common problems Flashcards Preview

0 BOARDS > common problems > Flashcards

Flashcards in common problems Deck (234):
1

cutaneous pain

localized on skin/surface of body

2

visceral pain

poorly localized (ex: internal organs)

3

somatic pain

non-localized
originates: muscle, bone, nerves, blood vessels, supporting tissue

4

neuropathic pain

freq caused by tumor
involves nerve pathway injury/compression

5

WHO Ladder of Pain Management: Step 1

ASA
APAP
NSAID
+/- adjuvant

6

WHO Ladder of Pain Management: Step 2

APAP or ASA +codeine
hydrocodone
oxycodone
dihydrocodone
tramadol (not with APAP or ASA)
+/- adjuvant

7

WHO Ladder of Pain Management: Step 3

morphine
hydromorphone
methadone
levorphanol
fentanyl
oxycodone
+/- non-opioid analgesics
+/- adjuvant

8

adjuvant analgesics

drugs with other indications that may be analgesic in specific circumstances
- anticonvulsants, antidepressants, local anaesthetic, corticosteroid, etc.
- can be used at any step in WHO ladder

9

NSAIDS

prostaglandin inhibitors (via COX inhibition)
analgesic / antipyretic / antiplatelet
- used primarily as antiinflammatory agents

10

older patients + opioids: considerations

reduce starting doses by 25 - 50% + monitor freq for AE

11

What is the single most reliable indicator of existence and intensity of pain?

Subjective findings - patient report
WHOSE PAIN IS IT

12

Normal body temperature

37 C

13

When is it appropriate to start Tylenol given fever?

AFTER cultures are drawn.

14

Neuroleptic Malignant Syndrome

r/t SSRI toxicity
//or//
family hx significant for NMS

15

Malignant Hyperthermia is associated with what drug?

succinylcholine

16

Succs is contraindicated in what situation?

HYPERKALEMIA

17

most common cause of non-infectious fever

POST-OP ATELECTASIS

18

elevated eosinophils are present in what reactions?

allergic reactions
drug-induced fever

eiosinophilia implies allergic rxn!

19

Drug Induced Fever

Slow onset (7 - 10 days)
PCN derivatives most commonly induce

20

initial treatment for non-infection related post-op fever

hydration
increasing lung expansion

21

infectious etiology of fever is manifested in this lab

elevated WBC with L shift (bandemia)

22

likely etiology of WBC elevation over 30k

not due to infection - usually leukemia

23

treatment of infection-related post-op fever x3

supportive fluids + APAP
treat underlying source
gram stain, C&S all invasive lines/catheters

24

patient presents with 101.5 F lasting over 3 wks. ddx and plan of care?

it is FUO, ddx include endocarditis & malignancy

plan is to identify source of fever - no intervention otherwise

25

most important bit of history to collect regarding a headache

chronology - onset; when it started

26

tension headache: s/s x5

vice-like, squeezing, tight
generalized
intense around neck & back of head
no focal neuro sx
duration: several hours

27

Patient is complaining of a headache with a squeezing sensation that is generalized but specially intense around the back of her head. It has lasted for several hours and she has no focal deficits. Top differential?

tension headache

28

tension headache: tx x2

OTC analgesics
relaxation

29

migraine

r/t dilation + excessive pulsation of external carotid + branches, follows trigeminal nerve (V)
duration: 2 - 72 hours
types: classic vs common

30

classic vs common migraine

classic with aura
common without aura (literally, most pts have these)

31

migraine: s/s x6

- unilateralized throbbing occurs episodically, can be dull
- gradual build up
- focal neuro deficits: hallucinations, visual changes, aphasia, numbness, tingling, clumsiness
- n/v, photo & phonophobia

32

25 yo. F presents to ED with chief complaint unilateral throbbing that started 12 hours ago. Pt describes visual changes and numbness in her right hand following the pathway of the headache. What is primary diagnosis?

migraine headache

33

migraine headache: diagnostics

- baseline studies if new, r/o organic causes
- CT scan (r/o brain tumor)
- BMP
- CBC
- VDRL (r/o syphilis)
- ESR

34

You want to rule out neurosyphilis as the etiology of a migraine; what lab do you order?

