Step 2 - Internal Medicine

Front 1

how often should you screen for HTN and what age begin screening?

Back 1

every 2 years, start at 3 yrs old

Front 2

accepted cut off value for normal BP; and how do you diagnose HTN

Back 2

140/90; 3 separate measurements on 3 separate occasions >140/90

Front 3

is 145/75 HTN?

Back 3

yes, it's isolated systolic HTN. systolic and diastolic HTN both decrease life expectancy

Front 4

when should you treat HTN immediately?

Back 4

pregger and severe HTN like >210/>120

Front 5

Initial drug tx for HTN depends on what?

Back 5

classification

Front 6

normal is what and what is initial drug tx?

Back 6

<120/<80; no tx

Front 7

Prehypertension

Back 7

120-139/80-89; no tx unless compelling indications (DM, chronic kidney dz)

Front 8

Stage 1 HTN

Back 8

140-159/90-99; tx is thiazides or combo

Front 9

Stage 2 HTN

Back 9

>160/>100; tx is thiazide plus at least one other agent

Front 10

what is stage if BP = 168/60?

Back 10

stage 2 b/c classification is based on the worst number

Front 11

what are the five first line antihypertensive medications?

Back 11

1. thiazide diuretics (preferred agent in pts wtihout additional comorbidities)
2. B blockers
3. ACEIs
4. ARBs
5. Ca2+ channel blockers

Front 12

how do you choose which medication to give?

Back 12

based on comorbidities

Front 13

which medication is safe in pregnancy?

Back 13

hydralazine, labetalol or alpha-methyldopa
*in preeclampsia, mag sulfate lowers BP

Front 14

define a hypertensive urgency and emergency

Back 14

urgency: BP >200/120 without end organ damage
emergency: BP >200/120 with acute end organ damage
*tx with nitroprusside, nitroglycerin or B blocker (labetalol) emergently

Front 15

what is evidence of end organ damage?

Back 15

acute L ventricular failure, unstable angina, MI, encephalopathy (HAs, mental status changes, vomiting, blurred vision, dizziness, papilledema)

Front 16

when would you use an ACEI?

Back 16

pts with: heart failure, DM, ACS or unstable angina, acute or prior MI, high risk of coronary artery dz or CVA, chronic kidney dz

Front 17

when should you avoid ACEIs?

Back 17

pregnancy, angioedema, renovascular HTN (can cause renal failure)

Front 18

When would you use an aldosterone receptor blockers (ie: spironolactone, eplerenone)?

Back 18

pt with: heart failure, prior MI

Front 19

when should you avoid aldosterone receptor blockers?

Back 19

hyperkalemia, pregger

Front 20

when would you use and angiotensin receptor blocker (ARB: ie. losartan, irbesartan)?

Back 20

heart failure, DM, chronic kidney disease

Front 21

when should you avoid ARBs?

Back 21

pregger, renovascular HTN (can cause renal failure)

Front 22

when would you use B blockers?

Back 22

stable angina, ACS, unstable angina, acute or prior MI, high risk of coronary artery disease, atrial tachycardia or fibrilliation, thyrotoxicosis, essential tremor, migraines

Front 23

when should you avoid B blockers?

Back 23

asthma, COPD, heart block, sick sinus syndrome

Front 24

when would you use Ca2+ channel blocker?

Back 24

raynaud's syndrome, atrial tachyarrythmias

Front 25

When should you avoid Ca2+ channel blockers?

Back 25

heart block, sick sinus syndrome, CHF, pregger

Front 26

when should you give thiazide diuretics?

Back 26

heart failure, DM, high risk of coronary artery dz or CVA, osteoporosis

Front 27

when should you avoid thiazides?

Back 27

gout, electrolyte disturbances (ie. hyponatremia), pregger

Front 28

what's the difference b/w nitroprusside and nitroglycerin?

Back 28

nitroprusside dilates arteries and veins; nitroglycerin is a venodilator only

Front 29

which HTN meds are arterial dilators only?

Back 29

hydralazine, alpha-1 antagonists, Ca2+ channel blockers

Front 30

venodilators reduce what?
arterial dilators reduce what?
nitroprusside does what?

Back 30

veno- reduce preload
art- reduce afterload
nitroprusside reduces preload and afterload

Front 31

what are the benefits of lowering BP?

Back 31

lowers risk for CVA (HTN is most important CVA risk factor), heart dz, MI, atherosclerosis, and dissecting aortic aneurysm

Front 32

what is the most common cause of death among untreated hypertensive patients?

Back 32

coronary disease

Front 33

what is MCC of secondary HTN in female? what is the 2nd MCC?

Back 33

OCPs; renovascular HTN d/t fibrous dysplasia

Front 34

causes of secondary HTN in young man?

Back 34

ETOH, "exotic" conditions (pheochromocytoma, cushing's, conn's, polycystic kidney dz)

Front 35

causes of new onset secondary HTN in elderly?

