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Flashcards in Internal Medicine Pearls Deck (227):
1

Loratadine

Claritin

2

Catapres

Clonidine

3

What is the mechanism of clonidine

Stimulates alpha 2 adrenergic receptors

Central acting anti hypertensive

4

What is the most common cause of HTN in a young healthy non smoker?

Fibromuscular dysplasia

5

What is the most likely cause of HTN in a diabetic obese male with hyperlipemia?

Atherosclerosis

6

What treatment options are available for widely resistant bacterial infections

Consider using an older antibiotic like colistin that is no longer tested for resistance.

7

How does sepsis effect lactic acidosis

Sepsis increases the risk of lactic acidosis

8

How should metformin be adjusted for in patient hospital stay

It should be stopped to prevent lactic acidosis

9

How should a patient be managed for in patient alcohol detox

Fixed dose step down of Librium (longer hospital stay)

Referral to psych

For younger patients use 10 mg baclofen TID and Ativan PRN

Severity of symptoms is increased over the age of 45

10

What is the problem with using antipsychotics with anti-arrhythmics

Severe QT prolongation

Sedation with Benzos may be the only option for treating delirium in a patient on a phase III anti arrhythmic.

11

What is the mechanism of rabeprazole

Inhibits the hydrogen potassium ATPase of gastric parietal cells

12

Name the 1st generation cephalosporins

Cefazolin
Cephalexin

13

Name the third generation cephalosporins

Ceftibuten
Cefdinir
Cefotaximine
Ceftriaxone
Cefixime

14

Name the 4th generation cephalosporins

Cefepime

15

Name the fifth generation cephalosporins

Cetaroline

16

What is the community service board

Psychiatry evaluation that determines if the patient is unsafe for themself and the need for care. The referral does not require patient consents

17

What is a cosyntropin stimulation test

Baseline ACTH drawn.

30 minutes after cosyntropin IV injection of 1 µg cosyntropin draw blood for ACTH

60 minutes after 1 µg bolus cosyntropin injection draw blood for ACTH

18

What labs are a good indicator of gallstones and pancreatitis

AST three times of baseline

19

What are the common bugs the cause community acquired pneumonia

Typical's: strep pneumonia H. influenzae

Atypicals: Legionella, chlamydia, Mycoplasma

Special risk factors: alcoholics, aspiration

20

What are the two treatment options for community acquired pneumonia

1. Fluoroquinolone

2. Macrolide plus cephalosporin third-generation

21

What are the respiratory fluoroquinolones

1. Levofloxacin.
2. Avelox.

22

The patient is taking Lasix how do you check the kidney function

Do not get the FeNa with Lasix you will need to get the FeUria

23

How's the CNS Penetration of Zosyn

Poor

24

What is Todd's paralysis

Postictal states in which lethargy and confusion can remain for sometime. Maybe accompanied by focal neurologic deficits

25

Byetta

Exenatide

26

What is the mechanism of exenatide

Activates the GLP-1 receptor

27

When will serum urate become supersaturated

6.8

28

What serum level of urate should be treated to

Always treat below 6.0. If tophi are present treat to below 5.0

29

What items will induce a gout flair up

-Red meat, Beer, Shellfish, yeast, low dose ASA, Chemo, diuretics, ETOH, nicotine Aid

30

Are most gout patients over Producers or under excretor's

90% are Under excretor's

Less than 800 mg in 24 hours

31

How is gout managed

Managing flareups (Steroids, NSAIDs, colchicine)

Using urate lowering therapy

32

What options are available for urate lowering therapy

Uricosurics such as probenecid

Xanthine oxidase inhibitors such as allopurinol, Oxipurinol, or feboxustat

33

What is incentive spirometery

The program was intensive and involved breathing exercises, incentive spirometry, and education in active breathing and forced expiration techniques. Postoperative pulmonary complication rates for experimental and control groups were 18 and 35 percent, respectively, OR 0.52 [95% CI 0.30-0.92]. Median length of stay was one day shorter for the group receiving inspiratory muscle training.

34

What are the major causes of post operative fever

The five W's

-wind (atalectasis)
-water (UTI)
-wound (infection)
-walking (DVT's)
-Wonder drug

35

Semethicone

Gas X

36

What are the major causes of cellulitis

Strep pyogenes (GAS)
Staph aureus

37

What is the difference between erysipelas and cellulitis

Cellulitis is a deeper

Erysipelas is superficial, more demarcated border.

38

Is erysipelas more often strep or staph infection

More commonly strep. But could be either

39

Is cellulitis more commonly staph or strep

More commonly staph but could be either.

Staph is often associated with abscesses and a more purulent discharge.

