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2020 ABIM Awesome Review > 2018 General Internal Medicine 13% > Flashcards

2018 General Internal Medicine 13% Flashcards

1
Q

Pt with PAD risk factors and suspect PAD wtd?

A

Ankle brachial index
norm=1
diagnostic <0.9
1.3=arterosclerosis

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2
Q

68yo M p.w intermittent claudication of legs - quit smoking 10ya - BP left arm 128/84, BPR R arm 138/82 BP RLE 128.80 - ABI =

A

128/138=0.92

(choose higher UE SBP) LE/UE SBP

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3
Q

If equivocal ABI (0.9->1)

A

Excercise ABI

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4
Q

How to manage PVD

A

modify risk factors (BP, gluc, chol)
Anti plt agens ASA+- palvix

Treat claudication - supervised exc program>cilostazol>pentoxyifylline

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5
Q

Whatd medicatio nused in PAD reduced coronary events regardly of BP effect

A

ACEi

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6
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced overall mortality

A

T

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7
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced vascular mortaility

A

T

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8
Q

T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced cornoary events

A

T

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9
Q

DM goals

A

LDL<140/80 with PAD

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10
Q

Pt with sudden onlset pain in foot, discoloration of oot h/o afib - petal and poterior tibila pulses not felt wtd?

A

anticoag –> arteriogram r/o embolic event from afib–> tPA

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11
Q

Pt wit sudden onset black/blue toes, pulses felt, had cardiac cath earlier and BP elevated wtd?

A

Adequate BP control

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12
Q

Metabolic syndrome

A

Obestiy waist in males–> 40”/102cm (>35 asian)
–>35”/88cm in female (31” asian)

TGAs –> >150mg/dl
Low HDL in males–> < 40mg/dl
–> <50 mg/dl

BP –> >130/85
FBS –> >100

Tx: Diet, exercise, drugs

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13
Q

Which antilipid medication woudl tx component of metabolic syndrome

A

Fibrate

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14
Q

Obesity leading cause of death in US

A

BMI
Normal 19-25
overweight >25 (50-60% of US population, check FBS,BP, lipids), (overweight + sedentary lifestyle = check FBS)
Obese stage I >30 (30% of US population, drugs indicated for tx–> Victoza)
Obese stage II >35
Morbid obesity >40 (bariatric surgery)

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15
Q

Complications of obesity

A 
Type II DM
Ca endometrial>breast>postate>colon
elevated LDL, TGA decreased HDL
inc'd CAD risk, SCD
OA
NASH (non alcoholic steatohepatitis)
OSA
FSG (focal segmental glomerulosclerosis)
(NOT OSTEOPOROSIS - protective)
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16
Q

45yo F gaining wight - BMI 31 FBS 105 wtd?

A

reduce caloric intake 500 to 1000 cal/day

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17
Q

Pt BMI 32 on reduced caloric intake and exercise, 3 months later with BMI 31 - what med for long term use

A

Orlistat (pancreatic lipase inhibitor)
Lorcaserin (serotinin-2C receptor agonist)
Phentermine-topiramate (nor adrenergic-anticonvulsant)
Liraglutide

Phentermine - short term ONLY, no indication for long term

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18
Q

Indications for bariatric surgery

A

BMI>35 with DM/hyperchol or HTN or CHF or OSA

BMI>40 with no other conditions

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19
Q

Bariatric surgery reduces mortality?

A

T

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20
Q

Post gastric bypass surgery - next day with horizontal nystagmus and opthalmoplegia dx?

A

Thiamine deficiency

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21
Q

Post bariatric surgeryc/o wk and dark colored urine, tenderness of back muscles - U dip stick + blood but no RBCs dx?

A

Rhabdomyolysis

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22
Q

Post bariatric srugery 3 days later with tachcardia nad tachypnea

A

PE

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23
Q

Post gastric bypass 2 days later with RR 22, HR 120, temp 100.8 dx?

A

Anastomatic suture /stable leak - gastrograffin study needed

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24
Q

Long term deficit post bariatric surgery

A

Vit D, B12, copper, iron

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25
Q

40yo F BMI 40 bariatric surgery 5rs ago presents w/ fatigue and painful parathesias.
Exam- shows spasticity and hyper reflexia
Labs - Hg 10, MCV 75, WBC 2450 w/ Neutorphils 30%, plt 110,000
BM bx-hypercellular marrow w/ some blast cells and ringed sideroblasts

A

cyanocobalamin deficiency

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26
Q

34yo F roux en y surgery 8 months ago - BMI dropped 40 to 28 - now BMI up to 35 - c/o heartburn

A

dx? Gastrogastic fistula

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27
Q

35yo F post bariatric surgery BMI 40-25 in 6 montsh - no kids - nauseous and bloating wtd?

A

preg test

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28
Q

Waist to hip ratio >0.9 in men >0.85 W risk factor

A

at any rate

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29
Q

Inc’d waist to hip ratio considered CAD risk factor in what group of patients -

A

older age

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30
Q

Exercise is associated w/

A 
protection against CAD
dec'd LDL, TGAs, and increased HDL
improved gluc tol
reduction of weight, BP, stress
red'd mortality from all causes
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31
Q

Pt s/p IWMI d/c’d with ASA, B blocker, ACEi and statin - what else would dec mortalty

A

exc 1hr day, 5 days / week (not just 3 days 1/2 hr)

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32
Q

Pt p/w flashes or streak of light shows, black dots, wavy curtain - cobwebs always move whereever pt looks - initally with normal visual acuity - fundoscopy with retina appearing folded/elevated wtd?

A

retinal detachment - Urgent opthal eval for laser tx

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33
Q

Pt with afib sudden onlset painless vision loss in one eye - fundscopy CHERRY RED SPOT IN MACULA etio?

A

retinal artery occlusion

etio: emboli

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34
Q

60yo with waldenstrom’s macroglobulinemia, HTN or P vera with sudden painless los of vision one eye - fundopscopy with multiple hmorrhages - thunder & clouds dx?

A

retinal vein occlusion

edge of door is blurry

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35
Q

Elderly man with blurry vision in CENTER, peripheral vision spares - fundscopy with yellow spots (druzen dx?

A

Macular degeneration

tx: quit smoking, anti oxidant vitamins, magnifying glass

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36
Q

Pt going for cataract surgery taking ASA or warfarin or plavix wtd?

A

continue ASA/warfarin
ASA+clopidogrel also continue
d/c tamsulosin (avoid floppy iris syndrome)

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37
Q

Young woman with blurry vision esp after excercise - regains vision gradually - wtd?

A

T2 MRI r/o Multiple sclerosis

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38
Q

Optic nerve infarction

A

temporal arteritis

tx: steroids

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39
Q

Pt with long standing DM, mild vision, fundscopy -> aneurysms with hemorrhage and exudates

A

non-prolif retinopathy (backgroudn) with macular edema

tx: TIGHTER glucose control

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40
Q

Pt with long standing DM with blurry vision Fundscopy->neovascularization

A

dx: prolif DM retinopathy

tx; lasery therapy (effect of laser therapy= peripheral and night vision decreased but central vision spared)

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41
Q

Pt with HgA1c of 7% has laser tx for DM retinopathy no response - wtd?

A

Tighter glucose control <6.5%

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42
Q

Pt with r eye pain, facial pain, n/v/ h/a blurry vision - R pupil mid dilated, sluggishly reactive - ciliary flush (+), hazy cornea with congestion

A

Glaucoma

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43
Q

25yo F dec’d vision in L eye with pain - paraesthesia in feet

A

optic neuritis

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44
Q

Elderly man with progessive loss of central vision - edge of door hazy

A

macular degeneration

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45
Q

Sudden loss of vision in one eye, fundoscopy Cherry red spot

A

retinal artery occlusion

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46
Q

Sudden loss of vision in one eye fundoscopy multiple hemorrhages and exudates

A

retinal vein occlusion

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47
Q

New onset shower of floaters with flashes of light and cobweb

A

retinal detachment

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48
Q

Magnifying glass (low vision aids)

A

macular degeneration (also anti-oxidant vit’s and quit smoking)

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49
Q

Crystals in retinal artery (Hollenhorst plauques)

A

Cholesterol emboli

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50
Q

Pt with intermittent visual loss - fundscopy with crystals in retinal artery wtd?

A

Carotid duplex US

tx: ASA

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51
Q

test to establish infective endocarditis

A

Blood ctx

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52
Q

60yo pt wit difficulty driving at night from glare from oncoming cars - diff reading road signs and fine print - dx?

A

Cataract

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53
Q

Pt with cataract surgery one week ago with eye ache and decreasing vision - otherwise well - afebrile - injected conjunctivea - layering of WBC in anterior chamber slit lamp with intraocular WBC - COTTON WOOL SPOTS??/ - dx?

A

endopthalmitis

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54
Q

Conjunctivitis

A

Viral - adneovirus (red eye, discharge gritty/sandy/burn, injected)
Bacterial (whitish, yellowish, greenish exudates)
Allergic (B/l, redness, watery discharge, itch, hx asthma), treat with cool compressions

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55
Q

Pt pw conjunctivitis with serous d/c - prescripbed abx eye drops (sulfacetaminde/neomycin) - 4th day is worse - dx?

A

allergy to drops

tx: d/c drops

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56
Q

Red eye with itchiness

A

allergic conjunctivitis

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57
Q

Pt with red eye with graves or RA with dry eyes and gritty sensation

A

Keratoconjunctivitis sicca

tx: artificial tears

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58
Q

Red eye with pain and photophobia, constricted irregular pupil - ciliary flush normal cornea and normal intraocular pressure - slit lamp - WBC in aquous humor or on corneal epithelium - ???consensual eye reflex with pain??? dx?

