Aquifer Material 2

Question 1

Clinical features of subarachnoid hemorrhage

Answer 1

Subarachnoid hemorrhage classically causes the “worst headache of my life,” so should be considered with a severe headache, especially in a patient with no history of headache.

Importantly, subarachnoid hemorrhage causes meningeal irritation, producing the Burdzinski and Kurnig’s signs, just like meningitis.

Headache seen with subarachnoid hemorrhage is usually of sudden onset. Photophobia can occur with a subarachnoid hemorrhage, but it is less common than with meningitis or migraines.

Question 2

Initial management of suspected meningitis

Answer 2

Question 3

Organisms requiring Droplet isolation

Answer 3

• B. pertussis,
• influenza virus,
• adenovirus,
• rhinovirus,
• N. meningitidis,
• and group A Streptococcus

Question 4

Organisms requiring Contact isolation

Answer 4

All infections spread by the fecal-oral route or skin colonization with infectious fomites

Question 5

Isolation precautions for C. difficile

Answer 5

Patients with C. difficile are a special subset of patients within Contact precautions.

Since C. difficile are spore-forming bacteria, use of alcohol gel is insufficient to eliminate hand carriage of these bacteria.

Instead, thorough handwashing with soap in addition to usual hand hygiene is the recommended method to prevent nosocomial transmission of C. difficile in addition to usual contact isolation precautions.

Question 6

Organisms requiring Airborne precautions

Answer 6

• Rubeolla/Measles
• VZV
• TB
• Smallpox
• SARS-CoV
• MERS-Cov

Question 7

Standard empiric regimen for meningitis

Answer 7

Vancomycin and ceftriaxone

Also, add ampicillin if:

• > 50 years old
• History of alcohol abuse
• Immunocompromised

Adding ampicillin makes the regimen cover Listeria monocytogenes and Haemophilus influenzae.

Question 8

Major categories of nosocomial infection

Answer 8

Question 9

A patient is admitted to the hospital for suspected bacterial meningitis. A lumbar puncture is performed, and the results are pending. While awaiting the cerebrospinal fluid (CSF) results, what type of isolation would be the most appropriate for this patient?

Answer 9

For a patient with suspected bacterial meningitis, droplet precautions are the most appropriate type of isolation while awaiting CSF results.

Question 10

How long should you wait before performing orthostatic vitals?

Answer 10

Only a few seconds. DO NOT wait 2 minutes.

Question 11

Workup for acute delirium is going to varry quite a bit depending on the history, but what two things should you always order for anyone with delirium?

Answer 11

CBC and Chem7

Question 12

Indications for acute dialysis

Answer 12

Question 13

Current thinking on contrast-induced nephropathy

Answer 13

The 2018 American College of Radiology Manual on Contrast Media concludes that CIN is a real but rare condition.

They suggest that if a renal function threshold is to be used to avoid use of iodinated contrast a cut of < 30 ml/min/1.73m² is best supported by the available data. In the case of AKI there is a lack of data but it is prudent to avoid iodinated contrast unless the potential benefits outweigh the risk.

Avoid it if you can, but do not let it disuade you from performing a potentially lifesaving diagnostic procedure

Question 14

What is going on in this patient’s eye?

Answer 14

Choroid tubercles

The most common occular manifestation of tuberculosis

Question 15

Specific definition of fever of unknown origin

Answer 15

FUO is a temperature greater than 38.3°C on several occasions lasting longer than three weeks with a diagnosis that remains uncertain after careful evaluation for three outpatient visits or three days of hospitalization.

Once diagnosed, all nonessential medications should be stopped, including acetominophen and ibuprofen.

Question 16

Adult onset Still’s Disease

Answer 16

Adult onset Still’s disease (AOSD) is a rare inflammatory disorder that affects the entire body (systemic disease). The cause of the disorder is unknown (idiopathic). Affected individuals may develop episodes of high, spiking fevers, a pink or salmon colored rash, joint pain, muscle pain, a sore throat and other symptoms associated with systemic inflammatory disease. The specific symptoms and frequency of episodes vary from one person to another and the progression of the disorder is difficult to predict.

Often shows high levels of ferritin on labs. Treat w/ prednisone.

Question 17

What are the most common infectious causes of FUO?

Answer 17

• An occult abscess
• Tuberculosis
• Endocarditis

Question 18

What are the most common malignant causes of fever of unknown origin?

Answer 18

Hodgkin’s and Non-Hodgkin’s lymphomas

Question 19

What are the most common autoimmune/autoinflammatory causes of fever of unknown origin?

Answer 19

• Adult-onset Still’s Disease
• SLE
• Temporal arteritis (particularly in adults over 50)

Question 20

Things to look for in a patient presenting with longstanding, untreated hypertension

Answer 20

• Retinal exam to look for hypertensive retinopathy
• Detailed cardiac exam to look for cardiomegaly or signs of heart failure
• Thorough examination of peripheral pulses and assessment of aortic width to assess for abdominal aortic aneurysm
• Thyroid exam – is this due to hyperthyroidism?