40

What treatment options are available treatment of cellulitis

Clindamycin
Bactrum plus amoxicillin

Less coverage of gram positive but still effective:
Doxycycline

41

What is a major complication of clindamycin

C. Diff associated diarrhea

42

Discuss necrotizing fasciitis

- Rapid progressing.
- Pockets of abscess.
- Be sure to draw lines surrounding the border.
- Ensure frequent short duration follow-up.
- Patient presents with disproportionate pain

43

What are the causes of necrotizing fasciitis

Clostridium

GAS

Poly microbial including anaerobes

44

What is Ranson scoring

A score based upon Ranson's criteria is one of the earliest scoring systems for severity in Acute Pancreatitis.

Ranson's criteria consist of 11 parameters. Five of the factors are assessed at admission and six are assessed during the next 48 hours

Mortality increases with an increasing score. Using the 11 component score, mortality was 0 to 3 percent when the score was

45

What are the components of Ranson scoring

At admission:
Age in years > 55 years
White blood cell count > 16000 cells/mm3
Blood glucose > 10 mmol/L (> 200 mg/dL)
Serum AST > 250 IU/L
Serum LDH > 350 IU/L

Within 48 hours:
Calcium (serum calcium 10%
Oxygen (hypoxemia PO2 4 mEq/L
Sequestration of fluids > 6 L

The criteria for point assignment is that a certain breakpoint be met at anytime during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to non-gallstone pancreatitis.

46

What is tachy - Brady syndrome

Also known as sick sinus syndrome

an umbrella term for a group of abnormal heart rhythms (arrhythmias) presumably caused by a malfunction of the sinus node, the heart's primary pacemaker. Bradycardia-tachycardia syndrome is a variant of sick sinus syndrome in which slow arrhythmias and fast arrhythmias alternate.

47

What are common etiologies to prerenal AKI

Hypovolemia (dehydration)
Decrease contractility
Systemic vasodilation (sepsis)
Renal vasoconstriction (NSAIDs, ACE/ARBs)

48

How can the determination of prerenal AKI be made?

FE(Na) 20
Uosm > 500

49

How can the determination of prerenal AKI be made if a patient is on lasics

FE(un)

50

What is the formula for FE(Na)

FE(Na)= [U(Na)/P(Na)] / [U(cr)/P(cr)]

51

How does PTH related chronic kidney disease

The greater the target range of PTH equals a more severe stage chronic kidney disease

Stage III as target PTH of 35 to 70

Stage IV has target PTH of 70 to 110

Stage V has target PTH 150 to 300

52

What are the key ingredients in a lactated ringer

130 mEq of Na ion = 130 mmol/L
109 mEq of Cl ion = 109 mmol/L
28 mEq of lactate = 28 mmol/L
4 mEq of K ion = 4 mmol/L
3 mEq of Ca ion = 1.5 mmol/L

Lactated Ringers has an osmolarity of 273 mOsm/L. The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis.

53

What are the SIRS criteria

Temp: > 38 °C or 90/min
RR >20/min or PaCO2 12,000 or 10% bands

54

What is leukocytosis

Leukocytosis is a white blood cell count (the leukocyte count) above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, and is observed in certain parasitic infections. It may also occur after strenuous exercise, convulsions such as epilepsy, emotional stress, pregnancy and labour, anesthesia, and epinephrine administration

55

What are the classifications of leukocytosis

There are five principal types of leukocytosis:
Neutrophilia (the most common form)
Lymphocytosis
Monocytosis
Eosinophilia
Basophilia

56

What is the band cell

A band cell (also called band neutrophil or stab cell) is a cell undergoing granulopoiesis, derived from a metamyelocyte, and leading to a mature granulocyte.
It is characterized by having a nucleus which is curved, but not lobar.
The term "band cell" implies a granulocytic lineage (neutrophil)

57

What is tacrolimus indicated

To induce immune suppression for transplants rejection therapy

58

What is the only fluoroquinolone that has anaerobic coverage

Avelox (moxifloxacin)

59

What is the normal levels of lactate

0.5 to 2.2

60

At what level of Lactate should sepsis be a concern

Lactate greater than 4.0 consider septic shock until proven otherwise

61

What bacterial infections is clindamycin used to treat

Aerobic Gram-positive cocci, including some members of the Staphylococcus and Streptococcus (e.g. pneumococcus) genera, but not enterococci.[13]

Anaerobic, Gram-negative rod-shaped bacteria, including some Bacteroides, Fusobacterium, and Prevotella, although resistance is increasing in Bacteroides fragilis.

Most aerobic Gram-negative bacteria (such as Pseudomonas, Legionella, Haemophilus influenzae and Moraxella) are resistant to clindamycin,[13][14] as are the facultative anaerobic Enterobacteriaceae.[15] A notable exception is Capnocytophaga canimorsus, for which clindamycin is a first-line drug of choice.[16]

62

What is the function of the AST / ALT ratio

When greater than 2.0, it is more likely to be associated with viral hepatitis, alcoholic hepatitis[4] or hepatocellular carcinoma

When greater than 1.0 but less than 2.0, it is likely to be associated with cirrhosis
It is normally less than 1.0

However, the AST/ALT ratio is less useful in scenarios where the liver enzymes are not elevated, or where multiple conditions co-exist.

