Medicine

Front 1

Non-ICU CAP Treatment

Back 1

Standard Empiric:
1. Ceftriaxone 1g IVPB STAT then qd
2. Azithromycin 500mg IVPB STAT then qd

Alternative Empiric (failed outpatient Rx, suspected resistant orgs, beta-lactam allergy):
1. levofloxacin 750mg qd x 5 days

Front 2

Complicated Female UTI

Back 2

1. ampicillin 1-2g IV q6hrs x 7-14d + gentamicin 3-5 mg/kg/day x 7-14d

2. Ceftriaxone 1g IV qd x 7-14d

3. Zosyn 3.375 g IV q6-8hrs x 7-14d

Front 3

Short Acting Insulin

Back 3

1. human insulin (novolin/humulin)

2. Aspart (Novolog)

3. Lispro (Humalog)

Front 4

Long-Acting Insulin

Back 4

1. NPH

2. Detemir (Levemir)

3. Glargine (Lantus)

Front 5

Sulfonylureas

Back 5

1. Glyburide

2. Glipizide

3. Gliclazide

4. Glimepiride

Front 6

Incretin Mimetic (GLP-1 Receptor Agonist)

Back 6

Exenatide (Byetta)

Front 7

Metformin

Back 7

aka Glucophage

Front 8

Beta Blockade in CAD

Back 8

Titrate to resting HR 55-60 and approximately 75% of the HR that produces angina with exertion

Front 9

VTE Prophylaxis

Back 9

Standard:
1. Enoxaparin 40mg SC daily

BMI > 30 or high VTE risk:
1. Enoxaparin 40mg SC bid

GFR < 30
1. Enoxaparin 30mg SC qd

*Caution if GFR < 15

Front 10

Stress Ulcer Prophylaxis

Back 10

Mechanical ventilation, home PPI/H2 blocker Rx, coagulopathy + 1 risk factor, or at least 3 risk factors

1. Pantoprazole 40 mg PO/IV qd

or

2. Famotidine 20 mg PO/IV bid

Front 11

Stress Ulcer Risk Factors

Back 11

1. Sepsis / Shock
2. Hepatic / Renal Failure
3. Significant Trauma
4. Post-OP Transplant
5. High-Dose Steroids
6. Extensive Burns

Front 12

Diets

Back 12

1. Regular

2. Carb Controlled

3. Low Fat

4. 2 gram Na

5. Mechanical Soft

6. Clear Liquid

Front 13

Adult Vaccinations

Back 13

1. Pneumococcal - age > 65 x 1

2. Influenza (Oct-Feb)
- contraindicatd if egg allergy

3. Pertussis

Front 14

Antiemetics

Back 14

1. Metoclopramide (Reglan)

2. Prochlorperazine (Compazine)

Front 15

Constipation

Back 15

1. Docusate Sodium (100 mg PO bid)

2. Milk of Magnesia (30 ml PO bid PRN)

Front 16

Sleep Hygeine

Back 16

1. Go to bed only when tired
2. Bed/bedroom only for sleep/sex
3. Fixed wake-up/bedtimes (regardless of amt of sleep)
4. Avoid naps
5. Get out of bed if unable to sleep w/in 15-20 min
6. No ETOH after 4pm
7. Fixed meal times

Front 17

Hypnotics

Back 17

1. Benzos = temazepam (15 mg PO qhs)

2. Nonbenzos = zolpidem, zaleplon, eszopiclone

3. Melatonin receptor agonist (ramelteon)

Front 18

Portosystemic Anastomoses

Back 18

1. Left gastric -- > esophageal

2. Paraumbilical -- > superficial / inferior epigastric (caput)

3. Superior rectal -- > middle / inferior rectal (internal hemorrhoids)

Front 19

Diverticulosis

Back 19

- painless hematochezia

- 2/2 low fiber diet

Front 20

Diverticulitis

Back 20

- fever, leukocytosis, LLQ pain

- BRBPR

- colovesicular fistula -- > pneumaturia

Front 21

Aminotransferases

Back 21

- ALT > AST in viral hepatitis
- AST > ALT in alcoholic hepatitis
- AST elevation in MI

