Board Basics Flashcards
EKG changes seen with unstable angina and NSTEMI?
- ST segment depression
- T wave inversions
Acute coronary syndromes occur due to what pathological situations?
- Coronary blood flow was disrupted
- Metabolic requirements exceed supply
Chest pain during the peripartum period
Spontaneous coronary artery dissection
What are other presentations besides chest pain that indicate ACS?
HF, pulmonary edema, shock, dysrhythmias
What are 2 signs (PE) of cardiac ischemia?
New MR murmur and S4 sound
ST-elevation equivalents?
- New LBBB
- Posterior MI (tall R waves and ST depression in V1-V4)
Indications for immediate angiography?
1) Hemodynamic instability
2) HF
3) sustained VT
4) New or worsening MR murmur
5) Refractory pain
What of the other causes of ST elevation?
- Acute pericarditis
- LV aneurysm
- Takotsubo’s cardiomyopathy
- Coronary vasospasm
- Acute stroke
- Normal variant
What is a scoring indicate and a TIMI score?
0–2: Low risk, likely will need stress test
3–7: Intermediate to high risk, will need early revascularization
What is a tool used for restratification to determine early angiography in patients with unstable angina and NSTEMI?
TIMI
Was indication for thrombolytic agents in setting of ACS? What is a “treatable” contraindication for thrombolytic therapy?
If PCI not available and will not be able to be performed within under 120 minutes. BP must be below 180/110
What is the timeline for PCI?
- 90 minutes from first medical contact and a PCI capable Health Center
- 120 minutes for first medical contact if transferred from a facility that does not have PCI capabilities
Reportedly 2 other indications for PCI in setting of ACS?
- Failure of thrombolytic therapy
- Cardiogenic shock or new HF
When should the patient not be given thrombolytic therapy if ACS suspected?
- NSTEMI
- Asymptomatic patients with onset of pain greater than 24 hours ago
A 58-year-old man with acute chest pain has ST segment elevation in leads II, III, and aVF. Blood pressure is 82/52 mmHg, and pulse rate is 54/M IN. Physical examination shows JVD, clear lungs, and no murmur or S3.
Visit diagnosis? What is the management of this patient?
RV Infarction
IV Fluids, ECG lead V4R tracing, and cardiac catheterization
Ordered further recommendations for temporary pacing the setting of acute MI?
- Symptomatic bradycardia (including complete heart block)
- Alternating LBBB and RBBB
- New or intermediate age bifascicular block with first-degree AV block
Patient recently suffered an MI approximately 4 days ago and then suddenly became hypotensive and went into cardiac arrest associated with PEA
LV free wall rupture
Post MI patient developed abrupt pulmonary edema and hypotension. Patient is noted to have a loud holosystolic murmur and thrill on physical exam.
VSD or papillary muscle rupture
All complications of acute MI occur approximately 2-7 days?
Mechanical complications (VSD, papillary muscle rupture, and LV free wall rupture)
What is the management of papillary muscle rupture and VSD?
Stabilize patient. Intra-aortic balloon pump, afterload reduction with sodium nitroprusside, diuretics followed by emergency surgical intervention
Which should post MI patient’s be screened for?
Depression
ICDs are indicated PostMI patients meeting all the following criteria:
- Greater than 40 days since MI or greater than 3 months since PCI or CABG
- LVEF less than 35% in setting of NYHA class II or III
- LVEF less than 30% in setting of NYHA class I
Symptoms and signs that increase likelihood of HF include:
1) PND
2) S3 (11 fold likelihood)
The likelihood of HF is decreased 50% by:
1) absence of dyspnea on exertion
2) absence of crackles on pulmonary auscultation
A BNP level of what is compatible with HF? What level rules out HF?
> 400; <100 unlikely to be CHF
What would the indication for endomyocardial biopsy be in setting of CHF?
If you suspect, giant cell myocarditis and sarcoidosis
Symptomatic patients with CHF and excessive daytime sleepiness should be evaluated for?
OSA
Cardiac MRI can assess for what?
hemochromatosis, sarcoidosis, and amyloidosis
What can increase BNP?
What decreases BNP?
Kidney failure, age, and female sex
Obesity
Medications to avoid in CHF?
NSAIDs
Thiazides (glitazones)
Do not implant ICD until when?
