ICCM - Quiz 1

what are the components to a preceptor presentation?

one-liner

past medical history

review of systems

physical exam

differential diagnosis

plan (meds, labs, imaging)

unstable angina diagnosis

history - pain at rest or a change in character of pain

additional - normal troponin, normal or minimal changes on EKG (potential ST depression or T wave inversion on EKG)

NSTEMI diangosis

positive troponin

additional - symptoms, no ST elevation on EKG, potential ST depression or T wave inversion on EKG

STEMI diangosis

ST elevation on EKG (2 continuous leads)

additional - positive troponin, symptoms, compensatory EKG changes

ACS medications

nitroglycerin

aspirin

heparin

ticagrelor - brand name is brilinta (alternative is clopidegrel)

ACS treatment

STEMI - cath lab within 90 min

unstable angina and NSTEMI - cath lab, but not immediately

nitroglycerin dosage for ACS

0.4 mg sublingual

repeat every 5 minutes for up to three doses

aspirin dosage for ACS

325 mg uncoated chewable

heparin IV bolus dosage for ACS

60 units/kg

max 4000 units

heparin IV drip dosage for ACS

12 units/kg

max 1000 units/hour

ticagrelor (brilinta) dosage for ACS

180 mg PO

clopidogrel dosage for ACS

300-600 mg loading dose

75mg PO QD after

what are the symptoms for atrial fibrillation?

palpitations, chest pain, dizziness, SOB

what are the two most common causes of atrial fibrillation?

CHF and sepsis

what are other causes of atrial fibrillation?

alcohol (holiday heart)

PE

pericarditis

myocarditis

valvular abnormalities

endocarditis

what trial supports that there is equal mortality to rhythm control vs rate control?

AFFIRM trial

what does the AFFIRM trial support?

equal mortality to rhythm control vs rate control in treatment for atrial fibrillation

the RACE II trial supports that when you rate control you should aim for a heart rate of what?

less than 110 bpm

what trial supports that you should aim for a heart rate of less than 110 bpm when rate controlling?

RACE II

what medications are used to rate control?

diltiazem or metoprolol

diltiazem dosage for rate control atrial fibrillation

bolus - 5, 10, 15, or 20 mg

drip - 5 mg/hour

what is happening during atrial fibrillation and what do you see on EKG?

multiple foci in the atria are firing, leading to the an irregularly irregular rhythm seen on EKG

what are you at risk for with atrial fibrillation?

stroke

what are the risk factors for atrial fibrillation?

hypertension

coronary artery disease

congestive heart failure

alcohol abuse

cocaine use

what arrhythmias are included in supra-ventricular tachycardia?

sinus tachycardia

atrial flutter

AVNRT - atrioventricular nodal reentrant tachycardia

AVRT - atrioventricular reentrant tachycardia (ex. WPW)

what does an EKG look like for supra-ventricular tachycardia?

regular narrow complex tachycardia

what is happening with the electrical conduction of the heart in sinus tachycardia?

follows normal pathway

heart rate >100 bpm

what is happening with the electrical conduction of the heart in atrial flutter?

dominant ectopic foci with an atrial rate of 250-350 bpm

what is happening with the electrical conduction of the heart in AVRT?

re-entry circuit through an accessory pathway (bundle of Kent)

what is happening with the electrical conduction of the heart in AVNRT?

re-entry circuit within or near the heart's AV node

what is the step-wise treatment for supra-ventricular tachycardia?

IV fluids

vagal maneuvers (valsalva, cough)

adenosine

which SVT would IV fluids treat?

sinus tachycardia

which SVT would vagal maneuvers treat and why?

AVRT or AVNRT

works by stimulating the vagus nerve -> blocking the AV node -> slowing down heart rate

which SVT would adenosine treat and why?

AVRT or AVNRT

works by producing a transient AV node block -> slowing down heart rate

which SVT would adenosine diagnose and why?

atrial flutter

works by slowing the conduction and can reveal the characteristic flutter waves on EKG, but won't break the rhythm/treat

why is adenosine considered diagnostic and therapeutic?

diagnostic - atrial flutter

therapeutic - AVRT and AVNRT

adenosine dosage for SVT

6, 12, 12 mg rapid IV push

what are the two types of ventricular tachycardia?

monomorphic

polymorphic

what does an EKG look like for ventricular tachycardia?

wide complex tachycardia

what are the treatment options for ventricular tachycardia for a patient with a pulse?

cardioversion

IV amiodarone

IV lidocaine

what is the treatment for ventricular tachycardia for a patient without a pulse?

defibrillation

what voltage is used to defibrillate a patient in ventricular tachycardia without a pulse?

