Cardiovascular

Question 1

What is acute myocardial infarction

Answer 1

known as ST elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS)

Question 2

A classic case for MI

Answer 2

A middle-aged or older man c/o gradual onset of intense and steady chest discomfort or pain that is described as squeezing, tightness, crushing, heavy pressure (an elephant sitting on my chest), or band-like

Question 3

What is MI characteristics

Answer 3

pain or discomfort may radiate to the left side of the neck, jaw, and left arm.

diaphoretic with cool, clammy skin

Women & elderly present with SOB, dyspnea, weakness, nausea and vomiting, fatigue, and syncope.

could also have back pain

Question 4

CHF sxs

Answer 4

older patients complains of acute onset of dyspnea, fatigue, dry cough, and swollen feet and ankles

Question 5

CHF characteristics

Answer 5

Lung exam reveal crackles on both the lung bases along with an S3 heart sound.

Question 6

CHF risk factors

Answer 6

HX of CAD, angina, prior MI, previous episode of CHF

Question 7

What is infective endocarditis

Answer 7

Known as bacterial endocarditis

Question 8

Patient presentation with endocarditis

Answer 8

patient presents with fever, chills, and malaise that is associated with onset of a new murmur

Question 9

Endocarditis skin findings

Answer 9

Found mainly on the fingers/hands and toes/feet

Known as sublingual hemorrhages (splinter hemorrhages on the nail bed)

Petechiae on the palate

painful violet- colored nodes on the fingers or feet (Osler nodes)

Nontender red spots on the palms/soles (Janaway lesions)

fundoycopic exam- rote spots or retinal hemorrhages

Question 10

Abdominal Aortic Aneurysm (AAA)

Presentation

Answer 10

sudden onset of severe, sharp excruciating pain located in the abdomen, flank, or back.

accompanied by a distended abdomen and abnormal vital signs (hypotension)

Question 11

AAA risk factors

Answer 11

older male patients who are smokers with hypertension are at higher risk

Chest x-ray- widened mediastinum, tracheal deviation, and obliteration of aortic knob

Question 12

where is apical impulse located

Answer 12

5th intercostal space by the midclavicular line on the left side of the chest

Question 13

what can cause displacement of the point of maximal impulse

Answer 13

Severe left ventricular hypertrophy and cardiomyopathy (PMI displaced laterally on the chest, larger in size (3 cm

Pregnancy 3rd trimester-PMI located slightly upward on the left side of the chest, may hear S3 heart sound during pregnancy

Question 14

Where does deoxygenated blood enter the body

Answer 14

enters the heart through superior vena cava and inferior vena cava

then flows through right atrium>tricuspid valve>right ventricle>pulmonic valve>pulmonary artery>the lungs>alveoli

Question 15

where does oxygenated blood exit the body

Answer 15

exits the lungs through the pulmonary veins and enters the heart

Question 16

Systolic murmurs

Answer 16

MR.ASS (mitral regurgitation/aortic stenosis-systolic)

Question 17

Diastolic murmurs

Answer 17

MS.ARD (mitral stenosis/aortic regurgitation =diastolic

Question 18

Mitral area

Answer 18

AKA apex or the apical area of the heart

5th left ICS (8-9cm from the midsternal line and slightly medial to the midclavicular line

PMI/apical pulse is located here

Question 19

Aortic area

Answer 19

2nd ICS to the right side of the upper border of the sternum

location also described as 2nd ICS by the right side of the sternum at the base of the heart. Also described as a murmur that is located on the right side of the upper sternum

Question 20

Erb’s point

Answer 20

located at 3rd & 4th ICS on the left sternal border

Question 21

MR.ASS (systolic murmurs mnemonics)

Answer 21

Described as occurring during S1, or as holosystolic, pansystolic, early systolic, late systolic, or midsytolic murmurs

louder and can radiate to the neck or axillae

Question 22

MS.ARD (diastolic murmurs mnemonics)

Answer 22

Diastole AKA as the s2 heart sound, early diastole, late diastole, or middiastole

indicative of heart disease

indicated abnormal

Question 23

Grade I heart murmur

Answer 23

very soft murmur heard only under optimal conditions

Question 24

Grade II heart murmur

Answer 24

Mild to moderate loud murmur

Question 25

Grade III heart murmur

Answer 25

loud murmur that is easily heard once the stethoscope is placed on the chest

Question 26

Grade IV heart murmur

Answer 26

louder murmur, 1st time that a thrill is present, thrill is a palpable murmur

Question 27

Grade V heart murmur

Answer 27

very loud heart murmur heard with edge of stethoscope off chest. Thrill is more obvious