3 months of guideline directed medical therapy (or 40 days after MI)
Preferred Beta Blocker in drug-induced cardiomyopathy?
Labetalol (due to alpha blocker activity to prevent coronary vasospasm); regular beta blockers can exacerbate
Rare disease characterized by biventricular enlargement, Refractory ventricular arrhythmias, and rapid progression to cardiogenic shock and young to middle-aged adults.
Giant Cell Myocarditis
Histologic examination of giant cell myocarditis demonstrates what?
Presence of multinucleated giant cells in the myocardium
Treatment for giant cell myocarditis?
Immunosuppression and/or elevated
Definitive treatment is by cardiac transplantation
When his peripartum cardiomyopathy diagnosed?
1 month for 5 months after delivery
What medications should be avoided in Partum cardiomyopathy?
ACE inhibitors, ARB, aldosterone antagonist (eplerenone)
What other medications are indicated in peripartum cardiomyopathy if LVEF is less than 35%?
Anticoagulation with heparin to warfarin
Should valsalva maneuver increase or decrease a murmur in HCM?
Increase (increase systemic resistance and afterload)
Screening for HCM?
1st degree relatives:
1) echo
2) EKG
3) genetic testing
medications to be avoided in HCM?
- Avoid vasodilating beta-blockers (carvedilol, labetalol, and nebivolol)
- Avoid digoxin, vasodilators, or diuretics which increased LV outflow obstruction for
The LV is preload dependent
What is the indication for surgery or septal ablation in patients with HCM?
- Outflow tract gradient of greater than 50 mmHg
- Continue symptoms despite maximal drug therapy
What medication be added if significant symptoms related to LVOT obstruction remain in hypertrophic cardiomyopathy?
Disopyramide
What are the indications for beta-blockers in patients with hypertrophic cardiomyopathy?
1 ejection fraction greater than 50%
2. Dyspnea
3. Chest pain
What findings on ECG may mimic ischemia in patients with HCM?
deeply inverted, symmetric T waves in leads V3 to V6; In the apical hypertrophic form of the disease
The two categories and etiologies of restrictive cardiomyopathy?
1) normal wall size
2) increased wall thickness
Three types of restrictive CM that have normal wall thickness?
1) Hemochromatosis
2) Radiation induced fibrosis
3) Eosinophilic diseases
Heart Failure symptoms with neuropathy and signs of proteinuria, hepatomegaly, periorbital ecchymosis, bruising, and low voltage ECG
AL amyloid cardiomyopathy
Most common extrinsic causes of sinus bradycardia or what medications?
- Beta-blockers
- Donepezil
- Neostigmine
- pyriDistigmine
Common causes of inappropriate sinus bradycardia are?
- Age-related myocardial fibrosis
- Hypothyroidism
- Inferior ischemia
Indications for pacemaker?
1) Symptomatic bradycardia
2) Permanent AF with bradycardia
3) Heart Block (Mobitz II and above)
4) Alternating LBBB and RBBB
What consists of the CHADSVASC score?
2 points: prior stroke or age >75
1 point: HTN, HF
1 point: DM, Vasc
1 point: female, ages 65-74
What medication is started for atrial fibrillation control if they have comorbid, WPW syndrome?
procainamide
When is warfarin indicated in AF?
valvular AF
Definitive treatment for typical atrial flutter?
catheter ablation
What is the classic ventricular rate of atrial flutter?
150 bpm due to 2:1 conduction ratio
When is VTE prophylaxis used post-discharge from hospital?
Postdischarge prophylaxis (up to 5 weeks)
1) Hip Fracture
2) Knee and Hip Replacement
3) Major Cancer Surgery
What score of zero eliminates the need for D-dimer testing or CTA?
PERC (Pulmonary Embolism Rule-Out) Score
What score from Well’s criteria indicates further testing for thrombus?
Well’s DVT (>1) or Well’s PE (>4) will need Duplex US or CTA, respectively
Low probability <1, <4 = D-dimer
Treatment of Superficial Vein Thrombophlebitis?
Supportive Care (Analgesia, warm compresses, and NSAIDs); if symptoms persist, image
When to A/C for superficial vein thrombosis?
> 5cm, close to deep venous system, or other risk factors exist
Distal Leg DVT
Asymptomatic
- Monitor with serial duplex US within 1-2 weeks
- 3-6 months of Eliquis or Xarelto
Proximal Leg DVT or PE
-Provoked tx duration?
