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Flashcards in Bardes Deck (65):
0

Chest pain – rule out? (How?)

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

1

Unstable angina versus MI?

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

2

MI treatment?

OH BATMAN
Oxygen
Heparin
Beta blocker
Aspirin
Thrombolytics
Morphine
Atorvastatin
Nitroglycerin

3

When to give thrombolytics over Cath Lab?

If Cath Lab, need what backup?

If Cath Lab is far away

Need CT surgery back up

4

Best response to aggressive patient with altered mental status?

Give 1:1

5

When to perform a coronary artery bypass graft?

Three vessel disease or left main stenosis

6

Problem with morphine for MI treatment?

Mask symptoms

7

Severe chest pain with nausea and vomiting – think?

Inferior wall MI – phrenic nerve activation causes nausea and vomiting

8

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

Clopidogrel

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

9

Drugs appropriate for stable angina?

Drug appropriate for unstable angina and MI?

Drugs appropriate for MI only?

Aspirin, beta blocker

Aspirin, Plavix, heparin, beta blocker

+Thrombolytics

10

Complicated UTI?

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

11

SIRS criteria?

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

12

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

Hypovolemic shock (cool, flat veins, weak pulse)

Cardiogenic (cool, JVD, weak pulse)

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

13

Shock - treatment?

1. IV fluids until CVP is 8 to 12, MAP greater than 65, SPO2 greater than 70
1.1 If no response - pressors (dopamine, then epinephrine)
1.2 If no response Dobutamine

2. Broad-spectrum antibiotics (Ceftriaxone, then vancomycin + zosyn)

14

Causes of cardiogenic pulmonary edema?

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

15

Causes of systolic dysfunction?

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

16

Drug that causes permanent systolic dysfunction?

Doxorubicin

17

Causes of diastolic dysfunction?

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

18

Systolic versus diastolic dysfunction – characteristic heart sound?

S3 versus S4

19

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

Kidney causes, hormone causes, drug causes

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

20

Treatment for systolic LV dysfunction that has a mortality benefit?

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

21

Functions of beta blockers?

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

22

Advice for treatment for systolic LV dysfunction?

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

23

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

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

24

Treatment for diastolic left ventricular dysfunction?

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

25

Non-cardiogenic causes of fluid in alveolar space?

1. Infection
2 ARDS
3. Sepsis
4. Trauma

26

The patient with URI – could treat with?

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

27

Drugs that can treat strep PNA?

Penicillin
All cephalosporins
Macrolides
Tetracycline
Fluoroquinolones
Bactrim
Vancomycin
Clindamycin

28

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

Penicillin, first-generation cephalosporin

Penicillin, all cephalosporins, vancomycin

29

Treatment for patients younger than 60 with community acquired pneumonia?

Treatment if patient is over 60 or with comorbidities?

Treatment of immunocompromised ?

Treatment of aspirational pneumonia?

1. Macrolides
2. Fluoroquinolones

1. Fluoroquinolone
2. Ceftriaxone plus macrolide

Add gentamicin

Add clindamycin

30

Treatment of hospital acquired pneumonia?

(All first line)
Ceftazadine/cefepime
Carbapenem
Zosyn

Or fluoroquinolone plus aminoglycoside

31

PNA Bugs:

Patients over 65 years with comorbidities – additional bacteria to worry about?

If immunocompromised/in-hospital/recent antibiotic use?

If aspiration?

HACEK

Pseudomonas, Klebsiella

Peptococcus, actinomyces

32

Why not broad-spectrum antibiotics for all?

Exception?

1. Resistance
2. Opportunistic infections (Candida, C diff)
3. Cost
4. Toxicity

Section: patients with immune reserve (leukemia, immunosuppressed)

33

Aminoglycosides in order of effectiveness/toxicity?

Amikacin (always causes deafness) >tobramycin >gentamicin

34

General causes of transaminase elevations?

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

35

Infectious causes of elevated transaminases?

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

36

Drugs and toxins that cause elevated transaminases?

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

37

Metabolic diseases that cause elevated transaminases?

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

38

Vascular disturbances that cause elevated transaminases?

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

39

General causes of increased alkaline phosphatase?

1. Mechanical Obstruction
2. Ileus
3. Mass lesions

40

Mechanical obstructions that increase alkaline phosphatase?

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

41

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

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

42

Mass lesions that increase alkaline phosphatase?

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

43

Lab values that are a measure of liver function?

PT, Bilirubin, albumin

44

Most common cause of fatigue?

Depression

45

Causes of prerenal azotemia?

1. Renovascular
2. Shock
3. Third spacing

46

Two general causes of intrarenal azotemia?

1. Glomerular
2. Interstitial

47

Causes of glomerular intrarenal azotemia? (distinguishing feature?)

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

48

Interstitial causes of intrarenal azotemia? (Distinguishing feature?)

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

49

Causes of postrenal azotemia?


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

50

Causes of acute interstitial nephritis?

Beta-lactam's, NSAIDs

51

Drugs with anticholinergic side effects?

Tricyclics, antipsychotics, antihistamines, opioids

52

Total capacity bladder? Residual capacity after urination?

500 mL; 50 mL

53

Post strep glomerulonephritis – look for?

ASO titers

54

Creatinine clearance formula?

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

55

Creatinine clearance values and interpretation?

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

56

Management of suspected meningitis?

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

57

Why get a CT scan with suspected meningitis?

Otherwise lumbar puncture can cause herniation

58

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

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

Amoxicillin

59

Bugs that cause endocarditis?

Gram-positive >Coxiella >HACEK >candida

60

Treatment for uncomplicated UTI?

Treatment for complicated UTI?

Treatment if pregnant?

Bactrim three days

Fluroquinolone to 14 days

Nitrofurantoin

61

Causes of post operation fever?

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

62

Imaging for fatty liver?

Sonogram

63

Increased alkaline phosphatase – imaging?

Sonogram/CT

64

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

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

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