Question 28

Grade VI heart murmur

Answer 28

murmur is so loud that it can be heard even with the stethoscope off the chest. thrill is easily palpated

Question 29

R/O AAA in an older male who has a pulsatile abdominal mass that is more than 3cm in width, what test is ordered

Answer 29

Abdominal ultrasound and CT

Question 30

Mnemoic (MOTIVATED APPLES)

Answer 30

``` Motivated M-mitral valve T-tricuspid valve AV-atrioventricular valves (lub sound of Lub-dub), closure of the mitral and tricuspid valves ``` ``` Apples A-aortic valve P-pulmonic valve S-semilunar valve (dub sound of Lub-dub), closure of the aortic and pulmonic valves ```

Question 31

S3 sound indicates what heart disease

Answer 31

CHF

Question 32

S4 sound indicates what heart disease

Answer 32

LVH

Question 33

What is the most common cardiac arrhythmia in the United States

Answer 33

Atrial fibrillation

Question 34

Risk factors for atrial fibrillation

Answer 34

HTN, CAD, ACS, caffeine, nicotine, hyperthyroidism, alcohol intake (holiday heart), heart failure, LVH, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), sleep apnea, paroxysmal AF

Question 35

AF classic case

Answer 35

patient reports the sudden onset of heart palpitations accompanied by feelings of weakness, dizziness, dyspnea/dyspnea on exertion, and reduction in exercise capacity. May complain of chest pain and feelings of passing out (presyncope to syncope). Rapid and irregular pulse may be more than 110 beats/min with hypotension.

Question 36

AF Treatment plan

Answer 36

1st determine underlying cause. Tx depends on patient type and risk factors for stroke Tool used is CHA2DS2VASc score Diagnostic test=12 lead EKG (does not show P waves, irregularly rhythm) New onset- EKG, TSH, electrolytes (calcium, potassium, magnesium, sodium), renal function, B-type natriuretic peptide 24 hour holter monitor lifestyle: avoid stimulants (caffeine, nicotine, decongestants) and alcohol

Question 37

AF treatment for new onset stable patients

Answer 37

cardio version within for 48 hours or rate control

Question 38

AF rate control medications are?

Answer 38

beta-blockers, calcium channel blockers, & digoxin

Question 39

What is the target goal INR for AF

Answer 39

2.0-3.0

Question 40

What is the proper procedure to check for pulses paradoxus

Answer 40

measured by using the BP cuff and stethoscope.

Question 41

What do you do if the INR <5.0

Answer 41

skip next dose and reduce the maintenance dose. Check INR once/twice a week when adjusting dose. Do not give vitamin K

Question 42

What do you do if the INR 5.0-9.0

Answer 42

hold one or two doses; with or without administration of low-dosed vitamin K. Monitor INR every 2-3 days until it is stable. Decrease the Coumadin maintenance dose.

Question 43

JNC 8 HTN TX goal 60 years or younger

Answer 43

<140/90, Same BP goal for all (including DM/CKD)

Question 44

JNC 8 HTN 60 years or older

Answer 44

<150/90 systolic BP goal increased by 10mm Hg except if DM and/or CKD

Question 45

JNC 8 HTN goal Black

Answer 45

<140/90, thiazide diuretics and CCBS (alone or combined with another drug class) if DM/CKD choose ACEI or ARB

Question 46

JNC HTN goal Non-black

Answer 46

<140/90, thiazide diuretics ACEI, ARB, or CCB (alone or combined with another drug class)

Question 47

JNC HTN goal | CKD age 18 or older

Answer 47

<140/90, initiate ACEI or ARB Applies to everyone regardless of race

Question 48

JNC HTN goal | DM age 18 or older

Answer 48

<140/90, include ACEI or ARB

Question 49

1st line therapy for HTN, hyperlipidemia, and type 2 DM

Answer 49

Lose weight, normal weight (18.5-24.9 stop smoking reduce stress level reduce dietary sodium (less than 2.4 g/2400 mg) maintain adequate intake of potassium, calcium, and magnesium limit alcohol intake (1oz or less per day for men, 0.5 oz or less per day for women) eat fatty-cold water fish (salmon, anchovy) three times a week

Question 50

HTN diet

Answer 50

DASH diet recommended for prehypertension, HTN, weight loss. Goal is to eat foods rich in potassium, magnesium, and calcium. Reduce red meat and processed foods. Eat more whole grains, legumes. Eat more fish and poultry.