63

Is a ALT or AST a better indicator of inflammation

ALT is a more specific indicator of liver inflammation than AST, as AST may be elevated also in diseases affecting other organs, such as myocardial infarction, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, musculoskeletal diseases, and trauma

64

What is the clinical significance of an elevated ALT

Significantly elevated levels of ALT(SGPT) often suggest the existence of other medical problems such as viral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy.

For this reason, ALT is commonly used as a way of screening for liver problems. Elevated ALT may also be caused by dietary choline deficiency. However, elevated levels of ALT do not automatically mean that medical problems exist.

Fluctuation of ALT levels is normal over the course of the day, and ALT levels can also increase in response to strenuous physical exercise

65

What pathologies will cause an increase and ALK PHOS

The normal range is 20 to 140 IU/L.

High ALP levels can show that the bile ducts are blocked.

Levels are significantly higher in children and pregnant women.

Also, elevated ALP indicates that there could be active bone formation occurring as ALP is a byproduct of osteoblast activity (such as the case in Paget's disease of bone).

Levels are also elevated in people with untreated Celiac Disease.

Lowered levels of ALP are less common than elevated levels.

66

What are the pathologies that will cause hyperbillirubinemia?

1. Mild rises in bilirubin may be caused by:
- Hemolysis or increased breakdown of red blood cells
- Gilbert's syndrome – a genetic disorder of bilirubin metabolism that can result in mild jaundice, found in about 5% of the population
- Rotor syndrome: non-itching jaundice, with rise of bilirubin in the patient's serum, mainly of the conjugated type.

2. Moderate rise in bilirubin may be caused by:
- Pharmaceutical drugs (especially antipsychotic, some sex hormones, and a wide range of other drugs)
- Sulfonamides are contraindicated in infants less than 2 months old (exception when used with pyrimethamine in treating toxoplasmosis) as they increase unconjugated bilirubin leading to kernicterus.[14]
- Hepatitis (levels may be moderate or high)
- Chemotherapy
- Biliary stricture (benign or malignant)

3. Very high levels of bilirubin may be caused by:
- Neonatal hyperbilirubinaemia, where the newborn's liver is not able to properly process the bilirubin causing jaundice
- Unusually large bile duct obstruction, e.g. stone in common bile duct, tumour obstructing common bile duct etc.
- Severe liver failure with cirrhosis (e.g. primary biliary cirrhosis)
- Crigler–Najjar syndrome
- Dubin–Johnson syndrome
- Choledocholithiasis (chronic or acute).

67

How can volume depletion be determined

1. urine Na concentration remains below 15 meq/L
2. Elevated specific gravity



68

What is S1Q3T3

EKG interpretation that shows an S wave in I a Q wave and inverted T wave in lead III. It is the classical sign of a PE

69

What is the wells score

Calculation used to determine the risk of Pulmonary embolism. Criteria include:
1. Symptoms of DVT (3)
2. No alternative dx (3)
3. tachycardia > 100 (1.5)
4. immobilizations or surgery (within 4 weeks) (1.5)
5. Hx of DVT (1.5)
6. hemoptysis (1)
7. malignancy (1)

Score greater than 6 is high probability
Score less than 2 is low probability.

70

Colace

docusate sodium

71

What is the mechanism of docusate sodium

stool softner.

Facilitates mixture of stool fat and water

72

Senna soft

Sennosides

73

What is the mechanism of sennosides

increases peristalsis (Stimulant laxative)

74

What are the 3 mechanism in which T-bili can be elevated

increased production (hemolysis),
intrahepatic causes (toxins, injury, gilberts),
posthepatic causes (obstruction/gall stones)

75

What are the major risk factors for NASH (non alcoholic steatohepatitis)

obesity
DM
hyperlipidemia

76

macule

A flat, generally less than 0.5 cm in diameter area of skin or mucous membranes with different color than surrounding tissue. Color may be tan, brown, blue, red, or hypopigmented; macules may have nonpalpable, fine scale.

77

patch

A flat, generally greater than 0.5cm in diameter area of skin or mucous membrane with different color than surrounding tissue. Color may be tan, brown, blue, red or hypopigmented; patches may have nonpalpable, fine scale.

78

Papule

Discrete, solid, elevated bodies, usually less than 0.5cm in diameter. Papules are further classified by shape, size, color and surface characteristics.

79

plaques

Discrete, solid, elevated bodies, broader than they are thick, measuring more than 0.5cm in diameter. Plaques may be further classified by shape, size, color and surface characteristics.

