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Question 1

B-blocker OD presents how?

Answer 1

bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, cardiogenic shock
IV fluids, atropine, IV glucagon (if profound hypotension)
glucagon ^cAMP, also helps with CCB OD

Question 2

WPW on EKG

Answer 2

short PR <0.12 (3 boxes), delta wave (upstroke of QRS), QRS widening with ST/T wave abnormalities

Question 3

testing with initial dx of HTN

Answer 3

UA (occult blood and PCR)
BMP/CMP
Lipid profile
EKG

Question 4

treatment for post-MI pericarditis (Dressler’s syndrome)

Answer 4

NSAIDs, steroids if refractory

-immunologic phenomena, ^ESR

Question 5

pulsus paradoxus

Answer 5

exaggerated decrease >10mmHg decrease in SBP with inspiration seen in cardiac tamponade, can occur in severe asthma and COPD
-inspiration decreases

Question 6

what murmurs should always be worked up? (Echo)

Answer 6

any diastolic

>3/6 continuous systolic

Question 7

BNP levels:
most pts with dyspnea due to CHF had BNP levels greater than ?? while levels less than ?? had a high negative predictive value for CHF as the cause of dyspnea

Answer 7

greater than 400 pg/mL

less than 100 pg/mL

Question 8

nonselective B blockers that may trigger bronchoconstriction

Answer 8

propranolol, nadolol, sotalol, timolol (later 1/2 of alphabet)

Question 9

cardioselective (B1) B blockers

Answer 9

metoprolol, atenolol, bisprolol, nebivolol

Question 10

features of constrictive pericarditis

Answer 10

RHF signs: ^JVP (>8), peripheral edema/ascites
clear lung fields
pericardial knock (mid diastolic sound- filling)
pulsus paradoxus
Kussmaul’s sign
pericardial thickening and calcification on (CXR)
x and y descents on JVP tracing

Question 11

cardiac amyloidosis features

Answer 11

increased ventricular wall thickness with normal/nondilated LV cavity on Echo
may have heavy proteinuria, periorbital purpura, hepatomegaly

Question 12

water bottle heart on CXR
maximal apical impulse that is difficult to palpate
think??

Answer 12

pericardial effusion without tamponade

-also, diminished heart sounds

Question 13

where do you hear an abnormal S4

Answer 13

in pts with decrease LV compliance: HTN HD, aortic stenosis, HCM, acute MI

Question 14

what is pulses bisferiens and when is it seen

Answer 14

biphasic pulse: 2 strong systolic peaks of aortic pulse from LV ejection separated by mid systolic dip
seen in aortic regurg, HOCM, large PDA

Question 15

murmur of mitral regurg

clinical features

Answer 15

holosystolic blowing murmur @ apex radiating to axilla

DOE, fatigue, a fib, HF signs

Question 16

1st steps in aortic dissection

Answer 16

if stable: CT angiography for diagnosis (#2: MRA)
if unstable: emergent pericardiocentesis +/- TEE for dx
TEE especially if pt has ^Cr (renal insufficiency)

Question 17

cyanide toxicity features

Answer 17

AMS, lactic acidosis, seizures, coma

may occur following nitropruside tx in pt with renal insufficiency

Question 18

meds shown to improve long-term survival in pts with LV systolic dysfunction

Answer 18

B-blockers
ACE-i/ARBs
spironolactone/epleronone
Afr. Am: hydralazine + nitrates

Question 19

medical management of aortic dissection

Answer 19

morphine for pain
IV B-blocker for target SBP of 100-120 mmHg
additional vasodilator (nitroprusside) if SBP remains^

Question 20

digoxin toxicity can occur more rapidly with the addition of what med ?

Answer 20

amiodarone, decrease digoxin by 25-50%

Question 21

what anti platelet therapy indicated after stent placement/post STEMI/NSTEMI

Answer 21

P2y12 receptor blockers (clopidogrel (plavix), prasugrel, ticagrelor) + ASA
in addition to B-blockers, ACE-i/ARBs, statins, spironolactone

Question 22

direct factor Xa inhibitors (apixaban) are indicated for

Answer 22

anticoagulation in nonvalvular afib and for management of DVT and PE

Question 23

normal vs elevated A-a gradient in respiratory distress

Answer 23

normal less than 15: hypoventilation is the cause

elevated is more than 30

Question 24

PE may cause pulmonary infarction leading to ?

Answer 24

hemoptysis

Question 25

what lung lesions are high probability for malignancy? what to do next? intermediate risk? low risk?

Answer 25

older than 60 yrs, smoking history, large lesion i.e. more than 2 cm, irregular margins intermed: more than 8 mm (PET) and sx excision if + low: smaller, serial CT scans

Question 26

PE can lead to effusions that tend to be

Answer 26

small, exudative, bloody, associated with pain

Question 27

lung protective strategy for ARDS on mechanical ventilation

Answer 27

low tidal volume ventilation (LTVV) to prevent over distending alveoli

Question 28

elevated B-hCG and AFP in setting of anterior mediastinal mass

Answer 28

nonseminomatous germ cell tumor seminomas: just B-hCG not AFP teratomas: no markers

Question 29

thymoma is associated with systemic syndromes including ?

Answer 29

myasthenia gravis and pemphigus

Question 30

lab findings in SIADH | treatment?

