Cardio/Pulm Flashcards
1
Q
Four primary things to look for on PFT and what they mean
A
FVC - the total amount of air that can be put out
FEV1 - How much air comes out in the first second
FEV1/FVC - amt of air expelled in the first second compared to total volume expelled
PEFR - peak flow (max airflow rate achieved)
2
Q
What is required for the diagnosis of asthma? What is used for monitoring asthma?
A
Spirometry (PFT) used for diagnosis
Peak flow is used for monitoring
3
Q
Asthma treatment
A
- SABA - emergency relief, albuterol
- ICS - controlling persistent asthma
4
Q
Exercise-induced asthma management
A
- SABA 15-30min prior to exercise
5
Q
Asthma controller medications
A
- ICS (fluticasone, mometasone, budesonide, beclomethasone, ciclesonide) – preferred controller treatment for persistent asthma. use daily for optimal effect
- ICS/LABA - (budesonide + formoterol, fluticasone + salmeterol, mometasone + formoterol) – should only be used in pts who are not controlled by ICS alone
- Leukotriene receptor antagonists or leukotriene modifiers (montelukast) — allergic rhinitis, often used with ICS
6
Q
Stepwise process for asthma management
A
Step 1 - SABA
Step 2 (mild asthma) - low dose ICS
Step 3 (moderate asthma) - low dose ICS + LABA
Step 4 (severe asthma) - medium dose ICS + LABA
7
Q
Severe asthma exacerbation management
A
ED treatment
SABA + systemic corticosteroids
8
Q
Warning signs of impending respiratory arrest
A
drowsiness or confusion
paradoxical throacoabdominal movement
absence of wheezing
bradycardia
absence of pulsus paradoxes
initial PEF or FEV1 < 25% of personal best/predicted value
9
Q
What should you get for every asthma exacerbation
A
peak flow
10
Q
Clinical findings for emphysema
A
increased AP diameter, hyper resonance (air trapping)
11
Q
Clinical findings chronic bronchitis
A
normal AP diameter, normal percussion (resonance), increased Hct, copious blood tinged mucus
12
Q
What is the electrolyte triad found in emphysema and chronic bronchitis
A
hypokalemia, hypochloremia, increased NaHCO3
13
Q
COPD management
A
SABA (albuterol), LAMA (tiotropium), or LABA (salmeterol)
14
Q
COPD exacerbation treatment
A
O2, bronchodilators (SABA), prednisone
Antibiotics (if increased dyspnea, incr sputum, incr sputum purulence)
NIV (BiPAP)
15
Q
TB diagnosis and treatment
A
Latent TB - no symptoms
TB disease - significant cough > 3 weeks, chest pain, hemoptysis or sputum production, weakness/fatigue, weight loss, lack of appetite, chills, fever, night sweats
CXR - cavitary lesion
Treatment - isoniazid (INH), rifampin, ethambutol, pyrazinamide (RIPE)
16
Q
Diseases caused by S. pneumoniae
A
COMPS
conjunctivitis
otitis media
meningits
pneumonia
sinusitis
17
Q
Diseases caused by H. influenzae
A
COMPS
conjunctivitis
otitis media
meningitis
pneumonia
sinusitis
18
Q
CAP treatment in persons with no significant comorbidities
A
doxycycline
azithromycin
amoxicillin
19
Q
Broad spectrum treatment for HAP
A
Vancomycin or linezolid
+
Pipercillin tazobactam (Zosyn)
Cefepime
Levofloxacin
Imipenem
Amikacin
** Vancomycin + Pipercillin-tazobactam
20
Q
VAP initial empiric treatment
A
3 antibiotics
Vancomycin or linezolid +
Pipericllin-tazobactam (Zosyn)
Cefepime
ceftazadime
imipenem
meropenem
aztreonam +
Levofloxacin
ciprofloxacin
Amikacin
Gentamicin
Polymyxin
** Vancomycin + Pipercillin-tazobactam + Levofloxacin
21
Q
Etiology/Pathology of pneumothorax
A
- Traumatic injury
- Spontaneous - COPD, asthma, tall, thin males, marijuana smoking
- air trapping and increased pressure can cause a medistinal shift –> compress the great vessels and heart (tension pneumothorax)
22
Q
S/s of pneumothorax
A
acute onset of SOB
tachypnea
pleuritic chest pain
23
Q
Pneumothorax physical exam findings
A
- hyper resonance to percussion
- absent breath sounds on injured side
- hypotension
- distended neck veins (late sign)
- tracheal deviation
24
Q
