csv-export-2 Flashcards
Best treatment for ventricular tachy in a pt with stable BP?
amidarone is drug of choice. lidocaine can also be used.
What type of arrhythmias can be treated by Digoxin?
atrial arrhythmias
Tx for sustained ventricular tachy with hemodynamic compromise?
Cardioversion
What role does carotid massage play in ventricular tachy?
None - useful for SUPRAventricular tachy (narrow complex)
What kind of pulse is found in aortic regurg?
bounding aka “water hammer”
What causes a bounding or water hammer pulse in aortic regurg?
AR is associated with an increased SV which produces an abrupt rise in the systolic BP and rapid distension of the peripheral arteries. Then during diastole, there is a regurg of blood back into the left ventricle, resulting in a low diastolic pressure and collapse of the peripheral arteries.
Fixed splitting of S2 plus a midsystolic pulmonary flow murmur?
ASD
Why is lidocaine not used prophylactically in patients with acute coronary sundromes to prevent ventricular fibrillation?
it increases the risk of asystole
3 most common causes of aortic stenosis?
senile calcific aortic stenosis, bicuspid aortic valve, and rheumatic heart disease.
When is a pt at risk for ACUTE pericarditis after an MI?
first several days - diffuse ST elevations, esp with PR depressions are typical ECG findings.
Common complication 3-7 days after an MI?
ventricular free wall rupture - presents with rapid deterioration of the pt 2dry to pericardial tamponade – pulseless electrical activity on ECG is common
common LATE complication of anterior wall MI?
ventricular aneurysm - can occur days to months after the initial infarction.
MILD hypovolemia can cause syncope in what population of pts?
elderly - they very poorly tolerate even what seems to be an insignificant loss of fluid - especially orthostatic syncope upon getting up in the morning.
Treatment of choice for DRessler’s syndrome?
NSAIDS. Corticosteroids can be used in refractory cases or if NSAIDs are CI.
Most likely artery that is occluded in acute inferior wall MI?
Right coronary artery, especially if it is complicated by right ventricular infarction (hypotension) and bradycardia.
LAD occlusion causes?
anterior wall MI
What can confirm a diagnosis of malignant hypertension?
Presence of papilledema - always suspect malig HTN if very high BPs (>/= 200/140).
leading cause of mitral stenosis worldwide?
Rheumatic heart disease
Pharmacologic management of variant (or Prinzmetal’s angina)?
calcium ch blockers and/or nitrates to prevent coronary vasoconstriction.
Greatest risk factor for variant angina?
smoking
When does variant angina classically occur?
at night and can be associated with transient ST elevation on ECG.
PITTING edema vs. non-pitting edema?
PITTING - due to increased movement of fluid from vascular space into interstitial space. Can be due to increased intravascular hydrostatic pressure (CHF, portal HTN), decreased plasma oncotic pressure (low albumin 2ndry to malnutrition, nephrotic sydnrome, cirrhosis), or increased capillary leak (burns, trauma, or infection).
First step in treating pt with a WITNESSED cardiac arrest?
defibrillation
tx for first degree heart block?
nothing - completely benign condition
A stenotic mitral valve causes increased left atrial pressure which in turn gets transmitted to the pulmonary vasculature. What symptoms can this increase in pulm vascular pressure cause?
exertional dyspnea, nocturnal cough, and hemoptysis (hemoptysis in particular should raise suspicion for mitral stenosis)
how do nitrates reduce chest pain in angina pectoris?
venodilation –> blood pools in systemic venous circulation –> decreases preload –> reduces ventricular volume and wall stress (stretch) –> decreased myocardial oxygen demand.
thiazide diuretic may cause electrolyte disturbances causing sudden syncope without warning signs. this is caused by?
ventricular arrhythmia - drug predisposis to this
s/sx of coarctation of the aorta?
majority of pts are asymptomatic - but common s/sx (when present) include headache, epistaxis, cold extremities, delayed femoral pulse, or HTN in the upper extremity. In adults, enlarged pulsatile collateral vessels may be palpated in the intercostal spaces anteriorly, in the axilla or in the interscapular area. Also, upper extremity may be preferentially well developed.
Almost pathognomonic for coarctation of aorta?
3 sign -indentations of the aorta at the site of the coarctation and pre and post stenotic dilation along the left paramedian border.
Patent ductus arteriosus is associated with?
birth at high altitudes and maternal rubella infection.
aortic aneurysms present with what s/sx?
hoarseness, chest pain, dysphagia or a dry cough.
When is surgery indicated for an aortic aneurysm?
aneurysm > 6 cm in diameter, persistent pain, continued elevated BP or wide expansion of the aneurysm.
