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IM 3 Flashcards

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1
Q

CF-12 38yo F present to your office for evaluation of menstrual irregularity. She states that her periods started when she was 12yo and have been regular ever since, coming once every 28-30 days. She had 3 previous uncomplicated pregnancies and deliveries. However, appx 9 mths ago, her cycles seemed to lengthen, for the last 3 mths she has not had a period at all. She stopped breast-feeding 3 years ago, but over the last 3 mths she noticed she could express a small amount of milky fluid from her breast. She had bilateral tubal ligation after her last preg, and she has no other medical or surgical history. Takes no meds, except vitamins. Over the last year or so, she thinks she has gained about 10lb, feels as if she has no energy depsite adequate sleep. Noticed some mild thinning of her hair and slightly more coarse skin texture. She denies headaches or visual changes. Her physical exam, including pelvic and breast are normal. She is not obese or hirsute. You elicit slightly whitish nipple discharge. her pregnancy test is negative. Dx? Etiology?

A

Hypothyroidism and hyperporlactinemia. Oligomenorrhea and galactorrhea due to hypothyroidism. Thinning hair, weight gain, previous normal menses.

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2
Q

Amenorrhea:

A

Primary - absence of menarche by 16yrs, regardless of 2ndary characteristics. Secondary- absence of menstration for 3 or more months in women with normal past menses.

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3
Q

Oligomenorrhea:

A

Menses at infrequent intervals of more than 40 days or less than 9 menses a yr.

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4
Q

Polycystic Ovarian Syndrome:

A

Syndrome; infertility, hirsutism, obesity and amenorrhea or oligomenorrhea.

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5
Q

Differential for hypothalamic-pit-ovarian axis?

A

nutrition, excess exercise, stress, infiltrative dz.
PCOS >30% cases.
Empty sella syndrome (CSF herniation into pit fossa), Shehan syndrome, obstructive hemorrhage.
Premature ovarian failure (loss of functional ovarian follicles before 40)

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6
Q

PCOS: history, labs, therapy

A

Irregular menses since menarche, obesity, hirsutism.

Slightly elevated testosterone, elevated LH/FSH 2:1,

TX-OCP

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7
Q

Hypothyroidsims: history, labs, therapy

A

Fatigue, cold intolerance.

Elevated TSH

TX-thyroxine replacement

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8
Q

Hyperprolactinemia: history, labs, therapy

A

Headache, bitemporal hemianopsia, galactorrhea, meds, hypthyroidism.

Elevated prolacin level

TX-underlying

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9
Q

Ovarian failure: history, labs, therapy

A

Hotflashes, hypoestrogenemia.

Elevated FSH and LH.

TX-Replacment of hormones

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10
Q

Sheehan sydnrome: history, labs, therapy

A

Postpartum hemorrhage, unable to breast feed.

Low pit hormones (FSH, TSH, ACTH).

TX- replace hormones

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11
Q

Most common cause of hypothyroidism in the US?

A 
Lymphocytic thyroiditis (Hashimotos), 
followed by surgical or radioactive iodine uptake.  
Worldwide - Iodine deficiency.
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12
Q

Elderly with dementia, depression. Must rule out? Other symptoms to consider?

A

hypothyroidism; fatigue weight gain, msl cramping, cold intolerance, hair thinning, menstrual changes or carpel tunnel syndrome.
Myxedema dull facies, swollen eyes, doughy extremities - hydrophilic polysaccharides in dermis, sparse hair and thickened tongue.

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13
Q

Hormone levels in hypothyroidism? What if she’s pregnant?

A 
TSH high, Free T4 or Estimated by T3uptake.  
Excess TBG (pregnancy or OCPs) : T4 will be high, T3 uptake will be low.  
UPTAKE HIGH T3 T4 = HYPERTHYROID;  UPTAKE LOW T3 T4 = HYPOTHYROID
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14
Q

Euthyroid:

A

Fatigue is usually only symptom, slightly elevated TSH, normal T3-T4.
In 5 years patient will progress to overt hypothyroidism.
Derangement of cholesterol metabolism, Thyroid replacement can be prescribed to reduce cardiovascular risk.

