Boards

  1. Sensitivity Vs Specificity
    Sensitivity: True Positives; the degree to which those who have a disease screen/test positive


    Specificity: True Negative; the degree to which those who do not have a disease screen/test negative
  2. Top 5 Killers of adults in the United States
    • 1. Heart Disease (CAD)
    • 2. Colorectal Cancer
    • 3. Lower Respiratory disease
    • 4. Unintentional accident
    • 5. CVA stroke
  3. Cancer in women

    1. Responsible for the highest mortality?
    2. Leading GYN-associated cancer killer
    3. Highest incidence other than skin cancer?
    • 1. Lung cancer
    • 2. Ovarian cancer
    • 3. Breast cancer
  4. Cancer in Men

    1. Responsible for the highest mortality
    2. Other than skin cancer, 2nd most common cancer in men and #2 cancer killer
    • 1. Lung Cancer
    • 2. Prostate cancer
  5. Combining cancer in men and women

    1. Leading cancer killer
    2. Second leading cancer killer
    • 1. Lung cancer
    • 2. Colorectal cancer
  6. What is the best way to advocate for change concerning disparities in your area as an ACNP






    B. Start at your facility


    • • When initiating change, you always begin at the most local level and then progress upward and outward
    • • Begin at hospital level, then community level, then the region, then the state, then national
  7. In treating patients, which comes first

    A. Medical Condition
    B. Psychosocial condition
    • In treating patients, medical condition is always treated first before psychosocial conditions
  8. In most states, the NP must notify the Department of Health of the following 5 diagnosis:
    • • Gonorrhea
    • • Chlamydia
    • • Syphilis
    • • HIV
    • • TB
  9. What are the key ethical principles?
    • 1. Nonmaleficence: the duty to do no harm
    • 2. Utilitarianism: the right act is the one that produces the greatest good for the greatest number
    • 3. Beneficence: The duty to prevent harm and promote good
    • 4. Justice: The duty to be fair
    • 5. Fidelity: the duty to be faithful
    • 6. Veracity: the duty to be truthful
    • 7. Autonomy: the duty to respect an individual’s thoughts and actions
  10. Which of the following is most important to evaluate statistical significance when reviewing the literature?






    C. Consider the sample size










    • • Level of significance: the probability level of which the results of statistical analyses are judged to indicate a statistically significant difference between groups
    • • A small confidence interval implies a very precise range of values
  11. 1. Define Quality Assurance:
    2. Define Quality improvement/Define Continuous Process Improvement
    • 1. QA- A process for evaluating the care of patients using established standards of care to ensure quality
    • 2. CQI- quality can be improved by Continually monitoring structure, process, and outcome
  12. Continuous Process Improvement measures what three measures to improve nursing
    • • Structure: inputs into care such as resources, equipment, or numbers and qualifications of staff
    • • Processes of care: Include assessments, planning, performing treatments and managing complications
    • • Outcomes: include complications, adverse events, short term results of treatment and long term results of patient health and functioning
  13. Goals set forth in Healthy people 2020 by the US department of health and human services include?
    • • Increase the quality and years of healthy life
    • • Eliminate health disparities among Americans
  14. Who is not required to follow HIPPA?
    • • Law enforcement
    • • Municipal offices
    • • CPS/Schools
    • • Employers/Workman’s comp
    • • Life insurance
  15. An insurance company is calling to verify some patient appointments. What is the first thing to look for or ask before disclosing information?
    • Is there a medical release form signed by the patient?

    o If so, then give the requested information to them
  16. Define root cause analysis
    • A tool for identifying prevention strategies to ensure safety… Why why why
  17. There is a 60-year-old patient with a new diagnosis of cancer. To appropriately plan for discharge, what should the NP do?

    a. Consult CM
    b. Consult SW
    c. Refer to oncology
    d. Refer to hospice


    e. Consult case management
    • • Case management- mobilize, monitor, and control resources that a patient uses during course of an illness while balancing quality and cost
    • • (moves patient through the system appropriately)
  18. What does Medicare A cover?
    • • covers inpatient/hospitalization
    • • skilled nursing facility services
    • • home health services associated with inpatient event
    • • hospice associated with inpatient event
    • • Most individuals qualify to receive benefits at 65 years of age
  19. What does Medicare B cover?
    • • Covers physician services
    • • Outpatient hospital services
    • • Laboratory and diagnostic procedures
    • • Medical equipment
    • • Some home health services




    •  Medicare pays 80% of the patient’s bill for physician services and the patient pays 20%
    •  NPs and CNS receive 85% of physician reimbursement for services provided in collaboration with a physician
  20. What does Medicare C cover?
    • • A+B=C
    • • Medicare Advantage
    • • Patients entitled to Part A and enrolled in Part B, are eligible to receive all of their health care services through one of the provider organizations under part C (HMOs, PPOs, etc)
  21. You notice there have been less favorable outcomes and satisfaction surveys in patients treated for sickle cell anemia. How do you approach this problem?


    a. Ask the patients treated how care can be improved
    b. Look back at prior treatment given to see how outcomes can be improved
    c. Form a standardized Tx plans for all pts that can be used by all healthcare staff
    d. Form individualized Tx plans that can be used by all healthcare staff
    C- Form a standardized Tx plans for all pts that can be used by all healthcare staff




    • Think quality assurance – standards of care
  22. You have transferred a pt to the SNF. The MD in charge at that facility calls for info about the pt’s medical care. What do you do?

    a. Direct him to look it up in the EMR
    b. Refuse to share protected health information
    c. Instruct him to call the department head
    d. Share the information he requests
    C-Share the information he requests
  23. Your patient has refused human blood products based on religious beliefs. He is now rapidly destabilizing. What do you do?


    a. Administer PRBCs as needed
    b. Call the ethics committee
    c. Continue to research alternative treatments
    d. Ask the family to give permission now that he’s unconscious
    C- Continue to research alternative treatments
  24. Discharge planning is underway for a pt who has been very debilitated after treatment for end-stage liver cancer. His wife is also debilitated and the children live out of state. What is the best choice?


    a. Hospice
    b. Home Health care
    c. SNF
    d. Private Duty RN
    C- SNF- Subacute nursing facility
  25. The medical resident obtained consent for an operative procedure. On your visit, the pt is confused/refusing the procedure.


    a. Cancel the surgery
    b. Have the wife sign another consent
    c. Call the resident to clarify the patient was not confused when he signed the first consent


    d. Consult neurology
    C- Call the resident to clarify the patient was not confused when he signed the first consent

    • Was the patient able to:

    • o Communicate, understand, reason, differentiate
    • o Remember CURD
  26. A code you are in does not go well, and staff members afterwards are criticizing each other. How do you deal with the situation?


    a.Schedule an in-service to discuss common code mistakes
    b.Meet with each team member individually
    c.set up exercises to increase collaboration during a code
    d.Meet with all who participated in the code and have a one-time briefing
    C- Meet with all who participated in the code and have a one-time briefing



    • Risk management

    o Action taking initiatives

     Correction and education
  27. Your patient is not doing well and family/wife is at bedside crying. You are preparing to talk to the family. What do you do first?


    a. Place a social work consult
    b. Explicitly explain the situation, the outcomes, and care involved.
    c. Ask if the patient has an advanced directive
    d. Set up a family meeting in a room with a specific time and date
    C- Ask if the patient has an advanced directive
  28. Appropriate level of physical exam documentation

    1. Problem focused
    2. Expanded problem focused
    • 1. A limited examination of the affected body area or organ system
    • 2. A limited examination of the affected body area or organ system and any other symptomatic or related body areas or organ systems
  29. Appropriate level of physical exam documentation

    1. Detailed
    2. Comprehensive
    • 1.An extended examination of the affected body areas or organ system and any other symptomatic or related body area or organ system
    • 2. A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area or organ system
  30. What is the normal range for serum osmolality?


    What is the Normal Urine Sodium?

    • And why do you check for it?



    What is the normal Urine specific gravity?
    • Serum osmolality (usually2X NA) (275-295mosm/kg)




    • Urine Sodium (10 to 20mEq/L)





    o Distinguish renal from non-renal causes






    • Urine specific gravity (1.010 to 1.030)
  31. Urine sodium >20 suggest?


    Urine Sodium <10 suggest?
    • • Urine NA >20 = renal salt wasting (problem with the kidneys
    • • Urine NA<10 = renal retention of sodium to compensate for extra renal fluid losses (problem other than the kidneys)
  32. 1. What is Hypotonic Hyponatremia




    2. Hypovolemic w/urine NA <10 mEq/L




    3. Hypovolemic w/urine NA>20 mEq/L
    • 1. water excess- results in low plasma osmolality, the extracellular fluid volume states may be low volume, normal volume, or high volume
    • 2. Hypovolemic w/urine NA <10 mEq/L

    • Dehydration, Diarrhea, vomiting

    3.Hypovolemic w/urine NA>20 mEq/L

    • • Low volume and kidneys cannot conserve Na
    • • Diuretics, ACE inhibitors, Mineralocorticoid deficiency
  33. 1. Hypervolemic, hypotonic hyponatremia




    2. Hypertonic Hyponatremia
    1.Hypervolemic, hypotonic hyponatremia

    • Need to restrict water

    o Edematous states, CHF, Liver disease, Advance renal failure


    2.Hypertonic Hyponatremia


    • • Serum osmolality >290 mosm/kg
    • o Hyperglycemia: Usually from HHNK
    • o Osmolality is high and the Na is low
  34. What is the management of Hyponatremia?
    • 1. Treat based on cause
    • 2. Treat underlying condition
    • 3. If hypovolemic, give NS IV
    • 4. If urine sodium>20, treat cause
    • 5. If hypervolemic, implement water restriction
    • 6. If the patient is symptomatic, give NS IV with a loop diuretic
    • 7. If CNS symptoms are present, consider 3% NS IV with loop diuretics
  35. Causes of hypernatremia


    What is the management of hypernatremia?
    • Usually due to excess water loss; always indicates hyperosmolality (ie water deficit of water). Excess sodium intake is rare


    • 1. Severe hypernatremia with hypovolemia should be treated with NS IV followed by ½ NS
    • 2. Hypernatremia with euvolemia should be treated with free water (D5W)
    • 3. Hypernatremia with hypervolemia should be treated with free water and loop diuretics, may need dialysis
  36. Hypokalemia

    1. Causes of Hypokalemia




    2. Related signs and symptoms




    3. Laboratory/diagnosis
    1. Causes

    • • chronic use of diuretics,
    • • GI loss, excess renal loss and alkalosis.
    • • Elevated serum epi in trauma pts may contribute to hypokalemia

    2. Signs/symptoms

    • Muscular weakness, fatigue and muscle cramps, constipation or ileus due to smooth muscle involvement


    • If sever (K<2.5mEq/L), may see flaccid paralysis, tetany, hyperreflexia and rhabdomyolysis (check cK)

    • 3. Laboratory/Diagnosis
    • Decreased amplitude on ECG, broad T waves, Prominent U waves, PVCs, V-tach, or V-fib
  37. Management of Hypokalemia
    • 1. Oral replacement if >2.5 mEq and no ECG abnormalities
    • 2. IV replacement at 10 mEq/hr if cannot take p.o.
    • 3. If <2.5mEq or severe signs/symptoms are present, give 40mEq/L/hr IV-check q3hrs and institute continuous ECG monitoring

    • Mg++ deficiency frequently impairs K+ correction
  38. Hyperkalemia

    1. Causes




    2. Related signs and symptoms




    3. Laboratory/diagnosis
    1. Causes include excess intake, renal failure, drugs (ie NSAIDs) hypoaldosteronism, and cell death. Shifts of intracellular K+ to the extracellular space occure with acidosis

    • K+ increases 0.7mEq/L with each 0.1 drop in pH

    2. Signs/symptoms

    • Weakness, flaccid paralysis, abd distention, diarrhea

    3. Laboratory/diagnosis – Tall Peaked waves
  39. Management of Hyperkalemia
    1. Exchange resins (Kayexalate) 

    • • As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging it for sodium ions.
    • 2. If K+>6.5mEq/L or cardiac toxicity or muscle paralysis is present, consider:
    • • Insulin 10 U with one amp D50 (pushes K+ into the cell)
  40. 1. What is the normal total calcium?
    2. What is the normal Ionized calcium?
    • 1. Total calcium= 2.2-2.6mmol/L (8.5-10.5mg/dl)
    • 2. ionized calcium= 1.1-1.4mmol/L (4.5-5.5mg/dl)
  41. 1. What is the relationship between Ionized calcium and albumin levels?
    it is useful to measure the ionized calcium level when the serum albumin is not within normal range

    • • The amt of total calcium varies with the level of serum albumin
    • • 50% of calcium is bound to albumin, a normal calcium level in the presence of a low albumin level suggest the patient it hypercalcemic
    • • Corrected calcium (mg/dl) =measured total Ca (mg/dl) + 0.8

    o Or 4.0 – serum albumin

     4.0 represents the avg albumin level
  42. Hypocalcemia

    1. Causes




    2. Related signs and symptoms




    3. Laboratory/diagnosis
    • 1. causes include hypoparathyrodism, hypomagnesemia, pancreatitis, renal failure, severe trauma, and multiple blood transfusion
    • 2. signs and symptoms – think overdrive

    • Increased DTRs, muscle/abd cramps, Trousseau’s/chvostek’s sign, convulsion,

    3. Laboratory/diagnosis: prolonged QT interval
  43. Management of Hypocalcemia
    • 1. Check pH – look for alkalosis
    • 2. Check PTH and mg levels
    • 3. If acute, IV calcium gluconate
    • 4. If chronic, oral supplements, vit D, aluminum hydroxide
  44. Hypercalcemia

    1. Causes




    2. Related signs and symptoms
    • 1. Causes include hyperparathyroidism, hyperthyroidism, Vit D intoxication, prolonged immobilization,
    • 2. Signs and symptoms – think sluggish

    • • Fatigue, muscle weakness, depression, anorexia, N/V, constipation
    • • Severe hypercalcemia can cause coma and death

     Serum Ca++ >12 is considered a medical emergency
  45. 1. pH< 7.35 with pCO2>45 indicates?
    2. And what are the causes?
    3. S/S
    4. Laboratory/diagnostics
    • 1. Respiratory acidosis
    • 2. Results from decreased alveolar ventilation – decrease RR
    • 3. Signs and symptoms

    • Somnolence and confusion, coma, hand tremors with contraction/jerking of muscles, increased ICP


    4. Lab


    • • pH<7.35, pCO2>45mmHg, Serum HCO>26mEq/L
    • • low serum chloride(<93) in chronic patients
  46. Management of Respiratory Acidosis
    • 1. Narcan – 0.04 to 2mg
    • 2. Improve ventilation, intubate if necessary (GCS<8)
    • 3. Increase rate on ventilator
  47. 1. pH> 7.45 with pCO2<35 indicates?
    2. And what are the causes?
    3. S/S
    4. Laboratory/diagnostics
    • 1. Respiratory Alkalosis
    • 2. Hyperventilation decreases arterial pCO2 and increase pH.
    • 3. Signs/symptoms

