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Mersfelder IM Rotation Study Guide

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tylerwise's version from 2015-07-30 18:12

Afib and Flutter

Question Answer
Thrombosis preventionWarfarin
Dabigatran (do not use in valvular disease)
Rivaroxaban (do not use in valvular disease)
Apixaban (do not use in valvular disease)
Heart RATE controlBeta-blockers
Non-DHP CCBs (diltiazem, verapamil)
Digoxin (does not affect BP, best to use in someone with tachycardia due to Afib, but with low BP)
Amiodarone
Heart RHYTHM controlFlecainide (do not use in structural heart disease; may cause arrhythmias
Propafenone (do not use in structural heart disease; may cause arrhythmias)
Dofetilide (causes QTc prolongation and must be started while admitted)
Amiodarone
AF prevention following cardioversionDronedarone
Dofetilide
Propafenone
Sotalol
Amiodarone (last line)
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Serotonin Syndrome

Question Answer
Causes of serotonin syndrome5-HT3 receptor antagonists, linezolid, lithium, MAOIs, 5-HT1 receptor agonists, mirtazapine, SNRIs, SSRIs, TCAs, tramadol, trazodone, valproic acid
Serotonin syndrome triadNeurologic changes
Autonomic instability or hyperactivity
Neuromuscular abnormalities
Neurologic changes (symptoms)Altered mental status
Agitation
Confusion
Ataxia
Akathisia
Autonomic instability (symptoms)Diaphoresis
Tachycardia
Hypertension
Hyperthermia
Nausea
Diarrhea
Shivering
Neuromuscular changes (symptoms)Tremor
Muscle rigidity
Hyperreflexia
Clonus
Treatment stepsDiscontinue offending medications
Initiate benzodiazepines
Fluid resuscitation and maintenance
Oxygen PRN
Optional treatments PRN
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Bacterial Meningitis

Question Answer
Most common bacteria strainsStreptococcus pneumoniae
Neisseria meningitidis
Empiric therapy
Ages 2 to 50 years
Ceftriaxone 2g IV Q12h or Cefotaxime 2g IV Q4-6h
Vancomycin 15-20mg/kg Q8-12h with goal trough of 15-20mcg/mL
Empiric therapy
Ages 50+ years or immunocompromised patients
Ceftriaxone 2g IV Q12h or Cefotaxime 2g IV Q4-6h
Vancomycin 15-20mg/kg Q8-12h with goal trough of 15-20mcg/mL
Ampicillin 2g IV Q4h (to cover for Listeria
Empiric therapy for suspected nosocomial meningitisCeftazidime or cefepime or meropenem (to cover for Pseudomonas
Vancomycin
Ceftriaxone or cefotaxime
(Intended coverage spectrum)
H. influenzae
M. meningitidis
P. pneumoniae
Vancomycin
(Intended coverage spectrum)
Drug-resistant S. pneumoniae
Ampicillin
(Intended coverage spectrum)
Listeria monocytogenes
Rifampin
(Intended coverage spectrum)
Threat of cephalosporin-resistant pneumococci
Ceftazidime or cefepime or meropenem
(Intended coverage spectrum)
Pseudomonas aeruginosa
H. influenzae
N. meningitidis
S. pneumoniae
Prophylaxis for H. influenzae exposureRifampin 600mg PO daily for 4 days
Prophylaxis for N. meningitidis exposureRifampin 600mg PO Q12h for 2 days
or ceftriaxone 250mg IM x 1 dose
or ciprofloxacin 500mg PO x 1 dose
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Adrenal Insufficiency

Question Answer
Medicine causes of primary adrenal insufficiencyKetoconazole
Etomidate
Rifampin
Phenytoin
Phenobarbital
Medicine causes of secondary adrenal insufficiencyMirtazapine
Progestins
Common cause of acute adrenal crisisAbrupt withdrawal of chronic exogenous glucocorticoids
Symptoms of adrenal insufficiencyWeakness
Weight loss
GI symptoms (N/V/D)
Cravings for salt
Memory impairment
Depression
Postural dizziness/hypotension
Loss of libido (in women)
Treatments for primary adrenal insufficiencyHydrocortisone (drug of choice) 15-25mg/day
Prednisone 2.5mg/day
+/- Fludrocortisone for mineralocorticoid supplementation in hyperkalemia
Treatments for secondary adrenal insufficiencyHydrocortisone (drug of choice) 15-25mg/day
Prednisone 2.5mg/day
Treatments for adrenal crisisHydrocortisone 100mg via rapid infusion
then 10mg/h infusion or 100-200mg bolus Q24 hours for 24-48 hours
then switch to oral hydrocortisone 50mg Q6-8h
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Endocarditis