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15
Q

Levothyroxine tx and expected outcome on this medication:

A

Long half life 6-7 days, once daily dosing.
Dosing at low levels 25-50ug/d and increase 4-6 weeks to avg ~2ug/kg body wt.
TSH takes 6-8 weeks to readjust to new dosing level.

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16
Q

42yo for her annual physical. On exam, neck fullness. When you palpaite her thyroid, it is enlarged, smooth, rubbery, and nontender. The patient is asymptomatic. You send her for thyroid function testing: Her T4, fT4 and T3 are normal, but TSH slightly elevated. Which of the following is likely diagnosis??

A

Hashimoto Thyroiditis

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17
Q

Which of the following laboratory tests could be performed to confirm your diagnosis of the patient?

A

Antithyroid Ab -
Antithyroperoxidase Ab
Antimicrosomal Ab (markers not the cause).
Biopsy will show lymphocytic infiltration and fibrosis of the gland - pathognomonic.

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18
Q

19yo gymnast, menses has ceased for the last 3 mths. Prior she was regular. Denies excess dieting, although she does work out with her team 3 hours daily. Her physical examination is normal except for her body mass index of 20kg/m2. Which labs should be ordered?

A

b-Hcg

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19
Q

35yo F diagnosed with hypothyroidism 4 weeks ago presents to your office complaining of persistent feeling of fatigue and sluggishness. After confirming your diagnosis with a measurement of TSH, you started her on levothyroxine 50ug daily. She has been reading about her diagnosis on the internet and wants to try desiccated thyroid extract instead of the medicine you gave her. On exam weighs 175, hr 64. Next best test?

A

Increase her dose of levothyroxine and have her come back in 4 weeks. Medications like Fe containing vitamins should be taken at different times because they may interfere with absorption.

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20
Q

49yo F presents to ER complaining of 4 week history of progressive abdominal swelling and discomfort. She has no other GI symptoms, normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one was complicate by excessive blood loss, requiring blood transfuion. She is happily married for 20yrs, exercises, does not smoke, drinks occasionally. Wild in her youth, does not use drugs now. HIV negative at the time of her last child. Temp is 100.3 P 88bpm BP 94/60. She is thin, her complexion is sallow, sclerae are icteric, chest is clear, RRR no murmur. Abd distended, mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, fluid wave. No peripheral edema. Lab studies are normal except sNa 129 ablumin 2.8, tb 4 prothromin 15 sec, hgb 12 and MCV 102, Plts 78,000 Dx? next step?

A

Acites caused by portal hypertension as a complication of hepatic cirrhosis. Paracentesis to evaluate ascitic fluid to try determine etiology as well as evaluate for spontaneous bacterial peritonitis.

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21
Q

Ascites:

A

Abnormal accumulation >25ml of fluid within the peritoneal cavity.
Tx Sodium Restriction, spirinolactone, loops; large volume paracentesis.

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22
Q

Chronic Hepatitis:

A

Hepatic inflammation and necrosis for at least 6 mths.

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23
Q

Cirrhosis:

A

Histologic diagnosis reflecting irreversible chronic hepatic injury, which includes extensive fibrosis and formation of regenerate nodules

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24
Q

Portal Hypertension: Clinical? Dx? Tx?

A

Increased pressure gradient >10mmHg in the portal vein, usually resulting from resistance to portal flow mc cirrhosis.
Present: Splenomegaly, encephalopthy, bleeding varices.
Dx: Doppler US, SAAG: sAlb-aAlb >1.1 portal htn (transudative) <1.1 exudative BAD
Tx: Bblocker to dec portal htn, Sandostatin or Octeotride for splanchnic vasoconstriction.

