DIT notes / Step 3 Secrets Notes Flashcards by Tatyana Zinger

Syncope: what do you ALWAYS order?

ECG (then treadmill stress or echo if cardiogenic, EEG/CT /MRI if neurologic, etc)

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Patient started on a new medication and got first-dose orthostatic hypotension, which is likely?

alpha-1-antagonist, i.e. terazosin

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First thing you order for management in shock + what 3 things should you reassess after you give it?

IV fluid BOLUS (10/20mL/kg)

1) Blood pressure
2) Urine output (preferably after inserting Foley catheter)
3) Lungs (listen for crackles in case you caused CHF)

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If fluids fail to increase BP in septic and cardiogenic shock, what should you give next?

IV norepinephrine

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If fluids fail to increase BP in hemorrhagic shock, what should you give next?

Blood transfusions, source control

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Besides IV access, what other “tubes” should you be considering in a shock case?

Central venous catheter (for pressors!) or swan-ganz catheter

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What 4 unique elements of management should you consider for anaphylactic shock as opposed to other shock?

1) administer O2 / intubation / trach/ cricothyroidotomy if laryngeal edema
2) epinephrine
3) corticosteroids
4) monitor for at least 6 hours after initial reaction

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What is dopamine used for in acute setting?

Symptomatic bradycardia or cardiogenic shock from HF

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First line medications for hypertension treatment in general population, and in non-CKD blacks?

Gen: ACE/ARB/CCB/diuretic
Blacks: CCB/thiazide diuretic

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What populations do you avoid using CCBs in?

Heart failure, heart block, sick sinus syndrome

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What hypertension drugs are safe to use in pregnancy?

“Hypertensive Moms Love Nifedipine”:
Hydralazine
Methyldopa
Labetalol
Nifedipine

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Treatment for hypertensive emergency?

IV nitroprusside, labetalol, or nicardipine

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How is renal artery stenosis diagnosed and treated?

Dx: MRI or angiography
Tx: Balloon angioplasty

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Screening test for patient with secondary hypertension for cause as 1) Cushing syndrome 2) conn syndrome

1) 24 hour urine for free cortisol OR dexamethasone suppression test
2) plasma aldosterone : renin

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5 tests that should be ordered in every patient with HTN

1) ECG
2) H&H
3) BMP
4) lipid panel
5) urinalysis

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What two BP meds cause hypercholesterolemia?

Thiazides

Beta blockers

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Treatment for achalasia

Pneumatic dilation or botulism toxic administration

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Treatment for nutcracker esophagus / esophageal spasm, first and second line?

1st: CCBs

2nd line: Myotomy

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What are the timing-critical treatments to consider for patients being admitted for STEMI?

PCI (balloon angioplasty/stent) within 2 hours;

if not possible, do fibrinolytics (tPa) within 12 hours

ACS medication to avoid in 1) right sided MI and 2) inferior MIs

1) beta blockers

2) Nitroglycerin (bc RV, hypotension)

Treatment for prinzmetal angina

CCBs and nitroglycerin

Dx and treatment of chronic mesenteric ischemia?

Definitive dx: selective angiography of SMA

Tx: surgical revascularization

Outpatient treatment of chronic CHF(5)?

1) Sodium restriction
2) ACE-I
3) BB
4) diuretics (furosemide, spironolactone, etc)
5) Vasodilators
+/- digoxin if severe systolic HF/ decreased EF

Treatment of cor pulmonale(5)?

1) parenteral epoprostenol
2) bosentant
3) PDE5 inhibitor
4) CCB
5) heart-lung transplant

What degree heart block do you treat and how?

Second degree Mobitz type I: atropine or pacemaker only if symptomatic Second degree Mobitz type II and third degree: pacemaker

Treatment for WPW with a fib/tachy + eventual

Procainamide or quinidine | Eventual: radiofrequency catheter ablation of pathway

How do you treat v tach differently when patient is stable vs unstable, considering pulse is present in both?

Stable v tach: procainamide, amiodarone, or synchronized CV | Unstable v tach: synchronized CV

What size of AAA to do serial ultrasound vs management, and what is the management

<5 cm: serial U/S >5 cm, symptomatic, or rapidly enlarging: decrease HR with esmolol, decrease BP with nitroprusside or nicardipine, and then surgical correction Pulsatile AAA + hypotension: emergent laparotomy (bc ruptured)

What heart murmur radiates to axilla and what radiates to carotid?

Axilla: mitral regurgitation Carotid: aortic stenosis

Antibiotic prophylaxis used for dental procedures (patients with prosthetic valve/IE he/congenital heart dz)?

Amoxicillin (cephalexin or clinda if PCN allergy)

Empiric treatment for native valve endocarditis? | For prosthetic valve endocarditis?

NATIVE: Cephalosporin or PCN (oxacillin for MSSA, or vanco for MRSA) + aminoglycoside (gentamicin) PROSTHETIC: vanco + gentamicin + cefepime or carbapenem

Criteria for rheumatic fever?

``` JONES:(2 of 5) Joints: migratory poly arthritis O- heart - carditis Nodules, subQ Erythema marginatum Sydenham chorea ``` Or minor: prolonged PR , ESR, WBC, ETC

Definitive treatment for thoracic outlet syndrome?

Surgical ie cervical rib resection

Treatment for Leriche syndrome?

(Claudication in butt, butt atrophy, impotence in men) | Aortoiliac bypass graft

Management of claudication?

1) Conservative bc it is “angina of the extremities”: exercise, smoking cessation, cholesterol/BP/glucose control 2) aspirin > clopidogrel 3) cilostazol

DVT Ppx for low, medium, and high risk patients , and patients with high bleed risk

Low: early ambulation Medium: LMW heparin, low dose unfractionated heparin, or fondaparinux High: “,”, or oral vitamin K antagonist High risk of bleeding: pneumatic compression stockings

Treatment for superficial thrombophlebitis

NSAIDs, warm compresses, thrombectomy if nonresolving

Difference between restrictive cardiomyopathy and constrictive pericarditis?

Restrictive CM: ventricular biopsy ABNORMAL constrictive pericarditis: ventricular biopsy NORMAL

Treatment of HOCM

``` Beta blockers or disopyramide Avoid competitive sports AVOID inotropes (digoxin, diuretics, vasodilators) ```

Treatment of cardiac camponade

If stable: first confirm dx with echo | If unstable: pericardiocentesis

Thing to remember electrolyte changes with diuretic drugs

LOOPS LOSE Ca+2 Thiazides Keep Ca+2 (and glucose, lipids, Uric acid), lose Na+ Potassium sparing diuretics (spironolactone), bc of their name, are the only diuretics which KEEP K+

Anesthesia to give during labor?

Epidural (NOT spinal - this is different!)

Pre-eclampsia and eclampsia lead to what two fetal issues to remember?

IUGR, uteroplacental insufficiency

How is hemolytic disease of the newborn monitored and treated

1) Amniotic fluid spectrophotometry 2) Ultrasound 3) delivery if mature, with lecithin-to-sphingomyelin ratio 4) intrauterine transfusion 5) phenobarbital

How frequently should b-HCG increase in first trimester?

double every 2 days (if slower/stays same, may be threatened abortion/ectopic preg; if faster, may be mole/chorio)

when to give RhoGAM?

if mom Rh- and dad Rh+: 1) at 28 wks 3) after (~72 h) delivery OR after anything that causes transplacental bleeding: abortion, stillbirth, ectopic pregnancy, amniocentesis, CVS

What disorders are associated with prolonged gestation?

1) Anencephaly | 2) Placental sulfatase deficiency