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CLINICAL YR: Emergency Med EOR Exam_JD > EM EOR Topic List_Cardio_Pulm > Flashcards

EM EOR Topic List_Cardio_Pulm Flashcards

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1
Q

CXR findings indicative of acute bronchitis

A

thickening of bronchial walls in lower lobes

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2
Q

auscultation findings of acute bronchitis

A

wheezing and rhonchi

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3
Q

acute bronchitis patients complain of productive cough for _________

A

greater than 5 days

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4
Q

what is the treatment regimen for acute bronchitis?

A

symptomatic management

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5
Q

S/S of acute PE (six)

A

dyspnea, cough, pleuritic chest pain, tachypnea, tachycardia, JVD, decreased breath sounds

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6
Q

> = 5 mm induration to PPD skin test is considered POSITIVE for TB for the following people:

A

HIV positive
organ transplant
recent contact w/ TB pt
nodular/fibrotic changes on CXR

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7
Q

> = 10 mm induration to PPD skin test is considered POSITIVE for TB for the following people:

A

recent arrivals (< 5 yrs) from high-prevalence countries
IV drug users
resident/employee of high-risk congregate settings
children < 4 yrs

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8
Q

> = 15 mm induration to PPD skin test is considered POSITIVE for TB for the following people:

A

person with no known risk factors for TB

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9
Q

define ACUTE BACTERIAL ENDOCARDITIS and name MC organism

A

infection of normal valves with a virulent organism

S. aureus

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10
Q

define SUBACUTE BACTERIAL ENDOCARDITIS and name MC organism

A

indolent (causing little or no pain) infection of abnormal valves with less virulent organisms

S. viridans

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11
Q

what criteria are used to diagnose infective endocarditis and how does it work?

A

Duke’s Criteria

2 major or
1 major + 3 minor or
5 minor

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12
Q

list two main common clinical manifestations for infective endocarditis

A

persistent fever most common (part of generalized constitutional symptoms)

new onset of a murmur (or worsening of an existing murmur)

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13
Q

list five classic signs of infective endocarditis

A 
Osler's nodes
Janeway lesions
Roth spots (on retina)
splinter hemorrhages
clubbing
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14
Q

(SmartyPance)

what is the empiric treatment for infective endocarditis?

A

IV vanc

or

ampicillin/sulbactam PLUS aminoglycoside
(aminoglycosides include gentamicin, tobramycin)

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15
Q

(SmartyPance)

what arrhythmia is most commonly seen in patients with COPD? describe it

A

multifocal atrial tachycardia (MAT)

irregularly irregular w/ varying PR interval, various P wave morphologies (3 or more foci)

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16
Q

(SmartyPance)

define paroxysmal AFib

A

episodes of AF that terminate spontaneously w/in 7 days (most last <24 hrs)

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17
Q

(SmartyPance)

define persistent AF

A

episodes of AF that last more than 7 days and may require either pharm or electrical intervention to terminate

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18
Q

(SmartyPance)

define permanent AF

A

AF that has persisted for more than 1 yr, either because cardioversion has failed or not been attempted

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19
Q

(SmartyPance)

list some risk factors for AFib

A 
endocrine disorders
ETOH and drug use
advancing age
men more than women in all age groups
white persons more than black persons
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20
Q

(SmartyPance)

Most cases of AF are _____

A

asymptomatic (90%)

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21
Q

(SmartyPance)

two main characteristics of AFib

A

irregularly irregular

tachy (110-140 bpm)

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22
Q

(SmartyPance)
what are first line agents for rate control in
AF? what caution should be exercied?

A

beta blockers and CCB (can be IV or oral)

caution should be exercised in patients with REACTIVE AIRWAY DISEASE with beta blockers

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23
Q

(SmartyPance)

Open heart surgery may lead to what arrhythmia?

A

atrial flutter

atrial flutter may be a sequela of open heart surgery. After cardiac surgery, atrial flutter may be reentrant as a result of natural barriers, atrial incisions, and scar.

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24
Q

(SmartyPance)

what are typical symptoms of atrial flutter?

A

palpitations
presyncope
fatigue or poor exercise tolerance
mild dyspnea

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25
Q

(SmartyPance)

what is the main difference in treatment between atrial fibrillation and atrial flutter?

A

most cases of atrial flutter can be cured with RFA

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26
Q

(SmartyPance)

what is the most rapid way to lower the INR for a pt on warfarin who is vomiting blood?

A

fresh frozen plasma

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27
Q

(SmartyPance)

AFib definition/description

A

irregular heart rate that at high rate may cause
palpitations
fatigue
SOB

P waves are chaotic

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28
Q

(SmartyPance)

AFib - - what is happening to the heart when this occurs?

A

It occurs when upper chambers of heartbeat out of rhythm;

there are multiple atria foci

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29
Q

(SmartyPance)

what is atrial flutter? what does it look like on EKG?

A

atria w/ SINGLE foci

multiple P waves before QRS (sawtooth pattern)

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30
Q

(SmartyPance)

what is paroxysmal supreventricular tachycardia?

A

regular

fast (160-220 bpm) rate that begins and ends suddenly, originating in atria

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31
Q

(SmartyPance)

what is Beck’s triad? What condition does this term apply to?

A

THREE D’s
Distant heart sounds
Distended jugular veins
Decreased arterial pressure

this applies to cardiac tamponade

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32
Q

(SmartyPance)

one remarkable PE finding of AAA

A

pulsatile abdominal mass

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33
Q

(SmartyPance)

distinct presenting symptom of aortic dissection

A

sudden onset TEARING chest pain, BETWEEN SCAPULAS

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34
Q

(SmartyPance)

CXR widened mediastinum indicates

A

aortic dissection

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35
Q

(SmartyPance)

what are the P’s of arterial emboli?

A 
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia (inability to regulate core body temp)
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36
Q

(SmartyPance)

what are two most common causes of thrombus formation?

A

AFib

mitral stenosis

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37
Q

(SmartyPance)

what is gold standard for dx for arterial embolism/thrombosis?