80

nodules

Dermal or subdermal lesions that are firm, well-defined, and usually greater than 0.5cm in diameter. Cysts are fluid-filled nodules. Large nodules are called tumors.

81

pustules

Circumscribed elevations that contain pus. Pustules are usually less than 0.5cm in diameter.

82

vesicles

Fluid-filled cavities that are less than 0.5cm in diameter. Vesicles may be filled with fluid that is clear, serous, hemorrhagic or purulent.

83

bullae

Fluid-filled blisters greater than 0.5cm in diameter. Bullae can be filled with fluid that is clear, serous, hemorrhagic or purulent.

84

What is Inducible clinicamycin resistance

MRSA can develop resistance rapidly to single antibiotic treatment

85

How long should septic arthritis be treated

Four weeks IV antibiotics

86

How long should a septic bursitis be treated

Three weeks oral antibiotics

87

How does treatment of staph aureus cellulitis differ from strep cellulitis

Staff aureus requires two weeks IV vancomycin because staph aureus can seed other areas

88

The patient presents with coma, what are the medical treatments to counteract the coma.

Glucose (diabetes)

Thiamine (wernickes)

Flumazenil (Benzos)

Narcan (opiod antagonist)

89

What is the mechanism of benzonate

Anesthetizes respiratory passage, lung and pleural stretch receptors, reducing cough reflex

90

What are delirium tremens

Delirium tremens (DT) is defined by hallucinations, disorientation, tachycardia, hypertension, fever, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol. In the absence of complications, symptoms of DT can persist for up to seven days

91

How is the level of alcohol withdrawal determined

CIWA-Ar Score

Clinical Institute withdrawal assessment scale for alcohol revised

Less than 8 none to minimal withdrawal
8 to 15 mild
16 to 20 moderate
greater than 20 severe

92

What is a modified madrey's discriminate function

predict prognosis in alcoholic hepatitis

(4.6 x (PT test - control))+ S.Bilirubin in mg/dl

Prospective studies have shown that, it is useful in predicting short term prognosis especially mortality within 30 days. A value more than 32 implies poor outcome with one month mortality ranging between 35% to 45%.

93

How is obesity hyperventilation syndrome different from obstructive sleep apnea

Obesity hypoventilation syndrome is a form of sleep disordered breathing. Two subtypes are recognized, depending on the nature of disordered breathing detected on further investigations.

The first is OHS in the context of obstructive sleep apnea; this is confirmed by the occurrence of 5 or more episodes of apnea, hypopnea or respiratory-related arousals per hour (high apnea-hypopnea index) during sleep.

The second is OHS primarily due to "sleep hypoventilation syndrome"; this requires a rise of CO2 levels by 10 mmHg (1.3 kPa) after sleep compared to awake measurements and overnight drops in oxygen levels without simultaneous apnea or hypopnea.[1][3] Overall, 90% of all people with OHS fall into the first category, and 10% in the second.[2]
[edit]

94

Discuss GGT

Blood test results for GGT suggest that the normal value for men is 15-85 IU/L, whereas for women it is 5-55 IU/L.[9]

Elevated serum GGT activity can be found in diseases of the liver, biliary system, and pancreas. In this respect, it is similar to alkaline phosphatase (ALP) in detecting disease of the biliary tract. Indeed, the two markers correlate well, though there is conflicting data about whether GGT has better sensitivity.[10][11] In general, ALP is still the first test for biliary disease.

The main value of GGT over ALP is in verifying that ALP elevations are, in fact, due to biliary disease; ALP can also be increased in certain bone diseases, but GGT is not.[11] More recently, slightly elevated serum GGT has also been found to correlate with cardiovascular diseases and is under active investigation as a cardiovascular risk marker. GGT in fact accumulates in atherosclerotic plaques,[12] suggesting a potential role in pathogenesis of cardiovascular diseases,[13] and circulates in blood in the form of distinct protein aggregates,[14] some of which appear to be related to specific pathologies such as metabolic syndrome, alcohol addiction and chronic liver disease. High body mass index is associated with type 2 diabetes only in persons with high serum GGT.[15]

GGT is elevated by large quantities of alcohol ingestion. Determination of total serum GGT activity is however not specific to alcohol intoxication,[16] and the measurement of selected serum forms of the enzyme offer more specific information.[14] Isolated elevation or disproportionate elevation compared to other liver enzymes (such as ALP or ALT) may indicate alcohol abuse or alcoholic liver disease.[17] It may indicate excess alcohol consumption up to 3 or 4 weeks prior to the test. The mechanism for this elevation is unclear. Alcohol may increase GGT production by inducing hepatic microsomal production, or it may cause the leakage of GGT from hepatocytes.[18]
Numerous drugs can raise GGT levels, including barbiturates and phenytoin.[19] GGT elevation has also been occasionally reported following NSAIDs, St. John's wort, and aspirin. Elevated levels of GGT may also be due to congestive heart failure.[20]

95

Will alkaline phosphatase be elevated with alcoholic liver disease

No

96

How is magnesium effect with alcoholics

Alcoholics tend to waste total body stores magnesium

97

How is the spleen related to platelets

Splenomegaly will cause thrombocytopenia

98

What is traubes space

Traube's (semilunar) space is an anatomic region of some clinical importance. It is a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin.