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25
Spontaneous Bacterial Peritonitis:
Bac infection of ascitic fluid without any intaabdominal source of infection. 10-20% of cirrhotic patients high mortality. Fever, dec bowel sounds, few abd symptoms. Dx Paracentesis >250 PMNs or pos culture. Usually 1 organism, if polymicrobial think intestinal perf. Tx Cefotaxime or ampicilllin /sulbactam
26
Hepatitis C infection: Risk factors
Most commonly acquired through percutaneous exposure to blood. Risk factors: IV drug user, Sharing of straws to snort cocaine, hemodialysis, blood transfusion, tattooing, piercing. Sexual transmission rare. Vertical transmission is uncommon, unless high titers or HIV positive. 70-80% develop chronic hep C in the 10 yrs following infection. 20% of those develop cirrhosis among those 1-4% develop hepatocellular ca
27
Autoimmune hepatitis, test?
ANA, anti LKM (liver kidney microsome)
28
Hemochromatosis, test?
High transferrin saturation (>50), high ferritin
29
Wilson Disease, test?
Low Ceruloplasmin
30
Treatment of choice for Hep C?
HEP CAR: pegylated alpha antifuron and ribivarin SE Alpha I -flu like, depression. SE Ribivarin -hemolysis
31
15yo adolescent female with elevated liver enzymes and positive ANA?
Autoimmune Hepatitis, positive ANA and hypergamaglobulinemia, may have other signs and symptoms of LUPUS
32
56yo M with diabetes, tan skin, family history of cirrhosis?
Bronze diabetic with small testes, joint pain and chest pain. Hematochromatotis, DM, cirrhosis, hypogonadotrophic hypogonadism, arthropathy, and cardiomyopathy.
33
35yo M with ulcerative colitis
Sclerosing Cholangitis, autoimmune destruction of both the intrahepatic and extrahepatic bile ducts. Pt presents with jaundice and biliary obstuction; cholangiography characteristic for beading of the bile ducts.
34
56 yo F complaint of pruritis and fatigue
Primary Biliary Cirrhosis thought to be autoimmune leading to destruction of small/medium bile ducts. Pt women 50-60. Alk Phos 2x-5x normal
35
32yo M with Kayser Fleischer rings, dysarthria, and spacticity
Wilson's Dz inherited copper metabolism, cirrhosis with neurological changes.
36
CF-14 42 yo hispanic F presents ER with 24hr of severe , steady epigastric abdominal pain, radiating to her back, several episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spontaneously within hour or two. This time the pain did not improve. She has no medical history, takes no medication. Married, 3 children, does not drink alcohol or smoke cigarettes. PE: afebrile, tachycardic, P104 BP 115/74 and shallow respirations 22. Moving comfortably in stretcher, skin warm and diaphoretic, scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, no masses or organomegaly. Her stool is neg for occult blood. Labs TB 9.2 AST 78 ALT 92 Amylase 1249 WBC 16500 82% PMN 16% Lymph. Plain abdomen shows nonspecific gas pattern and no pneumoperitoneum. Dx? Etiology? Next step?
Acute Pancreatitis, due to choledocholithiasis. Next step right upper abdominal US.
37
Ranson Criteria for severity of pancreatitis? Initially?
``` intial: Glucose>200, Age >55, LDH >350, AST >250, WBC >16000 ```
38
Ranson Criteria for severity of pancreatitis? Within 48hrs
``` Worry about anemia, low volume state, hypoCa Hct drop >10, sCa 5, Base Def >4, Art PO2 6L ```
39
Most common cause of pancreatits in the US?
Alcohol, next is biliary tract dz usually stone, hypertriglyceridemia (>1000) hypercalcemia
40
Define low grade fever?
<101
41
Specific to pancreatitis? Amylase or lipase?
Lipase remanes elevated longer
42
Dx and Tx of Pancreatitis?