A 
Iridocylitis (Anterior uveitis)
Emergent referal to opthalmologist
intensive topical steroid to reduce inflammation
cycloplegics to prevent synechiae
tx underlying dz
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59
Q

Pt with red eyes and foreign body sensation with pain - corneal exam with DENDRITIC ULCER - branching pattern - fluorescin stain +

A

HSV I keratitis

Tx: topical triflurodine (no acyclovir)

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60
Q

Pt intubated on mechanic vent wit one eye redness - cornea white

A

Pseduomonas keratitis
Tx: topical antipseduomonal
IV anti-pseudomonals

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61
Q

Pt with contact lense develops conjunctivitis

A

Pseudomonas keratitis

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62
Q

Glaucoma

A

inc’d intraocular pressure- progressive visual loss 2/2 optic nerve damage
Complication - gradual loss of peripheral vision

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63
Q

Open ange glaucoma

A

gradual loss of peripheral vision
Cup to dis ratio >50%
Inc’d incidence in African americans

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64
Q

45yo F pw/ R eye pain and temporal headache - exam with conjunctival inection in R eye and vision 20/200 - pupil mid-dilated, fixed, non-reacitve wtD?

A

urgent referral to opthalmologist - before transfter - give PIOLCARPINE drops

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65
Q

22yo p/w ER with teary eyes - hit in eye with paintball - exam with mid conjunctival injection. pupillary reflex normal, vision normal. Slit exam with linear abnormality wtd?

A

No therapy f/u PRN

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66
Q

Pt p/w teary eye - pupillary reflex normal, wood lamp after fluorescin patttern of parallel lines of vertical abrasion - vision normal wtd?

A

every eyelid and remove foreign body

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67
Q

High velocity and insdustrial injury with hyphema (blood in anterior chamber

A

urgent referral to ophthalmologist

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68
Q

Pt witih conjunctiviti - exam layers of WBC in anterior chamber

A

refer to ophthalmoligst
Hypopyon - layering of white cells in anterior chamber
Could be ophthalmitis or keratitis - urgent referral needed

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69
Q

Pt with cough - exam with redness in conjunctiva - wtd?

A

nothing - subconjunctival hemorrhage resolves spontaneously in 1-2 weeks

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70
Q

Pt with diplopia of a few days duration with h/a - on exam lookign stright left is inward and right eye is also slightly inward - dx of b/l lateral rectus palsy made - dx?

A

cavernous sinus thrombosis (increased ICP)

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71
Q

Cellulits of periorbital area with warth swelling around eye wtd?

A

CT/MRI - orbital cellulitis-> cavernous sinus thrombosis

tx: IV anti-biotics

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72
Q

Pustule on lid margin

A

Stye

tx: warm compess - may need surgery

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73
Q

Vascular structure in conjunctiva - can spread to cornea and impair vision

A

dx: pterygum
Tx: surgery

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74
Q

Inflammed eyelid

A

blephritis

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75
Q

small nodule under tarsus

A

Chalazion
etio obstruction of meibomian gland -
Tx: warm compress - surgery may be needed

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76
Q

AIDS pt with blurry vision - fundsocpy with cheese, ketchup appearance, CD4 <25

A

Dx: CMV retinitis
tx: gancyclovir

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77
Q

How to manage otitis media

A

Amoxicillin

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78
Q

Pt with recurrent chronic ear infection p/w d/c and MASS producing out of tympanic membrane - hearing loss on that side - dx?

A

Cholesteatoma

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79
Q

????Pt with c/o hearing loss - esp in crowded area - wtd?

A

2 feet whisper test

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80
Q

?????If 2 feet whisper test abn - tuning fork at mastoid with no response - tunign for at forehead no response dx?

A

b/l presbycusosis

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81
Q

????30yo F with gradual hearing loss - whisper test abn, can hear better with tuning fork at mastoid process than near ear - keeping tunign for at forehead with better hearing in both ears - dx?

A

b/l otosclerosis
(abn growth of bone in middle ear - conductive hearing loss)
fixation of stapes bone
Tx - surgery

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82
Q

Pt with hearing loss in R ear - webber’s test localizes to R ear - exam with obstruction of typanic membrane by cerumen wtd?

A

Saline irrigation w/ manual removal

Webber test - tuning fork on forhead
Normal = hearing same both ears
If defective ear hears sound louder - CONDUCTIVE hearing loss
If normal ear hears sound better than SENSONEURAL hearing loss
RHINE test - first tuning for on mastoid bone - when can’t hear that tuning for in front of canal - normal(or sensoneural) if Air conduction (AC) louder than bone conduction (BC)
If BC>AC then conductive hearing loss

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83
Q

Pt pw c/o discarhge from R ear - exam with pain on pulling ear up and out - d/c and debri in ext auditory canal and partial obsstruction of typmapinc membrane dx?

A

Swimmer’s ear
Tx: poymyxin drops

partial TM obstruction, you don’t know where d/c is coming from

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84
Q

Pt with otitis externa in DM - red ear

A

malignant otitis externa
cover w/ antipseudomonal abx

???cover with 2 anti-pseddoonal abx - ceftazidime and amikacin/tobramycin

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85
Q

Pt going for surgery - pt has LBBB and asx wtd?

A

clear for surgery

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86
Q

Pt with severe PVDz going for vasc surgery or aneursym repair - wtd prior to OR

A

dipyridamole thallium or dobutamine stress test

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87
Q

Pt for elective surgery - multiple PVCs asx no evidence of ischemia

A

Clear for surgery

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88
Q

70 HTN OA going fo rhip replacement

A

Clear for surgery

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89
Q

Pt with colon CA going for colon surgery, father MI 49 wtd?

A

Clear for surgery

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90
Q

Pt with CABG 7ya with occasion CP on exertion schedule for urgent AAA 7.5cm in AM - abd tenderness and pulsatile mass wtd?

A

Emergency surgery - high risk - clear for surgery

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91
Q

After MI when should elective surgeries be done?

A

6 months

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92
Q

Pt with stable angina going for surgery wtd?

A

c/w angina meds pre and post surgery

before durign and after

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93
Q

Pt post op after CABG in CCU with confusion, disoriented, doesn’t follow commands, inattentive, pulling ET tube HR 100 wtd?

A

haldol

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94
Q

What med can cause delirium in elderly during post op period?

A

Meperidine (demerol)

side effect - seizures

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95
Q

Pt in recovery room and BP 160/104 not known HTN

A

morphine sulfate for adequate analgesia (pain causing htn)

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96
Q

Pt with severe abd pain - xray with air under diaphragm - c/s for clearance - while doing consult pt vomints and becomees bradycardic - EKG HR 48, some non-conducted p-waves and 1mm ST dep

A

Inc’d vagal tone from vomiting - clear for surgery

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97
Q

What has been shown to decrease risk of perioperative complications?

A

Lugn exapansion interventions (incentive spirometry, deep breathing, CPAP)

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98
Q

What is recognied as risk factor post non cardiac surgery

A

inc’d tropoinin T levels < 72hrs after surgery

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99
Q

40yo F s/w PNA - next mornign see’s “little green ppl in her room”
Or 40yo M a/w GIB see’s “spiders on ceiling” exam afebrile HR 84 bp OK==130/84, RR 16 - Mild tremulousness - fhx etoh abuse - thiamine give dx?

A

etoh hallucinations

DT with inc HR/BP

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100
Q

Pt had urgent surgery yesterday today oriented x 2, temp 101, HR 105 mild tremor dx?

A

etoh withdrawal

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101
Q

Pt with anxiet, tremors confusion HR 104, BP 150/92 deslusional and seizure

A 
Delirum tremons (hyperadrenergic state)
Tx Diazepa or chlordiazepoxide

lorazepam–> haldol–>phenobarb –>propofol

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102
Q

54yo chornic alcoholic to ER with confusion ataxia nystagmus diplopia

propylene glycol poisoning

A

Wernickes encephalopathy
Tx FIRST thiamine then glucose

nystagmus also seen in ICU pts w/ thiamine def in TPN

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103
Q

Chornic alcoholic with anterograde and partial retrograde amneis - confabulatory speech

A

Korsakoff psychosis - poor prognosis

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104
Q

Pt with SOB, tach and bounding pulse - CXR cadriomegaly

A

thiamine def - high output cardiac failure (beri beri)

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105
Q

Pt with h/o etoh in hosptial - gets thiamine, glucose and is fed well - 5 days later muscular weaknes - sob - CPK inc’d, Hg dec, reti ct inc’d

A

Refeeding syndrome - hypophosphatemia

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106
Q

Chornic etoh wit muscle sapsms - serum ca low, K low wtd?

A

FIRST give magnesium sulfate then K/Ca+

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107
Q

Pt underoes surgery - post op seizure tachy, consfused tachypnic

A

etoh withdrawal

the most effective strategy for addressing alcohol abuse is: SBIRT (Screening, Brief intervention and Referral for Treatment)

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108
Q

Lifetiem incidence etoh abuse and drug abuse

A

20%

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109
Q

???etoh abuse screening

A

Cage, AUDIT, 4 drinks on one occsion in men (3 in F)
C - cutting donw
A - annoyed
G - guilty
E eye opener?
Addressing etoh - SBIRT - screeing brief intervetion referral fo rtx

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110
Q

???Etoh abuse

A

Problems - failures to fulfil work/school oblig, use in hazardous situation, legal proglems with etoh use - constineud use despote social problems

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111
Q

???etoh dependence

A

keeps drinking - work/social school oblsigations sacrified - tolerance - needs more and more
desire to cut down but continues
withdrawal sx if stops

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112
Q

Pt p/w routine checkup - appears depressed - inc’d MCV, inc’d GGT - what wil establish chronic eetoh abuse

A

inc’d carboydrate free transferrin

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113
Q

Etoh abuser on sidewalk to ER pain in legs. no back pain. exam weakness fo foot and dec’d ankle jerk - dx?

A

etoh neuropathy

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114
Q

MCC death etoh abusers

A

heart disease

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115
Q

All true about alcoholism

A

inc’d malignancy incidence
inc’d MVA
inc’d suicides and drug OD
inc’d STDs

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116
Q

Best drug to tx etoh addiction in addition to support goups?

A

Naltrexone

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117
Q

Pt with normal FBS - white/gray spots on conjunctiva dx?

A

Vit A deficiency

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118
Q

Pt taking multiple vitamins p/w dizziness, headache, abd pain n/v elev LFTs. Ca 10.7mg/dl. xerosis of skin dx?

A

Vit A toxicity

seen in eating bear liver

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119
Q

Pt with nausea labs Ca 11, fundsocpy blurring of disk margin - pt takes multiple vitamins dx?