VDRL
- if positive, presumptive

35

Pt has 2 - 3 migraines per month. What is indicated for prophylactic therapy?

amitryptyline (Elavil)

36

migraine: acute attack mgmt

1. Rest in dark, quiet room
2. ASA STAT: pain relief
3. sumatriptan (Imitrex)
- 6 mg SQ stat, can repeat in 1 hr (3 max per day)
- 25 mg PO @ HA onset

37

cluster headache: s/s x8 + typical population

middle-aged men
- severe, unilateral, periorbital pain daily x several weeks (wk - mo between attacks)
- usually @ night, wake from sleep
- shorter than 2 hours
- ipsilateral nasal congestion, rhinorrhea, eye redness
exam otherwise normal

38

cluster headache: mgmt x3

- 100% O2
- sumatriptan (Imitrex) 6mg SQ - but PO meds usually unsatisfactory
- ergotamine tartrate (Ergostat) aerosol inhalation

39

best nutritional serum marker

prealbumin

40

hgb under 12 (M) or 13.5 (F) indicates what? x4

lack of iron or protein
poor oxygenation and perfusion

41

How does 1 unit PRBC affect H/H in general? If 8/24?

1 unit PRBC increases H/H 1/3
8/24 + 1 unit PRBC = H/H of 9/27

42

What is your first consideration for nutritional support?

PO supplements to diet

43

Patient requires nutrition support but GI tract is non-functional. What are 2 other options and when would you use them?

CVC: central - anticipated longer than 2 weeks
PICC line: peripheral - shorter

44

Patient requires nutrition support and GI tract is functional. What 3 options do you have and when would you use them?

enterostomal tube: anticipated longer than 6 weeks

nasoduodenal tube: shorter than 6 weeks and aspiration risk

nasogastric tube: shorter than 6 weeks and no aspiration risk

45

What solution should be used in parenteral feeds via PICC line?

less than 10% dextrose

46

enteral nutritional support: possible complications x7

THE PROBLEM IS THE SOLUTION
- hypernatremia
- aspiration
- dehydration
- vomiting, GI bleed, diarrhea
- tube obstruction

47

hypotonic hyponatremia: what & serum osmolality

serum osmolality less than 280 mosm/kg

body water excess = dilutes all fluids, causing clinical signs; either renal or extra-renal cause must be determined

48

hypovolemic hypotonic hyponatremia: causes

Renal Salt EXCRETION: kidneys can't conserve Na!
- diuretics
- ACE Inhibitors
- mineralcorticoid deficiency

49

hypervolemic hypotonic hyponatremia: treatment

WATER RESTRICTION

50

hypervolemic hypotonic hyponatremia: causes

- edematous states
- CHF
- liver disease
- advanced renal failure

51

hypovolemic hypotonic hyponatremia: treatment

IVF: NS

52

hypovolemic hypotonic hyponatremia + urine Na gt20: treatment

treat the cause

53

severe hypovolemic hypernatremia: treatment + important consideration

IVF: NS then 0.5 NS
* slowly to avoid cerebral edema *

54

hypervolemic hypernatremia: treatment x3

free water
loop diuretic
consider dialysis

55

hypokalemia: causes

losses: GI, excess renal
alkalosis

56

Heart failure patient who is on chronic diuretic is at risk for what?

hypokalemia

57

hypokalemia: EKG changes x6

decreased amplitude
broad T waves
U waves
rhythm abnormalities: PVCs, v tach, v fib

58

hypokalemia: s/s - general x5 + severe x4
what counts as severe hypokalemia?

muscle weakness, fatigue, cramps
constipation, ileus (d/t smooth muscles)

severe (lt 2.5 mEq/L): flaccid paralysis, tetany, hyporeflexia, rhabdo

59

hypokalemia: treatment x3

- PO replacement if K 2.5+ and normal EKG
- IV replacement 10 mEq/hr if PO not possible
- different for severe (40 mEq/L/hr IV)

60

severe hypokalemia: expected K value + treatment x4

K under 2.5
- IV repletion @ 40 mEq/L/hr
- K check q3hrs
- continuous EKG
- check Mg (deficiency impairs correction)

61

Your patient has sustained a dog, cat, or human bite, OH NOES. What do you do to reduce the risk of a gnarly infection, bro?!?!

high pressure irrigation (NS or LR) with 18-19 G needle

62

What types of bite wounds should be left open?

bite on hands or lower extremities, any wound older than 6 hours (heal by secondary intention)

63

what prophylactic antibiotics do you use for bites?

whether human bites require antibiotics is controversial, but for both human and animal bites:

3 - 7 days of PO abx with coverage for staph & anaerobes (amoxicillin clavulanate/Augmentin is a good choice)

64

GOOD CHOICE FOR BITES ABX PROPHYLAXIS

amoxicillin clavulanate (Augmentin) PO 3-7 days

65

Which of these require suturing
a. dog bite
b. puncture wound
c. clean laceration of elderly patients hand
d. abrasion

Clean laceration of elderly person's hand requires suturing

66

3 most common causes of cellulitis in the outpatient setting?