A

angiography

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38
Q

(SmartyPance)

initial treatment of acute arterial occlusion

A

IV heparin

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39
Q

(SmartyPance)

what is second treatment move for acute arterial occlusion after IV heparin, if not limb-threatening?

A

call VASCULAR SURGEON for angioplasty, graft, or endarterectomy

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40
Q

(SmartyPance)

what kind of murmur is heard with aortic stenosis?

A

harsh systolic ejection
crescendo-decrescendo murmur

at RUSB

w/ radiation to neck and apex

best heard by leaning forward with EXPIRATION

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41
Q

(SmartyPance)
what does this mean:

harsh systolic ejection
crescendo-decrescendo murmur

at RUSB

w/ radiation to neck and apex

best heard by leaning forward with EXPIRATION

A

aortic stenosis

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42
Q

(SmartyPance)

what kind of murmur is heard with aortic regurgitation?

A

soft, early diastolic blowing murmur

along L sternal border

w/ patient sitting leaning forward after EXHALING

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43
Q

(SmartyPance)
what does this mean:

soft, early diastolic blowing murmur

along L sternal border

w/ patient sitting leaning forward after EXHALING

A

aortic regurgitation (aka diastolic murmur)

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44
Q

(SmartyPance)

what kind of murmur is heard with mitral stenosis?

A

diastolic decrescendo low pitched rumbling murmur

w/ opening snap best heard at apex (mitral area)

w/ pt in lateral decubitus position

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45
Q

(SmartyPance)
what does this mean:

diastolic low pitched decrescendo rumbling murmur

w/ opening snap best heard at apex (mitral area)

w/ pt in lateral decubitus position

A

mitral stenosis

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46
Q

(SmartyPance)

what kind of murmur is heard with mitral regurgitation?

A

holosystolic high-pitched blowing murmur

at apex (mitral area)

that radiates to axilla with a split S2

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47
Q

(SmartyPance)
what does this mean:

holosystolic high-pitched blowing murmur

at apex (mitral area)

that radiates to axilla with a split S2

A

mitral regurgitation

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48
Q

(PPP)

most common valve involved in infective endocarditis

A

mitral valve
(M>A>T>P)

IV DRUG USERS: tricuspid valve is most commonly infected, rather than mitral

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49
Q

(PPP)

whats the difference between acute and subacute bac endocarditis?

A

acute: normal valves, virulent organism (prob S. aureus)
subacute: abnormal valves, less virulent organism (prob S. viridans)

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50
Q

(PPP)

what happens if you suspect infective endocarditis and get back negative blood cultures?

A

test for HACEK organisms!

gram negative organisms that are hard to culture

Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
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51
Q

(PPP)

what are the clinical manifestations of infective endocarditis? (two big ones, and a group of four)

A 
PERSISTENT FEVER (MC)
NEW ONSET OF MURMUR (or worsening of existing murmur)

also -
Osler nodes, Janeway lesions, splinter hemorrhages, Rosh spots

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52
Q

(PPP)

four diagnostic studies for suspected infective endocarditis

A

EKG
echo (TEE vs TTE)
blood cultures (before abx given)
labs: CBC, ESR/rheumatoid factor

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53
Q

(PPP)

how is native valve infective endocarditis treated (empirically), and for how long?

A

anti-staph PENICILLIN + CEFTRIAXONE (or GENTAMICIN)

penicillin allergy? suspect MRSA? get out vanc instead of penicillin

treat for 4-6 weeks

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54
Q

(PPP)

two most common causes of LEFT-sided HF?

A

CAD

HTN

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55
Q

(PPP)
the most common cause of RIGHT-sided HF?

what are two others?

A

most common cause of R-sided failure is LEFT-sided failure!

also -
pulmonary disease (COPD, pulm HTN)
&
mitral stenosis

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56
Q

(PPP)

what is another name for systolic HF?

A

HFrEF

REDUCED ejection fraction

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57
Q

(PPP)

what is the more common form of HF?

A

systolic HF, aka HFrEF

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58
Q

(PPP)

what is another name for diastolic HF?

A

HFpEF

PRESERVED ejection fraction

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59
Q

(PPP)

what murmur finding is indicative of diastolic HF (aka HFpEF)?

A

S4

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60
Q

(PPP)

what murmur finding is indicative of systolic HF (aka HFrEF)?

A

S3

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61
Q

(PPP)

two key characteristics of pt presentation for HF?

A

exertional dyspnea (SOB) –> SOB with rest

orthopnea (late sign)

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62
Q

(PPP)

one key sign of either type of HF

A

edema

think of signs of fluid –> rales/crackles, edema, JVD, ascites

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63
Q

(PPP)

four characteristics of systolic heart failure (HFrEF)

A

decreased ejection fraction
thin ventricular walls
dilated LV chamber
S3

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64
Q

(PPP)

four characteristics of diastolic heart failure (HFpEF)

A

preserved ejection fraction
THICK ventricular walls
small LV chamber
S4

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65
Q

(PPP)

three tests for HF, whether regular or congestive

A

echo
CXR
BNP

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66
Q

(PPP)

what does echo tell us for the testing of HF?

A

ejection fraction, ventricular fxn

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67
Q

(PPP)

what do CXR and BNP tell us for testing of HF?

A

CXR - Kerly B lines, maybe bat wings, pulm edema appearance

BNP > 100 = CHF is likely

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68
Q

(PPP)

what is the most common cause of pleural effusions?

A

CHF (90% of all transudates)

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69
Q

(PPP)

what are the single most effective meds for mortality benefit in HFrEF?

A

ACE INHIBITORS

can add BBlockers

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70
Q

(PPP)

basics of long-term management of HF

A

ACEI & diuretic for symptoms

ACEI>beta blockers

beta blockers usually added after ACEI or ARB, if additional treatment needed

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71
Q

(PPP)

how do we treat SVT (or PSVT)? (four categories)

A

STABLE (narrow, regular): vagal maneuver, adenosine (first line med mgmt), CCB (Diltiazem), BBlockers (metoprolol), digoxin

STABLE (wide): antiarrhythmics (amiodarone), procainamide for WPW

UNSTABLE: cardiovert

DEFINITIVE: RFA

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72
Q

(PPP)

how does VTach present on EKG?

