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Flashcards in Esquivel Deck (76):
1

Management for pt with Inferior wall ST elevations, JVD, parasternal lift, and clear lungs? Management?

MI with RV involvement
1. Preload dependent - give fluid (lung crackling suggests too much)
2. Give pressors if hypotensive

2

If pt with RV MI is fluid overloaded (crackles) but hypotensive - consider these causes?

1. papillary muscle ischemia/rupture
2. Arrhythmia

3

Pylonephritis with hypotension - management?

1. Goal-directed therapy - CVP 8-12; MAP>65

4

Septic shock pt with LV CHF - management?

Fluid until wedge pressure = 20

5

Treatment for CHF exacerbation?

L-M-N-O-P
Loop diuretic (Lasix)
Morphine (venous vasodilator)
Nitroglycerin
O2
Position (sit up)

6

Lasix - MoA? How does it to site of action?

Blocks Na-K-2Cl transporter

Transporter through the Organic Ion transporter in PCT

7

CHF with BP 160/90, pulse 110, BUN 35, Cr 1.2 - management?

Lasix

8

CHF with BP 160/90, pulse 110, BUN 60, Cr 2.3 - management?

1. Increasing doses of Lasix (Prerenal azotemia suggests low GFR - to get lasix into kidney, need to increase dose)
2. Metolazone (thiazide to prevent distal Na resorption; should be given before lasix)

9

CHF with BP 160/90, pulse 110, BUN 80, Cr 6.0 - management?

Increase C.O. with dobutamine or milrinone

10

CHF with BP 85/40, pulse 110, BUN 80, Cr 6.0 - management?

Dialyze

11

Milrinone - MoA?

inotropic vasodilator - inhibits cAMP PDE in cardiac and vascular tissue

12

Hypovolemia with met acidosis - tx?

1) Lactate
2) NS with amps (50 mEq) of Bicarb

13

Lactate - why does it good for metabolic acidosis? Will not work if?

Lactate -> pyruvate -> Ox Phos -> increases CO2 produced -> CO2 made into more Bicarb

Liver failure

14

vomiting leading to Met Alk - why hypoK? tx?

Low volume increases ALDO - increased K excretion

Tx: NS

15

Urine Cl should be?

10

16

Met Alk - after NS, increased urine excretion of?

Na (gets dragged out with bicarb)

17

Saline Responsive Alkalosis

Loss of Cholride
1. Vomiting
2. Diuretics (Volume contraction)
3. Posthypercapnia
4. CF

18

Saline unresponsive alkalosis

1. Primary Renin/ALDO
2. Bartter/Liddle
3. CHronic K depletion
4. Milk-alkali

19

When is Urine Na a poor indicator of volume?

1. Diuretics
2. Met Alk
3. Renal Salt Wasting

20

Low TSH, normal T4, normal T3?

Subclinical hyperthyroidism

21

Causes of hyperthyroidism (uptake seen on thyroid scan)?

1. Graves' disease (diffusely increased)
2. Surreptitious thyroid intake (normal/low)
3. Thyroiditis (decreased)
4. Toxic multinodular goiter (focally increased)
5. Non-thyroid illness

22

How to distinguish between surreptitious thyroid injection versus thyroiditis?

Increased thyroglobulin versus decreased thyroglobulin

23

Low TSH, low T3, low T4?

Hypothyroidism due to hypopituitarism

24

Pretibial myxedema seen with?

Hyperthyroidism

25

Why retain water with hypothyroidism?

Low T3/T4 stimulates pituitary increasing both TSH and ADH

26

Worst complication of hypothyroidism? Tx?

Myxedema coma

IV levothyroxine, IV hydrocortisone, empiric antibiotics

27

Low TSH, high T4, low T3?

Sick euthyroid

28

Normal TSH, low T3, normal T4

Version of sick euthyroid: low T3 syndrome

29

Patient with proptosis or tibial myxedema – treatment?

Steroids – neither will go away with anti-thyroid medications

30

Treatment for patients in thyroid storm?

1. nonselective beta blocker (Propranolol)
2. PTU
3. Potassium iodine
4. Dexamethasone/glucocorticoids
5. Cholestyramine

31

Steroids decreasing order of mineralocorticoids?

Fludrocortisone (exclusively Mineralocorticoids) Hydrocortisone >prednisone >methylprednisolone > dexanethasone (purely glucocorticoids)

32

Causes of refractory hypertension?

1. Renal artery stenosis
2. Conn's disease
3. Pheochromocytoma
4. Fibromuscular dysplasia

33

Patient with refractory hypertension – steps?

1. Aldosterone: renin ratio
2. If high aldosterone – CT scan
3. If high renin – digital subtraction renal angiography

34

Liddle syndrome? Aldosterone and renin levels?

Hyperactive ENaC channel. Low aldosterone and renin

35

Glucocorticoid-remediable aldosteronism? ALDO/renin levels?

Disease where genes for glucocorticoids and mineralocorticoids are coupled

High aldosterone, low renin

36

When to choose heparin over Lovenox?

High creatinine

37

DVT – how to determine the length of coagulation?

1. Provoked DVT: 3 to 6 months
2. Unprovoked DVT: 6 months than clotting workup

38

Causes of unprovoked DVTs?

1. Factor V Leiden
2. Protein C/S deficiency
3. Anti-phospholipid syndrome, lupus

39

When to use an inferior vena cava filter?

1. Contraindications to heparin (surgery, bleeding)
2. recurrent PEs despite heparin

40

Multiphasic P waves with fast versus slow heart rate?

Multifocal atrial tachycardia versus wandering pacemaker

41

COPD GOLD classes and treatment?

