Cardiology
63-year-old male presents with STEMI alert. Patient underwent coronary angiogram with drug-eluting stent to LAD. No PMH.
Which of the following medications should the patient be started on? (select all that apply)
A. Simvastatin
B. Prasugrel
C. Aspirin
D. Rosuvastatin
E. Apixaban
B. Prasugrel
C. Aspirin
D. Rosuvastatin
**DAPT + high-intensity statin
47 YO male with T2DM and HLD. He spent the day at the MN state fair 2 days ago, and since his return to IA had abdominal pain and nausea/vomiting. His BG sensor at home alerted him that his BG was >400 and he came to the ER. The following labs were obtained:
pH 7.25 - Na 131 (corrected 137) - K 3.9 - CO2 12
SCr 1.2 - Glucose 454 - Mg 1.4 - Phos 3.2 - AG 29
Beta Hydroxy butyrate 2.5 - Urine Ketones 20
What is wrong with this patient?
A. DKA
B. HHS
C. Gastroenteritis secondary to cyclosporiasis
D. Euglycemic ketoacidosis
A. DKA
Patient meets following critieria:
pH<7.3
BG >250
Beta hydroxybutyrate >0.5
CO2<18
72-year-old female presents with dyspnea that progressed over past 2 weeks, not improved with home albuterol inhaler/nebulizer. She does not use oxygen at home. PMH: COPD, GERD, hypothyroidism
Vitals on admit: RR 28 - HR 98 - SaO2 90% (2L O2 currently) - Dyspnea score = 7
What is the severity of the COPD exacerbation, and what medication regimen would you expect to see?
A. Severe. Prednisone 40 mg daily x 5 days. Continue home albuterol/nebulizer PRN.
B. Moderate. Methylprednisolone 500 mg IV daily x 3 days. Start Trelegy ellipta 100/62.5/25 mcg 1 puff daily.
C. Moderate. Prednisone 40 mg daily x 5 days. Continue home albuterol inhaler PRN, start duonebs 0.5/3 mg nebulizers Q1H x 3 doses then q4H.
D. Mild. 1 mg dexamethasone PO x 7 days. Continue home albuterol inhaler, but change to 2 puffs every hour for 3 doses, then 1-2 puffs every 4 hours.
C. Moderate. Prednisone 40 mg daily x 5 days. Continue home albuterol inhaler PRN, start duonebs 0.5/3 mg nebulizers Q1H x 3 doses then q4H.
Which of the following antimicrobials has pseudomonal coverage?
A. Augmentin
B. Ertapenem
C. Ciprofloxacin
D. Daptomycin
E. Doxycycline
C. Ciprofloxacin
90-year-old male presents with AMS that started over the last 2-3 days. Family of patient shares that he was recently started on new medication for HTN. Lab results as below:
SCr 0.86 mg/dL - Na 114 - K 3.4 - Mg 1.8 - BG 124
What is the likely cause of the patient's AMS and which HTN medication is to blame?
A. Hypokalemia - Lisinopril
B. Hypomagnesemia - Chlorthalidone
C. Hypoglycemia - Carvedilol
D. Hyponatremia - Hydrochlorothiazide
D. Hyponatremia - Hydrochlorothiazide
70-year-old female presents with NEW atrial fibrillation. PMH: HFrEF, asthma, CAD
Weight 70 kg - SCr 1.2 mg/dL
Is this patient a candidate for anticoagulation? Why, and what would you start?
A. No, low stroke risk, apixaban 5 mg BID
B. Yes, elevated stroke risk, rivaroxaban 15 mg QPM
C. Yes, elevated VTE risk, apixaban 10 mg BID
D. No, low VTE risk, rivaroxaban 20 mg QPM
B. Yes, elevated stroke risk
CrCl = 48 mL/min - dose reduction for rivaroxaban if CrCl <50 mL/min
**CHADs2VASc = 5 (female, age x2, CHF, CAD)
47 YO male with T2DM and HLD. He spent the day at the MN state fair 2 days ago, and since his return to IA had abdominal pain and nausea/vomiting. His BG sensor at home alerted him that his BG was >400 and he came to the ER. The following labs were obtained:
pH 7.25 - Na 131 (corrected 137) - K 3.9 - CO2 12
SCr 1.2 - Glucose 454 - Mg 1.4 - Phos 3.2 - AG 29
Based on lab results, how much magnesium is appropriate to give the patient for repletion?
