Aquifer Material

Question 1

Acute management of unstable angina

Answer 1

• Pharmacology: Heparin, Aspirin, Beta-blocker, Statin, Sublingual nitroglycerin
• Intervention: Non-emergent PCI

Question 2

“GI cocktail”

Answer 2

Refers to a combination of antacid, viscous lidocaine, and an anticholinergic.

Used for suspected GERD in the hospital setting.

Question 3

GP IIb/IIIa Inhibitors in Angioplasty for STEMI

Answer 3

In patients undergoing angioplasty, a GP IIb/IIIa inhibitor such as abciximab or eptifibatide inhibits platelet aggregation and may prevent platelet adhesion to the vessel wall.

While these medications increase the risk of bleeding (especially when used in combination with fibrinolytics) and can cause thrombocytopenia within 24 hours of initiation, they improve outcomes in patients with STEMI.

Question 4

Complications of an MI

Answer 4

• Chronically:
  
  • Bradyarrhythmia/heart block
  • Ventricular arrhythmia
  • Reduce ventricular function
  • Cardiogenic shock
  • Recurrent thrombosis
  • • 2-7 day window:
  • Papillary muscle rupture
  • Ventricular free wall rupture
  • Pericarditis
• ~Months later:
  
  • Dressler’s syndrome

Question 5

Standard post-MI discharge drug regimen

Answer 5

• ACE inhibitor
• Beta-blocker
• Aspirin and clopidogrel (dual antiplatelet therapy)
• Statin
• Sublingual nitroglycerin PRN

Question 6

Why dual antiplatelet therapy for one year after MI?

Answer 6

It has been shown to prevent stent thrombosis, specifically. After the one year, discontinuing is not associated with increased risk of thrombosis.

Question 7

In what context are ACE inhibitors usually recommended for post-MI hypertension treatment?

Answer 7

New left ventricular systolic dysfunction

Question 8

Guidelines for afib rate control

Answer 8

• HR <80 BPM is reasonable for symptomatic atrial fibrillation management.
• HR <110 BPM is reasonable if asymptomatic and LVEF is preserved.

Question 9

Anticoagulation recommendation for patients with afib AND valvular heart disease

Answer 9

Warfarin is the choice over heparin, titrated to an INR between 2 and 3

Otherwise, refer to CHADS-VASc system

Question 10

Anticoagulation recommendations for patients with afib in the absence of valvular heart disease

Answer 10

If 0, then no need for anticoagulation

If 1, then aspirin for sure, consider DOAC.

If 2 or more, then DOAC or warfarin

Question 11

Cheynes-Stokes respirations

Answer 11

• aka “periodic breathing”
• Oscillation between apnea and tachypnea
• Stroke, traumatic brain injury, brain tumors, congestive heart failure, or actively dying

Question 12

Potassium in DKA

Answer 12

Patients with DKA are often hyperkalemic, but potassium deficient!

The hyperkalemia is because the osmolarity forces potassium out of cells, and without intact insulin signaling it is not being siphoned back in.

However, they can’t stop peeing! So they quickly lose all of that potassium, becoming net potassium deficient. So, when you do treat with insulin, the potassium will start going back into cells and the patient will become hypokalemic.

For this reason, potassium must be added to fluids when treating DKA with fluid and insulin. If potassium drops below 3.3, begin IV potassium replacement immediately and delay the insulin treatment until potassium concentration is restored to a normal value ​

Question 13

When is it safe to stop an insulin drip on someone being treated for DKA?

Answer 13

When:

1. The anion gap is back to normal
2. The patient has received long-acting subcutaneous insulin
3. The patient can tolerate food PO

Question 14

Standard tests for a patient newly diagnosed with type II DM

Answer 14

• HbA1c
• Fasting lipids
• Urine albumin/creatinine ratio

Question 15

Abdominal pain that worsens with movement suggests. . .

Answer 15

. . . focal parietal peritoneal pain

Question 16

Non-megaloblatsic causes of macrocytosis

Answer 16

• Alcohol use disorder
• Liver disease
• Hypothyroidism
• Hydroxyurea
• Myelodysplasia
• Reticulocytosis

Question 17

When to consult an abdominal surgeon for explorative surgery in the setting of acute abdomen

Answer 17

• Cholecystitis
• Small bowel obstruction
• Perforation of an abdominal organ
• Complicated pancreatitis
  
  • ie, impacted gall stone, pancreatic abscess, large or symptomatic pseudocyst, necrotic pancreatitis

Question 18

Management of acute pancreatitis

Answer 18

• Isotonic IV fluids, pain control, and a soft, low fat diet as tolerated (if there is no vomiting and no ileus).
• Formerly patients with mild pancreatitis were kept NPO for several days until symptoms resolved however more recent trials have shown that a PO diet is safe.

