I'm Tired
Endo-schmendo
ED Part One
ED Part Two
Treatment Poutporri
Potpourri
100

What are the four main things that patients may mean when complaining of fatigue?

1) fatigue ("apathy" or "lack of energy") refers to a subjective lack of physical or mental energy during the day interfering with usual activities

2)  increased sleepiness ("drowsiness" or "hypersomnia") refers to the inability to maintain alertness and wakefulness during the day

3) weakness refers to lack of muscle strength, usually not associated with mental dysfunction

4) Dyspnea with exertion or lack of endurance

100

What are the three types of hyperparathyroidism and name a common cause of each?

Primary - Adenoma

Secondary - CKD, Dietary vitamin D deficiency

Tertiary - Renal failure

100

What diagnostic testing is required to make a diagnosis of Asthma in a patient presenting with shortness of breath?

No tests are required.  But you may order viral testing or a chest x-ray depending on the patient's presentation and time of the year.

100
In a patient with a low Wells criteria score meeting 8/8 PERC, what is the next testing required for the workup of a PE?

No further workup is required if 8/8 PERC are met, that essentially rules out a PE.

100

What is the first line treatment for a hemodynamically unstable patient (hypotensive, declining mental status, unresponsive) with this EKG? 

Electrical cardioversion 50-100J x 3 shocks, if they then don't convert - initiate ACLS protocols.

100

In a patient with suspicion for DKA, when is a VBG acceptable instead of an ABG?

If the patient is hemodynamically stable and does not have respiratory failure.

200

What are some can't miss causes of fatigue?

Tumor, Infection (such as HIV), renal failure, liver failure

200

Name three possible triggers of DKA.

Poor metabolic control or missed insulin doses

Medications (Steroids, antipsychotics, beta blockers, thiazide diuretics, fluroquinolones)

Illness/Infection

Drugs and alcohol

200

Define community acquired and nosocomial pneumonia.

CAP: acute infection of the pulmonary parenchyma acquired outside of the hospital

Nosocomial: Hospital acquired PNA - acquired >= 48 hours after hospital admission.; Ventilator associated PNA - acquired >= 48 hours after endotracheal intubation.

200

Describe the four types of heart blocks (how they appear on an EKG tracing).

1st  degree: PR-prolonged

Wenchebach: PR-interval gets longer, longer longer, until a complex is dropped.

Mobitz II: No QRS for every P wave

3rd degree: the P and QRS complexes have no consistent relationship

....If the R is far from P, then you have a first degree.  Longer longer longer drop, then you have a Wenchebach.  When some P's just don't go through, then you have a Mobitz II.  When the Ps and Qs just don't agree - then you have a third degree. ... 

200

When might a patient having s/sx of an NSTEMI need urgent cardiac catheterization?

Persistent chest pain and/or hypotension

200

We have used VINDICATE-P to help us form differentials this semester.  What do the letters stand for?

V - Vascular

I - Inflammatory / Infectious

N - Neoplasm

D - Degenerative / Drugs

I - Idiopathic / Iatrogenic

C - Congenital

A - Autoimmune

T - Traumatic

E - Endocrine/Metabolic

P - Psychiatric

300

Name two screening tools and how you may use them in working a differential for fatigue.

1) Epworth Sleepiness Scale - when considering sleep apnea on the differential for a patient.

2) PHQ-9 - used as part of a screening for depression.

300

What organs and or body parts are involved in the calcium homeostasis system?

Parathyroid glands

Bones

Kidneys

GI Tract

300

What factors may warrant inpatient management in a patient diagnosed with COVID-19? (Name three)

Oxygen requirement

Significant dyspnea or increased respiratory rate (>30/min)

Significant infectious sequelae  (myocarditis, pulmonary embolism, hypercarbia, AKI, etc)

Frequent falls

Unable to care for themselves at home.

300

Provide two possible diagnoses for each of the following: 1) a narrow complex QRS, regular  tachyarrhythmia; 2) a widened complex QRS, irregular tachyarrhythmia

1) Sinus tachycardia, SVT, A flutter, junctional tachycardia, AVNRT, AVRT, SANRT (and others!)

2) WPW, ventricular fibrillation, polymorphic VT (inc. torsades), AF, atrial flutter, focal AT with aberrant conduction (and others!)

300

Name two major contraindications to thrombolytic therapy: 

Hemorrhagic stroke

Severe hypo- or hyperglycemia

Uncontrolled severe hypertension

Significant bleeding conditions

300

Your patient is presenting with a headache with nausea and vomiting, of gradual onset, worse in morning.  You have a high suspicion for a brain tumor because of the patient's age and presentation.  Name two physical examination findings that may be present with that diagnosis?

Papilledema

Cognitive difficulties

Focal neurological deficits

400

Name four laboratory studies and how they may work the differential for fatigue.

TSH: evaluate thyroid function (hypo-, hyper-)

Glucose and/or HgbA1C: considering DM or level of glucose control

BMP/CMP: Lytes, Cr, LFTs

B-NP: Heart failure

CBC: Anemia, infections (must include differential)

HIV, ESR: May utilize to r/o can't miss diagnoses

400

If a patient has a high PTH level, what is the most likely cause?

Primary hyperparathyroidism

400

Name three physical examination findings that may be found in a patient with an acute aortic dissection?

Pulse deficit (checking peripheral pulses)

New heart murmur

Focal neurological deficit (chest pain + any neurological symptom)

Hypotension

Syncope

400

What are the EKG findings that occur in hypo- and hypercalcemia?

Hypocalcemia: QTc prolongation primarily by prolonging the ST segment

Hypercalcemia: shortened QT, ST segment elevation (Osborne waves), biphasic T waves, and prominent U waves. 

400

What is the first line outpatient treatment for CAP in a patient without significant comorbidities or lung problems and no allergies?

Amoxicillin 1g three times daily PLUS a macrolide (i.e. Azithromycin, doxycycline)

400

Name four conditions in which a D-Dimer may be elevated.

DVT

PE

Pregnancy

DIC

Sepsis

Recent MI

Recent surgery...

500

Name four of the red flags for fatigue.

1) Recent onset in a previously well patient.

2) Unintentional weight loss

3) Abnormal bleeding

4) Shortness of breath

5) Unexplained lymphadenopathy

6) Fever

7) Recent onset or progression of GI, CV, neuro, or rheumatological symptoms.

500

What are the five diagnostic criteria for DKA? 

Glucose > 250 mg/dL. (Rarely patients with DKA have near normal blood glucoses [euglycemic DKA]. This is more common in pregnant patients and patients taking SGLT2 inhibitors.)

pH ≤ 7.3

HCO3− ≤ 18 mEq/L

Positive serum ketones

Anion gap > 10 mEq/L

500

What are three signs of hemodynamic instability? (there are many!)

Hypotension

Narrow pulse pressure (<20mmHg)

Altered mental status (restless, combative, confused, lethargic)

Diminished or absent peripheral pulses 

Cool extremities

Prolonged capillary refill

500

In the workup of a patient with a suspected stroke, what is the preferred imaging?

CT of the head without contrast

500

You started your newly diagnosed atrial fibrillation patient on warfarin (Coumadin) and asked them to have an INR repeated in 7-10 days.  What is the therapeutic goal of the INR for atrial fibrillation?

2-3

500

Interpret this ABG: 

pH 7.6

PaO2 120 mm Hg

PaCO2 31 mm Hg

HCO3 25 mmol/L

Respiratory Alkalosis, Uncompensated