Back 35

renovascular HTN d/t atherosclerosis (ACEIs can precipitate renal failure)

Front 36

hints to secondary HTN and tests to order

Back 36

following 7 slides

Front 37

pheochromocytoma

Back 37

urinary catecholamines (vanillylmandelic acid, metanephrine) plus intermittent severe HTN, dizziness and diaphoresis

Front 38

Polycystic kidney disease

Back 38

flank mass, family hx, elevated creatinine, and elevated blood urea nitrogen (BUN)

Front 39

cushing's syndrome

Back 39

dexamethasone suppression test or 24 hour urine cortisol level

Front 40

renovascular HTN

Back 40

MR or CT angiogram, US, or ACEI nuclear renal scan, if there is a bruit on exam, tx with angioplasty and stenting

Front 41

where does fibromuscular dysplasia usually occur in the renal artery? what does it look like?

Back 41

mid-renal artery; beaded appearance; usually occurs without other evidence of atherosclerosis (young pts)

Front 42

conn's syndrome

Back 42

high aldosterone, low renin

Front 43

coarctation of aorta

Back 43

upper extremity HTN only, unequal pulses, radio-femoral delay, a/w turner's syndrome, rib notching on xray

Front 44

what are classic signs and symptoms of DM?

Back 44

polydipsia, polyuria, polyphagia, weight loss

Front 45

how do you dx DM?

Back 45

fasting plasma glucose of 126mg/dL or random glucose of 200mg/dL

Front 46

what is the goal of DM treatment?

Back 46

keep postprandial glucose <180-200 and fasting glucose <130. stricter control results in too many episodes of hypoglycemia (symptoms of sympathetic d/c and mental status changes)

Front 47

type I DM

Back 47

develop ketoacidosis, is HLA associated, <50% twin occurance, antibodies to insulin, insulitis (loss of most beta cells of pancreas), do NOT respond to oral hypoglycemics

Front 48

type II DM

Back 48

develop hyperosmolar state, no HLA assoc, >50% twin occurance, NO ketoacidosis, respond to oral hypoglycemics, NO antibodies to insulin, normal number of islet beta cells but with amyloid deposits

Front 49

how is C peptide important in DM?

Back 49

low C peptide = too much exogenous insulin (accidental overdose or factitious d/o)
high C peptide = insulinoma

Front 50

what kind of imaging contrast should be used in DM pts?

Back 50

iodinated contrast ONLY when absolutely necessary b/c IV contrast agents can precipitate acute renal failure, and make sure pt is well hydrated before using contrast agents

Front 51

what constitutes the dx of DKA?

Back 51

hyperglycemia, hyperketonemia, and metabolic acidosis; seen in DM1

Front 52

what is tx for DKA?

Back 52

fluids, IV regular insulin, potassium and phosphorus replacement. do NOT use bicarb unless the pH is <7

Front 53

what is nonketotic hyperglycemic hyperosmolar state?

Back 53

seen in DM2, hyperglycemia, hyperosmolarity without ketonemia

Front 54

how do you tx nonketotic hyperglycemic hyperosmolar state?

Back 54

IV fluids, IV insulin and electrolyte replacement

Front 55

what are some long term complications of DM?

Back 55

atherosclerosis, retinopathy, nephropathy (ACEIs help prevent this), infections, neuropathy, foot ulcers/infection/gangrene, peripheral neuropathy, gastroparesis, charcot's joints, impotence from autonomic neuropathy and PVD, cranial nerve palsies, orthostatic hypotension, silent MI

Front 56

what is MCC of non-traumatic amputations?

Back 56

DM

Front 57

how much insulin is usually required in DM1?

Back 57

0.5-1.0 U/kg body weight per day

Front 58

if pt has high 7am glucose, what should you do?

Back 58

increased NPH insulin at dinner the night before

Front 59

if pt has high noon glucose, what do you do?

Back 59

increase morning regular insulin or increase before-breakfast lispro or aspart insulin

Front 60

if pt has high 5pm glucose, what do you do?

Back 60

increase morning NPH or increase before-lunch lispro or aspart insulin

Front 61

if pt has high 9pm glucose, what do you do?

Back 61

increase dinner time regular insulin or increase before dinner lispro or aspart insulin

Front 62

what are the ultra rapid acting insulins?

Back 62

insulin aspart and insulin lispro; give right before meals

Front 63

what is the rapid acting insulin?

Back 63

regular insulin; can give IV to inpatients, give 0.5-1 hour before meals for outpatients

Front 64

what are the intermediate acting insulins?

Back 64

NPH insulin (is usually part of standard regimens that mix with shorter-acting insulin: 70/30, 50/50 of NPH/regular) and lente insulin

Front 65

what is the long acting insulin?

Back 65

ultralente insulin; provide basal insulin level, supplement with short acting insulin

Front 66

what is the ultra long acting insulin?

Back 66

insulin glargine; provide basal insulin level, supplement with short acting insulin

Front 67

what is the somogyi effect?