A

prolonged QT

regular, wide complex tach w/ no P waves

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73
Q

(PPP)

how do we treat VTach (four categories)?

A

STABLE: antiarrhythmics (amiodarone, lidocaine, procainamide)

UNSTABLE w/ PULSE: cardioversion (synchronized)

PULSELESS: defib/CPR

TORSADES: IV Mg+

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74
Q

(PPP)

best way to assess asthma exacerbation in acute asthma exacerbation

A

peak expiratory flow rate

can assess before and after treatment

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75
Q

(PPP)

what is the discharge criteria after treating an acute asthma exacerbation?

A

70% of peak expiratory flow rate (PEFR)

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76
Q

(PPP)

what are three short acting beta agonists used as first line trtmt for acute asthma exacerbation?

A

albuterol
terbutaline
epinephrine

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77
Q

(PPP)

what is an anticholinergic (antimuscarinic) used for relief of acute asthma exacerbation?

A

ipratropium

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78
Q

(PPP)

what are three corticosteroids used for relief of acute asthma exacerbation?

A

prednisone
methylprednisolone
prednisolone

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79
Q

(PPP)

How is acute bronchiolitis diagnosed?

A

clinically -

RSV causes it

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80
Q

(PPP)

how is acute bronchilitis treated?

A

supportive measures

  • humidified O2
  • IV fluid
  • antipyretics
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81
Q

(PPP)

how is pleural effusion diagnosed?

A

CXR (initial test of choice)

  • blunting of costophrenic angles (meniscus sign)
  • lat decubitus films are best

Diagnostic gold std = THORACENTESIS
(Light’s Criteria)

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82
Q

(PPP)

how is pleural effusion managed?

A

TREAT UNDERLYING DISEASE

thoracentesis (don’t remove >1.5L)
chest tube fluid drain if empyema
pleurodesis

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83
Q

(PPP)

how is acute bronchitis diagnosed?

A

clinically -

  • > 5 days cough
  • may have hemoptysis
  • may have wheezing and ronchi

may get CXR

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84
Q

(PPP)

how is acute bronchitis managed?

A 
symptomatically
 -  fluids
 - antitussives
 - antipyretics 
 - analgesics
(don't need abx)
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85
Q

(PPP)

how is acute epiglottitis diagnosed?

A

definitive diagnosis = LARYNGOSCOPY

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86
Q

(PPP)

buzz words for CXR sign for acute epiglottitis

A

THUMB OR THUMBPRINT sign

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87
Q

(PPP)

how is acute epiglotitis treated?

A

PROTECT THE AIRWAY
(OR –> intubation)

dexamethasone for airway edema

ABX –> ceftriaxone or cefotaxime
may add penicillin, ampicillin, or anti-staph Vanc

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88
Q

(PPP)

what is important to take care of with acute epiglottitis patients?

A

treat the family/close contacts with Rifampin

get everybody Hib vaccinated

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89
Q

(SmartyPance)

how is viral pneumonia diagnosed?

A

CXR –> bilteral interstitial infiltrates

rapid antigen testing swab

cold agglutinin titer negative

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90
Q

(SmartyPance)

how is viral pneumonia treated?

A

if influenza is origin, and symptoms <48 hrs, treat w/ oseltaimvir (Tamiflu)

treat symptoms w/ beta 2 agonists (albuterol), fluids, rest

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91
Q

(SmartyPance)

how is bacterial pneumonia diagnosed?

A

CXR –> patchy, segmental lobar, multilobar consolidation

blood cultures x2

sputum gram stain

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92
Q

(SmartyPance)

how is bacterial pneumonia treated?

A

OP:
doxy
macrolides (clarithromycin, azithromycin)

IP:
ceftriaxone + azithromycin/resp FQs (levofloxacin, moxifloxacin, gemifloxacin)

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93
Q

(SmartyPance)

how is PJP diagnosed? (five items)

A

CXR –> diffuse interstitial or bilteral perihilar infiltrates

Broncheoalveolar lavage PCR

Labs (increased LDH)

HIV test

Low O2 despite supplemental O2

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94
Q

(SmartyPance, PPP)

how is PJP treated?

A

TMP-SMX (Bactrim) x 21 days

if HIV positive, add prednisone

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95
Q

(PPP)

how is ARDS diagnosed?

A

three components:

1) severe hypoxemia refractory to O2
2) CXR: bilteral diffuse pulm infiltrates
3) absence of cardiogenic pulm edema (CHF)

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96
Q

(PPP)

how is ARDS treated?

A

VENTILATION: mechanical or noninvasive

TREAT UNDERLYING CAUSE

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97
Q

(PPP)

talk about CXR for ARDs

A

bilateral diffuse pulmonary infiltrates

similar to CHF, BUT,
ARDS classically spares the costophrenic angles

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98
Q

(PPP)

how is pneumothorax diagnosed?

A

CXR
- expiratory upright view

  • ->decreased peripheral markings (i.e. collapsed lung tissue)
  • ->companion lines
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99
Q

(PPP)

how is pneumothorax managed (size, severity)?

A

small - observation + supplemental O2

large - needle or catheter aspiration or chest tube or catheter thoracostomy

stable - chest tube or catheter thoracostmy + admit

tension - needle aspiration followed by chest tube thoracostomy

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100
Q

(PPP)

how is asthma diagnosed (ER)?

A

peak expiratory flow rate

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101
Q

(PPP)

how is asthma treated (“rescued”)?

A 
beta 2 agonists, short acting 
 - albuterol, terbutaline, epi
anticholinergics
 - ipratropium
corticodsteroids
 - prednisone, metylprednisolone, prednisolone
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102
Q

(PPP)

what is most common cause of croup?

A

parainfluenza virus type I

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103
Q

(PPP)

how is croup diagnosed?

A

clinically (once epiglottitis and FBO are r/o)

could do a CXR and look for STEEPLE SIGN (rarely done)

104
Q

(PPP)

how is croup managed?

A

mild? supportive care. Dexamethasone provides significant relief

moderate? dexamethasone PO or IM + supportive treatment. nebulized epi

severe? dexamethasone + nebulized epi + admit

105
Q

(PPP)

how are pulmonary emboli diagnosed?