CT abdomen, Treatment is mainly supportive (NPO, analgeisa-meperidine, IVF) Patients with severe pancreatitis will sequester fluid in abdomen, give copious IVFs.
43
Most common cause of death in severe pancreatitis?
``` Hypovolemic Shock, due to thirdspacing and inc capillary permeability. non cardio (ARDS) -pulmonary edema cardio -myoglobin dysfunction ```
44
Pancreatic complications?
Phlegmon, solid mass of inflammed pancrease with patchy necrosis. Pancreatic abscess. Pancreatic pseudocyst collection of inflammatory fluid and pancreatic secretions, most will resolve in 6 wks.
45
Gallstones?
Precipitated microcrystals in bile. Common in 10% of population, 10% will develop symptoms. "biliary colic" sudden onset after fatty meal. RUQ lasting 1-4hrs. Mild alk-phos and hyperbilirubinemia. HyperB >3 suggests common bile duct. Dx: US
46
Complication of Gallstones?
acute cholecystitis, E. coli and klebsiella are common in gallbladder. Dx HIDA scan Tx (NPO, IVF, Abx) colecystectomy in 48-72hrs.
47
Complication of Gallstones? Bilirubin >3?
Cholangitis, common bile duct obstuction. If septic requires urgent decompression of biliary tree. Either surgery or ERCP to remove the stones
48
43yo man alcoholic admitted to the hospital with acute pancreatitis. He is given IVF and placed NPO. What suggests poor prognosis?
Hct drop >10, BUN rise >5, Art PO2 4, Estimated Fluid Seq >6L
49
37yo noted to have gallstones on US. Placed on low fat diet. After 3 mths she is noted ot have severe right upper quadrant pain and fever of 102' and nausea. Dx?
Acute Cholecystitis
50
45yo M admitted for acute pancreatitsis, thought to be result of blunt abdominal trauma. 3mths he still has epigastric pain, but able to eat solid food. Amylase level is elevated at 260. Dx?
Pancreatic pseudocyst, abd pain and mass and persisitent hyperamylasemia
51
CF-15 72yo M in ER after fainting while in church. Stood up to sing a hym and then fell to the floor. Wife, reports unconcious for 5min. When he awakened, was groggy for another 2 min then he seemed himself. No abnormal movements, never happened before, wife reports for the last several months has had to curtail activities, such as mowing lawn, because he feels week and light headed. His medical history is osteoarthritis of his knees, take acetaminophen. PE, alert, talkative, smiling. Afebrile, P35 BP 118/72, unchanged when standing. Contusions on his face, left arm, chest wall, no lacerations. Chest is clear to auscultation, heart rhythm is regular but bradycardic with nondisplaced apical impulse. No focal deficits. Labratory examination shows normal blood counts, renal function, serum electrolyte levels, and neg cardiac enzymes. ECG shows: complete heart block. Dx? next step?
Syncope as a concequence of third deg AV block, next is placement of a permanent pacemaker.
52
Syncope:
Transient loss of conciousness and postural tone with subsequent spontaneous recovery.
53
Vasovagal Syncope:
Fainting due to excessive vagal tone causing impaired autonaumic responses such as hypotension without appropriate rise in HR or vasomotor activity. Precipitated by emotional stress or painful experience. Clear precipitating event, event lasts min with rapid recovery. Also triggered by physiological causing inc vagal tone micturition, defecation, coughing.
54
Neurological causes of syncope?
Autonomic dysfunction leading to orhtostatic hypotension: | DM, Parkinsonism, idiopathic dysautonomia
55
Carotid sinus hypersenativity?
Vagally mediated, older men episodes triggered by moving neck, tight collar, or shaving.
56
Orthostatic Hypotension?