A. 1 g MgSO4 IV over 1 hour - No recheck
B. 2 g MgSO4 IV over 30 minute - Recheck Mg in AM
C. 400 mg Mag Oxide PO for 5 days - No recheck
D. 4 g MgSO4 IV over 4 hours - Recheck Mg in AM
D. 4 g MgSO4 IV over 4 hours - Recheck Mg in AM
Patient was diagnosed with COPD. Initial questionnaires at the time of diagnosis; mMRC (score 3/4) and the CAAT (score 25/40). Eosinophil count drawn = 93.
Based on the information above, what therapy should this patient start on? What GOLD group letter would the patient be placed in?
A. Trelegy ellipta (fluticasone/umeclidinium/vilanterol) 100/62.5/25 mcg 1 puff daily. Category E.
B. Stiolto respimat (tiotropium/olodaterol) 2.5/2.5 mcg 2 puff daily. Category B.
C. Incruse ellipta (Umeclidinium) 62.5 mcg 1 puff daily. Category C.
D. Breo ellipta (Fluticasone/vilanterol) 200/25 mcg 1 puff daily. Category D.
B. Stiolto respimat (tiotropium/olodaterol) 2.5/2.5 mcg 2 puff daily. Category B.
**Based on mMRC >2, CAAT >10 and no prior exacerbations = Group B
**Recommended start of LAMA/LABA for Group B
Which of these patients needs anaerobic coverage?
A. 35-year-old teacher diagnosed with cystitis
B. 18-year-old student diagnosed with acute appendicitis
C. 85-year-old women who presents with flank pain, fever and dysuria
D. 8-year-old diagnosed with otitis media
B. 18-year-old student diagnosed with acute appendicitis
55-year-old male with PMH of DM and CKD. Presents to ER with potassium of 7.2 mEq/L, Ca 9 mg/dL and albumin 3.5 g/dL. ECG is abnormal with peaked T waves.
What is the best recommendation for initial treatment?
A. Regular insulin 10 units IV PLUS 50 g dextrose IV
B. 10% calcium gluconate (10mL) IV
C. Sodium polystyrene sulfonate 15 g PO
D. Sodium bicarbonate 50 mEq IV over 5 minutes
B. 10% calcium gluconate (10mL) IV
70-year-old female presents with NEW atrial fibrillation. PMH: HFrEF, asthma, CAD
Which of the following antiarrhythmic therapy would be the BEST choice for this patient?
A. Flecainide
B. Sotalol
C. Amiodarone
D. Propafenone
C. Amiodarone
47 YO male with T2DM and HLD. Diagnosed with DKA. Home glucose management is, insulin glargine 10 units daily in the AM, insulin aspart 0-5 units sliding scale with meals, empagliflozin 25 mg daily, and metformin ER 1000 mg BID.
What initial dosing of insulin is most appropriate?
A. 0.5 units/kg/day of insulin aspart in 3 divided doses with meals
B. 20 units insulin glargine twice daily and sliding scale insulin aspart 0-8 units TID with meals
C. Sliding scale insulin aspart 0-12 units every 6 hours
D. 0.3 units/kg insulin aspart once, then 0.1-0.2 units/kg every 2 hours (if BG >250, give 0.2 u/kg, if <250 give 0.1 u/kg)
D. 0.3 units/kg insulin aspart once, then 0.1-0.2 units/kg every 2 hours (if BG >250, give 0.2 u/kg, if <250 give 0.1 u/kg)
**Recommended by ADA guidelines for subcutaneous DKA management
COPD patient recently discharged on appropriate LABA/LAMA inhaler, seen in clinic with progressive worsening dyspnea for past 3 weeks, along with increased sputum production. Plan to treat exacerbation at home but team wants recommendation for which antibiotic to prescribe.
