Systemic/Endo

by Andrew Kendle and Allison Beaulieu

Rapid Reveal Board Review

Multiple Choice

The toxin produced by what bacterium binds to the presynaptic membrane and blocks acetylcholine release?

• Clostridium botulinum

• Clostridium tetani

​Tetanus and Botulism

• Botulism on the exam

  • Floppy baby or canned food

  • Antitoxin​

• Tetanus vaccine or Ig?

  • ​Unvaccinated dirty - Ig and V

  • ​Vaccinated, dirty - 5 yrs

  • ​Vaccinated, clean - 10 yrs

Multiple Choice

What set of DKA labs would you give insulin prior to K and not give Bicarb in?

• Potassium 3.4, pH 6.95

• Potassium 3.0, pH 7.25

• Potassium 5.5, pH 7.0

• Potassium 4.0, pH 6.8

DKA review one

• Bolus and workup first​

• K<3.5, K before insulin

• ​K<5.5, start K fluids

• ​pH generally not indicated for pH >6.9

Multiple Choice

Who is Sam dressed as in this picture?

• Madeline

• The Man in the Yellow Hat

• Georgie from It

• Coraline

• A Crossing Guard

TBH she nailed it

Multiple Choice

This antibiotic is indicated to cover Neisseria Meningiditis

• Ceftriaxone

• Vancomycin

Meningitis Coverage

• ​Babies: amp/gent

• ​>1 year: ceftriaxone 2g, Vanc

• ​Seizures/vesicular rash? Acyclovir

• ​Elderly/pregnant? Add Ampicillin

• ​Steroids - for possible Strep meningitis

Multiple Choice

Which is the first treatment you should give in a patient with suspected thyroid storm who is not in acute heart failure?

• Propranolol

• Fluids

• PTU/methimazole

• Iodine

Multiple Choice

How did Miha meet his wife?

• Elementary school chess club

• Middle school detention

• Fight club

• While practicing as a metal guitarist

• High school EKG club

Multiple Choice

Steroids are indicated in a patient with HIV/AIDs and suspected PJP pneumonia when this finding is present:

• CD4 count less than 200

• PAO2 less than 70

Pneumocystis Jirovecii

• ​Oxygen!

• ​Bactrim prophylaxis is indicated for CDC<200 or history of oropharyngeal candida

• ​Add steroids to treatment for PaO2<70 or A-a gradient >35

Multiple Choice

What is the most common precipitant of DKA?

• Insulin noncompliance/wrong regimen

• Infection

• Ischemic event

DKA part two

• ​infection, insulin, ischemia, new onset, steroids/meds

  • ​fun fact, in field capnography sensitive/specific

Multiple Choice

This organism is the likely cause of vomiting 3 hours after a barbecue of grilled chicken, cookies and potato salad.

• Staphylococcus aureus

• Bacillus Cereus

Food poisoning culprits

• ​Staph with rapid onset due to preformed toxin in foods left out

• ​B. cereus in 6-8 hours from rice, sauce or soup that is not refrigerated

Multiple Choice

Which of these causes of adrenal insufficiency would have hyperpigmentation and hyperkalemia?

• Autoimmune

• Steroid withdrawal

• Pituitary necrosis

Adrenal Insufficiency

• Autoimmune 70% of primary

• ​Secondary has low ACTH, normal mineralcorticoids, no skin changes

• ​Primary, not autoimmune:

  • adrenal hemorrhage (W-F)

    medications

  • infection

  • infiltrative

  • mets

• Secondary:

  • ​steroids

  • ​pituitary

  • ​trauma

Multiple Choice

What was Carolyn Martinez's first (and worst) costume?

• A football

• A michigan cheerleader

None provided but here is a stock photo representation of her brother

Multiple Choice

This clinical presentation of herpes zoster suggests an immunocompromised state:

• Lesions with superimposed bacterial infection

• Lesions in >2 dermatomes

Disseminated Zoster

• ​Lesions in 3+ dermatomes

• ​IV acyclovir, concern for immunocompromise

  • ​Can sometimes see hemorrhagic skin vesicles or CNS, PNA, other organ involvement

Multiple Choice

What calcium cutoff is considered "severe" as a treatment threshold

• 12

• 13

• 14

• 15

Severe high Ca in the ED

• Stones, bones, groans, thrones, psych overtones​

• Give fluids, stop thiazides

• ​High chance it is cancer

  • ​also primary endocrine

  • ​Granulomas

  • ​Vitamin A/D

  • ​Renal

  • ​Bone

• ​For test questions, calcitonin and bisphosphonates options

Multiple Choice

This tick-borne illness causes elevated LDH, low haptoglobin and elevated indirect bili.

