Snw's Internal Medicine- Ed Review (Usmle Step 3)

Front 1

Generic fever w/u

Back 1

has to undergo blood cx (2-3 independent sites prior to starting Abx)

CXR

urinalysis

Front 2

Basic tests to order on CCS

Back 2

CBC

BMP

Mg

ABG

etoh level

tox screen

LFT

CT scan (if needed)

LP (if needed)

blood cx (p/w fever)

urinalysis (p/w fever)

Front 3

Delirium tremens presentation

Back 3

Sxs can start 9-12 hrs after last drink with peak at 48-72 hrs

disoriented

agitated

hallucinating

perspiring

tx with benzodiazepine (eg chlordiazepoxide, diazepam, lorazepam, phenobarbital) and IV thiamine and folic acid

acute confusion and fever --> meningitis

Front 4

Alcoholic hallucinosis

Back 4

occurs ~48 hrs after stopping

p/w visual hallucinations not auditory hallucinations

not usually agitated, tachy, or hypertensive like in DT

tx with benzodiazepine AND anti-psychotic

Front 5

Liver failure with DT

Back 5

only benzos safe in liver failure is lorazepam or oxazepam

Front 6

DT refractory to benzos

Back 6

barbiturates or propofol

Front 7

Wernicke-Korsakoff syndrome

Back 7

Wernicke:

confusion

ataxia

ophthalmoplegia

due to thiamine deficiency & is reversible

Korsakoff:

amnesia with confabulation

irreversible

Front 8

Wet Beri Beri

Back 8

high output cardiac failure due to thiamine deficiency

intense vasodilation of peripheral arterioles bc low ATP levels

increases CO bc of low afterload (decr resistance) and increased venous return

leads to eccentric hypertrophy

Front 9

Pre-op labs

Back 9

T&S

CBC

PT, PTT, Fib

Front 10

Intracranial hemorrage

Back 10

intubation and hyperventilate to pCO2 of 25-30mm Hg

IV mannitol

get neurosurgery consult

Front 11

Acute altered mental status of unclear etiology

Back 11

naloxone

thiamine

dextrose

Front 12

Salicylate intoxication

Back 12

respiratory alkalosis (CO2 low) with anion gap metabolic acidosis

can also have:

tinnitus

pulmonary edema

coma secondary to edema

Front 13

Lactic acidosis secondary to aspirin toxicity

Back 13

poisons mitochondria that leads to anaerobic metabolism and production of lactate

Front 14

Activated charcoal

Back 14

can give for any potential overdose even if specific ingested substance is not known

Front 15

Tx of aspirin o/d

Back 15

activted charcoal

IV fluids

IV HCO3- to alkalinize urine that aids in drug excretion

psych consult

Front 16

Signs of upper GI bleed

Back 16

very high BUN

hypotension

hematochezia

Front 17

Angiodysplasia

Back 17

characterized by painless bleeding, which can be mild to massive

can be assoc with aortic stenosis

Front 18

Hypoglycemia Sxs

Back 18

irritability

tremulousness

diaphoresis

seizure

stupor

coma

Front 19

Factitious use of insulin

Back 19

hypoglycemia

elevated insulin

low c-peptide level

Front 20

Sulfonylurea o/d

Back 20

hypoglycemia

elevated insulin

elevated c-peptide

check sulfonylurea level

Front 21

W/u of pt in fire

Back 21

carboxyhemoglobin --> if elevated, give 100% O2

CXR

CBC

BMP

Front 22

Degree of burns

Back 22

1st degree:

erythematous and only superficial layer of skin with no blisters

2nd degree:

blistering and a white fibrinous exudate

3rd degree:

blackened, charred, or leathery w/no sensation

Front 23

Ventricular fibrilliation

Back 23

defibrillate with 360 J then several cycles of CPR

repeat 360 J

IV access

intubate

epinephrine IV or vasopressin q5 mins

amiodarone or lidocaine (prefer amiodarone)

Front 24

V Fib algorithm

Back 24

defibrillate --> CPR (5 cycles) --> check rhythm --> defibrillate --> CPR (5 cycles) --> epinephrine --> check rhythm --> defibrillate --> CPR --> amiodarone --> check rhythm --> defibrillate

Front 25

Synchronized shock

Back 25

defibrillation means UNSYNCHRONIZED

synchronized does it to ventricular contraction aka QRS complex so can only do if QRS complex is present