A

Vit A toxcity

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120
Q

Pt lives on tea and toast diet pw bleeding gums - perifollicular hemorrhage and non-healing ulcer - PT/PTT, plts’ normal dx?

A

Vit C deficiency - scurvy

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121
Q

PP+ pt on INH p/w pin pricks and tingling on legs - low MCV

A 
Vit B6 (pyridoxine) def 
- inc'd homocystine??
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122
Q

????Pt taking multiple vitamins with HEADACHES - fundoscopy papilledema

A

Pseduotumor cerebri

etio? Vit A intoxication

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123
Q

50yo chronic etoh with sensory ataxia with romberg +, dementia dec’d proprioception, spasticity optic neuropathy but normal pin prick sensation

A

Dx: subacute degen of cord 2/2 vit B12 def
high stepping gate
elev MMA??

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124
Q

Pt takes multiple vitamins p/w nausea, anorexia fatigue sever constip - Mucous membrane dry, Ca 11.3, pho 5.2 dx?

A

Vit D intoxication

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125
Q

Pt with dementia diarrhea dermatitis

A

Pellagra (niacin) deficiency

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126
Q

Diarrhea and LINEAR VERTICAL WHITE LINES on nails

A

Arsenic posoning

pic shows vertical or horizontal staight lines

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127
Q

Pt with long ICU stay on TPN with ALOPIECIA, hyeprkeratotoic rash, anemia, LOSS OF TASTE

A

Zinc deficincy

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128
Q

Post surgery NPO on IVF with inc’d PT 2.4 after 3 days, etio?

A

Factor VII def

vit K def

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129
Q

Pt post surgery in ICU with nausea is given phenothiazine - next day horizontal nystagmus ophthalmoplegia dx?

A

Wernicke’s encephalopathy

fyi: phenothiazine would cause immediate dystonic rxn and eyes not moving

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130
Q

???Cheilosis, glossitis, dermatitis

A

Vitamin B2 def (riboflavin)

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131
Q

???Iodine

A

goiter or hypothyroid

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132
Q

???Bleeding diathesis

A

Vit K def

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133
Q

???Cardiomyopathy, CHF

A

Selenium
hypophophatemia
Thiamine

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134
Q

Anxiety d/o

A 
Panic d/o
GADisorder
Phobias
Obsessive compulsive disorder
Post Traumatic disorder
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135
Q

Discrete period of intnese fear and anxiety, somatic sx SOB palpitations, trembiling diaphoresis ches tpain discormfort - one xam click+–>MVP

A

Panic d/o
(In perceived ‘difficult to escape situations’–>Agoraphobia)

Tx: TCAs/SSIs long term
Benzodiazepines short term

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136
Q

Percieved difficult to escape situation

A

Agoraphobia
TCA/SSR
benzo - short term

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137
Q

Excessive anxiety out of proportion of fear to impact of fear event

A

Gen anxiety d/o
Tx: SSRI
cognitive behav therapy

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138
Q

1) 40yo F with complaints of CP, palptiatons diaphoresis and numbness while watching movie/concer - happened couple times before EKG normal wtd?
2) what is the best long term management for this pt?

A

1) start benzos and re-eval in 2 weeks

2) SSRI’s

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139
Q

Pt with feeling of vibration sense inside body - has CP, palptiations, SOB - exam mid systolic click - dx?

A

Panic attack

best managment: Paroxetine

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140
Q

Persistent distressing thought -> obsession

Repetive response to the persistent thought -> compulsion

A

Dx. Obesessive Compulsive disorder

Tx: Fluoxetine (SSRI), Fluvoxamine (SSRI), Clomipramine (TCA), behavior modification (cognitive beh therapy)

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141
Q

Fear of public speaking with sweating and trembling

A

Phoic situation
tx: B Blocker
TCA

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142
Q

Vietname vet - saw friends die - pw nightmares, avoidance of remnder of even, flashbacks intrusive memories

A

Dx: PTSD
tx: Psychotx- first, SSRI-second

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143
Q

Young woman witih multiple complaints multiple organ systems >8 - exam NO macthcing physical findings to sx

A

Dx: somatic symptom d/o

These pts have high rate of utilization of health care. Monthly appointments w/ PCP for reassurance and decrease utilization of health care resources.

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144
Q

Pt with alteration or loss of physical fxn wihtout pathologic basis - pt is unawar/unconscious - NOT consciously producing sx -

A

dx: conversion d/o
Tx: usually responds to suggestive therapeutic modality

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145
Q

Young woman of high socioeconomic status related to health care field with h/o emtional trauma p/w deliberate production of signs and sx

A

dx: Factitious d/o on self

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146
Q

A man of low socioeconomic status with deliberte production of signs and symptoms pathologic lying and wandering

A

Factitcious disorder on others AKA Munchausen’s syndrome

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147
Q

Intentional prodxn of signs and sx for SECONDARY gains. Such as avoiding military duty or court case etc

A

malingering

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148
Q

Physical findings dont’ match multiple complaints

A

Somatization

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149
Q

Doctor shopping and high utilization of health care

A

Somatization

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150
Q

Needs PCP q1month appts

A

Somatization

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151
Q

Weakness one side of body but work up normal with MRI

A

Conversion d/o

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152
Q

Young white femail nurse deliberate prodxn of sign’s and sx

A

Facticious d/o

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153
Q

Factious d/o with pathologic lying and wandering

A

Muchausen

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154
Q

Exaggerated sx compared to physical exam - pending court case or military service

A

Malingering

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155
Q

Depression

A 
depressed mood
loss of interest in pleasurable activities
wt loss/gain
Insomnia or hypersomnia
Fatigue
Diminshed ability to concentrate
forgetfulness (mistaken for dementia)

Sx >2 weeks=depression
If sx after death in family and sx < 2 months - bereavement
> 2 years - dysthymia
If abv sx with delusions/hallucinations - depression with psychotic features

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156
Q

Depression

A

10 million/year w/ depression
MCC suicide in US
only 20% seek attention and 1/3 of them misdiagnosed

Tx with any antidepressant - 4-9mo for the first episode
HOw soon see response - 2-6 weeks
When to switch if no response - 6-8wks
Recurrent > 2 episodes of depression - 2 or more years
When stopping drug - taper it
Psychotx - Cognifitive tx - Thought->emtion->behavior
Interpersonal therapy: interpersonal social functioning
DON’T go from SSRI-> bupriopion (ok other way around)
also okay SSRI to SSRI or SSRI to NRI and other way around

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157
Q

Mcc suicide in US

A

major depression

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158
Q

Depression TOC (tx of choice)

A

anti antidperessant

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159
Q

Enuresis TOC

A

Imipramine (TCA)

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160
Q

Panic d/o TOC

A

Alprazolam-short term

SSRI-long term

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161
Q

Obsessive-compulsive d/o TOC

A

Fluoxetine
Clomipramine
Fluvoxamine

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162
Q

Chronic pain+/- depression TOC?

A

Amitriptyline

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163
Q

Smoking cessation TOC

A

bupropion

???nicotine replacement->bupropion->vareniciline

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164
Q

Insompnia TOC

A

Amitrptyline

???? trazadone

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165
Q

Overdose with low lethal potential TOC

A

citalopram (SSRI)

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166
Q

45yo M pw depression - stated on fluoxetine and starts to feel better in 3 weeks how long to continue

A

4-9 months

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167
Q

????83yo F awake, doesn’t respond to stimuli x few months - refelxes/power intact dx?

A

depression

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168
Q

Terminally ill pt with lung CA depressed, loss of appetite - loss of interest in life wtd?

A

Methyphenidate - elevates mood w/in days and can be used with other anti-depressants which take weeks

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169
Q

Drug-drug interactions

A

MAOIs (phenelzine, tranylcypromine, selegiline)

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170
Q

HTN crisis

A

MAOI (Phenelizine, tranylcypromine, selegiline)

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171
Q

Orhostatic hypotension

A

TCA (imipramine, clomipramine, amitrypyline, nortriptyline)

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172
Q

Antichol s/e (dil pupil, tachy, dry secrtions)

A

TCA (imipramine, clomipramine, amitrypyline, nortriptyline)

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173
Q

sexual dysfxn

A

SSRI (fluoxetine, citalopram, sertraline)

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174
Q

Least sexual dysfxn

A

Bupropion

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175
Q

Avoid in anorexia

A

SSRI/Buproprion

SSRI-fluoxetine, fluvoxamine, citalopram, sertraline

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176
Q

Avoid in Bulimia

A

Bupropion

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177
Q

Tx Bulimia

A

CBT–>SSRI (fluxoetine fluvoxamine, citalopram, sertraine)

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178
Q

62yo M HTN depression tx’d with BB and fluoxetine - alwso vitamins pw dec’d erections + unable to have orgasm for few moths wtd?

A

start PDEi

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179
Q

SSRI s/e

A

1-4 wks - Suicidal ideation -> d/c or consider other drug

2-6 weeks - restlessness/akastheisia -> switch drug or add benzodiazipine

2-4 wks -angry outbursts/lack of sleep, silliness, giggling
70% seen in bipolar d/o - change to lithium or mood stabilizer
10% seen in SSRIs–>alternative antidepressant or lower dose

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180
Q

Pt started on SSRI with cloudy urine dx?

A

retrograde ejaculation

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181
Q

Electroconvulsive therapy indicated for…

A

Refractor depression
Psychotic features
Suicidality
Catatonic stupor

can do in pregnancy

S/E - acute confusion, sz
long term - impaired memory
Relative contraindic - recent MI, aneurysm, CHF, COPD

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182
Q

Stop bupropion in

A

Mania state

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183
Q

Biplar d/o

A

Manic depressive - lamotrigine–> TEN

Manid/hypomanic (mild manic)

  • euphoria
  • inflated self esteem grandiosity
  • decreased need for sleep

tx: lithium, valproic acid/atypical antipsychotic

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184
Q

22yo started on fluoxetine(SSRI) for depression now starts playing music all night wtd?

