PGY4 - MISC Flashcards

Question

Unknown Wide Complex Tachycardia Differential

Answer 1

QRS\>120, HR\>100 * Ventricular tachycardia * SVT with aberrancy (BBB, WPW) Paced rhythms * A fib with WPW * Torsade de pointes * Drug overdose * Na channel blockers Hyperkalemia * Post-resuscitation * Artifact

Answer 2

1. Trauma 1. Hyphema 2. Open Globe 3. Iritis 2. Optic Neuritis 3. Acute Closed Angle Glaucoma

Answer 3

* CRAO * CRVO * Temporal Arteritis * Retinal Detachment * Vitreous Hem

Answer 4

1. Hx 1. Women \> Men 2. Unilateral 3. Loss of Central Vision 4. Rapid Progression 2. Exam 1. Normal Slit Lamp 3. Tx 1. Solumedrol 2. Ophtho consult

Answer 5

* Pres * Decreased VA * Redness * Fixed, mid-dilated pupil * IOP \> 40 * Firm Globe

Answer 6

* Pilocarpine * 1 gtt q15 min until pupil constricts * One drop in C/L eye (ppx) * Timolol * 1 drop q 30 min * Acetazolamide * 500 mg IV/IM/PO * Mannitol * 1 g/kg IV * Stat ophtho consult

Answer 7

* Presentation * Sudden * Monocular * Exam * Afferent pupillary defect * Cherry red spot at fovea * Tx * Ocular massage - 5 sec on, 5 sec off * Decrease IOP * Hyperbaric Oxygen Therapy * Stat Ophtho Consult

Answer 8

Normal pupillary constriction when light shined in unaffected eye No constriction when light shined in affected eye

Answer 9

* Pres * Monocular * Exam * Blood and Thunder Retina * Treatment * Call ophtho

Answer 10

* Pres * HA * Age \>50 * Assoc with Polymyalgia Rheumatica * Increased ESR * Tx * Prednisone 1mg/kg PO * NSAIDs * Call ophtho

Answer 11

* Pres * Flashing lights * Floaters * Cloudy/Curtain-Like vision loss * Look with US * Tx = Call ophtho

Answer 12

* Pres * Floaters or webs * Monocular * Exam * Decreased red reflex * Tx * Elevate head of bed * No anti-caog/reverse * Call ophtho

Answer 13

* Pres * HA, vision changes, abd pain, edema, pulm edema, * HTN systolic \>140 or diastolic \>90, * hyperreflexia, tachycardia, clonus * Labs: CBC, BUN/Cr, lytes, gluc, Ca/Mg/Phos, LFTs, UA, coags, D-dimer, fibrinogen, uric acid

Answer 14

* Starts at 20 weeks * Pre-E * HTN * \> 140 sys or \>90 dia twice (sep by 4 hrs) * \> 160 sys or \> 110 dia once * Proteinuria * Severe preeclampsia: * ≥ 160 systolic or ≥ 110 diastolic + * End Organ Dysfunction * Thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral or visual disturbances * Ecclampsia * Pre-E + Seizure * HELLP * Hemolysis * Elevated Liver Enzymes * Low Platelets

Answer 15

* IVF * Decrease BP if \> 160/105 * Hydralazine 5mg IV q20 * Labetalol 0.25 mg/kg double q 10 min (300mg max) * Severe Pre-E * Mg 4-6 gm IV over 30 min (sz ppx) * Ecclampsia * Mg as above * Benzos * Delivery

Answer 16

* Hold for: * Bradycardia * Loss of DTRs * Resp depression * Antidote for Mg toxicity is Ca

Answer 17

* Non massive: * No signs of clinical instability, hemodynamic compromise or RV strain * Submassive PE: * Acute PE without hypotension but with any of the following: * RV dysfunction or RV dilation on POCUS, * Elevated BNP * Elevated troponin * New ECG changes (RBBB, ST changes, anterolateral T wave inversions) * Massive PE: * Sustained hypotension * Pulselessness * Persistent bradycardia * Signs of shock

Answer 18

* Massive * Thrombolytics * rt-PA 10mg then 90mg over 2 hours * 50mg bolus for code dose * Must code for 45 minutes * Surgery second line

Answer 19

* Thrombolytics remain contreversial * Full Dose vs. Half Dose vs. Cath Directed * Anticoagulation * Heparin 80 u/kg then 18 u/kg/hr * OR Lovenox 1mg/kg SQ

Answer 20

PO: Xarelto or Elliquis

Answer 21

Calculate PESI Score

Answer 22

* Lovenox 1 mg/kg SC BID * OR NOACs * Xarelto * Elliquis

Answer 23

* RV infarct * LV infarct * Acute valvular insufficiency * Wall Rupture * Papillary Rupture * Tamponade * Thoracic Aortic Dissection

