Icm Final Fall 2011 Case Reviews

Front 1

Pts had mortality rate of ___ when treated within 70 mins vs ___ when treated after 700 mins.

The ideal tx time for MI from time of sxs onset is:

Back 1

1.3% vs 8.7%

90 mins

Front 2

Tx of MI within 2 hrs results in:

Tx 2-12 hrs:

Back 2

substantial myocardial salvage

Modest benefits if occluded artery opened.

Front 3

Most MIs are of what two types? What leads for each?
Where will you see reciprocal changes?

Back 3

Anterior (V1-V6)
Inferior (II, III, AVF) (worst)

On the opposite leads
Inferior opp leads: V1-V4

Front 4

How many pts delay seeking tx for MI for how long?

Back 4

26-44% of pts delay seeking tx for up to 4 hours.

Front 5

What is the cornerstone of MI dx?

Back 5

HISTORY

Front 6

Which pts have a high risk for AMI despite normal in-office EKG?

How many pts present abnormally?

Back 6

pressure, radiation to L arm, diaphoresis, male.

25%

Front 7

List some PE findings that may provide significant evidence of MI (6)

Back 7

Change in mental status, diaphoresis, JVD, S3-S4 sounds, bradycardia, low BP

Front 8

What 4 things do EKGs identify?

Back 8

1) dx atypical presentations
2) dx non-ischemic but poss life threatening causes of cp
3) to reduce risk of adverse outcome/hospital disposition
4) Establish therapeutic criteria

Front 9

How many pts have EKG changes from AMI on presentation?

Repeat at ___ mins if intial one is normal

Back 9

72%

20 mins

Front 10

What can find an MI earlier than an EKG?

What is the PPV of EKG dx of MI?

Back 10

Echo

90%

Front 11

Therapeutic intervention of MI in order:

Back 11

ABCs
O2
IV fluids
HR monitor/EKG

Front 12

What drug should be started in AMI pts with >90 mm HG systolic BP?

How do you reverse an OD of this drug?

Back 12

Nitroglycerin IV.

IV NS bolus of 250-500cc

Front 13

If there are no contraindications, what OTC med should be given right away to reduce mortality during/after an MI?

Back 13

aspirin

Front 14

What part does morphine play in AMI?

What dose and admin?

Back 14

Morphine: Decreases pain, anxiety, o2 demand and VD/preload.

2-5 mg IV every 5-30 mins PRN. Risk of hypotension

Front 15

What part do Beta Blockers play in AMI?

Contraindications?

Back 15

Decreases contractility, HR, and o2 demand.

CHF, COPD, AV block, bradycardia, hypotension

Front 16

What part does prophylactic lidocaine play in AMI?

What are the "risks" (2)?

Primary contraindication?

Back 16

NOT recommended unless pt is at risk:

multifocal MI
PVCs/Vtach >5/min

bradycardia

Front 17

What is the largest impact to delays in care for MI?

Back 17

Pt education

Front 18

What is a contraindication to thrombolytic therapy in AMI?

What is important about the EKG results before administering thrombolytic therapy?

Back 18

Hypotension (but no data actually exists supporting this)

Need to see STE in 2+ leads first

Front 19

What is the treatment plan for MI?
(1-5)

Back 19

1) supplemental o2 & thrombolytic tx to increase o2 supply
2) BBs and CCBs to decrease contractility and o2 demand
3) Nitro to increase metabolic substrate availability
4) anti-inflamms 5) antiplatelet and antithrombins to prevent reocclusion

Front 20

What are the most common organisms involved in penile discharge? (7)

Back 20

GC, Chlamydia, Ureaplasma, Mycoplasma, Trichomonas, Herpes simplex (atypical), coliforms (anal sex)

Front 21

Why are GC/Chlamydial infections of greater concern than acute sxs?

Are all pts with this symptomatic?

Back 21

They increase the risk of STD and of HIV transmission.

No.

