Clinical Flashcards
John Conner a recent patient of yours has a lot of stress from his daily life which hasn’t improved over the course of time he’s been meeting with you. You decide to start him on anti-hypertensive medication. You know from his history that he has chronic kidney disease. What should you prescribe him? A) ACEI B) Thiazide C) CCB D) yoga
A is correct Chronic kidney disease- start on angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) African American- start with Thiazide-type diuretic or calcium channel blocker (CCB) Everyone else can start with either: ACEI, ARB, or CCB
Doing routine physical exam of one of your adolescent patients who’s been complaining of leg pain during exercise at school you notice they have cold legs and what sounds like a heart murmur. You decide to check their bp in both their arm and leg and notice a 25mmHg difference in pressure, with the legs having the lower bp. How should you diagnose this condition? A) CT B) Ultrasound C) MRI D) Transthoracic echo
D) is correct They likely have coarctation of the aorta
You’re looking at some cross sectional anatomy laying on the desk of your physician friend and see a large mass on the top of the kidney. He says the patient has been having aniexty and headaches lately. Which hormone is likely causing these problems? What tests would you order? A) Tyrosine B) Epi C) NE D) ADH E) Aldosterone
C) NE This is likely pheochromocytoma which is an adrenal glad tumor secreting hormones; predominately NE (though Epi is a good second guess) Classic triad of symptoms: Headache, perspiration, and palpitations Test: 24 urine sample and plasma looking at hormone levels
You go to the lab to flirt with the on call nurse and notice a lab report for renin and aldosterone levels. Looking at the ratio of these two molecules is a diagnostic test for which condition? A) Hirsutism B) Pheochromocytoma C) Chrons D) Cushings E) Primary aldosteronism
E) primary aldosteronism Signs/symptoms are - hypokalemia, hypernatrimia and resistant hypertension
You have a hypertensive patients records indicate they had a diagnostic test called a polysomnography. What hypertensive issue may have been under investigation? A) Cushings B) polylipidemia C) Pheochromocytoma D) Coarctation of the aorta E) OSA
E) OSA obstructive sleep apnea Signs-snore, daytime sleepyness, apneic events at night Other tests-sleep score (Epworth sleepiness scale), pulse oxygen
Your first pediatric patient presents with leg swelling and has high bp. What follow up questions should you ask? With this information alone what test might you order to cover your basis since 85% of pediatric patients with hypertension have a disease with similar symptoms?
Do you have very foamy urine Test: BUN, Urinalysis, urine culture, renal ultrasound (likely small kidney on one side) They likey have renal parenchymal disease
According to the JNC 8 guidlines for hypertension at whay bp should you start someone on medication who is 43 y/o ? What if they’re 83 y/o?
>140/90 >150/90 > or equal to
What are the major risk factors for coronary heart disease CHD?
CHLOE cigarettes Hypertension Low HDL Old age Elder/family history
How do you insure an accurate bp? What are the steps?
Patient wait 5 mins with feet on ground proper size cuff 2/3 arm encircled Inflate about 20mmHg above systolic value avoid caffeine smoking etc beforehand Take 2 per visit (or at home, walgreens to avoid white coat htn) Take 2-3 x week for accurate numbers
Define the parameters of both hypertensive crisis and hypertensive urgency?
Hypertensive crisis is diastolic bp >120 plus end organ damage (indicate secondary htn) Hypertensive urgency there are no signs of end organ damage
What percentage of hypertension is primary vs secondary and what are the characteristics of each?
primary 95% Onset 20-50 y/o family history of htn no features of secondary htn no end organ damage secondary 5% 20 y/o or younger and 50 y/o or older No family history Acute severe end organ damage indicated with labs
Nearly all genes identified with the pathogenesis of primary hypertension involve what? A) congenital heart defects B) Atherosclerosis C) beta blocker use D) Impaired kidney sodium excretion D) baseline rates of albumen are high
D) impaired Na+ excretion in the kidney
What is your main focus when trying to diagnose someone with hypertension?
To determine if they have any signs of secondary htn. Lots of investigation into whether they have any end stage organ damage.
What are the 4 cardinal findings of shock? Explain each
- Hypotension systolic less than 90mmHg 2. oliguria (low urine output) blood shunting from kidneys 3. metal status change- aggitated to coma 4. metabolic acidosis- decrease in lactate being cleared due to liver and kidney failure (lack of O2, decreased perfusion).
How to you treat a patient with shock?
- VIP ventilation- O2 usually intubation Infuse- fluid resuscitation pump- vasoactive drugs (make sure the pump is full before you try to squeeze the vessels) 2. diagnose and treat at the same time 3. Arterial catheter if needed (blood gas) 4. Central venous catheter for fluid, drugs, measure CVP
What are some examples of obstructive shock?
pulmonary hypertension pulmonary embolism cardiac tamponade-fluid in pericardial sac tension pneumothorax constrictive pericarditis
You have a patient admitted that is sweating and feverish. Their blood pressure is 85/43 and they look ill. You see what looks to be an infected cut on their right leg. What lab tests would initially NOT be indicated? A) ABG B) BUN C) Blood culture D) CBC w/differential E) Potassium
E- all the others are appropriate when suspicious of septic shock. BUN is checking for kidney function ABG is arterial blood gas
You have a patient come into the clinic complaining of chest pain and your attending asks you which life threatening etiologies you need to r/o. What’s your response?
Heart: MI, aortic dissection, aortic stenosis Lungs: Pneumothorax, pulmonary embolism GI: perforating ulcer, esophageal rupture
Your patient comes to you complaining of fatigue, stating that “ I just get out of breath more easily when I’m going up stairs.” Upon auscultation of the chest you hear a holosytolic murmur and EKG shows a slight L axial deviation. What is a primary cause of this valvular disease? A. Ischemia B. Hypertrophic cardiomyopathy C. Infective endocarditis D. marfans syndrome
C. infective endocarditis. The valvular disease is mitral regurgitation. A and B are secondary causes D is associated with aortic dissection and other elastic tissue problems.
High pitched diastolic murmur (blowing) with water hammer pulse. heard best at erbs pt.
Aortic insuffiency/regurg
How would you detect mitral stenosis on auscultation and EKG?
Low-pitched diastolic rumble murmur Enlarged P wave indicated LAH Chest pain secondary to pulmonary htn, decreased exercise tolerance Common association: Rheumatic heart disease
What’s the most common valvular disease of the elderly?
Aortic stenosis
O2 decrease in the heart due to an ischemic event can lead to angina. What’s the typical duration of that pain? 1 min 3-5 min 10 min 22min
3-5 min 1 min or less unlikely cardiac more than 20 mins usually leads to an MI
How is angina usually described?
squeezing burning tightness choking. Not always pain 60% of these patients will have normal EKGs