A

d/c SSRI, start lithium or olanzapine

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185
Q

S/E lithium

A

Diabetes insipidus - impaired renal concetration
hypothyroid
hyperCa
Hand tremors

????Toxicty 1.5-2
N/V
slurred speech
nstagmus
ataxia
>2.5
Fasciculations
Delirium
Coma/death
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186
Q

Antipsychotic agents

A

Typical:
Phenothiazine : chlorpromazine, fluphenazine, thioridazine
Non-phenothiazine : haldol, loxapine

Atypicals:
Clozapine, (most efficacious, agranulocytosis) (dont rechallenge after d/c)
Olanzapine - inc’d gasting blood sugar, inc weight
quetiapine (seroquel) - well tolerated
Risperidone - efficacious and used in elderly

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187
Q

Pt on paroxetine (paxil) and olanzapine for major depression develops increasing blood sugears etio?

A

Olanzapine

increased blood sugars also w/ statin, BB, HCTZ, steroids, protease inhibits NOT ACE inhibitors

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188
Q

Side effects of typical agents

A

*Acute dystonic rxn - tx diphenhydramine/benztropine
*Akastheisa - motor restless, wantering - tx - dec or d/c drug
*Tardive dyskinesisa - smaking lips/tonue
*Neuroleptic malignant syndrome -> DTR decreased
????? cool down, dantroline
*prolonged QT interval- sotalol, aripiprazole, methadone

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189
Q

Pt with hallucinations, smaking lips, says he takes nerve pills not sure what d/o for - dx?

A

Schizophrenia

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190
Q

Pt has not been taking her meds - moves in with her son 6 months later says daughter in law trying to kill her - on exam smaks lip and tongue - etio?

A

Phenothiazine that she used to take 6mo ago

underlyind disease - paranoid schizophrenia

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191
Q

????Pt with schizophrenia develops parkinson’s dz - develops psychosis - refuses blood tets because of needle sticks

A

Quetiapine

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192
Q

Pt with parkinson’s dz, dementia, BPH and glaucoma becomes agitated and confused - best anti-psychotic

A

Quetiapine

193
Q

Hyperthermia with mental status changes, tremor and autonomic instability (inc’d HR, dec BP, n/v/d) and hyperreflexia

A 
Serotonin syndrome (SSRI+MAOI, SSRI+linezolid, SSRI+tramadol))
D/C med and start benzodiazepines-->cyproheptadine
194
Q

Hyperthermia with mental status change, autonomic dysxn with LEAD PIPE RIGIDITY and rhabdomylysis. hyporeflexia

A

Neurolptic malignant syndrome

?? - phenotiazine +- haldol
??Tx: bromocryptine or dantrolene

195
Q

Hyperthermia with sustained muscle contraction, HTN, diff ventillating patient with sudden inc in end tial CO21. hyporeflexia. - CPK inc’d. fhx of sudden death or fever on table during anesthesia

A

Neuroleptic malginant syndorme (inhalation anestetics

tx: rapid cooling/dantrolene

196
Q

Pt with hyperthermia, delirium HTN, tachcardia and diaphresis dx?

A

sympathomemetic crisis

  • (amphetamine+cocaine)
  • prescription diet pills
197
Q

Hyperthermia with mental status changes, tachycardia, dec’d bowel movements and urinary retention

A

antichoinergic delirium (antihistamine/TCAs)

198
Q

69yo F husband passed away 2 years ago now lives along several meds including ambien (zolpidem) 10g daily - appears confused and period of not routable. CT head mild atrophy - likely cause?

A

Drug induced

of note women should never take >5mg zolpidem per day

199
Q

Pt with depression - takes ambien for insomnia - on exam amnesia and confused

A

D/C ambien (zolpidem)

200
Q

70yo M wife died couple years ago - loss of appetite, weight last 6 months . he apprears depressed.- hearing voices or seeing thigns on wal.l dx?

A

Depression with psycotic features

201
Q

70yo M, wife a died couple yrs ago - loss of appetite/weight loss for last 6 months - pt says he sees her when he closes his eyes and frequnetly wakes up at night thinking she is nex to him - does not indulge any pelasurable acitviiteis dx?

A

Complicated grief

Rx Increase social activities

202
Q

????Borderline perosnality d/o

A

instability in self image, mood state, interperonsl relationship impulse control
social history many stormy relatinship
awknowldeges chornic anger control issue
marked swings in mmod thru day
at one moment frien or parted viewed as trusted then curel or betraying

203
Q

Best management for pt with borderline personality d.o

A

Behavioral psychotherapy

204
Q

Anorexia

A

<15% of ideal body weight
feel they are too fat
decreased BP, hypokalemia, hypoalbuminemia
at risk for sudden death from VTach
do NOT treat w/ antidepressants–> suppress appetite

205
Q

Bulimia

A 
NOT < 15% of ideal body weight
eat and purge - vomiting -> OR laxatives
callus on knuckles, submandibular LN+
Parotid enlargement, loss of inner dental enamel
esophagitis**
low Cl** low K and metabolic alkalosis
Urine Cl very low
206
Q

Young woman with new onset UGIB at party - Na 136, K2.7 Cl 80, bicarb 35, BMI 24 dx?

A 
Bulemia nervosa (GIB from vomiting)
mallory weiss tear
207
Q

How to treat Bulimia

A

psychotherapy

Fluoxetine

208
Q

????38yo woman on various antidepresants and analgestics for pain, consumes several extra pills of one of her meds, on arrival to the ER she is awake, soon after gets hypotensive, tachy and then seizure - tele shows widened QRS, ABG respiratory acidosis pt took what?

A 
TCA
Methadone (check QT interval)
209
Q

50yo brought with overdose of hypertension and angina meds - took 30 pills metoprolol BP 70 HR 35bpm with AV blcok - given atropine and IVF bolus w/ not much change wtd?

A

glucagon (cAMP) - inc contractility of myocardium

epinephrine drip

210
Q

Pt took OD of CCB - BP 80 systolic - HR 42/min started on IVF bolus and atropine what else to give pt -

A

slow i.v. calcium chloride to counteract peripheral vasodilatory effects of CCB.

211
Q

Pt pw inc’d SECRETION (salivation, etc), profuse sweating, n/v/SOB, tremors, fasciulations - exam pupils consdtricted HR< 50 what is poisoning?

A 
organophosphorus
dx test - RBC Acetylchoinesterase level
tx: remove contaminated clothing
activated charcoal
IV atropine (muscarinic antagonist, blocks Ach receptors)
IV pralidoxime (nicotinic)
212
Q

Pt and family feel tired, fatigued and somnolent - pt goes out and shovels the snow and feels better dx?

A

CO poisoning - call EMS and gt whole family out of house

213
Q

Firefighter brought after fighting fire - ABG 94% on 40% venti - soot in nares pt intubated - what FIO2 required -

A

100%

GBS/MG

214
Q

Heroin addict or pt on morphine or codeine develops URI with profuse lacrimation, sweating rhinorreha, yawing restlessness and diarrhea

A

Dx: opiate withdrawal
Tx: methadone

215
Q

24yo pt back from party agitated, talking fast but fluent - acting paranoid, diarphoretic, HR and BP up, low grade temp burn on oral mucosa, poor dentition, excoriations on skin, picking skin, hyperreflexia

A

Meth/speed (methamphetamine)

216
Q

24 yo pt back from party agitated - has seizure - +diaphoresis elev tmep/HR/BP - hyperreflexia

A

MDMA (ecstasy)

217
Q

24yo pt agitated after party not following commnads - diaphoresis, elev bp, temp, hr hyperreflexia Na 124

A

MDMA (ecstasy)

218
Q

Fever

A

Methamphetamine, MDMA (ecstasy), Bath salts

219
Q

HTN

A

Methamphetamine, MDMA (ecstasy), Bath salts

220
Q

tachy

A

Methamphetamine, MDMA (ecstasy), Bath salts

221
Q

Hyponatremia

A

MDMA (Ecstasy)

222
Q

agitated, psychotic but alert

A

Methamphetamine, Bath salts

223
Q

agitated, mental status change, seizure, or lethargy

A

MDMA (ecstasy)

224
Q

Skin pickering

A

Meth

225
Q

Oral musocsa burns

A

meth

226
Q

mydriasis

A

Methamphetamine, MDMA (ecstasy), Bath salts

227
Q

hyperreflexia

A

Methamphetamine, MDMA (ecstasy), Bath salts

228
Q

serotonergic and SIADH

A

MDMA (ecstasy)

229
Q

Your pt is receiving morphine sulfate and benzos for leg pain from an injury - agrees not to abuse drugs - urine tox 3 mo later - benzos, opiates, cocaine, marijuana + wtd?

A

taper benzo and d/c morphine

230
Q

80yo F h/o depression tx’d with imipramine 100mg daily and haldol 10mg daily now a/w delirium neck ridgidty, spasiticty - elev BP/HR - NMS, treatment?

A

tx: dantrolene or bromocryptine

231
Q

Most CC admission to hospital in elderly

A

CHF

232
Q

Delirium

A 
Flucuating course of inattention and altered conciousness
Etio - s/e poly pharmacy
meperidine (demerol), morphine
Fever, metabolic abn, and electrolyte distrubance
hypoxia,
Med/surg pt >65
etoh withdrawal
anticholingergics/anti histamines
antidepressants
alzhiemers meds: Donepezil, Rivastigmine
sedatives (ambien aka zolpidem), flexeril
Tx: correct underlying cuase
233
Q

72yo F episodes of inattentiveness and confusion esp at night - takes enalapril for HTN and diphenyhydramine for insomnia - this represents?

A

a drug reaction
tx: d/c diphenhydramine
cyclobenzaprine (flexeril) can also cause delirium in elderly

234
Q

T/F delirium in hospital related to inc’d mortality

A

T

235
Q

T/F delirium in hospital related to inc’d dementia

A

T

236
Q

T/F delirium in hospital related to inc’d institutaionalization

A

T

237
Q

Pt post hip surgery 2 days later, awake till 2am andconfused - prior to surgery on HCTZ, enalapril , MVI, atorvastatin, lorezepam - post surgery meds for BP and HLD restarted etio of confusion?

A

Lorazepam withdrawal

238
Q

Best tx for insomnia?

