Exam 1 Flashcards
1
Q
Virchow’s triad
A
stasis
vessel wall injury
hyper-coagulability
2
Q
3rd most common cardiovascular illness
A
VTE
3
Q
3rd most common cause of hospital related death
A
VTE
4
Q
most common preventable cause of hospital related death
A
VTE
5
Q
D Dimer
A
positive in presence of fibrin clot, good to rule out
6
Q
test of choice for DX of DVT
A
compression ultrasonography
7
Q
compression ultrasonography result if DVT
A
loss of vein compressibility, no blood flow with droppler tech
8
Q
gold standard for DVT Dx
A
contrast venography
9
Q
when do we do venography
A
in low risk pt with abnormal compression ultra
in high risk pt with normal compression ultra
10
Q
when do we repeat compression ultra
A
in moderate risk pt with normal 1st compression ultra
11
Q
the purpose of DVT tx
A
prevent PE
12
Q
complication of DVT
A
post thrombophlebitic syndrome
chronic venous insufficiency
13
Q
major difference in clinical presentation of DVT vs superficial thrombophlebitis
A
edema of extremity is uncommon in superficial thrombophlebitis
14
Q
major difference in tx of DVT vs superficial thrombophlebitis
A
anticoagulation rarely required in superficial thrombophlebitis. local heat, NSAIDs are tx.
15
Q
most common cause of PE
A
DVT (50-60% of proximal DVT embolize vs isolated calf DVT rarely embolize)
16
Q
PE classifications
A
massive PE
submassive PE
17
Q
massive PE
A
PE a/w SBP=40 for 15 min (that is not explained by hypovolemia, sepsis, acute MI, tension pneumothorax, new arrhythmia)
==> acute RV failure and death
18
Q
most common PE symptom
A
dyspnea
19
Q
PE signs
A
tachypnea, tachycardia, rales, decreased breath sounds, accentuated pulmonic component of the 2nd heart sound, JVD, sum/signs of LE DVT
20
Q
most common PE sign
A
tachypnea
21
Q
97% of pt with PE had one or more of three findings :
A
dyspnea, pleuritis chest pain, tachypnea
22
Q
labs for PE
A
same as DVT, consider troponin and BNP
23
Q
EKG of PE
A
S1Q3T3
24
Q
PE signs on CXR
A
hamptons hump and wester mark
25
gold standard for PE dx
pulmonary angio
26
tx of VTE
anticoag med, thrombolytics, thrombectomy/embolectomy, IVC filter, prophylactics
27
prophylactics for VTE
TED hose, sequential compression devices (SCDs), low dose SQ heparin & Lovenox
28
anti coag meds
IV unfractionated heparin, LMW heparin, warfarin, fondaparinux, oral factor Xa inhibitors, oral direct thrombin inhibitors
29
indication for IV unfrac. Heparin
initial tx of VTE
30
side effects of IV unfrac. heparin
bleeding, thrombocytopenia
31
indication of LMWH-Lovenox
FDA approved for output tx of DVT and stable PE
32
side effects of LMWH-Lovenox
bleeding, thrombocytopenia
33
indication of warfarin
long term tx of VTE
34
contraindication of lovenox-LMWH
CrCl<30. elderly, obese
35
contraindication of warfarin
pregnancy category x
36
side effects of warfarin
bleeding
37
factor Xa inhibitors are
fondaparinux, rivaroxaban,
38
oral direct thrombin inhibitors
dabigatran (not approved in US), argatroban, desirudin, lepirudin
39
duration of anti coag tx if underlying thrombophilia
indefinite
40
duration of anti coat tx if cancer
as long as cancer is active
41
thrombolytics used for ..