Why do pts with severe aortic stenosis have anginal chest pain?
due to increased myocardial oxygen demand 2dry to large left ventricular mass.
When is clopidogrel (plus aspirin) indicated for 2ndry prevention in a cardiac patient?
1) All patients with a UA/NSTEMI for at least 12 months (aspirin indefinitely)
How long is LMWH usually given post-MI?
first 48 hours typically
Classic physical exam findings for cardiac tamponade?
pulsus paradoxus and Beck’s triad (hypotension, jugular venous distention, and muffled heart sounds)
Why can a dual upstroke be present in HOCM?
occurs from midsystolic obstruction that develops as the heart contracts
What maneuver worsens the murmur of HOCM?
anything that decreases preload - valsava, standin g
Elevated BNP levels and an audible S3 are both signs of _____?
increased cardiac filling pressures due to volume overload.
Most useful test to assess coronary RE-occlusion after an MI?
CK-MB bc it returns to normal levesl within 1-2 days, while troponin T (genrally a more sensitive marker of cardiac injury) takes up to 10 days to return to normal after an MI.
Tx for hemodynamically stable SUPRAventricular tachy?
vagal maneuvers followed by adenosine and AV nodal blockers. adenosine decreases conduction through the AV node.
What should be suspected in otherwise young healthy pts who develp s/sx of CHF including paroxysmal nocturnal dyspnea, dyspnea on exertion, peripheral edema, hepatomegaly, cardiomegaly, bilateral pleural effusions,a nd a third heart sound?
Dilated cardiomyopathy 2ndry to myocarditis should be high on the DDx. Coxsackie B virus is the most common cause.
Most effective lifestyle intervention for reducing blood pressure?
decreased consumption of alcohol. smoking cessation decreases a pt’s risk of cardiovascular dz but does NOT improve blood pressure itself.
First line drugs for tx of cocaine-related cardiac ischemia?
benzodiazepines, nitrates, and aspirin - allays the anxiety and reduces the HTN and tachycardia
How long should a pt with an episode of rheumatic fever receive antibiotic prophylaxis with penicllin to prevent further attacks?
Treat until pt reaches age 18 to prevent repeat episodes which can worsen valvular function.
Most common cause of secondary HTN?
chronic oral contraceptive use - simply discontinuing its use can correct the problem
Tx for third degree heartblock?
pacemaker insertion
Tx for subacute bacterial endocarditis?
empiric ABX until causative bacterium is identivied. Native valve bacterial endocardities is most commonly due to Streptococcus viridans, which is highly susceptible to IV penicillin G or IV ceftriaxone.
Intensive retrosternal pain that radiates to the back of the chest along with normal ECG strongly suggests?
aortic dissection - check BP in both arms and auscultate for diasolic murmur of aortic regurg. TEE is the preferred diagnostic tool (bc MRI and CT are time consuming) but before performing procedure, HTN should be controlled.
How does adenosine have diagnostic value in a suspected supraventricular tachycardia?
an SVT is usually terminated by adenosine whereas other tachycardias are simply slowed.
Review of renin-angiotensin-aldosterone axis…
renin is produced by the juxtaglomerular cells of the kidney in response to hypOperfusion. Renin cleaves angiotensinogen to agiotensin I. In turn, angiotensin I is converted into angiotensin II by ACE in the lungs. Angiotensin II is a potent vasoconstrictor. It also promotes vasopressin (ADH) release from the pituitary and aldosterone prodxn from the adrenal cortex. Aldosterone acts on the distal convoluted tubules and collecting ducts to promote sodium and water resorption (at the expense of potassium).
In a patient with an MI who develops a cold leg, one should get an ECHO to rule out?
thrombus in the left ventricle that may have embolized to the leg. An MI results in blood stasis in the akinetic part of the heart with resultant thrombus formation.
typical presentation for bacillary angiomatosis?
immunocompromised indvidual (e.g. AIDS, malignancy, undergoing chemo, organ transplant recipients) with non specific constitutional symptoms PLUS characteristic lesions of the skin and viscera (angioma-like blood vessel growths). This condition is caused by Bartonella henselae and Bartonella quintana. Antibiotic treatment causes lesion regression.
What should be suspected in a pt that has areflexic weakness in the upper extremities and dissociated anesthesia (loss of pain and temp with preserved position and vibration) in a “cape” distribution?
