INTERNAL MEDICINE EOR EXAM REVIEW: CRITICAL CARE

Pulmonary Embolism
Wells criteria for Risk of DVT:

CLINICAL FEATURE POINTS
Active cancer (treatment within 6 months, or palliation) 1
Paralysis, paresis, or immobilization of lower extremity 1
Bedridden for more than 3 days because of surgery (within 4 weeks) 1
Localized tenderness along distribution of deep veins 1
Entire leg swollen 1
Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) 1
Unilateral pitting edema 1
Collateral superficial veins 1
Alternative diagnosis as likely as or more likely than DVT 2
Total points:
Risk score interpretation (probability of DVT): 3 points: high risk (75%); 1 to 2 points: moderate risk (17%);<1
point: low risk (3%)















Wells criteria for PE:
CLINICAL FEATURE POINTS
Clinical symptoms of DVT 3
Other diagnosis less likely than PE 3
Heart rate greater than 100 beats per minute [corrected] 1.5
Immobilization or surgery within past 4 weeks 1.5
Previous DVT or PE 1.5
Hemoptysis 1
Malignancy 1
Risk score interpretation (probability of DVT): >6 points: high risk (78.4%); 2 to 6 points: moderate risk
(27.8%); <2 points: low risk (3.4%)
Pharm for HTN single agents only lower by 10-20 mm Hg, may need a 2nd agents
Thiazides: HCTZ, chlorthalidone DOC for HTN but cant use once CrCl < 30
Ca sparing = good for osteoporosis pts
Need to check BMP before and after starting
Chlorthalidone has the most evidence but my preceptor
thinks it causes a lot of hypokalemia


Loops: furosemide

K-sparing: spironolactone,
eplerenone


Not very potent
ACEis: benazepril, enalapril,
lisinopril
Cough
Can cause renal failure = need to monitor BMP 1 week and
1 month
After starting and periodically after that, STOP if serum Cr by
30%
Ok to use in patients with no renal function left
Pregnancy D

ARBs: irbesartan, losartan,
olmesartan, valsartan

Same AEs as ACEIs and also pregnancy D
CCBs: dihydropyridine (nifedipine,
amlodipine) and non-
dihydropyridine (verapamil and
diltiazem)
Useful in the elderly
FDA warning about amlodipine, verapamil, and diltiazem
Use with simvastatin
Contraindicated in heart failure


Other direct vasodilators
(hydralazine, minoxidil)

-blockers Clonidine: only for refractory HTN due to risk of falls
Methyldopa: DOC for HTN in pregnancy

-Blockers Questionable role in the treatment of essential HTN unless
patient also has CHF or MI
Need strict -1 blockers for asthma/COPD patients so that
bronchial relaxation is not blocked (atenolol or metoprolol)
Propranolol and labetalol block at multiple sites
Can mask signs of hypoglycemia
Contraindications: heart block