    • • Decreased cerebral blood flow ->decrease ICP
    • • Light-headedness, anxiety, paresthesia, stoking glove tingling, tetany if very severe
    • 4. Lab
    • • pH>7.45, pCO2<35, HCO3 low if chronic
  48. Management of Respiratory Alkalosis
    • 1. Manage underlying cause
    • 2. If acute hyperventilation syndrome, have patient breath into a paper bag
    • 3. Decrease rate of ventilator as needed
    • 4. Sedation may be necessary
    • 5. Rapid correction of chronic alkalosis may result in metabolic acidosis
  49. Hallmark sign of metabolic acidosis?
    How do you evaluate the cause for tx of metabolic acidosis
    • 1. Hallmark sign is low serum HCO3
    • 2. Measurement of anion gap lends some clues toward evaluating the cause and considering treatments
  50. How do you measure the Anion gap?
    And how do you determine if Metabolic acidosis is acute?
    Anion gap = [(Na+) + (K+)] – (HCO3 + Cl-)



    • If the anion gap increased, the clinical situation is generally more acute
  51. 1. Increased Anion gap indicates
    2. Normal Anion gap indicates
    1. Increased Anion gap

    • • DKA
    • • Alcoholic KA
    • • Lactic acidosis
    • • Drug or chemical anion
    • 2. Normal Anion gap
    • • Diarrhea
    • • Ileostomy
    • • Renal tubular acidosis
    • • Recovery from DKA
  52. Management/Treatment for increased and normal Anion gap
    1. Increased gap

    • • Underlying disorder must be treated
    • • Fluid resuscitation
    • • HCO3 generally not indicated if acidosis is due to hypoxia or DKA
    • • HCO3 is indicated if significant hyperkalemia is present
    • 2. Normal gap
    • • Bicitra 10-30cc with meals and h.s.
    • • This is citric acid/sodium citrate used to make urine less acidic to prevent metabolic acidosis
  53. 1. Metabolic Alkalosis is characterized by?
    2. Causes?
    3. Signs and symptoms
    4. Lab/diagnostics
    1. Characterized by high plasma HCO3 and compensatory pCO2 rarely exceeds 55mmHg

    • • If pCO2 is >55mmHg, superimposed resp acidosis is likely
    • 2. Causes- post hypercapnia alkalosis, NG suction, vomiting, diuretics
    • 3. S/S- weakness and hyporeflexia may be present if K+ is very low
    • 4. Labs – pH >7.45, HCO3>26, pCO2>45
    • • Serum K+ and Cl is decreased
    • • May see increased anion gap
  54. Management of Metabolic Alkalosis
    • 1. Correct volume deficit with NaCl and KCL
    • 2. Discontinue diuretics
    • 3. H2 blockers in patients with GI loss
    • 4. Acetazolamide 250-500mg IV q4-6hrs if volume replacement is contraindicated

    • Diamox is a water pill the helps patient pee out bicarbonate
  55. What is the Adult Rule of Nine for measuring extent of burn injury?
    • • Each arm = 9%
    • • Each leg = 18%
    • • Thorax – 18%
    • • Back = 18%
    • • Head = 9%
    • • Perineum/genitals = 1%
  56. What are the categories of burns?
    • 1. First degree= Dry, red, no blisters, epidermis only
    • 2. 2nd degree (partial thickness) = moist, blisters beyond epidermis
    • 3. 3rd degree (full thickness) = dry, leathery, black, pearly, waxy; extends from epidermis to dermis to underlining tissues, fat, muscle and/or bone
  57. What is the management of burns?
    • prophylactic intubation if there are:

    • o burns to face,
    • o singed nares or eyebrows
    • o dark soot/mucous from nares and/or mouth
    • • Fluid resuscitation 4ml/kg X TBSA (total body surface area) during first 24hrs
    • o General rule ½ of all the fluid requirement needed during the first 24 hrs are administered with the first 8hrs of injury
    • • Maintain normal temp (37-37.5C)
  58. Lyme Dz
    • • Caused by a bite of a tick
    • • Usually identified by Erythema Margins and Bullseye rash
    • •Treatment

    • o Doxycycline or Oral amoxicillin
    • o Typically resolves in about 1-2weeks with tx
  59. 1. 58yo Japanese M with CP 4/10 for 3 hours, reluctant to answer questions. Which of the following in the ED warrant admission?

    a. Age
    b. Gender
    c. Pain level
    d. Ethnicity
    Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe)
  60. 1. The patient has been in a bar fight and has a human bite on his hand. What should you do next?




    B.   Order PO abx
  61. Your pt has been taking Thorazine and now has fever, sweating, lethargy, and a temp of 39.4 (102.92):




    A. Give IVF (flush it out. This is neuroleptic malignant syndrome)
  62. 1. Your patient has a fever 3 days post op, WBC are 15,000, Blood Cx (-), and Eos 9%. What is the dx?


    a) Viral infxn
    b) Bacterial infxn
    c) Malignant hyperthermia
    d) Drug fever
    E. Drug fever (eos – allergic rxn. Normal is 1-4%)
  63. Dietary protein intake recommended for critically ill patients receiving TF/TPN is based on nitrogen balance. What does this mean?
    The concept of nitrogen balance is the difference btw nitrogen intake and loss reflects gain or loss of total body protein.

    • If more nitrogen (protein) is given to the patient than lost, the patient is considered to be anabolic or “in positive nitrogen balance”. If more nitrogen is lost than given, the patient is considered to be catabolic or “in negative nitrogen balance”.

    • o A nitrogen balance within −4 or −5 g/day to +4 or +5 g/day is usually considered “nitrogen equilibrium”.
    • • Maintain nitrogen balance along with metabolic needs
  64. 1. Which electrolyte are you most concerned about monitoring in a cachexic patient?

    a. Mag
    b. Ca
    c. Na
    d. K+
    E. K+ (refeeding syndrome. hypokalemia. also hypophosphatemia)
  65. Which electrolyte do you monitor in Refeeding Syndrome?




    A. Phos (refeeding syndrome. hypokalemia. also hypophosphatemia)
  66. 1. Which lab do you monitor daily in a patient on nutritional supplements?




    D. BMP (And monitor LFTs weekly)
  67. What two types of headaches can be treated with triptans
    Migraines and cluster headaches
  68. Best alternative therapy to decrease pain in clavicle fracture
    Therapeutic touch/reiki
  69. ● The patient has had a dog bite and 3 doses of Tetanus in the past. The NP knows the recommendation for tetanus is that the:
    patient gets a booster if they have a dirty wound and haven’t had a tetanus shot in five years.
  70. 1. The most common cause of hyponatremic hyperosmolality?




    • D. Hyperglycemia (usually from HHNK
    • Serum osmolality >290
  71. 1. Your patient has a serum osmolality of 268 mOsm/kg and a serum sodium of 134 mEq/L. His urine has Na+ less than 10 mEq/L. You know that all of the following are possible explanations except:




    • C. Diuretics
    • (Na<10 is nonrenal cause. Diuretics are associated with renal cause, Urine Na >20)
  72. 1. A 61 yr old F c/o fatigue, muscle weakness, and constipation. She adds that she had felt her heart beating “abnormally” and she has been experiencing muscle spasms on occasion. You order and EKG and find decreased amplitude and broad T waves. Occasionally you also note prominent U waves. Of the following, which is the most likely Dx?

    a. Hypokalemia
    b. Hyperkalemia
    c. Hypocalcemia
    d. Hypermagnesemia
    A- Hypokalemia

    Lab/diagnostics

    • • Decreased amplitude on ECG
    • • Broad T waves
    • • Prominent U waves
    • • PVCa, V-tach, or V-fib
  73. 1. Type 1 DM patho 
    2. Signs and symptoms
    3. Labs
    4. Management
    1. Insulin dependent/juvenile diabetes.

    • • Ketone development usually occurs
    • 2. Polyuria, polydipsia, polyphagia
    • 3. FBG >126 on 2 separate occasions, Hgb A1c >7, elevated BUN/Creatinine, Ketonemia, Ketonuria
    • 4. Ketones = insulin therapy 0.5 u/kg/day
  74. 1. Type 2 DM patho
    2. Signs and symptoms
    3. Labs
    4. Management
    1. Adult onset, circulating insulin exists enough to prevent ketoacidosis, but is inadequate to meet pt insulin needs

    • • Associated with metabolic syndrome
    • 2. Polyuria, polydipsia, recurrent vaginitis in women
    • 3. No ketones in blood/urine
    • 4. Oral antidiabetic medication- glipizide
  75. What is the somogyi effect


    How do you treat it?
    Happens when the patient is hypoglycemic at 0300 but rebounds with an elevated blood glucose at 0700


    Tx: reduce or omit the at bedtime dose of insulin
  76. What is the Dawn Phenomenon?


    How do you treat it?
    Results when tissue becomes desensitized to insulin nocturnally. The blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700




    Add or increase the at bedtime dose of insulin
  77. 1. DKA patho
    2. Signs and symptoms
    3. Labs
    4. Management
    • 1. State of intracellular dehydration as a result of elevated blood glucose levels. Acute complication of type 1 DM
    • 2. Kussmaul breathing, Altered LOC, fruity breath
    • 3. Serum glucose >250, acidosis <7.30, low HCO3, pCO2, hyperkalemia,
    • 4. NS at least 1L, ½ NS, then D5 ½ NS, IV insulin 0.1u/Kg/hr
  78. 1. HHNK patho
    2. Signs and symptoms
    3. Labs
    4. Management
    • 1. Usually occurs as a complication of type 2 DM, pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion
    • 2. Polyuria, changes in LOC, hypotension, tachycardia
    • 3. Serum glucose >600, Osmo>310, elevated Hgb A1c, normal pH
    • 4. NS IV for massive fluid replacement (6-10L), then ½ NS, followed by D5 ½ NS
  79. 1. Hyperthyroidism cause/etiology
    2. Signs and symptoms
    3. Lab
    4. Management
    • 1. Onset most commonly btw 20-40 yrs of age, Grave’s disease is the most common presentation
    • 2. Everything is increased-weight loss, heat intolerance
    • 3. Low TSH, elevated T3, T4
    • 4. Propranolol for symptomatic relief, radioactive iodine used to destroy goiters
  80. 1. Hypothyroidism cause/etiology
    2. Signs and symptoms
    3. Lab
    4. Management
    • 1. Pituitary deficiency of TSH- known as hashimoto’s thyroiditis
    • 2. Everything slows down-weight gain, cold intolerance
    • 3. High TSH, Low T3 and T4 (T4 can be normal)
    • 4. Levothyroxine 50-100 mcg qday 1-2 weeks until symptoms stabilize; > 60 years of age decrease dosage
  81. What is the treatment of thyroid crisis?
    Thyroid crisis/storm is a result of untreated hyperthyroidism


    Tx- is anti-thyroid It works by decreasing the amount of thyroid hormone produced by the thyroid gland and blocking the conversion of thyroxine (T4) to triiodothyronine (T3).


    • Propylhiouracil 150-250mg q6hrs OR Methimazole 15-25mg q6 with other instructions
    • -i.e propranolol 0.5-2gm IV q4 or PO 20-120mg q6
  82. What is the treatment for Myxedema Coma?
    Myxedema Coma is a state of decompensated hypothyroidism



    • • Protect airway: Mechanical vent as needed
    • • Fluid replacement, as needed
    • • Levothyroxine 400mcg IV X1, then 100 mcg qday
    • • Support hypotension
    • • Slow rewarming with blankets (not hyperthermia blankets): avoid circulatory collapse
    • • Symptomatic care
  83. 1. Cushing’s syndrome cause/etiology
    2. Signs and symptoms
    3. Lab
    4. Management
    • 1. ACTH hypersecretion by the pituritary or chronic administration of glucocorticoids
    • 2. Mone face with buffalo hump
    • 3. Hyperglycemia, Hypernatremia, hypokalemia, Leukocytosis, elevated plasma cortisol in the a.m.
    • 4. Depends on the cause

    • • D/C medication inducing symptoms
    • • Transphenoidal resection of a pituritary adenoma
    • • Surgical removal of adrenal tumors
    • • Resection of ACTH secreting tumors
    • • Manage electrolyte balance
  84. 1. Addison’s disease cause/etiology
    2. Signs and symptoms
    3. Lab
    4. Management
    • 1. Deficient cortisol, androgens and aldosterone, pituitary failure resulting in decreased ACTH
    • 2. Hyperpigmentation in buccal mucosa and skin creases (especially knuckles, nail beds, nipples, palmar creases, and posterior neck)
    • 3. Hypoglycemia, hyponatremia, hyperkalemia, plasma cortisol <5mcg/dl @0800, cosyntropin
    • 4. Glucocorticoid and mineralocorticoid replacement

    • Inpatient- Hydrocortisone (Solu-Cortef) 100-300 mg IV initially with NS; replace volume with D5NS at 500cc/hr X4 hrs and then taper per condition
  85. 1. SIADH cause/etiology

    2. Signs and symptoms
      3. Lab
    1. Release of ADH occurs independent of osmolality or volume dependent stimulation

    • • Inappropriate Water retention, Tumor production of ADH, Skull fractures/head trauma
    • 2. Neurologic changes from hyponatremia, hypothermia, headache, seizures, decreased DTRs
    • 3. Hyponatremia-yet euvolemic, decreased serum osmolality <280, increased urine osmolality >100, urine NA >20
  86. Management of SIADH
    • Treat underlying cause
    • - If serum Na >120 restrict total fluids to 1000ml/24
    • - If serum Na 110-120 without neuro symptoms, restrict 500ml/24h
    • - If serum Na <110 or neuro symptoms present, replace with isotonic or hypertonic saline and Lasix at 1-2mEq/h, monitor NA, K+ losses hourly and replace
  87. 1. Diabetes Insipidus cause/etiology
    1. Can be related to Central or Nephrogenic

    • • Central: related to pituritary or hypothalamus damage resulting in ADH deficiency
    • • Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH
  88. Diabetes Insipidus



    1. Signs and symptoms
    2. Lab
    3. Management
    • 1. Thirst/cravings for water (fluid intake 5-20L/day), polyuria (2-20L/day), weight loss, fatigue, changes in LOC
    • 2. Hypernatremia, Elevated BUN/Cr, serum osmo>290, Urin Osmo<100, urine specific gravity low <1.005.