Front 22

Gonorrhea

Incubation:
Sxs:

Back 22

<2 wks

dysuria & discharge goes from clear to purulent (hey, now I get why this word is used preferentially over pus in medical docs...)

Front 23

Non-GC urethritis

Incubation of organisms:
Sxs:

Back 23

2-4 wks

less acute dysuria & discharge

Front 24

What might be causing urethritis with no discharge?

Back 24

exposure to spermicide/lube, or mechanical manipulation (back in my day, they called this 'spanking the football...' Wait, what?

Front 25

PE for penile discharge: what might be the cause of fever if present?

Back 25

Fever: some kind of itis or disseminated GC infection

Front 26

PE for penile discharge: what might be the cause of genital lesions? (4)

Back 26

Vesicles: herpes
Warts: HPV
Painless ulcers: syphilis or LGV
Painful ulcers: herpes or chancroid

Front 27

What is LGV in penile discharge?

Back 27

lymphogranuloma venereum caused by chlamydia types L1-L3.

Front 28

What differentiates granuloma inguinale from LGV?

Back 28

Lack of lymphadenopathy

Front 29

Describe a chancroid lesion

Back 29

painful with lymphadenopathy

Front 30

What causes syphilis and what is the ulcer like?

Back 30

Treponema.

painless with lymphadenopathy

Front 31

PE for penile discharge: Epididymitis vs
Torsion

Back 31

Unilateral testicular pain/swelling, firm epididymus

Torsion presents as unilateral high testicle with no cremaster reflex. sudden onset.

Front 32

PE for penile discharge: joint pain

Back 32

anticipate disseminated GC

Front 33

Describe some hallmarks of disseminated GC (3)

Back 33

Fever, joint pain, discharge.

Front 34

What is the most important pathogen cultured in NGU?

Description:

Back 34

Chlamydia

nonmotile gram neg. obligate intracellular parasite that cannot be cultured on artificial media

Front 35

How does one confirm urethritis? (4)

Then what?

Back 35

Mucuprurulent discharge on PE
+ leuks in sx male
>5 WBCs on gram stain of secretions
>10 WBCs on first void urine micro

Do a NAAT - tests for both GC & chlamydia

Front 36

Does the routine genital culture include testing for GC or chlamydia?

Back 36

No. Must special order.

Front 37

When testing for UTI, use ___ urine. When testing for urethritis using NAAT, use ___ urine.

Back 37

Midstream; first-void

Front 38

What would you expect from a gram stain of GC pus?

From NGU?

Back 38

Gram neg intracellular diplococci

WBCs only

Front 39

What test MUST be done for chlamydia & GC if rape is suspected?

Back 39

Culture (outside of routine genital culture)

Front 40

What are the screening recommendations for women and GC/Chlamydia (2)?

What about for men?

Back 40

At the annual pelvic for all women:

sexually active and <25 yo
All women >25 with risk factors (unprotected sex, drug use)

All men who have sex with other men.

Front 41

Your pt is 15 and presents with an STD. Can you dx & tx him without parental consent in all 50 states?

Back 41

Yes.

Front 42

What is the preferred tx of GC (and incidentally, chlamydia, too)?

Back 42

Ceftriaxone 250mg IM with Azithromycin 1 gm PO x1 dose

Must treat at time of visit after taking cultures.

You MUST attempt to tx the pts sexual partner(s).

Front 43

When should a pt follow up after dx of GC/chlamydia STD?

Back 43

3 months for retesting and HIV testing.

Front 44

What does PSGN stand for?

What are the sxs (6)?

Back 44

Post-streptococcal glomerulonephritis

Recent URI or strep infection, HTN, hematuria, oliguria, , flank pain, peripheral edema

Front 45

What are the common lab findings in PSGN (4)?

Back 45

ASO +, + antiDNaseB, elevated BUN/creatinine, low C3 but normal C4,

Front 46

What is the typical course of PGSN? (4)

Back 46

Self-limited.
Recovery in several weeks.
Control of HTN and fluid retention are key.
Monitor creatinine until WNL

Front 47

What type of diuretics should be avoided in tx of PSGN?