A

CT ANGIOGRAPHY (best initial test to confirm presence of PE)

tachypnea (MC sign)
sudden onset of triad: dyspnea (MC), pleuritic chest pain, hemoptysis/cough

106
Q

(PPP)

how are pulmonary emboli treated?

A

STABLE:
anticoagulation (1st line therapy)
- heparin bridge + coumadin or a NOAC (Dabigatran, Apixaban, Rivaroxaban, Edocaban)

IVC filter

UNSTABLE
thrombolysis
thrombectomy or embolectomy

107
Q

(PPP)

what is most definitive diagnostic test for FBO aspiration?

A

rigid bronchoscopy

you may try CXR or CT chest

108
Q

(PPP)

how do you treat/fix FBO aspiration?

A

get out the object

removal of foreign object via rigid bronchoscopy

109
Q

(SmartyPance)

how do you diagnose respiratory syncytial virus?

A

diagnosed with NASAL WASHING,
RSV antigen test

CXR can show diffuse infiltrates

110
Q

(SmartyPance)

how is RSV treated?

A

supportive measures include albuterol via neb, antipyretics, humidifed O2, wait 5-7 days

if tachypneic w/ feeding difficulties, visible retractions, or O2 desat <95% –> admit

111
Q

(SmartyPance)

what are the three most common causes of hemoptysis?

A

bronchitis (50%)

tumor mass (20%)

TB (8%)

112
Q

(SmartyPance)

what do we do to diagnose a pt who presents with hemoptysis?

A

examine the expectorate

cytology (lung cancer?)

fiberoptic bronchoscopy for CA

rigid bronchoscopy for massive bleeding cases

high-res CT

113
Q

(SmartyPance)

what do you do with a pt who presents with hemoptysis, esp massive hemoptysis?

A

massive? get aggressive, consult pulmonologist early

protect airway!!

114
Q

(PPP)

how is flu diagnosed?

A

rapid influenza nasal swab

or

viral culture

115
Q

(PPP)

how is flu treated?

A

mild? supportive, rest, acetaminophen or salicylates

high risk pts? antivirals (oseltamivir w/in 48 hrs of symptom onset)

116
Q

(SmartyPance)

how is small cell lung cancer diagnosed?

A

?? incidental finding of nodules on CXR??

then biopsy…

117
Q

(SmartyPance)

how is small cell lung cancer treated?

A

SCLC accounts for 15% of cases, 99% smokers.

very aggressive, doesn’t respond to surgery, these pts get chemo

118
Q

(SmartyPance)

how is NON-small cell lung cancer diagnosed?

A

?? incidental finding of pulm nodules on CXR??

…then biopsy…?

119
Q

(SmartyPance)

how is NON-small cell lung cancer treated?

A

NSCLC = 85% of cases

stages 1-2 –> surgery
stage 3 –> chemo, then surgery
stage 4 –> palliative care

120
Q

(PPP)

what infectious pathogen causes whooping cough?

A

aka pertussis

Bordatella pertussis
a gram negative coccobacillus

121
Q

(PPP)

how do we diagnose pertussis (whooping cough)?

A

clinically -
-but-
order both throat culture and PCR

lymphocytosis common

122
Q

(PPP)

how do we treat pertussis (whooping cough)?

A

supportive treatment

  • O2
  • nebulizers
  • mechanical vent as needed

abx to decrease contagiousness
- macrolides (azithromycin, erythromycin)

123
Q

(PPP)

how is tuberculosis diagnosed?

A

CXR (often initial test)

  • reactivation –> apical fibrocavitary disease MC
  • primary –> middle/lower lobe consolidation
  • miliary –> 2-4 mm millet-seed-like nodular lesions
124
Q

(PPP)

how is tuberculosis treated?

A

RIPE = Rifampin, Isoniazid, Pyrazinamide, Ethambutol

RIPE for 2 months
RI for 4 months after that

125
Q

(PPP)

what is the treatment of cardiac tamponade?

A

immediate PERIDCARDIOCENTESIS to remove the pressure

volume resuscitation and pressor support if needed

126
Q

what is the primary cause of ARDS?

A

sepsis

from the “mid-term exam”

127
Q

(RR)

what is the first line vasopressor or inotropic agent of choice for cardiogenic shock?

A

NOREPINEPHRINE

although norepi acts primarily on the vasculature to increase vascular tone, it is still the first recommended agent for cardiogenic shock

128
Q

(RR)

most common valve affected by IV drug use in terms of infectious endocarditis

A 
tricuspid valve
(it's the first valve the pathogens meet after they are introduced via nonsterile injection techniques)
129
Q

(RR)

how does acid-base physiology present for COPD exacerbation?

A

ACUTE-ON-CHRONIC HYPERCAPNIA

ACUTE RISE IN PaCO2 ON TOP OF A CHRONIC RESPIRATORY ACIDOSIS WITH METABOLIC COMPENSATION

130
Q

(RR)

in pure chronic hypercapnia, what happens to the pH, bicarb, PaCO2?

A

pH will be only slightly acidic (often falling in normal range due to compensation)

THE BICARB WILL INCREASE BY 1 FOR EACH 10 MM Hg OF PaCO2

131
Q

(RR)

two features of acute respiratory failure in terms of respiratory acidosis

A 
PaCO2 is elevated (>45 mmHg)
accompanying acidemia (pH < 7.35)
132
Q

(RR) Respiratory Acidosis

what are three features of chronic resp acidosis (such as COPD or obesity hypoventilation syndrome)?

A

1 - PaCO2 is elevatd (>45 mm Hg)
2 - normal or near-normal pH (pH ~ 7.4, renal compensation)
3 - elevated serum bicarb (>30 mEq/L)

133
Q

(RR) Resp Acidosis

what are two physiologic compensations for resp acidosis?

A

1 - CELLULAR BUFFERING
(occurs over minutes to hours, 1mEq/L for each 10 mm Hg increase in PaCO2)

2 - RENAL COMPENSATION
(occurs over 3-5 days, 3-5 mEq/L for each 10 mmHg increase in PaCO2, excretion of carbonic acid, bicarb reabsorption)

134
Q

(RR)

what does the FROM JANE acronym stand for, in terms of infectious endocarditis?