    • • Vasopressin challenge test is positive in central DI and negative in Nephrogenic DI
    • 3. If serum Na>150 give D5W IV to replace ½ volume deficit in 12-24hrs – rapid lowering can cause cerebral edema
    • • When Na <150 substitute ½ or .9NS
    • • DDAVP 1-4ug IV or SQ q12-24hrs for acute situations
    • • Maintenance dose of DDAVP is 10 q12-24hrs intra nasally
  89. What is pheochromocytoma


    What are the signs and symptoms?
    Is a rare but serious disease resulting from excess catecholamine release characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla


    S/S- labile Hypertension, diaphoresis, hyperglycemia, severe headaches, palpitations, tremor, tachycardia, weight loss, postural hypotension
  90. Pheochromocytoma



    1. Lab/diagnostics
    2. Management
    1. Plasma free metanephrienes –used to help detect or rule out tumor – (fastest test)

    • • TSH is normal, CT of adrenals used to confirm and localize tumor
    • 2. Assay of urine 24hr collection-
    • 3. Surgical removal of tumor is treatment of choice
    • • Treat symptoms
  91. What is the management of Hyponatremia?
    • 1. Treat based on cause
    • 2. Treat underlying condition
    • 3. If hypovolemic, give NS IV
    • 4. If urine sodium>20, treat cause
    • 5. If hypervolemic, implement water restriction
    • 6. If the patient is symptomatic, give NS IV with a loop diuretic
    • 7. If CNS symptoms are present, consider 3% NS IV with loop diuretics
  92. Heart Sounds and Anatomical Location

    1. S1
    2. S2
    3. Systole
    4. Diastole
    • 1. S1-closure of Mitral/tricuspid (AV)valves, opening of aortic/pulmonic (similumar) valves
    • 2. S2-closure of aortic/pulmonic valves, opening of mitral/tricuspid valves
    • 3. Systole-is period between S1 and S2
    • 4. Diastole- is period between S2 and S1
  93. 1. When do you hear S3?
    2. When do you hear S4?
    1. “Ken-Tuck-y” this happen with increased fluid status

    • a. i.e CHF or pregnancy
    • 2. “Ten-ne-ssee” this happens with there are stiff ventricular walls




    • i.e MI, left ventricular hypertrophy, chronic hypertension
  94. What are the stages of Murmurs?
    • 1/6=Barely audible
    • 2/6=Audible but faint
    • 3/6=Moderately loud; easily heard
    • 4/6=Loud; associated with a thrill
    • 5/6=Very loud; heard with one corner of stethoscope off the chest wall
    • 6/6=Loudest
  95. list location and sound of Mitral stenosis and mitral regurgitation
    1. Mitral stenosis:

    • • Mid-diastolic; apical “crescendo” rumble
    • • Loud S1 murmur
    • • Low pitched
    • 2. Mitral regurgitation:
    • • S3 with systolic murmur at 5th ICS MCL(apex)
    • • May radiate to the base or left axilla
    • • Musical, blowing, or high pitched
  96. list location and sound of Aortic stenosis and Aortic regurgitation
    1. Aortic Stenosis

    • • Systolic, blowing harsh murmur at 2nd right ICS
    • • Usually radiating to the neck
    • 2. Aortic regurgitation
    • • Diastolic, blowing murmur at 2nd left ICS
  97. What are the different types of heart failure
    • 1. Systolic HF: inability to contract results in decreased CO
    • 2. Diastolic HF: inability to relax and fill results in decreased CO
    • 3. Acute HF: abrupt onset usually follows acute MI or valve rupture
    • 4. Chronic HF: develops as a result of inadequate compensatory mechanisms that have been employed over time to improve CO
  98. What are the signs and symptoms of Acute HF
    Acute HF is Left sided HF

    • • Dyspnea at rest
    • • Coarse rales over all lung fields
    • • Wheezing frothy cough
    • • Appears generally healthy except for the acute event
    • • S3 gallop
    • • Murmur of mitral regurgitation (systolic murmur loudest at the apex)
  99. What are the signs and symptoms of Chronic HF?
    Chronic HF is right sided HF

    • • JVD
    • • Hepatomegaly, splenomegaly
    • • Dependent edema: as a result of increased capillary hydrostatic pressure
    • • Paroxysmal nocturnal dyspnea
    • • Appears chronically ill
    • • Abd fullness
    • • Displaced PMI
    • • Fatigue on exertion
    • • S3 and/or S4
  100. List HF classification and Manifestations per New York Heart Association (NYHA)
    • Class 1: No limitation of physical activity
    • Class 2: slight limits of physical activity but comfortable at rest (fatigue, palpitations, dyspnea, or angina)
    • Class 3: Marked limits of physical activity but comfortable at rest – 3 pillows
    • Class 4: Severe; inability to carry out any physical activity without discomfort (signs and symptoms while at rest)
  101. Lab/diagnostics for Heart Failure
    • • Hypoxemia and hypocapnia on ABG
    • • BMP usually normal unless chronic failure is present
    • • U/A
    • • CXR=pulmonary edema, kerley B lines, effusion
    • • ECHO=will show contractile/relaxation, valve fx, EF
    • • ECG=my show underlying Problem-Acute MI, dysrhythmia
    • • PFT for wheezing during exercise
  102. Management of Heart Failure
    Non-Pharmacologic

    • • Na restriction
    • • Rest/activity balance
    • • Weight reduction

    Pharmacologic

    • • ACE inhibitors
    • • Diuretics: Thiazide, loop
    • • Anticoagulation therapy for A-fib
  103. In-patient management of Acute Pulmonary Edema
    • 1. 02 at 1-2L while awaiting ABG
    • 2. place in sitting position
    • 3. Morphine 2-4mg IVP PRN
    • 4. Lasix 40mg IVP repeat 10 mins if no response
    • 5. If severe bronchospasm present give inhaled bronchodilator
    • 6. If severe, afterload and preload reduction with nipride and hydralazine
    • 7. If CI remains low, dobutamine 2.5-20ug/kg/min;

    • if SBP<100 dopamine 5-20ug/kg/min is preferred
  104. What are the JNC7 classification Guidelines for HTN
  105. 1. HTN treatment recommendation for non-African-American
    2. HTN tx rec for African American
    3. HTN tx rec for Adults>18 with CKD with or without diabetes
    1. Non-African-American

    • • Thiazide Diuretics (screen for sulfa allergy, monitor lytes)
    • • Calcium channel blockers (monitor HR, may cause HA, flushing, or bradycardia)
    • • ACE1 (avoid ARB, avoid with K+>5.5)
    • • ARB (avoid ACE, contraindicated in pregnancy, avoid K+>5.5)
    • 2. African American
    • • Thiazide diuretics (increases excretion of Na & H2O)
    • • CCB
    • 3. Adult>18 with CKD with or without diabetes
    • • ACE (causes vasodilation, blocks Na and water retention)
    • • ARB
    • • Regardless of race or other medical condition
  106. What is the recommended treatment Goals for HTN?
    1. Treatment goal for initial treatment is 1 month

    • • Increase dose or add second drug
    • • Continue to assess monthly until goal is reached
    • • Do not use an ACE1 and ARB together
    • • Refer to hypertensive specialist if 3 or more drugs are needed
  107. What is Hypertensive Urgency?
    What is the management?
    BP > 180/110 without progressive target organ dysfunction

    • May or may not be associated with severe HA, SOB, nose bleed, or severe anxiety

    Management –oral therapies

    • • Clonidine (catapress)- preprevents  vasoconstriction, causes vasodilation, and slow HR. Do not D/C abruptly=rebound HTN
    • • Captopril (Capoten)-
    • • Nifedipine (Procardia)
    • • Loop diuretics
  108. What is Hypertensive Emergency?
    What is the management?
    BP >180/120 with target organ dysfunction

    • May occur at a lower BP if complicated by evidence of impending or progressive target organ dysfunction

    Management- IV agents, critical care, art line needed

    • • BP should be lowered to 160-180 systolic or to less than 105 diastolic (no more than 25% within minutes to 1-2hrs) and then gradually lowered over several days with oral therapy
    • • Common agents- Nicardipine, Nipride
  109. List examples that could cause Hypertensive Emergency
    • • Malignant Hypertension
    • • Hypertensive encephalopathy
    • • Intracranial hemorrhage
    • • Unstable angina
    • • Acute MI
    • • Acute LV failure with pulmonary edema
    • • Dissecting aortic aneurysm
    • • Eclampsia
  110. What is Angina?
    What are the different types?
    Angina- decreased blood flow through the vessel that leads to tissue ischemia


    Types:

    • • Stable (classic or chronic) occurs with physical activity
    • • Prinzmetal’s (variant) occurs at various times, even rest
    • • Unstable (pre-infarction, rest or crescendo, coronary syndrome)
    • • Microvascular (metabolic syndrome)
  111. What is metabolic syndrome
    Metabolic syndrome

    • is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
  112. What are the physical exam findings of Angina?
    Signs and symptoms of Angina
    Physical Exam Findings

    • • May see signs of peripheral arterial disease
    • • Levine’s sign= Clenched fist sign
    • • Transient S4 not uncommon during angina

    Signs and symptoms

    • • Characteristic chest discomfort lasting several min
    • • Exertional is usually precipitated by physical activity; subsides with rest
    • • Nitroglycerin shortens or prevents attacks
  113. Lab and diagnostic findings for Angina
    • • ECG may be normal- with down sloping or ST segment, or T-wave peak or inversion
    • • Exercise ECG
    • • Serum lipid levels should be elevated
    • • Coronary angiography is the definitive diagnostic procedure but not indicated solely for diagnosis
  114. What are the normal Serum lipid levels?
    Desirable


    Borderline heart disease risk


    High heart disease risk




    Total Cholesterol


    <200


    200-239


    >240




    LDL (bad cholesterol)


    • <130
    • optimal <100


    130-159


    >160




    HDL (good cholesterol


    >50


    40-49


    <40




    Triglycerides


    <200


    200-399


    >400
  115. What are the management guidelines for Angina?
    • • Reduction of risk factors when possible
    • • Manage diet-decrease fats, unsaturated fats
    • • Low dose coated ASA
    • • Common pharmacotherapy

    • o Nitrates, beta blockers, CCB
    • • Optimizing lipid panel with ASCVD risk chart – statin therapy
    • • Initiate drug therapy
  116. What are the indications and medication for Statin therapy?
    High intensity therapy


    Mod intensity therapy


    Low intensity therapy




    Daily dose lowers LDL-C on average by >50%


    Daily dose lowers LDL-C on average by appx 30 to 50%


    Daily dose lowers LDL-C on average, by less than 30%




    • Atorvastatin 40-80mg
    • Rosuvastatin 20-40mg


    • Atorovastatin 10-20
    • Rosuvastatin 5-10
    • Simvastatin 20-40
    • Pravastatin 40-80
    • Lovastatin 40
    • Fluvastatin 80
    • Pitavastatin 2-4


    • Simvastatin 10
    • Pravastatin 10-20
    • Lovastatin 20
    • Fluvastatin 20-40
    • Pitavastatin 1mg
  117. What are the signs and symptoms of Myocardial infarct/ACS?
    • • 1/3 of pts give a hx of alteration in typical anginal pain
    • • Most infarcts occur at rest: pain similar to angina but more severe
    • • Nitro has little effect
    • • Cold sweat; weakness, impending doom, apprehension, light headedness, Syncope, dyspnea, cough, N/V
  118. MI/ACS



    1. List physical exam findings
    Physical findings

    • • Dysrhythmia very common
    • • S4 very common, pulmonary crackles
    • • Wheezing, tachycardia
    • • Low grade fever during first 48hrs
  119. MI/ACS Labs and diagnostics
    Lab/diagnostics

    • ECG changes- Peaked T waves, ST elevation, Q wave development

    • o Lead 1, aVL or V5-6= lateral
    • o Lead 2, 3, aVL = inferior
    • o V leads or V3 and V4 = anterior
    • o V1 and V2 = septal
    • o Tall R waves = posterior
    • • Elevated cardiac enzymes
    • • ECHO for bed side assessment of wall motion and EF
    • • Leukocytosis 10,000 to 20,000 on second day
  120. What is the management for MI/ACS?
    • 1. ASA 325 table to chew
    • 2. NTG SL q5mins X3
    • 3. 02 therapy, IV @KVO 3 PIVs
    • 4. 12 lead EKG and cardiac monitor
    • 5. Morphine 2-4mg IVP
    • 6. Lasix if pulmonary edema 40mg IVP
    • 7. Metoprolol 5mg X3 @ 2min intervals, then 50mg PO q6hrs 15min after last IV dose, if not contraindicated
    • 8. ACE inhibitor most beneficial when patient has failure or a large infarct to help prevent ventricular remodeling
    • 9. Heparin vs low molecular weight heparin (Lovenox 1mg/kg), monitor therapeutic coagulation values
  121. What are the normal coagulation values?
    • • INR = 0.8 to 1.2 sec
    • • Activated coagulation time (ACT)= 70 to 120sec
    • • APTT= 28-38sec
    • • PT= 11 to 16sec
    • • PTT= 60 to 90sec
  122. What are the therapeutic coagulation values for MI/ACS?
    INR


    MI: 2.5 to 3.5 X normal – Coumadin: 2 to 3




    ACT


    150 to 190 or >300sec post PTCA/sent




    APTT


    1.5 to 2.5 X normal




    PT


    1.5 to 2.5 X normal




    PTT


    1.5 to 2.5 X normal
  123. What are the indications for pharmacologic revascularization of MI/AC?


