Essential Internal Med Diagnoses pt 2

Question 1

autoantibodies for ehrymatoid arthritis

Answer 1

Genetics: HLA-DR1/4

Antibodies: Rf, anti-CCP

Question 2

is rheumatory arthritis an example of inflammatory or non-infl arthritis?

Answer 2

inflammatory. RA is characterizes by stiffness in the mornings/after rest, systemic symptoms, variable joint patterns.

Question 3

osteoarthritis is progressive deterioration of __ ___ and surrounding joint structures caused by factors with secondary components of inflamation

Answer 3

deterioration of articular cartilagre. abnormalities in biomechanical forces –> proinflammatory cytokines –> degradation of proteoglycans by MMPS, –> fissuring, cartilage loss and subcondral bone thieckening.

Question 4

T/f in osteoarthritis, activity makes the pain lesson (like in RA)

Answer 4

false. activity makes the pain worse, rest makes it better.

Question 5

4 hallmark features of osteoarthritis on XRAY

Answer 5

1. joint space narrowing
2. osteophytes
3. subchondral sclerosis
4. bone cysts.

Question 6

T/F people with anklysing spondylitis are positive for RF antibody (like in RA)

Answer 6

false. AS, psoriatic arthritis and reactive arthritis are examples of SERONEGATIVE arthropatheies in which they are negative for antibodies. they are assocaited with HLA-b27 though.

Question 7

key seronegative arthropathy that has significant sacroiliitis and enthesitis

Answer 7

ankylosing spondylitis.

Question 8

anchor drug for psoriatic arthritis

Answer 8

methotrexate

Question 9

Sarcoidosis and amyloidosis are infiltrative disesase that can lead to ___ cardiomyopathies. What is the mechanism?

Answer 9

restrictive cardiomyopahties; impaired ventricular filling with preserved systolic function in a non-dilated, non-hypertrophied ventricle, seconary to factors that decreased myocardial compliance.

Mechanism: reduced ventricular compliance –> increased LVEDP –> increased pulmonary venous pressure + decreased CO.

Question 10

Definition: idiopathic non-infectious granulomatous multi-system disease with lung involvedment in 90% of cases. Symptoms include chest symptoms like cough, dyspnea, chest pain, as well as skin changes like erythema nodosum, lupus pernio ,cardiac arrythmias, eveitis, arthralgia, peripheral lymphadenopathy, hepatosplenomegaly.

Answer 10

Sarcoidosis

Question 11

Lofgren’s syndrome symptoms and disease association

Answer 11

LEAF: lymphadenopathy, erythema nodosum, arthralgias, fever –> sarcoidosis.

Question 12

when do you not need to biopsy the lung in order to confirm sarcoidosis?

Answer 12

when the person has lofrgrens syndrome.

Question 13

last stage of sarcoidosis key xray/ct findings.

Answer 13

pulmonary fibrosis /honey combing on xray

Question 14

general treatments for sarcoidosis

Answer 14

• stages 1 and II often resolve spontaneously
• prednisone for other stages

NSAIDS if lofgrens.

Question 15

classic ECG and physical exam findings of pericarditis, and key management strategies for it

Answer 15

ECG findings: diffuse ST elevation and PR depression.

PE: Audible friction rub, which is the movement of inflamed pericardial layers against each other.

treatment: high ASA, NSAIDS, colchicine to reduce recrrance.

Question 16

Beck’s triad of pericardial effusion

Answer 16

low BP, elevated JVP, muffled heart sounds

Question 17

key physical exam findings for pericardial effusions

Answer 17

Beck’s triad (low BP, elevated JVP, muffled heart sounds), tachycardia, pulsus paradoxus.

ECG is gold standard for detection– can lead to pericardial tamponade, which shows low voltage, sinus tachycardia and electrical alternans due to heart swing. –> emergency

Question 18

etiology of aortic dissection

Answer 18

HTN (90% of cases), heritable disease (Marfans, EDS, Turner syndrome), aneurysm, iatrogenic (catheter/surgical), vasculitis, chronic syphilis infection, bicuspid AV

Question 19

type A and B aortic dissection, and how they differ in management

Answer 19

A. proximal flap in the ascending aorta–> surgical management

B. Distal flap in the aorta–> IV beta blockers, vasodilators, stents.

complications of either type can lead to sudden death, cardiogenic shock, hemodynamic instability, pericardial effusion, pericardial tamponade, MI and aortic insufficiency.

Question 20

note: be aware of the two key types of aortitis: giant cell and takayasu– plus patient profile.

Answer 20

Aortitis Definition: inflammatory diseases of the aorta Examples:
• Giant Cell Aortitis: 55+ F, often associated to temporal artertitis, can cause aneurysm/dissections
• Takayasu’s Aortitis: young F, occlusive disorder of aortic branch vessels (pulseless disease), associated with eye problems
Management: steroids

Question 21

S3 sound is elicited by high ___ sided pressures of the heart

Answer 21

left sided presures

Question 22

elevated JVP, hepatomegaly, ascietes nad peripheral edema is due to ___ sided heart failure/elevated __sided pressuers

Answer 22

high right sided pressure.