Question 19

Imaging in acute pancreatitis

Answer 19

1. RUQ ultrasound (to rule in/out gallstones)
   
   • Here you are looking for gallstones or CBD dilation
2. ERCP once RUQ ultrasound shows CBD dilation
3. CT ONLY WHEN there is suspicion of pseudocyst
   
   • Not generally used in the acute setting

Question 20

Criteria for antibiotics in acute pancreatitis

Answer 20

Antibiotic use in pancreatitis has been studied in controlled clinical trials but remains controversial.

With increasing severity of illness, organ dysfunction, and worsening pancreatic necrosis, some studies have shown benefit with prophylactic antibiotic therapy, and some have not.

Empiric (not prophylactic) antibiotic therapy should definitely be used in patients who appear to have infection complicating a severe pancreatitis course, such as infected pseudocyst or pancreatic abscess complicating extensive pancreatic necrosis.

Question 21

ERCP vs MRCP

Answer 21

MRCP is a noninvasive imaging test to detect obstruction of the biliary tree and pancreatic duct. It is slightly less sensitive than ERCP, but much less risky for patients since it is not invasive. It does not have the ability to be therapeutic.

ERCP directly cannulates the Ampulla of Vater and injects radio-opaque dye into the duct to outline an obstruction. Instruments can then be passed through the ampulla to allow for biopsy or dilation and release of gall stones.

Drainage of an obstructed bile duct with ERCP provides rapid relief of symptoms and improved outcomes in obstructive forms of pancreatitis, but carries a risk of complications including bleeding, perforated bowel, worsening pancreatitis, or even death. If this test was performed in a patient who clearly had non-obstructive pancreatitis that was already improving, the risk definitely outweighs the benefit.

Question 22

Lorazepam vs diazepam for alcohol withdrawal

Answer 22

Diazepam is the treatment of choice, BUT, it can only be given orally, which is often a problem when dealing with nausea/vomiting/psychological changes of alcohol withdrawal.

Lorazepam may be given intravenously, and so it is often used over diazepam in these situations.

Question 23

What is going on in this patient?

Answer 23

Angular cheilitis

An inflammatory lesion at the labial commissure, or corner of the mouth, which often occurs bilaterally. The condition manifests as deep cracks or splits and can be associated with malnutrition or deficiencies of iron or vitamin B12.

Question 24

What is going on in this patient?

Answer 24

A combination of atrophic glossitis and angular cheilitis

This is susipcious for folate or B12 deficiency. This individual may have megaloblastic anemia.

Question 25

A vegetarian with megaloblastic anemia is much more likely to have a ___ deficiency than a ___ deficiency.

Answer 25

A vegetarian with megaloblastic anemia is much more likely to have a **B12** deficiency than a **folate** deficiency. Fruits and vegetables are FULL of folate! It is the carnivores that are more at risk for folate problems.

Question 26

Reticulocyte production index

Answer 26

**In healthy individuals, the reticulocyte index is 1-2**. If the reticulocyte index is \<2, there is decreased red cell production. An RPI \> 2 with anemia indicates hemolysis leading to compensatory reticulocytosis. The reticulocyte maturation time is based on the patient's hematocrit. The maturation time corrects for the longer lifespan of prematurely released reticulocytes in the blood. Maturation time is **1.0** if the patient's hematocrit is **\> 35**, **1.5** if the hematocrit is **25-34, 2.0** if the hematocrit is **20-25**, and **2.5** if the hematocrit is **\< 20.**

Question 27

Burr cells

Answer 27

Aka echinocytes Red blood cells with multiple small projections with blunt edges symmetrically distributed across their surface as seen at 1:00 in the smear. **Burr cells** **can be an artifact, but can also be seen in patients with uremia, alkalosis and bile acid abnormalities.** Burr cells should not be confused with spur cells (acanthocytes) which have multiple thorn-like, irregularly spaced projections. They are seen in liver disease and certain neuromuscular disorders.

