UWORLD 8 - CCS Flashcards

Question

Therapy for COPD Exacerbation

Answer 1

Bronchodilators (inhaled) - albuterol nebulizer, continous Steriods (IV methyl prednisone) Antibiotics (oral or IV) Counseling Influenza vaccine pneumococcal vaccine

Answer 2

Mammography (not commonly used for women \<35) FNAB and/or Breast US Pap Smear

Answer 3

Reassurance Counseling (patient counseling, contraception advise, safe sex, smoking cessation. limit alcohol intake, safety plan, seat belt use, regular exercise) Follow up physical exam every 3 to 6 months for 1 year

Answer 4

**Inital BP lowering management** - If no evidence of stroke, lower DBP to 100-105 over 2-6 hours. Do NOT drop BP by more than 25% - IV nitroprusside (first line) - Alteratives (IV labetalol, nicardipine) - Transfer to ICU - Arterial line for BP measurement **After 25% drop in BP is achieved** **-** Transfer to ward - D/C arterial line - Change to PO anti-hypertensive **Once BP is under control** **-**Discharge to home - Lipid profile - Counseling (medication compliance, smoking cessation, exercise, limit alcohol intake, low salt diet)

Answer 5

IV access Oxygen Pulse Ox Cardiac Monitor BP Monitor

Answer 6

12 Lead ECG Head CT (without contrast) CBC BMP CXR UA Llipid profile

Answer 7

1. NPO 2. Complete bed rest 3. IV antihypertensive (IV Nitropressuide, continous) 4. Counseling

Answer 8

Oxygen Pulse Oximetry IV access

Answer 9

1. CXR-PA/Lateral 2. X-ray Neck 3. CBC 4. Rigid bronchoscopy

Answer 10

1. Bronchoscopy 2. Counseling Schedule appt in 1-2 weeks

Answer 11

IV access Pulse Ox Oxygen Cardiac Monitor ECG Glucometer Glucose

Answer 12

CBC BMP CXR TSH U/A Urine toxiciology screen Cardiac enzymes

Answer 13

1) Benzodiazepines (Alprazolam, sublingual, one time) 2) Reassurance 3) Counseling (patient counseling, no caffeine, no nicotine, no alcohol) Follow up in two weeks

Answer 14

**Indications** - symptomatic with 70% to 99% stenosis - Greatest benefit if done within 14 days of the last symptomatic event **Contraindications** - 100% carotid stenosis - Previous stroke with persistent neurologic symptoms - Poor surgical candidate Pharmcotherapy with **aspirin** is indicated prior to the procedure and shoudld be continued **indefinitey**. **Clopidogrel** is an **acceptable** **alternative** in patients who are unable to tolerate aspirin. **-Warfarin and heparin are NOT INDICATED unless there is AFIB** **-Pre-ops antibotics** (Cefazolin, 1 gram, IV) recommended due to frequent use of prosthetic material **- Risk factor management (**HTN, DM, smoking, dysplipidedmia)

Answer 15

**Antithrombotic therapy for AFIB** **-Heparin use for acute TIA is controversial** - **Anticoagulate with warfari, dabigatran, apixaban, or rivaroxaban** is used for all patients who can tolerate anticoagution therapy - **use of direct thrombin inhibitor or a factor Xa inhibitor is preferred** to **warfarin,** unless there are cost or compliance concerns, the patient is already on warfarin, or there is signifcant renal failure (GFR \<30)

Answer 16

Head CT (without contrast) CBC with diff BMP ECG Cardiac monitor Carotid Doppler Glucometer glucose Echocardiogram Lipid profile HBA1C MRI, head MRI, brain **Before CEA surgery** NPO PT/INR PTT

Answer 17

IV access Aspirin CEA Cefazolin, IV one time Counseling (no smoking, no alcohol, regular excerise, diabetic diet, med compliance, better BP control, DM control)/

Answer 18

HCG, qualitative Gram stain, cervix Gonococcal culture Chlamydial culture UA Urine culture CBC BMP VDRL or RPR HIV Pap smear

Answer 19

**IV access** **Normal Saline** **Antibotics** _Inpatient_: IV cefoxitin, IV doxycycline _Outpatient_: Doxycycline, oral x 14 days **Antimetics** **Analgesics** (IV morphine, one time) **Antipyretics** (Acetaminophen, IV) **NPO** **Bedrest** *\*Do not wait for culture results to initate empiric antibiotics against N.gonorrha and C.trachomatis*

Answer 20

**Intrinsic coagulation pathway** _Inherited causes_ Factor VIII (hemophilia A) Factor IX (hemophilia B) Factor XI Von Williebrand disease _Acquired causes_ Antiphospholipid syndrome Heparin use