Question 23

outline the neurohormonal compensatory mechanism in left heart failure

Answer 23

reduced cardiac output due to LHF–> back up of blood into L atrium –> back up in pulmonary circulation –> pulmonary edema –> reduced gas exchange and dyspnea .

this reduced CO –> reduced perfusion of renal artery –> RAAS and adrenergic activation –> renal salt and water retention –> more edema even though theres already pulmonary edema –> increased contractility and increased circulating volume –> increased cardiac outpupt –> organ perfusion –> increased afterload –> increaed LV workload, LV remodelling –> harmful

this is a good mechanism if it’s not chronic. but in LHF, it is.

leads to S3 and S4 sounds.

Question 24

exertional dyspnea, orthopnea, pulmonary edema (frothy, pink-tinged sputum), bibasilar rales, cough, nocturia, restlessness, confusion and S3/S4

these are symptoms of ___ sided heart failure

Answer 24

left heart failure

Question 25

right heart failure is aka __ ___

Answer 25

core pulmonale

Question 26

outline the mechanism of right heart failure

Answer 26

increaesd venosu pressure –> systolic volume overload –>increased RV worload –> RV hypertrophy –> decreased pumping ability.

Question 27

most common cause of right sided heart failure

Answer 27

left sided heart failure, pulmonary causes like emphysema, PE.

Question 28

location of aortic stenosis

Answer 28

right upper sternal boarder that radiates to carotids or apex.

Question 29

is aortic stenosis a systolic or diastolic murmur? Which shape? what additional sounds? what are it’s causes

Answer 29

aortic stenosis:

• systolic murmur
• systolic ejection murmur
• PARVUS ET TARFUS/apical carotid delay. Soft S2 and s4 present.
• causes: degenerative, rheumatic, biscuspid valve problems.

Question 30

location, shape, key findings and causes of pulmonic stenosis

Answer 30

left uppers ternal border, heard as a systolic ejection murmur.

• characteristic of a right ventricular heave, would hear a right sided S4

contract to force blood into the left ventricle. If the left ventricle is noncompliant, and atrial contraction forces blood through the atrioventricular valves, a S4 is produced by the blood striking the left ventricle.

Question 31

radiation course, shape, associated findings and causes of mitral regurgitation

Answer 31

radiates from apex –> axilla

• late systolic crescendo murmur
• increases with valsalva
• would see a dilated LV/LA, s3 sound.

Question 32

Corrigan’s pulse is indicative of what valve defect?

Answer 32

aoritc regurg in diastole

Question 33

__ sided murmurs will be louder on inspiration, and ___ sided murmurs will be louder on expiration.

Answer 33

Inspiration à R-sided murmurs will be LOUDER • Expirationà L-sided murmurs will be LOUDER

Question 34

how does valsalva change mitral valve prolapse sounds?

Answer 34

mitral valave prolapse will be a systolic murmur that gets LOUDER.

• every valsalva maneuver decreases preload, causing all murmurs to be QUIETER, except with HOCM and MVP

Question 35

outline the mechanism of pathology of aortic stenosis

Answer 35

pressure overload because of fixed obstruction/narrowing–> increased systolic pressure –> increased mechanical stress –> ventricle works harder –> wall thickening –> concentric hypertrophy (bigger from muscle)

Question 36

how does aortic stenosis affect pulse pressure?

Answer 36

narrows pulse pressure.

Question 37

what additional heart sound is created by aortic stenosis

Answer 37

1. systolic ejection murmur
2. S4 because of non-compliant/stiff ventricle.

Question 38

Austin-flitn murmur and water hammer pulse is associated with what valvular condition

Answer 38

aortic regurgitation.

Question 39

1 cause of mitral stenosis

Answer 39

rheumatic heart disease

Question 40

symptoms, physical exam findings and management of mitral stenosis.

Answer 40

Question 41

Major Jone’s criteria for rheumatic fever

Answer 41

carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.

Question 42

explain first degree heart block

Answer 42

not actually a block, just delayed PR interval >200ms. ALL P waves will conduct, just at a slower pace.

Question 43

Explain Type II A Wenckeback AVN block.

Answer 43

PR interval gradually lengthens before a P wave blocks and the cycle begins again.

Question 44

Explain Type IIB HP block

Answer 44

PR interval remains constant before a P wave blocks and the cycle begins again.

Question 45

explain type III Block

Answer 45

complete AV heart block. No p waves conduct to the ventricles. the atria and ventricles are not communicating and there is dissociation.

Question 46

Management of Afib

Answer 46

1. anticoagulants with target INR 2-3, NOACS
2. treat underlying cause
3. rate control: beta blockers, CCB, digoxin.
4. rhythm control: anti-arrhythmic (propafenone, amiodarone +/- cardioversion)
5. ablation for uncontrolled rhythm
6. pacemaker for uncontrolled rate.

Question 47

Answer 47

A flutter- regular ventricular rate.

Question 48

Answer 48

atrial fibrillation– abnormal ventricular response.