Flashcards in double star Deck (202)
LEVOFLOXACIN (LEVAQUIN) -- CLASS
CEFTRIAXONE (ROCEPHIN) -- CLASS
AZITHROMYCIN (ZITHROMAX) -- CLASS
CLARITHROMYCIN (BIAXIN) -- CLASS
ERYTHROMYCIN -- CLASS
CAP: mgmt for under 65 x4
MACROLIDE - 1 of the following:
- azithromycin (Zithromax)
- clarithromycin (Biaxin)
CAP: mgmt 65+ or comorbs x4
- levofloxacin (Levaquin)
- ciprofloxacin (Cipro)
- moxifloxacin (Avelox)
- gemifloxacin (Factive)
Pseudomonas pneumonia: inpt ICU mgmt (rx only)
antipneumococcal/antipseudomonal beta lactam
- piperacillin-tazobactam (Zosyn)
- cefepime (Maxipime)
- meropenem (Merrem)
- ciprofloxacin (Cipro)
- levofloxacin (Levaquin)
pneumonia: inpt ICU mgmt (rx only)
- ceftriaxone (Rocephin)
- azithromycin (Zithromax): resistance likely, avoid
community acquired MRSA pneumonia: rx x2
Group A Strep cellulitis
Bactrim + beta lactam (pcn, amoxicillin, Keflex)
Doxy/mino + beta lactam (same as above)
! -- same as CA-MRSA + BLs -- !
cephalexin (Keflex): class + generation of that class
1st generation cephalosporin
most common causes of cellulitis: outpatient
Strep pyogenes (group A) -- usually
Staph aureus (less common)
Strep etc. (B, C, G) - rare
most common causes of cellulitis: inpatient
- gram negs: E Coli, Klebsiella, Pseudomonas, Enterobacter
- S. aureus (MRSA? CA-MRSA? possibilities endless)
gram positive organisms
strep (strep pneumo is pneumococcus)
gram negative organisms
abx with gram neg coverage
abx with gram pos coverage
azotemia lab value
if allergic: doxycline or erythromycin
azithromycin or doxycycline
co-treat with gonorrhea (ceftriaxone)
azithromycin (to cover chlamydia)
#1 underdiagnosed psych disorder
which is the priority for patient who can't make own decision: next of kin or advanced directive?
next of kin - ask if they want to go with advanced directive
Top 4 Killers of adults
3: lower resp disease (asthma, COPD)
#1 mortality in US blacks
#1 mortality in US women
#1 cancer mortality in women
leading gyn cancer mortality in women
leading cancer incidence in women
top 2 cancer mortalities in men
top 2 cancer mortalities in all US adults
0.4 - 5.0
0.8 - 2.8
Tot T4 normal
4.5 - 11.5
80 - 230
urine Na normal
10 - 20
serum osm normal
285 - 295
80 - 100
26 - 34
32 - 36
M 40 - 54
F 37 - 47
240 - 450
ferritin high in anemia
fibrogen low in DIC
less than 170
FDP high in DIC
PT normal + prolonged
11 - 14 sec
PTT normal + prolonged
25 - 35 sec
3.5 - 5
3.5 - 5
Ca (total x2)
8.5 - 10.5 mg/dL
2.2 - 2.6 mmol/L
Ca (ionized x2)
4.5 - 5.5 mg/dL
1.1 - 1.4 mmol/L
CO/CI in hypovolemic shock?
CVP in hypovolemic shock?
PCWP in hypovolemic shock?
SVR in hypovolemic shock?
SVO2 in hypovolemic shock?
CO/CI in cardiogenic shock?
CVP in cardiogenic shock?
PCWP in cardiogenic shock?
SVR in cardiogenic shock?
SVO2 in cardiogenic shock?
CO/CI in septic shock?
↑ then ↓
CVP in septic shock?
↓ then ↑
PCWP in septic shock?
↓ then ↑
SVR in septic shock?
SVO2 in septic shock?
↓ then ↑
CO/CI in anaphylactic shock?
CVP in anaphylactic shock?
PCWP in anaphylactic shock?
SVR in anaphylactic shock?
SVO2 in anaphylactic shock?
CO/CI in neurogenic shock?
CVP in neurogenic shock?
PCWP in neurogenic shock?
SVR in neurogenic shock?
SVO2 in neurogenic shock?
CO/CI in obstructive shock?
CVP in obstructive shock?
PCWP in obstructive shock?
SVR in obstructive shock?