Pneumothorax diagnostic study of choice
A
CXR - air in pleural space with absent lung markings
25
Pneumothorax treatment
- needle decompression - first line therapy
- chest tube for patients with symptoms or >2cm
- tension pneumothorax - emergent needle decompression with 14G or 16G IV in the 2nd ICS MCL followed by chest tube placement
26
ARDS etiology and pathophysiology
inflammatory lung condition c/b direct or indirect injury to the lungs
27
Diagnostic and inclusion criteria for ARDS
- bilateral diffuse infiltrates c/b non-cardiogenic pulmonary edema/pulm capillary leak
- PAWP/PCWP < 19 mmHg (no evidence of L arterial HTN)
- PaO2/FiO2 < 200
28
Goals of ventilation for ARDS
- treat the underlying cause, support oxygenation, CO, ventilation
- optimize lung recovery to prevent lung injury
- PEEP = 5, PaO2 55-80, plateau pressure <30
- check plateau pressure q4h, if > 30 decr VT by 1mL/kg, if < 25 increase VT by 1mL/kg
- pH goal 7.3-7.45 - if pH is low increase RR, if pH is high decrease RR
29
Hemothorax etiology & pathophysiology
- blood accumulation in pleural space caused by some form of traumatic injury (usually) or injury to adjacent structures
30
S/s of hemothorax
dyspnea, tachypnea, pleuritic chest pain
31
physical exam findings for hemothorax
dullness to percussion (fluid accumulation)
decreased breath sounds on injured side
signs of hypovolemic shock
32
hemothorax diagnostic study of choice
CXR - blood in pleural space (white out)
33
Treatment for hemothorax
chest tube placement, autotransfusion, open thoracotomy in the presence of uncontrolled bleeding
34
Pulmonary embolism etiology/pathophysiology
thrombus in the arterial system of the lung preventing effective perfusion (not a ventilation problem)
most commonly d/t DVT, also seen in oncologic patients
35
signs/symptoms of pulmonary embolism
dyspnea, pleuritic chest pain, cough, hemoptysis
36
physical exam findings for pulmonary embolism
tachycardia + tachypnea
rales and S4 heart sound
37
pulmonary embolism diagnostic study of choice
CTA ***
D-dimer has high sensitivity, poor specificity
38
Treatment for pulmonary embolism
** anticoagulation - unfractionated LMWH, Warfarin (INR 2-3), rivaroxaban 15mg bid 3 weeks then 20mg daily
IVC filter (if anticoagulation is contraindicated), thrombectomy (large PE), or thrombolysis (TPA) (PE with shock or massive PE with a high risk of shock)
39
Describe the characteristics of a transudative pleural effusion
Transudative (water)
often c/b CHF, constrictive pericarditis, cirrhosis
SG < 1, protein < 3, LDH < 200
40
Describe the characteristics of an exudative pleural effusion
exudative (cellular material)
often c/b lung parenchymal infection, malignancy, pulmonary embolism
SG > 1, protein > 3, LDH > 200
41
Treatment for pleural effusion
if known to be from fluid overload (CHF or cirrhosis) --> diuresis
Symptomatic effusions - thoracentesis
infections effusions -antibiotic therapy, if 1/2 the hemithorax or empyema is present then place a tube thoracostomy
42
Equation for BP
BP = HR x SV x PVR
if you increase any part of this equation you increase BP and vice versa
43
What is the primary concern with HTN and what types of things are we looking for
Target organ damage
Brain - stroke, vascular (multi-infarct) dementia
CV - atherosclerosis, MI, LVH, HF
Kidney - hypertensive nephropathy, renal failure
Eye - hypertensive retinopathy
44
Lifestyle modifications for HTN and dislipidemia - what is most effective
weight reduction (most effective)
DASH diet, Na+ restriction, physical activity, alcohol moderation
45
Three primary medications used for HTN
diuretics (thiazide)
ACE/ARBS
CCB
46
Thiazide diuretics adverse effects
Na+, K+, Mg++ depleting
Less effective with GFR < 30 (loop diuretics are helpful with lower GFR, but not for BP)
47
ACE inhibitors (-pril suffix) adverse effects
ARBS (-sartan suffix)
