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221 Cards in this Set
- Front
- Back
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Define: positive cardiac stress test
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ST depressions > 0.2 mV
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Top 5 risk factors with non-cardiac surgery
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Signs of CHF; MI w/in 6 mo; frequent PVCs; non-sinus rhythm; age >70
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Effects of abdominal surgery on pulmonary parameters
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Major decrements to vital capacity and FRC
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Management of uremic platelet dysfunction
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Desmopression
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MC dialysis complication
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Hyperkalemia
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FENa < 1%
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Prerenal AKI
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FENa >2%
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Intrinsic AKI
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UNa in prerenal AKI
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Low (<10)
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UNa in intrinsic AKI
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High (>20)
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UOsms in prerenal AKI
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High (>500)
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UOsms in intrinsic AKI
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Low (<350)
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Specific gravity: prerenal AKI
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High
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Specific gravity: intrinsic AKI
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Low
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Poor prognosis: serum albumin < _____
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< 3
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One unit of platelets increases PLT# by…
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5-10k
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ABX PPX: Generic
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Cefazolin
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ABX PPX: Intestinal surgery
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Cefoxitin, cefotetan
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ABX PPX: Urologic surgery
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Ciprofloxacin
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ABX PPX: Head and Neck surgery
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Cefazolin or clinda/gent
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Immediate Post-Op Risks, 0-24 hours
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Hemorrhage, atelectasis, shock, oliguria
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Early Post-Op Risks, Days-Weeks
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N/V/poor PO; fever; infection; DVT/PE; obstruction/ileus;
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Late Post-Op Risks, Weeks-Months
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Adhesions/obstruction; hernia
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Incidence of Post-Op Ileus
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5%
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Dx: Post-operative foul-smelling crampy diarrhea with high WBC
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C. diff colitis
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Order of return of GI function
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Small bowel > stomach > colon
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MCC of post-op fever
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Atelectasis
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7 components of Wells criteria
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SSx of DVT; alternatives less likely; tachycardia; immobilization of surgery within 4 weeks; Hx of DVT/PE; hemoptysis; malignany
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Wells scoring and stratifying
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<2 low risk; 2-6 moderate risk; >6 high risk
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Drugs used for ABX bowel prep
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Erythromycin, neomycin
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Hold ASA for ___ prior to surgery
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10 days
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Hold Plavix for ___ days prior to surgery
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7
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Antihypertensives on day of surgery?
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Yes to β-blockers; no to diuretics/ACE/ARB
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Antithyroid medications on day of surgery?
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Hold
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Synthroid on day or surgery?
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Yes
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Oral hypoglycemic on day or surgery?
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Hold
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Insulin dosing on day of surgery
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Half normal dosing
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6 steps of wound healing
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Coagulation; inflammation; collagen synthesis; angiogenesis; epithelialization; contraction
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Three elements critical for collagen synthesis
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Iron, vit C, α-ketoglutarate
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At one month, wounds have achieved ___ of potential tensile strength
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85%
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Risk of infection with a dirty wound
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35%
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Epithelialization of primarily closed wounds occurs within ______
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24-48 hours
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Maximum potential tensile strength of primarily closed wounds compared to intact skin
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70-80%
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Basic concept of primary intention healing
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Wound edges brought together by suture; normal anatomy reapproximated
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Basic concept of secondary intention healing
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Wound left open, allowed to granulate; broader scar with slower healing
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Systemic factors affecting wound healing
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Age, nutrition, trauma, metabolic dz, immune status, rheum dz, smoking
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Local factors affecting wound healing
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Mechanical injury, infection, edema, ischemia, foreign bodies
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Define: superficial incisional surgical site infection
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Only involving skin and immediate subcutaneous tissues
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Define: deep incisional surgical site infection
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Skin and subcutaneous tissues down to fascia, muscle
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Define: organ/space surgical site infection