SVO2 in obstructive shock?
what is the difference between PAP and PAWP?
pulmonary artery pressure is essentially the "blood pressure" in the pulm art
pulmonary artery wedge pressure is a measurement using a swan ganz catheter and the inflation of a balloon in the pulm art to measure the pressure in front of it - a proxy for left ventricular pressure (and therefore function)
How soon should you order antibiotics in newly diagnosed septic shock?
Within 1 hour of diagnosis
SVR is high for which shocks and low for which shocks?
high for cardiogenic, hypovolemic, and obstructive
low for the distributives (septic, anaphylactic, neurogenic)
what are 5 potential causes of hypovolemic shock?
internal/external bleeding, burns, DKA/HHNK, severe dehydration
hypovolemic shock: mgmt
- fluid resuscitation - MAINSTAY! I mean, duh
- PRBCs when indicated by hgb/hct
what is the mainstay of treatment for hypovolemic shock?
fluid resuscitation duh
what % of blood loss constitutes hypovolemic shock?
results from a loss of greater than 20% circulating blood volume
what are 5 potential causes of cardiogenic shock?
MI (most common), dysrhythmia, pericardial tamponade, pulmonary edema, acute valvular regurg
what is the most common cause of cardiogenic shock?
cardiogenic shock: mgmt
- initial, careful admin of IVF
- vasopressor support
- nitroglycerin IV PRN ischemia
what is distributive shock?
3 types - all characterized by vasodilation, decreased intravascular volume, reduced peripheral vascular resistance, and loss of capillary integrity
septic, anaphylactic, neurogenic
why does hypovolemia result in septic shock?
hypovolemia develops as a result of blood pooling in the microcirculation
what is an important diagnostic to order for septic shock in addition to hemodynamic monitoring?
septic shock: mgmt
- crystalloid fluid resus (mainstay)
- upon diagnosis of sepsis, abx WITHIN 1 HOUR !!
what is the mainstay of treatment for septic shock?
crystalloid fluid resuscitation
what is anaphylactic shock?
IgE mediated reaction that occurs shortly after exposure to an allergen
anaphylactic shock: mgmt
- maintain airway
- diphenhydramine 25 - 75 mg IV or IM (depends on severity)
- epinephrine 0.3 - 0.5 mg (1:1000 sol) SQ or IM for respiratory distress, stridor, wheezing, etc.
- crystalloid IVF
- IV glucocorticosteroids
- consider H2 antagonist (ranitidine/Zantac)
- inhaled beta agonist for bronchospasm
what is the indication for epinephrine in anaphylactic shock management?
respiratory distress, stridor, wheezing, etc
what is obstructive shock?
inadequate CO d/t impaired ventricular FILLING
causes ex: massive PE (most common), tension pneumothorax, cardiac tamponade, obstructive valve disease
what are 4 causes of obstructive shock?
massive PE (most common), tension pneumothorax, cardiac tamponade, obstructive valve disease
what is the most common cause of obstructive shock?
obstructive shock: mgmt
- maintain BP while initiating tx of underlying cause
- fluid admin + vasopressors
what are the 5 steps of managing a patient (from start to finish?)
2 rhabdo labs
↑ urine myoglobin
↑ serum creatine kinase
lipid panel: normal
-- less than --
HDL: 40 - 60
lipid panel: DM/CAD
-- less than --
what is a major adverse effect of metoclopramide (Reglan)? what is metoclopramide's class?
anti-emetic agent + prokinetic (upper GI)
fragmented RBC bit
irregularly shaped, jagged, two pointed ends
often seen in hemolytic anemia
bone marrow produces ringed sideroblasts instead of healthy RBCs - r/t defect incorporating Fe into hgb
sideroblasts usually turn into RBCs
sideroblastic anemia: labs
AEIOU criteria for dialysis
e lectrolyte imbalance
which valve closures are S1?
tricuspid & mitral
what is between S1 + S2?
systole; ventricles are squeezing
which valve closures are S2?
pulmonic & aortic
what is between S2 + S1?
diastole; ventricles are filling
what is S3?
kentucky (slushy in a big balloon)
blood passively enters ventricle and sloshes because the vent is overflowing already OR it is a dilated/non-compliant wall
- think: hypovolemia, CHF, pregnancy
what is S4?
tennessee (z squeeze/ kick ball into wall)
atrial KICK into extra THICK wall like a soccer ball
- think: MI, LVH
which shocks have ↑ PAWP?
which shocks have ↓ SVR/SVRI?
distributive shocks: sepsis, anaphylaxis, neurogenic
in which 2 hemodynamic parameters are all shocks (except septic) ↓?
CO/CI & SVO2
CO/CI - ↑ then ↓
SVO2 - ↓ then ↑
CO/CI in septic shock?
↑ then ↓
SVO2 in septic shock?