Dulness to percussion is significant for splenomegaly

99

What is the difference in mechanism concerning vancomycin and oxicillin

Oxacillin is bacteriocidal vancomycin is bacteriostatic

100

What significance is a positive D-test for Clindamyosin

Positive D test indicates an inducible resistance

101

discuss how to determine basil and sliding scale insulin

Factor .3 is used for Insulin sensitive
factor .4 Is used for moderate patients
factor .5 for insulin resistant patients

Multiply the factor times the body weight in kilograms

Set 50% for basal insulin 50% for sliding scale Insulin. Have a sliding scale insulin broke up for each of the three meals.

Divide the daily caloric intake by the factor determines from body weight in kilograms To determine the sliding scale range

Once insulin total is greater than 200 change to a higher potency

102

What are Dercum's

Also known as adiposis Dolorosa

Rare disease that consists of painful lipomas

103

What are McGreers criteria for UTI

Includes only symptomatic urinary tract infections

No Indwelling Catheter
Must have three of the following:

fever >= 100.4°F/ > 38°C or chills
new or increased burning on urination, frequency or urgency
new flank or suprapubic pain or tenderness
new change in character of urine
worsening of mental or functional status


With Indwelling Catheter
Must have two of the following:

fever >= 100.4°F/ > 38°C or chills
new flank or suprapubic pain or tenderness
change in character of urine
worsening of mental or functional status

104

How is opiates withdrawal scored

COWS

Subjective score based off withdrawal symptoms including gooseflesh and pinpoint pupils along with trimmers sweats and arthralgias

Score:
5-12 = mild;
13-24 = moderate;
25-36 = moderately severe;
more than 36 = severe withdrawal

105

What is significant with a lactate of 4.0

One third of patients will die within one month

106

How is a upper G.I. bleed scored

Glasgow-Blatchford Bleeding Score (GBS)

107

Name the top 4 severe upper G.I. bleed

1. Esophageal varices

2. Borheaves

3. Peptic ulcer bleeds.

4. gastritis

108

What are the common causes of lower G.I.

Diverticulosis

Hemorrhoids

Malignancy

Colitis

Mesenteric ischemia, VTE

109

What is gave syndrome

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the antrum, or the last part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

110

What is Dieulafoy's lesion

medical condition characterized by a large tortuous arteriole in the stomach wall that erodes and bleeds. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. However, unlike most other aneurysms these are thought to be developmental malformations rather than degenerative changes.

The lesion will cease bleeding with the volume depletion

111

What is the generic treatment for an upper G.I. bleed

Use protonic for 24 hours with IV drip followed by oral

Two large bore IVs

Typing cross prepare for transfusion.

112

What is the ratio of a blood transfusion

4 units of blood

2 FFP

1 platelets

113

How is octreotide used for varices

It decreases the pressure to the varices

114

Mucomyst

Acetylcysteine

115

What are the three major liver function patterns

Hepatocellular
Cholestatic
Isolated hyperbillirubinemia

116

Outside of the liver what can cause a significant bump in AST

Acute MI

117

What are the causes of hepatocellular patterns

Viral
Toxins
Fatty Liver
Auto Immune
Hereditary

118

What is a cholestatic liver pattern

Increase in ALK PHOS

119

What are the causes of cholestatic pattern

Obstruction (us dilation)
1. Gall stones
2. Pancreatic cancer

Dilated
1. Sclerosing
2. PBC

120

What antibodies are associated with auto immune hepatitis

Anti smooth

121

What antibodies are associated with auto immune cholangitis

Anti mitochondria

122

What is the first blood cell line that is increased after chemo

Monocytes

123

What is the most specific EKG pattern for a pulmonary embolism

Inverted T waves on leads V1-V4

124

What is S1Q3T3

Indicates right heart strain.