-Unprovoked?
-Recurrent?
-3-6 months
-Extended
-Depends (whether provoked or unprovoked)
Indications for tPA in DVT/PE
1) massive DVT with either acute limb ischemia, severe edema, and/or venous insufficiency
Right-sided heart murmurs increase in intensity with work?
Inspiration
Hypertrophic cardiomyopathy murmurs increase intensity with what?
valsalva and on standing from squatting position
What heart murmur is described as a clinic and moves closer to S1 with a murmur lengthening with Valsalva maneuver and on standing from a squatting position?
Mitral valve prolapse
Fixed splitting occurs with ASD, VSD, and what other 2 causes?
RBBB, pulmonary valve stenosis
Paradoxical splitting occurs under what 3 manifestations?
LBBB, HCM, and severe AS
Signs of serious cardiac disease on cardiac physical exam include: (For characteristics)
- S4
- Murmur grade greater than 3/6 intensity
- Continues murmurs
- Any diastolic murmur
- Abnormal splitting of S2
What are the 3 different criteria that constitutes severe aortic stenosis?
- Aortic area of less than 1 cm²
- Aortic jet velocity (Vmax) greater than 4 m/s
- Mean transaortic pressure gradient greater than 40 mmHg
What are the 3 indications for aortic valve replacement and severe AS?
- Symptomatic: Syncope, presyncope, angina, and dyspnea
- Ejection fraction less than 50%
- A contaminant cardiac surgical procedure further indications
When is TAVI preferred over SAVR for symptomatic patients with severe AS?
- Age greater than 80 years
- Neuner patients with less than 10 years life especially
- Any age with a higher probability of surgical risk
MCC of hypercalcemia in the outpatient setting?
Primary Hyperparathyroidism
MCC of hypercalcemia in the inpatient setting?
Malignancy
Symptom presentations of hypercalcemia (non-incidental findings)?
1) Kidney Stones
2) Osteoporosis
3) Fractures (Osteopenia)
4) Pancreatitis
Hypercalcemia can also be caused with what medications?
Thiazide diuretics (non-PTH mediated)
Lithium (PTH-mediated)
What other rheumatological condition is associated with hypercalcemia (10%) and hypercalciuria (50%)
Sarcoidosis (mediastinal lymphadenopathy)
Calcium: Elevated
PTH: Elevated
Phosphorus: Low
Imaging: Chondrocalcinosis
Primary Hyperparathyroidism
Calcium: Markedly elevated
PTH: Suppressed
Phosphorus: Normal/Low
Imaging: Lung Cancer
Humoral Hypercalcemia of Malignancy
may or may not be mediated by PTH-related protein (PTHrP)
Calcium: Elevated
PTH: Suppressed
Phosphorus: Normal/Low
Imaging: Bone Mets in a known prostate cancer patient
Local Osteolytic Lesions
Lytic Bone Metastasis (Prostate, Breast, Lung, Renal) can release calcium from the broken down bone
Calcium: Elevated
PTH: Suppressed
Phosphorus: Elevated
Labs: Elevated Cr/Decreased eGFR, Anemia
MM: low phosphate = Fanconi syndrome
high phosphate = renal dysfunction from MM
Confirm with serum and urine electrophoresis
Calcium: Elevated
PTH: Suppressed
Phosphorus: Elevated
Calcitonin: Elevated
Granulomas (TB, Sarcoid)
Malignancy: B-cell Lymphoma
Elevated Vitamin D = high calcium = negative feedback to PTH = high phosophate
C4 elevated
Hereditary angioedema
Calcium: Elevated
PTH: Suppressed
Phosphorus: Elevated
Creatinine: Elevated
Bicarbonate: Elevated
CBC: Normal
History of osteoporosis
Milk-Alkali Syndrome: excessive ingestion of calcium carbonate to treat osteoporosis
Metabolic alkalosis
Calcium elevated
AKI
Other indirect cause of hypercalcemia (Endocrinological cause)?
Hyperthyroidism (direct stimulation of osteoclasts)
Two indications for acute treatment of hypercalcemia in the inpatient setting?