What antibiotic would you recommend for empiric treatment?
A. Doxycycline 100 mg PO BID x 5 days
B. Sulfamethoxazole-trimethoprim 800-160 mg PO BID x 3 days
C. Azithromycin 250 mg PO three times weekly x 1 month
D. Nitrofurantoin 100 mg BID x 7 days
A. Doxycycline 100 mg PO BID x 5 days
A 56-year-old admitted for lung abscess. Documented allergy to penicillin and tolerated cefazolin in the past. Hospitalist orders meropenem. Which of the following would be more appropriate for antimicrobial therapy?
A. Piperacillin-tazobactam
B. Clindamycin
C. Ceftriaxone + metronidazole
D. Cefepime
C. Ceftriaxone + metronidazole
86-year-old female was admitted for failure to thrive with poor intake and inability to care for herself anymore. Weight 100 kg, with available labs below.
SCr 0.85 mg/dL - Na 138 - K 4.8 - Phos 1.6
The team asks for recommendations for phosphorus replacement. Which is the BEST option?
A. 30 mM NaPhos IV over 4 hours
B. KPhos Neutral 500 mg PO x 1
C. 45 mM KPhos IV over 6 hours
D. 10 mM NaPhos IV over 3 hours
A. 30 mM NaPhos IV over 4 hours
**0.32 mmol/kg for Phos 1.6-2.2
53-year-old female diagnosed with new CHF. TTE findings = EF 50-55%. PMH: T1DM, HTN
Vitals: BP 115/55 mmHg - HR 68 bpm
Labs: SCr 0.85 mg/dL - K 4.5 mmol/L
Which GDMT would be the best to start?
A. Metoprolol succinate
B. Spironolactone
C. Dapagliflozin
D. Lisinopril
B. Spironolactone
Repeat labs are drawn for the patient. Based on your review, what does this mean? What should you and/or the nurse do? --new labs (old labs)-- pH 7.33 (7.25) - CO2 23 (12) - Glucose 185 (454) - AG 11 (29)
A. Still in DKA, continue current treatment
B. DKA resolved, contact physician to have new insulin orders placed
C. DKA converted to HHS, continue current treatment
D. DKA resolved, continue current treatment
B. DKA resolved, contact physician to have new insulin orders placed
**Considered out of DKA due to his BG <250, pH >7.3, CO2 >15, and anion gap <12
41-year-old male with PMH asthma, HLD and prediabetes, transfers to floor from ICU after being treated for severe asthma exacerbation. Upon review patient notes mild induced asthma as child but had not used albuterol inhaler for years up until family adopted new dose couple of months prior. Current inpatient orders include albuterol inhaler PRN, plus scheduled nebulizers.
Which of the following therapies would you recommend to start now and/or upon discharge?
A. Fluticasone 110 mcg/act daily PLUS albuterol 2 puff Q4h prn
B. Send new prescriptions for albuterol inhaler/nebulizer
C. Salmeterol 50 mcg/act daily
D. Mometasone/formoterol 100/50 mcg/act 2 puff BID PLUS 1 puff daily PRN
D. Mometasone/formoterol 100/50 mcg/act 2 puff BID PLUS 1 puff daily PRN
**Daily symptoms PLUS recent exacerbation = medium dose ICS-formoterol regimen
A 18-year-old has enterococcus faecium isolated from their abdominal abscess fluid. The patient was empirically started on piperacillin-tazobactam. Which of the following would provide the best empiric coverage for enterococcus faecium?
A. Linezolid
B. Nafcillin
C. Cefepime
D. Ertapenem
A. Linezolid
59-year-old male presents to hospital after several days of vomiting/diarrhea. Upon arrival, he had several runs of non-sustained VT. Initial labs as below:
Na 143 - K 3.2 - Mg 1.4 - Phos 3.2 - Ca 9
Which treatment would be best to give first?