Answer 21

CBC with differential BMP Bleeding Time PT PTT LFT Factor VIII, plasma Factor IX, plasma Factor XI, plasma

Answer 22

Factor VIII, therapy No aspirin Counseling Consult, genetics \*Monitor PTT value

Answer 23

pulse oximetry oxygen cardiac monitor continous BP monitor 12 lead ECG IV access ASA Nitroglycerine \*MUST ORDER THESE BEFORE PHYSICAL EXAM

Answer 24

12 lead ECG Cardiac enzymes CXR CBC BMP LFT Lipid profile PT/INR and PTT Echocardiography Cardiology consult Cardiac catherization

Answer 25

IV access Oxygen Aspirin Nitroglycerine Hepatrin Metoprolol Eptifibatide (GP IIB/IIIA inhibitor should be added before sendin gpatient for catherization) Simvastatin Cardiology consult Cardiac catherization NPO Bed rest Counseling

Answer 26

**Mild (barking cough, no stridor at rest, no retractions)** - cool humidified mist and oxygen (relieves airway edema and decreases viscosity of mucus) - monitor for development of bronchospasm in suspectible children - oral dexamethasone **Moderate-severe symptoms (stridor at rest, moderate-severe retractions, anxious/agitated)** - add nebulized epinephrine - if no improvement, admit **In all cases** - if bacterial infection is suspected, add antibiotics (2nd generation cephalosporin) - arrange outpatient follow up

Answer 27

oxygen pulse oximetry

Answer 28

CBC Neck Xray BMP

Answer 29

humidified air epinephrine (inhaled) dexamethasone (oral) counsel patient

Answer 30

**If impending respiratory arrest is suspected, then?** **-** Intubate, mechanically ventilate and admit to ICU - Administer nebulized albuterol/ipratropium - Administer systemic steriods

Answer 31

**PEFR \<40% predicted:** - Administer oxygen therapy with goal pulse ox \>=90% - Administer albuterol/ipratropium by nebulizer (q20 min) - IV steriods (then gradully taper) - Reassess PEFR every hour - Decision to admit within 4 hours **PEFR \>40% predicted:** - administer oxygen therapy with goal pulse ox\> or -90% - administer albuterol by nebulizer (q20mins) - consider oral steriods (gradually taper if initated) - If PEFR does not improve to \>70% predicted, then add ipratropium - decisiton to admit within 4 hours. **Decision to admit** - Admit for PEFR \<40% predicted at 4 hours - Consider admission for PEFR 40-70% at 4 hours - Discharge to home for PEFR \>70% at 4 hours

Answer 32

Pulse oximetry oxygen IV access Head elevation Cardiac monitor

Answer 33

Peak flow (PEFR) ABG ECG CXR CBC BMP

Answer 34

Oxygen albuterol, nebulizer Iptratropium bromide (nebulizer, continuous) Steriods counseling

Answer 35

CBC with diff BMP Serum magnesium Serum phosphate TSH FOBT Colonoscopy HBA1C

Answer 36

High fiber diet Metamucil (psyllium) oral hydration low salt diet low fat diet exercise program patient counseling

Answer 37

CBC with differential BMP LFT FOBT Abdominal xray Abdominal US UA PT/INR PTT

Answer 38

NPO IV access IV Normal saline IV analgesia (morphine) IV antiemetics IV cefoxitin Surgery consulut Laproscopy

Answer 39

CBC with diff BMP Blood cultures PT/INRPTT X-ray of the Knee Synovial fluid analaysis Synovial fluid gram stain & culture

Answer 40

**IV access IV NSS 0.9%** **Acetaminophen, oral, continuous** **NPO** **IV analgesia** (Morphine, IV, one time) **IV antibotics Ortopedic consult** **Arthroscopy** (when there is failure to adequately drain the knee joint with joint aspiration) **Counseling**

Answer 41

**Broad spectrum coverage** IV 3rd generation cephalosporin (ceftriaxone, ceftazidmine, cefotaxime) with IV vancomycin.

Answer 42

**_Gram stain shows gram-positive cocci_** _MRSA_: IV Vancomycin x 4-6 weeks _MSSA_: IV nafcillin or IV cefazolin for 2 weeks then 2-4 more weeks of oral antibiotics ***\*Staph aureus is the most common cause of non-gonococcal arthritis in adults*** **_Gram stain shows gram-negative bacilli_** IV 3rd geeneration cephalosporin (ceftriaxone x 14 days), then 14 days oral antibiotics