A 
sleep hygiene (aka cog. behavioral therapy)
(bed comfort,  noise level, temp in bedroom -optimal T 68F (YES BABY ...I SEE THIS), no caffine, , avoid naps DURING DAY, bed for sex and sleep -Not TV or office work. Fixed bedtime and wakup time
239
Q

???Best med to initiate sleep

A

ambien,

240
Q

Dementia

A

progressive deterioration in cognitive fxn, impaired memory judgement abstract thinking

Dx: 
First r/o treatable causes:
-Drugs
-Vit B12 def
-hypothyroid
-Normal pressure hydrocephalus (magnetic gait, incontinence..."wet wacky wobbly")
-heavy metal poisoning (lead)
-Infections (syphilis, whipples, lyme's, meningitis

Degenerative disease:

  • alheimer’s–> dilated ventricles and sulci and delusions
  • dementia with lewy body –> hallucinations
  • parkinson’s
  • Pick’s –> frontal temporal lobe dementia (aggressive behavior)
241
Q

????Dementia

A

???

dx:
assessing cognifitve status
MMSE - Score >23/30 normal
other screening tests
Clock drawing test
Making change test
Fxn assessment - basic ADLs
eating bathing dressing
Instrumental ADL
complex activities to maintian household - shippping, driving managming finances
242
Q

Ways to decrease falls

A

d/c psychotropic/targeted reduction in meds
Muscle strengthinging / balance exc - tai chi
unifocal lenses better than bifocal lenses
improve lighting
decrease hazards (rugs)
extra support in toilet/shower

243
Q

Best test to predict mobility and falls

A

Timed get “up and go” test (TUG) - arise from chair, walk 10 feet turn around and sit in chair
>14 sec= high risk for fall

Major predictor for fracture with fall is:
osteoporosis

244
Q

elderly pt with freq falls - what deficiency?

A

Vit D (muscle strength)

??(check 25,0H vit D level)

245
Q

85yo F in nursing home trips and falls - uses cane occasionally - wtd?

A

Physical therapy

246
Q

Pt in NH fell and suffered NON-dispaced fem fx of neck of femur wtd?

A

surgery and 3 parallel pins

247
Q

???Elderly pt fell and sustained displaced fx of femoral neck, wtd?

A

arthroplasty

248
Q

Pt with displaced fx of neck of femur - meta analysis has shown which procedure had better hip outcomes for sustained displaced fx of fremoral neck?

A

total hip arthroplasty (femur+ball + socket)

better than hemiarthropalsty (femur + ball only

249
Q

Intertrochanteric fx ->

A

hip comporession screws

250
Q

T/F elderly pt with acute compression vertebral fx - no advantage of verebroplasty over rehab and analgesia

A

T
If no response to conservative tx - then vertebroplasty

pain–> Rx calcitonin

251
Q

elderly pt with hip fx - s/p ORIF - confused and agitated in evenings (sundowning) wtd?

A

atypical antipsychotics (SSRI takes too long)

252
Q

Pt with dementia - can swallow bu teats only half meals - sometimes food in side of mouth wtd?

A

Aid with feedings

253
Q

lower rate of feeding tubes in nursing homes reflects what?

A

values of resident autonomy

254
Q

In advanced dementia pt who is not eating PEG has shown what?

A

NO change in nutritional status

255
Q

82yo h/o freq falls - BP 140/90 what to d/c ASA or diphenyhydramine?

A

diphenylhydramine

256
Q

???Drugs that cause depression

A 
BB
etoh
steroids
psychotropics
Parkinson's
CVA
257
Q

Urge incontince

A

problem: Detrusor overactivity

Tx: In order

1) lifestyle changes (weight loss)
2) bladder training aka timed BR visits
3) kegels (pelvic exercises)
4) Anticholinergic (TCA) - oxybutyn, ditropan, detrol

258
Q

Stress incontinence (coughing make pee)

A

problem: Decreased sphincter tone
tx: In order
1) weight loss
2) pelvic muscle exercises

259
Q

??PSA

A

> 18 - finasteride + alpha blocker

<18 - alpha blocker only

260
Q

Overflow incontinence

A

problem: Urethral obstruction, prostate hyperplasia, Detrusor underactivity, DM neuropathy, MS, Drugs: anticholingerics

Tx:
alpha blockers: terzosin/tamsulosin (flomax)
[also (finasteride plus alphablocker to tx prostatic hyperplasia) ]

cholingerics: bethanechol
[mneumonic: Bethany, call me maybe if u want to activate your bowels and bladder}

???(terazosin (better with HTN), tamsulosin (causes floppy iris syndrome if taken during cataract surgery)

261
Q

T/F Incontinence is normal part of aging

A

F

262
Q

MCC incontinence

A

Urge Incontinence

263
Q

Detrusor overactivity

A

Urge incontinence

264
Q

Decreased sphincter tone

A

Stress incontinence

265
Q

Side effect of anticholinergic

A

Detrusor underactivity
overflow incontinence

???s/e of some meds
passing urine involuntarily without urge to go
tx: benechol
surgery
catheterization
266
Q

Post void normal

A

urge and stress incontinence

267
Q

Post void residual >100mL

A

urethral obstruction and detrusor underactivity (overflow incontinence)

268
Q

Bladder trianing better than TCA (imipramine)

A

Urge incontinence

269
Q

Urodynamic studies

A

urethral obstruction, detrusor underactivity (overflow incontinence)

270
Q

Response to prazaosin or finasteride

A

Urethral obstruction

271
Q

Responds to cholinergics (bethanechol)

A

Detrusor underactivity - overflow incontinence

272
Q

Timed bathroom visits and diapers

A

Urge incontinence

273
Q

Oxyburtynin (ditropan), tolterodine (detrol)

A

Urge incontinence

274
Q

78yo F CVA with independent ADLs including toileting admitted with PNA - pt confused restraints applied - diazepham given for sleep - now INCONTINENT of urine

A

Functional incontinence

275
Q

67yo F DM urge to urinate every 30-60 min - leaks urine in dress - started wearing diaphers

A

urge incontinence

276
Q

94yo F in NH back after hip surery takign tylenol w/ codeine - MS intact - upset that is leaking urine and smells bad - never had this before

A

Overflow incontinence

277
Q

80yo M in NH dx with depression and started on desipramine (TCA) 2 weeks later nurse complains that pt smells of urine. What is the diagnosis and w.t.d. next?

A

dx: overflow incontinence

w. t.d next? Change TCA to other class

278
Q

67yo F NO DM has urine leakage - has to use bathroom with inc’ing freq including gtting up at night - no dysuria or fever wtd?

A

early morning urinalysis - u/a r/o UTI

279
Q

65yo M w/ symptomatic BPH - BP 90/65. PSA is normal. tx?

A

tamusulosin (flomax)

??(better with low BP) alpha blocker

280
Q

65yo M w/ BPH BP 140/85

A

terazosin (hytrin)

?? (ok if BP ok - lowers BP) alpha blocker

281
Q

BPH + hematuria

A

finasteride (proscar)

282
Q

Pt wakes up every morning and finds she has wet herself. she does not take any meds except
DIPHENYHYDRAMINE for sleep. w.t.d?

A

d/c diphenyhydramine (overflow incontinence)

283
Q

Pressure ulcer

Stages and treatment

A

Stage 1 - skin intact, non-blanchable redness
tx: static foam or gel mattress

Stage 2 - shallow ulcer red pink with wound bed
Tx: occlusive or semipermeable dressing that maintains a moist wound environment**

Stage III - full thickness tissue loss - SQ fat may be visible but no visible bone, tendon, muscle
Tx: debridement and Abx as needed

Stage IV - Full thickness tissue loss with exposed bone tendon or muscle
Tx: debridement and abx as needed

284
Q

Drugs to avoid in pregnancy

A 
Valproic acid
ACEi
Cipro
Methimazole (1st trim only avoid)
Radio Iodine I-131 
most Anti histamines
Warfarin > 5mg - 1st trimester (??nasal hypoplasia??)
Nitroprusside
Most Aminoglycosides
Doxycycline/Tetracycline
Mycophenolate mofetil
285
Q

Drugs safe in pregnancy

A 
Carbamazepine (side effects: neutropenia, SIADH)
Mg Sulfate
Latetolol
Furosemide
alpha methyl dopa
Hydralazine
Nitrofurantoin
Amoxicillin
Ampicillin
PTU - 1st trimester
Methimazole- 2nd trimester onwards
Hydroxazine
Chlorpheniramine
Heparin (remember "Heppy baby")
Warfarin <5mg ANYTIME
LMWH
Clonidine, BB
CCB
Procainamide
Gentamycin
B lactams
metronidazole
286
Q

Preg Pt with asx bacturia

A

Treat (ampicillin / nitrofurantoin NOT bactrim or cipro)

287
Q

Preg pt with detnal caries and ache - abx?

A

Augmentin

288
Q

Pt with post partum fver and chills

A

r/o post partum endometritis

MC etio is GBStresp –> 34-37 wks scrren for this , if + –> MCC mortality associated with preg in US

289
Q

Will immune globulin prevent rubella?

A

NO

290
Q

Preg woman exposed to…

A

Hep A -> immune globulin
Hep B -> Hep B immune globulin
Measles-> Immune glboulin w/in 1 wk
Varicella -> varicella immune globulin wi/ in 10 days

291
Q

Can preg pt get Hep B vaccine

A

YES

292
Q

What vaccines contraindicated in pregnancy

A 
Live vaccines
MMR
Varicella
Oral Polio
Yellow Fever
Shingles
293
Q

Can lactating woman receive vaccines?

A

YES

294
Q

??? Pt visits 3rd world country comes back with jaundice - hep A/B neg wtd?

A

Hep E serology 20% mortality

295
Q

Can HIV + mother breast feed?

A

NO

if she breast feeds–> should be on ART

296
Q

Can you treat LTBI/PPD in preg woman?

A

YES

297
Q

Can you tx MTB during preg?

A

YES

298
Q

When can 60yo get herpes vaccine

A

When on steroids and methotrexate

299
Q

22yo RA pt on ethanercept (Enbrel) - can she get HPV?

A

YES

300
Q

??? Which vaccine for 65yo pt - ?

A

Polysaccharid ePPSV23

301
Q

Which vacc for 65yo w/ no sig. medical hx.