    What would be the contraindication?
    Indication for pharmacologic revascularization

    • • Unrelieved CP (>30mins and <6hrs) WITH
    • • ST segment elevation >0.1 mV in two or more contiguous leads

    Contraindication

    • Active bleeding or risk thereof, including abnormal coagulation values
  124. Superficial Thrombosis



    1. Signs and symptoms
    2. Physical Exam findings
    3. Lab/diagnostics
    4. Management
    • 1. Sudden onset of pain
    • 2. Localized heat and erythema, low grade temp
    • 3. None
    • 4. Elevation of extremity, warm compresses, non-steroidal agents, D/C oral contraceptives
  125. Deep Thrombosis



    1. Signs and symptoms
    2. Physical Exam findings
    3. Lab/diagnostics
    4. Management
    • 1. Sudden onset of pain, pain or tenderness while walking, dull ache or tight feeling
    • 2. Edema distal to occlusion, low grade temp, skin may be cool to touch
    • 3. Ultrasound, D dimer, venography
    • 4. Bed rest with leg elevation until tenderness subsides, Lovenox 1mg/kg q12 or heparin infusion for 7 to 10 days, Coumadin for 12 weeks
  126. Peripheral Vascular Disease 



    1. Signs and symptoms
    2. Physical Exam findings
    3. Lab/diagnostics
    4. Management
    • 1. C/O calf pain, cold/numbness to extremities, progresses to pain at rest
    • 2. Shiny/hairless skin, cyanosis, pallor, ulcerations, reduced pulses
    • 3. Doppler U/S to evaluate flow, ABI, Xrays may show calcification, arteriography – most definitive test
    • 4. Smoking cessation, exercise, weight reduction, mngt or DM and hyperlipidemia, angioplasty, bypass surgery, amputation

    • Pharmacotherapy for symptom relief - Pentoxifylline (Trental), Cilostazol (Pletal)
  127. Chronic Venous Insufficiency   



    1. Signs and symptoms
    2. Physical Exam findings
    3. Lab/diagnostics
    4. Management
    • 1. Aching of the LE relieved by elevation, edema after prolonged standing, night cramps of the LE
    • 2. Trophic changes with brownish discoloration, stasis ulcers, LE edema, dermatitis may be common, cool to touch
    • 3. Nonspecifically diagnostics of CVI, R/O edema due to heart failure and other causes
    • 4. Bed rest with legs elevated to decrease edema, heavy duty elastic support stockings, weight reduction for obese, treat dermatitis or ulcers as indicated

    • Acute weeping dermatitis- wet compresses, 0.5% hydrocortisone cream after compresses, abx if bacterial infection
  128. Pericarditis

    1. Causes
    2. Signs and symptoms
    3. Physical findings
    • 1. Viruses most common cause, post MI, Renal failure, Endocarditis, drug or trauma induced, TB, septicemia
    • 2. Very localized retrosternal/precordial chest pain, pleuritic in nature

    • • Pain increased by deep inspiration, coughing, swallowing, pain relieved by sitting forward, SOB 2/2 pain
    • 3. Pericardial friction rub, fever may be present depending on underlying cause
  129. Pericarditis

    1. Lab, diagnostics
    . Lab, diagnostics

    • • ST segment elevation in all leads with return to normal in a few days
    • • Depression of PR segment highly indicative
    • • ESR elevation, positive BC if bacterial, CBC
    • • ECHO to confirm presence of pericardial fluid or other abnormalities
  130. Pericarditis


    5. Management
    Management

    • • NSAIDs are mainstay of tx- Ibuprofen 400-600q6-8hrs
    • • Indomethacin (Indocin) 25-50mg q8hrs for 2 weeks
    • • Corticosteroids are indicated only when there is total failure of high dose NSAIDS over several weeks and with relapsing pericarditis

    • o Dexamethasone 4mg IV may relieve pain in a few hrs
    • o Prednisone 60mg daily, then tapered




    • ABX in cases of bacterial infection




    • • Codeine 15-60 mg PO QID for pain
    • • Monitor for tamponade
  131. Endocarditis

    1. Causes
    2. Signs and symptoms
    3. Physical findings
    • 1. Infection of endothelial surface of the heart, usually caused by bacteria, known valvular disease recent dental work, genitourinary instruments, surgery of resp tract, HD IV catheters
    • 2. Fever and malaise, Night sweats and weight loss, General sick feeling
    • 3. Murmur often present, medium to high fever, Osler’s nodes: painful, red nodules in the distal phalanges, petechiale, purpura, pallor

    • • Splinter hemorrhages: linear, subungal splinter-appearing
    • • Janeway lesions: small macules on the palms and soles
    • • Roth spots: small retinal infarcts
  132. Endocarditis 
    4. Lab, diagnostics
    • • WBC may be normal or elevated but there is always a shift with bands
    • • ECHO for valvular damage
    • • Blood cultures for causative organism

    • o 3 separate cultures at 3 separate sites in 1 hr
    • • ESR always elevated
  133. Endocarditis management
    • • Hold abx until cultures are confirmed in stable and not acutely ill or cardiac failure
    • • In unstable patients empiric abx should be initiated

    • o PCN G 2million units IV q4
    • o Nafcillin (Unipen) 2 g IV q4
    • o Vanco- used for PCN-resistant strep and MRSA
  134. What are some Gerontology considerations for cardiovascular physiologic changes?
    • • Arterial walls thicken and stiffen-resulting in decreased compliance
    • • The heart becomes stiffer and increase in size related to LV and arterial hypertrophy
    • • Sclerosis of valves
    • • Maximum HR decrease, resting HR and CO are unaffected
    • • Baroreceptors that monitor BP become less sensitive
    • • Circulatory changes with diminished blood flow
    • • Loss of pacemaker cells with increased AV conduction time
    • • Arteriosclerosis and atherosclerosis
  135. Gerontology Considerations


    What are some Cardiovascular physical findings and/or results?
    • • Hypertension: increased risk for CVA, MI, and renal failure
    • • Heart murmurs are common
    • • Decrease cardiac reserve (may lead to orthostatic hypotension or syncope
    • • Overall diminished peripheral pulses and cool extremities
    • • Dysrhythmias
  136. 1. What disorder can be ruled out using the Cosyntropin stimulation test?




    B. Adrenal insufficiency


    Cosyntropin is a lab/diagnostic for Addison’s disease

    • • In healthy individuals, the cortisol level should increase above 18-20 µg/dl within 60 minutes on a 250 mg cosyntropin stimulation test.
    • • In Addison's disease, both the cortisol and aldosterone levels are low, and the cortisol will not rise during the cosyntropin stimulation test
  137. 1. You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness?




    B. TSH


    Lab/diagnostics for Hypothyroidism

    • • TSH usually elevated
    • • T3 and T4 decreased
    • • T3 not reliable test and T4 can also be normal in Hypothyroidism
  138. 1. For the past few months, 29 year old Janine has been gaining weight while experiencing amenorrhea and increasingly severe acne. She has gained more than 20 pounds, and you note that she is carrying her weight around the midline, w/BL purplish striae across both flanks. You suspect Cushing’s syndrome. Which of the following findings would not contribute to a Dx?




    B. After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol (In Cushings, pituitary does not respond to dexamethasone)
  139. 1. Which of the following is not a criteria of Metabolic Syndrome?




    D. BP > 140/90 (it’s ≥130/85)

    • • Waist > 40men >35women
    • • BP > 130/85
    • • TG > 150
    • • FBG> 100
    • • HDL< 40men <50women
  140. What is the treatment if a patient is hypotensive with Addison’s?
    IVF (D5NS) should be treatment of choice. Vasopressors are usually ineffective


    Inpatient management of Addison

    • • Hydrocortisone 100-300mg IV initially with NS;
    • • Replace volume with D5NS at 500cc/hr X4hrs and then taper per condition
    • • Treat underlying causes
  141. 23 yo F presents with DKA. ABD pH 7.3, glucose 520, BP 90/65, HR 120 and confused. Which of the following are not included in the initial management of DKA?



    C. Sodium bicarb is only indicated for DKA if pH <7.1



    DKA management

    • • Isotonic fluids (NS) at least 1L in first hr then 500cc/hr
    • • If glucose > 500 use ½ NS after first hr (as water deficits exceeds sodium loss)
    • • Glucose < 250 change to D5 ½ NS to prevent hypoglycemia
    • • Regular insulin
    • • Correct sever acidosis (pH<7.1) with bicarb gtt (44-48 mEq in 900ml ½ NS until pH>7.1
    • • Do not treat hyperkalemia
  142. Which of the following is contraindicated for a patient receiving a renal angiogram?



    D. Ace Inhibitor


    Ace inhibitors may cause cough, rash, taste disturbances, hyperkalemia, renal impairment etc
  143. 1.Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe?

    a. Tylenol
    b. ASA
    c. Coumadin 
    d. Plavix
    A- ASA (young with no risk factors/history)




    • Coumadin (would be used in old-65 with + RF/Hx)
  144. 1. Which of the following lipid panels shows 3 out of 4 abnormal values?

    a. TC 205, LDL 150, HDL 30, TG 300
    b. TC 150, LDL 99, HDL 35, TG 145
    c. TC 102, LDL 50, HDL 60, TG 102
    d. TC 180, LDL 136, HDL 25, TG 160
    D-TC 180, LDL 136, HDL 25, TG 160

    • • TC<200
    • • TG<150
    • • LDL<130 <100 <70
    • • HDL>50
  145. A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage?
    Stage III


    Class 3 indicates marked limitations of physical activity but comfortable at rest.
  146. Temporal Arteritis

    1. Causes
    2. Signs/Symptoms
    3. Lab/diagnostics
    4. Complications
    5. Management
    1. Inflamed or damaged temporal arteries can be linked to autoimmune response

    • • Also, known as giant cell arteritis
    • 2. Double vision, loss of vision in one eye, throbbing HA, fatigue, weakness, loss of appetite, jaw pain, fever, unintentional weight loss
    • 3. CBC, liver fx test, ESR, CRP, U/S, biopsy of the suspected artery to make a definitive diagnosis,
    • 4. Blindness, development of aneurysms, stroke, eye muscle weakness
    • 5. No cure, goal of tx is to minimize tissue damage
    • • If suspected treatment with steroids should begin immediately
  147. 62 yo M presents with angina after his daily walk.  Lipid panel reveals LDL 250, HDL 25, chol 350 and triglycerides 250. You prescribe niacin. How would you explain the mechanism of action to the pt?
    ● Niacin lowers LDL and increases HDL
  148. Peptic Ulcer Disease



    1. Causes
    2. Signs and Symptoms
    3. Physical findings
    4. Lab/diagnostics
    • 1. H.pylori, NSAIDs, ASA, and glucocorticoids
    • 2. Gnawing epigastric pain,

    • - Duodenal – relief of pain with eating
    • - Gastric – pain worsens with eating
    •   3.   Mild epigastric tenderness
    •          -     GI bleeding- melena, hematemesis or coffee emesis
    •   4.    endoscopy after 8-12 weeks of tx, H. pylori testing
  149. Peptic Ulcer Disease



    1. Out-patient management
    1. Acid-antisecretory agents

    • • H2 Receptor Antagonists –Zantac
    • • Proton Pump Inhibitors – protonic
    • 2. Mucosal Protective Agents
    • • Give 2hrs apart from other meds
    • • Sucralfate, pepto-bismol
    • 3. H. pylori eradication therapy- 2 abx +PPI or bismuth
    • • Flagyl, clarithromycin, amoxicillin
  150. Peptic Ulcer Disease



    1. In patient management
    • 1. IV access- fluid/blood products
    • 2. Baseline labs- CBC, PT/PTT, BMP
    • 3. O2
    • 4. Endoscopy; GI angiography
    • 5. Foley cath
    • 6. NPO/Nasogastric tube for lavage
    • 7. Upright or decubitus films-show free air in 75% cases
    • 8. Monitor abdomen- quiet, rigid with rebound tenderness
    • 9. IV H2 blockers
    • 10. If coagulopathy present, give FFP
    • 11. If thrombocytopenia (<50,000) exist, transfuse platelets
    • 12. GI/surgical evaluation
  151. GERD



    1. Causes
    2. Signs/Symptoms
    3. Diagnostic
    • 1. Incompetent lower esophageal sphincter, delayed gastric emptying
    • 2. Retrosternal burning, belching, dysphagia, hiccoughs, may be relieved by sitting up, antacids, water or food
    • 3. EGD to rule out cancer, Barrett’s esophagus, peptic ulcer
  152. Management of GERD
    1. Non-pharm

    • • Elevate head of bed, avoid alcohol, stop smoking
    • • Avoid spices caffeine, and peppermint
    • 2. Med
    • • Antacids PRN,
    • • H2 blockers, PPI,
    • 3. GI/surgical consult PRN
  153. Hepatitis

    1. Transmission

    • Hep A
    • Hep B
    • Hep C
    1. Hep A

    • • Contaminated water and food
    • • Blood and stool are infectious during 2-6 week
    • 2. Hep B
    • • Present in serum, saliva, semen, and vaginal
    • • Transmitted via blood & blood products sexual activity, and mother-fetus
    • 3. Hep C
    • • Source of infection uncertain
    • • Traditionally associated with blood transfusion/ IV drug use
  154. Hepatitis

    1. Signs and symptoms
    2. Laboratory/diagnostics
    1. Signs and symptoms

    • • Pre-icteric- fatigue, malaise, anorexia, N/V, HA
    • • Icteric- weight loss, jaundice, pruritus, RUQ pain, clay colored stool, dark urine

    • o Low grade fever, hepatosplenomegaly
    • 2. Lab/diagnostic

    • • WBC-low to normal
    • • U/A- Proteinuria, bilirubinuria
    • • Elevated AST and ALT (500-2000)
    • • LDH, bilirubin, AKP, and PT normal or slightly elevated
  155. Hepatitis A, B, and C serology test interpretation
    1. Hepatitis A

    • • Active Hep A = Anti-HAV, IgM
    • • Recovered Hep A = Anti-HAV, IgG 
    • 2. Hepatitis B
    • • Active Hep B = HBsAg, HBeAg , Anti-HBc, IgM
    • • Chronic Hep B = HBsAg, Anti-HBc, Anti-HBe, IgM, IgG
    • • Recovered Hep B = Anti-HBc, Anti-HBsAg
    • 3. Hepatitis C
    • • Acute Hep C = Anti-HCV, HCV RNA
    • • Chronic Hep C = Anti-HCV, HCV RNA
  156. Management of Hepatitis
    • 1. Generally supportive; rest during active phase
    • 2. Increased fluids to 3000 to 4000 ml/day
    • 3. Avoid alcohol or other drugs detoxified by the liver
    • 4. No/low protein diet
    • 5. Oxazepam (Serax) if sedation is necessary
    • 6. Vitamin K for prolonged PT (>15 sec)
    • 7. Lactulose 30ml orally or rectally for elevated ammonia levels: Hepatic encephalopathy
  157. Diverticulitis

    1. Signs and symptoms
    2. Physical findings
    3. Lab/diagnostics
    • 1. LLQ pain, constipation or loose stool, N/V
    • 2. Low grade fever, LLQ tenderness,

    • • Patients with free perforation present with a more dramatic picture and peritoneal signs
    • 3. Leukocytosis, Elevated ESR, stool heme,
    • • Sigmoidoscopy shows inflamed mucosa
    • • May consider CT scan to evaluate abscess
    • • Plain abd films for evidence of free air
  158. In-Patient management of Diverticulitis
    • 1. NPO dependent upon condition
    • 2. IV fluids to maintain hydration
    • 3. IV abx – flagyl, Cipro, ceftazidime, clindamycin, ampicillin
    • 4. If significant GI bleeding present, treat like PUD
    • 5. Surgical consultation
  159. Cholecystitis



    1. Signs and symptoms
    2. Physical findings
    3. Lab/diagnostics
    • 1. Precipitated by large or fatty food, sever pain epigastric/RUQ
    • 2. Physical findings

    • • Murphys sign deep pain under right rib cage
    • • RUQ tenderness to palpation
    • • Muscle guarding and rebound pain
    • • Fever
    • 3. Lab/diagnostic
    • • WBC 12-15000
    • • Elevated bili, ALT, AST, LDH, AKP Amylase
    • • Pain films show gallstones, HIDA scan, U/S gold standard
  160. Cholecystitis management
    • 1. Pain management
    • 2. NGT for gastric decompression
    • 3. Maintain NPO
    • 4. Crystalloid solutions
    • 5. IV abx, broad spectrum such as PCN
    • 6. Surgical consultation for lap choley
  161. Acute Pancreatitis



    1. Causes
    2. Signs and symptoms
    3. Physical findings
    4. Lab diagnostics
    • 1. Gallbladder disease, heavy alcohol use, hypercalemia
    • 2. Abrupt onset worsened by walking and lying supine