1) Acute increase in calcium with symptoms (Clinical: AMS, coma)
2) Ca levels greater than 14 (most likely Humoral Hypercalcemia of Malignancy)
Calcium: Elevated
PTH: Normal
What test should be included with initial workup in addition to: phosphorus, Vitamin D levels?
Urinary calcium level
Familial Hypocalciuric Hypercalcemia
Hyperparathyroidism is most common manifestation of what MEN syndrome?
MEN1
What other workup is indicated with hyperparathyroidism when surgery is indicated?
Imaging: MRI, CT, sestamibi scan, U/S
Tx of acute hypercalcemia in inpatient setting?
IV Fluids NS
IV Bisphosphonates
(Steroids if MM, Lymphoma, or Sarcoid)
Indications for parathyroidectomy in asymptomatic patients?
Calcium >1 of ULN
Age <50
CrCl <60
T <-2.5 or vertebral fracture
MEN1
MC: Hyperparathyroidism
Pituitary
Pancreas
MEN has 1 Penis (P)
MEN2
MC: Medullary thyroid cancer
Pheochromocytoma
Hyperparathyroidism
MCC of hypocalcemia
Low albumin
Albumin 1: 0.8 Total Ca
Check ionized calcium
Calcium: Low
PTH: Low
Phosphate: High
Vit D Levels: Variable
Hypo-parathyroid
Calcium: Low
PTH: High
Phosphate: High
1,25 Vitamin D: Low
CKD
Recent parathyroidectomy and hypocalcemia
Hungry Bone syndrome
Imparied PTH secretion and PTH resistance associated with what electrolyte abnormality?
Low Magnesium (Alcoholic, diarrhea, diuretics)
How to supplement Vit D in Kidney disease?
1,25 dihydroxy D
How to supplement Vit D in Liver disease?
25-hydroxy D
USPSTF osteoporosis screening?
> 65 with DEXA
<65 with risk factors based on FRAX score
If patient is receiving long-term steroids (>3 months), what testing should be done?
DEXA scan within 6 months if:
> 40
<40 if fracture or elevated FRAX
isolated increase in alkaline phosphatase?
liver disease or
PAGET’S
MCC of osteoporosis in men and women?
Women: estradiol deficiency
Men: testosterone deficiency
Secondary Causes of osteoporosis?
Endo: hyper-thyroid, hyper-parathyroid, Cushing’s (high steroids)
Malabsorption: Celiac, intestinal resection, Chron’s
Osteoporosis diagnosis confirmation (besides DEXA score)
1) DEXA <-2.5
2) Fragility Fracture (Fracture from standing height or lower)
Paget’s disease is a focal disorder of what?
Bone remodeling:
-greatly accelerated rates of bone turnover
-disruption of normal architecture of bone
-gross deformities of bone
Most patients that suffer from Paget’s are asymptomatic and the disease is suspected with what lab abnormality?
Elevated alk phos
Signs and symptoms associated with Paget’s Disease?
1) Bone pain, fractures
2) CN compression syndromes, spinal stenosis, nerve root syndromes
3) High-output cardiac failure
Diagnostic modality of Paget’s disease?
X-ray
1) asymptomatic - order bone scan and then X-ray areas with increase radionuclide uptake
2) symptomatic - order X-ray of painful area
Imaging findings of Paget’s?
1) Cotton wool skull
2) Cortical thickening
3) Focal osteolysis with coarsening of the trabecular pattern
When is treatment indicated in Paget’s?
1) Symptomatic - bone pain, fractures, radiculopathy
2) Involvement of a weight bearing bone or joint - even if asymptomatic
Tx of Paget’s Disease?
One time dose of IV Zoledronic acid
What specific type of Vitamin D do you test for?
25-hydroxyvitamin D
Vit D Level greater than 20
Osteomalacia is the failure of what?
Bone matrix to adequately mineralize; typically due to lack of calcium and phosphorus; most of time 2/2 Vit D deficiency
Workup of osteomalacia (labs and possible underlying causes)
Low calcium and low phosphorus
Intestinal malabsorption (celiac)
Metabolism - Liver issues
Kidney issues
Osteomalacia tx if Vit D deficiency is cause?
Ergocalciferol 1000-2000 U/daily
Calcium 1g/d
Most common cause of osteoporosis of women and men respectively?
Women: estrogen deficiency
Men: testosterone deficiency
Secondary causes of osteoporosis (two categories)?