What is a non-drug way to tx?

Back 47

K-sparing since pt has reduced GFR.

Dietary restriction of salt, K+, protein.

Front 48

What do RBC casts in urine cx indicate?

Back 48

That issue is in glomerulus/glomerulonephritis

Front 49

When would you perform a renal biopsy on a PSGN pt and what would you find on EM?

Back 49

Only if disease fails to resolve. Would see a subepithelial hump on EM.

Front 50

Would you expect a strep screen to be + or - in a pt with PSGN?

Back 50

Negative. Infection has passed.

Front 51

Will abx tx prevent PSGN?

Back 51

Nope. It will eliminate a carrier state of strep, though.

Front 52

What are the causes of pseudohematuria (4)?

What types of meds might cause it (5)?

Back 52

Medications, vegetable dyes, antiseptics, metabolites (porphyrin)

NSAIDs, Nitrofurantoin, Pyridium, ExLax, Rifampin

Front 53

What can cause a false + for blood in a UA dip (3)?

A false - (1)?

Back 53

semen
pH >9
contamination with cleanser

Huge Vit C doses. But generally unreliable.

Use micro analysis to diff.

Front 54

When the UA dip is + for blood, but micro is - for RBCs, consider what (2)?

Back 54

myoglobinuria secondary to muscle injury (runners) or hemoglobinuria (from hemolysis)

Front 55

What is the most common cause of hematuria worldwide?

Back 55

Schistosomaiasis

Front 56

If a pt is taking warfarin, can you ignore hematuria?

Back 56

Nope. 30% have underlying GU abnormalities.)

Front 57

What are the Centor criteria for Strep (4)?

Back 57

Hx of fever
Tonsillar exudate
Ant Cx lymphadenopathy
Absence of cough

Front 58

What is the first question you ask yourself in a pt presenting with palpitations?

How do you test (3)?

Back 58

Are the palpitations life-threatening?

Eval appearance, vitals, & EKG.

Front 59

What is the second question you ask yourself in a pt presenting with palpitations?

Back 59

Is there a cardiogenic problem causing the palpitations?

Front 60

What are the life-threatening dysrhythmias you need to rule out (3)?

Back 60

V-Tach
MI with PVCs
SVT with hypotension or poor perfusion

Front 61

What are the cardiogenic causes of palpitations and their hints (7)?

Back 61

Rhythm extremes, murmurs, clicks, syncope: CAD, MI, Valvular Heart Disease, Mitral Valve Prolapse

PSVT: abrupt onset HR >120
Afib, Aflutter: independent onset
Extra systoles: random jumps/skips

Front 62

What is the classic PE finding of a pt with Mitral Valve Prolapse?

Back 62

Mid-systolic click OR late systolic with late murmur.

Front 63

MVP etiology (7)

Back 63

Common. Highly variable. Often idiopathic. F>M, 14-30 yo. Confirmed with echo. Often asymptomatic

Front 64

What other mitral issue can occur with MVP?

Back 64

Mitral regurg over years. Sudden death is rare.

Front 65

What happens in MVP when the pt does a Valsalva maneuver?

Back 65

The click and murmur occur earlier.

Front 66

Where do arrhythmias originate in MVP?

What are the most common ones (3)?

Back 66

Ventricles. From papillary stress.

Front 67

At what stage do you tx pts with MVP?

So, what is the biggest concern?

Back 67

If you suspect mitral regurg, administer prophylactic abx against infective endocarditis for any procedures. May also consider antiarrhythmics for severe sxs.

Mitral regurg

Front 68

What hx questions should you focus on in a pt with SOB (5)?

Back 68

Time course + sudden or gradual onset?
CP?
Underlying cause like trauma, aspiration, or infection?
Meds?
Hx of same?

Front 69

Areas to focus on in PE of pt with SOB

GEN (4)
Other (4)

Back 69

GEN: AIRWAY, ANO, vitals, ability to talk.
Other: cyanosis, gallop (CHF), breath sounds, LE edema

Front 70

What is acute resp failure?