Back 67

the body's reaction to hypoglycemia. ex. if too much NPH or other longer acting insulin preparation is give the day or night before, the 3am glucose will be low (hypoglycemia) and the body reacts by releasing stress hormones which cause the 7am glucose to be high. treatment is to decrease insulin

Front 68

what is the dawn phenomenon?

Back 68

hyperglycemia caused by normal early AM growth hormone secretion. the 7am glucose is high without 4am hypoglycemia (glucose is normal or high at 4am). treatment is to increase insulin

Front 69

how do you follow compliance in DM pt?

Back 69

check hemoglobin A1c levels (overall control for previous 3 months). want it to be <7%

Front 70

how do you prepare DM pts for surgery?

Back 70

give 1/3 to 1/2 their normal insulin dose then monitor glucose closely through surgery and postop using D5W and IV regular insulin to maintain glucose control

Front 71

which drugs can mask manifestations of hypoglycemia (tachycardia, diaphoresis) and so can prevent early detection of DM?

Back 71

B blockers, but benefits might outweigh the risks

Front 72

when should you measure cholesterol (ie. fasting lipoprotein profile)?

Back 72

starting at age 20 and every 5 years after that

Front 73

what is the formula for calculating LDL?

Back 73

LDL = total cholesterol - HDL - (triglycerides/5)

Front 74

what is the goal for total cholesterol?
for triglycerides?
for LDL?
for HDL?

Back 74

total chol <200 (>240 = high)
triglycerides <150 (>200 = high)
LDL <160
HDL >60

Front 75

which component is used in treatment decision making?

Back 75

LDL

Front 76

what are markers for familial hypercholesterolemia?

Back 76

xanthelasma, corneal arcus, lipemic-looking serum, obesity

Front 77

what is a marker for familial hypertriglyceridemia?

Back 77

pancreatitis with no risk factors (no alcohol, no gallstones)

Front 78

what are secondary causes of hyperlipidemia?

Back 78

uncontrolled DM, hypothyroidism, uremia, the nephrotic syndrome, obstructive liver dz, excessive ETOH intake (increases triglycerides), and medications (OCPs, glucocorticoids, thiazides and B blockers)

Front 79

what dz process is involved in ~1/2 of all deaths in US b/w ages 35-65 and is the most important cause of permanent disability and accounts for more hospital days than any other illness?

Back 79

atherosclerosis

Front 80

what are the risk factors for coronary heart disease?

Back 80

age (men 45, women 55), family hx of premature CHD, current cig smoking, HTN, low HDL (<40)
***these are the risk factors used when deciding whether to tx hypercholesterolemia
***HDL = 60 is cardioprotective and negates one risk factor

Front 81

in a pt with NO CHD risk factors, and
a) LDL = <160, what is tx?
b) LDL = 160-189?
c) LDL = >190

Back 81

a) no tx
b) diet +/- medications
c) medications (+diet)

Front 82

in pt with >/=2 CHD risk factors, and
a) LDL = <100, what is tx?
b) LDL = 100-129
c) LDL = >130

Back 82

a) none
b) diet +/- medications
c) medications (+diet)

Front 83

in pt with known CAD or equivalent, and
a) LDL = <100
b) LDL = >100, what is tx?

Back 83

a) none
b) medications (+diet)

Front 84

in pt with very high risk, and
a) LDL = <70
b) LDL = 70-99
c) LDL = >100

Back 84

a) none
b) diet +/- medications
c) medications (+diet)

Front 85

what are considered CAD equivalents?

Back 85

DM, peripheral arterial atherosclerotic disease, symptomatic carotid artery dz, abdominal aortic aneurysm

Front 86

which pts are considered "very high risk"?

Back 86

pts with CAD who have had a MI, DM, or other severe and poorly controlled risk factors (ie. metabolic syndrome, heavy smoking)

Front 87

what is the initial treatment in pt with hypercholesterolemia?

Back 87

if lower risk pt, give them 3-6 months to try lifestyle modification before initiating drug tx

Front 88

a) what increases HDL (good chol)?
b) what decreases it?

Back 88

a) exercise, estrogens, moderate ETOH intake (1-2 drinks/day)
b) smoking, androgens, progesterone, hypertriglyceridemia

Front 89

what are the 1st line agents for hypercholesterolemia?

Back 89

niacin (poorly tolerated but effective, esp to raise HDL); bile acid binding resins (cholestyramine, colesevelam); HMG CoA reducatase inhibitors (statins- most effective, more expensive, potential liver/muscle damage); and ezetimibe (zetia- blocks cholesterol absorption and is often combined with a statin)

Front 90

what is the single most significant source of preventable morbidity and premature death in the US?

Back 90

smoking (whenever not sure which risk factor to eliminate, always pick smoking)

Front 91

what does a young person with emphysema but no smoking hx have?