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Involving anything that was surgically manipulated but is remote from the incision
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MC pathogens in early post-op infections (within 24 hours)
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Strep and Clostridium
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General bacterial dose to remember as risky for surgical site infection
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10^5
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Common major patient factors increasing risk of surgical site infections
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Smoking, diabetes, HIV, corticosteroids, malignancy
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MC bacteria associated with abdominal surgeries (GI, OB/GYN, Uro)
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GNRs, anaerobes
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5 Ws of post-operative infection
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Wound; Wind (pneumonia); Water (UTI); Walk (DVT/PE); Wonder drug
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MC bacteria associated with extraabdominal surgeries (cardiac, breast, ophthalmic, vascular, etc)
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Staph aureus and coagulase-negative staphylococci
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MC bacteria associated with head and neck surgery
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Streptococci and oropharyngeal anaerobes
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It is unusual to see a febrile wound infections prior to day ___ post-op
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Day 3
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Optimal ABX for PPX: GPCs
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First- or second-gen cephalosporins
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Optimal ABX for PPX: GNRs
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Third-gen cephalosporins
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Optimal ABX for PPX: Anaerobes
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Metronidazole, clindamycin
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MGMT: small hematoma
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Conservative
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Common sites for keloid formation
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Earlobes, shoulders, sternum, upper back
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Tx: keloid
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Corticosteroid injections, radiation, excision
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Classic features of visceral pain
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Poorly localizable, dull, aching
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Classic features of parietal pain
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Well-localized, sharp
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Visceral organs that localize to the epigastrium
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Stomach, duodenum, liver, biliary tree, pancreas
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Visceral organs that localize to the periumbilical region
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Jejunum, ileum, cecum, transverse colon
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Visceral organs that localize to the hypogastrium
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Descending colon, sigmoid, rectum, internal reproductive structures
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Classic diagnosis: LUQ pain with referred L shoulder pain
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Splenic rupture
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Classic triad of acute cholecystitis
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RUQ pain, fever, leukocytosis
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MC pathogenesis of cholecystitis
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Cystic duct obstruction with intraluminal pressure, irritation, inflammation
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Pain associated with “biliary colic”
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Fairly rapid onset with plateau and then resolution of several hours
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Associated features of biliary colic
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Nausea, vomiting, diaphoresis; not relieved by BM or flatus
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Pain associated with acute cholecystitis
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RUQ peritonitis aggravated by movement
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Classic presentation: pain relieved by vomiting
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SBO
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Classic presentation: pain and mucoid, bloody diarrhea
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Intussusception
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MCC of free intraperitoneal air
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Perforated peptic ulcer
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Important non-surgical causes of abdominal pain
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MI, zoster, LL pneumonia, Addisonian crisis, DKA, sickle cell crisis, porphyria
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Trauma “ABCDEF” acronym
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Airway, Breathing, Circulation, Disability (neurologic status), Exposure, Foley
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Important components of airway assessment
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Assess patency with jaw thrust, remove foreign body, intubate
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Important components of breathing assessment
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Ensure ventilation and manage processes that may impair it e.g. pneumothoraces, contusion, hemothorax, etc
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Important components of exposure
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Completely undress patient to assess
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Signs of urethral transection
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Blood at meatus; high-riding prostate; perineal or scrotal hematoma
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Fluid management in trauma
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Adults get 2L crystalloid bolus; peds bloused at 20 cc/kg
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3-to-1 rule for crystalloid
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3 units of crystalloid for every 1 unit of estimated blood loss
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Reminder of fluid compartments
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2/3 intracellular, 1/3 extracellular: ¾ extravascular, ¼ intravascular
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Three neck zones
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1: below cricoid cartilage; 2: cricoid to angle of mandible; 3: above angle of mandible
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What happened: you manipulated the neck after trauma, and the patient strokes out
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Dislodged a clot
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Injury to which neck zone generally requires surgery?
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Zone 2
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Dx: muffled heart sounds, JVD, hypotension
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Pericardial tamponade
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Dx: electrical alternans on EKG
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Pericardial tamponade
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SSx for tension pneumothorax
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Dyspnea, hypotension, tachycardia, JVD
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Where is the needle placed for needle decompression of pneumothorax?