Answer 43

Qualitive urine HCG Serum TSH Serum Prolactin CBC with differential PT/INR PTT

Answer 44

_Mild DUB (normal Hgb)_ **Iron supplementation alone is sufficient** _Moderate DUB (Hgb = 10-12)_ **Iron supplementation** **Progestin-only OCP (preferred in absence of active bleeding)** **Combination OCP (preferred in presence of active bleeding)** _Severe DUB (Hgb\<10)_ **Depending on severity, hospitalization, transfusion as needed** **Hormonal therapy: Combination OCPs with high estrogen if stable; IV estrogen if unstable** (D&C and/or surgery are rarely necessary)

Answer 45

OCP Iron sulfate Reassurance Counseling - Med. compliance - safe sex - regular exercise - seat belt use

Answer 46

Pulse Ox Oxygen Cardiac monitior BP monitor 12 lead ECG IV access

Answer 47

CBC with differenital BMP Chest x-ray CK-MB Troponin I ESR BLood cultures Echocardiography

Answer 48

NSAIDs Colchicine Reassurance Counseling

Answer 49

_Stable, alert and non-intoxicated_ - proceed with **abdominal CT with contrast** - If **no intradominal injury**, just **observe** and perform serial exams - If **intrabdominal injury +/- hemoperitoneum**, **hospitalize** and consider conservative management or immediate lapartomy, depending on the extend of injury and the quantity of blood loss _Unstable, unconscious or intoxicated_ - proceed with **abdominal US** - If there is **no intraperitoenal hemorrhage**, perform **abdominal CT**; then manage as above - If there **is intraperitoneal hemorrhage,** perform **immediate** **lapraotomy**. Surgery consult should be obtained in all cases.

Answer 50

C-spine immobilization IV access IV NSS 0.9% Pulse Oximetry Oxygen BP Monitor Cardiac Monitor *\*Cervical spine immobilization should be performed before the physical exam*

Answer 51

CBC with diff BMP LFT Serum Amylase Serum Lipase UA ABG PT/INR PTT Blood type & crossmatch Blood ethanol Urine toxicology screen Urine Qualitative HCG 12 lead ECG Spine Xray CXR Abdominal Ct Urine output \*Surgery ocnsult should be obtained immediately following the exam

Answer 52

NPO General Surgery consult Foley catheter IV analgesia IV anti-emetics Cousneling - Avoid contact sport - no alcohol - no smoking - seat belt use \*\*Surgery ocnsult should be obtained immediately following the exam

Answer 53

_Mild:_ - **No diagnostic investigations** - **Outpatient empiric antibotics** - If **purulent cellulitis** (purlent drainage or exudate, no drainable abscess), **MRSA** is suspected - **Clindamycin, TMP-SMX (Bactrim), Doxycycline or Linezolid** - If **nonpurlent** **cellulitis** (no purlent drainage, exudate, or abscess), beging empiric coverage for **beta-hemolytic streptocci and MSSA**- **Clinidamycin, Amoxiccillin + TMP-SMX, Amoxicllin+Doxyclicline, or Linezolid** _Severe: Systemic toxicity, extensive skin involvement, or failure of the inital antibiotics regimen_ - **Hospitalize** - **Limited diagnostic work-up** to rule out alternative diagnosies (xray of the affected extremity, CBC, BMP, blood cultures) - **Parenteral antibiotics with IV vancomycin** (until MRSA is ruled out) or clinidamycin; **switch to oral antibiotics upon clinical improvement** * \*Supportive therapy (leg elevation and heydration) in all cases; treatment of underlying conditions if present*

Answer 54

**NSAIDS** **(naptroxen, indomethacin) a**re the drugs of choice for acute gouty arthritis **if no contraindications** (renal failure, heart failure, PUD, NSAID allergy) are present If NSAIDS are contraindicated, **use intraarticular or oral steriods** If NSAIDs and Steriods cannt be given, **administer cholchicine,** but be aware of the **high incidence of side effects** (diarrhea, abdominal cramps, N&V). **Allopurinol** should not be presecribed in acute gouty arthritis because it may worsen the acute attack. It is primarily used for **prevention of recurrent gout.**

Answer 55

Avoid aspirin & diuretics (if possible), excessive amoutn of alcohol and purine rich food. For overweight and obese patients, recommend weight loss through diet and exercise.