300 joules (max)

amiodarone dosage for ventricular tachycardia

bolus - 150 mg IV over 10 minutes

drip - 1 mg/min for 6 hours

lidocaine dosage for ventricular tachycardia

bolus - 1 mg/kg IV

drip - 1-1.5 mg/kg at rate of 1-3 mg/min

T/F - amiodarone and IV lidocaine are equal mortality for treatment of ventricular tachycardia

true

what are the inferior EKG leads and artery associated?

II, III, aVF

RCA

what are the anterior EKG leads and artery associated?

V1-V4

LAD

what are the lateral EKG leads and artery associated?

I, aVL, V5, V6

LCfx

after an anterior STEMI what rhythm will a patient go into?

ventricular fibrillation

pulseless ventricular tachycardia

after an inferior STEMI what rhythm will a patient go into?

3rd degree heart block

normal PR interval for EKG

120s - 200 ms

normal QRS interval for EKG

< 120 ms

normal male QTc interval for EKG

< 440 ms

normal female QTc interval for EKG

< 460 ms

what does a prolonged QTc put a patient at risk for?

torsades de pointes

what labs and imaging should be obtained for all chest pain patients?

labs - CBC, CMP, magnesium, and troponin

imaging - EKG and chest x-ray

what is the dose for morphine and ondansetron (zofran) in the ED?

4 mg

gram positive bacteria list

staphylococcus

streptococcus

enterococcus

clostridium

listeria

bacillus

corynebacterium

gram negative bacteria list

escherichia

vibrio

salmonella

haemophilus

moraxella

pseudomonas

bartonella

pasturella

proteus

neisseria

klebsiella

enterobacter

helicobacter

yersinia

campylobacter

shigella

brucella

francisella

treponema

anaerobe bacteria list

bacteroides

eikenella

fusobacterium

eubacterium

atypical bacteria list

chlamydia

legionella

mycoplasma

what is unique about legionella

confirmatory diagnostic test - urine antigens

hyponatremia and elevated LFTs

what is the #1 cause of UTIs?

E. coli

what is the #2 cause of UTIs?

staphylococcus saprophyticus

what are 95% of blood culture contaminants?

staph epidermidis

staph hominis

staph haemolyticus

what are the different types of staphylococcus?

staph aureus

staph saprophyticus

staph epidermidis

staph hominis

staph hemolyticus

what are the different types of streptococcus?

alpha hemolytic - strep pneumoiae, strep viridans

beta hemolytic - group A (strep pyogenes), group B (strep agalactiae)

what are the different types of clostridium?

clostridium difficile

clostridium botulinum

clostridium perfringens

what are the different types of bacillus?

bacillus anthraces

bacillus cereus (reheated rice)

what are the non-STI chlamydias?

chlamydia pneumoniae

chlamydia psittaci

what is the history of penicillins?

discovered in 1928 by Dr. Fleming

a mold, Penicillium notatum, inhibited the growth of bacteria

what is the mechanism of action of penicillins?

inhibit bacterial cell wall synthesis

penicillin G (IM)

covers gram pos, gram neg, anaerobes

100% covers syphilis (treponema pallidum) and strep pyogenes

amoxicillin and ampicillin

covers gram pos, gram neg, anaerobes

100% covers strep pyogenes (not 100% for syphilis)

nafcillin, oxacillin, methacillin

covers gram pos ONLY

made to cover staph - good for MSSA

beta-lactamase inhibitors

covers gram pos, gram neg, anaerobes

amoxicillin/clavulanic acid (augmentin)

ampicillin/sulbactam (unasyn)

piperacillin/tazobactam (zosyn)

what is the MRSA and pseudomonas coverage for beta-lactamase inhibitors?