↓ then ↑
BPH: diagnostics to order
UA: r/o infection
PSA: 4+ abn
transrectal US: if palpable nodule or elevated PSA
Your BPH patient's labs came back with elevated PSA. What is your next order?
While performing a digital rectal exam your palpate a nodule on your patient's prostate. What is your next order?
- observe + refer to urologist as needed
- alpha blockers: terazosin, tamsulosin, prazocin (relax bladder/prostate muscles)
- 5-alpha-reductase inhibitors: finasteride (shrink prostate)
- surgery: TURP, if significant sx persist
Hep A lab markers
active: anti-HAV, IgM
recovered: anti-HAV, IgG
Hep B lab markers
active: anti-HBc, HbeAg, HbsAg, IgM
chronic: anti-HBc, anti-HbeAg, HbsAg, IgM, IgG
recovered: anti-HBc, anti-HbsAg
Hep C lab markers
acute: anti-HCV, HCV RNA
What test do you order to differentiate acute from chronic Hep C?
PCR (prior exposure vs current viremia)
cardiogenic & obstructive shock: PAWP
cardiogenic: ↑ - LV can't squeeze
obstructive: ↓ - LV isn't filled d/t obstruction of blood
cardiac tamponade can cause what kind of shock?
cardiogenic & obstructive
pulmonary edema can cause what kind of shock?
pulmonary embolus can cause what kind of shock?
very painful, severe, unilateral, perirbita
at night - wakes from sleep
ipsilateral: rhinorrhea, eye redness, nasal congestion
which headache do you treat with sumatriptan or ergotamine?
most common type of headache
vise-like, tight, generalized
no focal neuro sx
which headache do you treat with OTC?
classic (aura) vs common (no aura)
r/t dilation + excess pulsation of EXTERNAL CAROTID ARTERY; unilateral, dull or throbbing, focal neuro sx
follow trigeminal pathway
which headache do you treat prophylactically with elavil (Amitriptyline), divalproex (Depakote), verapamil (Calan)?
complications of enteral vs parenteral nutritional support
enteral: problems with the solution
- aspiration, d/v, GIB, hyperNa, dehydration, clog, etc
parenteral: problems with the delivery
- pneuo/hemo -thorax, art laceration, catheter sepsis/thrombosis, etc
what does urine Na tell you?
distinguishes renal from non-renal causes
20+ = think salt wasting (kidney problem)
-10 = think renal Na retention to compensate for extrarenal fluid loss
what is isotonic hyponatremia?
PSEUDO hyponatremia... lab artifact
usually occurs w hld or hyperproteinemia
describe the entire hypovolemia thought process.
what lab value do you expect indicating hyponatremia?
what two diagnostics do you assess next and how do you assess them?
1. ELECTROLYTES: hyponatremia is serum Na less than 135
2. OSMOLALITY: hypo-, iso-, hyper- tonic?
2a. if HYPERtonic, treat.
2b. if ISOtonic, treat.
2c. if HYPOtonic, continue to 3.
3. FLUID STATUS: hyper- or hypo- volemic?
3a. if HYPERvolemic, treat.
3b. if HYPOvolemic: fluid loss! Go to 4.
4. UNa, given fluid loss.
4a. 20+, salt wasting (extrarenal forced waste: meds)
4b. -10, salt-retaining (extrarenal fluid loss: kidneys compensating)
3 causes: hypovolemic hypotonic hyponatremia + urine Na under 10
FLUID LOSS: kidneys retain Na to compensate
C diff infection is associated with which electrolyte imbalance?
hypovolemic hypotonic hyponatremia + urine Na under 10
mega diarrhea = fluid loss = kidneys retain Na in an attempt to compensate
3 causes: hypovolemic hypotonic hyponatremia + urine Na 20+
SALT WASTING: what is making kidneys chuck the Na?
2. ACE inhibitors
3. mineralocorticoid deficiency
what is the most common electrolyte abnormality?
hyponatremia, and most likely --
hypervolemic hypotonic hyponatremia: fluid volume excess states like CHF, edema, liver failure, kidney failure.
4 causes of hypervolemic hypotonic hyponatremia
DISEASE PROCESSES LEADING TO FLUID RETENTION.
1. edematous state
3. liver disease
4. advanced renal failure
typical cause of hypertonic hyponatremia
Something else that is NOT sodium is causing HIGH SERUM OSMOLALITY.
ex: hyperglycemia -- typically HHNK
hypernatremia is usually due to what?
excess water loss (dehydration)
what three states can you have with hypernatremia, and what is the management of each?
hypervolemic hypernatremia: free water, loop diuretics, maybe HD
- loop diuretics will get rid of Na and water so replace with free water; HD will help if kidneys can't get rid of Na for some reason
euvolemic hypernatremia: free water
- will reduce Na concentration back to normal
hypovolemic hypernatremia: NS then ½ NS
- patient is extremely dehydrated which is causing the extreme Na concentration. replace fluid while keeping Na up.