    • • Pain improved by sitting and leaning forward
    • • Pain radiates to the back
    • • N/V, weakness, sweating, anxiety
    • 3. Under abd tender to palpation, distended abd, absent BS
    • • Grey Turner’s sign- flank discoloration
    • • Cullen’s sign- umbilical discoloration
    • 4. Elevated WBC, hyperglycemia, LDH & AST, amylase and lipase, BUN and coagulation,
    • • Hypocalcemia- levels <7 watch for chvostek & trousseau’s sign
    • • Elevated C-reactive protein suggest necrosis, CT
  162. Acute Pancreatitis management
    1. Prognostic signs at admission                                                   GWGLA HBCABE

    • • Greater than 55yrs   George Washington Got Lazy After He Broke C_A_B_E
    • • WBC>16000
    • • Glucose >200
    • • LDH>350
    • • AST>250
    • 2. Prognostic signs during first 48hrs
    • • Hct drop of >10
    • • BUN increase >5
    • • Calcium <8
    • • Arterial 02<60
    • • Base deficit>4
    • • Estimated fluid sequestration >6,000
    • 3. Bed rest, NPO, IV volume repletion, NG suction, pain control
    • 4. Once pt is pain free and has BS, may start clear diet
  163. Bowel Obstruction

    1. Signs and symptoms
    2. Physical findings
    3. Lab/diagnostic
    • 1. Cramping periumbilical pain initially, later becomes constant and diffuse, vomiting within mins
    • 2. Minimal distention (proximal), pronounced abd distention (distal), high pitched, tinkling BS, unable to pass stool/gas
    • 3. Elevated WBCs and values consistent with dehydration,

    • Plain films show dilated loops of bowel and air-fluid levels

    • o Horizontal pattern in SBO
    • o Frame pattern in LBO
  164. Management of Bowel Obstruction
    • 1. Fluid resuscitation
    • 2. NGT suction
    • 3. Broad spectrum abx
    • 4. Surgical intervention in all cases of complete obstruction
    • 5. In partial obstruction, may treat medically
  165. Ulcerative Colitis



    1. What is it
    2. Signs and symptoms
    3. Lab/diagnostic
    4. Management
    • 1. Diffuse mucosal inflammation of the colon, involves the rectum and may extend upward involving the whole colon with symptomatic episodes and remission
    • 2. Bloody diarrhea is the hallmark symptom
    • 3. Stool studies are negative, sigmoidoscopy establishes diagnosis
    • 4. Management

    • • Mesalamine (Canasa) sup or enema for 3-12 wks
    • • Hydrocortisone sup and enema
    • • iV abx cipro and flagyl
  166. Mesenteric Infarct



    1. What is it
    2. Causes
    3. s/s
    4. lab/diagnostic
    5. management
    • 1. result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of the bowel
    • 2. arterial or venous, coagulopathy following recent surgery
    • 3. sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings

    • • N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
    • 4. Lab/diagnostics
    • • Elevated amylase, leukocytosis, abd films, CT
    • 5. Emergent surgical intervention
  167. Appendicitis

    1. Signs and symptoms
    2. Physical findings
    3. Lab/diagnostics
    4. Management
    • 1. Colicky umbilical pain-pain shifts to RLQ after several hrs
    • 2. RLQ guarding with rebound tenderness,

    • • Psoas sign-pain with rt thigh extension
    • • Obturator sign- pain with internal rotation of flexed right thigh
    • • Positive Rovsing’s sign- RLQ pain when pressure is applied to the LLQ
    • 3. CT or U/S is diagnostic, WBC 10 to 20
    • 4. Management
    • • Surgical treatment, IV broad spectrum abx, IV fluids, Pain management
  168. Gerontology consideration with GI disorders
    1. Physiologic changes

    • • Decreased thirst and taste perception
    • • Decreased gastric motility with delayed emptying
    • • Impaired defecation signal, decreased liver size
    • 2. Possible findings and/or results- risk of
    • • Poor nutrition
    • • Altered drug absorption
    • • Decreased or impaired metabolism of drugs
    • • Dysphagia, NSAID induced ulcer
    • • Constipation
  169. 1. Which of the following displays a current or recent Hepatitis A infection?




    B. Anitbody-specific to IgM


    • Anti-HAV and IgM implies recent infection
    • IgG implies previous exposure and advises immunity
  170. 1. Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓BS. What is the diagnosis?
    Mesenteric Infarct


    sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings


    • N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
  171. Crohns

    1. What is it
    2. Presentation
    3. Treatment
    • 1) Mucosal inflammation and ulceration, structuring fistula development, and abscess formation
    • 2) Pt may present with a combo of the following:

    • • Chronic inflammation, intestinal obstruction, fistula formation, abscess formation
    • 3) Meds
    • • Aminosalicylates- mesalamine
    • • Corticosteroids
    • • Immunomodulatory- Tacrolimus
    • • Anti-TNF Monoclonal Antibodies – flagyl, Cipro
  172. Who is at the risk for both toxic and megacolon
    Crohns and Ulcerative Colitis
  173. Lower UTI



    1. Signs and symptoms
    2. Laboratory/diagnostics
    3. Management
    1) Signs and symptoms

    • • Dysuria, frequency, urgency, nocturia
    • 2) Laboratory/diagnostics
    • • U/A>10 WBC, nitrates, esterase detection
    • 3) Management
    • • 3 day abx therapy

    • o Bactrim, Cipro, augmentin
    • o Preganancy= amoxicillin, macrobid, Keflex
  174. Upper UTI



    1) Signs and symptoms
    2) Laboratory/diagnostics
    3) Management
    1) Signs and symptoms

    • • Flank, low back, abd pain, fever/chills, N/V AMS
    • 2) Laboratory/diagnostics
    • • U/A=WBC cast, elevated ESR with pyelonephritis
    • 3) Management
    • • 14 day vs 6 week course of abx

    • o TMP/SMX; Bactrim, Cipro, augmentin, gentamicin
    • o Pts with suspected pyelo with N/V or more severe illness should be hospitalized
  175. Renal insufficiency



    1) Symptoms/general concepts
    2) Stages of renal failure
    1) Symptoms/general concepts

    • • Pts are often asymptomatic until the late stages of disease
    • • There is a direct relationship btw nephron loss and renal fx
    • • Systemic changes not evident until overall renal fx is <20%-25% of normal
    • 2) Stages of renal reserve
    • • Diminished Renal reserve: 50% nephron loss, Cr doubles
    • • Renal insufficiency: 75% nephron loss, mild azotemia present
    • • End-Stage Renal disease: 90% nephron damage, azotemia, metabolic alterations
  176. Renal insufficiency



    1) Types – acute and chronic
    2) Management
    1) Types

    • Acute: Sudden impairment

    • o BUN increases out of proportion to cr
    • o Due to obstruction, ATN, or contrast media
    • o Reversible with proper therapy

    • Chronic: progressive impairment over months to yrs

    • o Steady increase in BUN and cr (10:1 ratio)
    • o Intrinsic kidney damage which is irreversible but progression can be slowed
  177. Management for Renal insufficiency
    1) Acute renal insufficiency

    • • Determine cause and intervene to prevent permanent kidney damage
    • 2) Chronic renal failure
    • • Institute mechanism to slow the progression of the renal failure

    • o Controlling HTN and DM
    • o Reducing dietary protein intake to 40g/day
    • o Modifying the dosage of medication
  178. Causes of Acute renal failure
    1) Pre renal (outside kidney)

    • Caused by conditions that impair renal perfusion-

    o Shock, dehydration, cardiac failure, burns, diarrhea, vasodilation/sepsis



    No damage to renal tubules



    2) Intrarenal (renal or intrinsic)

    • Disorders that directly affect the renal cortex or medulla

    • o Allergic disorders, obstruction of renal vessels, nephrotoxic agents, mismatched blood transfusions
    • 3) Post renal

    • Results from urine flow obstruction

    • o Mechanical- calculi, tumors, urethral strictures, BPH
    • o Functional- neurogenic bladder, diabetic neuropathy
  179. What is the criteria for Dialysis?
    • A- acidosis
    • E- electrolyte disarray
    • I- Intoxicants
    • O- Fluid overload
    • U- uremic symptoms (Nausea, seizure, pericarditis, bleeding)


    Do dialysis early – Keep BUN <100 Cr <10
  180. What is the management for acute renal failure?
    1) Prerenal:

    • • Expand intravascular volume, consider dopamine
    • 2) Intrarenal:
    • • Maintain renal perfusion, stop nephrotoxic drugs, renal replacement therapies as indicated
    • 3) Postrenal:
    • • Remove source of obstruction, check Foley, CT, renal ultrasound
  181. Renal Calculi: Nephrolithiasis



    1) Signs and symptoms
    2) Laboratory/diagnostics
    3) Management
    1) Signs and symptoms

    • • Frequency/urgency, Pain, bleeding, colic like flank pain, radiating pain to groin indicates the the stone has passed to the lower third of the ureter
    • 2) Lab/diagnostics
    • • Serum urine= elevated minerals responsible for stone formation (calcium, uric acid, creatinine, oxalate)
    • • Abd X-ray, CT should be performed
    • 3) Management
    • • Depends on stone type, location, extent of obstruction, fx of kidneys

    • o Analgesia and hydration – morphine, toradol, reglan
    • o If stone is obstructing outflow or accompanied by infection, removal is indicated
  182. Benign Prostatic Hypertrophy



    1) Signs and symptoms
    2) Laboratory/diagnostics
    3) Management
    1) Signs and symptoms

    • • Frequency, dysuria, urgency, nocturia, incontinence, hesitancy dribbling retention
    • 2) Laboratory/diagnostic
    • • U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
    • 3) Management
    • • Consult urologist, Alpha blocker-flomax,
    • • 5-alpha reductase inhibitor- proscar to shrink prostate
    • • TURP if urinary symptoms persist
    • • Avoid meds the worsen signs/symptoms of BPH

    o Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
  183. Gonorrhea

    1) Signs and symptoms
    2) Lab/diagnostic
    3) Treatment
    1) Signs/symptoms

    • • Females often asymptomatic (80%), dysuria, urinary frequency, green vaginal discharge, White/yellow-green penile discharge
    • 2) Lab
    • • Fram stain of discharge smear shows gram negative dipliococci and WBC
    • 3) Treatment-
    • • Rocephin 250 IM X1 dose to tx gonorrhea +
    • • Zithromax 1 g orally X1 to cover chlamydia
    • • Report to health department
  184. Syphilis



    1) Clinical stages
    1) Stages

    • • Primary- painless ulcer, located at site of exposure
    • • Secondary- flu-like symptoms, arthralgia, lymphadenopathy
    • • Latent- seropositive, but asymptomatic
    • • Tertiary- cardiac insufficiency, meningitis, aortic aneurysm, hemiplegia, hemiparesis
  185. Management of syphilis
    Treatment


    • Primary, secondary or early syphilis less than 1 yr

    o PCN G 2.4 IM

    • Late, latent and inderminate length; tertiary stage

    o PCN G 2.4 IM weekly X3

    • PCN allergy

    • o Doxycycline 100mg PO twice a day
    • o Erythromycin 500mg PO 4 Xday

    • Report to health department
  186. Chlamydia



    1) Signs and symptoms
    2) Lab/diagnostic
    3) Treatment
    1) Signs/symptoms

    • • Often asymptomatic, dysuria, thick cloudy penile discharge, painful intercourse
    • 2) Lab/diagnostic
    • • Chlamydia culture is most definitive test
    • 3) Treatment
    • • Azithromycin 1 g PO X1 dose or
    • • Doxycycline 100 PO twice a day X7 days
    • • Report to health department
  187. Vulvovginitis


    Signs/ symptoms of trich, BV, candidiasis and treatment
    1) Trichomonas- frothy yellowish-green discharge, pruritus, strawberry patches on cervix and vagina

    • • Flagyl 2 g PO single dose; 500mg PO bid x7 days
    • 2) Bacterial vaginosis- fishy smelling discharge, vaginal spotting
    • • Flagyl 2g PO single dose; 500mg PO Bid x7days; gel 0.75%, 5g intravaginally BID X5 days
    • • Clindamycin vaginal cream 2% 5g intravaginally at bedtime X7days; 300mg PO BID X7days
    • 3) Candidiasis-thick white, crud like discharge
    • • Monostate 1% 5g intravaginally at bedtime X7days
    • • Terconazole 80mg suppositoru at bedtime X3days
  188. What are the lab/diagnostics for prerenal disease, Inrarenal disease and post renal disease?



    1. Serum BUN
    2. Urine Sodium
    3. Specific Gravity
    4. Urinary sediment
    5. Fractional excretion of Sodium (FEna)
    Diagnostic test


    Prerenal disease


    Intrarenal disease


    Postrenal disease




    • Serum BUN
    • Cr ratio


    >10:1


    10:1


    10:1




    Urine sodium


    <20


    >40


    Usually >40




    Specific gravity


    >1.015


    <1.015


    <1.015




    Urinary sediment


    Normal/few hyaline casts


    Granular/white casts


    Normal




    FEna


    <1


    >3


    Usually >3
  189. What is the normal value of?



    1) HgB
    2) Hct
    3) TIBC
    4) Serum Iron
    5) MCV
    6) MCH
    7) MCHC
    • 1) Hgb = 14-18 (males) 12-16 (female)
    • 2) Hct = 40-54% (males) 37-47% (females)
    • 3) TIBC = 250-450
    • 4) Serum Iron = 50-150
    • 5) MCV = volume/size – 80-100
    • 6) MCH = amt/wt – 26-36%
    • 7) MCHC = consentration/color – 32-36%
  190. What are the characteristics and values of MCV?




    What are the characteristics and values of MCHC?
    • 1) Microcytic= <80
    • 2) Normocytic= 80-100
    • 3) Macrocytic= >100




    • 1) Hypochromic <32%
    • 2) Normochromic 32-36%
    • 3) Hyperchromic >36%
  191. 1) What are the differential diagnosis for Low MCV?




    2) What are the differential diagnosis for high MCV?