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Second interspace, midclavicular
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Classic finding with retroperitoneal hemorrhage
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Flank ecchymoses
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Classic finding with intraperitoneal hemorrhage
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Periumbilical hemorrhage
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Injuries associated with seatbelt trauma
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Lumbar spinal fracture, bowel or bladder perforation
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Common locations for bowel injury with blunt trauma
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Ligament of Treitz, ileocecal valve
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Define: + hemoperitoneum by DPL
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>10 mL
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Equation for SVR
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SVR = [MAP – CVP]/CO
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Equation for BP
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MAP – CVP or SVR x CO
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Shock with bradycardia MUST be…
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Neurogenic
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Skin is cool and clammy in which types of shock?
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Hypovolemic and cardiogenic
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Compensated hypovolemic shock involves loss of less than __% of blood volume
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<15%
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First manifestations of hypovolemic shock
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Mild tachycardia, tachypnea, orthostasis, decreased pulse pressure, oliguria
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Manifestations of uncompensated hypovolemic shock
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Frank hypotension, oligouria, significant tachycardia, confusion
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The first symptom of hypovolemic shock
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Tachycardia
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NS vs LR for hypovolemic shock resuscitation
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NS has risk of hyperchloremic acidosis, so LR is preferred
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Define: distributive shock
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Shock associated with very low SVR
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Types of distributive shock
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Septic, anaphylactic, neurogenic
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Common reason that tachycardia may be blunted in hypovolemic shock
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Patient on beta blockers
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Warm skin is characteristic of which types of shock?
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Distributive (septic, anaphylactic, neurogenic)
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Initial physical findings in septic shock
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Fever, tachycardia, warm skin with brisk pulses, and adequate urine output
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SIRS criteria
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HR > 90; T >38 or <36; RR >20 or PCO2 < 32; WBC >12 or <4 or >10% bands
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Glycemic control with sepsis
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Glucose 80-150 improves outcomes
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Dx: hypotension, stridor, clammy skin, edema
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Anaphylaxis
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Possible causes of cardiogenic shock
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MI, arrhythmia, valvular disease, tamponade, massive PE, etc.
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Presentation of cardiogenic shock
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Cold, clammy skin with JVD, rales, S3/S4
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Classic triad of spinal shock
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Hypotension, bradycardia, absent rectal tone
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Pulmonary capillary wedge pressure in cardiogenic shock
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Elevated (>20)
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Classic EKG for PE
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S1Q3T3: S wave in I, Q and T waves in III
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Management of acute MI
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MONAB : morphine, O2, nitrates, aspirin, beta blocker
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Classic inotrope for cardiogenic shock
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Dobutamine
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Three key end-points in successful shock resuscitation
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Normalization of lactate; normalization of mixed venous O2; normalization of UOP
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Pulmonary capillary wedge pressure = ?
