogenic diabetes insipidus
Dehydration
Nephrocalcinosis
What are the MSK and derm Sx/manifestations of hypercalcemia?
Bone pain
Arthritis
Osteoporosis
In hyperparathyroidism: Osteitis fibrosa cystica (subperiosteal resorption, bone cysts)
Itching
Keratitis, conjunctivitis
What are the GI Sx/manifestations of hypercalcemia?
Nausea, vomiting
Anorexia, weight loss
Constipation
Abdominal pain
Pancreatitis
Peptic ulcer disease
What are the neuro/psych Sx/manifestations of hypercalcemia?
Impaired concentration and memory
Confusion, stupor, coma
Lethargy and fatigue
Muscle weakness
Corneal calcification (band keratopathy)
What are the cardiac Sx/manifestations of hypercalcemia?
Hypertension
Shortened QT interval on electrocardiogram
Cardiac arrhythmias
Vascular calcification
What are the PTH-related causes of hypercalcemia?
Primary hyperparathyroidism
Tertiary hyperparathyroidism (assoc with renal failure or vitD deficiency)
What are the non-PTH-related causes of hypercalcemia?
Malignancy
Medications
Metabolic
Other
How can malignancy cause hypercalcemia?
- PTHrP (secreted by solid tumours, esp lung, head, and neck squamous CA, renal cell tumors)
- Local osteolysis by multiple myeloma, BrCA
Which medications cause hypercalcemia?
Thiazide diuretics
Lithium
Calcium antacids (milk-alkali syndrome)
Vitamin A intoxication
How does vitamin D cause hypercalcemia?
- usually OTC supplements
- granulomatous disease: sarcoidosis, berylliosis, TB
- Hodgkin’s lymphoma
What metabolic/endocrine disorders can cause hypercalcemia?
Hyperthyroid
Adrenal insufficiency
Acromegaly
Pheochromocytoma
What genetic disorder causes hypercalcemia? How? How common is it?
Familial hypocalciuric hypercalcemia
Mutation for calcium-sensing receptor.
Rare, but consider if young & not finding another cause.
You detect hypercalcemia, take a history and physical, and find a potential source. What do you do?
Stop source/cause, and re-check calcium.
You detect hypercalcemia, take a history and physical, and don’t find a potential source. What do you do?
PTH
Pt with hypercalcemia and no known cause has high PTH. What do you do?
Work up for cancer, notably:
- elevated PTHrP: adeno and squamous CA
- elevated alk phos: bone lysis (eg BrCA)
- myeloma screen
- elevated calcitriol: lymphoma, granulomatous disease
Pt with hypercalcemia, no known cause, high PTH has negative malignancy workup. What do you do?
Endocrinopathy workup; consider referral to endo
- hyperthyroid (TSH, T4)
- adrenal insufficiency (cortisol)
- acromegaly (insulin-like growth factor 1)
Pt with hypercalcemia, no known cause, has normal or high PTH. What do you do?
Check 24h urinary calcium level
Pt with hypercalcemia, no known cause, low/normal PTH has low 24h urinary calcium. What do you do?
Dx is Familial hypocalciuric hypercalcemia
Pt with hypercalcemia, no known cause, low/normal PTH has normal/high 24h urinary calcium. What do you do?
Dx is primary or tertiary hyperparathyroidism.
Consider surgical referral
What is the treatment for serotonin syndrome?
Supportive
Telemetry, benzos
Consider transfer to ICU
What are the physical exam findings of a pt with serotonin syndrome?
Classic triad:
- neuromuscular excitability
- autonomic dysfunction
- altered mental status
Vitals: tachycardia, HTN
Severe: swings in HR and BP, hyperthermia
Common:
- Deep tendon hyperreflexia
- Inducible or spontaneous muscle clonus
(Neuro findings typically more pronounced in lower extremities)
General: Agitation, Flushed skin and diaphoresis, dry mucus membranes
Neuro: Dilated pupils, Slow, continuous, horizontal eye movements (referred to as ocular clonus), tremor, akathisia, muscle rigidity, bilateral Babinski signs
GI: N/V/D, Increased bowel sounds
What labs do you do to confirm serotonin syndrome?
None: it’s a clinical diagnosis
What are the clinical features of NMS?
fever, rigidity, mental status changes, and autonomic instability
(Each of these presents in 97-100% of pt.)
Typically evolves over 1-3d.