Suspicious of cor pulmonale

125

What is polyglandular autoimmune disease

Autoimmune polyendocrine syndrome type 1 (APECED or Whitaker's syndrome)
Autoimmune polyendocrine syndrome type 2 (Schmidt's syndrome)
The most serious but rarest form is the X-linked polyendocrinopathy, immunodeficiency and diarrhea-syndrome, also called XLAAD (X-linked autoimmunity and allergic dysregulation) or IPEX (immune dysfunction, polyendocrinopathy, and enteropathy, X-linked). This is due to mutation of the FOXP3 gene on the X chromosome.[3] Most patients develop diabetes and diarrhea as neonates and many die due to autoimmune activity against many organs. Boys are affected, while girls are carriers and might suffer mild disease.
[edit]

126

What is the time period that is being examined when a creatinine measurement is taken

Previous 24 hours

127

Discuss contrast induced nephropathy

Typically occurs 2-5 days

Mucomyst to reduce inflammation
Increase fluids (125/hour)
Dialysis as necessary

128

What are the three most common bugs with CF

Pseudomonas Cepacia
Staph Aureus
Pseudomonas Aeriginosa

129

What is the correction factor for Na with elevated glucose

For every 100 over 100 multiply by 1.6 and add to Na.

476 glucose with Na 130
3.76x1.6=6
Corrected Na = 136

130

What is the general rule for fluid resuscitation

Volume: Hourly Rate
– Divide daily maintenance by 24 or use "4:2:1 rule"

Patient's Weight Range

Hourly maintenance fluid rate

if 10 kg or less---Pt. needs 4 mL/hr. for each kg

if 11-20 kg---Pt. needs 40 mL/hr. PLUS 2 mL/hr. for each kg over 10 (or 3mL/kg)

if more than 20 kg---Pt. needs 60 mL/hr. PLUS 1 mL/hr. for each kg over 20 (or 2mL/kg)

131

What is the difference between hypervolemia and dehydration?

Dehydration is loss of free water and is always associated with hypernatremia

132

How quickly should lactate be corrected

It should be normalized in 4 hours. Always treat to 2.0

133

Precedex

Dexmedetomidine

134

What is the mechanism of Dexmedetomidine

Produces centrally mediated sympatholytic, sedative and analgesic effects

Used for sedation

135

What is the child Pugh scoring

is used to assess the prognosis of chronic liver disease, mainly cirrhosis. Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation.


Points Cla. 1 yr. 2 yr
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%

136

Keppra

Levetiracetam

137

When is Levetiracetam indicated

Seizures

138

Should you go pressors through a peripheral line

No! Possibility of limb ischemia and loss of limb

139

Levophed

Norepinephrine

140

What is the problem of using dopamine as a pressor

Dopamine is very pro arrhythmic

Use levophed instead

141

How do you rule out cardiogenic shock

Echocardiogram

142

Should you give positive inotropes or chronotropes with diastolic heart failure

No. You will further exacerbate the problem

143

What is the mechanism of cyclosporine

Anti-IL2

144

What is boaz sign

Right shoulder pain associated with gall bladder disease

145

What are the baseline BNP levels that carry an 84% specificity

75 is BNP of 1800

146

What are the MDR risk factors

90 days prior abx use
2 days of hospital stay in previous 90 days
Chemotherapy
Dialysis
Long term care facility

147

What is the tx for outpatient CAP

Macrolide
Doxycycline

148

What is the tx for failed outpatient or in patient CAP

Levoquin

149

What is the to for ICU CAP

Ceftriaxone
Azithromycin

Or
Fluoroquinolone

150

What is the tx HCAP MDR

Vancomycin
Zosyn

151

What penacillins have pseudomonas coverage

1. All carbapenims except ertapenim
2. Tobramycin & Gentamycin
3. Levofloxacin & ciprofloxacin
4. Aztreonam

152

Bentyl

Dicyclomine

153

What is the mechanism and indications for dicyclomine

Anticholinergic and relaxes smooth muscle.

Indicated for IBS

154

What are Wellington wave on an EKG

Biphasic T waves in V1-V4

Indicates impending proximal LAD occlusion. Emergent cath necessary to prevent STEMI

155

What is used for DVT'S prophylaxis

1. Activity
2. Mechanical (SCD's)
3. Medical (heparin or lovenox)

156

When should you use heparin instead of lovenox

STEMI
Allergies

Heparin has a shorter half life (1.5 hrs) and is easily reversible with protamine.

Lovenox half life is 12 hours

157

What is an IJ line.

Internal jugular line (central venous line)

158

What is Hoffman sign

tingling sensation triggered by a mechanical stimulus in the distal part of an injured nerve. This sensation radiates peripherally, from the point where it is triggered to the cutaneous distribution of the nerve. The tingling response can be compared with that produced by a weak electric current, as in transcutaneous electrical nerve stimulation (TENS). This unpleasant sensation is not a severe pain and does not persist

159

What are muehrcke's lines

changes in the fingernail that may be a sign of an underlying medical disorder or condition. Muehrcke's lines are white lines (leukonychia) that extend all the way across the nail and lie parallel to the lunula (half moon). In contrast to Beau's lines, they are not grooved. The lines are actually in the vascular nail bed underneath the nail plate, and as such, they do not move with nail growth. Meuhrcke's lines disappear when pressure is placed over the nail, blanching the underlying nail bed.