Answer 56

CBC with diff BMP PT/INR PTT ESR Serum Uric Acid Xray of the foot/toes Synoval fluid analysis

Answer 57

Pulse Oximetry CBC with diff BMP ABG Serum LDH Sputum PCP stain CXR Blood G6PD (in anticipation of the potential need of dapsone or primaquine) HIV test by ELIZA HIV test by West. blot CD4 count HIV viral load

Answer 58

TMP-SMZ Glucocorticoids Oxygen Influneza vaccine Pneumococcal vaccine Start HAART (Efavirenz/Tenofovir/Emtricitable) Counseling - Medication compliance - no alcohol - safe sex - HIV support group - Patient counseling ***\*Must add steriods if P02 \<70 or A-a gradient is \>35 mm Hg***

Answer 59

Unexplained hematuria Flank pain Palpable flank mass Order Abdominal CT (provides presumptive diagnosis, provides staging info)

Answer 60

- **Obtain CT chest** for further staging info - **Bone** **scan** if there is **bone pain or elevated alkaline phosphatase** _Determine stage based on abmoninal CT/chest Ct/+/- bones scan_ - **Nephretcomy** is prefered for **isolated renal mass (**diagnostic and therapeutic) - **Biopsy** preferred for **suspected metastic dz**; further treatment dictated by result

Answer 61

CBC BMP LFT UA FOBT Abdominal CT Chest CT Serum Iron TIBC Ferritin PT PTT/INR BLood type and cross match

Answer 62

NPO Oncology consult Surgery consult PT PTT/INR blood type & Cross match IV cefazolin Nephrotomy Counseling - No smoking - No alcohol - Cancer diagnosis **\*Must remember to order nephretcomy**

Answer 63

Pulse Ox IV access BP monitor Oxygen 12 lead EKG Cardiac monitor

Answer 64

CBC with differential BMP LFT serum lipase Serum amylase Abominal or CXR PT/INR PTT Type and cross match

Answer 65

Bedrest NPO NG tube IV NSS IV analgesia (morphine) IV antiemetics IV antisecretory drug (PPI) IV antibotics (ampicilin--sulbactam) Surgery consult Lapartomy/laparoscopy Counseling - No smoking - patient counseling

Answer 66

Karoytpe analysis Serum FSH Serum LH Serum TSH BMP Fasting glucose Lipid profile Renal US Pelvic US Echocardiography Skeletal survey Hearing test

Answer 67

Growh hormone therapy Estrogen progesterone therapy Vitamin D Calcium Dietary consult Psychiatry consult (estimate IQ) Opthalmology consult Counseling - reglar diet - regular exercise - medication compliance - parent counseling

Answer 68

Goal BP \<140/90 for age \<60; CKD, DM Goal BP is \<150/90 for \> or = 60

Answer 69

_Afib/Aflutter (rate control)_ - **BB, Non-dihydroyrine CCB** _Angina pectoris_ - **BB, CCB** _MI_ - **ACE I/ARB, BB, or aldosterone antagonist** _CHF_ - **ACE I/ARB, BB, diuretic, or aldosterone antagonist** _DM (no proteinuria)_ - **Diuretic or ACE I** _Proteinuria_ - **ACE I or ARB** _Osteoporosis_ - **Thiazide diuretic** _BPH_ - **Alpha-blocker (Prazosin, Terazosin, or Doxazosin)**

Answer 70

make sure to repeat BP readings at least two more times over a period of weeks to months.

Answer 71

CBC BMP UA Lipid profile 12-lead ECG

Answer 72

**Life sytle modificaitons** - low salt diet - regular exercise - no smoking - no alsochol - calorie restricted diet - low fat diet **Oral antihypertensives**

Answer 73

CBC with diff BMP LFT UA Abdominal CT Blood culture

Answer 74

NPO IV access IV NSS 0.9% IV analgesia IV antiemetics (Phenergan) IV ampicillin-sulbactum Advance diet/clear liquids Counseling - High fiber diet - Medication compliance - Medication side effects - Regular excercise ***\*Empiric antibiotics and bowel rest should be initated immediately following the physical exam***

Answer 75

Pulse ox CBC with diff PT PTT/INR Bleeding time CXR

Answer 76

Analgesia (Nsaids or narcotics) chest physiotherapy Incentive spirometry Child protective service consult Psychiatric consult Regular diet Counsel parent ***\*Must promptly report suspicion of child abuse to child protective services***

Answer 77

**None** Menopause is a clinical diagnosis, defined by 12 months of ammenorrhea in a women over 45 years of age, in the absence of an alternative explanation.

