Flashcards in Esquivel Deck (76):
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
If pt with RV MI is fluid overloaded (crackles) but hypotensive - consider these causes?
1. papillary muscle ischemia/rupture
Pylonephritis with hypotension - management?
1. Goal-directed therapy - CVP 8-12; MAP>65
Septic shock pt with LV CHF - management?
Fluid until wedge pressure = 20
Treatment for CHF exacerbation?
Loop diuretic (Lasix)
Morphine (venous vasodilator)
Position (sit up)
Lasix - MoA? How does it to site of action?
Blocks Na-K-2Cl transporter
Transporter through the Organic Ion transporter in PCT
CHF with BP 160/90, pulse 110, BUN 35, Cr 1.2 - management?
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)
CHF with BP 160/90, pulse 110, BUN 80, Cr 6.0 - management?
Increase C.O. with dobutamine or milrinone
CHF with BP 85/40, pulse 110, BUN 80, Cr 6.0 - management?
Milrinone - MoA?
inotropic vasodilator - inhibits cAMP PDE in cardiac and vascular tissue
Hypovolemia with met acidosis - tx?
2) NS with amps (50 mEq) of Bicarb
Lactate - why does it good for metabolic acidosis? Will not work if?
Lactate -> pyruvate -> Ox Phos -> increases CO2 produced -> CO2 made into more Bicarb
vomiting leading to Met Alk - why hypoK? tx?
Low volume increases ALDO - increased K excretion
Urine Cl should be?
Met Alk - after NS, increased urine excretion of?
Na (gets dragged out with bicarb)
Saline Responsive Alkalosis
Loss of Cholride
2. Diuretics (Volume contraction)
Saline unresponsive alkalosis
1. Primary Renin/ALDO
3. CHronic K depletion
When is Urine Na a poor indicator of volume?
2. Met Alk
3. Renal Salt Wasting
Low TSH, normal T4, normal T3?
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
How to distinguish between surreptitious thyroid injection versus thyroiditis?
Increased thyroglobulin versus decreased thyroglobulin
Low TSH, low T3, low T4?
Hypothyroidism due to hypopituitarism
Pretibial myxedema seen with?
Why retain water with hypothyroidism?
Low T3/T4 stimulates pituitary increasing both TSH and ADH
Worst complication of hypothyroidism? Tx?
IV levothyroxine, IV hydrocortisone, empiric antibiotics
Low TSH, high T4, low T3?
Normal TSH, low T3, normal T4
Version of sick euthyroid: low T3 syndrome
Patient with proptosis or tibial myxedema – treatment?
Steroids – neither will go away with anti-thyroid medications
Treatment for patients in thyroid storm?
1. nonselective beta blocker (Propranolol)
3. Potassium iodine
Steroids decreasing order of mineralocorticoids?
Fludrocortisone (exclusively Mineralocorticoids) Hydrocortisone >prednisone >methylprednisolone > dexanethasone (purely glucocorticoids)
Causes of refractory hypertension?
1. Renal artery stenosis
2. Conn's disease
4. Fibromuscular dysplasia
Patient with refractory hypertension – steps?
1. Aldosterone: renin ratio
2. If high aldosterone – CT scan
3. If high renin – digital subtraction renal angiography
Liddle syndrome? Aldosterone and renin levels?
Hyperactive ENaC channel. Low aldosterone and renin
Glucocorticoid-remediable aldosteronism? ALDO/renin levels?
Disease where genes for glucocorticoids and mineralocorticoids are coupled
High aldosterone, low renin
When to choose heparin over Lovenox?
DVT – how to determine the length of coagulation?
1. Provoked DVT: 3 to 6 months
2. Unprovoked DVT: 6 months than clotting workup
Causes of unprovoked DVTs?
1. Factor V Leiden
2. Protein C/S deficiency
3. Anti-phospholipid syndrome, lupus
When to use an inferior vena cava filter?
1. Contraindications to heparin (surgery, bleeding)
2. recurrent PEs despite heparin
Multiphasic P waves with fast versus slow heart rate?
Multifocal atrial tachycardia versus wandering pacemaker
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)
Treatments for patients admitted for acute COPD exacerbation?
3. Steroids (5 days)
Peak flow in different types of asthma?
Normal: 350-500 (females); 450-600 (male)
Moderate: 100 to 300
Causes of decreased platelet production?
Causes of increased platelet destruction?
Causes of platelets splenic sequestration?
Parvovirus, CMV, EBV, HIV, hypothyroid, B12/folate deficiency
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
Treatment for ITP?
3. Rituximab, azathioprine, thrombopoetin
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
Diagnosed HIT with? If positive?
Serotonin release assay.
Stop heparin, start agatroban
Treatment options for DIC?
1. Packed RBC's
2. Platelet transfusion
4. IV vitamin K
Patient with uremic bleed – give?
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)
Primary versus secondary versus. Tertiary hyperparathyroid?
Increased parathyroid hormone
chronic kidney disease (increased parathyroid hormone but decreased calcium)
Transplanted kidney but increased parathyroid production
Patient with mass and positive technetium 99 sestamibi scan - next step?
1. No Need to biopsy
2. Remove it if indicated
Indications to remove parathyroid adenoma?
Osteoporosis, stones, renal disease, increased calcium excretion, age under 50, symptomatic
Treatment for hypercalcemia?
1. Normal saline (increases renal function and urine Na and Ca excretion)
4. Denosumab (RANK ligand inhibitor)
Causes of renal failure from hypercalcemia?
3. Renal artery vasoconstriction
4. Nephrocalcinosis leading to acute interstitial nephritis
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
Patient with DKA – management?
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)
Acid-base status for a patient with DKA?
Anion gap metabolic acidosis plus metabolic alkalosis (from vomiting)
Causes of hyperkalemia in DKA?
2. Decreased insulin
4. Acute kidney injury (cannot excrete potassium)
Of oral diabetes drugs - which do not cause hypoglycemia? Which do?
Metformin and pioglitazone
Imaging for pancreas? Liver? Biliary Stone? Biliary tree?
Consider SBP if?
1. White blood cells >500 or PMNs >250
2. Positive cultures
In patient with liver disease, causes of hepatic encephalopathy?
1. Medication noncompliance
3. Uremic bleeding
4. Increased protein intake
5. Too much Lasix
Role of IV albumen in ascites?
1. Prevents sudden hypotension if remove >5 L of fluid
2. Decreased risk of hepatorenal syndrome
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
In patients with recurrent pleural effusions – possible solution?
Talc and doxycycline – fuse pleura together
LDH over 1000
Causes of alternate mental status?
Electrolyte disturbances (sodium, calcium, bicarb, encephalopathy)
Patient "acting crazy" – Give?
Patient on EPO – goal hemoglobin?
10 to 11
Myelofibrosis versus myelophthisis versus myelodysplasia?
Hypocellular marrow/CD 34 staining
Marrow infiltrative process with immature forms
abnormal maturation (not noticeable in peripheral blood smear)
Causes of B12 deficiency?
1. Poor intake
2. Poor absorption (pernicious anemia/Crohn's/celiac)
SVT - tx?
Adenosine to break tachycardia and determine if flutter or not
Retrograde P wave means?