Question Answer
Organisms of acute endocarditisS. aureus
S. lugdunensis
S. pyogenes
Pneumococci species
Enterococci species
Organisms of subacute endocarditisS. viridans
Enterococci species
Coag-negative Staphylococci species
HACEK group
Organisms of community-acquired endocarditisStreptococci
Viridans group
HACEK organisms
Enterococci
Organisms of healthcare-acquired endocarditisS. aureus
Coag-negative staphylococci
Enterococci
P. aeruginosa
Risk factors of acquiring endocarditisIV drug use
Cardiac valvular abnormalities
Heart valve replacement
Implantable cardiac devises
Rheumatic heart disease
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Entresto

Question Answer
Function of EntrestoARB/Neprilysin inhibitor combination (ARNI)
Inhibiting neprilysin blocks the breakdown of beneficial neurohormones including natriuretic peptides, bradykinin, and adrenomedullin
The ARB is required to prevent conversion of Ang-I to Ang-II
Entresto ADRsHypotension
Hyperkalemia
Dry cough
Dizziness
Renal failure
Angioedema
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Gallbladder and Stones

Question Answer
Medications that may cause gallstonesCeftriaxone
Oral contraceptives
Clofibrate
Estrogen replacement
Progestins
Octreotide
Treatments for community acquired gallbladder infectionsCefazolin 1-2g IV Q8h
Cefuroxime 0.75-1.5g IV Q8h
Ceftriaxone 1-2g IV Q24h
Moxifloxacin 400mg IV daily
Ertapenem 1g IV daily
Treatments for nosocomial gallbladder infectionsZosyn 3.375g IV Q6h
Ticarcillin/clavulanate 3.1g IV Q6h
Imipenem/cilastatin 250-500mg IV Q6-8h
Meropenem 0.5-1g IV Q8h
Doripenem 500mg IV Q8h
Levofloxacin 500mg IV Q24h + Metronidazole 500mg IV Q8h
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Hypercalcemia

Question Answer
Medication causes of hypercalcemiaThiazide diuretics
Lithium
Vitamin A poisoning
Vitamin D poisoning
Symptoms of hypercalcemiaPolydipsia and polyuria
Constipation
Shortened QTc interval
Nephrolithiasis
Pancreatitis
Hypertension
Muscle weakness
Anorexia, nausea/vomiting
Decreased renal function
Dysrhythmias
Nephrocalcinosis
Peptic ulcer
Cardiomyopathy
Cognitive dysfunction
Hypercalcemia treatmentsBisphosphonates (first-line)
Calcitonin (IV) (first-line for acute)
Glucocorticoids (second-line)
Calcimimetics (cinacalcet) (second-line)
Denosumab (second-line)
Gallium nitrate
Mithramycin
Bisphosphonate MOABlock bone resorption by inhibiting development of osteoclast precursors into mature osteoclasts
Calcitonin MOAInhibits bone resorption and reduces tubular reabsorption of calcium
Glucocorticoid MOAInhibits production of 1,25-OHD
Calcimimetic MOAIncreases sensitivity for receptor activation by extracellular calcium which reduces PTH and serum calcium concentrations
Denosumab MOAInhibits RANKL (principal mediator of osteoclast survival)
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Hypothyroidism

Question Answer
Medication causes of hypothyroidismLithium
Amiodarone
Interferon-alfa
Interleukin-2
Tyrosine kinase inhibitors
Symptoms of hypothyroidismFatigue
Cold sensitivity
Constipation
Dry skin
Weight gain
Puffy face
Muscle weakness
Elevated lipid panels
Thinning hair
Bradycardia
Depression
Desiccated pig thyroid
Composition and important points
Natural T4/T3 in 4.2:1 ratio
Not recommended for thyroid replacement due to composition inconsistencies and antigenicity
Levothyroxine
Composition and important points
Synthetic T4
Drug of choice for thyroid replacement
Long half-life for QD dosing
Liothyronine
Composition and important points
Synthetic T3
Shorter half-life for TID dosing
Higher incidence of cardiovascular events vs. T4
Liotrix
Composition and important points
Synthetic T4/T3 in 4:1 ratio
Expensive
Lack rationale since T4 is converted to T3
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Ischemic Stroke