Strep pyogenes (GAS): the usual cause
Staph aureus: less common
Strep etc: rare

67

3 most common causes of inpatient cellulitis?

- GRAM NEGS (Klebsiella, E Coli, Pseudomonas, Enterobacter)
- Staph aureus
- Strep

68

Patient has sustained a wicked boil that looks super spider bitey. What do you suspect and how do you fix dat ish?!

MRSA!!!!
per IDSA: I & D + culture, NO ABX!

69

CA-MRSA cellulitis: 3 treatment options

sulfamethoxazole-trimethoprim (Bactrim)
doxycycline
clindamycin

70

GAS cellulitis: 3 tx options

sulfamethoxazole-trimethoprim (Bactrim) + beta lactam (PCN, amoxicillin, keflex)

doxy/minocycline + beta lactam (PCN, amoxicillin, keflex)

dlindamycin

71

Which antimicrobial indicated for cellulitis has strep and staph coverage?

Clindamycin - but it's not as effective as a beta lactam plus either Bactrim or doxy or mino

72

bull's eye rash is associated with what diease?treatment?

aka erythema migrans = Lyme disease

treatment: doxy

73

Rocky Mountain Spotted Fever treatment

doxyyyyy

74

Most important aspect of assessment of patient with suspected toxicity?

HISTORY

75

activated charcoal: indication & dose

use for GI decontamination

1 g/kg (max 50g) q4 hrs PRN
- in combination w Sorbitol (cathartic = poo city!)

76

ipecac: indications & contraindications

barfing up your guts after at home, SOLID ingestion

never use for: corrosives/detergents (esophageal erosion or aspiration pna may result)

77

APAP toxicity: s/s x4

- early: usually asymptomatic
- around 24 - 48 hrs: n & v
- RUQ pain
- hepatoxicity as manifested by: jaundice, elevated LFTs, prolonged PT, AMS

78

APAP toxicity: mgmt x3

- emesis if recent
- GI lavage, activated charcoal (1 gm/kg q4)
- N-Acetylcysteine (Mucomyst) + loading dose PO PRN

79

hyperkalemia: mnemonic + causes

M A C H I N E

M eds: NSAIDS, ACE-I
A cidosis
C ellular destruction (trauma, burns)
H ypoaldosteonism
I ncreased intake
Nephron damage (renal failure)
E xcretion impaired

80

hyperkalemia: mnemonic + s/s

M U R D E R

M uscle weakness (flaccid paralysis)
U OP decrease
R esp distress
D iarrhea, decreased heart FOC
E KG changes (peaked T + brady)
R eflexes (hyper or none)

81

hyperkalemia: general mgmt

- Kayexalate (exchange resins)
- if severe or cardiac toxicity or paralysis, insulin 10U + 1 amp D50

82

A patient is severely hyperkalemic with flaccid paralysis. What is the expected K level and treatment plan? What does that plan accomplish?

severe = 6.5+

insulin 10 U
+ one amp D50
- pushes K back into cell

83

calcium: 2 major roles, normal total and normal ionized values

mediates neuromuscular & cardiac fxn
normal TOTAL: 8.5 - 10.5 mg/dL
normal IONIZED: 4.5 - 5.5 mg/dL

84

Patient's albumin levels are abnormal and you want to measure calcium. Which form do you order and why?

IONIZED: does not vary with the albumin level

85

How do acidemia and alkalemia impact serum calcium levels?

acidemia INCREASES calcium
alkalemia DECREASES

86

hypocalcemia: causes x5

PANCREATITIS
hypomag, hypoPTH
renal failure
trauma

87

hypocalcemia: s/s - 3x major + 3x more

Calcium calms. Not enough, so wacko.