A

PCV 13 x 1

302
Q

40yo with HIV, CRF, malignancy or asplenia wtd?

A

Prevnar 13 (PCV 13)

303
Q

???45yo with DM, HIV CRF or aspelenia got PPSV23 at age 40 - wtd?

A

PPSV23 dose now

304
Q

???65yo Pt with DM, HIV, CRF asplenia PPSV at 40,45

A

give now

305
Q

???40yo DM tx for DKA d/cd wit PCV 13 wtd?

A

PPSV23 x 1 8 weeks later

306
Q

???40yo DM tx’d for DKA d/c’d with PPSV23 wtd?

A

PPSV23 at least 1y later

307
Q

Pt allergy to eggs (no hives) wtd?

A

can give flu vaccine in clinical settings; physicans office or hosital

308
Q

Pt with anaphylactic rxn to eggs -

A

non-egg flu vaccine

309
Q

Vaccine for joining college

A

Tdap

**also Meningococcal ACWY, B if inceeased risk, HPV (9-26y/o), and flu shot **

310
Q

Pt with laceration - had TD shot last year wtd?

A

Tdap

311
Q

???Preg pt had TD booster last year wtd?

A

Tdap

312
Q

preg pt20 wkks had Tdap shot 2 years ago. wtd?

A

Tdap now

313
Q

60yo M Tdap vacc pw swollen arem 50% bigger than other arm with soreness - ROM normal wtd?

A

reassuance

314
Q

> 60 ptwith h/o shingles wants to prvent shignles in future . wtd?

A
  • HZV vaccine (good for only 5-10yrs; give 60-70y/o; after 70, no efficacy) even if had before. NO need to ask if they had it before.
315
Q

Best pt to get IVIG

A

open wound fx at gym, TdT 12 yr ago

316
Q

Whic pt NO VZV vacc

A

pt with CLL/lymphoma

317
Q

65yo pt comes in for shingle vaccine and also wants pneumococcal vaccine wtd?

A

Shingles and pneumococcal vacc at the same time, in different arms.

318
Q

The following ok in pregnancy

A

electrical cardioversion for unstable rhythm,
procainamide
digoxin, for MS with CHF
verapamil

NONE are contraindicated

319
Q

Pt wit Mitral stenosis. Categorize mild mod and severa nd the treaments.

A

> 1.5 sq cm - mild–> no tx
1-1.5 sq cms - mod–> BB/dep on sx - need to inc diastolic filling time
<1 sq cm - severe –> baloon valvulopasty

320
Q

Pt with Mitral Stenosis and afib - how to tx?

A

Digoxin and BB, Anticoagulation

321
Q

Preg Pt with Mitral stenosis =started on BB - now has SOB w/ . inc’d JVD - lasix given wtd?

A

mitral valvuloplasty

322
Q

Pt with ASD wants to get pregnant wtd?

A

If shunt < 2:1 - then can get pregnant

If shunt >2:1 - surgery first

323
Q

;Contraindications to pregnancy

Name the conditions that are contraindicated

A 
Pulmonary HTN
Eisenmenger's syndrome (R pressure >L)
Marfan's syndorme with dilated aortic root
Dilated Cardiomyopathy with CHF
Severe AS
324
Q

Whic of the following is LEAST tolerated during preg

A

VSD with central cyanosis

325
Q

Can HOCM and MVP patients get pregnant?

A

yes

326
Q

10 days post partum pt come wit fatigue and SOB JVD+, echo shows dilated CM with EF 30% - dx?

A

postpartum Cardiomyopathy
occurs mainly in 3rd trim or post partum
If normalized - pt can get pregnant again but chance for Peripartum cardiomyopathy are inc’d

327
Q

Otherwise normal preg woman 14th week routine prenatal visit has S3+ and II/VI systolic murmur at the apex

A

functional heart sound and murmur due to normal vol overload of pregnancy

328
Q

Pt with HTN and preg what can yo use

A

Labetolol, alpha methyl dopa, hydralazine
CANNOT use ACEi or nitroprusside

mneumonic: Hyperternsive Moms Love Nifedipine
Hypertension during Pregnancy–> H for hydralazine, M for methyl dopa, L for Labetalol, and N for nifedipine.

329
Q

33wk preg - BP 160/104 and b/l pedal edema. plt 90,000 PT/PTT 16/50, urine –>proteinuria, BUN/Cr: 40/1.3, Uric acid 12

A

dx: DIC 2/2 pre-eclampsia
Tx: Deliver baby

330
Q

Causes of DIC in preg

A 
Dead fetus
Abruptio placentae
Amniotic fludi embolism
AFLP (acute fatty liver of pregnancy - inc'd d bili,  inc'd NH3, inc'd PT)
Pre-eclampsia
331
Q

Pre-eclampsia with seizure=

A

Eclampsia

Tx for seizure - MgSO4

332
Q

What anti-Sz med can’t use during preg

A

valproic acid

333
Q

Pt lactating post partum with prolactin >200

A

Dx: prolactinoma - check MRI
tx: bromocryptine

334
Q

???? Best tx for Thyrotoxicosis (graves dz) during PREGANCY

A

PTU
NO Methimazole 1st trimester
NO Radioiodine

335
Q

T?F Thyroxine requirement inc’s during pregnancy and gets back to normal postpartum

A

T

336
Q

T/F MCC amenorrhea is pregnancy

A

T

337
Q

T/F Insulin requirements inc’s by about 50% during pregnancy - needs tight control otherwise increased fetal loss and fetal malformations

A

T

338
Q

Pregnant woman with DM on oral meds wtd?

A

D/C oral meds start multiple insulin injections for tight glycemic control

339
Q

DM pt wants to conveive wtd?

A

screen for retinopathy and tx if prsent before conception - otherwise tough to treat retinopathy during pregnancy

340
Q

In non-DM F when to screen for gestational DM?

A

24-28 weeks (glucose tolderance test)

341
Q

Do people with gestational DM have higher risk of DM in future?

A

Yes - 50% with DM at end of 5-10 years

342
Q

Pt in labor with Iron def. anemia - MC seen in pt’s with….

A

No pre-natal care

343
Q

??? Pt with SLE gets pregnant ESR dec’d wtd?

A

Stop all drugs and monitor for spontaneous remission

344
Q

Pt had recent exacerbation of SLE (pregnant) wtd?

A

continue steroids

345
Q

Pt c/o itching what drugs can you use?

A

hydroxyzine

Chlorpheniramine

346
Q

Preg woman wants to fly from NY to LA - what is optimal time if she has to fly

A

2nd trimester

347
Q

These pregnant woman cna’t fly

A

h/o pre-eclampsia
History uncontrolled DM, HTN, anemia
h/o premature delivery
H/o incompetent cervix

348
Q

T/F Young women with pulm HTN should avoid pregnancy with progesterone ONLY meds - NOT estrogen containing meds

A

T

copper > progesterone IUD

349
Q

Pt on ocp going for elective surgery

A

STOP 1 month prior

350
Q

T/F Pregnant more prone to DVT/PE

A

T

351
Q

T/F Preg woman can use steroids

A

T

352
Q

Intrahepatic cholestasis of pregnancy

what is it and tx?

A 
Cholestasis - > inc'd serum bile acids ->pruritis
AST/ALT increased but < 200
Alk phos elevated
PT normal, Plt normal 
No DIC

tx:
Cholestyramine
Urodeoxycholate
Early delivery at sign of fetal distress

353
Q

22yo Pt 34 wk preg wit pruritis, ast/alt 20/22, alk phos mily elevated wtd?

A

Reassurance - pruritis gravidarum (mild intrahepatic cholestasis of pregnancy

354
Q

Acute Fatty liver of pregnancy

A
  • Carnitine def or choline def or Tetracycline use
  • p/w malaise, h/a nause, poor appet and abd pain
  • mod elev of AST/ALD>150, ammonia elev, bili elev, PT elevated
  • often a/w pre-eclampsia and DIC
  • Liver bx - microvesicular (mitochondrial damage)fatty change

Tx:
Resloves rapidly after DELIVERY of baby

355
Q

40yo with dysfunctional uterine bleed

A

tx: Medroxyprogestine acetate 10-21 days

356
Q

16yo asks for OCP wtd?

A

give it

357
Q

Pt wants to know tiem of start of OCP - last mentrual period 1 week ago when to start?

A

NOW

358
Q

Pt with dysmenorrhea, dysparenurnia - pelvic exam with enlarged ovaries and palpable bands on ligaments, no pelvic motion tenderness wtd?

A

Laparoscopy - r/o endometriosis (endometrial tissue in other places)

359
Q

Pt wants post coital contraception wtd?

A 
Start Levengestrel (plan B) within 72hr
works by  - inhibit ovulation and implantation

???and delayed onset of next menstrual period

360
Q

Pt missed OCP x 3 days and no sexual activity during that period wtd?

A

Take only most recently missed pill and another method of contraception x 1 week

361
Q

OCP complications

A

-HTN (in’d renin substrate**)
-DVT, stroke, PE
-Peliosis hepatits (rupture of cyst–>shock –>CT –>surgery)
-Budd chiari syndrome (hepatic vein throbosis) - abd pain, ascites, pedal edema
-Elevates theophylline level and causes toxicity
-Euthyroid thyroxenemia
-Mood swings
-erythema nodosum
-PCT( porphyria cutanea tarda)
????Melasma

362
Q

When NOT to use OCP

A 
h/o DVT
Pregnancy
CAD
HTN
migraine h/a
breast CA
smoker >35--> (progesterone only)
chronic hepatitis
363
Q

OCP failure can occur w/ use of

A

St John’s wart
Rifampin
Toclizumab

364
Q

Pt on oral contraceptive for long time brought to ER with shock BP 80/60, HR 120/min - suspect ruptured liver adenoma

A

Tx: surgery

Best test to Dx: CT scan

365
Q

pt wit hcrampy abd pain and vaginal spotting - last period 1 month ago preg test +. What is best dx test?

A

US to r/o ectopic pregnancy

366
Q

Effect of HRT on fibroids

A

May inc size but NO INCREASE in malignancy

367
Q

26 on OCP for past 2 months - c/o mid cycle spotting wtd?