    3) What are the differential diagnosis for normocytic?
    1) Microcytic- Iron deficiency anemia and thalassemia




    2) Macrocytic- B12 or folate deficiency, alcoholism, liver failure, and drug effects




    3) Anemia or chronic disease, sickle cell disease, renal failure, blood loss, and hemolysis
  192. Iron deficiency Anemia



    1) Signs and symptoms
    2) Lab/diagnostic
    3) Management
    1) Symptoms

    • • As the Hct falls- Pica, dyspnea and mild fatigue with exercise, spoon shaped nails
    • 2) Lab
    • • Low hgb, hct, MCV, MCHC, RBC, serum iron, serum fr
    • • High TIBC, RDW
    • 3) Management
    • • Oral ferrous sulfate 300-325mg 1-2hrs after meals
  193. Thalassemia



    1) What is it 
    2) Lab/diagnostic
    3) Management
    • 1) Genetically inherited disorders resulting in abnormal Hgb production and microcytic, hypochromic anemia
    • 2) Lab/diagnostic

    • • Low hgb, MCV, MCHC,
    • • Normal TIBC and ferritin
    • 3) Management
    • • No tx for mild to moderate, transfusion or splenectomy for severe
    • • Iron is contraindicated as iron overload can result
  194. Folic Acid Deficiency



    1) Signs and symptoms
    2) Lab/diagnostics
    3) Management
    1) Signs and symptoms

    • • Fatigue, dyspnea on exertion, HA, Glossitis,
    • 2) Laboratory/diagnostics
    • • Low Hct, RBC, serum folate
    • • Elevated MCV
    • • Normal MCHC
    • 3) Management
    • • Folate 1mg PO Q day
  195. Pernicious Anemia



    1) Signs and symptoms
    2) Lab/diagnostics
    3) Management
    1) Signs and symptoms

    • • Neuro like symptoms
    • 2) Lab/diagnostics
    • • Low Hgb, Hct, RBC, serum B12
    • • Increased MCV
    • 3) Management
    • • B12 (cyanocobalamin) 100mcg IM daily X1week
  196. Anemia of chronic disease



    1) Signs/symptoms
    2) Lab/diagnostics
    3) Management
    1) Signs/symptoms

    • • Fatigue, weakness, dyspnea on exertion, anorexia
    • 2) Lab/diagnostics
    • • Low Hgb, serum iron, TIBC
    • • High serum ferritin
    • • Normal MCV and MCHC
    • 3) Management
    • • Treat associated disease, provide nutritional support
  197. Leukemia 



    1) Signs/symptoms
    2) Lab/diagnostics
    3) Management
    1) Signs and symptoms

    • • May be asymptomatic, weight loss, fatigue
    • 2) Lab/diagnostics
    • • Elevated ESR, bone marrow aspiration is required to confirm the diagnosis
    • 3) Management
    • • Chemo, bone marrow transplant, control symptoms
  198. Classifications of leukemia
    1) Acute Nonlymphocytic Leukemia/Acute Myelogenous Leukemia

    • • Constitutes 80% of acute leukemia in adults
    • 2) Acute Lymphocytic Leukemia (ALL)
    • • 90% remission in children,

    • pancytopenia with circulating blast (hallmark of disease)
    • 3) Chronic Lymphocytic Leukemia (CLL)
    • • Most common in adults
    • • Lymphocytosis (hallmark disease)
    • 4) Chronic Myelogenous (CML)
    • • Philadelphia chromosome seen in leukemic cells (hallmark of disease)
  199. Lymphoma


    Diagnosis/staging
    1) Stage 1

    • • Disease localized to single lymph node or group
    • 2) Stage 2
    • • More than 1 lymph node group involved; confined to one side of the diaphragm
    • 3) Stage 3
    • • Lymph nodes or spleen involved; occurs on both sides of the diaphragm
    • 4) Stage 4
    • • Liver or bone marrow involvement
  200. What are the types of Lymphoma?
    1) Non hodgkins lymphoma

    • • Cause is unknown, may have viral etiology
    • • Often presents with lymphadenopathy
    • • Most common neoplasm btw 20-40 yrs
    • 2) Hodgkins disease
    • • Cause is unknown
    • • More common in males; avg age is 32 yrs
    • • Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups
    • • Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
  201. Idiopathic thrombocytopenia Purpura



    1) Lab/diagnostic
    2) Management
    3) Other consideration
    1) Lab/diagnostic

    • • Bone marrow analysis
    • 2) Management
    • • <20,000
    • • high dose corticosteroids may elevate within 2-3 days
    • • IV gamma globin 2-3 days, plt transfusion
    • 3) Other consideration
    • • Thrombocytopenic precaution
    • • Heparin induced thrombocytopenia purpura HIT

    o Argatroban, Lepirudin
  202. Disseminated Intravascular Coagulation (DIC)



    1) Associated conditions
    2) Signs and symptoms
    3) Lab/diagnostics
    1) Associated conditions

    • • Infection/sepsis, liver disease, massive trauma, extensive burns, shock, obstetrical complications, leukemia
    • 2) Signs and symptoms
    • • Bleeding vs thrombosis
  203. Lab/diagnostics for DIC
    • • Increase PT/PTT/FDP and low fibrinogen/plt
    • • Thrombocytopenia (pls <150,000)
    • • Hyperfibrinogenemia (fibrinogen <170)
    • • Increased fibrin degradation product FDP (>45 or >present at >1:100)
    • • Prolonged PT >19sec
    • • Prolonged PTT >42sec
    • • increased FDPs give a predictive accuracy of 96% for diagnosing DIC
  204. Management of DIC
    • 1) Goal- treat underlying condition and control bleeding
    • 2) transfusion for severe bleeding

    • • Platelets (for thrombocytopenia),
    • • FFP (to replace clotting factors) and
    • • cryo (to maintain fibrinogen levels)
    • 3) overall therapy is aimed at cessation of bleeding, increasing plasma fibrinogen and the platelet count, and decreasing FDRs
  205. 1. Which of the following is not an indicator of prerenal failure?




    D. Urine Na > 40  (this is postrenal)
  206. 1. 53 yo M  c/o dribbling and nocturia. You suspect BPH. PSA is 3.2. What confirms the dx?
    Transrectal ultrasound

    1) Laboratory/diagnostic

    • • U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
    • 2) Management
    • • Consult urologist, Alpha blocker-flomax,
    • • 5-alpha reductase inhibitor- proscar to shrink prostate
    • • TURP if urinary symptoms persist
    • • Avoid meds the worsen signs/symptoms of BPH


    Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
  207. 1. Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure?
    1. Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen)
  208. What is azotemia?
    Azotemia – an excess of nitrogenous waste products in the blood- high levels of uria


    BUN>100= tx dialysis
  209. ● What should the dietary protein requirement be with chronic renal insufficiency?
    ● <40g/day
  210. 1. Which lab value is expected in iron deficiency anemia?




    B. Elevated TIBC (>450)
  211. 1. Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not expected in her anemia?



    a. Low serum ferritin (<15)
    b. Low Hgb
    c. TIBC 300
    d. MCHC < 32%
    E. Low serum ferritin (<15)
  212. 1. 32 yo presents with c/o fever, night sweats and unexplained wt loss. Upon exam you note a swollen cervical lymph node. A subsequent CXR reveals mediastinal adenopathy. Which of the following is the dx?
    Hodgkin’s lymphoma


    Hodgkins disease


    • • Cause is unknown
    • • More common in males; avg age is 32 yrs
    • • Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups
    • • Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
  213. ● Know coagulation labs re: what blood products to give:
    • o PLT (150-400K) give PLT
    • o Clotting factors give FFP,(Factors V, VIII, PT:  INR)
    • o Fibrinogen (if <170 mg/dL) give Cryoprecipitate
  214. Lymphoma present in R axilla and R neck. What stage?
    Stage II – same side of diaphragm.
  215. What is Von Willenbrand disease and tx for sugery
    Lack of factor VIII


    Give DDAVP preoperatively
  216. What are the 12 Cranial nerves and their fx
    • 1. Olfactory= smell
    • 2. Optic= vision
    • 3. Oculomotor= most EOMs opening eyelids, pupillary constriction
    • 4. Trochlear= down and inward eye movement
    • 5. Trigeminal= Muscles of mastication, sensation of face, scalp, cornea, mucus, membranes and nose
    • 6. Abducens= lateral eye movement
    • 7. Facial= move face, close mouth and eyes, taste, saliva and tear secretion
    • 8. Acoustic= hearing and equilibrium
    • 9. Glossopharyngeal= speech sounds, gag reflex, carotid reflex, swallowing, taste
    • 10. Vagus= talking, swallowing, general sensation from the carotid body, carotid reflex
    • 11. Spinalaccessory= movement of trapezius, and sternomastoid muscles
    • 12. Hypoglossal= moves the tongue

    Type- Some, say, marry, money, but, my, brother, says, big, bras, matter, most
  217. What are the components of the mental status exam
    • 1. Appearance
    • 2. Behavior
    • 3. Cognition
    • 4. Thought processes
  218. Transient Ischemic Attack (TIA)



    1. Characteristic
    2. Signs and symptoms
    3. Lab/diagnostics
    • 1) TIA-period of acute cerebral insufficiency lasting less than 24hrs without residual deficits
    • 2) Signs and symptoms

    • • Altered vision, altered speech, motor impairment, sensory deficits, cognitive and behavioral abnormalities
    • 3) Lab/diagnostics
    • • CT is best in distinguishing btw ischemia, hemorrhage and tumor
    • • MRI is superior to CT in detecting ischemic infarcts
    • • Echocardiogram, Carotid Doppler and ultrasonography
    • • Cerebral angiography
  219. TIA classifications
    1) Vertebrobasilar- as a result of inadequate blood flow from vertebral arteries

    • • Presentations include: vertigo, ataxia, dizziness, visual field deficits, weakness, confusion
    • 2) Carotid- Due to carotid stenosis
    • • Presentations include: Aphasia, dysarthria (slurred speech), altered LOC, weakness, numbness
  220. Management of TIA
    • 1) Aspirin
    • 2) Plavix 75mg/day by mouth
    • 3) Ticlopidine: associated with agranulocytosis, thrombotic thrombocytopenia purpura and GI intolerance
    • 4) Assess for HTN
    • 5) Carotid endarterectomy decreases the risk of stroke and death in pts with recent TIA
  221. CVA


    Signs and symptoms of:



    1) CVA infarct
    2) Hemorrhagic CVA
    1) CVA infarct

    • • Changes in LOC, Motor weakness or paralysis
    • • Visual alterations, changes in vital signs
    • 2) Hemorrhagic CVA
    • • Signs seen on the opposite side of infarct or hemorrhage involvement
    • • Increase ICP, altered mentation, HA, vomiting
  222. Difference in signs and symptoms of hemorrhagic CVA
    1) Left (dominant) hemisphere involvement

    • • See right hemiparesis, aphasia, dysarthria, difficulty reading and writing
    • 2) Right (non-dominant) hemisphere involvement
    • • See left hemiparesis, right visual field changes, spatial disorientation
  223. Laboratory and diagnostics for CVA
    • 1) Head CT
    • 2) Cerebral angiography – images of blood vessels in brain
    • 3) Lumbar puncture for grade 1 and 2 aneurysm to detect blood in CSF

    • LP contraindicated with large bleeds due to brain stem herniation
  224. Management of CVA
    1) For thrombolytic strokes

    • • Fibrinolytic therapy is indicated less than 3-4.5 hrs of symptoms
    • 2) Surgical evacuation of bleeding
    • 3) Systemic BP stability – avoid hypotension, may exacerbate ischemic deficits
    • 4) Maintain Map 110-130 to treat cerebral vasospasm
    • 5) Nimotop- calcium channel antagonist, helps to counter vasospasm by preventing calcium from entering smooth muscle cells and causing contraction
    • 6) ICP goal <20
  225. Seizures


    Seizure classification for

    1) Partial

    • Simple
    • Complex
    1) Simple partial – common with cerebral lesions

    • • No loss of consciousness
    • • Motor symptoms often start in single muscle group and spread to entire side of body
    • • Paresthesia, flashing lights, vocalizations, hallucinations
    • 2) Complex partial
    • • Any simple partial followed by impaired level of consciousness
    • • May have aura, starring, or automatisms such as lip smacking and picking at clothing
  226. Seizures


    Seizure classification for

    1) Generalized

    • Absence (petite mal)
    • Tonic-clonic (grand mal)
    1) Absence- sudden arrest of motor activity with blank stare

    • • Common discovered in children/adolescents; begin and end suddenly
    • 2) Tonic-clonic
    • • May have aura
    • • Begins with tonic contraction (repetitive muscle contraction) loss of consciousness, then clonic contraction (maintained contraction of muscle)
    • • Last 2-5mins, followed by postictal period
  227. What is status Epilepticus
    • • Series of grand mal seizures of >10 min duration
    • • Medical emergency
    • • May occur when patient is awake or asleep
    • • Pt never gains consciousness between attacks
    • • Life threatening
  228. Management of seizures
    • 1) Parenteral anticonvulcents are used to stop convulsive seizures rapidly
    • 2) benzodiazepines: Diazepam (valium) 5-10mg IV
    • 3) Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min
    • 4) Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion
    • 5) Fosphenytoin (Cerebyx): prodrug of Dilantin
    • 6) Phenobarbital (luminal): administered if Dilantin is unresponsive
    • 7) Barbiturate coma or general anesthesia with neuromuscular blockade
  229. Myasthenia Gravis

    1) Cause
    2) Signs and symptoms
    3) Lab
    4) Management
    • 1) Decrease in acetylcholine receptor sites
    • 2) Ptosis, diplopia, dysarthria (slurred speech) dysphagia, fatigue, extreme weakness, resp difficulty- think visual changes, extreme weakness, and resp issue

    • • Sensory modalities and DTRs are normal
    • 3) Antibodies to acetylcholine AchR-ab are found in 80%
    • • Edrophonium (tensilon) test used to differentiate myasthenic vs cholinergic crisis
    • 4) No specific protocol- consult neurology
    • • Anticholinesterase drugs block the hydrolosis of acetylcjoline and are used for symptomatic improvement (pyridostigmine bromide)
    • • Immunosuppressive, plasmapheresis
    • • Vent support during crisis
  230. Multiple Sclerosis

    1) Cause
    2) Signs and symptoms
    3) Lab
    4) Management
    • 1) The body’s immune attacks myelin- key substance that serves as a nerve insulator and helps transmission of nerve signals
    • 2) Weakness, numbness, tingling, or unsteadiness in a limb, may progress to all limbs- think neurosensory
    • 3) Definitive diagnosis can never be based solely on labs
    • 4) No tx to prevent progression of the disease- neurology consult

    • • Recovery from relapse with steroid use
    • • Antispasmodics, interferon therapy
    • • Immunosuppressive, plasmapheresis
  231. Guillain-Barre Syndrome

    1) Causes/general concept
    2) Signs and symptoms
    3) Lab diagnostics
    4) Management
    • 1) The syndrome is usually preceded by suspected viral infection accompanied by fever 1 to 3 weeks before onset of bilateral muscle weakness in lower extremities
    • 2) Presentation- rapid progressive increase in paralysis
    • 3) CSF protein is elevated, CBC-early leukocytosis with left shift

    • • LP, MRI, CT are sometimes used in aiding diagnosis
    • 4) Tx-neuro consult- txis supportive while myelin is regenerated
    • • Symptoms begin to recede within 2 weeks with recovery in 2 yrs
  232. Meningitis

    1) General concept
    2) Signs and symptoms
    1) General concept

    • • Meningitis should be considered in any pt with fever and neurologic symptoms especial with hx of infection
    • • Acute bacterial meningitis is a medical emergency
    • 2) Symptoms
    • • Fever 101-103, severe HA, NV
    • • Nuchal rigidity (stiff neck), photophobia
    • • Positive kernig’s sign

    o Pain and spasms of the hamstring muscles

    • Positive Brudzinski’s sign

    o Legs flex at both the hips and knees in response to flexion of the head and neck to the chest
  233. Meningitis