MAJOR: trousseau, chvostek, QT prolongation

convulsions, hyper DTRs, muscle/abd cramps

88

hypocalcemia: mgmt x5

ACUTE: IV calcium gluconate
CHRONIC: PO supplements: Vit D, Ca, aluminum hydroxide
BOTH: blood pH - check for alkalosis

89

hypercalcemia: causes

hyperthyroidism, hyperPTH, Vitamin D intoxication, prolonged immobilization

90

hypercalcemia: s/s x9

Calcium calms. Too calm!

fatigue, muscle weakness
depression, anorexia
nausea, vomiting, constipation
severe: coma, death

91

What lab value of hypercalcemia is considered a medical emergency? Treatment plan?

over 12 mg/dL
- IV NS + loop diuretic

92

hypercalcemia: mgmt x3

calcitonin (if impaired cardiovascular or renal function)
dialysis
severe: IV NS with loop diuretics

93

respiratory acidosis: s/s x5

AMS (somnolence, confusion, coma)
MYOCLONUS + asterixis
↑ ICP (d/t ↑CBF = ↑ CSF pressure)

94

respiratory acidosis: mgmt x3 + rationale behind each

- if no obvious cause: naloxone (Narcan) 0.04 - 2mg IVP
- intubation (improve ventilation)
- ↑ RR on vent (blow off CO2)

95

respiratory alkalosis: values + cause

greater than pH 7.45
less than pCO2 35

r/t hyperventilation: blowing off CO2

96

respiratory alkalosis: s/s x4 - what are clinical symptoms related to?

sx r/t ↓ CBF
- light-headedness
- paresthesia, tingling in hands/feet
- anxiety
- tetany if severe

97

respiratory alkalosis: mgmt x4

PRIMARILY: TREAT UNDERLYING CAUSE! (Rarely life threatening. Is usually d/t a stimulus that must be removed.)

- acute hyperventilation syndrome: breathe into paper bag
- ↓ vent RR
- sedation

98

metabolic acidosis: hallmark lab values x2

↓ HCO3
evaluate anion gap

99

anion gap: normal, equation, meaning

NORMAL: 12 +/- 5 (7-17)

( Na + K ) - ( HCO3 + Cl )

seen in metabolic acidosis
higher gap = higher acuity

100

increased anion gap: causes mnemonic

M ethanol
U remia
D KA / AKA **
P ropylene glycol
I ron / INH
L actic acidosis **
E thylene glycol
S alicylates

101

normal anion gap: causes x4

- diarrhea (losing HCO3/base)
- ileostomy
- renal tubular acidosis
- DKA recovery

102

metabolic acidosis: mgmt x3

TREAT UNDERLYING CAUSE!
fluids
HCO3 (if significant hyperkalemia, NOT for DKA or hypoxia)

103

metabolic alkalosis: causes x4

the following are saline-responsive (volume contraction is the most common problem):
- ng suction, vomiting
- diuretics
- post-hypercapnia alkalosis

104

metabolic alkalosis: mgmt x4

saline-responsive (volume contraction is the most common problem):
- correct volume deficit with NaCl + KCl
- d/c diuretics
- if volume replacement contraindicated, acetazolamide (Diamox) 250 - 500mg IV q4 - 6hrs
- if GI loss (n/v), H2 blockers

105

first degree burn

NO BLISTERS
dry, red, painful
extent: epidermis only

106

second degree burn

aka partial thickness
BLISTERS!
moist, painless
extent: beyond epidermis

107

third degree burn

aka full thickness burn
dry, leathery, black or pearly waxy
extent: epidermis, dermis, underlying tissue (fat, muscle, bone)

108

burn mgmt: fluid requirements x4

~ 4 mL/kg x TBSA - first 24 hrs TOTAL (Parkland formula)
- half of this amount given during first 8 hrs
- remaining amount given during next 16 hours
- crystalloid NOT colloid

UNDER-RESUSCITATION IS A PROBLEM FYI

109

This is a major problem seen in burn care.

under-resuscitation/lack of fluids

110

When does fluid resuscitation begin for burn patients?

at the time of injury, not when they arrive at a facility

111

major acid-base and electrolyte complications associated with burn injuries x3

- metabolic acidosis: during early resuscitation phase
- hyperkalemia: first 24 - 48 hrs
- hypokalemia: after fluid resus/diuresis, approx 3 days post-burn

112

You should monitor a burn patient for hyperkalemia during what time period?

first 24 - 48 hrs after burn

113

You should monitor a burn patient for hypokalemia during what time period?