A

continue OCP

mid-cycle spotting–> increased estrogen and it dissappears

368
Q

19yo on OCP c/o moderate to severe mid-cycle bleeding fo rpast 2 months. no fhx endometrial CA. wtd?

A

D/C OCP and use intrauterine device (also can use higher dose estrogen continaing pill - stabilizes endometrium)

369
Q

Young woman exc 1hr / day BMI 23 mentstrual cycle 24-28 days - been having trouble conceiving wtd?

A

Ovulation kit to check basal body temp for ovulation

370
Q

Young woman trying to conceive for several years getting infertility tx p/w SOB and abd distenstion with pain - US reveals ascites and enlarged ovaries with inc’d number of ovarian folliclees. serum Na 148 Hg 16. dx?

A

Hyperstimulation syndrome

371
Q

Middle aged woman with pelvic pressure sensation, constipation, sensation of incomplete evacuation - colonscopy with ehmmorhoids - 3 grown childrne. dx?

A

Rectocele

372
Q

???Never events in health care settings

A 
Decub III/IV
Vasc catheter associated infxn
Catheter ass UTI
DVT/PE in hospital
HAPNA
ABO incompatibility
Pt fall
Disability or death from hypoglycemia
373
Q

???Time out before surgery to confirm

A

Correct pt
Correct side
Correct site
Type of procedure

374
Q

Insurance

A

Medicare Part A covers- hospital , skilled NH, Home Health, hospice services

Medicare Part B covers- physicians, Nurse Practicitoners, Social Wrkers, psychologist, lab tests, therapists, durable medical equipment

Medicare Part D covers - some of prescription med cost

Medicare Part C provides the benefits under Medicare parts A B and D thru medicare advantage plans which are managed care plans

Medigap - supplemntal insurance to cover part A/B, deductibles, and co-insurance as well as preventative care and other heatlh related goods/services

Medicaid - joint fed/state program that provides supplemental health insurance (including long tem custodial care in nursing home) to people of all ages who have low income and limited savings

375
Q

Advanced directive

A

Means for Pt to state what tx they accept or refuse if they lose decision making capacity.
Can also have proxy/surrogate who makes decisions for them when they cannot make decisions for themselves.

Surrogate/proxy - person autorized to make decision for incapacitated person - usually next of kin

376
Q

Can a surrogate withdraw alllifesuport including nutritional support in an incapacitated pt?

A

Yes
If pt awake/alert oriented - HCproxy NO ROLE IN DECISIONS

If pt awake/alert orients - FAMILY HAS NO ROLE IN DECISION MAKING including consent for procedures

DEcisions made by pt while awake and oriented stand if pt becomes unresponsive

377
Q

Living will

A

More focused advanced directive in which pt refuses life support in terminal condition - do NOT need lawyer to make a living will.

378
Q

Pt broughT in barelY conscious and confused - has terminal condition - Living will states pt doesn’t want tube or resuscitation - family insists on doing everything and threatens to sue if not intubated and resuscitated - wtd?

A

follow living will

379
Q

Fiduciary relationship btween physician and pt is base on which 4 things?

A

Justice
Autonomy - right of individual to self determination
Non-maleficence - do no harm
Benefecience - take action in best interest of patient

380
Q

Pt brought in unconscious with terminal condition - pt family wants everythign done - proxy says pt didn’t want to be intubated and resusitated and wants to make pt DNR wtd?

A

listen to proxy

381
Q

??? Pt brought in by family no living will - pt terminally ill and family wnats DNR wtd?

A

Determine patient wishes

382
Q

Can a physician give telephone order to nurse for DNR

A

No!!! - need to write on order sheet and document circumstances in progress note

383
Q

30yo Pt comes in and says sister has chronic reanl failure - sister parents and nephorlogist wants him to donate kdney - he doesn’t want to go thru surgery - wtd?

A

Reassure that you will be his advocate and represent his interests

384
Q

Husband wishes to discuss something perosnal and important about wife who is a patient

A

Listen to husband and decide whether to keep secret or not - keeping pt best interest in mind

??- if pt has spyhillis tell DOH

385
Q

Pt with PNA and pleural effusion - pt has that if he is going to be vent dependent - do not intubate. wtd?

A

intubate and place chest tube (since this could be reversible)

386
Q

T/F terminally ill patient palliative care along with standard care decreases mortality

A

T

387
Q

When woudl you insert ICD (or any expensive device) in pt with severe HF

A

Life expectancy of at least 1 year

388
Q

70yo M to ER with AWMI and shock - living will suggests if condition irreversible - not to be resuscitated - you do PCI which is unsuccessful and pt intubated - becomes hypotensive echo EF 25% - UOP 125cc - wtd?

A

withdraw all life support

389
Q

Pt with severe dementia and DNR in hospice care - develops PNA, what is comfort care?

A

Room air via nasal cannula or fan air

390
Q

Pt with end stage lung CA and SOB/pain - on O2 4l via NC. wtd?

A

morphine

391
Q

Terminall ill cancer pt with coarse rales wtd?

A

Glycopyrrolate (robinol)

suction

392
Q

Pt with chronic COPD told you in office doesnt want to be intubated or resuscitated - now in ER with severe COPD exacerbation - as you see him in ER he reminds you what he sadi about intubation - few minutes later lethargic and severly hypercapnic on ABG - no living will wtd?

A

DO NOT INTUBATE

393
Q

Pt with COPD exacerbation - living will states DNR but in ER he tells you to intubate wtd?

A

Yes intubate - follow pt wishes

394
Q

Elderly pt with ESRD refuses HD in will - could months later - in ER comatosed - son wants HD wtd?

A

No HD

395
Q

Elderly pt refusing HD in living will - brought to ER - son says recently father told him he wanted HD - pt now confused and lethargic wtd?

A

Discuss w/ son about outcome.

396
Q

Elderly pt dx with breast cancer - maeks advanced directive to be DNR - son moves in with her - he lost job recently. couple months later pt condition deteriorates and pt more SOB - son says she told him she now doens’t wnat DNR - and he wants you to intubate pt. wtd?

A

Refer to ethics committee

397
Q

Pt wants comfort measures only has durable power of attorney to son - doesn’t want to prlong life and wants only comfort measures if incompacitated - now has severe dementia - PNA and SOB - son wants abx - you will consider startin abx if….

A

Only if relieves symptoms

398
Q

Pt with hemiplegia after stroke 2ya - durable power of attorney to son - she takes place in activities at assisted living - excellent cognifitve fxn - she wants colonoscopy - son agrees but want to be there for consent as well b/c he is concerned mother may not take explanation of findings in right way. wtd?

A

tell son you will take consent from mother and proceed accordingly

399
Q

Pt with metastatic colon CA on wheelchair and trach - communicates in writing - daugther is durable power of attonry - she refuses his enrollment in an experimental clinical trial - wtd?

A

Talk to patient

400
Q

??? Your 74yo cantankerous and reclusive neighbor who lives along calls you to take a look at her - fatigued and uanble to get aroun - no tspoken with daughte rin 15 years - doesn’t want you to call her - BP ok, HR ok, orthostatic - S3, pedal edema refuses admission to hospital wtd?

A

Initial proceddings to declare her incompetent

401
Q

45yo GI bleed and hypotensive - refuses blood tx - wtd?

A

respect patient wishes - give IVF fluids

402
Q

80yo Vietnamese man dx colon CA - family tells not to give dx to father wtd?

A

Tell pt he is very sick and ask him who wants to make decisions for him
If pt says family to make decisions then comply with request.
If pt wants to know and make decision for self then comply with this request

403
Q

35yo F with Multiple Sclerosis and poor prognostic factors requests physician assisted suicide wtd?

A

Respond with empathy, compassioni and assess if she is getting adquate palliative care

404
Q

95yo pt noted in NH to have mass in L breast - refuses any w/u or tx - wtd depends on…

A

her ability to understand disease and its consequences

405
Q

Pt brain dead - can pt organs be donated wihtout his prior approval if proxy gives permission

A

Yes

406
Q

Can you stop tx if pt brain dead?

A

yes

407
Q

Is EEG required to confirm brain death?

A

NO

3 cardianl signs of brain death are:

  • Coma
  • absense of brianstem reflexes
  • Apnea test (no breathing if pcO2 60 or pcO2 increased by 20mm)

Respiratory drive and motor posturing signs are incompatible with brain death

408
Q

You observe nurse entering airborn isolation room without mask or touching a pt w/ contact isolation w/o gloves. What will you tell the nurse?

A

You are required to report his actions

409
Q

25yo w/ Fhx familial adenomatous polyps referred to you for colonoscopy but HMO refusing to pay for procedure. wtd?

A

Call medical director of HMO and discuss care

410
Q

60yo recurrent rectal bleeds, hemorrhoids neg. pt says can’t afford further testing, wtd?

A

advise colonoscopy

411
Q

Covering for your partner and pt comes to you to get premarital certificate signed - labs reveal RPR - and FTA positive, wtd?

A

False Positive test. Manual FTA (TP-PA treponema pallidum particle agglutination test or micro heme agglutination test)

412
Q

Medical Hold

A
  • if pt unable to express preference you CAN perform lifesaving procedure if alternative is death or severe disablity .
  • pt with certain psych condition and suicide attempts should be treated despite their wishes
  • In transient conditions such as drug induced deliruim/confusion, depression, and abnormal metabolic states, you should get a psych. consult to determine capacity

competency is determined by court

413
Q

Pt with attempted suicide brought to ER and refuses tx wtd?

A

Treat - pt in patholgical mental state, which may be treatable

414
Q

Nurse became + hep BeAg - request not to tell supervisor wtd?

A

inform infxn control team

415
Q

Pt dx with meningiococcal menigitis wants to sign out AMA

A

hold against will for public welfare

416
Q

Pt h/o indolent NHL and told therapy not needed - he aware that is slow growing tumor - stops eating and drinking cuz he doesnt want to diet a slow death. He started on setraline, 2 weeks later no response - Pt says he is only depressed about his illness wtd?

A

get Psych consult

417
Q

45yo Pt with PNA and bctx g neg rods - on 3rd day pt wants to sign out AMA wtd?