Back 91

alpha-1 antitrypsin deficiency

Front 92

what is involved in 50% fatal car accidents, 67% of drownings and homicides, 70-80% of death in fires, and 35% of suicides and is also the MCC of cirrhosis and esophageal varices?

Back 92

alcohol

Front 93

what are symptoms of Wernicke's syndrome?

Back 93

opthalmoplegia, nystagmus, ataxia, confusion; it is acute and often reversible and can be fatal

Front 94

what are symptoms of Korsakoff's syndrome?

Back 94

anterograde amnesia and confabulation, is chronic and irreversible

Front 95

wernicke's and korsakoff's syndromes are both caused by?

Back 95

thiamine deficiency and damage to mamillary bodies and thalamic nuclei

Front 96

What is stage 1 alcohol withdrawal?

Back 96

acute withdrawal syndrome: 12-48 hrs after last drink, tremors, sweating, hyperreflexia, and seizures ("rum fits")

Front 97

what is stage 2 alcohol withdrawal?

Back 97

alcoholic hallucinations: auditory and/or visual hallucinations and illusions with or without autonomic symptoms

Front 98

what is stage 3 alcohol withdrawal?

Back 98

delirium tremens: 2-4 days after last drink, hallucinations and illusions plus confusion, poor sleep and autonomic lability (sweating, increased pulse and temp); is occasionally fatal

Front 99

how do you treat alcohol withdrawal on inpatient basis?

Back 99

benzodiazepines and gradually taper dose over days

Front 100

signs of chronic liver dz in alcoholics?

Back 100

varices, hemorrhoids, caput medusae, jaundice, ascites, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, encephalopathy, asterixis, prolonged prothrombin time, hyperbilirubinemia, spontaneous bacterial peritonitis, hypoalbuminemia and anemia

Front 101

common conditions caused by alcohol abuse?

Back 101

gastritis, mallory-weiss tears, pancreatitis, peripheral neuropathy (via thiamine deficiency), brain damage (cerebellar degeneration), and cardiomyopahty

Front 102

what is best treatment for alcoholism?

Back 102

AA or other support group, also disulfiram can be tried (makes pts sick when they drink b/c of alcohol dehydrogenase enzyme inhibition)

Front 103

what are symptoms of fetal alcohol syndrome?

Back 103

mental retardation, microcephaly, microphthalmia, short palpebral fissures, midfacial hypoplasia and cardiac defects

Front 104

what is MCC of preventable mental retardation?

Back 104

fetal alcohol syndrome

Front 105

what kind of pneumonia is common in "skid row" alcoholics (homeless)?

Back 105

aspiration pneumonia via klebsiella (currant jelly sputum), anaerobes, e. coli, streptococci, staphylococci

Front 106

what are the most common vitamin and mineral deficiencies in alcoholics?

Back 106

folate, magnesium, and thiamine

Front 107

what should you give before glucose in alcoholics to prevent wernicke's encephalopathy?

Back 107

thiamine

Front 108

how do you treat bleeding varices?

Back 108

stabilization (IV fluids, blood), then upper endoscopy and sclerotherapy with cauterization, banding or vasopressin. for intractable cases, try transjugular intrahepatic portosystemic shunt (TIPS)

Front 109

what does high CO2 tell you?

Back 109

pt either has respiratory acidosis (pH <7.4) or is compensating for metabolic alkalosis (pH >7.4)

Front 110

what does low CO2 tell you?

Back 110

pt either has respiratory alkalosis (pH >7.4) or is compensating for metabolic acidosis (pH <7.4)

Front 111

what if pt has high bicarb?

Back 111

pt either has metabolic alkalosis (pH >7.4) or is compensating for respiratory acidosis (pH <7.4)

Front 112

what if pt has low bicarb?

Back 112

pt either has respiratory acidosis (pH <7.4) or is compensating for respiratory alkalosis (pH >7.4)

Front 113

common causes of respiratory acidosis?

Back 113

COPD, asthma, drugs (opoids, benzos, barbs, alcohol, and other respiratory depressants), chest wall problems (paralysis, pain), sleep apnea

Front 114

common causes of respiratory alkalosis?

Back 114

anxiety or hyperventilation, ASA or salicylate overdose

Front 115

common causes of metabolic acidosis?

Back 115

ethanol, DKA, uremia, lactic acidosis (sepsis or shock), methanol or ethylene glycol poisoning, ASA or salicylate overdose, diarrhea, carbonic anhydrase inhibitors

Front 116

common causes of metabolic alkalosis?

Back 116

diuretics (except carbonic anhydrase inhibitors), vomiting, volume contraction, antacid abuse, or milk-alkali syndrome, hyperaldosteronism

Front 117

what are two primary disturbances caused by salicylate overdose?

Back 117

respiratory alkalosis and metabolic acidosis; look for coexisting tinnitus, hypoglycemia, vomiting, and hx of swallowing several pills. alkalinization of the urine (with bicarb) speeds excretion

Front 118

what should you do first before trying bicarb to treat low pH?

