Flashcards in Bardes Deck (65):
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
Unstable angina versus MI?
ST depressions, T-wave inversions, but no troponin elevation
When to give thrombolytics over Cath Lab?
If Cath Lab, need what backup?
If Cath Lab is far away
Need CT surgery back up
Best response to aggressive patient with altered mental status?
When to perform a coronary artery bypass graft?
Three vessel disease or left main stenosis
Problem with morphine for MI treatment?
Severe chest pain with nausea and vomiting – think?
Inferior wall MI – phrenic nerve activation causes nausea and vomiting
Any patient with a stent needs to be put on which drug? For how long?
1 month if bare-metal stent
12 months if drugs-eluding stent
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
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
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
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)
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)
Causes of cardiogenic pulmonary edema?
1. Systolic dysfunction (decreased LV contractility)
2. Diastolic dysfunction (decreased LV compliance)
3. Mitral stenosis
Causes of systolic dysfunction?
2. dilated cardiomyopathy
3. valvular disease
6. Milieu (electrolytes, thyroid hormone)
7. Drugs (doxorubicin, alcohol, beta blockers, calcium channel blockers)
Drug that causes permanent systolic dysfunction?
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)
Systolic versus diastolic dysfunction – characteristic heart sound?
S3 versus S4
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
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)
Functions of beta blockers?
1. Decrease afterload
2. Increase filling
3. Antiarrhythmic (mortality benefit)
4. Less Remodeling
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
Treatment for systolic LV dysfunction that do not have a mortality benefit?
3. Nitroglycerin/nitrates alone
4. Hydralazine alone
Treatment for diastolic left ventricular dysfunction?
1. Beta blockers (decrease heart rate to increase feeling time)
2. Calcium channel blockers
Non-cardiogenic causes of fluid in alveolar space?
The patient with URI – could treat with?
Antibiotics – but don't do it (almost always viral)
Drugs that can treat strep PNA?
Antibiotics that will not treat H. influenzae? Antibiotics that will not treat atypical PNA?
Penicillin, first-generation cephalosporin
Penicillin, all cephalosporins, vancomycin
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?
2. Ceftriaxone plus macrolide
Treatment of hospital acquired pneumonia?
(All first line)
Or fluoroquinolone plus aminoglycoside
Patients over 65 years with comorbidities – additional bacteria to worry about?
If immunocompromised/in-hospital/recent antibiotic use?
Why not broad-spectrum antibiotics for all?
2. Opportunistic infections (Candida, C diff)
Section: patients with immune reserve (leukemia, immunosuppressed)
Aminoglycosides in order of effectiveness/toxicity?
Amikacin (always causes deafness) >tobramycin >gentamicin
General causes of transaminase elevations?
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)
5. Parasites (malaria, babesia)
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
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)
Vascular disturbances that cause elevated transaminases?
1. Arterial (shock liver)
2. Venus (Budd Chiari, cardiac, pulmonary hypertension)
3. Capillary (DIC, TTP, HUS)
General causes of increased alkaline phosphatase?
1. Mechanical Obstruction
3. Mass lesions
Mechanical obstructions that increase alkaline phosphatase?
1. Cholangiocarcinoma, pancreatic carcinoma
2. Obliteration – PBC, PSC
Biliary Obstruction caused by ileus that leads to increased alkaline phosphatase?
1. Severe illness
3. Drugs (sulfonylureas)
Mass lesions that increase alkaline phosphatase?
1. Cysts (especially from helminths - echinococcus, entamoeba)
3. Granulomas (TB, sarcoid, syphilis)
4. Malignant Neoplasms - HCC
5. Benign tumors – hemangiomas
Lab values that are a measure of liver function?
PT, Bilirubin, albumin
Most common cause of fatigue?
Causes of prerenal azotemia?
3. Third spacing
Two general causes of intrarenal azotemia?
Causes of glomerular intrarenal azotemia? (distinguishing feature?)
1. Glomerulonephritis (RBC casts)
2. Glomerular sclerosis (sonogram)
3. Nephrotic (3.5+ proteinuria)
4. Collagen vascular
Interstitial causes of intrarenal azotemia? (Distinguishing feature?)
1. ATN (muddy brown casts)
2. Acute interstitial (eosinophils)
3. Pyelonephritis (WBC cast)
Causes of postrenal azotemia?
1. Mechanical (prostate, stones, strictures, malignancies)
2. Neurogenic bladder
3. Drugs (anticholinergics, sympathomimetics, drugs with anticholinergic side effects)
Causes of acute interstitial nephritis?
Drugs with anticholinergic side effects?
Tricyclics, antipsychotics, antihistamines, opioids
Total capacity bladder? Residual capacity after urination?
500 mL; 50 mL
Post strep glomerulonephritis – look for?
Creatinine clearance formula?
((140 - age)/creatinine) * (weight/70) * (.8 if female)
Creatinine clearance values and interpretation?
>80 – normal
50-80 – mild renal failure
30-50 – moderate
15-30 – severe
<15 – failure
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
Why get a CT scan with suspected meningitis?
Otherwise lumbar puncture can cause herniation
Endocarditis – prophylaxis if? What drug to use for prophylaxis?
1. Congenital valve defect
2. Mechanical valve
3. Prior endocarditis
Bugs that cause endocarditis?
Gram-positive >Coxiella >HACEK >candida
Treatment for uncomplicated UTI?
Treatment for complicated UTI?
Treatment if pregnant?
Bactrim three days
Fluroquinolone to 14 days
Causes of post operation fever?
Wind – aerobic
Water – UTI
Walking – DVT
Imaging for fatty liver?
Increased alkaline phosphatase – imaging?