A

Fever
Roth spots (in the eye)
Osler nodes (hands)
Murmur

JANEway lesions
Anemia
Nail bed hemorrhage
Emboli

135
Q

(RR)

how is the diagnosis made for a patient presenting with aortic dissection symptoms?

A

CT ANGIOGRAPHY OF AORTA IS PREFERRED IMAGING MODALITY

diagnosis is made via imaging studies, CT angiography is the preferred modality

136
Q

(RR)

what is the treatment for proximal aortic dissections?

A

medical and surgical management:
AGGRESSIVE BLOOD PRESSURE CONTROL with BB such as ESMOLOL

(if bp is not controlled, then add vasodilators such as nicardipine or NITROPRUSSIDE)

137
Q

(RR)
“why is lowering the heart rate, not only the blood pressure, also an important step in the management of aortic dissection?”

A

“lowering the heart rate in aortic dissection decreases the potential propagation of the dissection flap by decreasing the shearing forces”

138
Q 
(RR)
a pt is found to have a low pitched rumbling diastolic apical murmur.  Which of the following is the most frequent presenting complaint associated with this murmur?
a) chest pain
b) dyspnea with exertion
c) hemoptysis
d) palpitations
A

B) DYSPNEA WITH EXERTION

139
Q

(RR)

Mitral stenosis is characterized by what?

A 
LEFT VENTRICULAR INFLOW OBSTRUCTION
resulting in
LOW PITCHED
RUMBLING
DIASTOLIC
APICAL MURMUR
140
Q

(RR)

what is the most common cause of mitral stenosis worldwide?

A

rheumatic heart disease

141
Q

(RR)

what is the most common presenting complaint for mitral stenosis, found in up to 70% of patients?

A

DYSPNEA WITH EXERTION

142
Q

(RR)

“How does mitral stenosis result in hoarseness?”

A

“Left atrial enlargement can cause compression of the recurrent laryngeal nerve resulting in hoarseness.”

143
Q

(RR)

What does mitral stenosis sound like upon auscultation?

A

LOUD S1 (although intensity diminishes as disease progresses)

OPENING SNAP

LOW-PITCHED

RUMBLING DIASTOLIC APICAL

murmur

144
Q 
(RR)
LOUD S1 (although intensity diminishes as disease progresses) OPENING SNAP LOW-PITCHED RUMBLING DIASTOLIC APICAL murmur
A

MITRAL STENOSIS

145
Q

(RR)

how do you distinguish tricuspid regurgitation from mitral regurgitation?

A

by the Carvallo Sign - a pansystolic murmur becomes LOUDER DURING INSPIRATION

this feature makes it tricuspid regurgitation

146
Q

(RR)

what is a common cause of tricuspid regurgitation?

A 
FUNCTIONAL OVERLOAD (such as pulmonary hypertension, RV dilation), or
STRUCTURAL LEAFLET ABNORMALITIES (endocarditis, Ebstein anomaly)
147
Q

(RR)

what valve is most often effected by IV drug use?

A

TRICUSPID REGURGITATION

“Tricuspid regurgitation can result from seeding of the tricuspid valve w/ bac as seen in endocarditis, creating vegetations that render the valve leaflets incompetent. This is usually due to intravenous drug use…”

148
Q

(RR)

“what is the most common cause of right heart failure?”

A

“left heart failure”

149
Q

(RR)

what are physical exam findings for tricuspid regurgitation?

A

JVD

BLOWING HOLOSYSTOLIC MURMUR best heard at the LEFT STERNAL BORDER that becomes LOUDER WITH INSPIRATION

150
Q

(RR)

what is the one most common cause for tricuspid regurgitation?

A

RV DILATION

“most commonly caused by RV dilation”

151
Q

(RR)

what are three physical exam findings that suggest CHF?

A

PRESENCE OF A THIRD HEART SOUND OR S3 GALLOP

HEPATOJUGULAR REFLUX

JUGULAR VENOUS DISTENTION

152
Q

(RR) BUZZWORDS

S3 gallop

A

CHF

“Jugular venous distention is seen in congestive heart failure, but has a lower likelihood ratio than an S3 gallop.”

153
Q 
(RR)
"You are concerned with hearing a new diastolic, rumbling murmur in one of your pts.  This murmur is best heard with the bell of the left sternal border at the fourth intercostal space and is louder during inspiration.  Which of the following is the most likely diagnosis?
a) aortic regurgitation
b) aortic stenosis
c) tricuspid regurgitation
d) tricuspid stenosis"
A

D) TRICUSPID STENOSIS

154
Q

(RR)

how do you describe tricuspid stenosis sounds?

A

DIASTOLIC RUMBLE
LOUDER THAN MITRAL STENOSIS DURING INSPIRATION

(this is a rare murmur)

155
Q

(RR)

“Tricuspid stenosis rarely occurs……

A

…alone, and almost always occurs with mitral stenosis…”

156
Q

(RR)

“what is rheumatic heart disease (also known as rheumatic fever)?”

A

“An antibody-cross reactivity inflammatory disease which follows Streptococcus pyogenes infection and causes heart (myocarditis), joint, skin and brain inflammation, most commonly occurring in 6-15 year olds.”

157
Q 
(RR)
"In normal hearts, which of the following heart valves is composed of two cusps?
a) aortic
b) mitral
c) pulmonic
d) tricuspid"
A

B) MITRAL

158
Q

(RR)

“Third degree, or complete, heart block is characterized by….

A

…absent conduction of all atrial impulses and complete electrical AV dissociation.”

159
Q

(RR)

what are the hallmark findings of third degree AV heart block?

A

“REGULAR PP INTERVALS UNRELATED TO REGULAR R-R INTERVALS with P WAVES THAT APPEAR TO MARCH THROUGH THE QRS-T COMPLEXES.”

160
Q

(RR)

what is HBsAg? What does it tell us about hepatitis infection?

