Cardiology & Pulmonary

Question 1

Pericarditis

Answer 1

Viral, post-MI, dressler syndrome (2-3 wks post MI)
Pleuritic pain, friction rub on exam
diffuse ST elevations and PR depressions on EKG
Echo may show pericardial effusion
Tx with aspirin (post-MI) or NSAID (viral)

Pericardiocentesis if tamponade sx

Question 2

Spontaneous pneumothorax

Answer 2

Sharp, sudden, nonradiating pleuritic chest pain
On side of pneumothorax: hyperresonance, decreased breath sounds, decreased chest wall expansion

CXR to diagnose

primiary - ruptured subpleural apical bleb, in tall thin young men
secondary - in COPD, trauma, TB, PCP, thoracentesis, subclavian line, bronchoscopy, PPV

Question 3

What is the treatment for stable angina? Which drugs have mortality benefit?

Answer 3

Aspirin, beta-blockers - mortality benefit

Also tx with sublingual nitroglycerin

Question 4

What are the TIMI score components, and how do you use TIMI score?

Answer 4

1 point each for:
Age >65
Three or more CAD risk factors
Known CAD
aspirin use in past 7 days
2+ episodes in 24 hours
ST deviation >0.5mm
Positive cardiac marker

If TIMI greater than 3, give heparin or enoxaparin and schedule for angiography and possible PCI vs CABG (invasive)

Question 5

When is PCI used in managing STEMI? What if you can’t use PCI?

Answer 5

PCI is preferred if can be performed within 90 minutes of presentation or within 120 minutes if needs transfer to a PCI capable hospital

If can’t use PCI (or too far), and no contraindications, thrombolytic therapy

Question 6

What are the common post-MI complications, and how many days after MI do they occur?

Answer 6

Day 1 - heart failure
Day 2-4 arrhythmia, pericarditis, ventricular-septal defect
Day 5-10 LV wall ruprutre, papillary muscle rupture
weeks - ventricular aneurysm, dressler syndrome

Question 7

What are physical exam findings in a VSD?

Answer 7

Narrow S2
Harsh holosytolic murmur at left lower sternal border, possibly associated with a thrill
Mid-diastolic apical rumble

Question 8

What are physical exam findings in an ASD?

Answer 8

Wide, fixed split S2

Systolic ejection murmur at left upper sternal border

Question 9

What is appropriate medical therapy for ACS?

Answer 9

dual antiplatelet therapy, betablocker, nitrate, anticoagulation

Question 10

What is the difference between mobitz 1 and 2 second-degree heart block?

Answer 10

I - progressive prolongation of PR

II - no progressive prolongation; may suddenly progress to complete heart block, needs pacemaker tx

Question 11

What is the cause of second-degree heart block type 1?

Answer 11

usually drugs - digoxin, beta-blockers, CCBs
Tx by stopping drugs, atropine PRN

Also possibly due to RCA ischemia or infarct

Question 12

What is the treatment of lyme carditis?

Answer 12

IV ceftraixone, then 21 day oral therapy

Presents with AV block

Question 13

Which drugs can you use to treat afib with RVR?

Answer 13

Rate control first line: metoprolol/esmolol (beta blockers) or diltiazem/verapimil (calcium channel blocker)

Question 14

What are the EKG features of WPW?

Answer 14

Short PR interval, delta wave, symptomatic tachycardia

Question 15

What are the EKG features of multifocal atrial tachycardia?

Answer 15

3 or more p wave morphologic patterns

variable PR interval

Question 16

What is the first-line treatment for ventricular tachycardia?

Answer 16

Amiodarone

Second lines: procainamide, sotalol, lidocaine

(may be wide complex tachycardia)

Question 17

What is the treatment for PVCs?

Answer 17

If symptomatic- beta blockade

Question 18

When should spironolactone be added to HF regimen?

Answer 18

NYHA class III-IV, serum K<5, creatinine <2.5
Associated with reduction in mortality by 30%, reduction in hospitalizations

Question 19

Which factors influence BNP levels, and how?

Answer 19

Obesity - decreases BNP

Renal failure, old age, female - increase BNP

Question 20

Mitral regurgitation murmur

Answer 20

Holosystolic, high-pitched “blowing murmur.” Loudest at apex and radiates toward axilla. Enhanced by maneuvers that increase total peripheral resistance or expiration.

Question 21

Tricuspid regurg murmur

Answer 21

Holosystolic, high-pitched “blowing murmur.” Loudest at tricuspid area and radiates to right sternal border, Enhanced by maneuvers that increases total peripheral resistance and with with inspiration.

Question 22

Aortic stenosis murmur

Answer 22

Crescendo-decrescendo systolic ejection murmur following ejection click. Radiates to carotids/apex. Pulses are weak compared to heart sounds.

Question 23

Ventricular septal defect murmur

Answer 23

Holosystolic, harsh-sounding murmur worse with inspiration. Loudest at tricuspid area. Newborns

Question 24

Mitral prolapse

Answer 24

Mitral prolapse Late systolic crescendo murmur with midsystolic click loudest at S2. Enhanced by standing or valsalva.

Question 25

Aortic regurgitation

Answer 25

Immediate high-pitched diastolic murmur. Wide pulse pressure when chronic; can present with bounding pulses and head bobbing

Question 26

Mitral stenosis

Answer 26

Follows opening snap. Delayed rumbling late diastolic murmur.

Question 27

Patent ductus arteriosis

Answer 27

Continuous machine-like murmur loudest at S2.

Question 28

How do you treat prinzmetal / variant angina?

Answer 28

Calcium channel blockers or nitrates

Question 29

Acute onset heart failure following a URI suggests what?

Answer 29

Dilated cardiomyopathy secondary to acute viral myocarditis (coxsackie B, adenovirus, enterovirus, HHV6, parvovirus B19)

Question 30

Features of severe aortic stenosis

Answer 30

Delayed/weak/slow rising carotid pulse (parvus et tardus)
single, soft S2
mid-late peaking systolic murmur, radiating to carotid, best heart at right 2nd intercostal
Exertional syncope

Question 31

Constrictive pericarditis

Answer 31

Progressive peripheral edema
ascites
elevated JVP
Middiastolic sound (pericardial knock)
Pericardial calcifications

Etiolgy: viral, post-cardiac surgery, post-radiation therapy, tuberculosis (endemic)

Question 32

Atrial septal defect

Answer 32

Wide fixed splitting S2

Question 33

Paradoxical split S2

Answer 33

Aortic stenosis or LBBB