unstable pt with PE, massive PE and cardiogenic shock, sever hypoxemia, substantial perfusion deficit on V/Q scan, RV dysfunction, entensive DVT
42
examples of thrombolytics
streptokinase, urokinase, rt-PA
43
IVC filter purpose
preventing DVT from propagating to lungs
44
absolute contraindication of IVC filter
active bleeding, anticoag
45
consideration of inpt vs outpt
```
pt is :
ambulatory and stable w/ nl vitals
low bleeding risk
no renal insufficiency
plan for LMWH/warfarin w/monitoring
monitoring &tx of recurrent VTE and bleeding complications
```
46
prognosis for VTE
mortality 10-30% within 30 days
20-25% of PE cases present as sudden death
risk for recurrent and chronic morbidity
quality of life: long term anti coag
47
RBC life span
120 days
48
Hgb levels in anemia
wm <14
49
Hgb to Htc level ratio
1:3
50
reticulocytes
immature RBCs
51
retic count
indication of RBC production (blue on smear)
52
normal retic count
.5-2.5%
53
polychromasia
reticulocytosis (lots of blue)
54
causes of anemia
decreased RBC production, Increased RBC destruction, Blood loss
55
decreased RBC production causes
iron def, B12, folate def, chronic dz
56
increased RBC destruction causes
hemeolysis
57
nl MCV
80-100fl
58
nl MCH
26-34
59
RDW indicator of what
indicator of the degree of variation in the size of RBC
60
nl RDW
11-15%
61
anisocytosis
variation in size
62
anemia not noticeable till
Hgb <7-8
63
three main categories of anemia
hypochromic, microcytic
normochromic, normocytic
macrocytic (megablastic)
64
hypochromic, microcytic anemia examples
iron deg, thalassemias, sideroblastic
65
normo anemia example
hypothyroidsm, liver dz, chronic dz
66
macro anemia examples
folate def and B12 def, hemolysis
67
ret count in hemolysis and hemorrhage
increased
68
retic count in B12 /folate def
normal
69
most common cause of micro, hypo anemia
fe def
70
most common causes of fe def anemia (IDA)
menstrual blood loss, pregnancy, GI blood loss
71
RDW in IDA is
elevated
72
special tests for IDA
serum ferritin (dec), serum Fe(dec), TIBC (inc),bone marrow biopsy
73
major iron storage and first to fall when IDA
serum ferritin <10ng/ml
74
dignostic of IDA
serum ferritin <10ng/ml
75
determining of the cause of IDA is very important because for example
occult malignancy like colon, upper GI CA commonly present w/anemia
76
tx of IDA
```
replace iron store
blood transfusion (maybe)
```
77
transfusion for IDA?
only if cerebrovascular or cardiopulmonary compromise, not recommended for iron replacement
78
thalassemias definition
inherited disorders of hgb production : alpha and Beta
79
thalassemia minor
dysfunction of one beta globulin chain, asymptomatic, hypochromic, microcytic
80
thalassemia major
cooley's anemia,
| severe dysfunction of both beta globulin chains, most die before 30
81
thalassemia lab eval
poikilocytosis (abnormal shapes), target cells, nucleated RBCs, NORMAL RDW (all RBCs are small)
82
thalassemia vs IDA RDW
nl is thalassemia, elevated in IDA
83
thalassemia tx
transfusion, splenectomy, iron chelation
84
why hgb should be >9 in thalassamia?
to prevent skeletal deformities and fractures
85
approach to micro anemia
check serum ferritin:
if low-->IDA
if nl-->check serum Fe nad TIBC
86
anemia of chronic dz (ACDz)
common in longstanding inflammatory dz, malignancy, autoimmune, chronic infection
87
etiology of ACDz
abnl iron metabolism, impaired erythropoeitin production
88
lab tests for ACDz
normo, nl or elevated ferritin, no dx lab test
89
tx of ACDz
treat cause, erythropoetin
90
myelodysplastic syndrome
acquired disorder of hematopoietic stem cells, resulting in a refractory anemia may lead to leukemia
91
etiology of myelodysplastic anm
idiopathic, 2 to radiation, chemotx, toxin exposure
92
sideroblastic anm
heterogenous group of disorders with abnl RBC iron metabolism
93
lab findings of sideroblastic anm
anisocytosis, poikilocytosis, ringed sideroblast, iron deposits
94
fe low, TIBC elevated, ferritin low
iron def
95
fe and TIBC nl, ferritin nl
no iron def
96
fe and TIBC low, ferritin nl/elevated
ACDz
97
fe high, TIBC nl, ferritin elevated
thalassemia
98
increased ret count due to ?
prior of recent hemorrhage, recent hemolysis
99
normal ret count due to?
normal bone marrow: with anemia of chronic dz, hypothyroidism, liver dz
abnormal bone marrow: myelofibrosis, leukemia, myeloma, matastases, renal failure
100
megablastic anemias
B12 and folate def, hemolysis (can be normo)
101
falsy elevated MCV due to?
