What lab changes will be seen in a patient with hyperaldosteronemia?
(1) Slightly increased Na, (2) Hypokalemia, (3) Metabolic alkalosis (HTN)
What lab findings are diagnostic of Hashimoto thyroiditis?
Hypothyroid will have high TSH low T3/T4, Anti-TPO antibodies and anti-thyroglobulin antibodies
What are the 5 basic criteria for metabolic syndrome?
1) Increased waist circumference (abdominal obesity), 2) BP >130/80, 3) Insulin resistance, 4) High triglycerides, 5) Low HDL
60 y/o obese patient presents with drity, velvety patches on the back of the neck. What is the diganosis and initial work-up?
Acanthosis nigricans, check glucose and good H&P looking for visceral malignancy
What is the appropriate tx of HTN in cases of pheochromocytoma?
Alpha blocker (phenozybenzamine, phentolamine) than beta blocker
What is the classic presention of a patient with hyperprolactinemia?
Male - Galactorrhea, gynecomatia, hypogonadism, decreased libido, impotence, low sperm count
Female is pre-menopausal - galactorrhea (maybe), amenorrhea, hypogonadism, infertility
Female post-menopausal - could be asx/subclinical
What is the parkland burn formula?
(4 mL water) x (body mass in kg) x (% burned surface area), Half given over 8 hours, second half given over next 16 hours, Still need maintenance IV fluids, this would also be LR ^
Pt presents with 2nd degree burns covering the anterior surface of both arms. What is the surface area of the burns?
Entire arm is 9% so anterior surface is 4.5x bilateral arm - total of 9% BSA
What are the complications to watch for in a patient that has suffered an electrical burn?
Compartment syndrome, Bony injures, Neurologic disturbances, Rhabdomylosis and myoglobinuria, Renal failure, Acidosis
Mine worker is brought into the ER after explosion occurred; examination of the burns, which is difficult 2/2 to pain at the site, reveals extension into the dermis and blisters. To what degree is this burn?
Second degree, because its still painful and not fully through the dermis (which would be 3rd degree)
What pulmonary pathology should you be watching for in a patient who had a salt-water near-drowning episode?
Pulmonary edema due to increased electrolyte concentration (hypertonic fluid draws water out into alveoli)
Where is an aspirated object such as a penny most likely to end up?
R main-stem bronchus
What is the next step in management of a patient that has aspirated an object that cannot be dislodged, and is now having difficulty moving air and is becoming hypoxic?
Emergency tracheotomy
What EKG abnormality is classic for patients with hypothermia?
J wave (occurs right after QRS small + spike)
What is the tx for a black widow spider bite?
antivenin (w/n 30 minutes of bite), clean abd bandage, observed for 24 hours, consider oral abx if needed, if lacodectism � benzos
After appropriate irrigation and cleansing, should a dog bite wound to the arm be left open or sutured closed?
Leave open (?)
What is the tx for a skin laceration on the dorsum of the hand that resulted from closed fist hitting a victim's mouth?
Copious irrigation, leave wound open, abx prophylaxis
Tx for hyperparathyroidism due to parathyroid hyperplasia?
Removal of the 3 1/2 glands and mark the last 1/2 with surgical clip so you can find it
What is the LDL goal for a patient with DM?
LDL <100 (could aim <70 if hx of atherosclerosis, Up to date??
What method is used to calculate fluid repletion in burn patients?
Parkland formula for lactated ringers, (4 mL) x (body mass in kg) x (BSA % burned), First half in 8 hours, second half over 16 hours, Also need maintenance IVF as this is just replacement
What cardiac medications are safe to treat the tachycardia and HTN associated with cocaine overdose?
Benzodiazepines; Alpha-antagonists (phentolamine, phenoxybenzamine)
What is given to treat acetaminophen overdose? What other does this medication have?
N-acetylcysteine (also used as anti-mucus drug for CF, sometimes -not really anymore- to prevent contrast nephropathy)
What medications are used in cases of cyanide poisoning?
Sodium thiosulfate (thiocyanate � renally excreted), Hydroxycobalamin (cyancocobalamin � urinated), Amylnitrate and sodium nitrate (forms cyanomethemoglobin)
A patient on haloperidol develops fever, muscle rigidity, confusion and diaphoresis. What is the drug of choice in treatment of this patient's condition?
Dantrolene (due to Neuroleptic Malignant Syndrome) and discontinue anti-psychotic
What kind of tumor is most common brain tumor?
Metastatic (primary from lung, breast, adenoma)
Lung cancer accompanied by muscle weakness is indicative of what?
Eaton-Lambert Syndrome (often from small cell lung cancer, pancoast tumor)
Antidote for aspirin?
Sodium bicarbonate, dialysis (if really early caught � charcoal)
Antidote for acetaminophen?
N-acetylcysteine
Antidote for opioids?
Naloxone
Antidote for benzos?
Flumazenil
Antidote for TCAs?
Sodium bicarb if QRS >100, benzo (diazepam) for seizures
Antidote for Atropine?