A

Hepatitis B surface Antigen

“When a patient has immunity due to vaccination, the HBsAg will be NEGATIVE since they are not acutely or chronically infection”

161
Q

(RR)

what is HBc? What does it indicate for hepatitis infection?

A

Hepatitis B core antibody

“The anti-HBc will be negative as they have not had a previous or an active infection”

162
Q

(RR)

what is HBs? What does it mean for hepatitis infection?

A

Hepatitis B surface antibody

“the anti HBs will be positive if a person was immunized against the virus by a vaccination”

163
Q

(RR)

What combination of hepatitis B serologic markers is indicative of hep B immunity secondary to vaccination?

A

HBsAg negative

anti-HBc negative

anti-HBs positive

164
Q

(RR)

“What does the HBeAg serologic marker for hepatitis B indicate?”

A

“Replication and infectivity. Its presence represents high levels of DNA in the serum and higher rates of transmission.”

165
Q

(RR)

“A first degree AV block is characterized by ___________

A

“a long PR interval (>200 ms)”

166
Q

(RR)

“A prolonged PR interval is a sign of _____

A

…A DELAYED CONDUCTION AT THE AV NODE BEFORE VENTRICULAR DEPOLARIZATION”

167
Q

(RR)

“What is the best management of first degree atrioventricular block?”

A

“No treatment is necessary”

168
Q

(RR)

for first degree heart block, what will the PR interval be?

A

> 0.20 s (200 msec)

169
Q

(RR)

Where is the aortic valve best appreciated?

A

THE RIGHT SECOND INTERCOSTAL SPACE JUST LATERAL TO THE STERNUM

170
Q

(SmartyPance)

“compare the timing of aortic valve murmurs”

A

AR MS –> diastolic murmurs
(Aortic Regurg Mitral Stenosis)

AS & MR –> systolic murmurs
(Aortic Stenosis Mitral Regurg)

171
Q

(RR)

what does aortic stenosis show on physical exam?

A

CRESCENDO-DECRESCENDO systolic murmur that
RADIATES TO THE CAROTIDS

PARADOXICALLY SPLIT S2, S4 GALLOP

172
Q

(RR)

“what is the most common sequela of mitral stenosis?”

A

“atrial fibrillation”

“increased atrial irritability and hypercoagulability associated with pregnancy combined with increased left atrial pressure, increase the risk of atrial fibrillation and left atrial thrombus formation”

173
Q

(RR)

what is a common historical finding of rheumatic fever?

A

GAS infection

174
Q

(RR)

“what ECG finding has the highest likelihood ratio for the diagnosis of heart failure?”

A

“ATRIAL FIBRILLATION”

175
Q

(RR)

acute decompensated heart failure - what is a key lab finding, i.e. what lab will be increased?

A

BNP will be increased

176
Q

(RR)

what is a type A aortic dissection?

A

it involves the ASCENDING AORTA

and it is a SURGICAL EMERGENCY

177
Q

(RR)

what is a Stanford Type B aortic dissection?

A

involves only DESCENDING AORTA

178
Q

(RR)

what are five components to managing aortic dissection?

A

1 - reduce bp to lowest tolerable level
2 - reduce HR <60bpm
3 - intravenous beta blockers (esmolol, labetalol, propanol)
4 - nitroprusside (only after HR s controlled)
5 - pain control

179
Q

(RR)

“Why is lowering the heart rate, not only the bp, also an important step in the management of aortic dissection?”

A

“lowering the heart rate in aortic dissection decreases the potential propagation of the dissection flap by decreasing the shearing forces.”

180
Q

(RR)

what does CXR show in an aortic dissection?

A

a widened mediastinum

181
Q

(RR)

what is the most common type of cardiomyopathy?

A

dilated cardiomyopathy

PE will show a S3 gallop

182
Q

(SmartyPance)

define angina

A

CHEST PAIN OR DISCOMFORT, heaviness, pressure, squeezing, tightness that is INCREASED WITH EXERTION OR EMOTION

183
Q

(SmartyPance)

define stable angina

A

PREDICTABLE

RELIEVED BY REST AND/OR NITRO

184
Q

(SmartyPance)

what is the treatment for stable angina?

A

BB
nitro

(if severe –> angioplasty and bypass)

185
Q

(SmartyPance)

what is the treatment for unstable angina?

A

pain control w/ nitro and morphine

IV access, O2

ASA, clopidogrel, BB (first line)
LMWH

(MONA –> morphine, oxygen, nitro, ASA)

admit to cardiac unit

186
Q

(SmartyPance)

what is Prinzmetal variant angina?

A

CORONARY ARTERY VASOSPASMS causing transient ST SEGMENT ELEVATIONS, NOT ASSOCIATED WITH A CLOT

187
Q

(PPP 53)

how do we treat Prinzmetal variant angina?

A

once dx is made,
CCB (1st line)
nitro (2nd line)

avoid BB

188
Q

(RR)
According to The Coronary Vasomotion Disorders International Study group, what are the three main criteria for diagnosis of Prinzmetal angina?

A

1 - nitrate-responsive anginal episodes either at rest, with diurnal characteristics, or precipitated by hyperventilation,
2 - transient ischemic EKG changes during the pain
3 - proof of transient coronary artery spasm

189
Q

(RR)

when are Prinzmetal angina attacks most common?

A

at night and at rest

190
Q

(RR)

how do you distinguish between L and R BBB?

A

WiLLiaM MaRRoW in V1 and V6

W in V1 and M in V6 = LBBB

M in V1 and W in V6 = RBBB

191
Q

(RR)

new LBBB + chest pain = ______ until proven otherwise

A

MI

new LBBB + chest pain = MI until proven otherwise

192
Q

(RR)

“What are causes of left bundle branch block?”

A

“Myocardial ischemia,
myocardial infarction or myocarditis,
but most often is caused by DEGENERATION OF THE CONDUCTION SYSTEM with age.”

193
Q

(RR)
A 65 y/o asymptomatic man is noted to have a murmur on cardiac auscultation. What findings are suggestive of chronic mitral regurgitation?

A

a HOLOSYSTOLIC MURMUR WITH RADIATION TO THE AXILLA

194
Q

(RR)

mitral regurg has what two forms?