Back 70

Abnormality of ventilation, diffusion, perfusion, or breathing control that dec o2 or increases CO2 beyond normal.

Front 71

What are the two types of Acute Resp Failure?

Back 71

Hypercapneic = inc CO2 with normal or dec o2

Nonhypercapneic = dec o2 with normal or dec CO2

Front 72

Can you dx Acute Resp Failure after one ABG?

Back 72

Nope. determined by repeated assessment of response to therapy.

Front 73

Bronchitis

Definition

Mech

Presentation

Back 73

Daily productive cough >3 mos/yr Usually in male smokers

chronic condition of excess mucus. Poor vent. May lead to CHF, or have underlying issues.

PE: cyanotic cachetic wheezes

Front 74

Emphysema

Definition

Mech

Presentation

Back 74

Smoking men. Rarely an a1-antitrypsin def.

abnormal, permanent enlargement of air spaces distal to terminal bronchioles.

PE: barrel chest, wheezing

Front 75

Pneumonia

Presentation

Back 75

causative organisms

Present with fever, tachypnea, tachycardia. Poss dullness to percussion, fremitus pectoriloquy.

Front 76

Pneumothorax

Etiology

Mech

Presentation

Severe

Back 76

Tall males or pts with underlying lung disease.

Rupture of a bleb into pleural space = deflation

Sudden onset SOB with pleuritic CP. Usually unilateral.

Tension pneumothorax = JVD, tracheal deviation

Front 77

Pulm Embolism

Common source

Presentation

Back 77

Usually from DVT

Sudden onset dyspnea with pleuritic CP. Hemoptysis and anxiety common. Increase pulmonic valve closure

Front 78

Define A-a gradient and calc.

Normal:

Back 78

= 150 - [PO2 + (PCO2/0.8)]

10-20

Front 79

What are some tests you should perform on a pt with COPD (5)?

Back 79

A-a gradient
CBC (r/o infection and confirm erythrocytosis)
CXR
FEV1/PEFR: usually low. Improves with B agonist.
Gram Stain of sputum

Front 80

What is a major warning sign of impending respiratory failure?

Back 80

Lethargy

Front 81

What is a Venturi mask and what concentration should you start at?

Back 81

Allows doc to prescribe actual oxygen percentage. Start at 24-28% FiO2.

Front 82

Tx of COPD (7)?

Back 82

O2
B-agonist inhalers
Steroids
Anticholinergics
Theophylline (not main tx)
OMM
Tx of infection if indicated

Front 83

Sickle Cell

Basic physiology

Clinical Course

Back 83

sickling of erythrocytes, inc blood viscosity

Typical pt is asymptomatic but anemic between episodes. Growth retardation, psychosocial, and infection issues are common.

Front 84

Life expectancy in Sickle Cell?

What might dispose pts to a vaso-occlusive crisis? (7)

Back 84

M: 42 W: 48 yo. Proper mgmt of infections will increase lifespan.

Cold, dehydration, stress, menses, ETOH, infection, UNKOWN.

Front 85

What organism is most likely to cause septicemia in Sickle Cell pts?

Meningitis?

Osteomyelitis?

Pneumonia?

Back 85

Strep. Pneumonia
Strep. Pneumonia
Salmonella
M. Pneumonia and viruses

Front 86

What is the SOC for the tx of FEBRILE Sickle Cell pts (5)?

Back 86

Hospitalization, blood draw, CSF, cultures and admin of parenteral abx @ >38.5C

Front 87

Treating pain in the Sickle Cell pt:

Hydration
Oxygen
Narcotics

Back 87

Aggressive hydration
Aggressive analgesics
Oxygen dictated by hypoxia sxs but not routine.

Front 88

What are some reasons Sickle Cell pts may be labeled as drug seekers (2)?

Back 88

Usually by doc who is not familiar with pt.
Pts also metabolize narcotics more rapidly - require higher doses more frequently.