Answer 78

**Estrogen-progesterone therapy** **Counseling** - regular exercise - high calcium diet - low salt diet - medication compliance - medication side effects - HRT

Answer 79

**Simple DVT** is often managed on an **outpatient** basis. Choices for **anticoagulant** therapy includes **LMWH (enoxparin) plus warfarn** or fondaparinux plus wafarin. **Enoxparin (lovenox) i**s the most commonly used LMWH. Coagulation monitoring is unnecessary for LMWH, but the **platelet count should be obtained on day 3 and 5 because of the risk of HIT.** **Warfarin is begun within 24 hours of heparin initation.** **Heparin is distoninuted after 5 days** if the **INR** has been **therapeutic** (INR =2-3) for 24-48 hours. **Stop heparin if platelet count drops under 100.000 or is reduced by \>50%**

Answer 80

Commonly used anticoagulant therapy is **unfractionated heparin (UFH) plus warfarin or LMWH plus warfarin.** In addition to monitoring the platelet count (as outline in outpatiet management), **PTT should also be monitored while on UFH**, with a **therapetic PTT goal of 60-80.**

Answer 81

CBC BMP D-dimer Lower extremity doppler US ***\*Must not delay diagnosis caused by failure to order US***

Answer 82

Heparin or fondaparinux Warfarin Bed rest Counseling - medication compiance - medication side effects - no smoking

Answer 83

INR (goal 2-3) Platelet count on day 3 and 5 PTT if UFH is used

Answer 84

Based on modified **Well's score** **PE unlikely** if Well's score \< or = 4, obtain **D-Dimer,** and proceed to **CT-PA or V/Q if D-dimer \>500.** **PE likely** (score \>4), proceed directly to **CT or V/Q** **Spiral CT pulmonary angiography (CT-PA) or V/Q scan provide definitive diagnosis** **Empirically start hepatrin/fondaparinux pending test results** - _Postive CT/High probabilty scan_: continue with therapy - _Negative CT/Low probabily scan_: discontinue heparin - _Inconclusive CT/Intermediate scan_: Order **pulmonary angiogram or serial lsower extremeity doppler**; presence of DVT or Positive pulmonary anigogram warrants treatment. **Pulmonary anigogram is the gold standard, but is only used if spiral CT or V/Q scan are inconclusive.**

Answer 85

LMWH + Warfarin, UFH + Warfarin, or Fondaparinux + Warfarin **SC LMWH i**s preferred in hemodynamicaly **stable patients without renal failure**, while **IV UFH** is preferred in cases of hemodynamic **instability**, **advanced renal failure, high risk of bleed and in anticipating for thrombolytic therapy.**

Answer 86

Pulse oxidmetry Oxygen IV access ECG Cardiac monitor

Answer 87

D-dimer Cardiac enzymes CBC BMP CXR ABG Spiral chest CT or V/Q scan \*Delay in diagnosis caused by failure to order d-dimer, spiral CT-PA or V/Q scan

Answer 88

DIscontinue OCP LMWH/UFH/Fondaparinux Warfarin Counseling - no smoking - medication compliance - medication side effects \*Do not delay treatment with heparin or fondaparinux \*Fialure to add warfarin to heparin or fondaparinux

Answer 89

CBC BMP LFTs Colonoscopy Abdominal CT CXR CEA UA ECG PT PTT/INR Blood type & cross match

Answer 90

NPO Pre-colonscopic MBP Polyethyelen glycol Pre-op antiotics hemicolectomy Oncology consult Surgery consult Counseling - cancer diagnosis - no smoking - no alcohol

Answer 91

CBC with diff BMP TSH Urine toxicology screen

Answer 92

Antipsychotic or BZD Mood stabilizer Psychiatry consultation Psychotherapy Counseling - Medicaiton compliance - medication side effects - suicide contract - regular exercise - patient education \*do not delay in treatment with antipsychotc or benzo \*Do not fail to add mood stabilizer

Answer 93

turbid appearance WBC \>1000 PMN predominance Glucose \<45 protein \>250

Answer 94

_Early empiric antibiotic therapy_ Broad spectrum coverage against major pathogens of bacterial mengitis: **IV 3rd generation cephalosporin** (ceftriaxone, cefotaxime, ceftazidime) **plus IV vancomycin** **Ampillicin** is added to this regimen if the patient is immunocompromised _Gram postive cocci_ *(Strep pneumo, mcc of acute bacterial mengigitis in adults)* **- continue with above therapy** _Gram negative cocci *(*_*Neisseria)* **- IV 3rd generation cephalosporin (ceftriaxone, cefotaxime)** _Gram positive bacilli *(Listeria)*_ **- IV ampillicn plus IV gentamycin** _Gram negative bacilli_ (Enterobacteriaceae) **-IV 3rd generation cephalosporin (ceftriaxone, cefotazime, ceftazidime) plus IV gentamycin**

Answer 95

CBC with diff UA BMP CXR Blood culture Lumbar puncture CSF cell count CSF glucose CSF protein CSF gram stain CSF bacterial antigen CSF culture Head CT \*Delay in diagnosis caused by failure to order CSF analysis

Answer 96

NPO Head elevation Complete bedresst IV access IV NSS 0.9 IV antibitoics IV dexamethasone IV antiemetics Anitpyretics Patient counseling \*Delay in treatment with parenteral antibitoics \*Failure to order steriods in pneumoccal mengitis.