Front 26

3 conditions for defibrillation (unsynchronized shock)

Back 26

V Fib

pulseless ventricular tachycardia

torsades de pointes

Front 27

Acetylcysteine

Back 27

acetomenophen toxicity antidote

only beneficial when used up to 24 hrs after ingestion

Front 28

Acetaminophen o/d Sxs

Back 28

anorexia

nausea

vomiting

diaphoresis

malaise

hepatotoxicity peaks 72-96 hrs post ingestion

Front 29

Alcohol hepatitis

Back 29

AST:ALT is 2:1

AST is NEVER >500

Front 30

Heart fluttering/palpitations vs chest pain

Back 30

1st step always EKG

chest pain:

2nd step consider stress test

fluttering/palpitations:

2nd step consider Holter monitor

Front 31

A fib EKG

Back 31

tachycardia

irregular rhythm

no p waves

tx with IV diltiazem & admit to telemetry unit

Front 32

Supraventricular tachycardia

Back 32

tachycardia

regular intervals

no p waves

1st step is carotid massage --> then adenosine

Front 33

Multifocal atrial tachycardia

Back 33

tachycardia

irregular intervals

p waves exist but have a different morphology

normally occurs in pt with underlying pulmonary issue --> treat hypoxemia

Front 34

A fib labs

Back 34

thyroid function test

cardiac enzymes

ECHO

ABG

Front 35

A Fib tx goals

Back 35

rate control HR < 110 @ rest

IV diltiazam, metoprolol

anticoagulation

warfarin

rhythm control

cardioversion if hemodynamically unstable

amiodarone, sotalol, dofetilide, ibutilide, propafenone, dronedarone, and flecainide

Front 36

Anticoagulation with A fib

Back 36

A fib secondary to valve always get anticoagulation

CHADS2 score

Chf

Htn

Age >75

Dm

Stroke or TIA (2 points)

score 0 --> aspirin

score 1 --> aspirin or anticoagulant

score 2+ --> anticoagulant for life

Front 37

Drugs for A fib anticoagulation

Back 37

warfarin with INR goal of 2-3

dabigatran --> direct thrombin inhibitor

rivaroxaban, abixaban --> Xa inhibitors

Front 38

Amiodarone side effects

Back 38

ataxia, parasthesias, peripheral neuropathy

hypo/hyperthyroid

hepatitis and cirrhosis

corneal deposits

cough with infiltrates on CXR

Front 39

SA node conduction on EKG

Back 39

p waves (atrial contraction)

bc a fib u dont have atrial contraction u have no p waves

Front 40

AV node conduction on EKG

Back 40

PR interval (part of diastole)

heart block leads to slowing of AV firing so u have prolonged PR interval

b-blockers and Ca channel blockers inhibit AV node conduction so lead to PR interval prolongation

Front 41

Purkinje fibers conduction on EKG

Back 41

QRS complex (ventricular contraction)

wide QRS complex indicates problem with ventricular conduction

Front 42

Young pt with SOB tests

Back 42

pulse ox

CXR

EKG

ProBNP

Troponin

Lactate

ABG

BMP

D-dimer

PT PTT Fib

If suspecting PE --> CT angio OR V/Q scan in pts with renal failure or contrast allergy

Front 43

Tx PE

Back 43

start LMWH and warfarin

Front 44

Vitamin K-dependent factors

Back 44

II

VII

IX

X

Protein C and S

II and X take > 5 days to decline so want to overlap with LMWH for 5-7 days

Front 45

PE secondary to malignancy

Back 45

LMWH indefinitely NOT warfarin

Front 46

Thrombolytics in PE

Back 46

only in persistent hypotension or shock

Front 47

PE cause w/u

Back 47

elderly: thorough w/u for malignancy

woman: antiphospholipid antibodies & FV Leiden (if FV Leiden, cannot get OCPs)

Front 48

P2Y12 ADP receptor inhibitors

Back 48

clopidogrel, prasugrel, and ticagrelor

inhibits plt aggregation

used in pts with coronary stents, peripheral vascular dz, & strokes

Front 49

Thromboxane A2 inhibitors

Back 49

abciximab, tirofiban, eptifibatide

inhibits fibrinogen cross-links via GP IIB/IIIA receptors

used to tx NSTEMI & STEMI