risk of hyperkalemia, renal impairment when used with aldosterone antagonist, cough, angioedema
Priority medication for HTN control in individuals with DM
DO NOT USE DURING PREGNANCY
48
CCB (-ipine suffix) adverse effects
ankle edema
AVOID USE IN HF, RENAL, OR HEPATIC IMPAIRMENT
49
Aldosterone antagonist adverse effects
gynecomastia with prolonged use (in men) risk for hyperkalemia
50
Hypertensive urgency characteristics
HTN with minimal or no acute target organ damage
SBP > 180 DBP > 120
51
Hypertensive emergency characteristics
HTN with acute target organ ischemia and damage
Neuro - encephalopathy, stroke, papilledema
CV - ACS, HF, pulmonary edema, aortic dissection
Renal - proteinuria, hematuria, acute renal failure
52
When treating hypertensive emergency what factors should you be monitoring
urine output (decreased), Cr (increased), or mental status (decrease) -- this may be an indication that lower BP cannot be tolerated
53
Therapy for hypertensive urgency
lower BP over a few hours with oral agents
goal is to return BP in outpatient setting over days/weeks/months
54
Therapy for hypertensive emergency
decrease MAP by approx 25% within minutes-2hrs with IV agents.
consider a-line
Goal is DBP < 110 within 2-6hrs
55
Common pharmacologic agents for hypertensive emergency
nitroprusside
labetalol
nicardipine
nitroglycerin
esmolol
hydralazine
56
Patho/etiology for CAD
result of endothelial damage
elevated LDL, endothelial dysfunction, vascular inflammation
57
Differentiate angina from MI
- change from typical anginal pattern, associated symptoms
- regional abnormality on ECG
- troponin changes
58
Stable angina s/s, diagnostic findings, treatment
symptoms occur with activity & relieved with rest or nitrate
diagnostic findings no cardiac enzyme elevation
treatment - prophylactic therapy -- lower lipids, nitrates, ASA, lifestyle modification
59
unstable angina s/s, diagnostics, and treatment
symptoms occur with activity and/or at rest and not easily relieved with rest or nitrates
no cardiac enzyme elevation may have signs of ischemia on ECG (ST depressions) during a symptomatic episode
treatment - nitrates, BB, ACE/ARB, morphine, ASA, ADP blocker (clopidogrel), heparin (if admitted)
60
NSTEMI s/s, diagnostics, and treatment
symptoms occur with activity and at rest
cardiac enzymes are elevated, signs of ischemia on ECG (ST depressions)
treatment - nitrates, BB, ACE/ARB, morphine, ASA, ADP blocker (clopidogrel), heparin (if admitted)
61
STEMI s/s, diagnostics, and treatment
symptoms usually occur at rest and not relieved with rest, may improve with high doses of nitrates
cardiac enzymes are elevated, ST elevation on ECG
treatment - ASA 325mg, SL nitrates, antiplatelet agents, heparin, cardiac cath/PCI, fibrinolysis if PCI is delayed
62
absolute contraindications for fibrinolysis
hx of cerebrovascular event
non-hemorrhagic stroke or head trauma < 3mo ago
cranial or spinal trauma < 2mo
known bleeding diathesis
active internal bleeding
63
guidelines of initiation of fibrinolysis
delayed PCI
goal (if presenting to PCI facility) door to balloon < 90min
goal (if presenting to non-PCI facility) door to balloon 120min
if fibrinolysis therapy is chosen, goal is < 30min of hospital presentation
64
ACS post hospital care
ABCDE
A ASA, anticoagulants, ACE/ARBs, aldosterone antagonist
B beta blockers, BP control
C cholesterol control, cigarettes (smoking cessation)
D diet, DM control
E education, exercise
65
Anterior & septal leads + coronary artery associated
V1, V2, V3, V4
LAD
66
Lateral leads + coronary artery associated
I aVL V5 V6
left circumflex
67
Inferior leads
II, III, aVF
RCA or Left circumflex
68
Treatment for congestion c/b heart failure
LMNOP
L - lasix (furosemide), monitor urine output
M - morphine
N - nitrates (vasodilation)
O - oxygen (consider BiPAP)
P - position (upright with legs over bed)
69
Treatment for poor perfusion c/b HF