Front 22

Hepatocellular Carcinoma

Back 22

- Hep B/C, Wilson's, hemochromatosis, alpha-1 AT, alcoholic cirrhosis

- polycythemia
- hypoglycemia

- alpha fetoprotein
- hematogenous spread

Front 23

Cholelithiasis

Back 23

- Female, fat, forty
- Crohn, CF, rapid wt loss
- Charcot triad = jaundice, fever, RUQ pain
- cholesterol stones = radiolucent
- pigment stones = radiopaque

Front 24

PT

Back 24

Extrinsic (I, II, V, VII, X)

Front 25

PTT

Back 25

All factors except VII, XIII (intrinsic)

Front 26

Causes of Acute Pancreatitis

Back 26

1. Choledocholithiasis (esp < 5mm)
2. ETOH
3. Drugs
4. ERCP
5. Hyperlipidemia (esp TG > 1000)
6. Hypercalcemia
7. Infection
8. Autoimmune
9. CF

Front 27

Acute Pancreatitis Eval

Back 27

1. Hydration status (sequestration) - HR, orthostatics, high HCT, BUN)
2. Abd pain radiating to back; guarding, rebound, distention
2. Jaundice
3. Bowel Sounds (Ileus)
4. Flank / umbilical ecchymosis (Grey-Turner / Cullen)
5. CRP indicative of severity

Front 28

Ascending Cholangitis

Back 28

- Gallstones + fever, chills, and/or rigors

Front 29

Amylase

Back 29

- High sens / low spec

- Elevated w/ intestinal ischemia, chronic renal insuff, perforated peptic ulcer, and disorders of salivary glands, fallopian tubes

Front 30

Lipase

Back 30

- More sensitive than amylase in acute alcoholic pancreatitis or late presentation (prolonged elevation)

- Elevated in chronic renal insuff, head trauma / intracranial mass, heparin therapy (LPL activation), critical illness

Front 31

Peritoneal Signs

Back 31

- Rebound tenderness
- Guarding
- Involuntary rigidity

Front 32

Phlegmon

Back 32

Walled off inflammatory mass without bacterial infection that may be palpable on physical examination

Front 33

Diverticulitis Organisms

Back 33

- Bacteroides
- Peptostreptococcus
- Clostridium
- Fusobacterium

- E. coli
- Strep

Front 34

Complicated Diverticulitis

Back 34

- Abscess or phlegmon
- Fistula
- Stricture
- Bowel obstruction
- Peritonitis

Front 35

Diverticulitis Presentation

Back 35

- Fever, leukocytosis, LLQ pain
- Constipation
- Perirectal fullness
- Trace + guaiac

Front 36

Diverticulitis Mortality

Back 36

Stage 1-2: < 5% (abscess)
Stage 3 = 13% (perforated -- > purulent peritonitis)
Stage 4 = 43% (free rupture of uninflamed diverticulum)

Front 37

Diverticulitis Diagnosis

Back 37

CT (95/100% sens/spec)
- Diverticula
- Inflammation of pericolic fat / adjacent tissues
- Wall thickness > 4mm
- Peridiverticular abscess

Front 38

Outpatient Diverticulitis Treatment

Back 38

Outpatient
- Cipro + metronidazole x 7-10d
- TMP-SMX + metronidazole
- Amoxicillin-clavulanate

Front 39

Inpatient Diverticulitis Treatment

Back 39

- Unable to tolerate PO
- Requiring narcotic analgesia
- Complicated diverticulitis