Answer 97

**_Pharmacotherapy (acute and maintenance)_** -_Acute_: **IV ampthotericin B plus oral flucotosine for 14 days** (alt. is fluconazole plus flucytosine). This regiment is discontinued if clinical improvement is noted. **Afterward**, it is followed by **consolidation therapy** with **fluconazole** 400 mg/d for **8-10 weeks**.. **HAART can be initated at the end of acute treatment.** **Maintenance therapy: Fluconazole 200 mg** is the preferred drug; consider itraconazole if patient is allergic to fluconazole. **Discountinue maintenance therapy in asymptomatic patients with CD4\>100** for 1 year. Reinstitue maintenace therapy if CD4 \<100. **_Management of ICP:_** - **Repeat LP daily** until OP \<200 mm H20 or \> 50% reduction - If high ICP persists despite daily LP, consider **lumbar drain or ventricular shunt.**

Answer 98

Lymphopenia and monocytosis on CBC postive HIV by ELIZA High opening pressure during LP CSF analysis shows mononuclear pleocytosis, slightly elevated protenin, presence of encapsulated yeast on India ink stain and postive CrAg.

Answer 99

CBC with differenital BMP Head CT/MRI Lumbar puncture CSF cell count CSF glucose CSF protein CSF gram stain CSF bacterial antigen CSF culture CSF CrAg CSF India ink stain CSF fungal culture CSF AFB Serum CrAg HIV by ELISA Blood Culture ***\*Delay in diagnosis cuased by failure to order CSF CrAg, CSF India ink stain, or CSF fungal culture***

Answer 100

**IV access** **Antifungals** - first IV amphotercin B, IV, continous & Flucoytosine, oral, continous - then discontinue after two weeks and start fluconazole, oral, continous **Counseling** - medication compliance - no smoking - no alcohol - safe sex- HIV support group

Answer 101

- Febrile encephalopathic patient with focal neuroloica deficits on the physical exam - CSF analysis revealing lymphotocytic pelocytosis, elevated protein, elevated RBCs but normal glucose - Temporal lobe abnormaltiies on CT/MRI

Answer 102

**Early empiric antiviral therapy with IV acyclovir** (pending PCR results) is recommended to avoid neurologic sequelae or death. Patient should be treated for **14-21 days.** - **Hydration with NSS** should be given to avoid acyclovir-induced kidney injury from crystal formation - **Adjust acyclovir dose in patietns with kidney failure**

Answer 103

CBC with diff UA BMP CXR Blood culture Urine culture Lumbar puncture CSF cell count CSF glucose CSF protein CSF gram stain CSF bacterial antigen CSF PCR for HSV CSF culture PIT/INR PTT Head CT/MRI ***\*delay in diagnosis cuased by failure to order PCR of CSF for HSV***

Answer 104

NPO Head elevation Complete bedrest IV access IV NSS 0.9% IV acyclovir IV antiemetics Patient counseling

Answer 105

include the presence of at least 3 of the following 5: - age \>50 - new onset headache - temporal artery tenderness or decreased pulsations - elevated ESR (\>50) and/or CRP - Biopsy showing necrotizing vasculitis or granulomas Additional amnifestations may include fever, fatigue, weight loss, jaw claudification, visual disturbances and symptoms of PMR

Answer 106

**_Uncomplicated temporal arteritis (can be managed as an outpatient)_** -_Acute therapy_: Begin with a **high dose oral steriod** (40-60 mg/day of prednisone) until clinical response is noted. Then, **slowly decrease steriod dose to 10 mg/day.** -_Maintenance therapy_: Once predinisone of 10 mg/day is achiveved, gradually taper predinisone in 1 mg decrements over a period of at least 9 months. **_Complicated (ex: vision loss)_** - acutely **initate IV steriods** (dexamethasone or methylprednisolone) for **three days**, and then **switch to oral steriods** as above. In all cases, **prophylactic therapy for gastroduodenal protection** with misoprostol, H2 blocker or PPI is indicated. **Prophylactic osteoporosis** prevention with clacium plus vitamin D is also indicated. **Baseline DEXA** scan should be obtained to assess the need for bispohosphonates.

