AAC 1 Flashcards
What is Well’s criteria
Used to determine pretest probability of PE:
♣ Wells Scoring Criteria:
• Clinical symptoms of DVT (leg swelling, pain with palpation) = 3
• Other diagnosis less likely than PE = 3
• Heart rate > 100 = 1.5
• Immobilization (>/= 3 days) or surgery in the previous 4 weeks = 1.5
• Previous DVT/PE = 1.5
• Hemoptysis = 1
• Malignancy = 1
Describe what to do for different scoring of Well’s
• Wells <2 = low probability
o Get D-dimer
♣ If low = likely not PE
♣ If elevated = continue with further testing
• Wells >4-6 = high probability o CTA with IV contrast ♣ Best test ♣ Must have normal kidney o V/Q scan ♣ Can perform with abnormal kidneys ♣ Must have a normal CXR
Describe CURB 65
PNEUMONIA SEVERITY SCORE:
• Criteria:
o C = Confusion (based upon a specific mental test or new disorientation to person, place, or time)
o U = Urea (BUN >7)
o R = Respiratory Rate >/= 30
o B = Blood Pressure (systolic <90 or diastolic <60)
o 65 = Age >65
Describe pneumococcal vaccine PPSV23 and who it is used for
♣ Contains capular material from 23 serotypes that have historically been responsible for the majority of pneumonoccal infections
♣ Because polysaccharides alone cannot be presented to T-cells, the vaccine induces a relatively T-cell-independent B-cell response that is less effective in young children and the elderly
Describe pneumococcal vaccine PCV13 and who it is used for
♣ Consists of capsular polysaccharides from 13 of the most common serotypes that have been covalently attached to the inactivated diphtheria toxin protein
♣ This polysaccharide-protein conjugate induces a T-cell-depended B-cell response, resulting in improved immunogenicity due to the formation of higher-affinity antibodies and memory cells
How will Leydig tumors present in terms of
- Testosterone
- Estrogen
- LH
- FSH
Elevated testosterone and estrogen (gynecomastia) with secondary inhibition of LH and FSH
Diagnose:
- Hypotension
- Increased venous pressure, JVD
- Clear lung sounds
Cardiac tamponade
What physical exam finding is often found in pericardial effusion
Inability to palpate PMI
Describe defect in Factor V Leiden
Most common hereditary thrombophilia
♣ Mutation that makes Factor Va resistant to inactivation by protein C
♣ Increased coagulation
Imaging for osteonecrosis of the femoral head
MRI
Describe hereditary hemorrhagic telangiectasia
♣ Aka Osler-Weber-Rendu syndrome
♣ Inherited disorder of blood vessels
♣ Presentation:
• Telangiectasias, recurrent epistaxis, skin discoloration, arteriovenous malformations, Gi bleeding, hematuria
o AVMs in the lungs can shunt blood from the right to the left side of the heart, causing chronic hypoxemia, digital clubbing, and reactive polycythemia
Describe CBC in polycythemia vera
♣ CBC will show an increase in all 3 cell lines (RBC, Leukocytes, and platelets)
Describe mutation in polycythemia vera
o JAK2 kinase mutation
♣ Normally, RBC production is depended on EPO released by the kidney and liver in response to tissue hypoxia
♣ EPO activates JAK2 tyrosine kinase, which differentiates late myelid cells into erythrocytes
♣ In PV, RBC production is driven by a constitutively active JAK2 gene rather than by tissue hypoxia; therefore, EPO levels tend to be low
What is the defect in Hashimotos
- Most common cause of hypothyroidism
* Autoimmune destruction (antithyroid peroxidase and antithyroglobulin antibodies)
What is the defect in Graves disease
• Thyroid stimulating immunoglobulin (TSI) stimulates TSH receptor
Describe CHADSVASC
• CHADSVASC Score risk of stroke for patients with A-fib/A-flutter o CHA(2)DS(2)VASc o Components: ♣ C = CHF or LVEF = 40% ♣ H = HTN ♣ A = Age >/= 75 ♣ D = DM ♣ S = Stroke/TIA/Thromboembolism ♣ V = Vascular disease ♣ A = Age 65-74 ♣ S = Sex (female)
Describe order of method for reading EKGs
- Rate
- Rhythm
- Axis
- Chambers
- Intervals
- Ischemia/Infarct
Method for rate in EKG
• (1) Count the number of QRS complexes on the full strip and multiply by 6
• (2) Count how many dark lines the QRS complexes are apart
o If two adjacent QRS complexes are one big line apart, the HR is 300
o If two adjacent QRS complexes are 2 big lines apart, the HR is 150
o . . . 300, 150, 100, 75, 60, 50,
Method for rhythm in EKG
♣ Normal sinus rhythm • All of the following MUST be true: o P wave must preceded every QRS o QRS must come after every P o P wave must be upright in lead II
Method for axis in EKG
• Basically everything between lead I and aVF (even though this is technically only 0 to 90)
• In a normal ECG, you would see a positive deflection of QRS in leads I and II or in Leads I and aVF
o The only time you need to look at lead II is if you are positive in lead I and negative in lead aVF
o Usually this means this is L axis deviation UNLESS it falls between -30 and 0
o So you need to check lead II
♣ If lead II is positive, then it is normal (between -30 and 0)
