Bardes

Question 0

Unstable angina versus MI?

Answer 0

ST depressions, T-wave inversions, but no troponin elevation

Question 1

Chest pain – rule out? (How?)

Answer 1

1. M I – troponins/EKG
2. PE – d-dimer/CT/VQ scan
3. Aortic dissection – TEE, chest x-ray
4. Pneumothorax – x-ray
5. Pericarditis – EKG

Question 2

MI treatment?

Answer 2

OH BATMAN
Oxygen
Heparin
Beta blocker
Aspirin
Thrombolytics
Morphine
Atorvastatin
Nitroglycerin

Question 3

When to give thrombolytics over Cath Lab?

If Cath Lab, need what backup?

Answer 3

If Cath Lab is far away

Need CT surgery back up

Question 4

Best response to aggressive patient with altered mental status?

Answer 4

Give 1:1

Question 5

When to perform a coronary artery bypass graft?

Answer 5

Three vessel disease or left main stenosis

Question 6

Problem with morphine for MI treatment?

Answer 6

Mask symptoms

Question 7

Severe chest pain with nausea and vomiting – think?

Answer 7

Inferior wall MI – phrenic nerve activation causes nausea and vomiting

Question 8

Any patient with a stent needs to be put on which drug? For how long?

Answer 8

Clopidogrel

1 month if bare-metal stent
12 months if drugs-eluding stent

Question 9

Drugs appropriate for stable angina?

Drug appropriate for unstable angina and MI?

Drugs appropriate for MI only?

Answer 9

Aspirin, beta blocker

Aspirin, Plavix, heparin, beta blocker

+Thrombolytics

Question 10

Complicated UTI?

Answer 10

1. Men or pregnant women
2. Diabetics/renal failure
3. History of pyelonephritis last year
4. Urinary track obstruction (indwelling catheter, stent, nephrostomy tube)
5. Antibiotic resistant organism
6. Immunocompromised

Question 11

SIRS criteria?

Answer 11

1. Temperatures over 30 or less than 36
2. RR over 20 or PaCO2<32
3. Heart rate over 90
4. WBC over 12 or under 4

Question 12

Three different types of shock and physical exam findings (Temperature, venous distention, pulse)?

Answer 12

Hypovolemic shock (cool, flat veins, weak pulse)

Cardiogenic (cool, JVD, weak pulse)

Decreased peripheral resistance (septic, toxic, neurogenic) (warm, flat veins, strong pulse)

Question 13

Shock - treatment?

Answer 13

1. IV fluids until CVP is 8 to 12, MAP greater than 65, SPO2 greater than 70
2. 1 If no response - pressors (dopamine, then epinephrine)
3. 2 If no response Dobutamine
4. Broad-spectrum antibiotics (Ceftriaxone, then vancomycin + zosyn)

Question 14

Causes of cardiogenic pulmonary edema?

Answer 14

1. Systolic dysfunction (decreased LV contractility)
2. Diastolic dysfunction (decreased LV compliance)
3. Mitral stenosis

Question 15

Causes of systolic dysfunction?

Answer 15

1. Ischemia
2. dilated cardiomyopathy
3. valvular disease
4. arrhythmia
5. myocarditis
6. Milieu (electrolytes, thyroid hormone)
7. Drugs (doxorubicin, alcohol, beta blockers, calcium channel blockers)

Question 16

Drug that causes permanent systolic dysfunction?

Answer 16

Doxorubicin

Question 17

Causes of diastolic dysfunction?

Answer 17

1. Acute ischemia
2. Thickened LV (hypertension, aortic stenosis, aortic coarctation, hypertrophic cardiomyopathy)
3. Restrictive cardiomyopathy (sarcoid, amyloid, hemochromatosis, Gaucher’s disease)

Question 18

Systolic versus diastolic dysfunction – characteristic heart sound?

Answer 18

S3 versus S4

Question 19

8 causes of secondary hypertension (and lab values needed to confirm)?

Answer 19

Kidney causes, hormone causes, drug causes

1. Pheochromocytoma (serum catecholamines/urine metanephrines)
2. Renovascular (renin)
3. Real insufficiency (creatinine)
4. Hypo/hyperthyroid (TSH)
5. Cushing’s/adrenal hyperplasia (cortisol)
6. Conns (aldosterone)
7. Amphetamine/cocaine (urine toxicology)
8. Sedative withdrawal

Question 20

Treatment for systolic LV dysfunction that has a mortality benefit?