MRSA - no coverage from augmentin, unasyn, or zosyn

pseudomonas - no coverage from augmentin or unasyn; 95% coverage from zosyn

hospital medicine

ED - range of acuity

clinical decision unit - observed for further treatment

general floor - admitted to the hospital

step-down - intermediate level of care

critical care - patients who require close monitoring and management

inpatient roles and responsibilites

admitting, consulting, rounding, notes, physical exam, evaluating changes in patients, writing orders, charting

rounding team

physician, APPs, pharmacy, RT, students, nursing

inpatient evaluation

detailed charts - vitals, labs, PMHx, previous hospitalization, outpatient notes, consulting, nursing report

observe trends, abnormalities, and actionable findings to determine care

inpatient HPI

CC, risk factors, emergency room course, hospital course, PMHx, meds and allergies, social and family Hx, ROS

note formatting

H&P and consult H&P

consult or daily progress note

discharge summary and death summary

inpatient physical exam evaluation

five required systems - general, HEENT, respiratory, cardiovascular, abdomen, perivascular and extremities/pulses

other - MSK, skin, GU, lymphatic, psychosocial

general - normal and abnormal

normal - alert and oriented to person, place and time; in no acute distress

abnormal - lethargic, laying in bed and minimally responsive. Appears in respiratory distress with tachypnea and increased work of breathing

HEENT - normal and abnormal

normal - normocephalic, atraumatic, non-icteric sclera, EOM grossly intact, PERRL(A)

abnormal - pupils unequal; right 2mm with reaction to light and left 6mm without reaction to light

respiratory - normal and abnormal

normal - slear to auscultation bilateral without wheezes, rhonchi, or rales; no use of accessory muscles

abnormal - bilateral expiratory wheezing throughout all lung fields, diminished in bilateral bases. Tachypnea with RR ~30bpm and use of accessory muscles

cardiovascular - normal and abnormal

normal - regular rate and rhythm, no murmur gallops or rubs noted

abnormal - irregular irregular rhythm with HR ~ 130bpm. grade IV systolic ejection murmur heard best at left sternal boarder

abdomen - normal and abnormal

normal - soft, non-distended, non-tender to light and deep palpation, normo-active bowel sounds in all 4-quadrants

abnormal - distended, firm abdomen with diffuse TTP worse in RLQ with rebound tenderness present. Bowel sounds hypoactive in all 4 quadrants

perivascular - normal and abnormal

normal - no pedal edema, dorsalis pedis 2+ bilateral

abnormal - 3+ bilateral lower extremity pitting edema. Absent left popliteal pulse with cyanotic left foot

inpatient orders

admission order set - pre-built in orders that are common for admission

may need to add or remove some of the orders within the set

DVT prophylaxis in hospitalized medical adults

non-pharm - intermittent pneumatic compression

pharm options - lovenox 40mg SQ QD or SQ heparin (5000 units SQ BID or TID if obese or cancer patient (no renal dose is needed)

high-risk patient groups for DVT

patients at highest risk of VTE include patients who are critically ill, patients with cancer or stroke, and patients with multiple risk factors for VTE including pregnancy, heart failure, myocardial infarction, old age (>75 years), previous VTE, prolonged immobility, renal failure, obesity, and inherited or acquired hypercoagulable states

DVT prophylaxis in cancer patients

lovenox 40mg SQ QD

renal dose adjustment is needed

stress ulcer ICU

ulceration of the upper gastrointestinal (GI) tract (esophagus, stomach, duodenum) that occurs due to hospitalization and is common in critically ill patients

can be occult or overt

high risk groups for stress ulcers

mechanical ventilation for more than 48 hours

bleeding diathesis (thrombocytopenia (platelet <50,000)

elevated international normalized ratio >1.5 or a partial thromboplastin time >2 times the control value

GI ulceration or bleeding within the past year

traumatic brain or spinal cord injury

severe burns >35 percent of the body surface area

two or more minor risk factors (eg, sepsis, intensive care unit stay >1 week, occult GI bleeding ≥6 days, glucocorticoid therapy)

nonsteroidal anti-inflammatories or antiplatelet agents

stress ulcer prophylaxis in the ICU

first-line - PPIs (pantoprazole (protonix) 40mg PO daily)

second-line - H2 blockers (famotidine (pepcid) 20mg PO daily)

PPI MOA

block acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane

H2 blocker MOA

antagonize the H2 receptors on the parietal cell, resulting in diminished gastric acid secretion

patient oral presentation

introduction - brief 1-liner, present HPI for new patients

data - vitals, pertinent physical exam, emergent/concerning labs

assessment and plan - principal problem and any secondary problems

use SOAP note format