A

acute and chronic

195
Q

(RR)

what causes acute mitral regurg?

A

sudden rupture of chord tendineae or acute papillary muscle dysfunction from cardiac ischemia

(this is an emergency!)

196
Q

(RR)

what is chronic mitral regurg?

A

gradual loss of competence of mitral valve

more common than acute

197
Q

(RR)

what are the characteristics of chronic mitral valve regurgitation?

A

holosystolic murmur at the apex which radiates to the axilla

198
Q

(RR)

how do we make diagnosis of mitral valve regurg?

A

echocardiogram

199
Q

(RR)

how do we treat acute mitral valve regurg?

A

nitroprusside
dobutamine
intra-aortic balloon pump
emergency surgery

200
Q

(RR)

how do we treat chronic mitral valve regurg?

A

anticoagulation
CHF Rx
valve repair or replacement

201
Q

(RR)

where are aortic valve murmurs best auscultated?

A

right

2nd intercostal space, just lateral to the sternum

202
Q

(RR)

where are pulmonic valve murmurs best auscultated?

A

on the LEFT

2nd intercostal space, just lateral to the sternum

203
Q

(RR)

where are tricuspid valve murmurs best auscultated?

A

on the LEFT

4th-5th intercostal space over LEFT sternal border

204
Q

(RR)

where are mitral valve murmurs best auscultated?

A

LEFT

5th intercostal space, midclavicular line (APEX)

205
Q

(RR)
“a 32-year old man presents to the emergency department with palpitations and occasional non-exertional chest pain. Physical exam reveals a tall, thin man with pectus excavatum. A late systolic murmur with a midsystolic click is heard on auscultation. Which of the following maneuvers will result in movement of the click later into systole?

a) inspiration
b) squatting
c) standing
d) Valsalva”

A

“B) SQUATTING”

“maneuvers that increase preload, such as squatting, or afterload, such as hand grip, move the click later in systole”

206
Q

(RR)

what kinds of maneuvers move the midsystolic click of mitral valve prolapse EARLIER into systole?

A

MANEUVERS THAT DECREASE PRELOAD, SUCH AS VALSALVA AND STANDING

“The midsystolic click is moved earlier in systole by maneuvers that decrease preload, such as Valsalva and standing.”

207
Q

(RR)

what kinds of maneuvers move the midsystolic click of mitral valve prolapse LATER into systole?

A

MANEUVERS THAT INCREASE PRELOAD

“Maneuvers that increase preload, such as squatting, or afterload, such as hand grip, move the click LATER in systole.”

208
Q

(RR)

what causes mitral valve prolapse?

A

myxomatous degeneration of the valve

(“most common cause of primary valvular disease in industrial countries”)

(I’m not sure what myxomatous means…something to do with the Greek word for mucus?)

209
Q

(RR)

what happens to the pulse pressure with aortic regurgitation?

A

WIDE PULSE PRESSURE

“Aortic regurgitation occurs when valve leaflets fail to close fully, causing blood to flow from the aorta back into the left ventricle during diastole. Increasing stroke volume followed by a rapid pressure drop during diastole results in a WIDE PULSE PRESSURE.”

210
Q

(RR)

what are s/s of atypical pneumonia?

A

(aka “walking pneumonia”)

no signs of lobar consolidation

presence of extrapulmonary symptoms

pt “looks better” than clinical picture

211
Q

(RR)

what is the treatment for atypical pneumonia?

A

tetracyclines (doxy, tetracycline)

macrolides (azithromycin, clarithomycin)

FQ’s

212
Q

(RR)

how do pts present for atypical pneumonia?

A

gradual onset of dry cough, dyspnea, extrapulmonary symptoms such as HA, myalgias, fatigue, GI disturbance

213
Q

(RR)

medications of choice for hypertensive emergency (mod to severe HTN w/ evidence of end-organ damage)?

A

nicardipine and labetalol

214
Q

(RR)
match the drug of choice for the following hypertensive emergencies:

acute MI - ?
aortic dissection - ?
eclampsia - ?

A

acute MI - nitro
aortic dissection - esmolol
eclampsia - mag sulfate, hydralazine

215
Q

(RR)

what are the goals of Hypertensive Emergency treatment?

A

“gradually reduce MAP by ~10-20% in the first hour and by a further 5-15% over the next 23 hours”

216
Q

(RR)

define MAT

A

irregular rhythm resulting from at least three different atrial foci

therefore, the EKG shows three different P wave morphologies

rate is about 100-180

217
Q

(RR)

treatment for MAT

A

supportive care directed toward underlying cause

218
Q

(RR)

“what is considered safe time period for cardioversion in new-onset atrial fibrillation or atrial flutter?”

A

“48 hours”

219
Q

(RR)

what kind of murmur is associated with hypertrophic obstructive cardiomyopathy?

A

holosystolic murmur heard best at APEX and LLSB that radiates to the suprasternal notch and DECREASES WITH MANEUVERS THAT INCREASE CARDIAC PRELOAD SUCH AS SQUATTING

220
Q

(RR)

what are the EKG findings usually associated with hypertrophic obstructive cardiomyopathy?

A

tall R and S waves associated with LVH, and

deep, DAGGER-LIKE Q WAVES IN INFERIOR AND LATERAL LEADS

221
Q

(RR)

treatment of pertussis?

A

azithromycin (macrolide)

although TMP-SMX may be used in macrolide-intolerant patients

222
Q

(RR)

if a patient has pertussis, and a glucose 6-phosphate dehydrogenase deficiency, what treatment should be chosen?

A

azithromycin

TMP-SMX is contraindicated in pts with glucose 6-phosphate dehydrogenase deficiency b/c it causes hemolysis

223
Q

(RR)

EKG findings suggestive of PE

A

S wave in Lead I
Q wave in Lead III
flipped T wave in Lead III

this is called the “S1-Q3-T3 pattern”

224
Q

(RR)

what is the treatment for unstable pulmonary embolism? stable pulmonary embolism?

A

Hemodynamically unstable pts are treated with THROMBOLYSIS.

Stable pts are treated with HEPARIN.