Back 118

correct underlying cause and/or saline (do use bicarb is pH <7.0)

Front 119

what are signs and symptoms of hyponatremia?

Back 119

confusion, lethargy, mental status changes, anorexia, seizures, disorientation, cramps, and coma

Front 120

what is first step in determining the cause of true hyponatremia?

Back 120

look at the volume status

Front 121

what are common causes of SIADH?

Back 121

head trauma, surgery, meningitis, small cell lung CA, painful states (trauma, postop), pulmonary infections, opoids or chlorpropamide

Front 122

what is treatment for SIADH?

Back 122

water restriction

Front 123

when can you expect potassium to be elevated?

Back 123

addison's disease and hypoaldosteroniam

Front 124

how do you treat
a) hypovolemic hyponatremia?
b)euvolemic and hypervolemic hyponatremia?

Back 124

a) saline
b) free water restriction and possibly diuretics for hypervolemia

Front 125

why shouldn't you correct hyponatremia rapidly?

Back 125

can cause brainstem damage (central pontine myelinolysis). only use hypertonic saline when pt has seizures due to hyponatremia (always pick normal saline for hypovolemic hyponatremia on boards!!!)

Front 126

what are causes of hypovolemic hyponatremia?

Back 126

dehydration, diuretics, DKA or DM, addison's dz, hypoaldosteronism (treatment is saline)

Front 127

what are causes of euvolemic hyponatremia?

Back 127

SIADH, psychogenic polydipsia, oxytocin use (tx: free water restriction)

Front 128

what are causes of hypervolemic hyponatremia?

Back 128

CHF, nephrotic syndrome, cirrhosis, toxemia, renal failure (tx: free water restriction and possibly diuretics)

Front 129

once glucose reaches 200mg/dL, how much does Na+ decrease by for each increase of 100mg/dL glucose?

Back 129

decreases by 1.6 mEq/L

Front 130

which two disease states can cause false (spurious) hyponatremia by their osmotic effect?

Back 130

hyperlipidemia and hyperproteinemia

Front 131

what is the MCC of hyponatremia in surgical pt?

Back 131

inappropriate or excessive fluid administration

Front 132

what are signs and symptoms of HYPERnatremia?

Back 132

confusion, mental status changes, hyperreflexia, seizures, coma

Front 133

what are common causes of hypernatremia?

Back 133

dehydration, inability to drink (dementia, paralysis), diuretics, DI, diarrhea, renal dz, iatrogenic administration of excessive salt

Front 134

what is treatment of hypernatremia?

Back 134

water replacement; may start with normal saline if pt very dehydrated and then switch to 1/2 normal

Front 135

distinguish between pituitary and nephrogenic DI

Back 135

pituitary DI responds to vasopressin, nephrogenic DOES NOT

Front 136

what are some causes of nephrogenic DI? and what is treatment?

Back 136

medications (lithium, demeclocycline, methoxyflurane, ampho B); tx is thiazide diuretic (paradoxical effect)

Front 137

what are causes of central DI (pituitary DI)?

Back 137

tumor, trauma, sarcoidosis, often idiopathic

Front 138

what are the symptoms of hypokalemia?

Back 138

muscle weakness (including smooth muscles) (and can lead to paralysis/death); can have ileus and/or hypotension

Front 139

what are the EKG changes in hypokalemia?

Back 139

loss of T wave, presence of U waves, PVCs, PACs, ventricular and atrial tachyarrhythmias

Front 140

Explain the process used to assist someone who is considering suicide.

Back 140

Be actively concerned and listen carefully. Be very positive without being condescending and try to utilize peer support for encouragement and acceptance. Do your best to get the person to the proper referral agency as soon as you can. In all cases do not leave the person alone.

Front 141

what cardiac drug causes the heart to be especially sensitive to hypoK?

Back 141

digitalis (watch K carefully)

Front 142

should you replace K fast? and what is best method of replacement?

Back 142

NO, oral, if have to give IV, don't exceed 20 mEq/hr

Front 143

what can cause a false hyperK?

Back 143

hemolyzed specimen

Front 144

what are signs and symptoms of hyperK?

Back 144

tall, peaked T waves, widening of QRS, PR interval prolongation, loss of P waves and a sine wave pattern;
arrhythmias include asystole and ventricular fib

Front 145

what are common causes of hyperkalemia?

Back 145

renal failure (acute or chronic), severe tissue destruction, hypoaldosteronism, medications (K sparring diuretics, B blockers, NSAIDs, ACEIs), adrenal insufficiency

Front 146

what is treatment for hyperK?

Back 146

decrease intake or sodium polystyrene resin; unless it's severely increased, then start with calcium gluconate (for cardioprotection) and then give sodium bicarb (alkalosis causes K+ to shift to inside of cells, and glucose with insulin (also forces K+ into cells). If pt has renal failure or initial tx is ineffective, emergent dialysis needed

Front 147

what is most common finding in hypocalcemia?