160

What are some clinical findings of the hands that are associated with cirrhosis

Asterixis
Hoffmann sign
Hypothenar
Muehrcke's lines
Clubbing

161

Phenergan

Promethazine

162

Endocort EC

Budesonide

163

What is the most common cause of death In a patient with cirrhosis

Bleeding and infection due to decreased protein production

164

What is the mechanism of rifaximin

Reduces ureas producing bacterial flora

165

Is albumin beneficial for cirrhosis

No clear benefit currently defined

166

What is prophylactic tx of gastroesophogeal varicies.

Non selective Beta blockers. Not preventative. Will decrease mortality.

Nadolol or propranolol

Goal of treatment is decrease of 25%

167

What is SBP

Spontaneous bacterial Peritonitis

168

What is the tx for SBP

Cefotaximine 2 gms IV Q 8 hrs x 5 days

If no encephalopathy or ARF can use PO Ofloxacin.

Major bugs include klebsiela, enterics, and E. coli

169

What causes decompensated cirrhosis

Constipation
Infection
Increased alcohol intake
Medication
Bleeding from esophageal varicies

170

What is hepatopulmonary syndrome

Triad of
1. Liver disease
2. Impaired oxygenation
3. Intrapulmonary vascular abnormalities (referred to as intrapulmonary vascular dilations - IPVD's)

PiO2 15

171

What is decompensated cirrhosis

1 of the four

1. Ascites
2. SBP
3. Worsening
4. Hepatic encephalopathy

172

What is a tips procedure

Transjugular intrahepatic portosystemic shunt or transjugular intrahepatic portosystemic stent shunting (commonly abbreviated as TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding (esophageal varices) or the buildup of fluid within the abdomen (ascites)

173

What is platypnea

refers to shortness of breath (dyspnea) that is relieved when lying down,[3] and worsens when sitting or standing up. It is the opposite of orthopnea. The word is derived from the Greek platus (= flat) and pnoia (=breath).

174

What must be considered if more than 5 L is pulled from a patient with ascites

Oncotic pressure is very low, add albumin replacement otherwise you may induce a hepatorenal syndrome. Death will occur in 1-2 weeks.

175

What are the seronegative arthritis

IBD associated
Ankylosing
Psoriatic
Reactive

176

What is 96 % specific test for RA

Anti-CCP

177

What is a CAT test

COPD Assessment Test

Subjective patient completed survey grading the patients severity of COPD

178

What is a good mnemonic to follow for keeping ROS organized.

RICHMAN

Respiratory
Infection
Cardiovascular
Heme/onc
Metabolites
Ailamentary
Neurological
Skin

179

What can be used to reduce immunogenicity of patients taking biologics

Methotrexate in addition to biologics grossly reduces immunogenicity responses against the biologics

180

What is the mechanism of plaquanil

Plaquanil prevents the lysosomes ability to modify pH and thus limits protein production and therefore modifies the immune system

181

What is the mechanism of etanercept

Binds and inhibits soluble TNF a

182

How is RA diagnosed

1. Points on arthritis
2. ESR / CRP
3. CCP / RF
4. Present greater than 6 weeks

183

Discuss the basic potency of the statins

Crestor is 2 times as potent as Lipitor
Lipitor is 2 times as potent as zocor
Zocor is 2 times as potent as prevastatin

184

What is the dosing regimen of Tylenol

1-2 tabs 325 mg PO Q 4-6 hrs PRN

Max is 1 gram/4 hours or 4 gram/ day

185

What is the dosing regimen of Motrin

Take 1-2 200 mg tabs PO Q 4-6 PRN

Max dose is 2400/ day

186

What is acapella breathing treatment

Acappella is a handheld device that combines the resistive features of a positive expiratory pressure (PEP) device with oscillations. The physiologic rationale is that by exhaling against resistance we slow down our expiratory phase of breathing.. This slower exhalation against resistance or positive pressure generates a back pressure which in turn splints or stents open the more peripheral airways and moves the equal pressure or choke point more central and so lessens airway collapse distally. This prolonged exhalation time also allows for collateral ventilation to occur. So, that with the assist of the pores of Kohn, canals of Lambert and channels of Martin, mucus can be mobilized from the distal or peripheral airways to the larger more central airways and thereby enhances secretion clearance. However, the patient or individual must be able to generate adequate air flow to use this device.

187

Uroxatrol

Alfuzosin

188

What is the mechanism of alfuzosin

Selectively antagonizes lower urinary tract Alpha-1-adrenergic receptors, relaxing smooth muscle and improving urine outflow.