large number of reticulocyte, RBC clumping
102
if B12 not replaced?
subacute combined degeneration of the spinal cord
103
daily B12 requirement
1-2 microg
104
pernicious anemia
def in IF --> B12 malabsorbtion and megablastic anemia due to autoantibodies against parietal cells
105
neuro findings in PA
dec. vibratory and position sense, ataxia, paresthesias, confusion, dementia
106
peripheral smears of PA
hypersegmentated neutrophils, anisocytosis, poikilocytosis, macro-ovalocytes, low platlets
107
lab findings of PA
low serum B12, positive Schilling test or antibodies to IF, elevated serum methylmalonic acid and homocysteine levels
108
Tx of PA
parenteral vitamin B12, Do not tx B12 def with folic acid alone
109
folic acid daily requirement
200 microg/day (400-800 for pregnants)
110
how long does it take to show folic acid def macro anemia?
4-5 months
111
folate def is common in
alcoholism, end of pregnancy, anticonvulsant therapy (enzyme inhibition reduces folate absorption), malabsorption syndromes, hemolytic anemias including sickle cell.
112
lab findings in FA def anemia
low serum folate level, homeosystein level is elevated but serum methylmalonic is normal
113
normal marrow can sustain RBC production ....nl
2-5 times
114
marrow cannot compensate for RBC survival time less than ...
20 days
115
clinical findings of H anemia
jaundice, gallstones, increased risk of salmonella and pneumococcus
116
classifications of hemolysis
intravascular: destruction w/in blood stream
extravascular: destruction in the reticuloendothelia system like spleen
117
lab findings in hemolysis
elevated retic count (polychromasia), increased unconjugated bilirubin, elevated serum LDH, plasma hgb increased (hemoglobinuria)
118
serum haptaglobin is low in ...
intravascular helysis
119
peripheral smear in hemolysis anemia
immature RBCs, nucleated RBCs, possible schistocytes
120
polychromasia ?
reticulocytosis, lots of blue --> lots of new
121
intravascular hemolysis classification
1.fragmentation syndromes 2. red cell enzyme defects 3.paroxysmal nocturnal hemoglobinuria
122
fragmentation syndrome
1. traumatic (macroangiopathic) from prosthetic valve 2. microangiopathic caused by RBC disruption from fibrin strands in vessles
123
red cell enzyme defects
G6PD def (Heinz bodies)
124
Heinz bodies a/w
G6PD
125
schistocyte a/w
fragmentation syndrome
126
extravascular hemolysis
1.hereditary spherocytosis 2. sickle cell anemia 3. autoimmune hemolytic anemia 4. incompatible blood transfusion 5. drug-induced hemolytic anemia
127
positive osmotic fragility test for ?
hereditary spherocytosis
128
positive coombs test (also called DAT)
autoimmune hemolytic anemia
129
RBCs in Hereditary Spherocytosis
normal MCV, smaller surface area, dense, globular appearance, lack central pallor , poorly deformable , trapped in splenic sinusoids, phagocytized by splenic macrophages
130
clinical features of HS
mild jaundice, scleral icterus, splenomegaly,
131
why need for increased folate in HS
chronic hemolysis
132
what test for HS
osmotic fragility test : increased hemolysis in hypotonic fluid
133
HS Tx
1.splenectomy : RBC lifespan to normal, remove risk of bilirubin gallstones 2. pnemococcal vaccine
134
sickle cell anemia
1. homeozygos form : sickle cell Dz with symptoms
| 2. heterozygos form: sickle cell trait no symp but carriers
135
male and female affected equally in ...
sickle cell anemia
136
RBCs in sickle cell anemia
sickle shaped when deoxy causing pain
137
sign and symptoms of sickle cell anemia
delayed growth, increased susceptibility to infections, dehydration, hypoxia, high altitude, intense exercise
138
clinical features are due to..