225
Q

(RR) BUZZWORDS

Hamptonhump

A

CXR abnormality of “pleural-based wedge infarct” indicating

PE

226
Q

(RR) BUZZWORDS

Westermarksign

A

CXR abnormality of “vascular cutoff sign” indicating

PE

227
Q

(RR)

EKG findings of Wolff-Parkinson-White

A

shortened PR interval with a slurring of the QR or R segment of the QRS segment known as the “DELTA WAVE”

228
Q

(RR)

what are the only two appropriate treatments of WPW reentrant tachycardia

A

procainamide and cardioversion

229
Q

(RR)

“what is the most common location for a AAA?”

A

“below the level of the RENAL ARTERIES (infrarenal)”

230
Q

(RR)

how do we diagnose AAA?

A

U/S

231
Q

(RR)

risk factors for AAA

A

male sex
older patients
smoking
HTN

232
Q 
(RR)
"which of the following pt hx elements is most indicative of cardiac syncope?
a) absence of a postdrome
b) postevent confusion
c) prodrome with dizziness and nausea
d) provocation with prolonged standing"
A

A) ABSENCE OF A POSTDROME

233
Q

(RR)

true cardiac etiologies typically have no _______

A

harbingers or postepisode symptomatology

234
Q

(RR)

“patients with what medical conditions have a high likelihood of dysrhythmia as a cause of syncope?”

A

“structural heart disease (e.g. cardiomyopathy, aortic stenosis) and heart failure”

235
Q

(RR)
“A 71-year-old woman presents with exertional dyspnea. A murmur is heard on cardiac auscultation. She reports a hx of acute rheumatic fever as a child. Which of the following murmurs suggests a diagnosis of mitral stenosis?
a) continuous, machine-like murmur
b) harsh systolic murmur radiating to carotids
c) high-pitched apical holosystolic murmur
d) mid-diastolic rumbling murmur”

A

D) MID-DIASTOLIC RUMBLING MURMUR

mitral stenosis is a diastolic murmur! and I guess it rumbles…

236
Q

(RR) BUZZWORDS

waterbottle shape of cardiac outline

A

cardiac tamponade/pericardial effusion

237
Q

(RR)

what happens to the EKG if pericardial effusion progresses to cardiac tamponade?

A

electrical alternans -

- - > alternating high and low QRS complex amplitudes between beats

238
Q

(RR)

“What is Beck’s triad?”

A

“hypotension with a narrowed pulse pressure,
JVD,
distant heart sounds,
all symptoms associated with acute cardiac tamponade”

239
Q

(RR)

what are three most common causes of pleural effusion in developed countries?

A

pneumonia
malignancy
CHF

240
Q

(RR)

what LDH values suggest EXUDATIVE pleural effusion?

A

pleural fluid LDH twice that of serum LDH

241
Q

(RR)

two adverse effects of ethambutol

A

optic neuritis

red-green color blindness

242
Q

(RR)

which TB drug requires supplementation with a certain vitamin…and what is the vitamin?

A

ISONIAZID

Pyridoxine (Vit B6)

243
Q

(RR)

“what are the options for outpt anticoagulation for atrial fibrillation?”

A

“warfarin or

new oral anticoagulant drugs (e.g. dabigatran, rivaroxaban, apixaban)”

244
Q

(RR)

AAA’s are frequently misdiagnosed b/c they present with symptoms consistent with _____

A

RENAL COLIC

“the combination of back and abdominal pain should prompt the consideration of AAA in all patients”

245
Q

(RR)

what is the AAA triad?

A

abdominal pain

hypotension

pulsatile abdominal mass

246
Q

(RR)

how long is a prolonged PR interval?

A

> .20 seconds (or >200 msec)

247
Q

(RR)

what are two characteristics of First Degree Heart Block?

A

rhythm will be regular

PR interval will be >0.20 seconds (or >200 msec)

248
Q

(RR)

what can abnormal EKG changes, including sinus tach, widened QRS intervals, regional ST segment elevations indicate?

A

myocarditis

249
Q

(RR)

what does physical exam show for myocarditis?

A

tachycardia disproportionate to fever or discomfort

250
Q

(RR)

what are “grouped beats” of the heart and what does it indicate?

A

“clustering of QRS complexes separated by a pause from a dropped beat. This is known as grouped beating and is characteristic of SECOND-DEGREE MOBITZ TYPE I AV BLOCK”

It’s prolongation of PR intervals until a beat is dropped (aka Wenckebach).

251
Q

(RR)
in a stable SVT patient, after vagal maneuvers and a single dose of adenosine 6 mg have been attempted and fail, it is most appropriate to give what?

A

adenosine 12 mg IV

252
Q

(RR)

in a pt w/ SVT w/ abrupt onset of tachycardia who becomes unstable, what do we do?

A

synchronized cardioversion

“Synchronized cardioversion as low as 50 to 100 joules may be effective”

253
Q

(RR)

in the setting of chest pain and elevated ST segments in V4R and V5R, what medicine is contraindicated?

A

NITROGLYCERIN

this is a right ventricular infarction, and pts are dependent upon preload to maintain cardiac output, so give them fluids and NO NITRO

254
Q

(RR)

what is the cause of the steeple sign seen on PA chest xray in croup pts?

A

SUPRAGLOTTIC NARROWING

255
Q

(RR)

treatment of acute pericarditis

A

NSAIDs and discharge home
add colchicine to reduce risk of recurrent pericarditis

(this may present with diffuse ST segment elevation and PR segment depression)

256
Q

(RR)

first-line antihypertensive med for hypertensive encephalopathy

A

nicardipine

(nicardipine and labetalol are meds of choice…nicardipine is a DHP CCB that is given as continuous infusion; labetalol is combined beta- and alpha-adrenergic blocker w/ rapid onset of action, so it can be given as bolus or continuous infusion)

257
Q

(RR)

most common group of pts who develop aortic dissection

A

those over 50 yrs of age w/ hx of chronic HTN

“CHRONIC HTN IS MOST COMMON AND MOST IMPORTANT PREDISPOSING RF”

CLINICAL YR: Emergency Med EOR Exam_JD (5 decks)

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