Clin Med 3

Question 1

NBTE form sterile thrombotic veg in undmged valves vs preexisting valve dz d/t?

Answer 1

PLT + fibrin, immune complexes, mononuclear cells vs blood flow turbulence

Question 2

dx & tx for NBTE vs IE

Answer 2

TEE > TTE, blood cx to r/o infxn, distinguish NBTE from IE. systemic anticoag vs blood cx (3/6), TTE>TEE, Duke (def, possible, rejected), CXR if right sided. blood cx before empiric abx x/ CHF valve dysfxn, abx prophylaxis, valve replace, hyper/acute graft rejection doesn’t occur -> no immunosuppress

Question 3

acute vs subacute IE bacteria & sxs

Answer 3

s. aureus, streptococcus, viridans; healthcare assoc; fever/chills, new murmurs, Jane way lesions vs s. epi, streptococcus, viridans, enterococci, H flu; community acquired; Osler, Roth, petechiae, splinter hem, mycotic aneurysm -> stroke

Question 4

early vs intermed vs late prosthetic valve endocarditis. general & microorg causes of tricuspid valve?

Answer 4

<2mo -> s. aureus, epi vs 2-12mo -> epi, aureus, viridans vs >12mo -> aureus, viridans, epi, enterococci. IVDU; aureus > candida > pseudomonas

Question 5

how can endocarditis show neg cx?

Answer 5

previous abx admin, inadeq micro technique, fastidious bacteria, intracell pathogens (Bartonella, brucella, coxiella, legionella)

Question 6

general risk factors for resp infxns

Answer 6

young age (small short airways), old age (immunosenescence), immunocomp, H+ pump inhibitor (dec stomach acid), prior resp infxn (dmged resp mucosa & epithelia)

Question 7

when do you start using SOFA score for sepsis?

Answer 7

if pt as <300 PaO2, <100 PLT, >2 bilirubin & Cr, GCS >10; resp 22, AMS, sbp <100mmHg

Question 8

HACEK can cause subacute IE by infecting which valves?

Answer 8

mech aortic and prosthetic tricuspid

Question 9

how to tx pts w/ chronic stable heart fail vs acute decomp heart fail vs refractory HTN vs cardiomyopathy w/ low EF?

Answer 9

loop, ACEI, BB vs loop, nitroprusside, NO BB; O2/assisted ventil by pos pressure vs inotropes, mech support vs transplant. GENERALLY AVOID NSAIDS & ALC

Question 10

constrictive pericarditis. sxs vs dx vs tx

Answer 10

dense fibrocalcific scar -> diastolic dysfxn -> dip/plateau, square root sign. pulsus paradoxus, Kussmaul, Beck’s, pericardial knock (S3) vs echo for pericardial thickness or biatrial enlg, cardiac cath to chk diastolic pressures in chambers & LV tracing vs pericardiectomy

Question 11

what does airway look like in peds? signs of resp distress in peds

Answer 11

larynx ant & higher, tongue = bigger, epiglottis flappy & bigger, airway smaller & shorter, more airway resistance. tachypnea, stridor, nasal flaring, grunting, drooling

Question 12

upper airway dzs for <6mo vs >6mo

Answer 12

congen: laryngo/tracheomalacia, vocal cord paralysis; acquired: croup, foreign body vs acquired inflam: croup, tracheitis, epiglottitis, abscess, anaphylax/angioedema; acquired noninflam: foreign body

Question 13

3 causes of pulm HTN & sequelae

Answer 13

inc venous pressure, flow, resistance –> R heart fail –> JVD, periph edema, ascites, S3, loud P2

Question 14

diag tests for pulm HTN

Answer 14

R cardiac cath = gold standard; MAP >25mmHg at rest; CXR lg central vessels & R heart; EKG RBBB, high R V1, RAD; echo for ejection jet; PFT lung vol <50%; V/Q to chk for chronic venous thromboembol dz

Question 15

tx meds for PAH

Answer 15

CCB x/ verapamil b/c neg ino; SGC like NO (CI = preg); prostanoids b/c prostacyclin = potent vasodil; endothelin receptor antag -sentan to block vasoconstrictor endothelin; PDE5I b/c prolong NO (sildenafil); end stage PH -> heart & lung transplant

Question 16

pulm renal syndrome sx vs dx

Answer 16

rapid; systemic complaints for few wks vs nonspecific dx x/ known vasculitis or connective tissue dz; high Cr, anti GBM ab, ANCA

Question 17

Goodpasture sx vs dx vs tx

Answer 17

rapid; glomerulonephritis from circ ab attacking type IV collagen in basement mem -> crescent formation, frothy sputum vs high Cr -> AKI, anti GBM ab, BAL, mild anemia, immunofluorescence igG vs plasmapheresis to remove ab, prednisone + cyclophosphamide to dec prod ab

Question 18

clin pres for sepsis

Answer 18

QSOFA, warm shock & cold shock (mottled -> cool & varicose vv), skin (petechiae, no cap refill -> vasopressors), AKI, elderly & immunocompromised may show hypothermia/glycemia or leukopenia

Question 19

how to dx sepsis? tx? tx goal?

Answer 19

clinical dx, 2 sets of blood cx, ABG, pulse ox, coag studies, PCR, inflam cytok. cx before abx if possible, broad spectrum abx w/in 1h, resusc crystalloids x30min for HoTN or lactatemia; vasopressors if fluids don’t work, PRBC if hgb<7, tidal vol 6mL/kg in ARDS. CVP 8-12, MAP >65

Question 20

what are the key diff b/w nml and COPD/obstruction in spirometry? what about restrictive lung dz?

Answer 20

COPD/obstruction has dec FEV1 & FVC, inc RV; scooping expiratory loop. same as nml loop but smaller

Question 21

when to do bronchoprovocation & how? what’s DLCO?

Answer 21

nml spirometry but sus variable obstruction/asthma -> exer or methacholine (bronchospasm; don’t give if sick). single breath diffusion & lung vol CO capacity for emphysema, pulm edema

Question 22

diff b/w metab acidosis vs resp acidosis. acidosis w/ metab compensation? what does ABG measure?

Answer 22

nml CO2, low pH vs high CO2, low pH. lesser change in pH w/ metab compensation. PaC/O2, pH, SaO2, HCO3 in arterial blood

Question 23

V/Q base < apex; why? how to fix V/Q mismatch? what happens in a shunt? can it be corrected by FiO2?

Answer 23

more blood flow & less air in base, vice versa in apex. inc FiO2. bypasses gas exchange. no

Question 24

what happens if gas diffusion takes longer? tx?

Answer 24

impaired diffusion -> thickened alveoli. raise alveolar O2, FiO2