deck 33 Flashcards
pathophys of AVMs in the lungs
Shunt blood from the right to the left side of the heart, causing chronic hypoxemia and reactive polycythemia OR can present as massive or sometimes fatal hemoptysis
treatment of homocystinuria
B6 (lowers homocysteine by acting as a cofactor for enzyme cystathionione beta-synthase, which metabolizes homocysteine into cystathionine)
other features of opioid intoxication
- AMS + hypothermia (opioids can impair thermogenesis) + miosis (which may be absent due to co-ingestions)
distillation of alcohol think
lead poisoning
labs with vitamin K deficiency
prolonged PT + PTT
management of symptomatic 3rd degree AV block
temporary pacemaker insertion
viral conjunctivitis treatment
1) warm or cold compresses
2) +/- antihistamine/decongestant drops
dual anti platelet therapy is…
aspirin + P2y12 receptor blocker (clopidogrel, prasugrel, ticagrelor)
STEMI in patient who recently had drug-eluting stent placed think…
- subacute stent thrombosis from medication noncompliance
- premature discontinuation of anti platelet therapy is the strongest predictor of stent thrombosis within the first 12 months
initial workup of HTN
UA (for occult hematuria and protein/creatinine ratio) + chem panel + lipid profile (risk stratification for CAD) + baseline ECG (to evaluate for CAD or LVH)
early finding in macular degeneration
Distortion of straight lines such that they appear wavy (use grid test to determine)
primary RFs for mac degeneration
Increasing age + smoking
presentation of macular degeneration
progressive and bilateral loss of central vision
PEA or systole management
- Uninterrupted CPR + vasopressors to maintain adequate cerebral and coronary perfusion
- no role for defibrillation or synchronized cardioversion
pulseless electrical cavity (PEA)
Presence of an organized rhythm on cardiac monitoring without a measurable BP or palpable pulse
cardioversion
delivers energy synchronized to the QRS complex
defibrillation
delivers energy randomly during the cardiac cycle without synchronization to the QRS complex
shockable rhythms
1) v fib
2) pulsess v tach
Exam findings suggestive of severe AS
1) diminish and delayed carotid pulse (“pulses parvus and tardus”) due to blood flow obstruction
2) mid to late-peaking systolic murmur from turbulence due to stenosis
3) presence of soft and single second heart sound (thickening and calcification of aortic leaflets leads to reduced mobility and causes a soft S2, as S2 is due mainly to sudden aortic valve closure)
presentation of spontaneous bacterial peritonitis
febrile + diffuse abdominal pain + AMS + hypotension + hypothermia (cirrhotics are often relatively hypothermic)
how to determine etiology of ascites
calculate serum-to-ascites albumin gradient (greater than 1.1 indicates portal hypertensive etiologies)
first question in evaluation of rectal bleeding
ask if low or large volume
minimal rectal bleeding causes
usually due to hemorrhoids or other benign conditions
minimal rectal bleeding evaluation
- if young (under 40) and no other CRC RF’s –> anoscopy (for hemorrhoids)
- if older than 50, then colonoscopy
general manifestations of hyperthyroidism
anxiety and insomnia palpitations heat intolerance increased perspiration weight loss without decreased appetite goiter
important cause of proximal muscle weakness with atrophy to think about
chronic hyperthyroid myopathy
cause of zenker diverticulum
sphincter dysfunction + esophageal dysmotility
evaluation of subclinical hypothyroidism
antithyroid peroxidase antibodies (patients with hashimoto’s can have subclinical hypothyroidism preceding overt hypothyroidism)
other impt cause of recurrent miscarriage
Hashimotos
most common presentation of primary hyperparathyroidism
asymptomatic hypercalcemia with elevated parathyroid hormone level
initial step in evaluation of cushing syndrome
Confirm hypercortisolism with a late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone test. If confirmed, then differentiate ACTH-dependent from ACTH-independent causes.
first step in evaluation of hypogonadism
1) determine if primary or secondary (if primary, LH/FSH should be elevated)
evaluation of secondary hypogonadism
- Measure serum prolactin + screen for other pituitary hormone deficiencies
causes of secondary hypogonadism
mass lesion in hypothalamus or pituitary, hyperprolactinemia, long-term use of glucocorticoids or opiates, severe systemic illness
prolactin relevance to hypogonadism
high prolactin can suppress testosterone production
euthyroid sick syndrome labs
fall in total and free T3 with normal T4 and TSH levels
irritant contact dermatitis of hand presentation
pruritus, erythema, vesicles, hyperkeratosis and fissuring of skin
DASH diet
diet high in fruits and vegetables and low in saturated fat and total fat
lifestyle modification with greatest efficacy
DASH diet then exercise then dietary sodium then alcohol
other promotility agent
erythromycin
diabetes drug category that induces weight loss
GLP-1 agonists (eg eventide, liraglutide)
aortic regurgitation presentation
exertional dyspnea + pounding heart sensation + widened pulse pressure
chronic aortic regurg pathophys
- portion of LV output leaks back into the LV, causing an increase in LV end-diastolic volume, myocardial hypertrophy, and chamber enlargement
- this increase in LV size brings the apex close to the chest wall, causing a pounding sensation and uncomfortable awareness of heartbeat, especially in the left lateral decubitus position.
chest pain with aortic stenosis
aortic outflow obstruction from supravalvular aortic stenosis can lead to LVH and exertional angina due to subendorcadial ischemia with increased myocardial oxygen demand during exercise
peri-infection pericarditis presentation
pleuritic chest pain + pericardial friction rub + diffuse ST-segmeent elevations on ECG less than 4 days following MI
renovascular HTN setting
1) resistant, severe HTN + diffuse atherosclerosis
2) also suspect if asymmetric kidney size, recurrent flash pulmonary edema or elevation in serum creatinine after starting ACE or ARB
clinical features of primary aldosteronism
1) easily provoked hypokalemia
2) slight hypernatremia
3) HTN w/ adrenal incidentaloma
important confounder of serum calcium
albumin (hypoalbuminemia)
ambulatory blood pressure monitoring (ABPM)
- pt wears BP cuff throughout a 24-hour period and BP is measured and recorded at routine intervals.
- used for masked HTN
masked HTN
- normal BP readings in clinic but elevated average BP throughout the day. Suggested by signs of hypertensive end-organ damage
signs of HTN end-organ damage
1) retinal arteriovenous nicking consistent with HTN retinopathy
2) increased QRS-complex voltage consistent with LV hypertrophy
signs of RV failure
1) elevated JVP
2) RV 3rd heart sound
3) tricuspid regurgitation murmur
4) hepatomegaly with pulsatile liver
5) lower-extremity edema + ascites + pleural effusions
right heart catheterization with cor pulmonale
elevated pulmonary systolic pressure
feature of edema that suggests nephrotic syndrome
periorbital/facial edema and pedal edema
when is wedge pressure elevated?
LV systolic or diastolic dysfunction
major COPD heart sequela
cor pulmonale