3 days post-burn (it's related to fluid volume resuscitation and diuresis)

114

What is an indication for prophylactic intubation in a burn patient?

to prevent laryngeal edema, which may develop after: burns to the face (singed nares/eyebrows, dark soot/mucous in mouth/nares)

always intubate patients with this presentation

115

* Per ABA: when do you refer a patient to a burn center? *
x 6

- partial thickness burn greater than 10% TBSA
- involvement of face, hands, feet, genitalia, perineum, major joints
- third degree burns, any age
- electrical, chemical, inhalation burns
- comorbs that complicate mgmt
- pts who require special social, emotional, rehab intervention

116

salicylate intoxication: s/s x11

TINNITUS
*elevated LFTs*
dizziness, HA
n/v, dehydration
hyperthermia
apnea, cyanosis, metabolic acidosis

117

salicylate intoxication: mgmt

- emesis if recent
- GI lavage, activated charcoal (1 gm/kg q4)
- severe acidosis: IV sodium bicarb

118

organophosphate (insecticide) poisoning: s/s x9

EXCESSIVE SALIVATION
* blurred vision, miosis
* bradycardia
AMS, HA
N/V/D

119

organophosphate poisoning: drug of choice for

atropine - addresses bradycardia & secretion management

120

antidepressant toxicity: causative agents

amytriptyline (Elavil)
fluoxetine (Prozac)
bupropion (Wellbutrin)
imipramine, nortriptyline

121

antidepressant toxicity: s/s x9

confusion, hallucinations, blurred vision
hypotension, tachycardia, dysrhythmias
urinary retention
hypothermia
seizures

122

antidepressant toxicity: mgmt x8

- ICU: if CNS or cardiac toxicity evident
- GI lavage, activated charcoal
- IV sodium bicarb (maintain pH, counter cardiac dysrhythmia)
* IV benzo diazepam (Valium): seizure control
if Serotonin Syndrome:
* dantrolene sodium (Dantrium):
- clonazepam (Klonopin): Serotoni rigor
- cooling blankets

123

seizure prophylaxis in anti-depressant toxicity?

diazepam (Valium) IV

124

Your patient has overdosed on Lexapro and you suspect Serotonin Syndrome. What is your treatment plan?

dantrolene sodium (Dantrium)
clonazepam (Klonopin): for rigors
cooling blankets: temp control

125

4 drugs that cause narcotic toxicity?

morphine
codeine
heroin
opium

126

narcotic toxicity: s/s x5

respiratory depression
miOsis
hypothermia
AMS, coma

127

miosis vs mydriasis in which toxicities

miosis: codeine, heroin, morphine
- think relaxation, euphoria

mydriasis: cocaine, extasy
- think amped up

128

contraindication in narcotic toxicity management

emetics

129

narcotic toxicity: mgmt x3

naloxone (Narcan) 0.04 - 2 mg IVP
butorphanol (Stadol)
GI lavage/activated charcoal

130

benzo OD: s/s x4

respiratory depression
AMS, coma
hyporeflexia

THINK RELAXED & EUPHORIC

131

benzo OD: mgmt

- HD & respiratory support
- flumazenil (Romazicon) IV
- GI lavage, activated charcoal

132

You suspect your patient is rejection their freshly transplanted appendix. What is your first order?

biopsy of transplanted organ

133

Standard anti-rejection induction agents

calcineurin inhibitor + antimetabolite + steroid

i.e.,

tacrolimus (Prograft) or Cyclosporine
+
azathioprine (Imuran) or mycophenolate mofetil (Cellcept)
+
prednisone

134

What steroid is administered as part of an anti-rejection drug regimen for transplant prophylaxis?

prednisone

135

Herpes Zoster: pathophysiology

aka shingles!

acute vesicular eruptions due to infection with varicella zoster virus - can be life-threatening in immunocompromised adults

136

Herpes Zoster: s/s x3

- pain along dermatome distribution (usually trunk)
- grouped vesicle eruption of erythema and exudate along dermatome
- regional lymphadenopathy

137

Herpes Zoster: mgmt x4

- acyclovir, famciclovir, or valacyclovir
- ophthalmology referral if ocular involvement
- gabapentin (Neurontin) for post-herpatic neuralgia
- zostavax if 50+ (uh isn't this prevention)

138

When is Zostavax appropriate?