Answer 107

CBC with differential ESR BMP UA Urine Culture Blood Culture Head CT CXR Temp. artery biopsy ***\*Delay in diagnosis cuased by failure to order temporal artery biopsy***

Answer 108

Biopsy, temporal artery, routine Prendisone, oral continous Aspirin, oral, continous Pantoproazole, oral, continous Calcium, oral, continous Vitamin D, oral, continous Counseling - patient counseling - medication compliance ***\*Delay in treatment with steriods***

Answer 109

Age \> 50 Bilateral pain and morning stiffness (lasting \> 30 mins) for more than a month and involving the shoulders, neck, hips or torso ESR \> 40 mm/hr or ESR \< 40 mm/hr plus elevated CRP Rapid response to steriods, usually within 3 days Exclusion of alternative diagnoses

Answer 110

Steriods are the mainstay of therapy Prompt resposne to **low dose steroids** is typical of PMR. Inital steriod dose is **maintained for two to four weeks** after symptoms resolution. Then it is **gradually tapered every two to four weeks** to the lowest dose that is needed to suppress the patient's symptoms and maintated at this level for one to two years. **Prophylactic therapy** with misoprostal, H2-blocker, or PPI is indicated for **gastroduodenal protection.** In addtion, calcium and vitamin D are recommended for **osteoporosis prevention.** **Baseline DEXA** scan should be ordered to assess the need for bisphosophonates.

Answer 111

CBC with differential BMP ESR CRP RF ANA Serum TSH SErum CPK CXR ***\*Delay in diagnosis caused by failure to order ESR and additonal lab testrs to rule out alternative diagnoses.***

Answer 112

Prednisone, oral, continuous Calcium, oral, continous, Vitamin D, oral, continuous Counseling - Patient counseling - Medication compliance

Answer 113

CBC with diff BMP UA Pregnancy test Pelvic US PT/INR PTT \**Delay in diagnosis caused by failure to order pelvic US* *\*\*Failure to rule out pregnancy by not ordering HCG*

Answer 114

IV access IV NSS 0.9% IV antiemetics IV analgesics NPO Bedrest Gynecology consult Laproscopy/Laparotomy Counseling *\*Delaying surgical intervention*

Answer 115

CBC with differential BMP LFT UA Pelvic US colonosocpy Mammogram Pap smear Abdominal/pelvic CT CA 125 CXR ECG PTT PT/INR * \*Delay in diagnosis caused by failure to order pelvic US/CT* * \*\*Failure to request preoperative orders: CBC, BMP, LFT, UA, FOBT/Colonoscopy, mammogram, pap smear, CXR, ECG, PTT, PT/INR and CA 125*

Answer 116

NPO Gynecology consult IV cefazolin DVT prophylaxis Laparotomy Oncology consult Counseling - cancer diagnosis - no smoking - no alcohol

Answer 117

CBC with differential BMP Abdominal x-ray UA *\*Delay in diagnosis caused by failure to order abdominal x-ray*

Answer 118

NPO IV access IV D5NS or D5-1/2 NS with KCL NG tube IV analgesics Gastroenterology consult Sigmoidoscopy Counseling *\*Failure to order, sigmoidsocopy, colonoscopy or rectal tube placement*

Answer 119

CBC with differential BMP LFT BLood cultures Adominal x-ray Abdominal US PTT PT/INR *\*Delay in diagnosis caused by failure to order CBC and adominal US*

Answer 120

NPO NG tube IV access IV D5-1/2NS or NS Analgestics (ex: ketorolac) IV antiemetics IV antibiotics Bed rest with BRP Surgery consult Laparoscopy/laparotomy Cousneling * \*delay in initating appoproiate empiric antibiotics* * \*\*failure to request cholecystectomy by laparoscopy or laparotomy*

Answer 121

**Empiric antibiotic therapy for 5-7 days** is recommended. **Oral amoxicillin-clavulanate is the drug of choice.** If **PCN allergy** is present, consider **doxycycline** **or respiratory fluoroquinolones** (levofloxacin or moxifloxacin) Supportive therapy include analgesics, nasal saline irrigation, topical glucocorticoids, and adequate hydration.

Answer 122

**_Emergency orders:_** IV access, IV fluids and BP monitor Proceed according to the patient's hemodynamic status **_Unstable (SBP \< 90 mm Hg)_** consult vascular surgery immediately surgical intervention without delay **_Stable (SBP \>90 and talking)_** urgent confirmatory test: urgent abdominal US or CT Consult vascular surgery surgical intervention *\*Pre-operative orders (CBC, MBP, PTT/PT/INR, blood type and cross match, IV cefazolin and NPO) should be requested, although the restults may not be obtained before surgery*

Answer 123

IV access BP monitor Cardiac monitor ECG Pulse Ox Oxygen

Answer 124

CBC with diff BMP PT/INR PTT Abdominal US/CT

Answer 125

discontinue metoprolol discountine aspirin NPO Bed rest IV fluids IV analgesics IV antiemetics Type and cross match Vascular surgery consult IV cefazolin Aneurysmectomy Counseling