♣ If lead II is negative, then it is real L axis deviation
EKG method for R atria
• Enlargement = peaked P-waves in lead 2
o Peaked = >2 little boxes in lead II and > 1 small box in lead V1
EKG method for L atria
• Enlargement = S shape P-wave in lead V1 (aka positive and then negative deflection)
o Because this is the point where direction changes from positive to negative
PR interval - how long should it be and what does it mean
♣ PR interval should be <5 small boxes (200 ms)
• Prolonged means heart blocks
o 1st degree = prolonged PR (>0.2 sec)
o 2nd degree Type I = PR getting longer and longer until dropped beat
o 2nd degree Type II = Dropped beat with stable PR
o 3rd degree = no relationship between P and QRS
QRS interval - how long should it be and what does it mean
♣ QRS should be <3 small boxes (120 ms)
• If QRS is narrow, then signal came from atria
• Prolonged = bundle branch block or signal being initiated by ventricle
What will you see in RBBB
♣ Will be seen more in V1 and V2 because these are anterior and RV is anterior
♣ Signal goes quickly to the L and then to the R slowly through cell to cell transmission
Change of direction is what causes bunny ears
What will you see in LBBB
♣ Will be seen more in V6 because these are posterior and LV is posterior
♣ Signal goes quickly to the r and then to the l slowly through cell to cell transmission
• Change of direction is what causes bunny ears
QT interval - how long should it be and what does it mean
♣ QT interval should be less than ½ RR interval
• Prolonged means that heart might produce another beat on its own (escape rhythm), and if QRS overlaps with a T then you can go into torsades
What are EKG signs of ischemia/infarct
- Q wave = sign of old ischemia
- T wave = inversion means ischemia
- ST elevation/depression = ischemia
What will you see on EKG in PE
S1Q3T3
o Large S waves in lead I
o Q waves in lead III
o Inverted T waves in lead III
Describe intermittent asthma - sx, nighttime awakenings, frequency of SABA use
o Symptoms: ♣ = 2 days/week o Nighttime awakenings: ♣ = 2x/month o Frequency of SABA use: ♣ = 2 days/week o Interference with normal activity ♣ None
Describe mild persistent asthma - sx, nighttime, SABA use
o Symptoms: ♣ >2 days/week but not daily o Nighttime awakenings: ♣ 3-4x/month o Frequency of SABA use: ♣ >2 days/week but not daily, and not more than 1x on any day o Interference with normal activity ♣ Minor limitation
Describe moderate persistent asthma - sx, nighttime, SABA use
o Symptoms: ♣ Daily o Nighttime awakenings: ♣ >1x/week but not nightly o Frequency of SABA use: ♣ Daily o Interference with normal activity ♣ Some limitation
Describe severe persistent asthma - sx, nighttime, SABA use
o Symptoms: ♣ Throughout the day o Nighttime awakenings: ♣ Often 7x/week o Frequency of SABA use: ♣ Several times per day o Interference with normal activity ♣ Extremely limited
Describe Paget disease of the bone
♣ Disorder of bone remodeling due to increased osteoclastic activity followed by increased osteoblastic activity
Clinical features of Pagets
- Mosaic pattern of woven and lamellar bone
- Increased hat size due to skull thickening
- Hearing loss due to impingement of cranial nerve
Abnormal labs in Paget
• Isolated elevation of alkaline phosphatase (due to end osteoblastic phase)
Treatment of Pagets
Bisphosphonates
What hematologic disorder is associated with nephrotic syndrome
Hypercoagulability
Due to increased loss of antithrombin, and altered leveles of protein C and S
Most common cause of anemia in alcoholics
Folate deficiency (macrocytic anemia) - NOT B12 deficiency
Describe presentation of rotator cuff impingement
♣ Pain with abduction, external rotation
♣ Subacromial tenderness
♣ Normal range of motion with positive impingement tests (e.g. Neer, Hawkins)
Describe presentation of adhesive capsulitis of the shoulder
♣ Decreased passive and active range of motion
♣ More stiffness than pain
Describe presentation of biceps tendinopathy
♣ Anterior shoulder pain
♣ Pain with lifting, carrying, or overhead reaching
♣ Weakness less common
Describe presentation of glenohumeral osteoarthritis
♣ Uncommon and usually caused by trauma
♣ Gradual onset of anterior or deep shoulder pain
♣ Decreased active and passive abduction and external rotation
Describe presentation of thrombotic thrombocytopenic purpura (TTP)
o Platelets used up in pathologic formation of microthrombi in small vessels o Due to decreased ADAMTS13, enzyme that normally cleaves vWF for degradation ♣ No vWF degradation = abnormal platelet adhesion = microthrombi o Findings (Pentad) – THINK: FAT RN ♣ F = Fever ♣ A = anemia (Microangiopathic hemolytic anemia = RBCs sheared by microthrombi) ♣ T = thrombocytopenia (platelets being used up) ♣ R = renal insufficiency (thrombi involve vessels of kidney) ♣ N = neurological symptoms – confusion, HA, seizures, coma (thrombi involve vessels of CNS)