prevention of Herpes Zoster in 50+

139

actinic keratoses what + describe + treatment

- PREMALIGNANT: 1/1000 progress to squamous cell carcinoma
- asymptomatic, can be tender
- rough, small-patches on sun-exposed skin
- flesh, pink, or hyperpigmented

tx w liquid nitrogen

140

Squamous Cell Carcinoma what + describe + treatment

- arise from actinic keratoses, develop over months (3-7% mets)
- firm, irregular papule or nodule
- keratotic, scaly bleeding

tx with bx & surgical excision (Mohs)

141

Seborrheic Keratoses what + describe + tx

BENIGN
non-painful lesions 3 - 20 mm diameter
beige/brown plaques
"stuck on" appearance

tx: liquid nitrogen or none

142

malignant skin cancers x3

Squamous Cell Carcinoma
Basal Cell Carcinoma
Malignant Melanoma

143

benign skin growths x2

Actinic Keratoses
Seborrheic Keratoses

144

Basal Cell Carcinoma: what + describe + tx

MALIGNANT! most common skin cancer
waxy, pearly lesion
slow growing (1 - 2cm)
telangiectatic vessels (spider veins)

tx: shave/punch bx + surgical excisino

145

Patient has spider veins, what cancer might you want to rule out?

basal cell carcinoma
aka telangiectatic vessels

146

What is the most common skin cancer?

basal cell carcinoma

147

What skin cancer has the highest mortality rate?

MALIGNANT MELANOMA

148

What malignant skin cancer can mets to any organ?

MALIGNANT MELANOMA

149

brain death criteria

No functional cranial nerves.

150

end-of-life care: 2 drugs used & indication

morphine: respiratory distress
scopolamine: secretion reduction

151

What is the antidote for CO poisoning?

100% oxygen

152

What is an anti-convulsant that accelerates acetaminophen toxicity?

phenytoin (Dilantin)

153

What are 2 hallmark signs of aminoglycoside toxicity?

ototoxicity
nephrotoxicity

154

What is the most common pathogen in surgical site infection?

Staphylococcus

155

What is the most common cause of third degree (full thickness) burns?

electrical

156

What is a common complication associated with circumferential burns?

compartment syndrome

157

Your patient who has sustained circumferential, full thickness burns on his lower extremities has now developed what you suspect to be compartment syndrome. What is your immediate plan of care?

surgical consult STAT to salvage limbs

158

All of the following statements concerning basal cell carcinoma are true except:
a. it is the most common cutaneous malignancy
b. it is associated with chronic sun exposure
c. it is most commonly found on the abdomen and trunk
d. it may be difficult to differentiate from malignant melanoma

c. Basal cell carcinoma is commonly found on the HEAD and NECK not abdomen and trunk

159

The clinical presentation of shingles includes all of the following EXCEPT:
a. unilateral vesicular eruption
b. pain during the eruption only
c. vesicular eruption in a dermatomal distrbuition
d. potential involvement of the cranial nerves

b. Shingles pain can last for months after the acute exacerbation

160

Most common bite seen in the ED?

human

161

Individuals most at risk for development of melanoma?

fair skinned
blue eye
red hair
freckles

162

Most common cause of fever?

infection

163

most common causes of FUO?

endocarditis
malignancy

164

surgical procedure with highest incidence of wound infection

colon resection

165

initial management of post-operative atelectasis

improve ventilation
IVF
CXR and blood cultures

166

best pain medication for chronic cancer pain

fentanyl patch (sustained release!)
rapid onset
short half life
allows patient to be lucid

167

post-surgical pain management alternative to morphine

ketorolac (Toradol)

168

most common sites of acute compartment syndrome

forearm
leg

169

how long to see healing response on pressure ulcer that is clean and well vascularized

2 days

170

70 M 2 weeks s/p CVA and sustained pharyngeal paralysis. He is unable to eat food without aspiration. What is the most appropriate method to provide nutrition to this patient?
a. TPN
b. surgical gastrostomy
c. NGT
d. PPN

B. surgical gastrostomy PEG tube

171

Symptoms of protein malnutrition include:
a. weakness and edema
b. fever and chills
c. skin rashes and hair loss
d. muscle wasting and hair loss

a. weakness and edema

172

anti-emetic that blocks serotonin 5HTC and can cause EPSE used for delayed gastric emptying

metoclopramide (Reglan)

173

most helpful tests in determining nutrition status

prealbumin
albumin
calcium

174

what acid-base imbalance causes urinary potassium excretion

metabolic alkalosis

175

fluid used in correction of hypernatremia

D5W (free water)