• Babesiosis

• Anaplasmosis

Multiple Choice

When should you give T4 in your bradycardia cold hypothyroid patient?

• After they don't improve with fluids warming and atropine

• As soon as you suspect the diagnosis

• Once all of your labs come back

Myxedema Coma

• Low everything

  • bradycardic and hypotensive

    • Can have effusion/tamponade

  • Hypothermic

  • Hypoactive/altered

• Hypothyroid plus a stressor

  • ​Treat for sepsis and treat thyroid early, mortality is high

• ​Out of scooby unmasking gifs :(

Multiple Choice

Which resident had idiopathic meconium ileus?

• Madison Kommor

• Thomas Powell

• Hannah Fox

• H

Multiple Choice

This is the most common finding in acute retroviral syndrome.

• Pharyngitis

• Diffuse adenopathy

Acute retroviral syndrome

• ​Varied early presentation of HIV, often misdiagnosed for other viral etiology

• ​Commonly fever, myalgias, fatigue, HA, diarrhea, pharyngitis, adenopathy

• ​There is an associated risk of opportunistic infection.

Multiple Choice

In which toxicologic hypoglycemia is glucagon indicated?

• Insulin overdose

• Jardiance overdose

• Glipizide Overdose

Hypoglycemia

• ​Beyond glucose...

• ​glucagon if they have the stores

• ​dextrose drip for long acting insulin/sulfonylureas

• octreotide for bad sulfonylurea

  • ​Must monitor >24hrs

  Activated charcoal

Multiple Choice

Patients in the James receive Cefepime for this cutoff.

• WBC<500

• ANC<500

Neutropenic fever

• ​<500 ANC or expected nadir <500

• ​Cefepime to cover gram negatives and Pseudomonas

• most identified pathogens are endogenous flora many GI, this is why you don't do a rectal

Multiple Choice

Which is true of HHS compared to DKA?

• Lower mortality

• Less volume deficit

• You start insulin later

HHS vs. DKA

• Chief component in HHS is osmolality/dehydration

  • ​in DKA it is insulin deficiency/acidosis

    • ​volume repletion first, TBW 8-12L deficit, get UOP

Multiple Select

Who has best earned the nickname "one liner machine"?

• Madison Kommor

• Madison Kommor

• Madison Kommor

Multiple Choice

This worm can be found using scotch tape.

• Enterobius

• Trichuris trichuria

Multiple Choice

What comes before d5 in an alcoholic presenting with high anion gap acidosis with normal osmolality?

• Fomepizole

• Thiamine

• B12

Alcoholic ketoacidosis

• Give fluids with d5 after thiamine

  • ​can precipitate wernickes/korsakoff

• ​buildup of NADH/NAD+ from acetaldehyde causes ketogenesis

Multiple Select

This is the first line pressor for septic shock.

• Epinephrine

• Norepinephrine

• Dopamine

Septic shock pressors

• ​Norepi 4ever

• ​But in peds, more cold shock, typically epi for inotropy

​First line pressor

Multiple Choice

Which would point you towards secondary adrenal insufficiency in a postpartum patient?

• Weight loss

• Lethargy

• Hyperkalemia

• Inability to lactate

Pituitary apoplexy

• ​Sheehan's syndrome from postpartum hemorrhage

  • ​Adrenal insufficiency (2ary), hypothyroid and hypogonadism

Multiple Choice

Does Michael Miles (and any sane human cough Carolyn cough) consider Nightmare before Christmas to be a Christmas or Halloween movie?

• Halloween, clearly

• I think it is a Christmas movie and also I eat bananas whole with the peel

• Both (this is still the wrong answer)

Did we get this far?

Thanks for playing!