Postural changes, rising from a seated position. | Postural drop in systolic bp by more than 20
57
Cardiogenic Syncope?
Rhythm disturbances and structural abnormalities, causing dec flow to brain. MC is bradyarrythmias. SSS (tachy/brady sydrome) is the most common cause for pacemaker placement.
58
First-Degree AV block?
Prolonged PR >200ms (>1large box) no need for pacing
59
Second-Degree AV block?
Mobitz 1- progressive lengthening of PR interval, if symptomatic pacemaker. Mobitz 2- dropped beats without lengthening of the PR interval, Pacemaker placement.
60
Third-Degree AV block?
complete heart block
61
18yo F brought to ER bc fainted at a rock concert. Apparently recovered spontaneously, did no exhibit any siezure activity, no medial history. HR 90 BP 110/70. Neurological exam is normal. Pregnancy test neg. Appropriate management?
Reassurance and discharge
62
67yo F DM, mild HTN. She is noted to have some diabetic retinopathy, states that she cannot feel her legs. She has recurrent episodes of lightheadedness when she gets up in the morning. Comes in now because she has fainted this morning. Likely cause of her syncope?
Autonomic neuropathy
63
74yo M no prior medical hx faints while shaving. Quickly recovers, no neurological deficits. Blood sugar is normal, ECG shows normal sinus rhythm. Most useful diagnostic test?
Carotic Massage
64
49yo admitted to ICU with diagnosis of inferior MI. HR 35bpm BP 90/50. ECG shows mobitz type 1 heart block. Next step?
Atropine, for bradycardia. Transvenous pacer is not usually necessary.
65
CF-16 28yo ER complaining of 2 days abd pain and diarrhea. Stools are frequent, 10-12 per day, small, sometimes visible blood and mucus, preceded by a sudden urge to defecate. The abd pain is crampy, diffuse, moderately severe, not relieved with defecation. In past 6-8mths, he has experianced similar episodes of abdominal pain and loose mucoid stools, but episodes were milder and resolved within 24-48hrs. No other medical history and takes no medications. He has neither traveled out of the US nor had contact with anyone with similar symptoms. Works as an accountant and does not smoke or drink alcohol. No family member with GI issues. PE T-99 P-98 BP 118/74. Appears uncomfortable, diaphoretic, lying still on stretcher. Sclerae are anicteric, oral mucosa is pink and clear without ulceration. Chest is clear, RRR no murmurs. Abd soft mildly distended, with hypoactive bowel sounds and minimal diffuse tenderness but no gaurding or rebound tenderness. LABS: WBC 15,800 with 82% PMN, Hgb 10.3 Plt 754,000 HIV assay is negative. RF and LF WNL. Plain film shows mildly dilated air filled colon with 4.5cm diameter and no pneumoperitoneum or air/fluid levels. Dx? Next Step?
Ulcerative Colitis, admit and r/o infection, and begin corticosteroid therapy. Abd pain, bloody diarrhea, abd xray localizing to colon. IBD vs Infectious Collitis E. Histolytica, Salmonella, Shigella, Camplobacter, C. Difficile
66
Etiology of IBD?
15-25 or 60-70, presents low grade fever. | Chronic nature, anemia, fatigue, wt loss.
67
Ulcerative colitis
Begins in rectum, proximally in a continous pattern. Dz limited to colon. Presenting as bloody diarrhea. Primary sclerosing cholangitis.
68
Crohns?
Gifts, Granulomas, Inflammatory- arthritis, uveitis, cholethiasis, Fistulas, Transmural, Skip lesions. Anywhere in GI mouth->anus usually presents as just crampy abdominal pain.
69
Chrons vs UC: skin
Erythema Nodosum Both, Pyoderma gangrenosum both
70
Chrons vs UC: Rheumatologic
Chrohns more common: Polyarticular and Ankylosing spndylitis, but can be seen in both
71
Chrons vs UC: Ocular
Uveitis in both