176

indication for sodium bicarbonate IV administration in hyperkalemia

stabilize myocardial membrane and counteract myocardial effects of hyperkalemia

177

Which of the following symptoms may be seen in a patient with hypomagnesemia?
a. muscle weakness and paralysis
b. nystagmus and paralysis
c. seizures and cardiac arrythmias
d. excessive thirst and confusion

C. seizures and cardiac arrythmias

CATS go numb
Convulsions
Arrythmias
Tetany
Seizures
Numb

178

most common cause of hyponatremia in the hospitalized patient

SIADH

179

30 yo. F with PMH of migraines and new onset HTN should be treated with:
a. enalapril (Vasotec)
b. amitriptyline (Elavil)
c. ASA
d. metoprolol

d. HTN and migraine should be treated with a beta blocker

180

40 yo. F with asthma develops HTN. Which of the following should be avoided in this patient?
a. metoprolol (Lopressor)
b. enalapril (Vasotec)
c. diltiazem (Cardizem)
d. furosemide (Lasix)

a. Beta blockers should not be used in patients with asthma due to ARF bronchospasm

181

65 yo. M with ESRD is on hemodialysis. Which of the following diets should be recommended?
a. low sodium
b. high protein
c. low potassium
d. restricted calories

C. low potassium diet is recommended with renal failure patients

182

diet recommended for renal failure patients

low potassium

183

80 yo. F is hospitalized for PNA and treated with IV abx. On day 2 the patient develops diarrhea and tests positive for C. diff. What is the best treatment?
a. gentamicin
b. clindamycin
c. doxycycline
d. vancomycin

d. PO vancomycin is best for C. diff. Metronidazole (Flagyl) is also used.

184

drugs used to treat c diff

vancomycin
metrondiazole (flagyl)

185

most common valvular heart disease in adults

aortic stenosis

186

The medical management of mitral regurgitation and LV dysfunction includes:
a. ACE Inhibitors and diuretics
b. CCB and BB
c. Diuretics and BB
d. Alpha blockers and diuretics

a. ACE Inhibitors and diuretics for mitral regurgitation and LV dysfunction - reduce afterload

187

Which of the following ppx measures should be implemented to prevent DVT in a 70 yo. patient s/p abdominal surgery?
a. IV heparin 2 hrs. post op
b. Preoperative ASA use
c. early ambulation
d. Compression wrapping of the lower extremities

Early ambulation

188

acute vs chronic pain

less than or more than 6 mo
- acute: caused by tissue damage
- chronic: continual or episodic, usually needs combo therapy

189

What oral temperature is considered fever? What interventions x3?

38.6 C / 101.5F
order cultures
anti-pyretics (Tylenol)
treat underlying cause

190

Rectal temperature considered fever?

+99.5F

191

priority intervention for NMS or malignant hyperthermia

likely r/t drugs (NMS: SSRI or MH: succinylcholine)

IVF to flush out agent

192

infectious causes of post-op fever

incision, point of entry for any catheter (IV), urinary tract, lungs, sinusitis (ng tubes), abscess

193

protein malnutrition: labs x2

albumin & prealbumin (early indicator)

194

What albumin value indicates protein malnutrition? At what value can edema be expected? Normal range?

- less than 3.5 g/dL
- less than 2.7 g/dL
- 3.5 - 5 g/dL

195

3.5 - 5 is the normal range for which 3 lab values?

albumin
K
phos

196

normal range for K?

3.5 - 5

197

normal range for phos?

3.5 - 5

198

hypotonic hyponatremia

,serum osmolality lt280
FVE

199

most common electrolyte imbalance

hyponatremia

200

hyponatremia: 3 evaluation steps

- urine Na (normal 10 - 20)
- serum osmolality (normal 2x Na)
- clinical status

201

urine Na normal

10 - 20

202

serum osmolality normal

285 - 295 mosm/kg

203

what can urine Na distinguish?