1. chronic hemolysis: aplastic crisis and dec in Hb, bilirubin gallstone
2. vaso-occlusive ischemic tissue injury: pain crises, osteonecrosis of femoral and humeral heads, CVA, MI, Splenic infarct, leg ulcers
139
most common feature of SS dz ?
pain in back, ribs, limbs lasting 5-7 days, tx with analg and fluid
140
lab finding of SS
low Hb,normo RBCs, elevated retic count, Hb electrophoresis reveals Hb S
141
screen SS with ...test
sickledex
142
peripheral smear in SS
few sickled RBCs, nucleated RBCs, target cells, howell-jolly bodies, thrombocytosis
143
tx of SS dz
RBC transfusion PRN, analgesics, fluid, O2, hydroxurea, bone marrow tp
144
chemotx
hydroxyurea suppresses bone marrow function of all cell lines
145
auto immune hemolytic anemia
RBCs with antigen-antibody complex are phagocytized by macrophages, and spherocytes are formed, they become smaller and destroyed in spleen.
146
smear of AI HA
polychromasia, spherocytosis, nucleated red cell
147
tx of Hemolysis
cause, corticosteroids, splenectomy, folic acid
148
incompatible blood transfusion
results in hemolysis
149
what test for incompatible BT
coombs test can detect antibodies
150
hemolytic dz of new born is a
incompatible BT (erythroblastosis)
151
aplastic anemia
acquired abnormality of bone marrow stem cells selective or total RBC, WBC, platelets
152
causes of aplastic anemia
chemical exposure, viral, ionizing radiation
153
hallmark of aplastic anemia
pancytopenia (anemia, leukopenia, thrombocytopenia)
154
clinical features of aplastic anemia
pancytopenia, absence of precursors for normoblasts, ganulocytes, megakaryocytes in bone marrow, weakness, infections, bleeding.
155
tx of aplastic anemia
cause, r/o other infections, hematology referral for blood component replacement, bone marrow transplant, immunosuppressive tx
156
preferred tx for aplastic anemia
bone marrow tp
157
infections resembling aplastic anemia
acute leukomia, myelodysplasia, PNH, granulomatous infxn such as TB
158
leading cause of disability in US
stroke
159
80% of strokes are
ischemic, rest is hemorrhagic
160
stroke risk factors
hx of neuro symp, degree of carotid stenosis, plaque charachteristics
161
symptomatic pt for stroke
contralateral weakness, contralateral sensory deficits, amaurosis fugax or hollenhorst plaque.
162
high risk groups for imaging of carotid bifurcation dz
>60 yo and one of : HTN, CAD, current smoking, 1st degree relative with Hx of stroke
163
management of asymptomatic carotid stenosis
tx HTN, Hyperlipidemia, DM, smoking, aspirin
164
indication for surgery/intervention
1. carotid endarterectomy (CEA)
| 2. carotid artery stenting (CAS)
165
chronic aorto-illiac occlusive dz
1. younger female 2. smoker with hyperlipidemia 3. small infrarenal aorta 4.chronic lower limb ischemia
166
tx of chronic aorto-illiac occlusive dz
1. aortic bypass 2. endovascular angio +/- stenting
167
acute aortic occlusive dz
1.vascular emergency 2. saddle embolism 3. in situ thrombosis of already diseased segment
168
presentation of acute aortic occlusive dz
neuro def (paralysis), absent femoral pulses
169
tx of acute aortic occlusive dz
quick imaging and operation
170
aneurysm definition
abnormal vessel dilation
171
dissection
a tear in intima and blood penetrates into media which splits longitudinally
172
aortic aneurysmal dz
degenerative and remodeling of aortic wall,
173
causes of aortic aneurysmal dz
genetic predisp, atherosclerotic, infection (TB, Syphilis), Marfans, Ehlers-Danlos
174
atherosclerotic aneu. 95% affects
abdominal aorta
175
AAA dx
UTZ: dx and size
| CT/MRI: plan endovascular therapy
176
AAA management
follow up if 5.5 cm, symptomatic, rapid expansion
177
AAA
majority asymptomatic
178
most common complaint in AAA
back pain
179
ruptured AAA a/w
abd pain, pulsatile abd mass, tenderness, hypotension
180
surgical repair of AAA
w/ dacron graft, percutaneous endovascular stent grafts,
181
aortic dissection can occur secondary to ?