Answer 20

1. ACE inhibitors
2. Beta blockers (metoprolol, busiprolol, Coreg)
3. Aldosterone receptor antagonists (spironolactone)
4. Combination nitrates and hydralazine (and African-Americans)
5. ARBS

Question 21

Functions of beta blockers?

Answer 21

1. Decrease afterload
2. Increase filling
3. Antiarrhythmic (mortality benefit)
4. Less Remodeling

Question 22

Advice for treatment for systolic LV dysfunction?

Answer 22

1. Give lots of drugs in the highest dose (as long as heart rate and blood pressure can tolerate)
2. Do not give ACE inhibitors, ARBs, and beta blockers in combination

Question 23

Treatment for systolic LV dysfunction that do not have a mortality benefit?

Answer 23

1. Digoxin
2. Diuretics
3. Nitroglycerin/nitrates alone
4. Hydralazine alone

Question 24

Treatment for diastolic left ventricular dysfunction?

Answer 24

1. Beta blockers (decrease heart rate to increase feeling time) 2. Calcium channel blockers

Question 25

Non-cardiogenic causes of fluid in alveolar space?

Answer 25

1. Infection 2 ARDS 3. Sepsis 4. Trauma

Question 26

The patient with URI – could treat with?

Answer 26

Antibiotics – but don't do it (almost always viral)

Question 27

Drugs that can treat strep PNA?

Answer 27

``` Penicillin All cephalosporins Macrolides Tetracycline Fluoroquinolones Bactrim Vancomycin Clindamycin ```

Question 28

Antibiotics that will not treat H. influenzae? Antibiotics that will not treat atypical PNA?

Answer 28

Penicillin, first-generation cephalosporin Penicillin, all cephalosporins, vancomycin

Question 29

Treatment for patients younger than 60 with community acquired pneumonia? Treatment if patient is over 60 or with comorbidities? Treatment of immunocompromised ? Treatment of aspirational pneumonia?

Answer 29

1. Macrolides 2. Fluoroquinolones 1. Fluoroquinolone 2. Ceftriaxone plus macrolide Add gentamicin Add clindamycin

Question 30

Treatment of hospital acquired pneumonia?

Answer 30

(All first line) Ceftazadine/cefepime Carbapenem Zosyn Or fluoroquinolone plus aminoglycoside

Question 31

PNA Bugs: Patients over 65 years with comorbidities – additional bacteria to worry about? If immunocompromised/in-hospital/recent antibiotic use? If aspiration?

Answer 31

HACEK Pseudomonas, Klebsiella Peptococcus, actinomyces

Question 32

Why not broad-spectrum antibiotics for all? Exception?

Answer 32

1. Resistance 2. Opportunistic infections (Candida, C diff) 3. Cost 4. Toxicity Section: patients with immune reserve (leukemia, immunosuppressed)

Question 33

Aminoglycosides in order of effectiveness/toxicity?

Answer 33

Amikacin (always causes deafness) >tobramycin >gentamicin

Question 34

General causes of transaminase elevations?

Answer 34

1. Infections 2. Toxins 3. Metabolic 4. Vascular

Question 35

Infectious causes of elevated transaminases?

Answer 35

1. Viral: (hepatitis A, B, C, E, EBV, CMV, HSV, HIV, HVZ, measles) 2. Bacteria (Salmonella typhi, leptospirosis) 3. Mycoplasma (MAI) 4. Fungi 5. Parasites (malaria, babesia)

Question 36

Drugs and toxins that cause elevated transaminases?

Answer 36

1. Drugs: antiepileptics, statins, leukotrienes, antifungal's, antivirals, acetaminophen, and NSAIDs 2. Alcohol and organic solvents 3. Natural: aflatoxin, amanita

Question 37

Metabolic diseases that cause elevated transaminases?

Answer 37

1. Inborn (Wilson's, hemachromatosis, alpha1-anti-trypsin) 2. Fatty liver, obesity, diabetes, starvation 3. Autoimmune (anti-smooth muscle antibodies)

Question 38

Vascular disturbances that cause elevated transaminases?

Answer 38

1. Arterial (shock liver) 2. Venus (Budd Chiari, cardiac, pulmonary hypertension) 3. Capillary (DIC, TTP, HUS)

Question 39

General causes of increased alkaline phosphatase?

Answer 39

1. Mechanical Obstruction 2. Ileus 3. Mass lesions

Question 40

Mechanical obstructions that increase alkaline phosphatase?

Answer 40

1. Cholangiocarcinoma, pancreatic carcinoma 2. Obliteration – PBC, PSC 3. Stone 4. Stricture

Question 41

Biliary Obstruction caused by ileus that leads to increased alkaline phosphatase?

Answer 41

1. Severe illness 2. Pregnancy 3. Drugs (sulfonylureas)

Question 42

Mass lesions that increase alkaline phosphatase?

Answer 42

1. Cysts (especially from helminths - echinococcus, entamoeba) 2. Abscesses 3. Granulomas (TB, sarcoid, syphilis) 4. Malignant Neoplasms - HCC 5. Benign tumors – hemangiomas

Question 43

Lab values that are a measure of liver function?

Answer 43

PT, Bilirubin, albumin

Question 44

Most common cause of fatigue?

Answer 44

Depression

Question 45

Causes of prerenal azotemia?

Answer 45

1. Renovascular 2. Shock 3. Third spacing

Question 46

Two general causes of intrarenal azotemia?

Answer 46

1. Glomerular | 2. Interstitial

Question 47

Causes of glomerular intrarenal azotemia? (distinguishing feature?)

Answer 47

1. Glomerulonephritis (RBC casts) 2. Glomerular sclerosis (sonogram) 3. Nephrotic (3.5+ proteinuria) 4. Collagen vascular

Question 48

Interstitial causes of intrarenal azotemia? (Distinguishing feature?)

Answer 48

1. ATN (muddy brown casts) 2. Acute interstitial (eosinophils) 3. Pyelonephritis (WBC cast)

Question 49

Causes of postrenal azotemia?

Answer 49

1. Mechanical (prostate, stones, strictures, malignancies) 2. Neurogenic bladder 3. Drugs (anticholinergics, sympathomimetics, drugs with anticholinergic side effects)

Question 50

Causes of acute interstitial nephritis?

Answer 50

Beta-lactam's, NSAIDs

Question 51

Drugs with anticholinergic side effects?

Answer 51

Tricyclics, antipsychotics, antihistamines, opioids

Question 52

Total capacity bladder? Residual capacity after urination?

Answer 52

500 mL; 50 mL

Question 53

Post strep glomerulonephritis – look for?

Answer 53

ASO titers

Question 54

Creatinine clearance formula?

Answer 54

((140 - age)/creatinine) * (weight/70) * (.8 if female)

Question 55

Creatinine clearance values and interpretation?

Answer 55