How do you differentiate SS from NMS?
Generally,
- SS more “up” (shivering, hyperreflexic, myoclonic, ataxic) and NMS more
- SS has N/V/D in prodrome, rare in NMS
- NMS slower, SS faster
What labs should you order in NMS, and what values would you expect?
CK
Early may not be too elevated
Typically >1000, sometimes up to 100 000s
What is creatine phosphokinase?
Same thing as CK (creatine kinase)
Sometimes called CPK
What is VRE?
Vancomycin-resistant enterococci
bacterial strains of the genus Enterococcus that are resistant to the antibiotic vancomycin (e.g., E. faecalis , E. faecium)
What should you do if your pt has klebsiella bacteremia (diagnostically)?
Always chase a source
Klebsiella is not a common pathogen: you want to know where it is coming from.
What is the relation of betablockers to thyroid function?
Can be used to treat Sx of hyperthyroidism (if not contraindicated)
hyperthyroidism is associated with an increased number of beta-adrenergic receptors; increased activity responsible for many of the Sx. Beta blockers block.
What is the dose conversion of Lasix from IV to oral or vice versa?
Potency of IV:oral is 2:1
So take oral dose and double it for IV, or take IV dose and cut it in half for oral.
Which valve is most commonly affected in IVDU-related endocarditis?
R sided
tricuspid
What is HLH?
Hemophagocytic lymphohistiocytosis
life-threatening syndrome of immune activation that results in widespread inflammation and tissue destruction. Manifestations include fever, hepatosplenomegaly, pancytopenia, and neurologic dysfunction (e.g., altered mental status, seizures).
What are the clinical / lab features of multiple myeloma?
CRAB: Calcium: hypercalcemia (> 2.75) Renal insufficiency: creatinine clearance < 40 mL/min or serum creatinine > 2 mg/dL Anemia (Hb < 10 g/dL) Bone lesions on MRI
What is the main criterion for diagnosis of multiple myeloma?
≥ 10% clonal bone marrow plasma cells in biopsy
What is sometimes done with parathyroid glands during a thyroid resection?
Put in the arm!
If you measure ACTH in a pt with SSx of adrenal insufficiency and it’s high, pt has …
Primary adrenal insufficiency
If you measure ACTH in a pt with SSx of adrenal insufficiency and it’s low, pt has …
secondary adrenal insufficiency: ACTH feedback loop is inhibited by alternate source (eg exogenous steroids)
If you have a young pt with hyponatremia and there’s no clear cause what test should you consider?
ACTH
What would you do to evaluate adrenal function in a pt with equivocal am cortisol?
Give ACTH, see if cortisol rises appropriately; if not, adrenal insufficiency
What can you do if you want an AM cortisol but pt needs to be on steroids?
Switch to dex: doesn’t act on the ACTH feedback loop
What is SPEP?
Serum Protein ElectroPhoresis
measures the amount of protein (e.g., albumin, globulins) in the blood.
Used to Dx multiple myeloma, Waldenstrom macroglobulinemia, amyloidosis, MGUS, and Castleman disease.
What disorders are associated with Anemia of Chronic Disease?
infections inflammation malignancy COPD heart failure trauma aging obesity DM
What are the lab findings for anemia of chronic disease?
Usually normocytic, normochromic, hypoproliferative (low retic)
Low iron
Low iron saturation
Low TIBC
Elevated or normal serum ferritin
K+ is 2.9, what do you do?
Give K+, and do it now
story of nephrologist who came to see pt, student waiting for staff, who said “you don’t wait for a K+ of 2.7”
When you’re replacing K+ for a pt with GI Sx, how long should you replace?
Till no longer vomiting or having diarrhea (till no longer losing it)
What medications should any pt with recent ACS be on?
Aspirin Other antiplatelet drugs (eg ticagrelor) Beta blocker ACE inhibitor (or ARB) Statin
What are the main side effects of colchicine?
Diarrhea
Name three things on the DDx for a pt with elevated ACE (on labs)
Sarcoid
Lymphoma
TB
Practical knowledge: When you have a new-to-you pt with a complex medical Hx/course in hospital that you haven’t fully reviewed and you’re presenting to your staff, what is one basic thing you should have?
Active problem list and a DDx for each
Eg pt is on O2, so they have hypoxia: PE? Pneumonia? MI, dissection, CHF? Severe anemia? Say what is most likely or what has been ruled out