Physostigmine
Antidote for Propranolol?
Glucagon, insulin + dextrose, calcium
Antidote for Digoxin?
Digoxin Antibody Fragments (if severe)
Antidote for cyanide?
Sodium thiosulfate, Hydroxocobalamin, Amylyl nitrate and sodium nitrate
Antidote for methemoglobin?
Methylene blue
Antidote for methanol or ethylene glycol?
Fomepizole, ethanol
Antidote for isoniazid?
Vitamin B6
Antidote for heparin?
Protamine sulfate
At what point in a patient with an elevated INR due to warfarin would you consider dosing vitamin K to reverse the warfarin?
INR >9 or with bleeding, (Consider around 5-9 as well)
What is the most sensitive test for MS?
MRI of brain and orbits (asymmetric white matter lesions of various ages), not radiologic diagnosis
What type of bite/sting can rarely cause acute pancreatitis?
Scorpion
In which endocrine disorder might weight loss completely eliminate the need for medication?
Type II DM, PCOS
What is the treatment for lead poisoning in adults? What is the treatment in children?
Adults - succimer, Children - low levels give succimer, but for increased ingestion (>70 microliters) use dimercaperol and EDTA
What is the next step in a management of a patient that presents to the ER with organophosphate poisoning?
Remove patients clothing, gown and glove prior to treatment, then give Atropine and pralidoxime
What classic toxin ingestion management options should NOT be chosen in patients presenting with alkaline fluid ingestion
No emetic agents, neutralizing agents or NG tube
A COPD patient comes to the ER with tachycardia and hypotension. During the evaluation he begins to have seizures. What is the most likely etiology?
Theophylline overdose/toxicity
Antidote for arsenic?
Dimercaperol, Succimer, Penicillamine
Antidote for anticholinesterases, organophosphates?
Atropine and pralidoxime
Antidote for carbon monoxide?
100% O2, maybe hyperbaric oxygen (possible intubation based on injury, thermal injury to throat will close quickly!)
Antidote for Copper?
Penicillamine
Antidote for iron?
Deferoxamine
Antidote for mercury?
Dimercaperol
Antidote for tPA?
Aminocaproic acid
What is the maximum number of epinephrine doses that can be given when treating cardiac arrest?
No limit for epinephrine, just ever 3-5 minutes
In treating pulseless ventricular tachycardia, what drug could be given in place of the first or second dose of epinephrine?
40 units of vasopressin
What piece of medical history should be obtained in deciding how to treat atrial fibrillation?
How long has this been going on? (New onset vs. pre-existing)
What is the ACLS protocol for ventricular fibrillation?
Shock every 2 minutes, epinephrine every 3 minutes, CPR 30:2 ratio in between and continuously check for pulse/rhythm to assure correct protocol, consider amiodarone or lidocaine (pg. 159 SU)
What is the underlying mechanism for septic shock?
Decreased total peripheral resistance often due to release of inflammatory mediators (ie: from GN bacteria, IDC or end-toxin mediated)
What is the antidote to antimuscarinic, anticholinergic agents?
Physostigmine
What is the antidote to benzodiazepines?
Flumazenil
What is the antidote to TCAs?
Sodium bicarb for prolonged QRS, diazepam for seizures
What is the antidote to warfarin?
Vitamin K, FFP
What is the antidote to Methanol, ethylene glycol (antifreeze)
Fomepizole or ethanol
What is the antidote to arsenic?
Dimercaprol, succimer or pencillamine
18 y/o male is found to have a systolic heart murmur heard at the apex and L lower sternal border that increases in intensity while standing after squatting. What dx?
Hypertrophic cardiomyopathy
What is the clinical definition of HTN?
>140/90 on 3 separate readings
Which blood product for severe anemia due to autoimmune hemolytic anemia?
Packed RBC's (pRBC's)
Which blood product for hemophilia?
Clotting factors - A give VIII (8), B give IX (9)
Which blood product for DIC?
FFP +/- platelets (only if real low)
Which blood product for shock due to trauma or post-partum hemorrhage?
Packed RBCs, IV fluids, very rarely can consider whole blood
Which blood product used to maintain BP during large volume paracentesis?
Albumin
Which blood product for hemorrhage due to warfarin overdose?
FFP
Which blood product is vWF-rich?
Cryoprecipitate
Which blood product for thrombocytopenia?
Platelets
Which vasopressor theoretically causes renal vasodilation?
Dopamine
Which vasopressor at high doses optimizes the alpha1-vasoconstriction?
Epinephrine
Which vasopressor is an ADH analogue?
Vasopressin
Which vasopressor is the best choice for anaphylactic shock?
Epinephrine
Which vasopressor is the best for septic shock?
Norepinephrine
Which vasopressor is best for cardiogenic shock?
Dobutamine
Which vasopressor causes vasoconstriction, but with bradycardia?
Phenylephrine
In Swan-Ganz catheter (pulmonary artery catheter), of what is the wedge pressure a good estimate of?