Back 147

tetany (tap on facial nerve/Chvostek's sign) or apply tourniquet or BP cuff and inflate to elicit hand muscle spasms (carpopedal spasms/trousseau's sign); other findings: depression, encephalopahty, dementia, laryngospasm, convulsions

Front 148

what does EKG show in hypocalcemia?

Back 148

QT interval prolongation

Front 149

What are the common causes of hypocalcemia?

Back 149

digeorge's syndrome (tetany shortly after birth, absent thymic shadow); renal failure (b/c of kidney's role in vit D metabolism), hypoparathyroidism (watch for post-thyroidectomy pts), vit D def, pseudohypoparathyroidism, acute pancreatitis

Front 150

which two electrolyte disturbances are hard to correct when coupled with hypomagnesemia?

Back 150

hypoK and hypoCa

Front 151

what are the skeletal effects of vitamin D deficiency in:
a) children
b) adults

Back 151

a) rickets
b) osteomalacia

Front 152

how do phosphorus and calcium levels correspond usually?

Back 152

in opposite directions

Front 153

what are symptoms of hypercalcemia?

Back 153

usually asymptomatic, but when are present: bones, stones, groans, and psych overtones (ie. osteopenia or pathologic fx, kidney stones, polyuria, abd pain, anorexia, constipation, ileus, N/V, depression, psychosis, delirium, confusion

Front 154

what does EKG show in hypercalcemia?

Back 154

QT interval shortening

Front 155

what are common causes of hypercalcemia?

Back 155

hyperparathyroidism (MCC in outpts), malignancy (MCC in inpts), vitamin A or D intoxication, sarcoidosis, thiazide diuretics, familial hypocalciuric hypercalcemia (low urinary calcium which is usually rare with hypercalcemia), immobilization

Front 156

what can cause hypercalcemia because of an increase in the protein-bound fraction of calcium, but pt will be asymptomatic b/c the ionized (unbound) fraction is unchanged?

Back 156

hyperproteinemia

Front 157

how do you treat hypercalcemia?

Back 157

IV fluids first, once hydrated give furosemide to cause calcium diuresis (thiazides are CONTRAINDICATED). other txs: phosphorus administration, calcitonin, diphosphonates, plicamycin and prednisone (for malignancy induced hyperCa2+)

Front 158

what can severe prolonged hypercalcemia cause?

Back 158

nephrocalcinosis, urolithiasis, renal failure from calcium salt deposits in kidneys

Front 159

when do you most often see hypoMg?

Back 159

alcoholics

Front 160

what is a classic cause of hyperMg?

Back 160

iatrogenic d/t preggers tx'd with magnesium sulfate for preeclampsia; on boards, often d/t renal failure. (should look for decreased DTRs, hypoTN, and resp depression)

Front 161

how do you treat hypoMg?

Back 161

oral replacement

Front 162

how do you treat hyperMg?

Back 162

stop mag sulfate tx if it is being given and supportive; IV hydration, furosemide, and dialysis as last resort

Front 163

when do you usually see hypophasphatemia and what are the signs and symptoms?

Back 163

pts with DKA and in alcoholics; neuromuscular disturbances (encephalopathy, weakness), rhabdomyolysis (esp in alcoholics), anemia with WBC and platelet dysfxn

Front 164

when do you see hyperphosphatemia; and how do you treat it?

Back 164

almost always seen in pts with renal failure; tx with phosphate restriction, dialysis, and possibly phosphate binding resins (calcium carbonate)

Front 165

what is the fluid of choice in trauma pts? what is the 2nd choice?

Back 165

ringer's lactate; normal saline

Front 166

what is maintenance fluid in NPO patient?

Back 166

D5W in 0.45% NS. and since hypoK can develop acutely in NPO pts, give K+ supplements (10 mEq KCl in the first liter of fluid each day)

Front 167

what are the fat soluble vitamins?

Back 167

A, D, E, K

Front 168

deficiency of fat soluble vitamins is often d/t what?

Back 168

malabsorption (ie: CF, cirrhosis, celiac dz, duodenal bypass, bile duct obstruction, pancreatic insufficiency, chronic giardiasis (tx with high dose oral supplements)

Front 169

alcoholics can have almost any vitamin deficiency, but which ones should you look for?

Back 169

folate, thiamine, magnesium

Front 170

what is MCC of B12 deficiency?

Back 170

pernicious anemia (antiparietal cell Abs destroy the ability to secrete instrisic factor)

Front 171

what conditions are associated with vitamin B12 def (pernicious anemia)?

Back 171

hypothyroidism and vitiligo

Front 172

how do you diagnose the cause of B12 def?

Back 172

Schilling's test (bunch of crazy stages where you give pt B12 and intrinsic factor, etc); can tell you if the B12 def is d/t pernicious anemia or malabsorption

Front 173

what are some other causes of B12 def?