- Make NPO
- NGT if obstruction / ileus
- Flagyl + cipro/ceftriaxone

Front 40

Psoas Sign

Back 40

Passively extend thigh while lying on side with knees extended

- Appendicitis in retrocecal orientation

Front 41

Depression Screen

Back 41

1. Sleep
2. Interest
3. Guilt
4. Energy
5. Concentration
6. Appetite
7. Psychomotor
8. Suicide

Front 42

Causes of Hypernatremia

Back 42

Sustained hyperNa only occurs when thirst or access to water is impaired

1. Net Water Loss
- Pure water loss (DI, unreplaced insensible losses)
- Hypotonic fluid loss (vomiting / diarrhea, NGT, osmotic diuresis, diuretics, burns)
2. Hypertonic Sodium Gain (bicarb, primary hyperaldosteronism, Cushing's, hypertonic feeding preparation)

Front 43

Signs / Symptoms of Hypernatremia (Adults)

Back 43

- Elderly often w/ few symptoms until Na > 160
- s/s of dehydration (tachycardia, decr turgor, dry MMs)
- Thirst (dissipates as hyperNa progresses)
- ALOC (correlates to severity)
- Muscle weakness
- Convulsions, coma
- Orthostasis, tachycardia 2/2 hypovolemia
- Brain shrinkage -- > vascular rupture (large acute changes)

Front 44

Hypernatremia Management

Back 44

1. Treat Underlying Cause
- Stop GI losses
- Control pyrexia
- Normalize glucose
- d/c diuretics, lactulose, Li
- Treat hyperCa, hypoK

2. Correction of HyperNa
- Rapid correction (1 mmol/L per hour) if developed over period of hours
- Slow correction (0.5 mmol/L per hour) w/ goal decrease in serum Na of 10 mmol/L per day --- > 145 mmol/L
- Pure water, D5W, one-quarter normal saline, half normal saline (decr infusion rate req'd for lower tonicity of fluid)

3. Anticonvulsant Rx, airway management if seizures

Front 45

Change in Serum Na

Back 45

Effect of 1L infusate on serum Na:

[Infusate Na - Serum Na] / TBW + 1

Effect of 1L infusate containing Na and K:

[(Infusate Na + infusate K) - serum Na] / TBW + 1

**divide goal change in Na by calculated change in Na for 1 L solution to obtain total # L solution req'd

Front 46

Infusates

Back 46

D5W = 40% ECF distribution

1/4 NS (34 mmol/L), 55% ECF distribution

1/2 NS (77 mmol/L), 73%

Ringer's Lactate (130 mmol/L), 97%

NS (154 mmol/L), 100%

Front 47

TBW

Back 47

TBW = ECF (40%) + ICF (60%)

Nonelderly men = 0.6 x body wt
Nonelderly women = 0.5 x body wt

Elderly men = 0.5
Elderly women = 0.45

Front 48

D5W

Back 48

ECF distribution = 40%

Front 49

Normal Saline

Back 49

- 0.9% = 154 mmol/L
- 100% ECF distribution

Front 50

Half Normal Saline

Back 50

- 77 mmol/L
- 73% ECF distribution

Front 51

Ringer's Lactate

Back 51

- 130 mmol/L Na
- 97% ECF distribution

Front 52

UC CRC Surveillance

Back 52

After 8 yrs if pancolitis, 15 yrs for L sided colitis. Repeat q1-2 yrs

Front 53

Wells Score for PE

Back 53

1. Clinical s/s of DVT (minimum leg swelling + pain with palpation)
2. Alternative dx less likely than PE
3. HR > 100
4. Immobilization or surgery w/in previous 4 wks
5. Previous DVT/PE
6. Hemoptysis
7. Malignancy

Front 54

Iron Deficiency s/s

Back 54

- Anemia
- Angular cheilosis
- Atrophic glossitis
- Pica
- Koilonychia
- Plummer-Vinson (Fe deficient anemia, esophageal web, atrophic glossitis)

Front 55

Non Gap Acidosis

Back 55

1. RTA
2. GI Losses
3. Ureteral fistula
4. Pancreatic fistula
5. Acetazolamide

Front 56

AFFIRM Trial

Back 56

Rate control = rhythm control in a-fib

Front 57

Goal Hgb in CAD

Back 57

> 9-10

Front 58

CHADS-2

Back 58

CHF, HTN, A, DM, Stroke

0 -- > ASA only
1 -- > ASA / coumadin / dabigatran
2+ -- > warfarin / dabigatran

Front 59

Pulmonary Edema 2/2 CHF

Back 59

1. Lasix
2. Morphine (venodilation)
3. Nitrates
4. Oxygen
5. Position / PPV

Front 60

Metformin

Back 60

d/c for Cr > 1.5 in men (1.4 in women) -- > risk of lactic acidosis with IV contrast