Question 51

Thiazide diuretics

Answer 51

Action: change the way that the kidney handles sodium, which increases output. Have a favorable effect with osteopenia/osteoporosis (slows down demineralization). Contains sulfa, should be avoided in patients with sulfa allergy. SE: "Hyper" Hyperglycemia ( caution with diabetics), hyperuricemia (can cause a gout attcack) Hypertriglyceridemia and hypercholestermia (check lipid profile) Hypo Hypokalemia (potentiates digoxin toxicity, increases risk of arrhythmias) Hyponatremia ( hold diuretic, restrict water intake, replace K+ loss) Hypomagnesimia Contraindications: sensitivity to sulfa drugs and thiazides Examples: hydrochlorothiazide 12.5 to 25 mg to PO daily chlorthalidone (hygroton) 12.5 to 25 mg PO daily indapamide (lozol) PO daily

Question 52

Loop diuretics

Answer 52

Action: inhibit the sodium-potassium-chloride pump of the kidney in the loop of Henle. SE: hypokalemia (potentiates digoxin toxicity, increase risk of arrhythmias) Hyponatremia (hold diuretic, restrict water intake, replace K+ loss) Hypomagnesemia Possibly altered excretion of lithium and salicylates Contraindications: sensitivity to loop diuretics Examples: furosemide (lasix) PO BID, bumetanide (bumex) PO BID

Question 53

Hypertensive retinopathy

Answer 53

copper and silver wire arterioles, arteriovenous nicking AV nicking occurs when a retinal vein is compressed by an arteriole that causes the venue to collapse

Question 54

Diabetic retinopathy

Answer 54

neovascularization, cotton wall spots, micro aneurysms

Question 55

What are the preferred medication treatment in elderly patients with isolated systolic HTN

Answer 55

low-dose thiazide diuretic or CCB (long-acting dihydropyridine)

Question 56

What is the side effect of spironolactone

Answer 56

gynecomastia

Question 57

What is a main complaint from patients on ACEIs or ARBS

Answer 57

dry cough

Question 58

What should the NP be cautious when prescribing ACEIs with potassium-sparing diuretics (triamterene & spironolactone)

Answer 58

Increase risk of hyperkalemia

Question 59

What effect does ACEIs or ARBs have on patient with bilateral renal artery stenosis?

Answer 59

predicate acute renal failure

Question 60

Alpha-blockers are not 1st line drugs for HTN except if patient has_____

Answer 60

preexisting BPH

Question 61

Why should women with HTN and osteopenia/osteoporosis receive thiazides?

Answer 61

Thiazides help bone loss by slowing down calcium loss (from the bone) and stimulating osteoclasts

Question 62

Left side heart failure

Answer 62

Remember lung. SXs are lung related such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

Question 63

right side heart failure

Answer 63

remember heart failure sxs are GI related( anorexia, nausea, and right upper quadrant abdominal pain)

Question 64

NYHA class II heart disease

Answer 64

ordinary physical activity results in fatigue, exertion dyspnea

Question 65

1st line treatment for stable HF

Answer 65

start on ACEI or ARB, then add a beta-blocker, aldosterone-receptor antagonist

Question 66

Risk factors for DVT

Answer 66

Stasis: prolonged travel, inactivity (more than 3 hours), bed rest, CHF Inherited coagulation disorders: Factor C deficiency, Leiden, Increased coagulation due to external factors: oral contraceptive use, pregnancy, bone fractures especially of the long bones, trauma, recent surgery, malignancy

Question 67

Classic case of DVT

Answer 67

A patient with risk factors for DVT c/o gradual onset of swelling on a lower extremity after a history of travel (more than 3 hours) or prolonged sitting. The patient c/o a painful and swollen lower extremity that is red and warm. If patient has PE, it may be accompanied by abrupt onset of chest pain, dyspnea, dizziness, or syncope. Many patients are asymptomatic.

Question 68

Tx plan for DVT

Answer 68

Homan's sign: lower leg pain on dorsiflexion of the foot CBC, platelets, clotting time (PT/PTT, INR), D-dimer level, chest x-ray, EKG ultrasonography Heparin IV then warfarin PO for 3-6 months