189

What bugs are associated with HCAP

MRSA.
Pseudomonas.
ESBL
Actinobacter

190

What is used to tx HCAP

1. Anti-Psuedomonal or cephalosporins or carbapinems
2. Fluoroquinolone or macrolide
3. Vancomycin

191

What is an acute measure of nutrition

Pre albumin

192

What is a long term measure of nutrition

Albumin

193

What is an acute measure of inflammation

CRP

194

What measurement is used for a longer more chronic perspective of inflammation

ESR

195

What effect does a PPI have on gastric emptying

Delays gastric emptying

196

What dose of steroids can induce glucocorticoid suppression

Greater than 20 g QD for more than 2 weeks has high risk

5 g QD can be used chronically with low risk

197

What steroid has little mineralcorticoid activity and can cross the placenta and CNS

Dexamethasone

198

What is the general steroid potency

Hydrocortisone 1 x
Prednisone 4 x
Solumedrol 5 x
Dexamethasone 20x

199

What role does adiponectin have with insulin

Makes cells sensitive to insulin

200

What effect does sulfa drugs have on creatinine clearance

Sulfa drugs compete for clearance and can increase Creatinine

201

Samsca

Tolvaptan

202

What are the indications for tolvaptan

Hyponatremia Hypervolemic

Hyponatremia Euvolemic

203

What is the mechanism of tolvaptan

Electively antagonizes vasopressin V2 receptors increasing free water secretion

204

What are the criteria determining admission or discharge for patients with a hx of syncope

Boston criteria
San Francisco criteria
Rose Criteria

205

What defines the San Francisco rule

“CHESS” mnemonic

• C - History of congestive heart failure
• H - Hematocrit

206

How is the severity of Pneumonia scored

Port score

Curb-65

207

What causes post influenza pneumonia

Staph Aureus

208

When is steroids indicated for meningitis

Strep meningitis

209

What does LDH measure or reflect

Tissue breakdown releases LDH, and therefore LDH can be measured as a surrogate for tissue breakdown, e.g. hemolysis. Other disorders indicated by elevated LDH include cancer, meningitis, encephalitis, acute pancreatitis, and HIV.

210

What is lemierre's syndrome?

Thrombophlebitis (Anerobic infection) of the internal jugular

211

What is Peutz-Jeghers syndrome

mucocutaneous melanin deposits (small black or brown dark spots) involving lips (> 95%), buccal mucosa (83%), nose, fingers, toes, and genitalia in Peutz-Jeghers syndrome

212

What is the mechanism of steroids

Inhibits NF-kB

213

What are the 5 p's associated with compartment syndrome

Pain
Palor
Poikylothermia
Parathesia
Pulseless

214

What is stills disease

Juvenile idiopathic arthritis

215

What is TTKG

The transtubular potassium gradient (TTKG) is an index reflecting the conservation of potassium in the cortical collecting ducts of the kidneys. TTKG is considered to reflect mainly aldosterone bioactivity with regard to its kaliuretic response.



TTKG is clinically useful in diagnosis for patients suffering from hyper or hypokalemia in determining renal or non-renal cause of the condition. Expected responses are for hyperkalemia or potassium ingestion to result in excretion of potassium and a TTKG to increase (e.g. >10) and for conditions of hypokalemia, for potassium to be retained and the TTKG to decrease (e.g.

216

Advil

Ibuprofen

217

Aleve

Naproxen sodium

218

What items on an EKG are suspicious of an MI or ACS

Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions

The physician should consider patient characteristics and risk factors to help determine initial risk.

219

What is tietze syndrome

Similar to costochondritis except that there is swelling in the effected joints.

A clinical diagnosis in the absence of other cardiopulmonary findings

220

Define pericarditis

triad of
1. pleuritic chest pain,
2. pericardial friction rub, and
3. diffuse electrocardiographic ST-T wave changes.

ECG usually demonstrates diffuse ST segment elevation and PR interval depression without T wave inversion.

Acute pericarditis should be considered in patients presenting with new-onset chest pain that increases with inspiration or when reclining, and is lessened by leaning forward

221

What findings are suggestive of pneumonia

Common symptoms include fever, chills, productive cough, and pleuritic chest pain.


Fever, egophony heard during auscultation of the lungs, and dullness to percussion of the posterior thorax are suggestive of pneumonia

222

What is required for diagnosis of hereditary hemochromatosis

Diagnosis requires confirmation of increased serum ferritin levels and transferrin saturation, with or without symptoms.

223

What are the symptoms of hereditary hemochromatosis

symptoms may include weakness, lethargy, arthralgias, and impotence.

Later manifestations include arthralgias, osteoporosis, cirrhosis, hepatocellular cancer, cardiomyopathy, dysrhythmia, diabetes mellitus, and hypogonadism

224

What gene is associated with hereditary hemochromatosis

HFE gene mutation of C282Y

225

Protonix

Pantoprazole

226

What is a Stryker needle

Needle used to evaluate for compartment syndrome

227

Plaquanil

Hydroxychloroquin