Syringomyelia - presence of a cavitary expansion of the spinal cord (known as a syringe) with destruction of the gray and white matter adjacent to and often communicating with the central canal. Most frequent site of involvement is the lower cervical or upper thoracic region. When syringes occur in the upper cervical cord and extend proximally to involve the medulla oblongata, the condition is called syringobulbia. Causes include congenital, trauma, inflammatory conditions,tumors, and idiopathic.
Strongest influence on long-term prognosis following an ST-elevation MI?
duration of time that passes before coronary blood flow is restored (via PTCA or fingrinolysis). Reperfusion injury can occur but benefits of reperfusion far outweigh the consequences of reperfusion injury.
Pt that presents with painLESS sub acute monocular vision loss?
DDx includes central retinal vein occlusion (CRVO) or central retinal artery occlusion (CRAO).
Most common histologic lesion of diabetic nephropathy?
diffuse glomerulosclerosis but NODULAR glomerulosclerosis (with Kimmelstiel-Wilson nodules) is pathognomonic.
What can cause insoluble crystal precipitation in the tubular lumen leading to acute renal failure 2dry to renal tubular obstruction?
hyperuricemia from tumor lysis syndrome, indinavir, acyclovir, and sulfonamide therapy.
Best initial test in a patient with suspected hepatocellular carcinoma (typically caused by chronic viral hepatitis or cirrhosis)?
AFP which is frequently elevated in hepatocellular carcinoma but is NOT EXCLUDED by a normal AFP level. If AFP is elevated, imaging (CT or MRI) will be needed to detect the lesion. Biopsy may ultimately be necessary in many patients if a concerning lesion is found on imaging.
Leukocytosis, anemia, and increased number of mature granulocytic forms (eg. segmented neutrophils and band forms on peripheral blood) with low leukocyte alkaline phosphatase score should raise suspicion for?
CML - typically seen after age 50. Presence of Philadelphia chromosome confirms dx.
Elevated leukocyte alkaline phosphatase is characteristic of?
Leukemoid reaction
tartrate resistant acid phosphatase is present in ?
hairy cell eukemia
Adult treatment panel 3 recommendation for CHD or CHD risk equivalent (such as DM or PAD)?
Goal LDL < 100
Adult treatment panel 3 recommendation for 2+ risk factors for coronary heart disease?
Goal LDL < 130
Adult treatment panel 3 recommendation for 0-1 risk factors for coronary heart disease?
Goal LDL < 160
Risk factors for coronary heart disease?
men >/= 45
CHD risk equivalents?
DM
Decreases triglyceride levels and increases HDL concentrations?
Niacin - NOT considered first line for reducing LDL levels
Most common cause of fatal sporadic encephalitis in the U.S.?
Herpes encephalitis 2dry to HSV-1. Affects the temporal lobe of the brain and presents acutely (< 1 week) with focal neuro findings such as AMA, cranial nerve deficits, hemiparesis, dysphasia, aphasia, ataxia, or focal seizures. Fever is present in approx 90% of pts.
India ink preparation is used to detect?
cryptococcal meningitis in immunocompromised patients.
What may simulate an iron deficiency anemia (microcytic/hypochromic) but with iron studies that reveal ELEVATED serum iron levels and decreased TIBC?
Sideroblastic anemia resulting from defective heme synthesis, most commonly due to pyridoxine-dependent impairment in early steps of protoporphyrin synthesis. Often caused by alcoholism or drugs such as isoniazid.
Pt with signs of ischemia (parasthesia, change in temperature, and non-detectable radial arterial pulsations) BUT NORMAL neuro exam is suspicious for?
embolus of the upper extremity arterial bed, specifically the radial artery. Immediate anticoagulation with heparin and surgical intervention (i.e. embolectomy) are crucial bc can lead to tissue death and amputation if not effectively treated in hours.
Diagnostic study of choice in multiple sclerosis?
MRI which shows white matter dz
Reliable screening test for hemochromatosis?
Percent transferrin saturation (greater than 45%) and serum ferritin level (greater than 1000 microg/L).
Complications of hemachromatosis?
chronic liver disease or cirrhosis, hepatocellular carcinoma, diabetes, pancreatic insufficiency, skin pigmentation
First step in management of acute pyelonephritis?
Blood and urine cultures FIRST, followed by IV antibiotics.
When does acute pyelonephritis become complicated?
progression to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis. Typically occurs in pts with DM, kidney stones, or other urologic abnormalities.