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Left ventricular end diastolic pressure
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Dobutamine receptor specificity
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B1=B2
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Epinephrine receptor specificity
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A1=A2=B1=B2
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Norepinephrine receptor specificity
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A1=A2>B1
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Dobutamine effects
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B1 = inotropic, B2 = vasodilatory -> increased CO, decreased SVR
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Dopamine effects
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B1 = inotropic, A1 = vasoconstrictive -> increased CO, increased SVR
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Norepinephrine effects
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B1 = inotropic, A1 = vasoconstrictive -> increased CO, increased SVR
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Classic pressor for septic shock
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Vasopressin
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Epinephrine effects
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B1 = inotrope, A1 = vasoconstriction B2 = bronchodilation -> increased CO, increased SVR
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Classic pressor for anaphylaxis
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Epinephrine
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Tx: neurogenic shock
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Pressors and IVF
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Three major causes of ventilator-associated morbidity
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Pneumonia; barotrauma/tension pneumo; decreased venous return and CO
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Three indications for intubation
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Airway protection with GCS <8; failure to oxygenate (hypoxia despite supplemental O2); failure to ventilate (hypercapnia, acidosis)
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Effect of ventilator minute ventilation settings on PCO2 and pH
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Increased MV = decreased CO2, increased pH
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On the ventilator, ___ is the marker of oxygenation
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PO2
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On the ventilator, ___ is the marker of ventilation
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PCO2
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Ventilator FiO2 setting associated with oxygen free radical injury
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FiO2 > 60%
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Five criteria for ARDS
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Fluffy infiltrates on CXR; PaO2/FiO2 ratio < 200; no heart failure; acute onset; presence of underlying cause
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Pathophysiology of ARDS
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Diffuse alveolar damage --> massive V/Q mismatch with significantly reduced pulmonary compliance
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MCC of ARDS
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Sepsis
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MCC of ARDS in the outpatient setting
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Pneumonia
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Use of PCWP to distinguish ARDS from CHF
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ARDS < 18, CHF > 18
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ARDS management
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Mechanical ventilation with low tidal volumes and PEEP
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Total body fluid is, on average, __% of total body weight
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60%
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Equation for plasma osmolality
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2Na + glucose/18 + BUN/2.8
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Osmolal gap equation
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Measured osmolality – calculated osmolality
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Normal osmolal gap
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<10
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Causes of elevated osmolal gap
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Lactic acidosis, ketoacidosis, methanol, ethanol
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Fluid losses equivalent to ECF
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Hemorrhage, GI losses (vomit, NG drainage, diarrhea), third spacing, inflammation
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Fluid losses equivalent to free water
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Fever, osmotic diuresis
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Metabolic disturbance associated with large volumes of normal saline infusion
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Hyperchloremic metabolic acidosis
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Metabolic disturbance associated with large volumes of lactated ringers infusion
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Metabolic alkalosis
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Volume of stomach secretions over 24 hours
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1-2L
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Volume of small bowel secretions over 24 hours
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2-3L
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Rule of thumb for estimating third space volume within the abdomen
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1L third-spaced intraabdominally for each quadrant traumatized/inflamed/operated on
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Basic rule for estimating fluid requirements
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100 cc for first 10 kg, 50 cc for next 10 kg, 20 cc for each remaining 10 kg
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Cardinal triad of hypovolemia
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Tachycardia, decreased pulse pressure, orthostasis
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BP is not affected until at least __% to __% of plasma volume is lost
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20-30%
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Free water deficit
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FWD = NBW – CBW
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Define “normal body water”
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0.6 x body weight in kg
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Define “current body water”
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NBW x (140/measured serum Na)
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BUN/Cr ratio in euvolemic patient
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BUN/Cr < 15
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What is the first thing you should do when you see hyponatremia?
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Calculate serum osmolality; if it is normal or high, you have pseudohyponatremia; if it is low, it is real
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What is a cause of hyperosmolar hyponatremia?