A. Administer 20 mEq IV over 1 hour x 4 doses
B. Administer MgSO4 2 g IV over 2 hours
C. Administer KPhos 15 mmol IV over 4 hours
D. Administer CaGluc 2 g IV over 5 minutes
B. Administer MgSO4 2 g IV over 2 hours
68-year-old male presents with SOB. The labs/vitals below resulted. PMH: HTN, HLD, DM, CHF
BP 110/62 mmHg - HR 55 bpm - SpO2 92% (3L O2)
pro-BNP = 25,265 pg/mL - hs-troponin = 25 ng/L
SCr 1.11 mg/dL - K 4.2 - Mg 1.8
Based on the findings above, what is the initial diagnosis and what initial medication would you give?
A. COPD exacerbation - 125 mg IV methylpred
B. NSTEMI - 325 mg aspirin
C. HF exacerbation - 40 mg IV furosemide
D. Renal failure - 10 mg PO lokelma
C. HF exacerbation - 40 mg IV furosemide
Home glucose management is, insulin glargine 10 units daily in the AM, insulin aspart 0-5 units sliding scale with meals, empagliflozin 25 mg daily, and metformin ER 1000 mg BID. Weight = 90 kg.
Hgb A1C on admit = 11.2
IP Glucose Management Tab over past 24 hours - BG (units of NovoLog given):
BG 454 (27 units) - 389 (18 units) - 229 (9 units) - 245 (9 units) - 202 (9 units) - 198 (9 units) - 180 (9 units)
When contacting physician for post-DKA orders, what would you recommend?
A. Give 60 units of insulin glargine tomorrow morning, when patient would normally take his long-acting insulin. Continue DKA insulin aspart until tomorrow morning, then start sliding scale insulin aspart 0-8 units TID with meals. Stop DKA fluids immediately.
B. Restart patients home insulin regimen now (insulin glargine 10 units daily and insulin aspart 0-5 units TID meals). Stop DKA fluids immediately.
C. Give 45 units of insulin glargine now. Two hours after the insulin glargine, give one more dose of 0.1 u/kg insulin aspart and stop DKA fluids. Order insulin aspart 15 units TID with meals.
D. Give 10 units of insulin glargine now. Two hours after the insulin glargine, give one more dose of 0.1 u/kg insulin aspart and stop DKA fluids. Order sliding scale insulin 0-5 units TID with meals. Continue DKA fluids until tomorrow morning, when patient has their breakfast.
C. Give 45 units of insulin glargine now. Two hours after the insulin glargine, give one more dose of 0.1 u/kg insulin aspart and stop DKA fluids. Order insulin aspart 15 units TID with meals.
**KT required 90 units total of insulin, regimen split it into half basal/half bolus
60-year-old male diagnosed with COPD reports experiencing symptoms most days of the week. mMRC score = 1, spirometry reveals a FEV1 of 70% of predicted and FEV1/FVC of 60% of predicted. No prior COPD exacerbations.
Which medication is best to initiate?
A. Inhaled fluticasone
B. Inhaled tiotropium
C. Inhaled fluticasone/salmeterol
D. Oral roflumilast
B. Inhaled tiotropium
**Group A COPD = recommended to initiate single LA bronchodilator (LAMA or LABA)
Which of the following agents can be used to treat Enterococcus faecalis? (Select all that apply)
A. Piperacillin-tazobactam
B. Cefepime
C. Linezolid
D. Ceftriaxone
E. Ampicillin
F. Ceftazidime
G. Daptomycin
A. Piperacillin-tazobactam
C. Linezolid
E. Ampicillin
G. Daptomycin
35-year-old male presents to the ER after missing dialysis for the last week. Initial labs result as below:
SCr 4.5 mg/dL - K 7.5 mEq/L - Phos 6.4 mmol/L
ECG = normal sinus
Of the options below, which is the best initial option to help clear the potassium?
A. Furosemide IV 80 mg x 1
B. Lokelma 10 g x 1
C. Albuterol 10 g inhaled x 1
D. Insulin regular 10 units IV x 1, PLUS 50 g dextrose
B. Lokelma 10 g x 1