When is CT or ultrasound indicated in the mgmt of acute pyelo?
if fever or clinical symptoms persist after 48-72 hours of appropriate antimicrobial therapy to r/o obstruction, abscess, or other complications.
what is allergic conjunctivitis?
an acute hypersensitivity reaction caused by environmental exposure to allergens. Characterized by intense itching, hyperemia, tearing, conjunctival edema, and eyelid edema but NO vision disturbances. Usually a positive family or personal history of asthma, seasonal rhinitis, atopic dermatitis, food allergies, or urticaria. Condition usually subsides wi 24 hours even wo treatment. Topical antihistamines, artificial tears, and cool compresses can help.
What is atopic keratoconjunctivitis?
SEVERE form of ocular allergy with itching, tearing, THICK mucus d/c, photophobia, and blurred vision.
What is blepharitis?
chronic inflammatory condition involving lid margins bilaterally. Crusty d/c is seen clinging to lashes in ANTERIOR blepharitis whereas hyperemic lid margins with telangiectasias are seen in POSTERIOR blepharitis.
What is dacrocystitis?
infection of the lacrimal sac due to obstruction of the nasolacrimal duct. It is characterized by pain, swelling, tenderness, and redness in the tear sac area. Mucous or pus can be expressed.
Classic presentation of Guillain-Barre syndrome?
ascending paralysis, areflexia and sensory changes 3-4 wks after a URI or gastroenteritis, PLUS albumino-cytologic dissociation (elevated protein despite normal cell count). Also can have cranial nerve paralysis and autonomic dysfunction.
Tx for Guillan-Barre syndrome?
IV immunoglobulin and plasmapheresis.
Major signs/sx for Waldenstrom’s macroglobulinemia:
1) increased size of the spleen, liver, and some lymph nodes
Diagnostic clues for Waldenstrom’s macroglobulinemia?
an IgM spike on electrophoresis which causes hyperviscosity of the blood (seen for example by retinal vein engorgement).
Management of newly diagnosed iron deficiency anemia in an elderly pt?
Secondary to chronic GI blood loss until proven otherwise. Colonoscopy should be next step in mgmt. A single negative occult blood test does not exclude the possiblity of GI bleeding.
Clinical features of interstitial nephritis?
fever, rash, and arthralgias. May be accompanied by peripheral eosinophilia, hematuria, sterile pyuria, eosinophiluria, and urine WBC casts.
What drugs provide a survival benefit in CHF pts?
ACE-I, ARBs, beta-blockers, and spironolactones.
Warfarin inhibits?
synthesis of Vit K dependent factors II, VII, IX, X, protein C and protein S.
Antibiotic choice for prophylaxis/treatment of infections caused by human or dog bites?
Amoxicillin-clavulanate (covers polymicrobial infections)
Main mechanism of kidney damage in SLE?
immune-complex mediated which activates complement leading to low serum C3.
Mechanism of kidney damage in post-strep glomerulonephritis?
immune-complex mediated which activates complement leading to low serum C3.
Management of spontaneous subconjunctival hemorrhage?
A benign finding that requires no treatment. Minor bruising that may be due to simple trauma from rubbing eyes, violent coughing spells, or hypertensive episodes. Usually disppears in 24-28 hours.
Role of dihydropyridine calcium channel blockers (such as nifedipine) in ACS pts?
contraindicated bc can worsen cardiac ischemia via peripheral vasodilation and reflex tachy.
Classic findings of erysipelas?
sharply demarcated, erythematous, edematous, tender skin lesion with raised borders. Legs are most frequently-involved site.
Population most at risk of developing SLE?
young, african-american women aged 20-40 years.
common SLE s/sx?
fatigue, painLESS oral ulcers, non-deforming arthritis (commonly affecting MCP/PIP hand joints) in 90%, low grade fever, weight loss, malar or discoid rash, hematologic abnormalities (thrombocytopenia and leukopenia), serositis, and proteinuria.
What pathological mechanism underlies exophthalmos of Graves disease?
1) sympathetic nervous system mediated lid retraction.
First step in management of a diabetic ulcer?
Proper wound care and debridement followed by antibiotics.
Most common nephropathy associated with carcinoma?
Membranous nephropathy; however, minimal change disease is a well-known complication of Hodgkin’s lymphoma.
Acanthosis nigricans is associated with?
1) insulin resistant states such as DM, acromegaly, obesity, and others
Reversible risk factors for premature atrial contractions?
tobacco and alcohol. beta-blockers are often helpful in pts who are symptomatic
Suspect what if there are signs of hypopituitarism plus headaches and bitemporal blindness?
craniopharyngiomas (benign suprasellar tumors).
Tremor that is somewhat suppressed at rest and exacerbated toward the end of a goal-directed movement?
essential tremor-first line tx is propranalol especially if the pt is hypertensive. Other possibilities include anticonvulsants such as primidone and topiramate.