Endo: Cushing’s (steroids), hyperthyroidism, hyperparathyroidism
Intestinal Absorption: celiac, Chron’s disease, intestinal resection)
What medications are associated with osteoporosis?
Thyroid hormone, steroids
phenobarbitol, phenytoin
thiazolidinediones
Encourage all patients with osteoporosis to do what?
- Stop tobacco and alcohol
- resistance exercise
- Calcium and Vit D supplementation
First Line therapy for anti-resorptive therapy?
Indications?
Alendronate or Risedronate (oral-bisphosphonates)
Osteoporosis
Osteopenia (high risk factors)
Fragility fracture
Vertebral fracture or hip fracture
When are oral bisphosphonates contraindicated?
CKD
Esophageal disease
choose IV zoledronate acid (once yearly)
What medication is preferred in patient’s with CKD stage IV or higher?
Denosumab (monoclonal antibody inhibits osteoclast activation)
not tolerant to bisphosphonates
When are IV bisphosphonates contraindicated?
CKD and severe hypocalcemia
What are primary causes of hypocalcemia?
Primary Autoimmune hypoparathyroidism
When is parathyroidectomy indicated?
- Primary hyperparathyroidism
- Symptoms - disease related to hypercalcemia
- Asymptomatic - Numbers (1, 2.5, 50, 60)
What medications can cause gynecomastia?
OPIOIDS!
Spironolactone, Cimetidine (H2 blocker), Anti-androgens
5-alpha reductase inhibitors (BPH and hair loss), protease inhibitors
What are other causes of gynecomastia? What should the initial workup include if there is no obvious cause?
Cirrhosis, CKD
Hyperthyroidism, Hypogonadism
Germ Cell Tumors
hCG, 8 AM fasting testosterone, estradiol levels
Treatment of gynecomastia in confirmed hypogonadism?
Testosterone (gel)
Treatment of gynecomastia with no hypogonadism?
Estrogen receptor modulators
aromatase inhibitors
What is an alternative renal marker that can estimate GFR, which is less influenced by age, sex, muscle mass, and body weight?
Serum cystatin C
What conditions can overestimate GFR with a falsely low/normal creatinine?
Old age, malnutrition
Liver disease
Protein detected on UA should always be followed up with what?
24 hour urine protein collection
protein-creatinine ratio
albumin-creatinine ratio
What test is used to evaluate diabetic kidney disease?
Urine Microalbumin (albumin-creatinine ratio)
30 to 300 = moderately increased albuminuria
> 300 = severely increased albuminuria
What is an abnormal protein-creatinine ratio defined as?
> 150 mg/g
Proteinuria is a maker of what structural (portion of the kidney) renal disease
Renal parenchyma
glomerular disease
Proteinuria is an independent marker for what?
CVD, PVD, and progressive kidney disease
Positional (orthostatic) proteinuria is diagnosed how?
Daytime (standing) urine collection
Nighttime (supine) urine collection
Hematuria is classified into what two categories?
Glomerular
Extraglomerular
Hematuria + proteinuria = ?
Glomerular Hematuria (even with no casts)
What are the qualifications of Extraglomerular hematuria?
- Normal erythrocyte morphology
- No presence of casts
- No presence of proteinuria
What microscopic findings or the urine indicate glomerular causes of hematuria?
- Erythrocyte- casts
- Dysmorphic erythrocytes (Mickey Mouse ears, acanthocytes (spiculated))
Should patients be evaluated for hematuria even if they take anti-platelets and/or anticoagulants?
YES
DDx of extraglomerular hematuria?
GU Cancer until proven otherwise
Infection, Drugs, Kidney stone, trauma
Sterile pyuria indicates what?
TB
Interstitial nephritis/cystitis
Urine Eosinophils indicates what?
AIN
postinfectious GN, atheroembolic disease of the kidney, small vessel vasculitis, septic emboli
Leukocytes in the urine generally indicate what?
Glomerular/Tubulointerstitial inflammation
infection, or an allergic reaction
Positive for blood on dipstick but, negative microscopic erythrocytes?
Hemolysis and Rhabdomyolysis
Urine lipids and fat generally indicate what?
severe proteinuria or nephrotic syndrome
What are renal casts?