Front 61

SubQ Heparin

Back 61

- DVT ppx in renal failure
- tid dosing
- Incr risk of HIT

Front 62

Iron Deficiency DDx

Back 62

- Chronic bleeding (GI, menstrual)
- Malnutrition
- Malabsorption (Celiac, Crohn's, incr gastric pH, subtotal gastrectomy)
- Increased demand (pregnancy, EPO)

Front 63

Inpatient DM Management

Back 63

- Sliding scale insulin + Lantus

- d/c metformin - serious acute illness predisposes to lactic acidosis
- Normal serum Cr at d/c prior to restarting metformin

Front 64

AMS DDx

Back 64

- Hypoxia
- Infection / sepsis
- Hypercarbia
- Brain injury
- Drug intoxication / withdrawal
- Uremia
- Endocrine / metabolic
- Acid/base imbalance
- DTs
- Delirium
- Pain, fever
- Dementia

Front 65

Warfarin Interactions

Back 65

- Broccoli, fresh melon, spinach
- Amiodarone
- Antibiotics (esp consider in patients treated for UTI)
- NSAIDs

Front 66

IV Nutrition

Back 66

D5W = 200 calories per liter

Front 67

VBG -- > ABG

Back 67

pH increases 0.03 - 0.05

PCO2 decreases 3-5 mmHg

Front 68

Causes of Hypercalcemia

Back 68

- CHIMPANZEES
1. Calcium (supplements)
2. Hyperparathyroidism
3. Infection (esp granulomatous - cocci, TB, histo)
4. Mets, Milk of Ca
5. Paget's Disease, TPN
6. Addison's Disease
7. Neoplasm
8. Zollinger-Ellison
9. Endocrine (thyrotoxicosis, pheo)
10. Excess Vit D
11. Sarcoidosis

Front 69

Treatment of Hypercalcemia

Back 69

1. NS (4-6 L) to prevent renal failure
2. Bisphophonates
3. Calcitonin (rapid tachyphylaxis)
4. Lasix if volume overloaded
5. Steroids (? utility in malignancy, granulomatous disease, Vit D intoxication)

Front 70

C. Diff Toxin

Back 70

- May persist up to 1 yr post-infection

Front 71

ESR > 100

Back 71

- Paraproteinemia
- Infective endocarditis
- Giant cell arteritis
- Osteomyelitis
- Subacute thyroiditis

Front 72

Hypercalcemic Crisis

Back 72

- Ca > 13-15
- Polyuria
- Dehydration
- Mental status changes

Front 73

Neupogen

Back 73

- aka filgrastim
- G-CSF analog
- Treatment of neutropenia s/p chemo

Front 74

Tertiary Hyperparathyroidism

Back 74

Renal failure -- > wasting -- > parathyroid hyperplasia -- > s/p renal transplant

Front 75

Common bone mets

Back 75

1. Lung
2. Thyroid
3. Prostate

Front 76

Linezolid

Back 76

- G+ including MRSA, VRE
- MAO inhibition

Front 77

Tumor Lysis Syndrome Labs

Back 77

1. Uric acid
2. Phos
3. Calcium
4. Creatinine (urate nephropathy)

Front 78

Tumor Lysis Syndrome Treatment

Back 78

- Allopurinol
- IVF +/- diuretics
- Rasburicase (recombinant urate oxidase)
- Alkalinization of urine (bicarb) to increase urate solubility (may cause metabolic alkalosis or CaPO4 precipitation)
- Consider HD if uric acid or phos > 10
- HD if uric acid or phos > 10

Front 79

GI Cocktail

Back 79

1. 30cc Maalox
2. 10cc viscous lidocaine