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Hyperglycemia (falsely lowers serum Na)
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Rule for correcting serum Na with hyperglycemia
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For every 100 mg/dL of glucose above normal, serum Na “drops” by 1.6
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Classic iatrogenic cause of hyponatremia
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Diuretics
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Causes of SIADH
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Tumors (small cell lung), Addison’s, hypothyroid, head trauma, pain
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Classic signs of hyponatremia
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Abnormal DTRs, seizure
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EKG in hypokalemia
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Flat T, ST depression, U waves
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Trick for estimating how much K to give in hypokalemia
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(4 – measured K) x 100
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Hyper- and hypo- K, Mg, and Ca can all cause…
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Arrhythmia or arrest
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Causes of hypokalemia
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Catecholamines, alkalemia, TPN without K, Conn’s, Cushing’s, renal artery stenosis
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When repleting K, do not exceed ___/hr
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40/hr
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Two key drugs associated with hyperkalemia
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ACE and spironolactone
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Causes of hyperkalemia
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Acidosis, tissue damage, anti-HTN drugs, iatrogenic
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Classic EKG in hyperkalemia
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Tented T waves
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Rapid treatment of hyperkalemia
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Calcium gluconate; insulin + glucose; albuterol; sodium bicarb drip
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Most calcium excreted in the ____
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Stool
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Calcium correction by albumin level
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0.8(Normal albumin – measured albumin) + measured Ca
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Causes of hypocalcemia
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Hypoparathyroidism, pancreatitis, massive soft-tissue infections like nec fasc, AKI/CKD, fistulas
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S/Sx of hypocalcemia
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Paresthesias, weakness, mylagias
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EKG in hypocalcemia
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Long QT
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Causes of hypercalcemia
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Hyperparathyroid, tumors (breast and myeloma), thiazides
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SSx of hypercalcemia
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Constitutional (fatigue, anorexia, N/V, etc) + polydipsia
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SSx of hyperkalemia
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Constitutional (fatigue, N/V) + colicky abdominal pain
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The biggest danger associated with TPN is…
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Infection
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Basal energy expenditure for males
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25 kcal/kg/day
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Basal energy expenditure for females
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22 kcal/kg/day
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Generalized protein requirements
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0.8-1 g/kg
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Primary substrate for colonocytes
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Short-chain fatty acids
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Primary substrate for enterocytes
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Glutamine
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Recall: MUDPILES
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Methanol; uremia; DKA; paraldehyde; infection/iron/INH; lactic acidosis; ethanol; salicylates
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Non-gap acidoses: HARD UP
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Hyperparathyroidism; adrenal insufficiency; RTA; diarrhea; ureteroenteric fistula; pancreatic fistula
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Normal anion gap
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10
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Causes of metabolic alkalosis
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Vomiting, NG suction; diuretics; hperaldosteronemia; lactated ringers, TPN
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Three anatomic areas of esophageal narrowing
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Cricopharyngeus; intersection of left mainstem bronchus and aortic arch; diaphragmatic hiatus
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Two components of achalasia
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LES hypertonicity and absent esophageal peristalsis
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Achalasia triad
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Dysphagia, regurgitation, weight loss
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Medical management for achalasia
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Nitrates, calcium channel blockers
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Procedural management for achalasia
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Endoscopic balloon dilation or Heller myotomy with fundoplication
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Presentation for diffuse esophageal spasm
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Dysphagia with substernal chest pain (often mimicking cardiac pain)
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Classic barium swallow: diffuse esophageal spasm
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Corkscrew esophagus
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Medical management for diffuse esophageal spasm
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Nitrates, calcium channel blockers
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Presentation for Zenker diverticulum
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Dysphagia with regurgitation, foul smelling breath, choking, aspiration
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Rate of rebleeding with esophageal varices
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70%
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Pharmacologic management of acute esophageal variceal bleeding
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Vasopressin and/or octreotide to dilate splanchnic bed and reduce portal pressures
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Risk factors for esophageal strictures
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Severe GERD, esophagitis
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Presentation of esophageal stricture
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Dysphagia +/- odynophagia
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What should you think of: patient recently got endoscopy, now with severe chest pain and fever
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Iatrogenic esophageal perforation
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MCC of esophageal perforation
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Iatrogenic
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MC location of Boerhaave’s syndrome
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Left side above GE junction
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Classic finding with esophageal rupture
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Mediastinal emphysema
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Atypical GERD symptoms
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N/V, choking, coughing, wheezing, hoarseness
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Gold standard: GERD dx
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24-hour pH monitoring
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Foods to avoid in GERD
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Alcohol, coffee, chocolate, peppermint, tobacco
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Rate of malignant transformation with Barrett’s
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1%/year
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Risk factors for esophageal cancer
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Smoking, drinking, nitrates, GERD, achalasia, chronic esophagitis
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Define: Schatzki’s ring
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Circumferential submucosal ring in lower esophagus, often accompanied by hiatal hernia
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