Cylindrical aggregates of Tamm-Horsfall mucoproteins that trap the intraluminal contents, which appear in the urine.
Erythrocyte casts
Glomerular disease (glomerulonephritis)
Leukocyte Casts
Inflammation or infection of
Renal parenchyma
Muddy Brown casts
ATN
Broad casts
CKD
Causes of SIADH?
Cancer (SCLC)
Intracranial pathology
Medications
What medications are associated with SIADH?
thiazide diuretics
SSRIs
tricyclic antidepressants
opioids
phenothiazines
carbamazepine
tx for hypovolemic hypotonic hyponatremia?
IV NS
What should the target treatment range be for chronic symptomatic isovolemic hypotonic hyponatremia?
4.0 6.0 in 24 hours
Acute true hyponatremia should be treated with what?
3% to raise Na level by 2.0 to 3.0
Indication to use 3% normal saline bolus?
Neurological symptoms including seizures/coma
correct by 2.0-4.0 as long as total increase does not go above 10.0 in 24 hours
Treatment to give patient with overcorrected serum sodium to prevent central pontine myelinosis?
Desmopressin and IV 5% Dextrose
You give ADH therapy to lower back the sodium levels
Treatment for chronic SIADH? (3 options)
fluid restriction
Demeclocycline
V1 and V2 receptor anatagonists Conivaptan and Tolvaptan
Most common causes of hyperkalemia?
Acute and Chronic Kidney Failure
Type IV RTA
Medications
Potassium shifts
Low urine flow states
What medications can cause hyperkalemia? (x4)
ACE/ARBs, potassium sparing diuretics, Sulfas, pentamidine
Significant hyperkalemia with a normal ECG suggests what?
Pseudohyperkalemia
Absolute levels of potassium cannot reliably determine whether a life threatening condition exists in setting of hyperkalemia. What can?
ECG changes
The most common causes of hypokalemia?
Pee and Poop (GI)
Diuretics
Vomiting/Diarrhea
Spot urine potassium-creatinine ratio of what confirms hypokalemia?
less than 13
Flaccid generalized weakness with hypokalemia in Mexican/Asian descent who have eaten a high carb meal or done physical exercise?
Hypokalemic periodic paralysis
What is hypokalemic periodic paralysis associated with?
thyrotoxicosis (treatment involves treating hyperthyroidism)
What test obviates the need for brain biopsy in PCNSLymphoma?
Vitreous biopsy when lymphoma is involved in the vitreous
Treatment for PCNSL?
HIV - start ART
Immunocompromised - stop Immunosuppression
Responds well to whole brain radiation and chemotherapy
avoid steroids
CTH with a homogeneously enhancing extra axial mass adherent to the dura and an enhancing dural “tail”
Meningioma
MRI shows multiple ring enhancing lesions with central necrosis; has significant surrounding edema and mass effect
Brain Mets
if new finding, assess for lung, breast, and melanoma
First line treatment for parenchymal and leptomeningeal tumors?
Glucocorticoids
Chemo for leptominengeal
Radiation/Resection for parenchymal
Central vertigo with dysarthria, diplopia, weakness, ataxia, or gait instability
Vertebrobasilar stroke
Exam for acute, persistent vertigo
HINTS
Head Impulse: catch up saccades late
Nystagmus: Bidirectional nystagmus (back and forth)
Test of Skew: Presence of vertical skew when hand is placed over eye
Non-stroke, severe, longer lasting vertigo (days), nausea and vomiting. Dx?
Vestibular neuronitis
Hearing loss with vestibular neuronitis
Labrynthritis
Vertigo hearing loss tinnitus
Meniere’s dz
Healing loss, tinnitus, unsteadiness, facial nerve involvement
Acoustic neuroma
Herpes Zoster with facial involvement and peripheral vertio
Ramsay Hunt Syndrome
BPPV tx
Epley’s maneuver
Meniere’s tx
Vestibular rehab and/or diuretics
Short term relief of vertigo
Benzo, antihistamines, antiemetics
*** Key treatment in vertigo, disequilibrium, and nonspecific dizziness
Vestibular and balance rehab
Unexplained fatigue lasting more than 6 consecutive months that impairs the ability to perform desired activity. Unrefreshing sleep, cognitive impairment, orthostatic intolerance
SEID
Systemic Exertion Intolerance Disease