IV vasodilators - nitroglycerin, nitroprusside, nesiritide
inotopic agents - dobutamine, milrinone
ultrafiltration
mechancial circulatory support (IABP, LVAD, RVAD)
cardiac transplant
70
What are the type types of infectious cardiac disease
endocarditis and pericarditis
71
Pericarditis
inflammation of the pericardium
usually d/t viral infection
c/b non-radiating pain, sharp, stabbing, knife-like chest pain over PMI
friction rub (maybe)
ECG - global concave ST elevations
pain relieved by position change
symptomatic treatment with NSAIDS
72
Endocarditis
infection of the endocardium
c/b bacteria** and fungi
high risk in patients with valvular disease & increased risk of pathogen introduction (IV drug users)
changing cardiac murmur
PE - acutely septic patient
Oslers nodes, janeway lesions, splinter hemorrhages
treatment - vancomycin
73
Three cardinal signs for cardiac tamponade
elevated jugular venous pressure, distant heart sounds, hypotension
(compression of cardiac chambers dye to increased pericardial pressure)
74
What drug is used to reverse BB OD
glucagon
75
Clinical presentation of ACS in the elderly (>75yo)
dyspnea
neuro symptoms - syncope, weakness, and acute confusion
chest pain or pressure < 50%
76
point of maximum impulse - what is it, the normal location
a palpable sensation of the underlying left ventricle
5th ICS, MCL
size of the impulse is about a nickle, gentle tab by one finger, timing is about 1/3 of systole
77
Displaced PMI - what does it mean
- PMI is usually displaced laterally - indicates increased LV volume
usually forceful -- pressure overload or HTN
78
Things to consider if you are unable to palpate the PMI
left lateral decubitus position enhancement, or consider other conditions -- thick chest wall, obesity or COPD
79
S1 - significance, heard best
marks the beginning of systole (pumping) c/b closure of the mitral and tricuspid valves
best heard at the apex wit the diaphragm
it is the "lub" of lub dub
heard simultaneously as the carotid upstroke
80
S2 - significance, heard best
marks the END of systole - produced by closure of the aortic and pulmonic valves
heard best at the base with the diaphragm
it is the "dub" of lub dub
81
physiologic split S2 - significance and heard best
fixed spit, no change with inspiration -- often found in uncorrected septal defect
paradoxical split - narrows or closes with inspiration -- found it conditions that delay aortic closure (LBBB)
best heard in the pulmonic region
82
pathologic S3 - significance and heard best
marker of ventricular overload and/or systolic dysfunction
heard best in early diastole "hooked" on the back end of S2 - low pitched, heard best with bell
S3 can be correlated with HF but associate it with other findings such as dyspnea, tachycardia, crackles
Lub-Dub-dub
83
S4 - significance, and heard best
Marker of poor diastolic function - often found in poorly controlled HTN or recurrent myocardial ischemia
heard in LATE diastole, "hooked" onto the front of S1
S4-S1-S2
84
Different pathology between systolic and diastolic cardiac murmurs
Systolic - benign or pathologic
Diastolic - always pathologic
85
pneumonic for systolic murmurs
MR PASS wins the MVP award
Mitral Regurgitation
Physiologic (innocent, functional)
Aortic Stenosis
systolic
Mitral Valve Prolapse
86
pneumonic for diastolic murmurs
MS. ARD
Mitral Stenosis
Aortic Regurgitation
Diastolic
87
systolic murmur is likely benign if
negative hx
lower grade (
88
Systolic murmur is likely pathologic if, what is the next step
abnormal hx
higher grade (IV/VI)
radiates to neck, axilla, or other locations
S1 and S2 are obliterated
+ thrill or heave
PMI is displaced
increase in intensity with supine to standing
89
difference between a radiating murmur and a carotid bruit
bruit - softer, unilateral, different sound than that in the chest
radiating murmur - louder, bilateral, same sound and timing as in the chest