Back 173

diphyllobothrium latum (tapeworm) and removal of the ileum

Front 174

what vitamin deficiency is a/w use of isoniazid?

Back 174

B6 (pyridoxine) deficiency; must give pts on this supplemental B6

Front 175

which class of drugs can cause folate deficiency?

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anticonvulsants (especially phenytoin)

Front 176

which vitamin is a teratogen and female pt must have pregger test before starting tx with meds containing this vitamin and must stay on birth control during tx?

Back 176

vitamin A (isotretinoin); acne med

Front 177

what are the physical findings a/w rickets (vit D def in kids)?

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craniotabes (poorly mineralized skull and bones that feel like a ping pong ball, rachitic rosary (costochondral beading with small round masses on the anterior rib cage, delayed fontanelle closure, bossing of skull, kyphoscoliosis, bowlegs, knock knees. bone changes first appear at the lower ends of the radius and ulna (xrays)

Front 178

what vitamin is given to all newborns as prophylaxis against hemorrhagic dz of the newborn

Back 178

vitamin K since it is required for synthesis of factors II, VII, IX and X and proteins C and S

Front 179

prothrombin time may be prolonged in cirrhosis b/c can't synthesize clotting factors, but vitamin K won't work with this condition. how do you tx?

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fresh frozen plasma

Front 180

what are symptoms of vit A deficiency?

Back 180

night blindness, scaly rash, xerophthalmia (dry eyes), bitot's spots (debris on conjunctiva), increased infections

Front 181

what are signs and symptoms of vitamin A toxicity?

Back 181

pseudotumor cerebri, bone thickening, teratogenicity

Front 182

what are signs and symptoms of vitamin D deficinecy?

Back 182

rickets, osteomalacia, hypocalcemia

Front 183

what are signs and symptoms of vitamin D toxicity?

Back 183

hypercalcemia, N/V, renal effects

Front 184

what are S&S of vit E def?

Back 184

anemia, peripheral neuropathy, ataxia

Front 185

what are S&S of vit E toxicity?

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necrotizing enterocolitis (infants)

Front 186

what are S&S of vitamin K def?

Back 186

hemorrhage, prolonged prothrombin time

Front 187

what are S&S of vit K toxicity?

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hemolysis (kernicterus)

Front 188

what are S&S of vitamin B1 (thiamine) def?

Back 188

wet beriberi (high output cardiac failure), dry beriberi (peripheral neuropathy), wernicke's and korsakoff's syndromes

Front 189

what are S&S of vitamin B2 (riboflavin) deficiency?

Back 189

cheilosis, angular stomatitis, dermatitis

Front 190

what are S&S of vitamin B3 (niacin) deficiency?

Back 190

pellagra (dementia, dermatitis, diarrhea), stomatitis

Front 191

what are S&S of vitamin B6 (pyridoxine) deficiency?

Back 191

peripheral neuropathy, cheilosis (scaling and fissures in corner of mouth), stomatitis (inflammation of mucous lining in any part of mouth), convulsions in infants, microcytic anemia, seborrheic dermatitis

Front 192

what are S&S of vit B6 toxicity?

Back 192

peripheral neuropathy (is the only B vitamin with toxicity)

Front 193

what are S&S of vit B12 deficiency?

Back 193

megaloblastic anemia plus neurologic symptoms

Front 194

what are S&S of folic acid deficiency?

Back 194

megaloblastic anemia WITHOUT neurologic symptoms

Front 195

what are S&S of vitamin C deficiency?

Back 195

scurvy (hemorrhages- skin petechiae, bone, gums, loose teeth, gingivitis), poor wound healing, hyperkeratotic hair follicles, bone pain (from periosteal hemorrhages)

Front 196

what are S&S of iron def?

Back 196

microcytic anemia, koilonychia (spoon fingernails)

Front 197

what are S&S of iron toxicity?

Back 197

hemochromatosis

Front 198

what are S&S of iodine deficiency?

Back 198

goiter, cretinism, hypothyroidism

Front 199

what are S&S of iodine toxicity?

Back 199

can cause myxedema

Front 200

what are S&S of fluorine def?

Back 200

dental caries (cavities)

Front 201

what are s&s of fluorine toxicity?

Back 201

fluorosis with mottling of teeth and bone exostoses

Front 202

what are S&S of zinc deficiency?

Back 202

hyposeugia (decreased taste), rash, slow wound healing

Front 203

what are s&s of copper deficiency?

Back 203

menke's disease (X-linked, kinky hair, MR)

Front 204

what are s&s of copper toxicity?

Back 204

Wilson's dz

Front 205

what are s&s of selenium deficiency?

Back 205

cardiomyopathy and muscle pain

Front 206

what are s&s of selenium toxicity?

Back 206

loss of hair and nails

Front 207

what are s&s of manganese toxicity?

Back 207

"manganese madness" in miners of ore

Front 208

what are s&s of chromium deficiency?