Question 69

Raynaud phenomenon

Answer 69

reversible vasospasm of the peripheral arterioles on the fingers and toes. Associated with an increased risk of autoimmune disorders (thyroid disorder, pernicious anemia, rheumatoid arthritis).

Question 70

Raynaud classic sxs

Answer 70

Think of the colors of the American flag. Classic case: middle-aged woman complains of chronic and recurrent episodes of color changes on her fingertips in a symmetric pattern (both hands and both feet). The colors ranges from white (pallor) and blue (cyanosis) to red (repurfusion). C/o numbness and tingling. Attacks last for several hours. Hands and feet become numb with very cold temps. Ischemic changes may be present after a severe episode such as shallow ulcers on some of the fingertips.

Question 71

Raynaud tx plan

Answer 71

Avoid touching cold objects, cold weather; avoid stimulants (caffeine) smoking cessation is important; nifedipine or amlodipine check distal pulses, ischemic signs do not use any vasoconstriction drugs; avoid nonselective beta-blockers

Question 72

1st line tx for hyperlipidemia

Answer 72

Lifestyle modifications, if presence of ASCVD or equivalents, need drug therapy

Question 73

Statin treatment for adult 21-75 years

Answer 73

Any type of ASCVD (CAD, PAD, stroke, TIA, etc). is given high intensity statins such as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg.

Question 74

what type of statin treatment is needed for an adult with LDL greater than 190?

Answer 74

high-intensity statins such as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg

Question 75

what type of statin treatment is recommended for an adult (up to 75 years age) with 10 year estimated ASCVD risk is 7.5% or higher

Answer 75

high intensity statin dosing

Question 76

if ASCVD risk is between 5%-7.5% what type of statin treatment is recommended?

Answer 76

lifestyle changes 1st

Question 77

patient with markedly high triglycerides >500 what treatment is recommended

Answer 77

lower triglyceride first with niacin or vibrate before treating high cholesterol and LDL levels.

Question 78

High triglycerides increase risk for what disease?

Answer 78

acute pancreatitis

Question 79

what education should be provided in patients with high triglycerides?

Answer 79

avoid alcohol, acetaminophen (hepatotoxic) obese patients: encourage weight loss and reduce simple carbohydrates, sugars, junk foods. Tx 1st before treating high LDL advise patient to reduce intake of simple carbohydrates, junk foods, fried foods

Question 80

What are the best agents to lowering triglycerides

Answer 80

niacin & vibrates

Question 81

ex's of bacterial endocarditis

Answer 81

splinter hemorrhages on nails Janeway lesions (red macules palms/soles not painful) Osler's nodes (painful violaceous nodes found mostly on pads of the fingers and toes, thenar eminence

Question 82

What can statins cause

Answer 82

memory loss, confusion, cognitive effects, which are reversible upon discontinuation of statin therapy

Question 83

what food and drugs should be avoided if patient is on simvastatin and lovastatin

Answer 83

grapefruit juice and macrocodes

Question 84

what are the sxs of rhabdomyolysis

Answer 84

muscle pain located on the calves, thighs, lower back, and shoulders, urine will be darker than normal (reddish-brown color). usually happen if patients are on statins

Question 85

Criteria for metabolic syndrome

Answer 85

abdominal obesity (>40 in men, >35 in women) HTN hyperlipidemia fasting plasma glucose>100 elevated triglycerides >150 decreased HDL <40

Question 86

What labs are considered for diagnose of metabolic syndrome

Answer 86

fasting blood glucose from 9-12 hours lipid profile (focusing on triglycerides and HDL)

Question 87

What are the risk factors for nonalcoholic fatty liver disease

Answer 87

obesity, diabetes, metabolic syndrome, HTN, certain drugs

Question 88

What are symptoms of nonalcoholic fatty liver disease

Answer 88

asymptomatic hepatomegaly mild-mod elevations of ALT & AST fatigue & malaise with RUQ pain