A

Tell pt, there is improper transition to outpt care

418
Q

Pt with AWMI, mentally competent, refuses admission - situation explained in detail about consequences pt understands but still refuses admission wtd?

A

gave nitrates, BB, ASA, ACEi and arrnage for home visiting nurse

419
Q

??? Pt of yours keeps calling 10 times fo rone rx - demands to be seen right away and wants clarification on simple things wtd?

A

Define limits of physician patient relationship

420
Q

Pt referred for medical clearance for cataract surgery by opthalmologist hx reveals that he reads a lot and falls asleep while reading

A

Report physician to ethics commitee

421
Q

You find your physician colleague with unethical behav or chemically impaired wtd?

A

report physician to ethics commitee

422
Q

Pharmaceutical company invites you to exotic location for free wtd?

A

Don’t go

423
Q

Pt bought plane ticket and wants to cancel it - wants note tha the was ill and couldn’t travel to get his refund back

A

don’t write the excuse letter

424
Q

For which is parental counsent required?

A

to administer tetanus vaccine booster in 17 y/o.

No consent for:
treat STD in 16yo
abortion on 15yo
prescribe OCP 14yo
17yo tx for substance abuse
425
Q

35yo F with multiple injuries to arms and legs nods in agreement to husband’s history - you suspect domestic abuse wtd?

A
  • As husband to step outside and interview pt
  • If injuries non-lifetreatening - don’t call police - discuss with pt - encourage her to seek help and give her hotline number
426
Q

Pt with bruises on inner arms - tells you she fell - exam reveals bruises on inner arms both old and new - has 2 children 5 and 2yo - recent dental work done wtd?

A

Domestic abuse counceling

427
Q

What is NOT a HIPPA violation

A

Pt asks for referral to a specialist and later calls for records to be sent to specialit without written consent (ok)
NOT OK to discuss rare case with your colleague so he may benefit

428
Q

T/F Periodic health evaluation shown improved rate of screening for colon CA, HTN

A

true

429
Q

Following pt education improved outcomes

A

Tobacco, firearm, etoh, physical activity, self skin exam, STD
NOTTTT self breast exam

Quit smoking - better chance with recurrent trying

430
Q

Most likley reason to quit smoking is

A

intention to quit

431
Q

Pt with COPD 2/2 smoking comes fir visit - you discuss quitting smoking - pt says he would like to quit but doesnt have a quite date yet. wtd?

A

Begin varenicline

432
Q

Pt wants help quitting nicotine patch/losange failed?

A

buproprion

433
Q

????If pt has h/o sz d/o and needs help quitting

A

NO buproprion
use varencicline
Monitor pt for behavior changes

434
Q

Chronic smoker doesn’t want to quit wtd?

A

Address barriers to quitting

435
Q

In discussion with your pt about quitting smoking what other information would help motivate pt to quit

A

Quitting smoking is the only way to prevent rate of lung fxn decline (not steroids, albuterol or tiotropium)

436
Q

Leading cause of mortality for 10-24yo

A

MVA>homocide>suicide

437
Q

Leading cause of prevatable premature death in US

A

Cigarette Smoking

438
Q

All true

A

injury from firearm at home > injury from intruder
seat belts dec mortality by 50%
Front airbags decrease mortality even further
child <13yo should be in back seat
helmets for bikes and motocycles reduced morbid and mortality
Fencing of pool and life vest on boat reduce mortality

439
Q

Drowning victim out of water 70 deg F - wtd - ?

A

CPR

440
Q

Elderly homeless man brought on cold day with bradycardia dec’d reflexes dilated pupils - J waves on EKG what does he have?

A

Hypothermia

Tx: passive rewarming with blankets

441
Q

28yo F runs marathonand collapses - on exam confused hypotensive tachy, fused, dry skin - temp 41deg C dx?

A

heat stroke

???tx: tx to hosptial
evaporative cooling - sponge with ice packs/sprink water wtih fans
complication - rhabdomyolysis.

442
Q

40 y/o F s/p bariatric surgery 5yrs ago presents w/ fatigue and parathesias.
Labs- Hg 10, MCV 105, WBC 2450, Plts 110,000.
BM- hypercellular marrow

A

dx? copper deficiency

443
Q

Blurry vision, floaters, and genital ulcer

A

Posterior uveitis

444
Q

Periorbital cellutitis (increased incidence in US..CT scans are being innaprop ordered)

A

erythema, induration, and tenderness, discharge. Extraoccular movements are painLESS

445
Q

Orbital cellulitis (most dangerous, eye pushed forward)

A
  • erythema, induration, and tenderness, discharge.
  • proptosis, edema of the conjunctiva, ophtalmoplegia
  • decreased visual acutiy
  • relative afferent pupillary defect
  • hx of sinusisits
  • extraocular movments are painFUL
446
Q

65y/o w/ heart disease w/ >4METS (flight of stairs, walks a hill w/o stopping, running a short distance, moving heav or able to pay blowing)

A

clear for sx

447
Q

which is a greater risk factor for surgery

A

S3

448
Q

65 y/o going for hip replacement in 2 wks. He has a cardiac stent and takes clopidogrel and ASA for the past 6 months. wtd?

A

wait 6 months and do surgery

449
Q

pt on anti-TNF meds going for major surgery, wtd?

A

hold before surgery and restart 2-4 wks after surgery, otherwise wound dehisence.

450
Q

Alcohlism timeline

A
  • Minor w/drawal symptoms–6hrs,–HR baseline–BP baseline
  • EtOH hallucinosis–24 to 48hrs –HR baseline– BP baseline
  • Delirium tremens – >48hrs –HR increased–BP increased (rebound adrenergic activity_
  • acute withdrawal seizure– 12to 24 hrs–HR baseline – BP baseline
  • Korsakoff’s psychosis -permenant demyelination
451
Q

Alcohol use disorders

A

Questions such as:
-Had times when you ended up drinking more, or longer than intended?
-Spent a lot of time drinking?or being sick or getting over other aftereffects?
-Wanted a. drink so badly you couldn’t think of anything else?
Full list on page 470.

Mild 2-3
Moderate 4-5
Severe 6 or more

452
Q

Post surgery NPO on IVF with inc’d PT 2.8 and PTT 65 sec after 7 days, etio?

A

Factor IX deficiency

vit K def

453
Q

Are antipsychocits (typical and atypical) FDA approved for managemnt of delirium?

A

NO

454
Q

A young woman tells you 2 months ago, her parther w as the best, but now he is the worst, last month, another partner was the best but he is also bad now. Dx?

A

borderline personality disorder

455
Q

A 24y/o pt came back from a party agitated and violent. Hallucinations and delusions. Diaphoresis. BP 160/110, HR 110, T 100.6, Hyperreflexia. Serum creat 1.8 HCO3 16, CPK 635

what drug?

A

methylenedioxypyrovalerone (MDPV)/ Bath salts

456
Q

agitated, violent, hallucination and delusions

A

Bath salts.

457
Q

leading cause of hypoglycemic attack in elderly

A

missing a meal

458
Q

leading presentation of hypoglycemic attack in elderly

A

change in mental status

459
Q

best way to decrease falls in hosptial settings

A

hospital elderly life program (LIFE)

460
Q

you found your pt w/ wrist restrains in the morning. nurse says pt was pulling out iv. what do you do?

A

–>send nurse for inservice on alternatives to physical restrains. protect and hide iv line–> bedside sitter –> restrains as LAST resort.

461
Q

elderly pt. w/ moderate dementia and knee OA not following directions, rubbing his hands over knees, unable to fall asleep. w.t.d?

A

topical capsaicin cream

462
Q

1)weight loss–>2) bladder training–> 3) pelvic m. exercises –> 4) oxybutynin

A

urge incontinence

463
Q

1)weight loss–> 2)kegels (pelvic muscles exercises)

A

stress incontinence

464
Q

Foul smelling ulcer on skin. wtd?

A

topical antibiotic containing metronidazole

465
Q

A 41 y/o pt w/ HIV, CRF, malignancy, or asplenia. Received PCV 13 last year. W.t.d?

A

pneumococcal vaccine (PPSV23)

466
Q

A 40 y/o pt w/ HIV, CRF, malignancy, or asplenia. Received PCV 13, 10 years ago, PPSV 23, 9 yrs ago. Wtd?

A

PPSV 23

467
Q

A 70 y/o Pt w/ HIV, CRF or Asplenia. Received PCV 13, 10 years ago, PPSV 23, 8 yrs ago. wtd?

A

PPSV23

468
Q

Pneumovax 23 serotypes , tell me about it.

A

-polysaccharide vaccine
-good for 5-10yrs
give at least 3 months after PCV13
-can give 2-3 doses in life

469
Q

Prevnar 13 serotypes, tell me about it.

A
  • polyconjugated vaccine
  • good for life (give only one)
  • give for immunocompromised
  • give to any 65 y/o or older
470
Q

50 y/o w/ COPD exacerbation being discharged,wtd?

A

PPSV23

471
Q

A 66 y/o w/ no sig. medical hx. PCV13 a year ago. wtd?

A

PPSV 23 x 1

472
Q

A73 y/o w/ no sig medical hx. PPSV 23 at age <65 y/o wtd?

A

PCV13

473
Q

A 65 y/o woman is being d/c in Nov. wtd?

A

Give flu shot and PCV 13 same day on different arms.

474
Q

how often flu shots?

A

1 yearly

475
Q

immune compromised pts w/ ESKD, HIV, malignancy, or asplenia. What vaccine should you NOT give?

A

LIve attenuated vaccine. DON’T use LAIV fo anyone for 2016-2017 as there was no benefit in 2015-2016.

476
Q

A 68 y/o widower lives alone. Presents w/ cellulitis of legs , has decreased pulses, ABI 0.8. You recommedn revascularization. He refuses sx and wants to go home. He is pleasant, awake, and alert. His MMS score is 23/30. Wtd?

A

seek guardianship

477
Q

What prevails in a conflict btwn living will and durable power of attorney when pt can’t make decision for self?

A

durable power of attorney

478
Q

You prescribe Varenicline (Chantix), what else do you do?

A

Monitor pt, his family and friends for behavior disturbances.

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