Question 28

Codocytes

Answer 28

aka target cells Red blood cells with a central color spot in the area of pallor (thereby resembling a target). Target cells can be seen in **thalassemia and liver disease**.

Question 29

Spur cells

Answer 29

aka acanthocytes Red blood cells with multiple thorn-like, irregularly spaced projections. They are seen in **cirrhotic liver disease and certain neuromuscular disorders.**

Question 30

Rouleaux

Answer 30

Stacks of red cell pancakes They are seen when there is **hyperfibrinogenemia or hypergammaglobulinemia** (such as in multiple myeloma).

Question 31

Which is a better way to sample for fecal occult blood: a digital rectal exam, or sending the patient home/to the bathroom with a kit?

Answer 31

Let the patient do it themselves! Not only are rectal exams uncomfortable for both parties, you may produce trauma that elicits blood and leads to a false-positive. For this reason, the evidence-based protocol is to let the patient sample it themself.

Question 32

What is the most common cause of B12 deficiency?

Answer 32

Pernicious anemia Although, it tends to be in older individuals, it also tends to occur early in females of African descent. If someone presents with new B12 deficiency and a history of autoimmune disease, you should be very suspicious of pernicious anemia.

Question 33

Blood tests for pernicious anemia

Answer 33

* Anti-parietal cell antibodies (sensitive, nonspecific) * Anti-intrinsic factor antibodies (specific, nonsensitive)

Question 34

How can you treat pernicious anemia?

Answer 34

Two ways: * Intramuscular B12 * High-dose oral B12 As it turns out, the terminal ileum has a small intrinsic-factor-independent absorptive capacity for B12 (about 1% of the total oral dose), so just increasing the oral dose is often sufficient. This way you save the patient from having to get regular intramuscular injections.

Question 35

Why shouldn't you take iron pills with tea?

Answer 35

Tannins decrease iron absorption Vitamin C, on the other hand, increases it! So substitute orange juice instead.

Question 36

What medications should you avoid taking with iron pills?

Answer 36

**Levothyroxine** and **many oral antibiotics** Wait 4 hours after taking iron pills before taking these medications.

Question 37

Vaccine recommendations for HIV-infected patients with CD4 count below 200

Answer 37

* All should receive Hep A and Hep B * All should receive influenza annually * All should receive streptococcal polysaccharide vaccines (see guidelines attached) * The **varicella, zoster, intranasal influenza, and measles, mumps, and rubella (MMR) vaccines** **are all contraindicated** in HIV-infected persons with a CD4+ cell count \< 200 cells/μL because they are **live vaccines.**

Question 38

Recommendations for Pap Tests in Females with HIV

Answer 38

Every female who is diagnosed with HIV needs a Papanicolaou (Pap) **test at the time of diagnosis** and another one **six to twelve months after.** If these are normal, then Pap tests should be obtained **annually.** If the results of three consecutive Pap smears are normal, the screening interval can be increased to every 3 years.

Question 39

Two most common causes of fever of unknown origin

Answer 39

Malignancies and non-infectious diseases

Question 40

When to start worrying about crypto\_\_ oragnisms in HIV patients

Answer 40

When CD4 count falls below 100 Cryptococci and cryptosporidium are the two to worry about.

Question 41

Three major categories of AIDS-related lymphomas

Answer 41

Question 42

Adverse effects of antiretrovirals

Answer 42

Question 43

Baseline Studies to Obtain Prior to ART Initiation

Answer 43

Question 44

Prophylaxis against opportunistic infections for AIDS patients

Answer 44

Question 45

Deciding whether or not to admit a patient with pneumonia

Answer 45

CURB-65 score * **C**onfusion * Blood **U**rea Nitrogen (\>19) * **R**espiratory Rate \> 30 * **B**lood pressure (systolic \< 90 or diastolic \< 60) * Age (**65** or older)

Question 46

Which pneumonia patients are highly contagious and therefore should be placed in respiratory isolation?

Answer 46

Not really those who walk in with a bacterial pneumonia, but **viral pneumonias** like influenza and **tuberculous pneumonia** are highly contagious.

Question 47

Benefits of the pneumococal vaccine

Answer 47

The pneumococcal vaccine has not shown any reduction in the risk of developing community-acquired pneumonia, but it can reduce the risk of invasive disease, including bacteremia, meningitis, or infection of other sterile sites.