Back 208

impaired glucose tolerance

Front 209

name the 4 types of shock

Back 209

hypovolemic
cardiogenic
septic
neurogenic

Front 210

what's the first thing you always do with pt in shock?

Back 210

give fluids; and if pt doesn't respond to fluid bolus, use invasive hemodynamic monitoring (swan-ganz catheter) to help make diagnostic and therapeutic decisions

Front 211

describe hypovolemic shock

Back 211

hx of fluid loss (blood, diarrhea, vomiting, sweating, diuretics, inability to drink water), cold/clammy skin, pale, fluid loss can be internal (ruptured AAA or spleen, with pancreatitis or after surg); other signs: orthostatic hypoTN, tachycardia, sunken eyes, skin tenting, sunken fontanel (in baby)

Front 212

describe cardiogenic shock

Back 212

hx of MI, chest pain, CHF or several risk factors for CAD; cold/clammy skin, pale; other signs: distended neck veins, pulmonary congestion. pts usually need diuretics (IV fluid can make them worse)

Front 213

describe neurogenic shock

Back 213

hx of severe CNS trauma or bleed, flushed skin. HR may be normal

Front 214

describe septic shock

Back 214

fever, changes in WBC count, flushed skin, warm to touch, extremes of age. use broad spectrum AbRx after pan-culturing pt (blood, sputum and urine cultures)

Front 215

what are the hemodynamic parameters (CO, PCWP, SVR, SVO2) of hypovolemic shock

Back 215

SVR is high; all others are low

Front 216

hemodynamic parameters of cardiogenic shock?

Back 216

PCWP and SVR are high, CO and SVO2 are low

Front 217

hemodynamic parameters of septic shock?

Back 217

high CO, high SVO2, low PCWP and low SVR

Front 218

hemodynamic parameters of neurogenic shock?

Back 218

all (CO, SVO2, SVR and PCWP) are low

Front 219

describe anaphylaxis

Back 219

look for bee stings, peanuts and shellfish and PCN, sulfa or other meds, tx with epinephrine and fluid and O2 (intubate if necessary). antihistamines help with mild cases, corticosteriods used when rxn is prolonged or severe, monitor all pts x 6 hrs after initial reaction

Front 220

describe pulmonary embolus

Back 220

look for risk factors for DVT (virchow's triad: endothelial damage, stasis, hypercoaguable state), hx of recent delivery (amniotic fluid embolus), fractures (fat emboli), DVT (+ homan's sign), recent surgery (esp ortho or pelvic surg) pts have CP, tachypnea, SOB, parasternal heave, right axis shift on EKG, and/or + ventilation/perfusion scan
tx with heparin to prevent further clotting and emboli

Front 221

what is common hx in pericardial tamponade and what is tx?

Back 221

stab wound in left chest, distended neck veins; do pericardiocentesis emergently

Front 222

describe toxic shock syndrome

Back 222

classic is woman of reproductive age who leaves tampon in too long, look for skin desquamination. c/t staph aureus

Front 223

What is first thing to think of in pt with shock?

Back 223

ABC's: airway, breathing, circulation. intubate at drop of a hat, keep NPO, avoid narcotics if possible (mental status changes are important clue to impending doom). Monitor EKG, vitals, Swan-Ganz parameters, urine output, ABGs, CXR, Hgb and Hct

Front 224

what is standard bolus to give most pts in shock?

Back 224

10-20 mL/kg of normal saline (roughly 1-2 L as fast as possible), can bolus again if first bolus doesn't work. watch for fluid overload esp in CHF or don't cause CHF

Front 225

what is a cause of shock especially in post-op pt who has taken steroids in past year and got NO steroids perioperatively. and what is tx?

Back 225

addison's disease. give pt steroids

Front 226

name some IV meds used to support blood pressure

Back 226

dobutamine, dopamine, NE, phenylepherine, epinephrine, and milrinone/amrinone

Front 227

what is MoA of dobutamine?

Back 227

B1 agonist to increase CO by increasing contractility (IV equivalent of digoxin)

Front 228

what is MoA of dopamine?

Back 228

low doses of dopamine hit dopamine receptors in renal vasculature to keep kidney perfused. high doses have B1 agonist effects to increase ocntractility, highest doese have alpha-1 effects and cause vasoconstriction

Front 229

what is MoA of NE?

Back 229

alpha-1 agonist, given in hypoTN to increase peripheral resistance so perfusion of vital organs can be maintained; also has B-agonist effects

Front 230

what is MoA of phenylephrine?

Back 230

alpha-1 agonistwha

Front 231

what is MoA of ephinephrine?

Back 231

used for cardiac arrest and anaphylaxis

Front 232

what is MoA of milrinone and amrinone?

Back 232

phosphodiesterase inhibitors used in refractory heart failure (NOT first line agents) b/c they have + ionotropic effect

Front 233

what do you do if you can't intubate pt d/t laryngeal edema?

Back 233

tracheostomy or cricothyroidotomy