Answer 30

hyponatremia serum osm less than 275 (hypotonic) urine osm more than 100 (concentrated) urine Na+ more than 40 mEq/L (salt wasting) *seen in small cell lung cancer tx: fluid restriction +/- salt tablets, demeclocycline only if unresponsive (decr. response to ADH) do not use NS or LR as may cause water retention; useful in hypovolemic hyponatremic patients

Question 31

what levels of PaCO2 are worrisome in an asthma exacerbation?

Answer 31

elevated or even normal (i.e. 50) as they should be low due to the hyperventilation implies inability to meet increased respiratory demands and impending respiratory failure

Question 32

inability to correct hypoxemia with increased FiO2 is seen in ?

Answer 32

intrapulmonary shunting- seen in decreased alveolar ventilation, a form of V/Q mismatch where V is 0 in certain areas (pneumonia, ARDS/atelectasis, severe PE, pulm. edema) (also seen in i in contrast, emphysema, interstitial lung disease, and PE(sometimes) are V/Q mismatches where V is greater than 0 so ^FiO2 will improve hypoxemia

Question 33

what disease? -bronchial thickening and dilation due to recurrent infection/inflammation -cough + mucopurulent sputum, hemoptysis, dyspnea how to diagnose?

Answer 33

bronchiectasis | high-resolution CT of chest

Question 34

pleural effusion shows what breath sounds, tactile fremitus, and percussion? in contrast to consolidation

Answer 34

decreased breath sounds and DECREASED tactile fremitus- fluid outside lung insulate sounds/vibrations inside the lung dullness to percussion In contrast, consolidation i.e. pna is fluid inside the lung which will result in increased breath sounds and tactile fremitus but still dullness to percussion

Question 35

outpatient empiric tx of CAP

Answer 35

healthy: macrolide (azithromycin) or doxycyline comorbidities: FQ (levaquin or moxifloxacin NOT cipro) + macrolide

Question 36

inpatient non-ICU empiric tx of CAP

Answer 36

``` IV FQ (levaquin or moxifloxacin) IV IV B-lactam + macrolide (ceftriaxone + azithromycin) ```

Question 37

ICU empiric tx of CAP

Answer 37

IV B-lactam + macrolide (rocephin + azithromycin) | IV B-lactam + FQ (rocephin + levaquin)

Question 38

score to help determine hospitalization in pneumonia

Answer 38

``` CURB-65: 1 pt for each Confusion Urea 20+ RR 30+ SBP less than 90 or DBP less than 60 Age 65+ 0: outpt tx, 1-2: possible inpt tx, 3-4: inpt, ICU if 4 ```

Question 39

how to treat bradycardia associated with hypothermia?

Answer 39

active rewarming and warmed IVF | atropine and cardiac pacing is NOT effective!

Question 40

decreased airflow rate during inspiration AND expiration is seen in ?

Answer 40

fixed upper-airway obstructions

Question 41

PE anticoagulation in pt with severe renal insufficiency (GFR less than 30)

Answer 41

unfractionated heparin over LMWH (lovenox) or fondaparinux, rivaroxaban reduced renal clearance increases anti-Xa activity levels and bleeding risk

Question 42

when to give abx for AE COPD

Answer 42

if 2+ cardinal symptoms: increased dyspneal, cough, sputum production or if requires mechanical ventilation

Question 43

ABG levels when to intubate

Answer 43

PaO2 less than 70, PaCO2 50+, pH less than 7.2 + hypercapnia | acceptable ranges on mech. vent: PaO2 50-60 with PaCO2 40-50 with pH btw 7.35-7.50

Question 44

ABG in PE

Answer 44

PaO2 and PaCO2 low, high pH (respiratory alkalosis) | A-a gradient typically elevated

Question 45

Well's criteria

Answer 45

3. 0 -s/s of DVT 3. 0 -alt. dx less likely than PE 1. 5 -HR 100+ 1. 5 -immob. 3+ days or sx in prev. 4 wks 1. 5 -prev. DVT/PE 1. 0 -hemoptysis 1. 0 -malignancy prev. 6 mo or palliative 4+ PE is likely

Question 46

PE tx

Answer 46

O2 LMWH (lovenox) better than unfractionated UNLESS renal insufficiency, for 5-10 days, INR 2-3 warfarin or NOACs start day 1 with hep then 3-6 months+ tPA not well defined, massive PE + hemodyn. unstable, or RHF catheter-directed thrombolysis IVC filter surgical thrombectomy (hemodyn. compr., lg prox thrombus, poor candidate for tPA)

Question 47

indications for IVC filter

Answer 47

CI to anticoag in pt with documented PE/DVT complication of current anticoag failure of adequate anticoag (i.e. DVT/PE while on tx) low pulm reserve at high risk of death from PE

Question 48

when higher INR indicated (2.5-3.5)

Answer 48

prosthetic mechanical heart valves, ppx of recurrent MI, tx of antiphospholipid Ab syndrome

Question 49

what makes a PE submassive? | tx?

Answer 49

evidence of right heart strain: elevated troponin OR elevated BNP OR increased RA/RV size on 2D Echo tx: heparin gtt-->coumadin

Question 50

what makes a PE massive? | tx?

Answer 50

``` submassive criteria (RH strain) + hypotension tx: tPA, thrombectomy if CI (otherwise thrombectomy used in CTEPH -chronic tromboembolic pulm. HTN) ```

Question 51

causes of hemoptysis

Answer 51

bronchitis (50%), lung cancer, TB, bronchiectasis, pneumonia | more rare: Goodpasture, PE w. pulm infarct, aspergilloma within cavities, mitral stenosis with ^PVP, hemophilia