Question Answer
Goal BP for use of TPA
Medications to use to achieve goal
<185/110
Labetalol or nicardipine
Goal BP after TPA use
Medication to use to achieve goal
<180/105
Labetaolol or nicardipine
Dosing for TPA0.9mg/kg (maximum of 90mg)
10% of total given as a bolus over 1 minute
90% of total dose given as an infusion over 1 hour
Medication classes used for secondary stroke preventionAntiplatelets
Antithrombotics
Antihypertensives
Statins
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Peritonitis

Question Answer
Most common primary bacterial peritonitis organismE. coli
Most common secondary bacterial peritonitis organismE. coli or Bacteroides fragilis
Primary bacterial peritonitis
Empiric therapy coverage
Cefotaxime 2g Q8h or ceftriaxone 2g Q24h
or
Piperacillin/tazobactam 3.375g Q6h
Prophylaxis after first occurrence of primary bacterial peritonitisCiprofloxacin 750mg QWeek or Norfloxacin 400mg QD
or
Bactrim DS QD
Treatment options for MILD-to-MODERATE community acquired peritonitisSingle agents
Cefoxitin
Ertapenem
Moxifloxacin
Tigecycline
Ticarcillin/clavulanate

Combination agent
Metronidazole PLUS
Cefazolin
Cefuroxime
Ceftriaxone
Cefotaxime
Ciprofloxacin
Levofloxacin
Treatment options for SEVERE community acquired peritonitisSingle agents
Imipenem-cilastatin
Meropenem
Doripenem
Pip/tazo

Combination agents
Metronidazole PLUS
Cefepime
Ceftazidime
Ciprofloxacin
Levofloxacin
Secondary bacterial peritonitis
Empiric therapy coverage
Ticarcillin/clavulanate 3.1g Q4-6h
Cefoxitin 2g Q6h
Ceftriazone 2g Q24h + Metronidazole 500mg Q8h
Imipenem-cilastatin 500mg Q6h
Meropenem 1g Q8h
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UTI

Question Answer
Acute uncomplicated cystitis
Treatments
Nitrofurantoin 100mg BID x 5 days
Bactrim DS BID x 3 days
Fosfomycin 3g x 1 dose
Fluoroquinolone x 3 days
Beta-lactam x 3-7 days
Acute pyelonephritis
Treatments
Ciprofloxacin 500mg BID x 7 days (may load with 400mg IV)
Levofloxacin 750mg PO daily for 5 days
Bactrim DS BID x 14 days
memorize

Venous Thromboembolism

Question Answer
Medication causes of VTEEstrogens (OCs and replacement)
Selective estrogen receptor modulators (SERMs)
Some cancer therapies
Heparin --> HIT
Warfarin MOAInhibits clotting factors II, VII, IX, and X
Why does DVT treatment with warfarin need to be bridged?Warfarin inhibits Substance C and Substance P which initially increases coagulability
Unfractionated heparin MOAInhibits clotting factors II and X
LMWH MOAInhibits clotting factor Xa
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Thrombosis RiskLowLow with bleedingIncreased with bleedingIncreased without bleeding risk
Hospitalized (Acutely ill)NoneNoneGCS or IPCDLMWH, UH, or fondaparinux
Hospitalized (Critically ill)LMWH or UHGCS or IPCDGCS or IPCDLMWH or UH
Major traumaIPCD, UH, or LMWH?IPCD?
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Thrombosis RiskLowHigh without bleeding riskIndwelling venous catheterChronically immobilized
Outpatient (cancer)NoneLMWH or UHNoneNone
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Thrombosis RiskModerate without bleedingModerate with bleedingHigh risk without bleedingHigh with cancer without bleeding
Surgical (abdominal)LMWH, UH, or IPCDIPCDLMWH or UH
Plus IPCD
LMWH for extended duration
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Drug Related Problems

Question Answer
What are the drug related problems?Indication without drug
Drug without indication
Therapeutic duplication
Correct route
Correct dose
Drug/drug interactions
Best drug
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Monitoring

TreatmentFactor Xa Monitoring
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
No
No
No
YES
YES
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TreatmentaPTT
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
No
No
YES
No
No
memorize

 

TreatmentPT
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
YES
No
No
No
No
memorize

 

TreatmentINR
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
YES
No
No
No
No
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TreatmentWeight
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
No
No
YES
No
YES
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TreatmentCrCl
Warfarin
Heparin prophylaxis
Heparin treatment
LMWH prophylaxis
LMWH treatment
No
No
No
YES
YES
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