Answer 24

* Treat underlying causes (bradycardia, tachycardia, ischemic, valve problem, ect) * If suspecting infarct... * Stat Cards consult for cath/IABP/ECMO * ASA and Heparin after CXR reviewed. Do not give BB * If no cath lab or contraindications consider thrombolytics * If TAD. .. stat CT surgery consult * Oxygenation/pulm edema: * Can trial BIPAP but may not tolerate well * Early intubation * Challenging due to hypotension, hypoxia and acidosis. * Maximize pre-intubation hemodynamics (small bolus, push dose pressors, preoxygenation, oxygenation during intubation. * Etomidate may be best choice for induction * If ↓BP / shock... * 250-500ml IVF bolus: eval response (need to be cautious). * Especially if dehydrated or RV infarction * BP \>90 * Consider dobutamine or milrinone (if patient on BB) * Dobutamine will need vasopressor (NE) * BP \< 90 * Consider NE. Can add on dobutamine * Optimize electrolytes (especially Ca) * Optimize H/H (higher threshold for transfusion, 10)

Answer 25

* Nadir Time * 10-14 d s/p chemo * ANC Calc * = WBC X ((PMN/100) +(Bands/100)) * Neutropenia * ANC \< 1500 * \< 500 = Severe * Neutropenic Fever * Temp \> 38.3 single or \>38 x 1 hr * + ANC \< 1500

Answer 26

* Tumor Lysis Syndrome * PE * Neutropenic Fever * Spinal Cord Compression * Hyperviscosity Syndrome * SVC Syndrome * Pericardial Disease * SIADH * Hypercalcemia

Answer 27

* High Risk Definition: * Shock * ANC \< 500, * ANC levels low for \> 7 days * Other organ dysfunction * MASCC Score \< 20 * Treatment * Empiric * One of: * Zosyn 4.5 gm IV * or Cefepime 2 gm IV * or Ticar/Clv or Imipenem/Cilastin * +/- Vanc 1gm IV * +/- Acyclovir 10 mg/kg IV

Answer 28

* Low Risk Definition: * No hypotension * No COPD * Age \< 60 * No dehydration * Solid tumor or hematologic malignancy * Minimal symptoms * MASCC \> 21 low risk * Empiric Treatment * Cipro 500mg q8 * + Augmentin 500mg q8 x7. * Talk with Onc - May d/c.

Answer 29

HypoNA with Euvolemia Water Restriction

Answer 30

* Timing * 2-3 d post chemo; * Labs * Increased * K * Phos * Uric Acid * Decreased * Calcium * Complicatons * ARF (from uric acid and calcium phos crystals), * Dysrhythmias * Neuromuscular problems

Answer 31

1. IVFs 2. Correct electrolytes 3. +/- Dialysis 4. Allopurinol- decrease uric acid production 5. Rasburicase- decrease uric acid levels (conversion to allantoin) 1. C/I in G6PD deficiency

Answer 32

* Steroids * Decadron 25mg * NS consult * Stat MRI

Answer 33

* Mild (\<12, no sx) * PO fluids * Mild (12-14, no sx) * IVF * Find Cause * Severe (\>14, severe sx) * IVF 200-300 mL/hr * Calcitonin 4 units/kg * Bisphosphonates after hydration * Dialysis * +/- Steroids * If due to calcitriol overproduction * Loop diuretics not recommended * Unless renal or heart failure,

Answer 34

* Sludging from ↑ proteins --\> * Fatigue * Neuro * HA, Sz, AMS, * Cardiac * MI, CHF. * Tx: * IVF, * Phlebotomy w/ PRBC replacement.

Answer 35

* Obstruction of blood through SVC due to internal intravascular invasion or external compression. * Lung cancer MCC. * Pres * Neck veins distended * SOB * ↑RR * Facial swelling * Work Up: CT chest w/ IV contrast * Tx: * Solu Medrol 250 mg IV * +/- Lasix 40 mg * If respiratory compromise, * most literature does not support * IV anticoagulation if due to thrombus * Definitive: * Chemo * Possible stent placement

Answer 36

WBC x Lymph% \<1000 --\> 91% probability CD4 \< 200

Answer 37

Dx of Exclusion CD4 ~200

Answer 38

* CD4 \<100 * CSF: * Inc opening pressure * Inc mono * +Crypto Ag

Answer 39

Ring enhancing lesions (with contrast)

Answer 40

* Local --\> Likely bacterial * Diffuse interstitial/granular --\> Likely PCP * Hilar --\> Crypto, histo, mycobac * Upper Lobe with Cavitation --\> TB