- urine Na 20+ mEq/L suggests RENAL problem (salt wasting)

- urine Na under 10 mEq/L suggests EXTRARENAL fluid loss (kidneys retaining Na to compensate)

204

parenteral nutritional support: possible complications x8

THE PROBLEM IS THE MODE OF DELIVERY
- pneumo or hemo -thorax
- arterial laceration
- air emboli (major complication of CVC line placement)
- catheter related sepsis or thrombosis
- HHNK, hyperglycemia

205

what is the general difference between complications of enteral and parenteral nutrition?

enteral: the problem is the SOLUTION
parenteral: the problem is the DELIVERY

206

isotonic hyponatremia: what & lab value

PSEUDOhyponatremia is a lab artifact
- occurs w extreme hld or hyperprot
- body water normal, asymptomatic
- tx r/t fat

serum osm 284 - 295 mosm/kg

207

hypovolemic hypotonic hyponatremia + urine Na lt 10 mEq/L: causes

DEHYDRATION
diarrhea, vomiting (more dehydration!)

208

hypertonic hyponatremia: serum osm & causes x2

serum osm over 290 mosm/kg
- hyperglycemia & HHNK

209

hypotonic hyponatremia: in general, 3 types/overarching cause

hypovolemic, urine Na under 10: dehydration
hypovolemic, urine Na 20+: kidneys can't conserve salt
hypervolemic, "traditional": edema-related

210

hyponatremia: general mgmt x5

- tx based on cause, treat underlying condition (esp urine Na 20+)
- hypovolemic: NS IVF
- hypervolemic: fluid restriction
- symptomatic: NS + loop
- CNS symptoms: 3%NS + loop

211

* Patient is hyponatremic and symptomatic. Treatment plan?

NS IVF + loop diuretic

212

* Patient is hyponatremic and CNS symptoms are manifesting. Treatment plan?

3%NS + loop diuretic

213

hypernatremia is usually d/t what?

hyperosmolality results from excess water loss; excess sodium intake is rare

214

euvolemic hypernatremia: treatment

free water (D5W)

215

Why do you order Mg level if patient is being treated for hypokalemia?

Mg deficiency can impair K repletion.

216

How does calcium relate to albumin?

IONIZED does not vary with albumin.
TOTAL is 50% bound to albumin

217

Your patient is hypoalbuminemic due to malnutrition with a normal calcium level. What do you suspect?

Actually hypercalcemia. Total calcium is 50% bound to albumin.

218

respiratory acidosis: values & cause

less than: pH 7.35
greater than: pCO2 45

cause: decreased alveolar ventilation

219

respiratory acidosis vs alkalosis presentation

acidosis: deathly ill
alkalosis: distress

220

Why should you avoid rapid correction of respiratory alkalosis?

Rapid correction may result in metabolic acidosis, "due to the renal compensatory drop in serum bicarbonate."

221

FUN FAX - C Diff + Vomiting = acid-base imbalances?

C Diff: acidosis because you're blowing out the bicarb
Vom: alkalosis because you up chucked the acid

222

metabolic alkalosis & respiratory acidosis

metabolic usually ↑↑ HCO3 - pCO2 rarely exceeds 55

if pCO2 is 55+ superimposed respiratory acidosis likely

223

emergent burn mgmt x3

- submerge in clean water ASAP then wrap in clean, wet towel (STERILE NS/towels) & take to hospital
- no ice, lotion, toothpaste, lard, butter, products
- VERY IMPORTANT: maintain normal temp (37-37.5)

224

burn: pain mgmt most commonly used

IV fentanyl or morphine

225

How do you care for a tar burn injury?

use a petroleum based product to remove burning tar

226

what is silver sulfadiazine used for in burn care even though this is based on very little evidence that I wrote all about in my spring research paper

topical antibacterial/antifungal for 2nd and 3rd degree burns

227

gastric lavage is bad but boards wants you to know what?

lavage until clear with 28 - 38F/ng tube for ingestions older than 30 minutes

228

with each 0.1 drop in pH, how much does K+ increase?

0.7

229

organophosphate poisoning: mgmt x3

- wash skin thoroughly
- activated charcoal if ingested insecticide
- atropine

230

benzo OD: reversal agent

flumazenil (Romazicon) IV

231

* acute organ rejection: s/s + initial intervention *

* immediate failure of tx organ
* flu-like symptoms (prodrome)

* immediate biopsy of transplanted organ!

232

how do anti-rejection induction agents used as transplant rejection prophylaxis work?

they significantly lower and nearly abolish circulating lymphoid cells that are critical to rejection response

233

What is the ABCDEE method for malignant melanoma?

A symmetrical
B order irregularity
C olor change
D iameter over 6mm
E levation
E nlargement

2+ more = 97% chance of malignant melanoma

234

Treatment for topical salicylate toxicity?

wash with warm tap water