    1) Lab/diagnostics
    1) Lab/diagnostic

    • LP-CSF will be cloudy or yellow in color with

    • o Increase pressure and protein
    • o Decreased glucose with presence of WBCs

    • CT of head indicated
  234. Management of Meningitis
    • 1) Control symptoms and maintain electrolyte balance
    • 2) High does parenteral antibiotic therapy

    • PCN G, Vanco with a 3rd gen cephalosporin until C&S is available, or fluoroquinolones
  235. Head trauma



    1) Signs and symptoms
    2) Diagnostics
    1) Decompensating patient may show signs of Cushing’s triad

    • • Widening pulse pressure
    • • Decreased RR and HR

    • o Battle signs: bruising behind ear at mastoid process
    • o Raccoon eyes Otorrhea or rhinorrhea
    • 2) Diagnostics

    • • Cervical spine films should be obtained for all pts
    • • Skull films and head CT
  236. Spinal cord trauma


    Site with signs and symptoms
    • C4 or above= quadriplegia; may require mechanical ventilation
    • C4-C5= quadriplegia; control of head, neck, shoulders, trapezius and elbow flexion
    • C5-C6= quad; some extension of wrist, index finger and thumb
    • C6-C7= elbow extension, capable of feeding, dressing
    • C7-T1= hand movement
    • T1-T2= paraplegia; upper extremity control but no trunk control
    • T3-T8= no trunk control
    • T9-T10= bowel and bladder reflex, moves trunk and upper thigh
    • T11-L1= most leg and some foot movement; ambulation poss
    • L1-L2= lower legs, feet and perineum; control bowel, bladder and sexual dysfunction if S2 to S4 spinal nerves are involved
  237. Management for spinal cord trauma
    1) Methylprednisolone 30 mg/kg IV bolus, followed by infusion of 5.4mg/kg/hr for 23 hrs

    • • Must bed administered within 8hrs of injury
    • 2) Consult neurology/neurosurgery
  238. Complication of Spinal cord trauma
    • 1) C4 injury or above: respiratory compromise
    • 2) T4-T6: may lead to autonomic dyserflexia- emergency

    • Caused by exaggerated autonomic response to a stimulus- symptoms include

    • o Diaphoresis and flushing above injury
    • o Chills and severe vasoconstriction below injury
    • o HTN, Bradycardia, HA, Nausea
    • o Tx- antihypertensive and stimulus removal
    • 3) T6 or above –neurogenic shock- massive vasodilation
  239. What is the difference between:



    1) Delirium
    2) Dementia
    1) Delirium: sudden, transient onset

    • • Causes- toxins, alcohol, trauma, impactions in the elderly, poor nutrition, electrolyte imbalances, anesthesia
    • 2) Dementia: gradual memory loss- neurocognitive disorder
    • • Cause- Atherosclerosis, neurotransmitter deficits, cortical atrophy, ventricular dilation, loss of brain cells, viral, Alzheimer’s disease
  240. Dementia mnemonic to rule out other disease
    • D= drug reaction/interaction
    • E= emotional disorder
    • M= metabolic/endocrine disorder
    • E= eye and ear disorders
    • N= nutritional problems
    • T= tumors
    • I= infection
    • A = arteriosclerosis
  241. What is Homonymous hemianopia
    Is a visual field loss on the left or right side of the vertical midline.


    It can affect one eye but usually affect both eyes
  242. What cranial nerves are sensory only
    CN- I (Olfactory), II (Optic), VIII (Acoustic)


    • Remember:
    • Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most
    • CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII


    On Old Olympus Towering Tops A Fin And German Viewed Some Hops
  243. What cranial nerves are both sensory and motor
    CN-V (trigeminal), VII (facial), IX (Glossopharyngeal), X (Vagus)


    • Remember:
    • Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most
    • CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII


    On Old Olympus Towering Tops A Fin And German Viewed Some Hops
  244. Cauda Equina syndrome

    1) What is it
    2) Signs and symptoms
    3) Causes
    • 1) Is a surgical emergency due to compression of spinal cord root-18 nerve roots of the cauda equine at base of spine.
    • 2) S/S : Pain, numbness, tingling & low back pain radiating into leg(s), 

    • S1-S2: weak plantar flexion w/loss of ankle jerks, foot drop. S3-S5: Loss of bowel/bladder. Muscle weakness, sensory loss in the dermatomal distribution of the affected nerve roots.


    3) Cause: tumor, spinal stenosis, herniated disc, CA, infxn, inflammation.
  245. ● You are examining a pt with PMH of seizures. Pt sustains a seizure lasting around 1 minutes. What is the most appropriate intervention?
    ● Valium 5-10 mg IV

    • Parenteral anticonvulcents are used to stop convulsive seizures rapidly benzodiazepines: Diazepam (valium) 5-10mg IV
    • Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min
    • Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion
    • Fosphenytoin (Cerebyx): prodrug of Dilantin
    • Phenobarbital (luminal): administered if Dilantin is unresponsive
    • Barbiturate coma or general anesthesia with neuromuscular blockade
  246. What CSF values are characteristic of bacterial meningitis?
    ↑ opening pressure, ↑ protein, WBC, ↓ glucose
  247. Asthma

    1) What is it
    2) Signs and symptoms
    3) Lab/diagnostics
    • 1) Widespread narrowing of the airways
    • 2) Signs and symptoms

    • • Resp distress at rest, difficulty speaking, RR>28, Pulse>110, cough, chest tightness
    • 3) Bad signs include-
    • • fatigue, absent breath sounds, paradoxical chest/abd movement, inability to maintain recumbency, cyanosis
  248. Asthma

    1) Lab/diagnostics
    • 1) Slight WBC elevation with eosinophilia
    • 2) PFT reveal obstructive dysfunction
    • 3) Hospitalization for

    • • FEV1<30% that does not increase to 40% after 1hr of therapy
    • • Peak flow <60L/min or does not improve >50% after 1 hr of tx
    • 4) ABG= resp alkalosis with mild hypoxemia
    • • Hypercapnia is a bad finding
    • • pCO2 >45 indicates emergency
    • • Normal pCO2 indicates a very sick patient
  249. Asthma

    1) Outpatient Management
    • Short acting B adrenergic agonist for symptom relief

    o Albuterol

    • Daily inhaled corticosteroids

    o Budesonide (Pulmicort)

    • Long acting B adrenergic agonist for persistent sympt

    o Salmeterol (serevent); theophylline

    • Inhaled anticholinergics may be added if necessary

    o Ipratropium bromide (atrovent)

    • Antilerkotriences useful in the maintenance of chronic

    o Montelukast (singler)
  250. Asthma

    1) Inpatient management
    • 1) Supplemental O2
    • 2) ABG for severe attacks
    • 3) Adequate hydration
    • 4) Inhaled sympathomimetics (adrenaline effects)

    • • Alupent 2.2ml q30-60mins, Proventil 3ml q30-60min
    • 5) Corticosteroids in pts who do not respond to sympathomim
    • • Methylprednisolone 60-125mg IV X1 then 20mg IV q4-6hrs until attack broken
    • 6) Parenteral sympathomimetics in pts unable to cooperate
    • • Aqueous epinephrine 1:1000 SQ q30-60min may repeat X4
    • 7) Anticholinergic (Atrovent) MDI 2-6puffs q4-6hrs
  251. Status Asthmaticus

    1) Management
    • 1) Oxygen
    • 2) IV D5 ½ NS
    • 3) Inhalation and parenteral sympathomimetics
    • 4) Methylprednisolone 60-125mg or hydrocortisone 300mg IV immediately
    • 5) Consider atrovent
    • 6) Monitor ABG q10-20min
    • 7) Intubate
  252. COPD

    1) Lab/diagnostics
    2) Outpatient management
    3) In patient management
    1) Low flattened diaphragm by CXR

    • • Low FEV1
    • • Increased TLC, FRC, RV, paCO2, HCO3
    • 2) Outpatient
    • • Inhaled ipratropium bromide or sympathomimetics mainstay of therapy
    • 3) Inpatient
    • • Supplemental O2
    • • Clients with purulent sputum should receive antimicrobials for 7-10 days

    • o Ampicillin or amoxicillin 500mg 4X daily
    • o Doxycycline 100mg BID
    • o Bactrim DS 1 tablet BID
  253. COPD

    1) Chronic bronchitis

    • s/s
    2) Emphysema
    • s/s
    1) Chronic Bronchitis- excessive secretion + productive cough for 3months in at least 2 consecutive yrs

    • • Copious sputum (purulent), stocky, obese
    • • Bulla, blebs, hyperinflation on CXR,
    • • hypercapnia, hypoxemia on ABG
    • 2) Emphysema= abnormal, permanent enlargement of the alveoli
    • • Progressive, constant dyspnea, sputum clear
    • • Thin wasted body, TLC increased
  254. TB management and drug regimen
    • 1) Notify local health department
    • 2) Med regimen

    • • Isoniazid 300mg, Rifampin 600mg, Pyrazinamide 1.5-2.0gm, Ethambutol 15mg/kg, or streptomycin 15mg/kg IM daily
    • • Continue the first 3 drugs daily for 2 months, then 4 months of INH and RIF daily

    o Persons with HIV should be treated for nine months
  255. Pneumonia
    CAP management
    1) Healthy patients <60 with no comorbidities and no recent abx therapy

    • • Macrolide- azithromycin, clarithromycin, erythromycin, or doxycycline
    • 2) Patients with health problems- COPD, DM, HF, Cancer, or >60 and no recent abx therapy
    • • Fluoroquinolone- levofloxacin, gemifloxacin, moxifloxacin
  256. Pneumonia
    Inpatient ICU management
    • 1) Supplemental O2
    • 2) Beta lactam (rocephin; Unasyn) + azithromycin or fluoroquinolone
    • 3) For pseudomonas infection

    • • Piperacillin-tazobactam (Zosyn), Cefepime or menopenem + Cipro or levofloxacin or beta lactam + aminoglycoside and fluoroquinolone
    • 4) For MRSA staph aureus infection
    • • Add vanco or linezolid
  257. Pneumonia

    1) What is HAP
    2) What is VAP
    1) Pneumonia that occurs 48hrs or more after admission

    • • Staph aureus, strep pneumoniae, and haemophilus influenza most common causative organisms
    • 2) Pneumonia that arises 48-72 after intubation
    • • Pseudomonas most common causative organism
  258. Treatment of pneumothorax
    • 1) Chest tube is first – 4th or 5th ICS, MAL
    • 2) Emergency

    • Needle thoracotomy- 2nd ICS, MCL
  259. Pulmonary Embolus

    1) Lab/diagnostics
    2) Management
    1) Lab/diagnostic

    • • VQ scan for clinically stable patients
    • • ABG- hypoxemia (saO2<90%, paCO2 <80), hypocapnia
    • • Spiral CT/D-dimer
    • 2) Management
    • • O2, fluids for hypotension and reduced CO
    • • Intubation for worsening hypercapnia
    • • Heparin and fibrinolytic therapy
  260. Modes of Ventilation

    1) Control
    2) Assist control
    3) SIMV/IMV
    4) CPAP
    5) Pressure Support
    6) PEEP
    • 1) Control- Machine dose all the work (preset TV & RR)
    • 2) Assist control- same as control + pt triggers the vent (if triggered the vent delivers preset volume
    • 3) SIMV/IMV- pt gets preset breaths at preset TV, (but takes own breath at whatever TV he pulls)
    • 4) CPAP- breathing spontaneously but at a pressure>atmospheric
    • 5) Pressure Support- unassisted inspiratory effort, (but a preset amt of airway pressure is delivered with each breath
    • 6) PEEP- maintains intrathoracic airway pressure above atmospheric throughout expiration
  261. Pulmonary Fx test

    1) FCV
    2) FEV1
    3) TLC
    4) FRC
    1) Obstructive=reduced airflow rates

    • • FVC-volume forcefully expelled from the lungs after maximal inspiration (80%-120%)
    • • FEV1-volume expelled in 1st second (>80%
    • 2) Restrictive= reduced volumes
    • • TLC-volume in lungs after maximal inspiration (<80%)
    • • FRC-functional residual capacity (75-120)
  262. At what point is HIV diagnosed as AIDs
    CD4 <200 or the presence of an opportunistic infection
  263. Osteoarthritis (OA)

    1) Pathology
    2) Joints
    3) Stiffness/Pain
    4) Management
    1) Patho/inflammation

    • • Degenerative joint disease with slow destruction of the articular cartilage-inflammation asymmetrical
    • 2) Joints
    • • Weight-bearing joints- swelling and edema, no redness or heat
    • 3) Stiffness/pain
    • • Better in the morning-worse as the day progresses
    • 4) Management
    • • ASA, Acetaminophen, NSAIDs, COX-2 inhibitors
  264. Rheumatoid Arthritis (RA)

    1) Pathology
    2) Joints
    3) Stiffness/Pain
    4) Labs
    5) Management
    1) Patho/inflammation

    • • Systemic autoimmune disease causing inflammation of connective tissue- inflammation symmetrical
    • 2) Joints
    • • Hands and wrist- swelling and edema with redness and heat complaints to joints
    • 3) Stiffness/pain
    • • Worse in the morning- better as the day progresses
    • 4) Labs
    • • ESR usually elevated, ANA (+) in 1/5 pts
    • 5) Management
    • • High does salicylates, NSAIDs, DMARDS

    o Corticosteroids, methotrexate, antimalarial, GOLD salt injection
  265. Giant Cell Arteritis

    1) What is it
    2) Signs and symptoms
    3) Lab/diagnostics
    4) Management
    • 1) Temporal arteritis- inflammatory condition primarily affecting pts over the age of 50- can lead to blindness
    • 2) S/S-scalp tenderness, HA, visual disturbance, fever
    • 3) Lab-high ESR, Temporal artery biopsy (+) in 85-95%
    • 4) Management-

    • Prednisone and referral
  266. Glaucoma

    1) Pathology
    2) Open/closed angle
    3) Management
    1) Pathology

    • • Increased intraocular pressure
    • 2) Open angle = chronic
    • • Asymptomatic, elevated IOP, cupping of the disc, constricted visual fields
    • • Alpha2-adrenergic agonist (brimonidine), Beta-adrenergic blockers (Timolol)
    • 3) Closed angle = acute
    • • Extreme pain, blurred vision, halos, dilated/fixed pupils
    • • Carbonianyhdrase inhibitors (diamox), osmotic diuretics (mannitol), surgery
  267. Cataract

    1) Pathology
    2) Signs and symptoms
    3) Management
    1) Pathology

    • Clouding and opacification of the normally clear lens of the eye

    • o Highest cause of treatable blindness
    • 2) Signs and symptoms

    • • Painless, clouded, blurred or dim vision, difficulty with vision at night, sensitivity to light
    • 3) Management
    • • Change glasses as cataract develops
    • • Refer to ophthalmologist for surgery
  268. Your asthmatic patient is on a SABA and ICS. She has no secretions but her symptoms are still not well controlled. What do you order next?