Answer 126

CBC with differential BMP Abdomnal x-ray Adominal US *\*delay in diagnosis caused by failure to order adominal US*

Answer 127

NPO NG Tube IV access IV fluids IV analgesics IV antiemetics Surgery consult Constrast Enema Counseling * \*Failutre to decompress the stomach with NG tube* * \*Delay in reduction with constrast enema* * \*requesting laparotomy for uncomplicated intussception*

Answer 128

Pulse ox, stat and continuous Oxygen, inhalation, continuous IV access, stat Cardiac monitor, stat Normal saline, 0.9 Nacl, continous, stat Finger stick glucose, stat

Answer 129

Urine pregnancy test, stat CBC with differential, stat BMP, stat Calcium, serum, stat EKG, 12 lead, stat serum amylase, stat serum lipase, stat UA, stat ABG, stat Serum osmolality, stat Serum ketones, qualitative, stat Reguarlar insulin, IV, continuous, Phenergan, IV, one time (for nausea) Discontinue oxygen

Answer 130

Admit patient to the ICU NPO Ved rest Vitals as per ICU protocol Urine outpout KCL, iV, continuous HbA1C level, routine Phosphorous, serum, stat (optional) Follow the patient with 1. BMP Q2-4 hours, then Q8-12 hours, then Q day 2. ABG Q2 hours x 2 days After 4 hours: 1. stop 0.9 NS and give 1/2 NS saline, IV continus Monitor potassium deficiency, add IV potassium chloride as needed Consider antibiotics if the preciptiating cause is an infection, get CXR, obtain blood cuylutres, UA and urine cultures Once nausea is decreased, start oral fluids Onc ethe patient is stabilized transfer to ward/floor

Answer 131

D/C IV insulin, IV fluids, cardiac monitor NPH insulin, subcutaneous, continous Regular insulin, subcutaneous, continuous Diabetic diet Advance diet

Answer 132

Diabetic teaching Patient education, diabetes Diabetic food care Home glucose monitoring, instructe patient No alscohol No smoking Safe sex No illegal drug use Regular excerise seat belt use \*follow up appointment in 10 days

Answer 133

**Emergency management: hemodynamicaly unstable, so A, B, C, D** A: **airway suction, pulse ox, stat and coninous monitoring, O2** B: **Endotracheal intubation** is indicated in patietns who cannot protect their airway or if O2 saturation does not improve with O2 nasal/face mask, or PaO2 \<55 or PCO\>50 on ABG C: **IV access, cardiac monitor, place a foley, obtain finger stick glucose** D: drugs: **Administer thiamine, dextrose 50% and naloxone - all are IV bolus one time dose**

Answer 134

Suction airway, stat pulse ox, stat and continous oxygen, inhalation, stat and intubation IV access, stat cardiac monitor, continous finger stick glucose, stat thiamine, IV stat, one time Dextrose 50%, IV stat, one time NS 0.9 NaCl, stat, continous, ABG, stat

Answer 135

EKG 12 lead, stat CBC with diff, stat BMP, stat CXR, portable, PA stat LFTs, stat UA, stat Urine toxicology screen, stat B-HCG, serum, qualiative, stat Blood alcohol stat

Answer 136

NG tube, gastric lavage, stat Activated charcol, oral, one time Naoloxone, IV, stat, continous

Answer 137

Decison about chaging patient lcoation move patient to ICU NPO bed rest, complete urine output, BMP, next eday Once the patietn is better, D/C oxygen, NG tube, cardiac monitor, IV fluids and naloxone Regular diet

Answer 138

psychiatry consult (stat (reason: suicide attemp) sucide precaustions suicide contract patient cousneling reassurance no acohol no smoking safe sex no illegal drug use reguar exercsie seat blet use \* start patient on antidepression if neeeded

Answer 139

elevate head of bed pulse ox, stat and continuous oxygen, inhalation and continuous IV access, stat Cardiac monitor 12-lead ECG, stat

Answer 140

CXR, PA and lateral views, stat CBC with diff, stat BMP, stat Troponin I, stat and Q6 hours x 2 LFTs, stat NT-proBNP, stat Furosemide (lasix) IV, stat and continous

Answer 141

Orders: admit to ward telemetry ambulate at will low satl, low cholesterol, diabetic diet fluid restriction input/output moniotor daily weights continue all home medications except glyburide KLC oral, ontinous (as long as lasix is given) start regular insulin sliding scle, ACHS Accu check ACHS Give 10 units regular insulin now Lovenox, SQ dialy for DVT prophylaxis BMP, next day (t to check renal function and electrolytes due to furosemid) HbA1c, routine lipid profie, routine Echocardiogram, routine (to asscess Left ventricular function)