Question 21

Quick table of antihypertensives, indications, and adverse effects

Answer 21

Question 22

DASH diet

Answer 22

When combined with reduced sodium, the Dietary Approaches to Stop Hypertension (DASH) diet, which involves foods low in saturated fats and rich in potassium and calcium, results in a blood pressure reduction similar to that achieved with a single antihypertensive agent.

Question 23

Treating a hypertensive emergency or hypertensive urgency

Answer 23

Patients in hypertensive emergencies are at risk for: MI, stroke, encephalopathy, renal failure, aortic dissection, retinal hemorrhage, and heart failure. Patients with hypertensive emergency must have evidence of active organ dysfunction – otherwise it is hypertensive urgency.

Hypertensive emergencies require immediate treatment, often with intravenous agents such as labetalol or nitroprusside. Meanwhile, hypertensive urgency can usually be treated over a longer period of time with oral agents.

Question 24

Signs of chronic hypertension on fundoscopic exam

Answer 24

Retinal arteriolar narrowing and arteriovenous crossing changes (“AV nicking”) may be seen in patients with long-standing hypertension.

Moderate or severe lightening in the appearance of the arteries (so called “copper-wiring” or “silver-wiring” respectively) may also be seen with long-standing hypertension. These are caused by the arteriolar thickening, which is an adaptive response to long-standing hypertension. These findings do not imply a hypertensive emergency.

In a patient being evaluated for hypertensive emergency versus urgency, the most important retinal findings to look for, with serious prognosis, include papilledema and hemorrhages, both of which indicate a more severe response to the hypertensive episode.

Question 25

What is the target to bring someone down to if they are in hypertensive urgency or emergency?

Answer 25

180/90

Question 26

What is one way to differentiate whether rhonchi are caused by secretions on pulmonary exam?

Answer 26

Have the patient cough and repeat the auscultation!

If the rhonchi are gone or significantly deminished, they were caused by secretions.

Question 27

Causes of common cold

Answer 27

Question 28

First-line treatments for acute sinusitis

Answer 28

• Nothing (they are largely self limited)
• Amoxicillin-clavulonate
• Doxycycline (if penicillin allegic)

If the above fail or symptoms persist for more than 12 weeks, use a broader agent. Chronic sinusitis is often polymicrobial.

Question 29

Interventions that have been shown to actually work to reduce symptoms of URI

Answer 29

• Non-selective antihistamines
• NSAIDs
• Ipratropium bromide

Question 30

Five A’s and Five R’s smoking cessation framework

Answer 30

Question 31

Evidence-based methods to aid smoking cessation in patients

Answer 31

• Counselling
• Nicotine patch or inhaler
• Varenicline (chantix)
• Buproprion (welbutrin)

Question 32

Varenicline (chantix)

Answer 32

Varenicline (Chantix) is the newest smoking-cessation medication. It is a nicotine acetylcholine receptor partial agonist, and in a randomized controlled trial patients had better quit rates than those who used bupropion.

For varenicline, the quit rate was 45% at three months compared to 34% for bupropion.

The Food and Drug Administration (FDA) has put out warnings of neuropsychiatric symptoms that occurred in patients who were taking varenicline. Patients should be monitored for suicidal ideation, increased agitation, vivid dreams, and depressed mood.

Question 33

Contraindications to buproprion

Answer 33

Bupropion frequently causes insomnia and very rarely induces seizures. Check for history of seizures, head injuries, or eating disorders.

Question 34

Tetralogy of fallot signs, symptoms, etiology

Answer 34

• Symptoms/Signs: Minimal exercise causes hypoxemia and cyanosis which is relieved by squatting, systolic murmur of ventricular septal defect
• Etiology: Abnormal neural crest cell migration leading to deviation of the infundibular septum, resulting in VSD and overriding aorta

Question 35

Febrile neutropenia predisposes to infection with. . .

Answer 35

. . . gram negatives, especially Pseudomonas aeruginosa.

These individuals are at particular risk for ecthyma ganrenosum, shown below.

Question 36

Cardiac changes of normal aging

Answer 36

On histology, there is also an accumulation of “lipofuscin” pigment, a perinuclear brownish pigment that is the result of subcellular membrane lipid oxidation.

Question 37

Lipofuscin

Answer 37

Perinuclear brownish pigment that is the result of subcellular membrane lipid oxidation.

Normally develop in an aging heart.

Question 38

Adverse effets of bisphosphonates

Answer 38

Question 39

Bacillary angiomatosis

Answer 39

When patients with advanced AIDS get infected with Bartonella hensleae, instead of cat scratch disease, they get bacillary angiomatosis

This is characterized by eruption of tender, red nodules with a purplish corona on the effected limbs. These nodules are highly vascular, and on histology are composed mostly of large endothelial cells producing vascular channels within the lesion, and a neutrophilic/lymphocytic infiltrate.

Question 40

Findings of pulmonary hypertension

Answer 40

• Progressive dyspnea
• Loud P2 and RV heave on exam

Question 41

Flutamide

Answer 41

Flutamide is a competitive testosterone antagonist

It acts at the level of the testosterone and DHT receptors in the prostate and in prostate cancer

Question 42

Adenomyosis is assocaited with ___ on bimanual exam

Answer 42

Adenomyosis is assocaited with uniform endometrial enlargement on bimanual exam