72
Chrons vs UC: Hepatobiliary
Cholelithiasis Fatty Liver in Crohns, Primary Sclerosing Cholangitis more common in UC
73
Chrons vs UC: Urologic
Chrons: Nephrolithiasis
74
Treatment of UC/Crohns
Mild to Moderate and Flares: Sulfasalazine or Mesalamine, for inflammation. Severe: Corticosteroids once in remission taper off in 6-8wks. Infliximab important in Crohns
75
Complicated UC?
Surgery, total colectomy for Carcinoma, Toxic Megacolon, Perforation, uncontrollable bleeding. Pts have increased incidenc of colon cancer.
76
Fever, leukocytosis, tachycardia, hypotension, altered mental state, colon to a diameter of >6cm?
TOXIC MEGACOLON, NPO-NasoGastric tube suctioning, IV fluids, IV Abx,
77
Followup for UC?
Annual colonoscopy, beginning 8yrs after diagnosis
78
32yo F history of chronic diarrhea and gallstones now has rectovaginal fistula. Which of the following is the most likely diagnosis?
Crohns
79
45yo M with history of UC is admitted to the hospital with 2-3 weeks of RUQ abdominal pain, jaundice and puritis. No fever and normal WBC. ERCP shows multifocal srictures of both intrahepatic and extrahepatic bile ducts with intervening segments of normal and dilated ducts. Dx?
Primary sclerosing colangitis
80
25yo M hospitalized for UC. Now developed abdominal distention, fever, and transverse colonic dilation of 7cm on Xray. Next step?
NPO/nasogastric tube - Abx and surgical intervention.
81
35yo F chronic crampy abdominal pain and intermittent constipation and diarrhea, no weight loss or GI bleeding. Her abdominal pain is usually relieved with defecation. Colonoscopy and upper endoscopy with biopsies are normal, stool cultures are negative. Dx?
Irritable Bowel Syndrome - diagnosis of exclusion
82
CF-17 54yo M Hx DM2 and CAD is addmitted to the coronary care unit with worsening angina and HTN. Pain is controlled with IV nitroglycerin, and he is treated with aspirin, B-Blocker to lower his heart rate, ACEI to lower his BP. Cardiac enzymes are normal. He undergoes coronary angiography, revealing no significant stenosis. Next day, urine output is 200mL over 24hrs. Examination at that time reveals he is afebrile, HR 56 BP 109/65. His fundus reveals dot hemorrhages and hard exudates, neck veins are flat, chest is clear, rhythm normal S4 gallop no mumurs or friction rub. His abdomen is soft without masses or bruits. He has no peripheral edema or rashes, normal pulses in all extremities. Labs: sNa 140 K 5.3 Cl 104 CO2 19, BUN 69. Cr 2.9 from 1.6 on admission. Clinical Problem? Next diagnostic step?
Acute Renal Failure, do a Urine analysis and U chemistries to determine the process.
83
Acute Renal Failure:
Abrupt decline in GFR. By the time Cr rises, GFR has fallen significantly.
84
Anuria:
Less than 50mL of urine output in 24hrs. Acute obstruction, crotical necrosis and vascular catastrophes (aortic dissection)
85
Oligouria:
Less than 400mL of urine ouput in 24hrs, lowest amount physiologically make. Oligouria is a poor prognostic sign in ARF. Oliguric renal failure has higher mortalitity rate.
86
Uremia:
Nonspecific symptoms: fatigue, weakness… look at total picture, may only have a slight BUN, but symptomatic due to other factors
87
Azotemia:
Elevated BUN without symtoms
88
Pre renal:
Diminished GFR as a result of decreased renal blood perfusion. Focus on effective intravascular volume not so much edema. What does the kidney see? BUN:Cr >20 Avoid Aspirin, NSAIDS, ACE-I UA: high specific gravity, normal microscopic findings.
89
Pre renal, true volume depletion?
GI loss, Renal loss (diuretics)
90
Pre renal, effective arterial blood volume?