TREAT UNDERLYING PROBLEM
- symptomatic: NS + loop diuretic
- CNS symptoms: 3% NS + loop diuretic
you have a symptomatic hyponatremic patient - what are 2 mgmt strategies?
other symptoms: NS + loop diuretic
CNS symptoms: 3% NS + loop
respiratory acidosis vs respiratory alkalosis: patient presentation
respiratory acidosis: this patient looks dead
respiratory alkalosis: this patient is in distress
what is the hallmark sign of metabolic acidosis?
low serum HCO3
your patient has metabolic acidosis - what is your next step? what does doing this this tell you?
calculate anion gap with
[Na + K] - [HCO3 + Cl]
normal anion gap is 12 +/- 5
if anion gap is increased, the metabolic acidosis is more acute
metabolic acidosis: MUD PILES + what it tells you?
D KA / AKA **
P ropylene glycol
I ron / INH
L actic acidosis **
E thylene glycol
mnemonic for causes of metabolic acidosis with increased anion gap
Indications and contraindications for sodium bicarb use in the treatment of metabolic acidosis?
contraindications: no bicarb if DKA or hypoxia
indications: give if severe hyperkalemia
what kind of acid/base abnormality would you expect for C Diff?
metabolic acidosis, because you are blowing base out your rear end
what kind of acid/base abnormality would you expect with hyperemesis gravidarum?
metabolic alkalosis, because you are up-chucking acid
why would you see hyperkalemia in metabolic acidosis?
your body is acidotic, meaning too much H
hydrogen/potassium pumps move extra H into the cell in exchange for a K
if the pump is moving lots of H into cells, then they are spewing out K
ipecac: indications + contraindications
indications: at home ingestions
contraindications: detergent and corrosives
gastric lavage: indications
only for ingestions greater than 30 minutes ago
activated charcoal: dosage
1g/kg to a max of 50g - in water
can repeat q4 hours
GI loss, diuretics and excess renal loss, alkalosis
muscular cramps/weakness, fatigue
if severe (less than 2.5): flaccid paralysis, tetany, rhabdomyolysis
hypokalemia: EKG findings
decreased wave amplitude
U waves, broad T waves
dysrhythmias: PVC, v tach, v fib
excess intake, renal failure, drugs (NSAIDs), hypoaldosteronism
hypoaldosteronism is associated with which electrolyte imbalance?
hyperkalemia - there is not enough aldosterone in the body to keep Na in, so all of the Na is going out in the urine. this means K is being kept instead, and it is really piling up in the serum.
conservation of Na
weakness, flaccid paralysis
abdominal distension, diarrhea
most patients won't have changes, but peaked T waves are classic
exchange resins: Kayexalate
multiple blood transfusions
pancreatitis is associated with what electrolyte imbalance?
calcium calms - not enough calcium = spastic.
trousseau's sign (twitch!)
hypocalcemia: EKG findings
prolonged QT interval
- look at blood pH, check for alkalosis
- acute: IV calcium gluconate
- chronic: oral supplements, Vit D, etc
vitamin D intoxication
calcium calms - too much calcium = sluggy.
fatigue, weakness, depresison, n/v, constipation
severe: coma and death (12+ = emergency)
what level of Ca is considered a medical emergency?
why hypocalcemia with alkalosis?
H and Ca compete for albumin binding site
alkalosis = not much H, therefore albumin binds the shit out of Ca
less Ca available
4 Ps of spinal cord injuries
spinal cord injury: C4 and above results in?
spinal cord injury: @ T1 - T2 results in?
paraplegia - can control upper extremities but not trunk
cervical spine contains nerves that control what parts of the body?
arm through hand
what parkinson's meds increase available dopamine?
what anticholinergics are helpful in parkinson's symptom alleviation?
what is the most common cause of dementia?
alzheimer's vs parkinson's deficiencies
alzheimer's: ACh deficiency
parkinson's: dopamine deficiency
Left (dominant) CVA symptoms
- difficulty reading/writing
right (non-dominant) CVA symptoms
R visual field change
vertebrobasilar TIA: symptoms
inadequate vertebral artery flow
- visual field deficit
think: DISORIENTATION + PERCEPTION
carotid TIA: symptoms
- altered LOC
think: CLOUDY + MOTOR