L atrial pressure
What is the classic ECG appearane in atrial flutter?
Sawtooth pattern of P waves
What side effects can arise form theophylline overdose?
Seizures, hyperthermia from excess muscle contraction, hypotension, cardiac tachyarrhythmais
What is the tx for Kawasaki disease in the acute phase?
High dose aspirin, IVIG (NO STEROIDS)
Pt presenting to ER after being involved in MVC. Does not open eyes or make any sounds, but he does withdrawal to pain. What is his GCS? What needs to be done?
GCS of 6 - need to intubate
MVC victim arrives to ER. HE is able to carry a conversation and even comment about the nurses hair. He is able to MAE on command, and has periorbital ecchymosis and surrounding superficial scrapes. What is his GCS? What radiological study does he definit
GCS of 15 - needs non-contrast CT of head
What interventions are effective in the management of elevated ICP?
IV mannitol, head to 30 degrees, intubate and possibly hyperventilation, decompression craniectomy
What are the sx of a basilar skull fracture?
Raccoon eyes, Battle's sign, blood behind TM (hemotympanum), CSF otorrhea or rhinorrhea
What heart disease has ST segement elevation in leads corresponding to perfusion of multiple arteries?
Acute pericarditis
Hypotension + distant heart sounds + distended neck veins?
Beck's triad for cardiac tamponade
Cardiac cath showing equal pressure in all heart chambers is what heart disease?
Constrictive pericarditis
Chest pain that lessens when the patient leans forward?
Acute pericarditis
What is the next step in evaluation of a pulsatile abd mass and bruit?
US for quick evaluation for AAA, CT abdomen for more accurate evaluation
What is the treatment for ventricular fibrillation?
Shock, epi q 3-5 minutes, CPR 30:2
What type of immunodeficiency increases the risk of anaphylactic transfusion reaction?
IgA deficiency
What would you find on physical xam of a patient with pericardial effusion?
Distant heart sounds, JVD, pulsus pardoxus (fall in SBP by >10 mmhg with inspiration), tacy HR and RR, electrical alternans on EKG, hypotension, diificult to palpate apical pulses
A patient is in the hospital and begins to have A fib with RVR. Previously pt had chronic A fib. What study has to be performed before the patient can be cardioverted?
TEE to look for clots!
Which antidepressants are associated with HTN Crisis? What substance can exacerbate this effort?
MAO-I with tyramine
What EKG finding is associated with hypothermia?
J wave (which occurs rght after the QRS and is seen as a small positive deflection)
What are the classical physical findings of endocarditis?
Fever, New murmur, splinter hemorrhages (subungal on fingers or toes), janeway lesions (painless purpura), Roth spots (rential hemorrhages), Osler nodes (painful lesions on pads of fingers and toes)
What would you suspect in an ER patient with blood in the urethral meatus or a high-riding prostate?
Bladder rupture or urethral injury (DO NOT PLACE A FOLEY!)
What are the 2 measures of how severe the hypotension is in shock?
Urine output, mental status (are they perfusing the braina and kidneys)
What causes a continuous, machine-like heart murmur?
PDA (patent ductus arteriosus)
What should be done to evaluate an extremity trauma?
Good neurovascular exam (may need to be serial exams, sensory, neuro, vascular) , CT or XR for bone injury, MRI for soft tissue injury, and angiography for BV injury
Since bleeding between the fetus and mother is a concern in trauma, what actions should be taken once the patient and the fetus are stabilized?
Check for Rh negative status if she is negative, give RhoGam administration
When is the greatest risk for post-operative MI? What is recommended perioperatively for patients with known CAD?
Within the first 48 hours after surgery, perioperatively recommend telemetry monitoring
What lab findings suggest hepatic disease during a pre-operative work-up?
Prolonged PT/PTT, low platelets, increased bilirubin, decreased albumin
What interventions are helpful in optimizing lung function in the post-op period in patients with preexisting lung disease?
Spirometry, pain control, deep breathing, physical therapy (stuff for everybody) things like albuterol and nebs (inhaled steroids, bronchodilators) these will be used in pt's with pre-existing disease
What studies are ordered to evaluate the cause of a fever in post-op patients?
CBC, UA, and blood cultures, CXR, look at surgical wound possible wound culture, sputum culture, Doppler US or CT angiogram if concern for PE or DVT
What is seen on abdominal XR or CT scan that indicates a ruptured viscus?
Free air under the diaphragm
What is the classic finding in the abdominal exam of a patient with mesenteric ischemia?
Pain out of proportion to the exam!
What is the usual lab panel ordered in a patient presenting to the ER with generalized abdominal pain?
CBC, CMP, LFTs, B-HCG (women), stool guiac, UA, Amylase and lipase, Lactic acid, cardiac enzymes in pt's >45, DM or women
What type of rejection that is treatable with immunosuppressive agents? What is the mechanism of this rejection? Within what time frame may it show up?
Acute rejection (NOT HYPERACUTE), proliferation of anti-donor T cells, 6 days to 1 year time frame