Answer 41

Pres - Unexplained Hypoxia - Inc LDH Tx - Steroids if PaO2 \< 70, A-a Grad \> 35

Answer 42

* Histo - Central/East US * Blasto - Central US * SW - Coccidio

Answer 43

* Candidadal Esophagitis - White plaque, scrapes away * Hairy Leukoplasia - White, corrugated lesions on edge of tongue * Diarrheal Infec * Salmonella - Recurrent bacteremia * C Dif * MAC/Cryptosporidium/Isospora

Answer 44

* Kaposis Sarcoma * HHV 8 * Pink/Purple papules/nodules

Answer 45

* Vaso Occlusive Crises * Pain Crisis * Consider cause - cold, trauma, dehydration * Dactylitis - painful swelling hands/feet * Stroke * Consider exchange transfusion * Priaprism * IVF, transfusion, drainage * Acute Chest * #1 Killer * Pulm Sx + New Infiltrate on CXR * Gets ABx * Hematologic Crisis * Splenic Sequestration * Enlarged spleen + decreased Hgb * Aplastic Crisis * Rapid decrease in Hgb and Retic * Causes - Folate def, infec * Transfuse * Infectious Issues * Functionally asplenic by 5 yo * Encapsulated org * S Pneumo, N Mening, Kleb, H Flu, Salmonella, Crypto, Pseudomonas * Osteomyelitis * Staph, Salmonella, E Coli

Answer 46

Some Nasty Killers Have Serious Capsule Protection * S Pneumo * Neisseria Menin * Klebsiella * H. Flu * Salmonella * Cryptococcus * Pseudomonas

Answer 47

THE MISFITS * Trauma (NAT), Tumor, Thermal * Heart/Lung: Bronchiolitis, pertussis, congenital heart * Endocrine: CAH, DM, Thyroid * Met Acidosis * Inborn Errors of Metabolism * Seizures * Feeding Abnormalities * Intestinal Disorders * Sepsis

Answer 48

* If ↓ glucose... D10 5 ml/kg IV/IO * If ↓ calcium... Ca Gluconate 100 mg/kg (up to 1 gm) IV over 10 min * If still seizing. * Phenobarbital 20 mg/kg IV (drug of choice in neonates - intubate!) * and/or Ativan 0.1mg/kg IV (may repeat in 10 min w 1/2 dose) * If still seizing... pyridoxine 100 mg q 5-15 min (max 500 mg) * If hyponatremic. ..4-6m L/kg 3%NacL

Answer 49

* Ampicillin 100 mg/kg IV * Cefotaxime 100 mg/kg IV or gentamycin 2.5 mg/kg IV * Acyclovir 10 mg/kg IV

Answer 50

* 20 ml/kg IVF * Pressors * Cold Shock - Dopamine or Epi * Warm Shock - Levo * Shock not improving - Hydrocortisone

Answer 51

* Likely respiratory etiology if... * Better w/ crying * No murmur * Normal EKG * ↑ O2 sat w O2. * Likely cardiac etiology if... * Worse w/ crying * Pos murmur * Abnormal EKG * No change in O2 sat w O2. * Tx for CHF/cyanosis * If hypercyanotic/Tet spell... * Calm child * Knee to chest position * Phenylephrine * Morphine 0.1 mg/kg IV or Ketamine * ± Propranolol 0.01-0.1 mg/kg IV

Answer 52

* C/f ductal dependent lesion * Consider PGE1 0.01-0.1 mcg/kg/min IV * Intubate. * Side effects-hypoTN, apnea, hyperpyrexia) * Use Atropine prior to intubation * Pressors * Non-cyanotic = Milrinone * Cyanotic = Levophed * Oxygen for most (except hypoplastic heart)

Answer 53

* Superficial - Epidermis * Superficial Partial - Dermis (Blisters) * Superficial Deep - White * Full - Underlying structures, no pain

Answer 54

18% - Front, Back, Legs 9% - Arms, Head 1% - Genitals Peds: Head is also 18%, legs are 14%

Answer 55

LR 2-4 ml x kg x % BSA (1/2 in First 8h, rest in 16hr)

Answer 56

15% in kids 20% in adults

Answer 57

30-50cc/hr Kids 1cc/kg/hr

Answer 58

* \>20% adults, \>10% kids/elderly * \>5% full thickness * Face/eyes/hand/feet/genital/perineum burns * Electrical (incl lightning) * Chemical burns * Inhalation injury * Circumferential Full thickness to chest or extremity * Concern for pt with preexist dz * No hospital capability for child burn

Answer 59

LR %TBSA x 10 - Initial wt in mL/hr (for 40-80Kg) For every 10kg over 80, increase rate by 100

Answer 60

5 Ts ## Footnote Tetralogy of Fallot Truncus Arteriosus Transposition of the Great Vessels Tricuspid Atresia TAPVR4-7