    C) Salmeterol (LABA)
  269. patient on a SABA only with multiple trips to the ER in the past 3 months
    You add an ICS: FLovent
  270. 1. What is paradoxical abdominal and diaphragmatic movement?



    B) Asthma ominous sign
  271. Exudative effusion findings
    ● higher ratio of pleural protein and LDH to serum levels

    • o Protein:  Pleural fluid: serum ratio > 0.5
    • o LDH: Pleural fluid : serum ratio > 0.6
    • o Pleural fluid LDH > 2/3  upper limit of serum LDH
  272. Positive TB findings
    Those with positive skin test should receive 6 months of INH

    • • 5mm= HIV persons, contacts of known case, or persons with CXR typical for TB
    • • 10mm= immigrants from high prevalence areas, high risk groups, health care workers
    • • 15mm= all others not in high prevalence groups
  273. Pseudomonas VAP treatment
    (zosyn, cefepime, or imipenem/meropenem) + (fluoroquinolone or azithromycin) ± gentamycin
  274. 37 yp s/p endotracheal intubation 2 days ago has fever, chills and purulent sputum. CXR = lung infiltrates. Which of the following is the best regimen for the pts condition?
    ● Cefepime and Cipro (Pseudomonas for VAP)
  275. What PFTs show asthma
    ● decreases in FEV1, FEV25-75, PEFR, FVC
  276. 38 yo F immobilized for 4 months. Examining her before releasing you note dyspnea and tachycardia. You suspect PE, but V/Q scan does not confirm. What is the next diagnostic test?
    Pulmonary angiography
  277. Elderly women who has a hx of lung dysfunctions comes to our office. She presents with a number of respiratory symptoms. Most severe c/o HA. Which is the most likely respiratory dx based on HA?
    Acute bronchitis FLUIDS
  278. 1. Your HIV patient has CMV. What is the appropriate treatment?

    a. Cefazolin   
    b. Ciprofloxacin
    c. Fluconazole
    d. Gemcyclovir
    Gemcyclovir (pick the ‘vir’)
  279. Know HIV testing:
    • HIV= ELISA confirmed with Western Blot. 
    • AIDS = CD4 <200 (800 is WDL) or <20%.
    • Ideal viral load (by   PCR) < 5000
  280. Differential diagnosis for ESR (sed rate) elevated
    RA, SLE, temporal arteritis, inflammation
  281. 28 yo F presents with fever, malaise, rash across the back and splinter hemorrhages. Hgb 10, positive ANA, UA proteinuria and elevated ESR. What is the suspected diagnosis?
    SLE
  282. Which of the following drugs can cause lupus-like symptoms?
    ● Procainamide
  283. RA management:
    ● methotrexate, DMARDS, corticosteroids, hydrochloroquine, gold salts. most cost effective: methotrexate (monitor LFTs)
  284. What is Felty’s syndrome:
    RA + joint swelling + enlarged spleen + leukopenia (complication of RA)
  285. Pt c/o wrist /hand, swollen redness & pain worse in  a.m and resolves as the day goes on. What dx would support RA?
    ↑ ESR
  286. OA Management:
    ASA, APAP (1st line), NSAIDS, Cox2 inhibitors (Celebrex). Swimming for non-pharm. Cane goes on opposite side.
  287. 57 yo M with PMH of cardiovascular disease presents with c/o of pain in both knees that is progressively worse throughout the day. You suspect OA. What medication is contraindicated?
    ● Celebrex r/t ARF, MI and pts PMH + for cardiac disease
  288. What is associated with HA, fever, and elevated ESR?
    Temporal Arteritis
  289. EYES: Best way to verify your treatment is working for open angle glaucoma?
    Tonometry (normal IOP is 10-20 mmHg)
  290. Which of the following meds is not indicated in the management of closed angle glaucoma?
    Alpha 2 adrenergic agonist (this is for open angle.)
  291. Normal range and value for hemodynamic parameters
    1) CVP= pressure exerted by fluid

    • • 0-6 mmHg
    • 2) PAP= A measure of systolic and diastolic pressures in pulmonary
    • • 15-25/5-15
    • 3) PCWP= left-sided heart function
    • • 6-12 mmHg
    • 4) CO= HRXSV
    • • 4-8 L/min
    • 5) CI= more accurate measure than CO due to body surface
    • • 2.5-4 L/min
    • 6) SVR= resistance of left ventricle pump
    • • 800-1200
    • 7) SVO2= assesses the effectiveness of peripheral oxygen delivery
    • • 60-80%
  292. CVP
    Elevated levels indicate
    Decreased levels indicate
    1) Elevated CVP

    • • Fluid overload, cardiogenic shock
    • 2) Decreased CVP
    • • Dehydration, distributive shock
  293. PAP and PCWP

    1) Elevated levels indicate
    2) Decreased levels indicate
    1) Elevated PAP

    • • Conditions that increase in the amt of fluid in the pulmonary arteries
    • • Hypervolemia, pulmonary hypertension
    • 2) Decreased PAP
    • • Hypovolemia
    • 3) Elevated PCWP
    • • Increased fluid, decreased elasticity of the ventricle
    • 4) Decreased PCWP
    • • Hypovolemia
  294. CO and SVO2

    1) Elevated levels indicate
    2) Decreased levels indicate
    1) Elevated CO

    • • Inotropic agents, excess fluid
    • 2) Decreased CO
    • • Drugs that decrease contractility, hypovolemia
  295. SVO2

    1) Elevated levels indicate
    2) Decreased levels indicate
    1) Elevated SVO2

    • • Values<60% implies increased tissue extraction of O2; the patient has tapped the venous reserve of O2
    • • Decreased O2 supply (decreased CO, FIO2, anemia), increased O2 demand (fever, shivering, increased WOB)
    • 2) Decreased SVO2
    • • Values >80% implies decreased tissue extraction of O2, high return of O2 is often a most early indicator of pt status chang
    • • Increased O2 supply (FiO2>need), decreased O2 demand (hypothermia), or decreased effective O2 delivery and uptake by the cells (sepsis, shift of the oxyhemoglobin curve left)
  296. Hypovolemic Shock

    1) What is it?
    2) Causes
    3) Labs/diagnostics
    4) Management
    • 1) Results from loss greater than 20% of circ blood volume
    • 2) Causes

    • • Internal/external bleeding, Burns, DKA/HHNK, dehydration
    • 3) Labs
    • • Decreased CO/CI, CVP, PCWP, SVO2; increased SVR
    • 4) Management: Fluid resuscitation, PRBCs when indicated
  297. Cardiogenic Shock

    1) What is it?
    2) Causes
    3) Lab/diagnostic
    4) Management
    • 1) Loss of effective contractility fx, results in impaired CO, impaired O2 delivery, and reduced tissue perfusion
    • 2) Causes

    • • Acute MI, ventricular aneurysm, dysrhythmia, tamponade, hypoxemia, pulmonary edema,
    • 3) Lab/diagnostic
    • • Increased CVP, PCWP, SVR; Decreased CO/CI, SVO2
    • 4) Management
    • • Careful admin of IV fluids, Vasopressor support, Nitro
  298. • Distributive Shock




    1) What is it
    1) Is three forms of shock characterized by

    • • vasodilation,
    • • decreased intravascular volume,
    • • reduced peripheral vascular resistance
    • • and loss of capillary integrity
    • 2) septic shock, anaphylactic shock, and neurogenic shock
  299. Septic Shock

    1) Causes
    2) Lab/diagnostic
    3) Management
    • 1) Infective organisms that invade the bloodstream and alter vascular tone; hypovolemia develops as a result of blood pooling in the microcirculation
    • 2) Lab/diagnostic

    • • Blood cultures, increased CO/CI, Decreased CVP, PCWP, SVR, SVO2
    • 3) Management
    • • Fluid resuscitation (crystalloid), vasopressor, abx tx
  300. Anaphylactic Shock

    1) Cause
    2) Lab/diagnostic
    3) Management
    • 1) IgE mediated reaction that occurs shortly after exposure to an allergen
    • 2) Lab/diagnostic

    • • Decreased CO/CI, CVP, PCWP, SVR, SVO2
    • 3) Management
    • • Airway management, Diphenhydramine 25-75mg IV/IM
    • • Epinephrine 0.3-0.5mg SQ/IM for resp distress, stridor, wheezing
    • • Crystalloids for volume expansion
    • • IV glucocorticosteroids as needed
    • • Consider Zantac or other H2 antagonist
    • • Inhaled beta agonist for bronchospasm
  301. Neurogenic Shock

    1) Causes
    2) Lab/diagnostics
    3) Management
    • 1) Loss of peripheral vasomotor tone as a result of spinal cord injury, regional anesthesia
    • 2) Lab/diagnostics

    • • Decreased CO/CI, CVP, PCWP, SVR, SVO2
    • 3) Management
    • • Airway management
    • • Crystalloids for volume expansion
    • • Vasopressors as needed for BP (dopamine, ephedrine, levo, neo
  302. Obstructive shock

    1) What is it
    2) Causes
    3) Lab/diagnostic
    4) Management
    • 1) Inadequate CO as a result of impaired ventricular filling
    • 2) Causes

    • • Massive PE, tension pneumothorax, acute cardiac tamponade, obstructed valvular disease,
    • 3) Lab/diagnostic
    • • Decreased CO/CI, PCWP; Increased PVR, CVP, SVO2
    • 4) Management
    • • Maintain BP while initiating tx of underlying cause
    • • Fluid admin with use of vasopressors (levo, dopamine)
  303. 1) What kind of shock is exhibited by the following values?  PCWP 18, CI 2.0, SVR 1800

    • Distributive
    • Cardiogenic
    • Obstructive
    • Hypovolemic
    • Cardiogenic


    Lab/diagnostic


    • Increased CVP, PCWP, SVR; Decreased CO/CI, SVO2
  304. 1. Your ventilated pt has these settings: SIMV, FiO2 60%, PEEP 5. You notice pulmonary shunting. What is your action?

    a. Increase PEEP to 10
    b. Order a Beta agonist nebulizer
    c. Increase FIO2 to 70%
    d. Add +5 Pressure Support
    Increase PEEP to 10 (shunting d/t atelectasis)
  305. 1. The NP correctly identifies the expected hemodynamic profile of a pt in hypovolemic shock as being most closely represented by which of the following?

    a. CO 3.5 L/min, CVP 1 mmHg, PCWP 4 mmHg, SVR 700
    b. CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR)
    c. CO 3.5 L/min, CVP 1 mmHg, PCWP 14 mmHg, SVR 1300
    d. CO 8.5 L/min, CVP 9 mmHg, PCWP 4 mmHg, SVR 700
    CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR)
  306. 1. A pt presents to the ED with intense abdominal pain that worsens when she coughs. A physical exam indicates abdominal tenderness, abd guarding. During the PE, the NP elicits RLQ pain when pressure is applied to LLQ. Her labs are: HR 140, SV 70ml/min, CVP 8 mm Hg, PCWP 4 mm Hg, SVR 600 dyn sec/cm3. Which of the following should be initiated for this pt?

    a. Norepinephrine
    b. Hydrocortisone suppositories
    c. Epinephrine
    d. PRBC transfusion
    Norepinephrine


    • Obstructive shock
    • Management


    • • Maintain BP while initiating tx of underlying cause
    • • Fluid admin with use of vasopressors (levo, dopamine
  307. 1. A 42 yr old F is brought to ED after spilling a pot of boiling water on her arms and chest. On exam you see that burned skin is broken, swollen with edema, and covered in blisters. She rates pain as “extremely painful.” You determine that the pt has burns over 20% of her TBSA. Which of the following most accurately describes the pts burn?

    a. 1st degree burn
    b. Full thickness burn
    c. Partial thickness burn
    d. 3rd degree burn
    Partial thickness burn
  308. ● How would you know cardiogenic shock:
    ● only shock with initially high wedge PCWP
  309. 1. What is CAM-ICU
    is an adaptation of the Confusion Assessment Method (CAM) score for use in ICU patients

    • 1. Acute onset of mental status changes or a fluctuating course and
    • 2. Inattention and
    • 3. Altered level of consciousness or
    • 4. Disorganized thinking =
    • 5. =Delirium
  310. Know anion gap
    • Anion gap = (Na +K)-(HCO3 + CI)
    • Normal 7-17
  311. Which of the following lab values would indicate a pre-renal ARF?



    D. FENa <1%
  312. PFT DLCO decreased in:



    A. Anemia
  313. Zyprexa causes:



    D. Prolonged QT
  314. ACE slow progression of renal insufficiency in:



    D. Chronic glomerrulonephritis with >1g/dL proteinuria
  315. Anti-cholinergic syndrome:



    D. confusion, hyperthermia, dilated pupils, HTN, and tachycardia
  316. Acetaminophen overdose- elevated LFTs



    B. within 24-48h
  317. SIADH lab values:



    D. Na <130, SOsmo <280
  318. Intermittent segments of erosion in the small bowel and colon:



    A. Crohn's disease
  319. Replacement therapy for primary adrenal insufficiency:



    A. Combination of glucocorticoids and mineralocorticoids
  320. Adrenal insufficiency:



    D. hyperpigmentation, tachycardia
  321. Obstructive lung disease



    C. Decreased FEV1/FVC
  322. Hallmark labs with TLS:



    C. Hypocalcemia
  323. Nocioceptive pain:



    B. Aching, throbbing, and localized
  324. Pre-renal failure caused by:



    B. hypoperfusion
  325. IDA:



    D. hypochromic, microcytic
  326. When treating a patient with dementia, which of the following medications has shown positive results?



    A. Risperidone
  327. Endocarditis + holosystolic murmur in the area of the apex of the heart:



    D. Mitral regurgitation
  328. Triple H therapy: hypervolemia, HTN, and hemodilution recommended in:



    B. Aneurysmal SAH
  329. Labs hypothyroidism:



    B. High TSH, decreased T3/T4
  330. 42F mensural irregularities and believes she is experiencing early menopause. Fatigue and restless. Thin woman with fine hair, moist, warm skin, goiter with bruit. HR 110, 140/80



    A. Graves' disease
  331. For MCV the addition of CPAP:



    A. Increased FRC
  332. Life-threatening cause of delirium:



    B. Hypoxia
  333. Posterior wall MI:



    C. Tall and wide R waves and ST depression in V1 and V2 leads
  334. Typical complication of mitral stenosis:



    D. Right-sided HF
  335. Adrenal insufficiency:



    A. Elevated BUN, low Na, high K
  336. Aortic stenosis: in addition to chest pain, which would indicate urgent need for aortic valve replacement?



    A. Syncope
  337. Colonoscopy: continuous areas of inflammation and ulceration extending from he rectum to the sigmoid colon. Colonic biopsies reveal crypt abscesses. Which of the following is he patient most likely to have?



    B. Ulcerative Colitis
  338. Adults 40-70 years old USPSTF recommends DMII screening:
    q3 years if overweight or obese
  339. 50 years or older annual:
    • FOBT to screen for colon cancer
    • Tonometry annually for those at increased risk for glaucoma
Author
Stevi
ID
355501
Card Set
Boards
Description
Updated