Nephrotic Synrdome, Cirrhosis w P-HTN, Severe Burns, Sepsis, SIRS.
91
Pre renal, medications?
ACE-I, NSAIDs
92
Pre renal, dec cardiac output?
CHF, Precardial Tamponade
93
Post renal:
Obstructive nephropathy, mc malignancy, prostatic obs. Look for hydronephrosis on renal US. UA: unable to conc urine, urine osmolarity equal to serum osmolarity and specific gravity 1.010.
94
Intrinsic renal:
Injury to renal glomeruli or tubules directly. UA: Isothenuric and often proteinuria, muddy brown casts
95
Intrinsic renal, Acute Tubular Necrosis:
Nephrotoxic Agent (aminoglycosides, radiocontrast, chemotherapy) Ischemic (hypotension, vascular catastrophe)
96
Intrinsic renal, Glomerulonephritis:
Postinfectious, Vasculitis, Immune complex dz (lupus, MPGN, cryoglobulinemia) UA severe protienuria, RBC casts
97
Intrinsic renal, Tubulointerstitial Nephritis:
Medications (cephalosporins, methicillin, rifampin) Infection (pyelonephritis, HIV) UA mild protienuria, uEos, White cell casts
98
Pre Renal UA FE-Na uNa?
High specific gravity, normal sediment / <20
99
ATN UA FE-Na uNa?
Isosthenuric with muddy brown granular casts / >1% / >20
100
Glomerulonephritis UA FE-Na uNa?
Moderate to severe protienuria with RBCs and RBC casts/ <1% / Variable
101
Interstitial Nephritis UA FE-Na uNa?
Mild to Moderate proienuria, RBC, WBC, and WBC casts / >1% / >20
102
Postrenal Failure UA FE-Na uNa?
Variable / 1% late / 20 late
103
Indications for dialysis in ARF?
Acidosis (metabolic pH6.5 or rapid rising treat medically first), Intoxications , Overload (fluid overload-pul edema), Uremic (pericarditis, encephalitis-AMS, GI bleed)
104
Hyperkalemia lethal level?
>7 meq/L: muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac arrhythmias including sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia, ventricular fibrillation, and asystole.
105
Calcium gluconate?
1gm/10ml over 2-3min with constant cardiac monitoring. Pt on digitalis? Continue same indication. Hypokalemia due to digitalis? Give Dig-Ab instead
106
Insuline/glucose?
glucose >250 give insulin alone, measure glucose in an hour. Give bolus injection of 10 units of regular insulin, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose).
107
Beta 2 agonist?
Epinephrine, Albuterol
108
Na Bicarb?
Only effective over prolonged use - 6hrs. Give 150 meq in one liter of 5 percent dextrose in water over two to four hours (if tolerates fluid)
109
GET K out of the body?
Loops, Kayexalate, Dialysis
110
63yo woman history of cervical cancer treated with hysterectomy and pelvic irradiation now presents with acute oliguric renal failure. On physical examination, normal JVP, normotensive without orthostatsis, benign abdominal examination. Urinalysis shows specific gravity of 1.010, no cells or casts on microscopy. Urinary FENa 2% and NA is 35. Next step?
Renal US, bilateral uretal obstruction: common for cervical cancer mets.
111
49yo man long standing hx of chronic renal failure as a consequence of diabetic nephropathy is brouth to ER for nausea, lethargy, and confusion. PE significant for elevated JVP, clear lungs, harsh systolic and diastolic sounds heard over the precordium. K 5.1, CO2 17, BUN 145 and Cr 9.8. Appropriate therapy?
Urgent Hemodialysis
112
62yo diabetic man underwent abdominal aortic aneurysm repair 2 days ago. He is treated with gentamicin for urinary tract infection. His urine output has fallen to 300ml over 24hrs, sCr risen from 1.1 on admission to 1.9. Laboratory values would be more consistent with prerenal etiology of renal insufficiency?
FENa

CK Internal Medicine (4 decks)

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