connective tissue dz,aneurysm, HTN, trauma
182
type of pain in aortic dissection
acute onset of tearing pain in either chest or abd
183
aortic dissection medical management
1. beta blockers, 2. add vasodilators like Nipride
184
complication of aortic dissection
aortic rupture, cardiac tamponade, acute aortic regurg, acute coronary ischemia
185
Peripheral vascular dz
arterial (PAD)
| venous
186
PAD
asymptomatic, intermittent claudication, critical leg ischemia-limb threat
187
intermittent claudication is a/w
PAD
188
peripheral venous dz
venous thrombosis, varicose veins, chronic venous insufficiency
189
most common form of PAD
chronic arterial insufficiency
190
chronic arterial insufficiency is most common in
elderly
191
underlying cause of chronic arterial insufficiency is
atherosclerosis
192
physical exam inspection finding in PAD
1. pallor w/raised extremity 2. dependent rubor 3. HAIR LOSS ON LEG/FOOT 4.ATROPIC SKIN/NAIL CHANGES 5.ulcers 6.necrosis/gangrene
193
PE palpation findings in PAD
1. pulses: femoral, popliteal, dorsalis pedis, posterior tibial 2. temp: cool 3. capillary refill: delayed
194
ABI (ankle-brachial index) is a/w
PAD , >1 nl
195
most common sites of PAD
superficial femoral and popliteal
196
atherosclerotic plaques frequently occur at ?
bifurcation: aortic, iliac, femoral
197
main symptom of PAD
claudication : ischemic pain in lower legs when walking resolve when standing or rest
198
claudication is more common in
calves (less frequent in buttocks and thighs)
199
Leriche syndrome
aortoiliac dz
200
Leriche syndrome vs venous dz
leg/foot pain usually improves when leg in dependent position; worsen when leg is raised. the opposite of venous dz.
201
rest pain?
with sever Leriche syndrome.
202
claudication worse prognosis
smoking and diabetes with overall amputation risk of 20%
203
non invasive testing for PAD
treadmill test/ABI, duplex ultrasound, magnetic resonance angio
204
claudication medical therapy
1. stop-start walking regimen 2. SMOKING CESSATION 3.lipid lowering, 4. aspirin 5. clopoidogrel 6. pentoxifylline 7. cilostazol
205
indications for intervention claudication
impacting life style despite therapy, rest ischemia, limb threat
206
claudication surgical approaches
1. endarterectomy 2.percutaneuos transluminal angioplasty(PTA) 3. stents 4. revascularization
207
endarterectomy
removal of atherosclerotic plaque
208
PTA
for localized dz w/short segments of obstructing plaque
209
stent for claudication
alternative to simple angioplasty
210
revascularization for claudication
aortofemoral bypass graft, femoral-popliteal, axillary-femoral
211
balloon angioplasty
one approach to limited PVD
212
bypass grafts are used for
aortoiliac and femoral-popliteal
213
Goretex grafts are most common for
fem-pop
214
claudication is a marker for..
systemic atherosclerosis
215
focal aortoiliac or iliac dz should be treated w/
angioplasty /stenting
216
occlusion longer than 5 cm, concomitant aneurysm, or in common femoral a. are better treated w/
surgery
217
initial tx in fem-pop dz
prolonged course of medical therapy
218
acute arterial obstruction
sudden cessation of blood flow to an extremity due: Acute Emergency
219
cases of acute arterial obstruction
embolism ( usually, from heart or aorta), thrombus in situ
220
5 Ps of acute obstruction
pain, pallor, paresthesia, paralysis, pulselessness
221
tx of acute obstruction
emergency: thrombectomy/embolectomy-dissolve via thrombolytic infusion-anricoag (heparin)-surgical bypass
222
raynaud's phenomenon
episodic digital schemia on exposure to cold or emotional stress
223
triphasic response in raynauds
pallor, cyanosis, rubor
224
cause of raynaud
arterial vasospasm followed by arteriolar and capillary dilation
225
2 categories of raynaud
1. raynaud dz: primary /idiopathic when 2ndary causes are excluded ~50%
2. 2ndary raynauds phenomenon
226
drug tx for raynauds
ca channel blockers (nifedipine, diltiazem), reserpine (adrenergic blocker), prazosin (alpha 1 adrenergic blocker)
227
varicose vein sx
aching/burning sensation, tired/heavy, worse w/standing, better by elevation (UNLIKE ARTERIAL DZ)
228
varicose veins signs
prominent surface veins, superficial thrombosis, rupture/local bleeding, stasis dermatitis (dark pigmentation), ulceration esp. NEAR ANKLE, edema