Class 1: FEV1 over 80% (PRN albuterol)
Class 2: FEV1 50-80. (Anti-cholinergic and long acting beta agonist = Tiotropium and salmeterol)
Class 3: FEV1 30-50(Inhaled steroids – fluticasone, budesonide)
Class 4: FEV1 <30 (theophylline, oral steroid)

42

Treatments for patients admitted for acute COPD exacerbation?

1. Beta-agonists
2. Anticholinergics
3. Steroids (5 days)
4. Antibiotics

43

Peak flow in different types of asthma?

Normal: 350-500 (females); 450-600 (male)
Mild >300
Moderate: 100 to 300
Severe <100

44

Causes of decreased platelet production?

Causes of increased platelet destruction?

Causes of platelets splenic sequestration?

Parvovirus, CMV, EBV, HIV, hypothyroid, B12/folate deficiency

HIV, lupus

Hepatitis B/C

45

When to get platelet transfusion? Why not give platelets more often?

If bleeding – 50,000
If not bleeding – 10,000

Risk of infection and risk of alloimmunization

46

Treatment for ITP?

1. Prednisone
2. IVIg
3. Rituximab, azathioprine, thrombopoetin

47

Signs of cholesterol emboli?

1. Livedo reticularis
2. Blue toes
3. Altered mental status
4. Hollenhorst plaque
5. Wedge shaped region kidney
6. Sudden blindness

48

Diagnosed HIT with? If positive?

Serotonin release assay.

Stop heparin, start agatroban

49

Treatment options for DIC?

1. Packed RBC's
2. Platelet transfusion
3. FFP
4. IV vitamin K

50

Patient with uremic bleed – give?

ddAVP

51

General causes of hypercalcemia?

1. Hyperparathyroid (Primary, tertiary, immobilization)
2. Vitamin D (Excess, sarcoid, lymphoma)
3. IL-6/TNF (Multiple myeloma)
4 Drugs (Thiazides/Li)
5. Genetic (familial hypocalcinuric hypercalcemia)
6. Igestions (milk alkali)

52

Primary versus secondary versus. Tertiary hyperparathyroid?

Increased parathyroid hormone

chronic kidney disease (increased parathyroid hormone but decreased calcium)

Transplanted kidney but increased parathyroid production

53

Patient with mass and positive technetium 99 sestamibi scan - next step?

1. No Need to biopsy
2. Remove it if indicated

54

Indications to remove parathyroid adenoma?

Osteoporosis, stones, renal disease, increased calcium excretion, age under 50, symptomatic

55

Treatment for hypercalcemia?

1. Normal saline (increases renal function and urine Na and Ca excretion)
2. Calcitonin
3. Bisphosphonates
4. Denosumab (RANK ligand inhibitor)
5. Dialysis

56

Causes of renal failure from hypercalcemia?

1. Prerenal
2. Stones
3. Renal artery vasoconstriction
4. Nephrocalcinosis leading to acute interstitial nephritis

57

Causes of hypercalcemia from malignancy?

1. PTHrP - squamous cell lung cancer
2. IL-6 and TNF - Multiple myeloma
3. Vitamin D – lymphoma
4. Local PTH/PTHrP – prostate cancer

58

Patient with DKA – management?

1. saline
2. Bolus insulin (.1 units per kilogram)
3. Insulin drip
4. Potassium depletion
5. EKG (it chest pain, measure troponins)
6. Look for cause (chest x-ray, blood cultures, urine culture)

59

Acid-base status for a patient with DKA?

Anion gap metabolic acidosis plus metabolic alkalosis (from vomiting)

60

Causes of hyperkalemia in DKA?

1. Acidosis
2. Decreased insulin
3. Hyperosmolarity
4. Acute kidney injury (cannot excrete potassium)

61

Of oral diabetes drugs - which do not cause hypoglycemia? Which do?

Metformin and pioglitazone

Sulfonylurea

62

Imaging for pancreas? Liver? Biliary Stone? Biliary tree?

CT
Ultrasound
Ultrasound
CT

63

Consider SBP if?

1. White blood cells >500 or PMNs >250
2. Positive cultures

64

In patient with liver disease, causes of hepatic encephalopathy?

1. Medication noncompliance
2. Infection
3. Uremic bleeding
4. Increased protein intake
5. Too much Lasix

65

Role of IV albumen in ascites?

1. Prevents sudden hypotension if remove >5 L of fluid
2. Decreased risk of hepatorenal syndrome

66

How to distinguish between prerenal azotemia versus a Hepatorenal syndrome?

Give 2 L normal saline and albumin – UA will reverse if it's just prerenal

67

In patients with recurrent pleural effusions – possible solution?

Talc and doxycycline – fuse pleura together

68

Empyema if?

PH <60
LDH over 1000

69

Causes of alternate mental status?

AEIOU TIPPS
Alcohol
Electrolyte disturbances (sodium, calcium, bicarb, encephalopathy)
Insulin
Overdose
Uremia

Trauma
Infection
Pharmacology
Psychiatry
Stroke/shock/seizure

70

Patient "acting crazy" – Give?

Olazapine

71

Patient on EPO – goal hemoglobin?

10 to 11

72

Myelofibrosis versus myelophthisis versus myelodysplasia?

Hypocellular marrow/CD 34 staining

versus
Marrow infiltrative process with immature forms

versus
abnormal maturation (not noticeable in peripheral blood smear)

73

Causes of B12 deficiency?

1. Poor intake
2. Poor absorption (pernicious anemia/Crohn's/celiac)
3. Metformin

74

SVT - tx?

Adenosine to break tachycardia and determine if flutter or not

75

Retrograde P wave means?

AV node

76

If pt's CHADS2 score is 0, when to anticoagulant?

Valvular dz (like MS)

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