``` >80 – normal 50-80 – mild renal failure 30-50 – moderate 15-30 – severe <15 – failure ```

Question 56

Management of suspected meningitis?

Answer 56

1. Two or three sets of blood cultures 2. Steroids decrease meningeal damage 3. Empiric Antibiotics 4. CT scan (to rule out malignancy) 5. LP within six hours 6. Droplet isolation

Question 57

Why get a CT scan with suspected meningitis?

Answer 57

Otherwise lumbar puncture can cause herniation

Question 58

Endocarditis – prophylaxis if? What drug to use for prophylaxis?

Answer 58

1. Congenital valve defect 2. Mechanical valve 3. Prior endocarditis Amoxicillin

Question 59

Bugs that cause endocarditis?

Answer 59

Gram-positive >Coxiella >HACEK >candida

Question 60

Treatment for uncomplicated UTI? Treatment for complicated UTI? Treatment if pregnant?

Answer 60

Bactrim three days Fluroquinolone to 14 days Nitrofurantoin

Question 61

Causes of post operation fever?

Answer 61

``` Wind – aerobic Water – UTI Walking – DVT Wound Wonder (drug) ```

Question 62

Imaging for fatty liver?

Answer 62

Sonogram

Question 63

Increased alkaline phosphatase – imaging?

Answer 63

Sonogram/CT

Question 64

mechanisms of diarrhea? Example? (Which continues despite fasting?)

Answer 64

1. Hypersecretion – Cholera (continues despite fasting) 2. Inflammation– Crohn's disease (continues despite fasting 3. Hypermotility– Hyperthyroidism 4. Malabsorption– Celiac sprue 5. Osmotic– Pancreatic insufficiency